2020 Drug Coverage - AllCare Health

2020 Drug Coverage allcare cco

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Table of Contents

ALLERGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132nd Gen Antihistamine & Decongestant Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Antihistamine - 1st Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Antihistamine - 2nd Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Nasal Anti-Inflammatory Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Nasal Mast Cell Stabilizers Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

ANTIEMESIS/ANTIVERTIGO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Antiemetic/Antivertigo Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

ANTIRETROVIRALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

ASTHMA AND COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-16Anticholinergic, Orally Inhaled Short Acting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Anticholinergics, Orally Inhaled Long Acting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Beta-Adrenergic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Beta-Adrenergic Agents, Inhaled, Short Acting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Beta-Adrenergic Agents, Inhaled, Ultra-Long Acting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Beta-Adrenergic Agents, Orally Inhaled, Long Acting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Beta-Adrenergic and Anticholinergic Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Beta-Adrenergic and Glucocorticoid Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Beta-Adrenergic-Anticholinergic-Glucocort, Inhaled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Glucocorticoids, Orally Inhaled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Interleukin-4(IL-4) Receptor Alpha Antagonist, Mab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Interleukin-5(IL-5) Receptor Alpha Antagonist, Mab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Leukotriene Receptor Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Mast Cell Stabilizers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Mast Cell Stabilizers, Orally Inhaled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Monoclonal Antibodies to Immunoglobulin E(IGE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Monoclonal Antibody - Interleukin - 5 Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Xanthines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

AUTONOMIC NERVOUS SYSTEM DISORDERS . . . . . . . . . . . . . . . . . . . 16-17Alzheimer’s Therapy, NMDA Receptor Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Cholinesterase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

BEHAVIORAL HEALTH – OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Adrenergics, Aromatic, Non-Catecholamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Anti-Alcoholic Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

AllCare Health AllCareHealth.com/Medicaid4

Barbiturates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Sedative-Hypnotics, Non-Barbiturate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

TX for Attention Deficit-Hyperact (ADHD)/Narcolepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

CARDIOVASCULAR DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18-22Ace Inhibitor/Calcium Channel Blocker Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Ace Inhibitor/Thiazide & Thiazide-Like Diuretic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Alpha/Beta-Adrenergic Blocking Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Alpha-Adrenergic Blocking Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Angiotensin Recept-Neprilysin Inhibitor Combo (ARNI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Angiotensin Receptor Antag ./Thiazide Diuretic Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Angiotensin Receptor Antgnst & Calc . Channel Blocker . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Antiarrhythmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Antihyperlipidemic - HMG COA Reductase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Antihyperlipidemic - PCSK9 Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Antihypertensives, Ace Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Antihypertensives, Angiotensin Receptor Antagonist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Antihypertensives, Sympatholytic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Antihypertensives, Vasodilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Beta-Adrenergic Blocking Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Beta-Adrenergic Blocking Agents/Thiazide & Related . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Bile Salt Sequestrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Calcium Channel Blocking Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Digitalis Glycosides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Lipotropics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Loop Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Potassium Sparing Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Potassium Sparing Diuretics in Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Pulm . Anti-HTN, Sel . C-GMP Phosphodiesterase T5 Inhib . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Thiazide and Related Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Vasodilators, Coronary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

CONTRACEPTION/OXYTOCICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-24Contraceptives, Intravaginal, Systemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Contraceptives, Implantable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Contraceptives, Injectable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Contraceptives, Intravaginal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Contraceptives, Oral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23


Contraceptives, Transdermal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Diaphragms/Cervical Cap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Oxytocics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

COUGH AND COLD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24-261st Gen Antihistamine & Decongestant Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

1st Gen Antihistamine-Decongestant - Analgesic Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Analgesic, Non-Sal . - 1st Generation Antihistamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Antitussives, Non-Narcotic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Decongest-Analgesic, Non-Salicylate Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Decongestant-Expectorant Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Expectorants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Narcotic Antituss-1st Gen . Antihistamine-Decongest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Narcotic Antituss-Decongestant-Expectorant Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Narcotic Antitussive-1st Generation Antihistamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Narcotic Antitussive-Expectorant Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Non-Narc Antitus-1st Gen Antihist-Decon-Analges CB . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Non-Narc Antituss-Decongestant-Analgesic-Expect CB . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Non-Narc Antitussive-1st Gen Antihistamine Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Non-Narc Antituss-Decongestant-Expectorant CMB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Non-Narcotic Antitussive and Expectorant Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Nose Preparations, Vasoconstrictors (RX) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Nose Preparations, Vasoconstrictors (OTC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Sympathomimetic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

DERMATOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-31Acne Agents, Topical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Antipruritics, Topical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Antipsoriatics Agents, Systemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Antipsoriatics Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Antiseborrheic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Emollients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Iodine Antiseptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Irritants/Counter-Irritants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Keratolytics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Oxidizing Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Protectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Rosacea Agents, Topical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Topical Agents, Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28


Topical Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Topical Antibiotics/Antiinflammatory, Steroidal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Topical Antifungal/Antiinflammatory, Steroid Agent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Topical Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Topical Anti-Inflammatory Steroidal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Topical Anti-Inflammatory, NSAIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Topical Antineoplastic & Premalignant Lesion Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Topical Antiparasitics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Topical Immunosuppressive Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Topical Local Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Topical Preparations, Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Topical Preparations, Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Topical Sulfonamides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

DIABETES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31-33Antihypergly, (DPP-4) Inhibitor & Biguanide Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Antihypergly, DPP-4, Enzyme Inhib & Thiazolidinedione . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Antihypergly, Incretin Mimetic (GLP-1 Recep . Agonist) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Antihyperglycemic-Sod/Gluc Contransport2 (SGLT2) Inhib . . . . . . . . . . . . . . . . . . . . . . . . . 31

Antihyperglycemic, Alpha-Glucosidase Inhib (N-S) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Antihyperglycemic, DPP-4 Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Antihyperglycemic, Insulin-Release Stimulant Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Antihyperglycemic, Insulin-Response Enhancer (N-S) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Antihyperglycemic, Insulin & GLP-1 Receptor Agonist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Antihyperglycemic, Insulin-Rel Stim . & Biguanide Comb . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Antihyperglycemic-SGL T2 Inhibitor & Biguanide Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Diabetic Ulcer Preparations, Topical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Hyperglycemics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Insulins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

EAR DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Ear Preparations, Misc . Anti-Infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Ear Preparations, Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Ear Preparations, Ear Wax Removers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Otic Preparations, Anti-Inflammatory-Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

ELECTROLYTE REGULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34-35Electrolyte Depleters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Potassium Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35


Sodium/Saline Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

ENDOCRINE DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35-36Antidiuretic and Vasopressor Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Antineoplastic LHRH (GNRH) Agonist, Pituitary Suppr . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Antithyroid Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Bone Formation Agents - Sclerostin Inhibitors, Mono . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Bone Resorption Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Growth Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

LHRH (GNRH) Antagonist, Pituitary Suppressant Agents . . . . . . . . . . . . . . . . . . . . . . . . . 36

LHRH (GNRH) Agnst Pit . Sup-Central Precocious Puberty . . . . . . . . . . . . . . . . . . . . . . . . 36

Menopausal Sympt Supp-Sel Estrogen Recep Modulator . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Parathyroid Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Pituitary Suppressive Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Thyroid Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

EYE DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36-39Artificial Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Carbonic Anhydrase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Eye Antibiotic-Corticoid Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Eye Anti-Infectives (Rx Only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Eye Inflammatory Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Eye Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Eye Preparations, Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Eye Sulfonamides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Miotics/Other Intraoc . Pressure Reducers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Mydriatics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Ophthalmic Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Ophthalmic Mass Cell Stabilizers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Ophthalmic Preparations, Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

GOUT AND RELATED DISEASES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Colchicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Hyperuricemia TX - Purine Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Uricosuric Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

HEMATOLOGICAL DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39-40Anticoagulants, Coumarin Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Antifibrinolytic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Direct Factor XA Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39


Heparin and Related Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Platelet Aggregation Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Sickle Cell Anemia Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Vitamin K Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

HORMONAL DEFICIENCY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40-41Androgen/Estrogen Preps for Female Sexual Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . 40

Androgenic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Estrogen & Selective Estrogen Recept Mod (Serm) Comb . . . . . . . . . . . . . . . . . . . . . . . . . 40

Estrogenic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Progestational Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

IMMUNIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

IMMUNOSUPPRESSION/MODULATION . . . . . . . . . . . . . . . . . . . . . . . . . . 41Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Immunosuppressives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

INFECTIOUS DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41-462nd Gen . Anaerobic Antiprotozoal-Antibacterial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Absorbable Sulfonamides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Aminoglycosides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Anaerobic Antiprotozoal-Antibacterial Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Antifungal Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Antifungal Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Antileprotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Antimalarial Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Anti-Mycobacterium Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Antiretroviral-Nucleoside, Nucleotide, Protease Inh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Antitubercular Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Antivirals, General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Cephalosporins - 1st Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Cephalosporins - 2nd Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Cephalosporins - 3rd Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Chemotherapeutics, Antibacterial, Misc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Hep C - NS5A, NS3/4A, Nucleotide NS5B Inhib . Combo . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Hep C Virus - NS5A & NS5B Polymerase Inhib . Combo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Hepatitis B Treatment Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Hepatitis C Treatment Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Hepatitis C Virus - NS5A and NS3/4A Inhibitor Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44


Lincosamides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Macrolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Nitrofuran Derivatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Quinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Rifamycins and Related Derivative Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Tetracyclines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Vancomycin and Derivatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

INFLAMMATORY DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46-48Anti-Inflammatory Tumor Necrosis Factor Inhibitor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Anti-Inflammatory, Pyrimidine Synthesis Inhibitor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Anti-Inflammatory, Phosphodiesterase-4 (PDE4) Inhib . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Glucocorticoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Interleukin-6 (IL-6) Receptor Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Janus Kinase (JAK) Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Mineralocorticoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

NSAIDS, Cyclooxygenase 2 Inhibitor - Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

NSAIDS, Cyclooxygenase Inhibitor - Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

LOCAL ANESTHESIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Local Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

LOWER GASTROINTESTINAL DISORDERS . . . . . . . . . . . . . . . . . . . . . .49-50Ammonia Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Antidiarrheals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Bile Salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Chronic Inflam . Colon DX, 5-A-Salicylat, Rectal TX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Drug TX-Chronic Inflam . Colon DX, 5-Aminosalicylat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Laxatives and Cathartics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Laxatives, Local, Rectal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Rectal/Lower Bowel Prep ., Glucocort . (Non-Hemorr) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

MISCELLANEOUS AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50Anaphylaxis Therapy Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Parasympathetic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

NEUROLOGICAL DISEASE – MISCELLANEOUS . . . . . . . . . . . . . . . . . . . .50Agents to Treat Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

ONCOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51


ORAL/PHARYNGEAL DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Dental Aids and Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Nose Preparations, Miscellaneous (RX) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Periodontal Collagenase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

OTHER DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51-52Antioxidant Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Appetite Stim . for Anorexia, Cachexia, Wasting Synd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Dietary Supplement, Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

General Inhalation Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Insecticides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Metabolic Deficiency Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Protein Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Thickening Agents, Oral, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

PAIN MANAGEMENT – ANALGESICS . . . . . . . . . . . . . . . . . . . . . . . . . 52-55Analgesic, Salicylate, Barbiturate, & Xanthine CMB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Analgesic, Non-Salicylate, Barbiturate, & Xanthine CMB . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Analgesic/Antipyretics, Salicylates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Analgesic/Antipyretics, Non-Salicylates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Analgesics, Narcotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Antimigraine Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Narc . & Non-Sal . Analgesic, Barbiturate & Xanthine CMB . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Narcotic Analgesic & Non-Salicylate Analgesic Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Narcotic and Salicylate Analgesic Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Narcotic Withdrawal Therapy Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

PARKINSONS DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Antiparkinsonism Drugs, Anticholinergic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Antiparkinsonism Drugs, Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Decarboxylase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

SEIZURE DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Anticonvulsant - Benzodiazepine Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Anticonvulsants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

SKELETAL MUSCLE DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Agents to TX Periodic Paralysis - Carbon Anhyd Inh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57


Please note any medication over $650 per fill, will require a PAAllCare CCO is a Generic Mandatory plan – generic drugs must be used when availableCertain drugs must be obtained through MedImpact Direct Specialty Pharmacy (MIDS)If you have questions concerning the AllCare CCO Drug Coverage Plan, please call (541) 471-4106

SMOKING CESSATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Smoking Deterrent Agents (Ganglionic Stim, Others) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Smoking Deterrent - Nicotinic Recept . Partial Agonist . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Smoking Deterrents, Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

UPPER GASTROINTESTINAL DISORDERS . . . . . . . . . . . . . . . . . . . . . 57-59Antacids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Anticholinergics/Antispasmodics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Antiflatulents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Anti-Ulcer Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Emetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Histamine H2-Receptor Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Intestinal Motility Stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Proton-Pump Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

URINARY TRACT – FUNCTIONAL DISORDERS . . . . . . . . . . . . . . . . . . . . 59Benign Prostatic Hypertrophy/Micturition Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Overactive Bladder Agents, BETA-3 Adrenergic Recep . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Urinary PH Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Urinary Tract Anesthetic/Analgesic Agnt (AZO-DYE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Urinary Tract Antispasmodic/Antiincontinence Agent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

VAGINAL DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60Vaginal Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Vaginal Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Vaginal Estrogen Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

VITAMIN AND/OR MINERAL DEFICIENCY . . . . . . . . . . . . . . . . . . . . . 60-61Cariostatic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Replacement Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Vitamin A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Vitamin B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Vitamin D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Vitamin E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61


Drug Table


LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available

PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit

MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit

Therapeutic Indication / Drug Name CommentALLERGY

2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONSTIER 1

LORATADINE/PSEUDOEPHEDRINE (TAB ER 12H) 5 MG‐120MG PAANTIHISTAMINES - 1ST GENERATION

TIER 1CHLORPHENIRAMINE (SYRUP) 2 MG/5 MLCHLORPHENIRAMINE (TAB ER) 12 MGCHLORPHENIRAMINE (TAB) 4 MGDIPHENHYDRAMINE (ELIXIR) 12.5MG/5MLDIPHENHYDRAMINE (LIQUID) 12.5MG/5MLDIPHENHYDRAMINE (SYRUP) 12.5MG/5MLDIPHENHYDRAMINE (TAB RAPDIS) 12.5 MGHYDROXYZINE (SOLUTION) 10 MG/5 ML DL: 90 IN 180 DAYSHYDROXYZINE (TAB) 10 MG, 25 MG, 50 MG DL: 90 IN 180 DAYSHYDROXYZINE PAM (CAP) 100 MG QL: 4 IN 1 DAYSHYDROXYZINE PAM (CAP) 25 MG, 50 MG QL: 6 IN 1 DAYSPROMETHAZINE (SYRUP) 6.25MG/5MLPROMETHAZINE (TAB) 12.5 MG, 25 MG, 50 MG

TIER 3CLEMASTINE FUM (TAB) 1.34 MG, 2.68 MG STCYPROHEPTADINE (SYRUP) 2 MG/5 MLCYPROHEPTADINE (TAB) 4 MG

ANTIHISTAMINES - 2ND GENERATIONTIER 1

CETIRIZINE (SOLUTION) 1 MG/ML, 5 MG/5 ML QL: 150 IN 30 DAYSCETIRIZINE (TAB) 10 MG, 5 MG QL: 1 IN 1 DAYSLORATADINE (SOLUTION) 5 MG/5 ML QL: 150 IN 30 DAYSLORATADINE (TAB RAPDIS) 10 MGLORATADINE (TAB) 10 MG QL: 1 IN 1 DAYS

NASAL ANTI-INFLAMMATORY STEROIDSTIER 1

FLUTICASONE PROP (SPRAY SUSP) 50 MCG QL: 16 IN 30 DAYS|3 IN 273 DAYS

TIER 3BUDESONIDE (SPRAY/PUMP) 32MCG STFLUNISOLIDE (SPRAY) 25 MCG STTRIAMCINOLONE ACET (SPRAY) 55 MCG ST

NASAL MAST CELL STABILIZERS AGENTSTIER 1

CROMOLYN SOD (SPRAY/PUMP) 5.2 MGANTIEMESIS/ANTIVERTIGO

ANTIEMETIC/ANTIVERTIGO AGENTSTIER 1

DIMENHYDRINATE (TAB) 50 MG





Therapeutic Indication / Drug Name CommentMECLIZINE (TAB CHEW) 25 MGMECLIZINE (TAB) 12.5 MG, 25 MGONDANSETRON (TAB RAPDIS) 4 MG, 8 MG QL: 180 IN 135 DAYSONDANSETRON (TAB) 4 MG, 8 MG QL: 180 IN 135 DAYSPROCHLORPERAZINE (SUPP.RECT) 25 MGPROCHLORPERAZINE (TAB) 10 MG, 5 MGPROMETHAZINE (SUPP.RECT) 25 MG, 50 MG, 12.5 MG

TIER 2DIMENHYDRINATE [DRAMAMINE] (TAB CHEW) 50 MG

TIER 3DOXYLAMINE SUCC/VIT B6 (TAB DR) 10 MG‐10MG PAONDANSETRON (SOLUTION) 4 MG/5 ML AL: ≤ 4 YEARSSCOPOLAMINE (PATCH TD 3) 1 MG/3 DAY

ANTIRETROVIRALSMay be subject to prior authorization and/or other utilization management restrictions

ALL ANTIRETROVIRAL AGENTS PAASTHMA AND COPD

ANTICHOLINERGIC, ORALLY INHALED SHORT ACTINGTIER 1

IPRATROPIUM BROMIDE (SOLUTION) 0.2 MG/ML AL: ≥ 18 YEARSTIER 2

IPRATROPIUM BROMIDE [ATROVENT HFA] 17MCG AL: ≥ 18 YEARSANTICHOLINERGICS, ORALLY INHALED LONG ACTING

TIER 2ACLIDINIUM BROMIDE [TUDORZA PRESSAIR] 400 MCG QL: 1 IN 23 DAYSUMECLIDINIUM BROMIDE [INCRUSE ELLIPTA] 62.5 MCG QL: 1 IN 23 DAYS

TIER 3TIOTROPIUM BROMIDE [SPIRIVA RESPIMAT] (MIST INHAL) 1.25 MCG, 2.5 MCG QL: 4 IN 30 DAYS

BETA-ADRENERGIC AGENTSTIER 1

ALBUTEROL SULF (SYRUP) 2 MG/5 MLALBUTEROL SULF (TAB ER 12H) 4 MG, 8 MGALBUTEROL SULF (TAB) 2 MG, 4 MG

TIER 3TERBUTALINE SULF (TAB) 5 MG, 2.5 MG ST

BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTINGTIER 1

ALBUTEROL SULF 90 MCG QL: 2 IN 30 DAYSALBUTEROL SULF (SOLUTION) 5 MG/MLALBUTEROL SULF (VIAL‐NEB) MULTIPLE STRENGTHSLEVALBUTEROL TARTRATE 45 MCG QL: 2 IN 23 DAYS

