149
I H2174_EK12V3 Accepted 8/13/2015 Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 16288, Version Number 18 This formulary was updated on November 1, 2016. For more recent information or other questions, please contact us, Trillium Community Health Plan, at 1(844) 867-1156 or, for TTY users, 711, October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday Friday from 8 a.m. to 8 p.m. Alternate technologies, such as voice mail, will be used after hours, on the weekends, and holidays from February 15 through September 30. Voice messages are reviewed and responded to within one business day, or visit http://www.trilliumadvantage.com. This information is available for free in other languages. Please call our Member Services number at 1(844) 867-1156. TTY users should call 711. From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday Friday from 8 a.m. to 8 p.m. Alternate technologies, such as voice mail, will be used after hours, on the weekends, and holidays from February 15 through September 30. Voice messages are reviewed and responded to within one business day. Trillium Community Health Plan ® is an HMO plan with a Medicare contract. Enrollment in Trillium Community Health Plan depends on contract renewal. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us”, or “our,” it means Trillium Community Health Plan. When it refers to “plan” or “our plan,” it means Trillium Advantage Dual SNP (HMO)/Trillium Advantage TLC ISNP (HMO)/Trillium Advantage TLC Community ISNP (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of

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Page 1: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

I

H2174_EK12V3 Accepted 8/13/2015

Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ISNP (HMO)

Trillium Advantage TLC Community ISNP (HMO)

2016 Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 16288, Version Number 18 This formulary was updated on November 1, 2016. For more recent information or other questions, please contact us, Trillium Community Health Plan, at 1(844) 867-1156 or, for TTY users, 711, October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday – Friday from 8 a.m. to 8 p.m. Alternate technologies, such as voice mail, will be used after hours, on the weekends, and holidays from February 15 through September 30. Voice messages are reviewed and responded to within one business day, or visit http://www.trilliumadvantage.com. This information is available for free in other languages. Please call our Member Services number at 1(844) 867-1156. TTY users should call 711. From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday – Friday from 8 a.m. to 8 p.m. Alternate technologies, such as voice mail, will be used after hours, on the weekends, and holidays from February 15 through September 30. Voice messages are reviewed and responded to within one business day. Trillium Community Health Plan® is an HMO plan with a Medicare contract. Enrollment in Trillium Community Health Plan depends on contract renewal. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us”, or “our,” it means Trillium Community Health Plan. When it refers to “plan” or “our plan,” it means Trillium Advantage Dual SNP (HMO)/Trillium Advantage TLC ISNP (HMO)/Trillium Advantage TLC Community ISNP (HMO).

This document includes a list of the drugs (formulary) for our plan which is current as of

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H2174_EK12V3 Accepted 8/13/2015

November 1, 2016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year.

What is the Trillium Advantage Dual SNP (HMO)/Trillium Advantage TLC ISNP (HMO)/Trillium Advantage TLC Community ISNP (HMO) Formulary?

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

Can the Formulary (drug list) change?

Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of November 1, 2016. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. Our plan only updates this printed drug formulary every month and posts the current formulary on our website. We make maintenance changes such as replacing a brand name drug with a generic product. Our plan sometimes modifies formularies as a result of new information on drug safety or effectiveness. We may expand the formulary by adding drugs, or placing a generic drug on a lower cost-sharing tier. Sometimes, we delete the step therapy or the quantity limit requirements. Our plan very seldom makes formulary changes (non-maintenance) such as removal of a drug, moving covered Part D drugs to a less preferred tier status, or adding step therapy or quantity limits.

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H2174_EK12V3 Accepted 8/13/2015

If our plan must make non-maintenance changes to a drug that we previously covered for you, we will continue to cover that drug for the remainder of the contract year. Our plan will notify all enrollees about these non-maintenance changes with an errata sheet.

How do I use the Formulary?

There are two ways to find your drug within the formulary:

Medical Condition

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

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 115. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?

Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

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

Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 18 tablets per prescription for sumatriptan. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B.

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H2174_EK12V3 Accepted 8/13/2015

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Trillium Advantage Dual SNP (HMO)/Trillium Advantage TLC ISNP (HMO)/Trillium Advantage TLC Community ISNP (HMO) formulary?” on page V for information about how to request an exception.

What are over-the counter (OTC) drugs?

OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Our plan pays for certain OTC drugs. The list of OTC drugs includes the following:

Loratadine 10mg tablet

Loratadine and pseudoephedrine 10-240mg tablet, sustained release

Loratadine 5mg/5ml syrup

Aspirin 81mg tablet

Aspirin 75mg chew tablet

Aspirin 81mg chew tablet

Aspirin 325mg tablet

Aspirin 500mg tablet

Aspirin 81mg tablet, delayed-release

Aspirin 325mg tablet, delayed-release

Aspirin 500mg tablet, delayed-release

Nicotine polacrilex gum 2mg

Nicotine polacrilex gum 4mg

Nicotine polacrilex lozenge 2mg

Nicotine polacrilex lozenge 4mg

Nicotine transdermal system 7mg/24hr

Nicotine transdermal system 14mg/24hr

Nicotine transdermal system 21mg/24hr

Our plan will provide these OTC drugs at no cost to you. The cost to our plan of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. For more information, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

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If you learn that our plan does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan.

