PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT
SOME OF THE DRUGS WE COVER IN THIS PLAN
2017 Abridged Formulary
(Partial List of Covered Drugs)
Value Plus (HMO)
January 1–December 31, 2017
H5591_2017_331 Accepted: 08/25/2016
Formulary ID 00017276, Version #6
EFFECTIVE 01/01/2017
This abridged formulary was updated on 08/05/2016. This is not a
complete list of drugs covered by our plan. For a complete listing
or other questions, please contact Martin’s Point Generations
Advantage Member Services at 1-866-544-7504 or, for TTY users, 711.
We are available 8 am–8 pm, seven days a week from October 1 to February 14; and Monday
through Friday the rest of the year. Or visit our website at www.MartinsPoint.org/Medicare.
Value Plus (HMO)
2017 Abridged Formulary
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 Martin’s Point Generations
Advantage. When it refers to “plan” or “our plan,” it means Generations Advantage Value Plus.
This document includes a partial list of the drugs (formulary) for our plan which is current as of
08/05/2016. For a complete, updated formulary, please contact us. Our contact information, along
with the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits,
formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2018,
and from time to time during the year.
Martin’s Point Generations Advantage is a health plan with a Medicare contract offering HMO,
HMO-POS, HMO SNP, and PPO products. Enrollment in a Martin’s Point Generations Advantage
plan depends on contract renewal.
This information may be available in other formats such as large print. For more information call
Member Services.
This information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments, and restrictions may apply.
The plan covers both brand name drugs and generic drugs. A generic drug is approved by the Food
and Drug Administration (FDA) as having the same active ingredient as the brand name drug.
Generally, generic drugs cost less than brand name drugs.
H5591_2017_331 Accepted: 08/25/2016
Formulary ID 00017276, Version #6
EFFECTIVE 01/01/2017
1
What is the Value Plus Abridged Formulary?
A formulary is a list of covered drugs selected by our plan in consultation with a team of health
care providers, which represents the prescription therapies believed to be a necessary part of a
quality treatment program. The plan will generally cover the drugs listed in our formulary as long
as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other
plan rules are followed. For more information on how to fill your prescriptions, please review
your Evidence of Coverage.
This document is a partial formulary and includes only some of the drugs covered by our plan.
For a complete listing of all prescription drugs covered by our plan, please visit our website or call
us. Our contact information, along with the date we last updated the formulary, appears on the
front and back cover pages.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the
year, we will not discontinue or reduce coverage of the drug during the 2017 coverage year except
when a new, less expensive generic drug becomes available or when new adverse information
about the safety or effectiveness of a drug is released. Other types of formulary changes, such as
removing a drug from our formulary, will not affect members who are currently taking the drug. It
will remain available at the same cost-sharing for those members taking it for the remainder of the
coverage year. We feel it is important that you have continued access for the remainder of the
coverage year to the formulary drugs that were available when you chose our plan, except for
cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step
therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected
members of the change at least 60 days before the change becomes effective, or at the time the
member requests a refill of the drug, at which time the member will receive a 60-day supply of the
drug. If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or
the drug’s manufacturer removes the drug from the market, we will immediately remove the drug
from our formulary and provide notice to members who take the drug. The enclosed formulary is
current as of 08/05/2016. To get updated information about the drugs covered by our plan, please
contact us. Our contact information appears on the front and back cover pages.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 8. 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”. If you know
what your drug is used for, look for the category name in the list that begins on page 8. Then
look under the category name for your drug.
2
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 53. The Index provides an alphabetical list of all of the drugs included in this
document. Both brand name drugs and generic drugs are listed in the Index. Look in the
Index and find your drug. Next to your drug, you will see the page number where you can find
coverage information. Turn to the page listed in the Index and find the name of your drug in
the first column of the list.
What are generic drugs?
Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA
as having the same active ingredient as the brand name drug. Generally, generic drugs cost less
than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements
and limits may include:

Prior Authorization: Our plan requires you or your physician to get prior authorization
for certain drugs. This means that you will need to get approval from us before you fill
your prescriptions. If you don’t get approval, we may not cover the drug.

Quantity Limits: For certain drugs, the plan limits the amount of the drug that we will
cover. For example, our plan provides 60 capsules per 30-day prescription for celecoxib
200mg. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your
medical condition before we will cover another drug for that condition. For example, if
Drug A and Drug B both treat your medical condition, we may not cover Drug B unless
you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the
formulary that begins on page 8. You can also get more information about the restrictions applied
to specific covered drugs by going to our website. We have posted on line documents that explain
our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our
contact information, along with the date we last updated the formulary, appears on the front and
back cover pages.
You can ask our plan to make an exception to these restrictions or limits or for a list of other,
similar drugs that may treat your health condition. See the section, “How do I request an exception
to the Generations Advantage Value Plus’s formulary?” on page 4 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. This document includes only a partial list of
covered drugs, so our plan may cover your drug. For more information, please contact us. Our
3
contact information, along with the date we last updated the formulary, appears on the front and
back cover pages.
If you learn that our 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 our 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 us.
You can ask our plan to make an exception and cover your drug. See below for information
about how to request an exception.
How do I request an exception to the Generations Advantage Value Plus’s
Formulary?
You can ask our plan to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.



You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will
be covered at a pre-determined cost-sharing level, and you would not be able to ask us to
provide the drug at a lower cost-sharing level.
You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on
the specialty tier. If approved this would lower the amount you must pay for your drug.
You can ask us to waive coverage restrictions or limits on your drug. For example, for
certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a
quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, our plan will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions
would not be as effective in treating your condition and/or would cause you to have adverse
medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, or utilization
restriction exception. When you request a formulary or utilization restriction exception you
should submit a statement from your prescriber or physician supporting your request.
Generally, we must make our decision within 72 hours of getting your prescriber’s supporting
statement. You can request an expedited (fast) exception if you or your doctor believe that your
health could be seriously harmed by waiting up to 72 hours for a decision. If your request to
expedite is granted, we must give you a decision no later than 24 hours after we get a supporting
statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary.
Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For
example, you may need a prior authorization from us before you can fill your prescription. You
should talk to your doctor to decide if you should switch to an appropriate drug that we cover or
request a formulary exception so that we will cover the drug you take. While you talk to your
doctor to determine the right course of action for you, we may cover your drug in certain cases
during the first 90 days you are a member of our plan.
4
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 98-day transition supply, consistent with dispensing increment,
(unless you have a prescription written for fewer days). We will cover more than one refill of
these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our
formulary or if your ability to get your drugs is limited, but you are past the first 90 days of
membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a
prescription for fewer days) while you pursue a formulary exception.
If you change your level of care, 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, but you are past
your first 90 days of membership in our plan, we will cover up to a temporary 30-day supply (or
31-days supply if you are a long term care resident) when you go to a network pharmacy. After
your first 30-day supply, you are required to use the plan’s exception process. Our transition
supply will not cover drugs that Medicare does not allow Part D plans to cover, such as drugs that
might be covered under Medicare Part B.
For more information
For more detailed information about your Generations Advantage Value Plus prescription drug
coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about our plan, please contact us. Our contact information, along with the
date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1877-486-2048. Or, visit www.medicare.gov.
Generations Advantage Value Plus’ Formulary
The abridged formulary that begins on page 8 provides coverage information about some of the
drugs covered by the plan. If you have trouble finding your drug in the list, turn to the index that
begins on page 53.
Remember: This is only a partial list of drugs covered by our plan. If your prescription is not in
this partial formulary, please contact us. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,
AVELOX) and generic drugs are listed in lower-case italics (e.g., azithromycin).
The information in the Requirements/Limits column tells you if our plan has any special
requirements for coverage of your drug.
5
6
Cost sharing
Tier 1
(Preferred
Generic)
Cost sharing
Tier 2
(Generic)
Cost sharing
Tier 3
(Preferred Brand)
Cost sharing
Tier 4
(Non-Preferred
Drug)
Cost sharing
Tier 5
(Specialty Tier)
$95
33% of the
cost
$100
33% of the
cost
$10
$18
$40
$0
$4
$47
Preferred
retail cost
sharing
(innetwork)
Standard
retail cost
sharing
(innetwork)
33% of
the cost
$100
$47
$18
$4
Mailorder
cost
sharing
33% of
the cost
$100
$47
$18
Longterm
care
(LTC)
cost
sharing
$4
33% of the cost, plus the
difference between the
Network and Non-Network
Pharmacy
$18 plus the cost difference
between the Network and
Non-Network Pharmacy
$47 plus the cost difference
between the Network and
Non-Network Pharmacy
$100 plus the cost difference
between the Network and
Non-Network Pharmacy
$4 plus the cost difference
between the Network and
Non-Network Pharmacy
Out-of-network
pharmacy retail
cost sharing
Your share of the cost when you get a 30-day supply (or less) of a covered
Part D prescription drug from:
2017 Generations Advantage Pharmacy Cost-Sharing Tiers for Initial Coverage Stage
33% of the
cost
$300
$141
$54
$12
Standard
retail cost
sharing
(innetwork)
33% of the
cost
$285
$120
$30
$0
Preferred
retail cost
sharing
(innetwork)
33% of
the cost
$250
$117.50
$45
$10
Mailorder
cost
sharing
Your share of the cost when you
get a 90-day supply of a covered
Part D prescription drug from:
Generations Advantage Value Plus’ Formulary
The abridged formulary that begins on page 8 provides coverage information about some of the
drugs covered by the plan. If you have trouble finding your drug in the list, turn to the index that
begins on page 53.
Remember: This is only a partial list of drugs covered by our plan. If your prescription is not in
this partial formulary, please contact us. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,
AVELOX) and generic drugs are listed in lower-case italics (e.g., azithromycin).
The information in the Requirements/Limits column tells you if our plan has any special
requirements for coverage of your drug.
Notes Key
B/D = Covered under Medicare B or D, PA
GEL = Gel
gm = gram
INJ = Injection
LA = Limited Access
lpop = lollipop
mL = milliliter
NM = Not available via mail
order
OINT = Ointment
PA = Prior Authorization
ptch = patch
QL = Quantity Limits
SOLN = Solution
ST = Step Therapy
supp = suppository
SUSP = Suspension
7
Drug Name
Drug Tier Requirements/Limits
ANALGESICS
GOUT
allopurinol tab
colchicine w/ probenecid
COLCRYS
probenecid
ULORIC
2
3
3
3
3
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
flurbiprofen TABS
ibuprofen SUSP
ibuprofen TABS 400mg, 600mg, 800mg
ketoprofen cap 50 mg
ketoprofen cap 75 mg
MELOXICAM SUSP
meloxicam TABS
nabumetone TABS
naproxen SUSP
naproxen TABS
naproxen TBEC
naproxen sodium TABS 275mg, 550mg
sulindac TABS
4
4
4
4
3
2
2
3
3
1
3
3
4
1
2
3
1
2
4
2
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)
2
2
2
3
QL
QL
QL
QL
(5000 mL
(400 tabs
(240 tabs
(240 tabs
DURAMORPH
endocet
fentanyl citrate LPOP
3
3
5
fentanyl patch 12 mcg/hr
4
B/D
QL (360 tabs / 30 days)
QL (120 lozenges / 30
days), PA
QL (10 patches / 30
days)
OPIOID ANALGESICS
acetaminophen w/ codeine SOLN
acetaminophen w/ codeine TABS
tramadol hcl TABS
tramadol-acetaminophen
/
/
/
/
30
30
30
30
days)
days)
days)
days)
OPIOID ANALGESICS, CII
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
8
Drug Name
fentanyl patch 25 mcg/hr
Drug Tier Requirements/Limits
4
QL (10 patches / 30
days)
4
QL (10 patches / 30
days), PA
4
QL (10 patches / 30
days), PA
4
QL (10 patches / 30
days), PA
5
QL (120 tabs / 30 days),
PA
2
QL (360 tabs / 30 days)
2
QL (360 tabs / 30 days)
2
QL (360 tabs / 30 days)
4
QL (5400 mL / 30 days)
fentanyl patch 50 mcg/hr
fentanyl patch 75 mcg/hr
fentanyl patch 100 mcg/hr
FENTORA
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
3
hydromorphone hcl LIQD
3
hydromorphone hcl TABS
3
lorcet plus tab 7.5-325
2
lorcet tab 5-325mg
2
lortab tab 5-325mg
2
lortab tab 7.5-325
2
lortab tab 10-325mg
2
methadone hcl SOLN 5mg/5ml, 10mg/5ml 3
methadone hcl 5mg
3
methadone hcl 10mg
3
morphine ext-rel tab 15mg, 30mg, 60mg, 3
100mg
morphine ext-rel tab 200mg
3
MORPHINE SUL INJ 4MG/ML
3
MORPHINE SUL INJ 10MG/ML
3
MORPHINE SULFATE SOLN 2mg/ml,
3
8mg/ml
MORPHINE SULFATE TABS
3
MORPHINE SULFATE ORAL SOL
3
oxycodone hcl CAPS
4
oxycodone hcl CONC
4
OXYCODONE HCL SOLN
4
oxycodone hcl TABS
3
oxycodone w/ acetaminophen 2.5-325mg 3
oxycodone w/ acetaminophen 5-325mg
3
oxycodone w/ acetaminophen 7.5-325mg 3
oxycodone w/ acetaminophen 10-325mg 3
QL (150 tabs / 30 days)
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)
(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
QL (180 tabs / 30 days)
QL (180 caps / 30 days)
QL
QL
QL
QL
QL
(180
(360
(360
(360
(360
tabs
tabs
tabs
tabs
tabs
/
/
/
/
/
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
9
30
30
30
30
30
days)
days)
days)
days)
days)
Drug Name
oxycodone w/ acetaminophen soln
Drug Tier Requirements/Limits
3
QL (1800 mL / 30 days)
ANESTHETICS
LOCAL ANESTHETICS
lidocaine inj 0.5%
lidocaine inj 2%
2
2
B/D
B/D
3
3
5
3
3
NM, PA
ANTI-INFECTIVES
ANTI-BACTERIALS - MISCELLANEOUS
amikacin sulfate SOLN
neomycin sulfate TABS
tobramycin NEBU
tobramycin inj 10mg/ml
tobramycin inj 80mg/2ml
ANTI-INFECTIVES - MISCELLANEOUS
aztreonam
BILTRICIDE
CAYSTON
clindamycin cap 75mg
clindamycin cap 300 mg
clindamycin hcl cap 150 mg
clindamycin phosphate in d5w
clindamycin phosphate inj
dapsone TABS
ivermectin TABS
LINEZOLID
methenamine hippurate
metronidazole TABS
metronidazole in nacl
nitrofurantoin macrocrystal 50mg, 100mg
3
3
5
1
1
1
3
2
3
3
5
4
2
2
4
nitrofurantoin monohyd macro
4
SIVEXTRO
sulfamethoxazole-trimethop ds
sulfamethoxazole-trimethoprim SUSP
sulfamethoxazole-trimethoprim TABS
sulfamethoxazole-trimethoprim inj
trimethoprim TABS
5
1
4
1
4
2
NM, LA, PA
PA; PA applies if 65
years and older after a
90 day supply in a
calendar year
PA; PA applies if 65
years and older after a
90 day supply in a
calendar year
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
10
.
