HMSA Akamai Advantage 2019 Formulary...on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

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List of Covered DrugsFormulary ID 00019312, version 18

This formulary was updated on 12/01/2019. For more recent information or other questions, please contact HMSA at 948-6000 on Oahu or 1 (800) 660-4672 toll-free. TTY users, call 711. Telephone hours are 8 a.m. to 8 p.m., seven days a week or visit http://www.hmsa.com/advantage.

2019Formulary

HMSA Akamai Advantage

H3832_5042_8700_16673_12_C

Note to existing members: This formulary has changed since last year. Please review this docu-ment to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means HMSA. When it refers to “plan” or “our plan,” it means HMSA Akamai Advantage.

This document includes a list of the drugs (formulary) for our plan which is current as of December 1, 2019. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.

What is the HMSA Akamai Advantage Formulary?A formulary is a list of covered drugs selected by HMSA Akamai Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a neces-sary part of a quality treatment program. HMSA Akamai Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an HMSA Akamai Advantage network pharmacy, and other plan rules are followed. For more infor-mation on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of

the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits, and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of December 1, 2019. To get updated informa-tion about the drugs covered by HMSA Akamai Advantage, please contact us. Our contact infor-mation appears on the front and back cover pages. We will inform members of any formulary changes to this comprehensive formulary by mail.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical ConditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 45. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find

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coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?HMSA Akamai Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active in-gredient as the brand name drug. Generally, gener-ic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?Some covered drugs may have additional require-ments or limits on coverage. These requirements and limits may include:

• Prior Authorization: HMSA Akamai Advantage requires you or your physician to get prior autho-rization for certain drugs. This means that you will need to get approval from HMSA Akamai Advantage before you fill your prescriptions. If you don’t get approval, HMSA Akamai Advantage may not cover the drug.

• Quantity Limits: For certain drugs, HMSA Aka-mai Advantage limits the amount of the drug that HMSA Akamai Advantage will cover. For exam-ple, HMSA Akamai Advantage provides 30 tablets per prescription for simvastatin. This may be in addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, HMSA Akamai Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For exam-ple, if Drug A and Drug B both treat your medi-cal condition, HMSA Akamai Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, HMSA Akamai Advan-tage will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restric-tions. You may also ask us to send you a copy. Our contact information, along with the date we

last updated the formulary, appears on the front and back cover pages.

You can ask HMSA Akamai Advantage to make an exception to these restrictions or limits or for a list of other similar drugs that may treat your health condition. See the section, “How do I request an exception to the HMSA Akamai Advantage formu-lary?” on this page for information about how to request an exception.

What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact our Customer Relations department and ask if your drug is covered. If you learn that HMSA Akamai Advantage does not cover your drug, you have two options:

• You can ask Customer Relations for a list of similar drugs that are covered by HMSA Akamai Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by HMSA Akamai Advantage.

• You can ask HMSA Akamai Advantage to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the HMSA Akamai Advantage Formulary?You can ask HMSA Akamai Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on tier 5. If approved, this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for cer-tain drugs, HMSA Akamai Advantage limits the amount of the drug that we will cover. If your

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drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, HMSA Akamai Advantage will only approve your request for an exception if the alter-native drugs included on the plan’s formulary, the lower cost-sharing drug, or additional utilization re-strictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering, or uti-lization restriction exception. When you request a formulary, tiering, or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s sup-porting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formu-lary but your ability to get it is limited. For exam-ple, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to deter-mine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care (LTC) facility, we will allow you to refill your prescrip-tion until we have provided you with a 31-day transition supply consistent with the dispensing increment (unless you have a prescription writ-ten for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Transition policyNew members in our plan may be taking drugs that aren’t on our formulary or that are subject to certain restrictions, such as prior authorization. Current members may also be affected by changes in our formulary from one year to the next. Mem-bers should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See the section, “How do I request an exception to HMSA Akamai Advantage formulary?” to learn more about how to request an exception. Please contact Customer Relations if your drug is not on our formulary, is subject to certain restrictions such as prior authorization, and you need to switch to a different drug that we cov-er or request a formulary exception. During the pe-riod of time members are talking to their doctors to determine a course of action, we may provide a temporary supply of a non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in our plan. If you are a current member affected by a formulary change from one year to the next, we will provide you with the opportunity to request a formulary excep-tion in advance for the following year.

When a member goes to a network pharmacy and we provide a temporary supply of a drug that isn’t on our formulary, or that has coverage restrictions or limits (but is otherwise considered a Part D drug), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transi-tion policy again. We will provide you with a

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written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.

If a new member is a resident of a long-term care facility (like a nursing home), we will also cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our plan. If the resident has been enrolled in our plan for more than 90 days and needs a drug that isn’t on our formulary or is subject to other restrictions, such as dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.

Current members are also eligible to receive a transition fill under certain conditions. If a current member enters a long-term care (LTC) facility, or is in an LTC facility and requires an emergency supply of non-formulary drugs, we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). We will cover more than one refill of these drugs for these members for the first 90 days. A member may experience a change in their level of care at an inpatient hospital facility or skilled nursing facility which results in non-coverage of drugs previously covered by Medicare Part D. For current members experiencing a level of care change, we will also cover a temporary 31-day transition supply as out-lined above.

Please note that our transition policy applies only to those drugs that are Part D drugs and bought at a network pharmacy. The transition policy can’t be used to buy a non-Part D drug or a drug out-of-network unless you qualify for out-of-network access.

For more informationFor more detailed information about your HMSA Akamai Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about HMSA Akamai Advan-tage, please contact us. Our contact information,

along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1 (800) MEDICARE [1 (800) 633-4227] 24 hours a day/seven days a week. TTY users should call 1 (877) 486-2048. Or visit http://www.medicare.gov.

HMSA Akamai Advantage FormularyThe formulary that begins on page 1 provides coverage information about the drugs covered by HMSA Akamai Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 45.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., FORTEO) and generic drugs are listed in lower-case italics (e.g., ibuprofen).

The information in the requirements/limits column tells you if HMSA Akamai Advantage has any special requirements for coverage of your drug.

Drug tier index:

Tier 1 - Preferred Generic

Tier 2 - Generic

Tier 3 - Preferred Brand

Tier 4 - Non-Preferred Drug

Tier 5 - Specialty Tier

Please refer to the Summary of Benefits or Evidence of Coverage for the specific copayment or coinsurance amount associated with each tier.

Abbreviations used in this FormularyPA – Prior Authorization: Requires that you or your physician receive approval from HMSA Akamai Advantage before we will cover your prescription.

QL – Quantity Limits: A limit on the amount of the drug that HMSA Akamai Advantage will cover.

ST – Step Therapy: Requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

M – Mail Order: These drugs are available through HMSA’s mail order pharmacy, CVS Caremark.

B/D – B or D: This drug may be covered under

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Medicare Part B or D depending upon the circum-stances. Information may need to be submitted describing the use and setting of the drug to make the determination. For more information, please call Customer Relations.

LA – Limited Availability: This prescription may be available only at certain pharmacies. For more information, please call Customer Relations.

Prescription drugs can be shipped to your home from the HMSA Akamai Advantage Mail Order pharmacy. Usually, a mail-order pharmacy order will get to you in no more than 14 days after the pharmacy receives the order. If your drugs do not arrive within this timeframe, please call 1 (855) 479-3659 toll-free, 24 hours a day, seven days a week; TTY users, call 711. You can also choose to sign up for our optional automatic delivery program by calling these numbers.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - Available at mail-order B/D - Covered under Medicare B or D LA - Limited Access

1

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol tab 1 M

colchicine w/ probenecid 2 M

COLCRYS QL (120 tabs / 30 days)

3 QL M

DUZALLO 4 M ST

febuxostat 2 M ST

MITIGARE QL (60 caps / 30 days)

3 QL M

probenecid 2 M

ULORIC 3 M ST

NSAIDS celecoxib CAPS 50mg

QL (240 caps / 30 days) 2 QL M

celecoxib CAPS 100mg QL (120 caps / 30 days)

2 QL M


2 QL M


2 QL M

diclofenac potassium QL (120 tabs / 30 days)

2 QL M

diclofenac sodium TB24; TBEC

2 M

diclofenac w/ misoprostol 2 M

diflunisal TABS 2 M

etodolac 2 M

etodolac er 2 M

fenoprofen calcium CAPS 400mg

2 M

fenoprofen calcium TABS 2 M

flurbiprofen TABS 2 M

ibu tab 600mg 1 M

ibu tab 800mg 1 M

ibuprofen SUSP 2 M

ibuprofen TABS 400mg, 600mg, 800mg

1 M

ketoprofen CAPS; CP24 2 M

meloxicam tabs 1 M

nabumetone TABS 2 M

naproxen TABS 1 M

naproxen dr 1 M

naproxen sodium TABS 275mg, 550mg

2 M

oxaprozin 2 M

piroxicam CAPS 2 M

sulindac TABS 1 M

tolmetin sodium 2 M

Drug Name Drug Tier

Requirements/Limits

OPIOID ANALGESICS acetaminophen w/ codeine 300-15mg

QL (400 tabs / 30 days)

2 QL M

acetaminophen w/ codeine 300-30mg


2 QL M

acetaminophen w/ codeine 300-60mg


2 QL M

acetaminophen w/ codeine soln

QL (2700 mL / 30 days)

2 QL M

acetaminophen-caff-dihydrocod

QL (300 caps / 30 days)

2 QL M

BELBUCA QL (60 buccal films / 30 days)

4 QL M PA

buprenorphine patch QL (4 patches / 28 days)

2 QL M PA

butorphanol nasal spray QL (10 mL / 30 days)

2 QL M

butorphanol tartrate SOLN 4 M

BUTRANS QL (4 patches / 28 days)

3 QL M PA

dvorah QL (300 tabs / 30 days)

2 QL M

nalbuphine hcl SOLN 4 M

tramadol hcl CP24 QL (30 caps / 30 days)

