Blue MedicareRx Value (PDP)
2014 Formulary (List of Covered Drugs)
Please read: This document
contains information about the
drugs we cover in this plan.
Customer Service
This formulary was updated on October 1, 2014. For more recent information or other questions, please
contact Blue MedicareRx Value (PDP) Customer Service at 1-866-755-2776 or, for TTY users, 711, 8 a.m. to
8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and
Monday to Friday (except holidays) from February 15 through September 30, or visit
www.partdkansascity.com/shop.
Y0071_14_17283_U_034 CMS Accepted 08/11/2013
38018MUSENMUB_034 S5726 013
Basic KS 14202, V15
Note to existing members:
This formulary has changed since last year. Please review this document
to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us” or “our,” it means
Blue Cross and Blue Shield of Kansas City. When it refers to “plan” or
“our plan,” it means Blue MedicareRx Value (PDP).
This document includes a list of the drugs (formulary) for our plan which
is current as of October 1, 2014. For an updated formulary,
please contact us. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription
drug benefit. Benefits, formulary, pharmacy network, premium and/or
copayments/coinsurance may change on January 1, 2015.
Basic KS 14202, V15
2
Effective Date November 1, 2014
What is the Blue MedicareRx Value
(PDP) formulary?
How do I use the formulary?
There are two ways to find your drug within the formulary:
A formulary is a list of covered drugs selected by our plan
in consultation with a team of health care providers, which
represents the prescription therapies believed to be a
necessary part of a quality treatment program. Our plan
will generally cover the drugs listed in our formulary as long
as the drug is medically necessary, the prescription is filled
at a plan network pharmacy, and other plan rules are
followed. For more information on how to fill your
prescriptions, please review your Evidence of Coverage.
Medical Condition
The formulary begins on page 7. 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 Medications.” If you
know what your drug is used for, look for the category name
in the list that begins on page 7. Then look under the
category name for your drug.
Can the formulary (drug list) change?
Generally, if you are taking a drug on our 2014 formulary
that was covered at the beginning of the year, we will not
discontinue or reduce coverage of the drug during the
2014 coverage year except when a new, less expensive generic
drug becomes available or when new adverse information
about the safety or effectiveness of a drug is released. Other
types of formulary changes, such as removing a drug from
our formulary, will not affect members who are currently
taking the drug. It will remain available at the same cost
sharing for those members taking it for the remainder of
the coverage year. We feel it is important that you have
continued access for the remainder of the coverage year to
the forumulary drugs that were available when you chose
our plan, except for cases in which you can save additional
money or we can ensure your safety.
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 38.
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?
Our plan 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.
If we remove drugs from our formulary, or add prior
authorization, quantity limits and/or step-therapy
restrictions on a drug or move a drug to a higher
cost-sharing tier, we must notify affected members of the
change at least 60 days before the change becomes effective,
or at the time the member requests a refill of the drug, at
which time the member will receive a 60-day supply of the
drug. If the Food and Drug Administration (FDA) deems
a drug on our formulary to be unsafe or the drug’s
manufacturer removes the drug from the market, we will
immediately remove the drug from our formulary and
provide notice to members who take the drug. The enclosed
formulary is current as of October 1, 2014. To get updated
information about the drugs covered by our plan, please
contact us. Our contact information appears on the front
and back cover pages. If any other type of approved
formulary change (nonmaintenance change) is made during
the year, we will notify you by sending you a list of these
changes, or by sending you an updated formulary.
Basic KS 14202, V15
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: Our plan requires you or your
physician to get prior authorization for certain drugs. This
means that you will need to get approval from our plan
before you fill your prescriptions. If you don't get approval,
our plan may not cover the drug.
Quantity Limits: For certain drugs, our plan limits the
amount of the drug that our plan will cover. For example,
our plan provides 100 units per ml per prescription for
3
Effective Date November 1, 2014
HUMALOG. This may be in addition to a standard
one-month or three-month supply.
How do I request an exception to the
Blue MedicareRx Value (PDP)'s
formulary?
Step Therapy: In some cases, our plan requires you to first
try certain drugs to treat your medical condition before we
will cover another drug for that condition. For example, if
Drug A and Drug B both treat your medical condition, our
plan may not cover Drug B unless you try Drug A first. If
Drug A does not work for you, our plan will then cover
Drug B.
You can ask our plan to make an exception to our coverage
rules. There are several types of exceptions that you can ask
us to make:
You can ask us to cover a drug even if it is not on our
formulary. If approved, this drug will be covered at a
predetermined cost-sharing level, and you would not be
able to ask us to provide the drug at a lower cost-sharing
level.
You can find out if your drug has any additional
requirements or limits by looking in the formulary that
begins on page 7. You can also get more information about
the restrictions applied to specific covered drugs by visiting
our website. Our contact information, along with the date
we last updated the formulary, appears on the front and
back cover pages.
You can ask us to cover a formulary drug at a lower
cost-sharing level if this drug is not on the specialty tier.
If approved this would lower the amount you must pay for
your drug.
You can ask our plan to make an exception to these
restrictions or limits or for a list of other, similar drugs that
may treat your health condition. See the section, “How do
I request an exception to the Blue MedicareRx Value
(PDP)'s formulary?” on page 4 for information about how
to request an exception.
You can ask us to waive coverage restrictions or limits
on your drug. For example, for certain drugs, our plan
limits the amount of the drug that we will cover. If your
drug has a quantity limit, you can ask us to waive the limit
and cover a greater amount.
Generally, our plan will only approve your request for an
What if my drug is not on the formulary? exception if the alternative drugs included on the plan’s
If your drug is not included in this formulary (list of covered formulary, the lower cost-sharing drug or additional
drugs), you should first contact Customer Service and ask utilization restrictions would not be as effective in treating
your condition and/or would cause you to have adverse
if your drug is covered.
medical effects.
If you learn that our plan does not cover your drug, you
You should contact us to ask us for an initial coverage
have two options:
decision for a formulary, tiering or utilization restriction
You can ask Customer Service for a list of similar drugs that exception. When you request a formulary, tiering or
are covered by our plan. When you receive the list, show it utilization restriction exception, you should submit a
to your doctor and ask him or her to prescribe a similar drug statement from your prescriber or physician supporting
your request. Generally, we must make our decision within
that is covered by our plan.
72 hours of getting your prescriber’s supporting statement.
You can ask our plan to make an exception and cover your You can request an expedited (fast) exception if you or your
drug. See below for information about how to request an
doctor believe that your health could be seriously harmed
exception.
by waiting up to 72 hours for a decision. If your request to
expedite is granted, we must give you a decision no later
than 24 hours after we get a supporting statement from your
doctor or other prescriber.
Basic KS 14202, V15
4
Effective Date November 1, 2014
What do I do before I can talk to my
doctor about changing my drugs or
requesting an exception?
For more information
For more detailed information about our plan prescription
drug coverage, please review your Evidence of Coverage and
other plan materials.
As a new or continuing member in our plan, you may be
taking drugs that are not on our formulary. Or, you may
be taking a drug that is on our formulary but your ability
to get it is limited. For example, you may need a prior
authorization from us before you can fill your prescription.
You should talk to your doctor to decide if you should
switch to an appropriate drug that we cover or request a
formulary exception so that we will cover the drug you take.
While you talk to your doctor to determine the right course
of action for you, we may cover your drug in certain cases
during the first 90 days you are a member of our plan.
If you have questions about our plan, please contact us. Our
contact information, along with the date we last updated
the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription
drug coverage, please call Medicare at 1-800-MEDICARE
(1-800-633-4227), 24 hours a day/7 days a week. TTY
users should call 1-877-486-2048. Or, visit
www.medicare.gov.
Our plan’s formulary
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 30-day supply (unless you have a prescription
written for fewer days) when you go to a network pharmacy.
After your first 30-day supply, we will not pay for these
drugs, even if you have been a member of the plan less than
90 days.
The formulary on page 7 provides coverage information
about some of the drugs covered by our plan. If you have
trouble finding your drug in the list, turn to the Index that
begins on page 38.
The first column of the chart lists the drug name.
Brand-name drugs are capitalized (e.g., HUMALOG) and
generic drugs are listed in lowercase italics (e.g., enalapril).
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, consistent with the
dispensing increment (unless you have a prescription written
for fewer days). We will cover more than one refill of these
drugs for the first 90 days you are a member of our plan. If
you need a drug that is not on our formulary, or if your
ability to get your drugs is limited, but you are past the first
90 days of membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have a
prescription for fewer days) while you pursue a formulary
exception.
The information in the Requirements/Limits column tells
you if our plan has any special requirements for coverage of
your drug.
QLL - Quantity Limits: Restricts the frequency, amount
or dosage of medication for which you can obtain benefits
each time you get a prescription filled (most often set on a
monthly basis).
PAR - Prior Authorization: The process of obtaining
approval for certain prescriptions before benefits will be
approved. You, your doctor or other network provider will
During the time when you are getting a temporary supply need to request prior authorization before you fill the
of a drug, you should talk to your prescriber or prescribing prescription.
physician to decide what to do when your supply runs out.
ST - Step Therapy: The process of first trying a certain
You can call Customer Service to ask for a list of covered
drug or drugs to determine if that drug or those drugs will
drugs that treat the same medical condition. This list can
help your doctor find a covered drug that might work for treat your medical condition before your plan will cover
you while you pursue a formulary exception. Please refer to another drug for that condition.
the Evidence of Coverage for more information about
B/D - Part B vs. Part D: This drug may be covered under
exceptions.
either your Part D prescripton drug benefits or as a Part B
drug under your medical benefits, as determined by
Medicare.
Basic KS 14202, V15
5
Effective Date November 1, 2014
LA - Limited Access: This prescription may be available
INJ - Injectable: The drug is available in injectable form.
only at certain pharmacies. For more information, consult
MO - Mail Orders: Prescription drugs available through
your Pharmacy Directory or call Customer Service at
1-866-755-2776, 8 a.m. to 8 p.m., seven days a week (except mail order.
Thanksgiving and Christmas) from October 1 through
February 14, and Monday to Friday (except holidays) from
February 15 through September 30. TTY/TDD users should
call 711.
Cost-sharing for a one-month supply of a covered Part D prescription drug
during the Initial Coverage Stage:
Cost-Sharing Tier 1 Preferred Generic
Preferred Network Pharmacy* (30-day supply) or Mail-Order Pharmacy** (30-day supply)
$1.00
Network Pharmacy (30-day supply) or Long-Term-Care Pharmacy (34-day supply)
$9.00
Cost-Sharing Tier 2 Non-Preferred Generic
Preferred Network Pharmacy* (30-day supply) or Mail-Order Pharmacy** (30-day supply)
Network Pharmacy (30-day supply) or Long-Term-Care Pharmacy (34-day supply)
$5.00
$13.00
Cost-Sharing Tier 3 Preferred Brand
Preferred Network Pharmacy* (30-day supply) or Mail-Order Pharmacy** (30-day supply)
$39.00
Network Pharmacy (30-day supply) or Long-Term-Care Pharmacy (34-day supply)
$44.00
Cost-Sharing Tier 4 Non-Preferred Brand
Preferred Network Pharmacy* (30-day supply) or Mail-Order Pharmacy** (30-day supply)
$90.00
Network Pharmacy (30-day supply) or Long-Term-Care Pharmacy (34-day supply)
$95.00
Cost-Sharing Tier 5 Injectable Drugs
Preferred Network Pharmacy* (30-day supply) or Mail-Order Pharmacy** (30-day supply)
$95.00
Network Pharmacy (30-day supply) or Long-Term-Care Pharmacy (34-day supply)
$95.00
Cost-Sharing Tier 6 Specialty Tier
Preferred Network Pharmacy* (30-day supply) or Mail-Order Pharmacy** (30-day supply)
25%
Network Pharmacy (30-day supply) or Long-Term-Care Pharmacy (34-day supply)
25%
Please refer to our Evidence of Coverage for more information for cost sharing.
* Preferred Network Pharmacy – A network pharmacy that offers covered drugs to members of our plan that may
have lower cost-sharing levels than other network pharmacies.
** Mail-Order Pharmacy – Mail-order service allows you to order a 30–90-day supply of drugs. The drugs available through
our plan’s mail-order service are marked as “mail-order” drugs in our drug list.
Basic KS 14202, V15
6
Effective Date November 1, 2014
Covered Medications by Therapeutic Category
Legend
Generic drugs are shown in lower-case italics (e.g. enalapril)
Brand-name drugs are shown in capital letters (e.g. HUMALOG)
QLL - Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits
each time you get a prescription filled (most often set on a monthly basis).
PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved.
You, your doctor or other network provider will need to request prior authorization before you fill the prescription.
ST - Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat
your medical condition before your plan will cover another drug for that condition.
B/D - Part B vs Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B
drug under your medical benefits, as determined by Medicare.
LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your
Pharmacy Directory or call Customer Service 1-866-755-2776, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving
and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through
September 30.. TTY/TDD users should call 711.
INJ - Injectable: The drug is available in injectable form.
MO - Mail Order: Prescription drugs available through mail order.
Drug Name
Anti - Infectives
abacavir
abacavir sulfate/lamivudine/
zidovudine
ABELCET
acyclovir caps
acyclovir sodium inj 500mg
acyclovir sodium inj 50mg/ml
acyclovir susp
acyclovir tabs
adefovir dipivoxil
ALBENZA
ALINIA
amantadine hcl caps
amantadine hcl tabs
amikacin sulfate
amoxicillin
amoxicillin/clavulanate
potassium
amoxicillin/clavulanate
potassium er
amphotericin b
ampicillin
ampicillin sodium inj 10gm,
125mg, 1gm, 250mg, 2gm
ampicillin sodium inj 500mg
APTIVUS CAPS
Basic KS 14202, V15
Drug Requirements/
Tier Limits
3
6
MO
MO
6
2
5
5
2
2
6
3
4
2
2
5
1
3
B/D PAR MO
MO
B/D PAR MO
B/D PAR
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
3
MO
5
1
5
B/D PAR MO
MO
MO
5
6
MO
7
Drug Requirements/
Tier Limits
Drug Name
APTIVUS ORAL SOLN
atovaquone
ATRIPLA
azithromycin inj 500mg
azithromycin pack
azithromycin susr 100mg/5ml
6
6
6
5
2
2
azithromycin susr 200mg/5ml
2
azithromycin tabs 250mg
2
azithromycin tabs 500mg
2
azithromycin tabs 600mg
2
bactocill in dextrose inj 0; 1gm/
50ml
bactocill in dextrose inj 0; 2gm/
50ml
BARACLUDE
CANCIDAS
CAPASTAT SULFATE
cefaclor
cefaclor er
cefadroxil
5
PAR MO
MO
MO
QLL(15 per 1 days)
MO
QLL(46 per 1 days)
MO
QLL(6 per 1 days)
MO
QLL(3 per 1 days)
MO
QLL(8 per 1 days)
MO
6
6
6
5
2
2
2
PAR MO
B/D PAR MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
cefazolin sodium inj 100gm,
10gm, 1gm; 5%, 20gm,
500mg
cefazolin sodium inj 1gm
cefazolin sodium/dextrose
cefdinir
cefepime inj 1gm, 2gm
cefepime inj 1gm/50ml, 2gm/
100ml
cefotaxime sodium inj 10gm
cefotaxime sodium inj 1gm,
2gm, 500mg
cefoxitin sodium inj 10gm,
2gm
cefoxitin sodium inj 1gm
cefpodoxime proxetil
cefprozil
cefuroxime axetil tabs
cephalexin caps 250mg, 500mg
cephalexin susr
cephalexin tabs
chloramphenicol sodium
succinate
chloroquine phosphate
cidofovir
ciprofloxacin hcl
ciprofloxacin i.v.-in d5w
ciprofloxacin inj 200mg/20ml
ciprofloxacin inj 400mg/40ml
clarithromycin
clarithromycin er
5
clindamycin hcl
clindamycin phosphate addvantage
clindamycin phosphate in d5w
clindamycin phosphate inj
clindamycin phosphate
pharmacy bulk package
clotrimazole troc
colistimethate sodium
COMPLERA
CRIXIVAN
DAPSONE
DARAPRIM
demeclocycline hcl tabs 150mg
2
5
MO
QLL(28 per 1 days)
MO
MO
MO
5
5
5
MO
MO
MO
2
5
6
3
4