Drug Name
vancomycin hcl CAPS
vancomycin hcl SOLR
Drug Tier Requirements/Limits
5
3
ANTIFUNGALS
fluconazole SUSR
fluconazole TABS
fluconazole inj nacl 200
fluconazole inj nacl 400
griseofulvin microsize SUSP
griseofulvin microsize TABS
griseofulvin ultramicrosize
itraconazole CAPS
ketoconazole TABS
nystatin TABS
terbinafine hcl TABS
3
2
3
3
3
4
4
4
4
3
2
PA
PA
QL (90 tabs / 365 days)
ANTIMALARIALS
atovaquone-proguanil hcl
chloroquine phosphate TABS
mefloquine hcl
PRIMAQUINE PHOSPHATE
quinine sulfate CAPS
4
3
3
3
4
PA
ANTIRETROVIRAL AGENTS
abacavir sulfate
EMTRIVA
ISENTRESS CHEW 25mg
ISENTRESS CHEW 100mg
ISENTRESS PACK
ISENTRESS TABS
lamivudine
NEVIRAPINE SUSP
nevirapine TB24
nevirapine tab 200mg
NORVIR
PREZISTA SUSP
PREZISTA TABS 75mg, 150mg
PREZISTA TABS 600mg, 800mg
REYATAZ
SUSTIVA CAPS 50mg
SUSTIVA CAPS 200mg
SUSTIVA TABS
TIVICAY 10mg
3
3
3
5
5
5
3
4
4
3
3
5
3
5
5
3
5
5
3
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
11
Drug Name
TIVICAY 25mg, 50mg
TYBOST
VIREAD
ZIAGEN SOLN
zidovudine cap 100mg
zidovudine syp 50mg/5ml
Drug Tier Requirements/Limits
5
3
5
3
4
4
ANTIRETROVIRAL COMBINATION AGENTS
ATRIPLA
EPZICOM
KALETRA SOL
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
lamivudine-zidovudine
TRUVADA TAB 100-150
TRUVADA TAB 133-200
TRUVADA TAB 167-250
TRUVADA TAB 200-300
5
5
5
3
5
4
5
5
5
5
QL
QL
QL
QL
1
3
4
3
3
5
LA, PA
(60
(30
(30
(30
tabs
tabs
tabs
tabs
/
/
/
/
30
30
30
30
ANTITUBERCULAR AGENTS
isoniazid TABS
isoniazid inj 100 mg/ml
isoniazid syp 50mg/5ml
paser d/r
rifampin CAPS
SIRTURO
ANTIVIRALS
acyclovir CAPS
acyclovir SUSP
acyclovir TABS
adefovir dipivoxil
DAKLINZA
entecavir
famciclovir TABS
ganciclovir inj 500mg
lamivudine (hbv)
moderiba tab 200mg
PEGASYS
PEGASYS PROCLICK
REBETOL SOLN
RELENZA DISKHALER
ribasphere CAPS
2
4
2
5
5
5
3
3
4
4
5
5
5
3
3
NM, PA
B/D
NM
NM, PA
NM, PA
NM
NM
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
12
days)
days)
days)
days)
Drug Name
ribasphere TABS 200mg
ribasphere TABS 400mg, 600mg
ribavirin cap 200mg
ribavirin tab 200mg
SOVALDI
TAMIFLU
valacyclovir hcl TABS
Drug Tier Requirements/Limits
4
NM
5
NM
3
NM
4
NM
5
NM, PA
3
3
CEPHALOSPORINS
cefaclor CAPS
cefaclor SUSR
cefaclor er tab 500mg
cefadroxil CAPS
cefadroxil SUSR
cefadroxil TABS
cefazolin inj
cefdinir CAPS
cefdinir SUSR
cefixime
cefprozil SUSR
cefprozil TABS
ceftriaxone sodium SOLR 1gm, 2gm,
10gm, 250mg, 500mg
cefuroxime axetil
cefuroxime sodium 1.5gm, 7.5gm, 750mg
cephalexin CAPS 250mg, 500mg
cephalexin SUSR
SUPRAX CAPS
suprax CHEW
SUPRAX SUSR 500mg/5ml
3
4
4
2
3
4
3
3
4
4
4
3
3
3
3
1
3
3
4
3
ERYTHROMYCINS/MACROLIDES
AZITHROMYCIN PACK
azithromycin SOLR; SUSR
azithromycin TABS
clarithromycin TABS
clarithromycin er
DIFICID
ery-tab
erythromycin base
3
3
1
3
4
5
4
4
FLUOROQUINOLONES
ciprofloxacin SUSR
ciprofloxacin er
4
4
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
13
Drug Name
ciprofloxacin hcl tab
ciprofloxacn inj 400mg/40ml
levofloxacin TABS
levofloxacin in d5w
levofloxacin inj 25mg/ml
levofloxacin oral soln 25 mg/ml
Drug Tier Requirements/Limits
1
4
1
3
4
4
PENICILLINS
amoxicillin CAPS; SUSR; TABS
1
amoxicillin CHEW
2
amoxicillin & pot clavulanate CHEW; SUSR 3
amoxicillin & pot clavulanate TABS
2
amoxicillin & pot clavulanate TB12
4
ampicillin cap
1
ampicillin sus
3
penicillin g procaine
4
penicillin v potassium
1
TETRACYCLINES
doxycycline (monohydrate) CAPS 50mg,
100mg
doxycycline (monohydrate) TABS
doxycycline hyclate CAPS
doxycycline hyclate 20 mg
doxycycline hyclate 100 mg
minocycline hcl CAPS
2
3
3
4
4
2
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
CYCLOPHOSPHAMIDE CAPS
dacarbazine
LEUKERAN
4
3
4
B/D
B/D
3
5
3
B/D
B/D
B/D
3
5
B/D
B/D
3
3
3
B/D
B/D
B/D
ANTHRACYCLINES
daunorubicin hcl
doxorubicin hcl liposomal inj 2mg/ml
doxorubicin inj 50mg
ANTIBIOTICS
bleomycin sulfate
mitomycin SOLR
ANTIMETABOLITES
adrucil
cytarabine 20mg/ml
fluorouracil SOLN
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
14
Drug Name
mercaptopurine TABS
methotrexate sodium inj
Drug Tier Requirements/Limits
4
2
B/D
ANTIMITOTIC, TAXOIDS
ABRAXANE
DOCETAXEL 80mg/4ml
DOCETAXEL SOLN 80MG/8ML
paclitaxel
5
5
5
4
B/D
B/D
B/D
B/D
3
2
2
3
B/D
B/D
B/D
B/D
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
4
5
5
5
5
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
NM, LA, PA
NM, PA
NM, PA
ANTIMITOTIC, VINCA ALKALOIDS
vinblastine sulfate
vincasar
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
VENCLEXTA STARTING PACK
YERVOY
ZOLINZA
HORMONAL ANTINEOPLASTIC AGENTS
anastrozole TABS
bicalutamide
exemestane
letrozole TABS
leuprolide inj 1mg/0.2
LUPRON DEPOT 3.75mg
2
3
4
3
3
5
NM, PA
NM, PA
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
15
Drug Name
LUPRON DEPOT INJ 11.25MG (3-MONTH)
LYSODREN
megestrol ac sus 40mg/ml
megestrol ac tab 20mg
megestrol ac tab 40mg
MEGESTROL SUS 625MG/5ML
tamoxifen citrate TABS
TRELSTAR DEP INJ 3.75MG
TRELSTAR LA INJ 11.25MG
XTANDI
ZYTIGA
Drug Tier Requirements/Limits
5
NM, PA
3
4
PA; PA if 65 years and
older
4
PA; PA if 65 years and
older
4
PA; PA if 65 years and
older
4
PA
1
5
NM, PA
5
NM, PA
5
NM, LA, PA
5
NM, LA, PA
KINASE INHIBITORS
AFINITOR
AFINITOR DISPERZ
ALECENSA
BOSULIF
CABOMETYX
CAPRELSA
COMETRIQ
COTELLIC
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
GLEEVEC 100mg
5
5
5
5
5
5
5
5
5
5
5
5
GLEEVEC 400mg
5
ICLUSIG
imatinib mesylate 100mg
5
5
imatinib mesylate 400mg
5
IMBRUVICA CAP 140MG
INLYTA
IRESSA
JAKAFI
LENVIMA 8 MG DAILY DOSE
LENVIMA 10 MG DAILY DOSE
LENVIMA 14 MG DAILY DOSE
5
5
5
5
5
5
5
NM, PA
NM, PA
NM, LA, PA
NM, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
QL (90 tabs
NM, PA
QL (60 tabs
NM, PA
NM, LA, PA
QL (90 tabs
NM, PA
QL (60 tabs
NM, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
/ 30 days),
/ 30 days),
/ 30 days),
/ 30 days),
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
16
Drug Name
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
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, PA
5
NM, LA, PA
5
NM, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
MISCELLANEOUS
bexarotene
DROXIA
hydroxyurea CAPS
LONSURF
mitoxantrone hcl
ODOMZO
SYLATRON KIT 200MCG
SYLATRON KIT 300MCG
SYLATRON KIT 600MCG
SYNRIBO
5
3
3
5
3
5
5
5
5
5
NM, PA
4
3
B/D
B/D
4
3
4
B/D
3
4
3
B/D
B/D
B/D
NM, PA
B/D, NM
NM, LA, PA
NM, PA
NM, PA
NM, PA
NM, PA
PLATINUM-BASED AGENTS
carboplatin
cisplatin
PROTECTIVE AGENTS
leucovorin calcium SOLR
leucovorin calcium TABS
mesna
B/D
TOPOISOMERASE INHIBITORS
etoposide SOLN
irinotecan inj 100/5ml
toposar
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
17
Drug Name
topotecan hcl
Drug Tier Requirements/Limits
5
B/D
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine besylate-benazepril hcl cap 2.5- 1
10 mg
amlodipine besylate-benazepril hcl cap 5- 1
10 mg
amlodipine besylate-benazepril hcl cap 5- 1
20 mg
amlodipine besylate-benazepril hcl cap 5- 1
40 mg
amlodipine besylate-benazepril hcl cap 10- 1
20 mg
amlodipine besylate-benazepril hcl cap 10- 1
40 mg
benazepril & hydrochlorothiazide
1
captopril & hydrochlorothiazide
1
enalapril maleate & hydrochlorothiazide
1
fosinopril sodium & hydrochlorothiazide
1
lisinopril & hydrochlorothiazide
1
moexipril-hydrochlorothiazide
1
quinapril-hydrochlorothiazide
1
ACE INHIBITORS
benazepril hcl TABS
captopril TABS
enalapril maleate TABS
fosinopril sodium
lisinopril TABS
moexipril hcl
perindopril erbumine
quinapril hcl
ramipril
trandolapril
1
1
1
1
1
1
1
1
1
1
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone
spironolactone TABS
4
1
ALPHA BLOCKERS
doxazosin mesylate 1mg, 2mg, 4mg
doxazosin mesylate 8mg
prazosin hcl
terazosin hcl
3
3
3
1
QL (30 tabs / 30 days)
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
18
Drug Name
amlodipine besylate-valsartan tab
amlodipine-valsartan-hydrochlorothiazide
tab
AZOR
BENICAR HCT
ENTRESTO
irbesartan-hydrochlorothiazide
losartan-hydrochlorothiazide
valsartan & hctz tab
Drug Tier Requirements/Limits
1
1
4
4
4
1
1
1
PA
ANGIOTENSIN II RECEPTOR ANTAGONISTS
BENICAR
irbesartan
losartan potassium
valsartan
4
1
1
1
ANTIARRHYTHMICS
amiodarone hcl TABS 200mg
amiodarone hcl TABS 400mg
disopyramide phosphate
1
4
4
DOFETILIDE
flecainide acetate
MULTAQ
NORPACE CR
4
3
4
4
pacerone 100mg, 400mg
pacerone 200mg
propafenone hcl
propafenone hcl 12hr
quinidine sulfate TABS
sorine
sotalol hcl
sotalol hcl (afib/afl)
4
1
3
4
2
2
2
3
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
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
19
Drug Name
choline fenofibrate
fenofibrate TABS 48mg, 54mg, 145mg,
160mg
fenofibrate micronized 67mg, 134mg,
200mg
gemfibrozil TABS
JUXTAPID
KYNAMRO
niacin er (antihyperlipidemic) 500mg
niacin er (antihyperlipidemic) 750mg,
1000mg
niacor
omega-3-acid ethyl esters
PRALUENT
VASCEPA
VYTORIN
WELCHOL
ZETIA TAB 10MG
Drug Tier Requirements/Limits
4
4
3
2
5
5
4
4
3
4
5
4
4
3
3
NM, LA, PA
NM, PA
QL (90 tabs / 30 days)
NM, PA
QL (30 tabs / 30 days)
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol & chlorthalidone
bisoprolol & hydrochlorothiazide
metoprolol & hydrochlorothiazide
propranolol & hydrochlorothiazide
3
1
3
3
BETA-BLOCKERS
acebutolol hcl CAPS
atenolol TABS
BYSTOLIC
carvedilol
labetalol hcl TABS
metoprolol succinate
metoprolol tartrate SOLN
metoprolol tartrate TABS 25mg, 50mg,
100mg
propranolol cap er
propranolol hcl SOLN; TABS
propranolol oral sol
timolol maleate TABS
2
1
4
1
3
3
3
1
4
3
3
4
CALCIUM CHANNEL BLOCKERS
afeditab cr
amlodipine besylate TABS
cartia xt
dilt-xr cap
3
1
3
3
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
20
Drug Name
Drug Tier Requirements/Limits
diltiazem cap
3
diltiazem cap er/12hr
4
diltiazem hcl SOLN; TABS
2
diltiazem hcl coated beads CP24
3
felodipine
3
nifedical
3
nifedipine er
3
taztia xt
3
verapamil cap er 100mg, 120mg, 180mg, 4
200mg, 240mg, 300mg
VERAPAMIL CAP ER 360mg
4
verapamil hcl SOLN
4
verapamil hcl TABS
1
verapamil hcl TBCR
2
verapamil tab er
2
DIGITALIS GLYCOSIDES
digitek .25mg
3
digitek .125mg
digoxin TABS 125mcg
digoxin TABS 250mcg
3
3
3
digoxin inj
DIGOXIN SOL 50MCG/ML
3
3
PA; PA
older
QL (30
QL (30
PA; PA
older
if 65 years and
tabs / 30 days)
tabs / 30 days)
if 65 years and
PA; PA if 65 years and
older
DIURETICS
acetazolamide CP12
acetazolamide TABS
amiloride & hydrochlorothiazide
amiloride hcl TABS
bumetanide inj 0.25/ml
bumetanide tab
chlorothiazide tabs
chlorthalidone 25mg, 50mg
furosemide SOLN
furosemide TABS
furosemide inj 10mg/ml
FUROSEMIDE INJ 10mg/ml
hydrochlorothiazide CAPS; TABS
indapamide
methyclothiazide
metolazone
4
3
2
3
3
3
3
3
2
1
2
2
1
2
3
3
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
21
Drug Name
spironolactone & hydrochlorothiazide
torsemide tabs
triamterene & hydrochlorothiazide TABS
triamterene & hydrochlorothiazide cap
37.5-25 mg
Drug Tier Requirements/Limits
3
2
1
1
MISCELLANEOUS
clonidine hcl PTWK
clonidine hcl TABS
hydralazine hcl SOLN
hydralazine hcl TABS
NORTHERA
RANEXA
4
1
3
2
5
3
NM, LA, PA
NITRATES
isosorb mononitrate tab
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate er
minitran
nitro-bid
nitroglycerin td patch
NITROSTAT
2
3
4
2
3
3
3
3
PULMONARY ARTERIAL HYPERTENSION
ADCIRCA