2 QL M PA

tramadol hcl er TB24 QL (30 tabs / 30 days)

2 QL M PA

tramadol hcl er (biphasic) 100mg


2 QL M PA



2 QL M PA



2 QL M PA

tramadol hcl tab 50 mg QL (240 tabs / 30 days)

2 QL M

tramadol-acetaminophen QL (240 tabs / 30 days)

2 QL M

trezix QL (300 caps / 30 days)

2 QL M


2

Drug Name Drug Tier

Requirements/Limits

OPIOID ANALGESICS, CII ABSTRAL

QL (120 tabs / 30 days) 5 QL M PA

ARYMO ER 15mg, 30mg QL (90 tabs / 30 days)

4 QL M PA

ARYMO ER 60mg QL (90 tabs / 30 days)

5 QL M PA

codeine sulfate QL (180 tabs / 30 days)

2 QL M

EMBEDA CAP 20-0.8MG QL (60 caps / 30 days)

4 QL M PA


4 QL M PA

EMBEDA CAP 50-2MG QL (60 caps / 30 days)

4 QL M PA


4 QL M PA


4 QL M PA

EMBEDA CAP 100-4MG QL (60 caps / 30 days)

5 QL M PA

endocet 2.5-325mg QL (360 tabs / 30 days)

2 QL M

endocet 5-325mg QL (360 tabs / 30 days)

2 QL M

endocet 7.5-325mg QL (240 tabs / 30 days)

2 QL M

endocet 10-325mg QL (180 tabs / 30 days)

2 QL M

fentanyl citrate LPOP QL (120 lozenges / 30 days)

5 QL M PA

fentanyl citrate TABS QL (120 tabs / 30 days)

5 QL M PA

fentanyl patch 12 mcg/hr QL (10 patches / 30 days)

2 QL M PA


2 QL M PA


2 QL M PA


2 QL M PA


2 QL M PA

Drug Name Drug Tier

Requirements/Limits

FENTORA QL (120 tabs / 30 days)

5 QL M PA

hydrocodone-acetaminophen 2.5-325mg


2 QL M

hydrocodone-acetaminophen 5-300mg


2 QL M



2 QL M



2 QL M

hydrocodone-acetaminophen 7.5-325 mg/15ml

QL (2700 mL / 30 days)

2 QL M



2 QL M



2 QL M

hydrocodone-acetaminophen tab 10-325mg


2 QL M

hydrocodone-ibuprofen tab 5-200mg


2 QL M

hydrocodone-ibuprofen tab 7.5-200 mg


2 QL M

hydrocodone-ibuprofen tab 10-200mg


2 QL M

hydromorphone hcl LIQD QL (600 mL / 30 days)

2 QL M

hydromorphone hcl SOLN 4 B/D M

hydromorphone hcl TABS QL (180 tabs / 30 days)

2 QL M

HYDROMORPHONE HYDROCHLORI SOLN 1mg/ml, 2mg/ml, 4mg/ml

4 B/D M

hydromorphone tab 8mg er QL (30 tabs / 30 days)

2 QL M PA


2 QL M PA


5 QL M PA

hydromorphone tabs 32mg er QL (30 tabs / 30 days)

5 QL M PA


3

Drug Name Drug Tier

Requirements/Limits

HYSINGLA ER QL (30 tabs / 30 days)

3 QL M PA

KADIAN 40mg, 200mg QL (60 caps / 30 days)

5 QL M PA

LAZANDA QL (30 bottles / 30 days)

5 QL M PA

levorphanol tartrate TABS 2mg


5 QL M

lorcet hd tab 10-325mg QL (180 tabs / 30 days)

2 QL M

lorcet plus tab 7.5-325 QL (180 tabs / 30 days)

2 QL M

lorcet tab 5-325mg QL (240 tabs / 30 days)

2 QL M

methadone hcl SOLN 5mg/5ml, 10mg/5ml

QL (450 mL / 30 days)

2 QL M PA

methadone hcl SOLN 10mg/ml

2 M

methadone hcl 5mg QL (90 tabs / 30 days)

2 QL M PA

methadone hcl 10mg QL (90 tabs / 30 days)

2 QL M PA

methadone hcl intensol QL (90 mL / 30 days)

2 QL M PA

MORPHABOND ER 15mg, 30mg


4 QL M PA

MORPHABOND ER 60mg, 100mg


5 QL M PA

morphine sul inj 1mg/ml 4 B/D M

morphine sulfate CP24 10mg, 20mg, 30mg, 40mg, 50mg, 60mg, 80mg


2 QL M PA

morphine sulfate CP24 100mg


5 QL M PA

MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml

4 B/D M

morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml

4 B/D M

morphine sulfate TABS 15mg


2 QL M

Drug Name Drug Tier

Requirements/Limits

morphine sulfate TABS 30mg


2 QL M

morphine sulfate beads QL (30 caps / 30 days)

2 QL M PA

morphine sulfate ext-rel tab 15mg, 30mg, 60mg, 100mg


2 QL M PA

morphine sulfate ext-rel tab 200mg


2 QL M PA

morphine sulfate oral soln 10mg/5ml

QL (900 mL / 30 days)

2 QL M


QL (750 mL / 30 days)

2 QL M


QL (180 mL / 30 days)

2 QL M

NUCYNTA 50mg, 75mg QL (180 tabs / 30 days)

4 QL M

NUCYNTA 100mg QL (180 tabs / 30 days)

5 QL M

NUCYNTA ER 50mg, 100mg, 200mg, 250mg


3 QL M PA

NUCYNTA ER 150mg QL (90 tabs / 30 days)

3 QL M PA

OXAYDO 5mg QL (540 tabs / 30 days)

4 QL M

OXAYDO 7.5mg QL (360 tabs / 30 days)

4 QL M

oxycodone hcl CAPS QL (180 caps / 30 days)

2 QL M

oxycodone hcl CONC QL (180 mL / 30 days)

2 QL M

oxycodone hcl SOLN QL (900 mL / 30 days)

2 QL M

oxycodone hcl TABS QL (180 tabs / 30 days)

2 QL M

oxycodone w/ acetaminophen 2.5-325mg


2 QL M

oxycodone w/ acetaminophen 5-325mg


2 QL M

oxycodone w/ acetaminophen 7.5-325mg


2 QL M


4

Drug Name Drug Tier

Requirements/Limits

oxycodone w/ acetaminophen 10-325mg


2 QL M

oxycodone-aspirin QL (360 tabs / 30 days)

2 QL M

oxycodone-ibuprofen QL (120 tabs / 30 days)

2 QL M

OXYCONTIN 10mg, 15mg, 20mg, 30mg, 40mg


4 QL M PA

OXYCONTIN 60mg, 80mg QL (60 tabs / 30 days)

5 QL M PA

oxymorphone tab QL (180 tabs / 30 days)

2 QL M

SUBSYS SPRAY 100MCG QL (120 sprays / 30 days)

5 QL M PA


5 QL M PA


5 QL M PA


5 QL M PA


5 QL M PA


5 QL M PA


5 QL M PA

vicodin es QL (180 tabs / 30 days)

2 QL M

vicodin hp QL (180 tabs / 30 days)

2 QL M

XTAMPZA ER 9mg, 13.5mg, 18mg, 27mg


4 QL M PA

XTAMPZA ER 36mg QL (240 caps / 30 days)

5 QL M PA

ZOHYDRO ER (ABUSE DETERRENT)


4 QL M PA

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) 2 B/D M

Drug Name Drug Tier

Requirements/Limits

lidocaine inj 0.5% 2 B/D M

lidocaine inj 1% 2 B/D M

lidocaine inj 1.5% preservative free (pf)

2 B/D M

lidocaine inj 2% preservative free (pf)

2 B/D M

lidocaine inj 4% preservative free (pf)

2 M

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 2 M

ARIKAYCE 5 LA PA

BETHKIS 5 PA

gentamicin in saline 2 M

gentamicin sulfate SOLN 2 M

neomycin sulfate TABS 2 M

paromomycin sulfate CAPS 2 M

streptomycin sulfate SOLR 5 M

SULFADIAZINE TABS 4 M

TOBI PODHALER 5 LA PA

tobramycin NEBU 5 PA

tobramycin inj 1.2 gm/30ml 2 M

tobramycin inj 1.2gm 5 M

tobramycin inj 10mg/ml 2 M

tobramycin inj 40mg/ml 2 M

tobramycin inj 80mg/2ml 2 M

ZEMDRI 5 M

ANTI-INFECTIVES - MISCELLANEOUS albendazole TABS 5 M

ALINIA 5 M

atovaquone SUSP 5 M

AZACTAM INJ 4 M

aztreonam 2 M

CAYSTON 5 LA PA

clindamycin hcl CAPS 2 M

clindamycin phosphate in d5w 2 M

CLINDAMYCIN PHOSPHATE IN NACL

4 M

clindamycin phosphate inj 2 M

clindamycin soln 75mg/5ml 2 M

colistimethate sodium SOLR 2 M

DALVANCE 5 M

dapsone TABS 2 M

DAPTOMYCIN 350mg 5 M

daptomycin 350mg, 500mg 5 M

EMVERM 5 M

ertapenem sodium 2 M

FIRVANQ 4 M

imipenem-cilastatin 2 M


5

Drug Name Drug Tier

Requirements/Limits

ivermectin TABS 2 M

linezolid in sodium chloride 4 M

linezolid inj 2 M

linezolid susp 5 M

linezolid tab 600mg 5 M

meropenem 2 M

MEROPENEM/SODIUM CHLORIDE

4 M

methenamine hippurate 2 M

metronidazole CAPS 2 M

METRONIDAZOLE SOLN 3 M

metronidazole TABS 1 M

metronidazole inj 2 M

NEBUPENT 4 B/D M

nitrofurantoin SUSP PA applies if 70 years and older after a 90 day supply in a calendar year

4 M PA

nitrofurantoin macrocrystal PA applies if 70 years and older after a 90 day supply in a calendar year

