(PDP) 2015 Formulary

Transcription

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Express Scripts Medicare (PDP)
2015 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN
Y0046_F00SNV5A Accepted, Formulary ID: 15431, V15
This formulary was updated on 10/16/2015. For more recent information or other questions, please
contact Express Scripts Medicare® (PDP) Customer Service at 1.800.758.4574; New York State
residents: 1.800.758.4570, or for TTY users, 1.800.716.3231, 24 hours a day, 7 days a week, or visit
http://www.Express-Scripts.com.
Note to existing members: This formulary has changed since last year. Please review this document
to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us,” or “our,” it means Medco Containment Life
Insurance Company and Medco Containment Insurance Company of New York. When it refers to
“plan” or “our plan,” it means Express Scripts Medicare.
This document includes a list of the drugs (formulary) for our plan, which is current as of October 16, 2015.
For an updated formulary, please contact us. Our contact information, along with the date we last updated
the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network and/or copayments/coinsurance may change on January 1, 2016, and from
time to time during the year.
This information is available for free in other languages. Please call our Customer Service numbers at
1.800.758.4574 (New York State residents: 1.800.758.4570). Customer Service is available 24 hours
a day, 7 days a week. TTY users should call 1.800.716.3231.
Esta información está disponible sin cargo en otros idiomas. Llame a los números de Servicio al cliente
al 1.800.758.4574 (residentes del estado de New York: 1.800.758.4570). El Servicio al cliente está
disponible las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al
1.800.716.3231.
This document is available in braille. Please contact Customer Service if you need plan information in
this format.
3
F00SNV5BW4
What is the Express Scripts Medicare Formulary?
A formulary is a list of covered drugs selected by Express Scripts Medicare in consultation with a team
of healthcare providers, which represents the prescription therapies believed to be a necessary part of a
quality treatment program. Express Scripts Medicare will generally cover the drugs listed in our
formulary as long as the drug is medically necessary, the prescription is filled at an Express Scripts
Medicare network pharmacy, and other plan rules are followed. For more information on how to fill
your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year,
we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a
new, less expensive generic drug becomes available or when new adverse information about the safety
or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from
our formulary, will not affect members who are currently taking the drug. It will remain available at the
same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is
important that you have continued access for the remainder of the coverage year to the formulary drugs
that were available when you chose our plan, except for cases in which you can save additional money
or we cannot ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of
the change at least 60 days before the change becomes effective, or at the time the member requests a
refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and
Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes
the drug from the market, we will immediately remove the drug from our formulary and provide notice
to members who take the drug. The enclosed formulary is current as of October 16, 2015. To get updated
information about the drugs covered by Express Scripts Medicare, please contact us. Our contact
information appears on the front and back cover pages. If there are additional changes made to the
formulary that affect you and are not mentioned above, you will be notified in writing of these changes
within a reasonable period of time from when the changes are made.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending
on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category “Cardiovascular, Hypertension/Lipids.” If you know what
your drug is used for, look for the category name in the list that begins on page 1. Then look under
the category name for your drug.
i
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that
begins on page 68. The Index provides an alphabetical list of all of the drugs included in this
document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and
find your drug. Next to your drug, you will see the page number where you can find coverage
information. Turn to the page listed in the Index and find the name of your drug in the first column
of the list.
What are generic drugs?
Express Scripts Medicare covers both brand-name drugs and generic drugs. A generic drug is approved
by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost
less than brand-name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and
limits may include:
 Prior Authorization: Express Scripts Medicare requires you or your physician to get
prior authorization for certain drugs. This means that you will need to get approval from
Express Scripts Medicare before you fill your prescriptions. If you don’t get approval,
Express Scripts Medicare may not cover the drug.
 Quantity Limits: For certain drugs, Express Scripts Medicare limits the amount of the drug that
Express Scripts Medicare will cover. For example, Express Scripts Medicare provides two
inhalers (17 grams) for a one-month supply per prescription for PROAIR® HFA. This may be
in addition to a standard one-month or three-month supply.
 Step Therapy: In some cases, Express Scripts Medicare requires you to first try certain drugs to
treat your medical condition before we will cover another drug for that condition. For example, if
Drug A and Drug B both treat your medical condition, Express Scripts Medicare may not cover
Drug B unless you try Drug A first. If Drug A does not work for you, Express Scripts Medicare
will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 1. You can also get more information about the restrictions applied to specific covered
drugs by visiting our website. We have posted online documents that explain our prior authorization and
step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with
the date we last updated the formulary, appears on the front and back cover pages.
You can ask Express Scripts Medicare to make an exception to these restrictions or limits or for a list
of other, similar drugs that may treat your health condition. See the section “How do I request an
exception to the Express Scripts Medicare Formulary?” on page iii for information about how to request
an exception.
ii
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Customer
Service and ask if your drug is covered.
If you learn that Express Scripts Medicare does not cover your drug, you have two options:
 You can ask Customer Service for a list of similar drugs that are covered by Express Scripts
Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a
similar drug that is covered by Express Scripts Medicare.
 You can ask Express Scripts Medicare to make an exception and cover your drug. See below for
information about how to request an exception.
How do I request an exception to the Express Scripts Medicare Formulary?
You can ask Express Scripts Medicare to make an exception to our coverage rules. There are several
types of exceptions that you can ask us to make.
 You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be
covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide
the drug at a lower cost-sharing level.
 You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the
specialty tier. If approved, this would lower the amount you must pay for your drug.
 You can ask us to waive coverage restrictions or limits on your drug. For example, for certain
drugs, Express Scripts Medicare limits the amount of the drug that we will cover. If your drug
has a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, Express Scripts Medicare will only approve your request for an exception if the alternative
drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions
would not be as effective in treating your condition and/or would cause you to have adverse medical
effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you request a formulary, tiering or utilization restriction exception,
you should submit a statement from your prescriber or physician supporting your request.
Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement.
You can request an expedited (fast) exception if you or your doctor believes that your health could be
seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we
must give you a decision no later than 24 hours after we get a supporting statement from your doctor or
other prescriber.
iii
What do I do before I can talk to my doctor about changing my drugs or requesting
an exception?
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or,
you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you
may need a prior authorization from us before you can fill your prescription. You should talk to your
doctor to decide if you should switch to an appropriate drug that we cover or request a formulary
exception so that we will cover the drug you take. While you talk to your doctor to determine the right
course of action for you, we may cover your drug in certain cases during the first 90 days you are a
member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will
cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to
a network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have
been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we
have provided you with up to a 98-day transition supply, consistent with dispensing increment (unless
you have a prescription written for fewer days). We will cover more than one refill of these drugs for the
first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your
ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will
cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you
pursue a formulary exception.
Other times when we will cover a temporary 31-day transition supply (or less, if you have a prescription
written for fewer days) include:






When you enter a long-term care facility
When you leave a long-term care facility
When you are discharged from a hospital
When you leave a skilled nursing facility
When you cancel hospice care
When you are discharged from a psychiatric hospital with a medication regimen that is
highly individualized
The plan will send you a letter within three business days of your filling a temporary transition supply,
notifying you that this was a temporary supply and explaining your options.
For more information
For more detailed information about your Express Scripts Medicare prescription drug coverage, please
review your Evidence of Coverage and other plan materials.
If you have questions about Express Scripts Medicare, please contact us. Our contact information, along
with the date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week. TTY users should call
1.877.486.2048. Or, visit http://www.medicare.gov.
iv
Express Scripts Medicare’s Formulary
The formulary that begins on page 1 provides coverage information about the drugs covered by
Express Scripts Medicare. If you have trouble finding your drug in the list, turn to the Index
that begins on page 68.
The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., NEXIUM®)
and generic drugs are listed in lowercase italics (e.g., omeprazole).
The information in the Requirements/Limits column tells you if Express Scripts Medicare has any
special requirements for coverage of your drug.
Your costs
The amount you pay for a covered drug will depend on:
 Your coverage stage. Express Scripts Medicare has different stages of coverage. In each stage,
the amount you pay for a drug may change.
 The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier may have
a different copayment or coinsurance amount. The “Drug Tiers” chart below explains what types
of drugs are included in each tier and shows how costs may change with each tier.
The Evidence of Coverage (EOC) has more information about the plan’s coverage stages and lists the
copayment and coinsurance amounts for each tier.
If you qualify for Extra Help
If you qualify for Extra Help for your prescription drugs, your copayments and coinsurance may be
lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for People
Who Get Extra Help Paying for Prescription Drugs (LIS Rider).” Please read it to find out what your
costs are. You can also contact Customer Service for more information.
Drug Tiers
Tier
Includes
Tier 5:
Specialty
Tier Drugs
This tier includes preferred
brand-name drugs as well as
some generic drugs.
This tier includes
non-preferred brand-name
drugs as well as some
generic drugs.
This tier includes very
high-cost brand-name and
generic drugs.
Tier 1:
Preferred
Generic Drugs
Tier 2:
Non-Preferred
Generic Drugs
Tier 3:
Preferred
Brand Drugs
Tier 4:
Non-Preferred
Brand Drugs
This tier includes many
commonly prescribed
low-cost drugs.
This tier includes
additional low-cost drugs.
Helpful Tips
This tier includes commonly prescribed generic
drugs and may include other low-cost drugs.
Use Tier 1 drugs for the lowest copayments.
This tier includes generic drugs and may include
other low-cost drugs. Use Tier 2 drugs to keep your
copayments low.
Drugs in this tier will generally have lower
copayments than non-preferred brand drugs.
Many non-preferred brand drugs have lower-cost
alternatives in Tiers 1, 2, and 3. Ask your doctor if
switching to a lower-cost generic or preferred brand
drug may be right for you.
To learn more about medications in this tier, you
may contact a pharmacist at the numbers listed on
the front and back covers of this document. Drugs
in this tier are limited up to a 31-day supply.
v
The abbreviations listed below may appear on the following pages in the Requirements/Limits column
that tells you if there are any special requirements for coverage of your drug.
List of Abbreviations
LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more
information, call Customer Service at 1.800.758.4574 (New York State residents: 1.800.758.4570),
24 hours a day, 7 days a week. TTY users should call 1.800.716.3231.
MO: Mail-Order Drug. This prescription drug is available through our home delivery pharmacy service,
as well as through our retail network pharmacies. Consider using mail order for your long-term
(maintenance) medications (such as high blood pressure medications). Retail network pharmacies
may be more appropriate for short-term prescriptions (such as antibiotics).
PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain
drugs. This means that you will need to get approval before you fill your prescription. If you don’t get
approval, we may not cover the drug.
QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B both
treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not
work for you, we will then cover Drug B.
vi
Drug Name
Drug
Tier
Requirements
/Limits
ANTI - INFECTIVES
Drug Name
Drug
Tier
Requirements
/Limits
LAMISIL ORAL
GRANULES IN
PACKET
3
MO
MYCAMINE
INTRAVENOUS
RECON SOLN 100
MG
5
MO
MYCAMINE
INTRAVENOUS
RECON SOLN 50
MG
3
MO
NOXAFIL ORAL
SUSPENSION
5
MO
nystatin oral
suspension
2
MO
nystatin oral tablet
2
MO
ORAVIG
3
MO
SPORANOX ORAL
SOLUTION
3
MO
terbinafine hcl oral
2
MO
MO
voriconazole
intravenous
4
MO
2
MO
3
MO
abacavir
3
MO
abacavirlamivudinezidovudine
2
MO
acyclovir oral
capsule
2
MO
acyclovir oral
suspension 200 mg/5
ml
3
MO
acyclovir oral tablet
2
MO
ANTIFUNGAL AGENTS
ABELCET
5
B/D PA; MO
AMBISOME
5
B/D PA; MO
amphotericin b
4
B/D PA; MO
CANCIDAS
5
B/D PA; MO
clotrimazole mucous
membrane
3
MO
CRESEMBA
INTRAVENOUS
5
ERAXIS(WATER
DILUENT)
INTRAVENOUS
RECON SOLN 100
MG
3
fluconazole in
dextrose(iso-o)
intravenous
piggyback 400
mg/200 ml
3
fluconazole oral
suspension for
reconstitution
3
fluconazole oral
tablet
1
MO
voriconazole oral
suspension for
reconstitution
flucytosine
3
MO
voriconazole oral
tablet
griseofulvin
microsize oral
suspension
3
MO
ANTIVIRALS
griseofulvin
microsize oral tablet
4
MO
griseofulvin
ultramicrosize
4
MO
itraconazole
3
MO; QL (124
per 31 days)
ketoconazole oral
2
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
1
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
FUZEON
SUBCUTANEOUS
RECON SOLN
5
MO
ganciclovir sodium
4
MO
HARVONI
5
PA; MO; QL
(28 per 28
days)
INTELENCE ORAL
TABLET 100 MG,
200 MG
5
MO
INTELENCE ORAL
TABLET 25 MG
3
INVIRASE ORAL
CAPSULE
3
MO
INVIRASE ORAL
TABLET
5
MO
ISENTRESS ORAL
POWDER IN
PACKET
3
MO
ISENTRESS ORAL
TABLET
5
MO
acyclovir sodium
intravenous solution
4
B/D PA; MO
adefovir
2
MO
amantadine hcl oral
capsule
3
MO
amantadine hcl oral
solution
2
MO
amantadine hcl oral
tablet
3
MO
APTIVUS ORAL
CAPSULE
5
MO
APTIVUS ORAL
SOLUTION
5
ATRIPLA
5
MO
BARACLUDE
ORAL SOLUTION
3
MO
BARACLUDE
ORAL TABLET
5
MO
cidofovir
4
B/D PA; MO
COMPLERA
5
MO
CRIXIVAN ORAL
CAPSULE 200 MG,
400 MG
3
MO
ISENTRESS ORAL
TABLET,CHEWAB
LE 100 MG
5
MO
didanosine
3
MO
3
MO
EDURANT
4
MO
ISENTRESS ORAL
TABLET,CHEWAB
LE 25 MG
EMTRIVA
3
MO
5
MO
entecavir
3
MO
KALETRA ORAL
SOLUTION
EPIVIR HBV
ORAL SOLUTION
3
MO
3
MO
EPIVIR ORAL
SOLUTION
3
MO
KALETRA ORAL
TABLET 100-25
MG
5
MO
EPZICOM
5
MO
KALETRA ORAL
TABLET 200-50
MG
EVOTAZ
4
MO
3
MO
famciclovir
3
MO
lamivudine oral
solution
lamivudine oral
tablet 100 mg
2
MO
2
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
lamivudine oral
tablet 150 mg, 300
mg
3
MO
REYATAZ ORAL
CAPSULE 150 MG,
200 MG, 300 MG
5
MO
lamivudinezidovudine
3
MO
5
MO
LEXIVA ORAL
SUSPENSION
3
MO
REYATAZ ORAL
POWDER IN
PACKET
3
MO
LEXIVA ORAL
TABLET
5
MO
ribasphere oral
capsule
3
MO
moderiba
2
MO
ribasphere oral
tablet 200 mg
moderiba dose pack
oral tablets,dose
pack 400 mg (7)400 mg (7), 600 mg
(7)- 600 mg (7)
2
MO
ribavirin oral
capsule
3
MO
ribavirin oral tablet
200 mg
3
MO
nevirapine oral
suspension
2
MO
rimantadine
2
MO
SELZENTRY
5
MO
nevirapine oral
tablet
3
MO
SOVALDI
5
PA; MO
stavudine
3
MO
NORVIR
3
MO
STRIBILD
5
MO
OLYSIO
5
PA; MO
SUSTIVA
3
MO
PREZCOBIX
4
MO
5
MO; LA
PREZISTA ORAL
SUSPENSION
5
MO
PREZISTA ORAL
TABLET 150 MG,
75 MG
3
MO
SYNAGIS
INTRAMUSCULA
R SOLUTION 50
MG/0.5 ML
TAMIFLU ORAL
CAPSULE 30 MG
3
MO; QL (84
per 180 days)
PREZISTA ORAL
TABLET 600 MG,
800 MG
5
MO
TAMIFLU ORAL
CAPSULE 45 MG,
75 MG
3
MO; QL (42
per 180 days)
REBETOL ORAL
SOLUTION
3
MO
3
MO; QL (600
per 180 days)
RELENZA
DISKHALER
3
MO; QL (60
per 180 days)
TAMIFLU ORAL
SUSPENSION FOR
RECONSTITUTIO
N
RESCRIPTOR
3
MO
TIVICAY
5
MO
RETROVIR
INTRAVENOUS
3
MO
TRIUMEQ
5
MO
TRUVADA
5
MO
TYZEKA
5
MO
3
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
valacyclovir
3
MO; QL (31
per 31 days)
3
MO
VALCYTE
5
MO
valganciclovir
3
MO
cefadroxil oral
suspension for
reconstitution 250
mg/5 ml, 500 mg/5
ml
VIDEX 2 GRAM
PEDIATRIC
3
MO
cefadroxil oral tablet
3
MO
VIEKIRA PAK
5
PA; MO; QL
(112 per 28
days)
cefazolin in dextrose
(iso-os) intravenous
piggyback 1 gram/50
ml
2
MO
VIRACEPT ORAL
TABLET
5
MO
2
MO
VIRAMUNE XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
100 MG
3
MO
cefazolin injection
recon soln 1 gram,
500 mg
cefazolin injection
recon soln 10 gram
3
cefdinir oral capsule
2
MO
VIRAZOLE
4
MO
3
MO
VIREAD
5
MO
cefdinir oral
suspension for
reconstitution
VITEKTA
4
MO
cefepime
4
MO
ZIAGEN ORAL
SOLUTION
3
MO
cefixime
3
MO
zidovudine oral
capsule
3
MO
cefotaxime injection
recon soln 1 gram, 2
gram, 500 mg
2
zidovudine oral
syrup
3
MO
cefoxitin intravenous
recon soln 1 gram
2
zidovudine oral
tablet
2
MO
recon soln 10 gram
2
recon soln 2 gram
4
cefpodoxime oral
suspension for
reconstitution
4
MO
cefpodoxime oral
tablet
3
MO
ceftazidime injection
recon soln 1 gram
3
MO
recon soln 2 gram
4
MO
CEPHALOSPORINS
cefaclor oral capsule
250 mg
2
MO
cefaclor oral capsule
500 mg
3
MO
cefadroxil oral
capsule
2
MO
Drug
Tier
Requirements
/Limits
MO
4
Drug Name
Drug
Tier
Requirements
/Limits
recon soln 6 gram
3
ceftriaxone injection
recon soln 10 gram
4
ceftriaxone injection
recon soln 250 mg,
500 mg
2
MO
ceftriaxone
intravenous recon
soln 1 gram
3
MO
ceftriaxone
intravenous recon
soln 2 gram
4
MO
cefuroxime axetil