TIER 2ALBUTEROL SULF [PROAIR RESPICLICK] 90 MCG QL: 2 IN 30 DAYS

BETA-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTING





Therapeutic Indication / Drug Name CommentTIER 2

OLODATEROL [STRIVERDI RESPIMAT] (MIST INHAL) 2.5 MCG QL: 4 IN 30 DAYS, AL: ≥ 18 YEARS

BETA-ADRENERGIC AGENTS, ORALLY INHALED,LONG ACTINGTIER 3

SALMETEROL XINAFOATE [SEREVENT DISKUS] 50 MCG QL: 2 IN 1 DAYS|60 IN 23 DAYS, AL: ≥ 18 YEARS, ST

BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONSTIER 1

IPRATROPIUM/ALBUTEROL SULF (AMPUL‐NEB) 0.5‐3MG/3 AL: ≥ 18 YEARSTIER 2

IPRATROPIUM/ALBUTEROL SULF [COMBIVENT RESPIMAT] (MIST INHAL) 20‐100 MCG

QL: 4 IN 23 DAYS, AL: ≥ 18 YEARS

TIOTROPIUM BR/OLODATEROL [STIOLTO RESPIMAT] (MIST INHAL) 2.5‐2.5MCG QL: 4 IN 30 DAYS

UMECLIDINIUM BRM/VILANTEROL TR [ANORO ELLIPTA] 62.5‐25MCG QL: 1 IN 23 DAYSBETA-ADRENERGIC AND GLUCOCORTICOID COMBINATIONS

TIER 1FLUTICASONE PROPION/SALMETEROL 100‐50 MCG, 250‐50 MCG, 500‐50 MCG QL: 2 IN 1 DAYS, ST

FLUTICASONE PROPION/SALMETEROL 55‐14 MCG, 113‐14 MCG, 232‐14 MCG

TIER 2BUDESONIDE/FORMOTEROL FUM [SYMBICORT] 80‐4.5 MCG, 160‐4.5MCG QL: 10.2 IN 23 DAYS, ST

TIER 3FLUTICASONE PROPION/SALMETEROL [ADVAIR HFA] 45‐21 MCG, 115‐21MCG, 230‐21MCG

QL: 12 IN 23 DAYS, ST

FLUTICASONE/VILANTEROL [BREO ELLIPTA] 100‐25MCG, 200‐25 MCG STMOMETASONE/FORMOTEROL [DULERA] 100‐5 MCG, 200‐5 MCG QL: 13 IN 23 DAYS, AL: ≥ 12

YEARS, STBETA-ADRENERGIC-ANTICHOLINERGIC-GLUCOCORT, INHALED

TIER 2FLUTICASONE/UMECLIDIN/VILANTER [TRELEGY ELLIPTA] 100‐62.5 ST

GLUCOCORTICOIDS, ORALLY INHALEDTIER 1

BUDESONIDE (AMPUL‐NEB) 0.25MG/2ML, 0.5 MG/2ML, 1 MG/2 ML AL: ≤ 5 YEARSTIER 2

BECLOMETHASONE DIP [QVAR REDIHALER] 40 MCG, 80 MCG QL: 1 IN 23 DAYSBUDESONIDE [PULMICORT FLEXHALER] 90 MCG, 180 MCG QL: 1 IN 23 DAYSFLUTICASONE FUROATE [ARNUITY ELLIPTA] 100 MCG, 200 MCGFLUTICASONE PROP [ARMONAIR RESPICLICK] 55 MCG, 232 MCGFLUTICASONE PROP [FLOVENT DISKUS] 100 MCG, 250 MCG, 50 MCG QL: 60 IN 23 DAYSFLUTICASONE PROP [FLOVENT HFA] 110 MCG, 44 MCG QL: 12 IN 23 DAYS

TIER 3FLUTICASONE PROP [FLOVENT HFA] 220 MCG QL: 12 IN 23 DAYS, ST





Therapeutic Indication / Drug Name CommentINTERLEUKIN-4(IL-4) RECEPTOR ALPHA ANTAGONIST, MAB

TIER 2DUPILUMAB [DUPIXENT] (SYRINGE) 300 MG/2ML PA, FL: FILLS≤1 IN 365 DAYS, MS

INTERLEUKIN-5(IL-5) RECEPTOR ALPHA ANTAGONIST, MABTIER 2

BENRALIZUMAB [FASENRA] (SYRINGE) 30 MG/ML PA, FL: FILLS≤1 IN 365 DAYS, MS

LEUKOTRIENE RECEPTOR ANTAGONISTSTIER 1

MONTELUKAST SOD (TAB CHEW) 4 MG QL: 30 IN 30 DAYS, AL: < 6 YEARS

MONTELUKAST SOD (TAB CHEW) 5 MG QL: 30 IN 30 DAYSMONTELUKAST SOD (TAB) 10 MG QL: 30 IN 30 DAYS

TIER 3MONTELUKAST SOD (GRAN PACK) 4 MG PA, QL: 30 IN 30 DAYS

MAST CELL STABILIZERSTIER 1

CROMOLYN SOD (ORAL CONC) 20 MG/MLMAST CELL STABILIZERS, ORALLY INHALED

TIER 1CROMOLYN SOD (AMPUL‐NEB) 20 MG/2 ML

MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E(IGE)TIER 2

OMALIZUMAB [XOLAIR] (SYRINGE) 75MG/0.5ML, 150 MG/ML PA, FL: FILLS≤1 IN 365 DAYS, MS

OMALIZUMAB [XOLAIR] (VIAL) 150 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

MONOCLONAL ANTIBODY - INTERLEUKIN-5 ANTAGONISTSTIER 2

MEPOLIZUMAB [NUCALA] (VIAL) 100 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

XANTHINESTIER 1

THEOPHYLLINE ANHYDROUS (ELIXIR) 80 MG/15MLTHEOPHYLLINE ANHYDROUS (SOLUTION) 80 MG/15MLTHEOPHYLLINE ANHYDROUS (TAB ER 12H) 100 MG, 200 MG, 300 MG, 450 MG

THEOPHYLLINE ANHYDROUS (TAB ER 24H) 400 MG, 600 MGTIER 2

THEOPHYLLINE ANHYDROUS [THEO‐24] (CAP ER 24H) 400 MG, 200 MG, 300 MG

AUTONOMIC NERVOUS SYSTEM DISORDERSALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS

TIER 1





Therapeutic Indication / Drug Name CommentMEMANTINE (SOLUTION) 2 MG/ML PAMEMANTINE (TAB) 5 MG, 10 MG

CHOLINESTERASE INHIBITORSTIER 1

DONEPEZIL (TAB RAPDIS) 5 MG, 10 MGDONEPEZIL (TAB) 23 MG, 10 MG, 5 MGGALANTAMINE HBR (CAP24H PEL) 8 MG, 16 MG, 24 MG PAGALANTAMINE HBR (SOLUTION) 4 MG/ML PAGALANTAMINE HBR (TAB) 12 MG, 4 MG, 8 MGRIVASTIGMINE (PATCH TD24) 4.6MG/24HR, 9.5MG/24HR PARIVASTIGMINE TARTRATE (CAP) 1.5 MG, 3 MG, 4.5 MG, 6 MG PA

BEHAVIORAL HEALTH - OTHERADRENERGICS, AROMATIC, NON-CATECHOLAMINE

TIER 1DEXTROAMPHETAMINE SULF (CAP ER) 10 MG, 15 MG, 5 MG QL: 2 IN 1 DAYS, AL: ≤ 19 YEARS

DEXTROAMPHETAMINE SULF (TAB) 10 MG, 5 MGDEXTROAMPHETAMINE/AMPHETAMINE (CAP ER 24H) 10 MG, 20 MG, 30 MG, 5 MG, 15 MG, 25 MG

QL: 2 IN 1 DAYS, AL: ≤ 19 YEARS

DEXTROAMPHETAMINE/AMPHETAMINE (TAB) MULTIPLE STRENGTHSTIER 3

LISDEXAMFETAMINE [VYVANSE] (CAP) MULTIPLE STRENGTHS PA, QL: 1 IN 1 DAYS, AL: ≥ 6 YEARS

LISDEXAMFETAMINE [VYVANSE] (TAB CHEW) 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

PA, QL: 1 IN 1 DAYS, AL: ≥ 6 YEARS

ANTI-ALCOHOLIC PREPARATIONSTIER 1

ACAMPROSATE CALC (TAB DR) 333 MGBARBITURATES

TIER 1PHENOBARBITAL (ELIXIR) 20 MG/5 MLPHENOBARBITAL (TAB) MULTIPLE STRENGTHS

NARCOTIC ANTAGONISTSTIER 1

NALTREXONE (TAB) 50 MGTIER 2

NALOXONE [NARCAN] (SPRAY) 4 MGSEDATIVE-HYPNOTICS,NON-BARBITURATE

TIER 1DIPHENHYDRAMINE (CAP) 50 MG, 25 MGDIPHENHYDRAMINE (TAB) 25 MGDOXYLAMINE SUCC (TAB) 25 MG

TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSYTIER 1





Therapeutic Indication / Drug Name CommentMETHYLPHENIDATE (30‐70) 20 MG, 10 MG, 30 MG, 40 MG, 50 MG, 60 MG QL: 2 IN 1 DAYS, AL: ≤ 19 YEARS

METHYLPHENIDATE (50‐50) 20 MG, 30 MG, 40 MG QL: 2 IN 1 DAYS, AL: ≤ 19 YEARS

METHYLPHENIDATE (SOLUTION) 5 MG/5 ML, 10 MG/5 ML QL: 20 IN 1 DAYSMETHYLPHENIDATE (TAB ER 24) 54 MG, 18 MG, 36 MG, 27 MG QL: 2 IN 1 DAYS, AL: ≤ 19 YEARS

METHYLPHENIDATE (TAB ER) 20 MG, 10 MG QL: 2 IN 1 DAYS, AL: ≤ 19 YEARS

METHYLPHENIDATE (TAB) 10 MG, 5 MG, 20 MGTIER 3

DEXMETHYLPHENIDATE (50‐50) 5 MG, 10 MG, 20 MG, 30 MG, 40 MG, 15 MG QL: 1 IN 1 DAYS|2 IN 1 DAYS, AL: ≤ 19 YEARS|≥ 6 YEARS, ST

DEXMETHYLPHENIDATE (TAB) 2.5 MG, 5 MG, 10 MG QL: 3 IN 1 DAYS, AL: ≥ 6 YEARS, ST

METHYLPHENIDATE [DAYTRANA] (PATCH TD24) 10MG/9HR, 15MG/9HR, 20 MG/9 HR, 30MG/9HR

PA, QL: 1 IN 1 DAYS, AL: ≤ 17 YEARS|≥ 6 YEARS

CARDIOVASCULAR DISEASEACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION

TIER 1AMLODIPINE BESYLATE/BENAZEPRIL (CAP) MULTIPLE STRENGTHS

ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETICTIER 1

BENAZEPRIL/HCTZ (TAB) 5‐6.25MG, 10‐12.5MG, 20‐12.5 MG, 20 MG‐25MGENALAPRIL/HCTZ (TAB) 10 MG‐25MG, 5MG‐12.5MGLISINOPRIL/HCTZ (TAB) 20‐12.5 MG, 20 MG‐25MG, 10‐12.5MG

ALPHA/BETA-ADRENERGIC BLOCKING AGENTSTIER 1

CARVEDILOL (TAB) 25 MG, 12.5 MG, 3.125 MG, 6.25 MGTIER 3

CARVEDILOL PHOSPHATE (CPMP 24HR) 10 MG, 20 MG, 40 MG, 80 MG PALABETALOL (TAB) 300 MG, 200 MG, 100 MG

ALPHA-ADRENERGIC BLOCKING AGENTSTIER 1

DOXAZOSIN MESYLATE (TAB) 1 MG, 2 MG, 4 MG, 8 MGPRAZOSIN (CAP) 1 MG, 2 MG, 5 MGTERAZOSIN (CAP) 1 MG, 2 MG, 5 MG, 10 MG

ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI)TIER 3

SACUBITRIL/VALSARTAN [ENTRESTO] (TAB) 24 MG‐26MG, 49 MG‐51MG, 97MG‐103MG

PA

ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMBTIER 1

IRBESARTAN/HCTZ (TAB) 150‐12.5MG, 300‐12.5MG





Therapeutic Indication / Drug Name CommentLOSARTAN/HCTZ (TAB) 50‐12.5 MG, 100MG‐25MG, 100‐12.5MGVALSARTAN/HCTZ (TAB) MULTIPLE STRENGTHS

ANGIOTENSIN RECEPTOR ANTGNST & CALC.CHANNEL BLOCKRTIER 1

AMLODIPINE BESYLATE/VALSARTAN (TAB) MULTIPLE STRENGTHSANTIARRHYTHMICS

TIER 1AMIODARONE (TAB) 200 MG, 400 MGDISOPYRAMIDE PHOSPHATE (CAP) 100 MG, 150 MGFLECAINIDE ACET (TAB) 100 MG, 50 MG, 150 MGMEXILETINE (CAP) 150 MG, 200 MG, 250 MGPROPAFENONE (TAB) 150 MG, 300 MG, 225 MGQUINIDINE GLUCONATE (TAB ER) 324 MGQUINIDINE SULF (TAB) 200 MG, 300 MG

TIER 2DISOPYRAMIDE PHOSPHATE [NORPACE CR] (CAP ER) 100 MG, 150 MG

TIER 3DOFETILIDE (CAP) 125 MCG, 250 MCG, 500 MCG

ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORSTIER 1

ATORVASTATIN CALC (TAB) 10 MG, 20 MG, 40 MG, 80 MGLOVASTATIN (TAB) 20 MG, 40 MG, 10 MGPRAVASTATIN SOD (TAB) 80 MG, 10 MG, 20 MG, 40 MGROSUVASTATIN CALC (TAB) 10 MG, 20 MG, 40 MG, 5 MGSIMVASTATIN (TAB) 5 MG, 10 MG, 20 MG, 40 MG, 80 MG

TIER 3FLUVASTATIN SOD (CAP) 20 MG, 40 MGFLUVASTATIN SOD (TAB ER 24H) 80 MGLOVASTATIN [ALTOPREV] (TAB ER 24H) 40 MG, 60 MG

ANTIHYPERLIPIDEMIC - PCSK9 INHIBITORSTIER 2

ALIROCUMAB [PRALUENT PEN] (PEN INJCTR) 75 MG/ML, 150 MG/ML PA, MSEVOLOCUMAB [REPATHA PUSHTRONEX] (WEAR INJCT) 420 MG/3.5 PA, MSEVOLOCUMAB [REPATHA SURECLICK] (PEN INJCTR) 140 MG/ML PA, MSEVOLOCUMAB [REPATHA SYRINGE] (SYRINGE) 140 MG/ML PA, MS

ANTIHYPERTENSIVES, ACE INHIBITORSTIER 1

BENAZEPRIL (TAB) 5 MG, 10 MG, 20 MG, 40 MGENALAPRIL (TAB) 5 MG, 10 MG, 20 MG, 2.5 MGFOSINOPRIL SOD (TAB) 40 MG, 10 MG, 20 MGLISINOPRIL (TAB) 5 MG, 10 MG, 20 MG, 40 MG, 2.5 MG, 30 MGQUINAPRIL (TAB) 10 MG, 20 MG, 5 MG, 40 MGRAMIPRIL (CAP) 1.25 MG, 2.5 MG, 5 MG, 10 MGTRANDOLAPRIL (TAB) 1 MG, 2 MG, 4 MG

TIER 3





Therapeutic Indication / Drug Name CommentCAPTOPRIL (TAB) 100 MG, 25 MG, 50 MG, 12.5 MGMOEXIPRIL (TAB) 7.5 MG, 15 MG

ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONISTTIER 1

IRBESARTAN (TAB) 150 MG, 300 MG, 75 MGLOSARTAN POT (TAB) 25 MG, 50 MG, 100 MGVALSARTAN (TAB) 320 MG, 160 MG, 80 MG, 40 MG

TIER 3OLMESARTAN (TAB) 5 MG, 20 MG, 40 MG STTELMISARTAN (TAB) 40 MG, 80 MG, 20 MG ST

ANTIHYPERTENSIVES, SYMPATHOLYTICTIER 1

CLONIDINE (TAB) 0.1 MG, 0.2 MG, 0.3 MG AL: ≥ 6 YEARSGUANFACINE (TAB) 1 MG, 2 MG QL: 3 IN 1 DAYS, AL: ≥ 6 YEARS

METHYLDOPA (TAB) 250 MG, 500 MGANTIHYPERTENSIVES, VASODILATORS

TIER 1HYDRALAZINE (TAB) 10 MG, 100 MG, 25 MG, 50 MGMINOXIDIL (TAB) 10 MG, 2.5 MG

BETA-ADRENERGIC BLOCKING AGENTSTIER 1

ACEBUTOLOL (CAP) 200 MG, 400 MGATENOLOL (TAB) 100 MG, 50 MG, 25 MGMETOPROLOL SUCC (TAB ER 24H) 25 MG, 50 MG, 100 MG, 200 MGMETOPROLOL TARTRATE (TAB) 100 MG, 50 MGPROPRANOLOL (SOLUTION) 20 MG/5 ML, 40MG/5MLPROPRANOLOL (TAB) 10 MG, 20 MG, 40 MG, 60 MG, 80 MGSOTALOL (TAB) 160 MG, 80 MG, 240 MG, 120 MG

TIER 3BETAXOLOL (TAB) 10 MG, 20 MGBISOPROLOL FUM (TAB) 10 MG, 5 MGNADOLOL (TAB) 40 MG, 80 MG, 20 MGPROPRANOLOL (CAP SA 24H) 80 MG, 120 MG, 160 MG, 60 MGTIMOLOL (TAB) 10 MG, 20 MG, 5 MG

BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & RELATEDTIER 1

ATENOLOL/CHLORTHALIDONE (TAB) 50 MG‐25MG, 100MG‐25MGBILE SALT SEQUESTRANTS

TIER 1CHOLESTYRAMINE (WITH SUGAR) (POWD PACK) 4 G DL: 60 DAYSCHOLESTYRAMINE (WITH SUGAR) (POWDER) 4 G DL: 60 DAYSCHOLESTYRAMINE/ASPARTAME (POWD PACK) 4 G DL: 60 DAYSCHOLESTYRAMINE/ASPARTAME (POWDER) 4 G DL: 60 DAYS

TIER 3





Therapeutic Indication / Drug Name CommentCOLESEVELAM (POWD PACK) 3.75 G STCOLESEVELAM (TAB) 625 MG STCOLESTIPOL (PACKET) 5 G STCOLESTIPOL (TAB) 1 G ST

