2019 Formulary (List of Covered Drugs)

H0148_19_167_RX_V2

Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association

Counties Los Angeles amp San Diego

This formulary was updated on The List of Covered Drugs may change throughout the year We will send you a notice before we make a change that affects you For more recent information or other questions please contact Blue Shield Promise Cal MediConnect Plan member services at 1-855-905-3825 (TTY 711) from 800 am ndash 800 pm seven days a week or visit www blueshieldcacompromisecalmediconnect

Formulary ID 19463 Version 24

12012019

If you have questions please call Blue Shield Promise Cal MediConnect Plan at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is freeFor more information visit wwwblueshieldcacompromisecalmediconnect ii

Introduction

This document is called the List of Covered Drugs (also known as the Drug List) It tells you which prescription drugs and over-the-counter drugs are covered by Blue Shield Promise Cal MediConnect Plan The Drug List also tells you if there are any special rules or restrictions on any drugs covered by Blue Shield Promise Cal MediConnect Plan Key terms and their definitions appear in the last chapter of the Member Handbook

Table of ContentsA Disclaimers iii

B Frequently Asked Questions (FAQ) iv

B1 What prescription drugs are on the List of Covered Drugs (We call the List of Covered Drugs the ldquoDrug Listrdquo for short) iv

B2 Does the Drug List ever change iv

B3 What happens when there is a change to the Drug List v

B4 Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs vi

B5 How will you know if the drug you want has limitations or if there are required actions to take to get the drug vi

B6 What happens if we change our rules about some drugs (for example prior authorization (approval) quantity limits andor step therapy restrictions) vi

B7 How can you find a drug on the Drug List vii

B8 What if the drug you want to take is not on the Drug List vii

B9 What if you are a new Blue Shield Promise Cal MediConnect Plan member and canrsquot find your drug on the Drug List or have a problem getting your drug vii

B10 Can you ask for an exception to cover your drug viii

B11 How can you ask for an exception viii

B12 How long does it take to get an exception viii

B13 What are generic drugs viii

B14 What are OTC drugs ix

B15 Does Blue Shield Promise Cal MediConnect Plan cover OTC non-drug products ix

B16 What is your copay ix

B17 What are drug tiers ix

C List of Covered Drugs ix

D List of Drugs by Medical Condition xiE Index of Covered Drugs

Blue Shield Promise Cal MediConnect Plan

2019 List of Covered Drugs (Formulary)

If you have questions please call Blue Shield Promise Cal MediConnect Plan at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is freeFor more information visit wwwblueshieldcacompromisecalmediconnect iii

A Disclaimers

This is a list of drugs that members can get in Blue Shield Promise Cal MediConnect

bull Blue Shield Promise Cal MediConnect is a health plan that contracts with both Medicare andMedi-Cal to provide benefits of both programs to enrollees

bull The List of Covered Drugs may change throughout the year We will send you a notice before wemake a change that affects you

bull Benefits andor copays may change on January 1 of 2019

bull You can always check Blue Shield Promise Cal MediConnectrsquos up-to-date List of Covered Drugsonline at wwwblueshieldcacompromisecalmediconnect or by calling 1-855-905-3825 (TTY711) 800 am to 800 pm seven days a week

bull Limitations copays and restrictions may apply For more information call Blue Shield PromiseCal MediConnect Member Services or read the Blue Shield Promise Cal MediConnect MemberHandbook

bull Copays for prescription drugs may vary based on the level of Extra Help you get Please contactthe plan for more details

bull Espantildeol (Spanish) ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos deasistencia linguumliacutestica Llame a Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY 711)De 800 am a 800 pm los siete diacuteas de la semana

bull 繁體中文 (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Blue ShieldPromise Cal MediConnect Plan 1-855-905-3825 (TTY 711) 每周七天办公每天早上800 至晚上800这是免费电话

bull Tiếng Việt (Vietnamese) CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenhcho bạn Gọi số Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY 711) 8 giờ saacutengndash8 giờ tối7 ngagravey trong tuần HOẶC Ban

bull Tagalog (Tagalog ndash Filipino) PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamitng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa Blue Shield Promise CalMediConnect Plan 1-855-905-3825 (TTY 711) Mula 8am-8pm 7 araw sa isang lingo

bullbull 한국어 (Korean) 주의bull한국어를bull사용하시는bull경우bull언어bull지원bull서비스를bull무료로bull이용하실bull수bull있습니다 BlueShield Promise Cal MediConnect Plan 1-855-905-3825 (TTY 711)번으로bull전화해bull주십시오 번으로bull전화해bull주십시오오후bull8시 7 일bull주일bull오전bull8시

bull Հայերեն (Armenian) ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող ենտրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY (հեռատիպ) 711) Ից 800 ndash 2000 շաբաթը յոթ օր

bull Русский (Russian) ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатныеуслуги перевода Звоните Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (телетайп 711) С 800 до 2000 без выходных

باشد توجه می فراھم شما برای رايگان بصورت زبانی تسھيلات کنيد می گفتگو فارسی زبان به با اگر 1-855-905-3825 (TTY 711) بگيريد تماس تا 8 ھفته8 روزه ھمه ش

Arabic

بالمجان ملحوظة لك تتوافر اللغوية المساعدة خدمات فإن اللغة اذكر تتحدث كنت برقم إذا والبكم(اتصل الصم ھاتف رقم

711( 1-855-905-3825 Blue Shield Promise Cal MediConnect Plan )والبكم الصم ھاتف من)711 رقم

حتى 800الساعة الأسبوع 800صباحا أيام طوال مساء

(PersianFarsi)

با اگر به زبان فارسی گفتگو می کنيد تسھيلات زبانی بصورت رايگان برای شما فراھم می باشد توجه 1-855-905-3825 (TTY 711) تماس بگيريد ش ھمه روزه ھفته8 تا 8

Arabic

If you have questions please call Blue Shield Promise Cal MediConnect Plan at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is freeFor more information visit wwwblueshieldcacompromisecalmediconnect iv

bull 日本語 (Japanese) 注意事項日本語を話される場合無料の言語支援をご利用いただけますBlue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY711) までお電話にてご連絡ください毎日8am～8pm

bull ਪਜਾਬੀ (Panjabi) ਧਿਆਨ ਦਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਦ ਹ ਤਾ ਭਾਸਾ ਵਿਚ ਸਹਾਇਤਾ ਸਵਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਧ ਹ Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY711) lsquoਤ ਕਾਲ ਕਰਸਵਰ 8 ਵਜ ਤ ਸਾਮ 8 ਵਜ ਤਕ ਹਫਤ ਵਿਚ 7 ਦਿਨ

bull ខមែរ (CambodianKhmer) បរយតន បើសនជាអនកនយាយ ភាសាខមែរ សេវាជនយផនែកភាសា ដោយមនគតឈនល គអាចមានសរាបបរើអនក ចរ ទរសពទ Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY711)ចាបពមោងមោង 800 ពរក ដល មោង 800 យប បរាពរថងៃកនងមយសបតាហ

bull You can get this document for free in other formats such as large print braille or audio Call 1-855-905-3825 (TTY users should call 711) 800 am ndash 800 pm seven days a week The call is free

bull You can make a standing request to get materials in a language other than English or in an alternate format now and in the future To make a request please contact Blue Shield Promise Cal MediConnect Plan Member Services

B 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

B1 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 Drug List are the drugs covered by Blue Shield Promise Cal MediConnect Plan The 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

bull Blue Shield Promise Cal MediConnect Plan will cover all medically necessary drugs on the Drug List if

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

you fill the prescription at a Blue Shield Promise Cal MediConnect Plan network pharmacy

bull In some cases you have to do something before you can get a drug (see question B4 below)

You can also see an up-to-date list of drugs that we cover on our website at wwwblueshieldcacompromisecalmediconnect or call member services at 1-855-905-3825

B2 Does the Drug List ever change

Yes Blue Shield Promise Cal MediConnect Plan may add or remove drugs on the Drug List during the year

(PersianFarsi)

Arabic

رقم ھاتف الصم والبكم( اتصل برقم إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان ملحوظة

711( 1-855-905-3825 Blue Shield Promise Cal MediConnect Plan )من )711 رقم ھاتف الصم والبكم

مساء طوال أيام الأسبوع 800صباحا حتى 800الساعة

(PersianFarsi)

Arabic

(PersianFarsi)

Arabic

(PersianFarsi)

Arabic

If you have questions please call Blue Shield Promise Cal MediConnect Plan at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is freeFor more information visit wwwblueshieldcacompromisecalmediconnect v

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

bull Decide to require or not require prior approval for a drug (Prior approval is permission fromBlue Shield Promise Cal MediConnect Plan before you can get a drug)

bull Add or change the amount of a drug you can get (called quantity limits)

bull Add or change step therapy restrictions on a drug (Step therapy means you must try one drugbefore we will cover another drug)

For more information on these drug rules see question B4

If you are taking a drug that was covered at the beginning of the year we will generally not remove or change coverage of that drug during the rest of the year unless

bull a new cheaper 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 or

bull a drug is removed from the market

Questions B3 and B6 below have more information on what happens when the Drug List changes

bull You can always check Blue Shield Promise Cal MediConnect Planrsquos up to date Drug List onlineat wwwblueshieldcacompromisecalmediconnect

bull You can also call Member Services to check the current Drug List at 1-855-905-3825 (TTY 711)800 am to 800 pm seven days a week

B3 What happens when there is a change to the Drug List

Some changes to the Drug List will happen immediately For example

bull A new generic drug becomes available Sometimes a new and cheaper drug comes alongthat works as well as a drug on the Drug List now When that happens we may remove thecurrent drug but your cost for the new drug will stay the same or will be lower When we addthe new generic drug we may also decide to keep the current drug on the list but change itscoverage rules or limits

We may not tell you before we make this change but we will send you information aboutthe specific change or changes we made

You or your provider can ask for an exception from these changes We will send you a notice with the steps you can take to ask for an exception Please see question B10 for more information on exceptions

bull A drug is taken off the market If the Food and Drug Administration (FDA) says a drug you aretaking is not safe or the drugrsquos manufacturer takes a drug off the market we will take it off theDrug List If you are taking the drug we will let you know that the drug has been taken off theDrug List and instruct you on what to do next

We may make other changes that affect the drugs you take We will tell you in advance about these other changes to the Drug List These changes might happen if

bull The FDA provides new guidance or there are new clinical guidelines about a drug

bull We add a generic drug that is not new to the market and

If you have questions please call Blue Shield Promise Cal MediConnect Plan at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is freeFor more information visit wwwblueshieldcacompromisecalmediconnect vi

Replace a brand name drug currently on the Drug List or

Change the coverage rules or limits for the brand name drug

When these changes happen we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill 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 Then you can

bull Get a 30 day supply of the drug before the change to the Drug List is made or

bull Ask for an exception from these changes Please see question B10 for more information aboutexceptions

B4 Are there any restrictions or limits on drug coverage or any required actions to take 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 prescribermust get approval from Blue Shield Promise Cal MediConnect Plan before you fill yourprescription Blue Shield Promise Cal MediConnect Plan may not cover the drug if you do notget approval

bull Quantity limits Sometimes Blue Shield Promise Cal MediConnect Plan limits the amount of adrug you can get

bull Step therapy Sometimes Blue Shield Promise Cal MediConnect Plan requires you to do steptherapy This means you will have to try drugs in a certain order for your medical conditionYou might have to try one drug before we will cover another drug If your doctor thinks the firstdrug 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 on pages You can also get more information by visiting our web site at wwwblueshieldcacompromisecalmediconnect 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 exception from these limits 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 questions B10-B12 for more information about exceptions

B5 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 has a column labeled ldquoNecessary actions restrictions or limits on userdquo

B6 What happens if we change our rules about some drugs (for example prior authorization (approval) quantity limits andor step therapy restrictions)

In some cases we will tell you in advance if we add or change prior approval quantity limits andor step therapy restrictions on a drug See question B3 for more information about this advance notice

If you have questions please call Blue Shield Promise Cal MediConnect Plan at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is freeFor more information visit wwwblueshieldcacompromisecalmediconnect vii

and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change

B7 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 Index of Covered Drugs section You can find it in the index that begins on page The Index provides an alphabetical list of all of the drugs included in this document Both brand name drugs and generic drugs are listed in the Index Look in the Index and find your drug Next to your drug you will see the page number where you can find coverage information Turn to the page listed in the Index and find the name of your drug in the first column of the list

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

B8 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 Member Services at 1-855-905-3825 (TTY 711) from 800 am ndash 800 pm seven days a week and ask about it If you learn that Blue Shield Promise Cal MediConnect Plan will not cover the drug you can do one of these things

bull Ask Member Services for a list of drugs like the one you want to take Then show the list to yourdoctor or other prescriber He or she can prescribe a drug on the Drug List that is like the oneyou want to take Or

bull You can ask the health plan to make an exception to cover your drug Please see questionsB10-B12 for more information about exceptions

B9 What if you are a new Blue Shield Promise Cal MediConnect Plan member and canrsquot find your drug on the Drug List or have a problem getting your drug

We can help We may cover a temporary 30-day supply of your drug during the 90 days you are a member of Blue Shield Promise Cal MediConnect Plan 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

If your prescription is written for fewer days we will allow multiple fills to provide up to a maximum of 30 days of medication

We will cover a 30 day supply 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 Blue Shield Promise Cal MediConnect Plan or

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

If you have questions please call Blue Shield Promise Cal MediConnect Plan at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is freeFor more information visit wwwblueshieldcacompromisecalmediconnect viii

If you are in a nursing home 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 If you have been in the plan for more than 90 days live in a long-term care facility and need a supply right away

bull We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days) whether or not you are a new Blue Shield Promise Cal MediConnect Plan member

bull This is in addition to the temporary supply during the first 90 days you are a member of Blue Shield Promise Cal MediConnect Plan

Transition Policy In circumstances where a beneficiary is changing from one treatment setting to another Blue Shield Promise Cal MediConnect Plan will ensure a fast process for approving non-formulary Part D drugs This process shall also apply to formulary Part D drugs that require prior authorization or step-therapy Examples of level of care changes are beneficiaries who are discharged from a hospital to a home beneficiaries who end their skilled nursing facility Medicare Part A stay and who need to revert to their Part D plan formulary beneficiaries who end a long-term care facility stay and return to the community and beneficiaries who are discharged from psychiatric hospitals with medication regimens that are highly individualized

B10 Can you ask for an exception to cover your drug

Yes You can ask Blue Shield Promise Cal MediConnect Plan to make an exception to cover a drug that is not on the Drug List

You can also ask us to change the rules on your drug

bull For example Blue Shield Promise Cal MediConnect Plan may limit the amount of a drug we will cover If your drug has a limit you can ask us to change the limit and cover more

bull Other examples You can ask us to drop step therapy restrictions or prior approval requirements

B11 How can you ask for an exception

To ask for an exception call Member Services Member services will work with you and your provider to help you ask for an exception You can also read Chapter 9 of the Member Handbook to learn more about exceptions

B12 How long does it take to get an exception

First we must get a statement from your prescriber supporting your request for an exception After we get the statement we will give you 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 we will give you a decision within 24 hours of getting your prescriberrsquos supporting statement

B13 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 their names are less commonly known Generic drugs are approved by the Food and Drug Administration (FDA)

Blue Shield Promise Cal MediConnect Plan covers both brand name drugs and generic drugs

If you have questions please call Blue Shield Promise Cal MediConnect Plan at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is freeFor more information visit wwwblueshieldcacompromisecalmediconnect ix

B14 What are OTC drugs

OTC stands for ldquoover-the-counterrdquo Blue Shield Promise Cal MediConnect Plan covers some OTC drugs when they are written as prescriptions by your provider

You can read the Blue Shield Promise Cal MediConnect Plan Drug List to see what OTC drugs are covered

B15 Does Blue Shield Promise Cal MediConnect Plan cover OTC non-drug products

Blue Shield Promise Cal MediConnect Plan covers some OTC non-drug products when they are written as prescriptions by your provider

Examples of OTC non-drug products include Vortex Adult Mask and VCF contraceptive 4 gel

You can read the Blue Shield Promise Cal MediConnect Plan Drug List to see what OTC non-drug products are covered

B16 What is your copay

You can read the Blue Shield Promise Cal MediConnect Plan Drug List to learn about the copay for each drug Blue Shield Promise Cal MediConnect Plan members living in nursing homes or other long-term care facilities will have no copays Some members getting long-term care in the community will also have no copays

Copays are listed by tiers Tiers are groups of drugs with the same copay Co-pay amount will vary depending on your level of Medi-Cal eligibility

Tier Description Co-payment30-day supply 90-day supply

Tier 1 Generic drugs $0 to $340 co-pay $0 to $340 co-payTier 2 Brand name drugs $0 to $850 co-pay $0 to $850 co-payTier 3 Non-Medicare Rx Over-

the-counter (OTC) drugs$0 co-pay $0 co-pay

B17 What are drug tiers

Tiers are groups of drugs on our Drug List

bull Tier 1 drugs are generic drugs

bull Tier 2 drugs are brand name drugs

bull Tier 3 drugs are Non-Medicare drugs and Over-the ndashCounter (OTC) drugs

C List of Covered Drugs

The following list of covered drugs gives you information about the drugs covered by Blue Shield Promise Cal MediConnect Plan If you have trouble finding your drug in the list turn to the Index of Covered Drugs that begins on page The Index alphabetically lists all drugs covered by Blue Shield Promise Cal MediConnect Plan

The first column of the chart lists the name of the drug Brand name drugs are capitalized (eg ELIQUIS) and generic drugs are listed in lower-case italics (eg simvastatin)

If you have questions please call Blue Shield Promise Cal MediConnect Plan at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is freeFor more information visit wwwblueshieldcacompromisecalmediconnect x

The information in the ldquoNecessary actions restrictions or limits on userdquo column tells you if Blue Shield Promise Cal MediConnect Plan has any rules for covering your drug

Legend for Abbreviations used for RequirementsLimits in the Drug List

Abbreviation Description ExplanationPA Prior authorization required You (or your physician) are required to get

prior authorization from Blue Shield Promise Cal MediConnect Plan before you fill your prescription for this drug Without prior approval Blue Shield Promise Cal MediConnect Plan may not cover this drug

QL Quantity limit Blue Shield Promise Cal MediConnect Plan limits the quantity to be covered within a specific time frame for this drug

ST Step therapy Before Blue Shield Promise Cal MediConnect Plan will provide coverage for this drug you must first try another drug(s) on the formulary to treat your medical condition This drug may only be covered if the other drug(s) does not work for you

BvD Requires a prior authorization to perform a Part B vs Part D coverage 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 Blue Shield Promise Cal MediConnect Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug Without prior approval Blue Shield Promise Cal MediConnect Plan may not cover this drug

Legend for Abbreviations used in the Drug List

Abbreviation NoteLA This prescription may be available only at certain pharmacies For more

information call Blue Shield Promise Cal MediConnect Plan Member ServicesMO This is a maintenance drug Up to a 90-day supply of this drug is available

through our network mail-order pharmacy and through some of our network retail pharmacies For more information call Blue Shield Promise Cal MediConnect Plan Member Services

NPD This drug is covered by Medi-Cal and is not a ldquoPart D drugrdquo If you have questions call Blue Shield Promise Cal MediConnect Plan Member Services

Note The NPD next to a drug means the drug is not a ldquoPart D drugrdquo You will not be required to pay a copay for these drugs These drugs also have different rules for appeals

bull An appeal is a formal way of asking us to review a decision we made about your coverage and to change it if you think we made a mistake For example we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medi-Cal

If you have questions please call Blue Shield Promise Cal MediConnect Plan at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is freeFor more information visit wwwblueshieldcacompromisecalmediconnect xi

bull If you or your doctor disagrees with our decision you can appeal If you ever have a question call Member Services at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week You can also read Chapter 9 of the Member Handbook to learn how to appeal a decision

D 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

Blue Shield of California Promise Health Plan Cal Mediconnect Formulary2019 (List of Covered Drugs)

Analgesics

Name of drugWhat the drug will costyou(tier level)

Necessary actionsrestrictions or limits onuse

Analgesicsacetaminophen with codeine 120-12mg5 solution

Tier 1 QL (1800 PER 30 DAYS)

acetaminophen with codeinephosphate (300mg-15mg tablet300mg-30mg tablet 300mg-60mgtablet)

ascomp with codeine capsule Tier 1 QL (180 PER 30 DAYS)

butalbitacetamincaffcodeine 50-325-30 capsule

Tier 1 PA QL (180 PER 30DAYS)

codeinebutalbitalasacaffein 30-50-325 capsule

hydrocodonebitartrateacetaminophen (10mg-325mg tablet 25-325 mg tablet 5mg-325mg tablet 75-325 mg tablet)

hydrocodonebitartrateacetaminophen (25-1085solution 5-217mg10 solution 75-32515 solution)

hydrocodoneibuprofen (10mg-200mgtablet 5mg-200mg tablet 75-200 mgtablet)

oxycodone hclacetaminophen (10mg-325mg tablet 5 mg-325mg tablet 75-325 mg tablet)

oxycodone hclaspirin 48355-325tablet

tramadol hclacetaminophen 375-325mg tablet

You can find information on what the symbols and abbreviations in this table meanby going to pages (x) and reading the explanation provided in the legends

Analgesics

Opioid Analgesics Long-actingbuprenorphine hcl 8 mg tab subl Tier 1 QL (3 PER 1 DAYS)

fentanyl (12 mcghr patch td72 25mcghr patch td72 50mcghr patchtd72)

Tier 1 ST QL (10 PER 30 DAYSOVER TIME)

fentanyl citrate (600 mcg lozenge hd800 mcg lozenge hd)

fentanyl citrate 200 mcg lozenge hd Tier 1 PA QL (120 PER 30DAYS)

hydromorphone hclpf (10 mgmlampul 10 mgml vial)

Tier 1 BvD

LAZANDA 300 MCG NASALSPRAY

methadone hcl (10 mg tablet 5 mgtablet)

methadone hcl 10 mg5 ml solution Tier 1 QL (600 PER 30 DAYS)

morphine sulfate (15 mg tablet er 30mg tablet er)

morphine sulfate (15 mg tablet 30 mgtablet)

morphine sulfate 10 mg5 ml solution Tier 1 QL (1800 PER 30 DAYS)

morphine sulfate 100 mg tablet er Tier 1 QL (30 PER 30 DAYS)

morphine sulfate 100 mg5ml solution Tier 1 QL (180 PER 30 DAYS)

oxycodone hcl (10 mg tab er 12h 15mg tab er 12h 20 mg tab er 12h 30mg tab er 12h 40 mg tab er 12h)

OXYCONTIN (ER 15 MGTABLET ER 30 MG TABLET)

Analgesics

Opioid Analgesics Short-actingcodeine sulfate (15 mg tablet 30 mgtablet 60 mg tablet)

hydromorphone hcl (2 mg tablet 4mg tablet)

hydromorphone hcl 8 mg tablet Tier 1 QL (90 PER 30 DAYS)

meperidine hcl (100 mg tablet 50 mgtablet)

meperidine hcl 50 mg5 ml solution Tier 1 PA QL (600 PER 30DAYS)

oxycodone hcl (10 mg tablet10mg05ml syringe 15 mg tablet 20mg tablet 20 mgml oral conc 5 mgcapsule 5 mg tablet)

oxycodone hcl 30 mg tablet Tier 1 QL (60 PER 30 DAYS)

oxycodone hcl 5 mg5 ml solution Tier 1 QL (250 PER 30 DAYS)

oxycodone hclacetaminophen 5-3255 ml solution

tramadol hcl 50 mg tablet Tier 1 QL (240 PER 30 DAYS)

Anesthetics

Local Anestheticslidocaine 5 adh patch Tier 1 PA

lidocaine 5 oint (g) Tier 1 BvD

lidocaine hcl (2 jelpf app 2 jelly(ml) 2 solution 4 solution40 mgml solution)

Tier 1

Anesthetics

lidocaineprilocaine (25 -25cream (g) 25 -25 kit)

Tier 1 PA

Anti-Addiction Substance Abuse Treatment Agents

Alcohol DeterrentsAnti-cravingacamprosate calcium 333 mg tablet dr Tier 1 MO (Maintenance Drug)

disulfiram (250 mg tablet 500 mgtablet)

Tier 1 MO (Maintenance Drug)

naltrexone hcl 50 mg tablet Tier 1

Opioid Dependence Treatmentsbuprenorphine hcl 2 mg tab subl Tier 1 QL (12 PER 1 DAYS)

buprenorphine hclnaloxone hcl (12mg-3 mg film 2 mg-05mg film 4mg-1mg film 8 mg-2 mg film)

Tier 1 PA MO (MaintenanceDrug)

buprenorphine hclnaloxone hcl 2 mg-05mg tab subl

Tier 1 QL (12 PER 1 DAYS)MO (Maintenance Drug)

buprenorphine hclnaloxone hcl 8 mg-2 mg tab subl

Tier 1 QL (3 PER 1 DAYS) MO(Maintenance Drug)

SUBOXONE (12 MG-3 MG SLFILM 2 MG-05 MG SL FILM 4MG-1 MG SL FILM 8 MG-2 MGSL FILM)

VIVITROL 380 MG VIAL +DILUENT

Tier 2 BvD

Opioid Reversal Agentsnaloxone hcl (04 mgml cartridge 04mgml vial 1 mgml syringe)

Tier 1

NARCAN 4 MG NASAL SPRAY Tier 2 QL (2 PER 1 DAYS)

Smoking Cessation Agentsbupropion hcl 150 mg tab er 12h Tier 1

CHANTIX (05 MG TABLET 1MG CONT MONTH BOX 1 MGTABLET)

Tier 2 PA

NICOTROL CARTRIDGEINHALER

Tier 2

NICOTROL NS 10 MGML SPRAY Tier 2

Anti-inflammatory Agents

Nonsteroidal Anti-inflammatory Drugscelecoxib (100 mg capsule 200 mgcapsule 400 mg capsule 50 mgcapsule)

diclofenac potassium 50 mg tablet Tier 1

diclofenac sodium (100 mg tab er 24h25 mg tablet dr 50 mg tablet dr 75mg tablet dr)

Tier 1

diflunisal 500 mg tablet Tier 1

etodolac (200 mg capsule 300 mgcapsule 400 mg tab er 24h 400 mgtablet 500 mg tab er 24h 500 mgtablet 600 mg tab er 24h)

fenoprofen calcium 600 mg tablet Tier 1

flurbiprofen (100 mg tablet 50 mgtablet)

Tier 1

ibuprofen (400 mg tablet 600 mgtablet 800 mg tablet)

indomethacin (25 mg capsule 50 mgcapsule 75 mg capsule er)

Tier 1 PA

ketoprofen (200 mg cap24h pel 50mg capsule 75 mg capsule)

Tier 1

ketorolac tromethamine 10 mg tablet Tier 1 PA QL (20 PER 30DAYS)

meclofenamate sodium (100 mgcapsule 50 mg capsule)

Tier 1

meloxicam (15 mg tablet 75 mgtablet)

nabumetone (500 mg tablet 750 mgtablet)

Tier 1

naproxen (250 mg tablet 375 mgtablet 375 mg tablet dr 500 mgtablet 500 mg tablet dr)

piroxicam (10 mg capsule 20 mgcapsule)

Tier 1

sulindac (150 mg tablet 200 mgtablet)

Tier 1

tolmetin sodium (400 mg capsule 600mg tablet)

Tier 1

Antibacterials

Aminoglycosidesamikacin sulfate 500 mg2ml vial Tier 1 BvD

gentamicin sulfate (03 drops 03 oint (g))

Tier 1

gentamicin sulfate 40 mgml vial Tier 1 BvD

neomycin sulfate 500 mg tablet Tier 1

paromomycin sulfate 250 mg capsule Tier 1

streptomycin sulfate 1 g vial Tier 1 BvD

Antibacterials

tobramycin 03 drops Tier 1

tobramycin in 0225 sod chlor 300mg5ml ampul-neb

tobramycin sulfate (12 g vial 40mgml vial)

Tier 1 BvD

tobramycinnebulizer 300 mg5mlampul-neb

Antibacterials Otheralcohol 70 pads Tier 1

bacitracin 500 unitg oint (g) Tier 1

clindamycin hcl (150 mg capsule 300mg capsule)

Tier 1

clindamycin phosphate (1 gel(gram) 1 lotion 1 med swab 1 solution 2 creamappl)

Tier 1

clindamycin phosphate (150 mgmlvial 300 mg2ml vial port)

Tier 1 BvD

colistin (colistimethate na) 150 mgvial

Tier 1 PA

daptomycin 500 mg vial Tier 1 PA

linezolid (100 mg5ml susp recon 600mg tablet)

Tier 1 PA

linezolid in dextrose 5 600mg300piggyback

Tier 1 PA

linezolid-09 sodium chloride600mg300 piggyback

Tier 1 PA

methenamine hippurate 1 g tablet Tier 1

METRO IV 500 MG100 ML Tier 1 BvD

metronidazole (075 cream (g) 075 gel (gram) 075 gel wappl 075 lotion 250 mg tablet 500 mgtablet)

Tier 1

Antibacterials

metronidazolesodium chloride500mg01l piggyback

Tier 1 BvD

mupirocin 2 oint (g) Tier 1 QL (22 PER 30 DAYSOVER TIME)

nitrofurantoin macrocrystal (100 mgcapsule 25 mg capsule 50 mgcapsule)

Tier 1

nitrofurantoin monohydm-cryst 100mg capsule

Tier 1

SIVEXTRO 200 MG TABLET Tier 2 PA

SIVEXTRO 200 MG VIAL Tier 2 BvD

tigecycline 50 mg vial Tier 1 BvD

trimethoprim 100 mg tablet Tier 1

vancomycin hcl (1 g vial 1 g vial port10 g vial)