You can ask our plan to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Trillium Advantage Dual SNP (HMO)/Trillium Advantage TLC ISNP (HMO)/Trillium Advantage TLC Community ISNP (HMO) Formulary?

You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

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

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

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

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H2174_EK12V3 Accepted 8/13/2015

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. A level of care change is a change in treatment setting: e.g. a change from home to a long-term care facility, or a discharge from an acute care setting. Trillium members who experience a level of care change will be given a one-time transition supply, upon request at the point of sale of a non-formulary Part D drug, or an override for a refill too soon due to dose changes by the prescriber before the regularly scheduled refill date.

For more information

For more detailed information about your plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

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H2174_EK12V3 Accepted 8/13/2015

The chart below lists the co-pay/coinsurance you will be responsible for during the Initial Coverage Limit. You remain in the Initial Coverage Limit until your total drug costs reach $3,310.00. If the Coverage Gap does not apply to you, then you remain in the Initial Coverage Limit until your total drug costs reach $4,850.00. Please refer to your Explanation of Benefits for your current benefit coverage.

Formulary Drug Tier

Description 31-Day Supply Retail Pharmacy Co-pay

90-Day Supply Mail-Order or Selected Retail Pharmacy Co-pay

Generic Includes preferred generic drugs. May include multiple source drugs.

Depending on your income and institutional status, you pay the following: - A $0 copay; or - A $1.20 copay; or - A $2.95 copay; or - A 25% coinsurance

Depending on your income and institutional status, you pay the following: - A $0 copay; or - A $1.20 copay; or - A $2.95 copay; or - A 25% coinsurance

Brand Includes preferred brand drugs.

Depending on your income and institutional status, you pay the following: - A $0 copay; or - A $3.60 copay; or - A $7.40 copay; or - A 25% coinsurance

Depending on your income and institutional status, you pay the following: - A $0 copay; or - A $3.60 copay; or - A $7.40 copay; or - A 25% coinsurance

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H2174_EK12V3 Accepted 8/13/2015

Trillium Advantage Dual SNP (HMO)/Trillium Advantage TLC ISNP (HMO)/Trillium Advantage TLC Community ISNP (HMO) Formulary

The formulary that begins on page 1 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 115. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., NEURONTIN) and generic drugs are listed in lower-case italics (e.g., gabapentin). The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.

Notes Abbreviation

Utilization Management Procedure

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

LA Limited Availability. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Trillium Member Service. Our contact information appears on the front and back cover pages.

MO This prescription drug is available through mail order. For more information consult your Pharmacy Directory or call Member Services. Our contact information appears on the front and back cover pages.

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

QL Drug has Quantity Limit. For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides up to 60 tablets per 30 days for omeprazole. This may be in addition to a standard one month or three month supply.

ST Step Therapy. In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B until you try Drug A first. If Drug A does not work for your, our plan will then cover Drug B.

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H2174_EK12V3 Accepted 8/13/2015

Trillium Advantage Dual SNP

Trillium Advantage TLC ISNP

Trillium Advantage TLC Community ISNP

List of Covered Drugs

Drug Category Page #

ANALGESICS ........................................................................................................................................................1

ANESTHETICS ......................................................................................................................................................6

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS .................................................................................7

ANTI-INFLAMMATORY AGENTS ...........................................................................................................................8

ANTIBACTERIALS .................................................................................................................................................8

ANTICONVULSANTS ........................................................................................................................................... 17

ANTIDEMENTIA AGENTS .................................................................................................................................... 21

ANTIDEPRESSANTS ............................................................................................................................................ 22

ANTIEMETICS .................................................................................................................................................... 25

ANTIFUNGALS ................................................................................................................................................... 26

ANTIGOUT AGENTS ........................................................................................................................................... 28

ANTIMIGRAINE AGENTS .................................................................................................................................... 28

ANTIMYASTHENIC AGENTS ................................................................................................................................ 29

ANTIMYCOBACTERIALS...................................................................................................................................... 30

ANTINEOPLASTICS ............................................................................................................................................. 30

ANTIPARASITICS ................................................................................................................................................ 36

ANTIPARKINSON AGENTS .................................................................................................................................. 37

ANTIPSYCHOTICS ............................................................................................................................................... 38

ANTISPASTICITY AGENTS ................................................................................................................................... 42

ANTIVIRALS ....................................................................................................................................................... 42

ANXIOLYTICS ..................................................................................................................................................... 46

BIPOLAR AGENTS .............................................................................................................................................. 47

BLOOD GLUCOSE REGULATORS .......................................................................................................................... 47

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS ....................................................................................... 50

