Healthfirst Medicare Plan Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT
THE DRUGS WE COVER IN THIS PLAN.
Formulario del Plan Medicare de Healthfirst
(Lista de medicamentos cubiertos)
LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN
SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN.
第一保健老人醫療保險計劃「處方藥一覽表」
(承保藥物目錄)
請閱讀：本文件含有關於我們在本計劃所承保藥物的資訊。
2017
New York
Nueva York
紐約
This formulary was updated on 08/23/2016. For more recent information or other questions, please contact
Healthfirst Medicare Plan at 1-888-260-1010 or, for TTY users, 711, 7 days a week, from 8am to 8pm.
Or visit www.healthfirst.org/medicare.
HPMS Approved Formulary File Submission ID 00017240, Version 6, Last Updated 08232016.
Healthfirst Medicare Plan
2017 Formulary (List of Covered Drugs)
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 Healthfirst Medicare Plan. When it refers to “plan” or “our plan,” it means Healthfirst Medicare Plan.
This document includes a list of the drugs (formulary) for our plan which is current as of August 23, 2016. 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, 2017, and from time to time during the year. Plan Medicare de Healthfirst
Formulario 2017 (Lista de medicamentos cubiertos)
Aviso a los actuales miembros: Este formulario sufrió cambios con respecto al año pasado. Lea este documento para asegurarse de que contiene los medicamentos que usted toma.
Cuando en esta lista de medicamentos (formulario) se utilicen los términos “nosotros” o “nuestro”, se referirá al Plan Medicare de Healthfirst. Cuando se utilicen los términos “plan” o “nuestro plan”, se referirá al Plan Medicare de Healthfirst.
Este documento contiene una lista de los medicamentos (formulario) de nuestro plan, actualizada el 23 de agosto de 2016. Para obtener el formulario actualizado, comuníquese con nosotros.
Encontrará nuestra información de contacto, así como la fecha de la última actualización del formulario, en la primera y última página de este folleto.
Por lo general, para obtener el beneficio de los medicamentos recetados usted debe dirigirse a las farmacias de la red. Los beneficios, el formulario, la red de farmacias y los copagos/coseguro pueden cambiar a partir del 1º de enero de 2017, y de forma periódica durante el año.
第一保健「老人醫療保險計劃」
2017年「處方藥一覽表」(承保藥物目錄)
現有會員請注意：去年以來本「處方藥一覽表」已經更動。請查閱本文件以確保其中仍然含有您服用的藥物。
本「藥物目錄」(「處方藥一覽表」)如果提到「我們」﹑或「我們的」，指的就是第一保健老人醫療保險計劃。如果
提到「本計劃」﹑或「我們的計劃」指的就是第一保健老人醫療保險計劃。在提到“計劃”或“我們的計劃，”意思
是第一保健「老人醫療保險」(Healthfirst Medicare Plan)。 本文件載有我們的計劃到2016年8月23日為止的藥
物目錄(「處方藥一覽表」)。如需最新的「處方藥一覽表」，
請與我們聯絡。我們的聯絡資訊連同我們最近更新「處方藥一覽表」的日期就印在封面與封底。
您一般必須使用網絡藥房才能享用您的處方配藥福利。福利、「處方藥一覽表」、藥房網絡與/或定額手續費/共
同保險2017年1月1日及該年度期間可能會不時變動。
H3359_QIP17_02v2 Accepted 09042016
H3359_QIP17_02v2s Accepted 09042016
H3359_QIP17_02v2ch Accepted 09042016
HPMS Approved Formulary File Submission ID 00017240, Version 6, Last Updated 08232016.
2017 Drug Formulary
Formulario de medicamentos 2017
2017 年「處方藥一覽表」
What is the Healthfirst Medicare Plan
Formulary?
A formulary is a list of covered drugs selected
by Healthfirst Medicare Plan in consultation
with a team of healthcare providers, which
represents the prescription therapies believed
to be a necessary part of a quality treatment
program. Healthfirst Medicare Plan will
generally cover the drugs listed in our formulary
as long as the drug is medically necessary, the
prescription is filled at a Healthfirst Medicare
Plan 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 2016
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.
i
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 August 23, 2016.
To get updated information about the drugs
covered by Healthfirst Medicare Plan, please
contact us. Our contact information appears
on the front and back cover pages. Healthfirst
Medicare Plan may update this formulary on
a monthly basis throughout the year. Updates
include additions, deletions, and utilization
management changes based on the most
recent CMS-approved formulary. An
up-to-date formulary can be downloaded
from www.healthfirst.org/medicare or can be
obtained by calling Member Services at the
number on the front and back cover pages.
With any change made, we will update our print
formularies with the new information.
A copy of updated formulary may be obtained
from our Website or by calling us.
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 Medications.” If
you know what your drug is used for, look for
the category name in the list that begins on
page 1. Then look under the category name for
your drug.
Alphabetical Listing
If you are not sure what category to look under,
you should look for your drug in the Index
that begins on page 57. The Index provides an
alphabetical list of all of the drugs included in
this document. Both brand-name drugs and
generic drugs are listed in the Index. Look in
the Index and find your drug.
2017 Drug Formulary
Formulario de medicamentos 2017
2017 年「處方藥一覽表」
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?
Healthfirst Medicare Plan covers both brandname 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 brandname 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: Healthfirst Medicare Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Healthfirst Medicare Plan before you fill your prescriptions. If you don’t get approval, Healthfirst Medicare Plan may not cover the drug.
• Quantity Limits: For certain drugs, Healthfirst
Medicare Plan limits the amount of the drug
that Healthfirst Medicare Plan will cover.
For example, Healthfirst Medicare Plan
provides 60 tablets every 30 days per
prescription for omeprazole 20mg. This may
be in addition to a standard one-month or
three-month supply.
• Step Therapy: In some cases, Healthfirst
Medicare Plan requires you to first try certain
drugs to treat your medical condition before
we will cover another drug for that condition.
For example, if Drug A and Drug B both treat
your medical condition, Healthfirst Medicare
Plan may not cover Drug B unless you try
Drug A first. If Drug A does not work for you,
Healthfirst Medicare Plan 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 online a document
that explains our prior authorization and step
therapy restrictions. You may also ask us to
send you a copy. Our contact information,
along with the date we last updated the
formulary, appears on the front and back
cover pages.
You can ask Healthfirst Medicare Plan to make
an exception to these restrictions or limits or
for a list of other, similar drugs that may treat
your health condition. See the section “How
do I request an exception to the Healthfirst
Medicare Plan’s formulary?” on page iii for
information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary
(list of covered drugs), you should first
contact Member Services and ask if your
drug is covered.
If you learn that Healthfirst Medicare Plan does
not cover your drug, you have two options:
• You can ask Member Services for a list of similar drugs that are covered by Healthfirst Medicare Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Healthfirst Medicare Plan.
• You can ask Healthfirst Medicare Plan to
make an exception and cover your drug. See
below for information about how to request
an exception.
ii
2017 Drug Formulary
Formulario de medicamentos 2017
2017 年「處方藥一覽表」
How do I request an exception to the
Healthfirst Medicare Plan’s Formulary?
You can ask Healthfirst Medicare Plan to make
an exception to our coverage rules. There are
several types of exceptions that you can ask
us to make.
• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a predetermined cost-
sharing level, and you would not be able to ask us to provide the drug at a lower cost-
sharing level.
• You can 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, Healthfirst Medicare Plan
limits the amount of the drug that we will
cover. If your drug has a quantity limit, you
can ask us to waive the limit and cover a
greater amount.
Generally, Healthfirst Medicare Plan will only
approve your request for an exception if
the alternative drugs included on the plan’s
formulary, the lower cost-sharing drug, or
additional utilization restrictions would not be
as effective in treating your condition
and/or would cause you to have adverse
medical effects.
You should contact us to ask us for an initial
coverage decision for a formulary, tiering, or
utilization restriction exception. When you
request a formulary, tiering, or utilization
restriction exception, you should submit a
statement from your prescriber or physician
supporting your request. Generally, we must
make our decision within 72 hours of getting
your prescriber’s supporting statement. You
can request an expedited (fast) exception if
you or your doctor believe that your health
iii
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 90 days.
If you are a resident of a long term care facility,
we will allow you to refill your prescription
until we have provided you with up to a 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
experience a change in your level of care,
2017 Drug Formulary
Formulario de medicamentos 2017
2017 年「處方藥一覽表」
such as a move from a hospital
to a home setting, and you need a drug that
is not on our formulary, or if your ability to
get your drugs is limited, we will cover a
one-time temporary supply for up to 30 days
(or 31 days if you are a long term care resident)
from a network pharmacy. During this period,
you should use the plan’s exception process
if you wish to have continued coverage of the
drug after the temporary supply is finished.
For more information
For more detailed information about your
Healthfirst Medicare Plan prescription drug
coverage, please review your Evidence of
Coverage and other plan materials.
If you have questions about Healthfirst
Medicare Plan, please contact us. Our
contact information, along with the date
we last updated the formulary, appears on
the front and back cover pages.
If you have general questions about
Medicare prescription drug coverage, please
call Medicare at 1-800-MEDICARE
(1-800-633-4227), 24 hours a day, 7 days a
week. TTY users should call 1-877-486-2048.
Or, visit www.medicare.gov.
Healthfirst Medicare Plan’s Formulary
The formulary that begins on page 1 provides
coverage information about some of the drugs
covered by Healthfirst Medicare Plan. If you
have trouble finding your drug in the list, turn to
the Index that begins on page 57.
The first column of the chart lists the drug
name. Brand-name drugs are capitalized (e.g.,
BENICAR), and generic drugs are listed in
lowercase italics (e.g., losartan).
The information in the Requirements/Limits
column tells you if Healthfirst Medicare Plan
has any special requirements for coverage of
your drug.
Drug Tiers
Tier
Tier 1: Generic Drugs
Tier 2: Preferred Brand Drugs
Tier 3: Nonpreferred Brand Drugs
Tier 4: Specialty Tier Drugs
Tier Includes:
Tier 1 is your lowest-cost tier. Most generic drugs on the
formulary are included in this tier. Generic drugs contain the
same active ingredients as brand drugs and are equally safe
and effective.
This is your middle-cost tier and includes preferred
brand drugs.
This is your higher-cost tier and includes nonpreferred
brand drugs.
The Specialty Tier is your highest-cost tier.
A Specialty Tier drug is a very high-cost or unique
prescription drug which may require special handling
and/or close monitoring. Specialty drugs may be brand
or generic.
Healthfirst Health Plan, Inc., dba Healthfirst Medicare Plan, offers HMO plans that contract with
the Federal Government. Healthfirst Medicare Plan has a contract with New York State Medicaid
for Healthfirst CompleteCare (HMO SNP) and a Coordination of Benefits Agreement with the New
York State Department of Health for the Healthfirst Life Improvement Plan (HMO SNP). Enrollment
in Healthfirst Medicare Plan depends on contract renewal. Healthfirst Medicare Plan complies with
applicable Federal civil rights laws and does not discriminate on the basis of race, color, national
origin, age, disability, or sex.
iv
2017 Drug Formulary
Formulario de medicamentos 2017
2017 年「處方藥一覽表」
¿Qué es el Formulario del Plan Medicare de
Healthfirst?
El formulario es una lista de los medicamentos
cubiertos seleccionados por el Plan Medicare
de Healthfirst, acordada con un equipo
de proveedores de atención médica, que
representa los tratamientos recetados que
se consideran necesarios como parte de un
programa de tratamiento de calidad.
En general, el Plan Medicare de Healthfirst
cubrirá los medicamentos incluidos en
nuestro formulario siempre que éstos sean
médicamente necesarios, se adquieran en
la farmacia de la red del Plan Medicare de
Healthfirst y sigan otras reglas del plan. Para
obtener más información sobre cómo adquirir
los medicamentos recetados, lea la Constancia
de Cobertura.
¿Puede variar el Formulario
(lista de medicamentos)?
En general, si usted está tomando un
medicamento que figura en nuestro formulario
2016 y que estaba cubierto al comienzo del
año, no suspenderemos ni restringiremos la
cobertura del medicamento durante el año
de cobertura 2017, salvo que se encuentre
disponible un nuevo medicamento genérico
y menos costoso, o que se dé a conocer
información adversa sobre la seguridad
o eficacia del medicamento. Otros tipos
de cambios como la eliminación de un
medicamento del formulario, no afectarán
a los miembros que estén tomando tal
medicamento. Seguirá estando disponible al
mismo precio compartido para los miembros
que lo toman por el resto del año de cobertura.
Consideramos que es importante que siga
teniendo acceso por lo que resta del año de
cobertura a los medicamentos del formulario
que estaban disponibles cuando usted eligió
nuestro plan, salvo en los casos en que pueda
ahorrar dinero o cuando podamos garantizar
su seguridad.
Si se eliminan medicamentos del formulario, se
añaden autorizaciones previas, se establecen
límites de cantidades o restricciones en
v
las terapias escalonadas con relación a un
medicamento, o si se reubica un medicamento
en un nivel superior de costo compartido,
comunicaremos el cambio a los miembros
afectados al menos 60 días antes de que
se haga efectivo dicho cambio, o cuando
el miembro solicite que se resurta un
medicamento, momento en que recibirá un
suministro de 60 días.
Si la Administración de Alimentos y Fármacos
de Estados Unidos (FDA, por sus siglas en
inglés) considera que un medicamento
de nuestro formulario no es seguro o si el
fabricante retira el medicamento del mercado,
quitaremos inmediatamente el medicamento
del formulario y avisaremos a los miembros que
lo toman. El formulario adjunto tendrá vigencia
a partir del 23 de agosto de 2016. Comuníquese
con nosotros para obtener información
actualizada sobre los medicamentos que cubre
el Plan Medicare de Healthfirst. Encontrará
nuestra información de contacto en la
primera y última página de este folleto. El
Plan Medicare de Healthfirst podrá actualizar
este formulario mensualmente a lo largo del
año. Las actualizaciones incluyen adiciones,
supresiones y cambios en la gestión del uso
basado en el último formulario aprobado por
CMS. Descargue el formulario actualizado en
el sitio www.healthfirst.org/ medicare o llame
a Servicios a los Miembros para obtenerlo,
al número que figura en la primera y última
página de este folleto. Al hacerse cambios,
se actualizará la nueva información en los
formularios impresos.
Se puede obtener copia del formulario
actualizado en nuestro sitio de internet o
pedirla por teléfono.
¿Cómo uso el Formulario?
Existen dos maneras de encontrar un
medicamento en el formulario:
Por Afección
El formulario comienza en la página 1. Los
medicamentos de este formulario se clasifican
en categorías según el tipo de afección médica
2017 Drug Formulary
Formulario de medicamentos 2017
2017 年「處方藥一覽表」
para cuyo tratamiento se utilizan. Por ejemplo,
los medicamentos que se usan para tratar
las afecciones cardíacas se enumeran en la
categoría “Medicamentos cardiovasculares”.
Si usted sabe para qué se usa el medicamento,
busque la categoría en la lista que comienza
en la página 1, y luego busque el medicamento
dentro de esa categoría.
Por orden alfabético
Si no está seguro en qué categoría buscar,
busque el medicamento en el Índice
que comienza en la página 57. El Índice
proporciona un listado alfabético de todos los
medicamentos incluidos en este documento,
tanto los genéricos como los de marca. Busque
en el índice y encuentre el medicamento
que necesita. Al lado del medicamento verá
el número de página donde encontrará
información sobre la cobertura. Vaya a la
página que figura en el Índice y busque el
nombre del medicamento en la primera
columna de la lista.
¿Qué son los medicamentos genéricos?
El Plan Medicare de Healthfirst cubre tanto
los medicamentos genéricos como los de
marca. Los medicamentos genéricos son los
medicamentos que la FDA determina que
contienen el mismo principio activo que
el medicamento de marca. En general, los
medicamentos genéricos son menos costosos
que los de marca.
¿Mi cobertura tiene restricciones?
Algunos medicamentos cubiertos pueden
tener requisitos o límites adicionales en la
cobertura, como:
• Límites en las cantidades: En el caso de
determinados medicamentos, el Plan
Medicare de Healthfirst limita la cantidad del
medicamento que cubre el plan. Por ejemplo,
el Plan Medicare de Healthfirst proporciona
60 comprimidos de omeprazol 20mg, cada
30 días, por receta. Esto puede sumarse al
suministro normal de un mes o tres meses.
• Terapia escalonada: En algunos casos,
el Plan Medicare de Healthfirst exige que
primero pruebe ciertos medicamentos para
el tratamiento de una afección médica antes
de que cubramos otro medicamento para
esa enfermedad. Por ejemplo, si tanto el
Medicamento A como el Medicamento B se
usan para el tratamiento de su afección, el
Plan Medicare de Healthfirst posiblemente no
cubra el Medicamento B hasta tanto usted no
pruebe el Medicamento A en primer lugar. Si
el Medicamento A no produce los resultados
esperados, el Plan Medicare de Healthfirst
cubrirá entonces el Medicamento B.
Para averiguar si su medicamento tiene
requisitos o límites adicionales, busque en
el formulario que comienza en la página 1.
También puede obtener más información sobre
las restricciones aplicadas a determinados
medicamentos en nuestro sitio web. Hemos
publicado un documento en Internet que
explica nuestras restricciones de autorización
previa y terapia escalonada. También puede
solicitar que le enviemos una copia. Encontrará
nuestra información de contacto, así como la
fecha de la última actualización del formulario,
en la primera y última página de este folleto.
Puede solicitar al Plan Medicare de Healthfirst
que haga una excepción a esas restricciones
• Autorización previa: El Plan Medicare de
o límites, o bien pedir una lista de otros
Healthfirst exige que usted o el médico
medicamentos similares que puedan servir
obtengan autorización previa para
para el tratamiento de su afección. Consulte
determinados medicamentos. Esto significa
que necesitará obtener la aprobación del Plan la sección “¿Cómo solicito una excepción al
formulario del Plan Medicare de Healthfirst?”
Medicare de Healthfirst antes de solicitar los
medicamentos recetados. Si no se obtiene la en la página iii, para obtener información sobre
cómo solicitar la excepción.
autorización, el Plan Medicare de Healthfirst
puede no cubrir el medicamento.
vi
2017 Drug Formulary
Formulario de medicamentos 2017
2017 年「處方藥一覽表」
¿Qué sucede si mi medicamento no se
encuentra en el Formulario?
Si el medicamento que necesita no
está incluido en este formulario (lista de
medicamentos cubiertos), comuníquese
primero con el departamento de Servicios
a los Miembros y pregunte si el plan cubre
el medicamento.
las restricciones o límites de cobertura de
su medicamento. Por ejemplo, en el caso
de determinados medicamentos, el Plan
Medicare de Healthfirst limita la cantidad del
medicamento que cubrirá. Si el medicamento
que necesita tiene un límite de cantidad, es
posible solicitarnos que se suprima el límite
para cubrir una cantidad mayor.
Si se le informa que el Plan Medicare de
Healthfirst no cubre el medicamento, tiene
dos opciones:
Generalmente, el Plan Medicare de Healthfirst
solo aprobará una solicitud de excepción si
los medicamentos alternativos incluidos en el
formulario del plan, el medicamento de costo
compartido más bajo o las restricciones de uso
adicionales no fuesen igualmente eficaces en el
tratamiento de su afección o pudiesen provocar
efectos clínicos adversos.
• Puede solicitar a Servicios a los Miembros una
lista de medicamentos similares que cubra el
Plan Medicare de Healthfirst. Cuando reciba el
listado, muéstreselo al médico y pídale que le
recete un medicamento similar que cubra el
Plan Medicare de Healthfirst.
Comuníquese con nosotros para solicitar una
decisión inicial con respecto a la excepción
• Puede solicitar al Plan Medicare de Healthfirst al formulario, de nivel o de restricciones de
utilización. Para solicitar una excepción
que se haga una excepción y se cubra el
al formulario, de nivel o restricciones de
medicamento. Lea la siguiente información
utilización, se debe presentar un certificado
sobre cómo solicitar una excepción.
de quien emitió la receta o del médico
respaldando su solicitud. En general, debemos
¿Cómo solicito una excepción al Formulario
tomar una decisión en un plazo de 72 horas
del Plan Medicare de Healthfirst?
después de haber recibido el certificado de
Es posible solicitar al Plan Medicare de
respaldo de su médico. Puede solicitar solicitar
Healthfirst que haga una excepción a las
una excepción expedita (acelerada) si usted
reglas de cobertura. Podrá solicitar distintos
o su médico consideran que su salud podría
tipos de excepciones.
verse gravemente comprometida por tener que
• Puede solicitar que se cubra un medicamento esperar 72 horas para conocer la decisión. Si
aun cuando no esté incluido en nuestro
se acepta su solicitud de resolución expedita,
formulario. En caso de aprobarse la solicitud,
deberemos comunicarle la decisión como
se cubrirá el medicamento al nivel de costo
máximo 24 horas después de haber recibido
compartido predeterminado, y usted no podrá el certificado de respaldo de su médico o de
pedir que le suministremos el medicamento a quien emitió la receta.
un nivel inferior de costo compartido.
¿Qué debo hacer antes de hablar con el
• Puede solicitar que se cubra un medicamento
médico sobre el cambio de medicamentos o
del formulario a un nivel inferior de costo
de solicitar una excepción?
compartido si el medicamento no se ncuentra
Como miembro nuevo o anterior de nuestro
en el nivel de medicamentos de especialidad.
plan, quizás usted esté tomando medicamentos
En caso de aprobarse la solicitud, esto
que no están incluidos en nuestro formulario.
reduciría el monto que debe pagar por
O bien puede estar tomando un medicamento
el medicamento.
que está en el formulario pero sus posibilidades
de obtenerlo son limitadas. Por ejemplo, puede
• Puede solicitar que dejemos sin efecto
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2017 年「處方藥一覽表」
necesitar nuestra autorización antes de adquirir
los medicamentos de su receta. Hable con
su médico para decidir si debe cambiar a un
medicamento adecuado que cubra el plan o
solicitar una excepción al formulario, para que
podamos cubrir el medicamento que necesita
tomar. Mientras decide con su médico qué
opción es mejor para usted, en determinados
casos podremos cubrir el medicamento
durante los primeros 90 días de afiliación
al plan.
si es residente de un centro de atención a largo
plazo) de una farmacia de la red. Durante ese
período, si desea recibir una cobertura continua
del medicamento después de finalizado el
suministro temporal, deberá hacer uso del
proceso de excepciones del plan.
Obtenga más información
Para obtener información detallada sobre la
cobertura de medicamentos recetados del
Plan Medicare de Healthfirst, lea la Constancia
de Cobertura y otros materiales sobre el plan.
Con respecto a los medicamentos que no están Si tiene dudas sobre el Plan Medicare de
incluidos en el formulario, o si sus posibilidades Healthfirst, comuníquese con nosotros.
de obtener los medicamentos son limitadas,
Encontrará nuestra información de contacto,
cubriremos un suministro temporal de 30
así como la fecha de la última actualización del
días (a menos que la receta indique menos
formulario, en la primera y última página
días) cuando se dirija a una farmacia de la red.
de este folleto.
Después del primer suministro de 30 días, no
pagaremos esos medicamentos aunque usted
Si desea hacer preguntas generales
haya sido miembro del plan durante menos de
sobre la cobertura de medicamentos
90 días.
recetados de Medicare, llame a Medicare al
1-800-MEDICARE (1-800-633-4227),
Si usted es residente de un centro de atención
las 24 horas del día, los 7 días de la semana.
a largo plazo, podrá solicitar que se resurtan
Los usuarios de TTY deben llamar al
los medicamentos recetados hasta que le
1-877-486-2048. O visite el sitio
proporcionemos un suministro transitorio
www.medicare.gov.
de 93 días, consistente con los incrementos
dispensados (a menos que tenga una receta
por menos días). Cubriremos más de un
resurtido de estos medicamentos durante los
primeros 90 días de su afiliación al plan. Si
necesita un medicamento que no está en el
formulario, o si sus posibilidades de obtener
el medicamento son limitadas pero hace más
de 90 días que usted es miembro del plan,
cubriremos un suministro de emergencia de 31
días de ese medicamento (salvo que la receta
indique menos días) mientras usted solicita una
excepción al formulario. Si sufre cambios en el
nivel de atención, como el traslado del hospital
al domicilio, y necesita un medicamento
que no está en nuestro formulario, o si sus
posibilidades de obtener los medicamentos
son limitadas, cubriremos por única vez un
suministro temporal de hasta 30 días (o 31 días
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2017 年「處方藥一覽表」
Formulario del Plan Medicare de Healthfirst
El formulario que comienza en la página 1
proporciona información sobre la cobertura de
algunos de los medicamentos que cubre el Plan
Medicare de Healthfirst. Si no logra encontrar
su medicamento en la lista, consulte el Índice
que comienza en la página 57.
En la primera columna del cuadro se
encuentran los nombres de los medicamentos.
Los medicamentos de marca están
en mayúscula (p. ej., BENICAR), y los
medicamentos genéricos figuran en minúscula
cursiva (p. ej. losartan).
La información en la columna Requisitos/
Límites indica si el Plan Medicare de Healthfirst
tiene algún requisito especial en cuanto a la
cobertura del medicamento.
NIVELES DE MEDICAMENTOS
NIVEL
Qué incluye cada nivel:
Nivel 1: Medicamentos genéricos
El Nivel 1 es el nivel de costo más bajo. La mayoría de los
medicamentos genéricos del formulario están incluidos
en este nivel. Los medicamentos genéricos contienen
los mismos principios activos que los medicamentos de
marca, y son igualmente eficaces y seguros.
Este es el nivel de costo medio e incluye los
medicamentos de marca preferidos.
Los medicamentos de este nivel tienen un costo más alto
e incluyen los medicamentos de marca no preferidos.
Nivel 2: Medicamentos de marca
preferidos
Nivel 3: Medicamentos de marca no
preferidos
Nivel 4: Medicamentos de
especialidad
El nivel de medicamentos de especialidad es el nivel de
mayor costo.
Los medicamentos de especialidad son medicamentos
recetados de muy alto costo o particulares que pueden
requerir un manejo especial o un seguimiento estrecho.
Pueden ser de marca o genéricos.