Tier 1 BvD

vancomycin hcl (125 mg capsule 250mg capsule)

Tier 1

Beta-lactam Cephalosporinscefaclor (125 mg5ml susp recon 250mg capsule 250 mg5ml susp recon375 mg5ml susp recon 500 mgcapsule 500 mg tab er 12h)

Tier 1

cefadroxil (1 g tablet 250 mg5mlsusp recon 500 mg capsule 500mg5ml susp recon)

Tier 1

cefazolin sodium (1 g vial 1 g vialport 10 g vial 100 g bulkbaginj 20 gvial 300g bulkbaginj 500 mg vial)

Tier 1 BvD

cefazolin sodiumdextrose iso-osmotic (1 g50 ml frozpiggy 1 g50ml piggyback)

Tier 1 BvD

cefdinir 300 mg capsule Tier 1

cefepime hcl (1 g vial 2 g vial) Tier 1 BvD

Antibacterials

cefepime hcl in dextrose 5 in water(in dextrose 5 1 g50 ml piggybackin dextrose 5 2 g50 ml piggyback)

Tier 1 BvD

cefepime hcl in iso-osmotic dextrose(in iso-osm dextrose 1 g50 mlfrozpiggy in iso-osm dextrose 2g100 ml frozpiggy)

Tier 1 BvD

cefotaxime sodium (1 g vial 2 g vial500 mg vial)

Tier 1 BvD

cefoxitin sodium 1 g vial Tier 1 PA

cefoxitin sodiumdextroseiso 1 g50ml piggyback

Tier 1 PA

cefpodoxime proxetil (100 mg tablet100 mg5ml susp recon 200 mg tablet50 mg5 ml susp recon)

Tier 1

cefprozil (125 mg5ml susp recon 250mg tablet 250 mg5ml susp recon 500mg tablet)

Tier 1

ceftazidime (1 g vial 1 g vial port 2 gvial 2 g vial port 6 g vial)

Tier 1 BvD

ceftazidime in dextrose 5 and water(in dextrose5water 1 g50 mlpiggyback in dextrose5water 2 g50ml piggyback)

Tier 1 BvD

ceftriaxone sodium (1 g vial 1 g vialport 10 g vial 100 g bulkbaginj 2 gvial 2 g vial port 250 mg vial 500 mgvial)

Tier 1 BvD

ceftriaxone sodium in iso-osmoticdextrose (in is-osm dextrose 1 g50 mlfrozpiggy in is-osm dextrose 1 g50ml piggyback in is-osm dextrose 2g50 ml frozpiggy in is-osm dextrose2 g50 ml piggyback)

Tier 1 BvD

cefuroxime axetil (250 mg tablet 500mg tablet)

Tier 1

cefuroxime sodium (15 g vial 75 gvial 750 mg vial)

Tier 1 BvD

Antibacterials

cephalexin (125 mg5ml susp recon250 mg capsule 250 mg tablet 250mg5ml susp recon 500 mg capsule500 mg tablet 750 mg capsule)

Tier 1

TEFLARO (400 MG VIAL 600 MGVIAL)

Tier 2 BvD

Beta-lactam Otheraztreonam 1 g vial Tier 1 BvD

CAYSTON 75 MG INHALSOLUTION

Tier 2 PA

ertapenem sodium 1 g vial Tier 1

imipenemcilastatin sodium (250 mgvial 500 mg vial)

Tier 1 BvD

meropenem (1 g vial 500 mg vial) Tier 1 BvD

meropenem in 09 sodium chloride(1 g50 ml piggyback 500mg50mlpiggyback)

Tier 1 BvD

Beta-lactam Penicillinsamoxicillin (125 mg tab chew 125mg5ml susp recon 200 mg5ml susprecon 250 mg capsule 250 mg tabchew 250 mg5ml susp recon 400mg5ml susp recon 500 mg capsule500 mg tablet 875 mg tablet)

Tier 1

amoxicillinpotassium clavulanate(200-2855 susp recon 200-285mgtab chew 250-125 mg tablet 250-6255 susp recon 400-57mg tabchew 400-57mg5 susp recon 500-125mg tablet 600-4295 susp recon 875-125 mg tablet)

Tier 1

ampicillin sodium (1 g vial 1 g vialport 10 g vial 125 mg vial)

Tier 1 BvD

ampicillin sodiumsulbactam sodium(15 g vial 15 g vial port 15 g vial 3g vial 3 g vial port)

Tier 1 BvD

Antibacterials

ampicillin trihydrate 500 mg capsule Tier 1

BICILLIN C-R (12 MILLIONUNIT 900-300 SYRINGE)

Tier 2 BvD

BICILLIN L-A (1200000 UNITS2400000 UNITS 600000UNITML)

Tier 2 BvD

dicloxacillin sodium (250 mg capsule500 mg capsule)

Tier 1

nafcillin in dextroseiso-osm 1 g50 mlfrozpiggy

Tier 1 BvD

nafcillin sodium (1 g vial 1 g vialport)

Tier 1 BvD

penicillin g potassium (g potassium20mm unit vial g potassium 5mmunit vial)

Tier 1 BvD

penicillin g sodium 5mm unit vial Tier 1 BvD

penicillin v potassium (125 mg5mlsoln recon 250 mg tablet 250 mg5mlsoln recon 500 mg tablet)

Tier 1

piperacillin sodiumtazobactamsodium (135 g vial 225 g vial 225 gvial port 3375 g vial 3375 g vialport 45 g vial 45 g vial port 405 gvial)

Tier 1 BvD

Macrolidesazithromycin (250 mg tablet 500 mgtablet)

Tier 1 QL (6 PER 30 DAYSOVER TIME)

azithromycin (500 mg vial 500 mgvial port)

Tier 1 BvD

azithromycin 1 g packet Tier 1 QL (3 PER 30 DAYSOVER TIME)

azithromycin 100 mg5ml susp recon Tier 1 QL (2 PER 30 DAYSOVER TIME)

Antibacterials

azithromycin 600 mg tablet Tier 1 QL (8 PER 30 DAYSOVER TIME)

clarithromycin (125 mg5ml susprecon 250 mg tablet 250 mg5ml susprecon 500 mg tab er 24h 500 mgtablet)

Tier 1

EES 400 FILMTAB Tier 1

ERYTHROCIN 250 MG FILMTAB Tier 1

ERYTHROCIN LACTOBIONATE(500 MG ADDVAN VIAL LACT500 MG VIAL)

Tier 2 BvD

erythromycin base (250 mg capsuledr 250 mg tablet 5 mggram oint (g)500 mg tablet)

Tier 1

erythromycin base in ethanol (inethanol 2 gel (gram) in ethanol 2 med swab in ethanol 2 solution)

Tier 1

erythromycin ethylsuccinate 400 mgtablet

Tier 1

ZMAX 2 G60 ML ORALSUSPENSION

Quinolonesciprofloxacin 500 mg5ml sus mc rec Tier 1

ciprofloxacin hcl (02 droperette03 drops 100 mg tablet 250 mgtablet 500 mg tablet 750 mg tablet)

Tier 1

ciprofloxacin lactate 400mg40ml vial Tier 1 BvD

ciprofloxacinciprofloxacin hcl (1000mg tbmp 24hr 500 mg tbmp 24hr)

Tier 1

levofloxacin (250 mg tablet250mg10ml solution 500 mg tablet500mg20ml solution 750 mg tablet)

Tier 1

levofloxacindextrose 5 in water (indextrose 5 500mg01l piggybackin dextrose 5 750mg15lpiggyback)

Tier 1 BvD

Antibacterials

moxifloxacin hcl (05 drops 400mg tablet)

Tier 1

ofloxacin (03 drops 400 mg tablet) Tier 1

SulfonamidesBLEPH-10 10 EYE DROPS Tier 1

silver sulfadiazine 1 cream (g) Tier 1

SSD 1 CREAM Tier 1

sulfacetamide sodium 10 drops Tier 1

sulfadiazine 500 mg tablet Tier 1

sulfamethoxazoletrimethoprim (200-40mg5 oral susp 400mg-80mg tablet800-160 mg tablet 800-16020 oralsusp)

Tier 1

Tetracyclinesdemeclocycline hcl (150 mg tablet300 mg tablet)

Tier 1

doxycycline hyclate 100 mg vial Tier 1 PA

tetracycline hcl (250 mg capsule 500mg capsule)

Tier 1

Anticonvulsants

Anticonvulsants OtherBRIVIACT (10 MG TABLET 10MGML ORAL SOLN 100 MGTABLET 25 MG TABLET 50 MGTABLET 75 MG TABLET)

BRIVIACT 50 MG5 ML VIAL Tier 2 PA

Anticonvulsants

DIASTAT 25 MG PEDI SYSTEM Tier 2 QL (5 PER 30 DAYS)

DIASTAT ACUDIAL (125-15-20MG 5-75-10 MG KT)

Tier 2

diazepam (10 mg tablet 2 mg tablet 5mg tablet)

diazepam (125-15-20 kit 5-75-10mgkit)

Tier 1

diazepam 25 mg kit Tier 1 QL (5 PER 30 DAYS)

diazepam 5 mg5 ml solution Tier 1 QL (1200 PER 30 DAYS)

EPIDIOLEX 100 MGMLSOLUTION

Tier 2 PA

levetiracetam (100 mgml solution1000 mg tablet 250 mg tablet 500 mgtablet 500 mg5ml solution 750 mgtablet)

levetiracetam 500 mg tab er 24h Tier 1 QL (180 PER 30 DAYS)MO (Maintenance Drug)

levetiracetam 500 mg5ml vial Tier 1 PA

POTIGA (200 MG TABLET 300MG TABLET 400 MG TABLET)

POTIGA 50 MG TABLET Tier 2 PA QL (270 PER 30DAYS) MO (MaintenanceDrug)

SPRITAM (1000 MG TABLET 250MG TABLET 500 MG TABLET750 MG TABLET)

Calcium Channel Modifying AgentsCELONTIN 300 MG KAPSEAL Tier 2 MO (Maintenance Drug)

ethosuximide (250 mg capsule 250mg5ml solution)

Anticonvulsants

LYRICA (100 MG CAPSULE 150MG CAPSULE 20 MGML ORALSOLUTION 200 MG CAPSULE225 MG CAPSULE 25 MGCAPSULE 300 MG CAPSULE 50MG CAPSULE 75 MG CAPSULE)

pregabalin (100 mg capsule 150 mgcapsule 20 mgml solution 200 mgcapsule 225 mg capsule 25 mgcapsule 300 mg capsule 50 mgcapsule 75 mg capsule)

zonisamide (100 mg capsule 25 mgcapsule 50 mg capsule)

Gamma-aminobutyric Acid (GABA) Augmenting Agentsclobazam (10 mg tablet 25 mgmloral susp 20 mg tablet)

Tier 1 PA

divalproex sodium (125 mg cap drspr 125 mg tablet dr 250 mg tab er24h 250 mg tablet dr 500 mg tab er24h 500 mg tablet dr)

gabapentin (100 mg capsule 250mg5ml solution 300 mg capsule 300mg6ml solution 400 mg capsule 600mg tablet 800 mg tablet)

GABITRIL (12 MG TABLET 16MG TABLET)

ONFI (10 MG TABLET 25MGML SUSPENSION 20 MGTABLET)

phenobarbital (100 mg tablet 15 mgtablet 162 mg tablet 20 mg5 mlelixir 30 mg tablet 324 mg tablet 60mg tablet 648 mg tablet 972mgtablet)

primidone (250 mg tablet 50 mgtablet)

SYMPAZAN (10 MG FILM 20 MGFILM 5 MG FILM)

Tier 2 PA QL (2 PER 1 DAYS)MO (Maintenance Drug)

Anticonvulsants

tiagabine hcl (12 mg tablet 16 mgtablet 2 mg tablet 4 mg tablet)

valproic acid (as sodium salt)(valproate sodium) (250 mg5mlsolution 500mg10ml solution)

valproic acid (as sodium salt) 500mg5ml vial

Tier 1 PA

valproic acid 250 mg capsule Tier 1 MO (Maintenance Drug)

vigabatrin (500 mg powd pack 500mg tablet)

Glutamate Reducing Agentsfelbamate (400 mg tablet 600 mgtablet 600 mg5ml oral susp)

FYCOMPA (10 MG TABLET 12MG TABLET 2 MG TABLET 4MG TABLET 8 MG TABLET)

Tier 2 PA QL (30 PER 30DAYS) MO (MaintenanceDrug)

FYCOMPA 05 MGML ORALSUSP

FYCOMPA 6 MG TABLET Tier 2 PA QL (60 PER 30DAYS) MO (MaintenanceDrug)

lamotrigine (100 mg tablet 150 mgtablet 200 mg tablet 25 mg tablet 25mg tb chw dsp 5 mg tb chw dsp)

lamotrigine 25mg (35) tab ds pk Tier 1

topiramate (100 mg cap spr 24 150mg cap spr 24 200 mg cap spr 24 25mg cap spr 24 50 mg cap spr 24)

topiramate (100 mg tablet 15 mg capsprink 200 mg tablet 25 mg capsprink 25 mg tablet 50 mg tablet)

Anticonvulsants

Sodium Channel AgentsAPTIOM (200 MG TABLET 400MG TABLET)

APTIOM 600 MG TABLET Tier 2 PA QL (60 PER 30DAYS) MO (MaintenanceDrug)

APTIOM 800 MG TABLET Tier 2 PA MO (MaintenanceDrug)

BANZEL (200 MG TABLET 40MGML SUSPENSION 400 MGTABLET)

carbamazepine (200 mg tab er 12h400 mg tab er 12h)

DILANTIN (100 MG CAPSULE 30MG CAPSULE 50 MG INFATAB)

DILANTIN 125 MG5 ML SUSP Tier 2 MO (Maintenance Drug)

fosphenytoin sodium (100mg pe2vial 500 pe10 vial)

Tier 1 PA

oxcarbazepine (150 mg tablet 300 mgtablet 300 mg5ml oral susp 600 mgtablet)

OXTELLAR XR (150 MGTABLET 300 MG TABLET 600MG TABLET)

PEGANONE 250 MG TABLET Tier 2 MO (Maintenance Drug)

PHENYTEK (200 MG CAPSULE300 MG CAPSULE)

phenytoin (100 mg4ml oral susp 125mg5ml oral susp 50 mg tab chew)

phenytoin sodium (50 mgml ampul50 mgml syringe 50 mgml vial)

Tier 1 PA

phenytoin sodium extended (100 mgcapsule 200 mg capsule 300 mgcapsule)

Anticonvulsants

VIMPAT (10 MGML SOLUTION100 MG TABLET 150 MGTABLET 200 MG TABLET 50 MGTABLET)

VIMPAT 200 MG20 ML VIAL Tier 2 PA QL (200 PER 5DAYS)

Antidementia Agents

Antidementia Agents Otherergoloid mesylates 1 mg tablet Tier 1 PA MO (Maintenance

Cholinesterase Inhibitorsdonepezil hcl (10 mg tab rapdis 10mg tablet 5 mg tab rapdis 5 mgtablet)

rivastigmine (133mg24h patch td2446mg24hr patch td24 95mg24hrpatch td24)

rivastigmine tartrate (15 mg capsule3 mg capsule 45 mg capsule 6 mgcapsule)

N-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl (10 mg tablet 2 mgmlsolution 5 mg tablet)

memantine hcl (14 mg cap spr 24 21mg cap spr 24 28 mg cap spr 24 7 mgcap spr 24)

memantine hcl 5 mg-10 mg tab ds pk Tier 1

Antidepressants

Antidepressantsamitriptyline hclchlordiazepoxide(125mg-5mg tablet 25 mg-10mgtablet)

perphenazineamitriptyline hcl (2 mg-10 mg tablet 2 mg-25 mg tablet 4mg-25 mg tablet 4 mg-50 mg tablet4mg-10mg tablet)

Antidepressants Otherbupropion hcl (100 mg tab sr 12h 100mg tablet 150 mg tab sr 12h 200 mgtab sr 12h 300 mg tab er 24h 75 mgtablet)

bupropion hcl 150 mg tab er 24h Tier 1 QL (30 PER 30 DAYS)MO (Maintenance Drug)

maprotiline hcl (25 mg tablet 50 mgtablet 75 mg tablet)

mirtazapine (15 mg tab rapdis 15 mgtablet 30 mg tab rapdis 30 mg tablet45 mg tab rapdis 45 mg tablet 75mg tablet)

nefazodone hcl (100 mg tablet 150mg tablet 200 mg tablet 250 mgtablet 50 mg tablet)

trazodone hcl (100 mg tablet 150 mgtablet 300 mg tablet 50 mg tablet)

Monoamine Oxidase InhibitorsEMSAM (12 MG24 HOURSPATCH 6 MG24 HOURS PATCH9 MG24 HOURS PATCH)

MARPLAN 10 MG TABLET Tier 2 MO (Maintenance Drug)

phenelzine sulfate 15 mg tablet Tier 1 MO (Maintenance Drug)

tranylcypromine sulfate 10 mg tablet Tier 1 MO (Maintenance Drug)

Antidepressants

SSRIs SNRIscitalopram hydrobromide (10 mgtablet 10 mg5 ml solution 20 mgtablet 40 mg tablet)

citalopram hydrobromide 20 mg10mlsolution

Tier 1

desvenlafaxine (100 mg tab er 24 100mg tab er 24h 50 mg tab er 24 50 mgtab er 24h)

desvenlafaxine fumarate (100 mg taber 24 50 mg tab er 24)

desvenlafaxine succinate (100 mg taber 24h 25 mg tab er 24h 50 mg tab er24h)

escitalopram oxalate (10 mg tablet 20mg tablet 5 mg tablet 5 mg5 mlsolution)

FETZIMA (ER 120 MG CAPSULEER 20 MG CAPSULE ER 40 MGCAPSULE ER 80 MG CAPSULE)

FETZIMA 20-40 MG TITRATIONPAK

Tier 2 PA

fluoxetine hcl (10 mg capsule 10 mgtablet 20 mg capsule 20 mg tablet 20mg5 ml solution 40 mg capsule 90mg capsule dr)

fluvoxamine maleate (100 mg tablet25 mg tablet 50 mg tablet)

paroxetine hcl (10 mg tablet 20 mgtablet 30 mg tablet 40 mg tablet)

PAXIL 10 MG5 ML SUSPENSION Tier 2 MO (Maintenance Drug)

sertraline hcl (100 mg tablet 20mgml oral conc 25 mg tablet 50 mgtablet)

TRINTELLIX (10 MG TABLET 20MG TABLET 5 MG TABLET)

Antidepressants

venlafaxine hcl (100 mg tablet 150mg cap er 24h 25 mg tablet 375 mgcap er 24h 375 mg tablet 50 mgtablet 75 mg cap er 24h 75 mgtablet)

VIIBRYD (10 MG TABLET 20 MGTABLET 40 MG TABLET)

VIIBRYD 10-20 MG STARTERPACK

Tier 2 PA

Tricyclicsamitriptyline hcl (10 mg tablet 100mg tablet 150 mg tablet 25 mgtablet 50 mg tablet 75 mg tablet)

amoxapine (100 mg tablet 150 mgtablet 25 mg tablet 50 mg tablet)

clomipramine hcl (25 mg capsule 50mg capsule 75 mg capsule)

desipramine hcl (10 mg tablet 100 mgtablet 150 mg tablet 25 mg tablet 50mg tablet 75 mg tablet)

imipramine hcl (10 mg tablet 25 mgtablet 50 mg tablet)

imipramine pamoate (100 mg capsule125 mg capsule 150 mg capsule 75mg capsule)

nortriptyline hcl (10 mg capsule 10mg5 ml solution 20 mg10mlsolution 25 mg capsule 50 mgcapsule 75 mg capsule)

protriptyline hcl (10 mg tablet 5 mgtablet)

SURMONTIL (100 MG CAPSULE25 MG CAPSULE 50 MGCAPSULE)

trimipramine maleate (100 mgcapsule 25 mg capsule 50 mgcapsule)

Antiemetics

Antiemetics Otherhydroxyzine hcl (10 mg tablet 10mg5 ml solution 25 mg tablet 50 mgtablet 50 mg25ml solution)

Tier 1 PA

meclizine hcl (125 mg tablet 25 mgtablet)

Tier 1

metoclopramide hcl (10 mg tablet 10mg10ml solution 5 mg tablet 5 mg5ml solution)

Tier 1

prochlorperazine 25 mg supprect Tier 1

prochlorperazine edisylate 5 mgmlvial

Tier 1 BvD

promethazine hcl (125 mg supprect125 mg tablet 25 mg supprect 25mg tablet 50 mg supprect 50 mgtablet 625mg5ml syrup)

Tier 1 PA

scopolamine 1 mg3 day patch td 3 Tier 1 PA

Emetogenic Therapy Adjunctsaprepitant (125 mg capsule 125mg-80mg cap ds pk 40 mg capsule 80 mgcapsule)

Tier 1 PA

dronabinol (10 mg capsule 25 mgcapsule 5 mg capsule)

Tier 1 PA

EMEND 125 MG POWDERPACKET

Tier 2 PA

granisetron hcl 1 mg tablet Tier 1 BvD

ondansetron (4 mg tab rapdis 8 mgtab rapdis)

Tier 1 BvD

ondansetron hcl (24 mg tablet 4 mgtablet 4 mg5 ml solution 8 mgtablet)

Tier 1 BvD

Antifungals

AntifungalsABELCET 100 MG20 ML VIAL Tier 2 BvD

AMBISOME 50 MG VIAL Tier 2 BvD

amphotericin b 50 mg vial Tier 1 BvD

caspofungin acetate (50 mg vial 70mg vial)

Tier 1 PA

ciclopirox 077 gel (gram) Tier 1

ciclopirox 8 solution Tier 1 PA

ciclopirox olamine (077 cream (g)077 suspension)

Tier 1

ciclopiroxureacamphmeneuc 8 solution

Tier 1 PA

clotrimazole (1 cream (g) 1 solution 10 mg troche)

Tier 1

econazole nitrate 1 cream (g) Tier 1

ERAXIS (WATER DILUENT) (100MG VIAL 50 MG VIAL)

Tier 2 PA

fluconazole (10 mgml susp recon 100mg tablet 150 mg tablet 200 mgtablet 40 mgml susp recon 50 mgtablet)

Tier 1

fluconazole in dextrose iso-osmotic(in dextroseiso-os 200mg01lpiggyback in dextroseiso-os400mg02l piggyback)

Tier 1 BvD

fluconazole in sodium chloride iso-osmotic (in nacliso-osm 200mg01lpggybk btl in nacliso-osm200mg01l piggyback in nacliso-osm400mg02l pggybk btl in nacliso-osm 400mg02l piggyback)

Tier 1 BvD

flucytosine (250 mg capsule 500 mgcapsule)

Tier 1

griseofulvin ultramicrosize (125 mgtablet 250 mg tablet)

Tier 1

Antifungals

griseofulvin microsize (125 mg5mloral susp 500 mg tablet)

Tier 1

itraconazole 100 mg capsule Tier 1 PA

ketoconazole (2 cream (g) 2 shampoo 200 mg tablet)

Tier 1

miconazole nitrate 200 mg suppvag Tier 1

NATACYN EYE DROPS Tier 2 PA

nystatin (100000g cream (g)100000g oint (g) 100000g powder100000ml oral susp 500k unit tablet)

Tier 1

terbinafine hcl 250 mg tablet Tier 1

terconazole (04 creamappl 08 creamappl 80 mg suppvag)

Tier 1

voriconazole (200 mg tablet 200mg5ml susp recon 50 mg tablet)

Tier 1 PA

voriconazole 200 mg vial Tier 1 BvD

ZOLINZA 100 MG CAPSULE Tier 2 PA

Antigout Agents

Antigout Agentsallopurinol (100 mg tablet 300 mgtablet)

colchicine 06 mg tablet Tier 1

probenecid 500 mg tablet Tier 1 MO (Maintenance Drug)

probenecidcolchicine 500-05 mgtablet

Antimigraine Agents

Ergot Alkaloidsdihydroergotamine mesylate05mgspry spraypump

Tier 1 PA

ergotamine tartratecaffeine 1 mg-100mg tablet

ergotamine tartratecaffeine 2-100mgsupprect

Tier 2

Serotonin (5-HT) 1b1d Receptor Agonistsrizatriptan benzoate (10 mg tabrapdis 10 mg tablet 5 mg tab rapdis5 mg tablet)

sumatriptan 20 mg spray Tier 1 QL (9 PER 30 DAYS)

sumatriptan succinate (100 mg tablet25 mg tablet 50 mg tablet)

sumatriptan succinate (4 mg05mlcartridge 4 mg05ml pen injctr 6mg05ml cartridge 6 mg05ml peninjctr)

Antimyasthenic Agents

Parasympathomimeticsguanidine hcl 125 mg tablet Tier 1

pyridostigmine bromide 60 mg tablet Tier 1 MO (Maintenance Drug)

Antimycobacterials

Antimycobacterials Otherdapsone (100 mg tablet 25 mg tablet) Tier 1 MO (Maintenance Drug)

PRIFTIN 150 MG TABLET Tier 2

rifabutin 150 mg capsule Tier 1

Antitubercularsethambutol hcl (100 mg tablet 400mg tablet)

Tier 1

isoniazid (100 mg tablet 300 mgtablet 50 mg5 ml solution)

Tier 1

PASER GRANULES 4 GMPACKET

Tier 2

pyrazinamide 500 mg tablet Tier 1

rifampin (150 mg capsule 300 mgcapsule)

Tier 1

rifampin 600 mg vial Tier 1 BvD

RIFATER TABLET Tier 2

TRECATOR 250 MG TABLET Tier 2

Antineoplastics

Alkylating AgentsBENDEKA 100 MG4 ML VIAL Tier 2 PA

busulfan 60 mg10ml vial Tier 1 PA

cyclophosphamide (25 mg capsule 50mg capsule)

Tier 2 PA

HEXALEN 50 MG CAPSULE Tier 2 PA

LEUKERAN 2 MG TABLET Tier 2

Antineoplastics

MATULANE 50 MG CAPSULE Tier 2

melphalan hcl 50 mg vial Tier 1 PA

TEMODAR 100 MG VIAL Tier 2 PA

TREANDA (100 MG VIAL 25 MGVIAL)

Tier 2 PA

YONDELIS 1 MG VIAL Tier 2 PA MO (MaintenanceDrug)

Antiandrogensabiraterone acetate 250 mg tablet Tier 1 PA

bicalutamide 50 mg tablet Tier 1 MO (Maintenance Drug)

ERLEADA 60 MG TABLET Tier 2 PA MO (MaintenanceDrug)

flutamide 125 mg capsule Tier 1 MO (Maintenance Drug)

nilutamide 150 mg tablet Tier 1 PA MO (MaintenanceDrug)

NUBEQA 300 MG TABLET Tier 2 PA QL (4 PER 1 DAYS)

XTANDI 40 MG CAPSULE Tier 2 PA MO (MaintenanceDrug)

YONSA 125 MG TABLET Tier 2 PA

ZYTIGA (250 MG TABLET 500MG TABLET)

Antiangiogenic AgentsPOMALYST (1 MG CAPSULE 2MG CAPSULE 3 MG CAPSULE 4MG CAPSULE)

REVLIMID (10 MG CAPSULE 15MG CAPSULE 25 MG CAPSULE5 MG CAPSULE)

Tier 2 PA LA MO (MaintenanceDrug)

THALOMID (100 MG CAPSULE150 MG CAPSULE 200 MGCAPSULE 50 MG CAPSULE)

Antineoplastics

AntiestrogensModifiersEMCYT 140 MG CAPSULE Tier 2 PA

FARESTON 60 MG TABLET Tier 2 MO (Maintenance Drug)

FASLODEX 250 MG5 MLSYRINGE

fulvestrant 250 mg5ml syringe Tier 1

SOLTAMOX (10 MG5 ML SOLN20 MG10 ML SOLN)

tamoxifen citrate (10 mg tablet 20 mgtablet)

toremifene citrate 60 mg tablet Tier 1 MO (Maintenance Drug)

AntimetabolitesALIMTA (100 MG VIAL 500 MGVIAL)

Tier 2 PA

clofarabine 20 mg20ml vial Tier 1 PA

DROXIA (200 MG CAPSULE 300MG CAPSULE 400 MGCAPSULE)

ELITEK (15 MG VIAL 75 MGVIAL)

Tier 2 BvD

fluorouracil (1 g20 ml vial 25 g50mlvial 5 g100 ml vial 500mg10ml vial)

Tier 1 PA

FOLOTYN (20 MGML VIAL 40MG2 ML VIAL)

Tier 2 PA

gemcitabine hcl (1 g vial 1 g263mlvial 100 mgml vial 2 g vial 2g526ml vial 200 mg vial 200mg526vial)

Tier 1 PA

hydroxyurea 500 mg capsule Tier 1 MO (Maintenance Drug)

LONSURF (15 MG-614 MGTABLET 20 MG-819 MGTABLET)

Tier 2 PA

Antineoplastics

PURIXAN 20 MGML ORAL SUSP Tier 2 PA

TABLOID 40 MG TABLET Tier 2 PA

AntineoplasticsGLEOSTINE (10 MG CAPSULE100 MG CAPSULE 40 MGCAPSULE 5 MG CAPSULE)

Tier 2 PA

LYNPARZA (100 MG TABLET150 MG TABLET 50 MGCAPSULE)

MESNEX 400 MG TABLET Tier 2

NINLARO (23 MG CAPSULE 3MG CAPSULE 4 MG CAPSULE)