oral tablet
2
MO
cefuroxime sodium
injection recon soln
1.5 gram, 750 mg
2
MO
cefuroxime sodium
intravenous
2
cephalexin oral
capsule 250 mg, 500
mg
1
cephalexin oral
suspension for
reconstitution
2
MO
cephalexin oral
tablet
2
MO
FORTAZ
INJECTION
RECON SOLN 6
GRAM
3
FORTAZ
INTRAVENOUS
3
SUPRAX ORAL
CAPSULE
4
Drug Name
Drug
Tier
Requirements
/Limits
SUPRAX ORAL
SUSPENSION FOR
RECONSTITUTIO
N 100 MG/5 ML,
200 MG/5 ML
4
MO
SUPRAX ORAL
SUSPENSION FOR
RECONSTITUTIO
N 500 MG/5 ML
4
TAZICEF
INJECTION
RECON SOLN 1
GRAM
3
TAZICEF
INJECTION
RECON SOLN 2
GRAM, 6 GRAM
3
MO
TEFLARO
3
MO
ERYTHROMYCINS / OTHER
MACROLIDES
MO
MO
azithromycin
intravenous
3
MO
azithromycin oral
packet
2
MO
azithromycin oral
suspension for
reconstitution
3
MO
azithromycin oral
tablet 250 mg
1
MO
azithromycin oral
tablet 250 mg (6
pack)
1
azithromycin oral
tablet 500 mg, 600
mg
2
MO
clarithromycin oral
suspension for
reconstitution 125
mg/5 ml
2
MO
5
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
atovaquoneproguanil oral tablet
62.5-25 mg
2
AZACTAM IN
DEXTROSE (ISOOSM)
INTRAVENOUS
PIGGYBACK 1
GRAM/50 ML
3
AZACTAM IN
DEXTROSE (ISOOSM)
INTRAVENOUS
PIGGYBACK 2
GRAM/50 ML
5
aztreonam injection
recon soln 1 gram
4
MO
BILTRICIDE
3
MO
CAPASTAT
4
CAYSTON
5
chloramphenicol sod
succinate
2
chloroquine
phosphate oral
tablet 250 mg
2
MO
chloroquine
phosphate oral
tablet 500 mg
3
MO
clindamycin hcl
2
MO
clindamycin in 5 %
dextrose intravenous
piggyback 300
mg/50 ml
4
MO
clindamycin in 5 %
piggyback 600
mg/50 ml
3
MO
clarithromycin oral
suspension for
reconstitution 250
mg/5 ml
4
MO
clarithromycin oral
tablet
3
MO
clarithromycin oral
tablet extended
release 24 hr
3
MO
e.e.s. 400 oral tablet
3
MO
E.E.S. GRANULES
3
MO
ery-tab
3
MO
erythrocin (as
stearate) oral tablet
250 mg
3
MO
ERYTHROCIN
INTRAVENOUS
RECON SOLN 500
MG
3
erythromycin
ethylsuccinate oral
tablet
3
MO
erythromycin oral
tablet 250 mg
4
MO
erythromycin oral
tablet 500 mg
3
MO
ZMAX
3
MO
ALBENZA
3
MO
ALINIA
3
MO
amikacin injection
solution 500 mg/2 ml
3
MO
atovaquone
2
MO
atovaquoneproguanil oral tablet
250-100 mg
3
MO
MISCELLANEOUS
ANTIINFECTIVES
Drug
Tier
Requirements
/Limits
MO
MO; LA; QL
(84 per 28
days)
6
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MO
gentamicin sulfate
(pf) intravenous
solution 80 mg/8 ml
2
hydroxychloroquine
oral
2
MO
imipenem-cilastatin
intravenous recon
soln 250 mg
3
MO
imipenem-cilastatin
intravenous recon
soln 500 mg
4
MO
clindamycin in 5 %
piggyback 900
mg/50 ml
2
clindamycin
pediatric
2
clindamycin
phosphate
600 mg/4 ml
2
COARTEM
3
MO
colistin
(colistimethate na)
4
MO
INVANZ
INJECTION
4
MO
CUBICIN
5
MO
3
MO
DAPSONE
3
MO
isoniazid oral
solution
DARAPRIM
3
MO
1
MO
ethambutol oral
tablet 100 mg
2
MO
isoniazid oral tablet
100 mg
2
MO
ethambutol oral
tablet 400 mg
3
MO
isoniazid oral tablet
300 mg
ivermectin oral
3
MO
gentamicin in nacl
(iso-osm)
intravenous
piggyback 100
mg/100 ml
3
MO
KETEK
3
MO
linezolid intravenous
3
linezolid oral
3
MO
mefloquine
2
MO
gentamicin in nacl
(iso-osm)
intravenous
piggyback 60 mg/50
ml
2
meropenem
intravenous recon
soln 500 mg
4
MO
2
MO
gentamicin in nacl
(iso-osm)
intravenous
piggyback 70 mg/50
ml, 80 mg/100 ml, 80
mg/50 ml, 90 mg/100
ml
2
metronidazole in
nacl (iso-os)
metronidazole oral
2
MO
MYCOBUTIN
3
MO
NEBUPENT
3
B/D PA; MO;
QL (6 per 28
days)
gentamicin injection
solution 40 mg/ml
2
neomycin
2
MO
paromomycin
4
MO
PASER
3
MO
MO
MO
MO
7
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
ZYVOX
INTRAVENOUS
PARENTERAL
SOLUTION 600
MG/300 ML
5
MO
ZYVOX ORAL
5
MO
amoxicillin oral
capsule
1
MO
amoxicillin oral
suspension for
reconstitution 125
mg/5 ml, 250 mg/5
ml
1
MO
amoxicillin oral
suspension for
reconstitution 200
mg/5 ml, 400 mg/5
ml
2
MO
amoxicillin oral
tablet
1
MO
amoxicillin oral
tablet,chewable 125
mg, 250 mg
1
MO
amoxicillin-pot
clavulanate oral
suspension for
reconstitution 20028.5 mg/5 ml, 60042.9 mg/5 ml
2
MO
amoxicillin-pot
clavulanate oral
suspension for
reconstitution 25062.5 mg/5 ml, 40057 mg/5 ml
3
MO
amoxicillin-pot
clavulanate oral
tablet 250-125 mg
3
MO
PENTAM
4
MO
PRIFTIN
3
MO
PRIMAQUINE
3
MO
pyrazinamide
3
MO
quinine sulfate
3
MO
rifabutin
2
MO
rifampin intravenous
2
MO
rifampin oral
3
MO
SIRTURO
5
MO; LA
STREPTOMYCIN
INTRAMUSCULA
R
3
MO
STROMECTOL
3
MO
SYNERCID
5
tinidazole
3
MO
tobramycin in 0.225
% nacl
2
B/D PA; MO;
QL (280 per 28
days)
tobramycin in 0.9 %
nacl intravenous
piggyback 80
mg/100 ml
2
MO
tobramycin sulfate
injection solution 10
mg/ml
2
MO
tobramycin sulfate
mg/ml
3
MO
TRECATOR
3
MO
TYGACIL
3
MO
XIFAXAN ORAL
TABLET 200 MG
3
MO
XIFAXAN ORAL
TABLET 550 MG
5
MO
Drug
Tier
Requirements
/Limits
PENICILLINS
8
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
AUGMENTIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 125-31.25 MG/5
ML
3
MO
BICILLIN C-R
3
MO
BICILLIN L-A
3
MO
dicloxacillin
2
MO
nafcillin in dextrose
iso-osm intravenous
piggyback 1 gram/50
ml
3
nafcillin injection
recon soln 1 gram
3
MO
nafcillin injection
recon soln 10 gram
5
MO
PENICILLIN G
POT IN
DEXTROSE
INTRAVENOUS
PIGGYBACK 2
MILLION UNIT/50
ML, 3 MILLION
UNIT/50 ML
3
penicillin g
potassium injection
recon soln 5 million
unit
3
MO
penicillin g procaine
intramuscular
syringe 1.2 million
unit/2 ml
2
MO
penicillin g sodium
4
MO
penicillin v
potassium
1
MO
pfizerpen-g injection
recon soln 5 million
unit
3
amoxicillin-pot
clavulanate oral
tablet 500-125 mg,
875-125 mg
2
MO
amoxicillin-pot
clavulanate oral
tablet extended
release 12 hr
3
MO
amoxicillin-pot
clavulanate oral
tablet,chewable
2
ampicillin oral
capsule
1
MO
ampicillin oral
suspension for
reconstitution 125
mg/5 ml
1
MO
ampicillin oral
suspension for
reconstitution 250
mg/5 ml
2
MO
ampicillin sodium
1 gram, 10 gram
3
MO
ampicillin sodium
125 mg
2
MO
ampicillin-sulbactam
15 gram
2
3 gram
4
intravenous recon
soln 1.5 gram
4
MO
MO
Drug
Tier
Requirements
/Limits
9
Drug Name
Drug
Tier
piperacillintazobactam
intravenous recon
soln 3.375 gram, 4.5
gram
3
ZOSYN IN
DEXTROSE (ISOOSM)
INTRAVENOUS
PIGGYBACK 2.25
GRAM/50 ML
3
ZOSYN IN
DEXTROSE (ISOOSM)
INTRAVENOUS
PIGGYBACK 3.375
GRAM/50 ML
3
Requirements
/Limits
Drug Name
MO
ofloxacin oral tablet
400 mg
Drug
Tier
Requirements
/Limits
3
SULFA'S / RELATED AGENTS
MO
sulfadiazine oral
3
MO
sulfamethoxazoletrimethoprim
intravenous
4
MO
sulfamethoxazoletrimethoprim oral
suspension
2
MO
sulfamethoxazoletrimethoprim oral
tablet
1
MO
demeclocycline oral
3
MO
doxy-100
3
MO
1
TETRACYCLINES
QUINOLONES
ciprofloxacin
2
ciprofloxacin hcl
oral
1
MO
doxycycline hyclate
intravenous
ciprofloxacin in 5 %
piggyback 200
mg/100 ml
3
MO
doxycycline hyclate
oral capsule
2
MO
2
MO
ciprofloxacin lactate
400 mg/40 ml
2
doxycycline hyclate
oral tablet 100 mg,
20 mg
doxycycline hyclate
oral tablet 50 mg
3
levofloxacin in d5w
intravenous
piggyback 500
mg/100 ml
3
MO
doxycycline hyclate
oral tablet,delayed
release (dr/ec)
4
MO
4
MO
levofloxacin
intravenous
3
MO
levofloxacin oral
solution
4
MO
doxycycline
monohydrate oral
capsule 100 mg, 50
mg, 75 mg
3
MO
levofloxacin oral
tablet
1
MO
doxycycline
monohydrate oral
suspension for
reconstitution
moxifloxacin
2
MO
doxycycline
monohydrate oral
tablet
3
MO
10
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
ANTINEOPLASTIC /
IMMUNOSUPPRESSANT
DRUGS
minocycline oral
capsule
2
MO
minocycline oral
tablet
3
MO
minocycline oral
tablet extended
release 24 hr
4
MO
VIBRAMYCIN
ORAL SYRUP
3
MO
Drug
Tier
Requirements
/Limits
ADJUNCTIVE AGENTS
amifostine
crystalline
5
MO
FUSILEV
4
MO
KEPIVANCE
5
leucovorin calcium
100 mg, 350 mg
2
MO
2
MO
MO
leucovorin calcium
oral
4
MO
LEVOLEUCOVORI
N CALCIUM
mesna
3
MO
MESNEX ORAL
5
MO
XGEVA
5
MO
URINARY TRACT AGENTS
MACRODANTIN
ORAL CAPSULE
25 MG
3
MO
methenamine
hippurate
3
nitrofurantoin
macrocrystal oral
capsule 100 mg
3
nitrofurantoin
macrocrystal oral
capsule 50 mg
2
nitrofurantoin
monohyd/m-cryst
2
nitrofurantoin oral
3
MO
PRIMSOL
4
MO
trimethoprim
2
MO
vancomycin
intravenous recon
soln 1,000 mg
2
vancomycin
intravenous recon
soln 10 gram
MO
MO
ANTINEOPLASTIC /
IMMUNOSUPPRESSANT DRUGS
ABRAXANE
5
MO
adrucil intravenous
solution 500 mg/10
ml
3
MO
AFINITOR
DISPERZ
5
PA; MO
MO
AFINITOR ORAL
TABLET 10 MG
5
PA; MO; QL
(62 per 31
days)
3
MO
AFINITOR ORAL
TABLET 2.5 MG, 5
MG, 7.5 MG
5
PA; MO
vancomycin
intravenous recon
soln 500 mg
4
MO
5
MO
vancomycin oral
capsule
3
MO
ALIMTA
INTRAVENOUS
RECON SOLN 500
MG
anastrozole
2
MO
VANCOMYCIN
11
Drug Name
Drug
Tier
Requirements
/Limits
ARRANON
3
ARZERRA
INTRAVENOUS
SOLUTION 100
MG/5 ML
5
AVASTIN
INTRAVENOUS
SOLUTION 25
MG/ML
3
AVASTIN
INTRAVENOUS
SOLUTION 25
MG/ML (16 ML)
3
azacitidine
2
MO
azathioprine
2
B/D PA; MO
BELEODAQ
5
MO
bexarotene
3
MO
bicalutamide
2
MO
BICNU
4
MO
bleomycin injection
recon soln 30 unit
3
BOSULIF ORAL
TABLET 100 MG
Drug Name
Drug
Tier
Requirements
/Limits
CELLCEPT ORAL
SUSPENSION FOR
RECONSTITUTIO
N
5
B/D PA; MO
cisplatin
2
MO
cladribine
4
MO
CLOLAR
4
MO
COMETRIQ
5
PA; MO
COSMEGEN
4
MO
cyclophosphamide
oral capsule
2
B/D PA; MO
cyclosporine
intravenous
4
B/D PA
cyclosporine
modified oral
capsule
3
B/D PA; MO
cyclosporine
modified oral
solution
4
B/D PA; MO
MO
cyclosporine oral
capsule
4
B/D PA; MO
3
PA; MO
5
B/D PA; MO
BOSULIF ORAL
TABLET 500 MG
3
PA; MO; QL
(31 per 31
days)
CYRAMZA
INTRAVENOUS
SOLUTION 10
MG/ML
5
B/D PA
BUSULFEX
4
CAPRELSA ORAL
TABLET 100 MG
5
MO; LA
CYRAMZA
INTRAVENOUS
SOLUTION 10
MG/ML (50 ML)
CAPRELSA ORAL
TABLET 300 MG
5
MO; LA; QL
(31 per 31
days)
cytarabine
2
MO
2
MO
carboplatin
3
MO
cytarabine (pf)
gram/20 ml (100
mg/ml)
CELLCEPT
INTRAVENOUS
3
B/D PA; MO
dacarbazine
intravenous recon
soln 200 mg
2
MO
daunorubicin
2
B/D PA; MO
MO
12
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
DAUNOXOME
4
MO
decitabine
5
MO
DOCEFREZ
INTRAVENOUS
RECON SOLN 20
MG
4
docetaxel
80 mg/4 ml (20
mg/ml), 80 mg/8 ml
(10 mg/ml)
3
MO
doxorubicin
50 mg/25 ml
2
MO
DROXIA
3
MO
ELLENCE
INTRAVENOUS
SOLUTION 200
MG/100 ML
4
MO
ELOXATIN
INTRAVENOUS
SOLUTION 100
MG/20 ML
4
MO
EMCYT
3
MO
epirubicin
50 mg/25 ml
4
MO
ERIVEDGE
5
PA; MO; QL
(31 per 31
days)
ERWINAZE
5
MO
ETOPOPHOS
4
MO
etoposide
intravenous
2
MO
exemestane
3
MO
FARESTON
3
MO
FARYDAK ORAL
CAPSULE 10 MG
5
PA; MO; QL
(12 per 21
days)
Drug
Tier
Requirements
/Limits
FARYDAK ORAL
CAPSULE 15 MG,
20 MG
5
PA; MO; QL
(6 per 21 days)
FASLODEX
5
MO
FIRMAGON KIT W
DILUENT
SYRINGE
3
MO
fludarabine
intravenous recon
soln
3
MO
fluorouracil
2.5 gram/50 ml
2
MO
flutamide
4
MO
FOLOTYN
INTRAVENOUS
SOLUTION 40
MG/2 ML (20
MG/ML)
5
MO
gemcitabine
intravenous recon
soln 1 gram
3
MO
gengraf oral capsule
3
B/D PA; MO
gengraf oral
solution
4
B/D PA; MO
GILOTRIF ORAL
TABLET 20 MG
5
PA; MO; QL
(62 per 31
days)
GILOTRIF ORAL
TABLET 30 MG
5
PA; MO; QL
(42 per 31
days)
GILOTRIF ORAL
TABLET 40 MG
5
PA; MO; QL
(31 per 31
days)
GLEEVEC ORAL
TABLET 100 MG
5
PA; MO
GLEEVEC ORAL
TABLET 400 MG
5
PA; MO; QL
(62 per 31
days)
13
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
HALAVEN
4
MO
5
PA; MO
HERCEPTIN
5
MO
HEXALEN
5
MO
JAKAFI ORAL
TABLET 10 MG, 15
MG, 20 MG, 5 MG
hydroxyurea
2
MO
JAKAFI ORAL
TABLET 25 MG
5
IBRANCE
5
PA; MO; QL
(21 per 28
days)
PA; MO; QL
(62 per 31
days)
JEVTANA
4
MO
ICLUSIG ORAL
TABLET 15 MG
5
PA; MO; QL
(93 per 31
days)
KEYTRUDA
5
MO
5
ICLUSIG ORAL
TABLET 45 MG
5
PA; MO; QL
(31 per 31
days)
PA; MO; QL
(62 per 31
days)
idarubicin
4
IFEX
INTRAVENOUS
RECON SOLN 1
GRAM
4
MO
LENVIMA ORAL
CAPSULE 10
MG/DAY (10 MG
[1]/DAY), 14 MG
(10 MG[1] -4
MG[1])/DAY, 20
MG/DAY (10 MG
[2]/DAY)
5
PA; MO; QL
(93 per 31
days)
ifosfamide
intravenous recon
soln 1 gram
3
MO
LENVIMA ORAL
CAPSULE 24 MG
(10 MG[2] -4
MG[1])/DAY
letrozole
2
MO
LEUKERAN
3
MO
IMBRUVICA
5
leuprolide
4
MO
LOMUSTINE
3
MO
LUPRON DEPOT
5
PA; MO
LUPRON DEPOT
(3 MONTH)
5
PA; MO
LUPRON DEPOT
(4 MONTH)
5
PA; MO
LUPRON DEPOT
(6 MONTH)
5
PA; MO
LUPRON DEPOTPED
INTRAMUSCULA
R KIT 11.25 MG, 15
MG
5
PA; MO
LYNPARZA
5
PA; MO
LYSODREN
3
MO
PA; MO; QL
(124 per 31
days)
INLYTA ORAL
TABLET 1 MG
5
PA; MO
INLYTA ORAL
TABLET 5 MG
5
PA; MO; QL
(124 per 31
days)
irinotecan
100 mg/5 ml
4
MO
ISTODAX
5
MO
IXEMPRA
INTRAVENOUS
RECON SOLN 45
MG
5
MO
Drug
Tier
Requirements
/Limits
14
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MATULANE
5
MO
NEORAL
3
B/D PA; MO
MEGACE ES
3
MO
NEXAVAR
5
PA; MO; LA
megestrol oral
suspension 400
mg/10 ml (40
mg/ml), 625 mg/5 ml
2
MO
NILANDRON
3
MO
NIPENT
4
MO
NULOJIX
5
B/D PA; MO
megestrol oral tablet
2
MO
5
MO
MEKINIST ORAL
TABLET 0.5 MG
5
PA; MO; QL
(124 per 31
days)
octreotide acetate
injection solution
1,000 mcg/ml, 500
mcg/ml
MEKINIST ORAL
TABLET 2 MG
5
PA; MO; QL
(31 per 31
days)
3
MO
melphalan hcl
4
octreotide acetate
injection solution
100 mcg/ml, 200
mcg/ml, 50 mcg/ml
mercaptopurine
2
MO
ONCASPAR
3
MO
methotrexate sodium
(pf) injection recon
soln
3
B/D PA
OPDIVO
INTRAVENOUS
SOLUTION 40
MG/4 ML
5
MO
methotrexate sodium
(pf) injection
solution
1
B/D PA; MO
oxaliplatin
100 mg/20 ml
4
MO
methotrexate sodium
oral
2
B/D PA; MO
paclitaxel
4
MO
mitomycin
intravenous recon
soln 20 mg
4
MO
PERJETA
5
MO
POMALYST
5
MO
3
B/D PA; MO
mitoxantrone
3
MO
PROGRAF
INTRAVENOUS
MUSTARGEN
4
MO
PURIXAN
5
MO
mycophenolate
mofetil oral capsule
2
B/D PA; MO
RAPAMUNE
ORAL SOLUTION
3
B/D PA; MO
mycophenolate
mofetil oral
suspension for
reconstitution
3
B/D PA; MO
RAPAMUNE
ORAL TABLET 1
MG
3
B/D PA; MO
5
B/D PA; MO
mycophenolate
mofetil oral tablet
2
B/D PA; MO
RAPAMUNE
ORAL TABLET 2
MG
mycophenolate
sodium
2
B/D PA; MO
REVLIMID
5
PA; MO; LA
15
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
SPRYCEL ORAL
TABLET 70 MG
5
PA; MO; QL
(62 per 31
days)
STIVARGA
5
PA; MO; QL
(84 per 28
days)
SUTENT ORAL
CAPSULE 12.5 MG
5
PA; MO
SUTENT ORAL
CAPSULE 25 MG,
37.5 MG
5
PA; MO; QL
(62 per 31
days)
SUTENT ORAL
CAPSULE 50 MG
5
PA; MO; QL
(31 per 31
days)
SYLVANT
INTRAVENOUS
RECON SOLN 100
MG
5
MO
SYNRIBO
4
MO
RHEUMATREX
ORAL
TABLETS,DOSE
PACK 2.5 MG
4
B/D PA; MO
RHEUMATREX
ORAL
TABLETS,DOSE
PACK 2.5 MG
(DOSE PACK 12),
2.5 MG (DOSE
PACK 16), 2.5 MG
(DOSE PACK 20),
2.5 MG (DOSE
PACK 8)
4
B/D PA
RITUXAN
5
PA; MO
SANDIMMUNE
3
B/D PA; MO
SANDOSTATIN
LAR DEPOT
INTRAMUSCULA
R KIT
4
MO
SIGNIFOR
5
PA; MO
TABLOID
3
MO
SIMULECT
INTRAVENOUS
RECON SOLN 20
MG
3
B/D PA; MO
tacrolimus oral
3
B/D PA; MO
TAFINLAR ORAL
CAPSULE 50 MG
5
sirolimus oral tablet
0.5 mg
2
B/D PA; MO
PA; MO; QL
(186 per 31
days)
5
sirolimus oral tablet
1 mg, 2 mg
3
B/D PA; MO
TAFINLAR ORAL
CAPSULE 75 MG
PA; MO; QL
(124 per 31
days)
SOLTAMOX
3
MO
tamoxifen
1
MO
SOMATULINE
DEPOT
3
MO
TARCEVA ORAL
TABLET 100 MG,
25 MG
5
PA; MO
SPRYCEL ORAL
TABLET 100 MG,
20 MG, 50 MG, 80
MG
5
PA; MO
TARCEVA ORAL
TABLET 150 MG
5
PA; MO; QL
(31 per 31
days)
SPRYCEL ORAL
TABLET 140 MG
5
TARGRETIN
ORAL
5
MO
TASIGNA ORAL
CAPSULE 150 MG
5
PA; MO
PA; MO; QL
(31 per 31
days)
16
Drug Name
TASIGNA ORAL
CAPSULE 200 MG
Drug
Tier
5
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
PA; MO; QL
(112 per 28
days)
vinblastine
2
vincasar pfs
1 mg/ml
1
1
MO
MO
THALOMID
5
PA; MO
thiotepa
5
MO
toposar
4
MO
topotecan
intravenous recon
soln
4
MO
vincristine
1 mg/ml
3
MO
TORISEL
5
MO
vinorelbine
50 mg/5 ml
TREANDA
INTRAVENOUS
RECON SOLN 100
MG
4
MO
VOTRIENT
5
PA; MO; QL
(124 per 31
days)
TREANDA
INTRAVENOUS
SOLUTION 45
MG/0.5 ML
4
MO
XALKORI ORAL
CAPSULE 200 MG
5
PA; MO
XALKORI ORAL
CAPSULE 250 MG
5
TRELSTAR
DEPOT
4
PA; MO; QL
(62 per 31
days)
XTANDI
5
TRELSTAR
INTRAMUSCULA
R SUSPENSION
FOR
RECONSTITUTIO
N
5
PA; MO; QL
(124 per 31
days)
4
MO
TRELSTAR
INTRAMUSCULA
R SYRINGE 11.25
MG/2 ML, 3.75
MG/2 ML
5
ZALTRAP
INTRAVENOUS
SOLUTION 100
MG/4 ML (25
MG/ML)
ZANOSAR
4
MO
ZELBORAF
5
PA; MO; QL
(248 per 31
days)
TRELSTAR LA
5
ZOLINZA
5
MO
tretinoin
(chemotherapy)
2
MO
ZORTRESS ORAL
TABLET 0.25 MG
3
B/D PA; MO
TRISENOX
4
MO
5
B/D PA; MO
TYKERB
5
PA; MO; LA;
QL (186 per 31
days)
ZORTRESS ORAL
TABLET 0.5 MG,
0.75 MG
ZYDELIG
5
PA; MO
VELCADE
5
MO
MO
MO
17
Drug Name
Drug
Tier
ZYKADIA
5
ZYTIGA
5
Requirements
/Limits
Drug Name
PA; MO; QL
(155 per 31
days)
clonazepam oral
tablet,disintegrating
3
PA; MO
diazepam rectal
2
PA; MO
DILANTIN 30 MG
3
MO
divalproex oral
capsule, sprinkle
3
MO
divalproex oral
tablet extended
release 24 hr
3
MO
PA; MO; QL
(124 per 31
days)
AUTONOMIC / CNS DRUGS,
NEUROLOGY / PSYCH
ANTICONVULSANTS
Drug
Tier
Requirements
/Limits
APTIOM ORAL
TABLET 200 MG,
400 MG, 800 MG
4
MO
divalproex oral
tablet,delayed
release (dr/ec)
2
MO
APTIOM ORAL
TABLET 600 MG
5
MO
epitol
1
MO
BANZEL ORAL
SUSPENSION
3
MO
ethosuximide
3
MO
felbamate
4
MO
BANZEL ORAL
TABLET 200 MG
3
MO
1
MO
BANZEL ORAL
TABLET 400 MG
5
MO
fosphenytoin
injection solution
100 mg pe/2 ml
4
MO
carbamazepine oral
capsule, er
multiphase 12 hr
3
MO
FYCOMPA ORAL
TABLET
gabapentin oral
capsule
2
MO
carbamazepine oral
suspension 100 mg/5
ml
3
MO
gabapentin oral
3
MO
2
MO
carbamazepine oral
tablet
2
MO
gabapentin oral
tablet 600 mg, 800
mg
carbamazepine oral
tablet extended
release 12 hr
3
MO
GABITRIL ORAL
TABLET 12 MG, 16
MG
3
MO
carbamazepine oral
tablet,chewable
2
MO
LAMICTAL ODT
3
MO
3
MO
CELONTIN ORAL
CAPSULE 300 MG
3
MO
LAMICTAL
STARTER (BLUE)
KIT
clonazepam oral
tablet
1
PA; MO
LAMICTAL
STARTER
(GREEN) KIT
3
MO
18
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MO
phenobarbital oral
elixir
3
phenobarbital oral
tablet 100 mg
2
phenobarbital oral
tablet 15 mg, 16.2
mg, 30 mg, 32.4 mg,
60 mg, 64.8 mg, 97.2
mg
2
MO
phenytoin oral
suspension 125 mg/5
ml
2
MO
phenytoin oral
tablet,chewable
2
MO
phenytoin sodium
extended
2
MO
phenytoin sodium
2
MO
POTIGA
3
MO
primidone
2
MO
SABRIL
5
MO; LA
TEGRETOL XR
ORAL TABLET
EXTENDED
RELEASE 12 HR
100 MG
3
MO
LAMICTAL
STARTER
(ORANGE) KIT
3
lamotrigine oral
tablet
2
MO
lamotrigine oral
tablet, chewable
dispersible
2
MO
lamotrigine oral
3
MO
LEVETIRACETAM
IN NACL (ISO-OS)
INTRAVENOUS
PIGGYBACK 1,000
MG/100 ML, 1,500
MG/100 ML
4
LEVETIRACETAM
IN NACL (ISO-OS)
INTRAVENOUS
PIGGYBACK 500
MG/100 ML
4
levetiracetam
intravenous
3
MO
levetiracetam oral
solution 100 mg/ml
3
MO
levetiracetam oral
tablet
2
MO
LYRICA
3
MO
tiagabine
4
MO
ONFI ORAL
SUSPENSION
3
PA; MO
topiramate oral
capsule, sprinkle
3
PA; MO
ONFI ORAL
TABLET 10 MG, 20
MG
3
PA; MO
topiramate oral
tablet
2
PA; MO
oxcarbazepine oral
suspension
3
MO
valproate sodium
1
MO
valproic acid
2
MO
oxcarbazepine oral
tablet
2
MO
2
MO
PEGANONE
4
MO
valproic acid (as
sodium salt) oral
VIMPAT
INTRAVENOUS
3
MO
MO
19
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
ropinirole oral tablet
extended release 24
hr 2 mg
3
MO
selegiline hcl
3
MO
tolcapone
3
MO
ANTIPARKINSONISM AGENTS
trihexyphenidyl
2
MO
APOKYN
5
MO; LA
ZELAPAR
3
MO
AZILECT
3
MO
benztropine injection
4
MO
MIGRAINE / CLUSTER HEADACHE
THERAPY
benztropine oral
1
MO
bromocriptine
4
MO
carbidopa
2
MO
carbidopa-levodopa
oral tablet
2
MO
carbidopa-levodopa
oral tablet extended
release
2
MO
carbidopa-levodopa
oral
3
carbidopa-levodopaentacapone
VIMPAT ORAL
SOLUTION
3
MO
VIMPAT ORAL
TABLET
3
MO
zonisamide
3
PA; MO
Drug
Tier
Requirements
/Limits
dihydroergotamine
2
MO
migergot
4
MO
naratriptan
3
MO; QL (18
per 28 days)
RELPAX
3
MO; QL (18
per 28 days)
rizatriptan
4
MO; QL (36
per 28 days)
MO
sumatriptan nasal
spray,non-aerosol
20 mg/actuation
2
MO; QL (18
per 28 days)
2
MO
2
MO; QL (36
per 28 days)
entacapone
2
MO
sumatriptan nasal
spray,non-aerosol 5
mg/actuation
MIRAPEX ER
4
MO
sumatriptan
succinate oral
2
MO; QL (18
per 28 days)
NEUPRO
4
MO
3
pramipexole oral
tablet
2
MO
MO; QL (16
per 28 days)
pramipexole oral
tablet extended
release 24 hr
3
MO
sumatriptan
succinate
subcutaneous
cartridge
3
MO; QL (16
per 28 days)
2
MO
sumatriptan
succinate
subcutaneous pen
injector 6 mg/0.5 ml
extended release 24
hr 12 mg, 4 mg, 6
mg, 8 mg
4
MO
sumatriptan
succinate
subcutaneous pen
injector 6 mg/0.5 ml
(auto-injector)
3
QL (16 per 28
days)
20
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
sumatriptan
succinate
subcutaneous
solution
3
zolmitriptan
2
MO; QL (16
per 28 days)
NAMENDA
TITRATION PAK
3
PA; MO
NAMENDA XR
3
PA; MO
NUEDEXTA
3
MO
rivastigmine tartrate
3
MO
MISCELLANEOUS
NEUROLOGICAL THERAPY
TECFIDERA
5
PA; MO
tetrabenazine
3
PA; MO
AMPYRA
5
PA; MO; LA
TYSABRI
5
PA; MO; LA
COPAXONE
SUBCUTANEOUS
SYRINGE 20
MG/ML
5
PA; MO; QL
(30 per 30
days)
XENAZINE
5
PA; MO; LA
COPAXONE
SUBCUTANEOUS
SYRINGE 40
MG/ML
5
PA; MO; QL
(12 per 28
days)
baclofen
2
MO
cyclobenzaprine oral
tablet
2
MO
donepezil oral tablet
10 mg, 5 mg
1
MO
dantrolene oral
capsule 100 mg
4
MO
donepezil oral tablet
23 mg
2
MO
3
MO
donepezil oral
2
MO
dantrolene oral
capsule 25 mg, 50
mg
3
B/D PA; MO
EXELON
TRANSDERMAL
4
MO
galantamine oral
capsule,ext rel.