3 M PA

nitrofurantoin monohyd macro PA applies if 70 years and older after a 90 day supply in a calendar year

3 M PA

ORBACTIV 5 M

PENTAM 300 4 M

pentamidine isethionate 2 M

polymyxin b sulfate SOLR 2 M

praziquantel TABS 2 M

SIVEXTRO 5 M

SOLOSEC 4 M

sulfamethoxazole-trimethop ds

1 M

sulfamethoxazole-trimethoprim inj

2 M

sulfamethoxazole-trimethoprim susp

2 M

sulfamethoxazole-trimethoprim tab 400-80mg

1 M

SYNERCID 5 M

tigecycline 5 M

trimethoprim TABS 1 M

VABOMERE 4 M

vancomycin hcl CAPS 125mg

2 M

vancomycin hcl CAPS 250mg

5 M

Drug Name Drug Tier

Requirements/Limits

vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg

2 M

VANCOMYCIN HYDROCHLORIDE SOLR

4 M

VANCOMYCIN IN NACL 4 M

VANCOMYCIN INJ 250MG 4 M

VIBATIV 5 M

XIFAXAN TAB 200MG QL (9 tabs / 30 days)

5 QL M

ANTIFUNGALS ABELCET 5 B/D M

AMBISOME 5 B/D M

amphotericin b SOLR 2 B/D M

caspofungin acetate 5 M

CRESEMBA 5 M

ERAXIS 5 M

fluconazole SUSR 2 M

fluconazole TABS 50mg, 100mg, 200mg

2 M

fluconazole TABS 150mg 1 M

fluconazole inj nacl 200 2 M

fluconazole inj nacl 400 2 M

flucytosine CAPS 5 M

griseofulvin microsize 2 M

griseofulvin ultramicrosize 2 M

itraconazole CAPS 2 M PA

itraconazole SOLN 5 M

ketoconazole TABS 2 M PA

MYCAMINE 5 M

NOXAFIL SOLN 5 M

NOXAFIL SUSP QL (630 mL / 30 days)

5 QL M

NOXAFIL TBEC QL (93 tabs / 30 days)

5 QL M

nystatin TABS 2 M

posaconazole QL (93 tabs / 30 days)

5 QL M

terbinafine hcl TABS QL (90 tabs / year)

1 QL M

TOLSURA 5 M PA

voriconazole SUSR; TABS 5 M

voriconazole inj 200mg 2 M

ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg

2 M

atovaquone-proguanil hcl tab 250-100 mg

2 M

chloroquine phosphate TABS

2 M


6

Drug Name Drug Tier

Requirements/Limits

COARTEM 4 M

mefloquine hcl 2 M

primaquine phosphate 26.3mg

2 M

PRIMAQUINE PHOSPHATE 26.3mg

3 M

quinine sulfate CAPS 2 M PA

ANTIRETROVIRAL AGENTS abacavir sulfate 2 M

APTIVUS 5 M

atazanavir sulfate 5 M

CRIXIVAN 4 M

didanosine 2 M

EDURANT 5 M

efavirenz CAPS 50mg 2 M

efavirenz CAPS 200mg 5 M

efavirenz TABS 5 M

EMTRIVA 3 M

fosamprenavir tab 700 mg 5 M

FUZEON 5

INTELENCE 25mg 4 M

INTELENCE 100mg, 200mg 5 M

INVIRASE 5 M

ISENTRESS CHEW 25mg 3 M

ISENTRESS CHEW 100mg 5 M

ISENTRESS PACK 3 M

ISENTRESS TABS 5 M

ISENTRESS HD 5 M

lamivudine 2 M

LEXIVA SUSP 4 M

nevirapine susp 50 mg/5ml 2 M

nevirapine tab 100mg er 2 M

nevirapine tab 200mg 2 M

nevirapine tab 400mg er 2 M

NORVIR PACK 4 M

NORVIR SOLN 4 M

PIFELTRO 5 M

PREZISTA SUSP QL (400 mL / 30 days)

5 QL M

PREZISTA TABS 75mg QL (480 tabs / 30 days)

3 QL M


5 QL M


5 QL M


5 QL M

RESCRIPTOR 4 M

REYATAZ PACK 5 M

Drug Name Drug Tier

Requirements/Limits

ritonavir 2 M

SELZENTRY SOLN 5 M

SELZENTRY TABS 25mg 4 M

SELZENTRY TABS 75mg, 150mg, 300mg

5 M

stavudine 2 M

tenofovir disoproxil fumarate 5 M

TIVICAY 10mg 3 M

TIVICAY 25mg, 50mg 5 M

TROGARZO 5 LA

TYBOST 4 M

VIDEX EC 125mg 4 M

VIDEX PEDIATRIC 4 M

VIRACEPT 5 M

VIRAMUNE SUSP 4 M

VIREAD POWD 5 M

VIREAD TABS 150mg, 200mg, 250mg

5 M

zidovudine cap 100mg 2 M

zidovudine syp 50mg/5ml 2 M

zidovudine tab 300mg 2 M

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine 2 M

abacavir sulfate-lamivudine-zidovudine

5 M

ATRIPLA 5 M

BIKTARVY 5 M

CIMDUO 5 M

COMPLERA 5 M

DELSTRIGO 5 M

DESCOVY 5 M

DOVATO 5 M

EVOTAZ 5 M

GENVOYA 5 M

JULUCA 5 M

KALETRA TAB 100-25MG 4 M

KALETRA TAB 200-50MG 5 M

lamivudine-zidovudine 2 M

lopinavir-ritonavir 2 M

ODEFSEY 5 M

PREZCOBIX 5 M

STRIBILD 5 M

SYMFI 5 M

SYMFI LO 5 M

SYMTUZA 5 M

TEMIXYS 5 M

TRIUMEQ 5 M


7

Drug Name Drug Tier

Requirements/Limits

TRUVADA TAB 100-150 QL (60 tabs / 30 days)