CARDIOVASCULAR AGENTS ............................................................................................................................... 53

CENTRAL NERVOUS SYSTEM AGENTS ................................................................................................................. 66

DENTAL AND ORAL AGENTS ............................................................................................................................... 69

DERMATOLOGICAL AGENTS ............................................................................................................................... 69

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ENZYME REPLACEMENT/MODIFIERS .................................................................................................................. 74

GASTROINTESTINAL AGENTS ............................................................................................................................. 75

GENITOURINARY AGENTS .................................................................................................................................. 77

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) ....................................................... 79

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) ...................................................... 80

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PROSTAGLANDINS) .......................................... 81

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) .......................... 81

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) ........................................................ 87

HORMONAL AGENTS, SUPPRESSANT (ADRENAL) ................................................................................................ 89

HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) ........................................................................................ 89

HORMONAL AGENTS, SUPPRESSANT (PITUITARY) .............................................................................................. 89

HORMONAL AGENTS, SUPPRESSANT (THYROID) ................................................................................................ 90

IMMUNOLOGICAL AGENTS ................................................................................................................................ 90

INFLAMMATORY BOWEL DISEASE AGENTS......................................................................................................... 95

METABOLIC BONE DISEASE AGENTS ................................................................................................................... 95

MISCELLANEOUS THERAPEUTIC AGENTS ............................................................................................................ 96

OPHTHALMIC AGENTS ....................................................................................................................................... 97

OTIC AGENTS .................................................................................................................................................... 99

RESPIRATORY TRACT/PULMONARY AGENTS .................................................................................................... 100

SKELETAL MUSCLE RELAXANTS ........................................................................................................................ 104

SLEEP DISORDER AGENTS ................................................................................................................................ 104

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES ...................................................................................... 105

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

Analgesics

Nonsteroidal Anti-inflammatory Drugs

celecoxib caps 100mg 1 QL (60 EA per 30 days) PA MO

celecoxib caps 200mg 1 QL (60 EA per 30 days) PA MO

celecoxib caps 400mg 1 QL (60 EA per 30 days) PA MO

celecoxib caps 50mg 1 QL (60 EA per 30 days) PA MO

diclofenac potassium tabs 50mg 1 MO

diclofenac sodium dr tbec 25mg 1 MO

diclofenac sodium dr tbec 50mg 1 MO

diclofenac sodium dr tbec 75mg 1 MO

diclofenac sodium er tb24 100mg 1 MO

diclofenac sodium/misoprostol tbec 50mg; 200mcg 1 MO

diclofenac sodium/misoprostol tbec 75mg; 200mcg 1 MO

diflunisal tabs 500mg 1 MO

etodolac er tb24 400mg 1 MO

etodolac er tb24 500mg 1 MO

etodolac er tb24 600mg 1 MO

etodolac caps 200mg 1 MO

etodolac caps 300mg 1 MO

etodolac tabs 400mg 1 MO

etodolac tabs 500mg 1 MO

fenoprofen calcium caps 200mg 1 MO

fenoprofen calcium caps 400mg 1 MO

fenoprofen calcium tabs 600mg 1 MO

FLECTOR PTCH 1.3% 1 QL (30 EA per 15 days) PA

flurbiprofen tabs 100mg 1 MO

flurbiprofen tabs 50mg 1 MO

ibuprofen susp 100mg/5ml 1

ibuprofen tabs 400mg 1 MO

ibuprofen tabs 600mg 1 MO

ibuprofen tabs 800mg 1 MO

INDOCIN SUSP 25MG/5ML 1 PA MO

indomethacin er cpcr 75mg 1 PA MO

indomethacin caps 25mg 1 PA MO

indomethacin caps 50mg 1 PA MO

ketoprofen er cp24 200mg 1 MO

ketoprofen caps 50mg 1 MO

ketoprofen caps 75mg 1 MO

ketorolac tromethamine inj 15mg/ml 1 PA

ketorolac tromethamine inj 300mg/10ml 1 PA

ketorolac tromethamine inj 30mg/ml 1 PA

ketorolac tromethamine inj 30mg/ml 1 PA

ketorolac tromethamine inj 30mg/ml 1 PA

ketorolac tromethamine tabs 10mg 1 QL (20 EA per 5 days) PA

meclofenamate sodium caps 100mg 1 MO

meclofenamate sodium caps 50mg 1 MO

mefenamic acid caps 250mg 1 MO

meloxicam susp 7.5mg/5ml 1 MO

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Drug Name

Drug

Tier Requirements/Limits

meloxicam tabs 15mg 1 MO

meloxicam tabs 7.5mg 1 MO

nabumetone tabs 500mg 1 MO

nabumetone tabs 750mg 1 MO

nalfon caps 400mg 1 MO

naproxen dr tbec 375mg 1 MO

naproxen dr tbec 500mg 1 MO

naproxen sodium cr tb24 375mg 1 MO

naproxen sodium er tb24 375mg 1 MO

naproxen sodium tabs 275mg 1 MO

naproxen sodium tabs 550mg 1 MO

naproxen susp 125mg/5ml 1 MO

naproxen tabs 250mg 1 MO

naproxen tabs 375mg 1 MO

naproxen tabs 500mg 1 MO

oxaprozin tabs 600mg 1 MO

oxycodone/ibuprofen tabs 400mg; 5mg 1

piroxicam caps 10mg 1 MO

piroxicam caps 20mg 1 MO

sulindac tabs 150mg 1 MO

sulindac tabs 200mg 1 MO

Opioid Analgesics, Long-acting

fentanyl pt72 100mcg/hr 1 QL (10 EA per 30 days)