pellets 24 hr
3
MO
LIORESAL
INTRATHECAL
SOLUTION 2,000
MCG/ML, 500
MCG/ML
3
B/D PA
galantamine oral
solution
4
MO
LIORESAL
INTRATHECAL
SOLUTION 50
MCG/ML
galantamine oral
tablet
3
MO
MESTINON ORAL
SYRUP
3
MO
GLATOPA
5
PA; MO; QL
(30 per 30
days)
MESTINON
TIMESPAN
3
MO
pyridostigmine
bromide
3
MO
tizanidine oral
capsule
4
MO
tizanidine oral tablet
2
MO
MO; QL (18
per 28 days)
memantine oral
tablet
3
PA; MO
NAMENDA
3
PA; MO
Drug
Tier
Requirements
/Limits
MUSCLE RELAXANTS /
ANTISPASMODIC THERAPY
21
Drug Name
Drug
Tier
Requirements
/Limits
NARCOTIC ANALGESICS
Drug Name
Drug
Tier
Requirements
/Limits
fentanyl citrate
buccal lozenge on a
handle 200 mcg
3
PA; MO; QL
(124 per 31
days)
fentanyl citrate
buccal lozenge on a
handle 400 mcg
3
PA; MO; QL
(120 per 31
days)
fentanyl citrate
buccal lozenge on a
handle 600 mcg
3
PA; MO; QL
(80 per 31
days)
acetaminophencodeine oral solution
300 mg-30 mg /12.5
ml
2
acetaminophencodeine oral tablet
300-15 mg, 300-30
mg
2
MO; QL (372
per 31 days)
acetaminophencodeine oral tablet
300-60 mg
2
MO; QL (186
per 31 days)
fentanyl citrate
buccal lozenge on a
handle 800 mcg
3
PA; MO; QL
(60 per 31
days)
buprenorphine hcl
injection syringe
4
QL (276 per 31
days)
3
MO; QL (10
per 31 days)
buprenorphine hcl
sublingual tablet 2
mg
3
MO; QL (310
per 31 days)
fentanyl transdermal
patch 72 hour 100
mcg/hr
3
MO; QL (10
per 30 days)
buprenorphine hcl
sublingual tablet 8
mg
3
MO; QL (78
per 31 days)
fentanyl transdermal
patch 72 hour 12
mcg/hr, 25 mcg/hr,
50 mcg/hr, 75
mcg/hr
BUTRANS
4
MO; QL (5 per
31 days)
3
MO; QL (5735
per 31 days)
codeine sulfate oral
tablet
3
MO; QL (186
per 31 days)
hydrocodoneacetaminophen oral
solution 7.5-325
mg/15 ml
duramorph (pf)
injection solution 0.5
mg/ml
3
MO; QL (4134
per 31 days)
3
MO; QL (372
per 31 days)
duramorph (pf)
mg/ml
3
QL (2067 per
31 days)
hydrocodoneacetaminophen oral
tablet 10-300 mg,
10-325 mg, 2.5-325
mg, 5-300 mg, 5-325
mg, 7.5-300 mg, 7.5325 mg
endocet oral tablet
10-325 mg, 5-325
mg, 7.5-325 mg
3
MO; QL (372
per 31 days)
hydrocodoneibuprofen oral tablet
7.5-200 mg
3
MO; QL (52
per 31 days)
fentanyl citrate
buccal lozenge on a
handle 1,200 mcg
3
PA; MO; QL
(40 per 31
days)
hydromorphone (pf)
mg/ml
3
MO; QL (124
per 31 days)
fentanyl citrate
buccal lozenge on a
handle 1,600 mcg
3
PA; MO; QL
(30 per 31
days)
hydromorphone oral
liquid
2
MO; QL (1550
per 31 days)
hydromorphone oral
tablet
3
MO; QL (186
per 31 days)
QL (4650 per
31 days)
22
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
methadone injection
3
QL (160 per 31
days)
morphine oral
solution
3
MO; QL (930
per 31 days)
methadone oral
solution 10 mg/5 ml
3
MO; QL (620
per 31 days)
morphine oral tablet
2
MO; QL (186
per 31 days)
methadone oral
solution 5 mg/5 ml
3
MO; QL (1240
per 31 days)
3
MO; QL (62
per 31 days)
methadone oral
tablet 10 mg
2
MO; QL (124
per 31 days)
extended release 100
mg
3
methadone oral
tablet 5 mg
2
MO; QL (248
per 31 days)
extended release 15
mg, 30 mg
MO; QL (124
per 31 days)
morphine
concentrate oral
solution
3
MO; QL (310
per 31 days)
extended release 200
mg
3
MO; QL (31
per 31 days)
morphine
intravenous syringe
2 mg/ml
3
QL (1034 per
31 days)
extended release 60
mg
3
MO; QL (103
per 31 days)
morphine
intravenous syringe
4 mg/ml
3
QL (517 per 31
days)
oxycodone oral
capsule
3
MO; QL (372
per 31 days)
4
morphine oral
capsule, er
multiphase 24 hr
120 mg
2
oxycodone oral
concentrate
MO; QL (186
per 31 days)
oxycodone oral
solution
2
MO; QL (1240
per 31 days)
morphine oral
capsule, er
multiphase 24 hr 30
mg, 45 mg, 60 mg,
75 mg, 90 mg
2
oxycodone oral
tablet 10 mg, 15 mg,
20 mg
3
MO; QL (186
per 31 days)
oxycodone oral
tablet 30 mg
3
MO; QL (139
per 31 days)
morphine oral
capsule,extend.relea
se pellets 10 mg, 20
mg, 30 mg, 50 mg,
60 mg
2
oxycodone oral
tablet 5 mg
3
MO; QL (372
per 31 days)
2
MO; QL (372
per 31 days)
morphine oral
se pellets 100 mg
2
oxycodoneacetaminophen oral
tablet 10-325 mg,
2.5-325 mg, 5-325
mg, 7.5-325 mg
oxycodone-aspirin
3
morphine oral
se pellets 80 mg
2
MO; QL (372
per 31 days)
MO; QL (52
per 31 days)
MO; QL (62
per 31 days)
MO; QL (93
per 31 days)
MO; QL (62
per 31 days)
MO; QL (78
per 31 days)
23
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
MO; QL (93
per 31 days)
ibuprofen oral
suspension
2
MO
ibuprofen oral tablet
400 mg, 600 mg, 800
mg
1
MO
ketoprofen oral
capsule
1
MO
ketoprofen oral
capsule,ext rel.
pellets 24 hr 200 mg
4
MO
meclofenamate oral
4
MO
mefenamic acid
4
MO
meloxicam oral
tablet 15 mg
1
MO
meloxicam oral
tablet 7.5 mg
1
MO; QL (31
per 31 days)
nabumetone
2
MO
naloxone injection
syringe 1 mg/ml
2
MO
naltrexone oral
3
MO
naproxen oral
suspension
2
MO
naproxen oral tablet
1
MO
naproxen oral
tablet,delayed
release (dr/ec)
2
MO
naproxen sodium
oral tablet 275 mg,
550 mg
2
MO
naproxen sodium
oral tablet, er
multiphase 24 hr
500 mg
2
MO
oxaprozin
3
MO
piroxicam
3
MO
SUBOXONE
SUBLINGUAL
FILM 12-3 MG
3
MO; QL (62
per 31 days)
oxymorphone oral
tablet extended
release 12 hr 10 mg,
15 mg, 20 mg, 5 mg,
7.5 mg
3
oxymorphone oral
tablet extended
release 12 hr 30 mg
3
MO; QL (70
per 31 days)
oxymorphone oral
tablet extended
release 12 hr 40 mg
3
MO; QL (52
per 31 days)
reprexain
3
MO; QL (52
per 31 days)
zamicet
3
QL (5735 per
31 days)
NON-NARCOTIC ANALGESICS
butorphanol tartrate
nasal
2
MO; QL (42.5
per 31 days)
celecoxib
3
MO
diclofenac potassium
2
MO
diclofenac sodium
oral
2
MO
diclofenac sodium
topical drops
1
MO
diflunisal
3
MO
etodolac oral
capsule
2
MO
etodolac oral tablet
2
MO
etodolac oral tablet
extended release 24
hr
3
MO
fenoprofen oral
tablet
3
MO
FLECTOR
4
PA; MO; QL
(60 per 30
days)
flurbiprofen
2
MO
Drug
Tier
Requirements
/Limits
24
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
SUBOXONE
SUBLINGUAL
FILM 2-0.5 MG
3
MO; QL (372
per 31 days)
ABILIFY ORAL
TABLET 5 MG
3
MO; QL (186
per 31 days)
alprazolam intensol
2
MO
SUBOXONE
SUBLINGUAL
FILM 4-1 MG, 8-2
MG
3
alprazolam oral
tablet
2
MO
amitriptyline
1
PA; MO
sulindac oral
2
MO
amoxapine
2
MO
tolmetin
3
MO
3
tramadol oral tablet
1
MO; QL (248
per 31 days)
aripiprazole oral
tablet 10 mg
MO; QL (93
per 31 days)
3
VIMOVO
3
MO
aripiprazole oral
tablet 15 mg, 2 mg
MO; QL (465
per 31 days)
VOLTAREN GEL
TOPICAL GEL 1 %
3
MO
aripiprazole oral
tablet 20 mg
3
MO; QL (62
per 31 days)
aripiprazole oral
tablet 30 mg
3
MO; QL (31
per 31 days)
aripiprazole oral
tablet 5 mg
3
MO; QL (186
per 31 days)
BRINTELLIX
ORAL TABLET 10
MG
4
MO; QL (62
per 31 days)
BRINTELLIX
ORAL TABLET 20
MG
4
MO; QL (31
per 31 days)
BRINTELLIX
ORAL TABLET 5
MG
4
MO; QL (124
per 31 days)
bupropion hcl oral
tablet
2
MO
bupropion hcl oral
tablet extended
release 100 mg
2
MO; QL (124
per 31 days)
bupropion hcl oral
tablet extended
release 150 mg
2
MO; QL (93
per 31 days)
bupropion hcl oral
tablet extended
release 200 mg
2
MO; QL (62
per 31 days)
MO; QL (93
per 31 days)
PSYCHOTHERAPEUTIC DRUGS
ABILIFY
MAINTENA
INTRAMUSCULA
R
SUSPENSION,EXT
ENDED REL
RECON
5
MO
ABILIFY
MAINTENA
INTRAMUSCULA
R
SUSPENSION,EXT
ENDED REL
SYRING
5
ABILIFY ORAL
TABLET 10 MG
3
MO; QL (93
per 31 days)
ABILIFY ORAL
TABLET 15 MG
3
MO; QL (62
per 31 days)
ABILIFY ORAL
TABLET 2 MG
3
MO; QL (465
per 31 days)
ABILIFY ORAL
TABLET 20 MG
5
MO; QL (62
per 31 days)
ABILIFY ORAL
TABLET 30 MG
5
MO; QL (31
per 31 days)
25
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
CYMBALTA
ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
60 MG
4
MO; QL (62
per 31 days)
desipramine oral
4
MO
dexedrine
3
MO
dextroamphetamine
oral capsule,
extended release
4
MO
dextroamphetamine
oral tablet
2
MO
2
MO
bupropion hcl oral
tablet extended
release 24 hr 150 mg
2
MO; QL (93
per 31 days)
bupropion hcl oral
tablet extended
2
MO; QL (62
per 31 days)
buspirone
2
MO
chlorpromazine
3
MO
citalopram oral
solution
2
MO
citalopram oral
tablet 10 mg
1
MO; QL (124
per 31 days)
citalopram oral
tablet 20 mg
1
MO; QL (62
per 31 days)
citalopram oral
tablet 40 mg
1
MO; QL (31
per 31 days)
dextroamphetamineamphetamine oral
capsule,extended
release 24hr
clomipramine
4
PA; MO
diazepam intensol
2
PA; MO
clorazepate
dipotassium
3
PA; MO
diazepam oral
solution 5 mg/5 ml
2
PA; MO
clozapine oral tablet
3
MO
diazepam oral tablet
2
PA; MO
clozapine oral
100 mg, 12.5 mg, 25
mg
3
doxepin oral
2
PA; MO
2
MO; QL (186
per 31 days)
CYMBALTA
ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
20 MG
4
duloxetine oral
capsule,delayed
release(dr/ec) 20 mg
duloxetine oral
capsule,delayed
2
MO; QL (124
per 31 days)
2
MO
CYMBALTA
ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
30 MG
4
duloxetine oral
capsule,delayed
duloxetine oral
capsule,delayed
2
MO; QL (62
per 31 days)
EMSAM
4
MO
ergoloid
2
MO
escitalopram oxalate
oral solution
4
MO
MO; QL (186
per 31 days)
MO; QL (124
per 31 days)
26
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
oral tablet 10 mg
3
MO; QL (62
per 31 days)
oral tablet 20 mg
3
MO; QL (31
per 31 days)
oral tablet 5 mg
3
MO; QL (124
per 31 days)
eszopiclone
2
ST; MO; QL
(31 per 31
days)
Drug
Tier
Requirements
/Limits
FETZIMA ORAL
CAPSULE,EXTEN
DED RELEASE 24
HR 20 MG
4
MO; QL (186
per 31 days)
FETZIMA ORAL
CAPSULE,EXTEN
DED RELEASE 24
HR 40 MG
4
MO; QL (93
per 31 days)
4
MO; QL (47
per 31 days)
FANAPT ORAL
TABLET 1 MG
4
MO; QL (744
per 31 days)
FETZIMA ORAL
CAPSULE,EXTEN
DED RELEASE 24
HR 80 MG
FANAPT ORAL
TABLET 10 MG, 8
MG
4
MO; QL (93
per 31 days)
fluoxetine oral
capsule 10 mg
1
MO; QL (248
per 31 days)
FANAPT ORAL
TABLET 12 MG
4
MO; QL (62
per 31 days)
fluoxetine oral
capsule 20 mg
1
MO
FANAPT ORAL
TABLET 2 MG
4
MO; QL (1080
per 90 days)
fluoxetine oral
capsule 40 mg
1
MO; QL (62
per 31 days)
FANAPT ORAL
TABLET 4 MG
4
MO; QL (186
per 31 days)
fluoxetine oral
solution
1
MO
FANAPT ORAL
TABLET 6 MG
4
MO; QL (124
per 31 days)
fluoxetine oral tablet
10 mg
1
MO; QL (248
per 31 days)
FANAPT ORAL
TABLETS,DOSE
PACK
4
MO; QL (8 per
28 days)
fluoxetine oral tablet
20 mg
2
MO
3
MO
FAZACLO ORAL
TABLET,DISINTE
GRATING 150 MG,
200 MG
4
fluphenazine
decanoate
fluphenazine hcl
2
MO
fluvoxamine oral
tablet 100 mg
3
MO; QL (93
per 31 days)
FETZIMA ORAL
CAPSULE,EXT
REL 24HR DOSE
PACK
4
fluvoxamine oral
tablet 25 mg
3
MO; QL (1080
per 90 days)
3
FETZIMA ORAL
CAPSULE,EXTEN
DED RELEASE 24
HR 120 MG
4
fluvoxamine oral
tablet 50 mg
MO; QL (186
per 31 days)
GEODON
INTRAMUSCULA
R
4
MO
guanfacine oral
tablet extended
release 24 hr
3
MO
MO; QL (28
per 28 days)
MO; QL (31
per 31 days)
27
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
haloperidol
2
MO
4
haloperidol
decanoate
3
MO
LATUDA ORAL
TABLET 120 MG
MO; QL (31
per 31 days)
4
haloperidol lactate
2
MO
LATUDA ORAL
TABLET 20 MG
MO; QL (248
per 31 days)
imipramine hcl
2
PA; MO
4
imipramine pamoate
3
PA; MO
LATUDA ORAL
TABLET 40 MG
MO; QL (124
per 31 days)
INTUNIV ER
4
MO
4
MO; QL (62
per 31 days)
INVEGA ORAL
TABLET
EXTENDED
RELEASE 24HR
1.5 MG
4
MO; QL (248
per 31 days)
LATUDA ORAL
TABLET 60 MG, 80
MG
lithium carbonate
2
MO
lithium citrate oral
solution 8 meq/5 ml
2
MO
INVEGA ORAL
TABLET
EXTENDED
RELEASE 24HR 3
MG
4
lorazepam intensol
3
PA; MO
lorazepam oral
tablet
2
PA; MO
loxapine succinate
2
MO
INVEGA ORAL
TABLET
EXTENDED
RELEASE 24HR 6
MG
4
maprotiline
2
MO
MARPLAN
3
MO
3
MO
INVEGA ORAL
TABLET
EXTENDED
RELEASE 24HR 9
MG
4
methylphenidate
oral capsule,er
biphasic 50-50
methylphenidate
oral solution
2
MO
methylphenidate
oral tablet
2
MO
INVEGA
SUSTENNA
INTRAMUSCULA
R SYRINGE 117
MG/0.75 ML, 156
MG/ML, 234
MG/1.5 ML
5
mirtazapine
2
MO
modafinil
3
PA; MO
nefazodone
2
MO
nortriptyline oral
capsule
2
MO
INVEGA
SUSTENNA
INTRAMUSCULA
R SYRINGE 39
MG/0.25 ML, 78
MG/0.5 ML
3
nortriptyline oral
solution
1
MO
olanzapine
intramuscular
4
MO
olanzapine oral
tablet 10 mg
2
MO; QL (62
per 31 days)
MO; QL (124
per 31 days)
MO; QL (62
per 31 days)
MO; QL (42
per 31 days)
MO
MO
Drug
Tier
Requirements
/Limits
28
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
PRISTIQ ORAL
TABLET
EXTENDED
RELEASE 24 HR
25 MG
3
MO
PRISTIQ ORAL
TABLET
EXTENDED
RELEASE 24 HR
50 MG
3
MO; QL (248
per 31 days)
protriptyline
3
MO
quetiapine oral
tablet 100 mg
2
MO; QL (248
per 31 days)
quetiapine oral
tablet 200 mg
2
MO; QL (124
per 31 days)
quetiapine oral
tablet 25 mg
2
MO; QL (932
per 31 days)
quetiapine oral
tablet 300 mg
2
MO; QL (83
per 31 days)
quetiapine oral
tablet 400 mg
2
MO; QL (62
per 31 days)
quetiapine oral
tablet 50 mg
2
MO; QL (496
per 31 days)
REXULTI ORAL
TABLET 0.25 MG
4
MO; QL (496
per 31 days)
REXULTI ORAL
TABLET 0.5 MG
4
MO; QL (248
per 31 days)
olanzapine oral
tablet 15 mg, 20 mg
2
MO; QL (31
per 31 days)
olanzapine oral
tablet 2.5 mg
2
MO; QL (248
per 31 days)
olanzapine oral
tablet 5 mg
2
MO; QL (124
per 31 days)
olanzapine oral
tablet 7.5 mg
2
MO; QL (83
per 31 days)
olanzapine oral
10 mg
4
MO; QL (62
per 31 days)
olanzapine oral
15 mg, 20 mg
4
MO; QL (31
per 31 days)
olanzapine oral
5 mg
4
MO; QL (124
per 31 days)
ORAP
3
MO
oxazepam
3
PA; MO
paroxetine hcl oral
tablet 10 mg
1
MO; QL (186
per 31 days)
paroxetine hcl oral
tablet 20 mg
1
MO; QL (93
per 31 days)
paroxetine hcl oral
tablet 30 mg
1
MO; QL (62
per 31 days)
paroxetine hcl oral
tablet 40 mg
1
MO; QL (47
per 31 days)
PAXIL ORAL
SUSPENSION
3
MO
REXULTI ORAL
TABLET 1 MG
4
MO; QL (124
per 31 days)
perphenazine
3
MO
REXULTI ORAL
TABLET 2 MG
4
MO; QL (62
per 31 days)
phenelzine
3
MO
4
PRISTIQ ORAL
TABLET
EXTENDED
RELEASE 24 HR
100 MG
3
MO; QL (124
per 31 days)
REXULTI ORAL
TABLET 3 MG
MO; QL (42
per 31 days)
REXULTI ORAL
TABLET 4 MG
4
MO; QL (31
per 31 days)
29
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
MO
RISPERDAL
CONSTA
INTRAMUSCULA
R SYRINGE 12.5
MG/2 ML, 25 MG/2
ML
3
RISPERDAL
CONSTA
INTRAMUSCULA
R SYRINGE 37.5
MG/2 ML, 50 MG/2
ML
5
MO
risperidone oral
solution
3
MO; QL (496
per 31 days)
risperidone oral
tablet 0.25 mg
2
MO; QL (1984
per 31 days)
risperidone oral
tablet 0.5 mg
2
MO; QL (992
per 31 days)
risperidone oral
tablet 1 mg
2
MO; QL (496
per 31 days)
risperidone oral
tablet 2 mg
2
MO; QL (248
per 31 days)
risperidone oral
tablet 3 mg
2
MO; QL (166
per 31 days)
risperidone oral
tablet 4 mg
2
MO; QL (124
per 31 days)
risperidone oral
0.25 mg
4
MO; QL (1984
per 31 days)
risperidone oral
0.5 mg
4
MO; QL (992
per 31 days)
risperidone oral
1 mg
4
MO; QL (496
per 31 days)
risperidone oral
2 mg
4
MO; QL (248
per 31 days)
Drug
Tier
Requirements
/Limits
risperidone oral
3 mg
4
MO; QL (166
per 31 days)
risperidone oral
4 mg
4
MO; QL (124
per 31 days)
RITALIN LA
ORAL
CAPSULE,ER
BIPHASIC 50-50 10
MG, 60 MG
3
MO
ROZEREM
3
MO; QL (31
per 31 days)
SAPHRIS (BLACK
CHERRY)
SUBLINGUAL
TABLET 10 MG
4
MO; QL (62
per 31 days)
SAPHRIS (BLACK
CHERRY)
SUBLINGUAL
TABLET 2.5 MG
4
MO
SAPHRIS (BLACK
CHERRY)
SUBLINGUAL
TABLET 5 MG
4
MO; QL (124
per 31 days)
SEROQUEL XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
150 MG
4
MO; QL (166
per 31 days)
SEROQUEL XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
200 MG
4
MO; QL (124
per 31 days)
SEROQUEL XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
300 MG
4
MO; QL (83
per 31 days)
30
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MO; QL (62
per 31 days)
venlafaxine oral
capsule,extended
release 24hr 75 mg
2
MO; QL (93
per 31 days)
venlafaxine oral
tablet 100 mg, 75 mg
2
MO; QL (93
per 31 days)
venlafaxine oral
tablet 25 mg
2
MO; QL (279
per 31 days)
venlafaxine oral
tablet 37.5 mg
2
MO; QL (186
per 31 days)
SEROQUEL XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
400 MG
4
SEROQUEL XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
50 MG
4
sertraline oral
concentrate
3
MO
venlafaxine oral
tablet 50 mg
2
MO; QL (155
per 31 days)
sertraline oral tablet
100 mg
1
MO; QL (62
per 31 days)
VERSACLOZ
5
LA
25 mg
1
MO; QL (248
per 31 days)
VIIBRYD ORAL
TABLET 10 MG
3
MO; QL (124
per 31 days)
50 mg
1
MO; QL (124
per 31 days)
VIIBRYD ORAL
TABLET 20 MG
3
MO; QL (62
per 31 days)
STRATTERA
3
MO
VIIBRYD ORAL
TABLET 40 MG
3
MO; QL (31
per 31 days)
SURMONTIL
4
PA; MO
3
temazepam
3
PA; MO
MO; QL (30
per 30 days)
thioridazine
2
MO
thiothixene
2
MO
VIIBRYD ORAL
TABLETS,DOSE
PACK 10 MG (7)20 MG (7)-40 MG
(16)
tranylcypromine
4
MO
XYREM
5
MO; LA
trazodone oral tablet
100 mg, 150 mg, 50
mg
1
MO
zaleplon oral
capsule 10 mg
2
ST; MO; QL
(62 per 31
days)
trazodone oral tablet
300 mg
3
MO
zaleplon oral
capsule 5 mg
2
trifluoperazine
2
MO
ST; MO; QL
(31 per 31
days)
venlafaxine oral
capsule,extended
release 24hr 150 mg
2
MO; QL (62
per 31 days)
ziprasidone hcl oral
capsule 20 mg
4
MO; QL (248
per 31 days)
4
venlafaxine oral
capsule,extended
release 24hr 37.5 mg
2
capsule 40 mg
MO; QL (124
per 31 days)
capsule 60 mg
4
MO; QL (83
per 31 days)
capsule 80 mg
4
MO; QL (62
per 31 days)
MO; QL (496
per 31 days)
MO; QL (186
per 31 days)
31
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
zolpidem oral tablet
1
ST; MO; QL
(31 per 31
days)
propafenone oral
tablet 150 mg, 225
mg
2
MO
zolpidem oral
tablet,ext release
multiphase
4
ST; MO; QL
(31 per 31
days)
propafenone oral
tablet 300 mg
3
MO
ZYPREXA
RELPREVV
INTRAMUSCULA
R SUSPENSION
FOR
RECONSTITUTIO
N 210 MG
5
quinidine gluconate
oral
4
MO
quinidine sulfate
oral tablet
2
MO
sorine oral tablet
120 mg, 160 mg, 80
mg
1
MO
sorine oral tablet
240 mg
1
sotalol af oral tablet
120 mg
2
MO
sotalol oral tablet
160 mg, 80 mg
2
MO
sotalol oral tablet
240 mg
3
MO
SOTYLIZE
3
TIKOSYN
3
LA
CARDIOVASCULAR,
HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone
2
B/D PA; MO
amiodarone oral
tablet 200 mg
2
MO
amiodarone oral
tablet 400 mg
3
MO
flecainide
2
MO
mexiletine
2
MO
pacerone oral tablet
100 mg
4
MO
pacerone oral tablet
200 mg
2
procainamide
injection solution
100 mg/ml
2
procainamide
injection solution
500 mg/ml
2
propafenone oral
capsule,extended
release 12 hr
4
MO
ANTIHYPERTENSIVE THERAPY
acebutolol
2
MO
amiloride oral
2
MO
MO
amiloridehydrochlorothiazide
1
MO
MO
amlodipine
1
MO
amlodipinebenazepril
3
MO
amlodipinevalsartan
3
MO
amlodipinevalsartan-hcthiazid
3
MO
atenolol
1
MO
atenololchlorthalidone
1
MO
MO
32
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
diltiazem hcl oral
capsule, extended
release 180 mg, 360
mg, 420 mg
3
MO
diltiazem hcl oral
capsule,extended
release 12 hr
3
MO
diltiazem hcl oral
capsule,extended
release 24hr 120 mg,
240 mg, 300 mg
2
MO
diltiazem hcl oral
tablet
2
MO
dilt-xr
2
MO
doxazosin oral tablet
1 mg, 2 mg, 4 mg
1
MO; QL (31
per 31 days)
doxazosin oral tablet
8 mg
1
MO; QL (62
per 31 days)
enalapril maleate
1
MO
enalaprilhydrochlorothiazide
2
MO
eplerenone
3
MO
eprosartan
3
MO
felodipine
3
MO
fosinopril
2
MO
fosinoprilhydrochlorothiazide
3
MO
furosemide injection
1
MO
furosemide oral
solution 10 mg/ml,
40 mg/5 ml
1
MO
furosemide oral
tablet
1
MO
guanfacine oral
tablet
2
MO
hydralazine injection
3
MO
hydralazine oral
2
MO
benazepril
1
MO
benazeprilhydrochlorothiazide
2
MO
BENICAR
4
MO
BENICAR HCT
4
MO
betaxolol oral
3
MO
BIDIL
3
MO
bisoprolol fumarate
2
MO
bisoprololhydrochlorothiazide
1
MO
bumetanide injection
2
MO
bumetanide oral
1
MO
BYSTOLIC
4
MO
candesartan
2
MO
candesartanhydrochlorothiazid
3
MO
captopril
1
MO
captoprilhydrochlorothiazide
2
MO
cartia xt
2
MO
carvedilol
1
MO
chlorothiazide
1
MO
chlorothiazide
sodium
2
MO
chlorthalidone oral
tablet 25 mg, 50 mg
2
MO
clonidine
4
MO; QL (4 per
28 days)
clonidine hcl oral
tablet
1
MO
COREG CR
3
MO
DEMSER
4
MO
diltiazem hcl
intravenous
3
Drug
Tier
Requirements
/Limits
33
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
nifedipine oral tablet
extended release
24hr
2
MO
nimodipine
3
MO
perindopril
erbumine
2
MO
phenoxybenzamine
3
MO
pindolol
3
MO
prazosin oral
1
MO
propranolol
intravenous
2
propranolol oral
capsule,extended
release 24 hr
3
MO
hydrochlorothiazide
1
MO
indapamide
1
MO
irbesartan
3
MO
irbesartanhydrochlorothiazide
3
MO
isradipine
3
MO
labetalol
2
MO
labetalol oral
2
MO
lisinopril
1
MO
lisinoprilhydrochlorothiazide
1
MO
losartan
2
MO
losartanhydrochlorothiazide
2
MO
propranolol oral
solution
2
MO
methyclothiazide
3
MO
1
MO
methyldopa
2
MO
propranolol oral
tablet
metolazone
2
MO
3
MO
metoprolol succinate
2
MO
propranololhydrochlorothiazid
metoprolol tahydrochlorothiaz
3
MO
quinapril
2
MO
2
MO
metoprolol tartrate
1
MO
quinaprilhydrochlorothiazide
ramipril
2
MO
metoprolol tartrate
oral
1
MO
REMODULIN
5
PA; MO; LA
reserpine
2
MO
minoxidil oral
2
MO
spironolactone
1
MO
moexipril
2
MO
2
MO
moexiprilhydrochlorothiazide
2
MO
spironolactonhydrochlorothiaz
TEKTURNA
3
MO
nadolol
2
MO
telmisartan
2
MO
nadololbendroflumethiazide
3
MO
telmisartanamlodipine
2
MO
nicardipine oral
2
MO
2
MO
nifedical xl
2
MO
telmisartanhydrochlorothiazid
34
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
terazosin oral
capsule 1 mg, 2 mg,
5 mg
1
MO; QL (31
per 31 days)
LANOXIN ORAL
TABLET 187.5
MCG, 62.5 MCG
terazosin oral
capsule 10 mg
1
MO; QL (62
per 31 days)
COAGULATION THERAPY
timolol maleate oral
2
MO
torsemide oral
2
MO
trandolapril
2
trandolaprilverapamil
3
MO
AGGRENOX
3
MO
aspirin-dipyridamole
3
MO
MO
BRILINTA ORAL
TABLET 90 MG
3
MO
3
MO
cilostazol
2
MO
triamterenehydrochlorothiazid
1
MO
clopidogrel
2
MO
dipyridamole oral
2
MO
valsartan
3
MO
EFFIENT
3
MO
valsartanhydrochlorothiazide
3
MO
ELIQUIS
3
MO
enoxaparin
3
MO
verapamil
2
MO
fondaparinux
4
MO
verapamil oral
capsule, 24 hr er
pellet ct
2
MO
3
verapamil oral
capsule,ext rel.