ADEMPAS
5
5
LETAIRIS
5
OPSUMIT
REMODULIN
REVATIO SUSR
5
5
5
sildenafil citrate (pulmonary hypertension) 3
TABS
TRACLEER
5
UPTRAVI TABS 200mcg
5
UPTRAVI TABS 400mcg
5
UPTRAVI TABS 600mcg
5
UPTRAVI TABS 800mcg
5
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
QL (90 tabs / 30 days),
NM, PA
NM, LA, PA
QL (480 tabs / 30 days),
NM, LA, PA
QL (240 tabs / 30 days),
NM, LA, PA
QL (150 tabs / 30 days),
NM, LA, PA
QL (120 tabs / 30 days),
NM, LA, PA
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
22
Drug Name
UPTRAVI TABS 1000mcg
UPTRAVI TABS 1200mcg, 1400mcg,
1600mcg
UPTRAVI TBPK
VENTAVIS
Drug Tier Requirements/Limits
5
QL (90 tabs / 30 days),
NM, LA, PA
5
QL (60 tabs / 30 days),
NM, LA, PA
5
NM, LA, PA
5
NM, PA
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
alprazolam tab 0.5mg
alprazolam tab 0.25mg
alprazolam tab 1mg
alprazolam tab 2 mg
buspirone hcl TABS
fluvoxamine maleate TABS 25mg, 50mg
fluvoxamine maleate TABS 100mg
lorazepam CONC
lorazepam TABS
1
1
1
1
2
3
3
3
1
QL
QL
QL
QL
(240
(480
(120
(150
tabs
tabs
tabs
tabs
/
/
/
/
30
30
30
30
days)
days)
days)
days)
4
5
5
5
5
5
5
5
4
5
3
4
1
1
1
3
3
3
3
3
3
QL
QL
QL
QL
PA
PA
PA
PA
PA
PA
(180 tabs / 30 days)
(90 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
PA
(120
(300
(240
(120
(300
(240
(480
(960
(120
QL (45 tabs / 30 days)
QL (150 mL / 30 days)
QL (150 tabs / 30 days)
ANTICONVULSANTS
APTIOM 200mg
APTIOM 400mg
APTIOM 600mg
APTIOM 800mg
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
BRIVIACT SOLN 10mg/ml
BRIVIACT SOLN 50mg/5ml
BRIVIACT TABS
carbamazepine CHEW
carbamazepine CP12; SUSP; TABS; TB12
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
tabs
tabs
tabs
tabs
tabs
tabs
tabs
tabs
tabs
/
/
/
/
/
/
/
/
/
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
23
30
30
30
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
days)
days)
days),
Drug Name
clorazepate dipotassium 15mg
Drug Tier Requirements/Limits
3
QL (180 tabs / 30 days),
PA
3
QL (240 mL / 30 days),
PA
3
QL (1200 mL / 30 days),
PA
1
QL (120 tabs / 30 days),
PA
3
3
4
2
4
4
QL (720 mL / 30 days),
PA
4
QL (180 tabs / 30 days),
PA
4
QL (90 tabs / 30 days),
PA
4
QL (60 tabs / 30 days),
PA
4
QL (30 tabs / 30 days),
PA
2
QL (1080 caps / 30
days)
2
QL (360 caps / 30 days)
2
QL (270 caps / 30 days)
4
QL (2160 mL / 30 days)
3
QL (180 tabs / 30 days)
3
QL (120 tabs / 30 days)
3
2
4
3
3
3
QL (120 caps / 30 days)
diazepam CONC
diazepam SOLN
diazepam TABS
dilantin
DILANTIN-125 SUS 125/5ML
divalproex sodium CSDR; TB24
divalproex sodium TBEC
epitol
FYCOMPA SUSP
FYCOMPA TABS 2mg
FYCOMPA TABS 4mg
FYCOMPA TABS 6mg
FYCOMPA TABS 8mg, 10mg, 12mg
gabapentin CAPS 100mg
gabapentin CAPS 300mg
gabapentin CAPS 400mg
gabapentin SOLN
gabapentin TABS 600mg
gabapentin TABS 800mg
lamotrigine CHEW
lamotrigine TABS
lamotrigine TB24
levetiracetam TABS; TB24
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 SUSP
3
3
3
5
4
5
4
QL (90 caps / 30 days)
QL (60 caps / 30 days)
QL (946 mL / 30 days)
PA
PA
PA
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
24
Drug Name
oxcarbazepine TABS
phenobarbital ELIX; TABS
phenytek
phenytoin CHEW; SUSP
phenytoin sodium SOLN
phenytoin sodium extended
POTIGA 50mg
POTIGA 200mg
POTIGA 300mg, 400mg
primidone TABS
roweepra
SABRIL PACK
SABRIL TABS
topiramate CPSP
topiramate TABS
valproate sodium SYRP
valproic acid
VIMPAT SOLN 10mg/ml
VIMPAT SOLN 200mg/20ml
VIMPAT TABS 50mg
VIMPAT TABS 100mg, 150mg, 200mg
zonisamide CAPS
Drug Tier Requirements/Limits
3
4
PA; PA if 65 years and
older
3
3
3
3
4
5
QL (180 tabs / 30 days)
5
QL (90 tabs / 30 days)
2
3
5
QL (180 packets / 30
days), NM, LA, PA
5
QL (180 tabs / 30 days),
NM, LA, PA
4
2
2
3
4
QL (1200 mL / 30 days)
4
4
QL (180 tabs / 30 days)
4
QL (60 tabs / 30 days)
3
ANTIDEMENTIA
donepezil hydrochloride TABS 5mg
donepezil hydrochloride TABS 10mg
donepezil hydrochloride TABS 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
MEMANTINE TITRATION PAK
2
2
4
3
3
4
4
4
4
4
4
3
4
4
4
QL (60 tabs / 30 days)
QL (60 tabs / 30 days)
QL (180 tabs / 30 days)
QL (90 tabs / 30 days)
QL (30 caps / 30 days)
PA;
PA;
PA;
PA;
PA
PA
PA
PA
if
if
if
if
<
<
<
<
30
30
30
30
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
25
yrs
yrs
yrs
yrs
Drug Name
NAMENDA
NAMENDA TITRATION PAK
NAMENDA XR
NAMENDA XR TITRATION PACK
NAMZARIC
rivastigmine tartrate
rivastigmine td patch 24hr 4.6 mg/24hr
rivastigmine td patch 24hr 9.5 mg/24hr
rivastigmine td patch 24hr 13.3 mg/24hr
Drug Tier Requirements/Limits
4
PA; PA if < 30 yrs
4
PA; PA if < 30 yrs
4
PA; PA if < 30 yrs
4
PA; PA if < 30 yrs
4
4
4
QL (30 patches / 30
days)
4
QL (30 patches / 30
days)
4
QL (30 patches / 30
days)
ANTIDEPRESSANTS
amitriptyline hcl TABS
4
amoxapine
bupropion hcl TABS
bupropion hcl TB12
bupropion hcl TB24 150mg
bupropion hcl TB24 300mg
citalopram hydrobromide SOLN
citalopram hydrobromide TABS 10mg,
20mg
citalopram hydrobromide TABS 40mg
clomipramine hcl CAPS
3
3
2
3
3
4
1
doxepin hcl CAPS; CONC
4
duloxetine hcl CPEP 20mg
duloxetine hcl CPEP 30mg
duloxetine hcl CPEP 60mg
EMSAM
4
4
4
5
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
4
2
2
4
4
4
4
1
1
1
1
4
PA; PA if 65 years and
older
QL (90 tabs / 30 days)
QL (30 tabs / 30 days)
QL (45 tabs / 30 days)
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)
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
26
Drug Name
fluoxetine hcl SOLN
fluoxetine hcl TABS 10mg
fluoxetine hcl TABS 20mg
imipramine hcl TABS
Drug Tier Requirements/Limits
3
4
QL (45 tabs / 30 days)
4
4
PA; PA if 65 years and
older
MARPLAN TAB 10MG
4
QL (180 tabs / 30 days)
mirtazapine TABS 7.5mg, 15mg
2
QL (45 tabs / 30 days)
mirtazapine TABS 30mg, 45mg
2
mirtazapine TBDP 15mg
3
QL (30 tabs / 30 days)
mirtazapine TBDP 30mg, 45mg
3
nortriptyline hcl CAPS
1
paroxetine hcl tabs 10mg, 20mg, 40mg
1
QL (45 tabs / 30 days)
paroxetine hcl tabs 30mg
1
QL (60 tabs / 30 days)
PAXIL SUSP
4
QL (900 mL / 30 days)
phenelzine sulfate TABS
3
PRISTIQ
3
QL (30 tabs / 30 days)
sertraline hcl CONC
4
sertraline hcl TABS 25mg, 50mg
1
QL (45 tabs / 30 days)
sertraline hcl TABS 100mg
1
trazodone hcl TABS 50mg, 100mg, 150mg 1
trimipramine maleate CAPS 25mg
4
QL (240 caps / 30
days), PA; PA if 65 years
and older
trimipramine maleate CAPS 50mg
4
QL (120 caps / 30
days), PA; PA if 65 years
and older
trimipramine maleate CAPS 100mg
4
QL (60 caps / 30 days),
PA; PA if 65 years and
older
TRINTELLIX 5mg
4
QL (120 tabs / 30 days)
TRINTELLIX 10mg
4
QL (60 tabs / 30 days)
TRINTELLIX 20mg
4
QL (30 tabs / 30 days)
venlafaxine hcl CP24 37.5mg, 75mg
2
QL (30 caps / 30 days)
venlafaxine hcl CP24 150mg
2
QL (60 caps / 30 days)
venlafaxine hcl TABS
3
VIIBRYD STARTER PACK
4
VIIBRYD TAB
4
QL (30 tabs / 30 days)
ANTIPARKINSONIAN AGENTS
amantadine hcl CAPS
amantadine hcl SYRP
APOKYN
AZILECT
4
2
5
3
QL (120 caps / 30 days)
NM, LA, PA
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
27
Drug Name
BENZTROPINE MESYLATE SOLN
benztropine mesylate TABS
Drug Tier Requirements/Limits
3
4
PA; PA if 65 years and
older
2
3
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
carbidopa-levodopa TABS
carbidopa-levodopa TBCR
carbidopa-levodopa TBDP
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
ropinirole tab 2mg
ropinirole tab 3mg
ropinirole tab 4mg
ropinirole tab 5mg
ANTIPSYCHOTICS
ABILIFY MAINTENA 300mg
ABILIFY MAINTENA 300mg, 400mg
aripiprazole
aripiprazole tab 2mg, 5mg, 10mg, 15mg
aripiprazole tab 20mg, 30mg
CLOZAPINE ODT 12.5mg, 25mg
CLOZAPINE ODT 100mg
5
5
5
4
5
4
4
CLOZAPINE ODT 150mg
4
CLOZAPINE ODT 200mg
5
clozapine tab 25mg
clozapine tab 50mg
clozapine tab 100mg
clozapine tab 200mg
FANAPT 1mg, 2mg, 4mg
FANAPT 6mg, 8mg, 10mg, 12mg
FANAPT TITRATION PACK
FAZACLO 12.5mg, 25mg
3
3
4
4
4
5
4
4
QL
QL
QL
QL
QL
PA
QL
PA
QL
PA
QL
PA
(1 vial / 28 days)
(1 syringe / 28 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
QL
QL
QL
QL
(270 tabs / 30 days)
(135 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(270 tabs / 30 days),
(180 tabs / 30 days),
(135 tabs / 30 days),
PA
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
28
Drug Name
FAZACLO 100mg
FAZACLO 150mg
FAZACLO 200mg
fluphenazine decanoate SOLN
GEODON SOLR
haloperidol TABS
haloperidol con lactate
haloperidol decanoate SOLN
haloperidol lactate inj 5 mg/ml
INVEGA 1.5mg, 3mg, 9mg
INVEGA 6mg
INVEGA SUST INJ 39 MG/0.25 ML
INVEGA SUST INJ 78 MG/0.5 ML
INVEGA SUST INJ 117 MG/0.75 ML
INVEGA SUST INJ 156MG/ML
INVEGA SUST INJ 234 MG/1.5 ML
INVEGA TRINZA
LATUDA 20mg
LATUDA 40mg, 120mg
LATUDA 60mg, 80mg
loxapine succinate
NUPLAZID
olanzapine SOLR
olanzapine TABS 2.5mg
olanzapine TABS 5mg
olanzapine TABS 7.5mg
olanzapine TABS 10mg, 15mg, 20mg
olanzapine TBDP 5mg
olanzapine TBDP 10mg, 15mg, 20mg
paliperidone 1.5mg, 3mg, 9mg
paliperidone 6mg
quetiapine fumarate
REXULTI 1mg
REXULTI 2mg
Drug Tier Requirements/Limits
5
QL (270 ea / 30 days),
PA
5
QL (180 ea / 30 days),
PA
5
QL (135 ea / 30 days),
PA
4
4
QL (6 mL / 3 days)
3
3
3
3
5
QL (30 ea / 30 days)
5
QL (60 ea / 30 days)
4
QL (1 injection / 28
days)
5
QL (1 injection / 28
days)
5
QL (1 injection / 28
days)
5
QL (1 injection / 28
days)
5
QL (1 injection / 28
days)
5
QL (1 syringe / 90 days)
4
QL (240 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (60 tabs / 30 days)
3
5
QL (60 tabs / 30 days),
NM, LA, PA
4
QL (3 vials / 1 day)
3
QL (240 tabs / 30 days)
3
QL (120 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (60 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (60 tabs / 30 days)
5
QL (30 tabs / 30 days)
5
QL (60 tabs / 30 days)
3
QL (90 tabs / 30 days)
5
QL (90 tabs / 30 days)
5
QL (60 tabs / 30 days)
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
29
Drug Name
REXULTI 3mg, 4mg
REXULTI .5mg
REXULTI .25mg
RISPERDAL INJ 12.5MG
Drug Tier Requirements/Limits
5
QL (30 tabs / 30 days)
5
QL (180 tabs / 30 days)
5
QL (360 tabs / 30 days)
4
QL (2 injections / 28
days)
4
QL (2 injections / 28
days)
5
QL (2 injections / 28
days)
5
QL (2 injections / 28
days)
4
QL (240 mL / 30 days)
2
QL (60 tabs / 30 days)
2
QL (120 tabs / 30 days)
2
QL (90 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
QL (120 tabs / 30 days)
4
QL (90 tabs / 30 days)
4
QL (240 tabs / 30 days)
4
QL (120 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
QL (120 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
PA; PA if 65 years and
older
5
QL (600 mL / 30 days),
PA
5
QL (120 caps / 30 days)
5
QL (60 caps / 30 days)
5
QL (30 caps / 30 days)
4
4
QL (60 caps / 30 days)
4
QL (90 caps / 30 days)
4
QL (2 vials / 28 days),
PA
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
risperidone SOLN
risperidone TABS 1mg, 2mg, 3mg
risperidone TABS 4mg
risperidone TABS .25mg, .5mg
risperidone TBDP 1mg, 2mg, 3mg
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
VERSACLOZ
VRAYLAR 1.5mg
VRAYLAR 3mg
VRAYLAR 4.5mg, 6mg
VRAYLAR THERAPY PACK
ziprasidone hcl 20mg, 40mg
ziprasidone hcl 60mg, 80mg
ZYPREXA RELPREVV INJ 210MG
ATTENTION DEFICIT HYPERACTIVITY DISORDER
amphetamine-dextroamphetamine cap sr
24hr 5 mg
amphetamine-dextroamphetamine cap sr
24hr 10 mg
amphetamine-dextroamphetamine cap sr
24hr 15 mg
4
QL (90 caps / 30 days)