5 QL M


5 QL M


5 QL M


5 QL M

ANTITUBERCULAR AGENTS cycloserine CAPS 5 M

ethambutol hcl TABS 2 M

isoniazid SYRP 2 M

isoniazid tabs 1 M

PASER D/R 4 M

PRIFTIN 4 M

pyrazinamide TABS 2 M

rifabutin 2 M

RIFAMATE 4 M

rifampin CAPS; SOLR 2 M

RIFATER 4 M

SIRTURO 5 M LA PA

TRECATOR 4 M

ANTIVIRALS acyclovir CAPS; TABS 1 M

acyclovir SUSP 2 M

acyclovir sodium 2 B/D M

adefovir dipivoxil 5 M

BARACLUDE SOLN 5 M

cidofovir 5 M

entecavir 5 M

EPCLUSA 5 PA

EPIVIR HBV SOLN 4 M

famciclovir 2 M

GANCICLOVIR INJ 500MG/10ML

4 B/D M

ganciclovir sodium 2 B/D M

HARVONI TAB 90-400MG 5 PA

lamivudine (hbv) 2 M

MAVYRET 5 PA

oseltamivir phosphate CAPS; SUSR

2 M

PEGASYS 5 PA

PEGASYS PROCLICK 5 PA

PREVYMIS 5 M

RELENZA DISKHALER 3 M

ribavirin 200mg 2

rimantadine hydrochloride 2 M

valacyclovir hcl TABS 2 M

valganciclovir hcl 5 M

Drug Name Drug Tier

Requirements/Limits

VEMLIDY 5 M

VOSEVI 5 PA

XOFLUZA 4 M

ZEPATIER 5 PA

CEPHALOSPORINS AVYCAZ 5 M

cefaclor 2 M

CEFACLOR ER TAB 500MG 4 M

cefadroxil CAPS 1 M

cefadroxil SUSR; TABS 2 M

CEFAZOLIN IN DEXTROSE 2GM/100ML-4%

3 M

cefazolin inj 2 M

cefazolin sodium SOLR 1gm 2 M

CEFAZOLIN SODIUM 1 GM/50ML

3 M

cefdinir 2 M

CEFEPIME 1GM SOLN 4 M

CEFEPIME 2GM SOLN 4 M

cefepime inj 1gm 2 M

cefepime inj 2gm 2 M

CEFEPIME/DEXTROSE 4 M

cefixime cap 400mg 2 M

cefixime susr 2 M

cefotaxime sodium 1gm, 500mg

2 M

cefotetan disodium 2 M

CEFOXITIN SODIUM 4 M

cefoxitin sodium 1gm, 2gm, 10gm

2 M

cefpodoxime proxetil 2 M

cefprozil 2 M

ceftazidime SOLR 2 M

CEFTAZIDIME/DEXTROSE 4 M

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

2 M

cefuroxime axetil 2 M

cefuroxime sodium 2 M

cephalexin CAPS 250mg, 500mg

1 M

cephalexin CAPS 750mg 2 M

cephalexin SUSR 2 M

cephalexin TABS 2 M

MAXIPIME 4 M

SUPRAX CHEW 4 M

SUPRAX SUSR 500mg/5ml 3 M

tazicef SOLR 2 M

TEFLARO 5 M


8

Drug Name Drug Tier

Requirements/Limits

ZERBAXA 5 M

ERYTHROMYCINS/MACROLIDES azithromycin PACK; SOLR; SUSR

2 M

azithromycin TABS 1 M

clarithromycin SUSR; TABS; TB24

2 M

DIFICID 5 M

e.e.s 400 2 M

ery-tab 2 M

ERYPED 400 5 M

ERYTHROCIN LACTOBIONATE

4 M

erythrocin stearate 2 M

erythromycin base 2 M

erythromycin cap 250mg ec 2 M

erythromycin ethylsuccinate SUSR 200mg/5ml

2 M

erythromycin ethylsuccinate SUSR 400mg/5ml

5 M

erythromycin ethylsuccinate TABS

2 M

erythromycin tab ec 2 M

FLUOROQUINOLONES BAXDELA 5 M

ciprofloxacin SUSR 2 M

ciprofloxacin hcl TABS 100mg

2 M

ciprofloxacin hcl TABS 250mg, 500mg, 750mg

1 M

ciprofloxacin in d5w 2 M

levofloxacin SOLN 2 M

levofloxacin TABS 1 M

levofloxacin in d5w 2 M

MOXIFLOXACIN HCL SOLN 4 M

moxifloxacin hcl TABS 2 M

moxifloxacin hcl in sodium chloride

2 M

PENICILLINS amoxicillin CAPS; SUSR; TABS

1 M

amoxicillin CHEW 2 M

amoxicillin & pot clavulanate 2 M

ampicillin & sulbactam sodium 2 M

ampicillin cap 500mg 2 M

ampicillin inj 2 M

ampicillin sodium 2 M

AUGMENTIN SUSP 125MG/5ML

4 M

Drug Name Drug Tier

Requirements/Limits

BACTOCILL INJ DEX 1GM 4 M

BACTOCILL INJ DEX 2GM 4 M

BICILLIN C-R 4 M

BICILLIN L-A 4 M

dicloxacillin sodium 2 M

NAFCILLIN IN DEXTROSE 4 M

nafcillin sodium 1gm, 2gm 2 M

nafcillin sodium 10gm 5 M

NAFCILLIN SODIUM FOR INJ 10GM

4 M

oxacillin sodium 1gm, 2gm 2 M

oxacillin sodium 10gm 5 M

PENICILLIN G POT IN DEXTROSE 1MU

4 M


4 M


4 M

PENICILLIN G PROCAINE 4 M

penicillin g sodium 2 M

penicillin v potassium SOLR 2 M

penicillin v potassium TABS 1 M

penicilln gk inj 5mu 2 M

penicilln gk inj 20mu 2 M

pfizerpen-g inj 5mu 2 M

pfizerpen-g inj 20mu 2 M

piper/tazoba inj 2-0.25gm 2 M





ZOSYN SOLN 4 M

TETRACYCLINES demeclocycline hcl 2 M

doxy 100 2 M

doxycycline (monohydrate) 2 M

doxycycline hyclate CAPS 2 M

doxycycline hyclate SOLR 2 M

doxycycline hyclate TABS 20mg, 100mg

2 M

doxycycline hyclate TBEC 2 M

doxycycline hyclate tab 75 mg dr

2 M


2 M


2 M

minocycline hcl CAPS; TABS

2 M


9

Drug Name Drug Tier

Requirements/Limits

minocycline tab 45mg er 2 M



mondoxyne nl cap 75mg 2 M

mondoxyne nl cap 100mg 2 M

morgidox cap 1x50mg 2 M

tetracycline hcl CAPS 2 M

VIBRAMYCIN SYRP 4 M

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA 5 B/D

cyclophosphamide CAPS 2 B/D M

cyclophosphamide SOLR 5 B/D M

dacarbazine 100mg 2 B/D M

EMCYT 4 M

GLEOSTINE 4 M

IFEX INJ 3GM 4 B/D M

ifosfamide inj 1gm/20ml 2 B/D M

IFOSFAMIDE INJ 3GM 4 B/D M

ifosfamide inj 3gm/60ml 2 B/D M

LEUKERAN 5 M

TREANDA 5 B/D M

ANTHRACYCLINES adriamycin SOLN 2 B/D M

doxorubicin hcl 2 B/D M

doxorubicin hcl liposomal 5 B/D M

epirubicin hcl 2 B/D M

ANTIBIOTICS bleomycin sulfate 2 B/D M

mitomycin SOLR 5 B/D M

ANTIMETABOLITES adrucil 2 B/D M

ALIMTA 5 B/D M

azacitidine 5 B/D M

cytarabine 2 B/D M

decitabine 5 B/D M

fludarabine phosphate 2 B/D M

fluorouracil SOLN 2 B/D M

gemcitabine inj soln 2 B/D M

gemcitabine inj solr 2 B/D M

INFUGEM 5 B/D M

mercaptopurine TABS 2 M

methotrexate sodium inj 2 B/D M

NIPENT 5 B/D M

PURIXAN 5

TABLOID 4 M

ANTIMITOTIC, TAXOIDS ABRAXANE 5 B/D M

Drug Name Drug Tier

Requirements/Limits

docetaxel CONC 20mg/ml, 80mg/4ml, 160mg/8ml

5 B/D M

DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml

5 B/D M

docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

5 B/D M

DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

5 B/D M

paclitaxel 2 B/D M

TAXOTERE 80mg/4ml 5 B/D M

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 2 B/D M

vincristine sulfate 2 B/D M

vinorelbine tartrate 2 B/D M

BIOLOGIC RESPONSE MODIFIERS ARZERRA 5 B/D M

AVASTIN 5 M LA PA

BELEODAQ 5 PA

BESPONSA 5 LA PA

BORTEZOMIB 5 M PA

DAURISMO 5 LA PA

ERBITUX 5 B/D M

ERIVEDGE 5 LA PA

FARYDAK 5 LA PA

HERCEPTIN 5 M PA

HERCEPTIN HYLECTA 5 M PA

IBRANCE 5 LA PA

IDHIFA 5 LA PA

KADCYLA 5 B/D M

KEYTRUDA SOLN 5 PA

KEYTRUDA SOLR 5 M PA

KISQALI 5 PA

KISQALI FEMARA 200 DOSE 5 PA



LIBTAYO 5 LA PA

LYNPARZA 5 LA PA

MYLOTARG 5 LA PA

NINLARO 5 PA

ODOMZO 5 LA PA

PERJETA 5 M PA

POTELIGEO 5 LA PA

RITUXAN 5 M LA PA

RITUXAN HYCELA 5 LA PA

RUBRACA 5 LA PA

TALZENNA 5 LA PA

TECENTRIQ 5 LA PA


10

Drug Name Drug Tier

Requirements/Limits

temsirolimus 5 B/D M

TIBSOVO 5 LA PA

TORISEL 5 B/D M

VECTIBIX 5 B/D M

VELCADE 5 M PA

VENCLEXTA 10mg, 50mg 4 LA PA

VENCLEXTA 100mg 5 LA PA

VENCLEXTA STARTING PACK

5 LA PA

VERZENIO 5 LA PA

YERVOY 5 M PA

ZEJULA 5 LA PA

ZOLINZA 5 PA

HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate 5 PA

anastrozole TABS 2 M

bicalutamide 2 M

DEPO-PROVERA INJ 400/ML 4 B/D M

ELIGARD INJ 7.5MG 4 B/D

ELIGARD INJ 22.5MG 4 B/D

ELIGARD INJ 30MG 4 B/D

ELIGARD INJ 45MG 4 B/D

ERLEADA 5 LA PA

exemestane 2 M

FASLODEX 5 B/D M

FIRMAGON 80mg 4 B/D

FIRMAGON 120mg 5 B/D

flutamide 2 M

fulvestrant 5 B/D M

hydroxyprogesterone caproate (antineoplastic)

5 B/D M

letrozole TABS 2 M

leuprolide inj 1mg/0.2 2 PA

LUPRON DEPOT (1-MONTH) 5 PA

LUPRON DEPOT INJ 11.25MG (3-MONTH)

5 PA

LUPRON DEPOT INJ 22.5MG (3-MONTH)

5 PA

LUPRON DEPOT INJ 30MG (4-MONTH)

5 PA

LYSODREN 3 M

megestrol ac sus 40mg/ml 4 M

megestrol ac tab 20mg 3 M

megestrol ac tab 40mg 3 M

megestrol sus 625mg/5ml 4 M PA

nilutamide 5 M

NUBEQA 5 LA PA

SOLTAMOX 5 M

tamoxifen citrate TABS 1 M

Drug Name Drug Tier

Requirements/Limits

toremifene citrate 5 M

TRELSTAR MIXJECT 5 PA

XTANDI 5 LA PA

ZYTIGA 500mg 5 LA PA

IMMUNOMODULATORS POMALYST 5 LA PA

REVLIMID 5 LA PA

THALOMID 5 PA

KINASE INHIBITORS AFINITOR

QL (30 tabs / 30 days) 5 QL PA

AFINITOR DISPERZ 2mg QL (150 tabs / 30 days)

5 QL PA


5 QL PA


5 QL PA

ALECENSA 5 LA PA

ALIQOPA 5 LA PA

ALUNBRIG 5 LA PA

BALVERSA 5 LA PA

BOSULIF 5 PA

BRAFTOVI 5 LA PA

CABOMETYX QL (30 tabs / 30 days)

5 QL LA PA

CALQUENCE 5 LA PA

CAPRELSA 5 LA PA

COMETRIQ 5 LA PA

COPIKTRA 5 LA PA

COTELLIC 5 LA PA

erlotinib hcl 25mg QL (90 tabs / 30 days)

5 QL PA

erlotinib hcl 100mg, 150mg QL (30 tabs / 30 days)

5 QL PA

GILOTRIF TAB 20MG 5 LA PA



ICLUSIG 5 LA PA

imatinib mesylate 100mg QL (90 tabs / 30 days)

5 QL PA

imatinib mesylate 400mg QL (60 tabs / 30 days)

5 QL PA

IMBRUVICA 5 LA PA

INLYTA 1mg QL (180 tabs / 30 days)

5 QL LA PA

INLYTA 5mg QL (120 tabs / 30 days)

5 QL LA PA

INREBIC 5 LA PA

IRESSA 5 LA PA


11

Drug Name Drug Tier

Requirements/Limits

JAKAFI QL (60 tabs / 30 days)

5 QL LA PA

LENVIMA 4 MG DAILY DOSE 5 LA PA

LENVIMA 8 MG DAILY DOSE 5 LA PA

LENVIMA 10 MG DAILY DOSE

5 LA PA

LENVIMA 12MG DAILY DOSE

5 LA PA


5 LA PA


5 LA PA


5 LA PA


5 LA PA

LORBRENA 5 LA PA

MEKINIST 5 LA PA

MEKTOVI 5 LA PA

NERLYNX 5 LA PA

NEXAVAR 5 LA PA

PIQRAY 200MG DAILY DOSE

5 PA


5 PA


5 PA

ROZLYTREK 5 LA PA

RYDAPT 5 PA

SPRYCEL 5 PA

STIVARGA 5 LA PA

SUTENT 5 PA

TAFINLAR 5 LA PA

TAGRISSO 5 LA PA

TARCEVA 25mg QL (90 tabs / 30 days)