pellets 24 hr
2
MO
heparin (porcine) in
5 % dex intravenous
parenteral solution
20,000 unit/500 ml
(40 unit/ml)
3
MO
verapamil oral tablet
1
MO
verapamil oral tablet
extended release
2
MO
heparin (porcine) in
5 % dex intravenous
parenteral solution
25,000 unit/250
ml(100 unit/ml),
25,000 unit/500 ml
(50 unit/ml)
heparin (porcine)
injection solution
3
MO
jantoven
1
MO
pentoxifylline
2
MO
PRADAXA
3
MO
PROMACTA
5
PA; MO; LA
SAVAYSA
4
MO
tranexamic acid
intravenous
3
MO
CARDIAC GLYCOSIDES
digitek
3
MO
digoxin injection
solution
2
MO
digoxin oral solution
50 mcg/ml
2
MO
digoxin oral tablet
125 mcg
2
MO
digoxin oral tablet
250 mcg
1
MO
35
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
omega-3 acid ethyl
esters
2
MO
pravastatin
1
MO; QL (31
per 31 days)
prevalite oral
powder
3
MO
simvastatin
1
MO; QL (31
per 31 days)
VASCEPA
3
MO
WELCHOL
3
MO
ZETIA
3
MO
warfarin
2
MO
XARELTO
3
MO
LIPID/CHOLESTEROL LOWERING
AGENTS
amlodipineatorvastatin
2
MO; QL (31
per 31 days)
atorvastatin
2
MO; QL (31
per 31 days)
cholestyramine light
oral powder in
packet
3
MO
colestipol oral
granules
3
MO
colestipol oral tablet
2
MO
CRESTOR
3
MO; QL (31
per 31 days)
fenofibrate
micronized
2
MO
fenofibrate
nanocrystallized
3
MO
fenofibrate oral
tablet 160 mg, 54 mg
3
MO
fenofibric acid
(choline)
2
MO
fluvastatin oral
capsule 20 mg
3
MO; QL (31
per 31 days)
fluvastatin oral
capsule 40 mg
3
MO; QL (62
per 31 days)
gemfibrozil oral
2
JUXTAPID
Drug
Tier
Requirements
/Limits
MISCELLANEOUS
CARDIOVASCULAR AGENTS
CORLANOR
3
PA; MO
ENTRESTO
3
PA; MO; QL
(60 per 30
days)
RANEXA
3
MO
isosorbide dinitrate
oral tablet 10 mg, 20
mg, 5 mg
3
MO
oral tablet 30 mg
2
MO
release
3
MO
MO
isosorbide
mononitrate
2
MO
5
MO; LA
nitro-bid
2
MO
lovastatin oral tablet
10 mg
1
MO; QL (31
per 31 days)
3
MO
lovastatin oral tablet
20 mg, 40 mg
1
MO; QL (62
per 31 days)
niacin oral tablet
extended release 24
hr
2
MO
NITRO-DUR
TRANSDERMAL
PATCH 24 HOUR
0.3 MG/HR, 0.8
MG/HR
nitroglycerin
intravenous
2
B/D PA
NITRATES
36
Drug Name
Drug
Tier
nitroglycerin
transdermal patch
24 hour
2
nitroglycerin
translingual
spray,non-aerosol
2
NITROSTAT
3
Requirements
/Limits
Drug Name
MO
CONDYLOX
TOPICAL GEL
3
MO
diclofenac sodium
topical gel
2
MO
fluorouracil topical
cream 5 %
3
MO
fluorouracil topical
solution
3
MO
imiquimod
3
MO
methoxsalen rapid
5
MO
PANRETIN
4
MO
podofilox
3
MO
PROTOPIC
3
PA; MO
prudoxin
4
MO
REGRANEX
3
MO; QL (30
per 31 days)
tacrolimus topical
3
MO
UVADEX
4
VALCHLOR
5
MO
VEREGEN
4
MO
MO
MO
DERMATOLOGICALS/TOPICA
L THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
Drug
Tier
Requirements
/Limits
acitretin oral
capsule 10 mg
2
MO
acitretin oral
capsule 17.5 mg, 25
mg
5
MO
calcipotriene topical
cream
4
ointment
4
MO
solution
3
MO
calcipotrienebetamethasone
2
MO
THERAPY FOR ACNE
4
PA; MO
calcitriol topical
2
MO
adapalene topical
cream
selenium sulfide
topical suspension
2
MO
adapalene topical
gel 0.1 %
4
PA; MO
adapalene topical
gel 0.3 %
2
PA; MO
avita topical cream
2
PA; MO
AZELEX
3
MO
claravis
3
MO
clindamycin
phosphate topical
foam
4
MO
MO
BURN THERAPY
silver sulfadiazine
2
MO
ssd
2
MO
MISCELLANEOUS
DERMATOLOGICALS
8-MOP
3
MO
ammonium lactate
topical
2
MO
CARAC
3
MO
37
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MO
TAZORAC
3
MO
3
PA; MO
MO
tretinoin
microspheres topical
gel with pump
tretinoin topical
cream 0.025 %
2
PA; MO
tretinoin topical
cream 0.05 %, 0.1 %
3
PA; MO
tretinoin topical gel
0.01 %, 0.025 %
3
PA; MO
clindamycin
phosphate topical
gel
3
clindamycin
phosphate topical
lotion
3
clindamycin
phosphate topical
solution
2
MO
clindamycin
phosphate topical
swab
2
MO
clindamycin-benzoyl
peroxide topical gel
1-5 %
4
MO
lidocaine (pf)
mg/ml (0.5 %)
1
MO
ery pads
3
MO
2
MO
erythromycin with
ethanol topical gel
2
MO
lidocaine hcl
mg/ml (2 %)
erythromycin with
ethanol topical
solution
2
MO
lidocaine hcl mucous
membrane gel
2
MO
2
MO
erythromycinbenzoyl peroxide
3
membrane jelly in
applicator
FINACEA
TOPICAL FOAM
3
2
FINACEA
TOPICAL GEL
3
MO
membrane solution 2
%
2
metronidazole
topical cream
3
MO
membrane solution 4
% (40 mg/ml)
metronidazole
topical gel 0.75 %
4
MO
lidocaine hcl
urethral
2
metronidazole
topical gel 1 %
2
MO
lidocaine topical
adhesive
patch,medicated
2
PA; MO
metronidazole
topical lotion
4
MO
lidocaine topical
ointment
3
MO
myorisan oral
capsule 10 mg, 20
mg, 40 mg
3
MO
lidocaine-prilocaine
topical cream
2
MO
neuac
3
MO
TOPICAL ANESTHETICS
MO
MO
TOPICAL ANTIBACTERIALS
38
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
ALTABAX
3
MO
TOPICAL CORTICOSTEROIDS
gentamicin topical
2
MO
3
MO
mupirocin
2
MO
alclometasone
topical cream
mupirocin calcium
3
MO
2
MO
sulfacetamide
sodium (acne)
3
MO
alclometasone
topical ointment
4
MO
SULFAMYLON
TOPICAL CREAM
3
MO
amcinonide topical
cream
amcinonide topical
lotion
2
MO
amcinonide topical
ointment
4
MO
apexicon e
2
MO
betamethasone
dipropionate
3
MO
betamethasone
valerate topical
cream
2
MO
betamethasone
valerate topical
foam
4
MO
betamethasone
valerate topical
lotion
3
MO
betamethasone
valerate topical
ointment
2
MO
betamethasone,
augmented topical
cream
2
MO
betamethasone,
augmented topical
gel
3
MO
betamethasone,
augmented topical
lotion
3
MO
betamethasone,
augmented topical
ointment
3
MO
CAPEX
3
MO
TOPICAL ANTIFUNGALS
ciclopirox topical
cream
3
MO
ciclopirox topical
gel
4
MO
ciclopirox topical
shampoo
3
MO
ciclopirox topical
solution
2
MO
ciclopirox topical
suspension
3
MO
clotrimazole topical
2
MO
clotrimazolebetamethasone
3
MO
econazole topical
2
MO
ketoconazole topical
2
MO
NAFTIN
3
MO
nyamyc
3
MO
nystatin topical
2
MO
nystatintriamcinolone
4
MO
nystop
3
MO
TOPICAL ANTIVIRALS
acyclovir topical
4
MO
DENAVIR
3
MO
ZOVIRAX
TOPICAL CREAM
4
MO
Drug
Tier
Requirements
/Limits
39
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
clobetasol topical
foam
4
MO
fluocinolone topical
oil
3
MO
clobetasol topical
gel
2
MO
ointment
3
MO
clobetasol topical
lotion
4
MO
solution
4
MO
clobetasol topical
ointment
2
MO
fluocinonide topical
cream 0.1 %
2
MO
clobetasol topical
shampoo
4
MO
gel
2
MO
clobetasol topical
solution
2
MO
ointment
2
MO
clobetasol topical
spray,non-aerosol
4
MO
solution
3
MO
clobetasol-emollient
topical cream
2
MO
fluocinonide-e
2
MO
clodan
3
MO
fluticasone topical
cream
2
MO
CORDRAN TAPE
LARGE ROLL
3
MO
fluticasone topical
lotion
4
MO
desonide topical
cream
4
MO
fluticasone topical
ointment
2
MO
desonide topical
lotion
4
MO
halobetasol
propionate
3
MO
desonide topical
ointment
3
MO
2
MO
desoximetasone
topical cream 0.05
%
4
MO
hydrocortisone
butyrate topical
ointment
2
MO
desoximetasone
topical cream 0.25
%
3
MO
hydrocortisone
butyrate topical
solution
hydrocortisone
butyr-emollient
2
MO
desoximetasone
topical gel
4
MO
2
MO
desoximetasone
topical ointment
4
MO
hydrocortisone
topical cream 1 %,
2.5 %
3
MO
diflorasone
4
MO
hydrocortisone
topical lotion 2.5 %
cream
3
MO
40
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
MO
lindane
4
MO
malathion
4
MO
permethrin topical
cream
3
MO
SKLICE
3
MO
hydrocortisone
topical ointment 1
%, 2.5 %
2
hydrocortisone
valerate topical
cream
2
hydrocortisone
valerate topical
ointment
4
MO
LOCOID TOPICAL
LOTION
3
MO
mometasone
2
MO
PANDEL
3
MO
prednicarbate
topical cream
2
MO
prednicarbate
topical ointment
3
MO
triamcinolone
acetonide topical
aerosol
2
MO
triamcinolone
acetonide topical
cream
2
MO
triamcinolone
acetonide topical
lotion
2
MO
triamcinolone
acetonide topical
ointment 0.025 %,
0.1 %, 0.5 %
2
MO
trianex
3
MO
triderm topical
cream
1
MO
MO
TOPICAL ENZYMES
SANTYL
3
MO
TOPICAL SCABICIDES /
PEDICULICIDES
EURAX
3
MO
Drug
Tier
Requirements
/Limits
DIAGNOSTICS /
MISCELLANEOUS AGENTS
acamprosate
2
MO
ACTONEL ORAL
TABLET 30 MG
4
MO
ADAGEN
5
MO
alendronate oral
tablet 40 mg
2
MO; QL (31
per 31 days)
anagrelide oral
capsule 0.5 mg
2
MO
anagrelide oral
capsule 1 mg
3
MO
ARALAST NP
INTRAVENOUS
RECON SOLN 500
MG
5
MO; LA
CARBAGLU
5
MO; LA
cevimeline
4
MO
CHEMET
3
MO
CLINIMIX
4.25%/D5W
SULFIT FREE
3
B/D PA
d10 % & 0.45 %
sodium chloride
2
d2.5 %-0.45 %
sodium chloride
1
d5 % and 0.9 %
sodium chloride
1
MO
d5 %-0.45 % sodium
chloride
1
MO
41
Drug Name
Drug
Tier
dextrose 10 % and
0.2 % nacl
2
dextrose 10 % in
water (d10w)
intravenous
parenteral solution
1
dextrose 5 % in
water (d5w)
intravenous
parenteral solution
1
dextrose 5 %lactated ringers
2
dextrose 5%-0.2 %
sod chloride
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
midodrine oral
tablet 10 mg, 5 mg
3
MO
midodrine oral
tablet 2.5 mg
2
MO
ORFADIN
5
LA
pilocarpine hcl oral
3
MO
PROLASTIN-C
5
MO; LA
RAVICTI
5
MO
RENVELA
3
MO
riluzole
3
MO
1
risedronate oral
tablet 30 mg
3
MO
dextrose 5%-0.3 %
sod.chloride
2
2
MO
dextrose with sodium
chloride
1
sodium chloride 0.9
% intravenous
parenteral solution
2
MO
disulfiram oral
tablet 250 mg
3
MO
sodium chloride
irrigation
3
disulfiram oral
tablet 500 mg
4
MO
sodium polystyrene
(sorb free)
SYPRINE
5
MO
etidronate disodium
4
MO
2
MO
EXJADE ORAL
TABLET,
DISPERSIBLE 125
MG
3
MO; LA
zoledronic acidmannitol-water
EXJADE ORAL
TABLET,
DISPERSIBLE 250
MG, 500 MG
5
FERRIPROX
5
MO
INCRELEX
5
MO; LA
kionex oral powder
3
levocarnitine (with
sugar)
levocarnitine oral
tablet
MO
MO
MO
SMOKING DETERRENTS
buproban
3
MO
CHANTIX
3
MO
CHANTIX
CONTINUING
MONTH BOX
3
MO
3
MO
MO
CHANTIX
STARTING
MONTH BOX
3
MO
NICOTROL
4
MO
3
MO
NICOTROL NS
4
MO
MO; LA
EAR, NOSE / THROAT
MEDICATIONS
42
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
ADRENAL HORMONES
azelastine nasal
aerosol,spray
3
a-hydrocort
2
MO
azelastine nasal
spray,non-aerosol
2
MO
cortisone
2
MO
DEPO-MEDROL
3
MO
BACTROBAN
NASAL
3
MO
dexamethasone
intensol
2
MO
chlorhexidine
gluconate mucous
membrane
1
MO
dexamethasone oral
elixir
1
MO
1
MO
ipratropium bromide
nasal
2
MO; QL (30
per 31 days)
olopatadine
3
MO
dexamethasone oral
tablet 0.5 mg, 0.75
mg, 1 mg, 1.5 mg, 2
mg, 4 mg
periogard
1
MO
dexamethasone oral
tablet 6 mg
2
MO
triamcinolone
acetonide dental
3
MO
1
MO
TYZINE NASAL
DROPS 0.05 %
3
MO
dexamethasone
sodium phosphate
injection
fludrocortisone
2
MO
hydrocortisone oral
2
MO
methylprednisolone
acetate
2
MO
methylprednisolone
oral tablet
2
B/D PA; MO
methylprednisolone
oral tablets,dose
pack
2
MO
methylprednisolone
sodium succ
125 mg
3
MO
methylprednisolone
sodium succ
40 mg
2
MO
MO
MISCELLANEOUS OTIC
PREPARATIONS
acetasol hc
4
MO
acetic acid otic
2
MO
fluocinolone
acetonide oil
3
MO
hydrocortisoneacetic acid
4
MO
ofloxacin otic
2
MO
OTIC STEROID / ANTIBIOTIC
CIPRO HC
4
MO
CIPRODEX
3
MO
COLY-MYCIN S
3
MO
CORTISPORIN-TC
3
MO
neomycinpolymyxin-hc otic
2
MO
ENDOCRINE/DIABETES
43
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
MO
DIABETES THERAPY
prednisolone sodium
phosphate oral
solution 15 mg/5 ml,
25 mg/5 ml (5
mg/ml), 5 mg base/5
ml (6.7 mg/5 ml)
2
prednisolone sodium
phosphate oral
2
B/D PA; MO
prednisone intensol
3
MO
prednisone oral
solution
2
MO
prednisone oral
tablet
1
B/D PA; MO
SOLU-CORTEF
(PF) INJECTION
RECON SOLN 100
MG/2 ML, 250
MG/2 ML
3
MO
SOLU-MEDROL
(PF) INJECTION
3
MO
SOLU-MEDROL
(PF)
INTRAVENOUS
RECON SOLN 500
MG/4 ML
3
MO
SOLU-MEDROL
INTRAVENOUS
RECON SOLN 2
GRAM
3
triamcinolone
acetonide injection
suspension 10 mg/ml
2
triamcinolone
acetonide injection
suspension 40 mg/ml
2
MO
MO
ANTITHYROID AGENTS
methimazole oral
tablet 10 mg, 5 mg
2
MO
propylthiouracil
2
MO
Drug
Tier
Requirements
/Limits
acarbose oral tablet
100 mg
2
MO; QL (93
per 31 days)
25 mg
2
MO; QL (372
per 31 days)
50 mg
2
MO; QL (186
per 31 days)
alcohol pads
2
MO
BYDUREON
3
MO; QL (4 per
28 days)
BYETTA
SUBCUTANEOUS
PEN INJECTOR 10
MCG/DOSE(250
MCG/ML) 2.4 ML
3
MO; QL (4.8
per 31 days)
BYETTA
SUBCUTANEOUS
PEN INJECTOR 5
MCG/DOSE (250
MCG/ML) 1.2 ML
3
MO; QL (2.4
per 31 days)
CYCLOSET
4
MO; QL (186
per 31 days)
GAUZE PADS 2X2
3
MO
glimepiride oral
tablet 1 mg
1
MO; QL (248
per 31 days)
glimepiride oral
tablet 2 mg
1
MO; QL (124
per 31 days)
glimepiride oral
tablet 4 mg
1
MO; QL (62
per 31 days)
glipizide oral tablet
10 mg
1
MO; QL (124
per 31 days)
5 mg
1
MO; QL (248
per 31 days)
extended release
24hr 10 mg
2
MO; QL (62
per 31 days)
extended release
24hr 2.5 mg
2
MO; QL (248
per 31 days)
44
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
extended release
24hr 5 mg
2
MO; QL (124
per 31 days)
HUMALOG MIX
50-50
3
MO
glipizide-metformin
oral tablet 2.5-250
mg
3
HUMALOG MIX
50-50 KWIKPEN
3
MO
3
MO
glipizide-metformin
oral tablet 2.5-500
mg, 5-500 mg
3
MO; QL (124
per 31 days)
HUMALOG MIX
75-25
HUMALOG MIX
75-25 KWIKPEN
3
MO
GLUCAGEN
HYPOKIT
3
MO
3
MO
GLUCAGON
EMERGENCY KIT
(HUMAN)
3
MO
HUMALOG
SUBCUTANEOUS
CARTRIDGE
3
MO
glyburide
micronized oral
tablet 1.5 mg
1
ST; MO; QL
(248 per 31
days)
HUMALOG
SUBCUTANEOUS
SOLUTION 100
UNIT/ML
3
glyburide
micronized oral
tablet 3 mg
1
ST; MO; QL
(124 per 31
days)
glyburide
micronized oral
tablet 6 mg
1
ST; MO; QL
(62 per 31
days)
HUMALOG
SUBCUTANEOUS
SOLUTION 100
UNIT/ML
(PREFILLED
SYRINGE)
HUMULIN 70/30
3
MO
glyburide oral tablet
1.25 mg
2
ST; MO; QL
(496 per 31
days)
HUMULIN 70/30
KWIKPEN
3
MO
HUMULIN N
3
MO
2.5 mg
2
HUMULIN N
KWIKPEN
3
MO
HUMULIN R
3
MO
5 mg
2
ST; MO; QL
(124 per 31
days)
HUMULIN R U-500
"CONCENTRATED
"
3
MO
glyburide-metformin
oral tablet 1.25-250
mg
2
ST; MO; QL
(248 per 31
days)
INSULIN PEN
NEEDLE
3
MO
glyburide-metformin
oral tablet 2.5-500
mg, 5-500 mg
2
INSULIN
SYRINGE (DISP)
U-100 0.3 ML
3
MO
HUMALOG
KWIKPEN
3
INSULIN
SYRINGE (DISP)
U-100 1 ML
3
MO
MO; QL (248
per 31 days)
ST; MO; QL
(248 per 31
days)
ST; MO; QL
(124 per 31
days)
MO
Drug
Tier
Requirements
/Limits
45
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
MO
nateglinide oral
tablet 120 mg
3
MO; QL (93
per 31 days)
nateglinide oral
tablet 60 mg
3
MO; QL (186
per 31 days)
NEEDLES,
INSULIN
DISP.,SAFETY
3
MO
NOVOFINE 32
3
MO
pioglitazone
3
MO; QL (31
per 31 days)
pioglitazoneglimepiride
4
MO; QL (31
per 31 days)
pioglitazonemetformin
4
MO; QL (93
per 31 days)
PRODIGY
INSULIN
SYRINGE
SYRINGE 0.3 ML
31 X 5/16", 1/2 ML
31 X 5/16"
3
PRODIGY
INSULIN
SYRINGE
SYRINGE 1 ML 28
X 1/2"
3
MO
PROGLYCEM
3
MO
repaglinide oral
tablet 0.5 mg
2
MO; QL (992
per 31 days)
repaglinide oral
tablet 1 mg
2
MO; QL (496
per 31 days)
repaglinide oral
tablet 2 mg
2
MO; QL (248
per 31 days)
RIOMET
3
MO; QL (791
per 31 days)
SYMLINPEN 120
3
PA; MO; QL
(18.9 per 31
days)
INSULIN
SYRINGE (DISP)
U-100 1/2 ML
3
INVOKANA
3
MO; QL (31
per 31 days)
JANUMET
4
MO; QL (62
per 31 days)
JANUMET XR
ORAL TABLET,
ER MULTIPHASE
24 HR 100-1,000
MG, 50-500 MG
4
MO; QL (31
per 31 days)
JANUMET XR
ORAL TABLET,
ER MULTIPHASE
24 HR 50-1,000 MG
4
MO; QL (62
per 31 days)
JANUVIA
4
MO; QL (31
per 31 days)
JENTADUETO
3
MO; QL (62
per 31 days)
LANTUS
3
MO
LANTUS
SOLOSTAR
4
MO
metformin oral
tablet 1,000 mg
1
MO; QL (78
per 31 days)
metformin oral
tablet 500 mg
1
MO; QL (155
per 31 days)
metformin oral
tablet 850 mg
1
MO; QL (93
per 31 days)
metformin oral
tablet extended
2
MO; QL (124
per 31 days)
metformin oral
tablet extended
2
MO; QL (78
per 31 days)
metformin oral
tablet extended
release 24hr 1,000
mg
3
MO; QL (78
per 31 days)
Drug
Tier
Requirements
/Limits
46
Drug Name
SYMLINPEN 60
Drug
Tier
3
Requirements
/Limits
Drug Name
PA; MO; QL
(10.5 per 31
days)
calcitriol oral
capsule 0.5 mcg
3
MO
calcitriol oral
solution
3
MO
CERDELGA
5
MO
CEREZYME
INTRAVENOUS
RECON SOLN 400
UNIT
5
MO
chorionic
gonadotropin,
human
2
PA; MO
danazol oral capsule
100 mg, 200 mg
4
MO
danazol oral capsule
50 mg
2
MO
desmopressin
injection
4
MO
desmopressin nasal
solution
4
MO
desmopressin nasal
spray,non-aerosol
4
MO
desmopressin oral
3
MO
doxercalciferol oral
2
MO
ELAPRASE
5
MO
FABRAZYME
INTRAVENOUS
RECON SOLN 35
MG
5
MO
fortical
3
MO
5
MO
TANZEUM
4
MO; QL (2 per
28 days)
tolazamide oral
tablet 250 mg
2
MO; QL (124
per 31 days)
tolazamide oral
tablet 500 mg
2
MO; QL (62
per 31 days)