RUBRACA (200 MG TABLET 250MG TABLET 300 MG TABLET)

VENCLEXTA (10 MG TABLET100 MG TABLET 50 MG TABLET)

VENCLEXTA STARTING PACK Tier 2

ZEJULA 100 MG CAPSULE Tier 2 PA

Antineoplastics Otheramifostine crystalline 500 mg vial Tier 1 PA

arsenic trioxide 12 mg6 ml vial Tier 1 BvD

ARZERRA (1000 MG50 MLVIAL 100 MG5 ML VIAL)

Tier 2 PA

AVASTIN (100 MG4 ML VIAL400 MG16 ML VIAL)

Tier 2 PA

azacitidine 100 mg vial Tier 1 PA

BALVERSA (3 MG TABLET 4 MGTABLET 5 MG TABLET)

BAVENCIO 200 MG10 ML VIAL Tier 2 PA MO (MaintenanceDrug)

BELEODAQ 500 MG VIAL Tier 2 PA MO (MaintenanceDrug)

Antineoplastics

BESPONSA 09 MG VIAL Tier 2 PA

bleomycin sulfate (15 unit vial 30unit vial)

Tier 1 PA

BLINCYTO 35MCGVIAL+STABILIZER

Tier 2 PA

bortezomib 35 mg vial Tier 1 PA

COPIKTRA (15 MG CAPSULE 25MG CAPSULE)

Tier 2 PA

dactinomycin 05 mg vial Tier 1 PA

DARZALEX (100 MG5 ML VIAL400 MG20 ML VIAL)

Tier 2 PA

DAURISMO (100 MG TABLET 25MG TABLET)

decitabine 50 mg vial Tier 1 PA

docetaxel (160 mg8ml vial160mg16ml vial 20 mg2 ml vial200mg10ml vial 20mgml(1) vial 80mg4 ml vial 80 mg8 ml vial)

Tier 1 PA

EMPLICITI (300 MG VIAL 400MG VIAL)

Tier 2 PA

ERWINAZE 10000 UNITS VIAL Tier 2 PA

GAZYVA 1000 MG40 ML VIAL Tier 2 PA

HALAVEN 1 MG2 ML VIAL Tier 2 PA

HERCEPTIN (150 MG VIAL 440MG VIAL)

IMFINZI (120 MG24 ML VIAL500 MG10 ML VIAL)

IMLYGIC 1 MILLION PFUMLVIAL

Tier 2 PA

IMLYGIC 100 MILLION PFUMLVL

INREBIC 100 MG CAPSULE Tier 2 PA QL (4 PER 1 DAYS)

Antineoplastics

ISTODAX 10 MG KIT Tier 2 PA

KADCYLA (100 MG VIAL 160MG VIAL)

Tier 2 PA

KEYTRUDA 100 MG4 ML VIAL Tier 2 PA MO (MaintenanceDrug)

KYPROLIS 10 MG VIAL Tier 2 PA

LARTRUVO (190 MG19 MLVIAL 500 MG50 ML VIAL)

leucovorin calcium (10 mg tablet 15mg tablet 25 mg tablet 5 mg tablet)

Tier 1

leucovorin calcium (100 mg vial 200mg vial 350 mg vial 50 mg vial 500mg vial)

Tier 1 PA

levoleucovorin calcium (10 mgmlvial 175 mg vial 50 mg vial)

Tier 1 PA

LIBTAYO 350 MG7 ML VIAL Tier 2 PA

LUMOXITI 1 MG VIAL Tier 2 PA

MARQIBO KIT Tier 2 PA

mitoxantrone hcl 2 mgml vial Tier 1 PA MO (MaintenanceDrug)

MYLOTARG 45 MG VIAL Tier 2 PA

ONCASPAR 3750 UNIT5 MLVIAL

Tier 2 PA

ONIVYDE 43 MG10 ML VIAL Tier 2 PA

OPDIVO (100 MG10 ML VIAL 240MG24 ML VIAL 40 MG4 MLVIAL)

oxaliplatin (100 mg vial 100mg20mlvial 50 mg vial 50 mg10ml vial)

Tier 1 PA

paclitaxel 6 mgml vial Tier 1 PA

PERJETA 420 MG14 ML VIAL Tier 2 PA

POLIVY 140 MG VIAL Tier 2 PA

Antineoplastics

PORTRAZZA 800 MG50 MLVIAL

Tier 2 PA

POTELIGEO 20 MG5 ML VIAL Tier 2 PA

PROLEUKIN 22 MILLION UNITVIAL

Tier 2 PA

REVLIMID (25 MG CAPSULE 20MG CAPSULE)

RITUXAN (100 MG10 ML VIAL500 MG50 ML VIAL)

Tier 2 PA

romidepsin 10 mg2 ml vial Tier 1 PA

ROZLYTREK 100 MG CAPSULE Tier 2 PA QL (5 PER 1 DAYS)

SYLVANT (100 MG VIAL 400 MGVIAL)

SYNRIBO 35 MGML VIAL Tier 2 PA MO (MaintenanceDrug)

TECENTRIQ (1200 MG20 MLVIAL 840 MG14 ML VIAL)

thiotepa 15 mg vial Tier 1 PA

TIBSOVO 250 MG TABLET Tier 2 PA

TRISENOX (10 MG10 MLAMPULE 12 MG6 ML VIAL)

Tier 2 PA

TURALIO 200 MG CAPSULE Tier 2 PA LA QL (4 PER 1DAYS)

UNITUXIN 175 MG 5 ML VIAL Tier 2 PA

VELCADE 35 MG VIAL Tier 2 PA

VITRAKVI (100 MG CAPSULE 20MGML SOLUTION 25 MGCAPSULE)

VIZIMPRO (15 MG TABLET 30MG TABLET 45 MG TABLET)

Tier 2 PA

VYXEOS 44 MG-100 MG VIAL Tier 2 PA

Antineoplastics

XOSPATA 40 MG TABLET Tier 2 PA MO (MaintenanceDrug)

XPOVIO 100 MG ONCE WEEKLYDOSE

Tier 2 PA QL (20 PER 28 DAYSOVER TIME)

XPOVIO 80 MG TWICE WEEKLYDOSE

YERVOY (200 MG40 ML VIAL 50MG10 ML VIAL)

Tier 2 PA

ZALTRAP (100 MG4 ML VIAL200 MG8 ML VIAL)

ZOLADEX 108 MG IMPLANTSYRN

Tier 1 PA

Tier 2 PA

Aromatase Inhibitors 3rd Generationanastrozole 1 mg tablet Tier 1 MO (Maintenance Drug)

exemestane 25 mg tablet Tier 1 MO (Maintenance Drug)

letrozole 25 mg tablet Tier 1 MO (Maintenance Drug)

Enzyme InhibitorsFARYDAK (10 MG CAPSULE 15MG CAPSULE 20 MG CAPSULE)

Tier 2 PA

IBRANCE (100 MG CAPSULE 125MG CAPSULE 75 MG CAPSULE)

IDHIFA (100 MG TABLET 50 MGTABLET)

KISQALI (200 MG DAILY DOSE400 MG DAILY DOSE 600 MGDAILY DOSE)

Antineoplastics

LORBRENA (100 MG TABLET 25MG TABLET)

Tier 2 PA

PIQRAY (250 MG DAILY DOSE300 MG DAILY DOSE)

Tier 2 PA QL (2 PER 1 DAYS)

PIQRAY 200 MG DAILY DOSE Tier 2 PA QL (1 PER 1 DAYS)

topotecan hcl (4 mg vial 4 mg4 mlvial)

Tier 1 PA

VERZENIO (100 MG TABLET 150MG TABLET 200 MG TABLET 50MG TABLET)

ZYDELIG (100 MG TABLET 150MG TABLET)

Molecular Target InhibitorsAFINITOR (10 MG TABLET 5MG TABLET 75 MG TABLET)

ALECENSA 150 MG CAPSULE Tier 2 PA MO (MaintenanceDrug)

ALIQOPA 60 MG VIAL Tier 2 PA MO (MaintenanceDrug)

ALUNBRIG (180 MG TABLET 30MG TABLET 90 MG TABLET)

ALUNBRIG 90 MG-180 MG TABPACK

Tier 2 PA

BOSULIF (100 MG TABLET 400MG TABLET 500 MG TABLET)

BRAFTOVI (50 MG CAPSULE 75MG CAPSULE)

Tier 2 PA

CABOMETYX (20 MG TABLET40 MG TABLET 60 MG TABLET)

CALQUENCE 100 MG CAPSULE Tier 2 PA MO (MaintenanceDrug)

CAPRELSA (100 MG TABLET 300MG TABLET)

Antineoplastics

COMETRIQ (100 MG DAILY-DOSE PK 140 MG DAILY-DOSEPK 60 MG DAILY-DOSE PACK)

COTELLIC 20 MG TABLET Tier 2 PA MO (MaintenanceDrug)

CYRAMZA (100 MG10 ML VIAL500 MG50 ML VIAL)

ERIVEDGE 150 MG CAPSULE Tier 2 PA MO (MaintenanceDrug)

erlotinib hcl (100 mg tablet 150 mgtablet 25 mg tablet)

GILOTRIF (20 MG TABLET 30MG TABLET 40 MG TABLET)

ICLUSIG (15 MG TABLET 45 MGTABLET)

imatinib mesylate (100 mg tablet 400mg tablet)

IMBRUVICA (140 MG CAPSULE140 MG TABLET 280 MGTABLET 420 MG TABLET 560MG TABLET 70 MG CAPSULE)

INLYTA (1 MG TABLET 5 MGTABLET)

IRESSA 250 MG TABLET Tier 2 PA

JAKAFI (10 MG TABLET 15 MGTABLET 20 MG TABLET 25 MGTABLET 5 MG TABLET)

JEVTANA 60 MG15 ML KIT Tier 2 PA

KYPROLIS (30 MG VIAL 60 MGVIAL)

LENVIMA (10 MG DAILY DOSE14 MG DAILY DOSE 18 MGDAILY DOSE 20 MG DAILYDOSE 24 MG DAILY DOSE 8 MGDAILY DOSE)

Antineoplastics

LENVIMA (12 MG DAILY DOSE4 MG CAPSULE)

Tier 2 PA

MEKINIST (05 MG TABLET 2MG TABLET)

MEKTOVI 15 MG TABLET Tier 2 PA

NERLYNX 40 MG TABLET Tier 2 PA

NEXAVAR 200 MG TABLET Tier 2 PA

ODOMZO 200 MG CAPSULE Tier 2 PA MO (MaintenanceDrug)

RYDAPT 25 MG CAPSULE Tier 2 PA MO (MaintenanceDrug)

SPRYCEL (100 MG TABLET 140MG TABLET 20 MG TABLET 50MG TABLET 70 MG TABLET 80MG TABLET)

STIVARGA 40 MG TABLET Tier 2 PA

SUTENT (125 MG CAPSULE 25MG CAPSULE 375 MGCAPSULE 50 MG CAPSULE)

Tier 2 PA

TAFINLAR (50 MG CAPSULE 75MG CAPSULE)

TAGRISSO (40 MG TABLET 80MG TABLET)

Tier 2 PA

TALZENNA (025 MG CAPSULE1 MG CAPSULE)

Tier 2 PA

TASIGNA (150 MG CAPSULE 200MG CAPSULE 50 MG CAPSULE)

TYKERB 250 MG TABLET Tier 2 PA MO (MaintenanceDrug)

VOTRIENT 200 MG TABLET Tier 2 PA MO (MaintenanceDrug)

XALKORI (200 MG CAPSULE 250MG CAPSULE)

Antineoplastics

ZELBORAF 240 MG TABLET Tier 2 PA MO (MaintenanceDrug)

ZYKADIA (150 MG CAPSULE 150MG TABLET)

Retinoidsbexarotene 75 mg capsule Tier 1 MO (Maintenance Drug)

PANRETIN 01 GEL Tier 2 PA

TARGRETIN 1 GEL Tier 2

tretinoin 10 mg capsule Tier 1 PA

Antiparasitics

Anthelminticsalbendazole 200 mg tablet Tier 1

ivermectin 3 mg tablet Tier 1

praziquantel 600 mg tablet Tier 1

AntiprotozoalsALINIA 500 MG TABLET Tier 2 PA

atovaquone 750 mg5ml oral susp Tier 1

atovaquoneproguanil hcl (250-100mg tablet 625-25 mg tablet)

Tier 1

chloroquine phosphate (250 mgtablet 500 mg tablet)

Tier 1

DARAPRIM 25 MG TABLET Tier 2

hydroxychloroquine sulfate 200 mgtablet

mefloquine hcl 250 mg tablet Tier 1

Antiparasitics

NEBUPENT 300 MG INHALPOWDER

PENTAM 300 VIAL Tier 2 PA

pentamidine isethionate 300 mg vial Tier 1 PA

pentamidine isethionate 300 mg vial-neb

primaquine phosphate 263 mg tablet Tier 2

PediculicidesScabicideslindane 1 shampoo Tier 1

permethrin 5 cream (g) Tier 1

Antiparkinson Agents

Anticholinergicsbenztropine mesylate (05 mg tablet 1mg tablet 2 mg tablet)

trihexyphenidyl hcl (2 mg tablet 2mg5 ml elixir 5 mg tablet)

Antiparkinson Agentscarbidopalevodopaentacapone(125-50 mg tablet 1875-75mg tablet25-100-200 tablet 3125-125 tablet375-150mg tablet 50-200-200 tablet)

Tier 1 ST MO (MaintenanceDrug)

Antiparkinson Agents Otherentacapone 200 mg tablet Tier 1 ST MO (Maintenance

tolcapone 100 mg tablet Tier 1 ST MO (MaintenanceDrug)

Dopamine AgonistsAPOKYN 30 MG3 MLCARTRIDGE

pramipexole di-hcl (0125 mg tablet025 mg tablet 05 mg tablet 075 mgtablet 1 mg tablet 15 mg tablet)

ropinirole hcl (025 mg tablet 05 mgtablet 1 mg tablet 2 mg tablet 3 mgtablet 4 mg tablet 5 mg tablet)

Dopamine Precursors L-Amino Acid Decarboxylase Inhibitorscarbidopalevodopa (10mg-100mgtablet 25mg-100mg tablet 25mg-100mg tablet er 25mg-250mg tablet50mg-200mg tablet er)

Monoamine Oxidase B (MAO-B) Inhibitorsrasagiline mesylate 05 mg tablet Tier 1 PA QL (30 PER 30

DAYS) MO (MaintenanceDrug)

rasagiline mesylate 1 mg tablet Tier 1 PA MO (MaintenanceDrug)

selegiline hcl (5 mg capsule 5 mgtablet)

Antipsychotics

1st GenerationTypicalchlorpromazine hcl (10 mg tablet 100mg tablet 200 mg tablet 25 mgtablet 50 mg tablet)

chlorpromazine hcl 25 mgml ampul Tier 1 PA

Antipsychotics

fluphenazine decanoate 25 mgml vial Tier 1 PA MO (MaintenanceDrug)

fluphenazine hcl (1 mg tablet 10 mgtablet 25 mg tablet 25 mg5mlelixir 5 mg tablet)

fluphenazine hcl 25 mgml vial Tier 1 PA

fluphenazine hcl 5 mgml oral conc Tier 1

haloperidol (05 mg tablet 1 mgtablet 10 mg tablet 2 mg tablet 20mg tablet 5 mg tablet)

haloperidol decanoate (100 mgmlampul 100 mgml vial 50 mgmlampul 50 mgml vial)

haloperidol lactate (5 mgml ampul 5mgml syringe 5 mgml vial)

Tier 1 PA

haloperidol lactate 2 mgml oral conc Tier 1 MO (Maintenance Drug)

loxapine succinate (10 mg capsule 25mg capsule 5 mg capsule 50 mgcapsule)

molindone hcl (10 mg tablet 25 mgtablet)

molindone hcl 5 mg tablet Tier 1

perphenazine (16 mg tablet 2 mgtablet 4 mg tablet 8 mg tablet)

pimozide (1 mg tablet 2 mg tablet) Tier 1 MO (Maintenance Drug)

prochlorperazine maleate (10 mgtablet 5 mg tablet)

Tier 1

thioridazine hcl (10 mg tablet 100 mgtablet 25 mg tablet 50 mg tablet)

thiothixene (1 mg capsule 10 mgcapsule 2 mg capsule 5 mg capsule)

trifluoperazine hcl (1 mg tablet 10 mgtablet 2 mg tablet 5 mg tablet)

Antipsychotics

2nd GenerationAtypicalABILIFY MAINTENA (ER 300MG SYR ER 300 MG VL ER 400MG SYR ER 400 MG VL)

aripiprazole (10 mg tab rapdis 10 mgtablet 15 mg tablet 2 mg tablet 5 mgtablet)

aripiprazole (20 mg tablet 30 mgtablet)

aripiprazole 1 mgml solution Tier 1 QL (900 PER 30 DAYS)MO (Maintenance Drug)

aripiprazole 15 mg tab rapdis Tier 1 QL (60 PER 30 DAYS)MO (Maintenance Drug)

ARISTADA (ER 1064 MG39 MLSYR ER 441 MG16 ML SYRNER 662 MG24 ML SYRN ER 882MG32 ML SYRN)

ARISTADA INITIO ER 675 MG24 Tier 2 PA

FANAPT (1 MG TABLET 10 MGTABLET 12 MG TABLET 2 MGTABLET 4 MG TABLET 6 MGTABLET 8 MG TABLET)

FANAPT TITRATION PACK Tier 2 PA

GEODON 20 MGML VIAL Tier 2 PA

INVEGA SUSTENNA (117MG075 ML 156 MGML SYRG234 MG15 ML 39 MG025 ML 78MG05 ML)

INVEGA TRINZA (273 MG0875ML 410 MG1315 ML 546MG175 ML 819 MG2625 ML)

LATUDA (120 MG TABLET 20MG TABLET 40 MG TABLET 60MG TABLET 80 MG TABLET)

NUPLAZID (10 MG TABLET 34MG CAPSULE)

Tier 2 PA

Antipsychotics

NUPLAZID 17 MG TABLET Tier 2 PA MO (MaintenanceDrug)

olanzapine (10 mg tab rapdis 10 mgtablet 15 mg tab rapdis 15 mg tablet25 mg tablet 20 mg tab rapdis 20mg tablet 5 mg tab rapdis 5 mgtablet 75 mg tablet)

olanzapine 10 mg vial Tier 1 PA

paliperidone (6 mg tab er 24 9 mg taber 24)

paliperidone 15 mg tab er 24 Tier 1 PA QL (240 PER 30DAYS) MO (MaintenanceDrug)

PERSERIS (ER 120 MG SYRINGEKIT ER 90 MG SYRINGE KIT)

Tier 2 PA

quetiapine fumarate (100 mg tablet200 mg tablet 25 mg tablet 300 mgtablet 400 mg tablet 50 mg tablet)

REXULTI (025 MG TABLET 05MG TABLET 1 MG TABLET 2MG TABLET 3 MG TABLET 4MG TABLET)

RISPERDAL CONSTA (125 MGSYR 25 MG SYR 375 MG SYR50 MG SYR)

risperidone (025 mg tab rapdis 025mg tablet 05 mg tab rapdis 05 mgtablet 1 mg tab rapdis 1 mg tablet 2mg tab rapdis 2 mg tablet 3 mg tabrapdis 3 mg tablet 4 mg tab rapdis 4mg tablet)

risperidone 1 mgml solution Tier 1 QL (240 PER 30 DAYS)MO (Maintenance Drug)

Antipsychotics

SAPHRIS (10 MG TABSUBLINGUAL 25 MG TABSUBLINGUAL 5 MG TABSUBLINGUAL)

VRAYLAR (15 MG CAPSULE 3MG CAPSULE 45 MG CAPSULE6 MG CAPSULE)

ziprasidone hcl (20 mg capsule 40 mgcapsule)

ZYPREXA RELPREVV (210 MGVL KIT 300 MG VL KIT 405 MGVL KIT)

Treatment-Resistantclozapine (100 mg tab rapdis 100 mgtablet 125 mg tab rapdis 150 mg tabrapdis 200 mg tab rapdis 200 mgtablet 25 mg tab rapdis 25 mg tablet50 mg tablet)

VERSACLOZ 50 MGMLSUSPENSION

Antispasticity Agents

Antispasticity Agentsbaclofen (10 mg tablet 20 mg tablet) Tier 1 MO (Maintenance Drug)

dantrolene sodium (100 mg capsule25 mg capsule 50 mg capsule)

tizanidine hcl (2 mg tablet 4 mgtablet)

Antivirals

Anti-HIV Agents Integrase Inhibitors (INSTI)BIKTARVY 50-200-25 MGTABLET

GENVOYA TABLET Tier 2 MO (Maintenance Drug)

ISENTRESS 100 MG POWDERPACKET

ISENTRESS 100 MG TABLETCHEW

ISENTRESS 400 MG TABLET Tier 2 MO (Maintenance Drug)

ISENTRESS HD 600 MG TABLET Tier 2 MO (Maintenance Drug)

STRIBILD TABLET Tier 2 MO (Maintenance Drug)

TIVICAY (10 MG TABLET 25 MGTABLET 50 MG TABLET)

Anti-HIV Agents Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)COMPLERA TABLET Tier 2 MO (Maintenance Drug)

DELSTRIGO 100-300-300 MG TAB Tier 2

EDURANT 25 MG TABLET Tier 2 QL (30 PER 30 DAYS)MO (Maintenance Drug)

efavirenz (200 mg capsule 50 mgcapsule 600 mg tablet)

INTELENCE (100 MG TABLET200 MG TABLET 25 MG TABLET)

nevirapine (100 mg tab er 24h 200 mgtablet 400 mg tab er 24h 50 mg5 mloral susp)

PIFELTRO 100 MG TABLET Tier 2

RESCRIPTOR (100 MG TABLET200 MG TABLET)

VIRAMUNE 50 MG5 ML SUSP Tier 2 MO (Maintenance Drug)

Antivirals

Anti-HIV Agents Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)abacavir sulfate (20 mgml solution300 mg tablet)

abacavir sulfatelamivudine 600-300mg tablet

abacavirlamivudinezidovudine 150-300 mg tablet

ATRIPLA TABLET Tier 2 MO (Maintenance Drug)

CIMDUO 300-300 MG TABLET Tier 2 MO (Maintenance Drug)

DESCOVY 200-25 MG TABLET Tier 2 MO (Maintenance Drug)

didanosine (125 mg capsule dr 200mg capsule dr 250 mg capsule dr 400mg capsule dr)

EMTRIVA (10 MGMLSOLUTION 200 MG CAPSULE)

JULUCA 50-25 MG TABLET Tier 2 MO (Maintenance Drug)

lamivudinezidovudine (150-300 mgtablet 150-300mg tablet)

ODEFSEY TABLET Tier 2 MO (Maintenance Drug)

RETROVIR 200 MG20 ML VIAL Tier 2 PA

stavudine (1 mgml soln recon 15 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule)

SYMFI 600-300-300 MG TABLET Tier 2 MO (Maintenance Drug)

SYMFI LO 400-300-300 MGTABLET

TEMIXYS 300-300 MG TABLET Tier 2

TRUVADA (100 MG-150 MGTABLET 133 MG-200 MGTABLET 167 MG-250 MGTABLET 200 MG-300 MGTABLET)

Antivirals

VIDEX (2 GM PEDIATRIC SOLN4 GM PEDIATRIC SOLN)

VIDEX EC 125 MG CAPSULE Tier 2 MO (Maintenance Drug)

ZERIT 1 MGML SOLUTION Tier 2 MO (Maintenance Drug)

zidovudine (10 mgml syrup 100 mgcapsule 300 mg tablet)

Anti-HIV Agents OtherDOVATO 50-300 MG TABLET Tier 2 QL (30 PER 30 DAYS)

MO (Maintenance Drug)

FUZEON 90 MG VIAL Tier 2 MO (Maintenance Drug)

SELZENTRY (150 MG TABLET20 MGML ORAL SOLN 25 MGTABLET 300 MG TABLET 75 MGTABLET)

TRIUMEQ 600-50-300 MGTABLET

TROGARZO 200 MG133 MLVIAL

Tier 2 BvD MO (MaintenanceDrug)

TYBOST 150 MG TABLET Tier 2 MO (Maintenance Drug)

Anti-HIV Agents Protease InhibitorsAPTIVUS (100 MGMLSOLUTION 250 MG CAPSULE)

atazanavir sulfate (150 mg capsule200 mg capsule 300 mg capsule)

CRIXIVAN (200 MG CAPSULE400 MG CAPSULE)

EVOTAZ 300 MG-150 MGTABLET

fosamprenavir calcium 700 mg tablet Tier 1 MO (Maintenance Drug)

INVIRASE 200 MG CAPSULE Tier 2 QL (300 PER 30 DAYS)MO (Maintenance Drug)

INVIRASE 500 MG TABLET Tier 2 MO (Maintenance Drug)

Antivirals

KALETRA (100-25 MG TABLET200-50 MG TABLET)

LEXIVA 50 MGML SUSPENSION Tier 2 MO (Maintenance Drug)

lopinavirritonavir 400-1005 solution Tier 1 MO (Maintenance Drug)

NORVIR (100 MG SOFTGEL CAP80 MGML SOLUTION)

NORVIR 100 MG POWDERPACKET

Tier 2

PREZCOBIX 800 MG-150 MGTABLET

PREZISTA (150 MG TABLET 600MG TABLET 75 MG TABLET 800MG TABLET)

PREZISTA 100 MGMLSUSPENSION

REYATAZ 50 MG POWDERPACKET

ritonavir 100 mg tablet Tier 1 MO (Maintenance Drug)

SYMTUZA 800-150-200-10 MGTAB

Tier 2

VIRACEPT (250 MG TABLET 625MG TABLET)

Anti-cytomegalovirus (CMV) Agentsvalganciclovir hcl 450 mg tablet Tier 1 MO (Maintenance Drug)

ZIRGAN 015 OPHTHALMICGEL

Tier 2

Anti-hepatitis B (HBV) Agentsadefovir dipivoxil 10 mg tablet Tier 1 PA

BARACLUDE 005 MGMLSOLUTION

entecavir (05 mg tablet 1 mg tablet) Tier 1 PA MO (MaintenanceDrug)

Antivirals

EPIVIR HBV 25 MG5 ML SOLN Tier 2 PA MO (MaintenanceDrug)

INTRON A (10 MILLION UNITSVIL 18 MILLION UNIT3 ML 25MILLION UNIT25ML)

Tier 2 PA

lamivudine (10 mgml solution 100mg tablet 150 mg tablet 300 mgtablet)

ribavirin (200 mg capsule 200 mgtablet 400 mg tablet 600 mg tablet)

Tier 1 PA

tenofovir disoproxil fumarate 300 mgtablet

VEMLIDY 25 MG TABLET Tier 2 PA MO (MaintenanceDrug)

VIREAD (150 MG TABLET 200MG TABLET 250 MG TABLETPOWDER)

Anti-hepatitis C (HCV) Agents Direct ActingHARVONI 45-200 MG TABLET Tier 2 PA QL (1 PER 1 DAYS)

MAVYRET 100-40 MG TABLET Tier 2 PA

VOSEVI 400-100-100 MG TABLET Tier 2 PA

Anti-hepatitis C (HCV) Agents OthersEPCLUSA 400 MG-100 MGTABLET

Tier 2 PA

HARVONI 90-400 MG TABLET Tier 2 PA

INTRON A (18 MILLION UNITSVIL 50 MILLION UNITS VIL)

Tier 2 PA

PEGASYS (180 MCG05 MLSYRINGE 180 MCGML VIAL)

Tier 2 PA

PEGASYS PROCLICK 180MCG05

Tier 2 PA

SYLATRON (200 MCG KIT 300MCG KIT 600 MCG KIT)

Antivirals

Anti-influenza Agentsamantadine hcl (100 mg capsule 100mg tablet 50 mg5 ml solution)

oseltamivir phosphate (45 mg capsule75 mg capsule)

oseltamivir phosphate 30 mg capsule Tier 1 QL (84 PER 180 DAYSOVER TIME)

oseltamivir phosphate 6 mgml susprecon

RELENZA 5 MG DISKHALER Tier 2 QL (56 PER 180 DAYSOVER TIME)

rimantadine hcl 100 mg tablet Tier 1

TAMIFLU 6 MGMLSUSPENSION

Antiherpetic Agentsacyclovir (200 mg capsule 200mg5ml oral susp 400 mg tablet 800mg tablet)

acyclovir 5 cream (g) Tier 1 QL (5 PER 30 DAYSOVER TIME)

acyclovir 5 oint (g) Tier 1 QL (30 PER 30 DAYS)

acyclovir sodium 50 mgml vial Tier 1 BvD

DENAVIR 1 CREAM Tier 2 PA

trifluridine 1 drops Tier 1

valacyclovir hcl (1000 mg tablet 500mg tablet)

Anxiolytics

Anxiolytics Otherbuspirone hcl (10 mg tablet 15 mgtablet 30 mg tablet 5 mg tablet 75mg tablet)

doxepin hcl (10 mg capsule 10 mgmloral conc 100 mg capsule 150 mgcapsule 25 mg capsule 50 mgcapsule 75 mg capsule)

triazolam (0125 mg tablet 025 mgtablet)

Benzodiazepinesalprazolam (025 mg tablet 05 mgtablet 1 mg tablet 2 mg tablet)

clonazepam (0125 mg tab rapdis025 mg tab rapdis 05 mg tab rapdis05 mg tablet 1 mg tab rapdis 1 mgtablet 2 mg tab rapdis 2 mg tablet)

clorazepate dipotassium (375 mgtablet 75 mg tablet)

clorazepate dipotassium 15 mg tablet Tier 1 QL (180 PER 30 DAYS)

lorazepam (05 mg tablet 1 mg tablet2 mg tablet)