CALCIUM CHANNEL BLOCKING AGENTSTIER 1

AMLODIPINE BESYLATE (TAB) 2.5 MG, 10 MG, 5 MGDILTIAZEM (CAP ER 24H) 180 MG, 240 MG, 300 MG, 120 MG, 360 MGDILTIAZEM (CAP ER DEG) 180 MG, 240 MG, 120 MGDILTIAZEM (CAP SA 24H) MULTIPLE STRENGTHSDILTIAZEM (TAB) 30 MG, 60 MG, 90 MG, 120 MGFELODIPINE (TAB ER 24H) 2.5 MG, 5 MG, 10 MGNIFEDIPINE (CAP) 10 MG, 20 MGNIFEDIPINE (TAB ER 24) 30 MG, 60 MG, 90 MGNIFEDIPINE (TAB ER) 90 MG, 60 MG, 30 MGVERAPAMIL (CAP24H PCT) 100 MG, 200 MG, 300 MGVERAPAMIL (TAB ER) 240 MG, 180 MG, 120 MGVERAPAMIL (TAB) 120 MG, 80 MG, 40 MG

TIER 3DILTIAZEM (CAP ER 12H) 90 MG, 120 MG, 60 MGVERAPAMIL (CAP24H PEL) 180 MG, 240 MG, 120 MG, 360 MG

DIGITALIS GLYCOSIDESTIER 1

DIGOXIN (TAB) 125 MCG, 250 MCGTIER 2

DIGOXIN (SOLUTION) 50 MCG/MLLIPOTROPICS

TIER 1EZETIMIBE (TAB) 10 MGFENOFIBRATE (TAB) 160 MG, 54 MGFENOFIBRATE NANOCRYSTALLIZED (TAB) 48 MG, 145MGGEMFIBROZIL (TAB) 600 MGNIACIN (TAB ER 24H) 500 MG, 750 MG, 1000 MG PANIACIN (TAB) 500 MGOMEGA‐3 ACID ETHYL ESTERS (CAP) 1 G PAOMEGA‐3S/DHA/EPA/FISH OIL (CAP DR) 120‐180‐60 QL: 1 PER DAYOMEGA‐3S/DHA/EPA/FISH OIL (CAP) 600‐1200MG QL: 1 PER DAYOMEGA‐3S/DHA/EPA/FISH OIL [CENTRUM PRONUTRIENTS OMEGA‐3] (CAP) 332.5 MG

QL: 1 PER DAY

OMEGA‐3S/DHA/EPA/FISH OIL [FISH OIL] (CAP DR) 300‐1000MG, 720‐1200MG QL: 1 PER DAY

OMEGA‐3S/DHA/EPA/FISH OIL [FISH OIL] (CAP) 360‐1200MG QL: 1 PER DAYOMEGA‐3S/DHA/EPA/FISH OIL [OCEAN BLUE OMEGA‐3] (CAP) 350 MG QL: 1 PER DAYOMEGA‐3S/DHA/EPA/FISH OIL [OMEGA ESSENTIALS BASIC] (LIQUID) 1400MG/5ML

QL: 1 PER DAY





Therapeutic Indication / Drug Name CommentOMEGA‐3S/DHA/EPA/FISH OIL [OMEGA POWER] (CAP) 1050 MG QL: 1 PER DAYOMEGA‐3S/DHA/EPA/FISH OIL [OMEGA‐3 FISH OIL] (CAP DR) 1000‐1400 QL: 1 PER DAYOMEGA‐3S/DHA/EPA/FISH OIL [VASCAZEN] (CAP) 900‐110 MG QL: 1 PER DAY

TIER 3FENOFIBRATE,MICRONIZED (CAP) 134 MG, 200 MG ST

LOOP DIURETICSTIER 1

FUROSEMIDE (SOLUTION) 10 MG/ML, 40MG/5MLFUROSEMIDE (TAB) 20 MG, 40 MG, 80 MGTORSEMIDE (TAB) 5 MG, 10 MG, 20 MG, 100 MG

TIER 3BUMETANIDE (TAB) 0.5 MG, 1 MG, 2 MG

POTASSIUM SPARING DIURETICSTIER 1

AMILORIDE (TAB) 5 MGSPIRONOLACTONE (TAB) 100 MG, 25 MG, 50 MG

POTASSIUM SPARING DIURETICS IN COMBINATIONTIER 1

AMILORIDE/HCTZ (TAB) 5 MG‐50 MGSPIRONOLACT/HCTZ (TAB) 25 MG‐25MGTRIAMTERENE/HCTZ (CAP) 37.5‐25 MGTRIAMTERENE/HCTZ (TAB) 75 MG‐50MG, 37.5‐25 MG

TIER 2SPIRONOLACT/HCTZ [ALDACTAZIDE] (TAB) 50 MG‐50MG

PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIBTIER 1

SILDENAFIL CIT (TAB) 20 MG QL: 3 IN 1 DAYS, AL: > 10 YEARS

THIAZIDE AND RELATED DIURETICSTIER 1

HCTZ (CAP) 12.5 MGHCTZ (TAB) 25 MG, 50 MG, 12.5 MGINDAPAMIDE (TAB) 2.5 MG, 1.25 MG

TIER 3CHLORTHALIDONE (TAB) 25 MG, 50 MGMETOLAZONE (TAB) 10 MG, 2.5 MG, 5 MG

VASODILATORS,CORONARYTIER 1

ISOSORBIDE DINIT (TAB ER) 40 MGISOSORBIDE DINIT (TAB) 10 MG, 20 MG, 30 MG, 5 MGISOSORBIDE MONONIT (TAB ER 24H) 60 MG, 120 MG, 30 MGISOSORBIDE MONONIT (TAB) 20 MGNITROGLYCERIN (PATCH TD24) 0.4MG/HR, 0.1MG/HR, 0.2MG/HR, 0.6MG/HR

NITROGLYCERIN (TAB SUBL) 0.3 MG, 0.4 MG, 0.6 MG






ISOSORBIDE DINIT [DILATRATE‐SR] (CAP ER) 40 MGISOSORBIDE DINIT [ISORDIL] (TAB) 40 MGNITROGLYCERIN [NITRO‐BID] (OINT. ) 2 %NITROGLYCERIN [NITRO‐DUR] (PATCH TD24) 0.3 MG/HR, 0.8MG/HR

TIER 3NITROGLYCERIN [NITROMIST] (SPRAY) 400MCG/SPR

CONTRACEPTION/OXYTOCICSCONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC

TIER 2ETONOGESTREL/ETHINYL ESTRADIOL [NUVARING] (VAG RING) .12‐.015MG DL: 100 DAYS

CONTRACEPTIVES,IMPLANTABLETIER 2

ETONOGESTREL [NEXPLANON] (IMPLANT) 68 MG DL: 100 DAYSCONTRACEPTIVES,INJECTABLE

TIER 1MEDROXYPROGESTERONE ACET (SYRINGE) 150 MG/ML DL: 100 DAYSMEDROXYPROGESTERONE ACET (VIAL) 150 MG/ML DL: 100 DAYS

CONTRACEPTIVES,INTRAVAGINALTIER 1

NONOXYNOL 9 (FOAM/APPL) 12.5 % DL: 100 DAYSNONOXYNOL 9 (GEL/PF APP) 4 % DL: 100 DAYS

TIER 2NONOXYNOL 9 [GYNOL II] (JELLY/APPL) 3 % DL: 100 DAYSNONOXYNOL 9 [TODAY CONTRACEPTIVE SPONGE] (CON.SPONGE) 1000 MG DL: 100 DAYS

NONOXYNOL 9 [VCF] (FILM) 28 % DL: 100 DAYSCONTRACEPTIVES,ORAL

TIER 1DESOG‐E.ESTRADIOL/E.ESTRADIOL (TAB) 21‐5 (28) DL: 100 DAYSDESOGESTREL‐ETHINYL ESTRADIOL (TAB) 7 DAYS X 3, 0.15‐0.03 DL: 100 DAYSETHINYL ESTRADIOL/DROSPIRENONE (TAB) 0.03MG‐3MG, 0.02‐3(28) DL: 100 DAYSETHYNODIOL D‐ETHINYL ESTRADIOL (TAB) 1 MG‐35MCG, 1 MG‐50MCG DL: 100 DAYSLEVONORGESTREL (TAB) 1.5 MG DL: 100 DAYSLEVONORGESTREL‐ETHIN ESTRADIOL (TAB) 0.15‐0.03, 6‐5‐10, 0.1‐0.02MG, 90‐20 MCG

DL: 100 DAYS

LEVONORGESTREL‐ETHIN ESTRADIOL (TBDSPK 3MO) 0.15‐0.03 DL: 100 DAYSL‐NORGEST/E.ESTRADIOL‐E.ESTRAD (TBDSPK 3MO) 100‐20(84), 150‐30(84) DL: 100 DAYS

NORETH‐ETHINYL ESTRADIOL/IRON (TAB CHEW) 0.8‐25(24), 0.4‐35(21) DL: 100 DAYSNORETHINDRONE (TAB) 0.35 MG DL: 100 DAYSNORETHINDRONE AC‐ETH ESTRADIOL (TAB) 1.5‐0.03MG, 1MG‐20MCG DL: 100 DAYSNORETHINDRONE‐E.ESTRADIOL‐IRON (TAB) 1MG‐20(24), 1.5‐30(21), 1MG‐20(21), 5‐7‐9‐7

DL: 100 DAYS





Therapeutic Indication / Drug Name CommentNORETHINDRONE‐ETHINYL ESTRAD (TAB) MULTIPLE STRENGTHS DL: 100 DAYSNORGESTIMATE‐ETHINYL ESTRADIOL (TAB) 0.25‐0.035, 7DAYSX3 28, 7DAYSX3 LO DL: 100 DAYS

NORGESTREL‐ETHINYL ESTRADIOL (TAB) 0.3‐0.03MG, 0.5 MG‐50 DL: 100 DAYSCONTRACEPTIVES,TRANSDERMAL

TIER 1NORELGESTROMIN/ETHIN.ESTRADIOL (PATCH TDWK) 150‐35/24H DL: 100 DAYS

DIAPHRAGMS/CERVICAL CAPTIER 1

DIAPHRAGMS, CONTOURED [CAYA CONTOURED] (DIAPHRAGM) 65 MM‐80MM DL: 100 DAYS

DIAPHRAGMS, WIDE SEAL [WIDE SEAL DIAPHRAGM] (DIAPHRAGM) MULTIPLE STRENGTHS

DL: 100 DAYS

OXYTOCICSTIER 1

METHYLERGONOVINE (TAB) 0.2 MGCOUGH AND COLD

1ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONSTIER 1

CHLORPHENIRAMINE/PSEUDOEPHED (LIQUID) 2‐30MG/5MLCHLORPHENIRAMINE/PSEUDOEPHED (TAB) 4 MG‐60 MGPHENYLEPHRINE HCL/PROMETH (SYRUP) 5‐6.25MG/5TRIPROLIDINE/PSEUDOEPHEDRINE (SYRUP) 1.25‐30/5TRIPROLIDINE/PSEUDOEPHEDRINE (TAB) 2.5MG‐60MG

1ST GEN ANTIHISTAMINE-DECONGESTANT-ANALGESIC COMBTIER 1

PSEUDOEPHED/ACETAMINOPHEN/CPM (TAB) 30‐500‐2MGTIER 2

P‐EPHED HCL/ACETAMINOPHN/DPHA [BENADRYL] (TAB) 30MG‐500MGANALGESIC, NON-SAL.- 1ST GENERATION ANTIHISTAMINE

TIER 1ACETAMINOPHEN/DIPHENHYDRAMINE (TAB) 500MG‐25MG

ANTITUSSIVES,NON-NARCOTICTIER 1

BENZONATATE (CAP) 100 MG, 200 MG QL: 30 IN 365 DAYSDEXTROMETHORPHAN HBR (LIQUID) 15 MG/5 MLDEXTROMETHORPHAN HBR (SYRUP) 5 MG/5 ML, 15 MG/5 ML, 7.5 MG/5ML

TIER 2DEXTROMETHORPHAN HBR [SCOT‐TUSSIN DM COUGH CHASER] (LOZENGE) 2.5 MGDEXTROMETHORPHAN HBR [SCOT‐TUSSIN] (LIQUID) 10 MG/5 ML

DECONGEST-ANALGESIC,NON-SALICYLATE COMB.TIER 2





Therapeutic Indication / Drug Name CommentPSEUDOEPHEDRINE/ACETAMINOPHEN [NEXAFED SINUS PRESSURE‐PAIN] (TAB) 30MG‐325MG

DECONGESTANT-EXPECTORANT COMBINATIONSTIER 1

GUAIFENESIN/PSEUDOEPHEDRNE (TAB ER 12H) 600MG‐60MG, 1200‐120MG

GUAIFENESIN/PSEUDOEPHEDRNE (TAB) 400MG‐60MGTIER 2

GUAIFENESIN/PSEUDOEPHEDRNE [TUSNEL PEDIATRIC] (DROPS) 50‐7.5MG/1

DECONGESTANTS, ORALTIER 2

PSEUDOEPHEDRINE [SUDAFED 24‐HOUR] (TAB ER 24H) 240 MGEXPECTORANTS

TIER 1GUAIFENESIN (LIQUID) 200 MG/5ML, 100 MG/5MLGUAIFENESIN (TAB ER 12H) 600 MGGUAIFENESIN (TAB) 400 MG, 200 MG

NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGESTTIER 1

PROMETHAZINE/PHENYLEPH/CODEINE (SYRUP) 6.25‐5‐10 AL: ≥ 12 YEARSNARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT COMB

TIER 1PSEUDOEPHED/CODEINE/GUAIFEN (SYRUP) 30‐10‐100 AL: ≥ 12 YEARS

NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINETIER 1

PROMETHAZINE HCL/CODEINE (SYRUP) 6.25‐10/5 AL: ≥ 12 YEARSNARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION

TIER 1CODEINE PHOSPHATE/GUAIFENESIN (LIQUID) 10‐100MG/5, 20‐200/10 AL: ≥ 12 YEARS

NON-NARC ANTITUS-1ST GEN ANTIHIST-DECON-ANALGES CBTIER 1

DM/P‐EPHED/ACETAMINOPH/DOXYLAM (CAP) 15‐30‐325DM/P‐EPHED/ACETAMINOPH/DOXYLAM (LIQUID) 30‐12.5/30DM/PSEUDOEPHED/ACETAMINOPH/CPM (PACKET) 30‐60‐1000

NON-NARC ANTITUSS-DECONGESTANT-ANALGESIC-EXPECT CBTIER 1

PSEUDOEPH/DM/GUAIFEN/ACETAMIN (CAP) 30‐10‐250NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB.

TIER 1PROMETHAZINE/DEXTROMETHORPHAN (SYRUP) 6.25‐15/5

NON-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT CMBTIER 1

GUAIFENESIN/DM/PSEUDOEPHEDRINE (LIQUID) 50‐5‐15/5GUAIFENESIN/DM/PSEUDOEPHEDRINE (SYRUP) 100‐10‐30





Therapeutic Indication / Drug Name CommentGUAIFENESIN/DM/PSEUDOEPHEDRINE (TAB) 200‐10‐30

TIER 2GUAIFENESIN/DM/PSEUDOEPHEDRINE [TUSNEL DM PEDIATRIC] (DROPS) 2.5‐7.5/ML

NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB.TIER 1

GUAIFENESIN/DEXTROMETHORPHAN (LIQUID) 100‐10MG/5, 200‐30MG/5GUAIFENESIN/DEXTROMETHORPHAN (SYRUP) 100‐10MG/5

NOSE PREPARATIONS, VASOCONSTRICTORS (RX)TIER 2

EPINEPHRINE [ADRENALIN CHLORIDE] (SOLUTION) 1 MG/MLNOSE PREPARATIONS, VASOCONSTRICTORS(OTC)

TIER 1OXYMETAZOLINE (MIST) 0.05 %OXYMETAZOLINE (SPRAY) 0.05 %OXYMETAZOLINE (SPRAY/PUMP) 0.05 %

SYMPATHOMIMETIC AGENTSTIER 1

PSEUDOEPHEDRINE (DROPS) 9.4MG/MLPSEUDOEPHEDRINE (LIQUID) 15 MG/5 MLPSEUDOEPHEDRINE (TAB ER) 120 MGPSEUDOEPHEDRINE (TAB) 30 MG, 60 MG

DERMATOLOGYACNE AGENTS,TOPICAL

TIER 1SULFACETAMIDE SOD (SUSPENSION) 10 % PA

ANTIPRURITICS,TOPICALTIER 1

DIPHENHYDRAMINE (CREAM ) 2 %DIPHENHYDRAMINE (GEL (ML)) 2 %DIPHENHYDRAMINE (SPRAY) 2 %DIPHENHYDRAMINE HCL/ZINC ACET (CREAM ) 2 %‐0.1 %

ANTIPSORIATIC AGENTS,SYSTEMICTIER 1

METHOXSALEN (CAP LQ RAP) 10 MGTIER 3

RISANKIZUMAB‐RZAA [SKYRIZI (2 SYRINGES) KIT] (SYRINGEKIT) 150MG/1.66 PA, MS

RISANKIZUMAB‐RZAA [SKYRIZI] (SYRINGE) 75 MG/0.83 PA, MSSECUKINUMAB [COSENTYX (2 SYRINGES)] (SYRINGE) 150 MG/ML PA, FL: FILLS≤1 IN 365 DAYS, MS

SECUKINUMAB [COSENTYX PEN (2 PENS)] (PEN INJCTR) 150 MG/ML PA, FL: FILLS≤1 IN 365 DAYS, MS

TILDRAKIZUMAB‐ASMN [ILUMYA] (SYRINGE) 100 MG/ML PA, MSANTIPSORIATICS AGENTS






ANTHRALIN [DRITHOCREME HP] (CREAM ) 1 %TIER 3

CALCIPOTRIENE (CREAM ) 0.005 % PA, QL: 60 IN 30 DAYSCALCIPOTRIENE (OINT. ) 0.005 % PA, QL: 60 IN 30 DAYSCALCIPOTRIENE (SOLUTION) 0.005 % PA, QL: 60 IN 30 DAYS

ANTISEBORRHEIC AGENTSTIER 1

SELENIUM SULFIDE (LOTION) 2.5 % PASELENIUM SULFIDE (SHAMPOO) 1 %SULFACETAMIDE SOD (CLEANSER) 10 % PA

TIER 2SULFACETAMIDE SOD [OVACE PLUS] (SHAMPOO) 10 % PA

EMOLLIENTSTIER 1

GLYCERIN (LIQUID) IODINE ANTISEPTICS

TIER 1POVIDONE‐IODINE (GEL (ML)) 10 %POVIDONE‐IODINE (LIQUID PKT) 10 %POVIDONE‐IODINE (MED. SWAB) 10 %POVIDONE‐IODINE (OINT. ) 10 %POVIDONE‐IODINE (SOLUTION) 7.5 %, 10 %POVIDONE‐IODINE (SPRAY) 10 %