tolbutamide
2
MO; QL (186
per 31 days)
TRADJENTA
3
MO; QL (31
per 31 days)
TRULICITY
SUBCUTANEOUS
PEN INJECTOR
0.75 MG/0.5 ML
4
MO; QL (4 per
28 days)
TRULICITY
SUBCUTANEOUS
PEN INJECTOR 1.5
MG/0.5 ML
4
VGO 20
3
MO
VGO 30
3
MO
VGO 40
3
MO
MO; QL (2 per
28 days)
MISCELLANEOUS HORMONES
Drug
Tier
Requirements
/Limits
ALDURAZYME
5
MO
ANDROGEL
3
PA; MO
ANDROID
3
MO
cabergoline
4
MO; QL (16
per 28 days)
calcitonin (salmon)
3
MO
calcitriol
1 mcg/ml
2
MO
KUVAN ORAL
POWDER IN
PACKET 500 MG
5
MO
calcitriol oral
capsule 0.25 mcg
2
MO
KUVAN ORAL
TABLET,SOLUBL
E
LUMIZYME
5
MO; LA
47
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MIACALCIN
INJECTION
4
MO
ZAVESCA
5
MO; LA
MYALEPT
5
PA; MO; LA
ZEMPLAR
INTRAVENOUS
3
MO
MYOZYME
5
MO
2
MO
NAGLAZYME
5
MO; LA
zoledronic acid
NATPARA
5
PA; MO; LA
oxandrolone oral
tablet 10 mg
5
PA; MO
oxandrolone oral
tablet 2.5 mg
3
PA; MO
paricalcitol oral
2
MO
SAMSCA ORAL
TABLET 15 MG
5
PA; MO; QL
(31 per 31
days)
SAMSCA ORAL
TABLET 30 MG
5
PA; MO; QL
(62 per 31
days)
SENSIPAR ORAL
TABLET 30 MG
3
MO
SENSIPAR ORAL
TABLET 60 MG, 90
MG
5
SOMAVERT
SUBCUTANEOUS
RECON SOLN 10
MG, 15 MG, 20 MG
THYROID HORMONES
levothyroxine oral
tablet 100 mcg, 25
mcg, 50 mcg, 75 mcg
1
MO
levothyroxine oral
tablet 112 mcg, 125
mcg, 137 mcg, 150
mcg, 175 mcg, 200
mcg, 300 mcg, 88
mcg
2
MO
levoxyl oral tablet
100 mcg, 112 mcg,
125 mcg, 137 mcg,
150 mcg, 175 mcg,
200 mcg, 25 mcg, 50
mcg, 75 mcg, 88 mcg
2
MO
MO
liothyronine oral
2
MO
1
MO
5
MO; LA
unithroid oral tablet
100 mcg, 150 mcg,
175 mcg, 25 mcg,
300 mcg, 50 mcg, 75
mcg
SOMAVERT
SUBCUTANEOUS
RECON SOLN 25
MG, 30 MG
5
MO
unithroid oral tablet
112 mcg, 125 mcg,
200 mcg, 88 mcg
2
MO
STIMATE
3
MO
SYNAREL
4
MO
testosterone
cypionate
intramuscular oil
200 mg/ml
3
MO
testosterone
enanthate
3
GASTROENTEROLOGY
MO
ANTIDIARRHEALS /
ANTISPASMODICS
atropine injection
syringe 0.05 mg/ml,
0.1 mg/ml
2
dicyclomine oral
capsule
2
MO
48
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
dicyclomine oral
solution
2
MO
dronabinol oral
capsule 10 mg
5
B/D PA; MO
dicyclomine oral
tablet
2
MO
dronabinol oral
capsule 2.5 mg, 5 mg
3
B/D PA; MO
glycopyrrolate
injection
3
MO
EMEND
INTRAVENOUS
3
MO
glycopyrrolate oral
tablet 1 mg
2
MO
EMEND ORAL
3
B/D PA; MO
glycopyrrolate oral
tablet 2 mg
3
MO
enulose
2
MO
gavilyte-c
2
MO
loperamide oral
capsule
2
MO
gavilyte-g
2
MO
gavilyte-n
2
MO
generlac
2
MO
granisetron (pf)
100 mcg/ml
3
MO
3
MO
MISCELLANEOUS
GASTROINTESTINAL AGENTS
alosetron
3
MO
ALOXI
3
MO; QL (10
per 31 days)
AMITIZA
3
MO
granisetron hcl
1 mg/ml (1 ml)
APRISO
3
MO
granisetron hcl oral
3
B/D PA; MO
ASACOL HD
3
MO
4
MO
balsalazide
3
MO
hydrocortisone
rectal enema
budesonide oral
3
MO
2
MO
CANASA
4
MO
CHENODAL
5
PA; MO; LA
lactulose oral
solution 10 gram/15
ml
CIMZIA
5
PA; MO
LINZESS
3
MO
CIMZIA POWDER
FOR RECONST
5
PA; MO
LOTRONEX
5
MO
2
MO
compro
3
MO
meclizine oral tablet
12.5 mg, 25 mg
constulose
2
MO
mesalamine with
cleansing wipe
3
MO
CORTIFOAM
3
MO
1
MO
CREON
3
MO
metoclopramide hcl
injection solution
cromolyn oral
4
MO
1
MO
CYSTADANE
3
MO
metoclopramide hcl
oral solution
DELZICOL
3
MO
metoclopramide hcl
oral tablet
1
MO
49
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MO
sulfazine ec
2
MO
SUPREP BOWEL
PREP KIT
3
MO
TRANSDERMSCOP
3
MO
metoclopramide hcl
oral
3
MOVIPREP
4
MO
ondansetron
2
B/D PA; MO
ondansetron hcl (pf)
injection solution
3
MO
trilyte with flavor
packets
2
MO
ondansetron hcl oral
solution
3
B/D PA; MO
UCERIS ORAL
5
MO
tablet 24 mg
2
B/D PA
ursodiol oral
capsule
2
MO
tablet 4 mg, 8 mg
2
B/D PA; MO
ursodiol oral tablet
3
MO
VIOKACE
3
MO
PENTASA
3
MO
3
MO
polyethylene glycol
3350 oral powder
2
MO
prochlorperazine
3
MO
prochlorperazine
edisylate injection
solution 10 mg/2 ml
(5 mg/ml)
2
MO
prochlorperazine
maleate oral
1
MO
procto-pak
2
MO
proctosol hc
1
MO
proctozone-hc
2
MO
ZENPEP ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
10,000-34,000 55,000 UNIT,
15,000-51,000 82,000 UNIT,
20,000-68,000 109,000 UNIT,
25,000-85,000136,000 UNIT,
3,000-10,00016,000 UNIT,
40,000-136,000218,000 UNIT
RECTIV
3
MO
RELISTOR
SUBCUTANEOUS
SOLUTION
3
MO
amoxicilclarithromylansopraz
2
MO
RELISTOR
SUBCUTANEOUS
SYRINGE
3
MO
carafate oral
suspension
4
MO
4
REMICADE
5
PA; MO
MO; QL (31
per 31 days)
SUCRAID
5
MO
DEXILANT ORAL
CAPSULE,BIPHAS
E DELAYED
RELEAS 30 MG
sulfasalazine oral
tablet
2
MO
ULCER THERAPY
50
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
MO
nizatidine oral
capsule
2
MO
nizatidine oral
solution
4
MO
omeprazole oral
capsule,delayed
release(dr/ec) 10
mg, 20 mg
2
MO; QL (31
per 31 days)
omeprazole oral
capsule,delayed
2
MO
omeprazole-sodium
bicarbonate oral
capsule 20-1.1 mggram
2
MO; QL (31
per 31 days)
omeprazole-sodium
bicarbonate oral
capsule 40-1.1 mggram
2
MO
pantoprazole oral
tablet,delayed
release (dr/ec) 20
mg
2
MO; QL (31
per 31 days)
pantoprazole oral
tablet,delayed
release (dr/ec) 40
mg
2
MO
rabeprazole
2
MO
ranitidine hcl oral
capsule
2
MO
ranitidine hcl oral
syrup
3
MO
ranitidine hcl oral
tablet 150 mg, 300
mg
1
MO
sucralfate oral tablet
2
MO
DEXILANT ORAL
CAPSULE,BIPHAS
E DELAYED
RELEAS 60 MG
4
esomeprazole
sodium
2
famotidine (pf)
1
famotidine (pf)-nacl
(iso-os)
2
famotidine oral
suspension
3
MO
famotidine oral
tablet 20 mg, 40 mg
1
MO
lansoprazole oral
capsule,delayed
2
MO; QL (31
per 31 days)
lansoprazole oral
capsule,delayed
2
MO
misoprostol
2
MO
NEXIUM ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
20 MG
3
MO; QL (31
per 31 days)
NEXIUM ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
40 MG
3
NEXIUM PACKET
ORAL GRANULES
DR FOR SUSP IN
PACKET 10 MG,
2.5 MG, 20 MG, 5
MG
3
NEXIUM PACKET
ORAL GRANULES
DR FOR SUSP IN
PACKET 40 MG
3
MO
MO
MO; QL (31
per 31 days)
MO
Drug
Tier
Requirements
/Limits
IMMUNOLOGY, VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
51
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
PROCRIT
INJECTION
SOLUTION 10,000
UNIT/ML, 2,000
UNIT/ML, 3,000
UNIT/ML, 4,000
UNIT/ML
3
PA; MO
ACTIMMUNE
5
MO
ARCALYST
5
PA; MO
ILARIS (PF)
5
PA; MO; LA
INTRON A
INJECTION
RECON SOLN
5
MO
INTRON A
INJECTION
SOLUTION 6
MILLION
UNIT/ML
3
MO
PROCRIT
INJECTION
SOLUTION 20,000
UNIT/ML, 40,000
UNIT/ML
5
PA; MO
LEUKINE
INJECTION
RECON SOLN
5
MO
PROLEUKIN
4
MO
REBIF (WITH
ALBUMIN)
5
PA; MO; QL
(6 per 28 days)
MOZOBIL
5
MO
5
NEULASTA
SUBCUTANEOUS
SYRINGE
5
PA; MO; QL
(2 per 31 days)
PA; MO; QL
(6 per 28 days)
NEUMEGA
5
MO
REBIF REBIDOSE
SUBCUTANEOUS
PEN INJECTOR 22
MCG/0.5 ML, 44
MCG/0.5 ML
NEUPOGEN
5
PA; MO
5
NORDITROPIN
FLEXPRO
5
PA; MO
PA; MO; QL
(12 per 28
days)
OMNITROPE
SUBCUTANEOUS
CARTRIDGE 5
MG/1.5 ML (3.3
MG/ML)
4
PA; MO
REBIF REBIDOSE
SUBCUTANEOUS
PEN INJECTOR
8.8MCG/0.2ML-22
MCG/0.5ML (6)
REBIF TITRATION
PACK
5
PA; MO; QL
(12 per 28
days)
SYLATRON
5
MO
PEGASYS
5
MO; QL (4 per
28 days)
VACCINES / MISCELLANEOUS
IMMUNOLOGICALS
PEGASYS
PROCLICK
5
MO; QL (4 per
28 days)
ACTHIB (PF)
3
MO
PEGINTRON
5
MO; QL (4 per
28 days)
3
MO
PEGINTRON
REDIPEN
5
MO; QL (4 per
28 days)
ADACEL(TDAP
ADOLESN/ADULT
)(PF)
INTRAMUSCULA
R SUSPENSION
BCG VACCINE,
LIVE (PF)
3
MO
BEXSERO (PF)
3
MO
52
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
IPOL INJECTION
SUSPENSION
3
IPOL INJECTION
SYRINGE
3
IXIARO (PF)
3
MO
MENACTRA (PF)
INTRAMUSCULA
R SOLUTION
3
MO
MENOMUNE A/C/Y/W-135 (PF)
3
MO
MENVEO A-C-YW-135-DIP (PF)
3
MO
M-M-R II (PF)
3
MO
PEDVAX HIB (PF)
3
MO
PRIVIGEN
5
PA; MO
PROQUAD (PF)
3
QUADRACEL (PF)
3
RABAVERT (PF)
3
MO
RAGWITEK
3
MO
RECOMBIVAX HB
(PF)
INTRAMUSCULA
R SUSPENSION 10
MCG/ML, 40
MCG/ML
3
B/D PA; MO
RECOMBIVAX HB
(PF)
INTRAMUSCULA
R SYRINGE 10
MCG/ML
3
B/D PA; MO
RECOMBIVAX HB
(PF)
INTRAMUSCULA
R SYRINGE 5
MCG/0.5 ML
3
B/D PA
ROTARIX
3
ROTATEQ
VACCINE
3
BOOSTRIX TDAP
3
MO
BOTOX
3
PA; MO
CERVARIX
VACCINE (PF)
3
MO
COMVAX (PF)
3
MO
DAPTACEL (DTAP
PEDIATRIC) (PF)
3
MO
ENGERIX-B (PF)
INTRAMUSCULA
R SYRINGE
3
B/D PA; MO
ENGERIX-B
PEDIATRIC (PF)
INTRAMUSCULA
R SUSPENSION
3
B/D PA; MO
ENGERIX-B
PEDIATRIC (PF)
INTRAMUSCULA
R SYRINGE
3
GAMASTAN S/D
3
MO
GARDASIL (PF)
3
MO
GARDASIL 9 (PF)
3
MO
GRASTEK
3
MO
HAVRIX (PF)
INTRAMUSCULA
R SUSPENSION
1,440 ELISA
UNIT/ML
3
MO
HAVRIX (PF)
INTRAMUSCULA
R SYRINGE 720
ELISA UNIT/0.5
ML
3
IMOVAX RABIES
VACCINE (PF)
3
MO
INFANRIX (DTAP)
(PF)
INTRAMUSCULA
R SUSPENSION
3
MO
B/D PA
Drug
Tier
Requirements
/Limits
MO
MO
53
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
MO
COLCRYS
3
MO
probenecid
2
MO
ULORIC
3
MO
TENIVAC (PF)
INTRAMUSCULA
R SYRINGE
3
TETANUS,DIPHTH
ERIA TOX
PED(PF)
3
TETANUSDIPHTHERIA
TOXOIDS-TD
3
TRUMENBA
3
TWINRIX (PF)
INTRAMUSCULA
R SUSPENSION
3
TYPHIM VI
INTRAMUSCULA
R SOLUTION
3
TYPHIM VI
INTRAMUSCULA
R SYRINGE
3
VAQTA (PF)
INTRAMUSCULA
R SUSPENSION 25
UNIT/0.5 ML
3
VAQTA (PF)
INTRAMUSCULA
R SYRINGE
3
VARIVAX (PF)
3
VARIZIG
INTRAMUSCULA
R SOLUTION
5
YF-VAX (PF)
3
MO
ZOSTAVAX (PF)
3
MO
MO
MO
MO
MO
MO
MO
MUSCULOSKELETAL /
RHEUMATOLOGY
GOUT THERAPY
allopurinol
1
MO
colchicineprobenecid
2
MO
Requirements
/Limits
OSTEOPOROSIS THERAPY
alendronate oral
solution
3
MO; QL (1350
per 31 days)
alendronate oral
tablet 10 mg, 5 mg
2
MO; QL (31
per 31 days)
alendronate oral
tablet 35 mg, 70 mg
2
MO; QL (4 per
28 days)
EVISTA
3
MO
FORTEO
4
PA; MO; QL
(2.4 per 28
days)
ibandronate oral
3
MO; QL (1 per
31 days)
PROLIA
4
MO
raloxifene
2
MO
risedronate oral
tablet 150 mg, 35
mg, 5 mg
2
MO
risedronate oral
tablet 35 mg (12
pack)
2
risedronate oral
tablet,delayed
release (dr/ec)
3
MO
OTHER RHEUMATOLOGICALS
ACTEMRA
INTRAVENOUS
SOLUTION 200
MG/10 ML (20
MG/ML), 400
MG/20 ML (20
MG/ML)
5
PA; MO
54
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
PA; MO
ACTEMRA
INTRAVENOUS
SOLUTION 80
MG/4 ML (20
MG/ML)
3
ACTEMRA
SUBCUTANEOUS
5
BENLYSTA
INTRAVENOUS
RECON SOLN 120
MG
3
DEPEN
TITRATABS
3
MO
ENBREL
SUBCUTANEOUS
RECON SOLN
5
PA; MO; QL
(8 per 28 days)
ENBREL
SUBCUTANEOUS
SYRINGE 25
MG/0.5ML (0.51)
5
ENBREL
SUBCUTANEOUS
SYRINGE 50
MG/ML (0.98 ML)
5
ENBREL
SURECLICK
5
PA; MO; QL
(4 per 28 days)
leflunomide
2
MO; QL (31
per 31 days)
ORENCIA
5
PA; MO
ORENCIA (WITH
MALTOSE)
5
PA; MO
OTEZLA
5
PA; MO
OTEZLA
STARTER
5
PA; MO
RIDAURA
4
MO
SAVELLA ORAL
TABLET
3
MO; QL (62
per 31 days)
PA; MO
Drug
Tier
Requirements
/Limits
SAVELLA ORAL
TABLETS,DOSE
PACK
3
MO; QL (1 per
31 days)
SIMPONI ARIA
5
PA; MO
OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
MO
PA; MO; QL
(8 per 28 days)
PA; MO; QL
(4 per 28 days)
camila
2
MO
CRINONE
VAGINAL GEL 4
%
4
MO
CRINONE
VAGINAL GEL 8
%
4
PA; MO
deblitane
3
MO
DEPO-PROVERA
INTRAMUSCULA
R SOLUTION
3
MO
DEPO-SUBQ
PROVERA 104
4
MO
errin
2
MO
ESTRACE
VAGINAL
3
MO
estradiol oral
1
MO
estradiol
transdermal patch
semiweekly
1
MO
estradiol
transdermal patch
weekly
1
MO; QL (4 per
28 days)
estradiol valerate
intramuscular oil 20
mg/ml
3
MO
estradiol valerate
intramuscular oil 40
mg/ml
2
MO
estradiolnorethindrone acet
3
MO
ESTRING
4
MO
55
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
CLEOCIN
VAGINAL
SUPPOSITORY
3
MO
clindamycin
phosphate vaginal
2
MO
metronidazole
vaginal
2
MO
miconazole-3
vaginal suppository
3
MO
NUVARING
4
MO
estropipate oral
tablet 0.75 mg
1
MO
estropipate oral
tablet 1.5 mg, 3 mg
2
MO
jinteli
3
MO
jolivette
2
MO
lyza
2
MO
medroxyprogesteron
e intramuscular
suspension
3
MO
medroxyprogesteron
e oral
1
MO
terconazole vaginal
cream
2
MO
MENEST
4
MO
3
MO
nora-be
2
MO
terconazole vaginal
suppository
norethindrone
(contraceptive)
2
MO
tranexamic acid oral
3
MO
vandazole
2
MO
norethindrone
acetate
3
MO
xulane
2
MO
2
norethindrone ac-eth
estradiol oral tablet
0.5-2.5 mg-mcg, 1-5
mg-mcg
3
MO
zazole vaginal cream
0.4 %
norlyroc
3
PREFEST
4
MO
PREMARIN ORAL
3
MO
PREMARIN
VAGINAL
3
MO
PREMPHASE
3
MO
PREMPRO
3
MO
progesterone
micronized
3
sharobel
VAGIFEM
ORAL CONTRACEPTIVES /
RELATED AGENTS
amethia
2
MO
amethyst
3
MO
apri
2
MO
aranelle (28)
2
MO
ashlyna
2
MO
aubra
2
MO
aviane
2
MO
MO
balziva (28)
2
MO
briellyn
2
MO
3
MO
cryselle (28)
2
MO
3
MO
cyclafem 1/35 (28)
2
MO
cyclafem 7/7/7 (28)
2
MO
delyla (28)
2
MISCELLANEOUS OB/GYN
56
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
levonest (28)
2
MO
levonorgestrelethinyl estrad oral
tablet 0.1-20 mgmcg
2
MO
tablet 90-20 mcg
2
tablets,dose pack,3
month
2
MO
levora-28
2
MO
loryna (28)
3
MO
desoge.estradiol/e.estradio
l
2
drospirenone-ethinyl
estradiol oral tablet
3-0.03 mg
3
ELLA
3
MO
emoquette
2
MO
enpresse
2
MO
falmina (28)
2
MO
gianvi (28)
2
MO
gildagia
2
MO
gildess 24 fe
2
MO
gildess oral tablet
1.5-30 mg-mcg
2
MO
low-ogestrel (28)
2
MO
lutera (28)
2
MO
introvale
4
MO
marlissa
2
MO
junel 1.5/30 (21)
2
MO
2
MO
junel 1/20 (21)
2
MO
microgestin 1.5/30
(21)
junel fe 1.5/30 (28)
2
MO
2
MO
junel fe 1/20 (28)
2
MO
microgestin 1/20
(21)
junel fe 24
2
MO
microgestin fe 1.5/30
(28)
2
MO
kariva (28)
2
MO
2
MO
kelnor 1/35 (28)
2
MO
microgestin fe 1/20
(28)
kimidess (28)
2
mononessa (28)
2
MO
l norgest/e.estradiole.estrad oral
tablets,dose pack,3
month 0.15 mg-30
mcg (84)/10 mcg (7)
2
necon 0.5/35 (28)
2
MO
necon 1/35 (28)
2
MO
necon 10/11 (28)
2
MO
necon 7/7/7 (28)
2
MO
larin 1.5/30 (21)
2
MO
nikki (28)
2
MO
larin 1/20 (21)
2
MO
2
MO
larin fe
2
MO
layolis fe
2
MO
leena 28
2
MO
noreth-ethinyl
estradiol-iron oral
tablet,chewable
0.8mg-25mcg(24)
and 75 mg (4)
lessina
2
MO
MO
57
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MO
zovia 1/35e (28)
2
MO
zovia 1/50e (28)
2
MO
4
MO
norethindronee.estradiol-iron oral
tablet 1 mg-20 mcg
(24)/75 mg (4)
2
nortrel 0.5/35 (28)
2
MO
nortrel 1/35 (21)
2
MO
nortrel 1/35 (28)
2
MO
OPHTHALMOLOGY
nortrel 7/7/7 (28)
2
MO
ANTIBIOTICS
ocella
2
MO
AZASITE
3
MO
ogestrel (28)
2
MO
3
MO
orsythia
2
MO
bacitracin
ophthalmic
pimtrea (28)
2
MO
2
MO
pirmella oral tablet
1-35 mg-mcg
2
MO
bacitracinpolymyxin b
ophthalmic
portia
2
MO
BESIVANCE
3
MO
previfem
2
MO
3
MO
quasense
4
MO
CILOXAN
OPHTHALMIC
OINTMENT
reclipsen (28)
2
MO
2
MO
sprintec (28)
2
MO
ciprofloxacin hcl
ophthalmic
sronyx
2
MO
erythromycin
ophthalmic
2
MO
tarina fe
2
MO
2
tri-legest fe
2
MO
garamycin
ophthalmic drops
trinessa (28)
2
MO
gatifloxacin
2
MO
tri-previfem (28)
2
MO
2
MO
tri-sprintec (28)
2
MO
gentak ophthalmic
ointment
trivora (28)
2
MO
gentamicin
ophthalmic drops
2
MO
velivet triphasic
regimen (28)
2
MO
gentamicin
ophthalmic ointment
1
MO
vestura (28)
2
MO
3
MO
vyfemla (28)
2
MO
levofloxacin
ophthalmic
wymzya fe
2
MO
MOXEZA
4
MO
zenchent (28)
2
MO
NATACYN
3
MO
zenchent fe
3
MO
OXYTOCICS
methylergonovine
oral
58
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
neomycinbacitracinpolymyxin
3
MO
CHOLINESTERASE INHIBITOR
MIOTICS
neomycinpolymyxingramicidin
2
MO
ofloxacin ophthalmic
2
MO
polymyxin b sulftrimethoprim
2
MO
tobramycin
2
MO
TOBREX
OPHTHALMIC
OINTMENT
3
MO
VIGAMOX
4
MO
trifluridine
3
MO
ZIRGAN
4
MO
PHOSPHOLINE
IODIDE
Drug
Tier
4
Requirements
/Limits
MO
CYCLOPLEGIC MYDRIATICS
ANTIVIRALS
BETA-BLOCKERS
atropine ophthalmic
drops
3
MO
DIRECT ACTING MIOTICS
pilocarpine hcl
ophthalmic drops 1
%, 2 %, 4 %
2
MO
MISCELLANEOUS
OPHTHALMOLOGICS
azelastine
ophthalmic
3
MO
cromolyn
ophthalmic
2
MO
CYSTARAN
5
MO
betaxolol ophthalmic
3
MO
epinastine
3
MO
BETOPTIC S
3
MO
LACRISERT
3
MO
carteolol
2
MO
LASTACAFT
3
MO
levobunolol
ophthalmic drops
0.5 %
2
MO
PATADAY
3
MO
PATANOL
3
MO
metipranolol
2
MO
PAZEO
3
MO
timolol maleate
ophthalmic drops
0.25 %
1
MO
proparacaine
2
MO
RESTASIS
3
MO; QL (90
per 31 days)
timolol maleate
ophthalmic drops
0.5 %
2
MO
timolol maleate
ophthalmic gel
forming solution
2
MO
TIMOPTIC
OCUDOSE (PF)
3
MO
NON-STEROIDAL ANTIINFLAMMATORY AGENTS
bromfenac
4
MO
diclofenac sodium
ophthalmic
2
MO
flurbiprofen sodium
1
MO
ILEVRO
3
MO
59
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
ketorolac
ophthalmic
2
MO
3
MO
NEVANAC
3
MO
neomycinpolymyxin-hc
ophthalmic
PROLENSA
3
MO
tobramycindexamethasone
3
MO
dexamethasone
sodium phosphate
ophthalmic
2
MO
DUREZOL
4
MO
fluorometholone
3
MO
FML FORTE
4
MO
FML S.O.P.