fentanyl pt72 12mcg/hr 1 QL (10 EA per 30 days)

fentanyl pt72 25mcg/hr 1 QL (10 EA per 30 days)

fentanyl pt72 37.5mcg/hr 1 QL (10 EA per 30 days)

fentanyl pt72 50mcg/hr 1 QL (10 EA per 30 days)

fentanyl pt72 62.5mcg/hr 1 QL (10 EA per 30 days)

fentanyl pt72 75mcg/hr 1 QL (10 EA per 30 days)

fentanyl pt72 87.5mcg/hr 1 QL (10 EA per 30 days)

hydromorphone hcl er t24a 12mg 1 QL (150 EA per 30 days) PA

hydromorphone hcl er t24a 16mg 1 QL (120 EA per 30 days) PA

hydromorphone hcl er t24a 32mg 1 QL (60 EA per 30 days) PA

hydromorphone hcl er t24a 8mg 1 QL (240 EA per 30 days) PA

methadone hcl intensol conc 10mg/ml 1

methadone hcl conc 10mg/ml 1

methadone hcl inj 10mg/ml 1

methadone hcl soln 10mg/5ml 1

methadone hcl soln 5mg/5ml 1

methadone hcl tabs 10mg 1

methadone hcl tabs 5mg 1

methadose sugar-free conc 10mg/ml 1

methadose conc 10mg/ml 1

morphine sulfate er cp24 100mg 1 QL (60 EA per 30 days)

morphine sulfate er cp24 10mg 1 QL (60 EA per 30 days)

morphine sulfate er cp24 120mg 1 QL (30 EA per 30 days)

morphine sulfate er cp24 20mg 1 QL (60 EA per 30 days)

morphine sulfate er cp24 30mg 1 QL (60 EA per 30 days)

Page 13: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

3

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

morphine sulfate er cp24 30mg 1 QL (30 EA per 30 days)

morphine sulfate er cp24 45mg 1 QL (30 EA per 30 days)

morphine sulfate er cp24 50mg 1 QL (60 EA per 30 days)

morphine sulfate er cp24 60mg 1 QL (30 EA per 30 days)

morphine sulfate er cp24 60mg 1 QL (60 EA per 30 days)

morphine sulfate er cp24 75mg 1 QL (30 EA per 30 days)

morphine sulfate er cp24 80mg 1 QL (60 EA per 30 days)

morphine sulfate er cp24 90mg 1 QL (30 EA per 30 days)

morphine sulfate er tbcr 100mg 1 QL (90 EA per 30 days)

morphine sulfate er tbcr 15mg 1 QL (90 EA per 30 days)

morphine sulfate er tbcr 200mg 1 QL (90 EA per 30 days)

morphine sulfate er tbcr 30mg 1 QL (90 EA per 30 days)

morphine sulfate er tbcr 60mg 1 QL (90 EA per 30 days)

morphine sulfate tabs 15mg 1

morphine sulfate tabs 30mg 1

NUCYNTA ER TB12 100MG 1 QL (60 EA per 30 days)

NUCYNTA ER TB12 150MG 1 QL (60 EA per 30 days)

NUCYNTA ER TB12 200MG 1 QL (60 EA per 30 days)

NUCYNTA ER TB12 250MG 1 QL (60 EA per 30 days)

NUCYNTA ER TB12 50MG 1 QL (60 EA per 30 days)

oxycodone hcl er t12a 10mg 1 QL (120 EA per 30 days) PA

oxycodone hcl er t12a 15mg 1 QL (120 EA per 30 days) PA

oxycodone hcl er t12a 20mg 1 QL (120 EA per 30 days) PA

oxycodone hcl er t12a 30mg 1 QL (120 EA per 30 days) PA

oxycodone hcl er t12a 40mg 1 QL (120 EA per 30 days) PA

oxycodone hcl er t12a 60mg 1 QL (120 EA per 30 days) PA

oxycodone hcl er t12a 80mg 1 QL (120 EA per 30 days) PA

oxymorphone hydrochloride er tb12 10mg 1 QL (60 EA per 30 days)

oxymorphone hydrochloride er tb12 15mg 1 QL (60 EA per 30 days)

oxymorphone hydrochloride er tb12 20mg 1 QL (60 EA per 30 days)