Healthfirst Health Plan, Inc., bajo el nombre comercial Plan Medicare de Healthfirst, ofrece
planes HMO que tienen contratos con el gobierno federal. El Plan Medicare de Healthfirst tiene
un contrato con el programa Medicaid de Nueva York para el Plan Atención Integral (HMO SNP)
de Healthfirst y un Acuerdo de Coordinación de Beneficios con el Departamento de Salud del
Estado de Nueva York para el Plan Mejor Calidad de Vida (HMO SNP) de Healthfirst. La inscripción
en el Plan Medicare de Healthfirst está sujeta a la renovación del contrato. El Plan Medicare de
Healthfirst cumple con las leyes federales de derechos civiles aplicables y no discrimina por
motivos de raza, color, nacionalidad, edad, discapacidad o sexo.
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2017 年「處方藥一覽表」
第一保健老人醫療保險計劃的
「處方藥一覽表」(Formulary)是甚麼？
「處方藥一覽表」(Formulary)是第一保健老人醫
療保險計劃根據其保健護理服務提供者團隊的意
見所選擇的承保藥物目錄，代表了公認為高品質治
療計劃必不可少組成部份的處方藥物治療。第一
保健老人醫療保險計劃一般會承保我們的「處方
藥一覽表」中列出的藥物，只要使用該藥物屬於醫
療上所必需，處方藥物又是在第一保健老人醫療
保險計劃的網絡藥房購買，並且所有其他的承保規
則均執行無誤。如要瞭解如何配取您的處方，請查
閱您的「承保證書」(Evidence of Coverage)。
「處方藥一覽表」（藥物目錄）是否會更動？
一般來說，如果您所服用的藥物列入我們2016年
的「處方藥一覽表」，在年初的時候獲得承保，在
2017承保年度我們不會終止或降低該藥物的承
保，除非市面上有了新的價格低廉的副廠藥或有關
某種藥物的安全性或有效性方面的負面資訊得以
公佈。諸如將藥物從我們的「處方藥一覽表」上刪
除等其他類型的更動則不會對目前使用該藥物的
會員產生影響。該類藥物在本承保年度的剩餘時
間內會以同樣的分攤費用為正在服用這些藥物的
會員提供。我們覺得，重要的是，在本承保年度剩
餘的時間裡，除了您能夠額外省錢或我們能夠確保
您的安全的情況之外，您能夠不間斷地得到您選
擇我們計劃的當時「處方藥一覽表」上所包括的藥
物。
如果我們從「處方藥一覽表」中刪除藥物，或對一
種藥物增加事前核准、數量限制及/或循序用藥限
定、或將一種藥物挪到費用分攤數額較高的層次，
我們必須在更動生效之前至少60天或在會員要求
增配該藥物時通知受到影響的會員，而且從那時起
會員將得到60天用量的該藥物。
如果食品與藥物管理總署(Food and Drug
xi
Administration)認為我們「處方藥一覽表」上的
藥物不安全或者該藥物的製造商從市場上撤回該
藥物，我們會立即將該藥物從我們的「處方藥一覽
表」上刪除，並通知服用該藥物的會員。此處所附
的「處方藥一覽表」資料截止於2016年8月23日。
如要獲取第一保健老人醫療保險計劃承保藥物的
最新資訊，請與我們聯絡。我們的聯絡資訊印在封
面和封底。年度期間第一保健老人醫療保險計劃可
能會按月更新本「處方藥一覽表」。更新包括根據
CMS最近核准的「處方藥一覽表」增刪和用藥管理
規定的更動。最新的「處方藥一覽表」可以到我們
的網站www.healthfirst.org/medicare 下載或致
電封面和封底印出的會員服務部電話號碼索取。如
果有任何更動，我們將把新資料更新至我們的印
刷版「處方藥一覽表」。最新的「處方藥一覽表」複
本可透過我們的網站或致電我們獲得。
我怎麼使用「處方藥一覽表」?
在「處方藥一覽表」上尋找藥物有兩種方法。
根據醫療狀況查找
「處方藥一覽表」從第1頁開始。本「處方藥一覽
表」上的藥物根據其用於治療的醫療狀況分為不
同的類別。例如，用來治療心臟狀況的藥物列在
「Cardiovascular Medications」類別。如果您知
道您的藥物用來治療甚麼症狀，即可到第1頁開始
的目錄中尋找該類別名稱。然後在該名稱項下尋找
您的藥物。
字母順序排列
如果您不能確定到哪一類去尋找，您可以到57頁
開始的索引中去尋找。索引提供了本文件中所包含
的所有藥物的字母順序排列。原廠藥與副廠藥都
在索引中列出。到索引中去查找您的藥物。在您的
藥物旁邊，您會看到頁碼，您可以在該頁找到承保
資訊。翻到索引中列出的頁碼，在目錄的第一欄即
可找到您的藥物的名稱。
2017 Drug Formulary
Formulario de medicamentos 2017
2017 年「處方藥一覽表」
甚麼叫副廠藥(generic drug)？
第一保健老人醫療保險計劃既承保原廠藥，也承
保副廠藥。副廠藥得到聯邦食品與藥物管理總署
(FDA)的核准，與原廠藥有相同的有效成份。一般
來說，副廠藥的費用要比原廠藥低。
我的承保是否有甚麼限制?
某些承保藥物可能有額外的承保規定或限制。這
些規定與限制可能包括：
• 事前授權：第一保健老人醫療保險計劃規定某
些藥物您或您的醫生必須取得事前授權。這意
味著您必須得到第一保健老人醫療保險計劃的
核准才能去配藥。如果您沒有得到核准，第一保
健老人醫療保險計劃可能不會承保該藥物。
• 數量限制：某些藥物第一保健老人醫療保險計
劃會限制第一保健老人醫療保險計劃承保該藥
物的數量。例如：omeprazole20毫克片劑，第
一保健老人醫療保險計劃每張處方每30天只能
提供60片。這可能是在標準的一個月或三個月
用量之外增加的規定。
• 循序用藥：某些情況下，第一保健老人醫療保
險計劃會要求您先試用某些藥物來治療您的症
狀，然後才能承保用於同樣症狀的其他藥物。例
如，如果藥物甲與藥物乙均可用於治療您的醫
療症狀，除非您先試用藥物甲，否則第一保健可
能不會承保藥物乙。如果藥物甲對您的症狀無
效，然後第一保健老人醫療保險計劃才會承保
藥物乙。
對我們的事前授權與循序用藥限制作了說明。您亦
可要求我們給您寄一份該文件。我們的聯絡資訊
連同我們最近更新「處方藥一覽表」的日期就印在
封面與封底。
您可以要求第一保健老人醫療保險計劃對這些限
制或限定作出例外處理，亦可索取一份可能用來治
療您的健康狀況的其他類似藥物的目錄。如要瞭
解如何提出例外處理要求，請見第xiii頁的「我如何
要求對第一保健老人醫療保險計劃的『處方藥一
覽表』作出例外處理﹖
」部份。
如果我的藥物不在「處方藥一覽表」上怎麼辦？
如果您的藥物沒有列入「處方藥一覽表」（承保藥
物目錄），您應首先聯絡會員服務部詢問您的藥物
是否獲得承保。
如果瞭解到第一保健老人醫療保險計劃不承保您
的藥物，您有兩種選擇：
• 您可以要求會員服務部提供一份獲得第一保健
老人醫療保險計劃承保的類似藥物目錄。收到
目錄之後，將其持往您的醫生處要求醫生開具
獲得第一保健老人醫療保險計劃承保的類似藥
物的處方。
• 您可以要求第一保健老人醫療保險計劃作出例
外處理，承保您的藥物。有關如何要求作出例外
處理，詳情請見下文。
如需瞭解您服用的藥物是否有任何額外的規定或
限制，請查看第1頁開始的「處方藥一覽表」。您亦
可瀏覽我們的網站瞭解有關適用於某些特定承保
藥物的限制的資訊。我們在網上貼出了一份文件，
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我如何要求對第一保健老人醫療保險計劃的「處
方藥一覽表」作出例外處理﹖
您可以要求第一保健老人醫療保險計劃對我們的
承保規則作出例外處理。您可以向我們提出多種類
別的例外處理要求。
出裁決。如果您或您的醫生認為等待72小時才得
到裁決可能會嚴重損害您的健康，您可以要求加快
(快速)例外處理。如果您的加快例外處理要求得到
採納，在收到您醫生或開具處方者的支持證言之
後，我們必須不得晚於24小時給您裁決。
• 即使您的藥物不在我們的「處方藥一覽表」上，
您也可以要求我們承保藥物。如經核准，我們將
以預先確定的費用分攤層次承保此藥，而您則
不能再要求我們以較低的費用分攤層次提供
此藥。
在與我的醫生討論更換藥物或要求作出例外處理
之前我應該做甚麼?
作為我們計劃的新老會員，您很可能正在服用我們
的「處方藥一覽表」上所沒有的藥物。或者，您服
用的藥物我們的「處方藥一覽表」上有，但是您獲
取該藥物的能力受到限制。例如，您可能必須得到
我們的事前授權才能去配藥。您應該問一問您的
醫生，確定是應該改用我們所承保的適當藥物，還
是要求對「處方藥一覽表」作出例外處理，讓我們
承保您所服用的藥物。在您與您的醫生討論確定下
一步怎麼辦的同時，在某些情況下，我們可以在會
員參加我們計劃的最初90天期間承保您的藥物。
• 如果「處方藥一覽表」上的藥物不是特殊層次藥
物，您可以要求我們以較低的費用分攤層次承
保此藥物。如經核准，這將降低您必須為您的藥
物支付的費用。
• 您可以要求我們豁免有關您所服用藥物的承保
限制或限定。例如，對於某些藥物來說，第一保
健老人醫療保險計劃對該藥物的承保數量有限
制。如果您的藥物有數量限制，您可以要求我們
豁免該限制，承保較大數量。
一般說來，只有在本計劃「處方藥一覽表」上的其
他藥物、分攤費用較低的藥物或額外用藥限制對
於治療您的症狀不那麼有效及/或可能給您帶來不
良醫療效果的情況下，第一保健老人醫療保險計劃
才能核准您的例外處理要求。
如果想要對「處方藥一覽表」、藥物層次或用藥限
制作出例外處理，您應該與我們聯絡，要求我們作
出初始承保決定(initial coverage decision)。在提
出「處方藥一覽表」、藥物層次或用藥限制的例外
處理要求時您應該遞交一份開具處方者或醫生的
證言來支持您的要求。一般來說，在收到您開具處
方者的支持證言之後，我們必須在72小時之內作
xiii
我們「處方藥一覽表」上沒有，或者您獲取藥物的
能力受到限制的藥物，如果您到網絡藥房配藥，您
的每一種藥物我們會承保30天的臨時用量(除非
您有處方規定較少的天數)。在最初的30天用量之
後，即使您成為本計劃會員的時間尚不足90天我
們也不會再承保這些藥物。
如果您住在一家長期護理設施，我們會容許您增配
您的處方藥物，直到我們遵照發放數量增加的準
則為您提供最多93天的過渡用量為止(除非您有處
方規定較少的天數)。在您成為我們計劃會員的最
初90天內，我們會承保這些藥物的一次以上增配。
如果您需要的藥物我們的「處方藥一覽表」上沒
有，或者您獲取您的藥物的能力受到限制，但是
您參加我們的計劃已經超過90天，在您尋求對
「處方藥一覽表」進行例外處理期間我們會承保
該藥物31天的緊急供應除非(您有處方規定較少的
2017 Drug Formulary
Formulario de medicamentos 2017
2017 年「處方藥一覽表」
天數)。如果您的護理層級發生變化，諸如從醫院
回到居家場合，而您需要我們的「處方藥一覽表」
上所沒有的藥物，或者如果您獲取您的藥物的能
力受到限制，我們會承保在網絡藥房購買的一次性
最多30天(如果您住在長期護理設施，則為31天)的
臨時用藥量。在此期間，如果您用完臨時用藥，如
果您希望繼續獲得該藥物的承保，您應該使用本
計劃的例外處理程序。
如要瞭解詳情
有關您的第一保健老人醫療保險計劃處方配藥承
保的詳細資訊，請查閱您的「承保證書」及計劃的
其他材料。
如果您有關於第一保健老人醫療保險計劃的問
題，請與我們聯絡。我們的聯絡資訊連同我們最
近更新「處方藥一覽表」的日期就印在封面與封
底。如果您對老人醫療保險處方配藥承保有一般
性的問題，請致電聯邦老人醫療保險，電話號碼
1-800-MEDICARE(1-800-633-4227)，服務時間
每週七天，每天24小時。聽力語言殘障服務用戶請
致電TTY 1-877-486-2048。或瀏覽網站
www.medicare.gov。
第一保健老人醫療保險計劃「處方藥一覽表」
從第1頁開始的「處方藥一覽表」提供有關第一保
健老人醫療保險計劃承保的某些藥物的承保資訊。
如果您在目錄中找不到您的藥物，請翻到第57頁開
始的索引。圖表的第一欄列出的是藥物名稱。原廠
藥名稱全部大寫(例如BENICAR)，副廠藥名稱則以
小寫斜體列出(例如losartan)。
規定/限制(Requirements/Limits)一欄的資訊告訴
您第一保健老人醫療保險對於您的藥物的承保是
否有甚麼特別的規定。
藥物層次
層次
層次包括：
第一層次：副廠藥
第一層次是您的費用最低的層次。「處方藥一覽表」上的大部份副廠藥都包括
在這一層次。副廠藥含有與原廠藥同樣的活性成份，同樣安全有效。
第二層次：優惠原廠藥
這是費用處於中間的層次，包括優惠原廠藥。
第三層次：非優惠原廠藥
這是費用較高的層次，包括非優惠原廠藥。
第四層次：特殊層次藥物
特殊層次是您的費用最高的層次。特殊層次藥物都是相當昂貴或特別的處方
藥物，可能需要特別的處理與/或密切監察。特殊藥物可能是原廠藥也可能是
副廠藥。
以第一保健老人醫療保險計劃Healthfirst Medicare Plan）的名稱運營的第一保健健保計劃公司
（Healthfirst Health Plan, Inc.）提供與聯邦政府簽有合約的管理式保健計劃。第一保健老人醫療保險計劃
與紐約州醫療補助計劃簽有關於第一保健惠康護理計劃（管理式保健計劃－特殊需要計劃）的合 約，並與
紐約州衛生署簽有關於第一保健生活改善計劃（管理式保健計劃－特殊需要計劃）的福利協調 協議。能否註
冊參加第一保健老人醫療保險計劃取決於政府合約是否續延。第一保健老人醫療保險計劃遵守適用的聯邦
民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視任何人。
xiv
H3359_LGL17_03 Accepted 09182016
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số
1-888-260-1010 (TTY 1-888-542-3821).
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.
Rufnummer: 1-888-260-1010 (TTY: 1-888-542-3821).
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-888-260-1010 (TTY 1-888-542-3821)번으로 전화해 주십시오.
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.
Звоните 1-888-260-1010 (телетайп: 1-888-542-3821).
1-888-620-1010 ‫ اتصل برقم‬.‫ فإن خدمات المساعدة اللغوية تت وافر لك بالمجان‬،‫ إذا كنت تتحدث اللغة العربية‬:‫ملحوظة‬
)1-888-542-3821 ‫(رقم هاتف الصم والبكم‬
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti.
Chiamare il numero 1-888-260-1010 (TTY 1-888-542-3821).
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis.
Ligue para 1-888-260-1010 (TTY 1-888-542-3821).
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou.
Rele 1-888-260-1010 (TTY 1-888-542-3821).
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń
pod numer 1-888-260-1010 (TTY 1-888-542-3821).
ध ्यान द :े ं यदि आप हि दं ी बोलत े ह ै ं तो आपक े लि ए म ुफ ्त म े ं भाषा सहायता स व
े ाएं उपलब ्ध ह ।ै ं
1-888-260-1010 (TTY 1-888-542-3821) पर कॉल कर ।े ं
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。
1-888-260-1010 (TTY 1-888-542-3821)まで、お電話にてご連絡ください。
CY17_4T_STANDARD eff 01/01/2017
Drug Name
Drug Tier Requirements/Limits
ANALGESICS
GOUT
allopurinol tab
colchicine w/ probenecid
COLCRYS
probenecid
ULORIC
1
1
2
1
2
QL (120 tabs / 30 days)
ST
NSAIDS
celecoxib CAPS 50mg
celecoxib CAPS 100mg
celecoxib CAPS 200mg
celecoxib CAPS 400mg
diclofenac potassium
diclofenac sodium TB24
diclofenac sodium TBEC
diflunisal
etodolac
etodolac er
flurbiprofen TABS
ibuprofen SUSP
ibuprofen TABS 400mg, 600mg, 800mg
ketoprofen CAPS
MELOXICAM SUSP
meloxicam TABS
nabumetone TABS
naproxen SUSP; TABS; TBEC
naproxen sodium TABS 275mg, 550mg
piroxicam CAPS
sulindac TABS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL
QL
QL
QL
QL
(240 caps / 30 days)
(120 caps / 30 days)
(60 caps / 30 days)
(30 caps / 30 days)
(120 tabs / 30 days)
1
1
1
QL (5000 mL / 30 days)
QL (400 tabs / 30 days)
OPIOID ANALGESICS
acetaminophen w/ codeine SOLN
acetaminophen w/ codeine TABS
butorphanol tartrate SOLN 1mg/ml,
2mg/ml
nalbuphine hcl SOLN
tramadol hcl TABS
tramadol-acetaminophen
1
1
1
QL (240 tabs / 30 days)
QL (240 tabs / 30 days)
1
1
1
1
B/D
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
OPIOID ANALGESICS, CII
DURAMORPH
endocet 5/325
endocet 7.5/325
endocet 10/325
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
1
CY17_4T_STANDARD eff 01/01/2017
Drug Name
fentanyl citrate LPOP
fentanyl patch 12 mcg/hr
fentanyl patch 25 mcg/hr
fentanyl patch 50 mcg/hr
fentanyl patch 75 mcg/hr
fentanyl patch 100 mcg/hr
FENTORA
Drug Tier Requirements/Limits
4
QL (120 lozenges / 30
days), PA
1
QL (10 patches / 30
days)
1
QL (10 patches / 30
days)
1
QL (10 patches / 30
days), PA
1
QL (10 patches / 30
days), PA
1
QL (10 patches / 30
days), PA
4
QL (120 tabs / 30 days),
PA
1
QL (360 tabs / 30 days)
1
QL (360 tabs / 30 days)
1
QL (360 tabs / 30 days)
1
QL (5400 mL / 30 days)
hydroco/apap tab 5-325mg
hydroco/apap tab 7.5-325
hydroco/apap tab 10-325mg
hydrocodone-acetaminophen 7.5-325
mg/15ml
hydrocodone-ibuprofen tab 7.5-200 mg
1
hydromorphone hcl LIQD
1
1
hydromorphone hcl SOLN 10mg/ml,
50mg/5ml, 500mg/50ml
hydromorphone hcl TABS
1
lorcet plus tab 7.5-325
1
lorcet tab 5-325mg
1
lortab tab 5-325mg
1
lortab tab 7.5-325
1
lortab tab 10-325mg
1
methadone hcl CONC
1
methadone hcl SOLN 5mg/5ml, 10mg/5ml 1
methadone hcl 5mg
1
methadone hcl 10mg
1
morphine ext-rel tab 15mg, 30mg, 60mg, 1
100mg
morphine ext-rel tab 200mg
1
MORPHINE SUL INJ 1MG/ML
1
MORPHINE SUL INJ 4MG/ML
1
MORPHINE SUL INJ 10MG/ML
1
MORPHINE SUL INJ 15MG/ML
1
MORPHINE SULFATE SOLN 2mg/ml,
1
8mg/ml, 150mg/30ml
morphine sulfate SOLN .5mg/ml, 1mg/ml, 1
4mg/ml, 8mg/ml
QL (150 tabs / 30 days)
B/D
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(270 tabs / 30 days)
(360 tabs / 30 days)
(360 tabs / 30 days)
(360 tabs / 30 days)
(360 tabs / 30 days)
(360 tabs / 30 days)
(120 mL / 30 days)
(600 mL / 30 days)
(240 tabs / 30 days)
(240 tabs / 30 days)
(90 tabs / 30 days)
QL (60 tabs / 30 days)
B/D
B/D
B/D
B/D
B/D
B/D
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
2
CY17_4T_STANDARD eff 01/01/2017
Drug Name
MORPHINE SULFATE TABS
MORPHINE SULFATE ORAL SOL
oxycodone hcl CAPS
oxycodone hcl CONC
OXYCODONE HCL SOLN
oxycodone hcl TABS
oxycodone w/ acetaminophen 2.5-325mg
oxycodone w/ acetaminophen 5-325mg
oxycodone w/ acetaminophen 7.5-325mg
oxycodone w/ acetaminophen 10-325mg
oxycodone w/ acetaminophen soln
Drug Tier Requirements/Limits
1
QL (180 tabs / 30 days)
1
1
QL (180 caps / 30 days)
1
1
1
QL (180 tabs / 30 days)
1
QL (360 tabs / 30 days)
1
QL (360 tabs / 30 days)
1
QL (360 tabs / 30 days)
1
QL (360 tabs / 30 days)
1
QL (1800 mL / 30 days)
ANESTHETICS
LOCAL ANESTHETICS
lidocaine
lidocaine
lidocaine
lidocaine
lidocaine
hcl (local anesth.)