4
MO
prednisolone acetate
2
MO
prednisolone sodium
phosphate
ophthalmic
3
MO
ORAL DRUGS FOR GLAUCOMA
acetazolamide oral
capsule, extended
release
3
MO
acetazolamide oral
tablet
2
MO
acetazolamide
sodium
2
MO
methazolamide oral
tablet 25 mg
3
MO
methazolamide oral
tablet 50 mg
4
MO
OTHER GLAUCOMA DRUGS
AZOPT
4
MO
bimatoprost
3
MO
COMBIGAN
3
MO
dorzolamide
2
MO
dorzolamide-timolol
3
MO
latanoprost
2
LUMIGAN
OPHTHALMIC
DROPS 0.01 %
3
SIMBRINZA
4
MO
TRAVATAN Z
3
MO
travoprost
(benzalkonium)
3
MO
Requirements
/Limits
STEROIDS
STEROID-SULFONAMIDE
COMBINATIONS
BLEPHAMIDE
4
MO
BLEPHAMIDE
S.O.P.
4
MO
MO
sulfacetamideprednisolone
2
MO
MO
SULFONAMIDES
BLEPH-10
3
MO
sulfacetamide
sodium ophthalmic
drops
2
MO
sulfacetamide
sodium ophthalmic
ointment
3
MO
STEROID-ANTIBIOTIC
COMBINATIONS
SYMPATHOMIMETICS
neomycinbacitracin-poly-hc
3
MO
neomycin-polymyxin
b-dexameth
2
MO
ALPHAGAN P
OPHTHALMIC
DROPS 0.1 %
3
MO
60
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
epinephrine
injection autoinjector
3
MO; QL (4 per
31 days)
EPIPEN 2-PAK
3
MO; QL (4 per
31 days)
EPIPEN JR 2-PAK
3
MO; QL (4 per
31 days)
hydroxyzine hcl oral
solution 10 mg/5 ml
2
PA; MO
hydroxyzine hcl oral
tablet
2
PA; MO
levocetirizine oral
solution
3
MO
ANTIHISTAMINE /
ANTIALLERGENIC AGENTS
levocetirizine oral
tablet
2
MO; QL (31
per 31 days)
adrenalin injection
solution 1 mg/ml
(1:1,000) (1ml)
2
promethazine
injection solution
2
MO
carbinoxamine
maleate
2
MO
promethazine oral
2
PA; MO
2
MO
cetirizine oral
solution 1 mg/ml
2
MO
promethazine rectal
suppository 12.5 mg,
25 mg
clemastine oral
tablet 2.68 mg
2
MO
promethazine rectal
suppository 50 mg
2
cyproheptadine oral
syrup
3
MO
promethegan rectal
suppository 25 mg
3
MO
cyproheptadine oral
tablet
2
MO
promethegan rectal
suppository 50 mg
4
MO
desloratadine oral
tablet
3
MO; QL (31
per 31 days)
desloratadine oral
4
MO; QL (31
per 31 days)
diphenhydramine hcl
mg/ml
2
diphenhydramine hcl
oral elixir
2
apraclonidine
3
MO
brimonidine
ophthalmic drops
0.15 %
3
MO
brimonidine
ophthalmic drops
0.2 %
2
MO
VASOCONSTRICTOR
DECONGESTANTS
naphazoline
1
MO
RESPIRATORY AND
ALLERGY
PULMONARY AGENTS
acetylcysteine
2
B/D PA; MO
ADEMPAS
5
PA; MO; LA
ADVAIR DISKUS
4
MO; QL (60
per 30 days)
ADVAIR HFA
4
MO
albuterol sulfate
inhalation solution
for nebulization 0.63
mg/3 ml, 1.25 mg/3
ml
2
B/D PA; MO
MO
61
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
B/D PA; MO
BREO ELLIPTA
3
MO; QL (60
per 31 days)
budesonide
inhalation
3
B/D PA; MO
budesonide nasal
2
MO; QL (25.8
per 31 days)
CINRYZE
5
PA; MO
COMBIVENT
RESPIMAT
3
MO; QL (8 per
31 days)
cromolyn inhalation
2
B/D PA; MO
DALIRESP
3
PA; MO
DULERA
3
MO; QL (26
per 31 days)
ELIXOPHYLLIN
ORAL ELIXIR 80
MG/15 ML
4
MO
ESBRIET
5
PA; MO; QL
(279 per 31
days)
FIRAZYR
5
PA; MO
FLOVENT DISKUS
INHALATION
BLISTER WITH
DEVICE 100
MCG/ACTUATION
, 50
MCG/ACTUATION
3
MO; QL (120
per 31 days)
FLOVENT DISKUS
INHALATION
BLISTER WITH
DEVICE 250
MCG/ACTUATION
3
MO; QL (300
per 31 days)
FLOVENT HFA
INHALATION HFA
AEROSOL
INHALER 110
MCG/ACTUATION
3
MO; QL (24
per 31 days)
albuterol sulfate
inhalation solution
for nebulization 2.5
mg /3 ml (0.083 %),
5 mg/ml
1
albuterol sulfate oral
syrup
1
MO
tablet
4
MO
tablet extended
release 12 hr
4
MO
ANORO ELLIPTA
4
MO
ARCAPTA
NEOHALER
4
MO; QL (60
per 31 days)
ARNUITY
ELLIPTA
3
MO
ASMANEX
TWISTHALER
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED 110
MCG (30 DOSES),
220 MCG (30
DOSES)
3
MO; QL (30
per 31 days)
ASMANEX
TWISTHALER
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED 220
MCG (120 DOSES)
3
ASMANEX
TWISTHALER
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED 220
MCG (60 DOSES)
3
MO; QL (60
per 31 days)
ATROVENT HFA
3
MO; QL (38.7
per 31 days)
MO; QL (240
per 31 days)
Drug
Tier
Requirements
/Limits
62
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MO; QL (36
per 31 days)
OFEV
5
PA; MO; QL
(62 per 31
days)
ORKAMBI
5
PA; MO; QL
(112 per 28
days)
PERFOROMIST
3
B/D PA; MO
PROAIR HFA
3
MO; QL (17
per 31 days)
PROAIR
RESPICLICK
3
MO; QL (17
per 31 days)
PULMICORT
INHALATION
SUSPENSION FOR
NEBULIZATION 1
MG/2 ML
3
B/D PA; MO
PULMOZYME
5
B/D PA; MO
QVAR
3
MO
FLOVENT HFA
INHALATION HFA
AEROSOL
INHALER 220
MCG/ACTUATION
3
FLOVENT HFA
INHALATION HFA
AEROSOL
INHALER 44
MCG/ACTUATION
3
flunisolide nasal
spray,non-aerosol
25 mcg (0.025 %)
2
fluticasone nasal
2
MO; QL (32
per 31 days)
FORADIL
AEROLIZER
3
MO
INCRUSE
ELLIPTA
3
MO
ipratropium bromide
inhalation
2
B/D PA; MO
SEREVENT
DISKUS
3
MO; QL (120
per 31 days)
KALYDECO ORAL
GRANULES IN
PACKET
5
MO; QL (56
per 28 days)
sildenafil oral
2
PA; MO; QL
(93 per 31
days)
KALYDECO ORAL
TABLET
5
MO
4
MO
LETAIRIS
5
PA; MO; LA
metaproterenol oral
syrup
1
MO
SPIRIVA
RESPIMAT
INHALATION
MIST 2.5
MCG/ACTUATION
metaproterenol oral
tablet
2
MO
SPIRIVA WITH
HANDIHALER
4
MO
montelukast oral
granules in packet
3
MO
SYMBICORT
3
MO; QL (20.4
per 31 days)
montelukast oral
tablet
2
MO
terbutaline oral
2
MO
2
MO
montelukast oral
tablet,chewable
2
MO
terbutaline
subcutaneous
2
MO
NASONEX
3
MO; QL (51
per 31 days)
theophylline oral
tablet extended
release
MO; QL (21.2
per 31 days)
MO; QL (50
per 31 days)
63
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
MO
oxybutynin chloride
oral tablet
2
MO
oxybutynin chloride
release 24hr
3
MO
tolterodine oral
capsule,extended
release 24hr
2
MO
tolterodine oral
tablet
4
MO
trospium oral
capsule,extended
release 24hr
4
MO
trospium oral tablet
3
MO
theophylline oral
tablet extended
release 12 hr
2
TRACLEER
5
PA; MO; LA
triamcinolone
acetonide nasal
3
MO; QL (33
per 31 days)
TUDORZA
PRESSAIR
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED 400
MCG/ACTUATION
3
MO; QL (1 per
31 days)
TUDORZA
PRESSAIR
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED 400
MCG/ACTUATION
(30 ACTUAT)
3
TYVASO
5
B/D PA; MO
XOLAIR
5
PA; MO; LA;
QL (6 per 28
days)
zafirlukast
2
QL (1 per 31
days)
Drug
Tier
Requirements
/Limits
BENIGN PROSTATIC
HYPERPLASIA(BPH) THERAPY
alfuzosin
3
MO
AVODART
3
MO
finasteride oral
tablet 5 mg
2
MO
JALYN
3
MO
tamsulosin
2
MO
MO
CHOLINERGIC STIMULANTS
bethanechol chloride
oral tablet 10 mg, 25
mg, 50 mg
3
MO
bethanechol chloride
oral tablet 5 mg
2
MO
UROLOGICALS
ANTICHOLINERGICS /
ANTISPASMODICS
flavoxate
3
MO
GELNIQUE
TRANSDERMAL
GEL IN
METERED-DOSE
PUMP
3
MO; QL (184
per 31 days)
GELNIQUE
TRANSDERMAL
GEL IN PACKET
3
oxybutynin chloride
oral syrup
2
MO; QL (31
per 31 days)
MISCELLANEOUS UROLOGICALS
CIALIS ORAL
TABLET 2.5 MG, 5
MG
3
PA; MO; QL
(31 per 31
days)
CYSTAGON
3
MO; LA
ELMIRON
3
MO
potassium citrate
3
MO
MO
64
Drug Name
Drug
Tier
Requirements
/Limits
VITAMINS, HEMATINICS /
ELECTROLYTES
ELECTROLYTES
calcium acetate oral
capsule
3
dextrose-kcl-nacl
2
eliphos
3
MO
klor-con 10
2
MO
klor-con 8
2
MO
klor-con m15
2
MO
klor-con m20
2
MO
K-TAB ORAL
TABLET
EXTENDED
RELEASE 10 MEQ,
20 MEQ
4
MO
k-tab oral tablet
extended release 8
meq
2
lactated ringers
intravenous
2
MO
magnesium sulfate
injection solution
2
MO
magnesium sulfate
injection syringe
2
NORMOSOL-R IN
5 % DEXTROSE
3
potassium chloridd5-0.45%nacl
intravenous
parenteral solution
10 meq/l, 40 meq/l
2
intravenous
parenteral solution
20 meq/l
2
MO
MO
Drug Name
Drug
Tier
Requirements
/Limits
intravenous
parenteral solution
30 meq/l
1
potassium chloride
in 0.9%nacl
intravenous
parenteral solution
20 meq/l, 40 meq/l
2
potassium chloride
in 5 % dex
intravenous
parenteral solution
20 meq/l, 40 meq/l
2
potassium chloride
in lr-d5 intravenous
parenteral solution
20 meq/l
2
potassium chloride
intravenous
piggyback 10
meq/100 ml, 20
meq/100 ml, 40
meq/100 ml
1
potassium chloride
1
MO
potassium chloride
oral capsule,
extended release
2
MO
potassium chloride
oral liquid
2
MO
potassium chloride
release 8 meq
2
MO
potassium chloride
oral tablet,er
particles/crystals
2
MO
potassium chloride0.45 % nacl
2
MO
65
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MO
AMINOSYN II 15
%
3
B/D PA
AMINOSYN II 7 %
3
B/D PA
AMINOSYN II 8.5
%
3
B/D PA
AMINOSYN II 8.5
%ELECTROLYTES
3
B/D PA
AMINOSYN M 3.5
%
3
B/D PA
AMINOSYN-HBC
7%
3
B/D PA
AMINOSYN-PF 10
%
3
B/D PA
AMINOSYN-PF 7
% (SULFITEFREE)
3
B/D PA
AMINOSYN-RF 5.2
%
3
B/D PA
potassium chlorided5-0.2%nacl
intravenous
parenteral solution
20 meq/l
2
intravenous
parenteral solution
20 meq/l
2
intravenous
parenteral solution
20 meq/l
2
intravenous
parenteral solution
40 meq/l
2
ringers intravenous
2
sodium chloride 0.45
% intravenous
parenteral solution
1
MO
CLINIMIX
5%/D15W
SULFITE FREE
3
B/D PA
sodium chloride 3 %
2
MO
3
B/D PA
sodium chloride 5 %
2
sodium chloride
intravenous
parenteral solution
2.5 meq/ml
2
CLINIMIX
5%/D25W
SULFITE-FREE
CLINIMIX
2.75%/D5W
SULFIT FREE
3
B/D PA
MISCELLANEOUS NUTRITION
PRODUCTS
CLINIMIX
4.25%/D10W SULF
FREE
3
B/D PA
AMINOSYN 7 %
WITH
ELECTROLYTES
3
B/D PA
CLINIMIX 4.25%D20W SULF-FREE
3
B/D PA
AMINOSYN 8.5 %ELECTROLYTES
3
B/D PA
CLINIMIX 4.25%D25W SULF-FREE
3
B/D PA
AMINOSYN II 10
%
3
B/D PA
CLINIMIX 5%D20W(SULFITEFREE)
3
B/D PA
MO
MO
66
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
FREAMINE HBC
6.9 %
3
B/D PA
prenatal vitamin
oral tablet
1
MO
HEPATAMINE 8%
3
B/D PA
2
MO
intralipid
intravenous
emulsion 20 %
3
B/D PA; MO
sodium fluoride oral
tablet
INTRALIPID
INTRAVENOUS
EMULSION 30 %
3
B/D PA
IONOSOL-B IN
D5W
3
IONOSOL-MB IN
D5W
3
ISOLYTE-P IN 5 %
DEXTROSE
3
ISOLYTE-S
3
liposyn iii
intravenous
emulsion 10 %
2
B/D PA
NEPHRAMINE 5.4
%
3
B/D PA
NORMOSOL-R PH
7.4
3
NUTRILIPID
3
PLASMA-LYTE
148
3
PLASMA-LYTE A
3
PLASMA-LYTE-56
IN 5 % DEXTROSE
3
premasol 10 %
2
B/D PA; MO
PREMASOL 6 %
3
B/D PA
travasol 10 %
3
B/D PA; MO
TROPHAMINE 10
%
3
B/D PA; MO
TROPHAMINE 6%
3
B/D PA
B/D PA
VITAMINS / HEMATINICS
67
Index
8
8-MOP .................................. 37
A
abacavir .................................. 1
abacavir-lamivudinezidovudine .......................... 1
ABELCET .............................. 1
ABILIFY .............................. 25
ABILIFY MAINTENA ........ 25
ABRAXANE ........................ 11
acamprosate .......................... 41
acarbose ................................ 44
acebutolol ............................. 32
acetaminophen-codeine ........ 22
acetasol hc ............................ 43
acetazolamide ....................... 60
acetazolamide sodium .......... 60
acetic acid ............................. 43
acetylcysteine ....................... 61
acitretin ................................. 37
ACTEMRA .................... 54, 55
ACTHIB (PF) ....................... 52
ACTIMMUNE ..................... 52
ACTONEL ........................... 41
acyclovir ........................... 1, 39
acyclovir sodium .................... 2
ADACEL(TDAP
ADOLESN/ADULT)(PF) 52
ADAGEN ............................. 41
adapalene .............................. 37
adefovir................................... 2
ADEMPAS ........................... 61
adrenalin ............................... 61
adrucil ................................... 11
ADVAIR DISKUS ............... 61
ADVAIR HFA ..................... 61
AFINITOR ........................... 11
AFINITOR DISPERZ .......... 11
AGGRENOX ....................... 35
a-hydrocort ........................... 43
ALBENZA ............................. 6
albuterol sulfate .............. 61, 62
alclometasone ....................... 39
alcohol pads .......................... 44
ALDURAZYME .................. 47
alendronate ..................... 41, 54
alfuzosin ............................... 64
ALIMTA .............................. 11
ALINIA .................................. 6
allopurinol ............................ 54
alosetron ............................... 49
ALOXI.................................. 49
ALPHAGAN P ..................... 60
alprazolam ............................ 25
alprazolam intensol............... 25
ALTABAX ........................... 39
amantadine hcl ........................ 2
AMBISOME .......................... 1
amcinonide ........................... 39
amethia ................................. 56
amethyst................................ 56
amifostine crystalline ........... 11
amikacin ................................. 6
amiloride ............................... 32
amiloride-hydrochlorothiazide
.......................................... 32
AMINOSYN 7 % WITH
ELECTROLYTES............ 66
AMINOSYN 8.5 %ELECTROLYTES............ 66
AMINOSYN II 10 % ........... 66
AMINOSYN II 15 % ........... 66
AMINOSYN II 7 % ............. 66
AMINOSYN II 8.5 % .......... 66
AMINOSYN II 8.5 %ELECTROLYTES............ 66
AMINOSYN M 3.5 %.......... 66
AMINOSYN-HBC 7%......... 66
AMINOSYN-PF 10 % ......... 66
AMINOSYN-PF 7 %
(SULFITE-FREE) ............ 66
AMINOSYN-RF 5.2 % ........ 66
amiodarone ........................... 32
AMITIZA ............................. 49
amitriptyline ......................... 25
amlodipine ............................ 32
amlodipine-atorvastatin ........ 36
amlodipine-benazepril .......... 32
amlodipine-valsartan ............ 32
amlodipine-valsartan-hcthiazid
.......................................... 32
ammonium lactate ................ 37
amoxapine ............................ 25
amoxicil-clarithromy-lansopraz
.......................................... 50
amoxicillin .............................. 8
amoxicillin-pot clavulanate 8, 9
amphotericin b ........................ 1
ampicillin ................................ 9
ampicillin sodium ................... 9
ampicillin-sulbactam .............. 9
AMPYRA ............................. 21
anagrelide ............................. 41
anastrozole ............................ 11
ANDROGEL ........................ 47
ANDROID ............................ 47
ANORO ELLIPTA ............... 62
apexicon e ............................. 39
APOKYN ............................. 20
apraclonidine ........................ 61
apri ........................................ 56
APRISO ................................ 49
APTIOM ............................... 18
APTIVUS ............................... 2
ARALAST NP...................... 41
aranelle (28) .......................... 56
ARCALYST ......................... 52
ARCAPTA NEOHALER ..... 62
aripiprazole ........................... 25
ARNUITY ELLIPTA ........... 62
ARRANON .......................... 12
ARZERRA ........................... 12
ASACOL HD ....................... 49
ashlyna .................................. 56
ASMANEX TWISTHALER 62
aspirin-dipyridamole............. 35
atenolol ................................. 32
atenolol-chlorthalidone ......... 32
atorvastatin ........................... 36
atovaquone .............................. 6
atovaquone-proguanil ............. 6
ATRIPLA ............................... 2
atropine ........................... 48, 59
ATROVENT HFA................ 62
aubra ..................................... 56
AUGMENTIN ........................ 9
AVASTIN............................. 12
aviane .................................... 56
avita ...................................... 37
AVODART........................... 64
68
azacitidine............................. 12
AZACTAM IN DEXTROSE
(ISO-OSM) ......................... 6
AZASITE ............................. 58
azathioprine .......................... 12
azelastine ........................ 43, 59
AZELEX .............................. 37
AZILECT ............................. 20
azithromycin ........................... 5
AZOPT ................................. 60
aztreonam ............................... 6
B
bacitracin .............................. 58
bacitracin-polymyxin b ........ 58
baclofen ................................ 21
BACTROBAN NASAL ....... 43
balsalazide ............................ 49
balziva (28)........................... 56
BANZEL .............................. 18
BARACLUDE ....................... 2
BCG VACCINE, LIVE (PF) 52
BELEODAQ ........................ 12
benazepril ............................. 33
benazepril-hydrochlorothiazide
.......................................... 33
BENICAR ............................ 33
BENICAR HCT ................... 33
BENLYSTA ......................... 55
benztropine ........................... 20
BESIVANCE ....................... 58
betamethasone dipropionate . 39
betamethasone valerate ........ 39
betamethasone, augmented... 39
betaxolol ......................... 33, 59
bethanechol chloride ............ 64
BETOPTIC S........................ 59
bexarotene ............................ 12
BEXSERO (PF).................... 52
bicalutamide ......................... 12
BICILLIN C-R ....................... 9
BICILLIN L-A ....................... 9
BICNU ................................. 12
BIDIL ................................... 33
BILTRICIDE .......................... 6
bimatoprost ........................... 60
bisoprolol fumarate .............. 33
bisoprolol-hydrochlorothiazide
.......................................... 33
bleomycin ............................. 12
BLEPH-10 ............................ 60
BLEPHAMIDE .................... 60
BLEPHAMIDE S.O.P. ......... 60
BOOSTRIX TDAP............... 53
BOSULIF ............................. 12
BOTOX ................................ 53
BREO ELLIPTA .................. 62
briellyn.................................. 56
BRILINTA ........................... 35
brimonidine .......................... 61
BRINTELLIX ...................... 25
bromfenac ............................. 59
bromocriptine ....................... 20
budesonide ...................... 49, 62
bumetanide ........................... 33
buprenorphine hcl ................. 22
buproban ............................... 42
bupropion hcl .................. 25, 26
buspirone .............................. 26
BUSULFEX ......................... 12
butorphanol tartrate .............. 24
BUTRANS ........................... 22
BYDUREON ........................ 44
BYETTA .............................. 44
BYSTOLIC .......................... 33
C
cabergoline ........................... 47
calcipotriene ......................... 37
calcipotriene-betamethasone 37
calcitonin (salmon) ............... 47
calcitriol .......................... 37, 47
calcium acetate ..................... 65
camila ................................... 55
CANASA.............................. 49
CANCIDAS............................ 1
candesartan ........................... 33
candesartan-hydrochlorothiazid
.......................................... 33
CAPASTAT ........................... 6
CAPEX ................................. 39
CAPRELSA.......................... 12
captopril ................................ 33
captopril-hydrochlorothiazide
.......................................... 33
CARAC ................................ 37
carafate ................................. 50
CARBAGLU ........................ 41
carbamazepine ...................... 18
carbidopa .............................. 20
carbidopa-levodopa .............. 20
carbidopa-levodopaentacapone ........................ 20
carbinoxamine maleate ......... 61
carboplatin ............................ 12
carteolol ................................ 59
cartia xt ................................. 33
carvedilol .............................. 33
CAYSTON ............................. 6
cefaclor ................................... 4
cefadroxil ................................ 4
cefazolin ................................. 4
cefazolin in dextrose (iso-os).. 4
cefdinir .................................... 4
cefepime ................................. 4
cefixime .................................. 4
cefotaxime .............................. 4
cefoxitin .................................. 4
cefpodoxime ........................... 4
ceftazidime ......................... 4, 5
ceftriaxone .............................. 5
cefuroxime axetil .................... 5
cefuroxime sodium ................. 5
celecoxib ............................... 24
CELLCEPT .......................... 12
CELLCEPT INTRAVENOUS
.......................................... 12
CELONTIN .......................... 18
cephalexin ............................... 5
CERDELGA ......................... 47
CEREZYME......................... 47
CERVARIX VACCINE (PF)
.......................................... 53
cetirizine ............................... 61
cevimeline............................. 41
CHANTIX ............................ 42
CHANTIX CONTINUING
MONTH BOX .................. 42
CHANTIX STARTING
MONTH BOX .................. 42
CHEMET .............................. 41
CHENODAL ........................ 49
chloramphenicol sod succinate
............................................ 6
chlorhexidine gluconate........ 43
chloroquine phosphate ............ 6
chlorothiazide ....................... 33
chlorothiazide sodium .......... 33
chlorpromazine ..................... 26
69
chlorthalidone ....................... 33
cholestyramine light ............. 36
chorionic gonadotropin, human
.......................................... 47
CIALIS ................................. 64
ciclopirox .............................. 39
cidofovir ................................. 2
cilostazol............................... 35
CILOXAN ............................ 58
CIMZIA ................................ 49
CIMZIA POWDER FOR
RECONST........................ 49
CINRYZE............................. 62
CIPRO HC............................ 43
CIPRODEX .......................... 43
ciprofloxacin......................... 10
ciprofloxacin hcl ............. 10, 58
ciprofloxacin in 5 % dextrose
.......................................... 10
ciprofloxacin lactate ............. 10
cisplatin ................................ 12
citalopram ............................. 26
cladribine .............................. 12
claravis ................................. 37
clarithromycin .................... 5, 6
clemastine ............................. 61
CLEOCIN............................. 56
clindamycin hcl ...................... 6
clindamycin in 5 % dextrose . 6,
7
clindamycin pediatric ............. 7
clindamycin phosphate .... 7, 37,
38, 56
clindamycin-benzoyl peroxide
.......................................... 38
CLINIMIX 5%/D15W
SULFITE FREE ............... 66
CLINIMIX 5%/D25W
SULFITE-FREE ............... 66
CLINIMIX 2.75%/D5W
SULFIT FREE.................. 66
CLINIMIX 4.25%/D10W
SULF FREE ..................... 66
CLINIMIX 4.25%/D5W
SULFIT FREE.................. 41
CLINIMIX 4.25%-D20W
SULF-FREE ..................... 66
CLINIMIX 4.25%-D25W
SULF-FREE ..................... 66
CLINIMIX 5%D20W(SULFITE-FREE).. 66
clobetasol .............................. 40
clobetasol-emollient ............. 40
clodan ................................... 40
CLOLAR .............................. 12
clomipramine ........................ 26
clonazepam ........................... 18
clonidine ............................... 33
clonidine hcl ......................... 33
clopidogrel ............................ 35
clorazepate dipotassium ....... 26
clotrimazole ...................... 1, 39
clotrimazole-betamethasone . 39
clozapine ............................... 26
COARTEM ............................ 7
codeine sulfate ...................... 22
colchicine-probenecid .......... 54
COLCRYS............................ 54
colestipol .............................. 36
colistin (colistimethate na) ..... 7
COLY-MYCIN S ................. 43
COMBIGAN ........................ 60
COMBIVENT RESPIMAT . 62
COMETRIQ ......................... 12
COMPLERA .......................... 2
compro .................................. 49
COMVAX (PF) .................... 53
CONDYLOX........................ 37
constulose ............................. 49
COPAXONE ........................ 21
CORDRAN TAPE LARGE
ROLL................................ 40
COREG CR .......................... 33
CORLANOR ........................ 36
CORTIFOAM ...................... 49
cortisone ............................... 43
CORTISPORIN-TC ............. 43
COSMEGEN ........................ 12
CREON ................................ 49
CRESEMBA .......................... 1
CRESTOR ............................ 36
CRINONE ............................ 55
CRIXIVAN ............................ 2
cromolyn ................... 49, 59, 62
cryselle (28) .......................... 56
CUBICIN................................ 7
cyclafem 1/35 (28)................ 56
cyclafem 7/7/7 (28) .............. 56
cyclobenzaprine .................... 21
cyclophosphamide ................ 12
CYCLOSET ......................... 44
cyclosporine .......................... 12
cyclosporine modified .......... 12
CYMBALTA ........................ 26
cyproheptadine ..................... 61
CYRAMZA .......................... 12
CYSTADANE ...................... 49
CYSTAGON ........................ 64
CYSTARAN......................... 59
cytarabine ............................. 12
cytarabine (pf) ...................... 12
D
d10 % & 0.45 % sodium
chloride ............................. 41
d2.5 %-0.45 % sodium
chloride ............................. 41
d5 % and 0.9 % sodium
chloride ............................. 41
d5 %-0.45 % sodium chloride
.......................................... 41
dacarbazine ........................... 12
DALIRESP ........................... 62
danazol .................................. 47
dantrolene ............................. 21
DAPSONE .............................. 7
DAPTACEL (DTAP
PEDIATRIC) (PF) ............ 53
DARAPRIM ........................... 7
daunorubicin ......................... 12
