WellCare 2013 Comprehensive Formulary, Medicare

Transcription

Comprehensive Formulary
(List of Covered Drugs)
Prescription Drug Plans
WellCare Extra (PDP) S5967-173-205
Please Read: This document contains information about the drugs we cover in this plan.
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.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits,
formulary, pharmacy network, premium and/or co-payments/coinsurance may change on
January 1 of each year.
Last updated (08/2012)
Formulary File # 13362
Formulary version # 6
Y0070_NA019443_WCM_FOR_ENG_FINAL_02 CMS Approved 08012012
©WellCare 2012 PDP_06_12
PD3V02FOR45592E
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What is the WellCare formulary?
A formulary is a list of covered drugs. WellCare selects the drugs by working with a team of
health care providers. The list contains the prescription medications we believe are a necessary
part of a quality treatment program. WellCare will generally cover the drugs listed in our
formulary as long as:
1. the drug is medically necessary,
2. the prescription is filled at a WellCare network pharmacy, and
3. other plan rules are followed.
For more information on how to fill your prescriptions, please see your Evidence of Coverage.
Can the formulary change?
In general, if you are taking a drug on our 2013 formulary that was covered at the beginning
of the year, we will not stop or reduce coverage of the drug during the 2013 coverage year.
However, there are some cases when we may stop or reduce coverage. These are:
• when a new, less expensive generic drug becomes available or
• when new negative 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. For those members, it will remain available at
the same cost share for the remainder of the coverage year. We think it’s important that you
can continue to get the formulary drugs that were available when you chose our plan for
the remainder of the coverage year. The only exceptions are for cases in which you can save
additional money or we can ensure your safety.
When we make certain changes to our formulary, we must notify the members who will be
affected by the changes. This includes if we:
• remove drugs from our formulary;
• add restrictions on a drug such as prior authorization, quantity limits and/or step therapy;
• move a drug to a higher cost-sharing tier.
If we make any of these changes, we must notify affected members at least 60 days before the
change goes into effect. We will also notify the member at the time he or she asks for a refill
of the drug. In that case, the member will receive a 60-day supply of the drug.
If the Food and Drug Administration announces that a drug on our formulary is unsafe, or a
drug manufacturer removes a drug from the market, we will immediately remove the drug from
our formulary and notify members who take the drug.
The enclosed formulary is current as of 08/2012. To get updated information about the drugs
covered by WellCare, please visit our website at www.wellcarepdp.com or call Customer
Service at the telephone number listed for your state/plan on the inside cover of this
formulary.
2013 Comprehensive Formulary | I
Every month, we update our printed formulary with a monthly addendum. Please contact
Customer Service or visit our website at www.wellcarepdp.com for more information.
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 Agents.” 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.
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 57. 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?
WellCare 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: WellCare requires you or your physician to get prior authorization for
certain drugs. This means that you will need to get approval from us before you fill your
prescriptions. If you don’t get approval, we may not cover the drug.
•�Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For
example, WellCare provides 9 tablets for 31 days per prescription for sumatriptan 25mg.
This may be in addition to a standard one-month or three-month supply.
•�Step Therapy: In some cases, WellCare requires you to first try certain drugs to treat your
medical condition before we will cover another drug for that condition. For example, if
Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you
try Drug A first. If Drug A does not work for you, we will then cover Drug B.
2013 Comprehensive Formulary | II
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 at www.wellcarepdp.com.
You can ask WellCare to make an exception to these restrictions or limits. See the section,
“How do I request an exception to the WellCare formulary?” on this page for information
about how to request an exception.
What if my drug is not on the formulary?
If your drug is not included in this formulary, you should first contact Customer Service and
confirm that your drug is not covered. You can contact Customer Service at the telephone
number listed for your state/plan on the inside cover of this formulary.
If you learn that WellCare does not cover your drug, you have two options:
• You can ask Customer Service for a list of similar drugs that are covered by WellCare. When
you receive the list, show it to your doctor and ask him or her to prescribe a similar drug
that we cover.
• You can ask WellCare to make an exception and cover your drug. See below for information about how to request an exception.
�
Which vaccines do you cover?
Your prescription benefit may cover many vaccines. For details, see the Immunological Agents
section. The cost for vaccines varies, depending on the facility where you receive them. For
best coverage, use a network pharmacy.
All commercially available vaccines are covered under Part D, except for those that are covered
under Medicare Part B, such as influenza or pneumococcal vaccines.
How do I request an exception to the WellCare formulary?
You can ask WellCare to make an exception to our coverage rules. There are several types of
formulary exceptions that you can ask us to make.
Initial Coverage Decision Exception
You can ask us to cover your drug even if it is not on our formulary.
Utilization Restriction Exception
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain
drugs, the amount of the drug that we cover is limited. If your drug has a quantity limit, you can
ask us to waive the limit and cover more.
2013 Comprehensive Formulary | III
Tiering Exception
You can ask us to provide a higher level of coverage for your drug. If your drug is listed in Tier 4
(Non-Preferred Brand), you can ask us to cover it at the cost-sharing amount for drugs in Tier 3
(Preferred Brand) instead. You must have tried and failed a medication in the lower tier in order
to have a tier exception approved. This would lower the amount you must pay for your drug.
Please note, if we grant your request to cover a drug that is not on our formulary, you may
not ask us to also provide a higher level of coverage for the drug. Also, you may not ask us to
provide a higher level of coverage for drugs that are in Tier 5 (Specialty).
Generally, WellCare will only approve your request for an exception if:
• the alternative drugs included on the plan’s formulary would not be as effective in treating
your condition;
• the lower-tiered drug would not be as effective in treating your condition;
• the additional utilization restrictions would not be as effective in treating your condition
and/or;
• the alternative drugs would cause you to have adverse medical effects.
You should contact us to ask us for a formulary exception for an initial coverage decision,
a tiering exception or a utilization restriction exception. When you request any of these
exceptions, 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 prescribing
physician’s supporting statement. You can request an expedited (fast) exception if you or your
doctor believe that your health could be seriously harmed by waiting up to 72 hours for a
decision. If your request for a fast review is granted, we must give you a decision no later than
24 hours after we get your prescriber’s or prescribing physician’s supporting statement.
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 93 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 93 days.
2013 Comprehensive Formulary | IV
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 a 98-day transition supply that meets the dispensing instructions
(unless you have a prescription written for fewer days). We will cover more than one refill of
these drugs for the first 98 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 98 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 seek a formulary exception.
If you experience a level of care change (such as being discharged or admitted to a longterm care facility), your physician or pharmacy can call our Provider Service Center and
request a one-time override. This one-time override will be a 31-day supply (unless you have a
prescription written for fewer days).
For more information
For more details about your WellCare prescription drug coverage, please review your Evidence
of Coverage and other plan materials.
If you have questions about WellCare, please call Customer Service at the telephone number
listed for your state/plan on the inside cover of this formulary. Or visit www.wellcarepdp.com.
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 1-877486-2048. Or, visit www.medicare.gov.
WellCare formulary
The comprehensive formulary that begins on page 1 provides coverage information about the
drugs covered by WellCare. If you have trouble finding your drug in the list, turn to the Index
that begins on page 57.
The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g.,
COUMADIN) and generic drugs are listed in lower-case italics (e.g., simvastatin).
The information in the Requirements/Limits column tells you if WellCare has any special
requirements for coverage of your drug.
• MS means the drug is available by mail-service (otherwise known as mail-order). Please
see Chapter 3 of your Evidence of Coverage for more information. When using WellCare’s
Preferred Mail-Service – Exactus Pharmacy SolutionsTM – you can receive a three-month
supply of Tier 1 medications for a $0 co-pay. You will save a minimum of 32 percent on
a three-month supply on all other prescriptions (excluding our Specialty Tier). Contact
Exactus at 1-866-892-9006 Monday–Thursday, 8 a.m. to 7 p.m. and Friday, 8 a.m. to 6 p.m.
Eastern. TTY users should call 1-866-507-6135. **
• PA stands for Prior Authorization: Please see page II for details.
• QL stands for Quantity Limits: Please see page II for details.
2013 Comprehensive Formulary | V
• LA stands for Limited Access medication. This medication is available from the Exactus
Specialty Pharmacy, and may be available from certain other pharmacies. For more
information, please refer to the Specialty Pharmacy section of your Pharmacy Directory or
contact Customer Service at the telephone number listed for your state/plan on the inside
cover of this formulary.
• ST stands for Step Therapy: Please see page II for details.
• CG stands for Coverage Gap: We provide additional coverage of this prescription drug in
the coverage gap. Please refer to our Evidence of Coverage for more information about this
coverage.
• † = Drug may be available for up to a 31-day supply only.
**This savings occurs when you use Exactus Pharmacy SolutionsTM, our preferred mail-service
pharmacy, as compared to using a non-preferred mail-service pharmacy.
Drug tier co-payment/coinsurance amounts
The WellCare formulary is divided into five tiers.
• Tier 1: Preferred Generic Drugs – Drugs that are available at the lowest cost share for this
plan.
• Tier 2: Non-Preferred Generic Drugs – Drugs that WellCare offers at a higher cost to you
than preferred generics.
• Tier 3: Preferred Brand Drugs – Drugs that WellCare may be able to offer at a lower cost to
you than non-preferred brand drugs.
• Tier 4: Non-Preferred Brand Drugs – Drugs that WellCare offers at a higher cost to you than
preferred brands.
• Tier 5: Specialty – Some injectables and other high-cost drugs. † Indicates drug may be available for up to a 31-day supply only.
�
Generic drugs are available in Tiers 1 and 2. Consult your Evidence of Coverage or Summary of
Benefits for your applicable co-pays/coinsurance and deductible amounts.
2013 Comprehensive Formulary | VI
How to read formulary listings:
DRUG
TYPE
DRUG
TIER
DRUG NAME
REQUIREMENTS/LIMITS
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
�
ANTICOAGULANTS
�
Therapeutic Category
Therapeutic Class
B
SPECIALTY BRAND DRUG
5†
QL (62 tablets per 31 days), MS
G
generic drug*
1
MS
Tier of Drug
Generic or Brand indicator
Name of Drug
† = Drug may be available for
up to a 31-day supply only
Requirements/Limits Codes:
LA = Limited Access
MS = Mail-Service Available
PA = Prior Authorization
QL = Quantity Limits
ST = Step Therapy
*CG = Coverage Gap
2013 Comprehensive Formulary | VII
COMPREHENSIVE FORMULARY
DRUG
DRUG
DRUG NAME
TYPE
TIER
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
G salsalate
2
OPIOID ANALGESICS, LONG-ACTING
G duramorph*
1
G fentanyl patch
2
methadone hcl concentrate, injection, oral
G
2
solution
G methadone hcl tablet*
1
G
methadose*
1
morphine sulfate er tablet extended release 12
G
1
hour*
G
morphine sulfate injection, oral solution*
1
G
morphine sulfate tablet*
1
G oxymorphone hydrochloride er
2
OPIOID ANALGESICS, SHORT-ACTING
G acetaminophen/codeine #3*
1
G
acetaminophen/codeine solution*
1
G
acetaminophen/codeine tablet 300mg; 15mg*
1
G co-gesic*
1
G codeine sulfate*
1
endocet tablet 325mg; 10mg, 325mg; 5mg,
G
1
325mg; 7.5mg, 500mg; 7.5mg*
G
endocet tablet 650mg; 10mg*
1
LAST UPDATE (08/2012)
REQUIREMENTS/LIMITS
MS
MS
QL (20 patches per 30 days), MS
MS
MS
MS
QL (124 lozenges per 31 days), PA,
MS
G
fentanyl citrate oral transmucosal
2
G
hydrocodone bitartrate/acetaminophen
tablet 750mg; 10mg*
hydrocodone/acetaminophen solution*
hydrocodone/acetaminophen tablet 325mg;
10mg, 325mg; 5mg, 325mg; 7.5mg, 500mg; 10mg,
500mg; 2.5mg, 500mg; 5mg, 500mg; 7.5mg*
hydrocodone/acetaminophen tablet 650mg;
10mg, 650mg; 7.5mg, 660mg; 10mg*
1
1
MS
1
1
G
G
G
*CG = Coverage Gap
LA Limited Access
MS Mail-Service Available
B Brand-Name G Generic
PA Prior Authorization QL Quantity Limited
ST Step Therapy
† = Drug may be available for up to a 31-day supply only
1
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
ANALGESICS (continued)
OPIOID ANALGESICS, SHORT-ACTING (continued)
G hydrocodone/acetaminophen tablet 750mg;
1
7.5mg*
G
hydrocodone/ibuprofen*
1
G hydromorphone hcl injection*
1
MS
G hydromorphone hcl tablet 2mg, 4mg*
1
G hydromorphone hcl tablet 8mg
2 QL (248 tablets per 31 days), MS
G
oxycodone hcl tablet*
1
G
oxycodone/acetaminophen capsule*
1
QL (248 capsules per 31 days), MS
oxycodone/acetaminophen tablet 325mg;
G
10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg,
1
500mg; 7.5mg*
oxycodone/acetaminophen tablet 650mg;
G 10mg*
1
G
reprexain tablet 10mg; 200mg*
1
G
stagesic*
1
G
tramadol hcl*
1
G tramadol hydrochloride/acetaminophen*
1
ANESTHETICS
LOCAL ANESTHETICS
G lidocaine hcl injection
2 MS
G
lidocaine hcl jelly gel 2%*
1
MS
G lidocaine ointment*
1
MS
G lidocaine viscous*
1
MS
G lidocaine/prilocaine cream*
1
MS
B
LIDODERM
4 QL (93 patches per 31 days), MS
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
B
CAMPRAL
4 MS
G disulfiram
2 MS
G
naltrexone hcl*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
2
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS (continued)
OPIOID ANTAGONISTS
G
buprenorphine hcl injection
2 PA, MS
G buprenorphine hcl tablet sublingual
2 PA, MS
G naloxone hcl injection 1mg/ml*
1
MS
B
SUBOXONE FILM
4 PA, MS
SMOKING CESSATION AGENTS
G
buproban*
1
MS
B
CHANTIX STARTING MONTH PAK
B
CHANTIX TABLET
B
NICOTROL NS
3 MS
ANTI-INFLAMMATORY AGENTS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
G
diclofenac potassium*
1
MS
G
diclofenac sodium dr*
1
MS
G
diclofenac sodium er
2 MS
G
diflunisal*
1
MS
G
etodolac er*
1
MS
G
etodolac*
1
MS
G
fenoprofen calcium*
1
MS
G
flurbiprofen tablet*
1
MS
G
ibuprofen*
1
MS
G
indomethacin*
1
MS
G
ketoprofen er
2 QL (31 capsules per 31 days), MS
G
ketoprofen*
1
MS
G
meloxicam suspension
2 MS
G
meloxicam tablet*
1
MS
G
nabumetone
2 MS
G naproxen sodium*
1
MS
G naproxen*
1
MS
G oxaprozin*
1
MS
G piroxicam*
1
MS
G sulindac*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
3
DRUG
DRUG NAME
TYPE
ANTIBACTERIALS
AMINOGLYCOSIDES
G amikacin sulfate injection*
G gentak ointment*
G gentamicin sulfate cream, ointment,
ophthalmic solution, injection*
G neomycin sulfate tablet*
G neomycin/polymyxin b sulfates*
G paromomycin sulfate*
B
TOBI
G
tobramycin sulfate injection
G
tobramycin sulfate ophthalmic solution*
B
ZYLET
ANTIBACTERIALS, OTHER
G
alcohol preps*
G
bacitracin*
G
bacitracin/polymyxin b*
G
clindamycin hcl capsule*
G
clindamycin phosphate add-vantage
G
clindamycin phosphate cream*
G
colistimethate sodium injection
B
CUBICIN
G
methenamine hippurate
G metronidazole cream, gel, lotion, tablet*
G
metronidazole in nacl 0.79%*
G
metronidazole vaginal gel*
G
mupirocin
G
neomycin/bacitracin/polymyxin*
G neomycin/polymyxin/gramicidin*
G
neomycin/polymyxin/hydrocortisone*
G
nitrofurantoin macrocrystalline
G
nitrofurantoin monohydrate
G
polycin b*
G silver sulfadiazine*
DRUG
REQUIREMENTS/LIMITS
TIER
1
1
MS
MS
1
MS
1
1
1
5†
2
1
4
MS
MS
MS
PA, MS
MS
MS
MS
1
1
1
1
2
1
2
5†
2
1
1
1
2
1
1
1
2
2
1
1
MS
MS
MS
MS
MS
MS
MS
PA, MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
4
DRUG
DRUG
DRUG NAME
TYPE
TIER
ANTIBACTERIALS (continued)
ANTIBACTERIALS, OTHER (continued)
G ssd*
1
G thermazene*
1
G trimethoprim sulfate/polymyxin b sulfate*
1
G trimethoprim tablet*
1
5†
B
TYGACIL
G
vancomycin hcl capsule
2
G vancomycin hcl injection 1000mg, 10gm
2
G
vandazole*
1
ZYVOX INJECTION, SUSPENSION
5†
B
RECONSTITUTED
B
ZYVOX TABLET
5†
BETA-LACTAM, CEPHALOSPORINS
G cefaclor*
1
G
cefadroxil*
1
G
cefazolin sodium
2
G cefdinir capsule*
1
G cefdinir suspension reconstituted
2
G
cefepime
2
G
cefotaxime sodium*
1
G
cefoxitin sodium injection 10gm, 1gm
2
G cefoxitin sodium injection 2gm*
1
G cefpodoxime proxetil suspension reconstituted 2
G cefpodoxime proxetil tablet*
1
G cefprozil*
1
G
ceftazidime
2
G
ceftazidime/dextrose
2
G
ceftriaxone sodium
2
G cefuroxime axetil suspension reconstituted
2
G
cefuroxime axetil tablet*
1
G
cefuroxime sodium injection 1.5gm, 750mg
2
G
cephalexin*
1
B
SUPRAX
4
REQUIREMENTS/LIMITS
MS
MS
MS
MS
PA, MS
PA, MS
PA, MS
MS
PA, MS
QL (62 tablets per 31 days), PA, MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
5
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
BETA-LACTAM, OTHER
G imipenem/cilastatin
2 MS
B
INVANZ
4 MS
G meropenem
2 MS
BETA-LACTAM, PENICILLINS
G
amoxicillin*
1
MS
G amoxicillin/clavulanate potassium*
1
MS
G amoxicillin/potassium clavulanate*
1
MS
ampicillin sodium injection 125mg, 1gm, 250mg,
G 2gm, 500mg
2 MS
G ampicillin*
1
MS
G
ampicillin-sulbactam
2 MS
B
BICILLIN C-R
3 MS
B
BICILLIN L-A
3 MS
G
dicloxacillin sodium*
1
MS
G
oxacillin sodium
2 MS
G
penicillin g potassium*
1
MS
B
PENICILLIN G PROCAINE
3 MS
G
penicillin v potassium*
1
MS
G
pfizerpen-g*
1
MS
G
piperacillin sodium/tazobactam sodium
2 MS
B
TIMENTIN
3 MS
MACROLIDES
B
AZASITE
3 MS
G azithromycin injection, tablet*
1
MS
G
azithromycin suspension reconstituted
2 MS
G
clarithromycin suspension reconstituted
2 MS
G clarithromycin tablet*
1
MS
G
e.e.s. 400*
1
MS
G
e.e.s. granules
2 MS
G
ery-tab*
1
MS
G
erythrocin lactobionate injection*
1
MS
G
erythrocin stearate tablet*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
6
DRUG
DRUG
DRUG NAME
TYPE
TIER
MACROLIDES (continued)
G erythromycin base tablet*
1
G
erythromycin ethylsuccinate tablet*
1
G erythromycin ointment*
1
G
erythromycin/sulfisoxazole suspension*
1
QUINOLONES
B
BESIVANCE
4
G
ciprofloxacin hcl ophthalmic solution*
1
G ciprofloxacin hcl tablet 250mg, 500mg, 750mg* 1
G
ciprofloxacin injection*
1
G levofloxacin in d5w
2
G
levofloxacin injection, oral solution, tablet
2
B
MOXEZA
4
G
ofloxacin ophthalmic solution, otic solution*
1
G
ofloxacin tablet
2
B
VIGAMOX
4
B
ZYMAXID
4
SULFONAMIDES
G
sodium sulfacetamide solution*
1
G
sulfacetamide sodium*
1
G
sulfadiazine
2
G
sulfamethoxazole/trimethoprim ds*
1
G
sulfamethoxazole/trimethoprim*
1
TETRACYCLINES
G
demeclocycline hcl
2
1
G doxycycline hyclate*
G
minocycline hcl capsule*
1
G
tetracycline hcl*
1
REQUIREMENTS/LIMITS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
7
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
levetiracetam injection 1000mg/100ml; 750mg/
G 100ml, 1500mg/100ml; 540mg/100ml, 500mg/
2 MS
100ml; 820mg/100ml
G levetiracetam injection 500mg/5ml*
1
MS
G levetiracetam oral solution, tablet*
1
MS
G phenobarbital tablet*
1
MS
†
PA, MS
B
POTIGA TABLET 200MG, 300MG, 400MG
5
B
POTIGA TABLET 50MG
4 PA, MS
CALCIUM CHANNEL MODIFYING AGENTS
B
CELONTIN
3 MS
G
ethosuximide*
1
MS
G
zonisamide*
1
MS
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
G
clonazepam odt
2 MS
G
clonazepam tablet*
1
MS
G
clorazepate dipotassium
2 MS
G diazepam gel
2 MS
G divalproex sodium dr*
1
MS
G
divalproex sodium er
2 MS
G divalproex sodium*
1
MS
G gabapentin capsule 100mg, 300mg*
1
G
gabapentin capsule 400mg*
1
G
gabapentin solution*
1
MS
G
gabapentin tablet 600mg*
1
G
gabapentin tablet 800mg*