TIER 2POVIDONE‐IODINE [BETADINE] (SOLUTION) 5 %POVIDONE‐IODINE [SUMMER'S EVE DOUCHE] (SOLUTION) 0.3 %

IRRITANTS/COUNTER-IRRITANTSTIER 1

CAPSAICIN (ADH. PATCH) 0.025 %CAPSAICIN (CREAM ) 0.025 %, 0.033 %, 0.075 %, 0.1 %MENTHOL (GEL (GRAM)) MENTHOL (POWDER) 1 %MENTHOL/ALOE VERA/VITAMIN E (GEL (GRAM)) 7 %

TIER 2MENTHOL [STOPAIN] (SPRAY) 6 %MENTHOL/ALOE VERA EXTRACT [ICY HOT] (GEL (GRAM)) 16 %METHYL SALICYLATE/MENTHOL [SALONPAS] (ADH. PATCH) 10 %‐3 % PA

KERATOLYTICSTIER 1

PODOFILOX (SOLUTION) 0.5 %OXIDIZING AGENTS

TIER 1CARBAMIDE PEROXIDE (SOLUTION) 10 %

PROTECTIVES






ALUMINUM HYDROXIDE (OINT. ) , 1.2 %CORN STARCH (POWDER) 83.7 %VIT A/VITAMIN D3/E/ALOE V/ZINC (OINT. ) ZINC OXIDE (OINT. ) 16 %, 20 %, 12.8%, ZINC OXIDE (PASTE ) 25 %

ROSACEA AGENTS, TOPICALTIER 1

METRONIDAZOLE (CREAM ) 0.75 % PAMETRONIDAZOLE (GEL (GRAM)) 0.75 % PAMETRONIDAZOLE (LOTION) 0.75 % PA

TIER 2METRONIDAZOLE [NORITATE] (CREAM ) 1 % PA

TOPICAL AGENTS,MISCELLANEOUSTIER 1

UREA (CREAM ) 20 % QL: 85 IN 30 DAYSTOPICAL ANTIBIOTICS

TIER 1BACITRACIN (OINT. ) 500 UNIT/GBACITRACIN (PACKET) 500 UNIT/GBACITRACIN ZINC (OINT. ) 500 UNIT/GBACITRACIN ZINC (PACKET) 500 UNIT/GBACITRACIN ZINC/POLYMYXIN B (OINT. ) 500‐10K/GBACITRACIN/POLYMYXIN B SULF (PACKET) GENTAMICIN SULF (OINT. ) 0.1 %, 0.3 %MUPIROCIN (OINT. ) 2 % QL: 112 IN 30 DAYSNEOMYCIN/BACITRACIN/POLYMYXINB (OINT PACK) 3.5‐400‐5KNEOMYCIN/BACITRACIN/POLYMYXINB (OINT. ) 3.5‐400‐5KNEOMYCN/BACITRC/POLYMYX/PRAMOX (OINT. ) 3.5‐10K‐10

TIER 3GENTAMICIN SULF (CREAM ) 0.1 %MUPIROCIN CALC (CREAM ) 2 % ST

TOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDALTIER 2

NEOMYC/BACIT/POLYMYX/HYDROCORT [CORTISPORIN] (OINT. ) 1 %NEOMYCIN/POLYMYXIN B/HYDROCORT [CORTISPORIN] (CREAM ) 0.5 %

TOPICAL ANTIFUNGAL/ANTIINFLAMMATORY,STERIOD AGENTTIER 1

CLOTRIMAZOLE/BETAMETHASONE DIP (CREAM ) 1 %‐0.05 %TOPICAL ANTIFUNGALS

TIER 1CICLOPIROX (SOLUTION) 8 %CLOTRIMAZOLE (CREAM ) 1 %CLOTRIMAZOLE (SOLUTION) 1 %MICONAZOLE NIT (AERO POWD) 2 %





Therapeutic Indication / Drug Name CommentMICONAZOLE NIT (CREAM ) 2 %MICONAZOLE NIT (CREAM(ML)) 2 %MICONAZOLE NIT (OINT. ) 2 %MICONAZOLE NIT (POWDER) 2 %MICONAZOLE NIT (TINCTURE) 2 %NYSTATIN (CREAM ) 100000/GNYSTATIN (OINT. ) 100000/GNYSTATIN (POWDER) 100000/G QL: 120 IN 30 DAYSTERBINAFINE (CREAM ) 1 %TOLNAFTATE (AERO POWD) 1 %TOLNAFTATE (CREAM ) 1 %TOLNAFTATE (POWDER) 1 %TOLNAFTATE (SOLUTION) 1 %

TIER 2MICONAZOLE NIT [LOTRIMIN AF] (SPRAY) 2 %TERBINAFINE [LAMISIL] (SPRAY) 1 % PA

TIER 3KETOCONAZOLE (CREAM ) 2 % FL: 3 IN 365 DAYS, STKETOCONAZOLE (SHAMPOO) 2 % STKETOCONAZOLE [NIZORAL A‐D] (SHAMPOO) 1 % STNYSTATIN/TRIAMCIN (CREAM ) 100000‐0.1 STNYSTATIN/TRIAMCIN (OINT. ) 100000‐0.1 ST

TOPICAL ANTI-INFLAMMATORY STEROIDALTIER 1

BETAMETHASONE DIP (CREAM ) 0.05 % PABETAMETHASONE DIP (GEL (GRAM)) 0.05 % PABETAMETHASONE DIP (LOTION) 0.05 % PABETAMETHASONE DIP (OINT. ) 0.05 % PABETAMETHASONE VALERATE (CREAM ) 0.1 % PABETAMETHASONE VALERATE (LOTION) 0.1 % PABETAMETHASONE VALERATE (OINT. ) 0.1 % PABETAMETHASONE/PROPYLENE GLYC (CREAM ) 0.05 % PABETAMETHASONE/PROPYLENE GLYC (LOTION) 0.05 % PABETAMETHASONE/PROPYLENE GLYC (OINT. ) 0.05 % PACLOBETASOL PROP (CREAM ) 0.05 % PACLOBETASOL PROP (OINT. ) 0.05 % PACLOBETASOL PROP (SOLUTION) 0.05 % PACLOBETASOL PROP/EMOLL (CREAM ) 0.05 % PAFLUOCINOLONE ACET (OIL) 0.01 % PAFLUOCINONIDE (CREAM ) 0.05 % PAFLUOCINONIDE (GEL (GRAM)) 0.05 % PAFLUOCINONIDE (OINT. ) 0.05 % PAFLUOCINONIDE (SOLUTION) 0.05 % PAFLUOCINONIDE/EMOLLIENT BASE (CREAM ) 0.05 % PAFLUTICASONE PROP (CREAM ) 0.05 % PA





Therapeutic Indication / Drug Name CommentFLUTICASONE PROP (OINT. ) 0.005 % PAHYDROCORTISONE (CREAM ) 0.5 %, 1 %, 2.5 %HYDROCORTISONE (CREAM PACK) 1 %HYDROCORTISONE (CRM/PE APP) 1 %HYDROCORTISONE (GEL (GRAM)) 1 %HYDROCORTISONE (LOTION) 2 %, 0.5 %, 1 %, 2.5 %HYDROCORTISONE (OINT. ) 1 %, 0.5 %, 2.5 %HYDROCORTISONE (SOLUTION) 1 %HYDROCORTISONE (SPRAY) 1 %HYDROCORTISONE ACET (CREAM ) 1 %, 0.5 %HYDROCORTISONE ACET (OINT. ) 1 %HYDROCORTISONE BUTYRATE (SOLUTION) 0.1 % PAHYDROCORTISONE/ALOE VERA (CREAM ) 1 %MOMETASONE FUROATE (CREAM ) 0.1 % PAMOMETASONE FUROATE (OINT. ) 0.1 % PAMOMETASONE FUROATE (SOLUTION) 0.1 % PATRIAMCINOLONE ACET (CREAM ) 0.025 %, 0.1 %, 0.5 % QL: 454 IN 365 DAYSTRIAMCINOLONE ACET (LOTION) 0.025 %, 0.1 % QL: 240 IN 365 DAYSTRIAMCINOLONE ACET (OINT. ) 0.025 %, 0.1 %, 0.5 % QL: 454 IN 365 DAYS

TOPICAL ANTI-INFLAMMATORY, NSAIDSTIER 1

DICLOFENAC SOD (GEL (GRAM)) 1 % QL: 100 IN 23 DAYSTOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGNTS

TIER 3FLUOROURACIL (CREAM ) 0.5 %, 5 % PAFLUOROURACIL (SOLUTION) 2 %, 5 % PAFLUOROURACIL [FLUOROPLEX] (CREAM ) 1 % PA

TOPICAL ANTIPARASITICSTIER 1

PERMETHRIN (CREAM ) 5 %PERMETHRIN (LIQUID) 1 %PIPERONYL BUTOX/PYRETHR/PERMET (KIT) 4‐.33‐.5%PIPERONYL BUTOXIDE/PYRETHRINS (SHAMPOO) 4%‐0.33%

TIER 3MALATHION (LOTION) 0.5 % ST

TOPICAL IMMUNOSUPPRESSIVE AGENTSTIER 1

TACROLIMUS (OINT. ) 0.03 %, 0.1 % PATOPICAL LOCAL ANESTHETICS

TIER 1LIDOCAINE (ADH. PATCH) 5 % PALIDOCAINE (OINT. ) 5 % QL: 60 IN 30 DAYSLIDOCAINE/PRILOCAINE (CREAM ) 2.5 %‐2.5% QL: 60 IN 30 DAYS

TIER 2





Therapeutic Indication / Drug Name CommentTETRACAINE/BENZOCAINE/BUTAMBEN [CETACAINE ANESTHETIC] (LIQUID) 2%‐14%‐2%

TOPICAL PREPARATIONS,ANTIBACTERIALSTIER 1

CHLORHEXIDINE GLUCONATE (LIQUID) 4 %, 2 %TOPICAL PREPARATIONS,MISCELLANEOUS

TIER 1CALCIUM ACET/ALUMINUM SULF (POWD PACK) 51 %‐49 %, 839‐1191MG, 952‐1347MG

PA

SOD CHLORIDE (SPRAY) 0.9 %, 0.65 %TIER 2

SOD CHLORIDE [NORMLGEL] (GEL (GRAM)) 0.9 %TOPICAL SULFONAMIDES

TIER 1SILVER SULFADIAZINE (CREAM ) 1 %

DIABETESANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDE COMB.

TIER 1ALOGLIPTIN BENZ/METFORMIN (TAB) 12.5‐500MG, 12.5‐1000 QL: 2 IN 1 DAYS

TIER 2LINAGLIPTIN/METFORMIN [JENTADUETO XR] (TAB BP 24H) 2.5‐1000MG, 5MG‐1000MG

PA

LINAGLIPTIN/METFORMIN [JENTADUETO] (TAB) 2.5‐500 MG, 2.5‐850 MG, 2.5‐1000MG

PA

ANTIHYPERGLY,DPP-4 ENZYME INHIB &THIAZOLIDINEDIONETIER 1

ALOGLIPTIN BENZ/PIOGLITAZONE (TAB) MULTIPLE STRENGTHS QL: 1 IN 1 DAYSANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST)

TIER 2EXENATIDE MICROSPHERES [BYDUREON BCISE] (AUTO INJCT) 2MG/0.85ML PA

EXENATIDE MICROSPHERES [BYDUREON PEN] (PEN INJCTR) 2MG/0.65ML PALIXISENATIDE [ADLYXIN] (PEN INJCTR) 20 MCG/0.2, 10‐20 (1) PA

TIER 3DULAGLUTIDE [TRULICITY] (PEN INJCTR) 0.75MG/0.5, 1.5 MG/0.5 PAEXENATIDE [BYETTA] (PEN INJCTR) 5MCG/0.02, 10MCG/0.04 PALIRAGLUTIDE [VICTOZA 2‐PAK] (PEN INJCTR) 0.6 MG/0.1 PA

ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIBTIER 2

ERTUGLIFLOZIN PIDOLATE [STEGLATRO] (TAB) 5 MG, 15 MG QL: 1 IN 1 DAYS, STTIER 3

EMPAGLIFLOZIN [JARDIANCE] (TAB) 10 MG, 25 MG PAANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIB (N-S)

TIER 1ACARBOSE (TAB) 100 MG, 50 MG, 25 MG





Therapeutic Indication / Drug Name CommentMIGLITOL (TAB) 25 MG, 50 MG, 100 MG

ANTIHYPERGLYCEMIC, DPP-4 INHIBITORSTIER 1

ALOGLIPTIN BENZOATE (TAB) 25 MG, 12.5 MG, 6.25 MG QL: 1 IN 1 DAYSTIER 2

LINAGLIPTIN [TRADJENTA] (TAB) 5 MG PA, QL: 1 IN 1 DAYSANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE

TIER 1GLIMEPIRIDE (TAB) 1 MG, 2 MG, 4 MGGLIPIZIDE (TAB ER 24) 10 MG, 5 MG, 2.5 MGGLIPIZIDE (TAB) 5 MG, 10 MGGLYBURIDE (TAB) 1.25 MG, 2.5 MG, 5 MGGLYBURIDE,MICRONIZED (TAB) 1.5 MG, 3 MG, 6 MG

TIER 3NATEGLINIDE (TAB) 60 MG, 120 MG QL: 3 IN 1 DAYS

ANTIHYPERGLYCEMIC, INSULIN-RESPONSE ENHANCER (N-S)TIER 1

PIOGLITAZONE (TAB) 15 MG, 30 MG, 45 MGTIER 2

ROSIGLITAZONE [AVANDIA] (TAB) 2 MG, 4 MGANTIHYPERGLYCEMIC,BIGUANIDE TYPE(NON-SULFONYLUREA)

TIER 1METFORMIN (TAB ER 24H) 750 MG, 500 MGMETFORMIN (TAB) 500 MG, 850 MG, 1000 MG

TIER 3METFORMIN (TAB ER 24) 1000 MG, 500 MG

ANTIHYPERGLYCEMIC,INSULIN & GLP-1 RECEPTOR AGONISTTIER 2

INSULIN DEGLUDEC/LIRAGLUTIDE [XULTOPHY 100‐3.6] (INSULN PEN) 100‐3.6/ML PA

TIER 3INSULIN GLARGINE/LIXISENATIDE [SOLIQUA 100‐33] (INSULN PEN) 100‐33/ML PA

ANTIHYPERGLYCEMIC,INSULIN-REL STIM.& BIGUANIDE CMBTIER 1

GLIPIZIDE/METFORMIN (TAB) 2.5‐250 MG, 2.5‐500 MG, 5 MG‐500MGGLYBURIDE/METFORMIN (TAB) 1.25‐250MG, 5 MG‐500MG, 2.5‐500 MG

ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR & BIGUANIDE COMBTIER 2

ERTUGLIFLOZIN/METFORMIN [SEGLUROMET] (TAB) MULTIPLE STRENGTHS QL: 2 IN 1 DAYS, ST

TIER 3EMPAGLIFLOZIN/METFORMIN [SYNJARDY XR] (TAB BP 24H) MULTIPLE STRENGTHS

PA

EMPAGLIFLOZIN/METFORMIN [SYNJARDY] (TAB) MULTIPLE STRENGTHS PA





Therapeutic Indication / Drug Name CommentDIABETIC ULCER PREPARATIONS,TOPICAL

TIER 2BECAPLERMIN [REGRANEX] (GEL (GRAM)) 0.01 % PA

HYPERGLYCEMICSTIER 1

DEXTROSE (GEL (GRAM)) 40 %DEXTROSE (GEL PACKET) 15 G/33 GDEXTROSE (LIQUID) 15G/59ML, 15 G/60 MLDEXTROSE (TAB CHEW) 1 GDEXTROSE (TAB CHEW) 4 G FL: FILLS≤2 IN 30 DAYS

TIER 2DEXTROSE/DEXTRIN/MALTOSE [INSTA‐GLUCOSE] (GEL (GRAM)) 24 G/31GGLUCAGON [GVOKE HYPOPEN] (AUTO INJCT) 0.5 MG/0.1, 1 MG/0.2ML QL: 6 PER YEARGLUCAGON [GVOKE SYRINGE] (SYRINGE) 0.5 MG/0.1, 1 MG/0.2ML QL: 6 PER YEARGLUCAGON,HUMAN RECOMBINANT [GLUCAGEN] (VIAL) 1 MG, 1 MG/ML QL: 6 PER YEAR

4 GLUCAGON,HUMAN RECOMBINANT [GLUCAGON] (VIAL) 1 MG, 1 MG/ML QL: 6 PER YEARGLUCAGON [BAQSIMI] (SPRAY) 3 MG QL: 6 PER YEAR

INSULINSTIER 1

INSULIN LISPRO [HUMALOG] (INSULN PEN) 100/MLINSULIN LISPRO [HUMALOG] (VIAL) 100/ML

TIER 2INSULIN GLARGINE [BASAGLAR KWIKPEN] (INSULN PEN) 100/ML (3)INSULIN LISPRO [ADMELOG SOLOSTAR] (INSULN PEN) 100/MLINSULIN LISPRO [ADMELOG] (VIAL) 100/MLINSULIN LISPRO PROTAMIN/LISPRO [HUMALOG MIX 75‐25 KWIKPEN] (INSULN PEN) 75‐25/MLINSULIN LISPRO PROTAMIN/LISPRO [HUMALOG MIX 75‐25] (VIAL) 75‐25/ML

INSULIN NPH HUM/REG INSULIN HM [NOVOLIN 70‐30 FLEXPEN] (INSULN PEN) 70‐30/MLINSULIN NPH HUM/REG INSULIN HM [NOVOLIN 70‐30] (VIAL) 70‐30/MLINSULIN NPH HUMAN ISOPHANE [NOVOLIN N] (VIAL) 100/MLINSULIN REGULAR, HUMAN [HUMULIN R U‐500 KWIKPEN] (INSULN PEN) 500/ML (3)INSULIN REGULAR, HUMAN [NOVOLIN R] (VIAL) 100/ML