DAUNOXOME .................... 13
deblitane ............................... 55
decitabine .............................. 13
delyla (28) ............................. 56
DELZICOL........................... 49
demeclocycline ..................... 10
DEMSER .............................. 33
DENAVIR ............................ 39
DEPEN TITRATABS .......... 55
DEPO-MEDROL ................. 43
DEPO-PROVERA ................ 55
DEPO-SUBQ PROVERA 104
.......................................... 55
desipramine........................... 26
desloratadine ......................... 61
desmopressin ........................ 47
desog-e.estradiol/e.estradiol . 57
desonide ................................ 40
70
desoximetasone .................... 40
dexamethasone ..................... 43
dexamethasone intensol........ 43
dexamethasone sodium
phosphate.................... 43, 60
dexedrine .............................. 26
DEXILANT .................... 50, 51
dextroamphetamine .............. 26
dextroamphetamineamphetamine .................... 26
dextrose 10 % and 0.2 % nacl
.......................................... 42
dextrose 10 % in water (d10w)
.......................................... 42
dextrose 5 % in water (d5w) 42
dextrose 5 %-lactated ringers42
dextrose 5%-0.2 % sod
chloride ............................. 42
dextrose 5%-0.3 %
sod.chloride ...................... 42
dextrose with sodium chloride
.......................................... 42
dextrose-kcl-nacl .................. 65
diazepam......................... 18, 26
diazepam intensol ................. 26
diclofenac potassium ............ 24
diclofenac sodium .... 24, 37, 59
dicloxacillin ............................ 9
dicyclomine .................... 48, 49
didanosine............................... 2
diflorasone ............................ 40
diflunisal ............................... 24
digitek ................................... 35
digoxin.................................. 35
dihydroergotamine ............... 20
DILANTIN 30 MG .............. 18
diltiazem hcl ......................... 33
dilt-xr .................................... 33
diphenhydramine hcl ............ 61
dipyridamole......................... 35
disulfiram ............................. 42
divalproex ............................. 18
DOCEFREZ ......................... 13
docetaxel............................... 13
donepezil .............................. 21
dorzolamide .......................... 60
dorzolamide-timolol ............. 60
doxazosin.............................. 33
doxepin ................................. 26
doxercalciferol ...................... 47
doxorubicin........................... 13
doxy-100 ............................... 10
doxycycline hyclate .............. 10
doxycycline monohydrate .... 10
dronabinol ............................. 49
drospirenone-ethinyl estradiol
.......................................... 57
DROXIA .............................. 13
DULERA .............................. 62
duloxetine ............................. 26
duramorph (pf) ..................... 22
DUREZOL ........................... 60
E
e.e.s. 400 ................................. 6
E.E.S. GRANULES................ 6
econazole .............................. 39
EDURANT ............................. 2
EFFIENT .............................. 35
ELAPRASE .......................... 47
eliphos .................................. 65
ELIQUIS .............................. 35
ELIXOPHYLLIN ................. 62
ELLA .................................... 57
ELLENCE ............................ 13
ELMIRON ............................ 64
ELOXATIN .......................... 13
EMCYT ................................ 13
EMEND ................................ 49
emoquette ............................. 57
EMSAM ............................... 26
EMTRIVA .............................. 2
enalapril maleate................... 33
enalapril-hydrochlorothiazide
.......................................... 33
ENBREL .............................. 55
ENBREL SURECLICK ....... 55
endocet.................................. 22
ENGERIX-B (PF) ................ 53
ENGERIX-B PEDIATRIC
(PF) ................................... 53
enoxaparin ............................ 35
enpresse ................................ 57
entacapone ............................ 20
entecavir ................................. 2
ENTRESTO.......................... 36
enulose .................................. 49
epinastine .............................. 59
epinephrine ........................... 61
EPIPEN 2-PAK .................... 61
EPIPEN JR 2-PAK ............... 61
epirubicin .............................. 13
epitol ..................................... 18
EPIVIR ................................... 2
EPIVIR HBV .......................... 2
eplerenone............................. 33
eprosartan ............................. 33
EPZICOM............................... 2
ERAXIS(WATER DILUENT)
............................................ 1
ergoloid ................................. 26
ERIVEDGE .......................... 13
errin....................................... 55
ERWINAZE ......................... 13
ery pads ................................. 38
ery-tab ..................................... 6
ERYTHROCIN ...................... 6
erythrocin (as stearate) ........... 6
erythromycin..................... 6, 58
erythromycin ethylsuccinate ... 6
erythromycin with ethanol .... 38
erythromycin-benzoyl peroxide
.......................................... 38
ESBRIET .............................. 62
escitalopram oxalate ....... 26, 27
esomeprazole sodium ........... 51
ESTRACE ............................ 55
estradiol ................................ 55
estradiol valerate ................... 55
estradiol-norethindrone acet . 55
ESTRING ............................. 55
estropipate............................. 56
eszopiclone ........................... 27
ethambutol .............................. 7
ethosuximide......................... 18
etidronate disodium .............. 42
etodolac................................. 24
ETOPOPHOS ....................... 13
etoposide ............................... 13
EURAX ................................ 41
EVISTA ................................ 54
EVOTAZ ................................ 2
EXELON .............................. 21
exemestane ........................... 13
EXJADE ............................... 42
F
FABRAZYME ..................... 47
falmina (28) .......................... 57
71
famciclovir ............................. 2
famotidine............................. 51
famotidine (pf)...................... 51
famotidine (pf)-nacl (iso-os) 51
FANAPT .............................. 27
FARESTON ......................... 13
FARYDAK........................... 13
FASLODEX ......................... 13
FAZACLO ........................... 27
felbamate .............................. 18
felodipine .............................. 33
fenofibrate ............................ 36
fenofibrate micronized ......... 36
fenofibrate nanocrystallized . 36
fenofibric acid (choline) ....... 36
fenoprofen ............................ 24
fentanyl ................................. 22
fentanyl citrate ...................... 22
FERRIPROX ........................ 42
FETZIMA............................. 27
FINACEA............................. 38
finasteride ............................. 64
FIRAZYR ............................. 62
FIRMAGON KIT W
DILUENT SYRINGE ...... 13
flavoxate ............................... 64
flecainide .............................. 32
FLECTOR ............................ 24
FLOVENT DISKUS ............ 62
FLOVENT HFA ............. 62, 63
fluconazole ............................. 1
fluconazole in dextrose(iso-o) 1
flucytosine .............................. 1
fludarabine ............................ 13
fludrocortisone ..................... 43
flunisolide ............................. 63
fluocinolone.......................... 40
fluocinolone acetonide oil .... 43
fluocinonide.......................... 40
fluocinonide-e....................... 40
fluorometholone ................... 60
fluorouracil ..................... 13, 37
fluoxetine.............................. 27
fluphenazine decanoate ........ 27
fluphenazine hcl ................... 27
flurbiprofen........................... 24
flurbiprofen sodium .............. 59
flutamide............................... 13
fluticasone ...................... 40, 63
fluvastatin ............................. 36
fluvoxamine .......................... 27
FML FORTE ........................ 60
FML S.O.P. .......................... 60
FOLOTYN ........................... 13
fondaparinux ......................... 35
FORADIL AEROLIZER ..... 63
FORTAZ ................................ 5
FORTEO .............................. 54
fortical .................................. 47
fosinopril .............................. 33
fosinopril-hydrochlorothiazide
.......................................... 33
fosphenytoin ......................... 18
FREAMINE HBC 6.9 % ...... 67
furosemide ............................ 33
FUSILEV.............................. 11
FUZEON ................................ 2
FYCOMPA ........................... 18
G
gabapentin ............................ 18
GABITRIL ........................... 18
galantamine .......................... 21
GAMASTAN S/D ................ 53
ganciclovir sodium ................. 2
garamycin ............................. 58
GARDASIL (PF) .................. 53
GARDASIL 9 (PF) ............... 53
gatifloxacin ........................... 58
GAUZE PADS 2 .................. 44
gavilyte-c .............................. 49
gavilyte-g .............................. 49
gavilyte-n .............................. 49
GELNIQUE .......................... 64
gemcitabine .......................... 13
gemfibrozil ........................... 36
generlac ................................ 49
gengraf .................................. 13
gentak ................................... 58
gentamicin .................. 7, 39, 58
gentamicin in nacl (iso-osm) .. 7
gentamicin sulfate (pf)............ 7
GEODON ............................. 27
gianvi (28) ............................ 57
gildagia ................................. 57
gildess ................................... 57
gildess 24 fe .......................... 57
GILOTRIF ............................ 13
GLATOPA ........................... 21
GLEEVEC ............................ 13
glimepiride ............................ 44
glipizide .......................... 44, 45
glipizide-metformin .............. 45
GLUCAGEN HYPOKIT...... 45
GLUCAGON EMERGENCY
KIT (HUMAN) ................. 45
glyburide ............................... 45
glyburide micronized ............ 45
glyburide-metformin............. 45
glycopyrrolate ....................... 49
granisetron (pf) ..................... 49
granisetron hcl ...................... 49
GRASTEK ............................ 53
griseofulvin microsize ............ 1
griseofulvin ultramicrosize ..... 1
guanfacine....................... 27, 33
H
HALAVEN ........................... 14
halobetasol propionate .......... 40
haloperidol ............................ 28
haloperidol decanoate ........... 28
haloperidol lactate ................ 28
HARVONI .............................. 2
HAVRIX (PF) ...................... 53
heparin (porcine) .................. 35
heparin (porcine) in 5 % dex 35
HEPATAMINE 8% .............. 67
HERCEPTIN ........................ 14
HEXALEN ........................... 14
HUMALOG .......................... 45
HUMALOG KWIKPEN ...... 45
HUMALOG MIX 50-50....... 45
HUMALOG MIX 50-50
KWIKPEN ........................ 45
HUMALOG MIX 75-25....... 45
HUMALOG MIX 75-25
KWIKPEN ........................ 45
HUMULIN 70/30 ................. 45
HUMULIN 70/30 KWIKPEN
.......................................... 45
HUMULIN N ....................... 45
HUMULIN N KWIKPEN .... 45
HUMULIN R........................ 45
HUMULIN R U-500 ............ 45
hydralazine ........................... 33
hydrochlorothiazide .............. 34
hydrocodone-acetaminophen 22
hydrocodone-ibuprofen ........ 22
72
hydrocortisone .... 40, 41, 43, 49
hydrocortisone butyrate ........ 40
hydrocortisone butyr-emollient
.......................................... 40
hydrocortisone valerate ........ 41
hydrocortisone-acetic acid.... 43
hydromorphone .................... 22
hydromorphone (pf) ............. 22
hydroxychloroquine ............... 7
hydroxyurea .......................... 14
hydroxyzine hcl .................... 61
I
ibandronate ........................... 54
IBRANCE ............................ 14
ibuprofen .............................. 24
ICLUSIG .............................. 14
idarubicin .............................. 14
IFEX ..................................... 14
ifosfamide ............................. 14
ILARIS (PF) ......................... 52
ILEVRO ............................... 59
IMBRUVICA ....................... 14
imipenem-cilastatin ................ 7
imipramine hcl...................... 28
imipramine pamoate ............. 28
imiquimod ............................ 37
IMOVAX RABIES VACCINE
(PF) ................................... 53
INCRELEX .......................... 42
INCRUSE ELLIPTA............ 63
indapamide ........................... 34
INFANRIX (DTAP) (PF)..... 53
INLYTA ............................... 14
INSULIN PEN NEEDLE ..... 45
INSULIN SYRINGE (DISP)
U-100 0.3 ML................... 45
U-100 1 ML...................... 45
U-100 1/2 ML................... 46
INTELENCE .......................... 2
intralipid ............................... 67
INTRALIPID ....................... 67
INTRON A ........................... 52
introvale ................................ 57
INTUNIV ER ....................... 28
INVANZ................................. 7
INVEGA............................... 28
INVEGA SUSTENNA ......... 28
INVIRASE ............................. 2
INVOKANA ........................ 46
IONOSOL-B IN D5W.......... 67
IONOSOL-MB IN D5W ...... 67
IPOL ..................................... 53
ipratropium bromide ....... 43, 63
irbesartan .............................. 34
irbesartan-hydrochlorothiazide
.......................................... 34
irinotecan .............................. 14
ISENTRESS ........................... 2
ISOLYTE-P IN 5 %
DEXTROSE ..................... 67
ISOLYTE-S .......................... 67
isoniazid.................................. 7
isosorbide dinitrate ............... 36
isosorbide mononitrate ......... 36
isradipine .............................. 34
ISTODAX ............................ 14
itraconazole ............................ 1
ivermectin ............................... 7
IXEMPRA ............................ 14
IXIARO (PF) ........................ 53
J
JAKAFI ................................ 14
JALYN ................................. 64
jantoven ................................ 35
JANUMET ........................... 46
JANUMET XR ..................... 46
JANUVIA ............................. 46
JENTADUETO .................... 46
JEVTANA ............................ 14
jinteli..................................... 56
jolivette ................................. 56
junel 1.5/30 (21) ................... 57
junel 1/20 (21) ...................... 57
junel fe 1.5/30 (28) ............... 57
junel fe 1/20 (28) .................. 57
junel fe 24 ............................. 57
JUXTAPID ........................... 36
K
KALETRA ............................. 2
KALYDECO ........................ 63
kariva (28) ............................ 57
kelnor 1/35 (28) .................... 57
KEPIVANCE ....................... 11
KETEK ................................... 7
ketoconazole ..................... 1, 39
ketoprofen ............................. 24
ketorolac ............................... 60
KEYTRUDA ........................ 14
kimidess (28) ........................ 57
kionex ................................... 42
klor-con 10............................ 65
klor-con 8.............................. 65
klor-con m15 ........................ 65
klor-con m20 ........................ 65
k-tab ...................................... 65
K-TAB .................................. 65
KUVAN ................................ 47
L
l norgest/e.estradiol-e.estrad . 57
labetalol ................................ 34
LACRISERT ........................ 59
lactated ringers...................... 65
lactulose ................................ 49
LAMICTAL ODT ................ 18
LAMICTAL STARTER
(BLUE) KIT ..................... 18
LAMICTAL STARTER
(GREEN) KIT .................. 18
LAMICTAL STARTER
(ORANGE) KIT ............... 19
LAMISIL ................................ 1
lamivudine .......................... 2, 3
lamivudine-zidovudine ........... 3
lamotrigine ............................ 19
LANOXIN ............................ 35
lansoprazole .......................... 51
LANTUS .............................. 46
LANTUS SOLOSTAR ......... 46
larin 1.5/30 (21) .................... 57
larin 1/20 (21) ....................... 57
larin fe ................................... 57
LASTACAFT ....................... 59
latanoprost ............................ 60
LATUDA .............................. 28
layolis fe ............................... 57
leena 28 ................................. 57
leflunomide ........................... 55
LENVIMA ............................ 14
lessina ................................... 57
LETAIRIS ............................ 63
letrozole ................................ 14
leucovorin calcium ............... 11
LEUKERAN......................... 14
LEUKINE ............................. 52
leuprolide .............................. 14
73
levetiracetam ........................ 19
LEVETIRACETAM IN NACL
(ISO-OS) .......................... 19
levobunolol ........................... 59
levocarnitine ......................... 42
levocarnitine (with sugar)..... 42
levocetirizine ........................ 61
levofloxacin .................... 10, 58
levofloxacin in d5w .............. 10
LEVOLEUCOVORIN
CALCIUM ....................... 11
levonest (28) ......................... 57
levonorgestrel-ethinyl estrad 57
levora-28............................... 57
levothyroxine ........................ 48
levoxyl .................................. 48
LEXIVA ................................. 3
lidocaine ............................... 38
lidocaine (pf) ........................ 38
lidocaine hcl ......................... 38
lidocaine-prilocaine .............. 38
lindane .................................. 41
linezolid .................................. 7
LINZESS .............................. 49
LIORESAL........................... 21
liothyronine .......................... 48
liposyn iii .............................. 67
lisinopril ............................... 34
lisinopril-hydrochlorothiazide
.......................................... 34
lithium carbonate .................. 28
lithium citrate ....................... 28
LOCOID ............................... 41
LOMUSTINE ....................... 14
loperamide ............................ 49
lorazepam ............................. 28
lorazepam intensol................ 28
loryna (28) ............................ 57
losartan ................................. 34
losartan-hydrochlorothiazide 34
LOTRONEX ........................ 49
lovastatin .............................. 36
low-ogestrel (28) .................. 57
loxapine succinate ................ 28
LUMIGAN ........................... 60
LUMIZYME ........................ 47
LUPRON DEPOT ................ 14
LUPRON DEPOT (3
MONTH) .......................... 14
LUPRON DEPOT (4
MONTH) .......................... 14
LUPRON DEPOT (6
MONTH) .......................... 14
LUPRON DEPOT-PED ....... 14
lutera (28) ............................. 57
LYNPARZA ......................... 14
LYRICA ............................... 19
LYSODREN ......................... 14
lyza ....................................... 56
M
MACRODANTIN ................ 11
magnesium sulfate ................ 65
malathion .............................. 41
maprotiline............................ 28
marlissa................................. 57
MARPLAN .......................... 28
MATULANE........................ 15
meclizine .............................. 49
meclofenamate...................... 24
medroxyprogesterone ........... 56
mefenamic acid..................... 24
mefloquine .............................. 7
MEGACE ES ....................... 15
megestrol .............................. 15
MEKINIST ........................... 15
meloxicam ............................ 24
melphalan hcl ....................... 15
memantine ............................ 21
MENACTRA (PF) ............... 53
MENEST .............................. 56
MENOMUNE - A/C/Y/W-135
(PF) ................................... 53
MENVEO A-C-Y-W-135-DIP
(PF) ................................... 53
mercaptopurine ..................... 15
meropenem ............................. 7
mesalamine with cleansing
wipe .................................. 49
mesna .................................... 11
MESNEX.............................. 11
MESTINON ......................... 21
MESTINON TIMESPAN .... 21
metaproterenol ...................... 63
metformin ............................. 46
methadone ............................ 23
methazolamide...................... 60
methenamine hippurate ........ 11
methimazole ......................... 44
methotrexate sodium ............ 15
methotrexate sodium (pf) ..... 15
methoxsalen rapid ................. 37
methyclothiazide................... 34
methyldopa ........................... 34
methylergonovine ................. 58
methylphenidate ................... 28
methylprednisolone .............. 43
methylprednisolone acetate .. 43
methylprednisolone sodium
succ ................................... 43
metipranolol .......................... 59
metoclopramide hcl ........ 49, 50
metolazone ............................ 34
metoprolol succinate ............. 34
metoprolol ta-hydrochlorothiaz
.......................................... 34
metoprolol tartrate ................ 34
metronidazole ............. 7, 38, 56
metronidazole in nacl (iso-os) 7
mexiletine ............................. 32
MIACALCIN ....................... 48
miconazole-3 ........................ 56
microgestin 1.5/30 (21) ........ 57
microgestin 1/20 (21) ........... 57
microgestin fe 1.5/30 (28) .... 57
microgestin fe 1/20 (28) ....... 57
midodrine .............................. 42
migergot ................................ 20
minocycline .......................... 11
minoxidil............................... 34
MIRAPEX ER ...................... 20
mirtazapine ........................... 28
misoprostol ........................... 51
mitomycin ............................. 15
mitoxantrone ......................... 15
M-M-R II (PF) ...................... 53
modafinil............................... 28
moderiba ................................. 3
moderiba dose pack ................ 3
moexipril............................... 34
moexipril-hydrochlorothiazide
.......................................... 34
mometasone .......................... 41
mononessa (28) ..................... 57
montelukast........................... 63
morphine ............................... 23
morphine concentrate ........... 23
MOVIPREP .......................... 50
74
MOXEZA ............................. 58
moxifloxacin......................... 10
MOZOBIL............................ 52
mupirocin ............................. 39
mupirocin calcium ................ 39
MUSTARGEN ..................... 15
MYALEPT ........................... 48
MYCAMINE.......................... 1
MYCOBUTIN ........................ 7
mycophenolate mofetil ......... 15
mycophenolate sodium ......... 15
myorisan ............................... 38
MYOZYME ......................... 48
N
nabumetone .......................... 24
nadolol .................................. 34
nadolol-bendroflumethiazide 34
nafcillin................................... 9
nafcillin in dextrose iso-osm .. 9
NAFTIN ............................... 39
NAGLAZYME..................... 48
naloxone ............................... 24
naltrexone ............................. 24
NAMENDA ......................... 21
NAMENDA TITRATION
PAK .................................. 21
NAMENDA XR ................... 21
naphazoline........................... 61
naproxen ............................... 24
naproxen sodium .................. 24
naratriptan............................. 20
NASONEX ........................... 63
NATACYN .......................... 58
nateglinide ............................ 46
NATPARA ........................... 48
NEBUPENT ........................... 7
necon 0.5/35 (28).................. 57
necon 1/35 (28)..................... 57
necon 10/11 (28)................... 57
necon 7/7/7 (28) ................... 57
NEEDLES, INSULIN
DISP.,SAFETY ................ 46
nefazodone ........................... 28
neomycin ................................ 7
neomycin-bacitracin-poly-hc 60
neomycin-bacitracinpolymyxin......................... 59
neomycin-polymyxin bdexameth .......................... 60
neomycin-polymyxingramicidin ......................... 59
neomycin-polymyxin-hc 43, 60
