Select Drug List - beere&purves · The Select Drug List, also called a formulary is a list of U.S. Food and Drug Administration (FDA) ... oral solution 120 mg-12 mg /5 ml (5 ml),

4 Tier Formulary

Select Drug ListSubject to Regulatory Approval

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1332531 40627CAMENABC Select Drig List Update BO 07 15

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Anthem Blue Cross Select Drug List

Your prescription drug benefit includes coverage for

medicines that you’ll find on the Select Drug List. You can

often find more savings when your doctor prescribes

medicine that is on our Select Drug List. Here are some

commonly asked questions and answers about how the

Select Drug List works with your prescription drug plan.

Q. What is a Select Drug List?

A. The Select Drug List, also called a formulary is a list of

U.S. Food and Drug Administration (FDA)-approved

brand-name and generic drugs that have been reviewed

and recommended for their quality and how well they

work. The review is done by the National Pharmacy and

Therapeutics (P&T) Process. The P&T Process is

performed by an independent group of practicing

doctors and pharmacists in charge of the research and

decisions surrounding our Select Drug List. This group

meets regularly to review new and existing drugs and

they choose the top drugs for our list—based on their

safety, how they work and their value.

Because the drugs on our list are reviewed from time to

time, it’s a good idea to check the list to find out if any

drugs have been added or removed. You can do this by

going to anthem.com/ca.

Q. What are Tiers?

A. Drugs on the Select Drug List are grouped into tiers.

There are several factors that are used to determine

under which tier a drug will be put in. This can include

(but it’s not limited to):

Cost of the drug

Cost of the drug in comparison to other drugs used for the same type of treatment

Availability of over-the-counter options

Other clinical and cost factors.

Q. What is a brand-name drug?

A. These are drugs that are developed by a company

who holds the rights to sell them. When the rights

expire, other drug companies can make their own

version of the drugs (see generic drugs below). You

may be more familiar with brand-name drugs through

advertising or because you know people who take

them. When you see a drug in all caps in this piece,

it is a brand-name drug.

Q. What is a generic drug?

A. Generics are simply copies of brand-name drugs.

Brand-name and generic drugs have the same active

ingredients, strength and dose. And the FDA requires

that generic drugs meet the same high standards for

purity, quality, safety and strength. When you see a

drug in all lowercase in this piece, it is a generic drug.

Q. What do I do if I am prescribed or currently taking a

prescription drug that is not on the Anthem Select

Drug List?

A. If you are prescribed or currently taking a non

formulary drug, you should discuss formulary

alternatives your physician. If your physician feels that

the medication is medically necessary, it will be

necessary to obtain Prior Authorization of Benefits in

order for the prescription to be a covered benefit.

Information is available to you and your physician

through the Certificate or Evidence of Coverage, health

plan web site and newsletters. You may also call

customer service for more information.

Q. Can I request that a drug be added to the

Select Drug List?

A. You or your doctor can put in a request to add a drug to

the Select Drug List. You can do this either in writing or

on our website. Requests are reviewed by the P&T

Process team during the Select Drug List review. Please

note that if a drug request is approved, it does not

guarantee coverage. Some drugs, such as those used

for cosmetic purposes, may be excluded from your

benefits. Please refer to your insurance Certificate or

Evidence of Coverage to know for sure.

Q. What if my medication is not covered?

A. You may want to first check with your doctor about

prescribing a drug that is covered. If your doctor

prescribes a drug that’s not covered, you will need to

pay the out-of-pocket cost that applies to drugs not on

the formulary.

Preventive Care Drugs: We cover preventive care drugs

with zero cost share in compliance with the Affordable

Care Act (ACA).

Please note: In selecting medications for the prescription

drug list, the therapeutic efficacy and cost effectiveness

are addressed for each category. All therapeutic

categories are represented on the drug list by at least one

medication. When a closed drug list is in effect, only

medications that are included on the drug list are a

covered service. In certain clinical situations, a member

may require use of a non-covered product. Anthem has

criteria that permits a member to obtain a non-covered

medication in a closed drug list plan. If specific criteria are

met, a member can receive a non-covered drug for a drug

list co-pay. The criteria preserves the clinical integrity of

the drug list and provides a process by which deviations

from the drug list may be allowed. An appeals process is in

place for any medications that do not meet the criteria.

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For more information about your drug plan, you can do the following:

Go to anthem.com/ca.

Call Customer Service at the number on your ID card.

Speech and hearing impaired users (TDD/TTY) should call 1-800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m., ET.

California Select Drug List

Table of Contents

Table of Contents

ANALGESICS ........................................................................................................................................................................................................................................................................................... 8ANESTHETICS ........................................................................................................................................................................................................................................................................................ 9ANTIARTHRITICS ................................................................................................................................................................................................................................................................................ 9ANTIASTHMATICS ......................................................................................................................................................................................................................................................................... 10ANTIBIOTICS ........................................................................................................................................................................................................................................................................................ 11ANTICOAGULANTS ...................................................................................................................................................................................................................................................................... 15ANTIDOTES ............................................................................................................................................................................................................................................................................................ 15ANTIFUNGALS .................................................................................................................................................................................................................................................................................... 15ANTIHISTAMINE AND DECONGESTANT COMBINATION ................................................................................................................................................................. 16ANTIHISTAMINES ............................................................................................................................................................................................................................................................................ 16ANTIHYPERGLYCEMICS ........................................................................................................................................................................................................................................................ 16ANTIINFECTIVES ............................................................................................................................................................................................................................................................................. 17ANTIINFECTIVES/MISCELLANEOUS ........................................................................................................................................................................................................................ 17ANTINEOPLASTICS ...................................................................................................................................................................................................................................................................... 17ANTIPARKINSON DRUGS ..................................................................................................................................................................................................................................................... 19ANTIPLATELET DRUGS .......................................................................................................................................................................................................................................................... 19ANTIVIRALS ........................................................................................................................................................................................................................................................................................... 20AUTONOMIC DRUGS .................................................................................................................................................................................................................................................................. 21BIOLOGICALS ..................................................................................................................................................................................................................................................................................... 21BLOOD ......................................................................................................................................................................................................................................................................................................... 24CARDIAC DRUGS ............................................................................................................................................................................................................................................................................ 24CARDIOVASCULAR ...................................................................................................................................................................................................................................................................... 26CNS DRUGS ........................................................................................................................................................................................................................................................................................... 27COLONY STIMULATING FACTORS ............................................................................................................................................................................................................................ 28CONTRACEPTIVES ....................................................................................................................................................................................................................................................................... 29COUGH/COLD PREPARATIONS .................................................................................................................................................................................................................................... 31DIAGNOSTIC ......................................................................................................................................................................................................................................................................................... 31DIURETICS .............................................................................................................................................................................................................................................................................................. 32EENT PREPS ......................................................................................................................................................................................................................................................................................... 32ELECT/CALORIC/H2O ................................................................................................................................................................................................................................................................ 33GASTROINTESTINAL .................................................................................................................................................................................................................................................................. 34HORMONES ........................................................................................................................................................................................................................................................................................... 35IMMUNOSUPPRESANT ............................................................................................................................................................................................................................................................. 36MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ............................................................................................................................................ 37MUSCLE RELAXANTS ............................................................................................................................................................................................................................................................... 37PRE-NATAL VITAMINS .............................................................................................................................................................................................................................................................. 37PSYCHOTHERAPEUTIC DRUGS ................................................................................................................................................................................................................................... 39SEDATIVE/HYPNOTICS ............................................................................................................................................................................................................................................................ 41SKIN PREPS .......................................................................................................................................................................................................................................................................................... 41SMOKING DETERRENTS ........................................................................................................................................................................................................................................................ 43THYROID PREPS .............................................................................................................................................................................................................................................................................. 43UNCLASSIFIED DRUG PRODUCTS ............................................................................................................................................................................................................................ 43VITAMINS .................................................................................................................................................................................................................................................................................................. 44

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NOTE: Not all medications and not all plans are subject to prior authorization and quantity limits. For more information regarding prior authorization or quantity limits, contact Member Services at the telephone number listed on your identification card.

List of Abbreviations

Tier 1: Tier 1 drugs have the lowest cost share. these drugs offer the greatest value compared to others that treat the same conditions.

Tier 2: Tier 2 drugs have a medium cost share. They may be preferred drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs.

Tier 3: Tier 3 drugs have a higher cost share. They may cost more than others used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA.

Tier 4: Tier 4 specialty drugs have the highest cost share. They may cost more than others used to treat the same condition. Specialty drugs are used to treat complex, chronic conditions and may need special handling.

$0: PREVENTATIVE DRUGS: For some members, this product may be covered at 100% with $0 cost share with a prescription from your provider if specified criteria are met.

DO: DOSE OPTIMIZATION REQUIRED. Normally involves the conversion from twice-daily dosing to a once-daily dosing schedule.

PA: PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled.

QL: QUANTITY LIMITS. Certain prescription drugs have specific quantity limits per prescription or per month.

ST: STEP THERAPY REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized. Please note: Foradil and Serevent are safety edits that prevent duplication of therapy.

Below is a list of drug name formatting patterns that may appear in the following pages.

List of Patterns

lowercase: Generic drugs

UPPERCASE BOLD: Brand name drugs

California Select Drug List

Drug Name Tier Notes

ANALGESICS

acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml

Tier 1 QL

acetaminophen-codeine oral solution 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml

Tier 1

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg

Tier 1 QL

ascomp with codeine oral capsule

Tier 1

buprenorphine hcl injection solution

Tier 2

buprenorphine hcl injection syringe

Tier 2

butalbital compound w/codeine oral capsule

Tier 1

butalbital-acetaminop-caf-cod oral capsule

Tier 1 QL

butalbital-acetaminophen-caff oral capsule

Tier 1

butalbital-acetaminophen-caff oral tablet

Tier 1

butalbital-aspirin-caffeine oral capsule

Tier 1

butorphanol tartrate nasal spray,non-aerosol

Tier 1 PA; QL

capacet oral capsule Tier 1

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg

Tier 1 QL

codeine-butalbital-asa-caff oral capsule

Tier 1

diclofenac potassium oral tablet

Tier 1

diflunisal oral tablet Tier 1


dihydroergotamine nasal spray,non-aerosol

Tier 2 QL

diskets oral tablet,soluble Tier 1

ELMIRON ORAL CAPSULE

Tier 3

endocet oral tablet Tier 1 QL

endodan oral tablet Tier 1

ERGOMAR SUBLINGUAL TABLET

Tier 3

fentanyl transdermal patch 72 hour

Tier 2 ST; QL

hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml), 2.5-167 mg/5 ml, 5-163 mg/7.5ml(7.5ml)

Tier 1 QL

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

Tier 1 QL

hydromorphone oral liquid Tier 1 QL

hydromorphone oral tablet 2 mg, 4 mg, 8 mg

Tier 1 QL

hydromorphone rectal suppository

Tier 1

ibuprofen-oxycodone oral tablet

Tier 1 QL

isometh-dichloral-acetaminophn oral capsule

Tier 1

ketorolac oral tablet Tier 1 QL

margesic oral capsule Tier 1

marten-tab oral tablet Tier 1

meperidine oral solution Tier 1 QL

meperidine oral tablet 100 mg, 50 mg

Tier 1 QL

meperitab oral tablet Tier 1 QL

methadone intensol oral concentrate

Tier 1 QL

methadone oral concentrate

Tier 1 QL

methadone oral solution 10 mg/5 ml, 5 mg/5 ml

Tier 1 QL

methadone oral tablet 10 mg, 5 mg

Tier 1 QL

methadone oral tablet,soluble

Tier 1 QL

Revised 4/1/2016

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methadose oral concentrate

Tier 1 QL

methadose oral tablet,soluble

Tier 1

migergot rectal suppository

Tier 1

morphine concentrate oral solution

Tier 1 QL

morphine oral capsule,extend.release pellets

Tier 2 QL

morphine oral solution 10 mg/5 ml, 20 mg/5 ml

Tier 1 QL

morphine oral tablet 15 mg, 30 mg

Tier 1 QL

morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg

Tier 2 QL

morphine rectal suppository

Tier 1

nalbuphine injection solution

Tier 2

naratriptan oral tablet Tier 1 QL

nodolor oral capsule Tier 1

oxycodone oral capsule Tier 1 QL

oxycodone oral concentrate

Tier 1 QL

oxycodone oral solution Tier 1 QL

oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg

Tier 1 QL

oxycodone-acetaminophen oral tablet

Tier 1 QL

oxycodone-aspirin oral tablet

Tier 1 QL

oxymorphone oral tablet 10 mg, 5 mg

Tier 1 QL

sumatriptan succinate oral tablet

Tier 1 QL

sumatriptan succinate subcutaneous cartridge

Tier 2 QL

sumatriptan succinate subcutaneous pen injector

Tier 2 QL

sumatriptan succinate subcutaneous solution

Tier 2 QL

sumatriptan succinate subcutaneous syringe

Tier 2 QL


tencon oral tablet Tier 1

tramadol oral tablet Tier 1 QL

vicodin es oral tablet Tier 1 QL

vicodin hp oral tablet Tier 1 QL

vicodin oral tablet Tier 1 QL

zamicet oral solution Tier 1 QL

zebutal oral capsule Tier 2

ANESTHETICS

lidocaine hcl mucous membrane solution

Tier 1

lidocaine viscous mucous membrane solution

Tier 1

lidocaine-prilocaine topical cream

Tier 1

lidocaine-prilocaine topical kit

Tier 1

phenazopyridine oral tablet

Tier 1

ANTIARTHRITICS

allopurinol oral tablet Tier 1

colchicine-probenecid oral tablet

Tier 1

COLCRYS ORAL TABLET

Tier 3 PA; QL

CUPRIMINE ORAL CAPSULE

Tier 3

diclofenac sodium oral tablet extended release 24 hr

Tier 1

diclofenac sodium oral tablet,delayed release (dr/ec)

