2019 List of Covered Drugs (Formulary) · 2018. 9. 28. · H2419, H5703_4184_FINAL_4259_C Formulary ID 19426 Version 4. Effective Date: 01/01/2019. SCHA Member Services 1-866-567-7242,

2019 List of Covered Drugs (Formulary) SeniorCare Complete (HMO SNP) & AbilityCare (HMO SNP)

IntroductionThis document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter (OTC) drugs are covered by SeniorCare Complete and AbilityCare. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by SeniorCare Complete and AbilityCare. Key terms and their de initions appear in the last chapter of the Member Handbook or Evidence of Coverage.

This List of Covered Drugs was updated on 08/2018. For more recent information or other questions, please call South Country Health Alliance Member Services at 1-866-567-7242, TTY users call 1-800-627-3529 or 711. Hours of Operation: October – March, 7 days a week, 8 a.m. – 8 p.m., April – September, Monday – Friday, 8 a.m. – 8 p.m.

H2419, H5703_4184_FINAL_4259_C Formulary ID 19426 Version 4

Effective Date: 01/01/2019

SCHA Member Services 1-866-567-7242, TTY 1-800-627-3529 or 711

CB5 MCOs 3-18

Civil Rights Notice

Discrimination is against the law. South Country Health Alliance (SCHA) does not discriminate on the basis of any of the following:

• race• color• national origin• creed• religion• sexual orientation• public assistance status• age

• disability (includingphysical or mentalimpairment)

• sex (including sexstereotypes and genderidentity)

• marital status• political beliefs

• medical condition• health status• receipt of health care

services• claims experience• medical history• genetic information

Auxiliary Aids and Services: SCHA provides auxiliary aids and services, like qualified interpreters or information in accessible formats, free of charge and in a timely manner to ensure an equal opportunity to participate in our health care programs. Contact SCHA Member Services at [email protected] or call 1-866-567-7242 (toll free), TTY 1-800-627-3529 or 711.

Language Assistance Services: SCHA provides translated documents and spoken language interpreting, free of charge and in a timely manner, when language assistance services are necessary to ensure limited English speakers have meaningful access to our information and services. Contact SCHA Member Services at [email protected] or call 1-866-567-7242 (toll free), TTY 1-800-627-3529 or 711.

Civil Rights ComplaintsYou have the right to file a discrimination complaint if you believe you were treated in a discriminatory way by SCHA. You may contact any of the following four agencies directly to file a discrimination complaint.

U.S. Department of Health and Human Services’ Office for Civil Rights (OCR)You have the right to file a complaint with the OCR, a federal agency, if you believe you have been discriminated against because of any of the following:

• race• color• national origin

• age• disability• sex

Contact the OCR directly to file a complaint:DirectorU.S. Department of Health and Human Services’ Office for Civil Rights200 Independence Avenue SWRoom 509FHHH BuildingWashington, DC 20201800-368-1019 (voice)800-537-7697 (TDD)Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Minnesota Department of Human Rights (MDHR)In Minnesota, you have the right to file a complaint with the MDHR if you believe you have been discriminated against because of any of the following:

• race• color• national origin• religion

• creed• sex• sexual orientation• marital status

• public assistance status• disability

Contact the MDHR directly to file a complaint:Minnesota Department of Human RightsFreeman Building, 625 North Robert StreetSt. Paul, MN 55155651-539-1100 (voice)800-657-3704 (toll free)711 or 800-627-3529 (MN Relay)651-296-9042 (fax)[email protected] (email)

Minnesota Department of Human Services (DHS)You have the right to file a complaint with DHS if you believe you have been discriminated against in our health care programs because of any of the following:

• race• color• national origin• creed• religion• sexual orientation• public assistance status• age

Complaints must be in writing and filed within 180 days of the date you discovered the alleged discrimination. The complaint must contain your name and address and describe the discrimination you are complaining about. After we get your complaint, we will review it and notify you in writing about whether we have authority to investigate. If we do, we will investigate the complaint.

DHS will notify you in writing of the investigation’s outcome. You have the right to appeal the outcome if you disagree with the decision. To appeal, you must send a written request to have DHS review the investigation outcome. Be brief and state why you disagree with the decision. Include additional information you think is important.

If you file a complaint in this way, the people who work for the agency named in the complaint cannot retaliate against you. This means they cannot punish you in any way for filing a complaint. Filing a complaint in this way does not stop you from seeking out other legal or administrative actions.

Contact DHS directly to file a discrimination complaint:Civil Rights CoordinatorMinnesota Department of Human ServicesEqual Opportunity and Access DivisionP.O. Box 64997St. Paul, MN 55164-0997651-431-3040 (voice) or use your preferred relay service

• disability (including physicalor mental impairment)

• sex (including sexstereotypes and genderidentity)

• marital status• political beliefs• medical condition

• health status• receipt of health care

services• claims experience• medical history• genetic information

SCHA Complaint Notice

You have the right to file a complaint with SCHA if you believe you have been discriminated against because of any of the following:

• medical condition• health status• receipt of health care services• claims experience• medical history• genetic information• disability (including mental or physical

impairment)• marital status• age

• sex (including sex stereotypes and genderidentity)

• sexual orientation• national origin• race• color• religion• creed• public assistance status• political beliefs

You can file a complaint and ask for help in filing a complaint in person or by mail, phone, fax, or email at:

Attn: Civil Rights CoordinatorSouth Country Health Alliance2300 Park Drive, Suite 100Owatonna, MN 55060Toll Free: 866-567-7242TTY: 800-627-3529 or 711Fax: 507-444-7774Email: [email protected]

American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral.

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If you have questions, please call South Country Health Alliance Member Services at 1-866-567-7242, TTY users call 1-800-627-3529 or 711. Hours of Operation: October – March, 7 days a week, 8 a.m. – 8 p.m., April – September, Monday – Friday, 8 a.m. – 8 p.m. The call is free. For more information, visit www.mnscha.org.

Table of ContentsA. Disclaimers .........................................................................................................................2

B. Frequently Asked Questions (FAQ) ....................................................................................2B1. What prescription drugs are on the List of Covered Drugs? (We call the List

of Covered Drugs the “Drug List” for short.)...........................................................2B2. Does the Drug List ever change? ...................................................................................2B3. What happens when there is a change to the Drug List? ...............................................3B4. Are there any restrictions or limits on drug coverage or any required actions to

take to get certain drugs? ......................................................................................4B5. How will you know if the drug you want has limitations or if there are any actions

required to get the drug?........................................................................................5B6. What happens if we change our rules about how we cover some drugs prior

authorization, quantity limits, and/or step therapy restrictions)? ............................5B7. How can you find a drug on the Drug List? ....................................................................5B8. What if the drug you want to take is not on the Drug List? .............................................5B9. What if you are a new SeniorCare Complete and AbilityCare member and can’t

find your drug on the Drug List or have a problem getting your drug? ..................6B10. Can you ask for an exception to cover your drug? .......................................................6B11. How can you ask for an exception? ..............................................................................6B12. How long does it take to get an exception? ..................................................................7B13. What are generic drugs? ..............................................................................................7B14. What are over-the-counter (OTC) drugs? ....................................................................7B15. Does SeniorCare Complete and AbilityCare cover non-drug OTC products? .............7B16. Can I get my drugs through ? ...................................7B17. What is your copay? .....................................................................................................7

C. Overview of the List of Covered Drugs ..............................................................................8C1. List of Drugs by Drug Type ............................................................................................8

D. Index of Covered Drugs .....................................................................................................74

E. List of Over-The-Counter (OTC) Drugs by Drug Type .....................................................83

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A. Disclaimers

SeniorCare Complete (HMO SNP) and AbilityCare (HMO SNP) are health plans that contract with bothMedicare and the Minnesota Medical Assistance (Medicaid) programs to provide benefits of both programsto enrollees. Enrollment in SeniorCare Complete and AbilityCare depends on contract renewal.

You can always check SeniorCare Complete’s and AbilityCare’s up-to-date List of Covered Drugs online atwww.mnscha.org or call Member Services at the number listed at the bottom of this page.

You can get this document for free in other formats, such as large print, braille, or audio. Call MemberServices at the number listed at the bottom of this page.

To make a standing request to get materials, now and in the future, in a language other than English or inan alternate format, call SeniorCare Complete Member Services at the number at the bottom of this page.

B. Frequently Asked Questions (FAQ)

Find answers 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 “Drug List” for short.)

The drugs on the Drug List that starts on page 9 are the drugs covered by SeniorCare Complete and Ability-Care. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

● SeniorCare Complete and AbilityCare 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 SeniorCare Complete and AbilityCare network pharmacy.

○ SeniorCare Complete and AbilityCare may have additional steps to access certain drugs. Seequestion B4 for more information.

You can also see an up-to-date list of drugs we cover on our website at www.mnscha.org or call Member Services at the number listed at the bottom of this page.

B2. Does the Drug List ever change?

Yes. SeniorCare Complete and AbilityCare may add or remove drugs on the Drug List during the year.

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

● Decide to require or not require prior authorization for a drug. (Prior authorization is permission fromSeniorCare Complete and AbilityCare before you can get a drug.)