Bipolar Agents

Mood Stabilizerscarbamazepine (100 mg cpmp 12hr100 mg tab chew 100 mg tab er 12h100 mg5ml oral susp 200 mg cpmp12hr 200 mg tablet 300 mg cpmp12hr)

Bipolar Agents

lithium carbonate (150 mg capsule300 mg capsule 300 mg tablet 300mg tablet er 450 mg tablet er 600 mgcapsule)

lithium citrate 8 meq5 ml solution Tier 1 MO (Maintenance Drug)

TEGRETOL XR 100 MG TABLET Tier 2 MO (Maintenance Drug)

Blood Glucose Regulators

Antidiabetic Agentsacarbose 100 mg tablet Tier 1 QL (90 PER 30 DAYS)

acarbose 25 mg tablet Tier 1 QL (360 PER 30 DAYS)MO (Maintenance Drug)

AVANDIA (2 MG TABLET 4 MGTABLET)

colesevelam hcl 375 g powd pack Tier 1 PA MO (MaintenanceDrug)

colesevelam hcl 625 mg tablet Tier 1 PA

CYCLOSET 08 MG TABLET Tier 2 PA MO (MaintenanceDrug)

glimepiride 1 mg tablet Tier 1 QL (240 PER 30 DAYS)MO (Maintenance Drug)

glipizide (10 mg tab er 24 5 mgtablet)

glipizide (10 mg tablet 5 mg tab er24)

glipizide 25 mg tab er 24 Tier 1 QL (240 PER 30 DAYS)MO (Maintenance Drug)

glyburide 125 mg tablet Tier 1 PA QL (480 PER 30DAYS) MO (MaintenanceDrug)

glyburidemicronized 15 mg tablet Tier 1 PA QL (240 PER 30DAYS) MO (MaintenanceDrug)

INVOKAMET (150-1000 MGTABLET 150-500 MG TABLET 50-1000 MG TABLET 50-500 MGTABLET)

INVOKAMET XR (150-1000 MGTAB 150-500 MG TABLET 50-1000 MG TAB 50-500 MGTABLET)

INVOKANA (100 MG TABLET300 MG TABLET)

JANUVIA (100 MG TABLET 25MG TABLET 50 MG TABLET)

metformin hcl (1000 mg tablet 750mg tab er 24h)

metformin hcl (500 mg tab er 24 500mg tablet)

metformin hcl 500 mg tab er 24h Tier 1 QL (120 PER 30 DAYS)MO (Maintenance Drug)

metformin hcl 850 mg tablet Tier 1 QL (90 PER 30 DAYS)MO (Maintenance Drug)

miglitol 100 mg tablet Tier 1 QL (90 PER 30 DAYS)MO (Maintenance Drug)

nateglinide (120 mg tablet 60 mgtablet)

OZEMPIC 025-05 MG DOSE PEN Tier 2 QL (15 PER 28 DAYSOVER TIME) MO(Maintenance Drug)

OZEMPIC 1 MG DOSE PEN Tier 2 QL (3 PER 28 DAYSOVER TIME) MO(Maintenance Drug)

pioglitazone hcl (15 mg tablet 30 mgtablet 45 mg tablet)

repaglinide (05 mg tablet 1 mgtablet 2 mg tablet)

SYMLINPEN 120 PEN INJECTOR Tier 2 PA MO (MaintenanceDrug)

TANZEUM (30 MG PEN INJECT50 MG PEN INJECT)

tolazamide (250 mg tablet 500 mgtablet)

tolbutamide 500 mg tablet Tier 1 QL (180 PER 30 DAYS)MO (Maintenance Drug)

TRADJENTA 5 MG TABLET Tier 2 QL (30 PER 30 DAYS)MO (Maintenance Drug)

TRULICITY (075 MG05 MLPEN 15 MG05 ML PEN)

Tier 2 QL (2 PER 28 DAYSOVER TIME) MO(Maintenance Drug)

VICTOZA 2-PAK 18 MG3 MLPEN

WELCHOL 375G PACKET Tier 2 PA MO (MaintenanceDrug)

Blood Glucose Regulatorsglipizidemetformin hcl (25-500 mgtablet 5 mg-500mg tablet)

glipizidemetformin hcl 25-250 mgtablet

glyburidemetformin hcl (25-500 mgtablet 5 mg-500mg tablet)

glyburidemetformin hcl 125-250mgtablet

JANUMET (50-1000 MG TABLET50-500 MG TABLET)

JANUMET XR (100-1000 MGTABLET 50-1000 MG TABLET)

JANUMET XR 50-500 MGTABLET

JENTADUETO (25 MG-1000 MGTAB 25 MG-500 MG TAB 25MG-850 MG TAB)

JENTADUETO XR 25 MG-1000MG

JENTADUETO XR 5 MG-1000MG TB

Glycemic AgentsBAQSIMI (3 MG SPRAY ONEPACK 3 MG SPRAY TWO PACK)

GLUCAGEN 1 MG HYPOKIT Tier 2

GLUCAGON 1 MG EMERGENCYKIT

KORLYM 300 MG TABLET Tier 2 PA MO (MaintenanceDrug)

PROGLYCEM 50 MGML ORALSUSP

Insulinsgauze bandage 2 x 2 bandage Tier 1

HUMALOG (100 UNITML VIAL100 UNITSML CARTRIDGE)

HUMALOG 100 UNITSMLKWIKPEN

HUMALOG MIX 50-50 KWIKPEN Tier 2 MO (Maintenance Drug)

HUMALOG MIX 50-50 VIAL Tier 2 MO (Maintenance Drug)

HUMULIN 70-30 VIAL Tier 2 MO (Maintenance Drug)

HUMULIN 7030 KWIKPEN Tier 2 MO (Maintenance Drug)

HUMULIN N 100 UNITML VIAL Tier 2 MO (Maintenance Drug)

HUMULIN N 100 UNITSMLKWIKPEN

HUMULIN R 100 UNITML VIAL Tier 2 MO (Maintenance Drug)

HUMULIN R 500 UNITSMLVIAL

insulin pen needles Tier 1 MO (Maintenance Drug)

insulin syringe 03 ml Tier 1 MO (Maintenance Drug)

LANTUS 100 UNITML VIAL Tier 2 MO (Maintenance Drug)

LANTUS SOLOSTAR 100UNITML

NOVOLIN 70-30 (100 UNITMLVIAL RELION VIAL)

NOVOLIN N (N 100 UNITMLVIAL RELION N 100 UNITML)

NOVOLIN R (R 100 UNITMLVIAL RELION R 100 UNITML)

NOVOLOG (100 UNITMLCARTRIDGE 100 UNITMLVIAL)

NOVOLOG 100 UNITMLFLEXPEN

NOVOLOG MIX 70-30 FLEXPENSYRN

NOVOLOG MIX 70-30 VIAL Tier 2 MO (Maintenance Drug)

TOUJEO MAX SOLOSTR 300UNITML

TOUJEO SOLOSTAR 300UNITML

Blood Products Modifiers Volume Expanders

AnticoagulantsCOUMADIN (1 MG TABLET 10MG TABLET 2 MG TABLET 25MG TABLET 3 MG TABLET 4MG TABLET 5 MG TABLET 6MG TABLET 75 MG TABLET)

ELIQUIS (25 MG TABLET 5 MGTABLET)

ELIQUIS 5 MG STARTER PACK Tier 2

enoxaparin sodium (100 mgmlsyringe 120mg8ml syringe 150mgml syringe 30mg03ml syringe40mg04ml syringe 60mg06mlsyringe 80mg08ml syringe)

Tier 1

fondaparinux sodium (10mg08mlsyringe 25 mg05 syringe 5mg04mlsyringe 75mg06 syringe)

Tier 1 PA

FRAGMIN (10000 UNITSMLSYRING 12500 UNITS05 ML15000 UNITS06 ML 18000UNITS072 ML 2500 UNITS02ML SYR 5000 UNITS02 MLSYR 7500 UNITS03 ML SYR95000 UNITS38 ML VL)

Tier 2

heparin sodiumporcine (1000ml vial10000ml vial 20000ml vial 5000mlvial)

Tier 1 BvD

warfarin sodium (1 mg tablet 10 mgtablet 2 mg tablet 25 mg tablet 3mg tablet 4 mg tablet 5 mg tablet 6mg tablet 75 mg tablet)

XARELTO (10 MG TABLET 15MG TABLET 25 MG TABLET 20MG TABLET)

XARELTO STARTER PACK Tier 2

Blood Formation Modifiersanagrelide hcl (05 mg capsule 1 mgcapsule)

ARANESP (10 MCG04 MLSYRINGE 100 MCG05 MLSYRINGE 100 MCGML VIAL150 MCG03 ML SYRINGE 200MCG04 ML SYRINGE 200MCGML VIAL 25 MCG042 MLSYRING 25 MCGML VIAL 300MCG06 ML SYRINGE 300MCGML VIAL 40 MCG04 MLSYRINGE 40 MCGML VIAL 500MCG1 ML SYRINGE 60 MCG03ML SYRINGE 60 MCGML VIAL)

DOPTELET ((10 TAB PK) 20 MGTAB (15 TAB PK) 20 MG TAB)

Tier 2 PA

DOPTELET (30 TAB PK) 20 MGTAB

EPOGEN (2000 UNITSML VIAL20000 UNITS2 ML VIAL 20000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL)

GRANIX (300 MCG05 ML SAFESYR 300 MCG05 ML SYRINGE480 MCG08 ML SAFE SYR 480MCG08 ML SYRINGE)

Tier 2 PA

LEUKINE 250 MCG VIAL Tier 2 PA

MIRCERA 100 MCG03 MLSYRINGE

NEULASTA (6 MG06 MLSYRINGE ONPRO 6 MG06 MLKIT)

Tier 2 PA

NEUPOGEN (300 MCG05 MLSYR 300 MCGML VIAL 480MCG08 ML SYR 480 MCG16ML VIAL)

Tier 2 PA

PROCRIT (10000 UNITSMLVIAL 2000 UNITSML VIAL20000 UNITSML VIAL 3000UNITSML VIAL 4000 UNITSMLVIAL 40000 UNITSML VIAL)

PROMACTA (125 MG SUSPENPACKET 125 MG TABLET 25MG TABLET 50 MG TABLET 75MG TABLET)

TAVALISSE (100 MG TABLET150 MG TABLET)

Tier 2 PA

ZARXIO (300 MCG05 MLSYRINGE 480 MCG08 MLSYRINGE)

Tier 2 PA

Hemostasis Agentstranexamic acid 650 mg tablet Tier 1 PA MO (Maintenance

Platelet Modifying Agentsaspirindipyridamole 25mg-200mgcpmp 12hr

BRILINTA (60 MG TABLET 90MG TABLET)

cilostazol (100 mg tablet 50 mgtablet)

clopidogrel bisulfate 75 mg tablet Tier 1 MO (Maintenance Drug)

dipyridamole (25 mg tablet 50 mgtablet 75 mg tablet)

Cardiovascular Agents

Alpha-adrenergic Agonistsclonidine (01mg24hr patch tdwk02mg24hr patch tdwk 03mg24hrpatch tdwk)

clonidine hcl (01 mg tablet 02 mgtablet 03 mg tablet)

guanfacine hcl (1 mg tablet 2 mgtablet)

methyldopa (250 mg tablet 500 mgtablet)

midodrine hcl (10 mg tablet 25 mgtablet 5 mg tablet)

Tier 1

NORTHERA (100 MG CAPSULE200 MG CAPSULE 300 MGCAPSULE)

Alpha-adrenergic Blocking Agentsdoxazosin mesylate (1 mg tablet 2 mgtablet 4 mg tablet 8 mg tablet)

prazosin hcl (1 mg capsule 2 mgcapsule 5 mg capsule)

terazosin hcl (1 mg capsule 10 mgcapsule 2 mg capsule 5 mg capsule)

Angiotensin II Receptor AntagonistsENTRESTO (24 MG-26 MGTABLET 49 MG-51 MG TABLET97 MG-103 MG TABLET)

irbesartan (150 mg tablet 300 mgtablet 75 mg tablet)

Tier 1

irbesartanhydrochlorothiazide (150-125mg tablet 300-125mg tablet)

Tier 1

losartan potassium (100 mg tablet 25mg tablet 50 mg tablet)

valsartan (160 mg tablet 320 mgtablet 40 mg tablet 80 mg tablet)

Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl (10 mg tablet 20 mgtablet 40 mg tablet 5 mg tablet)

captopril (100 mg tablet 125 mgtablet 25 mg tablet 50 mg tablet)

enalapril maleate (10 mg tablet 25mg tablet 20 mg tablet 5 mg tablet)

fosinopril sodium (10 mg tablet 20mg tablet 40 mg tablet)

lisinopril (10 mg tablet 25 mg tablet20 mg tablet 30 mg tablet 40 mgtablet 5 mg tablet)

moexipril hcl (15 mg tablet 75 mgtablet)

quinapril hcl (10 mg tablet 20 mgtablet 40 mg tablet 5 mg tablet)

ramipril (125 mg capsule 10 mgcapsule 25 mg capsule 5 mg capsule)

trandolapril (1 mg tablet 2 mg tablet4 mg tablet)

Antiarrhythmicsamiodarone hcl (100 mg tablet 200mg tablet 400 mg tablet)

disopyramide phosphate (100 mgcapsule 150 mg capsule)

dofetilide (125 mcg capsule 250 mcgcapsule 500 mcg capsule)

flecainide acetate (100 mg tablet 150mg tablet 50 mg tablet)

mexiletine hcl (150 mg capsule 200mg capsule 250 mg capsule)

MULTAQ 400 MG TABLET Tier 2 PA MO (MaintenanceDrug)

PACERONE (100 MG TABLET400 MG TABLET)

propafenone hcl (150 mg tablet 225mg tablet 300 mg tablet)

quinidine gluconate 324 mg tablet er Tier 1 MO (Maintenance Drug)

quinidine sulfate (200 mg tablet 300mg tablet)

sotalol hcl (120 mg tablet 160 mgtablet 240 mg tablet 80 mg tablet)

Beta-adrenergic Blocking Agentsacebutolol hcl (200 mg capsule 400mg capsule)

atenolol (100 mg tablet 25 mg tablet50 mg tablet)

betaxolol hcl (10 mg tablet 20 mgtablet)

bisoprolol fumarate (10 mg tablet 5mg tablet)

carvedilol (125 mg tablet 25 mgtablet 3125 mg tablet 625 mgtablet)

labetalol hcl (100 mg tablet 200 mgtablet 300 mg tablet)

metoprolol succinate (100 mg tab er24h 25 mg tab er 24h 50 mg tab er24h)

metoprolol succinate 200 mg tab er24h

metoprolol tartrate (100 mg tablet 25mg tablet 50 mg tablet)

nadolol (20 mg tablet 40 mg tablet80 mg tablet)

pindolol (10 mg tablet 5 mg tablet) Tier 1 MO (Maintenance Drug)

propranolol hcl (10 mg tablet 120 mgcap sa 24h 160 mg cap sa 24h 20 mgtablet 40 mg tablet 60 mg cap sa24h 60 mg tablet 80 mg cap sa 24h80 mg tablet)

timolol maleate (10 mg tablet 20 mgtablet 5 mg tablet)

Calcium Channel Blocking Agentsamlodipine besylate (10 mg tablet 25mg tablet 5 mg tablet)

diltiazem hcl (120 mg cap er 12h 120mg cap er 24h 120 mg cap er deg 120mg cap sa 24h 120 mg tablet 180 mgcap er 24h 180 mg cap er deg 180 mgcap sa 24h 240 mg cap er 24h 240 mgcap er deg 240 mg cap sa 24h 30 mgtablet 300 mg cap er 24h 300 mg capsa 24h 360 mg cap er 24h 360 mg capsa 24h 420 mg cap sa 24h 60 mg caper 12h 60 mg tablet 90 mg cap er12h 90 mg tablet)

felodipine (10 mg tab er 24h 25 mgtab er 24h 5 mg tab er 24h)

isradipine (25 mg capsule 5 mgcapsule)

nicardipine hcl (20 mg capsule 30 mgcapsule)

nifedipine (30 mg tab er 24 30 mgtablet er 60 mg tab er 24 60 mgtablet er 90 mg tab er 24 90 mgtablet er)

verapamil hcl (100 mg cap24h pct120 mg cap24h pel 120 mg tablet 120mg tablet er 180 mg cap24h pel 180mg tablet er 200 mg cap24h pct 240mg cap24h pel 240 mg tablet er 300mg cap24h pct 360 mg cap24h pel 40mg tablet 80 mg tablet)

Cardiovascular Agentsamiloridehydrochlorothiazide 5 mg-50 mg tablet

amlodipine besylatebenazepril hcl (10mg-20mg capsule 10 mg-40mgcapsule 25mg-10mg capsule 5 mg-10mg capsule 5 mg-20 mg capsule 5mg-40 mg capsule)

atenololchlorthalidone (100mg-25mgtablet 50 mg-25mg tablet)

benazepril hclhydrochlorothiazide(10-125mg tablet 20 mg-25mg tablet20-125 mg tablet 5-625mg tablet)

bisoprololfumaratehydrochlorothiazide (10-625mg tablet 25-625mg tablet 5-625mg tablet)

captoprilhydrochlorothiazide (25mg-15mg tablet 25 mg-25mg tablet50 mg-15mg tablet 50 mg-25mgtablet)

DEMSER 250 MG CAPSULE Tier 2 PA

enalapril maleatehydrochlorothiazide(10 mg-25mg tablet 5mg-125mgtablet)

fosinoprilsodiumhydrochlorothiazide (10-125mg tablet 20-125 mg tablet)

lisinoprilhydrochlorothiazide (10-125mg tablet 20 mg-25mg tablet 20-125 mg tablet)

losartanpotassiumhydrochlorothiazide (100-125mg tablet 100mg-25mg tablet50-125 mg tablet)

methyldopahydrochlorothiazide(250mg-15mg tablet 250mg-25mgtablet)

metoprololtartratehydrochlorothiazide (100mg-25mg tablet 100mg-50mg tablet 50mg-25mg tablet)

propranolol hclhydrochlorothiazide(40 mg-25mg tablet 80 mg-25mgtablet)

quinapril hclhydrochlorothiazide(10-125mg tablet 20 mg-25mg tablet20-125 mg tablet)

spironolacthydrochlorothiazid 25mg-25mg tablet

TEKTURNA HCT (150-125 MGTAB 150-25 MG TABLET 300-125MG TAB 300-25 MG TABLET)

triamterenehydrochlorothiazide(375-25 mg capsule 375-25 mgtablet 50 mg-25mg capsule 75 mg-50mg tablet)

valsartanhydrochlorothiazide (160-125mg tablet 160-25mg tablet 320-125mg tablet 320mg-25mg tablet80-125mg tablet)

Cardiovascular Agents OtherCORLANOR (5 MG TABLET 75MG TABLET)

CORLANOR 5 MG5 ML ORALSOLN

digoxin 125 mcg tablet Tier 1 QL (30 PER 30 DAYS)MO (Maintenance Drug)

digoxin 250 mcg tablet Tier 1 MO (Maintenance Drug)

digoxin 50 mcgml solution Tier 2 MO (Maintenance Drug)

pentoxifylline 400 mg tablet er Tier 1 MO (Maintenance Drug)

ranolazine (1000 mg tab er 12h 500mg tab er 12h)

TEKTURNA (150 MG TABLET300 MG TABLET)

UPTRAVI (1000 MCG TABLET1200 MCG TABLET 1400 MCGTABLET 1600 MCG TABLET 200MCG TABLET 400 MCGTABLET 600 MCG TABLET 800MCG TABLET)

UPTRAVI 200-800 TITRATIONPACK

Tier 2 PA

VYNDAMAX 61 MG CAPSULE Tier 2 PA QL (1 PER 1 DAYS)

VYNDAQEL 20 MG CAPSULE Tier 2 PA QL (4 PER 1 DAYS)

Diuretics Carbonic Anhydrase Inhibitorsacetazolamide (125 mg tablet 250 mgtablet 500 mg capsule er)

methazolamide (25 mg tablet 50 mgtablet)

Diuretics Loopbumetanide (05 mg tablet 1 mgtablet 2 mg tablet)

bumetanide 025 mgml vial Tier 1 BvD

furosemide (10 mgml solution 20 mgtablet 40 mg tablet 80 mg tablet)

furosemide (10 mgml syringe 10mgml vial)

Tier 1 BvD

torsemide (10 mg tablet 100 mgtablet 20 mg tablet 5 mg tablet)

Diuretics Potassium-sparingamiloride hcl 5 mg tablet Tier 1 MO (Maintenance Drug)

eplerenone (25 mg tablet 50 mgtablet)

spironolactone (100 mg tablet 25 mgtablet 50 mg tablet)

Diuretics Thiazidechlorothiazide (250 mg tablet 500 mgtablet)

chlorthalidone (25 mg tablet 50 mgtablet)

hydrochlorothiazide (125 mg capsule125 mg tablet 25 mg tablet 50 mgtablet)

indapamide (125 mg tablet 25 mgtablet)

methyclothiazide 5 mg tablet Tier 1 MO (Maintenance Drug)

metolazone (10 mg tablet 25 mgtablet 5 mg tablet)

Dyslipidemics Fibric Acid Derivativesfenofibrate (120 mg tablet 160 mgtablet 40 mg tablet 54 mg tablet)

fenofibrate nanocrystallized (145mgtablet 48 mg tablet)

fenofibrate nanocrystallized 160 mgtablet

Tier 1

fenofibratemicronized (134 mgcapsule 200 mg capsule 67 mgcapsule)

gemfibrozil 600 mg tablet Tier 1 MO (Maintenance Drug)

Dyslipidemics HMG CoA Reductase Inhibitorsatorvastatin calcium (10 mg tablet 20mg tablet 40 mg tablet 80 mg tablet)

lovastatin (10 mg tablet 20 mg tablet40 mg tablet)

pravastatin sodium (10 mg tablet 20mg tablet 40 mg tablet 80 mg tablet)

rosuvastatin calcium (10 mg tablet 20mg tablet 40 mg tablet 5 mg tablet)

simvastatin (10 mg tablet 20 mgtablet 40 mg tablet 5 mg tablet 80mg tablet)

Dyslipidemics Othercholestyramine (with sugar) (4 gpowd pack 4 g powder)

cholestyramineaspartame (4 g powdpack 4 g powder)

colestipol hcl (1 g tablet 5 g granules5 g packet)

ezetimibe 10 mg tablet Tier 1 MO (Maintenance Drug)

KYNAMRO 200 MGMLSYRINGE

niacin (1000 mg tab er 24h 500 mgtab er 24h 750 mg tab er 24h)

omega-3 acid ethyl esters 1 g capsule Tier 1 MO (Maintenance Drug)

REPATHA 140 MGMLSURECLICK

REPATHA 140 MGML SYRINGE Tier 2 PA MO (MaintenanceDrug)

REPATHA 420 MG35MLPUSHTRONX

VASCEPA (05 GM CAPSULE 1GM CAPSULE)

Vasodilators Direct-acting Arterialhydralazine hcl (10 mg tablet 100 mgtablet 25 mg tablet 50 mg tablet)

minoxidil (10 mg tablet 25 mgtablet)

Vasodilators Direct-acting Arterial Venousisosorbide dinitrate (10 mg tablet 20mg tablet 30 mg tablet 40 mg tableter 5 mg tablet)

isosorbide mononitrate (10 mg tablet120 mg tab er 24h 20 mg tablet 30mg tab er 24h 60 mg tab er 24h)

nitroglycerin (01mghr patch td2402mghr patch td24 03 mg tab subl04 mg tab subl 04mghr patch td2406 mg tab subl 06mghr patch td24)

NITROSTAT (03 MG TABLET SL04 MG TABLET SL 06 MGTABLET SL)

RECTIV 04 OINTMENT Tier 2 PA

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents Amphetaminesdextroamphetamine sulf-saccharateamphetamine sulf-aspartate (10 mg cap er 24h 10 mgtablet 125 mg tablet 15 mg cap er24h 15 mg tablet 20 mg cap er 24h20 mg tablet 25 mg cap er 24h 30 mgcap er 24h 30 mg tablet 5 mg cap er24h 5 mg tablet 75 mg tablet)

dextroamphetamine sulfate (10 mgcapsule er 10 mg tablet 15 mgcapsule er 5 mg capsule er 5 mgtablet)

Attention Deficit Hyperactivity Disorder Agents Non-amphetaminesatomoxetine hcl (10 mg capsule 25mg capsule 40 mg capsule)

clonidine hcl 01 mg tab er 12h Tier 1 PA MO (MaintenanceDrug)

dexmethylphenidate hcl (10 mg cpbp50-50 10 mg tablet 15 mg cpbp 50-50 25 mg tablet 20 mg cpbp 50-5025 mg cpbp 50-50 30 mg cpbp 50-5035 mg cpbp 50-50 40 mg cpbp 50-505 mg cpbp 50-50 5 mg tablet)

guanfacine hcl (1 mg tab er 24h 2 mgtab er 24h 3 mg tab er 24h 4 mg taber 24h)

methylphenidate hcl (10 mg tablet 10mg tablet er 20 mg tablet 20 mgtablet er 5 mg tablet)

methylphenidate hcl (18 mg tab er 2427 mg tab er 24 36 mg tab er 24 54mg tab er 24)

Central Nervous System OtherNUEDEXTA 20-10 MG CAPSULE Tier 2 PA

riluzole 50 mg tablet Tier 1 PA MO (MaintenanceDrug)

tetrabenazine (125 mg tablet 25 mgtablet)

Fibromyalgia Agentsduloxetine hcl (20 mg capsule dr 30mg capsule dr 60 mg capsule dr)

duloxetine hcl 40 mg capsule dr Tier 1 ST MO (MaintenanceDrug)

SAVELLA (100 MG TABLET 125MG TABLET 25 MG TABLET 50MG TABLET)

SAVELLA TITRATION PACK Tier 2 PA

Multiple Sclerosis AgentsAMPYRA ER 10 MG TABLET Tier 2 PA MO (Maintenance

AUBAGIO (14 MG TABLET 7 MGTABLET)

AVONEX (30 MCG VIAL KITPREFILLED SYR 30 MCG KT)

AVONEX PEN 30 MCG05 MLKIT

BETASERON 03 MG KIT Tier 2 PA MO (MaintenanceDrug)

dalfampridine 10 mg tab er 12h Tier 1 PA MO (MaintenanceDrug)

EXTAVIA (03 MG KIT 03 MGVIAL)

GILENYA 05 MG CAPSULE Tier 2 PA MO (MaintenanceDrug)

glatiramer acetate (20 mgml syringe40 mgml syringe)

PLEGRIDY 125 MCG05 ML PEN Tier 2 PA MO (MaintenanceDrug)

PLEGRIDY 125 MCG05 MLSYRING

PLEGRIDY PEN INJ STARTERPACK

Tier 2 PA

PLEGRIDY SYRINGE STARTERPACK

Tier 2 PA

REBIF (22 MCG05 MLSYRINGE 44 MCG05 MLSYRINGE)

REBIF REBIDOSE (22 MCG05ML 44 MCG05 ML)

REBIF REBIDOSE TITRATIONPACK

Tier 2 PA

REBIF TITRATION PACK Tier 2 PA

TECFIDERA (DR 120 MGCAPSULE DR 240 MG CAPSULE)

TECFIDERA STARTER PACK Tier 2 PA

Dental and Oral Agents

Dental and Oral Agentschlorhexidine gluconate 012 mouthwash

Tier 1

doxycycline hyclate (100 mg capsule100 mg tablet 150 mg tablet 20 mgtablet 50 mg capsule 75 mg tablet)

Tier 1

minocycline hcl (100 mg capsule 100mg tablet 50 mg capsule 50 mgtablet 75 mg capsule 75 mg tablet)

Tier 1

pilocarpine hcl (5 mg tablet 75 mgtablet)

triamcinolone acetonide 01 paste(g)

Tier 1

Dermatological Agents

Dermatological Agentsacitretin (10 mg capsule 25 mgcapsule)

Tier 1 PA

acitretin 175 mg capsule Tier 1

adapalene (01 cream (g) 01 gel(gram) 03 gel (gram) 03 gelwpump)

Tier 1

ammonium lactate 12 lotion Tier 1

AVITA 0025 GEL Tier 1 PA

betamethasone dipropionate 005 lotion

Tier 1

calcipotriene (0005 cream (g)0005 solution)

clotrimazolebetamethasonedipropionate (1 -005 cream (g) 1-005 lotion)

Tier 1

diclofenac sodium 1 gel (gram) Tier 1 PA MO (MaintenanceDrug)

diclofenac sodium 3 gel (gram) Tier 1 PA

doxycycline monohydrate (100 mgcapsule 100 mg tablet 50 mg capsule50 mg tablet)

Tier 1

ELIDEL 1 CREAM Tier 2 PA QL (30 PER 30DAYS)

erythromycinbenzoyl peroxide 3 -5 gel (gram)

Tier 1

fluorouracil (05 cream (g) 2 solution 5 cream (g) 5 solution)

Tier 1

fluticasone propionate (0005 oint(g) 005 cream (g))

Tier 1

imiquimod 375 crm md pmp Tier 1 PA

imiquimod 5 cream pack Tier 1 PA QL (12 PER 30 DAYSOVER TIME)

isotretinoin (10 mg capsule 20 mgcapsule 30 mg capsule 40 mgcapsule)