3
3
MO
MO
MO
MO
MO
MO
MO
Basic KS 14202, V15
5
5
3
5
5
MO
MO
MO
MO
5
5
MO
5
5
3
3
2
2
2
2
5
MO
MO
MO
MO
MO
MO
MO
2
6
2
5
5
5
2
2
MO
B/D PAR MO
MO
MO
MO
8
Drug Requirements/
Tier Limits
Drug Name
demeclocycline hcl tabs 300mg
dicloxacillin sodium
didanosine
doxy 100
doxycycline hyclate caps
doxycycline hyclate inj
doxycycline hyclate tabs
doxycycline monohydrate caps
100mg, 50mg
doxycycline monohydrate tabs
100mg
EDURANT
EMTRIVA
entecavir
EPIVIR HBV
EPIVIR ORAL SOLN
EPZICOM
erythrocin stearate
erythromycin
erythromycin base
erythromycin ethylsuccinate
ethambutol hcl
famciclovir tabs 125mg,
250mg
famciclovir tabs 500mg
4
2
2
5
2
5
2
2
MO
MO
MO
MO
MO
MO
MO
MO
2
MO
6
4
6
3
4
6
2
2
2
2
2
3
fluconazole
fluconazole in dextrose
fluconazole in nacl
flucytosine
FUZEON
2
5
5
6
6
MO
MO
PAR
MO
MO
MO
MO
MO
MO
MO
MO
QLL(60 per 30 days)
MO
QLL(21 per 7 days)
MO
MO
ganciclovir
gentamicin sulfate inj
gentamicin sulfate pediatric
griseofulvin microsize susp
griseofulvin ultramicrosize
HEPSERA
hydroxychloroquine sulfate
imipenem/cilastatin
INTELENCE TABS
100MG, 200MG
INTELENCE TABS 25MG
INVIRASE
ISENTRESS CHEW
ISENTRESS PACK
5
5
5
2
3
6
2
5
6
3
4
6
6
4
MO
QLL(60 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
ISENTRESS TABS
isoniazid syrp
isoniazid tabs
itraconazole
KALETRA ORAL SOLN
KALETRA TABS
ketoconazole tabs
lamivudine
lamivudine/zidovudine
levofloxacin in d5w
levofloxacin inj
levofloxacin tabs
6
1
1
3
4
6
2
3
6
5
5
2
LEXIVA SUSP
LEXIVA TABS
mefloquine hcl
MEPRON
meropenem
methenamine hippurate
methenamine mandelate
metro iv
metronidazole caps
metronidazole in nacl 0.79%
metronidazole tabs
minocycline hcl
MOXATAG
moxifloxacin hcl
4
6
2
6
5
2
2
5
2
5
2
2
4
2
MYCOBUTIN
NEBUPENT
neomycin sulfate
nevirapine er
nevirapine susp
nevirapine tabs
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
nitrofurantoin monohydrate/
macrocrystals
nitrofurantoin susp
NORVIR
NOXAFIL SUSP
nystatin susp
nystatin tabs
oxacillin sodium
paromomycin sulfate
PASER
3
3
2
4
4
3
4
4
4
MO
MO
MO
MO
QLL(21 per 1 days)
MO
MO
B/D PAR MO
MO
MO
MO
MO
MO
MO
MO
4
4
6
2
2
6
3
4
MO
MO
MO
MO
MO
MO
MO
MO
Basic KS 14202, V15
MO
MO
MO
PAR MO
MO
MO
MO
MO
MO
MO
QLL(14 per 1 days)
MO
MO
MO
MO
PAR MO
MO
MO
MO
MO
9
Drug Requirements/
Tier Limits
Drug Name
penicillin g potassium inj
20000000unit, 5mu
penicillin v potassium
PENTAM 300
pfizerpen-g
piperacillin sodium/tazobactam
sodium inj 2gm; 0.25gm,
36gm; 4.5gm, 3gm; 0.375gm
piperacillin sodium/tazobactam
sodium inj 4gm; 0.5gm
piperacillin/tazobactam
PREZISTA SUSP
PREZISTA TABS 150MG,
75MG
PREZISTA TABS 600MG,
800MG
PRIMAQUINE
PHOSPHATE
pyrazinamide
RESCRIPTOR
RETROVIR IV INFUSION
REYATAZ CAPS 100MG
REYATAZ CAPS 150MG,
200MG, 300MG
ribasphere caps
ribasphere tabs 200mg
ribavirin
rifabutin
rifampin caps
rifampin inj
rimantadine hcl
SELZENTRY
stavudine caps
stavudine oral soln
STREPTOMYCIN
SULFATE
STRIBILD
STROMECTOL
sulfadiazine
sulfamethoxazole/trimethoprim
ds
sulfamethoxazole/trimethoprim
inj
sulfamethoxazole/trimethoprim
susp
5
MO
1
5
5
5
MO
MO
MO
MO
5
5
6
4
MO
MO
MO
6
MO
3
MO
2
4
5
4
6
MO
MO
MO
3
3
3
3
2
5
2
6
3
2
5
MO
MO
MO
MO
MO
6
3
3
1
MO
MO
MO
MO
5
MO
1
MO
MO
MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
sulfamethoxazole/trimethoprim
tabs
SUSTIVA
TAMIFLU CAPS 30MG
1
MO
3
3
TAMIFLU CAPS 45MG
3
TAMIFLU CAPS 75MG
3
TAMIFLU SUSR
3
terbinafine hcl tabs
tetracycline hcl
tinidazole
TIVICAY
TOBI
tobramycin
tobramycin sulfate inj 1.2gm
tobramycin sulfate inj 1.2gm/
30ml, 10mg/ml, 40mg/ml,
80mg/2ml
TRECATOR
trimethoprim
TRIZIVIR
TRUVADA
TYZEKA
valacyclovir hcl
3
2
2
6
6
6
5
5
MO
QLL(84 per 1 days)
MO
QLL(42 per 1 days)
MO
QLL(56 per 365 days)
MO
QLL(360 per 180
days) MO
MO
MO
MO
MO
B/D PAR MO
B/D PAR MO
VALCYTE TABS
vancomycin hcl caps 125mg
6
6
vancomycin hcl caps 250mg
6
VANCOMYCIN HCL IN
DEXTROSE INJ 0; 1GM/
200ML
VANCOMYCIN HCL IN
DEXTROSE INJ 0; 500MG/
100ML, 0; 750MG/150ML
vancomycin hcl inj 1000mg,
10gm, 5000mg, 750mg
vancomycin hcl inj 500mg
VANCOMYCIN HCL INJ
750MG
VICTRELIS
VIDEX PEDIATRIC
VIRACEPT
5
MO
MO
MO
MO
PAR MO
QLL(30 per 1 days)
MO
MO
PAR QLL(40 per 1
days) MO
PAR QLL(80 per 1
days) MO
B/D PAR MO
5
B/D PAR
5
B/D PAR MO
5
5
B/D PAR
B/D PAR MO
6
3
6
PAR MO
MO
MO
Basic KS 14202, V15
4
1
6
6
6
3
MO
10
Drug Requirements/
Tier Limits
Drug Name
VIRAMUNE SUSP
VIRAMUNE XR
VIRAZOLE
VIREAD POWD
VIREAD TABS 150MG,
200MG, 250MG
VIREAD TABS 300MG
voriconazole inj
voriconazole susr
voriconazole tabs
ZIAGEN ORAL SOLN
zidovudine
ZYVOX INJ
ZYVOX SUSR
4
4
6
6
4
MO
MO
PAR MO
MO
MO
6
5
6
6
4
3
6
6
MO
MO
PAR MO
PAR MO
MO
MO
MO
PAR QLL(1800 per 1
days) MO
ZYVOX TABS
6 PAR QLL(28 per 1
days) MO
Antineoplastic & Immunosuppressant Drugs
ABRAXANE
6 B/D PAR MO
5 B/D PAR MO
adrucil
AFINITOR
6 PAR MO
AFINITOR DISPERZ
6 PAR MO
ALIMTA
6 PAR MO
ALKERAN TABS
4 B/D PAR MO
6 PAR MO
amifostine
3 MO
anastrozole
ARRANON
5 B/D PAR
ARZERRA
6 B/D PAR MO
ASTAGRAF XL
4 B/D PAR MO
AVASTIN
6 PAR MO
6 PAR MO
azacitidine
2 B/D PAR MO
azathioprine
BELEODAQ
6 PAR MO
3 MO
bicalutamide
BICNU
5 B/D PAR MO
5 B/D PAR MO
bleomycin sulfate
BOSULIF
6 PAR MO
BUSULFEX
5 B/D PAR
CAPRELSA
6 LA PAR MO
5 B/D PAR MO
carboplatin inj 150mg/15ml,
450mg/45ml, 50mg/5ml,
600mg/60ml
CEENU
4 MO
CELLCEPT
5 B/D PAR
INTRAVENOUS
CELLCEPT SUSR
6 B/D PAR MO
Effective Date November 1, 2014
Drug Name
cisplatin
cladribine
CLOLAR
COMETRIQ
COSMEGEN
cyclophosphamide tabs
cyclosporine caps
cyclosporine inj
cyclosporine modified caps
100mg, 25mg
cyclosporine modified caps
50mg
cyclosporine modified oral soln
CYRAMZA
cytarabine aqueous
cytarabine inj 100mg/ml,
20mg/ml
dacarbazine
DACOGEN
daunorubicin hcl
decitabine
dexrazoxane inj 250mg
dexrazoxane inj 500mg
DOCEFREZ
docetaxel inj 160mg/16ml,
20mg/0.5ml, 20mg/2ml,
80mg/2ml, 80mg/8ml
docetaxel inj 20mg/ml, 80mg/
4ml
DOXIL
doxorubicin hcl inj 10mg,
50mg
doxorubicin hcl inj 2mg/ml
ELITEK
ELLENCE
ELOXATIN INJ 100MG/
20ML, 50MG/10ML
ELSPAR
EMCYT
epirubicin hcl inj 200mg/
100ml, 50mg
epirubicin hcl inj 50mg/25ml
ERBITUX
ERIVEDGE
ERWINAZE
ETOPOPHOS
Basic KS 14202, V15
Drug Requirements/
Tier Limits
5
6
6
6
6
2
3
5
2
B/D PAR MO
B/D PAR MO
B/D PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
3
B/D PAR MO
3
6
5
5
B/D PAR MO
PAR
B/D PAR MO
B/D PAR MO
5
6
5
6
6
6
6
6
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR
B/D PAR
6
B/D PAR MO
5
5
B/D PAR MO
B/D PAR
5
6
5
6
B/D PAR MO
5
6
5
B/D PAR MO
MO
B/D PAR
5
6
6
6
5
B/D PAR MO
PAR MO
PAR MO
B/D PAR
B/D PAR MO
Drug Requirements/
Tier Limits
Drug Name
etoposide inj
exemestane
FARESTON
FASLODEX
FIRMAGON INJ 120MG
FIRMAGON INJ 80MG
fludarabine phosphate inj
50mg
fludarabine phosphate inj
50mg/2ml
fluorouracil inj
flutamide
FOLOTYN
FUSILEV
GAZYVA
gemcitabine
gemcitabine hcl inj 1gm,
200mg
gemcitabine hcl inj 2gm
gengraf
GILOTRIF
GLEEVEC
HALAVEN
hecoria caps 0.5mg, 1mg
hecoria caps 5mg
HERCEPTIN
HEXALEN
hydroxyurea
ICLUSIG
IDAMYCIN PFS
idarubicin hcl
IFEX
ifosfamide inj 1gm
ifosfamide inj 1gm/20ml, 3gm,
3gm/60ml
IMBRUVICA
INLYTA
irinotecan inj 100mg/5ml,
40mg/2ml
irinotecan inj 500mg/25ml
ISTODAX
IXEMPRA KIT
JAKAFI
JEVTANA
KADCYLA
letrozole
B/D PAR MO
B/D PAR MO
11
5
3
4
6
6
5
5
B/D PAR MO
MO
MO
PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
5
B/D PAR
5
3
6
5
6
6
6
B/D PAR MO
MO
B/D PAR MO
B/D PAR MO
PAR MO
B/D PAR
B/D PAR MO
6
2
6
6
6
2
6
6
6
2
6
6
6
5
5
5
B/D PAR
B/D PAR MO
PAR MO
PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
PAR MO
MO
MO
PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR MO
B/D PAR
6
6
5
PAR MO
PAR MO
B/D PAR MO
5
6
6
6
6
6
3
B/D PAR
PAR MO
B/D PAR MO
PAR MO
B/D PAR MO
PAR MO
MO
Effective Date November 1, 2014
Drug Name
leucovorin calcium inj 100mg,
200mg, 350mg, 50mg
leucovorin calcium inj 500mg
leucovorin calcium tabs
LEUKERAN
leuprolide acetate
LOMUSTINE
LUPRON DEPOT INJ
3.75MG, 7.5MG
LUPRON DEPOT-PED INJ
7.5MG
LYSODREN
MATULANE
megestrol acetate
MEKINIST
melphalan hydrochloride
mercaptopurine
mesna
MESNEX INJ
MESNEX TABS
methotrexate
methotrexate sodium inj 1gm
methotrexate sodium inj 25mg/
ml, 50mg/2ml
mitomycin
mitoxantrone hcl
MUSTARGEN
mycophenolate mofetil
NEXAVAR
NILANDRON
NIPENT
NULOJIX
octreotide acetate inj 1000mcg/
ml
octreotide acetate inj 100mcg/
ml, 200mcg/ml, 500mcg/ml,
50mcg/ml
ONCASPAR
ONTAK
oxaliplatin inj 100mg, 100mg/
20ml, 50mg/10ml
oxaliplatin inj 50mg
paclitaxel
PERJETA
POMALYST
PROGRAF INJ
Basic KS 14202, V15
Drug Requirements/
Tier Limits
5
MO
5
2
3
5
4
6
MO
MO
PAR MO
MO
PAR MO
6
PAR MO
3
6
3
6
5
2
5
5
4
2
5
5
MO
MO
PAR MO
PAR MO
B/D PAR
MO
MO
5
5
5
3
6
4
6
6
6
B/D PAR MO
MO
B/D PAR MO
B/D PAR MO
LA PAR MO
MO
B/D PAR MO
B/D PAR MO
PAR MO
5
PAR MO
6
6
6
B/D PAR MO
B/D PAR
B/D PAR MO
6
5
6
6
5
B/D PAR
B/D PAR MO
PAR MO
PAR MO
B/D PAR MO
MO
MO
MO
12
Drug Requirements/
Tier Limits
Drug Name
RAPAMUNE ORAL SOLN
RAPAMUNE TABS 0.5MG,
1MG
RAPAMUNE TABS 2MG
REVLIMID CAPS 10MG
3
3
B/D PAR MO
B/D PAR MO
6
6
REVLIMID CAPS 15MG,
20MG, 25MG
REVLIMID CAPS 2.5MG
REVLIMID CAPS 5MG
6
RITUXAN
SIMULECT INJ 10MG
SIMULECT INJ 20MG
sirolimus
SOLTAMOX
SPRYCEL
STIVARGA
SUTENT
SYNRIBO
TABLOID
tacrolimus caps 0.5mg, 1mg
tacrolimus caps 5mg
TAFINLAR
tamoxifen citrate
TARCEVA
TARGRETIN CAPS
TARGRETIN GEL
TASIGNA
TAXOTERE
THALOMID
toposar
topotecan hcl inj 4mg
topotecan hcl inj 4mg/4ml
TORISEL
TREANDA
tretinoin caps
TRISENOX
TYKERB
VECTIBIX
VELCADE
VIDAZA
vinblastine sulfate inj 1mg/ml
vincasar pfs
vincristine sulfate
vinorelbine tartrate
6
6
6
3
4
6
6
6
6
4
3
6
6
2
6
6
6
6
6
6
5
6
6
6
6
6
6
6
6
6
6
5
5
5
5
B/D PAR MO
LA PAR QLL(60 per
30 days) MO
LA PAR QLL(30 per
30 days) MO
LA PAR MO
LA PAR QLL(150 per
30 days) MO
PAR MO
B/D PAR
B/D PAR MO
B/D PAR MO
MO
PAR MO
PAR MO
PAR MO
MO
MO
B/D PAR MO
B/D PAR MO
PAR MO
MO
PAR MO
PAR MO
MO
PAR MO
B/D PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR MO
MO
B/D PAR MO
LA PAR MO
PAR MO
PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
6
6
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
VOTRIENT
XALKORI
XGEVA
6
6
6
XTANDI
YERVOY
ZALTRAP
ZANOSAR
ZELBORAF
ZOLINZA
ZORTRESS TABS 0.25MG
ZORTRESS TABS 0.5MG,
0.75MG
ZYDELIG
6
6
6
5
6
6
4
6
PAR MO
PAR MO
PAR QLL(1.7 per 28
days) MO
PAR MO
PAR MO
PAR MO
B/D PAR MO
PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
PAR QLL(60 per 30
days) MO
ZYKADIA
6 PAR MO
ZYTIGA
6 PAR MO
Autonomic & Cns Drugs, Neurology & Psych
ABILIFY DISCMELT TBDP 6 QLL(90 per 30 days)
10MG
MO
ABILIFY DISCMELT TBDP 6 QLL(60 per 30 days)
15MG
MO
ABILIFY INJ
5 MO
ABILIFY MAINTENA
6 MO
ABILIFY ORAL SOLN
4 QLL(900 per 30 days)
MO
ABILIFY TABS 10MG
4 QLL(90 per 30 days)
MO
ABILIFY TABS 15MG
4 QLL(60 per 30 days)
MO
ABILIFY TABS 20MG
6 QLL(60 per 30 days)
MO
ABILIFY TABS 2MG
4 QLL(450 per 30 days)
MO
ABILIFY TABS 30MG
6 QLL(30 per 30 days)
MO
ABILIFY TABS 5MG
4 QLL(180 per 30 days)
MO
ABSTRAL SUBL 100MCG 4 PAR QLL(120 per 30
days) MO
ABSTRAL SUBL 200MCG, 6 PAR QLL(120 per 30
300MCG, 400MCG,
days) MO
600MCG, 800MCG
2 QLL(390 per 30 days)
acetaminophen/codeine #2
MO
2 QLL(390 per 30 days)
acetaminophen/codeine #3
MO
Basic KS 14202, V15
6
13
Drug Requirements/
Tier Limits
Drug Name
acetaminophen/codeine #4
2
acetaminophen/codeine oral
soln
acetaminophen/codeine
phosphate
acetaminophen/codeine tabs
2
ACTIQ
6
ADASUVE
alprazolam tabs
4
3
amitriptyline hcl
amoxapine
amphetamine/
dextroamphetamine tabs
1.25mg; 1.25mg; 1.25mg;
1.25mg, 1.875mg; 1.875mg;
1.875mg; 1.875mg, 2.5mg;
2.5mg; 2.5mg; 2.5mg,
3.125mg; 3.125mg; 3.125mg;
3.125mg, 3.75mg; 3.75mg;
3.75mg; 3.75mg, 5mg; 5mg;
5mg; 5mg
amphetamine/
dextroamphetamine tabs
7.5mg; 7.5mg; 7.5mg; 7.5mg
APOKYN
APTIOM
AZILECT
baclofen
BANZEL SUSP
3
2
3
BANZEL TABS 200MG
4
BANZEL TABS 400MG
4
benztropine mesylate tabs
BRINTELLIX TABS 10MG
3
4
BRINTELLIX TABS 20MG
4
BRINTELLIX TABS 5MG
4
bromocriptine mesylate
budeprion sr tb12 150mg
2
2
2
2
QLL(390 per 30 days)
MO
QLL(4500 per 30
days)
QLL(390 per 30 days)
MO
QLL(390 per 30 days)
MO
PAR QLL(120 per 30
days) MO
QLL(90 per 30 days)
MO
PAR MO
MO
QLL(90 per 30 days)
MO
3
QLL(60 per 30 days)
MO
6
4
3
2
4
LA PAR MO
ST MO
MO
MO
QLL(2400 per 30
days) MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
MO
QLL(60 per 30 days)
ST MO
QLL(30 per 30 days)
ST MO
QLL(120 per 30 days)
ST MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
buprenorphine hcl/naloxone hcl
subl 2mg; 0.5mg
buprenorphine hcl/naloxone hcl
subl 8mg; 2mg
bupropion hcl er tb12 100mg
3
bupropion hcl er tb12 150mg
bupropion hcl er tb12 200mg
2
2
bupropion hcl sr tb12 100mg
3
2
2
bupropion hcl sr tb12 150mg
bupropion hcl sr tb12 200mg
2
2
bupropion hcl tabs 100mg
2
bupropion hcl tabs 75mg
2
bupropion hcl xl tb24 150mg
2
bupropion hcl xl tb24 300mg
2
buspirone hcl
carbamazepine
carbamazepine er
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
CELONTIN
chlorpromazine hcl inj
chlorpromazine hcl tabs
citalopram hydrobromide oral
soln
citalopram hydrobromide tabs
10mg
citalopram hydrobromide tabs
20mg
citalopram hydrobromide tabs
40mg
clomipramine hcl
clonazepam odt tbdp 0.125mg
2
2
2
2
2
2
4
5
2
2
clonazepam odt tbdp 0.25mg
3
clonazepam odt tbdp 0.5mg
3
Basic KS 14202, V15
2
2
2
4
3
PAR QLL(360 per 30
days) MO
PAR QLL(90 per 30
days) MO
QLL(120 per 30 days)
MO
MO
QLL(60 per 30 days)
MO
QLL(120 per 30 days)
MO
MO
QLL(60 per 30 days)
MO
QLL(135 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(600 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
QLL(4800 per 30
days) MO
QLL(2400 per 30
days) MO
QLL(1200 per 30
days) MO
14
Drug Requirements/
Tier Limits
Drug Name
clonazepam odt tbdp 1mg
3
clonazepam odt tbdp 2mg
3
clonazepam tabs 0.5mg
3
clonazepam tabs 1mg
3
clonazepam tabs 2mg
3
clorazepate dipotassium
3
clozapine odt tbdp 100mg
clozapine odt tbdp 12.5mg
4
4
clozapine odt tbdp 25mg
4
clozapine tabs 100mg
clozapine tabs 200mg
clozapine tabs 25mg
2
2
2
clozapine tabs 50mg
COPAXONE
cyclobenzaprine hcl tabs 10mg,
5mg
CYMBALTA CPEP 20MG
2
6
4
CYMBALTA CPEP 30MG
4
CYMBALTA CPEP 60MG
4
desipramine hcl
DESVENLAFAXINE ER
TB24 100MG
DESVENLAFAXINE ER
TB24 50MG
dextroamphetamine sulfate tabs
10mg
dextroamphetamine sulfate tabs
5mg
diazepam gel
2
4
diazepam intensol
3
diazepam oral soln
3
4
4
3
3
3
QLL(600 per 30 days)
MO
QLL(300 per 30 days)
MO
QLL(1200 per 30
days) MO
QLL(600 per 30 days)
MO
QLL(300 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(270 per 30 days)
QLL(2160 per 30
days)
QLL(1080 per 30
days)
QLL(270 per 30 days)
QLL(135 per 30 days)
QLL(1080 per 30
days)
QLL(540 per 30 days)
PAR MO
PAR MO
QLL(180 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
QLL(120 per 30 days)
MO
QLL(240 per 30 days)
MO
PAR QLL(180 per 30
days) MO
PAR QLL(90 per 30
days) MO
QLL(2 per 1 days)
MO
QLL(240 per 30 days)
MO
QLL(1200 per 30
days) MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
diazepam tabs 10mg
3
diazepam tabs 2mg
3
diazepam tabs 5mg
3
diclofenac potassium
diclofenac sodium dr
diclofenac sodium er
diflunisal
dihydroergotamine mesylate inj
DILANTIN CAPS 30MG
DILANTIN INFATABS
divalproex sodium
divalproex sodium dr
divalproex sodium er
donepezil hcl tabs 10mg, 5mg
2
2
2
2
5
3
3
2
2
2
2
donepezil hcl tbdp
2
doxepin hcl
duloxetine hcl cpep 20mg
3
2
duloxetine hcl cpep 30mg
2
duloxetine hcl cpep 60mg
2
duramorph inj 0.5mg/ml
duramorph inj 1mg/ml
EMSAM
5
5
4
endocet tabs 325mg; 10mg,
325mg; 5mg, 325mg; 7.5mg
endodan
2
entacapone
epitol
EQUETRO CP12 100MG
2
1
4
EQUETRO CP12 200MG
4
EQUETRO CP12 300MG
4
escitalopram oxalate oral soln
2
escitalopram oxalate tabs 10mg
2
Basic KS 14202, V15
2
QLL(120 per 30 days)
MO
QLL(600 per 30 days)
MO
QLL(240 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
PAR MO
QLL(180 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
B/D PAR MO
B/D PAR
QLL(30 per 30 days)
MO
QLL(360 per 30 days)
MO
QLL(360 per 30 days)
MO
MO
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(600 per 30 days)
MO
QLL(60 per 30 days)
MO
15
Drug Requirements/
Tier Limits
Drug Name
escitalopram oxalate tabs 20mg
2
escitalopram oxalate tabs 5mg
2
ethosuximide
etodolac
FANAPT TABS 10MG
2
2
4
FANAPT TABS 12MG
4
FANAPT TABS 1MG
4
FANAPT TABS 2MG
4
FANAPT TABS 4MG
4
FANAPT TABS 6MG
4
FANAPT TABS 8MG
4
FANAPT TITRATION
PACK
FAZACLO TBDP 100MG
FAZACLO TBDP 12.5MG
4
FAZACLO TBDP 150MG
FAZACLO TBDP 200MG
FAZACLO TBDP 25MG
4
4
4
felbamate susp
felbamate tabs
fentanyl citrate oral
transmucosal
fentanyl patches
6
3
6
FENTORA
6
FETZIMA CP24 120MG,
80MG
FETZIMA CP24 20MG
4
FETZIMA CP24 40MG
4
FETZIMA TITRATION
PACK
fluoxetine caps 10mg
4
4
4
4
4
2
QLL(30 per 30 days)
MO
QLL(120 per 30 days)
MO
MO
MO
QLL(72 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(720 per 30 days)
MO
QLL(360 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(8 per 30 days)
QLL(270 per 30 days)
QLL(2160 per 30
days)
QLL(180 per 30 days)
QLL(135 per 30 days)
QLL(1080 per 30
days)
MO
MO
PAR QLL(120 per 30
days) MO
QLL(15 per 30 days)
ST MO
PAR QLL(120 per 30
days) MO
PAR QLL(30 per 30
days) MO
PAR QLL(180 per 30
days) MO
PAR QLL(90 per 30
days) MO
PAR QLL(28 per 365
days) MO
QLL(240 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
fluoxetine caps 20mg
2
fluoxetine hcl caps 10mg
2
fluoxetine hcl caps 20mg
2
fluoxetine hcl caps 40mg
2
fluoxetine hcl oral soln
2
fluoxetine hcl tabs 10mg
2
fluoxetine hcl tabs 20mg
2
FLUOXETINE HCL TABS
60MG
fluphenazine decanoate
fluphenazine hcl conc
fluphenazine hcl elix
fluphenazine hcl inj
fluphenazine hcl tabs
flurbiprofen
fluvoxamine maleate tabs
100mg
fluvoxamine maleate tabs 25mg
4
fluvoxamine maleate tabs 50mg
2
FYCOMPA TABS 10MG,
12MG
FYCOMPA TABS 2MG
4
FYCOMPA TABS 4MG
4
FYCOMPA TABS 6MG
4
FYCOMPA TABS 8MG
4
gabapentin caps 100mg
2
gabapentin caps 300mg
2
gabapentin caps 400mg
2
gabapentin oral soln
2
Basic KS 14202, V15
5
2
2
5
2
2
2
2
4
QLL(120 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(600 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
MO
QLL(90 per 30 days)
MO
QLL(360 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(1080 per 30
days) MO
QLL(360 per 30 days)
MO
QLL(270 per 30 days)
MO
QLL(2160 per 30
days) MO
16
Drug Requirements/
Tier Limits
Drug Name
gabapentin tabs 600mg
2
gabapentin tabs 800mg
2
GABITRIL
galantamine hydrobromide
cp24
galantamine hydrobromide oral
soln
galantamine hydrobromide tabs
4
2
GEODON INJ
GILENYA
5
6
guanidine hcl
haloperidol
haloperidol decanoate
haloperidol lactate
hydrocodone/acetaminophen
oral soln 325mg/15ml; 10mg/
15ml
hydrocodone/acetaminophen
oral soln 325mg/15ml; 7.5mg/
15ml
hydrocodone/acetaminophen
tabs 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg
hydrocodone/ibuprofen tabs
7.5mg; 200mg
hydromorphone hcl inj 1mg/ml
hydromorphone hcl inj 2mg/ml,
4mg/ml
hydromorphone hcl tabs 2mg
2
2
5
5
2
hydromorphone hcl tabs 4mg
3
hydromorphone hcl tabs 8mg
3
ibuprofen susp
ibuprofen tabs 400mg, 600mg,
800mg
imipramine hcl
INTUNIV
1
1
2
2
QLL(180 per 30 days)
MO
QLL(135 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
PAR QLL(30 per 30
days) MO
MO
MO
MO
MO
QLL(2700 per 30
days) MO
2
QLL(3600 per 30
days) MO
2
QLL(360 per 30 days)
MO
2
QLL(480 per 30 days)
MO
5
5
3
2
4
MO
QLL(960 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
MO
MO
MO
QLL(30 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
INVEGA SUSTENNA INJ
117MG/0.75ML, 156MG/
ML, 234MG/1.5ML
INVEGA SUSTENNA INJ
39MG/0.25ML, 78MG/
0.5ML
INVEGA TB24 1.5MG
6
INVEGA TB24 3MG
4
INVEGA TB24 6MG
4
INVEGA TB24 9MG
6
KHEDEZLA TB24 100MG
4
KHEDEZLA TB24 50MG
4
lamotrigine
LATUDA TABS 120MG
2
6
LATUDA TABS 20MG
4
LATUDA TABS 40MG
4
LATUDA TABS 60MG
5
4
4
LATUDA TABS 80MG
4
LAZANDA
6
levetiracetam er tb24 500mg
2
levetiracetam er tb24 750mg
2
levetiracetam inj 500mg/5ml
levetiracetam oral soln
levetiracetam tabs
lithium carbonate
lithium carbonate er
lithium citrate
lorazepam tabs
5
2
2
1
1
2
3
loxapine
loxapine succinate
LYRICA CAPS 100MG
2
2
4
Basic KS 14202, V15
QLL(2 per 28 days)
MO
QLL(2 per 28 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(40 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(240 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(75 per 30 days)
MO
QLL(60 per 30 days)
MO
LA PAR QLL(30 per
30 days) MO
QLL(180 per 30 days)
MO
QLL(120 per 30 days)
MO
MO
MO
MO
MO
MO
MO
QLL(90 per 30 days)
MO
MO
MO
PAR QLL(180 per 30
days) MO
17
Drug Requirements/
Tier Limits
Drug Name
LYRICA CAPS 150MG
4
LYRICA CAPS 200MG
4
LYRICA CAPS 225MG,
300MG
LYRICA CAPS 25MG
4
LYRICA CAPS 50MG
4
LYRICA CAPS 75MG
4
LYRICA ORAL SOLN
4
maprotiline hcl tabs 25mg
2
maprotiline hcl tabs 50mg
2
maprotiline hcl tabs 75mg
MARPLAN
meloxicam tabs
2
3
2
methadone hcl conc
3
methadone hcl intensol
3
methadone hcl oral soln 10mg/
5ml
methadone hcl oral soln 5mg/
5ml
methadone hcl tabs 10mg
3
methadone hcl tabs 5mg
3
methadone hcl tbso
methadose conc
3
3
methadose sugar-free
3
methadose tbso
methylphenidate hcl
3
3
mirtazapine odt tbdp 15mg
2
mirtazapine odt tbdp 30mg
2
4
3
3
PAR QLL(120 per 30
days) MO
PAR QLL(90 per 30
days) MO
PAR QLL(60 per 30
days) MO
PAR QLL(720 per 30
days) MO
PAR QLL(360 per 30
days) MO
PAR QLL(240 per 30
days) MO
PAR QLL(900 per 30
days) MO
QLL(270 per 30 days)
MO
QLL(135 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(360 per 30 days)
MO
QLL(360 per 30 days)
MO
QLL(1800 per 30
days) MO
QLL(3600 per 30
days) MO
QLL(360 per 30 days)
MO
QLL(720 per 30 days)
MO
MO
QLL(360 per 30 days)
MO
QLL(360 per 30 days)
MO
MO
PAR QLL(90 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
mirtazapine odt tbdp 45mg
2
mirtazapine tabs 15mg
2
mirtazapine tabs 30mg
2
mirtazapine tabs 45mg
2
mirtazapine tabs 7.5mg
2
mirtazapine tbdp
2
modafinil tabs 100mg
3
modafinil tabs 200mg
6
morphine sulfate er tbcr
100mg, 200mg
morphine sulfate er tbcr 15mg,
30mg, 60mg
morphine sulfate inj 0.5mg/ml
morphine sulfate inj 10mg/ml,
150mg/30ml, 15mg/ml, 1mg/
ml, 50mg/ml
morphine sulfate inj 1mg/ml
morphine sulfate inj 25mg/ml,
2mg/ml, 4mg/ml
MORPHINE SULFATE INJ
8MG/ML
morphine sulfate oral soln
10mg/5ml
morphine sulfate oral soln
20mg/5ml
morphine sulfate oral soln
20mg/ml
morphine sulfate supp
morphine sulfate tabs 15mg
3
morphine sulfate tabs 30mg
3
nalbuphine hcl
naloxone hcl inj 0.4mg/ml
naloxone hcl inj 1mg/ml
naltrexone hcl
NAMENDA ORAL SOLN
5
5
5
2
3
Basic KS 14202, V15
3
5
5
5
5
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(90 per 30 days)
MO
PAR QLL(30 per 30
days) MO
PAR QLL(60 per 30
days) MO
QLL(180 per 30 days)
MO
QLL(120 per 30 days)
MO
B/D PAR
MO
B/D PAR MO
5
3
3
3
3
3
QLL(3600 per 30
days) MO
QLL(1800 per 30
days) MO
QLL(360 per 30 days)
MO
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
MO
MO
MO
QLL(300 per 30 days)
MO
18
Drug Requirements/
Tier Limits
Drug Name
NAMENDA TABS 10MG
3
NAMENDA TABS 5MG
3
NAMENDA TITRATION
PAK
NAMENDA XR
3
NAMENDA XR
TITRATION PACK
naproxen
naproxen dr
naproxen sodium tabs 275mg,
550mg
naratriptan hcl
3
nefazodone hcl tabs 100mg
2
nefazodone hcl tabs 150mg
2
nefazodone hcl tabs 200mg
2
nefazodone hcl tabs 250mg
2
nefazodone hcl tabs 50mg
2
nortriptyline hcl
NUEDEXTA
olanzapine odt tbdp 10mg
2
3
3
olanzapine odt tbdp 15mg
3
olanzapine odt tbdp 20mg
3
olanzapine odt tbdp 5mg
3
olanzapine tabs 10mg
3
olanzapine tabs 15mg
3
olanzapine tabs 2.5mg
3
olanzapine tabs 20mg
4
olanzapine tabs 5mg
3
3
2
2
2
3
QLL(60 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
PAR QLL(30 per 30
days) MO
PAR QLL(28 per 365
days) MO
MO
MO
MO
QLL(9 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(72 per 30 days)
MO
QLL(360 per 30 days)
MO
MO
MO
QLL(60 per 30 days)
MO
QLL(40 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(40 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(120 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
olanzapine tabs 7.5mg
3
ONFI SUSP
4
ONFI TABS 10MG
4
ONFI TABS 20MG
4
ORAP
oxazepam
3
2
oxcarbazepine
OXTELLAR XR TB24
150MG
OXTELLAR XR TB24
300MG
OXTELLAR XR TB24
600MG
oxycodone hcl caps
2
4
4
4
3
oxycodone hcl oral soln
oxycodone hcl tabs 10mg
3
3
oxycodone hcl tabs 15mg
3
oxycodone hcl tabs 20mg
3
oxycodone hcl tabs 30mg
3
oxycodone hcl tabs 5mg
3
oxycodone/acetaminophen
2
oxycodone/aspirin
2
oxycodone/ibuprofen
2
paroxetine hcl er tb24 12.5mg
2
paroxetine hcl er tb24 25mg
2
paroxetine hcl er tb24 37.5mg
2
paroxetine hcl tabs 10mg
2
paroxetine hcl tabs 20mg
2
Basic KS 14202, V15
QLL(80 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
QLL(120 per 30 days)
MO
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(1620 per 30
days) MO
MO
QLL(810 per 30 days)
MO
QLL(540 per 30 days)
MO
QLL(390 per 30 days)
MO
QLL(270 per 30 days)
MO
QLL(1620 per 30
days) MO
QLL(360 per 30 days)
MO
QLL(360 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(90 per 30 days)
MO
19
Drug Requirements/
Tier Limits
Drug Name
paroxetine hcl tabs 30mg
2
paroxetine hcl tabs 40mg
2
PAXIL SUSP
4
PEGANONE
perphenazine
perphenazine/amitriptyline
phenelzine sulfate
phenobarbital elix
4
2
3
3
3
phenobarbital tabs 100mg
phenobarbital tabs 15mg
3
3
phenobarbital tabs 16.2mg
3
phenobarbital tabs 30mg
3
phenobarbital tabs 32.4mg
3
phenobarbital tabs 60mg
3
phenobarbital tabs 64.8mg
3
phenobarbital tabs 97.2mg
3
phenytoin chew
phenytoin infatabs
phenytoin sodium
phenytoin sodium extended
phenytoin susp
POTIGA TABS 200MG,
300MG, 400MG
POTIGA TABS 50MG
3
3
5
2
2
4
pramipexole dihydrochloride
primidone
PRISTIQ TB24 100MG
2
2
4
PRISTIQ TB24 50MG
4
protriptyline hcl
pyridostigmine bromide
quetiapine fumarate tabs
100mg
2
2
3
4
QLL(60 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(1200 per 30
days) MO
MO
MO
MO
MO
QLL(3000 per 30
days) MO
QLL(120 per 30 days)
QLL(800 per 30 days)
MO
QLL(741 per 30 days)
MO
QLL(400 per 30 days)
MO
QLL(370 per 30 days)
MO
QLL(200 per 30 days)
MO
QLL(185 per 30 days)
MO
QLL(123 per 30 days)
MO
MO
MO
MO
MO
QLL(90 per 30 days)
MO
QLL(270 per 30 days)
MO
MO
MO
PAR QLL(120 per 30
days) MO
PAR QLL(240 per 30
days) MO
MO
MO
QLL(240 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
quetiapine fumarate tabs
200mg
quetiapine fumarate tabs 25mg
3
quetiapine fumarate tabs
300mg
quetiapine fumarate tabs
400mg
quetiapine fumarate tabs 50mg
3
RISPERDAL CONSTA INJ
12.5MG, 25MG
RISPERDAL CONSTA INJ
37.5MG
RISPERDAL CONSTA INJ
50MG
risperidone m-tab tbdp 0.5mg
5
risperidone m-tab tbdp 1mg
3
risperidone m-tab tbdp 2mg
3
3
3
6
6
3
3
risperidone m-tab tbdp 3mg
3
risperidone m-tab tbdp 4mg
3
risperidone odt tbdp 0.25mg
3
risperidone odt tbdp 0.5mg
3
risperidone odt tbdp 1mg
3
risperidone odt tbdp 2mg
3
risperidone odt tbdp 3mg
3
risperidone odt tbdp 4mg
3
risperidone oral soln
2
risperidone tabs 0.25mg
2
risperidone tabs 0.5mg
2
risperidone tabs 1mg
2
Basic KS 14202, V15
QLL(120 per 30 days)
MO
QLL(960 per 30 days)
MO
QLL(80 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(2 per 28 days)
MO
QLL(2 per 28 days)
MO
MO
QLL(960 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(160 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(1920 per 30
days) MO
QLL(960 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(160 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(1920 per 30
days) MO
QLL(960 per 30 days)
MO
QLL(480 per 30 days)
MO
20
Drug Requirements/
Tier Limits
Drug Name
risperidone tabs 2mg
2
risperidone tabs 3mg
2
risperidone tabs 4mg
2
rivastigmine tartrate
2
ropinirole hcl
roxicet tabs
2
2
ROZEREM
4
SABRIL PACK
4
SABRIL TABS
6
SAPHRIS SUBL 10MG
4
SAPHRIS SUBL 5MG
4
selegiline hcl
SEROQUEL XR TB24
150MG
SEROQUEL XR TB24
200MG
SEROQUEL XR TB24
300MG
SEROQUEL XR TB24
400MG
SEROQUEL XR TB24
50MG
sertraline hcl conc
2
4
sertraline hcl tabs 100mg
2
sertraline hcl tabs 25mg
2
sertraline hcl tabs 50mg
2
STRATTERA CAPS
100MG, 60MG, 80MG
STRATTERA CAPS 10MG,
18MG, 25MG, 40MG
SUBOXONE FILM 12MG;
3MG
4
4
4
4
4
2
4
4
QLL(240 per 30 days)
MO
QLL(160 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
QLL(360 per 30 days)
MO
QLL(30 per 30 days)
MO
LA QLL(180 per 30
days) MO
LA QLL(180 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(120 per 30 days)
MO
MO
QLL(160 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(80 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(300 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
PAR QLL(30 per 30
days) MO
PAR QLL(60 per 30
days) MO
PAR QLL(60 per 30
days) MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
SUBOXONE FILM 2MG;
0.5MG
SUBOXONE FILM 4MG;
1MG
SUBOXONE FILM 8MG;
2MG
SUBSYS
4
sulindac
sumatriptan nasal soln 20mg/
act
sumatriptan nasal soln 5mg/act
2
3
4
4
6
3
sumatriptan succinate inj
5
sumatriptan succinate refill
5
sumatriptan succinate tabs
SURMONTIL
thioridazine hcl
thiothixene
tiagabine hydrochloride
tizanidine hcl tabs
topiramate cpsp
topiramate tabs 100mg
topiramate tabs 200mg
topiramate tabs 25mg
topiramate tabs 50mg
tramadol hcl
3
4
3
2
3
2
2
2
2
2
2
2
tramadol hydrochloride/
acetaminophen
tranylcypromine sulfate
trazodone hcl
trifluoperazine hcl
TYSABRI
valproate sodium
valproic acid
venlafaxine hcl er cp24 150mg
2
venlafaxine hcl er cp24 37.5mg
2
Basic KS 14202, V15
3
1
2
6
5
2
2
PAR QLL(360 per 30
days) MO
PAR QLL(180 per 30
days) MO
PAR QLL(90 per 30
days) MO
LA PAR QLL(360 per
30 days) MO
MO
QLL(8 per 30 days)
MO
QLL(16 per 30 days)
MO
QLL(4 per 30 days)
MO
QLL(4 per 30 days)
MO
QLL(9 per 30 days)
MO
MO
PAR MO
MO
MO
MO
PAR MO
PAR QLL(480 per 30
days) MO
PAR QLL(240 per 30
days) MO
PAR QLL(1920 per
30 days) MO
PAR QLL(960 per 30
days) MO
QLL(240 per 30 days)
MO
QLL(300 per 30 days)
MO
MO
MO
MO
LA PAR MO
MO
MO
QLL(60 per 30 days)
MO
QLL(180 per 30 days)
MO
21
Drug Requirements/
Tier Limits
Drug Name
venlafaxine hcl er cp24 75mg
2
venlafaxine hcl er tb24 150mg
2
VENLAFAXINE HCL ER
TB24 225MG
venlafaxine hcl er tb24 37.5mg
3
venlafaxine hcl er tb24 75mg
2
venlafaxine hcl tabs 100mg
2
venlafaxine hcl tabs 25mg
2
venlafaxine hcl tabs 37.5mg
2
venlafaxine hcl tabs 50mg
2
venlafaxine hcl tabs 75mg
2
VERSACLOZ
6
VIIBRYD KIT
4
VIIBRYD TABS 10MG
4
VIIBRYD TABS 20MG
4
VIIBRYD TABS 40MG
4
VIMPAT INJ
5
VIMPAT ORAL SOLN
4
VIMPAT TABS 100MG
4
VIMPAT TABS 150MG
4
VIMPAT TABS 200MG
4
VIMPAT TABS 50MG
4
VOLTAREN GEL
3
XENAZINE
XYREM
6
6
2
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(113 per 30 days)
MO
QLL(450 per 30 days)
MO
QLL(300 per 30 days)
MO
QLL(225 per 30 days)
MO
QLL(150 per 30 days)
MO
LA QLL(600 per 30
days)
QLL(30 per 30 days)
ST MO
QLL(120 per 30 days)
ST MO
QLL(60 per 30 days)
ST MO
QLL(30 per 30 days)
ST MO
QLL(1200 per 30
days)
QLL(1200 per 30
days) MO
QLL(120 per 30 days)
MO
QLL(80 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(1000 per 30
days) MO
LA PAR MO
LA PAR QLL(540 per
30 days) MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
QLL(60 per 30 days)
MO
3 QLL(30 per 30 days)
zaleplon caps 5mg
MO
3 PAR QLL(180 per 30
zenzedi tabs 10mg
days) MO
3 PAR QLL(90 per 30
zenzedi tabs 5mg
days) MO
3 QLL(240 per 30 days)
ziprasidone hcl caps 20mg
MO
3 QLL(120 per 30 days)
ziprasidone hcl caps 40mg
MO
3 QLL(60 per 30 days)
ziprasidone hcl caps 60mg,
MO
80mg
3 QLL(30 per 30 days)
zolpidem tartrate
MO
2 MO
zonisamide
ZYPREXA INJ
5 QLL(60 per 30 days)
MO
Cardiovascular, Hypertension & Lipids
2 MO
acebutolol hcl
2 MO
afeditab cr
AGGRENOX
3 QLL(60 per 30 days)
MO
2 MO
amiloride hcl
amiloride/hydrochlorothiazide 1 MO
2 MO
aminocaproic acid syrp
2 MO
amiodarone hcl tabs
amlodipine besylate tabs 10mg, 1 QLL(30 per 30 days)
MO
2.5mg
1 QLL(45 per 30 days)
amlodipine besylate tabs 5mg
MO
2 QLL(30 per 30 days)
amlodipine besylate/
MO
atorvastatin calcium
amlodipine besylate/benazepril 1 MO
hcl
amlodipine besylate/benazepril 1 MO
hydrochloride
2 MO
atenolol
2 MO
atenolol/chlorthalidone
1 QLL(30 per 30 days)
atorvastatin calcium
MO
1 MO
benazepril hcl
1 MO
benazepril hcl/
hydrochlorothiazide
BIDIL
3 MO
zaleplon caps 10mg
Basic KS 14202, V15
3
22
Drug Requirements/
Tier Limits
Drug Name
bisoprolol fumarate/
hydrochlorothiazide
bumetanide inj
bumetanide tabs
BYSTOLIC
candesartan cilexetil tabs 16mg,
4mg, 8mg
candesartan cilexetil tabs 32mg
2
MO
5
1
3
2
candesartan cilexetil/
hydrochlorothiazide tabs 16mg;
12.5mg
candesartan cilexetil/
hydrochlorothiazide tabs 32mg;
12.5mg, 32mg; 25mg
captopril
captopril/hydrochlorothiazide
cartia xt
carvedilol
chlorothiazide
chlorthalidone tabs 25mg,
50mg
cholestyramine
cholestyramine light
cilostazol
clonidine hcl tabs
clopidogrel tabs 300mg
clopidogrel tabs 75mg
2
MO
MO
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
colestipol hcl
colestipol hcl for oral suspension
COREG CR
COUMADIN TABS
CRESTOR
2
2
4
4
3
digox tabs 125mcg
2
digox tabs 250mcg
digoxin oral soln
digoxin tabs 125mcg
2
2
2
digoxin tabs 250mcg
dilt-cd
dilt-xr
diltiazem cd
diltiazem hcl cd
2
2
2
2
2
2
2
QLL(30 per 30 days)
MO
1
1
2
2
1
1
MO
MO
MO
MO
MO
MO
2
2
2
1
2
2
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
MO
MO
ST MO
MO
QLL(30 per 30 days)
ST MO
QLL(30 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
diltiazem hcl er cp12
diltiazem hcl er cp24
diltiazem hcl tabs
DIOVAN TABS 160MG
2
2
2
3
DIOVAN TABS 320MG
3
DIOVAN TABS 40MG,
80MG
doxazosin mesylate
EFFIENT
3
ELIQUIS
3
enalapril maleate
enalapril maleate/
hydrochlorothiazide
enoxaparin sodium inj 100mg/
ml, 300mg/3ml, 30mg/0.3ml,
40mg/0.4ml, 60mg/0.6ml,
80mg/0.8ml
enoxaparin sodium inj 120mg/
0.8ml, 150mg/ml
eprosartan mesylate
1
1
MO
MO
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
5
MO
EXFORGE
4
EXFORGE HCT
4
felodipine er
fenofibrate caps 130mg, 43mg
fenofibrate micronized caps
134mg, 200mg
fenofibrate micronized caps
67mg
fenofibrate tabs 145mg, 48mg
fenofibrate tabs 160mg
2
2
2
fenofibrate tabs 54mg
2
fenofibric acid dr
flecainide acetate
fluvastatin
2
2
2
Basic KS 14202, V15
2
3
6
MO
4
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
MO
MO
QLL(60 per 30 days)
MO
2
2
2
23
Drug Requirements/
Tier Limits
Drug Name
fondaparinux sodium inj
10mg/0.8ml, 5mg/0.4ml,
7.5mg/0.6ml
fondaparinux sodium inj
2.5mg/0.5ml
fosinopril sodium
fosinopril sodium/
hydrochlorothiazide
furosemide inj
furosemide oral soln
furosemide tabs
gemfibrozil
heparin sodium dcu
heparin sodium inj 10000unit/
ml, 1000unit/ml, 20000unit/
ml, 5000unit/0.5ml,
5000unit/ml
heparin sodium/d5w inj 5%;
100unit/ml, 5%; 40unit/ml
heparin sodium/d5w inj 5%;
50unit/ml
heparin sodium/nacl 0.45%
heparin sodium/nacl 0.9%
heparin sodium/sodium
chloride 0.9% premix
hydralazine hcl inj
hydralazine hcl tabs
hydrochlorothiazide
indapamide
irbesartan
6
MO
5
MO
1
1
MO
MO
5
1
1
2
5
5
MO
MO
MO
MO
B/D PAR MO
B/D PAR MO
5
B/D PAR
5
B/D PAR MO
5
5
5
B/D PAR
B/D PAR
B/D PAR
5
2
1
1
1
irbesartan/hydrochlorothiazide
1
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate
isosorbide mononitrate er
jantoven
labetalol hcl tabs
LANOXIN TABS 125MCG
2
2
1
2
1
2
3
LANOXIN TABS 250MCG,
62.5MCG
lidocaine hcl inj 20mg/ml
lisinopril
lisinopril/hydrochlorothiazide
3
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
MO
5
1
1
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
losartan potassium tabs 100mg
1
losartan potassium tabs 25mg,
50mg
losartan potassium/
hydrochlorothiazide
lovastatin tabs 10mg, 20mg
1
lovastatin tabs 40mg
1
LOVAZA
methyldopa
metoprolol succinate er
metoprolol tartrate tabs
metoprolol/hydrochlorothiazide
mexiletine hcl
MICARDIS HCT TABS
12.5MG; 40MG, 25MG;
80MG
MICARDIS HCT TABS
12.5MG; 80MG
MICARDIS TABS 20MG,
40MG
MICARDIS TABS 80MG
3
2
3
1
2
2
3
micronized colestipol hcl
minoxidil tabs
moexipril hcl
moexipril/hydrochlorothiazide
nadolol/bendroflumethiazide
niacin er tbcr
2
2
1
1
2
3
NIACOR
nicardipine hcl caps
nifedical xl
nifedipine er
nitroglycerin pt24
nitroglycerin transdermal
NITROSTAT
omega-3-acid ethyl esters
pacerone
pentoxifylline er
perindopril erbumine
PRADAXA
3
2
2
2
2
2
3
3
2
2
1
4
Basic KS 14202, V15
1
1
3
3
3
Drug Requirements/
Tier Limits
Drug Name
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
pravastatin sodium
1
prazosin hcl
prevalite
PROMACTA
propafenone hcl
propranolol hcl er
propranolol hcl oral soln
propranolol hcl tabs
propranolol/hydrochlorothiazide
quinapril hcl
quinapril/hydrochlorothiazide
quinidine sulfate
quinidine sulfate er
ramipril
RANEXA
reserpine tabs 0.1mg
simvastatin
2
2
6
2
2
2
2
2
1
1
1
1
1
3
1
1
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
MO
MO
MO
QLL(60 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(60 per 30 days)
MO
sorine
sotalol hcl
sotalol hcl (af)
spironolactone
spironolactone/
hydrochlorothiazide
taztia xt
TEKTURNA
2
2
2
1
1
TEKTURNA HCT
4
telmisartan tabs 20mg, 40mg
3
telmisartan tabs 80mg
3
telmisartan/amlodipine
3
telmisartan/hydrochlorothiazide
tabs 12.5mg; 40mg, 25mg;
80mg
telmisartan/hydrochlorothiazide
tabs 12.5mg; 80mg
terazosin hcl
TIKOSYN
trandolapril
tranexamic acid inj
2
24
2
4
2
2
4
1
5
QLL(30 per 30 days)
MO
MO
MO
LA PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
triamterene/hydrochlorothiazide
caps 25mg; 37.5mg
triamterene/hydrochlorothiazide
tabs
TRILIPIX
TWYNSTA
1
MO
1
MO
3
3
valsartan tabs 160mg
3
valsartan tabs 320mg
3
valsartan tabs 40mg, 80mg
3
valsartan/hydrochlorothiazide
2
verapamil hcl er
verapamil hcl inj
verapamil hcl sr
verapamil hcl tabs