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

● Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug beforewe will cover another drug.)

For more information on these drug rules, see question B4.

If you are taking a drug that is not 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:

● a new, cheaper drug comes along that works as well as a drug on the Drug List now, or● we learn that a drug is not safe, or● a drug is removed from the market.

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

● You can always check SeniorCare Complete and AbilityCare’s current Drug List online atwww.mnscha.org.

● You can also call Member Services at the number listed at the bottom of this page to check the currentDrug List.

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

Some changes to the Drug List will happen immediately. For example:● A new generic drug becomes available. Sometimes, a new and cheaper drug comes along that

works as well as a drug on the Drug List now. When that happens, we may remove the current drug,but your cost for the new drug will stay the same or will be lower. When we add the new generic drug,we may also decide to keep the current drug on the list but change its coverage rules or limits.

○ We may not tell you before we make this change, but we will send you information about thespecific change or changes we made.

○ You or your provider can ask for an exception from these changes. We will send you a notice withthe steps you can take to ask for an exception. Please see questions B10-B12 for more informationon exceptions.

● A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are takingis not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If youare taking the drug, we will let you know. We will also send you a letter telling you that. Show the letterto your doctor or other prescriber and ask them about your next steps.

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:

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

● We add a generic drug that is not new to the market and○ Replace a brand name drug currently on the Drug List or

○ Change the coverage rules or limits for the brand name drug.

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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:

● Get a [insert supply limit 30-day supply of the drug before the change to the Drug List is made, or

● Ask for an exception from these changes. Please see questions B10-B12 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, your doc-tor, or other prescriber must do something before you can get the drug. For example:

● Prior authorization: For some drugs, you, your doctor, or other prescriber must get authorizationfrom SeniorCare Complete and AbilityCare before you fill your prescription. Prior authorization meansan approval from SeniorCare Complete and AbilityCare to seek services outside of our network or toget services not routinely covered by our network before you get the services. Prior authorization isdifferent from a referral. SeniorCare Complete and AbilityCare may not cover the drug if you do not getauthorization.

● Quantity limits: Sometimes SeniorCare Complete and AbilityCare limits the amount of a drug you canget.

● Step therapy: Sometimes SeniorCare Complete and AbilityCare requires you to do step therapy. Thismeans you will have to try drugs in a certain order for your medical condition. You might have to try onedrug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn’twork 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 9-60. You can also get more information by visiting our website at www.mnscha.org. We have posted online documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy.

You can ask for an exception to 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 any actions required to get the drug?

The Drug List on page 9 has a column labeled “Necessary actions, restrictions, or limits on use.”

B6. What happens if we change our rules about how we cover some drugs prior authorization, quantity limits, and/or step therapy restrictions)?

In some cases, we will tell you in advance if we add or change prior authorization, quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change.

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B7. How can you find a drug on the Drug List?

There are two ways to find a drug:

● You can search alphabetically (if you know how to spell the drug), or● You can search by drug type.

To search alphabetically, go to the Index of Covered Drugs section. You can find it on page 61. The Index of Covered Drugs is an alphabetical list of all of the drugs included in the Drug List. Both brand name drugs and generic drugs are listed in the index.

To search by drug type, find the section labeled “List of Drugs by Drug Type” on page 9. The drugs in this sec-tion are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the “Antimigraine Agents” category. That is where you will find drugs that treat migraines.

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

If you don’t see your drug on the Drug List, call Member Services at the number listed at the bottom of this page and ask about it. If you learn that SeniorCare Complete and AbilityCare will not cover the drug, you can do one of these things:

● Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctoror other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want totake. Or

● You can ask the health plan to make an exception to cover your drug. See questions B10-B12 for moreinformation about exceptions.

B9. What if you are a new SeniorCare Complete and AbilityCare member and can’t 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 first 90 days you are a member of SeniorCare Complete and AbilityCare. 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:

● you are taking a drug that is not on our Drug List, or● health plan rules do not let you get the amount ordered by your prescriber, or● the drug requires prior authorization by SeniorCare Complete and AbilityCare, or● you are taking a drug that is part of a step therapy restriction.

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:

● 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 SeniorCare Complete and AbilityCare member.

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● This is in addition to the temporary supply during the first 90 days you are a member of SeniorCareComplete and AbilityCare.

South Country Health Alliance will not apply early refill edits that would limit appropriate and necessary actions to Part D Drugs by enrollees who experience a Level of Care Change. These enrollees will be allowed to obtain a refill of their prescription(s) upon admission to or discharge from a LTC facility.

B10. Can you ask for an exception to cover your drug?

Yes. You can ask SeniorCare Complete and AbilityCare 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.

● For example, SeniorCare Complete and AbilityCare may limit the amount of a drug we will cover. If yourdrug has a limit, you can ask us to change the limit and cover more.

● Other examples: You can ask us to drop step therapy restrictions or prior authorization requirements.

B11. How can you ask for an exception?

To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9 of the Member Handbook or Evidence of Coverage 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 prescriber’s supporting statement.

B13. What are generic drugs?

Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).

SeniorCare Complete and AbilityCare covers both brand name drugs and generic drugs.

B14. What are over-the-counter (OTC) drugs?

OTC stands for “over-the-counter.” SeniorCare Complete and AbilityCare offers some OTC drugs through Medical Assistance (Medicaid) at no cost to you. You need a prescription for OTC drugs to be covered. These OTC drugs are listed in this Drug List starting on page 73.

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B15. Does SeniorCare Complete and AbilityCare cover non-drug OTC products?

SeniorCare Complete and AbilityCare covers some non-drug OTC products through Medical Assistance (Med-icaid). These non-drug OTC products are listed in this Drug List starting on page 73.

Examples of OTC non-drug products include Diafoods Thick-It oral powder and DuoDERM dressings.

B16. Can I get my drugs through Long-Term Supply?

We offer a way to get a long-term supply of “maintenance” drugs on our plan’s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.)

For more information about getting drugs for a long-term supply, please call Member Services at the number listed at the bottom of this page.

B17. What is your copay?

You can read the SeniorCare Complete and AbilityCare Drug List to learn about the copay for each drug.

A copay is an amount you may be required to pay as your share of the cost of a prescription drug. A copay is usually a set amount, rather than a percentage. For example, you might pay $0 to $8.50 for a prescription drug.

SeniorCare Complete and AbilityCare 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.

The Drug List includes copays listed by tiers.

● Tier 1 Generic drugs have the lowest copay. The copay is from $0 to $3.40, depending on your incomeand level of Medical Assistance (Medicaid) eligibility.

● Tier 1 Brand drugs have a higher copay. The copay is from $0 to $8.50, depending on your income andlevel of Medical Assistance (Medicaid) eligibility.

● OTCs have a $0 copay.

If you have questions, call Member Services at the number at the bottom of this page. We can help you under-stand what your copays will be.

C. Overview of the List of Covered DrugsThe List of Covered Drugs gives you information about the drugs covered by SeniorCare Complete and Abili-tyCare. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 61. The index alphabetically lists all drugs covered by SeniorCare Complete and AbilityCare.

C1. List of Drugs by Drug Type

The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the “Antimigraine Agents” category. That is where you will find drugs that treat migraines.

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Here are the meanings of the codes used in the “Necessary actions, restrictions, or limits on use” column:

B/D = This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

QL = Quantity Limit. For certain drugs, SeniorCare Complete and AbilityCare limits the amount of the drug that we will cover. For example, the plan provides twelve tablets per 30-day supply.

ST = Step Therapy. In some cases, SeniorCare Complete and AbilityCare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For ex-ample, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.

PA = Prior Authorization. SeniorCare Complete and AbilityCare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don’t get approval, the plan may not cover the drug.

LA = Limited Availability. This prescription may be available only at certain pharmacies. For more informa-tion, please contact Member Services at the number listed at the bottom of this page.

The first column of the table lists the name of the drug. Generic drugs are listed in lower-case italics (e.g., warfarin), brand name drugs are capitalized (e.g., COUMADIN), and OTC drugs and products are listed in lower case (e.g., aspirin). The information in the “Necessary actions, restrictions, or limits on use” column tells you if SeniorCare Complete and AbilityCare has any rules for covering your drug.