Tier 1 PA

methoxsalen 10 mg cap lq rap Tier 1 PA

nystatintriamcinolone acetonide(cream (g) oint (g))

Tier 1

PICATO (0015 GEL 005 GEL) Tier 2 PA

pimecrolimus 1 cream (g) Tier 1 PA QL (30 PER 30)

podofilox 05 solution Tier 1

REGRANEX 001 GEL Tier 2 PA QL (15 PER 30 DAYSOVER TIME)

SANTYL OINTMENT Tier 2

selenium sulfide 25 lotion Tier 1

tacrolimus (003 oint (g) 01 oint (g))

Tier 1 PA

tazarotene 01 cream (g) Tier 1 PA

TAZORAC (005 CREAM 005GEL 01 GEL)

Tier 2 PA

TOLAK 4 CREAM Tier 2 PA

tretinoin (001 gel (gram) 0025 cream (g) 0025 gel (gram) 005 cream (g) 005 gel (gram) 01 cream (g))

Tier 1 PA

VALCHLOR 0016 GEL Tier 2 PA MO (MaintenanceDrug)

ZYCLARA (25 CREAM PUMP375 CREAM 375 CREAMPUMP)

Tier 2 PA

ElectrolytesMineralsMetalsVitamins

Electrolyte Mineral Replacement09 sodium chloride (09 pggybkprt 09 pgy vl prt 09 09 ivsoln)

Tier 1 BvD

CARBAGLU 200 MG DISPERTABLET

fluoride (sodium) (025(055) tabchew 05(11)mg tab chew1mg(22mg) tab chew)

FLUORITAB 1 MG TABLETCHEW

KLOR-CON M15 TABLET Tier 1 MO (Maintenance Drug)

magnesium sulfate 4 meqml vial Tier 1 BvD

potassium chloride (10 meq capsuleer 10 meq tab er prt 10 meq tableter 20 meq tab er prt 20 meq tableter 20meq15ml liquid 40meq15mlliquid 8 meq capsule er 8 meq tableter)

potassium chloride (2 meqml ampul2 meqml vial)

Tier 1 BvD

potassium chloride in 09nacl 20meql iv soln

Tier 1 BvD

sodium chloride 045 (045 pggybk prt 045 045 iv soln)

Tier 1 BvD

sodium chloride irrig solution 09 irrig soln

Tier 1 BvD

ElectrolyteMineralMetal Modifiersdeferasirox (125 mg tab disper 250mg tab disper 500 mg tab disper)

DEPEN 250 MG TITRATAB Tier 2 MO (Maintenance Drug)

FREAMINE HBC 69 IV SOLN Tier 2 BvD

sodium polystyrene sulfonsorb 15g60 ml oral susp

Tier 1

sodium polystyrene sulfonate (15 g60ml oral susp 30 g120ml enema 50g200ml enema powder)

Tier 1

SPS (15 GM60 ML SUSPENSION30 GM120 ML ENEMA SUSP)

Tier 1

SYPRINE 250 MG CAPSULE Tier 2 PA

trientine hcl 250 mg capsule Tier 1 PA

ElectrolytesMineralsMetalsVitaminsAMINOSYN II 15 IV SOLUTION Tier 2 BvD

AMINOSYN-HBC 7 IVSOLUTION

Tier 2 BvD

AMINOSYN-PF 7 IV SOLUTION Tier 2 BvD

dextrose 10 in water (10 in water10 dehp fr bg 10 in water 10 iv soln)

Tier 1 BvD

dextrose 25 and 045 nacl 25-045 iv soln

Tier 1 BvD

dextrose 5 and 03 nacl 5 -03 iv soln

Tier 1 BvD

dextrose 5 in water (5 in waterpggybk prt 5 in water pgy vl prt 5 in water 5 iv soln 5 in water 5 vial)

Tier 1 BvD

dextrose 5 -02 sod chlorid 5 -02 iv soln

Tier 1 BvD

dextrose 5 -045 sod chlord 5 -045 iv soln

Tier 1 BvD

INTRALIPID (20 IV FAT EMUL30 IV FAT EMUL)

Tier 2 BvD

multivit-mins60iron fumfolic 27 mg-1 mg tablet

Tier 1

NEPHRAMINE 54 IVSOLUTION

Tier 2 BvD

potassium chloride in 5 dextrose inwater (in d5w 20 meql iv soln in d5w40 meql iv soln)

Tier 1 BvD

potassium chloride in dextrose 5 -045 sodium chloride (20 meql ivsoln 30 meql iv soln 40 meql ivsoln)

Tier 1 BvD

potassium chloride in lr-d5 20 meqliv soln

Tier 1 BvD

potassium chlorided5-02nacl 20meql iv soln

Tier 1 BvD

PREMASOL (10 IV SOLUTION6 IV SOLUTION)

Tier 2 BvD

PRENATAL PLUS IRON TABLET Tier 1 MO (Maintenance Drug)

PUREFE PLUS CAPSULE Tier 1

TPN ELECTROLYTES II IV SOLN Tier 2 BvD

TPN ELECTROLYTES VIAL Tier 2 BvD

TRAVASOL 10 SOLN VIAFLEX Tier 2 BvD

TROPHAMINE 10 IVSOLUTION

Tier 2 BvD

Gastrointestinal Agents

Antispasmodics Gastrointestinaldicyclomine hcl (10 mg capsule 20mg tablet)

glycopyrrolate (1 mg tablet 2 mgtablet)

Gastrointestinal Agents Otherdiphenoxylate hclatropine sulfate(25-0255 liquid 25-025mg tablet)

Tier 1

loperamide hcl 2 mg capsule Tier 1 MO (Maintenance Drug)

RELISTOR (12 MG06 MLSYRINGE 12 MG06 ML VIAL 8MG04 ML SYRINGE)

Tier 2 PA

ursodiol 300 mg capsule Tier 1 MO (Maintenance Drug)

Histamine2 (H2) Receptor Antagonistscimetidine (300 mg tablet 400 mgtablet 800 mg tablet)

cimetidine 200 mg tablet Tier 1

cimetidine hcl 300 mg5ml solution Tier 1 MO (Maintenance Drug)

famotidine (20 mg tablet 40 mgtablet)

nizatidine (150 mg capsule 300 mgcapsule)

ranitidine hcl (15 mgml syrup 150mg capsule 150 mg tablet 300 mgcapsule 300 mg tablet)

Irritable Bowel Syndrome Agentsalosetron hcl (05 mg tablet 1 mgtablet)

Tier 1 PA

AMITIZA (24 MCG CAPSULES 8MCG CAPSULE)

Laxativeslactulose (10 g15 ml solution 20 g30ml solution)

MIRALAX (POWDER POWDERPACKET)

Tier 1

peg 3350sod sulfsod bicarbsodchloridepotassium chloride (236-2274g soln recon 240-2272g solnrecon)

Tier 1

polyethylene glycol 3350 17g powdpack

polyethylene glycol 3350 17gdosepowder

sodium chloridenahco3kclpeg 420gsoln recon

Tier 1

Protectantsmisoprostol 100 mcg tablet Tier 1 MO (Maintenance Drug)

sucralfate 1 g tablet Tier 1 MO (Maintenance Drug)

Proton Pump Inhibitorslansoprazole (15 mg capsule dr 30 mgcapsule dr)

omeprazole (10 mg capsule dr 20 mgcapsule dr)

omeprazole 40 mg capsule dr Tier 1 QL (30 PER 30 DAYS)MO (Maintenance Drug)

pantoprazole sodium (20 mg tabletdr 40 mg tablet dr)

Genetic or Enzyme Disorder Replacement Modifiers Treatment

Genetic or Enzyme Disorder Replacement Modifiers TreatmentCREON (DR 12000 UNITSCAPSULE DR 24000 UNITSCAPSULE DR 3000 UNITSCAPSULE DR 36000 UNITSCAPSULE DR 6000 UNITSCAPSULE)

CYSTADANE 1 GRAM17 MLPOWDER

CYSTAGON (150 MG CAPSULE50 MG CAPSULE)

KUVAN (100 MG POWDERPACKET 100 MG TABLET 500MG POWDER PACKET)

miglustat 100 mg capsule Tier 1 PA MO (MaintenanceDrug)

nitisinone (10 mg capsule 2 mgcapsule 5 mg capsule)

Tier 1 PA

ORFADIN (10 MG CAPSULE 2MG CAPSULE 20 MG CAPSULE5 MG CAPSULE)

sodium phenylbutyrate 500 mg tablet Tier 1 PA MO (MaintenanceDrug)

SUCRAID 8500 UNITSML SOLN Tier 2 PA MO (MaintenanceDrug)

ZENPEP (DR 10000 UNITCAPSULE DR 15000 UNITCAPSULE DR 20000 UNITCAPSULE DR 25000 UNITCAPSULE DR 3000 UNITCAPSULE DR 40000 UNITCAPSULE DR 5000 UNITCAPSULE)

Genitourinary Agents

Antispasmodics UrinaryMYRBETRIQ (ER 25 MGTABLET ER 50 MG TABLET)

oxybutynin chloride (10 mg tab er 2415 mg tab er 24 5 mg tab er 24 5 mgtablet 5 mg5 ml syrup)

tolterodine tartrate (1 mg tablet 2 mgtablet)

Tier 1 ST QL (60 PER 30DAYS) MO (MaintenanceDrug)

tolterodine tartrate (2 mg cap er 24h4 mg cap er 24h)

trospium chloride 20 mg tablet Tier 1 ST MO (MaintenanceDrug)

Benign Prostatic Hypertrophy Agentsalfuzosin hcl 10 mg tab er 24h Tier 1 QL (30 PER 30 DAYS)

dutasteride 05 mg capsule Tier 1 QL (30 PER 30 DAYS)MO (Maintenance Drug)

finasteride 5 mg tablet Tier 1 QL (30 PER 30 DAYS)MO (Maintenance Drug)

tamsulosin hcl 04 mg capsule Tier 1 QL (60 PER 30 DAYS)MO (Maintenance Drug)

Genitourinary Agents Otherbethanechol chloride (10 mg tablet25 mg tablet 5 mg tablet 50 mgtablet)

Tier 1

CUPRIMINE 250 MG CAPSULE Tier 2 PA MO (MaintenanceDrug)

penicillamine 250 mg capsule Tier 1 PA MO (MaintenanceDrug)

potassium citrate (10 meq tablet er 5meq tablet er)

THIOLA 100 MG TABLET Tier 2

THIOLA EC (EC 100 MG TABLETEC 300 MG TABLET)

Tier 2 PA

Phosphate Binderscalcium acetate (667 mg capsule 667mg tablet)

RENAGEL 400 MG TABLET Tier 2 MO (Maintenance Drug)

sevelamer carbonate 800 mg tablet Tier 1 MO (Maintenance Drug)

sevelamer hcl (400 mg tablet 800 mgtablet)

Hormonal Agents Stimulant Replacement Modifying (Adrenal)

Hormonal Agents Stimulant Replacement Modifying (Adrenal)alclometasone dipropionate (005 cream (g) 005 oint (g))

Tier 1

betamethasone dipropionate (005 cream (g) 005 gel (gram) 005 oint (g))

Tier 1

betamethasonedipropionatepropylene glycol (005 cream (g) 005 lotion 005 oint (g))

Tier 1

betamethasone valerate (01 cream(g) 01 lotion 01 oint (g))

Tier 1

clobetasol propionate (005 cream(g) 005 gel (gram) 005 oint(g) 005 solution)

Tier 1

clobetasol propionateemoll 005 cream (g)

Tier 1

cortisone acetate 25 mg tablet Tier 1 BvD

desonide (005 cream (g) 005 lotion 005 oint (g))

Tier 1

desoximetasone (005 cream (g)005 gel (gram) 025 cream (g)025 oint (g))

Tier 1

dexamethasone (05 mg tablet 05mg5ml elixir 05 mg5ml solution075 mg tablet 1 mg tablet 15 mgtablet 2 mg tablet 4 mg tablet 6 mgtablet)

Tier 1 BvD

diflorasone diacetate (005 cream(g) 005 oint (g))

Tier 1

fludrocortisone acetate 01 mg tablet Tier 1 MO (Maintenance Drug)

fluocinolone acetonide (001 cream(g) 001 solution 0025 cream(g) 0025 oint (g))

Tier 1

fluocinolone acetonide oil 001 drops

Tier 1

fluocinonide (005 cream (g) 005 gel (gram) 005 oint (g) 005 solution)

Tier 1

fluocinonideemollient base 005 cream (g)

Tier 1

halobetasol propionate (005 cream(g) 005 oint (g))

Tier 1

hydrocortmin oilpetrolatwht 1 oint (g)

Tier 1

hydrocortisone (1 cream (g) 1 crmpe app 1 oint (g) 25 cream(g) 25 crmpe app 25 lotion25 oint (g))

Tier 1

hydrocortisone (10 mg tablet 20 mgtablet 5 mg tablet)

hydrocortisone valerate (02 cream(g) 02 oint (g))

Tier 1

methylprednisolone (16 mg tablet 32mg tablet 4 mg tablet 8 mg tablet)

Tier 1 BvD

methylprednisolone 4 mg tab ds pk Tier 1

mometasone furoate (01 cream (g)01 oint (g) 01 solution)

Tier 1

prednisolone 15 mg5 ml solution Tier 1 BvD

prednisolone sodium phosphate (10mg5 ml solution 15 mg5 mlsolution 20 mg5 ml solution 25mg5 ml solution 5 mg5 ml solution)

Tier 1 BvD

prednisone (1 mg tablet 10 mg tablet25 mg tablet 20 mg tablet 5 mgtablet)

Tier 1 BvD

triamcinolone acetonide (0025 cream (g) 0025 lotion 0025 oint (g) 01 cream (g) 01 lotion 01 oint (g) 05 cream(g) 05 oint (g))

Tier 1

TRIDESILON 005 CREAM Tier 1

Hormonal Agents Stimulant Replacement Modifying (Pituitary)

Hormonal Agents Stimulant Replacement Modifying (Pituitary)desmopressin (nonrefrigerated)10spray spraypump

desmopressin acetate (01 mg tablet01 mgml solution 02 mg tablet10spray spraypump)

HUMATROPE (12 MGCARTRIDGE 24 MGCARTRIDGE 5 MG VIAL 6 MGCARTRIDGE)

INCRELEX 40 MG4 ML VIAL Tier 2 PA

NORDITROPIN FLEXPRO (10MG15 15 MG15 30 MG3 ML 5MG15)

NUTROPIN AQ NUSPIN (10INJECTOR 20 INJECTOR)

SAIZEN (5 MG VIAL 88 MGCLICKEASY CARTG 88 MGVIAL)

SAIZEN 88 MG SAIZENPREPCART

SEROSTIM (4 MG VIAL 5 MGVIAL 6 MG VIAL)

ZORBTIVE 88 MG VIAL Tier 2 PA MO (MaintenanceDrug)

Hormonal Agents Stimulant Replacement Modifying (Prostaglandins)

Hormonal Agents Stimulant Replacement Modifying (Prostaglandins)misoprostol 200 mcg tablet Tier 1 MO (Maintenance Drug)

Hormonal Agents Stimulant Replacement Modifying (Sex HormonesModifiers)

Anabolic SteroidsANADROL-50 TABLET Tier 2 PA

oxandrolone (10 mg tablet 25 mgtablet)

AndrogensANDRODERM (2 MG24HRPATCH 4 MG24HR PATCH)

AVEED 750 MG3 ML VIAL Tier 2 PA MO (MaintenanceDrug)

danazol (100 mg capsule 200 mgcapsule 50 mg capsule)

Tier 1

methyltestosterone 10 mg capsule Tier 1 PA MO (MaintenanceDrug)

testosterone (125125g gel md pmp50 mg (1) gel packet)

testosterone 50 mg (1) gel (gram) Tier 1 PA

testosterone cypionate (100 mgmlvial 200 mgml vial)

EstrogensALORA (0025 MG PATCH 01MG PATCH)

estradiol (025mg24h patch tdsw0375mg24 patch tdsw 075mg24hpatch tdsw 005mg24h patch tdsw01mg24hr patch tdsw)

estradiol (025mg24h patch tdwk0375mg24 patch tdwk 075mg24hpatch tdwk 005mg24h patch tdwk006mg24h patch tdwk 01mg24hrpatch tdwk 05 mg tablet 1 mgtablet 2 mg tablet)

estropipate (075 mg tablet 15 mgtablet 3 mg tablet)

MENEST (03 MG TABLET 0625MG TABLET 125 MG TABLET)

PREMARIN (03 MG TABLET045 MG TABLET 0625 MGTABLET 09 MG TABLET 125MG TABLET)

PREMARIN VAGINAL CREAM-APPL

Hormonal Agents Stimulant Replacement Modifying (Sex Hormones Modifiers)ACTIVELLA 1 MG-05 MGTABLET

budesonide 3 mg capdr - er Tier 1

COMBIPATCH (005-014 MGPTCH 005-025 MG PTCH)

desog-eestradioleestradiol 21-5 (28)tablet

desogestrel-ethinyl estradiol (015-003 tablet 7 days x 3 tablet)

estradiolnorethindrone acetate (05-01 mg tablet 1 mg-05mg tablet)

ethinyl estradioldrospirenone (002-3(28) tablet 003mg-3mg tablet)

ethynodiol diacetate-ethinyl estradiol(1 mg-35mcg tablet 1 mg-50mcgtablet)

levonorgestrel-ethinyl estradiol (01-002mg tablet 015-003 tablet 015-003 tbdspk 3mo 6-5-10 tablet 90-20mcg tablet)

norethindrone 035 mg tablet Tier 1 MO (Maintenance Drug)

norethindrone acetate-ethinylestradiol (05mg-25 tablet 15-003mg tablet 1mg-20mcg tablet1mg-5mcg tablet)

norethindrone acetate-ethinylestradiolferrous fumarate (15-30(21)tablet 1mg-20(21) tablet 1mg-20(24)tablet 5-7-9-7 tablet)

norethindrone-ethinyl estradiol (04-0035 tablet 05-0035 tablet 1 mg-35mcg tablet 7 days x 3 tablet 7-9-5tablet)

norgestimate-ethinyl estradiol (025-0035 tablet 7daysx3 28 tablet7daysx3 lo tablet)

norgestrel-ethinyl estradiol (03-003mg tablet 05 mg-50 tablet)

PREMPHASE 0625-5 MG TABLET Tier 2 PA MO (MaintenanceDrug)

PREMPRO (03 MG-15 MGTABLET 045-15 MG TABLET0625-25 MG TABLET 0625-5 MGTABLET)

ProgestinsDEPO-PROVERA 400 MGMLVIAL

medroxyprogesterone acetate (10 mgtablet 25 mg tablet 5 mg tablet)

medroxyprogesterone acetate (150mgml syringe 150 mgml vial)

megestrol acetate (20 mg tablet 40mg tablet)

Tier 1 PA

megestrol acetate (400mg10ml oralsusp 625mg5ml oral susp)

norethindrone acetate 5 mg tablet Tier 1 MO (Maintenance Drug)

progesterone micronized (100 mgcapsule 200 mg capsule)

Selective Estrogen Receptor Modifying AgentsOSPHENA 60 MG TABLET Tier 2 PA MO (Maintenance

raloxifene hcl 60 mg tablet Tier 1 QL (30 PER 30 DAYS)MO (Maintenance Drug)

Hormonal Agents Stimulant Replacement Modifying (Thyroid)

Hormonal Agents Stimulant Replacement Modifying (Thyroid)levothyroxine sodium (100 mcgtablet 112 mcg tablet 125 mcg tablet137 mcg tablet 150 mcg tablet 175mcg tablet 200 mcg tablet 25 mcgtablet 300 mcg tablet 50 mcg tablet75 mcg tablet 88 mcg tablet)

LEVOXYL (100 MCG TABLET112 MCG TABLET 125 MCGTABLET 137 MCG TABLET 150MCG TABLET 175 MCGTABLET 200 MCG TABLET 25MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCGTABLET)

liothyronine sodium (25 mcg tablet 5mcg tablet 50 mcg tablet)

SYNTHROID (100 MCG TABLET112 MCG TABLET 125 MCGTABLET 137 MCG TABLET 150MCG TABLET 175 MCGTABLET 200 MCG TABLET 25MCG TABLET 300 MCGTABLET 50 MCG TABLET 75MCG TABLET 88 MCG TABLET)

UNITHROID (100 MCG TABLET112 MCG TABLET 125 MCGTABLET 150 MCG TABLET 175MCG TABLET 200 MCGTABLET 25 MCG TABLET 300MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCGTABLET)

Hormonal Agents Suppressant (Adrenal)

Hormonal Agents Suppressant (Adrenal)LYSODREN 500 MG TABLET Tier 2 MO (Maintenance Drug)

Hormonal Agents Suppressant (Pituitary)

Hormonal Agents Suppressant (Pituitary)bromocriptine mesylate (25 mgtablet 5 mg capsule)

cabergoline 05 mg tablet Tier 1 MO (Maintenance Drug)

ELIGARD (225 MG SYRINGEKIT 30 MG SYRINGE KIT 45 MGSYRINGE KIT 75 MG SYRINGEKIT)

FIRMAGON 2 X 120 MG KIT Tier 2 PA

FIRMAGON 80 MG KIT Tier 2 PA MO (MaintenanceDrug)

leuprolide acetate 1 mg02ml kit Tier 1 PA MO (MaintenanceDrug)

LUPRON DEPOT (1125 MG 3MOKIT 375 MG KIT)

Tier 2 PA

LUPRON DEPOT (DEPOT 225MG 3MO KIT DEPOT 45 MG6MO KIT DEPOT 75 MG KITDEPOT-4 MONTH KIT)

LUPRON DEPOT-PED (1125 MG3MO 75 MG KIT)

octreotide acetate (100 mcgml ampul100 mcgml vial 1000mcgml vial 200mcgml vial 50 mcgml ampul 50mcgml vial 500 mcgml ampul 500mcgml vial)

SIGNIFOR (03 MGML AMPULE06 MGML AMPULE 09 MGMLAMPULE)

SIGNIFOR LAR (10 MG KIT 10MG VIAL 30 MG KIT 30 MGVIAL)

Tier 2 PA

SOMATULINE DEPOT (120MG05 ML 60 MG02 ML 90MG03 ML)

SOMAVERT (10 MG VIAL 15 MGVIAL 20 MG VIAL 25 MG VIAL30 MG VIAL)

SYNAREL 2 MGML NASALSPRAY

Tier 2 PA

TRELSTAR (1125 MG VIAL 225MG VIAL 375 MG VIAL)

Hormonal Agents Suppressant (Thyroid)

Antithyroid Agentsmethimazole (10 mg tablet 5 mgtablet)

propylthiouracil 50 mg tablet Tier 1 MO (Maintenance Drug)

Immunological Agents

Angioedema AgentsFIRAZYR 30 MG3 ML SYRINGE Tier 2 PA

HAEGARDA (2000 UNIT VIAL3000 UNIT VIAL)

icatibant acetate 30 mg3 ml syringe Tier 1 PA

RUCONEST 2100 UNIT VIAL Tier 2 PA

Immune SuppressantsAFINITOR 25 MG TABLET Tier 2 PA MO (Maintenance

AFINITOR DISPERZ (2 MGTABLET 3 MG TABLET 5 MGTABLET)

ASTAGRAF XL (05 MGCAPSULE 1 MG CAPSULE 5 MGCAPSULE)

azathioprine 50 mg tablet Tier 1 BvD MO (MaintenanceDrug)

azathioprine sodium 100 mg vial Tier 1 BvD

cyclosporine (100 mg capsule 25 mgcapsule)

cyclosporine 250 mg5ml ampul Tier 1 PA

cyclosporine modified (100 mgcapsule 100 mgml solution 25 mgcapsule 50 mg capsule)

ENBREL (25 MG KIT 25 MG05ML SYRINGE 50 MGMLSYRINGE)

ENBREL 50 MGML MINICARTRIDGE

ENBREL 50 MGML SURECLICK Tier 2 PA MO (MaintenanceDrug)

ENVARSUS XR (075 MGTABLET 1 MG TABLET 4 MGTABLET)

HUMIRA (10 MG02 MLSYRINGE 20 MG04 MLSYRINGE 40 MG08 MLSYRINGE)

HUMIRA PEDI CROHN 40MG08 ML

HUMIRA PEN 40 MG08 ML Tier 2 PA MO (MaintenanceDrug)

HUMIRA PEN CROHN-UC-HS 40MG

HUMIRA PEN PS-UV-ADOL HS40 MG

HUMIRA(CF) (10 MG01 MLSYRING 40 MG04 ML SYRING)

Tier 2 PA

HUMIRA(CF) 20 MG02 MLSYRING

HUMIRA(CF) PEN 40 MG04 ML Tier 2 PA

KEVZARA (150 MG114 MLSYRINGE 200 MG114 MLSYRINGE)

KINERET 100 MG067 MLSYRINGE

mercaptopurine 50 mg tablet Tier 1 MO (Maintenance Drug)

methotrexate sodium 25 mg tablet Tier 1 MO (Maintenance Drug)

methotrexate sodium 25 mgml vial Tier 1 BvD

methotrexate sodiumpf (1 g vial 25mgml vial)

Tier 1 BvD

mycophenolate mofetil (200 mgmlsusp recon 250 mg capsule 500 mgtablet)

mycophenolate sodium (180 mg tabletdr 360 mg tablet dr)

NULOJIX 250 MG VIAL Tier 2 PA MO (MaintenanceDrug)

OTEZLA 28 DAY STARTERPACK

Tier 2 PA

OTEZLA 30 MG TABLET Tier 2 PA MO (MaintenanceDrug)

PROGRAF (02 MG GRANULEPACKET 1 MG GRANULEPACKET)

PROGRAF 5 MGML AMPULE Tier 2 BvD

sirolimus (1 mg tablet 1 mgmlsolution 2 mg tablet)

sirolimus 05 mg tablet Tier 1 QL (30 PER 30 DAYS)BvD MO (MaintenanceDrug)

tacrolimus (05 mg capsule 1 mgcapsule 5 mg capsule)

XATMEP 25 MGML ORALSOLUTION

XELJANZ 10 MG TABLET Tier 2 PA

XELJANZ 5 MG TABLET Tier 2 PA MO (MaintenanceDrug)

XELJANZ XR 11 MG TABLET Tier 2 PA MO (MaintenanceDrug)

ZORTRESS (025 MG TABLET 05MG TABLET 075 MG TABLET)

ZORTRESS 1 MG TABLET Tier 2 PA

Immunizing Agents PassiveATGAM 50 MGML AMPUL Tier 2 BvD

BIVIGAM LIQUID 10 VIAL Tier 2 BvD MO (MaintenanceDrug)

CARIMUNE NF 6 GM VIAL Tier 2 BvD MO (MaintenanceDrug)

GAMUNEX-C 1 GRAM10 MLVIAL

HYPERHEP B S-D (NEONATALSYRIN SYRINGE VIAL)

Tier 2 BvD

ImmunomodulatorsACTIMMUNE 100 MCG05 MLVIAL

Tier 2 PA

ARCALYST 220 MG INJECTION Tier 2 PA MO (MaintenanceDrug)

leflunomide (10 mg tablet 20 mgtablet)

OTEZLA STARTER PACK Tier 2 PA

RIDAURA 3 MG CAPSULE Tier 2 MO (Maintenance Drug)

SIMULECT 20 MG VIAL Tier 2 BvD

VaccinesACTHIB (VIAL WITH DILUENT) Tier 2

ADACEL TDAP (SYRINGEVIAL)

Tier 2

AFLURIA 2018-2019 (SYRINGEVIAL)

Tier 2

AFLURIA QUAD 2018-2019(SYRINGE VIAL)

Tier 2

BCG VACCINE (TICE STRAIN)VIAL

Tier 2

BEXSERO PREFILLED SYRINGE Tier 2

BOOSTRIX TDAP (SYRINGEVIAL)

Tier 2

DAPTACEL DTAP VACCINE Tier 2

DIPHTHERIA-TETANUSTOXOIDS-PED

Tier 2

ENGERIX-B 20 MCGML SYRN Tier 2 BvD

ENGERIX-B PEDI 10 MCG05SYRN

Tier 2 BvD

FLUAD 2018-2019 SYRINGE Tier 2

FLUARIX QUAD 2018-2019SYRINGE

Tier 2

FLUBLOK QUAD 2018-2019SYRINGE

Tier 2

FLUCELVAX QUAD 2017-2018SYR

Tier 2

FLUCELVAX QUAD 2018-2019(SYR VIAL)

Tier 2

FLULAVAL QUAD 2018-2019(SYR VIAL)

Tier 2

FLUVIRIN 2017-2018 SYRINGE Tier 2

FLUZONE QUAD 2018-2019(SYRINGE VIAL)

Tier 2

GARDASIL 9 (9 SYRINGE 9VIAL)

Tier 2

HAVRIX (1440 UNITSMLSYRINGE 1440 UNITSML VIAL720 UNIT05 ML SYRINGE 720UNITS05 ML VIAL)

Tier 2

HIBERIX VACCINE WITHDILUENT

Tier 2

IMOVAX RABIESVACCINE+DILUENT

Tier 2

INFANRIX DTAP VIAL Tier 2

IPOL VIAL Tier 2

IXIARO (6 MCG05 MLSYRINGE 6 UNIT(6 MCG)05MLSYR)

Tier 2

KINRIX (TIP-LOK SYRINGEVIAL)

Tier 2

M-M-R II VACCINE WITHDILUENT

Tier 2

MENACTRA VIAL Tier 2

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

Tier 2

PEDIARIX 05 ML SYRINGE Tier 2 BvD

PEDVAXHIB VACCINE VIAL Tier 2

PENTACEL ACTHIBCOMPONENT VIAL

Tier 2

PENTACEL DTAP-IPVCOMPONENT VL

Tier 2

PENTACEL VIAL KIT Tier 2

PNEUMOVAX 23 (23 SYRINGE23 VIAL)

