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Medicare Plus BlueSM PPO Essential, Vitality, Signature & Assure
2018 Comprehensive Formulary List of covered drugs
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.
This formulary was updated on June 1, 2018. For more recent information or other questions, please contact us, Medicare Plus Blue PPO Customer Service, at 1‑877‑241‑2583 or, for TTY users 711, Monday through Friday, 8 a.m. to 9 p.m. Eastern time. From October 1 through February 14, hours are from 8 a.m. to 9 p.m., Eastern time, seven days a week, or visit www.bcbsm.com/medicare.
The formulary and pharmacy network may change at any time. You will receive notice when necessary.
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and/or copayments/co‑insurance may change on January 1 of each year.
Updated: 06/01/2018 Formulary 18093, Version 18
Medicare Plus Blue is a PPO plan with a Medicare contract. Enrollment in Medicare Plus Blue depends on contract renewal.
www.bcbsm.com/medicare
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us,” or “our,” it means Blue Cross Blue Shield. When it refers to “plan” or “our plan,” it means Medicare Plus Blue PPO.
This document includes a list of the drugs (formulary) for our plan which is current as of June 1, 2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year.
What is the Medicare Plus Blue PPO Essential, Vitality, Signature & Assure Formulary? A formulary is a list of covered drugs selected by Medicare Plus Blue PPO in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Medicare Plus Blue PPO will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Medicare Plus Blue PPO network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost‑sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost‑sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60‑day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of June 1, 2018. To get updated information about the drugs covered by Medicare Plus Blue PPO, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid‑year non‑maintenance formulary change, we will send out an errata sheet to notify you of this change.
How do I use the Formulary? There are two ways to find your drug within the formulary:
Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.
Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page Index 1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand‑name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs? Medicare Plus Blue PPO cover both brand‑name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand‑name drug. Generally, generic drugs cost less than brand‑name drugs.
i
Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
• Prior Authorization: Medicare Plus Blue PPO requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Medicare Plus Blue PPO before you fill your prescriptions. If you don’t get approval, Medicare Plus Blue PPO may not cover the drug.
• Quantity Limits: For certain drugs, Medicare Plus Blue PPO limits the amount of the drug that Medicare Plus Blue PPO will cover. For example, Medicare Plus Blue PPO provides thirty‑one tablets per prescription for simvastatin. This may be in addition to a standard one‑month or three‑month supply.
• Step Therapy: In some cases, Medicare Plus Blue PPO requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Medicare Plus Blue PPO may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Medicare Plus Blue PPO will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You can ask Medicare Plus Blue PPO to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Medicare Plus Blue PPO’s formulary?” on page ii for information about how to request an exception.
What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Medicare Plus Blue PPO does not cover your drug, you have two options:
• You can ask Customer Service for a list of similar drugs that are covered by Medicare Plus Blue PPO. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Medicare Plus Blue PPO.
• You can ask Medicare Plus Blue PPO to make an exception and cover your drug. See below for information about how to request an exception.
How do I request an exception to the Medicare Plus Blue PPO Essential, Vitality, Signature & Assure Formulary? You can ask Medicare Plus Blue PPO to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
• You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will be covered at a pre‑determined cost‑sharing level, and you would not be able to ask us to provide the drug at a lower cost‑sharing level.
• For Medicare Plus Blue PPO Signature and Assure only: You can ask us to cover a formulary drug at a lower cost‑sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Medicare Plus Blue PPO limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, Medicare Plus Blue PPO will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost‑sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
ii
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31‑day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31‑day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long‑term care facility, we will allow you to refill your prescription until we have provided you with a 93‑day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31‑day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
If you move into (or out of) a long‑term care facility, you will continue to have access to your medications during the transition. If needed, limits on early prescription refills will be waived to assure that your medications are available through a new pharmacy provider when you are moving to or from a long‑term care facility. Contact Customer Service if you require assistance in your transition. For more detailed information about our Transition Policy, refer to your Evidence of Coverage or visit our website at www.bcbsm.com/medicare/help/forms‑documents.html
.
For more information For more detailed information about your Medicare Plus Blue PPO prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about Medicare Plus Blue PPO, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1‑800‑MEDICARE (1‑800‑633‑4227) 24 hours a day/ 7 days a week. TTY users should call 1‑877‑486‑2048. Or, visit www.medicare.gov.
Medicare Plus Blue PPO Essential, Vitality, Signature & Assure Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Medicare Plus Blue PPO. If you have trouble finding your drug in the list, turn to the Index that begins on page Index 1.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIVALO®) and generic drugs are listed in lower‑case italics (e.g., simvastatin).
The information in the Requirements/Limits column tells you if Medicare Plus Blue PPO has any special requirements for coverage of your drug.
iii
Tier Descriptions
Medicare Plus Blue PPO Drug Tier Costs
Tier Drug Description
Up to a 31‑day supply Up to a 90‑day supply**
Standard retail and standard
mail‑order cost‑sharing (in‑network)
Preferred retail and preferred mail/order
cost‑sharing (in‑network)
Long‑term care (LTC)
cost‑sharing
Out‑of network
cost‑sharing
Standard retail and standard
mail‑order cost‑sharing (in‑network)
Preferred retail and preferred mail/order
cost‑sharing (in‑network)
Tier 1 Preferred Generic
See your Evidence of Coverage Chart for member cost‑share details Tier 2 Generic
Tier 3 Preferred Brand‑Name
Tier 4 Non‑Preferred Drugs
Tier 5 Specialty See your Evidence of Coverage Chart for member cost‑share details
90‑day supply is not available
*Out‑of‑network pharmacy coverage is limited to certain situations. Consult your Evidence of Coverage for details. **Most pharmacies will fill a 90‑day supply of medication. Check with your pharmacist.
Drug Notes Code Definitions
Symbol Definition B/D This prescription drug may be covered under Medicare Part B or D depending on the circumstances.
Information may need to be submitted describing the use and setting of the drug to make the determination.
EX This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count toward your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.
LA Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, call Medicare Plus Blue PPO Customer Service at 1‑877‑241‑2583, Monday through Friday, 8 a.m. to 9 p.m. Eastern time. From October 1 through February 14, hours are from 8 a.m. to 9 p.m., Eastern time, seven days a week. TTY users should call 711.
PA Prior Authorization. The plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, we may not cover the drug.
QL Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover.
ST Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
NEDS Non‑Extended Day Supply. These drugs are not offered at a 90‑day supply. They are offered up to a 31‑day supply.
iv
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
1
Drug Name Drug
Tier
Requirements
/Limits
ANALGESICS
ANALGESICS, OTHER
diclofenac-
misoprostol oral
tablet,ir,delayed
rel,biphasic 50-200
mg-mcg
2
PRIALT
INTRATHECAL
SOLUTION
4
NONSTEROIDAL ANTI-
INFLAMMATORY DRUGS
CALDOLOR
INTRAVENOUS
RECON SOLN 800
MG/8 ML (100
MG/ML)
3
celecoxib oral
capsule 100 mg
2 QL (270 per
90 days)
celecoxib oral
capsule 200 mg, 400
mg
2 QL (180 per
90 days)
celecoxib oral
capsule 50 mg
2 QL (540 per
90 days)
diclofenac potassium
oral tablet
2
diclofenac sodium
oral tablet extended
release 24 hr
2
diclofenac sodium
oral tablet,delayed
release (dr/ec)
2
diclofenac sodium
topical gel 1 %
2 QL (1000 per
31 days)
diclofenac-
misoprostol oral
tablet,ir,delayed
rel,biphasic 75-200
mg-mcg
2
diflunisal oral tablet 2
etodolac oral
capsule
2
etodolac oral tablet 2
etodolac oral tablet
extended release 24
hr
2
fenoprofen oral
tablet
2
FLECTOR
TRANSDERMAL
PATCH 12 HOUR
4 PA
flurbiprofen oral
tablet
2
ibu oral tablet 2
ibuprofen oral
suspension
2
ibuprofen oral tablet
400 mg, 600 mg, 800
mg
2
ketoprofen oral
capsule
2
ketoprofen oral
capsule,ext rel.
pellets 24 hr 200 mg
2 QL (90 per 90
days)
meclofenamate oral
capsule
4
mefenamic acid oral
capsule
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
2
meloxicam oral
tablet
2
nabumetone oral
tablet
2
naproxen oral
suspension
2
naproxen oral tablet 2
naproxen oral
tablet,delayed
release (dr/ec)
2
naproxen sodium
oral tablet 275 mg,
550 mg
2
oxaprozin oral tablet 2
piroxicam oral
capsule
2
profeno oral tablet 2
salsalate oral tablet
750 mg
2
sulindac oral tablet 2
tolmetin oral capsule 2
tolmetin oral tablet 2
OPIOID ANALGESICS, LONG-
ACTING
BUPRENEX
INJECTION
SOLUTION
4 QL (801 per
90 days)
buprenorphine hcl
injection solution
4 QL (801 per
90 days)
buprenorphine hcl
injection syringe
4 QL (801 per
90 days)
Drug Name Drug
Tier
Requirements
/Limits
BUPRENORPHINE
TRANSDERMAL
PATCH WEEKLY
4 QL (12 per 84
days)
BUTRANS
TRANSDERMAL
PATCH WEEKLY
4 QL (12 per 84
days)
fentanyl transdermal
patch 72 hour 100
mcg/hr, 12 mcg/hr,
25 mcg/hr, 50
mcg/hr, 75 mcg/hr
2 QL (45 per 90
days)
KADIAN ORAL
CAPSULE,EXTEN
D.RELEASE
PELLETS 200 MG
4 QL (180 per
90 days)
levorphanol tartrate
oral tablet
2 QL (360 per
90 days)
methadone injection
solution
4
methadone intensol
oral concentrate
2
methadone oral
concentrate
2
methadone oral
solution
2
methadone oral
tablet
2
morphine oral
capsule,extend.relea
se pellets
4 QL (180 per
90 days)
morphine oral tablet
extended release 100
mg, 15 mg, 30 mg,
60 mg
4 QL (270 per
90 days)
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
3
morphine oral tablet
extended release 200
mg
4 QL (90 per 90
days)
OXYCODONE
ORAL SYRINGE
4 QL (540 per
90 days)
oxymorphone oral
tablet extended
release 12 hr
4 QL (180 per
90 days)
tramadol oral tablet
extended release 24
hr
2 QL (90 per 90
days)
tramadol oral tablet,
er multiphase 24 hr
2 QL (90 per 90
days)
OPIOID ANALGESICS, SHORT-
ACTING
ABSTRAL
SUBLINGUAL
TABLET
5 PA; QL (124
per 31 days);
NEDS
acetaminophen-
codeine oral solution
120 mg-12 mg /5 ml
(5 ml), 120-12 mg/5
ml, 300 mg-30 mg
/12.5 ml
2 QL (5167 per
31 days)
acetaminophen-
codeine oral tablet
300-15 mg, 300-30
mg
2 QL (1080 per
90 days)
acetaminophen-
codeine oral tablet
300-60 mg
2 QL (540 per
90 days)
butorphanol tartrate
injection solution 1
mg/ml
4 QL (2160 per
90 days)
Drug Name Drug
Tier
Requirements
/Limits
butorphanol tartrate
injection solution 2
mg/ml
4 QL (1080 per
90 days)
butorphanol tartrate
nasal spray,non-
aerosol
2 QL (15 per 90
days)
codeine sulfate oral
tablet 15 mg
2 QL (2160 per
90 days)
codeine sulfate oral
tablet 30 mg
2 QL (1080 per
90 days)
codeine sulfate oral
tablet 60 mg
2 QL (540 per
90 days)
duramorph (pf)
injection solution 0.5
mg/ml
4 QL (4133 per
31 days)
duramorph (pf)
injection solution 1
mg/ml
4 QL (6000 per
90 days)
endocet oral tablet
10-325 mg, 2.5-325
mg, 5-325 mg, 7.5-
325 mg
2 QL (1080 per
90 days)
fentanyl citrate (pf)
injection solution
2
fentanyl citrate
buccal lozenge on a
handle
5 PA; QL (124
per 31 days);
NEDS
FENTORA
BUCCAL TABLET,
EFFERVESCENT
5 PA; QL (124
per 31 days);
NEDS
hydrocodone-
acetaminophen oral
solution 7.5-325
mg/15 ml
2 QL (5735 per
31 days)
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
4
hydrocodone-
acetaminophen oral
tablet 10-300 mg, 5-
300 mg, 7.5-300 mg
2
hydrocodone-
acetaminophen oral
tablet 10-325 mg,
2.5-325 mg, 5-325
mg, 7.5-325 mg
2 QL (1080 per
90 days)
hydrocodone-
ibuprofen oral tablet
10-200 mg, 5-200
mg, 7.5-200 mg
2 QL (450 per
90 days)
hydromorphone (pf)
injection solution
4
hydromorphone
injection solution
4
HYDROMORPHO
NE INJECTION
SYRINGE 0.5
MG/0.5 ML
4
hydromorphone
injection syringe 1
mg/ml, 2 mg/ml, 4
mg/ml
4
hydromorphone oral
liquid
2 QL (4500 per
90 days)
hydromorphone oral
tablet 2 mg
2 QL (1350 per
90 days)
hydromorphone oral
tablet 4 mg
2 QL (720 per
90 days)
hydromorphone oral
tablet 8 mg
2 QL (360 per
90 days)
IBUDONE ORAL
TABLET 5-200 MG
4
Drug Name Drug
Tier
Requirements
/Limits
ibuprofen-oxycodone
oral tablet
2 QL (360 per
90 days)
LAZANDA NASAL
SPRAY,NON-
AEROSOL
5 PA; QL (31
per 31 days);
NEDS
lorcet (hydrocodone)
oral tablet
2 QL (1080 per
90 days)
lorcet hd oral tablet 2 QL (1080 per
90 days)
lorcet plus oral
tablet 7.5-325 mg
2 QL (1080 per
90 days)
morphine (pf)
injection solution 0.5
mg/ml, 1 mg/ml
4
morphine
concentrate oral
solution
2 QL (900 per
90 days)
morphine
intravenous
cartridge 10 mg/ml,
2 mg/ml, 4 mg/ml
4
morphine
intravenous solution
10 mg/ml
4
morphine oral
solution
2 QL (2700 per
90 days)
morphine oral tablet 2 QL (540 per
90 days)
nalbuphine injection
solution 10 mg/ml
4 QL (600 per
90 days)
nalbuphine injection
solution 20 mg/ml
4 QL (300 per
90 days)
NUCYNTA ORAL
TABLET 100 MG
4 QL (543 per
90 days)
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
5
NUCYNTA ORAL
TABLET 50 MG
4 QL (1086 per
90 days)
NUCYNTA ORAL
TABLET 75 MG
4 QL (726 per
90 days)
oxycodone oral
capsule
2 QL (1080 per
90 days)
oxycodone oral
concentrate
4 QL (540 per
90 days)
oxycodone oral
solution
4 QL (3600 per
90 days)
oxycodone oral
tablet 10 mg, 15 mg,
20 mg, 30 mg
2 QL (540 per
90 days)
oxycodone oral
tablet 5 mg
2 QL (1080 per
90 days)
oxycodone-
acetaminophen oral
tablet 10-325 mg,
2.5-325 mg, 5-325
mg, 7.5-325 mg
2 QL (1080 per
90 days)
oxycodone-aspirin
oral tablet
2 QL (1080 per
90 days)
oxymorphone oral
tablet
4 QL (540 per
90 days)
SUBSYS
SUBLINGUAL
SPRAY,NON-
AEROSOL
5 PA; QL (124
per 31 days);
NEDS
tramadol oral tablet 2 QL (720 per
90 days)
tramadol-
acetaminophen oral
tablet
2 QL (1080 per
90 days)
vicodin es oral tablet 2 QL (1080 per
90 days)
Drug Name Drug
Tier
Requirements
/Limits
vicodin hp oral
tablet
2 QL (1080 per
90 days)
vicodin oral tablet 2 QL (1080 per
90 days)
xylon 10 oral tablet 2 QL (450 per
90 days)
Drug Name Drug
Tier
Requirements
/Limits
ANESTHETICS
LOCAL ANESTHETICS
bupivacaine (pf)
injection solution 0.5
% (5 mg/ml), 0.75 %
(7.5 mg/ml)
2
chloroprocaine (pf)
injection solution
4
glydo mucous
membrane jelly in
applicator
2
lidocaine (pf)
injection solution
4
lidocaine (pf)
intravenous solution
4
lidocaine (pf)
intravenous syringe
4
lidocaine hcl
injection solution
4
lidocaine hcl
laryngotracheal
solution
4
lidocaine hcl mucous
membrane jelly
2
lidocaine hcl mucous
membrane jelly in
applicator
2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
6
lidocaine hcl mucous
membrane solution 4
% (40 mg/ml)
4
lidocaine topical
adhesive
patch,medicated
4 PA; QL (270
per 90 days)
lidocaine topical
ointment
4
lidocaine viscous
mucous membrane
solution
2
lidocaine-
epinephrine
injection solution 1.5
%-1:200,000
4
lidocaine-prilocaine
topical cream
2
NAROPIN (PF)
INJECTION
SOLUTION
4
polocaine injection
solution 1 % (10
mg/ml)
4
polocaine-mpf
injection solution
4
xylocaine dental-
epinephrine
injection cartridge
4
Drug Name Drug
Tier
Requirements
/Limits
ANTI -
ADDICTION/SUBSTANCE
ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-
CRAVING
acamprosate oral
tablet,delayed
release (dr/ec)
2
disulfiram oral
tablet
2
OPIOID DEPENDENCE
TREATMENTS
buprenorphine hcl
sublingual tablet
2
buprenorphine-
naloxone sublingual
tablet
2
naltrexone oral
tablet
2
SUBOXONE
SUBLINGUAL
FILM
3
VIVITROL
INTRAMUSCULA
R
SUSPENSION,EXT
ENDED REL
RECON
5 NEDS
OPIOID REVERSAL AGENTS
EVZIO INJECTION
AUTO-INJECTOR
4
naloxone injection
solution
2
naloxone injection
syringe
2
NARCAN NASAL
SPRAY,NON-
AEROSOL 4
MG/ACTUATION
4
SMOKING CESSATION AGENTS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
7
bupropion hcl
(smoking deter) oral
tablet extended
release 12 hr
2
CHANTIX
CONTINUING
MONTH BOX
ORAL TABLET
3
CHANTIX ORAL
TABLET
3
CHANTIX
STARTING
MONTH BOX
ORAL
TABLETS,DOSE
PACK
3
NICOTROL
INHALATION
CARTRIDGE
4
NICOTROL NS
NASAL
SPRAY,NON-
AEROSOL
4
Drug Name Drug
Tier
Requirements
/Limits
ANTIBACTERIALS
AMINOGLYCOSIDES
amikacin injection
solution 1,000 mg/4
ml, 500 mg/2 ml
4
BETHKIS
INHALATION
SOLUTION FOR
NEBULIZATION
5 B/D PA;
NEDS
gentak ophthalmic
(eye) ointment
2
gentamicin in nacl
(iso-osm)
intravenous
piggyback 100
mg/100 ml, 60 mg/50
ml, 70 mg/50 ml, 80
mg/100 ml, 80 mg/50
ml, 90 mg/100 ml
4
GENTAMICIN IN
NACL (ISO-OSM)
INTRAVENOUS
PIGGYBACK 100
MG/50 ML, 120
MG/100 ML
4
gentamicin injection
solution
4
gentamicin
ophthalmic (eye)
drops
2
gentamicin sulfate
(ped) (pf) injection
solution
4
gentamicin sulfate
(pf) intravenous
solution 100 mg/10
ml
4
GENTAMICIN
SULFATE (PF)
INTRAVENOUS
SOLUTION 60
MG/6 ML
4
gentamicin topical
cream
2
gentamicin topical
ointment
2
neomycin oral tablet 2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
8
paromomycin oral
capsule
2
STREPTOMYCIN
INTRAMUSCULA
R RECON SOLN
4
tobramycin in 0.225
% nacl inhalation
solution for
nebulization
5 B/D PA;
NEDS
tobramycin
ophthalmic (eye)
drops
1
tobramycin sulfate
injection recon soln
4
tobramycin sulfate
injection solution
4
ANTIBACTERIALS, OTHER
acetic acid otic (ear)
solution
2
AVC VAGINAL
CREAM
4
baciim
intramuscular recon
soln
4
bacitracin
intramuscular recon
soln
4
bacitracin
ophthalmic (eye)
ointment
2
BACTROBAN
NASAL
OINTMENT
3
BENZNIDAZOLE
ORAL TABLET
4
Drug Name Drug Tier
Requirements
/Limits
chloramphenicol sod
succinate
intravenous recon
soln
4
CLEOCIN
VAGINAL
SUPPOSITORY
4
clindacin etz topical
swab
2
clindacin p topical
swab
2
clindamycin hcl oral
capsule
2
CLINDAMYCIN IN
0.9 % SOD CHLOR
INTRAVENOUS
PIGGYBACK
4
clindamycin in 5 %
dextrose intravenous
piggyback
4
clindamycin
palmitate hcl oral
recon soln
4
clindamycin
pediatric oral recon
soln
4
clindamycin
phosphate injection
solution
4
clindamycin
phosphate
intravenous solution
4
clindamycin
phosphate topical
gel
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
9
clindamycin
phosphate topical
lotion
2
clindamycin
phosphate topical
solution
2
clindamycin
phosphate topical
swab
2
clindamycin
phosphate vaginal
cream
2
CLINDESSE
VAGINAL
CREAM,EXTENDE
D RELEASE
4
colistin
(colistimethate na)
injection recon soln
4
DALVANCE
INTRAVENOUS
SOLUTION
5 NEDS
daptomycin
intravenous recon
soln
4
lincomycin injection
solution
4
linezolid in dextrose
5% intravenous
parenteral solution
5 NEDS
linezolid oral
suspension for
reconstitution
2
linezolid oral tablet 2
Drug Name Drug
Tier
Requirements
/Limits
linezolid-0.9%
sodium chloride
intravenous
parenteral solution
5 NEDS
mafenide acetate
topical packet
2
methenamine
hippurate oral tablet
2
metro i.v.
intravenous
piggyback
4
metronidazole in
nacl (iso-os)
intravenous
piggyback
4
metronidazole oral
capsule
2
metronidazole oral
tablet
2
metronidazole
topical cream
2
metronidazole
topical gel
2
metronidazole
topical gel with
pump
2
metronidazole
topical lotion
2
metronidazole
vaginal gel
2
mupirocin calcium
topical cream
2
mupirocin topical
ointment
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
10
neomycin-
bacitracin-poly-hc
ophthalmic (eye)
ointment
2
neomycin-polymyxin
b gu irrigation
solution
4
neomycin-
polymyxin-
gramicidin
ophthalmic (eye)
drops
2
neomycin-
polymyxin-hc
ophthalmic (eye)
drops,suspension
2
neo-polycin hc
ophthalmic (eye)
ointment
2
nitrofurantoin
macrocrystal oral
capsule
2
nitrofurantoin
monohyd/m-cryst
oral capsule
2
nitrofurantoin oral
suspension
2
polymyxin b sulfate
injection recon soln
4
polymyxin b sulf-
trimethoprim
ophthalmic (eye)
drops
2
SYNERCID
INTRAVENOUS
RECON SOLN
5 NEDS
Drug Name Drug
Tier
Requirements
/Limits
tigecycline
intravenous recon
soln
4
tinidazole oral tablet 2
trimethoprim oral
tablet
2
TYGACIL
INTRAVENOUS
RECON SOLN
4
VANCOMYCIN IN
0.9 % SODIUM
CHL
INTRAVENOUS
PIGGYBACK
4
VANCOMYCIN IN
DEXTROSE 5 %
INTRAVENOUS
PIGGYBACK
4
vancomycin
intravenous recon
soln 1,000 mg, 10
gram, 5 gram, 500
mg
4
VANCOMYCIN
INTRAVENOUS
RECON SOLN 750
MG
4
vancomycin oral
capsule
4
vandazole vaginal
gel
2
XIFAXAN ORAL
TABLET 550 MG
4 QL (180 per
90 days)
BETA-LACTAM,
CEPHALOSPORINS
cefaclor oral capsule 2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
11
cefaclor oral tablet
extended release 12
hr
2
cefadroxil oral
capsule
2
cefadroxil oral
suspension for
reconstitution 250
mg/5 ml, 500 mg/5
ml
2
cefadroxil oral tablet 2
cefazolin in dextrose
(iso-os) intravenous
piggyback 1 gram/50
ml
4
cefazolin injection
recon soln
4
cefazolin
intravenous recon
soln
4
cefdinir oral capsule 2
cefdinir oral
suspension for
reconstitution
2
CEFEPIME IN
DEXTROSE 5 %
INTRAVENOUS
PIGGYBACK 1
GRAM/50 ML
4
cefepime in
dextrose,iso-osm
intravenous
piggyback
4
cefepime injection
recon soln 1 gram
4
Drug Name Drug
Tier
Requirements
/Limits
cefixime oral
suspension for
reconstitution
2
cefotaxime injection
recon soln 1 gram, 2
gram, 500 mg
4
CEFOTETAN IN
DEXTROSE, ISO-
OSM
INTRAVENOUS
PIGGYBACK
4
cefotetan injection
recon soln
4
cefoxitin in dextrose,
iso-osm intravenous
piggyback
4
cefoxitin intravenous
recon soln
4
cefpodoxime oral
suspension for
reconstitution
2
cefpodoxime oral
tablet
2
cefprozil oral
suspension for
reconstitution
2
cefprozil oral tablet 2
CEFTAZIDIME IN
D5W
INTRAVENOUS
PIGGYBACK
4
ceftazidime injection
recon soln
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
12
ceftriaxone in
dextrose,iso-os
intravenous
piggyback
4
ceftriaxone injection
recon soln 1 gram,
10 gram, 2 gram,
250 mg, 500 mg
4
CEFTRIAXONE
INJECTION
RECON SOLN 100
GRAM
4
ceftriaxone
intravenous recon
soln
4
cefuroxime axetil
oral tablet
2
cefuroxime sodium
injection recon soln
750 mg
4
cefuroxime sodium
intravenous recon
soln
4
cephalexin oral
capsule 250 mg, 500
mg
1
cephalexin oral
suspension for
reconstitution
1
cephalexin oral
tablet
1
FORTAZ
INJECTION
RECON SOLN 1
GRAM
4
Drug Name Drug
Tier
Requirements
/Limits
FORTAZ
INTRAVENOUS
RECON SOLN
4
SUPRAX ORAL
CAPSULE
4
SUPRAX ORAL
SUSPENSION FOR
RECONSTITUTIO
N 500 MG/5 ML
4
SUPRAX ORAL
TABLET,CHEWAB
LE
4
TAZICEF
INJECTION
RECON SOLN
4
TAZICEF
INTRAVENOUS
RECON SOLN
4
TEFLARO
INTRAVENOUS
RECON SOLN
4
ZERBAXA
INTRAVENOUS
RECON SOLN
4
BETA-LACTAM, OTHER
AZACTAM IN
DEXTROSE (ISO-
OSM)
INTRAVENOUS
PIGGYBACK 2
GRAM/50 ML
4
AZACTAM
INJECTION
RECON SOLN 2
GRAM
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
13
aztreonam injection
recon soln 1 gram
4
imipenem-cilastatin
intravenous recon
soln
4
INVANZ
INJECTION
RECON SOLN
4
INVANZ
INTRAVENOUS
RECON SOLN
4
meropenem
intravenous recon
soln
4
MEROPENEM-
0.9% SODIUM
CHLORIDE
INTRAVENOUS
PIGGYBACK
4
BETA-LACTAM, PENICILLINS
amoxicillin oral
capsule
1
amoxicillin oral
suspension for
reconstitution
1
amoxicillin oral
tablet
1
amoxicillin oral
tablet,chewable 125
mg, 250 mg
1
amoxicillin-pot
clavulanate oral
suspension for
reconstitution
2
Drug Name Drug
Tier
Requirements
/Limits
amoxicillin-pot
clavulanate oral
tablet
2
amoxicillin-pot
clavulanate oral
tablet extended
release 12 hr
2
amoxicillin-pot
clavulanate oral
tablet,chewable
2
ampicillin oral
capsule
2
ampicillin sodium
injection recon soln
4
ampicillin sodium
intravenous recon
soln
4
ampicillin-sulbactam
injection recon soln
4
ampicillin-sulbactam
intravenous recon
soln
4
BICILLIN C-R
INTRAMUSCULA
R SYRINGE
4
BICILLIN L-A
INTRAMUSCULA
R SYRINGE
4
dicloxacillin oral
capsule
2
nafcillin in dextrose
iso-osm intravenous
piggyback 1 gram/50
ml
4
nafcillin injection
recon soln
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
14
nafcillin intravenous
recon soln
4
oxacillin in
dextrose(iso-osm)
intravenous
piggyback
4
oxacillin injection
recon soln 10 gram,
2 gram
4
PENICILLIN G
POT IN
DEXTROSE
INTRAVENOUS
PIGGYBACK
4
penicillin g
potassium injection
recon soln
4
penicillin g procaine
intramuscular
syringe
4
penicillin g sodium
injection recon soln
4
penicillin v
potassium oral recon
soln
1
penicillin v
potassium oral tablet
1
pfizerpen-g injection
recon soln 5 million
unit
4
piperacillin-
tazobactam
intravenous recon
soln 2.25 gram,
3.375 gram, 4.5
gram, 40.5 gram
4
Drug Name Drug
Tier
Requirements
/Limits
ZOSYN IN
DEXTROSE (ISO-
OSM)
INTRAVENOUS
PIGGYBACK
4
ZOSYN
INTRAVENOUS
RECON SOLN 2.25
GRAM, 3.375
GRAM
4
MACROLIDES
AZASITE
OPHTHALMIC
(EYE) DROPS
4
azithromycin
intravenous recon
soln
4
azithromycin oral
packet
2
azithromycin oral
suspension for
reconstitution
2
azithromycin oral
tablet
2
clarithromycin oral
suspension for
reconstitution
2
clarithromycin oral
tablet
2
clarithromycin oral
tablet extended
release 24 hr
2 QL (180 per
90 days)
DIFICID ORAL
TABLET
5 QL (20 per 10
days); NEDS
e.e.s. 400 oral tablet 2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
15
ery pads topical
swab
2
erygel topical gel 2
ERYPED 200
ORAL
SUSPENSION FOR
RECONSTITUTIO
N
4
ERYPED 400
ORAL
SUSPENSION FOR
RECONSTITUTIO
N
4
ery-tab oral
tablet,delayed
release (dr/ec) 250
mg, 333 mg
4
ERY-TAB ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 500 MG
4
erythrocin (as
stearate) oral tablet
250 mg
2
ERYTHROCIN
INTRAVENOUS
RECON SOLN 500
MG
4
erythromycin
ethylsuccinate oral
suspension for
reconstitution
2
erythromycin
ethylsuccinate oral
tablet
2
Drug Name Drug
Tier
Requirements
/Limits
erythromycin
ophthalmic (eye)
ointment
2
erythromycin oral
capsule,delayed
release(dr/ec)
2
erythromycin oral
tablet
2
erythromycin with
ethanol topical gel
2
erythromycin with
ethanol topical
solution
2
erythromycin with
ethanol topical swab
2
QUINOLONES
BAXDELA
INTRAVENOUS
RECON SOLN
5 NEDS
BAXDELA ORAL
TABLET
5 NEDS
CETRAXAL OTIC
(EAR)
DROPPERETTE
3
CILOXAN
OPHTHALMIC
(EYE) OINTMENT
3
ciprofloxacin
(mixture) oral tablet,
er multiphase 24 hr
2 QL (14 per 14
days)
ciprofloxacin hcl
ophthalmic (eye)
drops
2
ciprofloxacin hcl
oral tablet
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
16
ciprofloxacin hcl
otic (ear)
dropperette
2
ciprofloxacin in 5 %
dextrose intravenous
piggyback 200
mg/100 ml
4
ciprofloxacin lactate
intravenous solution
400 mg/40 ml
4
ciprofloxacin oral
suspension,microcap
sule recon
2
floxin otic (ear)
drops
2
gatifloxacin
ophthalmic (eye)
drops
2
levofloxacin in d5w
intravenous
piggyback
4
levofloxacin
intravenous solution
4
levofloxacin
ophthalmic (eye)
drops
2
levofloxacin oral
solution
2
levofloxacin oral
tablet
2
MOXEZA
OPHTHALMIC
(EYE) DROPS,
VISCOUS
4
Drug Name Drug
Tier
Requirements
/Limits
moxifloxacin in nacl
(iso-osm)
intravenous
piggyback
4
moxifloxacin
ophthalmic (eye)
drops
2
moxifloxacin oral
tablet
2
ofloxacin ophthalmic
(eye) drops
2
ofloxacin oral tablet
300 mg, 400 mg
2
ofloxacin otic (ear)
drops
2
VIGAMOX
OPHTHALMIC
(EYE) DROPS
3
SULFONAMIDES
silver sulfadiazine
topical cream
2
ssd topical cream 2
sulfacetamide
sodium (acne)
topical suspension
2
sulfacetamide
sodium ophthalmic
(eye) drops
2
sulfacetamide
sodium ophthalmic
(eye) ointment
2
sulfadiazine oral
tablet
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
17
sulfamethoxazole-
trimethoprim
intravenous solution
4
sulfamethoxazole-
trimethoprim oral
suspension
1
sulfamethoxazole-
trimethoprim oral
tablet
1
sulfatrim oral
suspension
1
TETRACYCLINES
demeclocycline oral
tablet
4
doxy-100
intravenous recon
soln
4
doxycycline hyclate
oral capsule
2
doxycycline hyclate
oral tablet 100 mg,
20 mg
2
doxycycline hyclate
oral tablet 50 mg
4
doxycycline
monohydrate oral
suspension for
reconstitution
2
minocycline oral
capsule
2
minocycline oral
tablet
2
morgidox oral
capsule
2
Drug Name Drug
Tier
Requirements
/Limits
VIBRAMYCIN
ORAL SYRUP
4
Drug Name Drug
Tier
Requirements
/Limits
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
BRIVIACT
INTRAVENOUS
SOLUTION
4 PA
BRIVIACT ORAL
SOLUTION
4 PA; QL (1800
per 90 days)
BRIVIACT ORAL
TABLET
4 PA; QL (180
per 90 days)
KEPPRA
INTRAVENOUS
SOLUTION
4
levetiracetam in nacl
(iso-os) intravenous
piggyback
4
levetiracetam
intravenous solution
4
levetiracetam oral
solution
2
levetiracetam oral
tablet
2
levetiracetam oral
tablet extended
release 24 hr
2
roweepra oral tablet 2
roweepra xr oral
tablet extended
release 24 hr
2
SPRITAM ORAL
TABLET FOR
SUSPENSION
4
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
18
CALCIUM CHANNEL MODIFYING
AGENTS
CELONTIN ORAL
CAPSULE 300 MG
3
ethosuximide oral
capsule
2
ethosuximide oral
solution
2
LYRICA CR ORAL
TABLET
EXTENDED
RELEASE 24 HR
4
LYRICA ORAL
CAPSULE
4
LYRICA ORAL
SOLUTION
4
zonisamide oral
capsule
2
GAMMA-AMINOBUTYRIC ACID
(GABA) AUGMENTING AGENTS
DIASTAT
ACUDIAL
RECTAL KIT
4
DIASTAT RECTAL
KIT
4
diazepam rectal kit 4
divalproex oral
capsule, delayed rel
sprinkle
2
divalproex oral
tablet extended
release 24 hr
2
divalproex oral
tablet,delayed
release (dr/ec)
2
Drug Name Drug
Tier
Requirements
/Limits
gabapentin oral
capsule
2
gabapentin oral
solution
2
gabapentin oral
tablet 600 mg, 800
mg
2
GABITRIL ORAL
TABLET 12 MG, 16
MG
3
GRALISE 30-DAY
STARTER PACK
ORAL TABLET
EXTENDED
RELEASE 24 HR
4 PA
GRALISE ORAL
TABLET
EXTENDED
RELEASE 24 HR
4 PA
ONFI ORAL
SUSPENSION
4 QL (1440 per
90 days)
ONFI ORAL
TABLET 10 MG, 20
MG
4 QL (180 per
90 days)
phenobarbital oral
elixir
2
phenobarbital oral
tablet
2
primidone oral
tablet
2
SABRIL ORAL
POWDER IN
PACKET
5 NEDS
SABRIL ORAL
TABLET
5 NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
19
tiagabine oral tablet 4
valproate sodium
intravenous solution
4
valproic acid (as
sodium salt) oral
solution
2
valproic acid oral
capsule
2
vigabatrin oral
powder in packet
5 NEDS
GLUTAMATE REDUCING AGENTS
felbamate oral
suspension
4
felbamate oral tablet 4
FYCOMPA ORAL
SUSPENSION
4
FYCOMPA ORAL
TABLET 2 MG, 4
MG, 6 MG, 8 MG
4
LAMICTAL
STARTER (BLUE)
KIT ORAL
TABLETS,DOSE
PACK
3
LAMICTAL
STARTER
(GREEN) KIT
ORAL
TABLETS,DOSE
PACK
3
LAMICTAL
STARTER
(ORANGE) KIT
ORAL
TABLETS,DOSE
PACK
3
Drug Name Drug
Tier
Requirements
/Limits
lamotrigine oral
tablet
4
lamotrigine oral
tablet extended
release 24hr
4
lamotrigine oral
tablet, chewable
dispersible
4
lamotrigine oral
tablet,disintegrating
4
lamotrigine oral
tablets,dose pack
2
topiramate oral
capsule, sprinkle
2
topiramate oral
tablet
2
SODIUM CHANNEL AGENTS
APTIOM ORAL
TABLET
4
BANZEL ORAL
SUSPENSION
3
BANZEL ORAL
TABLET
3
carbamazepine oral
capsule, er
multiphase 12 hr
2
carbamazepine oral
suspension 100 mg/5
ml
2
carbamazepine oral
tablet
2
carbamazepine oral
tablet extended
release 12 hr
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
20
carbamazepine oral
tablet,chewable
2
CEREBYX
INJECTION
SOLUTION 500
MG PE/10 ML
4
DILANTIN 30 MG
ORAL CAPSULE
3
epitol oral tablet 2
fosphenytoin
injection solution
100 mg pe/2 ml
4
fosphenytoin
injection solution
500 mg pe/10 ml
2
oxcarbazepine oral
suspension
2
oxcarbazepine oral
tablet
2
OXTELLAR XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
4 ST
PEGANONE ORAL
TABLET
3
phenytoin oral
suspension
2
phenytoin oral
tablet,chewable
2
phenytoin sodium
extended oral
capsule
2
phenytoin sodium
intravenous solution
4
Drug Name Drug
Tier
Requirements
/Limits
phenytoin sodium
intravenous syringe
4
VIMPAT
INTRAVENOUS
SOLUTION
4
VIMPAT ORAL
SOLUTION
3
VIMPAT ORAL
TABLET
3
Drug Name Drug
Tier
Requirements
/Limits
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid oral tablet 2
CHOLINESTERASE INHIBITORS
donepezil oral tablet 4 QL (90 per 90
days)
donepezil oral
tablet,disintegrating
4 QL (90 per 90
days)
galantamine oral
capsule,ext rel.
pellets 24 hr
2 QL (90 per 90
days)
galantamine oral
solution
2
galantamine oral
tablet
2
rivastigmine tartrate
oral capsule
2
rivastigmine
transdermal patch
24 hour
4 QL (90 per 90
days)
N-METHYL-D-ASPARTATE (NMDA)
RECEPTOR ANTAGONIST
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
21
memantine oral
capsule,sprinkle,er
24hr
4 QL (90 per 90
days)
memantine oral
solution
2 QL (900 per
90 days)
memantine oral
tablet
2 QL (180 per
90 days)
MEMANTINE
ORAL
TABLETS,DOSE
PACK
3 QL (147 per
84 days)
NAMENDA
TITRATION PAK
ORAL
TABLETS,DOSE
PACK
3 QL (147 per
84 days)
NAMENDA XR
ORAL
CAP,SPRINKLE,ER
24HR DOSE PACK
4 QL (84 per 84
days)
NAMENDA XR
ORAL
CAPSULE,SPRINK
LE,ER 24HR
4 QL (90 per 90
days)
Drug Name Drug
Tier
Requirements
/Limits
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
bupropion hcl oral
tablet
2
bupropion hcl oral
tablet extended
release 12 hr
2
bupropion hcl oral
tablet extended
release 24 hr
2
mirtazapine oral
tablet
1
mirtazapine oral
tablet,disintegrating
1
olanzapine-
fluoxetine oral
capsule
4
MONOAMINE OXIDASE
INHIBITORS
EMSAM
TRANSDERMAL
PATCH 24 HOUR
4
MARPLAN ORAL
TABLET
4
phenelzine oral
tablet
2
tranylcypromine
oral tablet
4
SELECTIVE SEROTONIN
REUPTAKE
INHIBITORS/SEROTONIN AND
NOREPINEPHRINE REUPTAKE
INHIBITORS
BRISDELLE ORAL
CAPSULE
3
citalopram oral
solution
2
citalopram oral
tablet
2
DESVENLAFAXIN
E ORAL TABLET
EXTENDED
RELEASE 24 HR
4 ST
DESVENLAFAXIN
E ORAL TABLET
EXTENDED
RELEASE 24HR
4 ST
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
22
desvenlafaxine
succinate oral tablet
extended release 24
hr
4
duloxetine oral
capsule,delayed
release(dr/ec)
2
escitalopram oxalate
oral solution
2
escitalopram oxalate
oral tablet
2
FETZIMA ORAL
CAPSULE,EXT
REL 24HR DOSE
PACK
4 ST
FETZIMA ORAL
CAPSULE,EXTEN
DED RELEASE 24
HR
4 ST
fluoxetine oral
capsule
4
fluoxetine oral
capsule,delayed
release(dr/ec)
4
fluoxetine oral
solution
4
fluoxetine oral tablet
10 mg, 20 mg
4
FLUOXETINE
ORAL TABLET 60
MG
4
fluvoxamine oral
capsule,extended
release 24hr
2
fluvoxamine oral
tablet
2
Drug Name Drug
Tier
Requirements
/Limits
maprotiline oral tablet
2
nefazodone oral tablet
2
paroxetine hcl oral tablet
2
paroxetine hcl oral
tablet extended
release 24 hr
2
paroxetine
mesylate(menop.sym
) oral capsule
2
PAXIL ORAL SUSPENSION
4
PEXEVA ORAL TABLET
4
sertraline oral
concentrate
2
sertraline oral tablet 2
trazodone oral tablet 1
TRINTELLIX
ORAL TABLET 4 ST
venlafaxine oral
capsule,extended
release 24hr
2
venlafaxine oral tablet
2
VIIBRYD ORAL
TABLET 4 ST
VIIBRYD ORAL
TABLETS,DOSE
PACK 10 MG (7)-
20 MG (23)
4 ST
TRICYCLICS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
23
amitriptyline oral
tablet
2
amoxapine oral
tablet
2
clomipramine oral
capsule
4
desipramine oral
tablet
4
doxepin oral capsule 2
doxepin oral
concentrate
2
imipramine hcl oral
tablet
2
imipramine pamoate
oral capsule
2
nortriptyline oral
capsule
2
nortriptyline oral
solution
2
protriptyline oral
tablet
2
trimipramine oral
capsule
2
Drug Name Drug
Tier
Requirements
/Limits
ANTIEMETICS
ANTIEMETICS, OTHER
compro rectal
suppository
2
droperidol injection
solution
2
meclizine oral tablet
12.5 mg, 25 mg
2
metoclopramide hcl
injection syringe
4
phenadoz rectal
suppository
2
phenergan rectal
suppository
2
prochlorperazine
rectal suppository
2
promethazine oral
syrup
2
promethazine oral
tablet
2
promethazine rectal
suppository
2
promethegan rectal
suppository 25 mg,
50 mg
2
scopolamine base
transdermal patch 3
day
2
TRANSDERM-
SCOP
TRANSDERMAL
PATCH 3 DAY
3
EMETOGENIC THERAPY
ADJUNCTS
ANZEMET ORAL
TABLET
4 B/D PA
aprepitant oral
capsule
2 B/D PA
aprepitant oral
capsule,dose pack
2 B/D PA
dronabinol oral
capsule
4 B/D PA
EMEND ORAL
CAPSULE 125 MG,
40 MG
3 B/D PA
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
24
EMEND ORAL
SUSPENSION FOR
RECONSTITUTIO
N
3 B/D PA
granisetron hcl oral
tablet
2 B/D PA
ondansetron hcl (pf)
injection solution
4
ondansetron hcl (pf)
injection syringe
4
ondansetron hcl
intravenous solution
4
ondansetron hcl oral
solution
4 B/D PA
ondansetron hcl oral
tablet
2 B/D PA
ondansetron oral
tablet,disintegrating
2 B/D PA
SANCUSO
TRANSDERMAL
PATCH WEEKLY
5 QL (4 per 28
days); NEDS
Drug Name Drug
Tier
Requirements
/Limits
ANTIFUNGALS
ANTIFUNGALS
ABELCET
INTRAVENOUS
SUSPENSION
5 B/D PA;
NEDS
AMBISOME
INTRAVENOUS
SUSPENSION FOR
RECONSTITUTIO
N
5 B/D PA;
NEDS
amphotericin b
injection recon soln
4 B/D PA
CANCIDAS
INTRAVENOUS
RECON SOLN
4 B/D PA
caspofungin
intravenous recon
soln 50 mg
4 B/D PA
CASPOFUNGIN
INTRAVENOUS
RECON SOLN 70
MG
4 B/D PA
ciclodan topical
cream
2
ciclodan topical
solution
2
ciclopirox topical
cream
2
ciclopirox topical
gel
2
ciclopirox topical
shampoo
2
ciclopirox topical
solution
2
ciclopirox topical
suspension
2
clotrimazole mucous
membrane troche
2
clotrimazole topical
cream
2
clotrimazole topical
solution
2
clotrimazole-
betamethasone
topical cream
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
25
clotrimazole-
betamethasone topical lotion
2
econazole topical
cream 4
ERAXIS(WATER
DILUENT)
INTRAVENOUS
RECON SOLN
4
EXELDERM
TOPICAL CREAM
4
EXELDERM
TOPICAL
SOLUTION
4
fluconazole in
dextrose(iso-o) intravenous piggyback
4
fluconazole in nacl
(iso-osm) intravenous piggyback 200
mg/100 ml, 400
mg/200 ml
4
fluconazole oral
suspension for
reconstitution
2
fluconazole oral
tablet
2
flucytosine oral
capsule
2
griseofulvin
microsize oral
suspension
2
griseofulvin microsize oral tablet
2
Drug Name Drug
Tier
Requirements
/Limits
griseofulvin ultramicrosize oral tablet
2
itraconazole oral capsule
4
ketoconazole oral
tablet
2
ketoconazole topical
cream
2
ketoconazole topical
foam
2
ketoconazole topical
shampoo
2
MENTAX TOPICAL CREAM
4
miconazole-3 vaginal suppository
2
naftifine topical cream
2
NAFTIN TOPICAL
GEL
4
NATACYN
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
3
NOXAFIL ORAL
SUSPENSION
5 NEDS
NOXAFIL ORAL
TABLET,DELAYE
D RELEASE
(DR/EC)
5 QL (93 per 31
days); NEDS
nyamyc topical powder
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
26
nystatin oral
suspension
2
nystatin oral tablet 2
nystatin topical
cream
2
nystatin topical
ointment
2
nystatin topical
powder
2
nystatin-
triamcinolone
topical cream
2
nystatin-
triamcinolone
topical ointment
2
nystop topical
powder
2
oxiconazole topical
cream
2
OXISTAT
TOPICAL LOTION
4
SPORANOX ORAL
SOLUTION
3
terconazole vaginal
cream
2
terconazole vaginal
suppository
2
voriconazole
intravenous solution
4
voriconazole oral
suspension for
reconstitution
4
voriconazole oral
tablet
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Name Drug
Tier
Requirements
/Limits
ANTIGOUT AGENTS
ANTIGOUT AGENTS
allopurinol oral
tablet
1
COLCHICINE
ORAL TABLET
4 QL (360 per
90 days)
DUZALLO ORAL
TABLET 200-300
MG
4
probenecid oral
tablet
2
probenecid-
colchicine oral
tablet
2
ULORIC ORAL
TABLET
3 ST; QL (90 per
90 days)
ZURAMPIC ORAL
TABLET
4 PA
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
dihydroergotamine
nasal spray,non-
aerosol
2 QL (24 per 90
days)
migergot rectal
suppository
4
SEROTONIN (5-HT) 1B/1D
RECEPTOR AGONISTS
almotriptan malate
oral tablet
4 ST; QL (36 per
90 days)
eletriptan oral tablet 4 ST; QL (18 per
90 days)
frovatriptan oral
tablet
4 ST; QL (36 per
90 days)
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
27
naratriptan oral
tablet
2 QL (27 per 90
days)
RELPAX ORAL
TABLET
4 ST; QL (18 per
90 days)
rizatriptan oral
tablet
2 ST; QL (36 per
90 days)
rizatriptan oral
tablet,disintegrating
2 ST; QL (36 per
90 days)
sumatriptan nasal
spray,non-aerosol
4 QL (36 per 90
days)
sumatriptan
succinate oral tablet
2
sumatriptan
succinate
subcutaneous
cartridge
4
sumatriptan
succinate
subcutaneous pen
injector
4
sumatriptan
succinate
subcutaneous
solution
4
sumatriptan-
naproxen oral tablet
4 QL (30 per 90
days)
TREXIMET ORAL
TABLET 85-500
MG
4 QL (30 per 90
days)
zolmitriptan oral
tablet
2 QL (18 per 90
days)
zolmitriptan oral
tablet,disintegrating
2 QL (18 per 90
days)
Drug Name Drug
Tier
Requirements
/Limits
ZOMIG NASAL
SPRAY,NON-
AEROSOL
4 ST; QL (36 per
90 days)
Drug Name Drug
Tier
Requirements
/Limits
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
guanidine oral tablet 2
MESTINON ORAL
SYRUP
3
pyridostigmine
bromide oral tablet
2
pyridostigmine
bromide oral tablet
extended release
2
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone oral tablet 2
rifabutin oral
capsule
4
ANTITUBERCULARS
CAPASTAT
INJECTION
RECON SOLN
4
ethambutol oral
tablet
2
isoniazid injection
solution
4
isoniazid oral
solution
2
isoniazid oral tablet 2
PASER ORAL
GRANULES DR
FOR SUSP IN
PACKET
4
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
28
PRIFTIN ORAL
TABLET
4
pyrazinamide oral
tablet
2
rifampin intravenous
recon soln
4
rifampin oral
capsule
2
RIFATER ORAL
TABLET
4
SIRTURO ORAL
TABLET
5 PA; NEDS
TRECATOR ORAL
TABLET
4
Drug Name Drug
Tier
Requirements
/Limits
ANTINEOPLASTICS
ALKYLATING AGENTS
BENDEKA
INTRAVENOUS
SOLUTION
5 PA; NEDS
BICNU
INTRAVENOUS
RECON SOLN
4
busulfan intravenous
solution
4
cyclophosphamide
intravenous recon
soln
2 B/D PA
CYCLOPHOSPHA
MIDE ORAL
CAPSULE
4 B/D PA
dacarbazine
intravenous recon
soln 100 mg
2
dacarbazine
intravenous recon
soln 200 mg
4
EVOMELA
INTRAVENOUS
RECON SOLN
5 PA; NEDS
GLEOSTINE ORAL
CAPSULE
3
HEXALEN ORAL
CAPSULE
5 NEDS
ifosfamide
intravenous recon
soln 1 gram
4 B/D PA
ifosfamide
intravenous recon
soln 3 gram
2 B/D PA
ifosfamide
intravenous solution
2 B/D PA
LEUKERAN ORAL
TABLET
3
MATULANE
ORAL CAPSULE
5 NEDS
melphalan hcl
intravenous recon
soln
4
melphalan oral
tablet
4 B/D PA
MUSTARGEN
INJECTION
RECON SOLN
4
thiotepa injection
recon soln
4
TREANDA
INTRAVENOUS
RECON SOLN
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
29
VALCHLOR
TOPICAL GEL
5 NEDS
YONDELIS
INTRAVENOUS
RECON SOLN
5 PA; NEDS
ZANOSAR
INTRAVENOUS
RECON SOLN
4
ANTIANDROGENS
bicalutamide oral
tablet
2
ERLEADA ORAL
TABLET
5 PA; NEDS
flutamide oral
capsule
2
nilutamide oral
tablet
2
XTANDI ORAL
CAPSULE
5 PA; NEDS
ZYTIGA ORAL
TABLET
5 PA; NEDS
ANTIANGIOGENIC AGENTS
POMALYST ORAL
CAPSULE
5 PA; QL (31
per 31 days);
NEDS
REVLIMID ORAL
CAPSULE
5 PA; LA;
NEDS
THALOMID ORAL
CAPSULE
5 PA; NEDS
ANTIESTROGENS/MODIFIERS
EMCYT ORAL
CAPSULE 3
FARESTON ORAL TABLET
3
Drug Name Drug
Tier
Requirements
/Limits
FASLODEX
INTRAMUSCULA
R SYRINGE
5 NEDS
SOLTAMOX
ORAL SOLUTION
4
tamoxifen oral tablet 2
ANTIMETABOLITES
adrucil intravenous
solution 2.5 gram/50
ml, 5 gram/100 ml
2 B/D PA
adrucil intravenous
solution 500 mg/10
ml
4 B/D PA
ALIMTA
INTRAVENOUS
RECON SOLN
4
ARRANON
INTRAVENOUS
SOLUTION
4
cladribine
intravenous solution
4 B/D PA
clofarabine
intravenous solution
4
CLOLAR
INTRAVENOUS
SOLUTION
4
cytarabine (pf)
injection solution
100 mg/5 ml (20
mg/ml)
2 B/D PA
cytarabine (pf)
injection solution 2
gram/20 ml (100
mg/ml), 20 mg/ml
4 B/D PA
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
30
cytarabine injection
solution
4 B/D PA
DROXIA ORAL
CAPSULE
4
ELITEK
INTRAVENOUS
RECON SOLN
5 NEDS
floxuridine injection
recon soln
2
fluorouracil
intravenous solution
2.5 gram/50 ml, 5
gram/100 ml
4 B/D PA
fluorouracil
intravenous solution
500 mg/10 ml
2 B/D PA
gemcitabine
intravenous recon
soln
5 NEDS
gemcitabine
intravenous solution
1 gram/26.3 ml (38
mg/ml), 2 gram/52.6
ml (38 mg/ml), 200
mg/5.26 ml (38
mg/ml)
5 NEDS
hydroxyurea oral
capsule
2
mercaptopurine oral
tablet
2
NIPENT
INTRAVENOUS
RECON SOLN
4
PURIXAN ORAL
SUSPENSION
5 NEDS
Drug Name Drug
Tier
Requirements
/Limits
TABLOID ORAL
TABLET
3
ANTINEOPLASTICS, OTHER
ABRAXANE
INTRAVENOUS
SUSPENSION FOR
RECONSTITUTIO
N
4
adriamycin
intravenous solution
10 mg/5 ml, 2 mg/ml,
50 mg/25 ml
2 B/D PA
adriamycin
intravenous solution
20 mg/10 ml
4 B/D PA
amifostine
crystalline
intravenous recon
soln
5 NEDS
azacitidine injection
recon soln
5 NEDS
bleomycin injection
recon soln 15 unit
2 B/D PA
bleomycin injection
recon soln 30 unit
4 B/D PA
BORTEZOMIB
INTRAVENOUS
RECON SOLN
4
carboplatin
intravenous solution
4
cisplatin intravenous
solution
4
dactinomycin
intravenous recon
soln
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic
5-Specialty Drugs
3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
31
daunorubicin
intravenous solution
4
decitabine
intravenous recon
soln
5 NEDS
dexrazoxane hcl
intravenous recon
soln 250 mg
4
dexrazoxane hcl
intravenous recon
soln 500 mg
2
docetaxel
intravenous solution
160 mg/16 ml (10
mg/ml), 160 mg/8 ml
(20 mg/ml), 20 mg/2
ml (10 mg/ml), 20
mg/ml (1 ml), 80
mg/4 ml (20 mg/ml),
80 mg/8 ml (10
mg/ml)
5 NEDS
DOCETAXEL
INTRAVENOUS
SOLUTION 20
MG/ML
5 NEDS
doxorubicin
intravenous recon
soln
2 B/D PA
doxorubicin
intravenous solution
10 mg/5 ml, 2 mg/ml,
20 mg/10 ml
2 B/D PA
doxorubicin
intravenous solution
50 mg/25 ml
4 B/D PA
Drug Name Drug
Tier
Requirements
/Limits
doxorubicin, peg-
liposomal
intravenous
suspension
4 B/D PA
ELLENCE
INTRAVENOUS
SOLUTION
4
epirubicin
intravenous solution
200 mg/100 ml
4
epirubicin
intravenous solution
50 mg/25 ml
2
ERWINAZE
INJECTION
RECON SOLN
5 NEDS
ETHYOL
INTRAVENOUS
RECON SOLN
5 NEDS
fludarabine
intravenous recon
soln
4
fludarabine
intravenous solution
2
HALAVEN
INTRAVENOUS
SOLUTION
5 NEDS
idarubicin
intravenous solution
4
irinotecan
intravenous solution
100 mg/5 ml
4
irinotecan
intravenous solution
40 mg/2 ml, 500
mg/25 ml
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
32
ISTODAX
INTRAVENOUS
RECON SOLN
5 B/D PA;
NEDS
IXEMPRA
INTRAVENOUS
RECON SOLN
5 NEDS
KISQALI FEMARA
CO-PACK ORAL
TABLET
5 PA; NEDS
KISQALI ORAL
TABLET
5 PA; NEDS
KYPROLIS
INTRAVENOUS
RECON SOLN
5 PA; NEDS
leucovorin calcium
injection recon soln
4
leucovorin calcium
oral tablet
2
LONSURF ORAL
TABLET
5 PA; NEDS
mitomycin
intravenous recon
soln 20 mg, 5 mg
4
mitomycin
intravenous recon
soln 40 mg
5 NEDS
mitoxantrone
intravenous
concentrate
4
NINLARO ORAL
CAPSULE
5 PA; NEDS
ONCASPAR
INJECTION
SOLUTION
5 NEDS
Drug Name Drug
Tier
Requirements
/Limits
oxaliplatin
intravenous recon
soln
5 NEDS
oxaliplatin
intravenous solution
100 mg/20 ml
4
oxaliplatin
intravenous solution
50 mg/10 ml (5
mg/ml)
5 NEDS
paclitaxel
intravenous
concentrate
4
PROLEUKIN
INTRAVENOUS
RECON SOLN
5 NEDS
ROMIDEPSIN
INTRAVENOUS
RECON SOLN
5 B/D PA;
NEDS
SUPPRELIN LA
IMPLANT KIT
5 NEDS
SYNRIBO
SUBCUTANEOUS
RECON SOLN
5 NEDS
TEMODAR
INTRAVENOUS
RECON SOLN
4
TOTECT
INTRAVENOUS
RECON SOLN 500
MG
3
TRISENOX
INTRAVENOUS
SOLUTION 2
MG/ML
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
33
VALSTAR
INTRAVESICAL
SOLUTION
5 NEDS
VANTAS
IMPLANT KIT
4
VELCADE
INJECTION
RECON SOLN
4
vinblastine
intravenous solution
4 B/D PA
vincasar pfs
intravenous solution
1 mg/ml
4 B/D PA
vincasar pfs
intravenous solution
2 mg/2 ml
2 B/D PA
vincristine
intravenous solution
1 mg/ml
4 B/D PA
vincristine
intravenous solution
2 mg/2 ml
2 B/D PA
vinorelbine
intravenous solution
10 mg/ml
2
vinorelbine
intravenous solution
50 mg/5 ml
4
VYXEOS
INTRAVENOUS
RECON SOLN
5 NEDS
ZINECARD (AS
HCL)
INTRAVENOUS
RECON SOLN 250
MG
4
Drug Name Drug
Tier
Requirements
/Limits
ZOLINZA ORAL
CAPSULE
5 PA; NEDS
AROMATASE INHIBITORS, 3RD
GENERATION
anastrozole oral
tablet
2
exemestane oral
tablet
2
letrozole oral tablet 2
ENZYME INHIBITORS
ETOPOPHOS
INTRAVENOUS
RECON SOLN
4
etoposide
intravenous solution
2
toposar intravenous
solution
2
topotecan
intravenous recon
soln
4
topotecan
intravenous solution
2
MOLECULAR TARGET
INHIBITORS
AFINITOR
DISPERZ ORAL
TABLET FOR
SUSPENSION
5 PA; NEDS
AFINITOR ORAL
TABLET
5 PA; NEDS
ALECENSA ORAL
CAPSULE
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
34
ALIQOPA
INTRAVENOUS
RECON SOLN
5 PA; NEDS
ALUNBRIG ORAL
TABLET
5 PA; NEDS
ALUNBRIG ORAL
TABLETS,DOSE
PACK
5 PA; NEDS
BELEODAQ
INTRAVENOUS
RECON SOLN
5 PA; NEDS
BOSULIF ORAL
TABLET
5 PA; NEDS
CABOMETYX
ORAL TABLET
5 PA; NEDS
CALQUENCE
ORAL CAPSULE
5 PA; NEDS
CAMPTOSAR
INTRAVENOUS
SOLUTION 300
MG/15 ML
4
CAPRELSA ORAL
TABLET
5 NEDS
COMETRIQ ORAL
CAPSULE
5 PA; NEDS
COTELLIC ORAL
TABLET
5 PA; LA;
NEDS
ERIVEDGE ORAL
CAPSULE
5 PA; NEDS
FARYDAK ORAL
CAPSULE
5 PA; NEDS
GILOTRIF ORAL
TABLET
5 PA; QL (31
per 31 days);
NEDS
Drug Name Drug
Tier
Requirements
/Limits
IBRANCE ORAL
CAPSULE
5 PA; NEDS
ICLUSIG ORAL
TABLET
5 PA; NEDS
IDHIFA ORAL
TABLET
5 PA; NEDS
imatinib oral tablet 5 NEDS
IMBRUVICA
ORAL CAPSULE
5 PA; NEDS
IMBRUVICA
ORAL TABLET
5 PA; NEDS
INLYTA ORAL
TABLET
5 PA; NEDS
IRESSA ORAL
TABLET
5 NEDS
JAKAFI ORAL
TABLET
5 PA; NEDS
LENVIMA ORAL
CAPSULE
5 PA; NEDS
LYNPARZA ORAL
CAPSULE
5 PA; NEDS
LYNPARZA ORAL
TABLET
5 PA; NEDS
MEKINIST ORAL
TABLET
5 PA; NEDS
NERLYNX ORAL
TABLET
5 PA; NEDS
NEXAVAR ORAL
TABLET
5 PA; NEDS
ODOMZO ORAL
CAPSULE
5 PA; LA;
NEDS
RUBRACA ORAL
TABLET
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
35
RYDAPT ORAL
CAPSULE
5 PA; NEDS
SPRYCEL ORAL
TABLET
5 PA; NEDS
STIVARGA ORAL
TABLET
5 NEDS
SUTENT ORAL
CAPSULE
5 PA; NEDS
TAFINLAR ORAL
CAPSULE
5 PA; NEDS
TAGRISSO ORAL
TABLET
5 PA; LA;
NEDS
TARCEVA ORAL
TABLET
5 PA; NEDS
TASIGNA ORAL
CAPSULE
5 PA; NEDS
TYKERB ORAL
TABLET
5 NEDS
VENCLEXTA
ORAL TABLET 10
MG, 50 MG
4 PA
VENCLEXTA
ORAL TABLET
100 MG
5 PA; NEDS
VENCLEXTA
STARTING PACK
ORAL
TABLETS,DOSE
PACK
5 PA; NEDS
VERZENIO ORAL
TABLET
5 PA; NEDS
VOTRIENT ORAL
TABLET
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
XALKORI ORAL
CAPSULE
5 PA; QL (62
per 31 days);
NEDS
ZEJULA ORAL
CAPSULE
5 PA; NEDS
ZELBORAF ORAL
TABLET
5 PA; QL (248
per 31 days);
NEDS
ZYDELIG ORAL
TABLET
5 PA; NEDS
ZYKADIA ORAL
CAPSULE
5 PA; NEDS
MONOCLONAL
ANTIBODIES/ANTIBODY-DRUG
CONJUGATE
ARZERRA
INTRAVENOUS
SOLUTION
3 PA
AVASTIN
INTRAVENOUS
SOLUTION
5 NEDS
BAVENCIO
INTRAVENOUS
SOLUTION
5 PA; NEDS
BESPONSA
INTRAVENOUS
RECON SOLN
5 PA; NEDS
BLINCYTO
INTRAVENOUS
KIT
5 B/D PA;
NEDS
CYRAMZA
INTRAVENOUS
SOLUTION
5 PA; NEDS
DARZALEX
INTRAVENOUS
SOLUTION
5 PA; LA;
NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
36
EMPLICITI
INTRAVENOUS
RECON SOLN
5 PA; NEDS
ERBITUX
INTRAVENOUS
SOLUTION 100
MG/50 ML
4
ERBITUX
INTRAVENOUS
SOLUTION 200
MG/100 ML
3
GAZYVA
INTRAVENOUS
SOLUTION
5 PA; NEDS
HERCEPTIN
INTRAVENOUS
RECON SOLN
5 B/D PA;
NEDS
IMFINZI
INTRAVENOUS
SOLUTION
5 PA; NEDS
JEVTANA
INTRAVENOUS
SOLUTION
5 PA; NEDS
KADCYLA
INTRAVENOUS
RECON SOLN
5 B/D PA;
NEDS
KEYTRUDA
INTRAVENOUS
SOLUTION
5 NEDS
LARTRUVO
INTRAVENOUS
SOLUTION
5 PA; NEDS
MYLOTARG
INTRAVENOUS
RECON SOLN
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
OPDIVO
INTRAVENOUS
SOLUTION
5 NEDS
PERJETA
INTRAVENOUS
SOLUTION
5 NEDS
RITUXAN
HYCELA
SUBCUTANEOUS
SOLUTION
5 PA; NEDS
RITUXAN
INTRAVENOUS
CONCENTRATE
5 PA; NEDS
TECENTRIQ
INTRAVENOUS
SOLUTION
5 PA; NEDS
VECTIBIX
INTRAVENOUS
SOLUTION
5 NEDS
YERVOY
INTRAVENOUS
SOLUTION
5 PA; NEDS
ZALTRAP
INTRAVENOUS
SOLUTION
5 NEDS
RETINOIDS
bexarotene oral
capsule
5 PA; NEDS
PANRETIN
TOPICAL GEL
3
TARGRETIN
TOPICAL GEL
5 PA; NEDS
tretinoin
(chemotherapy) oral
capsule
5 NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
37
TREATMENT ADJUNCTS
allopurinol sodium
intravenous recon
soln
4
aloprim intravenous
recon soln
4
FUSILEV
INTRAVENOUS
RECON SOLN
5 NEDS
levoleucovorin
intravenous recon
soln 50 mg
2
levoleucovorin
intravenous solution
4
mesna intravenous
solution
4
MESNEX ORAL
TABLET
4
SYLATRON
SUBCUTANEOUS
KIT
5 NEDS
Drug Name Drug
Tier
Requirements
/Limits
ANTIPARASITICS
ANTHELMINTICS
ALBENZA ORAL
TABLET
4
BILTRICIDE
ORAL TABLET
3
ivermectin oral
tablet
2
praziquantel oral
tablet
2
ANTIHELMINTICS
SKLICE TOPICAL
LOTION 4
ANTIPROTOZOALS
ALINIA ORAL
SUSPENSION FOR
RECONSTITUTIO
N
3
ALINIA ORAL
TABLET
3
atovaquone oral
suspension
5 NEDS
atovaquone-
proguanil oral tablet
2
chloroquine
phosphate oral
tablet
2
COARTEM ORAL
TABLET
3
DARAPRIM ORAL
TABLET
3
hydroxychloroquine
oral tablet
1
mefloquine oral
tablet
2
NEBUPENT
INHALATION
RECON SOLN
4 B/D PA
PENTAM
INJECTION
RECON SOLN
4
PRIMAQUINE
ORAL TABLET
3
quinine sulfate oral
capsule
2
PEDICULICIDES/SCABICIDES
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
38
EURAX TOPICAL
LOTION
3
lindane topical
shampoo
2
malathion topical
lotion
4
permethrin topical
cream
2
Drug Name Drug
Tier
Requirements
/Limits
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine injection
solution
4
benztropine oral
tablet
2
trihexyphenidyl oral
elixir
2
trihexyphenidyl oral
tablet
2
ANTIPARKINSON AGENTS, OTHER
entacapone oral
tablet
2
tolcapone oral tablet 2
DOPAMINE AGONISTS
APOKYN
SUBCUTANEOUS
CARTRIDGE
5 NEDS
bromocriptine oral
capsule
2
bromocriptine oral
tablet
2
NEUPRO
TRANSDERMAL
PATCH 24 HOUR
4
pramipexole oral
tablet
2
pramipexole oral
tablet extended
release 24 hr
4
ropinirole oral tablet 2
ropinirole oral tablet
extended release 24
hr
2
DOPAMINE PRECURSORS/ L-
AMINO ACID DECARBOXYLASE
INHIBITORS
carbidopa oral
tablet
2
carbidopa-levodopa
oral tablet
2
carbidopa-levodopa
oral tablet extended
release
2
carbidopa-levodopa
oral
tablet,disintegrating
2
carbidopa-levodopa-
entacapone oral
tablet
2
DUOPA J-TUBE
INTESTINAL
PUMP
SUSPENSION
4 PA
MONOAMINE OXIDASE B (MAO-B)
INHIBITORS
rasagiline oral tablet 2
selegiline hcl oral
capsule
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
39
selegiline hcl oral
tablet
2
ZELAPAR ORAL
TABLET,DISINTE
GRATING
4
Drug Name Drug
Tier
Requirements
/Limits
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
ADASUVE
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED
5 NEDS
chlorpromazine
injection solution
4
chlorpromazine oral
tablet
4
fluphenazine
decanoate injection
solution
4
fluphenazine hcl
injection solution
4
fluphenazine hcl oral
concentrate
2
fluphenazine hcl oral
elixir
2
fluphenazine hcl oral
tablet
2
haloperidol
decanoate
intramuscular
solution
4
haloperidol lactate
injection solution
4
haloperidol lactate
intramuscular
syringe
4
haloperidol lactate
oral concentrate
2
haloperidol oral
tablet
2
loxapine succinate
oral capsule
2
perphenazine oral
tablet
2
pimozide oral tablet 2
prochlorperazine
edisylate injection
solution 10 mg/2 ml
(5 mg/ml)
4
prochlorperazine
maleate oral tablet
2
thioridazine oral
tablet
2
thiothixene oral
capsule
2
trifluoperazine oral
tablet
2
2ND GENERATION/ATYPICAL
ABILIFY
MAINTENA
INTRAMUSCULA
R
SUSPENSION,EXT
ENDED REL
RECON
5 ST; NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
40
ABILIFY
MAINTENA
INTRAMUSCULA
R
SUSPENSION,EXT
ENDED REL
SYRING
5 ST; NEDS
aripiprazole oral
solution
4
aripiprazole oral
tablet
4
aripiprazole oral
tablet,disintegrating
2
ARISTADA
INTRAMUSCULA
R
SUSPENSION,EXT
ENDED REL
SYRING
5 ST; NEDS
FANAPT ORAL
TABLET
4
FANAPT ORAL
TABLETS,DOSE
PACK
4
GEODON
INTRAMUSCULA
R RECON SOLN
4
INVEGA
SUSTENNA
INTRAMUSCULA
R SYRINGE 117
MG/0.75 ML, 156
MG/ML, 234
MG/1.5 ML, 78
MG/0.5 ML
5 ST; NEDS
Drug Name Drug
Tier
Requirements
/Limits
INVEGA
SUSTENNA
INTRAMUSCULA
R SYRINGE 39
MG/0.25 ML
4 ST
INVEGA TRINZA
INTRAMUSCULA
R SYRINGE
5 PA; NEDS
LATUDA ORAL
TABLET
4 ST
NUPLAZID ORAL
TABLET
5 PA; NEDS
olanzapine
intramuscular recon
soln
4
olanzapine oral
tablet
2
olanzapine oral
tablet,disintegrating
2
paliperidone oral
tablet extended
release 24hr
2
quetiapine oral
tablet
2
quetiapine oral
tablet extended
release 24 hr
2
REXULTI ORAL
TABLET
5 ST; NEDS
RISPERDAL
CONSTA
INTRAMUSCULA
R SYRINGE 12.5
MG/2 ML, 25 MG/2
ML
4 ST
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
41
RISPERDAL
CONSTA
INTRAMUSCULA
R SYRINGE 37.5
MG/2 ML, 50 MG/2
ML
5 ST; NEDS
risperidone oral
solution
2
risperidone oral
tablet
2
risperidone oral
tablet,disintegrating
2
SAPHRIS (BLACK
CHERRY)
SUBLINGUAL
TABLET
4 ST
VRAYLAR ORAL
CAPSULE
5 ST; NEDS
VRAYLAR ORAL
CAPSULE,DOSE
PACK
4 ST
ziprasidone hcl oral
capsule
2
ZYPREXA
RELPREVV
INTRAMUSCULA
R SUSPENSION
FOR
RECONSTITUTIO
N
5 NEDS
TREATMENT-RESISTANT
clozapine oral tablet 2
clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg
2
Drug Name Drug
Tier
Requirements
/Limits
CLOZAPINE
ORAL
TABLET,DISINTE
GRATING 150 MG
4
CLOZAPINE
ORAL
TABLET,DISINTE
GRATING 200 MG
5 NEDS
FAZACLO ORAL
TABLET,DISINTE
GRATING 150 MG,
200 MG
5 NEDS
VERSACLOZ
ORAL
SUSPENSION
5 NEDS
Drug Name Drug
Tier
Requirements
/Limits
ANTISPASTICITY AGENTS
ANTISPASTICITY AGENTS
baclofen oral tablet
10 mg, 20 mg
2
dantrolene oral
capsule
2
tizanidine oral
capsule
2
tizanidine oral tablet 2
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV)
AGENTS
cidofovir
intravenous solution
4
foscarnet
intravenous solution
2 B/D PA
ganciclovir sodium
intravenous recon
soln
4 B/D PA
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
42
ganciclovir sodium
intravenous solution
4 B/D PA
valganciclovir oral
recon soln
5 NEDS
valganciclovir oral
tablet
5 NEDS
ZIRGAN
OPHTHALMIC
(EYE) GEL
3
ANTI-HEPATITIS B (HBV) AGENTS
adefovir oral tablet 5 NEDS
BARACLUDE
ORAL SOLUTION
4
entecavir oral tablet 5 NEDS
EPIVIR HBV
ORAL SOLUTION
4
INTRON A
INJECTION
RECON SOLN
5 NEDS
INTRON A
INJECTION
SOLUTION
5 NEDS
lamivudine oral
tablet 100 mg
2
ANTI-HEPATITIS C (HCV) AGENTS,
DIRECT ACTING AGENTS
EPCLUSA ORAL
TABLET
5 PA; NEDS
HARVONI ORAL
TABLET
5 PA; NEDS
SOVALDI ORAL
TABLET
5 PA; NEDS
VOSEVI ORAL
TABLET
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
ANTI-HEPATITIS C (HCV) AGENTS,
OTHER
moderiba dose pack
oral tablets,dose
pack 200 mg (28)-
400 mg (28), 400 mg
(7)- 400 mg (7), 600
mg (7)- 600 mg (7)
5 NEDS
ribasphere ribapak
oral tablets,dose
pack 200 mg (28)-
400 mg (28), 400 mg
(7)- 400 mg (7), 600
mg (7)- 400 mg (7),
600 mg (7)- 600 mg
(7)
5 NEDS
ANTI-HEPATITIS C (HCV) AGENTS
moderiba dose pack
oral tablets,dose
pack 400-400 mg
(28)-mg (28), 600-
400 mg (28)-mg
(28), 600-600 mg
(28)-mg (28)
5 NEDS
moderiba oral tablet 4
PEGASYS
PROCLICK
SUBCUTANEOUS
PEN INJECTOR
5 QL (4 per 28
days); NEDS
PEGASYS
SUBCUTANEOUS
SOLUTION
5 QL (4 per 28
days); NEDS
PEGASYS
SUBCUTANEOUS
SYRINGE
5 QL (4 per 28
days); NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
43
PEGINTRON
SUBCUTANEOUS
KIT 50 MCG/0.5
ML
5 QL (4 per 28
days); NEDS
REBETOL ORAL
SOLUTION
3
ribasphere oral
capsule
4
ribasphere oral
tablet
4
ribasphere ribapak
oral tablets,dose
pack 200 mg (7)-
400 mg (7), 400-400
mg (28)-mg (28),
600-400 mg (28)-mg
(28), 600-600 mg
(28)-mg (28)
5 NEDS
ribavirin oral
capsule
4
ribavirin oral tablet
200 mg
4
ANTIHERPETIC AGENTS
acyclovir oral
capsule
2
acyclovir oral suspension 200 mg/5 ml
2
acyclovir oral tablet 2
acyclovir sodium
intravenous solution
4 B/D PA
acyclovir topical ointment
4
DENAVIR TOPICAL CREAM
4
Drug Name Drug
Tier
Requirements
/Limits
famciclovir oral
tablet
2
trifluridine
ophthalmic (eye)
drops
2
valacyclovir oral
tablet
2
ZOVIRAX
TOPICAL CREAM
4
ANTI-HIV AGENTS, INTEGRASE
INHIBITORS (INSTI)
BIKTARVY ORAL
TABLET
5 NEDS
GENVOYA ORAL
TABLET
5 NEDS
ISENTRESS HD
ORAL TABLET
5 NEDS
ISENTRESS ORAL
POWDER IN
PACKET
5 NEDS
ISENTRESS ORAL
TABLET
5 NEDS
ISENTRESS ORAL
TABLET,CHEWAB
LE 100 MG
5 NEDS
ISENTRESS ORAL
TABLET,CHEWAB
LE 25 MG
3
JULUCA ORAL
TABLET
5 NEDS
STRIBILD ORAL
TABLET
5 NEDS
TIVICAY ORAL
TABLET 10 MG
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
44
TIVICAY ORAL
TABLET 25 MG, 50
MG
5 NEDS
ANTI-HIV AGENTS, NON-
NUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITORS
(NNRTI)
ATRIPLA ORAL
TABLET
5 NEDS
COMPLERA ORAL
TABLET
5 NEDS
DESCOVY ORAL
TABLET
5 NEDS
EDURANT ORAL
TABLET
5 NEDS
efavirenz oral
capsule 200 mg
4
efavirenz oral
capsule 50 mg
2
efavirenz oral tablet 5 NEDS
INTELENCE ORAL
TABLET 100 MG,
200 MG
5 NEDS
INTELENCE ORAL
TABLET 25 MG
3
nevirapine oral
tablet
2
nevirapine oral
tablet extended
release 24 hr
2
RESCRIPTOR
ORAL TABLET
3
RESCRIPTOR
ORAL TABLET,
DISPERSIBLE
3
Drug Name Drug
Tier
Requirements
/Limits
SUSTIVA ORAL
CAPSULE 200 MG
5 NEDS
SUSTIVA ORAL
CAPSULE 50 MG
3
SUSTIVA ORAL
TABLET
5 NEDS
VIRAMUNE ORAL
SUSPENSION
4
ANTI-HIV AGENTS, NUCLEOSIDE
AND NUCLEOTIDE REVERSE
TRANSCRIPTASE INHIBITORS
(NRTI)
abacavir oral
solution
2
abacavir oral tablet 4
abacavir-lamivudine
oral tablet
5 NEDS
abacavir-
lamivudine-
zidovudine oral
tablet
5 NEDS
CIMDUO ORAL
TABLET
5 NEDS
didanosine oral
capsule,delayed
release(dr/ec) 200
mg, 250 mg, 400 mg
2
EMTRIVA ORAL
CAPSULE
3
EMTRIVA ORAL
SOLUTION
3
lamivudine oral
solution
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
45
lamivudine oral
tablet 150 mg, 300
mg
2
lamivudine-
zidovudine oral
tablet
2
ODEFSEY ORAL
TABLET
5 NEDS
RETROVIR
INTRAVENOUS
SOLUTION
4
stavudine oral
capsule
2
SYMFI LO ORAL
TABLET
5 NEDS
SYMFI ORAL
TABLET
5 NEDS
tenofovir disoproxil
fumarate oral tablet
5 NEDS
TRIUMEQ ORAL
TABLET
5 NEDS
TRUVADA ORAL
TABLET
5 NEDS
VIDEX 2 GRAM
PEDIATRIC ORAL
RECON SOLN
3
VIDEX 4 GRAM
PEDIATRIC ORAL
RECON SOLN
3
VIDEX EC ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
125 MG
3
Drug Name Drug
Tier
Requirements
/Limits
VIREAD ORAL
POWDER
5 NEDS
VIREAD ORAL
TABLET
5 NEDS
ZERIT ORAL
RECON SOLN
5 NEDS
ZIAGEN ORAL
SOLUTION
3
zidovudine oral
capsule
2
zidovudine oral
syrup
2
zidovudine oral
tablet
2
ANTI-HIV AGENTS, OTHER
FUZEON
SUBCUTANEOUS
RECON SOLN
5 NEDS
SELZENTRY
ORAL SOLUTION
5 NEDS
SELZENTRY
ORAL TABLET
150 MG, 300 MG,
75 MG
5 NEDS
SELZENTRY
ORAL TABLET 25
MG
4
TROGARZO
INTRAVENOUS
SOLUTION
5 NEDS
TYBOST ORAL
TABLET
3
ANTI-HIV AGENTS, PROTEASE
INHIBITORS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
46
APTIVUS ORAL
CAPSULE
5 NEDS
APTIVUS ORAL
SOLUTION
5 NEDS
atazanavir oral
capsule 150 mg, 200
mg
4
atazanavir oral
capsule 300 mg
5 NEDS
CRIXIVAN ORAL
CAPSULE 200 MG,
400 MG
3
EVOTAZ ORAL
TABLET
5 NEDS
fosamprenavir oral
tablet
5 NEDS
INVIRASE ORAL
CAPSULE
5 NEDS
INVIRASE ORAL
TABLET
5 NEDS
KALETRA ORAL
TABLET 100-25
MG
4
KALETRA ORAL
TABLET 200-50
MG
5 NEDS
LEXIVA ORAL
SUSPENSION
4
LEXIVA ORAL
TABLET
5 NEDS
lopinavir-ritonavir
oral solution
5 NEDS
NORVIR ORAL
CAPSULE
3
Drug Name Drug
Tier
Requirements
/Limits
NORVIR ORAL
SOLUTION
3
NORVIR ORAL
TABLET
3
PREZCOBIX
ORAL TABLET
5 NEDS
PREZISTA ORAL
SUSPENSION
5 NEDS
PREZISTA ORAL
TABLET 150 MG,
75 MG
4
PREZISTA ORAL
TABLET 600 MG,
800 MG
5 NEDS
REYATAZ ORAL
CAPSULE 150 MG,
200 MG, 300 MG
5 NEDS
REYATAZ ORAL
POWDER IN
PACKET
5 NEDS
ritonavir oral tablet 2
VIRACEPT ORAL
TABLET
5 NEDS
ANTI-INFLUENZA AGENTS
amantadine hcl oral
capsule
2
amantadine hcl oral
solution
2
amantadine hcl oral
tablet
2
oseltamivir oral
capsule 30 mg
2 QL (56 per
180 days)
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
47
oseltamivir oral
capsule 45 mg, 75
mg
2 QL (28 per
180 days)
oseltamivir oral
suspension for
reconstitution
2 QL (360 per
180 days)
RELENZA
DISKHALER
INHALATION
BLISTER WITH
DEVICE
4 QL (180 per
90 days)
rimantadine oral
tablet
2
TAMIFLU ORAL
SUSPENSION FOR
RECONSTITUTIO
N
3 QL (360 per
180 days)
Drug Name Drug
Tier
Requirements
/Limits
ANXIOLYTICS
ANXIOLYTICS, OTHER
buspirone oral tablet 2
meprobamate oral
tablet
4
BENZODIAZEPINES
alprazolam intensol
oral concentrate
2
alprazolam oral
tablet
2
clonazepam oral
tablet
2
clonazepam oral
tablet,disintegrating
2
clorazepate
dipotassium oral
tablet
2
diazepam intensol
oral concentrate
2
diazepam oral
concentrate
2
diazepam oral
solution 5 mg/5 ml
(1 mg/ml)
2
diazepam oral tablet 2
estazolam oral tablet 4
lorazepam intensol
oral concentrate
2
lorazepam oral
concentrate
2
lorazepam oral
tablet
2
triazolam oral tablet 4
Drug Name Drug
Tier
Requirements
/Limits
BIPOLAR AGENTS
MOOD STABILIZERS
lithium carbonate
oral capsule
2
lithium carbonate
oral tablet
2
lithium carbonate
oral tablet extended
release
2
lithium citrate oral
solution 8 meq/5 ml
2
BLOOD GLUCOSE
REGULATORS
ANTIDIABETIC AGENTS
acarbose oral tablet 2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
48
BYDUREON
BCISE
SUBCUTANEOUS
AUTO-INJECTOR
3 PA; QL (10.2
per 84 days)
BYDUREON
SUBCUTANEOUS
PEN INJECTOR
3 PA; QL (12
per 84 days)
BYDUREON
SUBCUTANEOUS
SUSPENSION,EXT
ENDED REL
RECON
3 PA; QL (12
per 84 days)
BYETTA
SUBCUTANEOUS
PEN INJECTOR 10
MCG/DOSE(250
MCG/ML) 2.4 ML
4 PA; QL (7.2
per 84 days)
BYETTA
SUBCUTANEOUS
PEN INJECTOR 5
MCG/DOSE (250
MCG/ML) 1.2 ML
4 PA; QL (3.6
per 84 days)
CYCLOSET ORAL
TABLET
4 QL (540 per
90 days)
FARXIGA ORAL
TABLET
3 ST; QL (90 per
90 days)
glimepiride oral
tablet
1
glipizide oral tablet 1
glipizide oral tablet
extended release
24hr 10 mg
1 QL (180 per
90 days)
glipizide oral tablet
extended release
24hr 2.5 mg, 5 mg
1 QL (270 per
90 days)
Drug Name Drug
Tier
Requirements
/Limits
glipizide-metformin
oral tablet
1
INVOKAMET
ORAL TABLET
150-1,000 MG, 150-
500 MG, 50-1,000
MG
3 ST; QL (180
per 90 days)
INVOKAMET
ORAL TABLET 50-
500 MG
3 ST; QL (360
per 90 days)
INVOKAMET XR
ORAL TABLET, IR
- ER, BIPHASIC
24HR 150-1,000
MG, 150-500 MG,
50-1,000 MG
3 ST; QL (180
per 90 days)
INVOKAMET XR
ORAL TABLET, IR
- ER, BIPHASIC
24HR 50-500 MG
3 ST; QL (360
per 90 days)
INVOKANA ORAL
TABLET 100 MG
3 ST; QL (180
per 90 days)
INVOKANA ORAL
TABLET 300 MG
3 ST; QL (90 per
90 days)
JANUMET ORAL
TABLET
3 QL (180 per
90 days)
JANUMET XR
ORAL TABLET,
ER MULTIPHASE
24 HR 100-1,000
MG
3 QL (90 per 90
days)
JANUMET XR
ORAL TABLET,
ER MULTIPHASE
24 HR 50-1,000
MG, 50-500 MG
3 QL (180 per
90 days)
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
49
JANUVIA ORAL
TABLET
3 QL (90 per 90
days)
JENTADUETO
ORAL TABLET
4 QL (180 per
90 days)
KOMBIGLYZE XR
ORAL TABLET,
ER MULTIPHASE
24 HR 2.5-1,000
MG
3 QL (180 per
90 days)
KOMBIGLYZE XR
ORAL TABLET,
ER MULTIPHASE
24 HR 5-1,000 MG,
5-500 MG
3 QL (90 per 90
days)
metformin oral
tablet
1
metformin oral
tablet extended
release 24 hr 500 mg
1 QL (360 per
90 days)
metformin oral
tablet extended
release 24 hr 750 mg
1 QL (180 per
90 days)
metformin oral
tablet extended
release (osm) 24 hr
1,000 mg
1 QL (180 per
90 days)
metformin oral
tablet extended
release (osm) 24 hr
500 mg
1 QL (450 per
90 days)
metformin oral
tablet,er
gast.retention 24 hr
500 mg
1 QL (360 per
90 days)
miglitol oral tablet 2
Drug Name Drug
Tier
Requirements
/Limits
nateglinide oral
tablet
1
ONGLYZA ORAL
TABLET
3 QL (90 per 90
days)
pioglitazone oral
tablet
1 QL (90 per 90
days)
pioglitazone-
glimepiride oral
tablet
1 QL (90 per 90
days)
pioglitazone-
metformin oral
tablet
1 QL (270 per
90 days)
repaglinide oral
tablet
1
repaglinide-
metformin oral
tablet
1
SYMLINPEN 120
SUBCUTANEOUS
PEN INJECTOR
4
SYMLINPEN 60
SUBCUTANEOUS
PEN INJECTOR
4
tolazamide oral
tablet
1
tolbutamide oral
tablet
1
TRADJENTA
ORAL TABLET
4 QL (90 per 90
days)
VICTOZA 2-PAK
SUBCUTANEOUS
PEN INJECTOR
3 PA; QL (27
per 90 days)
VICTOZA 3-PAK
SUBCUTANEOUS
PEN INJECTOR
3 PA; QL (27
per 90 days)
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
50
XIGDUO XR
ORAL TABLET, IR
- ER, BIPHASIC
24HR 10-1,000 MG,
10-500 MG
3 ST; QL (90 per
90 days)
XIGDUO XR
ORAL TABLET, IR
- ER, BIPHASIC
24HR 2.5-1,000
MG, 5-1,000 MG, 5-
500 MG
3 ST; QL (180
per 90 days)
GLYCEMIC AGENTS
GLUCAGEN
HYPOKIT
INJECTION
RECON SOLN
3
GLUCAGON
EMERGENCY KIT
(HUMAN)
INJECTION KIT
3
KORLYM ORAL
TABLET
5 PA; NEDS
PROGLYCEM
ORAL
SUSPENSION
4
INSULINS
APIDRA
SOLOSTAR U-100
INSULIN
SUBCUTANEOUS
INSULIN PEN
4
APIDRA U-100
INSULIN
SUBCUTANEOUS
SOLUTION
4
Drug Name Drug
Tier
Requirements
/Limits
HUMALOG
JUNIOR KWIKPEN
U-100
SUBCUTANEOUS
INSULIN PEN,
HALF-UNIT
3
HUMALOG
KWIKPEN
INSULIN
SUBCUTANEOUS
INSULIN PEN
3
HUMALOG MIX
50-50 INSULN U-
100
SUBCUTANEOUS
SUSPENSION
3
HUMALOG MIX
50-50 KWIKPEN
SUBCUTANEOUS
INSULIN PEN
3
HUMALOG MIX
75-25 KWIKPEN
SUBCUTANEOUS
INSULIN PEN
3
HUMALOG MIX
75-25(U-
100)INSULN
SUBCUTANEOUS
SUSPENSION
3
HUMALOG U-100
INSULIN
SUBCUTANEOUS
CARTRIDGE
3
HUMALOG U-100
INSULIN
SUBCUTANEOUS
SOLUTION
3
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
51
HUMULIN 70/30
U-100 INSULIN
SUBCUTANEOUS
SUSPENSION
3
HUMULIN 70/30
U-100 KWIKPEN
SUBCUTANEOUS
INSULIN PEN
3
HUMULIN N NPH
INSULIN
KWIKPEN
SUBCUTANEOUS
INSULIN PEN
3
HUMULIN N NPH
U-100 INSULIN
SUBCUTANEOUS
SUSPENSION
3
HUMULIN R
REGULAR U-100
INSULN
INJECTION
SOLUTION
3
HUMULIN R U-500
(CONC) INSULIN
SUBCUTANEOUS
SOLUTION
3
HUMULIN R U-500
(CONC) KWIKPEN
SUBCUTANEOUS
INSULIN PEN
3
LANTUS
SOLOSTAR U-100
INSULIN
SUBCUTANEOUS
INSULIN PEN
3
Drug Name Drug
Tier
Requirements
/Limits
LANTUS U-100
INSULIN
SUBCUTANEOUS
SOLUTION
3
LEVEMIR
FLEXTOUCH U-
100 INSULN
SUBCUTANEOUS
INSULIN PEN
3
LEVEMIR U-100
INSULIN
SUBCUTANEOUS
SOLUTION
3
NOVOLIN 70/30 U-
100 INSULIN
SUBCUTANEOUS
SUSPENSION
3
NOVOLIN N NPH
U-100 INSULIN
SUBCUTANEOUS
SUSPENSION
3
NOVOLIN R
REGULAR U-100
INSULN
INJECTION
SOLUTION
3
NOVOLOG
FLEXPEN U-100
INSULIN
SUBCUTANEOUS
INSULIN PEN
3
NOVOLOG MIX
70-30 U-100
INSULN
SUBCUTANEOUS
SOLUTION
3
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
52
NOVOLOG MIX
70-30FLEXPEN U-
100
SUBCUTANEOUS
INSULIN PEN
3
NOVOLOG
PENFILL U-100
INSULIN
SUBCUTANEOUS
CARTRIDGE
3
NOVOLOG U-100
INSULIN ASPART
SUBCUTANEOUS
SOLUTION
3
TOUJEO MAX
SOLOSTAR
SUBCUTANEOUS
INSULIN PEN
3
TOUJEO
SOLOSTAR U-300
INSULIN
SUBCUTANEOUS
INSULIN PEN
3
Drug Name Drug
Tier
Requirements
/Limits
BLOOD
PRODUCTS/MODIFIERS/VOLU
ME EXPANDERS
ANTICOAGULANTS
BEVYXXA ORAL
CAPSULE
4
COUMADIN ORAL
TABLET
4
ELIQUIS ORAL
TABLET
3
ELIQUIS ORAL
TABLETS,DOSE
PACK
3
enoxaparin
subcutaneous
solution
4
enoxaparin
subcutaneous
syringe
4
fondaparinux
subcutaneous
syringe
4
FRAGMIN
SUBCUTANEOUS
SOLUTION
4
FRAGMIN
SUBCUTANEOUS
SYRINGE
4
heparin (porcine) in
5 % dex intravenous
parenteral solution
4
heparin (porcine)
injection cartridge
4
heparin (porcine)
injection solution
4
heparin (porcine)
injection syringe
5,000 unit/ml
4
heparin(porcine) in
0.45% nacl
intravenous
parenteral solution
25,000 unit/250 ml,
25,000 unit/500 ml
4
heparin, porcine (pf)
injection solution
5,000 unit/0.5 ml
4
heparin, porcine (pf)
injection syringe
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
53
jantoven oral tablet 1
PRADAXA ORAL
CAPSULE
3
warfarin oral tablet 1
XARELTO ORAL
TABLET
3
XARELTO ORAL
TABLETS,DOSE
PACK
3
BLOOD FORMATION MODIFIERS
anagrelide oral
capsule
2
ARANESP (IN
POLYSORBATE)
INJECTION
SOLUTION 100
MCG/ML, 200
MCG/ML, 300
MCG/ML, 60
MCG/ML
5 PA; NEDS
ARANESP (IN
POLYSORBATE)
INJECTION
SOLUTION 25
MCG/ML, 40
MCG/ML
4 PA
ARANESP (IN
POLYSORBATE)
INJECTION
SYRINGE 10
MCG/0.4 ML, 25
MCG/0.42 ML, 40
MCG/0.4 ML
4 PA
Drug Name Drug
Tier
Requirements
/Limits
ARANESP (IN
POLYSORBATE)
INJECTION
SYRINGE 100
MCG/0.5 ML, 150
MCG/0.3 ML, 200
MCG/0.4 ML, 300
MCG/0.6 ML, 500
MCG/ML, 60
MCG/0.3 ML
5 PA; NEDS
EPOGEN
INJECTION
SOLUTION 10,000
UNIT/ML, 2,000
UNIT/ML, 20,000
UNIT/2 ML, 20,000
UNIT/ML, 3,000
UNIT/ML, 4,000
UNIT/ML
4 PA
LEUKINE
INJECTION
RECON SOLN
5 NEDS
MOZOBIL
SUBCUTANEOUS
SOLUTION
5 PA; NEDS
NEULASTA
SUBCUTANEOUS
SYRINGE
5 QL (1.2 per 28
days); NEDS
NEULASTA
SUBCUTANEOUS
SYRINGE, W/
WEARABLE
INJECTOR
5 QL (1.2 per 28
days); NEDS
NEUPOGEN
INJECTION
SOLUTION
5 NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
54
NEUPOGEN
INJECTION
SYRINGE
5 NEDS
NPLATE
SUBCUTANEOUS
RECON SOLN
5 PA; NEDS
PROCRIT
INJECTION
SOLUTION 10,000
UNIT/ML, 2,000
UNIT/ML, 20,000
UNIT/2 ML, 3,000
UNIT/ML, 4,000
UNIT/ML
4 PA
PROCRIT
INJECTION
SOLUTION 20,000
UNIT/ML, 40,000
UNIT/ML
5 PA; NEDS
PROMACTA
ORAL TABLET
5 PA; NEDS
ZARXIO
INJECTION
SYRINGE
5 NEDS
HEMOSTASIS AGENTS
AMICAR ORAL
TABLET 1,000 MG
4
tranexamic acid
intravenous solution
4
tranexamic acid oral
tablet
2 QL (90 per 63
days)
PLATELET MODIFYING AGENTS
aspirin-dipyridamole
oral capsule, er
multiphase 12 hr
4
Drug Name Drug
Tier
Requirements
/Limits
BRILINTA ORAL
TABLET
3
cilostazol oral tablet 2
clopidogrel oral
tablet
2
EFFIENT ORAL
TABLET
3
prasugrel oral tablet 2
Drug Name Drug
Tier
Requirements
/Limits
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine (pf)
epidural solution
2
clonidine hcl oral
tablet
2
clonidine
transdermal patch
weekly
1 QL (12 per 84
days)
midodrine oral
tablet
2
ALPHA-ADRENERGIC BLOCKING
AGENTS
doxazosin oral tablet 2
phenoxybenzamine
oral capsule
2
prazosin oral
capsule
2
terazosin oral
capsule
2
ANGIOTENSIN II II RECEPTOR
ANTAGONISTS
candesartan oral
tablet
1
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
55
candesartan-
hydrochlorothiazid
oral tablet
1
EDARBI ORAL
TABLET
4
EDARBYCLOR
ORAL TABLET
4
eprosartan oral
tablet
1
irbesartan oral
tablet
1
irbesartan-
hydrochlorothiazide
oral tablet
1
losartan oral tablet 1
losartan-
hydrochlorothiazide
oral tablet
1
olmesartan oral
tablet
1
olmesartan-
hydrochlorothiazide
oral tablet
1
telmisartan oral
tablet
1
telmisartan-
hydrochlorothiazid
oral tablet
1
valsartan oral tablet 1
valsartan-
hydrochlorothiazide
oral tablet
1
ANGIOTENSIN-CONVERTING
ENZYME (ACE) INHIBITORS
Drug Name Drug
Tier
Requirements
/Limits
benazepril oral
tablet
1
benazepril-
hydrochlorothiazide
oral tablet
1
captopril oral tablet 1
captopril-
hydrochlorothiazide
oral tablet
1
enalapril maleate
oral tablet
1
enalapril-
hydrochlorothiazide
oral tablet
1
fosinopril oral tablet 1
fosinopril-
hydrochlorothiazide
oral tablet
1
lisinopril oral tablet 1
lisinopril-
hydrochlorothiazide
oral tablet
1
moexipril oral tablet 1
moexipril-
hydrochlorothiazide
oral tablet
1
perindopril
erbumine oral tablet
1
quinapril oral tablet 1
quinapril-
hydrochlorothiazide
oral tablet
1
ramipril oral
capsule
1
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
56
trandolapril oral
tablet
1
ANTIARRHYTHMICS
adenosine
intravenous syringe
4
amiodarone
intravenous solution
4
amiodarone
intravenous syringe
4
amiodarone oral
tablet
2
dofetilide oral
capsule
2
flecainide oral tablet 2
mexiletine oral
capsule
2
MULTAQ ORAL
TABLET
3 QL (180 per
90 days)
NORPACE CR
ORAL CAPSULE,
EXTENDED
RELEASE
4
pacerone oral tablet
100 mg, 200 mg, 400
mg
2
procainamide
injection solution
4
propafenone oral
capsule,extended
release 12 hr
2
propafenone oral
tablet
2
quinidine gluconate
injection solution
4
Drug Name Drug
Tier
Requirements
/Limits
quinidine gluconate
oral tablet extended
release
2
quinidine sulfate
oral tablet
2
sorine oral tablet 2
sotalol af oral tablet 2
sotalol oral tablet 2
BETA-ADRENERGIC BLOCKING
AGENTS
acebutolol oral
capsule
2
atenolol oral tablet 1
atenolol-
chlorthalidone oral
tablet
1
betaxolol oral tablet 1
bisoprolol fumarate
oral tablet
1
bisoprolol-
hydrochlorothiazide
oral tablet
1
BYSTOLIC ORAL
TABLET 10 MG
4 ST; QL (360
per 90 days)
BYSTOLIC ORAL
TABLET 2.5 MG, 5
MG
4 ST; QL (90 per
90 days)
BYSTOLIC ORAL
TABLET 20 MG
4 ST; QL (180
per 90 days)
carvedilol oral tablet 1
carvedilol phosphate
oral capsule, er
multiphase 24 hr
2 QL (90 per 90
days)
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
57
COREG CR ORAL
CAPSULE, ER
MULTIPHASE 24
HR
4 QL (90 per 90
days)
labetalol
intravenous solution
4
labetalol
intravenous syringe
20 mg/4 ml (5
mg/ml)
4
labetalol oral tablet 1
metoprolol succinate
oral tablet extended
release 24 hr
1 QL (180 per
90 days)
metoprolol ta-
hydrochlorothiaz
oral tablet
1
metoprolol tartrate
intravenous solution
4
metoprolol tartrate
intravenous syringe
4
metoprolol tartrate
oral tablet 100 mg,
25 mg, 50 mg
1
nadolol oral tablet 1
pindolol oral tablet 1
propranolol
intravenous solution
4
propranolol oral
capsule,extended
release 24 hr
1
propranolol oral
solution
2
propranolol oral
tablet
1
Drug Name Drug
Tier
Requirements
/Limits
propranolol-
hydrochlorothiazid
oral tablet
1
timolol maleate oral
tablet
1
CALCIUM CHANNEL BLOCKING
AGENTS
afeditab cr oral
tablet extended
release
1 QL (90 per 90
days)
amlodipine oral
tablet
1
cartia xt oral
capsule,extended
release 24hr
1
diltiazem hcl
intravenous recon
soln
4
diltiazem hcl
intravenous solution
4
diltiazem hcl oral
capsule,ext.rel 24h
degradable
1
diltiazem hcl oral
capsule,extended
release 12 hr
1
diltiazem hcl oral
capsule,extended
release 24 hr
1
diltiazem hcl oral
capsule,extended
release 24hr
1
diltiazem hcl oral
tablet
1
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
58
diltiazem hcl oral
tablet extended
release 24 hr
1
dilt-xr oral
capsule,ext.rel 24h
degradable
1
felodipine oral tablet
extended release 24
hr
1 QL (90 per 90
days)
isradipine oral
capsule
2
matzim la oral tablet
extended release 24
hr
1
nicardipine
intravenous solution
4
nicardipine oral
capsule
1
nifedipine oral tablet
extended release
1 QL (90 per 90
days)
nifedipine oral tablet
extended release
24hr
1 QL (90 per 90
days)
nimodipine oral
capsule
4
nisoldipine oral
tablet extended
release 24 hr 17 mg,
20 mg, 25.5 mg, 34
mg, 40 mg, 8.5 mg
4 QL (90 per 90
days)
nisoldipine oral
tablet extended
release 24 hr 30 mg
4 QL (180 per
90 days)
taztia xt oral
capsule,extended
release 24 hr
1
Drug Name Drug
Tier
Requirements
/Limits
verapamil
intravenous solution
4
verapamil
intravenous syringe
4
verapamil oral
capsule, 24 hr er
pellet ct
1
verapamil oral
capsule,ext rel.
pellets 24 hr
1
verapamil oral tablet 1
verapamil oral tablet
extended release
1
CARDIOVASCULAR AGENTS,
OTHER
amlodipine-
atorvastatin oral
tablet
1 QL (90 per 90
days)
amlodipine-
benazepril oral
capsule
1
amlodipine-
olmesartan oral
tablet
1 QL (90 per 90
days)
amlodipine-
valsartan oral tablet
1
amlodipine-
valsartan-hcthiazid
oral tablet
1
BIDIL ORAL
TABLET
3
CORLANOR ORAL
TABLET
4 QL (180 per
90 days)
DEMSER ORAL
CAPSULE
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
59
digitek oral tablet
125 mcg
2 QL (90 per 90
days)
digitek oral tablet
250 mcg
2
digox oral tablet 125
mcg
2 QL (90 per 90
days)
digox oral tablet 250
mcg
2
digoxin injection
solution
4
digoxin oral solution
50 mcg/ml
2
digoxin oral tablet
125 mcg
2 QL (90 per 90
days)
digoxin oral tablet
250 mcg
2
ENTRESTO ORAL
TABLET
4
ezetimibe-
simvastatin oral
tablet
4 ST; QL (90 per
90 days)
nadolol-
bendroflumethiazide
oral tablet
1
NORTHERA ORAL
CAPSULE
5 NEDS
olmesartan-
amlodipin-hcthiazid
oral tablet
1 QL (90 per 90
days)
pentoxifylline oral
tablet extended
release
2
Drug Name Drug
Tier
Requirements
/Limits
RANEXA ORAL
TABLET
EXTENDED
RELEASE 12 HR
4
spironolacton-
hydrochlorothiaz
oral tablet
2
TEKTURNA HCT
ORAL TABLET
3 QL (90 per 90
days)
TEKTURNA ORAL
TABLET
3 QL (90 per 90
days)
telmisartan-
amlodipine oral
tablet
1
trandolapril-
verapamil oral
tablet, ir - er,
biphasic 24hr
1 QL (90 per 90
days)
triamterene-
hydrochlorothiazid
oral capsule
1
triamterene-
hydrochlorothiazid
oral tablet
1
VECAMYL ORAL
TABLET
5 PA; NEDS
DIURETICS, CARBONIC
ANHYDRASE INHIBITORS
acetazolamide oral
capsule, extended
release
2
acetazolamide oral
tablet
2
acetazolamide
sodium injection
recon soln
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
60
methazolamide oral
tablet
4
DIURETICS, LOOP
bumetanide injection
solution
4
bumetanide oral
tablet
1
ethacrynate sodium
intravenous recon
soln
4
furosemide injection
solution
4
furosemide injection
syringe
4
furosemide oral
solution 10 mg/ml,
40 mg/5 ml (8
mg/ml)
1
furosemide oral
tablet
1
torsemide oral tablet 2
DIURETICS, POTASSIUM-SPARING
amiloride oral tablet 2
amiloride-
hydrochlorothiazide
oral tablet
1
eplerenone oral
tablet
2
spironolactone oral
tablet
1
DIURETICS, THIAZIDE
chlorothiazide oral
tablet
1
Drug Name Drug
Tier
Requirements
/Limits
chlorothiazide
sodium intravenous
recon soln
4
chlorthalidone oral
tablet 25 mg, 50 mg
1
hydrochlorothiazide
oral capsule
1
hydrochlorothiazide
oral tablet
1
indapamide oral
tablet
1
methyclothiazide
oral tablet
2
metolazone oral
tablet
2
DYSLIPIDEMICS, FIBRIC ACID
DERIVATIVES
fenofibrate
micronized oral
capsule
2 QL (90 per 90
days)
fenofibrate
nanocrystallized
oral tablet
2
fenofibrate oral
tablet
2 QL (90 per 90
days)
fenofibric acid
(choline) oral
capsule,delayed
release(dr/ec) 135
mg
2 QL (90 per 90
days)
fenofibric acid
(choline) oral
capsule,delayed
release(dr/ec) 45 mg
2 QL (270 per
90 days)
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
61
fenofibric acid oral
tablet
2
gemfibrozil oral
tablet 2
LIPOFEN ORAL
CAPSULE
4
TRIGLIDE ORAL
TABLET 160 MG
4 QL (90 per 90
days)
DYSLIPIDEMICS, HMG COA
REDUCTASE INHIBITORS
atorvastatin oral
tablet 10 mg, 20 mg,
40 mg
1
atorvastatin oral
tablet 80 mg 1 QL (90 per 90
days)
fluvastatin oral
capsule 20 mg 1 QL (360 per
90 days)
fluvastatin oral
capsule 40 mg
1 QL (180 per
90 days)
fluvastatin oral
tablet extended
release 24 hr
1 QL (90 per 90
days)
LIVALO ORAL TABLET
4 ST
lovastatin oral tablet 10 mg, 20 mg
1 QL (270 per
90 days)
lovastatin oral tablet
40 mg 1 QL (180 per
90 days)
pravastatin oral
tablet
1 QL (90 per 90
days)
rosuvastatin oral
tablet
2 QL (90 per 90
days)
simvastatin oral
tablet
1 QL (90 per 90
days)
Drug Name Drug
Tier
Requirements
/Limits
DYSLIPIDEMICS, OTHER
cholestyramine (with
sugar) oral powder 2
cholestyramine (with
sugar) oral powder
in packet
2
cholestyramine light
oral powder
2
cholestyramine light
oral powder in
packet
2
colestipol oral granules
2
colestipol oral packet
2
colestipol oral tablet 2
ezetimibe oral tablet 2 QL (90 per 90
days)
JUXTAPID ORAL
CAPSULE
5 PA; NEDS
KYNAMRO
SUBCUTANEOUS SYRINGE
5 PA; NEDS
niacin oral tablet extended release 24 hr
2
omega-3 acid ethyl esters oral capsule
2
PRALUENT PEN
SUBCUTANEOUS
PEN INJECTOR
5 PA; NEDS
prevalite oral
powder
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
62
prevalite oral
powder in packet
2
REPATHA
PUSHTRONEX
SUBCUTANEOUS
WEARABLE
INJECTOR
5 PA; NEDS
REPATHA
SUBCUTANEOUS
SYRINGE
5 PA; NEDS
REPATHA
SURECLICK
SUBCUTANEOUS
PEN INJECTOR
5 PA; NEDS
triklo oral capsule 2
VASCEPA ORAL
CAPSULE
4
WELCHOL ORAL
POWDER IN
PACKET
3
WELCHOL ORAL
TABLET
3
VASODILATORS, DIRECT-ACTING
ARTERIAL/VENOUS
epoprostenol
(glycine)
intravenous recon
soln
5 NEDS
FLOLAN
INTRAVENOUS
RECON SOLN
5 NEDS
isosorbide dinitrate
oral tablet
2
isosorbide dinitrate
oral tablet extended
release
2
Drug Name Drug
Tier
Requirements
/Limits
isosorbide
mononitrate oral
tablet
2
isosorbide
mononitrate oral
tablet extended
release 24 hr
2
nitro-bid
transdermal
ointment
2
NITRO-DUR
TRANSDERMAL
PATCH 24 HOUR
4
nitroglycerin
intravenous solution
4
nitroglycerin
sublingual tablet
2
nitroglycerin
transdermal patch
24 hour
2
nitroglycerin
translingual
spray,non-aerosol
4
veletri intravenous
recon soln
5 NEDS
VASODILATORS, DIRECT-ACTING
ARTERIAL
hydralazine injection
solution
4
hydralazine oral
tablet
2
minoxidil oral tablet 2
VASOPRESSORS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
63
norepinephrine
bitartrate
intravenous solution
2
Drug Name Drug
Tier
Requirements
/Limits
CENTRAL NERVOUS SYSTEM
AGENTS
ATTENTION DEFICIT
HYPERACTIVITY DISORDER
AGENTS, AMPHETAMINES
dextroamphetamine
oral tablet
2 QL (540 per
90 days)
dextroamphetamine-
amphetamine oral
tablet 10 mg, 12.5
mg, 15 mg, 20 mg, 5
mg, 7.5 mg
2 QL (270 per
90 days)
dextroamphetamine-
amphetamine oral
tablet 30 mg
2 QL (180 per
90 days)
zenzedi oral tablet
10 mg, 5 mg
2 QL (540 per
90 days)
ATTENTION DEFICIT
HYPERACTIVITY DISORDER
AGENTS, NON-AMPHETAMINES
atomoxetine oral
capsule 10 mg, 18
mg, 25 mg, 40 mg,
60 mg
4 ST; QL (180
per 90 days)
atomoxetine oral
capsule 100 mg, 80
mg
4 ST; QL (90 per
90 days)
clonidine hcl oral
tablet extended
release 12 hr
2 QL (360 per
90 days)
guanfacine oral
tablet extended
release 24 hr
2
methylphenidate hcl
oral capsule, er
biphasic 30-70 20
mg, 40 mg
2
methylphenidate hcl
oral solution
2
methylphenidate hcl
oral tablet
2 QL (270 per
90 days)
CENTRAL NERVOUS SYSTEM,
OTHER
NUEDEXTA ORAL
CAPSULE
3 QL (180 per
90 days)
RADICAVA
INTRAVENOUS
PIGGYBACK
5 PA; NEDS
riluzole oral tablet 2
tetrabenazine oral
tablet 12.5 mg
5 PA; QL (248
per 31 days);
NEDS
tetrabenazine oral
tablet 25 mg
5 PA; QL (124
per 31 days);
NEDS
FIBROMYALGIA AGENTS
SAVELLA ORAL
TABLET
3 PA; QL (180
per 90 days)
SAVELLA ORAL
TABLETS,DOSE
PACK
4 PA; QL (165
per 84 days)
MULTIPLE SCLEROSIS AGENTS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
64
AMPYRA ORAL
TABLET
EXTENDED
RELEASE 12 HR
5 PA; QL (62
per 31 days);
NEDS
AUBAGIO ORAL
TABLET
5 PA; NEDS
AVONEX (WITH
ALBUMIN)
INTRAMUSCULA
R KIT
5 PA; NEDS
AVONEX
INTRAMUSCULA
R PEN INJECTOR
KIT
5 PA; NEDS
AVONEX
INTRAMUSCULA
R SYRINGE KIT
5 PA; NEDS
BETASERON
SUBCUTANEOUS
KIT
5 PA; NEDS
COPAXONE
SUBCUTANEOUS
SYRINGE 40
MG/ML
5 PA; NEDS
EXTAVIA
SUBCUTANEOUS
KIT
5 PA; NEDS
EXTAVIA
SUBCUTANEOUS
RECON SOLN
5 PA; NEDS
GILENYA ORAL
CAPSULE
5 PA; NEDS
glatiramer
subcutaneous
syringe
5 NEDS
Drug Name Drug
Tier
Requirements
/Limits
glatopa
subcutaneous
syringe
5 NEDS
PLEGRIDY
SUBCUTANEOUS
PEN INJECTOR
5 PA; NEDS
PLEGRIDY
SUBCUTANEOUS
SYRINGE
5 PA; NEDS
REBIF (WITH
ALBUMIN)
SUBCUTANEOUS
SYRINGE
5 PA; NEDS
REBIF REBIDOSE
SUBCUTANEOUS
PEN INJECTOR
5 PA; NEDS
REBIF TITRATION
PACK
SUBCUTANEOUS
SYRINGE
5 PA; NEDS
TECFIDERA ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
5 PA; QL (62
per 31 days);
NEDS
TYSABRI
INTRAVENOUS
SOLUTION
5 PA; LA;
NEDS
Drug Name Drug
Tier
Requirements
/Limits
DENTAL AND ORAL AGENTS
DENTAL AND ORAL AGENTS
cevimeline oral
capsule
2
chlorhexidine
gluconate mucous
membrane
mouthwash
2
oralone dental paste 2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
65
paroex oral rinse
mucous membrane
mouthwash
2
periogard mucous
membrane
mouthwash
2
pilocarpine hcl oral
tablet
2
triamcinolone
acetonide dental
paste
2
Drug Name Drug
Tier
Requirements
/Limits
DERMATOLOGICAL AGENTS
DERMATOLOGICAL AGENTS
acitretin oral
capsule
4
adapalene topical
cream
2
adapalene topical
gel
2
adapalene topical
gel with pump
2
ammonium lactate
topical cream
2
ammonium lactate
topical lotion
2
amnesteem oral
capsule
4
apexicon e topical
cream
4
avita topical cream 2
calcipotriene scalp
solution
4
calcipotriene topical
cream
4
calcipotriene topical
ointment
4
calcipotriene-
betamethasone
topical ointment
4
calcitrene topical
ointment
4
calcitriol topical
ointment
4
claravis oral capsule 4
clindamycin-benzoyl
peroxide topical gel
2
clindamycin-benzoyl
peroxide topical gel
with pump
2
CONDYLOX
TOPICAL GEL
3
DIFFERIN
TOPICAL LOTION
4
erythromycin-
benzoyl peroxide
topical gel
2
FINACEA
TOPICAL GEL
4
fluorouracil
intravenous solution
1 gram/20 ml
2 B/D PA
FLUOROURACIL
TOPICAL CREAM
0.5 %
4
fluorouracil topical
cream 5 %
2
fluorouracil topical
solution
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
66
imiquimod topical
cream in packet
2
isotretinoin oral
capsule
2
methoxsalen oral
capsule,liqd-
filled,rapid rel
5 NEDS
myorisan oral
capsule
4
neuac topical gel 2
PICATO TOPICAL
GEL 0.015 %
5 QL (3 per 31
days); NEDS
PICATO TOPICAL
GEL 0.05 %
5 QL (2 per 31
days); NEDS
podofilox topical
solution
2
SANTYL TOPICAL
OINTMENT
3
selenium sulfide
topical lotion
2
STELARA
INTRAVENOUS
SOLUTION
5 PA; NEDS
STELARA
SUBCUTANEOUS
SOLUTION
5 PA; NEDS
STELARA
SUBCUTANEOUS
SYRINGE
5 PA; NEDS
TACLONEX
TOPICAL
SUSPENSION
4
tacrolimus topical
ointment
4
Drug Name Drug
Tier
Requirements
/Limits
tazarotene topical
cream
4
TAZORAC
TOPICAL CREAM
0.05 %
4
TAZORAC
TOPICAL GEL
4
tretinoin topical
cream
2
tretinoin topical gel 2
UVADEX
INJECTION
SOLUTION
4
zenatane oral
capsule
4
Drug Name Drug
Tier
Requirements
/Limits
ELECTROLYTES/MINERALS/
METALS/VITAMINS
ELECTROLYTE/MINERAL
REPLACEMENT
AMINOSYN 10 %
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
AMINOSYN 7 %
WITH
ELECTROLYTES
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
AMINOSYN 8.5 %
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
67
AMINOSYN II 10
% INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
AMINOSYN II 15
% INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
AMINOSYN II 7 %
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
AMINOSYN II 8.5
% INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
AMINOSYN II 8.5
%-
ELECTROLYTES
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
AMINOSYN-HBC
7%
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
AMINOSYN-PF 10
% INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
AMINOSYN-PF 7
% (SULFITE-
FREE)
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
Drug Name Drug
Tier
Requirements
/Limits
AMINOSYN-RF 5.2
% INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
calcium chloride
intravenous solution
4
calcium chloride
intravenous syringe
4
calcium gluconate
intravenous solution
4
CARBAGLU ORAL
TABLET,
DISPERSIBLE
5 LA; NEDS
CLINIMIX
5%/D15W
SULFITE FREE
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
CLINIMIX
5%/D25W
SULFITE-FREE
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
CLINIMIX
2.75%/D5W
SULFIT FREE
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
CLINIMIX
4.25%/D10W SULF
FREE
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic
5-Specialty Drugs
3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
68
CLINIMIX
4.25%/D5W
SULFIT FREE
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
CLINIMIX 4.25%-
D20W SULF-FREE
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
CLINIMIX 4.25%-
D25W SULF-FREE
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
CLINIMIX 5%-
D20W(SULFITE-
FREE)
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
CLINIMIX E
4.25%/D10W SUL
FREE
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
cysteine (l-cysteine)
intravenous solution
2 B/D PA
d10 %-0.45 %
sodium chloride
intravenous
parenteral solution
4
d2.5 %-0.45 %
sodium chloride
intravenous
parenteral solution
4
Drug Name Drug
Tier
Requirements
/Limits
d5 % and 0.9 %
sodium chloride
intravenous
parenteral solution
4
d5 %-0.45 % sodium
chloride intravenous
parenteral solution
4
denta 5000 plus
dental cream
2
dextrose 10 % and
0.2 % nacl
intravenous
parenteral solution
4
dextrose 10 % in
water (d10w)
intravenous
parenteral solution
4 B/D PA
dextrose 20 % in
water (d20w)
intravenous
parenteral solution
4 B/D PA
dextrose 30 % in
water (d30w)
intravenous
parenteral solution
4 B/D PA
dextrose 40 % in
water (d40w)
intravenous
parenteral solution
4 B/D PA
dextrose 5 % in
water (d5w)
intravenous
parenteral solution
4
dextrose 5 % in
water (d5w)
intravenous
piggyback
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
69
dextrose 5 %-
lactated ringers
intravenous
parenteral solution
4
dextrose 5%-0.2 %
sod chloride
intravenous
parenteral solution
4
dextrose 5%-0.3 %
sod.chloride
intravenous
parenteral solution
4
dextrose 50 % in
water (d50w)
intravenous
parenteral solution
4 B/D PA
dextrose 70 % in
water (d70w)
intravenous
parenteral solution
4 B/D PA
dextrose with sodium
chloride intravenous
parenteral solution
4
ESCAVITE ORAL
TABLET,CHEWAB
LE
4
fluoride (sodium)
oral tablet
2
fluoride (sodium)
oral tablet,chewable
2
fluoritab oral
tablet,chewable
2
HEPATAMINE 8%
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
Drug Name Drug
Tier
Requirements
/Limits
intralipid
intravenous
emulsion 20 %
4 B/D PA
INTRALIPID
INTRAVENOUS
EMULSION 30 %
4 B/D PA
ISOLYTE S PH 7.4
INTRAVENOUS
PARENTERAL
SOLUTION
4
ISOLYTE-P IN 5 %
DEXTROSE
INTRAVENOUS
PARENTERAL
SOLUTION
4
ISOLYTE-S
INTRAVENOUS
PARENTERAL
SOLUTION
4
KABIVEN
INTRAVENOUS
EMULSION
4 B/D PA
klor-con 10 oral
tablet extended
release
2
klor-con 8 oral
tablet extended
release
2
klor-con m10 oral
tablet,er
particles/crystals
2
klor-con m15 oral
tablet,er
particles/crystals
2
klor-con m20 oral
tablet,er
particles/crystals
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
70
klor-con sprinkle
oral capsule,
extended release
2
k-tab oral tablet
extended release 8
meq
2
lactated ringers
intravenous
parenteral solution
4
lactated ringers
irrigation solution
4
levocarnitine (with
sugar) oral solution
2
levocarnitine oral
tablet
2
ludent fluoride oral
tablet,chewable
2
magnesium chloride
injection solution
4
magnesium sulfate
injection solution
4
magnesium sulfate
injection syringe
4
multi-vit with
fluoride-iron oral
drops
2
multi-vitamin with
fluoride oral drops
0.5 mg/ml
2
multivitamins with
fluoride oral
tablet,chewable 0.25
mg, 1 mg
2
multivit-fluor (vit e
acetate) oral drops
2
Drug Name Drug
Tier
Requirements
/Limits
NEPHRAMINE 5.4
% INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
NORMOSOL-R
INTRAVENOUS
PARENTERAL
SOLUTION
4
NORMOSOL-R PH
7.4
INTRAVENOUS
PARENTERAL
SOLUTION
4
PERIKABIVEN
INTRAVENOUS
EMULSION
4 B/D PA
PLASMA-LYTE
148
INTRAVENOUS
PARENTERAL
SOLUTION
4
PLASMA-LYTE A
INTRAVENOUS
PARENTERAL
SOLUTION
4
plenamine
intravenous
parenteral solution
4 B/D PA
potassium acetate
intravenous solution
2 meq/ml
4
potassium chlorid-
d5-0.45%nacl
intravenous
parenteral solution
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
71
potassium chloride
in 0.9%nacl
intravenous
parenteral solution
20 meq/l, 40 meq/l
4
potassium chloride
in 5 % dex
intravenous
parenteral solution
20 meq/l, 30 meq/l,
40 meq/l
4
potassium chloride
in lr-d5 intravenous
parenteral solution
4
potassium chloride
in water intravenous
piggyback
4
potassium chloride
intravenous solution
4
potassium chloride
oral capsule,
extended release
2
potassium chloride
oral liquid
2
potassium chloride
oral tablet extended
release
2
potassium chloride
oral tablet,er
particles/crystals
2
potassium chloride-
0.45 % nacl
intravenous
parenteral solution
4
Drug Name Drug
Tier
Requirements
/Limits
potassium chloride-
d5-0.2%nacl
intravenous
parenteral solution
20 meq/l, 30 meq/l,
40 meq/l
4
potassium chloride-
d5-0.3%nacl
intravenous
parenteral solution
20 meq/l
4
potassium chloride-
d5-0.9%nacl
intravenous
parenteral solution
4
potassium citrate
oral tablet extended
release
2
potassium phosphate
m-/d-basic
intravenous solution
4
premasol 10 %
intravenous
parenteral solution
4 B/D PA
PREMASOL 6 %
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
prenatal vitamin
oral tablet
2
PREVIDENT 5000
BOOSTER PLUS
DENTAL PASTE
4
PREVIDENT 5000
DRY MOUTH
DENTAL GEL
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
72
PREVIDENT 5000
SENSITIVE
DENTAL PASTE
4
ringer's intravenous
parenteral solution
4
ringer's irrigation
solution
4
sf 5000 plus dental
cream
2
sodium acetate
intravenous solution
4
sodium chloride 0.45
% intravenous
parenteral solution
4
sodium chloride 0.45
% intravenous
piggyback
4
sodium chloride 0.9
% intravenous
parenteral solution
4
sodium chloride 0.9
% intravenous
piggyback
4
sodium chloride 3 %
intravenous
parenteral solution
4
sodium chloride 5 %
intravenous
parenteral solution
4
sodium chloride
intravenous
parenteral solution
4
sodium chloride
irrigation solution
4
Drug Name Drug
Tier
Requirements
/Limits
sodium lactate
intravenous solution
4
sodium phosphate
intravenous solution
4
travasol 10 %
intravenous
parenteral solution
4 B/D PA
TROPHAMINE 10
% INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
TROPHAMINE 6%
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
ELECTROLYTE/MINERAL/METAL
MODIFIERS
CHEMET ORAL
CAPSULE
3
DEPEN
TITRATABS ORAL
TABLET
4
EXJADE ORAL
TABLET,
DISPERSIBLE
5 NEDS
FERRIPROX ORAL
SOLUTION
5 NEDS
FERRIPROX ORAL
TABLET
5 NEDS
FREAMINE HBC
6.9 %
INTRAVENOUS
PARENTERAL
SOLUTION
4 B/D PA
JADENU ORAL
TABLET
5 NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
73
kionex (with
sorbitol) oral
suspension
2
kionex oral powder 2
SAMSCA ORAL
TABLET
5 PA; NEDS
sodium polystyrene
(sorb free) oral
suspension
2
sodium polystyrene
sulfonate oral
powder
2
sodium polystyrene
sulfonate oral
suspension
2
sodium polystyrene
sulfonate rectal
enema 30 gram/120
ml
2
SODIUM
POLYSTYRENE
SULFONATE
RECTAL ENEMA
50 GRAM/200 ML
4
sps (with sorbitol)
oral suspension
2
sps (with sorbitol)
rectal enema
2
SYPRINE ORAL
CAPSULE
5 NEDS
trientine oral
capsule
5 NEDS
VELTASSA ORAL
POWDER IN
PACKET
4
Drug Name Drug
Tier
Requirements
/Limits
PHOSPHATE BINDERS
AURYXIA ORAL
TABLET
5 NEDS
FOSRENOL ORAL
POWDER IN
PACKET
4
FOSRENOL ORAL
TABLET,CHEWAB
LE
4
lanthanum oral
tablet,chewable
4
VITAMINS
FLUORABON
ORAL DROPS
4
fluoride (sodium)
oral drops
2
Drug Name Drug
Tier
Requirements
/Limits
GASTROINTESTINAL AGENTS
ANTISPASMODICS,
GASTROINTESTINAL
CUVPOSA ORAL
SOLUTION
4
dicyclomine oral
capsule
2
dicyclomine oral
solution
2
dicyclomine oral
tablet
2
glycopyrrolate oral
tablet 1 mg, 2 mg
2
methscopolamine
oral tablet
2
GASTROINTESTINAL AGENTS,
OTHER
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
74
amoxicil-
clarithromy-
lansopraz oral
combo pack
4
chlordiazepoxide-
clidinium oral
capsule
2
diphenoxylate-
atropine oral liquid
2
diphenoxylate-
atropine oral tablet
2
ENDARI ORAL
POWDER IN
PACKET
5 NEDS
ENTEREG ORAL
CAPSULE
4
GATTEX 30-VIAL
SUBCUTANEOUS
KIT
5 PA; NEDS
GATTEX ONE-
VIAL
SUBCUTANEOUS
KIT
5 PA; NEDS
loperamide oral
capsule
2
metoclopramide hcl
injection solution
4
metoclopramide hcl
oral solution
2
metoclopramide hcl
oral tablet
2
metoclopramide hcl
oral
tablet,disintegrating
2
Drug Name Drug
Tier
Requirements
/Limits
MOVANTIK ORAL
TABLET
4 PA
NUTRESTORE
ORAL POWDER IN
PACKET
4
PYLERA ORAL
CAPSULE
4
RELISTOR ORAL
TABLET
4 PA
RELISTOR
SUBCUTANEOUS
SOLUTION
4 PA; QL (16.8
per 28 days)
RELISTOR
SUBCUTANEOUS
SYRINGE
4 PA
ursodiol oral
capsule
2
ursodiol oral tablet 2
HISTAMINE2 (H2) RECEPTOR
ANTAGONISTS
famotidine (pf)
intravenous solution
4
famotidine (pf)-nacl
(iso-os) intravenous
piggyback
4
famotidine
intravenous solution
4
famotidine oral
suspension
2
famotidine oral
tablet 20 mg, 40 mg
2
nizatidine oral
capsule
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
75
nizatidine oral
solution
2
ranitidine hcl
injection solution
4
ranitidine hcl oral
capsule
1
ranitidine hcl oral
syrup
1
ranitidine hcl oral
tablet 150 mg, 300
mg
1
IRRITABLE BOWEL SYNDROME
AGENTS
alosetron oral tablet 4 PA
AMITIZA ORAL
CAPSULE
4 PA; QL (180
per 90 days)
LINZESS ORAL
CAPSULE
3
LAXATIVES
constulose oral
solution
2
enulose oral solution 2
gavilyte-c oral recon
soln
2
gavilyte-g oral recon
soln
2
gavilyte-n oral recon
soln
2
generlac oral
solution
2
GOLYTELY ORAL
POWDER IN
PACKET
4
Drug Name Drug
Tier
Requirements
/Limits
KRISTALOSE
ORAL PACKET
3
lactulose oral
solution
2
MOVIPREP ORAL
POWDER IN
PACKET
4
OSMOPREP ORAL
TABLET
4
peg 3350-
electrolytes oral
recon soln
2
peg-electrolyte oral
recon soln
2
polyethylene glycol
3350 oral powder
2
polyethylene glycol
3350 oral powder in
packet
2
SUPREP BOWEL
PREP KIT ORAL
RECON SOLN
4
trilyte with flavor
packets oral recon
soln
2
PROTECTANTS
misoprostol oral
tablet
2
sucralfate oral tablet 2
PROTON PUMP INHIBITORS
esomeprazole
magnesium oral
capsule,delayed
release(dr/ec)
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
76
lansoprazole oral
capsule,delayed
release(dr/ec)
2
omeppi oral capsule 4
omeprazole oral
capsule,delayed
release(dr/ec)
2
omeprazole-sodium
bicarbonate oral
capsule
4
omeprazole-sodium
bicarbonate oral
packet
4
pantoprazole
intravenous recon
soln
4
pantoprazole oral
tablet,delayed
release (dr/ec)
2
rabeprazole oral
tablet,delayed
release (dr/ec)
2
Drug Name Drug
Tier
Requirements
/Limits
GENETIC OR ENZYME
DISORDER: REPLACEMENT,
MODIFIERS, TREATMENT
GENETIC OR ENZYME DISORDER:
REPLACEMENT, MODIFIERS,
TREATMENT
ADAGEN
INTRAMUSCULA
R SOLUTION
5 NEDS
ALDURAZYME
INTRAVENOUS
SOLUTION
5 NEDS
BUPHENYL ORAL
TABLET
4
CERDELGA ORAL
CAPSULE
5 NEDS
CEREZYME
INTRAVENOUS
RECON SOLN 400
UNIT
5 NEDS
CHOLBAM ORAL
CAPSULE
5 PA; NEDS
CREON ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
3
CYSTADANE
ORAL POWDER
4
CYSTAGON ORAL
CAPSULE
4
ELAPRASE
INTRAVENOUS
SOLUTION
5 NEDS
ELELYSO
INTRAVENOUS
RECON SOLN
5 NEDS
FABRAZYME
INTRAVENOUS
RECON SOLN
5 NEDS
KANUMA
INTRAVENOUS
SOLUTION
5 PA; NEDS
KUVAN ORAL
POWDER IN
PACKET
5 NEDS
KUVAN ORAL
TABLET,SOLUBL
E
5 NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
77
LUMIZYME
INTRAVENOUS
RECON SOLN
5 B/D PA;
NEDS
miglustat oral
capsule
5 NEDS
NAGLAZYME
INTRAVENOUS
SOLUTION
5 NEDS
ORFADIN ORAL
CAPSULE
5 NEDS
ORFADIN ORAL
SUSPENSION
5 NEDS
PANCREAZE
ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
10,500-35,500-
61,500 UNIT,
16,800-56,800-
98,400 UNIT, 2,600-
6,200- 10,850 UNIT,
21,000-54,700-
83,900 UNIT, 4,200-
14,200- 24,600
UNIT
3
PERTZYE ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
4
PROCYSBI ORAL
CAPSULE,
DELAYED REL
SPRINKLE
5 PA; NEDS
RAVICTI ORAL
LIQUID
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
sodium
phenylbutyrate oral
powder
2
sodium
phenylbutyrate oral
tablet
4
STRENSIQ
SUBCUTANEOUS
SOLUTION
5 PA; NEDS
SUCRAID ORAL
SOLUTION
5 NEDS
VPRIV
INTRAVENOUS
RECON SOLN
5 NEDS
ZAVESCA ORAL
CAPSULE
5 NEDS
ZENPEP ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
10,000-32,000 -
42,000 UNIT,
10,000-34,000 -
55,000 UNIT,
15,000-51,000 -
82,000 UNIT,
20,000-63,000-
84,000 UNIT,
25,000-79,000-
105,000 UNIT,
25,000-85,000-
136,000 UNIT,
3,000-10,000-
16,000 UNIT, 5,000-
17,000- 24,000
UNIT
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
78
ZENPEP ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
40,000-126,000-
168,000 UNIT
5 NEDS
Drug Name Drug
Tier
Requirements
/Limits
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
flavoxate oral tablet 2
MYRBETRIQ
ORAL TABLET
EXTENDED
RELEASE 24 HR
3
oxybutynin chloride
oral syrup
2
oxybutynin chloride
oral tablet
2
oxybutynin chloride
oral tablet extended
release 24hr
2 QL (180 per
90 days)
tolterodine oral
capsule,extended
release 24hr
2
tolterodine oral
tablet
2
TOVIAZ ORAL
TABLET
EXTENDED
RELEASE 24 HR
3
trospium oral
capsule,extended
release 24hr
2 QL (90 per 90
days)
trospium oral tablet 2
VESICARE ORAL
TABLET
3
BENIGN PROSTATIC
HYPERTROPHY AGENTS
alfuzosin oral tablet
extended release 24
hr
2 QL (90 per 90
days)
CARDURA XL
ORAL TABLET
EXTENDED
RELEASE 24HR
4 QL (90 per 90
days)
dutasteride oral
capsule
2 QL (90 per 90
days)
finasteride oral
tablet 5 mg
2
tamsulosin oral
capsule,extended
release 24hr
2 QL (180 per
90 days)
GENITOURINARY AGENTS,
OTHER
bethanechol chloride
oral tablet
2
ELMIRON ORAL
CAPSULE
3
PHOSPHATE BINDERS
calcium acetate oral
capsule
2
calcium acetate oral
tablet 667 mg
2
eliphos oral tablet 2
PHOSLYRA ORAL
SOLUTION
4
RENAGEL ORAL
TABLET
4
RENVELA ORAL
TABLET
3
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
79
sevelamer carbonate
oral powder in
packet
2
sevelamer carbonate
oral tablet
2
Drug Name Drug
Tier
Requirements
/Limits
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/
MODIFYING (ADRENAL)
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/MOD
IFYING (ADRENAL)
a-hydrocort
injection recon soln
2
ala-cort topical
cream 2.5 %
2
alclometasone
topical cream
2
alclometasone
topical ointment
2
amcinonide topical
cream
4
amcinonide topical
lotion
4
amcinonide topical
ointment
4
betamethasone
dipropionate topical
cream
2
betamethasone
dipropionate topical
lotion
2
betamethasone
dipropionate topical
ointment
2
betamethasone
valerate topical
cream
2
betamethasone
valerate topical
lotion
2
betamethasone
valerate topical
ointment
2
betamethasone,
augmented topical
cream
2
betamethasone,
augmented topical
gel
2
betamethasone,
augmented topical
lotion
2
betamethasone,
augmented topical
ointment
2
budesonide oral
capsule,delayed,exte
nd.release
4
CAPEX TOPICAL
SHAMPOO
3
clobetasol scalp
solution
4
clobetasol topical
cream
4
clobetasol topical
foam
4
clobetasol topical
gel
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
80
clobetasol topical
lotion
4
clobetasol topical
ointment
4
clobetasol topical
shampoo
4
clobetasol topical
spray,non-aerosol
4
clobetasol-emollient
topical cream
4
clobetasol-emollient
topical foam
4
clodan topical
shampoo
4
CORDRAN LARGE
ROLL TOPICAL
TAPE
3
cortisone oral tablet 2
decadron oral elixir 1
decadron oral tablet 1
deltasone oral tablet
20 mg
2
desonide topical
cream
4
desonide topical
lotion
4
desonide topical
ointment
4
desoximetasone
topical cream
4
desoximetasone
topical gel
2
desoximetasone
topical ointment
4
Drug Name Drug
Tier
Requirements
/Limits
dexamethasone
intensol oral drops
2
dexamethasone oral
elixir
1
dexamethasone oral
solution
1
dexamethasone oral
tablet
1
dexamethasone
sodium phosphate
injection solution 4
mg/ml
4
dexamethasone
sodium phosphate
injection syringe
4
diflorasone topical
cream
4
diflorasone topical
ointment
4
fludrocortisone oral
tablet
2
fluocinolone
acetonide oil otic
(ear) drops
2
fluocinolone and
shower cap scalp oil
2
fluocinolone topical
cream
2
fluocinolone topical
oil
2
fluocinolone topical
ointment
2
fluocinolone topical
solution
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
81
fluocinonide topical
cream
4
fluocinonide topical
gel
4
fluocinonide topical
ointment
4
fluocinonide topical
solution
4
fluocinonide-e
topical cream
4
fluocinonide-
emollient topical
cream
4
fluticasone topical
cream
2
fluticasone topical
ointment
2
halobetasol
propionate topical
cream
2
halobetasol
propionate topical
ointment
2
HALOG TOPICAL
CREAM
4
hydrocortisone
butyrate topical
cream
2
hydrocortisone
butyrate topical
ointment
2
hydrocortisone
butyrate topical
solution
2
Drug Name Drug
Tier
Requirements
/Limits
hydrocortisone
butyr-emollient
topical cream
2
hydrocortisone oral
tablet
1
hydrocortisone
topical cream 2.5 %
2
hydrocortisone
topical cream with
perineal applicator
2.5 %
2
hydrocortisone
topical lotion 2.5 %
2
hydrocortisone
topical ointment 1
%, 2.5 %
2
hydrocortisone
valerate topical
cream
2
hydrocortisone
valerate topical
ointment
2
hydrocortisone-min
oil-wht pet topical
ointment
2
methylprednisolone
acetate injection
suspension
4
methylprednisolone
oral tablet
1
methylprednisolone
oral tablets,dose
pack
1
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
82
methylprednisolone
sodium succ injection recon soln 125 mg, 40 mg
4
methylprednisolone
sodium succ intravenous recon soln
4
mometasone topical cream
2
mometasone topical ointment
2
mometasone topical solution
2
nolix topical cream 4
PANDEL TOPICAL
CREAM
4
prednicarbate topical cream
2
prednicarbate
topical ointment 2
prednisolone oral
solution 15 mg/5 ml
2
prednisolone sodium phosphate oral
solution 10 mg/5 ml
4
prednisolone sodium
phosphate oral
solution 15 mg/5 ml
(3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5
mg base/5 ml (6.7
mg/5 ml)
2
Drug Name Drug
Tier
Requirements
/Limits
prednisolone sodium phosphate oral tablet,disintegrating 15 mg, 30 mg
2
prednisone intensol oral concentrate
2
prednisone oral
solution 2
prednisone oral
tablet 2
prednisone oral
tablets,dose pack 2
procto-med hc
topical cream with perineal applicator
2
procto-pak topical
cream with perineal
applicator
2
proctosol hc topical
cream with perineal
applicator
2
proctozone-hctopical cream with
perineal applicator
2
SOLU-CORTEF
(PF) INJECTION
RECON SOLN
4
SOLU-CORTEF
INJECTION
RECON SOLN
4
SOLU-MEDROL
INTRAVENOUS
RECON SOLN 2
GRAM
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
83
TOPICORT
TOPICAL
SPRAY,NON-
AEROSOL
4
triamcinolone
acetonide nasal
aerosol,spray
2
triamcinolone
acetonide topical
cream
2
triamcinolone
acetonide topical
lotion
2
triamcinolone
acetonide topical
ointment 0.025 %,
0.1 %, 0.5 %
2
triderm topical
cream
2
veripred 20 oral
solution
2
Drug Name Drug
Tier
Requirements
/Limits
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/
MODIFYING (PITUITARY)
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/MOD
IFYING (PITUITARY)
CHORIONIC
GONADOTROPIN,
HUMAN
INTRAMUSCULA
R RECON SOLN
4 PA
desmopressin
injection solution
4
desmopressin nasal
solution
4
desmopressin nasal
spray with pump
4
desmopressin nasal
spray,non-aerosol
4
desmopressin oral
tablet
2
EGRIFTA
SUBCUTANEOUS
RECON SOLN 1
MG
5 NEDS
GENOTROPIN
MINIQUICK
SUBCUTANEOUS
SYRINGE 0.2
MG/0.25 ML
4 PA
GENOTROPIN
MINIQUICK
SUBCUTANEOUS
SYRINGE 0.4
MG/0.25 ML, 0.6
MG/0.25 ML, 0.8
MG/0.25 ML, 1
MG/0.25 ML, 1.2
MG/0.25 ML, 1.4
MG/0.25 ML, 1.6
MG/0.25 ML, 1.8
MG/0.25 ML, 2
MG/0.25 ML
5 PA; NEDS
GENOTROPIN
SUBCUTANEOUS
CARTRIDGE
5 PA; NEDS
HUMATROPE
INJECTION
CARTRIDGE
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
84
HUMATROPE
INJECTION
RECON SOLN
5 PA; NEDS
INCRELEX
SUBCUTANEOUS
SOLUTION
5 PA; NEDS
MYALEPT
SUBCUTANEOUS
RECON SOLN
5 PA; NEDS
NORDITROPIN
FLEXPRO
SUBCUTANEOUS
PEN INJECTOR
5 PA; NEDS
NOVAREL
INTRAMUSCULA
R RECON SOLN
4 PA
NUTROPIN AQ
NUSPIN
SUBCUTANEOUS
PEN INJECTOR
5 PA; NEDS
OMNITROPE
SUBCUTANEOUS
CARTRIDGE
4 PA
OMNITROPE
SUBCUTANEOUS
RECON SOLN
5 PA; NEDS
PREGNYL
INTRAMUSCULA
R RECON SOLN
4 PA
SAIZEN
CLICK.EASY
SUBCUTANEOUS
CARTRIDGE
5 PA; NEDS
SAIZEN
SAIZENPREP
SUBCUTANEOUS
CARTRIDGE
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
SAIZEN
SUBCUTANEOUS
RECON SOLN
5 PA; NEDS
SEROSTIM
SUBCUTANEOUS
RECON SOLN 4
MG, 5 MG, 6 MG
5 PA; NEDS
STIMATE NASAL
SPRAY,NON-
AEROSOL
3
Drug Name Drug
Tier
Requirements
/Limits
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/
MODIFYING (SEX
HORMONES/MODIFIERS)
ANABOLIC STEROIDS
ANADROL-50
ORAL TABLET
4 PA
oxandrolone oral
tablet
2 PA
ANDROGENS
ANDRODERM
TRANSDERMAL
PATCH 24 HOUR
3 PA; QL (90
per 90 days)
ANDROGEL
TRANSDERMAL
GEL IN
METERED-DOSE
PUMP 20.25
MG/1.25 GRAM
(1.62 %)
3 PA; QL (450
per 90 days)
ANDROGEL
TRANSDERMAL
GEL IN PACKET
1.62 % (20.25
MG/1.25 GRAM)
3 PA; QL (225
per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
85
ANDROGEL
TRANSDERMAL
GEL IN PACKET
1.62 % (40.5
MG/2.5 GRAM)
3 PA; QL (450
per 90 days)
danazol oral capsule 2
METHITEST
ORAL TABLET
4
methyltestosterone
oral capsule
2
TESTIM
TRANSDERMAL
GEL
4 PA; QL (900
per 90 days)
testosterone
cypionate
intramuscular oil
4
testosterone
enanthate
intramuscular oil
4
testosterone
transdermal gel
2 PA; QL (900
per 90 days)
testosterone
transdermal gel in
packet 1 % (25
mg/2.5gram)
2 PA; QL (900
per 90 days)
ESTROGENS
amabelz oral tablet 2 PA
amethia lo oral
tablets,dose pack,3
month
2 QL (91 per 91
days)
amethia oral
tablets,dose pack,3
month
4 QL (91 per 91
days)
amethyst oral tablet 2
apri oral tablet 2
Drug Name Drug
Tier
Requirements
/Limits
ashlyna oral
tablets,dose pack,3
month
4 QL (91 per 91
days)
azurette (28) oral
tablet
2
bekyree (28) oral
tablet
2
blisovi fe 1.5/30 (28)
oral tablet
2
blisovi fe 1/20 (28)
oral tablet
2
camrese lo oral
tablets,dose pack,3
month
2 QL (91 per 91
days)
camrese oral
tablets,dose pack,3
month
4 QL (91 per 91
days)
caziant (28) oral
tablet
2
cyred oral tablet 2
daysee oral
tablets,dose pack,3
month
4 QL (91 per 91
days)
DEPO-ESTRADIOL
INTRAMUSCULA
R OIL
4
desogestrel-ethinyl
estradiol oral tablet
2
DIVIGEL
TRANSDERMAL
GEL IN PACKET
4
drospirenone-
e.estradiol-lm.fa
oral tablet
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
86
emoquette oral
tablet
2
enskyce oral tablet 2
estarylla oral tablet 2
ESTRACE
VAGINAL CREAM
3
estradiol oral tablet 2 PA
estradiol vaginal
cream
2
estradiol vaginal
tablet
2
estradiol valerate
intramuscular oil 20
mg/ml, 40 mg/ml
4
estradiol-
norethindrone acet
oral tablet
2 PA
ESTRING
VAGINAL RING
3 QL (1 per 90
days)
ethynodiol diac-eth
estradiol oral tablet
1-50 mg-mcg
2
FEMRING
VAGINAL RING
3 QL (1 per 90
days)
femynor oral tablet 2
fyavolv oral tablet 2 PA
isibloom oral tablet 2
jinteli oral tablet 2 PA
juleber oral tablet 2
junel 1/20 (21) oral
tablet
2
junel fe 1.5/30 (28)
oral tablet
2
Drug Name Drug
Tier
Requirements
/Limits
junel fe 1/20 (28)
oral tablet
2
kariva (28) oral
tablet
2
kelnor 1-50 oral
tablet
2
kimidess (28) oral
tablet
2
l norgest/e.estradiol-
e.estrad oral
tablets,dose pack,3
month 0.10 mg-20
mcg (84)/10 mcg (7)
2 QL (91 per 91
days)
l norgest/e.estradiol-
e.estrad oral
tablets,dose pack,3
month 0.15 mg-30
mcg (84)/10 mcg (7)
4 QL (91 per 91
days)
larin fe 1.5/30 (28)
oral tablet
2
larin fe 1/20 (28)
oral tablet
2
lillow oral tablet 2
LO LOESTRIN FE
ORAL TABLET
4
MENEST ORAL
TABLET 1.25 MG
4 PA
microgestin 1/20
(21) oral tablet
2
microgestin fe 1.5/30
(28) oral tablet
2
microgestin fe 1/20
(28) oral tablet
2
mimvey lo oral
tablet
2 PA
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
87
mimvey oral tablet 2 PA
mono-linyah oral
tablet
2
mononessa (28) oral
tablet
2
NATAZIA ORAL
TABLET
4
norethindrone ac-eth
estradiol oral tablet
0.5-2.5 mg-mcg, 1-5
mg-mcg
2 PA
norethindrone ac-eth
estradiol oral tablet
1-20 mg-mcg
2
norethindrone-
e.estradiol-iron oral
tablet 1 mg-20 mcg
(21)/75 mg (7)
2
norgestimate-ethinyl
estradiol oral tablet
2
NUVARING
VAGINAL RING
4 QL (3 per 84
days)
PREMARIN
VAGINAL CREAM
3
previfem oral tablet 2
rajani oral tablet 2
reclipsen (28) oral
tablet
2
SAFYRAL ORAL
TABLET
4
sprintec (28) oral
tablet
2
tarina fe 1/20 (28)
oral tablet
2
Drug Name Drug
Tier
Requirements
/Limits
tri femynor oral
tablet
2
tri-estarylla oral
tablet
2
tri-linyah oral tablet 2
tri-lo-estarylla oral
tablet
2
tri-lo-marzia oral
tablet
2
tri-lo-sprintec oral
tablet
2
trinessa (28) oral
tablet
2
trinessa lo oral
tablet
2
tri-previfem (28)
oral tablet
2
tri-sprintec (28) oral
tablet
2
tri-vylibra oral
tablet
2
tydemy oral tablet 2
velivet triphasic
regimen (28) oral
tablet
2
viorele (28) oral
tablet
2
vylibra oral tablet 2
xulane transdermal
patch weekly
2
yuvafem vaginal
tablet
2
zovia 1/50e (28) oral
tablet
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
88
PROGESTINS
camila oral tablet 2
deblitane oral tablet 2
DEPO-PROVERA
INTRAMUSCULA
R SUSPENSION
400 MG/ML
4
DEPO-SUBQ
PROVERA 104
SUBCUTANEOUS
SYRINGE
4
errin oral tablet 2
hydroxyprogesterone
caproate
intramuscular oil
4
jolivette oral tablet 2
lyza oral tablet 2
MAKENA (PF)
SUBCUTANEOUS
AUTO-INJECTOR
5 NEDS
MAKENA
INTRAMUSCULA
R OIL 250 MG/ML
(1 ML)
5 NEDS
medroxyprogesteron
e intramuscular
suspension
4
medroxyprogesteron
e intramuscular
syringe
4
medroxyprogesteron
e oral tablet
2
Drug Name Drug
Tier
Requirements
/Limits
megestrol oral
suspension 400
mg/10 ml (10 ml),
400 mg/10 ml (40
mg/ml), 625 mg/5 ml
4
megestrol oral tablet 2
nora-be oral tablet 2
norethindrone
(contraceptive) oral
tablet
2
norethindrone
acetate oral tablet
2
norlyroc oral tablet 2
progesterone
micronized oral
capsule
2
sharobel oral tablet 2
SELECTIVE ESTROGEN
RECEPTOR MODIFYING AGENTS
raloxifene oral tablet 1 QL (90 per 90
days)
Drug Name Drug
Tier
Requirements
/Limits
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/
MODIFYING (THYROID)
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/MOD
IFYING (THYROID)
levothyroxine
intravenous recon
soln 200 mcg, 500
mcg
1
levothyroxine oral
tablet
1
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
89
levoxyl oral tablet
100 mcg, 112 mcg,
125 mcg, 137 mcg,
150 mcg, 175 mcg,
200 mcg, 25 mcg, 50
mcg, 75 mcg, 88 mcg
1
liothyronine
intravenous solution
4
liothyronine oral
tablet
2
SYNTHROID
ORAL TABLET
4
thyroid (pork) oral
tablet 30 mg, 60 mg,
90 mg
4
THYROLAR-1 ORAL TABLET
3
THYROLAR-1/2 ORAL TABLET
3
THYROLAR-1/4 ORAL TABLET
3
THYROLAR-2 ORAL TABLET
3
THYROLAR-3 ORAL TABLET
3
unithroid oral tablet 1
Drug Name Drug
Tier
Requirements
/Limits
HORMONAL AGENTS,
SUPPRESSANT (ADRENAL)
HORMONAL AGENTS,
SUPPRESSANT (ADRENAL)
LYSODREN ORAL
TABLET 3
HORMONAL AGENTS,
SUPPRESSANT (PITUITARY)
HORMONAL AGENTS,
SUPPRESSANT (PITUITARY)
cabergoline oral
tablet
2
FIRMAGON KIT W
DILUENT
SYRINGE
SUBCUTANEOUS
RECON SOLN
4
leuprolide
subcutaneous kit
2
LUPRON DEPOT
(3 MONTH)
INTRAMUSCULA
R SYRINGE KIT
5 NEDS
LUPRON DEPOT
(4 MONTH)
INTRAMUSCULA
R SYRINGE KIT
5 NEDS
LUPRON DEPOT
(6 MONTH)
INTRAMUSCULA
R SYRINGE KIT
5 NEDS
LUPRON DEPOT
INTRAMUSCULA
R SYRINGE KIT
5 NEDS
LUPRON DEPOT-
PED (3 MONTH)
INTRAMUSCULA
R SYRINGE KIT
5 NEDS
LUPRON DEPOT-
PED
INTRAMUSCULA
R KIT
5 NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
90
octreotide acetate
injection solution
1,000 mcg/ml, 500
mcg/ml
5 NEDS
octreotide acetate
injection solution
100 mcg/ml, 200
mcg/ml, 50 mcg/ml
4
SANDOSTATIN
LAR DEPOT
INTRAMUSCULA
R
SUSPENSION,EXT
ENDED REL
RECON
5 NEDS
SIGNIFOR LAR
INTRAMUSCULA
R SUSPENSION
FOR
RECONSTITUTIO
N
5 NEDS
SIGNIFOR
SUBCUTANEOUS
SOLUTION
5 NEDS
SOMATULINE
DEPOT
SUBCUTANEOUS
SYRINGE
5 NEDS
SOMAVERT
SUBCUTANEOUS
RECON SOLN
5 PA; NEDS
SYNAREL NASAL
SPRAY,NON-
AEROSOL
3
Drug Name Drug
Tier
Requirements
/Limits
TRELSTAR
INTRAMUSCULA
R SUSPENSION
FOR
RECONSTITUTIO
N
5 NEDS
TRELSTAR
INTRAMUSCULA
R SYRINGE
5 NEDS
ZOLADEX
SUBCUTANEOUS
IMPLANT
4 QL (1.2 per 30
days)
Drug Name Drug
Tier
Requirements
/Limits
HORMONAL AGENTS,
SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole oral
tablet 10 mg, 5 mg
2
propylthiouracil oral
tablet
2
IMMUNOLOGICAL AGENTS
ANGIOEDEMA AGENTS
BERINERT
INTRAVENOUS
KIT
5 PA; NEDS
CINRYZE
INTRAVENOUS
RECON SOLN
5 NEDS
FIRAZYR
SUBCUTANEOUS
SYRINGE
5 PA; NEDS
HAEGARDA
SUBCUTANEOUS
RECON SOLN
5 NEDS
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
91
KALBITOR
SUBCUTANEOUS
SOLUTION
5 PA; NEDS
IMMUNE SUPPRESSANTS
ASTAGRAF XL
ORAL
CAPSULE,EXTEN
DED RELEASE
24HR 0.5 MG, 1
MG
4 B/D PA
ASTAGRAF XL
ORAL
CAPSULE,EXTEN
DED RELEASE
24HR 5 MG
5 B/D PA;
NEDS
azathioprine oral
tablet
2 B/D PA
azathioprine sodium
injection recon soln
4 B/D PA
BENLYSTA
INTRAVENOUS
RECON SOLN
5 NEDS
BENLYSTA
SUBCUTANEOUS
AUTO-INJECTOR
5 NEDS
BENLYSTA
SUBCUTANEOUS
SYRINGE
5 NEDS
CELLCEPT
INTRAVENOUS
RECON SOLN
4 B/D PA
CIMZIA POWDER
FOR RECONST
SUBCUTANEOUS
KIT
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
CIMZIA STARTER
KIT
SUBCUTANEOUS
SYRINGE KIT
5 PA; NEDS
CIMZIA
SUBCUTANEOUS
SYRINGE KIT
5 PA; NEDS
cyclosporine
intravenous solution
4 B/D PA
cyclosporine
modified oral
capsule
2 B/D PA
cyclosporine
modified oral
solution
2 B/D PA
cyclosporine oral
capsule
2 B/D PA
ENBREL MINI
SUBCUTANEOUS
CARTRIDGE
5 QL (8 per 28
days); NEDS
ENBREL
SUBCUTANEOUS
RECON SOLN
5 QL (16 per 28
days); NEDS
ENBREL
SUBCUTANEOUS
SYRINGE
5 QL (8 per 28
days); NEDS
ENBREL
SURECLICK
SUBCUTANEOUS
PEN INJECTOR
5 QL (8 per 28
days); NEDS
ENVARSUS XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
4 B/D PA
gengraf oral capsule
100 mg, 25 mg
2 B/D PA
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
92
gengraf oral solution 2 B/D PA
HUMIRA
PEDIATRIC
CROHN'S START
SUBCUTANEOUS
SYRINGE KIT
80MG/0.8ML
5 QL (2.8 per 28
days); NEDS
HUMIRA PEN
CROHN'S-UC-HS
START
SUBCUTANEOUS
PEN INJECTOR
KIT
5 QL (5.6 per 28
days); NEDS
HUMIRA PEN
PSORIASIS-
UVEITIS
SUBCUTANEOUS
PEN INJECTOR
KIT
5 QL (5.6 per 28
days); NEDS
HUMIRA PEN
SUBCUTANEOUS
PEN INJECTOR
KIT 40MG/0.8ML
5 QL (2.8 per 28
days); NEDS
HUMIRA
SUBCUTANEOUS
SYRINGE KIT 10
MG/0.2 ML, 20
MG/0.4 ML, 40
MG/0.8 ML
5 QL (5.6 per 28
days); NEDS
INFLECTRA
INTRAVENOUS
RECON SOLN
5 NEDS
KINERET
SUBCUTANEOUS
SYRINGE
5 PA; QL (18.8
per 28 days);
NEDS
methotrexate sodium
(pf) injection recon
soln
4
Drug Name Drug
Tier
Requirements
/Limits
methotrexate sodium
(pf) injection
solution
4
methotrexate sodium
injection solution
4
methotrexate sodium
oral tablet
1 B/D PA
mycophenolate
mofetil hcl
intravenous recon
soln
4 B/D PA
mycophenolate
mofetil oral capsule
2 B/D PA
mycophenolate
mofetil oral
suspension for
reconstitution
5 B/D PA;
NEDS
mycophenolate
mofetil oral tablet
2 B/D PA
mycophenolate
sodium oral
tablet,delayed
release (dr/ec)
4 B/D PA
NULOJIX
INTRAVENOUS
RECON SOLN
5 B/D PA;
NEDS
ORENCIA
CLICKJECT
SUBCUTANEOUS
AUTO-INJECTOR
5 PA; NEDS
ORENCIA
SUBCUTANEOUS
SYRINGE
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
93
OTREXUP (PF)
SUBCUTANEOUS
AUTO-INJECTOR
10 MG/0.4 ML, 12.5
MG/0.4 ML, 15
MG/0.4 ML, 17.5
MG/0.4 ML, 20
MG/0.4 ML, 22.5
MG/0.4 ML, 25
MG/0.4 ML
4
PROGRAF
INTRAVENOUS
SOLUTION
4 B/D PA
RAPAMUNE
ORAL SOLUTION
4 B/D PA
RASUVO (PF)
SUBCUTANEOUS
AUTO-INJECTOR
10 MG/0.2 ML, 12.5
MG/0.25 ML, 15
MG/0.3 ML, 17.5
MG/0.35 ML, 20
MG/0.4 ML, 22.5
MG/0.45 ML, 25
MG/0.5 ML, 30
MG/0.6 ML, 7.5
MG/0.15 ML
4
REMICADE
INTRAVENOUS
RECON SOLN
5 NEDS
SANDIMMUNE
ORAL SOLUTION
4 B/D PA
SIMPONI ARIA
INTRAVENOUS
SOLUTION
5 PA; NEDS
SIMPONI
SUBCUTANEOUS
PEN INJECTOR
5 PA; NEDS
Drug Name Drug Tier
Requirements
/Limits
SIMPONI
SUBCUTANEOUS
SYRINGE
5 PA; NEDS
sirolimus oral tablet 4 B/D PA
tacrolimus oral
capsule
2 B/D PA
TORISEL
INTRAVENOUS
RECON SOLN
5 PA; NEDS
XATMEP ORAL
SOLUTION
5 B/D PA;
NEDS
XELJANZ ORAL
TABLET
5 PA; NEDS
XELJANZ XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
5 PA; NEDS
ZORTRESS ORAL
TABLET 0.25 MG
4 B/D PA
ZORTRESS ORAL
TABLET 0.5 MG,
0.75 MG
5 B/D PA;
NEDS
IMMUNIZING AGENTS, PASSIVE
BIVIGAM
INTRAVENOUS
SOLUTION
5 PA; NEDS
CARIMUNE NF
NANOFILTERED
INTRAVENOUS
RECON SOLN 6
GRAM
5 PA; NEDS
CUVITRU
SUBCUTANEOUS
SOLUTION
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
94
CYTOGAM
INTRAVENOUS
SOLUTION 50
MG/ML
4
FLEBOGAMMA
DIF
INTRAVENOUS
SOLUTION
5 PA; NEDS
GAMASTAN S/D
INTRAMUSCULA
R SOLUTION
4 PA
GAMMAGARD
LIQUID
INJECTION
SOLUTION
5 PA; NEDS
GAMMAGARD S-
D (IGA < 1
MCG/ML)
INTRAVENOUS
RECON SOLN
5 PA; NEDS
GAMMAKED
INJECTION
SOLUTION
5 PA; NEDS
GAMMAPLEX
(WITH SORBITOL)
INTRAVENOUS
SOLUTION
5 PA; NEDS
GAMMAPLEX
INTRAVENOUS
SOLUTION
5 PA; NEDS
GAMUNEX-C
INJECTION
SOLUTION
5 PA; NEDS
HIZENTRA
SUBCUTANEOUS
SOLUTION
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
HYPERHEP B S/D
INTRAMUSCULA
R SOLUTION
4
HYPERHEP B S/D
INTRAMUSCULA
R SYRINGE
4
HYPERHEP B S-D
NEONATAL
INTRAMUSCULA
R SYRINGE
4
HYPERRAB (PF)
INTRAMUSCULA
R SOLUTION
4
HYPERRAB S/D
(PF)
INTRAMUSCULA
R SOLUTION
4
HYPERTET S/D
(PF)
INTRAMUSCULA
R SYRINGE
4
HYQVIA
SUBCUTANEOUS
SOLUTION
5 B/D PA;
NEDS
IMOGAM RABIES-
HT (PF)
INTRAMUSCULA
R SOLUTION
4
NABI-HB
INTRAMUSCULA
R SOLUTION
4
OCTAGAM
INTRAVENOUS
SOLUTION
5 PA; NEDS
PRIVIGEN
INTRAVENOUS
SOLUTION
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
95
THYMOGLOBULI
N INTRAVENOUS
RECON SOLN
5 NEDS
VARIZIG
INTRAMUSCULA
R SOLUTION
3
IMMUNOMODULATORS
ACTEMRA
SUBCUTANEOUS
SYRINGE
5 PA; NEDS
ACTIMMUNE
SUBCUTANEOUS
SOLUTION
5 NEDS
ARCALYST
SUBCUTANEOUS
RECON SOLN
5 PA; NEDS
ILARIS (PF)
SUBCUTANEOUS
SOLUTION
5 PA; NEDS
leflunomide oral
tablet
2 QL (90 per 90
days)
LEMTRADA
INTRAVENOUS
SOLUTION
5 PA; QL (6 per
365 days);
NEDS
OTEZLA ORAL
TABLET
5 PA; NEDS
OTEZLA
STARTER ORAL
TABLETS,DOSE
PACK 10 MG (4)-
20 MG (4)-30 MG
(47)
5 PA; NEDS
RIDAURA ORAL
CAPSULE
3
Drug Name Drug
Tier
Requirements
/Limits
SIMULECT
INTRAVENOUS
RECON SOLN
5 B/D PA;
NEDS
SYLVANT
INTRAVENOUS
RECON SOLN
5 PA; NEDS
SYNAGIS
INTRAMUSCULA
R SOLUTION
5 NEDS
XOLAIR
SUBCUTANEOUS
RECON SOLN
5 PA; NEDS
VACCINES
ACTHIB (PF)
INTRAMUSCULA
R RECON SOLN
3
ADACEL(TDAP
ADOLESN/ADULT
)(PF)
INTRAMUSCULA
R SUSPENSION
3
ADACEL(TDAP
ADOLESN/ADULT
)(PF)
INTRAMUSCULA
R SYRINGE
3
BCG VACCINE,
LIVE (PF)
PERCUTANEOUS
SUSPENSION FOR
RECONSTITUTIO
N
3
BEXSERO
INTRAMUSCULA
R SYRINGE
3
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
96
BOOSTRIX TDAP
INTRAMUSCULA
R SUSPENSION
3
BOOSTRIX TDAP
INTRAMUSCULA
R SYRINGE
3
DAPTACEL (DTAP
PEDIATRIC) (PF)
INTRAMUSCULA
R SUSPENSION
3
ENGERIX-B (PF)
INTRAMUSCULA
R SUSPENSION
3 B/D PA
ENGERIX-B (PF)
INTRAMUSCULA
R SYRINGE
3 B/D PA
ENGERIX-B
PEDIATRIC (PF)
INTRAMUSCULA
R SYRINGE
3 B/D PA
GARDASIL 9 (PF)
INTRAMUSCULA
R SUSPENSION
3
GARDASIL 9 (PF)
INTRAMUSCULA
R SYRINGE
3
HAVRIX (PF)
INTRAMUSCULA
R SUSPENSION
3
HAVRIX (PF)
INTRAMUSCULA
R SYRINGE
3
HIBERIX (PF)
INTRAMUSCULA
R RECON SOLN
3
Drug Name Drug
Tier
Requirements
/Limits
IMOVAX RABIES
VACCINE (PF)
INTRAMUSCULA
R RECON SOLN
3
INFANRIX (DTAP)
(PF)
INTRAMUSCULA
R SUSPENSION
3
INFANRIX (DTAP)
(PF)
INTRAMUSCULA
R SYRINGE
3
IPOL INJECTION
SUSPENSION
3
IXIARO (PF)
INTRAMUSCULA
R SYRINGE
3
KINRIX (PF)
INTRAMUSCULA
R SUSPENSION
3
KINRIX (PF)
INTRAMUSCULA
R SYRINGE
3
MENACTRA (PF)
INTRAMUSCULA
R SOLUTION
3
MENVEO A-C-Y-
W-135-DIP (PF)
INTRAMUSCULA
R KIT
3
M-M-R II (PF)
SUBCUTANEOUS
RECON SOLN
3
PEDIARIX (PF)
INTRAMUSCULA
R SYRINGE
3
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
97
PEDVAX HIB (PF)
INTRAMUSCULA
R SOLUTION
3
PENTACEL (PF)
INTRAMUSCULA
R KIT
3
PROQUAD (PF)
SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTIO
N
3
QUADRACEL (PF)
INTRAMUSCULA
R SUSPENSION
3
RABAVERT (PF)
INTRAMUSCULA
R SUSPENSION
FOR
RECONSTITUTIO
N
3
RECOMBIVAX HB
(PF)
INTRAMUSCULA
R SUSPENSION
3 B/D PA
RECOMBIVAX HB
(PF)
INTRAMUSCULA
R SYRINGE
3 B/D PA
ROTARIX ORAL
SUSPENSION FOR
RECONSTITUTIO
N
3
ROTATEQ
VACCINE ORAL
SOLUTION
3
Drug Name Drug
Tier
Requirements
/Limits
SHINGRIX (PF)
INTRAMUSCULA
R SUSPENSION
FOR
RECONSTITUTIO
N
3
STAMARIL (PF)
SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTIO
N
3
TENIVAC (PF)
INTRAMUSCULA
R SUSPENSION
3
TENIVAC (PF)
INTRAMUSCULA
R SYRINGE
3
TETANUS,DIPHTH
ERIA TOX
PED(PF)
INTRAMUSCULA
R SUSPENSION
3
TETANUS-
DIPHTHERIA
TOXOIDS-TD
INTRAMUSCULA
R SUSPENSION
3
TRUMENBA
INTRAMUSCULA
R SYRINGE
3
TWINRIX (PF)
INTRAMUSCULA
R SYRINGE
3
TYPHIM VI
INTRAMUSCULA
R SOLUTION
3
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
98
TYPHIM VI
INTRAMUSCULA
R SYRINGE
3
VAQTA (PF)
INTRAMUSCULA
R SUSPENSION
3
VAQTA (PF)
INTRAMUSCULA
R SYRINGE
3
VARIVAX (PF)
SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTIO
N
3
YF-VAX (PF)
SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTIO
N
3
ZOSTAVAX (PF)
SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTIO
N
3
Drug Name Drug
Tier
Requirements
/Limits
INFLAMMATORY BOWEL
DISEASE AGENTS
AMINOSALICYLATES
ASACOL HD
ORAL
TABLET,DELAYE
D RELEASE
(DR/EC)
3
balsalazide oral
capsule
2
CANASA RECTAL
SUPPOSITORY
3
DELZICOL ORAL
CAPSULE (WITH
DEL REL
TABLETS)
3
DIPENTUM ORAL
CAPSULE
4
LIALDA ORAL
TABLET,DELAYE
D RELEASE
(DR/EC)
4
mesalamine oral
tablet,delayed
release (dr/ec) 1.2
gram
4
MESALAMINE
ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 800 MG
3
mesalamine rectal
enema
4
mesalamine with
cleansing wipe
rectal enema kit
4
PENTASA ORAL
CAPSULE,
EXTENDED
RELEASE
3
GLUCOCORTICOIDS
colocort rectal
enema
2
hydrocortisone
rectal enema
2
hydrocortisone-
pramoxine rectal
cream 1-1 %
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
99
SULFONAMIDES
sulfasalazine oral
tablet
1
sulfasalazine oral
tablet,delayed
release (dr/ec)
2
Drug Name Drug
Tier
Requirements
/Limits
METABOLIC BONE DISEASE
AGENTS
METABOLIC BONE DISEASE
AGENTS
alendronate oral
solution
2
alendronate oral
tablet 10 mg, 40 mg,
5 mg
2 QL (90 per 90
days)
alendronate oral
tablet 35 mg, 70 mg
2 QL (12 per 84
days)
calcitonin (salmon)
nasal spray,non-
aerosol
2
calcitriol
intravenous solution
1 mcg/ml
4
calcitriol oral
capsule
2
calcitriol oral
solution
2
etidronate disodium
oral tablet
2
FORTEO
SUBCUTANEOUS
PEN INJECTOR
5 PA; QL (3 per
28 days);
NEDS
FOSAMAX PLUS
D ORAL TABLET
4 QL (12 per 84
days)
ibandronate
intravenous solution
4 B/D PA
ibandronate
intravenous syringe
4 B/D PA
ibandronate oral
tablet
2 QL (3 per 84
days)
MIACALCIN
INJECTION
SOLUTION
4
NATPARA
SUBCUTANEOUS
CARTRIDGE
5 PA; NEDS
pamidronate
intravenous solution
4
PARICALCITOL
HEMODIALYSIS
PORT INJECTION
SOLUTION
4
paricalcitol
intravenous solution
4
paricalcitol oral
capsule
2
PROLIA
SUBCUTANEOUS
SYRINGE
4 PA
risedronate oral
tablet 150 mg
2 QL (3 per 84
days)
risedronate oral
tablet 30 mg, 5 mg
2 QL (90 per 90
days)
risedronate oral
tablet 35 mg, 35 mg
(12 pack), 35 mg (4
pack)
2 QL (12 per 84
days)
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
100
risedronate oral
tablet,delayed
release (dr/ec)
2 QL (12 per 84
days)
SENSIPAR ORAL
TABLET
3
TYMLOS
SUBCUTANEOUS
PEN INJECTOR
3
XGEVA
SUBCUTANEOUS
SOLUTION
5 PA; NEDS
zoledronic acid
intravenous solution
4
zoledronic acid-
mannitol-water
intravenous
piggyback
4
ZOMETA
INTRAVENOUS
PIGGYBACK
5 NEDS
Drug Name Drug
Tier
Requirements
/Limits
MISCELLANEOUS
THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC
AGENTS
ACETADOTE
INTRAVENOUS
SOLUTION
3
acetylcysteine
intravenous solution
2
alcohol pads topical
pads, medicated
1
CALCIUM
DISODIUM
VERSENATE
INJECTION
SOLUTION
4
deferoxamine
injection recon soln
2
freamine iii 10 %
intravenous
parenteral solution
2 B/D PA
GAUZE PADS 2 X
2
2
INSULIN PEN
NEEDLE
1
INSULIN
SYRINGE (DISP)
U-100 0.3 ML, 1
ML, 1/2 ML
1
md-gastroview oral
solution
2
METHYLERGONO
VINE INJECTION
SOLUTION
4
METOPIRONE
ORAL CAPSULE
3
NEEDLES,
INSULIN
DISP.,SAFETY
1
NOVOFINE 32
NEEDLE
1
NOVOFINE PLUS
NEEDLE
1
NOVOPEN ECHO
SUBCUTANEOUS
INSULIN PEN
1
Drug Name Drug
Tier
Requirements
/Limits
2-GenericDrug Tier: 1-Preferred Generic
5-Specialty Drugs
3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
101
NOVOTWIST
NEEDLE 32
GAUGE X 1/5"
1
VGO 20 DEVICE 1
VGO 30 DEVICE 1
VGO 40 DEVICE 1
VIMIZIM
INTRAVENOUS
SOLUTION
5 PA; NEDS
water for irrigation,
sterile irrigation
solution
4
XIAFLEX
INJECTION
RECON SOLN
5 PA; QL (1 per
30 days);
NEDS
Drug Name Drug
Tier
Requirements
/Limits
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
atropine ophthalmic
(eye) drops
2
bacitracin-
polymyxin b
ophthalmic (eye)
ointment
2
CYSTARAN
OPHTHALMIC
(EYE) DROPS
5 NEDS
LACRISERT
OPHTHALMIC
(EYE) INSERT
3
neomycin-
bacitracin-
polymyxin
ophthalmic (eye)
ointment
2
neo-polycin
ophthalmic (eye)
ointment
2
polycin ophthalmic
(eye) ointment
2
RESTASIS
MULTIDOSE
OPHTHALMIC
(EYE) DROPS
3
RESTASIS
OPHTHALMIC
(EYE)
DROPPERETTE
3
OPHTHALMIC ANTI-ALLERGY
AGENTS
ALOCRIL
OPHTHALMIC
(EYE) DROPS
3
azelastine
ophthalmic (eye)
drops
2
cromolyn
ophthalmic (eye)
drops
2
EMADINE
OPHTHALMIC
(EYE) DROPS
4
epinastine
ophthalmic (eye)
drops
2
olopatadine
ophthalmic (eye)
drops 0.1 %
2
PAZEO
OPHTHALMIC (EYE) DROPS
3
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
102
OPHTHALMIC ANTIGLAUCOMA
AGENTS
ALPHAGAN P
OPHTHALMIC
(EYE) DROPS 0.1
%
3
apraclonidine
ophthalmic (eye)
drops
2
AZOPT
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
3
betaxolol ophthalmic
(eye) drops
1
BETOPTIC S
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
3
bimatoprost
ophthalmic (eye)
drops
4
brimonidine
ophthalmic (eye)
drops
2
carteolol ophthalmic
(eye) drops
2
COMBIGAN
OPHTHALMIC
(EYE) DROPS
3
COSOPT (PF)
OPHTHALMIC
(EYE)
DROPPERETTE
4
Drug Name Drug
Tier
Requirements
/Limits
dorzolamide
ophthalmic (eye)
drops
2
dorzolamide-timolol
ophthalmic (eye)
drops
2
IOPIDINE
OPHTHALMIC
(EYE)
DROPPERETTE
4
levobunolol
ophthalmic (eye)
drops 0.5 %
2
metipranolol
ophthalmic (eye)
drops
2
PHOSPHOLINE
IODIDE
OPHTHALMIC
(EYE) DROPS
3
pilocarpine hcl
ophthalmic (eye)
drops 1 %, 2 %, 4 %
2
SIMBRINZA
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
3
timolol maleate
ophthalmic (eye)
drops
1
timolol maleate
ophthalmic (eye) gel
forming solution
1
OPHTHALMIC ANTI-
INFLAMMATORIES
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
103
ACUVAIL (PF)
OPHTHALMIC
(EYE)
DROPPERETTE
4
BLEPHAMIDE
S.O.P.
OPHTHALMIC
(EYE) OINTMENT
3
bromfenac
ophthalmic (eye)
drops
2
dexamethasone
sodium phosphate
ophthalmic (eye)
drops
2
DUREZOL
OPHTHALMIC
(EYE) DROPS
3
fluorometholone
ophthalmic (eye)
drops,suspension
2
flurbiprofen sodium
ophthalmic (eye)
drops
2
FML FORTE
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
4
FML S.O.P.
OPHTHALMIC
(EYE) OINTMENT
4
ILEVRO
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
4
Drug Name Drug
Tier
Requirements
/Limits
ketorolac
ophthalmic (eye)
drops
2
NEVANAC
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
4
PRED MILD
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
3
PRED-G
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
4
PRED-G S.O.P.
OPHTHALMIC
(EYE) OINTMENT
4
prednisolone acetate
ophthalmic (eye)
drops,suspension
2
prednisolone sodium
phosphate
ophthalmic (eye)
drops
2
sulfacetamide-
prednisolone
ophthalmic (eye)
drops
1
TOBRADEX
OPHTHALMIC
(EYE) OINTMENT
3
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
104
TOBRADEX ST
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
3
tobramycin-
dexamethasone
ophthalmic (eye)
drops,suspension
2
OPHTHALMIC PROSTAGLANDIN
AND PROSTAMIDE ANALOGS
latanoprost
ophthalmic (eye)
drops
2
LUMIGAN
OPHTHALMIC
(EYE) DROPS 0.01
%
3
TRAVATAN Z
OPHTHALMIC
(EYE) DROPS
3
ZIOPTAN (PF)
OPHTHALMIC
(EYE)
DROPPERETTE
4
Drug Name Drug
Tier
Requirements
/Limits
OTIC AGENTS
OTIC AGENTS
CIPRO HC OTIC
(EAR)
DROPS,SUSPENSI
ON
4
CIPRODEX OTIC
(EAR)
DROPS,SUSPENSI
ON
3
COLY-MYCIN S
OTIC (EAR)
DROPS,SUSPENSI
ON
4
hydrocortisone-
acetic acid otic (ear)
drops
2
neomycin-
polymyxin-hc otic
(ear)
drops,suspension
2
neomycin-
polymyxin-hc otic
(ear) solution
2
Drug Name Drug
Tier
Requirements
/Limits
RESPIRATORY
TRACT/PULMONARY AGENTS
ANTIHISTAMINES
azelastine nasal
aerosol,spray
2
azelastine nasal
spray,non-aerosol
2
cetirizine oral
solution 1 mg/ml
2
cyproheptadine oral
syrup
2
cyproheptadine oral
tablet
2
desloratadine oral
tablet
2 QL (90 per 90
days)
desloratadine oral
tablet,disintegrating
2 QL (90 per 90
days)
diphenhydramine hcl
injection solution 50
mg/ml
4
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
105
diphenhydramine hcl
injection syringe
4
hydroxyzine hcl
intramuscular
solution
4
hydroxyzine hcl oral
solution 10 mg/5 ml
2
hydroxyzine hcl oral
tablet
2
hydroxyzine
pamoate oral
capsule 25 mg, 50
mg
2
levocetirizine oral
solution
2
levocetirizine oral
tablet
2 QL (90 per 90
days)
olopatadine nasal
spray,non-aerosol
2
ANTI-INFLAMMATORIES,
INHALED CORTICOSTEROIDS
ALVESCO
INHALATION HFA
AEROSOL
INHALER
3 QL (37 per 90
days)
ASMANEX HFA
AEROSOL
INHALER
3 QL (39 per 90
days)
Drug Name Drug
Tier
Requirements
/Limits
ASMANEX
TWISTHALER
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED 110
MCG (30 DOSES),
220 MCG (120
DOSES), 220 MCG
(30 DOSES), 220
MCG (60 DOSES)
3 QL (3 per 90
days)
BECONASE AQ
NASAL
SPRAY,NON-
AEROSOL
4
budesonide
inhalation
suspension for
nebulization
4 B/D PA
FLOVENT DISKUS
INHALATION
BLISTER WITH
DEVICE
3 QL (360 per
90 days)
FLOVENT HFA
AEROSOL
INHALER
3 QL (72 per 90
days)
flunisolide nasal
spray,non-aerosol
25 mcg (0.025 %)
2
fluticasone nasal
spray,suspension
2
mometasone nasal
spray,non-aerosol
2
OMNARIS NASAL
SPRAY,NON-
AEROSOL
4
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
106
PULMICORT
FLEXHALER
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED
3
QVAR
INHALATION
AEROSOL
3 QL (53 per 90
days)
QVAR
REDIHALER
INHALATION HFA
AEROSOL
BREATH
ACTIVATED
3 QL (64 per 90
days)
ANTILEUKOTRIENES
montelukast oral
granules in packet
2 QL (90 per 90
days)
montelukast oral
tablet
2 QL (90 per 90
days)
montelukast oral
tablet,chewable
2 QL (90 per 90
days)
zafirlukast oral
tablet
2 QL (180 per
90 days)
zileuton oral tablet,
er multiphase 12 hr
4 QL (360 per
90 days)
ZYFLO ORAL
TABLET
4
BRONCHODILATORS,
ANTICHOLINERGIC
ATROVENT HFA
AEROSOL
INHALER
3
ipratropium bromide
inhalation solution
1 B/D PA
Drug Name Drug
Tier
Requirements
/Limits
ipratropium bromide
nasal spray,non-
aerosol
1
SPIRIVA
RESPIMAT
INHALATION
MIST
3 QL (12 per 90
days)
SPIRIVA WITH
HANDIHALER
INHALATION
CAPSULE,
W/INHALATION
DEVICE
3 QL (90 per 90
days)
TUDORZA
PRESSAIR
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED
3 QL (3 per 90
days)
BRONCHODILATORS,
SYMPATHOMIMETIC
adrenalin injection
solution
4
albuterol sulfate
inhalation solution
for nebulization
1 B/D PA
albuterol sulfate oral
syrup
1
albuterol sulfate oral
tablet
1
albuterol sulfate oral
tablet extended
release 12 hr
1
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
107
ARCAPTA
NEOHALER
INHALATION
CAPSULE,
W/INHALATION
DEVICE
4 QL (90 per 90
days)
AUVI-Q
INJECTION AUTO-
INJECTOR
3
BROVANA
INHALATION
SOLUTION FOR
NEBULIZATION
4 B/D PA; QL
(360 per 90
days)
EPINEPHRINE
INJECTION AUTO-
INJECTOR 0.15
MG/0.15 ML, 0.3
MG/0.3 ML
4
EPINEPHRINE
INJECTION AUTO-
INJECTOR 0.15
MG/0.3 ML
3
EPIPEN 2-PAK
INJECTION AUTO-
INJECTOR
4
EPIPEN
INJECTION AUTO-
INJECTOR
4
EPIPEN JR 2-PAK
INJECTION AUTO-
INJECTOR
3
EPIPEN JR
INJECTION AUTO-
INJECTOR
3
levalbuterol hcl
inhalation solution
for nebulization
2 B/D PA
Drug Name Drug
Tier
Requirements
/Limits
LEVALBUTEROL
TARTRATE
INHALATION HFA
AEROSOL
INHALER
4 QL (90 per 90
days)
metaproterenol oral
syrup
2
metaproterenol oral
tablet
2
PERFOROMIST
INHALATION
SOLUTION FOR
NEBULIZATION
4 B/D PA
PROAIR HFA
AEROSOL
INHALER
3 QL (102 per
90 days)
PROAIR
RESPICLICK
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED
3 QL (12 per 90
days)
PROVENTIL HFA
AEROSOL
INHALER
3 QL (81 per 90
days)
SEREVENT
DISKUS
INHALATION
BLISTER WITH
DEVICE
3 QL (180 per
90 days)
STRIVERDI
RESPIMAT
INHALATION
MIST
3 QL (12 per 90
days)
terbutaline oral
tablet
2
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
108
terbutaline
subcutaneous
solution
4
VENTOLIN HFA
AEROSOL
INHALER
3 QL (216 per
90 days)
XOPENEX HFA
AEROSOL
INHALER
4 QL (90 per 90
days)
CYSTIC FIBROSIS AGENTS
CAYSTON
INHALATION
SOLUTION FOR
NEBULIZATION
5 PA; QL (84
per 28 days);
NEDS
KALYDECO ORAL
GRANULES IN
PACKET
5 PA; NEDS
KALYDECO ORAL
TABLET
5 PA; NEDS
ORKAMBI ORAL
TABLET
5 PA; NEDS
PULMOZYME
INHALATION
SOLUTION
5 B/D PA;
NEDS
TOBI PODHALER
INHALATION
CAPSULE
5 NEDS
TOBI PODHALER
INHALATION
CAPSULE,
W/INHALATION
DEVICE
5 NEDS
MAST CELL STABILIZERS
cromolyn inhalation
solution for
nebulization
2 B/D PA
Drug Name Drug
Tier
Requirements
/Limits
cromolyn oral
concentrate
4
PHOSPHODIESTERASE
INHIBITORS, AIRWAYS DISEASE
aminophylline
intravenous solution
4
DALIRESP ORAL
TABLET
4
ELIXOPHYLLIN
ORAL ELIXIR 80
MG/15 ML
4
theophylline oral
tablet extended
release 12 hr
2
theophylline oral
tablet extended
release 24 hr
2
PULMONARY
ANTIHYPERTENSIVES
ADCIRCA ORAL
TABLET
5 PA; QL (62
per 31 days);
NEDS
ADEMPAS ORAL
TABLET
5 PA; NEDS
LETAIRIS ORAL
TABLET
5 PA; NEDS
OPSUMIT ORAL
TABLET
5 PA; NEDS
ORENITRAM
ORAL TABLET
EXTENDED
RELEASE 0.125
MG
4 PA
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic
5-Specialty Drugs
2-Generic 3-Preferred Brand 4-Non-Preferred Drug
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
109
ORENITRAM
ORAL TABLET
EXTENDED
RELEASE 0.25 MG,
1 MG, 2.5 MG, 5
MG
5 PA; NEDS
REMODULIN
INJECTION
SOLUTION
5 B/D PA;
NEDS
REVATIO ORAL
SUSPENSION FOR
RECONSTITUTIO
N
5 PA; QL (180
per 30 days);
NEDS
sildenafil
(pulmonary arterial
hypertension)
intravenous solution
10 mg/12.5 ml
5 PA; QL (1163
per 31 days);
NEDS
sildenafil
(pulmonary arterial
hypertension) oral
tablet 20 mg
2 PA; QL (270
per 90 days)
TRACLEER ORAL
TABLET
5 PA; LA;
NEDS
TRACLEER ORAL
TABLET FOR
SUSPENSION
5 PA; LA;
NEDS
TYVASO
INHALATION
SOLUTION FOR
NEBULIZATION
5 B/D PA;
NEDS
TYVASO
INSTITUTIONAL
START KIT
INHALATION
SOLUTION FOR
NEBULIZATION
5 B/D PA;
NEDS
Drug Name Drug
Tier
Requirements
/Limits
TYVASO REFILL
KIT INHALATION
SOLUTION FOR
NEBULIZATION
5 B/D PA;
NEDS
TYVASO
STARTER KIT
INHALATION
SOLUTION FOR
NEBULIZATION
5 B/D PA;
NEDS
UPTRAVI ORAL
TABLET
5 PA; NEDS
UPTRAVI ORAL
TABLETS,DOSE
PACK
5 PA; NEDS
VENTAVIS
INHALATION
SOLUTION FOR
NEBULIZATION
5 B/D PA;
NEDS
PULMONARY FIBROSIS AGENTS
ESBRIET ORAL
CAPSULE
5 PA; NEDS
ESBRIET ORAL
TABLET
5 PA; NEDS
OFEV ORAL
CAPSULE
5 PA; NEDS
RESPIRATORY TRACT AGENTS,
OTHER
acetylcysteine
solution
2 B/D PA
ADVAIR DISKUS
INHALATION
BLISTER WITH
DEVICE
3 QL (180 per
90 days)
ADVAIR HFA
AEROSOL
INHALER
3 QL (36 per 90
days)
Drug Name Drug
Tier
Requirements
/Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug
5-Specialty Drugs
Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability
NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step
Therapy
Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.
110
ANORO ELLIPTA
INHALATION
BLISTER WITH
DEVICE
3 QL (180 per
90 days)
BREO ELLIPTA
INHALATION
BLISTER WITH
DEVICE
3 QL (180 per
90 days)
COMBIVENT
RESPIMAT
INHALATION
MIST
4
DULERA
INHALATION HFA
AEROSOL
INHALER
3 QL (39 per 90
days)
ipratropium-
albuterol inhalation
solution for
nebulization
2 B/D PA
PROLASTIN-C
INTRAVENOUS
RECON SOLN
5 PA; NEDS
PROLASTIN-C
INTRAVENOUS
SOLUTION
5 PA; NEDS
STIOLTO
RESPIMAT
INHALATION
MIST
3 QL (12 per 90
days)
SYMBICORT
INHALATION HFA
AEROSOL
INHALER
3 QL (30.6 per
90 days)
ZEMAIRA
INTRAVENOUS
RECON SOLN
5 PA; NEDS
Drug Name Drug
Tier
Requirements
/Limits
Drug Name Drug
Tier
Requirements
/Limits
SKELETAL MUSCLE
RELAXANTS
SKELETAL MUSCLE RELAXANTS
cyclobenzaprine oral
tablet
2
methocarbamol oral
tablet
2
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
zaleplon oral
capsule
2 QL (90 per 90
days)
zolpidem oral tablet 4 QL (90 per 90
days)
zolpidem oral
tablet,ext release
multiphase
4 QL (90 per 90
days)
zolpidem sublingual
tablet
4 QL (90 per 90
days)
SLEEP DISORDERS, OTHER
armodafinil oral
tablet
4 PA; QL (90
per 90 days)
HETLIOZ ORAL
CAPSULE
5 PA; QL (31
per 31 days);
NEDS
modafinil oral tablet 4 PA; QL (180
per 90 days)
ROZEREM ORAL
TABLET
3 QL (90 per 90
days)
XYREM ORAL
SOLUTION
5 PA; LA;
NEDS
Index 1
Index
A
abacavir ................................44 abacavir-lamivudine .............44 abacavir-lamivudine-
zidovudine ........................44 ABELCET............................24 ABILIFY MAINTENA..39, 40 ABRAXANE........................30 ABSTRAL..............................3 acamprosate............................6 acarbose................................47 acebutolol .............................56 ACETADOTE....................100 acetaminophen-codeine..........3 acetazolamide .......................59 acetazolamide sodium ..........59 acetic acid...............................8 acetylcysteine .............100, 109 acitretin.................................65 ACTEMRA ..........................95 ACTHIB (PF).......................95 ACTIMMUNE .....................95 ACUVAIL (PF)..................103 acyclovir ...............................43 acyclovir sodium ..................43 ADACEL(TDAP
ADOLESN/ADULT)(PF) 95 ADAGEN .............................76 adapalene..............................65 ADASUVE...........................39 ADCIRCA..........................108 adefovir.................................42 ADEMPAS.........................108 adenosine..............................56 adrenalin .............................106 adriamycin............................30 adrucil...................................29 ADVAIR DISKUS.............109 ADVAIR HFA ...................109 afeditab cr.............................57 AFINITOR ...........................33 AFINITOR DISPERZ ..........33 a-hydrocort ...........................79 ala-cort..................................79 ALBENZA ...........................37 albuterol sulfate ..................106 alclometasone .......................79
alcohol pads........................100 ALDURAZYME ..................76 ALECENSA .........................33 alendronate ...........................99 alfuzosin ...............................78 ALIMTA ..............................29 ALINIA ................................37 ALIQOPA ............................34 allopurinol ............................26 allopurinol sodium................37 almotriptan malate................26 ALOCRIL...........................101 aloprim..................................37 alosetron ...............................75 ALPHAGAN P...................102 alprazolam ............................47 alprazolam intensol...............47 ALUNBRIG .........................34 ALVESCO..........................105 amabelz.................................85 amantadine hcl......................46 AMBISOME ........................24 amcinonide ...........................79 amethia .................................85 amethia lo .............................85 amethyst................................85 AMICAR ..............................54 amifostine crystalline ...........30 amikacin .................................7 amiloride...............................60 amiloride-hydrochlorothiazide
..........................................60 aminophylline.....................108 AMINOSYN 10 % ...............66 AMINOSYN 7 % WITH
ELECTROLYTES............66 AMINOSYN 8.5 % ..............66 AMINOSYN II 10 % ...........67 AMINOSYN II 15 % ...........67 AMINOSYN II 7 % .............67 AMINOSYN II 8.5 % ..........67 AMINOSYN II 8.5 %-
ELECTROLYTES............67 AMINOSYN-HBC 7%.........67 AMINOSYN-PF 10 % .........67 AMINOSYN-PF 7 %
(SULFITE-FREE) ............67
AMINOSYN-RF 5.2 % ........67 amiodarone ...........................56 AMITIZA .............................75 amitriptyline .........................23 amlodipine ............................57 amlodipine-atorvastatin ........58 amlodipine-benazepril ..........58 amlodipine-olmesartan .........58 amlodipine-valsartan ............58 amlodipine-valsartan-hcthiazid
..........................................58 ammonium lactate ................65 amnesteem ............................65 amoxapine.............................23 amoxicil-clarithromy-lansopraz
..........................................74 amoxicillin............................13 amoxicillin-pot clavulanate ..13 amphotericin b ......................24 ampicillin..............................13 ampicillin sodium .................13 ampicillin-sulbactam ............13 AMPYRA .............................64 ANADROL-50 .....................84 anagrelide 53 .............................
anastrozole ............................33 ANDRODERM ....................84 ANDROGEL ..................84, 85 ANORO ELLIPTA.............110 ANZEMET ...........................23 apexicon e.............................65 APIDRA SOLOSTAR U-100
INSULIN ..........................50 APIDRA U-100 INSULIN ...50 APOKYN .............................38 apraclonidine ......................102 aprepitant ..............................23 apri ........................................85 APTIOM...............................19 APTIVUS .............................46 ARANESP (IN
POLYSORBATE) ............53 ARCALYST .........................95 ARCAPTA NEOHALER...107 aripiprazole ...........................40 ARISTADA..........................40 armodafinil .........................110
Index 2
ARRANON ..........................29 ARZERRA ...........................35 ASACOL HD .......................98 ashlyna..................................85 ASMANEX HFA ...............105 ASMANEX TWISTHALER
........................................105 aspirin-dipyridamole ............54 ASTAGRAF XL ..................91 atazanavir .............................46 atenolol .................................56 atenolol-chlorthalidone.........56 atomoxetine ..........................63 atorvastatin ...........................61 atovaquone ...........................37 atovaquone-proguanil...........37 ATRIPLA .............................44 atropine...............................101 ATROVENT HFA .............106 AUBAGIO ...........................64 AURYXIA ...........................73 AUVI-Q..............................107 AVASTIN ............................35 AVC .......................................8 avita ......................................65 AVONEX .............................64 AVONEX (WITH ALBUMIN)
..........................................64 azacitidine.............................30 AZACTAM ..........................12 AZACTAM IN DEXTROSE
(ISO-OSM).......................12 AZASITE .............................14 azathioprine ..........................91 azathioprine sodium .............91 azelastine ....................101, 104 azithromycin.........................14 AZOPT...............................102 aztreonam .............................13 azurette (28)..........................85 B baciim.....................................8 bacitracin ................................8 bacitracin-polymyxin b ......101 baclofen ................................41 BACTROBAN NASAL.........8 balsalazide ............................98 BANZEL ..............................19 BARACLUDE .....................42
BAVENCIO .........................35 BAXDELA...........................15 BCG VACCINE, LIVE (PF) 95 BECONASE AQ ................105 bekyree (28)..........................85 BELEODAQ ........................34 benazepril .............................55 benazepril-hydrochlorothiazide
..........................................55 BENDEKA...........................28 BENLYSTA .........................91 BENZNIDAZOLE .................8 benztropine ...........................38 BERINERT ..........................90 BESPONSA..........................35 betamethasone dipropionate .79 betamethasone valerate.........79 betamethasone, augmented...79 BETASERON ......................64 betaxolol .......................56, 102 bethanechol chloride.............78 BETHKIS ...............................7 BETOPTIC S......................102 BEVYXXA ..........................52 bexarotene ............................36 BEXSERO............................95 bicalutamide .........................29 BICILLIN C-R .....................13 BICILLIN L-A .....................13 BICNU..................................28 BIDIL ...................................58 BIKTARVY .........................43 BILTRICIDE........................37 bimatoprost.........................102 bisoprolol fumarate...............56 bisoprolol-hydrochlorothiazide
..........................................56 BIVIGAM ............................93 bleomycin .............................30 BLEPHAMIDE S.O.P. .......103 BLINCYTO..........................35 blisovi fe 1.5/30 (28) ............85 blisovi fe 1/20 (28) ...............85 BOOSTRIX TDAP...............96 BORTEZOMIB ....................30 BOSULIF .............................34 BREO ELLIPTA ................110 BRILINTA ...........................54 brimonidine ........................102
BRISDELLE.........................21 BRIVIACT ...........................17 bromfenac ...........................103 bromocriptine .......................38 BROVANA ........................107 budesonide....................79, 105 bumetanide ...........................60 BUPHENYL.........................76 bupivacaine (pf)......................5 BUPRENEX ...........................2 BUPRENORPHINE ...............2 buprenorphine hcl ...............2, 6 buprenorphine-naloxone.........6 bupropion hcl........................21 bupropion hcl (smoking deter)7 buspirone ..............................47 busulfan ................................28 butorphanol tartrate ................3 BUTRANS .............................2 BYDUREON........................48 BYDUREON BCISE............48 BYETTA ..............................48 BYSTOLIC...........................56 C
cabergoline 89 ...........................
CABOMETYX.....................34 calcipotriene .........................65 calcipotriene-betamethasone 65 calcitonin (salmon) ...............99 calcitrene...............................65 calcitriol ..........................65, 99 calcium acetate .....................78 calcium chloride ...................67 CALCIUM DISODIUM
VERSENATE.................100 calcium gluconate .................67 CALDOLOR ..........................1 CALQUENCE......................34 camila ...................................88 CAMPTOSAR......................34 camrese .................................85 camrese lo .............................85 CANASA..............................98 CANCIDAS..........................24 candesartan ...........................54 candesartan-hydrochlorothiazid
..........................................55 CAPASTAT .........................27 CAPEX .................................79
Index 3
CAPRELSA .........................34 captopril................................55 captopril-hydrochlorothiazide
..........................................55 CARBAGLU........................67 carbamazepine................19, 20 carbidopa ..............................38 carbidopa-levodopa ..............38 carbidopa-levodopa-
entacapone........................38 carboplatin............................30 CARDURA XL....................78 CARIMUNE NF
NANOFILTERED ...........93 carteolol ..............................102 cartia xt.................................57 carvedilol ..............................56 carvedilol phosphate.............56 caspofungin ..........................24 CASPOFUNGIN..................24 CAYSTON.........................108 caziant (28)...........................85 cefaclor ...........................10, 11 cefadroxil..............................11 cefazolin ...............................11 cefazolin in dextrose (iso-os)11 cefdinir .................................11 cefepime ...............................11 CEFEPIME IN DEXTROSE 5
%.......................................11 cefepime in dextrose,iso-osm
..........................................11 cefixime................................11 cefotaxime ............................11 cefotetan ...............................11 CEFOTETAN IN
DEXTROSE, ISO-OSM...11 cefoxitin................................11 cefoxitin in dextrose, iso-osm
..........................................11 cefpodoxime.........................11 cefprozil................................11 ceftazidime ...........................11 CEFTAZIDIME IN D5W ....11 ceftriaxone............................12 CEFTRIAXONE ..................12 ceftriaxone in dextrose,iso-os
..........................................12 cefuroxime axetil..................12
cefuroxime sodium...............12 celecoxib.................................1 CELLCEPT INTRAVENOUS
..........................................91 CELONTIN ..........................18 cephalexin.............................12 CERDELGA.........................76 CEREBYX ...........................20 CEREZYME ........................76 cetirizine .............................104 CETRAXAL.........................15 cevimeline ............................64 CHANTIX ..............................7 CHANTIX CONTINUING
MONTH BOX....................7 CHANTIX STARTING
MONTH BOX....................7 CHEMET 72 ..............................
chloramphenicol sod succinate ............................................8
chlordiazepoxide-clidinium..74 chlorhexidine gluconate .......64 chloroprocaine (pf) .................5 chloroquine phosphate..........37 chlorothiazide .......................60 chlorothiazide sodium ..........60 chlorpromazine.....................39 chlorthalidone.......................60 CHOLBAM ..........................76 cholestyramine (with sugar) .61 cholestyramine light .............61 CHORIONIC
GONADOTROPIN,
HUMAN...........................83 ciclodan ................................24 ciclopirox..............................24 cidofovir ...............................41 cilostazol...............................54 CILOXAN ............................15 CIMDUO..............................44 CIMZIA................................91 CIMZIA POWDER FOR
RECONST........................91 CIMZIA STARTER KIT .....91 CINRYZE.............................90 CIPRO HC..........................104 CIPRODEX ........................104 ciprofloxacin.........................16 ciprofloxacin (mixture).........15
ciprofloxacin hcl .............15, 16 ciprofloxacin in 5 % dextrose
..........................................16 ciprofloxacin lactate .............16 cisplatin.................................30 citalopram .............................21 cladribine ..............................29 claravis..................................65 clarithromycin.......................14 CLEOCIN...............................8 clindacin etz............................8 clindacin p ..............................8 clindamycin hcl ......................8 CLINDAMYCIN IN 0.9 %
SOD CHLOR......................8 clindamycin in 5 % dextrose ..8 clindamycin palmitate hcl.......8 clindamycin pediatric .............8 clindamycin phosphate .......8, 9 clindamycin-benzoyl peroxide
..........................................65 CLINDESSE...........................9 CLINIMIX 5%/D15W
SULFITE FREE ...............67 CLINIMIX 5%/D25W
SULFITE-FREE ...............67 CLINIMIX 2.75%/D5W
SULFIT FREE..................67 CLINIMIX 4.25%/D10W
SULF FREE......................67 CLINIMIX 4.25%/D5W
SULFIT FREE..................68 CLINIMIX 4.25%-D20W
SULF-FREE .....................68 CLINIMIX 4.25%-D25W
SULF-FREE .....................68 CLINIMIX 5%-
D20W(SULFITE-FREE)..68 CLINIMIX E 4.25%/D10W
SUL FREE........................68 clobetasol ........................79, 80 clobetasol-emollient .............80 clodan ...................................80 clofarabine ............................29 CLOLAR ..............................29 clomipramine........................23 clonazepam ...........................47 clonidine ...............................54 clonidine (pf) ........................54
Index 4
clonidine hcl ...................54, 63 clopidogrel............................54 clorazepate dipotassium .......47 clotrimazole..........................24 clotrimazole-betamethasone 24,
25
clozapine...............................41 CLOZAPINE........................41 COARTEM ..........................37 codeine sulfate........................3 COLCHICINE......................26 colestipol ..............................61 colistin (colistimethate na) .....9 colocort.................................98 COLY-MYCIN S ...............104 COMBIGAN ......................102 COMBIVENT RESPIMAT110 COMETRIQ .........................34 COMPLERA ........................44 compro..................................23 CONDYLOX .......................65 constulose .............................75 COPAXONE ........................64 CORDRAN TAPE LARGE
ROLL ...............................80 COREG CR..........................57 CORLANOR........................58 cortisone ...............................80 COSOPT (PF) ....................102 COTELLIC...........................34 COUMADIN........................52 CREON ................................76 CRIXIVAN ..........................46 cromolyn.....................101, 108 CUVITRU ............................93 CUVPOSA ...........................73 cyclobenzaprine..................110 cyclophosphamide................28 CYCLOPHOSPHAMIDE....28 CYCLOSET .........................48 cyclosporine .........................91 cyclosporine modified ..........91 cyproheptadine ...................104 CYRAMZA..........................35 cyred .....................................85 CYSTADANE......................76 CYSTAGON ........................76 CYSTARAN ......................101 cysteine (l-cysteine)..............68
cytarabine .............................30 cytarabine (pf) ......................29 CYTOGAM..........................94 D
d10 %-0.45 % sodium chloride
..........................................68 d2.5 %-0.45 % sodium
chloride.............................68 d5 % and 0.9 % sodium
chloride.............................68 d5 %-0.45 % sodium chloride
..........................................68 dacarbazine...........................28 dactinomycin ........................30 DALIRESP.........................108 DALVANCE ..........................9 danazol..................................85 dantrolene .............................41 dapsone.................................27 DAPTACEL (DTAP
PEDIATRIC) (PF)............96 daptomycin .............................9 DARAPRIM.........................37 DARZALEX ........................35 daunorubicin.........................31 daysee ...................................85 deblitane ...............................88 decadron ...............................80 decitabine..............................31 deferoxamine ......................100 deltasone...............................80 DELZICOL ..........................98 demeclocycline.....................17 DEMSER..............................58 DENAVIR ............................43 denta 5000 plus.....................68 DEPEN TITRATABS ..........72 DEPO-ESTRADIOL ............85 DEPO-PROVERA................88 DEPO-SUBQ PROVERA 104
..........................................88 DESCOVY ...........................44 desipramine ..........................23 desloratadine.......................104 desmopressin ........................83 desogestrel-ethinyl estradiol.85 desonide................................80 desoximetasone ....................80 DESVENLAFAXINE ..........21
desvenlafaxine succinate ......22 dexamethasone .....................80 dexamethasone intensol........80 dexamethasone sodium
phosphate ..................80, 103 dexrazoxane hcl ....................31 dextroamphetamine ..............63 dextroamphetamine-
amphetamine.....................63 dextrose 10 % and 0.2 % nacl
..........................................68 dextrose 10 % in water (d10w)
..........................................68 dextrose 20 % in water (d20w)
..........................................68 dextrose 30 % in water (d30w)
..........................................68 dextrose 40 % in water (d40w)
..........................................68 dextrose 5 % in water (d5w).68 dextrose 5 %-lactated ringers69 dextrose 5%-0.2 % sod
chloride .............................69 dextrose 5%-0.3 %
sod.chloride ......................69 dextrose 50 % in water (d50w)
..........................................69 dextrose 70 % in water (d70w)
..........................................69 dextrose with sodium chloride
..........................................69 DIASTAT .............................18 DIASTAT ACUDIAL ..........18 diazepam.........................18, 47 diazepam intensol .................47 diclofenac potassium ..............1 diclofenac sodium...................1 diclofenac-misoprostol ...........1 dicloxacillin ..........................13 dicyclomine ..........................73 didanosine.............................44 DIFFERIN ............................65 DIFICID ...............................14 diflorasone ............................80 diflunisal .................................1 digitek ...................................59 digox .....................................59 digoxin..................................59 dihydroergotamine................26
Index 5
DILANTIN 30 MG ..............20 diltiazem hcl ...................57, 58 dilt-xr....................................58 DIPENTUM .........................98 diphenhydramine hcl ..104, 105 diphenoxylate-atropine.........74 disulfiram ...............................6 divalproex.............................18 DIVIGEL..............................85 docetaxel...............................31 DOCETAXEL......................31 dofetilide 56 ...............................
donepezil ..............................20 dorzolamide........................102 dorzolamide-timolol ...........102 doxazosin..............................54 doxepin .................................23 doxorubicin...........................31 doxorubicin, peg-liposomal..31 doxy-100...............................17 doxycycline hyclate..............17 doxycycline monohydrate ....17 dronabinol.............................23 droperidol .............................23 drospirenone-e.estradiol-lm.fa
..........................................85 DROXIA ..............................30 DULERA............................110 duloxetine.............................22 DUOPA ................................38 duramorph (pf) .......................3 DUREZOL .........................103 dutasteride ............................78 DUZALLO ...........................26 E e.e.s. 400...............................14 econazole..............................25 EDARBI...............................55 EDARBYCLOR...................55 EDURANT...........................44 efavirenz ...............................44 EFFIENT..............................54 EGRIFTA .............................83 ELAPRASE..........................76 ELELYSO ............................76 eletriptan...............................26 eliphos ..................................78 ELIQUIS ..............................52 ELITEK................................30
ELIXOPHYLLIN...............108 ELLENCE ............................31 ELMIRON............................78 EMADINE..........................101 EMCYT................................29 EMEND..........................23, 24 emoquette .............................86 EMPLICITI ..........................36 EMSAM ...............................21 EMTRIVA............................44 enalapril maleate...................55 enalapril-hydrochlorothiazide
..........................................55 ENBREL ..............................91 ENBREL MINI ....................91 ENBREL SURECLICK .......91 ENDARI...............................74 endocet....................................3 ENGERIX-B (PF) ................96 ENGERIX-B PEDIATRIC
(PF)...................................96 enoxaparin ............................52 enskyce .................................86 entacapone ............................38 entecavir ...............................42 ENTEREG............................74 ENTRESTO..........................59 enulose..................................75 ENVARSUS XR ..................91 EPCLUSA ............................42 epinastine............................101 EPINEPHRINE ..................107 EPIPEN ..............................107 EPIPEN 2-PAK ..................107 EPIPEN JR .........................107 EPIPEN JR 2-PAK.............107 epirubicin..............................31 epitol.....................................20 EPIVIR HBV........................42 eplerenone ............................60 EPOGEN ..............................53 epoprostenol (glycine)..........62 eprosartan .............................55 ERAXIS(WATER DILUENT)
..........................................25 ERBITUX.............................36 ergoloid.................................20 ERIVEDGE ..........................34 ERLEADA ...........................29
errin.......................................88 ERWINAZE .........................31 ery pads.................................15 erygel ....................................15 ERYPED 200........................15 ERYPED 400........................15 ery-tab...................................15 ERY-TAB.............................15 ERYTHROCIN ....................15 erythrocin (as stearate) .........15 erythromycin.........................15 erythromycin ethylsuccinate.15 erythromycin with ethanol....15 erythromycin-benzoyl peroxide
..........................................65 ESBRIET............................109 ESCAVITE...........................69 escitalopram oxalate .............22 esomeprazole magnesium.....75 estarylla.................................86 estazolam ..............................47 ESTRACE ............................86 estradiol ................................86 estradiol valerate...................86 estradiol-norethindrone acet .86 ESTRING .............................86 ethacrynate sodium...............60 ethambutol ............................27 ethosuximide.........................18 ethynodiol diac-eth estradiol 86 ETHYOL ..............................31 etidronate disodium ..............99 etodolac...................................1 ETOPOPHOS .......................33 etoposide...............................33 EURAX ................................38 EVOMELA...........................28 EVOTAZ ..............................46 EVZIO ....................................6 EXELDERM ........................25 exemestane ...........................33 EXJADE ...............................72 EXTAVIA ............................64 ezetimibe...............................61 ezetimibe-simvastatin ...........59 F FABRAZYME .....................76 famciclovir............................43 famotidine.............................74
Index 6
famotidine (pf)......................74 famotidine (pf)-nacl (iso-os)74 FANAPT ..............................40 FARESTON .........................29 FARXIGA ............................48 FARYDAK...........................34 FASLODEX .........................29 FAZACLO ...........................41 felbamate ..............................19 felodipine..............................58 FEMRING............................86 femynor ................................86 fenofibrate ............................60 fenofibrate micronized .........60 fenofibrate nanocrystallized .60 fenofibric acid ......................61 fenofibric acid (choline) .......60 fenoprofen ..............................1 fentanyl...................................2 fentanyl citrate........................3 fentanyl citrate (pf).................3 FENTORA .............................3 FERRIPROX........................72 FETZIMA.............................22 FINACEA.............................65 finasteride .............................78 FIRAZYR.............................90 FIRMAGON KIT W
DILUENT SYRINGE ......89 flavoxate ...............................78 FLEBOGAMMA DIF ..........94 flecainide ..............................56 FLECTOR ..............................1 FLOLAN ..............................62 FLOVENT DISKUS ..........105 FLOVENT HFA.................105 floxin ....................................16 floxuridine ............................30 fluconazole ...........................25 fluconazole in dextrose(iso-o)
..........................................25 fluconazole in nacl (iso-osm)25 flucytosine ............................25 fludarabine............................31 fludrocortisone .....................80 flunisolide...........................105 fluocinolone..........................80 fluocinolone acetonide oil ....80 fluocinolone and shower cap 80
fluocinonide..........................81 fluocinonide-e.......................81 fluocinonide-emollient .........81 FLUORABON......................73 fluoride (sodium)............69, 73 fluoritab ................................69 fluorometholone .................103 fluorouracil .....................30, 65 FLUOROURACIL ...............65 fluoxetine..............................22 FLUOXETINE .....................22 fluphenazine decanoate ........39 fluphenazine hcl ...................39 flurbiprofen.............................1 flurbiprofen sodium............103 flutamide...............................29 fluticasone ....................81, 105 fluvastatin .............................61 fluvoxamine..........................22 FML FORTE ......................103 FML S.O.P. ........................103 fondaparinux.........................52 FORTAZ ..............................12 FORTEO ..............................99 FOSAMAX PLUS D............99 fosamprenavir.......................46 foscarnet ...............................41 fosinopril ..............................55 fosinopril-hydrochlorothiazide
..........................................55 fosphenytoin .........................20 FOSRENOL .........................73 FRAGMIN............................52 FREAMINE HBC 6.9 % ......72 freamine iii 10 % ................100 frovatriptan ...........................26 furosemide ............................60 FUSILEV..............................37 FUZEON ..............................45 fyavolv..................................86 FYCOMPA...........................19 G gabapentin ............................18 GABITRIL ...........................18 galantamine ..........................20 GAMASTAN S/D ................94 GAMMAGARD LIQUID ....94 GAMMAGARD S-D (IGA < 1
MCG/ML) ........................94
GAMMAKED ......................94 GAMMAPLEX ....................94 GAMMAPLEX (WITH
SORBITOL) .....................94 GAMUNEX-C......................94 ganciclovir sodium .........41, 42 GARDASIL 9 (PF)...............96 gatifloxacin ...........................16 GATTEX 30-VIAL ..............74 GATTEX ONE-VIAL ..........74 GAUZE PAD......................100 gavilyte-c ..............................75 gavilyte-g..............................75 gavilyte-n ..............................75 GAZYVA .............................36 gemcitabine...........................30 gemfibrozil ...........................61 generlac.................................75 gengraf ............................91, 92 GENOTROPIN.....................83 GENOTROPIN MINIQUICK
..........................................83 gentak .....................................7 gentamicin ..............................7 gentamicin in nacl (iso-osm) ..7 GENTAMICIN IN NACL
(ISO-OSM) .........................7 gentamicin sulfate (ped) (pf) ..7 gentamicin sulfate (pf)............7 GENTAMICIN SULFATE
(PF) .....................................7 GENVOYA ..........................43 GEODON .............................40 GILENYA ............................64 GILOTRIF............................34 glatiramer..............................64 glatopa ..................................64 GLEOSTINE ........................28 glimepiride............................48 glipizide ................................48 glipizide-metformin..............48 GLUCAGEN HYPOKIT......50 GLUCAGON EMERGENCY
KIT (HUMAN).................50 glycopyrrolate.......................73 glydo .......................................5 GOLYTELY.........................75 GRALISE .............................18
Index 7
GRALISE 30-DAY STARTER
PACK ...............................18 granisetron hcl ......................24 griseofulvin microsize ..........25 griseofulvin ultramicrosize...25 guanfacine ............................63 guanidine ..............................27 H HAEGARDA .......................90 HALAVEN...........................31 halobetasol propionate..........81 HALOG................................81 haloperidol............................39 haloperidol decanoate...........39 haloperidol lactate ................39 HARVONI ...........................42 HAVRIX (PF) ......................96 heparin (porcine) ..................52 heparin (porcine) in 5 % dex 52 heparin(porcine) in 0.45% nacl
..........................................52 heparin, porcine (pf) .............52 HEPATAMINE 8%..............69 HERCEPTIN........................36 HETLIOZ...........................110 HEXALEN ...........................28 HIBERIX (PF)......................96 HIZENTRA..........................94 HUMALOG JUNIOR
KWIKPEN U-100 ............50 HUMALOG KWIKPEN
INSULIN..........................50 HUMALOG MIX 50-50
INSULN U-100 ................50 HUMALOG MIX 50-50
KWIKPEN .......................50 HUMALOG MIX 75-25
KWIKPEN .......................50 HUMALOG MIX 75-25(U-
100)INSULN....................50 HUMALOG U-100 INSULIN
..........................................50 HUMATROPE...............83, 84 HUMIRA..............................92 HUMIRA PEDIATRIC
CROHN'S START ...........92 HUMIRA PEN .....................92 HUMIRA PEN CROHN'S-
UC-HS START ................92
HUMIRA PEN PSORIASIS-
UVEITIS ..........................92 HUMULIN 70/30 U-100
INSULIN ..........................51 HUMULIN 70/30 U-100
KWIKPEN........................51 HUMULIN N NPH INSULIN
KWIKPEN........................51 HUMULIN N NPH U-100
INSULIN ..........................51 HUMULIN R REGULAR U-
100 INSULN ....................51 HUMULIN R U-500 (CONC)
INSULIN ..........................51 HUMULIN R U-500 (CONC)
KWIKPEN........................51 hydralazine ...........................62 hydrochlorothiazide..............60 hydrocodone-acetaminophen.3,
4 hydrocodone-ibuprofen ..........4 hydrocortisone ................81, 98 hydrocortisone butyrate........81 hydrocortisone butyr-emollient
..........................................81 hydrocortisone valerate ........81 hydrocortisone-acetic acid..104 hydrocortisone-min oil-wht pet
..........................................81 hydrocortisone-pramoxine....98 hydromorphone ......................4 HYDROMORPHONE ...........4 hydromorphone (pf) ...............4 hydroxychloroquine..............37 hydroxyprogesterone caproate
..........................................88 hydroxyurea..........................30 hydroxyzine hcl ..................105 hydroxyzine pamoate .........105 HYPERHEP B S/D ..............94 HYPERHEP B S-D
NEONATAL ....................94 HYPERRAB (PF).................94 HYPERRAB S/D (PF) .........94 HYPERTET S/D (PF) ..........94 HYQVIA ..............................94 I ibandronate ...........................99 IBRANCE ............................34
ibu ...........................................1 IBUDONE ..............................4 ibuprofen.................................1 ibuprofen-oxycodone..............4 ICLUSIG ..............................34 idarubicin ..............................31 IDHIFA.................................34 ifosfamide .............................28 ILARIS (PF) .........................95 ILEVRO .............................103 imatinib.................................34 IMBRUVICA .......................34 IMFINZI ...............................36 imipenem-cilastatin ..............13 imipramine hcl......................23 imipramine pamoate .............23 imiquimod.............................66 IMOGAM RABIES-HT (PF)
..........................................94 IMOVAX RABIES VACCINE
(PF) ...................................96 INCRELEX ..........................84 indapamide ...........................60 INFANRIX (DTAP) (PF).....96 INFLECTRA ........................92 INLYTA ...............................34 INSULIN PEN NEEDLE ...100 INSULIN SYRINGE (DISP)
U-100..............................100 INTELENCE ........................44 intralipid ...............................69 INTRALIPID........................69 INTRON A ...........................42 INVANZ...............................13 INVEGA SUSTENNA.........40 INVEGA TRINZA ...............40 INVIRASE ...........................46 INVOKAMET......................48 INVOKAMET XR ...............48 INVOKANA.........................48 IOPIDINE...........................102 IPOL .....................................96 ipratropium bromide...........106 ipratropium-albuterol..........110 irbesartan ..............................55 irbesartan-hydrochlorothiazide
..........................................55 IRESSA ................................34 irinotecan ..............................31
Index 8
ISENTRESS .........................43 ISENTRESS HD ..................43 isibloom................................86 ISOLYTE S PH 7.4..............69 ISOLYTE-P IN 5 %
DEXTROSE.....................69 ISOLYTE-S..........................69 isoniazid ...............................27 isosorbide dinitrate ...............62 isosorbide mononitrate .........62 isotretinoin............................66 isradipine ..............................58 ISTODAX ............................32 itraconazole ..........................25 ivermectin.............................37 IXEMPRA............................32 IXIARO (PF)........................96 J JADENU ..............................72 JAKAFI ................................34 jantoven ................................53 JANUMET ...........................48 JANUMET XR.....................48 JANUVIA.............................49 JENTADUETO ....................49 JEVTANA............................36 jinteli.....................................86 jolivette.................................88 juleber...................................86 JULUCA...............................43 junel 1/20 (21) ......................86 junel fe 1.5/30 (28) ...............86 junel fe 1/20 (28) ..................86 JUXTAPID...........................61 K KABIVEN............................69 KADCYLA ..........................36 KADIAN ................................2 KALBITOR..........................91 KALETRA ...........................46 KALYDECO......................108 KANUMA............................76 kariva (28) ............................86 kelnor 1-50 ...........................86 KEPPRA...............................17 ketoconazole.........................25 ketoprofen...............................1 ketorolac .............................103 KEYTRUDA........................36
kimidess (28) ........................86 KINERET.............................92 KINRIX (PF)........................96 kionex ...................................73 kionex (with sorbitol) ...........73 KISQALI..............................32 KISQALI FEMARA CO-
PACK ...............................32 klor-con 10 ...........................69 klor-con 8 .............................69 klor-con m10 ........................69 klor-con m15 ........................69 klor-con m20 ........................69 klor-con sprinkle...................70 KOMBIGLYZE XR .............49 KORLYM.............................50 KRISTALOSE......................75 k-tab......................................70 KUVAN................................76 KYNAMRO .........................61 KYPROLIS ..........................32 L
l norgest/e.estradiol-e.estrad.86 labetalol ................................57 LACRISERT ......................101 lactated ringers .....................70 lactulose................................75 LAMICTAL STARTER
(BLUE) KIT .....................19 LAMICTAL STARTER
(GREEN) KIT ..................19 LAMICTAL STARTER
(ORANGE) KIT ...............19 lamivudine ................42, 44, 45 lamivudine-zidovudine.........45 lamotrigine............................19 lansoprazole..........................76 lanthanum .............................73 LANTUS SOLOSTAR U-100
INSULIN ..........................51 LANTUS U-100 INSULIN ..51 larin fe 1.5/30 (28)................86 larin fe 1/20 (28)...................86 LARTRUVO ........................36 latanoprost ..........................104 LATUDA..............................40 LAZANDA.............................4 leflunomide...........................95 LEMTRADA........................95
LENVIMA............................34 LETAIRIS ..........................108 letrozole ................................33 leucovorin calcium ...............32 LEUKERAN.........................28 LEUKINE.............................53 leuprolide..............................89 levalbuterol hcl ...................107 LEVALBUTEROL
TARTRATE ...................107 LEVEMIR FLEXTOUCH U-
100 INSULN ....................51 LEVEMIR U-100 INSULIN 51 levetiracetam.........................17 levetiracetam in nacl (iso-os)17 levobunolol .........................102 levocarnitine .........................70 levocarnitine (with sugar).....70 levocetirizine ......................105 levofloxacin ..........................16 levofloxacin in d5w ..............16 levoleucovorin ......................37 levorphanol tartrate.................2 levothyroxine........................88 levoxyl ..................................89 LEXIVA ...............................46 LIALDA ...............................98 lidocaine .................................6 lidocaine (pf) ..........................5 lidocaine hcl........................5, 6 lidocaine viscous ....................6 lidocaine-epinephrine .............6 lidocaine-prilocaine ................6 lillow.....................................86 lincomycin ..............................9 lindane ..................................38 linezolid ..................................9 linezolid in dextrose 5% .........9 linezolid-0.9% sodium chloride
............................................9 LINZESS ..............................75 liothyronine...........................89 LIPOFEN..............................61 lisinopril................................55 lisinopril-hydrochlorothiazide
..........................................55 lithium carbonate ..................47 lithium citrate........................47 LIVALO ...............................61
Index 9
LO LOESTRIN FE...............86 LONSURF............................32 loperamide............................74 lopinavir-ritonavir ................46 lorazepam .............................47 lorazepam intensol................47 lorcet (hydrocodone) ..............4 lorcet hd..................................4 lorcet plus ...............................4 losartan .................................55 losartan-hydrochlorothiazide 55 lovastatin ..............................61 loxapine succinate ................39 ludent fluoride ......................70 LUMIGAN .........................104 LUMIZYME ........................77 LUPRON DEPOT ................89 LUPRON DEPOT (3
MONTH)..........................89 LUPRON DEPOT (4
MONTH)..........................89 LUPRON DEPOT (6
MONTH)..........................89 LUPRON DEPOT-PED .......89 LUPRON DEPOT-PED (3
MONTH)..........................89 LYNPARZA.........................34 LYRICA ...............................18 LYRICA CR.........................18 LYSODREN.........................89 lyza .......................................88 M mafenide acetate.....................9 magnesium chloride .............70 magnesium sulfate................70 MAKENA ............................88 MAKENA (PF) ....................88 malathion..............................38 maprotiline ...........................22 MARPLAN ..........................21 MATULANE .......................28 matzim la ..............................58 md-gastroview....................100 meclizine ..............................23 meclofenamate .......................1 medroxyprogesterone ...........88 mefenamic acid ......................1 mefloquine............................37 megestrol ..............................88
MEKINIST...........................34 meloxicam ..............................2 melphalan .............................28 melphalan hcl .......................28 memantine ............................21 MEMANTINE......................21 MENACTRA (PF) ...............96 MENEST..............................86 MENTAX.............................25 MENVEO A-C-Y-W-135-DIP
(PF)...................................96 meprobamate ........................47 mercaptopurine.....................30 meropenem ...........................13 MEROPENEM-0.9%
SODIUM CHLORIDE .....13 mesalamine...........................98 MESALAMINE ...................98 mesalamine with cleansing
wipe ..................................98 mesna....................................37 MESNEX..............................37 MESTINON .........................27 metaproterenol....................107 metformin .............................49 methadone ..............................2 methadone intensol.................2 methazolamide......................60 methenamine hippurate ..........9 methimazole .........................90 METHITEST........................85 methocarbamol ...................110 methotrexate sodium ............92 methotrexate sodium (pf) .....92 methoxsalen..........................66 methscopolamine..................73 methyclothiazide ..................60 METHYLERGONOVINE .100 methylphenidate hcl .............63 methylprednisolone ..............81 methylprednisolone acetate ..81 methylprednisolone sodium
succ...................................82 methyltestosterone................85 metipranolol........................102 metoclopramide hcl ........23, 74 metolazone............................60 METOPIRONE ..................100 metoprolol succinate.............57
metoprolol ta-hydrochlorothiaz
..........................................57 metoprolol tartrate ................57 metro i.v..................................9 metronidazole .........................9 metronidazole in nacl (iso-os) 9 mexiletine .............................56 MIACALCIN .......................99 miconazole-3 ........................25 microgestin 1/20 (21) ...........86 microgestin fe 1.5/30 (28) ....86 microgestin fe 1/20 (28) .......86 midodrine..............................54 migergot................................26 miglitol .................................49 miglustat ...............................77 mimvey .................................87 mimvey lo .............................86 minocycline ..........................17 minoxidil...............................62 mirtazapine ...........................21 misoprostol ...........................75 mitomycin.............................32 mitoxantrone.........................32 M-M-R II (PF)......................96 modafinil.............................110 moderiba ...............................42 moderiba dose pack ..............42 moexipril...............................55 moexipril-hydrochlorothiazide
..........................................55 mometasone..................82, 105 mono-linyah..........................87 mononessa (28).....................87 montelukast.........................106 morgidox...............................17 morphine.........................2, 3, 4 morphine (pf)..........................4 morphine concentrate .............4 MOVANTIK ........................74 MOVIPREP..........................75 MOXEZA .............................16 moxifloxacin.........................16 moxifloxacin in nacl (iso-osm)
..........................................16 MOZOBIL............................53 MULTAQ .............................56 multi-vit with fluoride-iron...70 multi-vitamin with fluoride ..70
Index 10
multivitamins with fluoride..70 multivit-fluor (vit e acetate) .70 mupirocin ...............................9 mupirocin calcium..................9 MUSTARGEN.....................28 MYALEPT...........................84 mycophenolate mofetil .........92 mycophenolate mofetil hcl ...92 mycophenolate sodium.........92 MYLOTARG .......................36 myorisan ...............................66 MYRBETRIQ ......................78 N
NABI-HB .............................94 nabumetone ............................2 nadolol..................................57 nadolol-bendroflumethiazide59 nafcillin...........................13, 14 nafcillin in dextrose iso-osm 13 naftifine ................................25 NAFTIN ...............................25 NAGLAZYME.....................77 nalbuphine ..............................4 naloxone .................................6 naltrexone ...............................6 NAMENDA TITRATION
PAK..................................21 NAMENDA XR...................21 naproxen .................................2 naproxen sodium ....................2 naratriptan.............................27 NARCAN...............................6 NAROPIN (PF) ......................6 NATACYN ..........................25 NATAZIA ............................87 nateglinide ............................49 NATPARA...........................99 NEBUPENT .........................37 NEEDLES, INSULIN
DISP.,SAFETY ..............100 nefazodone ...........................22 neomycin ................................7 neomycin-bacitracin-poly-hc10 neomycin-bacitracin-
polymyxin.......................101 neomycin-polymyxin b gu ...10 neomycin-polymyxin-
gramicidin.........................10
neomycin-polymyxin-hc .....10, 104
neo-polycin.........................101 neo-polycin hc ......................10 NEPHRAMINE 5.4 % .........70 NERLYNX...........................34 neuac.....................................66 NEULASTA.........................53 NEUPOGEN ..................53, 54 NEUPRO..............................38 NEVANAC ........................103 nevirapine .............................44 NEXAVAR ..........................34 niacin ....................................61 nicardipine ............................58 NICOTROL............................7 NICOTROL NS......................7 nifedipine..............................58 nilutamide.............................29 nimodipine............................58 NINLARO ............................32 NIPENT................................30 nisoldipine ............................58 nitro-bid ................................62 NITRO-DUR........................62 nitrofurantoin........................10 nitrofurantoin macrocrystal ..10 nitrofurantoin monohyd/m-
cryst ..................................10 nitroglycerin .........................62 nizatidine ........................74, 75 nolix......................................82 nora-be..................................88 NORDITROPIN FLEXPRO 84 norepinephrine bitartrate ......63 norethindrone (contraceptive)
..........................................88 norethindrone acetate ...........88 norethindrone ac-eth estradiol
..........................................87 norethindrone-e.estradiol-iron
..........................................87 norgestimate-ethinyl estradiol
..........................................87 norlyroc ................................88 NORMOSOL-R....................70 NORMOSOL-R PH 7.4 .......70 NORPACE CR.....................56 NORTHERA ........................59
nortriptyline ..........................23 NORVIR...............................46 NOVAREL ...........................84 NOVOFINE 32...................100 NOVOFINE PLUS.............100 NOVOLIN 70/30 U-100
INSULIN ..........................51 NOVOLIN N NPH U-100
INSULIN ..........................51 NOVOLIN R REGULAR U-
100 INSULN ....................51 NOVOLOG FLEXPEN U-100
INSULIN ..........................51 NOVOLOG MIX 70-30 U-100
INSULN ...........................51 NOVOLOG MIX 70-
30FLEXPEN U-100 .........52 NOVOLOG PENFILL U-100
INSULIN ..........................52 NOVOLOG U-100 INSULIN
ASPART...........................52 NOVOPEN ECHO .............100 NOVOTWIST ....................101 NOXAFIL.............................25 NPLATE...............................54 NUCYNTA.........................4, 5 NUEDEXTA ........................63 NULOJIX .............................92 NUPLAZID ..........................40 NUTRESTORE ....................74 NUTROPIN AQ NUSPIN....84 NUVARING.........................87 nyamyc .................................25 nystatin .................................26 nystatin-triamcinolone ..........26 nystop ...................................26 O OCTAGAM..........................94 octreotide acetate ..................90 ODEFSEY ............................45 ODOMZO.............................34 OFEV..................................109 ofloxacin ...............................16 olanzapine.............................40 olanzapine-fluoxetine ...........21 olmesartan.............................55 olmesartan-amlodipin-
hcthiazid ...........................59
Index 11
olmesartan-
hydrochlorothiazide..........55 olopatadine .................101, 105 omega-3 acid ethyl esters .....61 omeppi..................................76 omeprazole ...........................76 omeprazole-sodium
bicarbonate .......................76 OMNARIS .........................105 OMNITROPE.......................84 ONCASPAR ........................32 ondansetron ..........................24 ondansetron hcl ....................24 ondansetron hcl (pf) .............24 ONFI 18 .....................................
ONGLYZA...........................49 OPDIVO...............................36 OPSUMIT ..........................108 oralone..................................64 ORENCIA ............................92 ORENCIA CLICKJECT ......92 ORENITRAM ............108, 109 ORFADIN ............................77 ORKAMBI.........................108 oseltamivir......................46, 47 OSMOPREP.........................75 OTEZLA ..............................95 OTEZLA STARTER............95 OTREXUP (PF) ...................93 oxacillin................................14 oxacillin in dextrose(iso-osm)
..........................................14 oxaliplatin.............................32 oxandrolone..........................84 oxaprozin................................2 oxcarbazepine.......................20 oxiconazole...........................26 OXISTAT.............................26 OXTELLAR XR ..................20 oxybutynin chloride..............78 oxycodone ..............................5 OXYCODONE.......................3 oxycodone-acetaminophen.....5 oxycodone-aspirin ..................5 oxymorphone......................3, 5 P pacerone ...............................56 paclitaxel ..............................32 paliperidone..........................40
pamidronate ..........................99 PANCREAZE ......................77 PANDEL ..............................82 PANRETIN ..........................36 pantoprazole .........................76 paricalcitol ............................99 PARICALCITOL .................99 paroex oral rinse ...................65 paromomycin..........................8 paroxetine hcl .......................22 paroxetine
mesylate(menop.sym).......22 PASER..................................27 PAXIL ..................................22 PAZEO ...............................101 PEDIARIX (PF) ...................96 PEDVAX HIB (PF)..............97 peg 3350-electrolytes ...........75 PEGANONE ........................20 PEGASYS ............................42 PEGASYS PROCLICK .......42 peg-electrolyte ......................75 PEGINTRON .......................43 PENICILLIN G POT IN
DEXTROSE .....................14 penicillin g potassium...........14 penicillin g procaine .............14 penicillin g sodium ...............14 penicillin v potassium...........14 PENTACEL (PF) .................97 PENTAM..............................37 PENTASA............................98 pentoxifylline........................59 PERFOROMIST ................107 PERIKABIVEN ...................70 perindopril erbumine ............55 periogard...............................65 PERJETA .............................36 permethrin ............................38 perphenazine.........................39 PERTZYE ............................77 PEXEVA ..............................22 pfizerpen-g 14 ............................
phenadoz...............................23 phenelzine.............................21 phenergan .............................23 phenobarbital ........................18 phenoxybenzamine...............54 phenytoin ..............................20
phenytoin sodium .................20 phenytoin sodium extended..20 PHOSLYRA .........................78 PHOSPHOLINE IODIDE ..102 PICATO................................66 pilocarpine hcl ..............65, 102 pimozide ...............................39 pindolol.................................57 pioglitazone ..........................49 pioglitazone-glimepiride.......49 pioglitazone-metformin ........49 piperacillin-tazobactam ........14 piroxicam................................2 PLASMA-LYTE 148 ...........70 PLASMA-LYTE A ..............70 PLEGRIDY ..........................64 plenamine .............................70 podofilox...............................66 polocaine.................................6 polocaine-mpf.........................6 polycin ................................101 polyethylene glycol 3350 75 .....
polymyxin b sulfate ..............10 polymyxin b sulf-trimethoprim
..........................................10 POMALYST.........................29 potassium acetate..................70 potassium chlorid-d5-
0.45%nacl .........................70 potassium chloride................71 potassium chloride in 0.9%nacl
..........................................71 potassium chloride in 5 % dex
..........................................71 potassium chloride in lr-d5...71 potassium chloride in water..71 potassium chloride-0.45 % nacl
..........................................71 potassium chloride-d5-
0.2%nacl ...........................71 potassium chloride-d5-
0.3%nacl ...........................71 potassium chloride-d5-
0.9%nacl ...........................71 potassium citrate ...................71 potassium phosphate m-/d-
basic ..................................71 PRADAXA...........................53 PRALUENT PEN.................61
Index 12
pramipexole..........................38 prasugrel ...............................54 pravastatin ............................61 praziquantel ..........................37 prazosin ................................54 PRED MILD ......................103 PRED-G .............................103 PRED-G S.O.P. ..................103 prednicarbate ........................82 prednisolone .........................82 prednisolone acetate ...........103 prednisolone sodium phosphate
..................................82, 103 prednisone ............................82 prednisone intensol...............82 PREGNYL ...........................84 PREMARIN .........................87 premasol 10 %......................71 PREMASOL 6 % .................71 prenatal vitamin oral tablet...71 prevalite..........................61, 62 PREVIDENT 5000 BOOSTER
PLUS ................................71 PREVIDENT 5000 DRY
MOUTH ...........................71 PREVIDENT 5000
SENSITIVE......................72 previfem ...............................87 PREZCOBIX........................46 PREZISTA ...........................46 PRIALT..................................1 PRIFTIN...............................28 PRIMAQUINE.....................37 primidone .............................18 PRIVIGEN ...........................94 PROAIR HFA ....................107 PROAIR RESPICLICK .....107 probenecid ............................26 probenecid-colchicine ..........26 procainamide ........................56 prochlorperazine...................23 prochlorperazine edisylate....39 prochlorperazine maleate oral
..........................................39 PROCRIT .............................54 procto-med hc.......................82 procto-pak.............................82 proctosol hc ..........................82 proctozone-hc .......................82
PROCYSBI ..........................77 profeno....................................2 progesterone micronized ......88 PROGLYCEM .....................50 PROGRAF............................93 PROLASTIN-C ..................110 PROLEUKIN .......................32 PROLIA................................99 PROMACTA........................54 promethazine ........................23 promethegan .........................23 propafenone ..........................56 propranolol ...........................57 propranolol-hydrochlorothiazid
..........................................57 propylthiouracil ....................90 PROQUAD (PF)...................97 protriptyline ..........................23 PROVENTIL HFA.............107 PULMICORT FLEXHALER
........................................106 PULMOZYME...................108 PURIXAN ............................30 PYLERA ..............................74 pyrazinamide ........................28 pyridostigmine bromide .......27 Q QUADRACEL (PF) .............97 quetiapine .............................40 quinapril................................55 quinapril-hydrochlorothiazide
..........................................55 quinidine gluconate ..............56 quinidine sulfate ...................56 quinine sulfate ......................37 QVAR.................................106 QVAR REDIHALER .........106 R RABAVERT (PF) ................97 rabeprazole ...........................76 RADICAVA.........................63 rajani.....................................87 raloxifene..............................88 ramipril .................................55 RANEXA .............................59 ranitidine hcl.........................75 RAPAMUNE 93 ........................
rasagiline ..............................38 RASUVO (PF) .....................93
RAVICTI..............................77 REBETOL ............................43 REBIF (WITH ALBUMIN) .64 REBIF REBIDOSE ..............64 REBIF TITRATION PACK.64 reclipsen (28) ........................87 RECOMBIVAX HB (PF).....97 RELENZA DISKHALER ....47 RELISTOR ...........................74 RELPAX...............................27 REMICADE .........................93 REMODULIN ....................109 RENAGEL ...........................78 RENVELA ...........................78 repaglinide ............................49 repaglinide-metformin..........49 REPATHA............................62 REPATHA PUSHTRONEX 62 REPATHA SURECLICK ....62 RESCRIPTOR......................44 RESTASIS..........................101 RESTASIS MULTIDOSE..101 RETROVIR ..........................45 REVATIO...........................109 REVLIMID...........................29 REXULTI .............................40 REYATAZ ...........................46 ribasphere .............................43 ribasphere ribapak ..........42, 43 ribavirin ................................43 RIDAURA............................95 rifabutin ................................27 rifampin ................................28 RIFATER .............................28 riluzole..................................63 rimantadine ...........................47 ringer's ..................................72 risedronate ....................99, 100 RISPERDAL CONSTA .40, 41 risperidone ............................41 ritonavir ................................46 RITUXAN ............................36 RITUXAN HYCELA ...........36 rivastigmine ..........................20 rivastigmine tartrate..............20 rizatriptan..............................27 ROMIDEPSIN......................32 ropinirole ..............................38 rosuvastatin...........................61
Index 13
ROTARIX ............................97 ROTATEQ VACCINE ........97 roweepra ...............................17 roweepra xr...........................17 ROZEREM.........................110 RUBRACA...........................34 RYDAPT..............................35 S
SABRIL................................18 SAFYRAL............................87 SAIZEN................................84 SAIZEN CLICK.EASY .......84 SAIZEN SAIZENPREP.......84 salsalate ..................................2 SAMSCA .............................73 SANCUSO ...........................24 SANDIMMUNE ..................93 SANDOSTATIN LAR
DEPOT.............................90 SANTYL ..............................66 SAPHRIS (BLACK
CHERRY) ........................41 SAVELLA............................63 scopolamine base..................23 selegiline hcl...................38, 39 selenium sulfide 66 ....................
SELZENTRY .......................45 SENSIPAR.........................100 SEREVENT DISKUS ........107 SEROSTIM ..........................84 sertraline ...............................22 sevelamer carbonate .............79 sf 5000 plus ..........................72 sharobel ................................88 SHINGRIX (PF)...................97 SIGNIFOR ...........................90 SIGNIFOR LAR ..................90 sildenafil (pulmonary arterial
hypertension)..................109 silver sulfadiazine.................16 SIMBRINZA......................102 SIMPONI .............................93 SIMPONI ARIA...................93 SIMULECT..........................95 simvastatin............................61 sirolimus ...............................93 SIRTURO.............................28 SKLICE................................37 sodium acetate ......................72
sodium chloride ....................72 sodium chloride 0.45 %........72 sodium chloride 0.9 %..........72 sodium chloride 3 %.............72 sodium chloride 5 %.............72 sodium lactate intravenous ...72 sodium phenylbutyrate .........77 sodium phosphate .................72 sodium polystyrene (sorb free)
..........................................73 sodium polystyrene sulfonate
..........................................73 SODIUM POLYSTYRENE
SULFONATE...................73 SOLTAMOX........................29 SOLU-CORTEF...................82 SOLU-CORTEF (PF)...........82 SOLU-MEDROL .................82 SOMATULINE DEPOT ......90 SOMAVERT........................90 sorine ....................................56 sotalol ...................................56 sotalol af ...............................56 SOVALDI ............................42 SPIRIVA RESPIMAT........106 SPIRIVA WITH
HANDIHALER..............106 spironolactone ......................60 spironolacton-hydrochlorothiaz
..........................................59 SPORANOX ........................26 sprintec (28)..........................87 SPRITAM.............................17 SPRYCEL ............................35 sps (with sorbitol).................73 ssd.........................................16 STAMARIL (PF) .................97 stavudine...............................45 STELARA ............................66 STIMATE.............................84 STIOLTO RESPIMAT.......110 STIVARGA..........................35 STRENSIQ...........................77 STREPTOMYCIN .................8 STRIBILD ............................43 STRIVERDI RESPIMAT ..107 SUBOXONE ..........................6 SUBSYS.................................5 SUCRAID ............................77
sucralfate...............................75 sulfacetamide sodium ...........16 sulfacetamide sodium (acne) 16 sulfacetamide-prednisolone 103 sulfadiazine...........................16 sulfamethoxazole-trimethoprim
..........................................17 sulfasalazine .........................99 sulfatrim................................17 sulindac...................................2 sumatriptan ...........................27 sumatriptan succinate ...........27 sumatriptan-naproxen ...........27 SUPPRELIN LA ..................32 SUPRAX ..............................12 SUPREP BOWEL PREP KIT
..........................................75 SUSTIVA .............................44 SUTENT...............................35 SYLATRON.........................37 SYLVANT ...........................95 SYMBICORT.....................110 SYMFI..................................45 SYMFI LO............................45 SYMLINPEN 120 ................49 SYMLINPEN 60 ..................49 SYNAGIS.............................95 SYNAREL............................90 SYNERCID ..........................10 SYNRIBO.............................32 SYNTHROID .......................89 SYPRINE .............................73 T TABLOID.............................30 TACLONEX.........................66 tacrolimus .......................66, 93 TAFINLAR ..........................35 TAGRISSO...........................35 TAMIFLU ............................47 tamoxifen..............................29 tamsulosin.............................78 TARCEVA ...........................35 TARGRETIN .......................36 tarina fe 1/20 (28) .................87 TASIGNA.............................35 tazarotene..............................66 TAZICEF..............................12 TAZORAC ...........................66 taztia xt .................................58
Index 14
TECENTRIQ........................36 TECFIDERA........................64 TEFLARO............................12 TEKTURNA ........................59 TEKTURNA HCT ...............59 telmisartan ............................55 telmisartan-amlodipine.........59 telmisartan-hydrochlorothiazid
..........................................55 TEMODAR ..........................32 TENIVAC (PF) ....................97 tenofovir disoproxil fumarate
..........................................45 terazosin ...............................54 terbutaline...................107, 108 terconazole ...........................26 TESTIM ...............................85 testosterone...........................85 testosterone cypionate ..........85 testosterone enanthate ..........85 TETANUS,DIPHTHERIA
TOX PED(PF) ..................97 TETANUS-DIPHTHERIA
TOXOIDS-TD..................97 tetrabenazine.........................63 THALOMID.........................29 theophylline........................108 thioridazine...........................39 thiotepa .................................28 thiothixene............................39 THYMOGLOBULIN...........95 thyroid (pork) .......................89 THYROLAR-1.....................89 THYROLAR-1/2..................89 THYROLAR-1/4..................89 THYROLAR-2.....................89 THYROLAR-3.....................89 tiagabine ...............................19 tigecycline ............................10 timolol maleate.............57, 102 tinidazole ..............................10 TIVICAY .......................43, 44 tizanidine ..............................41 TOBI PODHALER ............108 TOBRADEX ......................103 TOBRADEX ST ................104 tobramycin..............................8 tobramycin in 0.225 % nacl ...8 tobramycin sulfate ..................8
tobramycin-dexamethasone 104 tolazamide ............................49 tolbutamide...........................49 tolcapone ..............................38 tolmetin...................................2 tolterodine.............................78 TOPICORT ..........................83 topiramate.............................19 toposar ..................................33 topotecan ..............................33 TORISEL..............................93 torsemide ..............................60 TOTECT...............................32 TOUJEO MAX SOLOSTAR
..........................................52 TOUJEO SOLOSTAR U-300
INSULIN ..........................52 TOVIAZ ...............................78 TRACLEER .......................109 TRADJENTA.......................49 tramadol..............................3, 5 tramadol-acetaminophen ........5 trandolapril ...........................56 trandolapril-verapamil ..........59 tranexamic acid.....................54 TRANSDERM-SCOP..........23 tranylcypromine....................21 travasol 10 %........................72 TRAVATAN Z 104 ...................
trazodone ..............................22 TREANDA...........................28 TRECATOR.........................28 TRELSTAR..........................90 tretinoin (chemotherapy) ......36 tretinoin topical.....................66 TREXIMET..........................27 tri femynor............................87 triamcinolone acetonide .65, 83 triamterene-hydrochlorothiazid
..........................................59 triazolam...............................47 triderm ..................................83 trientine.................................73 tri-estarylla............................87 trifluoperazine ......................39 trifluridine.............................43 TRIGLIDE............................61 trihexyphenidyl.....................38 triklo .....................................62
tri-linyah ...............................87 tri-lo-estarylla .......................87 tri-lo-marzia ..........................87 tri-lo-sprintec ........................87 trilyte with flavor packets .....75 trimethoprim .........................10 trimipramine .........................23 trinessa (28) ..........................87 trinessa lo..............................87 TRINTELLIX.......................22 tri-previfem (28) ...................87 TRISENOX ..........................32 tri-sprintec (28) .....................87 TRIUMEQ............................45 tri-vylibra ..............................87 TROGARZO ........................45 TROPHAMINE 10 %...........72 TROPHAMINE 6%..............72 trospium................................78 TRUMENBA........................97 TRUVADA...........................45 TUDORZA PRESSAIR .....106 TWINRIX (PF).....................97 TYBOST...............................45 tydemy ..................................87 TYGACIL.............................10 TYKERB ..............................35 TYMLOS............................100 TYPHIM VI....................97, 98 TYSABRI .............................64 TYVASO............................109 TYVASO INSTITUTIONAL
START KIT....................109 TYVASO REFILL KIT......109 TYVASO STARTER KIT .109 U ULORIC ...............................26 unithroid ...............................89 UPTRAVI...........................109 ursodiol .................................74 UVADEX .............................66 V valacyclovir ..........................43 VALCHLOR ........................29 valganciclovir .......................42 valproate sodium ..................19 valproic acid .........................19 valproic acid (as sodium salt)
..........................................19
Index 15
valsartan ...............................55 valsartan-hydrochlorothiazide
..........................................55 VALSTAR ...........................33 vancomycin ..........................10 VANCOMYCIN ..................10 VANCOMYCIN IN 0.9 %
SODIUM CHL .................10 VANCOMYCIN IN
DEXTROSE 5 %..............10 vandazole..............................10 VANTAS..............................33 VAQTA (PF)........................98 VARIVAX (PF) ...................98 VARIZIG .............................95 VASCEPA............................62 VECAMYL ..........................59 VECTIBIX ...........................36 VELCADE ...........................33 veletri....................................62 velivet triphasic regimen (28)
..........................................87 VELTASSA .........................73 VENCLEXTA......................35 VENCLEXTA STARTING
PACK ...............................35 venlafaxine ...........................22 VENTAVIS........................109 VENTOLIN HFA...............108 verapamil ..............................58 veripred 20............................83 VERSACLOZ ......................41 VERZENIO..........................35 VESICARE ..........................78 VGO 20 ..............................101 VGO 30 ..............................101 VGO 40 ..............................101 VIBRAMYCIN ....................17 vicodin....................................5 vicodin es................................5 vicodin hp...............................5 VICTOZA 2-PAK ................49 VICTOZA 3-PAK ................49 VIDEX 2 GRAM PEDIATRIC
..........................................45 VIDEX 4 GRAM PEDIATRIC
..........................................45
VIDEX EC ...........................45 vigabatrin..............................19 VIGAMOX...........................16 VIIBRYD .............................22 VIMIZIM............................101 VIMPAT...............................20 vinblastine ............................33 vincasar pfs...........................33 vincristine .............................33 vinorelbine............................33 viorele (28) ...........................87 VIRACEPT ..........................46 VIRAMUNE ........................44 VIREAD...............................45 VIVITROL .............................6 voriconazole .........................26 VOSEVI ...............................42 VOTRIENT ..........................35 VPRIV..................................77 VRAYLAR...........................41 vylibra...................................87 VYXEOS..............................33 W
warfarin ................................53 water for irrigation, sterile..101 WELCHOL ..........................62 X XALKORI............................35 XARELTO ...........................53 XATMEP..............................93 XELJANZ ............................93 XELJANZ XR......................93 XGEVA..............................100 XIAFLEX...........................101 XIFAXAN ............................10 XIGDUO XR........................50 XOLAIR...............................95 XOPENEX HFA ................108 XTANDI...............................29 xulane ...................................87 xylocaine dental-epinephrine .6 xylon 10..................................5 XYREM..............................110 Y
YERVOY .............................36 YF-VAX (PF).......................98 YONDELIS ..........................29
yuvafem ................................87 Z
zafirlukast ...........................106 zaleplon...............................110 ZALTRAP ............................36 ZANOSAR ...........................29 ZARXIO ...............................54 ZAVESCA............................77 ZEJULA ...............................35 ZELAPAR ............................39 ZELBORAF .........................35 ZEMAIRA..........................110 zenatane ................................66 ZENPEP .........................77, 78 zenzedi..................................63 ZERBAXA ...........................12 ZERIT...................................45 ZIAGEN ...............................45 zidovudine ............................45 zileuton ...............................106 ZINECARD (AS HCL) ........33 ZIOPTAN (PF)...................104 ziprasidone hcl......................41 ZIRGAN ...............................42 ZOLADEX ...........................90 zoledronic acid....................100 zoledronic acid-mannitol-water
........................................100 ZOLINZA.............................33 zolmitriptan...........................27 zolpidem .............................110 ZOMETA ...........................100 ZOMIG .................................27 zonisamide............................18 ZORTRESS ..........................93 ZOSTAVAX (PF) ................98 ZOSYN.................................14 ZOSYN IN DEXTROSE (ISO-
OSM) ................................14 zovia 1/50e (28) ....................87 ZOVIRAX ............................43 ZURAMPIC .........................26 ZYDELIG.............................35 ZYFLO ...............................106 ZYKADIA............................35 ZYPREXA RELPREVV ......41 ZYTIGA ...............................29
This formulary was updated on June 1, 2018. For more recent information or other questions, please contact us, Medicare Plus Blue PPO Customer Service, at 1‑877‑241‑2583 or, for TTY users 711, Monday through Friday, 8 a.m. to 9 p.m. Eastern time. From October 1 through February 14, hours are from 8 a.m. to 9 p.m., Eastern time, seven days a week, or visit www.bcbsm.com/medicare.
H9572_T_18CompFormEVS_FINAL_7_18 Populated Template 05252018
DB 16052 JUN 18 R076063 EVS