oxymorphone hydrochloride er tb12 30mg 1 QL (60 EA per 30 days)

oxymorphone hydrochloride er tb12 40mg 1 QL (60 EA per 30 days)

oxymorphone hydrochloride er tb12 5mg 1 QL (60 EA per 30 days)

oxymorphone hydrochloride er tb12 7.5mg 1 QL (60 EA per 30 days)

tramadol hcl er tb24 100mg 1 QL (30 EA per 30 days)

tramadol hcl er tb24 100mg 1 QL (30 EA per 30 days)

tramadol hcl er tb24 200mg 1 QL (30 EA per 30 days)

tramadol hcl er tb24 200mg 1 QL (30 EA per 30 days)

tramadol hcl er tb24 300mg 1 QL (30 EA per 30 days)

tramadol hcl er tb24 300mg 1 QL (30 EA per 30 days)

Opioid Analgesics, Short-acting

ABSTRAL SUBL 100MCG 1 QL (120 EA per 30 days) PA

ABSTRAL SUBL 200MCG 1 QL (120 EA per 30 days) PA

ABSTRAL SUBL 300MCG 1 QL (120 EA per 30 days) PA

ABSTRAL SUBL 400MCG 1 QL (120 EA per 30 days) PA

ABSTRAL SUBL 600MCG 1 QL (120 EA per 30 days) PA

ABSTRAL SUBL 800MCG 1 QL (120 EA per 30 days) PA

acetaminophen/codeine #3 tabs 300mg; 30mg 1 QL (390 EA per 30 days)

Page 14: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

4

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

acetaminophen/codeine soln 120mg/5ml; 12mg/5ml 1 QL (5000 ML per 30 days)

acetaminophen/codeine tabs 300mg; 15mg 1 QL (390 EA per 30 days)

acetaminophen/codeine tabs 300mg; 60mg 1 QL (390 EA per 30 days)

ascomp/codeine caps 325mg; 50mg; 40mg; 30mg 1 PA

aspirin-caffeine-dihydrocodeine caps 356.4mg; 30mg; 16mg 1

butalbital/aspirin/caffeine/codeine caps 325mg; 50mg; 40mg;

30mg

1 PA

butorphanol tartrate inj 1mg/ml 1

butorphanol tartrate inj 2mg/ml 1

butorphanol tartrate soln 10mg/ml 1 QL (10 ML per 30 days)

carisoprodol/aspirin/codeine tabs 325mg; 200mg; 16mg 1 PA

codeine sulfate tabs 15mg 1

codeine sulfate tabs 30mg 1

codeine sulfate tabs 60mg 1

duramorph inj 0.5mg/ml 1

duramorph inj 1mg/ml 1

endocet tabs 325mg; 10mg 1 QL (360 EA per 30 days)

endocet tabs 325mg; 2.5mg 1 QL (360 EA per 30 days)

endocet tabs 325mg; 5mg 1 QL (360 EA per 30 days)

endocet tabs 325mg; 7.5mg 1 QL (360 EA per 30 days)

endodan tabs 325mg; 4.835mg 1 QL (360 EA per 30 days)

fentanyl citrate oral transmucosal lpop 1200mcg 1 QL (120 EA per 30 days) PA

fentanyl citrate oral transmucosal lpop 1600mcg 1 QL (120 EA per 30 days) PA

fentanyl citrate oral transmucosal lpop 200mcg 1 QL (120 EA per 30 days) PA

fentanyl citrate oral transmucosal lpop 400mcg 1 QL (120 EA per 30 days) PA

fentanyl citrate oral transmucosal lpop 600mcg 1 QL (120 EA per 30 days) PA

fentanyl citrate oral transmucosal lpop 800mcg 1 QL (120 EA per 30 days) PA

fentanyl citrate/nacl inj 50mcg/5ml; 0.9% 1 B/D

FENTORA TABS 100MCG 1 QL (112 EA per 28 days) PA

FENTORA TABS 200MCG 1 QL (112 EA per 28 days) PA

FENTORA TABS 400MCG 1 QL (112 EA per 28 days) PA

FENTORA TABS 600MCG 1 QL (112 EA per 28 days) PA

FENTORA TABS 800MCG 1 QL (112 EA per 28 days) PA

hydrocodone bitartrate/acetaminophen soln 325mg/15ml;

10mg/15ml

1 QL (5550 ML per 30 days)

hydrocodone bitartrate/acetaminophen soln 325mg/15ml;

7.5mg/15ml

1 QL (5550 ML per 30 days)

hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg 1 QL (390 EA per 30 days)

hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg 1 QL (390 EA per 30 days)

hydrocodone bitartrate/acetaminophen tabs 300mg; 7.5mg 1 QL (390 EA per 30 days)

hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg 1 QL (360 EA per 30 days)

hydrocodone/acetaminophen soln 500mg/15ml; 7.5mg/15ml 1 QL (3600 ML per 30 days)

hydrocodone/acetaminophen tabs 325mg; 10mg 1 QL (360 EA per 30 days)

hydrocodone/acetaminophen tabs 325mg; 5mg 1 QL (360 EA per 30 days)

hydrocodone/acetaminophen tabs 325mg; 7.5mg 1 QL (360 EA per 30 days)

hydrocodone/ibuprofen tabs 10mg; 200mg 1

hydrocodone/ibuprofen tabs 2.5mg; 200mg 1

hydrocodone/ibuprofen tabs 5mg; 200mg 1

Page 15: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

5

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

hydrocodone/ibuprofen tabs 7.5mg; 200mg 1

hydromorphone hcl/nacl inj 12mg/60ml; 0.9% 1

hydromorphone hcl/sodium chloride inj 10mg/50ml; 0.9% 1

hydromorphone hcl inj 15mg/30ml; 0.9% 1

hydromorphone hcl inj 2mg/ml 1

hydromorphone hcl inj 500mg/50ml 1

hydromorphone hcl inj 6mg/30ml; 0.9% 1 B/D

hydromorphone hcl liqd 1mg/ml 1

hydromorphone hcl tabs 2mg 1

hydromorphone hcl tabs 4mg 1

hydromorphone hcl tabs 8mg 1

hydromorphone hydrochloride/ nacl inj 100mg/100ml; 0.9% 1 B/D

hydromorphone hydrochloride/nacl inj 50mg/100ml; 0.9% 1 B/D

hydromorphone hydrochloride/sodium chloride inj

15mg/50ml; 0.9%

1

hydromorphone hydrochloride/sodium chloride inj 5mg/25ml;

0.9%

1

ibudone tabs 5mg; 200mg 1

LAZANDA SOLN 100MCG/ACT 1 QL (30 EA per 30 days) PA

LAZANDA SOLN 300MCG/ACT 1 QL (30 EA per 30 days) PA

LAZANDA SOLN 400MCG/ACT 1 QL (30 EA per 30 days) PA

lorcet hd tabs 325mg; 10mg 1 QL (360 EA per 30 days)

lorcet plus tabs 325mg; 7.5mg 1 QL (360 EA per 30 days)

lorcet tabs 325mg; 5mg 1 QL (360 EA per 30 days)

lortab tabs 325mg; 10mg 1 QL (360 EA per 30 days)

lortab tabs 325mg; 5mg 1 QL (360 EA per 30 days)

lortab tabs 325mg; 7.5mg 1 QL (360 EA per 30 days)

morphine sulfate add-vantage inj 25mg/ml 1

morphine sulfate/sodium chloride inj 50mg/50ml; 0.9% 1

morphine sulfate inj 0.5mg/ml 1

morphine sulfate inj 0.5mg/ml; 0.9% 1

morphine sulfate inj 10mg/ml 1

morphine sulfate inj 15mg/ml 1

morphine sulfate inj 15mg/ml 1

morphine sulfate inj 1mg/ml 1

morphine sulfate inj 1mg/ml 1

morphine sulfate inj 25mg/ml 1

morphine sulfate inj 2mg/ml 1

morphine sulfate inj 4mg/ml 1

morphine sulfate inj 50mg/ml 1

morphine sulfate inj 5mg/ml 1

morphine sulfate inj 8mg/ml 1

morphine sulfate inj 8mg/ml 1

morphine sulfate soln 100mg/5ml 1

morphine sulfate soln 10mg/5ml 1

morphine sulfate soln 20mg/5ml 1

nalbuphine hcl inj 10mg/ml 1

nalbuphine hcl inj 20mg/ml 1

Page 16: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

6

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

NUCYNTA TABS 100MG 1 QL (180 EA per 30 days)

NUCYNTA TABS 50MG 1 QL (180 EA per 30 days)

NUCYNTA TABS 75MG 1 QL (180 EA per 30 days)

oxycodone hcl caps 5mg 1

oxycodone hcl soln 5mg/5ml 1

oxycodone hcl tabs 10mg 1

oxycodone hcl tabs 15mg 1

oxycodone hcl tabs 20mg 1

oxycodone hcl tabs 30mg 1

oxycodone hcl tabs 5mg 1

oxycodone/acetaminophen soln 325mg/5ml; 5mg/5ml 1 QL (1800 ML per 30 days)

oxycodone/acetaminophen tabs 325mg; 10mg 1 QL (360 EA per 30 days)

oxycodone/acetaminophen tabs 325mg; 2.5mg 1 QL (360 EA per 30 days)

oxycodone/acetaminophen tabs 325mg; 5mg 1 QL (360 EA per 30 days)

oxycodone/acetaminophen tabs 325mg; 7.5mg 1 QL (360 EA per 30 days)

oxycodone/aspirin tabs 325mg; 4.835mg 1 QL (360 EA per 30 days)

oxymorphone hydrochloride tabs 10mg 1

oxymorphone hydrochloride tabs 5mg 1

pentazocine/naloxone hcl tabs 0.5mg; 50mg 1 PA

reprexain tabs 10mg; 200mg 1

roxicet soln 325mg/5ml; 5mg/5ml 1 QL (1800 ML per 30 days)

roxicet tabs 325mg; 5mg 1 QL (360 EA per 30 days)