Tier 2

PREVNAR 13 SYRINGE Tier 2

PROQUAD VIAL Tier 2

QUADRACEL DTAP-IPV VIAL Tier 2

RABAVERT RABIES VACC W-DILUENT

Tier 2

RECOMBIVAX HB (10 MCGMLSYR 10 MCGML VIAL 40MCGML VIAL 5 MCG05 MLSYR)

Tier 2 BvD

ROTARIX VACCINESUSPENSION

Tier 2

ROTATEQ VACCINE Tier 2

SHINGRIX VIAL KIT Tier 2 QL (2 PER 365 DAYSOVER TIME)

TDVAX VIAL Tier 2

TENIVAC SYRINGE Tier 2

TRUMENBA 120 MCG05 MLVACCIN

Tier 2

TWINRIX VACCINE SYRINGE Tier 2 BvD

TYPHIM VI (25 MCG05 ML AL25 MCG05 ML SYRNG)

Tier 2

VAQTA (25 UNITS05 MLSYRINGE 25 UNITS05 MLVIAL 50 UNITSML SYRINGE 50UNITSML VIAL)

Tier 2

VARIVAX VACCINE WITHDILUENT

Tier 2

XOFLUZA (20 MG TAB (40 MGDOSE) 40 MG TAB (80 MGDOSE))

YF-VAX (1 DOSE VIAL 5 DOSEVIAL)

Tier 2

ZOSTAVAX VIAL Tier 2

Inflammatory Bowel Disease Agents

Aminosalicylatesbalsalazide disodium 750 mg capsule Tier 1

DIPENTUM 250 MG CAPSULE Tier 2 MO (Maintenance Drug)

mesalamine (4 g60 ml enema 400 mgcap(drtab))

mesalamine 1000 mg supprect Tier 1

mesalamine wcleansing wipes 4 g60ml enema kit

PENTASA (250 MG CAPSULE 500MG CAPSULE)

Glucocorticoidshydrocortisone (100mg60ml enema25 crmpe app)

Tier 1

prednisolone acetate 1 drops susp Tier 1

Sulfonamidessulfasalazine (500 mg tablet 500 mgtablet dr)

Metabolic Bone Disease Agents

Metabolic Bone Disease Agentsalendronate sodium (10 mg tablet 40mg tablet 5 mg tablet)

alendronate sodium (35 mg tablet 70mg tablet)

calcitoninsalmonsynthetic 200sprayspraypump

calcitriol (025 mcg capsule 05 mcgcapsule)

cinacalcet hcl (60 mg tablet 90 mgtablet)

cinacalcet hcl 30 mg tablet Tier 1 PA QL (30 PER 30DAYS) MO (MaintenanceDrug)

doxercalciferol 05 mcg capsule Tier 1 QL (30 PER 30 DAYS)BvD MO (MaintenanceDrug)

doxercalciferol 25 mcg capsule Tier 1 BvD MO (MaintenanceDrug)

etidronate disodium (200 mg tablet400 mg tablet)

FORTEO 600 MCG24 ML PENINJ

ibandronate sodium 150 mg tablet Tier 1 QL (1 PER 30 DAYS)MO (Maintenance Drug)

NATPARA (100 MCG DOSECARTRIDGE 25 MCG DOSECARTRIDGE 50 MCG DOSECARTRIDGE 75 MCG DOSECARTRIDGE)

paricalcitol (1 mcg capsule 2 mcgcapsule 4 mcg capsule)

PROLIA 60 MGML SYRINGE Tier 2 PA MO (MaintenanceDrug)

risedronate sodium (35 mg tablet 35mg tablet dr)

risedronate sodium 150 mg tablet Tier 1 QL (1 PER 30 DAYS)MO (Maintenance Drug)

SENSIPAR (60 MG TABLET 90MG TABLET)

SENSIPAR 30 MG TABLET Tier 2 PA QL (30 PER 30DAYS) MO (MaintenanceDrug)

TYMLOS 80 MCG DOSE PENINJECTR

XGEVA 120 MG17 ML VIAL Tier 2 PA

zoledronic acid 4 mg vial Tier 1 BvD

zoledronic acid 4 mg5 ml vial Tier 1 BvD MO (MaintenanceDrug)

zoledronic acid in mannitol and waterfor injection (5 mg100ml pggybk btl5 mg100ml piggyback)

Tier 1 BvD

ZOMETA 4 MG100 MLINJECTION

Ophthalmic Agents

Ophthalmic Agentsbacitracinpolymyxin b sulfate 500-10kg oint (g)

Tier 1

neomycin sulfbacitracinpoly 35mg-400 oint (g)

Tier 1

neomycinbacitp-myxhydrocort 35-10k-1 oint (g)

Tier 1

neomycinpolymyxin bsulfatedexamethasone (01 dropssusp 35-10k-1 oint (g))

Tier 1

neomycinpolymyxin bhydrocort 35-10k-10 drops susp

Tier 1

neomycinpolymyxn bgramicidin175mg-10k drops

Tier 1

polymyxin b sulftrimethoprim 10000-1ml drops

Tier 1

sulfacetamide sodium 10 oint (g) Tier 1

sulfacetamideprednisolone sp 10 -023 drops

Tier 1

Ophthalmic Agents

tobramycindexamethasone 03 -01 drops susp

Tier 1

Ophthalmic Agents OtherCYSTARAN 044 EYE DROPS Tier 2 PA MO (Maintenance

LACRISERT 5 MG EYE INSERT Tier 2

proparacaine hcl 05 drops Tier 1

RESTASIS 005 EYE EMULSION Tier 2 PA QL (64 PER 30DAYS) MO (MaintenanceDrug)

RESTASIS MULTIDOSE 005EYE

Ophthalmic Anti-allergy Agentsazelastine hcl 005 drops Tier 1

cromolyn sodium 4 drops Tier 1

olopatadine hcl 01 drops Tier 1 QL (5 PER 30 DAYS)

olopatadine hcl 02 drops Tier 1

Ophthalmic Anti-inflammatoriesbromfenac sodium 009 drops Tier 1

dexamethasone sodium phosphate 01 drops

Tier 1

diclofenac sodium 01 drops Tier 1

fluorometholone 01 drops susp Tier 1

flurbiprofen sodium 003 drops Tier 1

ketorolac tromethamine (04 drops05 drops)

Tier 1

loteprednol etabonate 05 dropssusp

MAXIDEX 01 EYE DROPS Tier 2

Ophthalmic Agents

prednisolone sodium phosphate 1 drops

Tier 1

Ophthalmic Antiglaucoma AgentsALPHAGAN P 01 DROPS Tier 2 MO (Maintenance Drug)

AZOPT 1 EYE DROPS Tier 2 MO (Maintenance Drug)

betaxolol hcl 05 drops Tier 1 MO (Maintenance Drug)

brimonidine tartrate (015 drops02 drops)

carteolol hcl 1 drops Tier 1 MO (Maintenance Drug)

dorzolamide hcl 2 drops Tier 1 QL (10 PER 30 DAYS)MO (Maintenance Drug)

dorzolamide hcltimolol maleat 223-681 drops

levobunolol hcl 05 drops Tier 1 MO (Maintenance Drug)

metipranolol 03 drops Tier 1 MO (Maintenance Drug)

PHOSPHOLINE IODIDE 0125 Tier 2 MO (Maintenance Drug)

pilocarpine hcl (1 drops 2 drops4 drops)

timolol maleate (025 drops 025 sol-gel 05 drops 05 sol-gel)

Ophthalmic Prostaglandin and Prostamide Analogslatanoprost 0005 drops Tier 1 MO (Maintenance Drug)

TRAVATAN Z 0004 EYE DROP Tier 2 QL (5 PER 30 DAYSOVER TIME) MO(Maintenance Drug)

Otic Agents

hydrocortisoneacetic acid 1 -2 drops

Tier 1

Otic Agents

neomycin sulfatepolymyxin bsulfatehydrocortisone (drops suspsolution)

Tier 1

ofloxacin 300 mg tablet Tier 1

Respiratory Tract Pulmonary Agents

Anti-inflammatories Inhaled Corticosteroidsbudesonide (025mg2ml ampul-neb05 mg2ml ampul-neb 1 mg2 mlampul-neb)

FLOVENT DISKUS (100 MCGDISKUS 250 MCG DISKUS 50MCG DISKUS)

FLOVENT HFA (HFA 110 MCGINHALER HFA 220 MCGINHALER HFA 44 MCGINHALER)

flunisolide 25 mcg spray Tier 1 MO (Maintenance Drug)

fluticasone propionate 50 mcg spraysusp

PULMICORT FLEXHALER (180MCG FLEXHALER 90 MCGFLEXHALER)

QVAR REDIHALER (40 MCG 80MCG)

Antihistaminesazelastine hcl 137 mcg spraypump Tier 1 QL (60 PER 30 DAYS)

clemastine fumarate 268 mg tablet Tier 1 PA

cyproheptadine hcl 4 mg tablet Tier 1 PA

desloratadine 5 mg tablet Tier 1 MO (Maintenance Drug)

Antileukotrienesmontelukast sodium (10 mg tablet 4mg tab chew 5 mg tab chew)

zafirlukast (10 mg tablet 20 mgtablet)

Bronchodilators AnticholinergicATROVENT 17 MCG HFAINHALER

ipratropium bromide 02 mgmlsolution

ipratropium bromide 21 mcg spray Tier 1 MO (Maintenance Drug)

ipratropium bromide 42 mcg spray Tier 1

SPIRIVA 18 MCG CP-HANDIHALER

SPIRIVA RESPIMAT (125 MCGINH 25 MCG INH)

TUDORZA PRESSAIR 400 MCGINHAL

Bronchodilators Sympathomimeticalbuterol 90mg hfa inhaler (genericproair)

albuterol sulfate (063mg3ml vial-neb 125mg3ml vial-neb 25 mg05vial-neb 25 mg3ml vial-neb 5mgml solution)

albuterol sulfate (2 mg tablet 2 mg5ml syrup 4 mg tab er 12h 4 mgtablet 8 mg tab er 12h)

epinephrine (015015 auto injct015mg03 auto injct 03mg03 autoinjct)

Tier 1

fluticasone propionatesalmeterolxinafoate (113-14 mcg aer pow ba232-14 mcg aer pow ba 55-14 mcg aerpow ba)

Tier 1 ST QL (1 PER 30 DAYS)MO (Maintenance Drug)

levalbuterol hcl (031mg3ml vial-neb063mg3ml vial-neb 125mg05 vial-neb 125mg3ml vial-neb)

metaproterenol sulfate (10 mg tablet10 mg5 ml syrup 20 mg tablet)

PROAIR HFA 90 MCG INHALER Tier 2 QL (17 PER 30 DAYS)MO (Maintenance Drug)

PROAIR RESPICLICK 90 MCGINHLR

SEREVENT DISKUS 50 MCG Tier 2 PA MO (MaintenanceDrug)

STRIVERDI RESPIMAT INHALSPRAY

terbutaline sulfate (25 mg tablet 5mg tablet)

VENTOLIN HFA 90 MCGINHALER

Cystic Fibrosis AgentsKALYDECO (150 MG TABLET 25MG GRANULES PACKET 50 MGGRANULES PACKET 75 MGGRANULES PACKET)

ORKAMBI (100 MG-125 MGTABLET 200 MG-125 MGTABLET)

SYMDEKO 100150 MG-150 MGTABS

SYMDEKO 5075 MG-75 MGTABLETS

Mast Cell Stabilizerscromolyn sodium 20 mg2 ml ampul-neb

cromolyn sodium 20 mgml oral conc Tier 1

Phosphodiesterase Inhibitors Airways DiseaseDALIRESP (250 MCG TABLET500 MCG TABLET)

THEO-24 (ER 100 MG CAPSULEER 200 MG CAPSULE ER 300 MGCAPSULE ER 400 MG CAPSULE)

theophylline anhydrous (100 mg taber 12h 200 mg tab er 12h 300 mg taber 12h 400 mg tab er 24h 600 mg taber 24h 80 mg15ml elixir 80 mg15mlsolution)

Pulmonary AntihypertensivesADEMPAS (05 MG TABLET 1MG TABLET 15 MG TABLET 2MG TABLET 25 MG TABLET)

ambrisentan (10 mg tablet 5 mgtablet)

bosentan (125 mg tablet 625 mgtablet)

sildenafil citrate 20 mg tablet Tier 1 PA MO (MaintenanceDrug)

tadalafil 20 mg tablet Tier 1 PA MO (MaintenanceDrug)

TRACLEER 32 MG TABLET FORSUSP

Respiratory Tract Agents Otheracetylcysteine 200 mgml vial Tier 1 BvD

ANORO ELLIPTA 625-25 MCGINH

ZEMAIRA 1000 MG VIAL Tier 2 PA MO (MaintenanceDrug)

Respiratory Tract Pulmonary AgentsADVAIR HFA (HFA 115-21 MCGINHALER HFA 230-21 MCGINHALER HFA 45-21 MCGINHALER)

COMBIVENT RESPIMAT 20-100MCG

ESBRIET (267 MG CAPSULE 267MG TABLET 801 MG TABLET)

fluticasone propionatesalmeterolxinafoate (100-50 mcg blst wdev250-50 mcg blst wdev 500-50 mcgblst wdev)

ipratropiumalbuterol sulfate 05-3mg3 ampul-neb

OFEV (100 MG CAPSULE 150 MGCAPSULE)

PULMOZYME 1 MGML AMPUL Tier 2 BvD MO (MaintenanceDrug)

XOLAIR 150 MG VIAL Tier 2 PA MO (MaintenanceDrug)

Skeletal Muscle Relaxants

Skeletal Muscle Relaxantscarisoprodol (250 mg tablet 350 mgtablet)

chlorzoxazone 500 mg tablet Tier 1 PA

cyclobenzaprine hcl (10 mg tablet 5mg tablet)

methocarbamol 500 mg tablet Tier 1 PA QL (240 PER 30DAYS)

Sleep Disorder Agents

GABA Receptor Modulatorstemazepam (15 mg capsule 30 mgcapsule)

zaleplon (10 mg capsule 5 mgcapsule)

Tier 1

zolpidem tartrate (10 mg tablet 5 mgtablet)

Sleep Disorders OtherHETLIOZ 20 MG CAPSULE Tier 2 PA MO (Maintenance

modafinil (100 mg tablet 200 mgtablet)

ramelteon 8 mg tablet Tier 1 PA

ROZEREM 8 MG TABLET Tier 2 PA

XYREM 500 MGML ORALSOLUTION

Tier 2 PA LA

Uncategorized

Unclassifiedampicillin sodium 250 mg vial Tier 1 BvD

WINRHO SDF 1500 UNIT VIAL Tier 1 BvD

Blue Shield of California Promise Health Plan Cal Mediconnect Formulary2019 (ADDITIONAL DEMONSTRATION DRUGS)

Analgesics

Nonsteroidal Anti-inflammatory Drugsaspirin ((325 mg tablet 81 mg tabletdr) 325 mg tablet)

Tier 3 NPD

aspirin 325mg tablet Tier 3 NPD

Antifungals

Antifungalsmiconazole nitrate 2 creamappl Tier 3 NPD

Glycemic Agentsdextrose 4 g tab chew Tier 3 NPD

ElectrolytesMineralsMetalsVitaminscyanocobalamin (vitamin b-12) 500mcg tablet

Tier 3 NPD

folic acid 1 mg tablet Tier 3 NPD

Gastrointestinal Agents Othermag hydroxaluminum hydsimeth200-200-20 oral susp

Tier 3 NPD

Histamine2 (H2) Receptor Antagonistsranitidine hcl 75 mg tablet Tier 3 NPD

Laxativesbisacodyl 10 mg supprect Tier 3 NPD

docusate sodium 100 mg capsule Tier 3 NPD

DOK 100 MG SOFTGEL Tier 3 NPD

magnesium citrate solution Tier 3 NPD

STOOL SOFTENER ((100 MGCAPSULE 100 MG SOFTGEL)100 MG CAPSULE)

Tier 3 NPD

Proton Pump Inhibitorsomeprazole 20 mg tablet dr Tier 3 QL (60 PER 30 DAYS)

Antihistaminescetirizine hcl 10 mg tablet Tier 3 NPD

diphenhydramine hcl 125mg5mlliquid

Tier 3 NPD

diphenhydramine hcl 25 mg tablet Tier 3 PA NPD

fexofenadine hcl ((180 mg tablet 60mg tablet) 180 mg tablet)

Tier 3 NPD

Respiratory Tract Agents Othercodeine phosphateguaifenesin 10-100mg5 liquid

Tier 3 NPD

Non-Part D Drugs

ABREVA 10 CREAM Tier 3 QL (2 PER 30 DAYS)NPD

ALLI 60 MG CAPSULE Tier 3 PA NPD

aluminum hydroxide ((320 oral susp600 oral susp) 320 oral susp)

Tier 3 NPD

ARTIFICIAL TEARS 14 DROPS Tier 3 NPD

asacalcium carbmagaluminum 500mg tablet

Tier 3 NPD

ascorbate calcium 500 mg tablet Tier 3 NPD

ascorbic acid ((100 mg tablet 1000mg tablet 250 mg tablet 500 mgtablet) 100 mg tablet 1000 mg tablet250 mg tablet)

Tier 3 NPD

aspirin ((300 mg supprect 325 mgtablet dr 500 mg tablet dr 600 mgsupprect 81 mg tab chew) 300 mgsupprect 325 mg tablet dr 500 mgtablet dr 600 mg supprect)

Tier 3 NPD

Non-Part D Drugs

aspirincalcium carbonatemag 325mg tablet

Tier 3 NPD

bacitracin 500 unitg oint (g) Tier 3 NPD

bacitracin zinc 500 unitg oint (g) Tier 3 NPD

bacitracin zincpolymyxin b 500-10kgoint (g)

Tier 3 NPD

bacitracinpolymyxin b sulfate 500-10kg oint (g)

Tier 3 NPD

benzonatate ((100 mg capsule 200 mgcapsule) 100 mg capsule)

Tier 3 NPD

benzoyl peroxide 10 gel (gram) Tier 3 NPD

bisacodyl 5 mg tablet dr Tier 3 NPD

bismuth subsalicylate ((262 mg tabchew 262 mg tablet 525mg15ml oralsusp) 262 mg tab chew 262 mgtablet)

Tier 3 NPD

calaminezinc oxide 8 -8 lotion Tier 3 NPD

calcium carbonate ((200(500)mg tabchew 215(500)mg tab chew260mg(648) tablet 300mg(750) tabchew 500(1250) tab chew 500(1250)tablet 600 mg tablet) 200(500)mg tabchew 215(500)mg tab chew260mg(648) tablet 300mg(750) tabchew 500(1250) tab chew 500(1250)tablet)

Tier 3 NPD

calcium carbonatecholecalciferol(vitamin d3)(carbonatecholecalciferol (vitamind3) (250 mg-125 tablet 500 mg-125tablet 500 mg-200 tablet 500 mg-400tablet 500 mg-600 tablet)carbonatevitamin d3 250 mg-125tablet carbonatevitamin d3 500 mg-125 tablet carbonatevitamin d3 500mg-200 tablet carbonatevitamin d3500 mg-400 tablet)

Tier 3 NPD

Non-Part D Drugs

calcium gluconate ((45(500) mgtablet 60(650) mg tablet) 45(500) mgtablet)

Tier 3 NPD

cetirizine hcl 5 mg tablet Tier 3 NPD

chlorpheniramine maleate 2 mg5 mlsyrup

Tier 3 PA NPD

cimetidine 200 mg tablet Tier 3 NPD

clotrimazole ((1 cream (g) 1 creamappl 2 creamappl) 1 cream (g) 1 creamappl)

Tier 3 NPD

codeine phosphateguaifenesin ((10-100mg5 liquid 20-20010 liquid) 10-100mg5 liquid)

Tier 3 NPD

condoms latex lubricated each Tier 3 QL (24 PER 30 DAYS)NPD

cromolyn sodium 52 mg spraypump Tier 3 NPD

diphenhydramine hcl ((25 mg capsule25 mg tablet) 25 mg capsule)

Tier 3 PA NPD

docusate sodium ((250 mg capsule 50mg5 ml liquid) 250 mg capsule)

Tier 3 NPD

EARWAX TREATMENT 65DROPS

Tier 3 NPD

electrolytesdextrose solution Tier 3 NPD

ergocalciferol (vitamin d2) ((400tablet 50000 capsule 8000ml drops)400 tablet 50000 capsule)

Tier 3 NPD

famotidine 10 mg tablet Tier 3 NPD

Non-Part D Drugs

ferrous sulfate ((134 mg tablet 15mgml drops 220 (44)5 elixir 220(44)5 solution 300 mg5ml liquid324(65)mg tablet dr 325(65) mgtablet 325(65) mg tablet dr) 134 mgtablet 15 mgml drops 220 (44)5elixir 220 (44)5 solution 300 mg5mlliquid 324(65)mg tablet dr 325(65)mg tablet)

Tier 3 NPD

folic acid ((04 mg tablet 08 mgcapsule 08 mg tablet) 04 mg tablet08 mg capsule)

Tier 3 NPD

glycerin ((adult supprect pediatricsupprect) adult supprect)

Tier 3 NPD

hydrocortisone ((05 cream (g) 05 oint (g) 1 cream (g) 1 oint(g)) 05 cream (g) 05 oint (g) 1 cream (g))

Tier 3 NPD

hydrocortisone acetate 05 cream(g)

Tier 3 NPD

hydrocortisonealoe vera 1 cream(g)

Tier 3 NPD

ibuprofen ((100 mg tab chew 100 mgtablet 200 mg capsule 200 mg tablet50 mg125 drops susp) 100 mg tabchew 100 mg tablet 200 mg capsule200 mg tablet)

Tier 3 NPD

inhalerassist deviceaccesory each Tier 3 QL (2 PER 365 DAYS)NPD

ketotifen fumarate 0025 drops Tier 3 NPD

levonorgestrel 15 mg tablet Tier 3 NPD

loperamide hcl ((1 mg5 ml liquid1mg75ml liquid 2 mg tablet) 1 mg5ml liquid 1mg75ml liquid)

Tier 3 NPD

loperamide hcl 2 mg capsule Tier 3 MO (Maintenance Drug)NPD

loratadine ((10 mg tab rapdis 10 mgtablet) 10 mg tab rapdis)

Tier 3 NPD

Non-Part D Drugs

mag hydroxaluminum hydsimeth400-400-40 oral susp

Tier 3 NPD

magaluminumsod bicarbalginc 20mg-80mg tab chew

Tier 3 NPD

magaldrate 540mg5ml oral susp Tier 3 NPD

magnesium carbaluminum hydrox105-160mg tab chew

Tier 3 NPD

magnesium gluconate 27 mg(500)tablet

Tier 3 NPD

meclizine hcl ((125 mg tablet 25 mgtab chew) 125 mg tablet)

Tier 3 NPD

mecobalamin 5000 mcg tab rapdis Tier 3 NPD

miconazole nitrate 100 mg suppvag Tier 3 NPD

MURO-128 5 EYE DROPS Tier 3 NPD

NASAL DECON(P-EPHED)30MG5 ML

Tier 3 NPD

neomycin sulfatebacitracinzincpolymyxin b (neomycinsulfatebacitracin zincpolymyxin b(oint pack oint (g)) neomycinbacitracinpolymyxinb 35-400-5k oint pack)

Tier 3 NPD

neomycinpolymyxin bpramoxine35-10k-10 cream (g)

Tier 3 NPD

niacin ((100 mg tablet 1000 mg tableter 250 mg capsule er 250 mg tablet250 mg tablet er 50 mg tablet 500 mgcapsule er 500 mg tablet 500 mgtablet er 750 mg tablet er) 100 mgtablet 1000 mg tablet er 250 mgcapsule er 250 mg tablet 250 mgtablet er 50 mg tablet 500 mgcapsule er 500 mg tablet 500 mgtablet er)

Tier 3 NPD

niacinamide 500 mg tablet Tier 3 NPD

Non-Part D Drugs

nicotine 14mg patch Tier 3 QL (84 PER 365 DAYS)NPD

nicotine 2mg gum Tier 3 PA NPD

NIX COMPLETE LICE KIT Tier 3 NPD

nonoxynol 9 (9 (9 125 foamappl 94 gelpf app) 9 125 foamappl)

Tier 3 NPD

permethrin 1 liquid Tier 3 NPD

phentermine hcl ((15 mg capsule 30mg capsule) 15 mg capsule)

Tier 3 PA NPD

phytonadione (vit k1) 100 mcg tablet Tier 3 NPD

piperonyl butoxpyrethrpermet 4-33-5 kit

Tier 3 NPD

piperonyl butoxidepyrethrins 4-033 shampoo

Tier 3 NPD

pnv no121ironfolic acid 28mg-08mg tablet

Tier 3 NPD

pnv no133ferrous fumfolic 28mg-08mg tablet

Tier 3 NPD

polyvinyl alcohol 14 drops Tier 3 NPD

prenatal vit no130ironfolic 27mg-08mg tablet

Tier 3 NPD

prenatal vits96iron fumfolic 27mg-08mg tablet

Tier 3 NPD

promethazine hclcodeine 625-105syrup

Tier 3 PA QL (240 PER 30DAYS) NPD

promethazinedextromethorphan625-155 syrup

Tier 3 PA NPD

Non-Part D Drugs

promethazinephenylephcodeine625-5-10 syrup

Tier 3 PA NPD

pseudoephedrine hcl ((15 mg5 mlliquid 30 mg tablet 30 mg5 mlliquid 60 mg tablet 94mgml drops)15 mg5 ml liquid 30 mg tablet 30mg5 ml liquid 60 mg tablet)

Tier 3 NPD

pyrantel pamoate 50 mgml oral susp Tier 3 NPD

pyridoxine hcl (vitamin b6) ((100 mgtablet 200 mg tablet er 250 mgtablet 50 mg tablet 500 mg tablet)100 mg tablet 200 mg tablet er 250mg tablet 50 mg tablet)

Tier 3 NPD

QSYMIA ((1125 MG-69 MGCAPSULE 15 MG-92 MGCAPSULE 375 MG-23 MGCAPSULE 75 MG-46 MGCAPSULE) 1125 MG-69 MGCAPSULE 15 MG-92 MGCAPSULE 375 MG-23 MGCAPSULE)

Tier 3 PA NPD

riboflavin (vitamin b2) ((100 mgtablet 50 mg tablet) 100 mg tablet)

Tier 3 NPD

RID ((1-2-3 KIT KIT) COMPLETE1-2-3 LICE KIT)

Tier 3 NPD

SAXENDA 18 MG3 ML PEN Tier 3 PA NPD

selenium sulfide 1 shampoo Tier 3 NPD

sennosides 86 mg tablet Tier 3 NPD

SILACE 50 MG5 ML LIQUID Tier 3 NPD

simethicone ((125 mg capsule 125 mgtab chew 166mg capsule 40mg06mldrops susp 80 mg tab chew) 125 mgcapsule 125 mg tab chew 166mgcapsule 40mg06ml drops susp)

Tier 3 NPD

sodium bicarbonate ((325 mg tablet650 mg tablet) 325 mg tablet)

Tier 3 NPD

Non-Part D Drugs

sodium chloride ((065 spray 2 drops 5 drops) 065 spray 2 drops)

Tier 3 NPD

sodiumpotassiumsod chl drops Tier 3 NPD

STOOL SOFTENER 250 MGSOFTGEL

Tier 3 NPD

thiamine hcl 100 mg tablet Tier 3 NPD

tioconazole 65 oinpf app Tier 3 NPD

tolnaftate 1 cream (g) Tier 3 NPD

triamcinolone acetonide 55 mcg spray Tier 3 NPD

TRIPLE ANTIBIOTIC ((CURADOINT MEDI-FIRSTMEDICHOICE OINTMENT)CURAD OINT MEDI-FIRSTMEDICHOICE)

Tier 3 NPD

triprolidinepseudoephedrine 25mg-60mg tablet

Tier 3 PA NPD

vitamin a 10000 unit capsule Tier 3 NPD

vitamin e (dltocopheryl acet) 400 unitcapsule

Tier 3 NPD

vitamin e 400 unit capsule Tier 3 NPD

vitamin e acetate 400 unit capsule Tier 3 NPD

Index009 sodium chloride 74

Aabacavir sulfate 45abacavir sulfatelamivudine 45abacavir sulfatelamivudinezidovudine 45ABELCET 23ABILIFY MAINTENA 41abiraterone acetate 27ABREVA 113acamprosate calcium 4acarbose 51acebutolol hcl 62acetaminophen with codeine phosphate 1acetazolamide 66acetylcysteine 107acitretin 7273ACTHIB 95ACTIMMUNE 95ACTIVELLA 87acyclovir 49acyclovir sodium 49ADACEL TDAP 95adapalene 73adefovir dipivoxil 47ADEMPAS 107ADVAIR HFA 108AFINITOR 3492AFINITOR DISPERZ 92AFLURIA 2018-2019 95AFLURIA QUAD 2018-2019 95albendazole 37albuterol 90mg hfa inhaler (generic proair) 105albuterol sulfate 105alclometasone dipropionate 82alcohol 70 pads 7ALECENSA 34alendronate sodium 99alfuzosin hcl 81

