ATRIO Bronze Rx (Basin) (PPO)
ATRIO Bronze Rx (Rogue) (PPO)
ATRIO Bronze Rx (Umpqua) (PPO)
ATRIO Gold Rx (PPO)
ATRIO Gold Rx (Rogue) (PPO)
ATRIO Gold Rx (Willamette) (PPO)
ATRIO Silver Rx (PPO)
ATRIO Silver Rx (Rogue) (PPO)
ATRIO Silver Rx (Willamette) (PPO)
2017 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
DRAFT
HPMS Approved Formulary File 17084, Version Number 14
This formulary was updated on 06/01/2017. For more recent information or other questions, please contact
ATRIO Health Plans at 1-877-672-8620 or, for TTY/TDD users, 1-800-735-2900, 8 a.m. to 8 p.m., daily, or visit
atriohp.com/medicare.
The formulary may change at any time. You will receive notice when necessary.
This information is available for free in other languages. Please call our customer service number at 1-877672-8620 or, for TTY/TDD users, 1-800-735-2900, 8 a.m. to 8 p.m., Daily. Esta información está disponible de
forma gratuita en otros idiomas. Por favor llame a nuestro número de atención al cliente al 1-877-672-8620 o,
para los usuarios de TTY/TDD, 1-800 -735-2900, de 8 a.m. a 8 p.m., Diario.
Formulary ID: 17084 Version: 14
Y0084_PHARM_PPOCF_2017 Accepted
Date Updated: 06/01/2017
Date Effective:June 01, 2017
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 ATRIO Health Plans. When it refers to
“plan” or “our plan,” it means ATRIO Bronze Rx (Basin) (PPO), ATRIO Bronze Rx (Rogue) (PPO), ATRIO
Bronze Rx (Umpqua) (PPO), ATRIO Gold Rx (PPO), ATRIO Gold Rx (Rogue) (PPO), ATRIO Gold Rx
(Willamette) (PPO), ATRIO Silver Rx (PPO), ATRIO Silver Rx (Rogue) (PPO), and ATRIO Silver Rx
(Willamette) (PPO).
This document includes a list of the drugs (formulary) for our plan which is current as of 06/01/2017. For an
updated formulary, please contact us. Our contact information, along with the date we last updated the
formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2018, and from time to time
during the year.
What is the ATRIO Health Plans Formulary?
A formulary is a list of covered drugs selected by ATRIO Health Plans 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. ATRIO Health Plans will generally cover the drugs listed in our formulary as long as the
drug is medically necessary, the prescription is filled at an ATRIO Health Plans network pharmacy, and other
plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of
Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, we will
not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or effectiveness
of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not
affect members who are currently taking the drug. It will remain available at the same cost-sharing for those
members taking it for the remainder of the coverage year. We feel it is important that you have continued
access for the remainder of the coverage year to the formulary drugs that were available when you chose our
plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the
change at least 60 days before the change becomes effective, or at the time the member requests a refill of the
drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration
deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we
will immediately remove the drug from our formulary and provide notice to members who take the drug. The
enclosed formulary is current as of 06/01/2017. To get updated information about the drugs covered by ATRIO
Health Plans, please contact us. Our contact information appears on the front and back cover pages.
ATRIO Health Plans will notify members about any drugs that have been removed from the formulary or that
have had prior authorization, step therapy or quantity limits placed on them. Notification about these changes
will be made in several different ways. Your monthly Explanation of Benefits (EOB), which gives you a report of
all your drugs purchased in the previous month, will contain an insert listing all formulary changes which will
take effect 60 days from the date of the notice. Additionally, this insert will be posted on atriohp.com/medicare
or can be sent to you by calling 1-877-672-8620, Daily, 8am-8pm. TTY/TDD users should call 1-800-735-2900.
Finally, the most current version of the formulary containing all changes, will be available on
ii
atriohp.com/medicare or can be sent to you by calling 1-877-672-8620, Daily, 8am-8pm. TTY/TDD users
should call 1-800-735-2900.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the
type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are
listed under the category, “Cardiovascular Agents”. If you know what your drug is used for, look for the
category name in the list that begins on page 1. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on page
I-1. 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?
ATRIO Health Plans covers both brand name drugs and generic drugs. A generic drug is approved by the FDA
as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand
name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:
•
Prior Authorization: ATRIO Health Plans requires you or your physician to get prior authorization for
certain drugs. This means that you will need to get approval from ATRIO Health Plans before you fill
your prescriptions. If you don’t get approval, ATRIO Health Plans may not cover the drug.
•
Quantity Limits: For certain drugs, ATRIO Health Plans limits the amount of the drug that ATRIO
Health Plans will cover. For example, ATRIO Health Plans provides 30 per prescription for simvastatin.
This may be in addition to a standard one-month or three-month supply.
•
Step Therapy: In some cases, ATRIO Health Plans 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, ATRIO Health Plans may not cover Drug B unless you try Drug A
first. If Drug A does not work for you, ATRIO Health Plans will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins
on page 1. You can also get more information about the restrictions applied to specific covered drugs by
visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy
restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
iii
You can ask ATRIO Health Plans 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
ATRIO Health Plans’ formulary?” on page iv for information about how to request an exception.
What are over-the counter (OTC) drugs?
OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan.
ATRIO Health Plans pays for certain OTC drugs. ATRIO Health Plans will provide these OTC drugs at no cost
to you. The cost to ATRIO Health Plans of these OTC drugs will not count toward your total Part D drug costs
(that is, the amount you pay does not count for the coverage gap).
COVERED OVER-THE-COUNTER (OTC) DRUGS
Generic Name
(Reference Brand Name)
Dosage Form
cetirizine hydrochloride
(Zyrtec)
Chewable Tablets, Solution, Tablets
cetirizine hydrochloride/ pseudoephedrine
hydrochloride
(Zyrtec-D)
12 Hour Tablets
loratadine
(Claritin)
Solution, Tablets
loratadine/ pseudoephedrine sulfate
(Claritin-D)
12 Hour Tablets
24 Hour Tablets
ketotifen fumarate
(Zaditor)
Drops
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service
and ask if your drug is covered.
If you learn that ATRIO Health Plans does not cover your drug, you have two options:
•
You can ask Customer Service for a list of similar drugs that are covered by ATRIO Health Plans.
When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is
covered by ATRIO Health Plans.
•
You can ask ATRIO Health Plans to make an exception and cover your drug. See below for information
about how to request an exception.
How do I request an exception to the ATRIO Health Plans’ Formulary?
You can ask ATRIO Health Plans to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.
•
•
•
You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered
at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a
lower cost-sharing level.
You can ask us to cover a formulary drug at a lower cost-sharing level [if this drug is not on the
specialty tier]. If approved this would lower the amount you must pay for your drug.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
ATRIO Health Plans 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.
iv
Generally, ATRIO Health Plans will only approve your request for an exception if the alternative drugs included
on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as
effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction
exception. When you request a formulary or utilization restriction exception you should submit a
statement from your prescriber or physician supporting your request. Generally, we must make our
decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast)
exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for
a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we
get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may
be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior
authorization from us before you can fill your prescription. You should talk to your doctor to decide if you
should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the
drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your
drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a
temporary 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 30 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with 93-day transition supply, consistent with dispensing increment, (unless you have a
prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you
are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is
limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply
of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
If you are being admitted or discharged from a facility, we will cover “early refills” of previously covered drugs
as needed upon admission to or discharge from the facility.
For more information
For more detailed information about your ATRIO Health Plans prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about ATRIO Health Plans, 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 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit
http://www.medicare.gov.
v
ATRIO Health Plans Formulary
The formulary below provides coverage information about the drugs covered by ATRIO Health Plans. If you
have trouble finding your drug in the list, turn to the Index that begins on page I-1.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) and
generic drugs are listed in lower-case italics (e.g., rosuvastatin).
The information in the Requirements/Limits column tells you if ATRIO Health Plans has any special
requirements for coverage of your drug.
COST SHARING TIERS
Plan
ATRIO Bronze Rx (Basin) (PPO)
ATRIO Bronze Rx (Umpqua) (PPO)
ATRIO Bronze Rx (Rogue) (PPO)
ATRIO Silver Rx (PPO)
Drug Tier Name
Retail
Copayment
(1 month
supply)
Mail-Order
Copayment
(3 month
supply)
1
Preferred Generic Drugs
$10.00
$20.00
2
Generic Drugs
$20.00
$40.00
3
Preferred Brand Drugs
$45.00
$90.00
4
Non-Preferred Brand
Drugs
$95.00
$190.00
5
Specialty Tier Drugs
33%
Not Available
6
Select Care Drugs
$0
$0
1
Preferred Generic Drugs
$10.00
$20.00
2
Generic Drugs
$20.00
$40.00
3
Preferred Brand Drugs
$45.00
$90.00
4
Non-Preferred Brand
Drugs
$95.00
$190.00
5
Specialty Tier Drugs
29%
Not Available
6
Select Care Drugs
$0
$0
1
Preferred Generic Drugs
$6.00
$12.00
2
Generic Drugs
$15.00
$30.00
3
Preferred Brand Drugs
$40.00
$80.00
Drug
Tier
vi
Drug Tier Name
Retail
Copayment
(1 month
supply)
Mail-Order
Copayment
(3 month
supply)
4
Non-Preferred Brand
Drugs
$85.00
$170.00
5
Specialty Tier Drugs
29%
Not Available
6
Select Care Drugs
$0
$0
ATRIO Silver Rx (Rogue) (PPO) ATRIO
1
Preferred Generic Drugs
$6.00
$12.00
Silver Rx (Willamette) (PPO)
2
Generic Drugs
$15.00
$30.00
3
Preferred Brand Drugs
$40.00
$80.00
4
Non-Preferred Brand
Drugs
$85.00
$170.00
5
Specialty Tier Drugs
33%
Not Available
6
Select Care Drugs
$0
$0
ATRIO Gold Rx (PPO)
1
Preferred Generic Drugs
$4.00
$8.00
ATRIO Gold Rx (Rogue) (PPO)
2
Generic Drugs
$10.00
$20.00
ATRIO Gold Rx (Willamette) (PPO)
3
Preferred Brand Drugs
$35.00
$70.00
4
Non-Preferred Brand
Drugs
$75.00
$150.00
5
Specialty Tier Drugs
33%
Not Available
6
Select Care Drugs
$0
$0
Plan
Drug
Tier
vii
The following Utilization Management Restriction abbreviations may be found within the body of this
document
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION
DESCRIPTION
EXPLANATION
Prior Authorization Restriction
You (or your physician) are required to get prior
authorization from ATRIO Health Plans before
you fill your prescription for this drug. Without
prior approval, ATRIO Health Plans may not
cover this drug.
Prior Authorization Restriction
for
Part B vs Part D
Determination
This drug may be eligible for payment under
Medicare Part B or Part D. You (or your
physician) are required to get prior authorization
from ATRIO Health Plans to determine that this
drug is covered under Medicare Part D before
you fill your prescription for this drug. Without
prior approval, ATRIO Health Plans may not
cover this drug.
Prior Authorization Restriction
for
High Risk Medications
This drug has been deemed by CMS to be
potentially harmful and therefore, a High Risk
Medication for Medicare beneficiaries 65 years or
older. Members age 65 yrs or older are required
to get prior authorization from ATRIO Health
Plans before you fill your prescription for this
drug. Without prior approval, ATRIO Health
Plans may not cover this drug
PA NSO
Prior Authorization Restriction
for
New Starts Only
If you are a new member or if you have not taken
this drug before, you (or your physician) are
required to get prior authorization from ATRIO
Health Plans before you fill your prescription for
this drug. Without prior approval, ATRIO Health
Plans may not cover this drug.
QL
Quantity Limit Restriction
ATRIO Health Plans limits the amount of this
drug that is covered per prescription, or within a
specific time frame.
Step Therapy Restriction
Before ATRIO Health Plans will provide coverage
for this drug, you must first try another drug(s) to
treat your medical condition. This drug may only
be covered if the other drug(s) does not work for
you.
PA
PA BvD
PA-HRM
ST
viii
OTHER SPECIAL REQUIREMENTS FOR COVERAGE
ABBREVIATION
DESCRIPTION
EXPLANATION
LA
Limited Access Drug
This prescription may be available only at
certain pharmacies. For more information
consult your Pharmacy Directory or call
Customer Service at 1-877-672-8620, Daily,
8am-8pm. TTY/TDD users should call 1-800735-2900.
NDS
Non-Extended Days Supply
This drug is not available for a 90 day supply.
ix
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
1
Table of Contents
Analgesics.....................................................................................................................................................3
Anesthetics................................................................................................................................................. 10
Anti-Addiction/Substance Abuse Treatment Agents.................................................................................. 10
Antianxiety Agents..................................................................................................................................... 11
Antibacterials............................................................................................................................................. 14
Anticancer Agents...................................................................................................................................... 24
Anticholinergic Agents............................................................................................................................... 34
Anticonvulsants..........................................................................................................................................34
Antidementia Agents.................................................................................................................................. 38
Antidepressants.......................................................................................................................................... 39
Antidiabetic Agents.................................................................................................................................... 41
Antifungals................................................................................................................................................. 46
Antigout Agents......................................................................................................................................... 48
Antihistamines............................................................................................................................................48
Anti-Infectives (Skin And Mucous Membrane)..........................................................................................49
Antimigraine Agents...................................................................................................................................49
Antimycobacterials.....................................................................................................................................50
Antinausea Agents......................................................................................................................................50
Antiparasite Agents.................................................................................................................................... 52
Antiparkinsonian Agents............................................................................................................................53
Antipsychotic Agents..................................................................................................................................54
Antivirals (Systemic)...................................................................................................................................58
Blood Products/Modifiers/Volume Expanders........................................................................................... 64
Caloric Agents............................................................................................................................................ 67
Cardiovascular Agents............................................................................................................................... 71
Central Nervous System Agents................................................................................................................. 84
Contraceptives............................................................................................................................................87
Dental And Oral Agents.............................................................................................................................94
Dermatological Agents............................................................................................................................... 94
Devices..................................................................................................................................................... 100
Enzyme Replacement/Modifiers............................................................................................................... 100
Eye, Ear, Nose, Throat Agents................................................................................................................. 102
Gastrointestinal Agents............................................................................................................................ 106
Genitourinary Agents............................................................................................................................... 110
Heavy Metal Antagonists......................................................................................................................... 111
Hormonal Agents, Stimulant/Replacement/Modifying.............................................................................112
1
Immunological Agents..............................................................................................................................118
Inflammatory Bowel Disease Agents........................................................................................................ 127
Irrigating Solutions...................................................................................................................................128
Metabolic Bone Disease Agents................................................................................................................128
Miscellaneous Therapeutic Agents............................................................................................................130
Ophthalmic Agents................................................................................................................................... 132
Replacement Preparations........................................................................................................................ 133
Respiratory Tract Agents......................................................................................................................... 137
Skeletal Muscle Relaxants........................................................................................................................ 141
Sleep Disorder Agents.............................................................................................................................. 142
Vasodilating Agents..................................................................................................................................143
Vitamins And Minerals.............................................................................................................................144
2
Drug Name
Drug Tier
Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen-codeine oral solution 12012 mg/5 ml
acetaminophen-codeine oral tablet 300-15
mg
acetaminophen-codeine oral tablet 300-30 (Tylenol-Codeine #3)
mg
acetaminophen-codeine oral tablet 300-60 (Tylenol-Codeine #4)
mg
ALLZITAL ORAL TABLET 25-325
MG
2
QL (2700 per 30 days)
2
QL (360 per 30 days)
2
QL (360 per 30 days)
2
QL (180 per 30 days)
2
PA-HRM; QL (360 per
30 days); AGE (Max 64
Years)
PA-HRM; QL (180 per
30 days); AGE (Max 64
Years)
QL (60 per 30 days)
ascomp with codeine oral capsule 30-50325-40 mg
2
BELBUCA BUCCAL FILM 150
MCG, 300 MCG, 450 MCG, 600 MCG,
75 MCG, 750 MCG, 900 MCG
buprenorphine hcl injection solution 0.3
(Buprenex)
mg/ml
buprenorphine hcl injection syringe 0.3
mg/ml
butalbital compound w/codeine oral
capsule 30-50-325-40 mg
3
butalbital-acetaminop-caf-cod oral
capsule 50-300-40-30 mg
(Fioricet with Codeine)
2
2
2
2
2
butalbital-acetaminop-caf-cod oral
capsule 50-325-40-30 mg
butalbital-acetaminophen oral tablet 50325 mg
(Tencon)
2
butalbital-acetaminophen-caff oral
capsule 50-325-40 mg
(Esgic)
2
butalbital-acetaminophen-caff oral tablet (Esgic)
50-325-40 mg
2
PA-HRM; QL (180 per
30 days); AGE (Max 64
Years)
PA-HRM; QL (180 per
30 days); AGE (Max 64
Years)
PA-HRM; QL (180 per
30 days); AGE (Max 64
Years)
PA-HRM; QL (180 per
30 days); AGE (Max 64
Years)
PA-HRM; QL (180 per
30 days); AGE (Max 64
Years)
PA-HRM; QL (180 per
30 days); AGE (Max 64
Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
3
Drug Name
Requirements/Limits
2
butorphanol tartrate nasal spray,nonaerosol 10 mg/ml
BUTRANS TRANSDERMAL
PATCH WEEKLY 10 MCG/HOUR,
15 MCG/HOUR, 20 MCG/HOUR, 5
MCG/HOUR, 7.5 MCG/HOUR
capacet oral capsule 50-325-40 mg
2
PA-HRM; QL (180 per
30 days); AGE (Max 64
Years)
QL (5 per 28 days)
3
QL (4 per 28 days)
2
codeine sulfate oral tablet 15 mg, 30 mg,
60 mg
EMBEDA ORAL CAPSULE,ORAL
ONLY,EXT.REL PELL 100-4 MG, 200.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4
MG, 80-3.2 MG
endocet oral tablet 10-325 mg
endocet oral tablet 2.5-325 mg, 5-325 mg
endocet oral tablet 7.5-325 mg
endodan oral tablet 4.8355-325 mg
fentanyl citrate buccal lozenge on a
handle 1,200 mcg, 1,600 mcg, 200 mcg,
400 mcg, 600 mcg, 800 mcg
fentanyl transdermal patch 72 hour 100
mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr,
75 mcg/hr
fentanyl transdermal patch 72 hour 37.5
mcg/hour
fentanyl transdermal patch 72 hour 62.5
mcg/hour, 87.5 mcg/hour
hydrocodone-acetaminophen oral solution
10-325 mg/15 ml(15 ml), 2.5-167 mg/5
ml
hydrocodone-acetaminophen oral solution
7.5-325 mg/15 ml
hydrocodone-acetaminophen oral tablet
10-300 mg
hydrocodone-acetaminophen oral tablet
10-325 mg
2
PA-HRM; QL (180 per
30 days); AGE (Max 64
Years)
QL (180 per 30 days)
4
QL (60 per 30 days)
(Actiq)
2
2
2
2
5
QL (240 per 30 days)
QL (360 per 30 days)
QL (300 per 30 days)
QL (360 per 30 days)
PA; NDS; QL (120 per
30 days)
(Duragesic)
2
QL (10 per 30 days)
2
QL (10 per 30 days)
5
2
NDS; QL (10 per 30
days)
QL (2700 per 30 days)
(Hycet)
2
QL (2700 per 30 days)
(Xodol 10/300)
2
QL (390 per 30 days)
(Lorcet HD)
2
QL (360 per 30 days)
butalbital-aspirin-caffeine oral capsule
50-325-40 mg
(Fiorinal)
Drug Tier
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
4
Drug Name
hydrocodone-acetaminophen oral tablet
2.5-325 mg
hydrocodone-acetaminophen oral tablet
5-300 mg
hydrocodone-acetaminophen oral tablet
5-325 mg
hydrocodone-acetaminophen oral tablet
7.5-300 mg
hydrocodone-acetaminophen oral tablet
7.5-325 mg
hydrocodone-ibuprofen oral tablet 10-200
mg, 5-200 mg
hydrocodone-ibuprofen oral tablet 7.5200 mg
hydromorphone (pf) injection solution 10
(mg/ml) (5 ml)
hydromorphone (pf) injection solution 10
mg/ml
hydromorphone 10 mg/ml vial
p/f,sdv,latex-f 10 mg/ml
hydromorphone injection solution 2
mg/ml, 4 mg/ml
hydromorphone injection syringe 2
mg/ml, 4 mg/ml
hydromorphone oral liquid 1 mg/ml
hydromorphone oral tablet 2 mg, 4 mg, 8
mg
HYSINGLA ER ORAL
TABLET,ORAL ONLY,EXT.REL.24
HR 100 MG, 120 MG, 20 MG, 30 MG,
40 MG, 60 MG, 80 MG
LAZANDA NASAL SPRAY,NONAEROSOL 100 MCG/SPRAY, 300
MCG/SPRAY, 400 MCG/SPRAY
lorcet (hydrocodone) oral tablet 5-325
mg
lorcet hd oral tablet 10-325 mg
lorcet plus oral tablet 7.5-325 mg
margesic oral capsule 50-325-40 mg
Drug Tier
Requirements/Limits
(Verdrocet)
2
QL (360 per 30 days)
(Vicodin)
2
QL (390 per 30 days)
(Lorcet (hydrocodone))
2
QL (360 per 30 days)
(Vicodin ES)
2
QL (390 per 30 days)
(Lorcet Plus)
2
QL (360 per 30 days)
(Reprexain)
2
QL (150 per 30 days)
2
QL (150 per 30 days)
2
2
2
2
2
(Dilaudid)
(Dilaudid)
2
2
QL (1200 per 30 days)
QL (180 per 30 days)
3
QL (30 per 30 days)
5
PA; NDS; QL (30 per
30 days)
2
QL (360 per 30 days)
2
2
2
QL (360 per 30 days)
QL (360 per 30 days)
PA-HRM; QL (180 per
30 days); AGE (Max 64
Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
5
Drug Name
Drug Tier
methadone injection solution 10 mg/ml
methadone oral solution 10 mg/5 ml, 5
mg/5 ml
methadone oral tablet 10 mg
methadone oral tablet 5 mg
methadose oral tablet,soluble 40 mg
morphine 10 mg/ml carpuject outer, p/f,
l/f, suv 10 mg/ml
morphine 2 mg/ml carpuject outer, latexf, p/f 2 mg/ml
morphine 4 mg/ml syringe p/f, latex-free
4 mg/ml
morphine 8 mg/ml syringe 8 mg/ml
morphine concentrate oral solution 100
mg/5 ml (20 mg/ml)
morphine intramuscular pen injector 10
mg/0.7 ml
morphine intravenous cartridge 15 mg/ml
morphine intravenous syringe 10 mg/ml, 2
mg/ml, 4 mg/ml, 8 mg/ml
morphine oral solution 10 mg/5 ml
morphine oral solution 20 mg/5 ml (4
mg/ml)
MORPHINE ORAL TABLET 15 MG
MORPHINE ORAL TABLET 30 MG
morphine oral tablet extended release 100
mg, 200 mg, 60 mg
morphine oral tablet extended release 15
mg
morphine oral tablet extended release 30
mg
NUCYNTA ER ORAL TABLET
EXTENDED RELEASE 12 HR 100
MG, 150 MG, 200 MG, 250 MG, 50
MG
NUCYNTA ORAL TABLET 100 MG,
50 MG, 75 MG
oxycodone oral capsule 5 mg
oxycodone oral concentrate 20 mg/ml
oxycodone oral solution 5 mg/5 ml
2
2
(Dolophine)
(Dolophine)
2
2
2
2
Requirements/Limits
QL (1800 per 30 days)
QL (360 per 30 days)
QL (180 per 30 days)
QL (90 per 30 days)
2
2
2
2
QL (180 per 30 days)
2
2
2
2
2
QL (700 per 30 days)
QL (300 per 30 days)
(MS Contin)
4
4
2
QL (180 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
(MS Contin)
2
QL (180 per 30 days)
(MS Contin)
2
QL (120 per 30 days)
3
QL (60 per 30 days)
3
QL (181 per 30 days)
2
2
2
QL (180 per 30 days)
QL (120 per 30 days)
QL (1300 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
6
Drug Name
Drug Tier
oxycodone oral tablet 10 mg
oxycodone oral tablet 15 mg, 30 mg
oxycodone oral tablet 20 mg
oxycodone oral tablet 5 mg
oxycodone oral tablet,oral only,ext.rel.12
hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg,
60 mg
oxycodone oral tablet,oral only,ext.rel.12
hr 80 mg
oxycodone-acetaminophen oral solution
5-325 mg/5 ml
oxycodone-acetaminophen oral tablet 10325 mg
oxycodone-acetaminophen oral tablet
2.5-325 mg, 5-325 mg
oxycodone-acetaminophen oral tablet
7.5-325 mg
oxycodone-aspirin oral tablet 4.8355-325
mg
OXYCONTIN ORAL
TABLET,ORAL ONLY,EXT.REL.12
HR 10 MG, 15 MG, 20 MG, 30 MG, 40
MG, 60 MG
OXYCONTIN ORAL
TABLET,ORAL ONLY,EXT.REL.12
HR 80 MG
oxymorphone oral tablet 10 mg
oxymorphone oral tablet 5 mg
oxymorphone oral tablet extended release
12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40
mg, 5 mg, 7.5 mg
reprexain oral tablet 10-200 mg, 2.5-200
mg, 5-200 mg
tencon oral tablet 50-325 mg
(Roxicodone)
(OxyContin)
2
2
2
2
2
QL (180 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (180 per 30 days)
QL (60 per 30 days)
(OxyContin)
5
2
NDS; QL (120 per 30
days)
QL (1800 per 30 days)
(Endocet)
2
QL (240 per 30 days)
(Endocet)
2
QL (360 per 30 days)
(Percocet)
2
QL (300 per 30 days)
2
QL (360 per 30 days)
3
QL (60 per 30 days)
3
QL (120 per 30 days)
2
2
2
QL (120 per 30 days)
QL (180 per 30 days)
QL (60 per 30 days)
2
QL (150 per 30 days)
2
2
2
PA-HRM; QL (180 per
30 days); AGE (Max 64
Years)
QL (240 per 30 days)
QL (240 per 30 days)
2
2
QL (390 per 30 days)
QL (390 per 30 days)
(Roxicodone)
(Opana)
(Opana)
tramadol oral tablet 50 mg
(Ultram)
tramadol-acetaminophen oral tablet 37.5- (Ultracet)
325 mg
vicodin es oral tablet 7.5-300 mg
vicodin hp oral tablet 10-300 mg
Requirements/Limits
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
7
Drug Name
Drug Tier
vicodin oral tablet 5-300 mg
XARTEMIS XR ORAL TAB,ORAL
ONLY,IR - ER, BIPHASE 7.5-325 MG
XTAMPZA ER ORAL
CAPSULE,SPRINKLE,ER 12HR
TMPRR 13.5 MG, 18 MG, 9 MG
XTAMPZA ER ORAL
CAPSULE,SPRINKLE,ER 12HR
TMPRR 27 MG
XTAMPZA ER ORAL
CAPSULE,SPRINKLE,ER 12HR
TMPRR 36 MG
xylon 10 oral tablet 10-200 mg
zebutal oral capsule 50-325-40 mg
2
3
QL (390 per 30 days)
QL (300 per 30 days)
3
QL (60 per 30 days)
3
QL (120 per 30 days)
3
QL (240 per 30 days)
2
2
QL (150 per 30 days)
PA-HRM; QL (180 per
30 days); AGE (Max 64
Years)
QL (60 per 30 days)
ZOHYDRO ER ORAL CAPSULE,
ORAL ONLY, ER 12HR 10 MG, 15
MG, 20 MG, 30 MG, 40 MG, 50 MG
Nonsteroidal Anti-Inflammatory Agents
CALDOLOR INTRAVENOUS
RECON SOLN 400 MG/4 ML (100
MG/ML)
celecoxib oral capsule 100 mg, 200 mg,
400 mg, 50 mg
diclofenac potassium oral tablet 50 mg
diclofenac sodium oral tablet extended
release 24 hr 100 mg
diclofenac sodium oral tablet,delayed
release (dr/ec) 25 mg, 50 mg, 75 mg
diclofenac-misoprostol oral
tablet,ir,delayed rel,biphasic 50-200 mgmcg
diclofenac-misoprostol oral
tablet,ir,delayed rel,biphasic 75-200 mgmcg
diflunisal oral tablet 500 mg
etodolac oral capsule 200 mg, 300 mg
etodolac oral tablet 400 mg
etodolac oral tablet 500 mg
4
Requirements/Limits
4
(Celebrex)
2
(Voltaren-XR)
2
2
QL (60 per 30 days)
2
(Arthrotec 50)
2
(Arthrotec 75)
2
2
2
2
2
(Lodine)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
8
Drug Name
Drug Tier
etodolac oral tablet extended release 24
hr 400 mg, 500 mg, 600 mg
fenoprofen oral tablet 600 mg
FLECTOR TRANSDERMAL
PATCH 12 HOUR 1.3 %
flurbiprofen oral tablet 100 mg, 50 mg
ibuprofen oral suspension 100 mg/5 ml
ibuprofen oral tablet 400 mg, 600 mg,
800 mg
indomethacin oral capsule 25 mg
indomethacin oral capsule 50 mg
indomethacin oral capsule, extended
release 75 mg
indomethacin sodium intravenous recon
soln 1 mg
ketoprofen oral capsule 50 mg, 75 mg
ketoprofen oral capsule,ext rel. pellets 24
hr 200 mg
ketorolac injection cartridge 15 mg/ml
ketorolac injection cartridge 30 mg/ml
ketorolac injection solution 15 mg/ml
ketorolac injection solution 30 mg/ml (1
ml)
ketorolac injection syringe 30 mg/ml
ketorolac intramuscular solution 60 mg/2
ml
ketorolac oral tablet 10 mg
mefenamic acid oral capsule 250 mg
meloxicam oral suspension 7.5 mg/5 ml
meloxicam oral tablet 15 mg, 7.5 mg
nabumetone oral tablet 500 mg, 750 mg
naproxen oral suspension 125 mg/5 ml
naproxen oral tablet 250 mg, 375 mg
naproxen oral tablet 500 mg
naproxen oral tablet,delayed release
(dr/ec) 375 mg, 500 mg
naproxen sodium oral tablet 275 mg
naproxen sodium oral tablet 550 mg
piroxicam oral capsule 10 mg, 20 mg
sulindac oral tablet 150 mg, 200 mg
2
2
3
(Child Ibuprofen)
Requirements/Limits
PA
2
2
1
1
1
2
QL (240 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
2
2
2
(Ponstel)
(Mobic)
(Naprosyn)
(Naprosyn)
(EC-Naprosyn)
(Anaprox DS)
(Feldene)
2
2
2
2
QL (40 per 30 days)
QL (20 per 30 days)
QL (40 per 30 days)
QL (20 per 30 days)
2
2
QL (20 per 30 days)
QL (20 per 30 days)
2
2
2
1
2
2
1
1
2
QL (20 per 30 days)
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
9
Drug Name
Drug Tier
Requirements/Limits
2
2
2
tolmetin oral capsule 400 mg
tolmetin oral tablet 200 mg, 600 mg
VOLTAREN TOPICAL GEL 1 %
Anesthetics
Local Anesthetics
glydo mucous membrane jelly in
applicator 2 %
lidocaine (pf) injection solution 15 mg/ml (Xylocaine-MPF)
(1.5 %), 20 mg/ml (2 %), 5 mg/ml (0.5
%)
lidocaine (pf) injection solution 40 mg/ml
(4 %)
lidocaine hcl injection solution 10 mg/ml (Xylocaine)
(1 %), 20 mg/ml (2 %), 5 mg/ml (0.5 %)
lidocaine hcl mucous membrane jelly 2 %
lidocaine hcl mucous membrane solution
4 % (40 mg/ml)
lidocaine topical adhesive
(Lidoderm)
patch,medicated 5 %
lidocaine topical ointment 5 %
lidocaine viscous mucous membrane
solution 2 %
lidocaine-prilocaine topical cream 2.5-2.5
%
2
2
2
2
2
2
2
PA
2
2
2
Anti-Addiction/Substance Abuse
Treatment Agents
Anti-Addiction/Substance Abuse
Treatment Agents
acamprosate oral tablet,delayed release
(dr/ec) 333 mg
BUNAVAIL BUCCAL FILM 2.1-0.3
MG
BUNAVAIL BUCCAL FILM 4.2-0.7
MG, 6.3-1 MG
buprenorphine hcl sublingual tablet 2 mg,
8 mg
buprenorphine-naloxone sublingual tablet
2-0.5 mg, 8-2 mg
buproban oral tablet extended release 12
hr 150 mg
2
3
QL (30 per 30 days)
3
QL (60 per 30 days)
2
PA; QL (90 per 30
days)
QL (90 per 30 days)
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
10
Drug Name
Drug Tier
bupropion hcl (smoking deter) oral tablet (Zyban)
extended release 12 hr 150 mg
CHANTIX CONTINUING MONTH
BOX ORAL TABLET 1 MG
CHANTIX ORAL TABLET 0.5 MG, 1
MG
CHANTIX STARTING MONTH
BOX ORAL TABLETS,DOSE PACK
0.5 MG (11)- 1 MG (42)
disulfiram oral tablet 250 mg, 500 mg
(Antabuse)
naloxone injection solution 0.4 mg/ml
naloxone injection syringe 0.4 mg/ml, 1
mg/ml
naltrexone oral tablet 50 mg
(Revia)
NARCAN NASAL SPRAY,NONAEROSOL 4 MG/ACTUATION
NICOTROL INHALATION
CARTRIDGE 10 MG
SUBOXONE SUBLINGUAL FILM
12-3 MG, 8-2 MG
SUBOXONE SUBLINGUAL FILM 20.5 MG, 4-1 MG
ZUBSOLV SUBLINGUAL TABLET
0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9
MG, 2.9-0.71 MG, 5.7-1.4 MG
ZUBSOLV SUBLINGUAL TABLET
8.6-2.1 MG
Requirements/Limits
2
3
QL (168 per 84 days)
3
QL (168 per 84 days)
3
QL (53 per 28 days)
2
2
2
2
3
QL (4 per 30 days)
4
QL (1008 per 90 days)
3
QL (60 per 30 days)
3
QL (30 per 30 days)
3
QL (30 per 30 days)
3
QL (60 per 30 days)
(Xanax)
1
QL (120 per 30 days)
(Xanax)
(Xanax XR)
1
2
QL (150 per 30 days)
QL (120 per 30 days)
(Xanax XR)
2
QL (90 per 30 days)
1
QL (120 per 30 days)
1
1
QL (90 per 30 days)
QL (300 per 30 days)
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet 0.25 mg, 0.5 mg, 1
mg
alprazolam oral tablet 2 mg
alprazolam oral tablet extended release
24 hr 0.5 mg, 1 mg, 2 mg
alprazolam oral tablet extended release
24 hr 3 mg
chlordiazepoxide hcl oral capsule 10 mg,
25 mg, 5 mg
clonazepam oral tablet 0.5 mg, 1 mg
clonazepam oral tablet 2 mg
(Klonopin)
(Klonopin)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
11
Drug Name
Drug Tier
clonazepam oral tablet,disintegrating
0.125 mg, 0.25 mg, 0.5 mg, 1 mg
clonazepam oral tablet,disintegrating 2
mg
clorazepate dipotassium oral tablet 15
mg, 3.75 mg
clorazepate dipotassium oral tablet 7.5
mg
diazepam injection solution 5 mg/ml
diazepam intensol oral concentrate 5
mg/ml
diazepam oral solution 5 mg/5 ml (1
mg/ml)
diazepam oral tablet 10 mg, 2 mg, 5 mg
diazepam rectal kit 12.5-15-17.5-20 mg,
5-7.5-10 mg
diazepam rectal kit 2.5 mg
estazolam oral tablet 1 mg
2
QL (90 per 30 days)
2
QL (300 per 30 days)
2
QL (180 per 30 days)
2
QL (180 per 30 days)
2
2
QL (10 per 28 days)
QL (1200 per 30 days)
2
QL (1200 per 30 days)
(Valium)
(Diastat AcuDial)
1
2
QL (120 per 30 days)
(Diastat)
2
2
(Tranxene T-Tab)
2
estazolam oral tablet 2 mg
Requirements/Limits
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
benzodiazepine
hypnotic drug); QL (60
per 30 days); AGE
(Max 64 Years)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
benzodiazepine
hypnotic drug); QL (30
per 30 days); AGE
(Max 64 Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
12
Drug Name
Drug Tier
Requirements/Limits
flurazepam oral capsule 15 mg
2
flurazepam oral capsule 30 mg
2
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
benzodiazepine
hypnotic drug); QL (60
per 30 days); AGE
(Max 64 Years)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
benzodiazepine
hypnotic drug); QL (30
per 30 days); AGE
(Max 64 Years)
QL (150 per 30 days)
QL (2 per 30 days)
QL (150 per 30 days)
lorazepam 2 mg/ml oral concent 2 mg/ml
lorazepam injection solution 2 mg/ml
lorazepam intensol oral concentrate 2
mg/ml
lorazepam oral tablet 0.5 mg, 1 mg
lorazepam oral tablet 2 mg
midazolam oral syrup 2 mg/ml
ONFI ORAL SUSPENSION 2.5
MG/ML
ONFI ORAL TABLET 10 MG, 20 MG
(Lorazepam Intensol)
(Ativan)
2
2
2
(Ativan)
(Ativan)
1
1
2
5
temazepam oral capsule 15 mg, 22.5 mg,
30 mg
(Restoril)
5
2
QL (90 per 30 days)
QL (150 per 30 days)
QL (10 per 30 days)
PA NSO; NDS; QL
(480 per 30 days)
PA NSO; NDS; QL (60
per 30 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
benzodiazepine
hypnotic drug); QL (30
per 30 days); AGE
(Max 64 Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
13
Drug Name
temazepam oral capsule 7.5 mg
(Restoril)
Requirements/Limits
2
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
benzodiazepine
hypnotic drug); QL
(120 per 30 days); AGE
(Max 64 Years)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
benzodiazepine
hypnotic drug); QL
(120 per 30 days); AGE
(Max 64 Years)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
benzodiazepine
hypnotic drug); QL (60
per 30 days); AGE
(Max 64 Years)
2
triazolam oral tablet 0.125 mg
triazolam oral tablet 0.25 mg
Drug Tier
(Halcion)
2
Antibacterials
Aminoglycosides
BETHKIS INHALATION
SOLUTION FOR NEBULIZATION
300 MG/4 ML
gentamicin in nacl (iso-osm) intravenous
piggyback 100 mg/100 ml, 100 mg/50 ml,
60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml,
80 mg/50 ml, 90 mg/100 ml
gentamicin injection solution 40 mg/ml
gentamicin ped 20 mg/2 ml vial latexfree, sdv 20 mg/2 ml
5
PA BvD; NDS
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
14
Drug Name
Drug Tier
gentamicin sulfate (pf) intravenous
solution 100 mg/10 ml
neomycin oral tablet 500 mg
streptomycin intramuscular recon soln 1
gram
TOBI PODHALER INHALATION
CAPSULE, W/INHALATION
DEVICE 28 MG
tobramycin in 0.225 % nacl inhalation
solution for nebulization 300 mg/5 ml
tobramycin in 0.9 % nacl intravenous
piggyback 60 mg/50 ml
tobramycin sulfate injection solution 10
mg/ml, 40 mg/ml
Antibacterials, Miscellaneous
baciim intramuscular recon soln 50,000
unit
bacitracin intramuscular recon soln
50,000 unit
chloramphenicol sod succinate
intravenous recon soln 1 gram
clindamycin 75 mg/5 ml soln 75 mg/5 ml
clindamycin hcl oral capsule 150 mg, 300
mg, 75 mg
clindamycin in 5 % dextrose intravenous
piggyback 300 mg/50 ml, 600 mg/50 ml,
900 mg/50 ml
clindamycin pediatric oral recon soln 75
mg/5 ml
clindamycin phosphate injection solution
150 (mg/ml) (6 ml)
clindamycin phosphate injection solution
150 mg/ml
clindamycin phosphate intravenous
solution 600 mg/4 ml
colistin (colistimethate na) injection
recon soln 150 mg
CUBICIN INTRAVENOUS RECON
SOLN 500 MG
daptomycin intravenous recon soln 500
mg
2
Requirements/Limits
2
2
(Tobi)
5
NDS; QL (224 per 28
days)
5
PA BvD; NDS
2
2
2
(BACiiM)
2
2
(Cleocin Pediatric)
(Cleocin HCl)
2
2
(Cleocin in 5 %
dextrose)
2
2
2
(Cleocin)
2
(Cleocin)
2
(Coly-Mycin M
Parenteral)
2
(Cubicin)
5
NDS
5
NDS
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
15
Drug Name
Drug Tier
Requirements/Limits
linezolid intravenous parenteral solution
600 mg/300 ml
linezolid oral suspension for
reconstitution 100 mg/5 ml
linezolid oral tablet 600 mg
methenamine hippurate oral tablet 1
gram
metronidazole in nacl (iso-os)
intravenous piggyback 500 mg/100 ml
metronidazole oral capsule 375 mg
metronidazole oral tablet 250 mg, 500 mg
nitrofurantoin macrocrystal oral capsule
100 mg, 25 mg, 50 mg
(Zyvox)
5
NDS
(Zyvox)
5
NDS
(Zyvox)
(Hiprex)
5
2
NDS
(Metro I.V.)