5 QL LA PA

TARCEVA 100mg, 150mg QL (30 tabs / 30 days)

5 QL LA PA

TASIGNA 5 PA

TURALIO 5 LA PA

TYKERB 5 LA PA

VITRAKVI 5 LA PA

VIZIMPRO 5 LA PA

VOTRIENT 5 LA PA

XALKORI 5 LA PA

XOSPATA 5 LA PA

ZELBORAF 5 LA PA

ZYDELIG 5 LA PA

ZYKADIA 5 LA PA

Drug Name Drug Tier

Requirements/Limits

MISCELLANEOUS bexarotene 5 PA

HALAVEN 5 B/D M

hydroxyurea CAPS 2 M

IXEMPRA KIT 5 B/D M

LONSURF 5 PA

MATULANE 5 M LA

SYLATRON KIT 200MCG 5 M PA



SYNRIBO 5 PA

tretinoin CAPS 5 M

XPOVIO 60 MG ONCE WEEKLY

5 LA PA


5 LA PA

XPOVIO 80 MG TWICE WEEKLY

5 LA PA


5 LA PA

PLATINUM-BASED AGENTS carboplatin 2 B/D M

cisplatin SOLN 2 B/D M

oxaliplatin inj 50mg 5 B/D M

oxaliplatin inj 50mg/10ml 2 B/D M

oxaliplatin inj 100mg 5 B/D M

oxaliplatin inj 100mg/20ml 2 B/D M

PROTECTIVE AGENTS dexrazoxane hcl 5 B/D M

ELITEK 5 B/D M

KHAPZORY 5 B/D M

leucovorin calcium SOLR 2 B/D M

leucovorin calcium TABS 2 M

leucovorin calcium solr 2 B/D M

levoleucovorin calcium 175mg/17.5ml

5 B/D M

levoleucovorin calcium 250mg/25ml

2 B/D M

levoleucovorin calcium 50mg 5 B/D M

MESNEX TABS 5 M

TOPOISOMERASE INHIBITORS etoposide SOLN 2 B/D M

irinotecan hcl 2 B/D M

ONIVYDE 5 B/D

toposar 2 B/D M

topotecan hcl 5 B/D M

TOPOTECAN INJ 4MG/4ML 5 B/D M


12

Drug Name Drug Tier

Requirements/Limits

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl

1 M

benazepril & hydrochlorothiazide

1 M

captopril & hydrochlorothiazide

1 M

enalapril maleate & hydrochlorothiazide

1 M

fosinopril sodium & hydrochlorothiazide

1 M

lisinopril & hydrochlorothiazide 1 M

quinapril-hydrochlorothiazide 1 M

trandolapril-verapamil hcl 1 M

ACE INHIBITORS benazepril hcl TABS 1 M

captopril TABS 1 M

enalapril maleate TABS 1 M

EPANED 5 M

fosinopril sodium 1 M

lisinopril TABS 1 M

moexipril hcl 1 M

perindopril erbumine 1 M

QBRELIS 5 M

quinapril hcl 1 M

ramipril 1 M

trandolapril 1 M

ALDOSTERONE RECEPTOR ANTAGONISTS CAROSPIR 4 M

eplerenone 2 M

spironolactone TABS 1 M

ALPHA BLOCKERS doxazosin mesylate TABS 2 M

prazosin hcl 2 M

terazosin hcl 1 M

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil

1 M

amlodipine besylate-valsartan tab 5-160 mg

1 M


1 M


1 M

Drug Name Drug Tier

Requirements/Limits


1 M

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg

1 M

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg

1 M

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg

1 M


1 M


1 M

candesartan cilexetil-hydrochlorothiazide

1 M

EDARBYCLOR 4 M

ENTRESTO 3 M

irbesartan-hydrochlorothiazide 1 M

losartan-hydrochlorothiazide 1 M

olmesartan medoxomil-amlodipine-hydrochlorothiazide

1 M

olmesartan medoxomil-hydrochlorothiazide

1 M

telmisartan-amlodipine 1 M

telmisartan-hydrochlorothiazide

1 M

valsartan-hydrochlorothiazide 1 M

ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil 1 M

EDARBI 4 M

eprosartan mesylate 1 M

irbesartan 1 M

losartan potassium 1 M

olmesartan medoxomil TABS

1 M

telmisartan 1 M

valsartan 1 M

ANTIARRHYTHMICS amiodarone hcl soln 2 M

amiodarone tab 100mg 2 M



disopyramide phosphate 4 M

dofetilide 2 M

flecainide acetate 2 M

mexiletine hcl 2 M

MULTAQ 4 M


13

Drug Name Drug Tier

Requirements/Limits

NORPACE CR 4 M

pacerone 100mg, 400mg 2 M

pacerone 200mg 1 M

propafenone hcl 2 M

propafenone hcl 12hr 2 M

quinidine gluconate 2 M

quinidine sulfate 2 M

sorine 2 M

sotalol hcl 2 M

sotalol hcl (afib/afl) 2 M

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 5 M ST

atorvastatin calcium TABS 1 M

FLOLIPID 4 M ST

fluvastatin sodium cap 20 mg 1 M

fluvastatin sodium cap 40 mg 1 M

fluvastatin sodium tab sr 24 hr 80 mg

1 M

LIVALO 4 M ST

lovastatin 1 M

pravastatin sodium 1 M

rosuvastatin calcium 1 M

simvastatin TABS 5mg, 10mg, 20mg, 40mg

1 M

simvastatin TABS 80mg QL (30 tabs / 30 days)

1 QL M

ZYPITAMAG 4 M ST

ANTILIPEMICS, MISCELLANEOUS ANTARA 4 M

cholestyramine 2 M

cholestyramine light 2 M

choline fenofibrate 2 M

colesevelam hcl 2 M

colestipol hcl gran 2 M

colestipol hcl pack 2 M

colestipol hcl tabs 2 M

ezetimibe 2 M

ezetimibe-simvastatin 1 M

fenofibrate CAPS 2 M

fenofibrate TABS 40mg, 48mg, 54mg, 145mg, 160mg

2 M

fenofibrate TABS 120mg 5 M

fenofibrate micronized 2 M

fenofibric acid 2 M

gemfibrozil TABS 1 M

JUXTAPID 5 LA PA

KYNAMRO 5 M PA

niacin (antihyperlipidemic) 2 M

Drug Name Drug Tier

Requirements/Limits

niacin er (antihyperlipidemic) 2 M

niacor 2 M

omega-3-acid ethyl esters 2 M PA

PRALUENT Lower cost version - Tier 4

5 M PA

prevalite 2 M

TRIGLIDE 4 M

VASCEPA 4 M

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone 2 M

bisoprolol & hydrochlorothiazide

1 M

DUTOPROL 4 M

metoprolol & hctz tab 50-25mg

2 M


2 M


2 M

nadolol & bendroflumethiazide 2 M

propranolol & hydrochlorothiazide

2 M

BETA-BLOCKERS acebutolol hcl CAPS 2 M

atenolol TABS 1 M

betaxolol hcl 2 M

bisoprolol fumarate 2 M

BYSTOLIC 4 M

carvedilol 1 M

carvedilol er 2 M

KAPSPARGO SPRINKLE 4 M

labetalol hcl SOLN; TABS 2 M

metoprolol succinate 2 M

metoprolol tartrate SOCT 2 M

metoprolol tartrate SOLN 2 M

metoprolol tartrate TABS 25mg, 50mg, 100mg

1 M

nadolol TABS 2 M

pindolol 2 M

propranolol hcl er 2 M

propranolol inj 1mg/ml 2 M

propranolol oral sol 2 M

propranolol tab 2 M

SOTYLIZE 4 M

timolol maleate TABS 2 M


14

Drug Name Drug Tier

Requirements/Limits

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin calcium

1 M

CALCIUM CHANNEL BLOCKERS amlodipine besylate TABS 1 M

CARDIZEM LA 120mg 4 M

cartia xt 2 M

dilt-xr cap 2 M

diltiazem cap 180mg cd 2 M



diltiazem cap er/12hr 2 M

diltiazem er tab 180mg 2 M





diltiazem hcl TABS 2 M

diltiazem hcl coated beads cap sr 24hr

2 M

diltiazem hcl extended release beads cap sr

2 M

diltiazem inj 2 M

felodipine 2 M

isradipine 2 M

matzim la 2 M

nicardipine hcl CAPS 2 M

nifedipine TB24 2 M

nifedipine er 2 M

nimodipine CAPS 5 M

nisoldipine 2 M

NYMALIZE 5 M

taztia xt 2 M

verapamil hcl CP24; SOLN 2 M

verapamil hcl TABS; TBCR 1 M

DIGITALIS GLYCOSIDES digitek .25mg

PA if 70 years and older 2 M PA

digitek .125mg QL (30 tabs / 30 days)

2 QL M

digox 125mcg QL (30 tabs / 30 days)

2 QL M

digox 250mcg PA if 70 years and older

2 M PA

digoxin TABS 125mcg QL (30 tabs / 30 days)

2 QL M

digoxin TABS 250mcg PA if 70 years and older

2 M PA

Drug Name Drug Tier

Requirements/Limits

digoxin inj 2 M

digoxin sol 50mcg/ml PA if 70 years and older

2 M PA

LANOXIN PEDIATRIC 4 M

LANOXIN TABS 62.5 MCG QL (60 tabs / 30 days)