ALIMTA 28ALINIA 37ALIQOPA 34ALLI 113allopurinol 24ALORA 86alosetron hcl 78ALPHAGAN P 103alprazolam 50aluminum hydroxide 113ALUNBRIG 34amantadine hcl 49AMBISOME 23ambrisentan 107amifostine crystalline 29amikacin sulfate 6amiloride hcl 67amiloride hclhydrochlorothiazide 64AMINOSYN II 76AMINOSYN-HBC 76AMINOSYN-PF 76amiodarone hcl 61AMITIZA 78amitriptyline hcl 21amitriptyline hclchlordiazepoxide 19amlodipine besylate 63amlodipine besylatebenazepril hcl 64ammonium lactate 73amoxapine 21amoxicillin 10amoxicillinpotassium clavulanate 10amphotericin b 23ampicillin sodium 10110ampicillin sodiumsulbactam sodium 10ampicillin trihydrate 11AMPYRA 71ANADROL-50 86anagrelide hcl 58anastrozole 33ANDRODERM 86ANORO ELLIPTA 107

APOKYN 39aprepitant 22APTIOM 17APTIVUS 46ARANESP 58ARCALYST 95aripiprazole 41ARISTADA 41ARISTADA INITIO 41arsenic trioxide 29ARTIFICIAL TEARS 113ARZERRA 29ascomp with codeine capsule 1ascorbate calcium 113ascorbic acid 113aspirin 111113aspirin 325mg tablet 111113aspirin 81mg tablet 111aspirincalcium carbonatemagnesium 114aspirincalciumcarbonatemagnesiumaluminum hydroxide 113aspirindipyridamole 59ASTAGRAF XL 92atazanavir sulfate 46atenolol 62atenololchlorthalidone 64ATGAM 95atomoxetine hcl 70atorvastatin calcium 68atovaquone 37atovaquoneproguanil hcl 37ATRIPLA 45ATROVENT HFA 105AUBAGIO 71AVANDIA 51AVASTIN 29AVEED 86AVITA 73AVONEX 71AVONEX PEN 71azacitidine 29

azathioprine 92azathioprine sodium 92azelastine hcl 102104azithromycin 1112AZOPT 103aztreonam 10

Bbacitracin 7114bacitracin zinc 114bacitracin zincpolymyxin b sulfate 114bacitracinpolymyxin b sulfate 101114baclofen 43balsalazide disodium 98BALVERSA 29BANZEL 17BAQSIMI 55BARACLUDE 47BAVENCIO 29BCG VACCINE (TICE STRAIN) 96BELEODAQ 29benazepril hcl 61benazepril hclhydrochlorothiazide 64BENDEKA 26benzonatate 114benzoyl peroxide 114benztropine mesylate 38BESPONSA 30betamethasone dipropionate 7382betamethasone dipropionatepropyleneglycol 82betamethasone valerate 82BETASERON 71betaxolol hcl 62103bethanechol chloride 81bexarotene 37BEXSERO 96bicalutamide 27BICILLIN C-R 11BICILLIN L-A 11BIKTARVY 44

bisacodyl 112114bismuth subsalicylate 114bisoprolol fumarate 62bisoprolol fumaratehydrochlorothiazide 64BIVIGAM 95bleomycin sulfate 30BLEPH-10 13BLINCYTO 30BOOSTRIX TDAP 96bortezomib 30bosentan 107BOSULIF 34BRAFTOVI 34BRILINTA 59brimonidine tartrate 103BRIVIACT 13bromfenac sodium 102bromocriptine mesylate 90budesonide 87104bumetanide 66buprenorphine hcl 24buprenorphine hclnaloxone hcl 4bupropion hcl 519buspirone hcl 50busulfan 26butalbitalacetaminophencaffeinecodeinephosphate 1

Ccabergoline 90CABOMETYX 34calaminezinc oxide 114calcipotriene 73calcitoninsalmonsynthetic 99calcitriol 99calcium acetate 82calcium carbonate 114calcium carbonatecholecalciferol (vitamind3) 114calcium gluconate 115CALQUENCE 34

CAPRELSA 34captopril 61captoprilhydrochlorothiazide 64CARBAGLU 75carbamazepine 1750carbidopalevodopa 39carbidopalevodopaentacapone 38CARIMUNE NF NANOFILTERED 95carisoprodol 108carteolol hcl 103carvedilol 62caspofungin acetate 23CAYSTON 10cefaclor 8cefadroxil 8cefazolin sodium 8cefazolin sodiumdextrose iso-osmotic 8cefdinir 8cefepime hcl 8cefepime hcl in dextrose 5 in water 9cefepime hcl in iso-osmotic dextrose 9cefotaxime sodium 9cefoxitin sodium 9cefoxitin sodiumdextrose iso-osmotic 9cefpodoxime proxetil 9cefprozil 9ceftazidime 9ceftazidime in dextrose 5 and water 9ceftriaxone sodium 9ceftriaxone sodium in iso-osmotic dextrose 9cefuroxime axetil 9cefuroxime sodium 9celecoxib 5CELONTIN 14cephalexin 10cetirizine hcl 112115CHANTIX 5chlorhexidine gluconate 72chloroquine phosphate 37chlorothiazide 67chlorpheniramine maleate 115

chlorpromazine hcl 39chlorthalidone 67chlorzoxazone 108cholestyramine (with sugar) 68cholestyramineaspartame 68ciclopirox 23ciclopirox olamine 23ciclopiroxureacamphormentholeucalyptol 23cilostazol 59CIMDUO 45cimetidine 78115cimetidine hcl 78cinacalcet hcl 99ciprofloxacin 12ciprofloxacin hcl 12ciprofloxacin lactate 12ciprofloxacinciprofloxacin hcl 12citalopram hydrobromide 20clarithromycin 12clemastine fumarate 105clindamycin hcl 7clindamycin phosphate 7clobazam 15clobetasol propionate 82clobetasol propionateemollient base 82clofarabine 28clomipramine hcl 21clonazepam 50clonidine 60clonidine hcl 6070clopidogrel bisulfate 59clorazepate dipotassium 50clotrimazole 23115clotrimazolebetamethasone dipropionate 73clozapine 43codeine phosphatebutalbitalaspirincaffeine 1codeine phosphateguaifenesin 113115codeine sulfate 3colchicine 24colesevelam hcl 51colestipol hcl 68

colistin (as colistimethate sodium) 7COMBIPATCH 87COMBIVENT RESPIMAT 108COMETRIQ 35COMPLERA 44condoms latex lubricated 115COPIKTRA 30CORLANOR 65cortisone acetate 82COTELLIC 35COUMADIN 57CREON 79CRIXIVAN 46cromolyn sodium 102107115CUPRIMINE 81cyanocobalamin (vitamin b-12) 111cyclobenzaprine hcl 108cyclophosphamide 26CYCLOSET 51cyclosporine 92cyclosporine modified 93cyproheptadine hcl 105CYRAMZA 35CYSTADANE 80CYSTAGON 80CYSTARAN 102

Ddactinomycin 30dalfampridine 71DALIRESP 107danazol 86dantrolene sodium 43dapsone 26DAPTACEL DTAP 96daptomycin 7DARAPRIM 37DARZALEX 30DAURISMO 30decitabine 30deferasirox 75

DELSTRIGO 44demeclocycline hcl 13DEMSER 64DENAVIR 49DEPEN 75DEPO-PROVERA 88DESCOVY 45desipramine hcl 21desloratadine 105desmopressin acetate 84desmopressin acetate (non-refrigerated) 84desogestrel-ethinyl estradiol 87desogestrel-ethinyl estradiolethinyl estradiol 87desonide 82desoximetasone 83desvenlafaxine 20desvenlafaxine fumarate 20desvenlafaxine succinate 20dexamethasone 83dexamethasone sodium phosphate 102dexmethylphenidate hcl 70dextroamphetamine sulf-saccharateamphetamine sulf-aspartate 69dextroamphetamine sulfate 70dextrose 111dextrose 10 in water 76dextrose 25 and 045 sodium chloride 76dextrose 5 and 02 sodium chloride 76dextrose 5 and 03 sodium chloride 76dextrose 5 and 045 sodium chloride 76dextrose 5 and 09 sodium chloride 76dextrose 5 in water 76DIASTAT 14DIASTAT ACUDIAL 14diazepam 14diclofenac potassium 5diclofenac sodium 573102dicloxacillin sodium 11dicyclomine hcl 77didanosine 45diflorasone diacetate 83

diflunisal 5digoxin 6566dihydroergotamine mesylate 25DILANTIN 17DILANTIN-125 17diltiazem hcl 63DIPENTUM 98diphenhydramine hcl 113115diphenoxylate hclatropine sulfate 78DIPHTHERIA-TETANUS TOXOIDS-PED 96dipyridamole 59disopyramide phosphate 61disulfiram 4divalproex sodium 15docetaxel 30docusate sodium 112115dofetilide 61DOK 112115donepezil hcl 18DOPTELET 58dorzolamide hcl 103dorzolamide hcltimolol maleate 103DOVATO 46doxazosin mesylate 60doxepin hcl 50doxercalciferol 100doxycycline hyclate 1372doxycycline monohydrate 73dronabinol 22DROXIA 28duloxetine hcl 70dutasteride 81

EEES 400 12EARWAX TREATMENT DROPS 115econazole nitrate 23EDURANT 44efavirenz 44electrolytesdextrose 115

ELIDEL 73ELIGARD 90ELIQUIS 57ELITEK 28EMCYT 28EMEND 22EMPLICITI 30EMSAM 19EMTRIVA 45enalapril maleate 61enalapril maleatehydrochlorothiazide 64ENBREL 93ENBREL MINI 93ENBREL SURECLICK 93ENGERIX-B ADULT 96ENGERIX-B PEDIATRIC-ADOLESCENT96enoxaparin sodium 57entacapone 38entecavir 47ENTRESTO 60ENVARSUS XR 93EPCLUSA 48EPIDIOLEX 14epinephrine 105EPIVIR HBV 48eplerenone 67EPOGEN 58ERAXIS (WATER DILUENT) 23ergocalciferol (vitamin d2) 115ergoloid mesylates 18ergotamine tartratecaffeine 25ERIVEDGE 35ERLEADA 27erlotinib hcl 35ertapenem sodium 10ERWINAZE 30ERYTHROCIN LACTOBIONATE 12ERYTHROCIN STEARATE 12erythromycin base 12erythromycin base in ethanol 12erythromycin basebenzoyl peroxide 73

erythromycin ethylsuccinate 12ESBRIET 108escitalopram oxalate 20estradiol 86estradiolnorethindrone acetate 87estropipate 86ethambutol hcl 26ethinyl estradioldrospirenone 87ethosuximide 14ethynodiol diacetate-ethinyl estradiol 87etidronate disodium 100etodolac 5EVOTAZ 46exemestane 33EXTAVIA 71ezetimibe 68

Ffamotidine 78115FANAPT 41FARESTON 28FARYDAK 33FASLODEX 28felbamate 16felodipine 63fenofibrate 67fenofibrate nanocrystallized 67fenofibratemicronized 67fenoprofen calcium 5fentanyl 2fentanyl citrate 2ferrous sulfate 116FETZIMA 20fexofenadine hcl 113finasteride 81FIRAZYR 92FIRMAGON 90flecainide acetate 61FLOVENT DISKUS 104FLOVENT HFA 104FLUAD 2018-2019 96

FLUARIX QUAD 2018-2019 96FLUBLOK QUAD 2018-2019 96FLUCELVAX QUAD 2017-2018 96FLUCELVAX QUAD 2018-2019 96fluconazole 23fluconazole in dextrose iso-osmotic 23fluconazole in sodium chloride iso-osmotic 23flucytosine 23fludrocortisone acetate 83FLULAVAL QUAD 2018-2019 96flunisolide 104fluocinolone acetonide 83fluocinolone acetonide oil 83fluocinonide 83fluocinonideemollient base 83fluoride (sodium) 75FLUORITAB 75fluorometholone 102fluorouracil 2873fluoxetine hcl 20fluphenazine decanoate 40fluphenazine hcl 40flurbiprofen 5flurbiprofen sodium 102flutamide 27fluticasone propionate 73104fluticasone propionatesalmeterolxinafoate 106108FLUVIRIN 2017-2018 96fluvoxamine maleate 20FLUZONE QUAD 2018-2019 96folic acid 112116FOLOTYN 28fondaparinux sodium 57FORTEO 100fosamprenavir calcium 46fosinopril sodium 61fosinopril sodiumhydrochlorothiazide 64fosphenytoin sodium 17FRAGMIN 57FREAMINE HBC 75

fulvestrant 28furosemide 66FUZEON 46FYCOMPA 16

Ggabapentin 15GABITRIL 15GAMUNEX-C 95GARDASIL 9 96gauze bandage 55GAZYVA 30gemcitabine hcl 28gemfibrozil 67GENOTROPIN 85gentamicin sulfate 6GENVOYA 44GEODON 41GILENYA 71GILOTRIF 35glatiramer acetate 71GLEOSTINE 29glimepiride 51glipizide 5152glipizidemetformin hcl 54GLUCAGEN 55GLUCAGON EMERGENCY KIT 55glyburide 52glyburidemicronized 52glyburidemetformin hcl 54glycerin 116glycopyrrolate 77granisetron hcl 22GRANIX 58griseofulvin ultramicrosize 23griseofulvin microsize 24guanfacine hcl 6070guanidine hcl 25

HHAEGARDA 92

HALAVEN 30halobetasol propionate 83haloperidol 40haloperidol decanoate 40haloperidol lactate 40HARVONI 48HAVRIX 96heparin sodiumporcine 57HERCEPTIN 30HETLIOZ 109HEXALEN 26HIBERIX 96HUMALOG 55HUMALOG KWIKPEN U-100 55HUMALOG KWIKPEN U-200 55HUMALOG MIX 50-50 55HUMALOG MIX 50-50 KWIKPEN 55HUMALOG MIX 75-25 55HUMALOG MIX 75-25 KWIKPEN 55HUMATROPE 85HUMIRA 93HUMIRA PEDIATRIC CROHNS 93HUMIRA PEN 93HUMIRA PEN CROHNS-UC-HS 93HUMIRA PEN PSOR-UVEITS-ADOL HS 93HUMIRA(CF) 93HUMIRA(CF) PEN 93HUMULIN 70-30 55HUMULIN 7030 KWIKPEN 55HUMULIN N 55HUMULIN N KWIKPEN 55HUMULIN R 55HUMULIN R U-500 56hydralazine hcl 69hydrochlorothiazide 67hydrocodone bitartrateacetaminophen 1hydrocodoneibuprofen 1hydrocortisone 8399116hydrocortisone acetate 116hydrocortisone valerate 83hydrocortisoneacetic acid 104

hydrocortisonealoe vera 116hydrocortisonemineral oilpetrolatumwhite 83hydromorphone hcl 3hydromorphone hclpf 2hydroxychloroquine sulfate 37hydroxyurea 28hydroxyzine hcl 22HYPERHEP B S-D 95

Iibandronate sodium 100IBRANCE 33ibuprofen 5116icatibant acetate 92ICLUSIG 35IDHIFA 33imatinib mesylate 35IMBRUVICA 35IMFINZI 30imipenemcilastatin sodium 10imipramine hcl 21imipramine pamoate 21imiquimod 73IMLYGIC 30IMOVAX RABIES VACCINE 97INCRELEX 85indapamide 67indomethacin 5INFANRIX DTAP 97inhaler assist devices accessories 116INLYTA 35INREBIC 30insulin pen needles 56insulin syringe 03 ml 56insulin syringe 05 ml 56insulin syringe 1 ml 56INTELENCE 44INTRALIPID 76INTRON A 48INVEGA SUSTENNA 41INVEGA TRINZA 41

INVIRASE 46INVOKAMET 52INVOKAMET XR 52INVOKANA 52IPOL 97ipratropium bromide 105ipratropium bromidealbuterol sulfate 108irbesartan 60irbesartanhydrochlorothiazide 60IRESSA 35ISENTRESS 44ISENTRESS HD 44isoniazid 26isosorbide dinitrate 69isosorbide mononitrate 69isotretinoin 73isradipine 63ISTODAX 31itraconazole 24ivermectin 37IXIARO 97

JJAKAFI 35JANUMET 54JANUMET XR 54JANUVIA 52JENTADUETO 54JENTADUETO XR 5455JEVTANA 35JULUCA 45

KKADCYLA 31KALETRA 47KALYDECO 106ketoconazole 24ketoprofen 6ketorolac tromethamine 6102ketotifen fumarate 116KEVZARA 93

KEYTRUDA 31KINERET 93KINRIX 97KISQALI 33KLOR-CON M15 75KORLYM 55KUVAN 80KYNAMRO 68KYPROLIS 3135

Llabetalol hcl 62LACRISERT 102lactulose 78lamivudine 48lamivudinezidovudine 45lamotrigine 16lansoprazole 79LANTUS 56LANTUS SOLOSTAR 56LARTRUVO 31latanoprost 103LATUDA 41LAZANDA 23leflunomide 95LENVIMA 3536letrozole 33leucovorin calcium 31LEUKERAN 26LEUKINE 58leuprolide acetate 90levalbuterol hcl 106levetiracetam 14levobunolol hcl 103levofloxacin 12levofloxacindextrose 5 in water 12levoleucovorin calcium 31levonorgestrel 116levonorgestrel-ethinyl estradiol 87levothyroxine sodium 89LEVOXYL 89

LEXIVA 47LIBTAYO 31lidocaine 3lidocaine hcl 3lidocaineprilocaine 4lindane 38linezolid 7linezolid in 09 sodium chloride 7linezolid in dextrose 5 in water 7liothyronine sodium 89lisinopril 61lisinoprilhydrochlorothiazide 64lithium carbonate 51lithium citrate 51LONSURF 28loperamide hcl 78116lopinavirritonavir 47loratadine 116lorazepam 50LORBRENA 34losartan potassium 60losartan potassiumhydrochlorothiazide 65loteprednol etabonate 102lovastatin 68loxapine succinate 40LUMOXITI 31LUPRON DEPOT 91LUPRON DEPOT-PED 91LYNPARZA 29LYRICA 15LYSODREN 90

MM-M-R II VACCINE 97magaldrate 117magnesium carbonatealuminum hydroxide 117magnesium citrate 112magnesium gluconate 117magnesium hydroxidealuminumhydroxidesimethicone 112117magnesium sulfate 75

magnesium trisilicatealuminum hydroxsodbicarbalginic ac 117maprotiline hcl 19MARPLAN 19MARQIBO 31MATULANE 27MAVYRET 48MAXIDEX 102meclizine hcl 22117meclofenamate sodium 6mecobalamin 117medroxyprogesterone acetate 88mefloquine hcl 37megestrol acetate 88MEKINIST 36MEKTOVI 36meloxicam 6melphalan hcl 27memantine hcl 18MENACTRA 97MENEST 87MENVEO A-C-Y-W-135-DIP 97meperidine hcl 3mercaptopurine 94meropenem 10meropenem in 09 sodium chloride 10mesalamine 99mesalamine with cleansing wipes 99MESNEX 29metaproterenol sulfate 106metformin hcl 5253methadone hcl 2methazolamide 66methenamine hippurate 7methimazole 92methocarbamol 109methotrexate sodium 94methotrexate sodiumpf 94methoxsalen 74methyclothiazide 67methyldopa 60

methyldopahydrochlorothiazide 65methylphenidate hcl 70methylprednisolone 8384methyltestosterone 86metipranolol 103metoclopramide hcl 22metolazone 67metoprolol succinate 62metoprolol tartrate 62metoprolol tartratehydrochlorothiazide 65METRO IV 7metronidazole 7metronidazole in sodium chloride 8mexiletine hcl 61miconazole nitrate 24111117midodrine hcl 60miglitol 53miglustat 80minocycline hcl 72minoxidil 69MIRALAX 78MIRCERA 58mirtazapine 19misoprostol 7985mitoxantrone hcl 31modafinil 109moexipril hcl 61molindone hcl 40mometasone furoate 84montelukast sodium 105morphine sulfate 2moxifloxacin hcl 13MULTAQ 61multivitamin-minerals no60ferrousfumaratefolic acid 76mupirocin 8MURO-128 117mycophenolate mofetil 94mycophenolate sodium 94MYLOTARG 31MYRBETRIQ 80

Nnabumetone 6nadolol 62nafcillin in dextrose iso-osmotic 11nafcillin sodium 11naloxone hcl 4naltrexone hcl 4naproxen 6NARCAN 4NASAL DECON(PSEUDOEPHEDRINE) 117NATACYN 24nateglinide 53NATPARA 100NEBUPENT 38nefazodone hcl 19neomycin sulfate 6neomycin sulfatebacitracin zincpolymyxinb 117neomycin sulfatebacitracin zincpolymyxinbhydrocortisone 101neomycin sulfatebacitracinpolymyxin b 101neomycin sulfatepolymyxin bsulfategramicidin d 101neomycin sulfatepolymyxin bsulfatehydrocortisone 101104neomycin sulfatepolymyxin bsulfatepramoxine 117neomycinpolymyxin bsulfatedexamethasone 101NEPHRAMINE 76NERLYNX 36NEULASTA 58NEUPOGEN 58nevirapine 44NEXAVAR 36niacin 68117niacinamide 117nicardipine hcl 63nicotine 14mg patch 118

nicotine 21mg patch 118nicotine 2mg gum 118nicotine 4mg gum 118nicotine 7mg patch 118NICOTROL 5NICOTROL NS 5nifedipine 63nilutamide 27NINLARO 29nitisinone 80nitrofurantoin macrocrystal 8nitrofurantoin monohydratemacrocrystals 8nitroglycerin 69NITROSTAT 69NIX COMPLETE 118nizatidine 78nonoxynol 9 118NORDITROPIN FLEXPRO 85norethindrone 8788norethindrone acetate 88norethindrone acetate-ethinyl estradiol 87norethindrone acetate-ethinyl estradiolferrousfumarate 88norethindrone-ethinyl estradiol 88norgestimate-ethinyl estradiol 88norgestrel-ethinyl estradiol 88NORTHERA 60nortriptyline hcl 21NORVIR 47NOVOLIN 70-30 56NOVOLIN N 56NOVOLIN R 56NOVOLOG 56NOVOLOG FLEXPEN 56NOVOLOG MIX 70-30 56NOVOLOG MIX 70-30 FLEXPEN 56NUBEQA 27NUEDEXTA 70NULOJIX 94NUPLAZID 4142NUTROPIN AQ NUSPIN 85

nystatin 24nystatintriamcinolone acetonide 74

Ooctreotide acetate 91ODEFSEY 45ODOMZO 36OFEV 108ofloxacin 13104olanzapine 42olopatadine hcl 102omega-3 acid ethyl esters 68omeprazole 79112ONCASPAR 31ondansetron 22ondansetron hcl 22ONFI 15ONIVYDE 31OPDIVO 31ORFADIN 80ORKAMBI 106oseltamivir phosphate 49OSPHENA 89OTEZLA 9495oxaliplatin 31oxandrolone 86oxcarbazepine 17OXTELLAR XR 17oxybutynin chloride 81oxycodone hcl 23oxycodone hclacetaminophen 13oxycodone hclaspirin 1OXYCONTIN 2OZEMPIC 53

PPACERONE 62paclitaxel 31paliperidone 42PANRETIN 37pantoprazole sodium 79

paricalcitol 100paromomycin sulfate 6paroxetine hcl 20PASER 26PAXIL 20PEDIARIX 97PEDVAXHIB 97peg 3350sod sulfsod bicarbsodchloridepotassium chloride 79PEGANONE 17PEGASYS 48PEGASYS PROCLICK 48penicillamine 81penicillin g potassium 11penicillin g sodium 11penicillin v potassium 11PENTACEL 97PENTACEL ACTHIB COMPONENT 97PENTACEL DTAP-IPV COMPONENT 97PENTAM 300 38pentamidine isethionate 38PENTASA 99pentoxifylline 66PERJETA 31permethrin 38118perphenazine 40perphenazineamitriptyline hcl 19PERSERIS 42phenelzine sulfate 19phenobarbital 15phentermine hcl 118PHENYTEK 17phenytoin 17phenytoin sodium 17phenytoin sodium extended 17PHOSPHOLINE IODIDE 103phytonadione (vit k1) 118PICATO 74PIFELTRO 44pilocarpine hcl 72103pimecrolimus 74

pimozide 40pindolol 62pioglitazone hcl 53piperacillin sodiumtazobactam sodium 11piperonyl butoxidepyrethrins 118piperonyl butoxidepyrethrinspermethrin 118PIQRAY 34piroxicam 6PLEGRIDY 71PLEGRIDY PEN 71PNEUMOVAX 23 97podofilox 74POLIVY 31polyethylene glycol 3350 79polymyxin b sulfatetrimethoprim 101polyvinyl alcohol 118POMALYST 27PORTRAZZA 32potassium chloride 75potassium chloride in 09 sodium chloride 75potassium chloride in 5 dextrose in water 76potassium chloride in dextrose 5 and 09 sodium chloride 77potassium chloride in dextrose 5 -02 sodium chloride 77potassium chloride in dextrose 5 -045 sodium chloride 77potassium chloride in dextrose 5 and 03 sodium chloride 77potassium chloride in lactated ringers and 5 dextrose 77potassium citrate 81POTELIGEO 32POTIGA 14pramipexole di-hcl 39pravastatin sodium 68praziquantel 37prazosin hcl 60prednisolone 84prednisolone acetate 99prednisolone sodium phosphate 84103

prednisone 84pregabalin 15PREMARIN 87PREMASOL 77PREMPHASE 88PREMPRO 88PRENATAL PLUS IRON TABLET 77prenatal vit with calcium no130ferrousfumaratefolic acid 118prenatal vitamins no121ferrous fumaratefolicacid 118prenatal vits with calcium 133ferrousfumaratefolic acid 118prenatal vits with calcium no96ferrousfumaratefolic acid 118PREVNAR 13 97PREZCOBIX 47PREZISTA 47PRIFTIN 26primaquine phosphate 38primidone 15PROAIR HFA 106PROAIR RESPICLICK 106probenecid 24probenecidcolchicine 24prochlorperazine 22prochlorperazine edisylate 22prochlorperazine maleate 40PROCRIT 59progesterone micronized 88PROGLYCEM 55PROGRAF 94PROLEUKIN 32PROLIA 100PROMACTA 59promethazine hcl 22promethazine hclcodeine 118promethazine hcldextromethorphan hbr 118promethazinephenylephrine hclcodeine 119propafenone hcl 62proparacaine hcl 102

propranolol hcl 63propranolol hclhydrochlorothiazide 65propylthiouracil 92PROQUAD 97protriptyline hcl 21pseudoephedrine hcl 119PULMICORT FLEXHALER 104PULMOZYME 108PUREFE PLUS 77PURIXAN 29pyrantel pamoate 119pyrazinamide 26pyridostigmine bromide 25pyridoxine hcl (vitamin b6) 119

QQSYMIA 119QUADRACEL DTAP-IPV 97quetiapine fumarate 42quinapril hcl 61quinapril hclhydrochlorothiazide 65quinidine gluconate 62quinidine sulfate 62QVAR REDIHALER 104

RRABAVERT 97raloxifene hcl 89ramelteon 109ramipril 61ranitidine hcl 78112ranolazine 66rasagiline mesylate 39REBIF 7172REBIF REBIDOSE 72RECOMBIVAX HB 97RECTIV 69REGRANEX 74RELENZA 49RELISTOR 78RENAGEL 82

repaglinide 53REPATHA PUSHTRONEX 68REPATHA SURECLICK 68REPATHA SYRINGE 68RESCRIPTOR 44RESTASIS 102RESTASIS MULTIDOSE 102RETROVIR 45REVLIMID 2732REXULTI 42REYATAZ 47ribavirin 48riboflavin (vitamin b2) 119RID 119RIDAURA 95rifabutin 26rifampin 26RIFATER 26riluzole 70rimantadine hcl 49risedronate sodium 100RISPERDAL CONSTA 42risperidone 42ritonavir 47RITUXAN 32rivastigmine 18rivastigmine tartrate 18rizatriptan benzoate 25romidepsin 32ropinirole hcl 39rosuvastatin calcium 68ROTARIX 98ROTATEQ 98ROZEREM 109ROZLYTREK 32RUBRACA 29RUCONEST 92RYDAPT 36

SSAIZEN 85

SAIZEN-SAIZENPREP 85SANTYL 74SAPHRIS 43SAVELLA 71SAXENDA 119scopolamine 22selegiline hcl 39selenium sulfide 74119SELZENTRY 46sennosides 119SENSIPAR 100SEREVENT DISKUS 106SEROSTIM 85sertraline hcl 20sevelamer carbonate 82sevelamer hcl 82SHINGRIX 98SIGNIFOR 91SIGNIFOR LAR 91SILACE 119sildenafil citrate 107silver sulfadiazine 13simethicone 119SIMULECT 95simvastatin 68sirolimus 94SIVEXTRO 8sodium bicarbonate 119sodium chloride 120sodium chloride 045 75sodium chloride irrigating solution 75sodium chloridesodium bicarbonatepotassiumchloridepeg 79sodium phenylbutyrate 80sodium polystyrene sulfonate 75sodium polystyrene sulfonatesorbitolsolution 75sodiumpotassiumsodium chloride 120SOLTAMOX 28SOMATULINE DEPOT 91SOMAVERT 91

sotalol hcl 62SPIRIVA 105SPIRIVA RESPIMAT 105spironolactone 67spironolactonehydrochlorothiazide 65SPRITAM 14SPRYCEL 36SPS 75SSD 13stavudine 45STIVARGA 36STOOL SOFTENER 112120streptomycin sulfate 6STRIBILD 44STRIVERDI RESPIMAT 106SUBOXONE 4SUCRAID 80sucralfate 79sulfacetamide sodium 13101sulfacetamide sodiumprednisolone sodiumphosphate 101sulfadiazine 13sulfamethoxazoletrimethoprim 13sulfasalazine 99sulindac 6sumatriptan 25sumatriptan succinate 25SURMONTIL 21SUTENT 36SYLATRON 48SYLVANT 32SYMDEKO 106SYMFI 45SYMFI LO 45SYMLINPEN 120 53SYMLINPEN 60 53SYMPAZAN 15SYMTUZA 47SYNAREL 91SYNRIBO 32SYNTHROID 89