inj 0.5%
inj 1%
inj 1.5%
inj 2%
1
1
1
1
1
B/D
B/D
B/D
B/D
B/D
ANTI-INFECTIVES
ANTI-BACTERIALS - MISCELLANEOUS
amikacin sulfate SOLN
gentamicin in saline
gentamicin sulfate SOLN
gentamicin sulfate/0.9% s
neomycin sulfate TABS
paromomycin sulfate CAPS
streptomycin sulfate SOLR
sulfadiazine TABS
tobramycin NEBU
tobramycin inj 1.2 gm/30ml
tobramycin inj 1.2gm
tobramycin inj 10mg/ml
tobramycin inj 40mg/ml
tobramycin inj 80mg/2ml
1
1
1
1
1
1
1
3
4
1
4
1
1
1
NM, PA
ANTI-INFECTIVES - MISCELLANEOUS
ALBENZA
ALINIA
atovaquone SUSP
AZACTAM IN ISO-OSMOTIC DE
AZACTAM/DEX INJ 2GM
aztreonam
BILTRICIDE
4
3
4
3
3
1
2
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
3
CY17_4T_STANDARD eff 01/01/2017
Drug Name
CAYSTON
clindamycin cap 75mg
clindamycin cap 300mg
clindamycin hcl cap 150 mg
clindamycin phosphate SOLN
clindamycin phosphate in d5w
clindamycin phosphate inj
clindamycin sol 75mg/5ml
colistimethate sodium SOLR
CUBICIN
dapsone TABS
daptomycin
emverm
imipenem-cilastatin
INVANZ
ivermectin TABS
linezolid SOLN
LINEZOLID SUSR; TABS
LINEZOLID IN SODIUM CHLORIDE
meropenem
methenamine hippurate
metronidazole TABS
metronidazole in nacl
NEBUPENT
nitrofurantoin macrocrystal 50mg, 100mg
nitrofurantoin monohyd macro
PENTAM 300
SIVEXTRO
sulfamethoxazole-trimethop ds
sulfamethoxazole-trimethoprim
sulfamethoxazole-trimethoprim inj
SYNERCID
trimethoprim TABS
TYGACIL
vancomycin hcl CAPS
vancomycin hcl SOLR
VANCOMYCIN IN NACL
Drug Tier Requirements/Limits
4
NM, LA, PA
1
1
1
1
1
1
1
1
4
1
4
3
1
3
1
4
4
4
1
1
1
1
3
B/D
3
PA; PA applies if 65
years and older after a
90 day supply in a
calendar year
3
PA; PA applies if 65
years and older after a
90 day supply in a
calendar year
3
4
1
1
1
4
1
4
4
1
3
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
4
CY17_4T_STANDARD eff 01/01/2017
Drug Name
Drug Tier Requirements/Limits
ANTIFUNGALS
ABELCET
AMBISOME
amphotericin b SOLR
CANCIDAS
fluconazole SUSR; TABS
fluconazole in dextrose
fluconazole inj nacl 100
fluconazole inj nacl 200
fluconazole inj nacl 400
flucytosine CAPS
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole CAPS
ketoconazole TABS
MYCAMINE
NOXAFIL SUSP; TBEC
nystatin TABS
terbinafine hcl TABS
voriconazole SOLR
voriconazole SUSR; TABS
4
3
1
4
1
1
1
1
1
4
1
1
1
1
4
4
1
1
1
4
B/D
B/D
B/D
PA
PA
QL (90 tabs / 365 days)
ANTIMALARIALS
atovaquone-proguanil hcl
chloroquine phosphate TABS
COARTEM
mefloquine hcl
PRIMAQUINE PHOSPHATE
quinine sulfate CAPS
1
1
3
1
2
1
PA
ANTIRETROVIRAL AGENTS
abacavir sulfate
APTIVUS
CRIXIVAN
didanosine
EDURANT
EMTRIVA
FUZEON
INTELENCE 25mg
INTELENCE 100mg, 200mg
INVIRASE
ISENTRESS CHEW 25mg
ISENTRESS CHEW 100mg
ISENTRESS PACK
1
4
3
1
4
2
4
3
4
4
2
4
4
NM
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
5
CY17_4T_STANDARD eff 01/01/2017
Drug Name
ISENTRESS TABS
lamivudine
LEXIVA SUSP
LEXIVA TABS
NEVIRAPINE SUSP
nevirapine TABS; TB24
NORVIR
PREZISTA SUSP
PREZISTA TABS 75mg, 150mg
PREZISTA TABS 600mg, 800mg
RESCRIPTOR
RETROVIR IV INFUSION
REYATAZ
SELZENTRY
stavudine
SUSTIVA CAPS 50mg
SUSTIVA CAPS 200mg
SUSTIVA TABS
TIVICAY 10mg
TIVICAY 25mg, 50mg
TYBOST
VIDEX PEDIATRIC
VIRACEPT
VIREAD
VITEKTA
ZIAGEN SOLN
zidovudine
Drug Tier Requirements/Limits
4
1
3
4
1
1
2
4
2
4
3
2
4
4
1
2
4
4
2
4
2
3
4
4
4
2
1
ANTIRETROVIRAL COMBINATION AGENTS
ABACAVIR SULFATE-LAMIVUDINE
abacavir sulfate-lamivudine-zidovudine
ATRIPLA
COMPLERA
DESCOVY
EPZICOM
EVOTAZ
GENVOYA
KALETRA SOL
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
lamivudine-zidovudine
ODEFSEY
PREZCOBIX
STRIBILD
4
4
4
4
4
4
4
4
4
2
4
1
4
4
4
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
6
CY17_4T_STANDARD eff 01/01/2017
Drug Name
TRIUMEQ
TRUVADA TAB
TRUVADA TAB
TRUVADA TAB
TRUVADA TAB
100-150
133-200
167-250
200-300
Drug Tier Requirements/Limits
4
4
QL (60 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (30 tabs / 30 days)
ANTITUBERCULAR AGENTS
CAPASTAT SULFATE
cycloserine CAPS
ethambutol hcl TABS
isoniazid TABS
isoniazid inj 100 mg/ml
isoniazid syp 50mg/5ml
paser 4gm
PRIFTIN
pyrazinamide TABS
rifabutin
rifampin CAPS; SOLR
RIFATER
SIRTURO
TRECATOR
3
4
1
1
1
1
2
3
1
1
1
3
4
3
LA, PA
ANTIVIRALS
acyclovir CAPS
acyclovir SUSP
acyclovir TABS
acyclovir sodium
adefovir dipivoxil
BARACLUDE SOLN
DAKLINZA
entecavir
EPIVIR HBV SOLN
famciclovir TABS
ganciclovir inj 500mg
lamivudine (hbv)
moderiba tab 200mg
PEGASYS
PEGASYS PROCLICK
REBETOL SOLN
RELENZA DISKHALER
ribasphere
ribasphere 200mg
ribavirin 200mg
rimantadine hydrochloride
1
1
1
1
4
4
4
4
3
1
1
1
1
4
4
4
2
4
1
1
1
B/D
NM, PA
B/D
NM
NM, PA
NM, PA
NM
NM
NM
NM
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
7
CY17_4T_STANDARD eff 01/01/2017
Drug Name
SOVALDI
TAMIFLU
TYZEKA
valacyclovir hcl TABS
VALCYTE SOLR
valganciclovir hcl
ZEPATIER
Drug Tier Requirements/Limits
4
NM, PA
2
4
1
4
4
4
NM, PA
CEPHALOSPORINS
cefaclor
1
cefaclor monohydrate er
2
cefadroxil
1
CEFAZOLIN IN DEXTROSE 2GM/100ML-4% 2
cefazolin inj
1
cefazolin sodium 1gm, 20gm
1
cefazolin sodium 1 gm/50ml
2
cefdinir
1
cefepime hcl
1
cefixime
1
cefotaxime sodium 1gm, 2gm, 500mg
1
cefoxitin sodium
1
cefpodoxime proxetil
1
cefprozil
1
ceftazidime
1
CEFTAZIDIME/DEXTROSE
3
ceftriaxone sodium SOLR 1gm, 2gm,
1
10gm, 250mg, 500mg
cefuroxime axetil
1
cefuroxime sodium 1.5gm, 7.5gm, 750mg 1
cephalexin CAPS 250mg, 500mg
1
cephalexin SUSR
1
SUPRAX CAPS
2
suprax CHEW
3
SUPRAX SUSR 500mg/5ml
2
tazicef SOLR
1
tazicef vial
1
TEFLARO
4
ERYTHROMYCINS/MACROLIDES
AZITHROMYCIN PACK
azithromycin SOLR; SUSR; TABS
clarithromycin TABS
clarithromycin er
clarithromycin for susp
DIFICID
1
1
1
1
1
4
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
8
CY17_4T_STANDARD eff 01/01/2017
Drug Name
e.e.s. 400
erythrocin lactobionate
erythromycin base
erythromycin cap 250mg ec
erythromycin ethylsuccinate
erythromycin stearate
Drug Tier Requirements/Limits
1
3
1
1
1
1
FLUOROQUINOLONES
ciprofloxacin SUSR
ciprofloxacin er
ciprofloxacin hcl tab
ciprofloxacin in d5w
ciprofloxacin inj
levofloxacin TABS
levofloxacin in d5w
levofloxacin inj 25mg/ml
levofloxacin oral soln 25 mg/ml
1
1
1
1
1
1
1
1
1
PENICILLINS
amoxicillin
amoxicillin & pot clavulanate
ampicillin & sulbactam sodium
ampicillin cap 250 mg
ampicillin cap 500 mg
ampicillin for susp 125 mg/5ml
ampicillin for susp 250 mg/5ml
ampicillin inj
ampicillin sodium
BICILLIN L-A
dicloxacillin sodium
nafcillin sodium
oxacillin sodium 1gm, 2gm
oxacillin sodium 10gm
PENICILLIN G POT IN DEXTROSE
penicillin g procaine
penicillin g sodium
penicillin v potassium
penicilln gk inj 5mu
penicilln gk inj 20mu
pfizerpen-g
piperacillin sodium-tazobactam sodium
1
1
1
1
1
1
1
1
1
3
1
1
1
4
3
2
1
1
1
1
1
1
TETRACYCLINES
doxycycline (monohydrate) CAPS 50mg,
100mg
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
9
CY17_4T_STANDARD eff 01/01/2017
Drug Name
doxycycline (monohydrate) TABS
doxycycline hyclate CAPS; SOLR; TABS
minocycline hcl CAPS
morgidox cap 1x50mg
Drug Tier Requirements/Limits
1
1
1
1
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
BENDEKA
BICNU
BUSULFEX
CYCLOPHOSPHAMIDE CAPS
cyclophosphamide SOLR
dacarbazine
EMCYT
GLEOSTINE
HEXALEN
IFEX INJ 3GM
ifosfamide inj 1gm
ifosfamide inj 1gm/20ml
IFOSFAMIDE INJ 3GM
ifosfamide inj 3gm/60ml
LEUKERAN
melphalan hcl
MUSTARGEN
TREANDA
4
4
4
3
4
1
3
3
4
3
1
1
3
1
3
4
4
4
B/D, NM
B/D
B/D
B/D
B/D
B/D
1
1
4
1
1
4
B/D
B/D
B/D
B/D
B/D
B/D
1
4
B/D
B/D
1
4
4
4
1
1
1
B/D
B/D
B/D, NM
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D, NM
ANTHRACYCLINES
daunorubicin hcl
doxorubicin hcl 50mg
doxorubicin hcl liposomal inj 2mg/ml
doxorubicin inj 50mg
epirubicin hcl
idarubicin hcl
ANTIBIOTICS
bleomycin sulfate
mitomycin SOLR
ANTIMETABOLITES
adrucil
ALIMTA
azacitidine
cladribine
cytarabine 20mg/ml
fludarabine phosphate
fluorouracil SOLN
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
10
CY17_4T_STANDARD eff 01/01/2017
Drug Name
GEMCITABINE HCL SOLN
gemcitabine hcl SOLR
mercaptopurine TABS
METHOTREXATE SODIUM 50mg/2ml
methotrexate sodium 50mg/2ml,
100mg/4ml, 200mg/8ml, 250mg/10ml
methotrexate sodium inj
NIPENT
PURIXAN
TABLOID
Drug Tier Requirements/Limits
4
B/D
4
B/D
1
1
B/D
1
B/D
1
4
4
3
B/D
B/D
NM
4
4
4
B/D
B/D
B/D
4
4
4
1
4
B/D
B/D
B/D
B/D
B/D
2
1
1
B/D
B/D
B/D
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
3
4
NM, LA, PA
NM, PA
NM, LA, PA
NM, LA, PA
NM, PA
NM, LA, PA
B/D, NM
B/D, NM
NM, PA
NM, LA, PA
NM, PA
B/D, NM
NM, LA, PA
NM, LA, PA
NM, PA
NM, LA, PA
NM, LA, PA
ANTIMITOTIC, TAXOIDS
ABRAXANE
DOCEFREZ
DOCETAXEL CONC 20mg/ml, 80mg/4ml,
160mg/8ml
docetaxel CONC 140mg/7ml
DOCETAXEL SOLN
DOCETAXEL SOLN 80MG/8ML
paclitaxel
TAXOTERE 80mg/4ml
ANTIMITOTIC, VINCA ALKALOIDS
vinblastine sulfate
vincristine sulfate
vinorelbine tartrate
BIOLOGIC RESPONSE MODIFIERS
AVASTIN
BELEODAQ
ERIVEDGE
FARYDAK
HERCEPTIN
IBRANCE
ISTODAX
KADCYLA
KEYTRUDA
LYNPARZA
NINLARO
PROLEUKIN
RITUXAN
TECENTRIQ
VELCADE
VENCLEXTA 10mg, 50mg
VENCLEXTA 100mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
11
CY17_4T_STANDARD eff 01/01/2017
Drug Name
VENCLEXTA STARTING PACK
YERVOY
ZOLINZA
Drug Tier Requirements/Limits
4
NM, LA, PA
4
NM, PA
4
NM, PA
HORMONAL ANTINEOPLASTIC AGENTS
anastrozole TABS
bicalutamide
DEPO-PROVERA INJ 400/ML
exemestane
FARESTON
FASLODEX
flutamide
hydroxyprogesterone caproate
(antineoplastic)
letrozole TABS
leuprolide acetate KIT
LUPRON DEPOT 3.75mg
LUPRON DEPOT INJ 11.25MG (3-MONTH)
LYSODREN
megestrol ac sus 40mg/ml
1
1
3
1
4
4
1
3
megestrol ac tab 20mg
3
megestrol ac tab 40mg
3
MEGESTROL SUS 625MG/5ML
NILANDRON
nilutamide
SOLTAMOX
tamoxifen citrate TABS
TRELSTAR DEP INJ 3.75MG
TRELSTAR LA INJ 11.25MG
XTANDI
ZYTIGA
3
4
4
3
1
4
4
4
4
1
1
4
4
2
3
B/D
B/D
B/D
NM, PA
NM, PA
NM, PA
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA
NM,
NM,
NM,
NM,
PA
PA
LA, PA
LA, PA
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
LA,
PA
LA,
LA,
LA,
LA,
LA,
KINASE INHIBITORS
AFINITOR
AFINITOR DISPERZ
ALECENSA
BOSULIF
CABOMETYX
CAPRELSA
COMETRIQ
COTELLIC
GILOTRIF TAB 20MG
4
4
4
4
4
4
4
4
4
PA
PA
PA
PA
PA
PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
12
CY17_4T_STANDARD eff 01/01/2017
Drug Name
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
ICLUSIG
imatinib mesylate 100mg
imatinib mesylate 400mg
IMBRUVICA CAP 140MG
INLYTA
IRESSA
JAKAFI
LENVIMA 8 MG DAILY DOSE
LENVIMA 10 MG DAILY DOSE
LENVIMA 14 MG DAILY DOSE
LENVIMA 18 MG DAILY DOSE
LENVIMA 20 MG DAILY DOSE
LENVIMA 24 MG DAILY DOSE
MEKINIST
NEXAVAR
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
TAGRISSO
TARCEVA
TASIGNA
TYKERB
VOTRIENT
XALKORI
ZELBORAF
ZYDELIG
ZYKADIA
Drug Tier Requirements/Limits
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
QL (90 tabs / 30 days),
NM, PA
4
QL (60 tabs / 30 days),
NM, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, PA
4
NM, LA, PA
4
NM, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
MISCELLANEOUS
bexarotene
DROXIA
hydroxyurea CAPS
LONSURF
MATULANE
mitoxantrone hcl
ODOMZO
SYLATRON KIT 200MCG
SYLATRON KIT 300MCG
SYLATRON KIT 600MCG
4
2
1
4
4
1
4
4
4
4
NM, PA
NM, PA
LA
B/D, NM
NM, LA, PA
NM, PA
NM, PA
NM, PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
13
CY17_4T_STANDARD eff 01/01/2017
Drug Name
SYNRIBO
tretinoin (chemotherapy)
TRISENOX
Drug Tier Requirements/Limits
4
NM, PA
4
4
B/D
PLATINUM-BASED AGENTS
carboplatin
cisplatin
oxaliplatin
1
1
1
B/D
B/D
B/D
4
4
4
4
1
1
1
4
1
4
B/D
B/D
B/D
B/D, NM
B/D
1
1
1
1
4
4
B/D
B/D
B/D
B/D
B/D
B/D
PROTECTIVE AGENTS
amifostine crystalline
dexrazoxane
ELITEK
FUSILEV
leucovorin calcium SOLR
leucovorin calcium TABS
leucovorin calcium for inj 500 mg
levoleucovorin calcium
mesna
MESNEX TABS
B/D
B/D, NM
B/D
TOPOISOMERASE INHIBITORS
etoposide SOLN
irinotecan inj 40mg/2ml
irinotecan inj 100/5ml
irinotecan inj 500mg/25ml
TOPOTECAN HCL SOLN
topotecan hcl SOLR
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine--benazepril hcl cap 10-20 mg
amlodipine-benazepril hcl cap 2.5-10 mg
amlodipine-benazepril hcl cap 5-10 mg
amlodipine-benazepril hcl cap 5-20 mg
amlodipine-benazepril hcl cap 5-40 mg
amlodipine-benazepril hcl cap 10-40mg
benazepril & hydrochlorothiazide
captopril & hydrochlorothiazide
enalapril maleate & hydrochlorothiazide
fosinopril sodium & hydrochlorothiazide
lisinopril & hydrochlorothiazide
moexipril-hydrochlorothiazide
quinapril-hydrochlorothiazide
1
1
1
1
1
1
1
1
1
1
1
1
1
ACE INHIBITORS
benazepril hcl TABS
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
14
CY17_4T_STANDARD eff 01/01/2017
Drug Name
captopril TABS
enalapril maleate TABS
fosinopril sodium
lisinopril TABS
moexipril hcl
perindopril erbumine
quinapril hcl
ramipril
trandolapril
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone
spironolactone TABS
1
1
ALPHA BLOCKERS
doxazosin mesylate 1mg, 2mg, 4mg
doxazosin mesylate 8mg
prazosin hcl
terazosin hcl
1
1
1
1
QL (30 tabs / 30 days)
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS
amlodipine besylate-olmesartan medoxomil1
amlodipine besylate-valsartan tab 5-160
1
mg
amlodipine besylate-valsartan tab 5-320
1
mg
amlodipine besylate-valsartan tab 10-160 1
mg
amlodipine besylate-valsartan tab 10-320 1
mg
amlodipine-valsartan-hydrochlorothiazide 1
5-160-12.5mg
amlodipine-valsartan-hydrochlorothiazide 1
5-160-25mg
amlodipine-valsartan-hydrochlorothiazide 1
10-160-12.5mg
amlodipine-valsartan-hydrochlorothiazide 1
10-160-25mg
amlodipine-valsartan-hydrochlorothiazide 1
10-320-25mg
ENTRESTO
2
irbesartan-hydrochlorothiazide
1
losartan-hydrochlorothiazide
1
olmesartan medoxomil-amlodipine1
hydrochlorothiazide
olmesartan medoxomil-hydrochlorothiazide 1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
15
CY17_4T_STANDARD eff 01/01/2017
Drug Name
valsartan & hctz
valsartan & hctz
valsartan & hctz
valsartan & hctz
valsartan & hctz
tab
tab
tab
tab
tab
80-12.5mg
160-12.5mg
160-25mg
320-12.5mg
320-25mg
Drug Tier Requirements/Limits
1
1
1
1
1
ANGIOTENSIN II RECEPTOR ANTAGONISTS
irbesartan
losartan potassium
olmesartan medoxomil
valsartan
1
1
1
1
ANTIARRHYTHMICS
amiodarone hcl
disopyramide phosphate
1
3
DOFETILIDE
flecainide acetate
mexiletine hcl
MULTAQ
NORPACE CR
1
1
1
3
3
pacerone tab 100mg
propafenone hcl
propafenone hcl 12hr
quinidine gluconate TBCR
quinidine sulfate TABS
sotalol hcl
sotalol hcl (afib/afl)
1
1
1
1
1
1
1
PA; PA if 65 years and
older
NM
PA; PA if 65 years and
older
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS
atorvastatin calcium TABS
lovastatin
pravastatin sodium
rosuvastatin calcium
simvastatin TABS 5mg, 10mg, 20mg,
40mg
simvastatin TABS 80mg
1
1
1
1
1
1
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
ANTILIPEMICS, MISCELLANEOUS
cholestyramine
cholestyramine light
colestipol hcl
fenofibrate TABS 48mg, 54mg, 145mg,
160mg
fenofibrate micronized 67mg, 134mg,
200mg
1
1
1
1
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
16
CY17_4T_STANDARD eff 01/01/2017
Drug Name
gemfibrozil TABS
JUXTAPID
KYNAMRO
niacin (antihyperlipidemic)
niacin er (antihyperlipidemic) 500mg
niacin er (antihyperlipidemic) 750mg,
1000mg
omega-3-acid ethyl esters
PRALUENT
VASCEPA 1gm
WELCHOL
ZETIA TAB 10MG
Drug Tier Requirements/Limits
1
4
NM, LA, PA
4
NM, PA
1
1
QL (90 tabs / 30 days)
1
1
4
3
2
2
NM, PA
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol & chlorthalidone
bisoprolol & hydrochlorothiazide
metoprolol & hctz tab 50-25mg
metoprolol & hctz tab 100-25mg
metoprolol & hctz tab 100-50mg
propranolol & hydrochlorothiazide
1
1
1
1
1
1
BETA-BLOCKERS
acebutolol hcl CAPS
atenolol TABS
bisoprolol fumarate
BYSTOLIC
carvedilol
labetalol hcl TABS
metoprolol succinate
metoprolol tartrate SOLN
metoprolol tartrate TABS 25mg, 50mg,
100mg
nadolol TABS
pindolol
propranolol cap er
propranolol hcl SOLN; TABS
propranolol oral sol
timolol maleate TABS
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
CALCIUM CHANNEL BLOCKERS
amlodipine besylate TABS
cartia xt cap 120/24hr
cartia xt cap 180/24hr
cartia xt cap 240/24hr
cartia xt cap 300/24hr
1
1
1
1
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
17
CY17_4T_STANDARD eff 01/01/2017
Drug Name
dilt-xr cap
diltiazem cap 120mg cd
diltiazem cap 180mg cd
diltiazem cap 240mg cd
diltiazem cap 300mg cd
DILTIAZEM CAP 360MG CD
diltiazem cap er/12hr
diltiazem hcl SOLN; TABS
diltiazem hcl cap sr 24hr
diltiazem hcl coated beads cap sr 24hr
diltiazem hcl extended release beads cap
sr
felodipine
isradipine
nicardipine hcl CAPS
nifedipine TB24
nifedipine cr
nifedipine er
nifedipine xl
nimodipine CAPS
NYMALIZE
taztia xt
verapamil cap er 100mg, 120mg, 180mg,
200mg, 240mg, 300mg
VERAPAMIL CAP ER 360mg
verapamil hcl SOLN; TABS; TBCR
verapamil tab er
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
4
4
1
1
1
1
1
DIGITALIS GLYCOSIDES
digox 125mcg
digox 250mcg
1
1
digoxin TABS .25mg, 250mcg
1
digoxin TABS .125mg, 125mcg
digoxin inj
DIGOXIN SOL 50MCG/ML
1
1
1
QL (30
PA; PA
older
PA; PA
older
QL (30
tabs / 30 days)
if 65 years and
if 65 years and
tabs / 30 days)
PA; PA if 65 years and
older
DIURETICS
acetazolamide CP12; TABS
amiloride & hydrochlorothiazide
amiloride hcl TABS
bumetanide
chlorothiazide tabs
1
1
1
1
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
18
CY17_4T_STANDARD eff 01/01/2017
Drug Name
chlorthalidone 25mg, 50mg
furosemide SOLN; TABS
furosemide inj 10mg/ml
FUROSEMIDE INJ 10mg/ml
hydrochlorothiazide CAPS; TABS
indapamide
methazolamide TABS
methyclothiazide
metolazone
spironolactone & hydrochlorothiazide
torsemide tabs
triamterene & hydrochlorothiazide TABS
triamterene & hydrochlorothiazide cap
37.5-25 mg
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
MISCELLANEOUS
clonidine hcl PTWK; TABS
DEMSER
hydralazine hcl SOLN; TABS
midodrine hcl
minoxidil TABS
NORTHERA
RANEXA
1
4
1
1
1
4
2
NM, LA, PA
NITRATES
isosorb mononitrate tab
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate er
NITRO-DUR DIS 0.3MG/HR
NITRO-DUR DIS 0.8MG/HR
nitroglycerin OINT
nitroglycerin PT24; SUBL
nitroglycerin td patch
NITROSTAT
1
1
1
1
3
3
2
1
1
2
PULMONARY ARTERIAL HYPERTENSION
ADCIRCA
ADEMPAS
4
4
LETAIRIS
4
OPSUMIT
REMODULIN
REVATIO SUSR
4
4
4
NM, PA
QL (90 tabs / 30 days),
NM, LA, PA
QL (30 tabs / 30 days),
NM, LA, PA
NM, LA, PA
NM, LA, PA
QL (224 mL / 30 days),
NM, PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
19
CY17_4T_STANDARD eff 01/01/2017
Drug Name
Drug Tier Requirements/Limits
sildenafil citrate (pulmonary hypertension) 1
QL (90 tabs / 30 days),
TABS
NM, PA
TRACLEER 62.5mg
4
QL (120 tabs / 30 days),
NM, LA, PA
TRACLEER 125mg
4
QL (60 tabs / 30 days),
NM, LA, PA
UPTRAVI TABS 200mcg
4
QL (480 tabs / 30 days),
NM, LA, PA
UPTRAVI TABS 400mcg
4
QL (240 tabs / 30 days),
NM, LA, PA
UPTRAVI TABS 600mcg
4
QL (150 tabs / 30 days),
NM, LA, PA
UPTRAVI TABS 800mcg
4
QL (120 tabs / 30 days),
NM, LA, PA
UPTRAVI TABS 1000mcg
4
QL (90 tabs / 30 days),
NM, LA, PA