4 QL M

DIRECT RENIN INHIBITORS/COMBINATIONS aliskiren fumarate 2 M

TEKTURNA 4 M

TEKTURNA HCT 4 M

DIURETICS acetazolamide CP12; TABS 2 M

ALDACTAZIDE TAB 50/50 4 M

amiloride & hydrochlorothiazide

2 M

amiloride hcl TABS 2 M

bumetanide 2 M

chlorothiazide tabs 2 M

chlorthalidone 2 M

DIURIL SUS 250/5ML 4 M

DYRENIUM 4 M

ethacrynic acid 5 M

furosemide SOLN; TABS 1 M

furosemide inj 2 M

furosemide oral soln 8 mg/ml 1 M

hydrochlorothiazide CAPS; TABS

1 M

indapamide 2 M

methazolamide TABS 2 M

methyclothiazide 2 M

metolazone 2 M

spironolactone & hydrochlorothiazide

2 M

torsemide tabs 2 M

triamt/hctz cap 37.5-25 1 M

triamterene CAPS 2 M

triamterene & hydrochlorothiazide tabs

1 M

MISCELLANEOUS BIDIL 3 M

clonidine hcl TABS 1 M

clonidine hcl ptwk 2 M

CORLANOR SOLN 4 M

CORLANOR TABS 4 M

DEMSER 5 M PA

hydralazine hcl SOLN; TABS 2 M

KEVEYIS 5 PA

midodrine hcl 2 M


15

Drug Name Drug Tier

Requirements/Limits

minoxidil TABS 2 M

NORTHERA 5 LA PA

phenoxybenzamine hcl CAPS

5 M PA

ranolazine 2 M

VYNDAQEL 5 LA PA

NITRATES DILATRATE SR 4 M

ISORDIL TITRADOSE 40mg 5 M

isosorbide dinitrate 2 M

isosorbide dinitrate er 2 M

isosorbide mononitrate 1 M

isosorbide mononitrate er 2 M

minitran 2 M

NITRO-BID 3 M

NITRO-DUR .3mg/hr, .8mg/hr

4 M

nitroglycerin SOLN .4mg/spray

2 M

nitroglycerin SUBL 2 M

nitroglycerin td patch 2 M

PULMONARY ARTERIAL HYPERTENSION ADEMPAS 5 LA PA

alyq 5 PA

ambrisentan 5 LA PA

bosentan 5 LA PA

OPSUMIT 5 LA PA

ORENITRAM TAB 0.25MG 5 LA PA


ORENITRAM TAB 1MG 5 LA PA


ORENITRAM TAB 5MG 5 LA PA

REMODULIN 5 LA PA

REVATIO SUSR 5 PA

sildenafil citrate sus 10mg/ml (pulmonary hypertension)

5 PA

sildenafil citrate tab 20 mg (pulmonary hypertension)

2 PA

tadalafil (pulmonary hypertension)

5 PA

TRACLEER 5 LA PA

treprostinil 5 LA PA

TYVASO 5 PA

UPTRAVI 5 LA PA

VENTAVIS 5 PA

CENTRAL NERVOUS SYSTEM ANTIANXIETY ALPRAZOLAM CONC

QL (300 mL / 30 days) 4 QL M

Drug Name Drug Tier

Requirements/Limits

alprazolam TABS QL (150 tabs / 30 days)

2 QL M

buspirone hcl TABS 2 M

fluvoxamine maleate 2 M

fluvoxamine maleate er 100mg


2 QL M

fluvoxamine maleate er 150mg


2 QL M

lorazepam SOLN 2 M

lorazepam TABS QL (150 tabs / 30 days)

2 QL M

lorazepam intensol QL (150 mL / 30 days)

2 QL M

ANTICONVULSANTS APTIOM 5 M

BANZEL SUS 40MG/ML 5 M PA

BANZEL TAB 200MG 5 M PA

BANZEL TAB 400MG 5 M PA

BRIVIACT INJ 50MG/5ML 4 M PA

BRIVIACT SOL 10MG/ML 5 M PA

BRIVIACT TAB 10MG 5 M PA





carbamazepine CHEW; CP12; SUSP; TABS; TB12

2 M

CELONTIN 4 M

clobazam 2 M PA

clonazepam TABS 2mg QL (300 tabs / 30 days)

2 QL M

clonazepam TABS .5mg, 1mg


2 QL M

clonazepam TBDP 2mg QL (300 tabs / 30 days)

2 QL M

clonazepam TBDP .125mg, .25mg, .5mg, 1mg


2 QL M

clorazepate dipotassium QL (180 tabs / 30 days)

PA if 65 years and older

2 QL M PA

DIASTAT ACUDIAL 4 M

DIASTAT PEDIATRIC 4 M

diazepam TABS QL (120 tabs / 30 days)


2 QL M PA

diazepam gel 2 M


16

Drug Name Drug Tier

Requirements/Limits

diazepam inj 2 M

diazepam intensol QL (240 mL / 30 days)


2 QL M PA

diazepam oral soln 1 mg/ml QL (1200 mL / 30 days)


2 QL M PA

DILANTIN CAP 30MG 3 M

DILANTIN CAP 100MG 3 M

DILANTIN CHEW TAB 50MG 3 M

DILANTIN-125 SUSP 4 M

divalproex sodium CSDR; TB24; TBEC

2 M

EPIDIOLEX QL (600 mL / 30 days)

5 QL LA PA

epitol 2 M

ethosuximide CAPS; SOLN 2 M

felbamate SUSP 5 M

felbamate TABS 2 M

FYCOMPA SUSP 5 M PA

FYCOMPA TABS 2mg 4 M PA

FYCOMPA TABS 4mg, 6mg, 8mg, 10mg, 12mg

5 M PA

gabapentin CAPS 100mg QL (1080 caps / 30 days)

1 QL M


1 QL M


1 QL M

gabapentin SOLN QL (2160 mL / 30 days)

2 QL M

gabapentin TABS 600mg QL (180 tabs / 30 days)

2 QL M

gabapentin TABS 800mg QL (120 tabs / 30 days)

2 QL M

LAMICTAL ODT KIT 4 M

LAMICTAL XR KIT 4 M

lamotrigine CHEW; KIT; TB24; TBDP

2 M

lamotrigine TABS 1 M

levetiracetam SOLN; TABS; TB24

2 M

levetiracetam in sodium chloride

2 M

levetiracetam oral soln 100 mg/ml

2 M

LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg


3 QL M

Drug Name Drug Tier

Requirements/Limits

LYRICA CAPS 200mg QL (90 caps / 30 days)

3 QL M

LYRICA CAPS 225mg, 300mg


3 QL M

LYRICA SOLN QL (946 mL / 30 days)

3 QL M

NAYZILAM 4 M

oxcarbazepine 2 M

OXTELLAR XR 150mg, 300mg

4 M

OXTELLAR XR 600mg 5 M

PEGANONE 4 M

phenobarbital ELIX PA if 70 years and older

4 M PA

phenobarbital TABS PA if 70 years and older

3 M PA

PHENOBARBITAL SODIUM SOLN 65mg/ml


4 M PA

phenobarbital sodium SOLN 130mg/ml


4 M PA

PHENYTEK 3 M

phenytoin CHEW; SUSP 2 M

phenytoin sodium extended 2 M

phenytoin sodium inj 50mg/ml 2 M

pregabalin CAPS 25mg, 50mg, 75mg, 100mg, 150mg


2 QL M

pregabalin CAPS 200mg QL (90 caps / 30 days)

2 QL M

pregabalin CAPS 225mg, 300mg


2 QL M

pregabalin SOLN QL (946 mL / 30 days)

2 QL M

primidone TABS 2 M

roweepra 2 M

roweepra xr 2 M

SPRITAM 4 M

subvenite starter kit 2 M

subvenite tab 1 M

SYMPAZAN 5mg 4 M PA

SYMPAZAN 10mg, 20mg 5 M PA

tiagabine hcl 2 M

topiramate CPSP; CS24 2 M

topiramate TABS 1 M

TROKENDI XR 25mg, 50mg, 100mg

4 M


17

Drug Name Drug Tier

Requirements/Limits

TROKENDI XR 200mg 5 M

valproate sodium SOLN 2 M

valproic acid CAPS 2 M

vigabatrin powd pack 500mg QL (180 packets / 30 days)

5 QL LA PA

vigabatrin tab 500mg QL (180 tabs / 30 days)

5 QL LA PA

vigadrone QL (180 packets / 30 days)

5 QL LA PA

VIMPAT 50mg 4 M

VIMPAT 100mg, 150mg, 200mg

5 M

VIMPAT INJ 200MG/20ML 5 M

VIMPAT SOL 10MG/ML 5 M

zonisamide CAPS 2 M

ANTIDEMENTIA donepezil odt 5mg 2 M

donepezil odt 10mg 2 M

donepezil tab hcl 23mg 2 M

donepezil tabs 5mg 2 M

donepezil tabs 10mg 2 M

galantamine hydrobromide 2 M

galantamine hydrobromide er 2 M

memantine hcl cp24 PA if < 30 yrs

2 M PA

memantine soln PA if < 30 yrs

2 M PA

memantine tabs PA if < 30 yrs

2 M PA

NAMZARIC 4 M

rivastigmine tartrate 2 M

rivastigmine td patch 24hr 4.6 mg/24hr

2 M


2 M


2 M

ANTIDEPRESSANTS amitriptyline hcl TABS 3 M

amoxapine 3 M

APLENZIN 5 M

bupropion hcl TABS 2 M

bupropion hcl TB12 2 M

bupropion hcl TB24 150mg, 300mg

2 M

bupropion hcl TB24 450mg QL (30 tabs / 30 days)

2 QL M

Drug Name Drug Tier

Requirements/Limits

citalopram hydrobromide SOLN

2 M

citalopram hydrobromide TABS

1 M

clomipramine hcl CAPS 4 M PA

desipramine hcl TABS 4 M

desvenlafaxine succinate 2 M PA

doxepin hcl CAPS; CONC 3 M

duloxetine hcl CPEP 20mg QL (180 caps / 30 days)