Tier 1

ENBREL SUBCUTANEOUS RECON SOLN

Tier 4 PA; QL

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML)

Tier 4 PA; QL

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; QL

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT

Tier 4 PA; QL

Revised 4/1/2016

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HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT

Tier 4 PA; QL

HUMIRA PEN PSORIASIS STARTER SUBCUTANEOUS PEN INJECTOR KIT

Tier 4 PA; QL

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT

Tier 4 PA; QL

HUMIRA SUBCUTANEOUS SYRINGE KIT

Tier 4 PA; QL

ibuprofen oral suspension Tier 1

ibuprofen oral tablet Tier 1

indomethacin oral capsule Tier 1

indomethacin oral capsule, extended release

Tier 1

KINERET SUBCUTANEOUS SYRINGE

Tier 4 PA

leflunomide oral tablet Tier 2

meclofenamate oral capsule

Tier 1

meloxicam oral suspension

Tier 1 QL

meloxicam oral tablet Tier 1 QL

nabumetone oral tablet Tier 1

naproxen oral suspension Tier 1

naproxen oral tablet Tier 1

naproxen oral tablet,delayed release (dr/ec)

Tier 1

naproxen sodium oral tablet

Tier 1

ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN

Tier 4 PA; QL

ORENCIA SUBCUTANEOUS SYRINGE

Tier 4 PA; QL

probenecid oral tablet Tier 1

RIDAURA ORAL CAPSULE

Tier 3


SIMPONI ARIA INTRAVENOUS SOLUTION

Tier 4 PA

SIMPONI SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; QL

SIMPONI SUBCUTANEOUS SYRINGE

Tier 4 PA; QL

ANTIASTHMATICS

acetylcysteine solution Tier 2

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE

Tier 2 QL

ADVAIR HFA INHALATION HFA AEROSOL INHALER

Tier 2 QL

albuterol sulfate inhalation solution for nebulization

Tier 1

albuterol sulfate oral syrup Tier 1

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2 QL

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml

Tier 1 QL

cromolyn inhalation solution for nebulization

Tier 1

DALIRESP ORAL TABLET

Tier 3 QL

DULERA INHALATION HFA AEROSOL INHALER

Tier 2 QL

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION

Tier 2 QL

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION

Tier 2 QL

ipratropium bromide inhalation solution

Tier 1 QL

metaproterenol oral syrup Tier 1

Revised 4/1/2016

10


metaproterenol oral tablet Tier 1

montelukast oral granules in packet

Tier 1 QL

montelukast oral tablet Tier 1 QL

montelukast oral tablet,chewable

Tier 1 QL

PROAIR HFA INHALATION HFA AEROSOL INHALER

Tier 2 QL

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2 QL

PROVENTIL HFA INHALATION HFA AEROSOL INHALER

Tier 3 QL

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2 QL

QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION

Tier 2 QL

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

Tier 2 QL

SPIRIVA RESPIMAT INHALATION MIST

Tier 3 QL

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 3 QL

SYMBICORT INHALATION HFA AEROSOL INHALER

Tier 2 QL

theochron oral tablet extended release 12 hr

Tier 1

theophylline oral elixir Tier 1

theophylline oral solution Tier 1

theophylline oral tablet extended release

Tier 1

theophylline oral tablet extended release 12 hr

Tier 1

VENTOLIN HFA INHALATION HFA AEROSOL INHALER

Tier 3 QL


XOPENEX HFA INHALATION HFA AEROSOL INHALER

Tier 3 QL

ANTIBIOTICS

ak-poly-bac ophthalmic ointment

Tier 1

amikacin injection solution Tier 2

amoxicillin oral capsule Tier 1

amoxicillin oral suspension for reconstitution

Tier 1

amoxicillin oral tablet Tier 1

amoxicillin oral tablet,chewable

Tier 1

amoxicillin-pot clavulanate oral suspension for reconstitution

Tier 1

amoxicillin-pot clavulanate oral tablet

Tier 1

amoxicillin-pot clavulanate oral tablet extended release 12 hr

Tier 1

amoxicillin-pot clavulanate oral tablet,chewable

Tier 1

ampicillin oral capsule Tier 1

ampicillin oral suspension for reconstitution

Tier 1

ampicillin sodium injection recon soln

Tier 2

ampicillin sodium intravenous recon soln

Tier 2

ampicillin-sulbactam injection recon soln

Tier 2

ampicillin-sulbactam intravenous recon soln

Tier 2

avar topical cleanser Tier 1

avidoxy oral tablet Tier 1

azithromycin oral packet Tier 1 QL

azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml

Tier 1 QL

azithromycin oral tablet 250 mg, 500 mg, 600 mg

Tier 1 QL

aztreonam injection recon soln

Tier 2

bacitracin ophthalmic ointment

Tier 1

Revised 4/1/2016

11


bacitracin-polymyxin b ophthalmic ointment

Tier 1

BESIVANCE OPHTHALMIC DROPS,SUSPENSION

Tier 3

bp 10-1 topical cleanser Tier 1

cefaclor oral capsule Tier 1

cefaclor oral suspension for reconstitution

Tier 1

cefaclor oral tablet extended release 12 hr

Tier 1

cefadroxil oral capsule Tier 1

cefadroxil oral suspension for reconstitution

Tier 1

cefadroxil oral tablet Tier 1

cefazolin in dextrose (iso-os) intravenous piggyback

Tier 2

cefazolin injection recon soln

Tier 2

cefazolin intravenous recon soln

Tier 2

cefdinir oral capsule Tier 1

cefdinir oral suspension for reconstitution

Tier 1

cefditoren pivoxil oral tablet

Tier 1

cefotaxime injection recon soln

Tier 2

CEFOTETAN IN DEXTROSE, ISO-OSM INTRAVENOUS PIGGYBACK

Tier 2

cefotetan injection recon soln

Tier 2

cefotetan intravenous recon soln

Tier 2

cefpodoxime oral suspension for reconstitution

Tier 2

cefpodoxime oral tablet Tier 2

cefprozil oral suspension for reconstitution

Tier 1

cefprozil oral tablet Tier 1

ceftibuten oral capsule Tier 2

ceftibuten oral suspension for reconstitution

Tier 2


ceftriaxone in dextrose,iso-os intravenous piggyback

Tier 2

ceftriaxone injection recon soln

Tier 2

ceftriaxone intravenous recon soln

Tier 2

cefuroxime axetil oral tablet

Tier 1

cephalexin oral capsule Tier 1

cephalexin oral suspension for reconstitution

Tier 1

cephalexin oral tablet Tier 1

chloramphenicol sod succinate intravenous recon soln

Tier 2

CIPRODEX OTIC DROPS,SUSPENSION

Tier 3 PA

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg

Tier 1 QL

ciprofloxacin hcl ophthalmic drops

Tier 1

ciprofloxacin hcl oral tablet Tier 1 QL

ciprofloxacin hcl otic dropperette

Tier 1

clarithromycin oral suspension for reconstitution

Tier 1

clarithromycin oral tablet Tier 1

clarithromycin oral tablet extended release 24 hr

Tier 1

cleansing wash topical cleanser

Tier 1

CLINDACIN ETZ TOPICAL KIT

Tier 3

clindacin etz topical swab Tier 1

clindacin p topical swab Tier 1

CLINDACIN PAC TOPICAL KIT

Tier 3

clindamycin hcl oral capsule

Tier 1

clindamycin palmitate hcl oral recon soln

Tier 1

clindamycin pediatric oral recon soln

Tier 1

Revised 4/1/2016

12


clindamycin phosphate topical foam

Tier 1

clindamycin phosphate topical gel

Tier 1

clindamycin phosphate topical lotion

Tier 1

clindamycin phosphate topical solution

Tier 1

clindamycin phosphate topical swab

Tier 1

clindamycin phosphate vaginal cream

Tier 1

DAPSONE ORAL TABLET

Tier 3

demeclocycline oral tablet Tier 2

dicloxacillin oral capsule Tier 1

doxycycline hyclate oral capsule

Tier 1

doxycycline hyclate oral tablet

Tier 1

doxycycline hyclate oral tablet,delayed release (dr/ec)

Tier 1 PA

doxycycline monohydrate oral capsule

Tier 1

doxycycline monohydrate oral suspension for reconstitution

Tier 1

doxycycline monohydrate oral tablet

Tier 1

e.e.s. 400 oral tablet Tier 1

ery pads topical swab Tier 1

erygel topical gel Tier 1

ery-tab oral tablet,delayed release (dr/ec)

Tier 1

erythrocin (as stearate) oral tablet

Tier 1

erythromycin ethylsuccinate oral tablet

Tier 1

erythromycin ophthalmic ointment

Tier 1

erythromycin oral capsule,delayed release(dr/ec)

Tier 1

erythromycin oral tablet Tier 1

erythromycin with ethanol topical gel

Tier 1


erythromycin with ethanol topical solution

Tier 1

erythromycin with ethanol topical swab

Tier 1

erythromycin-benzoyl peroxide topical gel

Tier 1

ethambutol oral tablet Tier 1

garamycin ophthalmic drops

Tier 1

gentak ophthalmic ointment

Tier 1

gentamicin ophthalmic drops

Tier 1

gentamicin ophthalmic ointment

Tier 1

imipenem-cilastatin intravenous recon soln

Tier 2

INVANZ INJECTION RECON SOLN

Tier 3

INVANZ INTRAVENOUS RECON SOLN

Tier 3

isoniazid oral solution Tier 1

isoniazid oral tablet Tier 1

levofloxacin oral tablet Tier 1 QL

LINCOCIN INJECTION SOLUTION

Tier 3

lincomycin injection solution

Tier 2

linezolid oral tablet Tier 2 PA; QL

meropenem intravenous recon soln

Tier 2

metronidazole oral capsule

Tier 1

metronidazole oral tablet Tier 1

metronidazole vaginal gel Tier 1

minocycline oral capsule Tier 1

minocycline oral tablet Tier 1

minocycline oral tablet extended release 24 hr

Tier 1 PA

MORGIDOX 1X100 KIT Tier 3

MORGIDOX 2X100 KIT Tier 3

morgidox oral capsule Tier 1

mupirocin topical ointment Tier 1

nafcillin in dextrose iso-osm intravenous piggyback

Tier 2

Revised 4/1/2016

13


nafcillin injection recon soln

Tier 2

nafcillin intravenous recon soln

Tier 2

neomycin oral tablet Tier 1

neomycin-bacitracin-poly-hc ophthalmic ointment

Tier 1

neomycin-bacitracin-polymyxin ophthalmic ointment

Tier 1

neomycin-polymyxin b-dexameth ophthalmic drops,suspension

Tier 1

neomycin-polymyxin b-dexameth ophthalmic ointment

Tier 1

neomycin-polymyxin-gramicidin ophthalmic drops

Tier 1

neomycin-polymyxin-hc ophthalmic drops,suspension

Tier 1

neomycin-polymyxin-hc otic drops,suspension

Tier 1

neomycin-polymyxin-hc otic solution

Tier 1

neo-polycin hc ophthalmic ointment

Tier 1

neo-polycin ophthalmic ointment

Tier 1

nitrofurantoin macrocrystal oral capsule

Tier 1

nitrofurantoin monohyd/m-cryst oral capsule

Tier 1

nitrofurantoin oral suspension

Tier 1

ofloxacin ophthalmic drops Tier 1

ofloxacin oral tablet Tier 1 QL

ofloxacin otic drops Tier 1

ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE

Tier 3

oxacillin injection recon soln

Tier 2

oxacillin intravenous recon soln

Tier 2

penicillin g potassium injection recon soln

Tier 2


penicillin v potassium oral recon soln

Tier 1

penicillin v potassium oral tablet

Tier 1

pfizerpen-g injection recon soln

Tier 2

piperacillin-tazobactam intravenous recon soln

Tier 1

polycin ophthalmic ointment

Tier 1

polymyxin b sulf-trimethoprim ophthalmic drops

Tier 1

PRED-G OPHTHALMIC DROPS,SUSPENSION

Tier 3

PRED-G S.O.P. OPHTHALMIC OINTMENT

Tier 3

pyrazinamide oral tablet Tier 1

rifabutin oral capsule Tier 2

rifampin oral capsule Tier 1

RIFATER ORAL TABLET Tier 3

silver sulfadiazine topical cream

Tier 1

ssd topical cream Tier 1

sss 10-5 topical cream Tier 1

sss 10-5 topical foam Tier 1

STREPTOMYCIN INTRAMUSCULAR RECON SOLN

Tier 3

sulfacetamide sodium ophthalmic drops

Tier 1

sulfacetamide sodium ophthalmic ointment

Tier 1

sulfacetamide sodium-sulfur topical cleanser

Tier 1

sulfacetamide sodium-sulfur topical cream

Tier 1

sulfacetamide sodium-sulfur topical foam

Tier 1

sulfacetamide sodium-sulfur topical lotion

Tier 1

sulfacetamide sodium-sulfur topical pads, medicated

Tier 1

Revised 4/1/2016

14


sulfacetamide sodium-sulfur topical suspension

Tier 1

sulfacetamide sod-sulfur-urea topical cleanser

Tier 1

sulfacetamide-prednisolone ophthalmic drops

Tier 1

sulfacetamide-sulfur-cleansr23 topical kit

Tier 1

sulfacleanse 8-4 topical suspension

Tier 1

sulfadiazine oral tablet Tier 2

sulfamethoxazole-trimethoprim oral suspension

Tier 1

sulfamethoxazole-trimethoprim oral tablet

Tier 1

sulfatrim oral suspension Tier 1

SUPRAX ORAL CAPSULE

Tier 3

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

tetracycline oral capsule Tier 1

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

Tier 3 PA; QL

thermazene topical cream Tier 1

tobramycin in 0.225 % nacl inhalation solution for nebulization

Tier 4

tobramycin ophthalmic drops

Tier 1

tobramycin-dexamethasone ophthalmic drops,suspension

Tier 1

trimethoprim oral tablet Tier 1

vancomycin oral capsule Tier 2 PA

vandazole vaginal gel Tier 1

VIBATIV INTRAVENOUS RECON SOLN

Tier 3

VIGAMOX OPHTHALMIC DROPS

Tier 3

zencia topical cleanser Tier 1

ANTICOAGULANTS

enoxaparin subcutaneous solution

Tier 4


enoxaparin subcutaneous syringe

Tier 4

fondaparinux subcutaneous syringe

Tier 4 PA

jantoven oral tablet Tier 1

PRADAXA ORAL CAPSULE

Tier 3 QL

warfarin oral tablet Tier 1

ANTIDOTES

naltrexone oral tablet Tier 1

ANTIFUNGALS

CICLODAN KIT TOPICAL COMBO PACK

Tier 3

CICLODAN KIT TOPICAL SOLUTION

Tier 3

ciclodan topical cream Tier 1

ciclodan topical solution Tier 1

ciclopirox topical cream Tier 1

ciclopirox topical gel Tier 1

ciclopirox topical shampoo Tier 1

ciclopirox topical solution Tier 1

ciclopirox topical suspension

Tier 1

clotrimazole mucous membrane troche

Tier 1

clotrimazole topical cream Tier 1

clotrimazole topical solution

Tier 1

clotrimazole-betamethasone topical cream

Tier 1

clotrimazole-betamethasone topical lotion

Tier 1

econazole topical cream Tier 1

fluconazole oral suspension for reconstitution

Tier 1

fluconazole oral tablet Tier 1

flucytosine oral capsule Tier 1

griseofulvin microsize oral suspension

Tier 1

griseofulvin microsize oral tablet

Tier 1

griseofulvin ultramicrosize oral tablet

Tier 1

itraconazole oral capsule Tier 2 PA

Revised 4/1/2016

15


ketoconazole oral tablet Tier 1

ketoconazole topical cream

Tier 1

ketoconazole topical foam Tier 1

ketoconazole topical shampoo

Tier 1

naftifine topical cream Tier 2

nyamyc topical powder Tier 1

nystatin oral powder Tier 1

nystatin oral suspension Tier 1

nystatin oral tablet Tier 1

nystatin topical cream Tier 1

nystatin topical ointment Tier 1

nystatin topical powder Tier 1

nystatin-triamcinolone topical cream

Tier 1

nystatin-triamcinolone topical ointment

Tier 1

nystop topical powder Tier 1

terbinafine hcl oral tablet Tier 1 PA

terconazole vaginal cream Tier 1

terconazole vaginal suppository

Tier 1

ANTIHISTAMINE AND DECONGESTANT COMBINATION

promethazine vc oral syrup

Tier 1

ANTIHISTAMINES

azelastine ophthalmic drops

Tier 1 QL

diphenhydramine hcl injection solution

Tier 2

diphenhydramine hcl injection syringe

Tier 2

diphenhydramine hcl oral capsule

Tier 1

epinastine ophthalmic drops

Tier 1 QL

fexofenadine oral tablet Tier 1 QL

hydroxyzine hcl oral tablet Tier 1

hydroxyzine pamoate oral capsule

Tier 1

olopatadine ophthalmic drops

Tier 2 PA; QL


PATADAY OPHTHALMIC DROPS

Tier 3 PA; QL

promethazine oral syrup Tier 1

promethazine oral tablet Tier 1

ANTIHYPERGLYCEMICS

acarbose oral tablet Tier 1

glimepiride oral tablet Tier 1

glipizide oral tablet Tier 1

glipizide oral tablet extended release 24hr

Tier 1

glipizide-metformin oral tablet

Tier 1

glyburide oral tablet Tier 1

glyburide-metformin oral tablet

Tier 1

HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION

Tier 2

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION

Tier 2

HUMALOG SUBCUTANEOUS CARTRIDGE

Tier 2

HUMALOG SUBCUTANEOUS SOLUTION

Tier 2

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION

Tier 2

HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

Revised 4/1/2016

16


HUMULIN N SUBCUTANEOUS SUSPENSION

Tier 2

HUMULIN R INJECTION SOLUTION

Tier 2

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION

Tier 2

JANUVIA ORAL TABLET Tier 3 ST; QL

JARDIANCE ORAL TABLET

Tier 3 ST; QL

LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN

Tier 2

LANTUS SUBCUTANEOUS SOLUTION

Tier 2

LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN

Tier 2

LEVEMIR SUBCUTANEOUS SOLUTION

Tier 2

metformin oral tablet Tier 1

metformin oral tablet extended release 24 hr

Tier 1

metformin oral tablet extended release 24hr

Tier 1

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN N SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN R INJECTION SOLUTION

Tier 2

NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION

Tier 2

pioglitazone oral tablet Tier 1 QL


tolbutamide oral tablet Tier 1

ANTIINFECTIVES/MISCELLANEOUS

ALBENZA ORAL TABLET

Tier 3

ALINIA ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ALINIA ORAL TABLET Tier 3

atovaquone-proguanil oral tablet

Tier 1

BILTRICIDE ORAL TABLET

Tier 3

chloroquine phosphate oral tablet

Tier 1

COARTEM ORAL TABLET

Tier 3

DARAPRIM ORAL TABLET

Tier 3

hydroxychloroquine oral tablet

Tier 1

ivermectin oral tablet Tier 1

mefloquine oral tablet Tier 1

paromomycin oral capsule Tier 1

PRIMAQUINE ORAL TABLET

Tier 3

quinine sulfate oral capsule

Tier 1 PA; QL

ANTIINFECTIVES

ARESTIN DENTAL CARTRIDGE

Tier 3

ANTINEOPLASTICS

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG

Tier 4 PA; QL

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG

Tier 4 PA; QL

ALFERON N INJECTION SOLUTION

Tier 4

ALKERAN ORAL TABLET

Tier 4

anastrozole oral tablet Tier 2 PA; QL

BOSULIF ORAL TABLET100 MG, 500 MG

Tier 4 PA; QL

Revised 4/1/2016

17


BUSULFEX INTRAVENOUS SOLUTION

Tier 4

capecitabine oral tablet 150 mg, 500 mg

Tier 4 PA; QL

CAPRELSA ORAL TABLET 100 MG, 300 MG

Tier 4 PA; QL

COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG[1]-20 MG[1]), 140 MG/DAY(80 MG[1]-20 MG[3]), 60 MG/DAY (20 MG [3]/DAY)

Tier 4 PA; QL

CYCLOPHOSPHAMIDE ORAL CAPSULE

Tier 4

EMCYT ORAL CAPSULE Tier 4 PA

ERIVEDGE ORAL CAPSULE

Tier 4 PA; QL

ETOPOPHOS INTRAVENOUS RECON SOLN

Tier 4

etoposide oral capsule Tier 4

exemestane oral tablet Tier 4 PA; QL

FARESTON ORAL TABLET

Tier 4 QL

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN

Tier 4 PA

fludarabine intravenous recon soln

Tier 4

fludarabine intravenous solution

Tier 4

fluorouracil topical cream Tier 1

fluorouracil topical solution Tier 1

flutamide oral capsule Tier 2

GILOTRIF ORAL TABLET

Tier 3 QL

GLEEVEC ORAL TABLET 100 MG, 400 MG

Tier 4 PA; QL

HEXALEN ORAL CAPSULE

Tier 4

HYCAMTIN ORAL CAPSULE

Tier 4

hydroxyurea oral capsule Tier 2

ICLUSIG ORAL TABLET15 MG, 45 MG

Tier 4 PA; QL


imatinib oral tablet 100 mg, 400 mg

Tier 4 PA; QL

INLYTA ORAL TABLET 1 MG, 5 MG

Tier 4 PA; QL

INTRON A INJECTION RECON SOLN

Tier 4 PA

INTRON A INJECTION SOLUTION

Tier 4 PA

JAKAFI ORAL TABLET10 MG, 15 MG, 20 MG, 25 MG, 5 MG

Tier 4 PA; QL

letrozole oral tablet Tier 2 QL

LEUKERAN ORAL TABLET

Tier 4

leuprolide subcutaneous kit

Tier 4 PA

LYSODREN ORAL TABLET

Tier 4 QL

MATULANE ORAL CAPSULE

Tier 4

MEKINIST ORAL TABLET 0.5 MG, 2 MG

Tier 4 PA; QL

melphalan hcl intravenous recon soln

Tier 4

mercaptopurine oral tablet Tier 4

methotrexate sodium oral tablet

Tier 2

mitoxantrone intravenous concentrate

Tier 4

MYLERAN ORAL TABLET

Tier 4

NEXAVAR ORAL TABLET

Tier 4 PA; QL

NILANDRON ORAL TABLET

Tier 4 QL

PANRETIN TOPICAL GEL

Tier 3

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG

Tier 4 QL

REVLIMID ORAL CAPSULE

Tier 4 PA; QL

RITUXAN INTRAVENOUS CONCENTRATE

Tier 3 PA

SPRYCEL ORAL TABLET

Tier 4 PA; QL

Revised 4/1/2016

18


STIVARGA ORAL TABLET

Tier 4 PA; QL

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

Tier 4 PA; QL

TABLOID ORAL TABLET Tier 4

TAFINLAR ORAL CAPSULE

Tier 4 QL

tamoxifen oral tablet Tier 1 $0

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG

Tier 4 PA; QL

TASIGNA ORAL CAPSULE

Tier 4 PA; QL

temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg

Tier 4 PA; QL

topotecan intravenous recon soln

Tier 4

topotecan intravenous solution

Tier 4

TRELSTAR DEPOT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 4 PA; QL

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 4 PA; QL

TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML, 22.5 MG/2 ML, 3.75 MG/2 ML

Tier 4 PA; QL

TRELSTAR LA INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 4 PA; QL

tretinoin (chemotherapy) oral capsule

Tier 4

TYKERB ORAL TABLET Tier 3 PA; QL

VOTRIENT ORAL TABLET

Tier 4 PA; QL

XTANDI ORAL CAPSULE Tier 4 PA; QL

ZELBORAF ORAL TABLET

Tier 4 PA; QL

ZOLINZA ORAL CAPSULE

Tier 4 PA; QL


ZYTIGA ORAL TABLET250 MG

Tier 4 PA; QL

ANTIPARKINSON DRUGS

amantadine hcl oral capsule

Tier 1

amantadine hcl oral solution

Tier 1

amantadine hcl oral tablet Tier 1

APOKYN SUBCUTANEOUS CARTRIDGE

Tier 4

AZILECT ORAL TABLET Tier 3

benztropine oral tablet Tier 1

bromocriptine oral capsule Tier 1

bromocriptine oral tablet Tier 1

carbidopa oral tablet Tier 2

carbidopa-levodopa oral tablet

Tier 1

carbidopa-levodopa oral tablet extended release

Tier 1

carbidopa-levodopa oral tablet,disintegrating

Tier 1

entacapone oral tablet Tier 2

pramipexole oral tablet Tier 1

ropinirole oral tablet Tier 1

ropinirole oral tablet extended release 24 hr

Tier 1

selegiline hcl oral capsule Tier 1

selegiline hcl oral tablet Tier 1

trihexyphenidyl oral elixir Tier 1

trihexyphenidyl oral tablet Tier 1

ANTIPLATELET DRUGS

anagrelide oral capsule Tier 2

aspirin-dipyridamole oral capsule, er multiphase 12 hr

Tier 2 QL

cilostazol oral tablet Tier 2

clopidogrel oral tablet 300 mg

Tier 1

clopidogrel oral tablet 75 mg

Tier 1 QL

dipyridamole oral tablet Tier 1

ticlopidine oral tablet Tier 1

Revised 4/1/2016

19


ANTIVIRALS

abacavir oral tablet Tier 1

abacavir-lamivudine-zidovudine oral tablet

Tier 2

acyclovir oral capsule Tier 1

acyclovir oral suspension Tier 1

acyclovir oral tablet Tier 1

adefovir oral tablet Tier 4

APTIVUS ORAL CAPSULE

Tier 2

APTIVUS ORAL SOLUTION

Tier 2

ATRIPLA ORAL TABLET Tier 2

BARACLUDE ORAL SOLUTION

Tier 4 PA

cidofovir intravenous solution

Tier 2

CRIXIVAN ORAL CAPSULE

Tier 2

didanosine oral capsule,delayed release(dr/ec)

Tier 1

EDURANT ORAL TABLET

Tier 2

EMTRIVA ORAL CAPSULE

Tier 2

EMTRIVA ORAL SOLUTION

Tier 2

entecavir oral tablet Tier 4

EPIVIR HBV ORAL SOLUTION

Tier 2

EPZICOM ORAL TABLET Tier 2

famciclovir oral tablet Tier 1

foscarnet intravenous solution

Tier 2

FUZEON SUBCUTANEOUS RECON SOLN

Tier 2

ganciclovir sodium intravenous recon soln

Tier 4

HARVONI ORAL TABLET

Tier 4 PA; QL

INTELENCE ORAL TABLET

Tier 2

INVIRASE ORAL CAPSULE

Tier 2


INVIRASE ORAL TABLET

Tier 2

ISENTRESS ORAL TABLET

Tier 2

ISENTRESS ORAL TABLET,CHEWABLE

Tier 2

KALETRA ORAL SOLUTION

Tier 2

KALETRA ORAL TABLET

Tier 2

lamivudine oral tablet Tier 1

lamivudine-zidovudine oral tablet

Tier 1

LEXIVA ORAL SUSPENSION

Tier 2

LEXIVA ORAL TABLET Tier 2

moderiba dose pack oral tablets,dose pack

Tier 3

moderiba oral tablet Tier 3

nevirapine oral suspension Tier 1

nevirapine oral tablet Tier 1

NORVIR ORAL CAPSULE

Tier 2

NORVIR ORAL SOLUTION

Tier 2

NORVIR ORAL TABLET Tier 2

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; QL

PEGASYS SUBCUTANEOUS SOLUTION

Tier 4 PA; QL

PEGASYS SUBCUTANEOUS SYRINGE

Tier 4 PA; QL

PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT

Tier 4 PA

PEGINTRON SUBCUTANEOUS KIT

Tier 4 PA

PREZISTA ORAL SUSPENSION

Tier 2

PREZISTA ORAL TABLET

Tier 2

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

Tier 2 QL

Revised 4/1/2016

20


RESCRIPTOR ORAL TABLET

Tier 2

RESCRIPTOR ORAL TABLET, DISPERSIBLE

Tier 2

REYATAZ ORAL CAPSULE

Tier 2

ribasphere oral capsule Tier 3

ribasphere oral tablet Tier 3

ribasphere ribapak oral tablets,dose pack

Tier 3

ribavirin oral capsule Tier 3

ribavirin oral tablet Tier 3

rimantadine oral tablet Tier 1

SELZENTRY ORAL TABLET

Tier 2

stavudine oral capsule Tier 1

stavudine oral recon soln Tier 1

SUSTIVA ORAL CAPSULE

Tier 2

SUSTIVA ORAL TABLET Tier 2

TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG

Tier 2 QL

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION

Tier 2 QL

TRUVADA ORAL TABLET

Tier 2

TYZEKA ORAL TABLET Tier 4 PA

valacyclovir oral tablet Tier 1

VEREGEN TOPICAL OINTMENT

Tier 3

VIRACEPT ORAL TABLET

Tier 2

VIREAD ORAL TABLET Tier 2

zidovudine oral capsule Tier 1

zidovudine oral syrup Tier 1

zidovudine oral tablet Tier 1

ZIRGAN OPHTHALMIC GEL

Tier 3

AUTONOMIC DRUGS

amphetamine salt combo oral tablet

Tier 1 PA

bethanechol chloride oral tablet

Tier 2

cevimeline oral capsule Tier 2


dextroamphetamine oral capsule, extended release

Tier 1 PA

dextroamphetamine oral solution

Tier 1 PA

dextroamphetamine oral tablet

Tier 1 PA

dextroamphetamine-amphetamine oral capsule,extended release 24hr

Tier 1 PA

epinephrine injection auto-injector

Tier 2

EPIPEN 2-PAK INJECTION AUTO-INJECTOR

Tier 2

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR

Tier 2

galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg

Tier 2 QL

galantamine oral capsule,ext rel. pellets 24 hr 8 mg

Tier 2 DO

galantamine oral solution Tier 2 QL

galantamine oral tablet 12 mg, 4 mg

Tier 2 DO

galantamine oral tablet 8 mg

Tier 2 QL

guanidine oral tablet Tier 1

midodrine oral tablet Tier 1

phenoxybenzamine oral capsule

Tier 2

procentra oral solution Tier 1 PA

pyridostigmine bromide oral tablet

Tier 1

rivastigmine tartrate oral capsule 1.5 mg, 3 mg

Tier 2 DO

rivastigmine tartrate oral capsule 4.5 mg, 6 mg

Tier 2 QL

zenzedi oral tablet Tier 1 PA

BIOLOGICALS

ACTHIB (PF) INTRAMUSCULAR RECON SOLN

Tier 3 $0

Revised 4/1/2016

21


ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

AFLURIA 2015-2016 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

AFLURIA 2015-2016 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION

Tier 3 $0

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

Tier 3 $0

CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE

Tier 2 $0

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

EZ FLU 2015-16 (FLUVIRIN) (PF) INTRAMUSCULAR SYRINGE KIT

Tier 1 QL

EZ FLU 2015-16(FLUCELVAX)(PF) INTRAMUSCULAR SYRINGE KIT

Tier 1 $0; QL

FLUARIX QUAD 2015-2016 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL


FLUBLOK 2015-2016 (PF) INTRAMUSCULAR SOLUTION

Tier 1 $0; QL

FLUCELVAX 2015-2016 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLULAVAL QUAD 2015-2016 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

FLUMIST QUAD 2015-2016 NASAL NASAL SPRAY SYRINGE

Tier 1 $0; QL

FLUVIRIN 2015-2016 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLUVIRIN 2015-2016 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

FLUZONE 2015-2016 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

FLUZONE HIGH-DOSE 2015-16 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLUZONE INTRADERM QUAD 2015-16 INTRADERMAL SYRINGE

Tier 1 $0; QL

FLUZONE QUAD 2015-2016 (PF) INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

FLUZONE QUAD 2015-2016 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLUZONE QUAD 2015-2016 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

FLUZONE QUAD PEDI 2015-16 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

GAMASTAN S/D INTRAMUSCULAR SOLUTION

Tier 3

Revised 4/1/2016

22


GARDASIL (PF) INTRAMUSCULAR SUSPENSION

Tier 2 $0

GARDASIL (PF) INTRAMUSCULAR SYRINGE

Tier 2 $0

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION

Tier 2 $0

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

Tier 2 $0

HAVRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

HAVRIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN

Tier 3

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

IPOL INJECTION SUSPENSION

Tier 3 $0

IXIARO (PF) INTRAMUSCULAR SYRINGE

Tier 3

KINRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

KINRIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

MENACTRA (PF) INTRAMUSCULAR SOLUTION

Tier 3 $0

MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN

Tier 3 $0

MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN

Tier 3 $0


MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN

Tier 3 $0

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

Tier 3 $0

M-M-R II (PF) SUBCUTANEOUS RECON SOLN

Tier 3 $0

OCTAGAM INTRAVENOUS SOLUTION

Tier 3

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION

Tier 3 $0

PENTACEL (PF) INTRAMUSCULAR KIT

Tier 3 $0

PNEUMOVAX 23 INJECTION SOLUTION

Tier 2 $0

PNEUMOVAX 23 INJECTION SYRINGE

Tier 2 $0

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE

Tier 2 $0

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 $0

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 3

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION

Tier 3 $0

ROTATEQ VACCINE ORAL SUSPENSION

Tier 3 $0

TENIVAC (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

Revised 4/1/2016

23


TENIVAC (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION

Tier 3 $0

TRUMENBA INTRAMUSCULAR SYRINGE

Tier 2 $0

TWINRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

TWINRIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

TYPHIM VI INTRAMUSCULAR SOLUTION

Tier 3

TYPHIM VI INTRAMUSCULAR SYRINGE

Tier 3

VAQTA (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

VAQTA (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 $0

VIVOTIF BERNA VACCINE ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 2

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 2 $0

BLOOD

DROXIA ORAL CAPSULE

Tier 4


pentoxifylline oral tablet extended release

Tier 1

tranexamic acid intravenous solution

Tier 2

tranexamic acid oral tablet Tier 1

CARDIAC DRUGS

afeditab cr oral tablet extended release 30 mg

Tier 1 DO

afeditab cr oral tablet extended release 60 mg

Tier 1 QL

amlodipine oral tablet 10 mg

Tier 1 QL

amlodipine oral tablet 2.5 mg, 5 mg

Tier 1 DO

cartia xt oral capsule,extended release 24hr 120 mg, 180 mg

Tier 1 DO

cartia xt oral capsule,extended release 24hr 240 mg, 300 mg

Tier 1 QL

digox oral tablet Tier 1

digoxin oral solution Tier 1

digoxin oral tablet Tier 1

diltiazem hcl oral capsule, extended release 120 mg, 180 mg

Tier 1 DO

diltiazem hcl oral capsule, extended release 240 mg, 300 mg, 360 mg, 420 mg

Tier 1 QL

diltiazem hcl oral capsule,ext release degradable 120 mg, 180 mg

Tier 1 DO

diltiazem hcl oral capsule,ext release degradable 240 mg

Tier 1 QL

diltiazem hcl oral capsule,extended release 12 hr 120 mg, 90 mg

Tier 1 QL

diltiazem hcl oral capsule,extended release 12 hr 60 mg

Tier 1 DO; QL

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg

Tier 1 DO

diltiazem hcl oral capsule,extended release 24hr 240 mg, 300 mg, 360 mg

Tier 1 QL

Revised 4/1/2016

24


diltiazem hcl oral tablet Tier 1 QL

diltiazem hcl oral tablet extended release 24 hr 180 mg

Tier 1 DO

diltiazem hcl oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg

Tier 1 QL

dilt-xr oral capsule,ext release degradable 120 mg, 180 mg

Tier 1 DO

dilt-xr oral capsule,ext release degradable 240 mg

Tier 1 QL

disopyramide phosphate oral capsule

Tier 1

felodipine oral tablet extended release 24 hr 10 mg

Tier 1 QL

felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg

Tier 1 DO

flecainide oral tablet Tier 2

isosorbide dinitrate oral tablet

Tier 1

isosorbide dinitrate oral tablet extended release

Tier 1

isosorbide mononitrate oral tablet

Tier 1

isosorbide mononitrate oral tablet extended release 24 hr

Tier 1

LANOXIN ORAL TABLET Tier 3

matzim la oral tablet extended release 24 hr 180 mg

Tier 1 DO

matzim la oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg

Tier 1 QL

mexiletine oral capsule Tier 2

MULTAQ ORAL TABLET Tier 3

nifedical xl oral tablet extended release 24hr 30 mg

Tier 1 DO

nifedical xl oral tablet extended release 24hr 60 mg

Tier 1 QL

nifedipine oral capsule Tier 1 QL


nifedipine oral tablet extended release 24hr 30 mg

Tier 1 DO

nifedipine oral tablet extended release 24hr 60 mg, 90 mg

Tier 1 QL

nifedipine oral tablet extended release 30 mg

Tier 1 DO

nifedipine oral tablet extended release 60 mg, 90 mg

Tier 1 QL

nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 8.5 mg

Tier 1 DO

nisoldipine oral tablet extended release 24 hr 25.5 mg, 30 mg, 34 mg, 40 mg

Tier 1 QL

nitro-bid transdermal ointment

Tier 1

nitroglycerin oral capsule, extended release

Tier 1

nitroglycerin translingual aerosol,spray

Tier 2

nitroglycerin translingual spray,non-aerosol

Tier 2

NITROSTAT SUBLINGUAL TABLET

Tier 2

nitro-time oral capsule, extended release

Tier 1

procainamide injection solution

Tier 2

propafenone oral capsule,extended release 12 hr

Tier 2

propafenone oral tablet Tier 2

quinidine sulfate oral tablet Tier 1

quinidine sulfate oral tablet extended release

Tier 1

taztia xt oral capsule, extended release 120 mg, 180 mg

Tier 1 DO

taztia xt oral capsule, extended release 240 mg, 300 mg, 360 mg

Tier 1 QL

TIKOSYN ORAL CAPSULE

Tier 3

verapamil oral capsule, 24 hr er pellet ct 100 mg

Tier 1 DO

Revised 4/1/2016

25


verapamil oral capsule, 24 hr er pellet ct 200 mg, 300 mg

Tier 1 QL

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg

Tier 1

verapamil oral capsule,ext rel. pellets 24 hr 240 mg, 360 mg

Tier 1 QL

verapamil oral tablet 120 mg, 40 mg, 80 mg

Tier 1 QL

verapamil oral tablet extended release

Tier 1 QL

CARDIOVASCULAR

acebutolol oral capsule Tier 1

ADCIRCA ORAL TABLET

Tier 3 PA

amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-80 mg

Tier 1 QL

amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg

Tier 1 DO

amlodipine-benazepril oral capsule

Tier 1

amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-320 mg

Tier 1 QL

amlodipine-valsartan oral tablet 5-160 mg

Tier 1 DO

amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-25 mg

Tier 1 QL

amlodipine-valsartan-hcthiazid oral tablet 5-160-12.5 mg

Tier 1 DO

atenolol oral tablet Tier 1

atenolol-chlorthalidone oral tablet

Tier 1

atorvastatin oral tablet 10 mg, 20 mg, 40 mg

Tier 1 DO

atorvastatin oral tablet 80 mg

Tier 1 QL

benazepril oral tablet Tier 1


benazepril-hydrochlorothiazide oral tablet

Tier 1

BENICAR HCT ORAL TABLET 20-12.5 MG

Tier 3 DO

BENICAR HCT ORAL TABLET 40-12.5 MG, 40-25 MG

Tier 3 QL

BENICAR ORAL TABLET20 MG

Tier 3 DO

BENICAR ORAL TABLET40 MG, 5 MG

Tier 3 QL

betaxolol oral tablet Tier 1

bisoprolol fumarate oral tablet

Tier 1

bisoprolol-hydrochlorothiazide oral tablet

Tier 1

candesartan-hydrochlorothiazid oral tablet 16-12.5 mg

Tier 1 DO; QL

candesartan-hydrochlorothiazid oral tablet 32-12.5 mg

Tier 1 QL

candesartan-hydrochlorothiazid oral tablet 32-25 mg

Tier 1

clonidine hcl oral tablet Tier 1

doxazosin oral tablet Tier 1

enalapril maleate oral tablet

Tier 1

enalapril-hydrochlorothiazide oral tablet

Tier 1

ergoloid oral tablet Tier 2

fenofibrate micronized oral capsule

Tier 1

fenofibrate nanocrystallized oral tablet

Tier 1

fenofibrate oral tablet Tier 1

fenofibric acid (choline) oral capsule,delayed release(dr/ec)

Tier 1

fenofibric acid oral tablet Tier 1

fosinopril oral tablet Tier 1

fosinopril-hydrochlorothiazide oral tablet

Tier 1

gemfibrozil oral tablet Tier 1

guanfacine oral tablet Tier 1

hydralazine oral tablet Tier 1

Revised 4/1/2016

26


irbesartan oral tablet 150 mg, 75 mg

Tier 1 DO

irbesartan oral tablet 300 mg

Tier 1 QL

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg

Tier 1 QL

LETAIRIS ORAL TABLET Tier 4 PA

lisinopril oral tablet Tier 1

lisinopril-hydrochlorothiazide oral tablet

Tier 1

losartan oral tablet 100 mg Tier 1 QL

losartan oral tablet 25 mg, 50 mg

Tier 1 DO; QL

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg

Tier 1 QL

losartan-hydrochlorothiazide oral tablet 50-12.5 mg

Tier 1 DO

lovastatin oral tablet 10 mg, 20 mg

Tier 1 DO

lovastatin oral tablet 40 mg

Tier 1 QL

methyldopa oral tablet Tier 1

methyldopa-hydrochlorothiazide oral tablet

Tier 1

metoprolol succinate oral tablet extended release 24 hr

Tier 1

metoprolol ta-hydrochlorothiaz oral tablet

Tier 1

metoprolol tartrate oral tablet

Tier 1

minoxidil oral tablet Tier 1

nadolol-bendroflumethiazide oral tablet

Tier 1

niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg

Tier 1 QL

pravastatin oral tablet 10 mg, 20 mg, 40 mg

Tier 1 DO

pravastatin oral tablet 80 mg

Tier 1 QL

prazosin oral capsule Tier 1

propranolol oral capsule,extended release 24 hr

Tier 1


propranolol oral solution Tier 1

propranolol oral tablet Tier 1

propranolol-hydrochlorothiazid oral tablet

Tier 1

quinapril oral tablet Tier 1

quinapril-hydrochlorothiazide oral tablet

Tier 1

ramipril oral capsule Tier 1

REMODULIN INJECTION SOLUTION

Tier 4 PA

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

Tier 1 DO

simvastatin oral tablet 80 mg

Tier 1 PA; QL

sorine oral tablet Tier 2

sotalol af oral tablet Tier 2

sotalol oral tablet Tier 2

terazosin oral capsule Tier 1

timolol maleate oral tablet Tier 1

trandolapril oral tablet Tier 1

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr

Tier 1

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

Tier 1 QL

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg

Tier 1 DO

valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg

Tier 1 QL

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION

Tier 4 PA

WELCHOL ORAL POWDER IN PACKET

Tier 3

WELCHOL ORAL TABLET

Tier 3

CNS DRUGS

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT

Tier 3

AVONEX INTRAMUSCULAR PEN INJECTOR

Tier 3

Revised 4/1/2016

27


AVONEX INTRAMUSCULAR PEN INJECTOR KIT

Tier 3

AVONEX INTRAMUSCULAR SYRINGE

Tier 3

AVONEX INTRAMUSCULAR SYRINGE KIT

Tier 3

carbamazepine oral capsule, er multiphase 12 hr

Tier 1

carbamazepine oral suspension

Tier 1

carbamazepine oral tablet Tier 1

carbamazepine oral tablet extended release 12 hr

Tier 1

carbamazepine oral tablet,chewable

Tier 1

clonazepam oral tablet Tier 1

clonazepam oral tablet,disintegrating

Tier 1

divalproex oral capsule, sprinkle

Tier 1

divalproex oral tablet extended release 24 hr

Tier 1

divalproex oral tablet,delayed release (dr/ec)

Tier 1

epitol oral tablet Tier 1

ethosuximide oral capsule Tier 1

ethosuximide oral solution Tier 1

EXTAVIA SUBCUTANEOUS KIT

Tier 4 PA

EXTAVIA SUBCUTANEOUS RECON SOLN

Tier 4 PA

felbamate oral suspension Tier 1

felbamate oral tablet Tier 1

fosphenytoin injection solution

Tier 2

gabapentin oral capsule Tier 2

gabapentin oral solution Tier 2

gabapentin oral tablet Tier 2

GILENYA ORAL CAPSULE

Tier 4 PA; QL

lamotrigine oral tablet Tier 1


lamotrigine oral tablet, chewable dispersible

Tier 1

levetiracetam oral solution Tier 2

levetiracetam oral tablet Tier 2

levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg

Tier 2 PA; QL

memantine oral solution Tier 2

memantine oral tablet Tier 2

memantine oral tablets,dose pack

Tier 2

NUEDEXTA ORAL CAPSULE

Tier 3

oxcarbazepine oral suspension

Tier 1

oxcarbazepine oral tablet Tier 1

PEGANONE ORAL TABLET

Tier 3

phenytoin sodium extended oral capsule

Tier 1

primidone oral tablet Tier 1

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

Tier 3 PA

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR

Tier 3 PA

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

Tier 3 PA

tiagabine oral tablet Tier 2

topiramate oral capsule, sprinkle

Tier 1

topiramate oral tablet Tier 1

valproic acid (as sodium salt) oral solution

Tier 1

valproic acid oral capsule Tier 1

zonisamide oral capsule Tier 2

COLONY STIMULATING FACTORS

ARANESP (IN POLYSORBATE) INJECTION SOLUTION

Tier 4 PA

ARANESP (IN POLYSORBATE) INJECTION SYRINGE

Tier 4 PA

Revised 4/1/2016

28


MOZOBIL SUBCUTANEOUS SOLUTION

Tier 4 PA

NEULASTA SUBCUTANEOUS SYRINGE

Tier 4 PA; QL

PROMACTA ORAL TABLET

Tier 4 PA

CONTRACEPTIVES

altavera (28) oral tablet Tier 1 $0

alyacen 1/35 (28) oral tablet

Tier 1 $0

alyacen 7/7/7 (28) oral tablet

Tier 1 $0

amethia lo oral tablets,dose pack,3 month

Tier 1 $0

amethia oral tablets,dose pack,3 month

Tier 1 $0

amethyst oral tablet Tier 1 $0

apri oral tablet Tier 1 $0

aranelle (28) oral tablet Tier 1 $0

ashlyna oral tablets,dose pack,3 month

Tier 1 $0

aubra oral tablet Tier 1 $0

aviane oral tablet Tier 1 $0

azurette (28) oral tablet Tier 1 $0

balziva (28) oral tablet Tier 1 $0

BEKYREE (28) ORAL TABLET

Tier 1 $0

BEYAZ ORAL TABLET Tier 3 $0

BLISOVI 24 FE ORAL TABLET

Tier 1 $0

BLISOVI FE 1.5/30 (28) ORAL TABLET

Tier 1 $0

BLISOVI FE 1/20 (28) ORAL TABLET

Tier 1 $0

briellyn oral tablet Tier 1 $0

camila oral tablet Tier 1 $0

camrese lo oral tablets,dose pack,3 month

Tier 1 $0

camrese oral tablets,dose pack,3 month

Tier 1 $0

caziant (28) oral tablet Tier 1 $0

chateal oral tablet Tier 1 $0

cryselle (28) oral tablet Tier 1 $0


cyclafem 1/35 (28) oral tablet

Tier 1 $0

cyclafem 7/7/7 (28) oral tablet

Tier 1 $0

cyred oral tablet Tier 1 $0

dasetta 1/35 (28) oral tablet

Tier 1 $0

dasetta 7/7/7 (28) oral tablet

Tier 1 $0

daysee oral tablets,dose pack,3 month

Tier 1 $0

deblitane oral tablet Tier 1 $0

delyla (28) oral tablet Tier 1 $0

desog-e.estradiol/e.estradiol oral tablet

Tier 1 $0

desogestrel-ethinyl estradiol oral tablet

Tier 1 $0

drospirenone-ethinyl estradiol oral tablet

Tier 1 $0

elinest oral tablet Tier 1 $0

ELLA ORAL TABLET Tier 3 $0

emoquette oral tablet Tier 1 $0

enpresse oral tablet Tier 1 $0

enskyce oral tablet Tier 1 $0

errin oral tablet Tier 1 $0

estarylla oral tablet Tier 1 $0

falmina (28) oral tablet Tier 1 $0

gianvi (28) oral tablet Tier 1 $0

gildagia oral tablet Tier 1 $0

gildess 1.5/30 (21) oral tablet

Tier 1 $0

gildess 1/20 (21) oral tablet

Tier 1 $0

gildess 24 fe oral tablet Tier 1 $0

gildess fe 1.5/30 (28) oral tablet

Tier 1 $0

gildess fe 1/20 (28) oral tablet

Tier 1 $0

heather oral tablet Tier 1 $0

introvale oral tablets,dose pack,3 month

Tier 1 $0

jencycla oral tablet Tier 1 $0

jolessa oral tablets,dose pack,3 month

Tier 1 $0

jolivette oral tablet Tier 1 $0

Revised 4/1/2016

29


JULEBER ORAL TABLET

Tier 1 $0

junel 1.5/30 (21) oral tablet Tier 1 $0

junel 1/20 (21) oral tablet Tier 1 $0

junel fe 1.5/30 (28) oral tablet

Tier 1 $0

junel fe 1/20 (28) oral tablet

Tier 1 $0

junel fe 24 oral tablet Tier 1 $0

kariva (28) oral tablet Tier 1 $0

kelnor 1/35 (28) oral tablet Tier 1 $0

kurvelo oral tablet Tier 1 $0

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month

Tier 1 $0

larin 1.5/30 (21) oral tablet Tier 1 $0

larin 1/20 (21) oral tablet Tier 1 $0

larin fe 1.5/30 (28) oral tablet

Tier 1 $0

larin fe 1/20 (28) oral tablet

Tier 1 $0

layolis fe oral tablet,chewable

Tier 1 $0

leena 28 oral tablet Tier 1 $0

lessina oral tablet Tier 1 $0

levonest (28) oral tablet Tier 1 $0

levonorgestrel-ethinyl estrad oral tablet

Tier 1 $0

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month

Tier 1 $0

levora-28 oral tablet Tier 1 $0

LO LOESTRIN FE ORAL TABLET

Tier 3 $0

lomedia 24 fe oral tablet Tier 1 $0

loryna (28) oral tablet Tier 1 $0

low-ogestrel (28) oral tablet

Tier 1 $0

lutera (28) oral tablet Tier 1 $0

lyza oral tablet Tier 1 $0

marlissa oral tablet Tier 1 $0

medroxyprogesterone intramuscular suspension

Tier 1 $0

medroxyprogesterone intramuscular syringe

Tier 1 $0


microgestin 1.5/30 (21) oral tablet

Tier 1 $0

microgestin 1/20 (21) oral tablet

Tier 1 $0

microgestin fe 1.5/30 (28) oral tablet

Tier 1 $0

microgestin fe 1/20 (28) oral tablet

Tier 1 $0

MINASTRIN 24 FE ORAL TABLET,CHEWABLE

Tier 3 $0

mono-linyah oral tablet Tier 1 $0

mononessa (28) oral tablet Tier 1 $0

my way oral tablet 1.5 mg Tier 1 $0; QL

myzilra oral tablet Tier 1 $0

NATAZIA ORAL TABLET Tier 3 $0

necon 0.5/35 (28) oral tablet

Tier 1 $0

necon 1/35 (28) oral tablet Tier 1 $0

necon 1/50 (28) oral tablet Tier 1 $0

necon 10/11 (28) oral tablet

Tier 1 $0

necon 7/7/7 (28) oral tablet

Tier 1 $0

next choice one dose oral tablet

Tier 1 $0; QL

nikki (28) oral tablet Tier 1 $0

nora-be oral tablet Tier 1 $0

noreth-ethinyl estradiol-iron oral tablet,chewable

Tier 1 $0

norethindrone (contraceptive) oral tablet

Tier 1 $0

norethindrone ac-eth estradiol oral tablet

Tier 1 $0

norethindrone-e.estradiol-iron oral tablet

Tier 1 $0

norgestimate-ethinyl estradiol oral tablet

Tier 1 $0

norlyroc oral tablet Tier 1 $0

nortrel 0.5/35 (28) oral tablet

Tier 1 $0

nortrel 1/35 (21) oral tablet Tier 1 $0

nortrel 1/35 (28) oral tablet Tier 1 $0

nortrel 7/7/7 (28) oral tablet

Tier 1 $0

Revised 4/1/2016

30


NUVARING VAGINAL RING

Tier 3 $0

ocella oral tablet Tier 1 $0

ogestrel (28) oral tablet Tier 1 $0

orsythia oral tablet Tier 1 $0

philith oral tablet Tier 1 $0

pimtrea (28) oral tablet Tier 1 $0

pirmella oral tablet Tier 1 $0

portia oral tablet Tier 1 $0

previfem oral tablet Tier 1 $0

QUARTETTE ORAL TABLETS,DOSE PACK,3 MONTH

Tier 3 $0

quasense oral tablets,dose pack,3 month

Tier 1 $0

reclipsen (28) oral tablet Tier 1 $0

SAFYRAL ORAL TABLET

Tier 3 $0

setlakin oral tablets,dose pack,3 month

Tier 1 $0

sharobel oral tablet Tier 1 $0

sprintec (28) oral tablet Tier 1 $0

sronyx oral tablet Tier 1 $0

syeda oral tablet Tier 1 $0

tarina fe 1/20 (28) oral tablet

Tier 1 $0

tilia fe oral tablet Tier 1 $0

tri-estarylla oral tablet Tier 1 $0

tri-legest fe oral tablet Tier 1 $0

tri-linyah oral tablet Tier 1 $0

TRI-LO-ESTARYLLA ORAL TABLET

Tier 1 $0

TRI-LO-SPRINTEC ORAL TABLET

Tier 1 $0

trinessa (28) oral tablet Tier 1 $0

TRINESSA LO ORAL TABLET

Tier 1 $0

tri-previfem (28) oral tablet Tier 1 $0

tri-sprintec (28) oral tablet Tier 1 $0

trivora (28) oral tablet Tier 1 $0

velivet triphasic regimen (28) oral tablet

Tier 1 $0

vestura (28) oral tablet Tier 1 $0

viorele (28) oral tablet Tier 1 $0


vyfemla (28) oral tablet Tier 1 $0

wera (28) oral tablet Tier 1 $0

wymzya fe oral tablet,chewable

Tier 1 $0

xulane transdermal patch weekly

Tier 1 $0

zarah oral tablet Tier 1 $0

zenchent (28) oral tablet Tier 1 $0

zenchent fe oral tablet,chewable

Tier 1 $0

zovia 1/35e (28) oral tablet Tier 1 $0

zovia 1/50e (28) oral tablet Tier 1 $0

COUGH/COLD PREPARATIONS

benzonatate oral capsule Tier 1

cheratussin ac oral liquid Tier 1

guaifenesin ac oral liquid Tier 1

iophen c-nr oral liquid Tier 1

promethazine vc-codeine oral syrup

Tier 1

promethazine-codeine oral syrup

Tier 1

promethazine-dm oral syrup

Tier 1

promethazine-phenyleph-codeine oral syrup

Tier 1

DIAGNOSTIC

ACCU-CHEK AVIVA PLUS TEST STRP STRIP

Tier 2 QL

ACCU-CHEK AVIVA STRIP

Tier 2 QL

ACCU-CHEK COMPACT PLUS TEST STRIP

Tier 2 QL

ACCU-CHEK COMPACT TEST STRIP

Tier 2 QL

ACCU-CHEK SMARTVIEW TEST STRIP STRIP

Tier 2 QL

ACCUTREND GLUCOSE STRIP

Tier 2 QL

dipyridamole intravenous solution

Tier 2

GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN

Tier 2

Revised 4/1/2016

31


ONETOUCH ULTRA TEST STRIP

Tier 2 QL

ONETOUCH VERIO STRIP

Tier 2 QL

DIURETICS

acetazolamide oral capsule, extended release

Tier 1

acetazolamide oral tablet Tier 1

AMMONIUM CHLORIDE INTRAVENOUS SOLUTION

Tier 3

chlorthalidone oral tablet Tier 1

EDECRIN ORAL TABLET Tier 3

furosemide oral solution Tier 1

furosemide oral tablet Tier 1

hydrochlorothiazide oral capsule

Tier 1

hydrochlorothiazide oral tablet

Tier 1

indapamide oral tablet Tier 1

methazolamide oral tablet Tier 1

methyclothiazide oral tablet

Tier 1

spironolactone oral tablet Tier 1

torsemide oral tablet Tier 1

triamterene-hydrochlorothiazid oral capsule

Tier 1

triamterene-hydrochlorothiazid oral tablet

Tier 1

EENT PREPS

acetasol hc otic drops Tier 1

acetic acid otic solution Tier 1

acetic acid-aluminum acetate otic drops

Tier 1

ALOCRIL OPHTHALMIC DROPS

Tier 3 PA; QL

ALOMIDE OPHTHALMIC DROPS

Tier 3 PA; QL

apraclonidine ophthalmic drops

Tier 1

azelastine nasal aerosol,spray

Tier 1 QL

betaxolol ophthalmic drops Tier 1

bimatoprost ophthalmic drops

Tier 2


brimonidine ophthalmic drops

Tier 1

carteolol ophthalmic drops Tier 1

cromolyn ophthalmic drops

Tier 1 QL

CYSTARAN OPHTHALMIC DROPS

Tier 3

dexamethasone sodium phosphate ophthalmic drops

Tier 1

diclofenac sodium ophthalmic drops

Tier 1

dorzolamide ophthalmic drops

Tier 1

dorzolamide-timolol ophthalmic drops

Tier 1

fluocinolone acetonide oil otic drops

Tier 1

fluorometholone ophthalmic drops,suspension

Tier 1

fluticasone nasal spray,suspension

Tier 1 QL

hydrocortisone-acetic acid otic drops

Tier 1

ketorolac ophthalmic drops

Tier 1

LACRISERT OPHTHALMIC INSERT

Tier 3

latanoprost ophthalmic drops

Tier 1

LOTEMAX OPHTHALMIC DROPS,GEL

Tier 3

LOTEMAX OPHTHALMIC DROPS,SUSPENSION

Tier 3

LOTEMAX OPHTHALMIC OINTMENT

Tier 3

LUMIGAN OPHTHALMIC DROPS

Tier 3

metipranolol ophthalmic drops

Tier 1

naphazoline ophthalmic drops

Tier 1

PHOSPHOLINE IODIDE OPHTHALMIC DROPS

Tier 3

prednisolone acetate ophthalmic drops,suspension

Tier 1

Revised 4/1/2016

32


prednisolone sodium phosphate ophthalmic drops

Tier 1

RESTASIS OPHTHALMIC DROPPERETTE

Tier 3

timolol maleate ophthalmic drops

Tier 1

timolol maleate ophthalmic gel forming solution

Tier 1

TRAVATAN Z OPHTHALMIC DROPS

Tier 3

triamcinolone acetonide nasal aerosol,spray

Tier 1 QL

TYZINE NASAL DROPS Tier 3

TYZINE NASAL SPRAY,NON-AEROSOL

Tier 3

ELECT/CALORIC/H2O

calcium acetate oral tablet Tier 2

cytra k crystals oral packet Tier 1

cytra-k oral solution Tier 1

denta 5000 plus dental cream

Tier 1

dentagel dental gel Tier 1

EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ

Tier 3

effer-k oral tablet, effervescent 25 meq

Tier 1

eliphos oral tablet Tier 2 PA

fe c plus oral tablet Tier 1

fluoridex daily defense dental gel

Tier 1

FLUORIDEX SENSITIVITY RELIEF DENTAL GEL

Tier 3

fluoritab oral tablet,chewable

Tier 1

GLUCAGEN HYPOKIT INJECTION RECON SOLN

Tier 2

k-effervescent oral tablet, effervescent

Tier 1

kionex oral powder Tier 1

kionex oral suspension Tier 1


klor-con 10 oral tablet extended release

Tier 1

klor-con 8 oral tablet extended release

Tier 1

klor-con m10 oral tablet,er particles/crystals

Tier 1


Tier 1


Tier 1

klor-con/ef oral tablet, effervescent

Tier 1

ludent fluoride oral tablet,chewable

Tier 1

magnesium sulfate injection syringe

Tier 2

NUTRAMINE ORAL POWDER

Tier 3

potassium bicarb-citric acid oral tablet, effervescent

Tier 1

potassium chloride oral capsule, extended release

Tier 1

potassium chloride oral tablet extended release

Tier 1

potassium chloride oral tablet,er particles/crystals

Tier 1

potassium citrate oral tablet extended release

Tier 1

potassium citrate-citric acid oral solution

Tier 1

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE

Tier 3

RENVELA ORAL POWDER IN PACKET

Tier 3

RENVELA ORAL TABLET

Tier 3

sf 5000 plus dental cream Tier 1

sodium chloride 0.45 % intravenous parenteral solution

Tier 2

sodium chloride 0.45 % intravenous piggyback

Tier 2

sodium chloride 0.9 % intravenous parenteral solution

Tier 2

Revised 4/1/2016

33


sodium chloride 0.9 % intravenous piggyback

Tier 2

sodium chloride 3 % intravenous parenteral solution

Tier 2

sodium chloride 5 % intravenous parenteral solution

Tier 2

sodium chloride intravenous parenteral solution

Tier 2

sodium fluoride dental solution

Tier 1

sodium fluoride oral drops Tier 1

sodium fluoride oral tablet,chewable

Tier 1

sodium polystyrene (sorb free) oral suspension

Tier 1

sodium polystyrene sulfonate oral powder

Tier 1

sodium polystyrene sulfonate oral suspension

Tier 1

sodium polystyrene sulfonate rectal enema

Tier 1

sps oral suspension Tier 1

sps rectal enema Tier 1

GASTROINTESTINAL

ALOXI INTRAVENOUS SOLUTION

Tier 3

AMITIZA ORAL CAPSULE

Tier 3

anaspaz oral tablet,disintegrating

Tier 2

anucort-hc rectal suppository

Tier 1

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3

balsalazide oral capsule Tier 1

BUPHENYL ORAL TABLET

Tier 3 PA

CANTIL ORAL TABLET Tier 3

carafate oral suspension Tier 1

CESAMET ORAL CAPSULE

Tier 3 ST

cimetidine hcl oral solution Tier 1

cimetidine oral tablet Tier 1


CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT

Tier 4 PA; QL

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT

Tier 4 PA; QL

CIMZIA SUBCUTANEOUS SYRINGE KIT

Tier 4 PA; QL

COMPAZINE ORAL TABLET

Tier 1

constulose oral solution Tier 1

dicyclomine oral capsule Tier 1

dicyclomine oral solution Tier 1

dicyclomine oral tablet Tier 1

diphenoxylate-atropine oral liquid

Tier 1

diphenoxylate-atropine oral tablet

Tier 1

enulose oral solution Tier 1

famotidine oral suspension Tier 1

famotidine oral tablet Tier 1

gavilyte-c oral recon soln Tier 1

gavilyte-g oral recon soln Tier 1

gavilyte-n oral recon soln Tier 1

generlac oral solution Tier 1

glycopyrrolate oral tablet Tier 1

hydrocortisone acetate rectal suppository

Tier 1

hydrocortisone-pramox-e-pram#1 rectal kit,cream and towelette

Tier 1

hydrocortisone-pramoxine rectal cream

Tier 1

lactulose oral solution Tier 1

lansoprazole oral capsule,delayed release(dr/ec)

Tier 1 QL

lidocaine hcl-hydrocortison ac rectal cream

Tier 1

lidocaine hcl-hydrocortison ac rectal kit

Tier 1

lidocaine-hydrocortisone-aloe rectal gel

Tier 1

lidocaine-hydrocortisone-aloe rectal kit

Tier 1

Revised 4/1/2016

34


LOVAZA ORAL CAPSULE

Tier 3 QL

meclizine oral tablet Tier 1

methscopolamine oral tablet

Tier 1

metoclopramide hcl oral solution

Tier 1

metoclopramide hcl oral tablet

Tier 1

misoprostol oral tablet Tier 1

MOTOFEN ORAL TABLET

Tier 3

MOVIPREP ORAL POWDER IN PACKET

Tier 3

omega-3 acid ethyl esters oral capsule

Tier 1 QL

omeprazole oral capsule,delayed release(dr/ec)

Tier 1 QL

ondansetron hcl oral solution

Tier 2 QL

ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg

Tier 2 QL

ondansetron oral tablet,disintegrating 4 mg, 8 mg

Tier 2 QL

OSMOPREP ORAL TABLET

Tier 3

peg 3350-electrolytes oral recon soln

Tier 1

peg-3350 with flavor packs oral recon soln

Tier 1

phenadoz rectal suppository

Tier 1

pramcort rectal cream Tier 1

prochlorperazine maleate oral tablet

Tier 1

proctosol hc rectal cream Tier 1

proctozone-hc rectal cream

Tier 1

promethazine rectal suppository

Tier 1

promethegan rectal suppository

Tier 1

ranitidine hcl oral capsule Tier 1

ranitidine hcl oral syrup Tier 1

ranitidine hcl oral tablet Tier 1


REMICADE INTRAVENOUS RECON SOLN

Tier 4 PA

sucralfate oral tablet Tier 1

sulfasalazine oral tablet Tier 1

sulfasalazine oral tablet,delayed release (dr/ec)

Tier 1

sulfazine ec oral tablet,delayed release (dr/ec)

Tier 1

sulfazine oral tablet Tier 1

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY

Tier 3

trilyte with flavor packets oral recon soln

Tier 1

trimethobenzamide oral capsule

Tier 1

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 2

HORMONES

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP

Tier 3 PA; QL

ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

Tier 3 PA; QL

androxy oral tablet Tier 1

budesonide oral capsule,delayed,extend.release

Tier 2

cabergoline oral tablet Tier 1

calcitonin (salmon) nasal spray,non-aerosol

Tier 2 QL

chorionic gonadotropin, human intramuscular recon soln

Tier 4

covaryx h.s. oral tablet Tier 1

covaryx oral tablet Tier 1

danazol oral capsule Tier 2

desmopressin injection solution

Tier 1

desmopressin nasal aerosol,spray

Tier 1

Revised 4/1/2016

35


desmopressin nasal solution

Tier 1

desmopressin nasal spray,non-aerosol

Tier 1

desmopressin oral tablet Tier 1

dexamethasone intensol oral drops

Tier 1

dexamethasone oral elixir Tier 1

dexamethasone oral solution

Tier 1

dexamethasone oral tablet Tier 1

eemt hs oral tablet Tier 1

eemt oral tablet Tier 1

estradiol oral tablet Tier 1

estradiol transdermal patch semiweekly

Tier 1 QL

estradiol transdermal patch weekly

Tier 1 QL

estradiol-norethindrone acet oral tablet

Tier 1 $0

ESTRING VAGINAL RING

Tier 3

estrogens-methyltestosterone oral tablet

Tier 1

estropipate oral tablet Tier 1

fortical nasal spray,non-aerosol

Tier 2 QL

hydrocortisone oral tablet Tier 1

hydrocortisone rectal enema

Tier 1

jinteli oral tablet Tier 1

medroxyprogesterone oral tablet

Tier 1

METHITEST ORAL TABLET

Tier 3

methylergonovine oral tablet

Tier 1

methylprednisolone oral tablet

Tier 1

methylprednisolone oral tablets,dose pack

Tier 1

millipred dp oral tablets,dose pack

Tier 1

millipred oral tablet Tier 1

mimvey oral tablet Tier 1


norethindrone acetate oral tablet

Tier 1

OMNITROPE SUBCUTANEOUS CARTRIDGE

Tier 4 PA

OMNITROPE SUBCUTANEOUS RECON SOLN

Tier 4 PA

oxandrolone oral tablet Tier 2 PA

prednisolone oral solution Tier 1

prednisolone sodium phosphate oral solution

Tier 1

prednisone intensol oral concentrate

Tier 1

prednisone oral solution Tier 1

prednisone oral tablet Tier 1

prednisone oral tablets,dose pack

Tier 1

PREMARIN ORAL TABLET

Tier 3

PREMARIN VAGINAL CREAM

Tier 3

PREMPHASE ORAL TABLET

Tier 3

PREMPRO ORAL TABLET

Tier 3

progesterone micronized oral capsule

Tier 1

testosterone cypionate intramuscular oil

Tier 1

testosterone transdermal gel in metered-dose pump

Tier 2 PA; QL

testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)

Tier 2 PA; QL

VAGIFEM VAGINAL TABLET

Tier 3

veripred 20 oral solution Tier 1

IMMUNOSUPPRESANT

azathioprine oral tablet Tier 4

cyclosporine modified oral capsule

Tier 2

cyclosporine modified oral solution

Tier 2

cyclosporine oral capsule Tier 2

Revised 4/1/2016

36


ELIDEL TOPICAL CREAM

Tier 3 PA

gengraf oral capsule Tier 4

gengraf oral solution Tier 4

mycophenolate mofetil oral capsule

Tier 4

mycophenolate mofetil oral tablet

Tier 4

mycophenolate sodium oral tablet,delayed release (dr/ec)

Tier 4

RAPAMUNE ORAL SOLUTION

Tier 4

sirolimus oral tablet Tier 4

tacrolimus topical ointment Tier 1 PA

MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG

ACCU-CHEK AVIVA CONNECT METER

Tier 2

ACCU-CHEK AVIVA CONTROL SOLN SOLUTION

Tier 2

ACCU-CHEK AVIVA PLUS METER

Tier 2

ACCU-CHEK COMP BLUE CONT, M-H SOLUTION

Tier 2

ACCU-CHEK COMPACT PLUS CARE KIT

Tier 2

ACCU-CHEK COMPACT PLUS CONTROL SOLUTION

Tier 2

ACCU-CHEK FASTCLIX Tier 2

ACCU-CHEK FASTCLIX KIT

Tier 2

ACCU-CHEK MULTICLIX LANCET

Tier 2

ACCU-CHEK MULTICLIX LANCET KIT

Tier 2

ACCU-CHEK NANO Tier 2

ACCU-CHEK SAFE-T-PRO PLUS

Tier 2

ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION

Tier 2

ACCU-CHEK SOFT DEV LANCETS KIT

Tier 2


ACCU-CHEK SOFTCLIX LANCET DEV

Tier 2

ACCU-CHEK SOFTCLIX LANCETS

Tier 2

ACCU-CHEK VOICEMATE KIT

Tier 2

acti-lance lancets Tier 1

e-z ject lancets Tier 1

ONETOUCH DELICA LANC DEVICE KIT

Tier 2

ONETOUCH DELICA LANCETS

Tier 2

ONETOUCH SURESOFT LANCING DEV

Tier 2

ONETOUCH ULTRA CONTROL SOLUTION

Tier 2

ONETOUCH ULTRA2 KIT Tier 2

ONETOUCH ULTRAMINI KIT

Tier 2

ONETOUCH ULTRASOFT LANCETS

Tier 2

ONETOUCH VERIO HIGH CONTROL SOLUTION

Tier 2

ONETOUCH VERIO IQ METER

Tier 2

ONETOUCH VERIO SYNC KIT

Tier 2

ONETOUCH VERIO SYSTEM

Tier 2

MUSCLE RELAXANTS

baclofen oral tablet Tier 1

chlorzoxazone oral tablet Tier 1

cyclobenzaprine oral tablet Tier 1

dantrolene oral capsule Tier 2

tizanidine oral capsule Tier 1

tizanidine oral tablet Tier 1

PRE-NATAL VITAMINS

bal-care dha oral combo pack,tablet and cap,dr

Tier 1

c-nate dha oral capsule Tier 1

complete natal dha oral combo pack

Tier 1

completenate oral tablet,chewable

Tier 1

elite-ob 400 oral capsule Tier 1

elite-ob oral capsule Tier 1

Revised 4/1/2016

37


folbecal oral tablet, er multiphase 24 hr

Tier 1

folivane-ob oral capsule Tier 1

hemenatal ob + dha oral combo pack

Tier 1

hemenatal ob oral tablet Tier 1

inatal advance oral tablet Tier 1

inatal ultra oral tablet Tier 1

levomefolate dha oral capsule

Tier 1

macnatal cn dha oral capsule

Tier 1

mynatal advance oral tablet

Tier 1

mynatal oral capsule Tier 1

mynatal oral tablet Tier 1

mynatal plus oral tablet Tier 1

mynatal-z oral tablet Tier 1

mynate 90 plus oral tablet extended release

Tier 1

obstetrix dha oral combo pack,tablet and cap,dr

Tier 1

pnv ob+dha oral combo pack

Tier 1

pnv-dha + docusate oral capsule

Tier 1

pnv-dha oral capsule Tier 1

pnv-ferrous fumarate-docu-fa oral tablet

Tier 1

pnv-omega oral capsule Tier 1

pnv-select oral tablet Tier 1

pr natal 400 ec oral combo pack,tablet and cap,dr

Tier 1

pr natal 400 oral combo pack

Tier 1

pr natal 430 ec oral combo pack,tablet and cap,dr

Tier 1

pr natal 430 oral combo pack

Tier 1

prenaissance next oral tablet

Tier 1

prenaissance oral capsule Tier 1

prenaissance plus oral capsule

Tier 1

prenatabs fa oral tablet Tier 1


prenatabs rx oral tablet Tier 1

PRENATAL 19 (WITH DOCUSATE) ORAL TABLET

Tier 1

PRENATAL 19 ORAL TABLET,CHEWABLE

Tier 1

prenatal low iron oral tablet

Tier 1

prenatal plus (calcium carb) oral tablet

Tier 1

prenatal plus oral tablet Tier 1

prenatal-u oral capsule Tier 1

preplus oral tablet Tier 1

relnate dha oral capsule Tier 1

se-natal 19 (with docusate) oral tablet

Tier 1

se-natal 19 oral tablet,chewable

Tier 1

se-tan dha oral capsule Tier 1

taron-c dha oral capsule Tier 1

taron-prex prenatal-dha oral capsule

Tier 1

tl-select oral capsule Tier 1

triadvance oral tablet Tier 1

trinatal gt oral tablet Tier 1

trinatal rx 1 oral tablet Tier 1

trinate oral tablet Tier 1

tri-tabs dha oral combo pack

Tier 1

triveen-duo dha oral combo pack

Tier 1

triveen-one oral capsule Tier 1

triveen-prx rnf oral capsule Tier 1

trust natal dha oral combo pack

Tier 1

ultimatecare one nf oral capsule

Tier 1

ultimatecare one oral capsule

Tier 1

vemavite-prx-2 oral capsule

Tier 1

vena-bal dha oral combo pack,tablet and cap,dr

Tier 1

vinacal oral tablet Tier 1

vinate care oral tablet,chewable

Tier 1

Revised 4/1/2016

38


vinate dha oral capsule Tier 1

vinate gt oral tablet Tier 1

vinate ii oral tablet Tier 1

vinate m oral tablet Tier 1

vinate one oral tablet Tier 1

vinate pn care oral tablet Tier 1

vinate ultra oral tablet Tier 1

virt-pn dha oral capsule Tier 1

virt-pn oral tablet Tier 1

virt-pn plus oral capsule Tier 1

virt-select oral capsule Tier 1

vitafol-ob oral tablet Tier 1

vol-nate oral tablet Tier 1

vol-plus oral tablet Tier 1

vol-tab rx oral tablet Tier 1

vp-ch plus oral capsule Tier 1

vp-ch-pnv oral capsule Tier 1

vp-ggr-b6 oral tablet Tier 1

vp-heme ob + dha oral combo pack

Tier 1

vp-heme ob oral tablet Tier 1

vp-heme one oral capsule Tier 1

zatean-ch oral capsule Tier 1

zatean-pn dha oral capsule

Tier 1

zatean-pn plus oral capsule

Tier 1

zingiber oral tablet Tier 1

PSYCHOTHERAPEUTIC DRUGS

alprazolam oral tablet Tier 1

amitriptyline oral tablet Tier 1

amoxapine oral tablet Tier 1

aripiprazole oral solution Tier 2

aripiprazole oral tablet Tier 2

bupropion hcl oral tablet 100 mg

Tier 1 QL

bupropion hcl oral tablet 75 mg

Tier 1

bupropion hcl oral tablet extended release 100 mg

Tier 1 DO


Tier 1 $0; QL



Tier 1 QL

bupropion hcl oral tablet extended release 24 hr 150 mg

Tier 1 DO

bupropion hcl oral tablet extended release 24 hr 300 mg

Tier 1 QL

buspirone oral tablet Tier 1

chlorpromazine oral tablet Tier 1

citalopram oral solution Tier 1 QL

citalopram oral tablet 10 mg, 20 mg

Tier 1 DO

citalopram oral tablet 40 mg

Tier 1 QL

clomipramine oral capsule Tier 1

clozapine oral tablet Tier 2

clozapine oral tablet,disintegrating

Tier 2

desipramine oral tablet Tier 2

dexmethylphenidate oral capsule,er biphasic 50-50

Tier 1 PA

dexmethylphenidate oral tablet

Tier 1 PA

diazepam intensol oral concentrate

Tier 1

diazepam oral concentrate Tier 1

diazepam oral solution Tier 1

diazepam oral tablet Tier 1

doxepin oral capsule Tier 1

doxepin oral concentrate Tier 1

escitalopram oxalate oral solution

Tier 1 QL

escitalopram oxalate oral tablet 10 mg, 5 mg

Tier 1 DO

escitalopram oxalate oral tablet 20 mg

Tier 1 QL

fluoxetine oral capsule 10 mg, 20 mg

Tier 1 DO

fluoxetine oral capsule 40 mg

Tier 1 QL

fluoxetine oral capsule,delayed release(dr/ec)

Tier 1 QL

fluoxetine oral solution Tier 1 QL

fluoxetine oral tablet Tier 1 DO

Revised 4/1/2016

39


fluphenazine hcl oral concentrate

Tier 1

fluphenazine hcl oral elixir Tier 1

fluphenazine hcl oral tablet Tier 1

FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50

Tier 3 PA

haloperidol oral tablet Tier 1

imipramine hcl oral tablet Tier 1

lithium carbonate oral capsule

Tier 1

lithium carbonate oral tablet

Tier 1

lithium carbonate oral tablet extended release

Tier 1

lithium citrate oral solution Tier 1

loxapine succinate oral capsule

Tier 1

maprotiline oral tablet Tier 1

metadate er oral tablet extended release

Tier 1 PA

methylphenidate oral capsule, er biphasic 30-70

Tier 1 PA

methylphenidate oral capsule,er biphasic 50-50

Tier 1 PA

methylphenidate oral solution

Tier 1 PA

methylphenidate oral tablet

Tier 1 PA

methylphenidate oral tablet extended release

Tier 1 PA

methylphenidate oral tablet extended release 24hr

Tier 1 PA

mirtazapine oral tablet Tier 1

mirtazapine oral tablet,disintegrating

Tier 1

nefazodone oral tablet Tier 1

nortriptyline oral capsule Tier 1

nortriptyline oral solution Tier 1

olanzapine oral tablet Tier 2

olanzapine oral tablet,disintegrating

Tier 2

paliperidone oral tablet extended release 24hr

Tier 2


paroxetine hcl oral tablet 10 mg, 20 mg

Tier 1 DO

paroxetine hcl oral tablet 30 mg, 40 mg

Tier 1 QL

paroxetine hcl oral tablet extended release 24 hr 12.5 mg

Tier 1 DO

paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg

Tier 1 QL

perphenazine oral tablet Tier 1

phenelzine oral tablet Tier 1

pimozide oral tablet Tier 2

protriptyline oral tablet Tier 1

quetiapine oral tablet Tier 1

risperidone oral solution Tier 1

risperidone oral tablet Tier 1

risperidone oral tablet,disintegrating

Tier 1

sertraline oral concentrate Tier 1 QL

sertraline oral tablet 100 mg

Tier 1 QL

sertraline oral tablet 25 mg, 50 mg

Tier 1 DO

STRATTERA ORAL CAPSULE

Tier 3 PA

thioridazine oral tablet Tier 1

thiothixene oral capsule Tier 1

tranylcypromine oral tablet Tier 1

trazodone oral tablet Tier 1

trifluoperazine oral tablet Tier 1

venlafaxine oral capsule,extended release 24hr 150 mg

Tier 1 QL

venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg

Tier 1 DO

venlafaxine oral tablet Tier 1 QL

venlafaxine oral tablet extended release 24hr 150 mg, 225 mg

Tier 1 QL

venlafaxine oral tablet extended release 24hr 37.5 mg, 75 mg

Tier 1 DO

VYVANSE ORAL CAPSULE

Tier 3 PA

Revised 4/1/2016

40


ziprasidone hcl oral capsule

Tier 1

SEDATIVE/HYPNOTICS

phenobarbital oral elixir Tier 1

phenobarbital oral tablet Tier 1

SILENOR ORAL TABLET Tier 3 QL

zaleplon oral capsule Tier 1 QL

SKIN PREPS

acitretin oral capsule Tier 2

ACZONE TOPICAL GEL Tier 3

adapalene topical cream Tier 1

adapalene topical gel Tier 1

alclometasone topical cream

Tier 1

alclometasone topical ointment

Tier 1

ALTABAX TOPICAL OINTMENT

Tier 3

amcinonide topical cream Tier 1

amcinonide topical lotion Tier 1

amcinonide topical ointment

Tier 1

ammonium lactate topical cream

Tier 1

ammonium lactate topical lotion

Tier 1

amnesteem oral capsule Tier 1 PA

avita topical cream Tier 1 PA

benzoyl peroxide topical cleanser

Tier 1

benzoyl peroxide topical foam

Tier 1

betamethasone dipropionate topical cream

Tier 1

betamethasone dipropionate topical lotion

Tier 1

betamethasone dipropionate topical ointment

Tier 1

betamethasone valerate topical cream

Tier 1

betamethasone valerate topical foam

Tier 1

betamethasone valerate topical lotion

Tier 1


betamethasone valerate topical ointment

Tier 1

betamethasone, augmented topical cream

Tier 1

betamethasone, augmented topical gel

Tier 1

betamethasone, augmented topical lotion

Tier 1

betamethasone, augmented topical ointment

Tier 1

bpo topical gel Tier 1

bpo topical towelette Tier 1

calcipotriene scalp solution

Tier 1

calcipotriene topical cream Tier 1

calcipotriene topical ointment

Tier 1

calcitrene topical ointment Tier 1

claravis oral capsule Tier 1 PA

clindamycin-benzoyl peroxide topical gel

Tier 1

clobetasol scalp solution Tier 1

clobetasol topical cream Tier 1

clobetasol topical foam Tier 1

clobetasol topical gel Tier 1

clobetasol topical lotion Tier 1

clobetasol topical ointment Tier 1

clobetasol topical shampoo

Tier 1

clobetasol-emollient topical cream

Tier 1

cormax scalp solution Tier 1

dermazene topical cream Tier 1

desonide topical cream Tier 1

desonide topical lotion Tier 1

desonide topical ointment Tier 1

desoximetasone topical cream

Tier 1

desoximetasone topical gel

Tier 1

desoximetasone topical ointment

Tier 1

diflorasone topical cream Tier 1

Revised 4/1/2016

41


diflorasone topical ointment

Tier 1

EPIDUO TOPICAL GEL Tier 3

EPIDUO TOPICAL GEL WITH PUMP

Tier 3

FINACEA TOPICAL GEL Tier 3

fluocinolone and shower cap scalp oil

Tier 1

fluocinolone topical cream Tier 1

fluocinolone topical oil Tier 1

fluocinolone topical ointment

Tier 1

fluocinolone topical solution

Tier 1

fluocinonide topical cream Tier 1

fluocinonide topical gel Tier 1

fluocinonide topical ointment

Tier 1

fluocinonide topical solution

Tier 1

fluocinonide-e topical cream

Tier 1

fluticasone topical cream Tier 1

fluticasone topical lotion Tier 1

fluticasone topical ointment

Tier 1

halobetasol propionate topical cream

Tier 1

halobetasol propionate topical ointment

Tier 1

hydrocortisone butyrate topical cream

Tier 1

hydrocortisone butyrate topical ointment

Tier 1

hydrocortisone butyrate topical solution

Tier 1

hydrocortisone topical cream

Tier 1

hydrocortisone topical lotion

Tier 1

hydrocortisone topical ointment

Tier 1

hydrocortisone valerate topical cream

Tier 1

hydrocortisone valerate topical ointment

Tier 1


hydrocortisone-pramoxine topical cream

Tier 1

imiquimod topical cream in packet

Tier 1 PA; QL

iodoquinol-hc topical cream

Tier 1

lidocaine hcl-hydrocortison ac topical cream

Tier 1

lindane topical lotion Tier 1

lindane topical shampoo Tier 1

malathion topical lotion Tier 1

methoxsalen rapid oral capsule

Tier 2 PA

metronidazole topical cream

Tier 1

metronidazole topical lotion

Tier 1

mometasone topical cream

Tier 1

mometasone topical ointment

Tier 1

mometasone topical solution

Tier 1

OVACE PLUS TOPICAL CLEANSER,EXTENDED RELEASE

Tier 3

OVACE PLUS TOPICAL CREAM

Tier 3

OVACE PLUS WASH TOPICAL CLEANSER,GEL EXTENDED RELEASE

Tier 3

OXSORALEN TOPICAL LOTION

Tier 3

permethrin topical cream Tier 1

podofilox topical solution Tier 1

prednicarbate topical cream

Tier 1

prednicarbate topical ointment

Tier 1

prudoxin topical cream Tier 2

rosadan topical cream Tier 1

ROSADAN TOPICAL KIT, CLEANSER AND GEL

Tier 3

ROSADAN TOPICAL KIT,CLEANSER AND CREAM

Tier 3

Revised 4/1/2016

42


salacyn topical cream Tier 1

salacyn topical lotion Tier 1

salicylic acid er-ceramides topical combo pack

Tier 1

salicylic acid er-ceramides topical kit,cleanser and cream er

Tier 1

salicylic acid topical cream Tier 1

salicylic acid topical cream,extended release

Tier 1

salicylic acid topical film forming liquid w/appl

Tier 1

salicylic acid topical foam Tier 1

salicylic acid topical gel Tier 1

salicylic acid topical liquid Tier 1

salicylic acid topical lotion Tier 1

salicylic acid topical lotion,extended release

Tier 1

salicylic acid topical shampoo

Tier 1

salvax topical foam Tier 1

seb-prev topical cleanser Tier 1

selenium sulfide topical shampoo

Tier 1

spinosad topical suspension

Tier 1

sulfacetamide sodium (acne) topical suspension

Tier 1

sulfacetamide sodium topical cleanser

Tier 1

sulfacetamide sodium topical shampoo

Tier 1

tretinoin (emollient) topical cream

Tier 1

tretinoin topical cream Tier 1 PA

tretinoin topical gel Tier 1 PA

triamcinolone acetonide topical cream

Tier 1

triamcinolone acetonide topical lotion

Tier 1

triamcinolone acetonide topical ointment

Tier 1

trianex topical ointment Tier 1

triderm topical cream Tier 1

VOLTAREN TOPICAL GEL

Tier 3


zenatane oral capsule Tier 1 PA

SMOKING DETERRENTS

buproban oral tablet extended release

Tier 1 $0; QL

CHANTIX CONTINUING MONTH BOX ORAL TABLET

Tier 3 $0; QL

CHANTIX CONTINUING MONTH PAK ORAL TABLET

Tier 3 $0; QL

CHANTIX ORAL TABLET Tier 3 $0; QL

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

Tier 3 $0; QL

CHANTIX STARTING MONTH PAK ORAL TABLETS,DOSE PACK

Tier 3 $0; QL

THYROID PREPS

levothyroxine oral tablet Tier 1

levoxyl oral tablet Tier 1

liothyronine oral tablet Tier 1

methimazole oral tablet Tier 1

nature-throid oral tablet Tier 1

np thyroid oral tablet Tier 1

propylthiouracil oral tablet Tier 1

unithroid oral tablet Tier 1

westhroid oral tablet Tier 1

UNCLASSIFIED DRUG PRODUCTS

acamprosate oral tablet,delayed release (dr/ec)

Tier 2

alendronate oral solution Tier 1 QL

alendronate oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg

Tier 1 QL

alfuzosin oral tablet extended release 24 hr

Tier 1

amifostine crystalline intravenous recon soln

Tier 4 PA

buprenorphine hcl sublingual tablet 2 mg, 8 mg

Tier 1 PA; QL

CARBAGLU ORAL TABLET, DISPERSIBLE

Tier 4 PA

CHEMET ORAL CAPSULE

Tier 3

Revised 4/1/2016

43


chlorhexidine gluconate mucous membrane mouthwash

Tier 1

CIALIS ORAL TABLET10 MG, 2.5 MG, 20 MG, 5 MG

Tier 3 PA; QL

CYSTADANE ORAL POWDER

Tier 3

disulfiram oral tablet Tier 1

doxycycline hyclate oral tablet

Tier 1

FABRAZYME INTRAVENOUS RECON SOLN

Tier 4 PA

finasteride oral tablet Tier 1 PA

FORTEO SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; QL

FOSAMAX PLUS D ORAL TABLET

Tier 3 ST; QL

ibandronate oral tablet Tier 1 QL

KALYDECO ORAL TABLET

Tier 4 PA; QL

KUVAN ORAL TABLET,SOLUBLE

Tier 4 PA

leucovorin calcium oral tablet

Tier 2

levocarnitine (with sugar) oral solution

Tier 2

levocarnitine oral tablet Tier 2

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3 ST

NAGLAZYME INTRAVENOUS SOLUTION

Tier 4 PA

NYSTATIN (BULK) POWDER

Tier 1

oralone dental paste Tier 1

ORFADIN ORAL CAPSULE

Tier 4

oxybutynin chloride oral syrup

Tier 1

oxybutynin chloride oral tablet

Tier 1

oxybutynin chloride oral tablet extended release 24hr

Tier 1


paroex oral rinse mucous membrane mouthwash

Tier 1

periogard mucous membrane mouthwash

Tier 1

PROLIA SUBCUTANEOUS SYRINGE

Tier 3 PA; QL

PULMOZYME INHALATION SOLUTION

Tier 4 PA

raloxifene oral tablet Tier 1 $0

risedronate oral tablet 150 mg, 30 mg, 35 mg, 5 mg

Tier 1 QL

risedronate oral tablet,delayed release (dr/ec)

Tier 1 QL

SAVELLA ORAL TABLET

Tier 3 QL

SAVELLA ORAL TABLETS,DOSE PACK

Tier 3 QL

SENSIPAR ORAL TABLET

Tier 3

sodium chlor 0.9% bacteriostat injection solution

Tier 2

SYPRINE ORAL CAPSULE

Tier 3

triamcinolone acetonide dental paste

Tier 1

TYSABRI INTRAVENOUS SOLUTION

Tier 4 PA

XIAFLEX INJECTION RECON SOLN

Tier 4 PA

zoledronic acid intravenous recon soln

Tier 4

zoledronic acid-mannitol-water intravenous solution

Tier 4 PA

VITAMINS

cyanocobalamin (vitamin b-12) injection solution

Tier 1

ergocalciferol (vitamin d2) oral capsule

Tier 1

folic acid oral tablet Tier 1

vitamin d2 oral capsule Tier 1

Revised 4/1/2016

44

Revised 4/1/2016

45

40627CAMENABC

For more information, please visit anthem.com/ca.

If you have additional questions about your prescription benefits,

please call the Member Services number on your ID card.

Speech and hearing impaired (TDD/TTY users) should call

800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m., ET.

For the most current version of this Selected Drug List,

please visit anthem.com/ca.

Subject to Regulatory Approval

Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Documents

Select Drug List - beere&purves · The Select Drug List, also called a formulary is a list of U.S. Food and Drug Administration (FDA) ... oral solution 120 mg-12 mg /5 ml (5 ml),