TIER 3INSULIN ASPART PROT/INSULN ASP [NOVOLOG MIX 70‐30 FLEXPEN] (INSULN PEN) 70‐30/ML

ST

INSULIN ASPART PROT/INSULN ASP [NOVOLOG MIX 70‐30] (VIAL) 70‐30/ML ST

INSULIN DEGLUDEC [TRESIBA FLEXTOUCH U‐100] (INSULN PEN) 100/ML (3) PA

INSULIN DEGLUDEC [TRESIBA FLEXTOUCH U‐200] (INSULN PEN) 200/ML (3) PA





Therapeutic Indication / Drug Name CommentINSULIN DETEMIR [LEVEMIR FLEXTOUCH] (INSULN PEN) 100/ML (3) STINSULIN DETEMIR [LEVEMIR] (VIAL) 100/ML STINSULIN GLARGINE [LANTUS] (VIAL) 100/ML STINSULIN GLARGINE [TOUJEO MAX SOLOSTAR] (INSULN PEN) 300/ML (3) PAINSULIN GLARGINE [TOUJEO SOLOSTAR] (INSULN PEN) 300/ML PAINSULIN GLULISINE [APIDRA] (VIAL) 100/ML DL: 63 DAYS, STINSULIN LISPRO [HUMALOG JUNIOR KWIKPEN] (INS PEN HF) 100/ML PAINSULIN LISPRO [HUMALOG KWIKPEN U‐200] (INSULN PEN) 200/ML (3) PAINSULIN NPH HUM/REG INSULIN HM [HUMULIN 70/30 KWIKPEN] (INSULN PEN) 70‐30/ML

ST

INSULIN NPH HUM/REG INSULIN HM [HUMULIN 70‐30] (VIAL) 70‐30/ML STINSULIN NPH HUMAN ISOPHANE [HUMULIN N] (VIAL) 100/ML STINSULIN REGULAR, HUMAN [HUMULIN R] (VIAL) 100/ML STINSULIN DEGLUDEC [TRESIBA] (VIAL) 100/ML PAINSULIN LISPRO PROTAMIN/LISPRO [HUMALOG MIX 50‐50 KWIKPEN] (INSULN PEN) 50‐50/MLINSULIN NPH HUMAN ISOPHANE [HUMULIN N KWIKPEN] (INSULN PEN) 100/ML (3)

EAR DISORDERSEAR PREPARATIONS, MISC. ANTI-INFECTIVES

TIER 1ACETIC ACID (SOLUTION) 2 %, HYDROCORTISONE/ACETIC ACID (DROPS) 1 %‐2 %

EAR PREPARATIONS,ANTIBIOTICSTIER 1

CIPROFLOXACIN (DROPERETTE) 0.2 %NEOMYCIN/POLYMYXIN B/HYDROCORT (SOLUTION) 3.5‐10K‐1

TIER 3NEOMYC/COLIST/HYDROCORT/THONZN [COLY‐MYCIN S] (DROPS SUSP)

EAR PREPARATIONS,EAR WAX REMOVERSTIER 1

CARBAMIDE PEROXIDE (DROPS) 6.5 %OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICS

TIER 2CIPROFLOXACIN HCL/DEXAMETH [CIPRODEX] (DROPS SUSP) 0.3 %‐0.1%

TIER 3CIPROFLOXACIN/HYDROCORTISONE [CIPRO HC] (DROPS SUSP) 0.2 %‐1 %

ELECTROLYTE REGULATIONELECTROLYTE DEPLETERS

TIER 1CALCIUM ACET (CAP) 667 MGCALCIUM ACET (TAB) 667 MGSEVELAMER CARBONATE (POWD PACK) 0.8 G, 2.4 G PASEVELAMER CARBONATE (TAB) 800 MG

TIER 3





Therapeutic Indication / Drug Name CommentSEVELAMER HCL (TAB) 400 MG, 800 MG PA

POTASSIUM REPLACEMENTTIER 1

POTASSIUM &MAGNESIUM ASPARTATE (CAP) 250‐250 MGPOTASSIUM (TAB) 99 MGPOTASSIUM BICARBONATE/CIT AC (TAB EFF) 25 MEQPOTASSIUM CHLORIDE (CAP ER) 8 MEQ, 10 MEQPOTASSIUM CHLORIDE (TAB ER PRT) 10 MEQ, 20 MEQPOTASSIUM CHLORIDE (TAB ER) 10 MEQ, 8 MEQ, 20 MEQPOTASSIUM GLUC (TAB) 2.5 MEQ, 595(99)MG, 500(83)MG, 550(90)MG

TIER 3POTASSIUM CHLORIDE (LIQUID) 40MEQ/15ML, 20MEQ/15MLPOTASSIUM CHLORIDE (PACKET) 20 MEQ

SODIUM/SALINE PREPARATIONSTIER 1

0.9 % SOD CHLORIDE (SOLUTION) 0.9 %ENDOCRINE DISORDERS

ANTIDIURETIC AND VASOPRESSOR HORMONESTIER 1

DESMOPRESSIN ACET (TAB) 0.1 MG, 0.2 MG PATIER 2

DESMOPRESSIN ACET [STIMATE] (SPRAY/PUMP) 150/SPRAY PAANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR.

TIER 1LEUPROLIDE ACET (KIT) 1 MG/0.2ML PA, FL: FILLS≤1 IN 365 DAYS, MS

LEUPROLIDE ACET (VIAL) 1 MG/0.2ML PA, FL: FILLS≤1 IN 365 DAYS, MS

TIER 2GOSERELIN ACET [ZOLADEX] (IMPLANT) 10.8 MG, 3.6 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

LEUPROLIDE ACET [ELIGARD] (SYRINGE) 7.5 MG, 22.5 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

LEUPROLIDE ACET [LUPRON DEPOT] (SYRINGEKIT) 22.5 MG FL: FILLS≤1 IN 365 DAYS, ST, MS

TRIPTORELIN PAM [TRELSTAR] (VIAL) 11.25 MG, 3.75 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

ANTITHYROID PREPARATIONSTIER 1

METHIMAZOLE (TAB) 10 MG, 5 MGPROPYLTHIOURACIL (TAB) 50 MG

BONE FORMATION AGENTS - SCLEROSTIN INHIBITOR, MONOTIER 3

ROMOSOZUMAB‐AQQG [EVENITY (2 SYRINGES)] (SYRINGE) 210MG/2.34 PA, MSROMOSOZUMAB‐AQQG [EVENITY] (SYRINGE) 105MG/1.17 PA, MS





Therapeutic Indication / Drug Name CommentBONE RESORPTION INHIBITORS

TIER 1ALENDRONATE SOD (SOLUTION) 70 MG/75MLALENDRONATE SOD (TAB) 35 MG, 10 MG, 40 MG, 5 MG, 70 MGIBANDRONATE SOD (TAB) 150 MGRALOXIFENE (TAB) 60 MG

GROWTH HORMONESTIER 2

SOMATROPIN [GENOTROPIN] (CARTRIDGE) 12 MG/ML, 5 MG/ML PA, FL: FILLS≤1 IN 365 DAYS, MS

SOMATROPIN [GENOTROPIN] (SYRINGE) MULTIPLE STRENGTHS PA, FL: FILLS≤1 IN 365 DAYS, MS

SOMATROPIN [OMNITROPE] (VIAL) 5.8 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

LHRH(GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTSTIER 2

LEUPROLIDE ACET [LUPRON DEPOT] (SYRINGEKIT) 11.25 MG, 30 MG, 7.5 MG PA, FL: FILLS≤1 IN 365 DAYS, ST, MS

LHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTSTIER 2

ELAGOLIX SOD [ORILISSA] (TAB) 150 MG, 200 MG PALHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY

TIER 2LEUPROLIDE ACET [LUPRON DEPOT‐PED] (KIT) 11.25 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

LEUPROLIDE ACET [LUPRON DEPOT‐PED] (KIT) 7.5 MG, 15 MG FL: FILLS≤1 IN 365 DAYS, MSLEUPROLIDE ACET [LUPRON DEPOT‐PED] (SYRINGEKIT) 11.25 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

MENOPAUSAL SYMPT SUPP-SEL ESTROGEN RECEP MODULATORTIER 2

OSPEMIFENE [OSPHENA] (TAB) 60 MG PAPARATHYROID HORMONES

TIER 2PARATHYROID HORMONE [NATPARA] (CARTRIDGE) 25MCG/DOSE, 50MCG/DOSE, 75MCG/DOSE, 100 MCG

PA, FL: FILLS≤1 IN 365 DAYS, MS

PITUITARY SUPPRESSIVE AGENTSTIER 1

CABERGOLINE (TAB) 0.5 MG PATHYROID HORMONES

TIER 2LEVOTHYROXINE SOD [SYNTHROID] (TAB) MULTIPLE STRENGTHS

TIER 3LIOTHYRONINE SOD (TAB) 25 MCG, 5 MCG, 50 MCG ST

EYE DISORDERSARTIFICIAL TEARS






DEXTRAN 70/HYPROMELLOSE (DROPERETTE) DEXTRAN 70/HYPROMELLOSE (DROPS) 0.1%‐0.3%, GLYCERIN/PROPYLENE GLYCOL (DROPS) 0.3%‐1%POLYVINYL ALCOHOL (DROPS) 1.4 %POLYVINYL ALCOHOL/POVIDONE (DROPS) 0.5%‐0.6%

TIER 2DEXTRAN 70/HYPROMELLOSE/PF [GENTEAL TEARS] (DROPERETTE) 0.1%‐0.3%

CARBONIC ANHYDRASE INHIBITORSTIER 1

ACETAZOLAMIDE (CAP ER) 500 MGACETAZOLAMIDE (TAB) 125 MG, 250 MGMETHAZOLAMIDE (TAB) 50 MG, 25 MG

EYE ANTIBIOTIC-CORTICOID COMBINATIONSTIER 1

NEOMYCIN/BACIT/P‐MYX/HYDROCORT (OINT. ) 3.5‐10K‐1NEOMYCIN/POLYMYXIN B/DEXAMETHA (DROPS SUSP) 0.1 %NEOMYCIN/POLYMYXIN B/DEXAMETHA (OINT. ) 3.5‐10K‐.1NEOMYCIN/POLYMYXIN B/HYDROCORT (DROPS SUSP) 3.5‐10K‐10TOBRAMYCIN/DEXAMETHASONE (DROPS SUSP) 0.3 %‐0.1%

TIER 2TOBRAMYCIN/DEXAMETHASONE [TOBRADEX] (OINT. ) 0.3 %‐0.1%

EYE ANTIINFLAMMATORY AGENTSTIER 1

DEXAMETHASONE SOD PHOSPHATE (DROPS) 0.1 %DICLOFENAC SOD (DROPS) 0.1 %FLUOROMETHOLONE (DROPS SUSP) 0.1 %KETOROLAC TROMETHAMINE (DROPS) 0.4 %, 0.5 %PREDNISOLONE ACET (DROPS SUSP) 1 %

TIER 2DEXAMETHASONE [MAXIDEX] (DROPS SUSP) 0.1 %FLUOROMETHOLONE [FML FORTE] (DROPS SUSP) 0.25 %FLUOROMETHOLONE [FML S.O.P.] (OINT. ) 0.1 %PREDNISOLONE ACET [PRED MILD] (DROPS SUSP) 0.12 %

EYE ANTIVIRALSTIER 1

TRIFLURIDINE (DROPS) 1 %EYE PREPARATIONS, MISCELLANEOUS (OTC)

TIER 1LANOLIN/MINERAL OIL/PETROLATUM (OINT. ) MINERAL OIL/PETROLATUM,WHITE (OINT. ) 15 %‐83 %

TIER 2MINERAL OIL/PETROLATUM,WHITE [REFRESH LACRI‐LUBE] (OINT. ) 42.5‐56.8%





Therapeutic Indication / Drug Name CommentMINERAL OIL/PETROLATUM,WHITE [REFRESH P.M.] (OINT. ) 42.5‐57.3%

EYE SULFONAMIDESTIER 1

SULFACETAMIDE SOD (DROPS) 10 %SULFACETAMIDE SOD (OINT. ) 10 %SULFACETAMIDE/PREDNISOLONE SP (DROPS) 10 %‐0.23%

TIER 2SULFACETAMIDE/PREDNISOLONE [BLEPHAMIDE S.O.P.] (OINT) 10 %‐0.2 %

SULFACETAMIDE/PREDNISOLONE [BLEPHAMIDE] (DROPS SUSP) 10 %‐0.2 %

MIOTICS/OTHER INTRAOC. PRESSURE REDUCERSTIER 1

APRACLONIDINE (DROPS) 0.5 %BETAXOLOL (DROPS) 0.5 %BIMATOPROST (DROPS) 0.03 %BRIMONIDINE TARTRATE (DROPS) 0.15 %, 0.2 %CARTEOLOL (DROPS) 1 %DORZOLAMIDE (DROPS) 2 %LATANOPROST (DROPS) 0.005 %LEVOBUNOLOL (DROPS) 0.5 %METIPRANOLOL (DROPS) 0.3 %PILOCARPINE (DROPS) 1 %, 2 %, 4 %TIMOLOL (DROPS) 0.25 %, 0.5 %TIMOLOL (SOL‐GEL) 0.25 %, 0.5 %

TIER 2APRACLONIDINE [IOPIDINE] (DROPERETTE) 1 %DORZOLAMIDE HCL/TIMOLOL MALEAT [COSOPT] (DROPS) 22.3‐6.8/1ECHOTHIOPHATE IODIDE [PHOSPHOLINE IODIDE] (DROPS) 0.125 %TIMOLOL/PF [TIMOPTIC OCUDOSE] (DROPERETTE) 0.25 %, 0.5 %TRAVOPROST [TRAVATAN Z] (DROPS) 0.004 %

TIER 3BETAXOLOL [BETOPTIC S] (DROPS SUSP) 0.25 %BRINZOLAMIDE [AZOPT] (DROPS SUSP) 1 %

MYDRIATICSTIER 1

ATROPINE SULF (DROPS) 1 %ATROPINE SULF (OINT. ) 1 %CYCLOPENTOLATE (DROPS) 0.5 %, 1 %, 2 %HOMATROPINE HBR (DROPS) 5 %TROPICAMIDE (DROPS) 0.5 %, 1 %

TIER 2CYCLOPENTOLATE/PHENYLEPHRINE [CYCLOMYDRIL] (DROPS) 0.2 %‐1 %HYDROXYAMPHETAMINE/TROPICAMIDE [PAREMYD] (DROPS) 1 %‐0.25 %

OPHTHALMIC ANTIBIOTICS






BACITRACIN/POLYMYXIN B SULF (OINT. ) 500‐10K/GCIPROFLOXACIN (DROPS) 0.3 %ERYTHROMYCIN BASE (OINT. ) 5 MG/GRAMLEVOFLOXACIN (DROPS) 0.5 %MOXIFLOXACIN (DROPS) 0.5 %NEOMYCIN SULF/BACITRACIN/POLY (OINT. ) 3.5MG‐400NEOMYCIN/POLYMYXN B/GRAMICIDIN (DROPS) 1.75MG‐10KOFLOXACIN (DROPS) 0.3 %POLYMYXIN B SULF/TRIMETHOPRIM (DROPS) 10000‐1/MLTOBRAMYCIN (DROPS) 0.3 %

TIER 2MOXIFLOXACIN [MOXEZA] (DROPS VISC) 0.5 %TOBRAMYCIN [TOBREX] (OINT. ) 0.3 %

TIER 3CIPROFLOXACIN [CILOXAN] (OINT. ) 0.3 %GENTAMICIN SULF (DROPS) 0.3 %

OPHTHALMIC MAST CELL STABILIZERSTIER 1

CROMOLYN SOD (DROPS) 4 %TIER 3

NEDOCROMIL SOD [ALOCRIL] (DROPS) 2 %OPHTHALMIC PREPARATIONS, MISCELLANEOUS

TIER 1SOD CHLORIDE (DROPS) 2 %, 5 %, 0.65 %SOD CHLORIDE (OINT. ) 5 %

GOUT AND RELATED DISEASESCOLCHICINE

TIER 1COLCHICINE (TAB) 0.6 MG

HYPERURICEMIA TX - PURINE INHIBITORSTIER 1

ALLOPURINOL (TAB) 100 MG, 300 MGURICOSURIC AGENTS

TIER 1PROBENECID (TAB) 500 MGPROBENECID/COLCHICINE (TAB) 500‐0.5 MG

HEMATOLOGICAL DISORDERSANTICOAGULANTS,COUMARIN TYPE

TIER 1WARFARIN SOD (TAB) MULTIPLE STRENGTHS

ANTIFIBRINOLYTIC AGENTSTIER 1

TRANEXAMIC ACID (TAB) 650 MGDIRECT FACTOR XA INHIBITORS






APIXABAN [ELIQUIS] (TAB) 2.5 MG QL: 2 IN 1 DAYSAPIXABAN [ELIQUIS] (TAB) 5 MG QL: 74 IN 23 DAYSRIVAROXABAN [XARELTO] (TAB DS PK) 15 MG‐20MG FL: FILLS≤1 IN 180 DAYS

TIER 3RIVAROXABAN [XARELTO] (TAB) 10 MG, 15 MG, 20 MG

HEPARIN AND RELATED PREPARATIONSTIER 1

ENOXAPARIN SOD (SYRINGE) MULTIPLE STRENGTHSENOXAPARIN SOD (VIAL) 300MG/3MLHEPARIN SOD,PORCINE (SYRINGE) MULTIPLE STRENGTHSHEPARIN SOD,PORCINE (VIAL) 100/ML, 10 UNIT/MLHEPARIN SOD,PORCINE/PF (SYRINGE) MULTIPLE STRENGTHSHEPARIN SOD,PORCINE/PF (VIAL) 100/ML (1), 10 UNIT/ML

TIER 3FONDAPARINUX SOD (SYRINGE) 2.5 MG/0.5, 5MG/0.4ML, 7.5MG/0.6, 10MG/0.8ML

PLATELET AGGREGATION INHIBITORSTIER 1

ASPIRIN (TAB CHEW) 81 MGASPIRIN (TAB DR) 81 MG, 325 MG, 500 MG, 650 MGASPIRIN/DIPYRIDAMOLE (CPMP 12HR) 25MG‐200MGCILOSTAZOL (TAB) 100 MG, 50 MGCLOPIDOGREL BISULF (TAB) 75 MGPRASUGREL (TAB) 5 MG, 10 MG

SICKLE CELL ANEMIA AGENTSTIER 2

HYDROXYUREA [DROXIA] (CAP) 200 MG, 300 MG, 400 MGVITAMIN K PREPARATIONS

TIER 1PHYTONADIONE (VIT K1) (TAB) 5 MG, 100 MCG

HORMONAL DEFICIENCYANDROGEN/ESTROGEN PREPS FOR FEMALE SEXUAL DYSFUNC

TIER 2PRASTERONE (DHEA) [INTRAROSA] (INSERT) 6.5 MG PA

ANDROGENIC AGENTSTIER 1

TESTOSTERONE CYPIONATE (VIAL) 100 MG/ML, 200 MG/ML AL: <45 YOTIER 3

TESTOSTERONE (GEL (GRAM)) 50 MG (1%) PATESTOSTERONE (GEL MD PMP) 12.5/1.25G, 10 MG (2%) PATESTOSTERONE (GEL PACKET) 25MG(1%), 50 MG (1%) PATESTOSTERONE (SOL MD PMP) 30MG/1.5ML PA

ESTROGEN & SELECTIVE ESTROGEN RECEPT MOD(SERM)COMBTIER 2





Therapeutic Indication / Drug Name CommentESTROGENS,CONJ/BAZEDOXIFENE [DUAVEE] (TAB) 0.45‐20 MG PA

ESTROGENIC AGENTSTIER 1

ESTRADIOL (PATCH TDSW) MULTIPLE STRENGTHSESTRADIOL (PATCH TDWK) MULTIPLE STRENGTHSESTRADIOL (TAB) 1 MG, 2 MG, 0.5 MG, 10 MCGESTRADIOL/NORETHINDRONE ACET (TAB) 1 MG‐0.5MG, 0.5‐0.1 MG

TIER 2ESTRADIOL/NORETHINDRONE ACET [COMBIPATCH] (PATCH TDSW) .05‐.14/24, .05‐.25/24

TIER 3ESTROGEN,CON/M‐PROGEST ACET [PREMPRO] (TAB) 0.45‐1.5MG, 0.3‐1.5MG, 0.625‐5 MG, 0.625‐2.5

ST

ESTROGENS, CONJUGATED [PREMARIN] (TAB) 0.625 MG, 0.3 MG, 0.9 MG, 1.25 MG, 0.45MG

ST

PROGESTATIONAL AGENTSTIER 1

MEDROXYPROGESTERONE ACET (TAB) 10 MG, 2.5 MG, 5 MGNORETHINDRONE ACET (TAB) 5 MGPROGESTERONE, MICRONIZED (CAP) 100 MG, 200 MG

TIER 2MEDROXYPROGESTERONE ACET [DEPO‐PROVERA] (VIAL) 400 MG/ML ST

IMMUNIZATIONMay be subject to clinical guidelines and age restrictions

MULTIPLE AGENTS Check with your physician or pharmacist.