2 QL M


2 QL M


2 QL M

EMSAM 5 M PA

escitalopram oxalate SOLN 2 M

escitalopram oxalate TABS 1 M

FETZIMA 4 M PA

FETZIMA TITRATION PACK 4 M PA

fluoxetine cap 10mg 1 M



fluoxetine hcl CPDR; SOLN; TABS

2 M

imipramine hcl TABS 3 M

imipramine pamoate 4 M

maprotiline hcl 2 M

MARPLAN 4 M

mirtazapine TABS 1 M

mirtazapine TBDP 2 M

nefazodone hcl 2 M

nortriptyline hcl CAPS 2 M

nortriptyline hcl SOLN 4 M

paroxetine er tab QL (60 tabs / 30 days)

4 QL M

paroxetine hcl tabs 2 M

PAXIL SUSP 4 M

PEXEVA 10mg, 30mg QL (60 tabs / 30 days)

4 QL M

PEXEVA 20mg, 40mg QL (30 tabs / 30 days)

4 QL M

phenelzine sulfate TABS 2 M

protriptyline hcl 4 M

sertraline hcl CONC 2 M

sertraline hcl TABS 1 M

tranylcypromine sulfate 2 M

trazodone hcl TABS 50mg, 100mg, 150mg

1 M

trazodone hcl TABS 300mg 2 M


18

Drug Name Drug Tier

Requirements/Limits

trimipramine maleate CAPS 4 M

TRINTELLIX 4 M

venlafaxine cap er 1 M

venlafaxine tab 2 M

VIIBRYD STARTER PACK 4 M

VIIBRYD TAB 4 M

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS

QL (120 caps / 30 days) 2 QL M

amantadine hcl SYRP; TABS

2 M

APOKYN QL (20 cartridges / 30 days)

5 QL LA PA

benztropine mesylate inj 2 M

benztropine mesylate tab 0.5mg


3 M PA

benztropine mesylate tab 1mg PA if 70 years and older

3 M PA

benztropine mesylate tab 2mg PA if 70 years and older

3 M PA

bromocriptine mesylate CAPS; TABS

2 M

carbidopa TABS 5 M

carbidopa-levodopa 2 M

carbidopa/levodopa/entacapone

2 M

DUOPA 5 B/D

entacapone 2 M

GOCOVRI QL (60 caps / 30 days)

5 QL M LA PA

INBRIJA 5 LA PA

NEUPRO 4 M

OSMOLEX ER QL (30 tabs / 30 days)

4 QL M PA

pramipexole dihydrochloride 2 M

pramipexole tab 0.5mg 2 M


pramipexole tab 0.75 er 2 M





pramipexole tab 1.5mg er 2 M

pramipexole tab 1mg 2 M


pramipexole tab 3mg 2 M


Drug Name Drug Tier

Requirements/Limits

rasagiline mesylate TABS 2 M

ropinirole tab 0.5mg 2 M

ropinirole tab 0.25mg 2 M

ropinirole tab 1mg 2 M


ropinirole tab 2mg er 2 M








RYTARY 4 M

selegiline hcl CAPS; TABS 2 M

trihexyphenidyl hcl PA if 70 years and older

3 M PA

XADAGO 5 M

ZELAPAR 5 M

ANTIPSYCHOTICS ABILIFY MAINTENA

QL (1 injection / 28 days)

5 QL M

aripiprazole odt QL (60 tabs / 30 days)

5 QL M

aripiprazole oral solution 1 mg/ml

QL (900 mL / 30 days)

5 QL M

aripiprazole tab QL (30 tabs / 30 days)

2 QL M

ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml


5 QL M

ARISTADA 1064mg/3.9ml QL (1 injection / 56 days)

5 QL M

ARISTADA INITIO 5 M

chlorpromazine hcl TABS 2 M

CHLORPROMAZINE INJ 4 M

clozapine odt 12.5mg, 25mg 2 M PA

clozapine odt 100mg QL (270 tabs / 30 days)

2 QL M PA


2 QL M PA


5 QL M PA

clozapine tab 25mg 2 M

clozapine tab 50mg 2 M


19

Drug Name Drug Tier

Requirements/Limits

clozapine tab 100mg QL (270 tabs / 30 days)

2 QL M

clozapine tab 200mg QL (135 tabs / 30 days)

2 QL M

FANAPT QL (60 tabs / 30 days)

4 QL M

FANAPT TITRATION PACK 4 M

fluphenazine decanoate SOLN

2 M

fluphenazine hcl 2 M

GEODON INJ QL (6 mL / 3 days)

4 QL M

haloperidol TABS 2 M

haloperidol conc 2mg/ml 2 M

haloperidol decanoate SOLN 2 M

haloperidol lactate inj 5mg/ml 2 M

INVEGA SUST INJ 39 MG/0.25 ML


4 QL M



5 QL M



5 QL M

INVEGA SUST INJ 156MG/ML


5 QL M



5 QL M

INVEGA TRINZA QL (1 injection / 90 days)

5 QL M

LATUDA 20mg, 60mg, 80mg QL (60 tabs / 30 days)

4 QL M

LATUDA 40mg, 120mg QL (30 tabs / 30 days)

4 QL M

loxapine succinate 2 M

molindone hcl 2 M

NUPLAZID CAPS QL (30 caps / 30 days)

5 QL LA PA

NUPLAZID TABS 10MG QL (30 tabs / 30 days)

5 QL LA PA

Drug Name Drug Tier

Requirements/Limits

NUPLAZID TABS 17MG QL (60 tabs / 30 days)

5 QL LA PA

olanzapine SOLR QL (3 vials / 1 day)

2 QL M

olanzapine TABS 2.5mg QL (240 tabs / 30 days)

2 QL M

olanzapine TABS 5mg QL (120 tabs / 30 days)

2 QL M

olanzapine TABS 7.5mg, 15mg, 20mg


2 QL M

olanzapine TABS 10mg QL (60 tabs / 30 days)

2 QL M

olanzapine odt 5mg, 15mg, 20mg


2 QL M

olanzapine odt 10mg QL (60 tabs / 30 days)

2 QL M

paliperidone 1.5mg, 3mg, 9mg


5 QL M

paliperidone 6mg QL (60 tabs / 30 days)

5 QL M

perphenazine TABS 2 M

PERSERIS QL (1 injection / 30 days)

5 QL M

pimozide 2 M

quetiapine fumarate TABS 2 M

quetiapine fumarate TB24 50mg, 300mg, 400mg


2 QL M

quetiapine fumarate TB24 150mg, 200mg


2 QL M

REXULTI 1mg QL (90 tabs / 30 days)

5 QL M

REXULTI 2mg QL (60 tabs / 30 days)

5 QL M

REXULTI 3mg, 4mg QL (30 tabs / 30 days)

5 QL M

REXULTI .5mg QL (180 tabs / 30 days)

5 QL M

REXULTI .25mg QL (360 tabs / 30 days)

5 QL M

RISPERDAL INJ 12.5MG QL (2 injections / 28 days)

4 QL M


20

Drug Name Drug Tier

Requirements/Limits

RISPERDAL INJ 25MG QL (2 injections / 28 days)

4 QL M

RISPERDAL INJ 37.5MG QL (2 injections / 28 days)

5 QL M

RISPERDAL INJ 50MG QL (2 injections / 28 days)

5 QL M

risperidone SOLN QL (240 mL / 30 days)

2 QL M

risperidone TABS 2 M

risperidone odt .5mg QL (90 tabs / 30 days)

2 QL M

risperidone odt .25mg, 1mg, 2mg, 3mg, 4mg


2 QL M

SAPHRIS 2.5mg QL (240 tabs / 30 days)

4 QL M

SAPHRIS 5mg QL (120 tabs / 30 days)

4 QL M

SAPHRIS 10mg QL (60 tabs / 30 days)

4 QL M

thioridazine hcl TABS 2 M

thiothixene 2 M

trifluoperazine hcl 2 M

VERSACLOZ QL (600 mL / 30 days)

5 QL M PA

VRAYLAR 1.5mg QL (60 caps / 30 days)

5 QL M PA

VRAYLAR 3mg, 4.5mg, 6mg QL (30 caps / 30 days)

5 QL M PA

VRAYLAR THERAPY PACK 4 M PA

ziprasidone hcl QL (60 caps / 30 days)

2 QL M

ZYPREXA RELPREVV 300mg

QL (2 vials / 28 days)

5 QL M PA

ZYPREXA RELPREVV 405mg

QL (1 vial / 28 days)

5 QL M PA

ZYPREXA RELPREVV INJ 210MG

QL (2 vials / 28 days)

4 QL M PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER ADZENYS ER SUS 1.25MG

QL (450 ml / 30 days) 4 QL M

Drug Name Drug Tier

Requirements/Limits

ADZENYS XR-ODT 3.1mg, 6.3mg, 9.4mg


4 QL M

ADZENYS XR-ODT 12.5mg, 15.7mg, 18.8mg


4 QL M

amphetamine cap 10mg er QL (90 caps / 30 days)

2 QL M


2 QL M


2 QL M


2 QL M


2 QL M

amphetamine-dextroamphetamine cap sr 24hr 5 mg


2 QL M

amphetamine-dextroamphetamine tab 5 mg


2 QL M

amphetamine-dextroamphetamine tab 7.5 mg


2 QL M



2 QL M

amphetamine-dextroamphetamine tab 12.5 mg


2 QL M



2 QL M



2 QL M



2 QL M

APTENSIO XR 10mg, 15mg, 20mg, 30mg


4 QL M

APTENSIO XR 40mg, 50mg, 60mg


4 QL M

atomoxetine hcl 10mg, 18mg, 25mg


2 QL M

atomoxetine hcl 40mg QL (60 caps / 30 days)

2 QL M


21

Drug Name Drug Tier

Requirements/Limits

atomoxetine hcl 60mg, 80mg, 100mg


2 QL M

COTEMPLA XR-ODT QL (60 tabs / 30 days)