2
(Flagyl)
(Flagyl)
(Macrodantin)
2
2
2
nitrofurantoin monohyd/m-cryst oral
capsule 100 mg
(Macrobid)
2
nitrofurantoin oral suspension 25 mg/5 ml (Furadantin)
2
polymyxin b sulfate injection recon soln
500,000 unit
SYNERCID INTRAVENOUS
RECON SOLN 500 MG
2
5
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs);
QL (120 per 30 days);
AGE (Max 64 Years)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs);
QL (60 per 30 days);
AGE (Max 64 Years)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs);
QL (2400 per 30 days);
AGE (Max 64 Years)
NDS
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
16
Drug Name
Drug Tier
trimethoprim oral tablet 100 mg
vancomycin hcl 1g/200 ml bag 1
gram/200 ml
vancomycin intravenous recon soln 1,000
mg, 10 gram, 750 mg
vancomycin intravenous recon soln 500
mg
vancomycin oral capsule 125 mg, 250 mg
XIFAXAN ORAL TABLET 200 MG
2
2
XIFAXAN ORAL TABLET 550 MG
Cephalosporins
cefaclor oral capsule 250 mg, 500 mg
cefaclor oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
cefaclor oral tablet extended release 12
hr 500 mg
cefadroxil oral capsule 500 mg
cefadroxil oral suspension for
reconstitution 250 mg/5 ml, 500 mg/5 ml
cefadroxil oral tablet 1 gram
cefazolin in dextrose (iso-os) intravenous
piggyback 1 gram/50 ml, 2 gram/50 ml
cefazolin injection recon soln 1 gram, 10
gram, 500 mg
cefdinir oral capsule 300 mg
cefdinir oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml
cefditoren pivoxil oral tablet 200 mg
cefditoren pivoxil oral tablet 400 mg
CEFEPIME 1 GM INJECTION 1
GRAM/50 ML
cefepime hcl 1 gm vial 10's, sdv 1 gram
cefepime hcl 2 gram vial latex/f, sdv,
outer 2 gram
CEFEPIME INJECTION RECON
SOLN 1 GRAM, 2 GRAM
CEFEPIME-DEXTROSE 2 GM/50
ML 2 GRAM/50 ML
Requirements/Limits
2
2
(Vancocin)
5
5
5
NDS
PA; NDS; QL (9 per 30
days)
PA; NDS
2
2
2
2
2
2
2
2
2
2
(Spectracef)
2
2
4
(Maxipime)
(Maxipime)
2
2
(Maxipime)
4
4
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
17
Drug Name
cefixime oral suspension for
reconstitution 100 mg/5 ml, 200 mg/5 ml
cefotaxime injection recon soln 1 gram,
10 gram, 2 gram
cefotaxime injection recon soln 500 mg
cefoxitin 2 gm piggyback bag 2 gram/50
ml
cefoxitin 2 gm vial latex/f, outer 2 gram
cefoxitin intravenous recon soln 1 gram,
10 gram
cefoxitin intravenous recon soln 2 gram
cefpodoxime oral suspension for
reconstitution 100 mg/5 ml, 50 mg/5 ml
cefpodoxime oral tablet 100 mg, 200 mg
cefprozil oral suspension for
reconstitution 125 mg/5 ml, 250 mg/5 ml
cefprozil oral tablet 250 mg, 500 mg
ceftazidime injection recon soln 2 gram
ceftazidime injection recon soln 6 gram
ceftibuten oral capsule 400 mg
ceftibuten oral suspension for
reconstitution 180 mg/5 ml
ceftriaxone 1 gm piggyback l/g, single use
1 gram/50 ml
ceftriaxone 2 gm piggyback l/f, single use
2 gram/50 ml
ceftriaxone injection recon soln 1 gram,
10 gram, 250 mg, 500 mg
ceftriaxone intravenous recon soln 1
gram, 2 gram
cefuroxime axetil oral tablet 250 mg, 500
mg
cefuroxime sodium injection recon soln
750 mg
cefuroxime sodium intravenous recon soln
1.5 gram
cefuroxime sodium intravenous recon soln
7.5 gram
cephalexin oral capsule 250 mg, 500 mg
cephalexin oral capsule 750 mg
Drug Tier
(Suprax)
2
(Claforan)
2
Requirements/Limits
2
2
2
2
2
2
2
2
(Fortaz)
(TAZICEF)
(Cedax)
(Cedax)
2
2
2
2
2
2
2
2
2
2
(Zinacef)
2
(Zinacef)
2
(Zinacef)
2
(Keflex)
(Keflex)
1
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
18
Drug Name
Drug Tier
cephalexin oral suspension for
reconstitution 125 mg/5 ml, 250 mg/5 ml
cephalexin oral tablet 250 mg, 500 mg
MEFOXIN IN DEXTROSE (ISOOSM) INTRAVENOUS
PIGGYBACK 1 GRAM/50 ML, 2
GRAM/50 ML
SUPRAX ORAL CAPSULE 400 MG
SUPRAX ORAL SUSPENSION FOR
RECONSTITUTION 500 MG/5 ML
SUPRAX ORAL
TABLET,CHEWABLE 100 MG, 200
MG
tazicef injection recon soln 2 gram, 6
gram
TEFLARO INTRAVENOUS RECON
SOLN 400 MG, 600 MG
Macrolides
azithromycin intravenous recon soln 500
mg
azithromycin oral packet 1 gram
azithromycin oral suspension for
reconstitution 100 mg/5 ml, 200 mg/5 ml
azithromycin oral tablet 250 mg
azithromycin oral tablet 250 mg (6
pack), 500 mg (3 pack)
azithromycin oral tablet 500 mg
azithromycin oral tablet 600 mg
clarithromycin oral suspension for
reconstitution 125 mg/5 ml
clarithromycin oral suspension for
reconstitution 250 mg/5 ml
clarithromycin oral tablet 250 mg, 500
mg
clarithromycin oral tablet extended
release 24 hr 500 mg
DIFICID ORAL TABLET 200 MG
1
Requirements/Limits
1
4
4
4
4
2
4
(Zithromax)
2
(Zithromax)
(Zithromax)
2
2
(Zithromax Z-Pak)
2
2
(Zithromax TRI-PAK)
(Zithromax)
2
2
2
(Biaxin)
2
(Biaxin)
2
2
5
NDS; QL (20 per 10
days)
2
2
e.e.s. 400 oral tablet 400 mg
e.e.s. granules oral suspension for
reconstitution 200 mg/5 ml
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
19
Drug Name
Drug Tier
ery-tab oral tablet,delayed release
(dr/ec) 250 mg, 500 mg
ERY-TAB ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
erythrocin (as stearate) oral tablet 250
mg
ERYTHROCIN INTRAVENOUS
RECON SOLN 1,000 MG, 500 MG
erythromycin ethylsuccinate oral
suspension for reconstitution 200 mg/5 ml
erythromycin ethylsuccinate oral tablet
400 mg
erythromycin oral capsule,delayed
release(dr/ec) 250 mg
erythromycin oral tablet 250 mg, 500 mg
Miscellaneous B-Lactam Antibiotics
aztreonam injection recon soln 1 gram, 2
gram
CAYSTON INHALATION
SOLUTION FOR NEBULIZATION
75 MG/ML
imipenem-cilastatin intravenous recon
soln 250 mg, 500 mg
INVANZ INJECTION RECON SOLN
1 GRAM
meropenem intravenous recon soln 1
gram, 500 mg
Penicillins
amoxicillin oral capsule 250 mg, 500 mg
amoxicillin oral suspension for
reconstitution 125 mg/5 ml, 200 mg/5 ml,
250 mg/5 ml, 400 mg/5 ml
amoxicillin oral tablet 500 mg, 875 mg
amoxicillin oral tablet,chewable 125 mg,
250 mg
amoxicillin-pot clavulanate oral
suspension for reconstitution 200-28.5
mg/5 ml, 400-57 mg/5 ml
2
Requirements/Limits
4
2
4
(E.E.S. Granules)
2
(E.E.S. 400)
2
2
2
(Azactam)
2
5
(Primaxin IV)
LA; NDS
2
4
(Merrem)
2
1
1
1
1
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
20
Drug Name
amoxicillin-pot clavulanate oral
suspension for reconstitution 250-62.5
mg/5 ml
amoxicillin-pot clavulanate oral
suspension for reconstitution 600-42.9
mg/5 ml
amoxicillin-pot clavulanate oral tablet
250-125 mg
amoxicillin-pot clavulanate oral tablet
500-125 mg, 875-125 mg
amoxicillin-pot clavulanate oral tablet
extended release 12 hr 1,000-62.5 mg
amoxicillin-pot clavulanate oral
tablet,chewable 200-28.5 mg, 400-57 mg
ampicillin oral capsule 250 mg, 500 mg
ampicillin oral suspension for
reconstitution 125 mg/5 ml, 250 mg/5 ml
ampicillin sodium injection recon soln 1
gram, 10 gram, 125 mg, 2 gram, 250 mg,
500 mg
ampicillin sodium intravenous recon soln
2 gram
ampicillin-sulbactam injection recon soln
1.5 gram, 15 gram, 3 gram
BICILLIN C-R INTRAMUSCULAR
SYRINGE 1,200,000 UNIT/ 2
ML(600K/600K), 1,200,000 UNIT/ 2
ML(900K/300K)
BICILLIN L-A INTRAMUSCULAR
SYRINGE 1,200,000 UNIT/2 ML,
2,400,000 UNIT/4 ML, 600,000
UNIT/ML
dicloxacillin oral capsule 250 mg, 500 mg
nafcillin 2 gm vial 10's, latex-free 2 gram
nafcillin injection recon soln 1 gram, 10
gram
nafcillin intravenous recon soln 2 gram
oxacillin in dextrose(iso-osm)
intravenous piggyback 1 gram/50 ml, 2
gram/50 ml
Drug Tier
(Augmentin)
2
(Augmentin ES-600)
2
Requirements/Limits
2
(Augmentin)
2
(Augmentin XR)
2
2
1
1
2
2
(Unasyn)
2
4
4
2
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
21
Drug Name
Drug Tier
oxacillin injection recon soln 10 gram, 2
gram
oxacillin intravenous recon soln 1 gram
penicillin g pot in dextrose intravenous
piggyback 1 million unit/50 ml, 2 million
unit/50 ml, 3 million unit/50 ml
penicillin g potassium injection recon soln
5 million unit
penicillin g procaine intramuscular
syringe 1.2 million unit/2 ml, 600,000
unit/ml
penicillin gk 20 million unit 20 million
unit
penicillin v potassium oral recon soln 125
mg/5 ml, 250 mg/5 ml
penicillin v potassium oral tablet 250 mg,
500 mg
pfizerpen-g injection recon soln 20 million
unit
piperacillin-tazobactam intravenous
recon soln 2.25 gram, 3.375 gram, 4.5
gram, 40.5 gram
Quinolones
ciprofloxacin (mixture) oral tablet, er
multiphase 24 hr 1,000 mg, 500 mg
ciprofloxacin hcl oral tablet 100 mg, 750
mg
ciprofloxacin hcl oral tablet 250 mg, 500
mg
ciprofloxacin in 5 % dextrose intravenous
piggyback 200 mg/100 ml
ciprofloxacin in 5 % dextrose intravenous
piggyback 400 mg/200 ml
ciprofloxacin lactate intravenous solution
200 mg/20 ml, 400 mg/40 ml
ciprofloxacin oral
suspension,microcapsule recon 250 mg/5
ml, 500 mg/5 ml
levofloxacin in d5w intravenous
piggyback 250 mg/50 ml, 500 mg/100 ml,
750 mg/150 ml
2
Requirements/Limits
2
2
(Pfizerpen-G)
2
2
(Pfizerpen-G)
2
2
2
2
(Zosyn)
2
(Cipro XR)
2
1
(Cipro)
1
2
(Cipro in D5W)
2
2
(Cipro)
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
22
Drug Name
Drug Tier
levofloxacin intravenous solution 25
mg/ml
levofloxacin oral solution 250 mg/10 ml
levofloxacin oral tablet 250 mg, 500 mg,
750 mg
moxifloxacin oral tablet 400 mg
ofloxacin oral tablet 300 mg, 400 mg
Sulfonamides
sulfadiazine oral tablet 500 mg
sulfamethoxazole-trimethoprim
intravenous solution 400-80 mg/5 ml
sulfamethoxazole-trimethoprim oral
suspension 200-40 mg/5 ml
sulfamethoxazole-trimethoprim oral
tablet 400-80 mg
sulfamethoxazole-trimethoprim oral
tablet 800-160 mg
sulfasalazine oral tablet 500 mg
sulfasalazine oral tablet,delayed release
(dr/ec) 500 mg
sulfatrim oral suspension 200-40 mg/5 ml
Tetracyclines
demeclocycline oral tablet 150 mg, 300
mg
doxy-100 intravenous recon soln 100 mg
doxycycline hyclate intravenous recon
soln 100 mg
doxycycline hyclate oral capsule 100 mg,
50 mg
doxycycline hyclate oral tablet 100 mg,
20 mg
doxycycline hyclate oral tablet,delayed
release (dr/ec) 100 mg, 150 mg, 75 mg
doxycycline hyclate oral tablet,delayed
release (dr/ec) 200 mg, 50 mg
doxycycline monohydrate oral capsule
100 mg, 50 mg
doxycycline monohydrate oral capsule
150 mg
doxycycline monohydrate oral capsule 75
mg
2
(Levaquin)
(Avelox)
Requirements/Limits
2
1
2
2
2
2
(Sulfatrim)
2
(Bactrim)
1
(Bactrim DS)
1
(Azulfidine)
(Azulfidine EN-tabs)
2
2
2
2
(Doxy-100)
2
2
(Morgidox)
2
2
2
(Doryx)
2
(Mondoxyne NL)
2
2
(Monodox)
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
23
Drug Name
doxycycline monohydrate oral suspension
for reconstitution 25 mg/5 ml
doxycycline monohydrate oral tablet 100
mg
doxycycline monohydrate oral tablet 150
mg, 50 mg, 75 mg
MINOCIN INTRAVENOUS RECON
SOLN 100 MG
minocycline oral capsule 100 mg, 50 mg,
75 mg
minocycline oral tablet 100 mg, 50 mg,
75 mg
minocycline oral tablet extended release
24 hr 135 mg, 45 mg, 90 mg
tetracycline oral capsule 250 mg, 500 mg
tigecycline intravenous recon soln 50 mg
TYGACIL INTRAVENOUS RECON
SOLN 50 MG
Drug Tier
(Vibramycin)
2
(Avidoxy)
2
Requirements/Limits
2
5
(Minocin)
NDS
2
2
2
(Tygacil)
2
5
5
NDS
NDS
5
NDS
5
2
PA NSO; NDS; QL (4
per 21 days)
PA BvD
2
PA BvD
2
5
PA BvD
PA NSO; NDS; QL
(112 per 28 days)
5
PA NSO; NDS; QL (56
per 28 days)
PA NSO; NDS; QL (28
per 28 days)
PA NSO; NDS; QL
(240 per 30 days)
NDS
Anticancer Agents
Anticancer Agents
ABRAXANE INTRAVENOUS
SUSPENSION FOR
RECONSTITUTION 100 MG
ADCETRIS INTRAVENOUS
RECON SOLN 50 MG
adriamycin intravenous solution 2 mg/ml,
20 mg/10 ml
adrucil 2,500 mg/50 ml vial outer, latexfree 2.5 gram/50 ml
adrucil intravenous solution 500 mg/10 ml
AFINITOR DISPERZ ORAL
TABLET FOR SUSPENSION 2 MG, 3
MG, 5 MG
AFINITOR ORAL TABLET 10 MG
AFINITOR ORAL TABLET 2.5 MG,
5 MG, 7.5 MG
ALECENSA ORAL CAPSULE 150
MG
ALIMTA INTRAVENOUS RECON
SOLN 100 MG, 500 MG
5
5
5
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
24
Drug Name
Drug Tier
anastrozole oral tablet 1 mg
AVASTIN INTRAVENOUS
SOLUTION 25 MG/ML, 25 MG/ML
(16 ML)
azacitidine injection recon soln 100 mg
BAVENCIO INTRAVENOUS
SOLUTION 20 MG/ML
BELEODAQ INTRAVENOUS
RECON SOLN 500 MG
BENDEKA INTRAVENOUS
SOLUTION 25 MG/ML
bexarotene oral capsule 75 mg
(Arimidex)
bicalutamide oral tablet 50 mg
bleomycin injection recon soln 15 unit
bleomycin injection recon soln 30 unit
BLINCYTO INTRAVENOUS KIT 35
MCG
BOSULIF ORAL TABLET 100 MG
Requirements/Limits
2
5
PA NSO; NDS
5
5
NDS
PA NSO; NDS
5
PA NSO; NDS
5
PA NSO; NDS
(Targretin)
5
PA NSO; NDS; QL
(420 per 30 days)
(Casodex)
(Bleo 15K)
2
2
2
5
(Vidaza)
5
BOSULIF ORAL TABLET 500 MG
5
CABOMETYX ORAL TABLET 20
MG, 60 MG
CABOMETYX ORAL TABLET 40
MG
CAPRELSA ORAL TABLET 100 MG
5
CAPRELSA ORAL TABLET 300 MG
5
carboplatin intravenous solution 10
mg/ml
cladribine intravenous solution 10 mg/10
ml
COMETRIQ ORAL CAPSULE 100
MG/DAY(80 MG X1-20 MG X1), 140
MG/DAY(80 MG X1-20 MG X3), 60
MG/DAY (20 MG X 3/DAY)
COTELLIC ORAL TABLET 20 MG
2
5
5
PA BvD
PA BvD
PA NSO; NDS; QL
(140 per 365 days)
PA NSO; NDS; QL
(120 per 30 days)
PA NSO; NDS; QL (30
per 30 days)
PA NSO; NDS; QL (30
per 30 days)
PA NSO; NDS; QL (60
per 30 days)
PA NSO; NDS; QL (60
per 30 days)
PA NSO; NDS; QL (30
per 30 days)
2
PA BvD
5
PA NSO; NDS; QL
(112 per 28 days)
5
PA NSO; LA; NDS;
QL (63 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
25
Drug Name
Drug Tier
Requirements/Limits
cyclophosphamide intravenous recon soln
1 gram, 2 gram, 500 mg
CYCLOPHOSPHAMIDE ORAL
CAPSULE 25 MG, 50 MG
CYRAMZA INTRAVENOUS
SOLUTION 10 MG/ML, 10 MG/ML
(50 ML)
DARZALEX INTRAVENOUS
SOLUTION 20 MG/ML
decitabine intravenous recon soln 50 mg
docetaxel 160 mg/16 ml vial mdv,
sterile,l/f 160 mg/16 ml (10 mg/ml)
docetaxel intravenous solution 80 mg/4
ml (20 mg/ml)
docetaxel intravenous solution 80 mg/8
ml (10 mg/ml)
doxorubicin 200 mg/100 ml vial latexfree 2 mg/ml
doxorubicin intravenous solution 50
mg/25 ml
doxorubicin, peg-liposomal intravenous
suspension 2 mg/ml
DROXIA ORAL CAPSULE 200 MG,
300 MG, 400 MG
ELIGARD (3 MONTH)
SUBCUTANEOUS SYRINGE 22.5
MG
ELIGARD (4 MONTH)
SUBCUTANEOUS SYRINGE 30 MG
ELIGARD (6 MONTH)
SUBCUTANEOUS SYRINGE 45 MG
ELIGARD SUBCUTANEOUS
SYRINGE 7.5 MG (1 MONTH)
EMCYT ORAL CAPSULE 140 MG
EMPLICITI INTRAVENOUS
RECON SOLN 300 MG, 400 MG
ERIVEDGE ORAL CAPSULE 150
MG
ETOPOPHOS INTRAVENOUS
RECON SOLN 100 MG
etoposide intravenous solution 20 mg/ml
5
PA BvD; NDS
4
PA BvD; ST
5
PA NSO; NDS
5
PA NSO; LA; NDS
(Dacogen)
5
5
NDS
NDS
(Taxotere)
5
NDS
5
NDS
(Adriamycin)
2
PA BvD
(Adriamycin)
2
PA BvD
(Doxil)
5
PA BvD; NDS
3
4
QL (1 per 84 days)
4
QL (1 per 112 days)
4
QL (1 per 168 days)
4
5
5
NDS
PA NSO; NDS
5
PA NSO; NDS; QL (30
per 30 days)
4
(Toposar)
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
26
Drug Name
exemestane oral tablet 25 mg
FARESTON ORAL TABLET 60 MG
FARYDAK ORAL CAPSULE 10
MG, 15 MG, 20 MG
FASLODEX INTRAMUSCULAR
SYRINGE 250 MG/5 ML
floxuridine injection recon soln 0.5 gram
fluorouracil 5,000 mg/100 ml latex-free 5
gram/100 ml
fluorouracil intravenous solution 1
gram/20 ml
fluorouracil intravenous solution 2.5
gram/50 ml, 500 mg/10 ml
flutamide oral capsule 125 mg
GAZYVA INTRAVENOUS
SOLUTION 1,000 MG/40 ML
gemcitabine intravenous recon soln 1
gram, 200 mg
gemcitabine intravenous recon soln 2
gram
gemcitabine intravenous solution 1
gram/26.3 ml (38 mg/ml), 2 gram/52.6
ml (38 mg/ml), 200 mg/5.26 ml (38
mg/ml)
GILOTRIF ORAL TABLET 20 MG,
30 MG, 40 MG
GLEOSTINE ORAL CAPSULE 10
MG, 100 MG, 40 MG, 5 MG
HERCEPTIN INTRAVENOUS
RECON SOLN 440 MG
HEXALEN ORAL CAPSULE 50 MG
hydroxyurea oral capsule 500 mg
IBRANCE ORAL CAPSULE 100 MG,
125 MG, 75 MG
ICLUSIG ORAL TABLET 15 MG
Drug Tier
(Aromasin)
(Adrucil)
(Adrucil)
(Gemzar)
Requirements/Limits
2
5
5
NDS
PA NSO; NDS
5
NDS
2
2
PA BvD
PA BvD
2
PA BvD
2
PA BvD
2
5
PA NSO; NDS
5
NDS
5
NDS
5
NDS
5
PA NSO; NDS; QL (30
per 30 days)
4
(Hydrea)
5
PA NSO; NDS
5
2
5
NDS
ICLUSIG ORAL TABLET 45 MG
5
ifosfamide 1 gm/20 ml vial sdv,p/f,latexfree 1 gram/20 ml
ifosfamide intravenous recon soln 1 gram
2
PA NSO; NDS; QL (21
per 28 days)
PA NSO; NDS; QL (60
per 30 days)
PA NSO; NDS; QL (30
per 30 days)
PA BvD
2
PA BvD
5
(Ifex)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
27
Drug Name
ifosfamide-mesna intravenous kit 1-1
gram, 3,000-1,000 mg
imatinib oral tablet 100 mg
imatinib oral tablet 400 mg
Drug Tier
Requirements/Limits
5
PA BvD; NDS
(Gleevec)
5
(Gleevec)
5
PA NSO; NDS; QL (90
per 30 days)
PA NSO; NDS; QL (60
per 30 days)
PA NSO; NDS
IMBRUVICA ORAL CAPSULE 140
MG
IMLYGIC INJECTION
SUSPENSION 10EXP6 (1 MILLION)
PFU/ML
IMLYGIC INJECTION
SUSPENSION 10EXP8 (100
MILLION) PFU/ML
INLYTA ORAL TABLET 1 MG
5
INLYTA ORAL TABLET 5 MG
5
IRESSA ORAL TABLET 250 MG
5
irinotecan intravenous solution 100 mg/5 (Camptosar)
ml, 40 mg/2 ml
irinotecan intravenous solution 500 mg/25
ml
IXEMPRA INTRAVENOUS RECON
SOLN 15 MG, 45 MG
JAKAFI ORAL TABLET 10 MG, 15
MG, 20 MG, 25 MG, 5 MG
KEYTRUDA INTRAVENOUS
RECON SOLN 50 MG
KEYTRUDA INTRAVENOUS
SOLUTION 100 MG/4 ML (25
MG/ML)
KISQALI ORAL TABLET 200
MG/DAY (200 MG X 1), 400
MG/DAY (200 MG X 2), 600
MG/DAY (200 MG X 3)
KYPROLIS INTRAVENOUS
RECON SOLN 30 MG
KYPROLIS INTRAVENOUS
RECON SOLN 60 MG
2
5
PA NSO; NDS; QL (4
per 365 days)
5
PA NSO; NDS; QL (8
per 28 days)
5
PA NSO; NDS; QL
(180 per 30 days)
PA NSO; NDS; QL (60
per 30 days)
PA NSO; NDS; QL (60
per 30 days)
2
5
NDS
5
5
PA NSO; NDS; QL (60
per 30 days)
PA NSO; NDS
5
PA NSO; NDS
5
PA NSO; NDS; QL (63
per 28 days)
5
PA NSO; NDS; QL (12
per 28 days)
PA NSO; NDS; QL (6
per 28 days)
5
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
28
Drug Name
Drug Tier
Requirements/Limits
LARTRUVO INTRAVENOUS
SOLUTION 10 MG/ML
LENVIMA ORAL CAPSULE 10
MG/DAY (10 MG X 1/DAY), 14
MG/DAY(10 MG X 1-4 MG X 1), 18
MG/DAY (10 MG X 1-4 MG X2), 20
MG/DAY (10 MG X 2), 24
MG/DAY(10 MG X 2-4 MG X 1), 8
MG/DAY (4 MG X 2)
letrozole oral tablet 2.5 mg
(Femara)
LEUKERAN ORAL TABLET 2 MG
leuprolide subcutaneous kit 1 mg/0.2 ml
LONSURF ORAL TABLET 15-6.14
MG
LONSURF ORAL TABLET 20-8.19
MG
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT
11.25 MG, 22.5 MG
LUPRON DEPOT (4 MONTH)
INTRAMUSCULAR SYRINGE KIT
30 MG
LUPRON DEPOT (6 MONTH)
INTRAMUSCULAR SYRINGE KIT
45 MG
LUPRON DEPOT
INTRAMUSCULAR SYRINGE KIT
3.75 MG, 7.5 MG
LYNPARZA ORAL CAPSULE 50
MG
LYSODREN ORAL TABLET 500 MG
MARQIBO INTRAVENOUS KIT 5
MG/31 ML(0.16 MG/ML) FINAL
MATULANE ORAL CAPSULE 50
MG
megestrol oral tablet 20 mg, 40 mg
MEKINIST ORAL TABLET 0.5 MG
5
PA NSO; LA; NDS
5
PA NSO; NDS
MEKINIST ORAL TABLET 2 MG
5
2
4
2
5
5
5
PA NSO; NDS; QL
(100 per 28 days)
PA NSO; NDS; QL (80
per 28 days)
NDS; QL (1 per 84
days)
5
NDS; QL (1 per 84
days)
5
NDS; QL (1 per 168
days)
5
NDS
5
PA NSO; NDS; QL
(480 per 30 days)
NDS
PA NSO; NDS; QL (4
per 28 days)
NDS
5
5
5
2
5
PA NSO; NDS; QL (90
per 30 days)
PA NSO; NDS; QL (30
per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
29
Drug Name
Drug Tier
Requirements/Limits
melphalan hcl intravenous recon soln 50
(Alkeran)
mg
mercaptopurine oral tablet 50 mg
methotrexate sodium (pf) injection recon
soln 1 gram
methotrexate sodium (pf) injection
solution 25 mg/ml
methotrexate sodium injection solution 25
mg/ml
methotrexate sodium oral tablet 2.5 mg
mitoxantrone intravenous concentrate 2
mg/ml
NEXAVAR ORAL TABLET 200 MG
5
NDS
2
2
PA BvD
2
PA BvD
2
PA BvD
2
2
PA BvD; ST
5
NILANDRON ORAL TABLET 150
MG
nilutamide oral tablet 150 mg
(Nilandron)
NINLARO ORAL CAPSULE 2.3 MG,
3 MG, 4 MG
ODOMZO ORAL CAPSULE 200 MG
ONCASPAR INJECTION
SOLUTION 750 UNIT/ML
ONIVYDE INTRAVENOUS
DISPERSION 4.3 MG/ML
OPDIVO INTRAVENOUS
SOLUTION 100 MG/10 ML, 40 MG/4
ML
oxaliplatin intravenous recon soln 100
mg, 50 mg
oxaliplatin intravenous solution 100
mg/20 ml, 50 mg/10 ml (5 mg/ml)
paclitaxel intravenous concentrate 6
mg/ml
PERJETA INTRAVENOUS
SOLUTION 420 MG/14 ML (30
MG/ML)
POMALYST ORAL CAPSULE 1 MG,
2 MG, 3 MG, 4 MG
PORTRAZZA INTRAVENOUS
SOLUTION 800 MG/50 ML (16
MG/ML)
5
PA NSO; NDS; QL
(120 per 30 days)
NDS
5
5
5
5
NDS
PA NSO; NDS; QL (3
per 28 days)
PA NSO; LA; NDS
PA NSO; NDS
5
PA BvD; NDS
5
PA NSO; NDS
2
2
2
5
PA NSO; NDS
5
PA NSO; NDS; QL (21
per 28 days)
PA NSO; NDS; QL
(100 per 21 days)
5
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
30
Drug Name
Drug Tier
Requirements/Limits
PROLEUKIN INTRAVENOUS
RECON SOLN 22 MILLION UNIT
PURIXAN ORAL SUSPENSION 20
MG/ML
REVLIMID ORAL CAPSULE 10
MG, 15 MG, 2.5 MG, 20 MG, 25 MG,
5 MG
RITUXAN INTRAVENOUS
CONCENTRATE 10 MG/ML
RUBRACA ORAL TABLET 200 MG,
300 MG
SOLTAMOX ORAL SOLUTION 10
MG/5 ML
SPRYCEL ORAL TABLET 100 MG,
140 MG, 50 MG, 70 MG, 80 MG
SPRYCEL ORAL TABLET 20 MG
5
NDS
5
NDS
5
PA NSO; LA; NDS
5
PA NSO; NDS
5
PA NSO; NDS; QL
(120 per 30 days)
STIVARGA ORAL TABLET 40 MG
5
SUTENT ORAL CAPSULE 12.5 MG,
25 MG, 37.5 MG, 50 MG
SYLVANT INTRAVENOUS RECON
SOLN 100 MG, 400 MG
SYNRIBO SUBCUTANEOUS
RECON SOLN 3.5 MG
TABLOID ORAL TABLET 40 MG
TAFINLAR ORAL CAPSULE 50
MG, 75 MG
TAGRISSO ORAL TABLET 40 MG,
80 MG
tamoxifen oral tablet 10 mg, 20 mg
TARCEVA ORAL TABLET 100 MG,
25 MG
TARCEVA ORAL TABLET 150 MG
5
TARGRETIN ORAL CAPSULE 75
MG
TARGRETIN TOPICAL GEL 1 %
5
TASIGNA ORAL CAPSULE 150 MG,
200 MG
5
4
5
5
5
5
4
5
5
2
5
5
5
PA NSO; NDS; QL (30
per 30 days)
PA NSO; NDS; QL (60
per 30 days)
PA NSO; NDS; QL (84
per 28 days)
PA NSO; NDS; QL (30
per 30 days)
PA NSO; NDS
PA NSO; NDS; QL (28
per 28 days)
PA NSO; NDS; QL
(120 per 30 days)
PA NSO; LA; NDS;
QL (30 per 30 days)
PA NSO; NDS; QL (60
per 30 days)
PA NSO; NDS; QL (90
per 30 days)
PA NSO; NDS; QL
(420 per 30 days)
PA NSO; NDS; QL (60
per 28 days)
PA NSO; NDS; QL
(112 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
31
Drug Name
TECENTRIQ INTRAVENOUS
SOLUTION 1,200 MG/20 ML (60
MG/ML)
TEMODAR INTRAVENOUS
RECON SOLN 100 MG
teniposide intravenous solution 50 mg/5
ml
thiotepa injection recon soln 15 mg
(Tepadina)
toposar intravenous solution 20 mg/ml
topotecan hcl 4 mg/4 ml vial p/f, suv,
latex-free 4 mg/4 ml (1 mg/ml)
topotecan intravenous recon soln 4 mg
(Hycamtin)
TORISEL INTRAVENOUS RECON
SOLN 30 MG/3 ML (10 MG/ML)
(FIRST)
TREANDA INTRAVENOUS
RECON SOLN 100 MG
TRELSTAR 11.25 MG VIAL INNER,
SDV 11.25 MG
TRELSTAR 22.5 MG SYRINGE
OUTER, L/F, SDV 22.5 MG/2 ML
TRELSTAR 3.75 MG VIAL INNER,
SDV 3.75 MG
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 22.5 MG
TRELSTAR INTRAMUSCULAR
SYRINGE 11.25 MG/2 ML
TRELSTAR INTRAMUSCULAR
SYRINGE 3.75 MG/2 ML
tretinoin (chemotherapy) oral capsule 10
mg
TREXALL ORAL TABLET 10 MG,
15 MG, 5 MG, 7.5 MG
TYKERB ORAL TABLET 250 MG
UNITUXIN INTRAVENOUS
SOLUTION 3.5 MG/ML
VALSTAR INTRAVESICAL
SOLUTION 40 MG/ML
Drug Tier
Requirements/Limits
5
PA NSO; NDS; QL (20
per 21 days)
5
PA NSO; NDS
5
NDS
5
2
5
NDS
5
5
NDS
PA BvD; NDS; QL (4
per 28 days)
5
NDS
5
NDS; QL (1 per 84
days)
NDS; QL (1 per 168
days)
NDS
5
5
NDS
5
NDS; QL (1 per 168
days)
5
5
NDS; QL (1 per 84
days)
NDS
5
NDS
4
PA BvD; ST
5
5
NDS
PA NSO; NDS
5
NDS
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
32
Drug Name
Drug Tier
Requirements/Limits
VECTIBIX INTRAVENOUS
SOLUTION 100 MG/5 ML (20
MG/ML), 400 MG/20 ML (20
MG/ML)
VELCADE INJECTION RECON
SOLN 3.5 MG
VENCLEXTA ORAL TABLET 10
MG
VENCLEXTA ORAL TABLET 100
MG
VENCLEXTA ORAL TABLET 50
MG
VENCLEXTA STARTING PACK
ORAL TABLETS,DOSE PACK 10
MG-50 MG- 100 MG
vinblastine intravenous solution 1 mg/ml
vincasar pfs 2 mg/2 ml vial 2 mg/2 ml
vincasar pfs intravenous solution 1 mg/ml
vincristine 2 mg/2 ml vial p/f, sdv 2 mg/2 (Vincasar PFS)
ml
vincristine intravenous solution 1 mg/ml
(Vincasar PFS)
vinorelbine intravenous solution 10
(Navelbine)
mg/ml, 50 mg/5 ml
VOTRIENT ORAL TABLET 200 MG
5
PA NSO; NDS
5
PA NSO; NDS
3
PA NSO; LA; QL (60
per 30 days)
PA NSO; LA; NDS;
QL (120 per 30 days)
PA NSO; LA; QL (30
per 30 days)
PA NSO; LA; NDS;
QL (42 per 28 days)
XALKORI ORAL CAPSULE 200
MG, 250 MG
XTANDI ORAL CAPSULE 40 MG
5
YERVOY INTRAVENOUS
SOLUTION 200 MG/40 ML (5
MG/ML), 50 MG/10 ML (5 MG/ML)
YONDELIS INTRAVENOUS
RECON SOLN 1 MG
ZALTRAP INTRAVENOUS
SOLUTION 100 MG/4 ML (25
MG/ML), 200 MG/8 ML (25 MG/ML)
ZELBORAF ORAL TABLET 240 MG
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG
4
5
3
5
2
2
2
2
PA BvD
PA BvD
PA BvD
PA BvD
2
2
PA BvD
5
5
PA NSO; NDS; QL
(120 per 30 days)
PA NSO; NDS; QL (60
per 30 days)
PA NSO; NDS; QL
(120 per 30 days)
PA NSO; NDS
5
PA NSO; NDS
5
PA NSO; NDS
5
PA NSO; NDS; QL
(240 per 30 days)
QL (1 per 84 days)
5
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
33
Drug Name
Drug Tier
ZOLADEX SUBCUTANEOUS
IMPLANT 3.6 MG
ZOLINZA ORAL CAPSULE 100 MG
ZYDELIG ORAL TABLET 100 MG,
150 MG
ZYKADIA ORAL CAPSULE 150 MG
4
QL (1 per 28 days)
5
5
ZYTIGA ORAL TABLET 250 MG
5
NDS
PA NSO; NDS; QL (60
per 30 days)
PA NSO; NDS; QL
(140 per 28 days)
PA NSO; NDS; QL
(120 per 30 days)
5
Requirements/Limits
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine injection syringe 0.05 mg/ml, 0.1
mg/ml
propantheline oral tablet 15 mg
2
2
Anticonvulsants
Anticonvulsants
APTIOM ORAL TABLET 200 MG,
400 MG, 600 MG, 800 MG
BANZEL ORAL SUSPENSION 40
MG/ML
BANZEL ORAL TABLET 200 MG,
400 MG
BRIVIACT INTRAVENOUS
SOLUTION 50 MG/5 ML
BRIVIACT ORAL SOLUTION 10
MG/ML
BRIVIACT ORAL TABLET 10 MG,
100 MG, 25 MG, 50 MG, 75 MG
carbamazepine oral capsule, er
multiphase 12 hr 100 mg, 200 mg, 300 mg
carbamazepine oral suspension 100 mg/5
ml
carbamazepine oral tablet 200 mg
carbamazepine oral tablet extended
release 12 hr 100 mg, 200 mg, 400 mg
carbamazepine oral tablet,chewable 100
mg
CELONTIN ORAL CAPSULE 300
MG
DILANTIN ORAL CAPSULE 30 MG
5
NDS
5
NDS
5
NDS
4
QL (80 per 30 days)
4
QL (600 per 30 days)
5
NDS; QL (60 per 30
days)
(Carbatrol)
2
(Tegretol)
2
(Tegretol)
(Tegretol XR)
2
2
2
3
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
34
Drug Name
divalproex oral capsule, delayed rel
sprinkle 125 mg
divalproex oral tablet extended release 24
hr 250 mg, 500 mg
divalproex oral tablet,delayed release
(dr/ec) 125 mg, 250 mg, 500 mg
epitol oral tablet 200 mg
ethosuximide oral capsule 250 mg
ethosuximide oral solution 250 mg/5 ml
felbamate oral suspension 600 mg/5 ml
felbamate oral tablet 400 mg, 600 mg
fosphenytoin injection solution 100 mg
pe/2 ml, 500 mg pe/10 ml
FYCOMPA ORAL SUSPENSION 0.5
MG/ML
FYCOMPA ORAL TABLET 10 MG,
12 MG, 2 MG, 4 MG, 6 MG, 8 MG
gabapentin oral capsule 100 mg, 300 mg,
400 mg
gabapentin oral solution 250 mg/5 ml
gabapentin oral tablet 600 mg, 800 mg
GABITRIL ORAL TABLET 12 MG,
16 MG
GRALISE 30-DAY STARTER PACK
ORAL TABLET EXTENDED
RELEASE 24 HR 300 MG (9)- 600 MG
(69)
GRALISE ORAL TABLET
EXTENDED RELEASE 24 HR 300
MG, 600 MG
lamotrigine oral tablet 100 mg, 150 mg,
200 mg, 25 mg
lamotrigine oral tablet disintegrating,
dose pk 25 mg (21) -50 mg (7)
lamotrigine oral tablet disintegrating,
dose pk 25 mg(14)-50 mg (14)-100 mg
(7)
lamotrigine oral tablet disintegrating,
dose pk 50 mg (42) -100 mg (14)
Drug Tier
(Depakote Sprinkles)
2
(Depakote ER)
2
(Depakote)
2
(Zarontin)
(Zarontin)
(Felbatol)
(Felbatol)
(Cerebyx)
2
2
2
2
2
2
Requirements/Limits
4
4
(Neurontin)
2
(Neurontin)
(Neurontin)
2
2
3
4
ST; QL (78 per 30 days)
4
ST; QL (90 per 30 days)
(Lamictal)
2
(Lamictal ODT Starter
(Blue))
(Lamictal ODT Starter
(Orange))
2
(Lamictal ODT Starter
(Green))
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
35
Drug Name
lamotrigine oral tablet extended release
24hr 100 mg, 200 mg, 25 mg, 250 mg,
300 mg, 50 mg
lamotrigine oral tablet, chewable
dispersible 25 mg, 5 mg
lamotrigine oral tablet,disintegrating 100
mg, 200 mg, 25 mg, 50 mg
lamotrigine oral tablets,dose pack 25 mg
(35)
levetiracetam in nacl (iso-os) intravenous
piggyback 1,000 mg/100 ml, 1,500
mg/100 ml, 500 mg/100 ml
levetiracetam intravenous solution 500
mg/5 ml
levetiracetam oral solution 100 mg/ml
levetiracetam oral tablet 1,000 mg, 250
mg, 750 mg
levetiracetam oral tablet 500 mg
levetiracetam oral tablet extended release
24 hr 500 mg, 750 mg
LYRICA ORAL CAPSULE 100 MG,
150 MG, 200 MG, 225 MG, 25 MG,
300 MG, 50 MG, 75 MG
LYRICA ORAL SOLUTION 20