NEORAL .............................. 15
NEPHRAMINE 5.4 % ......... 67
neuac ..................................... 38
NEULASTA ......................... 52
NEUMEGA .......................... 52
NEUPOGEN ........................ 52
NEUPRO .............................. 20
NEVANAC .......................... 60
nevirapine ............................... 3
NEXAVAR .......................... 15
NEXIUM .............................. 51
NEXIUM PACKET ............. 51
niacin .................................... 36
nicardipine ............................ 34
NICOTROL .......................... 42
NICOTROL NS .................... 42
nifedical xl ............................ 34
nifedipine .............................. 34
nikki (28) .............................. 57
NILANDRON ...................... 15
nimodipine ............................ 34
NIPENT ................................ 15
nitro-bid ................................ 36
NITRO-DUR ........................ 36
nitrofurantoin ........................ 11
nitrofurantoin macrocrystal .. 11
nitrofurantoin monohyd/mcryst .................................. 11
nitroglycerin ................... 36, 37
NITROSTAT ........................ 37
nizatidine .............................. 51
nora-be .................................. 56
NORDITROPIN FLEXPRO 52
noreth-ethinyl estradiol-iron . 57
norethindrone (contraceptive)
.......................................... 56
norethindrone acetate ........... 56
norethindrone ac-eth estradiol
.......................................... 56
norethindrone-e.estradiol-iron
.......................................... 58
norlyroc ................................ 56
NORMOSOL-R IN 5 %
DEXTROSE ..................... 65
NORMOSOL-R PH 7.4 ....... 67
nortrel 0.5/35 (28)................. 58
nortrel 1/35 (21) .................... 58
nortrel 1/35 (28) .................... 58
nortrel 7/7/7 (28)................... 58
nortriptyline .......................... 28
NORVIR ................................. 3
NOVOFINE 32 ..................... 46
NOXAFIL............................... 1
NUEDEXTA ........................ 21
NULOJIX ............................. 15
NUTRILIPID ........................ 67
NUVARING ......................... 56
nyamyc ................................. 39
nystatin ............................. 1, 39
nystatin-triamcinolone .......... 39
nystop ................................... 39
O
ocella..................................... 58
octreotide acetate .................. 15
OFEV .................................... 63
ofloxacin ................... 10, 43, 59
ogestrel (28) .......................... 58
olanzapine ....................... 28, 29
olopatadine ........................... 43
OLYSIO ................................. 3
omega-3 acid ethyl esters ..... 36
omeprazole ........................... 51
omeprazole-sodium
bicarbonate ....................... 51
OMNITROPE ....................... 52
ONCASPAR ......................... 15
ondansetron........................... 50
ondansetron hcl ..................... 50
ondansetron hcl (pf) .............. 50
ONFI ..................................... 19
OPDIVO ............................... 15
ORAP ................................... 29
ORAVIG................................. 1
ORENCIA ............................ 55
ORENCIA (WITH
MALTOSE) ...................... 55
ORFADIN ............................ 42
ORKAMBI ........................... 63
orsythia ................................. 58
OTEZLA............................... 55
OTEZLA STARTER ............ 55
oxaliplatin ............................. 15
oxandrolone .......................... 48
oxaprozin .............................. 24
oxazepam .............................. 29
75
oxcarbazepine ....................... 19
oxybutynin chloride.............. 64
oxycodone ............................ 23
oxycodone-acetaminophen ... 23
oxycodone-aspirin ................ 23
oxymorphone........................ 24
P
pacerone ............................... 32
paclitaxel .............................. 15
PANDEL .............................. 41
PANRETIN .......................... 37
pantoprazole ......................... 51
paricalcitol ............................ 48
paromomycin .......................... 7
paroxetine hcl ....................... 29
PASER ................................... 7
PATADAY ........................... 59
PATANOL ........................... 59
PAXIL .................................. 29
PAZEO ................................. 59
PEDVAX HIB (PF) .............. 53
PEGANONE ........................ 19
PEGASYS ............................ 52
PEGASYS PROCLICK ....... 52
PEGINTRON ....................... 52
PEGINTRON REDIPEN ..... 52
PENICILLIN G POT IN
DEXTROSE ....................... 9
penicillin g potassium............. 9
penicillin g procaine ............... 9
penicillin g sodium ................. 9
penicillin v potassium............. 9
PENTAM ............................... 8
PENTASA ............................ 50
pentoxifylline ....................... 35
PERFOROMIST .................. 63
perindopril erbumine ............ 34
periogard............................... 43
PERJETA ............................. 15
permethrin ............................ 41
perphenazine......................... 29
pfizerpen-g ............................. 9
phenelzine............................. 29
phenobarbital ........................ 19
phenoxybenzamine ............... 34
phenytoin .............................. 19
phenytoin sodium ................. 19
phenytoin sodium extended .. 19
PHOSPHOLINE IODIDE .... 59
pilocarpine hcl ................ 42, 59
pimtrea (28) .......................... 58
pindolol................................. 34
pioglitazone .......................... 46
pioglitazone-glimepiride ...... 46
pioglitazone-metformin ........ 46
piperacillin-tazobactam ........ 10
pirmella................................. 58
piroxicam .............................. 24
PLASMA-LYTE 148 ........... 67
PLASMA-LYTE A .............. 67
PLASMA-LYTE-56 IN 5 %
DEXTROSE ..................... 67
podofilox .............................. 37
polyethylene glycol 3350 ..... 50
polymyxin b sulf-trimethoprim
.......................................... 59
POMALYST ........................ 15
portia..................................... 58
potassium chlorid-d50.45%nacl ......................... 65
potassium chloride ................ 65
potassium chloride in 0.9%nacl
.......................................... 65
potassium chloride in 5 % dex
.......................................... 65
potassium chloride in lr-d5 ... 65
potassium chloride-0.45 % nacl
.......................................... 65
potassium chloride-d50.2%nacl ........................... 66
potassium citrate ................... 64
POTIGA ............................... 19
PRADAXA ........................... 35
pramipexole .......................... 20
pravastatin ............................ 36
prazosin ................................ 34
prednicarbate ........................ 41
prednisolone acetate ............. 60
prednisolone sodium phosphate
.................................... 44, 60
prednisone ............................ 44
prednisone intensol ............... 44
PREFEST ............................. 56
PREMARIN ......................... 56
premasol 10 % ...................... 67
PREMASOL 6 % ................. 67
PREMPHASE....................... 56
PREMPRO ........................... 56
prenatal vitamin oral tablet ... 67
prevalite ................................ 36
previfem ................................ 58
PREZCOBIX .......................... 3
PREZISTA ............................. 3
PRIFTIN ................................. 8
PRIMAQUINE ....................... 8
primidone .............................. 19
PRIMSOL ............................. 11
PRISTIQ ............................... 29
PRIVIGEN ........................... 53
PROAIR HFA ...................... 63
PROAIR RESPICLICK........ 63
probenecid ............................ 54
procainamide ........................ 32
prochlorperazine ................... 50
prochlorperazine edisylate .... 50
prochlorperazine maleate ...... 50
PROCRIT ............................. 52
procto-pak ............................. 50
proctosol hc .......................... 50
proctozone-hc ....................... 50
PRODIGY INSULIN
SYRINGE ......................... 46
progesterone micronized ...... 56
PROGLYCEM ..................... 46
PROGRAF ............................ 15
PROLASTIN-C .................... 42
PROLENSA ......................... 60
PROLEUKIN ....................... 52
PROLIA ................................ 54
PROMACTA ........................ 35
promethazine ........................ 61
promethegan ......................... 61
propafenone .......................... 32
proparacaine ......................... 59
propranolol ........................... 34
propranolol-hydrochlorothiazid
.......................................... 34
propylthiouracil .................... 44
PROQUAD (PF) ................... 53
PROTOPIC ........................... 37
protriptyline .......................... 29
prudoxin ................................ 37
PULMICORT ....................... 63
76
PULMOZYME..................... 63
PURIXAN ............................ 15
pyrazinamide .......................... 8
pyridostigmine bromide ....... 21
Q
QUADRACEL (PF) ............. 53
quasense ............................... 58
quetiapine ............................. 29
quinapril ............................... 34
quinapril-hydrochlorothiazide
.......................................... 34
quinidine gluconate .............. 32
quinidine sulfate ................... 32
quinine sulfate ........................ 8
QVAR................................... 63
R
RABAVERT (PF) ................ 53
rabeprazole ........................... 51
RAGWITEK......................... 53
raloxifene.............................. 54
ramipril ................................. 34
RANEXA ............................. 36
ranitidine hcl ......................... 51
RAPAMUNE ....................... 15
RAVICTI.............................. 42
REBETOL .............................. 3
REBIF (WITH ALBUMIN) . 52
REBIF REBIDOSE .............. 52
REBIF TITRATION PACK 52
reclipsen (28) ........................ 58
RECOMBIVAX HB (PF) .... 53
RECTIV ............................... 50
REGRANEX ........................ 37
RELENZA DISKHALER ...... 3
RELISTOR ........................... 50
RELPAX .............................. 20
REMICADE ......................... 50
REMODULIN ...................... 34
RENVELA ........................... 42
repaglinide ............................ 46
reprexain ............................... 24
RESCRIPTOR ........................ 3
reserpine ............................... 34
RESTASIS ........................... 59
RETROVIR ............................ 3
REVLIMID .......................... 15
REXULTI ............................. 29
REYATAZ ............................. 3
RHEUMATREX .................. 16
ribasphere ............................... 3
ribavirin .................................. 3
RIDAURA ............................ 55
rifabutin .................................. 8
rifampin .................................. 8
riluzole .................................. 42
rimantadine ............................. 3
ringers ................................... 66
RIOMET ............................... 46
risedronate ...................... 42, 54
RISPERDAL CONSTA ....... 30
risperidone ............................ 30
RITALIN LA ........................ 30
RITUXAN ............................ 16
rivastigmine tartrate .............. 21
rizatriptan.............................. 20
ropinirole .............................. 20
ROTARIX ............................ 53
ROTATEQ VACCINE......... 53
ROZEREM ........................... 30
S
SABRIL ................................ 19
SAMSCA.............................. 48
SANDIMMUNE .................. 16
SANDOSTATIN LAR
DEPOT ............................. 16
SANTYL .............................. 41
SAPHRIS (BLACK
CHERRY) ........................ 30
SAVAYSA ........................... 35
SAVELLA ............................ 55
selegiline hcl ......................... 20
selenium sulfide .................... 37
SELZENTRY ......................... 3
SENSIPAR ........................... 48
SEREVENT DISKUS .......... 63
SEROQUEL XR............. 30, 31
sertraline ............................... 31
sharobel ................................ 56
SIGNIFOR............................ 16
sildenafil ............................... 63
silver sulfadiazine ................. 37
SIMBRINZA ........................ 60
SIMPONI ARIA ................... 55
SIMULECT .......................... 16
simvastatin ............................ 36
sirolimus ............................... 16
SIRTURO ............................... 8
SKLICE ................................ 41
sodium chloride .............. 42, 66
sodium chloride 0.45 % ........ 66
sodium chloride 0.9 % .......... 42
sodium chloride 3 % ............. 66
sodium chloride 5 % ............. 66
sodium fluoride ..................... 67
sodium polystyrene (sorb free)
.......................................... 42
SOLTAMOX ........................ 16
SOLU-CORTEF (PF) ........... 44
SOLU-MEDROL ................. 44
SOLU-MEDROL (PF) ......... 44
SOMATULINE DEPOT ...... 16
SOMAVERT ........................ 48
sorine .................................... 32
sotalol ................................... 32
sotalol af ............................... 32
SOTYLIZE ........................... 32
SOVALDI............................... 3
SPIRIVA RESPIMAT .......... 63
SPIRIVA WITH
HANDIHALER ................ 63
spironolactone....................... 34
spironolacton-hydrochlorothiaz
.......................................... 34
SPORANOX........................... 1
sprintec (28) .......................... 58
SPRYCEL............................. 16
sronyx ................................... 58
ssd ......................................... 37
stavudine ................................. 3
STIMATE ............................. 48
STIVARGA .......................... 16
STRATTERA ....................... 31
STREPTOMYCIN ................. 8
STRIBILD .............................. 3
STROMECTOL ..................... 8
SUBOXONE .................. 24, 25
SUCRAID............................. 50
sucralfate............................... 51
sulfacetamide sodium ........... 60
sulfacetamide sodium (acne) 39
sulfacetamide-prednisolone .. 60
sulfadiazine ........................... 10
sulfamethoxazole-trimethoprim
.......................................... 10
SULFAMYLON ................... 39
sulfasalazine ......................... 50
sulfazine ec ........................... 50
77
sulindac................................. 25
sumatriptan ........................... 20
sumatriptan succinate ..... 20, 21
SUPRAX ................................ 5
SUPREP BOWEL PREP KIT
.......................................... 50
SURMONTIL....................... 31
SUSTIVA ............................... 3
SUTENT............................... 16
SYLATRON......................... 52
SYLVANT ........................... 16
SYMBICORT....................... 63
SYMLINPEN 120 ................ 46
SYMLINPEN 60 .................. 47
SYNAGIS............................... 3
SYNAREL ........................... 48
SYNERCID ............................ 8
SYNRIBO ............................ 16
SYPRINE ............................. 42
T
TABLOID ............................ 16
tacrolimus ....................... 16, 37
TAFINLAR .......................... 16
TAMIFLU .............................. 3
tamoxifen.............................. 16
tamsulosin............................. 64
TANZEUM .......................... 47
TARCEVA ........................... 16
TARGRETIN ....................... 16
tarina fe ................................. 58
TASIGNA ...................... 16, 17
TAZICEF ............................... 5
TAZORAC ........................... 38
TECFIDERA ........................ 21
TEFLARO .............................. 5
TEGRETOL XR ................... 19
TEKTURNA ........................ 34
telmisartan ............................ 34
telmisartan-amlodipine ......... 34
telmisartan-hydrochlorothiazid
.......................................... 34
temazepam ............................ 31
TENIVAC (PF) .................... 54
terazosin ............................... 35
terbinafine hcl ......................... 1
terbutaline ............................. 63
terconazole ........................... 56
testosterone cypionate .......... 48
testosterone enanthate .......... 48
TETANUS,DIPHTHERIA
TOX PED(PF) .................. 54
TETANUS-DIPHTHERIA
TOXOIDS-TD .................. 54
tetrabenazine ......................... 21
THALOMID ......................... 17
theophylline .................... 63, 64
thioridazine ........................... 31
thiotepa ................................. 17
thiothixene ............................ 31
tiagabine ............................... 19
TIKOSYN ............................ 32
timolol maleate ............... 35, 59
TIMOPTIC OCUDOSE (PF)
.......................................... 59
tinidazole ................................ 8
TIVICAY................................ 3
tizanidine .............................. 21
tobramycin ............................ 59
tobramycin in 0.225 % nacl .... 8
tobramycin in 0.9 % nacl ........ 8
tobramycin sulfate .................. 8
tobramycin-dexamethasone .. 60
TOBREX .............................. 59
tolazamide ............................ 47
tolbutamide ........................... 47
tolcapone .............................. 20
tolmetin................................. 25
tolterodine ............................. 64
topiramate ............................. 19
toposar .................................. 17
topotecan .............................. 17
TORISEL.............................. 17
torsemide .............................. 35
TRACLEER ......................... 64
TRADJENTA ....................... 47
tramadol ................................ 25
trandolapril ........................... 35
trandolapril-verapamil .......... 35
tranexamic acid............... 35, 56
TRANSDERM-SCOP .......... 50
tranylcypromine.................... 31
travasol 10 % ........................ 67
TRAVATAN Z..................... 60
travoprost (benzalkonium) ... 60
trazodone .............................. 31
TREANDA ........................... 17
TRECATOR ........................... 8
TRELSTAR .......................... 17
TRELSTAR DEPOT ............17
TRELSTAR LA.................... 17
tretinoin................................. 38
tretinoin (chemotherapy) ...... 17
tretinoin microspheres .......... 38
triamcinolone acetonide. 41, 43,
44, 64
triamterene-hydrochlorothiazid
.......................................... 35
trianex ................................... 41
triderm .................................. 41
trifluoperazine....................... 31
trifluridine ............................. 59
trihexyphenidyl ..................... 20
tri-legest fe ............................ 58
trilyte with flavor packets ..... 50
trimethoprim ......................... 11
trinessa (28) .......................... 58
tri-previfem (28) ................... 58
TRISENOX .......................... 17
tri-sprintec (28) ..................... 58
TRIUMEQ .............................. 3
trivora (28) ............................ 58
TROPHAMINE 10 %........... 67
TROPHAMINE 6%.............. 67
trospium ................................ 64
TRULICITY ......................... 47
TRUMENBA ........................ 54
TRUVADA............................. 3
TUDORZA PRESSAIR ....... 64
TWINRIX (PF) ..................... 54
TYGACIL............................... 8
TYKERB .............................. 17
TYPHIM VI.......................... 54
TYSABRI ............................. 21
TYVASO .............................. 64
TYZEKA ................................ 3
TYZINE ................................ 43
U
UCERIS ................................ 50
ULORIC ............................... 54
unithroid ............................... 48
ursodiol ................................. 50
UVADEX ............................. 37
V
VAGIFEM ............................ 56
valacyclovir ............................ 4
VALCHLOR ........................ 37
VALCYTE ............................. 4
78
valganciclovir ......................... 4
valproate sodium .................. 19
valproic acid ......................... 19
valproic acid (as sodium salt)
.......................................... 19
valsartan ............................... 35
valsartan-hydrochlorothiazide
.......................................... 35
vancomycin .......................... 11
vandazole .............................. 56
VAQTA (PF) ........................ 54
VARIVAX (PF) ................... 54
VARIZIG ............................. 54
VASCEPA............................ 36
VELCADE ........................... 17
velivet triphasic regimen (28)
.......................................... 58
venlafaxine ........................... 31
verapamil .............................. 35
VEREGEN ........................... 37
VERSACLOZ ...................... 31
vestura (28) ........................... 58
VGO 20 ................................ 47
VGO 30 ................................ 47
VGO 40 ................................ 47
VIBRAMYCIN .................... 11
VIDEX 2 GRAM PEDIATRIC
............................................ 4
VIEKIRA PAK ...................... 4
VIGAMOX........................... 59
VIIBRYD ............................. 31
VIMOVO ............................. 25
VIMPAT......................... 19, 20
vinblastine ............................ 17
vincasar pfs ........................... 17
vincristine ............................. 17
vinorelbine ............................ 17
VIOKACE ............................ 50
VIRACEPT ............................ 4
VIRAMUNE XR .................... 4
VIRAZOLE ............................ 4
VIREAD ................................. 4
VITEKTA ............................... 4
VOLTAREN GEL ................ 25
voriconazole ........................... 1
VOTRIENT .......................... 17
vyfemla (28) ......................... 58
W
warfarin ................................ 36
WELCHOL .......................... 36
wymzya fe ............................ 58
X
XALKORI ............................ 17
XARELTO ........................... 36
XENAZINE .......................... 21
XGEVA ................................ 11
XIFAXAN .............................. 8
XOLAIR ............................... 64
XTANDI ............................... 17
xulane ................................... 56
XYREM................................ 31
Y
YF-VAX (PF) ....................... 54
Z
zafirlukast ............................. 64
zaleplon ................................ 31
ZALTRAP ............................ 17
zamicet.................................. 24
ZANOSAR ........................... 17
ZAVESCA ............................ 48
zazole .................................... 56
ZELAPAR ............................ 20
ZELBORAF ......................... 17
ZEMPLAR ........................... 48
zenchent (28) ........................ 58
zenchent fe ............................ 58
ZENPEP ............................... 50
ZETIA................................... 36
ZIAGEN ................................. 4
zidovudine .............................. 4
ziprasidone hcl ...................... 31
ZIRGAN ............................... 59
ZMAX .................................... 6
zoledronic acid...................... 48
zoledronic acid-mannitol-water
.......................................... 42
ZOLINZA ............................. 17
zolmitriptan........................... 21
zolpidem ............................... 32
zonisamide ............................ 20
ZORTRESS .......................... 17
ZOSTAVAX (PF) ................ 54
ZOSYN IN DEXTROSE (ISOOSM) ................................ 10
zovia 1/35e (28) .................... 58
zovia 1/50e (28) .................... 58
ZOVIRAX ............................ 39
ZYDELIG ............................. 17
ZYKADIA ............................ 18
ZYPREXA RELPREVV ...... 32
ZYTIGA ............................... 18
ZYVOX .................................. 8
79
This formulary was updated on 10/16/2015. For more recent information or other questions,
please contact Express Scripts Medicare Customer Service at 1.800.758.4574; New York State
residents: 1.800.758.4570, or for TTY users, 1.800.716.3231, 24 hours a day, 7 days a week, or
visit http://www.Express-Scripts.com.
Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract.
Enrollment in Express Scripts Medicare depends on contract renewal.
© 2014 Express Scripts Holding Company. All Rights Reserved. Express Scripts and “E” Logo are
trademarks of Express Scripts Holding Company and/or its subsidiaries. Other trademarks are the
property of their respective owners.
F00SNV5BW4

(PDP) 2015 Formulary

Transcription

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