UPTRAVI TABS 1200mcg, 1400mcg,
4
QL (60 tabs / 30 days),
1600mcg
NM, LA, PA
UPTRAVI TBPK
4
NM, LA, PA
VENTAVIS
4
NM, PA
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
alprazolam tab 0.5mg
alprazolam tab 0.25mg
alprazolam tab 1mg
alprazolam tab 2mg
buspirone hcl TABS
fluvoxamine maleate TABS 25mg, 50mg
fluvoxamine maleate TABS 100mg
lorazepam CONC
lorazepam SOLN
lorazepam TABS
1
1
1
1
1
1
1
1
1
1
QL
QL
QL
QL
(240
(480
(120
(150
tabs
tabs
tabs
tabs
/
/
/
/
30
30
30
30
days)
days)
days)
days)
3
4
4
4
4
4
4
3
4
QL (180 tabs / 30 days)
QL (90 tabs / 30 days)
QL (60 tabs / 30 days)
PA
PA
PA
PA
PA
PA
QL (45 tabs / 30 days)
QL (150 mL / 30 days)
QL (150 tabs / 30 days)
ANTICONVULSANTS
APTIOM 200mg
APTIOM 400mg
APTIOM 600mg, 800mg
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
BRIVIACT SOLN 10mg/ml
BRIVIACT SOLN 50mg/5ml
BRIVIACT TABS
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
20
CY17_4T_STANDARD eff 01/01/2017
Drug Name
carbamazepine CHEW; CP12; SUSP;
TABS; TB12
CELONTIN
clonazepam TABS 1mg
clonazepam TABS 2mg
clonazepam TABS .5mg
clonazepam TBDP 1mg
clonazepam TBDP 2mg
clonazepam TBDP .5mg
clonazepam TBDP .25mg
clonazepam TBDP .125mg
clorazepate dipotassium 3.75mg, 7.5mg
Drug Tier Requirements/Limits
1
3
1
1
1
1
1
1
1
1
1
clorazepate dipotassium 15mg
1
diazepam CONC
1
diazepam SOLN 1mg/ml
1
diazepam SOLN 5mg/ml
diazepam TABS
1
1
DIAZEPAM GEL
dilantin infatabs
DILANTIN-125 SUS 125/5ML
divalproex sodium
ethosuximide CAPS; SOLN
felbamate SUSP
felbamate TABS
FYCOMPA SUSP
1
2
2
1
1
4
1
3
FYCOMPA TABS 2mg
3
FYCOMPA TABS 4mg
3
FYCOMPA TABS 6mg
3
FYCOMPA TABS 8mg, 10mg, 12mg
3
gabapentin CAPS 100mg
1
gabapentin CAPS 300mg
gabapentin CAPS 400mg
gabapentin SOLN
1
1
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
PA
QL
PA
QL
PA
QL
PA
(120
(300
(240
(120
(300
(240
(480
(960
(120
tabs
tabs
tabs
tabs
tabs
tabs
tabs
tabs
tabs
/
/
/
/
/
/
/
/
/
30
30
30
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
days)
days)
days),
(180 tabs / 30 days),
(240 mL / 30 days),
(1200 mL / 30 days),
QL (120 tabs / 30 days),
PA
QL (720 mL / 30 days),
PA
QL (180 tabs / 30 days),
PA
QL (90 tabs / 30 days),
PA
QL (60 tabs / 30 days),
PA
QL (30 tabs / 30 days),
PA
QL (1080 caps / 30
days)
QL (360 caps / 30 days)
QL (270 caps / 30 days)
QL (2160 mL / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
21
CY17_4T_STANDARD eff 01/01/2017
Drug Name
gabapentin TABS 600mg
gabapentin TABS 800mg
GABITRIL 12mg, 16mg
lamotrigine CHEW; TABS; TB24
levetiracetam SOLN; TABS; TB24
LEVETIRACETAM IV
levetiracetam oral soln 100 mg/ml
LYRICA CAPS 25mg, 50mg, 75mg,
100mg, 150mg
LYRICA CAPS 200mg
LYRICA CAPS 225mg, 300mg
LYRICA SOLN
ONFI SUSP
ONFI TABS 10mg
ONFI TABS 20mg
oxcarbazepine
PEGANONE
phenobarbital ELIX; TABS
Drug Tier Requirements/Limits
1
QL (180 tabs / 30 days)
1
QL (120 tabs / 30 days)
3
1
1
3
1
2
QL (120 caps / 30 days)
2
2
2
4
3
4
1
3
3
PHENOBARBITAL SODIUM SOLN 65mg/ml 3
phenobarbital sodium SOLN 130mg/ml
3
phenytoin CHEW; SUSP
phenytoin sodium SOLN
phenytoin sodium extended 30mg,
100mg, 200mg, 300mg
phenytoin sodium extended 100mg,
200mg, 300mg
POTIGA 50mg
POTIGA 200mg
POTIGA 300mg, 400mg
primidone TABS
SABRIL PACK
1
1
2
SABRIL TABS
4
SPRITAM
TEGRETOL
TEGRETOL-XR
tiagabine hcl
topiramate CPSP; TABS
valproate sodium SOLN; SYRP
valproic acid
3
3
3
1
1
1
1
QL (90 caps / 30 days)
QL (60 caps / 30 days)
QL (946 mL / 30 days)
PA
PA
PA
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
1
3
4
4
1
4
QL (180 tabs / 30 days)
QL (90 tabs / 30 days)
QL (180 packets / 30
days), NM, LA, PA
QL (180 tabs / 30 days),
NM, LA, PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
22
CY17_4T_STANDARD eff 01/01/2017
Drug Name
VIMPAT SOLN 10mg/ml
VIMPAT SOLN 200mg/20ml
VIMPAT TABS 50mg
VIMPAT TABS 100mg, 150mg, 200mg
zonisamide CAPS
Drug Tier Requirements/Limits
3
QL (1200 mL / 30 days)
3
3
QL (180 tabs / 30 days)
3
QL (60 tabs / 30 days)
1
ANTIDEMENTIA
donepezil hydrochloride TABS 5mg
donepezil hydrochloride TABS 10mg,
23mg
donepezil hydrochloride TBDP 5mg
donepezil hydrochloride TBDP 10mg
galantamine hydrobromide SOLN
galantamine hydrobromide TABS 4mg
galantamine hydrobromide TABS 8mg
galantamine hydrobromide TABS 12mg
galantamine hydrobromide er 8mg, 16mg
galantamine hydrobromide er 24mg
memantine hcl SOLN
memantine hcl TABS 5mg
MEMANTINE HCL TABS 10mg
NAMENDA XR
NAMENDA XR TITRATION PACK
NAMZARIC CP24
rivastigmine tartrate
rivastigmine td patch 24hr 4.6 mg/24hr
1
1
QL (60 tabs / 30 days)
1
1
1
1
1
1
1
1
1
1
1
3
3
3
1
1
QL (60 tabs / 30 days)
rivastigmine td patch 24hr 9.5 mg/24hr
1
rivastigmine td patch 24hr 13.3 mg/24hr
1
QL (180 tabs / 30 days)
QL (90 tabs / 30 days)
QL (30 caps / 30 days)
PA;
PA;
PA;
PA;
PA;
PA
PA
PA
PA
PA
if
if
if
if
if
<
<
<
<
<
30
30
30
30
30
yrs
yrs
yrs
yrs
yrs
QL (30 patches / 30
days)
QL (30 patches / 30
days)
QL (30 patches / 30
days)
ANTIDEPRESSANTS
amitriptyline hcl TABS
3
amoxapine tab 25mg
amoxapine tab 50mg
amoxapine tab 100mg
amoxapine tab 150mg
bupropion hcl TABS
bupropion hcl TB12
bupropion hcl TB24 150mg
bupropion hcl TB24 300mg
citalopram hydrobromide SOLN
1
1
1
1
1
1
1
1
1
PA; PA if 65 years and
older
QL (90 tabs / 30 days)
QL (30 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
23
CY17_4T_STANDARD eff 01/01/2017
Drug Name
citalopram hydrobromide TABS 10mg,
20mg
citalopram hydrobromide TABS 40mg
clomipramine hcl CAPS
Drug Tier Requirements/Limits
1
QL (45 tabs / 30 days)
1
3
desipramine hcl TABS
doxepin hcl CAPS; CONC
1
3
duloxetine hcl CPEP 20mg
duloxetine hcl CPEP 30mg
duloxetine hcl CPEP 60mg
EMSAM
1
1
1
4
escitalopram oxalate SOLN
escitalopram oxalate TABS 5mg, 10mg
escitalopram oxalate TABS 20mg
FETZIMA 20mg
FETZIMA 40mg
FETZIMA 80mg, 120mg
FETZIMA TITRATION PACK
fluoxetine cap 10mg
fluoxetine cap 20mg
fluoxetine cap 40mg
fluoxetine hcl SOLN
fluoxetine hcl TABS 10mg
fluoxetine hcl TABS 20mg
imipramine hcl TABS
1
1
1
3
3
3
3
1
1
1
1
1
1
3
maprotiline hcl
MARPLAN TAB 10MG
mirtazapine TABS 7.5mg, 15mg
mirtazapine TABS 30mg, 45mg
mirtazapine TBDP 15mg
mirtazapine TBDP 30mg, 45mg
nefazodone hcl
nortriptyline hcl CAPS; SOLN
paroxetine hcl tabs 10mg, 20mg, 40mg
paroxetine hcl tabs 30mg
PAXIL SUSP
phenelzine sulfate TABS
PRISTIQ
protriptyline hcl
sertraline hcl CONC
1
3
1
1
1
1
1
1
1
1
3
1
2
1
1
QL (30 tabs / 30 days)
PA; PA if 65 years and
older
PA; PA if 65 years and
older
QL (180 caps / 30 days)
QL (120 caps / 30 days)
QL (60 caps / 30 days)
QL (30 patches / 30
days), PA
QL (600 mL / 30 days)
QL (45 tabs / 30 days)
QL (60 tabs / 30 days)
QL (180 caps / 30 days)
QL (90 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (120 caps / 30 days)
QL (45 tabs / 30 days)
PA; PA if 65 years and
older
QL (180 tabs / 30 days)
QL (45 tabs / 30 days)
QL (30 tabs / 30 days)
QL (45 tabs / 30 days)
QL (60 tabs / 30 days)
QL (900 mL / 30 days)
QL (30 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
24
CY17_4T_STANDARD eff 01/01/2017
Drug Name
Drug Tier Requirements/Limits
sertraline hcl TABS 25mg, 50mg
1
QL (45 tabs / 30 days)
sertraline hcl TABS 100mg
1
tranylcypromine sulfate
1
trazodone hcl TABS 50mg, 100mg, 150mg 1
trimipramine maleate CAPS 25mg
3
QL (240 caps / 30
days), PA; PA if 65 years
and older
trimipramine maleate CAPS 50mg
3
QL (120 caps / 30
days), PA; PA if 65 years
and older
trimipramine maleate CAPS 100mg
3
QL (60 caps / 30 days),
PA; PA if 65 years and
older
TRINTELLIX 5mg
3
QL (120 tabs / 30 days)
TRINTELLIX 10mg
3
QL (60 tabs / 30 days)
TRINTELLIX 20mg
3
QL (30 tabs / 30 days)
venlafaxine hcl CP24 37.5mg, 75mg
1
QL (30 caps / 30 days)
venlafaxine hcl CP24 150mg
1
QL (60 caps / 30 days)
venlafaxine hcl TABS
1
VIIBRYD STARTER PACK
3
VIIBRYD TAB
3
QL (30 tabs / 30 days)
ANTIPARKINSONIAN AGENTS
amantadine hcl CAPS
amantadine hcl SYRP; TABS
APOKYN
AZILECT
BENZTROPINE MESYLATE SOLN
benztropine mesylate TABS
1
1
4
2
1
3
bromocriptine mesylate CAPS; TABS
carbidopa-levodopa
CARBIDOPA/LEVODOPA/ENTACAPONE
ENTACAPONE
NEUPRO
pramipexole tab 0.5mg
pramipexole tab 0.25mg
pramipexole tab 0.75mg
pramipexole tab 0.125mg
pramipexole tab 1.5mg
pramipexole tab 1mg
ropinirole tab 0.5mg
ropinirole tab 0.25mg
ropinirole tab 1mg
1
1
1
1
3
1
1
1
1
1
1
1
1
1
QL (120 caps / 30 days)
NM, LA, PA
PA; PA if 65 years and
older
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
25
CY17_4T_STANDARD eff 01/01/2017
Drug Name
ropinirole tab
ropinirole tab
ropinirole tab
ropinirole tab
selegiline hcl
2mg
3mg
4mg
5mg
CAPS; TABS
Drug Tier Requirements/Limits
1
1
1
1
1
ANTIPSYCHOTICS
ABILIFY MAINTENA 300mg, 400mg
ABILIFY MAINTENA 300mg, 400mg
aripiprazole odt
aripiprazole oral solution 1 mg/ml
aripiprazole tab 2mg, 5mg, 10mg, 15mg
aripiprazole tab 20mg, 30mg
chlorpromazine hcl TABS
chlorpromazine inj
CLOZAPINE ODT 12.5mg, 25mg
CLOZAPINE ODT 100mg
4
4
4
4
1
4
1
3
1
1
CLOZAPINE ODT 150mg
1
CLOZAPINE ODT 200mg
4
clozapine tab 25mg
clozapine tab 50mg
clozapine tab 100mg
clozapine tab 200mg
FANAPT 1mg, 2mg, 4mg
FANAPT 6mg, 8mg, 10mg, 12mg
FANAPT TITRATION PACK
fluphenazine decanoate SOLN
fluphenazine hcl
GEODON SOLR
haloperidol TABS
haloperidol decanoate SOLN
haloperidol lactate inj 5 mg/ml
haloperidol lactate oral conc 2 mg/ml
INVEGA SUST INJ 39 MG/0.25 ML
1
1
1
1
3
4
3
1
1
3
1
1
1
1
3
INVEGA SUST INJ 78 MG/0.5 ML
4
INVEGA SUST INJ 117 MG/0.75 ML
4
INVEGA SUST INJ 156MG/ML
4
QL
QL
QL
QL
QL
QL
(1 syringe / 28 days)
(1 vial / 28 days)
(60 tabs / 30 days)
(900 mL / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
PA
QL (270 tabs / 30 days),
PA
QL (180 tabs / 30 days),
PA
QL (135 tabs / 30 days),
PA
QL
QL
QL
QL
(270 tabs / 30 days)
(135 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
QL (6 mL / 3 days)
QL (1
days)
QL (1
days)
QL (1
days)
QL (1
days)
injection / 28
injection / 28
injection / 28
injection / 28
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
26
CY17_4T_STANDARD eff 01/01/2017
Drug Name
INVEGA SUST INJ 234 MG/1.5 ML
Drug Tier Requirements/Limits
4
QL (1 injection / 28
days)
INVEGA TRINZA
4
QL (1 syringe / 90 days)
LATUDA 20mg
3
QL (240 tabs / 30 days)
LATUDA 40mg, 120mg
3
QL (30 tabs / 30 days)
LATUDA 60mg, 80mg
3
QL (60 tabs / 30 days)
loxapine succinate
1
molindone hcl
1
NUPLAZID
4
QL (60 tabs / 30 days),
NM, LA, PA
olanzapine SOLR
1
QL (3 vials / 1 day)
olanzapine TABS 2.5mg
1
QL (240 tabs / 30 days)
olanzapine TABS 5mg
1
QL (120 tabs / 30 days)
olanzapine TABS 7.5mg
1
QL (30 tabs / 30 days)
olanzapine TABS 10mg, 15mg, 20mg
1
QL (60 tabs / 30 days)
olanzapine TBDP 5mg
1
QL (30 tabs / 30 days)
olanzapine TBDP 10mg, 15mg, 20mg
1
QL (60 tabs / 30 days)
paliperidone 1.5mg, 3mg, 9mg
4
QL (30 tabs / 30 days)
paliperidone 6mg
4
QL (60 tabs / 30 days)
perphenazine TABS
1
pimozide
1
quetiapine fumarate TABS
1
QL (90 tabs / 30 days)
quetiapine fumarate TB24 50mg
1
QL (120 tabs / 30 days)
quetiapine fumarate TB24 150mg, 200mg 1
QL (30 tabs / 30 days)
quetiapine fumarate TB24 300mg, 400mg 1
QL (60 tabs / 30 days)
REXULTI 1mg
4
QL (90 tabs / 30 days)
REXULTI 2mg
4
QL (60 tabs / 30 days)
REXULTI 3mg, 4mg
4
QL (30 tabs / 30 days)
REXULTI .5mg
4
QL (180 tabs / 30 days)
REXULTI .25mg
4
QL (360 tabs / 30 days)
RISPERDAL INJ 12.5MG
3
QL (2 injections / 28
days)
RISPERDAL INJ 25MG
3
QL (2 injections / 28
days)
RISPERDAL INJ 37.5MG
4
QL (2 injections / 28
days)
RISPERDAL INJ 50MG
4
QL (2 injections / 28
days)
risperidone SOLN
1
QL (240 mL / 30 days)
risperidone TABS 1mg, 2mg, 3mg
1
QL (60 tabs / 30 days)
risperidone TABS 4mg
1
QL (120 tabs / 30 days)
risperidone TABS .25mg, .5mg
1
QL (90 tabs / 30 days)
risperidone TBDP 1mg, 2mg, 3mg
1
QL (60 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
27
CY17_4T_STANDARD eff 01/01/2017
Drug Name
risperidone TBDP 4mg
risperidone TBDP .25mg, .5mg
SAPHRIS 2.5mg
SAPHRIS 5mg
SAPHRIS 10mg
SEROQUEL XR 50mg
SEROQUEL XR 150mg, 200mg
SEROQUEL XR 300mg, 400mg
thioridazine hcl TABS
Drug Tier Requirements/Limits
1
QL (120 tabs / 30 days)
1
QL (90 tabs / 30 days)
3
QL (240 tabs / 30 days)
3
QL (120 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (120 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
PA; PA if 65 years and
older
1
1
4
QL (600 mL / 30 days),
PA
4
QL (120 caps / 30 days)
4
QL (60 caps / 30 days)
4
QL (30 caps / 30 days)
3
1
QL (60 caps / 30 days)
1
QL (90 caps / 30 days)
4
QL (2 vials / 28 days),
PA
4
QL (1 vial / 28 days), PA
3
QL (2 vials / 28 days),
PA
thiothixene
trifluoperazine hcl
VERSACLOZ
VRAYLAR 1.5mg
VRAYLAR 3mg
VRAYLAR 4.5mg, 6mg
VRAYLAR THERAPY PACK
ziprasidone hcl 20mg, 40mg
ziprasidone hcl 60mg, 80mg
ZYPREXA RELPREVV 300mg
ZYPREXA RELPREVV 405mg
ZYPREXA RELPREVV INJ 210MG
ATTENTION DEFICIT HYPERACTIVITY DISORDER
amphetamine-dextroamphetamine
24hr 5 mg
amphetamine-dextroamphetamine
24hr 10 mg
amphetamine-dextroamphetamine
24hr 15 mg
amphetamine-dextroamphetamine
24hr 20 mg
amphetamine-dextroamphetamine
24hr 25 mg
amphetamine-dextroamphetamine
24hr 30 mg
amphetamine-dextroamphetamine
mg
amphetamine-dextroamphetamine
mg
amphetamine-dextroamphetamine
mg
cap sr
1
QL (90 caps / 30 days)
cap sr
1
QL (90 caps / 30 days)
cap sr
1
QL (30 caps / 30 days)
cap sr
1
QL (30 caps / 30 days)
cap sr
1
QL (30 caps / 30 days)
cap sr
1
QL (30 caps / 30 days)
tab 5
1
QL (360 tabs / 30 days)
tab 7.5 1
QL (240 tabs / 30 days)
tab 10 1
QL (180 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
28
CY17_4T_STANDARD eff 01/01/2017
Drug Name
amphetamine-dextroamphetamine
12.5 mg
amphetamine-dextroamphetamine
mg
amphetamine-dextroamphetamine
mg
amphetamine-dextroamphetamine
mg
guanfacine er (adhd)
tab
Drug Tier Requirements/Limits
1
QL (144 tabs / 30 days)
tab 15 1
QL (120 tabs / 30 days)
tab 20 1
QL (90 tabs / 30 days)
tab 30 1
QL (60 tabs / 30 days)
metadate er tab 20mg
methylphenidate hcl TABS 5mg, 10mg
methylphenidate hcl TABS 20mg
methylphenidate hcl TBCR
methylphenidate hcl oral soln 5mg/5ml
methylphenidate hcl oral soln 10mg/5ml
STRATTERA 10mg, 18mg, 25mg
STRATTERA 40mg
STRATTERA 60mg, 80mg, 100mg
3
1
1
1
1
1
1
3
3
3
PA; PA if 65 years and
older
QL (90 tabs / 30 days)
QL (180 tabs / 30 days)
QL (90 tabs / 30 days)
QL (90 tabs / 30 days)
QL (1800 mL / 30 days)
QL (900 mL / 30 days)
QL (120 caps / 30 days)
QL (60 caps / 30 days)
QL (30 caps / 30 days)
HYPNOTICS
HETLIOZ
SILENOR 3mg
SILENOR 6mg
temazepam 7.5mg
4
2
2
1
temazepam 15mg
1
zolpidem tartrate TABS
3
NM, LA, PA
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 caps / 30 days),
PA; PA applies if 65
years and older after a
90 day supply in a
calendar year
QL (60 caps / 30 days),
PA; PA applies if 65
years and older after a
90 day supply in a
calendar year
QL (30 tabs / 30 days),
PA; PA applies if 65
years and older after a
90 day supply in a
calendar year
MIGRAINE
cafergot
dihydroergotamine mesylate 1mg/ml
ergotamine w/ caffeine
naratriptan hcl
RELPAX
3
1
4
1
2
QL (12 tabs / 30 days)
QL (12 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
29
CY17_4T_STANDARD eff 01/01/2017
Drug Name
rizatriptan benzoate
SUMATRIPTAN SOLN 5mg/act
SUMATRIPTAN SOLN 20mg/act
SUMATRIPTAN INJ 4MG/0.5ML
sumatriptan inj 6mg/0.5ml
sumatriptan succinate TABS
zolmitriptan TABS
zolmitriptan odt
Drug Tier Requirements/Limits
1
QL (18 tabs / 30 days)
1
QL (24 inhalers / 30
days)
1
QL (12 inhalers / 30
days)
1
QL (18 injections / 30
days)
1
QL (12 injections / 30
days)
1
QL (12 tabs / 30 days)
1
QL (12 tabs / 30 days)
1
QL (12 tabs / 30 days)
MISCELLANEOUS
lithium carbonate CAPS; TABS
lithium carbonate er
LITHIUM SOLN 8MEQ/5ML
NUEDEXTA
pyridostigmine tab 60mg
riluzole
TETRABENAZINE 12.5mg
1
1
2
3
1
1
4
TETRABENAZINE 25mg
4
PA
QL (240 tabs / 30 days),
NM, PA
QL (120 tabs / 30 days),
NM, PA
MULTIPLE SCLEROSIS AGENTS
AMPYRA
BETASERON
4
4
COPAXONE INJ 40MG/ML
4
GILENYA CAP 0.5MG
4
glatiramer acetate
4
TYSABRI
4
NM, LA, PA
QL (14 syringes / 28
days), NM, PA
QL (12 syringes / 28
days), NM, PA
QL (28 caps / 28 days),
NM, PA
QL (30 syringes / 30
days), NM, PA
NM, LA, PA
MUSCULOSKELETAL THERAPY AGENTS
baclofen TABS
cyclobenzaprine hcl TABS 5mg, 10mg
1
3
dantrolene sodium CAPS
tizanidine hcl TABS
1
1
PA; PA if 65 years and
older
NARCOLEPSY/CATAPLEXY
armodafinil 50mg
1
QL (150 tabs / 30 days),
PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
30
CY17_4T_STANDARD eff 01/01/2017
Drug Name
armodafinil 150mg
ARMODAFINIL 200mg
armodafinil 250mg
XYREM
Drug Tier Requirements/Limits
1
QL (60 tabs / 30 days),
PA
1
QL (30 tabs / 30 days),
PA
1
QL (30 tabs / 30 days),
PA
4
QL (540 mL / 30 days),
LA, PA
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium
buprenorphine hcl SUBL
buprenorphine hcl-naloxone hcl sl
1
1
1
bupropion hcl (smoking deterrent)
CHANTIX
CHANTIX CONTINUING MONTH
CHANTIX STARTER PACK
disulfiram TABS
naloxone inj 0.4mg/ml
naloxone inj 1mg/ml
naltrexone hcl TABS
NICOTROL INHALER
NICOTROL NS
SUBOXONE MIS 2-0.5MG
1
3
3
3
1
1
1
1
3
3
3
SUBOXONE MIS 4-1MG
3
SUBOXONE MIS 8-2MG
3
SUBOXONE MIS 12-3MG
3
PA
QL (120 tabs / 30 days),
PA
PA
PA
PA
QL (120 SL films / 30
days), PA
QL (120 SL films / 30
days), PA
QL (120 SL films / 30
days), PA
QL (60 SL films / 30
days), PA
ENDOCRINE AND METABOLIC
ANDROGENS
ANADROL-50
ANDRODERM
4
3
AXIRON
2
oxandrolone TABS
testosterone cypionate SOLN
testosterone enanthate SOLN
1
1
1
PA
QL (30 patches / 30
days), PA
QL (440 mL / 30 days),
PA
PA
PA
PA
ANTIDIABETICS, INJECTABLE
ALCOHOL SWABS
2
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
31
CY17_4T_STANDARD eff 01/01/2017
Drug Name
BYDUREON INJ
BYDUREON PEN
BYETTA
GAUZE PADS 2" X 2"
HUMULIN R INJ U-500
HUMULIN R U-500 KWIKPEN
INSULIN PEN NEEDLE
INSULIN SAFETY NEEDLES
INSULIN SYRINGE
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXTOUCH
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILL
NOVOLOG PENFILL
SYMLINPEN 60
SYMLINPEN 120
TOUJEO SOLOSTAR
TRESIBA FLEXTOUCH
TRULICITY
VICTOZA
Drug Tier Requirements/Limits
2
QL (4 vials / 28 days)
2
QL (4 pens / 28 days)
3
QL (1 pen / 30 days)
2
4
B/D
4
2
2
2
2
2
2
2
2
(brand RELION not
covered)
2
(brand RELION not
covered)
2
(brand RELION not
covered)
2
2
2
2
2
4
QL (8 pens / 30 days),
PA
4
QL (4 pens / 30 days),
PA
2
2
3
QL (4 pens / 28 days)
2
QL (3 pens / 30 days)
ANTIDIABETICS, ORAL
acarbose
FARXIGA 5mg
FARXIGA 10mg
glimepiride 1mg
glimepiride 2mg
glimepiride 4mg
glip/metform tab 2.5-250m
glip/metform tab 2.5-500m
glip/metform tab 5-500mg
glipizide TABS 5mg
1
2
2
1
1
1
1
1
1
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
(60 tabs / 30 days)
(30 tabs / 30 days)
(240 tabs / 30 days)
(120 tabs / 30 days)
(60 tabs / 30 days)
(240 tabs / 30 days)
(120 tabs / 30 days)
(120 tabs / 30 days)
(240 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
32
CY17_4T_STANDARD eff 01/01/2017
Drug Name
glipizide TABS 10mg
glipizide TB24 2.5mg
glipizide TB24 5mg
glipizide TB24 10mg
GLIPIZIDE XL TB24 2.5MG
GLIPIZIDE XL TB24 5MG
INVOKAMET TAB 50-500MG
INVOKAMET TAB 50-1000MG
INVOKAMET TAB 150-500MG
INVOKAMET TAB 150-1000MG
INVOKAMET XR TAB 50-500MG
INVOKAMET XR TAB 50-1000MG
INVOKAMET XR TAB 150-500MG
INVOKAMET XR TAB 150-1000MG
INVOKANA 100mg
INVOKANA 300mg
JANUMET
JANUMET XR TAB 50-500MG
JANUMET XR TAB 50-1000
JANUMET XR TAB 100-1000
JANUVIA
JENTADUETO
JENTADUETO TAB XR 2.5-1000 MG
JENTADUETO TAB XR 5-1000 MG
metformin er 500mg
metformin er 750mg
metformin hcl TABS 500mg
metformin hcl TABS 850mg
metformin hcl TABS 1000mg
nateglinide
pioglitazone hcl
repaglinide 2mg
repaglinide .5mg, 1mg
TRADJENTA
XIGDUO XR TAB 5-500MG
XIGDUO XR TAB 5-1000MG
XIGDUO XR TAB 10-500MG
XIGDUO XR TAB 10-1000MG
Drug Tier Requirements/Limits
1
QL (120 tabs / 30 days)
1
QL (240 tabs / 30 days)
1
QL (120 tabs / 30 days)
1
QL (60 tabs / 30 days)
1
QL (240 tabs / 30 days)
1
QL (120 tabs / 30 days)
2
QL (120 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (120 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (90 tabs / 30 days)
2
QL (30 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (30 tabs / 30 days)
2
QL (30 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (30 tabs / 30 days)
1
QL (120 tabs / 30 days);
(generic of
GLUCOPHAGE XR)
1
QL (60 tabs / 30 days);
(generic of
GLUCOPHAGE XR)
1
QL (150 tabs / 30 days)
1
QL (90 tabs / 30 days)
1
QL (75 tabs / 30 days)
1
QL (90 tabs / 30 days)
1
QL (30 tabs / 30 days)
1
QL (240 tabs / 30 days)
1
QL (120 tabs / 30 days)
2
QL (30 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (30 tabs / 30 days)
2
QL (30 tabs / 30 days)
BISPHOSPHONATES
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
33
CY17_4T_STANDARD eff 01/01/2017
Drug Name
alendronate sodium TABS 5mg, 10mg,
40mg
alendronate sodium TABS 35mg, 70mg
pamidronate disodium
zoledronic acid SOLN 5mg/100ml
zoledronic acid SOLR
zoledronic inj 4mg/5ml
Drug Tier Requirements/Limits
1
1
1
1
1
1
QL (4 tabs / 28 days)
B/D
B/D, NM
B/D, NM
B/D, NM
SENSIPAR 30mg
2
SENSIPAR 60mg
4
SENSIPAR 90mg
4
QL (120 tabs / 30 days),
NM
QL (60 tabs / 30 days),
NM
QL (120 tabs / 30 days),
NM
CALCIUM RECEPTOR AGONISTS
CHELATING AGENTS
CHEMET
DEPEN TITRATABS
EXJADE
FERRIPROX
sodium polystyrene sulfonate
sps susp 15gm/60ml
SYPRINE
3
4
4
4
1
1
4
NM, LA, PA
NM, LA, PA
CONTRACEPTIVES
altavera tab
aubra 0.1-0.02mg
caziant pak
cryselle-28
cyred tab
delyla 0.1-0.02mg
desogestrel & ethinyl estradiol
desogestrel-ethinyl estradiol (biphasic)
desogestrel-ethinyl estradiol (triphasic)
drospirenone-ethinyl estradiol
ELLA
estarylla tab 0.25-35
ethynodiol diacet & eth estrad
falmina
GIANVI
gildess 1.5/30
heather
JOLESSA TAB 0.15-0.03 MG
JOLIVETTE
larin 1.5/30
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
34
CY17_4T_STANDARD eff 01/01/2017
Drug Name
larissia tab
LEENA
levonor/ethi tab
levonorgestrel & eth estradiol
levonorgestrel (emergency oc)
levonorgestrel-eth estradiol (triphasic)
levonorgestrel-ethinyl estradiol (91-day)
loryna
low-ogestrel
medroxyprogesterone acetate
(contraceptive) SUSP
MEDROXYPROGESTERONE ACETATE
(CONTRACEPTIVE) SUSY
MICROGESTIN 1.5/30
MICROGESTIN 1/20
MICROGESTIN FE 1.5/30
MICROGESTIN FE 1/20
mono-linyah tab 0.25-35
MONONESSA
myzilra
necon 1/35-28
NECON 7/7/7
necon 10/11 28 day
NECON TAB 1/50-28
nikki 3-0.02mg
NORA-BE TAB
norethin acet & estrad-fe
norethindrone & eth estradiol
norethindrone (contraceptive)
norethindrone acet & eth estra
norethindrone acetate-ethinyl estradiol-fe
norethindrone-eth estradiol (triphasic)
norgest/ethi tab 0.25/35
norgestimate-ethinyl estradiol
norgestimate-ethinyl estradiol (triphasic)
norlyroc 0.35mg
NUVARING
OCELLA TAB 3-0.03MG
philith
setlakin tab
sharobel 0.35mg
sronyx
syeda
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
35
CY17_4T_STANDARD eff 01/01/2017
Drug Name
tri-linyah
tri-lo marzia
tri-lo-estarylla
TRINESSA
TRINESSA LO TAB
vestura
viorele
xulane
zarah
zenchent
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
ENDOMETRIOSIS
danazol CAPS
SYNAREL
1
4
ENZYME REPLACEMENTS
ADAGEN
ALDURAZYME
BUPHENYL TABS
CARBAGLU
CERDELGA
CEREZYME
CYSTADANE
CYSTAGON
FABRAZYME
KUVAN
levocarnitine (metabolic modifiers)
LUMIZYME
NAGLAZYME
ORFADIN
RAVICTI
sodium phenylbutyrate
ZAVESCA
4
4
4
4
4
4
4
3
4
4
1
4
4
4
4
4
4
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
B/D
NM,
NM,
NM,
NM,
NM,
NM,
LA,
LA,
LA,
LA,
PA
LA,
LA
LA,
LA,
LA,
PA
PA
PA
PA
LA,
LA,
LA,
PA
PA
LA,
PA
PA
PA
PA
PA
PA
PA
PA
ESTROGENS
DELESTROGEN 10mg/ml
estrace CREA
estradiol PTWK
3
3
3
estradiol TABS
3
estradiol valerate OIL
fyavolv tab 1-5mg
1
3
norethindrone acetate-ethinyl estradiol
3
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
36
CY17_4T_STANDARD eff 01/01/2017
Drug Name
VAGIFEM
yuvafem vaginal tablet 10 mcg
Drug Tier Requirements/Limits
3
1
GLUCOCORTICOIDS
a-hydrocort
1
cortisone acetate TABS
1
dexamethasone CONC; ELIX; SOLN; TABS 1
dexamethasone sodium phosphate
1
fludrocortisone acetate TABS
1
hydrocortisone TABS
1
methylpr ace inj 40mg/ml
1
methylpr ace inj 80mg/ml
1
methylpr ss inj 1gm
1
methylpr ss inj 40mg
1
methylpred pak 4mg
1
methylpred tab 4mg
1
methylpred tab 8mg
1
methylpred tab 16mg
1
methylpred tab 32mg
1
methylprednisolone sod succ
1
pred sod pho sol 5mg/5ml
1
prednisolone sol 15mg/5ml
1
prednisolone sol 25mg/5ml
1
prednisolone syp 15mg/5ml
1
prednisone con 5mg/ml
2
prednisone pak 5mg
1
prednisone pak 10mg
1
prednisone sol 5mg/5ml
1
prednisone tab 1mg
1
prednisone tab 2.5mg
1
prednisone tab 5mg
1
prednisone tab 10mg
1
prednisone tab 20mg
1
prednisone tab 50mg
1
SOLU-CORTEF 250mg
3
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
GLUCOSE ELEVATING AGENTS
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
PROGLYCEM SUS 50MG/ML
2
2
3
HUMAN GROWTH HORMONES
NORDITROPIN FLEXPRO
4
NM, PA
MISCELLANEOUS
cabergoline
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
37
CY17_4T_STANDARD eff 01/01/2017
Drug Name
Drug Tier Requirements/Limits
calcitonin (salmon)
1
B/D
FORTICAL
2
B/D
INCRELEX
4
NM, LA, PA
KORLYM
4
NM, LA, PA
LUPRON DEP-PED INJ 7.5MG
4
NM, PA
LUPRON DEP-PED INJ 11.25MG
4
NM, PA
LUPRON DEP-PED INJ 11.25MG (3-MONTH) 4
NM, PA
LUPRON DEP-PED INJ 15MG
4
NM, PA
LUPRON DEP-PED INJ 30MG (3-MONTH)
4
NM, PA
methylergonovine maleate TABS
1
MIACALCIN 200unit/ml
4
B/D
octreotide acetate 50mcg/ml, 100mcg/ml, 1
NM, PA
200mcg/ml
octreotide acetate 500mcg/ml,
4
NM, PA
1000mcg/ml
PROLIA
3
QL (1 syringe / 180
days), NM
raloxifene hcl
1
SANDOSTATIN LAR DEPOT
4
NM, PA
SIGNIFOR
4
NM, LA, PA
SOMATULINE DEPOT
4
NM, PA
SOMAVERT
4
NM, LA, PA
XGEVA
4
NM, PA
PARATHYROID HORMONES
FORTEO
4
NATPARA
4
QL (1 pen / 28 days),
NM, PA
NM, PA
PHOSPHATE BINDER AGENTS
AURYXIA
calcium acetate (phosphate binder)
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
4
1
2
2
2
PROGESTINS
medroxyprogesterone acetate tab
norethindrone acetate TABS
1
1
THYROID AGENTS
levothyroxine sodium TABS 25mcg,
50mcg, 88mcg, 100mcg, 112mcg,
125mcg, 137mcg, 150mcg, 175mcg,
200mcg
LEVOTHYROXINE SODIUM TABS 75mcg,
300mcg
1
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
38
CY17_4T_STANDARD eff 01/01/2017
Drug Name
LEVOXYL
liothyronine sodium TABS
methimazole TABS
propylthiouracil TABS
SYNTHROID
UNITHROID
Drug Tier Requirements/Limits
1
1
1
1
3
1
VASOPRESSINS
desmopressin acetate spray
desmopressin acetate spray refrigerated
desmopressin acetate tabs
desmopressin inj 4mcg/ml
DESMOPRESSIN SOL 0.01%
STIMATE
1
1
1
1
1
3
NM
GASTROINTESTINAL
ANTIEMETICS
compro supp
dronabinol
1
1
EMEND SUSR
EMEND CAP 40MG
EMEND CAP 80MG
EMEND CAP 125MG
EMEND PAK 80 & 125
granisetron hcl SOLN
granisetron hcl TABS
meclizine hcl TABS
metoclopramide hcl SOLN; TABS
metoclopramide inj
ondansetron hcl TABS
ondansetron hcl inj
ondansetron hcl oral soln
ondansetron odt
phenadoz
3
3
3
3
3
1
1
1
1
1
1
1
1
1
3
prochlorperazine inj
prochlorperazine maleate TABS
prochlorperazine supp
promethazine hcl SOLN; SUPP; SYRP;
TABS
promethegan
1
1
1
3
3
B/D, QL (60 caps / 30
days)
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
39
CY17_4T_STANDARD eff 01/01/2017
Drug Name
TRANSDERM-SCOP
Drug Tier Requirements/Limits
3
QL (10 patches / 30
days), PA; PA if 65 years
and older
ANTISPASMODICS
dicyclomine hcl CAPS
dicyclomine hcl SOLN 10mg/5ml
dicyclomine hcl TABS
glycopyrrolate TABS
glycopyrrolate inj
1
1
1
1
1
H2-RECEPTOR ANTAGONISTS
famotidine SOLN
famotidine SUSR
famotidine TABS 20mg, 40mg
famotidine inj
ranitidine hcl TABS 150mg, 300mg
ranitidine hcl inj
ranitidine syrup
1
1
1
1
1
1
1
INFLAMMATORY BOWEL DISEASE
APRISO
ASACOL HD
balsalazide disodium
budesonide ec
CANASA
colocort enema 100mg
DELZICOL
DIPENTUM
HYDROCORTISONE (ENEMA)
MESALAMINE TBEC
mesalamine enema
mesalamine w/ cleanser
sulfasalazine TABS
sulfasalazine ec
2
3
1
4
4
1
3
4
1
1
1
1
1
1
LAXATIVES
gavilyte-h
generlac
GOLYTELY
lactulose
lactulose (encephalopathy)
MOVIPREP
NULYTELY/FLAVOR PACKS
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate
1
1
2
1
1
3
2
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
40
CY17_4T_STANDARD eff 01/01/2017
Drug Name
PEG 3350-KCL-SOD BICARB-SOD
CHLORIDE-SOD SULFATE
peg 3350-potassium chloride-sod
bicarbonate-sod chloride
PEG 3350/ELECTROLYTES
polyethylene glycol 3350 PACK; POWD
SUPREP BOWEL PREP
Drug Tier Requirements/Limits
1
1
1
1
3
MISCELLANEOUS
alosetron hcl
AMITIZA CAP 8MCG
AMITIZA CAP 24MCG
cromolyn sodium (mastocytosis)
diphenoxylate w/ atropine
GATTEX
LINZESS 145mcg
LINZESS 290mcg
loperamide hcl CAPS
misoprostol TABS
MOVANTIK 12.5mg
MOVANTIK 25mg
RELISTOR SOLN
SUCRAID
sucralfate TABS
ursodiol CAPS; TABS
XIFAXAN 550mg
4
2
2
4
1
4
2
2
1
1
2
2
4
4
1
1
4
PA
QL (60 caps / 30 days)
QL (60 caps / 30 days)
NM, LA, PA
QL (60 caps / 30 days)
QL (30 caps / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
PA
LA
PA
PANCREATIC ENZYMES
CREON
ZENPEP
2
3
PROTON PUMP INHIBITORS
DEXILANT
esomeprazole magnesium
esomeprazole sodium inj
NEXIUM GRA 2.5MG DR
NEXIUM GRA 5MG DR
NEXIUM GRA 10MG DR
2
1
1
2
2
2
NEXIUM GRA 20MG DR
2
NEXIUM GRA 40MG DR
2
omeprazole cap 10mg
omeprazole cap 20mg
omeprazole cap 40mg
1
1
1
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30
days)
QL (30
days)
QL (30
days)
QL (30
QL (60
QL (30
packets / 30
packets / 30
packets / 30
caps / 30 days)
caps / 30 days)
caps / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
41
CY17_4T_STANDARD eff 01/01/2017
Drug Name
pantoprazole sodium tbec
Drug Tier Requirements/Limits
1
QL (30 tabs / 30 days)
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl
dutasteride
dutasteride-tamsulosin hcl
finasteride TABS 5mg
tamsulosin hcl
1
1
1
1
1
QL (30 tabs / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
MISCELLANEOUS
bethanechol chloride TABS
ELMIRON
potassium citrate (alkalinizer) 15meq
POTASSIUM CITRATE (ALKALINIZER)
540mg, 1080mg
1
3
1
1
URINARY ANTISPASMODICS
MYRBETRIQ 25mg
MYRBETRIQ 50mg
oxybutynin chloride SYRP
oxybutynin chloride TABS
oxybutynin chloride TB24 5mg
oxybutynin chloride TB24 10mg, 15mg
tolterodine tartrate cap er
tolterodine tartrate tabs
TOVIAZ
trospium chloride TABS
VESICARE
3
3
1
1
1
1
1
1
2
1
3
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 caps / 30 days)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
VAGINAL ANTI-INFECTIVES
clindamycin phosphate vaginal
metronidazole vaginal
terconazole vaginal
VANDAZOLE
ZAZOLE CREAM 0.8%
1
1
1
1
1
HEMATOLOGIC
ANTICOAGULANTS
COUMADIN
ELIQUIS
enoxaparin sodium 30mg/0.3ml,
40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml,
100mg/ml, 120mg/0.8ml, 150mg/ml
ENOXAPARIN SODIUM 300mg/3ml
fondaparinux sodium 2.5mg/0.5ml
3
3
1
PA
1
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
42
CY17_4T_STANDARD eff 01/01/2017
Drug Name
fondaparinux sodium 5mg/0.4ml,
7.5mg/0.6ml, 10mg/0.8ml
heparin sod (porcine) in d5w
HEPARIN SOD (PORCINE) IN D5W
heparin sod inj 1000/ml
heparin sod inj 5000/ml
heparin sod inj 10000/ml
heparin sod inj 20000/ml
HEPARIN SODIUM/D5W
HEPARIN SODIUM/NACL 0.45%
PRADAXA
warfarin sodium
XARELTO
XARELTO STARTER PACK
Drug Tier Requirements/Limits
4
2
2
1
1
1
1
2
2
2
1
2
2
B/D
B/D
B/D
B/D
HEMATOPOIETIC GROWTH FACTORS
GRANIX
LEUKINE
MOZOBIL
NEUPOGEN
PROCRIT 2000unit/ml, 3000unit/ml,
4000unit/ml, 10000unit/ml
PROCRIT 20000unit/ml, 40000unit/ml
4
4
4
4
2
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
PA
PA
4
NM, PA
anagrelide hcl
cilostazol
CINRYZE
FIRAZYR
pentoxifylline TBCR
PROMACTA 12.5mg
1
1
4
4
1
4
NM, LA, PA
NM, PA
PROMACTA 25mg
4
PROMACTA 50mg
4
PROMACTA 75mg
4
tranexamic acid SOLN; TABS
1
MISCELLANEOUS
QL (360 tabs / 30 days),
NM, LA, PA
QL (180 tabs / 30 days),
NM, LA, PA
QL (90 tabs / 30 days),
NM, LA, PA
QL (60 tabs / 30 days),
NM, LA, PA
PLATELET AGGREGATION INHIBITORS
ASPIRIN-DIPYRIDAMOLE
BRILINTA
clopidogrel bisulfate 75mg
EFFIENT
ZONTIVITY
1
2
1
3
3
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
43
CY17_4T_STANDARD eff 01/01/2017
Drug Name
Drug Tier Requirements/Limits
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)
HUMIRA INJ 10MG/0.2ML
4
HUMIRA KIT 20MG/0.4ML
4
HUMIRA KIT 40MG/0.8ML
4
HUMIRA PEDIATRIC CROHNS DISEASE
HUMIRA PEN
4
4
HUMIRA PEN-CROHNS DISEASE
HUMIRA PEN-PSORIASIS STAR
hydroxychloroquine sulfate
leflunomide TABS
methotrexate sodium tabs
REMICADE
XELJANZ
4
4
1
1
1
4
4
XELJANZ XR
4
QL (2 boxes
NM, PA
QL (2 boxes
NM, PA
QL (6 boxes
NM, PA
NM, PA
QL (6 boxes
NM, PA
NM, PA
NM, PA
/ 28 days),
/ 28 days),
/ 28 days),
/ 28 days),
NM, PA
QL (60 tabs / 30 days),
NM, PA
QL (30 tabs / 30 days),
NM, PA
IMMUNOGLOBULINS
BIVIGAM
CARIMUNE NANOFILTERED
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAGARD S/D
GAMMAKED
GAMMAPLEX 5gm/100ml, 10gm/200ml
GAMUNEX-C
OCTAGAM 1gm/20ml, 2gm/20ml,
2.5gm/50ml, 5gm/100ml, 10gm/200ml,
25gm/500ml
PRIVIGEN
4
4
4
2
4
4
4
4
4
4
NM, PA
NM, PA
NM, PA
B/D, NM
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
4
NM, PA
4
4
4
4
4
4
4
NM, LA, PA
NM, PA
B/D, NM
B/D, NM
B/D, NM
B/D, NM
NM, LA, PA
IMMUNOMODULATORS
ACTIMMUNE
ARCALYST
INTRON-A INJ 10MU
INTRON-A INJ 18MU
INTRON-A INJ 25MU
INTRON-A INJ 50MU
POMALYST CAP 1MG
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
44
CY17_4T_STANDARD eff 01/01/2017
Drug Name
POMALYST CAP 2MG
POMALYST CAP 3MG
POMALYST CAP 4MG
REVLIMID
THALOMID
Drug Tier Requirements/Limits
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, PA
IMMUNOSUPPRESSANTS
azathioprine SOLR; TABS
BENLYSTA
cyclosporine CAPS; SOLN
cyclosporine modified (for microemulsion)
mycophenolate mofetil CAPS; TABS
mycophenolate mofetil SUSR
mycophenolate sodium
NEORAL
NULOJIX
PROGRAF CAPS 5mg
PROGRAF CAPS .5mg, 1mg
RAPAMUNE SOLN
SANDIMMUNE SOLN 100mg/ml
sirolimus TABS 2mg
sirolimus TABS .5mg, 1mg
tacrolimus CAPS
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
1
4
1
1
1
4
1
2
4
4
3
4
2
4
1
1
4
2
4
B/D
NM, PA
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
B/D
B/D
VACCINES
ACTHIB
ADACEL
BCG VACCINE
BEXSERO
BOOSTRIX
CERVARIX
DAPTACEL
DIPHTHERIA/TETANUS TOXOID
ENGERIX-B SUSP
GARDASIL
GARDASIL 9
HAVRIX
HIBERIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
45
CY17_4T_STANDARD eff 01/01/2017
Drug Name
IXIARO
KINRIX
M-M-R II
MENACTRA
MENHIBRIX
MENOMUNE-A/C/Y/W-135
MENVEO
PEDIARIX
PEDVAX HIB
PENTACEL
PROQUAD
QUADRACEL
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
SYNAGIS
TENIVAC
TETANUS/DIPHTHERIA TOXOID
TRUMENBA
TWINRIX INJ
TYPHIM VI
VAQTA
VARIVAX
YF-VAX
ZOSTAVAX
Drug Tier Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
B/D
2
2
4
NM
2
B/D
2
B/D
2
2
2
2
2
2
2
QL (1 vial per lifetime)
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
KLOR-CON 8
KLOR-CON 10
klor-con m10
klor-con m15
klor-con m20
klor-con pow 20 meq
klor-con spr cap 8meq
klor-con spr cap 10meq
MAGNESIUM SULFATE SOLN 2gm/50ml,
4gm/100ml, 4gm/50ml, 20gm/500ml,
40gm/1000ml
magnesium sulfate SOLN 2gm/50ml, 50%
MAGNESIUM SULFATE SOLN 50%
MAGNESIUM SULFATE IN D5W
potassium chloride CPCR
1
1
1
1
1
1
1
1
2
1
1
2
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
46
CY17_4T_STANDARD eff 01/01/2017
Drug Name
POTASSIUM CHLORIDE SOLN 10%, 20%
potassium chloride TBCR 8meq
POTASSIUM CHLORIDE TBCR 20meq
potassium chloride microencapsulated
crystals cr
POTASSIUM CHLORIDE TAB CR 10 MEQ
SODIUM CHLORIDE SOLN 2.5meq/ml
sodium fluoride chew; tab; 1.1 (0.5 f)
mg/ml soln
TPN ELECTROLYTES
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
3
B/D
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
3
3
3
3
3
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
IV NUTRITION
AMINOSYN
AMINOSYN 7%/ELECTROLYTES
AMINOSYN 8.5%/ELECTROLYTE
AMINOSYN II
AMINOSYN II 8.5%/ELECTROL
AMINOSYN M
AMINOSYN-HBC
AMINOSYN-PF 7%
AMINOSYN-PF INJ 10%
AMINOSYN-RF
CLINIMIX 2.75%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 25%
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX 5%/DEXTROSE 20%
CLINIMIX 5%/DEXTROSE 25%
CLINIMIX INJ 4.25/D10
CLINIMIX INJ 4.25/D20
FREAMINE HBC 6.9%
FREAMINE III
HEPATAMINE
INTRALIPID INJ 20%
INTRALIPID INJ 30%
NEPHRAMINE
nutrilipid inj 20%
premasol sol 6%
premasol sol 10%
PROCALAMINE
PROSOL
TRAVASOL
TROPHAMINE INJ 10%
IV REPLACEMENT SOLUTIONS
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
47
CY17_4T_STANDARD eff 01/01/2017
Drug Name
DEXTROSE 2.5%/NACL 0.45%
DEXTROSE 5%
DEXTROSE 5% /ELECTROLYTE
DEXTROSE 5%/LACTATED RING
DEXTROSE 5%/NACL 0.2%
DEXTROSE 5%/NACL 0.3%
DEXTROSE 5%/NACL 0.9%
DEXTROSE 5%/NACL 0.33%
DEXTROSE 5%/NACL 0.45%
DEXTROSE 5%/NACL 0.225%
DEXTROSE 5%/POTASSIUM CHL
DEXTROSE 10% FLEX CONTAIN
DEXTROSE 10%/NACL 0.2%
DEXTROSE 10%/NACL 0.45%
DEXTROSE 50%
DEXTROSE INJ 70%
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
ISOLYTE P
ISOLYTE S
KCL0.15%/D5W/NACL0.2%
KCL0.15%/D5W/NACL0.225%
KCL 0.3%/D5W/NACL 0.9%
KCL 0.3%/D5W/NACL 0.45%
KCL 0.15%/D5W/NACL 0.9%
KCL 0.075%/D5W/NACL 0.45%
KCL IN NACL INJ .15-0.45
KCL/D5W INJ 0.3%
KCL/D5W/NACL INJ 0.22%/0.45%
KCL/D5W/NACL INJ .15/.33%
KCL/D5W/NACL INJ .15/.45%
KCL/NACL INJ 0.3-0.9
KCL/NACL INJ 0.15%-0.9%
LACTATED RINGER'S INJ
NORMOSOL-M IN D5W
NORMOSOL-R
NORMOSOL-R IN D5W
PLASMA-LYTE A
PLASMA-LYTE-56/D5W
PLASMA-LYTE-148
pot chloride inj 2meq/ml
Drug Tier Requirements/Limits
1
1
2
1
1
1
1
1
1
1
1
1
2
1
1
1
3
3
3
3
1
2
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
48
CY17_4T_STANDARD eff 01/01/2017
Drug Name
POTASSIUM CHLORIDE SOLN .4meq/ml,
10meq/100ml, 10meq/50ml,
20meq/100ml, 40meq/100ml
potassium chloride in nacl
RINGER'S
SODIUM CHLORIDE SOLN 3%, 5%
SODIUM CHLORIDE 0.45% VIA
SODIUM CHLORIDE INJ 0.9%
Drug Tier Requirements/Limits
1
1
1
1
1
1
VITAMINS
calcitriol CAPS
calcitriol inj
calcitriol oral soln 1 mcg/ml
paricalcitol CAPS
prenatal vitamin/folic acid > 0.8 mg
(generic)
1
1
1
1
1
B/D
B/D
B/D
B/D
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
bacitracin-poly-neomycin-hc
blephamide s.o.p.