4 QL M

DAYTRANA QL (30 patches / 30 days)

4 QL M

dexmethylphenidate hcl CP24 5mg, 10mg, 15mg, 20mg


2 QL M

dexmethylphenidate hcl CP24 25mg, 30mg, 35mg, 40mg


2 QL M

dexmethylphenidate hcl TABS 2.5mg, 5mg


2 QL M

dexmethylphenidate hcl TABS 10mg


2 QL M

DYANAVEL XR QL (240 ml / 30 days)

4 QL M

guanfacine er (adhd) PA if 70 years and older

3 M PA

metadate er tab 20mg QL (90 tabs / 30 days)

2 QL M

methylphenidate hcl CHEW QL (180 tabs / 30 days)

2 QL M

methylphenidate hcl CP24 10mg, 20mg, 30mg


2 QL M

methylphenidate hcl CP24 40mg, 60mg


2 QL M

methylphenidate hcl CPCR 10mg, 20mg, 30mg


2 QL M

methylphenidate hcl CPCR 40mg, 50mg, 60mg


2 QL M

methylphenidate hcl SOLN 5mg/5ml

QL (1800 mL / 30 days)

2 QL M

methylphenidate hcl SOLN 10mg/5ml

QL (900 mL / 30 days)

2 QL M

methylphenidate hcl TABS 5mg, 10mg


2 QL M

Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl TABS 20mg


2 QL M

methylphenidate hcl TB24 QL (60 tabs / 30 days)

2 QL M

methylphenidate hcl TBCR 18mg, 27mg, 36mg


2 QL M

methylphenidate hcl TBCR 54mg


2 QL M

methylphenidate hcl 72mg er QL (30 tabs / 30 days)

2 QL M

methylphenidate hcl er 27mg, 36mg


2 QL M

methylphenidate hcl er 54mg QL (30 tabs / 30 days)

2 QL M

methylphenidate tab 10mg er QL (90 tabs / 30 days)

2 QL M

methylphenidate tab 20mg er QL (90 tabs / 30 days)

2 QL M

MYDAYIS CAP 12.5MG QL (60 caps / 30 days)

4 QL M

MYDAYIS CAP 25MG QL (60 caps / 30 days)

4 QL M

MYDAYIS CAP 37.5MG QL (30 caps / 30 days)

4 QL M

MYDAYIS CAP 50MG QL (30 caps / 30 days)

4 QL M

QUILLICHEW ER 20mg, 30mg


4 QL M

QUILLICHEW ER 40mg QL (30 tabs / 30 days)

4 QL M

QUILLIVANT XR QL (360 mL / 30 days)

4 QL M

relexxii QL (30 tabs / 30 days)

2 QL M

VYVANSE CAPS 10mg, 20mg, 30mg


4 QL M

VYVANSE CAPS 40mg, 50mg, 60mg, 70mg


4 QL M

VYVANSE CHEW 10mg, 20mg, 30mg


4 QL M


22

Drug Name Drug Tier

Requirements/Limits

VYVANSE CHEW 40mg, 50mg, 60mg


4 QL M

HYPNOTICS HETLIOZ 5 LA PA

SILENOR 3mg QL (60 tabs / 30 days)

3 QL M

SILENOR 6mg QL (30 tabs / 30 days)

3 QL M

temazepam 7.5mg QL (30 caps / 30 days)

PA applies if 65 years and older after a 90 day supply in a calendar year

2 QL M PA

temazepam 15mg QL (60 caps / 30 days)


2 QL M PA

zolpidem tartrate TABS QL (30 tabs / 30 days)


2 QL M PA

MIGRAINE AIMOVIG

QL (1 pen / 30 days) 3 QL M PA

almotriptan malate QL (12 tabs / 30 days)

2 QL M

dihydroergotamine mesylate inj 1 mg/ml

5 M

dihydroergotamine mesylate nasal

QL (8 mL / 30 days)

5 QL M

eletriptan hydrobromide QL (12 tabs / 30 days)

2 QL M

EMGALITY SOAJ QL (2 pens / 30 days)

3 QL M PA

EMGALITY SOSY 120mg/ml QL (2 syringes / 30 days)

3 QL M PA

ergotamine w/ caffeine 2 M

frovatriptan succinate QL (18 tabs / 30 days)

2 QL M

naratriptan hcl QL (12 tabs / 30 days)

2 QL M

ONZETRA XSAIL QL (16 nosepieces / 30 days)

4 QL M ST

Drug Name Drug Tier

Requirements/Limits

rizatriptan benzoate QL (18 tabs / 30 days)

2 QL M

rizatriptan benzoate odt QL (18 tabs / 30 days)

2 QL M

sumatriptan inj 4mg/0.5ml QL (18 injections / 30 days)

2 QL M

sumatriptan inj 6mg/0.5ml QL (12 injections / 30 days)

2 QL M

sumatriptan succinate SOLN 5mg/act

QL (24 inhalers / 30 days)

2 QL M

sumatriptan succinate SOLN 20mg/act

QL (12 inhalers / 30 days)

2 QL M

sumatriptan succinate TABS QL (12 tabs / 30 days)

2 QL M

sumatriptan-naproxen sodium QL (9 tabs / 30 days)

2 QL M

TREXIMET TAB 10-60MG QL (9 tabs / 30 days)

5 QL M

ZEMBRACE SYMTOUCH QL (24 pens / 30 days)

5 QL M ST

zolmitriptan TABS QL (12 tabs / 30 days)

2 QL M

zolmitriptan odt QL (12 tabs / 30 days)

2 QL M

ZOMIG NASAL SPRAY QL (12 inhalers / 30 days)

4 QL M ST

MISCELLANEOUS AUSTEDO 6mg

QL (60 tabs / 30 days) 5 QL LA PA

AUSTEDO 9mg, 12mg QL (120 tabs / 30 days)

5 QL LA PA

EQUETRO 4 M

GRALISE 300mg QL (180 tabs / 30 days)

4 QL M PA

GRALISE 600mg QL (90 tabs / 30 days)

4 QL M PA

GRALISE STARTER 4 M PA

HORIZANT 4 M PA

INGREZZA CAPS QL (30 caps / 30 days)

5 QL PA

INGREZZA CPPK QL (28 caps / 28 days)

5 QL PA


23

Drug Name Drug Tier

Requirements/Limits

lithium carbonate CAPS; TABS

1 M

lithium carbonate TBCR 2 M

LITHIUM SOLN 8MEQ/5ML 4 M

LYRICA CR 82.5mg, 165mg QL (90 tabs / 30 days)

3 QL M PA

LYRICA CR 330mg QL (60 tabs / 30 days)

3 QL M PA

NUEDEXTA QL (60 caps / 30 days)

4 QL M PA

paroxetine mesylate (vasomotor)


4 QL M

pyridostigmine bromide SOLN

5 M

pyridostigmine bromide TBCR

2 M

pyridostigmine tab 60mg 2 M

riluzole 2 M

SAVELLA 12.5mg QL (480 tabs / 30 days)

4 QL M

SAVELLA 25mg QL (240 tabs / 30 days)

4 QL M


4 QL M


4 QL M

SAVELLA TITRATION PACK 4 M

tetrabenazine 12.5mg QL (240 tabs / 30 days)

5 QL PA

tetrabenazine 25mg QL (120 tabs / 30 days)

5 QL PA

TIGLUTIK QL (600 mL / 30 days)

5 QL M PA

MULTIPLE SCLEROSIS AGENTS BETASERON

QL (14 syringes / 28 days)

5 QL PA

dalfampridine 5 PA

GILENYA CAP 0.5MG QL (28 caps / 28 days)

5 QL PA

glatiramer acetate 20mg/ml QL (30 syringes / 30 days)

5 QL PA

glatiramer acetate 40mg/ml QL (12 syringes / 28 days)

5 QL PA

glatopa 20mg/ml QL (30 syringes / 30 days)

5 QL PA

Drug Name Drug Tier

Requirements/Limits

glatopa 40mg/ml QL (12 syringes / 28 days)

5 QL PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 2 M

BOTOX 5 M PA

cyclobenzaprine hcl TABS 5mg, 10mg


3 M PA

dantrolene sodium CAPS 2 M

tizanidine 2 M

XEOMIN INJ 50 UNITS 4 M PA



NARCOLEPSY/CATAPLEXY armodafinil 50mg

QL (90 tabs / 30 days) 2 QL M PA

armodafinil 150mg, 200mg, 250mg


2 QL M PA

modafinil 100mg QL (30 tabs / 30 days)

2 QL M PA

modafinil 200mg QL (60 tabs / 30 days)

2 QL M PA

XYREM QL (540 mL / 30 days)

5 QL LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 2 M

BUNAVAIL MIS 2.1-0.3MG QL (90 films / 30 days)

4 QL M

BUNAVAIL MIS 4.2-0.7MG QL (90 films / 30 days)

4 QL M

BUNAVAIL MIS 6.3-1MG QL (60 films / 30 days)

4 QL M

buprenorphine hcl SUBL QL (90 tabs / 30 days)

2 QL M PA

buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg

QL (90 films / 30 days)

2 QL M

buprenorphine hcl-naloxone hcl dihydrate 4-1mg


2 QL M



2 QL M



2 QL M


24

Drug Name Drug Tier

Requirements/Limits

buprenorphine hcl-naloxone hcl sl


2 QL M

bupropion hcl (smoking deterrent)

2 M

CHANTIX 4 M PA

CHANTIX CONTINUING MONTH

4 M PA

CHANTIX STARTER PACK 4 M PA

disulfiram TABS 2 M

fluoxetine hcl (pmdd) (generic of SARAFEM)

2 M

LUCEMYRA QL (228 tabs / 14 days)

5 QL M PA

naloxone inj 0.4mg/ml 2 M

naloxone inj 1mg/ml 2 M

naltrexone hcl TABS 2 M

NARCAN 3 M

NICOTROL INHAL

Documents

HMSA Akamai Advantage 2019 Formulary...on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary