2018 List of Covered Drugs

2018 List of Covered Drugs (Drug List)This formulary was updated on 01012018 If you have questions please call Centers Plan for FIDA Care Completersquos pharmacy help line at 1-888-266-7460 seven days a week from 8 am to 8 pm TTY users call 1-800-421-1220 The call is free

H3018_16702_CY2018_DrugList_V3_Rev_FINAL

For More Information visit wwwcentersplancomfidaEffective Date Last Updated Formulary ID

01201801201818001 Version 11

Centers Plan for FIDA Care Complete (Medicare-Medicaid Plan)

If you have questions please call Centers Plan for FIDA Care Complete at 1-888-266-7460

(TTY 711 or 1-800-421-1220) seven days a week from 8 am to 8 pm The call is free For

more information visit wwwcentersplancomfida i

2018 List of Covered Drugs (Drug List)

This formulary was updated on 01012018 If you have questions please call Centers Plan for FIDA Care Completersquos pharmacy help line at 1-888-266-7460 seven days a week from 8 am to 8 pm TTY users call 1-800-421-1220 The call is free

For More Information visit wwwcentersplancomfida

Effective Date Last Updated Formulary ID

012018 012018

18001 Version 11

more information visit wwwcentersplancomfida ii

Language Assistance Services Notification

English ATTENTION If you speak English language assistance services free of charge

are available to you Call 1-800-466-2745 (TTY 1-800-421-1220)

Spanish ATENCIOacuteN Si habla espantildeol tiene a su disposicioacuten servicios gratuitos de

asistencia linguumliacutestica Llame al 1-800-466-2745 (TTY 1-800-421-1220)

Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-466-

2745（TTY1-800-421-1220）

Russian

ВНИМАНИЕ Если вы говорите на русском языке то вам доступны

бесплатные услуги перевода Звоните 1-800-466-2745 (телетайп 1-800-421-

French

Creole

ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis

pou ou Rele 1-800-466-2745 (TTY 1-800-421-1220)

Korean 주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수

있습니다 1-800-466-2745 (TTY 1-800-421-1220)번으로 전화해 주십시오

Italian

ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di

assistenza linguistica gratuiti Chiamare il numero 1-800-466-2745 (TTY 1-800-

421-1220)

Yiddish פון פריי סערוויסעס הילף שפראך אייך פאר פארהאן זענען אידיש רעדט איר אויב אויפמערקזאם

(TTY 1-800-421-1220) 1-800-466-2745 רופט אפצאל

Bengali লকষয করনঃ যদি আপদন বাাংলা কথা বলতে পাতেন োহতল দনঃখেচায় ভাষা সহায়ো পদেতষবা উপলবধ আতে ফ ান করন ১-800-466-2745 (TTY ১-800-421-1220)

Polish UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy

językowej Zadzwoń pod numer 1-800-466-2745 (TTY 1-800-421-1220)

Arabic 2745-466-1800 برقم اتصل بالمجان لك تتوافر اللغوية المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظة

(1220-421-800-1 والبكم الصم هاتف رقم)

French ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont

proposeacutes gratuitement Appelez le 1-800-466-2745 (ATS 1-800-421-1220)

Urdu -466-800-1 کريں کال ہيں دستياب ميں مفت خدمات کی مدد کی زبان کو آپ تو ہيں بولتے اردو آپ اگر خبردار

2745 (TTY 1-800-421-1220)

Tagalog

PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga

serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-466-2745

(TTY 1-800-421-1220)

more information visit wwwcentersplancomfida iii

ΠΡΟΣΟΧΗ Αν μιλάτε ελληνικά στη διάθεσή σας βρίσκονται υπηρεσίες

γλωσσικής υποστήριξης οι οποίες παρέχονται δωρεάν Καλέστε 1-800-466-2745

(TTY 1-800-421-1220)

Albanian KUJDES Neumlse flitni shqip peumlr ju ka neuml dispozicion sheumlrbime teuml asistenceumls

gjuheumlsore pa pageseuml Telefononi neuml 1-800-466-2745 (TTY 1-800-421-1220)

more information visit wwwcentersplancomfida iv

Notice of Nondiscrimination

Discrimination is Against the Law

Centers Plan for Healthy Living LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Centers Plan for Healthy Living LLC does not exclude people or treat them differently because of race color national origin age disability or sex

Centers Plan for Healthy Living LLC provides

bull Free aids and services to people with disabilities to communicate effectively with us such aso Qualified sign language interpreterso Written information in other formats (large print audio accessible electronic formats

other formats)

bull Free language services to people whose primary language is not English such aso Qualified interpreterso Information written in other languages

If you need these services contact MemberParticipant Services at 1-844-274-5227 (TTY users please call 1-800-421-1220 or 711)

If you believe that Centers Plan for Healthy Living LLC has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Grievances and Appeals Department

By Mail Centers Plan for Healthy Living LLC Attn GampA Department 75 Vanderbilt Avenue Staten Island NY 10304- 2604

By Phone 1-844-274-5227 (TTY users call 1-800-421-1220) By Fax 1-347-505-7089 By Email GandAcentersplancom

You can file a grievance in person or by mail fax or email If you need help filing a grievance MemberParticipant Services is available to help you seven days a week from 8am to 8pm

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services 200 Independence Avenue SW

Room 509F HHH Building Washington DC 20201

1-800-368-1019 800-537-7697 (TDD)

Complaint forms are available at

httpwwwhhsgovocrofficefileindexhtml

more information visit wwwcentersplancomfida v

Centers Plan for FIDA Care Complete | 2018 List of Covered Drugs (Formulary)

This is a list of drugs that Participants can get in Centers Plan for FIDA Care Complete

Centers Plan for FIDA Care Complete (Medicare-Medicaid Plan) is a managed care

plan that contracts with both Medicare and the New York State Department of Health

(Medicaid) to provide benefits of both programs to Participants through the Fully

Integrated Duals Advantage (FIDA) Demonstration

The List of Covered Drugs andor pharmacy and provider networks may change

throughout the year We will send you a notice before we make a change that affects

Benefits may change on January 1 of each year

You can always check Centers Plan for FIDA Care Completersquos up-to-date List of

Covered Drugs online at wwwcentersplancomfida or by calling Centers Plan for

FIDA Care Complete Participant Services at 1-888-266-7460 (TTY users call 711 or 1-

800-421-1220)

Limitations and restrictions may apply For more information call Centers Plan for

FIDA Care Complete Participant Services or read the Centers Plan for FIDA Care

Complete Participant Handbook This means that you need to follow certain rules to

have Centers Plan for FIDA Care Complete pay for your services

There are no copays for any covered drugs

If you speak English language assistance services free of charge are available to

you Call 1-888-266-7460 (TTY 711 or 1-800-421-1220) seven days a week from 8

am to 8 pm

如果您使用中文您可以免費獲得語言援助服務請致電 1-888-266-7460（聽力障礙電傳711 或 1-800-421-1220)工作時間為每週 7 天每天早上八點到晚上八點

Si ou pale Kreyogravel Ayisyen wap jwenn segravevis asistans lang gratis disponib pou ou

Rele 1-888-266-7460 (TTY 711 oswa 1-800-421-1220) segravet jou pa semegraven apati 8 am

rive 8 pm

Se lei parla italiano puograve avvalersi dei servizi gratuiti di assistenza linguistica

Chiamare il numero 1-888-266-7460 (TTY 711 o 1-800-421-1220) sette giorni su

sette tra le ore 8 e le 20

한국어 를 사용하는 경우 무료로 언어 지원 서비스를 받을 수 있습니다 문의 1-888-

266-7460 (TTY 711 또는 1-800-421-1220) 연중무휴 오전 8시-오후 8시

more information visit wwwcentersplancomfida vi

Если вы говорите по-русски вам доступна бесплатная языковая поддержка

Звоните 1-888-266-7460 (номер для пользователей телетайпа (TTY) 711 или 1-

800-421-1220) с 800 до 2000 в любой день недели

Si habla espantildeol tiene a su disposicioacuten servicios de asistencia linguumliacutestica sin costos

Llame al 1-888-266-7460 (TTY 711 o 1-800-421-1220) los siete diacuteas de la semana

de 8 am a 8 pm

You can get this document for free in other formats such as large print braille or

audio Call 1-800-466-2745 (TTY 711 or 1-800-421-1220) seven days a week from 8

am to 8 pm The call is free

Centers Plan for FIDA Care Complete wants to make sure you have access to plan

materials in your preferred language So when you call wersquoll ask you for your

preferred reading language and whether or not you want your materials in that

language We might also reach out to you once or more a year to make sure the

information we have on file about your preference is correct Of course you are

always able to make changes to your preference by

bull Speaking with a live representative at 1-800-466-2745 (TTY 711 or 1-800-421-

1220 or) seven days a week from 8 am to 8 pm

bull Sending a letter to us at Centers Plan for FIDA Care Complete Attention

Participant Services 75 Vanderbilt Avenue Staten Island NY 10304 or

bull Emailing us at MemberServicescentersplancom

The State of New York has created a participant ombudsman program called the

Independent Consumer Advocacy Network (ICAN) to provide Participants free

confidential assistance on any services offered by Centers Plan for FIDA Care

Complete ICAN may be reached toll-free at 1-844-614-8800 or online at icannysorg

(TTY users call 711 then follow the prompts to dial 844-614-8800)

more information visit wwwcentersplancomfida vii

Frequently Asked Questions (FAQ)

Find answers here to questions you have about this List of Covered Drugs You can read

all of the FAQ to learn more or look for a question and answer

1 What prescription drugs are on the List of Covered Drugs (We call the List of Covered Drugs the ldquoDrug Listrdquo for short)

The drugs on the List of Covered Drugs that starts on page 3 are the drugs covered by

Centers Plan for FIDA Care Complete These drugs are available at pharmacies within

our network A pharmacy is in our network if we have an agreement with them to work

with us and provide you services We refer to these pharmacies as ldquonetwork pharmaciesrdquo

Centers Plan for FIDA Care Complete will cover all drugs on the Drug List if

bull your doctor or other prescriber says you need them to get better or stay healthy

bull the drug is medically necessary for your condition and

bull you fill the prescription at a Centers Plan for FIDA Care Complete network

pharmacy

Centers Plan for FIDA Care Complete may have additional steps to access certain

drugs (see question 5 below) In some cases you may have to do something before

you can get a drug like try other drugs first

You can also see an up-to-date list of drugs that we cover on our website at

wwwcentersplancomfida or call Participant Services at 1-888-266-7460 TTY users call

711 or 1-800-421-1220

2 Does the Drug List ever change

Yes Centers Plan for FIDA Care Complete may add or remove drugs on the Drug List

during the year Generally the

Drug List will only change if

bull a new drug comes along that works as well as a drug on the Drug List now or

bull we learn that a drug is not safe

We may also change our rules about drugs For example we could

more information visit wwwcentersplancomfida viii

bull Decide to require or not require prior approval for a drug (Prior approval is

permission from Centers Plan for FIDA Care Complete or your Interdisciplinary

Team (IDT) before you can get a drug)

bull Add or change the amount of a drug you can get (called ldquoquantity limitsrdquo)

bull Add or change step therapy restrictions on a drug (Step therapy means you must

try one drug before we will cover another drug)

(For more information on these drug rules see page ix)

We will tell you when a drug you are taking is removed from the Drug List We will also

tell you when we change our rules for covering a drug Questions 3 4 and 7 below have

more information on what happens when the Drug List changes

You can always check Centers Plan for FIDA Care Completersquos up to date Drug List

online at wwwcentersplancomfida You can also call Participant Services to check

the current Drug List at 1-888-266-7460

3 What happens when a cheaper drug comes along that works as well as a drug on the Drug List now

If a cheaper drug becomes available that works as well as a drug on the Drug List now

bull Your pharmacist may give you the cheaper drug the next time you fill your

prescription If you and your provider decide that the cheaper drug is not right for

you your provider can tell the pharmacist to continue to give you the drug you

take now

bull Centers Plan for FIDA Care Complete may decide to take the more expensive

drug off of the Drug List If you are taking a drug that we remove from the Drug

List because a cheaper drug that works just as well comes along we will tell you

at least 60 days before we remove it from the Drug List or when you ask for a

refill Then you can get a 60-day supply of the drug before the change to the Drug

List is made If we decide to remove a drug from the list we will notify you in

writing andor by phone at least 60 days before we remove the drug from the list

4 What happens when we find out a drug is not safe

If the Food and Drug Administration (FDA) says a drug you are taking is not safe we will

take it off the Drug List right away We will also send you a letter and call you to tell you

more information visit wwwcentersplancomfida ix

that the unsafe drug was taken off the Drug List After receiving this letter andor call

please contact your doctor and ask that he or she prescribe an alternative drug

5 Are there any restrictions or limits on drug coverage Or are there any required actions to take in order to get certain drugs

Yes some drugs have coverage rules or have limits on the amount you can get In some

cases you or your doctor or other prescriber must do something before you can get the

drug For example

bull Prior approval (or prior authorization) For some drugs you or your doctor or

other prescriber must get approval from Centers Plan for FIDA Care Complete or

your Interdisciplinary Team (IDT) before you fill your prescription If you donrsquot get

approval Centers Plan for FIDA Care Complete may not cover the drug

bull Quantity limits Sometimes Centers Plan for FIDA Care Complete limits the

amount of a drug you can get

bull Step therapy Sometimes Centers Plan for FIDA Care Complete requires you to

do step therapy This means you will have to try drugs in a certain order for your

medical condition You might have to try one drug before we will cover another

drug If your doctor thinks the first drug doesnrsquot work for you then we will cover the

second

You can find out if your drug has any additional requirements or limits by looking in the

tables beginning on page 3 You can also get more information by visiting our web site at

wwwcentersplancomfida We have posted online documents that explain our prior

authorization and step therapy restrictions You may also ask us to send you a copy

You can ask for an ldquoexceptionrdquo from these limits Please see question 11 for more

information on exceptions

If you are in a nursing facility or other long-term care facility and need a drug that is

not on the Drug List or if you cannot easily get the drug you need we can help

We will cover a 31-day emergency supply of the drug you need (unless you have a

prescription for fewer days) whether or not you are a new Centers Plan for FIDA

Care Complete Participant This will give you time to talk to your doctor or other

prescriber He or she can help you decide if there is a similar drug on the Drug List

you can take instead or whether to ask for an exception Please see question 11

for more information about exceptions

more information visit wwwcentersplancomfida x

6 How will you know if the drug you want has limitations or if there are required actions to take to get the drug

The List of Covered Drugs on page 3 has a column labeled ldquoNecessary actions

restrictions or limits on userdquo

7 What happens if we change our rules on how we cover some drugs For example if we add prior authorization (approval) quantity limits andor step therapy restrictions on a drug

We will tell you if we add prior approval quantity limits andor step therapy restrictions on

a drug We will tell you at least 60 days before the restriction is added or when you next

ask for a refill Then you can get a 60-day supply of the drug before the change to the

Drug List is made This gives you time to talk to your doctor or other prescriber about

what to do next

8 How can you find a drug on the Drug List

There are two ways to find a drug

bull You can search alphabetically (if you know how to spell the drug) or

bull You can search by medical condition

To search alphabetically go to the Alphabetical Listing section on page I-1 Then look

for the name of your drug in the list

To search by medical condition find the section labeled ldquoList of drugs by medical

conditionrdquo on page xviii The drugs in this section are grouped into categories depending

on the type of medical conditions they are used to treat For example if you have a heart

condition you should look in the category cardiovascular agents That is where you will

find drugs that treat heart conditions

9 What if the drug you want to take is not on the Drug List

If you donrsquot see your drug on the Drug List call Participant Services at 1-888-266-7460

(TTY users call 711 or 1-800-421-1220) and ask about it If you learn that Centers Plan

for FIDA Care Complete will not cover the drug you can do one of these things

more information visit wwwcentersplancomfida xi

bull Ask Participant Services for a list of drugs like the one you want to take Then

show the list to your doctor or other prescriber He or she can prescribe a drug on

the Drug List that is like the one you want to take Or

bull You can ask the plan or your Interdisciplinary Team (IDT) to make an exception to

cover your drug Please see question 11 for more information about exceptions

10 What if you are a new Centers Plan for FIDA Care Complete Participant and canrsquot find your drug on the Drug List or have a problem getting your drug

We can help We must cover up to 90 days of temporary supplies of your drug as

needed during the first 90 days you are a Participant of Centers Plan for FIDA Care

Complete This will give you time to talk to your doctor or other prescriber He or she can

help you decide if there is a similar drug on the Drug List you can take instead or whether

to ask for an exception

We will cover up to 90 days of temporary supplies of your drug if

bull you are taking a drug that is not on our Drug List or

bull health plan rules do not let you get the amount ordered by your prescriber or

bull the drug requires prior approval by Centers Plan for FIDA Care Complete or your

Interdisciplinary Team (IDT) or

bull you are taking a drug that is part of a step therapy restriction

If you live in a nursing facility or other long-term care facility you may refill your

prescription for as long as 91 days You may refill the drug multiple times during your first

90 days in the plan This gives your prescriber time to change your drugs to ones on the

Drug List or ask for an exception

If one of the following level of care change scenarios applies to you you might be entitled to a transition supply of the drugs you are currently taking

bull If you move into a long-term care facility from a hospital or other setting

bull If you leave a long-term care facility to return to your home

bull If you are discharged from the hospital to a home

bull If you are discharged from a skilled nursing facility

bull If your status changes from hospice to non-hospice

more information visit wwwcentersplancomfida xii

bull If you are discharged from a psychiatric hospital with an individualized medication

The level of care changes listed above are only some of the reasons you might qualify for

a transition supply for more information please contact Participant Services at 1-888-266-

7460 TTY users please call 711 or 1-800-421-1220 Representatives are available seven

days a week from 8 am to 8 pm

11 Can you ask for an exception to cover your drug

Yes You can ask Centers Plan for FIDA Care Complete or your Interdisciplinary Team

(IDT) to make an exception to cover a drug that is not on the Drug List

You can also ask Centers Plan for FIDA Care Complete or your IDT to change the rules

on your drug

bull For example Centers Plan for FIDA Care Complete may limit the amount of a drug

we will cover If your drug has

a limit you can ask us or your IDT to change the limit and cover more

bull Other examples You can ask us or your IDT to drop step therapy restrictions or

prior approval requirements

12 How long does it take to get an exception

First Centers Plan for FIDA Care Complete or your Interdisciplinary Team (IDT) must

receive a statement from your prescriber supporting your request for an exception After

we get the statement you will get a decision on your exception request within 72 hours

If you or your prescriber think your health may be harmed if you have to wait 72 hours for

a decision you can ask for an expedited exception This is a faster decision If your

prescriber supports your request you will get a decision within 24 hours of getting your

prescriberrsquos supporting statement

13 How can you ask for an exception

To ask for an exception call your Care Manager Your Care Manager will work with you

and your provider to help you ask for an exception

more information visit wwwcentersplancomfida xiii

14 What are generic drugs

Generic drugs are made up of the same ingredients as brand name drugs They usually

cost less than the brand name drug and usually donrsquot have well-known names Generic

drugs are approved by the Food and Drug Administration (FDA)

Centers Plan for FIDA Care Complete covers both brand name drugs and generic drugs

15 What are OTC drugs

OTC stands for ldquoover-the-counterrdquo Centers Plan for FIDA Care Complete covers some

OTC drugs when they are written as prescriptions by your provider

You can read the Centers Plan for FIDA Care Complete Drug List to see what OTC drugs

are covered

16 Does Centers Plan for FIDA Care Complete cover OTC non-drug products

Centers Plan for FIDA Care Complete covers some OTC non-drug products when they

are written as prescriptions by your provider Some examples of OTC non-drug products

are alcohol swabs and gauze pads

You can read the Centers Plan for FIDA Care Complete Drug List to see what OTC non-

drug products are covered

Centers Plan for FIDA Care Complete also offers a supplemental OTC benefit of $25 per

month to use on OTC items that are not covered by Medicare and Medicaid Unused

amounts will not carry over from one month to the next month Please see Chapter 4 of

your Participant Handbook for more information or call Participant Services at 1-800-466-

2745 (TTY users please call 711 or 1-800-421-1220) seven days a week from 8 am to

17 What is your copay

You will not be charged a copay for drugs on the Drug List

more information visit wwwcentersplancomfida xiv

18 What are drug tiers

Tiers are groups of drugs on our Drug List

Every drug on Centers Plan for FIDA Care Completersquos Drug List is in one of four (4) tiers

bull Tier 1 drugs are generic drugs covered by Medicare This is the lowest tier

bull Tier 2 drugs are brand name drugs and specialty drugs covered by Medicare

This is the highest tier

bull Tier 3 drugs are non-Part D drugs covered by Medicaid

bull Tier 4 drugs are Over-the-Counter (OTC) drugs covered by Medicaid

There is no cost to you for drugs on any of these tiers

more information visit wwwcentersplancomfida xv

List of Covered Drugs

The list of covered drugs that begins on page 3 gives you information about the drugs

covered by Centers Plan for FIDA Care Complete If you have trouble finding your drug in

the list turn to the Index that begins on page I-1

The first column of the chart lists the name of the drug Brand name drugs are capitalized

(eg NORTHERA) and generic drugs are listed in lower-case italics (eg clonidine)

The information in the necessary actions restrictions or limits on use column tells you if

Centers Plan for FIDA Care Complete has any rules for covering your drug

All of the drugs on this List of Covered Drugs are available by mail-order some of

the drugs on this List of Covered Drugs are available with an extended day supply

(for example 90-day supply)

The following Utilization Management abbreviations may be found within the body

of this document

COVERAGE NOTES ABBREVIATIONS

ABBREVIATION DESCRIPTION EXPLANATION

Utilization Management Restrictions

PA Prior Authorization

Restriction

You (or your physician) are required to get

prior authorization from Centers Plan for

FIDA Care Complete before you fill your

prescription for this drug Without prior

approval Centers Plan for FIDA Care

Complete may not cover this drug

PA BvD

Prior Authorization

Restriction

Part B vs Part D

Determination

This drug may be eligible for payment under

Medicare Part B or Part D You (or your

physician) are required to get prior

authorization from Centers Plan for FIDA

Care Complete to determine that this drug is

covered under Medicare Part D before you

fill your prescription for this drug Without

prior approval Centers Plan for FIDA Care

more information visit wwwcentersplancomfida xvi

PA-HRM Prior Authorization

Restriction for

High Risk Medications

This drug has been deemed by CMS to be

potentially harmful and therefore a High Risk

Medication for Medicare beneficiaries 65

years or older Participants age 65 years or

older are required to get prior authorization

from Centers Plan for FIDA Care Complete

before you fill your prescription for this

drug Without prior approval Centers Plan

for FIDA Care Complete may not cover this

PA NSO Prior Authorization

Restriction for

New Starts Only

If you are a new participant or if you have not

taken this drug before you (or your

Care Complete before you fill your

QL Quantity Limit Restriction

Centers Plan for FIDA Care Complete limits

the amount of this drug that is covered per

prescription or within a specific time frame

ST Step Therapy Restriction

Before Centers Plan for FIDA Care Complete

will provide coverage for this drug you must

first try another drug(s) to treat your medical

condition This drug may only be covered if

the other drug(s) does not work for you

more information visit wwwcentersplancomfida xvii

The following additional coverage note abbreviations may be found within the body

of this document

OTHER SPECIAL REQUIREMENTS FOR COVERAGE

LA Limited Access Drug

This prescription may be available only at

certain pharmacies For more information

consult your Pharmacy Directory or call

Member Services at 1-888-266-7460 seven

days a week from 8 am to 8 pm TTYTDD

users should call 1-800-421-1220

NM Non-Mail Order Drug

You may be able to receive greater than a 1-

month supply of most of the drugs on your

formulary via mail order at a reduced cost

share Drugs not available via your mail

order benefit are noted with ldquoNMrdquo in the

RequirementsLimits column of your

formulary

Not a Part D Drug This drug is a non-Part D drug or an OTC

drug or product

NDS No Extended Day Supply This drug is not available with an extended

day supply

Note The () next to a drug means the drug is not a ldquoPart D drugrdquo These drugs have

different rules for appeals An appeal is a formal way of asking for a review of and change

to a coverage decision if you think there was a mistake For example Centers Plan for

FIDA Care Complete or your Interdisciplinary Team (IDT) might decide that a drug that

you want is not covered or is no longer covered by Medicare or Medicaid If you or your

doctor or other prescriber disagrees with the decision you can appeal To ask for

instructions on how to appeal call Participant Services at 1-888-266-7460 or the

Independent Consumer Advocacy Network (ICAN) at 1-844-614-8800 (TTY users call

711 then follow the prompts to dial 844-614-8800) You can also read the Participant

Handbook to learn how to appeal a decision

more information visit wwwcentersplancomfida xviii

List of Drugs by Medical Condition

The drugs in this section are grouped into categories depending on the type of medical

conditions they are used to treat For example if you have a heart condition you should

look in the category cardiovascular agents That is where you will find drugs that treat

heart conditions

more information visit wwwcentersplancomfida 1

Analgesics 3

Anesthetics 15

Anti-AddictionSubstance Abuse Treatment Agents 16

Antianxiety Agents 17

Antibacterials 19

Anticancer Agents 30

Anticholinergic Agents 41

Anticonvulsants 41

Antidementia Agents 45

Antidepressants 46

Antidiabetic Agents 49

Antifungals 53

Antigout Agents 57

Antihistamines 58

Anti-Infectives (Skin And Mucous Membrane) 64

Antimigraine Agents 64

Antimycobacterials 65

Antinausea Agents 66

Antiparasite Agents 68

Antiparkinsonian Agents 69

Antipsychotic Agents 71

Antivirals (Systemic) 76

Blood ProductsModifiersVolume Expanders 82

Table of Contents

Caloric Agents 85

Cardiovascular Agents 90

Central Nervous System Agents 106

Contraceptives 110

Cough And Cold Products 118

Dental And Oral Agents 127

Dermatological Agents 127

Devices 135

Disinfectants (For Non-Dermatologic Use) 148

Enzyme ReplacementModifiers 148

Eye Ear Nose Throat Agents 150

Gastrointestinal Agents 158

Genitourinary Agents 172

Heavy Metal Antagonists 173

Hormonal Agents StimulantReplacementModifying 174

Immunological Agents 181

Inflammatory Bowel Disease Agents 192

Irrigating Solutions 193

Metabolic Bone Disease Agents 193

Miscellaneous Therapeutic Agents 195

Ophthalmic Agents 198

Replacement Preparations 199

Respiratory Tract Agents 206

Skeletal Muscle Relaxants 211

Sleep Disorder Agents 211

Vasodilating Agents 213

Vitamins And Minerals 214

You can find information on what the symbols and abbreviations in this table mean by going to

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Analgesics

Analgesics Miscellaneous

acephen 120 mg suppository outer

120 mg 4 $0

QL (30 per 30 days)

325 mg 4 $0

QL (30 per 30 days)

650 mg 4 $0

QL (30 per 30 days)

acetaminophen 120 mg suppos outer

120 mg (Acephen) 4 $0

QL (30 per 30 days)

acetaminophen 160 mg5 ml elx 160

mg5 ml (Non-Aspirin) 4 $0

QL (240 per 30 days)

acetaminophen 325 mg liqui-gel 325

mg (Pain Relief) 4 $0

acetaminophen 500 mg softgel 500

(Mapap

(acetaminophen)) 4 $0

acetaminophen 650 mg suppos 650

mg (Acephen) 4 $0

QL (30 per 30 days)

acetaminophen 80 mg rapid tab

childrens 80 mg

(Childrens

Acetaminophen) 4 $0

QL (30 per 30 days)

acetaminophen-codeine oral

solution 120-12 mg5 ml 1 $0

acetaminophen-codeine oral tablet

300-15 mg 1 $0

300-30 mg

(Tylenol-Codeine

3) 1 $0

300-60 mg

(Tylenol-Codeine

4) 1 $0

ascomp with codeine oral capsule

30-50-325-40 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

BELBUCA BUCCAL FILM 150

MCG 300 MCG 450 MCG 600

MCG 75 MCG 750 MCG 900

QL (60 per 30 days)

buprenorphine hcl injection solution

03 mgml (Buprenex) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

buprenorphine hcl injection syringe

03 mgml 1 $0

buprenorphine transdermal patch

weekly 10 mcghour 15 mcghour

20 mcghour 5 mcghour 75

mcghour

(Butrans) 1 $0

QL (4 per 28 days)

butalbital compound wcodeine oral

capsule 30-50-325-40 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

butalbital-acetaminop-caf-cod oral

capsule 50-300-40-30 mg 50-325-

40-30 mg

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

butalbital-acetaminophen oral

tablet 50-325 mg (Marten-Tab) 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

butalbital-acetaminophen-caff oral

capsule 50-325-40 mg (Capacet) 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

tablet 50-325-40 mg (Esgic) 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

butalbital-aspirin-caffeine oral

capsule 50-325-40 mg (Fiorinal) 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

tablet 50-325-40 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

BUTRANS TRANSDERMAL

PATCH WEEKLY 75

MCGHOUR

QL (4 per 28 days)

capacet oral capsule 50-325-40 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

child acetaminophen 80 mg25 ml

oral syringe 50s u-d oral syr 32

child pain-fever 160 mg5 ml 160

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml 4 $0

child pain-fever 80 mg tab chw 80

mg 4 $0

QL (30 per 30 days)

child tactinal 80 mg tab chw 80 mg

QL (30 per 30 days)

childrens fever reducing supp for

ages 3-6 years 120 mg 4 $0

QL (30 per 30 days)

childrens mapap 80 mg rapid 80

mg 4 $0

QL (30 per 30 days)

childs mapap 160 mg tab chew 160

mg 4 $0

QL (30 per 30 days)

codeine sulfate oral tablet 15 mg 30

mg 60 mg 1 $0

cvs acetaminophen 8-hr 650 mg

caplet 650 mg

(8 Hour Pain

Reliever) 4 $0

cvs arthritis pain er 650 mg caplet

650 mg 4 $0

cvs child non-asa 80 mg tb chw 80

mg 4 $0

QL (30 per 30 days)

cvs child pain rlf 160 mg5 ml

childrens af 160 mg5 ml 4 $0

cvs non-asa 80 mg tablet chw

childrens 80 mg 4 $0

QL (30 per 30 days)

cvs non-aspirin 500 mg caplet xtra-

strengthcaplet 500 mg 4 $0

cvs non-aspirin jr tab chew 160 mg

QL (30 per 30 days)

cvs pain relief 325 mg liq gel 325

mg 4 $0

cvs pain relief adult liquid 500

mg15 ml 4 $0

endocet oral tablet 10-325 mg 1 $0 QL (240 per 30 days)

endocet oral tablet 25-325 mg 5-

325 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

fentanyl citrate buccal lozenge on a

handle 1200 mcg 1600 mcg 200

mcg 400 mcg 600 mcg 800 mcg

(Actiq) 1 $0

PA QL (120 per 30

days) NDS

fentanyl transdermal patch 72 hour

100 mcghr 12 mcghr 25 mcghr

50 mcghr 75 mcghr

(Duragesic) 1 $0

QL (10 per 30 days)

feverall 120 mg suppository

childrens outer 120 mg 4 $0

QL (30 per 30 days)

feverall 325 mg suppository junior

str inner 325 mg 4 $0

QL (30 per 30 days)

feverall 650 mg suppository adult

inner 650 mg 4 $0

QL (30 per 30 days)

gnp pain reliever 500 mg caplt

capletx-strength 500 mg 4 $0

hydrocodone-acetaminophen oral

solution 25-167 mg5 ml 5-163

mg75ml(75ml)

solution 75-325 mg15 ml (Hycet) 1 $0

tablet 10-325 mg (Lorcet HD) 1 $0

tablet 25-325 mg (Verdrocet) 1 $0

tablet 5-325 mg

(Lorcet

(hydrocodone)) 1 $0

tablet 75-325 mg (Lorcet Plus) 1 $0

hydrocodone-ibuprofen oral tablet

75-200 mg 1 $0

hydromorphone (pf) injection

solution 10 (mgml) (5 ml) 10

hydromorphone injection solution 2

mgml 4 mgml 1 $0

hydromorphone injection syringe 2

mgml 4 mgml (Dilaudid) 1 $0

hydromorphone oral liquid 1 mgml (Dilaudid) 1 $0 QL (1200 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

hydromorphone oral tablet 2 mg 4

mg 8 mg (Dilaudid) 1 $0

HYSINGLA ER ORAL

TABLETORAL

ONLYEXTREL24 HR 100 MG

120 MG 20 MG 30 MG 40 MG

60 MG 80 MG

QL (30 per 30 days)

infant pain relv 80 mg08 ml af

gluten-free 80 mg08 ml 4 $0

QL (30 per 30 days)

infants pain relief susp drop 100

mgml 4 $0

QL (30 per 30 days)

jr pain-fever 160 mg rapid tab

juniorbubblegum 160 mg 4 $0

QL (30 per 30 days)

junior mapap 160 mg rapid tab 160

mg 4 $0

QL (30 per 30 days)

LAZANDA NASAL SPRAYNON-

AEROSOL 100 MCGSPRAY 300

MCGSPRAY 400 MCGSPRAY

PA QL (30 per 30

days) NDS

little remedies fever 160 mg5

afdfgluten-free 160 mg5 ml 4 $0

lorcet (hydrocodone) oral tablet 5-

325 mg 1 $0

lorcet hd oral tablet 10-325 mg 1 $0 QL (360 per 30 days)

lorcet plus oral tablet 75-325 mg 1 $0 QL (360 per 30 days)

mapap 160 mg5 ml liquid 160 mg5

ml 4 $0

mapap 160 mg5 ml suspension 160

mg5 ml 4 $0

mapap 325 mg tablet 325 mg 4 $0 QL (360 per 30 days)

mapap 500 mg caplet capletboxed

500 mg 4 $0

mapap 500 mg capsule 500 mg 4 $0 QL (240 per 30 days)

mapap 500 mg15 ml liquid 500

mg15 ml 4 $0

mapap 80 mg tablet chew 80 mg 4 $0 QL (30 per 30 days)

mapap arthritis er 650 mg cplt 650

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

masophen 325 mg tablet 325 mg 4 $0 QL (360 per 30 days)

methadone injection solution 10

mgml 1 $0

methadone oral solution 10 mg5

ml 5 mg5 ml 1 $0

methadone oral tablet 10 mg (Dolophine) 1 $0 QL (360 per 30 days)

methadose oral tabletsoluble 40 mg 1 $0 QL (90 per 30 days)

morphine 2 mgml carpuject outer

lf pf sdv 2 mgml 1 $0

morphine 4 mgml carpuject

outerlfpf sdv 4 mgml 1 $0

morphine 8 mgml syringe 8 mgml 1 $0

morphine concentrate oral solution

100 mg5 ml (20 mgml) 1 $0

morphine intravenous syringe 10

mgml 2 mgml 4 mgml 8 mgml 1 $0

morphine oral solution 10 mg5 ml 1 $0 QL (700 per 30 days)

morphine oral solution 20 mg5 ml

(4 mgml) 1 $0

MORPHINE ORAL TABLET 15

MG 2 $0

morphine oral tablet extended

release 100 mg 200 mg 60 mg (MS Contin) 1 $0

QL (60 per 30 days)

release 15 mg 30 mg (MS Contin) 1 $0

QL (90 per 30 days)

morphine sulfate 10 mgml vial 10

mgml 1 $0

non-asa childrens tab chew 160 mg

QL (30 per 30 days)

non-aspirin child 120 mg sup 120

mg 4 $0

QL (30 per 30 days)

non-aspirin childs drops 100 mgml

QL (30 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

non-aspirin x-str 167 mg5 ml 500

mg15 ml 4 $0

nortemp 80 mg08 ml drop 80

mg08 ml 4 $0

QL (30 per 30 days)

NUCYNTA ER ORAL TABLET

EXTENDED RELEASE 12 HR 100

MG 150 MG 200 MG 250 MG 50

QL (60 per 30 days)

NUCYNTA ORAL TABLET 100

MG 50 MG 75 MG 2 $0

oxycodone oral concentrate 20

mgml 1 $0

oxycodone oral solution 5 mg5 ml 1 $0 QL (1300 per 30 days)

oxycodone oral tablet 10 mg 1 $0 QL (180 per 30 days)

oxycodone oral tablet 15 mg 30 mg (Roxicodone) 1 $0 QL (120 per 30 days)

oxycodone oral tablet 5 mg (Roxicodone) 1 $0 QL (180 per 30 days)

oxycodone oral tabletoral

onlyextrel12 hr 10 mg 15 mg 20

mg 30 mg 40 mg 60 mg

(OxyContin) 1 $0

QL (60 per 30 days)

onlyextrel12 hr 80 mg (OxyContin) 1 $0

oxycodone-acetaminophen oral

tablet 10-325 mg (Endocet) 1 $0

tablet 25-325 mg 5-325 mg (Endocet) 1 $0

oxycodone-aspirin oral tablet

48355-325 mg 1 $0

OXYCONTIN ORAL

TABLETORAL

ONLYEXTREL12 HR 10 MG 15

MG 20 MG 30 MG 40 MG 60

QL (60 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

OXYCONTIN ORAL

TABLETORAL

oxymorphone oral tablet 10 mg (Opana) 1 $0 QL (120 per 30 days)

oxymorphone oral tablet extended

release 12 hr 10 mg 15 mg 20 mg

30 mg 40 mg 5 mg 75 mg

QL (60 per 30 days)

pain amp fever 325 mg tablet 325 mg

pediacare fever reducer susp 160

mg5 ml 4 $0

pharbetol 325 mg tablet regular

strength 325 mg 4 $0

pharbetol 500 mg caplet extra-str

caplet 500 mg 4 $0

pv child non-aspirin 80 mg tab

quick melts sf 80 mg 4 $0

QL (30 per 30 days)

pv childrens non-asa liq 160 mg5

ml 4 $0

pv infant non-asa 80 mg08 ml

aspirin free af 80 mg08 ml 4 $0

QL (30 per 30 days)

pv jr non-aspirin 160 mg tab quick

meltssf 160 mg 4 $0

QL (30 per 30 days)

qc non-aspirin 500 mg gelcap

gelcap ex-str 500 mg 4 $0

ra acetaminophen er 650 mg tab

650 mg

(8 Hour Pain

Reliever) 4 $0

ra athenol 325 mg tablet 325 mg 4 $0 QL (360 per 30 days)

ra child pain relief rapid tab rapid

melts grape 80 mg 4 $0

QL (30 per 30 days)

ra infant fever-pain rel susp 160

mg5 ml 4 $0

ra non-aspirin 160 mg5 ml

childrenscherry 160 mg5 ml 4 $0

reprexain oral tablet 25-200 mg 1 $0 QL (150 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

silapap infants drops infants 80

mg08 ml 4 $0

QL (30 per 30 days)

sm arthritis pain er 650 mg caplet

650 mg 4 $0

sm pain rel jr str tab chew 160 mg 4 $0 QL (30 per 30 days)

sm pain reliever 80 mg tab

QL (30 per 30 days)

tactinal 325 mg tablet 325 mg 4 $0 QL (360 per 30 days)

tactinal 500 mg tablet extra-strength

500 mg 4 $0

tencon oral tablet 50-325 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

tramadol oral tablet 50 mg (Ultram) 1 $0 QL (240 per 30 days)

tramadol-acetaminophen oral tablet

375-325 mg (Ultracet) 1 $0

tylophen 500 mg capsule 500 mg 4 $0 QL (240 per 30 days)

XTAMPZA ER ORAL

CAPSULESPRINKLEER 12HR

TMPRR 135 MG 18 MG 9 MG

QL (60 per 30 days)

XTAMPZA ER ORAL

TMPRR 27 MG

XTAMPZA ER ORAL

TMPRR 36 MG

zebutal oral capsule 50-325-40 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

Nonsteroidal Anti-Inflammatory

Agents

ADVIL 100 MG TABLET JR

STRENGTHCOATED 100 MG 4 $0

ADVIL 200 MG TABLET 200 MG

ADVIL JR STR 100 MG TAB

CHEW TB CHEW8

HOURGRAPE 100 MG

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

aspirin 300 mg suppository 300 mg

aspirin 325 mg tablet 325 mg (Bayer Aspirin) 4 $0

aspirin 81 mg chewable tablet 81

mg (Aspirin Childrens) 4 $0

aspirin buffered 325 mg tab 325 mg

(Buffered Aspirin) 4 $0

aspirin ec 325 mg tablet orange 325

mg (Aspir-Trin) 4 $0

aspirin ec 500 mg tablet 500 mg 4 $0

aspirin ec 81 mg tablet low dose 81

(Adult Aspirin

Regimen) 4 $0

aspir-low ec 81 mg tablet 81 mg 4 $0

aspir-trin ec 325 mg tablet 325 mg 4 $0

bufferin 325 mg tablet coated 325

mg 4 $0

CALDOLOR INTRAVENOUS

RECON SOLN 400 MG4 ML (100

MGML) 800 MG8 ML (100

celecoxib oral capsule 100 mg 200

mg 400 mg 50 mg (Celebrex) 1 $0

QL (60 per 30 days)

child ibu-drops 50 mg125 ml 50

mg125 ml 4 $0

CHILDRENS ADVIL 100 MG5

ML (OTC) 100 MG5 ML 4 $0

cvs child aspirin 81 mg chw tb 81

mg 4 $0

cvs ibuprofen 200 mg softgel liquid

filledsoftge 200 mg (Advil Liqui-Gel) 4 $0

diclofenac potassium oral tablet 50

mg 1 $0

diclofenac sodium oral tablet

extended release 24 hr 100 mg (Voltaren-XR) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

diclofenac sodium oral

tabletdelayed release (drec) 25 mg

50 mg 75 mg

diclofenac-misoprostol oral

tabletirdelayed relbiphasic 50-200

mg-mcg

(Arthrotec 50) 1 $0

mg-mcg

(Arthrotec 75) 1 $0

diflunisal oral tablet 500 mg 1 $0

ecotrin ec 325 mg tablet saftey

coated 325 mg 4 $0

ecpirin ec 325 mg tablet 325 mg 4 $0

etodolac oral capsule 200 mg 300

mg 1 $0

etodolac oral tablet 400 mg (Lodine) 1 $0

etodolac oral tablet 500 mg 1 $0

etodolac oral tablet extended

release 24 hr 400 mg 500 mg 600

fenoprofen oral tablet 600 mg (ProFeno) 1 $0

flurbiprofen oral tablet 100 mg 50

mg 1 $0

gnp chld ibuprofen 100 mg5 ml af

100 mg5 ml 4 $0

gnp ibuprofen jr str 100 mg tb 100

mg 4 $0

ibuprofen 200 mg tablet 200 mg (Advil) 4 $0

ibuprofen oral suspension 100 mg5

ml (Child Ibuprofen) 1 $0

ibuprofen oral tablet 400 mg 600

mg 800 mg 1 $0

indomethacin oral capsule 25 mg 1 $0

PA-HRM QL (240 per

30 days) AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM QL (120 per

30 days) AGE (Max

64 Years)

indomethacin oral capsule extended

release 75 mg 1 $0

PA-HRM QL (60 per

30 days) AGE (Max

64 Years)

indomethacin sodium intravenous

recon soln 1 mg 1 $0

infant ibuprofen 50 mg125 ml

dfafnon-staining 50 mg125 ml 4 $0

infants advil 50 mg125 ml 50

mg125 ml 4 $0

infants medi-profen susp 50 mg125

ml 4 $0

ketoprofen oral capsule 50 mg 75

mg 1 $0

ketoprofen oral capsuleext rel

pellets 24 hr 200 mg 1 $0

ketorolac oral tablet 10 mg 1 $0

PA-HRM QL (20 per

30 days) AGE (Max

64 Years)

mefenamic acid oral capsule 250 mg (Ponstel) 1 $0

meloxicam oral suspension 75 mg5

ml 1 $0

meloxicam oral tablet 15 mg 75 mg (Mobic) 1 $0

nabumetone oral tablet 500 mg 750

mg 1 $0

naproxen oral suspension 125 mg5

ml (Naprosyn) 1 $0

naproxen oral tablet 250 mg 375

mg 1 $0

naproxen oral tablet 500 mg (Naprosyn) 1 $0

naproxen oral tabletdelayed release

(drec) 375 mg 500 mg (EC-Naprosyn) 1 $0

piroxicam oral capsule 10 mg 20

mg (Feldene) 1 $0

ra aspirin 325 mg tablet 325 mg (Bayer Aspirin) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

sm buff aspirin 325 mg tab 325 mg 4 $0

sm ibuprofen ib 100 mg tablet junior

strength 100 mg (Advil) 4 $0

st joseph aspirin 81 mg chew

orange 81 mg 4 $0

st joseph aspirin ec 81 mg tb

enteric coated 81 mg 4 $0

sulindac oral tablet 150 mg 200 mg 1 $0

tri-buffered aspirin 325 mg tb

coated tablet 325 mg 4 $0

wal-profen 200 mg softgel softgel

200 mg 4 $0

Anesthetics

Local Anesthetics

glydo mucous membrane jelly in

applicator 2 1 $0

lidocaine (pf) injection solution 10

mgml (1 ) 15 mgml (15 ) 20

mgml (2 ) 5 mgml (05 )

(Xylocaine-MPF) 1 $0

mgml (4 ) 1 $0

lidocaine hcl injection solution 10

mgml (1 ) 20 mgml (2 ) 5

mgml (05 )

(Xylocaine) 1 $0

lidocaine hcl mucous membrane

jelly 2 1 $0

solution 4 (40 mgml) 1 $0

lidocaine topical adhesive

patchmedicated 5 (Lidoderm) 1 $0

PA QL (90 per 30

lidocaine topical ointment 5 1 $0 PA QL (90 per 30

lidocaine viscous mucous membrane

solution 2 1 $0

lidocaine-prilocaine topical cream

25-25 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Anti-AddictionSubstance

Abuse Treatment Agents

Anti-AddictionSubstance Abuse

Treatment Agents

acamprosate oral tabletdelayed

release (drec) 333 mg 1 $0

BUNAVAIL BUCCAL FILM 21-

03 MG 2 $0

QL (30 per 30 days)

07 MG 63-1 MG 2 $0

QL (60 per 30 days)

buprenorphine hcl sublingual tablet

2 mg 8 mg 1 $0

QL (90 per 30 days)

buprenorphine-naloxone sublingual

tablet 2-05 mg 8-2 mg 1 $0

QL (90 per 30 days)

bupropion hcl (smoking deter) oral

tablet extended release 12 hr 150

(Zyban) 1 $0

CHANTIX CONTINUING

MONTH BOX ORAL TABLET 1

CHANTIX ORAL TABLET 05

MG 1 MG 2 $0

CHANTIX STARTING MONTH

BOX ORAL TABLETSDOSE

PACK 05 MG (11)- 1 MG (42)

QL (53 per 28 days)

disulfiram oral tablet 250 mg 500

mg (Antabuse) 1 $0

naloxone injection solution 04

mgml 1 $0

naloxone injection syringe 04

mgml 1 mgml 1 $0

naltrexone oral tablet 50 mg 1 $0

NARCAN NASAL SPRAYNON-

AEROSOL 2 MGACTUATION 4

MGACTUATION

QL (4 per 30 days)

nicorelief 2 mg gum 2 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

NICORETTE 2 MG CHEWING

GUM WHITE ICE MINT 2 MG 4 $0

nicotine 14 mg24hr patch step 2

(otc) 14 mg24 hr (Nicoderm CQ) 4 $0

nicotine 2 mg chewing gum sugar

free 2 mg (Nicorelief) 4 $0

nicotine 2 mg lozenge mint 3

quittube 2 mg (Nicorette) 4 $0

nicotine 22 mg24hr patch 1 week

starter kit 22 mg24 hr 4 $0

nicotine 4 mg chewing gum 4 mg (Nicorelief) 4 $0

NICOTROL INHALATION

CARTRIDGE 10 MG 2 $0

ra nicotine 14 mg24hr patch (otc)

14 mg24 hr (Nicoderm CQ) 4 $0

ra nicotine 21 mg24hr patch step 1

ra nicotine 4 mg chewing gum

sfcoated mint 4 mg (Nicorelief) 4 $0

SUBOXONE SUBLINGUAL FILM

12-3 MG 8-2 MG 2 $0

QL (60 per 30 days)

2-05 MG 4-1 MG 2 $0

QL (30 per 30 days)

ZUBSOLV SUBLINGUAL

TABLET 07-018 MG 14-036

MG 114-29 MG 29-071 MG

57-14 MG

QL (30 per 30 days)

ZUBSOLV SUBLINGUAL

TABLET 86-21 MG 2 $0

QL (60 per 30 days)

Antianxiety Agents

Benzodiazepines

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

alprazolam oral tablet 025 mg 05

mg 1 mg (Xanax) 1 $0

alprazolam oral tablet 2 mg (Xanax) 1 $0 QL (150 per 30 days)

buspirone oral tablet 10 mg 15 mg

30 mg 5 mg 75 mg 1 $0

chlordiazepoxide hcl oral capsule

10 mg 25 mg 5 mg 1 $0

clonazepam oral tablet 05 mg 1 mg (Klonopin) 1 $0 QL (90 per 30 days)

clonazepam oral tablet 2 mg (Klonopin) 1 $0 QL (300 per 30 days)

clonazepam oral

tabletdisintegrating 0125 mg 025

mg 05 mg 1 mg

QL (90 per 30 days)

clonazepam oral

tabletdisintegrating 2 mg 1 $0

clorazepate dipotassium oral tablet

15 mg 375 mg 1 $0

75 mg (Tranxene T-Tab) 1 $0

DIASTAT ACUDIAL RECTAL

KIT 125-15-175-20 MG 5-75-10

DIASTAT RECTAL KIT 25 MG 2 $0

diazepam injection solution 5 mgml 1 $0 QL (10 per 28 days)

diazepam intensol oral concentrate

5 mgml 1 $0

diazepam oral solution 5 mg5 ml (1

mgml) 1 $0

diazepam oral tablet 10 mg 2 mg 5

mg (Valium) 1 $0

diazepam rectal kit 125-15-175-20

mg 5-75-10 mg (Diastat AcuDial) 1 $0

diazepam rectal kit 25 mg (Diastat) 1 $0

lorazepam injection solution 2

mgml 4 mgml (Ativan) 1 $0

QL (2 per 30 days)

lorazepam injection syringe 2 mgml 1 $0 QL (2 per 30 days)

lorazepam oral tablet 05 mg 1 mg (Ativan) 1 $0 QL (90 per 30 days)

lorazepam oral tablet 2 mg (Ativan) 1 $0 QL (150 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ONFI ORAL SUSPENSION 25

MGML 2 $0

PA NSO QL (480 per

30 days) NDS

ONFI ORAL TABLET 10 MG 20

MG 2 $0

PA NSO QL (60 per

30 days) NDS

temazepam oral capsule 15 mg 30

mg (Restoril) 1 $0

PA-HRM (High Risk

Med QL applies to all

members PA required

for 65 years and older

with over 90 days

cumulative use with

any benzodiazepine

hypnotic drug) QL (30

per 30 days) AGE

(Max 64 Years)

Antibacterials

Aminoglycosides

BETHKIS INHALATION

SOLUTION FOR

NEBULIZATION 300 MG4 ML

PA BvD NDS

gentamicin 10 mgml vial sdv 60

mg6 ml 1 $0

gentamicin in nacl (iso-osm)

intravenous piggyback 100 mg100

ml 100 mg50 ml 120 mg100 ml

60 mg50 ml 70 mg50 ml 80

mg100 ml 80 mg50 ml 90 mg100

gentamicin injection solution 40

mgml 1 $0

gentamicin sulfate (ped) (pf)

injection solution 20 mg2 ml 1 $0

gentamicin sulfate (pf) intravenous

solution 100 mg10 ml 1 $0

neomycin oral tablet 500 mg 1 $0

streptomycin intramuscular recon

soln 1 gram 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TOBI PODHALER INHALATION

CAPSULE WINHALATION

DEVICE 28 MG

tobramycin in 0225 nacl

inhalation solution for nebulization

300 mg5 ml

(Tobi) 1 $0

PA BvD NDS

intravenous piggyback 60 mg50 ml 1 $0

tobramycin sulfate injection solution

10 mgml 40 mgml 1 $0

Antibacterials Miscellaneous

bacitracin intramuscular recon soln

50000 unit (BACiiM) 1 $0

chloramphenicol sod succinate

intravenous recon soln 1 gram 1 $0

clindamycin 75 mg5 ml soln 75

mg5 ml (Cleocin Pediatric) 1 $0

clindamycin hcl oral capsule 150

mg 300 mg 75 mg (Cleocin HCl) 1 $0

clindamycin in 5 dextrose

ml 600 mg50 ml 900 mg50 ml

(Cleocin in 5

dextrose) 1 $0

clindamycin pediatric oral recon

soln 75 mg5 ml 1 $0

clindamycin phosphate injection

solution 150 (mgml) (6 ml) 1 $0

solution 150 mgml (Cleocin) 1 $0

clindamycin phosphate intravenous

solution 600 mg4 ml (Cleocin) 1 $0

colistin (colistimethate na) injection

recon soln 150 mg

(Coly-Mycin M

Parenteral) 1 $0

daptomycin intravenous recon soln

500 mg (Cubicin) 1 $0

linezolid intravenous parenteral

solution 600 mg300 ml (Zyvox) 1 $0

linezolid oral suspension for

reconstitution 100 mg5 ml (Zyvox) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

linezolid oral tablet 600 mg (Zyvox) 1 $0 NDS

linezolid-09 nacl 600 mg300 600

mg300 ml 1 $0

methenamine hippurate oral tablet 1

gram (Hiprex) 1 $0

metronidazole in nacl (iso-os)

(Metro IV) 1 $0

metronidazole oral tablet 250 mg

500 mg (Flagyl) 1 $0

nitrofurantoin macrocrystal oral

capsule 100 mg 25 mg 50 mg (Macrodantin) 1 $0

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use of

nitrofurantoin drugs)

AGE (Max 64 Years)

nitrofurantoin monohydm-cryst

oral capsule 100 mg (Macrobid) 1 $0

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use of

QL (60 per 30 days)

AGE (Max 64 Years)

polymyxin b sulfate injection recon

soln 500000 unit 1 $0

SYNERCID INTRAVENOUS

RECON SOLN 500 MG 2 $0

trimethoprim oral tablet 100 mg 1 $0

vancomycin in dextrose 5

intravenous piggyback 1 gram200

ml 500 mg100 ml 750 mg150 ml

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

vancomycin intravenous recon soln

1000 mg 10 gram 5 gram 500 mg

750 mg

vancomycin oral capsule 125 mg

250 mg (Vancocin) 1 $0

XIFAXAN ORAL TABLET 200

MG 2 $0

PA QL (9 per 30

days) NDS

MG 2 $0

PA NDS

Cephalosporins

cefaclor oral capsule 250 mg 500

mg 1 $0

cefaclor oral suspension for

reconstitution 125 mg5 ml 250

mg5 ml 375 mg5 ml

cefadroxil oral capsule 500 mg 1 $0

cefadroxil oral suspension for

mg5 ml

cefadroxil oral tablet 1 gram 1 $0

cefazolin in dextrose (iso-os)

cefazolin injection recon soln 1

gram 10 gram 500 mg 1 $0

cefazolin intravenous recon soln 1

gram 1 $0

cefdinir oral capsule 300 mg 1 $0

cefdinir oral suspension for

mg5 ml

cefditoren pivoxil oral tablet 200 mg 1 $0

cefditoren pivoxil oral tablet 400 mg (Spectracef) 1 $0

CEFEPIME 1 GM INJECTION 1

GRAM50 ML 2 $0

CEFEPIME INJECTION RECON

SOLN 1 GRAM 2 GRAM (Maxipime) 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CEFEPIME-DEXTROSE 2 GM50

ML 2 GRAM50 ML 2 $0

cefotaxime injection recon soln 1

gram 500 mg 1 $0

gram 2 gram (Claforan) 1 $0

cefoxitin 2 gm piggyback bag 2

gram50 ml 1 $0

cefoxitin intravenous recon soln 1

gram 10 gram 1 $0

gram 1 $0

cefpodoxime oral suspension for

reconstitution 100 mg5 ml 50 mg5

cefpodoxime oral tablet 100 mg 200

mg 1 $0

cefprozil oral suspension for

mg5 ml

cefprozil oral tablet 250 mg 500 mg 1 $0

ceftazidime injection recon soln 2

gram 6 gram (Fortaz) 1 $0

ceftibuten oral capsule 400 mg (Cedax) 1 $0

ceftibuten oral suspension for

reconstitution 180 mg5 ml (Cedax) 1 $0

ceftriaxone 1 gm piggyback lg

single use 1 gram50 ml 1 $0

ceftriaxone 2 gm piggyback lf

ceftriaxone injection recon soln 10

gram 250 mg 500 mg 1 $0

ceftriaxone intravenous recon soln 1

gram 2 gram 1 $0

cefuroxime axetil oral tablet 250

mg 500 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cefuroxime sodium injection recon

soln 750 mg (Zinacef) 1 $0

cefuroxime sodium intravenous

recon soln 15 gram 75 gram (Zinacef) 1 $0

cefuroxime-dextrose (iso-osm)

cephalexin oral capsule 250 mg

500 mg (Keflex) 1 $0

cephalexin oral suspension for

mg5 ml

cephalexin oral tablet 250 mg 500

mg 1 $0

MEFOXIN IN DEXTROSE (ISO-

OSM) INTRAVENOUS

PIGGYBACK 1 GRAM50 ML 2

GRAM50 ML

SUPRAX ORAL CAPSULE 400

MG 2 $0

SUPRAX ORAL

TABLETCHEWABLE 100 MG

200 MG

tazicef injection recon soln 1 gram

2 gram 6 gram 1 $0

TEFLARO INTRAVENOUS

RECON SOLN 400 MG 600 MG 2 $0

Macrolides

azithromycin intravenous recon soln

500 mg (Zithromax) 1 $0

azithromycin oral packet 1 gram (Zithromax) 1 $0

azithromycin oral suspension for

mg5 ml

(Zithromax) 1 $0

azithromycin oral tablet 250 mg (6

pack) 500 mg (3 pack) 1 $0

azithromycin oral tablet 250 mg

500 mg 600 mg (Zithromax) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

clarithromycin oral suspension for

mg5 ml

clarithromycin oral tablet 250 mg

500 mg 1 $0

clarithromycin oral tablet extended

release 24 hr 500 mg 1 $0

DIFICID ORAL TABLET 200 MG 2 $0 ST QL (20 per 10

days) NDS

ees 400 oral tablet 400 mg 2 $0

ees granules oral suspension for

reconstitution 200 mg5 ml 2 $0

ERYPED 200 ORAL

SUSPENSION FOR

RECONSTITUTION 200 MG5 ML

ERYPED 400 ORAL

SUSPENSION FOR

ery-tab oral tabletdelayed release

(drec) 250 mg 500 mg 1 $0

ERY-TAB ORAL

TABLETDELAYED RELEASE

(DREC) 333 MG

erythrocin (as stearate) oral tablet

250 mg 1 $0

ERYTHROCIN INTRAVENOUS

erythromycin ethylsuccinate oral

tablet 400 mg (EES 400) 1 $0

erythromycin oral capsuledelayed

release(drec) 250 mg 1 $0

erythromycin oral tablet 250 mg

500 mg 1 $0

Miscellaneous B-Lactam

Antibiotics

aztreonam injection recon soln 1

gram 2 gram (Azactam) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CAYSTON INHALATION

SOLUTION FOR

NEBULIZATION 75 MGML

LA NDS

imipenem-cilastatin intravenous

recon soln 500 mg (Primaxin IV) 1 $0

INVANZ INJECTION RECON

SOLN 1 GRAM 2 $0

meropenem intravenous recon soln

1 gram 500 mg (Merrem) 1 $0

Penicillins

amoxicillin oral capsule 250 mg

500 mg 1 $0

amoxicillin oral suspension for

mg5 ml 250 mg5 ml 400 mg5 ml

amoxicillin oral tablet 500 mg 875

mg 1 $0

amoxicillin oral tabletchewable 125

mg 250 mg 1 $0

amoxicillin-pot clavulanate oral

suspension for reconstitution 200-

285 mg5 ml 400-57 mg5 ml

625 mg5 ml

(Augmentin) 1 $0

429 mg5 ml

(Augmentin ES-

600) 1 $0

tablet 250-125 mg 1 $0

tablet 500-125 mg 875-125 mg (Augmentin) 1 $0

tabletchewable 200-285 mg 400-

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ampicillin oral capsule 250 mg 500

mg 1 $0

ampicillin oral suspension for

mg5 ml

ampicillin sodium injection recon

soln 1 gram 10 gram 125 mg 2

gram 250 mg 500 mg

ampicillin sodium intravenous recon

soln 2 gram 1 $0

ampicillin-sulbactam injection

recon soln 15 gram 15 gram 3

(Unasyn) 1 $0

BICILLIN C-R

INTRAMUSCULAR SYRINGE

1200000 UNIT 2

ML(600K600K) 1200000 UNIT

2 ML(900K300K)

BICILLIN L-A

1200000 UNIT2 ML 2400000

UNIT4 ML 600000 UNITML

dicloxacillin oral capsule 250 mg

500 mg 1 $0

nafcillin 2 gm vial sterile latex-free

2 gram 1 $0

nafcillin injection recon soln 1 gram 1 $0

nafcillin injection recon soln 10

gram 1 $0

nafcillin intravenous recon soln 2

gram 1 $0

oxacillin in dextrose(iso-osm)

ml 2 gram50 ml

oxacillin injection recon soln 10

gram 2 gram 1 $0

oxacillin intravenous recon soln 1

gram 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

penicillin g pot in dextrose

intravenous piggyback 1 million

unit50 ml 2 million unit50 ml 3

million unit50 ml

penicillin g potassium injection

recon soln 5 million unit (Pfizerpen-G) 1 $0

penicillin g procaine intramuscular

syringe 12 million unit2 ml

600000 unitml

penicillin gk 20 million unit 20

million unit (Pfizerpen-G) 1 $0

penicillin v potassium oral recon

soln 125 mg5 ml 250 mg5 ml 1 $0

penicillin v potassium oral tablet

250 mg 500 mg 1 $0

pfizerpen-g injection recon soln 20

million unit 1 $0

piperacillin-tazobactam intravenous

recon soln 225 gram 3375 gram

45 gram 405 gram

(Zosyn) 1 $0

Quinolones

BAXDELA ORAL TABLET 450

MG 2 $0

PA QL (28 per 14

days) NDS

ciprofloxacin hcl oral tablet 100 mg

750 mg 1 $0

500 mg (Cipro) 1 $0

ciprofloxacin in 5 dextrose

(Cipro in D5W) 1 $0

ciprofloxacin lactate intravenous

solution 200 mg20 ml 400 mg40

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ciprofloxacin oral

suspensionmicrocapsule recon 250

mg5 ml 500 mg5 ml

(Cipro) 1 $0

levofloxacin in d5w intravenous

piggyback 250 mg50 ml 500

mg100 ml 750 mg150 ml

levofloxacin intravenous solution 25

mgml 1 $0

levofloxacin oral solution 250

mg10 ml 1 $0

levofloxacin oral tablet 250 mg 500

mg 750 mg (Levaquin) 1 $0

moxifloxacin oral tablet 400 mg (Avelox) 1 $0

ofloxacin oral tablet 300 mg 400

mg 1 $0

Sulfonamides

sulfadiazine oral tablet 500 mg 1 $0

sulfamethoxazole-trimethoprim

intravenous solution 400-80 mg5

sulfamethoxazole-trimethoprim oral

suspension 200-40 mg5 ml (Sulfatrim) 1 $0

tablet 400-80 mg (Bactrim) 1 $0

tablet 800-160 mg (Bactrim DS) 1 $0

sulfatrim oral suspension 200-40

mg5 ml 1 $0

Tetracyclines

doxy-100 intravenous recon soln

100 mg 1 $0

doxycycline hyclate oral capsule

100 mg 50 mg (Morgidox) 1 $0

doxycycline hyclate oral tablet 100

mg 20 mg 1 $0

doxycycline monohydrate oral

capsule 100 mg 50 mg 75 mg (Mondoxyne NL) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

capsule 150 mg 1 $0

suspension for reconstitution 25

mg5 ml

(Vibramycin) 1 $0

doxycycline monohydrate oral tablet

100 mg (Avidoxy) 1 $0

150 mg 50 mg 75 mg 1 $0

minocycline oral capsule 100 mg

50 mg 75 mg (Minocin) 1 $0

minocycline oral tablet 100 mg 50

mg 75 mg 1 $0

tigecycline intravenous recon soln

50 mg (Tygacil) 1 $0

Anticancer Agents

ABRAXANE INTRAVENOUS

SUSPENSION FOR

RECONSTITUTION 100 MG

adriamycin intravenous solution 10

mg5 ml 20 mg10 ml 1 $0

PA BvD

adrucil intravenous solution 25

gram50 ml 500 mg10 ml 1 $0

PA BvD

AFINITOR DISPERZ ORAL

TABLET FOR SUSPENSION 2

MG 3 MG 5 MG

PA NSO QL (112 per

28 days) NDS

AFINITOR ORAL TABLET 10

MG 2 $0

PA NSO QL (56 per

28 days) NDS

MG 5 MG 75 MG 2 $0

PA NSO QL (28 per

28 days) NDS

ALECENSA ORAL CAPSULE 150

MG 2 $0

PA NSO QL (240 per

30 days) NDS

ALIMTA INTRAVENOUS

ALIQOPA INTRAVENOUS

PA NSO QL (3 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ALUNBRIG ORAL TABLET 30

MG 2 $0

PA NSO QL (180 per

30 days) NDS

anastrozole oral tablet 1 mg (Arimidex) 1 $0

AVASTIN INTRAVENOUS

SOLUTION 25 MGML 25

MGML (16 ML)

PA NSO NDS

azacitidine injection recon soln 100

mg (Vidaza) 1 $0

BAVENCIO INTRAVENOUS

SOLUTION 20 MGML 2 $0

PA NSO NDS

BELEODAQ INTRAVENOUS

PA NSO NDS

BENDEKA INTRAVENOUS

PA NSO NDS

BESPONSA INTRAVENOUS

RECON SOLN 09 MG (025

MGML INITIAL)

PA NSO NDS

bexarotene oral capsule 75 mg (Targretin) 1 $0 PA NSO QL (420 per

30 days) NDS

bicalutamide oral tablet 50 mg (Casodex) 1 $0

bleomycin injection recon soln 15

unit (Bleo 15K) 1 $0

PA BvD

unit 1 $0

PA BvD

BLINCYTO INTRAVENOUS KIT

35 MCG 2 $0

PA NSO QL (140 per

365 days) NDS

BOSULIF ORAL TABLET 100

MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 2 $0

PA NSO QL (30 per

30 days) NDS

CABOMETYX ORAL TABLET 20

MG 60 MG 2 $0

PA NSO QL (30 per

30 days) NDS

MG 2 $0

PA NSO QL (60 per

30 days) NDS

CALQUENCE ORAL CAPSULE

100 MG 2 $0

PA NSO QL (60 per

30 days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CAPRELSA ORAL TABLET 100

MG 2 $0

PA NSO QL (60 per

30 days) NDS

MG 2 $0

PA NSO QL (30 per

30 days) NDS

clofarabine intravenous solution 20

mg20 ml (Clolar) 1 $0

COMETRIQ ORAL CAPSULE 100

MGDAY(80 MG X1-20 MG X1)

140 MGDAY(80 MG X1-20 MG

X3) 60 MGDAY (20 MG X

PA NSO QL (112 per

28 days) NDS

COTELLIC ORAL TABLET 20

MG 2 $0

PA NSO LA QL (63

per 28 days) NDS

cyclophosphamide intravenous

recon soln 1 gram 2 gram 500 mg 1 $0

PA BvD NDS

CYCLOPHOSPHAMIDE ORAL

CAPSULE 25 MG 50 MG 2 $0

PA BvD ST

CYRAMZA INTRAVENOUS

SOLUTION 10 MGML 10

MGML (50 ML)

PA NSO NDS

DARZALEX INTRAVENOUS

PA NSO LA NDS

decitabine intravenous recon soln

50 mg (Dacogen) 1 $0

doxorubicin intravenous solution 10

mg5 ml 2 mgml 20 mg10 ml 50

mg25 ml

(Adriamycin) 1 $0

PA BvD

doxorubicin peg-liposomal

intravenous suspension 2 mgml (Doxil) 1 $0

PA BvD NDS

DROXIA ORAL CAPSULE 200

MG 300 MG 400 MG 2 $0

ELIGARD (3 MONTH)

SUBCUTANEOUS SYRINGE 225

ELIGARD (4 MONTH)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ELIGARD (6 MONTH)

ELIGARD SUBCUTANEOUS

SYRINGE 75 MG (1 MONTH) 2 $0

EMCYT ORAL CAPSULE 140

MG 2 $0

EMPLICITI INTRAVENOUS

PA NSO NDS

ERIVEDGE ORAL CAPSULE 150

MG 2 $0

PA NSO QL (30 per

30 days) NDS

ETOPOPHOS INTRAVENOUS

etoposide intravenous solution 20

mgml (Toposar) 1 $0

exemestane oral tablet 25 mg (Aromasin) 1 $0

FARESTON ORAL TABLET 60

MG 2 $0

FARYDAK ORAL CAPSULE 10

MG 15 MG 20 MG 2 $0

PA NSO NDS

FASLODEX INTRAMUSCULAR

SYRINGE 250 MG5 ML 2 $0

floxuridine injection recon soln 05

gram 1 $0

PA BvD

fluorouracil 5000 mg100 ml latex-

free 5 gram100 ml (Adrucil) 1 $0

PA BvD

fluorouracil intravenous solution 1

gram20 ml 1 $0

PA BvD

fluorouracil intravenous solution

25 gram50 ml 500 mg10 ml (Adrucil) 1 $0

PA BvD

flutamide oral capsule 125 mg 1 $0

GAZYVA INTRAVENOUS

SOLUTION 1000 MG40 ML 2 $0

PA NSO NDS

GILOTRIF ORAL TABLET 20

MG 30 MG 40 MG 2 $0

PA NSO QL (30 per

30 days) NDS

GLEOSTINE ORAL CAPSULE 10

MG 100 MG 40 MG 5 MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

HERCEPTIN INTRAVENOUS

PA NSO NDS

HEXALEN ORAL CAPSULE 50

MG 2 $0

hydroxyurea oral capsule 500 mg (Hydrea) 1 $0

IBRANCE ORAL CAPSULE 100

MG 125 MG 75 MG 2 $0

PA NSO QL (21 per

28 days) NDS

ICLUSIG ORAL TABLET 15 MG 2 $0 PA NSO QL (60 per

30 days) NDS

IDHIFA ORAL TABLET 100 MG

50 MG 2 $0

PA NSO QL (30 per

30 days) NDS

ifosfamide intravenous recon soln 1

gram 3 gram (Ifex) 1 $0

PA BvD

ifosfamide intravenous solution 1

gram20 ml 3 gram60 ml 1 $0

PA BvD

ifosfamide-mesna intravenous kit 1-

1 gram 3000-1000 mg 1 $0

PA BvD NDS

imatinib oral tablet 100 mg (Gleevec) 1 $0 PA NSO QL (90 per

30 days) NDS

IMBRUVICA ORAL CAPSULE

140 MG 2 $0

PA NSO NDS

IMFINZI INTRAVENOUS

SOLUTION 50 MGML 50

MGML (10 ML)

PA NSO NDS

IMLYGIC INJECTION

SUSPENSION 10EXP6 (1

MILLION) PFUML

PA NSO QL (4 per

365 days) NDS

IMLYGIC INJECTION

MILLION) PFUML

PA NSO QL (8 per 28

days) NDS

INLYTA ORAL TABLET 1 MG 2 $0 PA NSO QL (180 per

30 days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

IRESSA ORAL TABLET 250 MG 2 $0 PA NSO QL (60 per

30 days) NDS

IXEMPRA INTRAVENOUS

JAKAFI ORAL TABLET 10 MG

15 MG 20 MG 25 MG 5 MG 2 $0

PA NSO QL (60 per

30 days) NDS

KEYTRUDA INTRAVENOUS

PA NSO QL (4 per 21

days) NDS

PA NSO QL (8 per 21

days) NDS

KISQALI FEMARA CO-PACK

ORAL TABLET 200 MGDAY(200

MG X 1)-25 MG

PA NSO QL (49 per

28 days) NDS

MG X 2)-25 MG

PA NSO QL (70 per

28 days) NDS

MG X 3)-25 MG

PA NSO QL (91 per

28 days) NDS

KISQALI ORAL TABLET 200

MGDAY (200 MG X 1) 400

MGDAY (200 MG X 2) 600

MGDAY (200 MG X 3)

PA NSO QL (63 per

28 days) NDS

KYPROLIS INTRAVENOUS

PA NSO NDS

LARTRUVO INTRAVENOUS

PA NSO LA NDS

LENVIMA ORAL CAPSULE 10

MGDAY (10 MG X 1DAY) 14

MGDAY(10 MG X 1-4 MG X 1)

18 MGDAY (10 MG X 1-4 MG

X2) 20 MGDAY (10 MG X 2) 24

MGDAY(10 MG X 2-4 MG X 1) 8

MGDAY (4 MG X 2)

PA NSO NDS

letrozole oral tablet 25 mg (Femara) 1 $0

LEUKERAN ORAL TABLET 2

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

leuprolide subcutaneous kit 1

mg02 ml 1 $0

LONSURF ORAL TABLET 15-

614 MG 2 $0

PA NSO QL (100 per

28 days) NDS

819 MG 2 $0

PA NSO QL (80 per

28 days) NDS

LUPRON DEPOT (3 MONTH)

KIT 1125 MG 225 MG

KIT 30 MG

KIT 45 MG

LUPRON DEPOT

KIT 375 MG 75 MG

LYNPARZA ORAL CAPSULE 50

MG 2 $0

PA NSO QL (448 per

28 days) NDS

LYNPARZA ORAL TABLET 100

MG 150 MG 2 $0

PA NSO QL (120 per

30 days) NDS

LYSODREN ORAL TABLET 500

MG 2 $0

MATULANE ORAL CAPSULE 50

MG 2 $0

megestrol oral tablet 20 mg 40 mg 1 $0 PA NSO-HRM AGE

(Max 64 Years)

MEKINIST ORAL TABLET 05

MG 2 $0

PA NSO QL (90 per

30 days) NDS

MEKINIST ORAL TABLET 2 MG 2 $0 PA NSO QL (30 per

30 days) NDS

mercaptopurine oral tablet 50 mg 1 $0

methotrexate sodium (pf) injection

recon soln 1 gram 1 $0

PA BvD

solution 25 mgml 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

methotrexate sodium injection

PA BvD

methotrexate sodium oral tablet 25

mg 1 $0

PA BvD ST

mitoxantrone intravenous

concentrate 2 mgml 1 $0

MYLOTARG INTRAVENOUS

RECON SOLN 45 MG (1 MGML

INITIAL CONC)

PA NSO NDS

NERLYNX ORAL TABLET 40

MG 2 $0

PA NSO QL (180 per

30 days) NDS

NEXAVAR ORAL TABLET 200

MG 2 $0

PA NSO QL (120 per

30 days) NDS

nilutamide oral tablet 150 mg (Nilandron) 1 $0 NDS

NINLARO ORAL CAPSULE 23

MG 3 MG 4 MG 2 $0

PA NSO QL (3 per 28

days) NDS

ODOMZO ORAL CAPSULE 200

MG 2 $0

PA NSO LA NDS

ONCASPAR INJECTION

SOLUTION 750 UNITML 2 $0

PA NSO NDS

ONIVYDE INTRAVENOUS

DISPERSION 43 MGML 2 $0

PA BvD NDS

OPDIVO INTRAVENOUS

SOLUTION 100 MG10 ML 40

MG4 ML

PA NSO NDS

POMALYST ORAL CAPSULE 1

MG 2 MG 3 MG 4 MG 2 $0

PA NSO QL (21 per

28 days) NDS

PORTRAZZA INTRAVENOUS

SOLUTION 800 MG50 ML (16

PA NSO QL (100 per

21 days) NDS

PROLEUKIN INTRAVENOUS

RECON SOLN 22 MILLION UNIT 2 $0

PURIXAN ORAL SUSPENSION

20 MGML 2 $0

REVLIMID ORAL CAPSULE 10

MG 15 MG 25 MG 20 MG 25

MG 5 MG

PA NSO LA NDS

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Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

RITUXAN HYCELA

SUBCUTANEOUS SOLUTION

1400 MG117 ML (120 MGML)

1600 MG134 ML (120 MGML)

PA NSO NDS

RITUXAN INTRAVENOUS

CONCENTRATE 10 MGML 2 $0

PA NSO NDS

RUBRACA ORAL TABLET 200

MG 250 MG 300 MG 2 $0

PA NSO QL (120 per

30 days) NDS

RYDAPT ORAL CAPSULE 25

MG 2 $0

PA NSO QL (224 per

28 days) NDS

SOLTAMOX ORAL SOLUTION

10 MG5 ML 2 $0

SPRYCEL ORAL TABLET 100

MG 140 MG 50 MG 70 MG 80

PA NSO QL (30 per

30 days) NDS

SPRYCEL ORAL TABLET 20 MG 2 $0 PA NSO QL (60 per

30 days) NDS

STIVARGA ORAL TABLET 40

MG 2 $0

PA NSO QL (84 per

28 days) NDS

SUTENT ORAL CAPSULE 125

MG 25 MG 375 MG 50 MG 2 $0

PA NSO QL (30 per

30 days) NDS

SYLVANT INTRAVENOUS

PA NSO NDS

SYNRIBO SUBCUTANEOUS

PA NSO QL (28 per

28 days) NDS

TABLOID ORAL TABLET 40 MG 2 $0

TAFINLAR ORAL CAPSULE 50

MG 75 MG 2 $0

PA NSO QL (120 per

30 days) NDS

TAGRISSO ORAL TABLET 40

MG 80 MG 2 $0

PA NSO LA QL (30

per 30 days) NDS

tamoxifen oral tablet 10 mg 20 mg 1 $0

TARCEVA ORAL TABLET 100

MG 25 MG 2 $0

PA NSO QL (60 per

30 days) NDS

MG 2 $0

PA NSO QL (90 per

30 days) NDS

TARGRETIN TOPICAL GEL 1 2 $0 PA NSO QL (60 per

28 days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TASIGNA ORAL CAPSULE 150

MG 200 MG 2 $0

PA NSO QL (112 per

28 days) NDS

TECENTRIQ INTRAVENOUS

PA NSO QL (20 per

21 days) NDS

TEMODAR INTRAVENOUS

PA NSO NDS

thiotepa injection recon soln 15 mg (Tepadina) 1 $0 NDS

toposar intravenous solution 20

mgml 1 $0

TREANDA INTRAVENOUS

TRELSTAR 1125 MG VIAL

INNER SDV 1125 MG 2 $0

QL (1 per 84 days)

INNERSDV 225 MG 2 $0

QL (1 per 168 days)

TRELSTAR INTRAMUSCULAR

QL (1 per 84 days)

QL (1 per 168 days)

tretinoin (chemotherapy) oral

capsule 10 mg 1 $0

TREXALL ORAL TABLET 10

MG 15 MG 5 MG 75 MG 2 $0

PA BvD ST

TYKERB ORAL TABLET 250 MG 2 $0 NDS

UNITUXIN INTRAVENOUS

PA NSO NDS

VALSTAR INTRAVESICAL

VELCADE INJECTION RECON

SOLN 35 MG 2 $0

PA NSO NDS

VENCLEXTA ORAL TABLET 10

MG 2 $0

PA NSO LA QL (60

per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

VENCLEXTA ORAL TABLET

100 MG 2 $0

PA NSO LA QL (120

per 30 days) NDS

MG 2 $0

PA NSO LA QL (30

per 30 days)

VENCLEXTA STARTING PACK

ORAL TABLETSDOSE PACK 10

MG-50 MG- 100 MG

PA NSO LA QL (42

per 28 days) NDS

VERZENIO ORAL TABLET 100

MG 150 MG 200 MG 50 MG 2 $0

PA NSO QL (56 per

28 days) NDS

vinorelbine intravenous solution 10

mgml 50 mg5 ml (Navelbine) 1 $0

VOTRIENT ORAL TABLET 200

MG 2 $0

PA NSO QL (120 per

30 days) NDS

VYXEOS INTRAVENOUS

RECON SOLN 44-100 MG 2 $0

PA BvD NDS

XALKORI ORAL CAPSULE 200

MG 250 MG 2 $0

PA NSO QL (60 per

30 days) NDS

XATMEP ORAL SOLUTION 25

MGML 2 $0

PA BvD ST

XTANDI ORAL CAPSULE 40 MG 2 $0 PA NSO QL (120 per

30 days) NDS

YERVOY INTRAVENOUS

MGML) 50 MG10 ML (5

PA NSO NDS

YONDELIS INTRAVENOUS

PA NSO NDS

ZEJULA ORAL CAPSULE 100

MG 2 $0

PA NSO QL (90 per

30 days) NDS

ZELBORAF ORAL TABLET 240

MG 2 $0

PA NSO QL (240 per

30 days) NDS

ZOLADEX SUBCUTANEOUS

IMPLANT 108 MG 2 $0

QL (1 per 84 days)

IMPLANT 36 MG 2 $0

QL (1 per 28 days)

ZOLINZA ORAL CAPSULE 100

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ZYDELIG ORAL TABLET 100

MG 150 MG 2 $0

PA NSO QL (60 per

30 days) NDS

ZYKADIA ORAL CAPSULE 150

MG 2 $0

PA NSO QL (140 per

28 days) NDS

ZYTIGA ORAL TABLET 250 MG

500 MG 2 $0

PA NSO QL (120 per

30 days) NDS

Anticholinergic Agents

AntimuscarinicsAntispasmodics

atropine injection syringe 005

mgml 01 mgml 1 $0

propantheline oral tablet 15 mg 1 $0

Anticonvulsants

APTIOM ORAL TABLET 200 MG

400 MG 600 MG 800 MG 2 $0

ST NDS

BANZEL ORAL SUSPENSION 40

MGML 2 $0

ST NDS

BANZEL ORAL TABLET 200

MG 400 MG 2 $0

ST NDS

BRIVIACT INTRAVENOUS

QL (80 per 30 days)

BRIVIACT ORAL SOLUTION 10

MGML 2 $0

BRIVIACT ORAL TABLET 10

MG 100 MG 25 MG 50 MG 75

QL (60 per 30 days)

carbamazepine oral capsule er

multiphase 12 hr 100 mg 200 mg

300 mg

(Carbatrol) 1 $0

carbamazepine oral suspension 100

mg5 ml (Tegretol) 1 $0

carbamazepine oral tablet 200 mg (Epitol) 1 $0

carbamazepine oral tablet extended

(Tegretol XR) 1 $0

carbamazepine oral tabletchewable

100 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CELONTIN ORAL CAPSULE 300

MG 2 $0

DILANTIN ORAL CAPSULE 30

MG 1 $0

divalproex oral capsule delayed rel

sprinkle 125 mg

(Depakote

Sprinkles) 1 $0

divalproex oral tablet extended

release 24 hr 250 mg 500 mg (Depakote ER) 1 $0

divalproex oral tabletdelayed

release (drec) 125 mg 250 mg 500

(Depakote) 1 $0

epitol oral tablet 200 mg 1 $0

ethosuximide oral capsule 250 mg (Zarontin) 1 $0

ethosuximide oral solution 250 mg5

ml (Zarontin) 1 $0

felbamate oral suspension 600 mg5

ml (Felbatol) 1 $0

felbamate oral tablet 400 mg 600

mg (Felbatol) 1 $0

fosphenytoin injection solution 100

mg pe2 ml 500 mg pe10 ml (Cerebyx) 1 $0

FYCOMPA ORAL SUSPENSION

05 MGML 2 $0

FYCOMPA ORAL TABLET 10

MG 12 MG 2 MG 4 MG 6 MG 8

gabapentin oral capsule 100 mg

300 mg 400 mg (Neurontin) 1 $0

gabapentin oral solution 250 mg5

ml (Neurontin) 1 $0

gabapentin oral tablet 600 mg 800

mg (Neurontin) 1 $0

GABITRIL ORAL TABLET 12

MG 16 MG 2 $0

lamotrigine oral tablet 100 mg 150

mg 200 mg 25 mg (Lamictal) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

lamotrigine oral tablet extended

release 24hr 100 mg 200 mg 25

mg 250 mg 300 mg 50 mg

(Lamictal XR) 1 $0

lamotrigine oral tablet chewable

dispersible 25 mg 5 mg (Lamictal) 1 $0

levetiracetam intravenous solution

500 mg5 ml (Keppra) 1 $0

levetiracetam oral solution 100

mgml (Keppra) 1 $0

levetiracetam oral tablet 1000 mg

250 mg 500 mg 750 mg (Keppra) 1 $0

levetiracetam oral tablet extended

release 24 hr 500 mg 750 mg (Keppra XR) 1 $0

LYRICA ORAL CAPSULE 100

MG 150 MG 200 MG 225 MG 25

MG 300 MG 50 MG 75 MG

QL (90 per 30 days)

LYRICA ORAL SOLUTION 20

MGML 2 $0

oxcarbazepine oral suspension 300

mg5 ml (60 mgml) (Trileptal) 1 $0

oxcarbazepine oral tablet 150 mg

300 mg 600 mg (Trileptal) 1 $0

OXTELLAR XR ORAL TABLET

MG 300 MG 600 MG

PEGANONE ORAL TABLET 250

MG 2 $0

phenobarbital oral elixir 20 mg5 ml

(4 mgml) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

phenobarbital oral tablet 100 mg

15 mg 162 mg 30 mg 324 mg 60

mg 648 mg 972 mg

PA NSO-HRM AGE

(Max 64 Years)

phenytoin oral suspension 125 mg5

ml (Dilantin-125) 1 $0

phenytoin oral tabletchewable 50

mg (Dilantin Infatabs) 1 $0

phenytoin sodium extended oral

capsule 100 mg

(Dilantin

Extended) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

capsule 200 mg 300 mg (Phenytek) 1 $0

phenytoin sodium intravenous

syringe 50 mgml 1 $0

POTIGA ORAL TABLET 200 MG

300 MG 400 MG 2 $0

ST QL (90 per 30

days) NDS

POTIGA ORAL TABLET 50 MG 2 $0 ST QL (270 per 30

days) NDS

primidone oral tablet 250 mg 50 mg (Mysoline) 1 $0

ROWEEPRA ORAL TABLET

1000 MG 500 MG 750 MG 1 $0

SABRIL ORAL POWDER IN

PACKET 500 MG 2 $0

SABRIL ORAL TABLET 500 MG 2 $0 NDS

SPRITAM ORAL TABLET FOR

SUSPENSION 1000 MG 2 $0

ST QL (60 per 30

SUSPENSION 250 MG 500 MG

750 MG

ST QL (120 per 30

tiagabine oral tablet 2 mg 4 mg (Gabitril) 1 $0

topiramate oral capsule sprinkle 15

mg 25 mg (Topamax) 1 $0

topiramate oral capsulesprinkleer

24hr 100 mg 150 mg 200 mg 25

mg 50 mg

(Qudexy XR) 1 $0

topiramate oral tablet 100 mg 200

mg 25 mg 50 mg (Topamax) 1 $0

TROKENDI XR ORAL

CAPSULEEXTENDED RELEASE

24HR 100 MG 25 MG 50 MG

ST QL (30 per 30

TROKENDI XR ORAL

24HR 200 MG

ST QL (60 per 30

days) NDS

valproate sodium intravenous

solution 500 mg5 ml (100 mgml) (Depacon) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

valproic acid (as sodium salt) oral

solution 250 mg5 ml (Depakene) 1 $0

valproic acid oral capsule 250 mg (Depakene) 1 $0

vigabatrin oral powder in packet

500 mg (Sabril) 1 $0

VIMPAT INTRAVENOUS

ST QL (200 per 5

VIMPAT ORAL SOLUTION 10

MGML 2 $0

ST QL (1200 per 30

VIMPAT ORAL TABLET 100 MG

150 MG 200 MG 50 MG 2 $0

ST QL (60 per 30

zonisamide oral capsule 100 mg 25

mg (Zonegran) 1 $0

zonisamide oral capsule 50 mg 1 $0

Antidementia Agents

donepezil oral tablet 10 mg 5 mg (Aricept) 1 $0 QL (30 per 30 days)

donepezil oral tabletdisintegrating

10 mg 5 mg 1 $0

QL (30 per 30 days)

galantamine oral capsuleext rel

pellets 24 hr 16 mg 24 mg 8 mg (Razadyne ER) 1 $0

QL (30 per 30 days)

galantamine oral solution 4 mgml 1 $0 QL (200 per 30 days)

galantamine oral tablet 12 mg 4

mg 8 mg (Razadyne) 1 $0

QL (60 per 30 days)

memantine oral solution 2 mgml 1 $0 QL (360 per 30 days)

memantine oral tablet 10 mg 5 mg (Namenda) 1 $0 QL (60 per 30 days)

memantine oral tabletsdose pack 5-

(Namenda Titration

Pak) 1 $0

QL (49 per 28 days)

NAMENDA XR ORAL

CAPSPRINKLEER 24HR DOSE

PACK 7-14-21-28 MG

QL (28 per 28 days)

NAMENDA XR ORAL

14 MG 21 MG 28 MG 7 MG

QL (30 per 30 days)

NAMZARIC ORAL

PACK 7142128 MG-10 MG

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

NAMZARIC ORAL

14-10 MG 21-10 MG 28-10 MG

7-10 MG

QL (30 per 30 days)

rivastigmine tartrate oral capsule

15 mg 3 mg 45 mg 6 mg 1 $0

QL (60 per 30 days)

rivastigmine transdermal patch 24

hour 133 mg24 hour 46 mg24 hr

95 mg24 hr

(Exelon) 1 $0

QL (30 per 30 days)

Antidepressants

amitriptyline oral tablet 10 mg 100

mg 150 mg 25 mg 50 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

amoxapine oral tablet 100 mg 150

mg 25 mg 50 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

bupropion hcl oral tablet 100 mg

75 mg 1 $0

bupropion hcl oral tablet extended

(Wellbutrin SR) 1 $0

release 24 hr 150 mg 300 mg (Wellbutrin XL) 1 $0

citalopram oral solution 10 mg5 ml 1 $0 QL (600 per 30 days)

citalopram oral tablet 10 mg 20

mg 40 mg (Celexa) 1 $0

QL (30 per 30 days)

clomipramine oral capsule 25 mg

50 mg 75 mg (Anafranil) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

desipramine oral tablet 10 mg 25

mg (Norpramin) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

mg 50 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

desvenlafaxine succinate oral tablet

extended release 24 hr 100 mg 25

mg 50 mg

(Pristiq) 1 $0

QL (30 per 30 days)

doxepin oral capsule 10 mg 100

mg 150 mg 25 mg 50 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

doxepin oral concentrate 10 mgml 1 $0 PA NSO-HRM AGE

(Max 64 Years)

duloxetine oral capsuledelayed

release(drec) 20 mg 60 mg (Cymbalta) 1 $0

QL (60 per 30 days)

release(drec) 30 mg (Cymbalta) 1 $0

QL (30 per 30 days)

EMSAM TRANSDERMAL

PATCH 24 HOUR 12 MG24 HR 6

MG24 HR 9 MG24 HR

QL (30 per 30 days)

escitalopram oxalate oral solution 5

mg5 ml 1 $0

escitalopram oxalate oral tablet 10

mg 20 mg 5 mg (Lexapro) 1 $0

FETZIMA ORAL CAPSULEEXT

REL 24HR DOSE PACK 20 MG

(2)- 40 MG (26)

ST QL (56 per 365

FETZIMA ORAL

24 HR 120 MG 20 MG 40 MG 80

ST QL (30 per 30

fluoxetine oral capsule 10 mg 20

mg 40 mg (Prozac) 1 $0

fluoxetine oral capsuledelayed

QL (4 per 28 days)

fluoxetine oral solution 20 mg5 ml

(4 mgml) 1 $0

fluoxetine oral tablet 10 mg 20 mg (Sarafem) 1 $0

fluvoxamine oral capsuleextended

release 24hr 100 mg 150 mg 1 $0

fluvoxamine oral tablet 100 mg 25

mg 50 mg 1 $0

imipramine hcl oral tablet 10 mg 25

mg 50 mg (Tofranil) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

imipramine pamoate oral capsule

100 mg 125 mg 150 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

maprotiline oral tablet 25 mg 50

mg 75 mg 1 $0

MARPLAN ORAL TABLET 10

MG 2 $0

mirtazapine oral tablet 15 mg 30

mg 45 mg (Remeron) 1 $0

mirtazapine oral tablet 75 mg 1 $0

mirtazapine oral

tabletdisintegrating 15 mg 30 mg

(Remeron SolTab) 1 $0

nefazodone oral tablet 100 mg 150

mg 200 mg 250 mg 50 mg 1 $0

nortriptyline oral capsule 10 mg 25

mg 50 mg 75 mg (Pamelor) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

nortriptyline oral solution 10 mg5

ml 1 $0

PA NSO-HRM AGE

(Max 64 Years)

paroxetine hcl oral tablet 10 mg 20

mg 30 mg 40 mg (Paxil) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

paroxetine hcl oral tablet extended

(Paxil CR) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

PAXIL ORAL SUSPENSION 10

MG5 ML 2 $0

PA NSO-HRM AGE

(Max 64 Years)

perphenazine-amitriptyline oral

tablet 2-10 mg 2-25 mg 4-10 mg

4-25 mg 4-50 mg

PA NSO-HRM AGE

(Max 64 Years)

phenelzine oral tablet 15 mg (Nardil) 1 $0

protriptyline oral tablet 10 mg 5 mg 1 $0 PA NSO-HRM AGE

(Max 64 Years)

sertraline oral concentrate 20

mgml (Zoloft) 1 $0

sertraline oral tablet 100 mg 25

mg 50 mg (Zoloft) 1 $0

SURMONTIL ORAL CAPSULE

100 MG 25 MG 50 MG 2 $0

PA NSO-HRM AGE

(Max 64 Years)

tranylcypromine oral tablet 10 mg (Parnate) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

trazodone oral tablet 100 mg 150

mg 300 mg 50 mg 1 $0

trimipramine oral capsule 100 mg

25 mg 50 mg (Surmontil) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

TRINTELLIX ORAL TABLET 10

MG 20 MG 5 MG 2 $0

ST QL (30 per 30

venlafaxine oral capsuleextended

release 24hr 150 mg (Effexor XR) 1 $0

QL (30 per 30 days)

release 24hr 375 mg 75 mg (Effexor XR) 1 $0

QL (90 per 30 days)

venlafaxine oral tablet 100 mg 25

mg 375 mg 50 mg 75 mg 1 $0

VIIBRYD ORAL TABLET 10 MG

20 MG 40 MG 2 $0

ST QL (30 per 30

VIIBRYD ORAL TABLETSDOSE

PACK 10 MG (7)- 20 MG (23) 2 $0

ST QL (30 per 180

Antidiabetic Agents

Antidiabetic Agents Miscellaneous

acarbose oral tablet 100 mg 25 mg

50 mg (Precose) 1 $0

QL (90 per 30 days)

CYCLOSET ORAL TABLET 08

MG 2 $0

GLUCAGEN HYPOKIT

INJECTION RECON SOLN 1 MG 2 $0

GLUCAGON EMERGENCY KIT

(HUMAN) INJECTION KIT 1 MG 2 $0

GLYXAMBI ORAL TABLET 10-5

MG 25-5 MG 2 $0

ST QL (30 per 30

INVOKAMET ORAL TABLET

150-1000 MG 150-500 MG 50-

1000 MG

ST QL (60 per 30

INVOKAMET ORAL TABLET 50-

500 MG 2 $0

ST QL (120 per 30

INVOKAMET XR ORAL

TABLET IR - ER BIPHASIC

24HR 150-1000 MG 150-500 MG

50-1000 MG 50-500 MG

ST QL (60 per 30

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

INVOKANA ORAL TABLET 100

MG 2 $0

ST QL (60 per 30

MG 2 $0

ST QL (30 per 30

JANUMET ORAL TABLET 50-

1000 MG 50-500 MG 2 $0

QL (60 per 30 days)

JANUMET XR ORAL TABLET

ER MULTIPHASE 24 HR 100-

1000 MG

QL (30 per 30 days)

ER MULTIPHASE 24 HR 50-1000

MG 50-500 MG

QL (60 per 30 days)

JANUVIA ORAL TABLET 100

MG 25 MG 50 MG 2 $0

QL (30 per 30 days)

JARDIANCE ORAL TABLET 10

MG 25 MG 2 $0

ST QL (30 per 30

JENTADUETO ORAL TABLET

25-1000 MG 25-500 MG 25-850

QL (60 per 30 days)

JENTADUETO XR ORAL

24HR 25-1000 MG

QL (60 per 30 days)

JENTADUETO XR ORAL

24HR 5-1000 MG

QL (30 per 30 days)

KORLYM ORAL TABLET 300

MG 2 $0

PA QL (112 per 28

days) NDS

metformin oral tablet 1000 mg (Glucophage) 1 $0 QL (75 per 30 days)

metformin oral tablet extended

release 24 hr 500 mg (Glucophage XR) 1 $0

QL (90 per 30 days)

miglitol oral tablet 100 mg 25 mg

50 mg (Glyset) 1 $0

QL (90 per 30 days)

nateglinide oral tablet 120 mg 60

mg (Starlix) 1 $0

QL (90 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

pioglitazone oral tablet 15 mg 30

mg 45 mg (Actos) 1 $0

QL (30 per 30 days)

pioglitazone-glimepiride oral tablet

30-2 mg 30-4 mg (DUETACT) 1 $0

QL (30 per 30 days)

pioglitazone-metformin oral tablet

15-500 mg 15-850 mg (Actoplus MET) 1 $0

QL (90 per 30 days)

repaglinide oral tablet 05 mg 1 $0 QL (240 per 30 days)

repaglinide oral tablet 1 mg 2 mg (Prandin) 1 $0 QL (240 per 30 days)

repaglinide-metformin oral tablet 1-

500 mg 2-500 mg 1 $0

SYMLINPEN 120

SUBCUTANEOUS PEN

INJECTOR 2700 MCG27 ML

PA QL (108 per 28

days) NDS

SYMLINPEN 60

SUBCUTANEOUS PEN

PA QL (108 per 28

days) NDS

SYNJARDY ORAL TABLET 125-

1000 MG 125-500 MG 5-1000

MG 5-500 MG

ST QL (60 per 30

SYNJARDY XR ORAL TABLET

IR - ER BIPHASIC 24HR 10-1000

MG 25-1000 MG

ST QL (30 per 30

IR - ER BIPHASIC 24HR 125-

1000 MG 5-1000 MG

ST QL (60 per 30

TRADJENTA ORAL TABLET 5

MG 2 $0

QL (30 per 30 days)

TRULICITY SUBCUTANEOUS

PEN INJECTOR 075 MG05 ML

15 MG05 ML

QL (2 per 28 days)

VICTOZA 3-PAK

SUBCUTANEOUS PEN

INJECTOR 06 MG01 ML (18

MG3 ML)

QL (9 per 30 days)

Insulins

FIASP FLEXTOUCH

SUBCUTANEOUS INSULIN PEN

100 UNITML (3 ML)

QL (30 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

FIASP SUBCUTANEOUS

QL (40 per 28 days)

HUMULIN R U-500 (CONC)

KWIKPEN SUBCUTANEOUS

INSULIN PEN 500 UNITML (3

QL (24 per 28 days)

HUMULIN R U-500

(CONCENTRATED)

500 UNITML

QL (40 per 28 days)

LANTUS SOLOSTAR

100 UNITML (3 ML)

QL (30 per 28 days)

LANTUS SUBCUTANEOUS

QL (40 per 28 days)

NOVOLIN 7030

SUBCUTANEOUS SUSPENSION

100 UNITML (70-30)

QL (40 per 28 days)

NOVOLIN N SUBCUTANEOUS

SUSPENSION 100 UNITML 2 $0

QL (40 per 28 days)

NOVOLIN R INJECTION

QL (40 per 28 days)

NOVOLOG FLEXPEN

100 UNITML

QL (30 per 28 days)

NOVOLOG MIX 70-30 FLEXPEN

100 UNITML (70-30)

QL (30 per 28 days)

NOVOLOG MIX 70-30

100 UNITML (70-30)

QL (40 per 28 days)

NOVOLOG PENFILL

SUBCUTANEOUS CARTRIDGE

100 UNITML

QL (30 per 28 days)

NOVOLOG SUBCUTANEOUS

QL (40 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

SOLIQUA 10033

100 UNIT-33 MCGML

ST QL (30 per 30

TOUJEO SOLOSTAR

300 UNITML (15 ML)

XULTOPHY 10036

100 UNIT-36 MG ML (3 ML)

ST QL (15 per 28

Sulfonylureas

glimepiride oral tablet 1 mg 2 mg (Amaryl) 1 $0 QL (30 per 30 days)

glimepiride oral tablet 4 mg (Amaryl) 1 $0 QL (60 per 30 days)

glipizide oral tablet 10 mg (Glucotrol) 1 $0 QL (120 per 30 days)

glipizide oral tablet extended

release 24hr 10 mg (Glucotrol XL) 1 $0

QL (60 per 30 days)

release 24hr 25 mg 5 mg (Glucotrol XL) 1 $0

QL (30 per 30 days)

glipizide-metformin oral tablet 25-

250 mg 1 $0

500 mg 5-500 mg 1 $0

glyburide micronized oral tablet 15

mg 3 mg 6 mg (Glynase) 1 $0

PA-HRM AGE (Max

64 Years)

glyburide oral tablet 125 mg 25

mg 5 mg 1 $0

PA-HRM AGE (Max

64 Years)

glyburide-metformin oral tablet

125-250 mg 1 $0

PA-HRM AGE (Max

64 Years)

glyburide-metformin oral tablet 25-

500 mg 5-500 mg (Glucovance) 1 $0

PA-HRM AGE (Max

64 Years)

tolazamide oral tablet 250 mg 1 $0 QL (120 per 30 days)

tolbutamide oral tablet 500 mg 1 $0 QL (180 per 30 days)

Antifungals

3-day vaginal cream 2 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ABELCET INTRAVENOUS

SUSPENSION 5 MGML 2 $0

PA BvD NDS

aloe vesta 2 antifungal oint 2 4 $0

AMBISOME INTRAVENOUS

SUSPENSION FOR

PA BvD NDS

amphotericin b injection recon soln

50 mg 1 $0

PA BvD

anti-fungal 1 powder 1 4 $0

antifungal 2 cream 2 4 $0

baza antifungal 2 cream 12s 2

blis-to-sol 1 liquid 1 4 $0

CANCIDAS INTRAVENOUS

caspofungin intravenous recon soln

50 mg 70 mg (Cancidas) 2 $0

ciclopirox topical cream 077 (Ciclodan) 1 $0

ciclopirox topical gel 077 1 $0

ciclopirox topical shampoo 1 (Loprox) 1 $0

ciclopirox topical solution 8 (Ciclodan) 1 $0

ciclopirox topical suspension 077

(Loprox (as

olamine)) 1 $0

clotrim 1 vaginal cream 1 (Clotrimazole-7) 4 $0

clotrimazole 1 cream (otc) 1 (Antifungal

(clotrimazole)) 4 $0

clotrimazole 1 solution (otc) 1

clotrimazole insert 100 mg 4 $0

clotrimazole mucous membrane

troche 10 mg 1 $0

clotrimazole topical cream 1 (Antifungal

clotrimazole topical solution 1 1 $0

clotrimazole-7 cream 1 4 $0

clotrimazole-betamethasone topical

cream 1-005 (Lotrisone) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

lotion 1-005 1 $0

critic-aid clear af 2 oint 12s w

antifungal 2 4 $0

cvs af 1 spray powder 1 4 $0

cvs foot amp sneaker spray pwd 1 4 $0

cvs jock itch 1 cream 1 4 $0

dermafungal 2 ointment 2 4 $0

econazole topical cream 1 1 $0

fluconazole in nacl (iso-osm)

ml 400 mg200 ml

fluconazole oral suspension for

reconstitution 10 mgml 40 mgml (Diflucan) 1 $0

fluconazole oral tablet 100 mg 150

mg 200 mg 50 mg (Diflucan) 1 $0

fluconazole-dext 200 mg100 ml

inner suv 200 mg100 ml 1 $0

flucytosine oral capsule 250 mg

500 mg (Ancobon) 1 $0

formula 3 antifungal 1 soln 1 4 $0

fungi cure intensive 1 spray 1 4 $0

fungoid-d 1 cream 1 4 $0

griseofulvin microsize oral

suspension 125 mg5 ml 1 $0

griseofulvin microsize oral tablet

500 mg 1 $0

inzo antifungal 2 cream 2 4 $0

itraconazole oral capsule 100 mg (Sporanox) 1 $0

ketoconazole oral tablet 200 mg 1 $0

ketoconazole topical cream 2 1 $0

ketoconazole topical shampoo 2 (Nizoral) 1 $0

lamisil af defens 1 spray pwd 1

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

lamisil af defense 1 powder 1 4 $0

LAMISIL ANTIFUNGAL 1

SPRAY FOR ATHLETES FOOT 1

LAMISIL AT 1 GEL 1 4 $0

micatin 2 antifungal cream 2 4 $0

miconazole 3 combo pack 3 sup9gm

crm wapp 200 mg- 2 (9 gram) 4 $0

miconazole 3 combo pack 4 (200

mg)- 2 (9 gram)

(Miconazole-3

prefilcreamwipe) 4 $0

miconazole 7 100 mg vag supp 100

mg 4 $0

miconazole nitrate 2 cream 2 (Miconazole 7) 4 $0

miconazole-3 vaginal suppository

200 mg 1 $0

MONISTAT 3 COMBO PACK 4

(200 MG)- 2 (9 GRAM) 4 $0

monistat 7 cream 7 applicators 2

NOXAFIL ORAL SUSPENSION

200 MG5 ML (40 MGML) 2 $0

NOXAFIL ORAL

(DREC) 100 MG

nyamyc topical powder 100000

unitgram 1 $0

nyata topical powder 100000

unitgram 1 $0

nystatin oral suspension 100000

unitml 1 $0

nystatin oral tablet 500000 unit 1 $0

nystatin topical cream 100000

unitgram 1 $0

nystatin topical ointment 100000

unitgram 1 $0

nystatin topical powder 100000

unitgram (Nyamyc) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

nystatin-triamcinolone topical

cream 100000-01 unitg- 1 $0

ointment 100000-01 unitgram- 1 $0

nystop topical powder 100000

unitgram 1 $0

odor ctrl foot-sneaker 1 powd 1

qc 3 day vaginal 4 cream 200

mg5 gram (4 ) 4 $0

ra antifungal 1 cream 1 4 $0

ra antifungal 1 liquid spray liquid

spray 1 4 $0

remedy phytplx antifungal oint 2

terbinafine 1 cream 1 (Antifungal

(terbinafine)) 4 $0

terbinafine hcl oral tablet 250 mg (Lamisil) 1 $0

tolnaftate 1 cream 1 (Antifungal

(tolnaftate)) 4 $0

tolnaftate 1 spray powder 1 (AF) 4 $0

triple paste af 2 ointment 2 4 $0

vagistat-3 combo pack 200 mg- 2

(9 gram) 4 $0

voriconazole intravenous solution

200 mg (Vfend IV) 1 $0

voriconazole oral suspension for

reconstitution 200 mg5 ml (40

(Vfend) 1 $0

voriconazole oral tablet 200 mg 50

mg (Vfend) 1 $0

Antigout Agents

Antigout Agents Other

allopurinol oral tablet 100 mg 300

mg (Zyloprim) 1 $0

COLCRYS ORAL TABLET 06

MG 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

probenecid oral tablet 500 mg 1 $0

probenecid-colchicine oral tablet

500-05 mg 1 $0

ULORIC ORAL TABLET 40 MG

80 MG 2 $0

QL (30 per 30 days)

ZURAMPIC ORAL TABLET 200

MG 2 $0

ST QL (30 per 30

Antihistamines

alavert 10 mg odt 10 mg 4 $0

alavert d-12 allergy-sinus tab 5-120

mg 4 $0

aler-caps 25 mg capsule 25 mg 4 $0

aler-tab 25 mg tablet 25 mg 4 $0

alka-seltzer plus allergy tab 25 mg 4 $0

aller-chlor 2 mg5 ml syrup 2 mg5

ml 4 $0

aller-chlor 4 mg tablet 4 mg 4 $0

allerclear d-12hr tablet 5-120 mg 4 $0

allerclear d-24hr er tablet 10-240

mg 4 $0

allergy 4 mg tablet 4 mg 4 $0

allerhist-1 134 mg tablet 134 mg 4 $0

aller-tec d 5-120 mg tablet 5-120

mg 4 $0

ambi 60pse-4cpm tablet 4-60 mg 4 $0

antihistamine 25 mg capsule 25 mg

aprodine tablet 25-60 mg 4 $0

banophen 25 mg capsule 25 mg 4 $0

banophen 25 mg tablet 25 mg 4 $0

banophen allergy 125 mg5 ml af

125 mg5 ml 4 $0

benadryl allergy 25 mg ultratb

ultratab 25 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cetirizine hcl 1 mgml soln children

sf grape (otc) 1 mgml

(All Day Allergy

(cetirizine)) 4 $0

cetirizine hcl 10 mg chew tab

childrensouteru-d 10 mg

(All Day Allergy

(cetirizine)) 4 $0

cetirizine hcl 10 mg tablet 10 mg (24Hour Allergy) 4 $0

cetirizine hcl 5 mg tablet 5 mg 4 $0

cetirizine-pse er 5-120 mg tab 5-120

(All Day Allergy-

D) 4 $0

child allegra allergy 30 mg5 ml

child cetirizine 5 mg chew tab 5 mg

child loratadine 5 mg5 ml syr

grape sf 5 mg5 ml

(Allergy Relief

(loratadine)) 4 $0

child triaminic cold amp allergy 1-25

mg5 ml 4 $0

child wal-itin 5 mg5 ml soln 5 mg5

ml 4 $0

child wal-tap cold-allergy elx 1-25

mg5 ml 4 $0

child wal-zyr 1 mgml solution

cherry 1 mgml 4 $0

childrens wal-fex 30 mg5 ml 30

mg5 ml 4 $0

CHILDRENS ZYRTEC 10 MG

ODT 10 MG 4 $0

childs aller-tec 1 mgml soln 1

mgml 4 $0

CHILDS CLARITIN 5 MG TAB

CHEW 5 MG 4 $0

childs wal-zyr 10 mg chew tab 10

mg 4 $0

chlorhist 4 mg tablet 4 mg 4 $0

CLARITIN 10 MG LIQUI-GEL

CAP 10 MG 4 $0

CLARITIN 5 MG REDITABS 5

MG 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cold-allergy-sinus oral tablet 25-60

mg 4 $0

compoz 25 mg gelcap 25 mg 4 $0

cvs allergy 25 mg tablet 25 mg 4 $0

cvs allergy relief 10 mg sftgl 10 mg

cvs child allergy 10 mg chw tb 24

hrindooroutdoor 10 mg 4 $0

cvs cold amp cough nighttime liq 625-

25 mg5 ml 4 $0

cvs loratadine-d 24hr tablet non-

drowsy 10-240 mg 4 $0

cvs nighttime sleep 25 mg tab 25 mg

cvs ultra sleep 25 mg tablet 25 mg 4 $0

cyproheptadine oral syrup 2 mg5

ml 1 $0

PA-HRM AGE (Max

64 Years)

cyproheptadine oral tablet 4 mg 1 $0 PA-HRM AGE (Max

64 Years)

dailyhist-1 134 mg tablet 134 mg 4 $0

dayhist allergy 134 mg tablet 12 hr

relief 134 mg 4 $0

dayhist tablet 134 mg 4 $0

dimaphen elixir af grape gluten-f

1-25 mg5 ml 4 $0

dimetapp cold amp congest liquid

625-25 mg5 ml 4 $0

diphedryl 125 mg5 ml elixir 125

mg5 ml 4 $0

diphenhist 125 mg5 ml soln 125

mg5 ml 4 $0

diphenhist 25 mg capsule 25 mg 4 $0

diphenhist 25 mg captab captab 25

mg 4 $0

diphenhydramine 25 mg capsule

(otc) 25 mg (Aler-Cap) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

diphenhydramine hcl injection

diphenhydramine hcl oral elixir 125

mg5 ml

(Childrens Allergy

(diphenhyd)) 1 $0

PA-HRM AGE (Max

64 Years)

ed chlorped jr syrup 2 mg5 ml 4 $0

ed-a-hist 4 mg-10 mg tablet 4-10 mg

eql allergy relief 10 mg odt non-

drowsy 10 mg 4 $0

fexofenadine hcl 180 mg tablet 24

hour non-drowsy (otc) 180 mg (Allegra Allergy) 4 $0

fexofenadine hcl 30 mg5 ml 30

mg5 ml (Aller-ease) 4 $0

fexofenadine hcl 60 mg tablet

indooroutdoor (otc) 60 mg (Allegra Allergy) 4 $0

geri-dryl 125 mg5 ml liquid 125

mg5 ml 4 $0

hm z-sleep 25 mg softgel 25 mg 4 $0

hydroxyzine hcl intramuscular

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

hydroxyzine hcl oral solution 10

mg5 ml 1 $0

PA-HRM AGE (Max

64 Years)

hydroxyzine hcl oral tablet 10 mg

25 mg 50 mg 1 $0

PA-HRM AGE (Max

64 Years)

kro child nite time cold amp cgh 625-

25 mg5 ml 4 $0

levocetirizine oral solution 25 mg5

ml (Xyzal) 1 $0

levocetirizine oral tablet 5 mg (Xyzal) 1 $0

loratadine 10 mg softgel 10 mg (Claritin Liqui-Gel) 4 $0

loratadine 10 mg tablet 10 mg (Allerclear) 4 $0

loratadine-d 12 hour tablet non-

drowsy 5-120 mg 4 $0

nasal decongest-antihist tab 25-60

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

night sleep aid 50 mg30 ml lq 50

mg30 ml 4 $0

nytol 25 mg quickcaps caplet caplet

25 mg 4 $0

promethazine oral syrup 625 mg5

ml 1 $0

PA-HRM AGE (Max

64 Years)

promethazine vc oral syrup 625-5

mg5 ml 1 $0

ra acta-tabs pe tablet 4-10 mg 4 $0

ra allergy med 25 mg capsule 25 mg

ra allergy med 25 mg tablet 25 mg 4 $0

ra allergy med 25 mg tablet coated

minitabs 25 mg 4 $0

ra cetiri-d er tablet 5-120 mg 4 $0

ra child cetirizine 10 mg chew 24

ra lorata-d 24-hour tablet 10-240

mg 4 $0

ra loratadine 10 mg tablet non-

drowsy 10 mg (Allerclear) 4 $0

ra sleep tablet 25 mg 4 $0

ra sleep-aid softgel 25 mg 4 $0

siladryl 125 mg5 ml liquid 125

mg5 ml 4 $0

sm allergy relief 134 mg tab 134

mg 4 $0

sm cold amp allergy tablet 25-60 mg

sm sinus and allergy tablet

maximum strength 4-60 mg 4 $0

sm z-sleep 50 mg30 ml liquid

berrygluten-free 50 mg30 ml 4 $0

sudogest sinus amp allergy tab 4-60

mg 4 $0

unisom 50 mg sleepgels softgel 50

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

unisom 50 mg30 ml liquid 50 mg30

ml 4 $0

unisom sleep aid 25 mg tablet 25 mg

valu-dryl allergy med tab 25 mg 4 $0

wal-act d cold amp allergy tab 25-60

mg 4 $0

wal-dryl allergy 125 mg5 ml 125

mg5 ml 4 $0

wal-dryl allergy 25 mg capsule 25

mg 4 $0

wal-dryl allergy 25 mg minitab

minitab coated 25 mg 4 $0

wal-fex allergy 180 mg tablet 180

mg 4 $0

wal-fex allergy 60 mg tablet 60 mg 4 $0

wal-finate 4 mg tablet 4 mg 4 $0

wal-finate-d tablet 4-60 mg 4 $0

wal-itin 10 mg odt non-drowsy 10

mg 4 $0

wal-itin 10 mg tablet non-drowsy24

hr rlf 10 mg 4 $0

wal-itin d 12 hour tablet 5-120 mg 4 $0

wal-itin d 24 hour tablet 10-240 mg

wal-phed pe sinus-allergy tab 4-10

mg 4 $0

wal-phed sinus and allergy tab 4-60

mg 4 $0

wal-sleep z 25 mg odt 25 mg 4 $0

wal-sleep z 25 mg softgel 25 mg 4 $0

wal-sleep z 50 mg30 ml liquid

berry af df sf 50 mg30 ml 4 $0

wal-som 25 mg odt 25 mg 4 $0

wal-som 25 mg tablet 25 mg 4 $0

wal-som 50 mg softgel softgelmax

strength 50 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

wal-tap elixir 1-25 mg5 ml 4 $0

wal-zyr 10 mg tablet 10 mg 4 $0

wal-zyr d tablet 5-120 mg 4 $0

ZYRTEC 10 MG ODT 10 MG 4 $0

Anti-Infectives (Skin And

Mucous Membrane)

Anti-Infectives (Skin And Mucous

Membrane)

ABREVA 10 CREAM 10 4 $0

AVC VAGINAL VAGINAL

CREAM 15 2 $0

clindamycin phosphate vaginal

cream 2 (Cleocin) 1 $0

metronidazole vaginal gel 075 (Metrogel Vaginal) 1 $0

terconazole vaginal cream 04 (Terazol 7) 1 $0

terconazole vaginal cream 08 1 $0

terconazole vaginal suppository 80

mg 1 $0

Antimigraine Agents

dihydroergotamine injection

solution 1 mgml (DHE45) 1 $0

QL (30 per 28 days)

dihydroergotamine nasal spraynon-

aerosol 05 mgpump act (4 mgml) (Migranal) 1 $0

QL (8 per 28 days)

ERGOMAR SUBLINGUAL

TABLET 2 MG 2 $0

QL (40 per 28 days)

naratriptan oral tablet 1 mg 25 mg (Amerge) 1 $0 QL (18 per 28 days)

rizatriptan oral tablet 10 mg 5 mg (Maxalt) 1 $0 QL (18 per 28 days)

rizatriptan oral tabletdisintegrating

10 mg 5 mg (Maxalt-MLT) 1 $0

QL (18 per 28 days)

sumatriptan nasal spraynon-

aerosol 20 mgactuation 5

mgactuation

(Imitrex) 1 $0

QL (12 per 28 days)

sumatriptan succinate oral tablet

100 mg 25 mg 50 mg (Imitrex) 1 $0

QL (18 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

sumatriptan succinate subcutaneous

cartridge 4 mg05 ml 6 mg05 ml

(Imitrex STATdose

Kit Refill) 1 $0

QL (4 per 28 days)

pen injector 4 mg05 ml 6 mg05

(Imitrex STATdose

Pen) 1 $0

QL (4 per 28 days)

solution 6 mg05 ml (Imitrex) 1 $0

QL (4 per 28 days)

syringe 6 mg05 ml 1 $0

QL (4 per 28 days)

zolmitriptan oral tablet 25 mg 5

mg (Zomig) 1 $0

QL (12 per 28 days)

zolmitriptan oral

tabletdisintegrating 25 mg 5 mg (Zomig ZMT) 1 $0

QL (12 per 28 days)

Antimycobacterials

CAPASTAT INJECTION RECON

SOLN 1 GRAM 2 $0

dapsone oral tablet 100 mg 25 mg 1 $0

ethambutol oral tablet 100 mg 1 $0

ethambutol oral tablet 400 mg (Myambutol) 1 $0

isoniazid oral solution 50 mg5 ml 1 $0

isoniazid oral tablet 100 mg 300

mg 1 $0

PASER ORAL GRANULES DR

FOR SUSP IN PACKET 4 GRAM 2 $0

PRIFTIN ORAL TABLET 150 MG 2 $0

pyrazinamide oral tablet 500 mg 1 $0

rifabutin oral capsule 150 mg (Mycobutin) 1 $0

rifampin intravenous recon soln 600

mg (Rifadin) 1 $0

rifampin oral capsule 150 mg 300

mg (Rifadin) 1 $0

RIFATER ORAL TABLET 50-120-

300 MG 2 $0

SIRTURO ORAL TABLET 100

MG 2 $0

PA QL (188 per 168

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TRECATOR ORAL TABLET 250

MG 2 $0

Antinausea Agents

AKYNZEO ORAL CAPSULE 300-

05 MG 2 $0

PA BvD

aprepitant oral capsule 125 mg (Emend) 1 $0 PA BvD QL (2 per 28

aprepitant oral capsuledose pack

125 mg (1)- 80 mg (2) (Emend) 1 $0

PA BvD QL (6 per 28

compro rectal suppository 25 mg 1 $0

cvs motion sickness 50 mg tab 50

mg 4 $0

cvs motion sickness relief tab

chewable tablet 25 mg 4 $0

dimenhydrinate injection solution 50

mgml 1 $0

dramamine 50 mg tablet 50 mg 4 $0

dramamine less drowsy 25 mg tb 25

mg 4 $0

driminate 50 mg tablet 50 mg 4 $0

dronabinol oral capsule 10 mg 25

mg 5 mg (Marinol) 1 $0

EMEND 150 MG VIAL

OUTERSDV 150 MG 2 $0

QL (2 per 28 days)

EMEND INTRAVENOUS RECON

SOLN 150 MG 2 $0

QL (2 per 28 days)

EMEND ORAL SUSPENSION

FOR RECONSTITUTION 125 MG

(25 MG ML FINAL CONC)

PA BvD QL (6 per 28

granisetron (pf) intravenous

solution 100 mcgml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

granisetron hcl intravenous solution

1 mgml 1 mgml (1 ml) 1 $0

granisetron hcl oral tablet 1 mg 1 $0 PA BvD

meclizine 125 mg caplet caplet

(otc) 125 mg 4 $0

meclizine 25 mg tablet (otc) 25 mg (Dramamine Less

Drowsy) 4 $0

meclizine oral tablet 125 mg 1 $0 PA-HRM AGE (Max

64 Years)

meclizine oral tablet 25 mg (Dramamine Less

Drowsy) 1 $0

PA-HRM AGE (Max

64 Years)

medi-meclizine 25 mg tablet outer

fc 25 mg 4 $0

ondansetron hcl (pf) injection

ondansetron hcl oral solution 4

mg5 ml

(Zofran (as

hydrochloride)) 1 $0

PA BvD

ondansetron hcl oral tablet 24 mg 1 $0 PA BvD

ondansetron hcl oral tablet 4 mg 8

(Zofran (as

PA BvD

ondansetron oral

tabletdisintegrating 4 mg 8 mg (Zofran ODT) 1 $0

PA BvD

phenadoz rectal suppository 125

mg 25 mg 1 $0

PA-HRM AGE (Max

64 Years)

prochlorperazine edisylate injection

solution 10 mg2 ml (5 mgml) 1 $0

prochlorperazine maleate oral

tablet 10 mg 5 mg (Compazine) 1 $0

prochlorperazine rectal suppository

25 mg (Compazine) 1 $0

promethazine injection solution 25

mgml 50 mgml (Phenergan) 1 $0

PA-HRM AGE (Max

64 Years)

promethazine oral tablet 125 mg

25 mg 50 mg 1 $0

PA-HRM AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

promethazine rectal suppository

125 mg 25 mg (Phenadoz) 1 $0

PA-HRM AGE (Max

64 Years)

promethazine rectal suppository 50

mg (Phenergan) 1 $0

PA-HRM AGE (Max

64 Years)

promethegan rectal suppository

125 mg 25 mg 50 mg 1 $0

PA-HRM AGE (Max

64 Years)

ra motion sickness rlf tb chew

raspberry flavor 25 mg 4 $0

ra travel sickness 50 mg tab 50 mg 4 $0

scopolamine base transdermal patch

3 day 1 mg over 3 days (Transderm-Scop) 1 $0

QL (10 per 30 days)

TRANSDERM-SCOP

TRANSDERMAL PATCH 3 DAY

1 MG OVER 3 DAYS

QL (10 per 30 days)

travel sickness 25 mg tab chew 25

mg 4 $0

travel-ease 25 mg tablet 25 mg 4 $0

wal-dram 50 mg tablet 50 mg 4 $0

Antiparasite Agents

ALBENZA ORAL TABLET 200

MG 2 $0

ALINIA ORAL SUSPENSION

FOR RECONSTITUTION 100

MG5 ML

ALINIA ORAL TABLET 500 MG 2 $0

atovaquone oral suspension 750

mg5 ml (Mepron) 1 $0

atovaquone-proguanil oral tablet

250-100 mg (Malarone) 1 $0

625-25 mg

(Malarone

Pediatric) 1 $0

chloroquine phosphate oral tablet

250 mg 500 mg 1 $0

COARTEM ORAL TABLET 20-

120 MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

DARAPRIM ORAL TABLET 25

MG 2 $0

PA NDS

hydroxychloroquine oral tablet 200

mg (Plaquenil) 1 $0

IMPAVIDO ORAL CAPSULE 50

MG 2 $0

PA QL (84 per 28

days) NDS

ivermectin oral tablet 3 mg (Stromectol) 1 $0

mefloquine oral tablet 250 mg 1 $0

NEBUPENT INHALATION

PA BvD

paromomycin oral capsule 250 mg 1 $0

PENTAM INJECTION RECON

SOLN 300 MG 2 $0

PRIMAQUINE ORAL TABLET

263 MG 2 $0

quinine sulfate oral capsule 324 mg (Qualaquin) 1 $0 PA QL (42 per 7 days)

Antiparkinsonian Agents

amantadine hcl oral capsule 100 mg 1 $0

amantadine hcl oral solution 50

mg5 ml 1 $0

amantadine hcl oral tablet 100 mg 1 $0

APOKYN SUBCUTANEOUS

CARTRIDGE 10 MGML 2 $0

QL (60 per 30 days)

benztropine oral tablet 05 mg 1

mg 2 mg 1 $0

PA-HRM AGE (Max

64 Years)

bromocriptine oral capsule 5 mg (Parlodel) 1 $0

bromocriptine oral tablet 25 mg (Parlodel) 1 $0

cabergoline oral tablet 05 mg 1 $0

carbidopa-levodopa oral tablet 10-

100 mg 25-100 mg 25-250 mg (Sinemet) 1 $0

carbidopa-levodopa oral tablet

extended release 25-100 mg 50-200

(Sinemet CR) 1 $0

carbidopa-levodopa-entacapone

oral tablet 125-50-200 mg (Stalevo 50) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

entacapone oral tablet 200 mg (Comtan) 1 $0

GOCOVRI ORAL

24HR 137 MG

PA QL (60 per 30

days) NDS

GOCOVRI ORAL

24HR 685 MG

PA QL (30 per 30

days) NDS

NEUPRO TRANSDERMAL

PATCH 24 HOUR 1 MG24

HOUR 2 MG24 HOUR 3 MG24

HOUR 8 MG24 HOUR

QL (30 per 30 days)

pramipexole oral tablet 0125 mg

025 mg 05 mg 075 mg 1 mg 15

(Mirapex) 1 $0

rasagiline oral tablet 05 mg 1 mg (Azilect) 1 $0

ropinirole oral tablet 025 mg 05

mg 1 mg 2 mg 3 mg 4 mg 5 mg (Requip) 1 $0

ropinirole oral tablet extended

release 24 hr 12 mg 2 mg 4 mg 6

mg 8 mg

(Requip XL) 1 $0

selegiline hcl oral capsule 5 mg (Eldepryl) 1 $0

selegiline hcl oral tablet 5 mg 1 $0

trihexyphenidyl oral elixir 04 mgml 1 $0 PA-HRM AGE (Max

64 Years)

trihexyphenidyl oral tablet 2 mg 5

mg 1 $0

PA-HRM AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

XADAGO ORAL TABLET 100

MG 50 MG 2 $0

PA QL (30 per 30

days) NDS

Antipsychotic Agents

ABILIFY MAINTENA

INTRAMUSCULAR

SUSPENSIONEXTENDED REL

RECON 300 MG 400 MG

QL (1 per 28 days)

ABILIFY MAINTENA

INTRAMUSCULAR

SYRING 300 MG 400 MG

QL (1 per 28 days)

aripiprazole oral solution 1 mgml 1 $0 QL (900 per 30 days)

aripiprazole oral tablet 10 mg 15

mg 20 mg 30 mg 5 mg (Abilify) 1 $0

QL (30 per 30 days)

aripiprazole oral tablet 2 mg (Abilify) 1 $0 QL (60 per 30 days)

aripiprazole oral

QL (90 per 30 days)

aripiprazole oral

QL (60 per 30 days)

ARISTADA INTRAMUSCULAR

SYRING 1064 MG39 ML

QL (39 per 56 days)

SYRING 441 MG16 ML

QL (16 per 28 days)

SYRING 662 MG24 ML

QL (24 per 28 days)

SYRING 882 MG32 ML

QL (32 per 28 days)

chlorpromazine injection solution

25 mgml 1 $0

chlorpromazine oral tablet 10 mg

100 mg 200 mg 25 mg 50 mg 1 $0

clozapine oral tablet 100 mg (Clozaril) 1 $0 QL (270 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

clozapine oral tablet 200 mg 1 $0 QL (135 per 30 days)

clozapine oral tabletdisintegrating

100 mg 125 mg 25 mg (FazaClo) 1 $0

ST QL (90 per 30

150 mg (FazaClo) 1 $0

ST QL (180 per 30

ST QL (120 per 30

FANAPT ORAL TABLET 1 MG 2

MG 4 MG 2 $0

ST QL (60 per 30

FANAPT ORAL TABLET 10 MG

12 MG 6 MG 8 MG 2 $0

ST QL (60 per 30

days) NDS

FANAPT ORAL TABLETSDOSE

PACK 1MG(2)-2MG(2)- 4MG(2)-

6MG(2)

ST QL (8 per 28 days)

fluphenazine decanoate injection

fluphenazine hcl injection solution

25 mgml 1 $0

fluphenazine hcl oral concentrate 5

mgml 1 $0

fluphenazine hcl oral elixir 25 mg5

ml 1 $0

fluphenazine hcl oral tablet 1 mg 10

mg 25 mg 5 mg 1 $0

GEODON INTRAMUSCULAR

RECON SOLN 20 MGML (FINAL

QL (6 per 28 days)

haloperidol decanoate

intramuscular solution 100 mgml

50 mgml

(Haldol Decanoate) 1 $0

haloperidol lactate injection

solution 5 mgml (Haldol) 1 $0

haloperidol lactate oral concentrate

2 mgml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

haloperidol oral tablet 05 mg 1

mg 10 mg 2 mg 20 mg 5 mg 1 $0

INVEGA SUSTENNA

117 MG075 ML

INVEGA SUSTENNA

156 MGML

QL (1 per 28 days)

INVEGA SUSTENNA

234 MG15 ML

QL (15 per 28 days)

INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE 39

MG025 ML

INVEGA SUSTENNA

MG05 ML

QL (05 per 28 days)

INVEGA TRINZA

273 MG0875 ML

QL (0875 per 84

days) NDS

INVEGA TRINZA

410 MG1315 ML

QL (1315 per 84

days) NDS

INVEGA TRINZA

546 MG175 ML

INVEGA TRINZA

819 MG2625 ML

QL (2625 per 84

days) NDS

LATUDA ORAL TABLET 120

MG 20 MG 40 MG 60 MG 80

QL (30 per 30 days)

loxapine succinate oral capsule 10

mg 25 mg 5 mg 50 mg 1 $0

molindone oral tablet 10 mg 1 $0 QL (240 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

NUPLAZID ORAL TABLET 17

MG 2 $0

PA NSO QL (60 per

30 days) NDS

olanzapine intramuscular recon soln

10 mg (Zyprexa) 1 $0

QL (30 per 30 days)

olanzapine oral tablet 10 mg 15

mg 25 mg 20 mg 5 mg 75 mg (Zyprexa) 1 $0

QL (30 per 30 days)

olanzapine oral tabletdisintegrating

10 mg 15 mg 20 mg 5 mg (Zyprexa Zydis) 1 $0

QL (30 per 30 days)

paliperidone oral tablet extended

release 24hr 15 mg 3 mg 9 mg (Invega) 1 $0

QL (30 per 30 days)

release 24hr 6 mg (Invega) 1 $0

QL (60 per 30 days)

perphenazine oral tablet 16 mg 2

mg 4 mg 8 mg 1 $0

pimozide oral tablet 1 mg 2 mg (Orap) 1 $0

quetiapine oral tablet 100 mg 200

mg 25 mg 300 mg 400 mg 50 mg (Seroquel) 1 $0

QL (90 per 30 days)

quetiapine oral tablet extended

(Seroquel XR) 1 $0

QL (30 per 30 days)

release 24 hr 300 mg (Seroquel XR) 1 $0

QL (60 per 30 days)

REXULTI ORAL TABLET 025

MG 2 $0

ST QL (120 per 30

days) NDS

REXULTI ORAL TABLET 05 MG 2 $0 ST QL (60 per 30

days) NDS

REXULTI ORAL TABLET 1 MG

2 MG 3 MG 4 MG 2 $0

ST QL (30 per 30

days) NDS

RISPERDAL CONSTA

125 MG2 ML 25 MG2 ML

QL (4 per 28 days)

RISPERDAL CONSTA

QL (4 per 28 days)

risperidone oral solution 1 mgml (Risperdal) 1 $0 QL (480 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

risperidone oral tablet 025 mg 05

mg 1 mg 2 mg 3 mg 4 mg (Risperdal) 1 $0

QL (60 per 30 days)

risperidone oral

tabletdisintegrating 025 mg 2 mg 1 $0

QL (60 per 30 days)

risperidone oral

(Risperdal M-

TAB) 1 $0

QL (60 per 30 days)

risperidone oral

(Risperdal M-

TAB) 1 $0

SAPHRIS (BLACK CHERRY)

SUBLINGUAL TABLET 10 MG

25 MG 5 MG

ST QL (60 per 30

days) NDS

thioridazine oral tablet 10 mg 100

mg 25 mg 50 mg 1 $0

thiothixene oral capsule 1 mg 10

mg 2 mg 5 mg 1 $0

trifluoperazine oral tablet 1 mg 10

mg 2 mg 5 mg 1 $0

VERSACLOZ ORAL

ST QL (540 per 30

days) NDS

VRAYLAR ORAL CAPSULE 15

MG 3 MG 45 MG 6 MG 2 $0

ST QL (30 per 30

days) NDS

VRAYLAR ORAL

CAPSULEDOSE PACK 15 MG

(1)- 3 MG (6)

ziprasidone hcl oral capsule 20 mg

40 mg 60 mg 80 mg (Geodon) 1 $0

QL (60 per 30 days)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

QL (2 per 28 days)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

QL (2 per 28 days)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

QL (1 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Antivirals (Systemic)

Antiretrovirals

abacavir oral solution 20 mgml (Ziagen) 1 $0

abacavir oral tablet 300 mg (Ziagen) 1 $0

abacavir-lamivudine oral tablet

600-300 mg (Epzicom) 1 $0

abacavir-lamivudine-zidovudine

oral tablet 300-150-300 mg (Trizivir) 1 $0

APTIVUS ORAL CAPSULE 250

MG 2 $0

APTIVUS ORAL SOLUTION 100

MGML 2 $0

ATRIPLA ORAL TABLET 600-

200-300 MG 2 $0

COMPLERA ORAL TABLET 200-

25-300 MG 2 $0

CRIXIVAN ORAL CAPSULE 200

MG 400 MG 2 $0

DESCOVY ORAL TABLET 200-

25 MG 2 $0

didanosine oral capsuledelayed

release(drec) 125 mg 200 mg 250

mg 400 mg

(Videx EC) 1 $0

EDURANT ORAL TABLET 25

MG 2 $0

EMTRIVA ORAL CAPSULE 200

MG 2 $0

EMTRIVA ORAL SOLUTION 10

MGML 2 $0

EPIVIR HBV ORAL SOLUTION

25 MG5 ML (5 MGML) 2 $0

EVOTAZ ORAL TABLET 300-150

MG 2 $0

fosamprenavir oral tablet 700 mg (Lexiva) 1 $0 NDS

FUZEON SUBCUTANEOUS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GENVOYA ORAL TABLET 150-

150-200-10 MG 2 $0

INTELENCE ORAL TABLET 100

MG 200 MG 2 $0

MG 2 $0

INVIRASE ORAL CAPSULE 200

MG 2 $0

INVIRASE ORAL TABLET 500

MG 2 $0

ISENTRESS HD ORAL TABLET

600 MG 2 $0

ISENTRESS ORAL POWDER IN

PACKET 100 MG 2 $0

ISENTRESS ORAL TABLET 400

MG 2 $0

ISENTRESS ORAL

TABLETCHEWABLE 100 MG 25

KALETRA ORAL TABLET 100-

25 MG 2 $0

50 MG 2 $0

lamivudine oral solution 10 mgml (Epivir) 1 $0

lamivudine oral tablet 100 mg (Epivir HBV) 1 $0

lamivudine oral tablet 150 mg 300

mg (Epivir) 1 $0

lamivudine-zidovudine oral tablet

150-300 mg (Combivir) 1 $0

LEXIVA ORAL SUSPENSION 50

MGML 2 $0

LEXIVA ORAL TABLET 700 MG 2 $0 NDS

lopinavir-ritonavir oral solution

400-100 mg5 ml (Kaletra) 1 $0

nevirapine oral suspension 50 mg5

ml (Viramune) 1 $0

nevirapine oral tablet 200 mg (Viramune) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

nevirapine oral tablet extended

release 24 hr 100 mg 400 mg (Viramune XR) 1 $0

NORVIR ORAL CAPSULE 100

MG 2 $0

NORVIR ORAL SOLUTION 80

MGML 2 $0

NORVIR ORAL TABLET 100 MG 2 $0

ODEFSEY ORAL TABLET 200-

25-25 MG 2 $0

PREZCOBIX ORAL TABLET 800-

150 MG-MG 2 $0

PREZISTA ORAL SUSPENSION

100 MGML 2 $0

PREZISTA ORAL TABLET 150

MG 75 MG 2 $0

MG 800 MG 2 $0

RESCRIPTOR ORAL TABLET

200 MG 2 $0

DISPERSIBLE 100 MG 2 $0

RETROVIR INTRAVENOUS

REYATAZ ORAL CAPSULE 150

MG 200 MG 300 MG 2 $0

REYATAZ ORAL POWDER IN

PACKET 50 MG 2 $0

SELZENTRY ORAL SOLUTION

20 MGML 2 $0

SELZENTRY ORAL TABLET 150

MG 300 MG 75 MG 2 $0

MG 2 $0

stavudine oral capsule 15 mg 20

mg 30 mg 40 mg (Zerit) 1 $0

stavudine oral recon soln 1 mgml (Zerit) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

STRIBILD ORAL TABLET 150-

150-200-300 MG 2 $0

SUSTIVA ORAL CAPSULE 200

MG 2 $0

SUSTIVA ORAL TABLET 600

MG 2 $0

TIVICAY ORAL TABLET 10 MG 2 $0

TIVICAY ORAL TABLET 25 MG

50 MG 2 $0

TRIUMEQ ORAL TABLET 600-

50-300 MG 2 $0

TRUVADA ORAL TABLET 100-

150 MG 133-200 MG 167-250

MG 200-300 MG

VEMLIDY ORAL TABLET 25

MG 2 $0

QL (30 per 30 days)

VIDEX 2 GRAM PEDIATRIC

ORAL RECON SOLN 10 MGML

(FINAL)

VIRACEPT ORAL TABLET 250

MG 625 MG 2 $0

VIREAD ORAL POWDER 40

MGSCOOP (40 MGGRAM) 2 $0

VIREAD ORAL TABLET 150 MG

200 MG 250 MG 300 MG 2 $0

ZERIT ORAL RECON SOLN 1

MGML 2 $0

ZIAGEN ORAL SOLUTION 20

MGML 2 $0

zidovudine oral capsule 100 mg (Retrovir) 1 $0

zidovudine oral syrup 10 mgml (Retrovir) 1 $0

zidovudine oral tablet 300 mg 1 $0

Antivirals Miscellaneous

foscarnet intravenous solution 24

mgml (Foscavir) 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

oseltamivir oral capsule 30 mg (Tamiflu) 1 $0 QL (84 per 180 days)

oseltamivir oral suspension for

reconstitution 6 mgml (Tamiflu) 1 $0

RELENZA DISKHALER

INHALATION BLISTER WITH

DEVICE 5 MGACTUATION

rimantadine oral tablet 100 mg (Flumadine) 1 $0

SYNAGIS INTRAMUSCULAR

SOLUTION 100 MGML 50

MG05 ML

PA NDS

TAMIFLU ORAL SUSPENSION

Hcv Antivirals

DAKLINZA ORAL TABLET 30

MG 60 MG 90 MG 2 $0

PA QL (28 per 28

days) NDS

EPCLUSA ORAL TABLET 400-

100 MG 2 $0

PA QL (28 per 28

days) NDS

HARVONI ORAL TABLET 90-400

MG 2 $0

PA QL (30 per 30

days) NDS

MAVYRET ORAL TABLET 100-

40 MG 2 $0

PA QL (84 per 28

days) NDS

OLYSIO ORAL CAPSULE 150

MG 2 $0

PA QL (28 per 28

days) NDS

SOVALDI ORAL TABLET 400

MG 2 $0

PA QL (28 per 28

days) NDS

TECHNIVIE ORAL TABLET 125-

75-50 MG 2 $0

PA QL (56 per 28

days) NDS

VIEKIRA PAK ORAL

TABLETSDOSE PACK 125 MG-

75 MG -50 MG250 MG

PA QL (112 per 28

days) NDS

VIEKIRA XR ORAL TABLET IR

- ER BIPHASIC 24HR 833 MG-

50 MG- 3333 MG-200 MG

PA QL (84 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

VOSEVI ORAL TABLET 400-100-

100 MG 2 $0

PA QL (28 per 28

days) NDS

ZEPATIER ORAL TABLET 50-

100 MG 2 $0

PA QL (30 per 30

days) NDS

Interferons

INTRON A INJECTION RECON

SOLN 10 MILLION UNIT (1 ML)

18 MILLION UNIT (1 ML) 50

MILLION UNIT (1 ML)

PA NSO NDS

INTRON A INJECTION

SOLUTION 10 MILLION

UNITML 6 MILLION UNITML

PA NSO NDS

PEGASYS CONVENIENCE PACK

SUBCUTANEOUS KIT 180

MCG05 ML

PEGASYS PROCLICK

SUBCUTANEOUS PEN

INJECTOR 135 MCG05 ML 180

MCG05 ML

PEGASYS SUBCUTANEOUS

SOLUTION 180 MCGML 2 $0

SYRINGE 180 MCG05 ML 2 $0

PEGINTRON SUBCUTANEOUS

KIT 50 MCG05 ML 2 $0

SYLATRON SUBCUTANEOUS

KIT 200 MCG 300 MCG 600

PA NSO QL (4 per 28

days) NDS

Nucleosides And Nucleotides

acyclovir 1000 mg20 ml vial

10slatex-freesdv 50 mgml 2 $0

PA BvD NDS

acyclovir oral capsule 200 mg (Zovirax) 1 $0

acyclovir oral suspension 200 mg5

ml (Zovirax) 1 $0

acyclovir oral tablet 400 mg 800

mg (Zovirax) 1 $0

acyclovir sodium intravenous recon

soln 500 mg 2 $0

PA BvD NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

acyclovir sodium intravenous

PA BvD

adefovir oral tablet 10 mg (Hepsera) 1 $0 NDS

entecavir oral tablet 05 mg 1 mg (Baraclude) 1 $0 NDS

famciclovir oral tablet 125 mg 250

mg 500 mg 1 $0

ganciclovir sodium intravenous

recon soln 500 mg (Cytovene) 1 $0

PA BvD

ribasphere oral capsule 200 mg 1 $0

ribasphere oral tablet 200 mg 400

mg 600 mg 1 $0

ribavirin inhalation recon soln 6

gram (Virazole) 1 $0

PA BvD NDS

valacyclovir oral tablet 1 gram 500

mg (Valtrex) 1 $0

valganciclovir oral tablet 450 mg (Valcyte) 1 $0 NDS

ProductsModifiersVolume

Expanders

Anticoagulants

BEVYXXA ORAL CAPSULE 40

MG 80 MG 2 $0

QL (43 per 42 days)

CEPROTIN (BLUE BAR)

INTRAVENOUS RECON SOLN

500 UNIT

ELIQUIS ORAL TABLET 25 MG

5 MG 2 $0

enoxaparin subcutaneous solution

300 mg3 ml (Lovenox) 1 $0

enoxaparin subcutaneous syringe

100 mgml 120 mg08 ml 150

mgml 30 mg03 ml 40 mg04 ml

60 mg06 ml 80 mg08 ml

(Lovenox) 1 $0

fondaparinux subcutaneous syringe

10 mg08 ml 5 mg04 ml 75

mg06 ml

(Arixtra) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25 mg05 ml (Arixtra) 1 $0

heparin (porcine) in 5 dex

intravenous parenteral solution

20000 unit500 ml (40 unitml)

25000 unit250 ml(100 unitml)

heparin (porcine) injection solution

1000 unitml 10000 unitml

heparin 25000 unit250 ml (100

unitml)-045 nacl bag

lfinnersingle-use 25000 unit250

heparin porcine (pf) injection

solution 5000 unit05 ml 1 $0

syringe 5000 unit05 ml 1 $0

IPRIVASK SUBCUTANEOUS

PA QL (24 per 28

days) NDS

jantoven oral tablet 1 mg 10 mg 2

mg 25 mg 3 mg 4 mg 5 mg 6 mg

PRADAXA ORAL CAPSULE 110

MG 150 MG 75 MG 2 $0

ST QL (60 per 30

warfarin oral tablet 1 mg 10 mg 2

(Coumadin) 1 $0

XARELTO ORAL TABLET 10

MG 15 MG 20 MG 2 $0

XARELTO ORAL

TABLETSDOSE PACK 15 MG

(42)- 20 MG (9)

Blood Formation Modifiers

CINRYZE INTRAVENOUS

RECON SOLN 500 UNIT (5 ML) 2 $0

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

EPOGEN 10000 UNITSML VIAL

SDV PF OUTER 10000

UNITML

PA QL (12 per 28

EPOGEN INJECTION SOLUTION

2000 UNITML 20000 UNIT2

ML 20000 UNITML 3000

UNITML 4000 UNITML

PA QL (12 per 28

GRANIX SUBCUTANEOUS

SYRINGE 300 MCG05 ML 480

MCG08 ML

HAEGARDA SUBCUTANEOUS

RECON SOLN 2000 UNIT 3000

PA NDS

LEUKINE INJECTION RECON

SOLN 250 MCG 2 $0

MIRCERA INJECTION SYRINGE

100 MCG03 ML 200 MCG03

ML 50 MCG03 ML 75 MCG03

PA QL (06 per 28

MOZOBIL SUBCUTANEOUS

NEULASTA SUBCUTANEOUS

SYRINGE 6 MG06ML 2 $0

SYRINGE W WEARABLE

INJECTOR 6 MG06 ML

NEUPOGEN INJECTION

SOLUTION 300 MCGML 480

MCG16 ML

NEUPOGEN INJECTION

MCG08 ML

PROCRIT INJECTION

SOLUTION 10000 UNITML

ML 3000 UNITML 4000

UNITML

PA QL (12 per 28

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PROCRIT INJECTION

PA QL (12 per 28

days) NDS

PROCRIT INJECTION

PA QL (6 per 28

days) NDS

PROMACTA ORAL TABLET 125

MG 25 MG 50 MG 75 MG 2 $0

PA QL (30 per 30

days) NDS

ZARXIO INJECTION SYRINGE

300 MCG05 ML 480 MCG08

ST NDS

Hematologic Agents Miscellaneous

anagrelide oral capsule 05 mg (Agrylin) 1 $0

anagrelide oral capsule 1 mg 1 $0

protamine intravenous solution 10

mgml 1 $0

tranexamic acid intravenous

solution 1000 mg10 ml (100

(Cyklokapron) 1 $0

tranexamic acid oral tablet 650 mg (Lysteda) 1 $0 QL (30 per 30 days)

Platelet-Aggregation Inhibitors

aspirin-dipyridamole oral capsule

er multiphase 12 hr 25-200 mg (Aggrenox) 1 $0

BRILINTA ORAL TABLET 60

MG 90 MG 2 $0

cilostazol oral tablet 100 mg 50 mg 1 $0

clopidogrel oral tablet 75 mg (Plavix) 1 $0

dipyridamole oral tablet 25 mg 50

mg 75 mg 1 $0

EFFIENT ORAL TABLET 10 MG

5 MG 2 $0

QL (30 per 30 days)

pentoxifylline oral tablet extended

release 400 mg 1 $0

prasugrel oral tablet 10 mg 5 mg (Effient) 1 $0 QL (30 per 30 days)

Caloric Agents

AMINO ACIDS 15

INTRAVENOUS PARENTERAL

SOLUTION 15

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

AMINOSYN 10

SOLUTION 10

PA BvD

AMINOSYN 7 WITH

ELECTROLYTES

SOLUTION 7

PA BvD

AMINOSYN 85

SOLUTION 85

PA BvD

AMINOSYN 85 -

ELECTROLYTES

SOLUTION 85

PA BvD

AMINOSYN II 10

SOLUTION 10

PA BvD

AMINOSYN II 15

SOLUTION 15

PA BvD

AMINOSYN II 7

SOLUTION 7

PA BvD

AMINOSYN II 85

SOLUTION 85

PA BvD

AMINOSYN II 85 -

ELECTROLYTES

SOLUTION 85

PA BvD

AMINOSYN M 35

SOLUTION 35

PA BvD

AMINOSYN-HBC 7

SOLUTION 7

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

AMINOSYN-PF 10

SOLUTION 10

PA BvD

AMINOSYN-PF 7 (SULFITE-

FREE) INTRAVENOUS

PARENTERAL SOLUTION 7

PA BvD

AMINOSYN-RF 52

SOLUTION 52

PA BvD

CLINIMIX 5D15W SULFITE

FREE INTRAVENOUS

PA BvD

CLINIMIX 5D25W SULFITE-

FREE INTRAVENOUS

PA BvD

CLINIMIX 275D5W SULFIT

FREE INTRAVENOUS

PA BvD

CLINIMIX 425D10W SULF

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

CLINIMIX 425-D20W SULF-

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

CLINIMIX 5-D20W(SULFITE-

FREE) INTRAVENOUS

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CLINIMIX E 275D10W SUL

FREE INTRAVENOUS

PA BvD

CLINIMIX E 275D5W SULF

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

CLINIMIX E 5D15W SULFIT

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

CLINISOL SF 15

SOLUTION 15

PA BvD

dex4 glucose 4 gm tablet chew

grape flavor 4 gram 4 $0

dex4 glucose 40 gel 40 4 $0

dextrose 10 in water (d10w)

intravenous parenteral solution 10

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA BvD

intravenous syringe 1 $0

PA BvD

dextrose 5 in ringers intravenous

parenteral solution 5 1 $0

intravenous parenteral solution 1 $0

intravenous piggyback 5 1 $0

PA BvD

FREAMINE HBC 69

SOLUTION 69

PA BvD

FREAMINE III 10

SOLUTION 10

PA BvD

gluco burst 40 gel 40 4 $0

glucose 4 gram tablet chew naf

caffeine free 4 gram (Dex4 Glucose) 4 $0

glucose 40 gel tropical fruit 40

glutose 15 gel 3s outer u-d 40 4 $0

HEPATAMINE 8

SOLUTION 8

PA BvD

insta-glucose gel 24 gram31 gram

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

INTRALIPID INTRAVENOUS

EMULSION 20 30 2 $0

PA BvD

KABIVEN INTRAVENOUS

EMULSION 331-98-39 2 $0

PA BvD

NEPHRAMINE 54

SOLUTION 54

PA BvD

NUTRILIPID INTRAVENOUS

EMULSION 20 2 $0

PA BvD

PERIKABIVEN INTRAVENOUS

EMULSION 236-68-35 2 $0

PA BvD

PREMASOL 10

SOLUTION 10

PA BvD

PREMASOL 6 INTRAVENOUS

PARENTERAL SOLUTION 6 2 $0

PA BvD

PROCALAMINE 3

SOLUTION 3

PA BvD

PROSOL 20 INTRAVENOUS

PARENTERAL SOLUTION 2 $0

PA BvD

smoflipid intravenous emulsion 20

PA BvD

TRAVASOL 10

SOLUTION 10

PA BvD

TROPHAMINE 10

SOLUTION 10

PA BvD

TROPHAMINE 6

SOLUTION 6

PA BvD

trueplus glucose 15 gram gel cherry

15-400 gram-unit42 ml 4 $0

Cardiovascular Agents

Alpha-Adrenergic Agents

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

clonidine hcl oral tablet 01 mg 02

mg 03 mg (Catapres) 1 $0

clonidine transdermal patch weekly

01 mg24 hr (Catapres-TTS-1) 1 $0

QL (4 per 28 days)

QL (8 per 28 days)

cvs sinus pe decongestant tab 10 mg

doxazosin oral tablet 1 mg 2 mg 4

mg 8 mg (Cardura) 1 $0

guanfacine oral tablet 1 mg 2 mg 1 $0 PA-HRM AGE (Max

64 Years)

MEDI-PHENYL 5 MG TABLET

FCUD250S 5 MG 4 $0

midodrine oral tablet 10 mg 25 mg

5 mg 1 $0

nasal decongestant pe 10 mg tb non-

drowsy 10 mg 4 $0

NORTHERA ORAL CAPSULE

100 MG 200 MG 300 MG 2 $0

PA QL (180 per 30

days) NDS

phenylephrine hcl injection solution

10 mgml (Vazculep) 1 $0

prazosin oral capsule 1 mg 2 mg 5

mg (Minipress) 1 $0

ra sinus pres-cng rlf pe 10 mg

maximum strength 10 mg 4 $0

sudogest pe 10 mg tablet 10 mg 4 $0

wal-phed pe 10 mg tablet non-

drowsypse free 10 mg 4 $0

Angiotensin Ii Receptor

Antagonists

candesartan oral tablet 16 mg 32

mg 4 mg 8 mg (Atacand) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

candesartan-hydrochlorothiazid

oral tablet 16-125 mg 32-125 mg

32-25 mg

(Atacand HCT) 1 $0

EDARBI ORAL TABLET 40 MG

80 MG 2 $0

EDARBYCLOR ORAL TABLET

40-125 MG 40-25 MG 2 $0

ENTRESTO ORAL TABLET 24-26

MG 49-51 MG 97-103 MG 2 $0

QL (60 per 30 days)

irbesartan oral tablet 150 mg 300

mg 75 mg (Avapro) 1 $0

irbesartan-hydrochlorothiazide oral

tablet 150-125 mg 300-125 mg (Avalide) 1 $0

losartan oral tablet 100 mg 25 mg

50 mg (Cozaar) 1 $0

losartan-hydrochlorothiazide oral

tablet 100-125 mg 100-25 mg 50-

125 mg

(Hyzaar) 1 $0

olmesartan oral tablet 20 mg 40

mg 5 mg (Benicar) 1 $0

olmesartan-amlodipin-hcthiazid

oral tablet 20-5-125 mg 40-10-125

mg 40-10-25 mg 40-5-125 mg 40-

5-25 mg

(Tribenzor) 1 $0

olmesartan-hydrochlorothiazide

40-25 mg

(Benicar HCT) 1 $0

telmisartan oral tablet 20 mg 40

mg 80 mg (Micardis) 1 $0

valsartan oral tablet 160 mg 320

mg 40 mg 80 mg (Diovan) 1 $0

valsartan-hydrochlorothiazide oral

tablet 160-125 mg 160-25 mg 320-

125 mg 320-25 mg 80-125 mg

(Diovan HCT) 1 $0

Angiotensin-Converting Enzyme

Inhibitors

benazepril oral tablet 10 mg 5 mg 1 $0

benazepril oral tablet 20 mg 40 mg (Lotensin) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

benazepril-hydrochlorothiazide oral

tablet 10-125 mg 20-125 mg 20-

(Lotensin HCT) 1 $0

tablet 5-625 mg 1 $0

captopril oral tablet 100 mg 125

mg 25 mg 50 mg 1 $0

captopril-hydrochlorothiazide oral

tablet 25-15 mg 25-25 mg 50-15

mg 50-25 mg

enalapril maleate oral tablet 10 mg

25 mg 20 mg 5 mg (Vasotec) 1 $0

enalaprilat intravenous solution

125 mgml 1 $0

enalapril-hydrochlorothiazide oral

tablet 10-25 mg (Vaseretic) 1 $0

fosinopril oral tablet 10 mg 20 mg

40 mg 1 $0

fosinopril-hydrochlorothiazide oral

tablet 10-125 mg 20-125 mg 1 $0

lisinopril oral tablet 10 mg 20 mg

5 mg (Prinivil) 1 $0

40 mg (Zestril) 1 $0

lisinopril-hydrochlorothiazide oral

tablet 10-125 mg 20-125 mg 20-

(Zestoretic) 1 $0

moexipril oral tablet 15 mg 75 mg 1 $0

moexipril-hydrochlorothiazide oral

tablet 15-125 mg 15-25 mg 75-

125 mg

perindopril erbumine oral tablet 2

mg 4 mg 8 mg 1 $0

quinapril oral tablet 10 mg 20 mg

40 mg 5 mg (Accupril) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

quinapril-hydrochlorothiazide oral

tablet 10-125 mg 20-125 mg 20-

(Accuretic) 1 $0

ramipril oral capsule 125 mg 10

mg 25 mg 5 mg (Altace) 1 $0

trandolapril oral tablet 1 mg 2 mg

4 mg 1 $0

Antiarrhythmic Agents

amiodarone oral tablet 100 mg 200

mg 400 mg (Pacerone) 1 $0

disopyramide phosphate oral

capsule 100 mg 150 mg (Norpace) 1 $0

dofetilide oral capsule 125 mcg 250

mcg 500 mcg (Tikosyn) 1 $0

flecainide oral tablet 100 mg 150

mg 50 mg 1 $0

lidocaine (pf) intravenous syringe

100 mg5 ml (2 ) 50 mg5 ml (1

lidocaine in 5 dextrose (pf)

mgml (08 )

mexiletine oral capsule 150 mg 200

mg 250 mg 1 $0

MULTAQ ORAL TABLET 400

MG 2 $0

pacerone oral tablet 100 mg 200

mg 400 mg 1 $0

procainamide injection solution 100

mgml 500 mgml 1 $0

propafenone oral tablet 150 mg 225

mg 300 mg 1 $0

quinidine sulfate oral tablet 200 mg

300 mg 1 $0

Beta-Adrenergic Blocking Agents

acebutolol oral capsule 200 mg 400

mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

atenolol oral tablet 100 mg 25 mg

50 mg (Tenormin) 1 $0

atenolol-chlorthalidone oral tablet

100-25 mg (Tenoretic 100) 1 $0

50-25 mg (Tenoretic 50) 1 $0

betaxolol oral tablet 10 mg 20 mg 1 $0

bisoprolol fumarate oral tablet 10

mg 5 mg 1 $0

bisoprolol-hydrochlorothiazide oral

tablet 10-625 mg 25-625 mg 5-

625 mg

(Ziac) 1 $0

BYSTOLIC ORAL TABLET 10

MG 25 MG 20 MG 5 MG 2 $0

BYVALSON ORAL TABLET 5-80

MG 2 $0

carvedilol oral tablet 125 mg 25

mg 3125 mg 625 mg (Coreg) 1 $0

esmolol intravenous solution 100

mg10 ml (10 mgml) (Brevibloc) 1 $0

PA BvD NDS

labetalol intravenous solution 5

mgml 1 $0

labetalol oral tablet 100 mg 200

mg 300 mg 1 $0

metoprolol succinate oral tablet

mg 25 mg 50 mg

(Toprol XL) 1 $0

metoprolol ta-hydrochlorothiaz oral

tablet 100-25 mg 100-50 mg 1 $0

tablet 50-25 mg (Lopressor HCT) 1 $0

metoprolol tartrate intravenous

solution 5 mg5 ml (Lopressor) 1 $0

metoprolol tartrate oral tablet 100

mg 50 mg (Lopressor) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 1 $0

nadolol oral tablet 20 mg 40 mg 80

mg (Corgard) 1 $0

pindolol oral tablet 10 mg 5 mg 1 $0

propranolol intravenous solution 1

mgml 1 $0

propranolol oral capsuleextended

mg 80 mg

(Inderal LA) 1 $0

propranolol oral solution 20 mg5

ml (4 mgml) 40 mg5 ml (8 mgml) 1 $0

propranolol oral tablet 10 mg 20

mg 40 mg 60 mg 80 mg 1 $0

propranolol-hydrochlorothiazid

oral tablet 40-25 mg 80-25 mg 1 $0

sorine oral tablet 120 mg 160 mg

240 mg 80 mg 1 $0

sotalol 120 mg tablet 120 mg (Betapace) 1 $0

sotalol af oral tablet 120 mg 1 $0

sotalol oral tablet 160 mg 240 mg

80 mg (Betapace) 1 $0

timolol maleate oral tablet 10 mg

20 mg 5 mg 1 $0

Calcium-Channel Blocking Agents

cartia xt oral capsuleextended

mg 300 mg

dilt-cd oral capsuleextended

release 24hr 120 mg 1 $0

diltiazem 24hr er 180 mg cap 180

mg (Cardizem CD) 1 $0

diltiazem hcl intravenous solution 5

mgml 1 $0

diltiazem hcl oral capsuleextended

release 12 hr 120 mg 60 mg 90 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

release 24 hr 180 mg (Taztia XT) 1 $0

release 24 hr 420 mg (Tiazac) 1 $0

(Cardizem CD) 1 $0

diltiazem hcl oral tablet 120 mg 30

mg 60 mg (Cardizem) 1 $0

diltiazem hcl oral tablet 90 mg 1 $0

diltiazem hcl oral tablet extended

mg 360 mg 420 mg

(Cardizem LA) 1 $0

dilt-xr oral capsuleextrel 24h

degradable 120 mg 180 mg 240 mg 1 $0

matzim la oral tablet extended

mg 360 mg 420 mg

taztia xt oral capsuleextended

mg 300 mg 360 mg

verapamil intravenous syringe 25

mgml 1 $0

verapamil oral capsule 24 hr er

pellet ct 100 mg 200 mg 300 mg (Verelan PM) 1 $0

verapamil oral capsuleext rel

pellets 24 hr 120 mg 180 mg 240

mg 360 mg

(Verelan) 1 $0

verapamil oral tablet 120 mg 80 mg (Calan) 1 $0

verapamil oral tablet 40 mg 1 $0

verapamil oral tablet extended

release 120 mg 180 mg 240 mg (Calan SR) 1 $0

Miscellaneous

CORLANOR ORAL TABLET 5

MG 75 MG 2 $0

PA QL (60 per 30

DEMSER ORAL CAPSULE 250

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

digitek oral tablet 125 mcg 1 $0

PA-HRM High Risk

Med PA Required for

ages 65 and older and

dose is greater than

125mcg per day QL

(30 per 30 days) AGE

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

digox oral tablet 125 mcg 1 $0

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

digoxin 025 mgml syringe 250

mcgml 1 $0

PA-HRM AGE (Max

64 Years)

digoxin injection solution 250

mcgml (Lanoxin) 1 $0

PA-HRM AGE (Max

64 Years)

DIGOXIN ORAL SOLUTION 50

MCGML 2 $0

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

digoxin oral tablet 125 mcg (Digitek) 1 $0

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

dobutamine in d5w intravenous

parenteral solution 1000 mg250 ml

(4000 mcgml) 250 mg250 ml (1

mgml) 500 mg250 ml (2000

mcgml)

PA BvD

dobutamine intravenous solution

250 mg20 ml (125 mgml) 500

mg40 ml (125 mgml)

PA BvD

dopamine in 5 dextrose

intravenous solution 200 mg250 ml

(800 mcgml) 400 mg250 ml (1600

mcgml) 800 mg250 ml (3200

mcgml)

PA BvD

dopamine intravenous solution 200

mg5 ml (40 mgml) 400 mg5 ml

(80 mgml) 800 mg10 ml (80

mgml) 800 mg5 ml (160 mgml)

PA BvD

epinephrine injection auto-injector

015 mg03 ml (EpiPen Jr) 1 $0

QL (4 per 30 days)

03 mg03 ml (Auvi-Q) 1 $0

QL (4 per 30 days)

EPIPEN 2-PAK INJECTION

AUTO-INJECTOR 03 MG03 ML 1 $0

QL (4 per 30 days)

EPIPEN INJECTION AUTO-

INJECTOR 03 MG03 ML 1 $0

QL (4 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

EPIPEN JR 2-PAK INJECTION

AUTO-INJECTOR 015 MG03

QL (4 per 30 days)

FIRAZYR SUBCUTANEOUS

QL (18 per 30 days)

hydralazine injection solution 20

mgml 1 $0

hydralazine oral tablet 10 mg 100

mg 25 mg 50 mg 1 $0

LANOXIN ORAL TABLET 1875

MCG 2 $0

PA-HRM QL (30 per

30 days) AGE (Max

64 Years)

MCG 2 $0

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

milrinone in 5 dextrose

ml (200 mcgml) 40 mg200 ml (200

mcgml)

PA BvD NDS

milrinone intravenous solution 1

mgml 1 $0

PA BvD NDS

norepinephrine bitartrate

intravenous solution 1 mgml

(Levophed

(bitartrate)) 1 $0

PA BvD

RANEXA ORAL TABLET

EXTENDED RELEASE 12 HR

1000 MG 500 MG

Dihydropyridines

afeditab cr oral tablet extended

release 30 mg 60 mg 1 $0

amlodipine oral tablet 10 mg 25

mg 5 mg (Norvasc) 1 $0

amlodipine-benazepril oral capsule

10-20 mg 10-40 mg 5-10 mg 5-20

mg 5-40 mg

(Lotrel) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25-10 mg 1 $0

amlodipine-olmesartan oral tablet

10-20 mg 10-40 mg 5-20 mg 5-40

(Azor) 1 $0

amlodipine-valsartan oral tablet 10-

160 mg 10-320 mg 5-160 mg 5-

320 mg

(Exforge) 1 $0

amlodipine-valsartan-hcthiazid oral

tablet 10-160-125 mg 10-160-25

mg 10-320-25 mg 5-160-125 mg

5-160-25 mg

(Exforge HCT) 1 $0

CLEVIPREX INTRAVENOUS

EMULSION 25 MG50 ML 50

MG100 ML

felodipine oral tablet extended

isradipine oral capsule 25 mg 5 mg 1 $0

nicardipine oral capsule 20 mg 30

mg 1 $0

nifedipine oral tablet extended

release 24hr 30 mg 60 mg 90 mg (Procardia XL) 1 $0

release 30 mg 60 mg 90 mg (Adalat CC) 1 $0

Diuretics

amiloride oral tablet 5 mg 1 $0

amiloride-hydrochlorothiazide oral

tablet 5-50 mg 1 $0

bumetanide injection solution 025

mgml 1 $0

bumetanide oral tablet 05 mg 1

mg 2 mg 1 $0

chlorothiazide oral tablet 250 mg

500 mg 1 $0

chlorothiazide sodium intravenous

recon soln 500 mg (Diuril IV) 1 $0

chlorthalidone oral tablet 25 mg 50

mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

furosemide injection solution 10

mgml 1 $0

furosemide injection syringe 10

mgml 1 $0

furosemide oral solution 10 mgml

40 mg5 ml (8 mgml) 1 $0

furosemide oral tablet 20 mg 40

mg 80 mg (Lasix) 1 $0

hydrochlorothiazide oral capsule

125 mg (Microzide) 1 $0

hydrochlorothiazide oral tablet 125

mg 25 mg 50 mg 1 $0

indapamide oral tablet 125 mg 25

mg 1 $0

methyclothiazide oral tablet 5 mg 1 $0

metolazone oral tablet 10 mg 25

mg 5 mg 1 $0

spironolactone oral tablet 100 mg

25 mg 50 mg (Aldactone) 1 $0

spironolacton-hydrochlorothiaz oral

tablet 25-25 mg (Aldactazide) 1 $0

torsemide oral tablet 10 mg 20 mg (Demadex) 1 $0

torsemide oral tablet 100 mg 5 mg 1 $0

triamterene-hydrochlorothiazid oral

capsule 375-25 mg (Dyazide) 1 $0

capsule 50-25 mg 1 $0

tablet 375-25 mg (Maxzide-25mg) 1 $0

tablet 75-50 mg (Maxzide) 1 $0

Dyslipidemics

amlodipine-atorvastatin oral tablet

10-10 mg 10-20 mg 10-40 mg 10-

80 mg 5-10 mg 5-20 mg 5-40 mg

5-80 mg

(Caduet) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25-10 mg 25-20 mg 25-40 mg 1 $0

atorvastatin oral tablet 10 mg 20

mg 40 mg 80 mg (Lipitor) 1 $0

cholestyramine (with sugar) oral

powder 4 gram (Questran) 1 $0

cholestyramine light oral powder 4

gram 1 $0

cholestyramine light packet 4 gram 1 $0

cholestyramine packet 4 gram (Questran) 1 $0

colestipol hcl granules packet 5

gram (Colestid) 1 $0

colestipol oral granules 5 gram (Colestid) 1 $0

colestipol oral tablet 1 gram (Colestid) 1 $0

endur-acin er 500 mg tablet 500 mg

ezetimibe oral tablet 10 mg (Zetia) 1 $0

fenofibrate micronized oral capsule

130 mg 134 mg 200 mg 43 mg 67

fenofibrate nanocrystallized oral

tablet 145 mg 48 mg (Tricor) 1 $0

fenofibrate oral tablet 160 mg 54

mg 1 $0

fenofibric acid (choline) oral

capsuledelayed release(drec) 135

mg 45 mg

(Trilipix) 1 $0

fenofibric acid oral tablet 105 mg

35 mg (Fibricor) 1 $0

gemfibrozil oral tablet 600 mg (Lopid) 1 $0

JUXTAPID ORAL CAPSULE 10

MG 30 MG 40 MG 60 MG 2 $0

PA QL (30 per 30

days) NDS

MG 2 $0

PA QL (90 per 30

days) NDS

MG 2 $0

PA QL (45 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

KYNAMRO SUBCUTANEOUS

SYRINGE 200 MGML 2 $0

PA QL (4 per 28

days) NDS

LIVALO ORAL TABLET 1 MG 2

MG 4 MG 2 $0

QL (30 per 30 days)

lovastatin oral tablet 10 mg 20 mg

40 mg 1 $0

niacin 50 mg tablet 50 mg 4 $0

niacin 500 mg capsule sa 500 mg 4 $0

niacin 500 mg tablet 500 mg (Niacor) 4 $0

niacin oral tablet extended release

24 hr 1000 mg 500 mg 750 mg

(Niaspan

Extended-Release) 1 $0

niacin tr 500 mg caplet caplet 500

mg (Endur-Acin) 4 $0

niacinamide 500 mg tablet 500 mg (Niacin

(niacinamide)) 4 $0

niacor oral tablet 500 mg 1 $0

omega-3 acid ethyl esters oral

capsule 1 gram (Lovaza) 1 $0

plain niacin 500 mg tablet 500 mg (Niacor) 4 $0

PRALUENT PEN

SUBCUTANEOUS PEN

INJECTOR 150 MGML 75

PA QL (2 per 28

days) NDS

pravastatin oral tablet 10 mg 1 $0

pravastatin oral tablet 20 mg 40

mg 80 mg (Pravachol) 1 $0

prevalite oral powder 4 gram 1 $0

prevalite packet outer 4 gram 1 $0

REPATHA PUSHTRONEX

SUBCUTANEOUS WEARABLE

INJECTOR 420 MG35 ML

PA QL (35 per 28

days) NDS

REPATHA SURECLICK

SUBCUTANEOUS PEN

INJECTOR 140 MGML

PA QL (3 per 28

days) NDS

REPATHA SYRINGE

PA QL (3 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

rosuvastatin oral tablet 10 mg 20

mg 40 mg 5 mg (Crestor) 1 $0

simvastatin oral tablet 10 mg 20

mg 40 mg 5 mg (Zocor) 1 $0

simvastatin oral tablet 80 mg (Zocor) 1 $0 QL (30 per 30 days)

VASCEPA ORAL CAPSULE 05

GRAM 2 $0

WELCHOL ORAL POWDER IN

PACKET 375 GRAM 2 $0

WELCHOL ORAL TABLET 625

MG 2 $0

Renin-Angiotensin-Aldosterone

System Inhibitors

eplerenone oral tablet 25 mg 50 mg (Inspra) 1 $0

TEKAMLO ORAL TABLET 150-

10 MG 150-5 MG 300-10 MG

300-5 MG

TEKTURNA HCT ORAL TABLET

150-125 MG 150-25 MG 300-125

MG 300-25 MG

TEKTURNA ORAL TABLET 150

MG 300 MG 2 $0

Vasodilators

BIDIL ORAL TABLET 20-375

MG 2 $0

isosorbide dinitrate oral tablet 10

mg 20 mg 30 mg 1 $0

isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) 1 $0

isosorbide dinitrate oral tablet

extended release 40 mg (ISOCHRON) 1 $0

isosorbide mononitrate oral tablet

10 mg 20 mg 1 $0

mg 60 mg

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

minitran transdermal patch 24 hour

01 mghr 02 mghr 06 mghr 1 $0

QL (30 per 30 days)

04 mghr 1 $0

QL (60 per 30 days)

minoxidil oral tablet 10 mg 25 mg 1 $0

NITRO-BID TRANSDERMAL

OINTMENT 2 1 $0

nitroglycerin in 5 dextrose

(400 mcgml) 25 mg250 ml (100

mcgml) 50 mg250 ml (200

mcgml)

nitroglycerin intravenous solution

50 mg10 ml (5 mgml) 1 $0

nitroglycerin sublingual tablet 03

mg 04 mg 06 mg (Nitrostat) 1 $0

nitroglycerin transdermal patch 24

hour 01 mghr 02 mghr 06

(Minitran) 1 $0

QL (30 per 30 days)

hour 04 mghr (Minitran) 1 $0

QL (60 per 30 days)

Central Nervous System

Agents

Central Nervous System Agents

AMPYRA ORAL TABLET

PA QL (60 per 30

days) NDS

atomoxetine oral capsule 10 mg

100 mg 18 mg 25 mg 40 mg 60

mg 80 mg

(Strattera) 1 $0

AUBAGIO ORAL TABLET 14

MG 7 MG 2 $0

PA QL (28 per 28

days) NDS

AUSTEDO ORAL TABLET 12

MG 9 MG 2 $0

PA QL (120 per 30

days) NDS

AUSTEDO ORAL TABLET 6 MG 2 $0 PA QL (60 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

AVONEX (WITH ALBUMIN)

INTRAMUSCULAR KIT 30 MCG 2 $0

PA NDS

AVONEX INTRAMUSCULAR

PEN INJECTOR KIT 30 MCG05

PA NDS

SYRINGE KIT 30 MCG05 ML 2 $0

PA NDS

BETASERON SUBCUTANEOUS

KIT 03 MG 2 $0

PA NDS

caffeine citrate intravenous solution

60 mg3 ml (20 mgml) (Cafcit) 1 $0

caffeine citrate oral solution 60

mg3 ml (20 mgml) 1 $0

COPAXONE SUBCUTANEOUS

PA QL (12 per 28

days) NDS

dexmethylphenidate oral tablet 10

mg 25 mg 5 mg (Focalin) 1 $0

QL (60 per 30 days)

dextroamphetamine oral tablet 10

mg 5 mg (Zenzedi) 1 $0

dextroamphetamine-amphetamine

oral capsuleextended release 24hr

10 mg 15 mg 5 mg

(Adderall XR) 1 $0

QL (30 per 30 days)

20 mg 25 mg 30 mg

(Adderall XR) 1 $0

QL (60 per 30 days)

oral tablet 10 mg 125 mg 15 mg

20 mg 30 mg 5 mg 75 mg

(Adderall) 1 $0

QL (60 per 30 days)

EXTAVIA SUBCUTANEOUS KIT

03 MG 2 $0

PA NDS

flumazenil intravenous solution 01

mgml 1 $0

GILENYA ORAL CAPSULE 05

MG 2 $0

PA QL (28 per 28

days) NDS

glatiramer subcutaneous syringe 20

mgml (Copaxone) 1 $0

PA QL (30 per 30

days) NDS

PA QL (12 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

glatopa subcutaneous syringe 20

mgml 1 $0

PA QL (30 per 30

days) NDS

guanfacine oral tablet extended

(Intuniv ER) 1 $0

INGREZZA ORAL CAPSULE 40

MG 2 $0

PA QL (60 per 30

days) NDS

MG 2 $0

PA QL (30 per 30

days) NDS

LEMTRADA INTRAVENOUS

PA NDS

lithium carbonate oral capsule 150

mg 300 mg 600 mg 1 $0

lithium carbonate oral tablet 300

mg 1 $0

lithium carbonate oral tablet

extended release 300 mg (Lithobid) 1 $0

extended release 450 mg 1 $0

lithium citrate oral solution 8 meq5

ml 1 $0

methylphenidate hcl oral capsule er

biphasic 30-70 10 mg 20 mg 40

mg 50 mg 60 mg

QL (30 per 30 days)

biphasic 30-70 30 mg 1 $0

QL (60 per 30 days)

methylphenidate hcl oral capsuleer

biphasic 50-50 20 mg 40 mg (Ritalin LA) 1 $0

QL (30 per 30 days)

biphasic 50-50 30 mg (Ritalin LA) 1 $0

QL (60 per 30 days)

QL (30 per 30 days)

methylphenidate hcl oral solution 10

mg5 ml 5 mg5 ml (Methylin) 1 $0

methylphenidate hcl oral tablet 10

mg 20 mg 5 mg (Ritalin) 1 $0

QL (90 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

methylphenidate hcl oral tablet

extended release 24hr 18 mg 27

mg 54 mg

(Concerta) 1 $0

QL (30 per 30 days)

extended release 24hr 36 mg (Concerta) 1 $0

QL (60 per 30 days)

NUEDEXTA ORAL CAPSULE 20-

10 MG 2 $0

QL (60 per 30 days)

OCREVUS INTRAVENOUS

PA QL (20 per 180

days) NDS

PLEGRIDY SUBCUTANEOUS

PEN INJECTOR 125 MCG05 ML

63 MCG05 ML- 94 MCG05 ML

PA NDS

MCG05 ML- 94 MCG05 ML

PA NDS

RADICAVA INTRAVENOUS

PIGGYBACK 30 MG100 ML 2 $0

PA QL (2800 per 28

days) NDS

REBIF (WITH ALBUMIN)

MCG05 ML 44 MCG05 ML

PA NDS

REBIF REBIDOSE

SUBCUTANEOUS PEN

MCG05 ML 88MCG02ML-22

MCG05ML (6)

PA NDS

REBIF TITRATION PACK

SUBCUTANEOUS SYRINGE

88MCG02ML-22 MCG05ML

PA NDS

riluzole oral tablet 50 mg (Rilutek) 1 $0

SAVELLA ORAL TABLET 100

MG 125 MG 25 MG 50 MG 2 $0

QL (60 per 30 days)

SAVELLA ORAL

(5)-25 MG(8)-50 MG(42)

QL (60 per 30 days)

TECFIDERA ORAL

CAPSULEDELAYED

RELEASE(DREC) 120 MG

PA QL (14 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TECFIDERA ORAL

CAPSULEDELAYED

RELEASE(DREC) 120 MG (14)-

240 MG (46) 240 MG

PA QL (60 per 30

days) NDS

tetrabenazine oral tablet 125 mg

25 mg (Xenazine) 1 $0

PA QL (112 per 28

days) NDS

ZINBRYTA SUBCUTANEOUS

PA QL (1 per 28

days) NDS

Contraceptives

aftera 15 mg tablet 15 mg 4 $0 QL (6 per 365 days)

altavera (28) oral tablet 015-003

mg 1 $0

alyacen 135 (28) oral tablet 1-35

mg-mcg 1 $0

alyacen 777 (28) oral tablet

050751 mg- 35 mcg 1 $0

amethia lo oral tabletsdose pack3

month 010 mg-20 mcg (84)10 mcg

QL (91 per 84 days)

amethia oral tabletsdose pack3

QL (91 per 84 days)

apri oral tablet 015-003 mg 1 $0

aranelle (28) oral tablet 05105-

35 mg-mcg 1 $0

ashlyna oral tabletsdose pack3

aubra oral tablet 01-20 mg-mcg 1 $0

aviane oral tablet 01-20 mg-mcg 1 $0

azurette (28) oral tablet 015-002

mgx21 001 mg x 5 1 $0

balziva (28) oral tablet 04-35 mg-

mcg 1 $0

bekyree (28) oral tablet 015-002

mgx21 001 mg x 5 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

blisovi 24 fe oral tablet 1 mg-20

mcg (24)75 mg (4) 1 $0

blisovi fe 1530 (28) oral tablet 15

mg-30 mcg (21)75 mg (7) 1 $0

blisovi fe 120 (28) oral tablet 1 mg-

20 mcg (21)75 mg (7) 1 $0

briellyn oral tablet 04-35 mg-mcg 1 $0

camila oral tablet 035 mg 1 $0

camrese lo oral tabletsdose pack3

QL (91 per 84 days)

camrese oral tabletsdose pack3

QL (91 per 84 days)

caziant (28) oral tablet 0112515-

25 mg-mcg 1 $0

cryselle (28) oral tablet 03-30 mg-

mcg 1 $0

cyclafem 135 (28) oral tablet 1-35

mg-mcg 1 $0

cyclafem 777 (28) oral tablet

050751 mg- 35 mcg 1 $0

cyred oral tablet 015-003 mg 1 $0

dasetta 135 (28) oral tablet 1-35

mg-mcg 1 $0

dasetta 777 (28) oral tablet

050751 mg- 35 mcg 1 $0

daysee oral tabletsdose pack3

QL (91 per 84 days)

deblitane oral tablet 035 mg 1 $0

delyla (28) oral tablet 01-20 mg-

mcg 1 $0

desog-eestradioleestradiol oral

tablet 015-002 mgx21 001 mg x 5 (Azurette (28)) 1 $0

desogestrel-ethinyl estradiol oral

tablet 015-003 mg (Apri) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

drospirenone-ethinyl estradiol oral

tablet 3-002 mg (Gianvi (28)) 1 $0

tablet 3-003 mg (Ocella) 1 $0

econtra ez 15 mg tablet outer 15

mg 4 $0

QL (6 per 365 days)

elinest oral tablet 03-30 mg-mcg 1 $0

ELLA ORAL TABLET 30 MG 2 $0 QL (6 per 365 days)

emoquette oral tablet 015-003 mg 1 $0

enpresse oral tablet 50-30 (6)75-40

(5)125-30(10) 1 $0

enskyce oral tablet 015-003 mg 1 $0

errin oral tablet 035 mg 1 $0

estarylla oral tablet 025-35 mg-mcg 1 $0

ethynodiol diac-eth estradiol oral

tablet 1-35 mg-mcg (Kelnor 135 (28)) 1 $0

tablet 1-50 mg-mcg (Zovia 150E (28)) 1 $0

fallback solo 15 mg tablet outer 15

mg 4 $0

QL (6 per 365 days)

falmina (28) oral tablet 01-20 mg-

mcg 1 $0

femynor oral tablet 025-35 mg-mcg 1 $0

gianvi (28) oral tablet 3-002 mg 1 $0

gildagia oral tablet 04-35 mg-mcg 1 $0

heather oral tablet 035 mg 1 $0

introvale oral tabletsdose pack3

month 015 mg-30 mcg 1 $0

QL (91 per 84 days)

isibloom oral tablet 015-003 mg 1 $0

jencycla oral tablet 035 mg 1 $0

jolessa oral tabletsdose pack3

QL (91 per 84 days)

jolivette oral tablet 035 mg 1 $0

juleber oral tablet 015-003 mg 1 $0

junel 1530 (21) oral tablet 15-30

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

junel 120 (21) oral tablet 1-20 mg-

mcg 1 $0

junel fe 1530 (28) oral tablet 15

mg-30 mcg (21)75 mg (7) 1 $0

junel fe 120 (28) oral tablet 1 mg-

20 mcg (21)75 mg (7) 1 $0

junel fe 24 oral tablet 1 mg-20 mcg

(24)75 mg (4) 1 $0

kariva (28) oral tablet 015-002

mgx21 001 mg x 5 1 $0

kelnor 135 (28) oral tablet 1-35

mg-mcg 1 $0

kimidess (28) oral tablet 015-002

mgx21 001 mg x 5 1 $0

kurvelo oral tablet 015-003 mg 1 $0

l norgesteestradiol-eestrad oral

tabletsdose pack3 month 010 mg-

20 mcg (84)10 mcg (7)

(Amethia Lo) 1 $0

QL (91 per 84 days)

30 mcg (84)10 mcg (7)

(Amethia) 1 $0

QL (91 per 84 days)

larin 1530 (21) oral tablet 15-30

mg-mcg 1 $0

larin 120 (21) oral tablet 1-20 mg-

mcg 1 $0

larin 24 fe oral tablet 1 mg-20 mcg

(24)75 mg (4) 1 $0

larin fe 1530 (28) oral tablet 15

mg-30 mcg (21)75 mg (7) 1 $0

larin fe 120 (28) oral tablet 1 mg-

20 mcg (21)75 mg (7) 1 $0

larissia oral tablet 01-20 mg-mcg 1 $0

leena 28 oral tablet 05105-35

mg-mcg 1 $0

lessina oral tablet 01-20 mg-mcg 1 $0

levonest (28) oral tablet 50-30

(6)75-40 (5)125-30(10) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

levonor-eth estrad 015-003 outer

015-003 mg (Altavera (28)) 1 $0

QL (91 per 84 days)

levonorgestrel 15 mg tablet (otc)

15 mg (Aftera) 4 $0

QL (6 per 365 days)

levonorgestrel-ethinyl estrad oral

tablet 01-20 mg-mcg (Aubra) 1 $0

30 mcg

(Introvale) 1 $0

QL (91 per 84 days)

levonorg-eth estrad triphasic oral

tablet 50-30 (6)75-40 (5)125-

30(10)

(Enpresse) 1 $0

QL (91 per 84 days)

levora-28 oral tablet 015-003 mg 1 $0

lillow oral tablet 015-003 mg 1 $0

lomedia 24 fe oral tablet 1 mg-20

mcg (24)75 mg (4) 1 $0

loryna (28) oral tablet 3-002 mg 1 $0

low-ogestrel (28) oral tablet 03-30

mg-mcg 1 $0

lutera (28) oral tablet 01-20 mg-

mcg 1 $0

lyza oral tablet 035 mg 1 $0

marlissa oral tablet 015-003 mg 1 $0

microgestin 1530 (21) oral tablet

15-30 mg-mcg 1 $0

microgestin 120 (21) oral tablet 1-

20 mg-mcg 1 $0

microgestin fe 1530 (28) oral

tablet 15 mg-30 mcg (21)75 mg (7) 1 $0

microgestin fe 120 (28) oral tablet

1 mg-20 mcg (21)75 mg (7) 1 $0

mono-linyah oral tablet 025-35 mg-

mcg 1 $0

mononessa (28) oral tablet 025-35

mg-mcg 1 $0

my way 15 mg tablet (otc) 15 mg 4 $0 QL (6 per 365 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

myzilra oral tablet 50-30 (6)75-40

(5)125-30(10) 1 $0

necon 0535 (28) oral tablet 05-35

mg-mcg 1 $0

necon 150 (28) oral tablet 1-50 mg-

mcg 1 $0

necon 1011 (28) oral tablet 05-

351-35 mg-mcgmg-mcg 1 $0

necon 777 (28) oral tablet

050751 mg- 35 mcg 1 $0

next choice one dose 15 mg tb (otc)

15 mg 4 $0

QL (6 per 365 days)

nikki (28) oral tablet 3-002 mg 1 $0

nora-be oral tablet 035 mg 1 $0

noreth-estrad-fe 1-002(21)-75 1

mg-20 mcg (21)75 mg (7)

(Blisovi Fe 120

(28)) 1 $0

norethindrone (contraceptive) oral

tablet 035 mg (Camila) 1 $0

norethindrone ac-eth estradiol oral

tablet 1-20 mg-mcg (Junel 120 (21)) 1 $0

norethindrone-eestradiol-iron oral

tablet 1 mg-20 mcg (24)75 mg (4) (Blisovi 24 Fe) 1 $0

norgestimate-ethinyl estradiol oral

tablet 0180215025 mg-25 mcg

(Ortho Tri-Cyclen

LO (28)) 1 $0

(Ortho Tri-Cyclen

(28)) 1 $0

tablet 025-35 mg-mcg (Estarylla) 1 $0

norlyda oral tablet 035 mg 1 $0

norlyroc oral tablet 035 mg 1 $0

nortrel 0535 (28) oral tablet 05-35

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

nortrel 777 (28) oral tablet

050751 mg- 35 mcg 1 $0

NUVARING VAGINAL RING

012-0015 MG24 HR 2 $0

QL (1 per 28 days)

ocella oral tablet 3-003 mg 1 $0

ogestrel (28) oral tablet 05-50 mg-

mcg 1 $0

opcicon one-step 15 mg tablet 15

mg 4 $0

QL (6 per 365 days)

option 2 15 mg tablet 15 mg 4 $0 QL (6 per 365 days)

orsythia oral tablet 01-20 mg-mcg 1 $0

philith oral tablet 04-35 mg-mcg 1 $0

pimtrea (28) oral tablet 015-002

mgx21 001 mg x 5 1 $0

pirmella oral tablet 050751 mg-

35 mcg 1-35 mg-mcg 1 $0

portia oral tablet 015-003 mg 1 $0

previfem oral tablet 025-35 mg-mcg 1 $0

quasense oral tabletsdose pack3

QL (91 per 84 days)

react 15 mg tablet 15 mg 4 $0 QL (6 per 365 days)

reclipsen (28) oral tablet 015-003

mg 1 $0

setlakin oral tabletsdose pack3

QL (91 per 84 days)

sharobel oral tablet 035 mg 1 $0

sprintec (28) oral tablet 025-35 mg-

mcg 1 $0

sronyx oral tablet 01-20 mg-mcg 1 $0

syeda oral tablet 3-003 mg 1 $0

tarina fe 120 (28) oral tablet 1 mg-

20 mcg (21)75 mg (7) 1 $0

tilia fe oral tablet 1-20(5)1-30(7)

1mg-35mcg (9) 1 $0

tri femynor oral tablet

0180215025 mg-35 mcg (28) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

tri-estarylla oral tablet

0180215025 mg-35 mcg (28) 1 $0

tri-legest fe oral tablet 1-20(5)1-

30(7) 1mg-35mcg (9) 1 $0

tri-linyah oral tablet

0180215025 mg-35 mcg (28) 1 $0

tri-lo-estarylla oral tablet

0180215025 mg-25 mcg 1 $0

tri-lo-marzia oral tablet

0180215025 mg-25 mcg 1 $0

tri-lo-sprintec oral tablet

0180215025 mg-25 mcg 1 $0

trinessa (28) oral tablet

0180215025 mg-35 mcg (28) 1 $0

tri-previfem (28) oral tablet

0180215025 mg-35 mcg (28) 1 $0

tri-sprintec (28) oral tablet

0180215025 mg-35 mcg (28) 1 $0

trivora (28) oral tablet 50-30 (6)75-

40 (5)125-30(10) 1 $0

velivet triphasic regimen (28) oral

tablet 0112515-25 mg-mcg 1 $0

vestura (28) oral tablet 3-002 mg 1 $0

vienva oral tablet 01-20 mg-mcg 1 $0

viorele (28) oral tablet 015-002

mgx21 001 mg x 5 1 $0

vyfemla (28) oral tablet 04-35 mg-

mcg 1 $0

wera (28) oral tablet 05-35 mg-mcg 1 $0

xulane transdermal patch weekly

150-35 mcg24 hr 1 $0

QL (3 per 28 days)

zarah oral tablet 3-003 mg 1 $0

zenchent (28) oral tablet 04-35 mg-

mcg 1 $0

zovia 135e (28) oral tablet 1-35

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg-mcg 1 $0

Cough And Cold Products

25cpd-200gfn liquid 25-200 mg5 ml

2cpm-15dm-5peh liquid

sfafgluten-free 2-5-15 mg5 ml 4 $0

3brm-15dm-30pse liquid 3-30-15

mg5 ml 4 $0

actinel pediatric liquid 15-5-50

mg5 ml 4 $0

adult robitussin peak cold dm non-

drowsy 10-100 mg5 ml 4 $0

adult wal-tussin dm max liq

afcherry menthol 10-200 mg5 ml 4 $0

adult wal-tussin dm syrup

afcherryadult 10-100 mg5 ml 4 $0

adult wal-tussin liquid 100 mg5 ml

alka-seltzer plus day cap 5-10-325

mg 4 $0

alka-seltzer plus mucus-conges 10-

200 mg 4 $0

alka-seltzer plus sinus-cough 5-10-

325 mg 4 $0

ambi 10peh-4cpm-20dm tablet 4-10-

20 mg 4 $0

ambi 20dm-4cpm tablet 4-20 mg 4 $0

ambi 40pse-400gfn-20dm tablet 40-

20-400 mg 4 $0

ambi 60pse-4cpm-20dm tablet 4-60-

20 mg 4 $0

benzonatate 100 mg capsule 100 mg

(Tessalon Perles) 3 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

bio-dtuss dmx liquid 1-30-20 mg5

ml 4 $0

bionel pediatric liquid 15-5-50 mg5

ml 4 $0

bromfed dm cough syrup 2-30-10

mg5 ml 3 $0

bromphenir-pseudoephed-dm syr

(rx) 2-30-10 mg5 ml (Bromfed DM) 3 $0

brotapp dm liquid 1-15-5 mg5 ml 4 $0

centergy dm pediatric drops 1-2-3

mgml 3 $0

chest congestion amp sinus tab 10-400

mg 4 $0

child robitussin er 30 mg5 ml 30

mg5 ml 4 $0

child sudafed pe cough-cold lq 25-5

mg5 ml 4 $0

child triaminic cgh-congst syr 5-100

mg5 ml 4 $0

child wal-tussin 75 mg odt 75 mg 4 $0

childrens mucinex cough liq af 5-

100 mg5 ml 4 $0

childrens plus flu susp 1-25-5-160

mg5 ml 4 $0

childrens silfedrine liq 15 mg5 ml

CHILDS SUDAFED 15 MG5 ML

LIQ NON-DROWSYAFSF 15

MG5 ML

chl mucinex chest congest liq af

100 mg5 ml 4 $0

cold multi-symptom day-night

pseudoephedrine-free 2-5-10-325

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cold multi-symptom night liq af

honey lemon 625-5-10-325 mg15

cold-flu relief dn softgel 10-5-

325mg(d) 15-325-625mg 4 $0

cold-flu relief liquid 125-30-1000

mg30 ml 4 $0

congestac tablet 60-400 mg 4 $0

congest-eze 60-400 mg caplet 60-

400 mg 4 $0

coricidin hbp softgel 10-200 mg 4 $0

cough amp sore throat liquid cool

blast 125-30-1000 mg30 ml 4 $0

cough-cold tablet 4-30 mg 4 $0

cvs chest cong relief pe tab 10-400

mg 4 $0

cvs chest congest + cough liq 5-100

mg5 ml 4 $0

cvs child cold-cough day liq 25-5

mg5 ml 4 $0

cvs child cough amp runny nose 1-5-

160 mg5 ml 4 $0

cvs childrens plus cold susp

grapemulti-symptom 1-25-5-160

mg5 ml

cvs childs chest congest liq 100

mg5 ml 4 $0

cvs cold relief multi-symp cpl cplt

12 day12 night 2-5-10-325 mg 4 $0

cvs cough amp sore throat susp 160-5

mg5 ml 4 $0

cvs daytime-nighttime cold-flu

multi-symptwin pack 625-5-10-325

mg15 ml

cvs flu-severe cold liquid 5-10-325

mg15 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cvs mucus er 600 mg tablet 12 hour

600 mg 4 $0

cvs nighttime cough liquid cherry

flavor 625-15 mg15 ml 4 $0

cvs tussin cgh 15 mg liq gels non-

drowsy liq gels 15 mg 4 $0

cvs tussin max-str syrup 15 mg5 ml

daytime cold amp cough liquid 1000-

30 mg30 ml 4 $0

daytime cough liquid af gluten-free

5 mg5 ml 4 $0

daytime-nighttime cough liquid

15mg15ml(d) 125-30mg30ml 4 $0

delsym cough+chest cngst dm lq 5-

100 mg5 ml 4 $0

despec dm syrup 5-10-100 mg5 ml

despec-dm tablet 30-10-200 mg 4 $0

dextromethorphan er 30 mg5 ml 30

mg5 ml

(12-Hour Cough

Relief) 4 $0

diabetic tussin dm liquid 10-100

mg5 ml 4 $0

diabetic tussin dm max-str liq 10-

200 mg5 ml 4 $0

diabetic tussin ex liquid

afdfnafsf 100 mg5 ml 4 $0

dimaphen dm elixir grape

afgluten-f 1-25-5 mg5 ml 4 $0

DIMETAPP LONG-ACTING

COUGH LIQ 1-75 MG5 ML 4 $0

ed bron gp liquid 5-100 mg5 ml 4 $0

expectorant 100 mg5 ml syrup 100

mg5 ml 4 $0

expectorant dm cough liquid 20-300

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

expectorant max cough-cold 30-15

mg5 ml 4 $0

extra action cough syrup 10-100

mg5 ml 4 $0

flu hbp tablet 2-15-500 mg 4 $0

flu-severe cold-cough day pkt 10-

20-650 mg 4 $0

geri-tussin dm syrup 10-100 mg5

ml 4 $0

gnp chest congst-cough rlf tab 20-

400 mg 4 $0

guaifenesin 100 mg5 ml syrup 100

mg5 ml

(Adult Tussin

Chest Congestion) 4 $0

guaifenesin 200 mg tablet (otc) 200

mg (Coughtab) 4 $0

guaifenesin dm syrup (otc) 10-100

mg5 ml (Adult Tussin DM) 4 $0

guaifenesin er 1200 mg tablet 1200

mg (Mucinex) 4 $0

head congestion day-night pack 2-5-

10-325 mg 4 $0

intense cough reliever liquid 20-300

mg5 ml 4 $0

kidkare cough amp cold liquid 1-15-5

mg5 ml 4 $0

kro mucus dm 600-30 mg tablet 30-

600 mg 4 $0

liquibid d-r tablet 10-400 mg 4 $0

lohist-dm syrup 2-5-10 mg5 ml 4 $0

medi-phedrine 30 mg tablet 30 mg 4 $0

mucinex fast-max dm max liquid

maximum strength 5-100 mg5 ml 4 $0

mucus dm max 1200-60 mg tab 60-

1200 mg 4 $0

mucus relief 400 mg tablet df 400

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mucus relief dm tablet df 20-400

mg 4 $0

nasal-sinus decongest tab 30 mg 4 $0

neo-tuss liquid 30-200 mg5 ml 4 $0

night time cold med liquid 625-30-

15-500 mg15 ml 4 $0

nighttime d cold-flu rlf liq multi-

symptomcherry 625-30-15-500

mg15 ml

nohist-dm liquid 4-10-15 mg5 ml 4 $0

pecgen dmx 125-15 mg5 ml liq 15-

125 mg5 ml 4 $0

pediacare multi-symt cold liq non

drowsy grape 25-5 mg5 ml 4 $0

pediatric cough-cold syrup 100

mg5 ml 4 $0

promethazine-dm syrup 625-15

mg5 ml 3 $0

pseudoephed 30 mg5 ml soln 30

mg5 ml

(Nasal

Decongestant

(pseudoeph))

pseudoephedrine 30 mg tablet 30

(Nasal

Decongestant

(pseudoeph))

pseudoephedrine 60 mg tablet ex-

str non drowsy (otc) 60 mg (Sudogest) 4 $0

qc nighttime cold medicine liq 125-

30-1000 mg30 ml 4 $0

ra child plus cough-runny nose

pseudoephedrine free 1-5-160 mg5

ra childrens flu relief susp 1-25-5-

160 mg5 ml 4 $0

ra daytime-nighttime softgel cold-flu

relief 10-5-325mg(d) 15-325-

ra expectorant cough syrup 100

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ra flu formula gelcap 125-5-10-325

mg 4 $0

ra head cong cold relief cplt cplt12

day12 night 2-5-10-325 mg 4 $0

ra mucus relief 400 mg tablet 400

mg 4 $0

ra mucus relief er 600 mg tab 600

mg 4 $0

ra multi-symptom cold caplet

nighttimecplt 2-5-10-325 mg 4 $0

ra tussin cough liquid sf df af 10-

100 mg5 ml 4 $0

ra tussin dm syrup af 10-100 mg5

ml 4 $0

refenesen 400 mg tablet 400 mg 4 $0

refenesen pe caplet 10-400 mg 4 $0

robafen 100 mg5 ml syrup 100

mg5 ml 4 $0

robafen cough 15 mg liquidgel non-

drowsyliquidgel 15 mg 4 $0

robafen-dm syrup 10-100 mg5 ml 4 $0

robitussin cough-chest dm liq 5-100

mg5 ml 4 $0

robitussin cough-chest-cong dm 10-

200 mg 4 $0

ROBITUSSIN LONG-ACTING

LIQ 1-75 MG5 ML 4 $0

robitussin pediatric cough syp

aflong-acting 75 mg5 ml 4 $0

safetussin dm liquid 10-100 mg5 ml

sb cough control dm liquid 10-100

mg5 ml 4 $0

scot-tussin 100 mg5 ml liq 100

mg5 ml 4 $0

scot-tussin dm s-f liquid 2-15 mg5

ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

siltussin sa 100 mg5 ml syr 100

mg5 ml 4 $0

sm adult nasal decongestant lq 15

mg5 ml 4 $0

sm cough amp runny nose liquid 1-5

mg5 ml 4 $0

sm cough-head congestion lq 20-10-

667 mg5 ml 4 $0

sm flu severe cold-congestion

maximum strength 4-60-30-1000

sm mucus relief cough liquid

childrens af 5-100 mg5 ml 4 $0

sm nite time cold-flu liquid 75-60-

30-1000 mg30 ml 4 $0

sm nite time cold-flu rel sfgl softgel

625-30-15-325 mg 4 $0

sm nite time liquid 125-60-30-1000

mg30 ml 4 $0

sm pain reliever cold caplet 2-30-

15-325 mg 4 $0

sm pedia relief liquid 1-15-5 mg5

ml 4 $0

sm severe cold m-s caplet 30-15-500

mg 4 $0

sm tussin cf syrup 30-10-100 mg5

ml 4 $0

sm tussin dm max liquid gluten-free

af 10-200 mg5 ml 4 $0

soba pain reliever flu glcp gelcap

30-15-500 mg 4 $0

SUDAFED 30 MG TABLET 30

MG 4 $0

sudogest 30 mg tablet boxed 30 mg

sudogest 60 mg tablet 60 mg 4 $0

suphedrin liquid 15 mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

suphedrine pe combo pack cplt 5-

10-325 mg 4 $0

triaminic cold amp cough liquid

afchildsdaytime 25-5 mg5 ml 4 $0

triaminic daytime cold-cough

childrens cherry 25-5 mg5 ml 4 $0

tusnel diabetic liquid (otc) 10-100

mg5 ml 4 $0

TUSNEL LIQUID AFAFDF 30-

15-200 MG5 ML 4 $0

TUSSI PRES-B LIQUID 4-10-30

MG5 ML 4 $0

tussin cough liquid maximum

strength 15 mg5 ml 4 $0

tussin cough-cold-flu oral liquid 1-

25-5-160 mg5 ml 4 $0

tussin dm cough syrup afnon-

tussin dm syrup 15-100 mg5 ml 4 $0

vicks dayquil cough liquid af8 hr

rlf 5 mg5 ml 4 $0

vicks dayquil liquicaps cold amp flu 5-

10-325 mg 4 $0

vicks dayquil liquid coldflu relief

af 5-10-325 mg15 ml 4 $0

VICKS NYQUIL COLD amp FLU

LIQUID NIGHTTIME RELIEF

625-15-325 MG15 ML

vicks nyquil liquicaps cold amp flu

625-15-325 mg 4 $0

v-r infant non-asa cold drp 15-5-160

mg16 ml 4 $0

v-r non-aspirin flu gelcap gelatin

caplet 30-15-500 mg 4 $0

v-r pedia relief inf drops

decongestant + 75-25 mg08 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

vr triacting cold-cough liq 1-15-5

mg5 ml 4 $0

v-r tussin cf syrup 30-10-100 mg5

ml 4 $0

wal-phed 30 mg tablet non-drowsy

max-str 30 mg 4 $0

wal-phed pe day-night combo pk

caplet 5-10-325 mg 4 $0

wal-tussin cough 15 mg softgel 15

mg 4 $0

wal-tussin max str cough syrup

maximum strength 15 mg5 ml 4 $0

wal-tussin syrup 100 mg5 ml 4 $0

zephrex-d 30 mg tablet 30 mg 4 $0

zyncof 20-400 mg5 ml liquid 20-

400 mg5 ml 4 $0

Dental And Oral Agents

cevimeline oral capsule 30 mg (Evoxac) 1 $0

chlorhexidine gluconate mucous

membrane mouthwash 012

(Paroex Oral

Rinse) 1 $0

oralone dental paste 01 1 $0

paroex oral rinse mucous membrane

mouthwash 012 1 $0

periogard mucous membrane

mouthwash 012 1 $0

pilocarpine hcl oral tablet 5 mg 75

(Salagen

(pilocarpine)) 1 $0

triamcinolone acetonide dental

paste 01 (Oralone) 1 $0

Dermatological Agents

Dermatological Agents Other

acitretin oral capsule 10 mg 175

mg 25 mg (Soriatane) 1 $0

acne medication 10 gel 10 4 $0

acne medication 10 lotion 10 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ACNE MEDICATION 5

LOTION 5 4 $0

acyclovir topical ointment 5 (Zovirax) 1 $0 QL (30 per 30 days)

ALCOHOL PADS TOPICAL

PADS MEDICATED 1 $0

ALCOHOL PREP PADS 1 $0

amlactin 12 lotion 12 4 $0

ammonium lactate 12 cream

fragrance free (otc) 12 (Geri-Hydrolac) 4 $0

ammonium lactate 12 lotion

fragrance free (otc) 12 (AmLactin) 4 $0

ammonium lactate topical cream 12

(Geri-Hydrolac) 1 $0

ammonium lactate topical lotion 12

(AmLactin) 1 $0

benzoyl peroxide 10 gel aqueous

(otc) 10 (Acne Medication) 4 $0

BETADINE 5 SPRAY 5 4 $0

calcipotriene scalp solution 0005 1 $0

calcipotriene topical cream 0005 (Dovonex) 1 $0

calcipotriene topical ointment 0005

(Calcitrene) 1 $0

calcitrene topical ointment 0005 1 $0

calcitriol topical ointment 3

mcggram (Vectical) 1 $0

CASTELLANI PAINT MODIFIED

15 4 $0

CONDYLOX TOPICAL GEL 05

COSENTYX (2 SYRINGES)

PA NDS

COSENTYX PEN (2 PENS)

SUBCUTANEOUS PEN

INJECTOR 150 MGML

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cutter backwoods 25 spray 25 4 $0 QL (340 per 180 days)

cutter skinsations 7 spray 7 4 $0 QL (354 per 180 days)

cvs skin treatment body lotion 12

cvs zinc oxide ointment (Triple Paste) 4 $0

diclofenac sodium topical drops 15

diclofenac sodium topical gel 3 (Solaraze) 1 $0 PA QL (100 per 28

days) NDS

DUPIXENT SUBCUTANEOUS

PA NDS

FLECTOR TRANSDERMAL

PATCH 12 HOUR 13 2 $0

fluorouracil topical cream 05 (Carac) 1 $0 NDS

fluorouracil topical cream 5 (Efudex) 1 $0

fluorouracil topical solution 2 5

geri-hydrolac 12 lotion 12 4 $0

imiquimod topical cream in packet 5

(Aldara) 1 $0

PA NSO QL (24 per

30 days)

INSECT REPELLENT 20

SPRAY 20 4 $0

LACTINOL HX CREAM 4 $0

methoxsalen oral capsuleliqd-

filledrapid rel 10 mg (Oxsoralen Ultra) 1 $0

NATRAPEL 20 SPRAY 20 4 $0 QL (354 per 180 days)

off active 15 spray 15 4 $0 QL (340 per 180 days)

off deep woods 25 spray 25 4 $0 QL (340 per 180 days)

off deep woods dry 25 spray 25

off familycare 15 rplnt i spr 15

PANRETIN TOPICAL GEL 01 2 $0 NDS

persa-gel 10 12smax-strength 10

PICATO TOPICAL GEL 0015 2 $0 QL (3 per 56 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

podofilox topical solution 05 1 $0

ra zinc oxide ointment (Triple Paste) 4 $0

repel sportsmen 25 spray 25 4 $0 QL (368 per 180 days)

repel sportsmen max 40 spray 40

SANTYL TOPICAL OINTMENT

250 UNITGRAM 2 $0

SILIQ SUBCUTANEOUS

PA NDS

TALTZ AUTOINJECTOR

SUBCUTANEOUS AUTO-

INJECTOR 80 MGML

PA NDS

TALTZ SYRINGE

PA NDS

TOLAK TOPICAL CREAM 4 2 $0

topical light mineral oil (Lobana Bath) 4 $0

TREMFYA SUBCUTANEOUS

PA NDS

VALCHLOR TOPICAL GEL 0016

VOLTAREN TOPICAL GEL 1 1 $0

zenatane oral capsule 10 mg 20 mg

30 mg 40 mg 1 $0

zinc oxide 20 ointment 20 4 $0

Dermatological Antibacterials

bacitracin 500 unitgm ointmnt 500

unitgram (Bacitraycin Plus) 4 $0

bacitraycin plus 500 unitgm 500

unitgram 4 $0

clindamycin phosphate topical gel 1

(Cleocin T) 1 $0

clindamycin phosphate topical

lotion 1 (Cleocin T) 1 $0

solution 1 (Cleocin T) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

clindamycin phosphate topical swab

1 (Cleocin T) 1 $0

cvs bacitracin 500 unitgm oin 500

cvs triple antibiotic ointment 35mg-

400 unit- 5000 unitgram 4 $0

ery pads topical swab 2 1 $0

erythromycin with ethanol topical

gel 2 (Erygel) 1 $0

solution 2 1 $0

swab 2 (Ery Pads) 1 $0

gentamicin topical cream 01 1 $0

gentamicin topical ointment 01 1 $0

metronidazole topical cream 075 (MetroCream) 1 $0

metronidazole topical gel 075 (Rosadan) 1 $0

metronidazole topical gel 1 (Metrogel) 1 $0

metronidazole topical lotion 075 (MetroLotion) 1 $0

mupirocin calcium topical cream 2

(Bactroban) 1 $0

mupirocin topical ointment 2 (Centany) 1 $0

neomycin-polymyxin b gu irrigation

solution 40 mg-200000 unitml

(Neosporin GU

Irrigant) 1 $0

neosporin ointment original 35mg-

rosadan topical cream 075 1 $0

selenium sulfide topical lotion 25 1 $0

silver sulfadiazine topical cream 1

(Silvadene) 1 $0

ssd topical cream 1 1 $0

sulfacetamide sodium (acne) topical

suspension 10 (Klaron) 1 $0

triple antibiotic ointment 35mg-400

unit- 5000 unitgram 4 $0

Dermatological Anti-Inflammatory

Agents

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ala-cort topical cream 1 25 1 $0

alclometasone topical cream 005 1 $0

alclometasone topical ointment 005

aquanil hc 1 lotion 1 4 $0

beta hc 1 lotion 1 4 $0

betamethasone dipropionate topical

cream 005 1 $0

lotion 005 1 $0

ointment 005 1 $0

betamethasone valerate topical

cream 01 1 $0

lotion 01 1 $0

ointment 01 1 $0

betamethasone augmented topical

cream 005 1 $0

gel 005 1 $0

lotion 005 1 $0

ointment 005 (Diprolene) 1 $0

clobetasol 005 cream 005 (Temovate) 1 $0

clobetasol scalp solution 005 (Cormax) 1 $0

clobetasol-emollient topical cream

005 1 $0

clocortolone pivalate topical cream

01 (Cloderm) 1 $0

cormax scalp solution 005 1 $0

cortaid 1 cream 12 hr anti-itch 1

cortizone-10 1 creme 1 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cortizone-10 1 ointment 1 4 $0

cvs cortisone 1 healing lot 1 4 $0

dermarest eczema 1 lotion 1 4 $0

DERMAREST ECZEMA 1

LOTION 1 4 $0

desoximetasone topical cream 025

(Topicort) 1 $0

ELIDEL TOPICAL CREAM 1 2 $0

EUCRISA TOPICAL OINTMENT

2 2 $0

fluocinolone topical cream 001 1 $0

fluocinolone topical cream 0025 (Synalar) 1 $0

fluocinolone topical ointment 0025

(Synalar) 1 $0

fluocinonide topical cream 005 1 $0

fluocinonide topical gel 005 1 $0

fluocinonide topical ointment 005

fluocinonide topical solution 005 1 $0

fluocinonide-e topical cream 005 1 $0

fluticasone topical cream 005 (Cutivate) 1 $0

fluticasone topical ointment 0005 1 $0

halobetasol propionate topical

cream 005 (Ultravate) 1 $0

ointment 005 (Ultravate) 1 $0

hydro skin 1 lotion 1 4 $0

hydrocortisone 05 cream (otc)

05 4 $0

hydrocortisone 05 ointment 05

hydrocortisone 1 cream 1 4 $0

hydrocortisone 1 cream maximum

strength (otc) 1 (Ala-Cort) 4 $0

strength 1 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

hydrocortisone 1 lotion (otc) 1

(Anti-Itch (HC)) 4 $0

hydrocortisone 1 ointment

maximum strength (otc) 1 (Anti-Itch (HC)) 4 $0

hydrocortisone topical cream 1

25 (Ala-Cort) 1 $0

hydrocortisone topical lotion 25 1 $0

hydrocortisone topical ointment 1 (Anti-Itch (HC)) 1 $0

hydrocortisone topical ointment 25

mometasone topical cream 01 (Elocon) 1 $0

mometasone topical ointment 01 (Elocon) 1 $0

mometasone topical solution 01 1 $0

neosporin 1 anti-itch cream 1 4 $0

prednicarbate topical cream 01 (Dermatop) 1 $0

prednicarbate topical ointment 01

(Dermatop) 1 $0

preparation h hc 1 cream 1 4 $0

procto-med hc topical cream with

perineal applicator 25 1 $0

procto-pak topical cream with

proctosol hc topical cream with

proctozone-hc topical cream with

recort plus 1 cream 1 4 $0

tacrolimus topical ointment 003

01 (Protopic) 1 $0

triamcinolone acetonide topical

cream 0025 1 $0

cream 01 05 (Triderm) 1 $0

lotion 0025 01 1 $0

ointment 0025 01 05 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Dermatological Retinoids

adapalene topical cream 01 (Differin) 1 $0

adapalene topical gel 01 (Differin) 1 $0

tazarotene topical cream 01 (Avage) 1 $0

TAZORAC TOPICAL CREAM

005 2 $0

tretinoin topical cream 0025 (Avita) 1 $0 PA

tretinoin topical cream 005 01

(Retin-A) 1 $0

tretinoin topical gel 001 (Retin-A) 1 $0 PA

tretinoin topical gel 0025 (Avita) 1 $0 PA

Scabicides And Pediculicides

cvs lice killing shampoo maximum

strength 033-4 4 $0

malathion topical lotion 05 (Ovide) 1 $0

NIX 1 CREME RINSE LIQUID 1

permethrin topical cream 5 (Elimite) 1 $0

ra lice pyrinyl shampoo 033-4 4 $0

ra lice treatment 1 crm rinse

2x59ml 2 combs 1 4 $0

sb lice killing shampoo maximum

strength 033-4 4 $0

sm lice killing shampoo 1 4 $0

sm lice treatment 1 crm rinse 1

v-r lice cream rinse 1 4 $0

Devices

1ST TIER COMFORTOUCH 28G

LANCT 28 GAUGE 4 $0

LANCT 30 GAUGE 4 $0

ACCU-CHEK FASTCLIX

LANCETS 4 $0

ACCU-CHEK MULTICLIX

LANCETS 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ACCU-CHEK SAFE-T-PRO 23G

LANCT 23 GAUGE 4 $0

ACCU-CHEK SAFE-T-PRO PLUS

23G 23 GAUGE 4 $0

ACCU-CHEK SOFTCLIX

LANCETS 4 $0

ACTI-LANCE LITE 28G

LANCETS 28 GAUGE 4 $0

ACTI-LANCE SPECIAL 17G

ACTI-LANCE UNIVERS 23G

ADVANCED TRAVEL 28G

LANCETS 28GSINGLE-

USESTRL 28 GAUGE

ADVANCED TRAVEL 30G

ADVOCATE 26G LANCETS 26

GSTERILE 26 GAUGE 4 $0

ADVOCATE 26G LANCETS

STERILE 26 GAUGE 4 $0

TWIST TOP 30 GAUGE 4 $0

ALTERNATE SITE 26G

LANCETS RECAPPABLE 26

ASSURE COMFORT 30G

LANCETS 30 GAUGE

(1st Tier Unilet

ComforTouch) 4 $0

ASSURE HAEMOLANCE PLUS

18G 18 GAUGE 4 $0

21G 21 GAUGE 4 $0

25G 25 GAUGE 4 $0

28G 28 GAUGE 4 $0

ASSURE ID INSULIN SAFETY

SYRINGE 1 ML 29 GAUGE X 12 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ASSURE LANCE 25G LANCETS

25 GAUGE 4 $0

28 GAUGE 4 $0

ASSURE LANCE PLUS 21G

BD INSULIN SYR 03 ML

6MMX31G 03 ML 31 GAUGE X

BD INSULIN SYR 1 ML

BD MICROTAINER 21G

BD MICROTAINER 30G

BD ULTRA-FINE 33G LANCETS

33 GAUGE 4 $0

BD ULTRA-FINE II 30G

BD ULTRA-FINE PEN NDL

4MMX32G NANO 32 GAUGE X

BLOOD LANCETS 30G EASY

TWIST 30 GAUGE

(1st Tier Unilet

ComforTouch) 4 $0

BULLSEYE MINI SAFETY 21G

21 GAUGE 4 $0

LANCT 25 GAUGE 4 $0

CAREONE ULTRA THIN

LANCET 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CARESENS ULTRA THIN 30G

LANCET 30 GAUGE 4 $0

CARETOUCH TWIST 28G

CARETOUCH TWIST 30G

CLEVER CHEK ULTRA THIN

30G 30 GAUGE 4 $0

COAGUCHEK LANCETS 4 $0

COMFORT EZ SAFETY 21G

COMFORT LANCETS 4 $0

CVS THIN 26G LANCETS 26

GAUGE (Advocate Lancet) 4 $0

CVS ULTRA THIN 30G

DROPLET 30G LANCETS 30

GAUGE 4 $0

EASY COMFORT 30G LANCETS

30GTWIST TOPSTRL 30

EASY TOUCH 28G LANCETS

28GPULL TOPSTERILE 28

EASY TOUCH SAFETY 21G

EASY TOUCH TWIST 28G

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

EASY TWIST amp CAP 28G

EMBRACE 30G LANCETS 30

GAUGE 4 $0

E-Z JECT LANCETS 4 $0

EZ SMART 28G LANCETS 28

GAUGE 4 $0

E-ZJECT COLOR 32G LANCETS

32 GAUGE 4 $0

33 GAUGE 4 $0

E-ZJECT SUPER THIN 30G

LANCETS SUPER THIN 30

E-ZJECT THIN LANCETS 26

(Accu-Chek

FastClix) 4 $0

FIFTY50 SAFETY SEAL 30G

FINE 30 UNIVERSAL 30G

FINGERSTIX LANCETS 4 $0

FORA 30G LANCETS TWIST

OFFSINGLE USE 30 GAUGE

(1st Tier Unilet

ComforTouch) 4 $0

FORACARE 30G LANCETS 30

GAUGE 4 $0

FREESTYLE 28G LANCETS 28

GAUGE 4 $0

FREESTYLE INSULINX TEST

STRIP NO CODE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

STRIPS 4 $0

FREESTYLE LITE TEST STRIP 4 $0

FREESTYLE LITE TEST STRIPS

FREESTYLE TEST STRIPS 4 $0

FREESTYLE UNISTIK 2

LANCETS 4 $0

GAUZE PAD TOPICAL

BANDAGE 2 X 2 1 $0

GLUCOCOM 28G LANCETS 28

GAUGE 4 $0

GMATE 30G LANCETS 30

GAUGE 4 $0

GNP UNIVERSAL 1 STANDARD

21G 21 GAUGE 4 $0

GNP UNIVERSAL 1 SUPER THIN

30G 30 GAUGE 4 $0

HEALTHY ACCENTS UNILET

30G 30 GAUGE 4 $0

INCONTROL SUPER THIN 30G

LANCT 30 GAUGE 4 $0

INCONTROL ULTRA THIN 28G

LANCT 28 GAUGE 4 $0

INJECT EASE 28G LANCETS 28

GAUGE 4 $0

INSULIN SYRINGE-NEEDLE U-

100 SYRINGE 03 ML 29 GAUGE

(Ultilet Insulin

Syringe) 1 $0

100 SYRINGE 1 ML 29 GAUGE X

(Advocate

Syringes) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Lite Touch Insulin

Syringe) 1 $0

INVACARE 30G LANCETS 30

GAUGE 4 $0

KRO UNIVERSAL 1 THIN 26G

LANCT 26 GAUGE 4 $0

KROGER SUPER THIN

LANCETS 4 $0

LANCETS 33G 33 GAUGE (BD Ultra Fine

Lancets) 4 $0

LANCETS THIN 23G 23 GAUGE

LANCETS ULTRA THIN 26G 26

GAUGE 4 $0

LITE TOUCH 30G LANCETS 30

GAUGE 4 $0

LONGS THIN LANCETS 26G 26G

MEDLANCE PLUS 21G

LANCETS UNIVERSAL 21

MEDLANCE PLUS 30G

LANCETS SUPERLITE 12MM

30 GAUGE

MEDLANCE PLUS LITE 25G

LANCETS STERILE 25 GAUGE 4 $0

MICRO THIN 33G LANCETS

UNIVERSAL 1 33 GAUGE 4 $0

MICROLET LANCETS 4 $0

MONOLET 21G LANCETS 21

GAUGE 4 $0

MONOLET THIN 28G LANCETS

28 GAUGE 4 $0

MYGLUCOHEALTH 30G

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

NOVA SAFETY 23G LANCETS

23 GAUGE 4 $0

28 GAUGE 4 $0

NOVA SUREFLEX THIN

LANCETS 4 $0

ON CALL 30G LANCET 30

GAUGE 4 $0

ON CALL PLUS 30G LANCET 30

GAUGE 4 $0

ONE TOUCH DELICA 33G

ONETOUCH DELICA 30G

ONETOUCH DELICA 33G

ONETOUCH SURESOFT

LANCING DEV DEVICE amp 18G

LANCETS

ONETOUCH ULTRASOFT

LANCETS 4 $0

ON-THE-GO 30G LANCETS

GENTLE 15MM 30 GAUGE 4 $0

PEN NEEDLE DIABETIC

NEEDLE 29 GAUGE X 12

(1st Tier Unifine

Pentips) 1 $0

PHARMACIST CHOICE 30G

LANCETS ULTRA THIN 30

(1st Tier Unilet

ComforTouch) 4 $0

PRECISION XTRA TEST STRIPS

PRESSURE ACTIVATED 21G

PRO COMFORT 30G LANCETS

30 GAUGE 4 $0

PRO COMFORT 31G LANCET 31

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PRODIGY PRESSURE

ACTIVATED 28G 28 GAUGE 4 $0

PRODIGY SAFETY 26G

PRODIGY TWIST TOP 28G

PUSH BUTTON SAFETY 21G

RA E-ZJECT 26G LANCETS 26

GAUGE 4 $0

READYLANCE 21G SAFETY

RELIAMED 30G LANCETS 30

GAUGE 4 $0

RELIAMED SAFETY 23G

RELIAMED SAFETY 28G

LANCETS LATEX-FREE 28

RELIAMED SAFETY SEAL 28G

LANCT 28 GAUGE 4 $0

LANCT 30 GAUGE 4 $0

RELION THIN 26G LANCETS 26

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

RELION ULTRA THIN PLUS 33G

33 GAUGE 4 $0

RELION ULTRA THIN PLUS

LANCETS 4 $0

RIGHTEST GL300 30G LANCETS

30 GAUGE 4 $0

SAFETY 21G LANCETS LATEX-

FREE 21 GAUGE 4 $0

FREE 28 GAUGE 4 $0

SAFETY LANCETS 26G 26

GAUGE 4 $0

SAFETY SEAL 28G LANCETS 28

GAUGE 4 $0

SAFETY-LET 30G LANCETS 30

GAUGE 4 $0

SINGLE-LET LANCETS 4 $0

SM COLOR LANCETS 21G 21

GAUGE 4 $0

SM LANCETS 21G 21 GAUGE (Assure

Haemolance Plus) 4 $0

SM THIN LANCETS 26G 26

GAUGE 4 $0

SMART SENSE COLOR 33G

SMART SENSE STANDARD 21G

21 GAUGE 4 $0

SMART SENSE THIN 26G

SMARTEST LANCET 4 $0

SOFT TOUCH LANCETS 4 $0

SOLUS V2 28G LANCETS 28

GAUGE 4 $0

SOLUS V2 30G TWIST LANCETS

30 GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

STERILANCE TL TWIST 30G

STERILE PADS 2 X 2 2 X 2 1 $0

SUPER THIN 28G LANCETS

SURE COMFORT 18G LANCETS

18 GAUGE 4 $0

21 GAUGE 4 $0

23 GAUGE 4 $0

28 GAUGE 4 $0

30 GAUGE 4 $0

SURE-LANCE 26G LANCETS 26

GAUGE 4 $0

SURE-LANCE FLAT LANCETS 4 $0

SURE-LANCE THIN 28G

SURE-LANCE ULTRA THIN 30G

30 GAUGE 4 $0

SURE-TOUCH LANCET 4 $0

TECHLITE 28G LANCETS 28

GAUGE 4 $0

TELCARE ULTRA THIN 30G

THIN LANCETS 28G 28 GAUGE

TOPCARE UNIVERSAL1 33G

TOPCARE UNIVERSAL1 THIN

LANCET ULTRA THIN 30G 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TRUEPLUS 26G LANCETS 26

GAUGE 4 $0

TRUEPLUS SAFETY 28G

LANCETS 28G STERILE 28

TRUEPLUS SUPER THIN 28G

LANCET 28G STERILE 28

TRUEPLUS ULTRA THIN 30G

ULTILET 28G LANCETS 28

GAUGE 4 $0

ULTILET BASIC 30G LANCETS

30 GAUGE 4 $0

ULTILET CLASSIC 26G

LANCETS 4 $0

ULTILET CLASSIC 28G

ULTILET CLASSIC 30G

ULTILET CLASSIC 33G

ULTILET SAFETY 23G

ULTRA THIN 28G LANCETS

ULTRA THIN 28 GAUGE 4 $0

ULTRA THIN 31G LANCETS 31

GAUGE 4 $0

ULTRALANCE 26G LANCETS 26

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GAUGE 4 $0

ULTRA-THIN II 26G LANCET 26

GAUGE 4 $0

ULTRA-THIN II 28G LANCETS

28 GAUGE 4 $0

30 GAUGE 4 $0

ULTRATLC LANCETS 4 $0

UNILET COMFORTOUCH 26G

UNILET COMFORTOUCH

LANCET 4 $0

UNILET EXCELITE II LANCET 4 $0

UNILET EXCELITE LANCET 4 $0

UNILET GP LANCET 4 $0

UNILET MICRO THIN 33G

UNILET SUPER THIN 30G

LANCETS SINGLE-

USESTERILE 30 GAUGE

UNILET ULTRA THIN 28G

UNISTIK 3 COMFORT LANCET

UNISTIK 3 EXTRA 21G

UNISTIK 3 GENTLE 30G

UNISTIK 3 NORMAL 23G

UNISTIK 3 SAFETY 21G

UNISTIK CZT COMFORT 28G

UNISTIK CZT NORMAL 23G

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

UNISTIK SAFETY 28G LANCET

28 GAUGE 4 $0

UNISTIK SAFETY 30G LANCETS

30 GAUGE 4 $0

UNISTIK TOUCH 21G LANCETS

21 GAUGE 4 $0

23 GAUGE 4 $0

28 GAUGE 4 $0

30 GAUGE 4 $0

UNIVERSAL 1 33G LANCETS

FOR MEIJER 33 GAUGE 4 $0

VGO 40 DISPOSABLE DEVICE 1 $0

WALGREENS ULTRA THIN

LANCETS 4 $0

Disinfectants (For Non-

Dermatologic Use)

sm iodine tincture 4 $0

Enzyme

ReplacementModifiers

Enzyme ReplacementModifiers

ADAGEN INTRAMUSCULAR

ALDURAZYME INTRAVENOUS

CERDELGA ORAL CAPSULE 84

MG 2 $0

PA NDS

CEREZYME INTRAVENOUS

RECON SOLN 400 UNIT 2 $0

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Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CREON ORAL

CAPSULEDELAYED

RELEASE(DREC) 12000-38000 -

60000 UNIT 24000-76000 -

120000 UNIT 3000-9500- 15000

UNIT 36000-114000- 180000

UNIT 6000-19000 -30000 UNIT

ELAPRASE INTRAVENOUS

ELITEK INTRAVENOUS RECON

SOLN 15 MG 75 MG 2 $0

FABRAZYME INTRAVENOUS

KANUMA INTRAVENOUS

PA NDS

KRYSTEXXA INTRAVENOUS

KUVAN ORAL

TABLETSOLUBLE 100 MG 2 $0

NAGLAZYME INTRAVENOUS

ORFADIN ORAL CAPSULE 10

MG 20 MG 5 MG 2 $0

PA NDS

ORFADIN ORAL CAPSULE 2 MG 2 $0 PA NDS

ORFADIN ORAL SUSPENSION 4

MGML 2 $0

PA NDS

PROCYSBI ORAL CAPSULE

DELAYED REL SPRINKLE 25

MG 75 MG

PULMOZYME INHALATION

PA BvD NDS

STRENSIQ SUBCUTANEOUS

PA LA NDS

VIMIZIM INTRAVENOUS

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

VPRIV INTRAVENOUS RECON

SOLN 400 UNIT 2 $0

ZAVESCA ORAL CAPSULE 100

MG 2 $0

QL (90 per 30 days)

ZENPEP ORAL

CAPSULEDELAYED

55000 UNIT 15000-51000 -

82000 UNIT 20000-68000 -

109000 UNIT 25000-85000-

136000 UNIT 3000-10000-

16000 UNIT 40000-136000-

218000 UNIT 5000-17000 -

27000 UNIT

Eye Ear Nose Throat Agents

Miscellaneous

AKTEN (PF) OPHTHALMIC

(EYE) GEL 35 2 $0

altamist 065 nose spray 065 4 $0

apraclonidine ophthalmic (eye)

drops 05 (Iopidine) 1 $0

artificial tears 4 $0

artificial tears 14 drops 14 4 $0

artificial tears drops pf sterile 01-

03 4 $0

artificial tears eye drops strl 01-03

ARTIFICIAL TEARS EYE

OINTMENT 83-15 4 $0

atropine ophthalmic (eye) drops 1 1 $0

ayr saline 065 nose drops 065

ayr saline 065 nose spray 065

azelastine nasal aerosolspray 137

mcg (01 ) 1 $0

QL (30 per 25 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

azelastine ophthalmic (eye) drops

005 1 $0

bion tears eye drops 01-03 4 $0

cromolyn ophthalmic (eye) drops 4

cvs artificial tears drops sterile 1-

03 4 $0

cvs lubricant 06 eye drops 06

cvs lubricant dry eye rlf 1 1 4 $0

cvs lubricant eye drops dry eye

therapy 04-03 4 $0

cvs lubricant eye ointment pf 573-

425 4 $0

cvs lubricant gel eye drops 025-03

cvs lubricating eye drops dry eye

soln 05-09 4 $0

cvs nasal spray 005 005 4 $0

cvs nasal spray 005 no drip 005

cvs natural tears drops 01-03 4 $0

cvs saline 065 nasal spray 065

cvs saline 065 nose spray 065

cyclopentolate ophthalmic (eye)

drops 05 1 2 (Cyclogyl) 1 $0

CYSTARAN OPHTHALMIC

(EYE) DROPS 044 2 $0

deep sea 065 nose spray 065 4 $0

dristan long lasting mist 005 4 $0

epinastine ophthalmic (eye) drops

005 (Elestat) 1 $0

eq gentle 03 eye drops 03 4 $0

eq revive plus 05 eye drops 05

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

eql sinus nasal spray 005 4 $0

GENTEAL GEL DROPS 025-03

GENTEAL MILD 02 EYE

DROPS 02 4 $0

GENTEAL SEVERE 03 EYE

GEL PF STRL INNER 03 4 $0

GENTEAL TEARS 01-02-

03 01-03-02 4 $0

genteal tears 01-03 drop 01-

03 4 $0

ipratropium bromide nasal

spraynon-aerosol 003 1 $0

QL (30 per 28 days)

spraynon-aerosol 42 mcg (006 ) 1 $0

QL (15 per 10 days)

isopto tears 05 eye drops 05 4 $0

LACRISERT OPHTHALMIC

(EYE) INSERT 5 MG 2 $0

little remedies stuffy nose kt w

nasal aspirator 065 4 $0

lubricant 05-09 eye drops 05-

09 4 $0

lubricating plus 05 eye drps pf

30x04ml 05 4 $0

lubrifresh pm eye ointment 83-15

mucinex sinus-max nasal spray full

force 005 4 $0

muro-128 2 eye drops 2 4 $0

muro-128 5 eye ointment 5 4 $0

nasal relief 005 spray sinus

formula 005 4 $0

nasal spray 005 extra

moisturizing 005 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

natural balance tears eye drop 01-

03 4 $0

neo-synephrine 12 hour spray 005

nose 005 spray pump 005 4 $0

ocean 065 nasal spray include

travel size 065 4 $0

olopatadine ophthalmic (eye) drops

01 (Patanol) 1 $0

02 (Pataday) 1 $0

OTOVEL OTIC (EAR) SOLUTION

03-0025 (025 ML) 2 $0

phenylephrine hcl ophthalmic (eye)

drops 10 25 1 $0

proparacaine ophthalmic (eye)

drops 05 1 $0

pure amp gentle eye drops lubricant

03 4 $0

ra 12hr nasal spray 005 for sinus

005 4 $0

ra artificial tears drops dry eye

formula 1-03 4 $0

REFRESH CELLUVISC 1 EYE

DROPS 1 4 $0

REFRESH CLASSIC EYE DROPS

U-DPF30X4ML 14-06 4 $0

REFRESH LACRI-LUBE

OINTMENT 568-425 4 $0

retaine cmc 05 eye drops 05 4 $0

retaine hpmc 03 eye drops 03

retaine pm eye ointment 80-20 4 $0

saline mist 065 nose spry 065

sea soft 065 nasal mist 065 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

sinus relief nasal spray 005 005

sm nasal spray sinus 005 4 $0

sochlor 5 eye drops 5 4 $0

sodium chloride 5 eye drop 5 (Altachlore) 4 $0

sodium chloride 5 eye oint 5 (Altachlore) 4 $0

soothe night time lub eye oint 80-20

SYSTANE 03 EYE GEL 03 4 $0

SYSTANE GEL EYE DROPS 04-

03 4 $0

SYSTANE LIQUID GEL EYE

DROPS 04-03 4 $0

tears again 14 drops 14 4 $0

tears again eye ointment 80-20 4 $0

tears naturale free drops u-

d36x9mlpf 01-03 4 $0

ultra fresh pm ointment 4 $0

vicks qlearquil 005 mist 005 4 $0

vicks sinex 12 hour spray 005 4 $0

Eye Ear Nose Throat Anti-

Infectives Agents

acetic acid otic (ear) solution 2 1 $0

bacitracin ophthalmic (eye)

ointment 500 unitgram 1 $0

bacitracin-polymyxin b ophthalmic

(eye) ointment 500-10000

unitgram

(Polycin) 1 $0

bleph-10 ophthalmic (eye) drops 10

CIPRODEX OTIC (EAR)

DROPSSUSPENSION 03-01 2 $0

ciprofloxacin hcl ophthalmic (eye)

drops 03 (Ciloxan) 1 $0

ciprofloxacin hcl otic (ear)

dropperette 02 (Cetraxal) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

COLY-MYCIN S OTIC (EAR)

DROPSSUSPENSION 33-3-10-

05 MGML

erythromycin ophthalmic (eye)

ointment 5 mggram (05 ) 1 $0

gatifloxacin ophthalmic (eye) drops

05 (Zymaxid) 1 $0

gentak ophthalmic (eye) ointment

03 (3 mggram) 1 $0

gentamicin ophthalmic (eye) drops

03 1 $0

gentamicin ophthalmic (eye)

ointment 03 (3 mggram) (Gentak) 1 $0

levofloxacin ophthalmic (eye) drops

05 1 $0

MOXEZA OPHTHALMIC (EYE)

DROPS VISCOUS 05 2 $0

moxifloxacin ophthalmic (eye) drops

05 (Vigamox) 1 $0

NATACYN OPHTHALMIC (EYE)

DROPSSUSPENSION 5 2 $0

neomycin-bacitracin-poly-hc

ophthalmic (eye) ointment 35-400-

10000 mg-unitg-1

(Neo-Polycin HC) 1 $0

neomycin-bacitracin-polymyxin

10000 mg-unit-unitg

(Neo-Polycin) 1 $0

neomycin-polymyxin b-dexameth

ophthalmic (eye) dropssuspension

35mgml-10000 unitml-01

(Maxitrol) 1 $0

ophthalmic (eye) ointment 35 mgg-

10000 unitg-01

(Maxitrol) 1 $0

neomycin-polymyxin-gramicidin

ophthalmic (eye) drops 175 mg-

10000 unit-0025mgml

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

neomycin-polymyxin-hc ophthalmic

(eye) dropssuspension 35-10000-

10 mg-unit-mgml

neomycin-polymyxin-hc otic (ear)

dropssuspension 35-10000-1

mgml-unitml-

solution 35-10000-1 mgml-

unitml-

neo-polycin hc ophthalmic (eye)

ointment 35-400-10000 mg-unitg-

neo-polycin ophthalmic (eye)

ointment 35-400-10000 mg-unit-

ofloxacin ophthalmic (eye) drops 03

(Ocuflox) 1 $0

ofloxacin otic (ear) drops 03 (Floxin) 1 $0

polycin ophthalmic (eye) ointment

500-10000 unitgram 1 $0

polymyxin b sulf-trimethoprim

ophthalmic (eye) drops 10000 unit-

1 mgml

(Polytrim) 1 $0

REFRESH OPTIVE ADVANCED

DROPS 05-1-05 4 $0

sulfacetamide sodium ophthalmic

(eye) drops 10 (Bleph-10) 1 $0

(eye) ointment 10 1 $0

sulfacetamide-prednisolone

ophthalmic (eye) drops 10 -023

(025 )

TOBRADEX OPHTHALMIC

(EYE) OINTMENT 03-01 2 $0

TOBRADEX ST OPHTHALMIC

(EYE) DROPSSUSPENSION 03-

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

tobramycin ophthalmic (eye) drops

03 (Tobrex) 1 $0

tobramycin-dexamethasone

(TobraDex) 1 $0

trifluridine ophthalmic (eye) drops 1

(Viroptic) 1 $0

VIGAMOX OPHTHALMIC (EYE)

DROPS 05 2 $0

ZIRGAN OPHTHALMIC (EYE)

GEL 015 2 $0

ZYLET OPHTHALMIC (EYE)

Inflammatory Agents

ALREX OPHTHALMIC (EYE)

BROMSITE OPHTHALMIC (EYE)

DROPS 0075 2 $0

dexamethasone sodium phosphate

ophthalmic (eye) drops 01 1 $0

diclofenac sodium ophthalmic (eye)

drops 01 1 $0

DUREZOL OPHTHALMIC (EYE)

DROPS 005 2 $0

flunisolide nasal spraynon-aerosol

25 mcg (0025 ) 1 $0

QL (50 per 25 days)

fluorometholone ophthalmic (eye)

dropssuspension 01 (FML Liquifilm) 1 $0

flurbiprofen sodium ophthalmic

(eye) drops 003 1 $0

fluticasone nasal spraysuspension

50 mcgactuation

(24 Hour Allergy

Relief) 1 $0

ILEVRO OPHTHALMIC (EYE)

ketorolac ophthalmic (eye) drops

04 (Acular LS) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

05 (Acular) 1 $0

LOTEMAX OPHTHALMIC (EYE)

DROPSGEL 05 2 $0

OINTMENT 05 2 $0

prednisolone acetate ophthalmic

(eye) dropssuspension 1 (Omnipred) 1 $0

prednisolone sodium phosphate

PROLENSA OPHTHALMIC

RESTASIS MULTIDOSE

OPHTHALMIC (EYE) DROPS

QL (55 per 30 days)

RESTASIS OPHTHALMIC (EYE)

DROPPERETTE 005 2 $0

QL (60 per 30 days)

Gastrointestinal Agents

Antiflatulents

bicarsim forte 125 mg tablet 125 mg

cvs gas relief 125 mg chew tab extra

cvs gas relief 125 mg softgel softgel

125 mg 4 $0

cvs gas relief 80 mg tab chew 80 mg

cvs gas relief ex-str drops 40 mg06

ml 4 $0

gas relief 125 mg chew tablet max

strlactose-free 125 mg 4 $0

gas relief 80 tablet chew 80 mg 4 $0

gas-x ultra strength softgel 180 mg

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

inf gas rel 20 mg03 ml drop

20mg03ml dye free 40 mg06 ml 4 $0

mi-acid gas 80 mg tab chew 80 mg 4 $0

mytab gas 80 mg tablet chew 80 mg

mytab gas max str 125 mg tab 125

mg 4 $0

simethicone 180 mg softgel 180 mg

(Anti-Gas Ultra

Strength) 4 $0

v-r anti-gas 166 mg softgel 166 mg

Antiulcer Agents And Acid

Suppressants

acid reducer 20 mg tablet maximum

strength 20 mg 4 $0

acid reducer dr 20 mg cap 20 mg 4 $0

CARAFATE ORAL SUSPENSION

100 MGML 2 $0

cimetidine hcl oral solution 300

mg5 ml 1 $0

cimetidine oral tablet 200 mg (Acid Reducer

(cimetidine)) 1 $0

cimetidine oral tablet 300 mg 400

mg 800 mg 1 $0

cvs acid controller 10 mg tab 10 mg

cvs cimetidine 200 mg tablet (otc)

200 mg

(Acid Reducer

(cimetidine)) 4 $0

esomeprazole mag dr 20 mg cap

outer (otc) 20 mg (Nexium) 4 $0

esomeprazole sodium intravenous

recon soln 40 mg (Nexium IV) 1 $0

famotidine (pf) intravenous solution

20 mg2 ml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

famotidine (pf)-nacl (iso-os)

famotidine intravenous solution 10

mgml 1 $0

famotidine oral tablet 20 mg (Acid Controller) 1 $0

famotidine oral tablet 40 mg (Pepcid) 1 $0

gnp acid reducer 10 mg tablet 10

mg 4 $0

hm lansoprazole dr 15 mg cap

gluten-free3 bottle (otc) 15 mg

(Heartburn

Treatment 24

lansoprazole oral capsuledelayed

release(drec) 15 mg

(Heartburn

Treatment 24

release(drec) 30 mg (Prevacid) 1 $0

misoprostol oral tablet 100 mcg

200 mcg (Cytotec) 1 $0

omeprazole dr 20 mg tablet 20 mg 4 $0

omeprazole mag dr 206 mg cap two

14-days course 20 mg

(Acid Reducer

(omeprazole)) 4 $0

omeprazole oral capsuledelayed

release(drec) 10 mg 20 mg 40 mg 1 $0

pantoprazole intravenous recon soln

40 mg (Protonix) 1 $0

pantoprazole oral tabletdelayed

release (drec) 20 mg 40 mg (Protonix) 1 $0

PRILOSEC OTC 206 MG

TABLET OTC 20 MG 4 $0

pub famotidine 20 mg tablet max

strength (otc) 20 mg (Acid Controller) 4 $0

ranitidine 150 mg tablet maximum

strength (otc) 150 mg

(Acid Control

(ranitidine)) 4 $0

ranitidine 75 mg tablet sf sodium-

free 75 mg

(Acid Reducer

(ranitidine)) 4 $0

ranitidine hcl injection solution 25

mgml 50 mg2 ml (25 mgml) (Zantac) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ranitidine hcl oral syrup 15 mgml 1 $0

ranitidine hcl oral tablet 150 mg (Acid Control

(ranitidine)) 1 $0

ranitidine hcl oral tablet 300 mg (Zantac) 1 $0

sucralfate oral tablet 1 gram (Carafate) 1 $0

wal-zan 75 mg tablet 75 mg 4 $0

zantac 75 mg tablet 75 mg 4 $0

Gastrointestinal Agents Other

acid gone antacid liquid 95-358

mg15 ml 4 $0

almacone liquid 200-200-20 mg5

ml 4 $0

almacone-2 liquid 400-400-40 mg5

ml 4 $0

aluminum hydroxide gel sugar-free

320 mg5 ml 4 $0

AMITIZA ORAL CAPSULE 24

MCG 8 MCG 2 $0

QL (60 per 30 days)

antacid ii-simethicone liq 400-400-

30 mg5 ml 4 $0

40 mg5 ml 4 $0

antacid-antigas tab chew 1000-60

mg 4 $0

anti-diarrheal 1 mg5 ml liq 1 mg5

ml 4 $0

anti-diarrheal 2 mg caplet caplet 2

mg 4 $0

bismatrol 525 mg30 ml susp 262

mg15 ml 4 $0

bismatrol tablet chew 262 mg 4 $0

BUPHENYL ORAL TABLET 500

MG 2 $0

calci-chew tablet 500 mg calcium

(1250 mg) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

calcium 500 mg chewable tablet tab

chewpf 500 mg calcium (1250 mg)

(Calci-Chew) 4 $0

calcium antacid 1000 mg tab ultra

chew max str 400 mg calcium

(1000 mg)

calcium antacid 500 mg chw tab

assorted fruit 200 mg calcium (500

calcium antacid 750 mg tb chew

gluten-free 300 mg (750 mg) 4 $0

cal-gest 500 mg tablet chew 200 mg

calcium (500 mg) 4 $0

CARBAGLU ORAL TABLET

child soothe 400 mg tab chew 400

mg 4 $0

children pepto 400 mg tab chew

bubble gum naf 400 mg 4 $0

comfort gel max str susp max-str

400-400-40 mg5 ml 4 $0

comfort gel suspension regular str

cherry 200-200-20 mg5 ml 4 $0

constulose oral solution 10 gram15

ml 1 $0

cvs antacid plus anti-gas liq

maximum strength 400-400-40 mg5

cvs antacid ultra tab chew ultra

strength 400 mg calcium (1000 mg)

cvs antacid xtra str chew tab extra-

strength 300 mg (750 mg) 4 $0

cvs antacid-antigas liquid regular

strength 200-200-20 mg5 ml 4 $0

cvs antacid-simethicone liquid 200-

200-20 mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cvs anti-diarrheal 2 mg sftgel softgel

2 mg 4 $0

cvs anti-diarrheal suspension 262

mg15 ml 4 $0

cvs bismuth max-strength liq 525

mg15 ml 4 $0

cvs bismuth regular liquid 262

mg15 ml 4 $0

cvs flavor chew antacid 750 mg 300

mg (750 mg) 4 $0

cvs heartburn relief liquid 254-

2375 mg5 ml 4 $0

cvs lax dietary 500 mg caplet 500

mg 4 $0

cvs loperamide 1 mg75 ml liq mint

1 mg75 ml

(Anti-Diarrheal

(loperamide)) 4 $0

diamode 2 mg tablet outer fc 2 mg

dicyclomine oral capsule 10 mg (Bentyl) 1 $0

dicyclomine oral solution 10 mg5

ml 1 $0

dicyclomine oral tablet 20 mg 1 $0

diphenoxylate-atropine oral liquid

25-0025 mg5 ml 1 $0

PA-HRM AGE (Max

64 Years)

diphenoxylate-atropine oral tablet

25-0025 mg (Lomotil) 1 $0

PA-HRM AGE (Max

64 Years)

enulose oral solution 10 gram15 ml 1 $0

eq liquid antacid susp maximum

strength 400-400-40 mg5 ml 4 $0

foaming antacid liquid 95-358

mg15 ml 4 $0

GATTEX 30-VIAL

SUBCUTANEOUS KIT 5 MG 2 $0

PA NDS

gelusil tablet chewable cool mint

200-200-25 mg 4 $0

generlac oral solution 10 gram15

ml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

glycopyrrolate injection solution 02

mgml (Robinul) 1 $0

glycopyrrolate oral tablet 1 mg (Robinul) 1 $0

glycopyrrolate oral tablet 2 mg (Robinul Forte) 1 $0

IMODIUM A-D 1 MG75 ML

LIQUID MINT AGES 6+ 1

MG75 ML

imodium a-d 2 mg softgel 2 mg 4 $0

kaopectate 262 mg15 ml susp

vanilla flavor 262 mg15 ml 4 $0

kionex 15 gm60 ml suspension 15-

193 gram60 ml 1 $0

kionex oral powder 1 $0

lactulose oral solution 10 gram15

ml (Constulose) 1 $0

LINZESS ORAL CAPSULE 145

MCG 290 MCG 72 MCG 2 $0

QL (30 per 30 days)

liquid antacid suspension regular

strength 200-200-20 mg5 ml 4 $0

loperamide 1 mg5 ml liquid 1 mg5

(Anti-Diarrheal

(loperamide)) 4 $0

loperamide 1 mg75 ml susp mint 1

mg75 ml

(Anti-Diarrheal

(loperamide)) 4 $0

loperamide oral capsule 2 mg (Anti-Diarrheal

(loperamide)) 1 $0

maalox advanced suspension

regular strength 200-200-20 mg5

magnesium 250 mg tablet pf 250

mg 4 $0

magnesium 400 mg tablet gluten-

free 400 mg (MagOx) 4 $0

magnesium oxide 400 mg tablet

sfpfgluten-free 400 mg (MagOx) 4 $0

magnesium oxide 500 mg capsule

500 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

pfsflactose-free 500 mg

(Laxative Dietary

Supplement) 4 $0

mag-oxide magnesium 200 mg tab

200 mg magnesium 4 $0

masanti liquid 400-400-40 mg5 ml

medi-bismuth chew tablet 262 mg 4 $0

medi-first pep-t-med tab chew 262

mg 4 $0

methscopolamine oral tablet 25 mg

5 mg 1 $0

metoclopramide hcl injection

metoclopramide hcl oral solution 5

mg5 ml 1 $0

metoclopramide hcl oral tablet 10

mg 5 mg (Reglan) 1 $0

mgo 400 mg tablet 400 mg 4 $0

mi acid suspension 200-200-20

mg5 ml 400-400-40 mg5 ml 4 $0

mi-acid ds tablet 700-300 mg 4 $0

mintox maximum strength susp max

str lemon creme 400-400-40 mg5

mintox plus tablet chewable 200-

200-25 mg 4 $0

mintox suspension mint creme 200-

200-20 mg5 ml 4 $0

MOVANTIK ORAL TABLET 125

MG 25 MG 2 $0

QL (30 per 30 days)

NUTRESTORE ORAL POWDER

IN PACKET 5 GRAM 2 $0

OCALIVA ORAL TABLET 10

MG 5 MG 2 $0

PA QL (30 per 30

days) NDS

phillips 500 mg caplet 500 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ra antacid amp gas relief liquid

ra antacid xtra str chew tab tropical

fruits 300 mg (750 mg) 4 $0

ra magnesium 500 mg capsule 500

mg 4 $0

ra pink bismuth caplet capletsf 262

mg 4 $0

RAVICTI ORAL LIQUID 11

GRAMML 2 $0

PA NDS

RELISTOR ORAL TABLET 150

MG 2 $0

PA QL (90 per 30

days) NDS

RELISTOR SUBCUTANEOUS

PA QL (28 per 28

days) NDS

SYRINGE 12 MG06 ML 8

MG04 ML

PA QL (28 per 28

days) NDS

ri-gel ii suspension 400-400-40

mg5 ml 4 $0

riginic suspension 131-317 mg5 ml

ri-mox suspension 200-200-20 mg5

ml 4 $0

sm antacid anti-gas liquid 400-400-

30 mg5 ml 4 $0

sm foaming antacid tablet chew 80-

20 mg 4 $0

sm stomach relief caplet 262 mg 4 $0

sodium bicarb 650 mg tablet 10 gr

650 mg 4 $0

sodium phenylbutyrate oral tablet

500 mg (Buphenyl) 1 $0

sodium polystyrene (sorb free) oral

suspension 15 gram60 ml 1 $0

sodium polystyrene sulfonate rectal

enema 30 gram120 ml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

soothe 262 mg caplet caplet 262 mg

soothe 262 mg15 ml suspension sf

262 mg15 ml 4 $0

sps (with sorbitol) oral suspension

15-20 gram60 ml 1 $0

ursodiol oral capsule 300 mg (Actigall) 1 $0

ursodiol oral tablet 250 mg (URSO 250) 1 $0

ursodiol oral tablet 500 mg (URSO Forte) 1 $0

VELTASSA ORAL POWDER IN

PACKET 168 GRAM 252

GRAM 84 GRAM

QL (30 per 30 days)

VIBERZI ORAL TABLET 100

MG 75 MG 2 $0

ST QL (60 per 30

days) NDS

XERMELO ORAL TABLET 250

MG 2 $0

PA QL (90 per 30

days) NDS

Laxatives

alophen pills 5 mg 4 $0

bisac-evac 10 mg suppository 10 mg

bisacodyl 10 mg suppository 10 mg

(Bisac-Evac) 4 $0

bisacodyl ec 5 mg tablet 5 mg (Alophen) 4 $0

biscolax 10 mg suppository 10 mg 4 $0

cvs enema disposable 19-7

gram118 ml 4 $0

cvs fiber laxative 625 mg cplt caplet

625 mg 4 $0

cvs fiber therapy 500 mg caplt

soluble caplet 500 mg 4 $0

cvs kids 100 mg mini enema 100

mg5 ml 4 $0

cvs milk of magnesia susp 400 mg5

ml 4 $0

cvs mineral oil (Mineral Oil Extra

Heavy) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cvs natural fiber supp powder sf

orange flavor 34 gram58 gram 4 $0

cvs purelax powder 17 gramdose 4 $0

cvs purelax powder packet sf 10

daily doses 17 gram 4 $0

cvs stool softener-laxative tb 86-50

mg 4 $0

docu liquid 50 mg5 ml 50 mg5 ml

docusate sodium 100 mg tablet

crushable 100 mg (Docuprene) 4 $0

docusol mini-enema outer 283 mg 4 $0

dok 100 mg softgel softgel 100 mg 4 $0

dok 100 mg tablet 100 mg 4 $0

dok plus tablet 86-50 mg 4 $0

dulcolax ss 100 mg softgel 100 mg 4 $0

enema disposable 19-7 gram118 ml

enema ready to use 19-7 gram118

ml 4 $0

enema ready to use 2x133ml latex

free 19-7 gram118 ml 4 $0

enemeez mini enema 5cc tubes

outer 283 mg5 ml 4 $0

enemeez plus mini enema outer 283-

20 mg5 ml 4 $0

eq fiber therapy powder 4 $0

eql fiber therapy powder 34 gram7

gram 4 $0

eql senna laxative 86 mg tab 86 mg

equalactin 500 mg tab chew 500 mg

evac-u-gen 86 mg tablet 86 mg 4 $0

fiber laxative 625 mg caplet caplet

625 mg 4 $0

fiber tablet unboxed 625 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

fiber therapy powder 2 gram19

gram 4 $0

fiber-lax captabs 500mg

polycarbophil 625 mg 4 $0

FLEET BISACODYL 10 MG

ENEMA 10 MG30 ML 4 $0

gavilyte-c oral recon soln 240-

2272-672 -584 gram 1 $0

gavilyte-g oral recon soln 236-

2274-674 -586 gram 1 $0

gavilyte-n oral recon soln 420 gram 1 $0

glycolax powder 7 doses (otc) 17

gramdose 4 $0

healthylax powder packet 14x17gm

outer 17 gram 4 $0

hydrocil instant packet 4 $0

KONSYL 6 GM PACKET SF

GLUTEN-F OUTER 6 GRAM 4 $0

konsyl fiber 625 mg caplet caplet sf

625 mg 4 $0

konsyl psyllium fiber packet orange

gluten free 34 gram 4 $0

kro gentlelax 17 gram powder 17

gramdose 4 $0

magic bullet 10 mg suppos 10 mg 4 $0

medi-natural senna tablet 86-50 mg

medi-natural tablet 86 mg 4 $0

milk of magnesia suspension 400

mg5 ml 4 $0

mineral oil laxative 4 $0

MINERAL OIL LIGHT

VISCOSITY NF 4 $0

MOVIPREP ORAL POWDER IN

PACKET 100-75-2691 GRAM 2 $0

natural fiber lax powder 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

natural fiber laxative powder 34

gram58 gram 4 $0

natural senna laxative tab 86 mg 4 $0

oral saline laxative liquid sf ginger

lemon 72-27 gram15 ml 4 $0

peg 3350-electrolytes oral recon

soln 236-2274-674 -586 gram (GaviLyte-G) 1 $0

soln 240-2272-672 -584 gram

(Colyte with Flavor

Packs) 1 $0

peg-electrolyte soln oral recon soln

420 gram (GaviLyte-N) 1 $0

peri-colace tablet 86-50 mg 4 $0

phillips lax liqui-gels 100 mg 4 $0

phosphate oral saline laxative sf

ginger lemon 72-27 gram15 ml 4 $0

polyethylene glycol 3350 oral

powder 17 gramdose (ClearLax) 1 $0

powder in packet 17 gram (ClearLax) 1 $0

polyethylene glycol 3350 powd 17

grams pktsouter (otc) 17 gram (ClearLax) 4 $0

once-daily doses (otc) 17 gramdose

(ClearLax) 4 $0

polyethylene glycol 3350 powd

outer (otc) 17 gram (ClearLax) 4 $0

promolaxin 100 mg tablet 100 mg 4 $0

pure amp gentle saline enema 19-7

gram118 ml 4 $0

pv natural fiber laxative pwd 34

gram11 gram 4 $0

pv oral saline laxative kit sf 72-27

gram15 ml 4 $0

pv phosphate laxative solution sf 4 $0

qc mineral oil heavy (Mineral Oil Extra

Heavy) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

qc natura-lax 17 gm powder 17

gramdose 4 $0

ra col-rite 100 mg capsule 100 mg 4 $0

ra enema twin pack 2 x 45oz rtu

19-7 gram118 ml 4 $0

ra fast relief lax 10 mg supp 10 mg 4 $0

ra fiber laxative powder 34 gram7

gram 4 $0

ra laxative peg 3350 powder 14

once-daily doses 17 gramdose 4 $0

ra mineral oil extra-heavy extra-

heavy 4 $0

ra natural fiber 100 powder 34

gram58 gram 4 $0

ra p-col rite tablet 86-50 mg 4 $0

ra senna-lax 86 mg tablet 86 mg 4 $0

reguloid powder orange 4 $0

senexon 88 mg5 ml liquid 88 mg5

ml 4 $0

senexon tablet 86 mg 4 $0

senexon-s tablet 86-50 mg 4 $0

senna 86 mg tablet 86 mg 4 $0

senna 88 mg5 ml syrup grx 88

mg5 ml 4 $0

sennosides-docusate sodium tab 86-

50 mg (Colace 2-In-1) 4 $0

senokot-s tablet 86-50 mg 4 $0

silace 50 mg5 ml liquid 50 mg5 ml

silace 60 mg15 ml syrup 60 mg15

ml 4 $0

sm clearlax powder 17 gramdose 4 $0

sm fiber laxative 500 mg cplt 500

mg 4 $0

sm fiber smooth powder 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

sm oral saline laxative liquid sf 4 $0

smoothlax powder packet sf 10

stool softener 100 mg softgel softgel

100 mg 4 $0

240 mg 4 $0

SUPREP BOWEL PREP KIT

ORAL RECON SOLN 175-313-

16 GRAM

trilyte with flavor packets oral recon

soln 420 gram 1 $0

womans laxative ec 5 mg tab

womans stool softener 100 mg 100

mg 4 $0

Phosphate Binders

calcium acetate oral capsule 667 mg 1 $0

calcium acetate oral tablet 667 mg (Calphron) 1 $0

eliphos oral tablet 667 mg 1 $0

PHOSLYRA ORAL SOLUTION

667 MG (169 MG CALCIUM)5

RENAGEL ORAL TABLET 400

MG 800 MG 2 $0

RENVELA ORAL TABLET 800

MG 2 $0

sevelamer carbonate oral powder in

packet 08 gram 24 gram (Renvela) 1 $0

sevelamer carbonate oral tablet 800

mg (Renvela) 1 $0

VELPHORO ORAL

TABLETCHEWABLE 500 MG 2 $0

Genitourinary Agents

Antispasmodics Urinary

bethanechol chloride oral tablet 10

mg 25 mg 5 mg 50 mg (Urecholine) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MYRBETRIQ ORAL TABLET

MG 50 MG

oxybutynin chloride oral syrup 5

mg5 ml 1 $0

oxybutynin chloride oral tablet 5 mg 1 $0

oxybutynin chloride oral tablet

mg 5 mg

(Ditropan XL) 1 $0

tolterodine oral capsuleextended

release 24hr 2 mg 4 mg (Detrol LA) 1 $0

tolterodine oral tablet 1 mg 2 mg (Detrol) 1 $0

TOVIAZ ORAL TABLET

MG 8 MG

trospium oral capsuleextended

trospium oral tablet 20 mg 1 $0

VESICARE ORAL TABLET 10

MG 5 MG 2 $0

Miscellaneous

alfuzosin oral tablet extended

release 24 hr 10 mg (Uroxatral) 1 $0

dutasteride oral capsule 05 mg (Avodart) 1 $0

dutasteride-tamsulosin oral capsule

er multiphase 24 hr 05-04 mg (Jalyn) 1 $0

QL (30 per 30 days)

finasteride oral tablet 5 mg (Proscar) 1 $0

tamsulosin oral capsuleextended

release 24hr 04 mg (Flomax) 1 $0

terazosin oral capsule 1 mg 10 mg

2 mg 5 mg 1 $0

Heavy Metal Antagonists

CUPRIMINE ORAL CAPSULE

250 MG 2 $0

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

deferoxamine injection recon soln 2

gram 500 mg (Desferal) 1 $0

DEPEN TITRATABS ORAL

TABLET 250 MG 2 $0

PA NDS

EXJADE ORAL TABLET

DISPERSIBLE 125 MG 250 MG

500 MG

PA NDS

FERRIPROX ORAL SOLUTION

100 MGML 2 $0

PA NDS

FERRIPROX ORAL TABLET 500

MG 2 $0

PA NDS

JADENU ORAL TABLET 180

MG 360 MG 90 MG 2 $0

PA NDS

JADENU SPRINKLE ORAL

GRANULES IN PACKET 180 MG

360 MG 90 MG

PA NDS

SYPRINE ORAL CAPSULE 250

MG 2 $0

PA QL (240 per 30

days) NDS

Hormonal Agents

StimulantReplacementModif

Androgens

ANADROL-50 ORAL TABLET 50

MG 2 $0

PA NDS

ANDRODERM TRANSDERMAL

HOUR 4 MG24 HR

PA QL (30 per 30

ANDROGEL TRANSDERMAL

GEL IN METERED-DOSE PUMP

2025 MG125 GRAM (162 )

PA QL (150 per 30

GEL IN PACKET 162 (2025

MG125 GRAM) 162 (405

MG25 GRAM)

PA QL (150 per 30

androxy oral tablet 10 mg 1 $0

danazol oral capsule 100 mg 200

mg 50 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

oxandrolone oral tablet 10 mg 25

mg (Oxandrin) 1 $0

testosterone cypionate

intramuscular oil 100 mgml 200

(Depo-

Testosterone) 1 $0

testosterone enanthate

intramuscular oil 200 mgml 1 $0

PA QL (5 per 28 days)

testosterone transdermal gel 50

mg5 gram (1 ) (Testim) 1 $0

PA QL (300 per 30

testosterone transdermal gel in

packet 1 (25 mg25gram) 1

(50 mg5 gram)

(AndroGel) 1 $0

PA QL (300 per 30

Estrogens And Antiestrogens

amabelz oral tablet 05-01 mg 1-

05 mg 1 $0

COMBIPATCH TRANSDERMAL

PATCH SEMIWEEKLY 005-014

MG24 HR 005-025 MG24 HR

PA-HRM QL (8 per

28 days) AGE (Max

64 Years)

DUAVEE ORAL TABLET 045-20

MG 2 $0

PA-HRM AGE (Max

64 Years)

ESTRACE VAGINAL CREAM

001 (01 MGGRAM) 2 $0

estradiol oral tablet 05 mg 1 mg 2

mg (Estrace) 1 $0

PA-HRM AGE (Max

64 Years)

estradiol transdermal patch

semiweekly 0025 mg24 hr 005

mg24 hr 0075 mg24 hr 01

mg24 hr

(Alora) 1 $0

PA-HRM QL (8 per

28 days) AGE (Max

64 Years)

semiweekly 00375 mg24 hr (Minivelle) 1 $0

PA-HRM QL (8 per

28 days) AGE (Max

64 Years)

estradiol transdermal patch weekly

0025 mg24 hr 00375 mg24 hr

005 mg24 hr 006 mg24 hr 0075

mg24 hr 01 mg24 hr

(Climara) 1 $0

PA-HRM QL (4 per

28 days) AGE (Max

64 Years)

estradiol vaginal tablet 10 mcg (Vagifem) 1 $0 QL (18 per 28 days)

estradiol valerate intramuscular oil

20 mgml 40 mgml (Delestrogen) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

estradiol-norethindrone acet oral

tablet 05-01 mg 1-05 mg (Activella) 1 $0

PA-HRM AGE (Max

64 Years)

estropipate oral tablet 075 mg 15

mg 3 mg 1 $0

PA-HRM AGE (Max

64 Years)

FEMRING VAGINAL RING 005

MG24 HR 01 MG24 HR 2 $0

QL (1 per 84 days)

lopreeza oral tablet 05-01 mg 1-

05 mg 1 $0

PA-HRM AGE (Max

64 Years)

MENEST ORAL TABLET 03 MG

0625 MG 125 MG 2 $0

PA-HRM AGE (Max

64 Years)

mimvey lo oral tablet 05-01 mg 1 $0 PA-HRM AGE (Max

64 Years)

mimvey oral tablet 1-05 mg 1 $0 PA-HRM AGE (Max

64 Years)

PREMARIN INJECTION RECON

SOLN 25 MG 2 $0

PREMARIN ORAL TABLET 03

MG 045 MG 0625 MG 09 MG

125 MG

PA-HRM AGE (Max

64 Years)

PREMARIN VAGINAL CREAM

0625 MGGRAM 2 $0

PREMPHASE ORAL TABLET

0625 MG (14) 0625MG-5MG(14) 2 $0

PA-HRM AGE (Max

64 Years)

PREMPRO ORAL TABLET 03-

15 MG 045-15 MG 0625-25

MG 0625-5 MG

PA-HRM AGE (Max

64 Years)

raloxifene oral tablet 60 mg (Evista) 1 $0

yuvafem vaginal tablet 10 mcg 1 $0 QL (18 per 28 days)

GlucocorticoidsMineralocorticoids

a-hydrocort injection recon soln 100

mg 1 $0

betamethasone acetsod phos

injection suspension 6 mgml

(Celestone

Soluspan) 1 $0

cortisone oral tablet 25 mg 1 $0 PA BvD

dexamethasone oral elixir 05 mg5

ml 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

dexamethasone oral tablet 05 mg

075 mg 1 mg 15 mg 2 mg 4 mg

PA BvD

injection solution 10 mgml 4 mgml 1 $0

EMFLAZA ORAL SUSPENSION

2275 MGML 2 $0

PA QL (39 per 30

days) NDS

EMFLAZA ORAL TABLET 18

MG 2 $0

PA QL (30 per 30

days) NDS

MG 36 MG 6 MG 2 $0

PA QL (60 per 30

days) NDS

fludrocortisone oral tablet 01 mg 1 $0

hydrocortisone oral tablet 10 mg 20

mg 5 mg (Cortef) 1 $0

PA BvD

KENALOG INJECTION

SUSPENSION 10 MGML 40

methylprednisolone acetate

injection suspension 40 mgml 80

(Depo-Medrol) 1 $0

methylprednisolone oral tablet 16

mg 32 mg 4 mg 8 mg (Medrol) 1 $0

PA BvD

methylprednisolone oral

tabletsdose pack 4 mg (Medrol (Pak)) 1 $0

PA BvD

methylprednisolone sodium succ

injection recon soln 125 mg 40 mg 1 $0

intravenous recon soln 1000 mg (Solu-Medrol) 1 $0

prednisolone sodium phosphate oral

solution 15 mg5 ml (3 mgml) 25

mg5 ml (5 mgml)

PA BvD

solution 5 mg base5 ml (67 mg5

(Pediapred) 1 $0

PA BvD

prednisone oral solution 5 mg5 ml 1 $0 PA BvD

prednisone oral tablet 1 mg 25 mg

5 mg 50 mg 1 $0

PA BvD

prednisone oral tablet 10 mg 1 $0 PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

prednisone oral tablet 20 mg (Deltasone) 1 $0 PA BvD

prednisone oral tabletsdose pack 10

mg 10 mg (48 pack) 5 mg 5 mg

(48 pack)

PA BvD

SOLU-CORTEF (PF) INJECTION

RECON SOLN 100 MG2 ML 2 $0

Pituitary

desmopressin 10 mcg01 ml spr 10

mcgspray (01 ml) (DDAVP) 1 $0

desmopressin injection solution 4

mcgml (DDAVP) 1 $0

desmopressin nasal solution 01

mgml (refrigerate) (DDAVP) 1 $0

desmopressin nasal spraynon-

aerosol 10 mcgspray (01 ml) 1 $0

desmopressin oral tablet 01 mg 02

mg (DDAVP) 1 $0

GENOTROPIN MINIQUICK

MG025 ML

MG025 ML 06 MG025 ML 08

MG025 ML 1 MG025 ML 12

MG025 ML 14 MG025 ML 16

MG025 ML 18 MG025 ML 2

MG025 ML

PA NDS

GENOTROPIN SUBCUTANEOUS

CARTRIDGE 12 MGML (36

UNITML) 5 MGML (15

UNITML)

PA NDS

HUMATROPE INJECTION

CARTRIDGE 12 MG (36 UNIT)

24 MG (72 UNIT) 6 MG (18

PA NDS

HUMATROPE INJECTION

RECON SOLN 5 (15 UNIT) MG 2 $0

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

INCRELEX SUBCUTANEOUS

LUPRON DEPOT-PED (3

MONTH) INTRAMUSCULAR

SYRINGE KIT 30 MG

LUPRON DEPOT-PED

INTRAMUSCULAR KIT 1125

MG 15 MG 75 MG (PED)

NORDITROPIN FLEXPRO

SUBCUTANEOUS PEN

MGML) 15 MG15 ML (10

MGML) 30 MG3 ML (10

PA NDS

NORDITROPIN FLEXPRO

SUBCUTANEOUS PEN

NUTROPIN AQ NUSPIN

SUBCUTANEOUS PEN

MGML) 20 MG2 ML (10

MGML) 5 MG2 ML (25

PA NDS

octreotide acet 100 mcgml syr

outersingle-dose10 100 mcgml (1

octreotide acetate injection solution

1000 mcgml 500 mcgml (Sandostatin) 1 $0

200 mcgml (Sandostatin) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

OMNITROPE SUBCUTANEOUS

CARTRIDGE 10 MG15 ML (67

MGML) 5 MG15 ML (33

PA NDS

SAIZEN CLICKEASY

88 MG151 ML (FINAL CONC)

PA NDS

SAIZEN SUBCUTANEOUS

PA NDS

SANDOSTATIN LAR DEPOT

INTRAMUSCULAR

RECON 10 MG 20 MG 30 MG

SEROSTIM SUBCUTANEOUS

RECON SOLN 4 MG 5 MG 6 MG 2 $0

PA NDS

SIGNIFOR SUBCUTANEOUS

SOLUTION 03 MGML (1 ML)

06 MGML (1 ML) 09 MGML (1

QL (60 per 30 days)

SOMATULINE DEPOT

MG05 ML 60 MG02 ML 90

MG03 ML

QL (1 per 28 days)

SOMAVERT SUBCUTANEOUS

RECON SOLN 10 MG 15 MG 20

MG 25 MG 30 MG

SUPPRELIN LA IMPLANT KIT

50 MG (65 MCGDAY) 2 $0

QL (1 per 360 days)

SYNAREL NASAL SPRAYNON-

AEROSOL 2 MGML 2 $0

TRIPTODUR INTRAMUSCULAR

SUSPENSION FOR

QL (1 per 168 days)

ZOMACTON SUBCUTANEOUS

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ZORBTIVE SUBCUTANEOUS

PA NDS

Progestins

DEPO-PROVERA

INTRAMUSCULAR SOLUTION

400 MGML

QL (10 per 28 days)

hydroxyprogesterone caproate

PA NSO

medroxyprogesterone intramuscular

suspension 150 mgml (Depo-Provera) 1 $0

QL (1 per 84 days)

syringe 150 mgml (Depo-Provera) 1 $0

QL (1 per 84 days)

medroxyprogesterone oral tablet 10

mg 25 mg 5 mg (Provera) 1 $0

megestrol oral suspension 400

mg10 ml (40 mgml) 1 $0

PA-HRM AGE (Max

64 Years)

norethindrone acetate oral tablet 5

mg (Aygestin) 1 $0

progesterone in oil intramuscular

oil 50 mgml 1 $0

progesterone micronized oral

capsule 100 mg 200 mg (Prometrium) 1 $0

Thyroid And Antithyroid Agents

levothyroxine intravenous recon

soln 100 mcg 200 mcg 500 mcg 1 $0

levothyroxine oral tablet 100 mcg

112 mcg 125 mcg 137 mcg 150

300 mcg 50 mcg 75 mcg 88 mcg

(Levo-T) 1 $0

liothyronine oral tablet 25 mcg 5

mcg 50 mcg (Cytomel) 1 $0

methimazole oral tablet 10 mg 5 mg (Tapazole) 1 $0

propylthiouracil oral tablet 50 mg 1 $0

Immunological Agents

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ACTEMRA INTRAVENOUS

MGML) 400 MG20 ML (20

MGML) 80 MG4 ML (20

PA NDS

ACTEMRA SUBCUTANEOUS

PA NDS

ARCALYST SUBCUTANEOUS

ASTAGRAF XL ORAL

24HR 05 MG 1 MG 5 MG

PA BvD

azathioprine oral tablet 50 mg (Imuran) 1 $0 PA BvD

azathioprine sodium injection recon

soln 100 mg 1 $0

PA BvD

CARIMUNE NF NANOFILTERED

12 GRAM 3 GRAM 6 GRAM

PA BvD NDS

CIMZIA POWDER FOR

RECONST SUBCUTANEOUS KIT

400 MG (200 MG X 2 VIALS)

PA NDS

CIMZIA SUBCUTANEOUS

SYRINGE KIT 400 MG2 ML (200

MGML X 2)

PA NDS

cyclosporine intravenous solution

250 mg5 ml (Sandimmune) 1 $0

PA BvD

cyclosporine modified oral capsule

100 mg 25 mg 50 mg (Gengraf) 1 $0

PA BvD

cyclosporine modified oral solution

100 mgml (Gengraf) 1 $0

PA BvD

cyclosporine oral capsule 100 mg

25 mg (Sandimmune) 1 $0

PA BvD

ENBREL SUBCUTANEOUS

PA NDS

ENBREL SUBCUTANEOUS

RECON SOLN 25 MG (1 ML) 2 $0

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ENBREL SUBCUTANEOUS

SYRINGE 25 MG05ML (051) 50

MGML (098 ML)

PA NDS

ENBREL SURECLICK

SUBCUTANEOUS PEN

INJECTOR 50 MGML (098 ML)

PA NDS

ENVARSUS XR ORAL TABLET

075 MG 1 MG 4 MG

PA BvD

FLEBOGAMMA DIF

INTRAVENOUS SOLUTION 10

PA BvD NDS

GAMASTAN SD

15-18 RANGE 15-18 RANGE

(10 ML) 15-18 RANGE (2 ML)

PA BvD

GAMMAGARD LIQUID

INJECTION SOLUTION 10 2 $0

PA BvD NDS

GAMMAGARD S-D (IGA lt 1

MCGML) INTRAVENOUS

RECON SOLN 10 GRAM 5

PA BvD NDS

GAMMAPLEX (WITH

SORBITOL) INTRAVENOUS

SOLUTION 5

PA BvD NDS

GAMMAPLEX INTRAVENOUS

SOLUTION 10 2 $0

PA BvD NDS

gengraf oral capsule 100 mg 25

mg 50 mg 1 $0

PA BvD

gengraf oral solution 100 mgml 1 $0 PA BvD

HUMIRA PEDIATRIC CROHNS

START SUBCUTANEOUS

SYRINGE KIT 40 MG08 ML 40

MG08 ML (6 PACK)

PA NDS

HUMIRA PEN CROHNS-UC-HS

START SUBCUTANEOUS PEN

INJECTOR KIT 40 MG08 ML

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

HUMIRA PEN PSORIASIS-

UVEITIS SUBCUTANEOUS PEN

PA NDS

HUMIRA PEN SUBCUTANEOUS

PEN INJECTOR KIT 40 MG08

PA NDS

HUMIRA SUBCUTANEOUS

MG04 ML 40 MG08 ML

PA NDS

HYPERRAB SD (PF)

150 UNITML 150 UNITML (10

HYQVIA SUBCUTANEOUS

SOLUTION 10 GRAM 100 ML

(10 ) 25 GRAM 25 ML (10 )

20 GRAM 200 ML (10 ) 30

GRAM 300 ML (10 ) 5 GRAM

50 ML (10 )

PA BvD NDS

ILARIS (PF) SUBCUTANEOUS

RECON SOLN 180 MG12 ML

(150 MGML)

PA NDS

IMOGAM RABIES-HT (PF)

150 UNITML

INFLECTRA INTRAVENOUS

PA NDS

KEVZARA SUBCUTANEOUS

MG114 ML

PA QL (228 per 28

days) NDS

KINERET SUBCUTANEOUS

PA QL (1876 per 28

days) NDS

leflunomide oral tablet 10 mg 20

mg (Arava) 1 $0

mycophenolate mofetil hcl

intravenous recon soln 500 mg

(CellCept

Intravenous) 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mycophenolate mofetil oral capsule

250 mg (CellCept) 1 $0

PA BvD

mycophenolate mofetil oral

(CellCept) 1 $0

PA BvD NDS

mycophenolate mofetil oral tablet

PA BvD

mycophenolate sodium oral

tabletdelayed release (drec) 180

mg 360 mg

(Myfortic) 1 $0

PA BvD

NULOJIX INTRAVENOUS

PA BvD NDS

OCTAGAM INTRAVENOUS

SOLUTION 10 5 2 $0

PA BvD NDS

ORENCIA (WITH MALTOSE)

250 MG

PA NDS

ORENCIA CLICKJECT

SUBCUTANEOUS AUTO-

INJECTOR 125 MGML

PA NDS

ORENCIA SUBCUTANEOUS

SYRINGE 125 MGML 50 MG04

ML 875 MG07 ML

PA NDS

OTEZLA ORAL TABLET 30 MG 2 $0 PA QL (60 per 30

days) NDS

OTEZLA STARTER ORAL

(4)-20 MG (4)-30 MG (47) 10 MG

(4)-20 MG (4)-30 MG(19)

PA QL (60 per 30

days) NDS

OTREXUP (PF)

SUBCUTANEOUS AUTO-

INJECTOR 10 MG04 ML 125

MG04 ML 15 MG04 ML 175

MG04 ML 20 MG04 ML 225

MG04 ML 25 MG04 ML

PRIVIGEN INTRAVENOUS

SOLUTION 10 2 $0

PA BvD NDS

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Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PROGRAF INTRAVENOUS

PA BvD

RAPAMUNE ORAL SOLUTION 1

MGML 2 $0

PA BvD NDS

RASUVO (PF) SUBCUTANEOUS

AUTO-INJECTOR 10 MG02 ML

125 MG025 ML 15 MG03 ML

175 MG035 ML 20 MG04 ML

225 MG045 ML 25 MG05 ML

275 MG055 ML 30 MG06 ML

75 MG015 ML

REMICADE INTRAVENOUS

PA NDS

RIDAURA ORAL CAPSULE 3

MG 2 $0

SIMPONI ARIA INTRAVENOUS

PA NDS

SIMPONI SUBCUTANEOUS PEN

MG05 ML

PA NDS

SIMPONI SUBCUTANEOUS

PA NDS

sirolimus oral tablet 05 mg 1 mg (Rapamune) 1 $0 PA BvD

sirolimus oral tablet 2 mg (Rapamune) 1 $0 PA BvD NDS

STELARA INTRAVENOUS

PA NDS

STELARA SUBCUTANEOUS

PA NDS

tacrolimus oral capsule 05 mg 1

mg 5 mg (Prograf) 1 $0

PA BvD

TYSABRI INTRAVENOUS

PA LA QL (15 per 28

days) NDS

XELJANZ ORAL TABLET 5 MG 2 $0 PA QL (60 per 30

days) NDS

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Tier level

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drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

XELJANZ XR ORAL TABLET

PA QL (30 per 30

days) NDS

ZORTRESS ORAL TABLET 025

MG 05 MG 075 MG 2 $0

PA BvD NDS

Vaccines

ACTHIB (PF) INTRAMUSCULAR

RECON SOLN 10 MCG05 ML 2 $0

ADACEL(TDAP

ADOLESNADULT)(PF)

INTRAMUSCULAR

SUSPENSION 2 LF-(25-5-3-5

MCG)-5LF05 ML

ADACEL(TDAP

ADOLESNADULT)(PF)

LF-(25-5-3-5 MCG)-5LF05 ML

BCG VACCINE LIVE (PF)

PERCUTANEOUS SUSPENSION

PA BvD

BEXSERO INTRAMUSCULAR

SYRINGE 50-50-50-25 MCG05

BOOSTRIX TDAP

INTRAMUSCULAR

SUSPENSION 25-8-5 LF-MCG-

LF05ML

BOOSTRIX TDAP

25-8-5 LF-MCG-LF05ML

CERVARIX VACCINE (PF)

20-20 MCG05 ML

DAPTACEL (DTAP PEDIATRIC)

(PF) INTRAMUSCULAR

LF05ML

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Name of Drug

Tier level

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drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ENGERIX-B (PF)

INTRAMUSCULAR

SUSPENSION 20 MCGML

PA BvD

ENGERIX-B (PF)

PA BvD

ENGERIX-B PEDIATRIC (PF)

INTRAMUSCULAR

SUSPENSION 10 MCG05 ML

PA BvD

MCG05 ML

PA BvD

GARDASIL (PF)

INTRAMUSCULAR

SUSPENSION 20-40-40-20

MCG05 ML

GARDASIL 9 (PF)

INTRAMUSCULAR

SUSPENSION 05 ML

GARDASIL 9 (PF)

HAVRIX (PF)

INTRAMUSCULAR

SUSPENSION 1440 ELISA

UNITML 720 ELISA UNIT05

HAVRIX (PF)

1440 ELISA UNITML 720

ELISA UNIT05 ML

HIBERIX (PF)

INTRAMUSCULAR RECON

SOLN 10 MCG05 ML

IMOVAX RABIES VACCINE (PF)

INTRAMUSCULAR RECON

SOLN 25 UNIT

PA BvD

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Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

INFANRIX (DTAP) (PF)

INTRAMUSCULAR

LF05ML

IPOL INJECTION SUSPENSION

40-8-32 UNIT05 ML 2 $0

IPOL INJECTION SYRINGE 40-8-

32 UNIT05 ML 2 $0

IXIARO (PF) INTRAMUSCULAR

KINRIX (PF) INTRAMUSCULAR

SUSPENSION 25 LF-58 MCG-10

LF05 ML

SYRINGE 25 LF-58 MCG-10

LF05 ML

MENACTRA (PF)

INTRAMUSCULAR SOLUTION 4

MCG05 ML

MENHIBRIX (PF)

INTRAMUSCULAR RECON

SOLN 5-25 MCG05 ML

MENOMUNE - ACYW-135 (PF)

SUBCUTANEOUS RECON SOLN

50 MCG

MENOMUNE - ACYW-135

50 MCG

MENVEO A-C-Y-W-135-DIP (PF)

INTRAMUSCULAR KIT 10-5

MCG05 ML

M-M-R II (PF) SUBCUTANEOUS

RECON SOLN 1000-12500

TCID5005 ML

PEDIARIX (PF)

MCG-25LF-25 MCG-10LF05 ML

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Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PEDVAX HIB (PF)

75 MCG05 ML

PENTACEL (PF)

INTRAMUSCULAR KIT 15 LF

UNIT-20 MCG-5 LF05 ML

PENTACEL DTAP-IPV COMPNT

(PF) INTRAMUSCULAR

SUSPENSION 15 LF-48 MCG- 5

LF UNIT05ML

PROQUAD (PF)

FOR RECONSTITUTION

10EXP3-43-3- 399 TCID5005

QUADRACEL (PF)

INTRAMUSCULAR

LF UNIT05ML

RABAVERT (PF)

INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION 25 UNIT

PA BvD

RECOMBIVAX HB (PF)

INTRAMUSCULAR

SUSPENSION 10 MCGML 40

PA BvD

RECOMBIVAX HB (PF)

MCGML 5 MCG05 ML

PA BvD

RECOMBIVAX HB 5 MCG05

ML VL OUTER PF SDV 5

MCG05 ML

PA BvD

ROTARIX ORAL SUSPENSION

FOR RECONSTITUTION 10EXP6

CCID50ML

ROTATEQ VACCINE ORAL

SOLUTION 2 ML 2 $0

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Tier level

What the

drug will

cost you

Necessary Actions

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Limits on Use

SHINGRIX (PF)

INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION 50 MCG05

QL (2 per 365 days)

SHINGRIX GE ANTIGEN

COMPONENT

INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION 50 MCG

QL (2 per 365 days)

TENIVAC (PF)

INTRAMUSCULAR SYRINGE 5-

2 LF UNIT05 ML

TENIVAC VIAL LF PF OUTER

SUV 5 LF UNIT- 2 LF

UNIT05ML

TETANUSDIPHTHERIA TOX

PED(PF) INTRAMUSCULAR

SUSPENSION 5-25 LF UNIT05

TETANUS-DIPHTHERIA

TOXOIDS-TD

INTRAMUSCULAR

TICE BCG INTRAVESICAL

SUSPENSION FOR

PA BvD

TRUMENBA INTRAMUSCULAR

TWINRIX (PF)

INTRAMUSCULAR

SUSPENSION 720 ELISA UNIT -

20 MCGML

TWINRIX (PF)

720 ELISA UNIT -20 MCGML

page number xv

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Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TYPHIM VI INTRAMUSCULAR

SOLUTION 25 MCG05 ML 2 $0

VAQTA (PF) INTRAMUSCULAR

SYRINGE 25 UNIT05 ML 50

UNITML

VARIVAX (PF)

UNIT05 ML

QL (2 per 365 days)

YF-VAX (PF) SUBCUTANEOUS

SUSPENSION FOR

RECONSTITUTION 10 EXP474

UNIT05 ML

ZOSTAVAX (PF)

UNIT065 ML

QL (1 per 365 days)

Inflammatory Bowel Disease

Agents

alosetron oral tablet 05 mg 1 mg (Lotronex) 1 $0 NDS

APRISO ORAL

24HR 0375 GRAM

balsalazide oral capsule 750 mg (Colazal) 1 $0

budesonide oral

capsuledelayedextendrelease 3 mg (Entocort EC) 1 $0

CANASA RECTAL

SUPPOSITORY 1000 MG 2 $0

colocort rectal enema 100 mg60 ml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

DELZICOL ORAL CAPSULE

(WITH DEL REL TABLETS) 400

DIPENTUM ORAL CAPSULE 250

MG 2 $0

ST NDS

hydrocortisone rectal enema 100

mg60 ml (Colocort) 1 $0

LIALDA ORAL

(DREC) 12 GRAM

mesalamine oral tabletdelayed

release (drec) 800 mg (Asacol HD) 1 $0

sulfasalazine oral tablet 500 mg (Azulfidine) 1 $0

sulfasalazine oral tabletdelayed

release (drec) 500 mg

(Azulfidine EN-

tabs) 1 $0

UCERIS RECTAL FOAM 2

MGACTUATION 2 $0

Irrigating Solutions

acetic acid irrigation solution 025

LACTATED RINGERS

IRRIGATION SOLUTION 2 $0

ringers irrigation solution 1 $0

sodium chloride irrigation solution

09 (Sterile Saline) 1 $0

sorbitol irrigation solution 3 33

sorbitol-mannitol urethral solution

27-054 g100 ml 1 $0

water for irrigation sterile

irrigation solution

(Curity Sterile

Water) 1 $0

Metabolic Bone Disease

Agents

Metabolic Bone Disease Agents

alendronate oral solution 70 mg75

ml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

alendronate oral tablet 10 mg 40

mg 5 mg 1 $0

alendronate oral tablet 35 mg 1 $0 QL (4 per 28 days)

alendronate oral tablet 70 mg (Fosamax) 1 $0 QL (4 per 28 days)

calcitonin (salmon) nasal

spraynon-aerosol 200

unitactuation

QL (37 per 28 days)

calcitriol intravenous solution 1

mcgml 1 $0

calcitriol oral capsule 025 mcg 05

mcg (Rocaltrol) 1 $0

calcitriol oral solution 1 mcgml (Rocaltrol) 1 $0

doxercalciferol intravenous solution

4 mcg2 ml (Hectorol) 1 $0

doxercalciferol oral capsule 05

mcg 1 mcg 25 mcg (Hectorol) 1 $0

FORTEO SUBCUTANEOUS PEN

INJECTOR 20 MCGDOSE - 600

MCG24 ML

PA QL (24 per 28

ibandronate intravenous solution 3

mg3 ml 1 $0

QL (3 per 84 days)

ibandronate intravenous syringe 3

mg3 ml (Boniva) 1 $0

QL (3 per 84 days)

ibandronate oral tablet 150 mg (Boniva) 1 $0 QL (1 per 28 days)

MIACALCIN INJECTION

NATPARA SUBCUTANEOUS

CARTRIDGE 100 MCGDOSE 25

MCGDOSE 50 MCGDOSE 75

MCGDOSE

PA QL (2 per 28

days) NDS

PARICALCITOL 10 MCG2 ML

VIAL MDVINNERLATEX-FREE

5 MCGML

paricalcitol hemodialysis port

injection solution 2 mcgml 1 $0

paricalcitol intravenous solution 2

mcgml (Zemplar) 1 $0

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Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PARICALCITOL INTRAVENOUS

SOLUTION 5 MCGML (Zemplar) 1 $0

paricalcitol oral capsule 1 mcg 2

mcg (Zemplar) 1 $0

paricalcitol oral capsule 4 mcg 1 $0

PROLIA SUBCUTANEOUS

QL (1 per 180 days)

RAYALDEE ORAL

24 HR 30 MCG

QL (60 per 30 days)

risedronate oral tablet 150 mg (Actonel) 1 $0 QL (1 per 28 days)

risedronate oral tablet 30 mg 5 mg (Actonel) 1 $0 QL (30 per 30 days)

SENSIPAR ORAL TABLET 30

MG 2 $0

QL (60 per 30 days)

MG 2 $0

QL (60 per 30 days)

MG 2 $0

TYMLOS SUBCUTANEOUS PEN

INJECTOR 80 MCG (3120

MCG156 ML)

PA QL (156 per 30

zoledronic acid intravenous recon

soln 4 mg 1 $0

zoledronic acid intravenous solution

4 mg5 ml (Zometa) 1 $0

zoledronic acid-mannitol-water

intravenous piggyback 5 mg100 ml (Reclast) 1 $0

zoledronic ac-mannitol-09nacl

ZOMETA INTRAVENOUS

Miscellaneous Therapeutic

Agents

Miscellaneous Therapeutic Agents

ACTIMMUNE SUBCUTANEOUS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

amifostine crystalline intravenous

recon soln 500 mg (Ethyol) 1 $0

BENLYSTA INTRAVENOUS

PA NDS

BENLYSTA SUBCUTANEOUS

AUTO-INJECTOR 200 MGML 2 $0

PA QL (4 per 28

days) NDS

PA QL (4 per 28

days) NDS

CETYLEV ORAL TABLET

EFFERVESCENT 25 GRAM 500

CYSTADANE ORAL POWDER 1

GRAM17 ML 2 $0

droperidol injection solution 25

mgml 1 $0

ELMIRON ORAL CAPSULE 100

MG 2 $0

ENDARI ORAL POWDER IN

PACKET 5 GRAM 2 $0

PA QL (180 per 30

days) NDS

ergoloid oral tablet 1 mg 1 $0

EXONDYS 51 INTRAVENOUS

SOLUTION 50 MGML 50

MGML (10 ML)

PA LA NDS

fomepizole intravenous solution 1

gramml 1 $0

guanidine oral tablet 125 mg 1 $0

hydroxyzine pamoate oral capsule

100 mg 1 $0

PA-HRM AGE (Max

64 Years)

25 mg 50 mg (Vistaril) 1 $0

PA-HRM AGE (Max

64 Years)

KEVEYIS ORAL TABLET 50 MG 2 $0 PA QL (120 per 30

days) NDS

leucovorin calcium 100 mg vial

sdvpflatex-free 100 mg 1 $0

latex-free pf sdv 200 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

leucovorin calcium injection recon

soln 100 mg 350 mg 50 mg 1 $0

leucovorin calcium injection

leucovorin calcium oral tablet 10

mg 15 mg 25 mg 5 mg 1 $0

levocarnitine (with sugar) oral

solution 100 mgml (Carnitor) 1 $0

levocarnitine oral tablet 330 mg (Carnitor) 1 $0

LEVOLEUCOVORIN

175 MG

levoleucovorin intravenous recon

soln 50 mg (Fusilev) 1 $0

mesna intravenous solution 100

mgml (Mesnex) 1 $0

MESNEX ORAL TABLET 400

MG 2 $0

MESTINON ORAL SYRUP 60

MG5 ML 2 $0

MINERAL OIL HEAVY (Mineral Oil

Heavy) 4 $0

PROGLYCEM ORAL

pyridostigmine bromide oral tablet

60 mg (Mestinon) 1 $0

extended release 180 mg

(Mestinon

Timespan) 1 $0

ra feminine care douche 4 $0

RENFLEXIS INTRAVENOUS

PA NDS

sb disp douche extra clns vampw 4 $0

summers eve dche-xtra clns

12sextra-cleansing 4 $0

summers eve douche-ultra clns

12s2pkultra clns 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

THALOMID ORAL CAPSULE 100

MG 150 MG 200 MG 50 MG 2 $0

PA NSO QL (60 per

30 days) NDS

THIOLA ORAL TABLET 100 MG 2 $0 NDS

TOTECT INTRAVENOUS

TYBOST ORAL TABLET 150 MG 2 $0 QL (30 per 30 days)

VISTOGARD ORAL GRANULES

QL (24 per 14 days)

XURIDEN ORAL GRANULES IN

PACKET 2 GRAM 2 $0

PA QL (120 per 30

days) NDS

Ophthalmic Agents

Antiglaucoma Agents

acetazolamide oral capsule

extended release 500 mg (Diamox Sequels) 1 $0

acetazolamide oral tablet 125 mg

250 mg 1 $0

acetazolamide sodium injection

ALPHAGAN P OPHTHALMIC

(EYE) DROPS 01 2 $0

betaxolol ophthalmic (eye) drops 05

brimonidine ophthalmic (eye) drops

02 1 $0

carteolol ophthalmic (eye) drops 1

COMBIGAN OPHTHALMIC

(EYE) DROPS 02-05 2 $0

dorzolamide ophthalmic (eye) drops

2 (Trusopt) 1 $0

dorzolamide-timolol ophthalmic

(eye) drops 223-68 mgml (Cosopt) 1 $0

latanoprost ophthalmic (eye) drops

0005 (Xalatan) 1 $0

levobunolol ophthalmic (eye) drops

05 (Betagan) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

LUMIGAN OPHTHALMIC (EYE)

DROPS 001 2 $0

QL (25 per 25 days)

methazolamide oral tablet 25 mg 50

mg (Neptazane) 1 $0

metipranolol ophthalmic (eye) drops

03 1 $0

PHOSPHOLINE IODIDE

pilocarpine hcl ophthalmic (eye)

drops 1 2 4 (Isopto Carpine) 1 $0

SIMBRINZA OPHTHALMIC

(EYE) DROPSSUSPENSION 1-02

timolol maleate ophthalmic (eye)

drops 025 05 (Timoptic) 1 $0

timolol maleate ophthalmic (eye) gel

forming solution 025 05 (Timoptic-XE) 1 $0

TRAVATAN Z OPHTHALMIC

(EYE) DROPS 0004 2 $0

QL (25 per 25 days)

ZIOPTAN (PF) OPHTHALMIC

(EYE) DROPPERETTE 00015 2 $0

QL (30 per 30 days)

Replacement Preparations

calcitrate + vit d caplet 315-250

mg-unit 4 $0

calcitrate 200 mg (950 mg) tab 200

mg (950 mg) 4 $0

calcium 500+d tablet chew 500

mg(1250mg) -400 unit (Calcium 500 + D) 4 $0

calcium 600 + vit d 400 softgl 600

mg(1500mg) -400 unit

(Calcium 600 with

Vitamin D3) 4 $0

calcium 600 + vit d softgel 600

mg(1500mg) -500 unit 4 $0

calcium 600 mg tablet 600 mg

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

calcium 600 mg tablet sf pf 600

mg calcium (1500 mg) (Calcium 600) 4 $0

calcium 600+d softgel 600 mg

calcium- 200 unit 4 $0

calcium 600-vit d3 500 softgel rapid

release sftgl 600 mg(1500mg) -500

(Calcium 600 with

Vitamin D3) 4 $0

calcium carb 1250 mg5 ml sus 500

mg5 ml (1250 mg5 ml) 4 $0

calcium carbonate 648 mg tab 260

mg calcium (648 mg) 4 $0

calcium chloride intravenous

syringe 100 mgml (10 ) 1 $0

calcium cit 315-vit d3 250 tab 315-

250 mg-unit

(Calcitrate-Vitamin

D) 4 $0

calcium citrate - vit d caplet caplet

coated 315-200 mg-unit

(Calcium Citrate +

D) 4 $0

calcium gluconate 500 mg tab 45

mg (500 mg) 4 $0

mg (648 mg) 4 $0

CALCIUM-500 MG TABLET

CHEWABLE SOY FREE YEAST

FREE 500-100 MG-UNIT

CALTRATE 600 + D SOFT CHEW

TAB CHOCOLATE TRUFFLE 600

MG (1500 MG)-800 UNIT

citracal + d maximum caplet 315-

250 mg-unit 4 $0

citrus calcium + d tablet 315-250

mg-unit 4 $0

cvs calcium citrate-vit d cplt caplet

315-250 mg-unit

(Calcitrate-Vitamin

D) 4 $0

cvs calcium citrate-vit d tab 315-250

mg-unit

(Calcitrate-Vitamin

D) 4 $0

cvs magnesium 250 mg tablet 250

mg 4 $0

cvs pediatric electrolyte soln 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cvs pediatric electrolyte soln af pf

d10 -045 sodium chloride

d5 and 09 sodium chloride

dextrose 10 and 02 nacl

dextrose 5 -lactated ringers

dextrose 5-02 sod chloride

dextrose 5-03 sodchloride

dextrose with sodium chloride

intravenous parenteral solution 5-

electrolyte-48 in d5w intravenous

parenteral solution 1 $0

eq calcium citrate-d tablet

sfpfgluten-free 315-250 mg-unit

(Calcitrate-Vitamin

D) 4 $0

gnp calcium 600+d3+min chew tb

pfglutenfyeastf 600 mg calcium-

800 unit-40 mg

hi potency cal 600 mg caplet 600 mg

hm calcium 600+d plus tab chew

gluten-free 600 mg calcium- 800

unit-40 mg

IONOSOL-B IN D5W

SOLUTION 5

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

IONOSOL-MB IN D5W

SOLUTION 5

ISOLYTE-P IN 5 DEXTROSE

SOLUTION 5

ISOLYTE-S INTRAVENOUS

klor-con m10 oral tableter

particlescrystals 10 meq 1 $0

klor-con sprinkle oral capsule

extended release 10 meq 8 meq 1 $0

liquid calcium 600-vit d3 sfgl 600

mg(1500mg) -400 unit 4 $0

liquid calcium 600-vit d3 sfgl

softgelpfgluten-f 600 mg(1500mg)

-500 unit

liquid calcium with vitamin d

softgel sf pf 600 mg calcium- 200

mag delay dr 70 mg tablet 70 mg 4 $0

mag64 dr 64 mg tablet 64 mg 4 $0

mag-g 500 mg tablet 27 mg (500

mg) 4 $0

magnesium 300 mg capsule 300 mg

magnesium sulfate in d5w

magnesium sulfate in water

gram500 ml (4 ) 40 gram1000

ml (4 )

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

intravenous piggyback 2 gram50 ml

(4 ) 4 gram100 ml (4 ) 4

gram50 ml (8 )

magnesium sulfate injection solution

4 meqml (50 ) 1 $0

magnesium sulfate injection syringe

4 meqml 1 $0

natural calcium 500 mg tablet 500

NORMOSOL-M IN 5

DEXTROSE INTRAVENOUS

PARENTERAL SOLUTION

NORMOSOL-R PH 74

SOLUTION

nu-mag 715 mg tablet 715 mg 4 $0

oralyte freezer pops 4 $0

oralyte solution 4 $0

oysco-500 tablet 500 mg calcium

(1250 mg) 4 $0

oyster shell calcium 500 mg tb

500mg elemental ca 500 mg calcium

(1250 mg)

oyster shell calcium-vit d tab 250

(625)-125 mg-unit 4 $0

pediatric electrolyte solution 4 $0

PLASMA-LYTE 148

SOLUTION

PLASMA-LYTE A

SOLUTION

PLASMA-LYTE-56 IN 5

potassium acetate intravenous

solution 2 meqml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

potassium chlorid-d5-045nacl

meql 30 meql 40 meql

potassium chloride in 09nacl

meql 40 meql

potassium chloride in 5 dex

potassium chloride in lr-d5

meql 40 meql

potassium chloride intravenous

piggyback 10 meq100 ml 10

meq50 ml 20 meq100 ml 20

meq100 ml

potassium chloride oral capsule

extended release 10 meq 8 meq

(Klor-Con

Sprinkle) 1 $0

potassium chloride oral liquid 20

meq15 ml 40 meq15 ml 1 $0

potassium chloride oral tablet

extended release 10 meq 20 meq 8

(K-Tab) 1 $0

potassium chloride oral tableter

particlescrystals 10 meq (Klor-Con M10) 1 $0

potassium chloride-045 nacl

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

potassium chloride-d5-02nacl

meql 20 meql 30 meql 40 meql

meql 40 meql

potassium citrate oral tablet

extended release 10 meq (1080 mg) (Urocit-K 10) 1 $0

extended release 15 meq (Urocit-K 15) 1 $0

potassium citrate-citric acid oral

packet 3300-1002 mg (Cytra K Crystals) 1 $0

ra cal 600-vit d3-min chew tab 600

mg calcium- 400 unit-40 mg 4 $0

ra calcium 600 mg tablet pf 600 mg

ra magnesium 250 mg tablet 250 mg

ra pediatric electrolyte soln af 4 $0

ra pediatric freezer pops 4 $0

ringers intravenous parenteral

solution 1 $0

sm calcium citrate-vit d cplt caplet

gluten-free 315-250 mg-unit

(Calcitrate-Vitamin

D) 4 $0

sm magnesium 250 mg tablet 250

mg 4 $0

sm pediatric electrolyte soln 4 $0

sodium acetate intravenous solution

2 meqml 1 $0

sodium chloride 045 intravenous

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

sodium chloride 100 meq40 ml

25s sdv 25 meqml 1 $0

sodium chloride intravenous

parenteral solution 25 meqml 1 $0

sodium lactate intravenous solution

5 meqml 1 $0

sodium phosphate intravenous

solution 3 mmolml 1 $0

TPN ELECTROLYTES II IV

SOLN 25S20ML50ML FTV 18-

18-5-45-35 MEQ20 ML

TPN ELECTROLYTES

INTRAVENOUS SOLUTION 35-

20-5 MEQ20 ML

Respiratory Tract Agents

Anti-Inflammatories Inhaled

Corticosteroids

ADVAIR DISKUS INHALATION

BLISTER WITH DEVICE 100-50

MCGDOSE 250-50 MCGDOSE

500-50 MCGDOSE

QL (60 per 30 days)

ADVAIR HFA INHALATION

HFA AEROSOL INHALER 115-21

MCGACTUATION 230-21

MCGACTUATION 45-21

MCGACTUATION

QL (12 per 28 days)

ARNUITY ELLIPTA

DEVICE 100 MCGACTUATION

200 MCGACTUATION

QL (30 per 30 days)

BREO ELLIPTA INHALATION

QL (60 per 30 days)

budesonide inhalation suspension

for nebulization 025 mg2 ml 05

mg2 ml 1 mg2 ml

(Pulmicort) 1 $0

PA BvD

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Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

DULERA INHALATION HFA

AEROSOL INHALER 100-5

MCGACTUATION 200-5

MCGACTUATION

QL (13 per 28 days)

FLOVENT DISKUS

50 MCGACTUATION

QL (60 per 30 days)

FLOVENT DISKUS

FLOVENT HFA INHALATION

HFA AEROSOL INHALER 110

MCGACTUATION

QL (12 per 28 days)

MCGACTUATION

QL (24 per 28 days)

MCGACTUATION

QVAR INHALATION AEROSOL

40 MCGACTUATION 2 $0

SYMBICORT 160-45 MCG

INHALER 60 INHALATIONS 160-

45 MCGACTUATION

QL (12 per 25 days)

SYMBICORT INHALATION HFA

MCGACTUATION 80-45

MCGACTUATION

QL (11 per 25 days)

Antileukotrienes

montelukast oral granules in packet

4 mg (Singulair) 1 $0

montelukast oral tablet 10 mg (Singulair) 1 $0

montelukast oral tabletchewable 4

mg 5 mg (Singulair) 1 $0

zafirlukast oral tablet 10 mg 20 mg (Accolate) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Bronchodilators

albuterol sulfate inhalation solution

mg3 ml 25 mg 3 ml (0083 ) 5

PA BvD

albuterol sulfate oral syrup 2 mg5

ml 1 $0

albuterol sulfate oral tablet

extended release 12 hr 4 mg 8 mg 1 $0

ANORO ELLIPTA INHALATION

MCGACTUATION

QL (60 per 30 days)

ATROVENT HFA INHALATION

MCGACTUATION

COMBIVENT RESPIMAT

INHALATION MIST 20-100

MCGACTUATION

QL (8 per 30 days)

FORADIL AEROLIZER

INHALATION CAPSULE

WINHALATION DEVICE 12

QL (60 per 30 days)

INCRUSE ELLIPTA

ipratropium bromide inhalation

solution 002 1 $0

PA BvD

levalbuterol tartrate inhalation hfa

aerosol inhaler 45 mcgactuation (Xopenex HFA) 1 $0

QL (30 per 30 days)

metaproterenol oral syrup 10 mg5

ml 1 $0

metaproterenol oral tablet 10 mg

20 mg 1 $0

PROAIR HFA INHALATION HFA

AEROSOL INHALER 90

MCGACTUATION

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Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PROAIR RESPICLICK

INHALATION AEROSOL

POWDR BREATH ACTIVATED

90 MCGACTUATION

SEREVENT DISKUS

DEVICE 50 MCGDOSE

QL (60 per 30 days)

SPIRIVA RESPIMAT

INHALATION MIST 125

MCGACTUATION 25

MCGACTUATION

SPIRIVA WITH HANDIHALER

INHALATION CAPSULE

STIOLTO RESPIMAT

MCGACTUATION

QL (4 per 28 days)

STRIVERDI RESPIMAT

INHALATION MIST 25

MCGACTUATION

QL (4 per 28 days)

terbutaline oral tablet 25 mg 5 mg 1 $0

terbutaline subcutaneous solution 1

mgml 1 $0

theophylline in dextrose 5

mg100 ml 200 mg50 ml 400

mg250 ml 400 mg500 ml 800

mg250 ml

theophylline oral solution 80 mg15

ml 1 $0

theophylline oral tablet extended

(Theochron) 1 $0

release 24 hr 400 mg 600 mg 1 $0

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Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TRELEGY ELLIPTA

DEVICE 100-625-25 MCG

Respiratory Tract Agents Other

acetylcysteine intravenous solution

200 mgml (20 ) (Acetadote) 1 $0

PA BvD

acetylcysteine solution 100 mgml

(10 ) 200 mgml (20 ) 1 $0

PA BvD

CINQAIR INTRAVENOUS

PA NDS

cromolyn inhalation solution for

nebulization 20 mg2 ml 1 $0

PA BvD

cromolyn sodium nasal spray 52

mgspray (4 )

(Nasal Allergy

Symptom Control) 4 $0

DALIRESP ORAL TABLET 500

MCG 2 $0

QL (30 per 30 days)

ESBRIET ORAL CAPSULE 267

MG 2 $0

PA QL (270 per 30

days) NDS

ESBRIET ORAL TABLET 267 MG 2 $0 PA QL (270 per 30

days) NDS

FASENRA SUBCUTANEOUS

PA QL (1 per 28

days) NDS

KALYDECO ORAL GRANULES

IN PACKET 50 MG 75 MG 2 $0

PA QL (60 per 30

days) NDS

KALYDECO ORAL TABLET 150

MG 2 $0

PA QL (60 per 30

days) NDS

NUCALA SUBCUTANEOUS

PA LA QL (1 per 28

days) NDS

OFEV ORAL CAPSULE 100 MG

150 MG 2 $0

PA QL (60 per 30

days) NDS

ORKAMBI ORAL TABLET 100-

125 MG 200-125 MG 2 $0

PA QL (120 per 30

days) NDS

PROLASTIN-C INTRAVENOUS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

sodium chloride 09 inhal vl u-d

suv pf (rx) 09 3 $0

XOLAIR SUBCUTANEOUS

PA NDS

Skeletal Muscle Relaxants

baclofen oral tablet 10 mg 20 mg 1 $0

carisoprodol oral tablet 250 mg

350 mg (Soma) 1 $0

PA-HRM QL (120 per

30 days) AGE (Max

64 Years)

chlorzoxazone oral tablet 500 mg 1 $0 PA-HRM AGE (Max

64 Years)

cyclobenzaprine oral tablet 10 mg 5

mg 1 $0

PA-HRM AGE (Max

64 Years)

dantrolene oral capsule 100 mg 1 $0

dantrolene oral capsule 25 mg 50

mg (Dantrium) 1 $0

methocarbamol oral tablet 500 mg (Robaxin) 1 $0 PA-HRM AGE (Max

64 Years)

methocarbamol oral tablet 750 mg (Robaxin-750) 1 $0 PA-HRM AGE (Max

64 Years)

revonto intravenous recon soln 20

mg 1 $0

tizanidine oral tablet 2 mg 1 $0

tizanidine oral tablet 4 mg (Zanaflex) 1 $0

Sleep Disorder Agents

armodafinil oral tablet 150 mg 200

mg 250 mg 50 mg (Nuvigil) 1 $0

BELSOMRA ORAL TABLET 10

MG 15 MG 20 MG 5 MG 2 $0

QL (30 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

eszopiclone oral tablet 1 mg 2 mg

3 mg (Lunesta) 1 $0

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any non-

benzodiazepine

per 30 days) AGE

(Max 64 Years)

HETLIOZ ORAL CAPSULE 20

MG 2 $0

PA QL (30 per 30

days) NDS

SILENOR ORAL TABLET 3 MG

6 MG 2 $0

QL (30 per 30 days)

XYREM ORAL SOLUTION 500

MGML 2 $0

LA QL (540 per 30

days) NDS

zaleplon oral capsule 10 mg 5 mg (Sonata) 1 $0

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any non-

benzodiazepine

per 30 days) AGE

(Max 64 Years)

zolpidem oral tablet 10 mg 5 mg (Ambien) 1 $0

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any non-

benzodiazepine

per 30 days) AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Vasodilating Agents

ADCIRCA ORAL TABLET 20 MG 2 $0 PA QL (60 per 30

days) NDS

ADEMPAS ORAL TABLET 05

MG 1 MG 15 MG 2 MG 25 MG 2 $0

PA QL (90 per 30

days) NDS

epoprostenol (glycine) intravenous

recon soln 05 mg (Flolan) 1 $0

PA NDS

LETAIRIS ORAL TABLET 10

MG 5 MG 2 $0

PA QL (30 per 30

days) NDS

OPSUMIT ORAL TABLET 10 MG 2 $0 PA QL (30 per 30

days) NDS

ORENITRAM ORAL TABLET

EXTENDED RELEASE 0125 MG 2 $0

EXTENDED RELEASE 025 MG

1 MG 25 MG 5 MG

PA NDS

REMODULIN INJECTION

SOLUTION 1 MGML 10

MGML 25 MGML 5 MGML

PA NDS

sildenafil (antihypertensive)

intravenous solution 10 mg125 ml (Revatio) 1 $0

PA QL (375 per 1

day) NDS

sildenafil (antihypertensive) oral

tablet 20 mg (Revatio) 1 $0

PA QL (90 per 30

TRACLEER ORAL TABLET 125

MG 625 MG 2 $0

PA LA QL (60 per 30

days) NDS

TRACLEER ORAL TABLET FOR

PA QL (112 per 28

days) NDS

TYVASO INHALATION

SOLUTION FOR

(06 MGML)

PA NDS

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Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

UPTRAVI ORAL TABLET 1000

MCG 1200 MCG 1400 MCG

1600 MCG 400 MCG 600 MCG

800 MCG

PA QL (60 per 30

days) NDS

MCG 2 $0

PA QL (240 per 30

days) NDS

UPTRAVI ORAL

TABLETSDOSE PACK 200 MCG

(140)- 800 MCG (60)

PA QL (400 per 365

days) NDS

Vitamins And Minerals

a thru z advanced formula tab

gluten-free 18-400 mg-mcg 4 $0

a thru z advanced formula tab new

formula 4 $0

a thru z advanced formula tab w

lutein amp lycopene 18-500-300-250

mg-mcg-mcg-mcg

a thru z select 50+ formula tb

advanced formula 04-300-250 mg-

mcg-mcg

a thru z select men 50+ tablet 300-

600-300 mcg 4 $0

a thru z select multivit tab 500-300-

250 mcg 4 $0

a thru z select tablet adults

50+iron-free 04-300-250 mg-mcg-

a thru z select tablet new

formulation 4 $0

a thru z select womens tablet 4 $0

abc plus tablet 04-300-250 mg-

mcg-mcg 4 $0

adult multi gummies 200 mcg 4 $0

adult multivitamin gummies

assorted flavors 200 mcg 4 $0

adult one daily gummies 200 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

adults 50 plus multivitamin tb 04-

300-250 mg-mcg-mcg 4 $0

animal chews tablet 4 $0

antioxidant softgel softgel 4 $0

apatate forte liquid 4 $0

b complete tablet 4 $0

b complex capsule (Super B-50

Complex) 4 $0

b complex formula 1 tablet 4 $0

b complex tablet 4 $0

b-12 500 mcg tablet 500 mcg 4 $0

b-12 dots 500 mcg tablet 500 mcg 4 $0

baby ddrops 400 unitdrop 400

unitdrop 4 $0

baby vitamin d3 400 unitdrop 400

unit02 ml 4 $0

balance b-100 tablet 4 $0

balance b-50 tablet innerpfglutenf

balanced b-100 tablet 4 $0

balanced b-100 tablet 100 mg 4 $0

balanced b-complex caplet pfno-

lactose 400 mcg 4 $0

b-complex plus vitamin c cplt caplet

(Super B Complex-

Vitamin C) 4 $0

b-complex tablet 04 mg (B Complex 100) 4 $0

b-complex with b12 tablet 4 $0

b-complex with c tablet (Super B Complex-

Vitamin C) 4 $0

b-complex with vit c caplet

sfpfgluten-free 400 mcg 4 $0

bee-zee tablet 4 $0

biosupp liquid 4 $0

biotin 300 mcg tablet sfpflactose-

free 300 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

biovol syrup 4 $0

calcarb 600 w-vitamin d tab 600

mg(1500mg) -200 unit 4 $0

calcidol drops 8000 unitml 4 $0

calcium 1000 + d3 caplet 1000

mg(2500 mg)-800 unit 4 $0

calcium 250-vit d3 125 tablet 250-

125 mg-unit

(Oyster Shell +

D3) 4 $0

calcium 500-vit d3 600 tablet 500mg

(1250mg) -600 unit (Os-Cal 500 + D3) 4 $0

calcium 600 + vit d 400 caplet sf

pf caplet 600 mg(1500mg) -400

calcium 600 + vit d tablet 600-125

mg-unit 4 $0

calcium 600-vit d3 200 tablet 600

mg(1500mg) -200 unit 4 $0

(Calcium 600 +

D(3)) 4 $0

calcium 600-vit d3 800 tablet pf

sfgluten-free 600 mg(1500mg) -

800 unit

(Caltrate with

Vitamin D3) 4 $0

centamin liquid 9 mg iron15 ml 4 $0

central-vite seniors tablet 4 $0

centram-care multivit-min liq 9 mg

iron15 ml 4 $0

centravites 50 plus tablet 4 $0

centravites 50 plus tablet outer 04-

300-250 mg-mcg-mcg 4 $0

centrum adults tablet 18-400 mg-

mcg 4 $0

centrum complete multivit tab 18-

400 mg-mcg 4 $0

centrum multivit-mineral liq 9 mg

iron15 ml 4 $0

centrum silver tablet for adult 50+

04-300-250 mg-mcg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

centrum women tablet 18-400 mg-

mcg 4 $0

century tablet adults under 50 18-

400 mg-mcg 4 $0

century ultimate mens tablet 300-

600-300 mcg 4 $0

century ultimate womens tab 18-

400 mg-mcg 4 $0

cerovite advanced form tab 18-400

mg-mcg 4 $0

cerovite jr tablet chew 4 $0

cerovite liquid 9 mg iron15 ml 4 $0

cerovite senior tablet 4 $0

certavite sr-antioxidant tab 04-300-

250 mg-mcg-mcg 4 $0

certavite-antioxidant liquid 9 mg

iron15 ml 4 $0

certavite-antioxidant tablet 18-400

mg-mcg 4 $0

chewable-vite tablet 4 $0

chew-vites-iron tablet chew 4 $0

child chew + iron tab chew 4 $0

child chew vitamin tablet 4 $0

child ferrous sulfate 15 mgml 15

mg iron (75 mg)ml (Childrens Iron) 4 $0

child multivitamin plus iron 18 mg

iron 4 $0

childrens chew vitamin tab 4 $0

childrens chewable vitamin 4 $0

childrens multivit tab chew 4 $0

childrens vit-iron tab chew 4 $0

compete tablet 4 $0

complete multi 50+ tablet 500-300-

250 mcg 4 $0

complete multi tablet 18-500-300-

250 mg-mcg-mcg-mcg 4 $0

complete multivitamin tab 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

complete senior tablet 4 $0

cvs b-1 100 mg tablet pf sfgluten-

free 100 mg 4 $0

cvs bal b-100 tablet 4 $0

cvs b-complex-vit c caplet caplet (Super B Complex-

Vitamin C) 4 $0

cvs calcium 500 + vit d tablet oyster

shell 500 mg(1250mg) -125 unit 4 $0

cvs calcium 500-vit d3 200 tab sf

pf 500 mg(1250mg) -200 unit 4 $0

cvs calcium 600-vit d3 800 tab pf

800 unit

(Caltrate with

Vitamin D3) 4 $0

cvs child vit-mineral tab 4 $0

cvs childs vitamin-iron tb 4 $0

cvs daily gummies pf gluten-free

200 mcg 4 $0

cvs daily multiple tablet 4 $0

cvs daily multiple tablet for women

cvs iron 27 mg tablet 240 mg (27 mg

iron) 4 $0

cvs iron 65 mg tablet

sfpflactosefree 325 mg (65 mg

cvs mens daily gummies pf gluten-

free 200 mcg 4 $0

cvs mens multi-vit tablet 4 $0

cvs prenatal vitamin tablet 4 $0

cvs spectravite adult 50+ tabs 04-

300-250 mg-mcg-mcg 4 $0

cvs spectravite adult gummy 200

mcg 4 $0

cvs spectravite advanced tab 18-400

mg-mcg 4 $0

cvs spectravite senior tab 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cvs spectravite ultra mens tb 300-

600-300 mcg 4 $0

cvs spectravite ultra women tb 18-

400 mg-mcg 4 $0

cvs super b complx amp c cplt caplet

pf 4 $0

cvs vitamin c 1000 mg tb chw 1000

mg 4 $0

cvs vitamin d3 400 unitdrop 400

unitdrop (Baby Ddrops) 4 $0

cvs vitamin d3 400unitml drop

infants wdropper 400 unitml (D-Vi-Sol) 4 $0

cvs womens daily gummies pf

gluten-free 200 mcg 4 $0

cyanocobalamin 1000 mcgml

outerlatex-free 1000 mcgml (Vitamin B-12) 3 $0

d3 dots 2000 unit tablet pf 2000

unit 4 $0

daily multi vitamin-iron tab 4 $0

daily multiple tablet 18-400 mg-mcg

daily multiple vitamin tab sugar

coated 4 $0

daily multivitamin-iron tablet 18-

400 mg-mcg 4 $0

daily value multivitamin tab sf

lactose-free 4 $0

daily vitamin + iron tablet 4 $0

daily vitamin formula tablet 4 $0

daily vitamin formula-iron tab 18-

400 mg-mcg 4 $0

daily vite tablet sf pf 4 $0

daily vite tablet sfpf 4 $0

daily vite with iron tablet 4 $0

daily-vite tablet 4 $0

daily-vites with iron tablet 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

delta d3 400 unit tablet lactose free

sf 400 unit 4 $0

dino-life extra c tab chew 4 $0

dino-life iron-zinc tb chew 4 $0

dino-life tablet chewable 4 $0

d-vi-sol 400 unitsml drop 400

unitml 4 $0

eldertonic elixir 05-06-7-07 mg 4 $0

ellis tonic 4 $0

endur-amide sr 500 mg tablet 500

mg 4 $0

ENDUR-AMIDE SR 750 MG

TABLET 750 MG 4 $0

eq child complete chew tablet 18 mg

iron 4 $0

eq complete multivitamin tab 04-

300-250 mg-mcg-mcg 4 $0

eq complete multivitamin tab gluten-

free 18-400 mg-mcg 4 $0

eq one daily mens tablet gluten free

400-20-300 mcg 4 $0

eql central-vite tablet 04-300-250

mg-mcg-mcg 4 $0

eql century mature tablet 400-30

mcg 4 $0

eql eye health plus lutein tab 1000

unit-200 mg-60 unit-2 mg 4 $0

eql iron supplement 325 mg tab

coated 325 mg (65 mg iron) 4 $0

eql one daily mens tablet 4 $0

ergocalciferol 8000 unitsml 8000

unitml (Calcidol) 4 $0

essentia tablet 18-400 mg-mcg 4 $0

essential balance tablet 4 $0

essential daily tablet wiron amp

calcium 18-04 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

feosol 65 mg tablet 325 mg (65 mg

iron) 4 $0

ferate 27 mg tablet 240 mg (27 mg

iron) 4 $0

ferocon capsule 110-05 mg 3 $0

ferretts 325 mg tablet 325 mg (106

mg iron) 4 $0

ferrex 150 capsule outer u-d 150

mg iron 4 $0

ferrex 150 plus capsule 150-50-50

mg 4 $0

ferric x-150 capsule 150 mg iron 4 $0

ferrocite tablet 324 mg (106 mg

iron) 4 $0

ferrous fumarate 324 mg tab 324 mg

(106 mg iron) (Ferrocite) 4 $0

ferrous gluconate 240 mg tab

240mg=27mg elemental 240 mg (27

mg iron)

(Ferate) 4 $0

ferrous gluconate 324 mg tab 324

mg (36 mg iron) 324 mg (375 mg

iron) 324 mg (38 mg iron)

ferrous gluconate 325 mg tab sugar

ferrous sulf 220 mg5 ml elix 220 mg

(44 mg iron)5 ml (FeroSul) 4 $0

ferrous sulf 300 mg5 ml liq 300 mg

(60 mg iron)5 ml 4 $0

ferrous sulf ec 324 mg tablet 324 mg

(65 mg iron) 4 $0

ferrous sulfate 325 mg tablet

pfsfgluten-free 325 mg (65 mg

(Feosol) 4 $0

flintstones complete tablet 4 $0

flintstones extra c tab chew 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

flintstones tablet chewable 4 $0

flintstones with iron tab chew 18 mg

iron 4 $0

fluoride (sodium) oral tablet 1 mg

(22 mg sod fluoride) 1 $0

folic acid 1 mg tablet (rx) 1 mg 3 $0

folic acid 1000 mcg tablet pfsf

(otc) 1 mg 4 $0

folic acid 400 mcg tablet

sfpflactose-free 400 mcg 4 $0

fosfree tablet 1755-145 mg 4 $0

geriaton liquid 4 $0

gnp century mature tablet gluten-

free 04-300-250 mg-mcg-mcg 4 $0

gnp century tablet adults 50+ 04-

300-250 mg-mcg-mcg 4 $0

gnp one daily essential tablet 4 $0

gummi bear multivit tab chew

multivit amp minerals 4 $0

hair vitamins 4 $0

hemocyte tablet u-ublister pk 324

mg (106 mg iron) 4 $0

hi-b complex tablet 4 $0

hm animal shapes complete chew

childs w choline 18 mg iron 4 $0

hm complete 50+ tablet 04-300-250

mg-mcg-mcg 4 $0

hm complete women tablet 18-400

mg-mcg 4 $0

hm one daily with iron tablet gluten-

free 18-400 mg-mcg 4 $0

hm super vitamin b complex gluten-

free 400 mcg 4 $0

honey bears chew tab 4 $0

honey bears-iron-zinc tab chew 4 $0

icaps plus tablet lactose free 4 $0

iferex 150 capsule 150 mg iron 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

iron 27 mg tablet 236 mg (27 mg

iron) 4 $0

kenwood therapeutic liquid 4 $0

kids multivitamin complete tab 18

mg iron 4 $0

kobee tablet 04 mg 4 $0

kpn tablet 4 $0

kro prenatal vitamins tablet 28-800

mg-mcg 4 $0

life-pack womens pfsf 08 mg 4 $0

liquid c 500 mg5 ml liquid 500

mg5 ml 4 $0

little animals child tb chw 4 $0

little animals-iron tab chew 4 $0

lysiplex plus liquid 4 $0

MACUVITE EYE CARE TABLET

7160 UNIT-113 MG-100 UNIT 4 $0

mega multivitamin-mineral tab 4 $0

mega multivit-chelated min tab 4 $0

mens multivitamin gummies 200

mcg 4 $0

MEPHYTON 5 MG TABLET 5

MG 3 $0

milltrium senior multivit tab 4 $0

multi complete-iron tablet 18-400

mg-mcg 4 $0

multi for her tablet 18 mg iron-600

mcg-80 mcg 4 $0

multi-day plus iron tablet 18-400

mg-mcg 4 $0

multi-delyn liquid sfaf 4 $0

multi-delyn with iron liquid 10 mg

iron5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

multilex tablet 4 $0

multilex-t-m-minerals tab 4 $0

multiple vitamin with iron tab (Daily Multi-

VitaminsIron) 4 $0

multiple vitamin w-minerals tb 4 $0

multiple vitamins tablet one daily 4 $0

multivitamin child tab chew (ANIMAL

CHEWS) 4 $0

multi-vitamin daily tablet 4 $0

multivitamin-mineral liquid 9 mg

iron15 ml 4 $0

multivitamins tablet (Daily Multi-

Vitamin) 4 $0

multivit-fluor 025 mgml drop (otc)

025 mgml 4 $0

multivit-iron child tab chew

childrens 4 $0

multivit-mineral hp cap 4 $0

multivit-minerals tablet (Bee-Zee) 4 $0

multivit-minerals tablet sfpf (Bee-Zee) 4 $0

my favorite multiple liquid 4 $0

myvitalife soft-gel capsule 4 $0

NASCOBAL 500 MCG NASAL

SPRAY OUTER 500 MCGSPRAY

nephplex rx tablet 1-60-300-125

mg-mg-mcg-mg 3 $0

nephron fa tablet 666-75-1 mg 3 $0

nephro-vite rx tablet 1-60-300 mg-

mg-mcg 3 $0

niacinamide er 500 mg tablet 500

mg (Endur-amide) 4 $0

nu-iron 150 capsule 150 mg iron 4 $0

ocutabs tablet sf wlutein 4 $0

onccor tablet 200-10-10 mcg 4 $0

once daily tablet 4 $0

once daily with iron tablet 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

oncovite tablet 4 $0

one daily complete tablet 4 $0

one daily complete tablet 18-04 mg

one daily essential tablet 4 $0

one daily for women tablet 18-04

mg 4 $0

one daily gummy vites gummie 200

mcg 4 $0

one daily maximum tablet 18-04 mg

one daily multivitamin tab 4 $0

one daily multivitamin tablet 4 $0

one daily multivitamin-iron tb 18-

400 mg-mcg 4 $0

one daily plus iron tablet 18-400

mg-mcg 4 $0

one daily tablet 4 $0

one daily tablet mens formula 4 $0

one daily with minerals tablet 4 $0

one-a-day essential tablet 4 $0

one-a-day max formula tab 4 $0

one-a-day mens tablet 400-20-300

mcg 4 $0

one-a-day teen advantage tab 18-

400 mg-mcg 4 $0

one-a-day teen advantage tab 9 mg

iron-400 mcg 4 $0

oysco 500-vit d3 200 tablet 500

mg(1250mg) -200 unit 4 $0

oyster shell 500-vit d3 200 tb 500

mg(1250mg) -200 unit 4 $0

oyster shell calcium tablet 500

mg(1250mg) -400 unit 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

oyster shell calcium-vit d tab

pfsfgluten-free 500 mg(1250mg)

-400 unit

oystercal-d 500 mg-400 unit tb 500

mg(1250mg) -400 unit 4 $0

perry prenatal capsule 135-04 mg

pharmacist multi-vite tab 4 $0

phytonadione 1 mg05 ml syr latex-

free pfsdv 1 mg05 ml 3 $0

pnv prenatal plus multivit tab sf

gluten-free 27 mg iron- 1 mg 2 $0

ALL RX PRENATAL

VITAMINS

COVERABLE

UNDER PART D

poly-iron 150 mg capsule 150 mg

iron 4 $0

poly-vita drops 1500-35-400 unit-

mg-unitml 4 $0

poly-vita with iron drops 1500 unit-

400 unit-10 mgml 4 $0

poly-vitamin drops 1500-35-400

unit-mg-unitml 4 $0

poly-vitamin tab chew 4 $0

polyvitamin w-iron drops 1500

unit-400 unit-10 mgml 4 $0

polyvitamin with iron tab chew 4 $0

prenatal formula tablet 28 mg iron-

800 mcg 4 $0

prenatal multivitamin tablet 28 mg

iron- 800 mcg 4 $0

prenatal tablet (otc) 27 mg iron- 08

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

prenatal tablet 27 mg iron- 800 mcg

(Prenatal) 4 $0

(Prenatal Tablet) 4 $0

prenatal tablet outer (otc) 27 mg

iron- 08 mg 4 $0

prenatal vitamin plus low iron oral

tablet 27 mg iron- 1 mg 2 $0

ALL RX PRENATAL

VITAMINS

COVERABLE

UNDER PART D

prenatal vitamin tablet 27 mg iron-

800 mcg 4 $0

prenatal vitamins tablet phosphorus

free 28 mg iron- 800 mcg 4 $0

prosight tablet 5000-60-30 unit-mg-

unit 4 $0

pub multivitamin 50 plus tab 4 $0

pyridoxine 100 mgml vial 25s 100

mgml 3 $0

pyridoxine 250 mg tablet 250 mg (Vitamin B-6) 4 $0

qc child complete vit chew tab 18

mg iron 4 $0

qc childrens chewable tablet 4 $0

qc maximum daily multivit tab 18-

04 mg 4 $0

QUFLORA 0125 MG GUMMIES

0125 MG FLUORIDE 4 $0

ra balanced b-100 tablet 04 mg 4 $0

ra b-complex tablet pf 4 $0

ra b-complex tablet pf (B Complex 1) 4 $0

ra central-vite senior tablet 04-300-

250 mg-mcg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ra central-vite tablet 18-400 mg-

mcg 4 $0

ra hi-cal plus vitamin d tab 500

mg(1250mg) -200 unit 4 $0

ra one daily energy tablet 4 $0

ra one daily maximum tablet 18-04

mg 4 $0

ra one daily plus iron tablet 4 $0

ra one daily tablet pf 4 $0

ra oyster shell 500-vit d3 200

naturalpf 500 mg(1250mg) -200

ra prenatal tablet 28 mg iron- 800

mcg 4 $0

ra therapeutic m multivit tab 18-04

mg 4 $0

ra vit b-12 1000 mcgml liq 1000

mcgml 4 $0

ra vitamin b-12 1000 mcg tab

timed-release 1000 mcg (Vitamin B-12) 4 $0

ra vitamin c 1000 mg tab sa

wbioflavonoids 1000 mg 4 $0

ra vitamin c 1000 mg tablet

pfsfnatural 1000 mg 4 $0

ra vitamin c 500 mg tab chew pf

500 mg 4 $0

ra vitamin c tr 500 mg caplet

capletpfsf 500 mg 4 $0

ra vitamin d3 1000 unit tab

sfglutenfyeastf 1000 unit 4 $0

rena-vite rx tablet 1-60-300 mg-mg-

mcg 3 $0

right step prenatal vit tab 27 mg

iron- 08 mg 4 $0

scooby-doo one a day tablet 4 $0

senior tabs 04-300-250 mg-mcg-

mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

sentry multivit amp mineral cplt 18-

500-300-250 mg-mcg-mcg-mcg 4 $0

sentry senior multivitamin tab

sodiumfyeastf 500-300-250 mcg 4 $0

sentry senior tablet 04-300-250 mg-

mcg-mcg 4 $0

sentry tablet 18-400 mg-mcg 4 $0

sm animal shapes complete chew

gluten-free 18 mg iron 4 $0

sm animal shapes tab chew (ANIMAL

CHEWS) 4 $0

sm animal shapes tab chew toddlers

sm animal shapes w-iron tab

chewable 4 $0

sm b complex with vit c tablet

gluten-free

(Super B Complex-

Vitamin C) 4 $0

sm balanced b-50 tablet 4 $0

sm complete multi-vit-mineral

advanced formula 18-400 mg-mcg 4 $0

sm complete senior formula tab 4 $0

sm complete senior formula tab 04-

300-250 mg-mcg-mcg 4 $0

sm complete tablet 27-04 mg 4 $0

sm hair skin and nails caplet caplet

gluten-free 4 $0

sm multivitamin w-iron tab (Daily Multi-

VitaminsIron) 4 $0

sm multivitamins tablet (Daily Multi-

Vitamin) 4 $0

sm natural balanced b-100 tab 100

mg 4 $0

sm one daily multivitamin tab 400

mcg 4 $0

sm prenatal vitamins tablet 28 mg

iron- 800 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

sm super b complex-c caplet caplet

sm therapeutic m tablet 27-04 mg 4 $0

sm ultimate mens complete tab 300-

600-300 mcg 4 $0

sm vitamin b complex tablet gluten-

free 04 mg (B Complex 100) 4 $0

sm vitamin b-100 complex tab

gluten-free 04 mg 4 $0

sm vitamin d3 4000 unit sftgl

softgel gluten-free 4000 unit 4 $0

sodium fluoride 05 mgml drop df

sfgluten-free 05 mg (11 mg

sodfluorid)ml

stress b tablet 4 $0

stress b with zinc tablet 4 $0

stress formula tablet 4 $0

stress formula with iron tab 4 $0

stress formula with iron tab 500 mg-

400 mcg- 18 mg iron 4 $0

400 mcg- 27 mg iron 4 $0

stress formula with zinc tab 4 $0

stress-c tablet 4 $0

stress-c with iron tablet 500 mg-400

mcg- 18 mg iron 4 $0

sunvite tablet 18 mg iron-400 mcg-

25 mcg 4 $0

super b complex tablet pf 400 mcg

super b maxi complex caplet 04 mg

super b with vit c capsule 4 $0

super b-50 complex capsule 4 $0

super b-50 complex plus tab 4 $0

super calcium 600-vit d3 400 sf pf

600 mg(1500mg) -400 unit

(Calcium 600 +

D(3)) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

super multiple vit-mineral tab 4 $0

super multivitamin tablet 4 $0

super quints b-50 tablet 04 mg 4 $0

super quints b-50 tablets 4 $0

super thera vite m tablet 4 $0

superior 35 vit-mineral tab sa 4 $0

superplex-t tablet 4 $0

support liquid 4 $0

support-500 softgel 4 $0

sv hair skin and nails caplet 1 mg

iron-667 mcg-1000 mcg 4 $0

tab-a-vite tablet 4 $0

tab-a-vite with iron tablet 4 $0

tab-a-vite-minerals tablet 4 $0

thera caplet 4 $0

thera m plus tablet 9 mg iron-400

mcg 4 $0

thera tablet 400 mcg 4 $0

thera-d 2000 tablet 2000 unit 4 $0

theradex m tablet 27-04 mg 4 $0

thera-m caplet 4 $0

thera-m caplet caplet 27-04 mg 4 $0

thera-m tablet wbeta carotene 9 mg

iron-400 mcg 4 $0

therapeutic-m tablet 9 mg iron-400

mcg 4 $0

thera-tabs m caplet caplet 27 mg

iron-400 mcg 4 $0

thera-tabs tablet 4 $0

theratrum complete 50 plus

pfcaplet 4 $0

theratrum complete tablet mfg error

theratrum complete tablet wlutein

pf 4 $0

therems tablet 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

therems-m tablet 27-04 mg 4 $0

tl icon capsule 110-05 mg 3 $0

total b with vit c caplet 4 $0

totalday multiple tablet sa 4 $0

tricon capsule 110-05 mg 3 $0

tri-vi-sol drops 750 unit-35 mg -400

unitml 4 $0

tri-vita drops 1500-35-400 unit-mg-

unitml 4 $0

tri-vitamin drops 1500-35-400 unit-

mg-unitml 4 $0

ultra b-100 complex tablet 4 $0

unicomplex-m tablet 4 $0

v-c forte capsule 1 mg 3 $0

vic-forte capsule 1 mg 3 $0

vision plus lutein vitamin tab 4 $0

vision vitamins 4 $0

vit d2 125 mg (50000 unit) capsule

50000 unit 3 $0

vitalets tablet chewable child

orangesf 4 $0

vitamin a 10000 unit capsule

soluble 10000 unit 4 $0

vitamin and minerals tablet 4 $0

vitamin b complex capsule 4 $0

vitamin b complex tablet 500 mg-

400 mcg- 18 mg iron 4 $0

vitamin b complex-vit c cap 4 $0

vitamin b complex-vit c cap (Super BC) 4 $0

vitamin b-1 50 mg tablet 50 mg 4 $0

vitamin b-12 1000 mcg tablet 1000

mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

vitamin b12 500 mcg tablet 500 mcg

vitamin b12-folic acid tablet 500-

400 mcg 4 $0

vitamin b-50 complex tablet

sfpfdairy-free 04 mg (B Complex 100) 4 $0

vitamin b-6 250 mg tablet pf 250

mg 4 $0

vitamin b-complex amp c caplet pfno

lactosecplt 400-500 mcg-mg 4 $0

vitamin c 1000 mg tablet 1000 mg

vitamin c 1500 mg tablet sa

nafsfstarchfree 1500 mg 4 $0

vitamin c 250 mg tablet 250 mg 4 $0

vitamin c 250 mg tablet chew pf

250 mg 4 $0

vitamin c 500 mg tablet chew 500

mg 4 $0

vitamin c tr 500 mg caplet caplet

500 mg 4 $0

vitamin d 1000 unit tablet 1000

unit 4 $0

vitamin d3 1000 unit softgel pf

sfgluten-free 1000 unit 4 $0

vitamin d3 1000 unit tablet sfpf

1000 unit 4 $0

vitamin d3 10000 unit softgel

softgel 10000 unit (Maximum D3) 4 $0

softgelpfsf 10000 unit (Maximum D3) 4 $0

vitamin d3 2000 unit softgel 2000

unit 4 $0

2000 unit (D3 DOTS) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

vitamin d3 400 unit tab chew

orange pf 400 unit (Kids Vitamin D3) 4 $0

vitamin d3 400 unit tablet sfpf 400

unit 4 $0

vitamin d3 400 unit5 ml liq 400

unit5 ml 4 $0

vitamin d3 400 unitml drop

supplement drop 400 unitml (D-Vi-Sol) 4 $0

vitamin d3 5000 unit capsule sf pf

5000 unit

(Dialyvite Vitamin

D) 4 $0

VITAMIN D3 5000 UNITML

DROPS SF PF YEAST-FREE

5000 UNITML

vitamin d-400 tablet easy to swallow

400 unit 4 $0

vitamin k 100 mcg tablet

pfnafwheat-free 100 mcg 4 $0

vitamin k-1 1 mg05 ml ampul

sdvlatex-free 1 mg05 ml 3 $0

vitamin k-1 10 mgml ampul

sdvlatex-free 10 mgml 3 $0

vitamins for hair tablet 4 $0

vitatrum tablet 18-500-300-250 mg-

mcg-mcg-mcg 4 $0

vitrum 50+ senior tablet 500-300-

250 mcg 4 $0

vitrum senior tablet ffpf 4 $0

vol-care rx tablet 1-60-300 mg-mg-

mcg 3 $0

vp-vite rx tablet 1-60-300 mg-mg-

mcg 3 $0

v-r calcium 400 + d 133 caplet 400-

1333 mg-unit 4 $0

v-r natural b-100 tablet 4 $0

womens multivitamin gummies

gluten-f lactose-f 200 mcg 4 $0

yelets tablet 18-400 mg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

zoo chews gummie tablet 4 $0

more information visit wwwcentersplancomfida

1 12 hour nasal spray 153

1ST TIER UNILET

COMFORTOUCH 135

3 3 day vaginal 57

3-day vaginal 53

A a thru z 214

a thru z advanced formula 214

a thru z high potency 214

a thru z select 214

a thru z select 50+ formula 214

a thru z select womens 214

abacavir 76

abacavir-lamivudine 76

abc plus 214

ABELCET 54

ABILIFY MAINTENA 71

ABRAXANE 30

ABREVA 64

acamprosate 16

acarbose 49

ACCU-CHEK FASTCLIX 135

ACCU-CHEK MULTICLIX

LANCET 135

ACCU-CHEK SAFE-T-PRO

PLUS 136

ACCU-CHEK SOFTCLIX

LANCETS 136

acebutolol 94

acephen 3

acetaminophen 3 5 10

acetaminophen-codeine 3

acetazolamide 198

acetazolamide sodium 198

acetic acid 154 193

acetylcysteine 210

acid controller 159

acid gone antacid 161

acid reducer (famotidine) 159

acid reducer (omeprazole) 159

acitretin 127

acne medication 127

ACNE MEDICATION 128

acta-tabs pe 62

ACTEMRA 182

ACTHIB (PF) 187

ACTI-LANCE LANCETS 136

ACTIMMUNE 195

actinel pediatric 118

acyclovir 81 128

acyclovir sodium 81 82

ADACEL(TDAP

ADOLESNADULT)(PF) 187

ADAGEN 148

adapalene 135

ADCIRCA 213

adefovir 82

ADEMPAS 213

adriamycin 30

adrucil 30

adult multivitamin gummies 214

adult nasal decongestant 125

adult one daily gummies 214

adult robitussin peak cold dm

adult wal-tussin 118

adult wal-tussin dm max 118

adults 50 plus 215

ADVAIR DISKUS 206

ADVAIR HFA 206

ADVANCED TRAVEL

LANCETS 136

ADVIL 11

ADVOCATE LANCET 136

afeditab cr 100

AFINITOR 30

AFINITOR DISPERZ 30

aftera 110

a-hydrocort 176

AKTEN (PF) 150

AKYNZEO 66

ala-cort 132

alavert 58

alavert d-12 allergy-sinus 58

ALBENZA 68

albuterol sulfate 208

alclometasone 132

ALCOHOL PADS 128

ALCOHOL PREP PADS 128

ALDURAZYME 148

ALECENSA 30

alendronate 193 194

aler-cap 58

aler-tab 58

alfuzosin 173

ALIMTA 30

ALINIA 68

ALIQOPA 30

alka-seltzer plus allergy 58

alka-seltzer plus day 118

alka-seltzer plus mucus-conges

alka-seltzer plus sinus-cough 118

aller-chlor 58

allerclear d-12hr 58

allergy (chlorpheniramine) 58

allergy (diphenhydramine) 60

allergy medication 62

allergy medicine 62

allergy relief (cetirizine) 60

allergy relief (clemastine) 62

allergy relief (loratadine) 61

allerhist-1 58

aller-tec d 58

allopurinol 57

almacone 161

almacone-2 161

aloe vesta antifungal (micon) 54

alophen 167

alosetron 192

ALPHAGAN P 198

alprazolam 18

ALREX 157

altamist 150

altavera (28) 110

ALTERNATE SITE LANCET

aluminum hydroxide gel 161

ALUNBRIG 31

alyacen 135 (28) 110

alyacen 777 (28) 110

amabelz 175

amantadine hcl 69

ambi 10peh-4cpm-20dm 118

ambi 20dm-4cpm 118

ambi 40pse-400gfn-20dm 118

ambi 60pse-4cpm 58

ambi 60pse-4cpm-20dm 118

AMBISOME 54

amethia 110

amethia lo 110

amifostine crystalline 196

amiloride 101

amiloride-hydrochlorothiazide

AMINO ACIDS 15 85

AMINOSYN 10 86

AMINOSYN 7 WITH

ELECTROLYTES 86

AMINOSYN 85 86

AMINOSYN 85 -

ELECTROLYTES 86

AMINOSYN II 10 86

AMINOSYN II 15 86

AMINOSYN II 7 86

AMINOSYN II 85 86

AMINOSYN II 85 -

ELECTROLYTES 86

AMINOSYN M 35 86

AMINOSYN-HBC 7 86

AMINOSYN-PF 10 87

AMINOSYN-PF 7

(SULFITE-FREE) 87

AMINOSYN-RF 52 87

amiodarone 94

AMITIZA 161

amitriptyline 46

amlactin 128

amlodipine 100

amlodipine-atorvastatin 102 103

amlodipine-benazepril 100 101

amlodipine-olmesartan 101

amlodipine-valsartan 101

amlodipine-valsartan-hcthiazid

ammonium lactate 128

amoxapine 46

amoxicillin 26

amoxicillin-pot clavulanate 26

amphotericin b 54

ampicillin 27

ampicillin sodium 27

ampicillin-sulbactam 27

AMPYRA 106

ANADROL-50 174

anagrelide 85

anastrozole 31

ANDRODERM 174

ANDROGEL 174

androxy 174

animal chews 215

animal shape vitamins 229

animal shapes complete 222 229

animal shapes plus iron 229

ANORO ELLIPTA 208

antacid anti-gas 162 166

antacid anti-gas (ca carb-sim)

antacid ext str (calcium carb) 166

antacid extra-strength 162

antacid ii plus simethicone 161

antacid plus anti-gas 162

antacid ultra strength 162

antacid with simethicone 162

antacid-antigas ii 166

antacid-simethicone ds 161

anti-diarrheal 163

anti-diarrheal (loperamide) 161

antifungal (terbinafine) 57

antifungal (tolnaftate) 54 57

antifungal cream 54

anti-gas maximum strength 159

antihistamine 58

antioxidant 215

apatate forte 215

APOKYN 69

apraclonidine 150

aprepitant 66

apri 110

APRISO 192

aprodine 58

APTIOM 41

APTIVUS 76

aquanil hc 132

aranelle (28) 110

ARCALYST 182

aripiprazole 71

ARISTADA 71

armodafinil 211

ARNUITY ELLIPTA 206

arthritis pain relief (acetam)5 11

ARTIFICIAL TEARS

(PETROMIN) 150

artificial tears (pf) 150

artificial tears (polyvin alc) 150

artificial tears(dext70-hypro) 150

artificial tears(glycerin-peg) 151

ascomp with codeine 3

ascorbic acid (vitamin c) 219

ashlyna 110

aspirin 12 14

aspirin buffered 12

aspirin-dipyridamole 85

aspir-low 12

aspir-trin 12

ASSURE HAEMOLANCE

PLUS 136

ASSURE ID INSULIN

SAFETY 136

ASSURE LANCE 137

ASSURE LANCE PLUS 137

ASTAGRAF XL 182

atenolol 95

atenolol-chlorthalidone 95

athenol 10

atomoxetine 106

atorvastatin 103

atovaquone 68

atovaquone-proguanil 68

ATRIPLA 76

atropine 41 150

ATROVENT HFA 208

AUBAGIO 106

aubra 110

AUSTEDO 106

AVASTIN 31

AVC VAGINAL 64

aviane 110

AVONEX 107

ayr saline 150

azacitidine 31

azathioprine 182

azathioprine sodium 182

azelastine 150 151

azithromycin 24

aztreonam 25

azurette (28) 110

B b complete 215

b complex 1 215

b complex 100 230

b complex-vitamin b12 215

b complex-vitamin c-folic acid

215 222 230

b-12 dots 215

baby ddrops 215

bacitracin 20 130 131 154

bacitracin-polymyxin b 154

bacitraycin plus 130

baclofen 211

bal b-100 218

bal b-50 218

balance b-100 215

balance b-50 215

balanced b-100 215 227

balsalazide 192

balziva (28) 110

banophen 58

banophen allergy 58

BANZEL 41

BAVENCIO 31

BAXDELA 28

baza antifungal 54

BCG VACCINE LIVE (PF) 187

b-complex 227

b-complex with vitamin c 215

218 229 232 233

BD INSULIN SYRINGE

ULTRA-FINE 137

BD MICROTAINER LANCET

BD ULTRA FINE LANCETS

BD ULTRA-FINE II LANCETS

BD ULTRA-FINE NANO PEN

NEEDLES 137

bee-zee 215

bekyree (28) 110

BELBUCA 3

BELEODAQ 31

BELSOMRA 211

benadryl allergy 58

benazepril 92

benazepril-hydrochlorothiazide

BENDEKA 31

BENLYSTA 196

benzonatate 118 119

benzoyl peroxide 128

benztropine 69

BESPONSA 31

BETADINE 128

beta-hc 132

betamethasone acetsod phos 176

betamethasone dipropionate 132

betamethasone valerate 132

betamethasone augmented 132

BETASERON 107

betaxolol 95 198

bethanechol chloride 172

BETHKIS 19

BEVYXXA 82

bexarotene 31

BEXSERO 187

bicalutamide 31

bicarsim forte 158

BICILLIN C-R 27

BICILLIN L-A 27

BIDIL 105

bio-dtuss dmx 119

bion tears (pf) 151

bionel pediatric 119

biosupp 215

biotin 215

biovol 216

bisac-evac 167

bisacodyl 167

biscolax 167

bismatrol 161

bismuth 163

bismuth maximum strength 163

bisoprolol fumarate 95

bisoprolol-hydrochlorothiazide

bleomycin 31

bleph-10 154

BLINCYTO 31

blisovi 24 fe 111

blisovi fe 1530 (28) 111

blisovi fe 120 (28) 111

blis-to-sol (tolnaftate) 54

BOOSTRIX TDAP 187

BOSULIF 31

BREO ELLIPTA 206

briellyn 111

BRILINTA 85

brimonidine 198

BRIVIACT 41

bromfed dm 119

bromocriptine 69

brompheniramine-pseudoeph-

dm 118 119

BROMSITE 157

brotapp dm 119

budesonide 192 206

buffered aspirin 15

bufferin 12

BULLSEYE MINI SAFETY

LANCETS 137

bumetanide 101

BUNAVAIL 16

BUPHENYL 161

buprenorphine 4

buprenorphine hcl 3 4 16

buprenorphine-naloxone 16

bupropion hcl 46

bupropion hcl (smoking deter)16

buspirone 18

butalbital compound wcodeine 4

butalbital-acetaminop-caf-cod 4

butalbital-acetaminophen 4

butalbital-acetaminophen-caff 4

butalbital-aspirin-caffeine 4

BUTRANS 4

BYSTOLIC 95

BYVALSON 95

C cabergoline 69

CABOMETYX 31

ca-d3-mag ox-zinc-cop-mang-

bor 201 205

caffeine citrate 107

calcarb 600 with vitamin d 216

calci-chew 161

calcidol 216

calcipotriene 128

calcitonin (salmon) 194

calcitrate 199

calcitrate-vitamin d 199

calcitrene 128

calcitriol 128 194

calcium 500 + d 218

calcium 500 + d (d3) 218

calcium 600 199 205

calcium 600 + d(3) 200 216

calcium 600 with vitamin d3

199 202

calcium acetate 172

calcium antacid 162

calcium carbonate 162 200

calcium carbonate-vitamin d3

199 200 216 218 230

CALCIUM CARBONATE-

VITAMIN D3 200

calcium chloride 200

calcium citrate-vitamin d3 200

201 205

calcium gluconate 200

calcium+d 234

CALDOLOR 12

cal-gest antacid 162

CALQUENCE 31

CALTRATE 600 + D 200

camila 111

camrese 111

camrese lo 111

CANASA 192

CANCIDAS 54

candesartan 91

capacet 4

CAPASTAT 65

CAPRELSA 32

captopril 93

captopril-hydrochlorothiazide 93

CARAFATE 159

CARBAGLU 162

carbamazepine 41

carbidopa-levodopa 69

CAREONE ULTRA THIN

LANCET 137

CARESENS LANCETS 138

CARETOUCH TWIST

LANCET 138

CARIMUNE NF

NANOFILTERED 182

carisoprodol 211

carteolol 198

cartia xt 96

carvedilol 95

caspofungin 54

CASTELLANI PAINT

MODIFIED 128

CAYSTON 26

caziant (28) 111

cefaclor 22

cefadroxil 22

cefazolin 22

cefazolin in dextrose (iso-os) 22

cefdinir 22

cefditoren pivoxil 22

CEFEPIME 22

CEFEPIME IN DEXTROSE 5

CEFEPIME IN

DEXTROSEISO-OSM 22

cefotaxime 23

cefoxitin 23

cefoxitin in dextrose iso-osm 23

cefpodoxime 23

cefprozil 23

ceftazidime 23

ceftibuten 23

ceftriaxone 23

ceftriaxone in dextroseiso-os 23

cefuroxime axetil 23

cefuroxime sodium 24

celecoxib 12

CELONTIN 42

centamin 216

centergy dm 119

central-vite 228

central-vite for seniors 216

central-vite senior 227

central-vite with lycopene 220

centram-care 216

centravites 50 plus 216

centrum 216

centrum complete 216

centrum silver 216

centrum women 217

century 217

century adults 50+ 222

century mature 220 222

century ultimate mens 217

century ultimate womens 217

cephalexin 24

CEPROTIN (BLUE BAR) 82

CERDELGA 148

CEREZYME 148

cerovite 217

cerovite advanced formula 217

cerovite jr 217

cerovite senior 217

certavite senior-antioxidant 217

certavite-antioxid (iron gluc) 217

certavite-antioxidant 217

cetiri-d 62

cetirizine 59

cetirizine-pseudoephedrine 59

CETYLEV 196

cevimeline 127

CHANTIX 16

CHANTIX CONTINUING

MONTH BOX 16

CHANTIX STARTING

MONTH BOX 16

chest congestion relief pe 120

chest congestion-cough relief

chest-sinus congestion relief 119

chewable-vite 217

chewable-vite with iron 217

child allergy relf(cetirizine) 60

child chest congestion + cough

child complete multivitamin 220

child cough and sore throat 120

child mucinex chest congestion

child multivitamin plus iron 217

child non-aspirin quick melts 10

child plus cough and runnynose

child triaminic cold-allergy 59

child triaminic cough-congest

child vitamin with minerals 218

child wal-tap cold-allergy 59

child wal-tussin cough relief 119

children night time cold-cough

childrens acetaminophen 4

CHILDRENS ADVIL 12

childrens allegra allergy 59

childrens aller-tec 59

childrens aspirin 12

childrens cetirizine 59 62

childrens chest congestion 120

childrens chewable 227

childrens chewable vitamin 217

CHILDRENS CLARITIN 59

childrens cold-cough daytime

childrens complete vitamin 227

childrens cough and runnynose

childrens fever reducing 5

childrens flu relief 123

childrens ibu-drops 12

childrens ibuprofen 13

childrens mapap 5

childrens mucinex cough 119

childrens non-aspirin 5 10

childrens pain relief 5

childrens pain reliever 10 11

childrens pain-fever relief 4 5 7

childrens pepto 162

childrens plus flu 119

childrens plus multi-symp cold

childrens robitussin er 119

childrens silfedrine 119

childrens soothe 162

CHILDRENS SUDAFED 119

childrens sudafed pe cough 119

childrens tactinal 5

childrens wal-fex 59

childrens wal-zyr 59

CHILDRENS ZYRTEC

ALLERGY 59

childs chew vite 217

childs chewable vitaminsiron

childs vitamin with iron 218

childsiron 217

chlophedianol-guaifenesin 118

chlordiazepoxide hcl 18

chlorhexidine gluconate 127

chlorhist 59

chloroquine phosphate 68

chlorothiazide 101

chlorothiazide sodium 101

chlorpheniramine-phenyleph-dm

chlorpromazine 71

chlorthalidone 101

chlorzoxazone 211

cholecalciferol (vitamin d3) 215

219 233 234

CHOLECALCIFEROL

(VITAMIN D3) 234

cholestyramine (with sugar) 103

cholestyramine light 103

ciclopirox 54

cilostazol 85

cimetidine 159

cimetidine hcl 159

CIMZIA 182

CIMZIA POWDER FOR

RECONST 182

CINQAIR 210

CINRYZE 83

CIPRODEX 154

ciprofloxacin 29

ciprofloxacin hcl 28 154

ciprofloxacin in 5 dextrose 28

ciprofloxacin lactate 28

citalopram 46

citracal + d maximum 200

citrus calcium 200

clarithromycin 25

CLARITIN LIQUI-GEL 59

CLARITIN REDITABS 59

clearlax 171

CLEVER CHEK LANCETS 138

CLEVIPREX 101

clindamycin hcl 20

clindamycin in 5 dextrose 20

clindamycin palmitate hcl 20

clindamycin pediatric 20

clindamycin phosphate 20 64

130 131

CLINIMIX 5D15W

SULFITE FREE 87

CLINIMIX 5D25W

SULFITE-FREE 87

CLINIMIX 275D5W

SULFIT FREE 87

FREE 87

CLINIMIX 425D5W

SULFIT FREE 87

CLINIMIX 425-D20W

SULF-FREE 87

CLINIMIX 425-D25W

SULF-FREE 87

CLINIMIX 5-

D20W(SULFITE-FREE) 87

CLINIMIX E 275D10W

SUL FREE 88

CLINIMIX E 275D5W

SULF FREE 88

CLINIMIX E 425D10W

SUL FREE 88

CLINIMIX E 425D25W

SUL FREE 88

CLINIMIX E 425D5W

SULF FREE 88

CLINIMIX E 5D15W

SULFIT FREE 88

CLINIMIX E 5D20W

SULFIT FREE 88

CLINIMIX E 5D25W

SULFIT FREE 88

CLINISOL SF 15 88

clobetasol 132

clobetasol-emollient 132

clocortolone pivalate 132

clofarabine 32

clomipramine 46

clonazepam 18

clonidine 91

clonidine hcl 91

clopidogrel 85

clorazepate dipotassium 18

clotrimazole 54

clotrimazole-7 54

clotrimazole-betamethasone 54

clozapine 71 72

COAGUCHEK LANCETS 138

COARTEM 68

codeine sulfate 5

COLCRYS 57

cold and allergy(triprolidine) 62

cold and cough (diphenhydr-pe)

cold multi-symptom daynight

cold multi-symptom nighttime

cold relief ms daynight 120

cold-allergy-sinus 60

cold-flu relief 120

cold-flu relief daynight 120

colestipol 103

colistin (colistimethate na) 20

colocort 192

COLOR LANCETS 144

col-rite 171

COLY-MYCIN S 155

COMBIGAN 198

COMBIPATCH 175

COMBIVENT RESPIMAT 208

COMETRIQ 32

COMFORT EZ LANCETS 138

comfort gel 162

comfort gel extra strength 162

COMFORT LANCETS 138

compete 217

COMPLERA 76

complete 229

complete 50+ 222

complete multi 217

complete multi 50+ 217

complete multivitamin 217 220

complete multivitamin-mineral

220 229

complete senior 218 229

complete women 222

compoz 60

compro 66

CONDYLOX 128

congestac 120

congest-eze 120

constulose 162

COPAXONE 107

coricidin hbp 120

CORLANOR 97

cormax 132

cortaid 132

cortisone 176

cortisone (hydrocortisone) 133

cortizone-10 132 133

cortizone-10 with aloe 132

COSENTYX PEN (2 PENS) 128

COTELLIC 32

cough and cold (chlorphen-dm)

cough and runny nose 125

cough control dm 124

cough syrup dm 122

cough-sore throat night 120

CREON 149

critic-aid clear af 55

CRIXIVAN 76

cromolyn 151 210

cryselle (28) 111

CUPRIMINE 173

cutter backwoods 129

cutter skinsations 129

cyanocobalamin (vitamin b-12)

215 219 228 232 233

cyclafem 135 (28) 111

cyclafem 777 (28) 111

cyclobenzaprine 211

cyclopentolate 151

cyclophosphamide 32

CYCLOPHOSPHAMIDE 32

CYCLOSET 49

cyclosporine 182

cyclosporine modified 182

cyproheptadine 60

CYRAMZA 32

cyred 111

CYSTADANE 196

CYSTARAN 151

D d10 -045 sodium chloride

d3 dots 219

daily gummies 218

daily multiple 218 219

daily multi-vitamin 224

daily multivitamin with iron 219

daily multi-vitaminsiron 219

daily value 219

daily vitamin formula 219

daily vitamin formula-iron 219

daily vitamin formula-minerals

daily vitamin with iron 219

daily vitesiron 219

dailyhist-1 60

daily-vite 219

DAKLINZA 80

DALIRESP 210

danazol 174

dantrolene 211

dapsone 65

DAPTACEL (DTAP

PEDIATRIC) (PF) 187

daptomycin 20

DARAPRIM 69

DARZALEX 32

dasetta 135 (28) 111

dasetta 777 (28) 111

dayhist 60

dayhist allergy 60

daysee 111

daytime cold and cough 121

day-time cough 121

daytime-nighttime 123

daytime-nighttime cold-flu 120

daytime-nighttime cough 121

deblitane 111

decitabine 32

decongestant cough 125

deep sea nasal 151

deferoxamine 174

delsym cough-chest congest dm

delta d3 220

delyla (28) 111

DELZICOL 193

DEMSER 97

DEPEN TITRATABS 174

DEPO-PROVERA 181

dermafungal 55

dermarest eczema (hydrocort)

DERMAREST ECZEMA

(PRAMOXINE) 133

DESCOVY 76

desipramine 46

desmopressin 178

desog-eestradioleestradiol 111

desogestrel-ethinyl estradiol 111

desoximetasone 133

despec-dm (phenyleph-dm-

guaif) 121

despec-dm (pseudoeph-dm-

guaif) 121

desvenlafaxine succinate 46

dex4 glucose 88

dexamethasone 176 177

dexamethasone sodium

phosphate 157 177

dexmethylphenidate 107

dextroamphetamine 107

dextroamphetamine-

amphetamine 107

dextromethorphan polistirex 121

dextromethorphan-guaifenesin

dextrose 5 in ringers 89

dextrose 5 in water (d5w) 89

dextrose 5 -lactated ringers201

diabetic tussin dm 121

diabetic tussin ex 121

diamode 163

DIASTAT 18

DIASTAT ACUDIAL 18

diazepam 18

diazepam intensol 18

diclofenac potassium 12

diclofenac sodium 12 13 129

diclofenac-misoprostol 13

dicloxacillin 27

dicyclomine 163

didanosine 76

DIFICID 25

diflunisal 13

digitek 98

digox 98

digoxin 98 99

DIGOXIN 98

dihydroergotamine 64

DILANTIN 42

dilt-cd 96

diltiazem hcl 96 97

dilt-xr 97

dimaphen (pe) 60

dimaphen dm 121

dimenhydrinate 66

dimetapp cold-congestion 60

(CPM-DM) 121

dino-life 220

dino-life with extra c 220

dino-life with iron-zinc 220

DIPENTUM 193

diphedryl 60

diphenhist 60

diphenhydramine hcl 60 61

diphenoxylate-atropine 163

dipyridamole 85

disopyramide phosphate 94

disposable enema 168

disulfiram 16

divalproex 42

dobutamine 99

dobutamine in d5w 99

docu 168

docusate sodium 168

docusol 168

dofetilide 94

dok 168

dok plus 168

donepezil 45

dopamine 99

dopamine in 5 dextrose 99

dorzolamide 198

dorzolamide-timolol 198

douche vinegar and water extra

doxazosin 91

doxepin 46 47

doxercalciferol 194

doxorubicin 32

doxorubicin peg-liposomal 32

doxy-100 29

doxycycline hyclate 29

doxycycline monohydrate 29 30

dramamine 66

dramamine less drowsy 66

driminate 66

dristan long lasting 151

dronabinol 66

droperidol 196

DROPLET LANCETS 138

drospirenone-ethinyl estradiol

DROXIA 32

DUAVEE 175

dulcolax stool softener (dss) 168

DULERA 207

duloxetine 47

DUPIXENT 129

DUREZOL 157

dutasteride 173

dutasteride-tamsulosin 173

d-vi-sol 220

E ec prin 13

ees 400 25

ees granules 25

EASY COMFORT LANCETS

EASY TOUCH LANCETS 138

EASY TOUCH SAFETY

LANCETS 138

EASY TOUCH TWIST

LANCETS 138 139

EASY TWIST AND CAP

LANCETS 139

econazole 55

econtra ez 112

ecotrin 13

ed a-hist 61

ed bron gp 121

ed chlorped jr 61

EDARBI 92

EDARBYCLOR 92

EDURANT 76

EFFIENT 85

ELAPRASE 149

eldertonic 220

electrolyte-48 in d5w 201

ELIDEL 133

ELIGARD 33

ELIGARD (3 MONTH) 32

elinest 112

eliphos 172

ELIQUIS 82

ELITEK 149

ELLA 112

ellis tonic 220

ELMIRON 196

EMBRACE LANCETS 139

EMCYT 33

EMEND 66

EMEND (FOSAPREPITANT)

EMFLAZA 177

emoquette 112

EMPLICITI 33

EMSAM 47

EMTRIVA 76

enalapril maleate 93

enalaprilat 93

enalapril-hydrochlorothiazide 93

ENBREL 182 183

ENBREL SURECLICK 183

ENDARI 196

endocet 5

endur-acin 103

endur-amide 220

ENDUR-AMIDE 220

enema 171

enema disposable 167 168

enemeez 168

enemeez plus 168

ENGERIX-B (PF) 188

enoxaparin 82

enpresse 112

enskyce 112

entacapone 70

entecavir 82

ENTRESTO 92

enulose 163

ENVARSUS XR 183

EPCLUSA 80

epinastine 151

epinephrine 99

EPIPEN 99

EPIPEN 2-PAK 99

EPIPEN JR 2-PAK 100

epitol 42

EPIVIR HBV 76

eplerenone 105

EPOGEN 84

epoprostenol (glycine) 213

eq gentle 151

equalactin 168

ergocalciferol (vitamin d2) 220

ergoloid 196

ERGOMAR 64

ERIVEDGE 33

errin 112

ery pads 131

ERYPED 200 25

ERYPED 400 25

ery-tab 25

ERY-TAB 25

ERYTHROCIN 25

erythrocin (as stearate) 25

erythromycin 25 155

erythromycin ethylsuccinate 25

erythromycin with ethanol 131

ESBRIET 210

escitalopram oxalate 47

esmolol 95

esomeprazole magnesium 159

esomeprazole sodium 159

essentia 220

essential balance with lutein 220

essential daily 220

estarylla 112

ESTRACE 175

estradiol 175

estradiol valerate 175

estradiol-norethindrone acet 176

estropipate 176

eszopiclone 212

ethambutol 65

ethosuximide 42

ethynodiol diac-eth estradiol 112

etodolac 13

ETOPOPHOS 33

etoposide 33

EUCRISA 133

evac-u-gen (sennosides) 168

EVOTAZ 76

exemestane 33

EXJADE 174

EXONDYS 51 196

expectorant 121

expectorant cough syrup 123

expectorant dm 121

expectorant max strength 122

EXTAVIA 107

eye health plus lutein 220

E-Z JECT LANCETS 139 143

E-Z JECT THIN LANCETS 143

EZ SMART LANCETS 139

ezetimibe 103

F FABRAZYME 149

fallback solo 112

falmina (28) 112

famciclovir 82

famotidine 160

famotidine (pf) 159

famotidine (pf)-nacl (iso-os) 160

FANAPT 72

FARESTON 33

FARYDAK 33

FASENRA 210

FASLODEX 33

felbamate 42

felodipine 101

feminine care douche 197

FEMRING 176

femynor 112

fenofibrate 103

fenofibrate micronized 103

fenofibrate nanocrystallized 103

fenofibric acid 103

fenofibric acid (choline) 103

fenoprofen 13

fentanyl 6

fentanyl citrate 6

feosol 221

ferate 221

ferocon 221

ferretts 221

ferrex 150 221

ferrex 150 plus 221

ferric x-150 221

FERRIPROX 174

ferrocite 221

ferrous fumarate 221

ferrous gluconate 221 223

ferrous sulfate 217 221

FETZIMA 47

feverall 6

fexofenadine 61

FIASP 52

FIASP FLEXTOUCH 51

fiber (calcium polycarbophil)

fiber (psyllium husksugar) 168

fiber laxative (ca polycarbo) 167

fiber laxative (husksugar) 171

fiber laxative (methylcellulo)171

fiber smooth 171

fiber therapy (m-cellsugar) 169

fiber therapy (m-cellulose) 167

fiber therapy(psyl seed-sugar)

fiber-lax 169

FIFTY50 SAFETY SEAL

LANCETS 139

finasteride 173

FINE 30 UNIVERSAL

LANCETS 139

FINGERSTIX LANCETS 139

FIRAZYR 100

flavor chews antacid 163

FLEBOGAMMA DIF 183

flecainide 94

FLECTOR 129

FLEET BISACODYL 169

flintstones complete (iron) 221

flintstones multivitamin 222

flintstones with iron 222

flintstonesextra c 221

FLOVENT DISKUS 207

FLOVENT HFA 207

floxuridine 33

flu and severe cold-daytime 120

flu formula daytime-nighttime

flu hbp 122

flu severe cold-congestion 125

fluconazole 55

fluconazole in dextrose(iso-o) 55

fluconazole in nacl (iso-osm) 55

flucytosine 55

fludrocortisone 177

flumazenil 107

flunisolide 157

fluocinolone 133

fluocinonide 133

fluocinonide-e 133

fluoride (sodium) 222 230

fluorometholone 157

fluorouracil 33 129

fluoxetine 47

fluphenazine decanoate 72

fluphenazine hcl 72

flurbiprofen 13

flurbiprofen sodium 157

flu-severe cold-cough daytime

flutamide 33

fluticasone 133 157

fluvoxamine 47

foaming antacid 163 166

folic acid 222

fomepizole 196

fondaparinux 82 83

foot and sneaker 55

FORACARE LANCETS 139

FORADIL AEROLIZER 208

formula 3 55

FORTEO 194

fosamprenavir 76

foscarnet 79

fosfree 222

fosinopril 93

fosinopril-hydrochlorothiazide

fosphenytoin 42

FREAMINE HBC 69 89

FREAMINE III 10 89

FREESTYLE INSULINX 139

STRIPS 140

FREESTYLE LANCETS 139

FREESTYLE LITE STRIPS 140

FREESTYLE TEST 140

FREESTYLE UNISTIK 2 140

fungi cure 55

fungoid-d 55

furosemide 102

FUZEON 76

FYCOMPA 42

G gabapentin 42

GABITRIL 42

galantamine 45

GAMASTAN SD 183

GAMMAGARD LIQUID 183

MCGML) 183

GAMMAPLEX 183

GAMMAPLEX (WITH

SORBITOL) 183

ganciclovir sodium 82

GARDASIL (PF) 188

GARDASIL 9 (PF) 188

gas relief 158

gas relief 80 158

gas relief extra strength 158

gas-x ultra-strength 158

gatifloxacin 155

GATTEX 30-VIAL 163

GAUZE PAD 140

gavilyte-c 169

gavilyte-g 169

gavilyte-n 169

GAZYVA 33

gelusil antacid and anti-gas 163

gemfibrozil 103

generlac 163

gengraf 183

GENOTROPIN 178

gentak 155

gentamicin 19 131 155

gentamicin in nacl (iso-osm) 19

gentamicin sulfate (ped) (pf) 19

gentamicin sulfate (pf) 19

GENTEAL GEL 152

GENTEAL MILD 152

GENTEAL SEVERE 152

genteal tears 152

GENTEAL TEARS (DXTRN-

HPM-GLY) 152

gentlelax 169

GENVOYA 77

GEODON 72

geriaton 222

geri-dryl 61

geri-hydrolac 129

geri-tussin dm 122

gianvi (28) 112

gildagia 112

GILENYA 107

GILOTRIF 33

glatiramer 107

glatopa 108

GLEOSTINE 33

glimepiride 53

glipizide 53

glipizide-metformin 53

GLUCAGEN HYPOKIT 49

GLUCAGON EMERGENCY

KIT (HUMAN) 49

gluco burst 89

GLUCOCOM LANCETS 140

glucose 89

glucose gel 89

glutose 15 89

glyburide 53

glyburide micronized 53

glyburide-metformin 53

glycolax 169

glycopyrrolate 164

glydo 15

GLYXAMBI 49

GMATE LANCETS 140

GOCOVRI 70

granisetron (pf) 66

granisetron hcl 67

GRANIX 84

griseofulvin microsize 55

guaifenesin 122

guanfacine 91 108

guanidine 196

gummi bear multivitamin 222

H HAEGARDA 84

hair vitamins 222

hairskin and nails 229 231

halobetasol propionate 133

haloperidol 73

haloperidol decanoate 72

haloperidol lactate 72

HARVONI 80

HAVRIX (PF) 188

head congestion cold relief 124

head congestion day-night 122

HEALTHY ACCENTS

UNILET LANCET 140

healthylax 169

heartburn relief 163

heather 112

hemocyte 222

heparin (porcine) 83

heparin (porcine) in 5 dex 83

heparin(porcine) in 045 nacl

heparin porcine (pf) 83

HEPATAMINE 8 89

HERCEPTIN 34

HETLIOZ 212

HEXALEN 34

hi-b complex 222

HIBERIX (PF) 188

hi-cal plus vit d 228

high potency calcium 201

honey bears 222

honey bears with iron-zinc 222

HUMATROPE 178

HUMIRA 184

HUMIRA PEDIATRIC

CROHNS START 183

HUMIRA PEN 184

HUMIRA PEN CROHNS-UC-

HS START 183

UVEITIS 184

KWIKPEN 52

HUMULIN R U-500

(CONCENTRATED) 52

hydralazine 100

hydrochlorothiazide 102

hydrocil instant 169

hydrocodone-acetaminophen 6

hydrocodone-ibuprofen 6

hydrocortisone 133 134 177

hydrocortisone acetate 133

hydromorphone 6 7

hydromorphone (pf) 6

hydroskin 133

hydroxychloroquine 69

hydroxyurea 34

hydroxyzine hcl 61

hydroxyzine pamoate 196

HYPERRAB SD (PF) 184

HYQVIA 184

HYSINGLA ER 7

I ibandronate 194

IBRANCE 34

ibuprofen 12 13 15

ibuprofen jr strength 13

icaps plus 222

ICLUSIG 34

IDHIFA 34

iferex 150 222

ifosfamide 34

ifosfamide-mesna 34

ILARIS (PF) 184

ILEVRO 157

imatinib 34

IMBRUVICA 34

IMFINZI 34

imipenem-cilastatin 26

imipramine hcl 47

imipramine pamoate 47

imiquimod 129

IMLYGIC 34

imodium a-d 164

IMODIUM A-D 164

IMOVAX RABIES VACCINE

(PF) 188

IMPAVIDO 69

INCONTROL SUPER THIN

LANCETS 140

INCONTROL ULTRA THIN

LANCETS 140

INCRELEX 179

INCRUSE ELLIPTA 208

indapamide 102

indomethacin 13 14

indomethacin sodium 14

INFANRIX (DTAP) (PF) 189

infant fever reducer-pain relf 10

infants advil 14

infants gas relief 159

infants ibuprofen 14

infants medi-profen 14

infants non-aspirin 10

infants non-aspirin cold 126

infants pain relief 7

infants pain reliever 7

INFLECTRA 184

INGREZZA 108

INJECT EASE LANCETS 140

INLYTA 34

INSECT REPELLENT

(PICARIDIN) 129

insta-glucose 89

INSULIN SYRINGE-NEEDLE

U-100 140 141

INTELENCE 77

intense cough 122

INTRALIPID 90

INTRON A 81

introvale 112

INVACARE LANCETS 141

INVANZ 26

INVEGA SUSTENNA 73

INVEGA TRINZA 73

INVIRASE 77

INVOKAMET 49

INVOKAMET XR 49

INVOKANA 50

inzo antifungal 55

iodine 148

IONOSOL-B IN D5W 201

IONOSOL-MB IN D5W 202

IPOL 189

ipratropium bromide 152 208

IPRIVASK 83

irbesartan 92

irbesartan-hydrochlorothiazide

IRESSA 35

iron 223

iron (ferrous sulfate) 218 220

iron high potency 218

ISENTRESS 77

ISENTRESS HD 77

isibloom 112

ISOLYTE-P IN 5

DEXTROSE 202

ISOLYTE-S 202

isoniazid 65

isopto tears 152

isosorbide dinitrate 105

isosorbide mononitrate 105

isradipine 101

itraconazole 55

ivermectin 69

IXEMPRA 35

IXIARO (PF) 189

J JADENU 174

JADENU SPRINKLE 174

JAKAFI 35

jantoven 83

JANUMET 50

JANUMET XR 50

JANUVIA 50

JARDIANCE 50

jencycla 112

JENTADUETO 50

JENTADUETO XR 50

jock itch (terbinafine) 55

jolessa 112

jolivette 112

jr str non-aspirin quick melts 10

juleber 112

junel 1530 (21) 112

junel 120 (21) 113

junel fe 1530 (28) 113

junel fe 120 (28) 113

junel fe 24 113

junior mapap 7

JUXTAPID 103

K KABIVEN 90

KALETRA 77

KALYDECO 210

KANUMA 149

kaopectate (bismuth subsalicy)

kariva (28) 113

kelnor 135 (28) 113

KENALOG 177

ketoconazole 55

ketoprofen 14

ketorolac 14 157 158

KEVEYIS 196

KEVZARA 184

KEYTRUDA 35

kidkare coughcold 122

kids mini enema 167

kids multivitamin complete 223

kimidess (28) 113

KINERET 184

KINRIX (PF) 189

kionex 164

kionex (with sorbitol) 164

KISQALI 35

klor-con m10 202

klor-con m15 202

klor-con m20 202

klor-con sprinkle 202

kobee 223

konsyl (sugar) 169

konsyl fiber 169

KONSYL SUGAR-FREE 169

KORLYM 50

kpn 223

KRYSTEXXA 149

kurvelo 113

KUVAN 149

KYNAMRO 104

KYPROLIS 35

L l norgesteestradiol-eestrad 113

labetalol 95

LACRISERT 152

LACTATED RINGERS 193

LACTINOL HX 129

lactulose 164

LAMISIL (AEROSOL) 56

lamisil af 55 56

LAMISIL AT 56

lamivudine 77

lamivudine-zidovudine 77

lamotrigine 42 43

LANCETS 136 137 138 139

141 142 144

LANCETSTHIN 141 145

LANCETSULTRA THIN 141

LANOXIN 100

lansoprazole 160

LANTUS 52

LANTUS SOLOSTAR 52

larin 1530 (21) 113

larin 120 (21) 113

larin 24 fe 113

larin fe 1530 (28) 113

larin fe 120 (28) 113

larissia 113

LARTRUVO 35

latanoprost 198

LATUDA 73

laxative (bisacodyl) 171

laxative dietary supplement 163

laxative peg 3350 171

LAZANDA 7

leena 28 113

leflunomide 184

LEMTRADA 108

LENVIMA 35

lessina 113

LETAIRIS 213

letrozole 35

leucovorin calcium 196 197

LEUKERAN 35

LEUKINE 84

leuprolide 36

levalbuterol tartrate 208

levetiracetam 43

levobunolol 198

levocarnitine 197

levocarnitine (with sugar) 197

levocetirizine 61

levofloxacin 29 155

levofloxacin in d5w 29

levoleucovorin 197

LEVOLEUCOVORIN 197

levonest (28) 113

levonorgestrel 114

levonorgestrel-ethinyl estrad 114

levonorg-eth estrad triphasic 114

levora-28 114

levothyroxine 181

LEXIVA 77

LIALDA 193

lice cream rinse 135

lice killing 135

lice killing (permethrin) 135

lice pyrinyl shampoo 135

lice treatment 135

lice treatment (permethrin) 135

lidocaine 15

lidocaine (pf) 15 94

lidocaine hcl 15

lidocaine in 5 dextrose (pf) 94

lidocaine viscous 15

lidocaine-prilocaine 15

life-pack womens 223

lillow 114

linezolid 20 21

linezolid-09 sodium chloride

LINZESS 164

liothyronine 181

liquibid d-r 122

liquid antacid 163 164

liquid c 223

lisinopril 93

lisinopril-hydrochlorothiazide 93

LITE TOUCH LANCETS 141

lithium carbonate 108

lithium citrate 108

little animals 223

little animals-iron 223

little remedies 152

little remedies fever and pain 7

LIVALO 104

lohist-dm 122

lomedia 24 fe 114

LONSURF 36

loperamide 163 164

lopinavir-ritonavir 77

lopreeza 176

lorata-d 62

loratadine 59 61 62

loratadine-d 60 61

lorazepam 18

lorcet (hydrocodone) 7

lorcet hd 7

lorcet plus 7

loryna (28) 114

losartan 92

losartan-hydrochlorothiazide 92

LOTEMAX 158

lovastatin 104

low-ogestrel (28) 114

loxapine succinate 73

lubricant dry eye relief 151

lubricant eye 151

lubricant eye (cmc-glycer)(pf)

lubricant eye (cmc-glycerin) 152

lubricant eye (pg-peg 400) 151

lubricant eye (propyl glycol) 151

lubricant gel 151

lubricating drops 151

lubricating plus 152

lubrifresh pm 152

LUMIGAN 199

LUPRON DEPOT 36

LUPRON DEPOT-PED 179

LUPRON DEPOT-PED (3

MONTH) 179

lutera (28) 114

LYNPARZA 36

LYRICA 43

lysiplex plus 223

LYSODREN 36

lyza 114

M maalox advanced 164

MACUVITE EYE CARE 223

mag 64 202

mag-delay 202

mag-g 202

magnesium 200 205

magnesium (oxideaa chelate)

magnesium oxide 164 165 166

magnesium sulfate 203

magnesium sulfate in d5w 202

magnesium sulfate in water 202

malathion 135

mapap (acetaminophen) 7

mapap arthritis pain 7

mapap extra strength 7

maprotiline 48

marlissa 114

MARPLAN 48

masanti double strength 165

masophen 8

MATULANE 36

matzim la 97

MAVYRET 80

maximum daily multivitamin

meclizine 67

medi-bismuth 165

medi-meclizine 67

medi-natural 169

medi-natural senna-stool 169

medi-phedrine 122

MEDI-PHENYL 91

MEDLANCE PLUS LANCETS

medroxyprogesterone 181

mefenamic acid 14

mefloquine 69

MEFOXIN IN DEXTROSE

(ISO-OSM) 24

mega multiplechelated mineral

mega multivitamin with mineral

megestrol 36 181

MEKINIST 36

meloxicam 14

memantine 45

MENACTRA (PF) 189

MENEST 176

MENHIBRIX (PF) 189

MENOMUNE - ACYW-135

(PF) 189

mens daily gummies 218

mens multi-vitamin 218

mens one daily 220

MENVEO A-C-Y-W-135-DIP

(PF) 189

MEPHYTON 223

mercaptopurine 36

meropenem 26

mesalamine 193

mesna 197

MESNEX 197

MESTINON 197

metaproterenol 208

metformin 50

methadone 8

methadose 8

methazolamide 199

methenamine hippurate 21

methimazole 181

methocarbamol 211

methotrexate sodium 37

methotrexate sodium (pf) 36

methoxsalen 129

methscopolamine 165

methyclothiazide 102

methylphenidate hcl 108 109

methylprednisolone 177

methylprednisolone acetate 177

metipranolol 199

metoclopramide hcl 165

metolazone 102

metoprolol succinate 95

metoprolol ta-hydrochlorothiaz

metoprolol tartrate 95 96

metronidazole 21 64 131

metronidazole in nacl (iso-os) 21

mexiletine 94

mgo 165

MIACALCIN 194

mi-acid 165

mi-acid gas relief 159

micatin 56

miconazole 7 56

miconazole nitrate 56

miconazole-3 56

miconazole-skin clnsr17 56

MICRO THIN LANCETS 141

microgestin 1530 (21) 114

microgestin fe 1530 (28) 114

MICROLET LANCET 141

midodrine 91

miglitol 50

milk of magnesia 167 169

milltrium senior 223

milrinone 100

milrinone in 5 dextrose 100

mimvey 176

mimvey lo 176

mineral oil 130 167 170

MINERAL OIL 197

mineral oil extra heavy 171

mineral oil laxative 169

MINERAL OIL LIGHT 169

minitran 106

minocycline 30

minoxidil 106

mintox 165

mintox maximum strength 165

mintox plus 165

MIRCERA 84

mirtazapine 48

misoprostol 160

mitoxantrone 37

M-M-R II (PF) 189

moexipril 93

moexipril-hydrochlorothiazide

molindone 73

mometasone 134

MONISTAT 3 56

monistat 7 56

MONOLET LANCETS 141

MONOLET THIN LANCETS

mono-linyah 114

mononessa (28) 114

montelukast 207

morphine 8

MORPHINE 8

morphine concentrate 8

motion sickness 66

motion sickness relief(mecliz)

MOVANTIK 165

MOVIPREP 169

MOXEZA 155

moxifloxacin 29 155

MOZOBIL 84

mucinex fast-max dm max 122

mucinex sinus-max 152

mucus dm 122

mucus dm max 122

mucus relief 122 124

mucus relief cough 125

mucus relief dm 123

mucus relief er 121 124

MULTAQ 94

multi complete with iron 223

multi for her 223

multi-day with iron 223

multi-delyn 223

multi-delyn with iron 223

multilex 224

multilex-t and m 224

multiple vitamin-minerals 224

multiple vitamins 224

multiple vitamins with iron 224

multi-symptom cold night time

multivitamin 224 229

multivitamin 50 plus 227

multi-vitamin hpminerals 224

multi-vitamin with fluoride 224

multivitamin with iron 224 229

multivitamin with minerals 224

mupirocin 131

mupirocin calcium 131

muro 128 152

my favorite multiple 224

my way 114

mycophenolate mofetil 185

mycophenolate mofetil hcl 184

mycophenolate sodium 185

MYGLUCOHEALTH

LANCETS 141

MYLOTARG 37

MYRBETRIQ 173

mytab gas 159

mytab gas maximum strength

my-vitalife 224

myzilra 115

N nabumetone 14

nadolol 96

nafcillin 27

NAGLAZYME 149

naloxone 16

naltrexone 16

NAMENDA XR 45

NAMZARIC 45 46

naproxen 14

naratriptan 64

NARCAN 16

nasal and sinus decongestant 123

nasal decongestant (pe) 91

nasal decongest-antihistamine 61

nasal relief 152

nasal spray (oxymetazoline) 151

nasal spray 12 hour sinus 152

nasal spray extra moisturizing

nasal spray sinus 154

NASCOBAL 224

NATACYN 155

nateglinide 50

NATPARA 194

NATRAPEL 129

natural b-100 234

natural b-100 complex 229

natural balance tears 153

natural calcium 203

natural fiber laxative (sugar) 170

natural fiber laxative sf 171

natural fiber laxative smooth 171

natural fiber laxative therapy 169

natural fiber laxative(aspart) 170

natural fiber supplement 168

natural senna laxative 170

natural tears (pf) 151

natura-lax 171

NEBUPENT 69

necon 0535 (28) 115

necon 150 (28) 115

necon 1011 (28) 115

necon 777 (28) 115

nefazodone 48

neomycin 19

neomycin-bacitracin-poly-hc 155

neomycin-polymyxin b gu 131

neomycin-polymyxin b-

dexameth 155

neomycin-polymyxin-

gramicidin 155

neomycin-polymyxin-hc 156

neo-polycin 156

neo-polycin hc 156

neosporin (neo-bac-polym) 131

neosporin anti-itch 134

neo-synephrine 12 h spr (oxym)

neo-tuss 123

nephplex rx 224

NEPHRAMINE 54 90

nephron fa 224

nephro-vite rx 224

NERLYNX 37

NEULASTA 84

NEUPOGEN 84

NEUPRO 70

nevirapine 77 78

NEXAVAR 37

next choice one dose 115

niacin 104

niacinamide 104 224

niacor 104

nicardipine 101

nicorelief 16

NICORETTE 17

nicotine 17

nicotine (polacrilex) 17

NICOTROL 17

nifedipine 101

night time cold 123

night time cold medicine 123

night time cold-flu 125

night time cold-flu relief 125

nighttime cough 121

nighttime sleep aid (diphen) 62

nighttime sleep-aid (doxylamn)

nikki (28) 115

nilutamide 37

NINLARO 37

nite time 125

nite time-d cold-flu relief 123

NITRO-BID 106

nitrofurantoin macrocrystal 21

nitroglycerin 106

nitroglycerin in 5 dextrose 106

NIX CREME RINSE 135

nohist-dm 123

non-aspirin 5 8 10

non-aspirin child 8

non-aspirin childrens 8

non-aspirin cold 125

non-aspirin extra strength 5 9

non-aspirin flu 126

non-aspirin jr strength 5

non-aspirin pain relief 10

nora-be 115

NORDITROPIN FLEXPRO 179

norepinephrine bitartrate 100

norethindrone (contraceptive)

norethindrone acetate 181

norethindrone ac-eth estradiol

norethindrone-eestradiol-iron

norgestimate-ethinyl estradiol

norlyda 115

norlyroc 115

NORMOSOL-M IN 5

DEXTROSE 203

NORMOSOL-R PH 74 203

nortemp 9

NORTHERA 91

nortrel 0535 (28) 115

nortrel 135 (21) 115

nortrel 135 (28) 115

nortrel 777 (28) 116

nortriptyline 48

NORVIR 78

nose spray 153

NOVA SAFETY LANCETS 142

NOVA SUREFLEX LANCETS

NOVOLIN 7030 52

NOVOLIN N 52

NOVOLIN R 52

NOVOLOG 52

NOVOLOG FLEXPEN 52

NOVOLOG MIX 70-30 52

NOVOLOG MIX 70-30

FLEXPEN 52

NOVOLOG PENFILL 52

NOXAFIL 56

NUCALA 210

NUCYNTA 9

NUCYNTA ER 9

NUEDEXTA 109

nu-iron 224

NULOJIX 185

nu-mag 203

NUPLAZID 74

NUTRESTORE 165

NUTRILIPID 90

NUTROPIN AQ NUSPIN 179

NUVARING 116

nyamyc 56

nyata 56

nystatin 56

nystatin-triamcinolone 57

nystop 57

nytol 62

O OCALIVA 165

ocean nasal 153

ocella 116

OCREVUS 109

OCTAGAM 185

octreotide acetate 179

ocutabs 224

ODEFSEY 78

ODOMZO 37

odor control foot-sneaker 57

OFEV 210

off active 129

off deep woods 129

off deep woods dry 129

off familycare (with deet) 129

ofloxacin 29 156

ogestrel (28) 116

olanzapine 74

olmesartan 92

olopatadine 153

OLYSIO 80

omega-3 acid ethyl esters 104

omeprazole 160

omeprazole magnesium 160

OMNITROPE 180

ON CALL LANCET 142

ON CALL PLUS LANCET 142

ONCASPAR 37

onccor 224

once daily 224

oncovite 225

ondansetron 67

ondansetron hcl 67

ondansetron hcl (pf) 67

one daily 225 228

one daily complete 225

one daily energy 228

one daily essential 222 225

one daily for women 225

one daily gummy vites 225

one daily maximum 225 228

one daily multi-vit w-mineral

one daily multivitamin 225 229

one daily multivit-iron(folic) 225

one daily plus iron 222 225 228

one daily plus minerals 225

one daily with iron 224 225

one-a-day essential 225

one-a-day maximum formula225

one-a-day mens multivitamin

one-a-day teen advantage 225

ONETOUCH DELICA

LANCETS 142

ONETOUCH SURESOFT

LANCING DEV 142

ONETOUCH ULTRASOFT

LANCETS 142

ONFI 19

ONIVYDE 37

ON-THE-GO LANCETS 142

opcicon one-step 116

OPDIVO 37

OPSUMIT 213

option-2 116

oral saline laxative 170 172

oralone 127

oralyte 203

ORENCIA 185

ORENCIA CLICKJECT 185

ORENITRAM 213

ORFADIN 149

ORKAMBI 210

orsythia 116

oseltamivir 80

OTEZLA 185

OTEZLA STARTER 185

OTOVEL 153

OTREXUP (PF) 185

oxacillin 27

oxacillin in dextrose(iso-osm) 27

oxandrolone 175

oxcarbazepine 43

OXTELLAR XR 43

oxybutynin chloride 173

oxycodone 9

oxycodone-acetaminophen 9

oxycodone-aspirin 9

OXYCONTIN 9 10

oxymorphone 10

oysco 500d 225

oysco-500 203

oyster shell calcium 500 203

oyster shell calcium-vit d2 203

226 228

oystercal-d 226

P pacerone 94

pain and fever 10

pain relief 5

pain relief adult 5

pain reliever extra strength 6

pain reliever flu 125

pain reliever jr strength 11

paliperidone 74

PANRETIN 129

pantoprazole 160

paricalcitol 194 195

PARICALCITOL 194 195

paroex oral rinse 127

paromomycin 69

paroxetine hcl 48

PASER 65

PAXIL 48

p-col rite 171

pecgen dmx 123

pedia relief 125

pedia relief infant 126

pediacare fever reducer 10

pediacare multi-symptom cold

PEDIARIX (PF) 189

pediatric cough and cold 123

pediatric electrolyte 200 201

203 205

pediatric freezer pops 205

pediatric multivitamin 224 229

PEDVAX HIB (PF) 190

peg 3350-electrolytes 170

PEGANONE 43

PEGASYS 81

PEGASYS CONVENIENCE

PACK 81

PEGASYS PROCLICK 81

peg-electrolyte soln 170

PEGINTRON 81

PEN NEEDLE DIABETIC 142

penicillin g pot in dextrose 28

penicillin g potassium 28

penicillin g procaine 28

penicillin v potassium 28

PENTACEL (PF) 190

PENTACEL DTAP-IPV

COMPNT (PF) 190

PENTAM 69

pentoxifylline 85

pep-t-med 165

peri-colace 170

PERIKABIVEN 90

perindopril erbumine 93

periogard 127

permethrin 135

perphenazine 74

perphenazine-amitriptyline 48

perry prenatal 226

persa-gel 129

pfizerpen-g 28

pharbetol 10

pharmacist favorite multi-vit 226

phenadoz 67

phenelzine 48

phenobarbital 43

phenylephrine hcl 91 153

phenytoin 43

phenytoin sodium 44

phenytoin sodium extended 43

philith 116

phillips 165

phillips liqui-gels 170

PHOSLYRA 172

phosphate laxative 170

PHOSPHOLINE IODIDE 199

phytonadione (vitamin k1) 226

PICATO 129 130

pilocarpine hcl 127 199

pimozide 74

pimtrea (28) 116

pindolol 96

pink bismuth 166

pioglitazone 51

pioglitazone-glimepiride 51

pioglitazone-metformin 51

piperacillin-tazobactam 28

pirmella 116

piroxicam 14

PLASMA-LYTE 148 203

PLASMA-LYTE A 203

PLASMA-LYTE-56 IN 5

DEXTROSE 203

PLEGRIDY 109

pnv cmb95-ferrous fumarate-fa

podofilox 130

polycin 156

polyethylene glycol 3350 170

poly-iron 226

polymyxin b sulfate 21

poly-vita 226

poly-vita (iron) 226

poly-vitamin 226

polyvitamin with iron 226

poly-vitamin with iron 226

poly-vitamins 226

POMALYST 37

portia 116

PORTRAZZA 37

potassium acetate 203

potassium chloride 204

potassium chloride in lr-d5 204

potassium citrate 205

potassium citrate-citric acid 205

POTIGA 44

PRADAXA 83

PRALUENT PEN 104

pramipexole 70

prasugrel 85

pravastatin 104

prazosin 91

PRECISION XTRA TEST 142

prednicarbate 134

prednisolone acetate 158

158 177

prednisone 177 178

PREMARIN 176

PREMASOL 10 90

PREMASOL 6 90

PREMPHASE 176

PREMPRO 176

prenatal 223 227 229

prenatal formula 226

prenatal multivitamins 226

prenatal plus (calcium carb) 226

prenatal tablet 228

prenatal vitamin 218 226 227

prenatal vitamin plus low iron

prenatal vit-iron fum-folic ac 227

prenatal vits96-iron fum-folic

preparation h hydrocortisone 134

PRESSURE ACTIVATED

LANCETS 142

prevalite 104

previfem 116

PREZCOBIX 78

PREZISTA 78

PRIFTIN 65

PRILOSEC OTC 160

PRIMAQUINE 69

primidone 44

PRIVIGEN 185

PRO COMFORT LANCET 142

PROAIR HFA 208

PROAIR RESPICLICK 209

probenecid 58

probenecid-colchicine 58

procainamide 94

PROCALAMINE 3 90

prochlorperazine 67

prochlorperazine edisylate 67

prochlorperazine maleate 67

PROCRIT 84 85

procto-med hc 134

procto-pak 134

proctosol hc 134

proctozone-hc 134

PROCYSBI 149

PRODIGY LANCETS 143

PRODIGY TWIST TOP

LANCET 143

progesterone in oil 181

progesterone micronized 181

PROGLYCEM 197

PROGRAF 186

PROLASTIN-C 210

PROLENSA 158

PROLEUKIN 37

PROLIA 195

PROMACTA 85

promethazine 62 67 68

promethazine vc 62

promethazine-dm 123

promethegan 68

promolaxin 170

propafenone 94

propantheline 41

proparacaine 153

propranolol 96

propylthiouracil 181

PROQUAD (PF) 190

prosight 227

PROSOL 20 90

protamine 85

protriptyline 48

pseudoephedrine hcl 123

PULMOZYME 149

pure and gentle disposable 170

pure and gentle eye 153

purelax 168

PURIXAN 37

PUSH BUTTON SAFETY

LANCETS 143

pyrazinamide 65

pyridostigmine bromide 197

pyridoxine (vitamin b6) 227

Q QUADRACEL (PF) 190

quasense 116

quetiapine 74

QUFLORA 227

quinapril 93

quinapril-hydrochlorothiazide 94

quinidine sulfate 94

quinine sulfate 69

QVAR 207

R RABAVERT (PF) 190

RADICAVA 109

raloxifene 176

ramipril 94

RANEXA 100

ranitidine hcl 160 161

RAPAMUNE 186

rasagiline 70

RASUVO (PF) 186

RAVICTI 166

RAYALDEE 195

react 116

READYLANCE SAFETY

LANCETS 143

ready-to-use enema 168

REBIF (WITH ALBUMIN) 109

REBIF REBIDOSE 109

REBIF TITRATION PACK 109

reclipsen (28) 116

RECOMBIVAX HB (PF) 190

recort plus 134

refenesen 124

refenesen pe 124

REFRESH CELLUVISC 153

REFRESH CLASSIC (PF) 153

REFRESH LACRI-LUBE 153

REFRESH OPTIVE

ADVANCED 156

reguloid 171

RELENZA DISKHALER 80

RELIAMED LANCET 143

RELIAMED SAFETY SEAL

LANCETS 143

RELION THIN LANCETS 143

LANCETS 144

RELISTOR 166

remedy phytoplex antifungal 57

REMICADE 186

REMODULIN 213

RENAGEL 172

rena-vite rx 228

RENFLEXIS 197

RENVELA 172

repaglinide 51

repaglinide-metformin 51

REPATHA PUSHTRONEX 104

REPATHA SURECLICK 104

REPATHA SYRINGE 104

repel sportsmen 130

repel sportsmen max 130

reprexain 10

RESCRIPTOR 78

RESTASIS 158

RESTASIS MULTIDOSE 158

retaine cmc 153

retaine hpmc 153

retaine pm 153

RETROVIR 78

revive plus 151

REVLIMID 37

revonto 211

REXULTI 74

REYATAZ 78

ribasphere 82

ribavirin 82

RIDAURA 186

rifabutin 65

rifampin 65

RIFATER 65

ri-gel ii 166

right step prenatal vitamins 228

RIGHTEST GL300 LANCETS

riginic 166

riluzole 109

rimantadine 80

ri-mox 166

ringers 193 205

risedronate 195

RISPERDAL CONSTA 74

risperidone 74 75

RITUXAN 38

RITUXAN HYCELA 38

rivastigmine 46

rivastigmine tartrate 46

rizatriptan 64

robafen 124

robafen cough 124

robafen dm 124

robitussin cough-chest cong dm

robitussin pediatric 124

ropinirole 70

rosadan 131

rosuvastatin 105

ROTARIX 190

ROTATEQ VACCINE 190

ROWEEPRA 44

RUBRACA 38

RYDAPT 38

S SABRIL 44

safe tussin dm 124

SAFETY LANCETS 144

SAFETY SEAL LANCETS 144

SAFETY-LET LANCETS 144

SAIZEN 180

SAIZEN CLICKEASY 180

saline mist 153

saline nasal 151

saline nose 151

SANTYL 130

SAVELLA 109

scooby-doo one a day 228

scopolamine base 68

scot-tussin dm 124

scot-tussin expectorant 124

sea soft nasal mist 153

selegiline hcl 70

selenium sulfide 131

SELZENTRY 78

senexon 171

senexon-s 171

senior tabs 228

senna 171

senna lax 171

senna laxative 168

sennosides-docusate sodium 171

senokot-s 171

SENSIPAR 195

sentry 229

sentry (with lutein) 229

sentry senior 229

SEREVENT DISKUS 209

SEROSTIM 180

sertraline 48

setlakin 116

sevelamer carbonate 172

sharobel 116

SHINGRIX (PF) 191

SHINGRIX GE ANTIGEN

COMPONENT 191

SIGNIFOR 180

silace 171

siladryl sa 62

silapap 11

sildenafil (antihypertensive) 213

SILENOR 212

SILIQ 130

siltussin sa 125

silver sulfadiazine 131

SIMBRINZA 199

simethicone 159

SIMPONI 186

SIMPONI ARIA 186

simvastatin 105

SINGLE-LET 144

sinus and allergy(pseudoephed)

sinus pe decongestant 91

sinus relief (oxymetazoline) 154

sirolimus 186

SIRTURO 65

skin treatment 129

sleep aid (diphenhydramine) 62

sleep tablet (diphenhydramine)

SMART SENSE LANCETS 144

SMARTEST LANCET 144

smoflipid 90

smoothlax 172

sochlor 154

sodium acetate 205

sodium bicarbonate 166

sodium chloride 154 193 206

sodium chloride 045 205

sodium lactate 206

sodium phenylbutyrate 166

sodium phosphate 206

sodium polystyrene (sorb free)

sodium polystyrene sulfonate

SOFT TOUCH LANCETS 144

SOLIQUA 10033 53

SOLTAMOX 38

SOLU-CORTEF (PF) 178

SOLUS V2 LANCETS 144

SOMATULINE DEPOT 180

SOMAVERT 180

soothe (bismuth subsalicylate)

soothe night time lubricant 154

soothe regular strength 167

sorbitol 193

sorbitol-mannitol 193

sorine 96

sotalol 96

sotalol af 96

SOVALDI 80

spectravite adult 218

spectravite adult 50+ 218

spectravite advanced formula

spectravite senior 218

spectravite ultra mens sr 219

spectravite ultra women 219

SPIRIVA RESPIMAT 209

SPIRIVA WITH

HANDIHALER 209

spironolactone 102

spironolacton-hydrochlorothiaz

sprintec (28) 116

SPRITAM 44

SPRYCEL 38

sps (with sorbitol) 167

sronyx 116

ssd 131

st joseph aspirin 15

stavudine 78

STELARA 186

STERILANCE TL 145

STERILE PADS 145

STIOLTO RESPIMAT 209

STIVARGA 38

stomach relief 166

stool softener 172

stool softener (docusate cal) 172

stool softener-laxative 168

STRENSIQ 149

streptomycin 19

stress b with zinc 230

stress b-biotin 230

stress formula 230

stress formula 600 c 230

stress formula plus iron 230

stress formula with iron 230

stress formula with iron(sulf)230

stress formula with zinc 230

STRIBILD 79

STRIVERDI RESPIMAT 209

SUBOXONE 17

sucralfate 161

SUDAFED 125

sudogest 125

sudogest pe 91

sudogest sinus and allergy 62

sulfacetamide sodium 156

sulfacetamide sodium (acne) 131

sulfacetamide-prednisolone 156

sulfadiazine 29

sulfasalazine 193

sulfatrim 29

sulindac 15

sumatriptan 64

sumatriptan succinate 64 65

summers eve disposable douche

summers eve extra cleansing 197

sunvite 230

super b complex-vitamin c 219

super b maxi complex 230

super bc 230

super b-50 complex 230

super b-50 complex plus 230

super multiple 231

super multivitamin 231

super quints 231

super quints b-50 231

super thera vite m 231

SUPER THIN LANCETS 145

superior 35 231

superplex-t 231

suphedrin 125

suphedrine pe day-night 126

suphedrine severe cold max str

support 231

support-500 231

SUPPRELIN LA 180

SUPRAX 24

SURE COMFORT LANCETS

SURE-LANCE 145

SURE-LANCE ULTRA THIN

SURE-TOUCH LANCET 145

SURMONTIL 48

SUSTIVA 79

SUTENT 38

syeda 116

SYLATRON 81

SYLVANT 38

SYMBICORT 207

SYMLINPEN 120 51

SYMLINPEN 60 51

SYNAGIS 80

SYNAREL 180

SYNERCID 21

SYNJARDY 51

SYNJARDY XR 51

SYNRIBO 38

SYPRINE 174

SYSTANE GEL 154

SYSTANE LIQUID GEL 154

T tab-a-vite 231

tab-a-viteiron 231

tab-a-vite-minerals 231

TABLOID 38

tacrolimus 134 186

tactinal 11

tactinal extra strength 11

TAFINLAR 38

TAGRISSO 38

TALTZ AUTOINJECTOR 130

TALTZ SYRINGE 130

TAMIFLU 80

tamoxifen 38

tamsulosin 173

TARCEVA 38

TARGRETIN 38

tarina fe 120 (28) 116

TASIGNA 39

tazarotene 135

tazicef 24

TAZORAC 135

taztia xt 97

tears again 154

tears again (pva) 154

tears naturale free (pf) 154

TECENTRIQ 39

TECFIDERA 109 110

TECHLITE LANCETS 145

TECHNIVIE 80

TEFLARO 24

TEKAMLO 105

TEKTURNA 105

TEKTURNA HCT 105

TELCARE LANCETS 145

telmisartan 92

temazepam 19

TEMODAR 39

tencon 11

TENIVAC (PF) 191

terazosin 173

terbinafine hcl 57

terbutaline 209

terconazole 64

testosterone 175

testosterone cypionate 175

testosterone enanthate 175

PED(PF) 191

TETANUS-DIPHTHERIA

TOXOIDS-TD 191

tetrabenazine 110

THALOMID 198

the magic bullet 169

theophylline 209

theophylline in dextrose 5 209

thera 231

thera m plus (ferrous fumarat)

thera-d 231

theradex m 231

thera-m 231

therapeutic liquid 223

therapeutic m + beta-carotene

therapeutic-m 231

therapeutic-m vitaminminerals

thera-tabs 231

thera-tabs m 231

theratrum complete 50 plus 231

theratrum complete with lutein

therems 231

therems-m 232

THIN LANCETS 144

THIOLA 198

thioridazine 75

thiotepa 39

thiothixene 75

tiagabine 44

TICE BCG 191

tigecycline 30

tilia fe 116

timolol maleate 96 199

TIVICAY 79

tizanidine 211

tl icon 232

TOBI PODHALER 20

TOBRADEX 156

TOBRADEX ST 156

tobramycin 157

tobramycin in 0225 nacl 20

tobramycin sulfate 20

tobramycin-dexamethasone 157

TOLAK 130

tolazamide 53

tolbutamide 53

tolnaftate 57

tolterodine 173

TOPCARE UNIVERSAL1

LANCET 145

topiramate 44

toposar 39

torsemide 102

total bc 232

totalday multiple 232

TOTECT 198

TOUJEO SOLOSTAR 53

TOVIAZ 173

TPN ELECTROLYTES 206

TPN ELECTROLYTES II 206

TRACLEER 213

TRADJENTA 51

tramadol 11

tramadol-acetaminophen 11

trandolapril 94

tranexamic acid 85

TRANSDERM-SCOP 68

tranylcypromine 48

TRAVASOL 10 90

TRAVATAN Z 199

travel sickness 68

travel sickness (meclizine) 68

travel-ease (meclizine) 68

trazodone 49

TREANDA 39

TRECATOR 66

TRELEGY ELLIPTA 210

TRELSTAR 39

TREMFYA 130

tretinoin 135

tretinoin (chemotherapy) 39

TREXALL 39

tri femynor 116

triacting m-sym coldcough 127

triamcinolone acetonide 127 134

triaminic cold and cough (pe)

triamterene-hydrochlorothiazid

tri-buffered aspirin 15

tricon 232

tri-estarylla 117

trifluoperazine 75

trifluridine 157

trihexyphenidyl 70

tri-legest fe 117

tri-linyah 117

tri-lo-estarylla 117

tri-lo-marzia 117

tri-lo-sprintec 117

trilyte with flavor packets 172

trimethoprim 21

trimipramine 49

trinessa (28) 117

TRINTELLIX 49

triple antibiotic 131

triple paste af 57

tri-previfem (28) 117

TRIPTODUR 180

tri-sprintec (28) 117

TRIUMEQ 79

tri-vi-sol 232

tri-vita 232

tri-vitamin 232

trivora (28) 117

TROKENDI XR 44

TROPHAMINE 10 90

TROPHAMINE 6 90

trospium 173

trueplus glucose with vit d3 90

TRUEPLUS LANCETS 146

TRULICITY 51

TRUMENBA 191

TRUVADA 79

tusnel diabetic 126

TUSNEL NEW FORMULA 126

TUSSI PRES-B 126

tussin cf 125 127

tussin cough (dm only) 121 126

tussin cough-chest congestion

tussin cough-cold-flu 126

tussin dm 124 126

tussin dm max 125

tussin maximum strength 121

TWINRIX (PF) 191

TYBOST 198

TYKERB 39

tylophen 11

TYMLOS 195

TYPHIM VI 192

TYSABRI 186

TYVASO 213

U UCERIS 193

ULORIC 58

ULTILET BASIC LANCETS

ULTILET CLASSIC

LANCETS 146

ULTILET LANCETS 146

ULTILET SAFETY LANCETS

ultimate mens complete 50+ 230

ultra b-100 complex 232

ultra fresh pm 154

ultra sleep (doxylamine succ) 60

ULTRA THIN II LANCETS 147

ULTRA THIN LANCETS 138

ULTRA THIN PLUS

LANCETS 144

ULTRA TLC LANCETS 147

ULTRALANCE LANCETS 146

ULTRA-THIN II LANCETS147

unicomplex-m 232

UNILET COMFORTOUCH

LANCET 147

UNILET EXCELITE II

LANCET 147

UNILET EXCELITE LANCET

UNILET GP LANCET 147

UNILET LANCET 147

UNILET SUPER THIN

LANCETS 147

unisom (diphenhydramine) 63

unisom (doxylamine) 63

unisom sleepgels 62

UNISTIK 3 COMFORT

LANCET 147

UNISTIK 3 EXTRA LANCET

UNISTIK 3 GENTLE 147

UNISTIK 3 LANCETS 147

UNISTIK 3 NORMAL

LANCET 147

UNISTIK CZT LANCET 147

UNISTIK SAFETY 148

UNISTIK TOUCH LANCETS

UNITUXIN 39

UNIVERSAL 1 LANCETS 140

141 148

UPTRAVI 214

ursodiol 167

V vagistat-3 57

valacyclovir 82

VALCHLOR 130

valganciclovir 82

valproate sodium 44

valproic acid 45

valproic acid (as sodium salt) 45

valsartan 92

valsartan-hydrochlorothiazide 92

VALSTAR 39

valu-dryl allergy 63

vancomycin 22

vancomycin in dextrose 5 21

VAQTA (PF) 192

VARIVAX (PF) 192

VASCEPA 105

v-c forte 232

VELCADE 39

velivet triphasic regimen (28)

VELPHORO 172

VELTASSA 167

VEMLIDY 79

VENCLEXTA 39 40

VENCLEXTA STARTING

PACK 40

venlafaxine 49

verapamil 97

VERSACLOZ 75

VERZENIO 40

VESICARE 173

vestura (28) 117

VGO 40 148

VIBERZI 167

vic-forte 232

vicks dayquil cold-flu relief 126

vicks dayquil cough 126

vicks nyquil coldflu liquicap

VICKS NYQUIL NIGHTTIME

RELIEF 126

vicks qlearquil(oxymetazoline)

vicks sinex 12-hour 154

VICTOZA 51

VIEKIRA PAK 80

VIEKIRA XR 80

vienva 117

vigabatrin 45

VIGAMOX 157

VIIBRYD 49

VIMIZIM 149

VIMPAT 45

vinorelbine 40

viorele (28) 117

VIRACEPT 79

VIREAD 79

vision 232

vision plus lutein 232

VISTOGARD 198

vit b complex-folic acid 215

230 233

vitalets 232

vitamin a 232

vitamin b complex 215 227

vitamin b complex with c 232

vitamin b-1 218 232

vitamin b12-folic acid 233

vitamin b-6 233

vitamin c 228 233

vitamin d3 228 230 233 234

vitamin k 234

vitamin k1 234

vitamins and minerals 232

vitamins b complex 215 232

vitamins for hair 234

vitatrum 234

vitrum senior 234

vol-care rx 234

VOLTAREN 130

voriconazole 57

VOSEVI 81

VOTRIENT 40

VPRIV 150

vp-vite rx 234

VRAYLAR 75

vyfemla (28) 117

VYXEOS 40

W wal-act d cold and allergy 63

wal-dram 68

wal-dryl allergy 63

wal-fex allergy 63

wal-finate 63

wal-finate-d 63

wal-itin 59 63

wal-itin d 63

wal-itin d 12 hour 63

wal-phed 63 127

wal-phed pe 91

wal-phed pe day-night 127

wal-phed pe sinus and allergy 63

wal-profen 15

wal-sleep z 63

wal-som (diphenhydramine) 63

wal-som (doxylamine) 63

wal-tap 64

wal-tussin 127

wal-tussin cough 127

wal-tussin dm 118

wal-tussin max strength cough

wal-zan 75 161

wal-zyr (cetirizine) 64

wal-zyr d 64

warfarin 83

water for irrigation sterile 193

WELCHOL 105

wera (28) 117

womans laxative 172

womens daily gummies 219

womens stool softener 172

X XADAGO 71

XALKORI 40

XARELTO 83

XATMEP 40

XELJANZ 186

XELJANZ XR 187

XERMELO 167

XIFAXAN 22

XOLAIR 211

XTAMPZA ER 11

XTANDI 40

xulane 117

XULTOPHY 10036 53

XURIDEN 198

XYREM 212

Y yelets 234

YERVOY 40

YF-VAX (PF) 192

YONDELIS 40

yuvafem 176

Z zafirlukast 207

zaleplon 212

zantac 75 161

zarah 117

ZARXIO 85

ZAVESCA 150

zebutal 11

ZEJULA 40

ZELBORAF 40

zenatane 130

zenchent (28) 117

ZENPEP 150

ZEPATIER 81

zephrex-d 127

ZERIT 79

ZIAGEN 79

zidovudine 79

ZINBRYTA 110

zinc oxide 129 130

ZIOPTAN (PF) 199

ziprasidone hcl 75

ZIRGAN 157

ZOLADEX 40

zoledronic acid 195

ZOLINZA 40

zolmitriptan 65

zolpidem 212

ZOMACTON 180 181

ZOMETA 195

zonisamide 45

zoo chews 2

ZORBTIVE 181

ZORTRESS 187

ZOSTAVAX (PF) 192

zovia 135e (28) 117

zovia 150e (28) 118

z-sleep 61 62

ZUBSOLV 17

ZURAMPIC 58

ZYDELIG 41

ZYKADIA 41

ZYLET 157

zyncof 127

ZYPREXA RELPREVV 75

ZYRTEC 64

ZYTIGA 41

01201801201818001 Version 11

Centers Plan for FIDA Care Complete Participant Services75 Vanderbilt AvenueStaten Island NY 10304Telephone 1-800-466-2745Pharmacy Help Line 1-888-266-7460TTY 1-800-421-1220 or 711Days amp Hours of Operation Seven days a week from 8 am to 8 pmEmail MemberServicescentersplancomWebsite wwwcentersplancomfida

Centers Plan for FIDA Care Complete (Medicare-Medicaid Plan)2018 List of Covered Drugs (Drug List)



























Table of Contents

INDEX

1

3

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

more information visit wwwcentersplancomfida i

2018 List of Covered Drugs (Drug List)

For More Information visit wwwcentersplancomfida

Effective Date Last Updated Formulary ID

012018 012018

18001 Version 11

2745（TTY1-800-421-1220）

Russian

French

Creole

pou ou Rele 1-800-466-2745 (TTY 1-800-421-1220)

Italian

421-1220)

(TTY 1-800-421-1220) 1-800-466-2745 רופט אפצאל

2745 (TTY 1-800-421-1220)

Tagalog

(TTY 1-800-421-1220)

other formats)

1-800-368-1019 800-537-7697 (TDD)

800-421-1220)

am to 8 pm

rive 8 pm

de 8 am a 8 pm

pharmacy

711 or 1-800-421-1220

take now

drug For example

second

what to do next

on your drug

are covered

of this document

Restriction

PA BvD

Prior Authorization

Restriction

Part B vs Part D

Determination

Restriction for

New Starts Only

of this document

formulary

drug or product

day supply

heart conditions

Analgesics 3

Anesthetics 15

Antibacterials 19

Anticonvulsants 41

Antidepressants 46

Antifungals 53

Antigout Agents 57

Antihistamines 58

Table of Contents

Caloric Agents 85

Contraceptives 110

Devices 135

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Analgesics

120 mg 4 $0

QL (30 per 30 days)

325 mg 4 $0

QL (30 per 30 days)

650 mg 4 $0

QL (30 per 30 days)

(Mapap

mg (Acephen) 4 $0

QL (30 per 30 days)

childrens 80 mg

(Childrens

Acetaminophen) 4 $0

QL (30 per 30 days)

300-15 mg 1 $0

300-30 mg

(Tylenol-Codeine

3) 1 $0

300-60 mg

(Tylenol-Codeine

4) 1 $0

30-50-325-40 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

MCG 300 MCG 450 MCG 600

QL (60 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

03 mgml 1 $0

mcghour

(Butrans) 1 $0

QL (4 per 28 days)

capsule 30-50-325-40 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

capsule 50-300-40-30 mg 50-325-

40-30 mg

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

tablet 50-325-40 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

BUTRANS TRANSDERMAL

PATCH WEEKLY 75

MCGHOUR

QL (4 per 28 days)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml 4 $0

mg 4 $0

QL (30 per 30 days)

mg 4 $0

QL (30 per 30 days)

mg 4 $0

QL (30 per 30 days)

mg 60 mg 1 $0

caplet 650 mg

(8 Hour Pain

Reliever) 4 $0

650 mg 4 $0

mg 4 $0

QL (30 per 30 days)

mg 4 $0

mg15 ml 4 $0

325 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Actiq) 1 $0

PA QL (120 per 30

days) NDS

50 mcghr 75 mcghr

(Duragesic) 1 $0

QL (10 per 30 days)

QL (30 per 30 days)

inner 650 mg 4 $0

QL (30 per 30 days)

mg75ml(75ml)

tablet 5-325 mg

(Lorcet

(hydrocodone)) 1 $0

75-200 mg 1 $0

mgml 4 mgml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

HYSINGLA ER ORAL

TABLETORAL

120 MG 20 MG 30 MG 40 MG

60 MG 80 MG

QL (30 per 30 days)

mgml 4 $0

QL (30 per 30 days)

mg 4 $0

QL (30 per 30 days)

PA QL (30 per 30

days) NDS

325 mg 1 $0

ml 4 $0

mg5 ml 4 $0

500 mg 4 $0

mg15 ml 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml 1 $0

ml 5 mg5 ml 1 $0

100 mg5 ml (20 mgml) 1 $0

(4 mgml) 1 $0

MG 2 $0

QL (60 per 30 days)

QL (90 per 30 days)

mgml 1 $0

QL (30 per 30 days)

mg 4 $0

QL (30 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg15 ml 4 $0

mg08 ml 4 $0

QL (30 per 30 days)

MG 150 MG 200 MG 250 MG 50

QL (60 per 30 days)

MG 50 MG 75 MG 2 $0

mgml 1 $0

(OxyContin) 1 $0

QL (60 per 30 days)

48355-325 mg 1 $0

OXYCONTIN ORAL

TABLETORAL

MG 20 MG 30 MG 40 MG 60

QL (60 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

OXYCONTIN ORAL

TABLETORAL

30 mg 40 mg 5 mg 75 mg

QL (60 per 30 days)

mg5 ml 4 $0

caplet 500 mg 4 $0

QL (30 per 30 days)

ml 4 $0

QL (30 per 30 days)

meltssf 160 mg 4 $0

QL (30 per 30 days)

650 mg

(8 Hour Pain

Reliever) 4 $0

QL (30 per 30 days)

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg08 ml 4 $0

QL (30 per 30 days)

650 mg 4 $0

QL (30 per 30 days)

500 mg 4 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

375-325 mg (Ultracet) 1 $0

XTAMPZA ER ORAL

QL (60 per 30 days)

XTAMPZA ER ORAL

TMPRR 27 MG

XTAMPZA ER ORAL

TMPRR 36 MG

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

Agents

CHEW TB CHEW8

HOURGRAPE 100 MG

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Adult Aspirin

Regimen) 4 $0

mg 4 $0

MGML) 800 MG8 ML (100

QL (60 per 30 days)

mg125 ml 4 $0

ML (OTC) 100 MG5 ML 4 $0

mg 4 $0

mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

50 mg 75 mg

mg-mcg

(Arthrotec 50) 1 $0

mg-mcg

(Arthrotec 75) 1 $0

coated 325 mg 4 $0

mg 1 $0

100 mg5 ml 4 $0

mg 4 $0

mg 800 mg 1 $0

PA-HRM QL (240 per

30 days) AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM QL (120 per

30 days) AGE (Max

64 Years)

release 75 mg 1 $0

PA-HRM QL (60 per

30 days) AGE (Max

64 Years)

mg125 ml 4 $0

ml 4 $0

mg 1 $0

PA-HRM QL (20 per

30 days) AGE (Max

64 Years)

ml 1 $0

mg 1 $0

ml (Naprosyn) 1 $0

mg 1 $0

mg (Feldene) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

orange 81 mg 4 $0

200 mg 4 $0

Anesthetics

Local Anesthetics

applicator 2 1 $0

mgml (1 ) 15 mgml (15 ) 20

mgml (2 ) 5 mgml (05 )

mgml (4 ) 1 $0

mgml (1 ) 20 mgml (2 ) 5

mgml (05 )

(Xylocaine) 1 $0

jelly 2 1 $0

PA QL (90 per 30

solution 2 1 $0

25-25 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Treatment Agents

03 MG 2 $0

QL (30 per 30 days)

07 MG 63-1 MG 2 $0

QL (60 per 30 days)

2 mg 8 mg 1 $0

QL (90 per 30 days)

tablet 2-05 mg 8-2 mg 1 $0

QL (90 per 30 days)

(Zyban) 1 $0

CHANTIX CONTINUING

MG 1 MG 2 $0

PACK 05 MG (11)- 1 MG (42)

QL (53 per 28 days)

mg (Antabuse) 1 $0

mgml 1 $0

mgml 1 mgml 1 $0

MGACTUATION

QL (4 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

NICOTROL INHALATION

12-3 MG 8-2 MG 2 $0

QL (60 per 30 days)

2-05 MG 4-1 MG 2 $0

QL (30 per 30 days)

ZUBSOLV SUBLINGUAL

TABLET 07-018 MG 14-036

MG 114-29 MG 29-071 MG

57-14 MG

QL (30 per 30 days)

ZUBSOLV SUBLINGUAL

QL (60 per 30 days)

Antianxiety Agents

Benzodiazepines

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

30 mg 5 mg 75 mg 1 $0

10 mg 25 mg 5 mg 1 $0

clonazepam oral

mg 05 mg 1 mg

QL (90 per 30 days)

clonazepam oral

15 mg 375 mg 1 $0

KIT 125-15-175-20 MG 5-75-10

5 mgml 1 $0

mgml) 1 $0

mg (Valium) 1 $0

QL (2 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MGML 2 $0

PA NSO QL (480 per

30 days) NDS

MG 2 $0

PA NSO QL (60 per

30 days) NDS

mg (Restoril) 1 $0

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any benzodiazepine

per 30 days) AGE

(Max 64 Years)

Antibacterials

Aminoglycosides

BETHKIS INHALATION

SOLUTION FOR

PA BvD NDS

mg6 ml 1 $0

ml 100 mg50 ml 120 mg100 ml

60 mg50 ml 70 mg50 ml 80

mg100 ml 80 mg50 ml 90 mg100

mgml 1 $0

soln 1 gram 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CAPSULE WINHALATION

DEVICE 28 MG

300 mg5 ml

(Tobi) 1 $0

PA BvD NDS

ml 600 mg50 ml 900 mg50 ml

(Cleocin in 5

dextrose) 1 $0

soln 75 mg5 ml 1 $0

recon soln 150 mg

(Coly-Mycin M

Parenteral) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg300 ml 1 $0

gram (Hiprex) 1 $0

(Metro IV) 1 $0

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use of

AGE (Max 64 Years)

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use of

QL (60 per 30 days)

AGE (Max 64 Years)

soln 500000 unit 1 $0

ml 500 mg100 ml 750 mg150 ml

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

750 mg

MG 2 $0

PA QL (9 per 30

days) NDS

MG 2 $0

PA NDS

Cephalosporins

mg 1 $0

mg5 ml 375 mg5 ml

mg5 ml

gram 1 $0

mg5 ml

GRAM50 ML 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ML 2 GRAM50 ML 2 $0

gram 500 mg 1 $0

gram50 ml 1 $0

gram 10 gram 1 $0

gram 1 $0

mg 1 $0

mg5 ml

gram 250 mg 500 mg 1 $0

gram 2 gram 1 $0

mg 500 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml

mg 1 $0

OSM) INTRAVENOUS

GRAM50 ML

MG 2 $0

SUPRAX ORAL

200 MG

2 gram 6 gram 1 $0

TEFLARO INTRAVENOUS

Macrolides

mg5 ml

(Zithromax) 1 $0

pack) 500 mg (3 pack) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml

500 mg 1 $0

days) NDS

ERYPED 200 ORAL

SUSPENSION FOR

ERYPED 400 ORAL

SUSPENSION FOR

(drec) 250 mg 500 mg 1 $0

ERY-TAB ORAL

(DREC) 333 MG

250 mg 1 $0

tablet 400 mg (EES 400) 1 $0

500 mg 1 $0

Antibiotics

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CAYSTON INHALATION

SOLUTION FOR

LA NDS

SOLN 1 GRAM 2 $0

Penicillins

500 mg 1 $0

mg 1 $0

mg 250 mg 1 $0

285 mg5 ml 400-57 mg5 ml

625 mg5 ml

(Augmentin) 1 $0

429 mg5 ml

(Augmentin ES-

600) 1 $0

tablet 250-125 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 1 $0

mg5 ml

gram 250 mg 500 mg

soln 2 gram 1 $0

(Unasyn) 1 $0

BICILLIN C-R

1200000 UNIT 2

ML(600K600K) 1200000 UNIT

2 ML(900K300K)

BICILLIN L-A

1200000 UNIT2 ML 2400000

500 mg 1 $0

2 gram 1 $0

gram 1 $0

ml 2 gram50 ml

gram 2 gram 1 $0

gram 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

million unit50 ml

600000 unitml

soln 125 mg5 ml 250 mg5 ml 1 $0

250 mg 500 mg 1 $0

million unit 1 $0

45 gram 405 gram

(Zosyn) 1 $0

Quinolones

MG 2 $0

PA QL (28 per 14

days) NDS

750 mg 1 $0

500 mg (Cipro) 1 $0

(Cipro in D5W) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ciprofloxacin oral

mg5 ml 500 mg5 ml

(Cipro) 1 $0

mg100 ml 750 mg150 ml

mgml 1 $0

mg10 ml 1 $0

mg 1 $0

Sulfonamides

mg5 ml 1 $0

Tetracyclines

100 mg 1 $0

mg 20 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

capsule 150 mg 1 $0

mg5 ml

(Vibramycin) 1 $0

150 mg 50 mg 75 mg 1 $0

mg 75 mg 1 $0

Anticancer Agents

SUSPENSION FOR

mg5 ml 20 mg10 ml 1 $0

PA BvD

gram50 ml 500 mg10 ml 1 $0

PA BvD

MG 3 MG 5 MG

PA NSO QL (112 per

28 days) NDS

MG 2 $0

PA NSO QL (56 per

28 days) NDS

MG 5 MG 75 MG 2 $0

PA NSO QL (28 per

28 days) NDS

MG 2 $0

PA NSO QL (240 per

30 days) NDS

ALIMTA INTRAVENOUS

ALIQOPA INTRAVENOUS

PA NSO QL (3 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

PA NSO QL (180 per

30 days) NDS

AVASTIN INTRAVENOUS

SOLUTION 25 MGML 25

MGML (16 ML)

PA NSO NDS

mg (Vidaza) 1 $0

PA NSO NDS

BENDEKA INTRAVENOUS

PA NSO NDS

MGML INITIAL)

PA NSO NDS

30 days) NDS

PA BvD

unit 1 $0

PA BvD

35 MCG 2 $0

PA NSO QL (140 per

365 days) NDS

MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 2 $0

PA NSO QL (30 per

30 days) NDS

MG 60 MG 2 $0

PA NSO QL (30 per

30 days) NDS

MG 2 $0

PA NSO QL (60 per

30 days) NDS

100 MG 2 $0

PA NSO QL (60 per

30 days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

PA NSO QL (60 per

30 days) NDS

MG 2 $0

PA NSO QL (30 per

30 days) NDS

PA NSO QL (112 per

28 days) NDS

MG 2 $0

PA NSO LA QL (63

per 28 days) NDS

PA BvD NDS

PA BvD ST

CYRAMZA INTRAVENOUS

SOLUTION 10 MGML 10

MGML (50 ML)

PA NSO NDS

PA NSO LA NDS

mg25 ml

(Adriamycin) 1 $0

PA BvD

PA BvD NDS

MG 300 MG 400 MG 2 $0

ELIGARD (3 MONTH)

ELIGARD (4 MONTH)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ELIGARD (6 MONTH)

MG 2 $0

PA NSO NDS

MG 2 $0

PA NSO QL (30 per

30 days) NDS

mgml (Toposar) 1 $0

MG 2 $0

MG 15 MG 20 MG 2 $0

PA NSO NDS

gram 1 $0

PA BvD

gram20 ml 1 $0

PA BvD

GAZYVA INTRAVENOUS

PA NSO NDS

MG 30 MG 40 MG 2 $0

PA NSO QL (30 per

30 days) NDS

MG 100 MG 40 MG 5 MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA NSO NDS

MG 2 $0

MG 125 MG 75 MG 2 $0

PA NSO QL (21 per

28 days) NDS

30 days) NDS

50 MG 2 $0

PA NSO QL (30 per

30 days) NDS

PA BvD

1 gram 3000-1000 mg 1 $0

PA BvD NDS

30 days) NDS

140 MG 2 $0

PA NSO NDS

IMFINZI INTRAVENOUS

SOLUTION 50 MGML 50

MGML (10 ML)

PA NSO NDS

IMLYGIC INJECTION

MILLION) PFUML

PA NSO QL (4 per

365 days) NDS

IMLYGIC INJECTION

MILLION) PFUML

PA NSO QL (8 per 28

days) NDS

30 days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

30 days) NDS

IXEMPRA INTRAVENOUS

15 MG 20 MG 25 MG 5 MG 2 $0

PA NSO QL (60 per

30 days) NDS

PA NSO QL (4 per 21

days) NDS

PA NSO QL (8 per 21

days) NDS

MG X 1)-25 MG

PA NSO QL (49 per

28 days) NDS

MG X 2)-25 MG

PA NSO QL (70 per

28 days) NDS

MG X 3)-25 MG

PA NSO QL (91 per

28 days) NDS

MGDAY (200 MG X 1) 400

MGDAY (200 MG X 2) 600

MGDAY (200 MG X 3)

PA NSO QL (63 per

28 days) NDS

PA NSO NDS

PA NSO LA NDS

X2) 20 MGDAY (10 MG X 2) 24

MGDAY (4 MG X 2)

PA NSO NDS

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg02 ml 1 $0

614 MG 2 $0

PA NSO QL (100 per

28 days) NDS

819 MG 2 $0

PA NSO QL (80 per

28 days) NDS

KIT 1125 MG 225 MG

KIT 30 MG

KIT 45 MG

LUPRON DEPOT

KIT 375 MG 75 MG

MG 2 $0

PA NSO QL (448 per

28 days) NDS

MG 150 MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 2 $0

(Max 64 Years)

MG 2 $0

PA NSO QL (90 per

30 days) NDS

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA BvD

mg 1 $0

PA BvD ST

INITIAL CONC)

PA NSO NDS

MG 2 $0

PA NSO QL (180 per

30 days) NDS

MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 3 MG 4 MG 2 $0

PA NSO QL (3 per 28

days) NDS

MG 2 $0

PA NSO LA NDS

ONCASPAR INJECTION

PA NSO NDS

ONIVYDE INTRAVENOUS

PA BvD NDS

OPDIVO INTRAVENOUS

MG4 ML

PA NSO NDS

MG 2 MG 3 MG 4 MG 2 $0

PA NSO QL (21 per

28 days) NDS

PA NSO QL (100 per

21 days) NDS

20 MGML 2 $0

MG 15 MG 25 MG 20 MG 25

MG 5 MG

PA NSO LA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

RITUXAN HYCELA

1400 MG117 ML (120 MGML)

1600 MG134 ML (120 MGML)

PA NSO NDS

RITUXAN INTRAVENOUS

PA NSO NDS

MG 250 MG 300 MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 2 $0

PA NSO QL (224 per

28 days) NDS

10 MG5 ML 2 $0

MG 140 MG 50 MG 70 MG 80

PA NSO QL (30 per

30 days) NDS

MG 2 $0

PA NSO QL (84 per

28 days) NDS

MG 25 MG 375 MG 50 MG 2 $0

PA NSO QL (30 per

30 days) NDS

SYLVANT INTRAVENOUS

PA NSO NDS

PA NSO QL (28 per

28 days) NDS

MG 75 MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 80 MG 2 $0

PA NSO LA QL (30

per 30 days) NDS

MG 25 MG 2 $0

PA NSO QL (60 per

30 days) NDS

MG 2 $0

PA NSO QL (90 per

30 days) NDS

28 days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 200 MG 2 $0

PA NSO QL (112 per

28 days) NDS

PA NSO QL (20 per

21 days) NDS

TEMODAR INTRAVENOUS

PA NSO NDS

mgml 1 $0

TREANDA INTRAVENOUS

QL (1 per 84 days)

QL (1 per 168 days)

QL (1 per 84 days)

QL (1 per 168 days)

capsule 10 mg 1 $0

MG 15 MG 5 MG 75 MG 2 $0

PA BvD ST

PA NSO NDS

SOLN 35 MG 2 $0

PA NSO NDS

MG 2 $0

PA NSO LA QL (60

per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100 MG 2 $0

PA NSO LA QL (120

per 30 days) NDS

MG 2 $0

PA NSO LA QL (30

per 30 days)

MG-50 MG- 100 MG

PA NSO LA QL (42

per 28 days) NDS

MG 150 MG 200 MG 50 MG 2 $0

PA NSO QL (56 per

28 days) NDS

MG 2 $0

PA NSO QL (120 per

30 days) NDS

VYXEOS INTRAVENOUS

PA BvD NDS

MG 250 MG 2 $0

PA NSO QL (60 per

30 days) NDS

MGML 2 $0

PA BvD ST

30 days) NDS

YERVOY INTRAVENOUS

MGML) 50 MG10 ML (5

PA NSO NDS

MG 2 $0

PA NSO QL (90 per

30 days) NDS

MG 2 $0

PA NSO QL (240 per

30 days) NDS

IMPLANT 108 MG 2 $0

QL (1 per 84 days)

IMPLANT 36 MG 2 $0

QL (1 per 28 days)

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 150 MG 2 $0

PA NSO QL (60 per

30 days) NDS

MG 2 $0

PA NSO QL (140 per

28 days) NDS

500 MG 2 $0

PA NSO QL (120 per

30 days) NDS

mgml 01 mgml 1 $0

Anticonvulsants

400 MG 600 MG 800 MG 2 $0

ST NDS

MGML 2 $0

ST NDS

MG 400 MG 2 $0

ST NDS

QL (80 per 30 days)

MGML 2 $0

MG 100 MG 25 MG 50 MG 75

QL (60 per 30 days)

300 mg

(Carbatrol) 1 $0

(Tegretol XR) 1 $0

100 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

MG 1 $0

sprinkle 125 mg

(Depakote

Sprinkles) 1 $0

(Depakote) 1 $0

ml (Zarontin) 1 $0

ml (Felbatol) 1 $0

mg (Felbatol) 1 $0

05 MGML 2 $0

ml (Neurontin) 1 $0

mg (Neurontin) 1 $0

MG 16 MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 250 mg 300 mg 50 mg

(Lamictal XR) 1 $0

mgml (Keppra) 1 $0

250 mg 500 mg 750 mg (Keppra) 1 $0

MG 150 MG 200 MG 225 MG 25

MG 300 MG 50 MG 75 MG

QL (90 per 30 days)

MGML 2 $0

MG 300 MG 600 MG

MG 2 $0

(4 mgml) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

15 mg 162 mg 30 mg 324 mg 60

mg 648 mg 972 mg

PA NSO-HRM AGE

(Max 64 Years)

capsule 100 mg

(Dilantin

Extended) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

300 MG 400 MG 2 $0

ST QL (90 per 30

days) NDS

1000 MG 500 MG 750 MG 1 $0

PACKET 500 MG 2 $0

ST QL (60 per 30

750 MG

ST QL (120 per 30

24hr 100 mg 150 mg 200 mg 25

mg 50 mg

(Qudexy XR) 1 $0

TROKENDI XR ORAL

24HR 100 MG 25 MG 50 MG

ST QL (30 per 30

TROKENDI XR ORAL

24HR 200 MG

ST QL (60 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

VIMPAT INTRAVENOUS

ST QL (200 per 5

MGML 2 $0

ST QL (1200 per 30

150 MG 200 MG 50 MG 2 $0

ST QL (60 per 30

mg (Zonegran) 1 $0

Antidementia Agents

10 mg 5 mg 1 $0

QL (30 per 30 days)

QL (60 per 30 days)

(Namenda Titration

Pak) 1 $0

QL (49 per 28 days)

NAMENDA XR ORAL

PACK 7-14-21-28 MG

QL (28 per 28 days)

NAMENDA XR ORAL

14 MG 21 MG 28 MG 7 MG

QL (30 per 30 days)

NAMZARIC ORAL

PACK 7142128 MG-10 MG

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

NAMZARIC ORAL

14-10 MG 21-10 MG 28-10 MG

7-10 MG

QL (30 per 30 days)

15 mg 3 mg 45 mg 6 mg 1 $0

QL (60 per 30 days)

95 mg24 hr

(Exelon) 1 $0

QL (30 per 30 days)

Antidepressants

mg 150 mg 25 mg 50 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

mg 25 mg 50 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

75 mg 1 $0

QL (30 per 30 days)

PA NSO-HRM AGE

(Max 64 Years)

mg (Norpramin) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

mg 50 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

mg 50 mg

(Pristiq) 1 $0

QL (30 per 30 days)

mg 150 mg 25 mg 50 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Max 64 Years)

QL (60 per 30 days)

QL (30 per 30 days)

EMSAM TRANSDERMAL

MG24 HR 9 MG24 HR

QL (30 per 30 days)

mg5 ml 1 $0

(2)- 40 MG (26)

ST QL (56 per 365

FETZIMA ORAL

24 HR 120 MG 20 MG 40 MG 80

ST QL (30 per 30

QL (4 per 28 days)

(4 mgml) 1 $0

mg 50 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

100 mg 125 mg 150 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 75 mg 1 $0

MG 2 $0

mirtazapine oral

mg 200 mg 250 mg 50 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

ml 1 $0

PA NSO-HRM AGE

(Max 64 Years)

PA NSO-HRM AGE

(Max 64 Years)

(Paxil CR) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

MG5 ML 2 $0

PA NSO-HRM AGE

(Max 64 Years)

4-25 mg 4-50 mg

PA NSO-HRM AGE

(Max 64 Years)

mgml (Zoloft) 1 $0

100 MG 25 MG 50 MG 2 $0

PA NSO-HRM AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 300 mg 50 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

MG 20 MG 5 MG 2 $0

ST QL (30 per 30

QL (30 per 30 days)

QL (90 per 30 days)

mg 375 mg 50 mg 75 mg 1 $0

20 MG 40 MG 2 $0

ST QL (30 per 30

PACK 10 MG (7)- 20 MG (23) 2 $0

ST QL (30 per 180

Antidiabetic Agents

QL (90 per 30 days)

MG 2 $0

GLUCAGEN HYPOKIT

MG 25-5 MG 2 $0

ST QL (30 per 30

150-1000 MG 150-500 MG 50-

1000 MG

ST QL (60 per 30

500 MG 2 $0

ST QL (120 per 30

INVOKAMET XR ORAL

24HR 150-1000 MG 150-500 MG

50-1000 MG 50-500 MG

ST QL (60 per 30

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

ST QL (60 per 30

MG 2 $0

ST QL (30 per 30

1000 MG 50-500 MG 2 $0

QL (60 per 30 days)

1000 MG

QL (30 per 30 days)

MG 50-500 MG

QL (60 per 30 days)

MG 25 MG 50 MG 2 $0

QL (30 per 30 days)

MG 25 MG 2 $0

ST QL (30 per 30

25-1000 MG 25-500 MG 25-850

QL (60 per 30 days)

JENTADUETO XR ORAL

24HR 25-1000 MG

QL (60 per 30 days)

JENTADUETO XR ORAL

24HR 5-1000 MG

QL (30 per 30 days)

MG 2 $0

PA QL (112 per 28

days) NDS

QL (90 per 30 days)

50 mg (Glyset) 1 $0

QL (90 per 30 days)

mg (Starlix) 1 $0

QL (90 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (30 per 30 days)

30-2 mg 30-4 mg (DUETACT) 1 $0

QL (30 per 30 days)

QL (90 per 30 days)

500 mg 2-500 mg 1 $0

SYMLINPEN 120

SUBCUTANEOUS PEN

PA QL (108 per 28

days) NDS

SYMLINPEN 60

SUBCUTANEOUS PEN

PA QL (108 per 28

days) NDS

1000 MG 125-500 MG 5-1000

MG 5-500 MG

ST QL (60 per 30

MG 25-1000 MG

ST QL (30 per 30

1000 MG 5-1000 MG

ST QL (60 per 30

MG 2 $0

QL (30 per 30 days)

15 MG05 ML

QL (2 per 28 days)

VICTOZA 3-PAK

SUBCUTANEOUS PEN

MG3 ML)

QL (9 per 30 days)

Insulins

FIASP FLEXTOUCH

100 UNITML (3 ML)

QL (30 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

FIASP SUBCUTANEOUS

QL (40 per 28 days)

QL (24 per 28 days)

HUMULIN R U-500

(CONCENTRATED)

500 UNITML

QL (40 per 28 days)

LANTUS SOLOSTAR

100 UNITML (3 ML)

QL (30 per 28 days)

LANTUS SUBCUTANEOUS

QL (40 per 28 days)

NOVOLIN 7030

100 UNITML (70-30)

QL (40 per 28 days)

NOVOLIN R INJECTION

QL (40 per 28 days)

NOVOLOG FLEXPEN

100 UNITML

QL (30 per 28 days)

100 UNITML (70-30)

QL (30 per 28 days)

NOVOLOG MIX 70-30

100 UNITML (70-30)

QL (40 per 28 days)

NOVOLOG PENFILL

100 UNITML

QL (30 per 28 days)

QL (40 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

SOLIQUA 10033

100 UNIT-33 MCGML

ST QL (30 per 30

TOUJEO SOLOSTAR

300 UNITML (15 ML)

XULTOPHY 10036

ST QL (15 per 28

Sulfonylureas

QL (60 per 30 days)

QL (30 per 30 days)

250 mg 1 $0

500 mg 5-500 mg 1 $0

PA-HRM AGE (Max

64 Years)

mg 5 mg 1 $0

PA-HRM AGE (Max

64 Years)

125-250 mg 1 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

Antifungals

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ABELCET INTRAVENOUS

PA BvD NDS

SUSPENSION FOR

PA BvD NDS

50 mg 1 $0

PA BvD

(Loprox (as

olamine)) 1 $0

troche 10 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

lotion 1-005 1 $0

antifungal 2 4 $0

ml 400 mg200 ml

500 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg)- 2 (9 gram)

(Miconazole-3

mg 4 $0

200 mg 1 $0

(200 MG)- 2 (9 GRAM) 4 $0

200 MG5 ML (40 MGML) 2 $0

NOXAFIL ORAL

(DREC) 100 MG

unitgram 1 $0

unitml 1 $0

unitgram 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cream 100000-01 unitg- 1 $0

unitgram 1 $0

mg5 gram (4 ) 4 $0

spray 1 4 $0

(terbinafine)) 4 $0

(tolnaftate)) 4 $0

(9 gram) 4 $0

(Vfend) 1 $0

mg (Vfend) 1 $0

Antigout Agents

mg (Zyloprim) 1 $0

MG 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

500-05 mg 1 $0

80 MG 2 $0

QL (30 per 30 days)

MG 2 $0

ST QL (30 per 30

Antihistamines

mg 4 $0

ml 4 $0

mg 4 $0

125 mg5 ml 4 $0

ultratab 25 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(All Day Allergy

(cetirizine)) 4 $0

(All Day Allergy

(cetirizine)) 4 $0

(All Day Allergy-

D) 4 $0

grape sf 5 mg5 ml

(Allergy Relief

(loratadine)) 4 $0

mg5 ml 4 $0

ml 4 $0

mg5 ml 4 $0

cherry 1 mgml 4 $0

mg5 ml 4 $0

ODT 10 MG 4 $0

mgml 4 $0

CHEW 5 MG 4 $0

mg 4 $0

CAP 10 MG 4 $0

MG 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

25 mg5 ml 4 $0

drowsy 10-240 mg 4 $0

ml 1 $0

PA-HRM AGE (Max

64 Years)

relief 134 mg 4 $0

1-25 mg5 ml 4 $0

625-25 mg5 ml 4 $0

mg5 ml 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml

(Childrens Allergy

(diphenhyd)) 1 $0

PA-HRM AGE (Max

64 Years)

drowsy 10 mg 4 $0

mg5 ml 4 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

mg5 ml 1 $0

PA-HRM AGE (Max

64 Years)

25 mg 50 mg 1 $0

PA-HRM AGE (Max

64 Years)

25 mg5 ml 4 $0

ml (Xyzal) 1 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg30 ml 4 $0

25 mg 4 $0

ml 1 $0

PA-HRM AGE (Max

64 Years)

mg5 ml 1 $0

minitabs 25 mg 4 $0

mg 4 $0

mg5 ml 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ml 4 $0

mg 4 $0

mg5 ml 4 $0

mg 4 $0

hr rlf 10 mg 4 $0

mg 4 $0

strength 50 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Mucous Membrane)

Membrane)

AVC VAGINAL VAGINAL

CREAM 15 2 $0

mg 1 $0

Antimigraine Agents

QL (30 per 28 days)

QL (8 per 28 days)

ERGOMAR SUBLINGUAL

TABLET 2 MG 2 $0

QL (40 per 28 days)

QL (18 per 28 days)

mgactuation

(Imitrex) 1 $0

QL (12 per 28 days)

100 mg 25 mg 50 mg (Imitrex) 1 $0

QL (18 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Imitrex STATdose

Kit Refill) 1 $0

QL (4 per 28 days)

(Imitrex STATdose

Pen) 1 $0

QL (4 per 28 days)

mg (Zomig) 1 $0

QL (12 per 28 days)

zolmitriptan oral

QL (12 per 28 days)

Antimycobacterials

SOLN 1 GRAM 2 $0

mg 1 $0

mg (Rifadin) 1 $0

300 MG 2 $0

MG 2 $0

PA QL (188 per 168

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

Antinausea Agents

05 MG 2 $0

PA BvD

125 mg (1)- 80 mg (2) (Emend) 1 $0

PA BvD QL (6 per 28

mg 4 $0

mgml 1 $0

mg 4 $0

EMEND 150 MG VIAL

QL (2 per 28 days)

SOLN 150 MG 2 $0

QL (2 per 28 days)

PA BvD QL (6 per 28

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(otc) 125 mg 4 $0

Drowsy) 4 $0

64 Years)

Drowsy) 1 $0

PA-HRM AGE (Max

64 Years)

fc 25 mg 4 $0

mg5 ml

(Zofran (as

PA BvD

(Zofran (as

PA BvD

ondansetron oral

PA BvD

mg 25 mg 1 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

25 mg 50 mg 1 $0

PA-HRM AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM AGE (Max

64 Years)

mg (Phenergan) 1 $0

PA-HRM AGE (Max

64 Years)

125 mg 25 mg 50 mg 1 $0

PA-HRM AGE (Max

64 Years)

QL (10 per 30 days)

TRANSDERM-SCOP

1 MG OVER 3 DAYS

QL (10 per 30 days)

mg 4 $0

Antiparasite Agents

MG 2 $0

MG5 ML

250-100 mg (Malarone) 1 $0

625-25 mg

(Malarone

Pediatric) 1 $0

250 mg 500 mg 1 $0

120 MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

PA NDS

mg (Plaquenil) 1 $0

MG 2 $0

PA QL (84 per 28

days) NDS

NEBUPENT INHALATION

PA BvD

SOLN 300 MG 2 $0

263 MG 2 $0

mg5 ml 1 $0

APOKYN SUBCUTANEOUS

QL (60 per 30 days)

mg 2 mg 1 $0

PA-HRM AGE (Max

64 Years)

100 mg 25-100 mg 25-250 mg (Sinemet) 1 $0

(Sinemet CR) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GOCOVRI ORAL

24HR 137 MG

PA QL (60 per 30

days) NDS

GOCOVRI ORAL

24HR 685 MG

PA QL (30 per 30

days) NDS

NEUPRO TRANSDERMAL

HOUR 8 MG24 HOUR

QL (30 per 30 days)

025 mg 05 mg 075 mg 1 mg 15

(Mirapex) 1 $0

mg 8 mg

(Requip XL) 1 $0

64 Years)

mg 1 $0

PA-HRM AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 50 MG 2 $0

PA QL (30 per 30

days) NDS

ABILIFY MAINTENA

INTRAMUSCULAR

RECON 300 MG 400 MG

QL (1 per 28 days)

ABILIFY MAINTENA

INTRAMUSCULAR

QL (1 per 28 days)

QL (30 per 30 days)

aripiprazole oral

QL (90 per 30 days)

aripiprazole oral

QL (60 per 30 days)

SYRING 1064 MG39 ML

QL (39 per 56 days)

SYRING 441 MG16 ML

QL (16 per 28 days)

SYRING 662 MG24 ML

QL (24 per 28 days)

SYRING 882 MG32 ML

QL (32 per 28 days)

25 mgml 1 $0

100 mg 200 mg 25 mg 50 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100 mg 125 mg 25 mg (FazaClo) 1 $0

ST QL (90 per 30

ST QL (180 per 30

ST QL (120 per 30

MG 4 MG 2 $0

ST QL (60 per 30

12 MG 6 MG 8 MG 2 $0

ST QL (60 per 30

days) NDS

PACK 1MG(2)-2MG(2)- 4MG(2)-

6MG(2)

25 mgml 1 $0

mgml 1 $0

ml 1 $0

mg 25 mg 5 mg 1 $0

QL (6 per 28 days)

50 mgml

2 mgml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 10 mg 2 mg 20 mg 5 mg 1 $0

INVEGA SUSTENNA

117 MG075 ML

INVEGA SUSTENNA

156 MGML

QL (1 per 28 days)

INVEGA SUSTENNA

234 MG15 ML

QL (15 per 28 days)

INVEGA SUSTENNA

MG025 ML

INVEGA SUSTENNA

MG05 ML

QL (05 per 28 days)

INVEGA TRINZA

273 MG0875 ML

QL (0875 per 84

days) NDS

INVEGA TRINZA

410 MG1315 ML

QL (1315 per 84

days) NDS

INVEGA TRINZA

546 MG175 ML

INVEGA TRINZA

819 MG2625 ML

QL (2625 per 84

days) NDS

MG 20 MG 40 MG 60 MG 80

QL (30 per 30 days)

mg 25 mg 5 mg 50 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

PA NSO QL (60 per

30 days) NDS

QL (30 per 30 days)

QL (60 per 30 days)

mg 4 mg 8 mg 1 $0

QL (90 per 30 days)

(Seroquel XR) 1 $0

QL (30 per 30 days)

QL (60 per 30 days)

MG 2 $0

ST QL (120 per 30

days) NDS

2 MG 3 MG 4 MG 2 $0

ST QL (30 per 30

days) NDS

RISPERDAL CONSTA

QL (4 per 28 days)

RISPERDAL CONSTA

QL (4 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (60 per 30 days)

risperidone oral

QL (60 per 30 days)

risperidone oral

(Risperdal M-

TAB) 1 $0

QL (60 per 30 days)

risperidone oral

(Risperdal M-

TAB) 1 $0

25 MG 5 MG

ST QL (60 per 30

days) NDS

mg 25 mg 50 mg 1 $0

mg 2 mg 5 mg 1 $0

VERSACLOZ ORAL

ST QL (540 per 30

days) NDS

MG 3 MG 45 MG 6 MG 2 $0

ST QL (30 per 30

days) NDS

VRAYLAR ORAL

(1)- 3 MG (6)

40 mg 60 mg 80 mg (Geodon) 1 $0

QL (60 per 30 days)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

QL (2 per 28 days)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

QL (2 per 28 days)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

QL (1 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Antiretrovirals

600-300 mg (Epzicom) 1 $0

MG 2 $0

MGML 2 $0

200-300 MG 2 $0

25-300 MG 2 $0

MG 400 MG 2 $0

25 MG 2 $0

mg 400 mg

(Videx EC) 1 $0

MG 2 $0

MGML 2 $0

25 MG5 ML (5 MGML) 2 $0

MG 2 $0

FUZEON SUBCUTANEOUS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

150-200-10 MG 2 $0

MG 200 MG 2 $0

MG 2 $0

600 MG 2 $0

PACKET 100 MG 2 $0

MG 2 $0

ISENTRESS ORAL

25 MG 2 $0

50 MG 2 $0

mg (Epivir) 1 $0

150-300 mg (Combivir) 1 $0

MGML 2 $0

400-100 mg5 ml (Kaletra) 1 $0

ml (Viramune) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

MGML 2 $0

25-25 MG 2 $0

150 MG-MG 2 $0

100 MGML 2 $0

MG 75 MG 2 $0

MG 800 MG 2 $0

200 MG 2 $0

MG 200 MG 300 MG 2 $0

PACKET 50 MG 2 $0

20 MGML 2 $0

MG 300 MG 75 MG 2 $0

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

150-200-300 MG 2 $0

MG 2 $0

50 MG 2 $0

50-300 MG 2 $0

150 MG 133-200 MG 167-250

MG 200-300 MG

MG 2 $0

QL (30 per 30 days)

(FINAL)

MG 625 MG 2 $0

200 MG 250 MG 300 MG 2 $0

MGML 2 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

RELENZA DISKHALER

MG05 ML

PA NDS

Hcv Antivirals

MG 60 MG 90 MG 2 $0

PA QL (28 per 28

days) NDS

100 MG 2 $0

PA QL (28 per 28

days) NDS

MG 2 $0

PA QL (30 per 30

days) NDS

40 MG 2 $0

PA QL (84 per 28

days) NDS

MG 2 $0

PA QL (28 per 28

days) NDS

MG 2 $0

PA QL (28 per 28

days) NDS

75-50 MG 2 $0

PA QL (56 per 28

days) NDS

VIEKIRA PAK ORAL

75 MG -50 MG250 MG

PA QL (112 per 28

days) NDS

50 MG- 3333 MG-200 MG

PA QL (84 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100 MG 2 $0

PA QL (28 per 28

days) NDS

100 MG 2 $0

PA QL (30 per 30

days) NDS

Interferons

MILLION UNIT (1 ML)

PA NSO NDS

INTRON A INJECTION

SOLUTION 10 MILLION

PA NSO NDS

MCG05 ML

PEGASYS PROCLICK

SUBCUTANEOUS PEN

MCG05 ML

KIT 200 MCG 300 MCG 600

PA NSO QL (4 per 28

days) NDS

PA BvD NDS

ml (Zovirax) 1 $0

mg (Zovirax) 1 $0

soln 500 mg 2 $0

PA BvD NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA BvD

mg 500 mg 1 $0

PA BvD

mg 600 mg 1 $0

PA BvD NDS

mg (Valtrex) 1 $0

Expanders

Anticoagulants

MG 80 MG 2 $0

QL (43 per 42 days)

CEPROTIN (BLUE BAR)

500 UNIT

5 MG 2 $0

100 mgml 120 mg08 ml 150

60 mg06 ml 80 mg08 ml

(Lovenox) 1 $0

10 mg08 ml 5 mg04 ml 75

mg06 ml

(Arixtra) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA QL (24 per 28

days) NDS

MG 150 MG 75 MG 2 $0

ST QL (60 per 30

(Coumadin) 1 $0

MG 15 MG 20 MG 2 $0

XARELTO ORAL

(42)- 20 MG (9)

CINRYZE INTRAVENOUS

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

SDV PF OUTER 10000

UNITML

PA QL (12 per 28

UNITML 4000 UNITML

PA QL (12 per 28

GRANIX SUBCUTANEOUS

MCG08 ML

PA NDS

SOLN 250 MCG 2 $0

100 MCG03 ML 200 MCG03

PA QL (06 per 28

SYRINGE W WEARABLE

INJECTOR 6 MG06 ML

NEUPOGEN INJECTION

MCG16 ML

NEUPOGEN INJECTION

MCG08 ML

PROCRIT INJECTION

ML 3000 UNITML 4000

UNITML

PA QL (12 per 28

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PROCRIT INJECTION

PA QL (12 per 28

days) NDS

PROCRIT INJECTION

PA QL (6 per 28

days) NDS

MG 25 MG 50 MG 75 MG 2 $0

PA QL (30 per 30

days) NDS

300 MCG05 ML 480 MCG08

ST NDS

mgml 1 $0

(Cyklokapron) 1 $0

MG 90 MG 2 $0

mg 75 mg 1 $0

5 MG 2 $0

QL (30 per 30 days)

release 400 mg 1 $0

Caloric Agents

AMINO ACIDS 15

SOLUTION 15

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

AMINOSYN 10

SOLUTION 10

PA BvD

AMINOSYN 7 WITH

ELECTROLYTES

SOLUTION 7

PA BvD

AMINOSYN 85

SOLUTION 85

PA BvD

AMINOSYN 85 -

ELECTROLYTES

SOLUTION 85

PA BvD

AMINOSYN II 10

SOLUTION 10

PA BvD

AMINOSYN II 15

SOLUTION 15

PA BvD

AMINOSYN II 7

SOLUTION 7

PA BvD

AMINOSYN II 85

SOLUTION 85

PA BvD

AMINOSYN II 85 -

ELECTROLYTES

SOLUTION 85

PA BvD

AMINOSYN M 35

SOLUTION 35

PA BvD

AMINOSYN-HBC 7

SOLUTION 7

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

AMINOSYN-PF 10

SOLUTION 10

PA BvD

FREE) INTRAVENOUS

PA BvD

AMINOSYN-RF 52

SOLUTION 52

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE) INTRAVENOUS

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

CLINISOL SF 15

SOLUTION 15

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA BvD

FREAMINE HBC 69

SOLUTION 69

PA BvD

FREAMINE III 10

SOLUTION 10

PA BvD

HEPATAMINE 8

SOLUTION 8

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

EMULSION 20 30 2 $0

PA BvD

KABIVEN INTRAVENOUS

EMULSION 331-98-39 2 $0

PA BvD

NEPHRAMINE 54

SOLUTION 54

PA BvD

EMULSION 20 2 $0

PA BvD

EMULSION 236-68-35 2 $0

PA BvD

PREMASOL 10

SOLUTION 10

PA BvD

PROCALAMINE 3

SOLUTION 3

PA BvD

TRAVASOL 10

SOLUTION 10

PA BvD

TROPHAMINE 10

SOLUTION 10

PA BvD

TROPHAMINE 6

SOLUTION 6

PA BvD

15-400 gram-unit42 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (4 per 28 days)

QL (8 per 28 days)

64 Years)

FCUD250S 5 MG 4 $0

5 mg 1 $0

drowsy 10 mg 4 $0

100 MG 200 MG 300 MG 2 $0

PA QL (180 per 30

days) NDS

mg (Minipress) 1 $0

Antagonists

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

32-25 mg

(Atacand HCT) 1 $0

80 MG 2 $0

40-125 MG 40-25 MG 2 $0

MG 49-51 MG 97-103 MG 2 $0

QL (60 per 30 days)

50 mg (Cozaar) 1 $0

tablet 100-125 mg 100-25 mg 50-

125 mg

(Hyzaar) 1 $0

oral tablet 20-5-125 mg 40-10-125

mg 40-10-25 mg 40-5-125 mg 40-

5-25 mg

(Tribenzor) 1 $0

40-25 mg

(Benicar HCT) 1 $0

tablet 160-125 mg 160-25 mg 320-

125 mg 320-25 mg 80-125 mg

(Diovan HCT) 1 $0

Inhibitors

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

tablet 10-125 mg 20-125 mg 20-

(Lotensin HCT) 1 $0

mg 25 mg 50 mg 1 $0

tablet 25-15 mg 25-25 mg 50-15

mg 50-25 mg

125 mgml 1 $0

40 mg 1 $0

tablet 10-125 mg 20-125 mg 1 $0

tablet 10-125 mg 20-125 mg 20-

(Zestoretic) 1 $0

tablet 15-125 mg 15-25 mg 75-

125 mg

mg 4 mg 8 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

tablet 10-125 mg 20-125 mg 20-

(Accuretic) 1 $0

4 mg 1 $0

mg 50 mg 1 $0

100 mg5 ml (2 ) 50 mg5 ml (1

mgml (08 )

mg 250 mg 1 $0

MG 2 $0

mg 400 mg 1 $0

mgml 500 mgml 1 $0

mg 300 mg 1 $0

300 mg 1 $0

mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100-25 mg (Tenoretic 100) 1 $0

50-25 mg (Tenoretic 50) 1 $0

mg 5 mg 1 $0

tablet 10-625 mg 25-625 mg 5-

625 mg

(Ziac) 1 $0

MG 25 MG 20 MG 5 MG 2 $0

MG 2 $0

mg 3125 mg 625 mg (Coreg) 1 $0

PA BvD NDS

mgml 1 $0

mg 300 mg 1 $0

mg 25 mg 50 mg

(Toprol XL) 1 $0

tablet 100-25 mg 100-50 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 1 $0

mg (Corgard) 1 $0

mgml 1 $0

mg 80 mg

(Inderal LA) 1 $0

mg 40 mg 60 mg 80 mg 1 $0

240 mg 80 mg 1 $0

20 mg 5 mg 1 $0

mg 300 mg

mgml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Cardizem CD) 1 $0

mg 360 mg 420 mg

(Cardizem LA) 1 $0

mg 360 mg 420 mg

mg 300 mg 360 mg

mgml 1 $0

mg 360 mg

(Verelan) 1 $0

Miscellaneous

MG 75 MG 2 $0

PA QL (60 per 30

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

mcgml 1 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

MCGML 2 $0

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

(4000 mcgml) 250 mg250 ml (1

mgml) 500 mg250 ml (2000

mcgml)

PA BvD

250 mg20 ml (125 mgml) 500

mg40 ml (125 mgml)

PA BvD

(800 mcgml) 400 mg250 ml (1600

mcgml) 800 mg250 ml (3200

mcgml)

PA BvD

(80 mgml) 800 mg10 ml (80

PA BvD

QL (4 per 30 days)

03 mg03 ml (Auvi-Q) 1 $0

QL (4 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (4 per 30 days)

QL (18 per 30 days)

mgml 1 $0

mg 25 mg 50 mg 1 $0

MCG 2 $0

PA-HRM QL (30 per

30 days) AGE (Max

64 Years)

MCG 2 $0

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

ml (200 mcgml) 40 mg200 ml (200

mcgml)

PA BvD NDS

mgml 1 $0

PA BvD NDS

(Levophed

(bitartrate)) 1 $0

PA BvD

RANEXA ORAL TABLET

1000 MG 500 MG

Dihydropyridines

10-20 mg 10-40 mg 5-10 mg 5-20

mg 5-40 mg

(Lotrel) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25-10 mg 1 $0

10-20 mg 10-40 mg 5-20 mg 5-40

(Azor) 1 $0

160 mg 10-320 mg 5-160 mg 5-

320 mg

(Exforge) 1 $0

tablet 10-160-125 mg 10-160-25

mg 10-320-25 mg 5-160-125 mg

5-160-25 mg

(Exforge HCT) 1 $0

MG100 ML

mg 1 $0

Diuretics

tablet 5-50 mg 1 $0

mgml 1 $0

mg 2 mg 1 $0

500 mg 1 $0

mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml 1 $0

40 mg5 ml (8 mgml) 1 $0

mg 25 mg 50 mg 1 $0

mg 1 $0

mg 5 mg 1 $0

Dyslipidemics

10-10 mg 10-20 mg 10-40 mg 10-

80 mg 5-10 mg 5-20 mg 5-40 mg

5-80 mg

(Caduet) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25-10 mg 25-20 mg 25-40 mg 1 $0

gram 1 $0

130 mg 134 mg 200 mg 43 mg 67

mg 1 $0

mg 45 mg

(Trilipix) 1 $0

MG 30 MG 40 MG 60 MG 2 $0

PA QL (30 per 30

days) NDS

MG 2 $0

PA QL (90 per 30

days) NDS

MG 2 $0

PA QL (45 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA QL (4 per 28

days) NDS

MG 4 MG 2 $0

QL (30 per 30 days)

40 mg 1 $0

24 hr 1000 mg 500 mg 750 mg

(Niaspan

(niacinamide)) 4 $0

PRALUENT PEN

SUBCUTANEOUS PEN

PA QL (2 per 28

days) NDS

REPATHA PUSHTRONEX

PA QL (35 per 28

days) NDS

REPATHA SURECLICK

SUBCUTANEOUS PEN

INJECTOR 140 MGML

PA QL (3 per 28

days) NDS

REPATHA SYRINGE

PA QL (3 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GRAM 2 $0

MG 2 $0

System Inhibitors

10 MG 150-5 MG 300-10 MG

300-5 MG

150-125 MG 150-25 MG 300-125

MG 300-25 MG

MG 300 MG 2 $0

Vasodilators

MG 2 $0

mg 20 mg 30 mg 1 $0

10 mg 20 mg 1 $0

mg 60 mg

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (30 per 30 days)

04 mghr 1 $0

QL (60 per 30 days)

OINTMENT 2 1 $0

(400 mcgml) 25 mg250 ml (100

mcgml) 50 mg250 ml (200

mcgml)

50 mg10 ml (5 mgml) 1 $0

(Minitran) 1 $0

QL (30 per 30 days)

QL (60 per 30 days)

Agents

AMPYRA ORAL TABLET

PA QL (60 per 30

days) NDS

100 mg 18 mg 25 mg 40 mg 60

mg 80 mg

(Strattera) 1 $0

MG 7 MG 2 $0

PA QL (28 per 28

days) NDS

MG 9 MG 2 $0

PA QL (120 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA NDS

KIT 03 MG 2 $0

PA NDS

mg3 ml (20 mgml) 1 $0

PA QL (12 per 28

days) NDS

QL (60 per 30 days)

10 mg 15 mg 5 mg

(Adderall XR) 1 $0

QL (30 per 30 days)

20 mg 25 mg 30 mg

(Adderall XR) 1 $0

QL (60 per 30 days)

20 mg 30 mg 5 mg 75 mg

(Adderall) 1 $0

QL (60 per 30 days)

03 MG 2 $0

PA NDS

mgml 1 $0

MG 2 $0

PA QL (28 per 28

days) NDS

PA QL (30 per 30

days) NDS

PA QL (12 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml 1 $0

PA QL (30 per 30

days) NDS

(Intuniv ER) 1 $0

MG 2 $0

PA QL (60 per 30

days) NDS

MG 2 $0

PA QL (30 per 30

days) NDS

PA NDS

mg 300 mg 600 mg 1 $0

mg 1 $0

ml 1 $0

mg 50 mg 60 mg

QL (30 per 30 days)

QL (60 per 30 days)

QL (30 per 30 days)

QL (60 per 30 days)

QL (30 per 30 days)

QL (90 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 54 mg

(Concerta) 1 $0

QL (30 per 30 days)

QL (60 per 30 days)

10 MG 2 $0

QL (60 per 30 days)

OCREVUS INTRAVENOUS

PA QL (20 per 180

days) NDS

PA NDS

PA QL (2800 per 28

days) NDS

PA NDS

REBIF REBIDOSE

SUBCUTANEOUS PEN

MCG05ML (6)

PA NDS

MG 125 MG 25 MG 50 MG 2 $0

QL (60 per 30 days)

SAVELLA ORAL

(5)-25 MG(8)-50 MG(42)

QL (60 per 30 days)

TECFIDERA ORAL

CAPSULEDELAYED

PA QL (14 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TECFIDERA ORAL

CAPSULEDELAYED

240 MG (46) 240 MG

PA QL (60 per 30

days) NDS

PA QL (112 per 28

days) NDS

PA QL (1 per 28

days) NDS

Contraceptives

mg 1 $0

mg-mcg 1 $0

050751 mg- 35 mcg 1 $0

QL (91 per 84 days)

35 mg-mcg 1 $0

mgx21 001 mg x 5 1 $0

mcg 1 $0

mgx21 001 mg x 5 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg (24)75 mg (4) 1 $0

mg-30 mcg (21)75 mg (7) 1 $0

20 mcg (21)75 mg (7) 1 $0

QL (91 per 84 days)

25 mg-mcg 1 $0

mcg 1 $0

mg-mcg 1 $0

050751 mg- 35 mcg 1 $0

mg-mcg 1 $0

050751 mg- 35 mcg 1 $0

QL (91 per 84 days)

mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

QL (6 per 365 days)

(5)125-30(10) 1 $0

mg 4 $0

QL (6 per 365 days)

mcg 1 $0

QL (91 per 84 days)

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg 1 $0

mg-30 mcg (21)75 mg (7) 1 $0

20 mcg (21)75 mg (7) 1 $0

(24)75 mg (4) 1 $0

mgx21 001 mg x 5 1 $0

mg-mcg 1 $0

mgx21 001 mg x 5 1 $0

20 mcg (84)10 mcg (7)

(Amethia Lo) 1 $0

QL (91 per 84 days)

30 mcg (84)10 mcg (7)

(Amethia) 1 $0

QL (91 per 84 days)

mg-mcg 1 $0

mcg 1 $0

(24)75 mg (4) 1 $0

mg-30 mcg (21)75 mg (7) 1 $0

20 mcg (21)75 mg (7) 1 $0

mg-mcg 1 $0

(6)75-40 (5)125-30(10) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

015-003 mg (Altavera (28)) 1 $0

QL (91 per 84 days)

15 mg (Aftera) 4 $0

QL (6 per 365 days)

30 mcg

(Introvale) 1 $0

QL (91 per 84 days)

tablet 50-30 (6)75-40 (5)125-

30(10)

(Enpresse) 1 $0

QL (91 per 84 days)

mcg (24)75 mg (4) 1 $0

mg-mcg 1 $0

mcg 1 $0

15-30 mg-mcg 1 $0

20 mg-mcg 1 $0

tablet 15 mg-30 mcg (21)75 mg (7) 1 $0

1 mg-20 mcg (21)75 mg (7) 1 $0

mcg 1 $0

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(5)125-30(10) 1 $0

mg-mcg 1 $0

mcg 1 $0

050751 mg- 35 mcg 1 $0

15 mg 4 $0

QL (6 per 365 days)

mg-20 mcg (21)75 mg (7)

(Blisovi Fe 120

(28)) 1 $0

(Ortho Tri-Cyclen

LO (28)) 1 $0

(Ortho Tri-Cyclen

(28)) 1 $0

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

050751 mg- 35 mcg 1 $0

012-0015 MG24 HR 2 $0

QL (1 per 28 days)

mcg 1 $0

mg 4 $0

QL (6 per 365 days)

mgx21 001 mg x 5 1 $0

35 mcg 1-35 mg-mcg 1 $0

QL (91 per 84 days)

mg 1 $0

QL (91 per 84 days)

mcg 1 $0

20 mcg (21)75 mg (7) 1 $0

1mg-35mcg (9) 1 $0

0180215025 mg-35 mcg (28) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

0180215025 mg-35 mcg (28) 1 $0

30(7) 1mg-35mcg (9) 1 $0

0180215025 mg-35 mcg (28) 1 $0

0180215025 mg-25 mcg 1 $0

0180215025 mg-35 mcg (28) 1 $0

40 (5)125-30(10) 1 $0

tablet 0112515-25 mg-mcg 1 $0

mgx21 001 mg x 5 1 $0

mcg 1 $0

150-35 mcg24 hr 1 $0

QL (3 per 28 days)

mcg 1 $0

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg-mcg 1 $0

mg5 ml 4 $0

mg 4 $0

200 mg 4 $0

325 mg 4 $0

20 mg 4 $0

20-400 mg 4 $0

20 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ml 4 $0

mg5 ml 3 $0

mgml 3 $0

mg 4 $0

mg5 ml 4 $0

100 mg5 ml 4 $0

mg5 ml 4 $0

MG5 ML

100 mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

325mg(d) 15-325-625mg 4 $0

mg30 ml 4 $0

400 mg 4 $0

blast 125-30-1000 mg30 ml 4 $0

mg 4 $0

mg5 ml 4 $0

160 mg5 ml 4 $0

mg5 ml

mg5 ml 4 $0

12 day12 night 2-5-10-325 mg 4 $0

mg5 ml 4 $0

mg15 ml

mg15 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

600 mg 4 $0

flavor 625-15 mg15 ml 4 $0

30 mg30 ml 4 $0

5 mg5 ml 4 $0

15mg15ml(d) 125-30mg30ml 4 $0

100 mg5 ml 4 $0

mg5 ml

(12-Hour Cough

Relief) 4 $0

mg5 ml 4 $0

200 mg5 ml 4 $0

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml 4 $0

20-650 mg 4 $0

ml 4 $0

400 mg 4 $0

mg5 ml

(Adult Tussin

mg (Coughtab) 4 $0

mg (Mucinex) 4 $0

10-325 mg 4 $0

mg5 ml 4 $0

600 mg 4 $0

1200 mg 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

15-500 mg15 ml 4 $0

mg15 ml

125 mg5 ml 4 $0

mg5 ml 4 $0

mg5 ml 3 $0

mg5 ml

(Nasal

Decongestant

(pseudoeph))

(Nasal

Decongestant

(pseudoeph))

30-1000 mg30 ml 4 $0

160 mg5 ml 4 $0

relief 10-5-325mg(d) 15-325-

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

day12 night 2-5-10-325 mg 4 $0

mg 4 $0

100 mg5 ml 4 $0

ml 4 $0

mg5 ml 4 $0

200 mg 4 $0

LIQ 1-75 MG5 ML 4 $0

mg5 ml 4 $0

ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml 4 $0

667 mg5 ml 4 $0

30-1000 mg30 ml 4 $0

625-30-15-325 mg 4 $0

mg30 ml 4 $0

15-325 mg 4 $0

ml 4 $0

mg 4 $0

ml 4 $0

af 10-200 mg5 ml 4 $0

30-15-500 mg 4 $0

MG 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

10-325 mg 4 $0

mg5 ml 4 $0

15-200 MG5 ML 4 $0

MG5 ML 4 $0

25-5-160 mg5 ml 4 $0

rlf 5 mg5 ml 4 $0

10-325 mg 4 $0

af 5-10-325 mg15 ml 4 $0

625-15-325 MG15 ML

625-15-325 mg 4 $0

mg16 ml 4 $0

caplet 30-15-500 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml 4 $0

ml 4 $0

max-str 30 mg 4 $0

caplet 5-10-325 mg 4 $0

mg 4 $0

400 mg5 ml 4 $0

(Paroex Oral

Rinse) 1 $0

mouthwash 012 1 $0

(Salagen

(pilocarpine)) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ACNE MEDICATION 5

LOTION 5 4 $0

PADS MEDICATED 1 $0

(AmLactin) 1 $0

(Calcitrene) 1 $0

15 4 $0

PA NDS

SUBCUTANEOUS PEN

INJECTOR 150 MGML

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

days) NDS

PA NDS

FLECTOR TRANSDERMAL

(Aldara) 1 $0

PA NSO QL (24 per

30 days)

INSECT REPELLENT 20

SPRAY 20 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

250 UNITGRAM 2 $0

SILIQ SUBCUTANEOUS

PA NDS

TALTZ AUTOINJECTOR

SUBCUTANEOUS AUTO-

INJECTOR 80 MGML

PA NDS

TALTZ SYRINGE

PA NDS

30 mg 40 mg 1 $0

unitgram 4 $0

(Cleocin T) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

1 (Cleocin T) 1 $0

gel 2 (Erygel) 1 $0

solution 2 1 $0

(Bactroban) 1 $0

(Neosporin GU

Irrigant) 1 $0

(Silvadene) 1 $0

Agents

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cream 005 1 $0

lotion 005 1 $0

ointment 005 1 $0

cream 01 1 $0

lotion 01 1 $0

ointment 01 1 $0

cream 005 1 $0

gel 005 1 $0

lotion 005 1 $0

005 1 $0

01 (Cloderm) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

DERMAREST ECZEMA 1

LOTION 1 4 $0

(Topicort) 1 $0

2 2 $0

(Synalar) 1 $0

05 4 $0

strength 1 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25 (Ala-Cort) 1 $0

(Dermatop) 1 $0

01 (Protopic) 1 $0

cream 0025 1 $0

lotion 0025 01 1 $0

ointment 0025 01 05 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

005 2 $0

(Retin-A) 1 $0

strength 033-4 4 $0

2x59ml 2 combs 1 4 $0

strength 033-4 4 $0

Devices

LANCT 28 GAUGE 4 $0

LANCT 30 GAUGE 4 $0

ACCU-CHEK FASTCLIX

LANCETS 4 $0

ACCU-CHEK MULTICLIX

LANCETS 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

LANCT 23 GAUGE 4 $0

23G 23 GAUGE 4 $0

ACCU-CHEK SOFTCLIX

LANCETS 4 $0

ACTI-LANCE LITE 28G

ADVANCED TRAVEL 28G

LANCETS 28GSINGLE-

USESTRL 28 GAUGE

ADVANCED TRAVEL 30G

ALTERNATE SITE 26G

ASSURE COMFORT 30G

LANCETS 30 GAUGE

(1st Tier Unilet

ComforTouch) 4 $0

18G 18 GAUGE 4 $0

21G 21 GAUGE 4 $0

25G 25 GAUGE 4 $0

28G 28 GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25 GAUGE 4 $0

28 GAUGE 4 $0

BD INSULIN SYR 1 ML

BD MICROTAINER 21G

BD MICROTAINER 30G

33 GAUGE 4 $0

TWIST 30 GAUGE

(1st Tier Unilet

ComforTouch) 4 $0

21 GAUGE 4 $0

LANCT 25 GAUGE 4 $0

CAREONE ULTRA THIN

LANCET 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CARETOUCH TWIST 28G

CARETOUCH TWIST 30G

30G 30 GAUGE 4 $0

CVS ULTRA THIN 30G

GAUGE 4 $0

30GTWIST TOPSTRL 30

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GAUGE 4 $0

32 GAUGE 4 $0

33 GAUGE 4 $0

(Accu-Chek

FastClix) 4 $0

(1st Tier Unilet

ComforTouch) 4 $0

GAUGE 4 $0

STRIP NO CODE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

STRIPS 4 $0

FREESTYLE UNISTIK 2

LANCETS 4 $0

GAUZE PAD TOPICAL

BANDAGE 2 X 2 1 $0

GAUGE 4 $0

21G 21 GAUGE 4 $0

30G 30 GAUGE 4 $0

LANCT 30 GAUGE 4 $0

LANCT 28 GAUGE 4 $0

GAUGE 4 $0

(Ultilet Insulin

Syringe) 1 $0

(Advocate

Syringes) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Lite Touch Insulin

Syringe) 1 $0

GAUGE 4 $0

LANCT 26 GAUGE 4 $0

KROGER SUPER THIN

LANCETS 4 $0

Lancets) 4 $0

GAUGE 4 $0

MEDLANCE PLUS 21G

MEDLANCE PLUS 30G

30 GAUGE

GAUGE 4 $0

28 GAUGE 4 $0

MYGLUCOHEALTH 30G

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

23 GAUGE 4 $0

28 GAUGE 4 $0

NOVA SUREFLEX THIN

LANCETS 4 $0

GAUGE 4 $0

ONETOUCH DELICA 30G

ONETOUCH DELICA 33G

ONETOUCH SURESOFT

LANCETS

ONETOUCH ULTRASOFT

LANCETS 4 $0

PEN NEEDLE DIABETIC

(1st Tier Unifine

Pentips) 1 $0

(1st Tier Unilet

ComforTouch) 4 $0

30 GAUGE 4 $0

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PRODIGY PRESSURE

PRODIGY SAFETY 26G

GAUGE 4 $0

RELIAMED SAFETY 23G

RELIAMED SAFETY 28G

LANCT 28 GAUGE 4 $0

LANCT 30 GAUGE 4 $0

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

33 GAUGE 4 $0

LANCETS 4 $0

30 GAUGE 4 $0

FREE 21 GAUGE 4 $0

FREE 28 GAUGE 4 $0

GAUGE 4 $0

21 GAUGE 4 $0

GAUGE 4 $0

30 GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

18 GAUGE 4 $0

21 GAUGE 4 $0

23 GAUGE 4 $0

28 GAUGE 4 $0

30 GAUGE 4 $0

GAUGE 4 $0

SURE-LANCE THIN 28G

30 GAUGE 4 $0

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GAUGE 4 $0

TRUEPLUS SAFETY 28G

GAUGE 4 $0

30 GAUGE 4 $0

ULTILET CLASSIC 26G

LANCETS 4 $0

ULTILET CLASSIC 28G

ULTILET CLASSIC 30G

ULTILET CLASSIC 33G

ULTILET SAFETY 23G

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GAUGE 4 $0

28 GAUGE 4 $0

30 GAUGE 4 $0

UNILET COMFORTOUCH

LANCET 4 $0

LANCETS SINGLE-

USESTERILE 30 GAUGE

UNISTIK 3 EXTRA 21G

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

28 GAUGE 4 $0

30 GAUGE 4 $0

21 GAUGE 4 $0

23 GAUGE 4 $0

28 GAUGE 4 $0

30 GAUGE 4 $0

LANCETS 4 $0

Dermatologic Use)

Enzyme

MG 2 $0

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CREON ORAL

CAPSULEDELAYED

60000 UNIT 24000-76000 -

120000 UNIT 3000-9500- 15000

UNIT 36000-114000- 180000

UNIT 6000-19000 -30000 UNIT

SOLN 15 MG 75 MG 2 $0

KANUMA INTRAVENOUS

PA NDS

KUVAN ORAL

MG 20 MG 5 MG 2 $0

PA NDS

MGML 2 $0

PA NDS

MG 75 MG

PA BvD NDS

PA LA NDS

VIMIZIM INTRAVENOUS

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

SOLN 400 UNIT 2 $0

MG 2 $0

QL (90 per 30 days)

ZENPEP ORAL

CAPSULEDELAYED

55000 UNIT 15000-51000 -

82000 UNIT 20000-68000 -

109000 UNIT 25000-85000-

136000 UNIT 3000-10000-

16000 UNIT 40000-136000-

218000 UNIT 5000-17000 -

27000 UNIT

Miscellaneous

(EYE) GEL 35 2 $0

03 4 $0

OINTMENT 83-15 4 $0

mcg (01 ) 1 $0

QL (30 per 25 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

005 1 $0

03 4 $0

therapy 04-03 4 $0

425 4 $0

soln 05-09 4 $0

CYSTARAN OPHTHALMIC

005 (Elestat) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GENTEAL MILD 02 EYE

DROPS 02 4 $0

03 01-03-02 4 $0

03 4 $0

QL (30 per 28 days)

QL (15 per 10 days)

09 4 $0

30x04ml 05 4 $0

force 005 4 $0

formula 005 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

03 4 $0

01 (Patanol) 1 $0

02 (Pataday) 1 $0

03-0025 (025 ML) 2 $0

drops 10 25 1 $0

drops 05 1 $0

03 4 $0

005 4 $0

formula 1-03 4 $0

DROPS 1 4 $0

U-DPF30X4ML 14-06 4 $0

REFRESH LACRI-LUBE

OINTMENT 568-425 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

03 4 $0

DROPS 04-03 4 $0

d36x9mlpf 01-03 4 $0

Infectives Agents

unitgram

(Polycin) 1 $0

CIPRODEX OTIC (EAR)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

05 MGML

05 (Zymaxid) 1 $0

03 (3 mggram) 1 $0

03 1 $0

05 1 $0

05 (Vigamox) 1 $0

10000 mg-unitg-1

10000 mg-unit-unitg

(Neo-Polycin) 1 $0

(Maxitrol) 1 $0

10000 unitg-01

(Maxitrol) 1 $0

10000 unit-0025mgml

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

10 mg-unit-mgml

mgml-unitml-

unitml-

(Ocuflox) 1 $0

500-10000 unitgram 1 $0

1 mgml

(Polytrim) 1 $0

DROPS 05-1-05 4 $0

(025 )

TOBRADEX OPHTHALMIC

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

03 (Tobrex) 1 $0

(TobraDex) 1 $0

(Viroptic) 1 $0

DROPS 05 2 $0

GEL 015 2 $0

Inflammatory Agents

DROPS 0075 2 $0

drops 01 1 $0

DROPS 005 2 $0

25 mcg (0025 ) 1 $0

QL (50 per 25 days)

50 mcgactuation

(24 Hour Allergy

Relief) 1 $0

04 (Acular LS) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

05 (Acular) 1 $0

DROPSGEL 05 2 $0

OINTMENT 05 2 $0

PROLENSA OPHTHALMIC

RESTASIS MULTIDOSE

QL (55 per 30 days)

QL (60 per 30 days)

Antiflatulents

125 mg 4 $0

ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

(Anti-Gas Ultra

Strength) 4 $0

Suppressants

strength 20 mg 4 $0

100 MGML 2 $0

mg5 ml 1 $0

(cimetidine)) 1 $0

mg 800 mg 1 $0

200 mg

(Acid Reducer

(cimetidine)) 4 $0

20 mg2 ml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml 1 $0

mg 4 $0

(Heartburn

Treatment 24

release(drec) 15 mg

(Heartburn

Treatment 24

(Acid Reducer

(omeprazole)) 4 $0

PRILOSEC OTC 206 MG

(Acid Control

(ranitidine)) 4 $0

free 75 mg

(Acid Reducer

(ranitidine)) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(ranitidine)) 1 $0

mg15 ml 4 $0

ml 4 $0

320 mg5 ml 4 $0

MCG 8 MCG 2 $0

QL (60 per 30 days)

30 mg5 ml 4 $0

40 mg5 ml 4 $0

mg 4 $0

ml 4 $0

mg 4 $0

mg15 ml 4 $0

MG 2 $0

(1250 mg) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Calci-Chew) 4 $0

(1000 mg)

mg 4 $0

400-400-40 mg5 ml 4 $0

cherry 200-200-20 mg5 ml 4 $0

ml 1 $0

strength 200-200-20 mg5 ml 4 $0

200-20 mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

2 mg 4 $0

mg15 ml 4 $0

mg (750 mg) 4 $0

2375 mg5 ml 4 $0

mg 4 $0

1 mg75 ml

(Anti-Diarrheal

(loperamide)) 4 $0

ml 1 $0

25-0025 mg5 ml 1 $0

PA-HRM AGE (Max

64 Years)

25-0025 mg (Lomotil) 1 $0

PA-HRM AGE (Max

64 Years)

strength 400-400-40 mg5 ml 4 $0

mg15 ml 4 $0

GATTEX 30-VIAL

PA NDS

200-200-25 mg 4 $0

ml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml (Robinul) 1 $0

MG75 ML

193 gram60 ml 1 $0

MCG 290 MCG 72 MCG 2 $0

QL (30 per 30 days)

strength 200-200-20 mg5 ml 4 $0

(Anti-Diarrheal

(loperamide)) 4 $0

mg75 ml

(Anti-Diarrheal

(loperamide)) 4 $0

(loperamide)) 1 $0

mg 4 $0

500 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Laxative Dietary

Supplement) 4 $0

mg 4 $0

5 mg 1 $0

mg5 ml 1 $0

mg5 ml 400-400-40 mg5 ml 4 $0

200-25 mg 4 $0

200-20 mg5 ml 4 $0

MG 25 MG 2 $0

QL (30 per 30 days)

MG 5 MG 2 $0

PA QL (30 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

fruits 300 mg (750 mg) 4 $0

mg 4 $0

GRAMML 2 $0

PA NDS

MG 2 $0

PA QL (90 per 30

days) NDS

PA QL (28 per 28

days) NDS

MG04 ML

PA QL (28 per 28

days) NDS

mg5 ml 4 $0

ml 4 $0

30 mg5 ml 4 $0

20 mg 4 $0

650 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

262 mg15 ml 4 $0

15-20 gram60 ml 1 $0

PACKET 168 GRAM 252

GRAM 84 GRAM

QL (30 per 30 days)

MG 75 MG 2 $0

ST QL (60 per 30

days) NDS

MG 2 $0

PA QL (90 per 30

days) NDS

Laxatives

(Bisac-Evac) 4 $0

gram118 ml 4 $0

625 mg 4 $0

mg5 ml 4 $0

ml 4 $0

Heavy) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

ml 4 $0

20 mg5 ml 4 $0

gram 4 $0

625 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

gram 4 $0

2272-672 -584 gram 1 $0

2274-674 -586 gram 1 $0

gramdose 4 $0

outer 17 gram 4 $0

625 mg 4 $0

gramdose 4 $0

mg5 ml 4 $0

MINERAL OIL LIGHT

VISCOSITY NF 4 $0

PACKET 100-75-2691 GRAM 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

gram58 gram 4 $0

soln 240-2272-672 -584 gram

(Colyte with Flavor

Packs) 1 $0

(ClearLax) 4 $0

gram118 ml 4 $0

gram11 gram 4 $0

gram15 ml 4 $0

Heavy) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

gramdose 4 $0

19-7 gram118 ml 4 $0

gram 4 $0

heavy 4 $0

gram58 gram 4 $0

ml 4 $0

mg5 ml 4 $0

50 mg (Colace 2-In-1) 4 $0

ml 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100 mg 4 $0

240 mg 4 $0

16 GRAM

soln 420 gram 1 $0

mg 4 $0

Phosphate Binders

MG 800 MG 2 $0

MG 2 $0

mg (Renvela) 1 $0

VELPHORO ORAL

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 50 MG

mg5 ml 1 $0

mg 5 mg

(Ditropan XL) 1 $0

TOVIAZ ORAL TABLET

MG 8 MG

MG 5 MG 2 $0

Miscellaneous

QL (30 per 30 days)

2 mg 5 mg 1 $0

250 MG 2 $0

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TABLET 250 MG 2 $0

PA NDS

EXJADE ORAL TABLET

500 MG

PA NDS

100 MGML 2 $0

PA NDS

MG 2 $0

PA NDS

MG 360 MG 90 MG 2 $0

PA NDS

360 MG 90 MG

PA NDS

MG 2 $0

PA QL (240 per 30

days) NDS

Hormonal Agents

Androgens

MG 2 $0

PA NDS

HOUR 4 MG24 HR

PA QL (30 per 30

2025 MG125 GRAM (162 )

PA QL (150 per 30

MG125 GRAM) 162 (405

MG25 GRAM)

PA QL (150 per 30

mg 50 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg (Oxandrin) 1 $0

(Depo-

Testosterone) 1 $0

PA QL (300 per 30

(50 mg5 gram)

(AndroGel) 1 $0

PA QL (300 per 30

05 mg 1 $0

MG24 HR 005-025 MG24 HR

PA-HRM QL (8 per

28 days) AGE (Max

64 Years)

MG 2 $0

PA-HRM AGE (Max

64 Years)

001 (01 MGGRAM) 2 $0

mg (Estrace) 1 $0

PA-HRM AGE (Max

64 Years)

mg24 hr 0075 mg24 hr 01

mg24 hr

(Alora) 1 $0

PA-HRM QL (8 per

28 days) AGE (Max

64 Years)

PA-HRM QL (8 per

28 days) AGE (Max

64 Years)

0025 mg24 hr 00375 mg24 hr

005 mg24 hr 006 mg24 hr 0075

mg24 hr 01 mg24 hr

(Climara) 1 $0

PA-HRM QL (4 per

28 days) AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM AGE (Max

64 Years)

mg 3 mg 1 $0

PA-HRM AGE (Max

64 Years)

MG24 HR 01 MG24 HR 2 $0

QL (1 per 84 days)

05 mg 1 $0

PA-HRM AGE (Max

64 Years)

0625 MG 125 MG 2 $0

PA-HRM AGE (Max

64 Years)

SOLN 25 MG 2 $0

MG 045 MG 0625 MG 09 MG

125 MG

PA-HRM AGE (Max

64 Years)

0625 MGGRAM 2 $0

0625 MG (14) 0625MG-5MG(14) 2 $0

PA-HRM AGE (Max

64 Years)

15 MG 045-15 MG 0625-25

MG 0625-5 MG

PA-HRM AGE (Max

64 Years)

mg 1 $0

(Celestone

Soluspan) 1 $0

ml 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

075 mg 1 mg 15 mg 2 mg 4 mg

PA BvD

2275 MGML 2 $0

PA QL (39 per 30

days) NDS

MG 2 $0

PA QL (30 per 30

days) NDS

MG 36 MG 6 MG 2 $0

PA QL (60 per 30

days) NDS

PA BvD

KENALOG INJECTION

(Depo-Medrol) 1 $0

PA BvD

mg5 ml (5 mgml)

PA BvD

(Pediapred) 1 $0

PA BvD

5 mg 50 mg 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(48 pack)

PA BvD

Pituitary

mcgml (DDAVP) 1 $0

mg (DDAVP) 1 $0

MG025 ML

MG025 ML 06 MG025 ML 08

MG025 ML 1 MG025 ML 12

MG025 ML 14 MG025 ML 16

MG025 ML 18 MG025 ML 2

MG025 ML

PA NDS

UNITML) 5 MGML (15

UNITML)

PA NDS

HUMATROPE INJECTION

24 MG (72 UNIT) 6 MG (18

PA NDS

HUMATROPE INJECTION

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

LUPRON DEPOT-PED (3

SYRINGE KIT 30 MG

LUPRON DEPOT-PED

NORDITROPIN FLEXPRO

SUBCUTANEOUS PEN

MGML) 30 MG3 ML (10

PA NDS

NORDITROPIN FLEXPRO

SUBCUTANEOUS PEN

NUTROPIN AQ NUSPIN

SUBCUTANEOUS PEN

MGML) 20 MG2 ML (10

MGML) 5 MG2 ML (25

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MGML) 5 MG15 ML (33

PA NDS

SAIZEN CLICKEASY

PA NDS

SAIZEN SUBCUTANEOUS

PA NDS

INTRAMUSCULAR

PA NDS

QL (60 per 30 days)

SOMATULINE DEPOT

MG05 ML 60 MG02 ML 90

MG03 ML

QL (1 per 28 days)

MG 25 MG 30 MG

50 MG (65 MCGDAY) 2 $0

QL (1 per 360 days)

AEROSOL 2 MGML 2 $0

SUSPENSION FOR

QL (1 per 168 days)

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA NDS

Progestins

DEPO-PROVERA

400 MGML

QL (10 per 28 days)

PA NSO

QL (1 per 84 days)

mg10 ml (40 mgml) 1 $0

PA-HRM AGE (Max

64 Years)

mg (Aygestin) 1 $0

oil 50 mgml 1 $0

soln 100 mcg 200 mcg 500 mcg 1 $0

112 mcg 125 mcg 137 mcg 150

(Levo-T) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ACTEMRA INTRAVENOUS

MGML) 400 MG20 ML (20

MGML) 80 MG4 ML (20

PA NDS

ASTAGRAF XL ORAL

PA BvD

soln 100 mg 1 $0

PA BvD

PA BvD NDS

CIMZIA POWDER FOR

PA NDS

CIMZIA SUBCUTANEOUS

MGML X 2)

PA NDS

PA BvD

100 mg 25 mg 50 mg (Gengraf) 1 $0

PA BvD

ENBREL SUBCUTANEOUS

PA NDS

ENBREL SUBCUTANEOUS

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ENBREL SUBCUTANEOUS

MGML (098 ML)

PA NDS

ENBREL SURECLICK

SUBCUTANEOUS PEN

PA NDS

075 MG 1 MG 4 MG

PA BvD

FLEBOGAMMA DIF

PA BvD NDS

GAMASTAN SD

(10 ML) 15-18 RANGE (2 ML)

PA BvD

GAMMAGARD LIQUID

PA BvD NDS

MCGML) INTRAVENOUS

PA BvD NDS

GAMMAPLEX (WITH

SOLUTION 5

PA BvD NDS

SOLUTION 10 2 $0

PA BvD NDS

mg 50 mg 1 $0

PA BvD

START SUBCUTANEOUS

MG08 ML (6 PACK)

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA NDS

HUMIRA SUBCUTANEOUS

MG04 ML 40 MG08 ML

PA NDS

HYPERRAB SD (PF)

HYQVIA SUBCUTANEOUS

(10 ) 25 GRAM 25 ML (10 )

20 GRAM 200 ML (10 ) 30

50 ML (10 )

PA BvD NDS

(150 MGML)

PA NDS

150 UNITML

PA NDS

MG114 ML

PA QL (228 per 28

days) NDS

PA QL (1876 per 28

days) NDS

mg (Arava) 1 $0

(CellCept

Intravenous) 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA BvD

(CellCept) 1 $0

PA BvD NDS

PA BvD

mg 360 mg

(Myfortic) 1 $0

PA BvD

NULOJIX INTRAVENOUS

PA BvD NDS

OCTAGAM INTRAVENOUS

SOLUTION 10 5 2 $0

PA BvD NDS

250 MG

PA NDS

ORENCIA CLICKJECT

SUBCUTANEOUS AUTO-

INJECTOR 125 MGML

PA NDS

ML 875 MG07 ML

PA NDS

days) NDS

OTEZLA STARTER ORAL

(4)-20 MG (4)-30 MG (47) 10 MG

(4)-20 MG (4)-30 MG(19)

PA QL (60 per 30

days) NDS

OTREXUP (PF)

SUBCUTANEOUS AUTO-

MG04 ML 15 MG04 ML 175

MG04 ML 20 MG04 ML 225

MG04 ML 25 MG04 ML

SOLUTION 10 2 $0

PA BvD NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PROGRAF INTRAVENOUS

PA BvD

MGML 2 $0

PA BvD NDS

125 MG025 ML 15 MG03 ML

175 MG035 ML 20 MG04 ML

225 MG045 ML 25 MG05 ML

275 MG055 ML 30 MG06 ML

75 MG015 ML

PA NDS

MG 2 $0

PA NDS

MG05 ML

PA NDS

STELARA INTRAVENOUS

PA NDS

PA BvD

TYSABRI INTRAVENOUS

PA LA QL (15 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA QL (30 per 30

days) NDS

MG 05 MG 075 MG 2 $0

PA BvD NDS

Vaccines

ADACEL(TDAP

ADOLESNADULT)(PF)

INTRAMUSCULAR

MCG)-5LF05 ML

ADACEL(TDAP

ADOLESNADULT)(PF)

LF-(25-5-3-5 MCG)-5LF05 ML

PA BvD

BOOSTRIX TDAP

INTRAMUSCULAR

LF05ML

BOOSTRIX TDAP

20-20 MCG05 ML

(PF) INTRAMUSCULAR

LF05ML

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ENGERIX-B (PF)

INTRAMUSCULAR

SUSPENSION 20 MCGML

PA BvD

ENGERIX-B (PF)

PA BvD

INTRAMUSCULAR

PA BvD

MCG05 ML

PA BvD

GARDASIL (PF)

INTRAMUSCULAR

MCG05 ML

GARDASIL 9 (PF)

INTRAMUSCULAR

SUSPENSION 05 ML

GARDASIL 9 (PF)

HAVRIX (PF)

INTRAMUSCULAR

HAVRIX (PF)

ELISA UNIT05 ML

HIBERIX (PF)

INTRAMUSCULAR RECON

SOLN 10 MCG05 ML

INTRAMUSCULAR RECON

SOLN 25 UNIT

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

INTRAMUSCULAR

LF05ML

40-8-32 UNIT05 ML 2 $0

32 UNIT05 ML 2 $0

LF05 ML

MENACTRA (PF)

MCG05 ML

MENHIBRIX (PF)

INTRAMUSCULAR RECON

SOLN 5-25 MCG05 ML

50 MCG

MENOMUNE - ACYW-135

50 MCG

MCG05 ML

TCID5005 ML

PEDIARIX (PF)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PEDVAX HIB (PF)

75 MCG05 ML

PENTACEL (PF)

(PF) INTRAMUSCULAR

LF UNIT05ML

PROQUAD (PF)

FOR RECONSTITUTION

10EXP3-43-3- 399 TCID5005

QUADRACEL (PF)

INTRAMUSCULAR

LF UNIT05ML

RABAVERT (PF)

INTRAMUSCULAR

SUSPENSION FOR

PA BvD

RECOMBIVAX HB (PF)

INTRAMUSCULAR

PA BvD

RECOMBIVAX HB (PF)

MCGML 5 MCG05 ML

PA BvD

MCG05 ML

PA BvD

CCID50ML

SOLUTION 2 ML 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

SHINGRIX (PF)

INTRAMUSCULAR

SUSPENSION FOR

QL (2 per 365 days)

SHINGRIX GE ANTIGEN

COMPONENT

INTRAMUSCULAR

SUSPENSION FOR

QL (2 per 365 days)

TENIVAC (PF)

2 LF UNIT05 ML

SUV 5 LF UNIT- 2 LF

UNIT05ML

TETANUS-DIPHTHERIA

TOXOIDS-TD

INTRAMUSCULAR

SUSPENSION FOR

PA BvD

TWINRIX (PF)

INTRAMUSCULAR

20 MCGML

TWINRIX (PF)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

UNITML

VARIVAX (PF)

UNIT05 ML

QL (2 per 365 days)

SUSPENSION FOR

UNIT05 ML

ZOSTAVAX (PF)

UNIT065 ML

QL (1 per 365 days)

Agents

APRISO ORAL

24HR 0375 GRAM

budesonide oral

CANASA RECTAL

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

ST NDS

LIALDA ORAL

(DREC) 12 GRAM

(Azulfidine EN-

tabs) 1 $0

MGACTUATION 2 $0

LACTATED RINGERS

27-054 g100 ml 1 $0

irrigation solution

(Curity Sterile

Water) 1 $0

Agents

ml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 5 mg 1 $0

unitactuation

QL (37 per 28 days)

mcgml 1 $0

MCG24 ML

PA QL (24 per 28

mg3 ml 1 $0

QL (3 per 84 days)

MIACALCIN INJECTION

MCGDOSE

PA QL (2 per 28

days) NDS

5 MCGML

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg (Zemplar) 1 $0

PROLIA SUBCUTANEOUS

QL (1 per 180 days)

RAYALDEE ORAL

24 HR 30 MCG

QL (60 per 30 days)

MG 2 $0

QL (60 per 30 days)

MG 2 $0

QL (60 per 30 days)

MG 2 $0

MCG156 ML)

PA QL (156 per 30

soln 4 mg 1 $0

ZOMETA INTRAVENOUS

Agents

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA NDS

PA QL (4 per 28

days) NDS

PA QL (4 per 28

days) NDS

CETYLEV ORAL TABLET

GRAM17 ML 2 $0

mgml 1 $0

MG 2 $0

PACKET 5 GRAM 2 $0

PA QL (180 per 30

days) NDS

SOLUTION 50 MGML 50

MGML (10 ML)

PA LA NDS

gramml 1 $0

100 mg 1 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

soln 100 mg 350 mg 50 mg 1 $0

mg 15 mg 25 mg 5 mg 1 $0

LEVOLEUCOVORIN

175 MG

mgml (Mesnex) 1 $0

MG 2 $0

MG5 ML 2 $0

Heavy) 4 $0

PROGLYCEM ORAL

(Mestinon

Timespan) 1 $0

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 150 MG 200 MG 50 MG 2 $0

PA NSO QL (60 per

30 days) NDS

TOTECT INTRAVENOUS

QL (24 per 14 days)

PACKET 2 GRAM 2 $0

PA QL (120 per 30

days) NDS

Ophthalmic Agents

Antiglaucoma Agents

250 mg 1 $0

(EYE) DROPS 01 2 $0

02 1 $0

COMBIGAN OPHTHALMIC

(EYE) DROPS 02-05 2 $0

2 (Trusopt) 1 $0

0005 (Xalatan) 1 $0

05 (Betagan) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

DROPS 001 2 $0

QL (25 per 25 days)

mg (Neptazane) 1 $0

03 1 $0

PHOSPHOLINE IODIDE

(EYE) DROPS 0004 2 $0

QL (25 per 25 days)

QL (30 per 30 days)

mg-unit 4 $0

mg (950 mg) 4 $0

(Calcium 600 with

Vitamin D3) 4 $0

mg(1500mg) -500 unit 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Calcium 600 with

Vitamin D3) 4 $0

mg5 ml (1250 mg5 ml) 4 $0

250 mg-unit

(Calcitrate-Vitamin

D) 4 $0

(Calcium Citrate +

D) 4 $0

mg (500 mg) 4 $0

mg (648 mg) 4 $0

MG (1500 MG)-800 UNIT

250 mg-unit 4 $0

mg-unit 4 $0

315-250 mg-unit

(Calcitrate-Vitamin

D) 4 $0

mg-unit

(Calcitrate-Vitamin

D) 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Calcitrate-Vitamin

D) 4 $0

800 unit-40 mg

unit-40 mg

IONOSOL-B IN D5W

SOLUTION 5

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

IONOSOL-MB IN D5W

SOLUTION 5

mg(1500mg) -400 unit 4 $0

-500 unit

mg) 4 $0

gram500 ml (4 ) 40 gram1000

ml (4 )

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(4 ) 4 gram100 ml (4 ) 4

gram50 ml (8 )

4 meqml (50 ) 1 $0

4 meqml 1 $0

NORMOSOL-M IN 5

PARENTERAL SOLUTION

NORMOSOL-R PH 74

SOLUTION

(1250 mg) 4 $0

(1250 mg)

(625)-125 mg-unit 4 $0

PLASMA-LYTE 148

SOLUTION

PLASMA-LYTE A

SOLUTION

PLASMA-LYTE-56 IN 5

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

meql 40 meql

meq100 ml

(Klor-Con

Sprinkle) 1 $0

(K-Tab) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

meql 40 meql

solution 1 $0

(Calcitrate-Vitamin

D) 4 $0

mg 4 $0

2 meqml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

5 meqml 1 $0

18-5-45-35 MEQ20 ML

TPN ELECTROLYTES

20-5 MEQ20 ML

Corticosteroids

500-50 MCGDOSE

QL (60 per 30 days)

MCGACTUATION 230-21

MCGACTUATION 45-21

MCGACTUATION

QL (12 per 28 days)

ARNUITY ELLIPTA

200 MCGACTUATION

QL (30 per 30 days)

QL (60 per 30 days)

mg2 ml 1 mg2 ml

(Pulmicort) 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MCGACTUATION 200-5

MCGACTUATION

QL (13 per 28 days)

FLOVENT DISKUS

50 MCGACTUATION

QL (60 per 30 days)

FLOVENT DISKUS

MCGACTUATION

QL (12 per 28 days)

MCGACTUATION

QL (24 per 28 days)

MCGACTUATION

45 MCGACTUATION

QL (12 per 25 days)

MCGACTUATION 80-45

MCGACTUATION

QL (11 per 25 days)

Antileukotrienes

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Bronchodilators

mg3 ml 25 mg 3 ml (0083 ) 5

PA BvD

ml 1 $0

MCGACTUATION

QL (60 per 30 days)

MCGACTUATION

COMBIVENT RESPIMAT

MCGACTUATION

QL (8 per 30 days)

FORADIL AEROLIZER

INHALATION CAPSULE

QL (60 per 30 days)

INCRUSE ELLIPTA

solution 002 1 $0

PA BvD

QL (30 per 30 days)

ml 1 $0

20 mg 1 $0

AEROSOL INHALER 90

MCGACTUATION

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PROAIR RESPICLICK

INHALATION AEROSOL

90 MCGACTUATION

SEREVENT DISKUS

DEVICE 50 MCGDOSE

QL (60 per 30 days)

SPIRIVA RESPIMAT

INHALATION MIST 125

MCGACTUATION 25

MCGACTUATION

INHALATION CAPSULE

STIOLTO RESPIMAT

MCGACTUATION

QL (4 per 28 days)

STRIVERDI RESPIMAT

INHALATION MIST 25

MCGACTUATION

QL (4 per 28 days)

mgml 1 $0

mg100 ml 200 mg50 ml 400

mg250 ml 400 mg500 ml 800

mg250 ml

ml 1 $0

(Theochron) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TRELEGY ELLIPTA

PA BvD

(10 ) 200 mgml (20 ) 1 $0

PA BvD

CINQAIR INTRAVENOUS

PA NDS

PA BvD

mgspray (4 )

(Nasal Allergy

MCG 2 $0

QL (30 per 30 days)

MG 2 $0

PA QL (270 per 30

days) NDS

PA QL (1 per 28

days) NDS

PA QL (60 per 30

days) NDS

MG 2 $0

PA QL (60 per 30

days) NDS

NUCALA SUBCUTANEOUS

PA LA QL (1 per 28

days) NDS

150 MG 2 $0

PA QL (60 per 30

days) NDS

125 MG 200-125 MG 2 $0

PA QL (120 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

suv pf (rx) 09 3 $0

XOLAIR SUBCUTANEOUS

PA NDS

350 mg (Soma) 1 $0

PA-HRM QL (120 per

30 days) AGE (Max

64 Years)

mg 1 $0

PA-HRM AGE (Max

64 Years)

mg (Dantrium) 1 $0

64 Years)

mg 1 $0

MG 15 MG 20 MG 5 MG 2 $0

QL (30 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

3 mg (Lunesta) 1 $0

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any non-

benzodiazepine

per 30 days) AGE

(Max 64 Years)

MG 2 $0

PA QL (30 per 30

days) NDS

6 MG 2 $0

QL (30 per 30 days)

MGML 2 $0

LA QL (540 per 30

days) NDS

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any non-

benzodiazepine

per 30 days) AGE

(Max 64 Years)

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any non-

benzodiazepine

per 30 days) AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Vasodilating Agents

days) NDS

MG 1 MG 15 MG 2 MG 25 MG 2 $0

PA QL (90 per 30

days) NDS

PA NDS

MG 5 MG 2 $0

PA QL (30 per 30

days) NDS

1 MG 25 MG 5 MG

PA NDS

REMODULIN INJECTION

SOLUTION 1 MGML 10

MGML 25 MGML 5 MGML

PA NDS

PA QL (375 per 1

day) NDS

PA QL (90 per 30

MG 625 MG 2 $0

PA LA QL (60 per 30

days) NDS

PA QL (112 per 28

days) NDS

TYVASO INHALATION

SOLUTION FOR

(06 MGML)

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

1600 MCG 400 MCG 600 MCG

800 MCG

PA QL (60 per 30

days) NDS

MCG 2 $0

PA QL (240 per 30

days) NDS

UPTRAVI ORAL

(140)- 800 MCG (60)

PA QL (400 per 365

days) NDS

formula 4 $0

mg-mcg-mcg-mcg

mcg-mcg

600-300 mcg 4 $0

250 mcg 4 $0

formulation 4 $0

mcg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

300-250 mg-mcg-mcg 4 $0

Complex) 4 $0

unitdrop 4 $0

unit02 ml 4 $0

(Super B Complex-

Vitamin C) 4 $0

bee-zee tablet 4 $0

biosupp liquid 4 $0

free 300 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

biovol syrup 4 $0

mg(1500mg) -200 unit 4 $0

mg(2500 mg)-800 unit 4 $0

125 mg-unit

(Oyster Shell +

D3) 4 $0

(1250mg) -600 unit (Os-Cal 500 + D3) 4 $0

mg-unit 4 $0

mg(1500mg) -200 unit 4 $0

(Calcium 600 +

D(3)) 4 $0

800 unit

(Caltrate with

Vitamin D3) 4 $0

iron15 ml 4 $0

300-250 mg-mcg-mcg 4 $0

mcg 4 $0

400 mg-mcg 4 $0

iron15 ml 4 $0

04-300-250 mg-mcg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg 4 $0

400 mg-mcg 4 $0

600-300 mcg 4 $0

400 mg-mcg 4 $0

mg-mcg 4 $0

250 mg-mcg-mcg 4 $0

iron15 ml 4 $0

mg-mcg 4 $0

iron 4 $0

compete tablet 4 $0

250 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

free 100 mg 4 $0

Vitamin C) 4 $0

shell 500 mg(1250mg) -125 unit 4 $0

pf 500 mg(1250mg) -200 unit 4 $0

800 unit

(Caltrate with

Vitamin D3) 4 $0

200 mcg 4 $0

iron) 4 $0

free 200 mcg 4 $0

300-250 mg-mcg-mcg 4 $0

mcg 4 $0

mg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

600-300 mcg 4 $0

400 mg-mcg 4 $0

pf 4 $0

mg 4 $0

unit 4 $0

coated 4 $0

400 mg-mcg 4 $0

lactose-free 4 $0

400 mg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

sf 400 unit 4 $0

unitml 4 $0

ellis tonic 4 $0

mg 4 $0

TABLET 750 MG 4 $0

iron 4 $0

300-250 mg-mcg-mcg 4 $0

free 18-400 mg-mcg 4 $0

400-20-300 mcg 4 $0

mg-mcg-mcg 4 $0

mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

iron) 4 $0

mg iron) 4 $0

mg iron 4 $0

mg 4 $0

iron) 4 $0

mg iron)

(Ferate) 4 $0

(60 mg iron)5 ml 4 $0

(65 mg iron) 4 $0

(Feosol) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

iron 4 $0

(otc) 1 mg 4 $0

free 04-300-250 mg-mcg-mcg 4 $0

300-250 mg-mcg-mcg 4 $0

hair vitamins 4 $0

mg (106 mg iron) 4 $0

mg-mcg-mcg 4 $0

mg-mcg 4 $0

free 18-400 mg-mcg 4 $0

free 400 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

iron) 4 $0

mg iron 4 $0

kpn tablet 4 $0

mg-mcg 4 $0

mg5 ml 4 $0

7160 UNIT-113 MG-100 UNIT 4 $0

mcg 4 $0

MG 3 $0

mg-mcg 4 $0

mcg-80 mcg 4 $0

mg-mcg 4 $0

iron5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

VitaminsIron) 4 $0

CHEWS) 4 $0

iron15 ml 4 $0

Vitamin) 4 $0

025 mgml 4 $0

childrens 4 $0

mg-mg-mcg-mg 3 $0

mg-mcg 3 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

mcg 4 $0

400 mg-mcg 4 $0

mg-mcg 4 $0

mcg 4 $0

400 mg-mcg 4 $0

iron-400 mcg 4 $0

mg(1250mg) -200 unit 4 $0

mg(1250mg) -400 unit 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

-400 unit

mg(1250mg) -400 unit 4 $0

ALL RX PRENATAL

VITAMINS

COVERABLE

UNDER PART D

iron 4 $0

mg-unitml 4 $0

400 unit-10 mgml 4 $0

unit-mg-unitml 4 $0

800 mcg 4 $0

iron- 800 mcg 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Prenatal) 4 $0

iron- 08 mg 4 $0

ALL RX PRENATAL

VITAMINS

COVERABLE

UNDER PART D

800 mcg 4 $0

unit 4 $0

mgml 3 $0

mg iron 4 $0

04 mg 4 $0

250 mg-mcg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg 4 $0

mg(1250mg) -200 unit 4 $0

mg 4 $0

mcg 4 $0

mg 4 $0

mcgml 4 $0

500 mg 4 $0

mcg 3 $0

iron- 08 mg 4 $0

mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

500-300-250 mg-mcg-mcg-mcg 4 $0

mcg-mcg 4 $0

CHEWS) 4 $0

chewable 4 $0

gluten-free

(Super B Complex-

Vitamin C) 4 $0

300-250 mg-mcg-mcg 4 $0

gluten-free 4 $0

VitaminsIron) 4 $0

Vitamin) 4 $0

mg 4 $0

mcg 4 $0

iron- 800 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

600-300 mcg 4 $0

sodfluorid)ml

400 mcg- 18 mg iron 4 $0

400 mcg- 27 mg iron 4 $0

25 mcg 4 $0

600 mg(1500mg) -400 unit

(Calcium 600 +

D(3)) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

support liquid 4 $0

iron-667 mcg-1000 mcg 4 $0

thera caplet 4 $0

mcg 4 $0

thera-m caplet 4 $0

iron-400 mcg 4 $0

mcg 4 $0

iron-400 mcg 4 $0

pfcaplet 4 $0

pf 4 $0

therems tablet 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

unitml 4 $0

mg-unitml 4 $0

50000 unit 3 $0

orangesf 4 $0

400 mcg- 18 mg iron 4 $0

mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

400 mcg 4 $0

mg 4 $0

250 mg 4 $0

mg 4 $0

500 mg 4 $0

unit 4 $0

1000 unit 4 $0

unit 4 $0

2000 unit (D3 DOTS) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

unit 4 $0

unit5 ml 4 $0

5000 unit

(Dialyvite Vitamin

D) 4 $0

5000 UNITML

400 unit 4 $0

mcg-mcg-mcg 4 $0

250 mcg 4 $0

mcg 3 $0

1333 mg-unit 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

1ST TIER UNILET

COMFORTOUCH 135

3 3 day vaginal 57

3-day vaginal 53

A a thru z 214

a thru z select 214

abacavir 76

abc plus 214

ABELCET 54

ABILIFY MAINTENA 71

ABRAXANE 30

ABREVA 64

acamprosate 16

acarbose 49

ACCU-CHEK MULTICLIX

LANCET 135

PLUS 136

ACCU-CHEK SOFTCLIX

LANCETS 136

acebutolol 94

acephen 3

acetazolamide 198

acetic acid 154 193

acetylcysteine 210

acid controller 159

acitretin 127

acne medication 127

ACNE MEDICATION 128

acta-tabs pe 62

ACTEMRA 182

ACTHIB (PF) 187

ACTIMMUNE 195

acyclovir 81 128

ADACEL(TDAP

ADAGEN 148

adapalene 135

ADCIRCA 213

adefovir 82

ADEMPAS 213

adriamycin 30

adrucil 30

adults 50 plus 215

ADVAIR DISKUS 206

ADVAIR HFA 206

ADVANCED TRAVEL

LANCETS 136

ADVIL 11

ADVOCATE LANCET 136

afeditab cr 100

AFINITOR 30

AFINITOR DISPERZ 30

aftera 110

a-hydrocort 176

AKTEN (PF) 150

AKYNZEO 66

ala-cort 132

alavert 58

ALBENZA 68

alclometasone 132

ALCOHOL PADS 128

ALDURAZYME 148

ALECENSA 30

alendronate 193 194

aler-cap 58

aler-tab 58

alfuzosin 173

ALIMTA 30

ALINIA 68

ALIQOPA 30

aller-chlor 58

allergy medicine 62

allerhist-1 58

aller-tec d 58

allopurinol 57

almacone 161

almacone-2 161

alophen 167

alosetron 192

ALPHAGAN P 198

alprazolam 18

ALREX 157

altamist 150

altavera (28) 110

ALUNBRIG 31

alyacen 135 (28) 110

alyacen 777 (28) 110

amabelz 175

amantadine hcl 69

ambi 20dm-4cpm 118

ambi 60pse-4cpm 58

AMBISOME 54

amethia 110

amethia lo 110

amiloride 101

AMINO ACIDS 15 85

AMINOSYN 10 86

AMINOSYN 7 WITH

ELECTROLYTES 86

AMINOSYN 85 86

AMINOSYN 85 -

ELECTROLYTES 86

AMINOSYN II 10 86

AMINOSYN II 15 86

AMINOSYN II 7 86

AMINOSYN II 85 86

AMINOSYN II 85 -

ELECTROLYTES 86

AMINOSYN M 35 86

AMINOSYN-HBC 7 86

AMINOSYN-PF 10 87

AMINOSYN-PF 7

(SULFITE-FREE) 87

AMINOSYN-RF 52 87

amiodarone 94

AMITIZA 161

amitriptyline 46

amlactin 128

amlodipine 100

amoxapine 46

amoxicillin 26

amphotericin b 54

ampicillin 27

AMPYRA 106

ANADROL-50 174

anagrelide 85

anastrozole 31

ANDRODERM 174

ANDROGEL 174

androxy 174

animal chews 215

ANORO ELLIPTA 208

anti-diarrheal 163

antifungal cream 54

antihistamine 58

antioxidant 215

apatate forte 215

APOKYN 69

apraclonidine 150

aprepitant 66

apri 110

APRISO 192

aprodine 58

APTIOM 41

APTIVUS 76

aquanil hc 132

aranelle (28) 110

ARCALYST 182

aripiprazole 71

ARISTADA 71

armodafinil 211

ARNUITY ELLIPTA 206

ARTIFICIAL TEARS

(PETROMIN) 150

ashlyna 110

aspirin 12 14

aspirin buffered 12

aspir-low 12

aspir-trin 12

ASSURE HAEMOLANCE

PLUS 136

ASSURE ID INSULIN

SAFETY 136

ASSURE LANCE 137

ASTAGRAF XL 182

atenolol 95

athenol 10

atomoxetine 106

atorvastatin 103

atovaquone 68

ATRIPLA 76

atropine 41 150

ATROVENT HFA 208

AUBAGIO 106

aubra 110

AUSTEDO 106

AVASTIN 31

AVC VAGINAL 64

aviane 110

AVONEX 107

ayr saline 150

azacitidine 31

azathioprine 182

azelastine 150 151

azithromycin 24

aztreonam 25

azurette (28) 110

B b complete 215

b complex 1 215

b complex 100 230

215 222 230

b-12 dots 215

baby ddrops 215

baclofen 211

bal b-100 218

bal b-50 218

balance b-100 215

balance b-50 215

balsalazide 192

balziva (28) 110

banophen 58

banophen allergy 58

BANZEL 41

BAVENCIO 31

BAXDELA 28

baza antifungal 54

b-complex 227

218 229 232 233

BD INSULIN SYRINGE

ULTRA-FINE 137

NEEDLES 137

bee-zee 215

bekyree (28) 110

BELBUCA 3

BELEODAQ 31

BELSOMRA 211

benadryl allergy 58

benazepril 92

BENDEKA 31

BENLYSTA 196

benzonatate 118 119

benztropine 69

BESPONSA 31

BETADINE 128

beta-hc 132

BETASERON 107

betaxolol 95 198

BETHKIS 19

BEVYXXA 82

bexarotene 31

BEXSERO 187

bicalutamide 31

bicarsim forte 158

BICILLIN C-R 27

BICILLIN L-A 27

BIDIL 105

bio-dtuss dmx 119

bion tears (pf) 151

biosupp 215

biotin 215

biovol 216

bisac-evac 167

bisacodyl 167

biscolax 167

bismatrol 161

bismuth 163

bleomycin 31

bleph-10 154

BLINCYTO 31

blisovi 24 fe 111

blisovi fe 1530 (28) 111

blisovi fe 120 (28) 111

BOOSTRIX TDAP 187

BOSULIF 31

BREO ELLIPTA 206

briellyn 111

BRILINTA 85

brimonidine 198

BRIVIACT 41

bromfed dm 119

bromocriptine 69

dm 118 119

BROMSITE 157

brotapp dm 119

budesonide 192 206

buffered aspirin 15

bufferin 12

LANCETS 137

bumetanide 101

BUNAVAIL 16

BUPHENYL 161

buprenorphine 4

bupropion hcl 46

buspirone 18

BUTRANS 4

BYSTOLIC 95

BYVALSON 95

C cabergoline 69

CABOMETYX 31

bor 201 205

calci-chew 161

calcidol 216

calcipotriene 128

calcitrate 199

calcitrene 128

calcitriol 128 194

calcium 500 + d 218

calcium 500 + d (d3) 218

calcium 600 199 205

calcium 600 + d(3) 200 216

199 202

calcium acetate 172

calcium antacid 162

199 200 216 218 230

CALCIUM CARBONATE-

VITAMIN D3 200

201 205

calcium+d 234

CALDOLOR 12

CALQUENCE 31

camila 111

camrese 111

camrese lo 111

CANASA 192

CANCIDAS 54

candesartan 91

capacet 4

CAPASTAT 65

CAPRELSA 32

captopril 93

CARAFATE 159

CARBAGLU 162

carbamazepine 41

CAREONE ULTRA THIN

LANCET 137

CARETOUCH TWIST

LANCET 138

CARIMUNE NF

NANOFILTERED 182

carisoprodol 211

carteolol 198

cartia xt 96

carvedilol 95

caspofungin 54

CASTELLANI PAINT

MODIFIED 128

CAYSTON 26

caziant (28) 111

cefaclor 22

cefadroxil 22

cefazolin 22

cefdinir 22

CEFEPIME 22

CEFEPIME IN

DEXTROSEISO-OSM 22

cefotaxime 23

cefoxitin 23

cefpodoxime 23

cefprozil 23

ceftazidime 23

ceftibuten 23

ceftriaxone 23

celecoxib 12

CELONTIN 42

centamin 216

centergy dm 119

central-vite 228

centram-care 216

centrum 216

centrum silver 216

centrum women 217

century 217

cephalexin 24

CERDELGA 148

CEREZYME 148

cerovite 217

cerovite jr 217

cerovite senior 217

cetiri-d 62

cetirizine 59

CETYLEV 196

cevimeline 127

CHANTIX 16

CHANTIX CONTINUING

MONTH BOX 16

CHANTIX STARTING

MONTH BOX 16

chewable-vite 217

CHILDRENS ADVIL 12

childrens mapap 5

childrens pepto 162

CHILDRENS ZYRTEC

ALLERGY 59

childsiron 217

chlorhist 59

chlorothiazide 101

chlorpromazine 71

chlorthalidone 101

chlorzoxazone 211

219 233 234

CHOLECALCIFEROL

(VITAMIN D3) 234

ciclopirox 54

cilostazol 85

cimetidine 159

cimetidine hcl 159

CIMZIA 182

CIMZIA POWDER FOR

RECONST 182

CINQAIR 210

CINRYZE 83

CIPRODEX 154

ciprofloxacin 29

citalopram 46

citrus calcium 200

clarithromycin 25

clearlax 171

CLEVIPREX 101

clindamycin hcl 20

130 131

CLINIMIX 5D15W

SULFITE FREE 87

CLINIMIX 5D25W

SULFITE-FREE 87

CLINIMIX 275D5W

SULFIT FREE 87

FREE 87

CLINIMIX 425D5W

SULFIT FREE 87

CLINIMIX 425-D20W

SULF-FREE 87

CLINIMIX 425-D25W

SULF-FREE 87

CLINIMIX 5-

CLINIMIX E 275D10W

SUL FREE 88

CLINIMIX E 275D5W

SULF FREE 88

CLINIMIX E 425D10W

SUL FREE 88

CLINIMIX E 425D25W

SUL FREE 88

CLINIMIX E 425D5W

SULF FREE 88

CLINIMIX E 5D15W

SULFIT FREE 88

CLINIMIX E 5D20W

SULFIT FREE 88

CLINIMIX E 5D25W

SULFIT FREE 88

CLINISOL SF 15 88

clobetasol 132

clofarabine 32

clomipramine 46

clonazepam 18

clonidine 91

clonidine hcl 91

clopidogrel 85

clotrimazole 54

clotrimazole-7 54

clozapine 71 72

COARTEM 68

codeine sulfate 5

COLCRYS 57

cold-flu relief 120

colestipol 103

colocort 192

COLOR LANCETS 144

col-rite 171

COLY-MYCIN S 155

COMBIGAN 198

COMBIPATCH 175

COMETRIQ 32

comfort gel 162

COMFORT LANCETS 138

compete 217

COMPLERA 76

complete 229

complete 50+ 222

complete multi 217

220 229

complete women 222

compoz 60

compro 66

CONDYLOX 128

congestac 120

congest-eze 120

constulose 162

COPAXONE 107

coricidin hbp 120

CORLANOR 97

cormax 132

cortaid 132

cortisone 176

COTELLIC 32

cough syrup dm 122

CREON 149

CRIXIVAN 76

cromolyn 151 210

cryselle (28) 111

CUPRIMINE 173

215 219 228 232 233

cyclafem 135 (28) 111

cyclafem 777 (28) 111

cyclobenzaprine 211

cyclopentolate 151

cyclophosphamide 32

CYCLOPHOSPHAMIDE 32

CYCLOSET 49

cyclosporine 182

cyproheptadine 60

CYRAMZA 32

cyred 111

CYSTADANE 196

CYSTARAN 151

d3 dots 219

daily gummies 218

daily value 219

daily vitesiron 219

dailyhist-1 60

daily-vite 219

DAKLINZA 80

DALIRESP 210

danazol 174

dantrolene 211

dapsone 65

DAPTACEL (DTAP

PEDIATRIC) (PF) 187

daptomycin 20

DARAPRIM 69

DARZALEX 32

dasetta 135 (28) 111

dasetta 777 (28) 111

dayhist 60

dayhist allergy 60

daysee 111

day-time cough 121

deblitane 111

decitabine 32

deep sea nasal 151

deferoxamine 174

delta d3 220

delyla (28) 111

DELZICOL 193

DEMSER 97

DEPEN TITRATABS 174

DEPO-PROVERA 181

dermafungal 55

DERMAREST ECZEMA

(PRAMOXINE) 133

DESCOVY 76

desipramine 46

desmopressin 178

desoximetasone 133

guaif) 121

dex4 glucose 88

phosphate 157 177

dextroamphetamine-

amphetamine 107

diamode 163

DIASTAT 18

DIASTAT ACUDIAL 18

diazepam 18

dicloxacillin 27

dicyclomine 163

didanosine 76

DIFICID 25

diflunisal 13

digitek 98

digox 98

digoxin 98 99

DIGOXIN 98

DILANTIN 42

dilt-cd 96

diltiazem hcl 96 97

dilt-xr 97

dimaphen (pe) 60

dimaphen dm 121

dimenhydrinate 66

(CPM-DM) 121

dino-life 220

DIPENTUM 193

diphedryl 60

diphenhist 60

dipyridamole 85

disulfiram 16

divalproex 42

dobutamine 99

docu 168

docusate sodium 168

docusol 168

dofetilide 94

dok 168

dok plus 168

donepezil 45

dopamine 99

dorzolamide 198

doxazosin 91

doxepin 46 47

doxercalciferol 194

doxorubicin 32

doxy-100 29

dramamine 66

driminate 66

dronabinol 66

droperidol 196

DROPLET LANCETS 138

DROXIA 32

DUAVEE 175

DULERA 207

duloxetine 47

DUPIXENT 129

DUREZOL 157

dutasteride 173

d-vi-sol 220

E ec prin 13

ees 400 25

ees granules 25

EASY TOUCH SAFETY

LANCETS 138

EASY TOUCH TWIST

LANCETS 138 139

EASY TWIST AND CAP

LANCETS 139

econazole 55

econtra ez 112

ecotrin 13

ed a-hist 61

ed bron gp 121

ed chlorped jr 61

EDARBI 92

EDARBYCLOR 92

EDURANT 76

EFFIENT 85

ELAPRASE 149

eldertonic 220

ELIDEL 133

ELIGARD 33

elinest 112

eliphos 172

ELIQUIS 82

ELITEK 149

ELLA 112

ellis tonic 220

ELMIRON 196

EMBRACE LANCETS 139

EMCYT 33

EMEND 66

EMFLAZA 177

emoquette 112

EMPLICITI 33

EMSAM 47

EMTRIVA 76

enalaprilat 93

ENBREL 182 183

ENDARI 196

endocet 5

endur-acin 103

endur-amide 220

ENDUR-AMIDE 220

enema 171

enemeez 168

enemeez plus 168

ENGERIX-B (PF) 188

enoxaparin 82

enpresse 112

enskyce 112

entacapone 70

entecavir 82

ENTRESTO 92

enulose 163

ENVARSUS XR 183

EPCLUSA 80

epinastine 151

epinephrine 99

EPIPEN 99

EPIPEN 2-PAK 99

EPIPEN JR 2-PAK 100

epitol 42

EPIVIR HBV 76

eplerenone 105

EPOGEN 84

eq gentle 151

equalactin 168

ergoloid 196

ERGOMAR 64

ERIVEDGE 33

errin 112

ery pads 131

ERYPED 200 25

ERYPED 400 25

ery-tab 25

ERY-TAB 25

ERYTHROCIN 25

erythromycin 25 155

ESBRIET 210

esmolol 95

essentia 220

essential daily 220

estarylla 112

ESTRACE 175

estradiol 175

estropipate 176

eszopiclone 212

ethambutol 65

ethosuximide 42

etodolac 13

ETOPOPHOS 33

etoposide 33

EUCRISA 133

EVOTAZ 76

exemestane 33

EXJADE 174

EXONDYS 51 196

expectorant 121

expectorant dm 121

EXTAVIA 107

ezetimibe 103

F FABRAZYME 149

fallback solo 112

falmina (28) 112

famciclovir 82

famotidine 160

famotidine (pf) 159

FANAPT 72

FARESTON 33

FARYDAK 33

FASENRA 210

FASLODEX 33

felbamate 42

felodipine 101

FEMRING 176

femynor 112

fenofibrate 103

fenofibric acid 103

fenoprofen 13

fentanyl 6

fentanyl citrate 6

feosol 221

ferate 221

ferocon 221

ferretts 221

ferrex 150 221

ferrex 150 plus 221

ferric x-150 221

FERRIPROX 174

ferrocite 221

FETZIMA 47

feverall 6

fexofenadine 61

FIASP 52

FIASP FLEXTOUCH 51

fiber smooth 171

fiber-lax 169

FIFTY50 SAFETY SEAL

LANCETS 139

finasteride 173

FINE 30 UNIVERSAL

LANCETS 139

FIRAZYR 100

FLEBOGAMMA DIF 183

flecainide 94

FLECTOR 129

FLEET BISACODYL 169

FLOVENT DISKUS 207

FLOVENT HFA 207

floxuridine 33

flu hbp 122

fluconazole 55

flucytosine 55

fludrocortisone 177

flumazenil 107

flunisolide 157

fluocinolone 133

fluocinonide 133

fluocinonide-e 133

fluorometholone 157

fluorouracil 33 129

fluoxetine 47

fluphenazine hcl 72

flurbiprofen 13

flutamide 33

fluticasone 133 157

fluvoxamine 47

folic acid 222

fomepizole 196

fondaparinux 82 83

foot and sneaker 55

formula 3 55

FORTEO 194

fosamprenavir 76

foscarnet 79

fosfree 222

fosinopril 93

fosphenytoin 42

FREAMINE HBC 69 89

FREAMINE III 10 89

STRIPS 140

FREESTYLE TEST 140

fungi cure 55

fungoid-d 55

furosemide 102

FUZEON 76

FYCOMPA 42

G gabapentin 42

GABITRIL 42

galantamine 45

GAMASTAN SD 183

MCGML) 183

GAMMAPLEX 183

GAMMAPLEX (WITH

SORBITOL) 183

GARDASIL (PF) 188

GARDASIL 9 (PF) 188

gas relief 158

gas relief 80 158

gatifloxacin 155

GATTEX 30-VIAL 163

GAUZE PAD 140

gavilyte-c 169

gavilyte-g 169

gavilyte-n 169

GAZYVA 33

gemfibrozil 103

generlac 163

gengraf 183

GENOTROPIN 178

gentak 155

GENTEAL GEL 152

GENTEAL MILD 152

GENTEAL SEVERE 152

genteal tears 152

HPM-GLY) 152

gentlelax 169

GENVOYA 77

GEODON 72

geriaton 222

geri-dryl 61

geri-hydrolac 129

geri-tussin dm 122

gianvi (28) 112

gildagia 112

GILENYA 107

GILOTRIF 33

glatiramer 107

glatopa 108

GLEOSTINE 33

glimepiride 53

glipizide 53

GLUCAGEN HYPOKIT 49

GLUCAGON EMERGENCY

KIT (HUMAN) 49

gluco burst 89

glucose 89

glucose gel 89

glutose 15 89

glyburide 53

glycolax 169

glycopyrrolate 164

glydo 15

GLYXAMBI 49

GMATE LANCETS 140

GOCOVRI 70

granisetron (pf) 66

granisetron hcl 67

GRANIX 84

guaifenesin 122

guanfacine 91 108

guanidine 196

H HAEGARDA 84

hair vitamins 222

haloperidol 73

HARVONI 80

HAVRIX (PF) 188

HEALTHY ACCENTS

UNILET LANCET 140

healthylax 169

heather 112

hemocyte 222

HEPATAMINE 8 89

HERCEPTIN 34

HETLIOZ 212

HEXALEN 34

hi-b complex 222

HIBERIX (PF) 188

honey bears 222

HUMATROPE 178

HUMIRA 184

HUMIRA PEDIATRIC

CROHNS START 183

HUMIRA PEN 184

HS START 183

UVEITIS 184

KWIKPEN 52

HUMULIN R U-500

(CONCENTRATED) 52

hydralazine 100

hydromorphone 6 7

hydroskin 133

hydroxyurea 34

hydroxyzine hcl 61

HYQVIA 184

HYSINGLA ER 7

I ibandronate 194

IBRANCE 34

ibuprofen 12 13 15

icaps plus 222

ICLUSIG 34

IDHIFA 34

iferex 150 222

ifosfamide 34

ifosfamide-mesna 34

ILARIS (PF) 184

ILEVRO 157

imatinib 34

IMBRUVICA 34

IMFINZI 34

imipramine hcl 47

imiquimod 129

IMLYGIC 34

imodium a-d 164

IMODIUM A-D 164

(PF) 188

IMPAVIDO 69

LANCETS 140

INCRELEX 179

INCRUSE ELLIPTA 208

indapamide 102

indomethacin 13 14

infants advil 14

INFLECTRA 184

INGREZZA 108

INLYTA 34

INSECT REPELLENT

(PICARIDIN) 129

insta-glucose 89

U-100 140 141

INTELENCE 77

intense cough 122

INTRALIPID 90

INTRON A 81

introvale 112

INVANZ 26

INVEGA SUSTENNA 73

INVEGA TRINZA 73

INVIRASE 77

INVOKAMET 49

INVOKAMET XR 49

INVOKANA 50

inzo antifungal 55

iodine 148

IPOL 189

IPRIVASK 83

irbesartan 92

IRESSA 35

iron 223

ISENTRESS 77

ISENTRESS HD 77

isibloom 112

ISOLYTE-P IN 5

DEXTROSE 202

ISOLYTE-S 202

isoniazid 65

isopto tears 152

isradipine 101

itraconazole 55

ivermectin 69

IXEMPRA 35

IXIARO (PF) 189

J JADENU 174

JADENU SPRINKLE 174

JAKAFI 35

jantoven 83

JANUMET 50

JANUMET XR 50

JANUVIA 50

JARDIANCE 50

jencycla 112

JENTADUETO 50

JENTADUETO XR 50

jolessa 112

jolivette 112

juleber 112

junel 1530 (21) 112

junel 120 (21) 113

junel fe 1530 (28) 113

junel fe 120 (28) 113

junel fe 24 113

junior mapap 7

JUXTAPID 103

K KABIVEN 90

KALETRA 77

KALYDECO 210

KANUMA 149

kariva (28) 113

kelnor 135 (28) 113

KENALOG 177

ketoconazole 55

ketoprofen 14

KEVEYIS 196

KEVZARA 184

KEYTRUDA 35

kids mini enema 167

kimidess (28) 113

KINERET 184

KINRIX (PF) 189

kionex 164

KISQALI 35

klor-con m10 202

klor-con m15 202

klor-con m20 202

kobee 223

konsyl (sugar) 169

konsyl fiber 169

KORLYM 50

kpn 223

KRYSTEXXA 149

kurvelo 113

KUVAN 149

KYNAMRO 104

KYPROLIS 35

labetalol 95

LACRISERT 152

LACTINOL HX 129

lactulose 164

lamisil af 55 56

LAMISIL AT 56

lamivudine 77

lamotrigine 42 43

LANCETS 136 137 138 139

141 142 144

LANCETSTHIN 141 145

LANOXIN 100

lansoprazole 160

LANTUS 52

LANTUS SOLOSTAR 52

larin 1530 (21) 113

larin 120 (21) 113

larin 24 fe 113

larin fe 1530 (28) 113

larin fe 120 (28) 113

larissia 113

LARTRUVO 35

latanoprost 198

LATUDA 73

LAZANDA 7

leena 28 113

leflunomide 184

LEMTRADA 108

LENVIMA 35

lessina 113

LETAIRIS 213

letrozole 35

LEUKERAN 35

LEUKINE 84

leuprolide 36

levetiracetam 43

levobunolol 198

levocarnitine 197

levocetirizine 61

levofloxacin 29 155

levoleucovorin 197

LEVOLEUCOVORIN 197

levonest (28) 113

levonorgestrel 114

levora-28 114

levothyroxine 181

LEXIVA 77

LIALDA 193

lice killing 135

lice treatment 135

lidocaine 15

lidocaine hcl 15

lillow 114

linezolid 20 21

LINZESS 164

liothyronine 181

liquibid d-r 122

liquid c 223

lisinopril 93

lithium citrate 108

little animals 223

little remedies 152

LIVALO 104

lohist-dm 122

lomedia 24 fe 114

LONSURF 36

loperamide 163 164

lopreeza 176

lorata-d 62

loratadine 59 61 62

loratadine-d 60 61

lorazepam 18

lorcet hd 7

lorcet plus 7

loryna (28) 114

losartan 92

LOTEMAX 158

lovastatin 104

lubricant eye 151

lubricant gel 151

lubrifresh pm 152

LUMIGAN 199

LUPRON DEPOT 36

LUPRON DEPOT-PED (3

MONTH) 179

lutera (28) 114

LYNPARZA 36

LYRICA 43

lysiplex plus 223

LYSODREN 36

lyza 114

mag 64 202

mag-delay 202

mag-g 202

magnesium 200 205

malathion 135

maprotiline 48

marlissa 114

MARPLAN 48

masophen 8

MATULANE 36

matzim la 97

MAVYRET 80

meclizine 67

medi-bismuth 165

medi-meclizine 67

medi-natural 169

medi-phedrine 122

MEDI-PHENYL 91

mefenamic acid 14

mefloquine 69

MEFOXIN IN DEXTROSE

(ISO-OSM) 24

megestrol 36 181

MEKINIST 36

meloxicam 14

memantine 45

MENACTRA (PF) 189

MENEST 176

MENHIBRIX (PF) 189

MENOMUNE - ACYW-135

(PF) 189

mens one daily 220

(PF) 189

MEPHYTON 223

mercaptopurine 36

meropenem 26

mesalamine 193

mesna 197

MESNEX 197

MESTINON 197

metaproterenol 208

metformin 50

methadone 8

methadose 8

methazolamide 199

methimazole 181

methocarbamol 211

methoxsalen 129

methscopolamine 165

metipranolol 199

metolazone 102

mexiletine 94

mgo 165

MIACALCIN 194

mi-acid 165

micatin 56

miconazole 7 56

miconazole-3 56

MICROLET LANCET 141

midodrine 91

miglitol 50

milrinone 100

mimvey 176

mimvey lo 176

MINERAL OIL 197

minitran 106

minocycline 30

minoxidil 106

mintox 165

mintox plus 165

MIRCERA 84

mirtazapine 48

misoprostol 160

mitoxantrone 37

M-M-R II (PF) 189

moexipril 93

molindone 73

mometasone 134

MONISTAT 3 56

monistat 7 56

MONOLET LANCETS 141

mono-linyah 114

mononessa (28) 114

montelukast 207

morphine 8

MORPHINE 8

motion sickness 66

MOVANTIK 165

MOVIPREP 169

MOXEZA 155

moxifloxacin 29 155

MOZOBIL 84

mucus dm 122

mucus dm max 122

mucus relief dm 123

MULTAQ 94

multi for her 223

multi-delyn 223

multilex 224

mupirocin 131

muro 128 152

my way 114

MYGLUCOHEALTH

LANCETS 141

MYLOTARG 37

MYRBETRIQ 173

mytab gas 159

my-vitalife 224

myzilra 115

N nabumetone 14

nadolol 96

nafcillin 27

NAGLAZYME 149

naloxone 16

naltrexone 16

NAMENDA XR 45

NAMZARIC 45 46

naproxen 14

naratriptan 64

NARCAN 16

nasal relief 152

NASCOBAL 224

NATACYN 155

nateglinide 50

NATPARA 194

NATRAPEL 129

natural b-100 234

natural calcium 203

natura-lax 171

NEBUPENT 69

necon 0535 (28) 115

necon 150 (28) 115

necon 1011 (28) 115

necon 777 (28) 115

nefazodone 48

neomycin 19

dexameth 155

neomycin-polymyxin-

gramicidin 155

neo-polycin 156

neo-polycin hc 156

neo-tuss 123

nephplex rx 224

NEPHRAMINE 54 90

nephron fa 224

nephro-vite rx 224

NERLYNX 37

NEULASTA 84

NEUPOGEN 84

NEUPRO 70

nevirapine 77 78

NEXAVAR 37

niacin 104

niacinamide 104 224

niacor 104

nicardipine 101

nicorelief 16

NICORETTE 17

nicotine 17

NICOTROL 17

nifedipine 101

night time cold 123

nighttime cough 121

nikki (28) 115

nilutamide 37

NINLARO 37

nite time 125

NITRO-BID 106

nitroglycerin 106

NIX CREME RINSE 135

nohist-dm 123

non-aspirin 5 8 10

non-aspirin child 8

non-aspirin flu 126

nora-be 115

norlyda 115

norlyroc 115

NORMOSOL-M IN 5

DEXTROSE 203

nortemp 9

NORTHERA 91

nortrel 0535 (28) 115

nortrel 135 (21) 115

nortrel 135 (28) 115

nortrel 777 (28) 116

nortriptyline 48

NORVIR 78

nose spray 153

NOVOLIN 7030 52

NOVOLIN N 52

NOVOLIN R 52

NOVOLOG 52

NOVOLOG FLEXPEN 52

NOVOLOG MIX 70-30

FLEXPEN 52

NOVOLOG PENFILL 52

NOXAFIL 56

NUCALA 210

NUCYNTA 9

NUCYNTA ER 9

NUEDEXTA 109

nu-iron 224

NULOJIX 185

nu-mag 203

NUPLAZID 74

NUTRESTORE 165

NUTRILIPID 90

NUVARING 116

nyamyc 56

nyata 56

nystatin 56

nystop 57

nytol 62

O OCALIVA 165

ocean nasal 153

ocella 116

OCREVUS 109

OCTAGAM 185

ocutabs 224

ODEFSEY 78

ODOMZO 37

OFEV 210

off active 129

off deep woods 129

ofloxacin 29 156

ogestrel (28) 116

olanzapine 74

olmesartan 92

olopatadine 153

OLYSIO 80

omeprazole 160

OMNITROPE 180

ON CALL LANCET 142

ONCASPAR 37

onccor 224

once daily 224

oncovite 225

ondansetron 67

ondansetron hcl 67

one daily 225 228

ONETOUCH DELICA

LANCETS 142

ONETOUCH SURESOFT

LANCING DEV 142

ONETOUCH ULTRASOFT

LANCETS 142

ONFI 19

ONIVYDE 37

OPDIVO 37

OPSUMIT 213

option-2 116

oralone 127

oralyte 203

ORENCIA 185

ORENITRAM 213

ORFADIN 149

ORKAMBI 210

orsythia 116

oseltamivir 80

OTEZLA 185

OTEZLA STARTER 185

OTOVEL 153

OTREXUP (PF) 185

oxacillin 27

oxandrolone 175

oxcarbazepine 43

OXTELLAR XR 43

oxycodone 9

oxycodone-aspirin 9

OXYCONTIN 9 10

oxymorphone 10

oysco 500d 225

oysco-500 203

226 228

oystercal-d 226

P pacerone 94

pain and fever 10

pain relief 5

pain relief adult 5

paliperidone 74

PANRETIN 129

pantoprazole 160

paromomycin 69

paroxetine hcl 48

PASER 65

PAXIL 48

p-col rite 171

pecgen dmx 123

pedia relief 125

PEDIARIX (PF) 189

203 205

PEDVAX HIB (PF) 190

PEGANONE 43

PEGASYS 81

PEGASYS CONVENIENCE

PACK 81

PEGASYS PROCLICK 81

PEGINTRON 81

PENTACEL (PF) 190

PENTACEL DTAP-IPV

COMPNT (PF) 190

PENTAM 69

pentoxifylline 85

pep-t-med 165

peri-colace 170

PERIKABIVEN 90

periogard 127

permethrin 135

perphenazine 74

perry prenatal 226

persa-gel 129

pfizerpen-g 28

pharbetol 10

phenadoz 67

phenelzine 48

phenobarbital 43

phenytoin 43

phenytoin sodium 44

philith 116

phillips 165

PHOSLYRA 172

PICATO 129 130

pimozide 74

pimtrea (28) 116

pindolol 96

pink bismuth 166

pioglitazone 51

pirmella 116

piroxicam 14

PLASMA-LYTE 148 203

PLASMA-LYTE A 203

PLASMA-LYTE-56 IN 5

DEXTROSE 203

PLEGRIDY 109

podofilox 130

polycin 156

poly-iron 226

poly-vita 226

poly-vitamin 226

poly-vitamins 226

POMALYST 37

portia 116

PORTRAZZA 37

POTIGA 44

PRADAXA 83

PRALUENT PEN 104

pramipexole 70

prasugrel 85

pravastatin 104

prazosin 91

prednicarbate 134

158 177

prednisone 177 178

PREMARIN 176

PREMASOL 10 90

PREMASOL 6 90

PREMPHASE 176

PREMPRO 176

prenatal tablet 228

PRESSURE ACTIVATED

LANCETS 142

prevalite 104

previfem 116

PREZCOBIX 78

PREZISTA 78

PRIFTIN 65

PRILOSEC OTC 160

PRIMAQUINE 69

primidone 44

PRIVIGEN 185

PROAIR HFA 208

probenecid 58

procainamide 94

PROCALAMINE 3 90

prochlorperazine 67

PROCRIT 84 85

procto-med hc 134

procto-pak 134

proctosol hc 134

proctozone-hc 134

PROCYSBI 149

PRODIGY LANCETS 143

PRODIGY TWIST TOP

LANCET 143

PROGLYCEM 197

PROGRAF 186

PROLASTIN-C 210

PROLENSA 158

PROLEUKIN 37

PROLIA 195

PROMACTA 85

promethazine vc 62

promethazine-dm 123

promethegan 68

promolaxin 170

propafenone 94

propantheline 41

proparacaine 153

propranolol 96

PROQUAD (PF) 190

prosight 227

PROSOL 20 90

protamine 85

protriptyline 48

PULMOZYME 149

purelax 168

PURIXAN 37

PUSH BUTTON SAFETY

LANCETS 143

pyrazinamide 65

quasense 116

quetiapine 74

QUFLORA 227

quinapril 93

quinine sulfate 69

QVAR 207

R RABAVERT (PF) 190

RADICAVA 109

raloxifene 176

ramipril 94

RANEXA 100

RAPAMUNE 186

rasagiline 70

RASUVO (PF) 186

RAVICTI 166

RAYALDEE 195

react 116

READYLANCE SAFETY

LANCETS 143

REBIF REBIDOSE 109

reclipsen (28) 116

recort plus 134

refenesen 124

refenesen pe 124

REFRESH OPTIVE

ADVANCED 156

reguloid 171

RELIAMED LANCET 143

LANCETS 143

LANCETS 144

RELISTOR 166

REMICADE 186

REMODULIN 213

RENAGEL 172

rena-vite rx 228

RENFLEXIS 197

RENVELA 172

repaglinide 51

REPATHA SYRINGE 104

repel sportsmen 130

reprexain 10

RESCRIPTOR 78

RESTASIS 158

retaine cmc 153

retaine hpmc 153

retaine pm 153

RETROVIR 78

revive plus 151

REVLIMID 37

revonto 211

REXULTI 74

REYATAZ 78

ribasphere 82

ribavirin 82

RIDAURA 186

rifabutin 65

rifampin 65

RIFATER 65

ri-gel ii 166

riginic 166

riluzole 109

rimantadine 80

ri-mox 166

ringers 193 205

risedronate 195

RISPERDAL CONSTA 74

risperidone 74 75

RITUXAN 38

RITUXAN HYCELA 38

rivastigmine 46

rizatriptan 64

robafen 124

robafen cough 124

robafen dm 124

ropinirole 70

rosadan 131

rosuvastatin 105

ROTARIX 190

ROTATEQ VACCINE 190

ROWEEPRA 44

RUBRACA 38

RYDAPT 38

S SABRIL 44

safe tussin dm 124

SAFETY LANCETS 144

SAIZEN 180

saline mist 153

saline nasal 151

saline nose 151

SANTYL 130

SAVELLA 109

scopolamine base 68

scot-tussin dm 124

selegiline hcl 70

SELZENTRY 78

senexon 171

senexon-s 171

senior tabs 228

senna 171

senna lax 171

senna laxative 168

senokot-s 171

SENSIPAR 195

sentry 229

sentry senior 229

SEREVENT DISKUS 209

SEROSTIM 180

sertraline 48

setlakin 116

sharobel 116

SHINGRIX (PF) 191

SHINGRIX GE ANTIGEN

COMPONENT 191

SIGNIFOR 180

silace 171

siladryl sa 62

silapap 11

SILENOR 212

SILIQ 130

siltussin sa 125

SIMBRINZA 199

simethicone 159

SIMPONI 186

SIMPONI ARIA 186

simvastatin 105

SINGLE-LET 144

sirolimus 186

SIRTURO 65

skin treatment 129

SMARTEST LANCET 144

smoflipid 90

smoothlax 172

sochlor 154

sodium acetate 205

sodium lactate 206

SOLIQUA 10033 53

SOLTAMOX 38

SOMAVERT 180

sorbitol 193

sorine 96

sotalol 96

sotalol af 96

SOVALDI 80

SPIRIVA WITH

HANDIHALER 209

spironolactone 102

sprintec (28) 116

SPRITAM 44

SPRYCEL 38

sronyx 116

ssd 131

stavudine 78

STELARA 186

STERILANCE TL 145

STERILE PADS 145

STIVARGA 38

stomach relief 166

stool softener 172

STRENSIQ 149

streptomycin 19

stress b-biotin 230

stress formula 230

STRIBILD 79

SUBOXONE 17

sucralfate 161

SUDAFED 125

sudogest 125

sudogest pe 91

sulfadiazine 29

sulfasalazine 193

sulfatrim 29

sulindac 15

sumatriptan 64

sunvite 230

super bc 230

super multiple 231

super quints 231

superior 35 231

superplex-t 231

suphedrin 125

support 231

support-500 231

SUPPRELIN LA 180

SUPRAX 24

SURE-LANCE 145

SURMONTIL 48

SUSTIVA 79

SUTENT 38

syeda 116

SYLATRON 81

SYLVANT 38

SYMBICORT 207

SYMLINPEN 120 51

SYMLINPEN 60 51

SYNAGIS 80

SYNAREL 180

SYNERCID 21

SYNJARDY 51

SYNJARDY XR 51

SYNRIBO 38

SYPRINE 174

SYSTANE GEL 154

T tab-a-vite 231

tab-a-viteiron 231

TABLOID 38

tacrolimus 134 186

tactinal 11

TAFINLAR 38

TAGRISSO 38

TALTZ SYRINGE 130

TAMIFLU 80

tamoxifen 38

tamsulosin 173

TARCEVA 38

TARGRETIN 38

tarina fe 120 (28) 116

TASIGNA 39

tazarotene 135

tazicef 24

TAZORAC 135

taztia xt 97

tears again 154

TECENTRIQ 39

TECFIDERA 109 110

TECHNIVIE 80

TEFLARO 24

TEKAMLO 105

TEKTURNA 105

TEKTURNA HCT 105

TELCARE LANCETS 145

telmisartan 92

temazepam 19

TEMODAR 39

tencon 11

TENIVAC (PF) 191

terazosin 173

terbinafine hcl 57

terbutaline 209

terconazole 64

testosterone 175

PED(PF) 191

TETANUS-DIPHTHERIA

TOXOIDS-TD 191

tetrabenazine 110

THALOMID 198

theophylline 209

thera 231

thera-d 231

theradex m 231

thera-m 231

therapeutic-m 231

thera-tabs 231

thera-tabs m 231

therems 231

therems-m 232

THIN LANCETS 144

THIOLA 198

thioridazine 75

thiotepa 39

thiothixene 75

tiagabine 44

TICE BCG 191

tigecycline 30

tilia fe 116

TIVICAY 79

tizanidine 211

tl icon 232

TOBI PODHALER 20

TOBRADEX 156

TOBRADEX ST 156

tobramycin 157

TOLAK 130

tolazamide 53

tolbutamide 53

tolnaftate 57

tolterodine 173

TOPCARE UNIVERSAL1

LANCET 145

topiramate 44

toposar 39

torsemide 102

total bc 232

TOTECT 198

TOUJEO SOLOSTAR 53

TOVIAZ 173

TRACLEER 213

TRADJENTA 51

tramadol 11

trandolapril 94

tranexamic acid 85

TRANSDERM-SCOP 68

tranylcypromine 48

TRAVASOL 10 90

TRAVATAN Z 199

travel sickness 68

trazodone 49

TREANDA 39

TRECATOR 66

TRELEGY ELLIPTA 210

TRELSTAR 39

TREMFYA 130

tretinoin 135

TREXALL 39

tri femynor 116

tricon 232

tri-estarylla 117

trifluoperazine 75

trifluridine 157

trihexyphenidyl 70

tri-legest fe 117

tri-linyah 117

tri-lo-marzia 117

tri-lo-sprintec 117

trimethoprim 21

trimipramine 49

trinessa (28) 117

TRINTELLIX 49

triple paste af 57

TRIPTODUR 180

TRIUMEQ 79

tri-vi-sol 232

tri-vita 232

tri-vitamin 232

trivora (28) 117

TROKENDI XR 44

TROPHAMINE 10 90

TROPHAMINE 6 90

trospium 173

TRULICITY 51

TRUMENBA 191

TRUVADA 79

tusnel diabetic 126

TUSSI PRES-B 126

tussin cf 125 127

tussin dm 124 126

tussin dm max 125

TWINRIX (PF) 191

TYBOST 198

TYKERB 39

tylophen 11

TYMLOS 195

TYPHIM VI 192

TYSABRI 186

TYVASO 213

U UCERIS 193

ULORIC 58

ULTILET CLASSIC

LANCETS 146

ULTILET LANCETS 146

ultra fresh pm 154

ULTRA THIN PLUS

LANCETS 144

unicomplex-m 232

UNILET COMFORTOUCH

LANCET 147

UNILET EXCELITE II

LANCET 147

UNILET LANCET 147

UNILET SUPER THIN

LANCETS 147

unisom sleepgels 62

UNISTIK 3 COMFORT

LANCET 147

UNISTIK 3 NORMAL

LANCET 147

UNISTIK SAFETY 148

UNITUXIN 39

141 148

UPTRAVI 214

ursodiol 167

V vagistat-3 57

valacyclovir 82

VALCHLOR 130

valganciclovir 82

valproate sodium 44

valproic acid 45

valsartan 92

VALSTAR 39

vancomycin 22

VAQTA (PF) 192

VARIVAX (PF) 192

VASCEPA 105

v-c forte 232

VELCADE 39

VELPHORO 172

VELTASSA 167

VEMLIDY 79

VENCLEXTA 39 40

VENCLEXTA STARTING

PACK 40

venlafaxine 49

verapamil 97

VERSACLOZ 75

VERZENIO 40

VESICARE 173

vestura (28) 117

VGO 40 148

VIBERZI 167

vic-forte 232

RELIEF 126

VICTOZA 51

VIEKIRA PAK 80

VIEKIRA XR 80

vienva 117

vigabatrin 45

VIGAMOX 157

VIIBRYD 49

VIMIZIM 149

VIMPAT 45

vinorelbine 40

viorele (28) 117

VIRACEPT 79

VIREAD 79

vision 232

VISTOGARD 198

230 233

vitalets 232

vitamin a 232

vitamin b-1 218 232

vitamin b-6 233

vitamin c 228 233

vitamin d3 228 230 233 234

vitamin k 234

vitamin k1 234

vitatrum 234

vitrum senior 234

vol-care rx 234

VOLTAREN 130

voriconazole 57

VOSEVI 81

VOTRIENT 40

VPRIV 150

vp-vite rx 234

VRAYLAR 75

vyfemla (28) 117

VYXEOS 40

wal-dram 68

wal-dryl allergy 63

wal-fex allergy 63

wal-finate 63

wal-finate-d 63

wal-itin 59 63

wal-itin d 63

wal-phed 63 127

wal-phed pe 91

wal-profen 15

wal-sleep z 63

wal-tap 64

wal-tussin 127

wal-tussin dm 118

wal-zan 75 161

wal-zyr d 64

warfarin 83

WELCHOL 105

wera (28) 117

womans laxative 172

X XADAGO 71

XALKORI 40

XARELTO 83

XATMEP 40

XELJANZ 186

XELJANZ XR 187

XERMELO 167

XIFAXAN 22

XOLAIR 211

XTAMPZA ER 11

XTANDI 40

xulane 117

XULTOPHY 10036 53

XURIDEN 198

XYREM 212

Y yelets 234

YERVOY 40

YF-VAX (PF) 192

YONDELIS 40

yuvafem 176

Z zafirlukast 207

zaleplon 212

zantac 75 161

zarah 117

ZARXIO 85

ZAVESCA 150

zebutal 11

ZEJULA 40

ZELBORAF 40

zenatane 130

zenchent (28) 117

ZENPEP 150

ZEPATIER 81

zephrex-d 127

ZERIT 79

ZIAGEN 79

zidovudine 79

ZINBRYTA 110

zinc oxide 129 130

ZIOPTAN (PF) 199

ziprasidone hcl 75

ZIRGAN 157

ZOLADEX 40

zoledronic acid 195

ZOLINZA 40

zolmitriptan 65

zolpidem 212

ZOMACTON 180 181

ZOMETA 195

zonisamide 45

zoo chews 2

ZORBTIVE 181

ZORTRESS 187

ZOSTAVAX (PF) 192

zovia 135e (28) 117

zovia 150e (28) 118

z-sleep 61 62

ZUBSOLV 17

ZURAMPIC 58

ZYDELIG 41

ZYKADIA 41

ZYLET 157

zyncof 127

ZYPREXA RELPREVV 75

ZYRTEC 64

ZYTIGA 41

01201801201818001 Version 11



























Table of Contents

INDEX

1

3

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

2745（TTY1-800-421-1220）

Russian

French

Creole

pou ou Rele 1-800-466-2745 (TTY 1-800-421-1220)

Italian

421-1220)

(TTY 1-800-421-1220) 1-800-466-2745 רופט אפצאל

2745 (TTY 1-800-421-1220)

Tagalog

(TTY 1-800-421-1220)

other formats)

1-800-368-1019 800-537-7697 (TDD)

800-421-1220)

am to 8 pm

rive 8 pm

de 8 am a 8 pm

pharmacy

711 or 1-800-421-1220

take now

drug For example

second

what to do next

on your drug

are covered

of this document

Restriction

PA BvD

Prior Authorization

Restriction

Part B vs Part D

Determination

Restriction for

New Starts Only

of this document

formulary

drug or product

day supply

heart conditions

Analgesics 3

Anesthetics 15

Antibacterials 19

Anticonvulsants 41

Antidepressants 46

Antifungals 53

Antigout Agents 57

Antihistamines 58

Table of Contents

Caloric Agents 85

Contraceptives 110

Devices 135

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Analgesics

120 mg 4 $0

QL (30 per 30 days)

325 mg 4 $0

QL (30 per 30 days)

650 mg 4 $0

QL (30 per 30 days)

(Mapap

mg (Acephen) 4 $0

QL (30 per 30 days)

childrens 80 mg

(Childrens

Acetaminophen) 4 $0

QL (30 per 30 days)

300-15 mg 1 $0

300-30 mg

(Tylenol-Codeine

3) 1 $0

300-60 mg

(Tylenol-Codeine

4) 1 $0

30-50-325-40 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

MCG 300 MCG 450 MCG 600

QL (60 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

03 mgml 1 $0

mcghour

(Butrans) 1 $0

QL (4 per 28 days)

capsule 30-50-325-40 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

capsule 50-300-40-30 mg 50-325-

40-30 mg

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

tablet 50-325-40 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

BUTRANS TRANSDERMAL

PATCH WEEKLY 75

MCGHOUR

QL (4 per 28 days)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml 4 $0

mg 4 $0

QL (30 per 30 days)

mg 4 $0

QL (30 per 30 days)

mg 4 $0

QL (30 per 30 days)

mg 60 mg 1 $0

caplet 650 mg

(8 Hour Pain

Reliever) 4 $0

650 mg 4 $0

mg 4 $0

QL (30 per 30 days)

mg 4 $0

mg15 ml 4 $0

325 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Actiq) 1 $0

PA QL (120 per 30

days) NDS

50 mcghr 75 mcghr

(Duragesic) 1 $0

QL (10 per 30 days)

QL (30 per 30 days)

inner 650 mg 4 $0

QL (30 per 30 days)

mg75ml(75ml)

tablet 5-325 mg

(Lorcet

(hydrocodone)) 1 $0

75-200 mg 1 $0

mgml 4 mgml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

HYSINGLA ER ORAL

TABLETORAL

120 MG 20 MG 30 MG 40 MG

60 MG 80 MG

QL (30 per 30 days)

mgml 4 $0

QL (30 per 30 days)

mg 4 $0

QL (30 per 30 days)

PA QL (30 per 30

days) NDS

325 mg 1 $0

ml 4 $0

mg5 ml 4 $0

500 mg 4 $0

mg15 ml 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml 1 $0

ml 5 mg5 ml 1 $0

100 mg5 ml (20 mgml) 1 $0

(4 mgml) 1 $0

MG 2 $0

QL (60 per 30 days)

QL (90 per 30 days)

mgml 1 $0

QL (30 per 30 days)

mg 4 $0

QL (30 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg15 ml 4 $0

mg08 ml 4 $0

QL (30 per 30 days)

MG 150 MG 200 MG 250 MG 50

QL (60 per 30 days)

MG 50 MG 75 MG 2 $0

mgml 1 $0

(OxyContin) 1 $0

QL (60 per 30 days)

48355-325 mg 1 $0

OXYCONTIN ORAL

TABLETORAL

MG 20 MG 30 MG 40 MG 60

QL (60 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

OXYCONTIN ORAL

TABLETORAL

30 mg 40 mg 5 mg 75 mg

QL (60 per 30 days)

mg5 ml 4 $0

caplet 500 mg 4 $0

QL (30 per 30 days)

ml 4 $0

QL (30 per 30 days)

meltssf 160 mg 4 $0

QL (30 per 30 days)

650 mg

(8 Hour Pain

Reliever) 4 $0

QL (30 per 30 days)

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg08 ml 4 $0

QL (30 per 30 days)

650 mg 4 $0

QL (30 per 30 days)

500 mg 4 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

375-325 mg (Ultracet) 1 $0

XTAMPZA ER ORAL

QL (60 per 30 days)

XTAMPZA ER ORAL

TMPRR 27 MG

XTAMPZA ER ORAL

TMPRR 36 MG

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

Agents

CHEW TB CHEW8

HOURGRAPE 100 MG

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Adult Aspirin

Regimen) 4 $0

mg 4 $0

MGML) 800 MG8 ML (100

QL (60 per 30 days)

mg125 ml 4 $0

ML (OTC) 100 MG5 ML 4 $0

mg 4 $0

mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

50 mg 75 mg

mg-mcg

(Arthrotec 50) 1 $0

mg-mcg

(Arthrotec 75) 1 $0

coated 325 mg 4 $0

mg 1 $0

100 mg5 ml 4 $0

mg 4 $0

mg 800 mg 1 $0

PA-HRM QL (240 per

30 days) AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM QL (120 per

30 days) AGE (Max

64 Years)

release 75 mg 1 $0

PA-HRM QL (60 per

30 days) AGE (Max

64 Years)

mg125 ml 4 $0

ml 4 $0

mg 1 $0

PA-HRM QL (20 per

30 days) AGE (Max

64 Years)

ml 1 $0

mg 1 $0

ml (Naprosyn) 1 $0

mg 1 $0

mg (Feldene) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

orange 81 mg 4 $0

200 mg 4 $0

Anesthetics

Local Anesthetics

applicator 2 1 $0

mgml (1 ) 15 mgml (15 ) 20

mgml (2 ) 5 mgml (05 )

mgml (4 ) 1 $0

mgml (1 ) 20 mgml (2 ) 5

mgml (05 )

(Xylocaine) 1 $0

jelly 2 1 $0

PA QL (90 per 30

solution 2 1 $0

25-25 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Treatment Agents

03 MG 2 $0

QL (30 per 30 days)

07 MG 63-1 MG 2 $0

QL (60 per 30 days)

2 mg 8 mg 1 $0

QL (90 per 30 days)

tablet 2-05 mg 8-2 mg 1 $0

QL (90 per 30 days)

(Zyban) 1 $0

CHANTIX CONTINUING

MG 1 MG 2 $0

PACK 05 MG (11)- 1 MG (42)

QL (53 per 28 days)

mg (Antabuse) 1 $0

mgml 1 $0

mgml 1 mgml 1 $0

MGACTUATION

QL (4 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

NICOTROL INHALATION

12-3 MG 8-2 MG 2 $0

QL (60 per 30 days)

2-05 MG 4-1 MG 2 $0

QL (30 per 30 days)

ZUBSOLV SUBLINGUAL

TABLET 07-018 MG 14-036

MG 114-29 MG 29-071 MG

57-14 MG

QL (30 per 30 days)

ZUBSOLV SUBLINGUAL

QL (60 per 30 days)

Antianxiety Agents

Benzodiazepines

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

30 mg 5 mg 75 mg 1 $0

10 mg 25 mg 5 mg 1 $0

clonazepam oral

mg 05 mg 1 mg

QL (90 per 30 days)

clonazepam oral

15 mg 375 mg 1 $0

KIT 125-15-175-20 MG 5-75-10

5 mgml 1 $0

mgml) 1 $0

mg (Valium) 1 $0

QL (2 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MGML 2 $0

PA NSO QL (480 per

30 days) NDS

MG 2 $0

PA NSO QL (60 per

30 days) NDS

mg (Restoril) 1 $0

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any benzodiazepine

per 30 days) AGE

(Max 64 Years)

Antibacterials

Aminoglycosides

BETHKIS INHALATION

SOLUTION FOR

PA BvD NDS

mg6 ml 1 $0

ml 100 mg50 ml 120 mg100 ml

60 mg50 ml 70 mg50 ml 80

mg100 ml 80 mg50 ml 90 mg100

mgml 1 $0

soln 1 gram 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CAPSULE WINHALATION

DEVICE 28 MG

300 mg5 ml

(Tobi) 1 $0

PA BvD NDS

ml 600 mg50 ml 900 mg50 ml

(Cleocin in 5

dextrose) 1 $0

soln 75 mg5 ml 1 $0

recon soln 150 mg

(Coly-Mycin M

Parenteral) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg300 ml 1 $0

gram (Hiprex) 1 $0

(Metro IV) 1 $0

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use of

AGE (Max 64 Years)

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use of

QL (60 per 30 days)

AGE (Max 64 Years)

soln 500000 unit 1 $0

ml 500 mg100 ml 750 mg150 ml

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

750 mg

MG 2 $0

PA QL (9 per 30

days) NDS

MG 2 $0

PA NDS

Cephalosporins

mg 1 $0

mg5 ml 375 mg5 ml

mg5 ml

gram 1 $0

mg5 ml

GRAM50 ML 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ML 2 GRAM50 ML 2 $0

gram 500 mg 1 $0

gram50 ml 1 $0

gram 10 gram 1 $0

gram 1 $0

mg 1 $0

mg5 ml

gram 250 mg 500 mg 1 $0

gram 2 gram 1 $0

mg 500 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml

mg 1 $0

OSM) INTRAVENOUS

GRAM50 ML

MG 2 $0

SUPRAX ORAL

200 MG

2 gram 6 gram 1 $0

TEFLARO INTRAVENOUS

Macrolides

mg5 ml

(Zithromax) 1 $0

pack) 500 mg (3 pack) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml

500 mg 1 $0

days) NDS

ERYPED 200 ORAL

SUSPENSION FOR

ERYPED 400 ORAL

SUSPENSION FOR

(drec) 250 mg 500 mg 1 $0

ERY-TAB ORAL

(DREC) 333 MG

250 mg 1 $0

tablet 400 mg (EES 400) 1 $0

500 mg 1 $0

Antibiotics

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CAYSTON INHALATION

SOLUTION FOR

LA NDS

SOLN 1 GRAM 2 $0

Penicillins

500 mg 1 $0

mg 1 $0

mg 250 mg 1 $0

285 mg5 ml 400-57 mg5 ml

625 mg5 ml

(Augmentin) 1 $0

429 mg5 ml

(Augmentin ES-

600) 1 $0

tablet 250-125 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 1 $0

mg5 ml

gram 250 mg 500 mg

soln 2 gram 1 $0

(Unasyn) 1 $0

BICILLIN C-R

1200000 UNIT 2

ML(600K600K) 1200000 UNIT

2 ML(900K300K)

BICILLIN L-A

1200000 UNIT2 ML 2400000

500 mg 1 $0

2 gram 1 $0

gram 1 $0

ml 2 gram50 ml

gram 2 gram 1 $0

gram 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

million unit50 ml

600000 unitml

soln 125 mg5 ml 250 mg5 ml 1 $0

250 mg 500 mg 1 $0

million unit 1 $0

45 gram 405 gram

(Zosyn) 1 $0

Quinolones

MG 2 $0

PA QL (28 per 14

days) NDS

750 mg 1 $0

500 mg (Cipro) 1 $0

(Cipro in D5W) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ciprofloxacin oral

mg5 ml 500 mg5 ml

(Cipro) 1 $0

mg100 ml 750 mg150 ml

mgml 1 $0

mg10 ml 1 $0

mg 1 $0

Sulfonamides

mg5 ml 1 $0

Tetracyclines

100 mg 1 $0

mg 20 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

capsule 150 mg 1 $0

mg5 ml

(Vibramycin) 1 $0

150 mg 50 mg 75 mg 1 $0

mg 75 mg 1 $0

Anticancer Agents

SUSPENSION FOR

mg5 ml 20 mg10 ml 1 $0

PA BvD

gram50 ml 500 mg10 ml 1 $0

PA BvD

MG 3 MG 5 MG

PA NSO QL (112 per

28 days) NDS

MG 2 $0

PA NSO QL (56 per

28 days) NDS

MG 5 MG 75 MG 2 $0

PA NSO QL (28 per

28 days) NDS

MG 2 $0

PA NSO QL (240 per

30 days) NDS

ALIMTA INTRAVENOUS

ALIQOPA INTRAVENOUS

PA NSO QL (3 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

PA NSO QL (180 per

30 days) NDS

AVASTIN INTRAVENOUS

SOLUTION 25 MGML 25

MGML (16 ML)

PA NSO NDS

mg (Vidaza) 1 $0

PA NSO NDS

BENDEKA INTRAVENOUS

PA NSO NDS

MGML INITIAL)

PA NSO NDS

30 days) NDS

PA BvD

unit 1 $0

PA BvD

35 MCG 2 $0

PA NSO QL (140 per

365 days) NDS

MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 2 $0

PA NSO QL (30 per

30 days) NDS

MG 60 MG 2 $0

PA NSO QL (30 per

30 days) NDS

MG 2 $0

PA NSO QL (60 per

30 days) NDS

100 MG 2 $0

PA NSO QL (60 per

30 days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

PA NSO QL (60 per

30 days) NDS

MG 2 $0

PA NSO QL (30 per

30 days) NDS

PA NSO QL (112 per

28 days) NDS

MG 2 $0

PA NSO LA QL (63

per 28 days) NDS

PA BvD NDS

PA BvD ST

CYRAMZA INTRAVENOUS

SOLUTION 10 MGML 10

MGML (50 ML)

PA NSO NDS

PA NSO LA NDS

mg25 ml

(Adriamycin) 1 $0

PA BvD

PA BvD NDS

MG 300 MG 400 MG 2 $0

ELIGARD (3 MONTH)

ELIGARD (4 MONTH)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ELIGARD (6 MONTH)

MG 2 $0

PA NSO NDS

MG 2 $0

PA NSO QL (30 per

30 days) NDS

mgml (Toposar) 1 $0

MG 2 $0

MG 15 MG 20 MG 2 $0

PA NSO NDS

gram 1 $0

PA BvD

gram20 ml 1 $0

PA BvD

GAZYVA INTRAVENOUS

PA NSO NDS

MG 30 MG 40 MG 2 $0

PA NSO QL (30 per

30 days) NDS

MG 100 MG 40 MG 5 MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA NSO NDS

MG 2 $0

MG 125 MG 75 MG 2 $0

PA NSO QL (21 per

28 days) NDS

30 days) NDS

50 MG 2 $0

PA NSO QL (30 per

30 days) NDS

PA BvD

1 gram 3000-1000 mg 1 $0

PA BvD NDS

30 days) NDS

140 MG 2 $0

PA NSO NDS

IMFINZI INTRAVENOUS

SOLUTION 50 MGML 50

MGML (10 ML)

PA NSO NDS

IMLYGIC INJECTION

MILLION) PFUML

PA NSO QL (4 per

365 days) NDS

IMLYGIC INJECTION

MILLION) PFUML

PA NSO QL (8 per 28

days) NDS

30 days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

30 days) NDS

IXEMPRA INTRAVENOUS

15 MG 20 MG 25 MG 5 MG 2 $0

PA NSO QL (60 per

30 days) NDS

PA NSO QL (4 per 21

days) NDS

PA NSO QL (8 per 21

days) NDS

MG X 1)-25 MG

PA NSO QL (49 per

28 days) NDS

MG X 2)-25 MG

PA NSO QL (70 per

28 days) NDS

MG X 3)-25 MG

PA NSO QL (91 per

28 days) NDS

MGDAY (200 MG X 1) 400

MGDAY (200 MG X 2) 600

MGDAY (200 MG X 3)

PA NSO QL (63 per

28 days) NDS

PA NSO NDS

PA NSO LA NDS

X2) 20 MGDAY (10 MG X 2) 24

MGDAY (4 MG X 2)

PA NSO NDS

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg02 ml 1 $0

614 MG 2 $0

PA NSO QL (100 per

28 days) NDS

819 MG 2 $0

PA NSO QL (80 per

28 days) NDS

KIT 1125 MG 225 MG

KIT 30 MG

KIT 45 MG

LUPRON DEPOT

KIT 375 MG 75 MG

MG 2 $0

PA NSO QL (448 per

28 days) NDS

MG 150 MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 2 $0

(Max 64 Years)

MG 2 $0

PA NSO QL (90 per

30 days) NDS

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA BvD

mg 1 $0

PA BvD ST

INITIAL CONC)

PA NSO NDS

MG 2 $0

PA NSO QL (180 per

30 days) NDS

MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 3 MG 4 MG 2 $0

PA NSO QL (3 per 28

days) NDS

MG 2 $0

PA NSO LA NDS

ONCASPAR INJECTION

PA NSO NDS

ONIVYDE INTRAVENOUS

PA BvD NDS

OPDIVO INTRAVENOUS

MG4 ML

PA NSO NDS

MG 2 MG 3 MG 4 MG 2 $0

PA NSO QL (21 per

28 days) NDS

PA NSO QL (100 per

21 days) NDS

20 MGML 2 $0

MG 15 MG 25 MG 20 MG 25

MG 5 MG

PA NSO LA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

RITUXAN HYCELA

1400 MG117 ML (120 MGML)

1600 MG134 ML (120 MGML)

PA NSO NDS

RITUXAN INTRAVENOUS

PA NSO NDS

MG 250 MG 300 MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 2 $0

PA NSO QL (224 per

28 days) NDS

10 MG5 ML 2 $0

MG 140 MG 50 MG 70 MG 80

PA NSO QL (30 per

30 days) NDS

MG 2 $0

PA NSO QL (84 per

28 days) NDS

MG 25 MG 375 MG 50 MG 2 $0

PA NSO QL (30 per

30 days) NDS

SYLVANT INTRAVENOUS

PA NSO NDS

PA NSO QL (28 per

28 days) NDS

MG 75 MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 80 MG 2 $0

PA NSO LA QL (30

per 30 days) NDS

MG 25 MG 2 $0

PA NSO QL (60 per

30 days) NDS

MG 2 $0

PA NSO QL (90 per

30 days) NDS

28 days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 200 MG 2 $0

PA NSO QL (112 per

28 days) NDS

PA NSO QL (20 per

21 days) NDS

TEMODAR INTRAVENOUS

PA NSO NDS

mgml 1 $0

TREANDA INTRAVENOUS

QL (1 per 84 days)

QL (1 per 168 days)

QL (1 per 84 days)

QL (1 per 168 days)

capsule 10 mg 1 $0

MG 15 MG 5 MG 75 MG 2 $0

PA BvD ST

PA NSO NDS

SOLN 35 MG 2 $0

PA NSO NDS

MG 2 $0

PA NSO LA QL (60

per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100 MG 2 $0

PA NSO LA QL (120

per 30 days) NDS

MG 2 $0

PA NSO LA QL (30

per 30 days)

MG-50 MG- 100 MG

PA NSO LA QL (42

per 28 days) NDS

MG 150 MG 200 MG 50 MG 2 $0

PA NSO QL (56 per

28 days) NDS

MG 2 $0

PA NSO QL (120 per

30 days) NDS

VYXEOS INTRAVENOUS

PA BvD NDS

MG 250 MG 2 $0

PA NSO QL (60 per

30 days) NDS

MGML 2 $0

PA BvD ST

30 days) NDS

YERVOY INTRAVENOUS

MGML) 50 MG10 ML (5

PA NSO NDS

MG 2 $0

PA NSO QL (90 per

30 days) NDS

MG 2 $0

PA NSO QL (240 per

30 days) NDS

IMPLANT 108 MG 2 $0

QL (1 per 84 days)

IMPLANT 36 MG 2 $0

QL (1 per 28 days)

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 150 MG 2 $0

PA NSO QL (60 per

30 days) NDS

MG 2 $0

PA NSO QL (140 per

28 days) NDS

500 MG 2 $0

PA NSO QL (120 per

30 days) NDS

mgml 01 mgml 1 $0

Anticonvulsants

400 MG 600 MG 800 MG 2 $0

ST NDS

MGML 2 $0

ST NDS

MG 400 MG 2 $0

ST NDS

QL (80 per 30 days)

MGML 2 $0

MG 100 MG 25 MG 50 MG 75

QL (60 per 30 days)

300 mg

(Carbatrol) 1 $0

(Tegretol XR) 1 $0

100 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

MG 1 $0

sprinkle 125 mg

(Depakote

Sprinkles) 1 $0

(Depakote) 1 $0

ml (Zarontin) 1 $0

ml (Felbatol) 1 $0

mg (Felbatol) 1 $0

05 MGML 2 $0

ml (Neurontin) 1 $0

mg (Neurontin) 1 $0

MG 16 MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 250 mg 300 mg 50 mg

(Lamictal XR) 1 $0

mgml (Keppra) 1 $0

250 mg 500 mg 750 mg (Keppra) 1 $0

MG 150 MG 200 MG 225 MG 25

MG 300 MG 50 MG 75 MG

QL (90 per 30 days)

MGML 2 $0

MG 300 MG 600 MG

MG 2 $0

(4 mgml) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

15 mg 162 mg 30 mg 324 mg 60

mg 648 mg 972 mg

PA NSO-HRM AGE

(Max 64 Years)

capsule 100 mg

(Dilantin

Extended) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

300 MG 400 MG 2 $0

ST QL (90 per 30

days) NDS

1000 MG 500 MG 750 MG 1 $0

PACKET 500 MG 2 $0

ST QL (60 per 30

750 MG

ST QL (120 per 30

24hr 100 mg 150 mg 200 mg 25

mg 50 mg

(Qudexy XR) 1 $0

TROKENDI XR ORAL

24HR 100 MG 25 MG 50 MG

ST QL (30 per 30

TROKENDI XR ORAL

24HR 200 MG

ST QL (60 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

VIMPAT INTRAVENOUS

ST QL (200 per 5

MGML 2 $0

ST QL (1200 per 30

150 MG 200 MG 50 MG 2 $0

ST QL (60 per 30

mg (Zonegran) 1 $0

Antidementia Agents

10 mg 5 mg 1 $0

QL (30 per 30 days)

QL (60 per 30 days)

(Namenda Titration

Pak) 1 $0

QL (49 per 28 days)

NAMENDA XR ORAL

PACK 7-14-21-28 MG

QL (28 per 28 days)

NAMENDA XR ORAL

14 MG 21 MG 28 MG 7 MG

QL (30 per 30 days)

NAMZARIC ORAL

PACK 7142128 MG-10 MG

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

NAMZARIC ORAL

14-10 MG 21-10 MG 28-10 MG

7-10 MG

QL (30 per 30 days)

15 mg 3 mg 45 mg 6 mg 1 $0

QL (60 per 30 days)

95 mg24 hr

(Exelon) 1 $0

QL (30 per 30 days)

Antidepressants

mg 150 mg 25 mg 50 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

mg 25 mg 50 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

75 mg 1 $0

QL (30 per 30 days)

PA NSO-HRM AGE

(Max 64 Years)

mg (Norpramin) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

mg 50 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

mg 50 mg

(Pristiq) 1 $0

QL (30 per 30 days)

mg 150 mg 25 mg 50 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Max 64 Years)

QL (60 per 30 days)

QL (30 per 30 days)

EMSAM TRANSDERMAL

MG24 HR 9 MG24 HR

QL (30 per 30 days)

mg5 ml 1 $0

(2)- 40 MG (26)

ST QL (56 per 365

FETZIMA ORAL

24 HR 120 MG 20 MG 40 MG 80

ST QL (30 per 30

QL (4 per 28 days)

(4 mgml) 1 $0

mg 50 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

100 mg 125 mg 150 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 75 mg 1 $0

MG 2 $0

mirtazapine oral

mg 200 mg 250 mg 50 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

ml 1 $0

PA NSO-HRM AGE

(Max 64 Years)

PA NSO-HRM AGE

(Max 64 Years)

(Paxil CR) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

MG5 ML 2 $0

PA NSO-HRM AGE

(Max 64 Years)

4-25 mg 4-50 mg

PA NSO-HRM AGE

(Max 64 Years)

mgml (Zoloft) 1 $0

100 MG 25 MG 50 MG 2 $0

PA NSO-HRM AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 300 mg 50 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

MG 20 MG 5 MG 2 $0

ST QL (30 per 30

QL (30 per 30 days)

QL (90 per 30 days)

mg 375 mg 50 mg 75 mg 1 $0

20 MG 40 MG 2 $0

ST QL (30 per 30

PACK 10 MG (7)- 20 MG (23) 2 $0

ST QL (30 per 180

Antidiabetic Agents

QL (90 per 30 days)

MG 2 $0

GLUCAGEN HYPOKIT

MG 25-5 MG 2 $0

ST QL (30 per 30

150-1000 MG 150-500 MG 50-

1000 MG

ST QL (60 per 30

500 MG 2 $0

ST QL (120 per 30

INVOKAMET XR ORAL

24HR 150-1000 MG 150-500 MG

50-1000 MG 50-500 MG

ST QL (60 per 30

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

ST QL (60 per 30

MG 2 $0

ST QL (30 per 30

1000 MG 50-500 MG 2 $0

QL (60 per 30 days)

1000 MG

QL (30 per 30 days)

MG 50-500 MG

QL (60 per 30 days)

MG 25 MG 50 MG 2 $0

QL (30 per 30 days)

MG 25 MG 2 $0

ST QL (30 per 30

25-1000 MG 25-500 MG 25-850

QL (60 per 30 days)

JENTADUETO XR ORAL

24HR 25-1000 MG

QL (60 per 30 days)

JENTADUETO XR ORAL

24HR 5-1000 MG

QL (30 per 30 days)

MG 2 $0

PA QL (112 per 28

days) NDS

QL (90 per 30 days)

50 mg (Glyset) 1 $0

QL (90 per 30 days)

mg (Starlix) 1 $0

QL (90 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (30 per 30 days)

30-2 mg 30-4 mg (DUETACT) 1 $0

QL (30 per 30 days)

QL (90 per 30 days)

500 mg 2-500 mg 1 $0

SYMLINPEN 120

SUBCUTANEOUS PEN

PA QL (108 per 28

days) NDS

SYMLINPEN 60

SUBCUTANEOUS PEN

PA QL (108 per 28

days) NDS

1000 MG 125-500 MG 5-1000

MG 5-500 MG

ST QL (60 per 30

MG 25-1000 MG

ST QL (30 per 30

1000 MG 5-1000 MG

ST QL (60 per 30

MG 2 $0

QL (30 per 30 days)

15 MG05 ML

QL (2 per 28 days)

VICTOZA 3-PAK

SUBCUTANEOUS PEN

MG3 ML)

QL (9 per 30 days)

Insulins

FIASP FLEXTOUCH

100 UNITML (3 ML)

QL (30 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

FIASP SUBCUTANEOUS

QL (40 per 28 days)

QL (24 per 28 days)

HUMULIN R U-500

(CONCENTRATED)

500 UNITML

QL (40 per 28 days)

LANTUS SOLOSTAR

100 UNITML (3 ML)

QL (30 per 28 days)

LANTUS SUBCUTANEOUS

QL (40 per 28 days)

NOVOLIN 7030

100 UNITML (70-30)

QL (40 per 28 days)

NOVOLIN R INJECTION

QL (40 per 28 days)

NOVOLOG FLEXPEN

100 UNITML

QL (30 per 28 days)

100 UNITML (70-30)

QL (30 per 28 days)

NOVOLOG MIX 70-30

100 UNITML (70-30)

QL (40 per 28 days)

NOVOLOG PENFILL

100 UNITML

QL (30 per 28 days)

QL (40 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

SOLIQUA 10033

100 UNIT-33 MCGML

ST QL (30 per 30

TOUJEO SOLOSTAR

300 UNITML (15 ML)

XULTOPHY 10036

ST QL (15 per 28

Sulfonylureas

QL (60 per 30 days)

QL (30 per 30 days)

250 mg 1 $0

500 mg 5-500 mg 1 $0

PA-HRM AGE (Max

64 Years)

mg 5 mg 1 $0

PA-HRM AGE (Max

64 Years)

125-250 mg 1 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

Antifungals

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ABELCET INTRAVENOUS

PA BvD NDS

SUSPENSION FOR

PA BvD NDS

50 mg 1 $0

PA BvD

(Loprox (as

olamine)) 1 $0

troche 10 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

lotion 1-005 1 $0

antifungal 2 4 $0

ml 400 mg200 ml

500 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg)- 2 (9 gram)

(Miconazole-3

mg 4 $0

200 mg 1 $0

(200 MG)- 2 (9 GRAM) 4 $0

200 MG5 ML (40 MGML) 2 $0

NOXAFIL ORAL

(DREC) 100 MG

unitgram 1 $0

unitml 1 $0

unitgram 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cream 100000-01 unitg- 1 $0

unitgram 1 $0

mg5 gram (4 ) 4 $0

spray 1 4 $0

(terbinafine)) 4 $0

(tolnaftate)) 4 $0

(9 gram) 4 $0

(Vfend) 1 $0

mg (Vfend) 1 $0

Antigout Agents

mg (Zyloprim) 1 $0

MG 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

500-05 mg 1 $0

80 MG 2 $0

QL (30 per 30 days)

MG 2 $0

ST QL (30 per 30

Antihistamines

mg 4 $0

ml 4 $0

mg 4 $0

125 mg5 ml 4 $0

ultratab 25 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(All Day Allergy

(cetirizine)) 4 $0

(All Day Allergy

(cetirizine)) 4 $0

(All Day Allergy-

D) 4 $0

grape sf 5 mg5 ml

(Allergy Relief

(loratadine)) 4 $0

mg5 ml 4 $0

ml 4 $0

mg5 ml 4 $0

cherry 1 mgml 4 $0

mg5 ml 4 $0

ODT 10 MG 4 $0

mgml 4 $0

CHEW 5 MG 4 $0

mg 4 $0

CAP 10 MG 4 $0

MG 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

25 mg5 ml 4 $0

drowsy 10-240 mg 4 $0

ml 1 $0

PA-HRM AGE (Max

64 Years)

relief 134 mg 4 $0

1-25 mg5 ml 4 $0

625-25 mg5 ml 4 $0

mg5 ml 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml

(Childrens Allergy

(diphenhyd)) 1 $0

PA-HRM AGE (Max

64 Years)

drowsy 10 mg 4 $0

mg5 ml 4 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

mg5 ml 1 $0

PA-HRM AGE (Max

64 Years)

25 mg 50 mg 1 $0

PA-HRM AGE (Max

64 Years)

25 mg5 ml 4 $0

ml (Xyzal) 1 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg30 ml 4 $0

25 mg 4 $0

ml 1 $0

PA-HRM AGE (Max

64 Years)

mg5 ml 1 $0

minitabs 25 mg 4 $0

mg 4 $0

mg5 ml 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ml 4 $0

mg 4 $0

mg5 ml 4 $0

mg 4 $0

hr rlf 10 mg 4 $0

mg 4 $0

strength 50 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Mucous Membrane)

Membrane)

AVC VAGINAL VAGINAL

CREAM 15 2 $0

mg 1 $0

Antimigraine Agents

QL (30 per 28 days)

QL (8 per 28 days)

ERGOMAR SUBLINGUAL

TABLET 2 MG 2 $0

QL (40 per 28 days)

QL (18 per 28 days)

mgactuation

(Imitrex) 1 $0

QL (12 per 28 days)

100 mg 25 mg 50 mg (Imitrex) 1 $0

QL (18 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Imitrex STATdose

Kit Refill) 1 $0

QL (4 per 28 days)

(Imitrex STATdose

Pen) 1 $0

QL (4 per 28 days)

mg (Zomig) 1 $0

QL (12 per 28 days)

zolmitriptan oral

QL (12 per 28 days)

Antimycobacterials

SOLN 1 GRAM 2 $0

mg 1 $0

mg (Rifadin) 1 $0

300 MG 2 $0

MG 2 $0

PA QL (188 per 168

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

Antinausea Agents

05 MG 2 $0

PA BvD

125 mg (1)- 80 mg (2) (Emend) 1 $0

PA BvD QL (6 per 28

mg 4 $0

mgml 1 $0

mg 4 $0

EMEND 150 MG VIAL

QL (2 per 28 days)

SOLN 150 MG 2 $0

QL (2 per 28 days)

PA BvD QL (6 per 28

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(otc) 125 mg 4 $0

Drowsy) 4 $0

64 Years)

Drowsy) 1 $0

PA-HRM AGE (Max

64 Years)

fc 25 mg 4 $0

mg5 ml

(Zofran (as

PA BvD

(Zofran (as

PA BvD

ondansetron oral

PA BvD

mg 25 mg 1 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

25 mg 50 mg 1 $0

PA-HRM AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM AGE (Max

64 Years)

mg (Phenergan) 1 $0

PA-HRM AGE (Max

64 Years)

125 mg 25 mg 50 mg 1 $0

PA-HRM AGE (Max

64 Years)

QL (10 per 30 days)

TRANSDERM-SCOP

1 MG OVER 3 DAYS

QL (10 per 30 days)

mg 4 $0

Antiparasite Agents

MG 2 $0

MG5 ML

250-100 mg (Malarone) 1 $0

625-25 mg

(Malarone

Pediatric) 1 $0

250 mg 500 mg 1 $0

120 MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

PA NDS

mg (Plaquenil) 1 $0

MG 2 $0

PA QL (84 per 28

days) NDS

NEBUPENT INHALATION

PA BvD

SOLN 300 MG 2 $0

263 MG 2 $0

mg5 ml 1 $0

APOKYN SUBCUTANEOUS

QL (60 per 30 days)

mg 2 mg 1 $0

PA-HRM AGE (Max

64 Years)

100 mg 25-100 mg 25-250 mg (Sinemet) 1 $0

(Sinemet CR) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GOCOVRI ORAL

24HR 137 MG

PA QL (60 per 30

days) NDS

GOCOVRI ORAL

24HR 685 MG

PA QL (30 per 30

days) NDS

NEUPRO TRANSDERMAL

HOUR 8 MG24 HOUR

QL (30 per 30 days)

025 mg 05 mg 075 mg 1 mg 15

(Mirapex) 1 $0

mg 8 mg

(Requip XL) 1 $0

64 Years)

mg 1 $0

PA-HRM AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 50 MG 2 $0

PA QL (30 per 30

days) NDS

ABILIFY MAINTENA

INTRAMUSCULAR

RECON 300 MG 400 MG

QL (1 per 28 days)

ABILIFY MAINTENA

INTRAMUSCULAR

QL (1 per 28 days)

QL (30 per 30 days)

aripiprazole oral

QL (90 per 30 days)

aripiprazole oral

QL (60 per 30 days)

SYRING 1064 MG39 ML

QL (39 per 56 days)

SYRING 441 MG16 ML

QL (16 per 28 days)

SYRING 662 MG24 ML

QL (24 per 28 days)

SYRING 882 MG32 ML

QL (32 per 28 days)

25 mgml 1 $0

100 mg 200 mg 25 mg 50 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100 mg 125 mg 25 mg (FazaClo) 1 $0

ST QL (90 per 30

ST QL (180 per 30

ST QL (120 per 30

MG 4 MG 2 $0

ST QL (60 per 30

12 MG 6 MG 8 MG 2 $0

ST QL (60 per 30

days) NDS

PACK 1MG(2)-2MG(2)- 4MG(2)-

6MG(2)

25 mgml 1 $0

mgml 1 $0

ml 1 $0

mg 25 mg 5 mg 1 $0

QL (6 per 28 days)

50 mgml

2 mgml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 10 mg 2 mg 20 mg 5 mg 1 $0

INVEGA SUSTENNA

117 MG075 ML

INVEGA SUSTENNA

156 MGML

QL (1 per 28 days)

INVEGA SUSTENNA

234 MG15 ML

QL (15 per 28 days)

INVEGA SUSTENNA

MG025 ML

INVEGA SUSTENNA

MG05 ML

QL (05 per 28 days)

INVEGA TRINZA

273 MG0875 ML

QL (0875 per 84

days) NDS

INVEGA TRINZA

410 MG1315 ML

QL (1315 per 84

days) NDS

INVEGA TRINZA

546 MG175 ML

INVEGA TRINZA

819 MG2625 ML

QL (2625 per 84

days) NDS

MG 20 MG 40 MG 60 MG 80

QL (30 per 30 days)

mg 25 mg 5 mg 50 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

PA NSO QL (60 per

30 days) NDS

QL (30 per 30 days)

QL (60 per 30 days)

mg 4 mg 8 mg 1 $0

QL (90 per 30 days)

(Seroquel XR) 1 $0

QL (30 per 30 days)

QL (60 per 30 days)

MG 2 $0

ST QL (120 per 30

days) NDS

2 MG 3 MG 4 MG 2 $0

ST QL (30 per 30

days) NDS

RISPERDAL CONSTA

QL (4 per 28 days)

RISPERDAL CONSTA

QL (4 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (60 per 30 days)

risperidone oral

QL (60 per 30 days)

risperidone oral

(Risperdal M-

TAB) 1 $0

QL (60 per 30 days)

risperidone oral

(Risperdal M-

TAB) 1 $0

25 MG 5 MG

ST QL (60 per 30

days) NDS

mg 25 mg 50 mg 1 $0

mg 2 mg 5 mg 1 $0

VERSACLOZ ORAL

ST QL (540 per 30

days) NDS

MG 3 MG 45 MG 6 MG 2 $0

ST QL (30 per 30

days) NDS

VRAYLAR ORAL

(1)- 3 MG (6)

40 mg 60 mg 80 mg (Geodon) 1 $0

QL (60 per 30 days)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

QL (2 per 28 days)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

QL (2 per 28 days)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

QL (1 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Antiretrovirals

600-300 mg (Epzicom) 1 $0

MG 2 $0

MGML 2 $0

200-300 MG 2 $0

25-300 MG 2 $0

MG 400 MG 2 $0

25 MG 2 $0

mg 400 mg

(Videx EC) 1 $0

MG 2 $0

MGML 2 $0

25 MG5 ML (5 MGML) 2 $0

MG 2 $0

FUZEON SUBCUTANEOUS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

150-200-10 MG 2 $0

MG 200 MG 2 $0

MG 2 $0

600 MG 2 $0

PACKET 100 MG 2 $0

MG 2 $0

ISENTRESS ORAL

25 MG 2 $0

50 MG 2 $0

mg (Epivir) 1 $0

150-300 mg (Combivir) 1 $0

MGML 2 $0

400-100 mg5 ml (Kaletra) 1 $0

ml (Viramune) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

MGML 2 $0

25-25 MG 2 $0

150 MG-MG 2 $0

100 MGML 2 $0

MG 75 MG 2 $0

MG 800 MG 2 $0

200 MG 2 $0

MG 200 MG 300 MG 2 $0

PACKET 50 MG 2 $0

20 MGML 2 $0

MG 300 MG 75 MG 2 $0

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

150-200-300 MG 2 $0

MG 2 $0

50 MG 2 $0

50-300 MG 2 $0

150 MG 133-200 MG 167-250

MG 200-300 MG

MG 2 $0

QL (30 per 30 days)

(FINAL)

MG 625 MG 2 $0

200 MG 250 MG 300 MG 2 $0

MGML 2 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

RELENZA DISKHALER

MG05 ML

PA NDS

Hcv Antivirals

MG 60 MG 90 MG 2 $0

PA QL (28 per 28

days) NDS

100 MG 2 $0

PA QL (28 per 28

days) NDS

MG 2 $0

PA QL (30 per 30

days) NDS

40 MG 2 $0

PA QL (84 per 28

days) NDS

MG 2 $0

PA QL (28 per 28

days) NDS

MG 2 $0

PA QL (28 per 28

days) NDS

75-50 MG 2 $0

PA QL (56 per 28

days) NDS

VIEKIRA PAK ORAL

75 MG -50 MG250 MG

PA QL (112 per 28

days) NDS

50 MG- 3333 MG-200 MG

PA QL (84 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100 MG 2 $0

PA QL (28 per 28

days) NDS

100 MG 2 $0

PA QL (30 per 30

days) NDS

Interferons

MILLION UNIT (1 ML)

PA NSO NDS

INTRON A INJECTION

SOLUTION 10 MILLION

PA NSO NDS

MCG05 ML

PEGASYS PROCLICK

SUBCUTANEOUS PEN

MCG05 ML

KIT 200 MCG 300 MCG 600

PA NSO QL (4 per 28

days) NDS

PA BvD NDS

ml (Zovirax) 1 $0

mg (Zovirax) 1 $0

soln 500 mg 2 $0

PA BvD NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA BvD

mg 500 mg 1 $0

PA BvD

mg 600 mg 1 $0

PA BvD NDS

mg (Valtrex) 1 $0

Expanders

Anticoagulants

MG 80 MG 2 $0

QL (43 per 42 days)

CEPROTIN (BLUE BAR)

500 UNIT

5 MG 2 $0

100 mgml 120 mg08 ml 150

60 mg06 ml 80 mg08 ml

(Lovenox) 1 $0

10 mg08 ml 5 mg04 ml 75

mg06 ml

(Arixtra) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA QL (24 per 28

days) NDS

MG 150 MG 75 MG 2 $0

ST QL (60 per 30

(Coumadin) 1 $0

MG 15 MG 20 MG 2 $0

XARELTO ORAL

(42)- 20 MG (9)

CINRYZE INTRAVENOUS

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

SDV PF OUTER 10000

UNITML

PA QL (12 per 28

UNITML 4000 UNITML

PA QL (12 per 28

GRANIX SUBCUTANEOUS

MCG08 ML

PA NDS

SOLN 250 MCG 2 $0

100 MCG03 ML 200 MCG03

PA QL (06 per 28

SYRINGE W WEARABLE

INJECTOR 6 MG06 ML

NEUPOGEN INJECTION

MCG16 ML

NEUPOGEN INJECTION

MCG08 ML

PROCRIT INJECTION

ML 3000 UNITML 4000

UNITML

PA QL (12 per 28

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PROCRIT INJECTION

PA QL (12 per 28

days) NDS

PROCRIT INJECTION

PA QL (6 per 28

days) NDS

MG 25 MG 50 MG 75 MG 2 $0

PA QL (30 per 30

days) NDS

300 MCG05 ML 480 MCG08

ST NDS

mgml 1 $0

(Cyklokapron) 1 $0

MG 90 MG 2 $0

mg 75 mg 1 $0

5 MG 2 $0

QL (30 per 30 days)

release 400 mg 1 $0

Caloric Agents

AMINO ACIDS 15

SOLUTION 15

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

AMINOSYN 10

SOLUTION 10

PA BvD

AMINOSYN 7 WITH

ELECTROLYTES

SOLUTION 7

PA BvD

AMINOSYN 85

SOLUTION 85

PA BvD

AMINOSYN 85 -

ELECTROLYTES

SOLUTION 85

PA BvD

AMINOSYN II 10

SOLUTION 10

PA BvD

AMINOSYN II 15

SOLUTION 15

PA BvD

AMINOSYN II 7

SOLUTION 7

PA BvD

AMINOSYN II 85

SOLUTION 85

PA BvD

AMINOSYN II 85 -

ELECTROLYTES

SOLUTION 85

PA BvD

AMINOSYN M 35

SOLUTION 35

PA BvD

AMINOSYN-HBC 7

SOLUTION 7

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

AMINOSYN-PF 10

SOLUTION 10

PA BvD

FREE) INTRAVENOUS

PA BvD

AMINOSYN-RF 52

SOLUTION 52

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE) INTRAVENOUS

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

CLINISOL SF 15

SOLUTION 15

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA BvD

FREAMINE HBC 69

SOLUTION 69

PA BvD

FREAMINE III 10

SOLUTION 10

PA BvD

HEPATAMINE 8

SOLUTION 8

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

EMULSION 20 30 2 $0

PA BvD

KABIVEN INTRAVENOUS

EMULSION 331-98-39 2 $0

PA BvD

NEPHRAMINE 54

SOLUTION 54

PA BvD

EMULSION 20 2 $0

PA BvD

EMULSION 236-68-35 2 $0

PA BvD

PREMASOL 10

SOLUTION 10

PA BvD

PROCALAMINE 3

SOLUTION 3

PA BvD

TRAVASOL 10

SOLUTION 10

PA BvD

TROPHAMINE 10

SOLUTION 10

PA BvD

TROPHAMINE 6

SOLUTION 6

PA BvD

15-400 gram-unit42 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (4 per 28 days)

QL (8 per 28 days)

64 Years)

FCUD250S 5 MG 4 $0

5 mg 1 $0

drowsy 10 mg 4 $0

100 MG 200 MG 300 MG 2 $0

PA QL (180 per 30

days) NDS

mg (Minipress) 1 $0

Antagonists

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

32-25 mg

(Atacand HCT) 1 $0

80 MG 2 $0

40-125 MG 40-25 MG 2 $0

MG 49-51 MG 97-103 MG 2 $0

QL (60 per 30 days)

50 mg (Cozaar) 1 $0

tablet 100-125 mg 100-25 mg 50-

125 mg

(Hyzaar) 1 $0

oral tablet 20-5-125 mg 40-10-125

mg 40-10-25 mg 40-5-125 mg 40-

5-25 mg

(Tribenzor) 1 $0

40-25 mg

(Benicar HCT) 1 $0

tablet 160-125 mg 160-25 mg 320-

125 mg 320-25 mg 80-125 mg

(Diovan HCT) 1 $0

Inhibitors

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

tablet 10-125 mg 20-125 mg 20-

(Lotensin HCT) 1 $0

mg 25 mg 50 mg 1 $0

tablet 25-15 mg 25-25 mg 50-15

mg 50-25 mg

125 mgml 1 $0

40 mg 1 $0

tablet 10-125 mg 20-125 mg 1 $0

tablet 10-125 mg 20-125 mg 20-

(Zestoretic) 1 $0

tablet 15-125 mg 15-25 mg 75-

125 mg

mg 4 mg 8 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

tablet 10-125 mg 20-125 mg 20-

(Accuretic) 1 $0

4 mg 1 $0

mg 50 mg 1 $0

100 mg5 ml (2 ) 50 mg5 ml (1

mgml (08 )

mg 250 mg 1 $0

MG 2 $0

mg 400 mg 1 $0

mgml 500 mgml 1 $0

mg 300 mg 1 $0

300 mg 1 $0

mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100-25 mg (Tenoretic 100) 1 $0

50-25 mg (Tenoretic 50) 1 $0

mg 5 mg 1 $0

tablet 10-625 mg 25-625 mg 5-

625 mg

(Ziac) 1 $0

MG 25 MG 20 MG 5 MG 2 $0

MG 2 $0

mg 3125 mg 625 mg (Coreg) 1 $0

PA BvD NDS

mgml 1 $0

mg 300 mg 1 $0

mg 25 mg 50 mg

(Toprol XL) 1 $0

tablet 100-25 mg 100-50 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 1 $0

mg (Corgard) 1 $0

mgml 1 $0

mg 80 mg

(Inderal LA) 1 $0

mg 40 mg 60 mg 80 mg 1 $0

240 mg 80 mg 1 $0

20 mg 5 mg 1 $0

mg 300 mg

mgml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Cardizem CD) 1 $0

mg 360 mg 420 mg

(Cardizem LA) 1 $0

mg 360 mg 420 mg

mg 300 mg 360 mg

mgml 1 $0

mg 360 mg

(Verelan) 1 $0

Miscellaneous

MG 75 MG 2 $0

PA QL (60 per 30

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

mcgml 1 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

MCGML 2 $0

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

(4000 mcgml) 250 mg250 ml (1

mgml) 500 mg250 ml (2000

mcgml)

PA BvD

250 mg20 ml (125 mgml) 500

mg40 ml (125 mgml)

PA BvD

(800 mcgml) 400 mg250 ml (1600

mcgml) 800 mg250 ml (3200

mcgml)

PA BvD

(80 mgml) 800 mg10 ml (80

PA BvD

QL (4 per 30 days)

03 mg03 ml (Auvi-Q) 1 $0

QL (4 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (4 per 30 days)

QL (18 per 30 days)

mgml 1 $0

mg 25 mg 50 mg 1 $0

MCG 2 $0

PA-HRM QL (30 per

30 days) AGE (Max

64 Years)

MCG 2 $0

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

ml (200 mcgml) 40 mg200 ml (200

mcgml)

PA BvD NDS

mgml 1 $0

PA BvD NDS

(Levophed

(bitartrate)) 1 $0

PA BvD

RANEXA ORAL TABLET

1000 MG 500 MG

Dihydropyridines

10-20 mg 10-40 mg 5-10 mg 5-20

mg 5-40 mg

(Lotrel) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25-10 mg 1 $0

10-20 mg 10-40 mg 5-20 mg 5-40

(Azor) 1 $0

160 mg 10-320 mg 5-160 mg 5-

320 mg

(Exforge) 1 $0

tablet 10-160-125 mg 10-160-25

mg 10-320-25 mg 5-160-125 mg

5-160-25 mg

(Exforge HCT) 1 $0

MG100 ML

mg 1 $0

Diuretics

tablet 5-50 mg 1 $0

mgml 1 $0

mg 2 mg 1 $0

500 mg 1 $0

mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml 1 $0

40 mg5 ml (8 mgml) 1 $0

mg 25 mg 50 mg 1 $0

mg 1 $0

mg 5 mg 1 $0

Dyslipidemics

10-10 mg 10-20 mg 10-40 mg 10-

80 mg 5-10 mg 5-20 mg 5-40 mg

5-80 mg

(Caduet) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25-10 mg 25-20 mg 25-40 mg 1 $0

gram 1 $0

130 mg 134 mg 200 mg 43 mg 67

mg 1 $0

mg 45 mg

(Trilipix) 1 $0

MG 30 MG 40 MG 60 MG 2 $0

PA QL (30 per 30

days) NDS

MG 2 $0

PA QL (90 per 30

days) NDS

MG 2 $0

PA QL (45 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA QL (4 per 28

days) NDS

MG 4 MG 2 $0

QL (30 per 30 days)

40 mg 1 $0

24 hr 1000 mg 500 mg 750 mg

(Niaspan

(niacinamide)) 4 $0

PRALUENT PEN

SUBCUTANEOUS PEN

PA QL (2 per 28

days) NDS

REPATHA PUSHTRONEX

PA QL (35 per 28

days) NDS

REPATHA SURECLICK

SUBCUTANEOUS PEN

INJECTOR 140 MGML

PA QL (3 per 28

days) NDS

REPATHA SYRINGE

PA QL (3 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GRAM 2 $0

MG 2 $0

System Inhibitors

10 MG 150-5 MG 300-10 MG

300-5 MG

150-125 MG 150-25 MG 300-125

MG 300-25 MG

MG 300 MG 2 $0

Vasodilators

MG 2 $0

mg 20 mg 30 mg 1 $0

10 mg 20 mg 1 $0

mg 60 mg

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (30 per 30 days)

04 mghr 1 $0

QL (60 per 30 days)

OINTMENT 2 1 $0

(400 mcgml) 25 mg250 ml (100

mcgml) 50 mg250 ml (200

mcgml)

50 mg10 ml (5 mgml) 1 $0

(Minitran) 1 $0

QL (30 per 30 days)

QL (60 per 30 days)

Agents

AMPYRA ORAL TABLET

PA QL (60 per 30

days) NDS

100 mg 18 mg 25 mg 40 mg 60

mg 80 mg

(Strattera) 1 $0

MG 7 MG 2 $0

PA QL (28 per 28

days) NDS

MG 9 MG 2 $0

PA QL (120 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA NDS

KIT 03 MG 2 $0

PA NDS

mg3 ml (20 mgml) 1 $0

PA QL (12 per 28

days) NDS

QL (60 per 30 days)

10 mg 15 mg 5 mg

(Adderall XR) 1 $0

QL (30 per 30 days)

20 mg 25 mg 30 mg

(Adderall XR) 1 $0

QL (60 per 30 days)

20 mg 30 mg 5 mg 75 mg

(Adderall) 1 $0

QL (60 per 30 days)

03 MG 2 $0

PA NDS

mgml 1 $0

MG 2 $0

PA QL (28 per 28

days) NDS

PA QL (30 per 30

days) NDS

PA QL (12 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml 1 $0

PA QL (30 per 30

days) NDS

(Intuniv ER) 1 $0

MG 2 $0

PA QL (60 per 30

days) NDS

MG 2 $0

PA QL (30 per 30

days) NDS

PA NDS

mg 300 mg 600 mg 1 $0

mg 1 $0

ml 1 $0

mg 50 mg 60 mg

QL (30 per 30 days)

QL (60 per 30 days)

QL (30 per 30 days)

QL (60 per 30 days)

QL (30 per 30 days)

QL (90 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 54 mg

(Concerta) 1 $0

QL (30 per 30 days)

QL (60 per 30 days)

10 MG 2 $0

QL (60 per 30 days)

OCREVUS INTRAVENOUS

PA QL (20 per 180

days) NDS

PA NDS

PA QL (2800 per 28

days) NDS

PA NDS

REBIF REBIDOSE

SUBCUTANEOUS PEN

MCG05ML (6)

PA NDS

MG 125 MG 25 MG 50 MG 2 $0

QL (60 per 30 days)

SAVELLA ORAL

(5)-25 MG(8)-50 MG(42)

QL (60 per 30 days)

TECFIDERA ORAL

CAPSULEDELAYED

PA QL (14 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TECFIDERA ORAL

CAPSULEDELAYED

240 MG (46) 240 MG

PA QL (60 per 30

days) NDS

PA QL (112 per 28

days) NDS

PA QL (1 per 28

days) NDS

Contraceptives

mg 1 $0

mg-mcg 1 $0

050751 mg- 35 mcg 1 $0

QL (91 per 84 days)

35 mg-mcg 1 $0

mgx21 001 mg x 5 1 $0

mcg 1 $0

mgx21 001 mg x 5 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg (24)75 mg (4) 1 $0

mg-30 mcg (21)75 mg (7) 1 $0

20 mcg (21)75 mg (7) 1 $0

QL (91 per 84 days)

25 mg-mcg 1 $0

mcg 1 $0

mg-mcg 1 $0

050751 mg- 35 mcg 1 $0

mg-mcg 1 $0

050751 mg- 35 mcg 1 $0

QL (91 per 84 days)

mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

QL (6 per 365 days)

(5)125-30(10) 1 $0

mg 4 $0

QL (6 per 365 days)

mcg 1 $0

QL (91 per 84 days)

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg 1 $0

mg-30 mcg (21)75 mg (7) 1 $0

20 mcg (21)75 mg (7) 1 $0

(24)75 mg (4) 1 $0

mgx21 001 mg x 5 1 $0

mg-mcg 1 $0

mgx21 001 mg x 5 1 $0

20 mcg (84)10 mcg (7)

(Amethia Lo) 1 $0

QL (91 per 84 days)

30 mcg (84)10 mcg (7)

(Amethia) 1 $0

QL (91 per 84 days)

mg-mcg 1 $0

mcg 1 $0

(24)75 mg (4) 1 $0

mg-30 mcg (21)75 mg (7) 1 $0

20 mcg (21)75 mg (7) 1 $0

mg-mcg 1 $0

(6)75-40 (5)125-30(10) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

015-003 mg (Altavera (28)) 1 $0

QL (91 per 84 days)

15 mg (Aftera) 4 $0

QL (6 per 365 days)

30 mcg

(Introvale) 1 $0

QL (91 per 84 days)

tablet 50-30 (6)75-40 (5)125-

30(10)

(Enpresse) 1 $0

QL (91 per 84 days)

mcg (24)75 mg (4) 1 $0

mg-mcg 1 $0

mcg 1 $0

15-30 mg-mcg 1 $0

20 mg-mcg 1 $0

tablet 15 mg-30 mcg (21)75 mg (7) 1 $0

1 mg-20 mcg (21)75 mg (7) 1 $0

mcg 1 $0

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(5)125-30(10) 1 $0

mg-mcg 1 $0

mcg 1 $0

050751 mg- 35 mcg 1 $0

15 mg 4 $0

QL (6 per 365 days)

mg-20 mcg (21)75 mg (7)

(Blisovi Fe 120

(28)) 1 $0

(Ortho Tri-Cyclen

LO (28)) 1 $0

(Ortho Tri-Cyclen

(28)) 1 $0

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

050751 mg- 35 mcg 1 $0

012-0015 MG24 HR 2 $0

QL (1 per 28 days)

mcg 1 $0

mg 4 $0

QL (6 per 365 days)

mgx21 001 mg x 5 1 $0

35 mcg 1-35 mg-mcg 1 $0

QL (91 per 84 days)

mg 1 $0

QL (91 per 84 days)

mcg 1 $0

20 mcg (21)75 mg (7) 1 $0

1mg-35mcg (9) 1 $0

0180215025 mg-35 mcg (28) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

0180215025 mg-35 mcg (28) 1 $0

30(7) 1mg-35mcg (9) 1 $0

0180215025 mg-35 mcg (28) 1 $0

0180215025 mg-25 mcg 1 $0

0180215025 mg-35 mcg (28) 1 $0

40 (5)125-30(10) 1 $0

tablet 0112515-25 mg-mcg 1 $0

mgx21 001 mg x 5 1 $0

mcg 1 $0

150-35 mcg24 hr 1 $0

QL (3 per 28 days)

mcg 1 $0

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg-mcg 1 $0

mg5 ml 4 $0

mg 4 $0

200 mg 4 $0

325 mg 4 $0

20 mg 4 $0

20-400 mg 4 $0

20 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ml 4 $0

mg5 ml 3 $0

mgml 3 $0

mg 4 $0

mg5 ml 4 $0

100 mg5 ml 4 $0

mg5 ml 4 $0

MG5 ML

100 mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

325mg(d) 15-325-625mg 4 $0

mg30 ml 4 $0

400 mg 4 $0

blast 125-30-1000 mg30 ml 4 $0

mg 4 $0

mg5 ml 4 $0

160 mg5 ml 4 $0

mg5 ml

mg5 ml 4 $0

12 day12 night 2-5-10-325 mg 4 $0

mg5 ml 4 $0

mg15 ml

mg15 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

600 mg 4 $0

flavor 625-15 mg15 ml 4 $0

30 mg30 ml 4 $0

5 mg5 ml 4 $0

15mg15ml(d) 125-30mg30ml 4 $0

100 mg5 ml 4 $0

mg5 ml

(12-Hour Cough

Relief) 4 $0

mg5 ml 4 $0

200 mg5 ml 4 $0

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml 4 $0

20-650 mg 4 $0

ml 4 $0

400 mg 4 $0

mg5 ml

(Adult Tussin

mg (Coughtab) 4 $0

mg (Mucinex) 4 $0

10-325 mg 4 $0

mg5 ml 4 $0

600 mg 4 $0

1200 mg 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

15-500 mg15 ml 4 $0

mg15 ml

125 mg5 ml 4 $0

mg5 ml 4 $0

mg5 ml 3 $0

mg5 ml

(Nasal

Decongestant

(pseudoeph))

(Nasal

Decongestant

(pseudoeph))

30-1000 mg30 ml 4 $0

160 mg5 ml 4 $0

relief 10-5-325mg(d) 15-325-

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

day12 night 2-5-10-325 mg 4 $0

mg 4 $0

100 mg5 ml 4 $0

ml 4 $0

mg5 ml 4 $0

200 mg 4 $0

LIQ 1-75 MG5 ML 4 $0

mg5 ml 4 $0

ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml 4 $0

667 mg5 ml 4 $0

30-1000 mg30 ml 4 $0

625-30-15-325 mg 4 $0

mg30 ml 4 $0

15-325 mg 4 $0

ml 4 $0

mg 4 $0

ml 4 $0

af 10-200 mg5 ml 4 $0

30-15-500 mg 4 $0

MG 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

10-325 mg 4 $0

mg5 ml 4 $0

15-200 MG5 ML 4 $0

MG5 ML 4 $0

25-5-160 mg5 ml 4 $0

rlf 5 mg5 ml 4 $0

10-325 mg 4 $0

af 5-10-325 mg15 ml 4 $0

625-15-325 MG15 ML

625-15-325 mg 4 $0

mg16 ml 4 $0

caplet 30-15-500 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml 4 $0

ml 4 $0

max-str 30 mg 4 $0

caplet 5-10-325 mg 4 $0

mg 4 $0

400 mg5 ml 4 $0

(Paroex Oral

Rinse) 1 $0

mouthwash 012 1 $0

(Salagen

(pilocarpine)) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ACNE MEDICATION 5

LOTION 5 4 $0

PADS MEDICATED 1 $0

(AmLactin) 1 $0

(Calcitrene) 1 $0

15 4 $0

PA NDS

SUBCUTANEOUS PEN

INJECTOR 150 MGML

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

days) NDS

PA NDS

FLECTOR TRANSDERMAL

(Aldara) 1 $0

PA NSO QL (24 per

30 days)

INSECT REPELLENT 20

SPRAY 20 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

250 UNITGRAM 2 $0

SILIQ SUBCUTANEOUS

PA NDS

TALTZ AUTOINJECTOR

SUBCUTANEOUS AUTO-

INJECTOR 80 MGML

PA NDS

TALTZ SYRINGE

PA NDS

30 mg 40 mg 1 $0

unitgram 4 $0

(Cleocin T) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

1 (Cleocin T) 1 $0

gel 2 (Erygel) 1 $0

solution 2 1 $0

(Bactroban) 1 $0

(Neosporin GU

Irrigant) 1 $0

(Silvadene) 1 $0

Agents

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cream 005 1 $0

lotion 005 1 $0

ointment 005 1 $0

cream 01 1 $0

lotion 01 1 $0

ointment 01 1 $0

cream 005 1 $0

gel 005 1 $0

lotion 005 1 $0

005 1 $0

01 (Cloderm) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

DERMAREST ECZEMA 1

LOTION 1 4 $0

(Topicort) 1 $0

2 2 $0

(Synalar) 1 $0

05 4 $0

strength 1 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25 (Ala-Cort) 1 $0

(Dermatop) 1 $0

01 (Protopic) 1 $0

cream 0025 1 $0

lotion 0025 01 1 $0

ointment 0025 01 05 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

005 2 $0

(Retin-A) 1 $0

strength 033-4 4 $0

2x59ml 2 combs 1 4 $0

strength 033-4 4 $0

Devices

LANCT 28 GAUGE 4 $0

LANCT 30 GAUGE 4 $0

ACCU-CHEK FASTCLIX

LANCETS 4 $0

ACCU-CHEK MULTICLIX

LANCETS 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

LANCT 23 GAUGE 4 $0

23G 23 GAUGE 4 $0

ACCU-CHEK SOFTCLIX

LANCETS 4 $0

ACTI-LANCE LITE 28G

ADVANCED TRAVEL 28G

LANCETS 28GSINGLE-

USESTRL 28 GAUGE

ADVANCED TRAVEL 30G

ALTERNATE SITE 26G

ASSURE COMFORT 30G

LANCETS 30 GAUGE

(1st Tier Unilet

ComforTouch) 4 $0

18G 18 GAUGE 4 $0

21G 21 GAUGE 4 $0

25G 25 GAUGE 4 $0

28G 28 GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25 GAUGE 4 $0

28 GAUGE 4 $0

BD INSULIN SYR 1 ML

BD MICROTAINER 21G

BD MICROTAINER 30G

33 GAUGE 4 $0

TWIST 30 GAUGE

(1st Tier Unilet

ComforTouch) 4 $0

21 GAUGE 4 $0

LANCT 25 GAUGE 4 $0

CAREONE ULTRA THIN

LANCET 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CARETOUCH TWIST 28G

CARETOUCH TWIST 30G

30G 30 GAUGE 4 $0

CVS ULTRA THIN 30G

GAUGE 4 $0

30GTWIST TOPSTRL 30

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GAUGE 4 $0

32 GAUGE 4 $0

33 GAUGE 4 $0

(Accu-Chek

FastClix) 4 $0

(1st Tier Unilet

ComforTouch) 4 $0

GAUGE 4 $0

STRIP NO CODE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

STRIPS 4 $0

FREESTYLE UNISTIK 2

LANCETS 4 $0

GAUZE PAD TOPICAL

BANDAGE 2 X 2 1 $0

GAUGE 4 $0

21G 21 GAUGE 4 $0

30G 30 GAUGE 4 $0

LANCT 30 GAUGE 4 $0

LANCT 28 GAUGE 4 $0

GAUGE 4 $0

(Ultilet Insulin

Syringe) 1 $0

(Advocate

Syringes) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Lite Touch Insulin

Syringe) 1 $0

GAUGE 4 $0

LANCT 26 GAUGE 4 $0

KROGER SUPER THIN

LANCETS 4 $0

Lancets) 4 $0

GAUGE 4 $0

MEDLANCE PLUS 21G

MEDLANCE PLUS 30G

30 GAUGE

GAUGE 4 $0

28 GAUGE 4 $0

MYGLUCOHEALTH 30G

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

23 GAUGE 4 $0

28 GAUGE 4 $0

NOVA SUREFLEX THIN

LANCETS 4 $0

GAUGE 4 $0

ONETOUCH DELICA 30G

ONETOUCH DELICA 33G

ONETOUCH SURESOFT

LANCETS

ONETOUCH ULTRASOFT

LANCETS 4 $0

PEN NEEDLE DIABETIC

(1st Tier Unifine

Pentips) 1 $0

(1st Tier Unilet

ComforTouch) 4 $0

30 GAUGE 4 $0

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PRODIGY PRESSURE

PRODIGY SAFETY 26G

GAUGE 4 $0

RELIAMED SAFETY 23G

RELIAMED SAFETY 28G

LANCT 28 GAUGE 4 $0

LANCT 30 GAUGE 4 $0

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

33 GAUGE 4 $0

LANCETS 4 $0

30 GAUGE 4 $0

FREE 21 GAUGE 4 $0

FREE 28 GAUGE 4 $0

GAUGE 4 $0

21 GAUGE 4 $0

GAUGE 4 $0

30 GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

18 GAUGE 4 $0

21 GAUGE 4 $0

23 GAUGE 4 $0

28 GAUGE 4 $0

30 GAUGE 4 $0

GAUGE 4 $0

SURE-LANCE THIN 28G

30 GAUGE 4 $0

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GAUGE 4 $0

TRUEPLUS SAFETY 28G

GAUGE 4 $0

30 GAUGE 4 $0

ULTILET CLASSIC 26G

LANCETS 4 $0

ULTILET CLASSIC 28G

ULTILET CLASSIC 30G

ULTILET CLASSIC 33G

ULTILET SAFETY 23G

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GAUGE 4 $0

28 GAUGE 4 $0

30 GAUGE 4 $0

UNILET COMFORTOUCH

LANCET 4 $0

LANCETS SINGLE-

USESTERILE 30 GAUGE

UNISTIK 3 EXTRA 21G

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

28 GAUGE 4 $0

30 GAUGE 4 $0

21 GAUGE 4 $0

23 GAUGE 4 $0

28 GAUGE 4 $0

30 GAUGE 4 $0

LANCETS 4 $0

Dermatologic Use)

Enzyme

MG 2 $0

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CREON ORAL

CAPSULEDELAYED

60000 UNIT 24000-76000 -

120000 UNIT 3000-9500- 15000

UNIT 36000-114000- 180000

UNIT 6000-19000 -30000 UNIT

SOLN 15 MG 75 MG 2 $0

KANUMA INTRAVENOUS

PA NDS

KUVAN ORAL

MG 20 MG 5 MG 2 $0

PA NDS

MGML 2 $0

PA NDS

MG 75 MG

PA BvD NDS

PA LA NDS

VIMIZIM INTRAVENOUS

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

SOLN 400 UNIT 2 $0

MG 2 $0

QL (90 per 30 days)

ZENPEP ORAL

CAPSULEDELAYED

55000 UNIT 15000-51000 -

82000 UNIT 20000-68000 -

109000 UNIT 25000-85000-

136000 UNIT 3000-10000-

16000 UNIT 40000-136000-

218000 UNIT 5000-17000 -

27000 UNIT

Miscellaneous

(EYE) GEL 35 2 $0

03 4 $0

OINTMENT 83-15 4 $0

mcg (01 ) 1 $0

QL (30 per 25 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

005 1 $0

03 4 $0

therapy 04-03 4 $0

425 4 $0

soln 05-09 4 $0

CYSTARAN OPHTHALMIC

005 (Elestat) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GENTEAL MILD 02 EYE

DROPS 02 4 $0

03 01-03-02 4 $0

03 4 $0

QL (30 per 28 days)

QL (15 per 10 days)

09 4 $0

30x04ml 05 4 $0

force 005 4 $0

formula 005 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

03 4 $0

01 (Patanol) 1 $0

02 (Pataday) 1 $0

03-0025 (025 ML) 2 $0

drops 10 25 1 $0

drops 05 1 $0

03 4 $0

005 4 $0

formula 1-03 4 $0

DROPS 1 4 $0

U-DPF30X4ML 14-06 4 $0

REFRESH LACRI-LUBE

OINTMENT 568-425 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

03 4 $0

DROPS 04-03 4 $0

d36x9mlpf 01-03 4 $0

Infectives Agents

unitgram

(Polycin) 1 $0

CIPRODEX OTIC (EAR)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

05 MGML

05 (Zymaxid) 1 $0

03 (3 mggram) 1 $0

03 1 $0

05 1 $0

05 (Vigamox) 1 $0

10000 mg-unitg-1

10000 mg-unit-unitg

(Neo-Polycin) 1 $0

(Maxitrol) 1 $0

10000 unitg-01

(Maxitrol) 1 $0

10000 unit-0025mgml

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

10 mg-unit-mgml

mgml-unitml-

unitml-

(Ocuflox) 1 $0

500-10000 unitgram 1 $0

1 mgml

(Polytrim) 1 $0

DROPS 05-1-05 4 $0

(025 )

TOBRADEX OPHTHALMIC

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

03 (Tobrex) 1 $0

(TobraDex) 1 $0

(Viroptic) 1 $0

DROPS 05 2 $0

GEL 015 2 $0

Inflammatory Agents

DROPS 0075 2 $0

drops 01 1 $0

DROPS 005 2 $0

25 mcg (0025 ) 1 $0

QL (50 per 25 days)

50 mcgactuation

(24 Hour Allergy

Relief) 1 $0

04 (Acular LS) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

05 (Acular) 1 $0

DROPSGEL 05 2 $0

OINTMENT 05 2 $0

PROLENSA OPHTHALMIC

RESTASIS MULTIDOSE

QL (55 per 30 days)

QL (60 per 30 days)

Antiflatulents

125 mg 4 $0

ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

(Anti-Gas Ultra

Strength) 4 $0

Suppressants

strength 20 mg 4 $0

100 MGML 2 $0

mg5 ml 1 $0

(cimetidine)) 1 $0

mg 800 mg 1 $0

200 mg

(Acid Reducer

(cimetidine)) 4 $0

20 mg2 ml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml 1 $0

mg 4 $0

(Heartburn

Treatment 24

release(drec) 15 mg

(Heartburn

Treatment 24

(Acid Reducer

(omeprazole)) 4 $0

PRILOSEC OTC 206 MG

(Acid Control

(ranitidine)) 4 $0

free 75 mg

(Acid Reducer

(ranitidine)) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(ranitidine)) 1 $0

mg15 ml 4 $0

ml 4 $0

320 mg5 ml 4 $0

MCG 8 MCG 2 $0

QL (60 per 30 days)

30 mg5 ml 4 $0

40 mg5 ml 4 $0

mg 4 $0

ml 4 $0

mg 4 $0

mg15 ml 4 $0

MG 2 $0

(1250 mg) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Calci-Chew) 4 $0

(1000 mg)

mg 4 $0

400-400-40 mg5 ml 4 $0

cherry 200-200-20 mg5 ml 4 $0

ml 1 $0

strength 200-200-20 mg5 ml 4 $0

200-20 mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

2 mg 4 $0

mg15 ml 4 $0

mg (750 mg) 4 $0

2375 mg5 ml 4 $0

mg 4 $0

1 mg75 ml

(Anti-Diarrheal

(loperamide)) 4 $0

ml 1 $0

25-0025 mg5 ml 1 $0

PA-HRM AGE (Max

64 Years)

25-0025 mg (Lomotil) 1 $0

PA-HRM AGE (Max

64 Years)

strength 400-400-40 mg5 ml 4 $0

mg15 ml 4 $0

GATTEX 30-VIAL

PA NDS

200-200-25 mg 4 $0

ml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml (Robinul) 1 $0

MG75 ML

193 gram60 ml 1 $0

MCG 290 MCG 72 MCG 2 $0

QL (30 per 30 days)

strength 200-200-20 mg5 ml 4 $0

(Anti-Diarrheal

(loperamide)) 4 $0

mg75 ml

(Anti-Diarrheal

(loperamide)) 4 $0

(loperamide)) 1 $0

mg 4 $0

500 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Laxative Dietary

Supplement) 4 $0

mg 4 $0

5 mg 1 $0

mg5 ml 1 $0

mg5 ml 400-400-40 mg5 ml 4 $0

200-25 mg 4 $0

200-20 mg5 ml 4 $0

MG 25 MG 2 $0

QL (30 per 30 days)

MG 5 MG 2 $0

PA QL (30 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

fruits 300 mg (750 mg) 4 $0

mg 4 $0

GRAMML 2 $0

PA NDS

MG 2 $0

PA QL (90 per 30

days) NDS

PA QL (28 per 28

days) NDS

MG04 ML

PA QL (28 per 28

days) NDS

mg5 ml 4 $0

ml 4 $0

30 mg5 ml 4 $0

20 mg 4 $0

650 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

262 mg15 ml 4 $0

15-20 gram60 ml 1 $0

PACKET 168 GRAM 252

GRAM 84 GRAM

QL (30 per 30 days)

MG 75 MG 2 $0

ST QL (60 per 30

days) NDS

MG 2 $0

PA QL (90 per 30

days) NDS

Laxatives

(Bisac-Evac) 4 $0

gram118 ml 4 $0

625 mg 4 $0

mg5 ml 4 $0

ml 4 $0

Heavy) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

ml 4 $0

20 mg5 ml 4 $0

gram 4 $0

625 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

gram 4 $0

2272-672 -584 gram 1 $0

2274-674 -586 gram 1 $0

gramdose 4 $0

outer 17 gram 4 $0

625 mg 4 $0

gramdose 4 $0

mg5 ml 4 $0

MINERAL OIL LIGHT

VISCOSITY NF 4 $0

PACKET 100-75-2691 GRAM 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

gram58 gram 4 $0

soln 240-2272-672 -584 gram

(Colyte with Flavor

Packs) 1 $0

(ClearLax) 4 $0

gram118 ml 4 $0

gram11 gram 4 $0

gram15 ml 4 $0

Heavy) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

gramdose 4 $0

19-7 gram118 ml 4 $0

gram 4 $0

heavy 4 $0

gram58 gram 4 $0

ml 4 $0

mg5 ml 4 $0

50 mg (Colace 2-In-1) 4 $0

ml 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100 mg 4 $0

240 mg 4 $0

16 GRAM

soln 420 gram 1 $0

mg 4 $0

Phosphate Binders

MG 800 MG 2 $0

MG 2 $0

mg (Renvela) 1 $0

VELPHORO ORAL

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 50 MG

mg5 ml 1 $0

mg 5 mg

(Ditropan XL) 1 $0

TOVIAZ ORAL TABLET

MG 8 MG

MG 5 MG 2 $0

Miscellaneous

QL (30 per 30 days)

2 mg 5 mg 1 $0

250 MG 2 $0

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TABLET 250 MG 2 $0

PA NDS

EXJADE ORAL TABLET

500 MG

PA NDS

100 MGML 2 $0

PA NDS

MG 2 $0

PA NDS

MG 360 MG 90 MG 2 $0

PA NDS

360 MG 90 MG

PA NDS

MG 2 $0

PA QL (240 per 30

days) NDS

Hormonal Agents

Androgens

MG 2 $0

PA NDS

HOUR 4 MG24 HR

PA QL (30 per 30

2025 MG125 GRAM (162 )

PA QL (150 per 30

MG125 GRAM) 162 (405

MG25 GRAM)

PA QL (150 per 30

mg 50 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg (Oxandrin) 1 $0

(Depo-

Testosterone) 1 $0

PA QL (300 per 30

(50 mg5 gram)

(AndroGel) 1 $0

PA QL (300 per 30

05 mg 1 $0

MG24 HR 005-025 MG24 HR

PA-HRM QL (8 per

28 days) AGE (Max

64 Years)

MG 2 $0

PA-HRM AGE (Max

64 Years)

001 (01 MGGRAM) 2 $0

mg (Estrace) 1 $0

PA-HRM AGE (Max

64 Years)

mg24 hr 0075 mg24 hr 01

mg24 hr

(Alora) 1 $0

PA-HRM QL (8 per

28 days) AGE (Max

64 Years)

PA-HRM QL (8 per

28 days) AGE (Max

64 Years)

0025 mg24 hr 00375 mg24 hr

005 mg24 hr 006 mg24 hr 0075

mg24 hr 01 mg24 hr

(Climara) 1 $0

PA-HRM QL (4 per

28 days) AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM AGE (Max

64 Years)

mg 3 mg 1 $0

PA-HRM AGE (Max

64 Years)

MG24 HR 01 MG24 HR 2 $0

QL (1 per 84 days)

05 mg 1 $0

PA-HRM AGE (Max

64 Years)

0625 MG 125 MG 2 $0

PA-HRM AGE (Max

64 Years)

SOLN 25 MG 2 $0

MG 045 MG 0625 MG 09 MG

125 MG

PA-HRM AGE (Max

64 Years)

0625 MGGRAM 2 $0

0625 MG (14) 0625MG-5MG(14) 2 $0

PA-HRM AGE (Max

64 Years)

15 MG 045-15 MG 0625-25

MG 0625-5 MG

PA-HRM AGE (Max

64 Years)

mg 1 $0

(Celestone

Soluspan) 1 $0

ml 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

075 mg 1 mg 15 mg 2 mg 4 mg

PA BvD

2275 MGML 2 $0

PA QL (39 per 30

days) NDS

MG 2 $0

PA QL (30 per 30

days) NDS

MG 36 MG 6 MG 2 $0

PA QL (60 per 30

days) NDS

PA BvD

KENALOG INJECTION

(Depo-Medrol) 1 $0

PA BvD

mg5 ml (5 mgml)

PA BvD

(Pediapred) 1 $0

PA BvD

5 mg 50 mg 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(48 pack)

PA BvD

Pituitary

mcgml (DDAVP) 1 $0

mg (DDAVP) 1 $0

MG025 ML

MG025 ML 06 MG025 ML 08

MG025 ML 1 MG025 ML 12

MG025 ML 14 MG025 ML 16

MG025 ML 18 MG025 ML 2

MG025 ML

PA NDS

UNITML) 5 MGML (15

UNITML)

PA NDS

HUMATROPE INJECTION

24 MG (72 UNIT) 6 MG (18

PA NDS

HUMATROPE INJECTION

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

LUPRON DEPOT-PED (3

SYRINGE KIT 30 MG

LUPRON DEPOT-PED

NORDITROPIN FLEXPRO

SUBCUTANEOUS PEN

MGML) 30 MG3 ML (10

PA NDS

NORDITROPIN FLEXPRO

SUBCUTANEOUS PEN

NUTROPIN AQ NUSPIN

SUBCUTANEOUS PEN

MGML) 20 MG2 ML (10

MGML) 5 MG2 ML (25

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MGML) 5 MG15 ML (33

PA NDS

SAIZEN CLICKEASY

PA NDS

SAIZEN SUBCUTANEOUS

PA NDS

INTRAMUSCULAR

PA NDS

QL (60 per 30 days)

SOMATULINE DEPOT

MG05 ML 60 MG02 ML 90

MG03 ML

QL (1 per 28 days)

MG 25 MG 30 MG

50 MG (65 MCGDAY) 2 $0

QL (1 per 360 days)

AEROSOL 2 MGML 2 $0

SUSPENSION FOR

QL (1 per 168 days)

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA NDS

Progestins

DEPO-PROVERA

400 MGML

QL (10 per 28 days)

PA NSO

QL (1 per 84 days)

mg10 ml (40 mgml) 1 $0

PA-HRM AGE (Max

64 Years)

mg (Aygestin) 1 $0

oil 50 mgml 1 $0

soln 100 mcg 200 mcg 500 mcg 1 $0

112 mcg 125 mcg 137 mcg 150

(Levo-T) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ACTEMRA INTRAVENOUS

MGML) 400 MG20 ML (20

MGML) 80 MG4 ML (20

PA NDS

ASTAGRAF XL ORAL

PA BvD

soln 100 mg 1 $0

PA BvD

PA BvD NDS

CIMZIA POWDER FOR

PA NDS

CIMZIA SUBCUTANEOUS

MGML X 2)

PA NDS

PA BvD

100 mg 25 mg 50 mg (Gengraf) 1 $0

PA BvD

ENBREL SUBCUTANEOUS

PA NDS

ENBREL SUBCUTANEOUS

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ENBREL SUBCUTANEOUS

MGML (098 ML)

PA NDS

ENBREL SURECLICK

SUBCUTANEOUS PEN

PA NDS

075 MG 1 MG 4 MG

PA BvD

FLEBOGAMMA DIF

PA BvD NDS

GAMASTAN SD

(10 ML) 15-18 RANGE (2 ML)

PA BvD

GAMMAGARD LIQUID

PA BvD NDS

MCGML) INTRAVENOUS

PA BvD NDS

GAMMAPLEX (WITH

SOLUTION 5

PA BvD NDS

SOLUTION 10 2 $0

PA BvD NDS

mg 50 mg 1 $0

PA BvD

START SUBCUTANEOUS

MG08 ML (6 PACK)

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA NDS

HUMIRA SUBCUTANEOUS

MG04 ML 40 MG08 ML

PA NDS

HYPERRAB SD (PF)

HYQVIA SUBCUTANEOUS

(10 ) 25 GRAM 25 ML (10 )

20 GRAM 200 ML (10 ) 30

50 ML (10 )

PA BvD NDS

(150 MGML)

PA NDS

150 UNITML

PA NDS

MG114 ML

PA QL (228 per 28

days) NDS

PA QL (1876 per 28

days) NDS

mg (Arava) 1 $0

(CellCept

Intravenous) 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA BvD

(CellCept) 1 $0

PA BvD NDS

PA BvD

mg 360 mg

(Myfortic) 1 $0

PA BvD

NULOJIX INTRAVENOUS

PA BvD NDS

OCTAGAM INTRAVENOUS

SOLUTION 10 5 2 $0

PA BvD NDS

250 MG

PA NDS

ORENCIA CLICKJECT

SUBCUTANEOUS AUTO-

INJECTOR 125 MGML

PA NDS

ML 875 MG07 ML

PA NDS

days) NDS

OTEZLA STARTER ORAL

(4)-20 MG (4)-30 MG (47) 10 MG

(4)-20 MG (4)-30 MG(19)

PA QL (60 per 30

days) NDS

OTREXUP (PF)

SUBCUTANEOUS AUTO-

MG04 ML 15 MG04 ML 175

MG04 ML 20 MG04 ML 225

MG04 ML 25 MG04 ML

SOLUTION 10 2 $0

PA BvD NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PROGRAF INTRAVENOUS

PA BvD

MGML 2 $0

PA BvD NDS

125 MG025 ML 15 MG03 ML

175 MG035 ML 20 MG04 ML

225 MG045 ML 25 MG05 ML

275 MG055 ML 30 MG06 ML

75 MG015 ML

PA NDS

MG 2 $0

PA NDS

MG05 ML

PA NDS

STELARA INTRAVENOUS

PA NDS

PA BvD

TYSABRI INTRAVENOUS

PA LA QL (15 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA QL (30 per 30

days) NDS

MG 05 MG 075 MG 2 $0

PA BvD NDS

Vaccines

ADACEL(TDAP

ADOLESNADULT)(PF)

INTRAMUSCULAR

MCG)-5LF05 ML

ADACEL(TDAP

ADOLESNADULT)(PF)

LF-(25-5-3-5 MCG)-5LF05 ML

PA BvD

BOOSTRIX TDAP

INTRAMUSCULAR

LF05ML

BOOSTRIX TDAP

20-20 MCG05 ML

(PF) INTRAMUSCULAR

LF05ML

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ENGERIX-B (PF)

INTRAMUSCULAR

SUSPENSION 20 MCGML

PA BvD

ENGERIX-B (PF)

PA BvD

INTRAMUSCULAR

PA BvD

MCG05 ML

PA BvD

GARDASIL (PF)

INTRAMUSCULAR

MCG05 ML

GARDASIL 9 (PF)

INTRAMUSCULAR

SUSPENSION 05 ML

GARDASIL 9 (PF)

HAVRIX (PF)

INTRAMUSCULAR

HAVRIX (PF)

ELISA UNIT05 ML

HIBERIX (PF)

INTRAMUSCULAR RECON

SOLN 10 MCG05 ML

INTRAMUSCULAR RECON

SOLN 25 UNIT

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

INTRAMUSCULAR

LF05ML

40-8-32 UNIT05 ML 2 $0

32 UNIT05 ML 2 $0

LF05 ML

MENACTRA (PF)

MCG05 ML

MENHIBRIX (PF)

INTRAMUSCULAR RECON

SOLN 5-25 MCG05 ML

50 MCG

MENOMUNE - ACYW-135

50 MCG

MCG05 ML

TCID5005 ML

PEDIARIX (PF)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PEDVAX HIB (PF)

75 MCG05 ML

PENTACEL (PF)

(PF) INTRAMUSCULAR

LF UNIT05ML

PROQUAD (PF)

FOR RECONSTITUTION

10EXP3-43-3- 399 TCID5005

QUADRACEL (PF)

INTRAMUSCULAR

LF UNIT05ML

RABAVERT (PF)

INTRAMUSCULAR

SUSPENSION FOR

PA BvD

RECOMBIVAX HB (PF)

INTRAMUSCULAR

PA BvD

RECOMBIVAX HB (PF)

MCGML 5 MCG05 ML

PA BvD

MCG05 ML

PA BvD

CCID50ML

SOLUTION 2 ML 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

SHINGRIX (PF)

INTRAMUSCULAR

SUSPENSION FOR

QL (2 per 365 days)

SHINGRIX GE ANTIGEN

COMPONENT

INTRAMUSCULAR

SUSPENSION FOR

QL (2 per 365 days)

TENIVAC (PF)

2 LF UNIT05 ML

SUV 5 LF UNIT- 2 LF

UNIT05ML

TETANUS-DIPHTHERIA

TOXOIDS-TD

INTRAMUSCULAR

SUSPENSION FOR

PA BvD

TWINRIX (PF)

INTRAMUSCULAR

20 MCGML

TWINRIX (PF)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

UNITML

VARIVAX (PF)

UNIT05 ML

QL (2 per 365 days)

SUSPENSION FOR

UNIT05 ML

ZOSTAVAX (PF)

UNIT065 ML

QL (1 per 365 days)

Agents

APRISO ORAL

24HR 0375 GRAM

budesonide oral

CANASA RECTAL

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

ST NDS

LIALDA ORAL

(DREC) 12 GRAM

(Azulfidine EN-

tabs) 1 $0

MGACTUATION 2 $0

LACTATED RINGERS

27-054 g100 ml 1 $0

irrigation solution

(Curity Sterile

Water) 1 $0

Agents

ml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 5 mg 1 $0

unitactuation

QL (37 per 28 days)

mcgml 1 $0

MCG24 ML

PA QL (24 per 28

mg3 ml 1 $0

QL (3 per 84 days)

MIACALCIN INJECTION

MCGDOSE

PA QL (2 per 28

days) NDS

5 MCGML

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg (Zemplar) 1 $0

PROLIA SUBCUTANEOUS

QL (1 per 180 days)

RAYALDEE ORAL

24 HR 30 MCG

QL (60 per 30 days)

MG 2 $0

QL (60 per 30 days)

MG 2 $0

QL (60 per 30 days)

MG 2 $0

MCG156 ML)

PA QL (156 per 30

soln 4 mg 1 $0

ZOMETA INTRAVENOUS

Agents

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA NDS

PA QL (4 per 28

days) NDS

PA QL (4 per 28

days) NDS

CETYLEV ORAL TABLET

GRAM17 ML 2 $0

mgml 1 $0

MG 2 $0

PACKET 5 GRAM 2 $0

PA QL (180 per 30

days) NDS

SOLUTION 50 MGML 50

MGML (10 ML)

PA LA NDS

gramml 1 $0

100 mg 1 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

soln 100 mg 350 mg 50 mg 1 $0

mg 15 mg 25 mg 5 mg 1 $0

LEVOLEUCOVORIN

175 MG

mgml (Mesnex) 1 $0

MG 2 $0

MG5 ML 2 $0

Heavy) 4 $0

PROGLYCEM ORAL

(Mestinon

Timespan) 1 $0

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 150 MG 200 MG 50 MG 2 $0

PA NSO QL (60 per

30 days) NDS

TOTECT INTRAVENOUS

QL (24 per 14 days)

PACKET 2 GRAM 2 $0

PA QL (120 per 30

days) NDS

Ophthalmic Agents

Antiglaucoma Agents

250 mg 1 $0

(EYE) DROPS 01 2 $0

02 1 $0

COMBIGAN OPHTHALMIC

(EYE) DROPS 02-05 2 $0

2 (Trusopt) 1 $0

0005 (Xalatan) 1 $0

05 (Betagan) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

DROPS 001 2 $0

QL (25 per 25 days)

mg (Neptazane) 1 $0

03 1 $0

PHOSPHOLINE IODIDE

(EYE) DROPS 0004 2 $0

QL (25 per 25 days)

QL (30 per 30 days)

mg-unit 4 $0

mg (950 mg) 4 $0

(Calcium 600 with

Vitamin D3) 4 $0

mg(1500mg) -500 unit 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Calcium 600 with

Vitamin D3) 4 $0

mg5 ml (1250 mg5 ml) 4 $0

250 mg-unit

(Calcitrate-Vitamin

D) 4 $0

(Calcium Citrate +

D) 4 $0

mg (500 mg) 4 $0

mg (648 mg) 4 $0

MG (1500 MG)-800 UNIT

250 mg-unit 4 $0

mg-unit 4 $0

315-250 mg-unit

(Calcitrate-Vitamin

D) 4 $0

mg-unit

(Calcitrate-Vitamin

D) 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Calcitrate-Vitamin

D) 4 $0

800 unit-40 mg

unit-40 mg

IONOSOL-B IN D5W

SOLUTION 5

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

IONOSOL-MB IN D5W

SOLUTION 5

mg(1500mg) -400 unit 4 $0

-500 unit

mg) 4 $0

gram500 ml (4 ) 40 gram1000

ml (4 )

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(4 ) 4 gram100 ml (4 ) 4

gram50 ml (8 )

4 meqml (50 ) 1 $0

4 meqml 1 $0

NORMOSOL-M IN 5

PARENTERAL SOLUTION

NORMOSOL-R PH 74

SOLUTION

(1250 mg) 4 $0

(1250 mg)

(625)-125 mg-unit 4 $0

PLASMA-LYTE 148

SOLUTION

PLASMA-LYTE A

SOLUTION

PLASMA-LYTE-56 IN 5

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

meql 40 meql

meq100 ml

(Klor-Con

Sprinkle) 1 $0

(K-Tab) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

meql 40 meql

solution 1 $0

(Calcitrate-Vitamin

D) 4 $0

mg 4 $0

2 meqml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

5 meqml 1 $0

18-5-45-35 MEQ20 ML

TPN ELECTROLYTES

20-5 MEQ20 ML

Corticosteroids

500-50 MCGDOSE

QL (60 per 30 days)

MCGACTUATION 230-21

MCGACTUATION 45-21

MCGACTUATION

QL (12 per 28 days)

ARNUITY ELLIPTA

200 MCGACTUATION

QL (30 per 30 days)

QL (60 per 30 days)

mg2 ml 1 mg2 ml

(Pulmicort) 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MCGACTUATION 200-5

MCGACTUATION

QL (13 per 28 days)

FLOVENT DISKUS

50 MCGACTUATION

QL (60 per 30 days)

FLOVENT DISKUS

MCGACTUATION

QL (12 per 28 days)

MCGACTUATION

QL (24 per 28 days)

MCGACTUATION

45 MCGACTUATION

QL (12 per 25 days)

MCGACTUATION 80-45

MCGACTUATION

QL (11 per 25 days)

Antileukotrienes

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Bronchodilators

mg3 ml 25 mg 3 ml (0083 ) 5

PA BvD

ml 1 $0

MCGACTUATION

QL (60 per 30 days)

MCGACTUATION

COMBIVENT RESPIMAT

MCGACTUATION

QL (8 per 30 days)

FORADIL AEROLIZER

INHALATION CAPSULE

QL (60 per 30 days)

INCRUSE ELLIPTA

solution 002 1 $0

PA BvD

QL (30 per 30 days)

ml 1 $0

20 mg 1 $0

AEROSOL INHALER 90

MCGACTUATION

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PROAIR RESPICLICK

INHALATION AEROSOL

90 MCGACTUATION

SEREVENT DISKUS

DEVICE 50 MCGDOSE

QL (60 per 30 days)

SPIRIVA RESPIMAT

INHALATION MIST 125

MCGACTUATION 25

MCGACTUATION

INHALATION CAPSULE

STIOLTO RESPIMAT

MCGACTUATION

QL (4 per 28 days)

STRIVERDI RESPIMAT

INHALATION MIST 25

MCGACTUATION

QL (4 per 28 days)

mgml 1 $0

mg100 ml 200 mg50 ml 400

mg250 ml 400 mg500 ml 800

mg250 ml

ml 1 $0

(Theochron) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TRELEGY ELLIPTA

PA BvD

(10 ) 200 mgml (20 ) 1 $0

PA BvD

CINQAIR INTRAVENOUS

PA NDS

PA BvD

mgspray (4 )

(Nasal Allergy

MCG 2 $0

QL (30 per 30 days)

MG 2 $0

PA QL (270 per 30

days) NDS

PA QL (1 per 28

days) NDS

PA QL (60 per 30

days) NDS

MG 2 $0

PA QL (60 per 30

days) NDS

NUCALA SUBCUTANEOUS

PA LA QL (1 per 28

days) NDS

150 MG 2 $0

PA QL (60 per 30

days) NDS

125 MG 200-125 MG 2 $0

PA QL (120 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

suv pf (rx) 09 3 $0

XOLAIR SUBCUTANEOUS

PA NDS

350 mg (Soma) 1 $0

PA-HRM QL (120 per

30 days) AGE (Max

64 Years)

mg 1 $0

PA-HRM AGE (Max

64 Years)

mg (Dantrium) 1 $0

64 Years)

mg 1 $0

MG 15 MG 20 MG 5 MG 2 $0

QL (30 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

3 mg (Lunesta) 1 $0

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any non-

benzodiazepine

per 30 days) AGE

(Max 64 Years)

MG 2 $0

PA QL (30 per 30

days) NDS

6 MG 2 $0

QL (30 per 30 days)

MGML 2 $0

LA QL (540 per 30

days) NDS

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any non-

benzodiazepine

per 30 days) AGE

(Max 64 Years)

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any non-

benzodiazepine

per 30 days) AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Vasodilating Agents

days) NDS

MG 1 MG 15 MG 2 MG 25 MG 2 $0

PA QL (90 per 30

days) NDS

PA NDS

MG 5 MG 2 $0

PA QL (30 per 30

days) NDS

1 MG 25 MG 5 MG

PA NDS

REMODULIN INJECTION

SOLUTION 1 MGML 10

MGML 25 MGML 5 MGML

PA NDS

PA QL (375 per 1

day) NDS

PA QL (90 per 30

MG 625 MG 2 $0

PA LA QL (60 per 30

days) NDS

PA QL (112 per 28

days) NDS

TYVASO INHALATION

SOLUTION FOR

(06 MGML)

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

1600 MCG 400 MCG 600 MCG

800 MCG

PA QL (60 per 30

days) NDS

MCG 2 $0

PA QL (240 per 30

days) NDS

UPTRAVI ORAL

(140)- 800 MCG (60)

PA QL (400 per 365

days) NDS

formula 4 $0

mg-mcg-mcg-mcg

mcg-mcg

600-300 mcg 4 $0

250 mcg 4 $0

formulation 4 $0

mcg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

300-250 mg-mcg-mcg 4 $0

Complex) 4 $0

unitdrop 4 $0

unit02 ml 4 $0

(Super B Complex-

Vitamin C) 4 $0

bee-zee tablet 4 $0

biosupp liquid 4 $0

free 300 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

biovol syrup 4 $0

mg(1500mg) -200 unit 4 $0

mg(2500 mg)-800 unit 4 $0

125 mg-unit

(Oyster Shell +

D3) 4 $0

(1250mg) -600 unit (Os-Cal 500 + D3) 4 $0

mg-unit 4 $0

mg(1500mg) -200 unit 4 $0

(Calcium 600 +

D(3)) 4 $0

800 unit

(Caltrate with

Vitamin D3) 4 $0

iron15 ml 4 $0

300-250 mg-mcg-mcg 4 $0

mcg 4 $0

400 mg-mcg 4 $0

iron15 ml 4 $0

04-300-250 mg-mcg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg 4 $0

400 mg-mcg 4 $0

600-300 mcg 4 $0

400 mg-mcg 4 $0

mg-mcg 4 $0

250 mg-mcg-mcg 4 $0

iron15 ml 4 $0

mg-mcg 4 $0

iron 4 $0

compete tablet 4 $0

250 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

free 100 mg 4 $0

Vitamin C) 4 $0

shell 500 mg(1250mg) -125 unit 4 $0

pf 500 mg(1250mg) -200 unit 4 $0

800 unit

(Caltrate with

Vitamin D3) 4 $0

200 mcg 4 $0

iron) 4 $0

free 200 mcg 4 $0

300-250 mg-mcg-mcg 4 $0

mcg 4 $0

mg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

600-300 mcg 4 $0

400 mg-mcg 4 $0

pf 4 $0

mg 4 $0

unit 4 $0

coated 4 $0

400 mg-mcg 4 $0

lactose-free 4 $0

400 mg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

sf 400 unit 4 $0

unitml 4 $0

ellis tonic 4 $0

mg 4 $0

TABLET 750 MG 4 $0

iron 4 $0

300-250 mg-mcg-mcg 4 $0

free 18-400 mg-mcg 4 $0

400-20-300 mcg 4 $0

mg-mcg-mcg 4 $0

mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

iron) 4 $0

mg iron) 4 $0

mg iron 4 $0

mg 4 $0

iron) 4 $0

mg iron)

(Ferate) 4 $0

(60 mg iron)5 ml 4 $0

(65 mg iron) 4 $0

(Feosol) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

iron 4 $0

(otc) 1 mg 4 $0

free 04-300-250 mg-mcg-mcg 4 $0

300-250 mg-mcg-mcg 4 $0

hair vitamins 4 $0

mg (106 mg iron) 4 $0

mg-mcg-mcg 4 $0

mg-mcg 4 $0

free 18-400 mg-mcg 4 $0

free 400 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

iron) 4 $0

mg iron 4 $0

kpn tablet 4 $0

mg-mcg 4 $0

mg5 ml 4 $0

7160 UNIT-113 MG-100 UNIT 4 $0

mcg 4 $0

MG 3 $0

mg-mcg 4 $0

mcg-80 mcg 4 $0

mg-mcg 4 $0

iron5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

VitaminsIron) 4 $0

CHEWS) 4 $0

iron15 ml 4 $0

Vitamin) 4 $0

025 mgml 4 $0

childrens 4 $0

mg-mg-mcg-mg 3 $0

mg-mcg 3 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

mcg 4 $0

400 mg-mcg 4 $0

mg-mcg 4 $0

mcg 4 $0

400 mg-mcg 4 $0

iron-400 mcg 4 $0

mg(1250mg) -200 unit 4 $0

mg(1250mg) -400 unit 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

-400 unit

mg(1250mg) -400 unit 4 $0

ALL RX PRENATAL

VITAMINS

COVERABLE

UNDER PART D

iron 4 $0

mg-unitml 4 $0

400 unit-10 mgml 4 $0

unit-mg-unitml 4 $0

800 mcg 4 $0

iron- 800 mcg 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Prenatal) 4 $0

iron- 08 mg 4 $0

ALL RX PRENATAL

VITAMINS

COVERABLE

UNDER PART D

800 mcg 4 $0

unit 4 $0

mgml 3 $0

mg iron 4 $0

04 mg 4 $0

250 mg-mcg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg 4 $0

mg(1250mg) -200 unit 4 $0

mg 4 $0

mcg 4 $0

mg 4 $0

mcgml 4 $0

500 mg 4 $0

mcg 3 $0

iron- 08 mg 4 $0

mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

500-300-250 mg-mcg-mcg-mcg 4 $0

mcg-mcg 4 $0

CHEWS) 4 $0

chewable 4 $0

gluten-free

(Super B Complex-

Vitamin C) 4 $0

300-250 mg-mcg-mcg 4 $0

gluten-free 4 $0

VitaminsIron) 4 $0

Vitamin) 4 $0

mg 4 $0

mcg 4 $0

iron- 800 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

600-300 mcg 4 $0

sodfluorid)ml

400 mcg- 18 mg iron 4 $0

400 mcg- 27 mg iron 4 $0

25 mcg 4 $0

600 mg(1500mg) -400 unit

(Calcium 600 +

D(3)) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

support liquid 4 $0

iron-667 mcg-1000 mcg 4 $0

thera caplet 4 $0

mcg 4 $0

thera-m caplet 4 $0

iron-400 mcg 4 $0

mcg 4 $0

iron-400 mcg 4 $0

pfcaplet 4 $0

pf 4 $0

therems tablet 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

unitml 4 $0

mg-unitml 4 $0

50000 unit 3 $0

orangesf 4 $0

400 mcg- 18 mg iron 4 $0

mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

400 mcg 4 $0

mg 4 $0

250 mg 4 $0

mg 4 $0

500 mg 4 $0

unit 4 $0

1000 unit 4 $0

unit 4 $0

2000 unit (D3 DOTS) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

unit 4 $0

unit5 ml 4 $0

5000 unit

(Dialyvite Vitamin

D) 4 $0

5000 UNITML

400 unit 4 $0

mcg-mcg-mcg 4 $0

250 mcg 4 $0

mcg 3 $0

1333 mg-unit 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

1ST TIER UNILET

COMFORTOUCH 135

3 3 day vaginal 57

3-day vaginal 53

A a thru z 214

a thru z select 214

abacavir 76

abc plus 214

ABELCET 54

ABILIFY MAINTENA 71

ABRAXANE 30

ABREVA 64

acamprosate 16

acarbose 49

ACCU-CHEK MULTICLIX

LANCET 135

PLUS 136

ACCU-CHEK SOFTCLIX

LANCETS 136

acebutolol 94

acephen 3

acetazolamide 198

acetic acid 154 193

acetylcysteine 210

acid controller 159

acitretin 127

acne medication 127

ACNE MEDICATION 128

acta-tabs pe 62

ACTEMRA 182

ACTHIB (PF) 187

ACTIMMUNE 195

acyclovir 81 128

ADACEL(TDAP

ADAGEN 148

adapalene 135

ADCIRCA 213

adefovir 82

ADEMPAS 213

adriamycin 30

adrucil 30

adults 50 plus 215

ADVAIR DISKUS 206

ADVAIR HFA 206

ADVANCED TRAVEL

LANCETS 136

ADVIL 11

ADVOCATE LANCET 136

afeditab cr 100

AFINITOR 30

AFINITOR DISPERZ 30

aftera 110

a-hydrocort 176

AKTEN (PF) 150

AKYNZEO 66

ala-cort 132

alavert 58

ALBENZA 68

alclometasone 132

ALCOHOL PADS 128

ALDURAZYME 148

ALECENSA 30

alendronate 193 194

aler-cap 58

aler-tab 58

alfuzosin 173

ALIMTA 30

ALINIA 68

ALIQOPA 30

aller-chlor 58

allergy medicine 62

allerhist-1 58

aller-tec d 58

allopurinol 57

almacone 161

almacone-2 161

alophen 167

alosetron 192

ALPHAGAN P 198

alprazolam 18

ALREX 157

altamist 150

altavera (28) 110

ALUNBRIG 31

alyacen 135 (28) 110

alyacen 777 (28) 110

amabelz 175

amantadine hcl 69

ambi 20dm-4cpm 118

ambi 60pse-4cpm 58

AMBISOME 54

amethia 110

amethia lo 110

amiloride 101

AMINO ACIDS 15 85

AMINOSYN 10 86

AMINOSYN 7 WITH

ELECTROLYTES 86

AMINOSYN 85 86

AMINOSYN 85 -

ELECTROLYTES 86

AMINOSYN II 10 86

AMINOSYN II 15 86

AMINOSYN II 7 86

AMINOSYN II 85 86

AMINOSYN II 85 -

ELECTROLYTES 86

AMINOSYN M 35 86

AMINOSYN-HBC 7 86

AMINOSYN-PF 10 87

AMINOSYN-PF 7

(SULFITE-FREE) 87

AMINOSYN-RF 52 87

amiodarone 94

AMITIZA 161

amitriptyline 46

amlactin 128

amlodipine 100

amoxapine 46

amoxicillin 26

amphotericin b 54

ampicillin 27

AMPYRA 106

ANADROL-50 174

anagrelide 85

anastrozole 31

ANDRODERM 174

ANDROGEL 174

androxy 174

animal chews 215

ANORO ELLIPTA 208

anti-diarrheal 163

antifungal cream 54

antihistamine 58

antioxidant 215

apatate forte 215

APOKYN 69

apraclonidine 150

aprepitant 66

apri 110

APRISO 192

aprodine 58

APTIOM 41

APTIVUS 76

aquanil hc 132

aranelle (28) 110

ARCALYST 182

aripiprazole 71

ARISTADA 71

armodafinil 211

ARNUITY ELLIPTA 206

ARTIFICIAL TEARS

(PETROMIN) 150

ashlyna 110

aspirin 12 14

aspirin buffered 12

aspir-low 12

aspir-trin 12

ASSURE HAEMOLANCE

PLUS 136

ASSURE ID INSULIN

SAFETY 136

ASSURE LANCE 137

ASTAGRAF XL 182

atenolol 95

athenol 10

atomoxetine 106

atorvastatin 103

atovaquone 68

ATRIPLA 76

atropine 41 150

ATROVENT HFA 208

AUBAGIO 106

aubra 110

AUSTEDO 106

AVASTIN 31

AVC VAGINAL 64

aviane 110

AVONEX 107

ayr saline 150

azacitidine 31

azathioprine 182

azelastine 150 151

azithromycin 24

aztreonam 25

azurette (28) 110

B b complete 215

b complex 1 215

b complex 100 230

215 222 230

b-12 dots 215

baby ddrops 215

baclofen 211

bal b-100 218

bal b-50 218

balance b-100 215

balance b-50 215

balsalazide 192

balziva (28) 110

banophen 58

banophen allergy 58

BANZEL 41

BAVENCIO 31

BAXDELA 28

baza antifungal 54

b-complex 227

218 229 232 233

BD INSULIN SYRINGE

ULTRA-FINE 137

NEEDLES 137

bee-zee 215

bekyree (28) 110

BELBUCA 3

BELEODAQ 31

BELSOMRA 211

benadryl allergy 58

benazepril 92

BENDEKA 31

BENLYSTA 196

benzonatate 118 119

benztropine 69

BESPONSA 31

BETADINE 128

beta-hc 132

BETASERON 107

betaxolol 95 198

BETHKIS 19

BEVYXXA 82

bexarotene 31

BEXSERO 187

bicalutamide 31

bicarsim forte 158

BICILLIN C-R 27

BICILLIN L-A 27

BIDIL 105

bio-dtuss dmx 119

bion tears (pf) 151

biosupp 215

biotin 215

biovol 216

bisac-evac 167

bisacodyl 167

biscolax 167

bismatrol 161

bismuth 163

bleomycin 31

bleph-10 154

BLINCYTO 31

blisovi 24 fe 111

blisovi fe 1530 (28) 111

blisovi fe 120 (28) 111

BOOSTRIX TDAP 187

BOSULIF 31

BREO ELLIPTA 206

briellyn 111

BRILINTA 85

brimonidine 198

BRIVIACT 41

bromfed dm 119

bromocriptine 69

dm 118 119

BROMSITE 157

brotapp dm 119

budesonide 192 206

buffered aspirin 15

bufferin 12

LANCETS 137

bumetanide 101

BUNAVAIL 16

BUPHENYL 161

buprenorphine 4

bupropion hcl 46

buspirone 18

BUTRANS 4

BYSTOLIC 95

BYVALSON 95

C cabergoline 69

CABOMETYX 31

bor 201 205

calci-chew 161

calcidol 216

calcipotriene 128

calcitrate 199

calcitrene 128

calcitriol 128 194

calcium 500 + d 218

calcium 500 + d (d3) 218

calcium 600 199 205

calcium 600 + d(3) 200 216

199 202

calcium acetate 172

calcium antacid 162

199 200 216 218 230

CALCIUM CARBONATE-

VITAMIN D3 200

201 205

calcium+d 234

CALDOLOR 12

CALQUENCE 31

camila 111

camrese 111

camrese lo 111

CANASA 192

CANCIDAS 54

candesartan 91

capacet 4

CAPASTAT 65

CAPRELSA 32

captopril 93

CARAFATE 159

CARBAGLU 162

carbamazepine 41

CAREONE ULTRA THIN

LANCET 137

CARETOUCH TWIST

LANCET 138

CARIMUNE NF

NANOFILTERED 182

carisoprodol 211

carteolol 198

cartia xt 96

carvedilol 95

caspofungin 54

CASTELLANI PAINT

MODIFIED 128

CAYSTON 26

caziant (28) 111

cefaclor 22

cefadroxil 22

cefazolin 22

cefdinir 22

CEFEPIME 22

CEFEPIME IN

DEXTROSEISO-OSM 22

cefotaxime 23

cefoxitin 23

cefpodoxime 23

cefprozil 23

ceftazidime 23

ceftibuten 23

ceftriaxone 23

celecoxib 12

CELONTIN 42

centamin 216

centergy dm 119

central-vite 228

centram-care 216

centrum 216

centrum silver 216

centrum women 217

century 217

cephalexin 24

CERDELGA 148

CEREZYME 148

cerovite 217

cerovite jr 217

cerovite senior 217

cetiri-d 62

cetirizine 59

CETYLEV 196

cevimeline 127

CHANTIX 16

CHANTIX CONTINUING

MONTH BOX 16

CHANTIX STARTING

MONTH BOX 16

chewable-vite 217

CHILDRENS ADVIL 12

childrens mapap 5

childrens pepto 162

CHILDRENS ZYRTEC

ALLERGY 59

childsiron 217

chlorhist 59

chlorothiazide 101

chlorpromazine 71

chlorthalidone 101

chlorzoxazone 211

219 233 234

CHOLECALCIFEROL

(VITAMIN D3) 234

ciclopirox 54

cilostazol 85

cimetidine 159

cimetidine hcl 159

CIMZIA 182

CIMZIA POWDER FOR

RECONST 182

CINQAIR 210

CINRYZE 83

CIPRODEX 154

ciprofloxacin 29

citalopram 46

citrus calcium 200

clarithromycin 25

clearlax 171

CLEVIPREX 101

clindamycin hcl 20

130 131

CLINIMIX 5D15W

SULFITE FREE 87

CLINIMIX 5D25W

SULFITE-FREE 87

CLINIMIX 275D5W

SULFIT FREE 87

FREE 87

CLINIMIX 425D5W

SULFIT FREE 87

CLINIMIX 425-D20W

SULF-FREE 87

CLINIMIX 425-D25W

SULF-FREE 87

CLINIMIX 5-

CLINIMIX E 275D10W

SUL FREE 88

CLINIMIX E 275D5W

SULF FREE 88

CLINIMIX E 425D10W

SUL FREE 88

CLINIMIX E 425D25W

SUL FREE 88

CLINIMIX E 425D5W

SULF FREE 88

CLINIMIX E 5D15W

SULFIT FREE 88

CLINIMIX E 5D20W

SULFIT FREE 88

CLINIMIX E 5D25W

SULFIT FREE 88

CLINISOL SF 15 88

clobetasol 132

clofarabine 32

clomipramine 46

clonazepam 18

clonidine 91

clonidine hcl 91

clopidogrel 85

clotrimazole 54

clotrimazole-7 54

clozapine 71 72

COARTEM 68

codeine sulfate 5

COLCRYS 57

cold-flu relief 120

colestipol 103

colocort 192

COLOR LANCETS 144

col-rite 171

COLY-MYCIN S 155

COMBIGAN 198

COMBIPATCH 175

COMETRIQ 32

comfort gel 162

COMFORT LANCETS 138

compete 217

COMPLERA 76

complete 229

complete 50+ 222

complete multi 217

220 229

complete women 222

compoz 60

compro 66

CONDYLOX 128

congestac 120

congest-eze 120

constulose 162

COPAXONE 107

coricidin hbp 120

CORLANOR 97

cormax 132

cortaid 132

cortisone 176

COTELLIC 32

cough syrup dm 122

CREON 149

CRIXIVAN 76

cromolyn 151 210

cryselle (28) 111

CUPRIMINE 173

215 219 228 232 233

cyclafem 135 (28) 111

cyclafem 777 (28) 111

cyclobenzaprine 211

cyclopentolate 151

cyclophosphamide 32

CYCLOPHOSPHAMIDE 32

CYCLOSET 49

cyclosporine 182

cyproheptadine 60

CYRAMZA 32

cyred 111

CYSTADANE 196

CYSTARAN 151

d3 dots 219

daily gummies 218

daily value 219

daily vitesiron 219

dailyhist-1 60

daily-vite 219

DAKLINZA 80

DALIRESP 210

danazol 174

dantrolene 211

dapsone 65

DAPTACEL (DTAP

PEDIATRIC) (PF) 187

daptomycin 20

DARAPRIM 69

DARZALEX 32

dasetta 135 (28) 111

dasetta 777 (28) 111

dayhist 60

dayhist allergy 60

daysee 111

day-time cough 121

deblitane 111

decitabine 32

deep sea nasal 151

deferoxamine 174

delta d3 220

delyla (28) 111

DELZICOL 193

DEMSER 97

DEPEN TITRATABS 174

DEPO-PROVERA 181

dermafungal 55

DERMAREST ECZEMA

(PRAMOXINE) 133

DESCOVY 76

desipramine 46

desmopressin 178

desoximetasone 133

guaif) 121

dex4 glucose 88

phosphate 157 177

dextroamphetamine-

amphetamine 107

diamode 163

DIASTAT 18

DIASTAT ACUDIAL 18

diazepam 18

dicloxacillin 27

dicyclomine 163

didanosine 76

DIFICID 25

diflunisal 13

digitek 98

digox 98

digoxin 98 99

DIGOXIN 98

DILANTIN 42

dilt-cd 96

diltiazem hcl 96 97

dilt-xr 97

dimaphen (pe) 60

dimaphen dm 121

dimenhydrinate 66

(CPM-DM) 121

dino-life 220

DIPENTUM 193

diphedryl 60

diphenhist 60

dipyridamole 85

disulfiram 16

divalproex 42

dobutamine 99

docu 168

docusate sodium 168

docusol 168

dofetilide 94

dok 168

dok plus 168

donepezil 45

dopamine 99

dorzolamide 198

doxazosin 91

doxepin 46 47

doxercalciferol 194

doxorubicin 32

doxy-100 29

dramamine 66

driminate 66

dronabinol 66

droperidol 196

DROPLET LANCETS 138

DROXIA 32

DUAVEE 175

DULERA 207

duloxetine 47

DUPIXENT 129

DUREZOL 157

dutasteride 173

d-vi-sol 220

E ec prin 13

ees 400 25

ees granules 25

EASY TOUCH SAFETY

LANCETS 138

EASY TOUCH TWIST

LANCETS 138 139

EASY TWIST AND CAP

LANCETS 139

econazole 55

econtra ez 112

ecotrin 13

ed a-hist 61

ed bron gp 121

ed chlorped jr 61

EDARBI 92

EDARBYCLOR 92

EDURANT 76

EFFIENT 85

ELAPRASE 149

eldertonic 220

ELIDEL 133

ELIGARD 33

elinest 112

eliphos 172

ELIQUIS 82

ELITEK 149

ELLA 112

ellis tonic 220

ELMIRON 196

EMBRACE LANCETS 139

EMCYT 33

EMEND 66

EMFLAZA 177

emoquette 112

EMPLICITI 33

EMSAM 47

EMTRIVA 76

enalaprilat 93

ENBREL 182 183

ENDARI 196

endocet 5

endur-acin 103

endur-amide 220

ENDUR-AMIDE 220

enema 171

enemeez 168

enemeez plus 168

ENGERIX-B (PF) 188

enoxaparin 82

enpresse 112

enskyce 112

entacapone 70

entecavir 82

ENTRESTO 92

enulose 163

ENVARSUS XR 183

EPCLUSA 80

epinastine 151

epinephrine 99

EPIPEN 99

EPIPEN 2-PAK 99

EPIPEN JR 2-PAK 100

epitol 42

EPIVIR HBV 76

eplerenone 105

EPOGEN 84

eq gentle 151

equalactin 168

ergoloid 196

ERGOMAR 64

ERIVEDGE 33

errin 112

ery pads 131

ERYPED 200 25

ERYPED 400 25

ery-tab 25

ERY-TAB 25

ERYTHROCIN 25

erythromycin 25 155

ESBRIET 210

esmolol 95

essentia 220

essential daily 220

estarylla 112

ESTRACE 175

estradiol 175

estropipate 176

eszopiclone 212

ethambutol 65

ethosuximide 42

etodolac 13

ETOPOPHOS 33

etoposide 33

EUCRISA 133

EVOTAZ 76

exemestane 33

EXJADE 174

EXONDYS 51 196

expectorant 121

expectorant dm 121

EXTAVIA 107

ezetimibe 103

F FABRAZYME 149

fallback solo 112

falmina (28) 112

famciclovir 82

famotidine 160

famotidine (pf) 159

FANAPT 72

FARESTON 33

FARYDAK 33

FASENRA 210

FASLODEX 33

felbamate 42

felodipine 101

FEMRING 176

femynor 112

fenofibrate 103

fenofibric acid 103

fenoprofen 13

fentanyl 6

fentanyl citrate 6

feosol 221

ferate 221

ferocon 221

ferretts 221

ferrex 150 221

ferrex 150 plus 221

ferric x-150 221

FERRIPROX 174

ferrocite 221

FETZIMA 47

feverall 6

fexofenadine 61

FIASP 52

FIASP FLEXTOUCH 51

fiber smooth 171

fiber-lax 169

FIFTY50 SAFETY SEAL

LANCETS 139

finasteride 173

FINE 30 UNIVERSAL

LANCETS 139

FIRAZYR 100

FLEBOGAMMA DIF 183

flecainide 94

FLECTOR 129

FLEET BISACODYL 169

FLOVENT DISKUS 207

FLOVENT HFA 207

floxuridine 33

flu hbp 122

fluconazole 55

flucytosine 55

fludrocortisone 177

flumazenil 107

flunisolide 157

fluocinolone 133

fluocinonide 133

fluocinonide-e 133

fluorometholone 157

fluorouracil 33 129

fluoxetine 47

fluphenazine hcl 72

flurbiprofen 13

flutamide 33

fluticasone 133 157

fluvoxamine 47

folic acid 222

fomepizole 196

fondaparinux 82 83

foot and sneaker 55

formula 3 55

FORTEO 194

fosamprenavir 76

foscarnet 79

fosfree 222

fosinopril 93

fosphenytoin 42

FREAMINE HBC 69 89

FREAMINE III 10 89

STRIPS 140

FREESTYLE TEST 140

fungi cure 55

fungoid-d 55

furosemide 102

FUZEON 76

FYCOMPA 42

G gabapentin 42

GABITRIL 42

galantamine 45

GAMASTAN SD 183

MCGML) 183

GAMMAPLEX 183

GAMMAPLEX (WITH

SORBITOL) 183

GARDASIL (PF) 188

GARDASIL 9 (PF) 188

gas relief 158

gas relief 80 158

gatifloxacin 155

GATTEX 30-VIAL 163

GAUZE PAD 140

gavilyte-c 169

gavilyte-g 169

gavilyte-n 169

GAZYVA 33

gemfibrozil 103

generlac 163

gengraf 183

GENOTROPIN 178

gentak 155

GENTEAL GEL 152

GENTEAL MILD 152

GENTEAL SEVERE 152

genteal tears 152

HPM-GLY) 152

gentlelax 169

GENVOYA 77

GEODON 72

geriaton 222

geri-dryl 61

geri-hydrolac 129

geri-tussin dm 122

gianvi (28) 112

gildagia 112

GILENYA 107

GILOTRIF 33

glatiramer 107

glatopa 108

GLEOSTINE 33

glimepiride 53

glipizide 53

GLUCAGEN HYPOKIT 49

GLUCAGON EMERGENCY

KIT (HUMAN) 49

gluco burst 89

glucose 89

glucose gel 89

glutose 15 89

glyburide 53

glycolax 169

glycopyrrolate 164

glydo 15

GLYXAMBI 49

GMATE LANCETS 140

GOCOVRI 70

granisetron (pf) 66

granisetron hcl 67

GRANIX 84

guaifenesin 122

guanfacine 91 108

guanidine 196

H HAEGARDA 84

hair vitamins 222

haloperidol 73

HARVONI 80

HAVRIX (PF) 188

HEALTHY ACCENTS

UNILET LANCET 140

healthylax 169

heather 112

hemocyte 222

HEPATAMINE 8 89

HERCEPTIN 34

HETLIOZ 212

HEXALEN 34

hi-b complex 222

HIBERIX (PF) 188

honey bears 222

HUMATROPE 178

HUMIRA 184

HUMIRA PEDIATRIC

CROHNS START 183

HUMIRA PEN 184

HS START 183

UVEITIS 184

KWIKPEN 52

HUMULIN R U-500

(CONCENTRATED) 52

hydralazine 100

hydromorphone 6 7

hydroskin 133

hydroxyurea 34

hydroxyzine hcl 61

HYQVIA 184

HYSINGLA ER 7

I ibandronate 194

IBRANCE 34

ibuprofen 12 13 15

icaps plus 222

ICLUSIG 34

IDHIFA 34

iferex 150 222

ifosfamide 34

ifosfamide-mesna 34

ILARIS (PF) 184

ILEVRO 157

imatinib 34

IMBRUVICA 34

IMFINZI 34

imipramine hcl 47

imiquimod 129

IMLYGIC 34

imodium a-d 164

IMODIUM A-D 164

(PF) 188

IMPAVIDO 69

LANCETS 140

INCRELEX 179

INCRUSE ELLIPTA 208

indapamide 102

indomethacin 13 14

infants advil 14

INFLECTRA 184

INGREZZA 108

INLYTA 34

INSECT REPELLENT

(PICARIDIN) 129

insta-glucose 89

U-100 140 141

INTELENCE 77

intense cough 122

INTRALIPID 90

INTRON A 81

introvale 112

INVANZ 26

INVEGA SUSTENNA 73

INVEGA TRINZA 73

INVIRASE 77

INVOKAMET 49

INVOKAMET XR 49

INVOKANA 50

inzo antifungal 55

iodine 148

IPOL 189

IPRIVASK 83

irbesartan 92

IRESSA 35

iron 223

ISENTRESS 77

ISENTRESS HD 77

isibloom 112

ISOLYTE-P IN 5

DEXTROSE 202

ISOLYTE-S 202

isoniazid 65

isopto tears 152

isradipine 101

itraconazole 55

ivermectin 69

IXEMPRA 35

IXIARO (PF) 189

J JADENU 174

JADENU SPRINKLE 174

JAKAFI 35

jantoven 83

JANUMET 50

JANUMET XR 50

JANUVIA 50

JARDIANCE 50

jencycla 112

JENTADUETO 50

JENTADUETO XR 50

jolessa 112

jolivette 112

juleber 112

junel 1530 (21) 112

junel 120 (21) 113

junel fe 1530 (28) 113

junel fe 120 (28) 113

junel fe 24 113

junior mapap 7

JUXTAPID 103

K KABIVEN 90

KALETRA 77

KALYDECO 210

KANUMA 149

kariva (28) 113

kelnor 135 (28) 113

KENALOG 177

ketoconazole 55

ketoprofen 14

KEVEYIS 196

KEVZARA 184

KEYTRUDA 35

kids mini enema 167

kimidess (28) 113

KINERET 184

KINRIX (PF) 189

kionex 164

KISQALI 35

klor-con m10 202

klor-con m15 202

klor-con m20 202

kobee 223

konsyl (sugar) 169

konsyl fiber 169

KORLYM 50

kpn 223

KRYSTEXXA 149

kurvelo 113

KUVAN 149

KYNAMRO 104

KYPROLIS 35

labetalol 95

LACRISERT 152

LACTINOL HX 129

lactulose 164

lamisil af 55 56

LAMISIL AT 56

lamivudine 77

lamotrigine 42 43

LANCETS 136 137 138 139

141 142 144

LANCETSTHIN 141 145

LANOXIN 100

lansoprazole 160

LANTUS 52

LANTUS SOLOSTAR 52

larin 1530 (21) 113

larin 120 (21) 113

larin 24 fe 113

larin fe 1530 (28) 113

larin fe 120 (28) 113

larissia 113

LARTRUVO 35

latanoprost 198

LATUDA 73

LAZANDA 7

leena 28 113

leflunomide 184

LEMTRADA 108

LENVIMA 35

lessina 113

LETAIRIS 213

letrozole 35

LEUKERAN 35

LEUKINE 84

leuprolide 36

levetiracetam 43

levobunolol 198

levocarnitine 197

levocetirizine 61

levofloxacin 29 155

levoleucovorin 197

LEVOLEUCOVORIN 197

levonest (28) 113

levonorgestrel 114

levora-28 114

levothyroxine 181

LEXIVA 77

LIALDA 193

lice killing 135

lice treatment 135

lidocaine 15

lidocaine hcl 15

lillow 114

linezolid 20 21

LINZESS 164

liothyronine 181

liquibid d-r 122

liquid c 223

lisinopril 93

lithium citrate 108

little animals 223

little remedies 152

LIVALO 104

lohist-dm 122

lomedia 24 fe 114

LONSURF 36

loperamide 163 164

lopreeza 176

lorata-d 62

loratadine 59 61 62

loratadine-d 60 61

lorazepam 18

lorcet hd 7

lorcet plus 7

loryna (28) 114

losartan 92

LOTEMAX 158

lovastatin 104

lubricant eye 151

lubricant gel 151

lubrifresh pm 152

LUMIGAN 199

LUPRON DEPOT 36

LUPRON DEPOT-PED (3

MONTH) 179

lutera (28) 114

LYNPARZA 36

LYRICA 43

lysiplex plus 223

LYSODREN 36

lyza 114

mag 64 202

mag-delay 202

mag-g 202

magnesium 200 205

malathion 135

maprotiline 48

marlissa 114

MARPLAN 48

masophen 8

MATULANE 36

matzim la 97

MAVYRET 80

meclizine 67

medi-bismuth 165

medi-meclizine 67

medi-natural 169

medi-phedrine 122

MEDI-PHENYL 91

mefenamic acid 14

mefloquine 69

MEFOXIN IN DEXTROSE

(ISO-OSM) 24

megestrol 36 181

MEKINIST 36

meloxicam 14

memantine 45

MENACTRA (PF) 189

MENEST 176

MENHIBRIX (PF) 189

MENOMUNE - ACYW-135

(PF) 189

mens one daily 220

(PF) 189

MEPHYTON 223

mercaptopurine 36

meropenem 26

mesalamine 193

mesna 197

MESNEX 197

MESTINON 197

metaproterenol 208

metformin 50

methadone 8

methadose 8

methazolamide 199

methimazole 181

methocarbamol 211

methoxsalen 129

methscopolamine 165

metipranolol 199

metolazone 102

mexiletine 94

mgo 165

MIACALCIN 194

mi-acid 165

micatin 56

miconazole 7 56

miconazole-3 56

MICROLET LANCET 141

midodrine 91

miglitol 50

milrinone 100

mimvey 176

mimvey lo 176

MINERAL OIL 197

minitran 106

minocycline 30

minoxidil 106

mintox 165

mintox plus 165

MIRCERA 84

mirtazapine 48

misoprostol 160

mitoxantrone 37

M-M-R II (PF) 189

moexipril 93

molindone 73

mometasone 134

MONISTAT 3 56

monistat 7 56

MONOLET LANCETS 141

mono-linyah 114

mononessa (28) 114

montelukast 207

morphine 8

MORPHINE 8

motion sickness 66

MOVANTIK 165

MOVIPREP 169

MOXEZA 155

moxifloxacin 29 155

MOZOBIL 84

mucus dm 122

mucus dm max 122

mucus relief dm 123

MULTAQ 94

multi for her 223

multi-delyn 223

multilex 224

mupirocin 131

muro 128 152

my way 114

MYGLUCOHEALTH

LANCETS 141

MYLOTARG 37

MYRBETRIQ 173

mytab gas 159

my-vitalife 224

myzilra 115

N nabumetone 14

nadolol 96

nafcillin 27

NAGLAZYME 149

naloxone 16

naltrexone 16

NAMENDA XR 45

NAMZARIC 45 46

naproxen 14

naratriptan 64

NARCAN 16

nasal relief 152

NASCOBAL 224

NATACYN 155

nateglinide 50

NATPARA 194

NATRAPEL 129

natural b-100 234

natural calcium 203

natura-lax 171

NEBUPENT 69

necon 0535 (28) 115

necon 150 (28) 115

necon 1011 (28) 115

necon 777 (28) 115

nefazodone 48

neomycin 19

dexameth 155

neomycin-polymyxin-

gramicidin 155

neo-polycin 156

neo-polycin hc 156

neo-tuss 123

nephplex rx 224

NEPHRAMINE 54 90

nephron fa 224

nephro-vite rx 224

NERLYNX 37

NEULASTA 84

NEUPOGEN 84

NEUPRO 70

nevirapine 77 78

NEXAVAR 37

niacin 104

niacinamide 104 224

niacor 104

nicardipine 101

nicorelief 16

NICORETTE 17

nicotine 17

NICOTROL 17

nifedipine 101

night time cold 123

nighttime cough 121

nikki (28) 115

nilutamide 37

NINLARO 37

nite time 125

NITRO-BID 106

nitroglycerin 106

NIX CREME RINSE 135

nohist-dm 123

non-aspirin 5 8 10

non-aspirin child 8

non-aspirin flu 126

nora-be 115

norlyda 115

norlyroc 115

NORMOSOL-M IN 5

DEXTROSE 203

nortemp 9

NORTHERA 91

nortrel 0535 (28) 115

nortrel 135 (21) 115

nortrel 135 (28) 115

nortrel 777 (28) 116

nortriptyline 48

NORVIR 78

nose spray 153

NOVOLIN 7030 52

NOVOLIN N 52

NOVOLIN R 52

NOVOLOG 52

NOVOLOG FLEXPEN 52

NOVOLOG MIX 70-30

FLEXPEN 52

NOVOLOG PENFILL 52

NOXAFIL 56

NUCALA 210

NUCYNTA 9

NUCYNTA ER 9

NUEDEXTA 109

nu-iron 224

NULOJIX 185

nu-mag 203

NUPLAZID 74

NUTRESTORE 165

NUTRILIPID 90

NUVARING 116

nyamyc 56

nyata 56

nystatin 56

nystop 57

nytol 62

O OCALIVA 165

ocean nasal 153

ocella 116

OCREVUS 109

OCTAGAM 185

ocutabs 224

ODEFSEY 78

ODOMZO 37

OFEV 210

off active 129

off deep woods 129

ofloxacin 29 156

ogestrel (28) 116

olanzapine 74

olmesartan 92

olopatadine 153

OLYSIO 80

omeprazole 160

OMNITROPE 180

ON CALL LANCET 142

ONCASPAR 37

onccor 224

once daily 224

oncovite 225

ondansetron 67

ondansetron hcl 67

one daily 225 228

ONETOUCH DELICA

LANCETS 142

ONETOUCH SURESOFT

LANCING DEV 142

ONETOUCH ULTRASOFT

LANCETS 142

ONFI 19

ONIVYDE 37

OPDIVO 37

OPSUMIT 213

option-2 116

oralone 127

oralyte 203

ORENCIA 185

ORENITRAM 213

ORFADIN 149

ORKAMBI 210

orsythia 116

oseltamivir 80

OTEZLA 185

OTEZLA STARTER 185

OTOVEL 153

OTREXUP (PF) 185

oxacillin 27

oxandrolone 175

oxcarbazepine 43

OXTELLAR XR 43

oxycodone 9

oxycodone-aspirin 9

OXYCONTIN 9 10

oxymorphone 10

oysco 500d 225

oysco-500 203

226 228

oystercal-d 226

P pacerone 94

pain and fever 10

pain relief 5

pain relief adult 5

paliperidone 74

PANRETIN 129

pantoprazole 160

paromomycin 69

paroxetine hcl 48

PASER 65

PAXIL 48

p-col rite 171

pecgen dmx 123

pedia relief 125

PEDIARIX (PF) 189

203 205

PEDVAX HIB (PF) 190

PEGANONE 43

PEGASYS 81

PEGASYS CONVENIENCE

PACK 81

PEGASYS PROCLICK 81

PEGINTRON 81

PENTACEL (PF) 190

PENTACEL DTAP-IPV

COMPNT (PF) 190

PENTAM 69

pentoxifylline 85

pep-t-med 165

peri-colace 170

PERIKABIVEN 90

periogard 127

permethrin 135

perphenazine 74

perry prenatal 226

persa-gel 129

pfizerpen-g 28

pharbetol 10

phenadoz 67

phenelzine 48

phenobarbital 43

phenytoin 43

phenytoin sodium 44

philith 116

phillips 165

PHOSLYRA 172

PICATO 129 130

pimozide 74

pimtrea (28) 116

pindolol 96

pink bismuth 166

pioglitazone 51

pirmella 116

piroxicam 14

PLASMA-LYTE 148 203

PLASMA-LYTE A 203

PLASMA-LYTE-56 IN 5

DEXTROSE 203

PLEGRIDY 109

podofilox 130

polycin 156

poly-iron 226

poly-vita 226

poly-vitamin 226

poly-vitamins 226

POMALYST 37

portia 116

PORTRAZZA 37

POTIGA 44

PRADAXA 83

PRALUENT PEN 104

pramipexole 70

prasugrel 85

pravastatin 104

prazosin 91

prednicarbate 134

158 177

prednisone 177 178

PREMARIN 176

PREMASOL 10 90

PREMASOL 6 90

PREMPHASE 176

PREMPRO 176

prenatal tablet 228

PRESSURE ACTIVATED

LANCETS 142

prevalite 104

previfem 116

PREZCOBIX 78

PREZISTA 78

PRIFTIN 65

PRILOSEC OTC 160

PRIMAQUINE 69

primidone 44

PRIVIGEN 185

PROAIR HFA 208

probenecid 58

procainamide 94

PROCALAMINE 3 90

prochlorperazine 67

PROCRIT 84 85

procto-med hc 134

procto-pak 134

proctosol hc 134

proctozone-hc 134

PROCYSBI 149

PRODIGY LANCETS 143

PRODIGY TWIST TOP

LANCET 143

PROGLYCEM 197

PROGRAF 186

PROLASTIN-C 210

PROLENSA 158

PROLEUKIN 37

PROLIA 195

PROMACTA 85

promethazine vc 62

promethazine-dm 123

promethegan 68

promolaxin 170

propafenone 94

propantheline 41

proparacaine 153

propranolol 96

PROQUAD (PF) 190

prosight 227

PROSOL 20 90

protamine 85

protriptyline 48

PULMOZYME 149

purelax 168

PURIXAN 37

PUSH BUTTON SAFETY

LANCETS 143

pyrazinamide 65

quasense 116

quetiapine 74

QUFLORA 227

quinapril 93

quinine sulfate 69

QVAR 207

R RABAVERT (PF) 190

RADICAVA 109

raloxifene 176

ramipril 94

RANEXA 100

RAPAMUNE 186

rasagiline 70

RASUVO (PF) 186

RAVICTI 166

RAYALDEE 195

react 116

READYLANCE SAFETY

LANCETS 143

REBIF REBIDOSE 109

reclipsen (28) 116

recort plus 134

refenesen 124

refenesen pe 124

REFRESH OPTIVE

ADVANCED 156

reguloid 171

RELIAMED LANCET 143

LANCETS 143

LANCETS 144

RELISTOR 166

REMICADE 186

REMODULIN 213

RENAGEL 172

rena-vite rx 228

RENFLEXIS 197

RENVELA 172

repaglinide 51

REPATHA SYRINGE 104

repel sportsmen 130

reprexain 10

RESCRIPTOR 78

RESTASIS 158

retaine cmc 153

retaine hpmc 153

retaine pm 153

RETROVIR 78

revive plus 151

REVLIMID 37

revonto 211

REXULTI 74

REYATAZ 78

ribasphere 82

ribavirin 82

RIDAURA 186

rifabutin 65

rifampin 65

RIFATER 65

ri-gel ii 166

riginic 166

riluzole 109

rimantadine 80

ri-mox 166

ringers 193 205

risedronate 195

RISPERDAL CONSTA 74

risperidone 74 75

RITUXAN 38

RITUXAN HYCELA 38

rivastigmine 46

rizatriptan 64

robafen 124

robafen cough 124

robafen dm 124

ropinirole 70

rosadan 131

rosuvastatin 105

ROTARIX 190

ROTATEQ VACCINE 190

ROWEEPRA 44

RUBRACA 38

RYDAPT 38

S SABRIL 44

safe tussin dm 124

SAFETY LANCETS 144

SAIZEN 180

saline mist 153

saline nasal 151

saline nose 151

SANTYL 130

SAVELLA 109

scopolamine base 68

scot-tussin dm 124

selegiline hcl 70

SELZENTRY 78

senexon 171

senexon-s 171

senior tabs 228

senna 171

senna lax 171

senna laxative 168

senokot-s 171

SENSIPAR 195

sentry 229

sentry senior 229

SEREVENT DISKUS 209

SEROSTIM 180

sertraline 48

setlakin 116

sharobel 116

SHINGRIX (PF) 191

SHINGRIX GE ANTIGEN

COMPONENT 191

SIGNIFOR 180

silace 171

siladryl sa 62

silapap 11

SILENOR 212

SILIQ 130

siltussin sa 125

SIMBRINZA 199

simethicone 159

SIMPONI 186

SIMPONI ARIA 186

simvastatin 105

SINGLE-LET 144

sirolimus 186

SIRTURO 65

skin treatment 129

SMARTEST LANCET 144

smoflipid 90

smoothlax 172

sochlor 154

sodium acetate 205

sodium lactate 206

SOLIQUA 10033 53

SOLTAMOX 38

SOMAVERT 180

sorbitol 193

sorine 96

sotalol 96

sotalol af 96

SOVALDI 80

SPIRIVA WITH

HANDIHALER 209

spironolactone 102

sprintec (28) 116

SPRITAM 44

SPRYCEL 38

sronyx 116

ssd 131

stavudine 78

STELARA 186

STERILANCE TL 145

STERILE PADS 145

STIVARGA 38

stomach relief 166

stool softener 172

STRENSIQ 149

streptomycin 19

stress b-biotin 230

stress formula 230

STRIBILD 79

SUBOXONE 17

sucralfate 161

SUDAFED 125

sudogest 125

sudogest pe 91

sulfadiazine 29

sulfasalazine 193

sulfatrim 29

sulindac 15

sumatriptan 64

sunvite 230

super bc 230

super multiple 231

super quints 231

superior 35 231

superplex-t 231

suphedrin 125

support 231

support-500 231

SUPPRELIN LA 180

SUPRAX 24

SURE-LANCE 145

SURMONTIL 48

SUSTIVA 79

SUTENT 38

syeda 116

SYLATRON 81

SYLVANT 38

SYMBICORT 207

SYMLINPEN 120 51

SYMLINPEN 60 51

SYNAGIS 80

SYNAREL 180

SYNERCID 21

SYNJARDY 51

SYNJARDY XR 51

SYNRIBO 38

SYPRINE 174

SYSTANE GEL 154

T tab-a-vite 231

tab-a-viteiron 231

TABLOID 38

tacrolimus 134 186

tactinal 11

TAFINLAR 38

TAGRISSO 38

TALTZ SYRINGE 130

TAMIFLU 80

tamoxifen 38

tamsulosin 173

TARCEVA 38

TARGRETIN 38

tarina fe 120 (28) 116

TASIGNA 39

tazarotene 135

tazicef 24

TAZORAC 135

taztia xt 97

tears again 154

TECENTRIQ 39

TECFIDERA 109 110

TECHNIVIE 80

TEFLARO 24

TEKAMLO 105

TEKTURNA 105

TEKTURNA HCT 105

TELCARE LANCETS 145

telmisartan 92

temazepam 19

TEMODAR 39

tencon 11

TENIVAC (PF) 191

terazosin 173

terbinafine hcl 57

terbutaline 209

terconazole 64

testosterone 175

PED(PF) 191

TETANUS-DIPHTHERIA

TOXOIDS-TD 191

tetrabenazine 110

THALOMID 198

theophylline 209

thera 231

thera-d 231

theradex m 231

thera-m 231

therapeutic-m 231

thera-tabs 231

thera-tabs m 231

therems 231

therems-m 232

THIN LANCETS 144

THIOLA 198

thioridazine 75

thiotepa 39

thiothixene 75

tiagabine 44

TICE BCG 191

tigecycline 30

tilia fe 116

TIVICAY 79

tizanidine 211

tl icon 232

TOBI PODHALER 20

TOBRADEX 156

TOBRADEX ST 156

tobramycin 157

TOLAK 130

tolazamide 53

tolbutamide 53

tolnaftate 57

tolterodine 173

TOPCARE UNIVERSAL1

LANCET 145

topiramate 44

toposar 39

torsemide 102

total bc 232

TOTECT 198

TOUJEO SOLOSTAR 53

TOVIAZ 173

TRACLEER 213

TRADJENTA 51

tramadol 11

trandolapril 94

tranexamic acid 85

TRANSDERM-SCOP 68

tranylcypromine 48

TRAVASOL 10 90

TRAVATAN Z 199

travel sickness 68

trazodone 49

TREANDA 39

TRECATOR 66

TRELEGY ELLIPTA 210

TRELSTAR 39

TREMFYA 130

tretinoin 135

TREXALL 39

tri femynor 116

tricon 232

tri-estarylla 117

trifluoperazine 75

trifluridine 157

trihexyphenidyl 70

tri-legest fe 117

tri-linyah 117

tri-lo-marzia 117

tri-lo-sprintec 117

trimethoprim 21

trimipramine 49

trinessa (28) 117

TRINTELLIX 49

triple paste af 57

TRIPTODUR 180

TRIUMEQ 79

tri-vi-sol 232

tri-vita 232

tri-vitamin 232

trivora (28) 117

TROKENDI XR 44

TROPHAMINE 10 90

TROPHAMINE 6 90

trospium 173

TRULICITY 51

TRUMENBA 191

TRUVADA 79

tusnel diabetic 126

TUSSI PRES-B 126

tussin cf 125 127

tussin dm 124 126

tussin dm max 125

TWINRIX (PF) 191

TYBOST 198

TYKERB 39

tylophen 11

TYMLOS 195

TYPHIM VI 192

TYSABRI 186

TYVASO 213

U UCERIS 193

ULORIC 58

ULTILET CLASSIC

LANCETS 146

ULTILET LANCETS 146

ultra fresh pm 154

ULTRA THIN PLUS

LANCETS 144

unicomplex-m 232

UNILET COMFORTOUCH

LANCET 147

UNILET EXCELITE II

LANCET 147

UNILET LANCET 147

UNILET SUPER THIN

LANCETS 147

unisom sleepgels 62

UNISTIK 3 COMFORT

LANCET 147

UNISTIK 3 NORMAL

LANCET 147

UNISTIK SAFETY 148

UNITUXIN 39

141 148

UPTRAVI 214

ursodiol 167

V vagistat-3 57

valacyclovir 82

VALCHLOR 130

valganciclovir 82

valproate sodium 44

valproic acid 45

valsartan 92

VALSTAR 39

vancomycin 22

VAQTA (PF) 192

VARIVAX (PF) 192

VASCEPA 105

v-c forte 232

VELCADE 39

VELPHORO 172

VELTASSA 167

VEMLIDY 79

VENCLEXTA 39 40

VENCLEXTA STARTING

PACK 40

venlafaxine 49

verapamil 97

VERSACLOZ 75

VERZENIO 40

VESICARE 173

vestura (28) 117

VGO 40 148

VIBERZI 167

vic-forte 232

RELIEF 126

VICTOZA 51

VIEKIRA PAK 80

VIEKIRA XR 80

vienva 117

vigabatrin 45

VIGAMOX 157

VIIBRYD 49

VIMIZIM 149

VIMPAT 45

vinorelbine 40

viorele (28) 117

VIRACEPT 79

VIREAD 79

vision 232

VISTOGARD 198

230 233

vitalets 232

vitamin a 232

vitamin b-1 218 232

vitamin b-6 233

vitamin c 228 233

vitamin d3 228 230 233 234

vitamin k 234

vitamin k1 234

vitatrum 234

vitrum senior 234

vol-care rx 234

VOLTAREN 130

voriconazole 57

VOSEVI 81

VOTRIENT 40

VPRIV 150

vp-vite rx 234

VRAYLAR 75

vyfemla (28) 117

VYXEOS 40

wal-dram 68

wal-dryl allergy 63

wal-fex allergy 63

wal-finate 63

wal-finate-d 63

wal-itin 59 63

wal-itin d 63

wal-phed 63 127

wal-phed pe 91

wal-profen 15

wal-sleep z 63

wal-tap 64

wal-tussin 127

wal-tussin dm 118

wal-zan 75 161

wal-zyr d 64

warfarin 83

WELCHOL 105

wera (28) 117

womans laxative 172

X XADAGO 71

XALKORI 40

XARELTO 83

XATMEP 40

XELJANZ 186

XELJANZ XR 187

XERMELO 167

XIFAXAN 22

XOLAIR 211

XTAMPZA ER 11

XTANDI 40

xulane 117

XULTOPHY 10036 53

XURIDEN 198

XYREM 212

Y yelets 234

YERVOY 40

YF-VAX (PF) 192

YONDELIS 40

yuvafem 176

Z zafirlukast 207

zaleplon 212

zantac 75 161

zarah 117

ZARXIO 85

ZAVESCA 150

zebutal 11

ZEJULA 40

ZELBORAF 40

zenatane 130

zenchent (28) 117

ZENPEP 150

ZEPATIER 81

zephrex-d 127

ZERIT 79

ZIAGEN 79

zidovudine 79

ZINBRYTA 110

zinc oxide 129 130

ZIOPTAN (PF) 199

ziprasidone hcl 75

ZIRGAN 157

ZOLADEX 40

zoledronic acid 195

ZOLINZA 40

zolmitriptan 65

zolpidem 212

ZOMACTON 180 181

ZOMETA 195

zonisamide 45

zoo chews 2

ZORBTIVE 181

ZORTRESS 187

ZOSTAVAX (PF) 192

zovia 135e (28) 117

zovia 150e (28) 118

z-sleep 61 62

ZUBSOLV 17

ZURAMPIC 58

ZYDELIG 41

ZYKADIA 41

ZYLET 157

zyncof 127

ZYPREXA RELPREVV 75

ZYRTEC 64

ZYTIGA 41

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Table of Contents

INDEX

1

3

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

(TTY 1-800-421-1220)

other formats)

1-800-368-1019 800-537-7697 (TDD)

800-421-1220)

am to 8 pm

rive 8 pm

de 8 am a 8 pm

pharmacy

711 or 1-800-421-1220

take now

drug For example

second

what to do next

on your drug

are covered

of this document

Restriction

PA BvD

Prior Authorization

Restriction

Part B vs Part D

Determination

Restriction for

New Starts Only

of this document

formulary

drug or product

day supply

heart conditions

Analgesics 3

Anesthetics 15

Antibacterials 19

Anticonvulsants 41

Antidepressants 46

Antifungals 53

Antigout Agents 57

Antihistamines 58

Table of Contents

Caloric Agents 85

Contraceptives 110

Devices 135

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Analgesics

120 mg 4 $0

QL (30 per 30 days)

325 mg 4 $0

QL (30 per 30 days)

650 mg 4 $0

QL (30 per 30 days)

(Mapap

mg (Acephen) 4 $0

QL (30 per 30 days)

childrens 80 mg

(Childrens

Acetaminophen) 4 $0

QL (30 per 30 days)

300-15 mg 1 $0

300-30 mg

(Tylenol-Codeine

3) 1 $0

300-60 mg

(Tylenol-Codeine

4) 1 $0

30-50-325-40 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

MCG 300 MCG 450 MCG 600

QL (60 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

03 mgml 1 $0

mcghour

(Butrans) 1 $0

QL (4 per 28 days)

capsule 30-50-325-40 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

capsule 50-300-40-30 mg 50-325-

40-30 mg

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

tablet 50-325-40 mg 1 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

BUTRANS TRANSDERMAL

PATCH WEEKLY 75

MCGHOUR

QL (4 per 28 days)

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml 4 $0

mg 4 $0

QL (30 per 30 days)

mg 4 $0

QL (30 per 30 days)

mg 4 $0

QL (30 per 30 days)

mg 60 mg 1 $0

caplet 650 mg

(8 Hour Pain

Reliever) 4 $0

650 mg 4 $0

mg 4 $0

QL (30 per 30 days)

mg 4 $0

mg15 ml 4 $0

325 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Actiq) 1 $0

PA QL (120 per 30

days) NDS

50 mcghr 75 mcghr

(Duragesic) 1 $0

QL (10 per 30 days)

QL (30 per 30 days)

inner 650 mg 4 $0

QL (30 per 30 days)

mg75ml(75ml)

tablet 5-325 mg

(Lorcet

(hydrocodone)) 1 $0

75-200 mg 1 $0

mgml 4 mgml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

HYSINGLA ER ORAL

TABLETORAL

120 MG 20 MG 30 MG 40 MG

60 MG 80 MG

QL (30 per 30 days)

mgml 4 $0

QL (30 per 30 days)

mg 4 $0

QL (30 per 30 days)

PA QL (30 per 30

days) NDS

325 mg 1 $0

ml 4 $0

mg5 ml 4 $0

500 mg 4 $0

mg15 ml 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml 1 $0

ml 5 mg5 ml 1 $0

100 mg5 ml (20 mgml) 1 $0

(4 mgml) 1 $0

MG 2 $0

QL (60 per 30 days)

QL (90 per 30 days)

mgml 1 $0

QL (30 per 30 days)

mg 4 $0

QL (30 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg15 ml 4 $0

mg08 ml 4 $0

QL (30 per 30 days)

MG 150 MG 200 MG 250 MG 50

QL (60 per 30 days)

MG 50 MG 75 MG 2 $0

mgml 1 $0

(OxyContin) 1 $0

QL (60 per 30 days)

48355-325 mg 1 $0

OXYCONTIN ORAL

TABLETORAL

MG 20 MG 30 MG 40 MG 60

QL (60 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

OXYCONTIN ORAL

TABLETORAL

30 mg 40 mg 5 mg 75 mg

QL (60 per 30 days)

mg5 ml 4 $0

caplet 500 mg 4 $0

QL (30 per 30 days)

ml 4 $0

QL (30 per 30 days)

meltssf 160 mg 4 $0

QL (30 per 30 days)

650 mg

(8 Hour Pain

Reliever) 4 $0

QL (30 per 30 days)

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg08 ml 4 $0

QL (30 per 30 days)

650 mg 4 $0

QL (30 per 30 days)

500 mg 4 $0

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

375-325 mg (Ultracet) 1 $0

XTAMPZA ER ORAL

QL (60 per 30 days)

XTAMPZA ER ORAL

TMPRR 27 MG

XTAMPZA ER ORAL

TMPRR 36 MG

PA-HRM QL (180 per

30 days) AGE (Max

64 Years)

Agents

CHEW TB CHEW8

HOURGRAPE 100 MG

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Adult Aspirin

Regimen) 4 $0

mg 4 $0

MGML) 800 MG8 ML (100

QL (60 per 30 days)

mg125 ml 4 $0

ML (OTC) 100 MG5 ML 4 $0

mg 4 $0

mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

50 mg 75 mg

mg-mcg

(Arthrotec 50) 1 $0

mg-mcg

(Arthrotec 75) 1 $0

coated 325 mg 4 $0

mg 1 $0

100 mg5 ml 4 $0

mg 4 $0

mg 800 mg 1 $0

PA-HRM QL (240 per

30 days) AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM QL (120 per

30 days) AGE (Max

64 Years)

release 75 mg 1 $0

PA-HRM QL (60 per

30 days) AGE (Max

64 Years)

mg125 ml 4 $0

ml 4 $0

mg 1 $0

PA-HRM QL (20 per

30 days) AGE (Max

64 Years)

ml 1 $0

mg 1 $0

ml (Naprosyn) 1 $0

mg 1 $0

mg (Feldene) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

orange 81 mg 4 $0

200 mg 4 $0

Anesthetics

Local Anesthetics

applicator 2 1 $0

mgml (1 ) 15 mgml (15 ) 20

mgml (2 ) 5 mgml (05 )

mgml (4 ) 1 $0

mgml (1 ) 20 mgml (2 ) 5

mgml (05 )

(Xylocaine) 1 $0

jelly 2 1 $0

PA QL (90 per 30

solution 2 1 $0

25-25 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Treatment Agents

03 MG 2 $0

QL (30 per 30 days)

07 MG 63-1 MG 2 $0

QL (60 per 30 days)

2 mg 8 mg 1 $0

QL (90 per 30 days)

tablet 2-05 mg 8-2 mg 1 $0

QL (90 per 30 days)

(Zyban) 1 $0

CHANTIX CONTINUING

MG 1 MG 2 $0

PACK 05 MG (11)- 1 MG (42)

QL (53 per 28 days)

mg (Antabuse) 1 $0

mgml 1 $0

mgml 1 mgml 1 $0

MGACTUATION

QL (4 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

NICOTROL INHALATION

12-3 MG 8-2 MG 2 $0

QL (60 per 30 days)

2-05 MG 4-1 MG 2 $0

QL (30 per 30 days)

ZUBSOLV SUBLINGUAL

TABLET 07-018 MG 14-036

MG 114-29 MG 29-071 MG

57-14 MG

QL (30 per 30 days)

ZUBSOLV SUBLINGUAL

QL (60 per 30 days)

Antianxiety Agents

Benzodiazepines

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

30 mg 5 mg 75 mg 1 $0

10 mg 25 mg 5 mg 1 $0

clonazepam oral

mg 05 mg 1 mg

QL (90 per 30 days)

clonazepam oral

15 mg 375 mg 1 $0

KIT 125-15-175-20 MG 5-75-10

5 mgml 1 $0

mgml) 1 $0

mg (Valium) 1 $0

QL (2 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MGML 2 $0

PA NSO QL (480 per

30 days) NDS

MG 2 $0

PA NSO QL (60 per

30 days) NDS

mg (Restoril) 1 $0

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any benzodiazepine

per 30 days) AGE

(Max 64 Years)

Antibacterials

Aminoglycosides

BETHKIS INHALATION

SOLUTION FOR

PA BvD NDS

mg6 ml 1 $0

ml 100 mg50 ml 120 mg100 ml

60 mg50 ml 70 mg50 ml 80

mg100 ml 80 mg50 ml 90 mg100

mgml 1 $0

soln 1 gram 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CAPSULE WINHALATION

DEVICE 28 MG

300 mg5 ml

(Tobi) 1 $0

PA BvD NDS

ml 600 mg50 ml 900 mg50 ml

(Cleocin in 5

dextrose) 1 $0

soln 75 mg5 ml 1 $0

recon soln 150 mg

(Coly-Mycin M

Parenteral) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg300 ml 1 $0

gram (Hiprex) 1 $0

(Metro IV) 1 $0

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use of

AGE (Max 64 Years)

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use of

QL (60 per 30 days)

AGE (Max 64 Years)

soln 500000 unit 1 $0

ml 500 mg100 ml 750 mg150 ml

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

750 mg

MG 2 $0

PA QL (9 per 30

days) NDS

MG 2 $0

PA NDS

Cephalosporins

mg 1 $0

mg5 ml 375 mg5 ml

mg5 ml

gram 1 $0

mg5 ml

GRAM50 ML 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ML 2 GRAM50 ML 2 $0

gram 500 mg 1 $0

gram50 ml 1 $0

gram 10 gram 1 $0

gram 1 $0

mg 1 $0

mg5 ml

gram 250 mg 500 mg 1 $0

gram 2 gram 1 $0

mg 500 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml

mg 1 $0

OSM) INTRAVENOUS

GRAM50 ML

MG 2 $0

SUPRAX ORAL

200 MG

2 gram 6 gram 1 $0

TEFLARO INTRAVENOUS

Macrolides

mg5 ml

(Zithromax) 1 $0

pack) 500 mg (3 pack) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml

500 mg 1 $0

days) NDS

ERYPED 200 ORAL

SUSPENSION FOR

ERYPED 400 ORAL

SUSPENSION FOR

(drec) 250 mg 500 mg 1 $0

ERY-TAB ORAL

(DREC) 333 MG

250 mg 1 $0

tablet 400 mg (EES 400) 1 $0

500 mg 1 $0

Antibiotics

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CAYSTON INHALATION

SOLUTION FOR

LA NDS

SOLN 1 GRAM 2 $0

Penicillins

500 mg 1 $0

mg 1 $0

mg 250 mg 1 $0

285 mg5 ml 400-57 mg5 ml

625 mg5 ml

(Augmentin) 1 $0

429 mg5 ml

(Augmentin ES-

600) 1 $0

tablet 250-125 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 1 $0

mg5 ml

gram 250 mg 500 mg

soln 2 gram 1 $0

(Unasyn) 1 $0

BICILLIN C-R

1200000 UNIT 2

ML(600K600K) 1200000 UNIT

2 ML(900K300K)

BICILLIN L-A

1200000 UNIT2 ML 2400000

500 mg 1 $0

2 gram 1 $0

gram 1 $0

ml 2 gram50 ml

gram 2 gram 1 $0

gram 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

million unit50 ml

600000 unitml

soln 125 mg5 ml 250 mg5 ml 1 $0

250 mg 500 mg 1 $0

million unit 1 $0

45 gram 405 gram

(Zosyn) 1 $0

Quinolones

MG 2 $0

PA QL (28 per 14

days) NDS

750 mg 1 $0

500 mg (Cipro) 1 $0

(Cipro in D5W) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ciprofloxacin oral

mg5 ml 500 mg5 ml

(Cipro) 1 $0

mg100 ml 750 mg150 ml

mgml 1 $0

mg10 ml 1 $0

mg 1 $0

Sulfonamides

mg5 ml 1 $0

Tetracyclines

100 mg 1 $0

mg 20 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

capsule 150 mg 1 $0

mg5 ml

(Vibramycin) 1 $0

150 mg 50 mg 75 mg 1 $0

mg 75 mg 1 $0

Anticancer Agents

SUSPENSION FOR

mg5 ml 20 mg10 ml 1 $0

PA BvD

gram50 ml 500 mg10 ml 1 $0

PA BvD

MG 3 MG 5 MG

PA NSO QL (112 per

28 days) NDS

MG 2 $0

PA NSO QL (56 per

28 days) NDS

MG 5 MG 75 MG 2 $0

PA NSO QL (28 per

28 days) NDS

MG 2 $0

PA NSO QL (240 per

30 days) NDS

ALIMTA INTRAVENOUS

ALIQOPA INTRAVENOUS

PA NSO QL (3 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

PA NSO QL (180 per

30 days) NDS

AVASTIN INTRAVENOUS

SOLUTION 25 MGML 25

MGML (16 ML)

PA NSO NDS

mg (Vidaza) 1 $0

PA NSO NDS

BENDEKA INTRAVENOUS

PA NSO NDS

MGML INITIAL)

PA NSO NDS

30 days) NDS

PA BvD

unit 1 $0

PA BvD

35 MCG 2 $0

PA NSO QL (140 per

365 days) NDS

MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 2 $0

PA NSO QL (30 per

30 days) NDS

MG 60 MG 2 $0

PA NSO QL (30 per

30 days) NDS

MG 2 $0

PA NSO QL (60 per

30 days) NDS

100 MG 2 $0

PA NSO QL (60 per

30 days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

PA NSO QL (60 per

30 days) NDS

MG 2 $0

PA NSO QL (30 per

30 days) NDS

PA NSO QL (112 per

28 days) NDS

MG 2 $0

PA NSO LA QL (63

per 28 days) NDS

PA BvD NDS

PA BvD ST

CYRAMZA INTRAVENOUS

SOLUTION 10 MGML 10

MGML (50 ML)

PA NSO NDS

PA NSO LA NDS

mg25 ml

(Adriamycin) 1 $0

PA BvD

PA BvD NDS

MG 300 MG 400 MG 2 $0

ELIGARD (3 MONTH)

ELIGARD (4 MONTH)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ELIGARD (6 MONTH)

MG 2 $0

PA NSO NDS

MG 2 $0

PA NSO QL (30 per

30 days) NDS

mgml (Toposar) 1 $0

MG 2 $0

MG 15 MG 20 MG 2 $0

PA NSO NDS

gram 1 $0

PA BvD

gram20 ml 1 $0

PA BvD

GAZYVA INTRAVENOUS

PA NSO NDS

MG 30 MG 40 MG 2 $0

PA NSO QL (30 per

30 days) NDS

MG 100 MG 40 MG 5 MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA NSO NDS

MG 2 $0

MG 125 MG 75 MG 2 $0

PA NSO QL (21 per

28 days) NDS

30 days) NDS

50 MG 2 $0

PA NSO QL (30 per

30 days) NDS

PA BvD

1 gram 3000-1000 mg 1 $0

PA BvD NDS

30 days) NDS

140 MG 2 $0

PA NSO NDS

IMFINZI INTRAVENOUS

SOLUTION 50 MGML 50

MGML (10 ML)

PA NSO NDS

IMLYGIC INJECTION

MILLION) PFUML

PA NSO QL (4 per

365 days) NDS

IMLYGIC INJECTION

MILLION) PFUML

PA NSO QL (8 per 28

days) NDS

30 days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

30 days) NDS

IXEMPRA INTRAVENOUS

15 MG 20 MG 25 MG 5 MG 2 $0

PA NSO QL (60 per

30 days) NDS

PA NSO QL (4 per 21

days) NDS

PA NSO QL (8 per 21

days) NDS

MG X 1)-25 MG

PA NSO QL (49 per

28 days) NDS

MG X 2)-25 MG

PA NSO QL (70 per

28 days) NDS

MG X 3)-25 MG

PA NSO QL (91 per

28 days) NDS

MGDAY (200 MG X 1) 400

MGDAY (200 MG X 2) 600

MGDAY (200 MG X 3)

PA NSO QL (63 per

28 days) NDS

PA NSO NDS

PA NSO LA NDS

X2) 20 MGDAY (10 MG X 2) 24

MGDAY (4 MG X 2)

PA NSO NDS

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg02 ml 1 $0

614 MG 2 $0

PA NSO QL (100 per

28 days) NDS

819 MG 2 $0

PA NSO QL (80 per

28 days) NDS

KIT 1125 MG 225 MG

KIT 30 MG

KIT 45 MG

LUPRON DEPOT

KIT 375 MG 75 MG

MG 2 $0

PA NSO QL (448 per

28 days) NDS

MG 150 MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 2 $0

(Max 64 Years)

MG 2 $0

PA NSO QL (90 per

30 days) NDS

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA BvD

mg 1 $0

PA BvD ST

INITIAL CONC)

PA NSO NDS

MG 2 $0

PA NSO QL (180 per

30 days) NDS

MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 3 MG 4 MG 2 $0

PA NSO QL (3 per 28

days) NDS

MG 2 $0

PA NSO LA NDS

ONCASPAR INJECTION

PA NSO NDS

ONIVYDE INTRAVENOUS

PA BvD NDS

OPDIVO INTRAVENOUS

MG4 ML

PA NSO NDS

MG 2 MG 3 MG 4 MG 2 $0

PA NSO QL (21 per

28 days) NDS

PA NSO QL (100 per

21 days) NDS

20 MGML 2 $0

MG 15 MG 25 MG 20 MG 25

MG 5 MG

PA NSO LA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

RITUXAN HYCELA

1400 MG117 ML (120 MGML)

1600 MG134 ML (120 MGML)

PA NSO NDS

RITUXAN INTRAVENOUS

PA NSO NDS

MG 250 MG 300 MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 2 $0

PA NSO QL (224 per

28 days) NDS

10 MG5 ML 2 $0

MG 140 MG 50 MG 70 MG 80

PA NSO QL (30 per

30 days) NDS

MG 2 $0

PA NSO QL (84 per

28 days) NDS

MG 25 MG 375 MG 50 MG 2 $0

PA NSO QL (30 per

30 days) NDS

SYLVANT INTRAVENOUS

PA NSO NDS

PA NSO QL (28 per

28 days) NDS

MG 75 MG 2 $0

PA NSO QL (120 per

30 days) NDS

MG 80 MG 2 $0

PA NSO LA QL (30

per 30 days) NDS

MG 25 MG 2 $0

PA NSO QL (60 per

30 days) NDS

MG 2 $0

PA NSO QL (90 per

30 days) NDS

28 days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 200 MG 2 $0

PA NSO QL (112 per

28 days) NDS

PA NSO QL (20 per

21 days) NDS

TEMODAR INTRAVENOUS

PA NSO NDS

mgml 1 $0

TREANDA INTRAVENOUS

QL (1 per 84 days)

QL (1 per 168 days)

QL (1 per 84 days)

QL (1 per 168 days)

capsule 10 mg 1 $0

MG 15 MG 5 MG 75 MG 2 $0

PA BvD ST

PA NSO NDS

SOLN 35 MG 2 $0

PA NSO NDS

MG 2 $0

PA NSO LA QL (60

per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100 MG 2 $0

PA NSO LA QL (120

per 30 days) NDS

MG 2 $0

PA NSO LA QL (30

per 30 days)

MG-50 MG- 100 MG

PA NSO LA QL (42

per 28 days) NDS

MG 150 MG 200 MG 50 MG 2 $0

PA NSO QL (56 per

28 days) NDS

MG 2 $0

PA NSO QL (120 per

30 days) NDS

VYXEOS INTRAVENOUS

PA BvD NDS

MG 250 MG 2 $0

PA NSO QL (60 per

30 days) NDS

MGML 2 $0

PA BvD ST

30 days) NDS

YERVOY INTRAVENOUS

MGML) 50 MG10 ML (5

PA NSO NDS

MG 2 $0

PA NSO QL (90 per

30 days) NDS

MG 2 $0

PA NSO QL (240 per

30 days) NDS

IMPLANT 108 MG 2 $0

QL (1 per 84 days)

IMPLANT 36 MG 2 $0

QL (1 per 28 days)

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 150 MG 2 $0

PA NSO QL (60 per

30 days) NDS

MG 2 $0

PA NSO QL (140 per

28 days) NDS

500 MG 2 $0

PA NSO QL (120 per

30 days) NDS

mgml 01 mgml 1 $0

Anticonvulsants

400 MG 600 MG 800 MG 2 $0

ST NDS

MGML 2 $0

ST NDS

MG 400 MG 2 $0

ST NDS

QL (80 per 30 days)

MGML 2 $0

MG 100 MG 25 MG 50 MG 75

QL (60 per 30 days)

300 mg

(Carbatrol) 1 $0

(Tegretol XR) 1 $0

100 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

MG 1 $0

sprinkle 125 mg

(Depakote

Sprinkles) 1 $0

(Depakote) 1 $0

ml (Zarontin) 1 $0

ml (Felbatol) 1 $0

mg (Felbatol) 1 $0

05 MGML 2 $0

ml (Neurontin) 1 $0

mg (Neurontin) 1 $0

MG 16 MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 250 mg 300 mg 50 mg

(Lamictal XR) 1 $0

mgml (Keppra) 1 $0

250 mg 500 mg 750 mg (Keppra) 1 $0

MG 150 MG 200 MG 225 MG 25

MG 300 MG 50 MG 75 MG

QL (90 per 30 days)

MGML 2 $0

MG 300 MG 600 MG

MG 2 $0

(4 mgml) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

15 mg 162 mg 30 mg 324 mg 60

mg 648 mg 972 mg

PA NSO-HRM AGE

(Max 64 Years)

capsule 100 mg

(Dilantin

Extended) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

300 MG 400 MG 2 $0

ST QL (90 per 30

days) NDS

1000 MG 500 MG 750 MG 1 $0

PACKET 500 MG 2 $0

ST QL (60 per 30

750 MG

ST QL (120 per 30

24hr 100 mg 150 mg 200 mg 25

mg 50 mg

(Qudexy XR) 1 $0

TROKENDI XR ORAL

24HR 100 MG 25 MG 50 MG

ST QL (30 per 30

TROKENDI XR ORAL

24HR 200 MG

ST QL (60 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

VIMPAT INTRAVENOUS

ST QL (200 per 5

MGML 2 $0

ST QL (1200 per 30

150 MG 200 MG 50 MG 2 $0

ST QL (60 per 30

mg (Zonegran) 1 $0

Antidementia Agents

10 mg 5 mg 1 $0

QL (30 per 30 days)

QL (60 per 30 days)

(Namenda Titration

Pak) 1 $0

QL (49 per 28 days)

NAMENDA XR ORAL

PACK 7-14-21-28 MG

QL (28 per 28 days)

NAMENDA XR ORAL

14 MG 21 MG 28 MG 7 MG

QL (30 per 30 days)

NAMZARIC ORAL

PACK 7142128 MG-10 MG

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

NAMZARIC ORAL

14-10 MG 21-10 MG 28-10 MG

7-10 MG

QL (30 per 30 days)

15 mg 3 mg 45 mg 6 mg 1 $0

QL (60 per 30 days)

95 mg24 hr

(Exelon) 1 $0

QL (30 per 30 days)

Antidepressants

mg 150 mg 25 mg 50 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

mg 25 mg 50 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

75 mg 1 $0

QL (30 per 30 days)

PA NSO-HRM AGE

(Max 64 Years)

mg (Norpramin) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

mg 50 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

mg 50 mg

(Pristiq) 1 $0

QL (30 per 30 days)

mg 150 mg 25 mg 50 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Max 64 Years)

QL (60 per 30 days)

QL (30 per 30 days)

EMSAM TRANSDERMAL

MG24 HR 9 MG24 HR

QL (30 per 30 days)

mg5 ml 1 $0

(2)- 40 MG (26)

ST QL (56 per 365

FETZIMA ORAL

24 HR 120 MG 20 MG 40 MG 80

ST QL (30 per 30

QL (4 per 28 days)

(4 mgml) 1 $0

mg 50 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

100 mg 125 mg 150 mg 75 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 75 mg 1 $0

MG 2 $0

mirtazapine oral

mg 200 mg 250 mg 50 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

ml 1 $0

PA NSO-HRM AGE

(Max 64 Years)

PA NSO-HRM AGE

(Max 64 Years)

(Paxil CR) 1 $0

PA NSO-HRM AGE

(Max 64 Years)

MG5 ML 2 $0

PA NSO-HRM AGE

(Max 64 Years)

4-25 mg 4-50 mg

PA NSO-HRM AGE

(Max 64 Years)

mgml (Zoloft) 1 $0

100 MG 25 MG 50 MG 2 $0

PA NSO-HRM AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 300 mg 50 mg 1 $0

PA NSO-HRM AGE

(Max 64 Years)

MG 20 MG 5 MG 2 $0

ST QL (30 per 30

QL (30 per 30 days)

QL (90 per 30 days)

mg 375 mg 50 mg 75 mg 1 $0

20 MG 40 MG 2 $0

ST QL (30 per 30

PACK 10 MG (7)- 20 MG (23) 2 $0

ST QL (30 per 180

Antidiabetic Agents

QL (90 per 30 days)

MG 2 $0

GLUCAGEN HYPOKIT

MG 25-5 MG 2 $0

ST QL (30 per 30

150-1000 MG 150-500 MG 50-

1000 MG

ST QL (60 per 30

500 MG 2 $0

ST QL (120 per 30

INVOKAMET XR ORAL

24HR 150-1000 MG 150-500 MG

50-1000 MG 50-500 MG

ST QL (60 per 30

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

ST QL (60 per 30

MG 2 $0

ST QL (30 per 30

1000 MG 50-500 MG 2 $0

QL (60 per 30 days)

1000 MG

QL (30 per 30 days)

MG 50-500 MG

QL (60 per 30 days)

MG 25 MG 50 MG 2 $0

QL (30 per 30 days)

MG 25 MG 2 $0

ST QL (30 per 30

25-1000 MG 25-500 MG 25-850

QL (60 per 30 days)

JENTADUETO XR ORAL

24HR 25-1000 MG

QL (60 per 30 days)

JENTADUETO XR ORAL

24HR 5-1000 MG

QL (30 per 30 days)

MG 2 $0

PA QL (112 per 28

days) NDS

QL (90 per 30 days)

50 mg (Glyset) 1 $0

QL (90 per 30 days)

mg (Starlix) 1 $0

QL (90 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (30 per 30 days)

30-2 mg 30-4 mg (DUETACT) 1 $0

QL (30 per 30 days)

QL (90 per 30 days)

500 mg 2-500 mg 1 $0

SYMLINPEN 120

SUBCUTANEOUS PEN

PA QL (108 per 28

days) NDS

SYMLINPEN 60

SUBCUTANEOUS PEN

PA QL (108 per 28

days) NDS

1000 MG 125-500 MG 5-1000

MG 5-500 MG

ST QL (60 per 30

MG 25-1000 MG

ST QL (30 per 30

1000 MG 5-1000 MG

ST QL (60 per 30

MG 2 $0

QL (30 per 30 days)

15 MG05 ML

QL (2 per 28 days)

VICTOZA 3-PAK

SUBCUTANEOUS PEN

MG3 ML)

QL (9 per 30 days)

Insulins

FIASP FLEXTOUCH

100 UNITML (3 ML)

QL (30 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

FIASP SUBCUTANEOUS

QL (40 per 28 days)

QL (24 per 28 days)

HUMULIN R U-500

(CONCENTRATED)

500 UNITML

QL (40 per 28 days)

LANTUS SOLOSTAR

100 UNITML (3 ML)

QL (30 per 28 days)

LANTUS SUBCUTANEOUS

QL (40 per 28 days)

NOVOLIN 7030

100 UNITML (70-30)

QL (40 per 28 days)

NOVOLIN R INJECTION

QL (40 per 28 days)

NOVOLOG FLEXPEN

100 UNITML

QL (30 per 28 days)

100 UNITML (70-30)

QL (30 per 28 days)

NOVOLOG MIX 70-30

100 UNITML (70-30)

QL (40 per 28 days)

NOVOLOG PENFILL

100 UNITML

QL (30 per 28 days)

QL (40 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

SOLIQUA 10033

100 UNIT-33 MCGML

ST QL (30 per 30

TOUJEO SOLOSTAR

300 UNITML (15 ML)

XULTOPHY 10036

ST QL (15 per 28

Sulfonylureas

QL (60 per 30 days)

QL (30 per 30 days)

250 mg 1 $0

500 mg 5-500 mg 1 $0

PA-HRM AGE (Max

64 Years)

mg 5 mg 1 $0

PA-HRM AGE (Max

64 Years)

125-250 mg 1 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

Antifungals

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ABELCET INTRAVENOUS

PA BvD NDS

SUSPENSION FOR

PA BvD NDS

50 mg 1 $0

PA BvD

(Loprox (as

olamine)) 1 $0

troche 10 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

lotion 1-005 1 $0

antifungal 2 4 $0

ml 400 mg200 ml

500 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg)- 2 (9 gram)

(Miconazole-3

mg 4 $0

200 mg 1 $0

(200 MG)- 2 (9 GRAM) 4 $0

200 MG5 ML (40 MGML) 2 $0

NOXAFIL ORAL

(DREC) 100 MG

unitgram 1 $0

unitml 1 $0

unitgram 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cream 100000-01 unitg- 1 $0

unitgram 1 $0

mg5 gram (4 ) 4 $0

spray 1 4 $0

(terbinafine)) 4 $0

(tolnaftate)) 4 $0

(9 gram) 4 $0

(Vfend) 1 $0

mg (Vfend) 1 $0

Antigout Agents

mg (Zyloprim) 1 $0

MG 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

500-05 mg 1 $0

80 MG 2 $0

QL (30 per 30 days)

MG 2 $0

ST QL (30 per 30

Antihistamines

mg 4 $0

ml 4 $0

mg 4 $0

125 mg5 ml 4 $0

ultratab 25 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(All Day Allergy

(cetirizine)) 4 $0

(All Day Allergy

(cetirizine)) 4 $0

(All Day Allergy-

D) 4 $0

grape sf 5 mg5 ml

(Allergy Relief

(loratadine)) 4 $0

mg5 ml 4 $0

ml 4 $0

mg5 ml 4 $0

cherry 1 mgml 4 $0

mg5 ml 4 $0

ODT 10 MG 4 $0

mgml 4 $0

CHEW 5 MG 4 $0

mg 4 $0

CAP 10 MG 4 $0

MG 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

25 mg5 ml 4 $0

drowsy 10-240 mg 4 $0

ml 1 $0

PA-HRM AGE (Max

64 Years)

relief 134 mg 4 $0

1-25 mg5 ml 4 $0

625-25 mg5 ml 4 $0

mg5 ml 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml

(Childrens Allergy

(diphenhyd)) 1 $0

PA-HRM AGE (Max

64 Years)

drowsy 10 mg 4 $0

mg5 ml 4 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

mg5 ml 1 $0

PA-HRM AGE (Max

64 Years)

25 mg 50 mg 1 $0

PA-HRM AGE (Max

64 Years)

25 mg5 ml 4 $0

ml (Xyzal) 1 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg30 ml 4 $0

25 mg 4 $0

ml 1 $0

PA-HRM AGE (Max

64 Years)

mg5 ml 1 $0

minitabs 25 mg 4 $0

mg 4 $0

mg5 ml 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ml 4 $0

mg 4 $0

mg5 ml 4 $0

mg 4 $0

hr rlf 10 mg 4 $0

mg 4 $0

strength 50 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Mucous Membrane)

Membrane)

AVC VAGINAL VAGINAL

CREAM 15 2 $0

mg 1 $0

Antimigraine Agents

QL (30 per 28 days)

QL (8 per 28 days)

ERGOMAR SUBLINGUAL

TABLET 2 MG 2 $0

QL (40 per 28 days)

QL (18 per 28 days)

mgactuation

(Imitrex) 1 $0

QL (12 per 28 days)

100 mg 25 mg 50 mg (Imitrex) 1 $0

QL (18 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Imitrex STATdose

Kit Refill) 1 $0

QL (4 per 28 days)

(Imitrex STATdose

Pen) 1 $0

QL (4 per 28 days)

mg (Zomig) 1 $0

QL (12 per 28 days)

zolmitriptan oral

QL (12 per 28 days)

Antimycobacterials

SOLN 1 GRAM 2 $0

mg 1 $0

mg (Rifadin) 1 $0

300 MG 2 $0

MG 2 $0

PA QL (188 per 168

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

Antinausea Agents

05 MG 2 $0

PA BvD

125 mg (1)- 80 mg (2) (Emend) 1 $0

PA BvD QL (6 per 28

mg 4 $0

mgml 1 $0

mg 4 $0

EMEND 150 MG VIAL

QL (2 per 28 days)

SOLN 150 MG 2 $0

QL (2 per 28 days)

PA BvD QL (6 per 28

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(otc) 125 mg 4 $0

Drowsy) 4 $0

64 Years)

Drowsy) 1 $0

PA-HRM AGE (Max

64 Years)

fc 25 mg 4 $0

mg5 ml

(Zofran (as

PA BvD

(Zofran (as

PA BvD

ondansetron oral

PA BvD

mg 25 mg 1 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

25 mg 50 mg 1 $0

PA-HRM AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM AGE (Max

64 Years)

mg (Phenergan) 1 $0

PA-HRM AGE (Max

64 Years)

125 mg 25 mg 50 mg 1 $0

PA-HRM AGE (Max

64 Years)

QL (10 per 30 days)

TRANSDERM-SCOP

1 MG OVER 3 DAYS

QL (10 per 30 days)

mg 4 $0

Antiparasite Agents

MG 2 $0

MG5 ML

250-100 mg (Malarone) 1 $0

625-25 mg

(Malarone

Pediatric) 1 $0

250 mg 500 mg 1 $0

120 MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

PA NDS

mg (Plaquenil) 1 $0

MG 2 $0

PA QL (84 per 28

days) NDS

NEBUPENT INHALATION

PA BvD

SOLN 300 MG 2 $0

263 MG 2 $0

mg5 ml 1 $0

APOKYN SUBCUTANEOUS

QL (60 per 30 days)

mg 2 mg 1 $0

PA-HRM AGE (Max

64 Years)

100 mg 25-100 mg 25-250 mg (Sinemet) 1 $0

(Sinemet CR) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GOCOVRI ORAL

24HR 137 MG

PA QL (60 per 30

days) NDS

GOCOVRI ORAL

24HR 685 MG

PA QL (30 per 30

days) NDS

NEUPRO TRANSDERMAL

HOUR 8 MG24 HOUR

QL (30 per 30 days)

025 mg 05 mg 075 mg 1 mg 15

(Mirapex) 1 $0

mg 8 mg

(Requip XL) 1 $0

64 Years)

mg 1 $0

PA-HRM AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 50 MG 2 $0

PA QL (30 per 30

days) NDS

ABILIFY MAINTENA

INTRAMUSCULAR

RECON 300 MG 400 MG

QL (1 per 28 days)

ABILIFY MAINTENA

INTRAMUSCULAR

QL (1 per 28 days)

QL (30 per 30 days)

aripiprazole oral

QL (90 per 30 days)

aripiprazole oral

QL (60 per 30 days)

SYRING 1064 MG39 ML

QL (39 per 56 days)

SYRING 441 MG16 ML

QL (16 per 28 days)

SYRING 662 MG24 ML

QL (24 per 28 days)

SYRING 882 MG32 ML

QL (32 per 28 days)

25 mgml 1 $0

100 mg 200 mg 25 mg 50 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100 mg 125 mg 25 mg (FazaClo) 1 $0

ST QL (90 per 30

ST QL (180 per 30

ST QL (120 per 30

MG 4 MG 2 $0

ST QL (60 per 30

12 MG 6 MG 8 MG 2 $0

ST QL (60 per 30

days) NDS

PACK 1MG(2)-2MG(2)- 4MG(2)-

6MG(2)

25 mgml 1 $0

mgml 1 $0

ml 1 $0

mg 25 mg 5 mg 1 $0

QL (6 per 28 days)

50 mgml

2 mgml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 10 mg 2 mg 20 mg 5 mg 1 $0

INVEGA SUSTENNA

117 MG075 ML

INVEGA SUSTENNA

156 MGML

QL (1 per 28 days)

INVEGA SUSTENNA

234 MG15 ML

QL (15 per 28 days)

INVEGA SUSTENNA

MG025 ML

INVEGA SUSTENNA

MG05 ML

QL (05 per 28 days)

INVEGA TRINZA

273 MG0875 ML

QL (0875 per 84

days) NDS

INVEGA TRINZA

410 MG1315 ML

QL (1315 per 84

days) NDS

INVEGA TRINZA

546 MG175 ML

INVEGA TRINZA

819 MG2625 ML

QL (2625 per 84

days) NDS

MG 20 MG 40 MG 60 MG 80

QL (30 per 30 days)

mg 25 mg 5 mg 50 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

PA NSO QL (60 per

30 days) NDS

QL (30 per 30 days)

QL (60 per 30 days)

mg 4 mg 8 mg 1 $0

QL (90 per 30 days)

(Seroquel XR) 1 $0

QL (30 per 30 days)

QL (60 per 30 days)

MG 2 $0

ST QL (120 per 30

days) NDS

2 MG 3 MG 4 MG 2 $0

ST QL (30 per 30

days) NDS

RISPERDAL CONSTA

QL (4 per 28 days)

RISPERDAL CONSTA

QL (4 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (60 per 30 days)

risperidone oral

QL (60 per 30 days)

risperidone oral

(Risperdal M-

TAB) 1 $0

QL (60 per 30 days)

risperidone oral

(Risperdal M-

TAB) 1 $0

25 MG 5 MG

ST QL (60 per 30

days) NDS

mg 25 mg 50 mg 1 $0

mg 2 mg 5 mg 1 $0

VERSACLOZ ORAL

ST QL (540 per 30

days) NDS

MG 3 MG 45 MG 6 MG 2 $0

ST QL (30 per 30

days) NDS

VRAYLAR ORAL

(1)- 3 MG (6)

40 mg 60 mg 80 mg (Geodon) 1 $0

QL (60 per 30 days)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

QL (2 per 28 days)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

QL (2 per 28 days)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

QL (1 per 28 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Antiretrovirals

600-300 mg (Epzicom) 1 $0

MG 2 $0

MGML 2 $0

200-300 MG 2 $0

25-300 MG 2 $0

MG 400 MG 2 $0

25 MG 2 $0

mg 400 mg

(Videx EC) 1 $0

MG 2 $0

MGML 2 $0

25 MG5 ML (5 MGML) 2 $0

MG 2 $0

FUZEON SUBCUTANEOUS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

150-200-10 MG 2 $0

MG 200 MG 2 $0

MG 2 $0

600 MG 2 $0

PACKET 100 MG 2 $0

MG 2 $0

ISENTRESS ORAL

25 MG 2 $0

50 MG 2 $0

mg (Epivir) 1 $0

150-300 mg (Combivir) 1 $0

MGML 2 $0

400-100 mg5 ml (Kaletra) 1 $0

ml (Viramune) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

MGML 2 $0

25-25 MG 2 $0

150 MG-MG 2 $0

100 MGML 2 $0

MG 75 MG 2 $0

MG 800 MG 2 $0

200 MG 2 $0

MG 200 MG 300 MG 2 $0

PACKET 50 MG 2 $0

20 MGML 2 $0

MG 300 MG 75 MG 2 $0

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

150-200-300 MG 2 $0

MG 2 $0

50 MG 2 $0

50-300 MG 2 $0

150 MG 133-200 MG 167-250

MG 200-300 MG

MG 2 $0

QL (30 per 30 days)

(FINAL)

MG 625 MG 2 $0

200 MG 250 MG 300 MG 2 $0

MGML 2 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

RELENZA DISKHALER

MG05 ML

PA NDS

Hcv Antivirals

MG 60 MG 90 MG 2 $0

PA QL (28 per 28

days) NDS

100 MG 2 $0

PA QL (28 per 28

days) NDS

MG 2 $0

PA QL (30 per 30

days) NDS

40 MG 2 $0

PA QL (84 per 28

days) NDS

MG 2 $0

PA QL (28 per 28

days) NDS

MG 2 $0

PA QL (28 per 28

days) NDS

75-50 MG 2 $0

PA QL (56 per 28

days) NDS

VIEKIRA PAK ORAL

75 MG -50 MG250 MG

PA QL (112 per 28

days) NDS

50 MG- 3333 MG-200 MG

PA QL (84 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100 MG 2 $0

PA QL (28 per 28

days) NDS

100 MG 2 $0

PA QL (30 per 30

days) NDS

Interferons

MILLION UNIT (1 ML)

PA NSO NDS

INTRON A INJECTION

SOLUTION 10 MILLION

PA NSO NDS

MCG05 ML

PEGASYS PROCLICK

SUBCUTANEOUS PEN

MCG05 ML

KIT 200 MCG 300 MCG 600

PA NSO QL (4 per 28

days) NDS

PA BvD NDS

ml (Zovirax) 1 $0

mg (Zovirax) 1 $0

soln 500 mg 2 $0

PA BvD NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA BvD

mg 500 mg 1 $0

PA BvD

mg 600 mg 1 $0

PA BvD NDS

mg (Valtrex) 1 $0

Expanders

Anticoagulants

MG 80 MG 2 $0

QL (43 per 42 days)

CEPROTIN (BLUE BAR)

500 UNIT

5 MG 2 $0

100 mgml 120 mg08 ml 150

60 mg06 ml 80 mg08 ml

(Lovenox) 1 $0

10 mg08 ml 5 mg04 ml 75

mg06 ml

(Arixtra) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA QL (24 per 28

days) NDS

MG 150 MG 75 MG 2 $0

ST QL (60 per 30

(Coumadin) 1 $0

MG 15 MG 20 MG 2 $0

XARELTO ORAL

(42)- 20 MG (9)

CINRYZE INTRAVENOUS

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

SDV PF OUTER 10000

UNITML

PA QL (12 per 28

UNITML 4000 UNITML

PA QL (12 per 28

GRANIX SUBCUTANEOUS

MCG08 ML

PA NDS

SOLN 250 MCG 2 $0

100 MCG03 ML 200 MCG03

PA QL (06 per 28

SYRINGE W WEARABLE

INJECTOR 6 MG06 ML

NEUPOGEN INJECTION

MCG16 ML

NEUPOGEN INJECTION

MCG08 ML

PROCRIT INJECTION

ML 3000 UNITML 4000

UNITML

PA QL (12 per 28

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PROCRIT INJECTION

PA QL (12 per 28

days) NDS

PROCRIT INJECTION

PA QL (6 per 28

days) NDS

MG 25 MG 50 MG 75 MG 2 $0

PA QL (30 per 30

days) NDS

300 MCG05 ML 480 MCG08

ST NDS

mgml 1 $0

(Cyklokapron) 1 $0

MG 90 MG 2 $0

mg 75 mg 1 $0

5 MG 2 $0

QL (30 per 30 days)

release 400 mg 1 $0

Caloric Agents

AMINO ACIDS 15

SOLUTION 15

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

AMINOSYN 10

SOLUTION 10

PA BvD

AMINOSYN 7 WITH

ELECTROLYTES

SOLUTION 7

PA BvD

AMINOSYN 85

SOLUTION 85

PA BvD

AMINOSYN 85 -

ELECTROLYTES

SOLUTION 85

PA BvD

AMINOSYN II 10

SOLUTION 10

PA BvD

AMINOSYN II 15

SOLUTION 15

PA BvD

AMINOSYN II 7

SOLUTION 7

PA BvD

AMINOSYN II 85

SOLUTION 85

PA BvD

AMINOSYN II 85 -

ELECTROLYTES

SOLUTION 85

PA BvD

AMINOSYN M 35

SOLUTION 35

PA BvD

AMINOSYN-HBC 7

SOLUTION 7

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

AMINOSYN-PF 10

SOLUTION 10

PA BvD

FREE) INTRAVENOUS

PA BvD

AMINOSYN-RF 52

SOLUTION 52

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE) INTRAVENOUS

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

FREE INTRAVENOUS

PA BvD

CLINISOL SF 15

SOLUTION 15

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA BvD

FREAMINE HBC 69

SOLUTION 69

PA BvD

FREAMINE III 10

SOLUTION 10

PA BvD

HEPATAMINE 8

SOLUTION 8

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

EMULSION 20 30 2 $0

PA BvD

KABIVEN INTRAVENOUS

EMULSION 331-98-39 2 $0

PA BvD

NEPHRAMINE 54

SOLUTION 54

PA BvD

EMULSION 20 2 $0

PA BvD

EMULSION 236-68-35 2 $0

PA BvD

PREMASOL 10

SOLUTION 10

PA BvD

PROCALAMINE 3

SOLUTION 3

PA BvD

TRAVASOL 10

SOLUTION 10

PA BvD

TROPHAMINE 10

SOLUTION 10

PA BvD

TROPHAMINE 6

SOLUTION 6

PA BvD

15-400 gram-unit42 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (4 per 28 days)

QL (8 per 28 days)

64 Years)

FCUD250S 5 MG 4 $0

5 mg 1 $0

drowsy 10 mg 4 $0

100 MG 200 MG 300 MG 2 $0

PA QL (180 per 30

days) NDS

mg (Minipress) 1 $0

Antagonists

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

32-25 mg

(Atacand HCT) 1 $0

80 MG 2 $0

40-125 MG 40-25 MG 2 $0

MG 49-51 MG 97-103 MG 2 $0

QL (60 per 30 days)

50 mg (Cozaar) 1 $0

tablet 100-125 mg 100-25 mg 50-

125 mg

(Hyzaar) 1 $0

oral tablet 20-5-125 mg 40-10-125

mg 40-10-25 mg 40-5-125 mg 40-

5-25 mg

(Tribenzor) 1 $0

40-25 mg

(Benicar HCT) 1 $0

tablet 160-125 mg 160-25 mg 320-

125 mg 320-25 mg 80-125 mg

(Diovan HCT) 1 $0

Inhibitors

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

tablet 10-125 mg 20-125 mg 20-

(Lotensin HCT) 1 $0

mg 25 mg 50 mg 1 $0

tablet 25-15 mg 25-25 mg 50-15

mg 50-25 mg

125 mgml 1 $0

40 mg 1 $0

tablet 10-125 mg 20-125 mg 1 $0

tablet 10-125 mg 20-125 mg 20-

(Zestoretic) 1 $0

tablet 15-125 mg 15-25 mg 75-

125 mg

mg 4 mg 8 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

tablet 10-125 mg 20-125 mg 20-

(Accuretic) 1 $0

4 mg 1 $0

mg 50 mg 1 $0

100 mg5 ml (2 ) 50 mg5 ml (1

mgml (08 )

mg 250 mg 1 $0

MG 2 $0

mg 400 mg 1 $0

mgml 500 mgml 1 $0

mg 300 mg 1 $0

300 mg 1 $0

mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100-25 mg (Tenoretic 100) 1 $0

50-25 mg (Tenoretic 50) 1 $0

mg 5 mg 1 $0

tablet 10-625 mg 25-625 mg 5-

625 mg

(Ziac) 1 $0

MG 25 MG 20 MG 5 MG 2 $0

MG 2 $0

mg 3125 mg 625 mg (Coreg) 1 $0

PA BvD NDS

mgml 1 $0

mg 300 mg 1 $0

mg 25 mg 50 mg

(Toprol XL) 1 $0

tablet 100-25 mg 100-50 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 1 $0

mg (Corgard) 1 $0

mgml 1 $0

mg 80 mg

(Inderal LA) 1 $0

mg 40 mg 60 mg 80 mg 1 $0

240 mg 80 mg 1 $0

20 mg 5 mg 1 $0

mg 300 mg

mgml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Cardizem CD) 1 $0

mg 360 mg 420 mg

(Cardizem LA) 1 $0

mg 360 mg 420 mg

mg 300 mg 360 mg

mgml 1 $0

mg 360 mg

(Verelan) 1 $0

Miscellaneous

MG 75 MG 2 $0

PA QL (60 per 30

MG 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

mcgml 1 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

MCGML 2 $0

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

PA-HRM High Risk

Med PA Required for

125mcg per day AGE

(Max 64 Years)

(4000 mcgml) 250 mg250 ml (1

mgml) 500 mg250 ml (2000

mcgml)

PA BvD

250 mg20 ml (125 mgml) 500

mg40 ml (125 mgml)

PA BvD

(800 mcgml) 400 mg250 ml (1600

mcgml) 800 mg250 ml (3200

mcgml)

PA BvD

(80 mgml) 800 mg10 ml (80

PA BvD

QL (4 per 30 days)

03 mg03 ml (Auvi-Q) 1 $0

QL (4 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (4 per 30 days)

QL (18 per 30 days)

mgml 1 $0

mg 25 mg 50 mg 1 $0

MCG 2 $0

PA-HRM QL (30 per

30 days) AGE (Max

64 Years)

MCG 2 $0

PA-HRM High Risk

Med PA Required for

125mcg per day QL

(Max 64 Years)

ml (200 mcgml) 40 mg200 ml (200

mcgml)

PA BvD NDS

mgml 1 $0

PA BvD NDS

(Levophed

(bitartrate)) 1 $0

PA BvD

RANEXA ORAL TABLET

1000 MG 500 MG

Dihydropyridines

10-20 mg 10-40 mg 5-10 mg 5-20

mg 5-40 mg

(Lotrel) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25-10 mg 1 $0

10-20 mg 10-40 mg 5-20 mg 5-40

(Azor) 1 $0

160 mg 10-320 mg 5-160 mg 5-

320 mg

(Exforge) 1 $0

tablet 10-160-125 mg 10-160-25

mg 10-320-25 mg 5-160-125 mg

5-160-25 mg

(Exforge HCT) 1 $0

MG100 ML

mg 1 $0

Diuretics

tablet 5-50 mg 1 $0

mgml 1 $0

mg 2 mg 1 $0

500 mg 1 $0

mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml 1 $0

40 mg5 ml (8 mgml) 1 $0

mg 25 mg 50 mg 1 $0

mg 1 $0

mg 5 mg 1 $0

Dyslipidemics

10-10 mg 10-20 mg 10-40 mg 10-

80 mg 5-10 mg 5-20 mg 5-40 mg

5-80 mg

(Caduet) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25-10 mg 25-20 mg 25-40 mg 1 $0

gram 1 $0

130 mg 134 mg 200 mg 43 mg 67

mg 1 $0

mg 45 mg

(Trilipix) 1 $0

MG 30 MG 40 MG 60 MG 2 $0

PA QL (30 per 30

days) NDS

MG 2 $0

PA QL (90 per 30

days) NDS

MG 2 $0

PA QL (45 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA QL (4 per 28

days) NDS

MG 4 MG 2 $0

QL (30 per 30 days)

40 mg 1 $0

24 hr 1000 mg 500 mg 750 mg

(Niaspan

(niacinamide)) 4 $0

PRALUENT PEN

SUBCUTANEOUS PEN

PA QL (2 per 28

days) NDS

REPATHA PUSHTRONEX

PA QL (35 per 28

days) NDS

REPATHA SURECLICK

SUBCUTANEOUS PEN

INJECTOR 140 MGML

PA QL (3 per 28

days) NDS

REPATHA SYRINGE

PA QL (3 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GRAM 2 $0

MG 2 $0

System Inhibitors

10 MG 150-5 MG 300-10 MG

300-5 MG

150-125 MG 150-25 MG 300-125

MG 300-25 MG

MG 300 MG 2 $0

Vasodilators

MG 2 $0

mg 20 mg 30 mg 1 $0

10 mg 20 mg 1 $0

mg 60 mg

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

QL (30 per 30 days)

04 mghr 1 $0

QL (60 per 30 days)

OINTMENT 2 1 $0

(400 mcgml) 25 mg250 ml (100

mcgml) 50 mg250 ml (200

mcgml)

50 mg10 ml (5 mgml) 1 $0

(Minitran) 1 $0

QL (30 per 30 days)

QL (60 per 30 days)

Agents

AMPYRA ORAL TABLET

PA QL (60 per 30

days) NDS

100 mg 18 mg 25 mg 40 mg 60

mg 80 mg

(Strattera) 1 $0

MG 7 MG 2 $0

PA QL (28 per 28

days) NDS

MG 9 MG 2 $0

PA QL (120 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA NDS

KIT 03 MG 2 $0

PA NDS

mg3 ml (20 mgml) 1 $0

PA QL (12 per 28

days) NDS

QL (60 per 30 days)

10 mg 15 mg 5 mg

(Adderall XR) 1 $0

QL (30 per 30 days)

20 mg 25 mg 30 mg

(Adderall XR) 1 $0

QL (60 per 30 days)

20 mg 30 mg 5 mg 75 mg

(Adderall) 1 $0

QL (60 per 30 days)

03 MG 2 $0

PA NDS

mgml 1 $0

MG 2 $0

PA QL (28 per 28

days) NDS

PA QL (30 per 30

days) NDS

PA QL (12 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml 1 $0

PA QL (30 per 30

days) NDS

(Intuniv ER) 1 $0

MG 2 $0

PA QL (60 per 30

days) NDS

MG 2 $0

PA QL (30 per 30

days) NDS

PA NDS

mg 300 mg 600 mg 1 $0

mg 1 $0

ml 1 $0

mg 50 mg 60 mg

QL (30 per 30 days)

QL (60 per 30 days)

QL (30 per 30 days)

QL (60 per 30 days)

QL (30 per 30 days)

QL (90 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 54 mg

(Concerta) 1 $0

QL (30 per 30 days)

QL (60 per 30 days)

10 MG 2 $0

QL (60 per 30 days)

OCREVUS INTRAVENOUS

PA QL (20 per 180

days) NDS

PA NDS

PA QL (2800 per 28

days) NDS

PA NDS

REBIF REBIDOSE

SUBCUTANEOUS PEN

MCG05ML (6)

PA NDS

MG 125 MG 25 MG 50 MG 2 $0

QL (60 per 30 days)

SAVELLA ORAL

(5)-25 MG(8)-50 MG(42)

QL (60 per 30 days)

TECFIDERA ORAL

CAPSULEDELAYED

PA QL (14 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TECFIDERA ORAL

CAPSULEDELAYED

240 MG (46) 240 MG

PA QL (60 per 30

days) NDS

PA QL (112 per 28

days) NDS

PA QL (1 per 28

days) NDS

Contraceptives

mg 1 $0

mg-mcg 1 $0

050751 mg- 35 mcg 1 $0

QL (91 per 84 days)

35 mg-mcg 1 $0

mgx21 001 mg x 5 1 $0

mcg 1 $0

mgx21 001 mg x 5 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg (24)75 mg (4) 1 $0

mg-30 mcg (21)75 mg (7) 1 $0

20 mcg (21)75 mg (7) 1 $0

QL (91 per 84 days)

25 mg-mcg 1 $0

mcg 1 $0

mg-mcg 1 $0

050751 mg- 35 mcg 1 $0

mg-mcg 1 $0

050751 mg- 35 mcg 1 $0

QL (91 per 84 days)

mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

QL (6 per 365 days)

(5)125-30(10) 1 $0

mg 4 $0

QL (6 per 365 days)

mcg 1 $0

QL (91 per 84 days)

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg 1 $0

mg-30 mcg (21)75 mg (7) 1 $0

20 mcg (21)75 mg (7) 1 $0

(24)75 mg (4) 1 $0

mgx21 001 mg x 5 1 $0

mg-mcg 1 $0

mgx21 001 mg x 5 1 $0

20 mcg (84)10 mcg (7)

(Amethia Lo) 1 $0

QL (91 per 84 days)

30 mcg (84)10 mcg (7)

(Amethia) 1 $0

QL (91 per 84 days)

mg-mcg 1 $0

mcg 1 $0

(24)75 mg (4) 1 $0

mg-30 mcg (21)75 mg (7) 1 $0

20 mcg (21)75 mg (7) 1 $0

mg-mcg 1 $0

(6)75-40 (5)125-30(10) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

015-003 mg (Altavera (28)) 1 $0

QL (91 per 84 days)

15 mg (Aftera) 4 $0

QL (6 per 365 days)

30 mcg

(Introvale) 1 $0

QL (91 per 84 days)

tablet 50-30 (6)75-40 (5)125-

30(10)

(Enpresse) 1 $0

QL (91 per 84 days)

mcg (24)75 mg (4) 1 $0

mg-mcg 1 $0

mcg 1 $0

15-30 mg-mcg 1 $0

20 mg-mcg 1 $0

tablet 15 mg-30 mcg (21)75 mg (7) 1 $0

1 mg-20 mcg (21)75 mg (7) 1 $0

mcg 1 $0

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(5)125-30(10) 1 $0

mg-mcg 1 $0

mcg 1 $0

050751 mg- 35 mcg 1 $0

15 mg 4 $0

QL (6 per 365 days)

mg-20 mcg (21)75 mg (7)

(Blisovi Fe 120

(28)) 1 $0

(Ortho Tri-Cyclen

LO (28)) 1 $0

(Ortho Tri-Cyclen

(28)) 1 $0

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

050751 mg- 35 mcg 1 $0

012-0015 MG24 HR 2 $0

QL (1 per 28 days)

mcg 1 $0

mg 4 $0

QL (6 per 365 days)

mgx21 001 mg x 5 1 $0

35 mcg 1-35 mg-mcg 1 $0

QL (91 per 84 days)

mg 1 $0

QL (91 per 84 days)

mcg 1 $0

20 mcg (21)75 mg (7) 1 $0

1mg-35mcg (9) 1 $0

0180215025 mg-35 mcg (28) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

0180215025 mg-35 mcg (28) 1 $0

30(7) 1mg-35mcg (9) 1 $0

0180215025 mg-35 mcg (28) 1 $0

0180215025 mg-25 mcg 1 $0

0180215025 mg-35 mcg (28) 1 $0

40 (5)125-30(10) 1 $0

tablet 0112515-25 mg-mcg 1 $0

mgx21 001 mg x 5 1 $0

mcg 1 $0

150-35 mcg24 hr 1 $0

QL (3 per 28 days)

mcg 1 $0

mg-mcg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg-mcg 1 $0

mg5 ml 4 $0

mg 4 $0

200 mg 4 $0

325 mg 4 $0

20 mg 4 $0

20-400 mg 4 $0

20 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ml 4 $0

mg5 ml 3 $0

mgml 3 $0

mg 4 $0

mg5 ml 4 $0

100 mg5 ml 4 $0

mg5 ml 4 $0

MG5 ML

100 mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

325mg(d) 15-325-625mg 4 $0

mg30 ml 4 $0

400 mg 4 $0

blast 125-30-1000 mg30 ml 4 $0

mg 4 $0

mg5 ml 4 $0

160 mg5 ml 4 $0

mg5 ml

mg5 ml 4 $0

12 day12 night 2-5-10-325 mg 4 $0

mg5 ml 4 $0

mg15 ml

mg15 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

600 mg 4 $0

flavor 625-15 mg15 ml 4 $0

30 mg30 ml 4 $0

5 mg5 ml 4 $0

15mg15ml(d) 125-30mg30ml 4 $0

100 mg5 ml 4 $0

mg5 ml

(12-Hour Cough

Relief) 4 $0

mg5 ml 4 $0

200 mg5 ml 4 $0

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml 4 $0

20-650 mg 4 $0

ml 4 $0

400 mg 4 $0

mg5 ml

(Adult Tussin

mg (Coughtab) 4 $0

mg (Mucinex) 4 $0

10-325 mg 4 $0

mg5 ml 4 $0

600 mg 4 $0

1200 mg 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

15-500 mg15 ml 4 $0

mg15 ml

125 mg5 ml 4 $0

mg5 ml 4 $0

mg5 ml 3 $0

mg5 ml

(Nasal

Decongestant

(pseudoeph))

(Nasal

Decongestant

(pseudoeph))

30-1000 mg30 ml 4 $0

160 mg5 ml 4 $0

relief 10-5-325mg(d) 15-325-

mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

day12 night 2-5-10-325 mg 4 $0

mg 4 $0

100 mg5 ml 4 $0

ml 4 $0

mg5 ml 4 $0

200 mg 4 $0

LIQ 1-75 MG5 ML 4 $0

mg5 ml 4 $0

ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml 4 $0

667 mg5 ml 4 $0

30-1000 mg30 ml 4 $0

625-30-15-325 mg 4 $0

mg30 ml 4 $0

15-325 mg 4 $0

ml 4 $0

mg 4 $0

ml 4 $0

af 10-200 mg5 ml 4 $0

30-15-500 mg 4 $0

MG 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

10-325 mg 4 $0

mg5 ml 4 $0

15-200 MG5 ML 4 $0

MG5 ML 4 $0

25-5-160 mg5 ml 4 $0

rlf 5 mg5 ml 4 $0

10-325 mg 4 $0

af 5-10-325 mg15 ml 4 $0

625-15-325 MG15 ML

625-15-325 mg 4 $0

mg16 ml 4 $0

caplet 30-15-500 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg5 ml 4 $0

ml 4 $0

max-str 30 mg 4 $0

caplet 5-10-325 mg 4 $0

mg 4 $0

400 mg5 ml 4 $0

(Paroex Oral

Rinse) 1 $0

mouthwash 012 1 $0

(Salagen

(pilocarpine)) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ACNE MEDICATION 5

LOTION 5 4 $0

PADS MEDICATED 1 $0

(AmLactin) 1 $0

(Calcitrene) 1 $0

15 4 $0

PA NDS

SUBCUTANEOUS PEN

INJECTOR 150 MGML

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

days) NDS

PA NDS

FLECTOR TRANSDERMAL

(Aldara) 1 $0

PA NSO QL (24 per

30 days)

INSECT REPELLENT 20

SPRAY 20 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

250 UNITGRAM 2 $0

SILIQ SUBCUTANEOUS

PA NDS

TALTZ AUTOINJECTOR

SUBCUTANEOUS AUTO-

INJECTOR 80 MGML

PA NDS

TALTZ SYRINGE

PA NDS

30 mg 40 mg 1 $0

unitgram 4 $0

(Cleocin T) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

1 (Cleocin T) 1 $0

gel 2 (Erygel) 1 $0

solution 2 1 $0

(Bactroban) 1 $0

(Neosporin GU

Irrigant) 1 $0

(Silvadene) 1 $0

Agents

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

cream 005 1 $0

lotion 005 1 $0

ointment 005 1 $0

cream 01 1 $0

lotion 01 1 $0

ointment 01 1 $0

cream 005 1 $0

gel 005 1 $0

lotion 005 1 $0

005 1 $0

01 (Cloderm) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

DERMAREST ECZEMA 1

LOTION 1 4 $0

(Topicort) 1 $0

2 2 $0

(Synalar) 1 $0

05 4 $0

strength 1 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25 (Ala-Cort) 1 $0

(Dermatop) 1 $0

01 (Protopic) 1 $0

cream 0025 1 $0

lotion 0025 01 1 $0

ointment 0025 01 05 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

005 2 $0

(Retin-A) 1 $0

strength 033-4 4 $0

2x59ml 2 combs 1 4 $0

strength 033-4 4 $0

Devices

LANCT 28 GAUGE 4 $0

LANCT 30 GAUGE 4 $0

ACCU-CHEK FASTCLIX

LANCETS 4 $0

ACCU-CHEK MULTICLIX

LANCETS 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

LANCT 23 GAUGE 4 $0

23G 23 GAUGE 4 $0

ACCU-CHEK SOFTCLIX

LANCETS 4 $0

ACTI-LANCE LITE 28G

ADVANCED TRAVEL 28G

LANCETS 28GSINGLE-

USESTRL 28 GAUGE

ADVANCED TRAVEL 30G

ALTERNATE SITE 26G

ASSURE COMFORT 30G

LANCETS 30 GAUGE

(1st Tier Unilet

ComforTouch) 4 $0

18G 18 GAUGE 4 $0

21G 21 GAUGE 4 $0

25G 25 GAUGE 4 $0

28G 28 GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

25 GAUGE 4 $0

28 GAUGE 4 $0

BD INSULIN SYR 1 ML

BD MICROTAINER 21G

BD MICROTAINER 30G

33 GAUGE 4 $0

TWIST 30 GAUGE

(1st Tier Unilet

ComforTouch) 4 $0

21 GAUGE 4 $0

LANCT 25 GAUGE 4 $0

CAREONE ULTRA THIN

LANCET 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CARETOUCH TWIST 28G

CARETOUCH TWIST 30G

30G 30 GAUGE 4 $0

CVS ULTRA THIN 30G

GAUGE 4 $0

30GTWIST TOPSTRL 30

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GAUGE 4 $0

32 GAUGE 4 $0

33 GAUGE 4 $0

(Accu-Chek

FastClix) 4 $0

(1st Tier Unilet

ComforTouch) 4 $0

GAUGE 4 $0

STRIP NO CODE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

STRIPS 4 $0

FREESTYLE UNISTIK 2

LANCETS 4 $0

GAUZE PAD TOPICAL

BANDAGE 2 X 2 1 $0

GAUGE 4 $0

21G 21 GAUGE 4 $0

30G 30 GAUGE 4 $0

LANCT 30 GAUGE 4 $0

LANCT 28 GAUGE 4 $0

GAUGE 4 $0

(Ultilet Insulin

Syringe) 1 $0

(Advocate

Syringes) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Lite Touch Insulin

Syringe) 1 $0

GAUGE 4 $0

LANCT 26 GAUGE 4 $0

KROGER SUPER THIN

LANCETS 4 $0

Lancets) 4 $0

GAUGE 4 $0

MEDLANCE PLUS 21G

MEDLANCE PLUS 30G

30 GAUGE

GAUGE 4 $0

28 GAUGE 4 $0

MYGLUCOHEALTH 30G

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

23 GAUGE 4 $0

28 GAUGE 4 $0

NOVA SUREFLEX THIN

LANCETS 4 $0

GAUGE 4 $0

ONETOUCH DELICA 30G

ONETOUCH DELICA 33G

ONETOUCH SURESOFT

LANCETS

ONETOUCH ULTRASOFT

LANCETS 4 $0

PEN NEEDLE DIABETIC

(1st Tier Unifine

Pentips) 1 $0

(1st Tier Unilet

ComforTouch) 4 $0

30 GAUGE 4 $0

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PRODIGY PRESSURE

PRODIGY SAFETY 26G

GAUGE 4 $0

RELIAMED SAFETY 23G

RELIAMED SAFETY 28G

LANCT 28 GAUGE 4 $0

LANCT 30 GAUGE 4 $0

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

33 GAUGE 4 $0

LANCETS 4 $0

30 GAUGE 4 $0

FREE 21 GAUGE 4 $0

FREE 28 GAUGE 4 $0

GAUGE 4 $0

21 GAUGE 4 $0

GAUGE 4 $0

30 GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

18 GAUGE 4 $0

21 GAUGE 4 $0

23 GAUGE 4 $0

28 GAUGE 4 $0

30 GAUGE 4 $0

GAUGE 4 $0

SURE-LANCE THIN 28G

30 GAUGE 4 $0

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GAUGE 4 $0

TRUEPLUS SAFETY 28G

GAUGE 4 $0

30 GAUGE 4 $0

ULTILET CLASSIC 26G

LANCETS 4 $0

ULTILET CLASSIC 28G

ULTILET CLASSIC 30G

ULTILET CLASSIC 33G

ULTILET SAFETY 23G

GAUGE 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GAUGE 4 $0

28 GAUGE 4 $0

30 GAUGE 4 $0

UNILET COMFORTOUCH

LANCET 4 $0

LANCETS SINGLE-

USESTERILE 30 GAUGE

UNISTIK 3 EXTRA 21G

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

28 GAUGE 4 $0

30 GAUGE 4 $0

21 GAUGE 4 $0

23 GAUGE 4 $0

28 GAUGE 4 $0

30 GAUGE 4 $0

LANCETS 4 $0

Dermatologic Use)

Enzyme

MG 2 $0

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

CREON ORAL

CAPSULEDELAYED

60000 UNIT 24000-76000 -

120000 UNIT 3000-9500- 15000

UNIT 36000-114000- 180000

UNIT 6000-19000 -30000 UNIT

SOLN 15 MG 75 MG 2 $0

KANUMA INTRAVENOUS

PA NDS

KUVAN ORAL

MG 20 MG 5 MG 2 $0

PA NDS

MGML 2 $0

PA NDS

MG 75 MG

PA BvD NDS

PA LA NDS

VIMIZIM INTRAVENOUS

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

SOLN 400 UNIT 2 $0

MG 2 $0

QL (90 per 30 days)

ZENPEP ORAL

CAPSULEDELAYED

55000 UNIT 15000-51000 -

82000 UNIT 20000-68000 -

109000 UNIT 25000-85000-

136000 UNIT 3000-10000-

16000 UNIT 40000-136000-

218000 UNIT 5000-17000 -

27000 UNIT

Miscellaneous

(EYE) GEL 35 2 $0

03 4 $0

OINTMENT 83-15 4 $0

mcg (01 ) 1 $0

QL (30 per 25 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

005 1 $0

03 4 $0

therapy 04-03 4 $0

425 4 $0

soln 05-09 4 $0

CYSTARAN OPHTHALMIC

005 (Elestat) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

GENTEAL MILD 02 EYE

DROPS 02 4 $0

03 01-03-02 4 $0

03 4 $0

QL (30 per 28 days)

QL (15 per 10 days)

09 4 $0

30x04ml 05 4 $0

force 005 4 $0

formula 005 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

03 4 $0

01 (Patanol) 1 $0

02 (Pataday) 1 $0

03-0025 (025 ML) 2 $0

drops 10 25 1 $0

drops 05 1 $0

03 4 $0

005 4 $0

formula 1-03 4 $0

DROPS 1 4 $0

U-DPF30X4ML 14-06 4 $0

REFRESH LACRI-LUBE

OINTMENT 568-425 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

03 4 $0

DROPS 04-03 4 $0

d36x9mlpf 01-03 4 $0

Infectives Agents

unitgram

(Polycin) 1 $0

CIPRODEX OTIC (EAR)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

05 MGML

05 (Zymaxid) 1 $0

03 (3 mggram) 1 $0

03 1 $0

05 1 $0

05 (Vigamox) 1 $0

10000 mg-unitg-1

10000 mg-unit-unitg

(Neo-Polycin) 1 $0

(Maxitrol) 1 $0

10000 unitg-01

(Maxitrol) 1 $0

10000 unit-0025mgml

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

10 mg-unit-mgml

mgml-unitml-

unitml-

(Ocuflox) 1 $0

500-10000 unitgram 1 $0

1 mgml

(Polytrim) 1 $0

DROPS 05-1-05 4 $0

(025 )

TOBRADEX OPHTHALMIC

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

03 (Tobrex) 1 $0

(TobraDex) 1 $0

(Viroptic) 1 $0

DROPS 05 2 $0

GEL 015 2 $0

Inflammatory Agents

DROPS 0075 2 $0

drops 01 1 $0

DROPS 005 2 $0

25 mcg (0025 ) 1 $0

QL (50 per 25 days)

50 mcgactuation

(24 Hour Allergy

Relief) 1 $0

04 (Acular LS) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

05 (Acular) 1 $0

DROPSGEL 05 2 $0

OINTMENT 05 2 $0

PROLENSA OPHTHALMIC

RESTASIS MULTIDOSE

QL (55 per 30 days)

QL (60 per 30 days)

Antiflatulents

125 mg 4 $0

ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

(Anti-Gas Ultra

Strength) 4 $0

Suppressants

strength 20 mg 4 $0

100 MGML 2 $0

mg5 ml 1 $0

(cimetidine)) 1 $0

mg 800 mg 1 $0

200 mg

(Acid Reducer

(cimetidine)) 4 $0

20 mg2 ml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml 1 $0

mg 4 $0

(Heartburn

Treatment 24

release(drec) 15 mg

(Heartburn

Treatment 24

(Acid Reducer

(omeprazole)) 4 $0

PRILOSEC OTC 206 MG

(Acid Control

(ranitidine)) 4 $0

free 75 mg

(Acid Reducer

(ranitidine)) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(ranitidine)) 1 $0

mg15 ml 4 $0

ml 4 $0

320 mg5 ml 4 $0

MCG 8 MCG 2 $0

QL (60 per 30 days)

30 mg5 ml 4 $0

40 mg5 ml 4 $0

mg 4 $0

ml 4 $0

mg 4 $0

mg15 ml 4 $0

MG 2 $0

(1250 mg) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Calci-Chew) 4 $0

(1000 mg)

mg 4 $0

400-400-40 mg5 ml 4 $0

cherry 200-200-20 mg5 ml 4 $0

ml 1 $0

strength 200-200-20 mg5 ml 4 $0

200-20 mg5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

2 mg 4 $0

mg15 ml 4 $0

mg (750 mg) 4 $0

2375 mg5 ml 4 $0

mg 4 $0

1 mg75 ml

(Anti-Diarrheal

(loperamide)) 4 $0

ml 1 $0

25-0025 mg5 ml 1 $0

PA-HRM AGE (Max

64 Years)

25-0025 mg (Lomotil) 1 $0

PA-HRM AGE (Max

64 Years)

strength 400-400-40 mg5 ml 4 $0

mg15 ml 4 $0

GATTEX 30-VIAL

PA NDS

200-200-25 mg 4 $0

ml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mgml (Robinul) 1 $0

MG75 ML

193 gram60 ml 1 $0

MCG 290 MCG 72 MCG 2 $0

QL (30 per 30 days)

strength 200-200-20 mg5 ml 4 $0

(Anti-Diarrheal

(loperamide)) 4 $0

mg75 ml

(Anti-Diarrheal

(loperamide)) 4 $0

(loperamide)) 1 $0

mg 4 $0

500 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Laxative Dietary

Supplement) 4 $0

mg 4 $0

5 mg 1 $0

mg5 ml 1 $0

mg5 ml 400-400-40 mg5 ml 4 $0

200-25 mg 4 $0

200-20 mg5 ml 4 $0

MG 25 MG 2 $0

QL (30 per 30 days)

MG 5 MG 2 $0

PA QL (30 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

fruits 300 mg (750 mg) 4 $0

mg 4 $0

GRAMML 2 $0

PA NDS

MG 2 $0

PA QL (90 per 30

days) NDS

PA QL (28 per 28

days) NDS

MG04 ML

PA QL (28 per 28

days) NDS

mg5 ml 4 $0

ml 4 $0

30 mg5 ml 4 $0

20 mg 4 $0

650 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

262 mg15 ml 4 $0

15-20 gram60 ml 1 $0

PACKET 168 GRAM 252

GRAM 84 GRAM

QL (30 per 30 days)

MG 75 MG 2 $0

ST QL (60 per 30

days) NDS

MG 2 $0

PA QL (90 per 30

days) NDS

Laxatives

(Bisac-Evac) 4 $0

gram118 ml 4 $0

625 mg 4 $0

mg5 ml 4 $0

ml 4 $0

Heavy) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

ml 4 $0

20 mg5 ml 4 $0

gram 4 $0

625 mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

gram 4 $0

2272-672 -584 gram 1 $0

2274-674 -586 gram 1 $0

gramdose 4 $0

outer 17 gram 4 $0

625 mg 4 $0

gramdose 4 $0

mg5 ml 4 $0

MINERAL OIL LIGHT

VISCOSITY NF 4 $0

PACKET 100-75-2691 GRAM 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

gram58 gram 4 $0

soln 240-2272-672 -584 gram

(Colyte with Flavor

Packs) 1 $0

(ClearLax) 4 $0

gram118 ml 4 $0

gram11 gram 4 $0

gram15 ml 4 $0

Heavy) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

gramdose 4 $0

19-7 gram118 ml 4 $0

gram 4 $0

heavy 4 $0

gram58 gram 4 $0

ml 4 $0

mg5 ml 4 $0

50 mg (Colace 2-In-1) 4 $0

ml 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

100 mg 4 $0

240 mg 4 $0

16 GRAM

soln 420 gram 1 $0

mg 4 $0

Phosphate Binders

MG 800 MG 2 $0

MG 2 $0

mg (Renvela) 1 $0

VELPHORO ORAL

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 50 MG

mg5 ml 1 $0

mg 5 mg

(Ditropan XL) 1 $0

TOVIAZ ORAL TABLET

MG 8 MG

MG 5 MG 2 $0

Miscellaneous

QL (30 per 30 days)

2 mg 5 mg 1 $0

250 MG 2 $0

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TABLET 250 MG 2 $0

PA NDS

EXJADE ORAL TABLET

500 MG

PA NDS

100 MGML 2 $0

PA NDS

MG 2 $0

PA NDS

MG 360 MG 90 MG 2 $0

PA NDS

360 MG 90 MG

PA NDS

MG 2 $0

PA QL (240 per 30

days) NDS

Hormonal Agents

Androgens

MG 2 $0

PA NDS

HOUR 4 MG24 HR

PA QL (30 per 30

2025 MG125 GRAM (162 )

PA QL (150 per 30

MG125 GRAM) 162 (405

MG25 GRAM)

PA QL (150 per 30

mg 50 mg 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg (Oxandrin) 1 $0

(Depo-

Testosterone) 1 $0

PA QL (300 per 30

(50 mg5 gram)

(AndroGel) 1 $0

PA QL (300 per 30

05 mg 1 $0

MG24 HR 005-025 MG24 HR

PA-HRM QL (8 per

28 days) AGE (Max

64 Years)

MG 2 $0

PA-HRM AGE (Max

64 Years)

001 (01 MGGRAM) 2 $0

mg (Estrace) 1 $0

PA-HRM AGE (Max

64 Years)

mg24 hr 0075 mg24 hr 01

mg24 hr

(Alora) 1 $0

PA-HRM QL (8 per

28 days) AGE (Max

64 Years)

PA-HRM QL (8 per

28 days) AGE (Max

64 Years)

0025 mg24 hr 00375 mg24 hr

005 mg24 hr 006 mg24 hr 0075

mg24 hr 01 mg24 hr

(Climara) 1 $0

PA-HRM QL (4 per

28 days) AGE (Max

64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA-HRM AGE (Max

64 Years)

mg 3 mg 1 $0

PA-HRM AGE (Max

64 Years)

MG24 HR 01 MG24 HR 2 $0

QL (1 per 84 days)

05 mg 1 $0

PA-HRM AGE (Max

64 Years)

0625 MG 125 MG 2 $0

PA-HRM AGE (Max

64 Years)

SOLN 25 MG 2 $0

MG 045 MG 0625 MG 09 MG

125 MG

PA-HRM AGE (Max

64 Years)

0625 MGGRAM 2 $0

0625 MG (14) 0625MG-5MG(14) 2 $0

PA-HRM AGE (Max

64 Years)

15 MG 045-15 MG 0625-25

MG 0625-5 MG

PA-HRM AGE (Max

64 Years)

mg 1 $0

(Celestone

Soluspan) 1 $0

ml 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

075 mg 1 mg 15 mg 2 mg 4 mg

PA BvD

2275 MGML 2 $0

PA QL (39 per 30

days) NDS

MG 2 $0

PA QL (30 per 30

days) NDS

MG 36 MG 6 MG 2 $0

PA QL (60 per 30

days) NDS

PA BvD

KENALOG INJECTION

(Depo-Medrol) 1 $0

PA BvD

mg5 ml (5 mgml)

PA BvD

(Pediapred) 1 $0

PA BvD

5 mg 50 mg 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(48 pack)

PA BvD

Pituitary

mcgml (DDAVP) 1 $0

mg (DDAVP) 1 $0

MG025 ML

MG025 ML 06 MG025 ML 08

MG025 ML 1 MG025 ML 12

MG025 ML 14 MG025 ML 16

MG025 ML 18 MG025 ML 2

MG025 ML

PA NDS

UNITML) 5 MGML (15

UNITML)

PA NDS

HUMATROPE INJECTION

24 MG (72 UNIT) 6 MG (18

PA NDS

HUMATROPE INJECTION

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

LUPRON DEPOT-PED (3

SYRINGE KIT 30 MG

LUPRON DEPOT-PED

NORDITROPIN FLEXPRO

SUBCUTANEOUS PEN

MGML) 30 MG3 ML (10

PA NDS

NORDITROPIN FLEXPRO

SUBCUTANEOUS PEN

NUTROPIN AQ NUSPIN

SUBCUTANEOUS PEN

MGML) 20 MG2 ML (10

MGML) 5 MG2 ML (25

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MGML) 5 MG15 ML (33

PA NDS

SAIZEN CLICKEASY

PA NDS

SAIZEN SUBCUTANEOUS

PA NDS

INTRAMUSCULAR

PA NDS

QL (60 per 30 days)

SOMATULINE DEPOT

MG05 ML 60 MG02 ML 90

MG03 ML

QL (1 per 28 days)

MG 25 MG 30 MG

50 MG (65 MCGDAY) 2 $0

QL (1 per 360 days)

AEROSOL 2 MGML 2 $0

SUSPENSION FOR

QL (1 per 168 days)

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA NDS

Progestins

DEPO-PROVERA

400 MGML

QL (10 per 28 days)

PA NSO

QL (1 per 84 days)

mg10 ml (40 mgml) 1 $0

PA-HRM AGE (Max

64 Years)

mg (Aygestin) 1 $0

oil 50 mgml 1 $0

soln 100 mcg 200 mcg 500 mcg 1 $0

112 mcg 125 mcg 137 mcg 150

(Levo-T) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ACTEMRA INTRAVENOUS

MGML) 400 MG20 ML (20

MGML) 80 MG4 ML (20

PA NDS

ASTAGRAF XL ORAL

PA BvD

soln 100 mg 1 $0

PA BvD

PA BvD NDS

CIMZIA POWDER FOR

PA NDS

CIMZIA SUBCUTANEOUS

MGML X 2)

PA NDS

PA BvD

100 mg 25 mg 50 mg (Gengraf) 1 $0

PA BvD

ENBREL SUBCUTANEOUS

PA NDS

ENBREL SUBCUTANEOUS

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

ENBREL SUBCUTANEOUS

MGML (098 ML)

PA NDS

ENBREL SURECLICK

SUBCUTANEOUS PEN

PA NDS

075 MG 1 MG 4 MG

PA BvD

FLEBOGAMMA DIF

PA BvD NDS

GAMASTAN SD

(10 ML) 15-18 RANGE (2 ML)

PA BvD

GAMMAGARD LIQUID

PA BvD NDS

MCGML) INTRAVENOUS

PA BvD NDS

GAMMAPLEX (WITH

SOLUTION 5

PA BvD NDS

SOLUTION 10 2 $0

PA BvD NDS

mg 50 mg 1 $0

PA BvD

START SUBCUTANEOUS

MG08 ML (6 PACK)

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

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Limits on Use

PA NDS

HUMIRA SUBCUTANEOUS

MG04 ML 40 MG08 ML

PA NDS

HYPERRAB SD (PF)

HYQVIA SUBCUTANEOUS

(10 ) 25 GRAM 25 ML (10 )

20 GRAM 200 ML (10 ) 30

50 ML (10 )

PA BvD NDS

(150 MGML)

PA NDS

150 UNITML

PA NDS

MG114 ML

PA QL (228 per 28

days) NDS

PA QL (1876 per 28

days) NDS

mg (Arava) 1 $0

(CellCept

Intravenous) 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA BvD

(CellCept) 1 $0

PA BvD NDS

PA BvD

mg 360 mg

(Myfortic) 1 $0

PA BvD

NULOJIX INTRAVENOUS

PA BvD NDS

OCTAGAM INTRAVENOUS

SOLUTION 10 5 2 $0

PA BvD NDS

250 MG

PA NDS

ORENCIA CLICKJECT

SUBCUTANEOUS AUTO-

INJECTOR 125 MGML

PA NDS

ML 875 MG07 ML

PA NDS

days) NDS

OTEZLA STARTER ORAL

(4)-20 MG (4)-30 MG (47) 10 MG

(4)-20 MG (4)-30 MG(19)

PA QL (60 per 30

days) NDS

OTREXUP (PF)

SUBCUTANEOUS AUTO-

MG04 ML 15 MG04 ML 175

MG04 ML 20 MG04 ML 225

MG04 ML 25 MG04 ML

SOLUTION 10 2 $0

PA BvD NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

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Limits on Use

PROGRAF INTRAVENOUS

PA BvD

MGML 2 $0

PA BvD NDS

125 MG025 ML 15 MG03 ML

175 MG035 ML 20 MG04 ML

225 MG045 ML 25 MG05 ML

275 MG055 ML 30 MG06 ML

75 MG015 ML

PA NDS

MG 2 $0

PA NDS

MG05 ML

PA NDS

STELARA INTRAVENOUS

PA NDS

PA BvD

TYSABRI INTRAVENOUS

PA LA QL (15 per 28

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

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Restrictions or

Limits on Use

PA QL (30 per 30

days) NDS

MG 05 MG 075 MG 2 $0

PA BvD NDS

Vaccines

ADACEL(TDAP

ADOLESNADULT)(PF)

INTRAMUSCULAR

MCG)-5LF05 ML

ADACEL(TDAP

ADOLESNADULT)(PF)

LF-(25-5-3-5 MCG)-5LF05 ML

PA BvD

BOOSTRIX TDAP

INTRAMUSCULAR

LF05ML

BOOSTRIX TDAP

20-20 MCG05 ML

(PF) INTRAMUSCULAR

LF05ML

page number xv

Name of Drug

Tier level

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drug will

cost you

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Limits on Use

ENGERIX-B (PF)

INTRAMUSCULAR

SUSPENSION 20 MCGML

PA BvD

ENGERIX-B (PF)

PA BvD

INTRAMUSCULAR

PA BvD

MCG05 ML

PA BvD

GARDASIL (PF)

INTRAMUSCULAR

MCG05 ML

GARDASIL 9 (PF)

INTRAMUSCULAR

SUSPENSION 05 ML

GARDASIL 9 (PF)

HAVRIX (PF)

INTRAMUSCULAR

HAVRIX (PF)

ELISA UNIT05 ML

HIBERIX (PF)

INTRAMUSCULAR RECON

SOLN 10 MCG05 ML

INTRAMUSCULAR RECON

SOLN 25 UNIT

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

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Limits on Use

INTRAMUSCULAR

LF05ML

40-8-32 UNIT05 ML 2 $0

32 UNIT05 ML 2 $0

LF05 ML

MENACTRA (PF)

MCG05 ML

MENHIBRIX (PF)

INTRAMUSCULAR RECON

SOLN 5-25 MCG05 ML

50 MCG

MENOMUNE - ACYW-135

50 MCG

MCG05 ML

TCID5005 ML

PEDIARIX (PF)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

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Limits on Use

PEDVAX HIB (PF)

75 MCG05 ML

PENTACEL (PF)

(PF) INTRAMUSCULAR

LF UNIT05ML

PROQUAD (PF)

FOR RECONSTITUTION

10EXP3-43-3- 399 TCID5005

QUADRACEL (PF)

INTRAMUSCULAR

LF UNIT05ML

RABAVERT (PF)

INTRAMUSCULAR

SUSPENSION FOR

PA BvD

RECOMBIVAX HB (PF)

INTRAMUSCULAR

PA BvD

RECOMBIVAX HB (PF)

MCGML 5 MCG05 ML

PA BvD

MCG05 ML

PA BvD

CCID50ML

SOLUTION 2 ML 2 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

SHINGRIX (PF)

INTRAMUSCULAR

SUSPENSION FOR

QL (2 per 365 days)

SHINGRIX GE ANTIGEN

COMPONENT

INTRAMUSCULAR

SUSPENSION FOR

QL (2 per 365 days)

TENIVAC (PF)

2 LF UNIT05 ML

SUV 5 LF UNIT- 2 LF

UNIT05ML

TETANUS-DIPHTHERIA

TOXOIDS-TD

INTRAMUSCULAR

SUSPENSION FOR

PA BvD

TWINRIX (PF)

INTRAMUSCULAR

20 MCGML

TWINRIX (PF)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

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Limits on Use

UNITML

VARIVAX (PF)

UNIT05 ML

QL (2 per 365 days)

SUSPENSION FOR

UNIT05 ML

ZOSTAVAX (PF)

UNIT065 ML

QL (1 per 365 days)

Agents

APRISO ORAL

24HR 0375 GRAM

budesonide oral

CANASA RECTAL

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 2 $0

ST NDS

LIALDA ORAL

(DREC) 12 GRAM

(Azulfidine EN-

tabs) 1 $0

MGACTUATION 2 $0

LACTATED RINGERS

27-054 g100 ml 1 $0

irrigation solution

(Curity Sterile

Water) 1 $0

Agents

ml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 5 mg 1 $0

unitactuation

QL (37 per 28 days)

mcgml 1 $0

MCG24 ML

PA QL (24 per 28

mg3 ml 1 $0

QL (3 per 84 days)

MIACALCIN INJECTION

MCGDOSE

PA QL (2 per 28

days) NDS

5 MCGML

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg (Zemplar) 1 $0

PROLIA SUBCUTANEOUS

QL (1 per 180 days)

RAYALDEE ORAL

24 HR 30 MCG

QL (60 per 30 days)

MG 2 $0

QL (60 per 30 days)

MG 2 $0

QL (60 per 30 days)

MG 2 $0

MCG156 ML)

PA QL (156 per 30

soln 4 mg 1 $0

ZOMETA INTRAVENOUS

Agents

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PA NDS

PA QL (4 per 28

days) NDS

PA QL (4 per 28

days) NDS

CETYLEV ORAL TABLET

GRAM17 ML 2 $0

mgml 1 $0

MG 2 $0

PACKET 5 GRAM 2 $0

PA QL (180 per 30

days) NDS

SOLUTION 50 MGML 50

MGML (10 ML)

PA LA NDS

gramml 1 $0

100 mg 1 $0

PA-HRM AGE (Max

64 Years)

PA-HRM AGE (Max

64 Years)

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

soln 100 mg 350 mg 50 mg 1 $0

mg 15 mg 25 mg 5 mg 1 $0

LEVOLEUCOVORIN

175 MG

mgml (Mesnex) 1 $0

MG 2 $0

MG5 ML 2 $0

Heavy) 4 $0

PROGLYCEM ORAL

(Mestinon

Timespan) 1 $0

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MG 150 MG 200 MG 50 MG 2 $0

PA NSO QL (60 per

30 days) NDS

TOTECT INTRAVENOUS

QL (24 per 14 days)

PACKET 2 GRAM 2 $0

PA QL (120 per 30

days) NDS

Ophthalmic Agents

Antiglaucoma Agents

250 mg 1 $0

(EYE) DROPS 01 2 $0

02 1 $0

COMBIGAN OPHTHALMIC

(EYE) DROPS 02-05 2 $0

2 (Trusopt) 1 $0

0005 (Xalatan) 1 $0

05 (Betagan) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

DROPS 001 2 $0

QL (25 per 25 days)

mg (Neptazane) 1 $0

03 1 $0

PHOSPHOLINE IODIDE

(EYE) DROPS 0004 2 $0

QL (25 per 25 days)

QL (30 per 30 days)

mg-unit 4 $0

mg (950 mg) 4 $0

(Calcium 600 with

Vitamin D3) 4 $0

mg(1500mg) -500 unit 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Calcium 600 with

Vitamin D3) 4 $0

mg5 ml (1250 mg5 ml) 4 $0

250 mg-unit

(Calcitrate-Vitamin

D) 4 $0

(Calcium Citrate +

D) 4 $0

mg (500 mg) 4 $0

mg (648 mg) 4 $0

MG (1500 MG)-800 UNIT

250 mg-unit 4 $0

mg-unit 4 $0

315-250 mg-unit

(Calcitrate-Vitamin

D) 4 $0

mg-unit

(Calcitrate-Vitamin

D) 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Calcitrate-Vitamin

D) 4 $0

800 unit-40 mg

unit-40 mg

IONOSOL-B IN D5W

SOLUTION 5

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

IONOSOL-MB IN D5W

SOLUTION 5

mg(1500mg) -400 unit 4 $0

-500 unit

mg) 4 $0

gram500 ml (4 ) 40 gram1000

ml (4 )

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(4 ) 4 gram100 ml (4 ) 4

gram50 ml (8 )

4 meqml (50 ) 1 $0

4 meqml 1 $0

NORMOSOL-M IN 5

PARENTERAL SOLUTION

NORMOSOL-R PH 74

SOLUTION

(1250 mg) 4 $0

(1250 mg)

(625)-125 mg-unit 4 $0

PLASMA-LYTE 148

SOLUTION

PLASMA-LYTE A

SOLUTION

PLASMA-LYTE-56 IN 5

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

meql 40 meql

meq100 ml

(Klor-Con

Sprinkle) 1 $0

(K-Tab) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

meql 40 meql

solution 1 $0

(Calcitrate-Vitamin

D) 4 $0

mg 4 $0

2 meqml 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

5 meqml 1 $0

18-5-45-35 MEQ20 ML

TPN ELECTROLYTES

20-5 MEQ20 ML

Corticosteroids

500-50 MCGDOSE

QL (60 per 30 days)

MCGACTUATION 230-21

MCGACTUATION 45-21

MCGACTUATION

QL (12 per 28 days)

ARNUITY ELLIPTA

200 MCGACTUATION

QL (30 per 30 days)

QL (60 per 30 days)

mg2 ml 1 mg2 ml

(Pulmicort) 1 $0

PA BvD

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

MCGACTUATION 200-5

MCGACTUATION

QL (13 per 28 days)

FLOVENT DISKUS

50 MCGACTUATION

QL (60 per 30 days)

FLOVENT DISKUS

MCGACTUATION

QL (12 per 28 days)

MCGACTUATION

QL (24 per 28 days)

MCGACTUATION

45 MCGACTUATION

QL (12 per 25 days)

MCGACTUATION 80-45

MCGACTUATION

QL (11 per 25 days)

Antileukotrienes

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Bronchodilators

mg3 ml 25 mg 3 ml (0083 ) 5

PA BvD

ml 1 $0

MCGACTUATION

QL (60 per 30 days)

MCGACTUATION

COMBIVENT RESPIMAT

MCGACTUATION

QL (8 per 30 days)

FORADIL AEROLIZER

INHALATION CAPSULE

QL (60 per 30 days)

INCRUSE ELLIPTA

solution 002 1 $0

PA BvD

QL (30 per 30 days)

ml 1 $0

20 mg 1 $0

AEROSOL INHALER 90

MCGACTUATION

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

PROAIR RESPICLICK

INHALATION AEROSOL

90 MCGACTUATION

SEREVENT DISKUS

DEVICE 50 MCGDOSE

QL (60 per 30 days)

SPIRIVA RESPIMAT

INHALATION MIST 125

MCGACTUATION 25

MCGACTUATION

INHALATION CAPSULE

STIOLTO RESPIMAT

MCGACTUATION

QL (4 per 28 days)

STRIVERDI RESPIMAT

INHALATION MIST 25

MCGACTUATION

QL (4 per 28 days)

mgml 1 $0

mg100 ml 200 mg50 ml 400

mg250 ml 400 mg500 ml 800

mg250 ml

ml 1 $0

(Theochron) 1 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

TRELEGY ELLIPTA

PA BvD

(10 ) 200 mgml (20 ) 1 $0

PA BvD

CINQAIR INTRAVENOUS

PA NDS

PA BvD

mgspray (4 )

(Nasal Allergy

MCG 2 $0

QL (30 per 30 days)

MG 2 $0

PA QL (270 per 30

days) NDS

PA QL (1 per 28

days) NDS

PA QL (60 per 30

days) NDS

MG 2 $0

PA QL (60 per 30

days) NDS

NUCALA SUBCUTANEOUS

PA LA QL (1 per 28

days) NDS

150 MG 2 $0

PA QL (60 per 30

days) NDS

125 MG 200-125 MG 2 $0

PA QL (120 per 30

days) NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

suv pf (rx) 09 3 $0

XOLAIR SUBCUTANEOUS

PA NDS

350 mg (Soma) 1 $0

PA-HRM QL (120 per

30 days) AGE (Max

64 Years)

mg 1 $0

PA-HRM AGE (Max

64 Years)

mg (Dantrium) 1 $0

64 Years)

mg 1 $0

MG 15 MG 20 MG 5 MG 2 $0

QL (30 per 30 days)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

3 mg (Lunesta) 1 $0

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any non-

benzodiazepine

per 30 days) AGE

(Max 64 Years)

MG 2 $0

PA QL (30 per 30

days) NDS

6 MG 2 $0

QL (30 per 30 days)

MGML 2 $0

LA QL (540 per 30

days) NDS

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any non-

benzodiazepine

per 30 days) AGE

(Max 64 Years)

PA-HRM (High Risk

members PA required

with over 90 days

cumulative use with

any non-

benzodiazepine

per 30 days) AGE

(Max 64 Years)

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

Vasodilating Agents

days) NDS

MG 1 MG 15 MG 2 MG 25 MG 2 $0

PA QL (90 per 30

days) NDS

PA NDS

MG 5 MG 2 $0

PA QL (30 per 30

days) NDS

1 MG 25 MG 5 MG

PA NDS

REMODULIN INJECTION

SOLUTION 1 MGML 10

MGML 25 MGML 5 MGML

PA NDS

PA QL (375 per 1

day) NDS

PA QL (90 per 30

MG 625 MG 2 $0

PA LA QL (60 per 30

days) NDS

PA QL (112 per 28

days) NDS

TYVASO INHALATION

SOLUTION FOR

(06 MGML)

PA NDS

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

1600 MCG 400 MCG 600 MCG

800 MCG

PA QL (60 per 30

days) NDS

MCG 2 $0

PA QL (240 per 30

days) NDS

UPTRAVI ORAL

(140)- 800 MCG (60)

PA QL (400 per 365

days) NDS

formula 4 $0

mg-mcg-mcg-mcg

mcg-mcg

600-300 mcg 4 $0

250 mcg 4 $0

formulation 4 $0

mcg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

300-250 mg-mcg-mcg 4 $0

Complex) 4 $0

unitdrop 4 $0

unit02 ml 4 $0

(Super B Complex-

Vitamin C) 4 $0

bee-zee tablet 4 $0

biosupp liquid 4 $0

free 300 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

biovol syrup 4 $0

mg(1500mg) -200 unit 4 $0

mg(2500 mg)-800 unit 4 $0

125 mg-unit

(Oyster Shell +

D3) 4 $0

(1250mg) -600 unit (Os-Cal 500 + D3) 4 $0

mg-unit 4 $0

mg(1500mg) -200 unit 4 $0

(Calcium 600 +

D(3)) 4 $0

800 unit

(Caltrate with

Vitamin D3) 4 $0

iron15 ml 4 $0

300-250 mg-mcg-mcg 4 $0

mcg 4 $0

400 mg-mcg 4 $0

iron15 ml 4 $0

04-300-250 mg-mcg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg 4 $0

400 mg-mcg 4 $0

600-300 mcg 4 $0

400 mg-mcg 4 $0

mg-mcg 4 $0

250 mg-mcg-mcg 4 $0

iron15 ml 4 $0

mg-mcg 4 $0

iron 4 $0

compete tablet 4 $0

250 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

free 100 mg 4 $0

Vitamin C) 4 $0

shell 500 mg(1250mg) -125 unit 4 $0

pf 500 mg(1250mg) -200 unit 4 $0

800 unit

(Caltrate with

Vitamin D3) 4 $0

200 mcg 4 $0

iron) 4 $0

free 200 mcg 4 $0

300-250 mg-mcg-mcg 4 $0

mcg 4 $0

mg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

600-300 mcg 4 $0

400 mg-mcg 4 $0

pf 4 $0

mg 4 $0

unit 4 $0

coated 4 $0

400 mg-mcg 4 $0

lactose-free 4 $0

400 mg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

sf 400 unit 4 $0

unitml 4 $0

ellis tonic 4 $0

mg 4 $0

TABLET 750 MG 4 $0

iron 4 $0

300-250 mg-mcg-mcg 4 $0

free 18-400 mg-mcg 4 $0

400-20-300 mcg 4 $0

mg-mcg-mcg 4 $0

mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

iron) 4 $0

mg iron) 4 $0

mg iron 4 $0

mg 4 $0

iron) 4 $0

mg iron)

(Ferate) 4 $0

(60 mg iron)5 ml 4 $0

(65 mg iron) 4 $0

(Feosol) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

iron 4 $0

(otc) 1 mg 4 $0

free 04-300-250 mg-mcg-mcg 4 $0

300-250 mg-mcg-mcg 4 $0

hair vitamins 4 $0

mg (106 mg iron) 4 $0

mg-mcg-mcg 4 $0

mg-mcg 4 $0

free 18-400 mg-mcg 4 $0

free 400 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

iron) 4 $0

mg iron 4 $0

kpn tablet 4 $0

mg-mcg 4 $0

mg5 ml 4 $0

7160 UNIT-113 MG-100 UNIT 4 $0

mcg 4 $0

MG 3 $0

mg-mcg 4 $0

mcg-80 mcg 4 $0

mg-mcg 4 $0

iron5 ml 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

VitaminsIron) 4 $0

CHEWS) 4 $0

iron15 ml 4 $0

Vitamin) 4 $0

025 mgml 4 $0

childrens 4 $0

mg-mg-mcg-mg 3 $0

mg-mcg 3 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mg 4 $0

mcg 4 $0

400 mg-mcg 4 $0

mg-mcg 4 $0

mcg 4 $0

400 mg-mcg 4 $0

iron-400 mcg 4 $0

mg(1250mg) -200 unit 4 $0

mg(1250mg) -400 unit 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

-400 unit

mg(1250mg) -400 unit 4 $0

ALL RX PRENATAL

VITAMINS

COVERABLE

UNDER PART D

iron 4 $0

mg-unitml 4 $0

400 unit-10 mgml 4 $0

unit-mg-unitml 4 $0

800 mcg 4 $0

iron- 800 mcg 4 $0

mg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

(Prenatal) 4 $0

iron- 08 mg 4 $0

ALL RX PRENATAL

VITAMINS

COVERABLE

UNDER PART D

800 mcg 4 $0

unit 4 $0

mgml 3 $0

mg iron 4 $0

04 mg 4 $0

250 mg-mcg-mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

mcg 4 $0

mg(1250mg) -200 unit 4 $0

mg 4 $0

mcg 4 $0

mg 4 $0

mcgml 4 $0

500 mg 4 $0

mcg 3 $0

iron- 08 mg 4 $0

mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

500-300-250 mg-mcg-mcg-mcg 4 $0

mcg-mcg 4 $0

CHEWS) 4 $0

chewable 4 $0

gluten-free

(Super B Complex-

Vitamin C) 4 $0

300-250 mg-mcg-mcg 4 $0

gluten-free 4 $0

VitaminsIron) 4 $0

Vitamin) 4 $0

mg 4 $0

mcg 4 $0

iron- 800 mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

600-300 mcg 4 $0

sodfluorid)ml

400 mcg- 18 mg iron 4 $0

400 mcg- 27 mg iron 4 $0

25 mcg 4 $0

600 mg(1500mg) -400 unit

(Calcium 600 +

D(3)) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

support liquid 4 $0

iron-667 mcg-1000 mcg 4 $0

thera caplet 4 $0

mcg 4 $0

thera-m caplet 4 $0

iron-400 mcg 4 $0

mcg 4 $0

iron-400 mcg 4 $0

pfcaplet 4 $0

pf 4 $0

therems tablet 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

unitml 4 $0

mg-unitml 4 $0

50000 unit 3 $0

orangesf 4 $0

400 mcg- 18 mg iron 4 $0

mcg 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

400 mcg 4 $0

mg 4 $0

250 mg 4 $0

mg 4 $0

500 mg 4 $0

unit 4 $0

1000 unit 4 $0

unit 4 $0

2000 unit (D3 DOTS) 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

unit 4 $0

unit5 ml 4 $0

5000 unit

(Dialyvite Vitamin

D) 4 $0

5000 UNITML

400 unit 4 $0

mcg-mcg-mcg 4 $0

250 mcg 4 $0

mcg 3 $0

1333 mg-unit 4 $0

page number xv

Name of Drug

Tier level

What the

drug will

cost you

Necessary Actions

Restrictions or

Limits on Use

1ST TIER UNILET

COMFORTOUCH 135

3 3 day vaginal 57

3-day vaginal 53

A a thru z 214

a thru z select 214

abacavir 76

abc plus 214

ABELCET 54

ABILIFY MAINTENA 71

ABRAXANE 30

ABREVA 64

acamprosate 16

acarbose 49

ACCU-CHEK MULTICLIX

LANCET 135

PLUS 136

ACCU-CHEK SOFTCLIX

LANCETS 136

acebutolol 94

acephen 3

acetazolamide 198

acetic acid 154 193

acetylcysteine 210

acid controller 159

acitretin 127

acne medication 127

ACNE MEDICATION 128

acta-tabs pe 62

ACTEMRA 182

ACTHIB (PF) 187

ACTIMMUNE 195

acyclovir 81 128

ADACEL(TDAP

ADAGEN 148

adapalene 135

ADCIRCA 213

adefovir 82

ADEMPAS 213

adriamycin 30

adrucil 30

adults 50 plus 215

ADVAIR DISKUS 206

ADVAIR HFA 206

ADVANCED TRAVEL

LANCETS 136

ADVIL 11

ADVOCATE LANCET 136

afeditab cr 100

AFINITOR 30

AFINITOR DISPERZ 30

aftera 110

a-hydrocort 176

AKTEN (PF) 150

AKYNZEO 66

ala-cort 132

alavert 58

ALBENZA 68

alclometasone 132

ALCOHOL PADS 128

ALDURAZYME 148

ALECENSA 30

alendronate 193 194

aler-cap 58

aler-tab 58

alfuzosin 173

ALIMTA 30

ALINIA 68

ALIQOPA 30

aller-chlor 58

allergy medicine 62

allerhist-1 58

aller-tec d 58

allopurinol 57

almacone 161

almacone-2 161

alophen 167

alosetron 192

ALPHAGAN P 198

alprazolam 18

ALREX 157

altamist 150

altavera (28) 110

ALUNBRIG 31

alyacen 135 (28) 110

alyacen 777 (28) 110

amabelz 175

amantadine hcl 69

ambi 20dm-4cpm 118

ambi 60pse-4cpm 58

AMBISOME 54

amethia 110

amethia lo 110

amiloride 101

AMINO ACIDS 15 85

AMINOSYN 10 86

AMINOSYN 7 WITH

ELECTROLYTES 86

AMINOSYN 85 86

AMINOSYN 85 -

ELECTROLYTES 86

AMINOSYN II 10 86

AMINOSYN II 15 86

AMINOSYN II 7 86

AMINOSYN II 85 86

AMINOSYN II 85 -

ELECTROLYTES 86

AMINOSYN M 35 86

AMINOSYN-HBC 7 86

AMINOSYN-PF 10 87

AMINOSYN-PF 7

(SULFITE-FREE) 87

AMINOSYN-RF 52 87

amiodarone 94

AMITIZA 161

amitriptyline 46

amlactin 128

amlodipine 100

amoxapine 46

amoxicillin 26

amphotericin b 54

ampicillin 27

AMPYRA 106

ANADROL-50 174

anagrelide 85

anastrozole 31

ANDRODERM 174

ANDROGEL 174

androxy 174

animal chews 215

ANORO ELLIPTA 208

anti-diarrheal 163

antifungal cream 54

antihistamine 58

antioxidant 215

apatate forte 215

APOKYN 69

apraclonidine 150

aprepitant 66

apri 110

APRISO 192

aprodine 58

APTIOM 41

APTIVUS 76

aquanil hc 132

aranelle (28) 110

ARCALYST 182

aripiprazole 71

ARISTADA 71

armodafinil 211

ARNUITY ELLIPTA 206

ARTIFICIAL TEARS

(PETROMIN) 150

ashlyna 110

aspirin 12 14

aspirin buffered 12

aspir-low 12

aspir-trin 12

ASSURE HAEMOLANCE

PLUS 136

ASSURE ID INSULIN

SAFETY 136

ASSURE LANCE 137

ASTAGRAF XL 182

atenolol 95

athenol 10

atomoxetine 106

atorvastatin 103

atovaquone 68

ATRIPLA 76

atropine 41 150

ATROVENT HFA 208

AUBAGIO 106

aubra 110

AUSTEDO 106

AVASTIN 31

AVC VAGINAL 64

aviane 110

AVONEX 107

ayr saline 150

azacitidine 31

azathioprine 182

azelastine 150 151

azithromycin 24

aztreonam 25

azurette (28) 110

B b complete 215

b complex 1 215

b complex 100 230

215 222 230

b-12 dots 215

baby ddrops 215

baclofen 211

bal b-100 218

bal b-50 218

balance b-100 215

balance b-50 215

balsalazide 192

balziva (28) 110

banophen 58

banophen allergy 58

BANZEL 41

BAVENCIO 31

BAXDELA 28

baza antifungal 54

b-complex 227

218 229 232 233

BD INSULIN SYRINGE

ULTRA-FINE 137

NEEDLES 137

bee-zee 215

bekyree (28) 110

BELBUCA 3

BELEODAQ 31

BELSOMRA 211

benadryl allergy 58

benazepril 92

BENDEKA 31

BENLYSTA 196

benzonatate 118 119

benztropine 69

BESPONSA 31

BETADINE 128

beta-hc 132

BETASERON 107

betaxolol 95 198

BETHKIS 19

BEVYXXA 82

bexarotene 31

BEXSERO 187

bicalutamide 31

bicarsim forte 158

BICILLIN C-R 27

BICILLIN L-A 27

BIDIL 105

bio-dtuss dmx 119

bion tears (pf) 151

biosupp 215

biotin 215

biovol 216

bisac-evac 167

bisacodyl 167

biscolax 167

bismatrol 161

bismuth 163

bleomycin 31

bleph-10 154

BLINCYTO 31

blisovi 24 fe 111

blisovi fe 1530 (28) 111

blisovi fe 120 (28) 111

BOOSTRIX TDAP 187

BOSULIF 31

BREO ELLIPTA 206

briellyn 111

BRILINTA 85

brimonidine 198

BRIVIACT 41

bromfed dm 119

bromocriptine 69

dm 118 119

BROMSITE 157

brotapp dm 119

budesonide 192 206

buffered aspirin 15

bufferin 12

LANCETS 137

bumetanide 101

BUNAVAIL 16

BUPHENYL 161

buprenorphine 4

bupropion hcl 46

buspirone 18

BUTRANS 4

BYSTOLIC 95

BYVALSON 95

C cabergoline 69

CABOMETYX 31

bor 201 205

calci-chew 161

calcidol 216

calcipotriene 128

calcitrate 199

calcitrene 128

calcitriol 128 194

calcium 500 + d 218

calcium 500 + d (d3) 218

calcium 600 199 205

calcium 600 + d(3) 200 216

199 202

calcium acetate 172

calcium antacid 162

199 200 216 218 230

CALCIUM CARBONATE-

VITAMIN D3 200

201 205

calcium+d 234

CALDOLOR 12

CALQUENCE 31

camila 111

camrese 111

camrese lo 111

CANASA 192

CANCIDAS 54

candesartan 91

capacet 4

CAPASTAT 65

CAPRELSA 32

captopril 93

CARAFATE 159

CARBAGLU 162

carbamazepine 41

CAREONE ULTRA THIN

LANCET 137

CARETOUCH TWIST

LANCET 138

CARIMUNE NF

NANOFILTERED 182

carisoprodol 211

carteolol 198

cartia xt 96

carvedilol 95

caspofungin 54

CASTELLANI PAINT

MODIFIED 128

CAYSTON 26

caziant (28) 111

cefaclor 22

cefadroxil 22

cefazolin 22

cefdinir 22

CEFEPIME 22

CEFEPIME IN

DEXTROSEISO-OSM 22

cefotaxime 23

cefoxitin 23

cefpodoxime 23

cefprozil 23

ceftazidime 23

ceftibuten 23

ceftriaxone 23

celecoxib 12

CELONTIN 42

centamin 216

centergy dm 119

central-vite 228

centram-care 216

centrum 216

centrum silver 216

centrum women 217

century 217

cephalexin 24

CERDELGA 148

CEREZYME 148

cerovite 217

cerovite jr 217

cerovite senior 217

cetiri-d 62

cetirizine 59

CETYLEV 196

cevimeline 127

CHANTIX 16

CHANTIX CONTINUING

MONTH BOX 16

CHANTIX STARTING

MONTH BOX 16

chewable-vite 217

CHILDRENS ADVIL 12

childrens mapap 5

childrens pepto 162

CHILDRENS ZYRTEC

ALLERGY 59

childsiron 217

chlorhist 59

chlorothiazide 101

chlorpromazine 71

chlorthalidone 101

chlorzoxazone 211

219 233 234

CHOLECALCIFEROL

(VITAMIN D3) 234

ciclopirox 54

cilostazol 85

cimetidine 159

cimetidine hcl 159

CIMZIA 182

CIMZIA POWDER FOR

RECONST 182

CINQAIR 210

CINRYZE 83

CIPRODEX 154

ciprofloxacin 29

citalopram 46

citrus calcium 200

clarithromycin 25

clearlax 171

CLEVIPREX 101

clindamycin hcl 20

130 131

CLINIMIX 5D15W

SULFITE FREE 87

CLINIMIX 5D25W

SULFITE-FREE 87

CLINIMIX 275D5W

SULFIT FREE 87

FREE 87

CLINIMIX 425D5W

SULFIT FREE 87

CLINIMIX 425-D20W

SULF-FREE 87

CLINIMIX 425-D25W

SULF-FREE 87

CLINIMIX 5-

CLINIMIX E 275D10W

SUL FREE 88

CLINIMIX E 275D5W

SULF FREE 88

CLINIMIX E 425D10W

SUL FREE 88

CLINIMIX E 425D25W

SUL FREE 88

CLINIMIX E 425D5W

SULF FREE 88

CLINIMIX E 5D15W

SULFIT FREE 88

CLINIMIX E 5D20W

SULFIT FREE 88

CLINIMIX E 5D25W

SULFIT FREE 88

CLINISOL SF 15 88

clobetasol 132

clofarabine 32

clomipramine 46

clonazepam 18

clonidine 91

clonidine hcl 91

clopidogrel 85

clotrimazole 54

clotrimazole-7 54

clozapine 71 72

COARTEM 68

codeine sulfate 5

COLCRYS 57

cold-flu relief 120

colestipol 103

colocort 192

COLOR LANCETS 144

col-rite 171

COLY-MYCIN S 155

COMBIGAN 198

COMBIPATCH 175

COMETRIQ 32

comfort gel 162

COMFORT LANCETS 138

compete 217

COMPLERA 76

complete 229

complete 50+ 222

complete multi 217

220 229

complete women 222

compoz 60

compro 66

CONDYLOX 128

congestac 120

congest-eze 120

constulose 162

COPAXONE 107

coricidin hbp 120

CORLANOR 97

cormax 132

cortaid 132

cortisone 176

COTELLIC 32

cough syrup dm 122

CREON 149

CRIXIVAN 76

cromolyn 151 210

cryselle (28) 111

CUPRIMINE 173

215 219 228 232 233

cyclafem 135 (28) 111

cyclafem 777 (28) 111

cyclobenzaprine 211

cyclopentolate 151

cyclophosphamide 32

CYCLOPHOSPHAMIDE 32

CYCLOSET 49

cyclosporine 182

cyproheptadine 60

CYRAMZA 32

cyred 111

CYSTADANE 196

CYSTARAN 151

d3 dots 219

daily gummies 218

daily value 219

daily vitesiron 219

dailyhist-1 60

daily-vite 219

DAKLINZA 80

DALIRESP 210

danazol 174

dantrolene 211

dapsone 65

DAPTACEL (DTAP

PEDIATRIC) (PF) 187

daptomycin 20

DARAPRIM 69

DARZALEX 32

dasetta 135 (28) 111

dasetta 777 (28) 111

dayhist 60

dayhist allergy 60

daysee 111

day-time cough 121

deblitane 111

decitabine 32

deep sea nasal 151

deferoxamine 174

delta d3 220

delyla (28) 111

DELZICOL 193

DEMSER 97

DEPEN TITRATABS 174

DEPO-PROVERA 181

dermafungal 55

DERMAREST ECZEMA

(PRAMOXINE) 133

DESCOVY 76

desipramine 46

desmopressin 178

desoximetasone 133

guaif) 121

dex4 glucose 88

phosphate 157 177

dextroamphetamine-

amphetamine 107

diamode 163

DIASTAT 18

DIASTAT ACUDIAL 18

diazepam 18

dicloxacillin 27

dicyclomine 163

didanosine 76

DIFICID 25

diflunisal 13

digitek 98

digox 98

digoxin 98 99

DIGOXIN 98

DILANTIN 42

dilt-cd 96

diltiazem hcl 96 97

dilt-xr 97

dimaphen (pe) 60

dimaphen dm 121

dimenhydrinate 66

(CPM-DM) 121

dino-life 220

DIPENTUM 193

diphedryl 60

diphenhist 60

dipyridamole 85

disulfiram 16

divalproex 42

dobutamine 99

docu 168

docusate sodium 168

docusol 168

dofetilide 94

dok 168

dok plus 168

donepezil 45

dopamine 99

dorzolamide 198

doxazosin 91

doxepin 46 47

doxercalciferol 194

doxorubicin 32

doxy-100 29

dramamine 66

driminate 66

dronabinol 66

droperidol 196

DROPLET LANCETS 138

DROXIA 32

DUAVEE 175

DULERA 207

duloxetine 47

DUPIXENT 129

DUREZOL 157

dutasteride 173

d-vi-sol 220

E ec prin 13

ees 400 25

ees granules 25

EASY TOUCH SAFETY

LANCETS 138

EASY TOUCH TWIST

LANCETS 138 139

EASY TWIST AND CAP

LANCETS 139

econazole 55

econtra ez 112

ecotrin 13

ed a-hist 61

ed bron gp 121

ed chlorped jr 61

EDARBI 92

EDARBYCLOR 92

EDURANT 76

EFFIENT 85

ELAPRASE 149

eldertonic 220

ELIDEL 133

ELIGARD 33

elinest 112

eliphos 172

ELIQUIS 82

ELITEK 149

ELLA 112

ellis tonic 220

ELMIRON 196

EMBRACE LANCETS 139

EMCYT 33

EMEND 66

EMFLAZA 177

emoquette 112

EMPLICITI 33

EMSAM 47

EMTRIVA 76

enalaprilat 93

ENBREL 182 183

ENDARI 196

endocet 5

endur-acin 103

endur-amide 220

ENDUR-AMIDE 220

enema 171

enemeez 168

enemeez plus 168

ENGERIX-B (PF) 188

enoxaparin 82

enpresse 112

enskyce 112

entacapone 70

entecavir 82

ENTRESTO 92

enulose 163

ENVARSUS XR 183

EPCLUSA 80

epinastine 151

epinephrine 99

EPIPEN 99

EPIPEN 2-PAK 99

EPIPEN JR 2-PAK 100

epitol 42

EPIVIR HBV 76

eplerenone 105

EPOGEN 84

eq gentle 151

equalactin 168

ergoloid 196

ERGOMAR 64

ERIVEDGE 33

errin 112

ery pads 131

ERYPED 200 25

ERYPED 400 25

ery-tab 25

ERY-TAB 25

ERYTHROCIN 25

erythromycin 25 155

ESBRIET 210

esmolol 95

essentia 220

essential daily 220

estarylla 112

ESTRACE 175

estradiol 175

estropipate 176

eszopiclone 212

ethambutol 65

ethosuximide 42

etodolac 13

ETOPOPHOS 33

etoposide 33

EUCRISA 133

EVOTAZ 76

exemestane 33

EXJADE 174

EXONDYS 51 196

expectorant 121

expectorant dm 121

EXTAVIA 107

ezetimibe 103

F FABRAZYME 149

fallback solo 112

falmina (28) 112

famciclovir 82

famotidine 160

famotidine (pf) 159

FANAPT 72

FARESTON 33

FARYDAK 33

FASENRA 210

FASLODEX 33

felbamate 42

felodipine 101

FEMRING 176

femynor 112

fenofibrate 103

fenofibric acid 103

fenoprofen 13

fentanyl 6

fentanyl citrate 6

feosol 221

ferate 221

ferocon 221

ferretts 221

ferrex 150 221

ferrex 150 plus 221

ferric x-150 221

FERRIPROX 174

ferrocite 221

FETZIMA 47

feverall 6

fexofenadine 61

FIASP 52

FIASP FLEXTOUCH 51

fiber smooth 171

fiber-lax 169

FIFTY50 SAFETY SEAL

LANCETS 139

finasteride 173

FINE 30 UNIVERSAL

LANCETS 139

FIRAZYR 100

FLEBOGAMMA DIF 183

flecainide 94

FLECTOR 129

FLEET BISACODYL 169

FLOVENT DISKUS 207

FLOVENT HFA 207

floxuridine 33

flu hbp 122

fluconazole 55

flucytosine 55

fludrocortisone 177

flumazenil 107

flunisolide 157

fluocinolone 133

fluocinonide 133

fluocinonide-e 133

fluorometholone 157

fluorouracil 33 129

fluoxetine 47

fluphenazine hcl 72

flurbiprofen 13

flutamide 33

fluticasone 133 157

fluvoxamine 47

folic acid 222

fomepizole 196

fondaparinux 82 83

foot and sneaker 55

formula 3 55

FORTEO 194

fosamprenavir 76

foscarnet 79

fosfree 222

fosinopril 93

fosphenytoin 42

FREAMINE HBC 69 89

FREAMINE III 10 89

STRIPS 140

FREESTYLE TEST 140

fungi cure 55

fungoid-d 55

furosemide 102

FUZEON 76

FYCOMPA 42

G gabapentin 42

GABITRIL 42

galantamine 45

GAMASTAN SD 183

MCGML) 183

GAMMAPLEX 183

GAMMAPLEX (WITH

SORBITOL) 183

GARDASIL (PF) 188

GARDASIL 9 (PF) 188

gas relief 158

gas relief 80 158

gatifloxacin 155

GATTEX 30-VIAL 163

GAUZE PAD 140

gavilyte-c 169

gavilyte-g 169

gavilyte-n 169

GAZYVA 33

gemfibrozil 103

generlac 163

gengraf 183

GENOTROPIN 178

gentak 155

GENTEAL GEL 152

GENTEAL MILD 152

GENTEAL SEVERE 152

genteal tears 152

HPM-GLY) 152

gentlelax 169

GENVOYA 77

GEODON 72

geriaton 222

geri-dryl 61

geri-hydrolac 129

geri-tussin dm 122

gianvi (28) 112

gildagia 112

GILENYA 107

GILOTRIF 33

glatiramer 107

glatopa 108

GLEOSTINE 33

glimepiride 53

glipizide 53

GLUCAGEN HYPOKIT 49

GLUCAGON EMERGENCY

KIT (HUMAN) 49

gluco burst 89

glucose 89

glucose gel 89

glutose 15 89

glyburide 53

glycolax 169

glycopyrrolate 164

glydo 15

GLYXAMBI 49

GMATE LANCETS 140

GOCOVRI 70

granisetron (pf) 66

granisetron hcl 67

GRANIX 84

guaifenesin 122

guanfacine 91 108

guanidine 196

H HAEGARDA 84

hair vitamins 222

haloperidol 73

HARVONI 80

HAVRIX (PF) 188

HEALTHY ACCENTS

UNILET LANCET 140

healthylax 169

heather 112

hemocyte 222

HEPATAMINE 8 89

HERCEPTIN 34

HETLIOZ 212

HEXALEN 34

hi-b complex 222

HIBERIX (PF) 188

honey bears 222

HUMATROPE 178

HUMIRA 184

HUMIRA PEDIATRIC

CROHNS START 183

HUMIRA PEN 184

HS START 183

UVEITIS 184

KWIKPEN 52

HUMULIN R U-500

(CONCENTRATED) 52

hydralazine 100

hydromorphone 6 7

hydroskin 133

hydroxyurea 34

hydroxyzine hcl 61

HYQVIA 184

HYSINGLA ER 7

I ibandronate 194

IBRANCE 34

ibuprofen 12 13 15

icaps plus 222

ICLUSIG 34

IDHIFA 34

iferex 150 222

ifosfamide 34

ifosfamide-mesna 34

ILARIS (PF) 184

ILEVRO 157

imatinib 34

IMBRUVICA 34

IMFINZI 34

imipramine hcl 47

imiquimod 129

IMLYGIC 34

imodium a-d 164

IMODIUM A-D 164

(PF) 188

IMPAVIDO 69

LANCETS 140

INCRELEX 179

INCRUSE ELLIPTA 208

indapamide 102

indomethacin 13 14

infants advil 14

INFLECTRA 184

INGREZZA 108

INLYTA 34

INSECT REPELLENT

(PICARIDIN) 129

insta-glucose 89

U-100 140 141

INTELENCE 77

intense cough 122

INTRALIPID 90

INTRON A 81

introvale 112

INVANZ 26

INVEGA SUSTENNA 73

INVEGA TRINZA 73

INVIRASE 77

INVOKAMET 49

INVOKAMET XR 49

INVOKANA 50

inzo antifungal 55

iodine 148

IPOL 189

IPRIVASK 83

irbesartan 92

IRESSA 35

iron 223

ISENTRESS 77

ISENTRESS HD 77

isibloom 112

ISOLYTE-P IN 5

DEXTROSE 202

ISOLYTE-S 202

isoniazid 65

isopto tears 152

isradipine 101

itraconazole 55

ivermectin 69

IXEMPRA 35

IXIARO (PF) 189

J JADENU 174

JADENU SPRINKLE 174

JAKAFI 35

jantoven 83

JANUMET 50

JANUMET XR 50

JANUVIA 50

JARDIANCE 50

jencycla 112

JENTADUETO 50

JENTADUETO XR 50

jolessa 112

jolivette 112

juleber 112

junel 1530 (21) 112

junel 120 (21) 113

junel fe 1530 (28) 113

junel fe 120 (28) 113

junel fe 24 113

junior mapap 7

JUXTAPID 103

K KABIVEN 90

KALETRA 77

KALYDECO 210

KANUMA 149

kariva (28) 113

kelnor 135 (28) 113

KENALOG 177

ketoconazole 55

ketoprofen 14

KEVEYIS 196

KEVZARA 184

KEYTRUDA 35

kids mini enema 167

kimidess (28) 113

KINERET 184

KINRIX (PF) 189

kionex 164

KISQALI 35

klor-con m10 202

klor-con m15 202

klor-con m20 202

kobee 223

konsyl (sugar) 169

konsyl fiber 169

KORLYM 50

kpn 223

KRYSTEXXA 149

kurvelo 113

KUVAN 149

KYNAMRO 104

KYPROLIS 35

labetalol 95

LACRISERT 152

LACTINOL HX 129

lactulose 164

lamisil af 55 56

LAMISIL AT 56

lamivudine 77

lamotrigine 42 43

LANCETS 136 137 138 139

141 142 144

LANCETSTHIN 141 145

LANOXIN 100

lansoprazole 160

LANTUS 52

LANTUS SOLOSTAR 52

larin 1530 (21) 113

larin 120 (21) 113

larin 24 fe 113

larin fe 1530 (28) 113

larin fe 120 (28) 113

larissia 113

LARTRUVO 35

latanoprost 198

LATUDA 73

LAZANDA 7

leena 28 113

leflunomide 184

LEMTRADA 108

LENVIMA 35

lessina 113

LETAIRIS 213

letrozole 35

LEUKERAN 35

LEUKINE 84

leuprolide 36

levetiracetam 43

levobunolol 198

levocarnitine 197

levocetirizine 61

levofloxacin 29 155

levoleucovorin 197

LEVOLEUCOVORIN 197

levonest (28) 113

levonorgestrel 114

levora-28 114

levothyroxine 181

LEXIVA 77

LIALDA 193

lice killing 135

lice treatment 135

lidocaine 15

lidocaine hcl 15

lillow 114

linezolid 20 21

LINZESS 164

liothyronine 181

liquibid d-r 122

liquid c 223

lisinopril 93

lithium citrate 108

little animals 223

little remedies 152

LIVALO 104

lohist-dm 122

lomedia 24 fe 114

LONSURF 36

loperamide 163 164

lopreeza 176

lorata-d 62

loratadine 59 61 62

loratadine-d 60 61

lorazepam 18

lorcet hd 7

lorcet plus 7

loryna (28) 114

losartan 92

LOTEMAX 158

lovastatin 104

lubricant eye 151

lubricant gel 151

lubrifresh pm 152

LUMIGAN 199

LUPRON DEPOT 36

LUPRON DEPOT-PED (3

MONTH) 179

lutera (28) 114

LYNPARZA 36

LYRICA 43

lysiplex plus 223

LYSODREN 36

lyza 114

mag 64 202

mag-delay 202

mag-g 202

magnesium 200 205

malathion 135

maprotiline 48

marlissa 114

MARPLAN 48

masophen 8

MATULANE 36

matzim la 97

MAVYRET 80

meclizine 67

medi-bismuth 165

medi-meclizine 67

medi-natural 169

medi-phedrine 122

MEDI-PHENYL 91

mefenamic acid 14

mefloquine 69

MEFOXIN IN DEXTROSE

(ISO-OSM) 24

megestrol 36 181

MEKINIST 36

meloxicam 14

memantine 45

MENACTRA (PF) 189

MENEST 176

MENHIBRIX (PF) 189

MENOMUNE - ACYW-135

(PF) 189

mens one daily 220

(PF) 189

MEPHYTON 223

mercaptopurine 36

meropenem 26

mesalamine 193

mesna 197

MESNEX 197

MESTINON 197

metaproterenol 208

metformin 50

methadone 8

methadose 8

methazolamide 199

methimazole 181

methocarbamol 211

methoxsalen 129

methscopolamine 165

metipranolol 199

metolazone 102

mexiletine 94

mgo 165

MIACALCIN 194

mi-acid 165

micatin 56

miconazole 7 56

miconazole-3 56

MICROLET LANCET 141

midodrine 91

miglitol 50

milrinone 100

mimvey 176

mimvey lo 176

MINERAL OIL 197

minitran 106

minocycline 30

minoxidil 106

mintox 165

mintox plus 165

MIRCERA 84

mirtazapine 48

misoprostol 160

mitoxantrone 37

M-M-R II (PF) 189

moexipril 93

molindone 73

mometasone 134

MONISTAT 3 56

monistat 7 56

MONOLET LANCETS 141

mono-linyah 114

mononessa (28) 114

montelukast 207

morphine 8

MORPHINE 8

motion sickness 66

MOVANTIK 165

MOVIPREP 169

MOXEZA 155

moxifloxacin 29 155

MOZOBIL 84

mucus dm 122

mucus dm max 122

mucus relief dm 123

MULTAQ 94

multi for her 223

multi-delyn 223

multilex 224

mupirocin 131

muro 128 152

my way 114

MYGLUCOHEALTH

LANCETS 141

MYLOTARG 37

MYRBETRIQ 173

mytab gas 159

my-vitalife 224

myzilra 115

N nabumetone 14

nadolol 96

nafcillin 27

NAGLAZYME 149

naloxone 16

naltrexone 16

NAMENDA XR 45

NAMZARIC 45 46

naproxen 14

naratriptan 64

NARCAN 16

nasal relief 152

NASCOBAL 224

NATACYN 155

nateglinide 50

NATPARA 194

NATRAPEL 129

natural b-100 234

natural calcium 203

natura-lax 171

NEBUPENT 69

necon 0535 (28) 115

necon 150 (28) 115

necon 1011 (28) 115

necon 777 (28) 115

nefazodone 48

neomycin 19

dexameth 155

neomycin-polymyxin-

gramicidin 155

neo-polycin 156

neo-polycin hc 156

neo-tuss 123

nephplex rx 224

NEPHRAMINE 54 90

nephron fa 224

nephro-vite rx 224

NERLYNX 37

NEULASTA 84

NEUPOGEN 84

NEUPRO 70

nevirapine 77 78

NEXAVAR 37

niacin 104

niacinamide 104 224

niacor 104

nicardipine 101

nicorelief 16

NICORETTE 17

nicotine 17

NICOTROL 17

nifedipine 101

night time cold 123

nighttime cough 121

nikki (28) 115

nilutamide 37

NINLARO 37

nite time 125

NITRO-BID 106

nitroglycerin 106

NIX CREME RINSE 135

nohist-dm 123

non-aspirin 5 8 10

non-aspirin child 8

non-aspirin flu 126

nora-be 115

norlyda 115

norlyroc 115

NORMOSOL-M IN 5

DEXTROSE 203

nortemp 9

NORTHERA 91

nortrel 0535 (28) 115

nortrel 135 (21) 115

nortrel 135 (28) 115

nortrel 777 (28) 116

nortriptyline 48

NORVIR 78

nose spray 153

NOVOLIN 7030 52

NOVOLIN N 52

NOVOLIN R 52

NOVOLOG 52

NOVOLOG FLEXPEN 52

NOVOLOG MIX 70-30

FLEXPEN 52

NOVOLOG PENFILL 52

NOXAFIL 56

NUCALA 210

NUCYNTA 9

NUCYNTA ER 9

NUEDEXTA 109

nu-iron 224

NULOJIX 185

nu-mag 203

NUPLAZID 74

NUTRESTORE 165

NUTRILIPID 90

NUVARING 116

nyamyc 56

nyata 56

nystatin 56

nystop 57

nytol 62

O OCALIVA 165

ocean nasal 153

ocella 116

OCREVUS 109

OCTAGAM 185

ocutabs 224

ODEFSEY 78

ODOMZO 37

OFEV 210

off active 129

off deep woods 129

ofloxacin 29 156

ogestrel (28) 116

olanzapine 74

olmesartan 92

olopatadine 153

OLYSIO 80

omeprazole 160

OMNITROPE 180

ON CALL LANCET 142

ONCASPAR 37

onccor 224

once daily 224

oncovite 225

ondansetron 67

ondansetron hcl 67

one daily 225 228

ONETOUCH DELICA

LANCETS 142

ONETOUCH SURESOFT

LANCING DEV 142

ONETOUCH ULTRASOFT

LANCETS 142

ONFI 19

ONIVYDE 37

OPDIVO 37

OPSUMIT 213

option-2 116

oralone 127

oralyte 203

ORENCIA 185

ORENITRAM 213

ORFADIN 149

ORKAMBI 210

orsythia 116

oseltamivir 80

OTEZLA 185

OTEZLA STARTER 185

OTOVEL 153

OTREXUP (PF) 185

oxacillin 27

oxandrolone 175

oxcarbazepine 43

OXTELLAR XR 43

oxycodone 9

oxycodone-aspirin 9

OXYCONTIN 9 10

oxymorphone 10

oysco 500d 225

oysco-500 203

226 228

oystercal-d 226

P pacerone 94

pain and fever 10

pain relief 5

pain relief adult 5

paliperidone 74

PANRETIN 129

pantoprazole 160

paromomycin 69

paroxetine hcl 48

PASER 65

PAXIL 48

p-col rite 171

pecgen dmx 123

pedia relief 125

PEDIARIX (PF) 189

203 205

PEDVAX HIB (PF) 190

PEGANONE 43

PEGASYS 81

PEGASYS CONVENIENCE

PACK 81

PEGASYS PROCLICK 81

PEGINTRON 81

PENTACEL (PF) 190

PENTACEL DTAP-IPV

COMPNT (PF) 190

PENTAM 69

pentoxifylline 85

pep-t-med 165

peri-colace 170

PERIKABIVEN 90

periogard 127

permethrin 135

perphenazine 74

perry prenatal 226

persa-gel 129

pfizerpen-g 28

pharbetol 10

phenadoz 67

phenelzine 48

phenobarbital 43

phenytoin 43

phenytoin sodium 44

philith 116

phillips 165

PHOSLYRA 172

PICATO 129 130

pimozide 74

pimtrea (28) 116

pindolol 96

pink bismuth 166

pioglitazone 51

pirmella 116

piroxicam 14

PLASMA-LYTE 148 203

PLASMA-LYTE A 203

PLASMA-LYTE-56 IN 5

DEXTROSE 203

PLEGRIDY 109

podofilox 130

polycin 156

poly-iron 226

poly-vita 226

poly-vitamin 226

poly-vitamins 226

POMALYST 37

portia 116

PORTRAZZA 37

POTIGA 44

PRADAXA 83

PRALUENT PEN 104

pramipexole 70

prasugrel 85

pravastatin 104

prazosin 91

prednicarbate 134

158 177

prednisone 177 178

PREMARIN 176

PREMASOL 10 90

PREMASOL 6 90

PREMPHASE 176

PREMPRO 176

prenatal tablet 228

PRESSURE ACTIVATED

LANCETS 142

prevalite 104

previfem 116

PREZCOBIX 78

PREZISTA 78

PRIFTIN 65

PRILOSEC OTC 160

PRIMAQUINE 69

primidone 44

PRIVIGEN 185

PROAIR HFA 208

probenecid 58

procainamide 94

PROCALAMINE 3 90

prochlorperazine 67

PROCRIT 84 85

procto-med hc 134

procto-pak 134

proctosol hc 134

proctozone-hc 134

PROCYSBI 149

PRODIGY LANCETS 143

PRODIGY TWIST TOP

LANCET 143

PROGLYCEM 197

PROGRAF 186

PROLASTIN-C 210

PROLENSA 158

PROLEUKIN 37

PROLIA 195

PROMACTA 85

promethazine vc 62

promethazine-dm 123

promethegan 68

promolaxin 170

propafenone 94

propantheline 41

proparacaine 153

propranolol 96

PROQUAD (PF) 190

prosight 227

PROSOL 20 90

protamine 85

protriptyline 48

PULMOZYME 149

purelax 168

PURIXAN 37

PUSH BUTTON SAFETY

LANCETS 143

pyrazinamide 65

quasense 116

quetiapine 74

QUFLORA 227

quinapril 93

quinine sulfate 69

QVAR 207

R RABAVERT (PF) 190

RADICAVA 109

raloxifene 176

ramipril 94

RANEXA 100

RAPAMUNE 186

rasagiline 70

RASUVO (PF) 186

RAVICTI 166

RAYALDEE 195

react 116

READYLANCE SAFETY

LANCETS 143

REBIF REBIDOSE 109

reclipsen (28) 116

recort plus 134

refenesen 124

refenesen pe 124

REFRESH OPTIVE

ADVANCED 156

reguloid 171

RELIAMED LANCET 143

LANCETS 143

LANCETS 144

RELISTOR 166

REMICADE 186

REMODULIN 213

RENAGEL 172

rena-vite rx 228

RENFLEXIS 197

RENVELA 172

repaglinide 51

REPATHA SYRINGE 104

repel sportsmen 130

reprexain 10

RESCRIPTOR 78

RESTASIS 158

retaine cmc 153

retaine hpmc 153

retaine pm 153

RETROVIR 78

revive plus 151

REVLIMID 37

revonto 211

REXULTI 74

REYATAZ 78

ribasphere 82

ribavirin 82

RIDAURA 186

rifabutin 65

rifampin 65

RIFATER 65

ri-gel ii 166

riginic 166

riluzole 109

rimantadine 80

ri-mox 166

ringers 193 205

risedronate 195

RISPERDAL CONSTA 74

risperidone 74 75

RITUXAN 38

RITUXAN HYCELA 38

rivastigmine 46

rizatriptan 64

robafen 124

robafen cough 124

robafen dm 124

ropinirole 70

rosadan 131

rosuvastatin 105

ROTARIX 190

ROTATEQ VACCINE 190

ROWEEPRA 44

RUBRACA 38

RYDAPT 38

S SABRIL 44

safe tussin dm 124

SAFETY LANCETS 144

SAIZEN 180

saline mist 153

saline nasal 151

saline nose 151

SANTYL 130

SAVELLA 109

scopolamine base 68

scot-tussin dm 124

selegiline hcl 70

SELZENTRY 78

senexon 171

senexon-s 171

senior tabs 228

senna 171

senna lax 171

senna laxative 168

senokot-s 171

SENSIPAR 195

sentry 229

sentry senior 229

SEREVENT DISKUS 209

SEROSTIM 180

sertraline 48

setlakin 116

sharobel 116

SHINGRIX (PF) 191

SHINGRIX GE ANTIGEN

COMPONENT 191

SIGNIFOR 180

silace 171

siladryl sa 62

silapap 11

SILENOR 212

SILIQ 130

siltussin sa 125

SIMBRINZA 199

simethicone 159

SIMPONI 186

SIMPONI ARIA 186

simvastatin 105

SINGLE-LET 144

sirolimus 186

SIRTURO 65

skin treatment 129

SMARTEST LANCET 144

smoflipid 90

smoothlax 172

sochlor 154

sodium acetate 205

sodium lactate 206

SOLIQUA 10033 53

SOLTAMOX 38

SOMAVERT 180

sorbitol 193

sorine 96

sotalol 96

sotalol af 96

SOVALDI 80

SPIRIVA WITH

HANDIHALER 209

spironolactone 102

sprintec (28) 116

SPRITAM 44

SPRYCEL 38

sronyx 116

ssd 131

stavudine 78

STELARA 186

STERILANCE TL 145

STERILE PADS 145

STIVARGA 38

stomach relief 166

stool softener 172

STRENSIQ 149

streptomycin 19

stress b-biotin 230

stress formula 230

STRIBILD 79

SUBOXONE 17

sucralfate 161

SUDAFED 125

sudogest 125

sudogest pe 91

sulfadiazine 29

sulfasalazine 193

sulfatrim 29

sulindac 15

sumatriptan 64

sunvite 230

super bc 230

super multiple 231

super quints 231

superior 35 231

superplex-t 231

suphedrin 125

support 231

support-500 231

SUPPRELIN LA 180

SUPRAX 24

SURE-LANCE 145

SURMONTIL 48

SUSTIVA 79

SUTENT 38

syeda 116

SYLATRON 81

SYLVANT 38

SYMBICORT 207

SYMLINPEN 120 51

SYMLINPEN 60 51

SYNAGIS 80

SYNAREL 180

SYNERCID 21

SYNJARDY 51

SYNJARDY XR 51

SYNRIBO 38

SYPRINE 174

SYSTANE GEL 154

T tab-a-vite 231

tab-a-viteiron 231

TABLOID 38

tacrolimus 134 186

tactinal 11

TAFINLAR 38

TAGRISSO 38

TALTZ SYRINGE 130

TAMIFLU 80

tamoxifen 38

tamsulosin 173

TARCEVA 38

TARGRETIN 38

tarina fe 120 (28) 116

TASIGNA 39

tazarotene 135

tazicef 24

TAZORAC 135

taztia xt 97

tears again 154

TECENTRIQ 39

TECFIDERA 109 110

TECHNIVIE 80

TEFLARO 24

TEKAMLO 105

TEKTURNA 105

TEKTURNA HCT 105

TELCARE LANCETS 145

telmisartan 92

temazepam 19

TEMODAR 39

tencon 11

TENIVAC (PF) 191

terazosin 173

terbinafine hcl 57

terbutaline 209

terconazole 64

testosterone 175

PED(PF) 191

TETANUS-DIPHTHERIA

TOXOIDS-TD 191

tetrabenazine 110

THALOMID 198

theophylline 209

thera 231

thera-d 231

theradex m 231

thera-m 231

therapeutic-m 231

thera-tabs 231

thera-tabs m 231

therems 231

therems-m 232

THIN LANCETS 144

THIOLA 198

thioridazine 75

thiotepa 39

thiothixene 75

tiagabine 44

TICE BCG 191

tigecycline 30

tilia fe 116

TIVICAY 79

tizanidine 211

tl icon 232

TOBI PODHALER 20

TOBRADEX 156

TOBRADEX ST 156

tobramycin 157

TOLAK 130

tolazamide 53

tolbutamide 53

tolnaftate 57

tolterodine 173

TOPCARE UNIVERSAL1

LANCET 145

topiramate 44

toposar 39

torsemide 102

total bc 232

TOTECT 198

TOUJEO SOLOSTAR 53

TOVIAZ 173

TRACLEER 213

TRADJENTA 51

tramadol 11

trandolapril 94

tranexamic acid 85

TRANSDERM-SCOP 68

tranylcypromine 48

TRAVASOL 10 90

TRAVATAN Z 199

travel sickness 68

trazodone 49

TREANDA 39

TRECATOR 66

TRELEGY ELLIPTA 210

TRELSTAR 39

TREMFYA 130

tretinoin 135

TREXALL 39

tri femynor 116

tricon 232

tri-estarylla 117

trifluoperazine 75

trifluridine 157

trihexyphenidyl 70

tri-legest fe 117

tri-linyah 117

tri-lo-marzia 117

tri-lo-sprintec 117

trimethoprim 21

trimipramine 49

trinessa (28) 117

TRINTELLIX 49

triple paste af 57

TRIPTODUR 180

TRIUMEQ 79

tri-vi-sol 232

tri-vita 232

tri-vitamin 232

trivora (28) 117

TROKENDI XR 44

TROPHAMINE 10 90

TROPHAMINE 6 90

trospium 173

TRULICITY 51

TRUMENBA 191

TRUVADA 79

tusnel diabetic 126

TUSSI PRES-B 126

tussin cf 125 127

tussin dm 124 126

tussin dm max 125

TWINRIX (PF) 191

TYBOST 198

TYKERB 39

tylophen 11

TYMLOS 195

TYPHIM VI 192

TYSABRI 186

TYVASO 213

U UCERIS 193

ULORIC 58

ULTILET CLASSIC

LANCETS 146

ULTILET LANCETS 146

ultra fresh pm 154

ULTRA THIN PLUS

LANCETS 144

unicomplex-m 232

UNILET COMFORTOUCH

LANCET 147

UNILET EXCELITE II

LANCET 147

UNILET LANCET 147

UNILET SUPER THIN

LANCETS 147

unisom sleepgels 62

UNISTIK 3 COMFORT

LANCET 147

UNISTIK 3 NORMAL

LANCET 147

UNISTIK SAFETY 148

UNITUXIN 39

141 148

UPTRAVI 214

ursodiol 167

V vagistat-3 57

valacyclovir 82

VALCHLOR 130

valganciclovir 82

valproate sodium 44

valproic acid 45

valsartan 92

VALSTAR 39

vancomycin 22

VAQTA (PF) 192

VARIVAX (PF) 192

VASCEPA 105

v-c forte 232

VELCADE 39

VELPHORO 172

VELTASSA 167

VEMLIDY 79

VENCLEXTA 39 40

VENCLEXTA STARTING

PACK 40

venlafaxine 49

verapamil 97

VERSACLOZ 75

VERZENIO 40

VESICARE 173

vestura (28) 117

VGO 40 148

VIBERZI 167

vic-forte 232

RELIEF 126

VICTOZA 51

VIEKIRA PAK 80

VIEKIRA XR 80

vienva 117

vigabatrin 45

VIGAMOX 157

VIIBRYD 49

VIMIZIM 149

VIMPAT 45

vinorelbine 40

viorele (28) 117

VIRACEPT 79

VIREAD 79

vision 232

VISTOGARD 198

230 233

vitalets 232

vitamin a 232

vitamin b-1 218 232

vitamin b-6 233

vitamin c 228 233

vitamin d3 228 230 233 234

vitamin k 234

vitamin k1 234

vitatrum 234

vitrum senior 234

vol-care rx 234

VOLTAREN 130

voriconazole 57

VOSEVI 81

VOTRIENT 40

VPRIV 150

vp-vite rx 234

VRAYLAR 75

vyfemla (28) 117

VYXEOS 40

wal-dram 68

wal-dryl allergy 63

wal-fex allergy 63

wal-finate 63

wal-finate-d 63

wal-itin 59 63

wal-itin d 63

wal-phed 63 127

wal-phed pe 91

wal-profen 15

wal-sleep z 63

wal-tap 64

wal-tussin 127

wal-tussin dm 118

wal-zan 75 161

wal-zyr d 64

warfarin 83

WELCHOL 105

wera (28) 117

womans laxative 172

X XADAGO 71

XALKORI 40

XARELTO 83

XATMEP 40

XELJANZ 186

XELJANZ XR 187

XERMELO 167

XIFAXAN 22

XOLAIR 211

XTAMPZA ER 11

XTANDI 40

xulane 117

XULTOPHY 10036 53

XURIDEN 198

XYREM 212

Y yelets 234

YERVOY 40

YF-VAX (PF) 192

YONDELIS 40

yuvafem 176

Z zafirlukast 207

zaleplon 212

zantac 75 161

zarah 117

ZARXIO 85

ZAVESCA 150

zebutal 11

ZEJULA 40

ZELBORAF 40

zenatane 130

zenchent (28) 117

ZENPEP 150

ZEPATIER 81

zephrex-d 127

ZERIT 79

ZIAGEN 79

zidovudine 79

ZINBRYTA 110

zinc oxide 129 130

ZIOPTAN (PF) 199

ziprasidone hcl 75

ZIRGAN 157

ZOLADEX 40

zoledronic acid 195

ZOLINZA 40

zolmitriptan 65

zolpidem 212

ZOMACTON 180 181

ZOMETA 195

zonisamide 45

zoo chews 2

ZORBTIVE 181

ZORTRESS 187

ZOSTAVAX (PF) 192

zovia 135e (28) 117

zovia 150e (28) 118

z-sleep 61 62

ZUBSOLV 17

ZURAMPIC 58

ZYDELIG 41

ZYKADIA 41

ZYLET 157

zyncof 127

ZYPREXA RELPREVV 75

ZYRTEC 64

ZYTIGA 41

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Table of Contents

INDEX

1

3

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

Documents

2018 List of Covered Drugs