warfarin sodium
WELCHOL
XARELTO TABS 10MG,
20MG
XARELTO TABS 15MG
2
5
2
2
1
3
3
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
ZETIA
4
3
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(42 per 30 days)
MO
PAR QLL(30 per 30
days) MO
Dermatologicals/Topical Therapy
6 MO
acitretin
2 MO
adapalene gel 0.1%
2 MO
alclometasone dipropionate
3 MO
amcinonide
3 MO
amnesteem caps 10mg
4 MO
amnesteem caps 20mg, 40mg
2 MO
augmented betamethasone
dipropionate
2 MO
betamethasone dipropionate
2 MO
betamethasone valerate crea
2 MO
betamethasone valerate lotn
2 MO
betamethasone valerate oint
3 QLL(120 per 30 days)
calcipotriene crea
MO
3 QLL(60 per 30 days)
calcipotriene external soln
MO
3 QLL(120 per 30 days)
calcipotriene oint
MO
Basic KS 14202, V15
25
Drug Requirements/
Tier Limits
Drug Name
CARAC
ciclodan crea
ciclodan external soln
ciclopirox
ciclopirox nail lacquer
ciclopirox olamine
ciclopirox topical solution kit
clindamycin phosphate external
soln
clindamycin phosphate gel
clindamycin phosphate lotn
clindamycin phosphate swab
clobetasol propionate
clobetasol propionate e
clobetasol propionate emollient
clotrimazole external crea
clotrimazole external soln
clotrimazole/betamethasone
dipropionate
cormax scalp application
desonide
diclofenac sodium gel
4
3
3
3
3
3
3
2
MO
MO
PAR MO
MO
PAR MO
MO
PAR MO
MO
2
2
2
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
2
3
econazole nitrate
ELIDEL
2
4
ery
erythromycin
erythromycin/benzoyl peroxide
fluocinolone acetonide crea
fluocinolone acetonide external
soln
fluocinolone acetonide oint
fluocinonide crea 0.05%
fluocinonide external soln
fluocinonide gel
fluocinonide oint
fluocinonide-e
fluorouracil crea 5%
fluorouracil external soln
fluticasone propionate crea
fluticasone propionate lotn
fluticasone propionate oint
gentamicin sulfate crea
gentamicin sulfate oint 0.1%
halobetasol propionate
2
2
2
2
2
MO
MO
PAR QLL(100 per 30
days) MO
MO
PAR QLL(60 per 1
days) MO
MO
MO
MO
MO
MO
2
2
2
2
2
2
3
2
2
2
2
1
1
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
hydrocortisone butyrate
hydrocortisone crea 1%, 2.5%
hydrocortisone in absorbase
hydrocortisone lotn 2.5%
hydrocortisone oint 1%, 2.5%
hydrocortisone valerate
imiquimod
ketoconazole crea
ketoconazole sham
lidocaine hcl inj 2%
lidocaine hcl viscous
lidocaine oint
lidocaine ptch
2
2
2
2
2
2
3
2
2
5
1
2
3
lidocaine viscous
lidocaine/prilocaine crea
lidocaine/prilocaine kit
LIDODERM
1
2
2
3
lindane sham
malathion
methoxsalen
metronidazole crea
metronidazole gel 0.75%
metronidazole lotn
mometasone furoate
mupirocin oint
nyamyc
nystatin crea
nystatin oint
nystatin powd 100000unit/gm
nystatin/triamcinolone
nystop
PANRETIN
pedi-dri
permethrin crea
podofilox
prednicarbate
rosadan
SANTYL
4
3
6
2
2
2
2
2
2
2
2
2
2
2
6
2
2
2
2
2
4
selenium sulfide lotn
silver sulfadiazine
sodium sulfacetamide lotn
SOLARAZE
1
1
2
3
Basic KS 14202, V15
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
SORIATANE
ssd
sulfacetamide sodium
TAZORAC
tretinoin crea
MO
QLL(90 per 30 days)
MO
MO
MO
QLL(90 per 30 days)
MO
MO
MO
PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 1 days)
MO
MO
MO
MO
PAR QLL(100 per 30
days) MO
26
Drug Requirements/
Tier Limits
6
1
2
4
3
MO
MO
MO
MO
QLL(90 per 30 days)
MO
3 QLL(90 per 30 days)
tretinoin gel
MO
2 MO
triamcinolone acetonide crea
2 MO
triamcinolone acetonide lotn
2 MO
triamcinolone acetonide oint
2 MO
trianex
2 MO
triderm
UVADEX
5 B/D PAR
VALCHLOR
6 MO
3 MO
zenatane
Diagnostics & Miscellaneous Agents
2 MO
acetic acid 0.25%
2
acetylcysteine inj
ADAGEN
6 MO
alendronate sodium tabs 40mg 2 QLL(30 per 30 days)
MO
3 MO
anagrelide hydrochloride
BUPHENYL TABS
6 PAR MO
2 MO
buproban
2 MO
bupropion hcl sr tb12 150mg
2 MO
cevimeline hcl
CHANTIX
4 PAR MO
CHANTIX CONTINUING 4 PAR MO
MONTH PAK
CHANTIX STARTING
4 PAR MO
MONTH PAK
5 MO
dextrose 10%
5
dextrose 10% flex container
5
dextrose 10%/nacl 0.2%
5
dextrose 25%
5
dextrose 30%
5
dextrose 40%
5 MO
dextrose 5%
5 MO
dextrose 5% viaflex
5 MO
dextrose 5%/lactated ringers
5 MO
dextrose 50%
5
dextrose 70%
5
dextrose thermoject system
3 MO
disulfiram
EXJADE
6 LA PAR MO
Effective Date November 1, 2014
Drug Name
INCRELEX
lactated ringers dextrose 5%
viaflex
levocarnitine oral soln
levocarnitine tabs
midodrine hcl
NICOTROL NS
ORFADIN
pilocarpine hcl
pilocarpine hydrochloride
PROLASTIN-C
RENVELA PACK
RENVELA TABS
Drug Requirements/
Tier Limits
6
5
2
2
3
3
6
2
2
6
3
3
6
riluzole
3
sevelamer carbonate
5
sodium chloride inj 0.9%
5
sodium chloride pab
6
sodium phenylbutyrate
3
sodium polystyrene sulfonate
powd
3
sodium polystyrene sulfonate
susp 15gm/60ml, 30gm/120ml
3
sps
5
sterile water irrigation
5
sterile water irrigation plastic
bottle
5
sterile water irrigation w/
hanger
ZEMAIRA
6
Ear, Nose & Throat Medications
3
acetasol hc
1
acetic acid
1
acetic acid/aluminum acetate
2
azelastine hcl nasal soln
137mcg/spray
chlorhexidine gluconate mouth/ 1
throat soln
1
chlorhexidine gluconate oral
rinse
CIPRODEX
4
2
denta 5000 plus
2
dentagel
3
hydrocortisone/acetic acid
Basic KS 14202, V15
LA PAR MO
MO
B/D PAR MO
B/D PAR MO
MO
MO
LA MO
MO
MO
LA MO
QLL(90 per 30 days)
MO
QLL(270 per 30 days)
MO
MO
QLL(270 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
LA MO
MO
MO
MO
QLL(30 per 25 days)
MO
MO
MO
MO
MO
MO
MO
27
Drug Requirements/
Tier Limits
Drug Name
ipratropium bromide nasal soln
2
neomycin/polymyxin/hc
neomycin/polymyxin/
hydrocortisone
ofloxacin otic soln
paroex
periogard
sf 5000 plus
triamcinolone acetonide pste
triamcinolone in orabase
Endocrine/Diabetes
acarbose tabs 100mg
2
2
QLL(30 per 30 days)
MO
MO
MO
2
1
1
2
2
2
MO
MO
MO
MO
MO
MO
2
acarbose tabs 25mg
2
acarbose tabs 50mg
2
alcohol preps pads
ALDURAZYME
ANDROGEL GEL 25MG/
2.5GM, 50MG/5GM
ANDROGEL GEL
20.25MG/1.25GM
ANDROGEL GEL 40.5MG/
2.5GM
ANDROGEL PUMP GEL
1%
ANDROGEL PUMP GEL
1.62%
androxy
BYDUREON
1
6
3
BYETTA INJ 10MCG/
0.04ML
BYETTA INJ 5MCG/
0.02ML
calcitonin-salmon
3
calcitriol caps
calcitriol inj
calcitriol oral soln
CEREZYME INJ 200UNIT
CEREZYME INJ 400UNIT
cortisone acetate
CYCLOSET
2
5
2
6
6
2
4
QLL(90 per 30 days)
MO
QLL(360 per 30 days)
MO
QLL(180 per 30 days)
MO
MO
PAR MO
PAR QLL(300 per 30
days) MO
PAR QLL(30 per 30
days) MO
PAR QLL(60 per 30
days) MO
PAR QLL(300 per 30
days) MO
PAR QLL(150 per 30
days) MO
PAR MO
QLL(4 per 28 days)
MO
QLL(2.4 per 30 days)
MO
QLL(1.2 per 30 days)
MO
QLL(4 per 30 days)
MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
PAR
PAR MO
MO
QLL(180 per 30 days)
MO
3
3
3
3
4
3
3
2
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
desmopressin acetate inj
desmopressin acetate nasal soln
desmopressin acetate tabs
dexamethasone
dexamethasone sodium
phosphate inj
FABRAZYME
fludrocortisone acetate
gauze pads 2"x2"
5
3
3
1
5
glimepiride tabs 1mg
2
glimepiride tabs 2mg
2
glimepiride tabs 4mg
2
glipizide er tb24 10mg
1
glipizide er tb24 2.5mg
glipizide er tb24 5mg
6
1
1
5
5
5
PAR MO
MO
QLL(200 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
MO
MO
MO
6
3
3
3
3
PAR MO
MO
MO
MO
MO
3
MO
1
1
glipizide tabs 10mg
1
glipizide tabs 5mg
1
glipizide xl tb24 10mg
1
glipizide xl tb24 2.5mg
1
glipizide xl tb24 5mg
1
glipizide/metformin hcl tabs
2.5mg; 250mg
glipizide/metformin hcl tabs
2.5mg; 500mg, 5mg; 500mg
GLUCAGEN
GLUCAGEN HYPOKIT
GLUCAGON
EMERGENCY KIT
H.P. ACTHAR
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50
KWIKPEN
HUMALOG MIX 75/25
1
Basic KS 14202, V15
MO
MO
MO
MO
MO
1
28
Drug Requirements/
Tier Limits
Drug Name
HUMALOG MIX 75/25
KWIKPEN
HUMULIN 70/30
HUMULIN 70/30
KWIKPEN
HUMULIN 70/30 PEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN N U-100 PEN
HUMULIN R
HUMULIN R U-500
(CONCENTRATED)
hydrocortisone tabs
INSULIN PEN NEEDLE
3
MO
3
3
MO
MO
3
3
3
3
3
3
MO
MO
MO
MO
MO
MO
2
3
INSULIN SYRINGE (DISP)
U-100 0.3 ML
INSULIN SYRINGE (DISP)
U-100 1 ML
INSULIN SYRINGE (DISP)
U-100 1/2 ML
JANUMET
3
JANUMET XR TB24
1000MG; 100MG
JANUMET XR TB24
1000MG; 50MG, 500MG;
50MG
JANUVIA TABS 100MG
3
MO
QLL(200 per 30 days)
MO
QLL(200 per 30 days)
MO
QLL(200 per 30 days)
MO
QLL(200 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
JANUVIA TABS 25MG
3
JANUVIA TABS 50MG
3
KAZANO
3
KUVAN TBSO
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXPEN
LEVEMIR FLEXTOUCH
levothyroxine sodium inj
200mcg
levothyroxine sodium tabs
levoxyl
liothyronine sodium tabs
6
3
3
3
3
3
5
QLL(30 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
LA PAR MO
MO
MO
MO
MO
MO
MO
1
1
2
MO
MO
MO
3
3
3
3
3
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
metformin hcl er tb24 1000mg
1
metformin hcl er tb24 500mg
1
metformin hcl er tb24 500mg
1
metformin hcl er tb24 750mg
1
metformin hcl tabs 1000mg
1
metformin hcl tabs 500mg
1
metformin hcl tabs 850mg
1
methimazole
methylprednisolone
methylprednisolone acetate
methylprednisolone dose pack
methylprednisolone
sodiumsuccinate inj 1000mg,
125mg
methylprednisolone
sodiumsuccinate inj 40mg
NAGLAZYME
nateglinide tabs 120mg
1
2
5
2
5
nateglinide tabs 60mg
2
NEEDLES, INSULIN
DISP., SAFETY
NESINA TABS 12.5MG
3
NESINA TABS 25MG
3
NESINA TABS 6.25MG
3
NOVOPEN ECHO
3
OSENI TABS 12.5MG;
15MG
OSENI TABS 12.5MG;
30MG, 12.5MG; 45MG,
25MG; 15MG, 25MG;
30MG, 25MG; 45MG
oxandrolone tabs 10mg
oxandrolone tabs 2.5mg
pamidronate disodium
3
Basic KS 14202, V15
QLL(75 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(150 per 30 days)
MO
QLL(80 per 30 days)
MO
QLL(76 per 30 days)
MO
QLL(153 per 30 days)
MO
QLL(90 per 30 days)
MO
MO
MO
MO
MO
MO
5
6
2
3
3
6
3
5
LA PAR MO
QLL(90 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(200 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(200 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
PAR MO
PAR MO
B/D PAR MO
29
Drug Requirements/
Tier Limits
Drug Name
paricalcitol
pioglitazone hcl tabs 15mg
4
2
pioglitazone hcl tabs 30mg
2
pioglitazone hcl tabs 45mg
2
pioglitazone hcl-glimepiride
3
pioglitazone hcl/metformin hcl
2
PRANDIN TABS 0.5MG
4
PRANDIN TABS 1MG
4
PRANDIN TABS 2MG
4
prednisolone
prednisolone sodium phosphate
oral soln 15mg/5ml, 5mg/5ml
prednisone
prednisone intensol
PROGLYCEM
propylthiouracil
repaglinide tabs 0.5mg
2
2
repaglinide tabs 1mg
4
repaglinide tabs 2mg
4
RIOMET
4
SAMSCA TABS 15MG
6
SAMSCA TABS 30MG
6
SENSIPAR TABS 30MG
3
SENSIPAR TABS 60MG
6
SENSIPAR TABS 90MG
6
SOMAVERT INJ 10MG,
15MG, 20MG
SOMAVERT INJ 25MG,
30MG
SYMLINPEN 120
6
MO
MO
MO
MO
QLL(960 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(765 per 30 days)
MO
PAR QLL(120 per 30
days) MO
PAR QLL(60 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(120 per 30 days)
MO
LA PAR MO
6
LA PAR
4
PAR MO
1
2
3
2
4
B/D PAR MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(960 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
SYMLINPEN 60
SYNAREL
SYNTHROID
testosterone cypionate
testosterone enanthate
tolazamide tabs 250mg
4
6
3
5
5
2
tolazamide tabs 500mg
2
tolbutamide
2
triamcinolone acetonide inj
10mg/ml
triamcinolone acetonide inj
40mg/ml
unithroid tabs 100mcg,
112mcg, 125mcg, 150mcg,
175mcg, 200mcg, 25mcg,
300mcg, 50mcg, 75mcg,
88mcg
veripred 20
VICTOZA
5
ZAVESCA
Gastroenterology
balsalazide disodium
budesonide cp24
CIMZIA
6
CIMZIA STARTER KIT
6
compro
constulose
CREON
cromolyn sodium conc
CYSTADANE
DELZICOL
dicyclomine hcl
DIPENTUM
diphenoxylate/atropine tabs
dronabinol
EMEND CAPS
2
2
3
3
3
3
3
6
2
3
3
EMEND CAPS 125MG
3
Basic KS 14202, V15
PAR MO
PAR MO
MO
MO
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(180 per 30 days)
MO
MO
5
1
1
3
3
6
6
MO
MO
QLL(9 per 30 days)
MO
LA PAR MO
MO
MO
PAR QLL(6 per 28
days) MO
PAR QLL(6 per 28
days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
B/D PAR MO
B/D PAR QLL(12 per
30 days) MO
B/D PAR QLL(4 per
30 days) MO
30
Drug Requirements/
Tier Limits
Drug Name
EMEND CAPS 40MG
3
EMEND CAPS 80MG
3
enulose
famotidine susr
famotidine tabs 20mg, 40mg
GATTEX
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
generlac
HALFLYTELY BOWEL
PREP/FLAVOR PACKS
hydrocortisone enem
lactulose
lansoprazole
2
2
2
6
1
1
1
2
3
loperamide hcl caps
LOTRONEX TABS 0.5MG
2
3
LOTRONEX TABS 1MG
6
meclizine hcl tabs
mesalamine
metoclopramide hcl inj
metoclopramide hcl oral soln
metoclopramide hcl tabs
misoprostol
MOTOFEN
omeprazole cpdr
1
3
5
1
1
2
4
2
ondansetron hcl inj
ondansetron hcl tabs 4mg, 8mg
5
3
opium
opium tincture
opium tincture (paregoric)
pantoprazole sodium inj
pantoprazole sodium tbec
2
2
2
5
2
peg-3350/electrolytes
peg-3350/nacl/na bicarbonate/
kcl
polyethylene glycol 3350
prochlorperazine
2
2
MO
MO
QLL(30 per 30 days)
MO
MO
PAR QLL(60 per 30
days) MO
PAR QLL(60 per 30
days) MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
MO
B/D PAR QLL(90 per
30 days) MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
MO
MO
2
2
MO
MO
2
2
3
B/D PAR QLL(1 per
1 days) MO
B/D PAR QLL(8 per
30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
5 MO
prochlorperazine edisylate
2 MO
prochlorperazine maleate
2 MO
procto-pak
2 MO
proctosol hc
1 MO
proctozone-hc
2 MO
ranitidine hcl tabs
RELISTOR
5 PAR MO
REMICADE
6 PAR MO
2 MO
sucralfate tabs
2 MO
sulfasalazine
1 MO
sulfazine
2 MO
sulfazine ec
1 MO
trilyte
UCERIS
6 MO
2 MO
ursodiol
Immunology, Vaccines & Biotechnology
ACTHIB
3 MO
ACTIMMUNE
6 PAR MO
ADACEL
3 MO
ARANESP ALBUMIN FREE 6 PAR MO
INJ 100MCG/0.5ML,
100MCG/ML, 150MCG/
0.3ML, 150MCG/0.75ML,
200MCG/0.4ML, 200MCG/
ML, 300MCG/0.6ML,
300MCG/ML, 500MCG/
ML
ARANESP ALBUMIN FREE 5 PAR MO
INJ 25MCG/0.42ML,
25MCG/ML, 40MCG/
0.4ML, 40MCG/ML,
60MCG/0.3ML, 60MCG/
ML
ARCALYST
6 PAR MO
AVONEX
6 PAR MO
AVONEX PEN
6 PAR MO
BCG VACCINE
5
BIVIGAM
6 PAR MO
BOOSTRIX
3 MO
BOTOX
5 PAR MO
CARIMUNE
6 PAR MO
NANOFILTERED
CERVARIX
3 MO
COMVAX
3 MO
DAPTACEL
3 MO
Basic KS 14202, V15
31
Drug Requirements/
Tier Limits
Drug Name
DIPHTHERIA/TETANUS
TOXOIDS ADSORBED
PEDIATRIC
DYSPORT
ENGERIX-B
EXTAVIA
GAMASTAN S/D
GARDASIL
GENOTROPIN
GENOTROPIN
MINIQUICK INJ 0.2MG
GENOTROPIN
MINIQUICK INJ 0.4MG,
0.6MG, 0.8MG, 1.2MG,
1.4MG, 1.6MG, 1.8MG,
1MG, 2MG
HAVRIX INJ 1440ELU/ML
HAVRIX INJ 720ELU/
0.5ML
IMOVAX RABIES
(H.D.C.V.)
INFANRIX
INTRON-A INJ 10MU/ML
INTRON-A INJ
6000000UNIT/ML
INTRON-A W/DILUENT
INJ 10MU
INTRON-A W/DILUENT
INJ 18MU, 50MU
IPOL INACTIVATED IPV
IXIARO
LEUKINE
M-M-R II W/DILUENT 10
DOSE
MENACTRA
MENOMUNE-A/C/Y/W135
MENVEO
NEULASTA
3
NEUMEGA
6
NEUPOGEN
PEDVAX HIB
PEGASYS
PEGASYS PROCLICK
6
3
6
6
5
3
6
5
3
6
5
PAR MO
B/D PAR MO
PAR MO
PAR MO
MO
PAR MO
PAR MO
6
PAR MO
3
3
MO
3
MO
3
5
6
MO
PAR MO
PAR MO
5
PAR MO
6
PAR MO
3
3
6
3
MO
MO
PAR MO
MO
3
3
MO
MO
3
6
MO
PAR QLL(2 per 28
days) MO
PAR QLL(21 per 21
days) MO
PAR MO
MO
PAR MO
PAR MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
PROCRIT INJ 10000UNIT/ 5 PAR MO
ML, 2000UNIT/ML,
3000UNIT/ML, 4000UNIT/
ML
PROCRIT INJ 20000UNIT/ 6 PAR MO
ML, 40000UNIT/ML
PROLEUKIN
6 MO
PROQUAD
3
RABAVERT
5 MO
REBIF
6 PAR MO
REBIF REBIDOSE
6 PAR MO
REBIF REBIDOSE
6 PAR MO
TITRATION PACK
REBIF TITRATION PACK 6 PAR MO
RECOMBIVAX HB INJ
3 B/D PAR MO
10MCG/ML, 40MCG/ML
RECOMBIVAX HB INJ
3 B/D PAR
5MCG/0.5ML
ROTATEQ
3
SYLATRON
6 PAR MO
3 MO
tetanus toxoid adsorbed
TETANUS/DIPHTHERIA 3 MO
TOXOIDS-ADSORBED
ADULT
TEV-TROPIN
5 PAR MO
THYMOGLOBULIN
6 B/D PAR
TICE BCG
5 MO
TWINRIX
3 MO
TYPHIM VI
3
VAQTA
3 MO
VARIVAX
3 MO
VARIZIG
3
XEOMIN
5 PAR MO
YF-VAX
3 MO
ZOSTAVAX
3 MO
Musculoskeletal & Rheumatology
ACTEMRA INJ 200MG/
6 PAR MO
10ML, 400MG/20ML,
80MG/4ML
alendronate sodium tabs 10mg, 2 QLL(30 per 30 days)
MO
5mg
alendronate sodium tabs 35mg, 2 QLL(4 per 28 days)
MO
70mg
1 MO
allopurinol
5
aloprim
COLCRYS
4 PAR MO
Basic KS 14202, V15
32
Drug Requirements/
Tier Limits
Drug Name
ENBREL INJ 25MG,
50MG/ML
ENBREL INJ 25MG/0.5ML
6
ENBREL SURECLICK
6
EVISTA
3
FORTEO
5
HUMIRA INJ 20MG/0.4ML
6
HUMIRA INJ 40MG/0.8ML
6
HUMIRA PEN
6
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMIRA PEN-PSORIASIS
STARTER
ibandronate sodium inj
ibandronate sodium tabs
6
leflunomide
probenecid
raloxifene hydrochloride
3
2
3
SAVELLA TABS 100MG
3
SAVELLA TABS 12.5MG
3
SAVELLA TABS 25MG
3
SAVELLA TABS 50MG
3
SAVELLA TITRATION
PACK
SIMPONI
3
Obstetrics & Gynecology
altavera
alyacen 1/35
alyacen 7/7/7
apri
aranelle
aviane
azurette
6
6
5
2
6
3
3
3
3
3
3
3
PAR QLL(8 per 28
days) MO
PAR QLL(4.08 per 28
days) MO
PAR QLL(8 per 28
days) MO
QLL(30 per 30 days)
MO
PAR QLL(3 per 28
days) MO
PAR QLL(2 per 28
days) MO
PAR QLL(6 per 28
days) MO
PAR QLL(6 per 28
days) MO
PAR QLL(6 per 365
days) MO
PAR QLL(4 per 365
days) MO
B/D PAR
QLL(1 per 28 days)
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(1 per 365 days)
MO
PAR QLL(1 per 28
days) MO
MO
MO
MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
balziva
briellyn
camila
caziant
clindamycin phosphate crea
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
dasetta 1/35
dasetta 7/7/7
drospirenone/ethinyl estradiol
elinest
emoquette
enpresse-28
errin
estarylla
estradiol ptwk
3
3
3
3
2
3
3
3
3
3
3
3
3
3
3
3
3
estradiol tabs
falmina
gildagia
gildess 1.5/30
gildess 1/20
gildess fe 1.5/30
gildess fe 1/20
heather
introvale
jolessa
jolivette
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
kariva
kelnor 1/35
leena
lessina
levonest
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
low-ogestrel
lutera
lyza
marlissa
medroxyprogesterone acetate inj
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
Basic KS 14202, V15
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(4 per 28 days)
MO
PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
33
Drug Requirements/
Tier Limits
Drug Name
medroxyprogesterone acetate
tabs
MENEST
metronidazole vaginal
microgestin 1.5/30
microgestin 1/20
mono-linyah
mononessa
myzilra
necon 0.5/35-28
necon 1/35
necon 1/50-28
necon 10/11-28
necon 7/7/7
nora-be
norethindrone
norethindrone acetate
norgestimate/ethinyl estradiol
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
ocella
ogestrel
orsythia
philith
pirmella 1/35
portia-28
PREMARIN CREA
PREMARIN TABS
previfem
quasense
reclipsen
sprintec 28
sronyx
syeda
terconazole
tilia fe
tri-estarylla
tri-legest fe
tri-linyah
tri-previfem
tri-sprintec
trinessa
trivora-28
vandazole
velivet
1
MO
4
2
3
3
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
3
3
3
3
3
4
4
3
3
3
3
3
3
2
3
3
3
3
3
3
3
3
2
3
PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
viorele
zarah
zazole crea
zenchent
zovia 1/35e
zovia 1/50e
Ophthalmology
acetazolamide
acetazolamide er
ak-poly-bac
apraclonidine
azelastine hcl ophthalmic soln
bacitracin ophthalmic oint
bacitracin/polymyxin b
betaxolol hcl ophthalmic soln
BLEPHAMIDE S.O.P.