MG/ML
oxcarbazepine oral suspension 300 mg/5
ml (60 mg/ml)
oxcarbazepine oral tablet 150 mg, 300
mg, 600 mg
OXTELLAR XR ORAL TABLET
EXTENDED RELEASE 24 HR 150
MG, 300 MG, 600 MG
PEGANONE ORAL TABLET 250
MG
phenobarbital oral elixir 20 mg/5 ml (4
mg/ml)
phenobarbital oral tablet 100 mg, 15 mg,
16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2
mg
phenobarbital oral tablet 30 mg
phenytoin oral suspension 125 mg/5 ml
Drug Tier
(Lamictal XR)
2
(Lamictal)
2
(Lamictal ODT)
2
(Lamictal Starter
(Blue) Kit)
2
Requirements/Limits
2
(Keppra)
2
(Keppra)
(Keppra)
2
2
(Roweepra)
(Keppra XR)
2
2
3
QL (90 per 30 days)
3
QL (900 per 30 days)
(Trileptal)
2
(Trileptal)
2
4
3
(Dilantin-125)
2
QL (1500 per 30 days)
2
QL (90 per 30 days)
2
2
QL (200 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
36
Drug Name
Drug Tier
phenytoin oral tablet,chewable 50 mg
(Dilantin Infatabs)
phenytoin sodium extended oral capsule
(Dilantin Extended)
100 mg
phenytoin sodium extended oral capsule
(Phenytek)
200 mg, 300 mg
phenytoin sodium intravenous solution 50
mg/ml
phenytoin sodium intravenous syringe 50
mg/ml
POTIGA ORAL TABLET 200 MG,
300 MG, 400 MG
POTIGA ORAL TABLET 50 MG
primidone oral tablet 250 mg, 50 mg
ROWEEPRA ORAL TABLET 1,000
MG, 500 MG, 750 MG
SABRIL ORAL POWDER IN
PACKET 500 MG
SABRIL ORAL TABLET 500 MG
SPRITAM ORAL TABLET FOR
SUSPENSION 1,000 MG
SPRITAM ORAL TABLET FOR
SUSPENSION 250 MG, 500 MG, 750
MG
tiagabine oral tablet 2 mg, 4 mg
topiramate oral capsule, sprinkle 15 mg,
25 mg
topiramate oral capsule,sprinkle,er 24hr
100 mg, 150 mg, 200 mg, 25 mg, 50 mg
topiramate oral tablet 100 mg, 200 mg,
25 mg, 50 mg
TROKENDI XR ORAL
CAPSULE,EXTENDED RELEASE
24HR 100 MG, 200 MG, 25 MG, 50
MG
valproate sodium intravenous solution
500 mg/5 ml (100 mg/ml)
valproic acid (as sodium salt) oral
solution 250 mg/5 ml
valproic acid oral capsule 250 mg
(Mysoline)
Requirements/Limits
2
2
2
2
2
5
5
NDS; QL (90 per 30
days)
NDS; QL (270 per 30
days)
2
2
5
NDS
5
4
NDS
ST; QL (60 per 30 days)
4
ST; QL (120 per 30
days)
(Gabitril)
(Topamax)
2
2
(Qudexy XR)
2
(Topamax)
2
4
(Depacon)
2
(Depakene)
2
(Depakene)
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
37
Drug Name
VIMPAT INTRAVENOUS
SOLUTION 200 MG/20 ML
VIMPAT ORAL SOLUTION 10
MG/ML
VIMPAT ORAL TABLET 100 MG,
150 MG, 200 MG, 50 MG
zonisamide oral capsule 100 mg, 25 mg
zonisamide oral capsule 50 mg
Drug Tier
Requirements/Limits
4
QL (200 per 5 days)
5
NDS; QL (1200 per 30
days)
QL (60 per 30 days)
4
(Zonegran)
2
2
(Aricept)
2
2
QL (30 per 30 days)
QL (30 per 30 days)
(Razadyne ER)
2
QL (30 per 30 days)
(Razadyne)
2
2
QL (200 per 30 days)
QL (60 per 30 days)
2
2
2
QL (360 per 30 days)
QL (60 per 30 days)
QL (49 per 28 days)
3
QL (28 per 28 days)
3
QL (30 per 30 days)
3
QL (56 per 365 days)
3
QL (30 per 30 days)
2
QL (60 per 30 days)
2
QL (30 per 30 days)
Antidementia Agents
Antidementia Agents
donepezil oral tablet 10 mg, 23 mg, 5 mg
donepezil oral tablet,disintegrating 10
mg, 5 mg
galantamine oral capsule,ext rel. pellets
24 hr 16 mg, 24 mg, 8 mg
galantamine oral solution 4 mg/ml
galantamine oral tablet 12 mg, 4 mg, 8
mg
memantine oral solution 2 mg/ml
memantine oral tablet 10 mg, 5 mg
memantine oral tablets,dose pack 5-10
mg
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE
PACK 7-14-21-28 MG
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR 14
MG, 21 MG, 28 MG, 7 MG
NAMZARIC ORAL
CAP,SPRINKLE,ER 24HR DOSE
PACK 7/14/21/28 MG-10 MG
NAMZARIC ORAL
CAPSULE,SPRINKLE,ER 24HR 1410 MG, 21-10 MG, 28-10 MG, 7-10
MG
rivastigmine tartrate oral capsule 1.5 mg,
3 mg, 4.5 mg, 6 mg
rivastigmine transdermal patch 24 hour
13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24
hr
(Namenda)
(Namenda Titration
Pak)
(Exelon)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
38
Drug Name
Drug Tier
Requirements/Limits
Antidepressants
Antidepressants
amitriptyline oral tablet 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75 mg
amoxapine oral tablet 100 mg, 150 mg,
25 mg, 50 mg
BRINTELLIX ORAL TABLET 10
MG, 20 MG, 5 MG
bupropion hcl oral tablet 100 mg, 75 mg
bupropion hcl oral tablet extended release
12 hr 100 mg, 150 mg, 200 mg
bupropion hcl oral tablet extended release
24 hr 150 mg, 300 mg
citalopram oral solution 10 mg/5 ml
citalopram oral tablet 10 mg, 20 mg, 40
mg
clomipramine oral capsule 25 mg, 50 mg,
75 mg
desipramine oral tablet 10 mg, 25 mg
desipramine oral tablet 100 mg, 150 mg,
50 mg, 75 mg
desvenlafaxine succinate oral tablet
extended release 24 hr 100 mg, 25 mg, 50
mg
doxepin oral capsule 10 mg, 100 mg, 150
mg, 25 mg, 50 mg, 75 mg
doxepin oral concentrate 10 mg/ml
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
duloxetine oral capsule,delayed
release(dr/ec) 30 mg
duloxetine oral capsule,delayed
release(dr/ec) 40 mg
EMSAM TRANSDERMAL PATCH
24 HOUR 12 MG/24 HR, 6 MG/24
HR, 9 MG/24 HR
escitalopram oxalate oral solution 5 mg/5
ml
escitalopram oxalate oral tablet 10 mg,
20 mg, 5 mg
2
2
4
(Wellbutrin SR)
2
2
(Wellbutrin XL)
2
(Celexa)
2
1
(Anafranil)
2
(Norpramin)
2
2
(Pristiq)
2
QL (600 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
2
(Cymbalta)
2
2
(Cymbalta)
2
(Irenka)
2
5
(Cymbalta); QL (60 per
30 days)
(Cymbalta); QL (30 per
30 days)
(Irenka); QL (30 per 30
days)
NDS; QL (30 per 30
days)
2
(Lexapro)
1
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
39
Drug Name
Drug Tier
FETZIMA ORAL CAPSULE,EXT
REL 24HR DOSE PACK 20 MG (2)40 MG (26)
FETZIMA ORAL
CAPSULE,EXTENDED RELEASE 24
HR 120 MG, 20 MG, 40 MG, 80 MG
fluoxetine oral capsule 10 mg, 20 mg, 40
mg
fluoxetine oral capsule,delayed
release(dr/ec) 90 mg
fluoxetine oral solution 20 mg/5 ml (4
mg/ml)
fluoxetine oral tablet 10 mg, 20 mg
FLUOXETINE ORAL TABLET 60
MG
fluvoxamine oral capsule,extended
release 24hr 100 mg, 150 mg
fluvoxamine oral tablet 100 mg, 25 mg,
50 mg
imipramine hcl oral tablet 10 mg, 25 mg,
50 mg
imipramine pamoate oral capsule 100 mg,
125 mg, 150 mg, 75 mg
maprotiline oral tablet 25 mg, 50 mg, 75
mg
MARPLAN ORAL TABLET 10 MG
mirtazapine oral tablet 15 mg, 30 mg, 45
mg
mirtazapine oral tablet 7.5 mg
mirtazapine oral tablet,disintegrating 15
mg, 30 mg, 45 mg
nefazodone oral tablet 100 mg, 150 mg,
200 mg, 250 mg, 50 mg
nortriptyline oral capsule 10 mg, 25 mg,
50 mg, 75 mg
nortriptyline oral solution 10 mg/5 ml
olanzapine-fluoxetine oral capsule 12-25
mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50
mg
paroxetine hcl oral tablet 10 mg, 20 mg,
40 mg
4
Requirements/Limits
4
(Prozac)
1
(Prozac Weekly)
2
2
(Sarafem)
2
4
2
2
(Tofranil)
2
2
2
(Remeron)
4
2
(Remeron SolTab)
2
2
2
(Pamelor)
2
(Symbyax)
2
2
(Paxil)
1
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
40
Drug Name
paroxetine hcl oral tablet 30 mg
paroxetine hcl oral tablet extended
release 24 hr 12.5 mg, 25 mg, 37.5 mg
PAXIL ORAL SUSPENSION 10
MG/5 ML
perphenazine-amitriptyline oral tablet 210 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50
mg
phenelzine oral tablet 15 mg
PRISTIQ ORAL TABLET
EXTENDED RELEASE 24 HR 100
MG, 25 MG, 50 MG
protriptyline oral tablet 10 mg, 5 mg
sertraline oral concentrate 20 mg/ml
sertraline oral tablet 100 mg, 25 mg, 50
mg
SURMONTIL ORAL CAPSULE 100
MG, 25 MG, 50 MG
tranylcypromine oral tablet 10 mg
trazodone oral tablet 100 mg, 150 mg,
300 mg, 50 mg
trimipramine oral capsule 100 mg, 25 mg,
50 mg
TRINTELLIX ORAL TABLET 10
MG, 20 MG, 5 MG
venlafaxine oral capsule,extended release
24hr 150 mg, 37.5 mg, 75 mg
venlafaxine oral tablet 100 mg, 25 mg,
37.5 mg, 50 mg, 75 mg
venlafaxine oral tablet extended release
24hr 150 mg, 37.5 mg, 75 mg
venlafaxine oral tablet extended release
24hr 225 mg
VIIBRYD ORAL TABLET 10 MG, 20
MG, 40 MG
VIIBRYD ORAL TABLETS,DOSE
PACK 10 MG (7)- 20 MG (23)
Drug Tier
(Paxil)
(Paxil CR)
Requirements/Limits
2
2
4
2
(Nardil)
2
4
QL (30 per 30 days)
2
2
1
(Zoloft)
(Zoloft)
4
(Parnate)
2
1
(Surmontil)
2
4
(Effexor XR)
2
2
2
4
4
4
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
acarbose oral tablet 100 mg, 25 mg, 50
mg
(Precose)
6
QL (90 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
41
Drug Name
Drug Tier
alogliptin oral tablet 12.5 mg, 25 mg,
(Nesina)
6.25 mg
alogliptin-metformin oral tablet 12.5(Kazano)
1,000 mg, 12.5-500 mg
alogliptin-pioglitazone oral tablet 12.5-15 (Oseni)
mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg,
25-30 mg, 25-45 mg
CYCLOSET ORAL TABLET 0.8 MG
GLYXAMBI ORAL TABLET 10-5
MG, 25-5 MG
INVOKAMET ORAL TABLET 1501,000 MG, 150-500 MG, 50-1,000 MG
INVOKAMET ORAL TABLET 50500 MG
INVOKAMET XR ORAL TABLET,
IR - ER, BIPHASIC 24HR 150-1,000
MG, 150-500 MG, 50-1,000 MG, 50500 MG
INVOKANA ORAL TABLET 100
MG
INVOKANA ORAL TABLET 300
MG
JANUMET ORAL TABLET 50-1,000
MG, 50-500 MG
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 100-1,000 MG,
50-1,000 MG, 50-500 MG
JANUVIA ORAL TABLET 100 MG,
25 MG, 50 MG
JARDIANCE ORAL TABLET 10
MG, 25 MG
JENTADUETO ORAL TABLET 2.51,000 MG, 2.5-500 MG, 2.5-850 MG
JENTADUETO XR ORAL TABLET,
IR - ER, BIPHASIC 24HR 2.5-1,000
MG, 5-1,000 MG
KAZANO ORAL TABLET 12.5-1,000
MG, 12.5-500 MG
KOMBIGLYZE XR ORAL TABLET,
ER MULTIPHASE 24 HR 2.5-1,000
MG, 5-1,000 MG, 5-500 MG
Requirements/Limits
4
QL (30 per 30 days)
4
QL (60 per 30 days)
4
QL (30 per 30 days)
4
3
QL (180 per 30 days)
ST; QL (30 per 30 days)
3
ST; QL (60 per 30 days)
3
3
ST; QL (120 per 30
days)
ST; QL (60 per 30 days)
3
ST; QL (60 per 30 days)
3
ST; QL (30 per 30 days)
3
3
3
3
ST; QL (30 per 30 days)
3
3
4
QL (60 per 30 days)
4
QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
42
Drug Name
KORLYM ORAL TABLET 300 MG
metformin oral tablet 1,000 mg
metformin oral tablet 500 mg
metformin oral tablet 850 mg
metformin oral tablet extended release 24
hr 500 mg
metformin oral tablet extended release 24
hr 750 mg
metformin oral tablet extended release
24hr 1,000 mg
metformin oral tablet extended release
24hr 500 mg
miglitol oral tablet 100 mg, 25 mg, 50 mg
nateglinide oral tablet 120 mg, 60 mg
NESINA ORAL TABLET 12.5 MG, 25
MG, 6.25 MG
ONGLYZA ORAL TABLET 2.5 MG,
5 MG
OSENI ORAL TABLET 12.5-15 MG,
12.5-30 MG, 12.5-45 MG, 25-15 MG,
25-30 MG, 25-45 MG
pioglitazone oral tablet 15 mg, 30 mg, 45
mg
pioglitazone-glimepiride oral tablet 30-2
mg, 30-4 mg
pioglitazone-metformin oral tablet 15500 mg, 15-850 mg
repaglinide oral tablet 0.5 mg
repaglinide oral tablet 1 mg, 2 mg
repaglinide-metformin oral tablet 1-500
mg, 2-500 mg
SYMLINPEN 120 SUBCUTANEOUS
PEN INJECTOR 2,700 MCG/2.7 ML
SYMLINPEN 60 SUBCUTANEOUS
PEN INJECTOR 1,500 MCG/1.5 ML
SYNJARDY ORAL TABLET 12.51,000 MG, 12.5-500 MG, 5-1,000 MG,
5-500 MG
Drug Tier
Requirements/Limits
5
(Glucophage)
(Glucophage)
(Glucophage)
(Glucophage XR)
6
6
6
6
PA; NDS; QL (112 per
28 days)
QL (75 per 30 days)
QL (150 per 30 days)
QL (90 per 30 days)
QL (120 per 30 days)
(Glucophage XR)
6
QL (90 per 30 days)
(Fortamet)
6
ST; QL (60 per 30 days)
(Fortamet)
6
(Glyset)
(Starlix)
6
6
4
ST; QL (120 per 30
days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
4
QL (30 per 30 days)
4
QL (30 per 30 days)
(Actos)
6
QL (30 per 30 days)
(DUETACT)
6
QL (30 per 30 days)
(Actoplus MET)
6
QL (90 per 30 days)
(Prandin)
6
6
6
QL (240 per 30 days)
QL (240 per 30 days)
QL (150 per 30 days)
5
PA; NDS; QL (10.8 per
28 days)
PA; NDS; QL (6 per 28
days)
ST; QL (60 per 30 days)
5
3
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
43
Drug Name
Drug Tier
Requirements/Limits
SYNJARDY XR ORAL TABLET, IR
- ER, BIPHASIC 24HR 10-1,000 MG,
25-1,000 MG
SYNJARDY XR ORAL TABLET, IR
- ER, BIPHASIC 24HR 12.5-1,000
MG, 5-1,000 MG
TRADJENTA ORAL TABLET 5 MG
TRULICITY SUBCUTANEOUS PEN
INJECTOR 0.75 MG/0.5 ML, 1.5
MG/0.5 ML
VICTOZA
Insulins
HUMALOG KWIKPEN
SUBCUTANEOUS INSULIN PEN
100 UNIT/ML, 200 UNIT/ML (3 ML)
HUMALOG MIX 50-50 KWIKPEN
SUBCUTANEOUS INSULIN PEN
100 UNIT/ML (50-50)
HUMALOG MIX 50-50
SUBCUTANEOUS SUSPENSION 100
UNIT/ML (50-50)
HUMALOG MIX 75-25 KWIKPEN
SUBCUTANEOUS INSULIN PEN
100 UNIT/ML (75-25)
HUMALOG MIX 75-25
SUBCUTANEOUS SUSPENSION 100
UNIT/ML (75-25)
HUMALOG SUBCUTANEOUS
CARTRIDGE 100 UNIT/ML
HUMALOG SUBCUTANEOUS
SOLUTION 100 UNIT/ML
HUMULIN 70/30 KWIKPEN
SUBCUTANEOUS INSULIN PEN
100 UNIT/ML (70-30)
HUMULIN 70/30 SUBCUTANEOUS
SUSPENSION 100 UNIT/ML (70-30)
HUMULIN N KWIKPEN
SUBCUTANEOUS INSULIN PEN
100 UNIT/ML (3 ML)
HUMULIN N SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
3
ST; QL (30 per 30 days)
3
ST; QL (60 per 30 days)
3
3
3
3
QL (30 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
44
Drug Name
Drug Tier
HUMULIN R U-100 INJECTION
SOLUTION 100 UNIT/ML
HUMULIN R U-500 (CONC)
KWIKPEN SUBCUTANEOUS
INSULIN PEN 500 UNIT/ML (3 ML)
HUMULIN R U-500
(CONCENTRATED)
SUBCUTANEOUS SOLUTION 500
UNIT/ML
LANTUS SOLOSTAR
SUBCUTANEOUS INSULIN PEN
100 UNIT/ML (3 ML)
LANTUS SUBCUTANEOUS
SOLUTION 100 UNIT/ML
NOVOLIN 70/30 SUBCUTANEOUS
SUSPENSION 100 UNIT/ML (70-30)
NOVOLIN N SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
NOVOLIN R INJECTION
SOLUTION 100 UNIT/ML
NOVOLOG FLEXPEN
SUBCUTANEOUS INSULIN PEN
100 UNIT/ML
NOVOLOG MIX 70-30 FLEXPEN
SUBCUTANEOUS INSULIN PEN
100 UNIT/ML (70-30)
NOVOLOG MIX 70-30
SUBCUTANEOUS SOLUTION 100
UNIT/ML (70-30)
NOVOLOG PENFILL
SUBCUTANEOUS CARTRIDGE 100
UNIT/ML
NOVOLOG SUBCUTANEOUS
SOLUTION 100 UNIT/ML
TOUJEO SOLOSTAR
SUBCUTANEOUS INSULIN PEN
300 UNIT/ML (1.5 ML)
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg
(Amaryl)
glimepiride oral tablet 4 mg
(Amaryl)
glipizide oral tablet 10 mg
(Glucotrol)
Requirements/Limits
3
QL (40 per 28 days)
3
QL (24 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
QL (40 per 28 days)
3
QL (40 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
6
6
6
QL (30 per 30 days)
QL (60 per 30 days)
QL (120 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
45
Drug Name
glipizide oral tablet 5 mg
glipizide oral tablet extended release 24hr
10 mg
glipizide oral tablet extended release 24hr
2.5 mg, 5 mg
glipizide-metformin oral tablet 2.5-250
mg
glipizide-metformin oral tablet 2.5-500
mg, 5-500 mg
glyburide micronized oral tablet 1.5 mg, 3
mg, 6 mg
glyburide oral tablet 1.25 mg, 2.5 mg, 5
mg
glyburide-metformin oral tablet 1.25-250
mg
glyburide-metformin oral tablet 2.5-500
mg, 5-500 mg
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide oral tablet 500 mg
Drug Tier
Requirements/Limits
(Glucotrol)
(Glucotrol XL)
6
6
QL (60 per 30 days)
QL (60 per 30 days)
(Glucotrol XL)
6
QL (30 per 30 days)
6
QL (240 per 30 days)
6
QL (120 per 30 days)
6
6
6
6
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
QL (120 per 30 days)
QL (60 per 30 days)
QL (180 per 30 days)
5
PA BvD; NDS
5
PA BvD; NDS
2
5
PA BvD
NDS
(Glynase)
6
6
(Glucovance)
6
Antifungals
Antifungals
ABELCET INTRAVENOUS
SUSPENSION 5 MG/ML
AMBISOME INTRAVENOUS
SUSPENSION FOR
RECONSTITUTION 50 MG
amphotericin b injection recon soln 50 mg
CANCIDAS INTRAVENOUS
RECON SOLN 50 MG, 70 MG
ciclopirox topical cream 0.77 %
ciclopirox topical gel 0.77 %
ciclopirox topical shampoo 1 %
ciclopirox topical solution 8 %
ciclopirox topical suspension 0.77 %
clotrimazole mucous membrane troche 10
mg
clotrimazole topical cream 1 %
clotrimazole topical solution 1 %
(Loprox (as olamine))
(Loprox)
(Ciclodan)
(Loprox (as olamine))
(Athletic Foot Cream)
2
2
2
2
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
46
Drug Name
clotrimazole-betamethasone topical
cream 1-0.05 %
clotrimazole-betamethasone topical
lotion 1-0.05 %
econazole topical cream 1 %
EXELDERM TOPICAL CREAM 1 %
EXELDERM TOPICAL SOLUTION
1%
fluconazole in nacl (iso-osm) intravenous
piggyback 100 mg/50 ml, 200 mg/100 ml,
400 mg/200 ml
fluconazole oral suspension for
reconstitution 10 mg/ml, 40 mg/ml
fluconazole oral tablet 100 mg, 150 mg,
200 mg, 50 mg
flucytosine oral capsule 250 mg, 500 mg
griseofulvin microsize oral suspension 125
mg/5 ml
griseofulvin microsize oral tablet 500 mg
griseofulvin ultramicrosize oral tablet 125
mg, 250 mg
itraconazole oral capsule 100 mg
ketoconazole oral tablet 200 mg
ketoconazole topical cream 2 %
ketoconazole topical shampoo 2 %
miconazole-3 vaginal suppository 200 mg
NOXAFIL INTRAVENOUS
SOLUTION 300 MG/16.7 ML
NOXAFIL ORAL SUSPENSION 200
MG/5 ML (40 MG/ML)
NOXAFIL ORAL
TABLET,DELAYED RELEASE
(DR/EC) 100 MG
nyamyc topical powder 100,000
unit/gram
nyata topical powder 100,000 unit/gram
nystatin oral suspension 100,000 unit/ml
nystatin oral tablet 500,000 unit
nystatin topical cream 100,000 unit/gram
Drug Tier
(Lotrisone)
Requirements/Limits
2
2
2
4
4
2
(Diflucan)
2
(Diflucan)
2
(Ancobon)
5
2
(Gris-PEG
(ultramicrosize))
(Sporanox)
(Nizoral)
NDS
2
2
2
2
2
2
2
5
NDS
5
NDS
5
NDS
2
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
47
Drug Name
Drug Tier
nystatin topical ointment 100,000
unit/gram
nystatin topical powder 100,000
unit/gram
nystatin-triamcinolone topical cream
100,000-0.1 unit/g-%
nystatin-triamcinolone topical ointment
100,000-0.1 unit/gram-%
nystop topical powder 100,000 unit/gram
SPORANOX ORAL SOLUTION 10
MG/ML
terbinafine hcl oral tablet 250 mg
voriconazole intravenous solution 200 mg
voriconazole oral suspension for
reconstitution 200 mg/5 ml (40 mg/ml)
voriconazole oral tablet 200 mg, 50 mg
2
(Nystop)
Requirements/Limits
2
2
2
2
5
NDS
(Lamisil)
(Vfend IV)
(Vfend)
1
2
5
NDS
(Vfend)
5
NDS
Antigout Agents
Antigout Agents, Other
allopurinol oral tablet 100 mg, 300 mg
(Zyloprim)
COLCRYS ORAL TABLET 0.6 MG
probenecid oral tablet 500 mg
probenecid-colchicine oral tablet 500-0.5
mg
ULORIC ORAL TABLET 40 MG, 80
MG
ZURAMPIC ORAL TABLET 200 MG
2
2
2
2
3
QL (30 per 30 days)
3
ST; QL (30 per 30 days)
Antihistamines
Antihistamines
carbinoxamine maleate oral liquid 4 mg/5
ml
carbinoxamine maleate oral tablet 4 mg
clemastine oral tablet 2.68 mg
cyproheptadine oral syrup 2 mg/5 ml
cyproheptadine oral tablet 4 mg
diphenhydramine hcl injection solution 50
mg/ml
diphenhydramine hcl injection syringe 50
mg/ml
hydroxyzine hcl intramuscular solution
25 mg/ml, 50 mg/ml
2
2
2
2
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
48
Drug Name
Drug Tier
Requirements/Limits
2
2
hydroxyzine hcl oral solution 10 mg/5 ml
hydroxyzine hcl oral tablet 10 mg, 25 mg,
50 mg
levocetirizine oral solution 2.5 mg/5 ml
(Xyzal)
levocetirizine oral tablet 5 mg
(Xyzal)
promethazine oral syrup 6.25 mg/5 ml
2
2
2
PA-HRM; AGE (Max
64 Years)
Anti-Infectives (Skin And Mucous
Membrane)
Anti-Infectives (Skin And Mucous
Membrane)
AVC VAGINAL VAGINAL CREAM
15 %
clindamycin phosphate vaginal cream 2 % (Cleocin)
metronidazole vaginal gel 0.75 %
(Metrogel Vaginal)
terconazole vaginal cream 0.4 %
(Terazol 7)
terconazole vaginal cream 0.8 %
terconazole vaginal suppository 80 mg
3
2
2
2
2
2
Antimigraine Agents
Antimigraine Agents
almotriptan malate oral tablet 12.5 mg,
6.25 mg
dihydroergotamine injection solution 1
mg/ml
dihydroergotamine nasal spray,nonaerosol 0.5 mg/pump act. (4 mg/ml)
ERGOMAR SUBLINGUAL TABLET
2 MG
naratriptan oral tablet 1 mg, 2.5 mg
rizatriptan oral tablet 10 mg, 5 mg
rizatriptan oral tablet,disintegrating 10
mg, 5 mg
sumatriptan nasal spray,non-aerosol 20
mg/actuation, 5 mg/actuation
sumatriptan succinate oral tablet 100 mg,
25 mg, 50 mg
sumatriptan succinate subcutaneous
cartridge 4 mg/0.5 ml, 6 mg/0.5 ml
sumatriptan succinate subcutaneous pen
injector 4 mg/0.5 ml
(Axert)
2
QL (12 per 28 days)
(D.H.E.45)
5
(Migranal)
5
3
NDS; QL (30 per 28
days)
NDS; QL (8 per 28
days)
QL (40 per 28 days)
(Amerge)
(Maxalt)
(Maxalt-MLT)
2
2
2
QL (18 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
(Imitrex)
2
QL (12 per 28 days)
(Imitrex)
2
QL (18 per 28 days)
(Imitrex STATdose Kit
Refill)
(Imitrex STATdose
Pen)
2
QL (4 per 28 days)
2
QL (4 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
49
Drug Name
sumatriptan succinate subcutaneous pen
injector 6 mg/0.5 ml
sumatriptan succinate subcutaneous
solution 6 mg/0.5 ml
sumatriptan succinate subcutaneous
syringe 6 mg/0.5 ml
zolmitriptan oral tablet 2.5 mg, 5 mg
zolmitriptan oral tablet,disintegrating 2.5
mg, 5 mg
Drug Tier
Requirements/Limits
(Alsuma)
2
QL (4 per 28 days)
(Imitrex)
2
QL (4 per 28 days)
2
QL (4 per 28 days)
2
2
QL (12 per 28 days)
QL (12 per 28 days)
(Zomig)
(Zomig ZMT)
Antimycobacterials
Antimycobacterials
CAPASTAT INJECTION RECON
SOLN 1 GRAM
dapsone oral tablet 100 mg, 25 mg
ethambutol oral tablet 100 mg
ethambutol oral tablet 400 mg
isoniazid oral solution 50 mg/5 ml
isoniazid oral tablet 100 mg, 300 mg
PASER ORAL GRANULES DR FOR
SUSP IN PACKET 4 GRAM
PRIFTIN ORAL TABLET 150 MG
pyrazinamide oral tablet 500 mg
rifabutin oral capsule 150 mg
rifampin intravenous recon soln 600 mg
rifampin oral capsule 150 mg, 300 mg
RIFATER ORAL TABLET 50-120-300
MG
SIRTURO ORAL TABLET 100 MG
4
(Myambutol)
(Mycobutin)
(Rifadin)
(Rifadin)
2
2
2
2
1
4
4
2
2
2
2
4
5
TRECATOR ORAL TABLET 250 MG
PA; NDS; QL (188 per
168 days)
4
Antinausea Agents
Antinausea Agents
AKYNZEO ORAL CAPSULE 300-0.5
MG
aprepitant oral capsule 125 mg, 40 mg,
(Emend)
80 mg
aprepitant oral capsule,dose pack 125 mg (Emend)
(1)- 80 mg (2)
compro rectal suppository 25 mg
3
PA BvD
2
PA BvD
2
PA BvD
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
50
Drug Name
Drug Tier
dimenhydrinate injection solution 50
mg/ml
dronabinol oral capsule 10 mg, 2.5 mg, 5 (Marinol)
mg
EMEND INTRAVENOUS RECON
SOLN 150 MG
EMEND ORAL CAPSULE 125 MG,
40 MG, 80 MG
EMEND ORAL CAPSULE,DOSE
PACK 125 MG (1)- 80 MG (2)
EMEND ORAL SUSPENSION FOR
RECONSTITUTION 125 MG (25 MG/
ML FINAL CONC.)
granisetron (pf) intravenous solution 100
mcg/ml
granisetron hcl intravenous solution 1
mg/ml, 1 mg/ml (1 ml)
granisetron hcl oral tablet 1 mg
meclizine oral tablet 12.5 mg
meclizine oral tablet 25 mg
(Motion Relief
(meclizine))
ondansetron hcl (pf) injection solution 4
mg/2 ml
ondansetron hcl (pf) injection syringe 4
mg/2 ml
ondansetron hcl oral solution 4 mg/5 ml
(Zofran (as
hydrochloride))
ondansetron hcl oral tablet 24 mg
ondansetron hcl oral tablet 4 mg, 8 mg
(Zofran (as
hydrochloride))
ondansetron oral tablet,disintegrating 4
(Zofran ODT)
mg, 8 mg
phenadoz rectal suppository 12.5 mg, 25
mg
prochlorperazine edisylate injection
solution 10 mg/2 ml (5 mg/ml)
prochlorperazine maleate oral tablet 10
(Compazine)
mg, 5 mg
prochlorperazine rectal suppository 25
(Compazine)
mg
Requirements/Limits
2
2
PA
4
QL (2 per 28 days)
4
PA BvD
4
PA BvD
4
PA BvD
2
2
2
2
2
PA BvD
2
2
2
PA BvD
2
2
PA BvD
PA BvD
2
PA BvD
2
PA-HRM; AGE (Max
64 Years)
2
1
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
51
Drug Name
Drug Tier
promethazine oral tablet 12.5 mg, 25 mg,
50 mg
promethazine rectal suppository 12.5 mg, (Phenergan)
25 mg
promethazine rectal suppository 50 mg
(Promethegan)
2
promethegan rectal suppository 12.5 mg,
25 mg, 50 mg
TRANSDERM-SCOP
TRANSDERMAL PATCH 3 DAY 1.5
MG (1 MG OVER 3 DAYS)
2
2
2
4
Requirements/Limits
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
QL (10 per 30 days)
Antiparasite Agents
Antiparasite Agents
ALBENZA ORAL TABLET 200 MG
ALINIA ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML
ALINIA ORAL TABLET 500 MG
atovaquone oral suspension 750 mg/5 ml
atovaquone-proguanil oral tablet 250-100
mg
atovaquone-proguanil oral tablet 62.5-25
mg
chloroquine phosphate oral tablet 250
mg, 500 mg
COARTEM ORAL TABLET 20-120
MG
DARAPRIM ORAL TABLET 25 MG
hydroxychloroquine oral tablet 200 mg
ivermectin oral tablet 3 mg
mefloquine oral tablet 250 mg
NEBUPENT INHALATION RECON
SOLN 300 MG
paromomycin oral capsule 250 mg
PENTAM INJECTION RECON
SOLN 300 MG
PRIMAQUINE ORAL TABLET 26.3
MG
quinine sulfate oral capsule 324 mg
tinidazole oral tablet 250 mg
tinidazole oral tablet 500 mg
5
4
(Mepron)
(Malarone)
4
5
2
(Malarone Pediatric)
2
NDS
NDS
2
4
(Plaquenil)
(Stromectol)
5
2
2
2
4
PA; NDS
PA BvD
2
4
(Qualaquin)
(Tindamax)
4
QL (90 per 30 days)
2
2
2
PA; QL (42 per 7 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
52
Drug Name
Drug Tier
Requirements/Limits
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl oral capsule 100 mg
amantadine hcl oral solution 50 mg/5 ml
amantadine hcl oral tablet 100 mg
APOKYN SUBCUTANEOUS
CARTRIDGE 10 MG/ML
AZILECT ORAL TABLET 0.5 MG, 1
MG
benztropine injection solution 2 mg/2 ml
benztropine oral tablet 0.5 mg, 1 mg, 2
mg
bromocriptine oral capsule 5 mg
bromocriptine oral tablet 2.5 mg
cabergoline oral tablet 0.5 mg
carbidopa oral tablet 25 mg
carbidopa-levodopa oral tablet 10-100
mg, 25-100 mg, 25-250 mg
carbidopa-levodopa oral tablet extended
release 25-100 mg, 50-200 mg
carbidopa-levodopa oral
tablet,disintegrating 10-100 mg, 25-100
mg, 25-250 mg
carbidopa-levodopa-entacapone oral
tablet 12.5-50-200 mg
carbidopa-levodopa-entacapone oral
tablet 18.75-75-200 mg
carbidopa-levodopa-entacapone oral
tablet 25-100-200 mg
carbidopa-levodopa-entacapone oral
tablet 31.25-125-200 mg
carbidopa-levodopa-entacapone oral
tablet 37.5-150-200 mg
carbidopa-levodopa-entacapone oral
tablet 50-200-200 mg
COGENTIN INJECTION
SOLUTION 2 MG/2 ML
entacapone oral tablet 200 mg
2
2
2
5
NDS; QL (60 per 30
days)
3
(Cogentin)
2
2
(Parlodel)
(Parlodel)
(Lodosyn)
(Sinemet)
2
2
2
2
2
(Sinemet CR)
2
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
2
(Stalevo 50)
2
(Stalevo 75)
2
(Stalevo 100)
2
(Stalevo 125)
2
(Stalevo 150)
2
(Stalevo 200)
2
4
(Comtan)
PA-HRM; AGE (Max
64 Years)
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
53
Drug Name
Drug Tier
NEUPRO TRANSDERMAL PATCH
24 HOUR 1 MG/24 HOUR, 2 MG/24
HOUR, 3 MG/24 HOUR, 4 MG/24
HOUR, 6 MG/24 HOUR, 8 MG/24
HOUR
pramipexole oral tablet 0.125 mg, 0.25
mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg
rasagiline oral tablet 0.5 mg, 1 mg
ropinirole oral tablet 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg, 5 mg
ropinirole oral tablet extended release 24
hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg
selegiline hcl oral capsule 5 mg
selegiline hcl oral tablet 5 mg
trihexyphenidyl oral elixir 0.4 mg/ml
3
(Mirapex)
2
(Azilect)
(Requip)
2
2
(Requip XL)
2
(Eldepryl)
2
2
2
2
trihexyphenidyl oral tablet 2 mg, 5 mg
Requirements/Limits
QL (30 per 30 days)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
Antipsychotic Agents
Antipsychotic Agents
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON 300 MG, 400 MG
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING 300 MG, 400 MG
aripiprazole oral solution 1 mg/ml
aripiprazole oral tablet 10 mg, 15 mg, 20
mg, 30 mg, 5 mg
aripiprazole oral tablet 2 mg
aripiprazole oral tablet,disintegrating 10
mg
aripiprazole oral tablet,disintegrating 15
mg
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING 441 MG/1.6 ML
(Abilify)
(Abilify)
5
NDS; QL (1 per 28
days)
5
NDS; QL (1 per 28
days)
2
2
QL (900 per 30 days)
QL (30 per 30 days)
2
2
QL (60 per 30 days)
QL (90 per 30 days)
2
QL (60 per 30 days)
5
NDS; QL (1.6 per 28
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
54
Drug Name
Drug Tier
Requirements/Limits
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING 662 MG/2.4 ML
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING 882 MG/3.2 ML
chlorpromazine injection solution 25
mg/ml
chlorpromazine oral tablet 10 mg, 100
mg, 200 mg, 25 mg, 50 mg
clozapine oral tablet 100 mg
clozapine oral tablet 200 mg
clozapine oral tablet 25 mg
clozapine oral tablet 50 mg
clozapine oral tablet,disintegrating 100
mg, 12.5 mg, 150 mg, 200 mg, 25 mg
FANAPT ORAL TABLET 1 MG, 2
MG, 4 MG
FANAPT ORAL TABLET 10 MG, 12
MG, 6 MG, 8 MG
FANAPT ORAL TABLETS,DOSE
PACK 1MG(2)-2MG(2)- 4MG(2)6MG(2)
fluphenazine decanoate injection solution
25 mg/ml
fluphenazine hcl injection solution 2.5
mg/ml
fluphenazine hcl oral concentrate 5 mg/ml
fluphenazine hcl oral elixir 2.5 mg/5 ml
fluphenazine hcl oral tablet 1 mg, 10 mg,
2.5 mg, 5 mg
GEODON INTRAMUSCULAR
RECON SOLN 20 MG/ML (FINAL
CONC.)
haloperidol dec 50 mg/ml vial 50 mg/ml
haloperidol decanoate intramuscular
solution 100 mg/ml
haloperidol decanoate intramuscular
solution 50 mg/ml
haloperidol lactate injection solution 5
mg/ml
5
NDS; QL (2.4 per 28
days)
5
NDS; QL (3.2 per 28
days)
2
2
(Clozaril)
(Clozaril)
(FazaClo)
2
2
2
2
2
QL (270 per 30 days)
QL (135 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
ST
4
ST; QL (60 per 30 days)
5
ST; NDS; QL (60 per
30 days)
ST; QL (8 per 28 days)
4
2
2
2
2
2
4
(Haldol Decanoate)
(Haldol Decanoate)
2
2
(Haldol Decanoate)
2
(Haldol)
2
QL (6 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
55
Drug Name
Drug Tier
haloperidol lactate oral concentrate 2
mg/ml
haloperidol oral tablet 0.5 mg, 1 mg, 10
mg, 2 mg, 20 mg, 5 mg
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 117
MG/0.75 ML
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 156
MG/ML
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 234
MG/1.5 ML
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 39
MG/0.25 ML
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 78
MG/0.5 ML
INVEGA TRINZA
INTRAMUSCULAR SYRINGE 273
MG/0.875 ML
INVEGA TRINZA
INTRAMUSCULAR SYRINGE 410
MG/1.315 ML
INVEGA TRINZA
INTRAMUSCULAR SYRINGE 546
MG/1.75 ML
INVEGA TRINZA
INTRAMUSCULAR SYRINGE 819
MG/2.625 ML
LATUDA ORAL TABLET 120 MG,
20 MG, 40 MG, 60 MG, 80 MG
loxapine succinate oral capsule 10 mg, 25
mg, 5 mg, 50 mg
molindone oral tablet 10 mg
molindone oral tablet 25 mg
molindone oral tablet 5 mg
NUPLAZID ORAL TABLET 17 MG
2
Requirements/Limits
2
5
NDS; QL (0.75 per 28
days)
5
NDS; QL (1 per 28
days)
5
NDS; QL (1.5 per 28
days)
4
QL (0.25 per 28 days)
5
NDS; QL (0.5 per 28
days)
5
NDS; QL (0.875 per 84
days)
5
NDS; QL (1.315 per 84
days)
5
NDS; QL (1.75 per 84
days)
5
NDS; QL (2.625 per 84
days)
5
NDS; QL (30 per 30
days)
2
2
2
2
5
QL (240 per 30 days)
QL (270 per 30 days)
QL (120 per 30 days)
PA NSO; NDS; QL (60
per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
56
Drug Name
olanzapine intramuscular recon soln 10
mg
olanzapine oral tablet 10 mg, 15 mg, 2.5
mg, 20 mg, 5 mg, 7.5 mg
olanzapine oral tablet,disintegrating 10
mg, 15 mg, 20 mg, 5 mg
paliperidone oral tablet extended release
24hr 1.5 mg, 3 mg, 9 mg
paliperidone oral tablet extended release
24hr 6 mg
perphenazine oral tablet 16 mg, 2 mg, 4
mg, 8 mg
pimozide oral tablet 1 mg, 2 mg
quetiapine oral tablet 100 mg, 200 mg, 25
mg, 300 mg, 400 mg, 50 mg
quetiapine oral tablet extended release 24
hr 150 mg, 300 mg, 50 mg
quetiapine oral tablet extended release 24
hr 200 mg
quetiapine oral tablet extended release 24
hr 400 mg
REXULTI ORAL TABLET 0.25 MG
Drug Tier
Requirements/Limits
(Zyprexa)
2
QL (30 per 30 days)
(Zyprexa)
2
QL (30 per 30 days)
(Zyprexa Zydis)
2
QL (30 per 30 days)
(Invega)
5
(Invega)
5
NDS; QL (30 per 30
days)
NDS; QL (60 per 30
days)
2
(Orap)
(Seroquel)
2
2
QL (90 per 30 days)
(Seroquel XR)
2
ST; QL (60 per 30 days)
(Seroquel XR)
2
ST; QL (30 per 30 days)
(Seroquel XR)
5
ST; NDS; QL (60 per
30 days)
ST; NDS; QL (120 per
30 days)
ST; NDS; QL (60 per
30 days)
ST; NDS; QL (30 per
30 days)
QL (4 per 28 days)
5
REXULTI ORAL TABLET 0.5 MG
5
REXULTI ORAL TABLET 1 MG, 2
MG, 3 MG, 4 MG
RISPERDAL CONSTA
INTRAMUSCULAR SYRINGE 12.5
MG/2 ML, 25 MG/2 ML
RISPERDAL CONSTA
INTRAMUSCULAR SYRINGE 37.5
MG/2 ML, 50 MG/2 ML
risperidone oral solution 1 mg/ml
(Risperdal)
risperidone oral tablet 0.25 mg, 0.5 mg, 1 (Risperdal)
mg, 2 mg, 3 mg, 4 mg
risperidone oral tablet,disintegrating 0.25
mg
risperidone oral tablet,disintegrating 0.5 (Risperdal M-TAB)
mg, 1 mg, 2 mg
5
4
5
NDS; QL (4 per 28
days)
2
2
QL (480 per 30 days)
QL (60 per 30 days)
2
QL (60 per 30 days)
2
QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
57
Drug Name
Drug Tier
risperidone oral tablet,disintegrating 3
(Risperdal M-TAB)
mg, 4 mg
SAPHRIS (BLACK CHERRY)
SUBLINGUAL TABLET 10 MG, 2.5
MG, 5 MG
SEROQUEL XR ORAL TABLET
EXTENDED RELEASE 24 HR 150
MG, 300 MG, 50 MG
SEROQUEL XR ORAL TABLET
EXTENDED RELEASE 24 HR 200
MG
SEROQUEL XR ORAL TABLET
EXTENDED RELEASE 24 HR 400
MG
thioridazine oral tablet 10 mg, 100 mg,
25 mg, 50 mg
thiothixene oral capsule 1 mg, 10 mg, 2
mg, 5 mg
trifluoperazine oral tablet 1 mg, 10 mg, 2
mg, 5 mg
VERSACLOZ ORAL SUSPENSION
50 MG/ML
VRAYLAR ORAL CAPSULE 1.5
MG, 3 MG, 4.5 MG, 6 MG
VRAYLAR ORAL CAPSULE,DOSE
PACK 1.5 MG (1)- 3 MG (6)
ziprasidone hcl oral capsule 20 mg, 40
(Geodon)
mg, 60 mg, 80 mg
ZYPREXA RELPREVV
INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 210 MG
ZYPREXA RELPREVV
INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 300 MG
ZYPREXA RELPREVV
INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 405 MG
Requirements/Limits
2
QL (120 per 30 days)
4
ST; QL (60 per 30 days)
4
ST; QL (60 per 30 days)
4
ST; QL (30 per 30 days)
5
ST; NDS; QL (60 per
30 days)
2
PA NSO-HRM; AGE
(Max 64 Years)
2
2
5
4
ST; NDS; QL (540 per
30 days)
ST; NDS; QL (30 per
30 days)
ST; QL (7 per 30 days)
2
QL (60 per 30 days)
4
QL (2 per 28 days)
5
NDS; QL (2 per 28
days)
5
NDS; QL (1 per 28
days)
5
Antivirals (Systemic)
Antiretrovirals
abacavir oral tablet 300 mg
(Ziagen)
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
58
Drug Name
Drug Tier
abacavir-lamivudine oral tablet 600-300 (Epzicom)
mg
abacavir-lamivudine-zidovudine oral
(Trizivir)
tablet 300-150-300 mg
APTIVUS ORAL CAPSULE 250 MG
APTIVUS ORAL SOLUTION 100
MG/ML
ATRIPLA ORAL TABLET 600-200300 MG
COMPLERA ORAL TABLET 200-25300 MG
CRIXIVAN ORAL CAPSULE 200
MG, 400 MG
DESCOVY ORAL TABLET 200-25
MG
didanosine oral capsule,delayed
(Videx EC)
release(dr/ec) 125 mg, 200 mg, 250 mg,
400 mg
EDURANT ORAL TABLET 25 MG
EMTRIVA ORAL CAPSULE 200 MG
EMTRIVA ORAL SOLUTION 10
MG/ML
EPIVIR HBV ORAL SOLUTION 25
MG/5 ML (5 MG/ML)
EPZICOM ORAL TABLET 600-300
MG
EVOTAZ ORAL TABLET 300-150
MG
FUZEON SUBCUTANEOUS
RECON SOLN 90 MG
GENVOYA ORAL TABLET 150-150200-10 MG
INTELENCE ORAL TABLET 100
MG, 200 MG
INTELENCE ORAL TABLET 25 MG
INVIRASE ORAL CAPSULE 200 MG
INVIRASE ORAL TABLET 500 MG
ISENTRESS ORAL POWDER IN
PACKET 100 MG
ISENTRESS ORAL TABLET 400 MG
Requirements/Limits
5
NDS
5
NDS
5
4
NDS
5
NDS
5
NDS
4
5
NDS
2
5
3
3
NDS
4
5
NDS
5
NDS
5
NDS
5
NDS
5
NDS
3
5
5
3
NDS
NDS
5
NDS
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
59
Drug Name
Drug Tier
ISENTRESS ORAL
TABLET,CHEWABLE 100 MG, 25
MG
KALETRA ORAL SOLUTION 400100 MG/5 ML
KALETRA ORAL TABLET 100-25
MG
KALETRA ORAL TABLET 200-50
MG
lamivudine oral solution 10 mg/ml
lamivudine oral tablet 100 mg
lamivudine oral tablet 150 mg, 300 mg
lamivudine-zidovudine oral tablet 150300 mg
LEXIVA ORAL SUSPENSION 50
MG/ML
LEXIVA ORAL TABLET 700 MG
lopinavir-ritonavir oral solution 400-100
mg/5 ml
nevirapine oral suspension 50 mg/5 ml
nevirapine oral tablet 200 mg
nevirapine oral tablet extended release 24
hr 100 mg, 400 mg
NORVIR ORAL CAPSULE 100 MG
NORVIR ORAL SOLUTION 80
MG/ML
NORVIR ORAL TABLET 100 MG
ODEFSEY ORAL TABLET 200-25-25
MG
PREZCOBIX ORAL TABLET 800-150
MG-MG
PREZISTA ORAL SUSPENSION 100
MG/ML
PREZISTA ORAL TABLET 150 MG,
75 MG
PREZISTA ORAL TABLET 400 MG,
600 MG, 800 MG
RESCRIPTOR ORAL TABLET 200
MG
RESCRIPTOR ORAL TABLET,
DISPERSIBLE 100 MG
3
5
Requirements/Limits
NDS
3
5
(Epivir)
(Epivir HBV)
(Epivir)
(Combivir)
NDS
2
2
2
2
3
(Kaletra)
5
2
(Viramune)
(Viramune)
(Viramune XR)
2
2
2
NDS
3
3
3
5
NDS
5
NDS
4
3
5
NDS
4
4
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
60
Drug Name
Drug Tier
RETROVIR INTRAVENOUS
SOLUTION 10 MG/ML
REYATAZ ORAL CAPSULE 150
MG, 200 MG, 300 MG
REYATAZ ORAL POWDER IN
PACKET 50 MG
SELZENTRY ORAL TABLET 150
MG, 300 MG, 75 MG
SELZENTRY ORAL TABLET 25 MG
stavudine oral capsule 15 mg, 20 mg, 30
mg, 40 mg
stavudine oral recon soln 1 mg/ml
STRIBILD ORAL TABLET 150-150200-300 MG
SUSTIVA ORAL CAPSULE 200 MG,
50 MG
SUSTIVA ORAL TABLET 600 MG
TIVICAY ORAL TABLET 10 MG
TIVICAY ORAL TABLET 25 MG, 50
MG
TRIUMEQ ORAL TABLET 600-50300 MG
TRUVADA ORAL TABLET 100-150
MG, 133-200 MG, 167-250 MG, 200300 MG
VIDEX 2 GRAM PEDIATRIC ORAL
RECON SOLN 10 MG/ML (FINAL)
VIRACEPT ORAL TABLET 250 MG,
625 MG
VIREAD ORAL POWDER 40
MG/SCOOP (40 MG/GRAM)
VIREAD ORAL TABLET 150 MG,
200 MG, 250 MG, 300 MG
VITEKTA ORAL TABLET 150 MG,
85 MG
ZERIT ORAL RECON SOLN 1
MG/ML
ZIAGEN ORAL SOLUTION 20
MG/ML
zidovudine oral capsule 100 mg
zidovudine oral syrup 10 mg/ml
3
Requirements/Limits
5
NDS
5
NDS
5
NDS
4
2
(Zerit)
(Zerit)
2
5
NDS
4
4
4
5
NDS
5
NDS
5
NDS
3
4
5
NDS
5
NDS
5
NDS
3
4
(Retrovir)
(Retrovir)
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
61
Drug Name
Drug Tier
zidovudine oral tablet 300 mg
Antivirals, Miscellaneous
foscarnet intravenous solution 24 mg/ml
oseltamivir oral capsule 30 mg
oseltamivir oral capsule 45 mg
oseltamivir oral capsule 75 mg
RELENZA DISKHALER
INHALATION BLISTER WITH
DEVICE 5 MG/ACTUATION
rimantadine oral tablet 100 mg
SYNAGIS INTRAMUSCULAR
SOLUTION 100 MG/ML, 50 MG/0.5
ML
TAMIFLU ORAL CAPSULE 30 MG
TAMIFLU ORAL CAPSULE 45 MG
TAMIFLU ORAL CAPSULE 75 MG
TAMIFLU ORAL SUSPENSION
FOR RECONSTITUTION 6 MG/ML
Hcv Antivirals
DAKLINZA ORAL TABLET 30 MG,
60 MG, 90 MG
EPCLUSA ORAL TABLET 400-100
MG
HARVONI ORAL TABLET 90-400
MG
OLYSIO ORAL CAPSULE 150 MG
2
Requirements/Limits
(Foscavir)
(Tamiflu)
(Tamiflu)
(Tamiflu)
2
2
2
2
4
(Flumadine)
2
5
PA; NDS
3
3
3
3
QL (84 per 180 days)
QL (48 per 180 days)
QL (42 per 180 days)
QL (540 per 180 days)
5
PA; NDS; QL (28 per
28 days)
PA; NDS; QL (28 per
28 days)
PA; NDS; QL (30 per
30 days)
PA; NDS; QL (28 per
28 days)
PA; NDS; QL (28 per
28 days)
PA; NDS; QL (56 per
28 days)
PA; NDS; QL (112 per
28 days)
5
5
5
SOVALDI ORAL TABLET 400 MG
5
TECHNIVIE ORAL TABLET 12.5-7550 MG
VIEKIRA PAK ORAL
TABLETS,DOSE PACK 12.5 MG-75
MG -50 MG/250 MG
VIEKIRA XR ORAL TABLET, IR ER, BIPHASIC 24HR 8.33 MG-50
MG- 33.33 MG-200 MG
ZEPATIER ORAL TABLET 50-100
MG
5
5
PA BvD
QL (84 per 180 days)
QL (48 per 180 days)
QL (42 per 180 days)
5
PA; NDS; QL (84 per
28 days)
5
PA; NDS; QL (30 per
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
62
Drug Name
Interferons
INTRON A INJECTION RECON
SOLN 10 MILLION UNIT (1 ML), 18
MILLION UNIT (1 ML), 50
MILLION UNIT (1 ML)
INTRON A INJECTION SOLUTION
10 MILLION UNIT/ML, 6 MILLION
UNIT/ML
PEGASYS PROCLICK
SUBCUTANEOUS PEN INJECTOR
135 MCG/0.5 ML, 180 MCG/0.5 ML
PEGASYS SUBCUTANEOUS
SOLUTION 180 MCG/ML
PEGASYS SUBCUTANEOUS
SYRINGE 180 MCG/0.5 ML
PEGINTRON SUBCUTANEOUS
KIT 120 MCG/0.5 ML, 150 MCG/0.5
ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML
SYLATRON SUBCUTANEOUS KIT
200 MCG, 300 MCG, 600 MCG
Nucleosides And Nucleotides
acyclovir 1,000 mg/20 ml vial latexfree,sdv 50 mg/ml
acyclovir oral capsule 200 mg
acyclovir oral suspension 200 mg/5 ml
acyclovir oral tablet 400 mg, 800 mg
acyclovir sodium intravenous recon soln
500 mg
acyclovir sodium intravenous solution 50
mg/ml
adefovir oral tablet 10 mg
cidofovir intravenous solution 75 mg/ml
entecavir oral tablet 0.5 mg, 1 mg
famciclovir oral tablet 125 mg, 250 mg,
500 mg
ganciclovir sodium intravenous recon soln
500 mg
ribasphere oral capsule 200 mg
ribasphere oral tablet 200 mg, 400 mg,
600 mg
Drug Tier
(Zovirax)
(Zovirax)
(Zovirax)
(Hepsera)
(Baraclude)
(Cytovene)
Requirements/Limits
5
PA NSO; NDS
5
PA NSO; NDS
5
NDS
5
NDS
5
NDS
5
NDS
5
PA NSO; NDS; QL (4
per 28 days)
5
PA BvD; NDS
2
2
2
5
PA BvD; NDS
2
PA BvD
5
5
5
2
NDS
NDS
NDS
2
PA BvD
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
63
Drug Name
Drug Tier
ribasphere ribapak oral tablets,dose pack
200 mg (7)- 400 mg (7), 400-400 mg
(28)-mg (28), 600-400 mg (28)-mg
(28)
ribavirin inhalation recon soln 6 gram
ribavirin oral capsule 200 mg
ribavirin oral tablet 200 mg
TYZEKA ORAL TABLET 600 MG
valacyclovir oral tablet 1 gram, 500 mg
VALCYTE ORAL RECON SOLN 50
MG/ML
valganciclovir oral recon soln 50 mg/ml
valganciclovir oral tablet 450 mg
VEMLIDY ORAL TABLET 25 MG
5
NDS
5
2
2
5
2
5
PA BvD; NDS
(Virazole)
(Ribasphere)
(Ribasphere)
(Valtrex)
(Valcyte)
(Valcyte)
2
5
5
VIRAZOLE INHALATION RECON
SOLN 6 GRAM
Requirements/Limits
NDS
NDS
5
NDS
NDS; QL (30 per 30
days)
PA BvD; NDS
5
NDS
Blood Products/Modifiers/Volume
Expanders
Anticoagulants
CEPROTIN (BLUE BAR)
INTRAVENOUS RECON SOLN 500
UNIT
ELIQUIS ORAL TABLET 2.5 MG, 5
MG
enoxaparin subcutaneous solution 300
mg/3 ml
enoxaparin subcutaneous syringe 100
mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30
mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml,
80 mg/0.8 ml
fondaparinux subcutaneous syringe 10
mg/0.8 ml
fondaparinux subcutaneous syringe 2.5
mg/0.5 ml
fondaparinux subcutaneous syringe 5
mg/0.4 ml
fondaparinux subcutaneous syringe 7.5
mg/0.6 ml
3
(Lovenox)
2
(Lovenox)
2
(Arixtra)
2
QL (24 per 30 days)
(Arixtra)
2
QL (15 per 30 days)
(Arixtra)
2
QL (12 per 30 days)
(Arixtra)
2
QL (18 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
64
Drug Name
Drug Tier
heparin (porcine) in 5 % dex intravenous
parenteral solution 20,000 unit/500 ml
(40 unit/ml)
heparin (porcine) in 5 % dex intravenous
parenteral solution 25,000 unit/250
ml(100 unit/ml)
heparin (porcine) injection solution 1,000
unit/ml, 10,000 unit/ml, 20,000 unit/ml,
5,000 unit/ml
heparin 25,000 unit/250 ml (100
unit/ml)-0.45% nacl bag latex-free, inner
25,000 unit/250 ml
heparin, porcine (pf) injection solution
5,000 unit/0.5 ml
heparin, porcine (pf) injection syringe
5,000 unit/0.5 ml
IPRIVASK SUBCUTANEOUS
RECON SOLN 15 MG
jantoven oral tablet 1 mg, 10 mg, 2 mg,
2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
PRADAXA ORAL CAPSULE 110
MG, 150 MG, 75 MG
SAVAYSA ORAL TABLET 15 MG,
30 MG, 60 MG
warfarin oral tablet 1 mg, 10 mg, 2 mg,
(Jantoven)
2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
XARELTO ORAL TABLET 10 MG,
15 MG, 20 MG
XARELTO ORAL TABLETS,DOSE
PACK 15 MG (42)- 20 MG (9)
Blood Formation Modifiers
CINRYZE INTRAVENOUS RECON
SOLN 500 UNIT (5 ML)
EPOGEN 10,000 UNITS/ML VIAL
SDV, P/F, OUTER 10,000 UNIT/ML
EPOGEN INJECTION SOLUTION
2,000 UNIT/ML, 20,000 UNIT/2 ML,
20,000 UNIT/ML, 3,000 UNIT/ML,
4,000 UNIT/ML
Requirements/Limits
2
2
2
2
2
2
5
PA; NDS; QL (24 per
28 days)
1
4
ST; QL (60 per 30 days)
4
1
3
3
5
PA; NDS
3
PA; QL (12 per 28
days)
PA; QL (12 per 28
days)
3
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
65
Drug Name
Drug Tier
GRANIX SUBCUTANEOUS
SYRINGE 300 MCG/0.5 ML, 480
MCG/0.8 ML
LEUKINE INJECTION RECON
SOLN 250 MCG
MIRCERA INJECTION SYRINGE
100 MCG/0.3 ML, 150 MCG/0.3 ML,
200 MCG/0.3 ML, 30 MCG/0.3 ML, 50
MCG/0.3 ML, 75 MCG/0.3 ML
MOZOBIL SUBCUTANEOUS
SOLUTION 24 MG/1.2 ML (20
MG/ML)
NEULASTA SUBCUTANEOUS
SYRINGE 6 MG/0.6ML
NEULASTA SUBCUTANEOUS
SYRINGE, W/ WEARABLE
INJECTOR 6 MG/0.6 ML
NEUPOGEN INJECTION
SOLUTION 300 MCG/ML, 480
MCG/1.6 ML
NEUPOGEN INJECTION SYRINGE
300 MCG/0.5 ML, 480 MCG/0.8 ML
PROCRIT INJECTION SOLUTION
10,000 UNIT/ML, 2,000 UNIT/ML,
20,000 UNIT/2 ML, 3,000 UNIT/ML,
4,000 UNIT/ML
PROCRIT INJECTION SOLUTION
20,000 UNIT/ML
PROCRIT INJECTION SOLUTION
40,000 UNIT/ML
PROMACTA ORAL TABLET 12.5
MG, 25 MG, 50 MG, 75 MG
ZARXIO INJECTION SYRINGE 300
MCG/0.5 ML, 480 MCG/0.8 ML
Hematologic Agents, Miscellaneous
anagrelide oral capsule 0.5 mg
(Agrylin)
anagrelide oral capsule 1 mg
protamine intravenous solution 10 mg/ml
tranexamic acid intravenous solution
(Cyklokapron)
1,000 mg/10 ml (100 mg/ml)
tranexamic acid oral tablet 650 mg
(Lysteda)
Requirements/Limits
5
NDS
5
NDS
4
PA; QL (0.6 per 28
days)
5
NDS
5
NDS
5
NDS
5
NDS
5
NDS
3
PA; QL (12 per 28
days)
5
PA; NDS; QL (12 per
28 days)
PA; NDS; QL (6 per 28
days)
PA; NDS; QL (30 per
30 days)
ST; NDS
5
5
5
2
2
2
2
2
QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
66
Drug Name
Platelet-Aggregation Inhibitors
aspirin-dipyridamole oral capsule, er
multiphase 12 hr 25-200 mg
BRILINTA ORAL TABLET 60 MG,
90 MG
cilostazol oral tablet 100 mg, 50 mg
clopidogrel oral tablet 300 mg
clopidogrel oral tablet 75 mg
dipyridamole oral tablet 25 mg, 50 mg,
75 mg
EFFIENT ORAL TABLET 10 MG, 5
MG
pentoxifylline oral tablet extended
release 400 mg
Drug Tier
(Aggrenox)
Requirements/Limits
2
3
2
2
1
2
(Plavix)
(Plavix)
3
QL (30 per 30 days)
2
Caloric Agents
Caloric Agents
AMINO ACIDS 15 %
INTRAVENOUS PARENTERAL
SOLUTION 15 %
AMINOSYN 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
AMINOSYN 7 % WITH
ELECTROLYTES INTRAVENOUS
PARENTERAL SOLUTION 7 %
AMINOSYN 8.5 % INTRAVENOUS
PARENTERAL SOLUTION 8.5 %
AMINOSYN 8.5 %-ELECTROLYTES
INTRAVENOUS PARENTERAL
SOLUTION 8.5 %
AMINOSYN II 10 %
INTRAVENOUS PARENTERAL
SOLUTION 10 %
AMINOSYN II 15 %
INTRAVENOUS PARENTERAL
SOLUTION 15 %
AMINOSYN II 7 % INTRAVENOUS
PARENTERAL SOLUTION 7 %
AMINOSYN II 8.5 %
INTRAVENOUS PARENTERAL
SOLUTION 8.5 %
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
67
Drug Name
Drug Tier
Requirements/Limits
AMINOSYN II 8.5 %ELECTROLYTES INTRAVENOUS
PARENTERAL SOLUTION 8.5 %
AMINOSYN M 3.5 %
INTRAVENOUS PARENTERAL
SOLUTION 3.5 %
AMINOSYN-HBC 7%
INTRAVENOUS PARENTERAL
SOLUTION 7 %
AMINOSYN-PF 10 %
INTRAVENOUS PARENTERAL
SOLUTION 10 %
AMINOSYN-PF 7 % (SULFITEFREE) INTRAVENOUS
PARENTERAL SOLUTION 7 %
AMINOSYN-RF 5.2 %
INTRAVENOUS PARENTERAL
SOLUTION 5.2 %
CLINIMIX 5%/D15W SULFITE
FREE INTRAVENOUS
PARENTERAL SOLUTION 5 %
CLINIMIX 5%/D25W SULFITEFREE INTRAVENOUS
PARENTERAL SOLUTION 5 %
CLINIMIX 2.75%/D5W SULFIT
FREE INTRAVENOUS
PARENTERAL SOLUTION 2.75 %
CLINIMIX 4.25%/D10W SULF FREE
INTRAVENOUS PARENTERAL
SOLUTION 4.25 %
CLINIMIX 4.25%/D5W SULFIT
FREE INTRAVENOUS
PARENTERAL SOLUTION 4.25 %
CLINIMIX 4.25%-D20W SULF-FREE
INTRAVENOUS PARENTERAL
SOLUTION 4.25 %
CLINIMIX 4.25%-D25W SULF-FREE
INTRAVENOUS PARENTERAL
SOLUTION 4.25 %
CLINIMIX 5%-D20W(SULFITEFREE) INTRAVENOUS
PARENTERAL SOLUTION 5 %
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
68
Drug Name
Drug Tier
Requirements/Limits
CLINIMIX E 2.75%/D10W SUL
FREE INTRAVENOUS
PARENTERAL SOLUTION 2.75 %
CLINIMIX E 2.75%/D5W SULF
FREE INTRAVENOUS
PARENTERAL SOLUTION 2.75 %
CLINIMIX E 4.25%/D10W SUL
FREE INTRAVENOUS
PARENTERAL SOLUTION 4.25 %
CLINIMIX E 4.25%/D25W SUL
FREE INTRAVENOUS
PARENTERAL SOLUTION 4.25 %
CLINIMIX E 4.25%/D5W SULF
FREE INTRAVENOUS
PARENTERAL SOLUTION 4.25 %
CLINIMIX E 5%/D15W SULFIT
FREE INTRAVENOUS
PARENTERAL SOLUTION 5 %
CLINIMIX E 5%/D20W SULFIT
FREE INTRAVENOUS
PARENTERAL SOLUTION 5 %
CLINIMIX E 5%/D25W SULFIT
FREE INTRAVENOUS
PARENTERAL SOLUTION 5 %
CLINISOL SF 15 % INTRAVENOUS
PARENTERAL SOLUTION 15 %
dextrose 10 % in water (d10w)
intravenous parenteral solution 10 %
dextrose 20 % in water (d20w)
intravenous parenteral solution 20 %
dextrose 25 % in water (d25w)
intravenous syringe
dextrose 40 % in water (d40w)
intravenous parenteral solution 40 %
dextrose 5 % in ringers intravenous
parenteral solution 5 %
dextrose 5 % in water (d5w) intravenous
parenteral solution
dextrose 50 % in water (d50w)
intravenous parenteral solution
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
2
PA BvD
2
PA BvD
2
PA BvD
2
PA BvD
2
2
2
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
69
Drug Name
Drug Tier
Requirements/Limits
dextrose 50 % in water (d50w)
intravenous syringe
dextrose 70 % in water (d70w)
intravenous parenteral solution
FREAMINE HBC 6.9 %
INTRAVENOUS PARENTERAL
SOLUTION 6.9 %
FREAMINE III 10 %
INTRAVENOUS PARENTERAL
SOLUTION 10 %
HEPATAMINE 8% INTRAVENOUS
PARENTERAL SOLUTION 8 %
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
KABIVEN INTRAVENOUS
EMULSION 3.31-9.8-3.9 %
NEPHRAMINE 5.4 %
INTRAVENOUS PARENTERAL
SOLUTION 5.4 %
NUTRILIPID INTRAVENOUS
EMULSION 20 %
PERIKABIVEN INTRAVENOUS
EMULSION 2.36-6.8-3.5 %
PREMASOL 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
PREMASOL 6 % INTRAVENOUS
PARENTERAL SOLUTION 6 %
PROCALAMINE 3%
INTRAVENOUS PARENTERAL
SOLUTION 3 %
PROSOL 20 % INTRAVENOUS
PARENTERAL SOLUTION
smoflipid intravenous emulsion 20 %
TRAVASOL 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
TROPHAMINE 10 %
INTRAVENOUS PARENTERAL
SOLUTION 10 %
TROPHAMINE 6% INTRAVENOUS
PARENTERAL SOLUTION 6 %
2
PA BvD
2
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
4
PA BvD
PA BvD
4
PA BvD
4
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
70
Drug Name
Drug Tier
Requirements/Limits
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet 0.1 mg, 0.2 mg,
0.3 mg
clonidine transdermal patch weekly 0.1
mg/24 hr
clonidine transdermal patch weekly 0.2
mg/24 hr
clonidine transdermal patch weekly 0.3
mg/24 hr
clorpres oral tablet 0.1-15 mg, 0.2-15 mg,
0.3-15 mg
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8
mg
guanfacine oral tablet 1 mg, 2 mg
midodrine oral tablet 10 mg, 2.5 mg, 5
mg
NORTHERA ORAL CAPSULE 100
MG, 200 MG, 300 MG
phenylephrine hcl injection solution 10
mg/ml
prazosin oral capsule 1 mg, 2 mg, 5 mg
Angiotensin Ii Receptor Antagonists
BENICAR HCT ORAL TABLET 2012.5 MG, 40-12.5 MG, 40-25 MG
BENICAR ORAL TABLET 20 MG, 40
MG, 5 MG
candesartan oral tablet 16 mg, 32 mg, 4
mg, 8 mg
candesartan-hydrochlorothiazid oral
tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg
EDARBI ORAL TABLET 40 MG, 80
MG
EDARBYCLOR ORAL TABLET 4012.5 MG, 40-25 MG
ENTRESTO ORAL TABLET 24-26
MG, 49-51 MG, 97-103 MG
eprosartan oral tablet 600 mg
irbesartan oral tablet 150 mg, 300 mg, 75
mg
(Catapres)
1
(Catapres-TTS-1)
2
QL (4 per 28 days)
(Catapres-TTS-2)
2
QL (4 per 28 days)
(Catapres-TTS-3)
2
QL (8 per 28 days)
2
(Cardura)
2
2
PA-HRM; AGE (Max
64 Years)
2
5
(Vazculep)
2
(Minipress)
2
PA; NDS; QL (180 per
30 days)
2
2
(Atacand)
6
(Atacand HCT)
6
4
ST
4
ST
3
QL (60 per 30 days)
2
6
(Avapro)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
71
Drug Name
irbesartan-hydrochlorothiazide oral
tablet 150-12.5 mg, 300-12.5 mg
losartan oral tablet 100 mg, 25 mg, 50
mg
losartan-hydrochlorothiazide oral tablet
100-12.5 mg, 100-25 mg, 50-12.5 mg
olmesartan oral tablet 20 mg, 40 mg, 5
mg
olmesartan-amlodipin-hcthiazid oral
tablet 20-5-12.5 mg, 40-10-12.5 mg, 4010-25 mg, 40-5-12.5 mg, 40-5-25 mg
olmesartan-hydrochlorothiazide oral
tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg
telmisartan oral tablet 20 mg, 40 mg, 80
mg
telmisartan-hydrochlorothiazid oral
tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg
TRIBENZOR ORAL TABLET 20-512.5 MG, 40-10-12.5 MG, 40-10-25
MG, 40-5-12.5 MG, 40-5-25 MG
valsartan oral tablet 160 mg, 320 mg, 40
mg, 80 mg
valsartan-hydrochlorothiazide oral tablet
160-12.5 mg, 160-25 mg, 320-12.5 mg,
320-25 mg, 80-12.5 mg
Angiotensin-Converting Enzyme Inhibitors
benazepril oral tablet 10 mg, 5 mg
benazepril oral tablet 20 mg, 40 mg
benazepril-hydrochlorothiazide oral
tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg
benazepril-hydrochlorothiazide oral
tablet 5-6.25 mg
captopril oral tablet 100 mg, 12.5 mg, 25
mg, 50 mg
captopril-hydrochlorothiazide oral tablet
25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg
enalapril maleate oral tablet 10 mg, 2.5
mg, 20 mg, 5 mg
enalaprilat intravenous solution 1.25
mg/ml
Drug Tier
(Avalide)
6
(Cozaar)
6
(Hyzaar)
6
(Benicar)
2
(Tribenzor)
2
(Benicar HCT)
2
(Micardis)
6
(Micardis HCT)
6
Requirements/Limits
2
(Diovan)
6
(Diovan HCT)
6
(Lotensin)
(Lotensin HCT)
6
6
6
6
6
6
(Vasotec)
6
6
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
72
Drug Name
enalapril-hydrochlorothiazide oral tablet
10-25 mg
enalapril-hydrochlorothiazide oral tablet
5-12.5 mg
fosinopril oral tablet 10 mg, 20 mg, 40
mg
fosinopril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg
lisinopril oral tablet 10 mg, 2.5 mg, 20
mg, 30 mg, 40 mg, 5 mg
lisinopril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg
moexipril oral tablet 15 mg, 7.5 mg
moexipril-hydrochlorothiazide oral tablet
15-12.5 mg, 15-25 mg, 7.5-12.5 mg
perindopril erbumine oral tablet 2 mg, 4
mg, 8 mg
QBRELIS ORAL SOLUTION 1
MG/ML
quinapril oral tablet 10 mg, 20 mg, 40
mg, 5 mg
quinapril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg
ramipril oral capsule 1.25 mg, 10 mg, 2.5
mg, 5 mg
trandolapril oral tablet 1 mg, 2 mg
trandolapril oral tablet 4 mg
Antiarrhythmic Agents
amiodarone intravenous solution 50
mg/ml
amiodarone intravenous syringe 150 mg/3
ml
amiodarone oral tablet 100 mg, 200 mg,
400 mg
disopyramide phosphate oral capsule 100
mg, 150 mg
dofetilide oral capsule 125 mcg, 250 mcg,
500 mcg
flecainide oral tablet 100 mg, 150 mg, 50
mg
Drug Tier
(Vaseretic)
Requirements/Limits
6
6
6
6
(Zestril)
6
(Zestoretic)
6
6
6
6
4
(Accupril)
6
(Accuretic)
6
(Altace)
6
(Mavik)
6
6
ST
2
2
(Pacerone)
2
(Norpace)
2
(Tikosyn)
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
73
Drug Name
Drug Tier
lidocaine (pf) intravenous syringe 50
mg/5 ml (1 %)
lidocaine in 5 % dextrose (pf)
intravenous parenteral solution 8 mg/ml
(0.8 %)
mexiletine oral capsule 150 mg, 200 mg,
250 mg
MULTAQ ORAL TABLET 400 MG
pacerone oral tablet 100 mg, 200 mg, 400
mg
procainamide injection solution 100
mg/ml, 500 mg/ml
propafenone oral capsule,extended
release 12 hr 225 mg, 325 mg, 425 mg
propafenone oral tablet 150 mg, 225 mg,
300 mg
quinidine gluconate oral tablet extended
release 324 mg
quinidine sulfate oral tablet 200 mg, 300
mg
quinidine sulfate oral tablet extended
release 300 mg
Beta-Adrenergic Blocking Agents
acebutolol oral capsule 200 mg, 400 mg
atenolol oral tablet 100 mg, 25 mg, 50 mg
atenolol-chlorthalidone oral tablet 100-25
mg
atenolol-chlorthalidone oral tablet 50-25
mg
betaxolol oral tablet 10 mg, 20 mg
bisoprolol fumarate oral tablet 10 mg
bisoprolol fumarate oral tablet 5 mg
bisoprolol-hydrochlorothiazide oral tablet
10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg
BYSTOLIC ORAL TABLET 10 MG,
2.5 MG, 20 MG, 5 MG
BYVALSON ORAL TABLET 5-80
MG
carvedilol oral tablet 12.5 mg, 25 mg,
3.125 mg, 6.25 mg
2
Requirements/Limits
2
2
3
2
2
(Rythmol SR)
2
2
2
2
2
(Tenormin)
(Tenoretic 100)
2
1
1
(Tenoretic 50)
1
2
2
2
1
(Zebeta)
(Ziac)
3
3
(Coreg)
1
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
74
Drug Name
esmolol intravenous solution 100 mg/10
ml (10 mg/ml)
labetalol intravenous solution 5 mg/ml
labetalol oral tablet 100 mg, 200 mg, 300
mg
metoprolol succinate oral tablet extended
release 24 hr 100 mg, 200 mg, 25 mg, 50
mg
metoprolol ta-hydrochlorothiaz oral
tablet 100-25 mg, 100-50 mg
metoprolol ta-hydrochlorothiaz oral
tablet 50-25 mg
metoprolol tartrate intravenous solution 5
mg/5 ml
metoprolol tartrate intravenous syringe 5
mg/5 ml
metoprolol tartrate oral tablet 100 mg, 50
mg
metoprolol tartrate oral tablet 25 mg,
37.5 mg, 75 mg
nadolol oral tablet 20 mg, 40 mg, 80 mg
pindolol oral tablet 10 mg, 5 mg
propranolol intravenous solution 1 mg/ml
propranolol oral capsule,extended release
24 hr 120 mg, 160 mg, 60 mg, 80 mg
propranolol oral solution 20 mg/5 ml (4
mg/ml), 40 mg/5 ml (8 mg/ml)
propranolol oral tablet 10 mg, 20 mg, 40
mg, 60 mg, 80 mg
propranolol-hydrochlorothiazid oral
tablet 40-25 mg, 80-25 mg
sorine oral tablet 120 mg, 160 mg, 240
mg, 80 mg
sotalol 120 mg tablet 120 mg
sotalol af oral tablet 120 mg
sotalol oral tablet 160 mg, 80 mg
sotalol oral tablet 240 mg
timolol maleate oral tablet 10 mg, 20 mg,
5 mg
Drug Tier
(Brevibloc)
2
Requirements/Limits
PA BvD
2
2
(Toprol XL)
2
2
(Lopressor HCT)
2
(Lopressor)
2
2
(Lopressor)
1
1
(Corgard)
(Inderal LA)
2
2
2
2
2
2
2
2
(Sotalol AF)
(Sorine)
(Betapace)
2
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
75
Drug Name
Calcium-Channel Blocking Agents
cartia xt oral capsule,extended release
24hr 120 mg, 180 mg, 240 mg, 300 mg
diltiazem 24hr er 180 mg cap 180 mg
diltiazem 24hr er 360 mg cap 360 mg
diltiazem hcl intravenous recon soln 100
mg
diltiazem hcl intravenous solution 5
mg/ml
diltiazem hcl oral capsule, extended
release 180 mg, 360 mg, 420 mg
diltiazem hcl oral capsule,extended
release 12 hr 120 mg, 60 mg, 90 mg
diltiazem hcl oral capsule,extended
release 24hr 120 mg, 300 mg
diltiazem hcl oral capsule,extended
release 24hr 240 mg
diltiazem hcl oral tablet 120 mg, 30 mg,
60 mg
diltiazem hcl oral tablet 90 mg
diltiazem hcl oral tablet extended release
24 hr 180 mg, 240 mg, 300 mg, 360 mg,
420 mg
dilt-xr oral capsule,ext release
degradable 120 mg, 180 mg, 240 mg
matzim la oral tablet extended release 24
hr 180 mg, 240 mg, 300 mg, 360 mg, 420
mg
taztia xt oral capsule, extended release
120 mg, 180 mg, 240 mg, 300 mg, 360 mg
verapamil intravenous syringe 2.5 mg/ml
verapamil oral capsule, 24 hr er pellet ct
100 mg, 200 mg, 300 mg
verapamil oral capsule,ext rel. pellets 24
hr 120 mg, 180 mg, 240 mg, 360 mg
verapamil oral tablet 120 mg, 80 mg
verapamil oral tablet 40 mg
verapamil oral tablet extended release
120 mg, 180 mg, 240 mg
Drug Tier
Requirements/Limits
2
(Cartia XT)
(Cardizem CD)
2
2
2
2
(Tiazac)
2
2
(Cartia XT)
2
(Cardizem CD)
2
(Cardizem)
1
(Matzim LA)
1
2
2
2
2
(Verelan PM)
2
2
(Verelan)
2
(Calan)
1
1
1
(Calan SR)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
76
Drug Name
Drug Tier
Cardiovascular Agents, Miscellaneous
CORLANOR ORAL TABLET 5 MG,
7.5 MG
DEMSER ORAL CAPSULE 250 MG
digitek oral tablet 125 mcg
3
5
2
digitek oral tablet 250 mcg
2
digoxin 0.25 mg/ml syringe 250 mcg/ml
2
digoxin injection solution 250 mcg/ml
Requirements/Limits
(Lanoxin)
DIGOXIN ORAL SOLUTION 50
MCG/ML
2
3
NDS
PA-HRM; PA
REQUIRED: High
Risk Med for Ages 65
and Older and Dose is
Greater than 125mcg
per Day; QL (30 per 30
days); AGE (Max 64
Years)
PA-HRM; PA
REQUIRED: High
Risk Med for Ages 65
and Older; QL (30 per
30 days); AGE (Max 64
Years)
PA-HRM; PA
REQUIRED: High
Risk Med for Ages 65
and Older; AGE (Max
64 Years)
PA-HRM; PA
REQUIRED: High
Risk Med for Ages 65
and Older; AGE (Max
64 Years)
PA-HRM; PA
REQUIRED: High
Risk Med for Ages 65
and Older and Dose is
Greater than 125mcg
per Day; AGE (Max 64
Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
77
Drug Name
Drug Tier
Requirements/Limits
2
PA-HRM; PA
REQUIRED: High
Risk Med for Ages 65
and Older and Dose is
Greater than 125mcg
per Day; QL (30 per 30
days); AGE (Max 64
Years)
PA-HRM; PA
REQUIRED: High
Risk Med for Ages 65
and Older; QL (30 per
30 days); AGE (Max 64
Years)
PA BvD
2
PA BvD
2
PA BvD
2
PA BvD
digoxin oral tablet 125 mcg
(Digox)
2
digoxin oral tablet 250 mcg
(Lanoxin)
2
dobutamine in d5w intravenous
parenteral solution 1,000 mg/250 ml
(4,000 mcg/ml), 250 mg/250 ml (1
mg/ml), 500 mg/250 ml (2,000 mcg/ml)
dobutamine intravenous solution 250
mg/20 ml (12.5 mg/ml), 500 mg/40 ml
(12.5 mg/ml)
dopamine in 5 % dextrose intravenous
solution 200 mg/250 ml (800 mcg/ml),
400 mg/250 ml (1,600 mcg/ml), 800
mg/250 ml (3,200 mcg/ml)
dopamine intravenous solution 200 mg/5
ml (40 mg/ml), 400 mg/5 ml (80 mg/ml),
800 mg/10 ml (80 mg/ml), 800 mg/5 ml
(160 mg/ml)
epinephrine hcl (pf) injection solution 1
mg/ml (1 ml)
epinephrine injection auto-injector 0.15
(Auvi-Q)
mg/0.15 ml
epinephrine injection auto-injector 0.15
(EpiPen Jr)
mg/0.3 ml
epinephrine injection auto-injector 0.3 %
epinephrine injection auto-injector 0.3
mg/0.3 ml
epinephrine injection syringe 0.1 mg/ml
EPIPEN 2-PAK INJECTION AUTOINJECTOR 0.3 MG/0.3 ML
(Auvi-Q)
2
2
2
2
2
2
3
GENERIC FOR
ADRENACLICK
GENERIC FOR
EPIPEN
QL (4 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
78
Drug Name
Drug Tier
Requirements/Limits
EPIPEN INJECTION AUTOINJECTOR 0.3 MG/0.3 ML
EPIPEN JR 2-PAK INJECTION
AUTO-INJECTOR 0.15 MG/0.3 ML
FIRAZYR SUBCUTANEOUS
SYRINGE 30 MG/3 ML
hydralazine injection solution 20 mg/ml
hydralazine oral tablet 10 mg, 100 mg, 25
mg, 50 mg
LANOXIN ORAL TABLET 187.5
MCG
3
QL (4 per 30 days)
3
QL (4 per 30 days)
5
NDS
LANOXIN ORAL TABLET 62.5
MCG
4
2
2
4
milrinone in 5 % dextrose intravenous
piggyback 20 mg/100 ml (200 mcg/ml),
40 mg/200 ml (200 mcg/ml)
milrinone intravenous solution 1 mg/ml
norepinephrine bitartrate intravenous
(Levophed (bitartrate))
solution 1 mg/ml
RANEXA ORAL TABLET
EXTENDED RELEASE 12 HR 1,000
MG, 500 MG
Dihydropyridines
afeditab cr oral tablet extended release
30 mg, 60 mg
amlodipine oral tablet 10 mg, 2.5 mg, 5
(Norvasc)
mg
amlodipine-benazepril oral capsule 10-20 (Lotrel)
mg, 10-40 mg, 5-10 mg, 5-20 mg, 5-40
mg
amlodipine-benazepril oral capsule 2.5-10
mg
5
PA-HRM; PA
REQUIRED: High
Risk Med for Ages 65
and Older; QL (30 per
30 days); AGE (Max 64
Years)
PA-HRM; PA
REQUIRED: High
Risk Med for Ages 65
and Older and Dose is
Greater than 125mcg
per Day; QL (60 per 30
days); AGE (Max 64
Years)
PA BvD; NDS
5
2
PA BvD; NDS
PA BvD
3
2
1
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
79
Drug Name
amlodipine-olmesartan oral tablet 10-20
mg, 10-40 mg, 5-20 mg, 5-40 mg
amlodipine-valsartan oral tablet 10-160
mg, 10-320 mg, 5-160 mg, 5-320 mg
amlodipine-valsartan-hcthiazid oral
tablet 10-160-12.5 mg, 10-160-25 mg, 10320-25 mg, 5-160-12.5 mg, 5-160-25 mg
AZOR ORAL TABLET 10-20 MG, 1040 MG, 5-20 MG, 5-40 MG
CLEVIPREX INTRAVENOUS
EMULSION 50 MG/100 ML
felodipine oral tablet extended release 24
hr 10 mg, 2.5 mg, 5 mg
isradipine oral capsule 2.5 mg, 5 mg
nicardipine oral capsule 20 mg, 30 mg
nifedical xl oral tablet extended release
24hr 30 mg, 60 mg
nifedipine oral tablet extended release
24hr 30 mg, 60 mg, 90 mg
nifedipine oral tablet extended release 30
mg, 60 mg, 90 mg
Diuretics
amiloride oral tablet 5 mg
amiloride-hydrochlorothiazide oral tablet
5-50 mg
bumetanide injection solution 0.25 mg/ml
bumetanide oral tablet 0.5 mg, 1 mg, 2
mg
chlorothiazide oral tablet 250 mg, 500 mg
chlorothiazide sodium intravenous recon
soln 500 mg
chlorthalidone oral tablet 25 mg, 50 mg
DYRENIUM ORAL CAPSULE 100
MG, 50 MG
furosemide injection solution 10 mg/ml
furosemide injection syringe 10 mg/ml
furosemide oral solution 10 mg/ml, 40
mg/5 ml (8 mg/ml)
furosemide oral tablet 20 mg, 40 mg, 80
mg
hydrochlorothiazide oral capsule 12.5 mg
Drug Tier
(Azor)
2
(Exforge)
2
(Exforge HCT)
2
Requirements/Limits
2
4
2
2
2
2
(Procardia XL)
2
(Adalat CC)
2
2
2
2
2
(Diuril IV)
1
2
1
4
2
2
2
(Lasix)
1
(Microzide)
1
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
80
Drug Name
Drug Tier
hydrochlorothiazide oral tablet 12.5 mg,
25 mg, 50 mg
indapamide oral tablet 1.25 mg, 2.5 mg
methyclothiazide oral tablet 5 mg
metolazone oral tablet 10 mg, 2.5 mg, 5
mg
spironolactone oral tablet 100 mg, 25 mg,
50 mg
spironolacton-hydrochlorothiaz oral
tablet 25-25 mg
torsemide oral tablet 10 mg, 20 mg
torsemide oral tablet 100 mg, 5 mg
triamterene-hydrochlorothiazid oral
capsule 37.5-25 mg
triamterene-hydrochlorothiazid oral
capsule 50-25 mg
triamterene-hydrochlorothiazid oral
tablet 37.5-25 mg
triamterene-hydrochlorothiazid oral
tablet 75-50 mg
Dyslipidemics
ALTOPREV ORAL TABLET
EXTENDED RELEASE 24 HR 20
MG, 40 MG, 60 MG
amlodipine-atorvastatin oral tablet 10-10
mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-10
mg, 5-20 mg, 5-40 mg, 5-80 mg
amlodipine-atorvastatin oral tablet 2.5-10
mg, 2.5-20 mg, 2.5-40 mg
atorvastatin oral tablet 10 mg, 20 mg, 40
mg, 80 mg
cholestyramine light oral powder 4 gram
cholestyramine light oral powder in
packet 4 gram
cholestyramine packet outer 4 gram
colestipol hcl granules packet 5 gram
colestipol oral granules 5 gram
colestipol oral tablet 1 gram
ezetimibe oral tablet 10 mg
fenofibrate micronized oral capsule 130
mg, 134 mg, 200 mg, 43 mg, 67 mg
1
Requirements/Limits
1
2
2
(Aldactone)
2
(Aldactazide)
2
(Demadex)
2
2
2
(Dyazide)
2
(Maxzide-25mg)
1
(Maxzide)
1
4
(Caduet)
6
6
(Lipitor)
6
2
2
(Questran)
(Colestid)
(Colestid)
(Colestid)
(Zetia)
2
2
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
81
Drug Name
fenofibrate nanocrystallized oral tablet
145 mg, 48 mg
fenofibrate oral tablet 120 mg, 40 mg
fenofibrate oral tablet 160 mg, 54 mg
fenofibric acid (choline) oral
capsule,delayed release(dr/ec) 135 mg,
45 mg
fenofibric acid oral tablet 105 mg, 35 mg
fluvastatin oral capsule 20 mg, 40 mg
gemfibrozil oral tablet 600 mg
JUXTAPID ORAL CAPSULE 10 MG,
30 MG, 40 MG, 60 MG
JUXTAPID ORAL CAPSULE 20 MG
Drug Tier
(Tricor)
2
(Fenoglide)
2
2
2
(Trilipix)
(Fibricor)
(Lescol)
(Lopid)
2
2
1
5
5
JUXTAPID ORAL CAPSULE 5 MG
5
KYNAMRO SUBCUTANEOUS
SYRINGE 200 MG/ML
LIVALO ORAL TABLET 1 MG, 2
MG, 4 MG
lovastatin oral tablet 10 mg, 20 mg, 40
mg
niacin oral tablet extended release 24 hr
1,000 mg, 500 mg, 750 mg
niacor oral tablet 500 mg
omega-3 acid ethyl esters oral capsule 1
gram
PRALUENT PEN SUBCUTANEOUS
PEN INJECTOR 150 MG/ML, 75
MG/ML
PRALUENT SYRINGE
SUBCUTANEOUS SYRINGE 150
MG/ML, 75 MG/ML
pravastatin oral tablet 10 mg
pravastatin oral tablet 20 mg, 40 mg, 80
mg
prevalite oral powder 4 gram
prevalite packet outer 4 gram
REPATHA PUSHTRONEX
SUBCUTANEOUS WEARABLE
INJECTOR 420 MG/3.5 ML
5
3
Requirements/Limits
PA; NDS; QL (30 per
30 days)
PA; NDS; QL (90 per
30 days)
PA; NDS; QL (45 per
30 days)
PA; NDS; QL (4 per 28
days)
QL (30 per 30 days)
6
(Niaspan ExtendedRelease)
2
2
2
(Lovaza)
(Pravachol)
QL (120 per 30 days)
5
PA; NDS; QL (2 per 28
days)
5
PA; NDS; QL (2 per 28
days)
6
6
2
2
5
PA; NDS; QL (3.5 per
28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
82
Drug Name
Drug Tier
Requirements/Limits
REPATHA SURECLICK
SUBCUTANEOUS PEN INJECTOR
140 MG/ML
REPATHA SYRINGE
SUBCUTANEOUS SYRINGE 140
MG/ML
rosuvastatin oral tablet 10 mg, 20 mg, 40
mg, 5 mg
simvastatin oral tablet 10 mg, 20 mg, 40
mg, 5 mg
simvastatin oral tablet 80 mg
VASCEPA ORAL CAPSULE 0.5
GRAM
VASCEPA ORAL CAPSULE 1
GRAM
VYTORIN 10-10 ORAL TABLET 1010 MG
VYTORIN 10-20 ORAL TABLET 1020 MG
VYTORIN 10-40 ORAL TABLET 1040 MG
VYTORIN 10-80 ORAL TABLET 1080 MG
WELCHOL ORAL POWDER IN
PACKET 3.75 GRAM
WELCHOL ORAL TABLET 625 MG
ZETIA ORAL TABLET 10 MG
Renin-Angiotensin-Aldosterone System
Inhibitors
eplerenone oral tablet 25 mg, 50 mg
TEKAMLO ORAL TABLET 150-10
MG, 150-5 MG, 300-10 MG, 300-5 MG
TEKTURNA HCT ORAL TABLET
150-12.5 MG, 150-25 MG, 300-12.5
MG, 300-25 MG
TEKTURNA ORAL TABLET 150
MG, 300 MG
Vasodilators
BIDIL ORAL TABLET 20-37.5 MG
isosorbide dinitrate oral tablet 10 mg, 20
mg, 30 mg
5
PA; NDS; QL (3 per 28
days)
5
PA; NDS; QL (3 per 28
days)
(Crestor)
6
(Zocor)
6
(Zocor)
6
3
QL (30 per 30 days)
QL (240 per 30 days)
3
QL (120 per 30 days)
4
4
4
4
3
3
2
(Inspra)
2
3
ST
3
ST
3
ST
3
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
83
Drug Name
isosorbide dinitrate oral tablet 5 mg
isosorbide dinitrate oral tablet extended
release 40 mg
isosorbide mononitrate oral tablet 10 mg,
20 mg
isosorbide mononitrate oral tablet
extended release 24 hr 120 mg, 30 mg, 60
mg
minitran transdermal patch 24 hour 0.1
mg/hr, 0.2 mg/hr, 0.6 mg/hr
minitran transdermal patch 24 hour 0.4
mg/hr
minoxidil oral tablet 10 mg, 2.5 mg
NITRO-BID TRANSDERMAL
OINTMENT 2 %
nitroglycerin in 5 % dextrose intravenous
solution 100 mg/250 ml (400 mcg/ml), 25
mg/250 ml (100 mcg/ml), 50 mg/250 ml
(200 mcg/ml)
nitroglycerin intravenous solution 50
mg/10 ml (5 mg/ml)
nitroglycerin sublingual tablet 0.3 mg, 0.4
mg, 0.6 mg
nitroglycerin transdermal patch 24 hour
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
nitroglycerin transdermal patch 24 hour
0.4 mg/hr
NITROSTAT SUBLINGUAL
TABLET 0.3 MG, 0.4 MG, 0.6 MG
PROGLYCEM ORAL SUSPENSION
50 MG/ML
Drug Tier
(Isordil Titradose)
(ISOCHRON)
Requirements/Limits
2
2
2
2
2
QL (30 per 30 days)
2
QL (60 per 30 days)
2
2
2
2
(Nitrostat)
2
(Nitro-Dur)
2
QL (30 per 30 days)
(Nitro-Dur)
2
QL (60 per 30 days)
3
4
Central Nervous System Agents
Central Nervous System Agents
AMPYRA ORAL TABLET
EXTENDED RELEASE 12 HR 10
MG
AUBAGIO ORAL TABLET 14 MG, 7
MG
AUSTEDO ORAL TABLET 12 MG, 9
MG
5
PA; NDS; QL (60 per
30 days)
5
PA; NDS; QL (28 per
28 days)
PA; NDS; QL (120 per
30 days)
5
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
84
Drug Name
Drug Tier
Requirements/Limits
AUSTEDO ORAL TABLET 6 MG
5
AVONEX (WITH ALBUMIN)
INTRAMUSCULAR KIT 30 MCG
AVONEX INTRAMUSCULAR PEN
INJECTOR KIT 30 MCG/0.5 ML
AVONEX INTRAMUSCULAR
SYRINGE KIT 30 MCG/0.5 ML
BETASERON SUBCUTANEOUS
KIT 0.3 MG
caffeine citrate intravenous solution 60
mg/3 ml (20 mg/ml)
caffeine citrate oral solution 60 mg/3 ml
(20 mg/ml)
clonidine hcl oral tablet extended release
12 hr 0.1 mg
COPAXONE SUBCUTANEOUS
SYRINGE 20 MG/ML, 40 MG/ML
dexmethylphenidate oral tablet 10 mg,
2.5 mg, 5 mg
dextroamphetamine oral capsule,
extended release 10 mg, 15 mg, 5 mg
dextroamphetamine oral tablet 10 mg, 5
mg
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 10 mg, 15
mg, 5 mg
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 20 mg, 25
mg, 30 mg
dextroamphetamine-amphetamine oral
tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30
mg, 5 mg, 7.5 mg
EXTAVIA SUBCUTANEOUS KIT
0.3 MG
flumazenil intravenous solution 0.1 mg/ml
GILENYA ORAL CAPSULE 0.5 MG
5
PA; NDS; QL (60 per
30 days)
PA; NDS
5
PA; NDS
5
PA; NDS
5
PA; NDS
guanfacine oral tablet extended release
24 hr 1 mg, 2 mg, 3 mg, 4 mg
(Cafcit)
2
2
(Kapvay)
2
5
PA; NDS
(Focalin)
2
QL (60 per 30 days)
(Dexedrine Spansule)
2
QL (120 per 30 days)
(Zenzedi)
2
QL (180 per 30 days)
(Adderall XR)
2
QL (30 per 30 days)
(Adderall XR)
2
QL (60 per 30 days)
(Adderall)
2
QL (60 per 30 days)
5
PA; NDS
2
5
(Intuniv ER)
PA; NDS; QL (28 per
28 days)
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
85
Drug Name
Drug Tier
LEMTRADA INTRAVENOUS
SOLUTION 12 MG/1.2 ML
lithium carbonate oral capsule 150 mg,
300 mg, 600 mg
lithium carbonate oral tablet 300 mg
lithium carbonate oral tablet extended
release 300 mg
lithium carbonate oral tablet extended
release 450 mg
lithium citrate oral solution 8 meq/5 ml
methylphenidate oral capsule, er biphasic
30-70 10 mg, 20 mg, 40 mg, 50 mg, 60
mg
methylphenidate oral capsule, er biphasic
30-70 30 mg
methylphenidate oral capsule,er biphasic
50-50 20 mg, 40 mg
methylphenidate oral capsule,er biphasic
50-50 60 mg
methylphenidate oral solution 10 mg/5
ml, 5 mg/5 ml
methylphenidate oral tablet 10 mg, 20
mg, 5 mg
methylphenidate oral tablet extended
release 10 mg
methylphenidate oral tablet extended
release 20 mg
methylphenidate oral tablet extended
release 24hr 18 mg, 27 mg, 54 mg
methylphenidate oral tablet extended
release 24hr 36 mg
NUEDEXTA ORAL CAPSULE 20-10
MG
OCREVUS INTRAVENOUS
SOLUTION 30 MG/ML
PLEGRIDY SUBCUTANEOUS PEN
INJECTOR 125 MCG/0.5 ML, 63
MCG/0.5 ML- 94 MCG/0.5 ML
PLEGRIDY SUBCUTANEOUS
SYRINGE 125 MCG/0.5 ML, 63
MCG/0.5 ML- 94 MCG/0.5 ML
5
Requirements/Limits
PA; NDS
1
(Lithobid)
2
2
2
(Metadate CD)
2
2
QL (30 per 30 days)
(Metadate CD)
2
QL (60 per 30 days)
(Ritalin LA)
2
QL (30 per 30 days)
2
QL (30 per 30 days)
(Methylin)
2
QL (900 per 30 days)
(Ritalin)
2
QL (90 per 30 days)
2
QL (90 per 30 days)
(Metadate ER)
2
QL (90 per 30 days)
(Concerta)
2
QL (30 per 30 days)
(Concerta)
2
QL (60 per 30 days)
3
QL (60 per 30 days)
5
5
PA; NDS; QL (20 per
180 days)
PA; NDS
5
PA; NDS
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
86
Drug Name
Drug Tier
Requirements/Limits
REBIF (WITH ALBUMIN)
SUBCUTANEOUS SYRINGE 22
MCG/0.5 ML, 44 MCG/0.5 ML
REBIF REBIDOSE
SUBCUTANEOUS PEN INJECTOR
22 MCG/0.5 ML, 44 MCG/0.5 ML,
8.8MCG/0.2ML-22 MCG/0.5ML (6)
REBIF TITRATION PACK
SUBCUTANEOUS SYRINGE
8.8MCG/0.2ML-22 MCG/0.5ML (6)
riluzole oral tablet 50 mg
(Rilutek)
SAVELLA ORAL TABLET 100 MG,
12.5 MG, 25 MG, 50 MG
SAVELLA ORAL TABLETS,DOSE
PACK 12.5 MG (5)-25 MG(8)-50
MG(42)
STRATTERA ORAL CAPSULE 10
MG, 100 MG, 18 MG, 25 MG, 40 MG,
60 MG, 80 MG
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)- 240
MG (46), 240 MG
tetrabenazine oral tablet 12.5 mg, 25 mg (Xenazine)
5
PA; NDS
5
PA; NDS
5
PA; NDS
2
3
QL (60 per 30 days)
3
QL (60 per 30 days)
ZINBRYTA SUBCUTANEOUS
SYRINGE 150 MG/ML
5
3
5
PA; NDS; QL (14 per
30 days)
5
PA; NDS; QL (60 per
30 days)
5
PA; NDS; QL (112 per
28 days)
PA; NDS; QL (1 per 28
days)
Contraceptives
Contraceptives
altavera (28) oral tablet 0.15-0.03 mg
alyacen 1/35 (28) oral tablet 1-35 mgmcg
alyacen 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
amethia lo oral tablets,dose pack,3 month
0.10 mg-20 mcg (84)/10 mcg (7)
amethia oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
2
2
2
2
QL (91 per 84 days)
2
QL (91 per 84 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
87
Drug Name
Drug Tier
apri oral tablet 0.15-0.03 mg
aranelle (28) oral tablet 0.5/1/0.5-35 mgmcg
ashlyna oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
aubra oral tablet 0.1-20 mg-mcg
aviane oral tablet 0.1-20 mg-mcg
azurette (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
balziva (28) oral tablet 0.4-35 mg-mcg
bekyree (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
blisovi 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
blisovi fe 1.5/30 (28) oral tablet 1.5 mg30 mcg (21)/75 mg (7)
blisovi fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
briellyn oral tablet 0.4-35 mg-mcg
camila oral tablet 0.35 mg
camrese lo oral tablets,dose pack,3 month
0.10 mg-20 mcg (84)/10 mcg (7)
camrese oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
caziant (28) oral tablet 0.1/.125/.15-25
mg-mcg
cryselle (28) oral tablet 0.3-30 mg-mcg
cyclafem 1/35 (28) oral tablet 1-35 mgmcg
cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
cyred oral tablet 0.15-0.03 mg
dasetta 1/35 (28) oral tablet 1-35 mgmcg
dasetta 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
daysee oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
deblitane oral tablet 0.35 mg
delyla (28) oral tablet 0.1-20 mg-mcg
2
2
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
QL (91 per 84 days)
2
QL (91 per 84 days)
2
2
2
2
2
2
2
2
QL (91 per 84 days)
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
88
Drug Name
desog-e.estradiol/e.estradiol oral tablet
0.15-0.02 mgx21 /0.01 mg x 5
desogestrel-ethinyl estradiol oral tablet
0.15-0.03 mg
drospirenone-ethinyl estradiol oral tablet
3-0.02 mg
drospirenone-ethinyl estradiol oral tablet
3-0.03 mg
elinest oral tablet 0.3-30 mg-mcg
ELLA ORAL TABLET 30 MG
emoquette oral tablet 0.15-0.03 mg
enpresse oral tablet 50-30 (6)/75-40
(5)/125-30(10)
enskyce oral tablet 0.15-0.03 mg
errin oral tablet 0.35 mg
estarylla oral tablet 0.25-35 mg-mcg
ethynodiol diac-eth estradiol oral tablet
1-50 mg-mcg
falmina (28) oral tablet 0.1-20 mg-mcg
femynor oral tablet 0.25-35 mg-mcg
gianvi (28) oral tablet 3-0.02 mg
gildagia oral tablet 0.4-35 mg-mcg
gildess 1.5/30 (21) oral tablet 1.5-30 mgmcg
gildess 1/20 (21) oral tablet 1-20 mg-mcg
gildess 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
gildess fe 1.5/30 (28) oral tablet 1.5 mg30 mcg (21)/75 mg (7)
gildess fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
heather oral tablet 0.35 mg
introvale oral tablets,dose pack,3 month
0.15 mg-30 mcg
jencycla oral tablet 0.35 mg
jolessa oral tablets,dose pack,3 month
0.15 mg-30 mcg
jolivette oral tablet 0.35 mg
juleber oral tablet 0.15-0.03 mg
Drug Tier
(Bekyree (28))
2
(Cyred)
2
(Loryna (28))
2
(Syeda)
2
2
4
2
2
(Zovia 1/50E (28))
Requirements/Limits
QL (6 per 365 days)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
QL (91 per 84 days)
2
2
QL (91 per 84 days)
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
89
Drug Name
Drug Tier
junel 1.5/30 (21) oral tablet 1.5-30 mgmcg
junel 1/20 (21) oral tablet 1-20 mg-mcg
junel fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
junel fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
junel fe 24 oral tablet 1 mg-20 mcg
(24)/75 mg (4)
kariva (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
kelnor 1/35 (28) oral tablet 1-35 mg-mcg
kimidess (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
kurvelo oral tablet 0.15-0.03 mg
l norgest/e.estradiol-e.estrad oral
tablets,dose pack,3 month 0.10 mg-20
mcg (84)/10 mcg (7)
l norgest/e.estradiol-e.estrad oral
tablets,dose pack,3 month 0.15 mg-30
mcg (84)/10 mcg (7)
larin 1.5/30 (21) oral tablet 1.5-30 mgmcg
larin 1/20 (21) oral tablet 1-20 mg-mcg
larin 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
larin fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
larin fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
larissia oral tablet 0.1-20 mg-mcg
leena 28 oral tablet 0.5/1/0.5-35 mg-mcg
lessina oral tablet 0.1-20 mg-mcg
levonest (28) oral tablet 50-30 (6)/75-40
(5)/125-30(10)
levonor-eth estrad 0.15-0.03 outer 0.150.03 mg
levonorgestrel-ethinyl estrad oral tablet
0.1-20 mg-mcg
2
Requirements/Limits
2
2
2
2
2
2
2
(Amethia Lo)
2
2
QL (91 per 84 days)
(Amethia)
2
QL (91 per 84 days)
2
2
2
2
2
2
2
2
2
(Portia)
2
(Orsythia)
2
QL (91 per 84 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
90
Drug Name
Drug Tier
levonorgestrel-ethinyl estrad oral
(Quasense)
tablets,dose pack,3 month 0.15 mg-30
mcg
levonorg-eth estrad triphasic oral tablet
(Myzilra)
50-30 (6)/75-40 (5)/125-30(10)
levora-28 oral tablet 0.15-0.03 mg
lomedia 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
loryna (28) oral tablet 3-0.02 mg
low-ogestrel (28) oral tablet 0.3-30 mgmcg
lutera (28) oral tablet 0.1-20 mg-mcg
lyza oral tablet 0.35 mg
marlissa oral tablet 0.15-0.03 mg
microgestin 1.5/30 (21) oral tablet 1.5-30
mg-mcg
microgestin 1/20 (21) oral tablet 1-20
mg-mcg
microgestin fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
microgestin fe 1/20 (28) oral tablet 1 mg20 mcg (21)/75 mg (7)
mono-linyah oral tablet 0.25-35 mg-mcg
mononessa (28) oral tablet 0.25-35 mgmcg
myzilra oral tablet 50-30 (6)/75-40
(5)/125-30(10)
necon 0.5/35 (28) oral tablet 0.5-35 mgmcg
necon 1/35 (28) oral tablet 1-35 mg-mcg
necon 1/50 (28) oral tablet 1-50 mg-mcg
necon 10/11 (28) oral tablet 0.5-35/1-35
mg-mcg/mg-mcg
necon 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
nikki (28) oral tablet 3-0.02 mg
nora-be oral tablet 0.35 mg
noreth-ethinyl estradiol-iron oral
(Femcon Fe)
tablet,chewable 0.4mg-35mcg(21) and 75
mg (7)
Requirements/Limits
2
QL (91 per 84 days)
2
QL (91 per 84 days)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
91
Drug Name
norethindrone (contraceptive) oral tablet
0.35 mg
norethindrone ac-eth estradiol oral tablet
1-20 mg-mcg
norethindrone-e.estradiol-iron oral tablet
1 mg-20 mcg (24)/75 mg (4)
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-25 mcg
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
norgestimate-ethinyl estradiol oral tablet
0.25-35 mg-mcg
norlyroc oral tablet 0.35 mg
nortrel 0.5/35 (28) oral tablet 0.5-35 mgmcg
nortrel 1/35 (21) oral tablet 1-35 mgmcg
nortrel 1/35 (28) oral tablet 1-35 mgmcg
nortrel 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
NUVARING VAGINAL RING 0.120.015 MG/24 HR
ocella oral tablet 3-0.03 mg
ogestrel (28) oral tablet 0.5-50 mg-mcg
orsythia oral tablet 0.1-20 mg-mcg
philith oral tablet 0.4-35 mg-mcg
pimtrea (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
pirmella oral tablet 0.5/0.75/1 mg- 35
mcg, 1-35 mg-mcg
portia oral tablet 0.15-0.03 mg
previfem oral tablet 0.25-35 mg-mcg
quasense oral tablets,dose pack,3 month
0.15 mg-30 mcg
reclipsen (28) oral tablet 0.15-0.03 mg
setlakin oral tablets,dose pack,3 month
0.15 mg-30 mcg
sharobel oral tablet 0.35 mg
sprintec (28) oral tablet 0.25-35 mg-mcg
Drug Tier
(Jencycla)
2
(Larin 1/20 (21))
2
(Blisovi 24 Fe)
2
(Tri-Lo-Marzia)
2
(Tri-Linyah)
2
(Mono-Linyah)
2
Requirements/Limits
2
2
2
2
2
3
QL (1 per 28 days)
2
2
2
2
2
2
2
2
2
QL (91 per 84 days)
2
2
QL (91 per 84 days)
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
92
Drug Name
Drug Tier
sronyx oral tablet 0.1-20 mg-mcg
syeda oral tablet 3-0.03 mg
tarina fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
tilia fe oral tablet 1-20(5)/1-30(7) /1mg35mcg (9)
tri-estarylla oral tablet 0.18/0.215/0.25
mg-35 mcg (28)
tri-legest fe oral tablet 1-20(5)/1-30(7)
/1mg-35mcg (9)
tri-linyah oral tablet 0.18/0.215/0.25 mg35 mcg (28)
tri-lo-estarylla oral tablet 0.18/0.215/0.25
mg-25 mcg
tri-lo-marzia oral tablet 0.18/0.215/0.25
mg-25 mcg
tri-lo-sprintec oral tablet 0.18/0.215/0.25
mg-25 mcg
trinessa (28) oral tablet 0.18/0.215/0.25
mg-35 mcg (28)
tri-previfem (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
tri-sprintec (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
trivora (28) oral tablet 50-30 (6)/75-40
(5)/125-30(10)
velivet triphasic regimen (28) oral tablet
0.1/.125/.15-25 mg-mcg
vestura (28) oral tablet 3-0.02 mg
vienva oral tablet 0.1-20 mg-mcg
viorele (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
vyfemla (28) oral tablet 0.4-35 mg-mcg
wera (28) oral tablet 0.5-35 mg-mcg
wymzya fe oral tablet,chewable 0.4mg35mcg(21) and 75 mg (7)
xulane transdermal patch weekly 150-35
mcg/24 hr
zarah oral tablet 3-0.03 mg
zenchent (28) oral tablet 0.4-35 mg-mcg
2
2
2
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
QL (3 per 28 days)
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
93
Drug Name
Drug Tier
zenchent fe oral tablet,chewable 0.4mg35mcg(21) and 75 mg (7)
zovia 1/35e (28) oral tablet 1-35 mg-mcg
zovia 1/50e (28) oral tablet 1-50 mg-mcg
2
Requirements/Limits
2
2
Dental And Oral Agents
Dental And Oral Agents
cevimeline oral capsule 30 mg
chlorhexidine gluconate mucous
membrane mouthwash 0.12 %
oralone dental paste 0.1 %
periogard mucous membrane mouthwash
0.12 %
pilocarpine hcl oral tablet 5 mg, 7.5 mg
triamcinolone acetonide dental paste 0.1
%
(Evoxac)
(Periogard)
2
2
2
2
(Salagen (pilocarpine))
(Oralone)
2
2
(Soriatane)
4
5
Dermatological Agents
Dermatological Agents, Other
8-MOP ORAL CAPSULE 10 MG
acitretin oral capsule 10 mg, 17.5 mg, 25
mg
acyclovir topical ointment 5 %
ALCOHOL PADS TOPICAL PADS,
MEDICATED
ALCOHOL PREP PADS
ammonium lactate topical cream 12 %
ammonium lactate topical lotion 12 %
ANACAINE TOPICAL OINTMENT
10 %
calcipotriene scalp solution 0.005 %
calcipotriene topical cream 0.005 %
calcipotriene topical ointment 0.005 %
calcitrene topical ointment 0.005 %
calcitriol topical ointment 3 mcg/gram
CONDYLOX TOPICAL GEL 0.5 %
COSENTYX (150 MG/ML) 300 MG
DOSE-2 PENS 150 MG/ML
COSENTYX (150 MG/ML) 300 MG
DOSE-2 SYRINGES 150 MG/ML
COSENTYX PEN SUBCUTANEOUS
PEN INJECTOR 150 MG/ML
(Zovirax)
(Geri-Hydrolac)
(Skin Treatment)
(Dovonex)
(Calcitrene)
(Vectical)
2
1
NDS
QL (5 per 4 days)
1
2
2
4
2
2
2
2
2
4
5
PA; NDS
5
PA; NDS
5
PA; NDS
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
94
Drug Name
COSENTYX SUBCUTANEOUS
SYRINGE 150 MG/ML
DENAVIR TOPICAL CREAM 1 %
diclofenac sodium topical gel 3 %
DUPIXENT SUBCUTANEOUS
SYRINGE 300 MG/2 ML
fluorouracil topical cream 0.5 %
fluorouracil topical cream 5 %
fluorouracil topical solution 2 %, 5 %
imiquimod topical cream in packet 5 %
Drug Tier
(Solaraze)
(Carac)
(Efudex)
(Aldara)
Requirements/Limits
5
PA; NDS
5
5
5
NDS
NDS
PA; NDS
5
2
2
2
NDS
methoxsalen oral capsule,liqd-filled,rapid (Oxsoralen Ultra)
rel 10 mg
PANRETIN TOPICAL GEL 0.1 %
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
podofilox topical solution 0.5 %
(Condylox)
potassium hydroxide topical solution 5 %
REGRANEX TOPICAL GEL 0.01 %
5
SANTYL TOPICAL OINTMENT 250
UNIT/GRAM
SILIQ SUBCUTANEOUS SYRINGE
210 MG/1.5 ML
TALTZ 80 MG/ML AUTOINJECTOR
P/F,LATEX-FREE,OUTER 80
MG/ML
TALTZ AUTOINJECTOR (3 PACK)
SUBCUTANEOUS AUTOINJECTOR 80 MG/ML
TALTZ SYRINGE
SUBCUTANEOUS SYRINGE 80
MG/ML
TOLAK TOPICAL CREAM 4 %
VALCHLOR TOPICAL GEL 0.016 %
VEREGEN TOPICAL OINTMENT
15 %
zenatane oral capsule 10 mg, 20 mg, 30
mg, 40 mg
ZOVIRAX TOPICAL CREAM 5 %
4
5
3
3
2
2
5
PA NSO; QL (24 per 30
days)
NDS
NDS
QL (3 per 56 days)
QL (2 per 56 days)
PA; NDS; QL (30 per
30 days)
5
PA; NDS
5
PA; NDS
5
PA; NDS
5
PA; NDS
4
5
5
NDS
NDS
2
5
NDS; QL (5 per 4 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
95
Drug Name
Dermatological Antibacterials
clindamycin phosphate topical foam 1 %
clindamycin phosphate topical gel 1 %
clindamycin phosphate topical lotion 1 %
clindamycin phosphate topical solution 1
%
clindamycin phosphate topical swab 1 %
clindamycin-benzoyl peroxide topical gel
1.2 %(1 % base) -5 %
clindamycin-benzoyl peroxide topical gel
1-5 %
ery pads topical swab 2 %
erythromycin with ethanol topical gel 2 %
erythromycin with ethanol topical
solution 2 %
erythromycin with ethanol topical swab 2
%
erythromycin-benzoyl peroxide topical
gel 3-5 %
gentamicin topical cream 0.1 %
gentamicin topical ointment 0.1 %
metronidazole topical cream 0.75 %
metronidazole topical gel 0.75 %
metronidazole topical gel 1 %
metronidazole topical lotion 0.75 %
mupirocin calcium topical cream 2 %
mupirocin topical ointment 2 %
neomycin-polymyxin b gu irrigation
solution 40 mg-200,000 unit/ml
neuac topical gel 1.2 %(1 % base) -5 %
rosadan topical cream 0.75 %
selenium sulfide topical lotion 2.5 %
silver nitrate topical ointment 10 %
silver nitrate topical solution 10 %, 25 %,
50 %
silver sulfadiazine topical cream 1 %
ssd topical cream 1 %
sulfacetamide sodium (acne) topical
suspension 10 %
Drug Tier
(Evoclin)
(Cleocin T)
(Cleocin T)
(Cleocin T)
2
2
2
2
(Clindacin P)
(Duac)
2
2
(Benzaclin)
2
(Erygel)
2
2
2
(Ery Pads)
2
(Benzamycin)
2
(Rosadan)
(Rosadan)
(Metrogel)
(MetroLotion)
(Bactroban)
(Centany)
(Neosporin GU
Irrigant)
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
(Silvadene)
(Klaron)
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
96
Drug Name
Dermatological Anti-Inflammatory Agents
ala-cort topical cream 1 %
ala-cort topical cream 2.5 %
ala-scalp topical lotion 2 %
alclometasone topical cream 0.05 %
alclometasone topical ointment 0.05 %
betamethasone dipropionate topical
cream 0.05 %
betamethasone dipropionate topical
lotion 0.05 %
betamethasone dipropionate topical
ointment 0.05 %
betamethasone valerate topical cream 0.1
%
betamethasone valerate topical foam 0.12
%
betamethasone valerate topical lotion 0.1
%
betamethasone valerate topical ointment
0.1 %
betamethasone, augmented topical cream
0.05 %
betamethasone, augmented topical gel
0.05 %
betamethasone, augmented topical lotion
0.05 %
betamethasone, augmented topical
ointment 0.05 %
clobetasol 0.05% cream 0.05 %
clobetasol scalp solution 0.05 %
clobetasol topical foam 0.05 %
clobetasol topical gel 0.05 %
clobetasol topical lotion 0.05 %
clobetasol topical ointment 0.05 %
clobetasol topical shampoo 0.05 %
clobetasol-emollient topical cream 0.05 %
clocortolone pivalate topical cream 0.1 %
cormax scalp solution 0.05 %
desonide topical cream 0.05 %
desonide topical lotion 0.05 %
Drug Tier
Requirements/Limits
2
1
2
2
2
2
2
2
2
(Luxiq)
2
2
2
(Diprolene AF)
2
2
2
(Diprolene)
2
(Temovate)
(Cormax)
(Olux)
2
2
2
2
2
2
2
2
2
2
2
2
(Clobex)
(Temovate)
(Clodan)
(Cloderm)
(DesOwen)
(DesOwen)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
97
Drug Name
Drug Tier
desonide topical ointment 0.05 %
desoximetasone topical cream 0.05 %,
0.25 %
desoximetasone topical gel 0.05 %
desoximetasone topical ointment 0.05 %,
0.25 %
diflorasone topical cream 0.05 %
diflorasone topical ointment 0.05 %
ELIDEL TOPICAL CREAM 1 %
EUCRISA TOPICAL OINTMENT 2
%
fluocinonide topical cream 0.05 %
fluocinonide topical gel 0.05 %
fluocinonide topical ointment 0.05 %
fluocinonide topical solution 0.05 %
fluocinonide-e topical cream 0.05 %
fluticasone topical cream 0.05 %
fluticasone topical ointment 0.005 %
halobetasol propionate topical cream 0.05
%
halobetasol propionate topical ointment
0.05 %
hydrocortisone buty 0.1% cream 0.1 %
hydrocortisone butyrate topical ointment
0.1 %
hydrocortisone butyrate topical solution
0.1 %
hydrocortisone butyr-emollient topical
cream 0.1 %
hydrocortisone topical cream 1 %
hydrocortisone topical cream 2.5 %
hydrocortisone topical lotion 2.5 %
hydrocortisone topical ointment 1 %
hydrocortisone topical ointment 2.5 %
hydrocortisone valerate topical cream 0.2
%
hydrocortisone valerate topical ointment
0.2 %
mometasone topical cream 0.1 %
mometasone topical ointment 0.1 %
(Topicort)
2
2
(Topicort)
(Topicort)
2
2
(Psorcon)
2
2
3
3
(Ultravate)
2
2
2
2
2
2
2
2
(Ultravate)
2
(Locoid)
(Locoid)
2
2
(Locoid)
2
(Locoid Lipocream)
2
(Cortizone-10 Plus)
(Ala-Cort)
1
1
2
1
1
2
(Cutivate)
(Cortizone-10)
Requirements/Limits
2
(Elocon)
(Elocon)
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
98
Drug Name
Drug Tier
mometasone topical solution 0.1 %
prednicarbate topical cream 0.1 %
prednicarbate topical ointment 0.1 %
procto-med hc topical cream with
perineal applicator 2.5 %
procto-pak topical cream with perineal
applicator 1 %
proctosol hc topical cream with perineal
applicator 2.5 %
proctozone-hc topical cream with perineal
applicator 2.5 %
tacrolimus topical ointment 0.03 %, 0.1
%
triamcinolone acetonide topical cream
0.025 %, 0.5 %
triamcinolone acetonide topical cream 0.1
%
triamcinolone acetonide topical lotion
0.025 %, 0.1 %
triamcinolone acetonide topical ointment
0.025 %, 0.1 %, 0.5 %
trianex topical ointment 0.05 %
tridesilon topical cream 0.05 %
u-cort topical cream 1-10 %
Dermatological Retinoids
adapalene topical cream 0.1 %
adapalene topical gel 0.1 %
tazarotene topical cream 0.1 %
TAZORAC TOPICAL CREAM 0.05
%, 0.1 %
tretinoin gel micro 0.04% tube 0.04 %
tretinoin gel micro 0.1% tube 0.1 %
tretinoin microspheres topical gel with
pump 0.04 %, 0.1 %
tretinoin topical cream 0.025 %
tretinoin topical cream 0.05 %, 0.1 %
tretinoin topical gel 0.01 %, 0.025 %
tretinoin topical gel 0.05 %
Scabicides And Pediculicides
malathion topical lotion 0.5 %
2
2
2
2
(Dermatop)
(Dermatop)
Requirements/Limits
2
2
2
(Protopic)
2
1
(Triderm)
1
2
1
2
2
2
(Differin)
(Differin)
(Tazorac)
2
2
2
4
(Retin-A Micro)
(Retin-A Micro)
(Retin-A Micro Pump)
2
2
2
PA
PA
PA
(Avita)
(Retin-A)
(Retin-A)
(Atralin)
2
2
2
2
PA
PA
PA
PA
(Ovide)
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
99
Drug Name
permethrin topical cream 5 %
spinosad topical suspension 0.9 %
Drug Tier
(Elimite)
(Natroba)
Requirements/Limits
2
2
Devices
Devices
ASSURE ID INSULIN SAFETY
SYRINGE 1 ML 29 GAUGE X 1/2"
BD INSULIN SYR 0.3 ML
6MMX31G 0.3 ML 31 GAUGE X
15/64"
BD INSULIN SYR 0.5 ML
6MMX31G 1/2 ML 31 GAUGE X
15/64"
BD INSULIN SYR 1 ML 6MMX31G
1 ML 31 GAUGE X 15/64"
BD ULTRA-FINE PEN NDL
8MMX31G SHORT 31 GAUGE X
5/16"
GAUZE PAD TOPICAL BANDAGE
2X2"
GAUZE PADS, STERILE 2"X2" 2 X 2
"
INSULIN SYRINGE-NEEDLE U-100
SYRINGE 0.3 ML 29 GAUGE
INSULIN SYRINGE-NEEDLE U-100
SYRINGE 1 ML 29 GAUGE X 1/2"
INSULIN SYRINGE-NEEDLE U-100
SYRINGE 1/2 ML 28 GAUGE
PEN NEEDLE, DIABETIC NEEDLE
29 GAUGE X 1/2"
VGO 40 DISPOSABLE DEVICE
2
2
2
2
2
1
1
(Ultilet Insulin Syringe)
2
(BD Insulin Syringe
Safety-Lok)
(Lite Touch Insulin
Syringe)
(Insupen)
2
2
2
2
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN INTRAMUSCULAR
SOLUTION 250 UNIT/ML
ALDURAZYME INTRAVENOUS
SOLUTION 2.9 MG/5 ML
CEREZYME INTRAVENOUS
RECON SOLN 400 UNIT
5
NDS
5
NDS
5
NDS
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
100
Drug Name
Drug Tier
CREON ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000 60,000 UNIT, 24,000-76,000 -120,000
UNIT, 3,000-9,500- 15,000 UNIT,
36,000-114,000- 180,000 UNIT, 6,00019,000 -30,000 UNIT
ELAPRASE INTRAVENOUS
SOLUTION 6 MG/3 ML
ELITEK INTRAVENOUS RECON
SOLN 1.5 MG, 7.5 MG
FABRAZYME INTRAVENOUS
RECON SOLN 35 MG
KANUMA INTRAVENOUS
SOLUTION 2 MG/ML
KRYSTEXXA INTRAVENOUS
SOLUTION 8 MG/ML
KUVAN ORAL TABLET,SOLUBLE
100 MG
MYOZYME INTRAVENOUS
RECON SOLN 50 MG
NAGLAZYME INTRAVENOUS
SOLUTION 5 MG/5 ML
ORFADIN ORAL CAPSULE 10 MG,
2 MG, 20 MG, 5 MG
ORFADIN ORAL SUSPENSION 4
MG/ML
PERTZYE ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 16,000-57,50060,500 UNIT
PERTZYE ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 4,000-14,37515,125 UNIT, 8,000-28,750- 30,250
UNIT
PULMOZYME INHALATION
SOLUTION 1 MG/ML
STRENSIQ SUBCUTANEOUS
SOLUTION 100 MG/ML, 40 MG/ML
3
Requirements/Limits
5
NDS
5
NDS
5
NDS
5
PA; NDS
5
NDS
5
NDS
5
NDS
5
NDS
5
NDS
5
NDS
5
NDS
4
5
PA BvD; NDS
5
PA; LA; NDS
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
101
Drug Name
Drug Tier
Requirements/Limits
VIMIZIM INTRAVENOUS
SOLUTION 5 MG/5 ML (1 MG/ML)
VPRIV INTRAVENOUS RECON
SOLN 400 UNIT
ZAVESCA ORAL CAPSULE 100 MG
5
PA; NDS
5
NDS
5
NDS; QL (90 per 30
days)
ZENPEP ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-34,000 55,000 UNIT, 15,000-51,000 -82,000
UNIT, 20,000-68,000 -109,000 UNIT,
25,000-85,000- 136,000 UNIT, 3,00010,000- 16,000 UNIT, 40,000-136,000218,000 UNIT, 5,000-17,000 -27,000
UNIT
3
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents,
Miscellaneous
AKTEN (PF) OPHTHALMIC GEL
3.5 %
alcaine ophthalmic drops 0.5 %
altacaine ophthalmic drops 0.5 %
apraclonidine ophthalmic drops 0.5 %
atropine ophthalmic drops 1 %
azelastine nasal aerosol,spray 137 mcg
(0.1 %)
azelastine nasal spray,non-aerosol 0.15 %
(205.5 mcg)
azelastine ophthalmic drops 0.05 %
BEPREVE OPHTHALMIC DROPS
1.5 %
carteolol ophthalmic drops 1 %
cromolyn ophthalmic drops 4 %
cyclopentolate ophthalmic drops 0.5 %, 1
%, 2 %
CYSTARAN OPHTHALMIC DROPS
0.44 %
epinastine ophthalmic drops 0.05 %
flucaine ophthalmic drops 0.25-0.5 %
homatropaire ophthalmic drops 5 %
homatropine hbr ophthalmic drops 5 %
4
(Iopidine)
(Astepro)
(Cyclogyl)
2
2
2
2
2
QL (30 per 25 days)
2
QL (30 per 25 days)
2
4
ST
1
2
2
5
(Elestat)
(Homatropaire)
NDS
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
102
Drug Name
Drug Tier
Requirements/Limits
ipratropium bromide nasal spray,nonaerosol 0.03 %
ipratropium bromide nasal spray,nonaerosol 0.06 %
LACRISERT OPHTHALMIC
INSERT 5 MG
naphazoline ophthalmic drops 0.1 %
olopatadine nasal spray,non-aerosol 0.6
%
olopatadine ophthalmic drops 0.1 %
OTOVEL OTIC SOLUTION 0.3-0.025
% (0.25 ML)
PATADAY OPHTHALMIC DROPS
0.2 %
phenylephrine hcl ophthalmic drops 10 %,
2.5 %
proparacaine ophthalmic drops 0.5 %
TYZINE NASAL DROPS 0.1 %
TYZINE NASAL SPRAY,NONAEROSOL 0.1 %
Eye, Ear, Nose, Throat Anti-Infectives
Agents
acetasol hc otic drops 1-2 %
acetic acid otic solution 2 %
bacitracin ophthalmic ointment 500
unit/gram
bacitracin-polymyxin b ophthalmic
ointment 500-10,000 unit/gram
bleph-10 ophthalmic drops 10 %
CILOXAN OPHTHALMIC
OINTMENT 0.3 %
CIPRODEX OTIC
DROPS,SUSPENSION 0.3-0.1 %
ciprofloxacin hcl ophthalmic drops 0.3 %
ciprofloxacin hcl otic dropperette 0.2 %
COLY-MYCIN S OTIC
DROPS,SUSPENSION 3.3-3-10-0.5
MG/ML
erythromycin ophthalmic ointment 5
mg/gram (0.5 %)
gatifloxacin ophthalmic drops 0.5 %
2
QL (30 per 28 days)
2
QL (15 per 10 days)
3
(Patanase)
(Patanol)
1
2
QL (30.5 per 30 days)
2
3
4
ST
2
2
4
4
2
2
2
(Polycin)
2
2
4
3
(Ciloxan)
(Cetraxal)
2
2
4
2
(Zymaxid)
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
103
Drug Name
Drug Tier
gentak ophthalmic ointment 0.3 % (3
mg/gram)
gentamicin ophthalmic drops 0.3 %
gentamicin ophthalmic ointment 0.3 % (3
mg/gram)
hydrocortisone-acetic acid otic drops 1-2
%
levofloxacin ophthalmic drops 0.5 %
MOXEZA OPHTHALMIC DROPS,
VISCOUS 0.5 %
NATACYN OPHTHALMIC
DROPS,SUSPENSION 5 %
neomycin-bacitracin-poly-hc ophthalmic
ointment 3.5-400-10,000 mg-unit/g-1%
neomycin-bacitracin-polymyxin
ophthalmic ointment 3.5-400-10,000 mgunit-unit/g
neomycin-polymyxin b-dexameth
ophthalmic drops,suspension 3.5mg/ml10,000 unit/ml-0.1 %
neomycin-polymyxin b-dexameth
ophthalmic ointment 3.5 mg/g-10,000
unit/g-0.1 %
neomycin-polymyxin-gramicidin
ophthalmic drops 1.75 mg-10,000 unit0.025mg/ml
neomycin-polymyxin-hc ophthalmic
drops,suspension 3.5-10,000-10 mg-unitmg/ml
neomycin-polymyxin-hc otic
drops,suspension 3.5-10,000-1 mg/mlunit/ml-%
neomycin-polymyxin-hc otic solution 3.510,000-1 mg/ml-unit/ml-%
neo-polycin hc ophthalmic ointment 3.5400-10,000 mg-unit/g-1%
neo-polycin ophthalmic ointment 3.5-40010,000 mg-unit-unit/g
ofloxacin ophthalmic drops 0.3 %
ofloxacin otic drops 0.3 %
2
(Gentak)
2
2
(Acetasol HC)
2
Requirements/Limits
2
3
3
(Neo-Polycin HC)
2
(Neo-Polycin)
2
(Maxitrol)
2
(Maxitrol)
2
(Neosporin (neopolym-gramicid))
2
2
2
2
2
2
(Ocuflox)
(Floxin)
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
104
Drug Name
polymyxin b sulf-trimethoprim
ophthalmic drops 10,000 unit- 1 mg/ml
sulfacetamide sodium ophthalmic drops
10 %
sulfacetamide sodium ophthalmic
ointment 10 %
sulfacetamide-prednisolone ophthalmic
drops 10 %-0.23 % (0.25 %)
TOBRADEX OPHTHALMIC
OINTMENT 0.3-0.1 %
TOBRADEX ST OPHTHALMIC
DROPS,SUSPENSION 0.3-0.05 %
tobramycin ophthalmic drops 0.3 %
tobramycin-dexamethasone ophthalmic
drops,suspension 0.3-0.1 %
trifluridine ophthalmic drops 1 %
VIGAMOX OPHTHALMIC DROPS
0.5 %
ZIRGAN OPHTHALMIC GEL 0.15 %
ZYLET OPHTHALMIC
DROPS,SUSPENSION 0.3-0.5 %
Eye, Ear, Nose, Throat Anti-Inflammatory
Agents
ALREX OPHTHALMIC
DROPS,SUSPENSION 0.2 %
bromfenac ophthalmic drops 0.09 %
dexamethasone sodium phosphate
ophthalmic drops 0.1 %
diclofenac sodium ophthalmic drops 0.1
%
DUREZOL OPHTHALMIC DROPS
0.05 %
flunisolide nasal spray,non-aerosol 25
mcg (0.025 %)
fluocinolone acetonide oil otic drops 0.01
%
fluorometholone ophthalmic
drops,suspension 0.1 %
flurbiprofen sodium ophthalmic drops
0.03 %
Drug Tier
(Polytrim)
2
(Bleph-10)
2
Requirements/Limits
2
2
4
3
(Tobrex)
(TobraDex)
2
2
(Viroptic)
2
3
4
3
3
ST
2
2
2
3
2
(DermOtic Oil)
2
(FML Liquifilm)
2
(Ocufen)
2
QL (50 per 25 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
105
Drug Name
fluticasone nasal spray,suspension 50
mcg/actuation
ILEVRO OPHTHALMIC
DROPS,SUSPENSION 0.3 %
ketorolac ophthalmic drops 0.4 %
ketorolac ophthalmic drops 0.5 %
LOTEMAX OPHTHALMIC
DROPS,GEL 0.5 %
LOTEMAX OPHTHALMIC
DROPS,SUSPENSION 0.5 %
LOTEMAX OPHTHALMIC
OINTMENT 0.5 %
NEVANAC OPHTHALMIC
DROPS,SUSPENSION 0.1 %
prednisolone acetate ophthalmic
drops,suspension 1 %
prednisolone sodium phosphate
ophthalmic drops 1 %
PROLENSA OPHTHALMIC DROPS
0.07 %
RESTASIS MULTIDOSE
OPHTHALMIC DROPS 0.05 %
RESTASIS OPHTHALMIC
DROPPERETTE 0.05 %
triamcinolone acetonide nasal
aerosol,spray 55 mcg
XIIDRA OPHTHALMIC
DROPPERETTE 5 %
Drug Tier
(Children's Flonase
Allergy Rlf)
Requirements/Limits
1
3
(Acular LS)
(Acular)
2
2
3
3
3
3
(Pred Forte)
2
2
3
(Nasacort)
3
QL (5.5 per 30 days)
3
QL (60 per 30 days)
2
QL (16.5 per 30 days)
4
PA; QL (60 per 30
days)
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
amoxicil-clarithromy-lansopraz oral
combo pack 500-500-30 mg
CARAFATE ORAL SUSPENSION
100 MG/ML
cimetidine hcl oral solution 300 mg/5 ml
cimetidine oral tablet 200 mg
(Prevpac)
2
3
(Heartburn Relief
(cimetidine))
2
2
2
cimetidine oral tablet 300 mg, 400 mg,
800 mg
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
106
Drug Name
Drug Tier
DEXILANT ORAL
CAPSULE,BIPHASE DELAYED
RELEAS 30 MG, 60 MG
esomeprazole sodium intravenous recon
soln 20 mg
esomeprazole sodium intravenous recon
soln 40 mg
famotidine (pf) intravenous solution 20
mg/2 ml
famotidine (pf)-nacl (iso-os)
intravenous piggyback 20 mg/50 ml
famotidine 20 mg/2 ml vial latex-free, p/f,
sdv 20 mg/2 ml
famotidine 40 mg/4 ml vial 25's,outer 10
mg/ml
famotidine oral suspension 40 mg/5 ml (8
mg/ml)
famotidine oral tablet 20 mg, 40 mg
lansoprazole oral capsule,delayed
release(dr/ec) 15 mg
lansoprazole oral capsule,delayed
release(dr/ec) 30 mg
misoprostol oral tablet 100 mcg, 200 mcg
nizatidine oral capsule 150 mg, 300 mg
nizatidine oral solution 150 mg/10 ml
omeprazole oral capsule,delayed
release(dr/ec) 10 mg, 20 mg, 40 mg
pantoprazole intravenous recon soln 40
mg
pantoprazole oral tablet,delayed release
(dr/ec) 20 mg, 40 mg
ranitidine hcl injection solution 25 mg/ml,
50 mg/2 ml (25 mg/ml)
ranitidine hcl oral capsule 150 mg, 300
mg
ranitidine hcl oral syrup 15 mg/ml
ranitidine hcl oral tablet 150 mg
3
ranitidine hcl oral tablet 300 mg
sucralfate oral tablet 1 gram
Requirements/Limits
ST
2
(Nexium IV)
2
2
2
2
2
(Pepcid)
2
(Pepcid)
(Prevacid 24Hr)
1
2
(Prevacid)
2
(Cytotec)
2
2
2
1
(Protonix)
2
(Protonix)
1
(Zantac)
2
2
(Acid Control
(ranitidine))
(Zantac)
(Carafate)
2
1
1
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
107
Drug Name
Gastrointestinal Agents, Other
AMITIZA ORAL CAPSULE 24 MCG,
8 MCG
BUPHENYL ORAL TABLET 500 MG
CARBAGLU ORAL TABLET,
DISPERSIBLE 200 MG
constulose oral solution 10 gram/15 ml
cromolyn oral concentrate 100 mg/5 ml
dicyclomine oral capsule 10 mg
dicyclomine oral solution 10 mg/5 ml
dicyclomine oral tablet 20 mg
diphenoxylate-atropine oral liquid 2.50.025 mg/5 ml
diphenoxylate-atropine oral tablet 2.50.025 mg
enulose oral solution 10 gram/15 ml
GATTEX 5 MG 30-VIAL KIT 5 MG
GATTEX ONE-VIAL
SUBCUTANEOUS KIT 5 MG
generlac oral solution 10 gram/15 ml
glycopyrrolate injection solution 0.2
mg/ml
glycopyrrolate oral tablet 1 mg
glycopyrrolate oral tablet 2 mg
kionex 15 gm/60 ml suspension 15-19.3
gram/60 ml
kionex oral powder
lactulose oral solution 10 gram/15 ml
LINZESS ORAL CAPSULE 145
MCG, 290 MCG, 72 MCG
loperamide oral capsule 2 mg
Drug Tier
(Gastrocrom)
(Bentyl)
(Lomotil)
3
QL (60 per 30 days)
5
5
NDS
NDS
2
2
2
2
2
2
2
2
5
5
(Robinul)
(Robinul)
(Robinul Forte)
(Enulose)
(Anti-Diarrheal
(loperamide))
Requirements/Limits
PA; NDS
PA; NDS
2
2
2
2
2
2
2
3
QL (30 per 30 days)
2
2
2
methscopolamine oral tablet 2.5 mg, 5 mg
metoclopramide hcl injection solution 5
mg/ml
metoclopramide hcl oral solution 5 mg/5
ml
metoclopramide hcl oral tablet 10 mg, 5 (Reglan)
mg
2
1
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
108
Drug Name
Drug Tier
MOVANTIK ORAL TABLET 12.5
MG, 25 MG
NUTRESTORE ORAL POWDER IN
PACKET 5 GRAM
OCALIVA ORAL TABLET 10 MG, 5
MG
RAVICTI ORAL LIQUID 1.1
GRAM/ML
RELISTOR ORAL TABLET 150 MG
3
RELISTOR SUBCUTANEOUS
SOLUTION 12 MG/0.6 ML
RELISTOR SUBCUTANEOUS
SYRINGE 12 MG/0.6 ML, 8 MG/0.4
ML
sodium polystyrene (sorb free) oral
suspension 15 gram/60 ml
sodium polystyrene sulfonate rectal
enema 30 gram/120 ml
sps (with sorbitol) oral suspension 15-20
gram/60 ml
ursodiol oral capsule 300 mg
(Actigall)
ursodiol oral tablet 250 mg
(URSO 250)
ursodiol oral tablet 500 mg
(URSO Forte)
VELTASSA ORAL POWDER IN
PACKET 16.8 GRAM, 25.2 GRAM,
8.4 GRAM
VIBERZI ORAL TABLET 100 MG, 75
MG
XERMELO ORAL TABLET 250 MG
5
Requirements/Limits
QL (30 per 30 days)
4
5
5
5
Laxatives
gavilyte-c oral recon soln 240-22.72-6.72
-5.84 gram
gavilyte-g oral recon soln 236-22.74-6.74
-5.86 gram
gavilyte-n oral recon soln 420 gram
MOVIPREP ORAL POWDER IN
PACKET 100-7.5-2.691 GRAM
peg 3350-electrolytes oral recon soln 236- (GaviLyte-G)
22.74-6.74 -5.86 gram
5
PA; NDS; QL (30 per
30 days)
PA; NDS
PA; NDS; QL (90 per
30 days)
PA; NDS; QL (28 per
28 days)
PA; NDS; QL (28 per
28 days)
2
2
2
2
2
2
3
5
5
QL (30 per 30 days)
ST; NDS; QL (60 per
30 days)
PA; NDS; QL (90 per
30 days)
2
2
2
3
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
109
Drug Name
peg 3350-electrolytes oral recon soln 24022.72-6.72 -5.84 gram
peg-electrolyte soln oral recon soln 420
gram
polyethylene glycol 3350 oral powder 17
gram/dose
polyethylene glycol 3350 oral powder in
packet 17 gram
PREPOPIK ORAL POWDER IN
PACKET 10 MG-3.5 GRAM-12
GRAM
SUPREP BOWEL PREP KIT ORAL
RECON SOLN 17.5-3.13-1.6 GRAM
trilyte with flavor packets oral recon soln
420 gram
Phosphate Binders
AURYXIA ORAL TABLET 210 MG
IRON
calcium acetate oral capsule 667 mg
calcium acetate oral tablet 667 mg
eliphos oral tablet 667 mg
FOSRENOL ORAL POWDER IN
PACKET 1,000 MG, 750 MG
FOSRENOL ORAL
TABLET,CHEWABLE 1,000 MG, 500
MG, 750 MG
magnebind 400 oral tablet 400-200-1 mg
PHOSLYRA ORAL SOLUTION 667
MG (169 MG CALCIUM)/5 ML
RENAGEL ORAL TABLET 400 MG,
800 MG
RENVELA ORAL POWDER IN
PACKET 0.8 GRAM, 2.4 GRAM
RENVELA ORAL TABLET 800 MG
VELPHORO ORAL
TABLET,CHEWABLE 500 MG
Drug Tier
(Gavilyte-C)
2
(GaviLyte-N)
2
(Laxa Clear)
2
(Miralax)
2
Requirements/Limits
4
3
2
4
(Eliphos)
2
2
2
4
5
NDS
1
4
3
3
3
3
Genitourinary Agents
Antispasmodics, Urinary
bethanechol chloride oral tablet 10 mg,
25 mg, 5 mg, 50 mg
flavoxate oral tablet 100 mg
(Urecholine)
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
110
Drug Name
Drug Tier
MYRBETRIQ ORAL TABLET
EXTENDED RELEASE 24 HR 25
MG, 50 MG
oxybutynin chloride oral syrup 5 mg/5 ml
oxybutynin chloride oral tablet 5 mg
oxybutynin chloride oral tablet extended
release 24hr 10 mg, 15 mg, 5 mg
tolterodine oral capsule,extended release
24hr 2 mg, 4 mg
tolterodine oral tablet 1 mg, 2 mg
TOVIAZ ORAL TABLET
EXTENDED RELEASE 24 HR 4 MG,
8 MG
trospium oral capsule,extended release
24hr 60 mg
trospium oral tablet 20 mg
VESICARE ORAL TABLET 10 MG, 5
MG
Genitourinary Agents, Miscellaneous
alfuzosin oral tablet extended release 24
hr 10 mg
dutasteride oral capsule 0.5 mg
dutasteride-tamsulosin oral capsule, er
multiphase 24 hr 0.5-0.4 mg
finasteride oral tablet 5 mg
tamsulosin oral capsule,extended release
24hr 0.4 mg
terazosin oral capsule 1 mg, 10 mg, 2 mg,
5 mg
3
(Ditropan XL)
2
2
2
(Detrol LA)
2
(Detrol)
2
3
Requirements/Limits
2
2
3
(Uroxatral)
2
(Avodart)
(Jalyn)
2
2
(Proscar)
(Flomax)
1
2
QL (30 per 30 days)
1
Heavy Metal Antagonists
Heavy Metal Antagonists
CUPRIMINE ORAL CAPSULE 250
MG
deferoxamine injection recon soln 2 gram, (Desferal)
500 mg
DEPEN TITRATABS ORAL
TABLET 250 MG
EXJADE ORAL TABLET,
DISPERSIBLE 125 MG, 250 MG, 500
MG
5
NDS
2
PA BvD
5
NDS
5
NDS
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
111
Drug Name
Drug Tier
Requirements/Limits
FERRIPROX ORAL SOLUTION 100
MG/ML
FERRIPROX ORAL TABLET 500
MG
SYPRINE ORAL CAPSULE 250 MG
5
NDS
5
NDS
5
NDS
5
PA; NDS
3
PA; QL (30 per 30
days)
3
PA; QL (150 per 30
days)
3
PA; QL (150 per 30
days)
Hormonal Agents,
Stimulant/Replacement/Modifying
Androgens
ANADROL-50 ORAL TABLET 50
MG
ANDRODERM TRANSDERMAL
PATCH 24 HOUR 2 MG/24 HOUR, 4
MG/24 HR
ANDROGEL TRANSDERMAL GEL
IN METERED-DOSE PUMP 20.25
MG/1.25 GRAM (1.62 %)
ANDROGEL TRANSDERMAL GEL
IN PACKET 1.62 % (20.25 MG/1.25
GRAM), 1.62 % (40.5 MG/2.5 GRAM)
androxy oral tablet 10 mg
AXIRON TRANSDERMAL
SOLUTION IN METERED PUMP
W/APP 30 MG/ACTUATION (1.5
ML)
danazol oral capsule 100 mg, 200 mg, 50
mg
oxandrolone oral tablet 10 mg, 2.5 mg
testosterone cypionate intramuscular oil
100 mg/ml, 200 mg/ml
testosterone enanthate intramuscular oil
200 mg/ml
testosterone transdermal gel 50 mg/5
gram (1 %)
testosterone transdermal gel in metereddose pump 12.5 mg/ 1.25 gram (1 %)
testosterone transdermal gel in packet 1
% (25 mg/2.5gram)
testosterone transdermal gel in packet 1
% (50 mg/5 gram)
Estrogens And Antiestrogens
amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg
2
3
PA; QL (180 per 28
days)
2
(Oxandrin)
(Depo-Testosterone)
2
2
PA
2
PA; QL (5 per 28 days)
(Vogelxo)
2
(AndroGel)
2
(AndroGel)
2
(Vogelxo)
2
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
112
Drug Name
COMBIPATCH TRANSDERMAL
PATCH SEMIWEEKLY 0.05-0.14
MG/24 HR, 0.05-0.25 MG/24 HR
DUAVEE ORAL TABLET 0.45-20
MG
ESTRACE VAGINAL CREAM 0.01
% (0.1 MG/GRAM)
estradiol oral tablet 0.5 mg, 1 mg, 2 mg
estradiol transdermal patch semiweekly
0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05
mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr
estradiol transdermal patch weekly 0.025
mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24
hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1
mg/24 hr
estradiol valerate intramuscular oil 20
mg/ml, 40 mg/ml
estradiol-norethindrone acet oral tablet
0.5-0.1 mg
estradiol-norethindrone acet oral tablet 10.5 mg
ESTRING VAGINAL RING 2 MG
(7.5 MCG /24 HOUR)
estropipate oral tablet 0.75 mg, 1.5 mg, 3
mg
FEMRING VAGINAL RING 0.05
MG/24 HR, 0.1 MG/24 HR
fyavolv oral tablet 1-5 mg-mcg
Drug Tier
Requirements/Limits
3
PA-HRM; QL (8 per 28
days); AGE (Max 64
Years)
PA-HRM; AGE (Max
64 Years)
3
3
(Estrace)
2
(Minivelle)
2
(Climara)
2
(Delestrogen)
2
(Mimvey Lo)
2
(Activella)
2
4
2
4
2
jinteli oral tablet 1-5 mg-mcg
2
MENEST ORAL TABLET 0.3 MG,
0.625 MG, 1.25 MG, 2.5 MG
mimvey lo oral tablet 0.5-0.1 mg
4
mimvey oral tablet 1-0.5 mg
2
norethindrone ac-eth estradiol oral tablet (Fyavolv)
1-5 mg-mcg
2
2
PA-HRM; AGE (Max
64 Years)
PA-HRM; QL (8 per 28
days); AGE (Max 64
Years)
PA-HRM; QL (4 per 28
days); AGE (Max 64
Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
QL (1 per 84 days)
PA-HRM; AGE (Max
64 Years)
QL (1 per 84 days)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
113
Drug Name
Drug Tier
PREMARIN INJECTION RECON
SOLN 25 MG
PREMARIN ORAL TABLET 0.3 MG,
0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG
PREMARIN VAGINAL CREAM
0.625 MG/GRAM
PREMPHASE ORAL TABLET 0.625
MG (14)/ 0.625MG-5MG(14)
PREMPRO ORAL TABLET 0.3-1.5
MG, 0.45-1.5 MG, 0.625-2.5 MG,
0.625-5 MG
raloxifene oral tablet 60 mg
(Evista)
VAGIFEM VAGINAL TABLET 10
MCG
yuvafem vaginal tablet 10 mcg
Glucocorticoids/Mineralocorticoids
a-hydrocort injection recon soln 100 mg
betamethasone acet,sod phos injection
(Celestone Soluspan)
suspension 6 mg/ml
cortisone oral tablet 25 mg
dexamethasone oral elixir 0.5 mg/5 ml
dexamethasone oral tablet 0.5 mg, 0.75
mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg
dexamethasone sodium phosphate
injection solution 10 mg/ml, 4 mg/ml
EMFLAZA ORAL SUSPENSION