IMMUNOSUPPRESSION/MODULATIONIMMUNOMODULATORS

TIER 1IMIQUIMOD (CREAM PACK) 5 % PA

IMMUNOSUPPRESSIVESTIER 1

AZATHIOPRINE (TAB) 50 MGCYCLOSPORINE (CAP) 100 MG, 25 MGCYCLOSPORINE, MODIFIED (CAP) 50 MG, 25 MG, 100 MGCYCLOSPORINE, MODIFIED (SOLUTION) 100 MG/MLMYCOPHENOLATE MOFETIL (CAP) 250 MGMYCOPHENOLATE MOFETIL (SUSP RECON) 200 MG/MLMYCOPHENOLATE MOFETIL (TAB) 500 MGTACROLIMUS (CAP) 1 MG, 5 MG, 0.5 MG

TIER 2CYCLOSPORINE [SANDIMMUNE] (SOLUTION) 100 MG/ML

INFECTIOUS DISEASE2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL

TIER 1





Therapeutic Indication / Drug Name CommentTINIDAZOLE (TAB) 250 MG, 500 MG QL: 12 IN 60 DAYS

ABSORBABLE SULFONAMIDESTIER 1

SULFAMETHOXAZOLE/TRIMETHOPRIM (ORAL SUSP) 200‐40MG/5SULFAMETHOXAZOLE/TRIMETHOPRIM (TAB) 400MG‐80MG, 800‐160 MG

AMINOGLYCOSIDESTIER 1

NEOMYCIN SULF (TAB) 500 MG QL: 6 IN 1 DAYS, DL: 1 DAYS, FL: FILLS≤1 IN 30 DAYS

TOBRAMYCIN IN 0.225% SOD CHLOR (AMPUL‐NEB) 300 MG/5ML PA, FL: FILLS≤1 IN 365 DAYS, MS

ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTSTIER 1

METRONIDAZOLE (TAB) 250 MG, 500 MGANTHELMINTICS

TIER 1IVERMECTIN (TAB) 3 MGPRAZIQUANTEL (TAB) 600 MG PAPYRANTEL PAM (ORAL SUSP) 50 MG/ML

TIER 3ALBENDAZOLE (TAB) 200 MG PA

ANTIFUNGAL AGENTSTIER 1

CLOTRIMAZOLE (TROCHE) 10 MGFLUCONAZOLE (SUSP RECON) 40 MG/ML, 10 MG/ML DL: 21 IN 180 DAYSFLUCONAZOLE (TAB) 100 MG, 200 MG, 50 MG, 150 MG QL: 21 IN 180 DAYSITRACONAZOLE (SOLUTION) 10 MG/ML PAKETOCONAZOLE (TAB) 200 MG STTERBINAFINE (TAB) 250 MG QL: 1 PER DAY, FL: 84 DAYS PER

YEARTIER 3

ITRACONAZOLE (CAP) 100 MG PAVORICONAZOLE (SUSP RECON) 200 MG/5ML PAVORICONAZOLE (TAB) 50 MG, 200 MG PA

ANTIFUNGAL ANTIBIOTICSTIER 1

NYSTATIN (ORAL SUSP) 100000/MLNYSTATIN (TAB) 500K UNIT

TIER 3GRISEOFULVIN ULTRAMICROSIZE (TAB) 125 MG, 250 MG PAGRISEOFULVIN, MICROSIZE (ORAL SUSP) 125 MG/5ML PAGRISEOFULVIN, MICROSIZE (TAB) 500 MG PA

ANTILEPROTICSTIER 1

DAPSONE (TAB) 100 MG, 25 MG





Therapeutic Indication / Drug Name CommentANTIMALARIAL DRUGS

TIER 1HYDROXYCHLOROQUINE SULF (TAB) 200 MG

ANTI-MYCOBACTERIUM AGENTSTIER 1

ETHAMBUTOL (TAB) 100 MG, 400 MGISONIAZID (SOLUTION) 50 MG/5 MLISONIAZID (TAB) 100 MG, 300 MG

ANTIRETROVIRAL-NUCLEOSIDE,NUCLEOTIDE,PROTEASE INH.TIER 2

DARUNAVIR/COB/EMTRI/TENOF ALAF [SYMTUZA] (TAB) 800‐150 MG PAANTITUBERCULAR ANTIBIOTICS

TIER 1RIFAMPIN (CAP) 150 MG, 300 MG

ANTIVIRALS, GENERALTIER 1

ACYCLOVIR (CAP) 200 MGACYCLOVIR (ORAL SUSP) 200 MG/5ML QL: 30 IN 180 DAYS ≤ 5, DL: 30 IN

180 DAYSACYCLOVIR (TAB) 800 MG, 400 MGOSELTAMIVIR PHOSPHATE (CAP) 75 MG, 30 MG, 45 MGOSELTAMIVIR PHOSPHATE (SUSP RECON) 6 MG/ML QL: 3 IN 180 DAYSRIBAVIRIN (VIAL‐NEB) 6 G PA

TIER 2ZANAMIVIR [RELENZA] 5 MG

TIER 3BALOXAVIR MARBOXIL [XOFLUZA] (TAB) 20 MG, 40 MG PAVALACYCLOVIR (TAB) 1000 MG QL: 21 IN 60 DAYS|3 IN 1 DAYS

VALACYCLOVIR (TAB) 500 MG QL: 1 IN 1 DAYSCEPHALOSPORINS - 1ST GENERATION

TIER 1CEFADROXIL (CAP) 500 MGCEFADROXIL (SUSP RECON) 250 MG/5ML, 500 MG/5MLCEFADROXIL (TAB) 1 GCEPHALEXIN (CAP) 250 MG, 500 MGCEPHALEXIN (SUSP RECON) 125 MG/5ML, 250 MG/5MLCEPHALEXIN (TAB) 500 MG, 250 MG

CEPHALOSPORINS - 2ND GENERATIONTIER 1

CEFACLOR (CAP) 250 MG, 500 MGCEFACLOR (SUSP RECON) 125 MG/5ML, 250 MG/5ML, 375 MG/5MLCEFACLOR (TAB ER 12H) 500 MGCEFPROZIL (SUSP RECON) 125 MG/5ML, 250 MG/5MLCEFPROZIL (TAB) 250 MG, 500 MG





Therapeutic Indication / Drug Name CommentCEFUROXIME AXETIL (TAB) 250 MG, 500 MG

CEPHALOSPORINS - 3RD GENERATIONTIER 1

CEFDINIR (CAP) 300 MGCEFDINIR (SUSP RECON) 250 MG/5ML, 125 MG/5MLCEFIXIME (SUSP RECON) 100 MG/5MLCEFPODOXIME PROXETIL (SUSP RECON) 50 MG/5 ML, 100 MG/5MLCEFPODOXIME PROXETIL (TAB) 100 MG, 200 MG

CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC.TIER 1

TRIMETHOPRIM (TAB) 100 MGTIER 2

TRIMETHOPRIM [TRIMPEX] (SOLUTION) 50 MG/5 MLHEP C - NS5A, NS3/4A, NUCLEOTIDE NS5B INHIB COMBO

TIER 2SOFOSBUVIR/VELPATAS/VOXILAPREV [VOSEVI] (TAB) 400‐100 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

HEP C VIRUS - NS5A & NS5B POLYMERASE INHIB. COMBO.TIER 1

SOFOSBUVIR/VELPATASVIR (TAB) 400‐100 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

HEPATITIS B TREATMENT AGENTSTIER 1

ADEFOVIR DIPIVOXIL (TAB) 10 MG FL: FILLS≤1 IN 365 DAYS, MSENTECAVIR (TAB) 0.5 MG, 1 MG FL: FILLS≤1 IN 365 DAYS, MS

TIER 2ENTECAVIR [BARACLUDE] (SOLUTION) 0.05 MG/ML FL: FILLS≤1 IN 365 DAYS, MSLAMIVUDINE [EPIVIR HBV] (SOLUTION) 25 MG/5 ML AL: < 12 YEARS

HEPATITIS C TREATMENT AGENTSTIER 1

RIBAVIRIN (CAP) 200 MG PARIBAVIRIN (TAB) 200 MG, 600 MG PA

TIER 2PEGINTERFERON ALFA‐2A [PEGASYS PROCLICK] (PEN INJCTR) 180MCG/0.5 PA, FL: FILLS≤1 IN 365 DAYS, MS

PEGINTERFERON ALFA‐2A [PEGASYS] (SYRINGE) 180MCG/0.5 PA, FL: FILLS≤1 IN 365 DAYS, MS

PEGINTERFERON ALFA‐2A [PEGASYS] (VIAL) 180MCG/ML PA, FL: FILLS≤1 IN 365 DAYS, MS

PEGINTERFERON ALFA‐2B [PEGINTRON] (KIT) 50 MCG/0.5 PA, FL: FILLS≤1 IN 365 DAYS, MS

HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMBTIER 2

ELBASVIR/GRAZOPREVIR [ZEPATIER] (TAB) 50MG‐100MG PA, FL: FILLS≤1 IN 365 DAYS, MS





Therapeutic Indication / Drug Name CommentGLECAPREVIR/PIBRENTASVIR [MAVYRET] (TAB) 100MG‐40MG PA, FL: FILLS≤1 IN 365 DAYS, MS

LINCOSAMIDESTIER 1

CLINDAMYCIN (CAP) 150 MG, 75 MG, 300 MGCLINDAMYCIN PALMITATE (SOLN RECON) 75 MG/5 ML

MACROLIDESTIER 1

AZITHROMYCIN (PACKET) 1 GAZITHROMYCIN (SUSP RECON) 100 MG/5ML, 200 MG/5MLAZITHROMYCIN (TAB) 250 MG, 600 MG, 500 MGCLARITHROMYCIN (SUSP RECON) 125 MG/5ML, 250 MG/5ML PACLARITHROMYCIN (TAB ER 24H) 500 MG DL: 14 IN 180 DAYSCLARITHROMYCIN (TAB) 250 MG PACLARITHROMYCIN (TAB) 500 MG DL: 14 IN 180 DAYS

TIER 3ERYTHROMYCIN BASE (CAP DR) 250 MGERYTHROMYCIN BASE (TAB DR) 250 MG, 500 MGERYTHROMYCIN BASE (TAB) 250 MG, 500 MGERYTHROMYCIN BASE [ERY‐TAB] (TAB DR) 333 MGERYTHROMYCIN ETHYLSUCC (SUSP RECON) 200 MG/5ML, 400 MG/5ML FL: FILLS=1 IN 23 DAYSERYTHROMYCIN ETHYLSUCC (TAB) 400 MGERYTHROMYCIN STEARATE (TAB) 250 MG

NITROFURAN DERIVATIVESTIER 1

NITROFURANTOIN MACROCRYSTAL (CAP) 100 MG, 25 MG, 50 MGNITROFURANTOIN MONOHYD/M‐CRYST (CAP) 100 MG

TIER 3NITROFURANTOIN (ORAL SUSP) 25 MG/5 ML

PENICILLINSTIER 1

AMOXICILLIN (CAP) 250 MG, 500 MGAMOXICILLIN (SUSP RECON) MULTIPLE STRENGTHSAMOXICILLIN (TAB CHEW) 125 MG, 250 MGAMOXICILLIN (TAB) 875 MG, 500 MGAMOXICILLIN/POTASSIUM CLAV (SUSP RECON) MULTIPLE STRENGTHSAMOXICILLIN/POTASSIUM CLAV (TAB CHEW) 400‐57MG, 200‐28.5MGAMOXICILLIN/POTASSIUM CLAV (TAB ER 12H) 1000‐62.5AMOXICILLIN/POTASSIUM CLAV (TAB) 250‐125 MG, 500‐125 MG, 875‐125 MG

AMPICILLIN TRIHYDRATE (CAP) 250 MG, 500 MGDICLOXACILLIN SOD (CAP) 250 MG, 500 MGPENICILLIN V POT (SOLN RECON) 125 MG/5ML, 250 MG/5MLPENICILLIN V POT (TAB) 250 MG, 500 MG

TIER 2





Therapeutic Indication / Drug Name CommentAMOXICILLIN/POTASSIUM CLAV [AUGMENTIN] (SUSP RECON) 125‐31.25/

PENICILLIN G BENZATHINE [BICILLIN L‐A] (SYRINGE) 600000/ML, 1.2MM/2 ML, 2.4MM/4ML

QL: 4 IN 28 DAYS

QUINOLONESTIER 1

CIPROFLOXACIN (TAB) 250 MG, 500 MG, 750 MG, 100 MGLEVOFLOXACIN (TAB) 250 MG, 500 MG, 750 MG

TIER 2CIPROFLOXACIN [CIPRO] (SUS MC REC) 250 MG/5ML, 500 MG/5ML

TIER 3OFLOXACIN (TAB) 300 MG, 400 MG

RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICSTIER 2

RIFAXIMIN [XIFAXAN] (TAB) 550 MG, 200 MG PATETRACYCLINES

TIER 1DOXYCYCLINE HYCLATE (CAP) 100 MG, 50 MG QL: 60 IN 30 DAYSDOXYCYCLINE MONOHYDRATE (CAP) 100 MG, 50 MG QL: 60 IN 30 DAYSDOXYCYCLINE MONOHYDRATE (SUSP RECON) 25 MG/5 MLDOXYCYCLINE MONOHYDRATE (TAB) 100 MG, 50 MG

TIER 2DOXYCYCLINE CALC [VIBRAMYCIN] (SYRUP) 50 MG/5 ML

TIER 3TETRACYCLINE (CAP) 250 MG, 500 MG QL: 4 IN 1 DAYS

VANCOMYCIN AND DERIVATIVESTIER 1

VANCOMYCIN (CAP) 125 MG QL: 4 IN 1 DAYS|40 IN 23 DAYS

VANCOMYCIN (CAP) 250 MG PAVANCOMYCIN (SOLN RECON) 50 MG/ML PA

TIER 2VANCOMYCIN [FIRVANQ] (SOLN RECON) 25 MG/ML PA

INFLAMMATORY DISEASEANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR

TIER 2INFLIXIMAB‐DYYB [INFLECTRA] (VIAL) 100 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

TIER 3ADALIMUMAB [HUMIRA PEN] (PEN IJ KIT) 40MG/0.8ML PA, FL: FILLS≤1 IN 365 DAYS, MS

ADALIMUMAB [HUMIRA] (SYRINGEKIT) 40MG/0.8ML, 10MG/0.2ML, 20MG/0.4ML

PA, FL: FILLS≤1 IN 365 DAYS, MS

ETANERCEPT [ENBREL SURECLICK] (PEN INJCTR) 50MG/ML(1) PA, FL: FILLS≤1 IN 365 DAYS, MS





Therapeutic Indication / Drug Name CommentETANERCEPT [ENBREL] (SYRINGE) 50MG/ML(1), 25MG/0.5ML PA, FL: FILLS≤1 IN 365 DAYS, MS

ETANERCEPT [ENBREL] (VIAL) 25 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

INFLIXIMAB [REMICADE] (VIAL) 100 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITORTIER 1

LEFLUNOMIDE (TAB) 10 MG, 20 MGANTI-INFLAMMATORY,PHOSPHODIESTERASE-4(PDE4) INHIB.