SYNALGOS-DC CAPS 356.4MG; 30MG; 16MG 1

tramadol hcl tabs 50mg 1 QL (240 EA per 30 days)

tramadol hydrochloride/acetaminophen tabs 325mg; 37.5mg 1 QL (240 EA per 30 days)

verdrocet tabs 325mg; 2.5mg 1 QL (360 EA per 30 days)

vicodin es tabs 300mg; 7.5mg 1 QL (390 EA per 30 days)

vicodin hp tabs 300mg; 10mg 1 QL (390 EA per 30 days)

vicodin tabs 300mg; 5mg 1 QL (390 EA per 30 days)

xylon tabs 10mg; 200mg 1

zamicet soln 325mg/15ml; 10mg/15ml 1 QL (5550 ML per 30 days)

Anesthetics

Local Anesthetics

cidaleaze crea 3% 1

dermacinrx prizopak kit 2.5%; 2.5% 1

glydo gel 2% 1

lidocaine hcl jelly gel 2% 1

lidocaine hcl jelly gel 2% 1

lidocaine hcl jelly gel 2% 1

lidocaine hcl viscous soln 2% 1

lidocaine hcl gel 2% 1

lidocaine hcl inj 0.5% 1

lidocaine hcl inj 1% 1

lidocaine hcl inj 1% 1

lidocaine hcl inj 1.5% 1

lidocaine hcl inj 100mg/5ml 1

lidocaine hcl inj 2% 1

lidocaine hcl inj 2% 1

Page 17: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

7

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

lidocaine hcl inj 4% 1

lidocaine hcl inj 40mg/2ml 1

lidocaine hcl lotn 3% 1

lidocaine hcl soln 4% 1

lidocaine hcl soln 4% 1

lidocaine pak oint 5% 1

lidocaine viscous soln 2% 1

lidocaine-prilocaine-cream base crea 2.5%; 2.5% 1

lidocaine/prilocaine crea 2.5%; 2.5% 1

lidocaine/prilocaine kit 2.5%; 2.5% 1

lidocaine crea 3% 1

lidocaine oint 5% 1

lidocaine ptch 5% 1 PA

lidopin crea 3% 1

livixil pak kit 2.5%; 2.5% 1

lp lite pak kit 2.5%; 2.5% 1

premium lidocaine oint 5% 1

relador pak plus kit 2.5%; 2.5% 1

relador pak kit 2.5%; 2.5% 1

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

acamprosate calcium dr tbec 333mg 1 MO

disulfiram tabs 250mg 1 MO

disulfiram tabs 500mg 1 MO

Opioid Dependence Treatments

buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg 1 QL (360 EA per 30 days) PA

buprenorphine hcl/naloxone hcl subl 8mg; 2mg 1 QL (90 EA per 30 days) PA

buprenorphine hcl subl 2mg 1 QL (240 EA per 30 days) PA

buprenorphine hcl subl 8mg 1 QL (90 EA per 30 days) PA

BUTRANS PTWK 10MCG/HR 1 QL (4 EA per 28 days) PA

BUTRANS PTWK 15MCG/HR 1 QL (4 EA per 28 days) PA

BUTRANS PTWK 20MCG/HR 1 QL (4 EA per 28 days) PA

BUTRANS PTWK 5MCG/HR 1 QL (4 EA per 28 days) PA

BUTRANS PTWK 7.5MCG/HR 1 QL (4 EA per 28 days) PA

naltrexone hcl tabs 50mg 1

SUBOXONE FILM 12MG; 3MG 1 QL (60 EA per 30 days) PA

SUBOXONE FILM 2MG; 0.5MG 1 QL (360 EA per 30 days) PA

SUBOXONE FILM 4MG; 1MG 1 QL (180 EA per 30 days) PA

SUBOXONE FILM 8MG; 2MG 1 QL (90 EA per 30 days) PA

Opioid Reversal Agents

naloxone hcl inj 0.4mg/ml 1

naloxone hcl inj 0.4mg/ml 1

naloxone hcl inj 2mg/2ml 1

Smoking Cessation Agents

buproban tb12 150mg 1 QL (540 EA per 365 days)

bupropion hcl sr tb12 150mg 1 QL (540 EA per 365 days)

CHANTIX CONTINUING MONTH PAK TABS 1MG 1 QL (504 EA per 365 days)

CHANTIX STARTING MONTH PAK TABS 0 1 QL (159 EA per 365 days)

Page 18: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

8

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

CHANTIX TABS 0.5MG 1 QL (504 EA per 365 days)

CHANTIX TABS 1MG 1 QL (504 EA per 365 days)

NICOTROL NS SOLN 10MG/ML 1 QL (360 ML per 365 days)