22.75 MG/ML
EMFLAZA ORAL TABLET 18 MG
EMFLAZA ORAL TABLET 30 MG, 6
MG
EMFLAZA ORAL TABLET 36 MG
fludrocortisone oral tablet 0.1 mg
hydrocortisone oral tablet 10 mg, 20 mg,
5 mg
methylprednisolone acetate injection
suspension 40 mg/ml, 80 mg/ml
methylprednisolone oral tablet 16 mg, 32
mg, 4 mg, 8 mg
methylprednisolone oral tablets,dose pack
4 mg
Requirements/Limits
3
3
PA-HRM; AGE (Max
64 Years)
3
3
3
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
2
3
QL (18 per 28 days)
2
QL (18 per 28 days)
2
2
2
2
1
PA BvD
PA BvD
PA BvD
2
5
PA; NDS
5
PA; NDS; QL (30 per
30 days)
PA; NDS; QL (60 per
30 days)
PA; NDS
5
(Cortef)
5
2
2
(Depo-Medrol)
2
(Medrol)
2
(Medrol (Pak))
2
PA BvD
PA BvD
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introduction pages of this document
114
Drug Name
Drug Tier
methylprednisolone sodium succ injection
recon soln 125 mg, 40 mg
methylprednisolone sodium succ
intravenous recon soln 1,000 mg
prednisolone sodium phosphate oral
solution 15 mg/5 ml (3 mg/ml), 25 mg/5
ml (5 mg/ml)
prednisolone sodium phosphate oral
solution 5 mg base/5 ml (6.7 mg/5 ml)
prednisone oral solution 5 mg/5 ml
prednisone oral tablet 1 mg, 2.5 mg, 5
mg, 50 mg
prednisone oral tablet 10 mg
prednisone oral tablet 20 mg
prednisone oral tablets,dose pack 10 mg,
10 mg (48 pack), 5 mg, 5 mg (48 pack)
SOLU-CORTEF (PF) INJECTION
RECON SOLN 1,000 MG/8 ML, 100
MG/2 ML, 250 MG/2 ML, 500 MG/4
ML
Pituitary
desmopressin injection solution 4 mcg/ml
desmopressin nasal solution 0.1 mg/ml
(refrigerate)
desmopressin nasal spray,non-aerosol 10
mcg/spray (0.1 ml)
desmopressin oral tablet 0.1 mg, 0.2 mg
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE 0.2
MG/0.25 ML
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE 0.4
MG/0.25 ML, 0.6 MG/0.25 ML, 0.8
MG/0.25 ML, 1 MG/0.25 ML, 1.2
MG/0.25 ML, 1.4 MG/0.25 ML, 1.6
MG/0.25 ML, 1.8 MG/0.25 ML, 2
MG/0.25 ML
GENOTROPIN SUBCUTANEOUS
CARTRIDGE 12 MG/ML (36
UNIT/ML), 5 MG/ML (15 UNIT/ML)
2
(Solu-Medrol)
(Pediapred)
(Deltasone)
Requirements/Limits
2
2
PA BvD
2
PA BvD
2
1
PA BvD
PA BvD
1
1
2
PA BvD
PA BvD
4
(DDAVP)
(DDAVP)
(DDAVP)
2
2
QL (15 per 30 days)
2
QL (15 per 30 days)
2
4
PA
5
PA; NDS
5
PA; NDS
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introduction pages of this document
115
Drug Name
Drug Tier
HUMATROPE INJECTION
CARTRIDGE 12 MG (36 UNIT), 24
MG (72 UNIT), 6 MG (18 UNIT)
HUMATROPE INJECTION RECON
SOLN 5 (15 UNIT) MG
INCRELEX SUBCUTANEOUS
SOLUTION 10 MG/ML
LUPRON DEPOT-PED (3 MONTH)
INTRAMUSCULAR SYRINGE KIT
30 MG
LUPRON DEPOT-PED
INTRAMUSCULAR KIT 11.25 MG,
15 MG, 7.5 MG (PED)
NORDITROPIN FLEXPRO
SUBCUTANEOUS PEN INJECTOR
10 MG/1.5 ML (6.7 MG/ML), 15
MG/1.5 ML (10 MG/ML), 30 MG/3
ML (10 MG/ML)
NORDITROPIN FLEXPRO
SUBCUTANEOUS PEN INJECTOR 5
MG/1.5 ML (3.3 MG/ML)
NUTROPIN AQ NUSPIN
SUBCUTANEOUS PEN INJECTOR
10 MG/2 ML (5 MG/ML), 20 MG/2
ML (10 MG/ML), 5 MG/2 ML (2.5
MG/ML)
NUTROPIN AQ SUBCUTANEOUS
CARTRIDGE 10 MG/2 ML (5
MG/ML), 20 MG/2 ML (10 MG/ML)
octreotide acet 50 mcg/ml syr
outer,single-dose,10 50 mcg/ml (1 ml)
octreotide acetate injection solution 1,000 (Sandostatin)
mcg/ml, 500 mcg/ml
octreotide acetate injection solution 100 (Sandostatin)
mcg/ml, 200 mcg/ml
octreotide acetate injection solution 50
(Sandostatin)
mcg/ml
OMNITROPE SUBCUTANEOUS
CARTRIDGE 10 MG/1.5 ML (6.7
MG/ML), 5 MG/1.5 ML (3.3 MG/ML)
OMNITROPE SUBCUTANEOUS
RECON SOLN 5.8 MG
Requirements/Limits
5
PA; NDS
5
PA; NDS
5
NDS
5
NDS; QL (1 per 84
days)
5
NDS
5
PA; NDS
4
PA
5
PA; NDS
5
PA; NDS
2
5
NDS
2
2
5
PA; NDS
5
PA; NDS
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introduction pages of this document
116
Drug Name
Drug Tier
SAIZEN CLICK.EASY
SUBCUTANEOUS CARTRIDGE 8.8
MG/1.5 ML (FNL)
SAIZEN SUBCUTANEOUS RECON
SOLN 5 MG, 8.8 MG
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON 10 MG, 20 MG, 30 MG
SEROSTIM SUBCUTANEOUS
RECON SOLN 4 MG, 5 MG, 6 MG
SOMATULINE DEPOT
SUBCUTANEOUS SYRINGE 120
MG/0.5 ML, 60 MG/0.2 ML, 90
MG/0.3 ML
SOMAVERT SUBCUTANEOUS
RECON SOLN 10 MG, 15 MG, 20
MG, 25 MG, 30 MG
STIMATE NASAL SPRAY,NONAEROSOL 150 MCG/SPRAY (0.1
ML)
SUPPRELIN LA IMPLANT KIT 50
MG (65 MCG/DAY)
ZOMACTON SUBCUTANEOUS
RECON SOLN 10 MG
ZOMACTON SUBCUTANEOUS
RECON SOLN 5 MG
ZORBTIVE SUBCUTANEOUS
RECON SOLN 8.8 MG
Progestins
DEPO-PROVERA
INTRAMUSCULAR SOLUTION 400
MG/ML
hydroxyprogesterone caproate
intramuscular oil 250 mg/ml
medroxyprogesterone intramuscular
(Depo-Provera)
suspension 150 mg/ml
medroxyprogesterone intramuscular
(Depo-Provera)
syringe 150 mg/ml
medroxyprogesterone oral tablet 10 mg, (Provera)
2.5 mg, 5 mg
Requirements/Limits
5
PA; NDS
5
PA; NDS
5
NDS
5
PA; NDS
5
NDS; QL (1 per 28
days)
5
NDS
4
5
5
NDS; QL (1 per 360
days)
PA; NDS
4
PA
5
PA; NDS
4
QL (10 per 28 days)
2
PA NSO
2
QL (1 per 84 days)
2
QL (1 per 84 days)
1
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introduction pages of this document
117
Drug Name
megestrol oral suspension 400 mg/10 ml
(40 mg/ml)
megestrol oral suspension 625 mg/5 ml
norethindrone acetate oral tablet 5 mg
progesterone in oil intramuscular oil 50
mg/ml
progesterone micronized oral capsule 100
mg, 200 mg
Thyroid And Antithyroid Agents
levothyroxine intravenous recon soln 100
mcg, 200 mcg, 500 mcg
levothyroxine oral tablet 100 mcg, 125
mcg, 137 mcg, 150 mcg, 175 mcg, 200
mcg, 25 mcg, 75 mcg, 88 mcg
levothyroxine oral tablet 112 mcg, 300
mcg, 50 mcg
liothyronine intravenous solution 10
mcg/ml
liothyronine oral tablet 25 mcg, 5 mcg, 50
mcg
methimazole oral tablet 10 mg, 5 mg
propylthiouracil oral tablet 50 mg
Drug Tier
(Megace)
2
(Megace ES)
(Aygestin)
2
2
2
(Prometrium)
2
5
(Levoxyl)
1
(Unithroid)
1
(Triostat)
2
(Cytomel)
2
(Tapazole)
2
2
Requirements/Limits
NDS
Immunological Agents
Immunological Agents
ACTEMRA INTRAVENOUS
SOLUTION 200 MG/10 ML (20
MG/ML), 400 MG/20 ML (20
MG/ML), 80 MG/4 ML (20 MG/ML)
ACTEMRA SUBCUTANEOUS
SYRINGE 162 MG/0.9 ML
ARCALYST SUBCUTANEOUS
RECON SOLN 220 MG
ASTAGRAF XL ORAL
CAPSULE,EXTENDED RELEASE
24HR 0.5 MG, 1 MG, 5 MG
azathioprine oral tablet 50 mg
azathioprine sodium injection recon soln
100 mg
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN 6
GRAM
(Imuran)
5
PA; NDS
5
PA; NDS
5
NDS
4
PA BvD
2
2
PA BvD
PA BvD
5
PA BvD; NDS
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118
Drug Name
Drug Tier
Requirements/Limits
CELLCEPT INTRAVENOUS
INTRAVENOUS RECON SOLN 500
MG
CIMZIA POWDER FOR RECONST
SUBCUTANEOUS KIT 400 MG (200
MG X 2 VIALS)
CIMZIA SUBCUTANEOUS
SYRINGE KIT 400 MG/2 ML (200
MG/ML X 2)
cyclosporine intravenous solution 250
mg/5 ml
cyclosporine modified oral capsule 100
mg, 25 mg
cyclosporine modified oral capsule 50 mg
cyclosporine modified oral solution 100
mg/ml
cyclosporine oral capsule 100 mg, 25 mg
ENBREL SUBCUTANEOUS RECON
SOLN 25 MG (1 ML)
ENBREL SUBCUTANEOUS
SYRINGE 25 MG/0.5ML (0.51), 50
MG/ML (0.98 ML)
ENBREL SURECLICK
SUBCUTANEOUS PEN INJECTOR
50 MG/ML (0.98 ML)
ENVARSUS XR ORAL TABLET
EXTENDED RELEASE 24 HR 0.75
MG, 1 MG, 4 MG
FLEBOGAMMA DIF
INTRAVENOUS SOLUTION 10 %, 5
%
GAMASTAN S/D
INTRAMUSCULAR SOLUTION 1518 % RANGE, 15-18 % RANGE (10
ML), 15-18 % RANGE (2 ML)
GAMMAGARD LIQUID
INJECTION SOLUTION 10 %
GAMMAGARD S-D (IGA < 1
MCG/ML) INTRAVENOUS RECON
SOLN 10 GRAM, 5 GRAM
4
PA BvD
5
PA; NDS
5
PA; NDS
(Sandimmune)
2
PA BvD
(Neoral)
2
PA BvD
(Gengraf)
(Neoral)
2
2
PA BvD
PA BvD
(Sandimmune)
2
5
PA BvD
PA; NDS
5
PA; NDS
5
PA; NDS
4
PA BvD
5
PA BvD; NDS
3
PA BvD
5
PA BvD; NDS
5
PA BvD; NDS
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119
Drug Name
Drug Tier
Requirements/Limits
GAMMAPLEX (WITH SORBITOL)
INTRAVENOUS SOLUTION 5 %
GAMMAPLEX INTRAVENOUS
SOLUTION 10 %
GAMUNEX-C 20 GRAM/200 ML
VIAL P/F,LTX-FR,SUV,OUTER 20
GRAM/200 ML (10 %)
GAMUNEX-C INJECTION
SOLUTION 1 GRAM/10 ML (10 %)
gengraf oral capsule 100 mg, 25 mg, 50
mg
gengraf oral solution 100 mg/ml
HUMIRA PEDIATRIC CROHN'S
START SUBCUTANEOUS
SYRINGE KIT 40 MG/0.8 ML, 40
MG/0.8 ML (6 PACK)
HUMIRA PEN CROHN'S-UC-HS
START SUBCUTANEOUS PEN
INJECTOR KIT 40 MG/0.8 ML
HUMIRA PEN PSORIASIS-UVEITIS
SUBCUTANEOUS PEN INJECTOR
KIT 40 MG/0.8 ML
HUMIRA PEN SUBCUTANEOUS
PEN INJECTOR KIT 40 MG/0.8 ML
HUMIRA SUBCUTANEOUS
SYRINGE KIT 10 MG/0.2 ML, 20
MG/0.4 ML, 40 MG/0.8 ML
HYPERRAB S/D (PF)
INTRAMUSCULAR SOLUTION 150
UNIT/ML, 150 UNIT/ML (10 ML)
HYQVIA IG COMPONENT
SUBCUTANEOUS SOLUTION 10
GRAM/100 ML (10 %), 2.5 GRAM/25
ML (10 %), 20 GRAM/200 ML (10 %),
30 GRAM/300 ML (10 %), 5 GRAM/50
ML (10 %)
HYQVIA SUBCUTANEOUS
SOLUTION 10 GRAM /100 ML (10
%), 2.5 GRAM /25 ML (10 %), 20
GRAM /200 ML (10 %), 30 GRAM
/300 ML (10 %), 5 GRAM /50 ML (10
%)
5
PA BvD; NDS
5
PA BvD; NDS
5
PA BvD; NDS
5
PA BvD; NDS
2
PA BvD
2
5
PA BvD
PA; NDS
5
PA; NDS
5
PA; NDS
5
PA; NDS
5
PA; NDS
4
5
PA BvD; NDS
5
PA BvD; NDS
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120
Drug Name
Drug Tier
Requirements/Limits
ILARIS (PF) SUBCUTANEOUS
RECON SOLN 180 MG/1.2 ML (150
MG/ML)
ILARIS (PF) SUBCUTANEOUS
SOLUTION 150 MG/ML
IMOGAM RABIES-HT (PF)
INTRAMUSCULAR SOLUTION 150
UNIT/ML
KINERET SUBCUTANEOUS
SYRINGE 100 MG/0.67 ML
leflunomide oral tablet 10 mg, 20 mg
mycophenolate mofetil hcl intravenous
recon soln 500 mg
mycophenolate mofetil oral capsule 250
mg
mycophenolate mofetil oral suspension
for reconstitution 200 mg/ml
mycophenolate mofetil oral tablet 500 mg
mycophenolate sodium oral
tablet,delayed release (dr/ec) 180 mg,
360 mg
NULOJIX INTRAVENOUS RECON
SOLN 250 MG
OCTAGAM INTRAVENOUS
SOLUTION 10 %, 5 %
ORENCIA (WITH MALTOSE)
INTRAVENOUS RECON SOLN 250
MG
ORENCIA SUBCUTANEOUS
SYRINGE 125 MG/ML
OTEZLA ORAL TABLET 30 MG
5
PA; NDS
5
PA; NDS
4
5
PA; NDS; QL (18.76
per 28 days)
(Arava)
(CellCept Intravenous)
2
2
PA BvD
(CellCept)
2
PA BvD
(CellCept)
5
PA BvD; NDS
(CellCept)
(Myfortic)
2
2
PA BvD
PA BvD
5
PA BvD; NDS
5
PA BvD; NDS
5
PA; NDS
5
PA; NDS
5
PA; NDS; QL (60 per
30 days)
PA; NDS; QL (60 per
30 days)
OTEZLA STARTER ORAL
TABLETS,DOSE PACK 10 MG (4)-20
MG (4)-30 MG (47), 10 MG (4)-20 MG
(4)-30 MG(19)
5
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introduction pages of this document
121
Drug Name
Drug Tier
OTREXUP (PF) SUBCUTANEOUS
AUTO-INJECTOR 10 MG/0.4 ML,
12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5
MG/0.4 ML, 20 MG/0.4 ML, 22.5
MG/0.4 ML, 25 MG/0.4 ML, 7.5
MG/0.4 ML
PRIVIGEN INTRAVENOUS
SOLUTION 10 %
PROGRAF INTRAVENOUS
SOLUTION 5 MG/ML
RAPAMUNE ORAL SOLUTION 1
MG/ML
RASUVO (PF) SUBCUTANEOUS
AUTO-INJECTOR 10 MG/0.2 ML,
12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5
MG/0.35 ML, 20 MG/0.4 ML, 22.5
MG/0.45 ML, 25 MG/0.5 ML, 27.5
MG/0.55 ML, 30 MG/0.6 ML, 7.5
MG/0.15 ML
RIDAURA ORAL CAPSULE 3 MG
SIMPONI ARIA INTRAVENOUS
SOLUTION 12.5 MG/ML
SIMPONI SUBCUTANEOUS PEN
INJECTOR 100 MG/ML, 50 MG/0.5
ML
SIMPONI SUBCUTANEOUS
SYRINGE 100 MG/ML, 50 MG/0.5
ML
sirolimus oral tablet 0.5 mg, 1 mg
(Rapamune)
sirolimus oral tablet 2 mg
(Rapamune)
STELARA INTRAVENOUS
SOLUTION 130 MG/26 ML
STELARA SUBCUTANEOUS
SYRINGE 45 MG/0.5 ML, 90 MG/ML
tacrolimus oral capsule 0.5 mg, 1 mg, 5
(Prograf)
mg
TYSABRI INTRAVENOUS
SOLUTION 300 MG/15 ML
XELJANZ ORAL TABLET 5 MG
Requirements/Limits
3
5
PA BvD; NDS
4
PA BvD
5
PA BvD; NDS
3
5
5
NDS
PA; NDS
5
PA; NDS
5
PA; NDS
2
5
5
PA BvD
PA BvD; NDS
PA; NDS
5
PA; NDS
2
PA BvD
5
PA; LA; NDS; QL (15
per 28 days)
PA; NDS; QL (60 per
30 days)
5
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introduction pages of this document
122
Drug Name
Drug Tier
Requirements/Limits
XELJANZ XR ORAL TABLET
EXTENDED RELEASE 24 HR 11
MG
ZORTRESS ORAL TABLET 0.25
MG, 0.5 MG, 0.75 MG
Vaccines
ACTHIB (PF) INTRAMUSCULAR
RECON SOLN 10 MCG/0.5 ML
ADACEL(TDAP
ADOLESN/ADULT)(PF)
INTRAMUSCULAR SUSPENSION 2
LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
ADACEL(TDAP
ADOLESN/ADULT)(PF)
INTRAMUSCULAR SYRINGE 2 LF(2.5-5-3-5 MCG)-5LF/0.5 ML
BCG VACCINE, LIVE (PF)
PERCUTANEOUS SUSPENSION
FOR RECONSTITUTION 50 MG
BEXSERO INTRAMUSCULAR
SYRINGE 50-50-50-25 MCG/0.5 ML
BOOSTRIX TDAP
INTRAMUSCULAR SUSPENSION
2.5-8-5 LF-MCG-LF/0.5ML
BOOSTRIX TDAP
INTRAMUSCULAR SYRINGE 2.58-5 LF-MCG-LF/0.5ML
CERVARIX VACCINE (PF)
INTRAMUSCULAR SYRINGE 20-20
MCG/0.5 ML
COMVAX (PF) INTRAMUSCULAR
SUSPENSION 5-7.5-125 MCG/0.5 ML
DAPTACEL (DTAP PEDIATRIC)
(PF) INTRAMUSCULAR
SUSPENSION 15-10-5 LF-MCGLF/0.5ML
ENGERIX-B (PF)
INTRAMUSCULAR SUSPENSION
20 MCG/ML
ENGERIX-B (PF)
INTRAMUSCULAR SYRINGE 20
MCG/ML
5
PA; NDS; QL (30 per
30 days)
5
PA BvD; NDS
6
6
6
3
PA BvD
6
6
6
6
6
6
6
PA BvD
6
PA BvD
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123
Drug Name
Drug Tier
Requirements/Limits
ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SUSPENSION
10 MCG/0.5 ML
ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SYRINGE 10
MCG/0.5 ML
GARDASIL (PF)
INTRAMUSCULAR SUSPENSION
20-40-40-20 MCG/0.5 ML
GARDASIL (PF)
INTRAMUSCULAR SYRINGE 2040-40-20 MCG/0.5 ML
GARDASIL 9 (PF)
INTRAMUSCULAR SUSPENSION
0.5 ML
GARDASIL 9 (PF)
INTRAMUSCULAR SYRINGE 0.5
ML
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA
UNIT/ML, 720 ELISA UNIT/0.5 ML
HAVRIX (PF) INTRAMUSCULAR
SYRINGE 1,440 ELISA UNIT/ML,
720 ELISA UNIT/0.5 ML
HIBERIX (PF) INTRAMUSCULAR
RECON SOLN 10 MCG/0.5 ML
IMOVAX RABIES VACCINE (PF)
INTRAMUSCULAR RECON SOLN
2.5 UNIT
INFANRIX (DTAP) (PF)
INTRAMUSCULAR SUSPENSION
25-58-10 LF-MCG-LF/0.5ML
IPOL INJECTION SUSPENSION 408-32 UNIT/0.5 ML
IPOL INJECTION SYRINGE 40-8-32
UNIT/0.5 ML
IXIARO (PF) INTRAMUSCULAR
SYRINGE 6 MCG/0.5 ML
KINRIX (PF) INTRAMUSCULAR
SUSPENSION 25 LF-58 MCG-10
LF/0.5 ML
6
PA BvD
6
PA BvD
6
QL (1.5 per 365 days)
6
QL (1.5 per 365 days)
6
QL (1.5 per 365 days)
6
QL (1.5 per 365 days)
6
6
6
3
PA BvD
6
6
6
6
6
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introduction pages of this document
124
Drug Name
Drug Tier
KINRIX (PF) INTRAMUSCULAR
SYRINGE 25 LF-58 MCG-10 LF/0.5
ML
MENACTRA (PF)
INTRAMUSCULAR SOLUTION 4
MCG/0.5 ML
MENHIBRIX (PF)
INTRAMUSCULAR RECON SOLN
5-2.5 MCG/0.5 ML
MENOMUNE - A/C/Y/W-135 (PF)
SUBCUTANEOUS RECON SOLN 50
MCG
MENOMUNE - A/C/Y/W-135
SUBCUTANEOUS RECON SOLN 50
MCG
MENVEO A-C-Y-W-135-DIP (PF)
INTRAMUSCULAR KIT 10-5
MCG/0.5 ML
M-M-R II (PF) SUBCUTANEOUS
RECON SOLN 1,000-12,500
TCID50/0.5 ML
PEDIARIX (PF) INTRAMUSCULAR
SYRINGE 10 MCG-25LF-25 MCG10LF/0.5 ML
PEDVAX HIB (PF)
INTRAMUSCULAR SOLUTION 7.5
MCG/0.5 ML
PENTACEL (PF)
INTRAMUSCULAR KIT 15 LF
UNIT-20 MCG-5 LF/0.5 ML
PROQUAD (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 10EXP3-4.3-33.99 TCID50/0.5
QUADRACEL (PF)
INTRAMUSCULAR SUSPENSION
15 LF-48 MCG- 5 LF UNIT/0.5ML
RABAVERT (PF)
INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 2.5 UNIT
6
Requirements/Limits
6
6
6
6
6
6
QL (2 per 365 days)
6
6
6
6
QL (2 per 365 days)
6
3
PA BvD
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introduction pages of this document
125
Drug Name
Drug Tier
Requirements/Limits
RECOMBIVAX HB (PF)
INTRAMUSCULAR SUSPENSION
10 MCG/ML, 40 MCG/ML
RECOMBIVAX HB (PF)
INTRAMUSCULAR SYRINGE 10
MCG/ML, 5 MCG/0.5 ML
RECOMBIVAX HB 5 MCG/0.5 ML
VL OUTER, P/F, SDV 5 MCG/0.5 ML
ROTARIX ORAL SUSPENSION
FOR RECONSTITUTION 10EXP6
CCID50/ML
ROTATEQ VACCINE ORAL
SOLUTION 2 ML
TENIVAC (PF) INTRAMUSCULAR
SYRINGE 5-2 LF UNIT/0.5 ML
TETANUS,DIPHTHERIA TOX
PED(PF) INTRAMUSCULAR
SUSPENSION 5-25 LF UNIT/0.5 ML
TETANUS-DIPHTHERIA
TOXOIDS-TD INTRAMUSCULAR
SUSPENSION 2-2 LF UNIT/0.5 ML
TICE BCG INTRAVESICAL
SUSPENSION FOR
RECONSTITUTION 50 MG
TRUMENBA INTRAMUSCULAR
SYRINGE 120 MCG/0.5 ML
TWINRIX (PF) INTRAMUSCULAR
SUSPENSION 720 ELISA UNIT -20
MCG/ML
TWINRIX (PF) INTRAMUSCULAR
SYRINGE 720 ELISA UNIT -20
MCG/ML
TYPHIM VI INTRAMUSCULAR
SOLUTION 25 MCG/0.5 ML
TYPHIM VI INTRAMUSCULAR
SYRINGE 25 MCG/0.5 ML
VAQTA (PF) INTRAMUSCULAR
SUSPENSION 50 UNIT/ML
VAQTA (PF) INTRAMUSCULAR
SYRINGE 25 UNIT/0.5 ML, 50
UNIT/ML
6
PA BvD
6
PA BvD
6
PA BvD
3
3
6
6
6
3
PA BvD
6
6
6
6
6
6
6
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introduction pages of this document
126
Drug Name
Drug Tier
VAQTA 25 UNITS/0.5 ML VIAL
SDV, OUTER 25 UNIT/0.5 ML
VARIVAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 1,350 UNIT/0.5
ML
YF-VAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 10 EXP4.74
UNIT/0.5 ML
ZOSTAVAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 19,400
UNIT/0.65 ML
6
6
Requirements/Limits
QL (2 per 365 days)
6
6
QL (1 per 365 days)
5
3
NDS
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
alosetron oral tablet 0.5 mg, 1 mg
APRISO ORAL
CAPSULE,EXTENDED RELEASE
24HR 0.375 GRAM
ASACOL HD ORAL
TABLET,DELAYED RELEASE
(DR/EC) 800 MG
balsalazide oral capsule 750 mg
budesonide oral
capsule,delayed,extend.release 3 mg
colocort rectal enema 100 mg/60 ml
DELZICOL ORAL CAPSULE (WITH
DEL REL TABLETS) 400 MG
DIPENTUM ORAL CAPSULE 250
MG
hydrocortisone rectal enema 100 mg/60
ml
LIALDA ORAL TABLET,DELAYED
RELEASE (DR/EC) 1.2 GRAM
mesalamine oral tablet,delayed release
(dr/ec) 800 mg
UCERIS RECTAL FOAM 2
MG/ACTUATION
(Lotronex)
3
(Colazal)
(Entocort EC)
2
5
NDS
2
3
5
(Colocort)
ST; NDS
2
3
(Asacol HD)
2
3
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introduction pages of this document
127
Drug Name
Drug Tier
Requirements/Limits
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation solution 0.25 %
LACTATED RINGERS
IRRIGATION SOLUTION
ringer's irrigation solution
sodium chloride irrigation solution 0.9 %
sorbitol irrigation solution 3 %, 3.3 %
sorbitol-mannitol urethral solution 2.70.54 g/100 ml
water for irrigation, sterile irrigation
solution
2
3
(Sterile Saline)
2
2
2
2
(Curity Sterile Water)
2
(Fosamax)
(Miacalcin)
2
1
1
2
1
2
(Rocaltrol)
(Rocaltrol)
(Hectorol)
2
2
2
2
(Hectorol)
2
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate oral solution 70 mg/75 ml
alendronate oral tablet 10 mg, 5 mg
alendronate oral tablet 35 mg
alendronate oral tablet 40 mg
alendronate oral tablet 70 mg
calcitonin (salmon) nasal spray,nonaerosol 200 unit/actuation
calcitriol intravenous solution 1 mcg/ml
calcitriol oral capsule 0.25 mcg, 0.5 mcg
calcitriol oral solution 1 mcg/ml
doxercalciferol intravenous solution 4
mcg/2 ml
doxercalciferol oral capsule 0.5 mcg, 1
mcg, 2.5 mcg
etidronate disodium oral tablet 200 mg,
400 mg
FORTEO SUBCUTANEOUS PEN
INJECTOR 20 MCG/DOSE - 600
MCG/2.4 ML
FORTICAL NASAL SPRAY,NONAEROSOL 200 UNIT/ACTUATION
ibandronate intravenous solution 3 mg/3
ml
ibandronate intravenous syringe 3 mg/3
ml
ibandronate oral tablet 150 mg
QL (300 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (3.7 per 28 days)
2
4
QL (2.4 per 28 days)
4
QL (3.7 per 28 days)
2
QL (3 per 84 days)
(Boniva)
2
QL (3 per 84 days)
(Boniva)
2
QL (1 per 28 days)
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introduction pages of this document
128
Drug Name
Drug Tier
MIACALCIN INJECTION
SOLUTION 200 UNIT/ML
NATPARA SUBCUTANEOUS
CARTRIDGE 100 MCG/DOSE, 25
MCG/DOSE, 50 MCG/DOSE, 75
MCG/DOSE
pamidronate intravenous recon soln 30
mg, 90 mg
pamidronate intravenous solution 30
mg/10 ml (3 mg/ml), 60 mg/10 ml (6
mg/ml), 90 mg/10 ml (9 mg/ml)
paricalcitol hemodialysis port injection
solution 2 mcg/ml
PARICALCITOL HEMODIALYSIS
PORT INJECTION SOLUTION 5
MCG/ML
paricalcitol intravenous solution 2 mcg/ml
paricalcitol oral capsule 1 mcg, 2 mcg
paricalcitol oral capsule 4 mcg
PROLIA SUBCUTANEOUS
SYRINGE 60 MG/ML
RAYALDEE ORAL
CAPSULE,EXTENDED RELEASE 24
HR 30 MCG
risedronate oral tablet 150 mg
risedronate oral tablet 30 mg, 5 mg
risedronate oral tablet 35 mg
risedronate oral tablet 35 mg (12 pack),
35 mg (4 pack)
XGEVA SUBCUTANEOUS
SOLUTION 120 MG/1.7 ML (70
MG/ML)
ZEMPLAR INTRAVENOUS
SOLUTION 2 MCG/ML, 5 MCG/ML
zoledronic acid intravenous solution 4
mg/5 ml
zoledronic acid-mannitol-water
intravenous piggyback 5 mg/100 ml
zoledronic ac-mannitol-0.9nacl
intravenous piggyback 4 mg/100 ml
3
5
Requirements/Limits
PA; NDS; QL (2 per 28
days)
2
2
2
2
(Zemplar)
(Zemplar)
(Actonel)
(Actonel)
(Actonel)
2
2
2
3
QL (1 per 180 days)
5
NDS; QL (60 per 30
days)
2
2
2
2
QL (1 per 28 days)
QL (30 per 30 days)
QL (4 per 28 days)
QL (4 per 28 days)
5
PA; NDS
3
(Zometa)
2
(Reclast)
2
QL (100 per 300 days)
2
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129
Drug Name
Drug Tier
ZOMETA INTRAVENOUS
PIGGYBACK 4 MG/100 ML
Requirements/Limits
5
NDS
5
NDS
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTIMMUNE SUBCUTANEOUS
SOLUTION 100 MCG/0.5 ML
amifostine crystalline intravenous recon
(Ethyol)
soln 500 mg
BENLYSTA INTRAVENOUS
RECON SOLN 120 MG, 400 MG
BOTOX INJECTION RECON SOLN
100 UNIT
BOTOX INJECTION RECON SOLN
200 UNIT
buspirone oral tablet 10 mg, 15 mg, 30
mg, 5 mg, 7.5 mg
CERDELGA ORAL CAPSULE 84
MG
CETYLEV ORAL TABLET,
EFFERVESCENT 2.5 GRAM, 500
MG
CYSTADANE ORAL POWDER 1
GRAM/1.7 ML
dexrazoxane hcl intravenous recon soln
(Zinecard (as HCl))
250 mg, 500 mg
droperidol injection solution 2.5 mg/ml
ELMIRON ORAL CAPSULE 100 MG
ergoloid oral tablet 1 mg
EXONDYS 51 INTRAVENOUS
SOLUTION 50 MG/ML, 50 MG/ML
(10 ML)
fomepizole intravenous solution 1
gram/ml
FUSILEV INTRAVENOUS RECON
SOLN 50 MG
GLUCAGEN HYPOKIT INJECTION
RECON SOLN 1 MG
GLUCAGON EMERGENCY KIT
(HUMAN) INJECTION KIT 1 MG
guanidine oral tablet 125 mg
2
5
PA; NDS
4
PA; QL (4 per 90 days)
4
PA; QL (1 per 90 days)
2
5
PA; NDS
4
5
NDS
2
2
4
2
5
PA; LA; NDS
5
NDS
5
NDS
3
4
2
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130
Drug Name
Drug Tier
hydroxyzine pamoate oral capsule 100
mg
hydroxyzine pamoate oral capsule 25 mg, (Vistaril)
50 mg
INFLECTRA INTRAVENOUS
RECON SOLN 100 MG
KEVEYIS ORAL TABLET 50 MG
2
leucovorin calcium 200 mg vial sdv, p/f,
latex-free 200 mg
leucovorin calcium injection recon soln
100 mg, 350 mg, 50 mg
leucovorin calcium oral tablet 10 mg, 15
mg, 25 mg, 5 mg
levocarnitine (with sugar) oral solution
100 mg/ml
levocarnitine intravenous solution 200
mg/ml
levocarnitine oral tablet 330 mg
LEVOLEUCOVORIN
INTRAVENOUS RECON SOLN 175
MG
levoleucovorin intravenous recon soln 50
mg
mesna intravenous solution 100 mg/ml
MESNEX ORAL TABLET 400 MG
MESTINON ORAL SYRUP 60 MG/5
ML
methylergonovine injection solution 0.2
mg/ml (1 ml)
methylergonovine oral tablet 0.2 mg
MYOBLOC INTRAMUSCULAR
SOLUTION 10,000 UNIT/2 ML
MYOBLOC INTRAMUSCULAR
SOLUTION 2,500 UNIT/0.5 ML
MYOBLOC INTRAMUSCULAR
SOLUTION 5,000 UNIT/ML
NPLATE SUBCUTANEOUS RECON
SOLN 250 MCG, 500 MCG
2
Requirements/Limits
2
5
PA; NDS
5
PA; NDS; QL (120 per
30 days)
2
2
(Carnitor)
2
(Carnitor)
2
(Carnitor)
2
4
(Fusilev)
5
NDS
(Mesnex)
2
5
5
NDS
NDS
2
(Methergine)
2
4
4
4
5
PA; QL (2 per 90 days)
PA; QL (0.5 per 90
days)
PA; QL (1 per 90 days)
PA; NDS; QL (8 per 28
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
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131
Drug Name
Drug Tier
ORENCIA CLICKJECT
SUBCUTANEOUS AUTOINJECTOR 125 MG/ML
PROCYSBI ORAL CAPSULE,
DELAYED REL SPRINKLE 25 MG,
75 MG
pyridostigmine bromide oral tablet 60 mg (Mestinon)
pyridostigmine bromide oral tablet
(Mestinon Timespan)
extended release 180 mg
REMICADE INTRAVENOUS
RECON SOLN 100 MG
SENSIPAR ORAL TABLET 30 MG
SENSIPAR ORAL TABLET 60 MG,
90 MG
SIGNIFOR SUBCUTANEOUS
SOLUTION 0.3 MG/ML (1 ML), 0.6
MG/ML (1 ML), 0.9 MG/ML (1 ML)
SYNAREL NASAL SPRAY,NONAEROSOL 2 MG/ML
THALOMID ORAL CAPSULE 100
MG, 150 MG, 200 MG, 50 MG
THIOLA ORAL TABLET 100 MG
TYBOST ORAL TABLET 150 MG
Requirements/Limits
5
PA; NDS
5
NDS
2
2
5
PA; NDS
3
5
NDS
5
NDS; QL (60 per 30
days)
5
NDS
5
PA NSO; NDS; QL (60
per 30 days)
NDS
QL (30 per 30 days)
5
3
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule, extended
(Diamox Sequels)
release 500 mg
acetazolamide oral tablet 125 mg, 250 mg
acetazolamide sodium injection recon
soln 500 mg
ALPHAGAN P OPHTHALMIC
DROPS 0.1 %
AZOPT OPHTHALMIC
DROPS,SUSPENSION 1 %
betaxolol ophthalmic drops 0.5 %
BETOPTIC S OPHTHALMIC
DROPS,SUSPENSION 0.25 %
bimatoprost ophthalmic drops 0.03 %
brimonidine ophthalmic drops 0.15 %
(Alphagan P)
brimonidine ophthalmic drops 0.2 %
2
2
2
3
3
2
4
2
2
2
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132
Drug Name
Drug Tier
COMBIGAN OPHTHALMIC DROPS
0.2-0.5 %
dorzolamide ophthalmic drops 2 %
dorzolamide-timolol ophthalmic drops
22.3-6.8 mg/ml
latanoprost ophthalmic drops 0.005 %
levobunolol ophthalmic drops 0.5 %
LUMIGAN OPHTHALMIC DROPS
0.01 %
methazolamide oral tablet 25 mg, 50 mg
metipranolol ophthalmic drops 0.3 %
PHOSPHOLINE IODIDE
OPHTHALMIC DROPS 0.125 %
pilocarpine hcl ophthalmic drops 1 %, 2
%, 4 %
SIMBRINZA OPHTHALMIC
DROPS,SUSPENSION 1-0.2 %
timolol maleate ophthalmic drops 0.25 %,
0.5 %
timolol maleate ophthalmic gel forming
solution 0.25 %, 0.5 %
TRAVATAN Z OPHTHALMIC
DROPS 0.004 %
travoprost (benzalkonium) ophthalmic
drops 0.004 %
ZIOPTAN (PF) OPHTHALMIC
DROPPERETTE 0.0015 %
3
(Trusopt)
(Cosopt)
2
2
(Xalatan)
(Betagan)
2
2
3
(Neptazane)
2
2
3
(Isopto Carpine)
2
Requirements/Limits
QL (2.5 per 25 days)
3
(Timoptic)
1
(Timoptic-XE)
2
3
QL (2.5 per 25 days)
2
QL (2.5 per 25 days)
3
QL (30 per 30 days)
Replacement Preparations
Replacement Preparations
calcium chloride intravenous syringe 100
mg/ml (10 %)
d10 %-0.45 % sodium chloride
intravenous parenteral solution
d2.5 %-0.45 % sodium chloride
intravenous parenteral solution
d5 % and 0.9 % sodium chloride
intravenous parenteral solution
d5 %-0.45 % sodium chloride intravenous
parenteral solution
dextrose 10 % and 0.2 % nacl intravenous
parenteral solution
2
2
2
2
2
2
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133
Drug Name
Drug Tier
dextrose 5 %-lactated ringers intravenous
parenteral solution
dextrose 5%-0.2 % sod chloride
intravenous parenteral solution
dextrose 5%-0.3 % sod.chloride
intravenous parenteral solution
dextrose with sodium chloride
intravenous parenteral solution 5-0.2 %
dextrose-kcl-nacl intravenous solution 50.224-0.225 %
effer-k oral tablet, effervescent 25 meq
electrolyte-48 in d5w intravenous
parenteral solution
IONOSOL-B IN D5W
INTRAVENOUS PARENTERAL
SOLUTION 5 %
IONOSOL-MB IN D5W
INTRAVENOUS PARENTERAL
SOLUTION 5 %
ISOLYTE-P IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL
SOLUTION 5 %
ISOLYTE-S INTRAVENOUS
PARENTERAL SOLUTION
kcl 10 meq in d5w-0.3% nacl 24's 20
meq/l
KLOR-CON 10 ORAL TABLET
EXTENDED RELEASE 10 MEQ
klor-con m10 oral tablet,er
particles/crystals 10 meq
klor-con m15 oral tablet,er
particles/crystals 15 meq
klor-con m20 oral tablet,er
particles/crystals 20 meq
klor-con sprinkle oral capsule, extended
release 10 meq, 8 meq
magnesium sulfate in d5w intravenous
piggyback 1 gram/100 ml
magnesium sulfate in water intravenous
parenteral solution 20 gram/500 ml (4
%), 40 gram/1,000 ml (4 %)
2
Requirements/Limits
2
2
2
2
2
2
4
4
4
4
2
2
2
2
2
2
2
2
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introduction pages of this document
134
Drug Name
Drug Tier
magnesium sulfate in water intravenous
piggyback 2 gram/50 ml (4 %), 4
gram/100 ml (4 %), 4 gram/50 ml (8 %)
magnesium sulfate injection solution 4
meq/ml (50 %)
magnesium sulfate injection syringe 4
meq/ml
NORMOSOL-M IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL
SOLUTION
NORMOSOL-R IV SOLUTION
12'S,LATEX-FREE
NORMOSOL-R PH 7.4
INTRAVENOUS PARENTERAL
SOLUTION
PLASMA-LYTE 148 INTRAVENOUS
PARENTERAL SOLUTION
PLASMA-LYTE A INTRAVENOUS
PARENTERAL SOLUTION
PLASMA-LYTE-56 IN 5 %
DEXTROSE INTRAVENOUS
PARENTERAL SOLUTION 5 %
potassium acetate intravenous solution 2
meq/ml
potassium chlorid-d5-0.45%nacl
intravenous parenteral solution 10 meq/l,
20 meq/l, 30 meq/l, 40 meq/l
potassium chloride in 0.9%nacl
intravenous parenteral solution 20 meq/l,
40 meq/l
potassium chloride in 5 % dex
intravenous parenteral solution 20 meq/l,
30 meq/l, 40 meq/l
potassium chloride in lr-d5 intravenous
parenteral solution 20 meq/l
potassium chloride intravenous piggyback
10 meq/100 ml, 20 meq/100 ml, 30
meq/100 ml, 40 meq/100 ml
potassium chloride intravenous solution 2
meq/ml
2
Requirements/Limits
2
2
4
4
4
4
4
4
2
2
2
2
2
2
2
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135
Drug Name
potassium chloride oral capsule, extended
release 10 meq, 8 meq
potassium chloride oral liquid 20 meq/15
ml, 40 meq/15 ml
potassium chloride oral packet 20 meq
potassium chloride oral tablet extended
release 10 meq, 8 meq
potassium chloride oral tablet extended
release 20 meq
potassium chloride oral tablet,er
particles/crystals 10 meq
potassium chloride-0.45 % nacl
intravenous parenteral solution 20 meq/l
potassium chloride-d5-0.2%nacl
intravenous parenteral solution 10 meq/l,
20 meq/l, 30 meq/l, 40 meq/l
potassium chloride-d5-0.3%nacl
intravenous parenteral solution 20 meq/l
potassium chloride-d5-0.9%nacl
intravenous parenteral solution 20 meq/l,
40 meq/l
potassium citrate oral tablet extended
release 10 meq (1,080 mg)
potassium citrate oral tablet extended
release 15 meq
potassium citrate oral tablet extended
release 5 meq (540 mg)
potassium citrate-citric acid oral packet
3,300-1,002 mg
potassium cl 10 meq/50 ml sol single use
10 meq/50 ml
potassium cl 20 meq/50 ml sol single use
20 meq/50 ml
potassium cl er 20 meq tablet
microencapsulated 20 meq
ringer's intravenous parenteral solution
sodium acetate intravenous solution 2
meq/ml
sodium bicarbonate intravenous syringe
8.4 % (1 meq/ml)
Drug Tier
(Klor-Con Sprinkle)
Requirements/Limits
2
2
(Klor-Con)
(K-Tab)
2
2
(K-Tab)
2
(Klor-Con M10)
2
2
2
2
2
(Urocit-K 10)
2
(Urocit-K 15)
2
(Urocit-K 5)
2
(Cytra K Crystals)
2
2
2
(Klor-Con M20)
2
2
2
2
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136
Drug Name
Drug Tier
sodium chloride 0.45 % intravenous
parenteral solution 0.45 %
sodium chloride 0.9 % intravenous
parenteral solution 0.9 %
sodium chloride 3 % intravenous
parenteral solution 3 %
sodium chloride 5 % intravenous
parenteral solution 5 %
sodium chloride intravenous parenteral
solution 2.5 meq/ml
sodium lactate intravenous solution 5
meq/ml
sodium phosphate intravenous solution 3
mmol/ml
TPN ELECTROLYTES II IV SOLN
25'S,20ML/50ML FTV 18-18-5-4.5-35
MEQ/20 ML
TPN ELECTROLYTES
INTRAVENOUS SOLUTION 35-20-5
MEQ/20 ML
2
Requirements/Limits
2
2
2
2
2
2
4
4
Respiratory Tract Agents
Anti-Inflammatories, Inhaled
Corticosteroids
ADVAIR DISKUS INHALATION
BLISTER WITH DEVICE 100-50
MCG/DOSE, 250-50 MCG/DOSE, 50050 MCG/DOSE
ADVAIR HFA INHALATION HFA
AEROSOL INHALER 115-21
MCG/ACTUATION, 230-21
MCG/ACTUATION, 45-21
MCG/ACTUATION
ARNUITY ELLIPTA INHALATION
BLISTER WITH DEVICE 100
MCG/ACTUATION, 200
MCG/ACTUATION
BREO ELLIPTA INHALATION
BLISTER WITH DEVICE 100-25
MCG/DOSE, 200-25 MCG/DOSE
3
QL (60 per 30 days)
3
QL (12 per 28 days)
3
QL (30 per 30 days)
3
QL (60 per 30 days)
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137
Drug Name
budesonide inhalation suspension for
nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1
mg/2 ml
DULERA INHALATION HFA
AEROSOL INHALER 100-5
MCG/ACTUATION, 200-5
MCG/ACTUATION
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 100
MCG/ACTUATION, 50
MCG/ACTUATION
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 250
MCG/ACTUATION
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 110
MCG/ACTUATION
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 220
MCG/ACTUATION
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 44
MCG/ACTUATION
QVAR INHALATION AEROSOL 40
MCG/ACTUATION, 80
MCG/ACTUATION
SYMBICORT 160-4.5 MCG
INHALER 60 INHALATIONS 160-4.5
MCG/ACTUATION
SYMBICORT INHALATION HFA
AEROSOL INHALER 160-4.5
MCG/ACTUATION, 80-4.5
MCG/ACTUATION
Antileukotrienes
montelukast oral granules in packet 4 mg
montelukast oral tablet 10 mg
montelukast oral tablet,chewable 4 mg, 5
mg
zafirlukast oral tablet 10 mg, 20 mg
Drug Tier
(Pulmicort)
Requirements/Limits
2
PA BvD
3
QL (13 per 28 days)
3
QL (60 per 30 days)
3
QL (120 per 30 days)
3
QL (12 per 28 days)
3
QL (24 per 28 days)
3
QL (21.2 per 28 days)
3
QL (17.4 per 25 days)
3
QL (12 per 25 days)
3
QL (11 per 25 days)
(Singulair)
(Singulair)
(Singulair)
2
1
1
(Accolate)
2
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138
Drug Name
Drug Tier
Bronchodilators
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml,
2.5 mg /3 ml (0.083 %), 5 mg/ml
albuterol sulfate oral syrup 2 mg/5 ml
albuterol sulfate oral tablet 2 mg, 4 mg
albuterol sulfate oral tablet extended
release 12 hr 4 mg, 8 mg
ANORO ELLIPTA INHALATION
BLISTER WITH DEVICE 62.5-25
MCG/ACTUATION
ATROVENT HFA INHALATION
HFA AEROSOL INHALER 17
MCG/ACTUATION
COMBIVENT RESPIMAT
INHALATION MIST 20-100
MCG/ACTUATION
elixophyllin oral elixir 80 mg/15 ml
FORADIL AEROLIZER
INHALATION CAPSULE,
W/INHALATION DEVICE 12 MCG
INCRUSE ELLIPTA INHALATION
BLISTER WITH DEVICE 62.5
MCG/ACTUATION
ipratropium bromide inhalation solution
0.02 %
metaproterenol oral syrup 10 mg/5 ml
metaproterenol oral tablet 10 mg, 20 mg
PROAIR HFA INHALATION HFA
AEROSOL INHALER 90
MCG/ACTUATION
PROAIR RESPICLICK
INHALATION AEROSOL POWDR
BREATH ACTIVATED 90
MCG/ACTUATION
SEREVENT DISKUS INHALATION
BLISTER WITH DEVICE 50
MCG/DOSE
SPIRIVA RESPIMAT INHALATION
MIST 1.25 MCG/ACTUATION, 2.5
MCG/ACTUATION
2
Requirements/Limits
PA BvD
2
2
2
3
QL (60 per 30 days)
3
QL (25.8 per 28 days)
3
QL (8 per 30 days)
2
3
QL (60 per 30 days)
3
2
PA BvD
2
2
3
3
3
QL (60 per 30 days)
3
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introduction pages of this document
139
Drug Name
SPIRIVA WITH HANDIHALER
INHALATION CAPSULE,
W/INHALATION DEVICE 18 MCG
STIOLTO RESPIMAT
INHALATION MIST 2.5-2.5
MCG/ACTUATION
STRIVERDI RESPIMAT
INHALATION MIST 2.5
MCG/ACTUATION
terbutaline oral tablet 2.5 mg, 5 mg
terbutaline subcutaneous solution 1
mg/ml
theophylline in dextrose 5 % intravenous
parenteral solution 200 mg/100 ml, 200
mg/50 ml, 400 mg/250 ml, 400 mg/500
ml, 800 mg/250 ml
theophylline oral solution 80 mg/15 ml
theophylline oral tablet extended release
12 hr 100 mg, 200 mg, 300 mg
theophylline oral tablet extended release
12 hr 450 mg
theophylline oral tablet extended release
24 hr 400 mg, 600 mg
VENTOLIN HFA INHALATION
HFA AEROSOL INHALER 90
MCG/ACTUATION
Respiratory Tract Agents, Other
acetylcysteine intravenous solution 200
mg/ml (20 %)
acetylcysteine solution 100 mg/ml (10
%), 200 mg/ml (20 %)
CINQAIR INTRAVENOUS
SOLUTION 10 MG/ML
cromolyn inhalation solution for
nebulization 20 mg/2 ml
DALIRESP ORAL TABLET 500
MCG
ESBRIET ORAL CAPSULE 267 MG
Drug Tier
Requirements/Limits
3
3
QL (4 per 28 days)
3
QL (4 per 28 days)
2
5
NDS
2
(Theochron)
2
2
2
2
3
(Acetadote)
ESBRIET ORAL TABLET 267 MG
2
PA BvD
2
PA BvD
5
PA; NDS
2
PA BvD
3
QL (30 per 30 days)
5
PA; NDS; QL (270 per
30 days)
PA; NDS; QL (270 per
30 days)
5
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
140
Drug Name
Drug Tier
Requirements/Limits
ESBRIET ORAL TABLET 801 MG
5
KALYDECO ORAL GRANULES IN
PACKET 50 MG, 75 MG
KALYDECO ORAL TABLET 150
MG
NUCALA SUBCUTANEOUS
RECON SOLN 100 MG
OFEV ORAL CAPSULE 100 MG, 150
MG
ORKAMBI ORAL TABLET 100-125
MG, 200-125 MG
PROLASTIN-C INTRAVENOUS
RECON SOLN 1,000 MG
XOLAIR SUBCUTANEOUS RECON
SOLN 150 MG
5
5
PA; NDS; QL (90 per
30 days)
PA; NDS; QL (60 per
30 days)
PA; NDS; QL (60 per
30 days)
PA; LA; NDS; QL (1
per 28 days)
PA; NDS; QL (60 per
30 days)
PA; NDS; QL (120 per
30 days)
NDS
5
PA; NDS
5
5
5
5
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen oral tablet 10 mg, 20 mg
carisoprodol oral tablet 250 mg, 350 mg
chlorzoxazone oral tablet 500 mg
(Soma)
2
2
(Parafon Forte DSC)
2
2
cyclobenzaprine oral tablet 10 mg, 5 mg
cyclobenzaprine oral tablet 7.5 mg
dantrolene oral capsule 100 mg
dantrolene oral capsule 25 mg, 50 mg
metaxall oral tablet 800 mg
(Fexmid)
2
(Dantrium)
2
2
2
2
metaxalone oral tablet 400 mg
metaxalone oral tablet 800 mg
(Metaxall)
2
methocarbamol oral tablet 500 mg
(Robaxin)
2
methocarbamol oral tablet 750 mg
(Robaxin-750)
2
PA-HRM; QL (120 per
30 days); AGE (Max 64
Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
2
revonto intravenous recon soln 20 mg
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
141
Drug Name
tizanidine oral capsule 2 mg, 4 mg, 6 mg
tizanidine oral tablet 2 mg
tizanidine oral tablet 4 mg
Drug Tier
(Zanaflex)
(Zanaflex)
Requirements/Limits
2
2
2
Sleep Disorder Agents
Sleep Disorder Agents
armodafinil oral tablet 150 mg, 200 mg, (Nuvigil)
250 mg, 50 mg
BELSOMRA ORAL TABLET 10 MG,
15 MG, 20 MG, 5 MG
eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Lunesta)
2
PA
3
QL (30 per 30 days)
2
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug); QL (30
per 30 days); AGE
(Max 64 Years)
PA; NDS; QL (30 per
30 days)
HETLIOZ ORAL CAPSULE 20 MG
5
ROZEREM ORAL TABLET 8 MG
SILENOR ORAL TABLET 3 MG, 6
MG
XYREM ORAL SOLUTION 500
MG/ML
zaleplon oral capsule 10 mg, 5 mg
3
3
QL (30 per 30 days)
5
LA; NDS
2
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug); QL (60
per 30 days); AGE
(Max 64 Years)
(Sonata)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
142
Drug Name
Drug Tier
Requirements/Limits
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug); QL (30
per 30 days); AGE
(Max 64 Years)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug); QL (30
per 30 days); AGE
(Max 64 Years)
zolpidem oral tablet 10 mg, 5 mg
(Ambien)
2
zolpidem oral tablet,ext release
multiphase 12.5 mg, 6.25 mg
(Ambien CR)
2
Vasodilating Agents
Vasodilating Agents
ADCIRCA ORAL TABLET 20 MG
5
ADEMPAS ORAL TABLET 0.5 MG,
1 MG, 1.5 MG, 2 MG, 2.5 MG
CIALIS ORAL TABLET 2.5 MG, 5
MG
epoprostenol (glycine) intravenous recon (Flolan)
soln 0.5 mg
epoprostenol (glycine) intravenous recon (Flolan)
soln 1.5 mg
LETAIRIS ORAL TABLET 10 MG, 5
MG
OPSUMIT ORAL TABLET 10 MG
5
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.125 MG
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.25 MG, 1
MG, 2.5 MG
3
PA; NDS; QL (60 per
30 days)
PA; NDS; QL (90 per
30 days)
PA; QL (30 per 30
days)
2
5
NDS
5
3
PA; NDS; QL (30 per
30 days)
PA; NDS; QL (30 per
30 days)
PA
5
PA; NDS
5
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
143
Drug Name
Drug Tier
Requirements/Limits
REMODULIN INJECTION
SOLUTION 1 MG/ML, 10 MG/ML,
2.5 MG/ML, 5 MG/ML
sildenafil intravenous solution 10 mg/12.5 (Revatio)
ml
sildenafil oral tablet 20 mg
(Revatio)
5
PA; NDS
5
TRACLEER ORAL TABLET 125
MG, 62.5 MG
TYVASO INHALATION SOLUTION
FOR NEBULIZATION 1.74 MG/2.9
ML (0.6 MG/ML)
UPTRAVI ORAL TABLET 1,000
MCG, 1,200 MCG, 1,400 MCG, 1,600
MCG, 400 MCG, 600 MCG, 800 MCG
UPTRAVI ORAL TABLET 200 MCG
5
PA; NDS; QL (37.5 per
1 day)
PA; QL (90 per 30
days)
PA; LA; NDS; QL (60
per 30 days)
PA; NDS
UPTRAVI ORAL TABLETS,DOSE
PACK 200 MCG (140)- 800 MCG (60)
5
2
5
5
PA; NDS; QL (60 per
30 days)
5
PA; NDS; QL (240 per
30 days)
PA; NDS; QL (400 per
365 days)
Vitamins And Minerals
Vitamins And Minerals
multivit-fluor 0.25 mg/ml drop 0.25
mg/ml
pnv prenatal plus multivit tab s/f, glutenfree 27 mg iron- 1 mg
prenatal vitamin plus low iron oral tablet
27 mg iron- 1 mg
sodium fluoride oral tablet 1 mg fluoride
(2.2 mg)
2
3
3
(All Rx Prenatal
Vitamins Covered)
(All Rx Prenatal
Vitamins Covered)
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
144
Index
Index
Index
INDEX
8-MOP.................................... 94
abacavir...................................58
abacavir-lamivudine................. 59
abacavir-lamivudine-zidovudine 59
ABELCET.............................. 46
ABILIFY MAINTENA......... 54
ABRAXANE..........................24
acamprosate............................ 10
acarbose.................................. 41
acebutolol................................ 74
acetaminophen-codeine.............. 3
acetasol hc............................. 103
acetazolamide........................ 132
acetazolamide sodium............ 132
acetic acid...................... 103, 128
acetylcysteine.........................140
acitretin................................... 94
ACTEMRA.......................... 118
ACTHIB (PF)....................... 123
ACTIMMUNE.....................130
acyclovir............................ 63, 94
acyclovir sodium...................... 63
ADACEL(TDAP
ADOLESN/ADULT)(PF).... 123
ADAGEN.............................100
adapalene................................ 99
ADCETRIS............................ 24
ADCIRCA............................143
adefovir................................... 63
ADEMPAS...........................143
adriamycin...............................24