SYPRINE 76

TTABLOID 29tacrolimus 7494tadalafil 107TAFINLAR 36TAGRISSO 36TALZENNA 36TAMIFLU 49tamoxifen citrate 28tamsulosin hcl 81TANZEUM 53TARGRETIN 37TASIGNA 36TAVALISSE 59tazarotene 74TAZORAC 74TDVAX 98TECENTRIQ 32TECFIDERA 72TEFLARO 10TEGRETOL XR 51TEKTURNA 66TEKTURNA HCT 65temazepam 109TEMIXYS 45TEMODAR 27TENIVAC 98tenofovir disoproxil fumarate 48terazosin hcl 60terbinafine hcl 24terbutaline sulfate 106terconazole 24testosterone 86testosterone cypionate 86tetrabenazine 70tetracycline hcl 13THALOMID 27THEO-24 107theophylline anhydrous 107

thiamine hcl 120THIOLA 81THIOLA EC 81thioridazine hcl 40thiotepa 32thiothixene 40tiagabine hcl 16TIBSOVO 32tigecycline 8timolol maleate 63103tioconazole 120TIVICAY 44tizanidine hcl 43tobramycin 7tobramycin in 0225 sodium chloride 7tobramycin sulfate 7tobramycindexamethasone 102tobramycinnebulizer 7TOLAK 74tolazamide 53tolbutamide 53tolcapone 38tolmetin sodium 6tolnaftate 120tolterodine tartrate 81topiramate 16topotecan hcl 34toremifene citrate 28torsemide 66TOUJEO MAX SOLOSTAR 56TOUJEO SOLOSTAR 56TPN ELECTROLYTES 77TPN ELECTROLYTES II 77TRACLEER 107TRADJENTA 54tramadol hcl 3tramadol hclacetaminophen 1trandolapril 61tranexamic acid 59tranylcypromine sulfate 19TRAVASOL 77

TRAVATAN Z 103trazodone hcl 19TREANDA 27TRECATOR 26TRELSTAR 91tretinoin 3774triamcinolone acetonide 7284120triamterenehydrochlorothiazide 65triazolam 50TRIDESILON 84trientine hcl 76trifluoperazine hcl 40trifluridine 49trihexyphenidyl hcl 38trimethoprim 8trimipramine maleate 21TRINTELLIX 20TRIPLE ANTIBIOTIC 120triprolidine hclpseudoephedrine hcl 120TRISENOX 32TRIUMEQ 46TROGARZO 46TROPHAMINE 77trospium chloride 81TRULICITY 54TRUMENBA 98TRUVADA 45TUDORZA PRESSAIR 105TURALIO 32TWINRIX 98TYBOST 46TYKERB 36TYMLOS 100TYPHIM VI 98

UUNITHROID 90UNITUXIN 32UPTRAVI 66ursodiol 78

Vvalacyclovir hcl 49VALCHLOR 74valganciclovir hcl 47valproic acid 16valproic acid (as sodium salt) (valproatesodium) 16valsartan 60valsartanhydrochlorothiazide 65vancomycin hcl 8VAQTA 98VARIVAX VACCINE 98VASCEPA 68VELCADE 32VEMLIDY 48VENCLEXTA 29VENCLEXTA STARTING PACK 29venlafaxine hcl 21VENTOLIN HFA 106verapamil hcl 64VERSACLOZ 43VERZENIO 34VICTOZA 2-PAK 54VICTOZA 3-PAK 54VIDEX 46VIDEX EC 46vigabatrin 16VIIBRYD 21VIMPAT 18VIRACEPT 47VIRAMUNE 44VIREAD 48vitamin a 120vitamin e 120vitamin e (dl-alpha tocopheryl acetate) 120vitamin e acetate 120VITRAKVI 32VIVITROL 4VIZIMPRO 32voriconazole 24

VOSEVI 48VOTRIENT 36VRAYLAR 43VYNDAMAX 66VYNDAQEL 66VYXEOS 32

Wwarfarin sodium 57WELCHOL 54WINRHO SDF 110

XXALKORI 36XARELTO 57XATMEP 94XELJANZ 94XELJANZ XR 94XGEVA 101XOFLUZA 98XOLAIR 108XOSPATA 33XPOVIO 33XTANDI 27XYREM 109

YYERVOY 33YF-VAX 98YONDELIS 27YONSA 27

Zzafirlukast 105zaleplon 109ZALTRAP 33ZARXIO 59ZEJULA 29ZELBORAF 37ZEMAIRA 108ZENPEP 80

ZERIT 46zidovudine 46ziprasidone hcl 43ZIRGAN 47ZMAX 12ZOLADEX 33zoledronic acid 101zoledronic acid in mannitol and water forinjection 101ZOLINZA 24zolpidem tartrate 109ZOMETA 101zonisamide 15ZORBTIVE 85ZORTRESS 95ZOSTAVAX 98ZYCLARA 74ZYDELIG 34ZYKADIA 37ZYPREXA RELPREVV 43ZYTIGA 27

Category ListingAnalgesics 1Anesthetics 3Anti-Addiction Substance Abuse Treatment Agents 4Anti-inflammatory Agents 5Antibacterials 6Anticonvulsants 13Antidementia Agents 18Antidepressants 19Antiemetics 22Antifungals 23Antigout Agents 24Antimigraine Agents 25Antimyasthenic Agents 25Antimycobacterials 26Antineoplastics 26Antiparasitics 37Antiparkinson Agents 38Antipsychotics 39Antispasticity Agents 43Antivirals 44Anxiolytics 50Bipolar Agents 50Blood Glucose Regulators 51Blood Products Modifiers Volume Expanders 57Cardiovascular Agents 60Central Nervous System Agents 69Dental and Oral Agents 72Dermatological Agents 72ElectrolytesMineralsMetalsVitamins 74Gastrointestinal Agents 77Genetic or Enzyme Disorder Replacement Modifiers Treatment 79Genitourinary Agents 80Hormonal Agents Stimulant Replacement Modifying (Adrenal) 82Hormonal Agents Stimulant Replacement Modifying (Pituitary) 84Hormonal Agents Stimulant Replacement Modifying (Prostaglandins) 85Hormonal Agents Stimulant Replacement Modifying (Sex Hormones Modifiers) 86Hormonal Agents Stimulant Replacement Modifying (Thyroid) 89

Hormonal Agents Suppressant (Adrenal) 90Hormonal Agents Suppressant (Pituitary) 90Hormonal Agents Suppressant (Thyroid) 92Immunological Agents 92Inflammatory Bowel Disease Agents 98Metabolic Bone Disease Agents 99Non-Part D Drugs 113Ophthalmic Agents 101Otic Agents 103Respiratory Tract Pulmonary Agents 104Skeletal Muscle Relaxants 108Sleep Disorder Agents 109Uncategorized 110

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You can file a grievance in person or by mail fax or email If you need help filing a grievance the Grievance Coordinator at Blue Shield Promise Health Plan Grievance Department is available to help you

Grievances must be submitted to the Grievance Coordinator at Blue Shield Promise Health Plan Grievance Department within 60 calendar days from the time you have become aware of any alleged discrimination action A complaint must be in writing or reported verbally containing your name and address The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought

You can also go to our website at httpswwwblueshieldcacompromisecalmediconnect and submit your complaint

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)

Such complaints must be filed within 180 days from the date of the alleged discrimination Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

IMPORTANT NOTE To view this notice in a different language you can go to our website at httpswwwblueshieldcacompromiseaffordable-care-actasp

Language Assistance Notice

English

ATTENTION Language assistance services free of charge are available to you Call 1-855-905-3825 (TTY 711)

繁體中文 (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1-855-905-3825（TTY711)

한국어 (Korean)

주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-855-905-3825 (TTY 711)번으로 전화해 주십시오

Русский (Russian)

ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1-855-905-3825 (телетайп 711)

Kreyogravel Ayisyen (Haitian-Creole)

ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 1-855-905-3825 (TTY 711)

Franccedilais (French)

ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 1-855-905-3825 (TTY 711)

Portuguecircs (Portuguese)

ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 1-855-905-3825 (TTY 711)

Italiano (Italian)

ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero 1-855-905-3825 (TTY 711)

(Farsi)

ی ی یم ی یم م ی ی ی 1-855-905-3825 (TTY 771) یی

िहदी (Hindi)

या द यिद आप िहदी बोलत ह तो आपक िलए मत म भाषा सहायता सवाए पल ह 1-855-905-3825 (TTY 711) पर कॉल कर

Hmong (Hmong)

LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb rau koj Hu rau 1-855-905-3825 (TTY 711)

Espantildeol (Spanish)

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-855-905-3825 (TTY 711)

Tiếng Việt (Vietnamese)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-855-905-3825 (TTY 711)

Tagalog (Tagalog - Filipino)

PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-855-905-3825 (TTY 711)

(Arabic)

-1 ا اما ا ا اماد خدمات ا اذ د ت إذا م855-905-3825 (711YTT)

Polski (Polish)

UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń pod numer 1-855-905-3825 (TTY 711)

ພາສາລາວ (Lao)

ໂປດຊາບ ຖາວາ ທານເວາພາສາ ລາວ ການບລການຊວຍເຫອດານພາສາ ໂດຍບເສຽຄາ ແມນມພອມໃຫທານ ໂທຣ 1-855-905-3825 (TTY 711)

日本語 (Japanese)

注意事項日本語を話される場合無料の言語支援をご利用いただけます1-855-905-3825（TTY711）までお電話にてご連絡ください

ภาษาไทย (Thai)

เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-855-905-3825 (TTY 711)

λληνικά (Greek)

ΠΡΟΣΟΧΗ Αν μιλάτε ελληνικά στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης οι οποίες παρέχονται δωρεάν Καλέστε 1-855-905-3825 (TTY 711)

ਪਜਾਬੀ ਦ (Punjabi)

ਿਧਆਨ ਿਦਓ ਜ ਤਸ ਪਜਾਬੀ ਬਲਦ ਹ ਤਾ ਭਾਸ਼ਾ ਿਵਚ ਸਹਾਇਤਾ ਸਵਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਧ ਹ 1-855-905-3825 (TTY 711) ਤ ਕਾਲ ਕਰ

ែខមរ (Cambodian)

របយតន េបើសនជាអនកនយាយ ភាសាែខមរ េសវាជនយែផនកភាសា េដាយមនគតឈនល គអាចមានសរាបបេរអនក ចរ ទរសពទ 1-855-905-3825

(TTY 711)

Հայերեն (Armenian)

ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող ենտրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-855-905-3825 (TTY (հեռատիպ)711)

Formulary ID 19463 Version

601 Potrero Grande Dr Monterey Park CA 91755 wwwblueshieldcacompromisecalmediconnect

12012019

List of Covered Drugs

Alphabetical Listing

Category Listing

If you have questions please call Blue Shield Promise Cal MediConnect Plan at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is freeFor more information visit wwwblueshieldcacompromisecalmediconnect ii

Introduction

This document is called the List of Covered Drugs (also known as the Drug List) It tells you which prescription drugs and over-the-counter drugs are covered by Blue Shield Promise Cal MediConnect Plan The Drug List also tells you if there are any special rules or restrictions on any drugs covered by Blue Shield Promise Cal MediConnect Plan Key terms and their definitions appear in the last chapter of the Member Handbook

Table of ContentsA Disclaimers iii

B Frequently Asked Questions (FAQ) iv

B1 What prescription drugs are on the List of Covered Drugs (We call the List of Covered Drugs the ldquoDrug Listrdquo for short) iv

B2 Does the Drug List ever change iv

B3 What happens when there is a change to the Drug List v

B4 Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs vi

B5 How will you know if the drug you want has limitations or if there are required actions to take to get the drug vi

B6 What happens if we change our rules about some drugs (for example prior authorization (approval) quantity limits andor step therapy restrictions) vi

B7 How can you find a drug on the Drug List vii

B8 What if the drug you want to take is not on the Drug List vii

B9 What if you are a new Blue Shield Promise Cal MediConnect Plan member and canrsquot find your drug on the Drug List or have a problem getting your drug vii

B10 Can you ask for an exception to cover your drug viii

B11 How can you ask for an exception viii

B12 How long does it take to get an exception viii

B13 What are generic drugs viii

B14 What are OTC drugs ix

B15 Does Blue Shield Promise Cal MediConnect Plan cover OTC non-drug products ix

B16 What is your copay ix

B17 What are drug tiers ix

C List of Covered Drugs ix

D List of Drugs by Medical Condition xiE Index of Covered Drugs

Blue Shield Promise Cal MediConnect Plan

2019 List of Covered Drugs (Formulary)

A Disclaimers

Arabic

(PersianFarsi)

Arabic

(PersianFarsi)

Arabic

(PersianFarsi)

Arabic

(PersianFarsi)

Arabic

(PersianFarsi)

Arabic

Analgesics

Tier 1 BvD

Analgesics

Anesthetics

Tier 1

Anesthetics

Tier 1 PA

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 2

Tier 1

Tier 1 PA

Tier 1

Antibacterials

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1 BvD

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 2 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

SSD 1 CREAM Tier 1

Tier 1

Anticonvulsants

Tier 2

Tier 1

Tier 2 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Antidementia Agents

Antidepressants

Tier 1

Tier 2 PA

Antidepressants

Tier 2 PA

Antiemetics

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Antifungals

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Antifungals

Tier 1

Tier 1 PA

Antigout Agents

Antimigraine Agents

Tier 1 PA

Tier 2

Antimycobacterials

Tier 1

Tier 2

Tier 1

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 2 BvD

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Antiparasitics

Tier 1

Antiparasitics

Antipsychotics

Tier 1 PA

Tier 1

Antipsychotics

Tier 2 PA

Antipsychotics

Tier 2 PA

Antipsychotics

Antivirals

Tier 2

Antivirals

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antivirals

Anxiolytics

Bipolar Agents

Tier 1

Tier 1 PA

Tier 2

Tier 1 BvD

Tier 2 PA

Tier 1

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 2 PA

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

IPOL VIAL Tier 2

Tier 2

PROQUAD VIAL Tier 2

Tier 2

Tier 2 BvD

Tier 2

TDVAX VIAL Tier 2

Tier 2

Tier 1

Tier 1 BvD

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Otic Agents

Tier 1

Otic Agents

Tier 1

Tier 2 PA LA

Uncategorized

Analgesics

Tier 3 NPD

Antifungals

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Non-Part D Drugs

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

HHAEGARDA 92

SSAIZEN 85

SYPRINE 76

Mailing Address

Fax Number 1-323-889-2228

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

English

한국어 (Korean)

Italiano (Italian)

(Farsi)

Hmong (Hmong)

(Arabic)

Polski (Polish)

(TTY 711)

12012019

Category Listing

A Disclaimers

Arabic

(PersianFarsi)

Arabic

(PersianFarsi)

Arabic

(PersianFarsi)

Arabic

(PersianFarsi)

Arabic

(PersianFarsi)

Arabic

Analgesics

Tier 1 BvD

Analgesics

Anesthetics

Tier 1

Anesthetics

Tier 1 PA

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 2

Tier 1

Tier 1 PA

Tier 1

Antibacterials

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1 BvD

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 2 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

SSD 1 CREAM Tier 1

Tier 1

Anticonvulsants

Tier 2

Tier 1

Tier 2 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Antidementia Agents

Antidepressants

Tier 1

Tier 2 PA

Antidepressants

Tier 2 PA

Antiemetics

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Antifungals

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Antifungals

Tier 1

Tier 1 PA

Antigout Agents

Antimigraine Agents

Tier 1 PA

Tier 2

Antimycobacterials

Tier 1

Tier 2

Tier 1

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 2 BvD

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Antiparasitics

Tier 1

Antiparasitics

Antipsychotics

Tier 1 PA

Tier 1

Antipsychotics

Tier 2 PA

Antipsychotics

Tier 2 PA

Antipsychotics

Antivirals

Tier 2

Antivirals

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antivirals

Anxiolytics

Bipolar Agents

Tier 1

Tier 1 PA

Tier 2

Tier 1 BvD

Tier 2 PA

Tier 1

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 2 PA

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

IPOL VIAL Tier 2

Tier 2

PROQUAD VIAL Tier 2

Tier 2

Tier 2 BvD

Tier 2

TDVAX VIAL Tier 2

Tier 2

Tier 1

Tier 1 BvD

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Otic Agents

Tier 1

Otic Agents

Tier 1

Tier 2 PA LA

Uncategorized

Analgesics

Tier 3 NPD

Antifungals

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Non-Part D Drugs

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

HHAEGARDA 92

SSAIZEN 85

SYPRINE 76

Mailing Address

Fax Number 1-323-889-2228

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

English

한국어 (Korean)

Italiano (Italian)

(Farsi)

Hmong (Hmong)

(Arabic)

Polski (Polish)

(TTY 711)

12012019

Category Listing

(PersianFarsi)

Arabic

(PersianFarsi)

Arabic

(PersianFarsi)

Arabic

(PersianFarsi)

Arabic

Analgesics

Tier 1 BvD

Analgesics

Anesthetics

Tier 1

Anesthetics

Tier 1 PA

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 2

Tier 1

Tier 1 PA

Tier 1

Antibacterials

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1 BvD

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 2 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

SSD 1 CREAM Tier 1

Tier 1

Anticonvulsants

Tier 2

Tier 1

Tier 2 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Antidementia Agents

Antidepressants

Tier 1

Tier 2 PA

Antidepressants

Tier 2 PA

Antiemetics

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Antifungals

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Antifungals

Tier 1

Tier 1 PA

Antigout Agents

Antimigraine Agents

Tier 1 PA

Tier 2

Antimycobacterials

Tier 1

Tier 2

Tier 1

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 2 BvD

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Antiparasitics

Tier 1

Antiparasitics

Antipsychotics

Tier 1 PA

Tier 1

Antipsychotics

Tier 2 PA

Antipsychotics

Tier 2 PA

Antipsychotics

Antivirals

Tier 2

Antivirals

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antivirals

Anxiolytics

Bipolar Agents

Tier 1

Tier 1 PA

Tier 2

Tier 1 BvD

Tier 2 PA

Tier 1

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 2 PA

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

IPOL VIAL Tier 2

Tier 2

PROQUAD VIAL Tier 2

Tier 2

Tier 2 BvD

Tier 2

TDVAX VIAL Tier 2

Tier 2

Tier 1

Tier 1 BvD

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Otic Agents

Tier 1

Otic Agents

Tier 1

Tier 2 PA LA

Uncategorized

Analgesics

Tier 3 NPD

Antifungals

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Non-Part D Drugs

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

HHAEGARDA 92

SSAIZEN 85

SYPRINE 76

Mailing Address

Fax Number 1-323-889-2228

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

English

한국어 (Korean)

Italiano (Italian)

(Farsi)

Hmong (Hmong)

(Arabic)

Polski (Polish)

(TTY 711)

12012019

Category Listing

Analgesics

Tier 1 BvD

Analgesics

Anesthetics

Tier 1

Anesthetics

Tier 1 PA

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 2

Tier 1

Tier 1 PA

Tier 1

Antibacterials

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1 BvD

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 2 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

SSD 1 CREAM Tier 1

Tier 1

Anticonvulsants

Tier 2

Tier 1

Tier 2 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Antidementia Agents

Antidepressants

Tier 1

Tier 2 PA

Antidepressants

Tier 2 PA

Antiemetics

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Antifungals

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Antifungals

Tier 1

Tier 1 PA

Antigout Agents

Antimigraine Agents

Tier 1 PA

Tier 2

Antimycobacterials

Tier 1

Tier 2

Tier 1

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 2 BvD

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Antiparasitics

Tier 1

Antiparasitics

Antipsychotics

Tier 1 PA

Tier 1

Antipsychotics

Tier 2 PA

Antipsychotics

Tier 2 PA

Antipsychotics

Antivirals

Tier 2

Antivirals

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antivirals

Anxiolytics

Bipolar Agents

Tier 1

Tier 1 PA

Tier 2

Tier 1 BvD

Tier 2 PA

Tier 1

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 2 PA

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

IPOL VIAL Tier 2

Tier 2

PROQUAD VIAL Tier 2

Tier 2

Tier 2 BvD

Tier 2

TDVAX VIAL Tier 2

Tier 2

Tier 1

Tier 1 BvD

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Otic Agents

Tier 1

Otic Agents

Tier 1

Tier 2 PA LA

Uncategorized

Analgesics

Tier 3 NPD

Antifungals

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Non-Part D Drugs

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

HHAEGARDA 92

SSAIZEN 85

SYPRINE 76

Mailing Address

Fax Number 1-323-889-2228

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

English

한국어 (Korean)

Italiano (Italian)

(Farsi)

Hmong (Hmong)

(Arabic)

Polski (Polish)

(TTY 711)

12012019

Category Listing

Analgesics

Tier 1 BvD

Analgesics

Anesthetics

Tier 1

Anesthetics

Tier 1 PA

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 2

Tier 1

Tier 1 PA

Tier 1

Antibacterials

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1 BvD

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 2 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

SSD 1 CREAM Tier 1

Tier 1

Anticonvulsants

Tier 2

Tier 1

Tier 2 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Antidementia Agents

Antidepressants

Tier 1

Tier 2 PA

Antidepressants

Tier 2 PA

Antiemetics

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Antifungals

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Antifungals

Tier 1

Tier 1 PA

Antigout Agents

Antimigraine Agents

Tier 1 PA

Tier 2

Antimycobacterials

Tier 1

Tier 2

Tier 1

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 2 BvD

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Antiparasitics

Tier 1

Antiparasitics

Antipsychotics

Tier 1 PA

Tier 1

Antipsychotics

Tier 2 PA

Antipsychotics

Tier 2 PA

Antipsychotics

Antivirals

Tier 2

Antivirals

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antivirals

Anxiolytics

Bipolar Agents

Tier 1

Tier 1 PA

Tier 2

Tier 1 BvD

Tier 2 PA

Tier 1

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 2 PA

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

IPOL VIAL Tier 2

Tier 2

PROQUAD VIAL Tier 2

Tier 2

Tier 2 BvD

Tier 2

TDVAX VIAL Tier 2

Tier 2

Tier 1

Tier 1 BvD

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Otic Agents

Tier 1

Otic Agents

Tier 1

Tier 2 PA LA

Uncategorized

Analgesics

Tier 3 NPD

Antifungals

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Non-Part D Drugs

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

HHAEGARDA 92

SSAIZEN 85

SYPRINE 76

Mailing Address

Fax Number 1-323-889-2228

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

English

한국어 (Korean)

Italiano (Italian)

(Farsi)

Hmong (Hmong)

(Arabic)

Polski (Polish)

(TTY 711)

12012019

Category Listing

Analgesics

Tier 1 BvD

Analgesics

Anesthetics

Tier 1

Anesthetics

Tier 1 PA

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 2

Tier 1

Tier 1 PA

Tier 1

Antibacterials

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1 BvD

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 2 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

SSD 1 CREAM Tier 1

Tier 1

Anticonvulsants

Tier 2

Tier 1

Tier 2 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Antidementia Agents

Antidepressants

Tier 1

Tier 2 PA

Antidepressants

Tier 2 PA

Antiemetics

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Antifungals

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Antifungals

Tier 1

Tier 1 PA

Antigout Agents

Antimigraine Agents

Tier 1 PA

Tier 2

Antimycobacterials

Tier 1

Tier 2

Tier 1

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 2 BvD

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Antiparasitics

Tier 1

Antiparasitics

Antipsychotics

Tier 1 PA

Tier 1

Antipsychotics

Tier 2 PA

Antipsychotics

Tier 2 PA

Antipsychotics

Antivirals

Tier 2

Antivirals

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antivirals

Anxiolytics

Bipolar Agents

Tier 1

Tier 1 PA

Tier 2

Tier 1 BvD

Tier 2 PA

Tier 1

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 2 PA

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

IPOL VIAL Tier 2

Tier 2

PROQUAD VIAL Tier 2

Tier 2

Tier 2 BvD

Tier 2

TDVAX VIAL Tier 2

Tier 2

Tier 1

Tier 1 BvD

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Otic Agents

Tier 1

Otic Agents

Tier 1

Tier 2 PA LA

Uncategorized

Analgesics

Tier 3 NPD

Antifungals

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Non-Part D Drugs

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

HHAEGARDA 92

SSAIZEN 85

SYPRINE 76

Mailing Address

Fax Number 1-323-889-2228

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

English

한국어 (Korean)

Italiano (Italian)

(Farsi)

Hmong (Hmong)

(Arabic)

Polski (Polish)

(TTY 711)

12012019

Category Listing

Analgesics

Tier 1 BvD

Analgesics

Anesthetics

Tier 1

Anesthetics

Tier 1 PA

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 2

Tier 1

Tier 1 PA

Tier 1

Antibacterials

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1 BvD

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 2 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

SSD 1 CREAM Tier 1

Tier 1

Anticonvulsants

Tier 2

Tier 1

Tier 2 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Antidementia Agents

Antidepressants

Tier 1

Tier 2 PA

Antidepressants

Tier 2 PA

Antiemetics

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Antifungals

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Antifungals

Tier 1

Tier 1 PA

Antigout Agents

Antimigraine Agents

Tier 1 PA

Tier 2

Antimycobacterials

Tier 1

Tier 2

Tier 1

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 2 BvD

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Antiparasitics

Tier 1

Antiparasitics

Antipsychotics

Tier 1 PA

Tier 1

Antipsychotics

Tier 2 PA

Antipsychotics

Tier 2 PA

Antipsychotics

Antivirals

Tier 2

Antivirals

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antivirals

Anxiolytics

Bipolar Agents

Tier 1

Tier 1 PA

Tier 2

Tier 1 BvD

Tier 2 PA

Tier 1

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 2 PA

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

IPOL VIAL Tier 2

Tier 2

PROQUAD VIAL Tier 2

Tier 2

Tier 2 BvD

Tier 2

TDVAX VIAL Tier 2

Tier 2

Tier 1

Tier 1 BvD

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Otic Agents

Tier 1

Otic Agents

Tier 1

Tier 2 PA LA

Uncategorized

Analgesics

Tier 3 NPD

Antifungals

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Non-Part D Drugs

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

HHAEGARDA 92

SSAIZEN 85

SYPRINE 76

Mailing Address

Fax Number 1-323-889-2228

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

English

한국어 (Korean)

Italiano (Italian)

(Farsi)

Hmong (Hmong)

(Arabic)

Polski (Polish)

(TTY 711)

12012019

Category Listing

Analgesics

Tier 1 BvD

Analgesics

Anesthetics

Tier 1

Anesthetics

Tier 1 PA

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 2

Tier 1

Tier 1 PA

Tier 1

Antibacterials

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 1

Antibacterials

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1 BvD

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 2 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

Tier 2 BvD

Tier 1

Tier 1 BvD

Antibacterials

Tier 1

SSD 1 CREAM Tier 1

Tier 1

Anticonvulsants

Tier 2

Tier 1

Tier 2 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Tier 1 PA

Anticonvulsants

Antidementia Agents

Antidepressants

Tier 1

Tier 2 PA

Antidepressants

Tier 2 PA

Antiemetics

Tier 1 PA

Tier 1

Tier 1 BvD

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Antifungals

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Antifungals

Tier 1

Tier 1 PA

Antigout Agents

Antimigraine Agents

Tier 1 PA

Tier 2

Antimycobacterials

Tier 1

Tier 2

Tier 1

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 2 BvD

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antineoplastics

Tier 2 PA

Antineoplastics

Antiparasitics

Tier 1

Antiparasitics

Antipsychotics

Tier 1 PA

Tier 1

Antipsychotics

Tier 2 PA

Antipsychotics

Tier 2 PA

Antipsychotics

Antivirals

Tier 2

Antivirals

Tier 2 PA

Tier 1 PA

Tier 2 PA

Antivirals

Anxiolytics

Bipolar Agents

Tier 1

Tier 1 PA

Tier 2

Tier 1 BvD

Tier 2 PA

Tier 1

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 BvD

Tier 1 BvD

Tier 2 BvD

Tier 1

Tier 2 PA

Tier 1 PA

Tier 1

Tier 1 PA

Tier 1

Tier 2 PA

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 BvD

Tier 1

Tier 1 PA

Tier 2 PA

Tier 1 BvD

Tier 2 PA

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

IPOL VIAL Tier 2

Tier 2

PROQUAD VIAL Tier 2

Tier 2

Tier 2 BvD

Tier 2

TDVAX VIAL Tier 2

Tier 2

Tier 1

Tier 1 BvD

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Ophthalmic Agents

Tier 1

Otic Agents

Tier 1

Otic Agents

Tier 1

Tier 2 PA LA

Uncategorized

Analgesics

Tier 3 NPD

Antifungals

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Non-Part D Drugs

Tier 3 PA NPD

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

Non-Part D Drugs

Tier 3 NPD

Tier 3 PA NPD

Tier 3 NPD

HHAEGARDA 92

SSAIZEN 85

SYPRINE 76

Mailing Address

Fax Number 1-323-889-2228

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

English

한국어 (Korean)

Italiano (Italian)

(Farsi)

Hmong (Hmong)

(Arabic)

Polski (Polish)

(TTY 711)

12012019

Category Listing

Documents

2019 Formulary (List of Covered Drugs)