1
GABITRIL
B
4 MS
B
ONFI
4 MS
G primidone*
1
MS
†
QL (186 packets per 31 days), PA, LA
5
B
SABRIL PACKET
B
SABRIL TABLET
5† QL (186 tablets per 31 days), PA, LA
G
valproate sodium*
1
MS
G valproic acid*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
8
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
ANTICONVULSANTS (continued)
GLUTAMATE REDUCING AGENTS
G felbamate
2 MS
G lamotrigine tablet chewable, tablet*
1
MS
G
topiramate*
1
MS
SODIUM CHANNEL AGENTS
B
BANZEL SUSPENSION
4 PA, MS
B
BANZEL TABLET 200MG
4 QL (248 tablets per 31 days), PA, MS
B
BANZEL TABLET 400MG
5† QL (248 tablets per 31 days), PA, MS
carbamazepine suspension, tablet chewable,
G
1
MS
tablet*
B
DILANTIN CAPSULE 30MG
3 MS
B
DILANTIN INFATABS
3 MS
G
epitol*
1
MS
G
fosphenytoin sodium*
1
MS
G
oxcarbazepine
2 MS
B
PEGANONE
4 MS
G phenytoin sodium extended capsule*
1
MS
G phenytoin sodium injection*
1
MS
G phenytoin suspension*
1
MS
B
TRILEPTAL SUSPENSION
4 MS
B
VIMPAT
4 MS
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
G
ergoloid mesylates
2 MS
CHOLINESTERASE INHIBITORS
G
donepezil hcl tablet dispersible, tablet
2 MS
B
EXELON PATCH 24 HOUR
3 QL (31 patches per 31 days), MS
B
3 MS
EXELON SOLUTION
galantamine hydrobromide capsule extended
G release 24 hour
G galantamine hydrobromide solution
2 QL (186 ml per 31 days), MS
G
galantamine hydrobromide tablet
G
rivastigmine tartrate
2 MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
9
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
ANTIDEMENTIA AGENTS (continued)
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
B
NAMENDA SOLUTION
3 MS
B
NAMENDA TABLET
B
NAMENDA TITRATION PAK
3 MS
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
G budeprion sr*
1
MS
G budeprion xl*
1
MS
G bupropion hcl sr*
1
MS
G bupropion hcl xl*
1
G bupropion hcl*
1
MS
G maprotiline hcl*
1
MS
G mirtazapine odt*
1
MS
G mirtazapine*
1
MS
G
nefazodone hcl*
1
MS
G trazodone hcl tablet 100mg, 150mg, 50mg*
1
MS
G
trazodone hcl tablet 300mg
2 MS
MONOAMINE OXIDASE INHIBITORS
B
EMSAM
4 QL (31 patches per 31 days), PA, MS
B
MARPLAN
4 MS
G phenelzine sulfate*
1
MS
G tranylcypromine sulfate
2 MS
SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS
G citalopram hydrobromide solution
2 MS
G citalopram hydrobromide tablet 10mg, 20mg*
1
G citalopram hydrobromide tablet 40mg*
1
CYMBALTA CAPSULE DELAYED RELEASE
4 QL (62 capsules per 31 days), PA, MS
B
PARTICLES 20MG, 30MG
CYMBALTA CAPSULE DELAYED RELEASE
B
PARTICLES 60MG
G
escitalopram oxalate solution
2 MS
G
escitalopram oxalate tablet
G fluoxetine hcl capsule, solution*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
10
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
ANTIDEPRESSANTS (continued)
SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS (continued)
G
fluvoxamine maleate*
1
MS
G paroxetine hcl*
1
B
PAXIL SUSPENSION
4 MS
B
PRISTIQ
G
sertraline hcl*
1
MS
venlafaxine hcl er capsule extended release 24
G
hour
venlafaxine hcl er tablet extended release 24
G
hour 150mg, 37.5mg, 75mg
G
venlafaxine hcl*
1
MS
B
VIIBRYD
4 QL (31 tablets per 31 days), ST, MS
TRICYCLICS
G
amitriptyline hcl*
1
MS
G
amoxapine*
1
MS
G
chlordiazepoxide/amitriptyline
2 MS
G
clomipramine hcl
2 MS
G
desipramine hcl
2 MS
G
doxepin hcl
2 MS
G
imipramine hcl
2 MS
G
imipramine pamoate
2 MS
G nortriptyline hcl capsule*
1
MS
G perphenazine/amitriptyline
2 MS
G
protriptyline hcl
2 MS
G trimipramine maleate
2 MS
ANTIEMETICS
ANTIEMETICS, OTHER
G meclizine hcl*
1
MS
G prochlorperazine edisylate injection*
1
MS
G prochlorperazine maleate tablet*
1
MS
G
prochlorperazine suppository*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
11
DRUG
DRUG NAME
TYPE
ANTIEMETICS (continued)
EMETOGENIC THERAPY ADJUNCTS
G
dronabinol
B
EMEND CAPSULE, PACK
G granisetron hcl injection
G
granisetron hcl tablet
G ondansetron hcl injection
G ondansetron hcl oral solution
G ondansetron hcl tablet
G ondansetron odt
ANTIFUNGALS
ANTIFUNGALS
G amphotericin b
B
CANCIDAS
G ciclopirox gel, shampoo
G
ciclopirox nail lacquer*
G
ciclopirox olamine*
G
ciclopirox suspension*
G clotrimazole cream, solution*
G clotrimazole troche
G
clotrimazole/betamethasone dipropionate*
G
econazole nitrate*
G
fluconazole in dextrose
G
fluconazole in nacl
G fluconazole*
G
flucytosine
G
griseofulvin microsize suspension
G
itraconazole
G ketoconazole*
B
MYCAMINE
B
NAFTIN
B
NATACYN
G
nyamyc*
DRUG
REQUIREMENTS/LIMITS
TIER
2
4
2
2
2
2
2
2
QL (62 capsules per 31 days), PA, MS
PA, MS
QL (10 ml per 31 days), PA, MS
PA, MS
PA, MS
MS
MS
2
5†
2
1
1
1
1
2
1
1
2
2
1
2
2
2
1
5†
3
3
1
MS
PA, MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
PA, MS
MS
PA, MS
MS
MS
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
12
DRUG
DRUG
DRUG NAME
TYPE
TIER
ANTIFUNGALS (continued)
ANTIFUNGALS (continued)
G nystatin vaginal*
1
G nystatin*
1
G nystatin/triamcinolone*
1
G
nystop*
1
G
pedi-dri*
1
G
terbinafine hcl*
1
G terconazole*
1
G voriconazole injection
2
G voriconazole tablet 200mg
2
G voriconazole tablet 50mg
2
G
zazole*
1
ANTIGOUT AGENTS
ANTIGOUT AGENTS
G allopurinol*
1
B
COLCRYS
3
G probenecid*
1
B
ULORIC
4
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
G
dihydroergotamine mesylate
2
G ergotamine tartrate/caffeine*
1
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
G
naratriptan hcl tablet
2
G sumatriptan nasal spray
2
G
sumatriptan succinate injection
2
G sumatriptan succinate injection refill
2
G sumatriptan succinate tablet
2
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
B
MESTINON SYRUP
3
B
MESTINON TIMESPAN
3
REQUIREMENTS/LIMITS
MS
MS
MS
MS
MS
MS
MS
PA, MS
MS
MS
MS
MS
ST, MS
MS
MS
QL (12 units per 31 days), MS
QL (8 ml per 31 days), MS
MS
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
13
DRUG
DRUG NAME
TYPE
ANTIMYASTHENIC AGENTS (continued)
PARASYMPATHOMIMETICS (continued)
G pyridostigmine bromide*
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
B
DAPSONE
B
MYCOBUTIN
ANTITUBERCULARS
B
CAPASTAT SULFATE
G ethambutol hcl*
G
isoniazid syrup
G isoniazid tablet*
B
PASER
B
PRIFTIN
G
pyrazinamide*
G
rifampin capsule, injection*
B
SEROMYCIN
B
TRECATOR
ANTINEOPLASTICS
ALKYLATING AGENTS
B
CEENU
G cyclophosphamide injection*
G cyclophosphamide tablet
B
HEXALEN
G ifosfamide*
B
LEUKERAN
B
MATULANE
TREANDA
B
ANTIANGIOGENIC AGENTS
B
CAPRELSA TABLET 100MG
B
CAPRELSA TABLET 300MG
B
REVLIMID
B
THALOMID
DRUG
REQUIREMENTS/LIMITS
TIER
1
MS
3
4
MS
MS
4
1
2
1
4
4
1
1
3
4
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
3
1
2
4
1
3
5†
5†
MS
PA, MS
PA, MS
PA, MS
MS
MS
MS
PA, MS
5†
5†
5†
5†
PA, LA
PA, MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
14
DRUG
DRUG NAME
TYPE
ANTINEOPLASTICS (continued)
ANTIANGIOGENIC AGENTS (continued)
B
VANDETANIB TABLET 100MG
B
VANDETANIB TABLET 300MG
ANTIESTROGENS/MODIFIERS
B
EMCYT
B
FARESTON
B
FASLODEX
G tamoxifen citrate*
ANTIMETABOLITES
B
DROXIA
B
ELITEK
G
hydroxyurea*
G
mercaptopurine
G
pentostatin*
B
TABLOID
ANTINEOPLASTICS, OTHER
B
ALIMTA
G amifostine
G
bleomycin sulfate*
B
ERIVEDGE
B
IXEMPRA KIT
B
JAKAFI
G
leucovorin calcium
B
MENEST
G
mesna*
B
MESNEX TABLET
G
mitoxantrone hcl*
B
ONTAK
B
PROLEUKIN
B
SYLATRON
B
TRISENOX
B
VELCADE
DRUG
REQUIREMENTS/LIMITS
TIER
5†
5†
4
5†
5†
1
PA, MS
MS
3
5†
1
2
1
4
MS
PA, MS
MS
MS
PA, MS
PA, MS
5†
2
1
5†
5†
5†
2
4
1
5†
1
5†
5†
5†
4
5†
PA, MS
PA, MS
PA, MS
PA, MS
PA, MS
MS
MS
MS
MS
PA, MS
PA, MS
PA, MS
PA, MS
PA, MS
PA, MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
15
DRUG
DRUG NAME
TYPE
ANTINEOPLASTICS (continued)
ANTINEOPLASTICS, OTHER (continued)
B
VIDAZA
DRUG
REQUIREMENTS/LIMITS
TIER
B
ZOLINZA
5†
B
5†
2
2
1
MS
MS
B
B
B
B
B
B
B
B
B
ZYTIGA
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole
exemestane
letrozole*
MOLECULAR TARGET INHIBITORS
AFINITOR
GLEEVEC TABLET 100MG
GLEEVEC TABLET 400MG
INLYTA
IRESSA
NEXAVAR
SPRYCEL
SUTENT
TARCEVA
PA, MS
QL (124 capsules per 31 days), PA,
MS
5†
5†
5†
5†
5†
5†
5†
5†
5†
B
TASIGNA
5†
B
B
B
B
TYKERB
VOTRIENT
XALKORI
ZELBORAF
MONOCLONAL ANTIBODIES
AVASTIN
CAMPATH
RITUXAN
RETINOIDS
PANRETIN
TARGRETIN
tretinoin capsule
5†
5†
5†
5†
PA, MS
QL (62 tablets per 31 days), LA
QL (124 tablets per 31 days), PA, LA
MS
5†
5†
5†
PA, MS
PA, LA
PA, LA
5†
5†
2
MS
PA, MS
MS
G
G
G
B
B
B
B
B
G
5†
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
16
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
ANTIPARASITICS
ANTHELMINTICS
B
ALBENZA
3 MS
B
STROMECTOL
4 MS
ANTIPROTOZOALS
B
ALINIA
4 PA, MS
G chloroquine phosphate*
1
MS
B
DARAPRIM
3 MS
G hydroxychloroquine sulfate*
1
MS
G mefloquine hcl*
1
MS
†
MS
B
MEPRON
5
B
PENTAM 300
4 PA, MS
PEDICULICIDES/SCABICIDES
G
acticin*
1
MS
G
malathion
2 MS
G permethrin*
1
MS
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
G
benztropine mesylate tablet
2 MS
G
trihexyphenidyl hcl
2 MS
ANTIPARKINSON AGENTS, OTHER
B
COMTAN
3 MS
B
TASMAR
4 MS
DOPAMINE AGONISTS
B
APOKYN
5† QL (90 ml per 30 days), PA, MS
G bromocriptine mesylate
2 MS
G
pramipexole dihydrochloride
2 MS
G ropinirole hcl*
1
MS
DOPAMINE PRECURSORS/L- AMINO ACID DECARBOXYLASE INHIBITORS
G
carbidopa/levodopa er*
1
MS
G
carbidopa/levodopa tablet*
1
MS
B
LODOSYN
4 MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
17
DRUG
DRUG
DRUG NAME
TYPE
TIER
ANTIPARKINSON AGENTS (continued)
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
B
AZILECT
4
G selegiline hcl
2
B
ZELAPAR
4
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
G
chlorpromazine hcl injection
2
G chlorpromazine hcl tablet*
1
G compro*
1
G fluphenazine decanoate*
1
G
fluphenazine hcl concentrate, elixir
2
G fluphenazine hcl injection, tablet*
1
B
HALDOL DECANOATE 100
3
B
HALDOL DECANOATE 50
3
G haloperidol decanoate*
1
G haloperidol lactate*
1
G haloperidol*
1
G loxapine succinate*
1
B
ORAP
3
G perphenazine*
1
G thioridazine hcl*
1
G
thiothixene*
1
G
trifluoperazine hcl*
1
2ND GENERATION/ATYPICAL
B
ABILIFY DISCMELT TABLET DISPERSIBLE 10MG
4
B
ABILIFY DISCMELT TABLET DISPERSIBLE 15MG
4
ABILIFY INJECTION
B
4
B
ABILIFY ORAL SOLUTION
4
B
ABILIFY TABLET
4
B
FANAPT
4
B
FANAPT TITRATION PACK
4
B
GEODON INJECTION
4
REQUIREMENTS/LIMITS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
PA, MS
PA, MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
18
DRUG
DRUG
DRUG NAME
TYPE
TIER
ANTIPSYCHOTICS (continued)
2ND GENERATION/ATYPICAL (continued)
INVEGA SUSTENNA INJECTION 117MG/0.75ML,
B
5†
156MG/ML, 234MG/1.5ML
INVEGA SUSTENNA INJECTION 39MG/0.25ML, 4
B
78MG/0.5ML
INVEGA TABLET EXTENDED RELEASE 24 HOUR
B
4
1.5MG, 3MG, 9MG
INVEGA TABLET EXTENDED RELEASE 24 HOUR
B
4
6MG
B
LATUDA
4
G
olanzapine injection
2
G olanzapine odt
2
G
olanzapine tablet
2
G
quetiapine fumarate*
1
B
RISPERDAL CONSTA INJECTION 12.5MG, 25MG 4
B
RISPERDAL CONSTA INJECTION 37.5MG, 50MG 5†
G
risperidone m-tab
2
G
risperidone odt
2
G risperidone solution
2
G
risperidone tablet*
1
B
SAPHRIS
4
SEROQUEL XR TABLET EXTENDED RELEASE 24
B
4
HOUR 150MG, 200MG
SEROQUEL XR TABLET EXTENDED RELEASE 24
B
4
HOUR 300MG, 400MG, 50MG
G
ziprasidone hcl capsule
2
5†
B
ZYPREXA RELPREVV
TREATMENT-RESISTANT
G
clozapine
2
B
FAZACLO TABLET DISPERSIBLE 12.5MG
4
ANTISPASTICITY AGENTS
ANTISPASTICITY AGENTS
G
baclofen tablet*
1
G
tizanidine hcl*
1
REQUIREMENTS/LIMITS
QL (1 syringe per 30 days), PA, MS
MS
PA, MS
MS
PA, MS
MS
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
19
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
G
foscarnet sodium*
1
PA, MS
G ganciclovir capsule*
1
MS
†
5
B
VALCYTE SOLUTION RECONSTITUTED
5† QL (124 tablets per 31 days), MS
B
VALCYTE TABLET
B
ZIRGAN GEL
4 MS
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
B
COMPLERA
4 MS
B
EDURANT
B
INTELENCE
G nevirapine
2 MS
B
RESCRIPTOR
3 MS
B
SUSTIVA
3 MS
B
VIRAMUNE SUSPENSION
3 MS
B
VIRAMUNE XR
4 MS
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE
INHIBITORS
B
ATRIPLA
G didanosine
2 MS
B
EMTRIVA
3 MS
B
EPIVIR HBV
4 MS
B
EPIVIR SOLUTION
4 MS
B
EPZICOM
3 MS
G
lamivudine
2 MS
G
lamivudine/zidovudine
2 MS
B
RETROVIR IV INFUSION
4 MS
G
stavudine
2 MS
B
TRIZIVIR
B
TRUVADA
B
VIDEX PEDIATRIC
4 MS
B
VIREAD
4 MS
B
ZERIT SOLUTION RECONSTITUTED
4 MS
B
ZIAGEN
3 MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
20
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
ANTIVIRALS (continued)
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE
INHIBITORS (continued)
G zidovudine capsule
2 MS
G zidovudine syrup, tablet*
1
MS
ANTI-HIV AGENTS, OTHER
B
FUZEON
5† QL (62 vials per 31 days), MS
B
ISENTRESS
B
SELZENTRY
ANTI-HIV AGENTS, PROTEASE INHIBITORS
5† QL (124 capsules per 31 days), MS
B
APTIVUS CAPSULE
B
APTIVUS SOLUTION
5† QL (310 ml per 31 days), MS
B
CRIXIVAN
3 MS
5† MS
B
INVIRASE
B
KALETRA
4 MS
B
LEXIVA
4 MS
B
NORVIR
4 MS
B
PREZISTA TABLET 150MG
3 MS
B
PREZISTA TABLET 400MG, 600MG
B
PREZISTA TABLET 75MG
B
REYATAZ CAPSULE 100MG, 150MG, 200MG
B
REYATAZ CAPSULE 300MG
B
VIRACEPT
3 MS
ANTI-INFLUENZA AGENTS
G
amantadine hcl*
1
MS
B
RELENZA DISKHALER
3 QL (120 disks per 365 days), MS
G
rimantadine hcl*
1
MS
B
TAMIFLU
3 MS
ANTIHEPATITIS AGENTS
B
BARACLUDE SOLUTION
4 MS
B
BARACLUDE TABLET
B
HEPSERA
QL (504 tablets per 365 days), PA,
5† MS
B
INCIVEK
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
21
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
ANTIVIRALS (continued)
ANTIHEPATITIS AGENTS (continued)
INTRON-A INJECTION 10MU/0.2ML, 10MU/ML, 4 PA, MS
B
3MU/0.2ML, 6000000UNIT/ML
B
INTRON-A INJECTION 5MU/0.2ML
5† PA, MS
INTRON-A W/DILUENT INJECTION 10MU,
B
4 PA, MS
18MU
5† PA, MS
B
INTRON-A W/DILUENT INJECTION 50MU
B
PEGASYS
5† PA, MS
5† PA, MS
B
PEGASYS PROCLICK
G
ribasphere tablet 200mg
2 MS
G
ribavirin tablet 200mg
2 MS
B
TYZEKA
4 PA, MS
5† QL (372 capsules per 31 days), PA,
B
VICTRELIS
MS
ANTIHERPETIC AGENTS
G
acyclovir capsule, suspension, tablet*
1
MS
G
acyclovir sodium*
1
MS
B
DENAVIR
3 MS
G
famciclovir
2 MS
G trifluridine
2 MS
G
valacyclovir hcl
B
ZOVIRAX CREAM, OINTMENT
4 MS
ANXIOLYTICS
ANXIOLYTICS, OTHER
G
alprazolam tablet*
1
MS
G
buspirone hcl*
1
MS
G
diazepam intensol*
1
MS
G
diazepam solution, tablet*
1
MS
G
estazolam*
1
MS
G
lorazepam tablet*
1
MS
G
meprobamate
2 PA, MS
G
oxazepam*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
22
DRUG
DRUG NAME
TYPE
BIPOLAR AGENTS
MOOD STABILIZERS
G lithium carbonate er*
G
lithium carbonate*
G
lithium citrate*
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
G
acarbose*
B
ACTOPLUS MET
B
ACTOS
B
AVANDAMET
B
AVANDARYL
B
AVANDIA
B
BYDUREON
B
BYETTA
B
DUETACT
G
glimepiride*
G
glipizide er*
G
glipizide xl*
G
glipizide*
G glipizide/metformin hcl*
G glyburide
G glyburide micronized
G
glyburide/metformin hcl
B
JANUMET
JANUMET XR TABLET EXTENDED RELEASE 24
B
HOUR 1000MG; 100MG
JANUMET XR TABLET EXTENDED RELEASE 24
B
HOUR 1000MG; 50MG, 500MG; 50MG
B
JANUVIA TABLET 100MG
B
JANUVIA TABLET 25MG, 50MG
B
JUVISYNC
B
KOMBIGLYZE XR
DRUG
REQUIREMENTS/LIMITS
TIER
1
1
1
MS
MS
MS
1
4
4
4
4
4
4
4
4
1
1
1
1
1
2
2
2
4
MS
MS
MS
4
4
4
4
4
4
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
23
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
BLOOD GLUCOSE REGULATORS (continued)
ANTIDIABETIC AGENTS (continued)
metformin hcl er tablet extended release 24
G
1
hour 1000mg*
G
1
hour 500mg*
G
1
hour 750mg*
G metformin hcl tablet 1000mg*
1
G
metformin hcl tablet 500mg*
1
G
metformin hcl tablet 850mg*
1
G nateglinide
2 MS
B
ONGLYZA
B
PRANDIMET
4 MS
B
PRANDIN
4 MS
B
SYMLINPEN 120
4 PA, MS
B
SYMLINPEN 60
4 PA, MS
G
tolazamide*
1
G
tolbutamide*
1
GLYCEMIC AGENTS
B
DEXTROSE 10% FLEX CONTAINER
3 MS
B
DEXTROSE 5%
3 MS
B
GLUCAGON EMERGENCY KIT
3 QL (4 kits per 31 days), MS
B
PROGLYCEM
4 MS
INSULINS
B
HUMALOG
B
HUMALOG KWIKPEN
B
HUMALOG MIX 50/50
B
HUMALOG MIX 50/50 KWIKPEN
B
HUMALOG MIX 75/25
B
HUMALOG MIX 75/25 KWIKPEN
B
HUMULIN 70/30
B
HUMULIN 70/30 PEN
B
HUMULIN N
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
24
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
BLOOD GLUCOSE REGULATORS (continued)
INSULINS (continued)
B
HUMULIN N U-100 PEN
B
HUMULIN R
B
HUMULIN R U-500 (CONCENTRATED)
3 QL (40 ml per 31 days), PA, MS
B
LANTUS
B
LANTUS SOLOSTAR
B
LEVEMIR
B
LEVEMIR FLEXPEN
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
B
COUMADIN
3 MS
enoxaparin sodium injection 100mg/ml, 150mg/
G
ml
enoxaparin sodium injection 120mg/0.8ml,
G
2 QL (22.4 ml per 31 days), MS
80mg/0.8ml
G enoxaparin sodium injection 300mg/3ml
G
40mg/0.4ml
G enoxaparin sodium injection 60mg/0.6ml
G fondaparinux sodium injection 10mg/0.8ml
G
fondaparinux sodium injection 2.5mg/0.5ml
G
fondaparinux sodium injection 5mg/0.4ml
G
fondaparinux sodium injection 7.5mg/0.6ml
G
heparin sodium*
1
MS
G
heparin sodium/d5w*
1
MS
G
heparin sodium/nacl 0.45%*
1
MS
G
heparin sodium/sodium chloride 0.9% premix* 1
MS
G
jantoven*
1
MS
B
PRADAXA
G
warfarin sodium*
1
MS
B
XARELTO TABLET 10MG
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
25
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS (continued)
BLOOD FORMATION MODIFIERS
G
anagrelide hydrochloride*
1
MS
B
LEUKINE
4 PA, MS
B
NEUMEGA
5† PA, MS
B
NEUPOGEN
5† PA, MS
PROCRIT INJECTION 10000UNIT/ML,
B
3 PA, MS
2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML
5† PA, MS
B
40000UNIT/ML
B
PROMACTA
COAGULANTS
G
tranexamic acid
2 MS
PLATELET MODIFYING AGENTS
B
AGGRENOX
4 MS
G
cilostazol*
1
MS
G
clopidogrel tablet 300mg
G
clopidogrel tablet 75mg*
1
G
dipyridamole
2 MS
G
ticlopidine hcl
2 MS
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
G
clonidine hcl tablet*
1
MS
G
clorpres*
1
MS
G
guanfacine hcl
2 MS
G
methyldopa
2 MS
G
methyldopa/hydrochlorothiazide
2 MS
G
midodrine hcl
2 MS
ALPHA-ADRENERGIC BLOCKING AGENTS
G
doxazosin mesylate*
1
MS
G
prazosin hcl*
1
MS
G
reserpine*
1
MS
G
terazosin hcl*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
26
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
CARDIOVASCULAR AGENTS (continued)
ANGIOTENSIN II RECEPTOR ANTAGONISTS
DIOVAN HCT TABLET 12.5MG; 160MG, 12.5MG;
B
80MG
DIOVAN HCT TABLET 12.5MG; 320MG, 25MG;
B
160MG, 25MG; 320MG
B
DIOVAN TABLET 160MG, 40MG, 80MG
B
DIOVAN TABLET 320MG
B
EDARBI
B
EDARBYCLOR
G losartan potassium tablet 100mg*
1
G
losartan potassium tablet 25mg, 50mg*
1
losartan potassium/hydrochlorothiazide
G
1
tablet 12.5mg; 100mg, 25mg; 100mg*
losartan potassium/hydrochlorothiazide
G
1
tablet 12.5mg; 50mg*
B
TWYNSTA
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
G benazepril hcl*
1
MS
G
benazepril hcl/hydrochlorothiazide*
1
MS
G
captopril*
1
MS
G
captopril/hydrochlorothiazide*
1
MS
G enalapril maleate*
1
MS
G
enalapril maleate/hydrochlorothiazide*
1
MS
G
fosinopril sodium*
1
MS
G
fosinopril sodium/hydrochlorothiazide*
1
MS
G
lisinopril*
1
MS
G
lisinopril/hydrochlorothiazide*
1
MS
G
moexipril hcl*
1
MS
G
moexipril/hydrochlorothiazide*
1
MS
quinapril hcl*
G
1
MS
G
quinapril/hydrochlorothiazide*
1
MS
G
ramipril*
1
MS
G
trandolapril*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
27
DRUG
DRUG NAME
TYPE
ANTIARRHYTHMICS
G amiodarone hcl tablet 200mg*
G
amiodarone hcl tablet 400mg
G
disopyramide phosphate
G
flecainide acetate
G
mexiletine hcl*
B
MULTAQ
B
NORPACE CR
G pacerone tablet 200mg*
G
procainamide hcl*
G
propafenone hcl*
G
quinidine gluconate er*
G
quinidine sulfate er*
G
quinidine sulfate*
G
sorine*
G
sotalol hcl (af)*
G
sotalol hcl*
B
TIKOSYN
BETA-ADRENERGIC BLOCKING AGENTS
G acebutolol hcl*
G
atenolol*
G
atenolol/chlorthalidone*
G
betaxolol hcl tablet*
G
bisoprolol fumarate*
G
bisoprolol fumarate/hydrochlorothiazide*
G
carvedilol*
B
COREG CR
G labetalol hcl*
G metoprolol succinate er*
G metoprolol tartrate*
G metoprolol/hydrochlorothiazide*
G
nadolol*
DRUG
REQUIREMENTS/LIMITS
TIER
1
2
2
2
1
4
4
1
1
1
1
1
1
1
1
1
4
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
1
1
1
1
1
1
1
3
1
1
1
1
1
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
28
DRUG
DRUG
DRUG NAME
TYPE
TIER
BETA-ADRENERGIC BLOCKING AGENTS (continued)
G
pindolol*
1
G
propranolol hcl er*
1
G
propranolol hcl*
1
G
propranolol/hydrochlorothiazide*
1
G
timolol maleate tablet*
1
CALCIUM CHANNEL BLOCKING AGENTS
G
amlodipine besylate*
1
G
amlodipine besylate/benazepril hcl
2
G
cartia xt*
1
G
dilt-cd*
1
G
dilt-xr*
1
G
diltiazem cd*
1
G
diltiazem hcl er*
1
G
diltiazem hcl*
1
G
diltzac*
1
G felodipine er
2
G
matzim la*
1
G
nicardipine hcl capsule*
1
G
nifediac cc
2
G
nifedical xl
2
G
nifedipine
2
G
nifedipine er
2
G
nimodipine
2
G
taztia xt*
1
G
verapamil hcl er*
1
G
verapamil hcl sr*
1
G
verapamil hcl tablet*
1
CARDIOVASCULAR AGENTS, OTHER
G digoxin*
1
B
LANOXIN
3
G
pentoxifylline er*
1
REQUIREMENTS/LIMITS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
29
DRUG
DRUG
DRUG NAME
TYPE
TIER
CARDIOVASCULAR AGENTS, OTHER (continued)
B
RANEXA
4
B
TEKTURNA
4
B
TEKTURNA HCT
4
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
G acetazolamide sodium
2
G
acetazolamide tablet*
1
DIURETICS, LOOP
G
bumetanide*
1
G furosemide*
1
G
torsemide tablet*
1
DIURETICS, POTASSIUM-SPARING
G
amiloride hcl*
1
G
amiloride/hydrochlorothiazide*
1
G
spironolactone*
1
G
spironolactone/hydrochlorothiazide*
1
G
triamterene/hydrochlorothiazide*
1
DIURETICS, THIAZIDE
G chlorothiazide sodium injection*
1
G
chlorothiazide tablet*
1
G
chlorthalidone*
1
G hydrochlorothiazide capsule*
1
G hydrochlorothiazide tablet 25mg, 50mg*
1
G
indapamide*
1
G
methyclothiazide*
1
G
metolazone*
1
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
ANTARA
B
3
G fenofibrate micronized
2
G
fenofibrate*
1
G gemfibrozil*
1
REQUIREMENTS/LIMITS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
30
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
G
atorvastatin calcium
B
LIVALO
4 MS
G lovastatin*
1
MS
G
pravastatin sodium*
1
G
simvastatin*
1
DYSLIPIDEMICS, OTHER
G cholestyramine light*
1
MS
G
cholestyramine*
1
MS
G
colestipol hcl granules
2 MS
G
colestipol hcl tablet*
1
MS
B
LOVAZA
4 MS
G micronized colestipol hcl*
1
MS
B
NIACOR
3 MS
B
NIASPAN
4 MS
G
prevalite*
1
MS
B
VYTORIN
B
WELCHOL
4 PA, MS
B
ZETIA
VASODILATORS, DIRECT-ACTING ARTERIAL
G
hydralazine hcl*
1
MS
G
minoxidil*
1
MS
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
G
isosorbide dinitrate er
2 MS
G
isosorbide dinitrate*
1
MS
G
isosorbide mononitrate er*
1
MS
MS
G
isosorbide mononitrate*
1
B
NITRO-BID
3 MS
G nitroglycerin injection, patch*
1
MS
G nitroglycerin transdermal patch*
1
MS
B
NITROSTAT
3 MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
31
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
G amphetamine/dextroamphetamine
2 PA, MS
G
dextroamphetamine sulfate
2 PA, MS
G
dextroamphetamine sulfate er
2 PA, MS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
G
dexmethylphenidate hcl
2 MS
B
INTUNIV
G metadate er
2 MS
methylphenidate hcl er tablet extended release
G
2 MS
20mg
G
methylphenidate hcl tablet
G
methylphenidate hydrochloride solution
2 MS
B
STRATTERA CAPSULE 100MG, 80MG
STRATTERA CAPSULE 10MG, 18MG, 25MG,
B
40MG, 60MG
CENTRAL NERVOUS SYSTEM, OTHER
G butalbital/acetaminophen/caffeine/codeine*
1
†
MS
B
RILUTEK
5
B
XENAZINE TABLET 12.5MG
B
XENAZINE TABLET 25MG
FIBROMYALGIA AGENTS
B
LYRICA
4 PA, MS
B
SAVELLA
3 MS
B
SAVELLA TITRATION PACK
3 MS
MULTIPLE SCLEROSIS AGENTS
5† QL (62 tablets per 31 days), PA, MS
B
AMPYRA
B
AVONEX
5† QL (4 syringes per 28 days), PA, MS
B
COPAXONE
B
EXTAVIA
5† QL (31 capsules per 31 days), PA, MS
B
GILENYA
5† QL (6 ml per 28 days), PA, MS
B
REBIF
5† QL (4.2 ml per 28 days), PA, MS
B
REBIF TITRATION PACK
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
32
DRUG
DRUG NAME
TYPE
DENTAL AND ORAL AGENTS
DENTAL AND ORAL AGENTS
G chlorhexidine gluconate oral rinse*
G
dentagel*
G
karigel*
G
periogard*
G
pilocarpine hcl tablet
G
triamcinolone in orabase*
DERMATOLOGICAL AGENTS
DERMATOLOGICAL AGENTS
B
8-MOP
G
ammonium lactate*
B
AZELEX
G
calcipotriene
B
CARAC
G clindamycin phosphate gel, lotion, solution*
B
CONDYLOX GEL
B
CURITY GAUZE PADS 2"X2"
G
erythromycin gel, topical solution*
G
erythromycin/benzoyl peroxide*
B
FINACEA
B
FLUOROPLEX
G fluorouracil
G
imiquimod
G
laclotion*
B
OXSORALEN ULTRA CAPSULE
G podofilox solution
PROTOPIC
B
B
REGRANEX
B
SANTYL
G selenium sulfide lotion*
B
SORIATANE
B
TAZORAC
DRUG
REQUIREMENTS/LIMITS
TIER
1
1
1
1
2
1
MS
MS
MS
MS
MS
MS
3
1
3
2
4
1
4
3
1
1
3
4
2
2
1
5†
2
4
4
4
1
5†
4
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
PA, MS
MS
PA, MS
MS
PA, MS
PA, MS
MS
MS
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
33
DRUG
DRUG NAME
TYPE
DERMATOLOGICAL AGENTS (continued)
DERMATOLOGICAL AGENTS (continued)
G
tretinoin cream, gel*
G
urea 40% cream
B
VOLTAREN GEL
ENZYME REPLACEMENT/MODIFIERS
ENZYME REPLACEMENT/MODIFIERS
B
ADAGEN
B
ALDURAZYME
B
BUPHENYL TABLET
B
CEREZYME
B
CREON
B
CYSTADANE
B
CYSTAGON
B
ELAPRASE
B
FABRAZYME
B
KUVAN
B
LUMIZYME
B
MYOZYME
B
NAGLAZYME
B
ORFADIN
B
SUCRAID
B
VPRIV
B
ZAVESCA
B
ZENPEP
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
G
atropine sulfate injection
G
dicyclomine hcl
G
glycopyrrolate*
G
methscopolamine bromide
G
propantheline bromide
DRUG
REQUIREMENTS/LIMITS
TIER
1
2
3
MS
MS
MS
5†
5†
5†
5†
4
3
4
5†
5†
5†
5†
5†
5†
5†
5†
5†
5†
4
PA, MS
PA, LA
PA, MS
PA, LA
MS
MS
PA, MS
PA, MS
PA, LA
PA, MS
PA, LA
PA, LA
PA, LA
PA, MS
MS
PA, MS
QL (93 capsules per 31 days), PA, LA
MS
2
2
1
2
2
MS
MS
MS
MS
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
34
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
GASTROINTESTINAL AGENTS (continued)
GASTROINTESTINAL AGENTS, OTHER
G cromolyn sodium oral concentrate
2 MS
G
diphenoxylate/atropine
2 MS
B
HALFLYTELY BOWEL PREP/FLAVOR PACKS
4 MS
G lonox
2 MS
G
loperamide hcl*
1
MS
G
metoclopramide hcl injection
2 MS
G
metoclopramide hcl oral solution, tablet*
1
MS
B
RELISTOR
4 PA, MS
G
ursodiol capsule 300mg
2 MS
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
G cimetidine
2 MS
G
cimetidine hcl solution
2 MS
G famotidine premixed solution*
1
MS
G
famotidine*
1
MS
G
ranitidine hcl injection, syrup
2 MS
G ranitidine hcl tablet*
1
MS
IRRITABLE BOWEL SYNDROME AGENTS
B
AMITIZA
4 ST, MS
B
LOTRONEX TABLET 0.5MG
B
LOTRONEX TABLET 1MG
LAXATIVES
G enulose*
1
MS
G gavilyte-c*
1
MS
G gavilyte-g*
1
MS
G
gavilyte-n/flavor pack*
1
MS
G generlac*
1
MS
G
lactulose*
1
MS
B
MOVIPREP
4 MS
B
NULYTELY/FLAVOR PACKS
4 MS
G
peg 3350/electrolytes*
1
MS
G
polyethylene glycol 3350*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
35
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
GASTROINTESTINAL AGENTS (continued)
LAXATIVES (continued)
B
SUPREP BOWEL PREP
4 MS
G
trilyte*
1
MS
PROTECTANTS
B
CARAFATE SUSPENSION
4 MS
G
misoprostol*
1
MS
G
sucralfate*
1
MS
PROTON PUMP INHIBITORS
B
DEXILANT
G omeprazole*
1
MS
G
pantoprazole sodium*
1
MS
B
PROTONIX INJECTION
4 MS
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
G oxybutynin chloride er
2 MS
G
oxybutynin chloride*
1
MS
G trospium chloride
2 MS
B
VESICARE
3 MS
BENIGN PROSTATIC HYPERTROPHY AGENTS
B
AVODART
G finasteride
2 MS
B
JALYN
B
RAPAFLO
G tamsulosin hcl*
1
MS
GENITOURINARY AGENTS, OTHER
G
bethanechol chloride tablet 10mg, 25mg, 5mg*
1
MS
G
bethanechol chloride tablet 50mg
2 MS
B
CIALIS TABLET 2.5MG, 5MG
G
phenazopyridine hcl*
1
MS
PHOSPHATE BINDERS
B
FOSRENOL
4 MS
B
RENAGEL
4 MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
36
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
GENITOURINARY AGENTS (continued)
PHOSPHATE BINDERS (continued)
B
RENVELA
4 MS
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
GLUCOCORTICOIDS/MINERALOCORTICOIDS
G a-methapred*
1
MS
G
alclometasone dipropionate*
1
MS
G
amcinonide*
1
MS
G
augmented betamethasone dipropionate*
1
MS
G
betamethasone dipropionate*
1
MS
G
betamethasone valerate*
1
MS
G
clobetasol propionate e*
1
MS
G
clobetasol propionate*
1
MS
B
CLODERM PUMP
4 MS
B
CORDRAN LOTION
4 MS
B
CORTIFOAM
4 MS
G cortisone acetate*
1
MS
G
desonide*
1
MS
G
desoximetasone
2 MS
G
dexamethasone intensol*
1
MS
G
dexamethasone sodium phosphate injection*
1
MS
G
dexamethasone*
1
MS
G
fludrocortisone acetate*
1
MS
G
fluocinolone acetonide body*
1
MS
G
fluocinolone acetonide scalp*
1
MS
G
fluocinolone acetonide*
1
MS
G fluocinonide*
1
MS
G
fluocinonide-e*
1
MS
G
fluticasone propionate cream, ointment*
1
MS
G
halobetasol propionate
2 MS
G
hydrocortisone butyrate*
1
MS
G
hydrocortisone cream, ointment, tablet*
1
MS
G
hydrocortisone lotion 2.5%*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
37
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
(continued)
GLUCOCORTICOIDS/MINERALOCORTICOIDS (continued)
G
hydrocortisone valerate*
1
MS
B
MEDROL TABLET 2MG
4 MS
G
methylprednisolone acetate injection*
1
MS
methylprednisolone sodium succinate
G injection*
1
MS
G
methylprednisolone tablet, dose pack*
1
MS
G
millipred tablet*
1
MS
G
mometasone furoate*
1
MS
G
prednicarbate
2 MS
G
prednisolone sodium phosphate solution*
1
MS
G
prednisone*
1
MS
G
proctocream hc*
1
MS
G
proctosol hc cream*
1
MS
triamcinolone acetonide cream, lotion,
G
1
MS
ointment*
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
G chorionic gonadotropin
2 PA, MS
G desmopressin acetate injection, tablet
2 MS
G
desmopressin acetate nasal solution
B
EGRIFTA
5† QL (62 vials per 31 days), PA, MS
B
HUMATROPE
5† PA, MS
5† PA, MS
B
HUMATROPE COMBO PACK
5† PA, LA
B
INCRELEX
B
TEV-TROPIN
4 PA, MS
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/
MODIFIERS)
ANABOLIC STEROIDS
B
ANADROL-50
5† PA, MS
G
oxandrolone tablet 10mg
G
oxandrolone tablet 2.5mg
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
38
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
MODIFIERS) (continued)
ANDROGENS
G
androxy
2 MS
G
danazol
2 MS
B
METHITEST
3 PA, MS
B
TESTIM
3 PA, MS
G testosterone cypionate*
1
PA, MS
G testosterone enanthate*
1
PA, MS
ESTROGENS
G amethia*
1
MS
G
amethyst*
1
MS
G
apri*
1
MS
G
aranelle*
1
MS
G
aviane*
1
MS
G
balziva*
1
MS
G
brevicon-28*
1
MS
G
briellyn*
1
MS
G
caziant*
1
MS
G
cesia*
1
MS
B
COMBIPATCH
3 MS
G
cryselle-28*
1
MS
G
cyclafem 1/35*
1
MS
G
cyclafem 7/7/7*
1
MS
G
emoquette*
1
MS
G
enpresse-28*
1
MS
ESTRACE CREAM
B
4 MS
G
estradiol*
1
MS
G
estradiol/norethindrone acetate*
1
MS
G
estropipate
2 MS
G
gianvi*
1
MS
G
introvale*
1
MS
G
jinteli*
1
MS
G
junel 1.5/30*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
39
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
ESTROGENS (continued)
G junel 1/20*
1
MS
G
junel fe 1.5/30*
1
MS
G
junel fe 1/20*
1
MS
G
kariva*
1
MS
G
kelnor 1/35*
1
MS
G
leena*
1
MS
G
lessina-28*
1
MS
G
levora 0.15/30-28*
1
MS
G
loryna*
1
MS
G
low-ogestrel*
1
MS
G
lutera*
1
MS
G
marlissa*
1
MS
G
microgestin 1.5/30*
1
MS
G
microgestin 1/20*
1
MS
G
microgestin fe 1.5/30*
1
MS
G
microgestin fe*
1
MS
G
mononessa*
1
MS
G
myzilra*
1
MS
G
necon 0.5/35-28*
1
MS
G necon 1/35-28*
1
MS
G
necon 1/50-28*
1
MS
G
necon 10/11-28*
1
MS
G
necon 7/7/7*
1
MS
G
nortrel 0.5/35 (28)*
1
MS
G
nortrel 1/35 (21)*
1
MS
G
nortrel 1/35 (28)*
1
MS
G
nortrel 7/7/7*
1
MS
G
ocella*
1
MS
G
orsythia*
1
MS
G
philith*
1
MS
G
portia-28*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
40
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
ESTROGENS (continued)
B
PREMARIN CREAM, INJECTION
3 MS
B
PREMARIN TABLET
B
PREMPHASE
3 MS
B
PREMPRO
3 MS
B
PREVIFEM
3 MS
G quasense*
1
MS
G reclipsen*
1
MS
G solia*
1
MS
G
sprintec 28*
1
MS
G sronyx*
1
MS
G tri-legest fe*
1
MS
G tri-previfem*
1
MS
G tri-sprintec*
1
MS
G trinessa*
1
MS
G
trivora-28*
1
MS
G velivet*
1
MS
G vestura*
1
MS
B
VIVELLE-DOT
3 MS
G zeosa*
1
MS
G zovia 1/35e*
1
MS
G zovia 1/50e*
1
MS
PROGESTINS
G camila*
1
MS
G errin*
1
MS
G
jolivette*
1
MS
G
medroxyprogesterone acetate*
1
MS
G
megestrol acetate suspension*
1
MS
G
megestrol acetate tablet
2 MS
G next choice
2 MS
G
nora-be*
1
MS
G
norethindrone acetate*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
41
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
B
EVISTA
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
B
ARMOUR THYROID
3 MS
G
levothroid*
1
MS
G
levothyroxine sodium injection
2 MS
G
levothyroxine sodium tablet*
1
MS
G
levoxyl*
1
MS
G
liothyronine sodium tablet*
1
MS
G
np thyroid 30
2 MS
G
np thyroid 60
2 MS
G
np thyroid 90
2 MS
B
SYNTHROID
3 MS
B
THYROLAR-1/2
3 MS
G unithroid*
1
MS
HORMONAL AGENTS, SUPPRESSANT (ADRENAL)
HORMONAL AGENTS, SUPPRESSANT (ADRENAL)
B
LYSODREN
3 MS
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
B
SENSIPAR TABLET 30MG
B
B
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
B
ELIGARD INJECTION 22.5MG, 30MG, 7.5MG
4 PA, MS
5† PA, MS
B
ELIGARD INJECTION 45MG
G
leuprolide acetate
2 PA, MS
B
LUPRON DEPOT INJECTION 11.25MG, 22.5MG
5† QL (1 kit per 84 days), PA, MS
B
LUPRON DEPOT INJECTION 3.75MG, 7.5MG
B
LUPRON DEPOT INJECTION 30MG
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
42
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (continued)
HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (continued)
B
LUPRON DEPOT INJECTION 45MG
B
LUPRON DEPOT-PED INJECTION 11.25MG
B
LUPRON DEPOT-PED INJECTION 11.25MG
B
LUPRON DEPOT-PED INJECTION 15MG, 7.5MG 5† QL (1 kit per 28 days), PA, MS
B
LUPRON DEPOT-PED INJECTION 30MG
G
octreotide acetate
2 PA, MS
5† PA, MS
B
SANDOSTATIN LAR DEPOT
B
SOMATULINE DEPOT
5† PA, MS
5† PA, MS
B
SOMAVERT
5† MS
B
SYNAREL
5† QL (1 vial per 28 days), PA, MS
B
TRELSTAR DEPOT
B
TRELSTAR DEPOT MIXJECT
B
TRELSTAR LA
B
TRELSTAR LA MIXJECT
B
TRELSTAR MIXJECT
HORMONAL AGENTS, SUPPRESSANT (SEX HORMONES/MODIFIERS)
ANTIANDROGENS
G
bicalutamide*
1
MS
G
flutamide
2 MS
B
4 MS
NILANDRON
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
G
methimazole*
1
MS
G
propylthiouracil*
1
MS
IMMUNOLOGICAL AGENTS
IMMUNE SUPPRESSANTS
G azathioprine sodium*
1
PA, MS
G
azathioprine*
1
PA, MS
B
CELLCEPT SUSPENSION RECONSTITUTED
4 PA, MS
5† PA, MS
B
CIMZIA
B
CIMZIA STARTER KIT
5† PA, MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
43
DRUG
DRUG NAME
TYPE
IMMUNOLOGICAL AGENTS (continued)
IMMUNE SUPPRESSANTS (continued)
B
CUPRIMINE
G
cyclosporine
G cyclosporine modified
B
ENBREL INJECTION 25MG
B
ENBREL INJECTION 25MG/0.5ML, 50MG/ML
B
ENBREL SURECLICK
G
gengraf
G
hecoria
B
HUMIRA
B
HUMIRA PEN
B
HUMIRA PEN-CROHNS DISEASE STARTER
B
HUMIRA PEN-PSORIASIS STARTER
G
methotrexate sodium*
G
methotrexate*
G
mycophenolate mofetil
B
MYFORTIC
B
NULOJIX
B
PROGRAF INJECTION
B
RAPAMUNE
B
REMICADE
B
SANDIMMUNE INJECTION
B
SIMPONI
G
tacrolimus
B
TREXALL
B
ZORTRESS TABLET 0.25MG
B
ZORTRESS TABLET 0.5MG, 0.75MG
IMMUNIZING AGENTS, PASSIVE
B
CARIMUNE NANOFILTERED
B
GAMMAGARD LIQUID
B
THYMOGLOBULIN
DRUG
REQUIREMENTS/LIMITS
TIER
3
2
2
5†
5†
5†
2
2
5†
5†
5†
5†
1
1
2
4
5†
3
3
5†
4
5†
2
4
4
5†
MS
PA, MS
PA, MS
QL (8 syringes per 28 days), PA, MS
PA, MS
PA, MS
PA, MS
MS
PA, MS
PA, MS
PA, MS
PA, MS
PA, MS
PA, MS
PA, MS
PA, MS
MS
PA, MS
5†
5†
3
PA, MS
PA, MS
PA, MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
44
DRUG
DRUG NAME
TYPE
IMMUNOMODULATORS
B
ACTIMMUNE
B
ARCALYST
G
leflunomide*
B
RIDAURA
VACCINES
B
ACTHIB
B
ADACEL
B
BIOTHRAX
B
BOOSTRIX
B
CERVARIX
B
COMVAX
B
DAPTACEL
B
DECAVAC
B
DIPHTHERIA/TETANUS TOXOID PEDIATRIC
B
ENGERIX-B
B
GARDASIL
B
HAVRIX
B
INFANRIX
B
IPOL INACTIVATED IPV
B
IXIARO
B
JE-VAX
B
KINRIX
B
M-M-R II W/DILUENT 10 DOSE
B
MENACTRA
B
MENOMUNE-A/C/Y/W-135
B
MENVEO
B
PEDIARIX
B
PEDVAX HIB
B
PENTACEL
B
PROQUAD
B
RABAVERT
DRUG
REQUIREMENTS/LIMITS
TIER
5†
5†
1
3
3
3
4
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
3
4
3
3
4
3
4
PA, LA
PA, MS
MS
MS
PA
PA
PA
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
45
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
VACCINES (continued)
B
RECOMBIVAX HB
3 PA
B
ROTARIX
4
B
ROTATEQ
3
B
TENIVAC
3
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED
B
3
ADULT
B
TRIHIBIT
3
B
TRIPEDIA
3
B
TWINRIX
3
B
TYPHIM VI
3
B
VAQTA
3
B
VARIVAX
3
B
YF-VAX
3
B
ZOSTAVAX
4
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
B
ASACOL
3 MS
G
balsalazide disodium
2 MS
B
CANASA
4 MS
G mesalamine
2 MS
GLUCOCORTICOIDS
G budesonide capsule 3mg
2 MS
G
colocort
2 MS
G
hydrocortisone enema
2 MS
G
prednisolone*
1
MS
SULFONAMIDES
G sulfasalazine*
1
MS
G
sulfazine ec*
1
MS
METABOLIC BONE DISEASE AGENTS
METABOLIC BONE DISEASE AGENTS
G
alendronate sodium tablet 10mg, 40mg, 5mg*
1
MS
G
alendronate sodium tablet 35mg, 70mg*
1
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
46
DRUG
DRUG
DRUG NAME
TYPE
TIER
METABOLIC BONE DISEASE AGENTS (continued)
METABOLIC BONE DISEASE AGENTS (continued)
B
BONIVA INJECTION
4
G
calcitonin-salmon
2
G
calcitriol capsule, injection*
1
G
calcitriol oral solution
2
G
etidronate disodium
2
B
FORTEO
5†
G
fortical*
1
B
HECTOROL
3
G
ibandronate sodium
2
B
MIACALCIN INJECTION
4
pamidronate disodium injection 30mg/10ml,
G
2
90mg/10ml
B
PROLIA
4
B
ZOMETA
4
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G
B
3
X 1/2"
BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X
B
3
5/16"
BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 3
B
1/2"
BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/
B
3
16"
B
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM
3
G
fomepizole
2
HUMAPEN LUXURA HD
B
3
B
HUMAPEN MEMOIR
3
B
INTRALIPID
3
B
LACTATED RINGERS IRRIGATION
4
B
LIPOSYN II
3
B
LIPOSYN III
3
B
PHYSIOLYTE
3
REQUIREMENTS/LIMITS
MS
PA, MS
PA, MS
MS
QL (2.4 ml per 28 days), PA, MS
MS
PA, MS
QL (1 tablet per 28 days), MS
PA, MS
PA, MS
PA, MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
47
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
MISCELLANEOUS THERAPEUTIC AGENTS (continued)
MISCELLANEOUS THERAPEUTIC AGENTS (continued)
B
RINGERS IRRIGATION
4 MS
G sodium chloride 0.9%*
1
MS
OPHTHALMIC AGENTS
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
G
latanoprost*
1
MS
B
LUMIGAN
B
TRAVATAN Z
4 MS
OPHTHALMIC AGENTS, OTHER
G
ak-con*
1
MS
G
atropine sulfate ophthalmic solution, ointment 2 MS
B
LACRISERT
4 MS
G
phenylephrine hcl*
1
MS
B
RESTASIS
4 MS
G tropicamide
2 MS
OPHTHALMIC ANTI-ALLERGY AGENTS
B
ALOCRIL
3 MS
G
cromolyn sodium ophthalmic solution*
1
MS
B
PATADAY
4 MS
B
PATANOL
4 MS
OPHTHALMIC ANTI-INFLAMMATORIES
B
ALREX
4 MS
B
BROMDAY
G bromfenac
2 MS
B
CIPRODEX
4 MS
dexamethasone sodium phosphate
G
1
MS
ophthalmic solution*
G diclofenac sodium ophthalmic solution
2 MS
B
DUREZOL
4 MS
G
fluor-op*
1
MS
G
fluorometholone*
1
MS
G
flurbiprofen sodium ophthalmic solution*
1
MS
B
FML OINTMENT
3 MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
48
DRUG
DRUG
DRUG NAME
TYPE
TIER
OPHTHALMIC AGENTS (continued)
OPHTHALMIC ANTI-INFLAMMATORIES (continued)
G ketorolac tromethamine ophthalmic solution
2
B
LOTEMAX
4
neomycin/polymyxin/bacitracin/
G
1
hydrocortisone*
G
neomycin/polymyxin/dexamethasone*
1
B
NEVANAC
4
G prednisolone acetate*
1
prednisolone sodium phosphate ophthalmic
G
1
solution*
sulfacetamide sodium/prednisolone sodium
G
1
phosphate*
B
TOBRADEX OINTMENT
4
B
TOBRADEX ST
4
G tobramycin/dexamethasone*
1
B
VEXOL
4
OPHTHALMIC ANTIGLAUCOMA AGENTS
G acetazolamide er
2
B
ALPHAGAN P
4
B
AZOPT
3
G
betaxolol hcl solution
2
B
BETOPTIC-S
3
G
brimonidine tartrate solution 0.15%
2
G
brimonidine tartrate solution 0.2%*
1
G
carteolol hcl*
1
G dorzolamide hcl*
1
G
dorzolamide hcl/timolol maleate*
1
G
levobunolol hcl*
1
G
methazolamide*
1
G
metipranolol*
1
G
pilocarpine hcl solution
2
B
PILOPINE HS
3
G
timolol maleate ophthalmic gel forming*
1
REQUIREMENTS/LIMITS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
49
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
OPHTHALMIC AGENTS (continued)
OPHTHALMIC ANTIGLAUCOMA AGENTS (continued)
G timolol maleate ophthalmic solution*
1
MS
OTIC AGENTS
OTIC AGENTS
G acetic acid*
1
MS
G
acetic acid/aluminum acetate*
1
MS
G
neomycin/polymyxin/hc*
1
MS
RESPIRATORY TRACT AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
B
ADVAIR DISKUS
3 QL (60 blisters per 30 days), MS
B
ADVAIR HFA
3 QL (12 grams per 30 days), MS
B
ASMANEX INHALER
3 MS
B
DULERA
3 QL (13 grams per 30 days), MS
B
FLOVENT DISKUS
3 MS
B
FLOVENT HFA
3 MS
G
flunisolide*
1
MS
G
fluticasone propionate nasal spray*
1
MS
B
NASONEX
4 MS
B
QVAR
3 QL (21.9 grams per 31 days), MS
ANTIHISTAMINES
B
ASTELIN
3 MS
B
ASTEPRO
3 MS
G
azelastine hcl nasal spray
2 MS
G
carbinoxamine maleate
2 MS
G
clemastine fumarate tablet*
1
MS
G cyproheptadine hcl
2 MS
G
diphenhydramine hcl capsule 50mg, injection*
1
MS
G
hydroxyzine hcl
2 MS
G hydroxyzine pamoate
2 MS
G
levocetirizine dihydrochloride solution
2 MS
G
levocetirizine dihydrochloride tablet
G
phenadoz*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
50
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
RESPIRATORY TRACT AGENTS (continued)
ANTIHISTAMINES (continued)
G promethazine hcl
2 PA, MS
G promethazine vc
2 MS
G promethegan
2 MS
ANTILEUKOTRIENES
B
SINGULAIR
G zafirlukast*
1
BRONCHODILATORS, ANTICHOLINERGIC
B
ATROVENT HFA
G
ipratropium bromide inhalation solution*
1
PA, MS
G ipratropium bromide nasal solution*
1
MS
B
SPIRIVA HANDIHALER
BRONCHODILATORS, PHOSPHODIESTERASE INHIBITORS (XANTHINES)
G aminophylline*
1
MS
B
THEO-24
3 MS
G
theochron*
1
MS
G
theophylline cr*
1
MS
G theophylline er tablet extended release 12
1
MS
hour*
G
theophylline er tablet extended release 24 hour 2 MS
BRONCHODILATORS, SYMPATHOMIMETIC
G
albuterol sulfate er
2 MS
G
albuterol sulfate nebulization solution*
1
PA, MS
G
albuterol sulfate syrup, tablet*
1
MS
B
COMBIVENT
G epinephrine
2 MS
B
EPIPEN 2-PAK
4 MS
ipratropium bromide/albuterol sulfate
G nebulization solution*
1
PA, MS
G
metaproterenol sulfate syrup, tablet*
1
MS
B
SEREVENT DISKUS
3 QL (60 blisters per 30 days), MS
G
terbutaline sulfate*
1
MS
B
VENTOLIN HFA
3 MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
51
DRUG
DRUG NAME
TYPE
RESPIRATORY TRACT AGENTS (continued)
MAST CELL STABILIZERS
G cromolyn sodium nebulization solution*
PULMONARY ANTIHYPERTENSIVES
B
ADCIRCA
B
LETAIRIS
B
REMODULIN
B
REVATIO TABLET
B
TRACLEER
RESPIRATORY TRACT AGENTS, OTHER
G
acetylcysteine*
B
KALYDECO
B
PROLASTIN
B
PROLASTIN-C
B
PULMOZYME
B
TYZINE
B
XOLAIR
SKELETAL MUSCLE RELAXANTS
SKELETAL MUSCLE RELAXANTS
G carisoprodol tablet 350mg
G
cyclobenzaprine hcl tablet 10mg, 5mg
G
methocarbamol
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
G flurazepam hcl*
G
temazepam*
G
triazolam*
DRUG
REQUIREMENTS/LIMITS
TIER
1
PA, MS
5†
5†
5†
5†
5†
PA, MS
1
5†
5†
5†
5†
3
5†
PA, MS
PA, LA
PA, LA
PA, MS
MS
PA, LA
2
2
2
PA, MS
1
1
1
G
zaleplon
2
G
zolpidem tartrate tablet
SLEEP DISORDERS, OTHER
modafinil
PROVIGIL TABLET 100MG
PROVIGIL TABLET 200MG
2
MS
MS
MS
MS
2
3
5†
G
B
B
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
52
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
SLEEP DISORDER AGENTS (continued)
SLEEP DISORDERS, OTHER (continued)
B
XYREM
5† QL (558 ml per 31 days), PA, LA
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
B
EXJADE
5† PA, LA
G
kionex
2 MS
B
SODIUM LACTATE
4 MS
G
sodium polystyrene sulfonate
2 MS
G
sps
2 MS
B
SYPRINE
4 MS
ELECTROLYTE/MINERAL REPLACEMENT
B
AMINOSYN
3 MS
B
AMINOSYN 8.5%/ELECTROLYTES
3 MS
B
AMINOSYN II
3 MS
B
AMINOSYN II 4.25/DEXTROSE25%
3 MS
B
AMINOSYN II 5/DEXTROSE 25
3 MS
B
AMINOSYN II 8.5%/ELECTROLYTES
3 MS
B
AMINOSYN M
3 MS
B
AMINOSYN-HBC
3 MS
B
AMINOSYN-HF
3 MS
B
AMINOSYN-PF
3 MS
B
AMINOSYN-PF 7%
3 MS
B
AMINOSYN-RF
3 MS
G
calcium acetate
2 MS
1
MS
G citric acid/sodium citrate*
B
CLINIMIX 2.75%/DEXTROSE 5%
4 MS
B
4 MS
B
4 MS
B
4 MS
B
4 MS
B
CLINIMIX 5%/DEXTROSE 15%
4 MS
B
4 MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
53
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES (continued)
ELECTROLYTE/MINERAL REPLACEMENT (continued)
B
4 MS
B
CLINIMIX E 2.75%/DEXTROSE 10%
4 MS
B
4 MS
B
4 MS
B
4 MS
B
CLINIMIX E 5%/DEXTROSE 15%
4 MS
B
4 MS
B
4 MS
B
CLINISOL SF 15%
3 MS
G cytra-2*
1
G cytra-3*
1
B
DEXTROSE 10%/NACL 0.45%
3 MS
B
DEXTROSE 5%/ELECTROLYTE #48 VIAFLEX
3 MS
B
3 MS
B
DEXTROSE 2.5%/SODIUM CHLORIDE 0.45%
3 MS
B
DEXTROSE 5%/LACTATED RINGERS
3 MS
B
3 MS
B
3 MS
B
3 MS
B
3 MS
B
3 MS
B
DEXTROSE 5%/POTASSIUM CHLORIDE 0.15%
3 MS
G eliphos
2 MS
B
FREAMINE III
4 MS
B
FREAMINE III 3%
4 MS
B
HEPATAMINE
4 MS
B
HEPATASOL
4 MS
B
IONOSOL-B/DEXTROSE 5%
4 MS
B
IONOSOL-MB/DEXTROSE 5%
4 MS
B
ISOLYTE-H/DEXTROSE 5%
4 MS
B
ISOLYTE-M/DEXTROSE 5%
4 MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
54
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
B
ISOLYTE-P/DEXTROSE 5%
4 MS
B
ISOLYTE-S
4 MS
B
ISOLYTE-S/DEXTROSE 5%
4 MS
B
KCL 0.075%/D5W/NACL 0.45%
4 MS
B
KCL 0.15%/D5W/LR
4 MS
B
KCL 0.15%/D5W/NACL 0.2%
4 MS
B
KCL 0.15%/D5W/NACL 0.225%
4 MS
B
KCL 0.15%/D5W/NACL 0.9%
4 MS
B
KCL 0.3%/D5W/NACL 0.45%
4 MS
B
KCL 0.3%/D5W/NACL 0.9%
4 MS
G klor-con 10*
1
MS
G klor-con 25*
1
MS
G klor-con 8*
1
MS
G klor-con m10*
1
MS
G
klor-con m15*
1
MS
G klor-con m20*
1
MS
G
klor-con packet*
1
MS
B
LACTATED RINGERS
3 MS
LACTATED RINGERS VIAFLEX
B
3 MS
G magnesium sulfate
2 MS
B
NEPHRAMINE
4 MS
B
NORMOSOL-M IN D5W
3 MS
B
NORMOSOL-R
3 MS
B
NORMOSOL-R IN D5W
3 MS
B
PLASMA-LYTE A
4 MS
B
PLASMA-LYTE-148
4 MS
B
PLASMA-LYTE-56/D5W
4 MS
POTASSIUM CHLORIDE 0.15% D5W/NACL
B
4 MS
0.33%
B
4 MS
0.45% VIAFLEX
B
POTASSIUM CHLORIDE 0.15% NACL 0.9%
4 MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
55
DRUG
DRUG
DRUG NAME
REQUIREMENTS/LIMITS
TYPE
TIER
POTASSIUM CHLORIDE 0.15%/NACL 0.45%
B
4 MS
VIAFLEX
B
4 MS
0.45%
POTASSIUM CHLORIDE 0.224%/DEXTROSE 5%
B
4 MS
VIAFLEX
B
POTASSIUM CHLORIDE 0.3%/D5W/VIAFLEX
4 MS
B
POTASSIUM CHLORIDE 0.3%/NACL 0.9%
4 MS
G potassium chloride er*
1
MS
potassium chloride injection 0.4meq/ml,
G
2 MS
10meq/100ml, 10meq/50ml, 30meq/100ml
G
potassium chloride injection 2meq/ml*
1
MS
G
potassium chloride liquid*
1
MS
G
potassium chloride sr*
1
MS
B
PREMASOL
4 MS
B
PROCALAMINE
4 MS
B
PROSOL
4 MS
B
RINGERS INJECTION
4 MS
B
SODIUM CHLORIDE 0.45% VIAFLEX
3 MS
G
sodium chloride*
1
MS
G
sodium fluoride*
1
MS
G
tpn electrolytes*
1
MS
B
TRAVASOL
4 MS
B
TROPHAMINE
3 MS
VITAMINS
G prenatabs obn*
1
MS
G prenatal plus*
1
MS
G
prenatal plus/iron*
1
MS
*CG = Coverage Gap
LA Limited Access
ST Step Therapy
56
INDEX OF DRUG NAMES
Numerics
ALINIA ................................................................................... 17
allopurinol* ........................................................................ 13
8-MOP ................................................................................. 33
ALOCRIL .............................................................................48
ALPHAGAN P ...................................................................49
A
alprazolam tablet* ....................................................... 22
ABILIFY DISCMELT TABLET DISPERSIBLE 10MG 18
ALREX ...................................................................................48
ABILIFY DISCMELT TABLET DISPERSIBLE 15MG 18
amantadine hcl* ............................................................. 21
ABILIFY INJECTION .........................................................18
amcinonide* ..................................................................... 37
ABILIFY ORAL SOLUTION ...........................................18
a-methapred* ................................................................. 37
ABILIFY TABLET ................................................................18
amethia* ............................................................................ 39
acarbose* .......................................................................... 23
amethyst* .......................................................................... 39
acebutolol hcl* ................................................................28
amifostine ........................................................................... 15
acetaminophen/codeine #3* ...................................... 1
amikacin sulfate injection* ......................................... 4
acetaminophen/codeine solution* ......................... 1
amiloride hcl* .................................................................. 30
acetaminophen/codeine tablet 300mg, 15mg* . 1
amiloride/hydrochlorothiazide* ........................... 30
acetazolamide er .......................................................... 49
aminophylline* ................................................................. 51
acetazolamide sodium ...............................................30
AMINOSYN ....................................................................... 53
acetazolamide tablet* ................................................30
AMINOSYN 8.5%/ELECTROLYTES ........................ 53
acetic acid* ...................................................................... 50
AMINOSYN II ................................................................... 53
acetic acid/aluminum acetate* ............................ 50
AMINOSYN II 4.25/DEXTROSE25% ....................... 53
acetylcysteine* ................................................................ 52
AMINOSYN II 5/DEXTROSE 25 ............................... 53
ACTHIB ................................................................................ 45
AMINOSYN II 8.5%/ELECTROLYTES .................... 53
acticin* ................................................................................. 17
AMINOSYN M ................................................................. 53
ACTIMMUNE ....................................................................45
AMINOSYN-HBC ........................................................... 53
ACTOPLUS MET .............................................................. 23
AMINOSYN-HF ............................................................... 53
ACTOS ................................................................................. 23
AMINOSYN-PF ................................................................ 53
acyclovir capsule, suspension, tablet* ................ 22
AMINOSYN-PF 7% ........................................................ 53
acyclovir sodium* .......................................................... 22
AMINOSYN-RF ................................................................ 53
ADACEL ...............................................................................45
amiodarone hcl tablet 200mg* .............................. 28
ADAGEN ............................................................................. 34
amiodarone hcl tablet 400mg ................................ 28
ADCIRCA ............................................................................. 52
AMITIZA .............................................................................. 35
ADVAIR DISKUS .............................................................. 50
amitriptyline hcl* ............................................................. 11
ADVAIR HFA ..................................................................... 50
amlodipine besylate* ................................................... 29
AFINITOR .............................................................................16
amlodipine besylate/benazepril hcl .................... 29
AGGRENOX ......................................................................26
ammonium lactate* ..................................................... 33
ak-con* .............................................................................. 48
amoxapine* ........................................................................ 11
ALBENZA ............................................................................. 17
amoxicillin* ......................................................................... 6
albuterol sulfate er ........................................................ 51
amoxicillin/clavulanate potassium* ...................... 6
albuterol sulfate nebulization solution* ............. 51
amoxicillin/potassium clavulanate* ...................... 6
albuterol sulfate syrup, tablet* ............................... 51
amphetamine/dextroamphetamine ................... 32
alclometasone dipropionate* ................................. 37
amphotericin b ................................................................ 12
alcohol preps* ................................................................... 4
ampicillin sodium injection 125mg,
ALDURAZYME .................................................................. 34
1gm, 250mg, 2gm, 500mg .......................................... 6
alendronate sodium tablet 10mg, 40mg, 5mg*
ampicillin* ............................................................................ 6
.............................................................................................. 46
ampicillin-sulbactam ..................................................... 6
alendronate sodium tablet 35mg, 70mg* ......... 46
AMPYRA ............................................................................. 32
ALIMTA ................................................................................. 15
ANADROL-50 ................................................................... 38
*CG = Coverage Gap
57
INDEX OF DRUG NAMES
balsalazide disodium ................................................... 46
A (continued)
balziva* ............................................................................... 39
anagrelide hydrochloride* ........................................26
BANZEL SUSPENSION .................................................... 9
anastrozole ........................................................................16
BANZEL TABLET 200MG ............................................... 9
androxy ...............................................................................39
BANZEL TABLET 400MG ............................................... 9
ANTARA ..............................................................................30
BARACLUDE SOLUTION .............................................. 21
APOKYN .............................................................................. 17
BARACLUDE TABLET ..................................................... 21
apri* ......................................................................................39
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X APTIVUS CAPSULE .......................................................... 21
1/2" ...................................................................................... 47
APTIVUS SOLUTION ...................................................... 21
BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X aranelle* .............................................................................39
5/16" ................................................................................... 47
ARCALYST .........................................................................45
BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X ARMOUR THYROID ......................................................42
1/2" ...................................................................................... 47
ASACOL ............................................................................. 46
BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/
ASMANEX INHALER ..................................................... 50
16" ........................................................................................ 47
ASTELIN .............................................................................. 50
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM ... 47
ASTEPRO ............................................................................ 50
benazepril hcl* ................................................................ 27
atenolol* .............................................................................28
benazepril hcl/hydrochlorothiazide* ................. 27
atenolol/chlorthalidone* ..........................................28
benztropine mesylate tablet .................................... 17
atorvastatin calcium .................................................... 31
BESIVANCE .......................................................................... 7
ATRIPLA .............................................................................. 20
betamethasone dipropionate* .............................. 37
atropine sulfate injection .......................................... 34
betamethasone valerate* ......................................... 37
atropine sulfate ophthalmic solution, ointment
betaxolol hcl solution ..................................................49
.............................................................................................. 48
betaxolol hcl tablet* .................................................... 28
ATROVENT HFA ............................................................... 51
bethanechol chloride tablet 10mg, 25mg, 5mg*
augmented betamethasone dipropionate* .... 37
............................................................................................... 36
AVANDAMET ................................................................... 23
bethanechol chloride tablet 50mg ....................... 36
AVANDARYL ..................................................................... 23
BETOPTIC-S ......................................................................49
AVANDIA ............................................................................ 23
bicalutamide* .................................................................. 43
AVASTIN ..............................................................................16
BICILLIN C-R ....................................................................... 6
aviane* ................................................................................39
BICILLIN L-A ........................................................................ 6
AVODART ..........................................................................36
BIOTHRAX ......................................................................... 45
AVONEX ............................................................................. 32
bisoprolol fumarate* ................................................... 28
AZASITE ................................................................................. 6
bisoprolol fumarate/hydrochlorothiazide* .... 28
azathioprine sodium* .................................................. 43
bleomycin sulfate* ......................................................... 15
azathioprine* ................................................................... 43
BONIVA INJECTION ...................................................... 47
azelastine hcl nasal spray ......................................... 50
BOOSTRIX .......................................................................... 45
AZELEX ................................................................................. 33
brevicon-28* .................................................................... 39
AZILECT ................................................................................18
briellyn* ............................................................................... 39
azithromycin injection, tablet* ................................. 6
brimonidine tartrate solution 0.15% ....................49
azithromycin suspension reconstituted ............... 6
brimonidine tartrate solution 0.2%* ....................49
AZOPT ................................................................................ 49
BROMDAY .........................................................................48
bromfenac ........................................................................48
B
bromocriptine mesylate ............................................. 17
bacitracin* ........................................................................... 4
budeprion sr* .................................................................... 10
bacitracin/polymyxin b* .............................................. 4
budeprion xl* .................................................................... 10
baclofen tablet* ..............................................................19
budesonide capsule 3mg ............................................46
*CG = Coverage Gap
58
INDEX OF DRUG NAMES
cefadroxil* ........................................................................... 5
B (continued)
cefazolin sodium .............................................................. 5
bumetanide* ....................................................................30
cefdinir capsule* .............................................................. 5
BUPHENYL TABLET ....................................................... 34
cefdinir suspension reconstituted ........................... 5
buprenorphine hcl injection ....................................... 3
cefepime ............................................................................... 5
buprenorphine hcl tablet sublingual ...................... 3
cefotaxime sodium* ....................................................... 5
buproban* ........................................................................... 3
cefoxitin sodium injection 10gm, 1gm .................... 5
bupropion hcl sr* ............................................................10
cefoxitin sodium injection 2gm* .............................. 5
bupropion hcl xl* ............................................................10
cefpodoxime proxetil suspension reconstituted
bupropion hcl* .................................................................10
................................................................................................. 5
buspirone hcl* ................................................................. 22
cefpodoxime proxetil tablet* .................................... 5
butalbital/acetaminophen/caffeine/codeine*
cefprozil* .............................................................................. 5
............................................................................................... 32
ceftazidime ......................................................................... 5
BYDUREON ....................................................................... 23
ceftazidime/dextrose .................................................... 5
BYETTA ................................................................................ 23
ceftriaxone sodium ......................................................... 5
cefuroxime axetil suspension reconstituted ...... 5
C
cefuroxime axetil tablet* ............................................. 5
calcipotriene ..................................................................... 33
cefuroxime sodium injection 1.5gm, 750mg ........ 5
calcitonin-salmon ......................................................... 47
CELLCEPT SUSPENSION RECONSTITUTED ....... 43
calcitriol capsule, injection* ..................................... 47
CELONTIN ........................................................................... 8
calcitriol oral solution ................................................. 47
cephalexin* ......................................................................... 5
calcium acetate .............................................................. 53
CEREZYME ......................................................................... 34
camila* ................................................................................. 41
CERVARIX ........................................................................... 45
CAMPATH ...........................................................................16
cesia* .................................................................................... 39
CAMPRAL ............................................................................. 2
CHANTIX STARTING MONTH PAK ......................... 3
CANASA ............................................................................. 46
CHANTIX TABLET ............................................................ 3
CANCIDAS .......................................................................... 12
chlordiazepoxide/amitriptyline ............................... 11
CAPASTAT SULFATE ...................................................... 14
chlorhexidine gluconate oral rinse* ..................... 33
CAPRELSA TABLET 100MG .......................................... 14
chloroquine phosphate* ............................................. 17
CAPRELSA TABLET 300MG ......................................... 14
chlorothiazide sodium injection* .......................... 30
captopril* ........................................................................... 27
chlorothiazide tablet* ................................................. 30
captopril/hydrochlorothiazide* ............................ 27
chlorpromazine hcl injection .................................... 18
CARAC ................................................................................. 33
chlorpromazine hcl tablet* ....................................... 18
CARAFATE SUSPENSION ............................................ 36
chlorthalidone* ............................................................... 30
carbamazepine suspension,
cholestyramine light* ................................................... 31
tablet chewable, tablet* .......................................... 9
cholestyramine* .............................................................. 31
carbidopa/levodopa er* ............................................. 17
chorionic gonadotropin ............................................. 38
carbidopa/levodopa tablet* .................................... 17
CIALIS TABLET 2.5MG, 5MG ...................................... 36
carbinoxamine maleate ............................................ 50
ciclopirox gel, shampoo .............................................. 12
CARIMUNE NANOFILTERED .....................................44
ciclopirox nail lacquer* ................................................ 12
carisoprodol tablet 350mg ....................................... 52
ciclopirox olamine* ........................................................ 12
carteolol hcl* .................................................................. 49
ciclopirox suspension* .................................................. 12
cartia xt* ............................................................................29
cilostazol* .......................................................................... 26
carvedilol* .........................................................................28
cimetidine .......................................................................... 35
caziant* ............................................................................... 39
cimetidine hcl solution ................................................ 35
CEENU ................................................................................... 14
CIMZIA ................................................................................. 43
cefaclor* ............................................................................... 5
CIMZIA STARTER KIT .................................................... 43
*CG = Coverage Gap
59
INDEX OF DRUG NAMES
clotrimazole/betamethasone dipropionate* ..12
C (continued)
clozapine ............................................................................. 19
CIPRODEX ......................................................................... 48
codeine sulfate* ................................................................ 1
ciprofloxacin hcl ophthalmic solution* ................ 7
co-gesic* ............................................................................... 1
ciprofloxacin hcl tablet 250mg, 500mg, 750mg*
COLCRYS ............................................................................ 13
................................................................................................. 7
colestipol hcl granules .................................................. 31
ciprofloxacin injection* ................................................ 7
colestipol hcl tablet* ..................................................... 31
citalopram hydrobromide solution ......................10
colistimethate sodium injection ............................... 4
citalopram hydrobromide tablet 10mg, 20mg*
colocort ..............................................................................46
................................................................................................10
COMBIPATCH .................................................................. 39
citalopram hydrobromide tablet 40mg* ...........10
COMBIVENT ...................................................................... 51
citric acid/sodium citrate* ....................................... 53
COMPLERA ........................................................................ 20
clarithromycin suspension reconstituted ........... 6
compro* .............................................................................. 18
clarithromycin tablet* .................................................. 6
COMTAN ............................................................................ 17
clemastine fumarate tablet* .................................. 50
COMVAX ............................................................................ 45
clindamycin hcl capsule* ............................................. 4
CONDYLOX GEL ............................................................ 33
clindamycin phosphate add-vantage .................. 4
COPAXONE ...................................................................... 32
clindamycin phosphate cream* ............................... 4
CORDRAN LOTION ...................................................... 37
clindamycin phosphate gel, lotion, solution* ..33
COREG CR ......................................................................... 28
CLINIMIX 2.75%/DEXTROSE 5% .............................. 53
CORTIFOAM ..................................................................... 37
CLINIMIX 4.25%/DEXTROSE 10% ............................ 53
cortisone acetate* ........................................................ 37
CLINIMIX 4.25%/DEXTROSE 20% ........................... 53
COUMADIN ...................................................................... 25
CLINIMIX 4.25%/DEXTROSE 25% ........................... 53
CREON ................................................................................. 34
CLINIMIX 4.25%/DEXTROSE 5% .............................. 53
CRIXIVAN ............................................................................ 21
CLINIMIX 5%/DEXTROSE 15% .................................. 53
cromolyn sodium nebulization solution* ......... 52
CLINIMIX 5%/DEXTROSE 20% ................................. 53
cromolyn sodium ophthalmic solution* ...........48
CLINIMIX 5%/DEXTROSE 25% .................................54
cromolyn sodium oral concentrate .................... 35
CLINIMIX E 2.75%/DEXTROSE 10% .........................54
cryselle-28* ....................................................................... 39
CLINIMIX E 2.75%/DEXTROSE 5% ..........................54
CUBICIN ................................................................................ 4
CLINIMIX E 4.25%/DEXTROSE 25% ........................54
CUPRIMINE ........................................................................ 44
CLINIMIX E 4.25%/DEXTROSE 5% ..........................54
CURITY GAUZE PADS 2"X2" ...................................... 33
CLINIMIX E 5%/DEXTROSE 15% ...............................54
cyclafem 1/35* ................................................................. 39
CLINIMIX E 5%/DEXTROSE 20% .............................54
cyclafem 7/7/7* ............................................................. 39
CLINIMIX E 5%/DEXTROSE 25% ..............................54
cyclobenzaprine hcl tablet 10mg, 5mg ................ 52
CLINISOL SF 15% .............................................................54
cyclophosphamide injection* .................................. 14
clobetasol propionate e* ........................................... 37
cyclophosphamide tablet .......................................... 14
clobetasol propionate* .............................................. 37
cyclosporine ..................................................................... 44
CLODERM PUMP ............................................................ 37
cyclosporine modified ................................................. 44
clomipramine hcl ............................................................. 11
CYMBALTA CAPSULE DELAYED RELEASE clonazepam odt ............................................................... 8
PARTICLES 20MG,
clonazepam tablet* ........................................................ 8
30MG ................................................................................. 10
clonidine hcl tablet* .....................................................26
CYMBALTA CAPSULE DELAYED RELEASE clopidogrel tablet 300mg ...........................................26
PARTICLES 60MG ......................................................... 10
clopidogrel tablet 75mg* ............................................26
cyproheptadine hcl ...................................................... 50
clorazepate dipotassium ............................................. 8
CYSTADANE ..................................................................... 34
clorpres* .............................................................................26
CYSTAGON ...................................................................... 34
clotrimazole cream, solution* ................................. 12
cytra-2* .............................................................................. 54
clotrimazole troche ....................................................... 12
*CG = Coverage Gap
60
INDEX OF DRUG NAMES
diclofenac sodium ophthalmic solution ............48
C (continued)
dicloxacillin sodium* ...................................................... 6
cytra-3* ...............................................................................54
dicyclomine hcl ............................................................... 34
didanosine ......................................................................... 20
D
diflunisal* ............................................................................. 3
danazol ...............................................................................39
digoxin* ............................................................................... 29
DAPSONE ............................................................................ 14
dihydroergotamine mesylate ................................... 13
DAPTACEL ..........................................................................45
DILANTIN CAPSULE 30MG .......................................... 9
DARAPRIM .......................................................................... 17
DILANTIN INFATABS ...................................................... 9
DECAVAC ...........................................................................45
dilt-cd* ................................................................................ 29
demeclocycline hcl .......................................................... 7
diltiazem cd* .................................................................... 29
DENAVIR ............................................................................. 22
diltiazem hcl er* ............................................................. 29
dentagel* ............................................................................ 33
diltiazem hcl* ................................................................... 29
desipramine hcl ................................................................. 11
dilt-xr* ................................................................................. 29
desmopressin acetate injection, tablet ..............38
diltzac* ................................................................................ 29
desmopressin acetate nasal solution ..................38
DIOVAN HCT TABLET 12.5MG,
desonide* ........................................................................... 37
160MG, 12.5MG, 80MG ............................................. 27
desoximetasone .............................................................. 37
DIOVAN HCT TABLET 12.5MG,
dexamethasone intensol* ......................................... 37
320MG, 25MG, 160MG, 25MG, 320MG ............ 27
dexamethasone sodium phosphate injection*
DIOVAN TABLET 160MG, 40MG, 80MG ............. 27
............................................................................................... 37
DIOVAN TABLET 320MG ............................................ 27
dexamethasone sodium phosphate ophthalmic diphenhydramine hcl capsule 50mg, injection*
solution* ......................................................................... 48
...............................................................................................50
dexamethasone* ............................................................ 37
diphenoxylate/atropine ............................................. 35
DEXILANT ...........................................................................36
DIPHTHERIA/TETANUS TOXOID PEDIATRIC ... 45
dexmethylphenidate hcl ............................................ 32
dipyridamole .................................................................... 26
dextroamphetamine sulfate .................................... 32
disopyramide phosphate .......................................... 28
dextroamphetamine sulfate er .............................. 32
disulfiram ............................................................................. 2
DEXTROSE 10% FLEX CONTAINER .........................24
divalproex sodium dr* .................................................. 8
DEXTROSE 10%/NACL 0.2% ......................................54
divalproex sodium er ..................................................... 8
DEXTROSE 10%/NACL 0.45% ....................................54
divalproex sodium* ........................................................ 8
DEXTROSE 2.5%/SODIUM CHLORIDE 0.45% ...54
donepezil hcl tablet dispersible, tablet ................. 9
DEXTROSE 5% ..................................................................24
dorzolamide hcl* ...........................................................49
DEXTROSE 5%/ELECTROLYTE #48 VIAFLEX .....54
dorzolamide hcl/timolol maleate* ......................49
DEXTROSE 5%/LACTATED RINGERS ....................54
doxazosin mesylate* .................................................... 26
DEXTROSE 5%/NACL 0.2% ........................................54
doxepin hcl .......................................................................... 11
DEXTROSE 5%/NACL 0.225% ...................................54
doxycycline hyclate* ...................................................... 7
DEXTROSE 5%/NACL 0.33% ......................................54
dronabinol .......................................................................... 12
DEXTROSE 5%/NACL 0.45% .....................................54
DROXIA ................................................................................ 15
DEXTROSE 5%/NACL 0.9% ........................................54
DUETACT ........................................................................... 23
DEXTROSE 5%/POTASSIUM CHLORIDE 0.15% 54
DULERA ............................................................................... 50
diazepam gel ...................................................................... 8
duramorph* ........................................................................ 1
diazepam intensol* ....................................................... 22
DUREZOL ............................................................................48
diazepam solution, tablet* ....................................... 22
E
diclofenac potassium* .................................................. 3
diclofenac sodium dr* ................................................... 3
e.e.s. 400* ............................................................................. 6
diclofenac sodium er ..................................................... 3
e.e.s. granules ..................................................................... 6
*CG = Coverage Gap
61
INDEX OF DRUG NAMES
erythrocin lactobionate injection* ......................... 6
E (continued)
erythrocin stearate tablet* ........................................ 6
econazole nitrate* ......................................................... 12
erythromycin base tablet* ......................................... 7
EDARBI ................................................................................. 27
erythromycin ethylsuccinate tablet* .................... 7
EDARBYCLOR ................................................................... 27
erythromycin gel, topical solution* ...................... 33
EDURANT .......................................................................... 20
erythromycin ointment* .............................................. 7
EGRIFTA ...............................................................................38
erythromycin/benzoyl peroxide* ......................... 33
ELAPRASE ........................................................................... 34
erythromycin/sulfisoxazole suspension* ............ 7
ELIGARD INJECTION 22.5MG, 30MG, 7.5MG ....42
escitalopram oxalate solution ................................. 10
ELIGARD INJECTION 45MG .......................................42
escitalopram oxalate tablet ..................................... 10
eliphos ..................................................................................54
estazolam* ........................................................................ 22
ELITEK .................................................................................... 15
ESTRACE CREAM ............................................................ 39
EMCYT .................................................................................. 15
estradiol* ........................................................................... 39
EMEND CAPSULE, PACK .............................................. 12
estradiol/norethindrone acetate* ....................... 39
emoquette* ....................................................................... 39
estropipate ........................................................................ 39
EMSAM .................................................................................10
ethambutol hcl* .............................................................. 14
EMTRIVA ............................................................................ 20
ethosuximide* ................................................................... 8
enalapril maleate* ......................................................... 27
etidronate disodium .................................................... 47
enalapril maleate/hydrochlorothiazide* .......... 27
etodolac er* ....................................................................... 3
ENBREL INJECTION 25MG ..........................................44
etodolac* ............................................................................. 3
ENBREL INJECTION 25MG/0.5ML, 50MG/ML ..44
EVISTA ................................................................................. 42
ENBREL SURECLICK .......................................................44
EXELON PATCH 24 HOUR ........................................... 9
endocet tablet 325mg,
EXELON SOLUTION ....................................................... 9
10mg, 325mg, 5mg, 325mg, 7.5mg, 500mg,
exemestane ........................................................................ 16
7.5mg* .................................................................................. 1
EXJADE ................................................................................. 53
endocet tablet 650mg, 10mg* ..................................... 1
EXTAVIA .............................................................................. 32
ENGERIX-B .........................................................................45
enoxaparin sodium injection 100mg/ml,
F
150mg/ml ........................................................................ 25
FABRAZYME ...................................................................... 34
80mg/0.8ml ................................................................... 25
famciclovir ........................................................................ 22
enoxaparin sodium injection 300mg/3ml ......... 25
famotidine premixed solution* .............................. 35
famotidine* ...................................................................... 35
40mg/0.4ml ................................................................... 25
FANAPT ................................................................................ 18
enoxaparin sodium injection 60mg/0.6ml ........ 25
FANAPT TITRATION PACK ......................................... 18
enpresse-28* .....................................................................39
FARESTON .......................................................................... 15
enulose* .............................................................................. 35
FASLODEX .......................................................................... 15
epinephrine ........................................................................ 51
FAZACLO TABLET DISPERSIBLE 12.5MG ............... 19
EPIPEN 2-PAK ..................................................................... 51
felbamate ............................................................................ 9
epitol* .................................................................................... 9
felodipine er ...................................................................... 29
EPIVIR HBV ........................................................................ 20
fenofibrate micronized .............................................. 30
EPIVIR SOLUTION ......................................................... 20
fenofibrate* ...................................................................... 30
EPZICOM ........................................................................... 20
fenoprofen calcium* ..................................................... 3
ergoloid mesylates .......................................................... 9
fentanyl citrate oral transmucosal ......................... 1
ergotamine tartrate/caffeine* ................................ 13
fentanyl patch ................................................................... 1
ERIVEDGE ............................................................................. 15
FINACEA ............................................................................. 33
errin* ...................................................................................... 41
finasteride .......................................................................... 36
ery-tab* ................................................................................ 6
flecainide acetate .......................................................... 28
*CG = Coverage Gap
62
INDEX OF DRUG NAMES
F (continued)
G
FLOVENT DISKUS .......................................................... 50
gabapentin capsule 100mg, 300mg* ....................... 8
FLOVENT HFA ................................................................. 50
gabapentin capsule 400mg* ...................................... 8
fluconazole in dextrose ............................................... 12
gabapentin solution* ..................................................... 8
fluconazole in nacl ......................................................... 12
gabapentin tablet 600mg* .......................................... 8
fluconazole* ...................................................................... 12
gabapentin tablet 800mg* .......................................... 8
flucytosine .......................................................................... 12
GABITRIL ............................................................................... 8
fludrocortisone acetate* ........................................... 37
galantamine hydrobromide capsule extended
flunisolide* ........................................................................ 50
release 24 hour ............................................................... 9
fluocinolone acetonide body* ................................ 37
galantamine hydrobromide solution .................... 9
fluocinolone acetonide scalp* ................................ 37
galantamine hydrobromide tablet ........................ 9
fluocinolone acetonide* ............................................ 37
GAMMAGARD LIQUID ................................................ 44
fluocinonide* .................................................................... 37
ganciclovir capsule* ..................................................... 20
fluocinonide-e* ............................................................... 37
GARDASIL .......................................................................... 45
fluorometholone* ........................................................ 48
gavilyte-c* ......................................................................... 35
fluor-op* ........................................................................... 48
gavilyte-g* ......................................................................... 35
FLUOROPLEX .................................................................... 33
gavilyte-n/flavor pack* .............................................. 35
fluorouracil ....................................................................... 33
gemfibrozil* ...................................................................... 30
fluoxetine hcl capsule, solution* .............................10
generlac* ............................................................................ 35
fluphenazine decanoate* ...........................................18
gengraf ................................................................................ 44
fluphenazine hcl concentrate, elixir ......................18
gentak ointment* ............................................................ 4
fluphenazine hcl injection, tablet* .........................18
gentamicin sulfate cream,
flurazepam hcl* .............................................................. 52
ointment, ophthalmic solution, injection* ..... 4
flurbiprofen sodium ophthalmic solution* ..... 48
GEODON INJECTION .................................................... 18
flurbiprofen tablet* ........................................................ 3
gianvi* .................................................................................. 39
flutamide ............................................................................ 43
GILENYA ............................................................................. 32
fluticasone propionate cream, ointment* ....... 37
GLEEVEC TABLET 100MG ............................................ 16
fluticasone propionate nasal spray* .................. 50
GLEEVEC TABLET 400MG ........................................... 16
fluvoxamine maleate* ................................................... 11
glimepiride* ....................................................................... 23
FML OINTMENT ............................................................. 48
glipizide er* ........................................................................ 23
fomepizole ......................................................................... 47
glipizide xl* ......................................................................... 23
fondaparinux sodium injection 10mg/0.8ml .... 25
glipizide* ............................................................................. 23
fondaparinux sodium injection 2.5mg/0.5ml ..25
glipizide/metformin hcl* ............................................ 23
fondaparinux sodium injection 5mg/0.4ml ...... 25
GLUCAGON EMERGENCY KIT ................................ 24
fondaparinux sodium injection 7.5mg/0.6ml ..25
glyburide ............................................................................. 23
FORTEO ............................................................................... 47
glyburide micronized ................................................... 23
fortical* ............................................................................... 47
glyburide/metformin hcl ........................................... 23
foscarnet sodium* ....................................................... 20
glycopyrrolate* ............................................................... 34
fosinopril sodium* ......................................................... 27
granisetron hcl injection ............................................. 12
fosinopril sodium/hydrochlorothiazide* .......... 27
granisetron hcl tablet ................................................... 12
fosphenytoin sodium* ................................................... 9
griseofulvin microsize suspension .......................... 12
FOSRENOL ......................................................................... 36
guanfacine hcl ................................................................. 26
FREAMINE III ......................................................................54
H
FREAMINE III 3% .............................................................. 54
furosemide* ......................................................................30
HALDOL DECANOATE 100 ......................................... 18
FUZEON ............................................................................... 21
HALDOL DECANOATE 50 ........................................... 18
*CG = Coverage Gap
63
INDEX OF DRUG NAMES
500mg, 2.5mg, 500mg, 5mg, 500mg, 7.5mg* ...... 1
H (continued)
hydrocodone/acetaminophen tablet 650mg,
HALFLYTELY BOWEL PREP/FLAVOR PACKS .... 35
10mg, 650mg, 7.5mg, 660mg, 10mg* ..................... 1
halobetasol propionate ............................................. 37
haloperidol decanoate* ..............................................18
7.5mg* ................................................................................ 2
haloperidol lactate* ......................................................18
hydrocodone/ibuprofen* ........................................... 2
haloperidol* .......................................................................18
hydrocortisone butyrate* ......................................... 37
HAVRIX ................................................................................45
hydrocortisone cream, ointment, tablet* ........ 37
hecoria ................................................................................44
hydrocortisone enema ...............................................46
HECTOROL ........................................................................ 47
hydrocortisone lotion 2.5%* .................................... 37
heparin sodium* ............................................................. 25
hydrocortisone valerate* .......................................... 38
heparin sodium/d5w* ................................................. 25
hydromorphone hcl injection* ................................. 2
heparin sodium/nacl 0.45%* ................................... 25
hydromorphone hcl tablet 2mg, 4mg* ................. 2
heparin sodium/sodium chloride 0.9% premix*
hydromorphone hcl tablet 8mg .............................. 2
............................................................................................... 25
hydroxychloroquine sulfate* ................................... 17
HEPATAMINE ....................................................................54
hydroxyurea* .................................................................... 15
HEPATASOL ......................................................................54
hydroxyzine hcl ............................................................... 50
HEPSERA ............................................................................... 21
hydroxyzine pamoate ................................................. 50
HEXALEN ............................................................................. 14
HUMALOG ........................................................................24
I
HUMALOG KWIKPEN ...................................................24
HUMALOG MIX 50/50 ................................................24
ibandronate sodium .................................................... 47
HUMALOG MIX 50/50 KWIKPEN ...........................24
ibuprofen* ........................................................................... 3
HUMALOG MIX 75/25 .................................................24
ifosfamide* ........................................................................ 14
HUMALOG MIX 75/25 KWIKPEN ...........................24
imipenem/cilastatin ....................................................... 6
HUMAPEN LUXURA HD .............................................. 47
imipramine hcl .................................................................. 11
HUMAPEN MEMOIR ..................................................... 47
imipramine pamoate ..................................................... 11
HUMATROPE ....................................................................38
imiquimod ......................................................................... 33
HUMATROPE COMBO PACK ...................................38
INCIVEK ................................................................................ 21
HUMIRA ...............................................................................44
INCRELEX ............................................................................ 38
HUMIRA PEN .....................................................................44
indapamide* ..................................................................... 30
HUMIRA PEN-CROHNS DISEASE STARTER .......44
indomethacin* .................................................................. 3
............................................................................ 45
HUMIRA PEN-PSORIASIS STARTER .......................44
INFANRIX
HUMULIN 70/30 .............................................................24
INLYTA ................................................................................. 16
HUMULIN 70/30 PEN ...................................................24
INTELENCE ........................................................................ 20
HUMULIN N ......................................................................24
INTRALIPID ........................................................................ 47
HUMULIN N U-100 PEN .............................................. 25
INTRON-A INJECTION 10MU/0.2ML,
HUMULIN R ....................................................................... 25
10MU/ML, 3MU/0.2ML, 6000000UNIT/ML ..22
HUMULIN R U-500 (CONCENTRATED) ............... 25
INTRON-A INJECTION 5MU/0.2ML ..................... 22
hydralazine hcl* ............................................................... 31
INTRON-A W/DILUENT INJECTION 10MU, 18MU
hydrochlorothiazide capsule* .................................30
............................................................................................... 22
hydrochlorothiazide tablet 25mg, 50mg* .........30
INTRON-A W/DILUENT INJECTION 50MU ...... 22
hydrocodone bitartrate/acetaminophen tablet introvale* ........................................................................... 39
INTUNIV ............................................................................. 32
750mg,
INVANZ
................................................................................. 6
10mg* ................................................................................... 1
hydrocodone/acetaminophen solution* ............. 1
INVEGA SUSTENNA INJECTION 117MG/0.75ML,
156MG/ML, 234MG/1.5ML ....................................... 19
10mg, 325mg, 5mg, 325mg, 7.5mg, 500mg, 10mg,
*CG = Coverage Gap
64
COMPREHENSIVE
COMPRE
HENSIVE FO
FORMU
RMULARY
LARY
(08/2012)
INDEX OF DRUG NAMES
NAMES
JANUVIA TABLET 25MG, 50MG .............................. 23
I (continued)
JE-VAX ................................................................................. 45
INVEGA SUSTENNA INJECTION 39MG/0.25ML, jinteli* ................................................................................... 39
jolivette* .............................................................................. 41
78MG/0.5ML .................................................................19
junel 1.5/30* ....................................................................... 39
INVEGA TABLET EXTENDED RELEASE 24 HOUR junel 1/20* ..........................................................................40
1.5MG,
junel fe 1.5/30* .................................................................40
3MG, 9MG .......................................................................19
junel fe 1/20* ....................................................................40
INVEGA TABLET EXTENDED RELEASE 24 HOUR JUVISYNC ........................................................................... 23
6MG ....................................................................................19
INVIRASE ..............................................................................21
K
IONOSOL-B/DEXTROSE 5% .....................................54
IONOSOL-MB/DEXTROSE 5% ................................54
KALETRA .............................................................................. 21
IPOL INACTIVATED IPV ............................................... 45
KALYDECO ........................................................................ 52
ipratropium bromide inhalation solution* ........ 51
karigel* ................................................................................ 33
ipratropium bromide nasal solution* .................. 5
kariva* .................................................................................40
KCL 0.075%/D5W/NACL 0.45% .............................. 55
ipratropium bromide/albuterol sulfate nebulization solution* ............................................... 51
KCL 0.15%/D5W/LR ....................................................... 55
IRESSA ...................................................................................16
KCL 0.15%/D5W/NACL 0.2% .................................... 55
ISENTRESS ........................................................................... 21
KCL 0.15%/D5W/NACL 0.225% ............................... 55
ISOLYTE-H/DEXTROSE 5% .......................................54
KCL 0.15%/D5W/NACL 0.9% .................................... 55
ISOLYTE-M/DEXTROSE 5% ......................................54
KCL 0.3%/D5W/NACL 0.45% ................................... 55
ISOLYTE-P/DEXTROSE 5% ........................................ 55
KCL 0.3%/D5W/NACL 0.9% ..................................... 55
ISOLYTE-S .......................................................................... 55
kelnor 1/35* .......................................................................40
ISOLYTE-S/DEXTROSE 5% ........................................ 55
ketoconazole* .................................................................. 12
isoniazid syrup .................................................................. 14
ketoprofen er ..................................................................... 3
isoniazid tablet* ............................................................... 14
ketoprofen* ........................................................................ 3
isosorbide dinitrate er .................................................. 31
ketorolac tromethamine ophthalmic solution
isosorbide dinitrate* ...................................................... 31
...............................................................................................49
isosorbide mononitrate er* ....................................... 31
KINRIX .................................................................................. 45
isosorbide mononitrate* ............................................. 31
kionex ................................................................................... 53
itraconazole ...................................................................... 12
klor-con 10* ....................................................................... 55
IXEMPRA KIT ...................................................................... 15
klor-con 25* ...................................................................... 55
IXIARO ................................................................................. 45
klor-con 8* ........................................................................ 55
klor-con m10* .................................................................. 55
klor-con m15* ................................................................... 55
J
klor-con m20* ................................................................. 55
JAKAFI .................................................................................... 15
klor-con packet* ............................................................ 55
JALYN ...................................................................................36
KOMBIGLYZE XR ............................................................ 23
jantoven* ........................................................................... 25
KUVAN ................................................................................ 34
JANUMET ............................................................................ 23
JANUMET XR TABLET EXTENDED RELEASE 24 L
HOUR 1000MG,
100MG .............................................................................. 23
labetalol hcl* .................................................................... 28
laclotion* ........................................................................... 33
JANUMET XR TABLET EXTENDED RELEASE 24 LACRISERT .........................................................................48
HOUR 1000MG,
50MG, 500MG, 50MG .............................................. 23
LACTATED RINGERS ..................................................... 55
JANUVIA TABLET 100MG ............................................ 23
LACTATED RINGERS IRRIGATION ......................... 47
LACTATED RINGERS VIAFLEX .................................. 55
*CG = Coverage Gap
65
COMPREHENSIVE
HENSIVE FFO
ORMU
COMPRE
RMULARY
LARY
(08/2012)
INDEX OF DRUG NAMES
NAMES
lisinopril/hydrochlorothiazide* .............................. 27
L (continued)
lithium carbonate er* .................................................. 23
lactulose* ...........................................................................35
lithium carbonate* ....................................................... 23
lamivudine ........................................................................ 20
lithium citrate* ................................................................ 23
lamivudine/zidovudine .............................................. 20
LIVALO ................................................................................. 31
lamotrigine tablet chewable, tablet* ....................
LODOSYN .......................................................................... 17
LANOXIN ...........................................................................29
lonox ..................................................................................... 35
LANTUS ............................................................................... 25
loperamide hcl* .............................................................. 35
LANTUS SOLOSTAR ..................................................... 25
lorazepam tablet* ......................................................... 22
latanoprost* .................................................................... 48
loryna* ................................................................................40
LATUDA ...............................................................................19
losartan potassium tablet 100mg* ........................ 27
leena* .................................................................................. 40
losartan potassium tablet 25mg, 50mg* ........... 27
leflunomide* .....................................................................45
losartan potassium/hydrochlorothiazide tablet lessina-28* ........................................................................ 40
12.5mg,
LETAIRIS .............................................................................. 52
100mg, 25mg, 100mg* ................................................ 27
letrozole* .............................................................................16
losartan potassium/hydrochlorothiazide tablet leucovorin calcium ......................................................... 15
12.5mg,
LEUKERAN ........................................................................... 14
50mg* ............................................................................... 27
LEUKINE ...............................................................................26
LOTEMAX ..........................................................................49
leuprolide acetate .........................................................42
LOTRONEX TABLET 0.5MG ....................................... 35
LEVEMIR .............................................................................. 25
LOTRONEX TABLET 1MG ........................................... 35
LEVEMIR FLEXPEN .......................................................... 25
lovastatin* .......................................................................... 31
levetiracetam injection 1000mg/100ml,
LOVAZA ............................................................................... 31
750mg/100ml, 1500mg/100ml, 540mg/100ml, low-ogestrel* ...................................................................40
500mg/100ml, 820mg/100ml .................................... 8
loxapine succinate* ....................................................... 18
levetiracetam injection 500mg/5ml* .....................
LUMIGAN ...........................................................................48
levetiracetam oral solution, tablet* ....................... 8
LUMIZYME ......................................................................... 34
levobunolol hcl* ............................................................ 49
LUPRON DEPOT INJECTION 11.25MG, 22.5MG 42
levocetirizine dihydrochloride solution ............. 5
LUPRON DEPOT INJECTION 3.75MG, 7.5MG ... 42
levocetirizine dihydrochloride tablet ................. 5
LUPRON DEPOT INJECTION 30MG ...................... 42
levofloxacin in d5w ......................................................... 7
LUPRON DEPOT INJECTION 45MG ...................... 43
levofloxacin injection, oral solution, tablet ........ LUPRON DEPOT-PED INJECTION 11.25MG ........ 43
levora 0.15/30-28* ........................................................ 40
LUPRON DEPOT-PED INJECTION 15MG, 7.5MG levothroid* ........................................................................42
............................................................................................... 43
levothyroxine sodium injection ..............................
LUPRON DEPOT-PED INJECTION 30MG ............ 43
levothyroxine sodium tablet* .................................42
lutera* ..................................................................................40
levoxyl* ................................................................................42
LYRICA ................................................................................. 32
LEXIVA .................................................................................. 21
LYSODREN ........................................................................ 42
lidocaine hcl injection .................................................... 2
lidocaine hcl jelly gel 2%* ............................................. 2
M
lidocaine ointment* ........................................................ 2
lidocaine viscous* ............................................................ 2
magnesium sulfate ........................................................ 55
lidocaine/prilocaine cream* ...................................... 2
malathion ........................................................................... 17
LIDODERM ........................................................................... 2
maprotiline hcl* ............................................................... 10
liothyronine sodium tablet* .....................................42
marlissa* .............................................................................40
LIPOSYN II ......................................................................... 47
MARPLAN ........................................................................... 10
LIPOSYN III ........................................................................ 47
MATULANE ........................................................................ 14
lisinopril* ............................................................................. 27
matzim la* ......................................................................... 29
*CG = Coverage Gap
66
INDEX OF DRUG NAMES
methyldopa/hydrochlorothiazide .......................
M (continued)
methylphenidate hcl er tablet extended release meclizine hcl* ..................................................................... 11
20mg .................................................................................. 32
MEDROL TABLET 2MG ................................................38
methylphenidate hcl tablet ...................................... 32
medroxyprogesterone acetate* ............................. 41
methylphenidate hydrochloride solution ......... 32
mefloquine hcl* ............................................................... 17
methylprednisolone acetate injection* ............. 38
megestrol acetate suspension* ............................... 41
methylprednisolone sodium succinate injection*
megestrol acetate tablet ............................................ 41
............................................................................................... 38
meloxicam suspension .................................................. 3
methylprednisolone tablet, dose pack* ............. 38
meloxicam tablet* ........................................................... 3
metipranolol* ..................................................................49
MENACTRA ....................................................................... 45
metoclopramide hcl injection ................................. 35
MENEST ................................................................................ 15
metoclopramide hcl oral solution, tablet* ...... 35
MENOMUNE-A/C/Y/W-135 .................................... 45
metolazone* .................................................................... 30
MENVEO ............................................................................. 45
metoprolol succinate er* .......................................... 28
meprobamate ................................................................. 22
metoprolol tartrate* ................................................... 28
MEPRON .............................................................................. 17
metoprolol/hydrochlorothiazide* ....................... 28
mercaptopurine .............................................................. 15
metronidazole cream, gel, lotion, tablet* ........... 4
meropenem ........................................................................ 6
metronidazole in nacl 0.79%* ................................... 4
mesalamine ...................................................................... 46
metronidazole vaginal gel* ......................................... 4
mesna* ................................................................................. 15
mexiletine hcl* ................................................................. 28
MESNEX TABLET .............................................................. 15
MIACALCIN INJECTION .............................................. 47
MESTINON SYRUP ......................................................... 13
microgestin 1.5/30* ........................................................40
MESTINON TIMESPAN ................................................. 13
microgestin 1/20* ...........................................................40
metadate er ...................................................................... 32
microgestin fe 1.5/30* ..................................................40
metaproterenol sulfate syrup, tablet* ................ 5
microgestin fe* ................................................................40
metformin hcl er tablet extended release 24 micronized colestipol hcl* .......................................... 31
hour 1000mg* ................................................................24
midodrine hcl ................................................................... 26
metformin hcl er tablet extended release 24 millipred tablet* .............................................................. 38
hour 500mg* ..................................................................24
minocycline hcl capsule* ............................................. 7
metformin hcl er tablet extended release 24 minoxidil* ............................................................................ 31
hour 750mg* ..................................................................24
mirtazapine odt* ............................................................ 10
metformin hcl tablet 1000mg* ................................24
mirtazapine* ..................................................................... 10
metformin hcl tablet 500mg* ..................................24
misoprostol* ..................................................................... 36
metformin hcl tablet 850mg* ..................................24
mitoxantrone hcl* .......................................................... 15
methadone hcl concentrate,
M-M-R II W/DILUENT 10 DOSE .............................. 45
injection, oral solution ............................................... 1
modafinil ............................................................................ 52
methadone hcl tablet* .................................................. 1
moexipril hcl* ................................................................... 27
methadose* ......................................................................... 1
moexipril/hydrochlorothiazide* ............................ 27
methazolamide* ............................................................ 49
mometasone furoate* ................................................ 38
methenamine hippurate .............................................. 4
mononessa* .....................................................................40
methimazole* .................................................................. 43
morphine sulfate er tablet extended release 12 METHITEST ........................................................................39
hour* .................................................................................... 1
methocarbamol ............................................................. 52
morphine sulfate injection, oral solution* ........... 1
methotrexate sodium* ...............................................44
morphine sulfate tablet* .............................................. 1
methotrexate* .................................................................44
MOVIPREP .......................................................................... 35
methscopolamine bromide ...................................... 34
MOXEZA ............................................................................... 7
methyclothiazide* .........................................................30
MULTAQ ............................................................................ 28
methyldopa ......................................................................26
*CG = Coverage Gap
67
INDEX OF DRUG NAMES
next choice ......................................................................... 41
M (continued)
NIACOR ............................................................................... 31
mupirocin ............................................................................. 4
NIASPAN ............................................................................. 31
MYCAMINE ........................................................................ 12
nicardipine hcl capsule* ............................................. 29
MYCOBUTIN ..................................................................... 14
NICOTROL NS ................................................................... 3
mycophenolate mofetil ..............................................44
nifediac cc ......................................................................... 29
MYFORTIC .........................................................................44
nifedical xl ......................................................................... 29
MYOZYME ........................................................................ 34
nifedipine ........................................................................... 29
myzilra* .............................................................................. 40
nifedipine er ......................................................................29
NILANDRON ..................................................................... 43
N
nimodipine ........................................................................ 29
nabumetone ....................................................................... 3
NITRO-BID .......................................................................... 31
nadolol* ..............................................................................28
nitrofurantoin macrocrystalline .............................. 4
NAFTIN ................................................................................. 12
nitrofurantoin monohydrate .................................... 4
NAGLAZYME .................................................................... 34
nitroglycerin injection, patch* ................................. 31
naloxone hcl injection 1mg/ml* ................................ 3
nitroglycerin transdermal patch* .......................... 31
naltrexone hcl* .................................................................. 2
NITROSTAT ........................................................................ 31
NAMENDA SOLUTION ................................................10
nora-be* ............................................................................. 41
NAMENDA TABLET ........................................................10
norethindrone acetate* .............................................. 41
NAMENDA TITRATION PAK ......................................10
NORMOSOL-M IN D5W ............................................ 55
naproxen sodium* ........................................................... 3
NORMOSOL-R ................................................................ 55
naproxen* ............................................................................ 3
NORMOSOL-R IN D5W .............................................. 55
naratriptan hcl tablet ................................................... 13
NORPACE CR ................................................................... 28
NASONEX ......................................................................... 50
nortrel 0.5/35 (28)* ........................................................40
NATACYN ........................................................................... 12
nortrel 1/35 (21)* ..............................................................40
nateglinide .........................................................................24
nortrel 1/35 (28)* .............................................................40
necon 0.5/35-28* .......................................................... 40
nortrel 7/7/7* ..................................................................40
necon 1/35-28* ............................................................... 40
nortriptyline hcl capsule* ............................................ 11
necon 1/50-28* ............................................................... 40
NORVIR ................................................................................ 21
necon 10/11-28* .............................................................. 40
np thyroid 30 ................................................................... 42
necon 7/7/7* ................................................................... 40
np thyroid 60 ................................................................... 42
nefazodone hcl* ..............................................................10
np thyroid 90 ................................................................... 42
neomycin sulfate tablet* ............................................. 4
NULOJIX .............................................................................. 44
neomycin/bacitracin/polymyxin* .......................... 4
NULYTELY/FLAVOR PACKS ..................................... 35
neomycin/polymyxin b sulfates* ............................ 4
nyamyc* .............................................................................. 12
neomycin/polymyxin/bacitracin/
nystatin vaginal* ............................................................. 13
hydrocortisone* ......................................................... 49
nystatin* .............................................................................. 13
neomycin/polymyxin/dexamethasone* .......... 4
nystatin/triamcinolone* ............................................. 13
neomycin/polymyxin/gramicidin* ......................... 4
nystop* ................................................................................. 13
neomycin/polymyxin/hc* ........................................ 50
O
neomycin/polymyxin/hydrocortisone* ............... 4
NEPHRAMINE ................................................................... 55
ocella* ..................................................................................40
NEUMEGA ..........................................................................26
octreotide acetate ........................................................ 43
NEUPOGEN .......................................................................26
ofloxacin ophthalmic solution, otic solution* .. 7
NEVANAC ......................................................................... 49
ofloxacin tablet ................................................................ 7
nevirapine ......................................................................... 20
olanzapine injection ...................................................... 19
NEXAVAR ............................................................................16
olanzapine odt ................................................................. 19
*CG = Coverage Gap
68
INDEX OF DRUG NAMES
peg 3350/electrolytes* ................................................ 35
O (continued)
PEGANONE ......................................................................... 9
olanzapine tablet ............................................................19
PEGASYS ............................................................................. 22
omeprazole* .....................................................................36
PEGASYS PROCLICK ..................................................... 22
ondansetron hcl injection .......................................... 12
penicillin g potassium* .................................................. 6
ondansetron hcl oral solution ................................. 12
PENICILLIN G PROCAINE ............................................. 6
ondansetron hcl tablet ................................................ 12
penicillin v potassium* .................................................. 6
ondansetron odt ............................................................. 12
PENTACEL .......................................................................... 45
ONFI ........................................................................................ 8
PENTAM 300 ...................................................................... 17
ONGLYZA .......................................................................... 24
pentostatin* ...................................................................... 15
ONTAK ................................................................................. 15
pentoxifylline er* ............................................................ 29
ORAP .....................................................................................18
periogard* ......................................................................... 33
ORFADIN ............................................................................ 34
permethrin* ....................................................................... 17
orsythia* ............................................................................ 40
perphenazine* .................................................................. 18
oxacillin sodium ................................................................ 6
perphenazine/amitriptyline ....................................... 11
oxandrolone tablet 10mg ...........................................38
pfizerpen-g* ....................................................................... 6
oxandrolone tablet 2.5mg .........................................38
phenadoz* ......................................................................... 50
oxaprozin* ........................................................................... 3
phenazopyridine hcl* .................................................. 36
oxazepam* ........................................................................ 22
phenelzine sulfate* ........................................................ 10
oxcarbazepine ................................................................... 9
phenobarbital tablet* ................................................... 8
OXSORALEN ULTRA CAPSULE ................................ 33
phenylephrine hcl* ........................................................48
oxybutynin chloride er ................................................ 36
phenytoin sodium extended capsule* .................. 9
oxybutynin chloride* ................................................... 36
phenytoin sodium injection* ..................................... 9
oxycodone hcl tablet* .................................................. 2
phenytoin suspension* .................................................. 9
oxycodone/acetaminophen capsule* .................. 2
philith* .................................................................................40
oxycodone/acetaminophen tablet 325mg,
PHYSIOLYTE ..................................................................... 47
10mg, 325mg, 2.5mg, 325mg, 5mg, 325mg, 7.5mg, pilocarpine hcl solution .............................................. 49
500mg, 7.5mg* ................................................................. 2
pilocarpine hcl tablet .................................................. 33
oxycodone/acetaminophen tablet 650mg,
PILOPINE HS ..................................................................... 49
10mg* .................................................................................. 2
pindolol* ............................................................................. 29
oxymorphone hydrochloride er ............................... 1
piperacillin sodium/tazobactam sodium ........... 6
piroxicam* ........................................................................... 3
P
PLASMA-LYTE A ............................................................. 55
pacerone tablet 200mg* ............................................28
PLASMA-LYTE-148 ......................................................... 55
pamidronate disodium injection 30mg/10ml,
PLASMA-LYTE-56/D5W ............................................. 55
90mg/10ml ..................................................................... 47
podofilox solution ......................................................... 33
PANRETIN ...........................................................................16
polycin b* ............................................................................. 4
pantoprazole sodium* ................................................ 36
polyethylene glycol 3350* .......................................... 35
paromomycin sulfate* .................................................. 4
portia-28* ..........................................................................40
paroxetine hcl* ................................................................. 11
POTASSIUM CHLORIDE 0.15% D5W/NACL 0.33% PASER .................................................................................... 14
............................................................................................... 55
PATADAY .......................................................................... 48
POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45% PATANOL .......................................................................... 48
VIAFLEX ............................................................................ 55
PAXIL SUSPENSION ........................................................ 11
POTASSIUM CHLORIDE 0.15% NACL 0.9% ........ 55
PEDIARIX ............................................................................. 45
POTASSIUM CHLORIDE 0.15%/NACL 0.45% pedi-dri* .............................................................................. 13
VIAFLEX ............................................................................ 56
PEDVAX HIB ......................................................................45
*CG = Coverage Gap
69
INDEX OF DRUG NAMES
prochlorperazine edisylate injection* ................... 11
P (continued)
prochlorperazine maleate tablet* .......................... 11
POTASSIUM CHLORIDE 0.22% D5W/NACL prochlorperazine suppository* ................................ 11
0.45% ..................................................................................56
POTASSIUM CHLORIDE 0.224%/DEXTROSE 5% 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML
VIAFLEX ............................................................................56
.............................................................................................. 26
POTASSIUM CHLORIDE 0.3%/D5W/VIAFLEX ..56
POTASSIUM CHLORIDE 0.3%/NACL 0.9% .........56
40000UNIT/ML ........................................................... 26
potassium chloride er* ................................................56
proctocream hc* ........................................................... 38
potassium chloride injection 0.4meq/ml,
proctosol hc cream* .................................................... 38
10meq/100ml, 10meq/50ml, 30meq/100ml ....56
PROGLYCEM .................................................................... 24
potassium chloride injection 2meq/ml* ............56
PROGRAF INJECTION ................................................... 44
potassium chloride liquid* ........................................56
PROLASTIN ....................................................................... 52
potassium chloride sr* ................................................56
PROLASTIN-C .................................................................. 52
POTIGA TABLET 200MG, 300MG, 400MG ........... 8
PROLEUKIN ........................................................................ 15
POTIGA TABLET 50MG ................................................. 8
PROLIA ................................................................................. 47
PRADAXA ........................................................................... 25
PROMACTA ...................................................................... 26
pramipexole dihydrochloride ................................... 17
promethazine hcl ........................................................... 51
PRANDIMET ......................................................................24
promethazine vc ............................................................. 51
PRANDIN ............................................................................24
promethegan .................................................................... 51
pravastatin sodium* ..................................................... 31
propafenone hcl* .......................................................... 28
prazosin hcl* ....................................................................26
propantheline bromide .............................................. 34
prednicarbate ..................................................................38
propranolol hcl er* ....................................................... 29
prednisolone acetate* ............................................... 49
propranolol hcl* ............................................................. 29
prednisolone sodium phosphate ophthalmic propranolol/hydrochlorothiazide* ..................... 29
solution* ......................................................................... 49
propylthiouracil* ............................................................ 43
prednisolone sodium phosphate solution* ......38
PROQUAD ......................................................................... 45
prednisolone* .................................................................. 46
PROSOL .............................................................................. 56
prednisone* .......................................................................38
PROTONIX INJECTION ................................................ 36
PREMARIN CREAM, INJECTION ................................ 41
PROTOPIC ......................................................................... 33
PREMARIN TABLET ......................................................... 41
protriptyline hcl ................................................................ 11
PREMASOL .........................................................................56
PROVIGIL TABLET 100MG .......................................... 52
PREMPHASE ........................................................................ 41
PROVIGIL TABLET 200MG ......................................... 52
PREMPRO ............................................................................. 41
PULMOZYME ................................................................... 52
prenatabs obn* ...............................................................56
pyrazinamide* .................................................................. 14
prenatal plus* ..................................................................56
pyridostigmine bromide* ............................................ 14
prenatal plus/iron* .......................................................56
prevalite* ............................................................................. 31
Q
PREVIFEM ............................................................................. 41
PREZISTA TABLET 150MG ............................................ 21
quasense* ........................................................................... 41
PREZISTA TABLET 400MG, 600MG ......................... 21
quetiapine fumarate* .................................................. 19
PREZISTA TABLET 75MG .............................................. 21
quinapril hcl* .................................................................... 27
PRIFTIN ................................................................................. 14
quinapril/hydrochlorothiazide* ............................ 27
primidone* .......................................................................... 8
quinidine gluconate er* .............................................. 28
PRISTIQ .................................................................................. 11
quinidine sulfate er* ..................................................... 28
probenecid* ....................................................................... 13
quinidine sulfate* ........................................................... 28
procainamide hcl* .........................................................28
QVAR .................................................................................... 50
PROCALAMINE ................................................................56
*CG = Coverage Gap
70
INDEX OF DRUG NAMES
ROTARIX .............................................................................46
R
ROTATEQ ...........................................................................46
RABAVERT ..........................................................................45
ramipril* .............................................................................. 27
S
RANEXA ..............................................................................30
ranitidine hcl injection, syrup .................................. 35
SABRIL PACKET .................................................................. 8
ranitidine hcl tablet* .................................................... 35
SABRIL TABLET .................................................................. 8
RAPAFLO ............................................................................36
salsalate ................................................................................. 1
RAPAMUNE .......................................................................44
SANDIMMUNE INJECTION ........................................ 44
REBIF ...................................................................................... 32
SANDOSTATIN LAR DEPOT ..................................... 43
REBIF TITRATION PACK ............................................... 32
SANTYL ............................................................................... 33
reclipsen* ............................................................................. 41
SAPHRIS ............................................................................... 19
RECOMBIVAX HB .......................................................... 46
SAVELLA ............................................................................. 32
REGRANEX ......................................................................... 33
SAVELLA TITRATION PACK ...................................... 32
RELENZA DISKHALER ..................................................... 21
selegiline hcl ....................................................................... 18
RELISTOR ............................................................................ 35
selenium sulfide lotion* .............................................. 33
REMICADE ..........................................................................44
SELZENTRY ......................................................................... 21
REMODULIN ..................................................................... 52
SENSIPAR TABLET 30MG ............................................ 42
RENAGEL ............................................................................36
SENSIPAR TABLET 60MG ............................................42
RENVELA ............................................................................. 37
SENSIPAR TABLET 90MG ............................................ 42
reprexain tablet 10mg, 200mg* ................................. 2
SEREVENT DISKUS .......................................................... 51
RESCRIPTOR ..................................................................... 20
SEROMYCIN ...................................................................... 14
reserpine* ...........................................................................26
SEROQUEL XR TABLET EXTENDED RELEASE 24 RESTASIS ............................................................................ 48
HOUR 150MG,
RETROVIR IV INFUSION ............................................. 20
200MG .............................................................................. 19
REVATIO TABLET ............................................................ 52
SEROQUEL XR TABLET EXTENDED RELEASE 24 REVLIMID ............................................................................. 14
HOUR 300MG,
REYATAZ CAPSULE 100MG, 150MG, 200MG ...... 21
400MG, 50MG .............................................................. 19
REYATAZ CAPSULE 300MG ....................................... 21
sertraline hcl* .................................................................... 11
ribasphere tablet 200mg ............................................ 22
silver sulfadiazine* .......................................................... 4
ribavirin tablet 200mg ................................................. 22
SIMPONI ............................................................................. 44
RIDAURA .............................................................................45
simvastatin* ....................................................................... 31
rifampin capsule, injection* ....................................... 14
SINGULAIR .......................................................................... 51
RILUTEK ............................................................................... 32
SODIUM CHLORIDE 0.45% VIAFLEX ..................... 56
rimantadine hcl* ............................................................. 21
sodium chloride 0.9%* ................................................48
RINGERS INJECTION .....................................................56
sodium chloride* ............................................................ 56
RINGERS IRRIGATION ................................................. 48
sodium fluoride* ............................................................ 56
RISPERDAL CONSTA INJECTION 12.5MG, 25MG SODIUM LACTATE ........................................................ 53
................................................................................................19
sodium polystyrene sulfonate ................................ 53
RISPERDAL CONSTA INJECTION 37.5MG, 50MG sodium sulfacetamide solution* .............................. 7
................................................................................................19
solia* ...................................................................................... 41
risperidone m-tab ..........................................................19
SOMATULINE DEPOT .................................................. 43
risperidone odt .................................................................19
SOMAVERT ....................................................................... 43
risperidone solution .......................................................19
SORIATANE ....................................................................... 33
risperidone tablet* .........................................................19
sorine* ................................................................................. 28
RITUXAN ..............................................................................16
sotalol hcl (af)* ................................................................ 28
rivastigmine tartrate ...................................................... 9
sotalol hcl* ........................................................................ 28
ropinirole hcl* ................................................................... 17
SPIRIVA HANDIHALER ................................................... 51
*CG = Coverage Gap
71
INDEX OF DRUG NAMES
tamsulosin hcl* ............................................................... 36
S (continued)
TARCEVA ............................................................................. 16
spironolactone* ..............................................................30
TARGRETIN ........................................................................ 16
spironolactone/hydrochlorothiazide* ...............30
TASIGNA ............................................................................. 16
sprintec 28* ........................................................................ 41
TASMAR ............................................................................... 17
SPRYCEL ...............................................................................16
TAZORAC ........................................................................... 33
sps .......................................................................................... 53
taztia xt* ............................................................................ 29
sronyx* ................................................................................. 41
TEKTURNA ......................................................................... 30
ssd* .......................................................................................... 5
TEKTURNA HCT ..............................................................30
stagesic* ................................................................................ 2
temazepam* .................................................................... 52
stavudine ........................................................................... 20
TENIVAC ............................................................................. 46
STRATTERA CAPSULE 100MG, 80MG ................... 32
terazosin hcl* ................................................................... 26
STRATTERA CAPSULE 10MG,
terbinafine hcl* ................................................................ 13
18MG, 25MG, 40MG, 60MG ................................... 32
terbutaline sulfate* ....................................................... 51
STROMECTOL ................................................................... 17
terconazole* ..................................................................... 13
SUBOXONE FILM ............................................................. 3
TESTIM ................................................................................. 39
SUCRAID ............................................................................. 34
testosterone cypionate* ............................................ 39
sucralfate* .........................................................................36
testosterone enanthate* ........................................... 39
sulfacetamide sodium* ................................................. 7
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED sulfacetamide sodium/prednisolone sodium
ADULT ...............................................................................46
phosphate* .................................................................... 49
tetracycline hcl* ............................................................... 7
sulfadiazine ......................................................................... 7
TEV-TROPIN .....................................................................38
sulfamethoxazole/trimethoprim ds* .................... 7
THALOMID ......................................................................... 14
sulfamethoxazole/trimethoprim* .......................... 7
THEO-24 .............................................................................. 51
sulfasalazine* .................................................................. 46
theochron* ........................................................................ 51
sulfazine ec* .................................................................... 46
theophylline cr* ............................................................... 51
sulindac* ............................................................................... 3
theophylline er tablet extended release 12 hour*
sumatriptan nasal spray ............................................. 13
................................................................................................ 51
sumatriptan succinate injection ............................. 13
theophylline er tablet extended release 24 hour
sumatriptan succinate injection refill .................. 1
................................................................................................ 51
sumatriptan succinate tablet ................................... 13
thermazene* ...................................................................... 5
SUPRAX ................................................................................. 5
thioridazine hcl* .............................................................. 18
SUPREP BOWEL PREP ................................................... 36
thiothixene* .......................................................................18
SUSTIVA ............................................................................. 20
THYMOGLOBULIN ....................................................... 44
SUTENT ................................................................................16
THYROLAR-1/2 ................................................................ 42
SYLATRON ......................................................................... 15
ticlopidine hcl .................................................................. 26
SYMLINPEN 120 ............................................................... 24
TIKOSYN ............................................................................ 28
SYMLINPEN 60 ................................................................ 24
TIMENTIN ............................................................................ 6
SYNAREL ............................................................................. 43
timolol maleate ophthalmic gel forming* ........49
SYNTHROID ......................................................................42
timolol maleate ophthalmic solution* ............... 50
SYPRINE .............................................................................. 53
timolol maleate tablet* .............................................. 29
tizanidine hcl* ................................................................... 19
T
TOBI ........................................................................................ 4
TABLOID .............................................................................. 15
TOBRADEX OINTMENT ..............................................49
tacrolimus ..........................................................................44
TOBRADEX ST ..................................................................49
TAMIFLU .............................................................................. 21
tobramycin sulfate injection ..................................... 4
tamoxifen citrate* .......................................................... 15
tobramycin sulfate ophthalmic solution* .......... 4
*CG = Coverage Gap
72
COMPREHENSIVE
COMPRE
HENSIVE FO
FORMU
RMULARY
LARY
(08/2012)
INDEX OF DRUG NAMES
NAMES
trivora-28* ......................................................................... 41
T (continued)
TRIZIVIR ............................................................................... 20
tobramycin/dexamethasone* ............................... 49
TROPHAMINE .................................................................. 56
tolazamide* ......................................................................24
tropicamide ......................................................................48
tolbutamide* ....................................................................24
trospium chloride .......................................................... 36
topiramate* ........................................................................ 9
TRUVADA ........................................................................... 20
torsemide tablet* ...........................................................30
TWINRIX ............................................................................. 46
tpn electrolytes* .............................................................56
TWYNSTA ......................................................................... 27
TRACLEER ........................................................................... 52
TYGACIL ............................................................................... 5
tramadol hcl* .................................................................... 2
TYKERB ................................................................................. 16
tramadol hydrochloride/acetaminophen* ....... 2
TYPHIM VI ......................................................................... 46
trandolapril* ..................................................................... 27
TYZEKA ............................................................................... 22
tranexamic acid ..............................................................26
TYZINE ................................................................................ 52
tranylcypromine sulfate ..............................................10
TRAVASOL .........................................................................56
U
TRAVATAN Z ................................................................... 48
trazodone hcl tablet 100mg, 150mg, 50mg* .......10
ULORIC ................................................................................. 13
trazodone hcl tablet 300mg .....................................10
unithroid* .......................................................................... 42
TREANDA ............................................................................ 14
urea 40% cream ............................................................. 34
TRECATOR .......................................................................... 14
ursodiol capsule 300mg .............................................. 35
TRELSTAR DEPOT ........................................................... 43
V
TRELSTAR DEPOT MIXJECT ....................................... 43
TRELSTAR LA .................................................................... 43
valacyclovir hcl ............................................................... 22
TRELSTAR LA MIXJECT ................................................. 43
VALCYTE SOLUTION RECONSTITUTED ............ 20
TRELSTAR MIXJECT ........................................................ 43
VALCYTE TABLET ........................................................... 20
tretinoin capsule .............................................................16
valproate sodium* .......................................................... 8
tretinoin cream, gel* .................................................... 34
valproic acid* .................................................................... 8
TREXALL ..............................................................................44
vancomycin hcl capsule ............................................... 5
vancomycin hcl injection 1000mg, 10gm .............. 5
triamcinolone acetonide cream,
vandazole*
.......................................................................... 5
lotion, ointment* ........................................................38
triamcinolone in orabase* ........................................ 33
VANDETANIB TABLET 100MG .................................. 15
triamterene/hydrochlorothiazide* ......................30
VANDETANIB TABLET 300MG .................................. 15
triazolam* .......................................................................... 52
VAQTA ................................................................................ 46
trifluoperazine hcl* ........................................................18
VARIVAX ............................................................................. 46
trifluridine ..........................................................................22
VELCADE ............................................................................. 15
trihexyphenidyl hcl ......................................................... 17
velivet* ................................................................................. 41
TRIHIBIT .............................................................................. 46
venlafaxine hcl er capsule extended release 24 tri-legest fe* ....................................................................... 41
hour ..................................................................................... 11
TRILEPTAL SUSPENSION ............................................... 9
venlafaxine hcl er tablet extended release 24 trilyte* ..................................................................................36
hour 150mg,
trimethoprim sulfate/polymyxin b sulfate* ...... 5
37.5mg, 75mg .................................................................. 11
trimethoprim tablet* ..................................................... 5
venlafaxine hcl* ................................................................ 11
trimipramine maleate ................................................... 11
VENTOLIN HFA ................................................................51
trinessa* ............................................................................... 41
verapamil hcl er* ........................................................... 29
TRIPEDIA ............................................................................ 46
verapamil hcl sr* ............................................................ 29
tri-previfem* ..................................................................... 41
verapamil hcl tablet* ................................................... 29
TRISENOX ........................................................................... 15
VESICARE ............................................................................ 36
tri-sprintec* ....................................................................... 41
vestura* ............................................................................... 41
*CG = Coverage Gap
73
INDEX OF DRUG NAMES
ZETIA ..................................................................................... 31
V (continued)
ZIAGEN ................................................................................ 20
VEXOL ................................................................................. 49
zidovudine capsule ........................................................ 21
VICTRELIS ........................................................................... 22
zidovudine syrup, tablet* ........................................... 21
VIDAZA .................................................................................16
ziprasidone hcl capsule ............................................... 19
VIDEX PEDIATRIC ........................................................... 20
ZIRGAN GEL ...................................................................... 20
VIGAMOX ............................................................................ 7
ZOLINZA ............................................................................. 16
VIIBRYD ................................................................................. 11
zolpidem tartrate tablet ............................................ 52
VIMPAT .................................................................................. 9
ZOMETA ............................................................................. 47
VIRACEPT ............................................................................. 21
zonisamide* ........................................................................ 8
VIRAMUNE SUSPENSION .......................................... 20
ZORTRESS TABLET 0.25MG ....................................... 44
VIRAMUNE XR ................................................................. 20
ZORTRESS TABLET 0.5MG, 0.75MG ...................... 44
VIREAD ................................................................................ 20
ZOSTAVAX ........................................................................46
VIVELLE-DOT .................................................................... 41
zovia 1/35e* ....................................................................... 41
VOLTAREN GEL ............................................................... 34
zovia 1/50e* ....................................................................... 41
voriconazole injection .................................................. 13
ZOVIRAX CREAM, OINTMENT ................................ 22
voriconazole tablet 200mg ........................................ 13
ZYLET ..................................................................................... 4
voriconazole tablet 50mg .......................................... 13
ZYMAXID ............................................................................. 7
VOTRIENT ...........................................................................16
ZYPREXA RELPREVV ....................................................... 19
VPRIV .................................................................................... 34
ZYTIGA ................................................................................. 16
VYTORIN ............................................................................. 31
ZYVOX INJECTION,
SUSPENSION RECONSTITUTED ........................... 5
W
ZYVOX TABLET ................................................................. 5
warfarin sodium* ........................................................... 25
WELCHOL ........................................................................... 31
X
XALKORI ..............................................................................16
XARELTO TABLET 10MG ............................................. 25
XENAZINE TABLET 12.5MG ........................................ 32
XENAZINE TABLET 25MG ........................................... 32
XOLAIR ................................................................................ 52
XYREM ................................................................................. 53
Y
YF-VAX ............................................................................... 46
Z
zafirlukast* ......................................................................... 51
zaleplon ............................................................................... 52
ZAVESCA ............................................................................ 34
zazole* .................................................................................. 13
ZELAPAR ...............................................................................18
ZELBORAF ...........................................................................16
ZENPEP ................................................................................ 34
zeosa* ................................................................................... 41
ZERIT SOLUTION RECONSTITUTED .................... 20
*CG = Coverage Gap
74
This information is available for free in other languages. Please contact our Customer Service number at 1-877-374-4056, Monday–Friday, 8 a.m. to 2 a.m. Eastern. Between 10/01/12 and 02/14/13, representatives are available Monday–Sunday, 8 a.m. to 2 a.m. Eastern.
�
TTY users should call 1-877-247-6272.
�
Esta información se encuentra disponible gratis en otros idiomas. Por favor comuníquese con
�
nuestro Servicio al Cliente al 1-877-374-4056 de lunes a viernes de 8 a.m. a 2 a.m., hora del este. Entre
�
el 10/01/12 y el 02/14/13, los representantes están disponibles de lunes a domingo de 8 a.m. a 2 a.m.,
�
hora del este. Los usuarios de TTY deben llamar al 1-877-247-6272.
�
WellCare is a Medicare-approved Part D sponsor. The benefit information provided is a brief summary, not a
complete description of benefits. For more information, contact the plan. Limitations, co-payments and restrictions
may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/coinsurance may change on
January 1 of each year.
46823
P.O. Box 31389
�
Tampa, FL 33631-3389
�
www.wellcarepdp.com

WellCare 2013 Comprehensive Formulary, Medicare

Transcription

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