adrucil..................................... 24
ADVAIR DISKUS...............137
ADVAIR HFA..................... 137
afeditab cr............................... 79
AFINITOR............................ 24
AFINITOR DISPERZ........... 24
a-hydrocort............................ 114
AKTEN (PF)........................ 102
AKYNZEO............................ 50
ala-cort....................................97
ala-scalp.................................. 97
ALBENZA............................. 52
albuterol sulfate..................... 139
alcaine................................... 102
alclometasone.......................... 97
ALCOHOL PADS..................94
ALCOHOL PREP PADS....... 94
ALDURAZYME................. 100
ALECENSA........................... 24
alendronate............................ 128
alfuzosin................................ 111
ALIMTA................................ 24
ALINIA..................................52
allopurinol............................... 48
ALLZITAL.............................. 3
almotriptan malate...................49
alogliptin................................. 42
alogliptin-metformin................ 42
alogliptin-pioglitazone..............42
alosetron................................127
ALPHAGAN P.................... 132
alprazolam...............................11
ALREX................................ 105
altacaine................................ 102
altavera (28)........................... 87
ALTOPREV........................... 81
alyacen 1/35 (28).................... 87
alyacen 7/7/7 (28)................... 87
amabelz................................. 112
amantadine hcl.........................53
AMBISOME.......................... 46
amethia....................................87
amethia lo................................87
amifostine crystalline............. 130
amiloride................................. 80
amiloride-hydrochlorothiazide..80
AMINO ACIDS 15 %............ 67
AMINOSYN 10 %................. 67
AMINOSYN 7 % WITH
ELECTROLYTES................. 67
AMINOSYN 8.5 %................ 67
AMINOSYN 8.5 %ELECTROLYTES................. 67
AMINOSYN II 10 %..............67
AMINOSYN II 15 %..............67
AMINOSYN II 7 %................67
AMINOSYN II 8.5 %.............67
AMINOSYN II 8.5 %ELECTROLYTES................. 68
AMINOSYN M 3.5 %............ 68
AMINOSYN-HBC 7%........... 68
AMINOSYN-PF 10 %............68
AMINOSYN-PF 7 %
(SULFITE-FREE)..................68
AMINOSYN-RF 5.2 %.......... 68
amiodarone..............................73
AMITIZA.............................108
amitriptyline............................ 39
amlodipine............................... 79
amlodipine-atorvastatin........... 81
amlodipine-benazepril.............. 79
amlodipine-olmesartan............. 80
amlodipine-valsartan................80
amlodipine-valsartan-hcthiazid.80
ammonium lactate....................94
amoxapine............................... 39
amoxicil-clarithromy-lansopraz
.............................................. 106
amoxicillin...............................20
amoxicillin-pot clavulanate.20, 21
amphotericin b......................... 46
ampicillin.................................21
ampicillin sodium..................... 21
I-1
Index
Index
Index
ampicillin-sulbactam................ 21
AMPYRA...............................84
ANACAINE...........................94
ANADROL-50..................... 112
anagrelide................................ 66
anastrozole.............................. 25
ANDRODERM................... 112
ANDROGEL....................... 112
androxy................................. 112
ANORO ELLIPTA.............. 139
APOKYN............................... 53
apraclonidine......................... 102
aprepitant................................ 50
apri..........................................88
APRISO................................127
APTIOM................................ 34
APTIVUS............................... 59
aranelle (28)........................... 88
ARCALYST......................... 118
aripiprazole............................. 54
ARISTADA......................54, 55
armodafinil............................ 142
ARNUITY ELLIPTA.......... 137
ASACOL HD....................... 127
ascomp with codeine.................. 3
ashlyna.................................... 88
aspirin-dipyridamole................ 67
ASSURE ID INSULIN
SAFETY...............................100
ASTAGRAF XL.................. 118
atenolol....................................74
atenolol-chlorthalidone.............74
atorvastatin............................. 81
atovaquone.............................. 52
atovaquone-proguanil...............52
ATRIPLA...............................59
atropine............................34, 102
ATROVENT HFA............... 139
AUBAGIO............................. 84
aubra....................................... 88
AURYXIA........................... 110
AUSTEDO....................... 84, 85
AVASTIN.............................. 25
AVC VAGINAL.................... 49
aviane...................................... 88
AVONEX............................... 85
AVONEX (WITH
ALBUMIN)............................85
AXIRON.............................. 112
azacitidine............................... 25
azathioprine........................... 118
azathioprine sodium............... 118
azelastine............................... 102
AZILECT............................... 53
azithromycin............................19
AZOPT................................. 132
AZOR.....................................80
aztreonam................................20
azurette (28)........................... 88
baciim......................................15
bacitracin......................... 15, 103
bacitracin-polymyxin b...........103
baclofen................................. 141
balsalazide............................. 127
balziva (28).............................88
BANZEL................................ 34
BAVENCIO........................... 25
BCG VACCINE, LIVE (PF) 123
BD INSULIN PEN NEEDLE
UF SHORT.......................... 100
BD INSULIN SYRINGE
ULTRA-FINE......................100
bekyree (28)............................88
BELBUCA............................... 3
BELEODAQ.......................... 25
BELSOMRA........................ 142
benazepril................................ 72
benazepril-hydrochlorothiazide.72
BENDEKA............................ 25
BENICAR.............................. 71
BENICAR HCT..................... 71
BENLYSTA......................... 130
benztropine.............................. 53
BEPREVE............................ 102
betamethasone acet,sod phos.. 114
betamethasone dipropionate..... 97
betamethasone valerate............ 97
betamethasone, augmented.......97
BETASERON........................ 85
betaxolol.......................... 74, 132
bethanechol chloride...............110
BETHKIS...............................14
BETOPTIC S........................ 132
bexarotene...............................25
BEXSERO............................ 123
bicalutamide............................ 25
BICILLIN C-R.......................21
BICILLIN L-A....................... 21
BIDIL..................................... 83
bimatoprost............................132
bisoprolol fumarate.................. 74
bisoprolol-hydrochlorothiazide. 74
bleomycin................................ 25
bleph-10.................................103
BLINCYTO............................25
blisovi 24 fe..............................88
blisovi fe 1.5/30 (28)................88
blisovi fe 1/20 (28).................. 88
BOOSTRIX TDAP...............123
BOSULIF............................... 25
BOTOX................................ 130
BREO ELLIPTA.................. 137
briellyn.................................... 88
BRILINTA.............................67
brimonidine............................132
BRINTELLIX........................ 39
BRIVIACT............................. 34
bromfenac..............................105
bromocriptine.......................... 53
budesonide......................127, 138
I-2
Index
Index
Index
bumetanide.............................. 80
BUNAVAIL........................... 10
BUPHENYL........................ 108
buprenorphine hcl.................3, 10
buprenorphine-naloxone...........10
buproban................................. 10
bupropion hcl........................... 39
bupropion hcl (smoking deter). 11
buspirone............................... 130
butalbital compound w/codeine...3
butalbital-acetaminop-caf-cod....3
butalbital-acetaminophen........... 3
butalbital-acetaminophen-caff....3
butalbital-aspirin-caffeine.......... 4
butorphanol tartrate.................. 4
BUTRANS............................... 4
BYSTOLIC.............................74
BYVALSON...........................74
cabergoline.............................. 53
CABOMETYX.......................25
caffeine citrate......................... 85
calcipotriene............................ 94
calcitonin (salmon)................128
calcitrene................................. 94
calcitriol...........................94, 128
calcium acetate...................... 110
calcium chloride..................... 133
CALDOLOR............................8
camila......................................88
camrese................................... 88
camrese lo................................88
CANCIDAS........................... 46
candesartan............................. 71
candesartan-hydrochlorothiazid71
capacet...................................... 4
CAPASTAT........................... 50
CAPRELSA........................... 25
captopril.................................. 72
captopril-hydrochlorothiazide...72
CARAFATE.........................106
CARBAGLU........................108
carbamazepine......................... 34
carbidopa.................................53
carbidopa-levodopa.................. 53
carbidopa-levodopa-entacapone 53
carbinoxamine maleate............ 48
carboplatin.............................. 25
CARIMUNE NF
NANOFILTERED...............118
carisoprodol........................... 141
carteolol.................................102
cartia xt...................................76
carvedilol................................. 74
CAYSTON............................. 20
caziant (28)............................ 88
cefaclor....................................17
cefadroxil................................ 17
cefazolin.................................. 17
cefazolin in dextrose (iso-os)... 17
cefdinir.................................... 17
cefditoren pivoxil..................... 17
cefepime.................................. 17
CEFEPIME............................ 17
CEFEPIME IN DEXTROSE
5 %.......................................... 17
CEFEPIME IN
DEXTROSE,ISO-OSM..........17
cefixime...................................18
cefotaxime............................... 18
cefoxitin.................................. 18
cefoxitin in dextrose, iso-osm... 18
cefpodoxime............................ 18
cefprozil...................................18
ceftazidime.............................. 18
ceftibuten.................................18
ceftriaxone.............................. 18
ceftriaxone in dextrose,iso-os... 18
cefuroxime axetil..................... 18
cefuroxime sodium................... 18
celecoxib................................... 8
CELLCEPT
INTRAVENOUS................. 119
CELONTIN........................... 34
cephalexin.......................... 18, 19
CEPROTIN (BLUE BAR)..... 64
CERDELGA........................ 130
CEREZYME........................ 100
CERVARIX VACCINE (PF)
.............................................. 123
CETYLEV............................ 130
cevimeline................................ 94
CHANTIX............................. 11
CHANTIX CONTINUING
MONTH BOX........................11
CHANTIX STARTING
MONTH BOX........................11
chloramphenicol sod succinate..15
chlordiazepoxide hcl.................11
chlorhexidine gluconate............94
chloroquine phosphate..............52
chlorothiazide.......................... 80
chlorothiazide sodium.............. 80
chlorpromazine........................ 55
chlorthalidone.......................... 80
chlorzoxazone........................ 141
cholestyramine (with sugar).... 81
cholestyramine light................. 81
CIALIS................................. 143
ciclopirox.................................46
cidofovir.................................. 63
cilostazol................................. 67
CILOXAN............................103
cimetidine.............................. 106
cimetidine hcl......................... 106
CIMZIA............................... 119
CIMZIA POWDER FOR
RECONST............................119
CINQAIR.............................140
CINRYZE.............................. 65
CIPRODEX..........................103
I-3
Index
Index
Index
ciprofloxacin............................22
ciprofloxacin (mixture)........... 22
ciprofloxacin hcl...............22, 103
ciprofloxacin in 5 % dextrose... 22
ciprofloxacin lactate................ 22
citalopram............................... 39
cladribine.................................25
clarithromycin......................... 19
clemastine................................48
CLEVIPREX..........................80
clindamycin hcl........................ 15
clindamycin in 5 % dextrose..... 15
clindamycin palmitate hcl.........15
clindamycin pediatric............... 15
clindamycin phosphate.. 15, 49, 96
clindamycin-benzoyl peroxide.. 96
CLINIMIX 5%/D15W
SULFITE FREE.................... 68
CLINIMIX 5%/D25W
SULFITE-FREE.................... 68
CLINIMIX 2.75%/D5W
SULFIT FREE.......................68
CLINIMIX 4.25%/D10W
SULF FREE...........................68
CLINIMIX 4.25%/D5W
SULFIT FREE.......................68
CLINIMIX 4.25%-D20W
SULF-FREE.......................... 68
CLINIMIX 4.25%-D25W
SULF-FREE.......................... 68
CLINIMIX 5%D20W(SULFITE-FREE)....... 68
CLINIMIX E 2.75%/D10W
SUL FREE............................. 69
CLINIMIX E 2.75%/D5W
SULF FREE...........................69
CLINIMIX E 4.25%/D10W
SUL FREE............................. 69
CLINIMIX E 4.25%/D25W
SUL FREE............................. 69
CLINIMIX E 4.25%/D5W
SULF FREE...........................69
CLINIMIX E 5%/D15W
SULFIT FREE.......................69
CLINIMIX E 5%/D20W
SULFIT FREE.......................69
CLINIMIX E 5%/D25W
SULFIT FREE.......................69
CLINISOL SF 15 %............... 69
clobetasol.................................97
clobetasol-emollient................. 97
clocortolone pivalate................ 97
clomipramine........................... 39
clonazepam........................ 11, 12
clonidine.................................. 71
clonidine hcl....................... 71, 85
clopidogrel............................... 67
clorazepate dipotassium........... 12
clorpres....................................71
clotrimazole............................. 46
clotrimazole-betamethasone..... 47
clozapine..................................55
COARTEM............................ 52
codeine sulfate........................... 4
COGENTIN...........................53
COLCRYS............................. 48
colestipol................................. 81
colistin (colistimethate na)...... 15
colocort..................................127
COLY-MYCIN S................. 103
COMBIGAN........................ 133
COMBIPATCH....................113
COMBIVENT RESPIMAT. 139
COMETRIQ...........................25
COMPLERA..........................59
compro.................................... 50
COMVAX (PF).................... 123
CONDYLOX......................... 94
constulose.............................. 108
COPAXONE.......................... 85
CORLANOR......................... 77
cormax.................................... 97
cortisone................................ 114
COSENTYX...........................95
COSENTYX (2 SYRINGES).94
COSENTYX PEN.................. 94
COSENTYX PEN (2 PENS).. 94
COTELLIC............................ 25
CREON................................ 101
CRIXIVAN............................ 59
cromolyn.................102, 108, 140
cryselle (28)............................ 88
CUBICIN............................... 15
CUPRIMINE....................... 111
cyclafem 1/35 (28).................. 88
cyclafem 7/7/7 (28)................. 88
cyclobenzaprine......................141
cyclopentolate........................ 102
cyclophosphamide.................... 26
CYCLOPHOSPHAMIDE..... 26
CYCLOSET........................... 42
cyclosporine........................... 119
cyclosporine modified.............119
cyproheptadine.........................48
CYRAMZA............................26
cyred....................................... 88
CYSTADANE......................130
CYSTARAN........................ 102
d10 %-0.45 % sodium chloride 133
d2.5 %-0.45 % sodium chloride
.............................................. 133
d5 % and 0.9 % sodium chloride
.............................................. 133
d5 %-0.45 % sodium chloride..133
DAKLINZA...........................62
DALIRESP...........................140
danazol.................................. 112
dantrolene..............................141
dapsone....................................50
I-4
Index
Index
Index
DAPTACEL (DTAP
PEDIATRIC) (PF)............... 123
daptomycin.............................. 15
DARAPRIM.......................... 52
DARZALEX.......................... 26
dasetta 1/35 (28)..................... 88
dasetta 7/7/7 (28).................... 88
daysee......................................88
deblitane.................................. 88
decitabine................................ 26
deferoxamine......................... 111
delyla (28).............................. 88
DELZICOL.......................... 127
demeclocycline.........................23
DEMSER............................... 77
DENAVIR............................. 95
DEPEN TITRATABS.......... 111
DEPO-PROVERA............... 117
DESCOVY............................. 59
desipramine............................. 39
desmopressin..........................115
desog-e.estradiol/e.estradiol..... 89
desogestrel-ethinyl estradiol..... 89
desonide............................. 97, 98
desoximetasone........................98
desvenlafaxine succinate.......... 39
dexamethasone...................... 114
dexamethasone sodium
phosphate....................... 105, 114
DEXILANT......................... 107
dexmethylphenidate................. 85
dexrazoxane hcl..................... 130
dextroamphetamine................. 85
dextroamphetamineamphetamine........................... 85
dextrose 10 % and 0.2 % nacl. 133
dextrose 10 % in water (d10w) 69
dextrose 20 % in water (d20w) 69
dextrose 25 % in water (d25w) 69
dextrose 40 % in water (d40w) 69
dextrose 5 % in ringers.............69
dextrose 5 % in water (d5w).... 69
dextrose 5 %-lactated ringers. 134
dextrose 5%-0.2 % sod chloride
.............................................. 134
dextrose 5%-0.3 % sod.chloride
.............................................. 134
dextrose 50 % in water (d50w)
.......................................... 69, 70
dextrose 70 % in water (d70w) 70
dextrose with sodium chloride.134
dextrose-kcl-nacl....................134
diazepam................................. 12
diazepam intensol.....................12
diclofenac potassium.................. 8
diclofenac sodium......... 8, 95, 105
diclofenac-misoprostol............... 8
dicloxacillin............................. 21
dicyclomine............................108
didanosine................................59
DIFICID................................ 19
diflorasone...............................98
diflunisal....................................8
digitek..................................... 77
digoxin...............................77, 78
DIGOXIN.............................. 77
dihydroergotamine................... 49
DILANTIN............................ 34
diltiazem hcl............................ 76
dilt-xr...................................... 76
dimenhydrinate........................ 51
DIPENTUM.........................127
diphenhydramine hcl................ 48
diphenoxylate-atropine...........108
dipyridamole............................67
disopyramide phosphate........... 73
disulfiram................................ 11
divalproex................................35
dobutamine.............................. 78
dobutamine in d5w................... 78
I-5
docetaxel................................. 26
dofetilide..................................73
donepezil..................................38
dopamine................................. 78
dopamine in 5 % dextrose.........78
dorzolamide........................... 133
dorzolamide-timolol............... 133
doxazosin................................ 71
doxepin....................................39
doxercalciferol....................... 128
doxorubicin..............................26
doxorubicin, peg-liposomal.......26
doxy-100................................. 23
doxycycline hyclate..................23
doxycycline monohydrate... 23, 24
dronabinol............................... 51
droperidol.............................. 130
drospirenone-ethinyl estradiol.. 89
DROXIA................................ 26
DUAVEE............................. 113
DULERA............................. 138
duloxetine................................ 39
DUPIXENT........................... 95
DUREZOL...........................105
dutasteride............................. 111
dutasteride-tamsulosin........... 111
DYRENIUM......................... 80
e.e.s. 400..................................19
e.e.s. granules.......................... 19
econazole................................. 47
EDARBI.................................71
EDARBYCLOR.................... 71
EDURANT............................ 59
effer-k....................................134
EFFIENT............................... 67
ELAPRASE..........................101
electrolyte-48 in d5w.............. 134
ELIDEL................................. 98
ELIGARD..............................26
ELIGARD (3 MONTH)........ 26
Index
Index
Index
ELIGARD (4 MONTH)........ 26
ELIGARD (6 MONTH)........ 26
elinest...................................... 89
eliphos................................... 110
ELIQUIS................................ 64
ELITEK................................101
elixophyllin............................ 139
ELLA......................................89
ELMIRON........................... 130
EMBEDA.................................4
EMCYT..................................26
EMEND................................. 51
EMFLAZA...........................114
emoquette................................ 89
EMPLICITI............................26
EMSAM................................. 39
EMTRIVA............................. 59
enalapril maleate..................... 72
enalaprilat............................... 72
enalapril-hydrochlorothiazide...73
ENBREL.............................. 119
ENBREL SURECLICK.......119
endocet...................................... 4
endodan..................................... 4
ENGERIX-B (PF)................ 123
ENGERIX-B PEDIATRIC
(PF).......................................124
enoxaparin...............................64
enpresse................................... 89
enskyce....................................89
entacapone...............................53
entecavir.................................. 63
ENTRESTO........................... 71
enulose...................................108
ENVARSUS XR.................. 119
EPCLUSA.............................. 62
epinastine...............................102
epinephrine.............................. 78
epinephrine hcl (pf)................. 78
EPIPEN.................................. 79
EPIPEN 2-PAK......................78
EPIPEN JR 2-PAK................ 79
epitol....................................... 35
EPIVIR HBV..........................59
eplerenone................................83
EPOGEN................................65
epoprostenol (glycine)........... 143
eprosartan............................... 71
EPZICOM.............................. 59
ergoloid..................................130
ERGOMAR........................... 49
ERIVEDGE........................... 26
errin........................................ 89
ery pads................................... 96
ery-tab.....................................20
ERY-TAB...............................20
ERYTHROCIN..................... 20
erythrocin (as stearate)........... 20
erythromycin.................... 20, 103
erythromycin ethylsuccinate..... 20
erythromycin with ethanol........96
erythromycin-benzoyl peroxide 96
ESBRIET...................... 140, 141
escitalopram oxalate................ 39
esmolol.................................... 75
esomeprazole sodium..............107
estarylla...................................89
estazolam.................................12
ESTRACE............................ 113
estradiol.................................113
estradiol valerate....................113
estradiol-norethindrone acet... 113
ESTRING.............................113
estropipate............................. 113
eszopiclone.............................142
ethambutol...............................50
ethosuximide............................35
ethynodiol diac-eth estradiol.....89
etidronate disodium................ 128
etodolac................................. 8, 9
ETOPOPHOS.........................26
etoposide..................................26
EUCRISA.............................. 98
EVOTAZ................................ 59
EXELDERM..........................47
exemestane.............................. 27
EXJADE...............................111
EXONDYS 51...................... 130
EXTAVIA.............................. 85
ezetimibe................................. 81
FABRAZYME..................... 101
falmina (28)............................89
famciclovir...............................63
famotidine..............................107
famotidine (pf)...................... 107
famotidine (pf)-nacl (iso-os) 107
FANAPT................................ 55
FARESTON...........................27
FARYDAK............................27
FASLODEX...........................27
felbamate.................................35
felodipine................................. 80
FEMRING........................... 113
femynor................................... 89
fenofibrate............................... 82
fenofibrate micronized............. 81
fenofibrate nanocrystallized..... 82
fenofibric acid.......................... 82
fenofibric acid (choline)...........82
fenoprofen................................. 9
fentanyl..................................... 4
fentanyl citrate.......................... 4
FERRIPROX....................... 112
FETZIMA.............................. 40
finasteride..............................111
FIRAZYR.............................. 79
flavoxate................................110
FLEBOGAMMA DIF......... 119
flecainide................................. 73
FLECTOR............................... 9
I-6
Index
Index
Index
FLOVENT DISKUS............ 138
FLOVENT HFA.................. 138
floxuridine............................... 27
flucaine.................................. 102
fluconazole.............................. 47
fluconazole in nacl (iso-osm)... 47
flucytosine............................... 47
fludrocortisone....................... 114
flumazenil................................ 85
flunisolide.............................. 105
fluocinolone acetonide oil....... 105
fluocinonide............................. 98
fluocinonide-e.......................... 98
fluorometholone..................... 105
fluorouracil........................ 27, 95
fluoxetine.................................40
FLUOXETINE...................... 40
fluphenazine decanoate............ 55
fluphenazine hcl....................... 55
flurazepam...............................13
flurbiprofen............................... 9
flurbiprofen sodium................ 105
flutamide................................. 27
fluticasone........................98, 106
fluvastatin................................82
fluvoxamine............................. 40
fomepizole............................. 130
fondaparinux........................... 64
FORADIL AEROLIZER.... 139
FORTEO.............................. 128
FORTICAL.......................... 128
foscarnet..................................62
fosinopril................................. 73
fosinopril-hydrochlorothiazide..73
fosphenytoin............................ 35
FOSRENOL......................... 110
FREAMINE HBC 6.9 %........ 70
FREAMINE III 10 %.............70
furosemide............................... 80
FUSILEV............................. 130
FUZEON............................... 59
fyavolv................................... 113
FYCOMPA............................ 35
gabapentin............................... 35
GABITRIL.............................35
galantamine............................. 38
GAMASTAN S/D................ 119
GAMMAGARD LIQUID... 119
GAMMAGARD S-D (IGA <
1 MCG/ML)......................... 119
GAMMAPLEX.................... 120
GAMMAPLEX (WITH
SORBITOL)......................... 120
GAMUNEX-C..................... 120
ganciclovir sodium................... 63
GARDASIL (PF)................. 124
GARDASIL 9 (PF)...............124
gatifloxacin............................103
GATTEX 30-VIAL...............108
GATTEX ONE-VIAL.......... 108
GAUZE PAD....................... 100
gavilyte-c............................... 109
gavilyte-g...............................109
gavilyte-n...............................109
GAZYVA............................... 27
gemcitabine............................. 27
gemfibrozil...............................82
generlac................................. 108
gengraf.................................. 120
GENOTROPIN....................115
GENOTROPIN
MINIQUICK....................... 115
gentak....................................104
gentamicin.................. 14, 96, 104
gentamicin in nacl (iso-osm).... 14
gentamicin sulfate (ped) (pf).. 14
gentamicin sulfate (pf)............ 15
GENVOYA............................ 59
GEODON...............................55
gianvi (28).............................. 89
gildagia....................................89
gildess 1.5/30 (21)................... 89
gildess 1/20 (21)......................89
gildess 24 fe............................. 89
gildess fe 1.5/30 (28)............... 89
gildess fe 1/20 (28).................. 89
GILENYA..............................85
GILOTRIF.............................27
GLEOSTINE..........................27
glimepiride...............................45
glipizide............................. 45, 46
glipizide-metformin.................. 46
GLUCAGEN HYPOKIT.....130
GLUCAGON
EMERGENCY KIT
(HUMAN)............................130
glyburide..................................46
glyburide micronized................ 46
glyburide-metformin................ 46
glycopyrrolate........................108
glydo....................................... 10
GLYXAMBI.......................... 42
GRALISE...............................35
GRALISE 30-DAY
STARTER PACK.................. 35
granisetron (pf).......................51
granisetron hcl......................... 51
GRANIX................................66
griseofulvin microsize...............47
griseofulvin ultramicrosize....... 47
guanfacine..........................71, 85
guanidine............................... 130
halobetasol propionate............. 98
haloperidol...............................56
haloperidol decanoate.............. 55
haloperidol lactate..............55, 56
HARVONI............................. 62
HAVRIX (PF)...................... 124
heather.................................... 89
heparin (porcine).....................65
I-7
Index
Index
Index
heparin (porcine) in 5 % dex....65
heparin(porcine) in 0.45% nacl 65
heparin, porcine (pf)................65
HEPATAMINE 8%................70
HERCEPTIN......................... 27
HETLIOZ.............................142
HEXALEN.............................27
HIBERIX (PF)..................... 124
homatropaire......................... 102
homatropine hbr.....................102
HUMALOG...........................44
HUMALOG KWIKPEN....... 44
HUMALOG MIX 50-50........ 44
HUMALOG MIX 50-50
KWIKPEN............................. 44
HUMALOG MIX 75-25........ 44
HUMALOG MIX 75-25
KWIKPEN............................. 44
HUMATROPE.....................116
HUMIRA............................. 120
HUMIRA PEDIATRIC
CROHN'S START............... 120
HUMIRA PEN.................... 120
HUMIRA PEN CROHN'SUC-HS START.................... 120
HUMIRA PEN PSORIASISUVEITIS.............................. 120
HUMULIN 70/30...................44
HUMULIN 70/30
KWIKPEN............................. 44
HUMULIN N........................ 44
HUMULIN N KWIKPEN.... 44
HUMULIN R U-100..............45
HUMULIN R U-500
(CONC) KWIKPEN.............. 45
HUMULIN R U-500
(CONCENTRATED).............45
hydralazine.............................. 79
hydrochlorothiazide............80, 81
hydrocodone-acetaminophen.. 4, 5
hydrocodone-ibuprofen.............. 5
hydrocortisone.......... 98, 114, 127
hydrocortisone butyrate........... 98
hydrocortisone butyr-emollient.98
hydrocortisone valerate............ 98
hydrocortisone-acetic acid...... 104
hydromorphone..........................5
hydromorphone (pf).................. 5
hydroxychloroquine................. 52
hydroxyprogesterone caproate117
hydroxyurea............................ 27
hydroxyzine hcl.................. 48, 49
hydroxyzine pamoate............. 131
HYPERRAB S/D (PF)......... 120
HYQVIA.............................. 120
HYQVIA IG COMPONENT
.............................................. 120
HYSINGLA ER.......................5
ibandronate............................128
IBRANCE.............................. 27
ibuprofen................................... 9
ICLUSIG................................27
ifosfamide................................ 27
ifosfamide-mesna..................... 28
ILARIS (PF).........................121
ILEVRO............................... 106
imatinib................................... 28
IMBRUVICA.........................28
imipenem-cilastatin.................. 20
imipramine hcl......................... 40
imipramine pamoate.................40
imiquimod................................95
IMLYGIC.............................. 28
IMOGAM RABIES-HT (PF)
.............................................. 121
IMOVAX RABIES
VACCINE (PF).................... 124
INCRELEX..........................116
INCRUSE ELLIPTA........... 139
indapamide.............................. 81
indomethacin............................. 9
indomethacin sodium..................9
INFANRIX (DTAP) (PF).... 124
INFLECTRA....................... 131
INLYTA.................................28
INSULIN SYRINGENEEDLE U-100................... 100
INTELENCE......................... 59
INTRALIPID.........................70
INTRON A............................ 63
introvale.................................. 89
INVANZ................................ 20
INVEGA SUSTENNA.......... 56
INVEGA TRINZA................ 56
INVIRASE............................. 59
INVOKAMET....................... 42
INVOKAMET XR.................42
INVOKANA.......................... 42
IONOSOL-B IN D5W.......... 134
IONOSOL-MB IN D5W...... 134
IPOL..................................... 124
ipratropium bromide....... 103, 139
IPRIVASK............................. 65
irbesartan................................ 71
irbesartan-hydrochlorothiazide.72
IRESSA.................................. 28
irinotecan.................................28
ISENTRESS..................... 59, 60
ISOLYTE-P IN 5 %
DEXTROSE......................... 134
ISOLYTE-S.......................... 134
isoniazid.................................. 50
isosorbide dinitrate............. 83, 84
isosorbide mononitrate............. 84
isradipine................................. 80
itraconazole............................. 47
ivermectin................................ 52
IXEMPRA............................. 28
IXIARO (PF)........................124
JAKAFI..................................28
I-8
Index
Index
Index
jantoven................................... 65
JANUMET.............................42
JANUMET XR...................... 42
JANUVIA.............................. 42
JARDIANCE......................... 42
jencycla................................... 89
JENTADUETO......................42
JENTADUETO XR............... 42
jinteli..................................... 113
jolessa......................................89
jolivette....................................89
juleber..................................... 89
junel 1.5/30 (21)......................90
junel 1/20 (21).........................90
junel fe 1.5/30 (28).................. 90
junel fe 1/20 (28)..................... 90
junel fe 24................................ 90
JUXTAPID............................ 82
KABIVEN..............................70
KALETRA.............................60
KALYDECO........................141
KANUMA........................... 101
kariva (28)..............................90
KAZANO...............................42
kelnor 1/35 (28)...................... 90
ketoconazole............................ 47
ketoprofen................................. 9
ketorolac............................9, 106
KEVEYIS............................. 131
KEYTRUDA......................... 28
kimidess (28).......................... 90
KINERET............................ 121
KINRIX (PF)................124, 125
kionex....................................108
kionex (with sorbitol)............ 108
KISQALI................................28
KLOR-CON 10.................... 134
klor-con m10..........................134
klor-con m15..........................134
klor-con m20..........................134
klor-con sprinkle.................... 134
KOMBIGLYZE XR.............. 42
KORLYM.............................. 43
KRYSTEXXA......................101
kurvelo.................................... 90
KUVAN............................... 101
KYNAMRO...........................82
KYPROLIS............................ 28
l norgest/e.estradiol-e.estrad.....90
labetalol...................................75
LACRISERT........................ 103
LACTATED RINGERS...... 128
lactulose.................................108
lamivudine............................... 60
lamivudine-zidovudine.............. 60
lamotrigine.........................35, 36
LANOXIN............................. 79
lansoprazole...........................107
LANTUS................................ 45
LANTUS SOLOSTAR...........45
larin 1.5/30 (21)...................... 90
larin 1/20 (21).........................90
larin 24 fe................................ 90
larin fe 1.5/30 (28).................. 90
larin fe 1/20 (28)..................... 90
larissia.....................................90
LARTRUVO..........................29
latanoprost.............................133
LATUDA............................... 56
LAZANDA.............................. 5
leena 28................................... 90
leflunomide............................ 121
LEMTRADA......................... 86
LENVIMA............................. 29
lessina......................................90
LETAIRIS............................ 143
letrozole...................................29
leucovorin calcium..................131
LEUKERAN..........................29
LEUKINE..............................66
I-9
leuprolide.................................29
levetiracetam........................... 36
levetiracetam in nacl (iso-os)... 36