4
QL (90 caps / 30 days)
4
QL (30 caps / 30 days)
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
30
Drug Name
amphetamine-dextroamphetamine
24hr 20 mg
amphetamine-dextroamphetamine
24hr 25 mg
amphetamine-dextroamphetamine
24hr 30 mg
amphetamine-dextroamphetamine
mg
amphetamine-dextroamphetamine
mg
amphetamine-dextroamphetamine
mg
amphetamine-dextroamphetamine
12.5 mg
amphetamine-dextroamphetamine
mg
amphetamine-dextroamphetamine
mg
amphetamine-dextroamphetamine
mg
guanfacine er (adhd)
cap sr
Drug Tier Requirements/Limits
4
QL (30 caps / 30 days)
cap sr
4
QL (30 caps / 30 days)
cap sr
4
QL (30 caps / 30 days)
tab 5
3
QL (360 tabs / 30 days)
tab 7.5 3
QL (240 tabs / 30 days)
tab 10 3
QL (180 tabs / 30 days)
tab
3
QL (144 tabs / 30 days)
tab 15 3
QL (120 tabs / 30 days)
tab 20 3
QL (90 tabs / 30 days)
tab 30 3
QL (60 tabs / 30 days)
4
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
4
3
3
4
4
4
4
4
4
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
5
3
3
2
temazepam 15mg
2
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
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
31
Drug Name
zolpidem tartrate TABS
Drug Tier Requirements/Limits
4
QL (30 tabs / 30 days),
PA; PA applies if 65
years and older after a
90 day supply in a
calendar year
MIGRAINE
dihydroergotamine mesylate 1mg/ml
naratriptan hcl
rizatriptan benzoate
SUMATRIPTAN SOLN 5mg/act
3
3
3
4
SUMATRIPTAN SOLN 20mg/act
4
SUMATRIPTAN INJ 4MG/0.5ML
4
sumatriptan inj 6mg/0.5ml
4
sumatriptan succinate TABS
zolmitriptan TABS
zolmitriptan odt
2
4
4
QL (12
QL (18
QL (24
days)
QL (12
days)
QL (18
days)
QL (12
days)
QL (12
QL (12
QL (12
tabs / 30 days)
tabs / 30 days)
inhalers / 30
inhalers / 30
injections / 30
injections / 30
tabs / 30 days)
tabs / 30 days)
tabs / 30 days)
MISCELLANEOUS
lithium carbonate CAPS
lithium carbonate TABS
lithium carbonate er
LITHIUM SOLN 8MEQ/5ML
NUEDEXTA
pyridostigmine tab 60mg
riluzole
TETRABENAZINE 12.5mg
1
2
2
3
4
3
3
5
TETRABENAZINE 25mg
5
PA
QL (240 tabs / 30 days),
NM, PA
QL (120 tabs / 30 days),
NM, PA
MULTIPLE SCLEROSIS AGENTS
AMPYRA
BETASERON
5
5
COPAXONE INJ 20MG/ML
5
COPAXONE INJ 40MG/ML
5
GILENYA
5
glatopa
5
TYSABRI
5
NM, LA, PA
QL (14 syringes / 28
days), NM, PA
QL (30 syringes / 30
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
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
32
Drug Name
Drug Tier Requirements/Limits
MUSCULOSKELETAL THERAPY AGENTS
baclofen TABS
cyclobenzaprine hcl TABS 5mg, 10mg
2
4
tizanidine hcl TABS
2
PA; PA if 65 years and
older
NARCOLEPSY/CATAPLEXY
armodafinil 50mg
4
armodafinil 150mg
4
ARMODAFINIL 200mg
4
armodafinil 250mg
4
XYREM
5
QL (150 tabs / 30 days),
PA
QL (60 tabs / 30 days),
PA
QL (30 tabs / 30 days),
PA
QL (30 tabs / 30 days),
PA
QL (540 mL / 30 days),
LA, PA
PSYCHOTHERAPEUTIC-MISC
buprenorphine hcl SUBL
buprenorphine hcl-naloxone hcl sl
3
3
buproban
CHANTIX
CHANTIX CONTINUING MONTH
CHANTIX STARTER PACK
naloxone inj 0.4mg/ml
naloxone inj 1mg/ml
naltrexone hcl TABS
NICOTROL INHALER
NICOTROL NS
SUBOXONE MIS 2-0.5MG
3
4
4
4
3
3
3
4
4
4
SUBOXONE MIS 4-1MG
4
SUBOXONE MIS 8-2MG
4
SUBOXONE MIS 12-3MG
4
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
5
4
AXIRON
3
PA
QL (30 patches / 30
days), PA
QL (440 mL / 30 days),
PA
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
33
Drug Name
oxandrolone tab 2.5mg
oxandrolone tab 10mg
testosterone cypionate SOLN
testosterone enanthate SOLN
Drug Tier Requirements/Limits
3
PA
3
PA
3
PA
3
PA
ANTIDIABETICS, INJECTABLE
ALCOHOL SWABS
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
3
3
3
4
3
5
5
3
3
3
3
3
3
3
3
NOVOLIN N
3
NOVOLIN R
3
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILL
NOVOLOG PENFILL
SYMLINPEN 60
3
3
3
3
3
5
SYMLINPEN 120
5
TOUJEO SOLOSTAR
TRESIBA FLEXTOUCH
TRULICITY
VICTOZA
3
3
4
3
QL (4 pens / 28 days)
QL (3 pens / 30 days)
3
3
3
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (4 vials / 28 days)
QL (4 pens / 28 days)
QL (1 pen / 30 days)
B/D
(brand RELION not
covered)
(brand RELION not
covered)
(brand RELION not
covered)
QL (8 pens / 30 days),
PA
QL (4 pens / 30 days),
PA
ANTIDIABETICS, ORAL
acarbose
FARXIGA 5mg
FARXIGA 10mg
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
34
Drug Name
glimepiride 1mg
glimepiride 2mg
glimepiride 4mg
glip/metform tab 5-500mg
glipizide TABS 5mg
glipizide TABS 10mg
glipizide TB24 2.5mg
glipizide TB24 5mg
glipizide TB24 10mg
glipizide-metformin hcl tab 2.5-250 mg
glipizide-metformin hcl tab 2.5-500 mg
INVOKAMET TAB 50-500MG
INVOKAMET TAB 50-1000MG
INVOKAMET TAB 150-500MG
INVOKAMET 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 XR 2.5-1000MG
JENTADUETO XR 5-1000MG
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 (240 tabs / 30 days)
1
QL (120 tabs / 30 days)
1
QL (60 tabs / 30 days)
1
QL (120 tabs / 30 days)
1
QL (240 tabs / 30 days)
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)
3
QL (120 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (90 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (30 tabs / 30 days)
1
QL (120 tabs / 30 days)
1
QL (60 tabs / 30 days)
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)
3
QL (30 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (30 tabs / 30 days)
BISPHOSPHONATES
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
35
Drug Name
alendronate sodium TABS 5mg, 10mg,
40mg
alendronate sodium TABS 35mg, 70mg
pamidronate disodium
Drug Tier Requirements/Limits
1
1
3
QL (4 tabs / 28 days)
B/D
SENSIPAR 30mg
3
SENSIPAR 60mg
5
SENSIPAR 90mg
5
QL (120 tabs / 30 days),
NM
QL (60 tabs / 30 days),
NM
QL (120 tabs / 30 days),
NM
CALCIUM RECEPTOR AGONISTS
CHELATING AGENTS
EXJADE
FERRIPROX
kionex powder
sodium polystyrene sulfonate
5
5
4
3
NM, LA, PA
NM, LA, PA
CONTRACEPTIVES
cryselle 28
2
medroxyprogesterone acetate 150 mg/ml 2
sprintec 28 day
2
tri-sprintec 28 day
2
TRINESSA
2
ENDOMETRIOSIS
danazol CAPS
SYNAREL
4
5
ENZYME REPLACEMENTS
ADAGEN
ALDURAZYME
BUPHENYL TABS
CARBAGLU
CERDELGA
CEREZYME
CYSTAGON
FABRAZYME
KUVAN
levocarnitine (metabolic modifiers)
LUMIZYME
NAGLAZYME
ORFADIN CAPS 2mg, 5mg, 10mg
ORFADIN SUSP
RAVICTI
5
5
5
5
5
5
4
5
5
4
5
5
5
5
5
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
B/D
NM,
NM,
NM,
NM,
NM,
LA,
LA,
LA,
LA,
PA
LA,
LA,
LA,
LA,
PA
PA
PA
PA
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
PA
PA
PA
PA
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
36
Drug Name
sodium phenylbutyrate
ZAVESCA
Drug Tier Requirements/Limits
5
NM, PA
5
NM, LA, PA
ESTROGENS
estrace CREA
estrad val inj 20mg/ml
estrad val inj 40mg/ml
estradiol PTWK
4
3
3
4
estradiol TABS
4
fyavolv tab 1-5mg
4
jinteli
4
norethindrone acetate-ethinyl estradiol
4
PREMARIN TABS
VAGIFEM
4
4
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
GLUCOCORTICOIDS
dexamethasone CONC; ELIX
dexamethasone TABS
hydrocortisone TABS
methylpr ss inj 1gm
methylpr ss inj 40mg
methylpred pak 4mg
methylpred tab 4mg
methylpred tab 8mg
methylpred tab 16mg
methylpred tab 32mg
pred sod pho sol 5mg/5ml
prednisolone sol 15mg/5ml
prednisolone sol 25mg/5ml
prednisone con 5mg/ml
prednisone sol 5mg/5ml
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 5mg
prednisone tab 10mg
prednisone tab 20mg
prednisone tab 50mg
3
2
3
3
3
2
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
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
3
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
37
Drug Name
GLUCAGON EMERGENCY KIT
PROGLYCEM SUS 50MG/ML
Drug Tier Requirements/Limits
3
4
HUMAN GROWTH HORMONES
GENOTROPIN
GENOTROPIN MINIQUICK .2mg
GENOTROPIN MINIQUICK .4mg, .6mg,
.8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg,
2mg
NORDITROPIN FLEXPRO
5
4
5
NM, PA
NM, PA
NM, PA
5
NM, PA
calcitonin (salmon)
FORTICAL
INCRELEX
KORLYM
LUPRON DEP-PED INJ 11.25MG
LUPRON DEP-PED INJ 15MG
methylergonovine maleate TABS
octreotide acetate 50mcg/ml, 100mcg/ml,
200mcg/ml
octreotide acetate 500mcg/ml,
1000mcg/ml
PROLIA
3
3
5
5
5
5
4
4
B/D
B/D
NM,
NM,
NM,
NM,
5
NM, PA
4
QL (1 syringe / 180
days), NM
raloxifene tab 60mg
SANDOSTATIN LAR DEPOT
SIGNIFOR
SOMATULINE DEPOT
SOMAVERT
XGEVA
3
5
5
5
5
5
MISCELLANEOUS
LA, PA
LA, PA
PA
PA
NM, PA
NM,
NM,
NM,
NM,
NM,
PA
LA, PA
PA
LA, PA
PA
PARATHYROID HORMONES
FORTEO
5
NATPARA
5
QL (1 pen / 28 days),
NM, PA
NM, PA
PHOSPHATE BINDER AGENTS
AURYXIA
calcium acetate (phosphate binder)
RENVELA PAK
RENVELA TAB 800MG
5
3
3
3
PROGESTINS
medroxyprogesterone acetate tab
norethindrone acetate TABS
1
3
THYROID AGENTS
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
38
Drug Name
levothyroxine sodium TABS 25mcg,
50mcg, 88mcg, 100mcg, 112mcg,
125mcg, 137mcg, 150mcg, 175mcg,
200mcg
LEVOTHYROXINE SODIUM TABS 75mcg,
300mcg
LEVOXYL
liothyronine sodium TABS
methimazole TABS
propylthiouracil TABS
SYNTHROID
UNITHROID
Drug Tier Requirements/Limits
2
2
2
3
2
3
4
2
VASOPRESSINS
desmopressin acetate spray refrigerated
desmopressin acetate tabs
desmopressin inj 4mcg/ml
4
3
4
GASTROINTESTINAL
ANTIEMETICS
dronabinol
4
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
4
4
4
4
3
4
2
1
2
3
3
3
2
4
phenergan SUPP
4
prochlorperazine inj
prochlorperazine maleate TABS
prochlorperazine supp
promethazine hcl SOLN; SUPP; SYRP;
TABS
3
1
4
4
B/D, QL (60 caps / 30
days)
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
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
39
Drug Name
promethegan
Drug Tier Requirements/Limits
4
PA; PA if 65 years and
older
4
QL (10 patches / 30
days), PA; PA if 65 years
and older
TRANSDERM-SCOP
ANTISPASMODICS
dicyclomine hcl CAPS
dicyclomine hcl SOLN 10mg/5ml
dicyclomine hcl TABS
glycopyrrolate TABS
glycopyrrolate inj
1
4
1
3
4
H2-RECEPTOR ANTAGONISTS
famotidine SUSR
famotidine TABS 20mg, 40mg
famotidine inj
ranitidine hcl TABS 150mg, 300mg
ranitidine hcl inj
ranitidine syrup
4
1
2
1
3
3
INFLAMMATORY BOWEL DISEASE
APRISO
ASACOL HD
budesonide ec
CANASA
DELZICOL
mesalamine w/ cleanser
sulfasalazine TABS
sulfasalazine ec
3
4
5
5
4
4
3
3
LAXATIVES
constulose
gavilyte-c
gavilyte-g
gavilyte-h
GOLYTELY
lactulose
MOVIPREP
NULYTELY/FLAVOR PACKS
PEG 3350-KCL-SOD BICARB-SOD
CHLORIDE-SOD SULFATE
polyethylene glycol 3350 POWD
SUPREP BOWEL PREP
trilyte
2
2
2
3
3
2
4
3
2
2
4
2
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
40
Drug Name
Drug Tier Requirements/Limits
MISCELLANEOUS
alosetron hcl
AMITIZA CAP 8MCG
AMITIZA CAP 24MCG
diphenoxylate w/ atropine
GATTEX
LINZESS 145mcg
LINZESS 290mcg
loperamide hcl CAPS
misoprostol TABS
MOVANTIK 12.5mg
MOVANTIK 25mg
RELISTOR
sucralfate TABS
XIFAXAN 550mg
5
3
3
3
5
3
3
2
3
3
3
5
3
5
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
PA
PANCREATIC ENZYMES
CREON
ZENPEP
3
4
PROTON PUMP INHIBITORS
DEXILANT
esomeprazole magnesium
NEXIUM GRA 2.5MG DR
NEXIUM GRA 5MG DR
NEXIUM GRA 10MG DR
3
4
3
3
3
NEXIUM GRA 20MG DR
3
NEXIUM GRA 40MG DR
3
omeprazole cap 10mg
omeprazole cap 20mg
omeprazole cap 40mg
pantoprazole sodium tbec
1
1
1
2
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
QL (30
packets / 30
packets / 30
packets / 30
caps / 30 days)
caps / 30 days)
caps / 30 days)
tabs / 30 days)
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl
dutasteride
dutasteride-tamsulosin hcl
finasteride TABS 5mg
tamsulosin hcl
2
4
4
2
3
QL (30 tabs / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
MISCELLANEOUS
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
41
Drug Name
bethanechol chloride TABS
POTASSIUM CITRATE (ALKALINIZER)
540mg, 1080mg
Drug Tier Requirements/Limits
3
4
URINARY ANTISPASMODICS
DARIFENACIN HYDROBROMIDE 7.5mg
DARIFENACIN HYDROBROMIDE 15mg
ENABLEX 7.5mg
ENABLEX 15mg
MYRBETRIQ 25mg
MYRBETRIQ 50mg
oxybutynin chloride SYRP
oxybutynin chloride TABS
oxybutynin chloride TB24 5mg
oxybutynin chloride TB24 10mg, 15mg
tolterodine tartrate CP24
tolterodine tartrate TABS
TOVIAZ
trospium chloride TABS
VESICARE
4
4
4
4
4
4
1
3
3
3
4
4
3
4
4
QL
QL
QL
QL
QL
QL
(60
(30
(60
(30
(60
(30
ea / 30 days)
ea / 30 days)
ea / 30 days)
ea / 30 days)
tabs / 30 days)
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 CREA
terconazole vaginal SUPP
ZAZOLE CREAM 0.8%
4
4
3
4
3
HEMATOLOGIC
ANTICOAGULANTS
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
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
jantoven
PRADAXA
warfarin sodium
4
4
3
3
3
3
3
3
3
1
3
1
B/D
B/D
B/D
B/D
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
42
Drug Name
XARELTO
XARELTO STARTER PACK
Drug Tier Requirements/Limits
3
3
HEMATOPOIETIC GROWTH FACTORS
GRANIX
LEUKINE
MOZOBIL
NEUPOGEN
PROCRIT 2000unit/ml, 3000unit/ml,
4000unit/ml, 10000unit/ml
PROCRIT 20000unit/ml, 40000unit/ml
5
5
5
5
3
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
PA
PA
5
NM, PA
anagrelide hcl
cilostazol
CINRYZE
FIRAZYR
pentoxifylline TBCR
PROMACTA 12.5mg
4
2
5
5
3
5
NM, LA, PA
NM, PA
PROMACTA 25mg
5
PROMACTA 50mg
5
PROMACTA 75mg
5
tranexamic acid SOLN
3
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
AGGRENOX
ASPIRIN-DIPYRIDAMOLE
BRILINTA
clopidogrel tab 75mg
EFFIENT
ZONTIVITY
4
4
4
1
4
4
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)
HUMIRA INJ 10MG/0.2ML
5
HUMIRA KIT 20MG/0.4ML
5
HUMIRA KIT 40MG/0.8ML
5
HUMIRA PEDIATRIC CROHNS DISEASE
5
QL (2 boxes / 28 days),
NM, PA
QL (2 boxes / 28 days),
NM, PA
QL (6 boxes / 28 days),
NM, PA
NM, PA
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
43
Drug Name
HUMIRA PEN
Drug Tier Requirements/Limits
5
QL (6 boxes / 28 days),
NM, PA
5
NM, PA
4
3
4
5
NM, PA
5
QL (60 tabs / 30 days),
NM, PA
5
QL (30 tabs / 30 days),
NM, PA
HUMIRA PEN-CROHNS DISEASE
hydroxychloroquine sulfate
leflunomide TABS
methotrexate sodium tabs
REMICADE
XELJANZ
XELJANZ XR
IMMUNOGLOBULINS
BIVIGAM
CARIMUNE NANOFILTERED
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAKED
GAMMAPLEX 10gm/200ml
GAMUNEX-C
OCTAGAM 1gm/20ml, 2gm/20ml
PRIVIGEN
5
5
5
3
5
5
5
5
5
5
NM, PA
NM, PA
NM, PA
B/D, NM
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
5
5
5
5
5
5
5
5
NM, LA, PA
NM, PA
B/D, NM
B/D, NM
B/D, NM
NM, LA, PA
NM, LA, PA
NM, PA
3
5
4
4
4
5
4
3
3
B/D
NM, PA
B/D
B/D
B/D
B/D
B/D
B/D
B/D
IMMUNOMODULATORS
ACTIMMUNE
ARCALYST
INTRON-A INJ 10MU
INTRON-A INJ 18MU
INTRON-A INJ 50MU
POMALYST
REVLIMID
THALOMID
IMMUNOSUPPRESSANTS
azathioprine TABS
BENLYSTA
cyclosporine CAPS
cyclosporine modified (for microemulsion)
mycophenolate mofetil CAPS; TABS
mycophenolate mofetil SUSR
mycophenolate sodium
NEORAL
SANDIMMUNE SOLN 100mg/ml
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
44
Drug Name
tacrolimus CAPS
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
Drug Tier Requirements/Limits
4
B/D
5
B/D
3
B/D
5
B/D
VACCINES
ADACEL
BOOSTRIX
ZOSTAVAX
3
3
3
QL (1 vial per lifetime)
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
KLOR-CON 8
KLOR-CON 10
klor-con m15
klor-con m20
klor-con spr cap 8meq
klor-con spr cap 10meq
magnesium sulfate SOLN 50%
MAGNESIUM SULFATE SOLN 50%
potassium chloride CPCR
POTASSIUM CHLORIDE SOLN
potassium chloride TBCR
potassium chloride microencapsulated
crystals cr
sodium fluoride chew; tab; 1.1 (0.5 f)
mg/ml soln
2
2
2
2
3
3
2
2
3
4
2
2
2
IV NUTRITION
INTRALIPID INJ 20%
INTRALIPID INJ 30%
premasol 6%
premasol 10%
4
4
2
4
B/D
B/D
B/D
B/D
IV REPLACEMENT SOLUTIONS
DEXTROSE 5%
DEXTROSE 5%/NACL 0.9%
DEXTROSE 10%/NACL 0.2%
KCL0.15%/D5W/NACL0.225%
LACTATED RINGER'S INJ
SODIUM CHLORIDE 0.45% VIA
SODIUM CHLORIDE INJ 0.9%
2
2
3
3
2
2
2
VITAMINS
calcitriol CAPS
3
B/D
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
45
Drug Name
calcitriol inj
calcitriol oral soln 1 mcg/ml
paricalcitol CAPS
prenatal vitamin/folic acid > 0.8 mg
(generic)
Drug Tier Requirements/Limits
4
B/D
4
B/D
4
B/D
2
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
bacitracin-poly-neomycin-hc
blephamide OINT
neomycin-polymy-dexameth
sulfacetamide sod-prednisolone
TOBRADEX OINT
TOBRADEX ST
tobramycin-dexamethasone
ZYLET
3
4
2
2
3
3
4
3
ANTI-INFECTIVES
BESIVANCE
CILOXAN OINT
ciprofloxacin hcl (ophth)
erythromycin (ophth)
gentak
gentamicin sulfate (ophth)
ilotycin
MOXEZA
neomycin-bacitracin zn-polymyxin
neomycin-polymyxin-gramicidin
ofloxacin (ophth)
polymyxin b-trimethoprim
sulfacet sod oin 10% op
sulfacetamide sodium (ophth)
tobramycin (ophth)
TOBREX OINT
VIGAMOX
ZIRGAN
3
3
2
2
2
2
2
3
3
3
2
2
3
3
2
4
3
4
ANTI-INFLAMMATORIES
ALREX
3
dexamethasone sodium phosphate (ophth) 3
diclofenac sodium (ophth)
3
DUREZOL
3
flurbiprofen sodium
1
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
46
Drug Name
ILEVRO
ketorolac tromethamine (ophth)
LOTEMAX
MAXIDEX
PREDNISOLONE ACETATE (OPHTH)
prednisolone sodium phosphate (ophth)
Drug Tier Requirements/Limits
3
3
3
3
3
3
ANTIALLERGICS
azelastine drop 0.05%
BEPREVE
cromolyn sodium (ophth)
LASTACAFT
PATADAY
PAZEO
3
3
1
4
3
3
ANTIGLAUCOMA
ALPHAGAN P SOL 0.1%
AZOPT
BETOPTIC-S
brimonidine sol 0.2%
BRIMONIDINE SOL 0.15%
COMBIGAN
dorzolamide hcl
dorzolamide hcl-timolol maleate
ISTALOL
latanoprost SOLN
LUMIGAN
metipranolol
SIMBRINZA
timolol maleate (ophth) soln
TIMOLOL MALEATE GEL
TRAVATAN Z
3
3
3
2
4
3
3
3
3
2
3
3
3
1
4
3
MISCELLANEOUS
CYSTARAN
naphazoline 0.1%
PROLENSA
proparacaine hcl SOLN
RESTASIS
5
1
3
2
3
NM, LA, PA
QL (64 vials / 30 days)
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
ANORO ELLIPTA
3
QL (60 inhalations / 30
days)
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
47
Drug Name
COMBIVENT RESPIMAT
Drug Tier Requirements/Limits
4
QL (2 inhalers / 30
days)
3
B/D
ipratropium-albuterol nebu
ANTICHOLINERGICS
ATROVENT HFA
4
INCRUSE ELLIPTA
ipratropium bromide SOLN
ipratropium bromide (nasal)
3
2
3
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
3
3
3
4
hydroxyzine hcl SOLN; SYRP; TABS
4
hydroxyzine pamoate CAPS
4
levocetirizine dihydrochloride SOLN
levocetirizine dihydrochloride TABS
4
2
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
albuterol sulfate TABS; TB12
PERFOROMIST
SEREVENT DISKUS
2
1
4
4
3
VENTOLIN HFA
3
XOPENEX HFA
3
B/D
B/D
QL (60 inhalations / 30
days)
QL (2 inhalers / 30
days)
QL (2 inhalers / 30
days)
LEUKOTRIENE MODULATORS
montelukast sodium CHEW; TABS
montelukast sodium PACK
zafirlukast
3
4
4
MAST CELL STABILIZERS
cromolyn sod neb 20mg/2ml
3
B/D
3
5
4
3
B/D
NM, LA, PA
MISCELLANEOUS
acetylcysteine SOLN 10%, 20%
ARALAST NP
DALIRESP
EPIPEN 2-PAK
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
48
Drug Name
EPIPEN-JR 2-PAK
ESBRIET
KALYDECO
OFEV
ORKAMBI
PROLASTIN-C
PULMOZYME
XOLAIR
ZEMAIRA
Drug Tier Requirements/Limits
3
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, LA, PA
5
NM, PA
5
NM, LA, PA
5
NM, LA, PA
NASAL STEROIDS
flunisolide (nasal)
fluticasone propionate (nasal)
mometasone furoate (nasal)
NASONEX
3
2
4
4
QL (2
QL (1
QL (2
QL (2
days)
bottles / 30 days)
bottle / 30 days)
bottles / 30 days)
inhalers / 30
ARNUITY ELLIPTA
3
budesonide (inhalation)
FLOVENT DISKUS 50mcg/blist,
100mcg/blist
FLOVENT DISKUS 250mcg/blist
4
3
FLOVENT HFA
3
PULMICORT FLEXHALER
3
QL (30 inhalations / 30
days)
B/D
QL (120 inhalations / 30
days)
QL (240 inhalations / 30
days)
QL (2 inhalers / 30
days)
QL (2 inhalers / 30
days)
STEROID INHALANTS
3
STEROID/BETA-AGONIST COMBINATIONS
ADVAIR DISKUS
3
ADVAIR HFA
BREO ELLIPTA
3
3
SYMBICORT
3
QL (60 inhalations / 30
days)
QL (1 inhaler / 30 days)
QL (60 blisters / 30
days)
QL (1 inhaler / 30 days)
XANTHINES
aminophylline inj
theophylline SOLN
theophylline TB12; TB24
3
4
3
TOPICAL
DERMATOLOGY, ACNE
AVITA
claravis
4
4
PA
PA
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
49
Drug Name
clindamycin phosphate (topical) GEL;
LOTN
clindamycin phosphate (topical) SOLN;
SWAB
erythromycin (acne aid)
myorisan
tretinoin CREA
TRETINOIN GEL .01%
tretinoin GEL .025%
zenatane
Drug Tier Requirements/Limits
4
3
3
4
4
4
4
4
PA
PA
PA
PA
PA
DERMATOLOGY, ANTIBIOTICS
gentamicin sulfate (topical)
mupirocin OINT
SILVER SULFADIAZINE CREA
SULFAMYLON CREA
SULFAMYLON PACK
3
2
2
4
5
DERMATOLOGY, ANTIFUNGALS
ciclopirox CREA; SUSP
clotrimazole (topical)
ketoconazole cream
nyamyc
nystatin (topical)
nystop
3
3
3
3
3
3
DERMATOLOGY, ANTIPRURITIC
DOXEPIN HCL (ANTIPRURITIC)
procto-med
procto-pak
proctosol hc cre 2.5%
proctozone hc
4
4
4
4
4
DERMATOLOGY, ANTIPSORIATICS
acitretin
calcipotriene CREA
calcipotriene SOLN
TAZORAC CREA
5
4
4
4
PA
PA
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole shampoo
selenium sulfide LOTN
2
2
DERMATOLOGY, CORTICOSTEROIDS
ala-cort
alclometasone dipropionate CREA
alclometasone dipropionate OINT
1
4
3
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
50
Drug Name
betamethasone dipropionate (topical)
CREA; OINT
betamethasone dipropionate (topical)
LOTN
betamethasone dipropionate augmented
CREA
betamethasone dipropionate augmented
GEL; LOTN
BETAMETHASONE DIPROPIONATE
AUGMENTED OINT
betamethasone valerate CREA; LOTN;
OINT
fluocinonide GEL
fluocinonide SOLN
fluticasone propionate CREA
fluticasone propionate OINT
halobetasol propionate
hydrocortisone (topical) CREA; OINT
hydrocortisone (topical) LOTN
mometasone furoate CREA; OINT; SOLN
triamcinolone acetonide (topical) CREA;
OINT
triamcinolone acetonide (topical) LOTN
triderm
Drug Tier Requirements/Limits
4
3
3
4
4
3
4
4
2
2
4
1
3
3
2
3
2
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine PTCH
4
lidocaine hcl GEL
lidocaine hcl SOLN 4%
lidocaine oint 5%
lidocaine-prilocaine
3
1
4
4
QL (3 patches / 1 day),
PA
PA
PA
PA
PA
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
ammonium lactate CREA
ammonium lactate LOTN
diclofenac sodium (topical) 1% gel
fluorouracil (topical) CREA 5%
fluorouracil (topical) SOLN
metronidazole (topical) CREA; LOTN
metronidazole gel 0.75%
podofilox SOLN
tacrolimus (topical)
TARGRETIN GEL
VALCHLOR
3
2
3
4
4
4
4
3
4
5
5
PA
NM, PA
NM, LA, PA
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
51
Drug Name
Drug Tier Requirements/Limits
DERMATOLOGY, SCABICIDES AND PEDICULIDES
malathion
permethrin
4
3
DERMATOLOGY, WOUND CARE AGENTS
REGRANEX
SANTYL
SODIUM CHLORIDE 0.9%
STERILE WATER IRRIGATION
5
4
1
2
PA
MOUTH/THROAT/DENTAL AGENTS
chlorhexidine gluconate (mouth-throat)
clotrimazole TROC
lidocaine hcl (mouth-throat)
nystatin (mouth-throat)
periogard
triamcinolone acetonide (mouth)
1
4
1
3
1
3
OTIC
ACETIC ACID (OTIC)
CIPRODEX
fluocinolone acetonide (otic)
neomycin-polymyxin-hc (otic)
3
3
4
3
You can find information on what the symbols and abbreviations on this table mean by
going to page 7.