LIST OF DRUGS BY DRUG TYPE

You can find information on what the symbols and abbreviations in this table mean by going to page 8. 9

Name of drug What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

ANALGESICS ANALGESICS, OTHER acetaminophen-codeine oral solution 120-12 mg/5 ml $0-$3.40 (Tier 1-Generic) acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg

$0-$3.40 (Tier 1-Generic)

ascomp with codeine oral capsule 30-50-325-40 mg $0-$3.40 (Tier 1-Generic) PA butalbital compound w/codeine oral capsule 30-50-325-40 mg $0-$3.40 (Tier 1-Generic) PA butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg $0-$3.40 (Tier 1-Generic) PA butalbital-acetaminophen oral tablet 50-325 mg $0-$3.40 (Tier 1-Generic) PA butalbital-acetaminophen-caff oral capsule 50-325-40 mg $0-$3.40 (Tier 1-Generic) PA butalbital-acetaminophen-caff oral tablet 50-325-40 mg $0-$3.40 (Tier 1-Generic) PA butalbital-aspirin-caffeine oral capsule 50-325-40 mg $0-$3.40 (Tier 1-Generic) PA carisoprodol-asa-codeine oral tablet 200-325-16 mg $0-$3.40 (Tier 1-Generic) PA carisoprodol-aspirin oral tablet 200-325 mg $0-$3.40 (Tier 1-Generic) PA hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg


hydrocodone-ibuprofen oral tablet 10-200 mg, 7.5-200 mg $0-$3.40 (Tier 1-Generic) IBU ORAL TABLET 600 MG, 800 MG $0-$3.40 (Tier 1-Generic) ibuprofen-oxycodone oral tablet 400-5 mg $0-$3.40 (Tier 1-Generic) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg


oxycodone-aspirin oral tablet 4.8355-325 mg $0-$3.40 (Tier 1-Generic) pentazocine-naloxone oral tablet 50-0.5 mg $0-$3.40 (Tier 1-Generic) PA tramadol-acetaminophen oral tablet 37.5-325 mg $0-$3.40 (Tier 1-Generic) NONSTEROIDAL ANTI-INFLAMMATORY DRUGS celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg $0-$3.40 (Tier 1-Generic)

diclofenac potassium oral tablet 50 mg $0-$3.40 (Tier 1-Generic) diclofenac sodium oral tablet extended release 24 hr 100 mg $0-$3.40 (Tier 1-Generic) diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg


diflunisal oral tablet 500 mg $0-$3.40 (Tier 1-Generic) etodolac oral capsule 200 mg, 300 mg $0-$3.40 (Tier 1-Generic) etodolac oral tablet 400 mg, 500 mg $0-$3.40 (Tier 1-Generic) etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg


flurbiprofen oral tablet 100 mg, 50 mg $0-$3.40 (Tier 1-Generic) hydrocodone-ibuprofen oral tablet 5-200 mg $0-$3.40 (Tier 1-Generic) ibuprofen oral suspension 100 mg/5 ml $0-$3.40 (Tier 1-Generic) ibuprofen oral tablet 400 mg, 600 mg, 800 mg $0-$3.40 (Tier 1-Generic) indomethacin oral capsule 25 mg, 50 mg $0-$3.40 (Tier 1-Generic) PA indomethacin oral capsule, extended release 75 mg $0-$3.40 (Tier 1-Generic) PA ketoprofen oral capsule 75 mg $0-$3.40 (Tier 1-Generic) ketorolac oral tablet 10 mg $0-$3.40 (Tier 1-Generic) PA; QL (20 EA per 30 days) meclofenamate oral capsule 100 mg, 50 mg $0-$3.40 (Tier 1-Generic) meloxicam oral tablet 15 mg, 7.5 mg $0-$3.40 (Tier 1-Generic) nabumetone oral tablet 500 mg, 750 mg $0-$3.40 (Tier 1-Generic) naproxen oral suspension 125 mg/5 ml $0-$3.40 (Tier 1-Generic) naproxen oral tablet 250 mg, 375 mg, 500 mg $0-$3.40 (Tier 1-Generic)





naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg $0-$3.40 (Tier 1-Generic) naproxen sodium oral tablet 275 mg, 550 mg $0-$3.40 (Tier 1-Generic) piroxicam oral capsule 10 mg, 20 mg $0-$3.40 (Tier 1-Generic) sulindac oral tablet 150 mg, 200 mg $0-$3.40 (Tier 1-Generic) OPIOID ANALGESICS, LONG-ACTING buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour

$0-$3.40 (Tier 1-Generic) QL (4 EA per 28 days)

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour


methadone oral solution 10 mg/5 ml $0-$3.40 (Tier 1-Generic) QL (1200 ML per 30 days) methadone oral solution 5 mg/5 ml $0-$3.40 (Tier 1-Generic) QL (2400 ML per 30 days) methadone oral tablet 10 mg $0-$3.40 (Tier 1-Generic) QL (240 EA per 30 days) methadone oral tablet 5 mg $0-$3.40 (Tier 1-Generic) QL (180 EA per 30 days) morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg


oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg

$0-$3.40 (Tier 1-Generic) PA

OPIOID ANALGESICS, SHORT-ACTING butorphanol tartrate nasal spray,non-aerosol 10 mg/ml $0-$3.40 (Tier 1-Generic) QL (5 ML per 30 days) duramorph (pf) injection solution 0.5 mg/ml, 1 mg/ml $0-$3.40 (Tier 1-Generic) B/D fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

$0-$3.40 (Tier 1-Generic) PA; QL (120 EA per 30 days)

hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml


hydromorphone injection syringe 2 mg/ml $0-$3.40 (Tier 1-Generic) hydromorphone oral tablet 2 mg, 4 mg, 8 mg $0-$3.40 (Tier 1-Generic) QL (120 EA per 30 days) LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY

$0-$8.50 (Tier 1-Brand) PA; QL (600 EA per 30 days)

LAZANDA NASAL SPRAY,NON-AEROSOL 300 MCG/SPRAY, 400 MCG/SPRAY

$0-$8.50 (Tier 1-Brand) PA; QL (150 EA per 30 days)

meperidine oral solution 50 mg/5 ml $0-$3.40 (Tier 1-Generic) PA; QL (900 ML per 30 days) meperidine oral tablet 100 mg, 50 mg $0-$3.40 (Tier 1-Generic) PA; QL (180 EA per 30 days) morphine oral tablet 15 mg, 30 mg $0-$3.40 (Tier 1-Generic) QL (120 EA per 30 days) oxycodone oral solution 5 mg/5 ml $0-$3.40 (Tier 1-Generic) QL (5400 ML per 30 days) oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg $0-$3.40 (Tier 1-Generic) QL (120 EA per 30 days) tramadol oral tablet 50 mg $0-$3.40 (Tier 1-Generic) QL (240 EA per 30 days) ANESTHETICS LOCAL ANESTHETICS diclofenac sodium topical gel 1 % $0-$3.40 (Tier 1-Generic) lidocaine hcl mucous membrane jelly 2 % $0-$3.40 (Tier 1-Generic) lidocaine hcl mucous membrane solution 4 % (40 mg/ml) $0-$3.40 (Tier 1-Generic) lidocaine topical adhesive patch,medicated 5 % $0-$3.40 (Tier 1-Generic) PA; QL (90 EA per 30 days) lidocaine topical ointment 5 % $0-$3.40 (Tier 1-Generic) lidocaine-prilocaine topical cream 2.5-2.5 % $0-$3.40 (Tier 1-Generic) ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ ANTI-CRAVING acamprosate oral tablet,delayed release (dr/ec) 333 mg $0-$3.40 (Tier 1-Generic) disulfiram oral tablet 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) OPIOID DEPENDENCE TREATMENTS buprenorphine hcl sublingual tablet 2 mg, 8 mg $0-$3.40 (Tier 1-Generic)





buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg $0-$3.40 (Tier 1-Generic) naltrexone oral tablet 50 mg $0-$3.40 (Tier 1-Generic) OPIOID REVERSAL AGENTS naloxone injection solution 0.4 mg/ml $0-$3.40 (Tier 1-Generic) naloxone injection syringe 0.4 mg/ml, 1 mg/ml $0-$3.40 (Tier 1-Generic) NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

$0-$8.50 (Tier 1-Brand)

SMOKING CESSATION AGENTS bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg


CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG $0-$8.50 (Tier 1-Brand) QL (336 EA per 365 days) CHANTIX ORAL TABLET 0.5 MG, 1 MG $0-$8.50 (Tier 1-Brand) QL (336 EA per 365 days) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)

$0-$8.50 (Tier 1-Brand) QL (106 EA per 365 days)

NICOTROL INHALATION CARTRIDGE 10 MG $0-$8.50 (Tier 1-Brand) NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML $0-$8.50 (Tier 1-Brand) ANTIBACTERIALS AMINOGLYCOSIDES amikacin injection solution 500 mg/2 ml $0-$3.40 (Tier 1-Generic) gentak ophthalmic (eye) ointment 0.3 % (3 mg/gram) $0-$3.40 (Tier 1-Generic) gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml


gentamicin injection solution 40 mg/ml $0-$3.40 (Tier 1-Generic) gentamicin ophthalmic (eye) drops 0.3 % $0-$3.40 (Tier 1-Generic) gentamicin topical cream 0.1 % $0-$3.40 (Tier 1-Generic) gentamicin topical ointment 0.1 % $0-$3.40 (Tier 1-Generic) neomycin oral tablet 500 mg $0-$3.40 (Tier 1-Generic) paromomycin oral capsule 250 mg $0-$3.40 (Tier 1-Generic) streptomycin intramuscular recon soln 1 gram $0-$3.40 (Tier 1-Generic) TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 % $0-$8.50 (Tier 1-Brand) tobramycin ophthalmic (eye) drops 0.3 % $0-$3.40 (Tier 1-Generic) tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml $0-$3.40 (Tier 1-Generic) tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 %