levobunolol.............................133
levocarnitine.......................... 131
levocarnitine (with sugar)...... 131
levocetirizine............................49
levofloxacin......................23, 104
levofloxacin in d5w.................. 22
LEVOLEUCOVORIN......... 131
levoleucovorin........................ 131
levonest (28)........................... 90
levonorgestrel-ethinyl estrad
.......................................... 90, 91
levonorg-eth estrad triphasic.... 91
levora-28..................................91
levothyroxine......................... 118
LEXIVA................................. 60
LIALDA...............................127
lidocaine.................................. 10
lidocaine (pf).....................10, 74
lidocaine hcl.............................10
lidocaine in 5 % dextrose (pf).. 74
lidocaine viscous...................... 10
lidocaine-prilocaine.................. 10
linezolid................................... 16
LINZESS.............................. 108
liothyronine............................118
lisinopril.................................. 73
lisinopril-hydrochlorothiazide...73
lithium carbonate..................... 86
lithium citrate.......................... 86
LIVALO................................. 82
lomedia 24 fe........................... 91
LONSURF............................. 29
loperamide............................. 108
lopinavir-ritonavir.................... 60
lorazepam................................ 13
lorazepam intensol................... 13
lorcet (hydrocodone).................5
Index
Index
Index
lorcet hd.................................... 5
lorcet plus..................................5
loryna (28)..............................91
losartan................................... 72
losartan-hydrochlorothiazide....72
LOTEMAX.......................... 106
lovastatin................................. 82
low-ogestrel (28)..................... 91
loxapine succinate....................56
LUMIGAN.......................... 133
LUPRON DEPOT................. 29
LUPRON DEPOT (3
MONTH)................................29
LUPRON DEPOT (4
MONTH)................................29
LUPRON DEPOT (6
MONTH)................................29
LUPRON DEPOT-PED.......116
LUPRON DEPOT-PED (3
MONTH)..............................116
lutera (28)...............................91
LYNPARZA.......................... 29
LYRICA.................................36
LYSODREN.......................... 29
lyza......................................... 91
magnebind 400....................... 110
magnesium sulfate..................135
magnesium sulfate in d5w....... 134
magnesium sulfate in water
.......................................134, 135
malathion................................ 99
maprotiline.............................. 40
margesic.................................... 5
marlissa................................... 91
MARPLAN............................40
MARQIBO.............................29
MATULANE......................... 29
matzim la.................................76
meclizine..................................51
medroxyprogesterone............. 117
mefenamic acid.......................... 9
mefloquine............................... 52
MEFOXIN IN DEXTROSE
(ISO-OSM)............................. 19
megestrol......................... 29, 118
MEKINIST............................ 29
meloxicam................................. 9
melphalan hcl...........................30
memantine............................... 38
MENACTRA (PF)............... 125
MENEST..............................113
MENHIBRIX (PF)...............125
MENOMUNE - A/C/Y/W135........................................ 125
MENOMUNE - A/C/Y/W135 (PF)................................ 125
MENVEO A-C-Y-W-135-DIP
(PF).......................................125
mercaptopurine........................ 30
meropenem.............................. 20
mesalamine............................ 127
mesna.................................... 131
MESNEX............................. 131
MESTINON......................... 131
metaproterenol.......................139
metaxall.................................141
metaxalone............................ 141
metformin................................ 43
methadone................................. 6
methadose..................................6
methazolamide....................... 133
methenamine hippurate............ 16
methimazole...........................118
methocarbamol...................... 141
methotrexate sodium................30
methotrexate sodium (pf)........ 30
methoxsalen.............................95
methscopolamine....................108
methyclothiazide...................... 81
methylergonovine................... 131
methylphenidate.......................86
methylprednisolone................ 114
methylprednisolone acetate.... 114
methylprednisolone sodium
succ....................................... 115
metipranolol...........................133
metoclopramide hcl................ 108
metolazone.............................. 81
metoprolol succinate................ 75
metoprolol ta-hydrochlorothiaz 75
metoprolol tartrate...................75
metronidazole............... 16, 49, 96
metronidazole in nacl (iso-os)..16
mexiletine................................ 74
MIACALCIN....................... 129
miconazole-3............................47
microgestin 1.5/30 (21)........... 91
microgestin 1/20 (21).............. 91
microgestin fe 1.5/30 (28)........91
microgestin fe 1/20 (28)...........91
midazolam............................... 13
midodrine.................................71
miglitol.................................... 43
milrinone................................. 79
milrinone in 5 % dextrose......... 79
mimvey.................................. 113
mimvey lo.............................. 113
minitran...................................84
MINOCIN..............................24
minocycline..............................24
minoxidil................................. 84
MIRCERA............................. 66
mirtazapine..............................40
misoprostol............................ 107
mitoxantrone........................... 30
M-M-R II (PF)..................... 125
moexipril................................. 73
moexipril-hydrochlorothiazide..73
molindone................................ 56
mometasone....................... 98, 99
I-10
Index
Index
Index
mono-linyah.............................91
mononessa (28)....................... 91
montelukast........................... 138
morphine................................... 6
MORPHINE............................ 6
morphine concentrate.................6
MOVANTIK........................ 109
MOVIPREP..........................109
MOXEZA.............................104
moxifloxacin............................23
MOZOBIL..............................66
MULTAQ.............................. 74
multi-vitamin with fluoride..... 144
mupirocin.................................96
mupirocin calcium....................96
mycophenolate mofetil........... 121
mycophenolate mofetil hcl...... 121
mycophenolate sodium........... 121
MYOBLOC.......................... 131
MYOZYME......................... 101
MYRBETRIQ...................... 111
myzilra.................................... 91
nabumetone............................... 9
nadolol.....................................75
nafcillin................................... 21
NAGLAZYME.................... 101
naloxone.................................. 11
naltrexone............................... 11
NAMENDA XR.................... 38
NAMZARIC.......................... 38
naphazoline............................103
naproxen................................... 9
naproxen sodium........................9
naratriptan.............................. 49
NARCAN...............................11
NATACYN.......................... 104
nateglinide............................... 43
NATPARA...........................129
NEBUPENT...........................52
necon 0.5/35 (28).................... 91
necon 1/35 (28)....................... 91
necon 1/50 (28)....................... 91
necon 10/11 (28)..................... 91
necon 7/7/7 (28)...................... 91
nefazodone...............................40
neomycin................................. 15
neomycin-bacitracin-poly-hc...104
neomycin-bacitracin-polymyxin
.............................................. 104
neomycin-polymyxin b gu.........96
neomycin-polymyxin bdexameth............................... 104
neomycin-polymyxingramicidin..............................104
neomycin-polymyxin-hc......... 104
neo-polycin............................ 104
neo-polycin hc........................ 104
NEPHRAMINE 5.4 %........... 70
NESINA................................. 43
neuac....................................... 96
NEULASTA...........................66
NEUPOGEN..........................66
NEUPRO............................... 54
NEVANAC.......................... 106
nevirapine................................ 60
NEXAVAR............................ 30
niacin.......................................82
niacor...................................... 82
nicardipine............................... 80
NICOTROL........................... 11
nifedical xl...............................80
nifedipine................................. 80
nikki (28)................................91
NILANDRON....................... 30
nilutamide................................30
NINLARO............................. 30
NITRO-BID........................... 84
nitrofurantoin.......................... 16
nitrofurantoin macrocrystal..... 16
I-11
nitrofurantoin monohyd/mcryst........................................ 16
nitroglycerin............................ 84
nitroglycerin in 5 % dextrose....84
NITROSTAT......................... 84
nizatidine............................... 107
nora-be.................................... 91
NORDITROPIN FLEXPRO
.............................................. 116
norepinephrine bitartrate..........79
noreth-ethinyl estradiol-iron..... 91
norethindrone (contraceptive)..92
norethindrone acetate.............118
norethindrone ac-eth estradiol
.........................................92, 113
norethindrone-e.estradiol-iron.. 92
norgestimate-ethinyl estradiol.. 92
norlyroc................................... 92
NORMOSOL-M IN 5 %
DEXTROSE......................... 135
NORMOSOL-R................... 135
NORMOSOL-R PH 7.4....... 135
NORTHERA......................... 71
nortrel 0.5/35 (28)...................92
nortrel 1/35 (21)......................92
nortrel 1/35 (28)......................92
nortrel 7/7/7 (28).....................92
nortriptyline.............................40
NORVIR................................ 60
NOVOLIN 70/30.................... 45
NOVOLIN N..........................45
NOVOLIN R..........................45
NOVOLOG............................ 45
NOVOLOG FLEXPEN......... 45
NOVOLOG MIX 70-30..........45
NOVOLOG MIX 70-30
FLEXPEN..............................45
NOVOLOG PENFILL...........45
NOXAFIL..............................47
NPLATE.............................. 131
Index
Index
Index
NUCALA............................. 141
NUCYNTA..............................6
NUCYNTA ER....................... 6
NUEDEXTA..........................86
NULOJIX.............................121
NUPLAZID........................... 56
NUTRESTORE................... 109
NUTRILIPID........................ 70
NUTROPIN AQ.................. 116
NUTROPIN AQ NUSPIN...116
NUVARING..........................92
nyamyc.................................... 47
nyata....................................... 47
nystatin.............................. 47, 48
nystatin-triamcinolone............. 48
nystop......................................48
OCALIVA............................ 109
ocella.......................................92
OCREVUS............................. 86
OCTAGAM..........................121
octreotide acetate...................116
ODEFSEY..............................60
ODOMZO.............................. 30
OFEV....................................141
ofloxacin.......................... 23, 104
ogestrel (28)........................... 92
olanzapine............................... 57
olanzapine-fluoxetine............... 40
olmesartan...............................72
olmesartan-amlodipin-hcthiazid72
olmesartan-hydrochlorothiazide72
olopatadine............................ 103
OLYSIO................................. 62
omega-3 acid ethyl esters......... 82
omeprazole............................ 107
OMNITROPE...................... 116
ONCASPAR.......................... 30
ondansetron............................. 51
ondansetron hcl........................51
ondansetron hcl (pf)................ 51
ONFI...................................... 13
ONGLYZA............................ 43
ONIVYDE............................. 30
OPDIVO.................................30
OPSUMIT............................ 143
oralone.................................... 94
ORENCIA............................121
ORENCIA (WITH
MALTOSE).......................... 121
ORENCIA CLICKJECT..... 132
ORENITRAM......................143
ORFADIN........................... 101
ORKAMBI...........................141
orsythia................................... 92
oseltamivir............................... 62
OSENI.................................... 43
OTEZLA.............................. 121
OTEZLA STARTER............121
OTOVEL.............................. 103
OTREXUP (PF)................... 122
oxacillin...................................22
oxacillin in dextrose(iso-osm)..21
oxaliplatin............................... 30
oxandrolone........................... 112
oxcarbazepine..........................36
OXTELLAR XR.................... 36
oxybutynin chloride................111
oxycodone..............................6, 7
oxycodone-acetaminophen......... 7
oxycodone-aspirin......................7
OXYCONTIN..........................7
oxymorphone.............................7
pacerone.................................. 74
paclitaxel.................................30
paliperidone............................. 57
pamidronate...........................129
PANRETIN........................... 95
pantoprazole.......................... 107
paricalcitol.............................129
PARICALCITOL.................129
paromomycin........................... 52
paroxetine hcl.................... 40, 41
PASER................................... 50
PATADAY...........................103
PAXIL.................................... 41
PEDIARIX (PF)...................125
PEDVAX HIB (PF).............. 125
peg 3350-electrolytes...... 109, 110
PEGANONE..........................36
PEGASYS.............................. 63
PEGASYS PROCLICK......... 63
peg-electrolyte soln................ 110
PEGINTRON........................ 63
PEN NEEDLE, DIABETIC.100
penicillin g pot in dextrose........22
penicillin g potassium............... 22
penicillin g procaine................. 22
penicillin v potassium............... 22
PENTACEL (PF)................. 125
PENTAM............................... 52
pentoxifylline...........................67
PERIKABIVEN..................... 70
perindopril erbumine................ 73
periogard................................. 94
PERJETA...............................30
permethrin............................. 100
perphenazine............................57
perphenazine-amitriptyline....... 41
PERTZYE............................ 101
pfizerpen-g...............................22
phenadoz................................. 51
phenelzine................................ 41
phenobarbital...........................36
phenylephrine hcl..............71, 103
phenytoin........................... 36, 37
phenytoin sodium..................... 37
phenytoin sodium extended.......37
philith...................................... 92
PHOSLYRA.........................110
PHOSPHOLINE IODIDE... 133
I-12
Index
Index
Index
PICATO................................. 95
pilocarpine hcl.................. 94, 133
pimozide.................................. 57
pimtrea (28)............................92
pindolol....................................75
pioglitazone............................. 43
pioglitazone-glimepiride........... 43
pioglitazone-metformin............ 43
piperacillin-tazobactam............22
pirmella................................... 92
piroxicam.................................. 9
PLASMA-LYTE 148............ 135
PLASMA-LYTE A...............135
PLASMA-LYTE-56 IN 5 %
DEXTROSE......................... 135
PLEGRIDY........................... 86
podofilox................................. 95
polyethylene glycol 3350........ 110
polymyxin b sulfate..................16
polymyxin b sulf-trimethoprim105
POMALYST.......................... 30
portia.......................................92
PORTRAZZA........................ 30
potassium acetate...................135
potassium chlorid-d50.45%nacl.............................. 135
potassium chloride.......... 135, 136
potassium chloride in 0.9%nacl
.............................................. 135
potassium chloride in 5 % dex.135
potassium chloride in lr-d5..... 135
potassium chloride-0.45 % nacl
.............................................. 136
potassium chloride-d50.2%nacl................................ 136
potassium chloride-d50.3%nacl........................ 134, 136
potassium chloride-d50.9%nacl................................ 136
potassium citrate....................136
potassium citrate-citric acid... 136
potassium hydroxide................ 95
POTIGA................................. 37
PRADAXA............................ 65
PRALUENT PEN..................82
PRALUENT SYRINGE........82
pramipexole.............................54
pravastatin...............................82
prazosin................................... 71
prednicarbate...........................99
prednisolone acetate...............106
prednisolone sodium phosphate
.......................................106, 115
prednisone..............................115
PREMARIN.........................114
PREMASOL 10 %..................70
PREMASOL 6 %....................70
PREMPHASE...................... 114
PREMPRO...........................114
prenatal plus (calcium carb).. 144
prenatal vitamin plus low iron.144
PREPOPIK...........................110
prevalite...................................82
previfem...................................92
PREZCOBIX..........................60
PREZISTA............................. 60
PRIFTIN................................ 50
PRIMAQUINE...................... 52
primidone.................................37
PRISTIQ.................................41
PRIVIGEN...........................122
PROAIR HFA......................139
PROAIR RESPICLICK.......139
probenecid............................... 48
probenecid-colchicine............... 48
procainamide........................... 74
PROCALAMINE 3%.............70
prochlorperazine...................... 51
prochlorperazine edisylate........51
prochlorperazine maleate......... 51
PROCRIT.............................. 66
procto-med hc.......................... 99
procto-pak............................... 99
proctosol hc............................. 99
proctozone-hc.......................... 99
PROCYSBI...........................132
progesterone in oil..................118
progesterone micronized.........118
PROGLYCEM.......................84
PROGRAF...........................122
PROLASTIN-C.................... 141
PROLENSA......................... 106
PROLEUKIN........................ 31
PROLIA............................... 129
PROMACTA......................... 66
promethazine......................49, 52
promethegan............................ 52
propafenone............................. 74
propantheline........................... 34
proparacaine.......................... 103
propranolol.............................. 75
propranolol-hydrochlorothiazid 75
propylthiouracil..................... 118
PROQUAD (PF).................. 125
PROSOL 20 %........................ 70
protamine................................ 66
protriptyline.............................41
PULMOZYME.................... 101
PURIXAN..............................31
pyrazinamide........................... 50
pyridostigmine bromide.......... 132
QBRELIS............................... 73
QUADRACEL (PF).............125
quasense.................................. 92
quetiapine................................ 57
quinapril.................................. 73
quinapril-hydrochlorothiazide...73
quinidine gluconate.................. 74
quinidine sulfate.......................74
quinine sulfate..........................52
I-13
Index
Index
Index
QVAR...................................138
RABAVERT (PF)................ 125
raloxifene.............................. 114
ramipril................................... 73
RANEXA............................... 79
ranitidine hcl.......................... 107
RAPAMUNE....................... 122
rasagiline................................. 54
RASUVO (PF)......................122
RAVICTI..............................109
RAYALDEE........................ 129
REBIF (WITH ALBUMIN).. 87
REBIF REBIDOSE................87
REBIF TITRATION PACK..87
reclipsen (28).......................... 92
RECOMBIVAX HB (PF).....126
REGRANEX......................... 95
RELENZA DISKHALER..... 62
RELISTOR...........................109
REMICADE.........................132
REMODULIN..................... 144
RENAGEL...........................110
RENVELA........................... 110
repaglinide............................... 43
repaglinide-metformin..............43
REPATHA PUSHTRONEX. 82
REPATHA SURECLICK......83
REPATHA SYRINGE.......... 83
reprexain................................... 7
RESCRIPTOR....................... 60
RESTASIS............................106
RESTASIS MULTIDOSE... 106
RETROVIR........................... 61
REVLIMID............................31
revonto...................................141
REXULTI.............................. 57
REYATAZ............................. 61
ribasphere................................ 63
ribasphere ribapak................... 64
ribavirin...................................64
RIDAURA........................... 122
rifabutin...................................50
rifampin...................................50
RIFATER.............................. 50
riluzole.................................... 87
rimantadine............................. 62
ringer's........................... 128, 136
risedronate.............................129
RISPERDAL CONSTA.........57
risperidone......................... 57, 58
RITUXAN............................. 31
rivastigmine............................. 38
rivastigmine tartrate................ 38
rizatriptan............................... 49
ropinirole................................. 54
rosadan....................................96
rosuvastatin............................. 83
ROTARIX............................126
ROTATEQ VACCINE.........126
ROWEEPRA..........................37
ROZEREM.......................... 142
RUBRACA............................ 31
SABRIL..................................37
SAIZEN................................117
SAIZEN CLICK.EASY....... 117
SANDOSTATIN LAR
DEPOT................................. 117
SANTYL................................ 95
SAPHRIS (BLACK
CHERRY)..............................58
SAVAYSA..............................65
SAVELLA.............................. 87
selegiline hcl............................ 54
selenium sulfide........................96
SELZENTRY.........................61
SENSIPAR........................... 132
SEREVENT DISKUS.......... 139
SEROQUEL XR.................... 58
SEROSTIM.......................... 117
sertraline................................. 41
I-14
setlakin....................................92
sharobel................................... 92
SIGNIFOR...........................132
sildenafil................................ 144
SILENOR.............................142
SILIQ......................................95
silver nitrate.............................96
silver sulfadiazine.....................96
SIMBRINZA........................133
SIMPONI............................. 122
SIMPONI ARIA.................. 122
simvastatin.............................. 83
sirolimus................................ 122
SIRTURO.............................. 50
smoflipid..................................70
sodium acetate....................... 136
sodium bicarbonate................ 136
sodium chloride...............128, 137
sodium chloride 0.45 %...........137
sodium chloride 0.9 %............ 137
sodium chloride 3 %............... 137
sodium chloride 5 %............... 137
sodium fluoride...................... 144
sodium lactate........................137
sodium phosphate................... 137
sodium polystyrene (sorb free)
.............................................. 109
sodium polystyrene sulfonate.. 109
SOLTAMOX..........................31
SOLU-CORTEF (PF)...........115
SOMATULINE DEPOT......117
SOMAVERT........................ 117
sorbitol.................................. 128
sorbitol-mannitol....................128
sorine.......................................75
sotalol......................................75
sotalol af..................................75
SOVALDI.............................. 62
spinosad.................................100
SPIRIVA RESPIMAT..........139
Index
Index
Index
SPIRIVA WITH
HANDIHALER................... 140
spironolactone..........................81
spironolacton-hydrochlorothiaz 81
SPORANOX.......................... 48
sprintec (28)........................... 92
SPRITAM.............................. 37
SPRYCEL.............................. 31
sps (with sorbitol)..................109
sronyx..................................... 93
ssd........................................... 96
stavudine..................................61
STELARA............................ 122
STERILE GAUZE PAD...... 100
STIMATE.............................117
STIOLTO RESPIMAT.........140
STIVARGA............................31
STRATTERA.........................87
STRENSIQ...........................101
streptomycin............................ 15
STRIBILD..............................61
STRIVERDI RESPIMAT.... 140
SUBOXONE.......................... 11
sucralfate...............................107
sulfacetamide sodium............. 105
sulfacetamide sodium (acne)....96
sulfacetamide-prednisolone.....105
sulfadiazine..............................23
sulfamethoxazole-trimethoprim 23
sulfasalazine............................ 23
sulfatrim.................................. 23
sulindac..................................... 9
sumatriptan............................. 49
sumatriptan succinate.........49, 50
SUPPRELIN LA.................. 117
SUPRAX................................ 19
SUPREP BOWEL PREP KIT
.............................................. 110
SURMONTIL........................ 41
SUSTIVA............................... 61
SUTENT................................ 31
syeda....................................... 93
SYLATRON.......................... 63
SYLVANT............................. 31
SYMBICORT.......................138
SYMLINPEN 120.................. 43
SYMLINPEN 60.................... 43
SYNAGIS...............................62
SYNAREL........................... 132
SYNERCID........................... 16
SYNJARDY...........................43
SYNJARDY XR.................... 44
SYNRIBO.............................. 31
SYPRINE............................. 112
TABLOID.............................. 31
tacrolimus........................ 99, 122
TAFINLAR........................... 31
TAGRISSO............................ 31
TALTZ AUTOINJECTOR....95
TALTZ AUTOINJECTOR (3
PACK)....................................95
TALTZ SYRINGE................ 95
TAMIFLU............................. 62
tamoxifen................................ 31
tamsulosin..............................111
TARCEVA............................. 31
TARGRETIN........................ 31
tarina fe 1/20 (28)................... 93
TASIGNA.............................. 31
tazarotene................................99
tazicef......................................19
TAZORAC.............................99
taztia xt...................................76
TECENTRIQ......................... 32
TECFIDERA......................... 87
TECHNIVIE.......................... 62
TEFLARO............................. 19
TEKAMLO............................ 83
TEKTURNA..........................83
TEKTURNA HCT.................83
telmisartan.............................. 72
telmisartan-hydrochlorothiazid.72
temazepam.........................13, 14
TEMODAR............................32
tencon........................................7
teniposide.................................32
TENIVAC (PF).................... 126
terazosin................................ 111
terbinafine hcl.......................... 48
terbutaline............................. 140
terconazole.............................. 49
testosterone............................112
testosterone cypionate............ 112
testosterone enanthate............112
TETANUS,DIPHTHERIA
TOX PED(PF)...................... 126
TETANUS-DIPHTHERIA
TOXOIDS-TD......................126
tetrabenazine........................... 87
tetracycline.............................. 24
THALOMID........................ 132
theophylline........................... 140
theophylline in dextrose 5 %... 140
THIOLA...............................132
thioridazine..............................58
thiotepa................................... 32
thiothixene...............................58
tiagabine..................................37
TICE BCG............................126
tigecycline................................24
tilia fe...................................... 93
timolol maleate.................75, 133
tinidazole................................. 52
TIVICAY............................... 61
tizanidine............................... 142
TOBI PODHALER................ 15
TOBRADEX........................ 105
TOBRADEX ST...................105
tobramycin.............................105
tobramycin in 0.225 % nacl...... 15
I-15
Index
Index
Index
tobramycin in 0.9 % nacl.......... 15
tobramycin sulfate................... 15
tobramycin-dexamethasone.... 105
TOLAK.................................. 95
tolazamide............................... 46
tolbutamide..............................46
tolmetin................................... 10
tolterodine............................. 111
topiramate............................... 37
toposar.................................... 32
topotecan.................................32
TORISEL............................... 32
torsemide................................. 81
TOUJEO SOLOSTAR........... 45
TOVIAZ............................... 111
TPN ELECTROLYTES.......137
TPN ELECTROLYTES II... 137
TRACLEER......................... 144
TRADJENTA........................ 44
tramadol....................................7
tramadol-acetaminophen............7
trandolapril..............................73
tranexamic acid....................... 66
TRANSDERM-SCOP............52
tranylcypromine.......................41
TRAVASOL 10 %.................. 70
TRAVATAN Z.....................133
travoprost (benzalkonium).... 133
trazodone.................................41
TREANDA............................ 32
TRECATOR.......................... 50
TRELSTAR........................... 32
tretinoin...................................99
tretinoin (chemotherapy).........32
tretinoin microspheres.............. 99
TREXALL............................. 32
triamcinolone acetonide
................................... 94, 99, 106
triamterene-hydrochlorothiazid 81
trianex.....................................99
triazolam................................. 14
TRIBENZOR......................... 72
tridesilon..................................99
tri-estarylla..............................93
trifluoperazine......................... 58
trifluridine............................. 105
trihexyphenidyl........................ 54
tri-legest fe.............................. 93
tri-linyah..................................93
tri-lo-estarylla..........................93
tri-lo-marzia............................ 93
tri-lo-sprintec...........................93
trilyte with flavor packets.......110
trimethoprim............................17
trimipramine............................41
trinessa (28)............................93
TRINTELLIX........................ 41
tri-previfem (28)..................... 93
tri-sprintec (28).......................93
TRIUMEQ............................. 61
trivora (28)............................. 93
TROKENDI XR.................... 37
TROPHAMINE 10 %............ 70
TROPHAMINE 6%............... 70
trospium................................ 111
TRULICITY.......................... 44
TRUMENBA....................... 126
TRUVADA............................ 61
TWINRIX (PF).................... 126
TYBOST...............................132
TYGACIL.............................. 24
TYKERB................................32
TYPHIM VI......................... 126
TYSABRI............................. 122
TYVASO.............................. 144
TYZEKA................................64
TYZINE............................... 103
UCERIS............................... 127
u-cort.......................................99
ULORIC.................................48
UNITUXIN........................... 32
UPTRAVI............................ 144
ursodiol..................................109
VAGIFEM........................... 114
valacyclovir..............................64
VALCHLOR.......................... 95
VALCYTE............................. 64
valganciclovir...........................64
valproate sodium......................37
valproic acid............................ 37
valproic acid (as sodium salt).. 37
valsartan..................................72
valsartan-hydrochlorothiazide.. 72
VALSTAR..............................32
vancomycin..............................17
vancomycin in dextrose 5 %..... 17
VAQTA (PF).................126, 127
VARIVAX (PF)....................127
VASCEPA.............................. 83
VECTIBIX............................. 33
VELCADE............................. 33
velivet triphasic regimen (28)...93
VELPHORO.........................110
VELTASSA.......................... 109
VEMLIDY............................. 64
VENCLEXTA........................ 33
VENCLEXTA STARTING
PACK..................................... 33
venlafaxine.............................. 41
VENTOLIN HFA................ 140
verapamil.................................76
VEREGEN.............................95
VERSACLOZ.........................58
VESICARE...........................111
vestura (28)............................ 93
VGO 40.................................100
VIBERZI.............................. 109
vicodin.......................................8
vicodin es................................... 7
vicodin hp.................................. 7
I-16
Index
Index
Index
VICTOZA 3-PAK.................. 44
VIDEX 2 GRAM
PEDIATRIC.......................... 61
VIEKIRA PAK...................... 62
VIEKIRA XR........................ 62
vienva...................................... 93
VIGAMOX...........................105
VIIBRYD............................... 41
VIMIZIM............................. 102
VIMPAT.................................38
vinblastine................................33
vincasar pfs..............................33
vincristine................................ 33
vinorelbine............................... 33
viorele (28)............................. 93
VIRACEPT............................ 61
VIRAZOLE............................64
VIREAD.................................61
VITEKTA.............................. 61
VOLTAREN.......................... 10
voriconazole.............................48
VOTRIENT............................33
VPRIV.................................. 102
VRAYLAR............................ 58
vyfemla (28)........................... 93
VYTORIN 10-10.................... 83
VYTORIN 10-20.................... 83
VYTORIN 10-40.................... 83
VYTORIN 10-80.................... 83
warfarin...................................65
water for irrigation, sterile..... 128
WELCHOL............................ 83
wera (28)................................ 93
wymzya fe................................93
XALKORI............................. 33
XARELTO............................. 65
XARTEMIS XR...................... 8
XELJANZ............................ 122
XELJANZ XR......................123
XERMELO.......................... 109
XGEVA................................ 129
XIFAXAN............................. 17
XIIDRA................................106
XOLAIR...............................141
XTAMPZA ER........................ 8
XTANDI................................ 33
xulane......................................93
xylon 10.................................... 8
XYREM............................... 142
YERVOY............................... 33
YF-VAX (PF)....................... 127
YONDELIS............................33
yuvafem................................. 114
zafirlukast..............................138
zaleplon................................. 142
ZALTRAP..............................33
zarah....................................... 93
ZARXIO.................................66
ZAVESCA............................ 102
zebutal.......................................8
ZELBORAF........................... 33
ZEMPLAR........................... 129
zenatane.................................. 95
zenchent (28).......................... 93
zenchent fe...............................94
ZENPEP............................... 102
ZEPATIER.............................62
ZERIT.................................... 61
ZETIA.................................... 83
ZIAGEN.................................61
zidovudine.......................... 61, 62
ZINBRYTA........................... 87
ZIOPTAN (PF).....................133
ziprasidone hcl......................... 58
ZIRGAN.............................. 105
ZOHYDRO ER....................... 8
ZOLADEX....................... 33, 34
zoledronic acid....................... 129
zoledronic acid-mannitol-water
.............................................. 129
I-17
zoledronic ac-mannitol-0.9nacl
.............................................. 129
ZOLINZA.............................. 34
zolmitriptan............................. 50
zolpidem................................ 143
ZOMACTON....................... 117
ZOMETA............................. 130
zonisamide............................... 38
ZORBTIVE.......................... 117
ZORTRESS.......................... 123
ZOSTAVAX (PF).................127
zovia 1/35e (28)...................... 94
zovia 1/50e (28)...................... 94
ZOVIRAX..............................95
ZUBSOLV..............................11
ZURAMPIC...........................48
ZYDELIG.............................. 34
ZYKADIA............................. 34
ZYLET................................. 105
ZYPREXA RELPREVV........58
ZYTIGA.................................34
This formulary was updated 06/01/2017. For more recent information or other questions, please contact
ATRIO Health Plans at 1-877-672-8620 or, for TTY/TDD users, 1-800-735-2900, 8 a.m. to 8 p.m., daily, or visit
atriohp.com/medicare.
ATRIO Health Plans has PPO and HMO D-SNP plans with a Medicare Contract. Enrollment in ATRIO Health
Plans depends on contract renewal.