Network Health
2016 Standard Preferred
Drug List
For the latest version of Network Health Preferred Drug list, log onto
networkhealth.com/formulary
October 2016
S0-010-61-10/16
-1Please refer to the member/participant’s Certificate of Coverage, Summary Plan Description, Policy, Prescription Drug Rider, and
Prescription Benefit Summary of Member/Participant Responsibility Table for particular plan design limitations. Network Health’s
PDL and prior authorization policies govern the rules and restrictions outlined in this document.
LAST UPDATED 10/2016
PURPOSE
Network Health developed the Preferred Drug List (PDL) to provide members/participants and practitioners
with a listing of commonly prescribed medications. This listing includes preferred and non-preferred
medications and indicates which Co-Payment/Co-Insurance tier applies. Tiers 1, 2 and 4 indicate preferred
medications. Tiers 3 and 5 indicate non-preferred medications. For members/participants with a three tier or
four-tier benefit, please reference the tables below for further explanation of tiering. Defined medications
listed in the ACA Preventative Drug List are subject to a $0 Co-Payment.
Three-Tier Benefit
Tier 1
Generics
Four-Tier Benefit
Tier 1
Generics
Tier 2
Preferred Brand/Preferred
Specialty
Tier 2
Preferred-Brand
Tier 3
Non-Preferred Brand/Non-Preferred
Specialty
Tier 3
Non-Preferred
Brand
Tier4
Preferred/Non-Preferred
Specialty
DEVELOPMENT OF THE PREFERRED DRUG LIST
Network Health’s Pharmacy and Therapeutics Committee (P and T Committee) developed the PDL
document. This committee, composed of practitioners and pharmacists from various medical specialties,
reviewed the medications in all therapeutic categories based on safety, effectiveness and cost.
PDL development and maintenance is a dynamic process. The P and T Committee will regularly review new
and existing medications to ensure the PDL remains responsive to the needs of members/participants and
health care providers. The PDL will be updated periodically. For the latest version of the Network Health
PDL, go to networkhealth.com
Network Health Pharmaceutical Benefits Management Program is based on optimal standards of medical practice.
Network Health’s P and T Committee develops and monitors all pharmaceutical management policies, procedures,
authorization criteria and the PDL.
Network Health delegates to the Pharmacy Benefits Management (PBM) company the approval process for prior
authorization required medications, non-formulary medications, vacation override, quantity level limits and
prescriber status exceptions. A pharmacist reviews all authorization/ exception requests that do not meet Network
Health’s criteria. If the pharmacist determines a denial is warranted, The PBM provides the verbal and written
communication of the denial, and how the denial may be appealed. The processing of appeals remains a Network
Health function.
PREFERRED DRUG LIST MEDICATIONS
The PDL applies to prescription medications provided to outpatients. This is typically limited to medications
obtained from participating pharmacies. Co-Payments/Co-Insurances and utilization management rules may
also apply to medications administered in the practitioner’s office. The PDL does not apply to medications
given in the inpatient hospital setting. Please refer to your Summary of Member/Participant Responsibility
Table and your Prescription Drug (Rx) Rider for which Co-Payments apply to your benefit.
UNAPPROVED USE OF PREFERRED DRUG LIST MEDICATIONS
The Certificate of Coverage, Summary Plan Description or policy states a medication will be eligible for
coverage only if it is a Food and Drug Administration (FDA) approved medication used for non-experimental
reasons. Non-experimental uses include the labeled indication(s) (FDA-approved) and other indications
accepted as effective by scientific evidence and informed professional opinion. Experimental and
investigational drugs, and drugs used for cosmetic purposes, such as weight loss or erectile dysfunction are
not eligible for coverage. Members/participants should refer to the Certificate of Coverage, Summary Plan
Description or policy for a detailed list of exclusions.
-2Please refer to the member/participant’s Certificate of Coverage, Summary Plan Description, Policy, Prescription Drug Rider, and
Prescription Benefit Summary of Member/Participant Responsibility Table for particular plan design limitations. Network Health’s
PDL and prior authorization policies govern the rules and restrictions outlined in this document.
LAST UPDATED 10/2016
CO-PAYMENT/CO-INSURANCE DETERMINATION
The information listed in this document contains the most commonly-prescribed medications and was current
at the time of publishing, however, changes occur frequently. The member/participant’s actual CoPayment/Co-Insurance will be determined at the time the prescription is filled. The member/participant will
only pay the applicable Co-Payment/Co-Insurance for the prescription unless one of the following conditions
apply:
· GENERIC MEDICATIONS
If the practitioner indicates "Dispense As Written", or if the member/participant requests the brand name
product for a medication where a generic is available, the member/participant must pay the applicable
Co-Payment/Co-Insurance plus the ancillary charge. The ancillary charge is the cost difference between
the brand name product and the generic product. When a generic substitution conflicts with state
regulations or restrictions, the pharmacist must gain approval from the prescriber to use the generic
equivalent.
·
NON-PRESCRIPTION MEDICATIONS
Unless a specific exception is made, non-prescription or over-the-counter (OTC) products are not
covered. If a prescription is written for a medication available as an OTC product, the prescription
product will not be covered. If the member/participant or practitioner insists on the prescription product,
the member/participant will be responsible for the entire cost of the prescription.
·
SPECIALTY PRODUCTS
The P and T Committee designated certain pharmaceutical products as specialty products. The PDL lists
these products and indicates if they are preferred or non-preferred. For members/participants with a
three-tier prescription benefit, these products will be covered as tier 2 (preferred products) and tier 3
(non-preferred products). For members/participants with a four-tier benefit, all specialty products will be
covered as tier 4. For members/participants with a five-tier prescription benefit, these products will be
covered as tier 4 (preferred products) and tier 5 (non-preferred products). Specialty products must be
obtained through Network Health’s contracted specialty pharmacy (unless otherwise indicated in the
Network Health PDL, in the member/participant’s Prescription Drug (RX) Rider, or if the medication is
administered in the practitioner’s office).
·
COMPOUNDED PRESCRIPTIONS
Approved compounded prescriptions will be covered at the tier 3 Co-Payment/Co-Insurance amount.
Please refer to the Prescription Benefit Summary of Member/Participant Responsibility Table located
under the Prescription Coverage tab in the Member/Participant Handbook for specific Co-Payment/CoInsurance information.
SMOKING CESSATION PRODUCTS
The prescription and OTC smoking cessation products listed in this document will be covered at no cost for
up to 180 days per year (two quitting attempts per year at a 90 days per quit attempt). The year is 365 days
from your first prescription fill.
PREFERRED DRUG LIST ORGANIZATION
Medications are grouped by drug-class categories. Please refer to the INDEX section at the back of the PDL
for an alphabetical listing of medications, as well as a reference to the specific page number each medication
falls on. Members/participants will need to locate the medication within the chapter section to verify which
tier the medication falls within, as well as determine if there are any special requirements or limitations for
using the medication. When a medication is only available as a brand name product, it is listed in CAPITAL
LETTERS. When a generic is available, it is listed using the generic name in bolded lowercase letters. It
should be noted that even if a medication is listed, it does not necessarily mean that all strengths and dosage
forms have the same Co-Payment/Co-Insurance and/or limitations. Some of the common exceptions have
been indicated, however, due to the size of the PDL, a comprehensive listing of all dosage forms and names
was not possible. For information on medications that are not listed, please call Caremark at 855-282-8476 or
go to www.caremark.com.
-3Please refer to the member/participant’s Certificate of Coverage, Summary Plan Description, Policy, Prescription Drug Rider, and
Prescription Benefit Summary of Member/Participant Responsibility Table for particular plan design limitations. Network Health’s
PDL and prior authorization policies govern the rules and restrictions outlined in this document.
LAST UPDATED 10/2016
PRIOR AUTHORIZATION, QUANTITY LIMITS, STEP THERAPY
To promote the most appropriate utilization, certain medications have additional restrictions applied to them.
These restrictions have been established by the P and T Committee with input from local practitioners and
consideration of the current medical literature, and are indicated in the COMMENTS column of the PDL. In
the case of medications requiring prior authorization, the member/participant’s practitioner must request
approval for coverage prior to the prescription being filled. These medications contain the letters “PA” in the
COMMENTS column. Prescriptions for medications with quantity limits may not be dispensed in quantities
greater than is listed. The COMMENTS column identifies these medications with “QL=” followed by the
limit. Finally, some medications follow step therapy rules. That means different product(s) must be tried
before Network Health will cover the requested medication. These medications are indicated in the
COMMENTS column with “ST”. If the member/participant and their practitioner feel that any of the above
restrictions do not meet the needs of the member/participant, the practitioner may call the PBM to have a
request for an exception reviewed.
SELF-ADMINISTERED INJECTABLES
Self-administered injectables refer to an injection given by the member/participant or caregiver in the home.
This does not include those drugs delivered via IM (intramuscular), IV (intravenous) or IA (intra-arterial)
injections or any drug administered through infusion. In order to promote the appropriate level of care, those
medications that can safely be self-administered will only be available under the prescription benefit. If these
medications are administered in the office, they will only be covered for one dose unless it is determined that
the member/participant cannot self-inject. These drugs usually require prior authorization. Contact the prior
authorization center to review the clinical and/or location criteria. These medications contain the letters “SA”
in the COMMENTS column. These injections must be obtained with a prescription and from a Network
Health participating specialty pharmacy unless noted on the PDL.
The information listed in this document contains the most commonly prescribed medications and was
current at the time of posting, however, changes occur frequently. The actual Co-Payment/CoInsurance will be determined at the time the prescription is filled. Individual and Family Plan (IFP)
members who have a ridered condition may have drugs that are listed in the PDL that are not covered.
For more information about your IFP benefits contact Network Health Customer Service at 855-2751400. For additional prescription drug information, log onto www.caremark.com or call Caremark at
855-282-8476
-4Please refer to the member/participant’s Certificate of Coverage, Summary Plan Description, Policy, Prescription Drug Rider, and
Prescription Benefit Summary of Member/Participant Responsibility Table for particular plan design limitations. Network Health’s
PDL and prior authorization policies govern the rules and restrictions outlined in this document.
LAST UPDATED 10/2016
LEGEND
TIER
DESCRIPTION
0
ACA Preventive Medications
1
Tier 1
2
3
4
5
Tier 2
Tier 3
Preferred Specialty
Non-Preferred Specialty
TYPE
DESCRIPTION
QL
Quantity Limit
There is a limit on the amount of this drug that is covered per prescription, or within a
specific time frame.
PA
Prior Authorization
You (or your physician) are required to get prior authorization before you fill your
prescription for this drug. Without prior approval, we may not cover this drug.
ST
Step Therapy
In some cases, you may be required to first try certain drugs to treat your medical
condition before we will cover another drug for that condition.
GL
Gender Limit
This prescription drug may only be covered for a single gender.
AL1
Age Limit
This prescription drug may only be covered if you meet the minimum or maximum age
limit.
Custom
This drug has unique restrictions.
SA/PAR
You (or your physician) are required to get prior authorization before you fill your
prescription for this drug. Without prior approval, we may not cover this drug.
MN-PA
Medical necessity prior authorization.
C
SA
MN
-5-
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
adult aspirin ec low strength tab dr 81 mg
anacin tab dr 81 mg
aspir-81 tab dr 81 mg
aspir-low tab dr 81 mg
aspir-trin tab dr 325 mg
aspirin (chew tab 81 mg, tab 81 mg, tab dr 81 mg,
81 mg, 325 mg, tab 325 mg, tab dr 325 mg)
aspirin adult low dose tab dr 81 mg
aspirin adult low strength (chew tab 81 mg, tab dr
81 mg)
aspirin childrens chew tab 81 mg
aspirin ec (ec 81 mg, ec 325 mg, ec tab dr 81 mg,
ec tab dr 325 mg)
aspirin ec lo-dose tab dr 81 mg
aspirin ec low dose tab dr 81 mg
aspirin ec low strength tab dr 81 mg
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
-6-
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
aspirin low strength chew tab 81 mg
ACA Preventive Medications
aspirtab tab dr 324 mg
bayer advanced aspirin reg st tab 325 mg
bayer aspirin (tab 325 mg, tab dr 325 mg)
bayer aspirin ec low dose tab dr 81 mg
bayer aspirin regimen tab dr 325 mg
bayer low dose (chew tab 81 mg, tab dr 81 mg)
bayer low strength tab dr 81 mg
LIMITS & RESTRICTIONS
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
CAMBIA PACKET 50 MG
Tier 3
celecoxib (cap 50 mg, cap 100 mg, cap 200 mg,
cap 400 mg)
Tier 1
childrens aspirin (chew tab 81 mg, 81 mg)
ACA Preventive Medications
childrens aspirin low strength chew tab 81 mg
cvs aspirin (tab 325 mg, tab dr 81 mg)
cvs aspirin adult low dose chew tab 81 mg
cvs aspirin adult low strength tab dr 81 mg
cvs aspirin child chew tab 81 mg
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
-7-
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
QL
9 packets per fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
cvs aspirin ec (ec tab dr 81 mg, ec tab dr 325 mg)
ACA Preventive Medications
cvs aspirin low dose tab dr 81 mg
cvs aspirin low strength chew tab 81 mg
cvs childrens aspirin chew tab 81 mg
LIMITS & RESTRICTIONS
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
diclofenac potassium tab 50 mg
Tier 1
diclofenac sodium (solution 1.5 %, tab dr 25 mg,
tab dr 50 mg, tab dr 75 mg)
Tier 1
diclofenac sodium er tab er 24h 100 mg
Tier 1
diclofenac-misoprostol (tab dr 50-0.2 mg, tab dr
75-0.2 mg)
Tier 1
diflunisal tab 500 mg
Tier 1
DYLOJECT SOLUTION 37.5 MG/ML
Tier 3
ec-81 aspirin tab dr 81 mg
ACA Preventive Medications
ecotrin low strength tab dr 81 mg
ecpirin tab dr 325 mg
eq adult aspirin low strength tab dr 81 mg
eq aspirin (tab 325 mg, tab dr 325 mg)
eq aspirin adult low dose tab dr 81 mg
eq aspirin low dose (chew tab 81 mg, tab dr 81
mg)
eq childrens aspirin chew tab 81 mg
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
-8-
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
eql adult aspirin low strength tab dr 81 mg
ACA Preventive Medications
eql aspirin ec tab dr 325 mg
eql aspirin low dose (chew tab 81 mg, tab dr 81
mg)
eql aspirin tab 325 mg
eql childrens aspirin chew tab 81 mg
LIMITS & RESTRICTIONS
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
etodolac (cap 200 mg, cap 300 mg, tab 400 mg,
tab 500 mg)
Tier 1
etodolac er (er tab er 24h 400 mg, er tab er 24h
500 mg, er tab er 24h 600 mg)
Tier 1
fenoprofen calcium (cap 200 mg, cap 400 mg, tab
600 mg)
Tier 1
FLECTOR PATCH 1.3 %
Tier 3
flurbiprofen (tab 50 mg, tab 100 mg)
Tier 1
gnp adult aspirin low strength (chew tab 81 mg,
tab dr 81 mg)
ACA Preventive Medications
gnp aspirin (tab 325 mg, tab dr 81 mg, tab dr 325
mg)
gnp aspirin low dose tab dr 81 mg
goodsense aspirin low dose tab dr 81 mg
halfprin tab dr 81 mg
hm aspirin (chew tab 81 mg, tab 325 mg)
hm aspirin ec low dose tab dr 81 mg
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
-9-
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
ibuprofen (tab 400 mg, tab 600 mg, tab 800 mg)
Tier 1
indomethacin (cap 25 mg, cap 50 mg)
Tier 1
indomethacin er cap er 75 mg
Tier 1
indomethacin sodium recon soln 1 mg
Tier 3
ketoprofen (cap 50 mg, cap 75 mg)
Tier 1
ketoprofen er cap er 24h 200 mg
Tier 1
ketorolac tromethamine tab 10 mg
Tier 1
kls aspirin ec tab dr 325 mg
ACA Preventive Medications
kls aspirin low dose tab dr 81 mg
kp aspirin tab dr 81 mg
LIMITS & RESTRICTIONS
ACA Preventive Medications
ACA Preventive Medications
meclofenamate sodium (cap 50 mg, cap 100 mg)
Tier 1
mefenamic acid cap 250 mg
Tier 1
meloxicam (suspension 7.5 mg/5ml, tab 7.5 mg,
tab 15 mg)
Tier 1
miniprin low dose tab dr 81 mg
ACA Preventive Medications
mm aspirin tab 325 mg
ACA Preventive Medications
nabumetone (tab 500 mg, tab 750 mg)
Tier 1
naproxen (suspension 125 mg/5ml, tab 250 mg,
tab 375 mg, 375 mg, tab 500 mg)
Tier 1
naproxen dr (dr tab dr 375 mg, dr tab dr 500 mg)
Tier 1
naproxen kit tab 500 mg
Tier 1
naproxen sodium (tab 275 mg, tab 550 mg)
Tier 1
naproxen sodium er (er tab er 24h 500 mg, er tab
er 24h 375 mg)
Tier 3
norwich aspirin tab 325 mg
ACA Preventive Medications
oxaprozin tab 600 mg
Tier 1
PENNSAID SOLUTION 2 %
Tier 3
piroxicam (cap 10 mg, cap 20 mg)
Tier 1
- 10 -
QL
20 tablets per fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
px enteric aspirin (tab dr 81 mg, tab dr 325 mg)
ACA Preventive Medications
qc aspirin (tab 325 mg, tab dr 325 mg)
LIMITS & RESTRICTIONS
ACA Preventive Medications
qc aspirin low dose chew tab 81 mg
ACA Preventive Medications
qc aspirin low dose tab dr 81 mg
ACA Preventive Medications
qc childrens aspirin chew tab 81 mg
ra aspirin adult low dose chew tab 81 mg
ra aspirin adult low strength (chew tab 81 mg, tab
dr 81 mg)
ra aspirin childrens chew tab 81 mg
ra aspirin ec (ec tab dr 81 mg, ec tab dr 325 mg)
ra aspirin ec adult low st tab dr 81 mg
ra aspirin tab 325 mg
ra childrens aspirin chew tab 81 mg
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
salsalate (tab 500 mg, tab 750 mg)
Tier 1
sb aspirin (tab 325 mg, tab dr 81 mg)
ACA Preventive Medications
sb aspirin ec tab dr 325 mg
sb childrens aspirin chew tab 81 mg
ACA Preventive Medications
ACA Preventive Medications
- 11 -
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
sm aspirin adult low strength (chew tab 81 mg, tab
dr 81 mg)
ACA Preventive Medications
sm aspirin ec low strength tab dr 81 mg
ACA Preventive Medications
sm aspirin ec tab dr 325 mg
sm aspirin low dose tab dr 81 mg
sm aspirin tab 325 mg
sm childrens aspirin chew tab 81 mg
LIMITS & RESTRICTIONS
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
SPRIX SOLUTION 15.75 MG/SPRAY
Tier 3
st joseph aspirin (chew tab 81 mg, tab dr 81 mg)
ACA Preventive Medications
sulindac (tab 150 mg, tab 200 mg)
Tier 1
tgt aspirin (chew tab 81 mg, tab 325 mg, tab dr 81
mg)
ACA Preventive Medications
tgt aspirin ec tab dr 325 mg
ACA Preventive Medications
tgt aspirin low dose tab dr 81 mg
tgt childrens aspirin chew tab 81 mg
th aspirin low dose (chew tab 81 mg, tab dr 81 mg)
th aspirin tab 325 mg
th enteric aspirin tab dr 325 mg
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
- 12 -
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
QL
5 inhalers per fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
AL1
At least 45 yrs old
QL
100 / 1 fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
TIVORBEX (CAP 20 MG, CAP 40 MG)
Tier 3
tolmetin sodium (cap 400 mg, tab 200 mg, tab 600
mg)
Tier 1
VIVLODEX (CAP 5 MG, CAP 10 MG)
Tier 3
ZIPSOR CAP 25 MG
Tier 3
ZORVOLEX (CAP 18 MG, CAP 35 MG)
Tier 3
LIMITS & RESTRICTIONS
OPIOID ANALGESICS, LONG-ACTING
BELBUCA (FILM 75 MCG, FILM 150 MCG, FILM
300 MCG, FILM 450 MCG, FILM 600 MCG, FILM
750 MCG, FILM 900 MCG)
Tier 3
BUTRANS (PATCH WK 5, PATCH WK 7.5,
PATCH WK 10, PATCH WK 15, PATCH WK 20)
Tier 3
EMBEDA (CAP ER 20-0.8 MG, CAP ER 30-1.2
MG, CAP ER 50-2 MG, CAP ER 60-2.4 MG, CAP
ER 80-3.2 MG, CAP ER 100-4 MG)
Tier 3
EXALGO TB24 DETER 32 MG
Tier 3
fentanyl (patch 72hr 12, patch 72hr 75, patch 72hr
50, patch 72hr 25, patch 72hr 100)
Tier 1
fentanyl (patch 72hr 62.5, patch 72hr 87.5, patch
72hr 37.5)
Tier 3
hydromorphone hcl er (er tb24 deter 16 mg, er
tb24 deter 12 mg, er tb24 deter 8 mg)
Tier 1
HYDROMORPHONE HCL ER TB24 DETER 32
MG
Tier 1
HYSINGLA ER (ER TB24 DETER 60 MG, ER
TB24 DETER 30 MG, ER TB24 DETER 80 MG,
ER TB24 DETER 100 MG, ER TB24 DETER 20
MG, ER TB24 DETER 120 MG, ER TB24 DETER
40 MG)
Tier 3
KADIAN (CAP ER 24H 40 MG, CAP ER 24H 200
MG)
Tier 3
levorphanol tartrate tab 2 mg
Tier 1
methadone hcl (conc 10 mg/ml, solution 5 mg/5ml,
solution 10 mg/5ml, tab 5 mg, tab 10 mg, tab sol
40 mg)
Tier 1
methadone hcl intensol conc 10 mg/ml
Tier 1
METHADONE HCL SOLUTION 10 MG/ML
Tier 3
methadose tab sol 40 mg
Tier 1
morphine sulfate er (er cap er 24h 50 mg, er cap
er 24h 100 mg, er cap er 24h 60 mg, er cap er 24h
30 mg, er cap er 24h 10 mg, er cap er 24h 20 mg,
er cap er 24h 80 mg, er tab er 15 mg, er tab er 30
mg, er tab er 60 mg, er tab er 100 mg, er tab er
200 mg)
Tier 1
- 13 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
morphine sulfate er beads (er beads cap er 24h 60
mg, er beads cap er 24h 45 mg, er beads cap er
24h 120 mg, er beads cap er 24h 75 mg, er beads
cap er 24h 30 mg, er beads cap er 24h 90 mg)
Tier 1
NUCYNTA ER (ER TAB ER 12H 100 MG, ER TAB
ER 12H 250 MG, ER TAB ER 12H 50 MG, ER
TAB ER 12H 150 MG, ER TAB ER 12H 200 MG)
Tier 2
OPANA ER (ER TB12 DETER 5 MG, ER TB12
DETER 15 MG, ER TB12 DETER 30 MG, ER
TB12 DETER 7.5 MG, ER TB12 DETER 20 MG,
ER TB12 DETER 40 MG, ER TB12 DETER 10
MG)
OXYCODONE HCL ER (ER TB12 DETER 30 MG,
ER TB12 DETER 15 MG, ER TB12 DETER 60
MG)
Tier 3
Tier 1
oxycodone hcl er (er tb12 deter 80 mg, er tb12
deter 10 mg, er tb12 deter 20 mg, er tb12 deter 40
mg)
Tier 1
OXYCONTIN (TB12 DETER 60 MG, TB12 DETER
30 MG, TB12 DETER 15 MG)
Tier 2
oxymorphone hcl er (er tab er 12h 10 mg, er tab er
12h 20 mg, er tab er 12h 15 mg, er tab er 12h 40
mg, er tab er 12h 5 mg, er tab er 12h 7.5 mg, er
tab er 12h 30 mg)
Tier 1
tramadol hcl er (biphasic) (er tab er 24h 200 mg, er
tab er 24h 100 mg, er tab er 24h 300 mg)
Tier 1
tramadol hcl er (er cap er 24h 100 mg, er cap er
24h 300 mg, er cap er 24h 200 mg)
Tier 3
tramadol hcl er (er tab er 24h 300 mg, er tab er
24h 200 mg, er tab er 24h 100 mg)
Tier 1
tramadol hcl er cap er 24h 150 mg
Tier 3
XTAMPZA ER (ER CP12 DETER 27 MG, ER
CP12 DETER 18 MG, ER CP12 DETER 13.5 MG,
ER CP12 DETER 36 MG, ER CP12 DETER 9 MG)
Tier 3
ZOHYDRO ER (ER CP12 DETER 50 MG, ER
CP12 DETER 30 MG, ER CP12 DETER 15 MG,
ER CP12 DETER 20 MG, ER CP12 DETER 40
MG, ER CP12 DETER 10 MG)
LIMITS & RESTRICTIONS
C
Generic for Conzip
Tier 3
OPIOID ANALGESICS, SHORT-ACTING
acetaminophen-codeine #2 tab 300-15 mg
Tier 1
acetaminophen-codeine #3 tab 300-30 mg
Tier 1
acetaminophen-codeine #4 tab 300-60 mg
Tier 1
acetaminophen-codeine (solution 120-12 mg/5ml,
tab 300-15 mg, tab 300-30 mg, tab 300-60 mg)
Tier 1
apap-caff-dihydrocodeine cap 320.5-30-16 mg
Tier 1
ascomp-codeine cap 50-325-40-30 mg
Tier 1
aspirin-caff-dihydrocodeine cap 356.4-30-16 mg
Tier 1
belladonna alkaloids-opium suppos 16.2-60 mg
Tier 3
- 14 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
belladonna-opium suppos 16.2-30 mg
Tier 3
butalbital-apap-caff-cod (cap 50-300-40-30 mg,
cap 50-325-40-30 mg)
Tier 1
butalbital-asa-caff-codeine cap 50-325-40-30 mg
Tier 1
butorphanol tartrate solution 10 mg/ml
Tier 1
CAPITAL/CODEINE SUSPENSION 120-12
MG/5ML
Tier 2
carisoprodol-aspirin-codeine tab 200-325-16 mg
Tier 1
codeine sulfate (tab 15 mg, tab 30 mg, tab 60 mg)
Tier 1
endocet (tab 5-325 mg, tab 7.5-325 mg, tab 10325 mg)
Tier 1
endodan tab 4.8355-325 mg
Tier 1
hydrocodone-acetaminophen (solution 2.5-108
mg/5ml, solution 5-217 mg/10ml, solution 7.5-325
mg/15ml, solution 10-325 mg/15ml, tab 2.5-325
mg, tab 5-300 mg, tab 5-325 mg, tab 7.5-325 mg,
tab 7.5-300 mg, tab 10-325 mg, tab 10-300 mg)
Tier 1
hydrocodone-ibuprofen (tab 2.5-200 mg, tab 5-200
mg, tab 7.5-200 mg, tab 10-200 mg)
Tier 1
hydromorphone hcl (liquid 1 mg/ml, solution 1
mg/ml, solution 2 mg/ml, solution 4 mg/ml, tab 2
mg, tab 4 mg, tab 8 mg)
Tier 1
hydromorphone hcl pf (solution 10 mg/ml, solution
50 mg/5ml, solution 500 mg/50ml)
Tier 1
hydromorphone hcl suppos 3 mg
Tier 3
ibudone tab 5-200 mg
Tier 1
lorcet hd tab 10-325 mg
Tier 1
lorcet plus tab 7.5-325 mg
Tier 1
lorcet tab 5-325 mg
Tier 1
lortab (tab 5-325 mg, tab 7.5-325 mg, tab 10-325
mg)
Tier 1
LORTAB ELIXIR 10-300 MG/15ML
Tier 3
meperidine hcl (solution 25 mg/ml, solution 50
mg/ml, solution 50 mg/5ml, solution 100 mg/ml, tab
50 mg, tab 100 mg)
Tier 1
MEPERIDINE HCL SOLUTION 10 MG/ML
Tier 1
morphine sulfate (concentrate) (20 mg/ml, solution
20 mg/ml, solution 100 mg/5ml)
Tier 1
morphine sulfate (solution 10 mg/5ml, solution 20
mg/5ml, tab 15 mg, tab 30 mg)
Tier 1
NUCYNTA (TAB 50 MG, TAB 75 MG, TAB 100
MG)
Tier 2
OPANA SOLUTION 1 MG/ML
Tier 2
LIMITS & RESTRICTIONS
QL
- 15 -
2 bottles per fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
oxycodone hcl (cap 5 mg, conc 100 mg/5ml,
solution 5 mg/5ml, tab 5 mg, tab 10 mg, tab 15 mg,
tab 20 mg, tab 30 mg)
Tier 1
oxycodone-acetaminophen (tab 2.5-325 mg, tab 5325 mg, tab 7.5-325 mg, tab 10-325 mg)
Tier 1
oxycodone-aspirin tab 4.8355-325 mg
Tier 1
oxycodone-ibuprofen tab 5-400 mg
Tier 1
oxymorphone hcl (tab 5 mg, tab 10 mg)
Tier 1
PRIMLEV (TAB 5-300 MG, TAB 7.5-300 MG, TAB
10-300 MG)
Tier 2
reprexain tab 10-200 mg
Tier 1
ROXICET SOLUTION 5-325 MG/5ML
Tier 2
roxicet tab 5-325 mg
Tier 1
tramadol hcl tab 50 mg
Tier 1
tramadol-acetaminophen tab 37.5-325 mg
Tier 1
verdrocet tab 2.5-325 mg
Tier 1
vicodin es tab 7.5-300 mg
Tier 1
vicodin hp tab 10-300 mg
Tier 1
vicodin tab 5-300 mg
Tier 1
XARTEMIS XR TAB ER 7.5-325 MG
Tier 3
xylon tab 10-200 mg
Tier 1
zamicet solution 10-325 mg/15ml
Tier 1
LIMITS & RESTRICTIONS
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl (pf) solution 4 %
Tier 1
lidocaine hcl solution 4 %
Tier 1
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calcium tab dr 333 mg
Tier 1
disulfiram (tab 250 mg, tab 500 mg)
Tier 1
naltrexone hcl tab 50 mg
Tier 1
OPIOID DEPENDENCE TREATMENTS
BUNAVAIL (FILM 2.1-0.3 MG, FILM 4.2-0.7 MG,
FILM 6.3-1 MG)
Tier 3
buprenorphine hcl (sl tab 2 mg, sl tab 8 mg,
solution 0.3 mg/ml)
Tier 1
buprenorphine hcl-naloxone hcl (sl tab 2-0.5 mg, sl
tab 8-2 mg)
Tier 1
SUBOXONE (FILM 2-0.5 MG, FILM 4-1 MG, FILM
8-2 MG, FILM 12-3 MG)
Tier 2
- 16 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
ZUBSOLV (SL TAB 1.4-0.36 MG, SL TAB 2.9-0.71
MG, SL TAB 5.7-1.4 MG, SL TAB 8.6-2.1 MG, SL
TAB 11.4-2.9 MG)
Tier 3
LIMITS & RESTRICTIONS
OPIOID REVERSAL AGENTS
NARCAN LIQUID 4 MG/0.1ML
Tier 2
SMOKING CESSATION AGENTS
buproban tab er 12h 150 mg
ACA Preventive Medications
C
Refer to the forward
bupropion hcl er (smoking det) (er 150 mg, er tab
er 12h 150 mg)
ACA Preventive Medications
C
Refer to the forward
CHANTIX (TAB 0.5 MG, TAB 1 MG)
ACA Preventive Medications
C
Refer to the forward
CHANTIX CONTINUING MONTH PAK TAB 1 MG
ACA Preventive Medications
C
Refer to the forward
CHANTIX STARTING MONTH PAK TAB 0.5 MG
X 11 & 1 MG X 42
ACA Preventive Medications
C
Refer to the forward
cvs nicotine (7 mg/24hr, 14 mg/24hr, 21 mg/24hr,
patch 24hr 14 mg/24hr, patch 24hr 7 mg/24hr)
ACA Preventive Medications
C
Refer to the forward
cvs nicotine polacrilex (2 mg, gum 2 mg, gum 4
mg, lozenge 2 mg, lozenge 4 mg)
ACA Preventive Medications
C
Refer to the forward
cvs nts step 1 patch 24hr 21 mg/24hr
ACA Preventive Medications
C
Refer to the forward
eq nicotine (gum 2 mg, 2 mg, gum 4 mg, lozenge 4
mg, patch 24hr 14 mg/24hr, patch 24hr 21
mg/24hr, patch 24hr 7 mg/24hr)
ACA Preventive Medications
C
Refer to the forward
eq nicotine polacrilex (gum 2 mg, gum 4 mg,
lozenge 2 mg, lozenge 4 mg)
ACA Preventive Medications
C
Refer to the forward
eq nicotine step 3 patch 24hr 7 mg/24hr
ACA Preventive Medications
C
Refer to the forward
eql nicotine (patch 24hr 14 mg/24hr, patch 24hr 7
mg/24hr, patch 24hr 21 mg/24hr)
ACA Preventive Medications
C
Refer to the forward
eql nicotine polacrilex (gum 2 mg, gum 4 mg,
lozenge 2 mg, lozenge 4 mg)
ACA Preventive Medications
C
Refer to the forward
gnp nicotine mini lozenge 2 mg
ACA Preventive Medications
C
Refer to the forward
gnp nicotine polacrilex (gum 2 mg, gum 4 mg,
lozenge 2 mg, lozenge 4 mg)
ACA Preventive Medications
C
Refer to the forward
hm nicotine (patch 24hr 21 mg/24hr, patch 24hr 7
mg/24hr, patch 24hr 14 mg/24hr)
ACA Preventive Medications
C
Refer to the forward
hm nicotine polacrilex (gum 2 mg, gum 4 mg,
lozenge 2 mg, lozenge 4 mg)
ACA Preventive Medications
C
Refer to the forward
kls quit2 (gum 2 mg, lozenge 2 mg)
ACA Preventive Medications
C
Refer to the forward
kls quit4 (gum 4 mg, lozenge 4 mg)
ACA Preventive Medications
C
Refer to the forward
nicorelief (gum 2 mg, gum 4 mg, lozenge 2 mg,
lozenge 4 mg)
ACA Preventive Medications
C
Refer to the forward
nicotine (patch 24hr 21 mg/24hr, patch 24hr 7
mg/24hr, patch 24hr 14 mg/24hr)
ACA Preventive Medications
C
Refer to the forward
- 17 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
NICOTINE KIT 21-14-7 MG/24HR
ACA Preventive Medications
nicotine mini (lozenge 2 mg, lozenge 4 mg)
ACA Preventive Medications
nicotine polacrilex (gum 2 mg, lozenge 2 mg, 2
mg, 4 mg, gum 4 mg, lozenge 4 mg)
C
Refer to the forward
ACA Preventive Medications
C
Refer to the forward
nicotine step 1 patch 24hr 21 mg/24hr
ACA Preventive Medications
C
Refer to the forward
nicotine step 2 patch 24hr 14 mg/24hr
ACA Preventive Medications
C
Refer to the forward
nicotine step 3 patch 24hr 7 mg/24hr
ACA Preventive Medications
C
Refer to the forward
NICOTROL INHALER 10 MG
ACA Preventive Medications
C
Refer to the forward
NICOTROL NS SOLUTION 10 MG/ML
ACA Preventive Medications
C
Refer to the forward
px stop smoking aid (gum 2 mg, gum 4 mg,
lozenge 2 mg, lozenge 4 mg)
ACA Preventive Medications
C
Refer to the forward
qc nicotine polacrilex gum 4 mg
ACA Preventive Medications
C
Refer to the forward
ra mini nicotine (lozenge 2 mg, lozenge 4 mg)
ACA Preventive Medications
C
Refer to the forward
ra nicotine (gum 2 mg, gum 4 mg, patch 24hr 21
mg/24hr, patch 24hr 7 mg/24hr, patch 24hr 14
mg/24hr)
ACA Preventive Medications
C
Refer to the forward
ra nicotine polacrilex (gum 2 mg, gum 4 mg,
lozenge 2 mg, lozenge 4 mg)
ACA Preventive Medications
C
Refer to the forward
sm nicotine (gum 4 mg, lozenge 2 mg, patch 24hr
14 mg/24hr, patch 24hr 7 mg/24hr, patch 24hr 21
mg/24hr)
ACA Preventive Medications
C
Refer to the forward
sm nicotine polacrilex (gum 2 mg, gum 4 mg,
lozenge 4 mg)
ACA Preventive Medications
C
Refer to the forward
sw nicotine polacrilex (gum 2 mg, gum 4 mg,
lozenge 2 mg, lozenge 4 mg)
ACA Preventive Medications
C
Refer to the forward
tgt nicotine (gum 2 mg, gum 4 mg)
ACA Preventive Medications
C
Refer to the forward
tgt nicotine polacrilex (gum 2 mg, gum 4 mg,
lozenge 2 mg, lozenge 4 mg)
ACA Preventive Medications
C
Refer to the forward
tgt nicotine step one patch 24hr 21 mg/24hr
ACA Preventive Medications
C
Refer to the forward
tgt nicotine step three patch 24hr 7 mg/24hr
ACA Preventive Medications
C
Refer to the forward
tgt nicotine step two patch 24hr 14 mg/24hr
ACA Preventive Medications
C
Refer to the forward
thrive (gum 2 mg, gum 4 mg)
ACA Preventive Medications
C
Refer to the forward
- 18 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
ANTIBACTERIALS
AMINOGLYCOSIDES
gentak ointment 0.3 %
Tier 1
gentamicin sulfate (cream 0.1 %, ointment 0.1 %,
ointment 0.3 %, solution 0.3 %)
Tier 1
neomycin sulfate tab 500 mg
Tier 1
paromomycin sulfate cap 250 mg
Tier 1
TOBRADEX OINTMENT 0.3-0.1 %
Tier 2
tobramycin solution 0.3 %
Tier 1
TOBREX OINTMENT 0.3 %
Tier 2
YODOXIN (TAB 210 MG, TAB 650 MG)
Tier 3
ANTIBACTERIALS, OTHER
ALTABAX OINTMENT 1 %
Tier 3
bacitracin ointment 500 unit/gm
Tier 1
BACTROBAN NASAL OINTMENT 2 %
Tier 2
CENTANY AT KIT 2 %
Tier 2
CLEOCIN SUPPOS 100 MG
Tier 2
clindamycin hcl (cap 75 mg, cap 150 mg, cap 300
mg)
Tier 1
clindamycin palmitate hcl recon soln 75 mg/5ml
Tier 1
clindamycin phosphate (cream 2 %, foam 1 %, gel
1 %, lotion 1 %, solution 1 %, solution 150 mg/ml)
Tier 1
FIRST-METRONIDAZOLE 100 RECON SUSP 100
MG/ML
Tier 3
FIRST-METRONIDAZOLE 50 RECON SUSP 50
MG/ML
Tier 3
FIRST-VANCOMYCIN 25 SOLUTION 25 MG/ML
Tier 3
FIRST-VANCOMYCIN 50 SOLUTION 50 MG/ML
Tier 3
hyolev mb tab 81 mg
Tier 1
methenamine hippurate tab 1 gm
Tier 1
methenamine mandelate (tab 0.5 gm, tab 1 gm)
Tier 1
metronidazole (cap 375 mg, cream 0.75 %, gel
0.75 %, gel 1 %, lotion 0.75 %, tab 250 mg, tab
500 mg)
Tier 1
MONUROL PACKET 3 GM
Tier 3
mupirocin calcium cream 2 %
Tier 1
mupirocin ointment 2 %
Tier 1
nitrofurantoin macrocrystal (cap 25 mg, cap 50 mg,
cap 100 mg)
Tier 1
- 19 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
nitrofurantoin monohyd macro cap 100 mg
Tier 1
nitrofurantoin suspension 25 mg/5ml
Tier 1
NORITATE CREAM 1 %
Tier 2
phosphasal tab 81.6 mg
Tier 1
PRIMSOL SOLUTION 50 MG/5ML
Tier 3
rosadan (cream 0.75 %, gel 0.75 %)
Tier 1
ROSADAN (KIT 0.75 % (CREAM), KIT 0.75 %
(GEL))
Tier 3
tinidazole (tab 250 mg, tab 500 mg)
Tier 1
trimethoprim tab 100 mg
Tier 1
ur n-c tab 81.6 mg
Tier 1
urelle tab 81 mg
Tier 1
uretron d/s tab
Tier 1
urin ds tab
Tier 1
uro-458 tab 81 mg
Tier 1
uro-l tab 81 mg
Tier 1
uroav-81 tab 81 mg
Tier 1
utira-c tab 81.6 mg
Tier 1
utrona-c tab 81.6 mg
Tier 1
vancomycin hcl (recon soln 10 gm, recon soln 500
mg, recon soln 1000 mg, recon soln 5000 mg)
Tier 1
VANCOMYCIN HCL RECON SOLN 750 MG
Tier 2
VANCOMYCIN+SYRSPEND SF PH4
SUSPENSION 50 MG/ML
Tier 3
vandazole gel 0.75 %
Tier 1
XIFAXAN TAB 200 MG
Tier 2
LIMITS & RESTRICTIONS
QL
9 tablets per fill
BETA-LACTAM, CEPHALOSPORINS
CEDAX (CAP 400 MG, RECON SUSP 90
MG/5ML, RECON SUSP 180 MG/5ML)
Tier 3
cefaclor (cap 250 mg, cap 500 mg)
Tier 1
CEFACLOR (RECON SUSP 125, RECON SUSP
250, RECON SUSP 375)
Tier 1
cefaclor er tab er 12h 500 mg
Tier 3
cefadroxil (cap 500 mg, recon susp 250 mg/5ml,
recon susp 500 mg/5ml, tab 1 gm)
Tier 1
cefdinir (cap 300 mg, recon susp 125 mg/5ml,
recon susp 250 mg/5ml)
Tier 1
cefditoren pivoxil (tab 200 mg, tab 400 mg)
Tier 1
cefixime (recon susp 100, recon susp 200)
Tier 3
- 20 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
cefpodoxime proxetil (recon susp 50 mg/5ml,
recon susp 100 mg/5ml, tab 100 mg, tab 200 mg)
Tier 1
cefprozil (recon susp 125 mg/5ml, recon susp 250
mg/5ml, tab 250 mg, tab 500 mg)
Tier 1
CEFTIBUTEN (CAP 400 MG, RECON SUSP 180
MG/5ML)
Tier 1
CEFTIN (RECON SUSP 125, RECON SUSP 250)
Tier 2
cefuroxime axetil (tab 250 mg, tab 500 mg)
Tier 1
cephalexin (cap 250 mg, cap 500 mg, cap 750 mg,
recon susp 125 mg/5ml, recon susp 250 mg/5ml,
tab 250 mg, tab 500 mg)
Tier 1
SUPRAX (CAP 400 MG, CHEW TAB 100 MG,
CHEW TAB 200 MG, RECON SUSP 500
MG/5ML)
LIMITS & RESTRICTIONS
Tier 3
BETA-LACTAM, PENICILLINS
amoxicillin (cap 250 mg, cap 500 mg, chew tab
125 mg, chew tab 250 mg, recon susp 125
mg/5ml, recon susp 200 mg/5ml, recon susp 250
mg/5ml, recon susp 400 mg/5ml, tab 500 mg, tab
875 mg)
AMOXICILLIN ER TAB ER 24H 775 MG
Tier 1
Tier 1
amoxicillin-pot clavulanate (chew tab 200-28.5 mg,
chew tab 400-57 mg, recon susp 200-28.5 mg/5ml,
recon susp 250-62.5 mg/5ml, recon susp 400-57
mg/5ml, recon susp 600-42.9 mg/5ml, tab 250-125
mg, tab 500-125 mg, tab 875-125 mg)
Tier 1
amoxicillin-pot clavulanate er tab er 12h 1000-62.5
mg
Tier 1
ampicillin (cap 250 mg, cap 500 mg)
Tier 1
AMPICILLIN (RECON SUSP 125, RECON SUSP
250)
Tier 1
AUGMENTIN RECON SUSP 125-31.25 MG/5ML
Tier 2
dicloxacillin sodium (cap 250 mg, cap 500 mg)
Tier 1
MOXATAG TAB ER 24H 775 MG
Tier 3
penicillin v potassium (recon soln 125 mg/5ml,
recon soln 250 mg/5ml, tab 250 mg, tab 500 mg)
Tier 1
MACROLIDES
AZASITE SOLUTION 1 %
Tier 3
azithromycin (packet 1 gm, recon susp 100
mg/5ml, recon susp 200 mg/5ml, tab 250 mg, tab
500 mg, tab 600 mg)
Tier 1
clarithromycin (recon susp 125 mg/5ml, recon
susp 250 mg/5ml, tab 250 mg, tab 500 mg)
Tier 1
clarithromycin er tab er 24h 500 mg
Tier 1
E.E.S. 400 TAB 400 MG
Tier 1
- 21 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
E.E.S. GRANULES RECON SUSP 200 MG/5ML
Tier 2
ery pad 2 %
Tier 1
ERY-TAB (TAB DR 250 MG, TAB DR 333 MG,
TAB DR 500 MG)
Tier 2
ERYPED 200 RECON SUSP 200 MG/5ML
Tier 2
ERYPED 400 RECON SUSP 400 MG/5ML
Tier 2
ERYTHROCIN STEARATE TAB 250 MG
Tier 1
erythromycin (gel 2 %, ointment 5 mg/gm, pad 2
%, solution 2 %)
Tier 1
ERYTHROMYCIN BASE (TAB 250 MG, TAB 500
MG)
Tier 1
erythromycin base cp dr part 250 mg
Tier 1
ERYTHROMYCIN ETHYLSUCCINATE TAB 400
MG
Tier 1
ilotycin ointment 5 mg/gm
Tier 1
PCE (TAB DR 333 MG, TAB DR 500 MG)
Tier 3
LIMITS & RESTRICTIONS
QUINOLONES
BESIVANCE SUSPENSION 0.6 %
Tier 3
CILOXAN OINTMENT 0.3 %
Tier 2
ciprofloxacin (recon susp 250 (5%), recon susp
500 (10%))
Tier 1
ciprofloxacin hcl (solution 0.2 %, solution 0.3 %,
tab 100 mg, tab 250 mg, tab 500 mg, tab 750 mg)
Tier 1
ciprofloxacin-ciproflox hcl er (er tab er 24h 500 mg,
er tab er 24h 1000 mg)
Tier 1
FACTIVE TAB 320 MG
Tier 3
gatifloxacin solution 0.5 %
Tier 1
levofloxacin (solution 0.5 %, solution 25 mg/ml, tab
250 mg, tab 500 mg, tab 750 mg)
Tier 1
moxifloxacin hcl tab 400 mg
Tier 1
ofloxacin (solution 0.3 %, tab 400 mg)
Tier 1
OTIPRIO SUSPENSION 6 %
Tier 3
VIGAMOX SOLUTION 0.5 %
Tier 2
SULFONAMIDES
silver sulfadiazine cream 1 %
Tier 1
ssd cream 1 %
Tier 1
sulfacetamide sodium (ointment 10 %, solution 10
%)
Tier 1
sulfamethoxazole-trimethoprim (solution 400-80
mg/5ml, suspension 200-40 mg/5ml, tab 400-80
mg, tab 800-160 mg)
Tier 1
- 22 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
sulfatrim pediatric suspension 200-40 mg/5ml
Tier 1
LIMITS & RESTRICTIONS
TETRACYCLINES
avidoxy tab 100 mg
Tier 2
demeclocycline hcl (tab 150 mg, tab 300 mg)
Tier 1
DOXYCYCLINE CAP DR 40 MG
Tier 3
doxycycline hyclate (cap 50 mg, cap 100 mg,
recon soln 100 mg, tab 20 mg, tab 100 mg)
Tier 2
doxycycline monohydrate (cap 50 mg, cap 75 mg,
cap 100 mg, recon susp 25 mg/5ml, tab 50 mg, tab
75 mg, tab 100 mg)
Tier 2
minocycline hcl (cap 50 mg, cap 75 mg, cap 100
mg, tab 50 mg, tab 75 mg, tab 100 mg)
Tier 1
minocycline hcl er (er tab er 24h 135 mg, er tab er
24h 90 mg, er tab er 24h 45 mg)
Tier 1
morgidox cap 100 mg
Tier 2
NUTRIDOX KIT 75 MG
Tier 3
ORACEA CAP DR 40 MG
Tier 3
tetracycline hcl (cap 250 mg, cap 500 mg)
Tier 1
VIBRAMYCIN SYRUP 50 MG/5ML
Tier 3
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
BRIVIACT (SOLUTION 10 MG/ML, SOLUTION 50
MG/5ML, TAB 10 MG, TAB 25 MG, TAB 50 MG,
TAB 75 MG, TAB 100 MG)
FYCOMPA (SUSPENSION 0.5 MG/ML, TAB 2
MG, TAB 4 MG, TAB 6 MG, TAB 8 MG, TAB 10
MG, TAB 12 MG)
Tier 3
Tier 2
levetiracetam (solution 100 mg/ml, solution 500
mg/5ml, tab 250 mg, tab 500 mg, tab 750 mg, tab
1000 mg)
Tier 1
levetiracetam er (er tab er 24h 750 mg, er tab er
24h 500 mg)
Tier 1
POTIGA (TAB 50 MG, TAB 200 MG, TAB 300 MG,
TAB 400 MG)
Tier 2
roweepra tab 500 mg
Tier 1
CALCIUM CHANNEL MODIFYING AGENTS
ethosuximide (cap 250 mg, solution 250 mg/5ml)
Tier 1
zonisamide (cap 25 mg, cap 50 mg, cap 100 mg)
Tier 1
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
diazepam (gel 2.5 mg, gel 10 mg, gel 20 mg)
Tier 1
divalproex sodium (125 mg, tab dr 125 mg, tab dr
250 mg, tab dr 500 mg)
Tier 1
- 23 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
divalproex sodium er (er tab er 24h 250 mg, er tab
er 24h 500 mg)
Tier 1
gabapentin (cap 100 mg, cap 300 mg, cap 400
mg, solution 250 mg/5ml, solution 300 mg/6ml, tab
600 mg, tab 800 mg)
Tier 1
GABITRIL (TAB 12 MG, TAB 16 MG)
Tier 3
GRALISE (TAB 300 MG, TAB 600 MG)
Tier 3
GRALISE STARTER MISC 300 & 600 MG
Tier 3
ONFI (SUSPENSION 2.5 MG/ML, TAB 10 MG,
TAB 20 MG)
Tier 2
phenobarbital (elixir 20 mg/5ml, solution 20
mg/5ml, tab 15 mg, tab 16.2 mg, tab 30 mg, tab
32.4 mg, tab 60 mg, tab 64.8 mg, tab 97.2 mg, tab
100 mg)
Tier 1
primidone (tab 50 mg, tab 250 mg)
Tier 1
STAVZOR (CAP DR 125 MG, CAP DR 250 MG,
CAP DR 500 MG)
Tier 3
tiagabine hcl (tab 2 mg, tab 4 mg)
Tier 1
valproate sodium syrup 250 mg/5ml
Tier 1
valproic acid (cap 250 mg, solution 250 mg/5ml,
syrup 250 mg/5ml)
Tier 1
LIMITS & RESTRICTIONS
GLUTAMATE REDUCING AGENTS
felbamate (suspension 600 mg/5ml, tab 400 mg,
tab 600 mg)
Tier 2
LAMICTAL CHEW TAB 2 MG
Tier 2
LAMICTAL STARTER (KIT 25 (84)-100(14) MG,
KIT 25 (35) MG, KIT 25 (42)-100 (7) MG)
Tier 2
LAMICTAL XR (KIT 25 (21)-50 (7) MG, KIT 25 50
100 MG, KIT 50 100 200 MG)
Tier 3
lamotrigine (chew tab 5 mg, chew tab 25 mg, tab
25 mg, tab 100 mg, tab 150 mg, tab 200 mg)
Tier 1
lamotrigine (kit 25 (21)-50 (7) mg, kit 25 & 50 &
100 mg, kit 50 (42)-100(14) mg, tab disp 25 mg,
tab disp 50 mg, tab disp 100 mg, tab disp 200 mg)
Tier 2
lamotrigine er (er tab er 24h 100 mg, er tab er 24h
25 mg, er tab er 24h 200 mg, er tab er 24h 50 mg,
er tab er 24h 300 mg, er tab er 24h 250 mg)
Tier 3
topiramate (cap sprink 15 mg, cap sprink 25 mg,
tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg)
Tier 1
topiramate er (er cp24 sprnk 150 mg, er cp24
sprnk 50 mg, er cp24 sprnk 200 mg, er cp24 sprnk
25 mg, er cp24 sprnk 100 mg)
Tier 1
TROKENDI XR (CAP ER 24H 50 MG, CAP ER
24H 25 MG, CAP ER 24H 100 MG, CAP ER 24H
200 MG)
Tier 3
- 24 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
SODIUM CHANNEL AGENTS
APTIOM (TAB 200 MG, TAB 400 MG, TAB 600
MG, TAB 800 MG)
Tier 2
carbamazepine (chew tab 100 mg, suspension
100 mg/5ml, tab 200 mg)
Tier 1
carbamazepine er (er cap er 12h 300 mg, er cap
er 12h 200 mg, er cap er 12h 100 mg, er tab er
12h 400 mg, er tab er 12h 100 mg, er tab er 12h
200 mg)
Tier 1
DILANTIN CAP 30 MG
Tier 2
epitol tab 200 mg
Tier 1
oxcarbazepine (suspension 300 mg/5ml, tab 150
mg, tab 300 mg, tab 600 mg)
Tier 1
OXTELLAR XR (TAB ER 24H 600 MG, TAB ER
24H 300 MG, TAB ER 24H 150 MG)
Tier 2
PHENYTEK (CAP 200 MG, CAP 300 MG)
Tier 2
phenytoin (chew tab 50 mg, suspension 125
mg/5ml)
Tier 1
phenytoin infatabs chew tab 50 mg
Tier 1
phenytoin sodium extended cap 100 mg
Tier 1
VIMPAT (SOLUTION 10 MG/ML, TAB 50 MG,
TAB 100 MG, TAB 150 MG, TAB 200 MG)
Tier 2
ST
ANTIDEMENTIA AGENTS
CHOLINESTERASE INHIBITORS
donepezil hcl (tab 5 mg, tab 10 mg, tab disp 5 mg,
tab disp 10 mg)
Tier 1
donepezil hcl tab 23 mg
Tier 3
galantamine hydrobromide (solution 4 mg/ml, tab 4
mg, tab 8 mg, tab 12 mg)
Tier 1
galantamine hydrobromide er (er cap er 24h 8 mg,
er cap er 24h 24 mg, er cap er 24h 16 mg)
Tier 1
rivastigmine (patch 24hr 9.5 mg/24hr, patch 24hr
13.3 mg/24hr, patch 24hr 4.6 mg/24hr)
Tier 2
rivastigmine tartrate (cap 1.5 mg, cap 3 mg, cap
4.5 mg, cap 6 mg)
Tier 1
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine hcl (solution 2 mg/ml, tab 5 mg, tab 5
(28)-10 (21) mg, tab 10 mg)
Tier 1
NAMENDA XR (CAP ER 24H 7 MG, CAP ER 24H
21 MG, CAP ER 24H 28 MG, CAP ER 24H 14
MG)
Tier 3
NAMENDA XR TITRATION PACK CAP ER 24H 7
& 14 & 21 &28 MG
Tier 3
- 25 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
bupropion hcl (tab 75 mg, tab 100 mg)
Tier 1
bupropion hcl er (sr) (er tab er 12h 150 mg, er tab
er 12h 100 mg, er tab er 12h 200 mg)
Tier 1
bupropion hcl er (xl) (er tab er 24h 150 mg, er tab
er 24h 300 mg)
Tier 1
chlordiazepoxide-amitriptyline (tab 5-12.5 mg, tab
10-25 mg)
Tier 1
FORFIVO XL TAB ER 24H 450 MG
Tier 3
mirtazapine (tab 7.5 mg, tab 15 mg, tab 30 mg, tab
45 mg, tab disp 15 mg, tab disp 30 mg, tab disp 45
mg)
Tier 1
olanzapine-fluoxetine hcl (cap 3-25 mg, cap 6-25
mg, cap 6-50 mg, cap 12-50 mg, cap 12-25 mg)
Tier 1
perphenazine-amitriptyline (tab 2-10 mg, tab 2-25
mg, tab 4-10 mg, tab 4-25 mg, tab 4-50 mg)
Tier 1
MONOAMINE OXIDASE INHIBITORS
phenelzine sulfate tab 15 mg
Tier 1
tranylcypromine sulfate tab 10 mg
Tier 1
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR
BRINTELLIX (TAB 5 MG, TAB 10 MG, TAB 20
MG)
Tier 3
BRISDELLE CAP 7.5 MG
Tier 3
citalopram hydrobromide (solution 10 mg/5ml, tab
10 mg, tab 20 mg, tab 40 mg)
Tier 1
desvenlafaxine er (er tab er 24h 100 mg, er tab er
24h 50 mg)
Tier 3
DESVENLAFAXINE FUMARATE ER (ER TAB ER
24H 100 MG, ER TAB ER 24H 50 MG)
Tier 3
escitalopram oxalate (solution 5 mg/5ml, tab 5 mg,
tab 10 mg, tab 20 mg)
Tier 1
FETZIMA (CAP ER 24H 40 MG, CAP ER 24H 80
MG, CAP ER 24H 20 MG, CAP ER 24H 120 MG)
Tier 3
FETZIMA TITRATION CP24 THPK 20 & 40 MG
Tier 3
fluoxetine hcl (cap 10 mg, cap 20 mg, cap 40 mg,
solution 20 mg/5ml, tab 10 mg, tab 20 mg)
Tier 1
fluoxetine hcl (cap dr 90 mg, tab 60 mg)
Tier 3
fluoxetine hcl (pmdd) (cap 10 mg, cap 20 mg)
Tier 1
fluvoxamine maleate (tab 25 mg, tab 50 mg, tab
100 mg)
Tier 1
fluvoxamine maleate er (er cap er 24h 150 mg, er
cap er 24h 100 mg)
Tier 1
- 26 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
maprotiline hcl (tab 25 mg, tab 50 mg, tab 75 mg)
Tier 1
nefazodone hcl (tab 50 mg, tab 100 mg, tab 150
mg, tab 200 mg, tab 250 mg)
Tier 1
paroxetine hcl (tab 10 mg, tab 20 mg, tab 30 mg,
tab 40 mg)
Tier 1
paroxetine hcl er (er tab er 24h 25 mg, er tab er
24h 12.5 mg, er tab er 24h 37.5 mg)
Tier 1
PAXIL SUSPENSION 10 MG/5ML
Tier 3
PEXEVA (TAB 10 MG, TAB 20 MG, TAB 30 MG,
TAB 40 MG)
Tier 3
PRISTIQ (TAB ER 24H 25 MG, TAB ER 24H 50
MG, TAB ER 24H 100 MG)
Tier 3
SARAFEM (TAB 10 MG, TAB 20 MG)
Tier 3
sertraline hcl (conc 20 mg/ml, tab 25 mg, tab 50
mg, tab 100 mg)
Tier 1
trazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg,
tab 300 mg)
Tier 1
TRINTELLIX (TAB 5 MG, TAB 10 MG, TAB 20
MG)
Tier 3
venlafaxine hcl (tab 25 mg, tab 37.5 mg, tab 50
mg, tab 75 mg, tab 100 mg)
Tier 1
venlafaxine hcl er (er cap er 24h 75 mg, er cap er
24h 37.5 mg, er cap er 24h 150 mg)
Tier 1
venlafaxine hcl er (er tab er 24h 37.5 mg, er tab er
24h 75 mg, er tab er 24h 150 mg)
Tier 3
VENLAFAXINE HCL ER TAB ER 24H 225 MG
Tier 3
VIIBRYD (TAB 10 MG, TAB 20 MG, TAB 40 MG)
Tier 2
QL
34 tablets per fill
VIIBRYD STARTER PACK KIT 10 & 20 MG
Tier 2
QL
34 tablets per fill
TRICYCLICS
amitriptyline hcl (tab 10 mg, tab 25 mg, tab 50 mg,
tab 75 mg, tab 100 mg, tab 150 mg)
Tier 1
amoxapine (tab 25 mg, tab 50 mg, tab 100 mg, tab
150 mg)
Tier 1
clomipramine hcl (cap 25 mg, cap 50 mg, cap 75
mg)
Tier 1
desipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg,
tab 75 mg, tab 100 mg, tab 150 mg)
Tier 1
doxepin hcl (cap 10 mg, cap 25 mg, cap 50 mg,
cap 75 mg, cap 100 mg, cap 150 mg, conc 10
mg/ml)
Tier 1
imipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg)
Tier 1
imipramine pamoate (cap 75 mg, cap 100 mg, cap
125 mg, cap 150 mg)
Tier 1
- 27 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
nortriptyline hcl (cap 10 mg, cap 25 mg, cap 50
mg, cap 75 mg, solution 10 mg/5ml)
Tier 1
protriptyline hcl (tab 5 mg, tab 10 mg)
Tier 1
LIMITS & RESTRICTIONS
ANTIEMETICS
ANTIEMETICS, OTHER
AKYNZEO CAP 300-0.5 MG
Tier 2
compazine suppos 25 mg
Tier 1
compro suppos 25 mg
Tier 1
DICLEGIS TAB DR 10-10 MG
Tier 3
metoclopramide hcl (solution 5 mg/5ml, solution 10
mg/10ml, tab 5 mg, tab 10 mg, tab disp 5 mg)
Tier 1
METOCLOPRAMIDE HCL TAB DISP 10 MG
Tier 3
perphenazine (tab 2 mg, tab 4 mg, tab 8 mg, tab
16 mg)
Tier 1
prochlorperazine maleate (tab 5 mg, tab 10 mg)
Tier 1
prochlorperazine suppos 25 mg
Tier 1
TRANSDERM-SCOP (1.5 MG) PATCH 72HR 1
MG/3DAYS
Tier 3
trimethobenzamide hcl cap 300 mg
Tier 1
PA
EMETOGENIC THERAPY ADJUNCTS
ANZEMET (TAB 50 MG, TAB 100 MG)
Tier 3
CESAMET CAP 1 MG
Tier 3
dronabinol (cap 2.5 mg, cap 5 mg, cap 10 mg)
Tier 1
EMEND (CAP 40 MG, CAP 125 MG)
QL
1 tablet per fill
Tier 2
QL
1 capsule per fill
EMEND CAP 80 & 125 MG
Tier 2
QL
1 pack per fill
EMEND CAP 80 MG
Tier 2
QL
2 capsules per fill
EMEND RECON SUSP 125 MG
Tier 2
granisetron hcl tab 1 mg
Tier 1
QL
2 tablets per fill
ondansetron (tab disp 4 mg, tab disp 8 mg)
Tier 1
ondansetron hcl (solution 4 mg/5ml, tab 4 mg, tab
8 mg, tab 24 mg)
Tier 1
SANCUSO PATCH 3.1 MG/24HR
Tier 3
QL
1 patch per fill
VARUBI TAB 90 MG
Tier 3
QL
4 tablets per fill
ZUPLENZ (FILM 4 MG, FILM 8 MG)
Tier 3
- 28 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
ANTIFUNGALS
ciclodan (cream 0.77 %, solution 8 %)
Tier 1
ciclopirox (gel 0.77 %, shampoo 1 %, solution 8 %)
Tier 1
ciclopirox olamine (cream 0.77 %, suspension 0.77
%)
Tier 1
ciclopirox treatment kit 8 %
Tier 1
ciclopirox-vitamin e kit 8 & 5 %
Tier 1
clotrimazole (lozenge 10 mg, troche 10 mg)
Tier 1
econazole nitrate cream 1 %
Tier 1
EXELDERM (CREAM 1 %, SOLUTION 1 %)
Tier 3
fluconazole (recon susp 10 mg/ml, recon susp 40
mg/ml, tab 50 mg, tab 100 mg, tab 150 mg, tab
200 mg, 200 mg)
Tier 1
griseofulvin microsize (suspension 125 mg/5ml,
tab 500 mg)
Tier 1
griseofulvin ultramicrosize (tab 125 mg, tab 250
mg)
Tier 1
itraconazole cap 100 mg
Tier 1
PA
QL
JUBLIA SOLUTION 10 %
Tier 3
KERYDIN SOLUTION 5 %
Tier 3
ketoconazole (cream 2 %, foam 2 %, shampoo 2
%, tab 200 mg)
Tier 1
LAMISIL (PACKET 125 MG, PACKET 187.5 MG)
Tier 3
LUZU CREAM 1 %
Tier 3
MICONAZOLE 3 SUPPOS 200 MG
Tier 1
NAFTIFINE HCL CREAM 1 %
Tier 2
naftifine hcl cream 2 %
Tier 1
NAFTIN (CREAM 1 %, GEL 1 %, GEL 2 %)
Tier 2
nyamyc powder 100000 unit/gm
Tier 1
nystatin (cream 100000 unit/gm, ointment 100000
unit/gm, powder, powder 100000 unit/gm,
suspension 100000 unit/ml, tab 500000 unit)
Tier 1
nystatin-triamcinolone (cream, ointment)
Tier 1
nystop powder 100000 unit/gm
Tier 1
oxiconazole nitrate cream 1 %
Tier 2
OXISTAT LOTION 1 %
Tier 2
SPORANOX SOLUTION 10 MG/ML
Tier 2
terbinafine hcl tab 250 mg
Tier 1
34 capsules per fill
PA
- 29 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
terconazole (cream 0.4 %, cream 0.8 %)
Tier 1
QL
1 tube per fill
terconazole suppos 80 mg
Tier 1
QL
1 box (3 suppositories) per
fill
zazole suppos 80 mg
Tier 1
QL
8 inhalers per fill
ANTIGOUT AGENTS
allopurinol (tab 100 mg, tab 300 mg)
Tier 1
colchicine cap 0.6 mg
Tier 1
COLCHICINE TAB 0.6 MG
Tier 1
colchicine-probenecid tab 0.5-500 mg
Tier 1
COLCRYS TAB 0.6 MG
Tier 2
probenecid tab 500 mg
Tier 1
ULORIC (TAB 40 MG, TAB 80 MG)
Tier 2
ZURAMPIC TAB 200 MG
Tier 3
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
CAFERGOT TAB 1-100 MG
Tier 2
dihydroergotamine mesylate solution 4 mg/ml
Tier 2
MIGERGOT SUPPOS 2-100 MG
Tier 1
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
almotriptan malate (tab 6.25 mg, tab 12.5 mg)
Tier 3
QL
9 tablets per fill
frovatriptan succinate tab 2.5 mg
Tier 1
QL
9 / fill
naratriptan hcl (tab 1 mg, tab 2.5 mg)
Tier 1
QL
9 tablets per fill
ONZETRA XSAIL 11 MG/NOSEPC
Tier 3
QL
8 / 30 days
RELPAX (TAB 20 MG, TAB 40 MG)
Tier 3
QL
9 tablets per fill
rizatriptan benzoate (tab 5 mg, tab 10 mg, tab disp
5 mg, tab disp 10 mg)
Tier 1
QL
9 tablets per fill
sumatriptan solution 20 mg/act
Tier 1
QL
6 devices per fill
sumatriptan solution 5 mg/act
Tier 1
PA
QL
6 devices per fill
QL
8 injections per fill
sumatriptan succinate (soln a-inj 4, soln a-inj 6,
solution 4, solution 6)
Tier 1
sumatriptan succinate (tab 25 mg, tab 50 mg, tab
100 mg)
Tier 1
QL
9 tablets per fill
sumatriptan succinate refill (soln cart 4, soln cart 6)
Tier 1
QL
8 injections per fill
- 30 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
SUMATRIPTAN SUCCINATE SOLN PRSYR 6
MG/0.5ML
Tier 1
QL
8 injections per fill
SUMAVEL DOSEPRO (SOLN J-INJ 4, SOLN JINJ 6)
Tier 3
QL
8 kits per fill
TREXIMET TAB 10-60 MG
Tier 3
QL
9 / fill
TREXIMET TAB 85-500 MG
Tier 3
QL
9 tablets per fill
ZECUITY PATCH 6.5 MG/4HR
Tier 3
zolmitriptan (tab 2.5 mg, tab 5 mg, tab disp 2.5 mg,
tab disp 5 mg)
Tier 1
QL
9 tablets per fill
ZOMIG (SOLUTION 2.5 MG, SOLUTION 5 MG)
Tier 2
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
MESTINON SYRUP 60 MG/5ML
Tier 3
pyridostigmine bromide er tab er 180 mg
Tier 1
pyridostigmine bromide tab 60 mg
Tier 1
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone (tab 25 mg, tab 100 mg)
Tier 1
ANTITUBERCULARS
ethambutol hcl (tab 100 mg, tab 400 mg)
Tier 1
isoniazid (tab 100 mg, tab 300 mg)
Tier 1
ISONIAZID SYRUP 50 MG/5ML
Tier 1
rifampin (cap 150 mg, cap 300 mg)
Tier 1
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN TAB 2 MG
Tier 2
cyclophosphamide (cap 25 mg, cap 50 mg)
Tier 3
ANTIANDROGENS
bicalutamide tab 50 mg
Tier 1
ANTIESTROGENS/MODIFIERS
tamoxifen citrate tab 10 mg
Tier 1
QL
120 tablets per fill
tamoxifen citrate tab 20 mg
Tier 1
QL
60 tablets per fill
ANTIMETABOLITES
hydroxyurea cap 500 mg
Tier 1
mercaptopurine tab 50 mg
Tier 1
- 31 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
ANTINEOPLASTICS, OTHER
levoleucovorin calcium (recon soln 50 mg, solution
175 mg/17.5ml)
Tier 1
LEVOLEUCOVORIN CALCIUM PF SOLUTION
250 MG/25ML
Tier 3
MESNEX TAB 400 MG
Tier 2
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole tab 1 mg
Tier 1
exemestane tab 25 mg
Tier 1
letrozole tab 2.5 mg
Tier 1
ENZYME INHIBITORS
etoposide (cap 50 mg, solution 1 gm/50ml, solution
100 mg/5ml, solution 500 mg/25ml)
Tier 1
ANTIPARASITICS
ANTIHELMINTHICS
ALBENZA TAB 200 MG
Tier 2
ivermectin tab 3 mg
Tier 1
SKLICE LOTION 0.5 %
Tier 2
SOOLANTRA CREAM 1 %
Tier 3
PA
ANTIPROTOZOALS
ALINIA (RECON SUSP 100 MG/5ML, TAB 500
MG)
Tier 2
atovaquone-proguanil hcl (tab 62.5-25 mg, tab
250-100 mg)
Tier 1
PA
chloroquine phosphate (tab 250 mg, tab 500 mg)
Tier 1
PA
COARTEM TAB 20-120 MG
Tier 2
PA
hydroxychloroquine sulfate tab 200 mg
Tier 1
PA
mefloquine hcl tab 250 mg
Tier 1
PA
NEBUPENT RECON SOLN 300 MG
Tier 2
primaquine phosphate tab 26.3 mg
Tier 2
PA
quinine sulfate cap 324 mg
Tier 1
PA
QL
1 container per fill
PEDICULICIDES/SCABICIDES
acticin cream 5 %
Tier 1
EURAX (CREAM 10 %, LOTION 10 %)
Tier 2
- 32 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
lindane (lotion 1 %, shampoo 1 %)
Tier 1
malathion lotion 0.5 %
Tier 1
NATROBA SUSPENSION 0.9 %
Tier 2
permethrin cream 5 %
Tier 1
SPINOSAD SUSPENSION 0.9 %
Tier 1
ULESFIA LOTION 5 %
Tier 2
LIMITS & RESTRICTIONS
PA
PA
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine mesylate (tab 0.5 mg, tab 1 mg, tab 2
mg)
Tier 1
trihexyphenidyl hcl (elixir 0.4 mg/ml, tab 2 mg, tab
5 mg)
Tier 1
ANTIPARKINSON AGENTS, OTHER
amantadine hcl (cap 100 mg, syrup 50 mg/5ml, tab
100 mg)
Tier 1
carbidopa-levodopa-entacapone (tab 12.5-50-200
mg, tab 18.75-75-200 mg, tab 25-100-200 mg, tab
31.25-125-200 mg, tab 37.5-150-200 mg, tab 50200-200 mg)
Tier 1
entacapone tab 200 mg
Tier 1
DOPAMINE AGONISTS
bromocriptine mesylate (cap 5 mg, tab 2.5 mg)
Tier 1
NEUPRO (PATCH 24HR 4 MG/24HR, PATCH
24HR 1 MG/24HR, PATCH 24HR 6 MG/24HR,
PATCH 24HR 2 MG/24HR, PATCH 24HR 8
MG/24HR, PATCH 24HR 3 MG/24HR)
Tier 2
pramipexole dihydrochloride (tab 0.125 mg, tab
0.25 mg, tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab
1.5 mg)
Tier 1
pramipexole dihydrochloride er (er tab er 24h 2.25
mg, er tab er 24h 3 mg, er tab er 24h 1.5 mg, er
tab er 24h 0.375 mg, er tab er 24h 4.5 mg, er tab
er 24h 3.75 mg, er tab er 24h 0.75 mg)
Tier 3
ropinirole hcl (tab 0.25 mg, tab 0.5 mg, tab 1 mg,
tab 2 mg, tab 3 mg, tab 4 mg, tab 5 mg)
Tier 1
ropinirole hcl er (er tab er 24h 2 mg, er tab er 24h
12 mg, er tab er 24h 8 mg, er tab er 24h 4 mg, er
tab er 24h 6 mg)
Tier 1
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa tab 25 mg
Tier 1
carbidopa-levodopa (tab 10-100 mg, tab 25-250
mg, tab 25-100 mg, tab disp 10-100 mg, tab disp
25-250 mg, tab disp 25-100 mg)
Tier 1
- 33 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
carbidopa-levodopa er (er tab er 25-100 mg, er tab
er 50-200 mg)
Tier 1
RYTARY (CAP ER 23.75-95 MG, CAP ER 36.25145 MG, CAP ER 48.75-195 MG, CAP ER 61.25245 MG)
Tier 3
LIMITS & RESTRICTIONS
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
AZILECT (TAB 0.5 MG, TAB 1 MG)
Tier 3
selegiline hcl (cap 5 mg, tab 5 mg)
Tier 1
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
chlorpromazine hcl (tab 10 mg, tab 25 mg, tab 50
mg, tab 100 mg, tab 200 mg)
Tier 1
fluphenazine hcl (conc 5 mg/ml, elixir 2.5 mg/5ml,
tab 1 mg, tab 2.5 mg, tab 5 mg, tab 10 mg)
Tier 1
haloperidol (tab 0.5 mg, tab 1 mg, tab 2 mg, tab 5
mg, tab 10 mg, tab 20 mg)
Tier 1
haloperidol lactate conc 2 mg/ml
Tier 1
loxapine succinate (cap 5 mg, cap 10 mg, cap 25
mg, cap 50 mg)
Tier 1
MOLINDONE HCL (TAB 5 MG, TAB 10 MG)
Tier 1
pimozide (tab 1 mg, tab 2 mg)
Tier 1
thioridazine hcl (tab 10 mg, tab 25 mg, tab 50 mg,
tab 100 mg)
Tier 1
thiothixene (cap 1 mg, cap 2 mg, cap 5 mg, cap 10
mg)
Tier 1
trifluoperazine hcl (tab 1 mg, tab 2 mg, tab 5 mg,
tab 10 mg)
Tier 1
2ND GENERATION/ATYPICAL
aripiprazole (solution 1 mg/ml, tab 2 mg, tab 5 mg,
tab 10 mg, tab 15 mg, tab 20 mg, tab 30 mg)
Tier 2
FANAPT (TAB 1 MG, TAB 2 MG, TAB 4 MG)
Tier 3
QL
45 tablets per fill
ST
FANAPT (TAB 8 MG, TAB 10 MG, TAB 12 MG)
Tier 3
FANAPT TAB 6 MG
Tier 3
ST
QL
62 tablets per fill
ST
FANAPT TITRATION PACK TAB 1 & 2 & 4 & 6
MG
Tier 3
LATUDA (TAB 20 MG, TAB 40 MG, TAB 60 MG,
TAB 80 MG, TAB 120 MG)
Tier 3
QL
55 tablets per fill
ST
ST
- 34 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
olanzapine (tab 2.5 mg, tab 5 mg, tab 7.5 mg, tab
10 mg, tab 15 mg, tab 20 mg, tab disp 5 mg, tab
disp 10 mg, tab disp 15 mg, tab disp 20 mg)
Tier 1
paliperidone er (er tab er 24h 3 mg, er tab er 24h
1.5 mg, er tab er 24h 6 mg, er tab er 24h 9 mg)
Tier 2
quetiapine fumarate (tab 25 mg, tab 50 mg, tab
100 mg, tab 200 mg, tab 300 mg, tab 400 mg)
Tier 1
risperidone (solution 1 mg/ml, tab 0.25 mg, tab 0.5
mg, tab 1 mg, tab 2 mg, tab 3 mg, tab 4 mg, tab
disp 0.25 mg, tab disp 0.5 mg, tab disp 1 mg, tab
disp 2 mg, tab disp 3 mg, tab disp 4 mg)
Tier 1
risperidone m-tab (tab disp 0.5 mg, tab disp 1 mg,
tab disp 2 mg, tab disp 3 mg, tab disp 4 mg)
Tier 1
SAPHRIS (SL TAB 2.5 MG, SL TAB 5 MG, SL
TAB 10 MG)
Tier 3
SEROQUEL XR (TAB ER 24H 50 MG, TAB ER
24H 200 MG, TAB ER 24H 400 MG, TAB ER 24H
300 MG, TAB ER 24H 150 MG)
Tier 3
ziprasidone hcl (cap 20 mg, cap 40 mg, cap 60
mg, cap 80 mg)
Tier 1
LIMITS & RESTRICTIONS
ST
ST
TREATMENT-RESISTANT
clozapine (tab 25 mg, tab 50 mg, tab 100 mg, tab
200 mg)
Tier 1
clozapine (tab disp 12.5 mg, tab disp 25 mg, tab
disp 100 mg, tab disp 150 mg, tab disp 200 mg)
Tier 3
ANTIVIRALS
ANTI-HEPATITIS B (HBV) AGENTS
EPIVIR HBV SOLUTION 5 MG/ML
Tier 2
lamivudine tab 100 mg
Tier 1
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
ISENTRESS (CHEW TAB 25 MG, CHEW TAB 100
MG)
Tier 3
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
EDURANT TAB 25 MG
Tier 2
nevirapine (suspension 50 mg/5ml, tab 200 mg)
Tier 1
nevirapine er (er tab er 24h 400 mg, er tab er 24h
100 mg)
Tier 2
RESCRIPTOR (TAB 100 MG, TAB 200 MG)
Tier 3
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate tab 300 mg
Tier 1
didanosine (cap dr 125 mg, cap dr 200 mg, cap dr
250 mg, cap dr 400 mg)
Tier 1
EMTRIVA (CAP 200 MG, SOLUTION 10 MG/ML)
Tier 3
- 35 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
lamivudine (solution 10 mg/ml, tab 150 mg, tab
300 mg)
Tier 1
stavudine (cap 15 mg, cap 20 mg, cap 30 mg, cap
40 mg, recon soln 1 mg/ml)
Tier 1
VIDEX (RECON SOLN 2 GM, RECON SOLN 4
GM)
Tier 3
ZIAGEN SOLUTION 20 MG/ML
Tier 3
zidovudine (cap 100 mg, syrup 50 mg/5ml, tab 300
mg)
Tier 1
LIMITS & RESTRICTIONS
ANTI-HIV AGENTS, OTHER
TYBOST TAB 150 MG
Tier 2
ANTI-HIV AGENTS, PROTEASE INHIBITORS
CRIXIVAN (CAP 200 MG, CAP 400 MG)
Tier 3
VIRACEPT (TAB 250 MG, TAB 625 MG)
Tier 3
ANTI-INFLUENZA AGENTS
RELENZA DISKHALER AER POW BA 5
MG/BLISTER
Tier 2
QL
20 blisters per fill
TAMIFLU (CAP 30 MG, CAP 45 MG, CAP 75 MG)
Tier 2
QL
34 capsules per fill
TAMIFLU RECON SUSP 6 MG/ML
Tier 2
QL
25mg bottle: 3 bottles per fill
ANTIHERPETIC AGENTS
acyclovir (cap 200 mg, ointment 5 %, suspension
200 mg/5ml, tab 400 mg, tab 800 mg)
Tier 1
DENAVIR CREAM 1 %
Tier 3
famciclovir (tab 125 mg, tab 500 mg)
Tier 1
QL
21 tablets per fill
famciclovir tab 250 mg
Tier 1
QL
68 tablets per fill
SITAVIG TAB 50 MG
Tier 3
QL
2 tablets per fill
trifluridine solution 1 %
Tier 1
valacyclovir hcl (tab 1 gm, tab 500 mg)
Tier 1
QL
34 caplets per fill
XERESE CREAM 5-1 %
Tier 3
ZOVIRAX CREAM 5 %
Tier 2
ANXIOLYTICS
ANXIOLYTICS, OTHER
buspirone hcl (tab 5 mg, tab 7.5 mg, tab 10 mg,
tab 15 mg, tab 30 mg)
Tier 1
meprobamate (tab 200 mg, tab 400 mg)
Tier 1
- 36 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
BENZODIAZEPINES
alprazolam (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab
2 mg, tab disp 0.25 mg, tab disp 0.5 mg, tab disp 1
mg, tab disp 2 mg)
Tier 1
alprazolam er (er tab er 24h 2 mg, er tab er 24h 3
mg, er tab er 24h 1 mg, er tab er 24h 0.5 mg)
Tier 1
alprazolam xr (tab er 24h 2 mg, tab er 24h 1 mg,
tab er 24h 0.5 mg, tab er 24h 3 mg)
Tier 1
chlordiazepoxide hcl (cap 5 mg, cap 10 mg, cap 25
mg)
Tier 1
clonazepam (tab 0.5 mg, tab 1 mg, tab 2 mg, tab
disp 0.125 mg, tab disp 0.25 mg, tab disp 0.5 mg,
tab disp 1 mg, tab disp 2 mg)
Tier 1
clorazepate dipotassium (tab 3.75 mg, tab 7.5 mg,
tab 15 mg)
Tier 1
diazepam (conc 5 mg/ml, solution 1 mg/ml, tab 2
mg, tab 5 mg, tab 10 mg)
Tier 1
diazepam intensol conc 5 mg/ml
Tier 1
lorazepam (conc 2 mg/ml, tab 0.5 mg, tab 1 mg,
tab 2 mg)
Tier 1
lorazepam intensol conc 2 mg/ml
Tier 1
oxazepam (cap 10 mg, cap 15 mg, cap 30 mg)
Tier 1
BIPOLAR AGENTS
MOOD STABILIZERS
lithium carbonate (cap 150 mg, cap 300 mg, cap
600 mg, tab 300 mg)
Tier 1
lithium carbonate er (er tab er 300 mg, er tab er
450 mg)
Tier 1
lithium solution 8 meq/5ml
Tier 3
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
acarbose (tab 25 mg, tab 50 mg, tab 100 mg)
Tier 1
ACTOPLUS MET XR (TAB ER 24H 15-1000 MG,
TAB ER 24H 30-1000 MG)
Tier 3
ALOGLIPTIN BENZOATE (TAB 6.25 MG, TAB
12.5 MG, TAB 25 MG)
Tier 3
MN
MN-PA
ALOGLIPTIN-METFORMIN HCL (TAB 12.5-1000
MG, TAB 12.5-500 MG)
Tier 3
MN
MN-PA
ALOGLIPTIN-PIOGLITAZONE (TAB 12.5-30 MG,
TAB 12.5-45 MG, TAB 12.5-15 MG, TAB 25-15
MG, TAB 25-30 MG, TAB 25-45 MG)
Tier 3
MN
MN-PA
AVANDAMET TAB 2-1000 MG
Tier 3
AVANDIA (TAB 2 MG, TAB 4 MG, TAB 8 MG)
Tier 2
- 37 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
BYDUREON (PEN 2 MG, 2 MG)
Tier 2
BYETTA 10 MCG PEN SOLN PEN 10
MCG/0.04ML
Tier 3
BYETTA 5 MCG PEN SOLN PEN 5 MCG/0.02ML
Tier 3
chlorpropamide (tab 100 mg, tab 250 mg)
Tier 1
CYCLOSET TAB 0.8 MG
Tier 3
FARXIGA (TAB 5 MG, TAB 10 MG)
Tier 3
glimepiride (tab 1 mg, tab 2 mg, tab 4 mg)
Tier 1
glipizide (tab 5 mg, tab 10 mg)
Tier 1
glipizide er (er tab er 24h 5 mg, er tab er 24h 10
mg, er tab er 24h 2.5 mg)
Tier 1
glipizide xl (tab er 24h 2.5 mg, tab er 24h 5 mg, tab
er 24h 10 mg)
Tier 1
glipizide-metformin hcl (tab 2.5-500 mg, 2.5-500
mg, tab 2.5-250 mg, tab 5-500 mg)
Tier 1
glyburide (tab 1.25 mg, tab 2.5 mg, tab 5 mg)
Tier 1
glyburide micronized (tab 1.5 mg, tab 3 mg, tab 6
mg)
Tier 1
glyburide-metformin (tab 1.25-250 mg, tab 2.5-500
mg, tab 5-500 mg)
Tier 1
GLYXAMBI (TAB 10-5 MG, TAB 25-5 MG)
Tier 3
INVOKAMET (TAB 50-500 MG, TAB 50-1000 MG,
TAB 150-500 MG, TAB 150-1000 MG)
Tier 2
INVOKAMET XR (TAB ER 24H 50-1000 MG, TAB
ER 24H 150-1000 MG, TAB ER 24H 50-500 MG,
TAB ER 24H 150-500 MG)
Tier 3
INVOKANA (TAB 100 MG, TAB 300 MG)
Tier 2
JANUMET (TAB 50-500 MG, TAB 50-1000 MG)
Tier 2
JANUMET XR (TAB ER 24H 50-1000 MG, TAB
ER 24H 100-1000 MG, TAB ER 24H 50-500 MG)
Tier 2
JANUVIA (TAB 25 MG, TAB 50 MG, TAB 100 MG)
Tier 2
JARDIANCE (TAB 10 MG, TAB 25 MG)
Tier 3
JENTADUETO (TAB 2.5-1000 MG, TAB 2.5-850
MG, TAB 2.5-500 MG)
Tier 2
JENTADUETO XR (TAB ER 24H 5-1000 MG, TAB
ER 24H 2.5-1000 MG)
Tier 3
KAZANO (TAB 12.5-500 MG, TAB 12.5-1000 MG)
Tier 3
MN
MN-PA
KOMBIGLYZE XR (TAB ER 24H 5-500 MG, TAB
ER 24H 2.5-1000 MG, TAB ER 24H 5-1000 MG)
Tier 3
MN
MN-PA
metformin hcl (tab 500 mg, tab 850 mg, tab 1000
mg)
Tier 1
ST
ST
ST
- 38 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
metformin hcl er (er tab er 24h 750 mg, er tab er
24h 500 mg)
Tier 1
metformin hcl er (mod) tab er 24h 500 mg
Tier 1
metformin hcl er (osm) tab er 24h 500 mg
Tier 1
miglitol (tab 25 mg, tab 50 mg, tab 100 mg)
Tier 1
nateglinide (tab 60 mg, tab 120 mg)
Tier 1
NESINA (TAB 6.25 MG, TAB 12.5 MG, TAB 25
MG)
Tier 3
MN
MN-PA
ONGLYZA (TAB 2.5 MG, TAB 5 MG)
Tier 3
MN
MN-PA
OSENI (TAB 12.5-15 MG, TAB 12.5-30 MG, TAB
12.5-45 MG, TAB 25-15 MG, TAB 25-45 MG, TAB
25-30 MG)
Tier 3
MN
MN-PA
pioglitazone hcl (tab 15 mg, tab 30 mg, tab 45 mg)
Tier 1
QL
34 tablets per fill
pioglitazone hcl-glimepiride (tab 30-4 mg, tab 30-2
mg)
Tier 1
pioglitazone hcl-metformin hcl (-metformin tab 15500 mg, -metformin tab 15-850 mg)
Tier 1
repaglinide (tab 0.5 mg, tab 1 mg, tab 2 mg)
Tier 1
repaglinide-metformin hcl (tab 1-500 mg, tab 2-500
mg)
Tier 2
RIOMET SOLUTION 500 MG/5ML
Tier 3
SYMLINPEN 120 SOLN PEN 2700 MCG/2.7ML
Tier 3
SYMLINPEN 60 SOLN PEN 1500 MCG/1.5ML
Tier 3
SYNJARDY (TAB 5-1000 MG, TAB 5-500 MG,
TAB 12.5-1000 MG, TAB 12.5-500 MG)
Tier 3
TANZEUM (PEN 30 MG, PEN 50 MG)
Tier 3
tolazamide (tab 250 mg, tab 500 mg)
Tier 1
tolbutamide tab 500 mg
Tier 1
TRADJENTA TAB 5 MG
Tier 2
TRULICITY (SOLN PEN 0.75, SOLN PEN 1.5)
Tier 3
VICTOZA SOLN PEN 18 MG/3ML
Tier 2
XIGDUO XR (TAB ER 24H 5-500 MG, TAB ER
24H 10-1000 MG, TAB ER 24H 10-500 MG, TAB
ER 24H 5-1000 MG)
Tier 3
ST
ST
GLYCEMIC AGENTS
GLUCAGEN DIAGNOSTIC RECON SOLN 1 MG
Tier 2
GLUCAGEN HYPOKIT RECON SOLN 1 MG
Tier 2
GLUCAGON EMERGENCY KIT 1 MG
Tier 2
glucagon hcl (diagnostic) recon soln 1 mg
Tier 2
- 39 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
INSULINS
AFREZZA (POWDER 4 (60) & 8 (30), POWDER 4
(30) & 8 (60), POWDER 4 (90) & 8 (90), POWDER
4, POWDER 8 (60)& 12 (30))
Tier 3
MN
MN-PA
APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML
Tier 3
MN
MN-PA
APIDRA SOLUTION 100 UNIT/ML
Tier 3
MN
MN-PA
HUMALOG (SOLN CART 100, SOLUTION 100)
Tier 3
MN
MN-PA
HUMALOG KWIKPEN (SOLN PEN 100, SOLN
PEN 200)
Tier 3
MN
MN-PA
HUMALOG MIX 50/50 KWIKPEN SUSP PEN (5050) 100 UNIT/ML
Tier 3
MN
MN-PA
HUMALOG MIX 50/50 SUSPENSION (50-50) 100
UNIT/ML
Tier 3
MN
MN-PA
HUMALOG MIX 75/25 KWIKPEN SUSP PEN (7525) 100 UNIT/ML
Tier 3
MN
MN-PA
HUMALOG MIX 75/25 SUSPENSION (75-25) 100
UNIT/ML
Tier 3
MN
MN-PA
HUMULIN 50/50 (50-50) 100 UNIT/ML
Tier 3
MN
MN-PA
HUMULIN 70/30 KWIKPEN SUSP PEN (70-30)
100 UNIT/ML
Tier 3
MN
MN-PA
HUMULIN 70/30 PEN SUSP PEN (70-30) 100
UNIT/ML
Tier 3
MN
MN-PA
HUMULIN 70/30 SUSPENSION (70-30) 100
UNIT/ML
Tier 3
MN
MN-PA
HUMULIN N KWIKPEN SUSP PEN 100 UNIT/ML
Tier 3
MN
MN-PA
HUMULIN N PEN SUSP PEN 100 UNIT/ML
Tier 3
MN
MN-PA
HUMULIN N SUSPENSION 100 UNIT/ML
Tier 3
MN
MN-PA
HUMULIN R SOLUTION 100 UNIT/ML
Tier 3
MN
MN-PA
HUMULIN R U-500 (CONCENTRATED)
SOLUTION 500 UNIT/ML
Tier 2
HUMULIN R U-500 KWIKPEN SOLN PEN 500
UNIT/ML
Tier 2
LANTUS SOLOSTAR SOLN PEN 100 UNIT/ML
Tier 2
LANTUS SOLUTION 100 UNIT/ML
Tier 2
LEVEMIR FLEXTOUCH SOLN PEN 100 UNIT/ML
Tier 2
LEVEMIR SOLUTION 100 UNIT/ML
Tier 2
NOVOLIN 70/30 RELION SUSPENSION (70-30)
100 UNIT/ML
Tier 2
NOVOLIN 70/30 SUSPENSION (70-30) 100
UNIT/ML
Tier 2
- 40 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
NOVOLIN N RELION SUSPENSION 100 UNIT/ML
Tier 2
NOVOLIN N SUSPENSION 100 UNIT/ML
Tier 2
NOVOLIN R RELION SOLUTION 100 UNIT/ML
Tier 2
NOVOLIN R SOLUTION 100 UNIT/ML
Tier 2
NOVOLOG FLEXPEN SOLN PEN 100 UNIT/ML
Tier 2
NOVOLOG MIX 70/30 FLEXPEN SUSP PEN (7030) 100 UNIT/ML
Tier 2
NOVOLOG MIX 70/30 SUSPENSION (70-30) 100
UNIT/ML
Tier 2
NOVOLOG PENFILL SOLN CART 100 UNIT/ML
Tier 2
NOVOLOG SOLUTION 100 UNIT/ML
Tier 2
TOUJEO SOLOSTAR SOLN PEN 300 UNIT/ML
Tier 2
TRESIBA FLEXTOUCH (SOLN PEN 100, SOLN
PEN 200)
Tier 3
LIMITS & RESTRICTIONS
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
ELIQUIS (TAB 2.5 MG, TAB 5 MG)
Tier 2
enoxaparin sodium (solution 30 mg/0.3ml, solution
40 mg/0.4ml, solution 60 mg/0.6ml, solution 80
mg/0.8ml, solution 100 mg/ml, solution 120
mg/0.8ml, solution 150 mg/ml, solution 300
mg/3ml)
Tier 1
fondaparinux sodium (solution 2.5 mg/0.5ml,
solution 5 mg/0.4ml, solution 7.5 mg/0.6ml,
solution 10 mg/0.8ml)
FRAGMIN (SOLUTION 2500 UNIT/0.2ML,
SOLUTION 5000 UNIT/0.2ML, SOLUTION 7500
UNIT/0.3ML, SOLUTION 10000 UNIT/ML,
SOLUTION 12500 UNIT/0.5ML, SOLUTION 15000
UNIT/0.6ML, SOLUTION 18000 UNT/0.72ML,
SOLUTION 95000 UNIT/3.8ML)
heparin sodium (porcine) pf solution 5000
unit/0.5ml
Tier 1
Tier 3
Tier 1
PRADAXA (CAP 75 MG, CAP 110 MG, CAP 150
MG)
Tier 2
SAVAYSA (TAB 15 MG, TAB 30 MG, TAB 60 MG)
Tier 3
warfarin sodium (tab 1 mg, tab 2 mg, tab 2.5 mg,
tab 3 mg, tab 4 mg, tab 5 mg, tab 6 mg, tab 7.5
mg, tab 10 mg)
Tier 1
XARELTO (TAB 10 MG, TAB 15 MG, TAB 20 MG)
Tier 2
XARELTO STARTER PACK TAB THPK 15 & 20
MG
Tier 2
COAGULANTS
AMICAR (SYRUP 25 %, TAB 500 MG, TAB 1000
MG)
Tier 2
- 41 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
tranexamic acid tab 650 mg
Tier 1
LIMITS & RESTRICTIONS
PLATELET MODIFYING AGENTS
aspirin-dipyridamole er cap er 12h 25-200 mg
Tier 2
BRILINTA TAB 90 MG
Tier 2
cilostazol (tab 50 mg, tab 100 mg)
Tier 1
clopidogrel bisulfate (tab 75 mg, tab 300 mg)
Tier 1
dipyridamole (solution 5 mg/ml, tab 25 mg, tab 50
mg, tab 75 mg)
Tier 1
EFFIENT (TAB 5 MG, TAB 10 MG)
Tier 2
ticlopidine hcl tab 250 mg
Tier 1
ZONTIVITY TAB 2.08 MG
Tier 3
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine hcl (patch wk 0.1 mg/24hr, patch wk 0.2
mg/24hr, patch wk 0.3 mg/24hr)
Tier 1
clonidine hcl (tab 0.1 mg, tab 0.2 mg, tab 0.3 mg)
Tier 1
guanfacine hcl (tab 1 mg, tab 2 mg)
Tier 1
methyldopa (tab 250 mg, tab 500 mg)
Tier 1
midodrine hcl (tab 2.5 mg, tab 5 mg, tab 10 mg)
Tier 1
QL
5 patches per fill
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate (tab 1 mg, tab 2 mg, tab 4 mg,
tab 8 mg)
Tier 1
phenoxybenzamine hcl cap 10 mg
Tier 1
prazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg)
Tier 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS
BENICAR (TAB 5 MG, TAB 20 MG, TAB 40 MG)
Tier 2
candesartan cilexetil (tab 4 mg, tab 8 mg, tab 16
mg, tab 32 mg)
Tier 1
EDARBI (TAB 40 MG, TAB 80 MG)
Tier 3
eprosartan mesylate tab 600 mg
Tier 1
irbesartan (tab 75 mg, tab 150 mg, tab 300 mg)
Tier 1
losartan potassium (tab 25 mg, tab 50 mg, tab 100
mg)
Tier 1
telmisartan (tab 20 mg, tab 40 mg, tab 80 mg)
Tier 1
valsartan (tab 40 mg, tab 80 mg, tab 160 mg, tab
320 mg)
Tier 1
- 42 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
benazepril hcl (tab 5 mg, tab 10 mg, tab 20 mg,
tab 40 mg)
Tier 1
captopril (tab 12.5 mg, tab 25 mg, tab 50 mg, tab
100 mg)
Tier 1
enalapril maleate (tab 2.5 mg, tab 5 mg, tab 10
mg, tab 20 mg)
Tier 1
EPANED RECON SOLN 1 MG/ML
Tier 3
fosinopril sodium (tab 10 mg, tab 20 mg, tab 40
mg)
Tier 1
lisinopril (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20
mg, tab 30 mg, tab 40 mg)
Tier 1
moexipril hcl (tab 7.5 mg, tab 15 mg)
Tier 1
perindopril erbumine (tab 2 mg, tab 4 mg, tab 8
mg)
Tier 1
QBRELIS SOLUTION 1 MG/ML
Tier 3
quinapril hcl (tab 5 mg, tab 10 mg, tab 20 mg, tab
40 mg)
Tier 1
ramipril (cap 1.25 mg, cap 2.5 mg, cap 5 mg, cap
10 mg)
Tier 1
trandolapril (tab 1 mg, tab 2 mg, tab 4 mg)
Tier 1
ANTIARRHYTHMICS
amiodarone hcl (tab 100 mg, tab 200 mg, tab 400
mg)
Tier 1
disopyramide phosphate (cap 100 mg, cap 150
mg)
Tier 1
dofetilide (cap 125 mcg, cap 250 mcg, cap 500
mcg)
Tier 2
flecainide acetate (tab 50 mg, tab 100 mg, tab 150
mg)
Tier 1
mexiletine hcl (cap 150 mg, cap 200 mg, cap 250
mg)
Tier 1
MULTAQ TAB 400 MG
Tier 2
PA
C
pacerone (tab 100 mg, tab 200 mg, tab 400 mg)
Tier 1
propafenone hcl (tab 150 mg, tab 225 mg, tab 300
mg)
Tier 1
propafenone hcl er (er cap er 12h 425 mg, er cap
er 12h 325 mg, er cap er 12h 225 mg)
Tier 1
quinidine gluconate er tab er 324 mg
Tier 1
sorine (tab 80 mg, tab 120 mg, tab 160 mg, tab
240 mg)
Tier 1
sotalol hcl (af) (tab 80 mg, tab 120 mg, tab 160
mg)
Tier 1
- 43 -
Must be prescribed by a
cardiologist to be covered
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
sotalol hcl (tab 80 mg, tab 120 mg, tab 160 mg, tab
240 mg)
Tier 1
SOTALOL HCL SOLUTION 150 MG/10ML
Tier 3
SOTYLIZE SOLUTION 5 MG/ML
Tier 3
LIMITS & RESTRICTIONS
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl (cap 200 mg, cap 400 mg)
Tier 1
atenolol (tab 25 mg, tab 50 mg, tab 100 mg)
Tier 1
betaxolol hcl (tab 10 mg, tab 20 mg)
Tier 1
bisoprolol fumarate (tab 5 mg, tab 10 mg)
Tier 1
BYSTOLIC (TAB 2.5 MG, TAB 5 MG, TAB 10 MG,
TAB 20 MG)
Tier 3
carvedilol (tab 3.125 mg, tab 6.25 mg, tab 12.5
mg, tab 25 mg)
Tier 1
COREG CR (CAP ER 24H 20 MG, CAP ER 24H
40 MG, CAP ER 24H 10 MG, CAP ER 24H 80
MG)
Tier 3
HEMANGEOL SOLUTION 4.28 MG/ML
Tier 3
INDERAL XL (CAP ER 24H 80 MG, CAP ER 24H
120 MG)
Tier 3
INNOPRAN XL (CAP ER 24H 120 MG, CAP ER
24H 80 MG)
Tier 3
labetalol hcl (tab 100 mg, tab 200 mg, tab 300 mg)
Tier 1
metoprolol succinate er (er tab er 24h 25 mg, er
tab er 24h 200 mg, er tab er 24h 100 mg, er tab er
24h 50 mg)
Tier 1
metoprolol tartrate (tab 25 mg, tab 37.5 mg, tab 50
mg, tab 75 mg, tab 100 mg)
Tier 1
nadolol (tab 20 mg, tab 40 mg, tab 80 mg)
Tier 1
pindolol (tab 5 mg, tab 10 mg)
Tier 1
propranolol hcl (solution 1 mg/ml, solution 20
mg/5ml, solution 40 mg/5ml, tab 10 mg, tab 20 mg,
tab 40 mg, tab 60 mg, tab 80 mg)
Tier 1
propranolol hcl er (er cap er 24h 60 mg, er cap er
24h 160 mg, er cap er 24h 120 mg, er cap er 24h
80 mg)
Tier 1
timolol maleate (tab 5 mg, tab 10 mg, tab 20 mg)
Tier 1
CALCIUM CHANNEL BLOCKING AGENTS
afeditab cr (tab er 24h 60 mg, tab er 24h 30 mg)
Tier 1
amlodipine besylate (tab 2.5 mg, tab 5 mg, tab 10
mg)
Tier 1
CARDIZEM LA TAB ER 24H 120 MG
Tier 3
cartia xt (cap er 24h 120 mg, cap er 24h 240 mg,
cap er 24h 180 mg, cap er 24h 300 mg)
Tier 1
- 44 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
dilt-xr (cap er 24h 240 mg, cap er 24h 180 mg, cap
er 24h 120 mg)
Tier 1
diltiazem cd (cap er 24h 240 mg, cap er 24h 300
mg, cap er 24h 120 mg, cap er 24h 180 mg)
Tier 1
diltiazem hcl (tab 30 mg, tab 60 mg, tab 90 mg, tab
120 mg)
Tier 1
diltiazem hcl er (er cap er 12h 60 mg, er cap er
12h 120 mg, er cap er 12h 90 mg, er cap er 24h
180 mg, er cap er 24h 120 mg, er cap er 24h 240
mg)
Tier 1
diltiazem hcl er beads (er beads cap er 24h 360
mg, er beads cap er 24h 240 mg, er beads cap er
24h 120 mg, er beads cap er 24h 300 mg, er
beads cap er 24h 420 mg, er beads cap er 24h
180 mg)
LIMITS & RESTRICTIONS
Tier 1
diltiazem hcl er coated beads (er beads cap er 24h
240 mg, er beads cap er 24h 360 mg, er beads
cap er 24h 120 mg, er beads cap er 24h 300 mg,
er beads cap er 24h 180 mg, er beads tab er 24h
420 mg, er beads tab er 24h 300 mg, er beads tab
er 24h 360 mg, er beads tab er 24h 240 mg, er
beads tab er 24h 180 mg)
Tier 1
felodipine er (er tab er 24h 10 mg, er tab er 24h 5
mg, er tab er 24h 2.5 mg)
Tier 1
isradipine (cap 2.5 mg, cap 5 mg)
Tier 1
matzim la (tab er 24h 420 mg, tab er 24h 360 mg,
tab er 24h 240 mg, tab er 24h 300 mg, tab er 24h
180 mg)
Tier 1
nicardipine hcl (cap 20 mg, cap 30 mg, solution 2.5
mg/ml)
Tier 1
nifediac cc (tab er 24h 60 mg, tab er 24h 30 mg)
Tier 1
nifedical xl (tab er 24h 30 mg, tab er 24h 60 mg)
Tier 1
nifedipine (cap 10 mg, cap 20 mg)
Tier 1
nifedipine er (er tab er 24h 60 mg, er tab er 24h 90
mg, er tab er 24h 30 mg)
Tier 1
nifedipine er osmotic release (er tab er 24h 60 mg,
er tab er 24h 30 mg, er tab er 24h 90 mg)
Tier 1
nifedipine er osmotic tab er 24h 60 mg
Tier 1
nimodipine cap 30 mg
Tier 1
nisoldipine er (er tab er 24h 17 mg, er tab er 24h
25.5 mg, er tab er 24h 34 mg, er tab er 24h 8.5
mg, er tab er 24h 40 mg, er tab er 24h 30 mg, er
tab er 24h 20 mg)
Tier 1
taztia xt (cap er 24h 360 mg, cap er 24h 240 mg,
cap er 24h 300 mg, cap er 24h 180 mg, cap er 24h
120 mg)
Tier 1
verapamil hcl (tab 40 mg, tab 80 mg, tab 120 mg)
Tier 1
- 45 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
verapamil hcl er (er cap er 24h 240 mg, er cap er
24h 200 mg, er cap er 24h 360 mg, er cap er 24h
180 mg, er cap er 24h 300 mg, er cap er 24h 120
mg, er cap er 24h 100 mg, er tab er 120 mg, er tab
er 180 mg, er tab er 240 mg)
Tier 1
LIMITS & RESTRICTIONS
CARDIOVASCULAR AGENTS, OTHER
ALDACTAZIDE TAB 50-50 MG
Tier 3
amiloride-hydrochlorothiazide tab 5-50 mg
Tier 1
amlodipine besy-benazepril hcl (cap 2.5-10 mg,
cap 5-20 mg, cap 5-10 mg, cap 5-40 mg, cap 1040 mg, cap 10-20 mg)
Tier 1
amlodipine besylate-valsartan (tab 5-160 mg, tab
5-320 mg, tab 10-160 mg, tab 10-320 mg)
Tier 1
amlodipine-valsartan-hctz (tab 5-160-12.5 mg, tab
5-160-25 mg, tab 10-160-25 mg, tab 10-320-25
mg, tab 10-160-12.5 mg)
Tier 1
atenolol-chlorthalidone (tab 50-25 mg, tab 100-25
mg)
Tier 1
AZOR (TAB 5-20 MG, TAB 5-40 MG, TAB 10-40
MG, TAB 10-20 MG)
Tier 3
benazepril-hydrochlorothiazide (tab 5-6.25 mg, tab
10-12.5 mg, tab 20-25 mg, tab 20-12.5 mg)
Tier 1
BENICAR HCT (TAB 20-12.5 MG, TAB 40-25 MG,
TAB 40-12.5 MG)
Tier 2
BIDIL TAB 20-37.5 MG
Tier 2
bisoprolol-hydrochlorothiazide (tab 2.5-6.25 mg,
tab 5-6.25 mg, tab 10-6.25 mg)
Tier 1
BYVALSON TAB 5-80 MG
Tier 3
candesartan cilexetil-hctz (tab 16-12.5 mg, tab 3225 mg, tab 32-12.5 mg)
Tier 1
captopril-hydrochlorothiazide (tab 25-15 mg, tab
25-25 mg, tab 50-15 mg, tab 50-25 mg)
Tier 1
CORLANOR (TAB 5 MG, TAB 7.5 MG)
Tier 3
digitek (tab 125 mcg, tab 250 mcg)
Tier 1
digox (tab 125 mcg, tab 250 mcg)
Tier 1
digoxin (tab 125 mcg, tab 250 mcg)
Tier 1
DUTOPROL (TAB ER 24H 50-12.5 MG, TAB ER
24H 100-12.5 MG, TAB ER 24H 25-12.5 MG)
Tier 3
EDARBYCLOR (TAB 40-12.5 MG, TAB 40-25 MG)
Tier 3
enalapril-hydrochlorothiazide (tab 5-12.5 mg, tab
10-25 mg)
Tier 1
ENTRESTO (TAB 24-26 MG, TAB 49-51 MG, TAB
97-103 MG)
Tier 2
fosinopril sodium-hctz (tab 10-12.5 mg, tab 2012.5 mg)
Tier 1
- 46 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
irbesartan-hydrochlorothiazide (tab 150-12.5 mg,
tab 300-12.5 mg)
Tier 1
LANOXIN (TAB 62.5 MCG, TAB 187.5 MCG)
Tier 3
lisinopril-hydrochlorothiazide (tab 10-12.5 mg, tab
20-25 mg, tab 20-12.5 mg)
Tier 1
losartan potassium-hctz (tab 50-12.5 mg, tab 10025 mg, tab 100-12.5 mg)
Tier 1
metoprolol-hydrochlorothiazide (tab 50-25 mg, tab
100-50 mg, tab 100-25 mg)
Tier 1
moexipril-hydrochlorothiazide (tab 7.5-12.5 mg, tab
15-12.5 mg, tab 15-25 mg)
Tier 1
nadolol-bendroflumethiazide (tab 40-5 mg, tab 805 mg)
Tier 1
pentoxifylline er tab er 400 mg
Tier 1
PRESTALIA (TAB 3.5-2.5 MG, TAB 7-5 MG, TAB
14-10 MG)
Tier 3
propranolol-hctz (tab 40-25 mg, tab 80-25 mg)
Tier 1
quinapril-hydrochlorothiazide (tab 10-12.5 mg, tab
20-25 mg, tab 20-12.5 mg)
Tier 1
RANEXA (TAB ER 12H 1000 MG, TAB ER 12H
500 MG)
Tier 3
spironolactone-hctz tab 25-25 mg
Tier 1
TEKTURNA (TAB 150 MG, TAB 300 MG)
Tier 3
TEKTURNA HCT (TAB 150-25 MG, TAB 150-12.5
MG, TAB 300-12.5 MG, TAB 300-25 MG)
Tier 3
telmisartan-amlodipine (tab 40-5 mg, tab 40-10
mg, tab 80-10 mg, tab 80-5 mg)
Tier 1
telmisartan-hctz (tab 40-12.5 mg, tab 80-12.5 mg,
tab 80-25 mg)
Tier 1
trandolapril-verapamil hcl er (er tab er 1-240 mg,
er tab er 2-180 mg, er tab er 2-240 mg, er tab er 4240 mg)
Tier 3
triamterene-hctz (cap 37.5-25 mg, cap 50-25 mg,
tab 37.5-25 mg, tab 75-50 mg)
Tier 1
TRIBENZOR (TAB 20-5-12.5 MG, TAB 40-5-12.5
MG, TAB 40-10-12.5 MG, TAB 40-10-25 MG, TAB
40-5-25 MG)
Tier 3
valsartan-hydrochlorothiazide (tab 80-12.5 mg, tab
160-25 mg, tab 160-12.5 mg, tab 320-25 mg, tab
320-12.5 mg)
Tier 1
LIMITS & RESTRICTIONS
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide er cap er 12h 500 mg
Tier 1
ACETAZOLAMIDE TAB 125 MG
Tier 1
acetazolamide tab 250 mg
Tier 1
- 47 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
DIURETICS, LOOP
bumetanide (tab 0.5 mg, tab 1 mg, tab 2 mg)
Tier 1
ethacrynic acid tab 25 mg
Tier 3
furosemide (solution 10 mg/ml, tab 20 mg, tab 40
mg, tab 80 mg)
Tier 1
torsemide (tab 5 mg, tab 10 mg, tab 20 mg, tab
100 mg)
Tier 1
DIURETICS, POTASSIUM-SPARING
amiloride hcl tab 5 mg
Tier 1
DYRENIUM (CAP 50 MG, CAP 100 MG)
Tier 3
eplerenone (tab 25 mg, tab 50 mg)
Tier 1
spironolactone (tab 25 mg, tab 50 mg, tab 100 mg)
Tier 1
DIURETICS, THIAZIDE
chlorothiazide (tab 250 mg, tab 500 mg)
Tier 1
chlorthalidone (tab 25 mg, tab 50 mg)
Tier 1
hydrochlorothiazide (cap 12.5 mg, tab 12.5 mg, tab
25 mg, tab 50 mg)
Tier 1
indapamide (tab 1.25 mg, tab 2.5 mg)
Tier 1
methyclothiazide tab 5 mg
Tier 1
metolazone (tab 2.5 mg, tab 5 mg, tab 10 mg)
Tier 1
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
ANTARA (CAP 30 MG, CAP 90 MG)
Tier 3
fenofibrate (cap 50 mg, cap 150 mg)
Tier 2
fenofibrate (tab 48 mg, tab 54 mg, tab 145 mg, tab
160 mg)
Tier 1
fenofibrate micronized (cap 43 mg, cap 67 mg, cap
130 mg, cap 134 mg, cap 200 mg)
Tier 1
fenofibrate tab 120 mg
Tier 3
fenofibrate tab 40 mg
Tier 3
fenofibric acid (cap dr 45 mg, cap dr 135 mg, tab
35 mg, tab 105 mg)
Tier 1
gemfibrozil tab 600 mg
Tier 1
C
Generic for Fenoglide
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
ALTOPREV (TAB ER 24H 20 MG, TAB ER 24H 60
MG, TAB ER 24H 40 MG)
Tier 3
atorvastatin calcium (tab 10 mg, tab 20 mg, tab 40
mg, tab 80 mg)
Tier 1
fluvastatin sodium (cap 20 mg, cap 40 mg)
Tier 1
LESCOL XL TAB ER 24H 80 MG
Tier 3
- 48 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIVALO (TAB 1 MG, TAB 2 MG, TAB 4 MG)
Tier 3
lovastatin (tab 10 mg, tab 20 mg, tab 40 mg)
Tier 1
pravastatin sodium (tab 10 mg, tab 20 mg, tab 40
mg, tab 80 mg)
Tier 1
rosuvastatin calcium (tab 5 mg, tab 10 mg, tab 20
mg, tab 40 mg)
Tier 1
simvastatin (tab 5 mg, tab 10 mg, tab 20 mg, tab
40 mg, tab 80 mg)
Tier 1
LIMITS & RESTRICTIONS
DYSLIPIDEMICS, OTHER
ADVICOR (TAB ER 24H 1000-40 MG, TAB ER
24H 750-20 MG, TAB ER 24H 1000-20 MG, TAB
ER 24H 500-20 MG)
Tier 2
cholestyramine (packet 4 gm, powder 4 gm/dose)
Tier 1
cholestyramine light (packet 4 gm, powder 4
gm/dose)
Tier 1
colestipol hcl (granules 5 gm, packet 5 gm, tab 1
gm)
Tier 1
LIPTRUZET (TAB 10-40 MG, TAB 10-20 MG, TAB
10-10 MG, TAB 10-80 MG)
Tier 3
niacin er (antihyperlipidemic) (er tab er 500 mg, er
tab er 750 mg, er tab er 1000 mg)
Tier 1
NIACOR TAB 500 MG
Tier 1
omega-3-acid ethyl esters cap 1 gm
Tier 1
prevalite (packet 4 gm, powder 4 gm/dose)
Tier 1
SIMCOR (TAB ER 24H 1000-40 MG, TAB ER 24H
500-40 MG, TAB ER 24H 1000-20 MG, TAB ER
24H 750-20 MG, TAB ER 24H 500-20 MG)
Tier 3
VASCEPA CAP 1 GM
Tier 2
VYTORIN (TAB 10-40 MG, TAB 10-20 MG, TAB
10-80 MG, TAB 10-10 MG)
Tier 2
WELCHOL (PACKET 3.75 GM, TAB 625 MG)
Tier 2
ZETIA TAB 10 MG
Tier 2
C
STB
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine hcl (tab 10 mg, tab 25 mg, tab 50 mg,
tab 100 mg)
Tier 1
minoxidil (tab 2.5 mg, tab 10 mg)
Tier 1
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
GONITRO PACKET 400 MCG
Tier 3
ISORDIL TITRADOSE TAB 40 MG
Tier 3
isosorbide dinitrate (tab 5 mg, tab 10 mg, tab 20
mg, tab 30 mg)
Tier 1
isosorbide dinitrate er tab er 40 mg
Tier 1
- 49 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
isosorbide mononitrate (tab 10 mg, tab 20 mg)
Tier 1
isosorbide mononitrate er (er tab er 24h 30 mg, er
tab er 24h 120 mg, er tab er 24h 60 mg)
Tier 1
minitran (patch 24hr 0.1, patch 24hr 0.6, patch
24hr 0.4, patch 24hr 0.2)
Tier 1
NITRO-BID OINTMENT 2 %
Tier 2
NITRO-DUR (PATCH 24HR 0.3, PATCH 24HR
0.8)
Tier 2
nitroglycerin (aero soln 400 mcg/spray, patch 24hr
0.1 mg/hr, patch 24hr 0.4 mg/hr, patch 24hr 0.2
mg/hr, patch 24hr 0.6 mg/hr, sl tab 0.3 mg, sl tab
0.4 mg, sl tab 0.6 mg, solution 0.4 mg/spray)
Tier 1
nitroglycerin er (er cap er 2.5 mg, er cap er 6.5 mg,
er cap er 9 mg)
LIMITS & RESTRICTIONS
Tier 1
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
ADZENYS XR-ODT (TAB ER DISP 3.1 MG, TAB
ER DISP 6.3 MG, TAB ER DISP 9.4 MG, TAB ER
DISP 12.5 MG, TAB ER DISP 15.7 MG, TAB ER
DISP 18.8 MG)
Tier 3
amphetamine-dextroamphet er (er cap er 24h 25
mg, er cap er 24h 20 mg, er cap er 24h 5 mg, er
cap er 24h 15 mg, er cap er 24h 10 mg, er cap er
24h 30 mg)
Tier 1
amphetamine-dextroamphetamine (tab 5 mg, tab
7.5 mg, tab 10 mg, tab 12.5 mg, tab 15 mg, tab 20
mg, tab 30 mg)
Tier 1
dexedrine (tab 5 mg, tab 10 mg)
Tier 1
dextroamphetamine sulfate (solution 5 mg/5ml, tab
5 mg, tab 10 mg)
Tier 1
dextroamphetamine sulfate er (er cap er 24h 15
mg, er cap er 24h 10 mg, er cap er 24h 5 mg)
Tier 1
EVEKEO (TAB 5 MG, TAB 10 MG)
Tier 3
methamphetamine hcl tab 5 mg
Tier 1
VYVANSE (CAP 10 MG, CAP 20 MG, CAP 30
MG, CAP 40 MG, CAP 50 MG, CAP 60 MG, CAP
70 MG)
Tier 2
ZENZEDI (TAB 2.5 MG, TAB 7.5 MG, TAB 15 MG,
TAB 20 MG, TAB 30 MG)
Tier 1
zenzedi (tab 5 mg, tab 10 mg)
Tier 1
PA
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
APTENSIO XR (CAP ER 24H 50 MG, CAP ER
24H 30 MG, CAP ER 24H 40 MG, CAP ER 24H 10
MG, CAP ER 24H 60 MG, CAP ER 24H 15 MG,
CAP ER 24H 20 MG)
Tier 3
clonidine hcl er tab er 12h 0.1 mg
Tier 1
- 50 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
DAYTRANA (PATCH 10, PATCH 15, PATCH 20,
PATCH 30)
Tier 3
dexmethylphenidate hcl (tab 2.5 mg, tab 5 mg, tab
10 mg)
Tier 1
dexmethylphenidate hcl er (er cap er 24h 30 mg,
er cap er 24h 20 mg, er cap er 24h 40 mg, er cap
er 24h 15 mg, er cap er 24h 5 mg, er cap er 24h
10 mg)
FOCALIN XR (CAP ER 24H 25 MG, CAP ER 24H
35 MG)
LIMITS & RESTRICTIONS
Tier 1
Tier 3
guanfacine hcl er (er tab er 24h 1 mg, er tab er
24h 4 mg, er tab er 24h 2 mg, er tab er 24h 3 mg)
Tier 2
metadate er tab er 20 mg
Tier 1
methylphenidate hcl (chew tab 2.5 mg, chew tab 5
mg, chew tab 10 mg)
Tier 3
methylphenidate hcl (solution 5 mg/5ml, solution
10 mg/5ml, tab 5 mg, tab 10 mg, tab 20 mg)
Tier 1
methylphenidate hcl er (cd) (er cap er 10 mg, er
cap er 20 mg, er cap er 30 mg, er cap er 40 mg, er
cap er 50 mg, er cap er 60 mg)
Tier 1
methylphenidate hcl er (er tab er 10 mg, er tab er
20 mg, er tab er 24h 54 mg, er tab er 24h 36 mg,
er tab er 36 mg, er tab er 54 mg)
Tier 1
methylphenidate hcl er (er tab er 18 mg, er tab er
24h 27 mg, er tab er 24h 18 mg, er tab er 27 mg)
Tier 1
methylphenidate hcl er (la) (er cap er 24h 40 mg,
er cap er 24h 30 mg, er cap er 24h 20 mg)
Tier 1
QUILLIVANT XR RECON SUSP 25 MG/5ML
Tier 3
RITALIN LA (CAP ER 24H 10 MG, CAP ER 24H
60 MG)
Tier 3
STRATTERA (CAP 10 MG, CAP 18 MG, CAP 25
MG, CAP 40 MG, CAP 60 MG, CAP 80 MG, CAP
100 MG)
Tier 2
C
C
QL
C
Generic for Methylin
Generic for Metadate CD
34 tablets
Generic for Ritalin LA
CENTRAL NERVOUS SYSTEM, OTHER
ALLZITAL TAB 25-325 MG
Tier 3
butalbital-acetaminophen tab 50-325 mg
Tier 1
butalbital-apap-caffeine (cap 50-300-40 mg, cap
50-325-40 mg, tab 50-325-40 mg)
Tier 1
butalbital-asa-caffeine cap 50-325-40 mg
Tier 1
butalbital-aspirin-caffeine cap 50-325-40 mg
Tier 1
HORIZANT (TAB ER 300 MG, TAB ER 600 MG)
Tier 3
NAMZARIC (CAP ER 24H 7-10 MG, CAP ER 24H
14-10 MG, CAP ER 24H 28-10 MG, CAP ER 24H
21-10 MG)
Tier 3
NUEDEXTA CAP 20-10 MG
Tier 2
ST
- 51 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
FIBROMYALGIA AGENTS
duloxetine hcl (cp dr part 20 mg, cp dr part 30 mg,
cp dr part 60 mg)
Tier 1
duloxetine hcl cp dr part 40 mg
Tier 3
LYRICA (CAP 25 MG, CAP 50 MG, CAP 75 MG,
CAP 100 MG, CAP 150 MG, CAP 200 MG, CAP
225 MG, CAP 300 MG, SOLUTION 20 MG/ML)
Tier 3
SAVELLA (TAB 12.5 MG, TAB 25 MG, TAB 50
MG, TAB 100 MG)
Tier 2
SAVELLA TITRATION PACK MISC 12.5 & 25 &
50 MG
Tier 2
PA
DENTAL AND ORAL AGENTS
cevimeline hcl cap 30 mg
Tier 1
oralone paste 0.1 %
Tier 1
pilocarpine hcl (tab 5 mg, tab 7.5 mg)
Tier 1
SALIVAMAX PACKET
Tier 3
triamcinolone acetonide (cream 0.1 %, paste 0.1
%)
Tier 1
DERMATOLOGICAL AGENTS
ACANYA GEL 1.2-2.5 %
Tier 2
ACZONE (GEL 5 %, GEL 7.5 %)
Tier 3
adapalene (cream 0.1 %, gel 0.1 %, gel 0.3 %)
Tier 1
ADAPALENE LOTION 0.1 %
Tier 1
ALA SCALP LOTION 2 %
Tier 2
ALCORTIN A GEL 1-2-1 %
Tier 3
amnesteem (cap 10 mg, cap 20 mg, cap 40 mg)
Tier 2
ANALPRAM E KIT 2.5-1 & 1 %
Tier 2
ANASTIA LOTION 2.75 %
Tier 3
ASTERO GEL 4 %
Tier 3
AVAR (FOAM %, PAD %)
Tier 3
avar cleanser emulsion 10-5 %
Tier 1
AVAR LS (FOAM %, PAD %)
Tier 3
avar-e emollient cream 10-5 %
Tier 1
avar-e green cream 10-5 %
Tier 1
avita (cream 0.025 %, gel 0.025 %)
Tier 1
AZELEX CREAM 20 %
Tier 3
benzoyl peroxide foam 9.8 %
Tier 1
benzoyl peroxide short contact foam 9.8 %
Tier 1
- 52 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
benzoyl peroxide-erythromycin gel 5-3 %
Tier 1
bp 10-1 emulsion 10-1 %
Tier 1
BP CLEANSING WASH EMULSION 10-4 %
Tier 1
bp foam foam 9.8 %
Tier 1
calcipotriene (cream 0.005 %, ointment 0.005 %,
solution 0.005 %)
Tier 1
calcipotriene-betameth diprop ointment 0.0050.064 %
Tier 1
calcitrene ointment 0.005 %
Tier 1
calcitriol ointment 3 mcg/gm
Tier 1
carb-o-philic/40 (cream 40 %, gel 40 %)
Tier 1
cerisa wash emulsion 10-1 %
Tier 1
cerovel (gel 40 %, lotion 40 %)
Tier 1
claravis (cap 10 mg, cap 20 mg, cap 30 mg, cap
40 mg)
Tier 2
clindacin etz swab 1 %
Tier 1
clindacin-p swab 1 %
Tier 1
clindamycin phos-benzoyl perox (gel 1-5 %, gel
1.2-5 %)
Tier 1
clindamycin phosphate swab 1 %
Tier 1
clindamycin-tretinoin gel 1.2-0.025 %
Tier 2
clotrimazole-betamethasone (cream %, lotion %)
Tier 1
CONDYLOX GEL 0.5 %
Tier 2
DERMASORB XM KIT 39 %
Tier 3
dermazene cream 1-1 %
Tier 1
diclofenac sodium gel 1 %
Tier 1
DIFFERIN LOTION 0.1 %
Tier 2
DOXEPIN HCL CREAM 5 %
Tier 2
ELIDEL CREAM 1 %
Tier 2
EPIDUO FORTE GEL 0.3-2.5 %
Tier 2
EPIDUO GEL 0.1-2.5 %
Tier 2
FABIOR FOAM 0.1 %
Tier 3
FINACEA (FOAM 15 %, GEL 15 %)
Tier 2
fluorouracil (cream 5 %, solution 2 %, solution 5
%)
Tier 1
GORDOFILM SOLUTION 16.7-16.7 %
Tier 3
GORDONS UREA OINTMENT 40 %
Tier 3
GRANULEX AERO SOLN 0.12-788-87 MG/GM
Tier 3
LIMITS & RESTRICTIONS
PA
- 53 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
hydrocortisone (cream 1 %, cream 2.5 %, lotion
2.5 %, ointment 2.5 %)
Tier 1
hydrocortisone ace-pramoxine (cream 1-1 %,
cream 2.5-1 %)
Tier 1
hydrocortisone-iodoquinol cream 1-1 %
Tier 1
imiquimod cream 5 %
Tier 1
KERAFOAM 42 FOAM 42 %
Tier 3
KERAFOAM FOAM 30 %
Tier 3
KERALYT SCALP KIT 6 %
Tier 3
latrix suspension 50 %
Tier 1
LATRIX XM EMULSION 45 %
Tier 3
lidocaine (ointment 5 %, patch 5 %)
Tier 1
lidocaine hcl solution 4 %
Tier 1
lidocaine pak ointment 5 %
Tier 1
lidocaine-hydrocortisone ace (cream 3-0.5 %, kit 22 %, kit 3-1 %, kit 3-0.5 %, kit 3-2.5 %)
Tier 1
lidocaine-prilocaine cream 2.5-2.5 %
Tier 1
MIRVASO GEL 0.33 %
Tier 3
myorisan (cap 10 mg, cap 20 mg, cap 30 mg, cap
40 mg)
Tier 2
neuac gel 1.2-5 %
Tier 1
NOVACORT GEL 1-2 %
Tier 3
ONEXTON GEL 1.2-3.75 %
Tier 3
PICATO (GEL 0.015 %, GEL 0.05 %)
Tier 3
PLEXION CLEANSING CLOTH PAD 9.8-4.8 %
Tier 3
podofilox solution 0.5 %
Tier 1
prascion emulsion 10-5 %
Tier 1
prascion fc pad 10-5 %
Tier 1
procto-med hc cream 2.5 %
Tier 1
proctozone-hc cream 2.5 %
Tier 1
PROMISEB COMPLETE KIT
Tier 3
pyrogallic acid ointment 25-2 %
Tier 3
rea lo 39 cream 39 %
Tier 1
rea lo 40 (40 cm 40 %, 40 tion 40 %)
Tier 1
RECTIV OINTMENT 0.4 %
Tier 2
REGRANEX GEL 0.01 %
Tier 2
remeven cream 50 %
Tier 1
RETIN-A MICRO PUMP GEL 0.08 %
Tier 2
LIMITS & RESTRICTIONS
QL
- 54 -
1 tube per fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
rosanil cleanser emulsion 10-5 %
Tier 1
ROSANIL KIT 10-5 %
Tier 3
ROSULA WASH LIQUID 10-4.5 %
Tier 3
salacyn (cream 6 %, lotion 6 %)
Tier 1
salicylic acid (cream 6 %, foam 6 %, gel 6 %, liquid
27.5 %, lotion 6 %, shampoo 6 %)
Tier 1
salicylic acid er solution 28.5 %
Tier 1
salicylic acid in ammon lact foam 6 %
Tier 1
salicylic acid liquid 26 %
Tier 3
salicylic acid wart remover liquid 27.5 %
Tier 1
salicylic acid-cleanser (kit 6 % (lotion), kit 6 %
(cream))
Tier 1
SALVAX DUO PLUS KIT 6 & 35 %
Tier 3
SANTYL (250, OINTMENT 250)
Tier 3
seb-prev wash liquid 10 %
Tier 1
selenium sulf-pyrithione-urea shampoo 2.25 %
Tier 1
selenium sulfide (lotion 2.5 %, shampoo 2.25 %)
Tier 1
SERNIVO EMULSION 0.05 %
Tier 3
sodium sulfacetamide shampoo 10 %
Tier 1
SODIUM SULFACETAMIDE WASH LIQUID 10 %
Tier 3
SORILUX FOAM 0.005 %
Tier 2
ss 10-2 solution 10-2 %
Tier 1
sss 10-5 cream 10-5 %
Tier 1
sulfacetamide sod-sulfur wash kit 9-4.5 %
Tier 1
sulfacetamide sodium (acne) lotion 10 %
Tier 1
sulfacetamide sodium (gel 10 % (cleans), liquid 10
%, suspension 10 %)
Tier 1
sulfacetamide sodium-sulfur (cream 9.8-4.8 %,
cream 10-2 %, cream 10-5 %, emulsion 10-5 %,
foam 10-5 %, liquid 9-4.5 %, liquid 9-4 %, liquid
9.8-4.8 %, liquid 10-2 %, lotion 9.8-4.8 %, lotion
10-5 %, pad 10-5 %, pad 10-4 %, suspension 8-4
%)
Tier 1
sulfacetamide sodium-sulfur suspension 10-5 %
Tier 3
SULFACETAMIDE-SULFUR IN UREA EMULSION
10-5 %
Tier 3
sulfacetamide-sulfur in urea gel 10-5 %
Tier 1
sulfacleanse 8/4 suspension 8-4 %
Tier 1
SUMAXIN CP KIT 10-4 %
Tier 3
TACLONEX SUSPENSION 0.005-0.064 %
Tier 3
LIMITS & RESTRICTIONS
- 55 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
tacrolimus (ointment 0.03 %, ointment 0.1 %)
Tier 2
TAZORAC (CREAM 0.05 %, CREAM 0.1 %, GEL
0.05 %, GEL 0.1 %)
Tier 2
TBC AERO SOLN 650-72.5-0.1 MG/0.82ML
Tier 1
TERSI FOAM 2.25 %
Tier 3
tretinoin (cream 0.025 %, cream 0.05 %, cream
0.1 %, gel 0.01 %, gel 0.025 %, gel 0.05 %)
Tier 1
tretinoin microsphere (gel 0.04 %, gel 0.1 %)
Tier 1
tretinoin microsphere pump (pump gel 0.04 %,
pump gel 0.1 %)
Tier 1
u-kera e cream 40 %
Tier 1
UMECTA EMULSION 40 %
Tier 3
umecta mousse foam 40 %
Tier 1
UMECTA PD (EMULSION %, SUSPENSION %)
Tier 3
URAMAXIN FOAM 20 %
Tier 3
URAMAXIN GT KIT 45 %
Tier 3
urea (cream 39 %, cream 40 %, cream 45 %,
cream 47 %, cream 50 %, emulsion 50 %, gel 40
%, lotion 40 %, lotion 45 %, suspension 50 %)
Tier 1
urea hydrating foam 35 %
Tier 1
urea in zn undecyl-lactic acid emulsion 50 %
Tier 1
urea nail film suspension 40 %
Tier 1
urea nail gel 45 %
Tier 1
UREA NAIL STICK 50 %
Tier 3
UREVAZ CREAM 44 %
Tier 3
UTOPIC CREAM 41 %
Tier 3
zenatane (cap 10 mg, cap 20 mg, cap 30 mg, cap
40 mg)
Tier 2
zencia liquid 9-4 %
Tier 1
ZITHRANOL SHAMPOO 1 %
Tier 2
ZITHRANOL-RR CREAM 1.2 %
Tier 2
ZONALON CREAM 5 %
Tier 3
ZYCLARA CREAM 3.75 %
Tier 3
LIMITS & RESTRICTIONS
PA
ENZYME REPLACEMENT/MODIFIERS
CREON (CP DR PART 3000-9500, CP DR PART
6000, CP DR PART 12000, CP DR PART 24000,
CP DR PART 36000)
Tier 2
PANCREAZE (CP DR PART 4200, CP DR PART
10500, CP DR PART 16800, CP DR PART 21000)
Tier 2
pancrelipase (lip-prot-amyl) cp dr part 5000 unit
Tier 1
- 56 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
PERTZYE (CP DR PART 8000, CP DR PART
16000)
Tier 3
ULTRESA (CP DR PART 13800, CP DR PART
20700, CP DR PART 23000)
Tier 3
VIOKACE (TAB 10440, TAB 20880)
Tier 3
ZENPEP (CP DR PART 3000-10000, CP DR
PART 10000, CP DR PART 15000, CP DR PART
20000, CP DR PART 25000, CP DR PART 40000)
Tier 3
LIMITS & RESTRICTIONS
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
b-donna tab 16.2 mg
Tier 1
chlordiazepoxide-clidinium cap 5-2.5 mg
Tier 1
CUVPOSA SOLUTION 1 MG/5ML
Tier 3
dicyclomine hcl (cap 10 mg, solution 10 mg/5ml,
tab 20 mg)
Tier 1
DONNATAL ELIXIR 16.2 MG/5ML
Tier 2
DONNATAL EXTENTABS TAB ER
Tier 2
glycopyrrolate (tab 1 mg, tab 2 mg)
Tier 1
hyoscyamine sulfate (elixir 0.125 mg/5ml, sl tab
0.125 mg, solution 0.125 mg/ml, tab 0.125 mg, tab
disp 0.125 mg)
Tier 1
hyoscyamine sulfate er tab er 12h 0.375 mg
Tier 1
nulev tab disp 0.125 mg
Tier 2
phenohytro tab 16.2 mg
Tier 1
GASTROINTESTINAL AGENTS, OTHER
amoxicill-clarithro-lansopraz misc
Tier 1
cromolyn sodium conc 100 mg/5ml
Tier 1
diphenoxylate-atropine (liquid mg/5ml, tab mg)
Tier 1
ENTEREG CAP 12 MG
Tier 3
FULYZAQ TAB DR 125 MG
Tier 3
MOVANTIK (TAB 12.5 MG, TAB 25 MG)
Tier 3
MYTESI TAB DR 125 MG
Tier 3
OMECLAMOX-PAK MISC 500-500-20 MG
Tier 3
opium tincture 10 mg/ml (1%)
Tier 1
paregoric tincture 2 mg/5ml
Tier 1
PYLERA CAP 140-125-125 MG
Tier 3
ursodiol (cap 300 mg, tab 250 mg, tab 500 mg)
Tier 1
- 57 -
QL
1 pack per fill
QL
1 pack per fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
cimetidine (tab 300 mg, tab 400 mg, tab 800 mg)
Tier 1
cimetidine hcl solution 300 mg/5ml
Tier 1
famotidine (recon susp 40 mg/5ml, tab 40 mg)
Tier 1
nizatidine (cap 150 mg, cap 300 mg)
Tier 1
nizatidine solution 15 mg/ml
Tier 3
ranitidine hcl (cap 150 mg, cap 300 mg, syrup 15
mg/ml, syrup 75 mg/5ml, syrup 150 mg/10ml, tab
300 mg)
Tier 1
IRRITABLE BOWEL SYNDROME AGENTS
AMITIZA (CAP 8 MCG, CAP 24 MCG)
Tier 3
LINZESS (CAP 145 MCG, CAP 290 MCG)
Tier 2
LAXATIVES
COLYTE WITH FLAVOR PACKS RECON SOLN
227.1 GM
Tier 3
constulose solution 10 gm/15ml
Tier 1
enulose solution 10 gm/15ml
Tier 1
gavilyte-c recon soln 240 gm
Tier 1
gavilyte-g recon soln 236 gm
Tier 1
gavilyte-h kit 5-210 mg-gm
ACA Preventive Medications
gavilyte-n with flavor pack recon soln 420 gm
Tier 1
generlac solution 10 gm/15ml
Tier 1
GIALAX KIT
Tier 3
GOLYTELY RECON SOLN 227.1 GM
Tier 3
KRISTALOSE (PACKET 10 GM, PACKET 20 GM)
Tier 3
lactulose (solution 10 gm/15ml, solution 20
gm/30ml)
Tier 1
lactulose encephalopathy solution 10 gm/15ml
Tier 1
MOVIPREP RECON SOLN 100 GM
ACA Preventive Medications
OSMOPREP TAB 1.102-0.398 GM
Tier 3
peg 3350-kcl-na bicarb-nacl recon soln 420 gm
Tier 1
peg 3350/electrolytes recon soln 240 gm
Tier 1
peg-3350/electrolytes recon soln 236 gm
Tier 1
peg-prep kit 5-210 mg-gm
AL1
50 to 74 yrs old
AL1
50 to 74 yrs old
ACA Preventive Medications
AL1
50 to 74 yrs old
PREPOPIK PACKET 10-3.5-12 MG-GM-GM
ACA Preventive Medications
AL1
50 to 74 yrs old
SUCLEAR KIT
ACA Preventive Medications
AL1
50 to 74 yrs old
- 58 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
SUPREP BOWEL PREP SOLUTION
ACA Preventive Medications
trilyte recon soln 420 gm
Tier 1
AL1
50 to 74 yrs old
PROTECTANTS
CARAFATE SUSPENSION 1 GM/10ML
Tier 2
misoprostol (tab 100 mcg, tab 200 mcg)
Tier 1
sucralfate tab 1 gm
Tier 1
PROTON PUMP INHIBITORS
ACIPHEX SPRINKLE (CAP SPRINK 5 MG, CAP
SPRINK 10 MG)
Tier 3
PA
DEXILANT (CAP DR 30 MG, CAP DR 60 MG)
Tier 3
PA
esomeprazole magnesium cap dr 40 mg
Tier 2
PA
esomeprazole strontium (cap dr 24.65 mg, cap dr
49.3 mg)
Tier 3
PA
FIRST-LANSOPRAZOLE SUSPENSION 3 MG/ML
Tier 3
PA
FIRST-OMEPRAZOLE SUSPENSION 2 MG/ML
Tier 3
PA
lansoprazole (cap dr 15 mg, cap dr 30 mg)
Tier 1
NEXIUM (PACKET 2.5 MG, PACKET 5 MG,
PACKET 10 MG, PACKET 20 MG, PACKET 40
MG)
Tier 3
omeprazole (cap dr 20 mg, cap dr 40 mg)
Tier 1
omeprazole cap dr 10 mg
Tier 1
OMEPRAZOLE+SYRSPEND SF ALKA
SUSPENSION 2 MG/ML
Tier 3
pantoprazole sodium tab dr 20 mg
Tier 1
pantoprazole sodium tab dr 40 mg
Tier 1
PREVACID SOLUTAB (TAB DISP 15 MG, TAB
DISP 30 MG)
Tier 3
PROTONIX PACKET 40 MG
Tier 3
PA
rabeprazole sodium tab dr 20 mg
Tier 1
PA
darifenacin hydrobromide er (er tab er 24h 7.5 mg,
er tab er 24h 15 mg)
Tier 2
ST
flavoxate hcl tab 100 mg
Tier 1
GELNIQUE (GEL 3 (28) % (MG/ACT), GEL 10 %)
Tier 3
PA
QL
34 capsules per fill
34 tablets per fill
QL
PA
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
ST
- 59 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
MYRBETRIQ (TAB ER 24H 25 MG, TAB ER 24H
50 MG)
Tier 3
oxybutynin chloride (syrup 5 mg/5ml, tab 5 mg)
Tier 1
oxybutynin chloride er (er tab er 24h 5 mg, er tab
er 24h 10 mg, er tab er 24h 15 mg)
Tier 1
tolterodine tartrate (tab 1 mg, tab 2 mg)
Tier 1
tolterodine tartrate er (er cap er 24h 2 mg, er cap
er 24h 4 mg)
Tier 1
TOVIAZ (TAB ER 24H 8 MG, TAB ER 24H 4 MG)
Tier 3
ST
trospium chloride er cap er 24h 60 mg
Tier 1
ST
trospium chloride tab 20 mg
Tier 1
VESICARE (TAB 5 MG, TAB 10 MG)
Tier 3
ST
ST
BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin hcl er tab er 24h 10 mg
Tier 1
CARDURA XL (TAB ER 24H 4 MG, TAB ER 24H 8
MG)
Tier 3
CIALIS (TAB 2.5 MG, TAB 5 MG)
Tier 3
PA
QL
dutasteride cap 0.5 mg
Tier 1
dutasteride-tamsulosin hcl cap 0.5-0.4 mg
Tier 2
finasteride tab 5 mg
Tier 1
RAPAFLO (CAP 4 MG, CAP 8 MG)
Tier 3
tamsulosin hcl cap 0.4 mg
Tier 1
terazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg, cap
10 mg)
Tier 1
30 tablets per fill
GENITOURINARY AGENTS, OTHER
av-phos 250 neutral tab 155-852-130 mg
Tier 1
bethanechol chloride (tab 5 mg, tab 10 mg, tab 25
mg, tab 50 mg)
Tier 1
citric acid-sodium citrate solution 334-500 mg/5ml
Tier 1
cytra k crystals packet 3300-1002 mg
Tier 1
cytra-2 solution 500-334 mg/5ml
Tier 1
CYTRA-3 SYRUP 550-500-334 MG/5ML
Tier 1
cytra-k solution 1100-334 mg/5ml
Tier 1
ELMIRON CAP 100 MG
Tier 2
encare gel 4 %
ACA Preventive Medications
ENCARE SUPPOS 100 MG
ACA Preventive Medications
- 60 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
GYNOL II GEL 2 %
ACA Preventive Medications
OPTIONS GYNOL II CONTRACEPTIVE GEL 3 %
ACA Preventive Medications
ORACIT SOLUTION 490-640 MG/5ML
Tier 3
phenazopyridine hcl tab 200 mg
Tier 1
phospha 250 neutral tab 155-852-130 mg
Tier 1
pot & sod cit-cit ac solution 550-500-334 mg/5ml
Tier 1
potassium citrate er (er tab er 5 (540, er tab er 10
(1080, er tab er 15 (1620)
Tier 1
potassium citrate-citric acid (packet 3300-1002
mg, solution 1100-334 mg/5ml)
Tier 1
PYRIDIUM TAB 100 MG
Tier 3
sod citrate-citric acid solution 500-334 mg/5ml
Tier 1
TODAY SPONGE MISC 1000 MG
ACA Preventive Medications
tricitrates solution 550-500-334 mg/5ml
Tier 1
VCF VAGINAL CONTRACEPTIVE (FILM 28 %,
FOAM 12.5 %)
ACA Preventive Medications
vcf vaginal contraceptive gel 4 %
ACA Preventive Medications
virt-phos 250 neutral tab 155-852-130 mg
Tier 1
virtrate-2 solution 500-334 mg/5ml
Tier 1
virtrate-3 solution 550-500-334 mg/5ml
Tier 1
virtrate-k solution 1100-334 mg/5ml
Tier 1
PHOSPHATE BINDERS
calcium acetate (phos binder) (cap 667 mg, tab
667 mg)
Tier 1
calcium acetate cap 667 mg
Tier 1
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
alclometasone dipropionate (cream 0.05 %,
ointment 0.05 %)
Tier 1
anucort-hc suppos 25 mg
Tier 1
anusol-hc suppos 25 mg
Tier 2
betamethasone dipropionate (cream 0.05 %, lotion
0.05 %, ointment 0.05 %)
Tier 1
betamethasone dipropionate aug (cream 0.05 %,
gel 0.05 %, lotion 0.05 %, ointment 0.05 %)
Tier 1
betamethasone valerate (cream 0.1 %, foam 0.12
%, lotion 0.1 %, ointment 0.1 %)
Tier 1
clobetasol propionate (cream 0.05 %, foam 0.05
%, gel 0.05 %, liquid 0.05 %, lotion 0.05 %,
ointment 0.05 %, shampoo 0.05 %, solution 0.05
%)
Tier 1
clobetasol propionate e cream 0.05 %
Tier 1
- 61 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
clobetasol propionate emulsion foam 0.05 %
Tier 1
clocortolone pivalate cream 0.1 %
Tier 1
clocortolone pivalate pump cream 0.1 %
Tier 1
clodan shampoo 0.05 %
Tier 1
CORDRAN TAPE 4 MCG/SQCM
Tier 3
cormax scalp application solution 0.05 %
Tier 1
cortisone acetate tab 25 mg
Tier 1
deltasone tab 20 mg
Tier 1
DERMATOP (CREAM 0.1 %, OINTMENT 0.1 %)
Tier 3
DESONATE GEL 0.05 %
Tier 3
desonide (cream 0.05 %, lotion 0.05 %, ointment
0.05 %)
Tier 1
DESOXIMETASONE (CREAM 0.05 %,
OINTMENT 0.05 %)
Tier 1
desoximetasone (cream 0.25 %, gel 0.05 %,
ointment 0.25 %)
Tier 1
dexamethasone (elixir 0.5 mg/5ml, solution 0.5
mg/5ml, tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5
mg, tab 2 mg, tab 4 mg, tab 6 mg)
Tier 1
DEXAMETHASONE INTENSOL CONC 1 MG/ML
Tier 3
dexamethasone sod phosphate pf solution 10
mg/ml
Tier 1
dexamethasone sodium phosphate (solution 4
mg/ml, solution 10 mg/ml, solution 20 mg/5ml,
solution 100 mg/10ml, solution 120 mg/30ml)
Tier 1
DEXPAK 10 DAY TAB THPK 1.5 MG (35)
Tier 3
DEXPAK 13 DAY TAB THPK 1.5 MG (51)
Tier 3
DEXPAK 6 DAY TAB THPK 1.5 MG (21)
Tier 3
DIFLORASONE DIACETATE (CREAM 0.05 %,
OINTMENT 0.05 %)
Tier 1
fludrocortisone acetate tab 0.1 mg
Tier 1
fluocinolone acetonide (cream 0.01 %, cream
0.025 %, ointment 0.025 %, solution 0.01 %)
Tier 1
fluocinolone acetonide body oil 0.01 %
Tier 1
fluocinolone acetonide scalp oil 0.01 %
Tier 1
fluocinonide (cream 0.05 %, cream 0.1 %, gel 0.05
%, ointment 0.05 %, solution 0.05 %)
Tier 1
fluocinonide-e cream 0.05 %
Tier 1
flurandrenolide cream 0.05 %
Tier 3
FLURANDRENOLIDE LOTION 0.05 %
Tier 3
fluticasone propionate (cream 0.05 %, lotion 0.05
%, ointment 0.005 %)
Tier 1
LIMITS & RESTRICTIONS
QL
- 62 -
2 rolls per fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
halobetasol propionate (cream 0.05 %, ointment
0.05 %)
Tier 1
HALOG (CREAM 0.1 %, OINTMENT 0.1 %)
Tier 2
hydrocortisone (tab 5 mg, tab 10 mg, tab 20 mg)
Tier 1
hydrocortisone acetate (suppos 25 mg, suppos 30
mg)
Tier 1
hydrocortisone butyr lipo base cream 0.1 %
Tier 1
hydrocortisone butyrate (cream 0.1 %, ointment
0.1 %, solution 0.1 %)
Tier 1
hydrocortisone valerate (cream 0.2 %, ointment
0.2 %)
Tier 1
LOCOID LOTION 0.1 %
Tier 3
MEDROL TAB 2 MG
Tier 3
methylprednisolone (pak) tab 4 mg
Tier 1
methylprednisolone (tab 4 mg, tab 8 mg, tab 16
mg, tab 32 mg, tab thpk 4 mg)
Tier 1
MILLIPRED (SOLUTION 10 MG/5ML, TAB 5 MG)
Tier 3
MILLIPRED DP (TAB THPK 5 MG (48), TAB
THPK 5 MG (21))
Tier 3
MILLIPRED DP 12-DAY TAB THPK 5 MG (48)
Tier 3
mometasone furoate (cream 0.1 %, ointment 0.1
%, solution 0.1 %)
Tier 1
prednisolone (solution 15, syrup 15)
Tier 1
prednisolone sodium phosphate (solution 6.7 (5
base) mg/5ml, solution 15 mg/5ml, tab disp 10 mg,
tab disp 15 mg, tab disp 30 mg)
Tier 1
PREDNISOLONE SODIUM PHOSPHATE
SOLUTION 25 MG/5ML
Tier 1
prednisone (solution 5 mg/5ml, tab 1 mg, tab 2.5
mg, tab 5 mg, tab 10 mg, tab 20 mg, tab 50 mg,
tab thpk 5 mg (48), tab thpk 5 mg (21), tab thpk 10
mg (48), tab thpk 10 mg (21))
Tier 1
RAYOS (TAB DR 1 MG, TAB DR 2 MG, TAB DR 5
MG)
Tier 3
TOPICORT (CREAM 0.05 %, OINTMENT 0.05 %)
Tier 2
triamcinolone acetonide (aero soln 0.147 mg/gm,
cream 0.025 %, cream 0.1 %, cream 0.5 %, lotion
0.025 %, lotion 0.1 %, ointment 0.025 %, ointment
0.1 %, ointment 0.5 %)
Tier 1
triderm cream 0.1 %
Tier 1
ULTRAVATE X (CREAM) KIT 0.05 & 10 %
Tier 3
ULTRAVATE X (OINTMENT) KIT 0.05 & 10 %
Tier 3
VERDESO FOAM 0.05 %
Tier 3
LIMITS & RESTRICTIONS
- 63 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
desmopressin ace rhinal tube solution 0.01 %
Tier 1
desmopressin ace spray refrig solution 0.01 %
Tier 1
desmopressin acetate (tab 0.1 mg, tab 0.2 mg)
Tier 1
desmopressin acetate spray solution 0.01 %
Tier 1
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANDROGENS
ANDRODERM (PATCH 24HR 4 MG/24HR,
PATCH 24HR 2 MG/24HR)
Tier 3
PA
ANDROGEL (GEL 20.25 MG/1.25GM, GEL 40.5
MG/2.5GM)
Tier 2
PA
ANDROGEL PUMP GEL 20.25 MG/ACT (1.62%)
Tier 2
PA
ANDROID CAP 10 MG
Tier 1
ANDROXY TAB 10 MG
Tier 3
AVEED SOLUTION 750 MG/3ML
Tier 3
AXIRON SOLUTION 30 MG/ACT
Tier 3
danazol (cap 50 mg, cap 100 mg, cap 200 mg)
Tier 1
NATESTO GEL 5.5 MG/ACT
Tier 3
oxandrolone (tab 2.5 mg, tab 10 mg)
Tier 1
STRIANT MISC 30 MG
Tier 3
PA
TESTOPEL PELLET 75 MG
Tier 3
PA
testosterone (gel 10 mg/act (2%), gel 12.5 mg/act
(1%), gel 25 mg/2.5gm (1%), gel 50 mg/5gm (1%))
Tier 1
PA
testosterone (pellet 12.5 mg, pellet 25 mg, pellet
37.5 mg, pellet 50 mg, pellet 87.5 mg, pellet 100
mg, pellet 200 mg)
Tier 3
PA
testosterone cypionate (solution 100 mg/ml,
solution 200 mg/ml)
Tier 1
testosterone enanthate solution 200 mg/ml
Tier 1
TESTRED CAP 10 MG
Tier 2
PA
PA
ESTROGENS
aftera tab 1.5 mg
ACA Preventive Medications
altavera tab 0.15-30 mg-mcg
ACA Preventive Medications
alyacen 1/35 tab 1-35 mg-mcg
ACA Preventive Medications
alyacen 7/7/7 tab 0.5/0.75/1-35 mg-mcg
ACA Preventive Medications
amabelz (tab 0.5-0.1 mg, tab 1-0.5 mg)
Tier 1
- 64 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
amethia lo tab 0.1-0.02 & 0.01 mg
ACA Preventive Medications
amethia tab 0.15-0.03 &0.01 mg
ACA Preventive Medications
amethyst tab 90-20 mcg
ACA Preventive Medications
ANGELIQ (TAB 0.25-0.5 MG, TAB 0.5-1 MG)
Tier 3
apri tab 0.15-30 mg-mcg
ACA Preventive Medications
aranelle tab 0.5/1/0.5-35 mg-mcg
ACA Preventive Medications
ashlyna tab 0.15-0.03 &0.01 mg
ACA Preventive Medications
aubra tab 0.1-20 mg-mcg
ACA Preventive Medications
aviane tab 0.1-20 mg-mcg
ACA Preventive Medications
azurette tab 0.15-0.02/0.01 mg (21/5)
ACA Preventive Medications
balziva tab 0.4-35 mg-mcg
ACA Preventive Medications
bekyree tab 0.15-0.02/0.01 mg (21/5)
ACA Preventive Medications
BEYAZ TAB 3-0.02-0.451 MG
ACA Preventive Medications
blisovi 24 fe tab 1-20 mg-mcg(24)
ACA Preventive Medications
blisovi fe 1.5/30 tab 1.5-30 mg-mcg
ACA Preventive Medications
blisovi fe 1/20 tab 1-20 mg-mcg
ACA Preventive Medications
briellyn tab 0.4-35 mg-mcg
ACA Preventive Medications
camrese lo tab 0.1-0.02 & 0.01 mg
ACA Preventive Medications
camrese tab 0.15-0.03 &0.01 mg
ACA Preventive Medications
caziant tab 0.1/0.125/0.15 -0.025 mg
ACA Preventive Medications
cesia tab 0.1/0.125/0.15 -0.025 mg
ACA Preventive Medications
chateal tab 0.15-30 mg-mcg
ACA Preventive Medications
CLIMARA PRO PATCH WK 0.045-0.015 MG/DAY
Tier 2
COMBIPATCH (PATCH TW 0.05-0.14, PATCH
TW 0.05-0.25)
Tier 2
covaryx hs tab 0.625-1.25 mg
Tier 1
covaryx tab 1.25-2.5 mg
Tier 1
cryselle-28 tab 0.3-30 mg-mcg
ACA Preventive Medications
cyclafem 1/35 tab 1-35 mg-mcg
ACA Preventive Medications
cyclafem 7/7/7 tab 0.5/0.75/1-35 mg-mcg
ACA Preventive Medications
cyred tab 0.15-30 mg-mcg
ACA Preventive Medications
dasetta 1/35 tab 1-35 mg-mcg
ACA Preventive Medications
dasetta 7/7/7 tab 0.5/0.75/1-35 mg-mcg
ACA Preventive Medications
daysee tab 0.15-0.03 &0.01 mg
ACA Preventive Medications
- 65 -
C
One dispenser=3
copayments
C
One dispenser=3
copayments
C
One dispenser=3
copayments
C
One dispenser=3
copayments
C
One dispenser=3
copayments
C
One dispenser=3
copayments
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
DELESTROGEN OIL 10 MG/ML
Tier 3
delyla tab 0.1-20 mg-mcg
ACA Preventive Medications
desogestrel-ethinyl estradiol (tab 0.15-30 mg-mcg,
tab 0.15-0.02/0.01 mg (21/5))
ACA Preventive Medications
DIVIGEL (GEL 0.25 MG/0.25GM, GEL 0.5
MG/0.5GM, GEL 1 MG/GM)
Tier 3
drospirenone-ethinyl estradiol (tab 3-0.03 mg, tab
3-0.02 mg)
ACA Preventive Medications
DUAVEE TAB 0.45-20 MG
Tier 2
econtra ez tab 1.5 mg
ACA Preventive Medications
eemt hs tab 0.625-1.25 mg
Tier 1
eemt tab 1.25-2.5 mg
Tier 1
ELESTRIN GEL 0.52 MG/0.87 GM (0.06%)
Tier 3
elinest tab 0.3-30 mg-mcg
ACA Preventive Medications
emoquette tab 0.15-30 mg-mcg
ACA Preventive Medications
ENJUVIA (TAB 0.3 MG, TAB 0.45 MG, TAB 0.625
MG, TAB 0.9 MG, TAB 1.25 MG)
Tier 3
enpresse-28 tab
ACA Preventive Medications
enskyce tab 0.15-30 mg-mcg
ACA Preventive Medications
est estrogens-methyltest ds tab 1.25-2.5 mg
Tier 1
est estrogens-methyltest hs tab 0.625-1.25 mg
Tier 1
est estrogens-methyltest tab 1.25-2.5 mg
Tier 1
estarylla tab 0.25-35 mg-mcg
ACA Preventive Medications
ESTRACE CREAM 0.1 MG/GM
Tier 2
estradiol (patch tw 0.025 mg/24hr, patch tw 0.0375
mg/24hr, patch tw 0.05 mg/24hr, patch tw 0.075
mg/24hr, patch tw 0.1 mg/24hr)
Tier 1
estradiol (patch wk 0.025 mg/24hr, patch wk
0.0375 mg/24hr, patch wk 0.05 mg/24hr, patch wk
0.06 mg/24hr, patch wk 0.075 mg/24hr, patch wk
0.1 mg/24hr)
Tier 1
estradiol (pellet 18 mg, pellet 20 mg, pellet 31 mg,
pellet 37.5 mg, pellet 50 mg)
Tier 3
estradiol (tab 0.5 mg, tab 1 mg, tab 2 mg)
Tier 1
estradiol valerate (oil 20 mg/ml, oil 40 mg/ml)
Tier 1
estradiol-norethindrone acet (tab 0.5-0.1 mg, tab
1-0.5 mg)
Tier 1
ESTRING RING 2 MG
Tier 2
ESTROGEL GEL 0.75 MG/1.25 GM (0.06%)
Tier 3
estropipate (tab 0.75 mg, tab 1.5 mg, tab 3 mg)
Tier 1
EVAMIST SOLUTION 1.53 MG/SPRAY
Tier 2
LIMITS & RESTRICTIONS
- 66 -
QL
34 packets per fill
QL
2 pumps per fill
QL
10 patches per fill
QL
5 patches per fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
FALESSA KIT 20-1-0.1 MCG-MG
ACA Preventive Medications
fallback solo tab 1.5 mg
ACA Preventive Medications
falmina tab 0.1-20 mg-mcg
ACA Preventive Medications
FEMRING (RING 0.05 MG/24HR, RING 0.1
MG/24HR)
Tier 3
fyavolv (tab 0.5-2.5, tab 1-5)
Tier 1
gianvi tab 3-0.02 mg
ACA Preventive Medications
gildagia tab 0.4-35 mg-mcg
ACA Preventive Medications
gildess 1.5/30 tab 1.5-30 mg-mcg
ACA Preventive Medications
gildess 1/20 tab 1-20 mg-mcg
ACA Preventive Medications
gildess 24 fe tab 1-20 mg-mcg(24)
ACA Preventive Medications
gildess fe 1.5/30 tab 1.5-30 mg-mcg
ACA Preventive Medications
gildess fe 1/20 tab 1-20 mg-mcg
ACA Preventive Medications
introvale tab 0.15-0.03 mg
ACA Preventive Medications
jevantique lo tab 0.5-2.5 mg-mcg
ACA Preventive Medications
jinteli tab 1-5 mg-mcg
Tier 1
jolessa tab 0.15-0.03 mg
ACA Preventive Medications
juleber tab 0.15-30 mg-mcg
ACA Preventive Medications
junel 1.5/30 tab 1.5-30 mg-mcg
ACA Preventive Medications
junel 1/20 tab 1-20 mg-mcg
ACA Preventive Medications
junel fe 1.5/30 tab 1.5-30 mg-mcg
ACA Preventive Medications
junel fe 1/20 tab 1-20 mg-mcg
ACA Preventive Medications
junel fe 24 tab 1-20 mg-mcg(24)
ACA Preventive Medications
kaitlib fe chew tab 0.8-25 mg-mcg
ACA Preventive Medications
kariva tab 0.15-0.02/0.01 mg (21/5)
ACA Preventive Medications
kelnor 1/35 tab 1-35 mg-mcg
ACA Preventive Medications
kimidess tab 0.15-0.02/0.01 mg (21/5)
ACA Preventive Medications
kurvelo tab 0.15-30 mg-mcg
ACA Preventive Medications
larin 1.5/30 tab 1.5-30 mg-mcg
ACA Preventive Medications
larin 1/20 tab 1-20 mg-mcg
ACA Preventive Medications
larin 24 fe tab 1-20 mg-mcg(24)
ACA Preventive Medications
larin fe 1.5/30 tab 1.5-30 mg-mcg
ACA Preventive Medications
larin fe 1/20 tab 1-20 mg-mcg
ACA Preventive Medications
larissia tab 0.1-20 mg-mcg
ACA Preventive Medications
layolis fe chew tab 0.8-25 mg-mcg
ACA Preventive Medications
leena tab 0.5/1/0.5-35 mg-mcg
ACA Preventive Medications
- 67 -
C
One dispenser=3
copayments
C
One dispenser=3
copayments
C
One dispenser=3
copayments
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
lessina tab 0.1-20 mg-mcg
ACA Preventive Medications
levonest tab
ACA Preventive Medications
levonorg-eth estrad triphasic tab
ACA Preventive Medications
levonorgest-eth estrad 91-day (tab 0.1-0.02 & 0.01
mg, tab 0.15-0.03 &0.01 mg, tab 0.15-0.03 mg)
ACA Preventive Medications
levonorgestrel tab 0.75 mg
ACA Preventive Medications
levonorgestrel tab 1.5 mg
ACA Preventive Medications
levonorgestrel-ethinyl estrad (tab 0.1-20 mg-mcg,
tab 0.15-30 mg-mcg, tab 90-20 mcg)
ACA Preventive Medications
levora 0.15/30 (28) tab 0.15-30 mg-mcg
ACA Preventive Medications
LO LOESTRIN FE TAB 1 MG-10 MCG / 10 MCG
ACA Preventive Medications
LO MINASTRIN FE THER PACK 1 MG-10 MCG /
10 MCG
ACA Preventive Medications
lomedia 24 fe tab 1-20 mg-mcg(24)
ACA Preventive Medications
lopreeza (tab 0.5-0.1 mg, tab 1-0.5 mg)
Tier 1
loryna tab 3-0.02 mg
ACA Preventive Medications
low-ogestrel tab 0.3-30 mg-mcg
ACA Preventive Medications
lutera tab 0.1-20 mg-mcg
ACA Preventive Medications
marlissa tab 0.15-30 mg-mcg
ACA Preventive Medications
MENEST (TAB 0.3 MG, TAB 0.625 MG, TAB 1.25
MG, TAB 2.5 MG)
Tier 3
MENOSTAR PATCH WK 14 MCG/24HR
Tier 3
microgestin 1.5/30 tab 1.5-30 mg-mcg
ACA Preventive Medications
microgestin 1/20 tab 1-20 mg-mcg
ACA Preventive Medications
microgestin 24 fe tab 1-20 mg-mcg
ACA Preventive Medications
microgestin fe 1.5/30 tab 1.5-30 mg-mcg
ACA Preventive Medications
microgestin fe 1/20 tab 1-20 mg-mcg
ACA Preventive Medications
mimvey lo tab 0.5-0.1 mg
Tier 1
mimvey tab 1-0.5 mg
Tier 1
MINASTRIN 24 FE CHEW TAB 1-20 MG-MCG(24)
ACA Preventive Medications
mono-linyah tab 0.25-35 mg-mcg
ACA Preventive Medications
mononessa tab 0.25-35 mg-mcg
ACA Preventive Medications
my way tab 1.5 mg
ACA Preventive Medications
myzilra tab
ACA Preventive Medications
NATAZIA TAB 3/2-2/2-3/1 MG
ACA Preventive Medications
necon 0.5/35 (28) tab 0.5-35 mg-mcg
ACA Preventive Medications
necon 1/35 (28) tab 1-35 mg-mcg
ACA Preventive Medications
- 68 -
C
One dispenser=3
copayments
QL
2 tablets per fill
QL
5 patches per fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
NECON 1/50 (28) TAB 1-50 MG-MCG
ACA Preventive Medications
NECON 10/11 (28) TAB 35 MCG
ACA Preventive Medications
necon 7/7/7 tab 0.5/0.75/1-35 mg-mcg
ACA Preventive Medications
next choice one dose tab 1.5 mg
ACA Preventive Medications
next choice tab 0.75 mg
ACA Preventive Medications
nikki tab 3-0.02 mg
ACA Preventive Medications
norethin ace-eth estrad-fe (tab mg-mcg, tab mgmcg(24))
ACA Preventive Medications
norethin-eth estradiol-fe chew tab 0.8-25 mg-mcg
ACA Preventive Medications
norethindrone acet-ethinyl est tab 1-20 mg-mcg
ACA Preventive Medications
norethindrone-eth estradiol (tab 0.5-2.5, tab 1-5)
Tier 1
norgestim-eth estrad triphasic (tab mg-25 mcg, tab
mg-35 mcg)
ACA Preventive Medications
norgestimate-eth estradiol tab 0.25-35 mg-mcg
ACA Preventive Medications
norgestrel-ethinyl estradiol tab 0.3-30 mg-mcg
ACA Preventive Medications
NORINYL 1+50 (28) TAB 1-50 MG-MCG
ACA Preventive Medications
nortrel 0.5/35 (28) tab 0.5-35 mg-mcg
ACA Preventive Medications
nortrel 1/35 (21) tab 1-35 mg-mcg
ACA Preventive Medications
nortrel 1/35 (28) tab 1-35 mg-mcg
ACA Preventive Medications
nortrel 7/7/7 tab 0.5/0.75/1-35 mg-mcg
ACA Preventive Medications
NUVARING RING 0.12-0.015 MG/24HR
ACA Preventive Medications
ocella tab 3-0.03 mg
ACA Preventive Medications
OGESTREL TAB 0.5-50 MG-MCG
ACA Preventive Medications
opcicon one-step tab 1.5 mg
ACA Preventive Medications
orsythia tab 0.1-20 mg-mcg
ACA Preventive Medications
ORTHO EVRA PATCH WK 150-35 MCG/24HR
ACA Preventive Medications
OVCON-50 TAB 50-1 MCG-MG
ACA Preventive Medications
philith tab 0.4-35 mg-mcg
ACA Preventive Medications
pimtrea tab 0.15-0.02/0.01 mg (21/5)
ACA Preventive Medications
pirmella 1/35 tab 1-35 mg-mcg
ACA Preventive Medications
pirmella 7/7/7 tab 0.5/0.75/1-35 mg-mcg
ACA Preventive Medications
portia-28 tab 0.15-30 mg-mcg
ACA Preventive Medications
PREFEST TAB 1/1-0.09 MG (15/15)
Tier 3
PREMARIN (CREAM 0.625 MG/GM, TAB 0.3 MG,
TAB 0.45 MG, TAB 0.625 MG, TAB 0.9 MG, TAB
1.25 MG)
Tier 2
PREMPHASE TAB 0.625-5 MG
Tier 2
PREMPRO (TAB 0.3-1.5 MG, TAB 0.45-1.5 MG,
TAB 0.625-5 MG, TAB 0.625-2.5 MG)
Tier 2
- 69 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
previfem tab 0.25-35 mg-mcg
ACA Preventive Medications
QUARTETTE TAB 42-21-21-7 DAYS
ACA Preventive Medications
quasense tab 0.15-0.03 mg
ACA Preventive Medications
react tab 1.5 mg
ACA Preventive Medications
reclipsen tab 0.15-30 mg-mcg
ACA Preventive Medications
SAFYRAL TAB 3-0.03-0.451 MG
ACA Preventive Medications
setlakin tab 0.15-0.03 mg
ACA Preventive Medications
solia tab 0.15-30 mg-mcg
ACA Preventive Medications
sprintec 28 tab 0.25-35 mg-mcg
ACA Preventive Medications
sronyx tab 0.1-20 mg-mcg
ACA Preventive Medications
syeda tab 3-0.03 mg
ACA Preventive Medications
take action tab 1.5 mg
ACA Preventive Medications
tarina fe 1/20 tab 1-20 mg-mcg
ACA Preventive Medications
TAYTULLA CAP 1-20 MG-MCG(24)
ACA Preventive Medications
tilia fe tab 1-20/1-30/1-35 mg-mcg
ACA Preventive Medications
tri-estarylla tab 0.18/0.215/0.25 mg-35 mcg
ACA Preventive Medications
tri-legest fe tab 1-20/1-30/1-35 mg-mcg
ACA Preventive Medications
tri-linyah tab 0.18/0.215/0.25 mg-35 mcg
ACA Preventive Medications
tri-lo-estarylla tab 0.18/0.215/0.25 mg-25 mcg
ACA Preventive Medications
tri-lo-marzia tab 0.18/0.215/0.25 mg-25 mcg
ACA Preventive Medications
tri-lo-sprintec tab 0.18/0.215/0.25 mg-25 mcg
ACA Preventive Medications
tri-previfem tab 0.18/0.215/0.25 mg-35 mcg
ACA Preventive Medications
tri-sprintec tab 0.18/0.215/0.25 mg-35 mcg
ACA Preventive Medications
trinessa (28) tab 0.18/0.215/0.25 mg-35 mcg
ACA Preventive Medications
trinessa lo tab 0.18/0.215/0.25 mg-25 mcg
ACA Preventive Medications
trivora (28) tab
ACA Preventive Medications
VAGIFEM TAB 10 MCG
Tier 2
velivet tab 0.1/0.125/0.15 -0.025 mg
ACA Preventive Medications
vestura tab 3-0.02 mg
ACA Preventive Medications
vienva tab 0.1-20 mg-mcg
ACA Preventive Medications
viorele tab 0.15-0.02/0.01 mg (21/5)
ACA Preventive Medications
vyfemla tab 0.4-35 mg-mcg
ACA Preventive Medications
wera tab 0.5-35 mg-mcg
ACA Preventive Medications
wymzya fe chew tab 0.4-35 mg-mcg
ACA Preventive Medications
XULANE PATCH WK 150-35 MCG/24HR
ACA Preventive Medications
- 70 -
C
One dispenser=3
copayments
C
One dispenser=3
copayments
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
zarah tab 3-0.03 mg
ACA Preventive Medications
zenchent (, tab)
ACA Preventive Medications
zenchent fe chew tab 0.4-35 mg-mcg
ACA Preventive Medications
zeosa chew tab 0.4-35 mg-mcg
ACA Preventive Medications
zovia 1/35e (28) tab 1-35 mg-mcg
ACA Preventive Medications
ZOVIA 1/50E (28) TAB 1-50 MG-MCG
ACA Preventive Medications
PROGESTERONE AGONISTS/ANTAGONISTS
ELLA TAB 30 MG
ACA Preventive Medications
QL
2 tablets per fill
PROGESTINS
camila tab 0.35 mg
ACA Preventive Medications
CRINONE (GEL 4 %, GEL 8 %)
Tier 2
deblitane tab 0.35 mg
ACA Preventive Medications
DEPO-PROVERA SUSPENSION 400 MG/ML
Tier 2
DEPO-SUBQ PROVERA 104 SUSP PRSYR 104
MG/0.65ML
ACA Preventive Medications
ENDOMETRIN INSERT 100 MG
Tier 3
errin tab 0.35 mg
ACA Preventive Medications
FIRST-PROGESTERONE VGS 100 SUPPOS 100
MG
Tier 3
PA
FIRST-PROGESTERONE VGS 200 SUPPOS 200
MG
Tier 3
PA
FIRST-PROGESTERONE VGS 25 SUPPOS 25
MG
Tier 3
PA
FIRST-PROGESTERONE VGS 400 SUPPOS 400
MG
Tier 3
PA
FIRST-PROGESTERONE VGS 50 SUPPOS 50
MG
Tier 3
PA
heather tab 0.35 mg
ACA Preventive Medications
IMPLANON IMPLANT 68 MG
ACA Preventive Medications
jencycla tab 0.35 mg
ACA Preventive Medications
jolivette tab 0.35 mg
ACA Preventive Medications
LILETTA (52 MG) IUD 18.6 MCG/DAY
ACA Preventive Medications
lyza tab 0.35 mg
ACA Preventive Medications
medroxyprogesterone acetate (susp prsyr 150
mg/ml, suspension 150 mg/ml)
ACA Preventive Medications
medroxyprogesterone acetate (tab 2.5 mg, tab 5
mg, tab 10 mg)
Tier 1
PA
PA
- 71 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
megestrol acetate (suspension 40 mg/ml,
suspension 400 mg/10ml, suspension 625 mg/5ml,
tab 20 mg, tab 40 mg)
Tier 1
MIRENA (52 MG) IUD 20 MCG/24HR
ACA Preventive Medications
NEXPLANON IMPLANT 68 MG
ACA Preventive Medications
nora-be tab 0.35 mg
ACA Preventive Medications
norethindrone acetate tab 5 mg
Tier 1
norethindrone tab 0.35 mg
ACA Preventive Medications
norlyroc tab 0.35 mg
ACA Preventive Medications
progesterone micronized (cap 100 mg, cap 200
mg)
Tier 1
progesterone oil 50 mg/ml
Tier 1
sharobel tab 0.35 mg
ACA Preventive Medications
SKYLA IUD 13.5 MG
ACA Preventive Medications
PA
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
OSPHENA TAB 60 MG
Tier 3
raloxifene hcl tab 60 mg
Tier 1
C
Covered at no cost share for
women over age 35 with an
approved zero cost sharing
form
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROID (TAB 15 MG, TAB 120 MG,
TAB 180 MG, TAB 240 MG, TAB 300 MG)
Tier 3
levothyroxine sodium (tab 25 mcg, tab 50 mcg, tab
75 mcg, tab 88 mcg, tab 100 mcg, tab 112 mcg,
tab 125 mcg, tab 137 mcg, tab 150 mcg, tab 175
mcg, tab 200 mcg, tab 300 mcg)
Tier 1
levoxyl (tab 25 mcg, tab 50 mcg, tab 75 mcg, tab
88 mcg, tab 100 mcg, tab 112 mcg, tab 125 mcg,
tab 137 mcg, tab 150 mcg, tab 175 mcg, tab 200
mcg)
Tier 1
liothyronine sodium (tab 5 mcg, tab 25 mcg, tab 50
mcg)
Tier 1
NATURE-THROID (TAB 16.25 MG, TAB 32.5 MG,
TAB 48.75 MG, TAB 65 MG, TAB 81.25 MG, TAB
97.5 MG, TAB 113.75 MG, TAB 130 MG, TAB
146.25 MG, TAB 162.5 MG, TAB 195 MG, TAB
260 MG, TAB 325 MG)
Tier 3
np thyroid (tab 30 mg, tab 60 mg, tab 90 mg)
Tier 1
THYROLAR-1 TAB 60 (12.5-50) MG (MCG)
Tier 3
THYROLAR-1/2 TAB 30 (6.25-25) MG (MCG)
Tier 3
THYROLAR-1/4 TAB 15 (3.1-12.5) MG (MCG)
Tier 3
THYROLAR-2 TAB 120 (25-100) MG (MCG)
Tier 3
THYROLAR-3 TAB 180 (37.5-150) MG (MCG)
Tier 3
- 72 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
TIROSINT (CAP 13 MCG, CAP 25 MCG, CAP 50
MCG, CAP 75 MCG, CAP 88 MCG, CAP 100
MCG, CAP 112 MCG, CAP 125 MCG, CAP 137
MCG, CAP 150 MCG)
Tier 3
unithroid (tab 25 mcg, tab 50 mcg, tab 75 mcg, tab
88 mcg, tab 100 mcg, tab 112 mcg, tab 125 mcg,
tab 137 mcg, tab 150 mcg, tab 175 mcg, tab 200
mcg, tab 300 mcg)
Tier 1
unithroid direct (tab 25 mcg, tab 50 mcg, tab 75
mcg, tab 88 mcg, tab 100 mcg, tab 112 mcg, tab
125 mcg, tab 150 mcg, tab 175 mcg, tab 200 mcg,
tab 300 mcg)
LIMITS & RESTRICTIONS
Tier 1
WESTHROID (TAB 32.5 MG, TAB 65 MG, TAB
97.5 MG, TAB 130 MG, TAB 195 MG)
Tier 3
WP THYROID (TAB 16.25 MG, TAB 32.5 MG,
TAB 48.75 MG, TAB 65 MG, TAB 81.25 MG, TAB
97.5 MG, TAB 113.75 MG, TAB 130 MG)
Tier 3
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
SENSIPAR TAB 30 MG
Tier 2
QL
31 tablets per fill
QL
10 tablets per fill
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline tab 0.5 mg
Tier 1
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole (tab 5 mg, tab 10 mg)
Tier 1
propylthiouracil tab 50 mg
Tier 1
IMMUNOLOGICAL AGENTS
IMMUNE SUPPRESSANTS
AZASAN (TAB 75 MG, TAB 100 MG)
Tier 2
azathioprine tab 50 mg
Tier 1
cyclosporine (cap 25 mg, cap 100 mg)
Tier 1
cyclosporine modified (cap 25 mg, cap 50 mg, cap
100 mg, solution 100 mg/ml)
Tier 1
gengraf (cap 25 mg, cap 50 mg, cap 100 mg,
solution 100 mg/ml)
Tier 1
methotrexate sodium (pf) (solution 1 gm/40ml,
solution 50 mg/2ml, solution 100 mg/4ml, solution
200 mg/8ml, solution 250 mg/10ml)
Tier 1
methotrexate sodium (recon soln 1 gm, solution 25
mg/ml, solution 50 mg/2ml, solution 250 mg/10ml)
Tier 1
methotrexate tab 2.5 mg
Tier 1
mycophenolate mofetil (cap 250 mg, recon susp
200 mg/ml, tab 500 mg)
Tier 1
mycophenolate sodium (tab dr 180 mg, tab dr 360
mg)
Tier 1
- 73 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
OTREXUP (SOLN A-INJ 7.5, SOLN A-INJ 10,
SOLN A-INJ 15, SOLN A-INJ 17.5, SOLN A-INJ
20, SOLN A-INJ 22.5, SOLN A-INJ 25)
Tier 3
SA
OTREXUP SOLN A-INJ 12.5 MG/0.4ML
Tier 3
PA
PROGRAF SOLUTION 5 MG/ML
Tier 2
RHEUMATREX TAB 2.5 MG
Tier 2
SANDIMMUNE SOLUTION 100 MG/ML
Tier 2
tacrolimus (cap 0.5 mg, cap 1 mg, cap 5 mg)
Tier 1
SA / PAR
IMMUNOMODULATORS
leflunomide (tab 10 mg, tab 20 mg)
Tier 1
QL
34 tablets per fill
QL
5 tablets per fill
QL
34 tablets per fill
INFLAMMATORY BOW EL DISEASE AGENTS
AMINOSALICYLATES
APRISO CAP ER 24H 0.375 GM
Tier 2
ASACOL HD TAB DR 800 MG
Tier 2
balsalazide disodium cap 750 mg
Tier 1
CANASA SUPPOS 1000 MG
Tier 2
DELZICOL CAP DR 400 MG
Tier 2
DIPENTUM CAP 250 MG
Tier 3
LIALDA TAB DR 1.2 GM
Tier 3
mesalamine enema 4 gm
Tier 1
mesalamine-cleanser kit 4 gm
Tier 1
PENTASA (CAP ER 250 MG, CAP ER 500 MG)
Tier 2
SFROWASA ENEMA 4 GM/60ML
Tier 2
GLUCOCORTICOIDS
colocort enema 100 mg/60ml
Tier 1
hydrocortisone enema 100 mg/60ml
Tier 1
procto-pak cream 1 %
Tier 1
proctosol hc cream 2.5 %
Tier 1
proctozone-hc cream 2.5 %
Tier 1
SULFONAMIDES
sulfasalazine (tab 500 mg, tab dr 500 mg)
Tier 1
METABOLIC BONE DISEASE AGENTS
alendronate sodium (tab 35 mg, tab 70 mg)
Tier 1
alendronate sodium (tab 5 mg, tab 10 mg, tab 40
mg)
Tier 1
alendronate sodium solution 70 mg/75ml
Tier 1
- 74 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
BINOSTO EFFER TAB 70 MG
Tier 3
LIMITS & RESTRICTIONS
QL
5 tablets per fill
ST
calcitonin (salmon) solution 200 unit/act
Tier 1
calcitriol (cap 0.25 mcg, cap 0.5 mcg, solution 1
mcg/ml)
Tier 1
doxercalciferol (cap 0.5 mcg, cap 1 mcg, cap 2.5
mcg)
Tier 1
FOSAMAX PLUS D (TAB 70-2800, TAB 70-5600)
Tier 3
HECTOROL SOLUTION 2 MCG/ML
Tier 3
ibandronate sodium tab 150 mg
Tier 1
MIACALCIN SOLUTION 200 UNIT/ML
Tier 3
paricalcitol (cap 1 mcg, cap 2 mcg, cap 4 mcg)
Tier 3
PROLIA SOLUTION 60 MG/ML
Tier 3
risedronate sodium (tab 35 mg, tab dr 35 mg)
Tier 1
QL
5 tablets per fill
ST
ST
QL
5 tablets per fill
ST
risedronate sodium (tab 5 mg, tab 30 mg)
QL
Tier 1
34 tablets per fill
ST
risedronate sodium tab 150 mg
Tier 1
ST
MISCELLANEOUS THERAPEUTIC AGENTS
ACCU-CHEK ACTIVE STRIP
Tier 2
ACCU-CHEK AVIVA (SOLUTION, STRIP)
Tier 2
ACCU-CHEK AVIVA PLUS STRIP
Tier 2
ACCU-CHEK COMFORT CURVE (SOLUTION,
STRIP)
Tier 2
ACCU-CHEK COMPACT PLUS STRIP
Tier 2
ACCU-CHEK COMPACT TEST DRUM STRIP
Tier 2
ACCU-CHEK INSTANT PLUS TEST
Tier 2
ACCU-CHEK SMARTVIEW STRIP
Tier 2
CAYA DIAPHRAGM
ACA Preventive Medications
CETYLEV (EFFER TAB 2.5 GM, EFFER TAB 500
MG)
Tier 3
DEXCOM G4 PLAT PED RCV/SHARE KIT
Tier 3
DEXCOM G4 PLAT PED RECEIVER KIT
Tier 3
DEXCOM G4 PLATINUM RCV/SHARE KIT
Tier 3
DEXCOM G4 PLATINUM RECEIVER KIT
Tier 3
- 75 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
DEXCOM G4 PLATINUM TRANSMITTER KIT
Tier 3
DEXCOM G4 SENSOR KIT
Tier 3
DEXCOM G5 MOB/G4 PLAT SENSOR KIT
Tier 3
DEXCOM G5 MOBILE RECEIVER KIT
Tier 3
DEXCOM G5 MOBILE TRANSMITTER KIT
Tier 3
isometheptene-apap-dichloral cap 65-325-100 mg
Tier 1
isometheptene-caffeine-apap tab 65-20-325 mg
Tier 1
isometheptene-dichloral-apap cap 65-100-325 mg
Tier 1
methergine tab 0.2 mg
Tier 1
methylergonovine maleate tab 0.2 mg
Tier 1
migragesic ida cap 325-65-100 mg
Tier 1
nodolor cap 325-65-100 mg
Tier 1
OMNIFLEX DIAPHRAGM DIAPHRAGM
ACA Preventive Medications
ONETOUCH TEST STRIP
Tier 2
ONETOUCH ULTRA BLUE STRIP
Tier 2
ONETOUCH ULTRA CONTROL SOLUTION
Tier 2
ONETOUCH VERIO (SOLUTION, SOLUTION
HIGH, STRIP)
Tier 2
ORTHO DIAPHRAGM ALL-FLEX (DIAPHRAGM
DIAPHRAGM 65, DIAPHRAGM DIAPHRAGM 70,
DIAPHRAGM DIAPHRAGM 75, DIAPHRAGM
DIAPHRAGM 80)
ACA Preventive Medications
ORTHO DIAPHRAGM COIL (DIAPHRAGM KIT
50, DIAPHRAGM KIT 100, DIAPHRAGM KIT 105)
LIMITS & RESTRICTIONS
ACA Preventive Medications
ORTHO DIAPHRAGM FLAT (DIAPHRAGM KIT
55, DIAPHRAGM KIT 60, DIAPHRAGM KIT 65,
DIAPHRAGM KIT 70, DIAPHRAGM KIT 75,
DIAPHRAGM KIT 80, DIAPHRAGM KIT 85,
DIAPHRAGM KIT 90, DIAPHRAGM KIT 95)
ACA Preventive Medications
WIDE-SEAL DIAPHRAGM 60 DIAPHRAGM 2 %
ACA Preventive Medications
WIDE-SEAL DIAPHRAGM 65 DIAPHRAGM 2 %
ACA Preventive Medications
WIDE-SEAL DIAPHRAGM 70 DIAPHRAGM 2 %
ACA Preventive Medications
WIDE-SEAL DIAPHRAGM 75 DIAPHRAGM 2 %
ACA Preventive Medications
WIDE-SEAL DIAPHRAGM 80 DIAPHRAGM 2 %
ACA Preventive Medications
WIDE-SEAL DIAPHRAGM 85 DIAPHRAGM 2 %
ACA Preventive Medications
WIDE-SEAL DIAPHRAGM 90 DIAPHRAGM 2 %
ACA Preventive Medications
WIDE-SEAL DIAPHRAGM 95 DIAPHRAGM 2 %
ACA Preventive Medications
- 76 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
ak-poly-bac ointment 500-10000 unit/gm
Tier 1
altafrin (solution 2.5 %, solution 10 %)
Tier 1
atropine sulfate solution 1 %
Tier 1
bacitra-neomycin-polymyxin-hc ointment 1 %
Tier 1
bacitracin-polymyxin b ointment 500-10000
unit/gm
Tier 1
BLEPHAMIDE S.O.P. OINTMENT 10-0.2 %
Tier 2
BLEPHAMIDE SUSPENSION 10-0.2 %
Tier 2
CYCLOMYDRIL SOLUTION 0.2-1 %
Tier 3
cyclopentolate hcl (solution 0.5 %, solution 1 %,
solution 2 %)
Tier 1
homatropaire solution 5 %
Tier 1
homatropine hbr solution 5 %
Tier 1
LACRISERT INSERT 5 MG
Tier 2
LASTACAFT SOLUTION 0.25 %
Tier 3
naphazoline hcl solution 0.1 %
Tier 1
neo-polycin hc ointment 1 %
Tier 1
neo-polycin ointment 3.5-400-10000
Tier 1
neomycin-bacitracin zn-polymyx ointment 5-40010000
Tier 1
neomycin-polymyxin-dexameth (ointment,
suspension)
Tier 1
neomycin-polymyxin-gramicidin solution 1.7510000-.025
Tier 1
neomycin-polymyxin-hc suspension 3.5-10000-1
Tier 1
phenylephrine hcl (solution 2.5 %, solution 10 %)
Tier 1
polycin ointment 500-10000 unit/gm
Tier 1
polymyxin b-trimethoprim solution 10000-0.1
unit/ml-%
Tier 1
prednisolon-moxiflox-bromfenac solution 1-0.50.09 %
Tier 3
PREDNISOLON-MOXIFLOX-KETOROLAC
SOLUTION 1-0.5-0.5 %
Tier 3
RESTASIS EMULSION 0.05 %
Tier 3
sulfacetamide-prednisolone solution 10-0.23 %
Tier 1
TOBRADEX ST SUSPENSION 0.3-0.05 %
Tier 2
tobramycin-dexamethasone suspension 0.3-0.1 %
Tier 1
QL
- 77 -
68 vials per fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
tropicamide (solution 0.5 %, solution 1 %)
Tier 1
ZYLET SUSPENSION 0.5-0.3 %
Tier 3
LIMITS & RESTRICTIONS
OPHTHALMIC ANTI-ALLERGY AGENTS
ALOCRIL SOLUTION 2 %
Tier 2
ALOMIDE SOLUTION 0.1 %
Tier 3
azelastine hcl solution 0.05 %
Tier 1
BEPREVE SOLUTION 1.5 %
Tier 2
cromolyn sodium solution 4 %
Tier 1
EMADINE SOLUTION 0.05 %
Tier 3
epinastine hcl solution 0.05 %
Tier 1
olopatadine hcl solution 0.1 %
Tier 2
PATADAY SOLUTION 0.2 %
Tier 2
PAZEO SOLUTION 0.7 %
Tier 2
OPHTHALMIC ANTI-INFLAMMATORIES
ACUVAIL SOLUTION 0.45 %
Tier 3
ALREX SUSPENSION 0.2 %
Tier 3
bromfenac sodium (once-daily) solution 0.09 %
Tier 1
bromfenac sodium solution 0.09 %
Tier 1
dexamethasone sodium phosphate solution 0.1 %
Tier 1
diclofenac sodium solution 0.1 %
Tier 1
DUREZOL EMULSION 0.05 %
Tier 3
FLAREX SUSPENSION 0.1 %
Tier 3
fluorometholone suspension 0.1 %
Tier 1
flurbiprofen sodium solution 0.03 %
Tier 1
FML FORTE SUSPENSION 0.25 %
Tier 2
FML OINTMENT 0.1 %
Tier 2
ILEVRO SUSPENSION 0.3 %
Tier 2
ketorolac tromethamine (solution 0.4 %, solution
0.5 %)
Tier 1
LOTEMAX (GEL 0.5 %, OINTMENT 0.5 %,
SUSPENSION 0.5 %)
Tier 2
MAXIDEX SUSPENSION 0.1 %
Tier 3
NEVANAC SUSPENSION 0.1 %
Tier 2
PRED MILD SUSPENSION 0.12 %
Tier 2
prednisolone acetate suspension 1 %
Tier 1
PROLENSA SOLUTION 0.07 %
Tier 3
VEXOL SUSPENSION 1 %
Tier 3
- 78 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
XIIDRA SOLUTION 5 %
Tier 3
LIMITS & RESTRICTIONS
OPHTHALMIC ANTIGLAUCOMA AGENTS
ALPHAGAN P SOLUTION 0.1 %
Tier 2
apraclonidine hcl solution 0.5 %
Tier 1
AZOPT SUSPENSION 1 %
Tier 2
betaxolol hcl solution 0.5 %
Tier 1
BETIMOL (SOLUTION 0.25 %, SOLUTION 0.5 %)
Tier 3
BETOPTIC-S SUSPENSION 0.25 %
Tier 2
brimonidine tartrate (solution 0.15 %, solution 0.2
%)
Tier 1
carteolol hcl solution 1 %
Tier 1
COMBIGAN SOLUTION 0.2-0.5 %
Tier 3
COSOPT PF SOLUTION 22.3-6.8 MG/ML
Tier 2
dorzolamide hcl solution 2 %
Tier 1
dorzolamide hcl-timolol mal solution 22.3-6.8
mg/ml
Tier 1
IOPIDINE SOLUTION 1 %
Tier 3
ISTALOL SOLUTION 0.5 %
Tier 3
levobunolol hcl (solution 0.25 %, solution 0.5 %)
Tier 1
methazolamide (tab 25 mg, tab 50 mg)
Tier 1
metipranolol solution 0.3 %
Tier 1
pilocarpine hcl (solution 1 %, solution 2 %, solution
4 %)
Tier 1
RESCULA SOLUTION 0.15 %
Tier 3
SIMBRINZA SUSPENSION 1-0.2 %
Tier 3
timolol maleate (gel f soln 0.25 %, gel f soln 0.5 %,
solution 0.25 %, solution 0.5 %)
Tier 1
TIMOPTIC OCUDOSE (SOLUTION 0.25 %,
SOLUTION 0.5 %)
Tier 3
ST
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
bimatoprost solution 0.03 %
Tier 1
latanoprost solution 0.005 %
Tier 1
LUMIGAN SOLUTION 0.01 %
Tier 2
ST
TRAVATAN Z SOLUTION 0.004 %
Tier 2
ST
travoprost solution 0.004 %
Tier 1
ST
ZIOPTAN SOLUTION 0.0015 %
Tier 3
ST
ST
- 79 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
OTIC AGENTS
acetasol hc solution 2-1 %
Tier 1
acetic acid solution 2 %
Tier 1
CIPRO HC SUSPENSION 0.2-1 %
Tier 2
CIPRODEX SUSPENSION 0.3-0.1 %
Tier 2
COLY-MYCIN S SUSPENSION 3.3-3-10-0.5
MG/ML
Tier 3
CORTISPORIN-TC SUSPENSION 3.3-3-10-0.5
MG/ML
Tier 3
fluocinolone acetonide oil 0.01 %
Tier 1
hydrocortisone-acetic acid solution 1-2 %
Tier 1
neomycin-polymyxin-hc (solution 1 %, solution 3.510000-1, suspension 3.5-10000-1)
Tier 1
OTOVEL SOLUTION 0.3-0.025 %
Tier 3
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
AEROSPAN AERO SOLN 80 MCG/ACT
Tier 3
QL
2 inhalers per fill
ALVESCO (AERO SOLN 80, AERO SOLN 160)
Tier 3
QL
2 inhalers per fill
ARNUITY ELLIPTA (AER POW BA 100, AER
POW BA 200)
Tier 3
QL
2 inhalers per fill
ASMANEX 120 METERED DOSES AER POW BA
220 MCG/INH
Tier 2
QL
120 inhalations per fill
ASMANEX 14 METERED DOSES AER POW BA
220 MCG/INH
Tier 2
QL
120 inhalations per fill
ASMANEX 30 METERED DOSES (30 AER POW
BA 110, 30 AER POW BA 220)
Tier 2
QL
120 inhalations per fill
ASMANEX 60 METERED DOSES AER POW BA
220 MCG/INH
Tier 2
QL
120 inhalations per fill
ASMANEX 7 METERED DOSES AER POW BA
110 MCG/INH
Tier 2
QL
120 inhalations per fill
ASMANEX HFA (AEROSOL 100, AEROSOL 200)
Tier 2
QL
2 inhalers per fill
BECONASE AQ SUSPENSION 42 MCG/SPRAY
Tier 3
PA
QL
2 inhalers per fill
budesonide (suspension 0.25, suspension 0.5,
suspension 1)
Tier 1
FLOVENT DISKUS (AER POW BA 50, AER POW
BA 100, AER POW BA 250)
Tier 2
QL
2 inhalers per fill
FLOVENT HFA (AEROSOL 44, AEROSOL 110,
AEROSOL 220)
Tier 2
QL
2 inhalers per fill
flunisolide solution 25 mcg/act (0.025%)
Tier 1
QL
2 inhalers per fill
- 80 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
mometasone furoate suspension 50 mcg/act
Tier 1
LIMITS & RESTRICTIONS
PA
QL
OMNARIS SUSPENSION 50 MCG/ACT
2 inhalers per fill
PA
Tier 3
QL
4 inhalers per fill
PROPEL IMPLANT 370 MCG
Tier 3
PROPEL MINI IMPLANT 370 MCG
Tier 3
PULMICORT FLEXHALER AER POW BA 180
MCG/ACT
Tier 3
QL
3 inhalers per fill
PULMICORT FLEXHALER AER POW BA 90
MCG/ACT
Tier 3
QL
2 inhalers per fill
QNASL AERO SOLN 80 MCG/ACT
Tier 3
PA
QL
QNASL CHILDRENS AERO SOLN 40 MCG/ACT
PA
Tier 3
QL
QVAR (AERO SOLN 40, AERO SOLN 80)
Tier 3
VERAMYST SUSPENSION 27.5 MCG/SPRAY
Tier 3
QL
2 inhalers per fill
3 inhalers per fill
PA
QL
ZETONNA AERO SOLN 37 MCG/ACT
2 inhalers per fill
2 inhalers per fill
PA
Tier 3
QL
2 inhalers per fill
ANTIHISTAMINES
azelastine hcl (solution 0.1 %, solution 0.15 %)
Tier 1
CLARINEX SYRUP 0.5 MG/ML
Tier 3
clemastine fumarate (syrup 0.67 mg/5ml, tab 2.68
mg)
Tier 1
cyproheptadine hcl (syrup 2 mg/5ml, tab 4 mg)
Tier 1
desloratadine (tab 5 mg, tab disp 2.5 mg, tab disp
5 mg)
Tier 1
hydroxyzine hcl (solution 10 mg/5ml, syrup 10
mg/5ml, tab 10 mg, tab 25 mg, tab 50 mg)
Tier 1
hydroxyzine pamoate (cap 25 mg, cap 50 mg, cap
100 mg)
Tier 1
levocetirizine dihydrochloride (solution 2.5 mg/5ml,
tab 5 mg)
Tier 1
olopatadine hcl solution 0.6 %
Tier 1
phenadoz (suppos 12.5 mg, suppos 25 mg)
Tier 1
phenergan (suppos 12.5 mg, suppos 25 mg,
suppos 50 mg)
Tier 1
- 81 -
QL
3 inhalers per fill
QL
4 inhalers per fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
promethazine hcl (solution 6.25 mg/5ml, solution
25 mg/ml, solution 50 mg/ml, suppos 12.5 mg,
suppos 25 mg, suppos 50 mg, syrup 6.25 mg/5ml,
tab 12.5 mg, tab 25 mg, tab 50 mg)
Tier 1
promethegan (suppos 12.5 mg, suppos 25 mg,
suppos 50 mg)
Tier 1
LIMITS & RESTRICTIONS
ANTILEUKOTRIENES
montelukast sodium (chew tab 4 mg, chew tab 5
mg, packet 4 mg, tab 10 mg)
Tier 1
zafirlukast (tab 10 mg, tab 20 mg)
Tier 1
ZYFLO CR TAB ER 12H 600 MG
Tier 3
ZYFLO TAB 600 MG
Tier 3
BRONCHODILATORS, ANTICHOLINERGIC
ATROVENT HFA AERO SOLN 17 MCG/ACT
Tier 2
QL
3 inhalers per fill
INCRUSE ELLIPTA AER POW BA 62.5 MCG/INH
Tier 2
QL
60 inhalations per fill
ipratropium bromide solution 0.02 %
Tier 1
ipratropium bromide solution 0.03 %
Tier 1
QL
2 bottles per fill
ipratropium bromide solution 0.06 %
Tier 1
QL
3 bottles per fill
SEEBRI NEOHALER CAP 15.6 MCG
Tier 3
QL
2 boxes per fill
SPIRIVA HANDIHALER CAP 18 MCG
Tier 2
SPIRIVA RESPIMAT AERO SOLN 2.5 MCG/ACT
Tier 2
QL
2 inhalers per fill
TUDORZA PRESSAIR AER POW BA 400
MCG/ACT
Tier 2
QL
2 inhalers per fill
ADRENACLICK SOLN A-INJ 0.15 MG/0.15ML
Tier 2
QL
1 kit per fill
albuterol sulfate (nebu soln 0.63 mg/3ml, nebu
soln 1.25 mg/3ml, nebu soln (2.5 mg/3ml) 0.083%,
nebu soln (5 mg/ml) 0.5%, syrup 2 mg/5ml, tab 2
mg, tab 4 mg)
Tier 1
albuterol sulfate er (er tab er 12h 8 mg, er tab er
12h 4 mg)
Tier 1
ARCAPTA NEOHALER CAP 75 MCG
Tier 3
QL
60 capsules per fill
AUVI-Q SOLN A-INJ 0.15 MG/0.15ML
Tier 2
QL
1 kit per fill
BROVANA NEBU SOLN 15 MCG/2ML
Tier 3
QL
60 inhalations per fill
EPINEPHRINE SOLN A-INJ 0.15 MG/0.15ML
Tier 1
QL
1 kit per fill
epinephrine soln a-inj 0.3 mg/0.3ml
Tier 1
QL
1 kit per fill
BRONCHODILATORS, SYMPATHOMIMETIC
- 82 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
EPIPEN JR 2-PAK SOLN A-INJ 0.15 MG/0.3ML
Tier 2
QL
1 kit per fill
FORADIL AEROLIZER CAP 12 MCG
Tier 2
QL
1 box per fill
levalbuterol hcl (nebu soln 0.31 mg/3ml, nebu soln
0.63 mg/3ml, nebu soln 1.25 mg/3ml, nebu soln
1.25 mg/0.5ml)
Tier 1
PERFOROMIST NEBU SOLN 20 MCG/2ML
Tier 2
PROAIR HFA AERO SOLN 108 (90 BASE)
MCG/ACT
Tier 2
QL
2 inhalers per fill
PROAIR RESPICLICK AER POW BA 108 (90
BASE) MCG/ACT
Tier 2
QL
2 inhalers per fill
PROVENTIL HFA AERO SOLN 108 (90 BASE)
MCG/ACT
Tier 3
MN
MN-PA
QL
2 inhalers per fill
SEREVENT DISKUS AER POW BA 50
MCG/DOSE
Tier 2
QL
2 boxes per fill
STRIVERDI RESPIMAT AERO SOLN 2.5
MCG/ACT
Tier 3
QL
120 inhalations per fill
VENTOLIN HFA AERO SOLN 108 (90 BASE)
MCG/ACT
MN
MN-PA
Tier 3
QL
2 inhalers per fill
MN
MN-PA
QL
4 inhalers per fill
XOPENEX HFA AEROSOL 45 MCG/ACT
LIMITS & RESTRICTIONS
PA
Tier 3
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
aminophylline solution 25 mg/ml
Tier 1
DALIRESP TAB 500 MCG
Tier 2
difil-g forte liquid 100-100 mg/5ml
Tier 1
ELIXOPHYLLIN ELIXIR 80 MG/15ML
Tier 3
LUFYLLIN TAB 400 MG
Tier 3
THEO-24 (CAP ER 24H 400 MG, CAP ER 24H
100 MG, CAP ER 24H 200 MG, CAP ER 24H 300
MG)
Tier 3
theochron (tab er 12h 300 mg, tab er 12h 200 mg,
tab er 12h 100 mg)
Tier 1
theophylline er (er tab er 12h 200 mg, er tab er
12h 450 mg, er tab er 12h 100 mg, er tab er 12h
300 mg, er tab er 24h 400 mg, er tab er 24h 600
mg)
Tier 1
theophylline solution 80 mg/15ml
Tier 1
RESPIRATORY TRACT AGENTS, OTHER
ADVAIR DISKUS (AER POW BA 100-50, AER
POW BA 250-50, AER POW BA 500-50)
Tier 2
QL
2 inhalers per fill
ADVAIR HFA (AEROSOL 45-21, AEROSOL 11521, AEROSOL 230-21)
Tier 2
QL
2 inhalers per fill
- 83 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
ANORO ELLIPTA AER POW BA 62.5-25
MCG/INH
Tier 2
benzonatate (cap 100 mg, cap 150 mg, cap 200
mg)
Tier 1
BEVESPI AEROSPHERE AEROSOL 9-4.8
MCG/ACT
Tier 3
BREO ELLIPTA (AER POW BA 100-25, AER
POW BA 200-25)
Tier 2
CLARINEX-D 12 HOUR TAB ER 12H 2.5-120 MG
Tier 3
COMBIVENT RESPIMAT AERO SOLN 20-100
MCG/ACT
Tier 2
cromolyn sodium nebu soln 20 mg/2ml
Tier 1
DULERA (AEROSOL 100-5, AEROSOL 200-5)
Tier 2
DYMISTA SUSPENSION 137-50 MCG/ACT
Tier 3
LIMITS & RESTRICTIONS
QL
60 inhalations per fill
QL
2 inhalers per fill
QL
QL
Tier 1
hydrocodone-homatropine (syrup mg/5ml, tab mg)
Tier 1
hydromet syrup 5-1.5 mg/5ml
Tier 1
ipratropium-albuterol solution 0.5-2.5 (3) mg/3ml
Tier 1
phenyleph-promethazine-cod syrup 5-6.25-10
mg/5ml
Tier 1
promethazine vc plain syrup 6.25-5 mg/5ml
Tier 1
promethazine vc/codeine syrup 6.25-5-10 mg/5ml
Tier 1
promethazine-codeine syrup 6.25-10 mg/5ml
Tier 1
promethazine-dm syrup 6.25-15 mg/5ml
Tier 1
promethazine-phenylephrine syrup 6.25-5 mg/5ml
Tier 1
pseudoeph-chlorphen-hydrocod solution 60-4-5
mg/5ml
Tier 1
SEMPREX-D CAP 8-60 MG
Tier 3
STIOLTO RESPIMAT AERO SOLN 2.5-2.5
MCG/ACT
Tier 3
SYMBICORT (AEROSOL 80-4.5, AEROSOL 1604.5)
Tier 3
tussigon tab 5-1.5 mg
Tier 1
TUSSIONEX PENNKINETIC ER LIQUID ER 10-8
MG/5ML
Tier 2
UTIBRON NEOHALER CAP 27.5-15.6 MCG
Tier 3
2 inhalers per fill
PA
QL
hydrocod polst-cpm polst er susp 10-8 mg/5ml
2 inhalers per fill
- 84 -
2 inhalers per fill
QL
205 vials per fill
QL
120 inhalations per fill
MN
MN-PA
QL
2 inhalers per fill
QL
2 boxes per fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
SKELETAL MUSCLE RELAXANTS
AMRIX (CAP ER 24H 15 MG, CAP ER 24H 30
MG)
Tier 3
baclofen (tab 10 mg, tab 20 mg)
Tier 1
carisoprodol (tab 250 mg, tab 350 mg)
Tier 1
carisoprodol-aspirin tab 200-325 mg
Tier 1
chlorzoxazone tab 500 mg
Tier 1
cyclobenzaprine hcl (tab 5 mg, tab 7.5 mg, tab 10
mg)
Tier 1
dantrolene sodium (cap 25 mg, cap 50 mg, cap
100 mg)
Tier 1
METAXALONE TAB 400 MG
Tier 1
metaxalone tab 800 mg
Tier 1
methocarbamol (tab 500 mg, tab 750 mg)
Tier 1
orphenadrine citrate er tab er 12h 100 mg
Tier 1
tizanidine hcl (cap 2 mg, cap 4 mg, cap 6 mg, tab
2 mg, tab 4 mg)
Tier 1
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
estazolam (tab 1 mg, tab 2 mg)
Tier 1
eszopiclone (tab 1 mg, tab 2 mg, tab 3 mg)
Tier 1
quazepam tab 15 mg
Tier 1
temazepam (cap 7.5 mg, cap 15 mg, cap 22.5 mg,
cap 30 mg)
Tier 1
triazolam (tab 0.125 mg, tab 0.25 mg)
Tier 1
zaleplon (cap 5 mg, cap 10 mg, 10 mg)
Tier 1
zolpidem tartrate (sl tab 1.75 mg, sl tab 3.5 mg)
Tier 2
PA
QL
zolpidem tartrate (tab 5 mg, tab 10 mg)
Tier 1
zolpidem tartrate er (er tab er 6.25 mg, er tab er
12.5 mg)
Tier 1
ZOLPIMIST SOLUTION 5 MG/ACT
Tier 3
20 tablets per fill
SLEEP DISORDERS, OTHER
armodafinil (tab 50 mg, tab 150 mg, tab 200 mg,
tab 250 mg)
Tier 2
BELSOMRA (TAB 5 MG, TAB 10 MG, TAB 15
MG, TAB 20 MG)
Tier 3
flurazepam hcl (cap 15 mg, cap 30 mg)
Tier 1
modafinil (tab 100 mg, tab 200 mg)
Tier 1
PA
PA
- 85 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
ROZEREM TAB 8 MG
Tier 3
LIMITS & RESTRICTIONS
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
kionex (powder, suspension 15 gm/60ml)
Tier 1
sodium polystyrene sulfonate (powder, suspension
15 gm/60ml, suspension 30 gm/120ml, suspension
50 gm/200ml)
Tier 1
sps suspension 15 gm/60ml
Tier 1
VELTASSA (PACKET 8.4 GM, PACKET 16.8 GM,
PACKET 25.2 GM)
Tier 2
ELECTROLYTE/MINERAL REPLACEMENT
airavite tab 2.5-25-1 mg
Tier 1
av-vite fb tab 2.5-25-1 mg
Tier 1
bprotected pedia iron solution 75 (15 fe) mg/ml
ACA Preventive Medications
durlaza cap er 24h 162.5 mg
Tier 3
effer-k effer tab 25 meq
Tier 1
effervescent pot chloride effer tab 25 meq
Tier 1
epiflur (chew tab 0.55 (0.25 mg, chew tab 1.1 (0.5
mg)
ACA Preventive Medications
fabb tab 2.2-25-1 mg
Tier 1
fer-gen-sol 75 (15 fe) mg/0.6ml
AL1
0.5 to 1 yrs old
AL1
Up to 5 yrs old
ACA Preventive Medications
AL1
0.5 to 1 yrs old
fer-iron solution 75 (15 fe) mg/ml
ACA Preventive Medications
AL1
0.5 to 1 yrs old
ferosul elixir 220 (44 fe) mg/5ml
ACA Preventive Medications
AL1
0.5 to 1 yrs old
FERRAPLUS 90 TAB 90-1 MG
Tier 3
FERREX 150 FORTE PLUS CAP 50-100 MG
Tier 1
ferrous sulfate (75 (15 mg/0.6ml, elixir 220 (44
mg/5ml, liquid 220 (44 mg/5ml, solution 75 (15
mg/0.6ml, solution 75 (15 mg/ml, syrup 300 (60
mg/5ml)
ACA Preventive Medications
AL1
0.5 to 1 yrs old
FLUOR-A-DAY (CHEW TAB 0.25 MG, CHEW TAB
0.5 MG, CHEW TAB 1 MG)
Tier 3
fluor-a-day solution 0.275 (0.125 f) mg/drop
ACA Preventive Medications
AL1
Up to 5 yrs old
FLUORABON SOLUTION 0.55 (0.25 F) MG/0.6ML
ACA Preventive Medications
AL1
Up to 5 yrs old
fluoritab (chew tab 1.1 (0.5 mg, solution 0.275
(0.125 mg/drop)
ACA Preventive Medications
AL1
Up to 5 yrs old
fluoritab chew tab 2.2 (1 f) mg
Tier 1
FLURA-DROPS SOLUTION 0.55 (0.25 F)
MG/DROP
ACA Preventive Medications
AL1
Up to 5 yrs old
- 86 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
folbee tab 2.5-25-1 mg
Tier 1
iron supplement childrens solution 75 (15 fe)
mg/ml
ACA Preventive Medications
k-effervescent effer tab 25 meq
Tier 1
K-PHOS TAB 500 MG
Tier 3
k-prime effer tab 25 meq
Tier 1
k-sol (solution 20 (10%), solution 40 (20%))
Tier 1
k-vescent (effer tab 25, packet 20)
Tier 1
klor-con (packet 20, tab er 8)
Tier 1
klor-con 10 tab er 10 meq
Tier 1
klor-con m10 tab er 10 meq
Tier 1
klor-con m20 tab er 20 meq
Tier 1
klor-con sprinkle (cap er 8, cap er 10)
Tier 1
klor-con/ef effer tab 25 meq
Tier 1
LOZI-FLUR LOZENGE 2.2 (1 F) MG
Tier 3
ludent (chew tab 0.55 (0.25 mg, chew tab 1.1 (0.5
mg)
ACA Preventive Medications
ludent chew tab 2.2 (1 f) mg
Tier 1
MYKIDZ IRON 10 SUSPENSION 15 MG/1.5ML
ACA Preventive Medications
nufol tab 2.5-25-1 mg
Tier 1
pot bicarb-pot chloride effer tab 25 meq
Tier 1
potassium bicarbonate effer tab 25 meq
Tier 1
potassium chloride (packet 20 meq, solution 10
meq/100ml, solution 20 meq/15ml (10%), solution
40 meq/15ml (20%))
Tier 1
potassium chloride crys er (crys er tab er 10, crys
er tab er 20)
Tier 1
potassium chloride er (er cap er 8, er cap er 10, er
tab er 8, er tab er 10, er tab er 20)
Tier 1
POTASSIUM CHLORIDE SOLUTION 10
MEQ/50ML
Tier 1
renaf (chew tab 0.55 (0.25 mg, chew tab 1.1 (0.5
mg)
AL1
0.5 to 1 yrs old
AL1
Up to 5 yrs old
AL1
0.5 to 1 yrs old
ACA Preventive Medications
AL1
Up to 5 yrs old
sodiphluor solution 1.1 (0.5 f) mg/ml
ACA Preventive Medications
AL1
Up to 5 yrs old
sodium fluoride (chew tab 0.55 (0.25 mg, chew tab
1.1 (0.5 mg, solution 1.1 (0.5 mg/ml, tab 1.1 (0.5
mg)
ACA Preventive Medications
AL1
Up to 5 yrs old
sodium fluoride (chew tab 2.2 mg, tab 2.2 mg)
Tier 1
SSKI SOLUTION 1 GM/ML
Tier 2
tl gard rx tab 2.2-25-1 mg
Tier 1
- 87 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
virt-gard tab 2.2-25-1 mg
Tier 1
virt-vite tab 2.5-25-1 mg
Tier 1
VITATRUE MISC 30-1.4 & 300 MG
Tier 3
wee care suspension 15 mg/1.25ml
ACA Preventive Medications
AL1
0.5 to 1 yrs old
aqueous vitamin d liquid 400 unit/ml
ACA Preventive Medications
AL1
At least 65 yrs old
bio-d-mulsion liquid 400 unt/0.03ml
ACA Preventive Medications
AL1
At least 65 yrs old
bprotected pedia d-vite liquid 400 unit/ml
ACA Preventive Medications
AL1
At least 65 yrs old
COMPLETENATE CHEW TAB 29-1 MG
Tier 3
cvs childrens vitamin d chew tab 400 unit
ACA Preventive Medications
AL1
At least 65 yrs old
cvs d3 cap 400 unit
ACA Preventive Medications
AL1
At least 65 yrs old
AL1
Up to 55 yrs old
GL
Female
QL
100 / 1 fill
AL1
At least 65 yrs old
AL1
At least 65 yrs old
cvs folic acid (tab 400 mcg, tab 800 mcg)
LIMITS & RESTRICTIONS
ACA Preventive Medications
cvs vitamin d infants liquid 400 unit/ml
ACA Preventive Medications
cvs vitamin d3 cap 400 unit
ACA Preventive Medications
cyanocobalamin solution 1000 mcg/ml
Tier 1
d 400 (400 chew tab 400, 400 tab 400)
ACA Preventive Medications
AL1
At least 65 yrs old
d-400 tab 400 unit
ACA Preventive Medications
AL1
At least 65 yrs old
d-vita liquid 400 unit/ml
ACA Preventive Medications
AL1
At least 65 yrs old
d3 kids chew tab 400 unit
ACA Preventive Medications
AL1
At least 65 yrs old
delta d3 tab 400 unit
ACA Preventive Medications
AL1
At least 65 yrs old
dialyvite tab
Tier 1
AL1
Up to 55 yrs old
GL
Female
QL
100 / 1 fill
eql folic acid tab 400 mcg
ACA Preventive Medications
eql vitamin d gummies child chew tab 400 unit
ACA Preventive Medications
AL1
At least 65 yrs old
eql vitamin d-3 tab 400 unit
ACA Preventive Medications
AL1
At least 65 yrs old
ergocalciferol cap 50000 unit
Tier 1
floriva plus solution 0.25 mg/ml
Tier 1
- 88 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
folic acid tab 1 mg
Tier 1
gnp folic acid tab 400 mcg
LIMITS & RESTRICTIONS
ACA Preventive Medications
AL1
Up to 55 yrs old
GL
Female
QL
100 / 1 fill
gnp vitamin d (chew tab 400, 400)
ACA Preventive Medications
AL1
At least 65 yrs old
healthy kids vitamin d3 chew tab 400 unit
ACA Preventive Medications
AL1
At least 65 yrs old
AL1
Up to 55 yrs old
GL
Female
QL
100 / 1 fill
AL1
At least 65 yrs old
AL1
At least 65 yrs old
AL1
Up to 55 yrs old
GL
Female
QL
100 / 1 fill
AL1
At least 65 yrs old
hm folic acid tab 400 mcg
ACA Preventive Medications
hm vitamin d tab 400 unit
ACA Preventive Medications
hydroxocobalamin solution 1000 mcg/ml
Tier 1
INFED SOLUTION 50 MG/ML
Tier 3
just d liquid 400 unit/ml
ACA Preventive Medications
kp folic acid tab 800 mcg
ACA Preventive Medications
kp vitamin d chew tab 400 unit
ACA Preventive Medications
levocarnitine (solution 1 gm/10ml, tab 330 mg)
Tier 1
M-VIT TAB
Tier 3
MACNATAL CN DHA CAP 28-1-250 MG
Tier 3
MEPHYTON TAB 5 MG
Tier 2
multi vitamin/fluoride (chew tab 0.25 mg, chew tab
1 mg)
Tier 1
multi-vit/fluoride solution 0.25 mg/ml
Tier 1
multi-vitamin/fluoride (chew tab 0.5 mg, solution
0.25 mg/ml)
Tier 1
multivitamin/fluoride (chew tab 0.25 mg, chew tab
0.5 mg, chew tab 1 mg)
Tier 1
multivitamins/fluoride (chew tab 0.25 mg, chew tab
0.5 mg, chew tab 1 mg)
Tier 1
mvc-fluoride (chew tab 0.25 mg, chew tab 0.5 mg,
chew tab 1 mg)
Tier 1
MYNATAL PLUS TAB
Tier 3
MYNATAL-Z TAB
Tier 3
NASCOBAL SOLUTION 500 MCG/0.1ML
Tier 3
- 89 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
nephronex tab
Tier 1
NIVA-PLUS TAB 27-1 MG
Tier 3
O-CAL FA TAB 27-1 MG
Tier 3
O-CAL PRENATAL TAB
Tier 3
OB COMPLETE GOLD CAP 27.5-1-200 MG
Tier 3
pa vitamin d-3 gummy chew tab 400 unit
ACA Preventive Medications
PNV FE FUM/DOCUSATE/FOLIC ACID TAB 29-1
MG
Tier 3
PNV FOLIC ACID + IRON TAB 27-1 MG
Tier 3
PNV PRENATAL PLUS MULTIVITAMIN TAB 27-1
MG
Tier 3
PNV TABS 29-1 TAB 29-1 MG
Tier 3
PNV-DHA CAP 27-0.6-0.4-300 MG
Tier 1
PNV-OMEGA CAP 28-0.6-0.4-340 MG
Tier 3
PREFERA OB TAB 34-1 MG
Tier 3
PRENA1 CHEW TAB 1.4 MG
Tier 3
PRENA1 PEARL CAP ER 30-1.4-200 MG
Tier 3
PRENAISSANCE BALANCE CAP 30-1-260 MG
Tier 3
PRENAISSANCE CAP 29-1.25-325 MG
Tier 3
PRENAISSANCE HARMONY DHA MISC 27-1 &
380 MG
Tier 3
PRENAISSANCE NEXT TAB 1.2 MG
Tier 3
PRENAISSANCE NEXT-B TAB 1.22 MG
Tier 3
PRENAISSANCE PLUS CAP 28-1-250 MG
Tier 3
PRENATA CHEW TAB 29-1 MG
Tier 3
PRENATABS FA TAB
Tier 1
PRENATABS RX TAB 29-1 MG
Tier 1
PRENATAL 19 (19 CHEW TAB MG, 19 TAB MG)
Tier 3
PRENATAL 19 (19 CHEW TAB, 19 TAB)
Tier 1
PRENATAL LOW IRON TAB 27-1 MG
Tier 3
PRENATAL PLUS IRON TAB 29-1 MG
Tier 3
PRENATAL PLUS TAB 27-1 MG
Tier 3
PRENATAL TAB 27-1 MG
Tier 3
PRENATAL VITAMIN PLUS LOW IRON TAB 27-1
MG
Tier 3
PRENATAL-U CAP 106.5-1 MG
Tier 3
PRENATE AM TAB 1 MG
Tier 3
PRENATE CHEW TAB 0.6-0.4 MG
Tier 3
- 90 -
AL1
At least 65 yrs old
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
PRENATE DHA CAP 28-0.6-0.4-300 MG
Tier 3
PRENATE ELITE TAB 26-0.6-0.4 MG
Tier 3
PRENATE ENHANCE CAP 28-0.6-0.4-400 MG
Tier 3
PRENATE ESSENTIAL (CAP 18-0.6-0.4-300 MG,
CAP 29-0.6-0.4-340 MG)
Tier 3
PRENATE MINI (CAP 18-0.6-0.4-350 MG, CAP
29-0.6-0.4-350 MG)
Tier 3
PRENATE PIXIE CAP 10-0.6-0.4-200 MG
Tier 3
PRENATE RESTORE CAP 27-0.6-0.4-400 MG
Tier 3
PREPLUS TAB 27-1 MG
Tier 3
px folic acid tab 400 mcg
QUFLORA FE CHEW TAB 0.25 MG
ra folic acid (tab 400 mcg, tab 800 mcg)
ACA Preventive Medications
ACA Preventive Medications
Tier 1
RULAVITE DHA CAP 27-0.6-0.4-300 MG
Tier 3
SE-NATAL 19 (19 TAB MG, 19 CHEW TAB MG)
Tier 3
sm vitamin d tab 400 unit
th folic acid tab 400 mcg
AL1
Up to 55 yrs old
GL
Female
QL
100 / 1 fill
AL1
Up to 55 yrs old
GL
Female
QL
100 / 1 fill
AL1
Up to 55 yrs old
GL
Female
QL
100 / 1 fill
AL1
At least 65 yrs old
AL1
Up to 55 yrs old
GL
Female
QL
100 / 1 fill
AL1
At least 65 yrs old
Tier 3
rena-vite rx tab 1 mg
sm folic acid tab 400 mcg
LIMITS & RESTRICTIONS
ACA Preventive Medications
ACA Preventive Medications
ACA Preventive Medications
th vitamin d3 chew tab 400 unit
ACA Preventive Medications
THRIVITE 19 TAB 29-1 MG
Tier 3
THRIVITE RX TAB 29-1 MG
Tier 3
TRICARE PRENATAL 1 CHEW TAB 4.5-1 MG
Tier 3
TRICARE PRENATAL COMPLEAT MISC 27-1
MG
Tier 3
TRICARE PRENATAL DHA ONE CAP 27-1-500
MG
Tier 3
TRICARE TAB
Tier 3
- 91 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
TRINATAL RX 1 TAB 60-1 MG
Tier 3
TRINATE TAB
Tier 1
VINATE ONE TAB 60-1 MG
Tier 3
VIRT NATE TAB 28-1 MG
Tier 3
VIRT-NATE DHA CAP 28-1-200 MG
Tier 3
VIRT-PN DHA CAP 27-0.6-0.4-300 MG
Tier 3
VIRT-PN PLUS CAP 28-0.6-0.4-340 MG
Tier 3
VITAFOL GUMMIES CHEW TAB 3.33-0.333-34.8
MG
Tier 3
VITAFOL-OB TAB
Tier 3
vitamin d (cholecalciferol) (cap 400, chew tab 400,
tab 400)
ACA Preventive Medications
vitamin d (ergocalciferol) cap 50000 unit
Tier 1
vitamin d (liqui400 unit/ml, 400 unit, cap 400 unit)
AL1
At least 65 yrs old
ACA Preventive Medications
AL1
At least 65 yrs old
vitamin d-400 tab 400 unit
ACA Preventive Medications
AL1
At least 65 yrs old
vitamin d2 tab 400 unit
ACA Preventive Medications
AL1
At least 65 yrs old
vitamin d3 (cap 400 unit, chew tab 400 unit, liquid
400 unit/ml, liquid 1200 unit/15ml, tab 400 unit)
ACA Preventive Medications
AL1
At least 65 yrs old
vol-care rx tab 1 mg
Tier 1
VOL-NATE TAB 28-1 MG
Tier 3
VOL-PLUS TAB 27-1 MG
Tier 3
VOL-TAB RX TAB 29-1 MG
Tier 3
VP-GGR-B6 PRENATAL TAB 1.2 MG
Tier 3
VP-PNV-DHA CAP 28-1-215.8 MG
Tier 3
vp-vite rx tab 1 mg
Tier 1
WELLESSE VITAMIN D3 LIQUID 1000
UNIT/10ML
ACA Preventive Medications
AL1
At least 65 yrs old
ZATEAN-PN DHA CAP 27-0.6-0.4-300 MG
Tier 3
ZATEAN-PN PLUS CAP 28-0.6-0.4-340 MG
Tier 3
- 92 -
LAST UPDATED 10/2016
LIST OF COVERED SPECIALTY MEDICATIONS
UNLESS OTHERWISE SPECIFIED BELOW OR IN YOUR PRESCRIPTION DRUG (RX) RIDER, OR ADMINISTERED IN THE OFFICE OR
BY HOME INFUSION, ALL SPECIALTY PRODUCTS MUST BE OBTAINED FROM CAREMARK SPECIALTY PHARMACY AT 1-800-2372767. FOR MEMBERS/PARTICIPANTS WITH A 4 TIER BENEFIT ALL SPECIALTY PRODUCTS ARE CONSIDERED TIER 4.
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
ANALGESICS
OPIOID ANALGESICS, SHORT-ACTING
LAZANDA (SOLUTION 100, SOLUTION 300,
SOLUTION 400)
C
not restricted to Caremark
C
not restricted to Caremark
C
not restricted to Caremark
Non-Preferred Specialty
C
not restricted to Caremark
AVYCAZ RECON SOLN 2.5 (2-0.5) GM
Non-Preferred Specialty
C
not restricted to Caremark
DALVANCE RECON SOLN 500 MG
Non-Preferred Specialty
C
not restricted to Caremark
linezolid (recon susp 100 mg/5ml, solution 600
mg/300ml, tab 600 mg)
Preferred Specialty
C
not restricted to Caremark
LINEZOLID IN SODIUM CHLORIDE SOLUTION
600-0.9 MG/300ML-%
Preferred Specialty
C
not restricted to Caremark
ORBACTIV (RECON SOLN 400 MG, 400 MG)
Non-Preferred Specialty
C
not restricted to Caremark
SIVEXTRO (RECON SOLN 200 MG, TAB 200
MG)
Preferred Specialty
C
not restricted to Caremark
vancomycin hcl (cap 125 mg, cap 250 mg)
Preferred Specialty
C
not restricted to Caremark
XIFAXAN TAB 550 MG
Preferred Specialty
C
not restricted to Caremark
ZERBAXA RECON SOLN 1.5 (1-0.5) GM
Non-Preferred Specialty
C
not restricted to Caremark
ZYVOX SOLUTION 200 MG/100ML
Preferred Specialty
C
not restricted to Caremark
Non-Preferred Specialty
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
VIVITROL RECON SUSP 380 MG
Preferred Specialty
OPIOID DEPENDENCE TREATMENTS
PROBUPHINE IMPLANT KIT IMPLANT 74.2 MG
Non-Preferred Specialty
OPIOID REVERSAL AGENTS
EVZIO SOLN A-INJ 0.4 MG/0.4ML
ANTIBACTERIALS
ANTIBACTERIALS, OTHER
MACROLIDES
DIFICID TAB 200 MG
Preferred Specialty
PA
QL
- 93 -
20 tablets per fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
TETRACYCLINES
SOLODYN (TAB ER 24H 55 MG, TAB ER 24H
115 MG, TAB ER 24H 80 MG, TAB ER 24H 65
MG, TAB ER 24H 105 MG)
Preferred Specialty
C
not restricted to Caremark
C
not restricted to Caremark
C
not restricted to Caremark
ANTICONVULSANTS
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
SABRIL (PACKET 500 MG, TAB 500 MG)
Preferred Specialty
SODIUM CHANNEL AGENTS
BANZEL (SUSPENSION 40 MG/ML, TAB 200 MG,
TAB 400 MG)
Non-Preferred Specialty
ANTIDEPRESSANTS
MONOAMINE OXIDASE INHIBITORS
EMSAM (PATCH 24HR 6 MG/24HR, PATCH
24HR 9 MG/24HR, PATCH 24HR 12 MG/24HR)
Preferred Specialty
ANTIFUNGALS
ABELCET SUSPENSION 5 MG/ML
Preferred Specialty
C
not restricted to Caremark
AMBISOME RECON SUSP 50 MG
Non-Preferred Specialty
C
not restricted to Caremark
CRESEMBA (CAP 186 MG, RECON SOLN 372
MG)
Preferred Specialty
C
not restricted to Caremark
flucytosine (cap 250 mg, cap 500 mg)
Preferred Specialty
C
not restricted to Caremark
NOXAFIL (SOLUTION 300 MG/16.7ML,
SUSPENSION 40 MG/ML, TAB DR 100 MG)
Preferred Specialty
C
not restricted to Caremark
PA
ONMEL TAB 200 MG
Preferred Specialty
C
QL
voriconazole (recon soln 200 mg, recon susp 40
mg/ml, tab 50 mg, tab 200 mg)
Preferred Specialty
C
not restricted to Caremark
34 / fill
not restricted to Caremark
ANTIGOUT AGENTS
KRYSTEXXA SOLUTION 8 MG/ML
Preferred Specialty
ANTIMIGRAINE AGENTS
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
ZEMBRACE SYMTOUCH SOLN A-INJ 3
MG/0.5ML
Non-Preferred Specialty
- 94 -
QL
8 injections per fill
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
ANTIMYCOBACTERIALS
ANTITUBERCULARS
CAPASTAT SULFATE RECON SOLN 1 GM
Preferred Specialty
SIRTURO TAB 100 MG
Preferred Specialty
C
not restricted to Caremark
C
not restricted to Caremark
C
not restricted to Caremark
ANTINEOPLASTICS
ALKYLATING AGENTS
BENDEKA SOLUTION 100 MG/4ML
Non-Preferred Specialty
BUSULFEX SOLUTION 6 MG/ML
Preferred Specialty
EVOMELA RECON SOLN 50 MG
Non-Preferred Specialty
GLEOSTINE (CAP 10 MG, CAP 40 MG, CAP 100
MG)
Preferred Specialty
GLEOSTINE CAP 5 MG
Non-Preferred Specialty
HEXALEN CAP 50 MG
Preferred Specialty
MATULANE CAP 50 MG
Preferred Specialty
melphalan hcl recon soln 50 mg
Preferred Specialty
TEMODAR RECON SOLN 100 MG
Preferred Specialty
temozolomide (cap 5 mg, cap 20 mg, cap 100 mg,
cap 140 mg, cap 180 mg, cap 250 mg)
Preferred Specialty
TREANDA (RECON SOLN 25 MG, RECON SOLN
100 MG, SOLUTION 45 MG/0.5ML, SOLUTION
180 MG/2ML)
Preferred Specialty
VALCHLOR GEL 0.016 %
Preferred Specialty
YONDELIS RECON SOLN 1 MG
Non-Preferred Specialty
ZANOSAR RECON SOLN 1 GM
Preferred Specialty
ANTIANDROGENS
nilutamide tab 150 mg
Preferred Specialty
XTANDI CAP 40 MG
Preferred Specialty
ZYTIGA TAB 250 MG
Preferred Specialty
ANTIANGIOGENIC AGENTS
POMALYST (CAP 1 MG, CAP 2 MG, CAP 3 MG,
CAP 4 MG)
Preferred Specialty
REVLIMID (CAP 2.5 MG, CAP 5 MG, CAP 10 MG,
CAP 15 MG, CAP 20 MG, CAP 25 MG)
Preferred Specialty
THALOMID (CAP 50 MG, CAP 100 MG, CAP 150
MG, CAP 200 MG)
Preferred Specialty
ANTIESTROGENS/MODIFIERS
FASLODEX SOLUTION 250 MG/5ML
Preferred Specialty
- 95 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
ANTIMETABOLITES
ALIMTA (RECON SOLN 100 MG, RECON SOLN
500 MG)
Preferred Specialty
capecitabine (tab 150 mg, tab 500 mg)
Preferred Specialty
cladribine solution 10 mg/10ml
Preferred Specialty
CLOLAR SOLUTION 1 MG/ML
Preferred Specialty
cytarabine (pf) (solution 20 mg/ml, solution 100
mg/ml)
Preferred Specialty
cytarabine (recon soln 1 gm, recon soln 2 gm,
recon soln 100 mg, recon soln 500 mg, solution 20
mg/ml)
Preferred Specialty
DEPOCYT SUSPENSION 50 MG/5ML
Preferred Specialty
ELITEK (RECON SOLN 1.5 MG, RECON SOLN
7.5 MG)
Preferred Specialty
FOLOTYN (SOLUTION 20 MG/ML, SOLUTION 40
MG/2ML)
Preferred Specialty
gemcitabine hcl (recon soln 1 gm, recon soln 2
gm, recon soln 200 mg, solution 1 gm/26.3ml,
solution 2 gm/52.6ml, solution 200 mg/5.26ml)
Preferred Specialty
LONSURF (TAB 15-6.14 MG, TAB 20-8.19 MG)
Preferred Specialty
NIPENT RECON SOLN 10 MG
Preferred Specialty
PURIXAN SUSPENSION 2000 MG/100ML
Non-Preferred Specialty
C
not restricted to Caremark
PA
ANTINEOPLASTICS, OTHER
ABRAXANE RECON SUSP 100 MG
Non-Preferred Specialty
amifostine recon soln 500 mg
Preferred Specialty
azacitidine recon susp 100 mg
Preferred Specialty
BLEO 15K RECON SOLN 15 (15000 IU) UNIT
Non-Preferred Specialty
CAMPTOSAR SOLUTION 300 MG/15ML
Preferred Specialty
COSMEGEN RECON SOLN 0.5 MG
Preferred Specialty
CYRAMZA (SOLUTION 100 MG/10ML,
SOLUTION 500 MG/50ML)
Preferred Specialty
daunorubicin hcl injectable 5 mg/ml
Preferred Specialty
decitabine recon soln 50 mg
Preferred Specialty
dexrazoxane (recon soln 250 mg, recon soln 500
mg)
Preferred Specialty
DOCEFREZ (RECON SOLN 20 MG, RECON
SOLN 80 MG)
Non-Preferred Specialty
DOCETAXEL (CONC 20 MG/0.5ML, CONC 80
MG/2ML, CONC 140 MG/7ML, CONC 160
MG/8ML, SOLUTION 200 MG/20ML)
Non-Preferred Specialty
docetaxel (conc 20 mg/ml, conc 80 mg/4ml,
solution 20 mg/2ml, solution 80 mg/8ml, solution
160 mg/16ml)
Non-Preferred Specialty
- 96 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
docetaxel (non-alcohol) (solution 20 mg/ml,
solution 80 mg/4ml, solution 160 mg/8ml)
Non-Preferred Specialty
doxorubicin hcl liposomal injectable 2 mg/ml
Preferred Specialty
DOXORUBICIN HCL RECON SOLN 50 MG
Preferred Specialty
doxorubicin hcl solution 2 mg/ml
Preferred Specialty
epirubicin hcl (solution 50 mg/25ml, solution 200
mg/100ml)
Preferred Specialty
ERWINAZE RECON SOLN 10000 UNIT
Preferred Specialty
FARYDAK (CAP 10 MG, CAP 15 MG, CAP 20
MG)
Preferred Specialty
fludarabine phosphate (recon soln 50 mg, solution
50 mg/2ml)
Preferred Specialty
HALAVEN SOLUTION 1 MG/2ML
Non-Preferred Specialty
idarubicin hcl (solution 5 mg/5ml, solution 10
mg/10ml, solution 20 mg/20ml)
Preferred Specialty
IMLYGIC (SUSPENSION 1000000, SUSPENSION
100000000)
Non-Preferred Specialty
irinotecan hcl (solution 40 mg/2ml, solution 100
mg/5ml)
Preferred Specialty
ISTODAX RECON SOLN 10 MG
Non-Preferred Specialty
IXEMPRA KIT (KIT RECON SOLN 15 MG, KIT
RECON SOLN 45 MG)
Non-Preferred Specialty
JEVTANA SOLUTION 60 MG/1.5ML
Preferred Specialty
lipodox 50 injectable 2 mg/ml
Preferred Specialty
lipodox injectable 2 mg/ml
Preferred Specialty
LYNPARZA CAP 50 MG
Preferred Specialty
MARQIBO SUSPENSION 5 MG/31ML
Non-Preferred Specialty
mitoxantrone hcl (conc 20 mg/10ml, conc 25
mg/12.5ml, conc 30 mg/15ml)
Preferred Specialty
ONCASPAR SOLUTION 750 UNIT/ML
Preferred Specialty
ONIVYDE INJECTABLE 43 MG/10ML
Non-Preferred Specialty
oxaliplatin (recon soln 50 mg, recon soln 100 mg,
solution 50 mg/10ml, solution 100 mg/20ml)
Preferred Specialty
paclitaxel (conc 30 mg/5ml, conc 100 mg/16.7ml,
conc 150 mg/25ml, conc 300 mg/50ml)
Preferred Specialty
PHOTOFRIN RECON SOLN 75 MG
Preferred Specialty
PROLEUKIN RECON SOLN 22000000 UNIT
Preferred Specialty
PROVENGE SUSPENSION
Preferred Specialty
SYLATRON (KIT 200 MCG, KIT 300 MCG, KIT
600 MCG)
Preferred Specialty
SYNRIBO RECON SOLN 3.5 MG
Preferred Specialty
- 97 -
PA
PA
SA
SA / PAR
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
TAXOTERE (CONC 20 MG/0.5ML, CONC 80
MG/2ML)
Non-Preferred Specialty
TENIPOSIDE SOLUTION 10 MG/ML
Preferred Specialty
THERACYS RECON SUSP 81 MG/VIAL
Preferred Specialty
thiotepa recon soln 15 mg
Preferred Specialty
VALSTAR SOLUTION 40 MG/ML
Preferred Specialty
VELCADE RECON SOLN 3.5 MG
Preferred Specialty
VORAXAZE RECON SOLN 1000 UNIT
Non-Preferred Specialty
XOFIGO SOLUTION 30 MCCI/ML
Non-Preferred Specialty
ZALTRAP (SOLUTION 100 MG/4ML, SOLUTION
200 MG/8ML)
Preferred Specialty
ZOLINZA CAP 100 MG
Preferred Specialty
ENZYME INHIBITORS
BELEODAQ RECON SOLN 500 MG
Non-Preferred Specialty
HYCAMTIN (CAP 0.25 MG, CAP 1 MG)
Non-Preferred Specialty
topotecan hcl (recon soln 4 mg, solution 4 mg/4ml)
Non-Preferred Specialty
MOLECULAR TARGET INHIBITORS
AFINITOR (TAB 2.5 MG, TAB 5 MG, TAB 7.5 MG,
TAB 10 MG)
Preferred Specialty
PA
AFINITOR DISPERZ (TAB SOL 2 MG, TAB SOL 3
MG, TAB SOL 5 MG)
Preferred Specialty
PA
ALECENSA CAP 150 MG
Preferred Specialty
PA
BOSULIF (TAB 100 MG, TAB 500 MG)
Preferred Specialty
PA
CABOMETYX (TAB 20 MG, TAB 40 MG, TAB 60
MG)
Preferred Specialty
PA
CAPRELSA (TAB 100 MG, TAB 300 MG)
Preferred Specialty
COMETRIQ (100 MG DAILY DOSE) KIT 1 X 80 &
1 X 20 MG
Non-Preferred Specialty
COMETRIQ (140 MG DAILY DOSE) KIT 1 X 80 &
3 X 20 MG
Non-Preferred Specialty
COMETRIQ (60 MG DAILY DOSE) KIT 20 MG
Non-Preferred Specialty
COTELLIC TAB 20 MG
Preferred Specialty
ERIVEDGE CAP 150 MG
Preferred Specialty
GILOTRIF (TAB 20 MG, TAB 30 MG, TAB 40 MG)
Preferred Specialty
IBRANCE (CAP 75 MG, CAP 100 MG, CAP 125
MG)
Preferred Specialty
ICLUSIG (TAB 15 MG, TAB 45 MG)
Preferred Specialty
PA
imatinib mesylate (tab 100 mg, tab 400 mg)
Preferred Specialty
PA
- 98 -
SA
SA / PAR
PA
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
IMBRUVICA CAP 140 MG
Preferred Specialty
INLYTA (TAB 1 MG, TAB 5 MG)
Preferred Specialty
IRESSA TAB 250 MG
Preferred Specialty
JAKAFI (TAB 5 MG, TAB 10 MG, TAB 15 MG,
TAB 20 MG, TAB 25 MG)
Preferred Specialty
KYPROLIS (RECON SOLN 30 MG, RECON
SOLN 60 MG)
Preferred Specialty
LENVIMA 10 MG DAILY DOSE CAP THPK 10 MG
Preferred Specialty
LENVIMA 14 MG DAILY DOSE CAP THPK 10 & 4
MG
Preferred Specialty
LENVIMA 18 MG DAILY DOSE CAP THPK 10 & 4
(2) MG
Preferred Specialty
LENVIMA 20 MG DAILY DOSE CAP THPK 10 (2)
MG
Preferred Specialty
LENVIMA 24 MG DAILY DOSE CAP THPK 10 (2)
& 4 MG
Preferred Specialty
LENVIMA 8 MG DAILY DOSE CAP THPK 4 (2)
MG
Preferred Specialty
MEKINIST (TAB 0.5 MG, TAB 2 MG)
Preferred Specialty
PA
NEXAVAR TAB 200 MG
Preferred Specialty
PA
NINLARO (CAP 2.3 MG, CAP 3 MG, CAP 4 MG)
Preferred Specialty
ODOMZO CAP 200 MG
Non-Preferred Specialty
SPRYCEL (TAB 20 MG, TAB 50 MG, TAB 70 MG,
TAB 80 MG, TAB 100 MG, TAB 140 MG)
Preferred Specialty
STIVARGA TAB 40 MG
Preferred Specialty
PA
PA
PA
C
SUTENT (CAP 12.5 MG, CAP 25 MG, CAP 37.5
MG, CAP 50 MG)
Preferred Specialty
TAFINLAR (CAP 50 MG, CAP 75 MG)
Preferred Specialty
PA
TARCEVA (TAB 25 MG, TAB 100 MG, TAB 150
MG)
Preferred Specialty
PA
TASIGNA (CAP 150 MG, CAP 200 MG)
Preferred Specialty
PA
TORISEL SOLUTION 25 MG/ML
Non-Preferred Specialty
TYKERB TAB 250 MG
Preferred Specialty
PA
VENCLEXTA (TAB 10 MG, TAB 50 MG, TAB 100
MG)
Preferred Specialty
PA
VENCLEXTA STARTING PACK TAB THPK 10 &
50 & 100 MG
Preferred Specialty
PA
VOTRIENT TAB 200 MG
Preferred Specialty
- 99 -
not restricted to Caremark
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
XALKORI (CAP 200 MG, CAP 250 MG)
Preferred Specialty
ZELBORAF TAB 240 MG
Preferred Specialty
PA
PA
C
ZYDELIG (TAB 100 MG, TAB 150 MG)
Preferred Specialty
ZYKADIA CAP 150 MG
Preferred Specialty
not restricted to Caremark
PA
MONOCLONAL ANTIBODIES
ADCETRIS RECON SOLN 50 MG
Preferred Specialty
ARZERRA (CONC 100 MG/5ML, CONC 1000
MG/50ML)
Preferred Specialty
AVASTIN (SOLUTION 100 MG/4ML, SOLUTION
400 MG/16ML)
Preferred Specialty
BLINCYTO RECON SOLN 35 MCG
Preferred Specialty
DARZALEX (SOLUTION 100 MG/5ML,
SOLUTION 400 MG/20ML)
Non-Preferred Specialty
EMPLICITI (RECON SOLN 300 MG, RECON
SOLN 400 MG)
Non-Preferred Specialty
GAZYVA SOLUTION 1000 MG/40ML
Preferred Specialty
HERCEPTIN RECON SOLN 440 MG
Preferred Specialty
KADCYLA (RECON SOLN 100 MG, RECON
SOLN 160 MG)
Preferred Specialty
KEYTRUDA (RECON SOLN 50 MG, SOLUTION
100 MG/4ML)
Non-Preferred Specialty
OPDIVO (SOLUTION 40 MG/4ML, SOLUTION
100 MG/10ML)
Preferred Specialty
PERJETA SOLUTION 420 MG/14ML
Preferred Specialty
PORTRAZZA SOLUTION 800 MG/50ML
Non-Preferred Specialty
RITUXAN (SOLUTION 100 MG/10ML, SOLUTION
500 MG/50ML)
Preferred Specialty
SYLVANT (RECON SOLN 100 MG, RECON
SOLN 400 MG)
Preferred Specialty
TAGRISSO (TAB 40 MG, TAB 80 MG)
Preferred Specialty
TECENTRIQ SOLUTION 1200 MG/20ML
Preferred Specialty
UNITUXIN SOLUTION 17.5 MG/5ML
Preferred Specialty
VECTIBIX (SOLUTION 100 MG/5ML, SOLUTION
400 MG/20ML)
Non-Preferred Specialty
YERVOY (SOLUTION 50 MG/10ML, SOLUTION
200 MG/40ML)
Preferred Specialty
PA
RETINOIDS
bexarotene cap 75 mg
Preferred Specialty
- 100 -
C
not restricted to Caremark
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
PANRETIN GEL 0.1 %
Preferred Specialty
PA
TARGRETIN GEL 1 %
Preferred Specialty
tretinoin cap 10 mg
Preferred Specialty
C
not restricted to Caremark
C
not restricted to Caremark
C
not restricted to Caremark
ANTIPARASITICS
ANTIHELMINTHICS
EMVERM CHEW TAB 100 MG
Non-Preferred Specialty
ANTIPROTOZOALS
atovaquone suspension 750 mg/5ml
DARAPRIM TAB 25 MG
Preferred Specialty
Preferred Specialty
PA
C
IMPAVIDO CAP 50 MG
not restricted to Caremark
Non-Preferred Specialty
ANTIPARKINSON AGENTS
ANTIPARKINSON AGENTS, OTHER
NUPLAZID TAB 17 MG
Preferred Specialty
tolcapone tab 100 mg
Preferred Specialty
DOPAMINE AGONISTS
APOKYN SOLUTION 10 MG/ML
Preferred Specialty
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
DUOPA SUSPENSION 4.63-20 MG/ML
Non-Preferred Specialty
ANTIPSYCHOTICS
2ND GENERATION/ATYPICAL
ABILIFY MAINTENA (RECON SUSP 300 MG,
RECON SUSP 400 MG)
ARISTADA (PRSYR 441 MG/1.6ML, PRSYR 662
MG/2.4ML, PRSYR 882 MG/3.2ML)
INVEGA SUSTENNA (SUSPENSION 39
MG/0.25ML, SUSPENSION 78 MG/0.5ML,
SUSPENSION 117 MG/0.75ML, SUSPENSION
156 MG/ML, SUSPENSION 234 MG/1.5ML)
INVEGA TRINZA (SUSPENSION 273
MG/0.875ML, SUSPENSION 410 MG/1.315ML,
SUSPENSION 546 MG/1.75ML, SUSPENSION
819 MG/2.625ML)
REXULTI (TAB 0.25 MG, TAB 0.5 MG, TAB 1 MG,
TAB 2 MG, TAB 3 MG, TAB 4 MG)
Non-Preferred Specialty
C
not restricted to Caremark
ST
Non-Preferred Specialty
C
not restricted to Caremark
ST
Non-Preferred Specialty
C
not restricted to Caremark
ST
Preferred Specialty
C
not restricted to Caremark
ST
Preferred Specialty
C
not restricted to Caremark
ST
- 101 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
RISPERDAL CONSTA (RECON SUSP 12.5 MG,
RECON SUSP 25 MG, RECON SUSP 37.5 MG,
RECON SUSP 50 MG)
Preferred Specialty
VRAYLAR (CAP 1.5 MG, CAP 3 MG, CAP 4.5
MG, CAP 6 MG, CAP THPK 1.5 & 3 MG)
Non-Preferred Specialty
ZYPREXA RELPREVV (RECON SUSP 210 MG,
RECON SUSP 300 MG, RECON SUSP 405 MG)
Non-Preferred Specialty
C
not restricted to Caremark
ST
ST
C
not restricted to Caremark
ST
TREATMENT-RESISTANT
not restricted to Caremark
VERSACLOZ SUSPENSION 50 MG/ML
Non-Preferred Specialty
C
ST
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
ganciclovir sodium recon soln 500 mg
Preferred Specialty
valganciclovir hcl recon soln 50 mg/ml
Preferred Specialty
valganciclovir hcl tab 450 mg
ZIRGAN GEL 0.15 %
C
not restricted to Caremark
Preferred Specialty
C
not restricted to Caremark
Preferred Specialty
C
not restricted to Caremark
adefovir dipivoxil tab 10 mg
Preferred Specialty
C
not restricted to Caremark
BARACLUDE SOLUTION 0.05 MG/ML
Preferred Specialty
C
not restricted to Caremark
entecavir (tab 0.5 mg, tab 1 mg)
Preferred Specialty
C
not restricted to Caremark
TYZEKA TAB 600 MG
Preferred Specialty
C
not restricted to Caremark
DAKLINZA (TAB 30 MG, TAB 60 MG, TAB 90 MG)
Preferred Specialty
PA
EPCLUSA TAB 400-100 MG
Preferred Specialty
PA
HARVONI TAB 90-400 MG
Preferred Specialty
PA
INTRON A (RECON SOLN 10000000 UNIT,
RECON SOLN 18000000 UNIT, RECON SOLN
50000000 UNIT, SOLUTION 6000000 UNIT/ML,
SOLUTION 10000000 UNIT/ML)
Preferred Specialty
SA
MODERIBA (MISC 200 400 MG, MISC 400 600
MG)
Non-Preferred Specialty
C
not restricted to Caremark
MODERIBA 1200 DOSE PACK TAB 600 MG
Non-Preferred Specialty
C
not restricted to Caremark
MODERIBA 800 DOSE PACK TAB 400 MG
Non-Preferred Specialty
C
not restricted to Caremark
ANTI-HEPATITIS B (HBV) AGENTS
ANTI-HEPATITIS C (HCV) AGENTS
- 102 -
SA / PAR
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
moderiba tab 200 mg
Preferred Specialty
C
PEG-INTRON (KIT 50, KIT 80, KIT 120, KIT 150)
Preferred Specialty
SA
SA / PAR
PEG-INTRON REDIPEN (KIT 50, KIT 80, KIT 120,
KIT 150)
Preferred Specialty
SA
SA / PAR
PEG-INTRON REDIPEN PAK 4 KIT 120
MCG/0.5ML
Preferred Specialty
SA
SA / PAR
PEGASYS (SOLUTION 180 MCG/ML, SOLUTION
180 MCG/0.5ML)
Preferred Specialty
SA
SA / PAR
PEGASYS PROCLICK (SOLUTION 135,
SOLUTION 180)
Preferred Specialty
SA
SA / PAR
PEGINTRON (KIT 50, KIT 80, KIT 120, KIT 150)
Preferred Specialty
SA
SA / PAR
REBETOL SOLUTION 40 MG/ML
Preferred Specialty
C
ribasphere (cap 200 mg, tab 200 mg)
Preferred Specialty
RIBASPHERE (TAB 400 MG, TAB 600 MG)
Preferred Specialty
RIBASPHERE RIBAPAK (TAB 200 & 400 MG,
TAB 400 MG, TAB 400 & 600 MG, TAB 600 MG)
Non-Preferred Specialty
C
not restricted to Caremark
RIBATAB (MISC 400 & 600 MG, TAB 400 MG,
TAB 600 MG)
Non-Preferred Specialty
C
not restricted to Caremark
ribavirin (cap 200 mg, tab 200 mg)
Preferred Specialty
C
not restricted to Caremark
SOVALDI TAB 400 MG
Preferred Specialty
PA
TECHNIVIE TAB 12.5-75-50 MG
Preferred Specialty
PA
VIEKIRA PAK TAB THPK 12.5-75-50 &250 MG
Non-Preferred Specialty
PA
VIEKIRA XR TAB ER 24H 200-8.33-50- 33.33 MG
Non-Preferred Specialty
PA
ZEPATIER TAB 50-100 MG
Non-Preferred Specialty
PA
C
C
not restricted to Caremark
not restricted to Caremark
not restricted to Caremark
not restricted to Caremark
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
GENVOYA TAB 150-150-200-10 MG
Preferred Specialty
C
not restricted to Caremark
ISENTRESS (PACKET 100 MG, TAB 400 MG)
Preferred Specialty
C
not restricted to Caremark
STRIBILD TAB 150-150-200-300 MG
Preferred Specialty
C
not restricted to Caremark
TIVICAY (TAB 10 MG, TAB 25 MG)
Preferred Specialty
C
not restricted to Caremark
TIVICAY TAB 50 MG
Preferred Specialty
C
not restricted to Caremark
VITEKTA (TAB 85 MG, TAB 150 MG)
Preferred Specialty
C
not restricted to Caremark
- 103 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA TAB 600-200-300 MG
Preferred Specialty
C
not restricted to Caremark
COMPLERA TAB 200-25-300 MG
Preferred Specialty
C
not restricted to Caremark
INTELENCE (TAB 25 MG, TAB 100 MG, TAB 200
MG)
Preferred Specialty
C
not restricted to Caremark
ODEFSEY TAB 200-25-25 MG
Non-Preferred Specialty
SUSTIVA (CAP 50 MG, CAP 200 MG, TAB 600
MG)
Non-Preferred Specialty
C
not restricted to Caremark
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir-lamivudine-zidovudine tab 300-150-300
mg
Preferred Specialty
C
not restricted to Caremark
DESCOVY TAB 200-25 MG
Non-Preferred Specialty
C
not restricted to Caremark
EPZICOM TAB 600-300 MG
Preferred Specialty
C
not restricted to Caremark
lamivudine-zidovudine tab 150-300 mg
Preferred Specialty
C
not restricted to Caremark
TRUVADA (TAB 100-150 MG, TAB 133-200 MG,
TAB 167-250 MG, TAB 200-300 MG)
Preferred Specialty
C
not restricted to Caremark
VIREAD (POWDER 40 MG/GM, TAB 150 MG,
TAB 200 MG, TAB 250 MG, TAB 300 MG)
Preferred Specialty
C
not restricted to Caremark
FUZEON (KIT 90 MG, RECON SOLN 90 MG)
Preferred Specialty
C
not restricted to Caremark
PREZCOBIX TAB 800-150 MG
Non-Preferred Specialty
C
not restricted to Caremark
SELZENTRY (TAB 150 MG, TAB 300 MG)
Preferred Specialty
C
not restricted to Caremark
TRIUMEQ TAB 600-50-300 MG
Non-Preferred Specialty
C
not restricted to Caremark
APTIVUS (CAP 250 MG, SOLUTION 100 MG/ML)
Preferred Specialty
C
not restricted to Caremark
EVOTAZ TAB 300-150 MG
Non-Preferred Specialty
C
not restricted to Caremark
INVIRASE (CAP 200 MG, TAB 500 MG)
Preferred Specialty
C
not restricted to Caremark
KALETRA (SOLUTION 400-100 MG/5ML, TAB
100-25 MG, TAB 200-50 MG)
Preferred Specialty
C
not restricted to Caremark
LEXIVA (SUSPENSION 50 MG/ML, TAB 700 MG)
Preferred Specialty
C
not restricted to Caremark
NORVIR (CAP 100 MG, SOLUTION 80 MG/ML,
TAB 100 MG)
Preferred Specialty
C
not restricted to Caremark
PREZISTA (SUSPENSION 100 MG/ML, TAB 75
MG, TAB 150 MG, TAB 600 MG, TAB 800 MG)
Preferred Specialty
C
not restricted to Caremark
ANTI-HIV AGENTS, OTHER
ANTI-HIV AGENTS, PROTEASE INHIBITORS
- 104 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
REYATAZ (CAP 150 MG, CAP 200 MG, CAP 300
MG, PACKET 50 MG)
Preferred Specialty
not restricted to Caremark
C
ANTI-INFLUENZA AGENTS
RAPIVAB SOLUTION 200 MG/20ML
Non-Preferred Specialty
ANTIHERPETIC AGENTS
ALFERON N SOLUTION 5000000 UNIT/ML
Preferred Specialty
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
CEPROTIN (RECON SOLN 500, RECON SOLN
1000)
Non-Preferred Specialty
DEFITELIO SOLUTION 200 MG/2.5ML
Non-Preferred Specialty
IPRIVASK (15 MG, RECON SOLN 15 MG)
Non-Preferred Specialty
THROMBATE III (RECON SOLN 500, RECON
SOLN 1000)
Preferred Specialty
C
not restricted to Caremark
BLOOD FORMATION MODIFIERS
ARANESP (ALBUMIN FREE) (SOLN PRSYR 25
MCG/0.42ML, SOLN PRSYR 40 MCG/0.4ML,
SOLN PRSYR 60 MCG/0.3ML, SOLN PRSYR 100
MCG/0.5ML, SOLN PRSYR 150 MCG/0.3ML,
SOLN PRSYR 200 MCG/0.4ML, SOLN PRSYR
300 MCG/0.6ML, SOLN PRSYR 500 MCG/ML,
SOLUTION 10 MCG/0.4ML, SOLUTION 25
MCG/ML, SOLUTION 40 MCG/ML, SOLUTION 60
MCG/ML, SOLUTION 100 MCG/ML, SOLUTION
200 MCG/ML, SOLUTION 300 MCG/ML)
Preferred Specialty
EPOGEN (SOLUTION 2000, SOLUTION 3000,
SOLUTION 4000, SOLUTION 10000, SOLUTION
20000)
Non-Preferred Specialty
GRANIX (SOLN PRSYR 300 MCG/0.5ML, SOLN
PRSYR 480 MCG/0.8ML)
PA
SA
SA / PAR
PA
SA
SA / PAR
Non-Preferred Specialty
SA
SA / PAR
LEUKINE RECON SOLN 250 MCG
Preferred Specialty
SA
SA / PAR
MIRCERA (SOLN PRSYR 50, SOLN PRSYR 75,
SOLN PRSYR 100, SOLN PRSYR 200)
Non-Preferred Specialty
SA
SA / PAR
MOZOBIL SOLUTION 24 MG/1.2ML
Non-Preferred Specialty
NEULASTA ONPRO PREF SY KT 6 MG/0.6ML
Preferred Specialty
SA
SA / PAR
NEULASTA SOLN PRSYR 6 MG/0.6ML
Preferred Specialty
SA
SA / PAR
NEUMEGA RECON SOLN 5 MG
Preferred Specialty
QL
21 vials per fill
SA
SA / PAR
SA / PAR
NEUPOGEN (SOLN PRSYR 300 MCG/0.5ML,
SOLN PRSYR 480 MCG/0.8ML, SOLUTION 300
MCG/ML, SOLUTION 480 MCG/1.6ML)
Preferred Specialty
SA
NPLATE (RECON SOLN 250 MCG, RECON
SOLN 500 MCG)
Preferred Specialty
PA
- 105 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
PROCRIT (SOLUTION 2000, SOLUTION 3000,
SOLUTION 4000, SOLUTION 10000, SOLUTION
20000, SOLUTION 40000)
Preferred Specialty
PROMACTA (TAB 12.5 MG, TAB 25 MG, TAB 50
MG, TAB 75 MG)
Preferred Specialty
PA
ZARXIO (SOLN PRSYR 300 MCG/0.5ML, SOLN
PRSYR 480 MCG/0.8ML)
Preferred Specialty
SA
PA
SA
SA / PAR
SA / PAR
COAGULANTS
ADVATE (RECON SOLN 250, RECON SOLN 500,
RECON SOLN 1000, RECON SOLN 1500,
RECON SOLN 2000, RECON SOLN 3000,
RECON SOLN 4000)
Preferred Specialty
ADYNOVATE (RECON SOLN 250, RECON SOLN
500, RECON SOLN 1000, RECON SOLN 2000)
Non-Preferred Specialty
AFSTYLA (KIT 250, KIT 500, KIT 1000, KIT 2000,
KIT 3000)
Non-Preferred Specialty
ALPHANATE/VWF COMPLEX/HUMAN (RECON
SOLN 250, RECON SOLN 500, RECON SOLN
1000, RECON SOLN 1500, RECON SOLN 2000)
Preferred Specialty
ALPROLIX (RECON SOLN 250, RECON SOLN
500, RECON SOLN 1000, RECON SOLN 2000,
RECON SOLN 3000)
Non-Preferred Specialty
AMICAR SOLUTION 0.25 GM/ML
Non-Preferred Specialty
BEBULIN RECON SOLN 200-1200 UNIT
Preferred Specialty
BEBULIN VH RECON SOLN 200-1200 UNIT
Preferred Specialty
BENEFIX (KIT 250, 250, 500, KIT 500, KIT 1000,
1000, KIT 2000, KIT 3000, RECON SOLN 250,
RECON SOLN 500, RECON SOLN 1000, RECON
SOLN 2000)
Preferred Specialty
COAGADEX (RECON SOLN 250, RECON SOLN
500)
Non-Preferred Specialty
CORIFACT KIT 1000-1600 UNIT
Preferred Specialty
FEIBA NF RECON SOLN
Preferred Specialty
FEIBA RECON SOLN
Preferred Specialty
FEIBA VH IMMUNO RECON SOLN
Preferred Specialty
HELIXATE FS (KIT 250, KIT 500, KIT 1000, KIT
2000, KIT 3000)
Preferred Specialty
HEMOFIL M (HEOFIL 401-800, HEOFIL 8011700, HEOFIL RECON SOLN 220-400, HEOFIL
RECON SOLN 250, HEOFIL RECON SOLN 401800, HEOFIL RECON SOLN 500, HEOFIL
RECON SOLN 801-1500, HEOFIL RECON SOLN
1000, HEOFIL RECON SOLN 1501-2000, HEOFIL
RECON SOLN 1700, HEOFIL RECON SOLN
1701-2000)
Preferred Specialty
HUMATE-P (RECON SOLN 250-600, RECON
SOLN 500-1200, RECON SOLN 1000-2400)
Preferred Specialty
- 106 -
C
not restricted to Caremark
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
IDELVION (RECON SOLN 250, RECON SOLN
500, RECON SOLN 1000, RECON SOLN 2000)
Non-Preferred Specialty
IXINITY RECON SOLN 1500 UNIT
Non-Preferred Specialty
KCENTRA (KIT 500, KIT 1000)
Non-Preferred Specialty
KOATE-DVI (RECON SOLN 250, RECON SOLN
500, RECON SOLN 1000)
Preferred Specialty
KOGENATE FS (KIT 250, KIT 500, KIT 1000, KIT
2000, KIT 3000)
Preferred Specialty
KOGENATE FS BIO-SET (KIT 250, KIT 500, KIT
1000, KIT 2000, KIT 3000)
Preferred Specialty
KOVALTRY (RECON SOLN 250, RECON SOLN
500, RECON SOLN 1000, RECON SOLN 2000,
RECON SOLN 3000)
Preferred Specialty
MONOCLATE-P (KIT 1000, KIT 1500)
Preferred Specialty
MONONINE RECON SOLN 1000 UNIT
Preferred Specialty
NOVOSEVEN (1200 MCG, 2400 MCG, 4800
MCG)
Preferred Specialty
NOVOSEVEN RT (RECON SOLN 1 MG, RECON
SOLN 2 MG, RECON SOLN 5 MG, RECON SOLN
8 MG)
Preferred Specialty
NUWIQ (KIT 250, KIT 500, KIT 1000, KIT 2000,
RECON SOLN 250, RECON SOLN 500, RECON
SOLN 1000, RECON SOLN 2000)
Preferred Specialty
OBIZUR RECON SOLN 500 UNIT
Non-Preferred Specialty
PROFILNINE (RECON SOLN 500, RECON SOLN
1000, RECON SOLN 1500)
Preferred Specialty
PROFILNINE SD (RECON SOLN 500, 500,
RECON SOLN 1000, 1000, 1500, RECON SOLN
1500)
Preferred Specialty
RECOMBINATE (RECON SOLN 220-400,
RECON SOLN 401-800, RECON SOLN 801-1240,
RECON SOLN 1241-1800, RECON SOLN 18012400)
LIMITS & RESTRICTIONS
Preferred Specialty
RIASTAP RECON SOLN
Preferred Specialty
RIXUBIS (RECON SOLN 250, RECON SOLN 500,
RECON SOLN 1000, RECON SOLN 2000,
RECON SOLN 3000)
Non-Preferred Specialty
TRETTEN RECON SOLN 2000-3125 UNIT
Non-Preferred Specialty
VONVENDI (RECON SOLN 650, RECON SOLN
1300)
Non-Preferred Specialty
WILATE (KIT 500-500, KIT 1000-1000, RECON
SOLN 450-450, RECON SOLN 500-500, RECON
SOLN 900-900, RECON SOLN 1000-1000)
Non-Preferred Specialty
XYNTHA (KIT 250, KIT 500, KIT 1000, KIT 2000)
Non-Preferred Specialty
XYNTHA SOLOFUSE (KIT 250, KIT 500, KIT
1000, KIT 2000, KIT 3000)
Non-Preferred Specialty
- 107 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
PLATELET MODIFYING AGENTS
KENGREAL RECON SOLN 50 MG
Non-Preferred Specialty
CARDIOVASCULAR AGENTS
CARDIOVASCULAR AGENTS, OTHER
NORTHERA (CAP 100 MG, CAP 200 MG, CAP
300 MG)
Non-Preferred Specialty
VECAMYL TAB 2.5 MG
Preferred Specialty
C
not restricted to Caremark
C
not restricted to Caremark
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
KEVEYIS TAB 50 MG
Non-Preferred Specialty
DIURETICS, LOOP
ethacrynate sodium recon soln 50 mg
Non-Preferred Specialty
DYSLIPIDEMICS, OTHER
JUXTAPID (CAP 5 MG, CAP 10 MG, CAP 20 MG,
CAP 30 MG, CAP 40 MG, CAP 60 MG)
Preferred Specialty
PA
KYNAMRO SOLN PRSYR 200 MG/ML
Preferred Specialty
PA
PRALUENT (SOLN PEN 75 MG/ML, SOLN PEN
150 MG/ML, SOLN PRSYR 75 MG/ML, SOLN
PRSYR 150 MG/ML)
Preferred Specialty
REPATHA PUSHTRONEX SYSTEM SOLN CART
420 MG/3.5ML
REPATHA SOLN PRSYR 140 MG/ML
PA
SA
Preferred Specialty
PA
SA
Preferred Specialty
Preferred Specialty
SA / PAR
PA
SA
REPATHA SURECLICK SOLN A-INJ 140 MG/ML
SA / PAR
SA / PAR
PA
SA
SA / PAR
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM, OTHER
riluzole tab 50 mg
Preferred Specialty
PA
tetrabenazine (tab 12.5 mg, tab 25 mg)
Preferred Specialty
PA
MULTIPLE SCLEROSIS AGENTS
PA
AMPYRA TAB ER 12H 10 MG
Preferred Specialty
AUBAGIO (TAB 7 MG, TAB 14 MG)
Preferred Specialty
- 108 -
C
must be prescribed by a
neurologist
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
AVONEX PEN AUT-IJ KIT 30 MCG/0.5ML
TIER
LIMITS & RESTRICTIONS
Non-Preferred Specialty
AVONEX PREFILLED PREF SY KT 30
MCG/0.5ML
Non-Preferred Specialty
BETASERON KIT 0.3 MG
Preferred Specialty
COPAXONE 40 MG/ML
Preferred Specialty
EXTAVIA KIT 0.3 MG
Non-Preferred Specialty
GILENYA CAP 0.5 MG
Preferred Specialty
glatopa 20 mg/ml
Preferred Specialty
LEMTRADA SOLUTION 12 MG/1.2ML
Non-Preferred Specialty
PLEGRIDY (SOLN PEN 125, SOLN PRSYR 125)
Non-Preferred Specialty
PLEGRIDY STARTER PACK (PACK SOLN PEN
63 94, PACK SOLN PRSYR 63 94)
REBIF (SOLN PRSYR 22, SOLN PRSYR 44)
Non-Preferred Specialty
Preferred Specialty
REBIF REBIDOSE (SOLN A-INJ 22, SOLN A-INJ
44)
Preferred Specialty
REBIF REBIDOSE TITRATION PACK SOLN AINJ 6X8.8 & 6X22 MCG
Preferred Specialty
REBIF TITRATION PACK SOLN PRSYR 6X8.8 &
6X22 MCG
Preferred Specialty
TECFIDERA (CAP DR 120 MG, CAP DR 240 MG,
MISC 120 & 240 MG)
Preferred Specialty
TYSABRI CONC 300 MG/15ML
Preferred Specialty
ZINBRYTA SOLN PRSYR 150 MG/ML
Non-Preferred Specialty
MN
MN-PA
QL
4 pens per fill
SA
SA / PAR
MN
MN-PA
QL
4 vials per fill
PA
QL
1 kit per fill
MN
MN-PA
SA
SA / PAR
QL
1 kit per fill
MN
MN-PA
SA
SA / PAR
MN
MN-PA
SA
SA / PAR
QL
15 syringes per fill
SA
SA / PAR
QL
15 syringes per fill
SA
SA / PAR
QL
15 syringes per fill
SA
SA / PAR
QL
15 syringes per fill
SA
SA / PAR
DENTAL AND ORAL AGENTS
KEPIVANCE RECON SOLN 6.25 MG
Preferred Specialty
- 109 -
C
not restricted to Caremark
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
DERMATOLOGICAL AGENTS
ABSORICA (CAP 25 MG, CAP 35 MG)
Non-Preferred Specialty
C
not restricted to Caremark
acitretin (cap 10 mg, cap 17.5 mg, cap 25 mg)
Preferred Specialty
C
not restricted to Caremark
COSENTYX SENSOREADY PEN SOLN A-INJ
150 MG/ML
Preferred Specialty
COSENTYX SOLN PRSYR 150 MG/ML
PA
SA
Preferred Specialty
SA / PAR
PA
SA
SA / PAR
dermacinrx prizopak kit 2.5-2.5 %
Non-Preferred Specialty
diclofenac sodium gel 3 %
Preferred Specialty
C
not restricted to Caremark
ENSTILAR FOAM 0.005-0.064 %
Non-Preferred Specialty
C
not restricted to Caremark
fluorouracil cream 0.5 %
Preferred Specialty
C
not restricted to Caremark
methoxsalen cap 10 mg
Non-Preferred Specialty
methoxsalen rapid cap 10 mg
Non-Preferred Specialty
C
not restricted to Caremark
RYNODERM CREAM 37.5 %
Non-Preferred Specialty
C
not restricted to Caremark
STELARA (SOLN PRSYR 45 MG/0.5ML, SOLN
PRSYR 90 MG/ML)
Non-Preferred Specialty
TALTZ (SOLN A-INJ 80 MG/ML, SOLN PRSYR 80
MG/ML)
Non-Preferred Specialty
ZYCLARA PUMP (PUMP CREAM 2.5 %, PUMP
CREAM 3.75 %)
Preferred Specialty
PA
SA
SA / PAR
PA
SA
SA / PAR
C
not restricted to Caremark
C
not restricted to Caremark
C
not restricted to Caremark
ENZYME REPLACEMENT/MODIFIERS
ADAGEN SOLUTION 250 UNIT/ML
Preferred Specialty
ALDURAZYME SOLUTION 2.9 MG/5ML
Preferred Specialty
BUPHENYL TAB 500 MG
Preferred Specialty
CERDELGA CAP 84 MG
Preferred Specialty
CEREDASE SOLUTION 80 UNIT/ML
Preferred Specialty
CEREZYME (RECON SOLN 200, RECON SOLN
400)
Preferred Specialty
CYSTADANE POWDER
Preferred Specialty
ELAPRASE SOLUTION 6 MG/3ML
Preferred Specialty
ELELYSO RECON SOLN 200 UNIT
Preferred Specialty
FABRAZYME (RECON SOLN 5 MG, RECON
SOLN 35 MG)
Non-Preferred Specialty
- 110 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
KANUMA SOLUTION 20 MG/10ML
Preferred Specialty
KUVAN (PACKET 100 MG, PACKET 500 MG,
TAB SOL 100 MG)
Preferred Specialty
PA
LUMIZYME RECON SOLN 50 MG
Preferred Specialty
AL1
At least 8 yrs old
MYOZYME RECON SOLN 50 MG
Preferred Specialty
AL1
Up to 7 yrs old
NAGLAZYME SOLUTION 1 MG/ML
Preferred Specialty
ORFADIN (CAP 2 MG, 2 MG, CAP 5 MG, CAP 10
MG, CAP 20 MG, SUSPENSION 4 MG/ML)
Preferred Specialty
PROCYSBI (CAP DR 25 MG, CAP DR 75 MG)
Preferred Specialty
RAVICTI LIQUID 1.1 GM/ML
Preferred Specialty
sodium phenylbutyrate powder 3 gm/tsp
Preferred Specialty
STRENSIQ (SOLUTION 18 MG/0.45ML,
SOLUTION 28 MG/0.7ML, SOLUTION 40 MG/ML,
SOLUTION 80 MG/0.8ML)
Preferred Specialty
SA
SA / PAR
SUCRAID SOLUTION 8500 UNIT/ML
Preferred Specialty
C
VIMIZIM SOLUTION 5 MG/5ML
Preferred Specialty
VPRIV RECON SOLN 400 UNIT
Preferred Specialty
ZAVESCA CAP 100 MG
Preferred Specialty
not restricted to Caremark
GASTROINTESTINAL AGENTS
GASTROINTESTINAL AGENTS, OTHER
CHENODAL TAB 250 MG
Non-Preferred Specialty
CHOLBAM (CAP 50 MG, CAP 250 MG)
Preferred Specialty
GATTEX (5 MG, KIT 5 MG)
Non-Preferred Specialty
SA
OCALIVA (TAB 5 MG, TAB 10 MG)
Preferred Specialty
PA
RELISTOR (SOLUTION 8 MG/0.4ML, SOLUTION
12 MG/0.6ML, TAB 150 MG)
Preferred Specialty
SA / PAR
IRRITABLE BOWEL SYNDROME AGENTS
alosetron hcl (tab 0.5 mg, tab 1 mg)
Preferred Specialty
VIBERZI (TAB 75 MG, TAB 100 MG)
Non-Preferred Specialty
C
not restricted to Caremark
C
not restricted to Caremark
GENITOURINARY AGENTS
GENITOURINARY AGENTS, OTHER
CUPRIMINE CAP 250 MG
Preferred Specialty
PHOSPHATE BINDERS
AURYXIA TAB 1 GM 210 MG(FE)
Preferred Specialty
FOSRENOL (CHEW TAB 500 MG, CHEW TAB
750 MG, CHEW TAB 1000 MG, PACKET 750 MG,
PACKET 1000 MG)
Preferred Specialty
- 111 -
C
not restricted to Caremark
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
RENAGEL (TAB 400 MG, TAB 800 MG)
Preferred Specialty
C
not restricted to Caremark
RENVELA (PACKET 0.8 GM, PACKET 2.4 GM,
TAB 800 MG)
Preferred Specialty
C
not restricted to Caremark
VELPHORO CHEW TAB 500 MG
Preferred Specialty
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
KORLYM TAB 300 MG
Non-Preferred Specialty
PA
C
not restricted to Caremark
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
ACTHAR HP GEL 80 UNIT/ML
Preferred Specialty
PA
desmopressin acetate solution 4 mcg/ml
Preferred Specialty
C
GENOTROPIN (RECON SOLN 5 MG, RECON
SOLN 12 MG)
Preferred Specialty
GENOTROPIN MINIQUICK (RECON SOLN 0.2
MG, RECON SOLN 0.4 MG, RECON SOLN 0.6
MG, RECON SOLN 0.8 MG, RECON SOLN 1 MG,
RECON SOLN 1.2 MG, RECON SOLN 1.4 MG,
RECON SOLN 1.6 MG, RECON SOLN 1.8 MG,
RECON SOLN 2 MG)
Preferred Specialty
HUMATROPE (RECON SOLN 5 MG, RECON
SOLN 6 MG, RECON SOLN 12 MG, RECON
SOLN 24 MG)
Non-Preferred Specialty
INCRELEX SOLUTION 40 MG/4ML
Preferred Specialty
NORDITROPIN FLEXPRO (SOLUTION 5
MG/1.5ML, SOLUTION 10 MG/1.5ML, SOLUTION
15 MG/1.5ML, SOLUTION 30 MG/3ML)
Non-Preferred Specialty
NUTROPIN AQ NUSPIN 10 SOLUTION 10
MG/2ML
Preferred Specialty
NUTROPIN AQ NUSPIN 5 SOLUTION 5 MG/2ML
PA
SA
SA
OMNITROPE (RECON SOLN 5.8 MG, SOLUTION
5 MG/1.5ML, SOLUTION 10 MG/1.5ML)
SA / PAR
SA / PAR
PA
SA / PAR
PA
SA
- 112 -
SA / PAR
PA
SA
Non-Preferred Specialty
SA / PAR
PA
SA
Preferred Specialty
SA / PAR
PA
SA
NUTROPIN AQ PEN (PEN SOLUTION 10, PEN
SOLUTION 20)
SA / PAR
PA
SA
Preferred Specialty
SA / PAR
PA
SA
Preferred Specialty
SA / PAR
PA
SA
HP ACTHAR GEL 80 UNIT/ML
NUTROPIN AQ NUSPIN 20 SOLUTION 20
MG/2ML
PA
SA
Preferred Specialty
not restricted to Caremark
SA / PAR
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
SAIZEN (RECON SOLN 5 MG, RECON SOLN 8.8
MG)
Non-Preferred Specialty
SAIZEN CLICK.EASY RECON SOLN 8.8 MG
Non-Preferred Specialty
PA
SA
PA
SA
SEROSTIM (RECON SOLN 4 MG, RECON SOLN
5 MG, RECON SOLN 6 MG)
Non-Preferred Specialty
STIMATE SOLUTION 1.5 MG/ML
Preferred Specialty
TEV-TROPIN RECON SOLN 5 MG
Non-Preferred Specialty
ZOMACTON (RECON SOLN 5 MG, RECON
SOLN 10 MG)
Non-Preferred Specialty
ZORBTIVE RECON SOLN 8.8 MG
SA / PAR
PA
SA
C
SA / PAR
not restricted to Caremark
PA
PA
SA
Non-Preferred Specialty
SA / PAR
SA / PAR
PA
SA
SA / PAR
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANDROGENS
ANADROL-50 TAB 50 MG
Preferred Specialty
C
not restricted to Caremark
C
not restricted to Caremark
PROGESTINS
hydroxyprogesterone caproate solution 1.25
gm/5ml
Preferred Specialty
MAKENA OIL 250 MG/ML
Preferred Specialty
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
SENSIPAR (TAB 60 MG, TAB 90 MG)
Preferred Specialty
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
EGRIFTA (RECON SOLN 1 MG, RECON SOLN 2
MG)
Preferred Specialty
ELIGARD (KIT 7.5 MG, KIT 22.5 MG, KIT 30 MG,
KIT 45 MG)
Preferred Specialty
FIRMAGON (RECON SOLN 80 MG, RECON
SOLN 120 MG)
Preferred Specialty
leuprolide acetate kit 1 mg/0.2ml
Preferred Specialty
LUPANETA PACK (PACKKIT3.755MG,
PACKKIT11.255MG)
Non-Preferred Specialty
LUPRON DEPOT (KIT 3.75 MG, KIT 7.5 MG, KIT
11.25 MG, KIT 22.5 MG, KIT 30 MG, KIT 45 MG)
Preferred Specialty
PA
SA
- 113 -
SA / PAR
PA
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
octreotide acetate (solution 50 mcg/ml, solution
100 mcg/ml, solution 200 mcg/ml, solution 500
mcg/ml, solution 1000 mcg/ml)
Preferred Specialty
SANDOSTATIN LAR DEPOT (KIT 10 MG, KIT 20
MG, KIT 30 MG)
Non-Preferred Specialty
SIGNIFOR (SOLUTION 0.3 MG/ML, SOLUTION
0.6 MG/ML, SOLUTION 0.9 MG/ML)
Preferred Specialty
SIGNIFOR LAR (RECON SUSP 20 MG, RECON
SUSP 40 MG, RECON SUSP 60 MG)
Non-Preferred Specialty
SOMATULINE DEPOT (SOLUTION 60 MG/0.2ML,
SOLUTION 90 MG/0.3ML, SOLUTION 120
MG/0.5ML)
Non-Preferred Specialty
SOMAVERT (RECON SOLN 10 MG, RECON
SOLN 15 MG, RECON SOLN 20 MG, RECON
SOLN 25 MG, RECON SOLN 30 MG)
LIMITS & RESTRICTIONS
SA
SA / PAR
Preferred Specialty
SUPPRELIN LA KIT 50 MG
Preferred Specialty
SYNAREL SOLUTION 2 MG/ML
Preferred Specialty
TRELSTAR (RECON SUSP 3.75 MG, RECON
SUSP 11.25 MG)
Preferred Specialty
TRELSTAR DEPOT MIXJECT RECON SUSP 3.75
MG
Preferred Specialty
TRELSTAR LA MIXJECT RECON SUSP 11.25
MG
Preferred Specialty
TRELSTAR MIXJECT (RECON SUSP 3.75 MG,
RECON SUSP 11.25 MG, RECON SUSP 22.5
MG)
Preferred Specialty
VANTAS KIT 50 MG
Preferred Specialty
ZOLADEX (IMPLANT 3.6 MG, IMPLANT 10.8 MG)
Preferred Specialty
C
not restricted to Caremark
IMMUNOLOGICAL AGENTS
ANGIOEDEMA (HAE) AGENTS
BERINERT KIT 500 UNIT
Preferred Specialty
CINRYZE RECON SOLN 500 UNIT
Preferred Specialty
FIRAZYR SOLUTION 30 MG/3ML
Preferred Specialty
KALBITOR SOLUTION 10 MG/ML
Preferred Specialty
RUCONEST RECON SOLN 2100 UNIT
Non-Preferred Specialty
PA
IMMUNE SUPPRESSANTS
ASTAGRAF XL (CAP ER 24H 1 MG, CAP ER 24H
0.5 MG, CAP ER 24H 5 MG)
Non-Preferred Specialty
CIMZIA KIT 2 X 200 MG
Non-Preferred Specialty
PA
SA
CIMZIA PREFILLED KIT 2 X 200 MG/ML
Non-Preferred Specialty
PA
SA
- 114 -
SA / PAR
SA / PAR
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
CIMZIA STARTER KIT KIT 6 X 200 MG/ML
Non-Preferred Specialty
PA
SA
ENBREL (RECON SOLN 25 MG, SOLN PRSYR
25 MG/0.5ML, SOLN PRSYR 50 MG/ML)
Preferred Specialty
ENBREL SURECLICK SOLN A-INJ 50 MG/ML
Preferred Specialty
PA
SA
SA / PAR
PA
SA
ENTYVIO RECON SOLN 300 MG
SA / PAR
SA / PAR
Non-Preferred Specialty
PA
HUMIRA (PREF SY KT 10 MG/0.2ML, PREF SY
KT 20 MG/0.4ML)
HUMIRA PEDIATRIC CROHNS START PREF SY
KT 40 MG/0.8ML
Preferred Specialty
Preferred Specialty
Preferred Specialty
HUMIRA PEN PEN KIT 40 MG/0.8ML
HUMIRA PEN-CROHNS STARTER PEN KIT 40
MG/0.8ML
HUMIRA PEN-PSORIASIS STARTER PEN KIT 40
MG/0.8ML
Preferred Specialty
Preferred Specialty
QL
2 injections per fill
SA
SA / PAR
PA
QL
1 pack per fill
SA
SA / PAR
PA
QL
4 syringes per fill
SA
SA / PAR
PA
QL
1 pack per fill
SA
SA / PAR
PA
QL
1 pack per fill
SA
SA / PAR
PA
HUMIRA PREF SY KT 40 MG/0.8ML
KINERET SOLN PRSYR 100 MG/0.67ML
Preferred Specialty
Preferred Specialty
QL
4 syringes per fill
SA
SA / PAR
PA
SA
NULOJIX RECON SOLN 250 MG
Preferred Specialty
ORENCIA CLICKJECT SOLN A-INJ 125 MG/ML
Preferred Specialty
PA
ORENCIA RECON SOLN 250 MG
Preferred Specialty
PA
ORENCIA SOLN PRSYR 125 MG/ML
Preferred Specialty
PA
SA
- 115 -
SA / PAR
SA / PAR
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
RAPAMUNE SOLUTION 1 MG/ML
Preferred Specialty
RASUVO (SOLN A-INJ 7.5 MG/0.15ML, SOLN AINJ 10 MG/0.2ML, SOLN A-INJ 12.5 MG/0.25ML,
SOLN A-INJ 15 MG/0.3ML, SOLN A-INJ 17.5
MG/0.35ML, SOLN A-INJ 20 MG/0.4ML, SOLN AINJ 22.5 MG/0.45ML, SOLN A-INJ 25 MG/0.5ML,
SOLN A-INJ 27.5 MG/0.55ML, SOLN A-INJ 30
MG/0.6ML)
Non-Preferred Specialty
SA
SA / PAR
PA
SIMPONI (SOLN A-INJ 50 MG/0.5ML, SOLN AINJ 100 MG/ML, SOLN PRSYR 50 MG/0.5ML,
SOLN PRSYR 100 MG/ML)
Non-Preferred Specialty
SIMPONI ARIA SOLUTION 50 MG/4ML
Preferred Specialty
sirolimus (tab 0.5 mg, tab 1 mg, tab 2 mg)
Preferred Specialty
XELJANZ TAB 5 MG
Preferred Specialty
PA
XELJANZ XR TAB ER 24H 11 MG
Preferred Specialty
PA
ZORTRESS (TAB 0.25 MG, TAB 0.5 MG, TAB
0.75 MG)
Non-Preferred Specialty
QL
1 injection per fill
SA
SA / PAR
PA
IMMUNIZING AGENTS, PASSIVE
ANASCORP RECON SOLN
Preferred Specialty
ATGAM INJECTABLE 50 MG/ML
Preferred Specialty
BIVIGAM (SOLUTION 5 GM/50ML, SOLUTION 10
GM/100ML)
Non-Preferred Specialty
CARIMUNE NF (RECON SOLN 3 GM, RECON
SOLN 6 GM, RECON SOLN 12 GM)
Preferred Specialty
CYTOGAM INJECTABLE 50 MG/ML
Preferred Specialty
FLEBOGAMMA (SOLUTION 5 GM/100ML,
SOLUTION 10 GM/200ML)
Non-Preferred Specialty
FLEBOGAMMA DIF (SOLUTION 0.5 GM/10ML,
SOLUTION 2.5 GM/50ML, SOLUTION 5
GM/50ML, SOLUTION 5 GM/100ML, SOLUTION
10 GM/100ML, SOLUTION 10 GM/200ML,
SOLUTION 20 GM/400ML, SOLUTION 20
GM/200ML)
Non-Preferred Specialty
GAMASTAN S/D INJECTABLE
Preferred Specialty
GAMMAGARD (SOLUTION 1 GM/10ML,
SOLUTION 2.5 GM/25ML, SOLUTION 5
GM/50ML, SOLUTION 10 GM/100ML, SOLUTION
20 GM/200ML, SOLUTION 30 GM/300ML)
Preferred Specialty
GAMMAGARD S/D (RECON SOLN 0.5 GM,
RECON SOLN 2.5 GM, RECON SOLN 5 GM,
RECON SOLN 10 GM)
Preferred Specialty
GAMMAGARD S/D LESS IGA (RECON SOLN 5
GM, RECON SOLN 10 GM)
Preferred Specialty
- 116 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
GAMMAKED (SOLUTION 1 GM/10ML,
SOLUTION 2.5 GM/25ML, SOLUTION 5
GM/50ML, SOLUTION 10 GM/100ML, SOLUTION
20 GM/200ML)
Preferred Specialty
GAMMAPLEX (SOLUTION 2.5 GM/50ML,
SOLUTION 5 GM/100ML, SOLUTION 10
GM/200ML, SOLUTION 20 GM/400ML)
Non-Preferred Specialty
GAMUNEX (SOLUTION 1 GM/10ML, SOLUTION
2.5 GM/25ML, SOLUTION 5 GM/50ML,
SOLUTION 10 GM/100ML, SOLUTION 20
GM/200ML)
LIMITS & RESTRICTIONS
Preferred Specialty
GAMUNEX-C (SOLUTION 1 GM/10ML,
SOLUTION 2.5 GM/25ML, SOLUTION 5
GM/50ML, SOLUTION 10 GM/100ML, SOLUTION
20 GM/200ML, SOLUTION 40 GM/400ML)
Preferred Specialty
HIZENTRA (SOLUTION 1 GM/5ML, SOLUTION 2
GM/10ML, SOLUTION 4 GM/20ML, SOLUTION 10
GM/50ML)
Non-Preferred Specialty
SA
SA / PAR
Non-Preferred Specialty
SA
SA / PAR
HYQVIA (KIT 2.5 GM/25ML, KIT 5 GM/50ML, KIT
10 GM/100ML, KIT 20 GM/200ML, KIT 30
GM/300ML)
OCTAGAM (SOLUTION 1 GM/20ML, SOLUTION
2 GM/20ML, SOLUTION 2.5 GM/50ML,
SOLUTION 5 GM/50ML, SOLUTION 5 GM/100ML,
SOLUTION 10 GM/200ML, SOLUTION 10
GM/100ML, SOLUTION 20 GM/200ML,
SOLUTION 25 GM/500ML)
Non-Preferred Specialty
PRIVIGEN (SOLUTION 5 GM/50ML, SOLUTION
10 GM/100ML, SOLUTION 20 GM/200ML,
SOLUTION 40 GM/400ML)
Non-Preferred Specialty
THYMOGLOBULIN RECON SOLN 25 MG
Preferred Specialty
VARIZIG (RECON SOLN 125 UNIT, SOLUTION
125 UNIT/1.2ML)
Non-Preferred Specialty
WINRHO SDF (SOLUTION 1500 UNIT/1.3ML,
SOLUTION 2500 UNIT/2.2ML, SOLUTION 5000
UNIT/4.4ML, SOLUTION 15000 UNIT/13ML)
Preferred Specialty
IMMUNOMODULATORS
ACTEMRA (SOLN PRSYR 162 MG/0.9ML,
SOLUTION 80 MG/4ML, SOLUTION 200
MG/10ML, SOLUTION 400 MG/20ML)
Preferred Specialty
ACTIMMUNE SOLUTION 2000000 UNIT/0.5ML
Preferred Specialty
SA
ARCALYST RECON SOLN 220 MG
Non-Preferred Specialty
SA
BENLYSTA (RECON SOLN 120 MG, RECON
SOLN 400 MG)
Preferred Specialty
ILARIS RECON SOLN 180 MG
Preferred Specialty
PA
SA
Preferred Specialty
- 117 -
SA / PAR
SA / PAR
PA
SA
OTEZLA (TAB 30 MG, TAB THPK 10 20 30 MG)
SA / PAR
SA / PAR
PA
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
RIDAURA CAP 3 MG
Preferred Specialty
C
not restricted to Caremark
SIMULECT (RECON SOLN 10 MG, RECON
SOLN 20 MG)
Preferred Specialty
C
not restricted to Caremark
SYNAGIS (SOLUTION 50 MG/0.5ML, SOLUTION
100 MG/ML)
Preferred Specialty
VACCINES
BCG VACCINE INJECTABLE
Preferred Specialty
INFLAMMATORY BOW EL DISEASE AGENTS
AMINOSALICYLATES
GIAZO TAB 1.1 GM
Non-Preferred Specialty
ST
GLUCOCORTICOIDS
PA
budesonide cp dr part 3 mg
ENTOCORT EC CAP ER 24H 3 MG
Preferred Specialty
Preferred Specialty
C
PA
C
UCERIS FOAM 2 MG/ACT
Non-Preferred Specialty
UCERIS TAB ER 24H 9 MG
Preferred Specialty
must be prescribed by a
gastroenterologist to be
covered
must be prescribed by a
gastroenterologist to be
covered
METABOLIC BONE DISEASE AGENTS
FORTEO SOLUTION 600 MCG/2.4ML
Preferred Specialty
SA
SA / PAR
ST
NATPARA (CARTRIDGE 25 MCG, CARTRIDGE
50 MCG, CARTRIDGE 75 MCG, CARTRIDGE 100
MCG)
pamidronate disodium (recon soln 30 mg, recon
soln 90 mg, solution 30 mg/10ml, solution 90
mg/10ml)
Preferred Specialty
PA
SA
Preferred Specialty
PAMIDRONATE DISODIUM SOLUTION 6 MG/ML
Preferred Specialty
XGEVA SOLUTION 120 MG/1.7ML
Preferred Specialty
zoledronic acid (conc 4 mg/5ml, solution 5
mg/100ml)
Preferred Specialty
ZOLEDRONIC ACID (RECON SOLN 4 MG,
SOLUTION 4 MG/100ML)
Preferred Specialty
ZOMETA SOLUTION 4 MG/100ML
Preferred Specialty
SA / PAR
C
not restricted to Caremark
C
not restricted to Caremark
MISCELLANEOUS THERAPEUTIC AGENTS
EXONDYS 51 (51 SOLUTION 500 MG/10ML, 51
SOLUTION 100 MG/2ML)
Non-Preferred Specialty
- 118 -
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
MYALEPT RECON SOLN 11.3 MG
Preferred Specialty
PA
SA
MYOBLOC (SOLUTION 2500 UNIT/0.5ML,
SOLUTION 5000 UNIT/ML, SOLUTION 10000
UNIT/2ML)
Preferred Specialty
NETSPOT KIT
Non-Preferred Specialty
PRAXBIND SOLUTION 2.5 GM/50ML
Non-Preferred Specialty
PRIALT (SOLUTION 100 MCG/ML, SOLUTION
500 MCG/20ML, SOLUTION 500 MCG/5ML)
Preferred Specialty
SOLIRIS SOLUTION 10 MG/ML
Preferred Specialty
SURFAXIN SUSPENSION 30 MG/ML
Non-Preferred Specialty
THYROGEN RECON SOLN 1.1 MG
Preferred Specialty
VISTOGARD PACKET 10 GM
Non-Preferred Specialty
XIAFLEX RECON SOLN 0.9 MG
Non-Preferred Specialty
XURIDEN PACKET 2 GM
Non-Preferred Specialty
SA / PAR
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
CYSTARAN SOLUTION 0.44 %
Preferred Specialty
EYLEA SOLUTION 2 MG/0.05ML
Preferred Specialty
JETREA SOLUTION 0.5 MG/0.2ML
Preferred Specialty
LUCENTIS (SOLUTION 0.3, SOLUTION 0.5)
Preferred Specialty
MACUGEN SOLUTION 0.3 MG
Preferred Specialty
VISUDYNE RECON SOLN 15 MG
Preferred Specialty
VITRASERT IMPLANT 4.5 MG
Non-Preferred Specialty
C
not restricted to Caremark
OPHTHALMIC ANTI-INFLAMMATORIES
ILUVIEN IMPLANT 0.19 MG
Non-Preferred Specialty
RESPIRATORY TRACT/PULMONARY AGENTS
CYSTIC FIBROSIS AGENTS
56 ampules per fill
BETHKIS NEBU SOLN 300 MG/4ML
Preferred Specialty
CAYSTON RECON SOLN 75 MG
Preferred Specialty
KALYDECO (PACKET 50 MG, PACKET 75 MG,
TAB 150 MG)
Preferred Specialty
ORKAMBI TAB 200-125 MG
Preferred Specialty
PA
TOBI PODHALER CAP 28 MG
Preferred Specialty
QL
224 capsules per fill
tobramycin nebu soln 300 mg/5ml
Preferred Specialty
QL
56 ampules per fill
- 119 -
QL
PA
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
tobramycin pak nebu soln 300 mg/5ml
Preferred Specialty
QL
ADCIRCA TAB 20 MG
Preferred Specialty
PA
ADEMPAS (TAB 0.5 MG, TAB 1 MG, TAB 1.5 MG,
TAB 2 MG, TAB 2.5 MG)
Preferred Specialty
FLOLAN (RECON SOLN 0.5 MG, RECON SOLN
1.5 MG)
Preferred Specialty
LETAIRIS (TAB 5 MG, TAB 10 MG)
Preferred Specialty
OPSUMIT TAB 10 MG
Preferred Specialty
ORENITRAM (TAB ER 0.125 MG, TAB ER 0.25
MG, TAB ER 1 MG, TAB ER 2.5 MG)
Non-Preferred Specialty
REMODULIN (SOLUTION 1 MG/ML, SOLUTION
2.5 MG/ML, SOLUTION 5 MG/ML, SOLUTION 10
MG/ML)
Preferred Specialty
REVATIO RECON SUSP 10 MG/ML
Preferred Specialty
PA
sildenafil citrate (solution 10 mg/12.5ml, tab 20
mg)
Preferred Specialty
PA
TRACLEER (TAB 62.5 MG, TAB 125 MG)
Preferred Specialty
TYVASO REFILL SOLUTION 0.6 MG/ML
Preferred Specialty
TYVASO SOLUTION 0.6 MG/ML
Preferred Specialty
TYVASO STARTER SOLUTION 0.6 MG/ML
Preferred Specialty
UPTRAVI (TAB 200 MCG, TAB 400 MCG, TAB
600 MCG, TAB 800 MCG, TAB 1000 MCG, TAB
1200 MCG, TAB 1400 MCG, TAB 1600 MCG, TAB
THPK 200 & 800 MCG)
Preferred Specialty
VELETRI (RECON SOLN 0.5 MG, RECON SOLN
1.5 MG)
Preferred Specialty
VENTAVIS (SOLUTION 10 MCG/ML, SOLUTION
20 MCG/ML)
Preferred Specialty
56 / fill
PULMONARY ANTIHYPERTENSIVES
RESPIRATORY TRACT AGENTS, OTHER
ARALAST NP (RECON SOLN 400 MG, RECON
SOLN 500 MG, RECON SOLN 800 MG, RECON
SOLN 1000 MG)
Preferred Specialty
CINQAIR SOLUTION 100 MG/10ML
Non-Preferred Specialty
PA
ESBRIET CAP 267 MG
Preferred Specialty
PA
GLASSIA SOLUTION 1000 MG/50ML
Non-Preferred Specialty
NUCALA RECON SOLN 100 MG
Preferred Specialty
PA
OFEV (CAP 100 MG, CAP 150 MG)
Preferred Specialty
PA
PROLASTIN-C RECON SOLN 1000 MG
Preferred Specialty
C
- 120 -
not restricted to Caremark
LAST UPDATED 10/2016
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
PULMOZYME SOLUTION 1 MG/ML
Preferred Specialty
VIRAZOLE RECON SOLN 6 GM
Preferred Specialty
C
XOLAIR RECON SOLN 150 MG
Preferred Specialty
PA
ZEMAIRA RECON SOLN 1000 MG
Preferred Specialty
C
BOTOX (RECON SOLN 100, RECON SOLN 200)
Preferred Specialty
PA
BOTOX COSMETIC (RECON SOLN 50, RECON
SOLN 100)
Preferred Specialty
PA
DYSPORT (GLABELLAR LINES) RECON SOLN
300 UNIT
Non-Preferred Specialty
PA
DYSPORT (RECON SOLN 300, RECON SOLN
500)
Non-Preferred Specialty
PA
RYANODEX RECON SUSP 250 MG
Non-Preferred Specialty
XEOMIN (RECON SOLN 50, RECON SOLN 100)
Preferred Specialty
XEOMIN RECON SOLN 200 UNIT
Preferred Specialty
not restricted to Caremark
not restricted to Caremark
SKELETAL MUSCLE RELAXANTS
PA
SLEEP DISORDER AGENTS
SLEEP DISORDERS, OTHER
HETLIOZ CAP 20 MG
Non-Preferred Specialty
XYREM SOLUTION 500 MG/ML
Preferred Specialty
C
not restricted to Caremark
C
not restricted to Caremark
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
EXJADE (TAB SOL 125 MG, TAB SOL 250 MG,
TAB SOL 500 MG)
Preferred Specialty
FERRIPROX SOLUTION 100 MG/ML
Preferred Specialty
FERRIPROX TAB 500 MG
Preferred Specialty
JADENU (TAB 90 MG, TAB 180 MG, TAB 360
MG)
Non-Preferred Specialty
SAMSCA (TAB 15 MG, TAB 30 MG)
Non-Preferred Specialty
SYPRINE CAP 250 MG
Non-Preferred Specialty
PA
ELECTROLYTE/MINERAL REPLACEMENT
CARBAGLU TAB 200 MG
Non-Preferred Specialty
INJECTAFER SOLUTION 750 MG/15ML
Non-Preferred Specialty
- 121 -
LAST UPDATED 10/2016
Index of covered drugs
ADAPALENE
A
abacavir sulfate
abacavir-lamivudine-zidovudine
ABELCET
ABILIFY MAINTENA
35
104
94
101
ABRAXANE
96
ABSORICA
110
52
ADCETRIS
100
ADCIRCA
120
adefovir dipivoxil
102
ADEMPAS
120
ADRENACLICK
adult aspirin ec low strength
82
6
ADVAIR DISKUS
83
83
acamprosate calcium
16
ADVAIR HFA
ACANYA
52
ADVATE
106
acarbose
37
ADVICOR
49
ACCU-CHEK ACTIVE
75
ADYNOVATE
ACCU-CHEK AVIVA
75
ADZENYS XR-ODT
50
ACCU-CHEK AVIVA PLUS
75
AEROSPAN
80
ACCU-CHEK COMFORT CURVE
75
afeditab cr
44
ACCU-CHEK COMPACT PLUS
75
AFINITOR
98
ACCU-CHEK COMPACT TEST DRUM
75
AFINITOR DISPERZ
98
ACCU-CHEK INSTANT PLUS TEST
75
AFREZZA
40
ACCU-CHEK SMARTVIEW
75
AFSTYLA
106
acebutolol hcl
44
aftera
64
acetaminophen-codeine
14
airavite
86
acetaminophen-codeine #2
14
ak-poly-bac
77
acetaminophen-codeine #3
14
AKYNZEO
28
acetaminophen-codeine #4
14
ALA SCALP
52
acetasol hc
80
ALBENZA
32
ACETAZOLAMIDE
47
albuterol sulfate
82
acetazolamide
47
albuterol sulfate er
82
acetazolamide er
47
alclometasone dipropionate
61
acetic acid
80
ALCORTIN A
52
ACIPHEX SPRINKLE
59
ALDACTAZIDE
46
acitretin
110
ALDURAZYME
110
ACTEMRA
117
ALECENSA
98
ACTHAR HP
112
alendronate sodium
74
acticin
ACTIMMUNE
32
117
ALFERON N
106
105
alfuzosin hcl er
60
ACTOPLUS MET XR
37
ALIMTA
96
ACUVAIL
78
ALINIA
32
acyclovir
36
ALKERAN
31
ACZONE
52
allopurinol
30
ADAGEN
110
ALLZITAL
51
adapalene
52
almotriptan malate
30
- 122 -
LAST UPDATED 10/2016
ALOCRIL
78
amoxicillin
21
ALOGLIPTIN BENZOATE
37
AMOXICILLIN ER
21
ALOGLIPTIN-METFORMIN HCL
37
amoxicillin-pot clavulanate
21
ALOGLIPTIN-PIOGLITAZONE
37
amoxicillin-pot clavulanate er
21
ALOMIDE
78
amphetamine-dextroamphet er
50
amphetamine-dextroamphetamine
50
ampicillin
21
AMPICILLIN
21
alosetron hcl
ALPHAGAN P
ALPHANATE/VWF COMPLEX/HUMAN
111
79
106
alprazolam
37
AMPYRA
alprazolam er
37
AMRIX
85
alprazolam xr
37
anacin
6
ALPROLIX
108
106
ANADROL-50
113
ALREX
78
ANALPRAM E
52
ALTABAX
19
ANASCORP
altafrin
77
ANASTIA
52
altavera
64
anastrozole
32
ALTOPREV
48
ANDRODERM
64
ALVESCO
80
ANDROGEL
64
alyacen 1/35
64
ANDROGEL PUMP
64
alyacen 7/7/7
64
ANDROID
64
amabelz
64
ANDROXY
64
amantadine hcl
33
ANGELIQ
65
AMBISOME
94
ANORO ELLIPTA
84
amethia
65
ANTARA
48
amethia lo
65
anucort-hc
61
amethyst
65
anusol-hc
61
AMICAR
41,106
ANZEMET
28
116
amifostine
96
apap-caff-dihydrocodeine
14
amiloride hcl
48
APIDRA
40
amiloride-hydrochlorothiazide
46
APIDRA SOLOSTAR
40
aminophylline
83
APOKYN
amiodarone hcl
43
apraclonidine hcl
79
AMITIZA
58
apri
65
amitriptyline hcl
27
APRISO
74
amlodipine besy-benazepril hcl
46
APTENSIO XR
50
amlodipine besylate
44
APTIOM
25
amlodipine besylate-valsartan
46
APTIVUS
104
amlodipine-valsartan-hctz
46
aqueous vitamin d
amnesteem
52
ARALAST NP
amoxapine
27
aranelle
amoxicill-clarithro-lansopraz
57
ARANESP (ALBUMIN FREE)
- 123 -
101
88
120
65
105
LAST UPDATED 10/2016
ARCALYST
117
ATRIPLA
104
ARCAPTA NEOHALER
82
atropine sulfate
77
aripiprazole
34
ATROVENT HFA
82
ARISTADA
101
armodafinil
85
aubra
65
ARMOUR THYROID
72
AUGMENTIN
21
ARNUITY ELLIPTA
80
AURYXIA
ARZERRA
100
AUBAGIO
108
111
AUVI-Q
82
ASACOL HD
74
av-phos 250 neutral
60
ascomp-codeine
14
av-vite fb
86
ashlyna
65
AVANDAMET
37
ASMANEX 120 METERED DOSES
80
AVANDIA
37
ASMANEX 14 METERED DOSES
80
AVAR
52
ASMANEX 30 METERED DOSES
80
avar cleanser
52
ASMANEX 60 METERED DOSES
80
AVAR LS
52
ASMANEX 7 METERED DOSES
80
avar-e emollient
52
ASMANEX HFA
80
avar-e green
52
aspir-81
6
AVASTIN
aspir-low
6
AVEED
64
aspir-trin
6
aviane
65
aspirin
6
avidoxy
23
aspirin adult low dose
6
avita
52
aspirin adult low strength
6
AVONEX
109
aspirin childrens
6
AVONEX PEN
109
aspirin ec
6
AVONEX PREFILLED
109
aspirin ec lo-dose
6
AVYCAZ
93
aspirin ec low dose
6
AXIRON
64
aspirin ec low strength
6
azacitidine
96
aspirin low dose
7
AZASAN
73
aspirin low strength
7
AZASITE
21
73
aspirin-caff-dihydrocodeine
14
azathioprine
aspirin-dipyridamole er
42
azelastine hcl
aspirtab
ASTAGRAF XL
100
78,81
7
AZELEX
52
114
AZILECT
34
ASTERO
52
azithromycin
21
atenolol
44
AZOPT
79
atenolol-chlorthalidone
46
AZOR
46
azurette
65
ATGAM
atorvastatin calcium
atovaquone
atovaquone-proguanil hcl
116
48
101
32
B
b-donna
- 124 -
57
LAST UPDATED 10/2016
bacitra-neomycin-polymyxin-hc
77
betamethasone dipropionate aug
61
bacitracin
19
betamethasone valerate
61
bacitracin-polymyxin b
77
BETASERON
baclofen
85
betaxolol hcl
BACTROBAN NASAL
19
bethanechol chloride
balsalazide disodium
74
BETHKIS
119
balziva
65
BETIMOL
79
BANZEL
94
BETOPTIC-S
79
BEVESPI AEROSPHERE
84
BARACLUDE
102
109
44,79
60
bayer advanced aspirin reg st
7
bexarotene
bayer aspirin
7
BEYAZ
65
bayer aspirin ec low dose
7
bicalutamide
31
bayer aspirin regimen
7
BIDIL
46
bayer low dose
7
bimatoprost
79
bayer low strength
7
BINOSTO
75
100
BCG VACCINE
118
bio-d-mulsion
88
BEBULIN
106
bisoprolol fumarate
44
BEBULIN VH
106
bisoprolol-hydrochlorothiazide
46
BECONASE AQ
80
BIVIGAM
116
bekyree
65
BLEO 15K
96
BELBUCA
13
BLEPHAMIDE
77
BELEODAQ
98
BLEPHAMIDE S.O.P.
77
belladonna alkaloids-opium
14
BLINCYTO
100
belladonna-opium
15
blisovi 24 fe
65
BELSOMRA
85
blisovi fe 1.5/30
65
benazepril hcl
43
blisovi fe 1/20
65
benazepril-hydrochlorothiazide
46
BOSULIF
98
BENDEKA
95
BOTOX
121
BENEFIX
106
BOTOX COSMETIC
121
BENICAR
42
bp 10-1
53
BENICAR HCT
46
BP CLEANSING WASH
53
bp foam
53
BENLYSTA
117
benzonatate
84
bprotected pedia d-vite
88
benzoyl peroxide
52
bprotected pedia iron
86
benzoyl peroxide short contact
52
BREO ELLIPTA
84
benzoyl peroxide-erythromycin
53
briellyn
65
benztropine mesylate
33
BRILINTA
42
BEPREVE
78
brimonidine tartrate
79
BERINERT
114
BRINTELLIX
26
BESIVANCE
22
BRISDELLE
26
betamethasone dipropionate
61
BRIVIACT
23
- 125 -
LAST UPDATED 10/2016
bromfenac sodium
78
calcium acetate (phos binder)
61
bromfenac sodium (once-daily)
78
CAMBIA
bromocriptine mesylate
33
camila
71
BROVANA
82
CAMPTOSAR
96
camrese
65
7
budesonide
80,118
bumetanide
48
camrese lo
65
BUNAVAIL
16
CANASA
74
BUPHENYL
110
candesartan cilexetil
42
buprenorphine hcl
16
candesartan cilexetil-hctz
46
buprenorphine hcl-naloxone hcl
16
CAPASTAT SULFATE
95
buproban
17
capecitabine
96
bupropion hcl
26
CAPITAL/CODEINE
15
bupropion hcl er (smoking det)
17
CAPRELSA
98
bupropion hcl er (sr)
26
captopril
43
bupropion hcl er (xl)
26
captopril-hydrochlorothiazide
46
buspirone hcl
36
CARAFATE
59
BUSULFEX
95
carb-o-philic/40
53
butalbital-acetaminophen
51
CARBAGLU
butalbital-apap-caff-cod
15
carbamazepine
25
butalbital-apap-caffeine
51
carbamazepine er
25
butalbital-asa-caff-codeine
15
carbidopa
33
butalbital-asa-caffeine
51
carbidopa-levodopa
33
butalbital-aspirin-caffeine
51
carbidopa-levodopa er
34
butorphanol tartrate
15
carbidopa-levodopa-entacapone
33
BUTRANS
13
CARDIZEM LA
44
BYDUREON
38
CARDURA XL
60
BYETTA 10 MCG PEN
38
CARIMUNE NF
116
BYETTA 5 MCG PEN
38
carisoprodol
85
BYSTOLIC
44
carisoprodol-aspirin
85
BYVALSON
46
carisoprodol-aspirin-codeine
15
carteolol hcl
79
cartia xt
44
C
121
cabergoline
73
carvedilol
44
CABOMETYX
98
CAYA
75
CAFERGOT
30
CAYSTON
calcipotriene
53
caziant
65
calcipotriene-betameth diprop
53
CEDAX
20
calcitonin (salmon)
75
cefaclor
20
calcitrene
53
CEFACLOR
20
cefaclor er
20
cefadroxil
20
calcitriol
calcium acetate
53,75
61
- 126 -
119
LAST UPDATED 10/2016
cefdinir
20
ciclodan
29
cefditoren pivoxil
20
ciclopirox
29
cefixime
20
ciclopirox olamine
29
cefpodoxime proxetil
21
ciclopirox treatment
29
cefprozil
21
ciclopirox-vitamin e
29
CEFTIBUTEN
21
cilostazol
42
CEFTIN
21
CILOXAN
22
cefuroxime axetil
21
cimetidine
58
cimetidine hcl
58
celecoxib
7
CENTANY AT
19
CIMZIA
114
cephalexin
21
CIMZIA PREFILLED
114
CEPROTIN
105
CIMZIA STARTER KIT
115
CERDELGA
110
CINQAIR
120
CEREDASE
110
CINRYZE
114
CEREZYME
110
CIPRO HC
80
cerisa wash
53
CIPRODEX
80
cerovel
53
ciprofloxacin
22
CESAMET
28
ciprofloxacin hcl
22
cesia
65
ciprofloxacin-ciproflox hcl er
22
CETYLEV
75
citalopram hydrobromide
26
cevimeline hcl
52
citric acid-sodium citrate
60
CHANTIX
17
cladribine
96
CHANTIX CONTINUING MONTH PAK
17
claravis
53
CHANTIX STARTING MONTH PAK
17
CLARINEX
81
chateal
65
CLARINEX-D 12 HOUR
84
clarithromycin
21
CHENODAL
111
childrens aspirin
7
clarithromycin er
21
childrens aspirin low strength
7
clemastine fumarate
81
chlordiazepoxide hcl
37
CLEOCIN
19
chlordiazepoxide-amitriptyline
26
CLIMARA PRO
65
chlordiazepoxide-clidinium
57
clindacin etz
53
chloroquine phosphate
32
clindacin-p
53
chlorothiazide
48
clindamycin hcl
19
chlorpromazine hcl
34
clindamycin palmitate hcl
19
chlorpropamide
38
clindamycin phos-benzoyl perox
53
chlorthalidone
48
clindamycin phosphate
chlorzoxazone
85
clindamycin-tretinoin
53
111
clobetasol propionate
61
CHOLBAM
19,53
cholestyramine
49
clobetasol propionate e
61
cholestyramine light
49
clobetasol propionate emulsion
62
CIALIS
60
clocortolone pivalate
62
- 127 -
LAST UPDATED 10/2016
clocortolone pivalate pump
62
cortisone acetate
62
clodan
62
CORTISPORIN-TC
80
CLOLAR
96
COSENTYX
110
clomipramine hcl
27
COSENTYX SENSOREADY PEN
110
clonazepam
37
COSMEGEN
96
clonidine hcl
42
COSOPT PF
79
clonidine hcl er
50
COTELLIC
98
clopidogrel bisulfate
42
covaryx
65
clorazepate dipotassium
37
covaryx hs
65
clotrimazole
29
CREON
56
clotrimazole-betamethasone
53
CRESEMBA
94
clozapine
35
CRINONE
71
106
CRIXIVAN
36
COAGADEX
COARTEM
32
cromolyn sodium
codeine sulfate
15
cryselle-28
colchicine
30
CUPRIMINE
COLCHICINE
30
CUVPOSA
57
colchicine-probenecid
30
cvs aspirin
7
COLCRYS
30
cvs aspirin adult low dose
7
colestipol hcl
49
cvs aspirin adult low strength
7
colocort
74
cvs aspirin child
7
COLY-MYCIN S
80
cvs aspirin ec
8
COLYTE WITH FLAVOR PACKS
58
cvs aspirin low dose
8
COMBIGAN
79
cvs aspirin low strength
8
COMBIPATCH
65
cvs childrens aspirin
8
COMBIVENT RESPIMAT
84
cvs childrens vitamin d
88
COMETRIQ (100 MG DAILY DOSE)
98
cvs d3
88
COMETRIQ (140 MG DAILY DOSE)
98
cvs folic acid
88
COMETRIQ (60 MG DAILY DOSE)
98
cvs nicotine
17
compazine
28
cvs nicotine polacrilex
17
cvs nts step 1
17
COMPLERA
104
57,78,84
65
111
COMPLETENATE
88
cvs vitamin d infants
88
compro
28
cvs vitamin d3
88
CONDYLOX
53
cyanocobalamin
88
constulose
58
cyclafem 1/35
65
109
cyclafem 7/7/7
65
COPAXONE 40 MG/ML
CORDRAN
62
cyclobenzaprine hcl
85
COREG CR
44
CYCLOMYDRIL
77
CORIFACT
106
cyclopentolate hcl
77
CORLANOR
46
cyclophosphamide
31
cormax scalp application
62
CYCLOSET
38
- 128 -
LAST UPDATED 10/2016
cyclosporine
73
DELZICOL
74
cyclosporine modified
73
demeclocycline hcl
23
cyproheptadine hcl
81
DENAVIR
36
CYRAMZA
96
DEPO-PROVERA
71
cyred
65
DEPO-SUBQ PROVERA 104
71
96
CYSTADANE
110
DEPOCYT
CYSTARAN
119
dermacinrx prizopak
110
cytarabine
96
DERMASORB XM
53
cytarabine (pf)
96
DERMATOP
62
116
dermazene
53
cytra k crystals
60
DESCOVY
104
cytra-2
60
desipramine hcl
27
CYTRA-3
60
desloratadine
81
cytra-k
60
desmopressin ace rhinal tube
64
desmopressin ace spray refrig
64
CYTOGAM
D
desmopressin acetate
64,112
d 400
88
desmopressin acetate spray
64
d-400
88
desogestrel-ethinyl estradiol
66
d-vita
88
DESONATE
62
d3 kids
88
desonide
62
DESOXIMETASONE
62
DAKLINZA
102
DALIRESP
83
desoximetasone
62
DALVANCE
93
desvenlafaxine er
26
danazol
64
DESVENLAFAXINE FUMARATE ER
26
dantrolene sodium
85
dexamethasone
62
dapsone
31
DEXAMETHASONE INTENSOL
62
101
dexamethasone sod phosphate pf
62
59
dexamethasone sodium phosphate
DARAPRIM
darifenacin hydrobromide er
DARZALEX
100
dasetta 1/35
62,78
DEXCOM G4 PLAT PED RCV/SHARE
75
65
DEXCOM G4 PLAT PED RECEIVER
75
dasetta 7/7/7
65
DEXCOM G4 PLATINUM RCV/SHARE
75
daunorubicin hcl
96
DEXCOM G4 PLATINUM RECEIVER
75
daysee
65
DEXCOM G4 PLATINUM TRANSMITTER
76
DAYTRANA
51
DEXCOM G4 SENSOR
76
deblitane
71
DEXCOM G5 MOB/G4 PLAT SENSOR
76
decitabine
96
DEXCOM G5 MOBILE RECEIVER
76
DEFITELIO
105
DEXCOM G5 MOBILE TRANSMITTER
76
DELESTROGEN
66
dexedrine
50
delta d3
88
DEXILANT
59
deltasone
62
dexmethylphenidate hcl
51
delyla
66
dexmethylphenidate hcl er
51
- 129 -
LAST UPDATED 10/2016
DEXPAK 10 DAY
62
DOCEFREZ
96
DEXPAK 13 DAY
62
DOCETAXEL
96
DEXPAK 6 DAY
62
docetaxel
96
dexrazoxane
96
docetaxel (non-alcohol)
97
dextroamphetamine sulfate
50
dofetilide
43
dextroamphetamine sulfate er
50
donepezil hcl
25
dialyvite
88
DONNATAL
57
DONNATAL EXTENTABS
57
diazepam
23,37
diazepam intensol
37
dorzolamide hcl
79
DICLEGIS
28
dorzolamide hcl-timolol mal
79
doxazosin mesylate
42
doxepin hcl
27
diclofenac potassium
diclofenac sodium
8
8,53,78,110
diclofenac sodium er
8
DOXEPIN HCL
53
diclofenac-misoprostol
8
doxercalciferol
75
dicloxacillin sodium
21
DOXORUBICIN HCL
97
dicyclomine hcl
57
doxorubicin hcl
97
didanosine
35
doxorubicin hcl liposomal
97
DIFFERIN
53
DOXYCYCLINE
23
DIFICID
93
doxycycline hyclate
23
difil-g forte
83
doxycycline monohydrate
23
DIFLORASONE DIACETATE
62
dronabinol
28
drospirenone-ethinyl estradiol
66
diflunisal
8
digitek
46
DUAVEE
66
digox
46
DULERA
84
digoxin
46
duloxetine hcl
52
dihydroergotamine mesylate
30
DUOPA
DILANTIN
25
DUREZOL
78
dilt-xr
45
durlaza
86
diltiazem cd
45
dutasteride
60
diltiazem hcl
45
dutasteride-tamsulosin hcl
60
diltiazem hcl er
45
DUTOPROL
46
diltiazem hcl er beads
45
DYLOJECT
8
diltiazem hcl er coated beads
45
DYMISTA
84
DIPENTUM
74
DYRENIUM
48
diphenoxylate-atropine
57
DYSPORT
121
dipyridamole
42
DYSPORT (GLABELLAR LINES)
121
disopyramide phosphate
43
disulfiram
16
E
divalproex sodium
23
E.E.S. 400
21
divalproex sodium er
24
E.E.S. GRANULES
22
DIVIGEL
66
ec-81 aspirin
- 130 -
101
8
LAST UPDATED 10/2016
econazole nitrate
29
ENJUVIA
66
econtra ez
66
enoxaparin sodium
41
ecotrin low strength
8
enpresse-28
66
ecpirin
8
enskyce
66
EDARBI
42
ENSTILAR
110
EDARBYCLOR
46
entacapone
33
EDURANT
35
entecavir
eemt
66
ENTEREG
eemt hs
66
ENTOCORT EC
effer-k
86
ENTRESTO
effervescent pot chloride
86
ENTYVIO
EFFIENT
42
enulose
58
EGRIFTA
113
EPANED
43
ELAPRASE
110
EPCLUSA
102
ELELYSO
110
EPIDUO
53
ELESTRIN
66
EPIDUO FORTE
53
ELIDEL
53
epiflur
86
epinastine hcl
78
ELIGARD
113
102
57
118
46
115
elinest
66
EPINEPHRINE
82
ELIQUIS
41
epinephrine
82
ELITEK
96
EPIPEN JR 2-PAK
83
ELIXOPHYLLIN
83
epirubicin hcl
97
ELLA
71
epitol
25
ELMIRON
60
EPIVIR HBV
35
EMADINE
78
eplerenone
48
EMBEDA
13
EPOGEN
EMEND
28
eprosartan mesylate
emoquette
66
EPZICOM
EMPLICITI
100
105
42
104
eq adult aspirin low strength
8
EMSAM
94
eq aspirin
8
EMTRIVA
35
eq aspirin adult low dose
8
EMVERM
101
eq aspirin low dose
8
enalapril maleate
43
eq childrens aspirin
8
enalapril-hydrochlorothiazide
46
eq nicotine
17
ENBREL
115
eq nicotine polacrilex
17
ENBREL SURECLICK
115
eq nicotine step 3
17
encare
60
eql adult aspirin low strength
9
ENCARE
60
eql aspirin
9
endocet
15
eql aspirin ec
9
endodan
15
eql aspirin low dose
9
ENDOMETRIN
71
eql childrens aspirin
9
- 131 -
LAST UPDATED 10/2016
eql folic acid
88
etoposide
32
eql nicotine
17
EURAX
32
eql nicotine polacrilex
17
EVAMIST
66
eql vitamin d gummies child
88
EVEKEO
50
eql vitamin d-3
88
EVOMELA
95
ergocalciferol
88
EVOTAZ
ERIVEDGE
98
EVZIO
93
errin
71
EXALGO
13
ERWINAZE
97
EXELDERM
29
ery
22
exemestane
32
ERY-TAB
22
EXJADE
121
ERYPED 200
22
EXONDYS 51
118
ERYPED 400
22
EXTAVIA
109
ERYTHROCIN STEARATE
22
EYLEA
119
erythromycin
22
ERYTHROMYCIN BASE
22
F
erythromycin base
22
fabb
86
ERYTHROMYCIN ETHYLSUCCINATE
22
FABIOR
53
ESBRIET
120
FABRAZYME
104
110
escitalopram oxalate
26
FACTIVE
22
esomeprazole magnesium
59
FALESSA
67
esomeprazole strontium
59
fallback solo
67
est estrogens-methyltest
66
falmina
67
est estrogens-methyltest ds
66
famciclovir
36
est estrogens-methyltest hs
66
famotidine
58
estarylla
66
FANAPT
34
estazolam
85
FANAPT TITRATION PACK
34
ESTRACE
66
FARXIGA
38
estradiol
66
FARYDAK
97
estradiol valerate
66
FASLODEX
95
estradiol-norethindrone acet
66
FEIBA
106
ESTRING
66
FEIBA NF
106
ESTROGEL
66
FEIBA VH IMMUNO
106
estropipate
66
felbamate
24
eszopiclone
85
felodipine er
45
108
FEMRING
67
ethacrynic acid
48
fenofibrate
48
ethambutol hcl
31
fenofibrate micronized
48
ethosuximide
23
fenofibric acid
48
ethacrynate sodium
etodolac
9
fenoprofen calcium
etodolac er
9
fentanyl
- 132 -
9
13
LAST UPDATED 10/2016
fer-gen-sol
86
fluocinolone acetonide scalp
62
fer-iron
86
fluocinonide
62
ferosul
86
fluocinonide-e
62
FERRAPLUS 90
86
FLUOR-A-DAY
86
FERREX 150 FORTE PLUS
86
fluor-a-day
86
FLUORABON
86
FERRIPROX
121
ferrous sulfate
86
fluoritab
86
FETZIMA
26
fluorometholone
78
FETZIMA TITRATION
26
fluorouracil
FINACEA
53
fluoxetine hcl
26
finasteride
60
fluoxetine hcl (pmdd)
26
FIRAZYR
114
fluphenazine hcl
34
FIRMAGON
113
FLURA-DROPS
86
FIRST-LANSOPRAZOLE
59
flurandrenolide
62
FIRST-METRONIDAZOLE 100
19
FLURANDRENOLIDE
62
FIRST-METRONIDAZOLE 50
19
flurazepam hcl
85
FIRST-OMEPRAZOLE
59
flurbiprofen
FIRST-PROGESTERONE VGS 100
71
flurbiprofen sodium
78
FIRST-PROGESTERONE VGS 200
71
fluticasone propionate
62
FIRST-PROGESTERONE VGS 25
71
fluvastatin sodium
48
FIRST-PROGESTERONE VGS 400
71
fluvoxamine maleate
26
FIRST-PROGESTERONE VGS 50
71
fluvoxamine maleate er
26
FIRST-VANCOMYCIN 25
19
FML
78
FIRST-VANCOMYCIN 50
19
FML FORTE
78
FLAREX
78
FOCALIN XR
51
flavoxate hcl
59
folbee
87
53,110
9
FLEBOGAMMA
116
folic acid
89
FLEBOGAMMA DIF
116
FOLOTYN
96
fondaparinux sodium
41
FORADIL AEROLIZER
83
FORFIVO XL
26
flecainide acetate
FLECTOR
FLOLAN
43
9
120
floriva plus
88
FORTEO
FLOVENT DISKUS
80
FOSAMAX PLUS D
75
FLOVENT HFA
80
fosinopril sodium
43
fluconazole
29
fosinopril sodium-hctz
46
flucytosine
94
FOSRENOL
fludarabine phosphate
97
FRAGMIN
41
fludrocortisone acetate
62
frovatriptan succinate
30
flunisolide
80
FULYZAQ
57
furosemide
48
fluocinolone acetonide
fluocinolone acetonide body
62,80
62
FUZEON
- 133 -
118
111
104
LAST UPDATED 10/2016
fyavolv
67
gildess fe 1.5/30
67
FYCOMPA
23
gildess fe 1/20
67
G
GILENYA
109
GILOTRIF
98
gabapentin
24
GLASSIA
120
GABITRIL
24
glatopa 20 mg/ml
109
galantamine hydrobromide
25
GLEOSTINE
95
galantamine hydrobromide er
25
glimepiride
38
GAMASTAN S/D
116
glipizide
38
GAMMAGARD
116
glipizide er
38
GAMMAGARD S/D
116
glipizide xl
38
GAMMAGARD S/D LESS IGA
116
glipizide-metformin hcl
38
GAMMAKED
117
GLUCAGEN DIAGNOSTIC
39
GAMMAPLEX
117
GLUCAGEN HYPOKIT
39
GAMUNEX
117
GLUCAGON EMERGENCY
39
GAMUNEX-C
117
glucagon hcl (diagnostic)
39
ganciclovir sodium
102
glyburide
38
22
glyburide micronized
38
GATTEX
111
glyburide-metformin
38
gavilyte-c
58
glycopyrrolate
57
gavilyte-g
58
GLYXAMBI
38
gavilyte-h
58
gnp adult aspirin low strength
9
gavilyte-n with flavor pack
58
gnp aspirin
9
gnp aspirin low dose
9
gatifloxacin
GAZYVA
100
GELNIQUE
59
gnp folic acid
89
gemcitabine hcl
96
gnp nicotine mini
17
gemfibrozil
48
gnp nicotine polacrilex
17
generlac
58
gnp vitamin d
89
gengraf
73
GOLYTELY
58
49
GENOTROPIN
112
GONITRO
GENOTROPIN MINIQUICK
112
goodsense aspirin low dose
9
gentak
19
GORDOFILM
53
gentamicin sulfate
19
GORDONS UREA
53
GRALISE
24
GENVOYA
103
GIALAX
58
GRALISE STARTER
24
gianvi
67
granisetron hcl
28
GIAZO
118
gildagia
67
GRANULEX
53
gildess 1.5/30
67
griseofulvin microsize
29
gildess 1/20
67
griseofulvin ultramicrosize
29
gildess 24 fe
67
guanfacine hcl
42
GRANIX
- 134 -
105
LAST UPDATED 10/2016
guanfacine hcl er
51
HUMIRA
115
GYNOL II
61
HUMIRA PEDIATRIC CROHNS START
115
HUMIRA PEN
115
HUMIRA PEN-CROHNS STARTER
115
HUMIRA PEN-PSORIASIS STARTER
115
H
HALAVEN
97
9
HUMULIN 50/50
40
halobetasol propionate
63
HUMULIN 70/30
40
HALOG
63
HUMULIN 70/30 KWIKPEN
40
haloperidol
34
HUMULIN 70/30 PEN
40
haloperidol lactate
34
HUMULIN N
40
HUMULIN N KWIKPEN
40
halfprin
HARVONI
102
healthy kids vitamin d3
89
HUMULIN N PEN
40
heather
71
HUMULIN R
40
HECTOROL
75
HUMULIN R U-500 (CONCENTRATED)
40
HUMULIN R U-500 KWIKPEN
40
HYCAMTIN
98
hydralazine hcl
49
hydrochlorothiazide
48
HELIXATE FS
106
HEMANGEOL
44
HEMOFIL M
heparin sodium (porcine) pf
106
41
HERCEPTIN
100
hydrocod polst-cpm polst er
84
HETLIOZ
121
hydrocodone-acetaminophen
15
HEXALEN
95
hydrocodone-homatropine
84
HIZENTRA
117
hydrocodone-ibuprofen
15
hm aspirin
hm aspirin ec
hm aspirin ec low dose
9
10
9
hydrocortisone
54,63,74
hydrocortisone ace-pramoxine
54
hydrocortisone acetate
63
hm folic acid
89
hydrocortisone butyr lipo base
63
hm nicotine
17
hydrocortisone butyrate
63
hm nicotine polacrilex
17
hydrocortisone valerate
63
hm vitamin d
89
hydrocortisone-acetic acid
80
homatropaire
77
hydrocortisone-iodoquinol
54
homatropine hbr
77
hydromet
84
HORIZANT
51
hydromorphone hcl
15
hydromorphone hcl er
13
HP ACTHAR
112
HUMALOG
40
HYDROMORPHONE HCL ER
13
HUMALOG KWIKPEN
40
hydromorphone hcl pf
15
HUMALOG MIX 50/50
40
hydroxocobalamin
89
HUMALOG MIX 50/50 KWIKPEN
40
hydroxychloroquine sulfate
32
HUMALOG MIX 75/25
40
hydroxyprogesterone caproate
HUMALOG MIX 75/25 KWIKPEN
40
hydroxyurea
31
113
HUMATE-P
106
hydroxyzine hcl
81
HUMATROPE
112
hydroxyzine pamoate
81
- 135 -
LAST UPDATED 10/2016
hyolev mb
19
INVEGA TRINZA
101
hyoscyamine sulfate
57
INVIRASE
104
hyoscyamine sulfate er
57
INVOKAMET
38
INVOKAMET XR
38
INVOKANA
38
IOPIDINE
79
ipratropium bromide
82
84
HYQVIA
HYSINGLA ER
117
13
I
ibandronate sodium
75
ipratropium-albuterol
IBRANCE
98
IPRIVASK
105
ibudone
15
irbesartan
42
ibuprofen
10
irbesartan-hydrochlorothiazide
47
ICLUSIG
98
IRESSA
99
idarubicin hcl
97
irinotecan hcl
97
87
IDELVION
107
iron supplement childrens
ILARIS
117
ISENTRESS
ILEVRO
78
isometheptene-apap-dichloral
76
ilotycin
22
isometheptene-caffeine-apap
76
119
isometheptene-dichloral-apap
76
ILUVIEN
35,103
imatinib mesylate
98
isoniazid
31
IMBRUVICA
99
ISONIAZID
31
imipramine hcl
27
ISORDIL TITRADOSE
49
imipramine pamoate
27
isosorbide dinitrate
49
imiquimod
54
isosorbide dinitrate er
49
IMLYGIC
97
isosorbide mononitrate
50
isosorbide mononitrate er
50
IMPAVIDO
101
IMPLANON
71
isradipine
45
INCRELEX
112
ISTALOL
79
INCRUSE ELLIPTA
82
ISTODAX
97
indapamide
48
itraconazole
29
INDERAL XL
44
ivermectin
32
indomethacin
10
IXEMPRA KIT
97
indomethacin er
10
IXINITY
indomethacin sodium
10
INFED
89
INJECTAFER
121
107
J
JADENU
121
INLYTA
99
JAKAFI
99
INNOPRAN XL
44
JANUMET
38
INTELENCE
104
JANUMET XR
38
INTRON A
102
JANUVIA
38
JARDIANCE
38
jencycla
71
introvale
INVEGA SUSTENNA
67
101
- 136 -
LAST UPDATED 10/2016
JENTADUETO
38
ketoconazole
29
JENTADUETO XR
38
ketoprofen
10
ketoprofen er
10
JETREA
119
jevantique lo
67
ketorolac tromethamine
JEVTANA
97
KEVEYIS
108
jinteli
67
KEYTRUDA
100
jolessa
67
kimidess
67
jolivette
71
KINERET
115
JUBLIA
29
kionex
86
juleber
67
klor-con
87
junel 1.5/30
67
klor-con 10
87
junel 1/20
67
klor-con m10
87
junel fe 1.5/30
67
klor-con m20
87
junel fe 1/20
67
klor-con sprinkle
87
junel fe 24
67
klor-con/ef
87
just d
89
kls aspirin ec
10
kls aspirin low dose
10
kls quit2
17
kls quit4
17
JUXTAPID
108
K
10,78
k-effervescent
87
KOATE-DVI
107
K-PHOS
87
KOGENATE FS
107
k-prime
87
KOGENATE FS BIO-SET
107
k-sol
87
KOMBIGLYZE XR
k-vescent
87
KORLYM
112
KADCYLA
100
KOVALTRY
107
38
KADIAN
13
kp aspirin
10
kaitlib fe
67
kp folic acid
89
KALBITOR
114
kp vitamin d
89
KALETRA
104
KRISTALOSE
58
KALYDECO
119
KRYSTEXXA
94
KANUMA
111
kurvelo
67
kariva
67
KUVAN
111
KAZANO
38
KYNAMRO
108
KCENTRA
107
KYPROLIS
99
kelnor 1/35
67
KENGREAL
108
L
KEPIVANCE
109
labetalol hcl
44
KERAFOAM
54
LACRISERT
77
KERAFOAM 42
54
lactulose
58
KERALYT SCALP
54
lactulose encephalopathy
58
KERYDIN
29
LAMICTAL
24
- 137 -
LAST UPDATED 10/2016
LAMICTAL STARTER
24
LEVEMIR FLEXTOUCH
40
LAMICTAL XR
24
levetiracetam
23
LAMISIL
29
levetiracetam er
23
levobunolol hcl
79
levocarnitine
89
lamivudine
lamivudine-zidovudine
35,36
104
lamotrigine
24
levocetirizine dihydrochloride
81
lamotrigine er
24
levofloxacin
22
LANOXIN
47
levoleucovorin calcium
32
lansoprazole
59
LEVOLEUCOVORIN CALCIUM PF
32
LANTUS
40
levonest
68
LANTUS SOLOSTAR
40
levonorg-eth estrad triphasic
68
larin 1.5/30
67
levonorgest-eth estrad 91-day
68
larin 1/20
67
levonorgestrel
68
larin 24 fe
67
levonorgestrel-ethinyl estrad
68
larin fe 1.5/30
67
levora 0.15/30 (28)
68
larin fe 1/20
67
levorphanol tartrate
13
larissia
67
levothyroxine sodium
72
LASTACAFT
77
levoxyl
72
latanoprost
79
LEXIVA
104
latrix
54
LIALDA
74
LATRIX XM
54
lidocaine
54
LATUDA
34
lidocaine hcl
layolis fe
67
lidocaine hcl (pf)
16
LAZANDA
93
lidocaine pak
54
leena
67
lidocaine-hydrocortisone ace
54
leflunomide
74
lidocaine-prilocaine
54
LEMTRADA
109
LILETTA (52 MG)
71
16,54
LENVIMA 10 MG DAILY DOSE
99
lindane
33
LENVIMA 14 MG DAILY DOSE
99
linezolid
93
LENVIMA 18 MG DAILY DOSE
99
LINEZOLID IN SODIUM CHLORIDE
93
LENVIMA 20 MG DAILY DOSE
99
LINZESS
58
LENVIMA 24 MG DAILY DOSE
99
liothyronine sodium
72
LENVIMA 8 MG DAILY DOSE
99
lipodox
97
LESCOL XL
48
lipodox 50
97
lessina
68
LIPTRUZET
49
lisinopril
43
lisinopril-hydrochlorothiazide
47
LETAIRIS
120
letrozole
32
LEUKINE
105
lithium
37
leuprolide acetate
113
lithium carbonate
37
levalbuterol hcl
83
lithium carbonate er
37
LEVEMIR
40
LIVALO
49
- 138 -
LAST UPDATED 10/2016
LO LOESTRIN FE
68
maprotiline hcl
27
LO MINASTRIN FE
68
marlissa
68
LOCOID
63
MARQIBO
97
lomedia 24 fe
68
MATULANE
95
LONSURF
96
matzim la
45
lopreeza
68
MAXIDEX
78
lorazepam
37
meclofenamate sodium
10
lorazepam intensol
37
MEDROL
63
lorcet
15
medroxyprogesterone acetate
71
lorcet hd
15
mefenamic acid
10
lorcet plus
15
mefloquine hcl
32
lortab
15
megestrol acetate
72
LORTAB
15
MEKINIST
99
loryna
68
meloxicam
10
losartan potassium
42
melphalan hcl
95
losartan potassium-hctz
47
memantine hcl
25
LOTEMAX
78
MENEST
68
lovastatin
49
MENOSTAR
68
low-ogestrel
68
meperidine hcl
15
loxapine succinate
34
MEPERIDINE HCL
15
LOZI-FLUR
87
MEPHYTON
89
LUCENTIS
119
meprobamate
36
ludent
87
mercaptopurine
31
LUFYLLIN
83
mesalamine
74
LUMIGAN
79
mesalamine-cleanser
74
LUMIZYME
111
MESNEX
32
LUPANETA PACK
113
MESTINON
31
LUPRON DEPOT
113
metadate er
51
LUPRON DEPOT-PED
114
METAXALONE
85
lutera
68
metaxalone
85
LUZU
29
metformin hcl
38
LYNPARZA
97
metformin hcl er
39
LYRICA
52
metformin hcl er (mod)
39
lyza
71
metformin hcl er (osm)
39
methadone hcl
13
METHADONE HCL
13
M
M-VIT
89
methadone hcl intensol
13
MACNATAL CN DHA
89
methadose
13
MACUGEN
119
methamphetamine hcl
50
MAKENA
113
methazolamide
79
malathion
33
methenamine hippurate
19
- 139 -
LAST UPDATED 10/2016
methenamine mandelate
19
mimvey
68
methergine
76
mimvey lo
68
methimazole
73
MINASTRIN 24 FE
68
methocarbamol
85
miniprin low dose
10
methotrexate
73
minitran
50
methotrexate sodium
73
minocycline hcl
23
methotrexate sodium (pf)
73
minocycline hcl er
23
49
methoxsalen
110
minoxidil
methoxsalen rapid
110
MIRCERA
105
methyclothiazide
48
MIRENA (52 MG)
72
methyldopa
42
mirtazapine
26
methylergonovine maleate
76
MIRVASO
54
methylphenidate hcl
51
misoprostol
59
methylphenidate hcl er
51
mitoxantrone hcl
97
methylphenidate hcl er (cd)
51
mm aspirin
10
methylphenidate hcl er (la)
51
modafinil
85
methylprednisolone
63
MODERIBA
102
methylprednisolone (pak)
63
moderiba
103
metipranolol
79
MODERIBA 1200 DOSE PACK
102
metoclopramide hcl
28
MODERIBA 800 DOSE PACK
102
METOCLOPRAMIDE HCL
28
moexipril hcl
43
metolazone
48
moexipril-hydrochlorothiazide
47
metoprolol succinate er
44
MOLINDONE HCL
34
metoprolol tartrate
44
mometasone furoate
metoprolol-hydrochlorothiazide
47
mono-linyah
metronidazole
19
MONOCLATE-P
mexiletine hcl
43
mononessa
68
MIACALCIN
75
MONONINE
107
MICONAZOLE 3
29
montelukast sodium
82
microgestin 1.5/30
68
MONUROL
19
microgestin 1/20
68
morgidox
23
microgestin 24 fe
68
morphine sulfate
15
microgestin fe 1.5/30
68
morphine sulfate (concentrate)
15
microgestin fe 1/20
68
morphine sulfate er
13
midodrine hcl
42
morphine sulfate er beads
14
MIGERGOT
30
MOVANTIK
57
miglitol
39
MOVIPREP
58
migragesic ida
76
MOXATAG
21
MILLIPRED
63
moxifloxacin hcl
22
MILLIPRED DP
63
MOZOBIL
105
MILLIPRED DP 12-DAY
63
MULTAQ
43
- 140 -
63,81
68
107
LAST UPDATED 10/2016
multi vitamin/fluoride
89
NARCAN
17
multi-vit/fluoride
89
NASCOBAL
89
multi-vitamin/fluoride
89
NATAZIA
68
multivitamin/fluoride
89
nateglinide
39
multivitamins/fluoride
89
NATESTO
64
mupirocin
19
NATPARA
118
mupirocin calcium
19
NATROBA
33
mvc-fluoride
89
NATURE-THROID
72
my way
68
NEBUPENT
32
necon 0.5/35 (28)
68
MYALEPT
119
mycophenolate mofetil
73
necon 1/35 (28)
68
mycophenolate sodium
73
NECON 1/50 (28)
69
MYKIDZ IRON 10
87
NECON 10/11 (28)
69
MYNATAL PLUS
89
necon 7/7/7
69
MYNATAL-Z
89
nefazodone hcl
27
neo-polycin
77
neo-polycin hc
77
neomycin sulfate
19
MYOBLOC
myorisan
MYOZYME
119
54
111
MYRBETRIQ
60
neomycin-bacitracin zn-polymyx
77
MYTESI
57
neomycin-polymyxin-dexameth
77
myzilra
68
neomycin-polymyxin-gramicidin
77
neomycin-polymyxin-hc
N
77,80
nephronex
90
39
nabumetone
10
NESINA
nadolol
44
NETSPOT
nadolol-bendroflumethiazide
47
neuac
NAFTIFINE HCL
29
NEULASTA
105
naftifine hcl
29
NEULASTA ONPRO
105
NAFTIN
29
NEUMEGA
105
NEUPOGEN
105
119
54
NAGLAZYME
111
naltrexone hcl
16
NEUPRO
33
NAMENDA XR
25
NEVANAC
78
NAMENDA XR TITRATION PACK
25
nevirapine
35
NAMZARIC
51
nevirapine er
35
naphazoline hcl
77
NEXAVAR
99
naproxen
10
NEXIUM
59
naproxen dr
10
NEXPLANON
72
naproxen kit
10
next choice
69
naproxen sodium
10
next choice one dose
69
naproxen sodium er
10
niacin er (antihyperlipidemic)
49
naratriptan hcl
30
NIACOR
49
- 141 -
LAST UPDATED 10/2016
nicardipine hcl
45
norgestim-eth estrad triphasic
69
nicorelief
17
norgestimate-eth estradiol
69
nicotine
17
norgestrel-ethinyl estradiol
69
NICOTINE
18
NORINYL 1+50 (28)
69
nicotine mini
18
NORITATE
20
nicotine polacrilex
18
norlyroc
72
nicotine step 1
18
NORTHERA
nicotine step 2
18
nortrel 0.5/35 (28)
69
nicotine step 3
18
nortrel 1/35 (21)
69
NICOTROL
18
nortrel 1/35 (28)
69
NICOTROL NS
18
nortrel 7/7/7
69
nifediac cc
45
nortriptyline hcl
28
nifedical xl
45
NORVIR
nifedipine
45
norwich aspirin
10
nifedipine er
45
NOVACORT
54
nifedipine er osmotic
45
NOVOLIN 70/30
40
nifedipine er osmotic release
45
NOVOLIN 70/30 RELION
40
nikki
69
NOVOLIN N
41
nilutamide
95
NOVOLIN N RELION
41
nimodipine
45
NOVOLIN R
41
NINLARO
99
NOVOLIN R RELION
41
NIPENT
96
NOVOLOG
41
nisoldipine er
45
NOVOLOG FLEXPEN
41
NITRO-BID
50
NOVOLOG MIX 70/30
41
NITRO-DUR
50
NOVOLOG MIX 70/30 FLEXPEN
41
nitrofurantoin
20
NOVOLOG PENFILL
41
nitrofurantoin macrocrystal
19
NOVOSEVEN
107
nitrofurantoin monohyd macro
20
NOVOSEVEN RT
107
nitroglycerin
50
NOXAFIL
94
nitroglycerin er
50
np thyroid
72
NIVA-PLUS
90
NPLATE
105
nizatidine
58
NUCALA
120
nodolor
76
NUCYNTA
15
nora-be
72
NUCYNTA ER
14
NUEDEXTA
51
108
104
NORDITROPIN FLEXPRO
112
norethin ace-eth estrad-fe
69
nufol
87
norethin-eth estradiol-fe
69
nulev
57
norethindrone
72
NULOJIX
115
norethindrone acet-ethinyl est
69
NUPLAZID
101
norethindrone acetate
72
NUTRIDOX
23
norethindrone-eth estradiol
69
NUTROPIN AQ NUSPIN 10
- 142 -
112
LAST UPDATED 10/2016
NUTROPIN AQ NUSPIN 20
112
ONEXTON
54
NUTROPIN AQ NUSPIN 5
112
ONFI
24
NUTROPIN AQ PEN
112
ONGLYZA
39
69
ONIVYDE
97
ONMEL
94
NUVARING
NUWIQ
107
nyamyc
29
ONZETRA XSAIL
30
nystatin
29
OPANA
15
nystatin-triamcinolone
29
OPANA ER
14
nystop
29
opcicon one-step
69
OPDIVO
O
opium
100
57
O-CAL FA
90
OPSUMIT
O-CAL PRENATAL
90
OPTIONS GYNOL II CONTRACEPTIVE
61
OB COMPLETE GOLD
90
ORACEA
23
OBIZUR
107
ORACIT
61
OCALIVA
111
oralone
52
69
ORBACTIV
93
OCTAGAM
117
ORENCIA
115
octreotide acetate
114
ORENCIA CLICKJECT
115
ODEFSEY
104
ORENITRAM
120
ODOMZO
99
ORFADIN
111
120
ORKAMBI
119
ocella
OFEV
120
ofloxacin
22
orphenadrine citrate er
85
OGESTREL
69
orsythia
69
olanzapine
35
ORTHO DIAPHRAGM ALL-FLEX
76
olanzapine-fluoxetine hcl
26
ORTHO DIAPHRAGM COIL
76
78,81
ORTHO DIAPHRAGM FLAT
76
olopatadine hcl
OMECLAMOX-PAK
57
ORTHO EVRA
69
omega-3-acid ethyl esters
49
OSENI
39
omeprazole
59
OSMOPREP
58
OMEPRAZOLE+SYRSPEND SF ALKA
59
OSPHENA
72
OMNARIS
81
OTEZLA
117
OMNIFLEX DIAPHRAGM
76
OTIPRIO
22
OMNITROPE
112
OTOVEL
80
ONCASPAR
97
OTREXUP
74
ondansetron
28
OVCON-50
69
ondansetron hcl
28
oxaliplatin
97
ONETOUCH TEST
76
oxandrolone
64
ONETOUCH ULTRA BLUE
76
oxaprozin
10
ONETOUCH ULTRA CONTROL
76
oxazepam
37
ONETOUCH VERIO
76
oxcarbazepine
25
- 143 -
LAST UPDATED 10/2016
oxiconazole nitrate
29
peg-prep
OXISTAT
29
PEGASYS
103
OXTELLAR XR
25
PEGASYS PROCLICK
103
oxybutynin chloride
60
PEGINTRON
103
oxybutynin chloride er
60
penicillin v potassium
21
oxycodone hcl
16
PENNSAID
10
OXYCODONE HCL ER
14
PENTASA
74
oxycodone hcl er
14
pentoxifylline er
47
oxycodone-acetaminophen
16
PERFOROMIST
83
oxycodone-aspirin
16
perindopril erbumine
43
oxycodone-ibuprofen
16
PERJETA
100
OXYCONTIN
14
permethrin
33
oxymorphone hcl
16
perphenazine
28
oxymorphone hcl er
14
perphenazine-amitriptyline
26
PERTZYE
57
PEXEVA
27
P
58
pa vitamin d-3 gummy
90
phenadoz
81
pacerone
43
phenazopyridine hcl
61
paclitaxel
97
phenelzine sulfate
26
paliperidone er
35
phenergan
81
pamidronate disodium
118
phenobarbital
24
PAMIDRONATE DISODIUM
118
phenohytro
57
PANCREAZE
56
phenoxybenzamine hcl
42
pancrelipase (lip-prot-amyl)
56
phenyleph-promethazine-cod
84
phenylephrine hcl
77
PANRETIN
101
pantoprazole sodium
59
PHENYTEK
25
paregoric
57
phenytoin
25
paricalcitol
75
phenytoin infatabs
25
paromomycin sulfate
19
phenytoin sodium extended
25
paroxetine hcl
27
philith
69
paroxetine hcl er
27
phospha 250 neutral
61
PATADAY
78
phosphasal
20
PAXIL
27
PHOTOFRIN
97
PAZEO
78
PICATO
54
PCE
22
pilocarpine hcl
peg 3350-kcl-na bicarb-nacl
58
pimozide
34
peg 3350/electrolytes
58
pimtrea
69
peg-3350/electrolytes
58
pindolol
44
52,79
PEG-INTRON
103
pioglitazone hcl
39
PEG-INTRON REDIPEN
103
pioglitazone hcl-glimepiride
39
PEG-INTRON REDIPEN PAK 4
103
pioglitazone hcl-metformin hcl
39
- 144 -
LAST UPDATED 10/2016
pirmella 1/35
69
prednisolone acetate
78
pirmella 7/7/7
69
prednisolone sodium phosphate
63
piroxicam
10
PREDNISOLONE SODIUM PHOSPHATE
63
PLEGRIDY
109
prednisone
63
PLEGRIDY STARTER PACK
109
PREFERA OB
90
PLEXION CLEANSING CLOTH
54
PREFEST
69
PNV FE FUM/DOCUSATE/FOLIC ACID
90
PREMARIN
69
PNV FOLIC ACID + IRON
90
PREMPHASE
69
PNV PRENATAL PLUS MULTIVITAMIN
90
PREMPRO
69
PNV TABS 29-1
90
PRENA1
90
PNV-DHA
90
PRENA1 PEARL
90
PNV-OMEGA
90
PRENAISSANCE
90
podofilox
54
PRENAISSANCE BALANCE
90
polycin
77
PRENAISSANCE HARMONY DHA
90
polymyxin b-trimethoprim
77
PRENAISSANCE NEXT
90
POMALYST
95
PRENAISSANCE NEXT-B
90
portia-28
69
PRENAISSANCE PLUS
90
PRENATA
90
PORTRAZZA
100
pot & sod cit-cit ac
61
PRENATABS FA
90
pot bicarb-pot chloride
87
PRENATABS RX
90
potassium bicarbonate
87
PRENATAL
90
potassium chloride
87
PRENATAL 19
90
POTASSIUM CHLORIDE
87
PRENATAL LOW IRON
90
potassium chloride crys er
87
PRENATAL PLUS
90
potassium chloride er
87
PRENATAL PLUS IRON
90
potassium citrate er
61
PRENATAL VITAMIN PLUS LOW IRON
90
potassium citrate-citric acid
61
PRENATAL-U
90
POTIGA
23
PRENATE
90
PRADAXA
41
PRENATE AM
90
PRALUENT
108
PRENATE DHA
91
pramipexole dihydrochloride
33
PRENATE ELITE
91
pramipexole dihydrochloride er
33
PRENATE ENHANCE
91
prascion
54
PRENATE ESSENTIAL
91
prascion fc
54
PRENATE MINI
91
pravastatin sodium
49
PRENATE PIXIE
91
PRENATE RESTORE
91
PRAXBIND
119
prazosin hcl
42
PREPLUS
91
PRED MILD
78
PREPOPIK
58
prednisolon-moxiflox-bromfenac
77
PRESTALIA
47
PREDNISOLON-MOXIFLOX-KETOROLAC
77
PREVACID SOLUTAB
59
prednisolone
63
prevalite
49
- 145 -
LAST UPDATED 10/2016
previfem
70
propafenone hcl er
43
PREZCOBIX
104
PROPEL
81
PREZISTA
104
PROPEL MINI
81
PRIALT
119
propranolol hcl
44
primaquine phosphate
32
propranolol hcl er
44
primidone
24
propranolol-hctz
47
PRIMLEV
16
propylthiouracil
73
PRIMSOL
20
PROTONIX
59
PRISTIQ
27
protriptyline hcl
28
PROVENGE
97
PRIVIGEN
117
PROAIR HFA
83
PROVENTIL HFA
83
PROAIR RESPICLICK
83
pseudoeph-chlorphen-hydrocod
84
probenecid
30
PULMICORT FLEXHALER
81
PROBUPHINE IMPLANT KIT
93
PULMOZYME
prochlorperazine
28
PURIXAN
96
prochlorperazine maleate
28
px aspirin
11
px enteric aspirin
11
PROCRIT
106
121
procto-med hc
54
px folic acid
91
procto-pak
74
px stop smoking aid
18
proctosol hc
74
PYLERA
57
PYRIDIUM
61
proctozone-hc
54,74
PROCYSBI
111
pyridostigmine bromide
31
PROFILNINE
107
pyridostigmine bromide er
31
PROFILNINE SD
107
pyrogallic acid
54
progesterone
72
progesterone micronized
72
Q
PROGRAF
74
QBRELIS
43
120
qc aspirin
11
PROLASTIN-C
PROLENSA
78
qc aspirin low dose
11
PROLEUKIN
97
qc childrens aspirin
11
PROLIA
75
qc nicotine polacrilex
18
QNASL
81
PROMACTA
106
promethazine hcl
82
QNASL CHILDRENS
81
promethazine vc plain
84
QUARTETTE
70
promethazine vc/codeine
84
quasense
70
promethazine-codeine
84
quazepam
85
promethazine-dm
84
quetiapine fumarate
35
promethazine-phenylephrine
84
QUFLORA FE
91
promethegan
82
QUILLIVANT XR
51
PROMISEB COMPLETE
54
quinapril hcl
43
propafenone hcl
43
quinapril-hydrochlorothiazide
47
- 146 -
LAST UPDATED 10/2016
quinidine gluconate er
43
RELPAX
30
quinine sulfate
32
remeven
54
QVAR
81
REMODULIN
R
120
rena-vite rx
91
renaf
87
ra aspirin
11
RENAGEL
112
ra aspirin adult low dose
11
RENVELA
112
ra aspirin adult low strength
11
repaglinide
39
ra aspirin childrens
11
repaglinide-metformin hcl
39
ra aspirin ec
11
REPATHA
108
ra aspirin ec adult low st
11
REPATHA PUSHTRONEX SYSTEM
108
ra childrens aspirin
11
REPATHA SURECLICK
108
ra folic acid
91
reprexain
16
ra mini nicotine
18
RESCRIPTOR
35
ra nicotine
18
RESCULA
79
ra nicotine polacrilex
18
RESTASIS
77
rabeprazole sodium
59
RETIN-A MICRO PUMP
54
raloxifene hcl
72
REVATIO
120
ramipril
43
REVLIMID
95
RANEXA
47
REXULTI
101
ranitidine hcl
58
REYATAZ
105
RAPAFLO
60
RHEUMATREX
74
RAPAMUNE
116
RIASTAP
107
RAPIVAB
105
ribasphere
103
RASUVO
116
RIBASPHERE
103
RAVICTI
111
RIBASPHERE RIBAPAK
103
RAYOS
63
RIBATAB
103
rea lo 39
54
ribavirin
103
rea lo 40
54
RIDAURA
118
react
70
rifampin
31
REBETOL
103
riluzole
108
REBIF
109
RIOMET
39
REBIF REBIDOSE
109
risedronate sodium
75
REBIF REBIDOSE TITRATION PACK
109
RISPERDAL CONSTA
REBIF TITRATION PACK
109
risperidone
35
risperidone m-tab
35
RITALIN LA
51
reclipsen
RECOMBINATE
70
107
102
RECTIV
54
RITUXAN
REGRANEX
54
rivastigmine
25
RELENZA DISKHALER
36
rivastigmine tartrate
25
RELISTOR
111
RIXUBIS
- 147 -
100
107
LAST UPDATED 10/2016
rizatriptan benzoate
30
SAVELLA
52
ropinirole hcl
33
SAVELLA TITRATION PACK
52
ropinirole hcl er
33
sb aspirin
11
rosadan
20
sb aspirin ec
11
ROSADAN
20
sb childrens aspirin
11
ROSANIL
55
sb low dose asa ec
12
rosanil cleanser
55
SE-NATAL 19
91
ROSULA WASH
55
seb-prev wash
55
rosuvastatin calcium
49
SEEBRI NEOHALER
82
roweepra
23
selegiline hcl
34
ROXICET
16
selenium sulf-pyrithione-urea
55
roxicet
16
selenium sulfide
55
ROZEREM
86
SELZENTRY
104
114
SEMPREX-D
84
RUCONEST
RULAVITE DHA
91
SENSIPAR
73,113
RYANODEX
121
SEREVENT DISKUS
83
RYNODERM
110
SERNIVO
55
SEROQUEL XR
35
RYTARY
34
S
SEROSTIM
113
sertraline hcl
27
SABRIL
94
setlakin
70
SAFYRAL
70
SFROWASA
74
72
SAIZEN
113
sharobel
SAIZEN CLICK.EASY
113
SIGNIFOR
114
salacyn
55
SIGNIFOR LAR
114
salicylic acid
55
sildenafil citrate
120
salicylic acid er
55
silver sulfadiazine
22
salicylic acid in ammon lact
55
SIMBRINZA
79
salicylic acid wart remover
55
SIMCOR
49
salicylic acid-cleanser
55
SIMPONI
116
SALIVAMAX
52
SIMPONI ARIA
116
salsalate
11
SIMULECT
118
SALVAX DUO PLUS
55
simvastatin
49
SAMSCA
121
sirolimus
116
SANCUSO
28
SIRTURO
95
SANDIMMUNE
74
SITAVIG
36
SIVEXTRO
93
SANDOSTATIN LAR DEPOT
114
SANTYL
55
SKLICE
32
SAPHRIS
35
SKYLA
72
SARAFEM
27
sm aspirin
12
SAVAYSA
41
sm aspirin adult low strength
12
- 148 -
LAST UPDATED 10/2016
sm aspirin ec
12
SSKI
87
sm aspirin ec low strength
12
sss 10-5
55
sm aspirin low dose
12
st joseph aspirin
12
sm childrens aspirin
12
stavudine
36
sm folic acid
91
STAVZOR
24
sm nicotine
18
STELARA
110
sm nicotine polacrilex
18
STIMATE
113
sm vitamin d
91
STIOLTO RESPIMAT
84
sod citrate-citric acid
61
STIVARGA
99
sodiphluor
87
STRATTERA
51
sodium fluoride
87
STRENSIQ
sodium phenylbutyrate
111
111
STRIANT
64
sodium polystyrene sulfonate
86
STRIBILD
103
sodium sulfacetamide
55
STRIVERDI RESPIMAT
83
SODIUM SULFACETAMIDE WASH
55
SUBOXONE
16
solia
70
SUCLEAR
58
119
SUCRAID
111
94
sucralfate
59
55
SOLIRIS
SOLODYN
SOMATULINE DEPOT
114
sulfacetamide sod-sulfur wash
SOMAVERT
114
sulfacetamide sodium
SOOLANTRA
32
sulfacetamide sodium (acne)
55
SORILUX
55
sulfacetamide sodium-sulfur
55
sorine
43
sulfacetamide-prednisolone
77
sotalol hcl
44
SULFACETAMIDE-SULFUR IN UREA
55
SOTALOL HCL
44
sulfacetamide-sulfur in urea
55
sotalol hcl (af)
43
sulfacleanse 8/4
55
SOTYLIZE
44
sulfamethoxazole-trimethoprim
22
SOVALDI
103
sulfasalazine
74
22,55
SPINOSAD
33
sulfatrim pediatric
23
SPIRIVA HANDIHALER
82
sulindac
12
SPIRIVA RESPIMAT
82
sumatriptan
30
spironolactone
48
sumatriptan succinate
30
spironolactone-hctz
47
SUMATRIPTAN SUCCINATE
31
SPORANOX
29
sumatriptan succinate refill
30
sprintec 28
70
SUMAVEL DOSEPRO
31
SPRIX
12
SUMAXIN CP
55
SPRYCEL
99
SUPPRELIN LA
sps
86
SUPRAX
21
sronyx
70
SUPREP BOWEL PREP
59
ss 10-2
55
SURFAXIN
119
ssd
22
SUSTIVA
104
- 149 -
114
LAST UPDATED 10/2016
SUTENT
99
telmisartan-hctz
47
sw nicotine polacrilex
18
temazepam
85
syeda
70
TEMODAR
95
SYLATRON
97
temozolomide
95
100
TENIPOSIDE
98
SYMBICORT
84
terazosin hcl
60
SYMLINPEN 120
39
terbinafine hcl
29
SYMLINPEN 60
39
terconazole
30
SYLVANT
SYNAGIS
118
TERSI
56
SYNAREL
114
TESTOPEL
64
SYNJARDY
39
testosterone
64
SYNRIBO
97
testosterone cypionate
64
SYPRINE
121
testosterone enanthate
64
TESTRED
64
T
TACLONEX
55
tacrolimus
56,74
TAFINLAR
99
TAGRISSO
100
take action
TALTZ
tetrabenazine
108
tetracycline hcl
23
TEV-TROPIN
113
tgt aspirin
12
tgt aspirin ec
12
70
tgt aspirin low dose
12
110
tgt childrens aspirin
12
TAMIFLU
36
tgt nicotine
18
tamoxifen citrate
31
tgt nicotine polacrilex
18
tamsulosin hcl
60
tgt nicotine step one
18
TANZEUM
39
tgt nicotine step three
18
TARCEVA
99
tgt nicotine step two
18
th aspirin
12
TARGRETIN
101
tarina fe 1/20
70
th aspirin low dose
12
TASIGNA
99
th enteric aspirin
12
TAXOTERE
98
th folic acid
91
TAYTULLA
70
th vitamin d3
91
TAZORAC
56
THALOMID
95
taztia xt
45
THEO-24
83
TBC
56
theochron
83
TECENTRIQ
100
theophylline
83
TECFIDERA
109
theophylline er
83
TECHNIVIE
103
THERACYS
98
TEKTURNA
47
thioridazine hcl
34
TEKTURNA HCT
47
thiotepa
98
telmisartan
42
thiothixene
34
telmisartan-amlodipine
47
thrive
18
- 150 -
LAST UPDATED 10/2016
THRIVITE 19
91
TOUJEO SOLOSTAR
41
THRIVITE RX
91
TOVIAZ
60
THROMBATE III
105
TRACLEER
THYMOGLOBULIN
117
TRADJENTA
39
THYROGEN
119
tramadol hcl
16
120
THYROLAR-1
72
tramadol hcl er
14
THYROLAR-1/2
72
tramadol hcl er (biphasic)
14
THYROLAR-1/4
72
tramadol-acetaminophen
16
THYROLAR-2
72
trandolapril
43
THYROLAR-3
72
trandolapril-verapamil hcl er
47
tiagabine hcl
24
tranexamic acid
42
ticlopidine hcl
42
TRANSDERM-SCOP (1.5 MG)
28
tilia fe
70
tranylcypromine sulfate
26
TRAVATAN Z
79
timolol maleate
44,79
TIMOPTIC OCUDOSE
79
travoprost
79
tinidazole
20
trazodone hcl
27
TIROSINT
73
TREANDA
95
103
TRELSTAR
114
TIVICAY
TIVORBEX
13
TRELSTAR DEPOT MIXJECT
114
tizanidine hcl
85
TRELSTAR LA MIXJECT
114
tl gard rx
87
TRELSTAR MIXJECT
114
TOBI PODHALER
119
TRESIBA FLEXTOUCH
41
TOBRADEX
19
tretinoin
TOBRADEX ST
77
tretinoin microsphere
56
tretinoin microsphere pump
56
tobramycin
19,119
56,101
120
TRETTEN
107
tobramycin-dexamethasone
77
TREXIMET
31
TOBREX
19
tri-estarylla
70
TODAY SPONGE
61
tri-legest fe
70
tolazamide
39
tri-linyah
70
tolbutamide
39
tri-lo-estarylla
70
101
tri-lo-marzia
70
tolmetin sodium
13
tri-lo-sprintec
70
tolterodine tartrate
60
tri-previfem
70
tolterodine tartrate er
60
tri-sprintec
70
TOPICORT
63
triamcinolone acetonide
topiramate
24
triamterene-hctz
47
topiramate er
24
triazolam
85
topotecan hcl
98
TRIBENZOR
47
TORISEL
99
TRICARE
91
torsemide
48
TRICARE PRENATAL 1
91
tobramycin pak
tolcapone
- 151 -
52,63
LAST UPDATED 10/2016
TRICARE PRENATAL COMPLEAT
91
ULTRESA
57
TRICARE PRENATAL DHA ONE
91
UMECTA
56
tricitrates
61
umecta mousse
56
triderm
63
UMECTA PD
56
trifluoperazine hcl
34
unithroid
73
trifluridine
36
unithroid direct
73
trihexyphenidyl hcl
33
UNITUXIN
100
trilyte
59
UPTRAVI
120
trimethobenzamide hcl
28
ur n-c
20
trimethoprim
20
URAMAXIN
56
TRINATAL RX 1
92
URAMAXIN GT
56
TRINATE
92
urea
56
trinessa (28)
70
urea hydrating
56
trinessa lo
70
urea in zn undecyl-lactic acid
56
TRINTELLIX
27
urea nail
56
TRIUMEQ
104
UREA NAIL
56
trivora (28)
70
urea nail film
56
TROKENDI XR
24
urelle
20
tropicamide
78
uretron d/s
20
trospium chloride
60
UREVAZ
56
trospium chloride er
60
urin ds
20
TRULICITY
39
uro-458
20
TRUVADA
104
uro-l
20
TUDORZA PRESSAIR
82
uroav-81
20
tussigon
84
ursodiol
57
TUSSIONEX PENNKINETIC ER
84
UTIBRON NEOHALER
84
TYBOST
36
utira-c
20
TYKERB
99
UTOPIC
56
TYSABRI
109
utrona-c
20
TYVASO
120
TYVASO REFILL
120
V
TYVASO STARTER
120
VAGIFEM
70
TYZEKA
102
valacyclovir hcl
36
VALCHLOR
95
U
valganciclovir hcl
102
valproate sodium
24
valproic acid
24
u-kera e
56
UCERIS
118
ULESFIA
33
valsartan
42
ULORIC
30
valsartan-hydrochlorothiazide
47
ULTRAVATE X (CREAM)
63
VALSTAR
98
ULTRAVATE X (OINTMENT)
63
vancomycin hcl
- 152 -
20,93
LAST UPDATED 10/2016
VANCOMYCIN HCL
20
vienva
70
VANCOMYCIN+SYRSPEND SF PH4
20
VIGAMOX
22
vandazole
20
VIIBRYD
27
VANTAS
114
VIIBRYD STARTER PACK
27
VARIZIG
117
VIMIZIM
111
VARUBI
28
VIMPAT
25
VASCEPA
49
VINATE ONE
92
VCF VAGINAL CONTRACEPTIVE
61
VIOKACE
57
vcf vaginal contraceptive
61
viorele
70
VECAMYL
108
VIRACEPT
36
VECTIBIX
100
VIRAZOLE
121
VELCADE
98
VIREAD
104
VELETRI
120
velivet
70
VIRT NATE
92
virt-gard
88
VIRT-NATE DHA
92
VELPHORO
112
VELTASSA
86
virt-phos 250 neutral
61
VENCLEXTA
99
VIRT-PN DHA
92
VENCLEXTA STARTING PACK
99
VIRT-PN PLUS
92
venlafaxine hcl
27
virt-vite
88
venlafaxine hcl er
27
virtrate-2
61
VENLAFAXINE HCL ER
27
virtrate-3
61
120
virtrate-k
61
VENTAVIS
VENTOLIN HFA
83
VISTOGARD
119
VERAMYST
81
VISUDYNE
119
verapamil hcl
45
VITAFOL GUMMIES
92
verapamil hcl er
46
VITAFOL-OB
92
VERDESO
63
vitamin d
92
verdrocet
16
vitamin d (cholecalciferol)
92
102
vitamin d (ergocalciferol)
92
VERSACLOZ
VESICARE
60
vitamin d-400
92
vestura
70
vitamin d2
92
VEXOL
78
vitamin d3
92
VIBERZI
111
VITATRUE
88
VIBRAMYCIN
23
VITEKTA
103
vicodin
16
VITRASERT
119
vicodin es
16
VIVITROL
93
vicodin hp
16
VIVLODEX
13
VICTOZA
39
vol-care rx
92
VIDEX
36
VOL-NATE
92
VIEKIRA PAK
103
VOL-PLUS
92
VIEKIRA XR
103
VOL-TAB RX
92
- 153 -
LAST UPDATED 10/2016
VONVENDI
107
XERESE
36
VORAXAZE
98
XGEVA
118
voriconazole
94
XIAFLEX
119
VOTRIENT
99
XIFAXAN
20,93
VP-GGR-B6 PRENATAL
92
XIGDUO XR
39
VP-PNV-DHA
92
XIIDRA
79
vp-vite rx
92
XOFIGO
98
VPRIV
111
XOLAIR
121
VRAYLAR
102
XOPENEX HFA
83
vyfemla
70
XTAMPZA ER
14
VYTORIN
49
XTANDI
95
VYVANSE
50
XULANE
70
XURIDEN
119
W
xylon
16
warfarin sodium
41
XYNTHA
107
wee care
88
XYNTHA SOLOFUSE
107
WELCHOL
49
XYREM
121
WELLESSE VITAMIN D3
92
wera
70
Y
WESTHROID
73
YERVOY
100
WIDE-SEAL DIAPHRAGM 60
76
YODOXIN
19
WIDE-SEAL DIAPHRAGM 65
76
YONDELIS
95
WIDE-SEAL DIAPHRAGM 70
76
WIDE-SEAL DIAPHRAGM 75
76
Z
WIDE-SEAL DIAPHRAGM 80
76
zafirlukast
82
WIDE-SEAL DIAPHRAGM 85
76
zaleplon
85
WIDE-SEAL DIAPHRAGM 90
76
ZALTRAP
98
WIDE-SEAL DIAPHRAGM 95
76
zamicet
16
WILATE
107
ZANOSAR
95
WINRHO SDF
117
zarah
71
WP THYROID
73
ZARXIO
wymzya fe
70
ZATEAN-PN DHA
92
ZATEAN-PN PLUS
92
X
ZAVESCA
106
111
zazole
30
41
ZECUITY
31
XARELTO STARTER PACK
41
ZELBORAF
100
XARTEMIS XR
16
ZEMAIRA
121
XALKORI
100
XARELTO
XELJANZ
116
ZEMBRACE SYMTOUCH
94
XELJANZ XR
116
zenatane
56
XEOMIN
121
zenchent
71
- 154 -
LAST UPDATED 10/2016
zenchent fe
71
ZUPLENZ
28
zencia
56
ZURAMPIC
30
ZENPEP
57
ZYCLARA
56
ZENZEDI
50
ZYCLARA PUMP
110
zenzedi
50
ZYDELIG
100
zeosa
71
ZYFLO
82
ZYFLO CR
82
ZEPATIER
103
ZERBAXA
93
ZYKADIA
ZETIA
49
ZYLET
ZETONNA
81
ZYPREXA RELPREVV
ZIAGEN
36
ZYTIGA
95
zidovudine
36
ZYVOX
93
ZINBRYTA
109
ZIOPTAN
79
ziprasidone hcl
35
ZIPSOR
13
ZIRGAN
102
ZITHRANOL
56
ZITHRANOL-RR
56
ZOHYDRO ER
14
ZOLADEX
114
zoledronic acid
118
ZOLEDRONIC ACID
118
ZOLINZA
98
zolmitriptan
31
zolpidem tartrate
85
zolpidem tartrate er
85
ZOLPIMIST
85
ZOMACTON
113
ZOMETA
118
ZOMIG
31
ZONALON
56
zonisamide
23
ZONTIVITY
42
ZORBTIVE
113
ZORTRESS
116
ZORVOLEX
13
zovia 1/35e (28)
71
ZOVIA 1/50E (28)
71
ZOVIRAX
36
ZUBSOLV
17
- 155 -
100
78
102
LAST UPDATED 10/2016
HMO plans underwritten by Network Health Plan. POS plans underwritten by Network Health
Insurance Corporation, or Network Health Insurance Corporation and Network Health Plan.
Self-funded plans administered by Network Health Plan or Network Health Administrative
Services, LLC.
- 156 -
Check in body for specific drug coverage.
LAST UPDATED 10/2016