ANTIBACTERIALS, OTHER acetic acid otic (ear) solution 2 % $0-$3.40 (Tier 1-Generic) bacitracin ophthalmic (eye) ointment 500 unit/gram $0-$3.40 (Tier 1-Generic) bacitracin-polymyxin b ophthalmic (eye) ointment 500-10,000 unit/gram


BACTROBAN NASAL NASAL OINTMENT 2 % $0-$8.50 (Tier 1-Brand) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg $0-$3.40 (Tier 1-Generic) clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml


clindamycin palmitate hcl oral recon soln 75 mg/5 ml $0-$3.40 (Tier 1-Generic) clindamycin phosphate injection solution 150 (mg/ml) (6 ml), 150 mg/ml


clindamycin phosphate intravenous solution 600 mg/4 ml $0-$3.40 (Tier 1-Generic) clindamycin phosphate topical gel 1 % $0-$3.40 (Tier 1-Generic) clindamycin phosphate topical lotion 1 % $0-$3.40 (Tier 1-Generic) clindamycin phosphate topical solution 1 % $0-$3.40 (Tier 1-Generic) clindamycin phosphate topical swab 1 % $0-$3.40 (Tier 1-Generic)





clindamycin phosphate vaginal cream 2 % $0-$3.40 (Tier 1-Generic) colistin (colistimethate na) injection recon soln 150 mg $0-$3.40 (Tier 1-Generic) daptomycin intravenous recon soln 500 mg $0-$3.40 (Tier 1-Generic) PA linezolid in dextrose 5% intravenous piggyback 600 mg/300 ml $0-$3.40 (Tier 1-Generic) B/D linezolid oral suspension for reconstitution 100 mg/5 ml $0-$3.40 (Tier 1-Generic) linezolid oral tablet 600 mg $0-$3.40 (Tier 1-Generic) methenamine hippurate oral tablet 1 gram $0-$3.40 (Tier 1-Generic) metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml


metronidazole oral capsule 375 mg $0-$3.40 (Tier 1-Generic) metronidazole oral tablet 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) metronidazole topical cream 0.75 % $0-$3.40 (Tier 1-Generic) metronidazole topical gel 0.75 %, 1 % $0-$3.40 (Tier 1-Generic) metronidazole topical lotion 0.75 % $0-$3.40 (Tier 1-Generic) metronidazole vaginal gel 0.75 % $0-$3.40 (Tier 1-Generic) mupirocin topical ointment 2 % $0-$3.40 (Tier 1-Generic) neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 3.5-400-10,000 mg-unit/g-1%


neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g


neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 %


neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 %


neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml


neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-10,000-10 mg-unit-mg/ml


nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg


nitrofurantoin monohyd/m-cryst oral capsule 100 mg $0-$3.40 (Tier 1-Generic) QL (180 EA per 365 days) polymyxin b sulfate injection recon soln 500,000 unit $0-$3.40 (Tier 1-Generic) polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml


tinidazole oral tablet 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) trimethoprim oral tablet 100 mg $0-$3.40 (Tier 1-Generic) vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg

$0-$3.40 (Tier 1-Generic) B/D

vancomycin oral capsule 125 mg, 250 mg $0-$3.40 (Tier 1-Generic) BETA-LACTAM, CEPHALOSPORINS cefaclor oral capsule 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) cefaclor oral tablet extended release 12 hr 500 mg $0-$3.40 (Tier 1-Generic) cefadroxil oral capsule 500 mg $0-$3.40 (Tier 1-Generic) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml


cefadroxil oral tablet 1 gram $0-$3.40 (Tier 1-Generic) cefazolin injection recon soln 1 gram, 500 mg $0-$3.40 (Tier 1-Generic) cefdinir oral capsule 300 mg $0-$3.40 (Tier 1-Generic) cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml


cefepime injection recon soln 1 gram, 2 gram $0-$3.40 (Tier 1-Generic)





cefotaxime injection recon soln 1 gram, 2 gram, 500 mg $0-$3.40 (Tier 1-Generic) cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram $0-$3.40 (Tier 1-Generic) cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml


cefpodoxime oral tablet 100 mg, 200 mg $0-$3.40 (Tier 1-Generic) cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml


cefprozil oral tablet 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) ceftazidime injection recon soln 1 gram, 2 gram, 6 gram $0-$3.40 (Tier 1-Generic) ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg


cefuroxime axetil oral tablet 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) cefuroxime sodium injection recon soln 750 mg $0-$3.40 (Tier 1-Generic) cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram $0-$3.40 (Tier 1-Generic) cephalexin oral capsule 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml


cephalexin oral tablet 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) SUPRAX ORAL CAPSULE 400 MG $0-$8.50 (Tier 1-Brand) TAZICEF INJECTION RECON SOLN 1 GRAM, 2 GRAM, 6 GRAM


TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG $0-$8.50 (Tier 1-Brand) PA BETA-LACTAM, OTHER aztreonam injection recon soln 1 gram $0-$3.40 (Tier 1-Generic) doripenem intravenous recon soln 500 mg $0-$3.40 (Tier 1-Generic) PA imipenem-cilastatin intravenous recon soln 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) B/D INVANZ INJECTION RECON SOLN 1 GRAM $0-$8.50 (Tier 1-Brand) PA meropenem intravenous recon soln 1 gram, 500 mg $0-$3.40 (Tier 1-Generic) VABOMERE INTRAVENOUS RECON SOLN 2 GRAM $0-$8.50 (Tier 1-Brand) PA BETA-LACTAM, PENICILLINS amoxicillin oral capsule 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml


amoxicillin oral tablet 500 mg, 875 mg $0-$3.40 (Tier 1-Generic) amoxicillin oral tablet,chewable 125 mg, 250 mg $0-$3.40 (Tier 1-Generic) amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml


amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg


amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg


amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 mg


ampicillin oral capsule 500 mg $0-$3.40 (Tier 1-Generic) ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg


ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram


BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML

$0-$8.50 (Tier 1-Brand)





dicloxacillin oral capsule 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) nafcillin injection recon soln 1 gram $0-$3.40 (Tier 1-Generic) penicillin g procaine intramuscular syringe 1.2 million unit/2 ml $0-$3.40 (Tier 1-Generic) penicillin g sodium injection recon soln 5 million unit $0-$3.40 (Tier 1-Generic) penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml


penicillin v potassium oral tablet 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram


MACROLIDES azithromycin intravenous recon soln 500 mg $0-$3.40 (Tier 1-Generic) azithromycin oral packet 1 gram $0-$3.40 (Tier 1-Generic) azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml


azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg


clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml


clarithromycin oral tablet 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) clarithromycin oral tablet extended release 24 hr 500 mg $0-$3.40 (Tier 1-Generic) DIFICID ORAL TABLET 200 MG $0-$8.50 (Tier 1-Brand) PA ery pads topical swab 2 % $0-$3.40 (Tier 1-Generic) erythrocin (as stearate) oral tablet 250 mg $0-$3.40 (Tier 1-Generic) ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG $0-$8.50 (Tier 1-Brand) erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml


erythromycin ethylsuccinate oral tablet 400 mg $0-$3.40 (Tier 1-Generic) erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) $0-$3.40 (Tier 1-Generic) erythromycin oral tablet 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) erythromycin with ethanol topical gel 2 % $0-$3.40 (Tier 1-Generic) erythromycin with ethanol topical solution 2 % $0-$3.40 (Tier 1-Generic) QUINOLONES ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg


ciprofloxacin hcl ophthalmic (eye) drops 0.3 % $0-$3.40 (Tier 1-Generic) ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg $0-$3.40 (Tier 1-Generic) ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml


ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml


levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml


levofloxacin intravenous solution 25 mg/ml $0-$3.40 (Tier 1-Generic) levofloxacin oral solution 250 mg/10 ml $0-$3.40 (Tier 1-Generic) levofloxacin oral tablet 250 mg, 500 mg, 750 mg $0-$3.40 (Tier 1-Generic) moxifloxacin in nacl (iso-osm) intravenous piggyback 400 mg/250 ml


moxifloxacin ophthalmic (eye) drops 0.5 % $0-$3.40 (Tier 1-Generic) moxifloxacin oral tablet 400 mg $0-$3.40 (Tier 1-Generic) ofloxacin ophthalmic (eye) drops 0.3 % $0-$3.40 (Tier 1-Generic) ofloxacin oral tablet 300 mg, 400 mg $0-$3.40 (Tier 1-Generic)