52
.
Index
A
abacavir sulfate
11
ABILIFY MAINTENA
28
ABRAXANE
15
acarbose
34
acebutolol hcl
20
acetaminophen w/ codeine
8
acetazolamide
21
ACETIC ACID (OTIC)
52
acetylcysteine
48
acitretin
50
ACTIMMUNE
44
acyclovir
12
ADACEL
45
ADAGEN
36
ADCIRCA
22
adefovir dipivoxil
12
ADEMPAS
22
adrucil
14
ADVAIR DISKUS
49
ADVAIR HFA
49
afeditab cr
20
AFINITOR
16
AFINITOR DISPERZ
16
AGGRENOX
43
ala-cort
50
albuterol sulfate
48
alclometasone dipropionate
50
ALCOHOL SWABS
34
ALDURAZYME
36
ALECENSA
16
alendronate sodium
36
alfuzosin hcl
41
allopurinol tab
8
alosetron hcl
41
ALPHAGAN P SOL 0.1%
47
alprazolam tab 0.25mg
23
alprazolam tab 0.5mg
23
alprazolam tab 1mg
23
alprazolam tab 2 mg
23
ALREX
46
amantadine hcl
27
amikacin sulfate
10
amiloride & hydrochlorothiazide
21
amiloride hcl
21
aminophylline inj
49
amiodarone hcl
19
AMITIZA CAP 24MCG
41
AMITIZA CAP 8MCG
41
amitriptyline hcl
26
amlodipine besylate
20
amlodipine besylate-benazepril hcl cap 1020 mg
18
amlodipine besylate-benazepril hcl cap 1040 mg
18
amlodipine besylate-benazepril hcl cap
2.5-10 mg
18
53
amlodipine besylate-benazepril hcl cap 510 mg
18
amlodipine besylate-benazepril hcl cap 520 mg
18
amlodipine besylate-benazepril hcl cap 540 mg
18
amlodipine besylate-valsartan tab
19
amlodipine-valsartan-hydrochlorothiazide
tab
19
ammonium lactate
51
amoxapine
26
amoxicillin
14
amoxicillin & pot clavulanate
14
amphetamine-dextroamphetamine cap sr
24hr 10 mg
30
amphetamine-dextroamphetamine cap sr
24hr 15 mg
30
amphetamine-dextroamphetamine cap sr
24hr 20 mg
31
amphetamine-dextroamphetamine cap sr
24hr 25 mg
31
amphetamine-dextroamphetamine cap sr
24hr 30 mg
31
amphetamine-dextroamphetamine cap sr
24hr 5 mg
30
amphetamine-dextroamphetamine tab 10
mg
31
amphetamine-dextroamphetamine tab
12.5 mg
31
amphetamine-dextroamphetamine tab 15
mg
31
amphetamine-dextroamphetamine tab 20
mg
31
amphetamine-dextroamphetamine tab 30
mg
31
amphetamine-dextroamphetamine tab 5
mg
31
amphetamine-dextroamphetamine tab 7.5
mg
31
ampicillin cap
14
ampicillin sus
14
AMPYRA
32
ANADROL-50
33
anagrelide hcl
43
anastrozole
15
ANDRODERM
33
ANORO ELLIPTA
47
APOKYN
27
APRISO
40
APTIOM
23
ARALAST NP
48
ARCALYST
44
aripiprazole
28
aripiprazole tab
28
ARMODAFINIL
33
armodafinil
33
ARNUITY ELLIPTA
49
ASACOL HD
40
ASPIRIN-DIPYRIDAMOLE
43
atenolol
20
atenolol & chlorthalidone
20
.
atorvastatin calcium
atovaquone-proguanil hcl
ATRIPLA
ATROVENT HFA
AURYXIA
AVASTIN
AVITA
AXIRON
azathioprine
azelastine drop 0.05%
azelastine spr 0.1%
azelastine spr 0.15%
AZILECT
AZITHROMYCIN
azithromycin
AZOPT
AZOR
aztreonam
19
11
12
48
38
15
49
33
44
47
48
48
27
13
13
47
19
10
B
bacitracin-poly-neomycin-hc
46
baclofen
33
BANZEL SUS 40MG/ML
23
BANZEL TAB 200MG
23
BANZEL TAB 400MG
23
BELEODAQ
15
benazepril & hydrochlorothiazide
18
benazepril hcl
18
BENICAR
19
BENICAR HCT
19
BENLYSTA
44
BENZTROPINE MESYLATE
28
benztropine mesylate
28
BEPREVE
47
BESIVANCE
46
betamethasone dipropionate (topical)
51
BETAMETHASONE DIPROPIONATE
AUGMENTED
51
betamethasone dipropionate augmented51
betamethasone valerate
51
BETASERON
32
bethanechol chloride
42
BETOPTIC-S
47
bexarotene
17
bicalutamide
15
BILTRICIDE
10
bisoprolol & hydrochlorothiazide
20
BIVIGAM
44
bleomycin sulfate
14
blephamide
46
BOOSTRIX
45
BOSULIF
16
BREO ELLIPTA
49
BRILINTA
43
BRIMONIDINE SOL 0.15%
47
brimonidine sol 0.2%
47
BRIVIACT
23
budesonide (inhalation)
49
budesonide ec
40
54
bumetanide inj 0.25/ml
bumetanide tab
BUPHENYL
buprenorphine hcl
buprenorphine hcl-naloxone hcl sl
buproban
bupropion hcl
buspirone hcl
BYDUREON INJ
BYDUREON PEN
BYETTA
BYSTOLIC
21
21
36
33
33
33
26
23
34
34
34
20
C
CABOMETYX
calcipotriene
calcitonin (salmon)
calcitriol
calcitriol inj
calcitriol oral soln 1 mcg/ml
calcium acetate (phosphate binder)
CANASA
CAPRELSA
captopril
captopril & hydrochlorothiazide
CARBAGLU
carbamazepine
carbidopa-levodopa
carboplatin
CARIMUNE NANOFILTERED
cartia xt
carvedilol
CAYSTON
cefaclor
cefaclor er tab 500mg
cefadroxil
cefazolin inj
cefdinir
cefixime
cefprozil
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
celecoxib
cephalexin
CERDELGA
CEREZYME
cetirizine syrup
CHANTIX
CHANTIX CONTINUING MONTH
CHANTIX STARTER PACK
chlorhexidine gluconate (mouth-throat)
chloroquine phosphate
chlorothiazide tabs
chlorthalidone
choline fenofibrate
ciclopirox
cilostazol
CILOXAN
16
50
38
45
46
46
38
40
16
18
18
36
23
28
17
44
20
20
10
13
13
13
13
13
13
13
13
13
13
8
13
36
36
48
33
33
33
52
11
21
21
20
50
43
46
.
CINRYZE
CIPRODEX
ciprofloxacin
ciprofloxacin er
ciprofloxacin hcl (ophth)
ciprofloxacin hcl tab
ciprofloxacn inj 400mg/40ml
cisplatin
citalopram hydrobromide
claravis
clarithromycin
clarithromycin er
clindamycin cap 300 mg
clindamycin cap 75mg
clindamycin hcl cap 150 mg
clindamycin phosphate (topical)
clindamycin phosphate in d5w
clindamycin phosphate inj
clindamycin phosphate vaginal
clomipramine hcl
clonazepam
clonidine hcl
clopidogrel tab 75mg
clorazepate dipotassium
clotrimazole
clotrimazole (topical)
CLOZAPINE ODT
clozapine tab 100mg
clozapine tab 200mg
clozapine tab 25mg
clozapine tab 50mg
colchicine w/ probenecid
COLCRYS
COMBIGAN
COMBIVENT RESPIMAT
COMETRIQ
constulose
COPAXONE INJ 20MG/ML
COPAXONE INJ 40MG/ML
COTELLIC
CREON
cromolyn sod neb 20mg/2ml
cromolyn sodium (ophth)
cryselle 28
cyclobenzaprine hcl
CYCLOPHOSPHAMIDE
cyclosporine
cyclosporine modified (for
microemulsion)
cyproheptadine hcl
CYSTAGON
CYSTARAN
cytarabine
D
dacarbazine
DAKLINZA
DALIRESP
danazol
43
52
13
13
46
14
14
17
26
49
13
13
10
10
10
50
10
10
42
26
23
22
43
23, 24
52
50
28
28
28
28
28
8
8
47
48
16
40
32
32
16
41
48
47
36
33
14
44
dapsone
10
DARIFENACIN HYDROBROMIDE
42
daunorubicin hcl
14
DELZICOL
40
desmopressin acetate spray refrigerated 39
desmopressin acetate tabs
39
desmopressin inj 4mcg/ml
39
dexamethasone
37
dexamethasone sodium phosphate
(ophth)
46
DEXILANT
41
DEXTROSE 10%/NACL 0.2%
45
DEXTROSE 5%
45
DEXTROSE 5%/NACL 0.9%
45
diazepam
24
diclofenac potassium
8
diclofenac sodium
8
diclofenac sodium (ophth)
46
diclofenac sodium (topical) 1% gel
51
dicyclomine hcl
40
DIFICID
13
digitek
21
digoxin
21
digoxin inj
21
DIGOXIN SOL 50MCG/ML
21
dihydroergotamine mesylate
32
dilantin
24
DILANTIN-125 SUS 125/5ML
24
dilt-xr cap
20
diltiazem cap
21
diltiazem cap er/12hr
21
diltiazem hcl
21
diltiazem hcl coated beads
21
diphenoxylate w/ atropine
41
disopyramide phosphate
19
divalproex sodium
24
DOCETAXEL
15
DOCETAXEL SOLN 80MG/8ML
15
DOFETILIDE
19
donepezil hydrochloride
25
dorzolamide hcl
47
dorzolamide hcl-timolol maleate
47
doxazosin mesylate
18
doxepin hcl
26
DOXEPIN HCL (ANTIPRURITIC)
50
doxorubicin hcl liposomal inj 2mg/ml
14
doxorubicin inj 50mg
14
doxycycline (monohydrate)
14
doxycycline hyclate
14
doxycycline hyclate 100 mg
14
doxycycline hyclate 20 mg
14
dronabinol
39
DROXIA
17
duloxetine hcl
26
DURAMORPH
8
DUREZOL
46
dutasteride
41
dutasteride-tamsulosin hcl
41
44
48
36
47
14
14
12
48
36
55
.
E
EFFIENT
EMEND CAP 125MG
EMEND CAP 40MG
EMEND CAP 80MG
EMEND PAK 80 & 125
EMSAM
EMTRIVA
ENABLEX
enalapril maleate
enalapril maleate & hydrochlorothiazide
endocet
ENOXAPARIN SODIUM
enoxaparin sodium
entecavir
ENTRESTO
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
epitol
eplerenone
EPZICOM
ERIVEDGE
ery-tab
erythromycin (acne aid)
erythromycin (ophth)
erythromycin base
ESBRIET
escitalopram oxalate
esomeprazole magnesium
estrace
estrad val inj 20mg/ml
estrad val inj 40mg/ml
estradiol
etoposide
exemestane
EXJADE
F
FABRAZYME
famciclovir
famotidine
famotidine inj
FANAPT
FANAPT TITRATION PACK
FARXIGA
FARYDAK
FAZACLO
felodipine
fenofibrate
fenofibrate micronized
fentanyl citrate
fentanyl patch 100 mcg/hr
fentanyl patch 12 mcg/hr
fentanyl patch 25 mcg/hr
fentanyl patch 50 mcg/hr
fentanyl patch 75 mcg/hr
FENTORA
FERRIPROX
FETZIMA
43
39
39
39
39
26
11
42
18
18
8
42
42
12
19
48
49
24
18
12
15
13
50
46
13
49
26
41
37
37
37
37
17
15
36
36
12
40
40
28
28
34
15
28, 29
21
20
20
8
9
8
9
9
9
9
36
26
56
FETZIMA TITRATION PACK
finasteride
FIRAZYR
FLEBOGAMMA DIF
flecainide acetate
FLOVENT DISKUS
FLOVENT HFA
fluconazole
fluconazole inj nacl 200
fluconazole inj nacl 400
flunisolide (nasal)
fluocinolone acetonide (otic)
fluocinonide
fluorouracil
fluorouracil (topical)
fluoxetine cap 10mg
fluoxetine cap 20mg
fluoxetine cap 40mg
fluoxetine hcl
fluphenazine decanoate
flurbiprofen
flurbiprofen sodium
fluticasone propionate
fluticasone propionate (nasal)
fluvoxamine maleate
FORTEO
FORTICAL
fosinopril sodium
fosinopril sodium & hydrochlorothiazide
furosemide
FUROSEMIDE INJ
furosemide inj
fyavolv tab 1-5mg
FYCOMPA
26
41
43
44
19
49
49
11
11
11
49
52
51
14
51
26
26
26
27
29
8
46
51
49
23
38
38
18
18
21
21
21
37
24
G
gabapentin
galantamine hydrobromide
galantamine hydrobromide er
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAKED
GAMMAPLEX
GAMUNEX-C
ganciclovir inj 500mg
GATTEX
GAUZE PADS 2" X 2"
gavilyte-c
gavilyte-g
gavilyte-h
gemfibrozil
GENOTROPIN
GENOTROPIN MINIQUICK
gentak
gentamicin sulfate (ophth)
gentamicin sulfate (topical)
GEODON
GILENYA
GILOTRIF TAB 20MG
24
25
25
44
44
44
44
44
12
41
34
40
40
40
20
38
38
46
46
50
29
32
16
.
GILOTRIF TAB 30MG
16
GILOTRIF TAB 40MG
16
glatopa
32
GLEEVEC
16
glimepiride
35
glip/metform tab 5-500mg
35
glipizide
35
glipizide-metformin hcl tab 2.5-250 mg 35
glipizide-metformin hcl tab 2.5-500 mg 35
GLUCAGEN HYPOKIT
37
GLUCAGON EMERGENCY KIT
38
glycopyrrolate
40
glycopyrrolate inj
40
GOLYTELY
40
granisetron hcl
39
GRANIX
43
griseofulvin microsize
11
griseofulvin ultramicrosize
11
guanfacine er (adhd)
31
H
halobetasol propionate
haloperidol
haloperidol con lactate
haloperidol decanoate
haloperidol lactate inj 5 mg/ml
HEPARIN SOD (PORCINE) IN D5W
heparin sod (porcine) in d5w
heparin sod inj 1000/ml
heparin sod inj 10000/ml
heparin sod inj 20000/ml
heparin sod inj 5000/ml
HEPARIN SODIUM/D5W
HERCEPTIN
HETLIOZ
HUMIRA INJ 10MG/0.2ML
HUMIRA KIT 20MG/0.4ML
HUMIRA KIT 40MG/0.8ML
HUMIRA PEDIATRIC CROHNS DISEASE
HUMIRA PEN
HUMIRA PEN-CROHNS DISEASE
HUMULIN R INJ U-500
HUMULIN R U-500 KWIKPEN
hydralazine hcl
hydrochlorothiazide
hydroco/apap tab 10-325mg
hydroco/apap tab 5-325mg
hydroco/apap tab 7.5-325
hydrocodone-acetaminophen 7.5-325
mg/15ml
hydrocodone-ibuprofen tab 7.5-200 mg
hydrocortisone
hydrocortisone (topical)
hydromorphone hcl
hydroxychloroquine sulfate
hydroxyurea
hydroxyzine hcl
hydroxyzine pamoate
51
29
29
29
29
42
42
42
42
42
42
42
15
31
43
43
43
43
44
44
34
34
22
21
9
9
9
9
9
37
51
9
44
17
48
48
57
I
IBRANCE
ibuprofen
ICLUSIG
ILEVRO
ilotycin
imatinib mesylate
IMBRUVICA CAP 140MG
imipramine hcl
INCRELEX
INCRUSE ELLIPTA
indapamide
INLYTA
INSULIN PEN NEEDLE
INSULIN SAFETY NEEDLES
INSULIN SYRINGE
INTRALIPID INJ 20%
INTRALIPID INJ 30%
INTRON-A INJ 10MU
INTRON-A INJ 18MU
INTRON-A INJ 50MU
INVEGA
INVEGA SUST INJ 117 MG/0.75 ML
INVEGA SUST INJ 156MG/ML
INVEGA SUST INJ 234 MG/1.5 ML
INVEGA SUST INJ 39 MG/0.25 ML
INVEGA SUST INJ 78 MG/0.5 ML
INVEGA TRINZA
INVOKAMET TAB 150-1000MG
INVOKAMET TAB 150-500MG
INVOKAMET TAB 50-1000MG
INVOKAMET TAB 50-500MG
INVOKANA
ipratropium bromide
ipratropium bromide (nasal)
ipratropium-albuterol nebu
irbesartan
irbesartan-hydrochlorothiazide
IRESSA
irinotecan inj 100/5ml
ISENTRESS
isoniazid
isoniazid inj 100 mg/ml
isoniazid syp 50mg/5ml
isosorb mononitrate tab
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate er
ISTALOL
ISTODAX
itraconazole
ivermectin
15
8
16
47
46
16
16
27
38
48
21
16
34
34
34
45
45
44
44
44
29
29
29
29
29
29
29
35
35
35
35
35
48
48
48
19
19
16
17
11
12
12
12
22
22
22
22
47
15
11
10
J
JAKAFI
jantoven
JANUMET
JANUMET XR TAB 100-1000
JANUMET XR TAB 50-1000
16
42
35
35
35
.
JANUMET XR TAB 50-500MG
JANUVIA
JENTADUETO
JENTADUETO XR 2.5-1000MG
JENTADUETO XR 5-1000MG
jinteli
JUXTAPID
35
35
35
35
35
37
20
K
KADCYLA
KALETRA SOL
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
KALYDECO
KCL0.15%/D5W/NACL0.225%
ketoconazole
ketoconazole cream
ketoconazole shampoo
ketoprofen cap 50 mg
ketoprofen cap 75 mg
ketorolac tromethamine (ophth)
KEYTRUDA
kionex powder
KLOR-CON 10
KLOR-CON 8
klor-con m15
klor-con m20
klor-con spr cap 10meq
klor-con spr cap 8meq
KORLYM
KUVAN
KYNAMRO
15
12
12
12
49
45
11
50
50
8
8
47
15
36
45
45
45
45
45
45
38
36
20
L
labetalol hcl
LACTATED RINGER'S INJ
lactulose
lamivudine
lamivudine (hbv)
lamivudine-zidovudine
lamotrigine
LANTUS
LANTUS SOLOSTAR
LASTACAFT
latanoprost
LATUDA
leflunomide
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
LENVIMA 8 MG DAILY DOSE
LETAIRIS
letrozole
leucovorin calcium
LEUKERAN
LEUKINE
leuprolide inj 1mg/0.2
20
45
40
11
12
12
24
34
34
47
47
29
44
16
16
17
17
17
16
22
15
17
14
43
15
LEVEMIR
LEVEMIR FLEXTOUCH
levetiracetam
levetiracetam oral soln 100 mg/ml
levocarnitine (metabolic modifiers)
levocetirizine dihydrochloride
levofloxacin
levofloxacin in d5w
levofloxacin inj 25mg/ml
levofloxacin oral soln 25 mg/ml
LEVOTHYROXINE SODIUM
levothyroxine sodium
LEVOXYL
lidocaine
lidocaine hcl
lidocaine hcl (mouth-throat)
lidocaine inj 0.5%
lidocaine inj 2%
lidocaine oint 5%
lidocaine-prilocaine
LINEZOLID
LINZESS
liothyronine sodium
lisinopril
lisinopril & hydrochlorothiazide
lithium carbonate
lithium carbonate er
LITHIUM SOLN 8MEQ/5ML
LONSURF
loperamide hcl
lorazepam
lorcet plus tab 7.5-325
lorcet tab 5-325mg
lortab tab 10-325mg
lortab tab 5-325mg
lortab tab 7.5-325
losartan potassium
losartan-hydrochlorothiazide
LOTEMAX
lovastatin
loxapine succinate
LUMIGAN
LUMIZYME
LUPRON DEP-PED INJ 11.25MG
LUPRON DEP-PED INJ 15MG
LUPRON DEPOT
LUPRON DEPOT INJ 11.25MG (3MONTH)
LYNPARZA
LYRICA
LYSODREN
58
M
MAGNESIUM SULFATE
magnesium sulfate
malathion
MARPLAN TAB 10MG
MAXIDEX
meclizine hcl
medroxyprogesterone acetate 150
34
34
24
24
36
48
14
14
14
14
39
39
39
51
51
52
10
10
51
51
10
41
39
18
18
32
32
32
17
41
23
9
9
9
9
9
19
19
47
19
29
47
36
38
38
15
16
15
24
16
45
45
52
27
47
39
.
mg/ml
medroxyprogesterone acetate tab
mefloquine hcl
megestrol ac sus 40mg/ml
megestrol ac tab 20mg
megestrol ac tab 40mg
MEGESTROL SUS 625MG/5ML
MEKINIST
MELOXICAM
meloxicam
MEMANTINE HCL
memantine hcl
MEMANTINE TITRATION PAK
mercaptopurine
mesalamine w/ cleanser
mesna
metadate er tab 20mg
metformin er
metformin hcl
methadone hcl
methadone hcl 10mg
methadone hcl 5mg
methenamine hippurate
methimazole
methotrexate sodium inj
methotrexate sodium tabs
methyclothiazide
methylergonovine maleate
methylphenidate hcl
methylphenidate hcl oral soln
methylpr ss inj 1gm
methylpr ss inj 40mg
methylpred pak 4mg
methylpred tab 16mg
methylpred tab 32mg
methylpred tab 4mg
methylpred tab 8mg
metipranolol
metoclopramide hcl
metoclopramide inj
metolazone
metoprolol & hydrochlorothiazide
metoprolol succinate
metoprolol tartrate
metronidazole
metronidazole (topical)
metronidazole gel 0.75%
metronidazole in nacl
metronidazole vaginal
minitran
minocycline hcl
mirtazapine
misoprostol
mitomycin
mitoxantrone hcl
moderiba tab 200mg
moexipril hcl
moexipril-hydrochlorothiazide
mometasone furoate
mometasone furoate (nasal)
36
38
11
16
16
16
16
17
8
8
25
25
25
15
40
17
31
35
35
9
9
9
10
39
15
44
21
38
31
31
37
37
37
37
37
37
37
47
39
39
21
20
20
20
10
51
51
10
42
22
14
27
41
14
17
12
18
18
51
49
59
montelukast sodium
morphine ext-rel tab
MORPHINE SUL INJ 10MG/ML
MORPHINE SUL INJ 4MG/ML
MORPHINE SULFATE
MORPHINE SULFATE ORAL SOL
MOVANTIK
MOVIPREP
MOXEZA
MOZOBIL
MULTAQ
mupirocin
mycophenolate mofetil
mycophenolate sodium
myorisan
MYRBETRIQ
48
9
9
9
9
9
41
40
46
43
19
50
44
44
50
42
N
nabumetone
NAGLAZYME
naloxone inj 0.4mg/ml
naloxone inj 1mg/ml
naltrexone hcl
NAMENDA
NAMENDA TITRATION PAK
NAMENDA XR
NAMENDA XR TITRATION PACK
NAMZARIC
naphazoline 0.1%
naproxen
naproxen sodium
naratriptan hcl
NASONEX
nateglinide
NATPARA
neomycin sulfate
neomycin-bacitracin zn-polymyxin
neomycin-polymy-dexameth
neomycin-polymyxin-gramicidin
neomycin-polymyxin-hc (otic)
NEORAL
NEUPOGEN
NEUPRO
NEVIRAPINE
nevirapine
nevirapine tab 200mg
NEXAVAR
NEXIUM GRA 10MG DR
NEXIUM GRA 2.5MG DR
NEXIUM GRA 20MG DR
NEXIUM GRA 40MG DR
NEXIUM GRA 5MG DR
niacin er (antihyperlipidemic)
niacor
NICOTROL INHALER
NICOTROL NS
nifedical
nifedipine er
NINLARO
8
36
33
33
33
26
26
26
26
26
47
8
8
32
49
35
38
10
46
46
46
52
44
43
28
11
11
11
17
41
41
41
41
41
20
20
33
33
21
21
15
.
nitro-bid
nitrofurantoin macrocrystal
nitrofurantoin monohyd macro
nitroglycerin td patch
NITROSTAT
NORDITROPIN FLEXPRO
norethindrone acetate
norethindrone acetate-ethinyl estradiol
NORPACE CR
NORTHERA
nortriptyline hcl
NORVIR
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILL
NOVOLOG PENFILL
NUEDEXTA
NULYTELY/FLAVOR PACKS
NUPLAZID
nyamyc
nystatin
nystatin (mouth-throat)
nystatin (topical)
nystop
O
OCTAGAM
octreotide acetate
ODOMZO
OFEV
ofloxacin (ophth)
olanzapine
omega-3-acid ethyl esters
omeprazole cap 10mg
omeprazole cap 20mg
omeprazole cap 40mg
ondansetron hcl
ondansetron hcl inj
ondansetron hcl oral soln
ondansetron odt
ONFI
OPSUMIT
ORFADIN
ORKAMBI
oxandrolone tab 10mg
oxandrolone tab 2.5mg
oxcarbazepine
oxybutynin chloride
OXYCODONE HCL
oxycodone hcl
oxycodone w/ acetaminophen
oxycodone w/ acetaminophen
oxycodone w/ acetaminophen
oxycodone w/ acetaminophen
oxycodone w/ acetaminophen
22
10
10
22
22
38
38
37
19
22
27
11
34
34
34
34
34
34
34
34
32
40
29
50
11
52
50
50
P
pacerone
paclitaxel
paliperidone
pamidronate disodium
pantoprazole sodium tbec
paricalcitol
paroxetine hcl tabs
paser d/r
PATADAY
PAXIL
PAZEO
PEG 3350-KCL-SOD BICARB-SOD
CHLORIDE-SOD SULFATE
PEGASYS
PEGASYS PROCLICK
penicillin g procaine
penicillin v potassium
pentoxifylline
PERFOROMIST
perindopril erbumine
periogard
permethrin
phenadoz
phenelzine sulfate
phenergan
phenobarbital
phenytek
phenytoin
phenytoin sodium
phenytoin sodium extended
pioglitazone hcl
podofilox
polyethylene glycol 3350
polymyxin b-trimethoprim
POMALYST
POTASSIUM CHLORIDE
potassium chloride
potassium chloride microencapsulated
crystals cr
POTASSIUM CITRATE (ALKALINIZER)
POTIGA
PRADAXA
PRALUENT
pramipexole tab 0.125mg
pramipexole tab 0.25mg
pramipexole tab 0.5mg
pramipexole tab 0.75mg
pramipexole tab 1.5mg
pramipexole tab 1mg
pravastatin sodium
prazosin hcl
pred sod pho sol 5mg/5ml
PREDNISOLONE ACETATE (OPHTH)
prednisolone sodium phosphate (ophth)
prednisolone sol 15mg/5ml
prednisolone sol 25mg/5ml
prednisone con 5mg/ml
prednisone sol 5mg/5ml
44
38
17
49
46
29
20
41
41
41
39
39
39
39
24
22
36
49
34
34
24, 25
42
9
9
10-325mg 9
2.5-325mg 9
5-325mg 9
7.5-325mg 9
soln
10
60
19
15
29
36
41
46
27
12
47
27
47
40
12
12
14
14
43
48
18
52
52
39
27
39
25
25
25
25
25
35
51
40
46
44
45
45
45
42
25
42
20
28
28
28
28
28
28
19
18
37
47
47
37
37
37
37
.
prednisone tab 10mg
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 20mg
prednisone tab 50mg
prednisone tab 5mg
PREMARIN
premasol 10%
premasol 6%
prenatal vitamin/folic acid > 0.8 mg
(generic)
PREZISTA
PRIMAQUINE PHOSPHATE
primidone
PRISTIQ
PRIVIGEN
probenecid
prochlorperazine inj
prochlorperazine maleate
prochlorperazine supp
PROCRIT
procto-med
procto-pak
proctosol hc cre 2.5%
proctozone hc
PROGLYCEM SUS 50MG/ML
PROLASTIN-C
PROLENSA
PROLEUKIN
PROLIA
PROMACTA
promethazine hcl
promethegan
propafenone hcl
propafenone hcl 12hr
proparacaine hcl
propranolol & hydrochlorothiazide
propranolol cap er
propranolol hcl
propranolol oral sol
propylthiouracil
PULMICORT FLEXHALER
PULMOZYME
pyridostigmine tab 60mg
37
37
37
37
37
37
37
45
45
RAVICTI
REBETOL SOLN
REGRANEX
RELENZA DISKHALER
RELISTOR
REMICADE
REMODULIN
RENVELA PAK
RENVELA TAB 800MG
repaglinide
RESTASIS
REVATIO
REVLIMID
REXULTI
29,
REYATAZ
ribasphere
12,
ribavirin cap 200mg
ribavirin tab 200mg
rifampin
riluzole
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
risperidone
RITUXAN
rivastigmine tartrate
rivastigmine td patch 24hr 13.3
mg/24hr
rivastigmine td patch 24hr 4.6 mg/24hr
rivastigmine td patch 24hr 9.5 mg/24hr
rizatriptan benzoate
ropinirole tab 0.25mg
ropinirole tab 0.5mg
ropinirole tab 1mg
ropinirole tab 2mg
ropinirole tab 3mg
ropinirole tab 4mg
ropinirole tab 5mg
rosuvastatin calcium
roweepra
46
11
11
25
27
44
8
39
39
39
43
50
50
50
50
38
49
47
15
38
43
39
40
19
19
47
20
20
20
20
39
49
49
32
Q
quetiapine fumarate
quinapril hcl
quinapril-hydrochlorothiazide
quinidine sulfate
quinine sulfate
29
18
18
19
11
R
raloxifene tab 60mg
ramipril
RANEXA
ranitidine hcl
ranitidine hcl inj
ranitidine syrup
38
18
22
40
40
40
61
S
SABRIL
SANDIMMUNE
SANDOSTATIN LAR DEPOT
SANTYL
SAPHRIS
selenium sulfide
SENSIPAR
SEREVENT DISKUS
SEROQUEL XR
sertraline hcl
SIGNIFOR
sildenafil citrate (pulmonary
hypertension)
SILENOR
SILVER SULFADIAZINE
SIMBRINZA
simvastatin
36
12
52
12
41
44
22
38
38
35
47
22
44
30
11
13
13
13
12
32
30
30
30
30
30
15
26
26
26
26
32
28
28
28
28
28
28
28
19
25
25
44
38
52
30
50
36
48
30
27
38
22
31
50
47
19
.
SIRTURO
SIVEXTRO
SODIUM CHLORIDE 0.45% VIA
SODIUM CHLORIDE 0.9%
SODIUM CHLORIDE INJ 0.9%
sodium fluoride chew; tab; 1.1 (0.5 f)
mg/ml soln
sodium phenylbutyrate
sodium polystyrene sulfonate
SOMATULINE DEPOT
SOMAVERT
sorine
sotalol hcl
sotalol hcl (afib/afl)
SOVALDI
spironolactone
spironolactone & hydrochlorothiazide
sprintec 28 day
SPRYCEL
STERILE WATER IRRIGATION
STIVARGA
STRATTERA
SUBOXONE MIS 12-3MG
SUBOXONE MIS 2-0.5MG
SUBOXONE MIS 4-1MG
SUBOXONE MIS 8-2MG
sucralfate
sulfacet sod oin 10% op
sulfacetamide sod-prednisolone
sulfacetamide sodium (ophth)
sulfamethoxazole-trimethop ds
sulfamethoxazole-trimethoprim
sulfamethoxazole-trimethoprim inj
SULFAMYLON
sulfasalazine
sulfasalazine ec
sulindac
SUMATRIPTAN
SUMATRIPTAN INJ 4MG/0.5ML
sumatriptan inj 6mg/0.5ml
sumatriptan succinate
SUPRAX
suprax
SUPREP BOWEL PREP
SUSTIVA
SUTENT
SYLATRON KIT 200MCG
SYLATRON KIT 300MCG
SYLATRON KIT 600MCG
SYMBICORT
SYMLINPEN 120
SYMLINPEN 60
SYNAREL
SYNRIBO
SYNTHROID
T
tacrolimus
tacrolimus (topical)
12
10
45
52
45
45
37
36
38
38
19
19
19
13
18
22
36
17
52
17
31
33
33
33
33
41
46
46
46
10
10
10
50
40
40
8
32
32
32
32
13
13
40
11
17
17
17
17
49
34
34
36
17
39
45
51
62
TAFINLAR
TAGRISSO
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TARCEVA
TARGRETIN
TASIGNA
TAZORAC
taztia xt
TECENTRIQ
temazepam
terazosin hcl
terbinafine hcl
terconazole vaginal
testosterone cypionate
testosterone enanthate
TETRABENAZINE
THALOMID
theophylline
thioridazine hcl
timolol maleate
timolol maleate (ophth) soln
TIMOLOL MALEATE GEL
TIVICAY
11,
tizanidine hcl
TOBRADEX
TOBRADEX ST
tobramycin
tobramycin (ophth)
tobramycin inj 10mg/ml
tobramycin inj 80mg/2ml
tobramycin-dexamethasone
TOBREX
tolterodine tartrate
topiramate
toposar
topotecan hcl
torsemide tabs
TOUJEO SOLOSTAR
TOVIAZ
TRACLEER
TRADJENTA
tramadol hcl
tramadol-acetaminophen
trandolapril
tranexamic acid
TRANSDERM-SCOP
TRAVATAN Z
trazodone hcl
TRELSTAR DEP INJ 3.75MG
TRELSTAR LA INJ 11.25MG
TRESIBA FLEXTOUCH
TRETINOIN
tretinoin
tri-sprintec 28 day
triamcinolone acetonide (mouth)
triamcinolone acetonide (topical)
triamterene & hydrochlorothiazide
triamterene & hydrochlorothiazide cap
17
17
13
16
41
17
51
17
50
21
15
31
18
11
42
34
34
32
44
49
30
20
47
47
12
33
46
46
10
46
10
10
46
46
42
25
17
18
22
34
42
22
35
8
8
18
43
40
47
27
16
16
34
50
50
36
52
51
22
.
37.5-25 mg
triderm
trilyte
trimethoprim
trimipramine maleate
TRINESSA
TRINTELLIX
trospium chloride
TRULICITY
TRUVADA TAB 100-150
TRUVADA TAB 133-200
TRUVADA TAB 167-250
TRUVADA TAB 200-300
TYBOST
TYKERB
TYSABRI
U
ULORIC
UNITHROID
UPTRAVI
V
VAGIFEM
valacyclovir hcl
VALCHLOR
valproate sodium
valproic acid
valsartan
valsartan & hctz tab
vancomycin hcl
VASCEPA
VELCADE
VENCLEXTA
VENCLEXTA STARTING PACK
venlafaxine hcl
VENTAVIS
VENTOLIN HFA
VERAPAMIL CAP ER
verapamil cap er
verapamil hcl
verapamil tab er
VERSACLOZ
VESICARE
VICTOZA
VIGAMOX
VIIBRYD STARTER PACK
VIIBRYD TAB
VIMPAT
vinblastine sulfate
vincasar
vincristine sulfate
vinorelbine tartrate
VIREAD
VOTRIENT
VRAYLAR
VRAYLAR THERAPY PACK
VYTORIN
22
51
40
10
27
36
27
42
34
12
12
12
12
12
17
32
8
39
22, 23
37
13
51
25
25
19
19
11
20
15
15
15
27
23
48
21
21
21
21
30
42
34
46
27
27
25
15
15
15
15
12
17
30
30
20
63
W
warfarin sodium
WELCHOL
42
20
X
XALKORI
XARELTO
XARELTO STARTER PACK
XELJANZ
XELJANZ XR
XGEVA
XIFAXAN
XIGDUO XR TAB 10-1000MG
XIGDUO XR TAB 10-500MG
XIGDUO XR TAB 5-1000MG
XIGDUO XR TAB 5-500MG
XOLAIR
XOPENEX HFA
XTANDI
XYREM
17
43
43
44
44
38
41
35
35
35
35
49
48
16
33
Y
YERVOY
15
Z
zafirlukast
ZAVESCA
ZAZOLE CREAM 0.8%
ZELBORAF
ZEMAIRA
zenatane
ZENPEP
ZETIA TAB 10MG
ZIAGEN
zidovudine cap 100mg
zidovudine syp 50mg/5ml
ziprasidone hcl
ZIRGAN
ZOLINZA
zolmitriptan
zolmitriptan odt
zolpidem tartrate
zonisamide
ZONTIVITY
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.75MG
ZOSTAVAX
ZYDELIG
ZYKADIA
ZYLET
ZYPREXA RELPREVV INJ 210MG
ZYTIGA
48
37
42
17
49
50
41
20
12
12
12
30
46
15
32
32
32
25
43
45
45
45
45
17
17
46
30
16
Martin’s Point Health Care complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. Martin’s Point Health Care
does not exclude people or treat them differently because of race, color, national origin, age, disability, or
sex.
Martin’s Point Health Care:
•
•
Provides free aids and services to people with disabilities to communicate effectively with us, such
as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats,
other formats)
Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact the Martin’s Point Generations Advantage Grievance Specialist.
If you believe that Martin’s Point Health Care has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Grievance Specialist, Martin’s Point Generations Advantage, PO Box 8832, Portland, ME 04104-8832, 1866-544-7504, TTY: 711, Fax: 207-828-7824. You can file a grievance in person, by mail, or by fax. If you
need help filing a grievance, the Martin’s Point Generations Advantage Grievance Specialist is available to
help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at
ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019 (TDD: 1-800-537-7697)
Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.
64
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Appelez le 1-866-544-7504 (ATS : 711).
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al
1-866-544-7504 (TTY: 711).
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung. Rufnummer: 1-866-544-7504 (TTY: 711).
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CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-866-5447504 (TTY: 711).
‫ )رﻗﻢ ھﺎﺗﻒ اﻟﺼﻢ‬866-544-7504-1 ‫ اﺗﺼﻞ ﺑﺮﻗﻢ‬.‫ ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن‬،‫ إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ‬:‫ﻣﻠﺤﻮظﺔ‬
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παρέχονται δωρεάν. Καλέστε 1-866-544-7504 (TTY: 711).
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.
Звоните 1-866-544-7504 (телетайп: 711).
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica
gratuiti. Chiamare il numero 1-866-544-7504 (TTY: 711).
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika
nang walang bayad. Tumawag sa 1-866-544-7504 (TTY: 711).
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-866-5447504 (TTY: 711)번으로 전화해 주십시오.
ध्यान द�: य�द आप िहं दी बोलते ह� तो आपके िलए मुफ्त म� भाषा सहायता सेवाएं उपलब्ध ह�। 1-866-544-7504 (TTY:
711) पर कॉल कर� ।
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod
numer 1-866-544-7504 (TTY: 711).
ध्यान �दनुहोस:् तपाइ�ले नेपाल� बोल्नुहुन्छ भने तपाइ�को �निम्त भाषा सहायता सेवाहरू �नःशुल्क रूपमा उपलब्ध छ । फोन गनह
ुर् ोस ् 1-866-544-7504
(�ट�टवाइ: 711) ।
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This abridged formulary was updated on 08/05/2016. This is not a
complete list of drugs covered by our plan. For a complete listing
or other questions, please contact Martin’s Point Generations
Advantage Member Services at 1-866-544-7504 or, for TTY users, 711.
We are available 8 am–8 pm, seven days a week from October 1 to February 14; and Monday
through Friday the rest of the year. Or visit our website at www.MartinsPoint.org/Medicare.