brimonidine tartrate
ophthalmic soln 0.2%
carteolol hcl
ciprofloxacin hcl
cromolyn sodium ophthalmic
soln
dexamethasone sodium
phosphate ophthalmic soln
diclofenac sodium ophthalmic
soln
dorzolamide hcl
dorzolamide hcl/timolol
maleate
erythromycin
fluorometholone
flurbiprofen sodium
gentak
gentamicin sulfate oint 0.3%
gentamicin sulfate ophthalmic
soln
ketorolac tromethamine
ophthalmic soln
LACRISERT
latanoprost
levobunolol hcl
levofloxacin ophthalmic soln
LUMIGAN
methazolamide
metipranolol
naphazoline hcl
Basic KS 14202, V15
Drug Requirements/
Tier Limits
3
3
2
3
3
3
MO
MO
2
2
1
2
2
2
1
2
4
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
1
2
2
MO
MO
MO
1
MO
2
MO
2
2
MO
MO
2
2
1
1
2
1
MO
MO
MO
MO
MO
MO
2
MO
3
2
1
2
3
2
2
1
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
Drug Requirements/
Tier Limits
2 MO
neo-polycin
2 MO
neo-polycin hc
neomycin/bacitracin/polymyxin 2 MO
neomycin/polymyxin/bacitracin 2 MO
zinc
neomycin/polymyxin/bacitracin/ 2 MO
hydrocortisone
2 MO
neomycin/polymyxin/
dexamethasone
1 MO
neomycin/polymyxin/
gramicidin
2 MO
neomycin/polymyxin/
hydrocortisone
2 MO
ofloxacin ophthalmic soln
2 MO
pilocarpine hcl
2 MO
polycin
1 MO
polymyxin b sulfate/
trimethoprim sulfate
2 MO
prednisolone acetate
prednisolone sodium phosphate 2 MO
ophthalmic soln
RESCULA
4 MO
2 MO
sodium sulfacetamide
ophthalmic soln
2 MO
sulfacetamide sodium
1 MO
sulfacetamide sodium/
prednisolone sodium phosphate
timolol maleate ophthalmic gel 1 MO
forming
timolol maleate ophthalmic soln 1 MO
tobramycin sulfate ophthalmic 1 MO
soln
2 MO
tobramycin/dexamethasone
TRAVATAN Z
3 MO
3 MO
travoprost
3 MO
trifluridine
trimethoprim sulfate/polymyxin 1 MO
b sulfate
2 MO
tropicamide
VIGAMOX
3 MO
ZIOPTAN
4 MO
ZIRGAN
3 MO
Respiratory, Allergy, Cough & Cold
2 B/D PAR MO
acetylcysteine inhalation soln
ADRENACLICK
5 QLL(2 per 1 days)
MO
MO
MO
MO
34
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
ADVAIR DISKUS
3
ADVAIR HFA
3
albuterol sulfate er
albuterol sulfate nebu 0.083%,
0.63mg/3ml, 1.25mg/3ml
albuterol sulfate nebu 0.5%
2
2
albuterol sulfate syrp
albuterol sulfate tabs
ASMANEX TWISTHALER
120 METERED DOSES
ASMANEX TWISTHALER
14 METERED DOSES
ASMANEX TWISTHALER
30 METERED DOSES
AEPB 110MCG/INH
ASMANEX TWISTHALER
30 METERED DOSES
AEPB 220MCG/INH
ASMANEX TWISTHALER
60 METERED DOSES
ASMANEX TWISTHALER
7 METERED DOSES
ATROVENT HFA
2
2
3
2
3
3
QLL(0.14 per 30
days) MO
3
QLL(0.24 per 30
days) MO
3
QLL(0.24 per 30
days) MO
MO
3
4
BREO ELLIPTA
3
COMBIVENT RESPIMAT
4
cromolyn sodium nebu
2
cyproheptadine hcl tabs
DALIRESP
4
4
diphenhydramine hcl inj
epinephrine
5
5
epinephrine hcl
EPIPEN 2-PAK
5
5
EPIPEN-JR 2-PAK
5
FIRAZYR
FLOVENT DISKUS AEPB
100MCG/BLIST
6
3
Basic KS 14202, V15
QLL(60 per 30 days)
MO
QLL(12 per 30 days)
MO
MO
B/D PAR QLL(360
per 30 days) MO
B/D PAR QLL(60 per
30 days) MO
MO
MO
QLL(0.24 per 30
days) MO
QLL(26 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(8 per 30 days)
MO
B/D PAR QLL(240
per 30 days) MO
MO
QLL(30 per 30 days)
MO
MO
QLL(2 per 1 days)
MO
MO
QLL(2 per 1 days)
MO
QLL(2 per 1 days)
MO
PAR MO
QLL(60 per 30 days)
MO
35
Drug Requirements/
Tier Limits
Drug Name
FLOVENT DISKUS AEPB
250MCG/BLIST, 50MCG/
BLIST
FLOVENT HFA AERO
110MCG/ACT
FLOVENT HFA AERO
220MCG/ACT
FLOVENT HFA AERO
44MCG/ACT
flunisolide
3
QLL(240 per 30 days)
MO
3
fluticasone propionate susp
2
ipratropium bromide
inhalation soln
ipratropium bromide/albuterol
sulfate
LETAIRIS
montelukast sodium chew
2
QLL(12 per 30 days)
MO
QLL(24 per 30 days)
MO
QLL(11 per 30 days)
MO
QLL(75 per 30 days)
MO
QLL(16 per 30 days)
MO
B/D PAR MO
montelukast sodium pack
3
montelukast sodium tabs
2
PROAIR HFA
3
PULMOZYME
QVAR
6
3
SEREVENT DISKUS
3
sildenafil
6
sildenafil citrate
6
SPIRIVA HANDIHALER
3
terbutaline sulfate tabs
theophylline
theophylline cr
theophylline er
TRACLEER
VENTAVIS
XOLAIR
2
2
2
2
6
6
6
zafirlukast
3
3
3
2
2
6
2
B/D PAR QLL(540
per 30 days) MO
LA PAR MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(18 per 30 days)
MO
B/D PAR MO
QLL(27 per 30 days)
MO
QLL(60 per 30 days)
MO
PAR QLL(90 per 30
days) MO
PAR QLL(90 per 30
days) MO
QLL(30 per 30 days)
MO
MO
MO
MO
LA PAR MO
PAR MO
LA PAR QLL(6 per
28 days) MO
QLL(60 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
Urologicals
AVODART
bethanechol chloride
CIALIS TABS 2.5MG, 5MG
Drug Requirements/
Tier Limits
3
2
4
CYSTAGON
finasteride tabs 5mg
flavoxate hcl
JALYN
oxybutynin chloride er tb24
10mg, 15mg
oxybutynin chloride er tb24
5mg
oxybutynin chloride syrp
3
2
2
3
2
oxybutynin chloride tabs
2
potassium citrate er tbcr
1080mg, 540mg
tamsulosin hcl
tolterodine tartrate tabs 1mg
2
2
2
MO
MO
PAR QLL(30 per 30
days) MO
LA MO
MO
MO
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(600 per 30 days)
MO
QLL(120 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
2 QLL(60 per 30 days)
tolterodine tartrate tabs 2mg
MO
2 QLL(60 per 30 days)
trospium chloride
MO
Vitamins, Hematinics & Electrolytes
AMINOSYN-HBC
5
AMINOSYN-PF
5
AMINOSYN-PF 7%
5
2 MO
bal-care dha
2 MO
calcium acetate caps
2 MO
complete natal dha
2 MO
completenate
dextrose 5%/potassium chloride 5
0.15%
2 MO
effervescent pot chloride
2 MO
fluoritab chew 1mg
2 MO
folcal dha
2 MO
folcaps omega 3
2 MO
folivane-ob
2 MO
folivane-prx dha nf
5
freamine iii
2 MO
hemenatal ob
2 MO
hemenatal ob + dha
HEPATAMINE
5
Basic KS 14202, V15
2
2
36
Drug Requirements/
Tier Limits
Drug Name
inatal advance
inatal ultra
k-effervescent
k-vescent tbef
kcl 0.075%/d5w/nacl 0.45%
kcl 0.15%/d5w/ nacl 0.3%
kcl 0.15%/d5w/nacl 0.45%
kcl 0.3%/d5w/lr iv lac ring
kcl 0.3%/d5w/nacl 0.45%
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
klor-con/ef
liposyn iii inj 2.5%; 10%,
2.5%; 30%
liposyn iii inj 2.5%; 20%
magnesium sulfate inj 40mg/
ml, 80mg/ml
magnesium sulfate inj 50%
pnv ob+dha
pnv prenatal plus multivitamin
pnv-dha
pnv-select
potassium chloride 0.15% d5w/
nacl 0.33%
potassium chloride 0.15% d5w/
nacl 0.45%
potassium chloride 0.15% d5w/
nacl 0.45% viaflex
potassium chloride 0.15%/d5w
potassium chloride 0.22% d5w/
nacl 0.45%
potassium chloride 0.224%/
d5w/nacl 0.45%
potassium chloride
0.224%d5w/nacl 0.45%
viaflex
potassium chloride 0.3%/d5w
potassium chloride cr
potassium chloride er
potassium chloride inj 0.4meq/
ml, 10meq/100ml, 10meq/
50ml, 20meq/100ml, 20meq/
2
2
1
1
5
5
5
5
5
1
1
1
2
2
1
5
MO
MO
MO
MO
5
5
MO
5
2
2
2
2
5
MO
MO
MO
MO
MO
5
MO
5
MO
MO
MO
MO
MO
MO
MO
MO
5
5
5
5
5
2
2
5
MO
MO
Effective Date November 1, 2014
Drug Name
50ml, 30meq/100ml, 40meq/
100ml
potassium chloride inj 2meq/ml
potassium chloride liqd
potassium chloride oral soln
potassium chloride sr
pr natal 400
pr natal 400 ec
pr natal 430
pr natal 430 ec
prenaissance
prenaissance plus
prenatabs fa
prenatabs obn
prenatal plus
prenatal tabs 120mg; 0; 0;
200mg; 400unit; 2mg; 12mcg;
27mg; 1mg; 20mg; 10mg;
3mg; 1.84mg; 22mg;
4000unit; 25mg
relnate dha
ringers injection
se-natal 19
se-tan dha
sodium bicarbonate inj 4.2%,
7.5%
sodium bicarbonate inj 8.4%
sodium bicarbonate partial fill
sodium chloride 0.45%
sodium chloride 0.45% viaflex
sodium chloride inj 3%, 4meq/
ml
sodium chloride inj 5%
sodium fluoride tabs
taron-prex
tl-care dha
tl-select
TPN ELECTROLYTES
triadvance
trinatal gt
trinatal rx 1
triveen-duo dha
triveen-prx rnf
ultimatecare one nf
vemavite-prx 2
vena-bal dha
Basic KS 14202, V15
Drug Requirements/
Tier Limits
5
1
1
2
2
2
2
2
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
5
2
2
5
MO
5
5
5
5
5
MO
MO
MO
MO
MO
5
2
2
2
2
5
2
2
2
2
2
2
2
2
Drug Name
virt-pn
virt-pn dha
vol-nate
vol-plus
vp-ch-pnv
zatean-ch
zatean-pn
zatean-pn dha
zatean-pn plus
Drug Requirements/
Tier Limits
2
2
2
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
37
Effective Date November 1, 2014
Index of Drugs:
Legend
Generic drugs are shown in lowercase italics (e.g. enalapril)
Brand-name drugs are shown in capital letters (e.g. HUMALOG)
The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and
generic drugs are listed. 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.
Drug Name
Page
abacavir..............................................................................7
abacavir sulfate/lamivudine/zidovudine................................7
ABELCET.........................................................................7
ABILIFY DISCMELT TBDP 10MG..............................13
ABILIFY DISCMELT TBDP 15MG..............................13
ABILIFY INJ...................................................................13
ABILIFY MAINTENA....................................................13
ABILIFY ORAL SOLN...................................................13
ABILIFY TABS 10MG....................................................13
ABILIFY TABS 15MG....................................................13
ABILIFY TABS 20MG....................................................13
ABILIFY TABS 2MG......................................................13
ABILIFY TABS 30MG....................................................13
ABILIFY TABS 5MG......................................................13
ABRAXANE....................................................................10
ABSTRAL SUBL 100MCG.............................................13
ABSTRAL SUBL 200MCG, 300MCG, 400MCG,
600MCG, 800MCG.....................................................13
acarbose tabs 100mg..........................................................27
acarbose tabs 25mg............................................................27
acarbose tabs 50mg............................................................27
acebutolol hcl.....................................................................22
acetaminophen/codeine #2..................................................13
acetaminophen/codeine #3..................................................13
acetaminophen/codeine #4..................................................13
acetaminophen/codeine oral soln.........................................13
acetaminophen/codeine phosphate.......................................13
acetaminophen/codeine tabs................................................13
acetasol hc.........................................................................27
acetazolamide....................................................................34
acetazolamide er................................................................34
acetic acid.........................................................................27
acetic acid 0.25%..............................................................26
acetic acid/aluminum acetate..............................................27
acetylcysteine inhalation soln..............................................34
acetylcysteine inj................................................................26
acitretin............................................................................25
Basic KS 14202, V15
38
Drug Name
Page
ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/
4ML..............................................................................32
ACTHIB..........................................................................31
ACTIMMUNE...............................................................31
ACTIQ............................................................................13
acyclovir caps.......................................................................7
acyclovir sodium inj 500mg..................................................7
acyclovir sodium inj 50mg/ml...............................................7
acyclovir susp.......................................................................7
acyclovir tabs.......................................................................7
ADACEL.........................................................................31
ADAGEN........................................................................26
adapalene gel 0.1%...........................................................25
ADASUVE......................................................................13
adefovir dipivoxil.................................................................7
ADRENACLICK.............................................................34
adrucil..............................................................................10
ADVAIR DISKUS...........................................................35
ADVAIR HFA.................................................................35
afeditab cr.........................................................................22
AFINITOR......................................................................10
AFINITOR DISPERZ.....................................................10
AGGRENOX..................................................................22
ak-poly-bac........................................................................34
ALBENZA.........................................................................7
albuterol sulfate er.............................................................35
albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/
3ml................................................................................35
albuterol sulfate nebu 0.5%...............................................35
albuterol sulfate syrp..........................................................35
albuterol sulfate tabs..........................................................35
alclometasone dipropionate.................................................25
alcohol preps pads..............................................................27
ALDURAZYME..............................................................27
alendronate sodium tabs 10mg, 5mg...................................32
alendronate sodium tabs 35mg, 70mg.................................32
alendronate sodium tabs 40mg...........................................26
Effective Date November 1, 2014
Drug Name
Page
ALIMTA..........................................................................10
ALINIA.............................................................................7
ALKERAN TABS............................................................10
allopurinol........................................................................32
aloprim.............................................................................32
alprazolam tabs.................................................................13
altavera.............................................................................32
alyacen 1/35......................................................................32
alyacen 7/7/7.....................................................................32
amantadine hcl caps.............................................................7
amantadine hcl tabs.............................................................7
amcinonide.......................................................................25
amifostine.........................................................................10
amikacin sulfate..................................................................7
amiloride hcl.....................................................................22
amiloride/hydrochlorothiazide............................................22
aminocaproic acid syrp.......................................................22
AMINOSYN-HBC..........................................................36
AMINOSYN-PF..............................................................36
AMINOSYN-PF 7%.......................................................36
amiodarone hcl tabs...........................................................22
amitriptyline hcl................................................................13
amlodipine besylate tabs 10mg, 2.5mg................................22
amlodipine besylate tabs 5mg..............................................22
amlodipine besylate/atorvastatin calcium.............................22
amlodipine besylate/benazepril hcl......................................22
amlodipine besylate/benazepril hydrochloride.......................22
amnesteem caps 10mg........................................................25
amnesteem caps 20mg, 40mg..............................................25
amoxapine........................................................................13
amoxicillin..........................................................................7
amoxicillin/clavulanate potassium.........................................7
amoxicillin/clavulanate potassium er.....................................7
amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg;
1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg,
2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg;
3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg,
5mg; 5mg; 5mg; 5mg......................................................13
amphetamine/dextroamphetamine tabs 7.5mg; 7.5mg;
7.5mg; 7.5mg.................................................................13
amphotericin b....................................................................7
ampicillin...........................................................................7
ampicillin sodium inj 10gm, 125mg, 1gm, 250mg, 2gm.......7
ampicillin sodium inj 500mg...............................................7
anagrelide hydrochloride....................................................26
anastrozole........................................................................10
ANDROGEL GEL 20.25MG/1.25GM..........................27
Basic KS 14202, V15
39
Drug Name
Page
ANDROGEL GEL 25MG/2.5GM, 50MG/5GM...........27
ANDROGEL GEL 40.5MG/2.5GM..............................27
ANDROGEL PUMP GEL 1%........................................27
ANDROGEL PUMP GEL 1.62%...................................27
androxy.............................................................................27
APOKYN.........................................................................13
apraclonidine....................................................................34
apri..................................................................................32
APTIOM.........................................................................13
APTIVUS CAPS................................................................7
APTIVUS ORAL SOLN...................................................7
aranelle.............................................................................32
ARANESP ALBUMIN FREE INJ 100MCG/0.5ML,
100MCG/ML, 150MCG/0.3ML, 150MCG/0.75ML,
200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML,
300MCG/ML, 500MCG/ML......................................31
ARANESP ALBUMIN FREE INJ 25MCG/0.42ML,
25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/
0.3ML, 60MCG/ML....................................................31
ARCALYST.....................................................................31
ARRANON.....................................................................10
ARZERRA.......................................................................10
ASMANEX TWISTHALER 120 METERED
DOSES.........................................................................35
ASMANEX TWISTHALER 14 METERED
DOSES.........................................................................35
ASMANEX TWISTHALER 30 METERED DOSES
AEPB 110MCG/INH...................................................35
ASMANEX TWISTHALER 30 METERED DOSES
AEPB 220MCG/INH...................................................35
ASMANEX TWISTHALER 60 METERED
DOSES.........................................................................35
ASMANEX TWISTHALER 7 METERED DOSES.......35
ASTAGRAF XL...............................................................10
atenolol.............................................................................22
atenolol/chlorthalidone.......................................................22
atorvastatin calcium..........................................................22
atovaquone..........................................................................7
ATRIPLA...........................................................................7
ATROVENT HFA..........................................................35
augmented betamethasone dipropionate...............................25
AVASTIN........................................................................10
aviane...............................................................................32
AVODART.....................................................................36
AVONEX........................................................................31
AVONEX PEN...............................................................31
azacitidine........................................................................10
Effective Date November 1, 2014
Drug Name
Page
azathioprine......................................................................10
azelastine hcl nasal soln 137mcg/spray.................................27
azelastine hcl ophthalmic soln.............................................34
AZILECT........................................................................13
azithromycin inj 500mg.......................................................7
azithromycin pack...............................................................7
azithromycin susr 100mg/5ml..............................................7
azithromycin susr 200mg/5ml..............................................7
azithromycin tabs 250mg.....................................................7
azithromycin tabs 500mg.....................................................7
azithromycin tabs 600mg.....................................................7
azurette.............................................................................32
bacitracin ophthalmic oint.................................................34
bacitracin/polymyxin b.......................................................34
baclofen............................................................................13
bactocill in dextrose inj 0; 1gm/50ml....................................7
bactocill in dextrose inj 0; 2gm/50ml....................................7
bal-care dha......................................................................36
balsalazide disodium..........................................................30
balziva..............................................................................33
BANZEL SUSP...............................................................13
BANZEL TABS 200MG.................................................13
BANZEL TABS 400MG.................................................13
BARACLUDE...................................................................7
BCG VACCINE..............................................................31
BELEODAQ...................................................................10
benazepril hcl....................................................................22
benazepril hcl/hydrochlorothiazide......................................22
benztropine mesylate tabs...................................................13
betamethasone dipropionate................................................25
betamethasone valerate crea................................................25
betamethasone valerate lotn................................................25
betamethasone valerate oint................................................25
betaxolol hcl ophthalmic soln..............................................34
bethanechol chloride...........................................................36
bicalutamide.....................................................................10
BICNU............................................................................10
BIDIL..............................................................................22
bisoprolol fumarate/hydrochlorothiazide..............................22
BIVIGAM........................................................................31
bleomycin sulfate...............................................................10
BLEPHAMIDE S.O.P.....................................................34
BOOSTRIX.....................................................................31
BOSULIF........................................................................10
BOTOX...........................................................................31
BREO ELLIPTA..............................................................35
briellyn.............................................................................33
Basic KS 14202, V15
40
Drug Name
Page
brimonidine tartrate ophthalmic soln 0.2%........................34
BRINTELLIX TABS 10MG............................................13
BRINTELLIX TABS 20MG............................................13
BRINTELLIX TABS 5MG..............................................13
bromocriptine mesylate.......................................................13
budeprion sr tb12 150mg...................................................13
budesonide cp24................................................................30
bumetanide inj..................................................................22
bumetanide tabs................................................................22
BUPHENYL TABS.........................................................26
buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg.................14
buprenorphine hcl/naloxone hcl subl 8mg; 2mg....................14
buproban..........................................................................26
bupropion hcl er tb12 100mg.............................................14
bupropion hcl er tb12 150mg.............................................14
bupropion hcl er tb12 200mg.............................................14
bupropion hcl sr tb12 100mg.............................................14
bupropion hcl sr tb12 150mg.............................................14
bupropion hcl sr tb12 150mg.............................................26
bupropion hcl sr tb12 200mg.............................................14
bupropion hcl tabs 100mg..................................................14
bupropion hcl tabs 75mg....................................................14
bupropion hcl xl tb24 150mg.............................................14
bupropion hcl xl tb24 300mg.............................................14
buspirone hcl.....................................................................14
BUSULFEX.....................................................................10
BYDUREON..................................................................27
BYETTA INJ 10MCG/0.04ML......................................27
BYETTA INJ 5MCG/0.02ML........................................27
BYSTOLIC......................................................................22
calcipotriene crea...............................................................25
calcipotriene external soln...................................................25
calcipotriene oint...............................................................25
calcitonin-salmon..............................................................27
calcitriol caps.....................................................................27
calcitriol inj.......................................................................27
calcitriol oral soln..............................................................27
calcium acetate caps...........................................................36
camila...............................................................................33
CANCIDAS......................................................................7
candesartan cilexetil tabs 16mg, 4mg, 8mg..........................22
candesartan cilexetil tabs 32mg...........................................22
candesartan cilexetil/hydrochlorothiazide tabs 16mg;
12.5mg..........................................................................22
candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg,
32mg; 25mg...................................................................22
CAPASTAT SULFATE.....................................................7
Effective Date November 1, 2014
Drug Name
Page
CAPRELSA.....................................................................10
captopril............................................................................22
captopril/hydrochlorothiazide..............................................22
CARAC...........................................................................25
carbamazepine..................................................................14
carbamazepine er...............................................................14
carbidopa/levodopa............................................................14
carbidopa/levodopa er........................................................14
carbidopa/levodopa odt.......................................................14
carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml,
600mg/60ml..................................................................10
CARIMUNE NANOFILTERED....................................31
carteolol hcl.......................................................................34
cartia xt............................................................................22
carvedilol..........................................................................22
caziant..............................................................................33
CEENU...........................................................................10
cefaclor................................................................................7
cefaclor er............................................................................7
cefadroxil............................................................................7
cefazolin sodium inj 100gm, 10gm, 1gm; 5%, 20gm,
500mg.............................................................................8
cefazolin sodium inj 1gm.....................................................8
cefazolin sodium/dextrose......................................................8
cefdinir...............................................................................8
cefepime inj 1gm, 2gm.........................................................8
cefepime inj 1gm/50ml, 2gm/100ml.....................................8
cefotaxime sodium inj 10gm.................................................8
cefotaxime sodium inj 1gm, 2gm, 500mg..............................8
cefoxitin sodium inj 10gm, 2gm...........................................8
cefoxitin sodium inj 1gm......................................................8
cefpodoxime proxetil.............................................................8
cefprozil..............................................................................8
cefuroxime axetil tabs...........................................................8
CELLCEPT INTRAVENOUS........................................10
CELLCEPT SUSR...........................................................10
CELONTIN....................................................................14
cephalexin caps 250mg, 500mg............................................8
cephalexin susr.....................................................................8
cephalexin tabs....................................................................8
CEREZYME INJ 200UNIT............................................27
CEREZYME INJ 400UNIT............................................27
CERVARIX.....................................................................31
cevimeline hcl....................................................................26
CHANTIX......................................................................26
CHANTIX CONTINUING MONTH PAK.................26
CHANTIX STARTING MONTH PAK........................26
Basic KS 14202, V15
41
Drug Name
Page
chloramphenicol sodium succinate.........................................8
chlorhexidine gluconate mouth/throat soln...........................27
chlorhexidine gluconate oral rinse.......................................27
chloroquine phosphate..........................................................8
chlorothiazide....................................................................22
chlorpromazine hcl inj.......................................................14
chlorpromazine hcl tabs......................................................14
chlorthalidone tabs 25mg, 50mg.........................................22
cholestyramine...................................................................22
cholestyramine light...........................................................22
CIALIS TABS 2.5MG, 5MG...........................................36
ciclodan crea......................................................................25
ciclodan external soln.........................................................25
ciclopirox...........................................................................25
ciclopirox nail lacquer........................................................25
ciclopirox olamine..............................................................25
ciclopirox topical solution kit..............................................25
cidofovir..............................................................................8
cilostazol...........................................................................22
CIMZIA..........................................................................30
CIMZIA STARTER KIT................................................30
CIPRODEX....................................................................27
ciprofloxacin hcl..................................................................8
ciprofloxacin hcl................................................................34
ciprofloxacin i.v.-in d5w......................................................8
ciprofloxacin inj 200mg/20ml..............................................8
ciprofloxacin inj 400mg/40ml..............................................8
cisplatin............................................................................11
citalopram hydrobromide oral soln......................................14
citalopram hydrobromide tabs 10mg...................................14
citalopram hydrobromide tabs 20mg...................................14
citalopram hydrobromide tabs 40mg...................................14
cladribine..........................................................................11
clarithromycin.....................................................................8
clarithromycin er.................................................................8
clindamycin hcl...................................................................8
clindamycin phosphate add-vantage......................................8
clindamycin phosphate crea................................................33
clindamycin phosphate external soln....................................25
clindamycin phosphate gel..................................................25
clindamycin phosphate in d5w..............................................8
clindamycin phosphate inj....................................................8
clindamycin phosphate lotn................................................25
clindamycin phosphate pharmacy bulk package......................8
clindamycin phosphate swab...............................................25
clobetasol propionate..........................................................25
clobetasol propionate e........................................................25
Effective Date November 1, 2014
Drug Name
Page
clobetasol propionate emollient............................................25
CLOLAR.........................................................................11
clomipramine hcl...............................................................14
clonazepam odt tbdp 0.125mg...........................................14
clonazepam odt tbdp 0.25mg.............................................14
clonazepam odt tbdp 0.5mg...............................................14
clonazepam odt tbdp 1mg..................................................14
clonazepam odt tbdp 2mg..................................................14
clonazepam tabs 0.5mg......................................................14
clonazepam tabs 1mg.........................................................14
clonazepam tabs 2mg.........................................................14
clonidine hcl tabs...............................................................22
clopidogrel tabs 300mg.......................................................22
clopidogrel tabs 75mg.........................................................22
clorazepate dipotassium......................................................14
clotrimazole external crea...................................................25
clotrimazole external soln...................................................25
clotrimazole troc..................................................................8
clotrimazole/betamethasone dipropionate.............................25
clozapine odt tbdp 100mg..................................................14
clozapine odt tbdp 12.5mg.................................................14
clozapine odt tbdp 25mg....................................................14
clozapine tabs 100mg.........................................................14
clozapine tabs 200mg.........................................................14
clozapine tabs 25mg...........................................................14
clozapine tabs 50mg...........................................................14
COLCRYS.......................................................................32
colestipol hcl......................................................................22
colestipol hcl for oral suspension..........................................22
colistimethate sodium...........................................................8
COMBIVENT RESPIMAT............................................35
COMETRIQ...................................................................11
COMPLERA.....................................................................8
complete natal dha.............................................................36
completenate......................................................................36
compro..............................................................................30
COMVAX.......................................................................31
constulose..........................................................................30
COPAXONE...................................................................14
COREG CR....................................................................22
cormax scalp application....................................................25
cortisone acetate.................................................................27
COSMEGEN..................................................................11
COUMADIN TABS.......................................................22
CREON..........................................................................30
CRESTOR......................................................................22
CRIXIVAN........................................................................8
Basic KS 14202, V15
42
Drug Name
Page
cromolyn sodium conc........................................................30
cromolyn sodium nebu.......................................................35
cromolyn sodium ophthalmic soln.......................................34
cryselle-28.........................................................................33
cyclafem 1/35....................................................................33
cyclafem 7/7/7...................................................................33
cyclobenzaprine hcl tabs 10mg, 5mg...................................14
cyclophosphamide tabs........................................................11
CYCLOSET....................................................................27
cyclosporine caps................................................................11
cyclosporine inj..................................................................11
cyclosporine modified caps 100mg, 25mg.............................11
cyclosporine modified caps 50mg.........................................11
cyclosporine modified oral soln............................................11
CYMBALTA CPEP 20MG.............................................14
CYMBALTA CPEP 30MG.............................................14
CYMBALTA CPEP 60MG.............................................14
cyproheptadine hcl tabs......................................................35
CYRAMZA......................................................................11
CYSTADANE.................................................................30
CYSTAGON...................................................................36
cytarabine aqueous.............................................................11
cytarabine inj 100mg/ml, 20mg/ml....................................11
dacarbazine.......................................................................11
DACOGEN....................................................................11
DALIRESP......................................................................35
DAPSONE........................................................................8
DAPTACEL....................................................................31
DARAPRIM......................................................................8
dasetta 1/35......................................................................33
dasetta 7/7/7.....................................................................33
daunorubicin hcl...............................................................11
decitabine.........................................................................11
DELZICOL.....................................................................30
demeclocycline hcl tabs 150mg..............................................8
demeclocycline hcl tabs 300mg..............................................8
denta 5000 plus................................................................27
dentagel............................................................................27
desipramine hcl.................................................................14
desmopressin acetate inj......................................................28
desmopressin acetate nasal soln............................................28
desmopressin acetate tabs....................................................28
desonide............................................................................25
DESVENLAFAXINE ER TB24 100MG.........................14
DESVENLAFAXINE ER TB24 50MG...........................14
dexamethasone...................................................................28
dexamethasone sodium phosphate inj...................................28
Effective Date November 1, 2014
Drug Name
Page
dexamethasone sodium phosphate ophthalmic soln................34
dexrazoxane inj 250mg......................................................11
dexrazoxane inj 500mg......................................................11
dextroamphetamine sulfate tabs 10mg.................................14
dextroamphetamine sulfate tabs 5mg...................................14
dextrose 10%.....................................................................26
dextrose 10% flex container................................................26
dextrose 10%/nacl 0.2%....................................................26
dextrose 25%.....................................................................26
dextrose 30%.....................................................................26
dextrose 40%....................................................................26
dextrose 5%.......................................................................26
dextrose 5% viaflex............................................................26
dextrose 5%/lactated ringers...............................................26
dextrose 5%/potassium chloride 0.15%...............................36
dextrose 50%.....................................................................26
dextrose 70%.....................................................................26
dextrose thermoject system...................................................26
diazepam gel.....................................................................14
diazepam intensol..............................................................14
diazepam oral soln.............................................................14
diazepam tabs 10mg..........................................................15
diazepam tabs 2mg............................................................15
diazepam tabs 5mg............................................................15
diclofenac potassium...........................................................15
diclofenac sodium dr..........................................................15
diclofenac sodium er...........................................................15
diclofenac sodium gel.........................................................25
diclofenac sodium ophthalmic soln......................................34
dicloxacillin sodium.............................................................8
dicyclomine hcl..................................................................30
didanosine...........................................................................8
diflunisal...........................................................................15
digox tabs 125mcg.............................................................22
digox tabs 250mcg.............................................................22
digoxin oral soln................................................................22
digoxin tabs 125mcg..........................................................22
digoxin tabs 250mcg..........................................................22
dihydroergotamine mesylate inj...........................................15
DILANTIN CAPS 30MG...............................................15
DILANTIN INFATABS.................................................15
dilt-cd...............................................................................22
dilt-xr...............................................................................22
diltiazem cd......................................................................22
diltiazem hcl cd.................................................................22
diltiazem hcl er cp12.........................................................23
diltiazem hcl er cp24.........................................................23
Basic KS 14202, V15
43
Drug Name
Page
diltiazem hcl tabs...............................................................23
DIOVAN TABS 160MG................................................23
DIOVAN TABS 320MG................................................23
DIOVAN TABS 40MG, 80MG......................................23
DIPENTUM...................................................................30
diphenhydramine hcl inj....................................................35
diphenoxylate/atropine tabs................................................30
DIPHTHERIA/TETANUS TOXOIDS ADSORBED
PEDIATRIC.................................................................31
disulfiram.........................................................................26
divalproex sodium..............................................................15
divalproex sodium dr.........................................................15
divalproex sodium er..........................................................15
DOCEFREZ...................................................................11
docetaxel inj 160mg/16ml, 20mg/0.5ml, 20mg/2ml, 80mg/
2ml, 80mg/8ml..............................................................11
docetaxel inj 20mg/ml, 80mg/4ml......................................11
donepezil hcl tabs 10mg, 5mg.............................................15
donepezil hcl tbdp..............................................................15
dorzolamide hcl.................................................................34
dorzolamide hcl/timolol maleate.........................................34
doxazosin mesylate.............................................................23
doxepin hcl........................................................................15
DOXIL............................................................................11
doxorubicin hcl inj 10mg, 50mg.........................................11
doxorubicin hcl inj 2mg/ml................................................11
doxy 100.............................................................................8
doxycycline hyclate caps........................................................8
doxycycline hyclate inj..........................................................8
doxycycline hyclate tabs........................................................8
doxycycline monohydrate caps 100mg, 50mg.........................8
doxycycline monohydrate tabs 100mg....................................8
dronabinol........................................................................30
drospirenone/ethinyl estradiol..............................................33
duloxetine hcl cpep 20mg...................................................15
duloxetine hcl cpep 30mg...................................................15
duloxetine hcl cpep 60mg...................................................15
duramorph inj 0.5mg/ml...................................................15
duramorph inj 1mg/ml......................................................15
DYSPORT.......................................................................31
econazole nitrate................................................................25
EDURANT.......................................................................8
effervescent pot chloride......................................................36
EFFIENT........................................................................23
ELIDEL...........................................................................25
elinest...............................................................................33
ELIQUIS.........................................................................23
Effective Date November 1, 2014
Drug Name
Page
ELITEK...........................................................................11
ELLENCE.......................................................................11
ELOXATIN INJ 100MG/20ML, 50MG/10ML.............11
ELSPAR...........................................................................11
EMCYT...........................................................................11
EMEND CAPS................................................................30
EMEND CAPS 125MG..................................................30
EMEND CAPS 40MG....................................................30
EMEND CAPS 80MG....................................................30
emoquette..........................................................................33
EMSAM..........................................................................15
EMTRIVA.........................................................................8
enalapril maleate...............................................................23
enalapril maleate/hydrochlorothiazide.................................23
ENBREL INJ 25MG, 50MG/ML...................................32
ENBREL INJ 25MG/0.5ML...........................................32
ENBREL SURECLICK...................................................32
endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg;
7.5mg............................................................................15
endodan............................................................................15
ENGERIX-B....................................................................31
enoxaparin sodium inj 100mg/ml, 300mg/3ml, 30mg/0.3ml,
40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml..........................23
enoxaparin sodium inj 120mg/0.8ml, 150mg/ml.................23
enpresse-28........................................................................33
entacapone........................................................................15
entecavir.............................................................................8
enulose..............................................................................30
epinephrine.......................................................................35
epinephrine hcl..................................................................35
EPIPEN 2-PAK...............................................................35
EPIPEN-JR 2-PAK..........................................................35
epirubicin hcl inj 200mg/100ml, 50mg..............................11
epirubicin hcl inj 50mg/25ml.............................................11
epitol................................................................................15
EPIVIR HBV.....................................................................8
EPIVIR ORAL SOLN.......................................................8
eprosartan mesylate............................................................23
EPZICOM........................................................................8
EQUETRO CP12 100MG..............................................15
EQUETRO CP12 200MG..............................................15
EQUETRO CP12 300MG..............................................15
ERBITUX........................................................................11
ERIVEDGE.....................................................................11
errin.................................................................................33
ERWINAZE....................................................................11
ery....................................................................................25
Basic KS 14202, V15
44
Drug Name
Page
erythrocin stearate................................................................8
erythromycin.......................................................................8
erythromycin.....................................................................25
erythromycin.....................................................................34
erythromycin base................................................................8
erythromycin ethylsuccinate..................................................8
erythromycin/benzoyl peroxide............................................25
escitalopram oxalate oral soln.............................................15
escitalopram oxalate tabs 10mg...........................................15
escitalopram oxalate tabs 20mg...........................................15
escitalopram oxalate tabs 5mg.............................................15
estarylla.............................................................................33
estradiol ptwk....................................................................33
estradiol tabs.....................................................................33
ethambutol hcl.....................................................................8
ethosuximide.....................................................................15
etodolac.............................................................................15
ETOPOPHOS................................................................11
etoposide inj......................................................................11
EVISTA...........................................................................32
exemestane........................................................................11
EXFORGE......................................................................23
EXFORGE HCT.............................................................23
EXJADE..........................................................................26
EXTAVIA........................................................................31
FABRAZYME..................................................................28
falmina.............................................................................33
famciclovir tabs 125mg, 250mg...........................................8
famciclovir tabs 500mg........................................................8
famotidine susr..................................................................30
famotidine tabs 20mg, 40mg..............................................30
FANAPT TABS 10MG...................................................15
FANAPT TABS 12MG...................................................15
FANAPT TABS 1MG.....................................................15
FANAPT TABS 2MG.....................................................15
FANAPT TABS 4MG.....................................................15
FANAPT TABS 6MG.....................................................15
FANAPT TABS 8MG.....................................................15
FANAPT TITRATION PACK.......................................15
FARESTON....................................................................11
FASLODEX....................................................................11
FAZACLO TBDP 100MG..............................................15
FAZACLO TBDP 12.5MG.............................................15
FAZACLO TBDP 150MG..............................................15
FAZACLO TBDP 200MG..............................................15
FAZACLO TBDP 25MG................................................15
felbamate susp...................................................................15
Effective Date November 1, 2014
Drug Name
Page
felbamate tabs...................................................................15
felodipine er......................................................................23
fenofibrate caps 130mg, 43mg............................................23
fenofibrate micronized caps 134mg, 200mg........................23
fenofibrate micronized caps 67mg.......................................23
fenofibrate tabs 145mg, 48mg............................................23
fenofibrate tabs 160mg......................................................23
fenofibrate tabs 54mg........................................................23
fenofibric acid dr...............................................................23
fentanyl citrate oral transmucosal........................................15
fentanyl patches.................................................................15
FENTORA......................................................................15
FETZIMA CP24 120MG, 80MG...................................15
FETZIMA CP24 20MG..................................................15
FETZIMA CP24 40MG..................................................15
FETZIMA TITRATION PACK.....................................15
finasteride tabs 5mg...........................................................36
FIRAZYR........................................................................35
FIRMAGON INJ 120MG..............................................11
FIRMAGON INJ 80MG................................................11
flavoxate hcl......................................................................36
flecainide acetate................................................................23
FLOVENT DISKUS AEPB 100MCG/BLIST................35
FLOVENT DISKUS AEPB 250MCG/BLIST, 50MCG/
BLIST...........................................................................35
FLOVENT HFA AERO 110MCG/ACT........................35
FLOVENT HFA AERO 220MCG/ACT........................35
FLOVENT HFA AERO 44MCG/ACT..........................35
fluconazole..........................................................................8
fluconazole in dextrose.........................................................8
fluconazole in nacl...............................................................8
flucytosine...........................................................................8
fludarabine phosphate inj 50mg.........................................11
fludarabine phosphate inj 50mg/2ml..................................11
fludrocortisone acetate........................................................28
flunisolide.........................................................................35
fluocinolone acetonide crea.................................................25
fluocinolone acetonide external soln.....................................25
fluocinolone acetonide oint.................................................25
fluocinonide crea 0.05%....................................................25
fluocinonide external soln...................................................25
fluocinonide gel.................................................................25
fluocinonide oint................................................................25
fluocinonide-e....................................................................25
fluoritab chew 1mg............................................................36
fluorometholone.................................................................34
fluorouracil crea 5%..........................................................25
Basic KS 14202, V15
45
Drug Name
Page
fluorouracil external soln....................................................25
fluorouracil inj..................................................................11
fluoxetine caps 10mg..........................................................15
fluoxetine caps 20mg..........................................................16
fluoxetine hcl caps 10mg.....................................................16
fluoxetine hcl caps 20mg.....................................................16
fluoxetine hcl caps 40mg....................................................16
fluoxetine hcl oral soln........................................................16
fluoxetine hcl tabs 10mg.....................................................16
fluoxetine hcl tabs 20mg.....................................................16
FLUOXETINE HCL TABS 60MG................................16
fluphenazine decanoate......................................................16
fluphenazine hcl conc.........................................................16
fluphenazine hcl elix..........................................................16
fluphenazine hcl inj...........................................................16
fluphenazine hcl tabs.........................................................16
flurbiprofen.......................................................................16
flurbiprofen sodium...........................................................34
flutamide..........................................................................11
fluticasone propionate crea..................................................25
fluticasone propionate lotn..................................................25
fluticasone propionate oint..................................................25
fluticasone propionate susp..................................................35
fluvastatin.........................................................................23
fluvoxamine maleate tabs 100mg........................................16
fluvoxamine maleate tabs 25mg..........................................16
fluvoxamine maleate tabs 50mg..........................................16
folcal dha..........................................................................36
folcaps omega 3..................................................................36
folivane-ob........................................................................36
folivane-prx dha nf............................................................36
FOLOTYN......................................................................11
fondaparinux sodium inj 10mg/0.8ml, 5mg/0.4ml, 7.5mg/
0.6ml.............................................................................23
fondaparinux sodium inj 2.5mg/0.5ml...............................23
FORTEO........................................................................32
fosinopril sodium...............................................................23
fosinopril sodium/hydrochlorothiazide.................................23
freamine iii.......................................................................36
furosemide inj....................................................................23
furosemide oral soln...........................................................23
furosemide tabs..................................................................23
FUSILEV.........................................................................11
FUZEON..........................................................................8
FYCOMPA TABS 10MG, 12MG...................................16
FYCOMPA TABS 2MG..................................................16
FYCOMPA TABS 4MG..................................................16
Effective Date November 1, 2014
Drug Name
Page
FYCOMPA TABS 6MG..................................................16
FYCOMPA TABS 8MG..................................................16
gabapentin caps 100mg......................................................16
gabapentin caps 300mg......................................................16
gabapentin caps 400mg......................................................16
gabapentin oral soln...........................................................16
gabapentin tabs 600mg......................................................16
gabapentin tabs 800mg......................................................16
GABITRIL......................................................................16
galantamine hydrobromide cp24.........................................16
galantamine hydrobromide oral soln...................................16
galantamine hydrobromide tabs..........................................16
GAMASTAN S/D...........................................................31
ganciclovir...........................................................................8
GARDASIL.....................................................................31
GATTEX.........................................................................30
gauze pads 2"x2"...............................................................28
gavilyte-c...........................................................................30
gavilyte-g...........................................................................30
gavilyte-n/flavor pack.........................................................30
GAZYVA.........................................................................11
gemcitabine.......................................................................11
gemcitabine hcl inj 1gm, 200mg.........................................11
gemcitabine hcl inj 2gm.....................................................11
gemfibrozil........................................................................23
generlac.............................................................................30
gengraf..............................................................................11
GENOTROPIN..............................................................31
GENOTROPIN MINIQUICK INJ 0.2MG...................31
GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG,
0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG,
2MG.............................................................................31
gentak...............................................................................34
gentamicin sulfate crea.......................................................25
gentamicin sulfate inj...........................................................8
gentamicin sulfate oint 0.1%.............................................25
gentamicin sulfate oint 0.3%.............................................34
gentamicin sulfate ophthalmic soln......................................34
gentamicin sulfate pediatric..................................................8
GEODON INJ................................................................16
gildagia.............................................................................33
gildess 1.5/30.....................................................................33
gildess 1/20........................................................................33
gildess fe 1.5/30.................................................................33
gildess fe 1/20....................................................................33
GILENYA........................................................................16
GILOTRIF......................................................................11
Basic KS 14202, V15
46
Drug Name
Page
GLEEVEC.......................................................................11
glimepiride tabs 1mg..........................................................28
glimepiride tabs 2mg..........................................................28
glimepiride tabs 4mg..........................................................28
glipizide er tb24 10mg.......................................................28
glipizide er tb24 2.5mg......................................................28
glipizide er tb24 5mg.........................................................28
glipizide tabs 10mg............................................................28
glipizide tabs 5mg..............................................................28
glipizide xl tb24 10mg.......................................................28
glipizide xl tb24 2.5mg......................................................28
glipizide xl tb24 5mg.........................................................28
glipizide/metformin hcl tabs 2.5mg; 250mg.........................28
glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg;
500mg...........................................................................28
GLUCAGEN...................................................................28
GLUCAGEN HYPOKIT................................................28
GLUCAGON EMERGENCY KIT.................................28
griseofulvin microsize susp....................................................8
griseofulvin ultramicrosize....................................................8
guanidine hcl....................................................................16
H.P. ACTHAR................................................................28
HALAVEN......................................................................11
HALFLYTELY BOWEL PREP/FLAVOR PACKS.........30
halobetasol propionate........................................................25
haloperidol........................................................................16
haloperidol decanoate.........................................................16
haloperidol lactate..............................................................16
HAVRIX INJ 1440ELU/ML...........................................31
HAVRIX INJ 720ELU/0.5ML........................................31
heather..............................................................................33
hecoria caps 0.5mg, 1mg....................................................11
hecoria caps 5mg................................................................11
hemenatal ob.....................................................................36
hemenatal ob + dha...........................................................36
heparin sodium dcu...........................................................23
heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/
ml, 5000unit/0.5ml, 5000unit/ml..................................23
heparin sodium/d5w inj 5%; 100unit/ml, 5%; 40unit/
ml..................................................................................23
heparin sodium/d5w inj 5%; 50unit/ml.............................23
heparin sodium/nacl 0.45%...............................................23
heparin sodium/nacl 0.9%.................................................23
heparin sodium/sodium chloride 0.9% premix.....................23
HEPATAMINE...............................................................36
HEPSERA.........................................................................8
HERCEPTIN..................................................................11
Effective Date November 1, 2014
Drug Name
Page
HEXALEN......................................................................11
HUMALOG....................................................................28
HUMALOG KWIKPEN.................................................28
HUMALOG MIX 50/50.................................................28
HUMALOG MIX 50/50 KWIKPEN..............................28
HUMALOG MIX 75/25.................................................28
HUMALOG MIX 75/25 KWIKPEN..............................28
HUMIRA INJ 20MG/0.4ML..........................................32
HUMIRA INJ 40MG/0.8ML..........................................32
HUMIRA PEN................................................................32
HUMIRA PEN-CROHNS DISEASESTARTER............32
HUMIRA PEN-PSORIASIS STARTER.........................32
HUMULIN 70/30...........................................................28
HUMULIN 70/30 KWIKPEN.......................................28
HUMULIN 70/30 PEN..................................................28
HUMULIN N.................................................................28
HUMULIN N KWIKPEN..............................................28
HUMULIN N U-100 PEN.............................................28
HUMULIN R.................................................................28
HUMULIN R U-500 (CONCENTRATED).................28
hydralazine hcl inj.............................................................23
hydralazine hcl tabs...........................................................23
hydrochlorothiazide...........................................................23
hydrocodone/acetaminophen oral soln 325mg/15ml; 10mg/
15ml..............................................................................16
hydrocodone/acetaminophen oral soln 325mg/15ml; 7.5mg/
15ml..............................................................................16
hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg.......................................................16
hydrocodone/ibuprofen tabs 7.5mg; 200mg.........................16
hydrocortisone butyrate......................................................26
hydrocortisone crea 1%, 2.5%............................................26
hydrocortisone enem...........................................................30
hydrocortisone in absorbase.................................................26
hydrocortisone lotn 2.5%...................................................26
hydrocortisone oint 1%, 2.5%............................................26
hydrocortisone tabs.............................................................28
hydrocortisone valerate.......................................................26
hydrocortisone/acetic acid...................................................27
hydromorphone hcl inj 1mg/ml...........................................16
hydromorphone hcl inj 2mg/ml, 4mg/ml..............................16
hydromorphone hcl tabs 2mg..............................................16
hydromorphone hcl tabs 4mg..............................................16
hydromorphone hcl tabs 8mg..............................................16
hydroxychloroquine sulfate....................................................8
hydroxyurea.......................................................................11
ibandronate sodium inj......................................................32
Basic KS 14202, V15
47
Drug Name
Page
ibandronate sodium tabs....................................................32
ibuprofen susp...................................................................16
ibuprofen tabs 400mg, 600mg, 800mg...............................16
ICLUSIG.........................................................................11
IDAMYCIN PFS.............................................................11
idarubicin hcl....................................................................11
IFEX................................................................................11
ifosfamide inj 1gm.............................................................11
ifosfamide inj 1gm/20ml, 3gm, 3gm/60ml..........................11
IMBRUVICA..................................................................11
imipenem/cilastatin.............................................................8
imipramine hcl..................................................................16
imiquimod........................................................................26
IMOVAX RABIES (H.D.C.V.).......................................31
inatal advance...................................................................36
inatal ultra.......................................................................36
INCRELEX.....................................................................27
indapamide.......................................................................23
INFANRIX......................................................................31
INLYTA..........................................................................11
INSULIN PEN NEEDLE...............................................28
INSULIN SYRINGE (DISP) U-100 0.3 ML..................28
INSULIN SYRINGE (DISP) U-100 1 ML.....................28
INSULIN SYRINGE (DISP) U-100 1/2 ML..................28
INTELENCE TABS 100MG, 200MG.............................8
INTELENCE TABS 25MG..............................................8
INTRON-A INJ 10MU/ML...........................................31
INTRON-A INJ 6000000UNIT/ML..............................31
INTRON-A W/DILUENT INJ 10MU..........................31
INTRON-A W/DILUENT INJ 18MU, 50MU..............31
introvale...........................................................................33
INTUNIV.......................................................................16
INVEGA SUSTENNA INJ 117MG/0.75ML, 156MG/
ML, 234MG/1.5ML.....................................................17
INVEGA SUSTENNA INJ 39MG/0.25ML, 78MG/
0.5ML...........................................................................17
INVEGA TB24 1.5MG...................................................17
INVEGA TB24 3MG......................................................17
INVEGA TB24 6MG......................................................17
INVEGA TB24 9MG......................................................17
INVIRASE.........................................................................8
IPOL INACTIVATED IPV............................................31
ipratropium bromide inhalation soln..................................35
ipratropium bromide nasal soln..........................................27
ipratropium bromide/albuterol sulfate.................................35
irbesartan..........................................................................23
irbesartan/hydrochlorothiazide............................................23
Effective Date November 1, 2014
Drug Name
Page
irinotecan inj 100mg/5ml, 40mg/2ml.................................11
irinotecan inj 500mg/25ml................................................11
ISENTRESS CHEW.........................................................8
ISENTRESS PACK...........................................................8
ISENTRESS TABS............................................................9
isoniazid syrp.......................................................................9
isoniazid tabs......................................................................9
isosorbide dinitrate.............................................................23
isosorbide dinitrate er.........................................................23
isosorbide mononitrate.......................................................23
isosorbide mononitrate er....................................................23
ISTODAX.......................................................................11
itraconazole.........................................................................9
IXEMPRA KIT................................................................11
IXIARO...........................................................................31
JAKAFI............................................................................11
JALYN.............................................................................36
jantoven............................................................................23
JANUMET......................................................................28
JANUMET XR TB24 1000MG; 100MG.......................28
JANUMET XR TB24 1000MG; 50MG, 500MG;
50MG...........................................................................28
JANUVIA TABS 100MG................................................28
JANUVIA TABS 25MG..................................................28
JANUVIA TABS 50MG..................................................28
JEVTANA.......................................................................11
jolessa................................................................................33
jolivette.............................................................................33
junel 1.5/30......................................................................33
junel 1/20.........................................................................33
junel fe 1.5/30...................................................................33
junel fe 1/20......................................................................33
k-effervescent.....................................................................36
k-vescent tbef.....................................................................36
KADCYLA......................................................................11
KALETRA ORAL SOLN..................................................9
KALETRA TABS...............................................................9
kariva...............................................................................33
KAZANO........................................................................28
kcl 0.075%/d5w/nacl 0.45%.............................................36
kcl 0.15%/d5w/ nacl 0.3%................................................36
kcl 0.15%/d5w/nacl 0.45%...............................................36
kcl 0.3%/d5w/lr iv lac ring................................................36
kcl 0.3%/d5w/nacl 0.45%.................................................36
kelnor 1/35.......................................................................33
ketoconazole crea...............................................................26
ketoconazole sham..............................................................26
Basic KS 14202, V15
48
Drug Name
Page
ketoconazole tabs.................................................................9
ketorolac tromethamine ophthalmic soln..............................34
KHEDEZLA TB24 100MG............................................17
KHEDEZLA TB24 50MG..............................................17
klor-con 10.......................................................................36
klor-con 8.........................................................................36
klor-con m10.....................................................................36
klor-con m15.....................................................................36
klor-con m20.....................................................................36
klor-con/ef.........................................................................36
KUVAN TBSO...............................................................28
labetalol hcl tabs................................................................23
LACRISERT....................................................................34
lactated ringers dextrose 5% viaflex.....................................27
lactulose............................................................................30
lamivudine..........................................................................9
lamivudine/zidovudine........................................................9
lamotrigine........................................................................17
LANOXIN TABS 125MCG............................................23
LANOXIN TABS 250MCG, 62.5MCG.........................23
lansoprazole.......................................................................30
LANTUS.........................................................................28
LANTUS SOLOSTAR....................................................28
latanoprost........................................................................34
LATUDA TABS 120MG................................................17
LATUDA TABS 20MG..................................................17
LATUDA TABS 40MG..................................................17
LATUDA TABS 60MG..................................................17
LATUDA TABS 80MG..................................................17
LAZANDA......................................................................17
leena.................................................................................33
leflunomide.......................................................................32
lessina...............................................................................33
LETAIRIS........................................................................35
letrozole............................................................................11
leucovorin calcium inj 100mg, 200mg, 350mg, 50mg.........12
leucovorin calcium inj 500mg............................................12
leucovorin calcium tabs......................................................12
LEUKERAN....................................................................12
LEUKINE.......................................................................31
leuprolide acetate...............................................................12
LEVEMIR.......................................................................28
LEVEMIR FLEXPEN.....................................................28
LEVEMIR FLEXTOUCH..............................................28
levetiracetam er tb24 500mg..............................................17
levetiracetam er tb24 750mg..............................................17
levetiracetam inj 500mg/5ml..............................................17
Effective Date November 1, 2014
Drug Name
Page
levetiracetam oral soln........................................................17
levetiracetam tabs..............................................................17
levobunolol hcl...................................................................34
levocarnitine oral soln........................................................27
levocarnitine tabs...............................................................27
levofloxacin in d5w..............................................................9
levofloxacin inj....................................................................9
levofloxacin ophthalmic soln...............................................34
levofloxacin tabs..................................................................9
levonest.............................................................................33
levonorgestrel/ethinyl estradiol.............................................33
levora 0.15/30-28.............................................................33
levothyroxine sodium inj 200mcg........................................28
levothyroxine sodium tabs...................................................28
levoxyl...............................................................................28
LEXIVA SUSP...................................................................9
LEXIVA TABS..................................................................9
lidocaine hcl inj 2%..........................................................26
lidocaine hcl inj 20mg/ml...................................................23
lidocaine hcl viscous...........................................................26
lidocaine oint....................................................................26
lidocaine ptch....................................................................26
lidocaine viscous................................................................26
lidocaine/prilocaine crea.....................................................26
lidocaine/prilocaine kit.......................................................26
LIDODERM...................................................................26
lindane sham.....................................................................26
liothyronine sodium tabs....................................................28
liposyn iii inj 2.5%; 10%, 2.5%; 30%..............................36
liposyn iii inj 2.5%; 20%..................................................36
lisinopril...........................................................................23
lisinopril/hydrochlorothiazide.............................................23
lithium carbonate..............................................................17
lithium carbonate er..........................................................17
lithium citrate...................................................................17
LOMUSTINE.................................................................12
loperamide hcl caps............................................................30
lorazepam tabs..................................................................17
losartan potassium tabs 100mg...........................................24
losartan potassium tabs 25mg, 50mg...................................24
losartan potassium/hydrochlorothiazide...............................24
LOTRONEX TABS 0.5MG............................................30
LOTRONEX TABS 1MG...............................................30
lovastatin tabs 10mg, 20mg...............................................24
lovastatin tabs 40mg..........................................................24
LOVAZA.........................................................................24
low-ogestrel........................................................................33
Basic KS 14202, V15
49
Drug Name
Page
loxapine............................................................................17
loxapine succinate..............................................................17
LUMIGAN......................................................................34
LUPRON DEPOT INJ 3.75MG, 7.5MG.......................12
LUPRON DEPOT-PED INJ 7.5MG.............................12
lutera................................................................................33
LYRICA CAPS 100MG...................................................17
LYRICA CAPS 150MG...................................................17
LYRICA CAPS 200MG...................................................17
LYRICA CAPS 225MG, 300MG....................................17
LYRICA CAPS 25MG.....................................................17
LYRICA CAPS 50MG.....................................................17
LYRICA CAPS 75MG.....................................................17
LYRICA ORAL SOLN....................................................17
LYSODREN....................................................................12
lyza...................................................................................33
M-M-R II W/DILUENT 10 DOSE................................31
magnesium sulfate inj 40mg/ml, 80mg/ml...........................36
magnesium sulfate inj 50%................................................36
malathion.........................................................................26
maprotiline hcl tabs 25mg..................................................17
maprotiline hcl tabs 50mg..................................................17
maprotiline hcl tabs 75mg..................................................17
marlissa............................................................................33
MARPLAN......................................................................17
MATULANE...................................................................12
meclizine hcl tabs...............................................................30
medroxyprogesterone acetate inj..........................................33
medroxyprogesterone acetate tabs.........................................33
mefloquine hcl.....................................................................9
megestrol acetate................................................................12
MEKINIST.....................................................................12
meloxicam tabs..................................................................17
melphalan hydrochloride....................................................12
MENACTRA..................................................................31
MENEST........................................................................33
MENOMUNE-A/C/Y/W-135........................................31
MENVEO.......................................................................31
MEPRON.........................................................................9
mercaptopurine..................................................................12
meropenem..........................................................................9
mesalamine.......................................................................30
mesna...............................................................................12
MESNEX INJ..................................................................12
MESNEX TABS..............................................................12
metformin hcl er tb24 1000mg...........................................29
metformin hcl er tb24 500mg.............................................29
Effective Date November 1, 2014
Drug Name
Page
metformin hcl er tb24 500mg.............................................29
metformin hcl er tb24 750mg.............................................29
metformin hcl tabs 1000mg...............................................29
metformin hcl tabs 500mg.................................................29
metformin hcl tabs 850mg.................................................29
methadone hcl conc............................................................17
methadone hcl intensol.......................................................17
methadone hcl oral soln 10mg/5ml.....................................17
methadone hcl oral soln 5mg/5ml.......................................17
methadone hcl tabs 10mg...................................................17
methadone hcl tabs 5mg.....................................................17
methadone hcl tbso.............................................................17
methadose conc..................................................................17
methadose sugar-free..........................................................17
methadose tbso...................................................................17
methazolamide..................................................................34
methenamine hippurate.......................................................9
methenamine mandelate......................................................9
methimazole......................................................................29
methotrexate......................................................................12
methotrexate sodium inj 1gm..............................................12
methotrexate sodium inj 25mg/ml, 50mg/2ml.....................12
methoxsalen.......................................................................26
methyldopa........................................................................24
methylphenidate hcl...........................................................17
methylprednisolone............................................................29
methylprednisolone acetate..................................................29
methylprednisolone dose pack..............................................29
methylprednisolone sodiumsuccinate inj 1000mg,
125mg...........................................................................29
methylprednisolone sodiumsuccinate inj 40mg.....................29
metipranolol......................................................................34
metoclopramide hcl inj.......................................................30
metoclopramide hcl oral soln...............................................30
metoclopramide hcl tabs.....................................................30
metoprolol succinate er.......................................................24
metoprolol tartrate tabs......................................................24
metoprolol/hydrochlorothiazide...........................................24
metro iv..............................................................................9
metronidazole caps...............................................................9
metronidazole crea.............................................................26
metronidazole gel 0.75%...................................................26
metronidazole in nacl 0.79%...............................................9
metronidazole lotn.............................................................26
metronidazole tabs...............................................................9
metronidazole vaginal........................................................33
mexiletine hcl....................................................................24
Basic KS 14202, V15
50
Drug Name
Page
MICARDIS HCT TABS 12.5MG; 40MG, 25MG;
80MG...........................................................................24
MICARDIS HCT TABS 12.5MG; 80MG......................24
MICARDIS TABS 20MG, 40MG..................................24
MICARDIS TABS 80MG...............................................24
microgestin 1.5/30.............................................................33
microgestin 1/20................................................................33
micronized colestipol hcl.....................................................24
midodrine hcl....................................................................27
minocycline hcl....................................................................9
minoxidil tabs...................................................................24
mirtazapine odt tbdp 15mg................................................17
mirtazapine odt tbdp 30mg................................................17
mirtazapine odt tbdp 45mg................................................18
mirtazapine tabs 15mg......................................................18
mirtazapine tabs 30mg......................................................18
mirtazapine tabs 45mg......................................................18
mirtazapine tabs 7.5mg.....................................................18
mirtazapine tbdp...............................................................18
misoprostol........................................................................30
mitomycin.........................................................................12
mitoxantrone hcl................................................................12
modafinil tabs 100mg........................................................18
modafinil tabs 200mg........................................................18
moexipril hcl.....................................................................24
moexipril/hydrochlorothiazide............................................24
mometasone furoate...........................................................26
mono-linyah......................................................................33
mononessa.........................................................................33
montelukast sodium chew...................................................35
montelukast sodium pack...................................................35
montelukast sodium tabs....................................................35
morphine sulfate er tbcr 100mg, 200mg..............................18
morphine sulfate er tbcr 15mg, 30mg, 60mg.......................18
morphine sulfate inj 0.5mg/ml............................................18
morphine sulfate inj 10mg/ml, 150mg/30ml, 15mg/ml, 1mg/
ml, 50mg/ml..................................................................18
morphine sulfate inj 1mg/ml...............................................18
morphine sulfate inj 25mg/ml, 2mg/ml, 4mg/ml..................18
MORPHINE SULFATE INJ 8MG/ML.........................18
morphine sulfate oral soln 10mg/5ml..................................18
morphine sulfate oral soln 20mg/5ml..................................18
morphine sulfate oral soln 20mg/ml....................................18
morphine sulfate supp........................................................18
morphine sulfate tabs 15mg................................................18
morphine sulfate tabs 30mg................................................18
MOTOFEN....................................................................30
Effective Date November 1, 2014
Drug Name
Page
MOXATAG......................................................................9
moxifloxacin hcl..................................................................9
mupirocin oint..................................................................26
MUSTARGEN................................................................12
MYCOBUTIN..................................................................9
mycophenolate mofetil........................................................12
myzilra.............................................................................33
nadolol/bendroflumethiazide..............................................24
NAGLAZYME................................................................29
nalbuphine hcl..................................................................18
naloxone hcl inj 0.4mg/ml..................................................18
naloxone hcl inj 1mg/ml.....................................................18
naltrexone hcl....................................................................18
NAMENDA ORAL SOLN.............................................18
NAMENDA TABS 10MG..............................................18
NAMENDA TABS 5MG................................................18
NAMENDA TITRATION PAK.....................................18
NAMENDA XR..............................................................18
NAMENDA XR TITRATION PACK............................18
naphazoline hcl.................................................................34
naproxen...........................................................................18
naproxen dr.......................................................................18
naproxen sodium tabs 275mg, 550mg.................................18
naratriptan hcl..................................................................18
nateglinide tabs 120mg......................................................29
nateglinide tabs 60mg........................................................29
NEBUPENT.....................................................................9
necon 0.5/35-28................................................................33
necon 1/35........................................................................33
necon 1/50-28...................................................................33
necon 10/11-28.................................................................33
necon 7/7/7.......................................................................33
NEEDLES, INSULIN DISP., SAFETY..........................29
nefazodone hcl tabs 100mg.................................................18
nefazodone hcl tabs 150mg.................................................18
nefazodone hcl tabs 200mg.................................................18
nefazodone hcl tabs 250mg.................................................18
nefazodone hcl tabs 50mg...................................................18
neo-polycin........................................................................34
neo-polycin hc....................................................................34
neomycin sulfate..................................................................9
neomycin/bacitracin/polymyxin...........................................34
neomycin/polymyxin/bacitracin zinc....................................34
neomycin/polymyxin/bacitracin/hydrocortisone.....................34
neomycin/polymyxin/dexamethasone....................................34
neomycin/polymyxin/gramicidin.........................................34
neomycin/polymyxin/hc......................................................27
Basic KS 14202, V15
51
Drug Name
Page
neomycin/polymyxin/hydrocortisone.....................................27
neomycin/polymyxin/hydrocortisone.....................................34
NESINA TABS 12.5MG.................................................29
NESINA TABS 25MG....................................................29
NESINA TABS 6.25MG.................................................29
NEULASTA....................................................................31
NEUMEGA.....................................................................31
NEUPOGEN..................................................................31
nevirapine er.......................................................................9
nevirapine susp....................................................................9
nevirapine tabs....................................................................9
NEXAVAR......................................................................12
niacin er tbcr.....................................................................24
NIACOR.........................................................................24
nicardipine hcl caps...........................................................24
NICOTROL NS.............................................................27
nifedical xl........................................................................24
nifedipine er......................................................................24
NILANDRON................................................................12
NIPENT..........................................................................12
nitrofurantoin macrocrystals.................................................9
nitrofurantoin monohydrate.................................................9
nitrofurantoin monohydrate/macrocrystals.............................9
nitrofurantoin susp..............................................................9
nitroglycerin pt24..............................................................24
nitroglycerin transdermal...................................................24
NITROSTAT..................................................................24
nora-be.............................................................................33
norethindrone....................................................................33
norethindrone acetate.........................................................33
norgestimate/ethinyl estradiol..............................................33
nortrel 0.5/35 (28)............................................................33
nortrel 1/35.......................................................................33
nortrel 7/7/7......................................................................33
nortriptyline hcl.................................................................18
NORVIR...........................................................................9
NOVOPEN ECHO........................................................29
NOXAFIL SUSP...............................................................9
NUEDEXTA...................................................................18
NULOJIX........................................................................12
nyamyc..............................................................................26
nystatin crea......................................................................26
nystatin oint......................................................................26
nystatin powd 100000unit/gm...........................................26
nystatin susp........................................................................9
nystatin tabs........................................................................9
nystatin/triamcinolone.......................................................26
Effective Date November 1, 2014
Drug Name
Page
nystop...............................................................................26
ocella................................................................................33
octreotide acetate inj 1000mcg/ml.......................................12
octreotide acetate inj 100mcg/ml, 200mcg/ml, 500mcg/ml,
50mcg/ml.......................................................................12
ofloxacin ophthalmic soln...................................................34
ofloxacin otic soln..............................................................27
ogestrel..............................................................................33
olanzapine odt tbdp 10mg..................................................18
olanzapine odt tbdp 15mg..................................................18
olanzapine odt tbdp 20mg..................................................18
olanzapine odt tbdp 5mg....................................................18
olanzapine tabs 10mg........................................................18
olanzapine tabs 15mg........................................................18
olanzapine tabs 2.5mg.......................................................18
olanzapine tabs 20mg........................................................18
olanzapine tabs 5mg..........................................................18
olanzapine tabs 7.5mg.......................................................19
omega-3-acid ethyl esters....................................................24
omeprazole cpdr.................................................................30
ONCASPAR....................................................................12
ondansetron hcl inj............................................................30
ondansetron hcl tabs 4mg, 8mg...........................................30
ONFI SUSP.....................................................................19
ONFI TABS 10MG.........................................................19
ONFI TABS 20MG.........................................................19
ONTAK..........................................................................12
opium...............................................................................30
opium tincture...................................................................30
opium tincture (paregoric)..................................................30
ORAP..............................................................................19
ORFADIN......................................................................27
orsythia.............................................................................33
OSENI TABS 12.5MG; 15MG.......................................29
OSENI TABS 12.5MG; 30MG, 12.5MG; 45MG,
25MG; 15MG, 25MG; 30MG, 25MG; 45MG............29
oxacillin sodium..................................................................9
oxaliplatin inj 100mg, 100mg/20ml, 50mg/10ml...............12
oxaliplatin inj 50mg..........................................................12
oxandrolone tabs 10mg......................................................29
oxandrolone tabs 2.5mg.....................................................29
oxazepam..........................................................................19
oxcarbazepine....................................................................19
OXTELLAR XR TB24 150MG......................................19
OXTELLAR XR TB24 300MG......................................19
OXTELLAR XR TB24 600MG......................................19
oxybutynin chloride er tb24 10mg, 15mg............................36
Basic KS 14202, V15
52
Drug Name
Page
oxybutynin chloride er tb24 5mg........................................36
oxybutynin chloride syrp.....................................................36
oxybutynin chloride tabs.....................................................36
oxycodone hcl caps..............................................................19
oxycodone hcl oral soln.......................................................19
oxycodone hcl tabs 10mg....................................................19
oxycodone hcl tabs 15mg....................................................19
oxycodone hcl tabs 20mg....................................................19
oxycodone hcl tabs 30mg....................................................19
oxycodone hcl tabs 5mg......................................................19
oxycodone/acetaminophen...................................................19
oxycodone/aspirin...............................................................19
oxycodone/ibuprofen...........................................................19
pacerone............................................................................24
paclitaxel...........................................................................12
pamidronate disodium.......................................................29
PANRETIN.....................................................................26
pantoprazole sodium inj.....................................................30
pantoprazole sodium tbec...................................................30
paricalcitol........................................................................29
paroex...............................................................................27
paromomycin sulfate............................................................9
paroxetine hcl er tb24 12.5mg............................................19
paroxetine hcl er tb24 25mg...............................................19
paroxetine hcl er tb24 37.5mg............................................19
paroxetine hcl tabs 10mg....................................................19
paroxetine hcl tabs 20mg....................................................19
paroxetine hcl tabs 30mg....................................................19
paroxetine hcl tabs 40mg....................................................19
PASER...............................................................................9
PAXIL SUSP....................................................................19
pedi-dri.............................................................................26
PEDVAX HIB.................................................................31
peg-3350/electrolytes..........................................................30
peg-3350/nacl/na bicarbonate/kcl.......................................30
PEGANONE...................................................................19
PEGASYS........................................................................31
PEGASYS PROCLICK...................................................31
penicillin g potassium inj 20000000unit, 5mu.....................9
penicillin v potassium...........................................................9
PENTAM 300...................................................................9
pentoxifylline er.................................................................24
perindopril erbumine.........................................................24
periogard...........................................................................27
PERJETA.........................................................................12
permethrin crea.................................................................26
perphenazine.....................................................................19
Effective Date November 1, 2014
Drug Name
Page
perphenazine/amitriptyline.................................................19
pfizerpen-g..........................................................................9
phenelzine sulfate...............................................................19
phenobarbital elix..............................................................19
phenobarbital tabs 100mg..................................................19
phenobarbital tabs 15mg....................................................19
phenobarbital tabs 16.2mg.................................................19
phenobarbital tabs 30mg....................................................19
phenobarbital tabs 32.4mg.................................................19
phenobarbital tabs 60mg....................................................19
phenobarbital tabs 64.8mg.................................................19
phenobarbital tabs 97.2mg.................................................19
phenytoin chew..................................................................19
phenytoin infatabs.............................................................19
phenytoin sodium...............................................................19
phenytoin sodium extended.................................................19
phenytoin susp...................................................................19
philith...............................................................................33
pilocarpine hcl...................................................................27
pilocarpine hcl...................................................................34
pilocarpine hydrochloride...................................................27
pioglitazone hcl tabs 15mg.................................................29
pioglitazone hcl tabs 30mg.................................................29
pioglitazone hcl tabs 45mg.................................................29
pioglitazone hcl-glimepiride................................................29
pioglitazone hcl/metformin hcl............................................29
piperacillin sodium/tazobactam sodium inj 2gm; 0.25gm,
36gm; 4.5gm, 3gm; 0.375gm............................................9
piperacillin sodium/tazobactam sodium inj 4gm; 0.5gm.........9
piperacillin/tazobactam........................................................9
pirmella 1/35....................................................................33
pnv ob+dha.......................................................................36
pnv prenatal plus multivitamin..........................................36
pnv-dha............................................................................36
pnv-select..........................................................................36
podofilox...........................................................................26
polycin..............................................................................34
polyethylene glycol 3350.....................................................30
polymyxin b sulfate/trimethoprim sulfate.............................34
POMALYST....................................................................12
portia-28..........................................................................33
potassium chloride 0.15% d5w/nacl 0.33%........................36
potassium chloride 0.15% d5w/nacl 0.45%........................36
potassium chloride 0.15% d5w/nacl 0.45% viaflex.............36
potassium chloride 0.15%/d5w..........................................36
potassium chloride 0.22% d5w/nacl 0.45%........................36
potassium chloride 0.224%/d5w/nacl 0.45%......................36
Basic KS 14202, V15
53
Drug Name
Page
potassium chloride 0.224%d5w/nacl 0.45% viaflex............36
potassium chloride 0.3%/d5w............................................36
potassium chloride cr..........................................................36
potassium chloride er..........................................................36
potassium chloride inj 0.4meq/ml, 10meq/100ml, 10meq/
50ml, 20meq/100ml, 20meq/50ml, 30meq/100ml,
40meq/100ml..........................................................36–37
potassium chloride inj 2meq/ml..........................................37
potassium chloride liqd.......................................................37
potassium chloride oral soln................................................37
potassium chloride sr..........................................................37
potassium citrate er tbcr 1080mg, 540mg...........................36
POTIGA TABS 200MG, 300MG, 400MG....................19
POTIGA TABS 50MG....................................................19
pr natal 400......................................................................37
pr natal 400 ec..................................................................37
pr natal 430......................................................................37
pr natal 430 ec..................................................................37
PRADAXA.......................................................................24
pramipexole dihydrochloride...............................................19
PRANDIN TABS 0.5MG...............................................29
PRANDIN TABS 1MG..................................................29
PRANDIN TABS 2MG..................................................29
pravastatin sodium............................................................24
prazosin hcl.......................................................................24
prednicarbate....................................................................26
prednisolone......................................................................29
prednisolone acetate...........................................................34
prednisolone sodium phosphate ophthalmic soln...................34
prednisolone sodium phosphate oral soln 15mg/5ml, 5mg/
5ml................................................................................29
prednisone.........................................................................29
prednisone intensol.............................................................29
PREMARIN CREA.........................................................33
PREMARIN TABS..........................................................33
prenaissance......................................................................37
prenaissance plus................................................................37
prenatabs fa.......................................................................37
prenatabs obn....................................................................37
prenatal plus.....................................................................37
prenatal tabs 120mg; 0; 0; 200mg; 400unit; 2mg; 12mcg;
27mg; 1mg; 20mg; 10mg; 3mg; 1.84mg; 22mg; 4000unit;
25mg.............................................................................37
prevalite............................................................................24
previfem............................................................................33
PREZISTA SUSP..............................................................9
PREZISTA TABS 150MG, 75MG....................................9
Effective Date November 1, 2014
Drug Name
Page
PREZISTA TABS 600MG, 800MG..................................9
PRIMAQUINE PHOSPHATE.........................................9
primidone.........................................................................19
PRISTIQ TB24 100MG..................................................19
PRISTIQ TB24 50MG....................................................19
PROAIR HFA.................................................................35
probenecid.........................................................................32
prochlorperazine................................................................30
prochlorperazine edisylate...................................................31
prochlorperazine maleate....................................................31
PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML,
3000UNIT/ML, 4000UNIT/ML.................................32
PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML.......32
procto-pak.........................................................................31
proctosol hc........................................................................31
proctozone-hc....................................................................31
PROGLYCEM................................................................29
PROGRAF INJ...............................................................12
PROLASTIN-C...............................................................27
PROLEUKIN..................................................................32
PROMACTA..................................................................24
propafenone hcl.................................................................24
propranolol hcl er...............................................................24
propranolol hcl oral soln.....................................................24
propranolol hcl tabs............................................................24
propranolol/hydrochlorothiazide..........................................24
propylthiouracil.................................................................29
PROQUAD.....................................................................32
protriptyline hcl.................................................................19
PULMOZYME...............................................................35
pyrazinamide......................................................................9
pyridostigmine bromide......................................................19
quasense............................................................................33
quetiapine fumarate tabs 100mg........................................19
quetiapine fumarate tabs 200mg........................................20
quetiapine fumarate tabs 25mg..........................................20
quetiapine fumarate tabs 300mg........................................20
quetiapine fumarate tabs 400mg........................................20
quetiapine fumarate tabs 50mg..........................................20
quinapril hcl.....................................................................24
quinapril/hydrochlorothiazide............................................24
quinidine sulfate................................................................24
quinidine sulfate er............................................................24
QVAR..............................................................................35
RABAVERT....................................................................32
raloxifene hydrochloride.....................................................32
ramipril............................................................................24
Basic KS 14202, V15
54
Drug Name
Page
RANEXA.........................................................................24
ranitidine hcl tabs..............................................................31
RAPAMUNE ORAL SOLN............................................12
RAPAMUNE TABS 0.5MG, 1MG.................................12
RAPAMUNE TABS 2MG..............................................12
REBIF..............................................................................32
REBIF REBIDOSE.........................................................32
REBIF REBIDOSE TITRATION PACK.......................32
REBIF TITRATION PACK...........................................32
reclipsen............................................................................33
RECOMBIVAX HB INJ 10MCG/ML, 40MCG/
ML................................................................................32
RECOMBIVAX HB INJ 5MCG/0.5ML........................32
RELISTOR......................................................................31
relnate dha........................................................................37
REMICADE....................................................................31
RENVELA PACK............................................................27
RENVELA TABS............................................................27
repaglinide tabs 0.5mg.......................................................29
repaglinide tabs 1mg..........................................................29
repaglinide tabs 2mg..........................................................29
RESCRIPTOR..................................................................9
RESCULA.......................................................................34
reserpine tabs 0.1mg..........................................................24
RETROVIR IV INFUSION.............................................9
REVLIMID CAPS 10MG...............................................12
REVLIMID CAPS 15MG, 20MG, 25MG......................12
REVLIMID CAPS 2.5MG..............................................12
REVLIMID CAPS 5MG.................................................12
REYATAZ CAPS 100MG.................................................9
REYATAZ CAPS 150MG, 200MG, 300MG....................9
ribasphere caps.....................................................................9
ribasphere tabs 200mg.........................................................9
ribavirin.............................................................................9
rifabutin.............................................................................9
rifampin caps......................................................................9
rifampin inj........................................................................9
riluzole.............................................................................27
rimantadine hcl...................................................................9
ringers injection.................................................................37
RIOMET.........................................................................29
RISPERDAL CONSTA INJ 12.5MG, 25MG................20
RISPERDAL CONSTA INJ 37.5MG.............................20
RISPERDAL CONSTA INJ 50MG................................20
risperidone m-tab tbdp 0.5mg............................................20
risperidone m-tab tbdp 1mg...............................................20
risperidone m-tab tbdp 2mg...............................................20
Effective Date November 1, 2014
Drug Name
Page
risperidone m-tab tbdp 3mg...............................................20
risperidone m-tab tbdp 4mg...............................................20
risperidone odt tbdp 0.25mg...............................................20
risperidone odt tbdp 0.5mg.................................................20
risperidone odt tbdp 1mg....................................................20
risperidone odt tbdp 2mg....................................................20
risperidone odt tbdp 3mg....................................................20
risperidone odt tbdp 4mg....................................................20
risperidone oral soln...........................................................20
risperidone tabs 0.25mg.....................................................20
risperidone tabs 0.5mg.......................................................20
risperidone tabs 1mg..........................................................20
risperidone tabs 2mg..........................................................20
risperidone tabs 3mg..........................................................20
risperidone tabs 4mg..........................................................20
RITUXAN.......................................................................12
rivastigmine tartrate..........................................................20
ropinirole hcl.....................................................................20
rosadan.............................................................................26
ROTATEQ.....................................................................32
roxicet tabs........................................................................20
ROZEREM.....................................................................20
SABRIL PACK................................................................20
SABRIL TABS.................................................................20
SAMSCA TABS 15MG...................................................29
SAMSCA TABS 30MG...................................................29
SANTYL..........................................................................26
SAPHRIS SUBL 10MG...................................................20
SAPHRIS SUBL 5MG.....................................................20
SAVELLA TABS 100MG................................................32
SAVELLA TABS 12.5MG...............................................32
SAVELLA TABS 25MG..................................................32
SAVELLA TABS 50MG..................................................32
SAVELLA TITRATION PACK......................................32
se-natal 19........................................................................37
se-tan dha.........................................................................37
selegiline hcl......................................................................20
selenium sulfide lotn..........................................................26
SELZENTRY....................................................................9
SENSIPAR TABS 30MG................................................29
SENSIPAR TABS 60MG................................................29
SENSIPAR TABS 90MG................................................29
SEREVENT DISKUS.....................................................35
SEROQUEL XR TB24 150MG......................................20
SEROQUEL XR TB24 200MG......................................20
SEROQUEL XR TB24 300MG......................................20
SEROQUEL XR TB24 400MG......................................20
Basic KS 14202, V15
55
Drug Name
Page
SEROQUEL XR TB24 50MG........................................20
sertraline hcl conc..............................................................20
sertraline hcl tabs 100mg...................................................20
sertraline hcl tabs 25mg.....................................................20
sertraline hcl tabs 50mg.....................................................20
sevelamer carbonate...........................................................27
sf 5000 plus.......................................................................27
sildenafil...........................................................................35
sildenafil citrate.................................................................35
silver sulfadiazine..............................................................26
SIMPONI........................................................................32
SIMULECT INJ 10MG..................................................12
SIMULECT INJ 20MG..................................................12
simvastatin........................................................................24
sirolimus...........................................................................12
sodium bicarbonate inj 4.2%, 7.5%...................................37
sodium bicarbonate inj 8.4%.............................................37
sodium bicarbonate partial fill............................................37
sodium chloride 0.45%......................................................37
sodium chloride 0.45% viaflex...........................................37
sodium chloride inj 0.9%...................................................27
sodium chloride inj 3%, 4meq/ml.......................................37
sodium chloride inj 5%......................................................37
sodium chloride pab...........................................................27
sodium fluoride tabs...........................................................37
sodium phenylbutyrate.......................................................27
sodium polystyrene sulfonate powd......................................27
sodium polystyrene sulfonate susp 15gm/60ml, 30gm/
120ml............................................................................27
sodium sulfacetamide lotn..................................................26
sodium sulfacetamide ophthalmic soln.................................34
SOLARAZE.....................................................................26
SOLTAMOX...................................................................12
SOMAVERT INJ 10MG, 15MG, 20MG.......................29
SOMAVERT INJ 25MG, 30MG....................................29
SORIATANE..................................................................26
sorine................................................................................24
sotalol hcl..........................................................................24
sotalol hcl (af)....................................................................24
SPIRIVA HANDIHALER...............................................35
spironolactone....................................................................24
spironolactone/hydrochlorothiazide......................................24
sprintec 28........................................................................33
SPRYCEL........................................................................12
sps.....................................................................................27
sronyx...............................................................................33
ssd.....................................................................................26
Effective Date November 1, 2014
Drug Name
Page
stavudine caps.....................................................................9
stavudine oral soln...............................................................9
sterile water irrigation........................................................27
sterile water irrigation plastic bottle....................................27
sterile water irrigation w/hanger.........................................27
STIVARGA.....................................................................12
STRATTERA CAPS 100MG, 60MG, 80MG.................20
STRATTERA CAPS 10MG, 18MG, 25MG, 40MG......20
STREPTOMYCIN SULFATE..........................................9
STRIBILD.........................................................................9
STROMECTOL...............................................................9
SUBOXONE FILM 12MG; 3MG..................................20
SUBOXONE FILM 2MG; 0.5MG.................................21
SUBOXONE FILM 4MG; 1MG....................................21
SUBOXONE FILM 8MG; 2MG....................................21
SUBSYS...........................................................................21
sucralfate tabs....................................................................31
sulfacetamide sodium.........................................................26
sulfacetamide sodium.........................................................34
sulfacetamide sodium/prednisolone sodium phosphate...........34
sulfadiazine.........................................................................9
sulfamethoxazole/trimethoprim ds.........................................9
sulfamethoxazole/trimethoprim inj........................................9
sulfamethoxazole/trimethoprim susp......................................9
sulfamethoxazole/trimethoprim tabs....................................10
sulfasalazine......................................................................31
sulfazine............................................................................31
sulfazine ec........................................................................31
sulindac............................................................................21
sumatriptan nasal soln 20mg/act.........................................21
sumatriptan nasal soln 5mg/act...........................................21
sumatriptan succinate inj...................................................21
sumatriptan succinate refill................................................21
sumatriptan succinate tabs.................................................21
SURMONTIL.................................................................21
SUSTIVA........................................................................10
SUTENT.........................................................................12
syeda.................................................................................33
SYLATRON....................................................................32
SYMLINPEN 120...........................................................29
SYMLINPEN 60.............................................................30
SYNAREL.......................................................................30
SYNRIBO........................................................................12
SYNTHROID.................................................................30
TABLOID.......................................................................12
tacrolimus caps 0.5mg, 1mg...............................................12
tacrolimus caps 5mg...........................................................12
Basic KS 14202, V15
56
Drug Name
Page
TAFINLAR.....................................................................12
TAMIFLU CAPS 30MG.................................................10
TAMIFLU CAPS 45MG.................................................10
TAMIFLU CAPS 75MG.................................................10
TAMIFLU SUSR.............................................................10
tamoxifen citrate................................................................12
tamsulosin hcl....................................................................36
TARCEVA......................................................................12
TARGRETIN CAPS.......................................................12
TARGRETIN GEL.........................................................12
taron-prex.........................................................................37
TASIGNA.......................................................................12
TAXOTERE....................................................................12
TAZORAC......................................................................26
taztia xt............................................................................24
TEKTURNA...................................................................24
TEKTURNA HCT.........................................................24
telmisartan tabs 20mg, 40mg.............................................24
telmisartan tabs 80mg........................................................24
telmisartan/amlodipine......................................................24
telmisartan/hydrochlorothiazide tabs 12.5mg; 40mg, 25mg;
80mg.............................................................................24
telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg............24
terazosin hcl......................................................................24
terbinafine hcl tabs............................................................10
terbutaline sulfate tabs.......................................................35
terconazole........................................................................33
testosterone cypionate..........................................................30
testosterone enanthate.........................................................30
tetanus toxoid adsorbed......................................................32
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED
ADULT........................................................................32
tetracycline hcl...................................................................10
TEV-TROPIN................................................................32
THALOMID...................................................................12
theophylline.......................................................................35
theophylline cr...................................................................35
theophylline er...................................................................35
thioridazine hcl.................................................................21
thiothixene........................................................................21
THYMOGLOBULIN.....................................................32
tiagabine hydrochloride......................................................21
TICE BCG......................................................................32
TIKOSYN.......................................................................24
tilia fe...............................................................................33
timolol maleate ophthalmic gel forming...............................34
timolol maleate ophthalmic soln..........................................34
Effective Date November 1, 2014
Drug Name
Page
tinidazole..........................................................................10
TIVICAY.........................................................................10
tizanidine hcl tabs.............................................................21
tl-care dha.........................................................................37
tl-select..............................................................................37
TOBI...............................................................................10
tobramycin........................................................................10
tobramycin sulfate inj 1.2gm..............................................10
tobramycin sulfate inj 1.2gm/30ml, 10mg/ml, 40mg/ml,
80mg/2ml......................................................................10
tobramycin sulfate ophthalmic soln.....................................34
tobramycin/dexamethasone.................................................34
tolazamide tabs 250mg......................................................30
tolazamide tabs 500mg......................................................30
tolbutamide.......................................................................30
tolterodine tartrate tabs 1mg...............................................36
tolterodine tartrate tabs 2mg...............................................36
topiramate cpsp..................................................................21
topiramate tabs 100mg......................................................21
topiramate tabs 200mg......................................................21
topiramate tabs 25mg........................................................21
topiramate tabs 50mg........................................................21
toposar..............................................................................12
topotecan hcl inj 4mg.........................................................12
topotecan hcl inj 4mg/4ml..................................................12
TORISEL........................................................................12
TPN ELECTROLYTES..................................................37
TRACLEER.....................................................................35
tramadol hcl......................................................................21
tramadol hydrochloride/acetaminophen...............................21
trandolapril.......................................................................24
tranexamic acid inj............................................................24
tranylcypromine sulfate......................................................21
TRAVATAN Z................................................................34
travoprost..........................................................................34
trazodone hcl.....................................................................21
TREANDA......................................................................12
TRECATOR...................................................................10
tretinoin caps.....................................................................12
tretinoin crea.....................................................................26
tretinoin gel.......................................................................26
tri-estarylla........................................................................33
tri-legest fe.........................................................................33
tri-linyah..........................................................................33
tri-previfem.......................................................................33
tri-sprintec........................................................................33
triadvance.........................................................................37
Basic KS 14202, V15
57
Drug Name
Page
triamcinolone acetonide crea...............................................26
triamcinolone acetonide inj 10mg/ml..................................30
triamcinolone acetonide inj 40mg/ml..................................30
triamcinolone acetonide lotn...............................................26
triamcinolone acetonide oint...............................................26
triamcinolone acetonide pste...............................................27
triamcinolone in orabase....................................................27
triamterene/hydrochlorothiazide caps 25mg; 37.5mg............25
triamterene/hydrochlorothiazide tabs...................................25
trianex..............................................................................26
triderm.............................................................................26
trifluoperazine hcl..............................................................21
trifluridine........................................................................34
TRILIPIX........................................................................25
trilyte................................................................................31
trimethoprim.....................................................................10
trimethoprim sulfate/polymyxin b sulfate.............................34
trinatal gt..........................................................................37
trinatal rx 1......................................................................37
trinessa..............................................................................33
TRISENOX.....................................................................12
triveen-duo dha.................................................................37
triveen-prx rnf...................................................................37
trivora-28.........................................................................33
TRIZIVIR.......................................................................10
tropicamide.......................................................................34
trospium chloride...............................................................36
TRUVADA.....................................................................10
TWINRIX.......................................................................32
TWYNSTA......................................................................25
TYKERB..........................................................................12
TYPHIM VI....................................................................32
TYSABRI.........................................................................21
TYZEKA.........................................................................10
UCERIS...........................................................................31
ultimatecare one nf............................................................37
unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg,
200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg.............30
ursodiol.............................................................................31
UVADEX........................................................................26
valacyclovir hcl..................................................................10
VALCHLOR...................................................................26
VALCYTE TABS.............................................................10
valproate sodium...............................................................21
valproic acid......................................................................21
valsartan tabs 160mg.........................................................25
valsartan tabs 320mg.........................................................25
Effective Date November 1, 2014
Drug Name
Page
valsartan tabs 40mg, 80mg................................................25
valsartan/hydrochlorothiazide.............................................25
vancomycin hcl caps 125mg................................................10
vancomycin hcl caps 250mg................................................10
VANCOMYCIN HCL IN DEXTROSE INJ 0; 1GM/
200ML..........................................................................10
VANCOMYCIN HCL IN DEXTROSE INJ 0; 500MG/
100ML, 0; 750MG/150ML..........................................10
vancomycin hcl inj 1000mg, 10gm, 5000mg, 750mg..........10
vancomycin hcl inj 500mg.................................................10
VANCOMYCIN HCL INJ 750MG...............................10
vandazole..........................................................................33
VAQTA...........................................................................32
VARIVAX........................................................................32
VARIZIG........................................................................32
VECTIBIX......................................................................12
VELCADE.......................................................................12
velivet...............................................................................33
vemavite-prx 2..................................................................37
vena-bal dha.....................................................................37
venlafaxine hcl er cp24 150mg...........................................21
venlafaxine hcl er cp24 37.5mg..........................................21
venlafaxine hcl er cp24 75mg.............................................21
venlafaxine hcl er tb24 150mg...........................................21
VENLAFAXINE HCL ER TB24 225MG.......................21
venlafaxine hcl er tb24 37.5mg..........................................21
venlafaxine hcl er tb24 75mg.............................................21
venlafaxine hcl tabs 100mg................................................21
venlafaxine hcl tabs 25mg..................................................21
venlafaxine hcl tabs 37.5mg...............................................21
venlafaxine hcl tabs 50mg..................................................21
venlafaxine hcl tabs 75mg..................................................21
VENTAVIS.....................................................................35
verapamil hcl er.................................................................25
verapamil hcl inj...............................................................25
verapamil hcl sr.................................................................25
verapamil hcl tabs..............................................................25
veripred 20........................................................................30
VERSACLOZ..................................................................21
VICTOZA.......................................................................30
VICTRELIS.....................................................................10
VIDAZA..........................................................................12
VIDEX PEDIATRIC.......................................................10
VIGAMOX......................................................................34
VIIBRYD KIT.................................................................21
VIIBRYD TABS 10MG...................................................21
VIIBRYD TABS 20MG...................................................21
Basic KS 14202, V15
58
Drug Name
Page
VIIBRYD TABS 40MG...................................................21
VIMPAT INJ...................................................................21
VIMPAT ORAL SOLN...................................................21
VIMPAT TABS 100MG.................................................21
VIMPAT TABS 150MG.................................................21
VIMPAT TABS 200MG.................................................21
VIMPAT TABS 50MG...................................................21
vinblastine sulfate inj 1mg/ml.............................................12
vincasar pfs.......................................................................12
vincristine sulfate...............................................................12
vinorelbine tartrate............................................................12
viorele...............................................................................34
VIRACEPT.....................................................................10
VIRAMUNE SUSP.........................................................10
VIRAMUNE XR.............................................................10
VIRAZOLE.....................................................................10
VIREAD POWD.............................................................10
VIREAD TABS 150MG, 200MG, 250MG.....................10
VIREAD TABS 300MG..................................................10
virt-pn..............................................................................37
virt-pn dha........................................................................37
vol-nate.............................................................................37
vol-plus.............................................................................37
VOLTAREN GEL...........................................................21
voriconazole inj.................................................................10
voriconazole susr................................................................10
voriconazole tabs................................................................10
VOTRIENT....................................................................13
vp-ch-pnv..........................................................................37
warfarin sodium................................................................25
WELCHOL.....................................................................25
XALKORI.......................................................................13
XARELTO TABS 10MG, 20MG....................................25
XARELTO TABS 15MG................................................25
XENAZINE.....................................................................21
XEOMIN........................................................................32
XGEVA...........................................................................13
XOLAIR..........................................................................35
XTANDI.........................................................................13
XYREM...........................................................................21
YERVOY.........................................................................13
YF-VAX...........................................................................32
zafirlukast.........................................................................35
zaleplon caps 10mg............................................................22
zaleplon caps 5mg..............................................................22
ZALTRAP.......................................................................13
ZANOSAR......................................................................13
Effective Date November 1, 2014
Drug Name
Page
zarah................................................................................34
zatean-ch..........................................................................37
zatean-pn..........................................................................37
zatean-pn dha...................................................................37
zatean-pn plus...................................................................37
ZAVESCA.......................................................................30
zazole crea.........................................................................34
ZELBORAF.....................................................................13
ZEMAIRA.......................................................................27
zenatane...........................................................................26
zenchent............................................................................34
zenzedi tabs 10mg.............................................................22
zenzedi tabs 5mg...............................................................22
ZETIA.............................................................................25
ZIAGEN ORAL SOLN...................................................10
zidovudine........................................................................10
ZIOPTAN.......................................................................34
ziprasidone hcl caps 20mg..................................................22
Basic KS 14202, V15
59
Drug Name
Page
ziprasidone hcl caps 40mg..................................................22
ziprasidone hcl caps 60mg, 80mg........................................22
ZIRGAN.........................................................................34
ZOLINZA.......................................................................13
zolpidem tartrate...............................................................22
zonisamide........................................................................22
ZORTRESS TABS 0.25MG............................................13
ZORTRESS TABS 0.5MG, 0.75MG..............................13
ZOSTAVAX....................................................................32
zovia 1/35e.......................................................................34
zovia 1/50e.......................................................................34
ZYDELIG........................................................................13
ZYKADIA.......................................................................13
ZYPREXA INJ.................................................................22
ZYTIGA..........................................................................13
ZYVOX INJ....................................................................10
ZYVOX SUSR.................................................................10
ZYVOX TABS.................................................................10
Effective Date November 1, 2014
Blue Cross and Blue Shield of Kansas City is a PDP plan with a Medicare contract. Enrollment in Blue Cross and
Blue Shield of Kansas City depends on contract renewal.
Blue Cross and Blue Shield of Kansas City and Anthem Insurance Companies, Inc. provide administrative services
for Blue MedicareRx plans. Blue Cross and Blue Shield of Kansas, Inc. is the legal entity under contract with the
Centers for Medicare & Medicaid Services (CMS) to offer the Part D plans noted. BCBSKS is the risk-bearing
entity licensed under applicable state law or under a federal waiver program to offer the Part D plans noted.Blue
Cross and Blue Shield of Kansas City's service area covers 30 counties in greater Kansas City and northwest Missouri,
plus Johnson and Wyandotte counties in Kansas. Blue Cross and Blue Shield of Kansas City, Blue Cross and Blue
Shield of Kansas, Inc. and Anthem Insurance Companies, Inc. are independent licensees of the Blue Cross and
Blue Shield Association. ®The Blue Cross and Blue Shield names and symbols are registered marks of the Blue
Cross and Blue Shield Association.
This information is available for free in other languages. Please contact our customer service number at
1-866-755-2776 or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas)
from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September
30.
Spanish (US):
Esta información está disponible sin cargo en otros idiomas. Póngase en contacto con el Servicio de Atención al
Cliente llamando al número 1-866-755-2776 o, para los usuarios de TTY, 711, de 8 a. m. a 8 p. m., los 7 días de
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Customer Service
This formulary was updated on October 1, 2014. For more recent information or other questions, please
contact Blue MedicareRx Value (PDP) Customer Service at 1-866-755-2776 or, for TTY users, 711, 8
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KS-KC

2014 Formulary (List of Covered Drugs)

2014 Formulary (List of Covered Drugs)