TIER 2APREMILAST [OTEZLA] (TAB DS PK) 10‐20‐30MG PA, FL: FILLS≤1 IN 365 DAYS, MS

APREMILAST [OTEZLA] (TAB) 30 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

GLUCOCORTICOIDSTIER 1

BUDESONIDE (CAPDR ‐ ER) 3 MG PADEXAMETHASONE (ELIXIR) 0.5 MG/5MLDEXAMETHASONE (SOLUTION) 0.5 MG/5MLDEXAMETHASONE (TAB DS PK) 1.5MG (51)DEXAMETHASONE (TAB) MULTIPLE STRENGTHSHYDROCORTISONE (TAB) 10 MG, 20 MG, 5 MGMETHYLPREDNISOLONE (TAB DS PK) 4 MGMETHYLPREDNISOLONE (TAB) 16 MG, 32 MG, 4 MG, 8 MGPREDNISOLONE (SOLUTION) 15 MG/5 MLPREDNISOLONE SOD PHOSPHATE (SOLUTION) 15 MG/5 ML, 5 MG/5 MLPREDNISONE (SOLUTION) 5 MG/5 MLPREDNISONE (TAB DS PK) 5 MG, 10 MGPREDNISONE (TAB) 1 MG, 10 MG, 2.5 MG, 20 MG, 5 MG, 50 MG

TIER 2DEXAMETHASONE [DEXAMETHASONE INTENSOL] (DROPS) 1 MG/MLHYDROCORTISONE SOD SUCC [SOLU‐CORTEF] (VIAL) 100 MGHYDROCORTISONE SOD SUCC/PF [SOLU‐CORTEF] (VIAL) 100 MG/2ML, 250 MG/2ML, 500 MG/4MLMETHYLPREDNISOLONE [MEDROL] (TAB) 2 MGPREDNISOLONE [MILLIPRED DP] (TAB DS PK) 5 MG (21), 5 MG (48)PREDNISOLONE [MILLIPRED] (TAB) 5 MGPREDNISONE [PREDNISONE INTENSOL] (ORAL CONC) 5 MG/ML

TIER 3METHYLPREDNISOLONE SOD SUCC/PF [SOLU‐MEDROL] (VIAL) 40 MG/ML, 125 MG/2ML

INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORSTIER 2





Therapeutic Indication / Drug Name CommentTOCILIZUMAB [ACTEMRA] (SYRINGE) 162 MG/0.9 PA, FL: FILLS≤1 IN 365 DAYS, MS

JANUS KINASE (JAK) INHIBITORSTIER 2

TOFACITINIB CIT [XELJANZ XR] (TAB ER 24H) 11 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

TOFACITINIB CIT [XELJANZ] (TAB) 5 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

MINERALOCORTICOIDSTIER 1

FLUDROCORTISONE ACET (TAB) 0.1 MGNSAIDS, CYCLOOXYGENASE 2 INHIBITOR - TYPE

TIER 1CELECOXIB (CAP) 100 MG, 200 MG QL: 30 IN 30 DAYS

NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPETIER 1

DICLOFENAC SOD (TAB DR) 25 MG, 50 MG, 75 MGDICLOFENAC SOD (TAB ER 24H) 100 MGIBUPROFEN (CAP) 200 MGIBUPROFEN (DROPS SUSP) 50 MG/1.25IBUPROFEN (ORAL SUSP) 100 MG/5MLIBUPROFEN (TAB CHEW) 100 MGIBUPROFEN (TAB) 400 MG, 600 MG, 200 MG, 800 MG, 100 MGKETOPROFEN (CAP) 50 MG, 75 MG, 25 MGMELOXICAM (TAB) 7.5 MG, 15 MGNABUMETONE (TAB) 500 MG, 750 MGNAPROXEN (ORAL SUSP) 125 MG/5MLNAPROXEN (TAB DR) 375 MG, 500 MGNAPROXEN (TAB) 250 MG, 375 MG, 500 MGNAPROXEN SOD (TBMP 24HR) 500 MG, 375 MGPIROXICAM (CAP) 10 MG, 20 MGSULINDAC (TAB) 150 MG, 200 MG

TIER 2INDOMETHACIN [INDOCIN] (SUPP.RECT) 50 MG

TIER 3ETODOLAC (CAP) 200 MG, 300 MGETODOLAC (TAB ER 24H) 600 MG, 400 MG, 500 MG PAETODOLAC (TAB) 400 MG, 500 MG PAFLURBIPROFEN (TAB) 50 MG, 100 MGINDOMETHACIN (CAP ER) 75 MGINDOMETHACIN (CAP) 25 MG, 50 MGINDOMETHACIN [INDOCIN] (ORAL SUSP) 25 MG/5 MLNAPROXEN SOD (TAB) 275 MG, 550 MG, 220 MG

LOCAL ANESTHESIALOCAL ANESTHETICS






LIDOCAINE (JELLY(ML)) 2 % QL: 30 IN 30 DAYSLIDOCAINE (SOLUTION) 2 %, 40 MG/ML DL: 10 IN 365 DAYS

LOWER GASTROINTESTINAL DISORDERSAMMONIA INHIBITORS

TIER 1LACTULOSE (SOLUTION) 10 G/15 ML QL: 2838 IN 30 DAYS, DL: 90 IN

360 DAYSANTIDIARRHEALS

TIER 1BISMUTH SUBSALICYLATE (ORAL SUSP) 262MG/15ML, 525MG/15MLBISMUTH SUBSALICYLATE (TAB CHEW) 262 MGBISMUTH SUBSALICYLATE (TAB) 262 MGDIPHENOXYLATE HCL/ATROPINE (LIQUID) 2.5‐.025/5DIPHENOXYLATE HCL/ATROPINE (TAB) 2.5‐.025MGLOPERAMIDE (CAP) 2 MG QL: 8 IN 1 DAYSLOPERAMIDE (TAB) 2 MG QL: 8 IN 1 DAYS

BILE SALTSTIER 1

URSODIOL (CAP) 300 MG QL: 2 IN 1 DAYSURSODIOL (TAB) 250 MG

CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TXTIER 1

MESALAMINE (ENEMA) 4 G/60 ML QL: 1800 IN 23 DAYSTIER 3

MESALAMINE (SUPP.RECT) 1000 MG PADRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT

TIER 1BALSALAZIDE DISOD (CAP) 750 MGSULFASALAZINE (TAB DR) 500 MGSULFASALAZINE (TAB) 500 MG

TIER 3MESALAMINE (TAB DR) 800 MG, 1.2 G PAMESALAMINE [APRISO] (CAP ER 24H) 0.375G PA

LAXATIVES AND CATHARTICSTIER 1

BISAC/NACL/NAHCO3/KCL/PEG 3350 (KIT) 5 MG‐210 GBISACODYL (TAB DR) 5 MGBISACODYL (TAB) 5 MGDOCUSATE SOD (CAP) 100 MG, 250 MG, 50 MGDOCUSATE SOD (LIQUID) 50 MG/5 MLDOCUSATE SOD (SYRUP) 60 MG/15ML, 50 MG/15MLDOCUSATE SOD (TAB) 100 MGMAGNESIUM HYDROXIDE (ORAL SUSP) 400 MG/5MLPOLYETHYLENE GLYCOL 3350 (POWD PACK) 17G





Therapeutic Indication / Drug Name CommentPOLYETHYLENE GLYCOL 3350 (POWDER) 17G/DOSEPSYLLIUM HUSK (CAP) 0.52GSENNOSIDES (TAB) 8.6 MGSOD CHLORIDE/NAHCO3/KCL/PEG (SOLN RECON) 420G

TIER 2PEG3350/SOD SUL/NACL/KCL/ASB/C [MOVIPREP] (POWD PACK) 7.5‐2.691G

PEG3350/SOD SULF,BICARB,CL/KCL [GOLYTELY] (POWD PACK) 227.1‐21.5SOD, POT,MAG SULFS [SUPREP] (SOLN RECON) 17.5‐3.13G

TIER 3PEG3350/SOD SULF,BICARB,CL/KCL (SOLN RECON) 236‐22.74G, 240‐22.72G

LAXATIVES, LOCAL/RECTALTIER 1

DOCUSATE SOD (ENEMA) 283 MG, 283 MG/5MLGLYCERIN (SUPP.RECT) ADULT, PEDIATRIC

TIER 2BISACODYL (ENEMA) 10MG/30MLGLYCERIN [PEDIA‐LAX] (SOL/PF APP) 2.8G/2.7ML

RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR)TIER 1

HYDROCORTISONE (ENEMA) 100MG/60MLTIER 2

HYDROCORTISONE ACET [CORTIFOAM] (FOAM/APPL) 10 %MISCELLANEOUS AGENTS

ANAPHYLAXIS THERAPY AGENTSTIER 1

EPINEPHRINE (AUTO INJCT) 0.15MG/0.3, 0.3MG/0.3, 0.15/0.15 QL: 4 IN 365 DAYSPARASYMPATHETIC AGENTS

TIER 1BETHANECHOL CHLORIDE (TAB) 10 MG, 25 MG, 5 MG, 50 MG

TIER 3CEVIMELINE (CAP) 30 MGPILOCARPINE (TAB) 5 MG

NEUROLOGICAL DISEASE - MISCELLANEOUSAGENTS TO TREAT MULTIPLE SCLEROSIS

TIER 1GLATIRAMER ACET (SYRINGE) 20 MG/ML PA, FL: FILLS≤1 IN 365 DAYS, MS

TIER 2DIMETHYL FUM [TECFIDERA] (CAP DR) 120‐240 MG, 120 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

FINGOLIMOD [GILENYA] (CAP) 0.5 MG, 0.25 MG PA, FL: FILLS≤1 IN 365 DAYS, MS





Therapeutic Indication / Drug Name CommentINTERFERON BETA‐1A [AVONEX PEN] (PEN IJ KIT) 30MCG/.5ML PA, FL: FILLS≤1 IN 365 DAYS, MS

INTERFERON BETA‐1A [AVONEX] (SYRINGEKIT) 30MCG/.5ML PA, FL: FILLS≤1 IN 365 DAYS, MS

INTERFERON BETA‐1A/ALBUMIN [AVONEX] (KIT) 30 MCG PA, FL: FILLS≤1 IN 365 DAYS, MS

INTERFERON BETA‐1B [EXTAVIA] (KIT) 0.3 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

INTERFERON BETA‐1B [EXTAVIA] (VIAL) 0.3 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

ONCOLOGYMay be subject to prior authorization and/or other utilization management restrictions

ALL ONCOLOGY AGENTS PA, MSORAL/PHARYNGEAL DISORDERS

DENTAL AIDS AND PREPARATIONSTIER 1

CHLORHEXIDINE GLUCONATE (MOUTHWASH) 0.12 %TRIAMCINOLONE ACET (PASTE ) 0.1 %

NOSE PREPARATIONS, MISCELLANEOUS (RX)TIER 1

IPRATROPIUM BROMIDE (SPRAY) 42 MCG, 21 MCG AL: ≥ 18 YEARSPERIODONTAL COLLAGENASE INHIBITORS

TIER 1DOXYCYCLINE HYCLATE (TAB) 20 MG, 100 MG

OTHER DRUGSANTIOXIDANT AGENTS

TIER 1ALPHA LIPOIC ACID (CAP) 600 MG QL: 1 IN 1 DAYS

APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND.TIER 1

MEGESTROL ACET (ORAL SUSP) 400MG/10MLCONDOMS

TIER 1CONDOMS, FEMALE [FC2 FEMALE CONDOM] (EACH) QL: 12 PER FILL, DL: 100 DAYS

CONDOMS, LATEX, LUBRICATED [CONDOMS] (EACH) QL: 12 PER FILL, DL: 100 DAYS

CONDOMS, LATEX, NON‐LUBRICATED [TRUSTEX‐RIA] (EACH) QL: 12 PER FILL, DL: 100 DAYS

CONDOMS, NON‐LATEX, LUBRICATED [DUREX AVANTI BARE REAL FEEL] (EACH) QL: 12 PER FILL, DL: 100 DAYS

DIAGNOSTIC PREPARATIONS,MISC.TIER 2

GLUCAGON (VIAL) 1 MG QL: 6 PER YEARDIETARY SUPPLEMENT, MISCELLANEOUS






ACETYLCYSTEINE (CAP) 600 MG PAOMEGA‐3S/DHA/EPA/FISH OIL [OMEGA‐3 FISH OIL] (CAP) 300‐1000MG QL: 1 PER DAYOMEGA‐3S/DHA/EPA/FISH OIL [OMEGA‐3] (TAB CHEW) 71MG‐425MG QL: 1 PER DAY

GENERAL INHALATION AGENTSTIER 1

SOD CHLORIDE FOR INHALATION (VIAL‐NEB) 0.9 %, 10 %, 3 %INSECTICIDES

TIER 1PERMETHRIN (SPRAY) 0.5 %

METABOLIC DEFICIENCY AGENTSTIER 1

LEVOCARNITINE (WITH SUGAR) (SOLUTION) 100 MG/ML PATIER 2

LEVOCARNITINE [CARNITOR SF] (SOLUTION) 100 MG/ML PAPROTEIN REPLACEMENT

TIER 1LEVOCARNITINE (TAB) 500 MG, 330 MG PA

THICKENING AGENTS, ORALTIER 1

CORN STARCH [RESOURCE THICKENUP] (POWDER) MALTODEXTRIN/XANTHAN GUM [THICKEN UP CLEAR] (POWDER) STARCH [THICK NOW] (POWDER) STARCH [THICK‐IT] (POWD PACK)

PAIN MANAGEMENT - ANALGESICSANALGESIC, SALICYLATE, BARBITURATE,& XANTHINE CMB

TIER 1BUTALBITAL/ASPIRIN/CAFFEINE (CAP) 50‐325‐40 QL: 30 IN 23 DAYSBUTALBITAL/ASPIRIN/CAFFEINE (TAB) 50‐325‐40 QL: 30 IN 23 DAYS

ANALGESIC,NON-SALICYLATE,BARBITURATE,&XANTHINE CMBTIER 1

BUTALB/ACETAMINOPHEN/CAFFEINE (CAP) 50‐325‐40 QL: 30 IN 23 DAYSBUTALB/ACETAMINOPHEN/CAFFEINE (TAB) 50‐325‐40 QL: 30 IN 23 DAYS

ANALGESIC/ANTIPYRETICS, SALICYLATESTIER 1

ASPIRIN (SUPP.RECT) 600 MG, 300 MGASPIRIN (TAB) 325 MG, 500 MGASPIRIN/ACETAMINOPHEN/CAFFEINE (TAB) 250‐250‐65ASPIRIN/CALCIUM CARBONATE/MAG (TAB) 325 MG

ANALGESIC/ANTIPYRETICS,NON-SALICYLATETIER 1

ACETAMINOPHEN (CAP) 325 MG, 500 MGACETAMINOPHEN (DROPS SUSP) 80MG/0.8MLACETAMINOPHEN (DROPS) 100 MG/MLACETAMINOPHEN (ELIXIR) 160 MG/5ML





Therapeutic Indication / Drug Name CommentACETAMINOPHEN (LIQUID) 160 MG/5ML, 500MG/15MLACETAMINOPHEN (ORAL SUSP) 160 MG/5MLACETAMINOPHEN (SOLUTION) 160 MG/5ML, 325/10.15, 650MG/20.3ACETAMINOPHEN (SUPP.RECT) 120 MG, 325 MG, 650 MGACETAMINOPHEN (TAB CHEW) 160 MG, 80 MGACETAMINOPHEN (TAB ER) 650 MGACETAMINOPHEN (TAB) 500 MG, 325 MG

TIER 2ACETAMINOPHEN [FEVERALL] (SUPP.RECT) 80 MG

ANALGESICS,NARCOTICSAll narcotic agents are limited to ≤90 morphine milligram equivalents (MME) per day

TIER 1HYDROMORPHONE (TAB) 2 MG PA, QL: 11.2 IN 1 DAYS, DL: 7

DAYS, FL: FILLS≤1 IN 60 DAYSHYDROMORPHONE (TAB) 4 MG PA, QL: 5.6 IN 1 DAYS, DL: 7 DAYS,

FL: FILLS≤1 IN 60 DAYSHYDROMORPHONE (TAB) 8 MG PA, QL: 2.8 IN 1 DAYS, DL: 7 DAYS,

FL: FILLS≤1 IN 60 DAYSMORPHINE SULF (SOLUTION) 10 MG/5 ML PA, QL: 45 IN 1 DAYS, DL: 7 DAYS,

FL: FILLS≤1 IN 60 DAYSMORPHINE SULF (SOLUTION) 100 MG/5ML PA, QL: 4 IN 1 DAYS, DL: 7 DAYS,

FL: FILLS≤1 IN 60 DAYSMORPHINE SULF (SOLUTION) 20 MG/5 ML PAMORPHINE SULF (TAB ER) 30 MG, 15 MG PA, QL: 3 IN 1 DAYSMORPHINE SULF (TAB ER) 60 MG PA, QL: 1 IN 1 DAYSOXYCODONE (TAB) 5 MG QL: 12 IN 1 DAYS, DL: 7 DAYS, FL:

FILLS≤1 IN 60 DAYSOXYCODONE (TAB) 10 MG QL: 6 IN 1 DAYS, DL: 7 DAYS, FL:

FILLS≤1 IN 60 DAYSOXYCODONE (TAB) 15 MG PA, QL: 4 IN 1 DAYS, DL: 7 DAYS,

FL: FILLS≤1 IN 60 DAYSOXYCODONE (TAB) 20 MG PA, QL: 3 IN 1 DAYS, DL: 7 DAYS,

FL: FILLS≤1 IN 60 DAYSOXYCODONE (TAB) 30 MG PA, QL: 2 IN 1 DAYS, DL: 7 DAYS,

FL: FILLS≤1 IN 60 DAYSTRAMADOL (TAB) 50 MG QL: 8 IN 1 DAYS, DL: 7 DAYS, FL:

FILLS≤1 IN 60 DAYSTIER 2

MORPHINE SULF [MORPHINE SULFATE] (TAB) 15 MG PA, QL: 6 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS

MORPHINE SULF [MORPHINE SULFATE] (TAB) 30 MG PA, QL: 3 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS

TIER 3FENTANYL (PATCH TD72) MULTIPLE STRENGTHS PA





Therapeutic Indication / Drug Name CommentMETHADONE (ORAL CONC) 10 MG/ML PA, QL: 10 IN 1 DAYSMETHADONE (SOLUTION) 10 MG/5 ML PA, QL: 10 IN 1 DAYS, DL: 7 DAYS,

FL: FILLS≤1 IN 60 DAYS

METHADONE (SOLUTION) 5 MG/5 ML PA, QL: 20 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS

METHADONE (TAB) 10 MG PA, QL: 2.8 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS

METHADONE (TAB) 5 MG PA, QL: 10 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS

MORPHINE SULF (CAP ER PEL) 50 MG, 20 MG, 60 MG PAMORPHINE SULF (CPMP 24HR) 120 MG, 90 MG, 60 MG, 30 MG PAMORPHINE SULF (SUPP.RECT) 10 MG, 20 MG, 5 MG, 30 MG PA, QL: 1 IN 1 DAYSMORPHINE SULF (TAB ER) 200 MG, 100 MG PA, QL: 60 IN 27 DAYS, FL: FILLS≤1

IN 180 DAYSANTIMIGRAINE PREPARATIONS

TIER 1NARATRIPTAN (TAB) 2.5 MG, 1 MG QL: 9 IN 23 DAYSRIZATRIPTAN BENZOATE (TAB RAPDIS) 5 MG, 10 MG QL: 9 IN 23 DAYSRIZATRIPTAN BENZOATE (TAB) 5 MG, 10 MG QL: 9 IN 23 DAYSSUMATRIPTAN SUCC (TAB) 50 MG, 100 MG, 25 MG QL: 9 IN 23 DAYSZOLMITRIPTAN (TAB RAPDIS) 5 MG, 2.5 MG QL: 9 IN 23 DAYSZOLMITRIPTAN (TAB) 2.5 MG, 5 MG QL: 9 IN 23 DAYS

TIER 2ERENUMAB‐AOOE [AIMOVIG AUTOINJECTOR] (AUTO INJCT) 70 MG/ML PA

TIER 3ERGOTAMINE TARTRATE/CAFFEINE (TAB) 1 MG‐100MG QL: 30 IN 23 DAYSERGOTAMINE TARTRATE/CAFFEINE [MIGERGOT] (SUPP.RECT) 2‐100MG QL: 30 IN 23 DAYSSUMATRIPTAN (SPRAY) 5 MG, 20 MG PA

NARC.& NON-SAL.ANALGESIC,BARBITURATE &XANTHINE CMBTIER 1

BUTALBIT/ACETAMIN/CAFF/CODEINE (CAP) 50‐325‐30 QL: 6 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS, AL: ≥ 12 YEARS

NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMBAll narcotic agents are limited to ≤90 morphine milligram equivalents (MME) per day

TIER 1ACETAMINOPHEN WITH CODEINE (SOLUTION) 120‐12MG/5 QL: 240 IN 1 DAYS, DL: 7 DAYS, FL:

FILLS≤1 IN 60 DAYS, AL: ≥ 12 YEARS

ACETAMINOPHEN WITH CODEINE (TAB) 300MG‐15MG, 300MG‐30MG QL: 20 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS, AL: ≥ 12 YEARS





Therapeutic Indication / Drug Name CommentACETAMINOPHEN WITH CODEINE (TAB) 300MG‐60MG QL: 10 IN 1 DAYS, DL: 7 DAYS, FL:

FILLS≤1 IN 60 DAYS, AL: ≥ 12 YEARS

HYDROCODONE/ACETAMINOPHEN (SOLUTION) 7.5‐325/15 QL: 180 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS

HYDROCODONE/ACETAMINOPHEN (TAB) 10MG‐300MG, 10MG‐325MG QL: 9 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS

HYDROCODONE/ACETAMINOPHEN (TAB) MULTIPLE STRENGTHS QL: 12 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS

OXYCODONE HCL/ACETAMINOPHEN (TAB) 10MG‐325MG QL: 6 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS

OXYCODONE HCL/ACETAMINOPHEN (TAB) 5 MG‐325MG, 2.5‐325 MG QL: 12 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS

OXYCODONE HCL/ACETAMINOPHEN (TAB) 7.5‐325 MG QL: 8 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS

NARCOTIC AND SALICYLATE ANALGESIC COMBINATIONTIER 1

OXYCODONE HCL/ASPIRIN (TAB) 4.8355‐325 QL: 8 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS

NARCOTIC WITHDRAWAL THERAPY AGENTSTIER 1

BUPRENORPHINE (TAB SUBL) 2 MG, 8 MG QL: 3 IN 1 DAYS, DL: 30 IN 180 DAYS

BUPRENORPHINE HCL/NALOXONE (FILM) 2 MG‐0.5MG, 8 MG‐2 MG QL: 3 IN 1 DAYS, DL: 30 IN 180 DAYS

BUPRENORPHINE HCL/NALOXONE (TAB SUBL) 2 MG‐0.5MG, 8 MG‐2 MG QL: 3 IN 1 DAYS, DL: 30 IN 180 DAYS

PARKINSONS DISEASEANTIPARKINSONISM DRUGS,ANTICHOLINERGIC

TIER 1BENZTROPINE MESYLATE (TAB) 0.5 MG, 1 MG, 2 MGTRIHEXYPHENIDYL (ELIXIR) 2 MG/5 MLTRIHEXYPHENIDYL (TAB) 2 MG, 5 MG

ANTIPARKINSONISM DRUGS,OTHERTIER 1

CARBIDOPA/LEVODOPA (TAB ER) 50MG‐200MG, 25MG‐100MGCARBIDOPA/LEVODOPA (TAB) 10MG‐100MG, 25MG‐100MG, 25MG‐250MG

ENTACAPONE (TAB) 200 MGPRAMIPEXOLE DI‐(TAB) MULTIPLE STRENGTHS PAROPINIROLE (TAB) MULTIPLE STRENGTHS PA

TIER 3AMANTADINE (CAP) 100 MG





Therapeutic Indication / Drug Name CommentAMANTADINE (SOLUTION) 50 MG/5 MLAMANTADINE (TAB) 100 MGCARBIDOPA/LEVODOPA [RYTARY] (CAP ER) 23.75‐95MG, 36.25‐145, 48.75‐195, 61.25‐245

ST

SELEGILINE (CAP) 5 MGSELEGILINE (TAB) 5 MGTOLCAPONE (TAB) 100 MG

DECARBOXYLASE INHIBITORSTIER 1

CARBIDOPA (TAB) 25 MGSEIZURE DISORDER

ANTICONVULSANT - BENZODIAZEPINE TYPETIER 1

CLONAZEPAM (TAB RAPDIS) 0.125 MG, 0.25 MG, 0.5 MG, 1 MG, 2 MGCLONAZEPAM (TAB) 0.5 MG, 1 MG, 2 MGDIAZEPAM (KIT) 5‐7.5‐10MG, 12.5‐15‐20, 2.5 MG QL: 4 IN 365 DAYS

ANTICONVULSANTSTIER 1

CARBAMAZEPINE (CPMP 12HR) 200 MG, 100 MG, 300 MGCARBAMAZEPINE (ORAL SUSP) 100 MG/5MLCARBAMAZEPINE (TAB CHEW) 100 MGCARBAMAZEPINE (TAB ER 12H) 100 MG, 200 MG, 400 MGCARBAMAZEPINE (TAB) 200 MGETHOSUXIMIDE (CAP) 250 MGETHOSUXIMIDE (SOLUTION) 250 MG/5MLFELBAMATE (ORAL SUSP) 600 MG/5MLFELBAMATE (TAB) 400 MG, 600 MGGABAPENTIN (CAP) 100 MG, 300 MG QL: 12 IN 1 DAYSGABAPENTIN (CAP) 400 MG QL: 9 IN 1 DAYSGABAPENTIN (TAB) 600 MG QL: 6 IN 1 DAYSGABAPENTIN (TAB) 800 MG QL: 4.5 IN 1 DAYSLEVETIRACETAM (SOLUTION) 500 MG/5ML, 100 MG/MLLEVETIRACETAM (TAB ER 24H) 500 MG, 750 MGLEVETIRACETAM (TAB) 750 MG, 250 MG, 500 MG, 1000 MGOXCARBAZEPINE (ORAL SUSP) 300 MG/5MLOXCARBAZEPINE (TAB) 300 MG, 600 MG, 150 MGPHENYTOIN (ORAL SUSP) 100 MG/4MLPHENYTOIN (TAB CHEW) 50 MGPRIMIDONE (TAB) 250 MG, 50 MGTIAGABINE (TAB) 4 MG, 12 MG, 16 MG, 2 MG STTOPIRAMATE (CAP SPRINK) 15 MG, 25 MG QL: 4 IN 1 DAYSTOPIRAMATE (TAB) 50 MG, 100 MG, 200 MG, 25 MGZONISAMIDE (CAP) 25 MG, 50 MG, 100 MG

TIER 2BRIVARACETAM [BRIVIACT] (TAB) 10 MG, 25 MG, 50 MG, 75 MG, 100 MG ST





Therapeutic Indication / Drug Name CommentLACOSAMIDE [VIMPAT] (SOLUTION) 10 MG/ML STLACOSAMIDE [VIMPAT] (TAB) 50 MG, 100 MG, 150 MG, 200 MG STMETHSUXIMIDE [CELONTIN] (CAP) 300 MG STPHENYTOIN [DILANTIN‐125] (ORAL SUSP) 125 MG/5MLPHENYTOIN SOD EXTENDED [DILANTIN] (CAP) 100 MG, 30 MGPHENYTOIN SOD EXTENDED [PHENYTEK] (CAP) 300 MG, 200 MG

TIER 3PREGABALIN (CAP) 200 MG, 300 MG, 225 MG PAPREGABALIN (CAP) 25 MG, 50 MG, 75 MG, 100 MG, 150 MG QL: 3 PER DAY

SKELETAL MUSCLE DISORDERAGENTS TO TX PERIODIC PARALYSIS - CARBON ANHYD INH

TIER 2DICHLORPHENAMIDE [KEVEYIS] (TAB) 50 MG PA, FL: FILLS≤1 IN 365 DAYS, MS

SKELETAL MUSCLE RELAXANTSTIER 1

BACLOFEN (TAB) 10 MG QL: 240 IN 30 DAYSBACLOFEN (TAB) 20 MG QL: 120 IN 30 DAYSCYCLOBENZAPRINE (TAB) 5 MG, 10 MGMETHOCARBAMOL (TAB) 500 MG, 750 MG

TIER 3TIZANIDINE (TAB) 2 MG, 4 MG QL: 3 IN 1 DAYS, ST

SMOKING CESSATIONSMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS)

TIER 1NICOTINE (PATCH TD24) 7MG/24HR, 14MG/24HR, 21 MG/24HR QL: 180 YEAR|30 IN 23 DAYSNICOTINE POLACRILEX (GUM) 2 MG, 4 MG QL: 24 IN 1 DAYS|4400 YEARNICOTINE POLACRILEX (LOZENGE) 4 MG, 2 MG QL: 24 IN 1 DAYS|3600 YEARNICOTINE POLACRILEX (LOZNG MINI) 4 MG, 2 MG QL: 24 IN 1 DAYS|3600 YEAR

TIER 2NICOTINE [NICOTINE PATCH] (PATCH DYSQ) 21‐14‐7MG QL: 180 YEAR|30 IN 23 DAYS

TIER 3NICOTINE [NICOTROL NS] (SPRAY) 10 MG/ML PANICOTINE [NICOTROL] (CARTRIDGE) 10 MG PA

SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONISTTIER 2

VARENICLINE TARTRATE [CHANTIX] (TAB DS PK) 0.5 (11)‐1 QL: 56 IN 21 DAYS, DL: 180 IN 365 DAYS

VARENICLINE TARTRATE [CHANTIX] (TAB) 0.5 MG, 1 MG QL: 60 IN 30 DAYS, DL: 180 IN 365 DAYS

SMOKING DETERRENTS, OTHERTIER 1

BUPROPION (TAB ER 12H) 150 MGUPPER GASTROINTESTINAL DISORDERS

ANTACIDS






ALUMINUM HYDROXIDE (ORAL SUSP) 320 MG/5ML, 600 MG/5MLCALCIUM CARBONATE (ORAL SUSP) 400 MG/5MLCALCIUM CARBONATE (TAB CHEW) MULTIPLE STRENGTHSMAG CARB/ALUMINUM HYDROX/ALGIN (ORAL SUSP) 131‐31.7/5, 358‐95/15

MAG HYDROX/ALUMINUM HYD/SIMETH (ORAL SUSP) 200‐200‐20, 400‐400‐40

MAG/ALUMINUM/SOD BICARB/ALGINC (TAB CHEW) 20 MG‐80MGMAGNESIUM CARB/ALUMINUM HYDROX (TAB CHEW) 105‐160MG

TIER 2MAG CARB/ALUMINUM HYDROX/ALGIN [GAVISCON] (ORAL SUSP) 237.5‐254

ANTICHOLINERGICS/ANTISPASMODICSTIER 1

DICYCLOMINE (CAP) 10 MGDICYCLOMINE (TAB) 20 MG

TIER 3DICYCLOMINE (SOLUTION) 10 MG/5 ML

ANTIFLATULENTSTIER 1

SIMETHICONE (CAP) 125 MG, 180 MG, 166MGSIMETHICONE (DROPS SUSP) 40MG/0.6MLSIMETHICONE (TAB CHEW) 80 MG, 125 MGSIMETHICONE (TAB) 125 MG

ANTI-ULCER PREPARATIONSTIER 1

MISOPROSTOL (TAB) 200 MCG, 100 MCGSUCRALFATE (TAB) 1 G

EMETICSTIER 1

IPECAC (SYRUP) HISTAMINE H2-RECEPTOR INHIBITORS

TIER 1FAMOTIDINE (ORAL SUSP) 40MG/5MLFAMOTIDINE (TAB) 20 MG, 40 MG, 10 MGFAMOTIDINE/CA CARB/MAG HYDROX (TAB CHEW) 10‐800‐165RANITIDINE (CAP) 150 MG, 300 MGRANITIDINE (SYRUP) 15 MG/MLRANITIDINE (TAB) 150 MG, 300 MG, 75 MG

TIER 3CIMETIDINE (SOLUTION) 300 MG/5MLCIMETIDINE (TAB) 200 MG, 300 MG, 400 MG, 800 MG

INTESTINAL MOTILITY STIMULANTSTIER 1





Therapeutic Indication / Drug Name CommentMETOCLOPRAMIDE (SOLUTION) 10 MG/10ML, 5 MG/5 ML DL: 90 IN 180 DAYSMETOCLOPRAMIDE (TAB) 10 MG QL: 6 IN 1 DAYS, DL: 90 IN 180

DAYSMETOCLOPRAMIDE (TAB) 5 MG QL: 12 IN 1 DAYS, DL: 90 IN 180

DAYSPANCREATIC ENZYMES

TIER 2LIPASE/PROTEASE/AMYLASE [CREON] (CAP DR) 6K‐19K‐30K, 12K‐38K‐60, 24‐76‐120KLIPASE/PROTEASE/AMYLASE [ZENPEP] (CAP DR) MULTIPLE STRENGTHS

PROTON-PUMP INHIBITORSTIER 1

LANSOPRAZOLE (CAP DR) 15 MG, 30 MGOMEPRAZOLE (CAP DR) 20 MG, 40 MG, 10 MGPANTOPRAZOLE SOD (TAB DR) 40 MG, 20 MG

TIER 3ESOMEPRAZOLE MAG (CAP DR) 20 MG, 40 MG QL: 1 IN 1 DAYS|60 IN 180 DAYS,

STLANSOPRAZOLE (TAB RAP DR) 15 MG, 30 MG STRABEPRAZOLE SOD (TAB DR) 20 MG QL: 30 IN 30 DAYS, ST

4OMEPRAZOLE (TAB RAP DR) 20 MG QL: 1 IN 1 DAYS, FL: 60 DAYS PER

YEARURINARY TRACT - FUNCTIONAL DISORDERS

BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTSTIER 1

FINASTERIDE (TAB) 5 MGTAMSULOSIN (CAP) 0.4 MG

TIER 3ALFUZOSIN (TAB ER 24H) 10 MG ST

OVERACTIVE BLADDER AGENTS, BETA-3 ADRENERGIC RECEPTIER 2

MIRABEGRON [MYRBETRIQ] (TAB ER 24H) 25 MG, 50 MG PAURINARY PH MODIFIERS

TIER 1POTASSIUM CIT (TAB ER) 5 MEQ, 10 MEQ, 15 MEQPOTASSIUM CIT/CITRIC ACID (SOLUTION) 1100‐334/5

URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE)TIER 1

PHENAZOPYRIDINE (TAB) 100 MG, 200 MG, 97.5 MGURINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG.

4SOLIFENACIN SUCC (TAB) 5 MG, 10 MG QL: 1 PER DAY

URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENTTIER 1





Therapeutic Indication / Drug Name CommentOXYBUTYNIN CHLORIDE (SYRUP) 5 MG/5 MLOXYBUTYNIN CHLORIDE (TAB ER 24) 5 MG, 10 MG, 15 MGOXYBUTYNIN CHLORIDE (TAB) 5 MG

TIER 3TOLTERODINE TARTRATE (CAP ER 24H) 4 MG, 2 MG QL: 1 IN 1 DAYS, STTOLTERODINE TARTRATE (TAB) 1 MG, 2 MG QL: 2 IN 1 DAYS, ST

VAGINAL DISORDERSVAGINAL ANTIBIOTICS

TIER 1CLINDAMYCIN PHOSPHATE (CREAM/APPL) 2 %

TIER 2METRONIDAZOLE [VANDAZOLE] (GEL W/APPL) 0.75 %

TIER 3CLINDAMYCIN PHOSPHATE [CLEOCIN] (SUPP.VAG) 100 MG

VAGINAL ANTIFUNGALSTIER 1

CLOTRIMAZOLE (CREAM/APPL) 1 %, 2 %MICONAZOLE NIT (CMB PF CRM) 200 MG‐2 %MICONAZOLE NIT (CREAM/APPL) 2 %, 4 %MICONAZOLE NIT (KIT) 200 MG‐2 %, 1200MG‐2%MICONAZOLE NIT (SUPP.VAG) 100 MG, 200 MGMICONAZOLE/CLEANSER 17 ON WIPE (KIT) 200 MG‐2 %

TIER 2MICONAZOLE NIT [MONISTAT 3] (CRM/PF APP) 4 %

TIER 3TERCONAZOLE (CREAM/APPL) 0.4 %, 0.8 % STTERCONAZOLE (SUPP.VAG) 80 MG ST

VAGINAL ESTROGEN PREPARATIONSTIER 2

ESTRADIOL [ESTRING] (VAG RING) 7.5MCG/24H QL: 1 IN 90 DAYS, DL: 90 DAYS

TIER 3ESTRADIOL (CREAM/APPL) 0.01 % QL: 42.5 IN 30 DAYSESTROGENS, CONJUGATED [PREMARIN] (CREAM/APPL) 0.625 MG/G PA

VITAMIN AND/OR MINERAL DEFICIENCY - refer to website for compCARIOSTATIC AGENTS

TIER 1FLUORIDE (SODIUM) (CREAM (G)) 0.011 FLUORIDE (SODIUM) (GEL (G)) 0.011 FLUORIDE (SODIUM) (TAB CHEW) MULTIPLE STRENGTHS FLUORIDE (SODIUM) [FLUORABON] (DROPS) MULTIPLE STRENGTHS

REPLACEMENT PREPARATIONSTIER 1

CALCIUM CARBONATE (TABLET) MULTIPLE STRENGTHS CALCIUM CARBONATE/VITAMIN D3 (TABLET) MULTIPLE STRENGTHS





Therapeutic Indication / Drug Name CommentFERROUS GLUCONATE (TABLET) MULTIPLE STRENGTHS FERROUS SULFATE (TABLET) MULTIPLE STRENGTHS MAGNESIUM OXIDE (TABLET) MULTIPLE STRENGTHS MULTIVITAMIN WITH MINERALS PEDIATRIC VITAMINS PRENATAL VITAMINS

VITAMIN ATIER 1

BETA‐CAROTENE (CAPSULE) MULTIPLE STRENGTHS VITAMIN A (CAPSULE) MULTIPLE STRENGTHS

VITAMIN BTIER 1

CYANOCOBALAMIN (VITAMIN B‐12) (TABLET) MULTIPLE STRENGTHS PYRIDOXINE (VITAMIN B‐6) (TABLET) MULTIPLE STRENGTHS RIBOFLAVIN(VITAMIN B‐2) (TABLET) MULTIPLE STRENGTHS THIAMINE(VITAMIN B‐1) (TABLET) MULTIPLE STRENGTHS

VITAMIN CTIER 1

ASCORBIC ACID (VITAMIN C) MULTIPLE STRENGTHS VITAMIN D

TIER 1CHOLECALCIFEROL (VITAMIN D3) MULTIPLE STRENGTHS ERGOCALCIFEROL (VITAMIN D2) MULTIPLE STRENGTHS

VITAMIN ETIER 1

VITAMIN E MIXED (CAPSULE) 400 UNIT, 1000 UNIT VITAMIN E MULTIPLE STRENGTHS

Updated on November 27, 2019Effective on January 1, 2020

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2020 Drug Coverage - AllCare Health