SULFONAMIDES silver sulfadiazine topical cream 1 % $0-$3.40 (Tier 1-Generic) ssd topical cream 1 % $0-$3.40 (Tier 1-Generic) sulfacetamide sodium (acne) topical suspension 10 % $0-$3.40 (Tier 1-Generic) sulfacetamide sodium ophthalmic (eye) drops 10 % $0-$3.40 (Tier 1-Generic) sulfacetamide sodium ophthalmic (eye) ointment 10 % $0-$3.40 (Tier 1-Generic) sulfadiazine oral tablet 500 mg $0-$3.40 (Tier 1-Generic) sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml


sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg


TETRACYCLINES doxy-100 intravenous recon soln 100 mg $0-$3.40 (Tier 1-Generic) doxycycline hyclate oral capsule 100 mg, 50 mg $0-$3.40 (Tier 1-Generic) doxycycline hyclate oral tablet 100 mg, 20 mg $0-$3.40 (Tier 1-Generic) doxycycline monohydrate oral capsule 100 mg, 50 mg $0-$3.40 (Tier 1-Generic) doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg


minocycline oral capsule 100 mg, 50 mg, 75 mg $0-$3.40 (Tier 1-Generic) minocycline oral tablet 100 mg, 50 mg, 75 mg $0-$3.40 (Tier 1-Generic) morgidox oral capsule 50 mg $0-$3.40 (Tier 1-Generic) tetracycline oral capsule 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) ANTICONVULSANTS ANTICONVULSANTS, OTHER BRIVIACT ORAL SOLUTION 10 MG/ML $0-$8.50 (Tier 1-Brand) ST BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG

$0-$8.50 (Tier 1-Brand) ST

levetiracetam oral solution 100 mg/ml $0-$3.40 (Tier 1-Generic) levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg $0-$3.40 (Tier 1-Generic) levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg


ROWEEPRA ORAL TABLET 1,000 MG, 750 MG $0-$3.40 (Tier 1-Generic) roweepra oral tablet 500 mg $0-$3.40 (Tier 1-Generic) ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG


SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG

$0-$8.50 (Tier 1-Brand) ST; QL (60 EA per 30 days)

SPRITAM ORAL TABLET FOR SUSPENSION 750 MG $0-$8.50 (Tier 1-Brand) ST; QL (120 EA per 30 days) CALCIUM CHANNEL MODIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG $0-$8.50 (Tier 1-Brand) ethosuximide oral capsule 250 mg $0-$3.40 (Tier 1-Generic) ethosuximide oral solution 250 mg/5 ml $0-$3.40 (Tier 1-Generic) LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

$0-$8.50 (Tier 1-Brand)

LYRICA ORAL SOLUTION 20 MG/ML $0-$8.50 (Tier 1-Brand) zonisamide oral capsule 100 mg, 25 mg, 50 mg $0-$3.40 (Tier 1-Generic) GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG, 5-7.5-10 MG

$0-$8.50 (Tier 1-Brand)

DIASTAT RECTAL KIT 2.5 MG $0-$8.50 (Tier 1-Brand) divalproex oral capsule, delayed rel sprinkle 125 mg $0-$3.40 (Tier 1-Generic)





divalproex oral tablet extended release 24 hr 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg


gabapentin oral capsule 100 mg, 300 mg, 400 mg $0-$3.40 (Tier 1-Generic) gabapentin oral solution 250 mg/5 ml $0-$3.40 (Tier 1-Generic) gabapentin oral tablet 600 mg, 800 mg $0-$3.40 (Tier 1-Generic) ONFI ORAL SUSPENSION 2.5 MG/ML $0-$8.50 (Tier 1-Brand) PA; QL (480 ML per 30 days) ONFI ORAL TABLET 10 MG, 20 MG $0-$8.50 (Tier 1-Brand) PA; QL (60 EA per 30 days) phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) $0-$3.40 (Tier 1-Generic) PA phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg


primidone oral tablet 250 mg, 50 mg $0-$3.40 (Tier 1-Generic) SABRIL ORAL TABLET 500 MG $0-$8.50 (Tier 1-Brand) PA; QL (180 EA per 30 days) tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg $0-$3.40 (Tier 1-Generic) valproic acid (as sodium salt) oral solution 250 mg/5 ml $0-$3.40 (Tier 1-Generic) valproic acid oral capsule 250 mg $0-$3.40 (Tier 1-Generic) vigabatrin oral powder in packet 500 mg $0-$3.40 (Tier 1-Generic) PA GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 mg/5 ml $0-$3.40 (Tier 1-Generic) felbamate oral tablet 400 mg, 600 mg $0-$3.40 (Tier 1-Generic) FYCOMPA ORAL SUSPENSION 0.5 MG/ML $0-$8.50 (Tier 1-Brand) ST FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

$0-$8.50 (Tier 1-Brand) ST; QL (30 EA per 30 days)

lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg


lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg $0-$3.40 (Tier 1-Generic) topiramate oral capsule, sprinkle 15 mg, 25 mg $0-$3.40 (Tier 1-Generic) topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg $0-$3.40 (Tier 1-Generic) SODIUM CHANNEL AGENTS APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG $0-$8.50 (Tier 1-Brand) ST; QL (30 EA per 30 days) APTIOM ORAL TABLET 600 MG $0-$8.50 (Tier 1-Brand) ST; QL (60 EA per 30 days) BANZEL ORAL SUSPENSION 40 MG/ML $0-$8.50 (Tier 1-Brand) PA; QL (2400 ML per 30 days) BANZEL ORAL TABLET 200 MG, 400 MG $0-$8.50 (Tier 1-Brand) PA; QL (240 EA per 30 days) carbamazepine oral suspension 100 mg/5 ml $0-$3.40 (Tier 1-Generic) carbamazepine oral tablet 200 mg $0-$3.40 (Tier 1-Generic) carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg


carbamazepine oral tablet,chewable 100 mg $0-$3.40 (Tier 1-Generic) DILANTIN ORAL CAPSULE 30 MG $0-$8.50 (Tier 1-Brand) epitol oral tablet 200 mg $0-$3.40 (Tier 1-Generic) oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) $0-$3.40 (Tier 1-Generic) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg $0-$3.40 (Tier 1-Generic) PEGANONE ORAL TABLET 250 MG $0-$8.50 (Tier 1-Brand) PHENYTEK ORAL CAPSULE 200 MG, 300 MG $0-$8.50 (Tier 1-Brand) phenytoin oral suspension 125 mg/5 ml $0-$3.40 (Tier 1-Generic) phenytoin oral tablet,chewable 50 mg $0-$3.40 (Tier 1-Generic) phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg


VIMPAT ORAL SOLUTION 10 MG/ML $0-$8.50 (Tier 1-Brand) ST; QL (1200 ML per 30 days) VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG $0-$8.50 (Tier 1-Brand) ST; QL (60 EA per 30 days) ANTIDEMENTIA AGENTS





ANTIDEMENTIA AGENTS, OTHER ergoloid oral tablet 1 mg $0-$3.40 (Tier 1-Generic) PA CHOLINESTERASE INHIBITORS donepezil oral tablet 10 mg, 23 mg, 5 mg $0-$3.40 (Tier 1-Generic) donepezil oral tablet,disintegrating 10 mg, 5 mg $0-$3.40 (Tier 1-Generic) galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg


galantamine oral tablet 12 mg, 4 mg, 8 mg $0-$3.40 (Tier 1-Generic) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg $0-$3.40 (Tier 1-Generic) rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr


N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine oral capsule,sprinkle,er 24hr 14 mg, 21 mg, 28 mg, 7 mg


memantine oral tablet 10 mg, 5 mg $0-$3.40 (Tier 1-Generic) memantine oral tablets,dose pack 5-10 mg $0-$3.40 (Tier 1-Generic) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7-14-21-28 MG

$0-$8.50 (Tier 1-Brand)

ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER bupropion hcl oral tablet 100 mg, 75 mg $0-$3.40 (Tier 1-Generic) bupropion hcl oral tablet extended release 12 hr 100 mg, 150 mg, 200 mg


bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg


FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG

$0-$8.50 (Tier 1-Brand)

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg $0-$3.40 (Tier 1-Generic) mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg $0-$3.40 (Tier 1-Generic) nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg


perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg


trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg $0-$3.40 (Tier 1-Generic) MONOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR

$0-$8.50 (Tier 1-Brand)

MARPLAN ORAL TABLET 10 MG $0-$8.50 (Tier 1-Brand) phenelzine oral tablet 15 mg $0-$3.40 (Tier 1-Generic) tranylcypromine oral tablet 10 mg $0-$3.40 (Tier 1-Generic) SSRIS/ SNRIS citalopram oral solution 10 mg/5 ml $0-$3.40 (Tier 1-Generic) citalopram oral tablet 10 mg, 20 mg, 40 mg $0-$3.40 (Tier 1-Generic) desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg


escitalopram oxalate oral solution 5 mg/5 ml $0-$3.40 (Tier 1-Generic) escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg $0-$3.40 (Tier 1-Generic) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)


FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG






fluoxetine oral capsule 10 mg, 20 mg, 40 mg $0-$3.40 (Tier 1-Generic) fluoxetine oral capsule,delayed release(dr/ec) 90 mg $0-$3.40 (Tier 1-Generic) fluoxetine oral solution 20 mg/5 ml (4 mg/ml) $0-$3.40 (Tier 1-Generic) fluoxetine oral tablet 10 mg, 20 mg $0-$3.40 (Tier 1-Generic) fluvoxamine oral tablet 100 mg, 25 mg, 50 mg $0-$3.40 (Tier 1-Generic) maprotiline oral tablet 25 mg, 50 mg, 75 mg $0-$3.40 (Tier 1-Generic) paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg $0-$3.40 (Tier 1-Generic) paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg


PAXIL ORAL SUSPENSION 10 MG/5 ML $0-$8.50 (Tier 1-Brand) sertraline oral concentrate 20 mg/ml $0-$3.40 (Tier 1-Generic) sertraline oral tablet 100 mg, 25 mg, 50 mg $0-$3.40 (Tier 1-Generic) TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG $0-$8.50 (Tier 1-Brand) ST venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg


venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg $0-$3.40 (Tier 1-Generic) venlafaxine oral tablet extended release 24hr 150 mg, 225 mg, 37.5 mg, 75 mg


VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG $0-$8.50 (Tier 1-Brand) ST VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)


TRICYCLICS amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg


amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg $0-$3.40 (Tier 1-Generic) clomipramine oral capsule 25 mg, 50 mg, 75 mg $0-$3.40 (Tier 1-Generic) PA desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg


doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg


doxepin oral concentrate 10 mg/ml $0-$3.40 (Tier 1-Generic) PA imipramine hcl oral tablet 10 mg, 25 mg, 50 mg $0-$3.40 (Tier 1-Generic) PA imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg


nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg $0-$3.40 (Tier 1-Generic) nortriptyline oral solution 10 mg/5 ml $0-$3.40 (Tier 1-Generic) protriptyline oral tablet 10 mg, 5 mg $0-$3.40 (Tier 1-Generic) trimipramine oral capsule 100 mg, 25 mg, 50 mg $0-$3.40 (Tier 1-Generic) PA ANTIEMETICS ANTIEMETICS, OTHER chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg


meclizine oral tablet 12.5 mg, 25 mg $0-$3.40 (Tier 1-Generic) metoclopramide hcl oral solution 5 mg/5 ml $0-$3.40 (Tier 1-Generic) metoclopramide hcl oral tablet 10 mg, 5 mg $0-$3.40 (Tier 1-Generic) perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg $0-$3.40 (Tier 1-Generic) prochlorperazine maleate oral tablet 10 mg, 5 mg $0-$3.40 (Tier 1-Generic) prochlorperazine rectal suppository 25 mg $0-$3.40 (Tier 1-Generic) promethazine oral tablet 12.5 mg, 25 mg, 50 mg $0-$3.40 (Tier 1-Generic) PA promethazine rectal suppository 12.5 mg, 25 mg $0-$3.40 (Tier 1-Generic) PA promethazine rectal suppository 50 mg $0-$3.40 (Tier 1-Generic)





promethegan rectal suppository 50 mg $0-$3.40 (Tier 1-Generic) PA scopolamine base transdermal patch 3 day 1 mg over 3 days $0-$3.40 (Tier 1-Generic) trimethobenzamide oral capsule 300 mg $0-$3.40 (Tier 1-Generic) PA EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 125 mg, 40 mg, 80 mg $0-$3.40 (Tier 1-Generic) B/D aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) $0-$3.40 (Tier 1-Generic) B/D dronabinol oral capsule 10 mg, 2.5 mg, 5 mg $0-$3.40 (Tier 1-Generic) B/D EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.)

$0-$8.50 (Tier 1-Brand) B/D

granisetron hcl oral tablet 1 mg $0-$3.40 (Tier 1-Generic) B/D ondansetron hcl oral solution 4 mg/5 ml $0-$3.40 (Tier 1-Generic) B/D ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg $0-$3.40 (Tier 1-Generic) B/D ondansetron oral tablet,disintegrating 4 mg, 8 mg $0-$3.40 (Tier 1-Generic) B/D SYNDROS ORAL SOLUTION 5 MG/ML $0-$8.50 (Tier 1-Brand) PA ANTIFUNGALS ANTIFUNGALS abelcet intravenous suspension 5 mg/ml $0-$8.50 (Tier 1-Brand) B/D AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG

$0-$8.50 (Tier 1-Brand) B/D

amphotericin b injection recon soln 50 mg $0-$3.40 (Tier 1-Generic) B/D caspofungin intravenous recon soln 50 mg, 70 mg $0-$3.40 (Tier 1-Generic) PA ciclopirox topical cream 0.77 % $0-$3.40 (Tier 1-Generic) ciclopirox topical solution 8 % $0-$3.40 (Tier 1-Generic) ciclopirox topical suspension 0.77 % $0-$3.40 (Tier 1-Generic) clotrimazole mucous membrane troche 10 mg $0-$3.40 (Tier 1-Generic) clotrimazole topical cream 1 % $0-$3.40 (Tier 1-Generic) clotrimazole topical solution 1 % $0-$3.40 (Tier 1-Generic) econazole topical cream 1 % $0-$3.40 (Tier 1-Generic) ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG, 50 MG

$0-$8.50 (Tier 1-Brand) PA

fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml


fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml


fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg $0-$3.40 (Tier 1-Generic) flucytosine oral capsule 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) griseofulvin microsize oral suspension 125 mg/5 ml $0-$3.40 (Tier 1-Generic) itraconazole oral capsule 100 mg $0-$3.40 (Tier 1-Generic) ketoconazole oral tablet 200 mg $0-$3.40 (Tier 1-Generic) ketoconazole topical cream 2 % $0-$3.40 (Tier 1-Generic) ketoconazole topical shampoo 2 % $0-$3.40 (Tier 1-Generic) MENTAX TOPICAL CREAM 1 % $0-$8.50 (Tier 1-Brand) MYCAMINE INTRAVENOUS RECON SOLN 100 MG, 50 MG $0-$8.50 (Tier 1-Brand) PA NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) $0-$8.50 (Tier 1-Brand) PA NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG


nyamyc topical powder 100,000 unit/gram $0-$3.40 (Tier 1-Generic) nystatin oral suspension 100,000 unit/ml $0-$3.40 (Tier 1-Generic) nystatin oral tablet 500,000 unit $0-$3.40 (Tier 1-Generic) nystatin topical cream 100,000 unit/gram $0-$3.40 (Tier 1-Generic) nystatin topical ointment 100,000 unit/gram $0-$3.40 (Tier 1-Generic)





nystatin topical powder 100,000 unit/gram $0-$3.40 (Tier 1-Generic) nystop topical powder 100,000 unit/gram $0-$3.40 (Tier 1-Generic) terbinafine hcl oral tablet 250 mg $0-$3.40 (Tier 1-Generic) terconazole vaginal cream 0.4 %, 0.8 % $0-$3.40 (Tier 1-Generic) terconazole vaginal suppository 80 mg $0-$3.40 (Tier 1-Generic) voriconazole intravenous solution 200 mg $0-$3.40 (Tier 1-Generic) voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml)


voriconazole oral tablet 200 mg, 50 mg $0-$3.40 (Tier 1-Generic) ANTIGOUT AGENTS ANTIGOUT AGENTS allopurinol oral tablet 100 mg, 300 mg $0-$3.40 (Tier 1-Generic) colchicine oral capsule 0.6 mg $0-$3.40 (Tier 1-Generic) colchicine oral tablet 0.6 mg $0-$3.40 (Tier 1-Generic) probenecid oral tablet 500 mg $0-$3.40 (Tier 1-Generic) probenecid-colchicine oral tablet 500-0.5 mg $0-$3.40 (Tier 1-Generic) ULORIC ORAL TABLET 40 MG, 80 MG $0-$8.50 (Tier 1-Brand) ST ANTI-INFLAMMATORY AGENTS GLUCOCORTICOIDS ala-cort topical cream 1 %, 2.5 % $0-$3.40 (Tier 1-Generic) alclometasone topical cream 0.05 % $0-$3.40 (Tier 1-Generic) alclometasone topical ointment 0.05 % $0-$3.40 (Tier 1-Generic) betamethasone dipropionate topical cream 0.05 % $0-$3.40 (Tier 1-Generic) betamethasone dipropionate topical lotion 0.05 % $0-$3.40 (Tier 1-Generic) betamethasone dipropionate topical ointment 0.05 % $0-$3.40 (Tier 1-Generic) betamethasone valerate topical cream 0.1 % $0-$3.40 (Tier 1-Generic) betamethasone valerate topical lotion 0.1 % $0-$3.40 (Tier 1-Generic) betamethasone valerate topical ointment 0.1 % $0-$3.40 (Tier 1-Generic) betamethasone, augmented topical cream 0.05 % $0-$3.40 (Tier 1-Generic) betamethasone, augmented topical gel 0.05 % $0-$3.40 (Tier 1-Generic) betamethasone, augmented topical lotion 0.05 % $0-$3.40 (Tier 1-Generic) betamethasone, augmented topical ointment 0.05 % $0-$3.40 (Tier 1-Generic) clobetasol scalp solution 0.05 % $0-$3.40 (Tier 1-Generic) clobetasol topical cream 0.05 % $0-$3.40 (Tier 1-Generic) clobetasol topical gel 0.05 % $0-$3.40 (Tier 1-Generic) clobetasol topical ointment 0.05 % $0-$3.40 (Tier 1-Generic) clobetasol-emollient topical cream 0.05 % $0-$3.40 (Tier 1-Generic) desonide topical cream 0.05 % $0-$3.40 (Tier 1-Generic) desonide topical lotion 0.05 % $0-$3.40 (Tier 1-Generic) desonide topical ointment 0.05 % $0-$3.40 (Tier 1-Generic) desoximetasone topical cream 0.05 %, 0.25 % $0-$3.40 (Tier 1-Generic) desoximetasone topical gel 0.05 % $0-$3.40 (Tier 1-Generic) desoximetasone topical ointment 0.05 %, 0.25 % $0-$3.40 (Tier 1-Generic) dexamethasone intensol oral drops 1 mg/ml $0-$3.40 (Tier 1-Generic) dexamethasone oral elixir 0.5 mg/5 ml $0-$3.40 (Tier 1-Generic) dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg


fluocinolone topical cream 0.01 %, 0.025 % $0-$3.40 (Tier 1-Generic) fluocinolone topical ointment 0.025 % $0-$3.40 (Tier 1-Generic) fluocinolone topical solution 0.01 % $0-$3.40 (Tier 1-Generic)





fluocinonide topical gel 0.05 % $0-$3.40 (Tier 1-Generic) fluocinonide topical ointment 0.05 % $0-$3.40 (Tier 1-Generic) fluocinonide topical solution 0.05 % $0-$3.40 (Tier 1-Generic) fluocinonide-e topical cream 0.05 % $0-$3.40 (Tier 1-Generic) fluticasone topical cream 0.05 % $0-$3.40 (Tier 1-Generic) fluticasone topical lotion 0.05 % $0-$3.40 (Tier 1-Generic) fluticasone topical ointment 0.005 % $0-$3.40 (Tier 1-Generic) halobetasol propionate topical cream 0.05 % $0-$3.40 (Tier 1-Generic) halobetasol propionate topical ointment 0.05 % $0-$3.40 (Tier 1-Generic) hydrocortisone butyrate topical cream 0.1 % $0-$3.40 (Tier 1-Generic) hydrocortisone butyrate topical ointment 0.1 % $0-$3.40 (Tier 1-Generic) hydrocortisone butyrate topical solution 0.1 % $0-$3.40 (Tier 1-Generic) hydrocortisone topical cream 1 %, 2.5 % $0-$3.40 (Tier 1-Generic) hydrocortisone topical lotion 2.5 % $0-$3.40 (Tier 1-Generic) hydrocortisone topical ointment 1 %, 2.5 % $0-$3.40 (Tier 1-Generic) hydrocortisone valerate topical cream 0.2 % $0-$3.40 (Tier 1-Generic) hydrocortisone valerate topical ointment 0.2 % $0-$3.40 (Tier 1-Generic) methylprednisolone oral tablets,dose pack 4 mg $0-$3.40 (Tier 1-Generic) mometasone topical cream 0.1 % $0-$3.40 (Tier 1-Generic) mometasone topical ointment 0.1 % $0-$3.40 (Tier 1-Generic) mometasone topical solution 0.1 % $0-$3.40 (Tier 1-Generic) prednisolone oral solution 15 mg/5 ml $0-$3.40 (Tier 1-Generic) prednisolone sodium phosphate oral solution 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)


prednisone oral solution 5 mg/5 ml $0-$3.40 (Tier 1-Generic) prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg


prednisone oral tablets,dose pack 10 mg, 10 mg (48 pack), 5 mg, 5 mg (48 pack)


triamcinolone acetonide topical cream 0.025 %, 0.1 %, 0.5 % $0-$3.40 (Tier 1-Generic) triamcinolone acetonide topical lotion 0.025 %, 0.1 % $0-$3.40 (Tier 1-Generic) triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %


triderm topical cream 0.1 % $0-$3.40 (Tier 1-Generic) ANTIMIGRAINE AGENTS ERGOT ALKALOIDS dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml)

$0-$3.40 (Tier 1-Generic) QL (8 ML per 30 days)

ergotamine-caffeine oral tablet 1-100 mg $0-$3.40 (Tier 1-Generic) SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS rizatriptan oral tablet 10 mg, 5 mg $0-$3.40 (Tier 1-Generic) QL (12 EA per 30 days) rizatriptan oral tablet,disintegrating 10 mg, 5 mg $0-$3.40 (Tier 1-Generic) QL (12 EA per 30 days) sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation


sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg $0-$3.40 (Tier 1-Generic) QL (9 EA per 30 days) sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml


sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml


sumatriptan succinate subcutaneous solution 6 mg/0.5 ml $0-$3.40 (Tier 1-Generic) QL (4 ML per 30 days) ANTIMYASTHENIC AGENTS





PARASYMPATHOMIMETICS guanidine oral tablet 125 mg $0-$3.40 (Tier 1-Generic) pyridostigmine bromide oral tablet 60 mg $0-$3.40 (Tier 1-Generic) pyridostigmine bromide oral tablet extended release 180 mg $0-$3.40 (Tier 1-Generic) ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER dapsone oral tablet 100 mg, 25 mg $0-$3.40 (Tier 1-Generic) rifabutin oral capsule 150 mg $0-$3.40 (Tier 1-Generic) ANTITUBERCULARS ethambutol oral tablet 100 mg, 400 mg $0-$3.40 (Tier 1-Generic) isoniazid oral tablet 100 mg, 300 mg $0-$3.40 (Tier 1-Generic) PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM

$0-$8.50 (Tier 1-Brand)

PRIFTIN ORAL TABLET 150 MG $0-$8.50 (Tier 1-Brand) pyrazinamide oral tablet 500 mg $0-$3.40 (Tier 1-Generic) rifampin intravenous recon soln 600 mg $0-$3.40 (Tier 1-Generic) rifampin oral capsule 150 mg, 300 mg $0-$3.40 (Tier 1-Generic) RIFATER ORAL TABLET 50-120-300 MG $0-$8.50 (Tier 1-Brand) SIRTURO ORAL TABLET 100 MG $0-$8.50 (Tier 1-Brand) PA TRECATOR ORAL TABLET 250 MG $0-$8.50 (Tier 1-Brand) ANTINEOPLASTICS ALKYLATING AGENTS cyclophosphamide oral capsule 25 mg, 50 mg $0-$3.40 (Tier 1-Generic) B/D GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG $0-$8.50 (Tier 1-Brand) PA HEXALEN ORAL CAPSULE 50 MG $0-$8.50 (Tier 1-Brand) PA LEUKERAN ORAL TABLET 2 MG $0-$8.50 (Tier 1-Brand) MATULANE ORAL CAPSULE 50 MG $0-$8.50 (Tier 1-Brand) VALCHLOR TOPICAL GEL 0.016 % $0-$8.50 (Tier 1-Brand) ANTIANDROGENS bicalutamide oral tablet 50 mg $0-$3.40 (Tier 1-Generic) ERLEADA ORAL TABLET 60 MG $0-$8.50 (Tier 1-Brand) PA flutamide oral capsule 125 mg $0-$3.40 (Tier 1-Generic) nilutamide oral tablet 150 mg $0-$3.40 (Tier 1-Generic) XTANDI ORAL CAPSULE 40 MG $0-$8.50 (Tier 1-Brand) PA YONSA ORAL TABLET 125 MG $0-$8.50 (Tier 1-Brand) PA ZYTIGA ORAL TABLET 250 MG, 500 MG $0-$8.50 (Tier 1-Brand) PA ANTIANGIOGENIC AGENTS POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG $0-$8.50 (Tier 1-Brand) PA REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG

$0-$8.50 (Tier 1-Brand) PA; LA

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

$0-$8.50 (Tier 1-Brand)

ANTIESTROGENS/MODIFIERS DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML


EMCYT ORAL CAPSULE 140 MG $0-$8.50 (Tier 1-Brand) FARESTON ORAL TABLET 60 MG $0-$8.50 (Tier 1-Brand) PA SOLTAMOX ORAL SOLUTION 10 MG/5 ML $0-$8.50 (Tier 1-Brand) tamoxifen oral tablet 10 mg, 20 mg $0-$3.40 (Tier 1-Generic) ANTIMETABOLITES DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG $0-$8.50 (Tier 1-Brand)





fluorouracil topical cream 0.5 %, 5 % $0-$3.40 (Tier 1-Generic) fluorouracil topical solution 2 %, 5 % $0-$3.40 (Tier 1-Generic) hydroxyurea oral capsule 500 mg $0-$3.40 (Tier 1-Generic) mercaptopurine oral tablet 50 mg $0-$3.40 (Tier 1-Generic) PURIXAN ORAL SUSPENSION 20 MG/ML $0-$8.50 (Tier 1-Brand) TABLOID ORAL TABLET 40 MG $0-$8.50 (Tier 1-Brand) PA ANTINEOPLASTICS, OTHER diclofenac sodium topical gel 3 % $0-$3.40 (Tier 1-Generic) leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg $0-$3.40 (Tier 1-Generic) LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG $0-$8.50 (Tier 1-Brand) PA LYNPARZA ORAL CAPSULE 50 MG $0-$8.50 (Tier 1-Brand) PA LYNPARZA ORAL TABLET 100 MG, 150 MG $0-$8.50 (Tier 1-Brand) PA MESNEX ORAL TABLET 400 MG $0-$8.50 (Tier 1-Brand) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG $0-$8.50 (Tier 1-Brand) PA ODOMZO ORAL CAPSULE 200 MG $0-$8.50 (Tier 1-Brand) PA SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG


SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG $0-$8.50 (Tier 1-Brand) PA VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG $0-$8.50 (Tier 1-Brand) PA VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG


ZOLINZA ORAL CAPSULE 100 MG $0-$8.50 (Tier 1-Brand) PA ZYDELIG ORAL TABLET 100 MG, 150 MG $0-$8.50 (Tier 1-Brand) PA AROMATASE INHIBITORS, 3RD GENERATION anastrozole oral tablet 1 mg $0-$3.40 (Tier 1-Generic) exemestane oral tablet 25 mg $0-$3.40 (Tier 1-Generic) letrozole oral tablet 2.5 mg $0-$3.40 (Tier 1-Generic) MOLECULAR TARGET INHIBITORS AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG


AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG $0-$8.50 (Tier 1-Brand) PA ALECENSA ORAL CAPSULE 150 MG $0-$8.50 (Tier 1-Brand) PA ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG $0-$8.50 (Tier 1-Brand) PA ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (23)


BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG $0-$8.50 (Tier 1-Brand) PA CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG $0-$8.50 (Tier 1-Brand) PA CALQUENCE ORAL CAPSULE 100 MG $0-$8.50 (Tier 1-Brand) PA CAPRELSA ORAL TABLET 100 MG, 300 MG $0-$8.50 (Tier 1-Brand) PA COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)


COTELLIC ORAL TABLET 20 MG $0-$8.50 (Tier 1-Brand) PA ERIVEDGE ORAL CAPSULE 150 MG $0-$8.50 (Tier 1-Brand) PA FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG $0-$8.50 (Tier 1-Brand) PA GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG $0-$8.50 (Tier 1-Brand) PA IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG $0-$8.50 (Tier 1-Brand) PA ICLUSIG ORAL TABLET 15 MG, 45 MG $0-$8.50 (Tier 1-Brand) PA IDHIFA ORAL TABLET 100 MG, 50 MG $0-$8.50 (Tier 1-Brand) PA imatinib oral tablet 100 mg, 400 mg $0-$3.40 (Tier 1-Generic) PA IMBRUVICA ORAL CAPSULE 140 MG, 70 MG $0-$8.50 (Tier 1-Brand) PA





IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG


INLYTA ORAL TABLET 1 MG, 5 MG $0-$8.50 (Tier 1-Brand) PA IRESSA ORAL TABLET 250 MG $0-$8.50 (Tier 1-Brand) PA JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG $0-$8.50 (Tier 1-Brand) PA KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG


KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3)


LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2)


MEKINIST ORAL TABLET 0.5 MG, 2 MG $0-$8.50 (Tier 1-Brand) PA NERLYNX ORAL TABLET 40 MG $0-$8.50 (Tier 1-Brand) PA NEXAVAR ORAL TABLET 200 MG $0-$8.50 (Tier 1-Brand) PA RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG $0-$8.50 (Tier 1-Brand) PA RYDAPT ORAL CAPSULE 25 MG $0-$8.50 (Tier 1-Brand) PA SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG


STIVARGA ORAL TABLET 40 MG $0-$8.50 (Tier 1-Brand) PA SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG $0-$8.50 (Tier 1-Brand) PA TAFINLAR ORAL CAPSULE 50 MG, 75 MG $0-$8.50 (Tier 1-Brand) PA TAGRISSO ORAL TABLET 40 MG, 80 MG $0-$8.50 (Tier 1-Brand) PA TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG $0-$8.50 (Tier 1-Brand) PA TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG $0-$8.50 (Tier 1-Brand) PA TYKERB ORAL TABLET 250 MG $0-$8.50 (Tier 1-Brand) PA VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG


VOTRIENT ORAL TABLET 200 MG $0-$8.50 (Tier 1-Brand) PA XALKORI ORAL CAPSULE 200 MG, 250 MG $0-$8.50 (Tier 1-Brand) PA ZEJULA ORAL CAPSULE 100 MG $0-$8.50 (Tier 1-Brand) PA ZELBORAF ORAL TABLET 240 MG $0-$8.50 (Tier 1-Brand) PA ZYKADIA ORAL CAPSULE 150 MG $0-$8.50 (Tier 1-Brand) PA RETINOIDS bexarotene oral capsule 75 mg $0-$3.40 (Tier 1-Generic) PANRETIN TOPICAL GEL 0.1 % $0-$8.50 (Tier 1-Brand) PA TARGRETIN TOPICAL GEL 1 % $0-$8.50 (Tier 1-Brand) PA tretinoin (chemotherapy) oral capsule 10 mg $0-$3.40 (Tier 1-Generic) TREATMENT ADJUNCTS LYSODREN ORAL TABLET 500 MG $0-$8.50 (Tier 1-Brand) ANTIPARASITICS ANTHELMINTICS ALBENZA ORAL TABLET 200 MG $0-$8.50 (Tier 1-Brand) BILTRICIDE ORAL TABLET 600 MG $0-$8.50 (Tier 1-Brand) ivermectin oral tablet 3 mg $0-$3.40 (Tier 1-Generic) ANTIPROTOZOALS ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML

$0-$8.50 (Tier 1-Brand)

ALINIA ORAL TABLET 500 MG $0-$8.50 (Tier 1-Brand)





atovaquone oral suspension 750 mg/5 ml $0-$3.40 (Tier 1-Generic) atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg $0-$3.40 (Tier 1-Generic) benznidazole oral tablet 100 mg, 12.5 mg $0-$3.40 (Tier 1-Generic) PA chloroquine phosphate oral tablet 250 mg, 500 mg $0-$3.40 (Tier 1-Generic) COARTEM ORAL TABLET 20-120 MG $0-$8.50 (Tier 1-Brand) DARAPRIM ORAL TABLET 25 MG $0-$8.50 (Tier 1-Brand) hydroxychloroquine oral tablet 200 mg $0-$3.40 (Tier 1-Generic) mefloquine oral tablet 250 mg $0-$3.40 (Tier 1-Generic) NEBUPENT INHALATION RECON SOLN 300 MG $0-$8.50 (Tier 1-Brand) B/D PENTAM INJECTION RECON SOLN 300 MG $0-$8.50 (Tier 1-Brand) PA PRIMAQUINE ORAL TABLET 26.3 MG $0-$3.40 (Tier 1-Generic) quinine sulfate oral capsule 324 mg $0-$3.40 (Tier 1-Generic) PEDICULICIDES/ SCABICIDES lindane topical shampoo 1 % $0-$3.40 (Tier 1-Generic) malathion topical lotion 0.5 % $0-$3.40 (Tier 1-Generic) permethrin topical cream 5 % $0-$3.40 (Tier 1-Generic) ANTIPARKINSON AGENTS ANTICHOLINERGICS benztropine oral tablet 0.5 mg, 1 mg, 2 mg $0-$3.40 (Tier 1-Generic) PA trihexyphenidyl oral elixir 0.4 mg/ml $0-$3.40 (Tier 1-Generic) PA trihexyphenidyl oral tablet 2 mg, 5 mg $0-$3.40 (Tier 1-Generic) PA ANTIPARKINSON AGENTS, OTHER amantadine hcl oral capsule 100 mg $0-$3.40 (Tier 1-Generic) amantadine hcl oral solution 50 mg/5 ml $0-$3.40 (Tier 1-Generic) amantadine hcl oral tablet 100 mg $0-$3.40 (Tier 1-Generic) entacapone oral tablet 200 mg $0-$3.40 (Tier 1-Generic) GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 137 MG, 68.5 MG


tolcapone oral tablet 100 mg $0-$3.40 (Tier 1-Generic) DOPAMINE AGONISTS APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML $0-$8.50 (Tier 1-Brand) PA bromocriptine oral capsule 5 mg $0-$3.40 (Tier 1-Generic) bromocriptine oral tablet 2.5 mg $0-$3.40 (Tier 1-Generic) NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR

$0-$8.50 (Tier 1-Brand)

pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg


pramipexole oral tablet extended release 24 hr 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg


ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg


ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg


DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg


carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 mg


carbidopa-levodopa oral tablet,disintegrating 10-100 mg, 25-100 mg, 25-250 mg






carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg


MONOAMINE OXIDASE B (MAO-B) INHIBITORS rasagiline oral tablet 0.5 mg, 1 mg $0-$3.40 (Tier 1-Generic) selegiline hcl oral capsule 5 mg $0-$3.40 (Tier 1-Generic) selegiline hcl oral tablet 5 mg $0-$3.40 (Tier 1-Generic) ANTIPSYCHOTICS 1ST GENERATION/ TYPICAL fluphenazine decanoate injection solution 25 mg/ml $0-$3.40 (Tier 1-Generic)

Documents

2019 List of Covered Drugs (Formulary) · 2018. 9. 28. · H2419, H5703_4184_FINAL_4259_C Formulary ID 19426 Version 4. Effective Date: 01/01/2019. SCHA Member Services 1-866-567-7242,