neomycin-polymy-dexameth
neomycin-polymyxin-hc (ophth)
sulfacetamide sod-prednisolone
TOBRADEX OINT
TOBRADEX ST
tobramycin-dexamethasone
ZYLET
1
3
1
1
1
2
2
1
2
ANTI-INFECTIVES
bacitracin (ophthalmic)
bacitracin-polymyxin b (ophth)
BESIVANCE
CILOXAN OINT
ciprofloxacin hcl (ophth)
erythromycin (ophth)
gatifloxacin (ophth)
gentamicin sulfate (ophth)
MOXEZA
NATACYN
neomycin-bacitracin zn-polymyxin
neomycin-polymyxin-gramicidin
ofloxacin (ophth)
polymyxin b-trimethoprim
sulfacet sod oin 10% op
1
1
2
2
1
1
1
1
2
3
1
1
1
1
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
49
CY17_4T_STANDARD eff 01/01/2017
Drug Name
sulfacetamide sodium (ophth)
tobramycin (ophth)
TOBREX OINT
trifluridine SOLN
VIGAMOX
ZIRGAN
Drug Tier Requirements/Limits
1
1
3
1
2
3
ANTI-INFLAMMATORIES
ALREX
2
bromfenac sodium (ophth)
1
dexamethasone sodium phosphate (ophth) 1
diclofenac sodium (ophth)
1
DUREZOL
2
FLUOROMETHOLONE
1
flurbiprofen sodium
1
ILEVRO
2
ketorolac tromethamine (ophth)
1
LOTEMAX
2
MAXIDEX
2
PREDNISOLONE ACETATE (OPHTH)
1
prednisolone sodium phosphate (ophth)
2
ANTIALLERGICS
azelastine drop 0.05%
BEPREVE
cromolyn sodium (ophth)
LASTACAFT
PATADAY
PAZEO
1
2
1
3
2
2
ANTIGLAUCOMA
ALPHAGAN P SOL 0.1%
AZOPT
betaxolol hcl (ophth)
BETOPTIC-S
brimonidine sol 0.2%
BRIMONIDINE SOL 0.15%
carteolol hcl (ophth)
COMBIGAN
dorzolamide hcl
dorzolamide hcl-timolol maleate
ISTALOL
latanoprost SOLN
levobunolol hcl
LUMIGAN
2
2
1
2
1
1
1
2
1
1
2
1
1
2
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
50
CY17_4T_STANDARD eff 01/01/2017
Drug Name
metipranolol
PHOSPHOLINE IODIDE
PILOCARPINE HCL SOLN
SIMBRINZA
timolol maleate (ophth) soln
TIMOLOL MALEATE GEL
TRAVATAN Z
Drug Tier Requirements/Limits
1
3
1
2
1
1
2
MISCELLANEOUS
CYSTARAN
naphazoline 0.1%
PROLENSA
proparacaine hcl SOLN
RESTASIS
4
1
2
1
2
NM, LA, PA
QL (64 vials / 30 days)
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
ANORO ELLIPTA
2
BEVESPI
COMBIVENT RESPIMAT
2
3
ipratropium-albuterol nebu
1
QL (60 inhalations / 30
days)
QL (1 inhaler / 30 days)
QL (2 inhalers / 30
days)
B/D
ANTICHOLINERGICS
ATROVENT HFA
3
INCRUSE ELLIPTA
ipratropium bromide SOLN
ipratropium bromide (nasal)
2
1
1
QL (2 inhalers / 30
days)
QL (1 inhaler / 30 days)
B/D
ANTIHISTAMINES
azelastine spr 0.1%
azelastine spr 0.15%
cetirizine syrup
cyproheptadine hcl SYRP; TABS
1
1
1
3
diphenhydramine inj
hydroxyzine hcl SOLN; SYRP; TABS
1
3
hydroxyzine pamoate CAPS
3
levocetirizine dihydrochloride
1
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
BETA AGONISTS
albuterol sulfate NEBU
albuterol sulfate SYRP; TABS; TB12
levalbuterol conc 1.25mg/0.5ml
1
1
1
B/D
B/D
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
51
CY17_4T_STANDARD eff 01/01/2017
Drug Name
LEVALBUTEROL TARTRATE HFA
SEREVENT DISKUS
terbutaline sulfate SOLN
terbutaline sulfate TABS
VENTOLIN HFA
XOPENEX HFA
Drug Tier Requirements/Limits
1
QL (2 inhalers / 30
days)
2
QL (60 inhalations / 30
days)
4
1
2
QL (2 inhalers / 30
days)
2
QL (2 inhalers / 30
days)
LEUKOTRIENE MODULATORS
montelukast sodium CHEW; PACK; TABS
zafirlukast
1
1
MAST CELL STABILIZERS
cromolyn sodium nebu
1
B/D
1
4
3
2
2
4
4
4
4
4
4
4
4
B/D
NM, LA, PA
1
1
QL (2 bottles / 30 days)
QL (1 bottle / 30 days)
ARNUITY ELLIPTA
2
budesonide (inhalation) .25mg/2ml,
.5mg/2ml
FLOVENT DISKUS 50mcg/blist,
100mcg/blist
FLOVENT DISKUS 250mcg/blist
1
QL (30 inhalations / 30
days)
B/D
FLOVENT HFA
2
MISCELLANEOUS
acetylcysteine SOLN 10%, 20%
ARALAST NP
DALIRESP
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
ESBRIET
KALYDECO
OFEV
ORKAMBI
PROLASTIN-C
PULMOZYME
XOLAIR
ZEMAIRA
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
PA
LA, PA
PA
LA, PA
LA, PA
NASAL STEROIDS
flunisolide (nasal)
fluticasone propionate (nasal)
STEROID INHALANTS
2
2
QL (120 inhalations / 30
days)
QL (240 inhalations / 30
days)
QL (2 inhalers / 30
days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
52
CY17_4T_STANDARD eff 01/01/2017
Drug Name
PULMICORT FLEXHALER
Drug Tier Requirements/Limits
2
QL (2 inhalers / 30
days)
STEROID/BETA-AGONIST COMBINATIONS
ADVAIR DISKUS
2
ADVAIR HFA
BREO ELLIPTA
2
2
SYMBICORT
2
QL (60 inhalations / 30
days)
QL (1 inhaler / 30 days)
QL (60 blisters / 30
days)
QL (1 inhaler / 30 days)
XANTHINES
aminophylline inj
theo-24
theophylline ELIX
theophylline SOLN; TB12; TB24
1
3
3
1
TOPICAL
DERMATOLOGY, ACNE
adapalene CREA
adapalene GEL .1%
AVITA
benzoyl peroxide-erythromycin
clindacin-p pad 1%
clindamycin phosphate (topical) GEL;
LOTN; SOLN; SWAB
ery pad 2%
erythromycin (acne aid)
isotretinoin CAPS
myorisan
sulfacetamide sodium (acne)
tretinoin CREA
TRETINOIN GEL .01%
tretinoin GEL .025%
zenatane
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA
PA
PA
PA
PA
PA
PA
DERMATOLOGY, ANTIBIOTICS
gentamicin sulfate (topical)
mupirocin OINT
SILVER SULFADIAZINE CREA
SSD
SULFAMYLON CREA
SULFAMYLON PACK
1
1
1
1
3
4
DERMATOLOGY, ANTIFUNGALS
ciclopirox CREA; GEL; SUSP
ciclopirox shampoo 1%
1
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
53
CY17_4T_STANDARD eff 01/01/2017
Drug Name
clotrimazole (topical)
ketoconazole cream
nystatin (topical)
Drug Tier Requirements/Limits
1
1
1
DERMATOLOGY, ANTIPRURITIC
DOXEPIN HCL (ANTIPRURITIC)
hydrocortisone (rectal)
procto-pak cre 1%
proctosol hc cre 2.5%
proctozone cre -hc 2.5%
1
1
1
1
1
DERMATOLOGY, ANTIPSORIATICS
acitretin
calcipotriene CREA
calcipotriene SOLN
8-MOP
TAZORAC CREA
4
1
1
3
3
PA
PA
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole shampoo
selenium sulfide LOTN
1
1
DERMATOLOGY, CORTICOSTEROIDS
alclometasone dipropionate
betamethasone dipropionate (topical)
betamethasone dipropionate augmented
CREA; GEL; LOTN
BETAMETHASONE DIPROPIONATE
AUGMENTED OINT
betamethasone valerate CREA; LOTN;
OINT
desoximetasone CREA
desoximetasone GEL
DESOXIMETASONE OINT .05%
desoximetasone OINT .25%
fluocinolone acetonide CREA; OIL; OINT;
SOLN
fluocinonide CREA .05%
fluocinonide GEL
fluocinonide SOLN
fluocinonide emulsified base
fluticasone propionate CREA
fluticasone propionate OINT
halobetasol propionate
hydrocortisone (topical)
hydrocortisone butyrate
hydrocortisone valerate
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
54
CY17_4T_STANDARD eff 01/01/2017
Drug Name
mometasone furoate CREA; OINT; SOLN
texacort soln 2.5%
triamcinolone acetonide (topical) CREA;
LOTN; OINT
Drug Tier Requirements/Limits
1
3
1
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine PTCH
1
lidocaine hcl GEL
lidocaine hcl SOLN 4%
lidocaine oint 5%
lidocaine-prilocaine
1
1
1
1
QL (3 patches / 1 day),
PA
PA
PA
PA
PA
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
ammonium lactate CREA; LOTN
diclofenac sodium (topical) 1% gel
fluorouracil (topical) CREA 5%
fluorouracil (topical) SOLN
imiquimod CREA
metronidazole (topical) CREA; LOTN
metronidazole gel 0.75%
PANRETIN
podofilox SOLN
rosadan cre 0.75%
tacrolimus (topical)
TARGRETIN GEL
VALCHLOR
1
1
1
1
1
1
1
4
1
1
1
4
4
PA
NM, PA
NM, LA, PA
DERMATOLOGY, SCABICIDES AND PEDICULIDES
EURAX
malathion
permethrin
3
1
1
DERMATOLOGY, WOUND CARE AGENTS
ACETIC ACID .25%
REGRANEX
SANTYL
SODIUM CHLORIDE 0.9%
STERILE WATER IRRIGATION
1
4
3
1
1
PA
MOUTH/THROAT/DENTAL AGENTS
cevimeline hcl
chlorhexidine gluconate (mouth-throat)
clotrimazole TROC
lidocaine hcl (mouth-throat)
nystatin (mouth-throat)
paroex sol 0.12%
1
1
1
1
1
1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
55
CY17_4T_STANDARD eff 01/01/2017
Drug Name
PILOCARPINE HCL (ORAL) 5mg
pilocarpine hcl (oral) 7.5mg
triamcinolone acetonide (mouth)
Drug Tier Requirements/Limits
1
1
1
OTIC
ACETIC ACID (OTIC)
acetic acid-aluminum acetate
CIPRODEX
fluocinolone acetonide (otic)
neomycin-polymyxin-hc (otic)
ofloxacin (otic)
Drug Name
1
1
2
1
1
1
Drug Tier Requirements/Limits
PART B DIABETIC METERS AND TEST
STRIPS
Breeze 2 Kits, Strips
Contour Kits, Strips
Contour Next EZ Kits, Strips
Contour Next USB Kits, Strips
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available
at mail-order B/D - Covered under Medicare B or D LA - Limited Access
56
CY17_4T_STANDARD eff 01/01/2017
Index
8
8-MOP .............................................54
A
abacavir sulfate ................................. 5
ABACAVIR SULFATE-LAMIVUDINE ........ 6
abacavir sulfate-lamivudine-zidovudine 6
ABELCET ........................................... 5
ABILIFY MAINTENA ...........................26
ABRAXANE .......................................11
acamprosate calcium .........................31
acarbose ..........................................32
acebutolol hcl ...................................17
acetaminophen w/ codeine .................. 1
acetazolamide ..................................18
ACETIC ACID ....................................55
ACETIC ACID (OTIC) .........................56
acetic acid-aluminum acetate .............56
acetylcysteine ..................................52
acitretin ...........................................54
ACTHIB ...........................................45
ACTIMMUNE .....................................44
acyclovir ........................................... 7
acyclovir sodium ................................ 7
ADACEL ...........................................45
ADAGEN ..........................................36
adapalene ........................................53
ADCIRCA .........................................19
adefovir dipivoxil ............................... 7
ADEMPAS.........................................19
adrucil .............................................10
ADVAIR DISKUS ...............................53
ADVAIR HFA .....................................53
AFINITOR ........................................12
AFINITOR DISPERZ ...........................12
a-hydrocort ......................................37
ALBENZA .......................................... 3
albuterol sulfate................................51
alclometasone dipropionate ................54
ALCOHOL SWABS .............................31
ALDURAZYME ...................................36
ALECENSA .......................................12
alendronate sodium ..........................34
alfuzosin hcl .....................................42
ALIMTA ............................................10
ALINIA .............................................. 3
allopurinol tab.................................... 1
alosetron hcl .................................... 41
ALPHAGAN P SOL 0.1%..................... 50
alprazolam tab 0.25mg ..................... 20
alprazolam tab 0.5mg ....................... 20
alprazolam tab 1mg .......................... 20
alprazolam tab 2mg .......................... 20
ALREX ............................................ 50
altavera tab ..................................... 34
amantadine hcl ................................ 25
AMBISOME ........................................ 5
amifostine crystalline ........................ 14
amikacin sulfate ................................. 3
amiloride & hydrochlorothiazide ......... 18
amiloride hcl .................................... 18
aminophylline inj .............................. 53
AMINOSYN ...................................... 47
AMINOSYN 7%/ELECTROLYTES .......... 47
AMINOSYN 8.5%/ELECTROLYTE ......... 47
AMINOSYN II ................................... 47
AMINOSYN II 8.5%/ELECTROL ........... 47
AMINOSYN M ................................... 47
AMINOSYN-HBC ............................... 47
AMINOSYN-PF 7% ............................ 47
AMINOSYN-PF INJ 10% ..................... 47
AMINOSYN-RF ................................. 47
amiodarone hcl ................................ 16
AMITIZA CAP 24MCG ........................ 41
AMITIZA CAP 8MCG .......................... 41
amitriptyline hcl ............................... 23
amlodipine besylate .......................... 17
amlodipine besylate-olmesartan
medoxomil ...................................... 15
amlodipine besylate-valsartan tab 10160 mg ........................................... 15
amlodipine besylate-valsartan tab 10320 mg ........................................... 15
amlodipine besylate-valsartan tab 5-160
mg ................................................. 15
amlodipine besylate-valsartan tab 5-320
mg ................................................. 15
amlodipine--benazepril hcl cap 10-20 mg
...................................................... 14
57
CY17_4T_STANDARD eff 01/01/2017
amlodipine-benazepril hcl cap 10-40mg
......................................................14
amlodipine-benazepril hcl cap 2.5-10 mg
......................................................14
amlodipine-benazepril hcl cap 5-10 mg 14
amlodipine-benazepril hcl cap 5-20 mg 14
amlodipine-benazepril hcl cap 5-40 mg 14
amlodipine-valsartan-hydrochlorothiazide
10-160-12.5mg ................................15
amlodipine-valsartan-hydrochlorothiazide
10-160-25mg ...................................15
amlodipine-valsartan-hydrochlorothiazide
10-320-25mg ...................................15
amlodipine-valsartan-hydrochlorothiazide
5-160-12.5mg ..................................15
amlodipine-valsartan-hydrochlorothiazide
5-160-25mg .....................................15
ammonium lactate ............................55
amoxapine tab 100mg .......................23
amoxapine tab 150mg .......................23
amoxapine tab 25mg ........................23
amoxapine tab 50mg ........................23
amoxicillin ........................................ 9
amoxicillin & pot clavulanate ............... 9
amphetamine-dextroamphetamine cap sr
24hr 10 mg ......................................28
amphetamine-dextroamphetamine cap sr
24hr 15 mg ......................................28
amphetamine-dextroamphetamine cap sr
24hr 20 mg ......................................28
amphetamine-dextroamphetamine cap sr
24hr 25 mg ......................................28
amphetamine-dextroamphetamine cap sr
24hr 30 mg ......................................28
amphetamine-dextroamphetamine cap sr
24hr 5 mg........................................28
amphetamine-dextroamphetamine tab
10 mg .............................................28
amphetamine-dextroamphetamine tab
12.5 mg ..........................................29
amphetamine-dextroamphetamine tab
15 mg .............................................29
amphetamine-dextroamphetamine tab
20 mg .............................................29
amphetamine-dextroamphetamine tab
30 mg .............................................29
amphetamine-dextroamphetamine tab 5
mg ................................................. 28
amphetamine-dextroamphetamine tab
7.5 mg............................................ 28
amphotericin b ................................... 5
ampicillin & sulbactam sodium ............. 9
ampicillin cap 250 mg ......................... 9
ampicillin cap 500 mg ......................... 9
ampicillin for susp 125 mg/5ml ............ 9
ampicillin for susp 250 mg/5ml ............ 9
ampicillin inj ...................................... 9
ampicillin sodium ............................... 9
AMPYRA .......................................... 30
ANADROL-50 ................................... 31
anagrelide hcl .................................. 43
anastrozole ..................................... 12
ANDRODERM ................................... 31
ANORO ELLIPTA ............................... 51
APOKYN .......................................... 25
APRISO ........................................... 40
APTIOM........................................... 20
APTIVUS ........................................... 5
ARALAST NP .................................... 52
ARCALYST ....................................... 44
aripiprazole odt ................................ 26
aripiprazole oral solution 1 mg/ml ...... 26
aripiprazole tab ................................ 26
armodafinil ................................. 30, 31
ARMODAFINIL.................................. 31
ARNUITY ELLIPTA ............................. 52
ASACOL HD ..................................... 40
ASPIRIN-DIPYRIDAMOLE ................... 43
atenolol .......................................... 17
atenolol & chlorthalidone ................... 17
atorvastatin calcium ......................... 16
atovaquone ....................................... 3
atovaquone-proguanil hcl .................... 5
ATRIPLA ............................................ 6
ATROVENT HFA ................................ 51
aubra 0.1-0.02mg ............................ 34
AURYXIA ......................................... 38
AVASTIN ......................................... 11
AVITA ............................................. 53
AXIRON .......................................... 31
azacitidine ....................................... 10
AZACTAM IN ISO-OSMOTIC DE ............ 3
58
CY17_4T_STANDARD eff 01/01/2017
AZACTAM/DEX INJ 2GM ...................... 3
azathioprine .....................................45
azelastine drop 0.05% .......................50
azelastine spr 0.1% ..........................51
azelastine spr 0.15% .........................51
AZILECT ..........................................25
azithromycin ..................................... 8
AZITHROMYCIN ................................. 8
AZOPT .............................................50
aztreonam ........................................ 3
B
bacitracin (ophthalmic) ......................49
bacitracin-polymyxin b (ophth) ...........49
bacitracin-poly-neomycin-hc ..............49
baclofen ..........................................30
balsalazide disodium .........................40
BANZEL SUS 40MG/ML ......................20
BANZEL TAB 200MG ..........................20
BANZEL TAB 400MG ..........................20
BARACLUDE ...................................... 7
BCG VACCINE...................................45
BELEODAQ .......................................11
benazepril & hydrochlorothiazide ........14
benazepril hcl ...................................14
BENDEKA .........................................10
BENLYSTA ........................................45
benzoyl peroxide-erythromycin ...........53
benztropine mesylate ........................25
BENZTROPINE MESYLATE ..................25
BEPREVE..........................................50
BESIVANCE ......................................49
betamethasone dipropionate (topical)..54
betamethasone dipropionate augmented
......................................................54
BETAMETHASONE DIPROPIONATE
AUGMENTED ....................................54
betamethasone valerate ....................54
BETASERON .....................................30
betaxolol hcl (ophth) .........................50
bethanechol chloride .........................42
BETOPTIC-S .....................................50
BEVESPI ..........................................51
bexarotene ......................................13
BEXSERO .........................................45
bicalutamide ....................................12
BICILLIN L-A ..................................... 9
BICNU ............................................ 10
BILTRICIDE ....................................... 3
bisoprolol & hydrochlorothiazide ......... 17
bisoprolol fumarate .......................... 17
BIVIGAM ......................................... 44
bleomycin sulfate ............................. 10
blephamide s.o.p. ............................ 49
BOOSTRIX ....................................... 45
BOSULIF ......................................... 12
BREO ELLIPTA ................................. 53
BRILINTA ........................................ 43
BRIMONIDINE SOL 0.15% ................. 50
brimonidine sol 0.2% ........................ 50
BRIVIACT ........................................ 20
bromfenac sodium (ophth) ................ 50
bromocriptine mesylate..................... 25
budesonide (inhalation) .................... 52
budesonide ec.................................. 40
bumetanide ..................................... 18
BUPHENYL ....................................... 36
buprenorphine hcl ............................ 31
buprenorphine hcl-naloxone hcl sl ...... 31
bupropion hcl................................... 23
bupropion hcl (smoking deterrent) ..... 31
buspirone hcl ................................... 20
BUSULFEX ....................................... 10
butorphanol tartrate ........................... 1
BYDUREON INJ ................................ 32
BYDUREON PEN ............................... 32
BYETTA ........................................... 32
BYSTOLIC ....................................... 17
C
cabergoline ..................................... 37
CABOMETYX .................................... 12
cafergot .......................................... 29
calcipotriene .................................... 54
calcitonin (salmon) ........................... 38
calcitriol .......................................... 49
calcitriol inj ..................................... 49
calcitriol oral soln 1 mcg/ml ............... 49
calcium acetate (phosphate binder) .... 38
CANASA .......................................... 40
CANCIDAS......................................... 5
CAPASTAT SULFATE ........................... 7
CAPRELSA ....................................... 12
captopril ......................................... 15
59
CY17_4T_STANDARD eff 01/01/2017
captopril & hydrochlorothiazide ...........14
CARBAGLU .......................................36
carbamazepine .................................21
CARBIDOPA/LEVODOPA/ENTACAPONE .25
carbidopa-levodopa ...........................25
carboplatin .......................................14
CARIMUNE NANOFILTERED ................44
carteolol hcl (ophth) ..........................50
cartia xt cap 120/24hr .......................17
cartia xt cap 180/24hr .......................17
cartia xt cap 240/24hr .......................17
cartia xt cap 300/24hr .......................17
carvedilol .........................................17
CAYSTON .......................................... 4
caziant pak ......................................34
cefaclor ............................................ 8
cefaclor monohydrate er ..................... 8
cefadroxil .......................................... 8
CEFAZOLIN IN DEXTROSE 2GM/100ML4% .................................................. 8
cefazolin inj....................................... 8
cefazolin sodium ................................ 8
cefazolin sodium 1 gm/50ml................ 8
cefdinir ............................................. 8
cefepime hcl ...................................... 8
cefixime ............................................ 8
cefotaxime sodium ............................. 8
cefoxitin sodium ................................ 8
cefpodoxime proxetil .......................... 8
cefprozil............................................ 8
ceftazidime ....................................... 8
CEFTAZIDIME/DEXTROSE ................... 8
ceftriaxone sodium ............................. 8
cefuroxime axetil ............................... 8
cefuroxime sodium ............................. 8
celecoxib .......................................... 1
CELONTIN ........................................21
cephalexin ........................................ 8
CERDELGA .......................................36
CEREZYME .......................................36
CERVARIX ........................................45
cetirizine syrup .................................51
cevimeline hcl ..................................55
CHANTIX .........................................31
CHANTIX CONTINUING MONTH ..........31
CHANTIX STARTER PACK ...................31
CHEMET .......................................... 34
chlorhexidine gluconate (mouth-throat)
...................................................... 55
chloroquine phosphate ........................ 5
chlorothiazide tabs ........................... 18
chlorpromazine hcl ........................... 26
chlorpromazine inj ............................ 26
chlorthalidone .................................. 19
cholestyramine ................................ 16
cholestyramine light ......................... 16
ciclopirox ........................................ 53
ciclopirox shampoo 1% ..................... 53
cilostazol ......................................... 43
CILOXAN ......................................... 49
CINRYZE ......................................... 43
CIPRODEX ....................................... 56
ciprofloxacin ...................................... 9
ciprofloxacin er .................................. 9
ciprofloxacin hcl (ophth).................... 49
ciprofloxacin hcl tab ............................ 9
ciprofloxacin in d5w ............................ 9
ciprofloxacin inj.................................. 9
cisplatin .......................................... 14
citalopram hydrobromide ............. 23, 24
cladribine ........................................ 10
clarithromycin .................................... 8
clarithromycin er ................................ 8
clarithromycin for susp ....................... 8
clindacin-p pad 1% ........................... 53
clindamycin cap 300mg....................... 4
clindamycin cap 75mg ........................ 4
clindamycin hcl cap 150 mg ................. 4
clindamycin phosphate ........................ 4
clindamycin phosphate (topical) ......... 53
clindamycin phosphate in d5w ............. 4
clindamycin phosphate inj ................... 4
clindamycin phosphate vaginal ........... 42
clindamycin sol 75mg/5ml ................... 4
CLINIMIX 2.75%/DEXTROSE 5% ........ 47
CLINIMIX 4.25%/DEXTROSE 25% ...... 47
CLINIMIX 4.25%/DEXTROSE 5% ........ 47
CLINIMIX 5%/DEXTROSE 15% .......... 47
CLINIMIX 5%/DEXTROSE 20% .......... 47
CLINIMIX 5%/DEXTROSE 25% .......... 47
CLINIMIX INJ 4.25/D10 .................... 47
CLINIMIX INJ 4.25/D20 .................... 47
60
CY17_4T_STANDARD eff 01/01/2017
clomipramine hcl ..............................24
clonazepam ......................................21
clonidine hcl .....................................19
clopidogrel bisulfate ..........................43
clorazepate dipotassium ....................21
clotrimazole .....................................55
clotrimazole (topical) .........................54
CLOZAPINE ODT ...............................26
clozapine tab 100mg .........................26
clozapine tab 200mg .........................26
clozapine tab 25mg ...........................26
clozapine tab 50mg ...........................26
COARTEM ......................................... 5
colchicine w/ probenecid ..................... 1
COLCRYS .......................................... 1
colestipol hcl ....................................16
colistimethate sodium......................... 4
colocort enema 100mg ......................40
COMBIGAN.......................................50
COMBIVENT RESPIMAT ......................51
COMETRIQ .......................................12
COMPLERA ........................................ 6
compro supp ....................................39
COPAXONE INJ 40MG/ML ...................30
cortisone acetate ..............................37
COTELLIC ........................................12
COUMADIN ......................................42
CREON ............................................41
CRIXIVAN ......................................... 5
cromolyn sodium (mastocytosis) .........41
cromolyn sodium (ophth) ...................50
cromolyn sodium nebu ......................52
cryselle-28 .......................................34
CUBICIN ........................................... 4
cyclobenzaprine hcl ...........................30
cyclophosphamide.............................10
CYCLOPHOSPHAMIDE ........................10
cycloserine ........................................ 7
cyclosporine .....................................45
cyclosporine modified (for
microemulsion) .................................45
cyproheptadine hcl ............................51
cyred tab .........................................34
CYSTADANE .....................................36
CYSTAGON.......................................36
CYSTARAN .......................................51
cytarabine ....................................... 10
D
dacarbazine ..................................... 10
DAKLINZA ......................................... 7
DALIRESP ....................................... 52
danazol ........................................... 36
dantrolene sodium ........................... 30
dapsone ............................................ 4
DAPTACEL ....................................... 45
daptomycin ....................................... 4
daunorubicin hcl ............................... 10
DELESTROGEN................................. 36
delyla 0.1-0.02mg ............................ 34
DELZICOL ....................................... 40
DEMSER .......................................... 19
DEPEN TITRATABS ........................... 34
DEPO-PROVERA INJ 400/ML .............. 12
DESCOVY .......................................... 6
desipramine hcl................................ 24
desmopressin acetate spray .............. 39
desmopressin acetate spray refrigerated
...................................................... 39
desmopressin acetate tabs ................ 39
desmopressin inj 4mcg/ml ................ 39
DESMOPRESSIN SOL 0.01% .............. 39
desogestrel & ethinyl estradiol ........... 34
desogestrel-ethinyl estradiol (biphasic) 34
desogestrel-ethinyl estradiol (triphasic)
...................................................... 34
desoximetasone ............................... 54
DESOXIMETASONE ........................... 54
dexamethasone ............................... 37
dexamethasone sodium phosphate ..... 37
dexamethasone sodium phosphate
(ophth) ........................................... 50
DEXILANT ....................................... 41
dexrazoxane .................................... 14
DEXTROSE 10% FLEX CONTAIN ......... 48
DEXTROSE 10%/NACL 0.2% ............. 48
DEXTROSE 10%/NACL 0.45% ............ 48
DEXTROSE 2.5%/NACL 0.45% ........... 48
DEXTROSE 5% ................................ 48
DEXTROSE 5% /ELECTROLYTE ........... 48
DEXTROSE 5%/LACTATED RING ........ 48
DEXTROSE 5%/NACL 0.2% ............... 48
DEXTROSE 5%/NACL 0.225% ............ 48
61
CY17_4T_STANDARD eff 01/01/2017
DEXTROSE 5%/NACL 0.3% ................48
DEXTROSE 5%/NACL 0.33% ..............48
DEXTROSE 5%/NACL 0.45% ..............48
DEXTROSE 5%/NACL 0.9% ................48
DEXTROSE 5%/POTASSIUM CHL.........48
DEXTROSE 50% ...............................48
DEXTROSE INJ 70% ..........................48
diazepam .........................................21
DIAZEPAM GEL .................................21
diclofenac potassium .......................... 1
diclofenac sodium .............................. 1
diclofenac sodium (ophth) ..................50
diclofenac sodium (topical) 1% gel ......55
dicloxacillin sodium ............................ 9
dicyclomine hcl .................................40
didanosine ........................................ 5
DIFICID ............................................ 8
diflunisal ........................................... 1
digox ...............................................18
digoxin ............................................18
digoxin inj ........................................18
DIGOXIN SOL 50MCG/ML ...................18
dihydroergotamine mesylate ..............29
dilantin infatabs ................................21
DILANTIN-125 SUS 125/5ML ..............21
diltiazem cap 120mg cd .....................18
diltiazem cap 180mg cd .....................18
diltiazem cap 240mg cd .....................18
diltiazem cap 300mg cd .....................18
DILTIAZEM CAP 360MG CD ................18
diltiazem cap er/12hr ........................18
diltiazem hcl .....................................18
diltiazem hcl cap sr 24hr ....................18
diltiazem hcl coated beads cap sr 24hr 18
diltiazem hcl extended release beads cap
sr....................................................18
dilt-xr cap ........................................18
DIPENTUM .......................................40
diphenhydramine inj .........................51
diphenoxylate w/ atropine ..................41
DIPHTHERIA/TETANUS TOXOID ..........45
disopyramide phosphate ....................16
disulfiram ........................................31
divalproex sodium .............................21
DOCEFREZ .......................................11
docetaxel .........................................11
DOCETAXEL ..................................... 11
DOCETAXEL SOLN 80MG/8ML ............ 11
DOFETILIDE .................................... 16
donepezil hydrochloride .................... 23
dorzolamide hcl................................ 50
dorzolamide hcl-timolol maleate ......... 50
doxazosin mesylate .......................... 15
doxepin hcl ...................................... 24
DOXEPIN HCL (ANTIPRURITIC) .......... 54
doxorubicin hcl ................................ 10
doxorubicin hcl liposomal inj 2mg/ml .. 10
doxorubicin inj 50mg ........................ 10
doxycycline (monohydrate) ........... 9, 10
doxycycline hyclate .......................... 10
dronabinol ....................................... 39
drospirenone-ethinyl estradiol ............ 34
DROXIA .......................................... 13
duloxetine hcl .................................. 24
DURAMORPH ..................................... 1
DUREZOL ........................................ 50
dutasteride ...................................... 42
dutasteride-tamsulosin hcl ................ 42
E
e.e.s. 400 ......................................... 9
EDURANT .......................................... 5
EFFIENT .......................................... 43
ELIQUIS .......................................... 42
ELITEK ............................................ 14
ELLA ............................................... 34
ELMIRON......................................... 42
EMCYT ............................................ 10
EMEND ........................................... 39
EMEND CAP 125MG .......................... 39
EMEND CAP 40MG ............................ 39
EMEND CAP 80MG ............................ 39
EMEND PAK 80 & 125 ....................... 39
EMSAM ........................................... 24
EMTRIVA ........................................... 5
emverm ............................................ 4
enalapril maleate ............................. 15
enalapril maleate & hydrochlorothiazide
...................................................... 14
endocet 10/325 ................................. 1
endocet 5/325 ................................... 1
endocet 7.5/325 ................................ 1
ENGERIX-B...................................... 45
62
CY17_4T_STANDARD eff 01/01/2017
enoxaparin sodium ............................42
ENOXAPARIN SODIUM .......................42
ENTACAPONE ...................................25
entecavir .......................................... 7
ENTRESTO .......................................15
EPIPEN 2-PAK...................................52
EPIPEN-JR 2-PAK ..............................52
epirubicin hcl ....................................10
EPIVIR HBV ....................................... 7
eplerenone .......................................15
EPZICOM .......................................... 6
ergotamine w/ caffeine ......................29
ERIVEDGE ........................................11
ery pad 2% ......................................53
erythrocin lactobionate ....................... 9
erythromycin (acne aid).....................53
erythromycin (ophth) ........................49
erythromycin base ............................. 9
erythromycin cap 250mg ec ................ 9
erythromycin ethylsuccinate ................ 9
erythromycin stearate ........................ 9
ESBRIET ..........................................52
escitalopram oxalate .........................24
esomeprazole magnesium ..................41
esomeprazole sodium inj ...................41
estarylla tab 0.25-35 .........................34
estrace ............................................36
estradiol ..........................................36
estradiol valerate ..............................36
ethambutol hcl .................................. 7
ethosuximide....................................21
ethynodiol diacet & eth estrad ............34
etodolac ........................................... 1
etodolac er ........................................ 1
etoposide .........................................14
EURAX .............................................55
EVOTAZ ............................................ 6
exemestane .....................................12
EXJADE ...........................................34
F
FABRAZYME .....................................36
falmina ............................................34
famciclovir ........................................ 7
famotidine .......................................40
famotidine inj ...................................40
FANAPT ...........................................26
FANAPT TITRATION PACK .................. 26
FARESTON ...................................... 12
FARXIGA ......................................... 32
FARYDAK ........................................ 11
FASLODEX ....................................... 12
felbamate ........................................ 21
felodipine ........................................ 18
fenofibrate ...................................... 16
fenofibrate micronized ...................... 16
fentanyl citrate .................................. 2
fentanyl patch 100 mcg/hr .................. 2
fentanyl patch 12 mcg/hr .................... 2
fentanyl patch 25 mcg/hr .................... 2
fentanyl patch 50 mcg/hr .................... 2
fentanyl patch 75 mcg/hr .................... 2
FENTORA .......................................... 2
FERRIPROX ..................................... 34
FETZIMA ......................................... 24
FETZIMA TITRATION PACK ................ 24
finasteride ....................................... 42
FIRAZYR ......................................... 43
FLEBOGAMMA DIF ............................ 44
flecainide acetate ............................. 16
FLOVENT DISKUS ............................. 52
FLOVENT HFA .................................. 52
fluconazole ........................................ 5
fluconazole in dextrose ....................... 5
fluconazole inj nacl 100....................... 5
fluconazole inj nacl 200....................... 5
fluconazole inj nacl 400....................... 5
flucytosine......................................... 5
fludarabine phosphate ...................... 10
fludrocortisone acetate ..................... 37
flunisolide (nasal) ............................. 52
fluocinolone acetonide ...................... 54
fluocinolone acetonide (otic) .............. 56
fluocinonide ..................................... 54
fluocinonide emulsified base .............. 54
FLUOROMETHOLONE ........................ 50
fluorouracil ...................................... 10
fluorouracil (topical) ......................... 55
fluoxetine cap 10mg ......................... 24
fluoxetine cap 20mg ......................... 24
fluoxetine cap 40mg ......................... 24
fluoxetine hcl ................................... 24
fluphenazine decanoate .................... 26
63
CY17_4T_STANDARD eff 01/01/2017
fluphenazine hcl................................26
flurbiprofen ....................................... 1
flurbiprofen sodium ...........................50
flutamide .........................................12
fluticasone propionate .......................54
fluticasone propionate (nasal) ............52
fluvoxamine maleate .........................20
fondaparinux sodium ................... 42, 43
FORTEO ...........................................38
FORTICAL ........................................38
fosinopril sodium ..............................15
fosinopril sodium & hydrochlorothiazide
......................................................14
FREAMINE HBC 6.9% ........................47
FREAMINE III ...................................47
furosemide .......................................19
furosemide inj ..................................19
FUROSEMIDE INJ ..............................19
FUSILEV ..........................................14
FUZEON ............................................ 5
fyavolv tab 1-5mg ............................36
FYCOMPA .........................................21
G
gabapentin ................................. 21, 22
GABITRIL .........................................22
galantamine hydrobromide.................23
galantamine hydrobromide er .............23
GAMASTAN S/D ................................44
GAMMAGARD LIQUID ........................44
GAMMAGARD S/D .............................44
GAMMAKED ......................................44
GAMMAPLEX .....................................44
GAMUNEX-C .....................................44
ganciclovir inj 500mg ......................... 7
GARDASIL........................................45
GARDASIL 9 .....................................45
gatifloxacin (ophth) ...........................49
GATTEX ...........................................41
GAUZE PADS 2 .................................32
gavilyte-h ........................................40
gemcitabine hcl ................................11
GEMCITABINE HCL ............................11
gemfibrozil .......................................17
generlac ..........................................40
gentamicin in saline ........................... 3
gentamicin sulfate.............................. 3
gentamicin sulfate (ophth) ................ 49
gentamicin sulfate (topical) ............... 53
gentamicin sulfate/0.9% s ................... 3
GENVOYA .......................................... 6
GEODON ......................................... 26
GIANVI ........................................... 34
gildess 1.5/30 .................................. 34
GILENYA CAP 0.5MG ......................... 30
GILOTRIF TAB 20MG......................... 12
GILOTRIF TAB 30MG......................... 13
GILOTRIF TAB 40MG......................... 13
glatiramer acetate ............................ 30
GLEOSTINE ..................................... 10
glimepiride ...................................... 32
glip/metform tab 2.5-250m ............... 32
glip/metform tab 2.5-500m ............... 32
glip/metform tab 5-500mg ................ 32
glipizide ..................................... 32, 33
GLIPIZIDE XL TB24 2.5MG ................ 33
GLIPIZIDE XL TB24 5MG ................... 33
GLUCAGEN HYPOKIT......................... 37
GLUCAGON EMERGENCY KIT ............. 37
glycopyrrolate .................................. 40
glycopyrrolate inj ............................. 40
GOLYTELY ....................................... 40
granisetron hcl ................................. 39
GRANIX .......................................... 43
griseofulvin microsize ......................... 5
griseofulvin ultramicrosize ................... 5
guanfacine er (adhd) ........................ 29
H
halobetasol propionate ...................... 54
haloperidol ...................................... 26
haloperidol decanoate ....................... 26
haloperidol lactate inj 5 mg/ml .......... 26
haloperidol lactate oral conc 2 mg/ml . 26
HAVRIX ........................................... 45
heather ........................................... 34
heparin sod (porcine) in d5w ............. 43
HEPARIN SOD (PORCINE) IN D5W ...... 43
heparin sod inj 1000/ml .................... 43
heparin sod inj 10000/ml .................. 43
heparin sod inj 20000/ml .................. 43
heparin sod inj 5000/ml .................... 43
HEPARIN SODIUM/D5W .................... 43
HEPARIN SODIUM/NACL 0.45% ......... 43
64
CY17_4T_STANDARD eff 01/01/2017
HEPATAMINE ....................................47
HERCEPTIN ......................................11
HETLIOZ ..........................................29
HEXALEN .........................................10
HIBERIX ..........................................45
HUMIRA INJ 10MG/0.2ML...................44
HUMIRA KIT 20MG/0.4ML ..................44
HUMIRA KIT 40MG/0.8ML ..................44
HUMIRA PEDIATRIC CROHNS DISEASE 44
HUMIRA PEN ....................................44
HUMIRA PEN-CROHNS DISEASE .........44
HUMIRA PEN-PSORIASIS STAR ...........44
HUMULIN R INJ U-500 .......................32
HUMULIN R U-500 KWIKPEN ..............32
hydralazine hcl .................................19
hydrochlorothiazide ...........................19
hydroco/apap tab 10-325mg ............... 2
hydroco/apap tab 5-325mg ................. 2
hydroco/apap tab 7.5-325 .................. 2
hydrocodone-acetaminophen 7.5-325
mg/15ml .......................................... 2
hydrocodone-ibuprofen tab 7.5-200 mg 2
hydrocortisone .................................37
HYDROCORTISONE (ENEMA) ..............40
hydrocortisone (rectal) ......................54
hydrocortisone (topical) .....................54
hydrocortisone butyrate .....................54
hydrocortisone valerate .....................54
hydromorphone hcl ............................ 2
hydroxychloroquine sulfate ................44
hydroxyprogesterone caproate
(antineoplastic) ................................12
hydroxyurea .....................................13
hydroxyzine hcl ................................51
hydroxyzine pamoate ........................51
I
IBRANCE..........................................11
ibuprofen .......................................... 1
ICLUSIG ..........................................13
idarubicin hcl ....................................10
IFEX INJ 3GM ...................................10
ifosfamide inj 1gm ............................10
ifosfamide inj 1gm/20ml ....................10
IFOSFAMIDE INJ 3GM ........................10
ifosfamide inj 3gm/60ml ....................10
ILEVRO ............................................50
imatinib mesylate ............................. 13
IMBRUVICA CAP 140MG .................... 13
imipenem-cilastatin ............................ 4
imipramine hcl ................................. 24
imiquimod ....................................... 55
IMOVAX RABIES (H.D.C.V.) ............... 45
INCRELEX ....................................... 38
INCRUSE ELLIPTA ............................ 51
indapamide ..................................... 19
INFANRIX ........................................ 45
INLYTA ........................................... 13
INSULIN PEN NEEDLE ....................... 32
INSULIN SAFETY NEEDLES ................ 32
INSULIN SYRINGE ............................ 32
INTELENCE ........................................ 5
INTRALIPID INJ 20% ........................ 47
INTRALIPID INJ 30% ........................ 47
INTRON-A INJ 10MU ......................... 44
INTRON-A INJ 18MU ......................... 44
INTRON-A INJ 25MU ......................... 44
INTRON-A INJ 50MU ......................... 44
INVANZ ............................................ 4
INVEGA SUST INJ 117 MG/0.75 ML .... 26
INVEGA SUST INJ 156MG/ML ............. 26
INVEGA SUST INJ 234 MG/1.5 ML ...... 27
INVEGA SUST INJ 39 MG/0.25 ML ...... 26
INVEGA SUST INJ 78 MG/0.5 ML ........ 26
INVEGA TRINZA ............................... 27
INVIRASE .......................................... 5
INVOKAMET TAB 150-1000MG ........... 33
INVOKAMET TAB 150-500MG ............. 33
INVOKAMET TAB 50-1000MG ............. 33
INVOKAMET TAB 50-500MG .............. 33
INVOKAMET XR TAB 150-1000MG ...... 33
INVOKAMET XR TAB 150-500MG ........ 33
INVOKAMET XR TAB 50-1000MG ........ 33
INVOKAMET XR TAB 50-500MG .......... 33
INVOKANA ...................................... 33
IONOSOL-B/DEXTROSE 5% ............... 48
IONOSOL-MB/DEXTROSE 5% ............ 48
IPOL INACTIVATED IPV ..................... 45
ipratropium bromide ......................... 51
ipratropium bromide (nasal) .............. 51
ipratropium-albuterol nebu ................ 51
irbesartan ....................................... 16
irbesartan-hydrochlorothiazide ........... 15
65
CY17_4T_STANDARD eff 01/01/2017
IRESSA ............................................13
irinotecan inj 100/5ml .......................14
irinotecan inj 40mg/2ml.....................14
irinotecan inj 500mg/25ml .................14
ISENTRESS ....................................5, 6
ISOLYTE P........................................48
ISOLYTE S .......................................48
isoniazid ........................................... 7
isoniazid inj 100 mg/ml ...................... 7
isoniazid syp 50mg/5ml ...................... 7
isosorb mononitrate tab .....................19
isosorbide dinitrate ...........................19
isosorbide dinitrate er ........................19
isosorbide mononitrate er ..................19
isotretinoin.......................................53
isradipine .........................................18
ISTALOL ..........................................50
ISTODAX .........................................11
itraconazole ...................................... 5
ivermectin......................................... 4
IXIARO ............................................46
J
JAKAFI ............................................13
JANUMET .........................................33
JANUMET XR TAB 100-1000 ...............33
JANUMET XR TAB 50-1000 .................33
JANUMET XR TAB 50-500MG ..............33
JANUVIA ..........................................33
JENTADUETO ....................................33
JENTADUETO TAB XR 2.5-1000 MG .....33
JENTADUETO TAB XR 5-1000 MG ........33
JOLESSA TAB 0.15-0.03 MG ...............34
JOLIVETTE .......................................34
JUXTAPID ........................................17
K
KADCYLA .........................................11
KALETRA SOL .................................... 6
KALETRA TAB 100-25MG .................... 6
KALETRA TAB 200-50MG .................... 6
KALYDECO .......................................52
KCL 0.075%/D5W/NACL 0.45% ..........48
KCL 0.15%/D5W/NACL 0.9% .............48
KCL 0.3%/D5W/NACL 0.45% .............48
KCL 0.3%/D5W/NACL 0.9% ...............48
KCL IN NACL INJ .15-0.45..................48
KCL/D5W INJ 0.3% ...........................48
KCL/D5W/NACL INJ .15/.33% ............ 48
KCL/D5W/NACL INJ .15/.45% ............ 48
KCL/D5W/NACL INJ 0.22%/0.45% ..... 48
KCL/NACL INJ 0.15%-0.9% ............... 48
KCL/NACL INJ 0.3-0.9....................... 48
KCL0.15%/D5W/NACL0.2% ............... 48
KCL0.15%/D5W/NACL0.225% ........... 48
ketoconazole ..................................... 5
ketoconazole cream .......................... 54
ketoconazole shampoo ...................... 54
ketoprofen ........................................ 1
ketorolac tromethamine (ophth) ........ 50
KEYTRUDA ...................................... 11
KINRIX ........................................... 46
KLOR-CON 10 .................................. 46
KLOR-CON 8 .................................... 46
klor-con m10 ................................... 46
klor-con m15 ................................... 46
klor-con m20 ................................... 46
klor-con pow 20 meq ........................ 46
klor-con spr cap 10meq .................... 46
klor-con spr cap 8meq ...................... 46
KORLYM .......................................... 38
KUVAN ............................................ 36
KYNAMRO ....................................... 17
L
labetalol hcl ..................................... 17
LACTATED RINGER'S INJ ................... 48
lactulose ......................................... 40
lactulose (encephalopathy) ................ 40
lamivudine ........................................ 6
lamivudine (hbv) ................................ 7
lamivudine-zidovudine ........................ 6
lamotrigine ...................................... 22
LANTUS .......................................... 32
LANTUS SOLOSTAR .......................... 32
larin 1.5/30 ..................................... 34
larissia tab ...................................... 35
LASTACAFT ..................................... 50
latanoprost ...................................... 50
LATUDA .......................................... 27
LEENA ............................................ 35
leflunomide ..................................... 44
LENVIMA 10 MG DAILY DOSE ............ 13
LENVIMA 14 MG DAILY DOSE ............ 13
LENVIMA 18 MG DAILY DOSE ............ 13
66
CY17_4T_STANDARD eff 01/01/2017
LENVIMA 20 MG DAILY DOSE .............13
LENVIMA 24 MG DAILY DOSE .............13
LENVIMA 8 MG DAILY DOSE ...............13
LETAIRIS .........................................19
letrozole ..........................................12
leucovorin calcium ............................14
leucovorin calcium for inj 500 mg .......14
LEUKERAN .......................................10
LEUKINE ..........................................43
leuprolide acetate .............................12
levalbuterol conc 1.25mg/0.5ml..........51
LEVALBUTEROL TARTRATE HFA ..........52
LEVEMIR ..........................................32
LEVEMIR FLEXTOUCH ........................32
levetiracetam ...................................22
LEVETIRACETAM IV ...........................22
levetiracetam oral soln 100 mg/ml ......22
levobunolol hcl .................................50
levocarnitine (metabolic modifiers) .....36
levocetirizine dihydrochloride .............51
levofloxacin ....................................... 9
levofloxacin in d5w ............................ 9
levofloxacin inj 25mg/ml ..................... 9
levofloxacin oral soln 25 mg/ml ........... 9
levoleucovorin calcium .......................14
levonor/ethi tab ................................35
levonorgestrel & eth estradiol .............35
levonorgestrel (emergency oc) ...........35
levonorgestrel-eth estradiol (triphasic) 35
levonorgestrel-ethinyl estradiol (91-day)
......................................................35
levothyroxine sodium ........................38
LEVOTHYROXINE SODIUM..................38
LEVOXYL ..........................................39
LEXIVA ............................................. 6
lidocaine ..........................................55
lidocaine hcl .....................................55
lidocaine hcl (local anesth.) ................. 3
lidocaine hcl (mouth-throat) ...............55
lidocaine inj 0.5% .............................. 3
lidocaine inj 1% ................................. 3
lidocaine inj 1.5% .............................. 3
lidocaine inj 2% ................................. 3
lidocaine oint 5% ..............................55
lidocaine-prilocaine ...........................55
linezolid ............................................ 4
LINEZOLID ........................................ 4
LINEZOLID IN SODIUM CHLORIDE ....... 4
LINZESS ......................................... 41
liothyronine sodium .......................... 39
lisinopril .......................................... 15
lisinopril & hydrochlorothiazide........... 14
lithium carbonate ............................. 30
lithium carbonate er ......................... 30
LITHIUM SOLN 8MEQ/5ML ................. 30
LONSURF ........................................ 13
loperamide hcl ................................. 41
lorazepam ....................................... 20
lorcet plus tab 7.5-325 ....................... 2
lorcet tab 5-325mg ............................ 2
lortab tab 10-325mg .......................... 2
lortab tab 5-325mg ............................ 2
lortab tab 7.5-325 .............................. 2
loryna ............................................. 35
losartan potassium ........................... 16
losartan-hydrochlorothiazide .............. 15
LOTEMAX ........................................ 50
lovastatin ........................................ 16
low-ogestrel .................................... 35
loxapine succinate ............................ 27
LUMIGAN ........................................ 50
LUMIZYME ....................................... 36
LUPRON DEPOT ................................ 12
LUPRON DEPOT INJ 11.25MG (3-MONTH)
...................................................... 12
LUPRON DEP-PED INJ 11.25MG .......... 38
LUPRON DEP-PED INJ 11.25MG (3MONTH) .......................................... 38
LUPRON DEP-PED INJ 15MG .............. 38
LUPRON DEP-PED INJ 30MG (3-MONTH)
...................................................... 38
LUPRON DEP-PED INJ 7.5MG ............. 38
LYNPARZA ....................................... 11
LYRICA ........................................... 22
LYSODREN ...................................... 12
M
magnesium sulfate ........................... 46
MAGNESIUM SULFATE ...................... 46
MAGNESIUM SULFATE IN D5W ........... 46
malathion ........................................ 55
maprotiline hcl ................................. 24
MARPLAN TAB 10MG ......................... 24
67
CY17_4T_STANDARD eff 01/01/2017
MATULANE .......................................13
MAXIDEX .........................................50
meclizine hcl ....................................39
medroxyprogesterone acetate
(contraceptive) .................................35
MEDROXYPROGESTERONE ACETATE
(CONTRACEPTIVE) ............................35
medroxyprogesterone acetate tab .......38
mefloquine hcl ................................... 5
megestrol ac sus 40mg/ml .................12
megestrol ac tab 20mg ......................12
megestrol ac tab 40mg ......................12
MEGESTROL SUS 625MG/5ML ............12
MEKINIST ........................................13
meloxicam ........................................ 1
MELOXICAM ...................................... 1
melphalan hcl ...................................10
memantine hcl .................................23
MEMANTINE HCL ..............................23
MENACTRA .......................................46
MENHIBRIX ......................................46
MENOMUNE-A/C/Y/W-135 ..................46
MENVEO ..........................................46
mercaptopurine ................................11
meropenem ...................................... 4
MESALAMINE ...................................40
mesalamine enema ...........................40
mesalamine w/ cleanser ....................40
mesna .............................................14
MESNEX ..........................................14
metadate er tab 20mg .......................29
metformin er ....................................33
metformin hcl ...................................33
methadone hcl................................... 2
methadone hcl 10mg .......................... 2
methadone hcl 5mg ........................... 2
methazolamide .................................19
methenamine hippurate ...................... 4
methimazole ....................................39
methotrexate sodium ........................11
METHOTREXATE SODIUM ...................11
methotrexate sodium inj ....................11
methotrexate sodium tabs .................44
methyclothiazide...............................19
methylergonovine maleate .................38
methylphenidate hcl ..........................29
methylphenidate hcl oral soln ............ 29
methylpr ace inj 40mg/ml ................. 37
methylpr ace inj 80mg/ml ................. 37
methylpr ss inj 1gm ......................... 37
methylpr ss inj 40mg ........................ 37
methylpred pak 4mg ........................ 37
methylpred tab 16mg ....................... 37
methylpred tab 32mg ....................... 37
methylpred tab 4mg ......................... 37
methylpred tab 8mg ......................... 37
methylprednisolone sod succ ............. 37
metipranolol .................................... 51
metoclopramide hcl .......................... 39
metoclopramide inj ........................... 39
metolazone ..................................... 19
metoprolol & hctz tab 100-25mg ........ 17
metoprolol & hctz tab 100-50mg ........ 17
metoprolol & hctz tab 50-25mg .......... 17
metoprolol succinate......................... 17
metoprolol tartrate ........................... 17
metronidazole .................................... 4
metronidazole (topical) ..................... 55
metronidazole gel 0.75% .................. 55
metronidazole in nacl .......................... 4
metronidazole vaginal ....................... 42
mexiletine hcl .................................. 16
MIACALCIN...................................... 38
MICROGESTIN 1.5/30 ....................... 35
MICROGESTIN 1/20 .......................... 35
MICROGESTIN FE 1.5/30................... 35
MICROGESTIN FE 1/20 ..................... 35
midodrine hcl ................................... 19
minocycline hcl ................................ 10
minoxidil ......................................... 19
mirtazapine ..................................... 24
misoprostol ..................................... 41
mitomycin ....................................... 10
mitoxantrone hcl .............................. 13
M-M-R II ......................................... 46
moderiba tab 200mg .......................... 7
moexipril hcl .................................... 15
moexipril-hydrochlorothiazide ............ 14
molindone hcl .................................. 27
mometasone furoate ........................ 55
mono-linyah tab 0.25-35................... 35
MONONESSA ................................... 35
68
CY17_4T_STANDARD eff 01/01/2017
montelukast sodium ..........................52
morgidox cap 1x50mg .......................10
morphine ext-rel tab .......................... 2
MORPHINE SUL INJ 10MG/ML .............. 2
MORPHINE SUL INJ 15MG/ML .............. 2
MORPHINE SUL INJ 1MG/ML ................ 2
MORPHINE SUL INJ 4MG/ML ................ 2
morphine sulfate ................................ 2
MORPHINE SULFATE........................2, 3
MORPHINE SULFATE ORAL SOL ........... 3
MOVANTIK .......................................41
MOVIPREP........................................40
MOXEZA ..........................................49
MOZOBIL .........................................43
MULTAQ ..........................................16
mupirocin ........................................53
MUSTARGEN ....................................10
MYCAMINE ........................................ 5
mycophenolate mofetil ......................45
mycophenolate sodium ......................45
myorisan .........................................53
MYRBETRIQ......................................42
myzilra ............................................35
N
nabumetone ...................................... 1
nadolol ............................................17
nafcillin sodium ................................. 9
NAGLAZYME .....................................36
nalbuphine hcl ................................... 1
naloxone inj 0.4mg/ml ......................31
naloxone inj 1mg/ml .........................31
naltrexone hcl ..................................31
NAMENDA XR ...................................23
NAMENDA XR TITRATION PACK ..........23
NAMZARIC .......................................23
naphazoline 0.1% .............................51
naproxen .......................................... 1
naproxen sodium ............................... 1
naratriptan hcl ..................................29
NATACYN .........................................49
nateglinide .......................................33
NATPARA .........................................38
NEBUPENT ........................................ 4
necon 1/35-28..................................35
necon 10/11 28 day ..........................35
NECON 7/7/7 ...................................35
NECON TAB 1/50-28 ......................... 35
nefazodone hcl................................. 24
neomycin sulfate ................................ 3
neomycin-bacitracin zn-polymyxin...... 49
neomycin-polymy-dexameth.............. 49
neomycin-polymyxin-gramicidin ......... 49
neomycin-polymyxin-hc (ophth)......... 49
neomycin-polymyxin-hc (otic)............ 56
NEORAL .......................................... 45
NEPHRAMINE ................................... 47
NEUPOGEN ...................................... 43
NEUPRO .......................................... 25
nevirapine ......................................... 6
NEVIRAPINE ...................................... 6
NEXAVAR ........................................ 13
NEXIUM GRA 10MG DR ..................... 41
NEXIUM GRA 2.5MG DR .................... 41
NEXIUM GRA 20MG DR ..................... 41
NEXIUM GRA 40MG DR ..................... 41
NEXIUM GRA 5MG DR ....................... 41
niacin (antihyperlipidemic) ................ 17
niacin er (antihyperlipidemic) ............ 17
nicardipine hcl ................................. 18
NICOTROL INHALER ......................... 31
NICOTROL NS .................................. 31
nifedipine ........................................ 18
nifedipine cr .................................... 18
nifedipine er .................................... 18
nifedipine xl ..................................... 18
nikki 3-0.02mg ................................ 35
NILANDRON .................................... 12
nilutamide ....................................... 12
nimodipine ...................................... 18
NINLARO ......................................... 11
NIPENT ........................................... 11
NITRO-DUR DIS 0.3MG/HR ................ 19
NITRO-DUR DIS 0.8MG/HR ................ 19
nitrofurantoin macrocrystal ................. 4
nitrofurantoin monohyd macro ............. 4
nitroglycerin .................................... 19
nitroglycerin td patch ........................ 19
NITROSTAT ..................................... 19
NORA-BE TAB .................................. 35
NORDITROPIN FLEXPRO .................... 37
norethin acet & estrad-fe .................. 35
norethindrone & eth estradiol ............ 35
69
CY17_4T_STANDARD eff 01/01/2017
norethindrone (contraceptive) ............35
norethindrone acet & eth estra ...........35
norethindrone acetate .......................38
norethindrone acetate-ethinyl estradiol 36
norethindrone acetate-ethinyl estradiolfe....................................................35
norethindrone-eth estradiol (triphasic) 35
norgest/ethi tab 0.25/35....................35
norgestimate-ethinyl estradiol ............35
norgestimate-ethinyl estradiol (triphasic)
......................................................35
norlyroc 0.35mg ...............................35
NORMOSOL-M IN D5W ......................48
NORMOSOL-R ...................................48
NORMOSOL-R IN D5W .......................48
NORPACE CR ....................................16
NORTHERA.......................................19
nortriptyline hcl ................................24
NORVIR ............................................ 6
NOVOLIN 70/30 ................................32
NOVOLIN N ......................................32
NOVOLIN R ......................................32
NOVOLOG ........................................32
NOVOLOG FLEXPEN ...........................32
NOVOLOG MIX 70/30 ........................32
NOVOLOG MIX 70/30 PREFILL ............32
NOVOLOG PENFILL............................32
NOXAFIL ........................................... 5
NUEDEXTA .......................................30
NULOJIX ..........................................45
NULYTELY/FLAVOR PACKS .................40
NUPLAZID ........................................27
nutrilipid inj 20% ..............................47
NUVARING .......................................35
NYMALIZE ........................................18
nystatin ............................................ 5
nystatin (mouth-throat) .....................55
nystatin (topical) ..............................54
O
OCELLA TAB 3-0.03MG ......................35
OCTAGAM ........................................44
octreotide acetate .............................38
ODEFSEY .......................................... 6
ODOMZO .........................................13
OFEV ...............................................52
ofloxacin (ophth) ..............................49
ofloxacin (otic) ................................. 56
olanzapine ....................................... 27
olmesartan medoxomil ...................... 16
olmesartan medoxomil-amlodipinehydrochlorothiazide .......................... 15
olmesartan medoxomilhydrochlorothiazide .......................... 15
omega-3-acid ethyl esters ................. 17
omeprazole cap 10mg....................... 41
omeprazole cap 20mg....................... 41
omeprazole cap 40mg....................... 41
ondansetron hcl ............................... 39
ondansetron hcl inj ........................... 39
ondansetron hcl oral soln .................. 39
ondansetron odt ............................... 39
ONFI .............................................. 22
OPSUMIT ........................................ 19
ORFADIN......................................... 36
ORKAMBI ........................................ 52
oxacillin sodium ................................. 9
oxaliplatin ....................................... 14
oxandrolone .................................... 31
oxcarbazepine ................................. 22
oxybutynin chloride .......................... 42
oxycodone hcl .................................... 3
OXYCODONE HCL ............................... 3
oxycodone w/ acetaminophen 10-325mg
........................................................ 3
oxycodone w/ acetaminophen 2.5-325mg
........................................................ 3
oxycodone w/ acetaminophen 5-325mg 3
oxycodone w/ acetaminophen 7.5-325mg
........................................................ 3
oxycodone w/ acetaminophen soln ....... 3
P
pacerone tab 100mg......................... 16
paclitaxel ........................................ 11
paliperidone .................................... 27
pamidronate disodium ...................... 34
PANRETIN ....................................... 55
pantoprazole sodium tbec ................. 42
paricalcitol....................................... 49
paroex sol 0.12% ............................. 55
paromomycin sulfate .......................... 3
paroxetine hcl tabs ........................... 24
paser 4gm ......................................... 7
70
CY17_4T_STANDARD eff 01/01/2017
PATADAY .........................................50
PAXIL ..............................................24
PAZEO .............................................50
PEDIARIX.........................................46
PEDVAX HIB .....................................46
PEG 3350/ELECTROLYTES ..................41
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate .............................................40
PEG 3350-KCL-SOD BICARB-SOD
CHLORIDE-SOD SULFATE...................41
peg 3350-potassium chloride-sod
bicarbonate-sod chloride ....................41
PEGANONE .......................................22
PEGASYS .......................................... 7
PEGASYS PROCLICK ........................... 7
PENICILLIN G POT IN DEXTROSE ......... 9
penicillin g procaine ........................... 9
penicillin g sodium ............................. 9
penicillin v potassium ......................... 9
penicilln gk inj 20mu .......................... 9
penicilln gk inj 5mu ............................ 9
PENTACEL ........................................46
PENTAM 300 ..................................... 4
pentoxifylline....................................43
perindopril erbumine .........................15
permethrin .......................................55
perphenazine ...................................27
pfizerpen-g ....................................... 9
phenadoz .........................................39
phenelzine sulfate .............................24
phenobarbital ...................................22
phenobarbital sodium ........................22
PHENOBARBITAL SODIUM ..................22
phenytoin ........................................22
phenytoin sodium .............................22
phenytoin sodium extended ...............22
philith..............................................35
PHOSPHOLINE IODIDE ......................51
PILOCARPINE HCL .............................51
pilocarpine hcl (oral) .........................56
PILOCARPINE HCL (ORAL)..................56
pimozide ..........................................27
pindolol ...........................................17
pioglitazone hcl ................................33
piperacillin sodium-tazobactam sodium. 9
piroxicam .......................................... 1
PLASMA-LYTE A ............................... 48
PLASMA-LYTE-148 ............................ 48
PLASMA-LYTE-56/D5W...................... 48
podofilox ......................................... 55
polyethylene glycol 3350 ................... 41
polymyxin b-trimethoprim ................. 49
POMALYST CAP 1MG ......................... 44
POMALYST CAP 2MG ......................... 45
POMALYST CAP 3MG ......................... 45
POMALYST CAP 4MG ......................... 45
pot chloride inj 2meq/ml ................... 48
potassium chloride ...................... 46, 47
POTASSIUM CHLORIDE ................ 47, 49
potassium chloride in nacl ................. 49
potassium chloride microencapsulated
crystals cr ....................................... 47
POTASSIUM CHLORIDE TAB CR 10 MEQ
...................................................... 47
potassium citrate (alkalinizer) ............ 42
POTASSIUM CITRATE (ALKALINIZER) . 42
POTIGA ........................................... 22
PRADAXA ........................................ 43
PRALUENT ....................................... 17
pramipexole tab 0.125mg ................. 25
pramipexole tab 0.25mg ................... 25
pramipexole tab 0.5mg ..................... 25
pramipexole tab 0.75mg ................... 25
pramipexole tab 1.5mg ..................... 25
pramipexole tab 1mg ........................ 25
pravastatin sodium ........................... 16
prazosin hcl ..................................... 15
pred sod pho sol 5mg/5ml ................. 37
PREDNISOLONE ACETATE (OPHTH) .... 50
prednisolone sodium phosphate (ophth)
...................................................... 50
prednisolone sol 15mg/5ml ............... 37
prednisolone sol 25mg/5ml ............... 37
prednisolone syp 15mg/5ml .............. 37
prednisone con 5mg/ml .................... 37
prednisone pak 10mg ....................... 37
prednisone pak 5mg ......................... 37
prednisone sol 5mg/5ml .................... 37
prednisone tab 10mg ........................ 37
prednisone tab 1mg.......................... 37
prednisone tab 2.5mg ....................... 37
prednisone tab 20mg ........................ 37
71
CY17_4T_STANDARD eff 01/01/2017
prednisone tab 50mg ........................37
prednisone tab 5mg ..........................37
premasol sol 10% .............................47
premasol sol 6% ...............................47
prenatal vitamin/folic acid > 0.8 mg
(generic) .........................................49
PREZCOBIX ....................................... 6
PREZISTA ......................................... 6
PRIFTIN ............................................ 7
PRIMAQUINE PHOSPHATE ................... 5
primidone ........................................22
PRISTIQ ..........................................24
PRIVIGEN ........................................44
probenecid ........................................ 1
PROCALAMINE ..................................47
prochlorperazine inj ..........................39
prochlorperazine maleate ...................39
prochlorperazine supp .......................39
PROCRIT ..........................................43
procto-pak cre 1% ............................54
proctosol hc cre 2.5% .......................54
proctozone cre -hc 2.5%....................54
PROGLYCEM SUS 50MG/ML ................37
PROGRAF .........................................45
PROLASTIN-C ...................................52
PROLENSA .......................................51
PROLEUKIN ......................................11
PROLIA ............................................38
PROMACTA.......................................43
promethazine hcl ..............................39
promethegan....................................39
propafenone hcl ................................16
propafenone hcl 12hr ........................16
proparacaine hcl ...............................51
propranolol & hydrochlorothiazide .......17
propranolol cap er .............................17
propranolol hcl .................................17
propranolol oral sol ...........................17
propylthiouracil .................................39
PROQUAD ........................................46
PROSOL ...........................................47
protriptyline hcl ................................24
PULMICORT FLEXHALER .....................53
PULMOZYME .....................................52
PURIXAN .........................................11
pyrazinamide .................................... 7
pyridostigmine tab 60mg .................. 30
Q
QUADRACEL .................................... 46
quetiapine fumarate ......................... 27
quinapril hcl .................................... 15
quinapril-hydrochlorothiazide ............. 14
quinidine gluconate .......................... 16
quinidine sulfate .............................. 16
quinine sulfate ................................... 5
R
RABAVERT ....................................... 46
raloxifene hcl ................................... 38
ramipril ........................................... 15
RANEXA .......................................... 19
ranitidine hcl ................................... 40
ranitidine hcl inj ............................... 40
ranitidine syrup ................................ 40
RAPAMUNE ...................................... 45
RAVICTI .......................................... 36
REBETOL SOLN .................................. 7
RECOMBIVAX HB .............................. 46
REGRANEX ...................................... 55
RELENZA DISKHALER ......................... 7
RELISTOR ....................................... 41
RELPAX ........................................... 29
REMICADE ....................................... 44
REMODULIN .................................... 19
RENVELA PAK 0.8GM ........................ 38
RENVELA PAK 2.4GM ........................ 38
RENVELA TAB 800MG ....................... 38
repaglinide ...................................... 33
RESCRIPTOR ..................................... 6
RESTASIS ....................................... 51
RETROVIR IV INFUSION ...................... 6
REVATIO ......................................... 19
REVLIMID........................................ 45
REXULTI ......................................... 27
REYATAZ ........................................... 6
ribasphere ......................................... 7
ribasphere 200mg .............................. 7
ribavirin 200mg ................................. 7
rifabutin ............................................ 7
rifampin ............................................ 7
RIFATER............................................ 7
riluzole ........................................... 30
rimantadine hydrochloride ................... 7
72
CY17_4T_STANDARD eff 01/01/2017
RINGER'S.........................................49
RISPERDAL INJ 12.5MG .....................27
RISPERDAL INJ 25MG ........................27
RISPERDAL INJ 37.5MG .....................27
RISPERDAL INJ 50MG ........................27
risperidone ................................. 27, 28
RITUXAN .........................................11
rivastigmine tartrate .........................23
rivastigmine td patch 24hr 13.3 mg/24hr
......................................................23
rivastigmine td patch 24hr 4.6 mg/24hr
......................................................23
rivastigmine td patch 24hr 9.5 mg/24hr
......................................................23
rizatriptan benzoate ..........................30
ropinirole tab 0.25mg ........................25
ropinirole tab 0.5mg ..........................25
ropinirole tab 1mg ............................25
ropinirole tab 2mg ............................26
ropinirole tab 3mg ............................26
ropinirole tab 4mg ............................26
ropinirole tab 5mg ............................26
rosadan cre 0.75% ...........................55
rosuvastatin calcium .........................16
ROTARIX .........................................46
ROTATEQ .........................................46
S
SABRIL ............................................22
SANDIMMUNE ..................................45
SANDOSTATIN LAR DEPOT .................38
SANTYL ...........................................55
SAPHRIS ..........................................28
selegiline hcl ....................................26
selenium sulfide ................................54
SELZENTRY ....................................... 6
SENSIPAR ........................................34
SEREVENT DISKUS ...........................52
SEROQUEL XR ..................................28
sertraline hcl .............................. 24, 25
setlakin tab ......................................35
sharobel 0.35mg...............................35
SIGNIFOR ........................................38
sildenafil citrate (pulmonary
hypertension) ...................................20
SILENOR ..........................................29
SILVER SULFADIAZINE ......................53
SIMBRINZA ..................................... 51
simvastatin ..................................... 16
sirolimus ......................................... 45
SIRTURO ........................................... 7
SIVEXTRO ......................................... 4
SODIUM CHLORIDE ..................... 47, 49
SODIUM CHLORIDE 0.45% VIA .......... 49
SODIUM CHLORIDE 0.9%.................. 55
SODIUM CHLORIDE INJ 0.9% ............ 49
sodium fluoride chew; tab; 1.1 (0.5 f)
mg/ml soln ...................................... 47
sodium phenylbutyrate ..................... 36
sodium polystyrene sulfonate ............ 34
SOLTAMOX ...................................... 12
SOLU-CORTEF ................................. 37
SOMATULINE DEPOT ........................ 38
SOMAVERT ...................................... 38
sotalol hcl ....................................... 16
sotalol hcl (afib/afl) .......................... 16
SOVALDI ........................................... 8
spironolactone ................................. 15
spironolactone & hydrochlorothiazide .. 19
SPRITAM ......................................... 22
SPRYCEL ......................................... 13
sps susp 15gm/60ml ........................ 34
sronyx ............................................ 35
SSD................................................ 53
stavudine .......................................... 6
STERILE WATER IRRIGATION ............ 55
STIMATE ......................................... 39
STIVARGA ....................................... 13
STRATTERA ..................................... 29
streptomycin sulfate ........................... 3
STRIBILD .......................................... 6
SUBOXONE MIS 12-3MG ................... 31
SUBOXONE MIS 2-0.5MG .................. 31
SUBOXONE MIS 4-1MG ..................... 31
SUBOXONE MIS 8-2MG ..................... 31
SUCRAID......................................... 41
sucralfate ........................................ 41
sulfacet sod oin 10% op .................... 49
sulfacetamide sodium (acne) ............. 53
sulfacetamide sodium (ophth) ............ 50
sulfacetamide sod-prednisolone ......... 49
sulfadiazine ....................................... 3
sulfamethoxazole-trimethop ds ............ 4
73
CY17_4T_STANDARD eff 01/01/2017
sulfamethoxazole-trimethoprim ........... 4
sulfamethoxazole-trimethoprim inj ....... 4
SULFAMYLON ...................................53
sulfasalazine ....................................40
sulfasalazine ec ................................40
sulindac ............................................ 1
SUMATRIPTAN ..................................30
SUMATRIPTAN INJ 4MG/0.5ML ...........30
sumatriptan inj 6mg/0.5ml ................30
sumatriptan succinate .......................30
suprax .............................................. 8
SUPRAX ............................................ 8
SUPREP BOWEL PREP ........................41
SUSTIVA ........................................... 6
SUTENT ...........................................13
syeda ..............................................35
SYLATRON KIT 200MCG .....................13
SYLATRON KIT 300MCG .....................13
SYLATRON KIT 600MCG .....................13
SYMBICORT .....................................53
SYMLINPEN 120 ................................32
SYMLINPEN 60 .................................32
SYNAGIS .........................................46
SYNAREL .........................................36
SYNERCID......................................... 4
SYNRIBO .........................................14
SYNTHROID .....................................39
SYPRINE ..........................................34
T
TABLOID ..........................................11
tacrolimus ........................................45
tacrolimus (topical) ...........................55
TAFINLAR ........................................13
TAGRISSO .......................................13
TAMIFLU ........................................... 8
tamoxifen citrate ..............................12
tamsulosin hcl ..................................42
TARCEVA .........................................13
TARGRETIN ......................................55
TASIGNA .........................................13
TAXOTERE .......................................11
tazicef .............................................. 8
tazicef vial ........................................ 8
TAZORAC .........................................54
taztia xt ...........................................18
TECENTRIQ ......................................11
TEFLARO ........................................... 8
TEGRETOL ....................................... 22
TEGRETOL-XR .................................. 22
temazepam ..................................... 29
TENIVAC ......................................... 46
terazosin hcl .................................... 15
terbinafine hcl .................................... 5
terbutaline sulfate ............................ 52
terconazole vaginal .......................... 42
testosterone cypionate ...................... 31
testosterone enanthate ..................... 31
TETANUS/DIPHTHERIA TOXOID ......... 46
TETRABENAZINE .............................. 30
texacort soln 2.5% ........................... 55
THALOMID ...................................... 45
theo-24........................................... 53
theophylline .................................... 53
thioridazine hcl ................................ 28
thiothixene ...................................... 28
tiagabine hcl .................................... 22
timolol maleate ................................ 17
timolol maleate (ophth) soln .............. 51
TIMOLOL MALEATE GEL..................... 51
TIVICAY ............................................ 6
tizanidine hcl ................................... 30
TOBRADEX ...................................... 49
TOBRADEX ST ................................. 49
tobramycin ........................................ 3
tobramycin (ophth) .......................... 50
tobramycin inj 1.2 gm/30ml ................ 3
tobramycin inj 1.2gm ......................... 3
tobramycin inj 10mg/ml ...................... 3
tobramycin inj 40mg/ml ...................... 3
tobramycin inj 80mg/2ml .................... 3
tobramycin-dexamethasone .............. 49
TOBREX .......................................... 50
tolterodine tartrate cap er ................. 42
tolterodine tartrate tabs .................... 42
topiramate ...................................... 22
topotecan hcl ................................... 14
TOPOTECAN HCL .............................. 14
torsemide tabs ................................. 19
TOUJEO SOLOSTAR .......................... 32
TOVIAZ ........................................... 42
TPN ELECTROLYTES .......................... 47
TRACLEER ....................................... 20
74
CY17_4T_STANDARD eff 01/01/2017
TRADJENTA ......................................33
tramadol hcl ...................................... 1
tramadol-acetaminophen .................... 1
trandolapril ......................................15
tranexamic acid ................................43
TRANSDERM-SCOP............................40
tranylcypromine sulfate .....................25
TRAVASOL .......................................47
TRAVATAN Z ....................................51
trazodone hcl ...................................25
TREANDA .........................................10
TRECATOR ........................................ 7
TRELSTAR DEP INJ 3.75MG ................12
TRELSTAR LA INJ 11.25MG ................12
TRESIBA FLEXTOUCH ........................32
tretinoin ..........................................53
TRETINOIN ......................................53
tretinoin (chemotherapy) ...................14
triamcinolone acetonide (mouth) ........56
triamcinolone acetonide (topical) ........55
triamterene & hydrochlorothiazide ......19
triamterene & hydrochlorothiazide cap
37.5-25 mg ......................................19
trifluoperazine hcl .............................28
trifluridine ........................................50
tri-linyah..........................................36
tri-lo marzia .....................................36
tri-lo-estarylla ..................................36
trimethoprim ..................................... 4
trimipramine maleate ........................25
TRINESSA ........................................36
TRINESSA LO TAB .............................36
TRINTELLIX ......................................25
TRISENOX........................................14
TRIUMEQ .......................................... 7
TROPHAMINE INJ 10% ......................47
trospium chloride ..............................42
TRULICITY .......................................32
TRUMENBA.......................................46
TRUVADA TAB 100-150 ...................... 7
TRUVADA TAB 133-200 ...................... 7
TRUVADA TAB 167-250 ...................... 7
TRUVADA TAB 200-300 ...................... 7
TWINRIX INJ ....................................46
TYBOST ............................................ 6
TYGACIL ........................................... 4
TYKERB........................................... 13
TYPHIM VI ....................................... 46
TYSABRI ......................................... 30
TYZEKA............................................. 8
U
ULORIC ............................................. 1
UNITHROID ..................................... 39
UPTRAVI ......................................... 20
ursodiol .......................................... 41
V
VAGIFEM ......................................... 37
valacyclovir hcl .................................. 8
VALCHLOR ...................................... 55
VALCYTE ........................................... 8
valganciclovir hcl ................................ 8
valproate sodium ............................. 22
valproic acid .................................... 22
valsartan ......................................... 16
valsartan & hctz tab 160-12.5mg ....... 16
valsartan & hctz tab 160-25mg .......... 16
valsartan & hctz tab 320-12.5mg ....... 16
valsartan & hctz tab 320-25mg .......... 16
valsartan & hctz tab 80-12.5mg ......... 16
vancomycin hcl .................................. 4
VANCOMYCIN IN NACL ........................ 4
VANDAZOLE .................................... 42
VAQTA ............................................ 46
VARIVAX ......................................... 46
VASCEPA......................................... 17
VELCADE......................................... 11
VENCLEXTA ..................................... 11
VENCLEXTA STARTING PACK ............. 12
venlafaxine hcl ................................. 25
VENTAVIS ....................................... 20
VENTOLIN HFA................................. 52
verapamil cap er .............................. 18
VERAPAMIL CAP ER .......................... 18
verapamil hcl ................................... 18
verapamil tab er .............................. 18
VERSACLOZ..................................... 28
VESICARE ....................................... 42
vestura ........................................... 36
VICTOZA ......................................... 32
VIDEX PEDIATRIC .............................. 6
VIGAMOX ........................................ 50
VIIBRYD STARTER PACK ................... 25
75
CY17_4T_STANDARD eff 01/01/2017
VIIBRYD TAB ....................................25
VIMPAT ...........................................23
vinblastine sulfate .............................11
vincristine sulfate ..............................11
vinorelbine tartrate ...........................11
viorele .............................................36
VIRACEPT ......................................... 6
VIREAD ............................................ 6
VITEKTA ........................................... 6
voriconazole ...................................... 5
VOTRIENT ........................................13
VRAYLAR .........................................28
VRAYLAR THERAPY PACK ...................28
W
warfarin sodium ................................43
WELCHOL ........................................17
X
XALKORI ..........................................13
XARELTO .........................................43
XARELTO STARTER PACK ...................43
XELJANZ ..........................................44
XELJANZ XR .....................................44
XGEVA.............................................38
XIFAXAN ..........................................41
XIGDUO XR TAB 10-1000MG ..............33
XIGDUO XR TAB 10-500MG ................33
XIGDUO XR TAB 5-1000MG ................33
XIGDUO XR TAB 5-500MG .................33
XOLAIR............................................52
XOPENEX HFA ..................................52
XTANDI ...........................................12
xulane .............................................36
XYREM.............................................31
Y
YERVOY ...........................................12
YF-VAX ............................................46
yuvafem vaginal tablet 10 mcg .......... 37
Z
zafirlukast ....................................... 52
zarah .............................................. 36
ZAVESCA ........................................ 36
ZAZOLE CREAM 0.8% ....................... 42
ZELBORAF ....................................... 13
ZEMAIRA ......................................... 52
zenatane ......................................... 53
zenchent ......................................... 36
ZENPEP ........................................... 41
ZEPATIER .......................................... 8
ZETIA TAB 10MG.............................. 17
ZIAGEN............................................. 6
zidovudine ......................................... 6
ziprasidone hcl ................................. 28
ZIRGAN .......................................... 50
zoledronic acid ................................. 34
zoledronic inj 4mg/5ml ..................... 34
ZOLINZA ......................................... 12
zolmitriptan ..................................... 30
zolmitriptan odt ............................... 30
zolpidem tartrate ............................. 29
zonisamide ...................................... 23
ZONTIVITY ...................................... 43
ZORTRESS TAB 0.25MG .................... 45
ZORTRESS TAB 0.5MG ...................... 45
ZORTRESS TAB 0.75MG .................... 45
ZOSTAVAX ...................................... 46
ZYDELIG ......................................... 13
ZYKADIA ......................................... 13
ZYLET ............................................. 49
ZYPREXA RELPREVV ......................... 28
ZYPREXA RELPREVV INJ 210MG ......... 28
ZYTIGA ........................................... 12
76
This formulary was updated on 8/23/2016.
For more recent information or other questions,
please contact Healthfirst Medicare Plan at 1-888-260-1010 or,
for TTY users, 711, 7 days a week, from 8am to 8pm.
Or visit www.healthfirst.org/medicare.
©2017 HF Management Services, LLC.