Anti-inflammatory Agents

Nonsteroidal Anti-inflammatory Drugs

diclofenac sodium gel 3% 1

tolmetin sodium caps 400mg 1 MO

tolmetin sodium tabs 200mg 1 MO

tolmetin sodium tabs 600mg 1 MO

Antibacterials

Aminoglycosides

amikacin sulfate inj 1gm/4ml 1

amikacin sulfate inj 500mg/2ml 1

garamycin soln 0.3% 1

gentak oint 0.3% 1

gentamicin sulfate pediatric inj 10mg/ml 1

gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml; 0.9% 1

gentamicin sulfate/0.9% sodium chloride inj 1.2mg/ml; 0.9% 1

gentamicin sulfate/0.9% sodium chloride inj 1.4mg/ml; 0.9% 1

gentamicin sulfate/0.9% sodium chloride inj 1.6mg/ml; 0.9% 1

gentamicin sulfate/0.9% sodium chloride inj 1mg/ml; 0.9% 1

gentamicin sulfate/0.9% sodium chloride inj 2mg/ml; 0.9% 1

gentamicin sulfate crea 0.1% 1

gentamicin sulfate inj 10mg/ml 1

gentamicin sulfate inj 10mg/ml 1

gentamicin sulfate inj 40mg/ml 1

gentamicin sulfate oint 0.1% 1

gentamicin sulfate oint 0.3% 1

gentamicin sulfate soln 0.3% 1

isotonic gentamicin inj 0.8mg/ml; 0.9% 1

neomycin sulfate tabs 500mg 1

neomycin/polymyxin b sulfates soln 40mg/ml; 200000unit/ml 1

paromomycin sulfate caps 250mg 1

streptomycin sulfate inj 1gm 1

tobramycin sulfate inj 1.2gm 1

tobramycin sulfate inj 10mg/ml 1

tobramycin sulfate inj 80mg/2ml 1

tobramycin sulfate soln 0.3% 1

TOBREX OINT 0.3% 1

ZYLET SUSP 0.5%; 0.3% 1

Antibacterials, Other

ALCOHOL PREP PADS PADS 70% 1

ALTABAX OINT 1% 1

baciim inj 50000unit 1

bacitracin inj 50000unit 1

bacitracin oint 500unit/gm 1

BACTROBAN NASAL OINT 2% 1

centany at kit 2% 1

Page 19: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

9

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

centany oint 2% 1

chloramphenicol sodium succinate inj 1gm 1

CLEOCIN SUPP 100MG 1

clindamycin hcl caps 150mg 1

clindamycin hcl caps 300mg 1

clindamycin hcl caps 75mg 1

clindamycin palmitate hcl solr 75mg/5ml 1

clindamycin phosphate add-vantage inj 150mg/ml 1

clindamycin phosphate add-vantage inj 900mg/6ml 1

clindamycin phosphate in d5w inj 300mg/50ml; 5% 1

clindamycin phosphate in d5w inj 600mg/50ml; 5% 1

clindamycin phosphate in d5w inj 900mg/50ml; 5% 1

clindamycin phosphate pharmacy bulk package inj 150mg/ml 1

clindamycin phosphate crea 2% 1

clindamycin phosphate inj 150mg/ml 1

clindamycin phosphate inj 150mg/ml 1

clindamycin phosphate inj 300mg/2ml 1

clindamycin phosphate inj 600mg/4ml 1

clindamycin phosphate inj 9000mg/60ml 1

clindamycin phosphate inj 900mg/6ml 1

clindamycin inj 900mg/6ml 1

colistimethate sodium inj 150mg 1 B/D

CORTISPORIN OINT 400UNIT/GM; 1%; 0.5%;

5000UNIT/GM

1

CUBICIN RF INJ 500MG 1

CUBICIN INJ 500MG 1

DALVANCE INJ 500MG 1

daptomycin inj 500mg 1

lansoprazole/amoxicillin/clarithromycin misc 0; 0; 0 1

LINCOCIN INJ 300MG/ML 1

lincomycin hcl inj 300mg/ml 1

linezolid inj 600mg/300ml 1

linezolid susr 100mg/5ml 1 QL (2400 ML per 30 days)

linezolid tabs 600mg 1 QL (60 EA per 30 days)

mafenide acetate pack 5% 1

methenamine hippurate tabs 1gm 1

methenamine mandelate tabs 0.5gm 1

methenamine mandelate tabs 1gm 1

methenamine mandelate tabs 1gm 1

metro iv inj 500mg/100ml; 0.74% 1

metronidazole in nacl 0.79% inj 500mg/100ml; 0.79% 1

metronidazole vaginal gel 0.75% 1

metronidazole caps 375mg 1

metronidazole crea 0.75% 1

metronidazole gel 0.75% 1

metronidazole gel 1% 1

metronidazole inj 500mg/100ml; 0.79% 1

metronidazole lotn 0.75% 1

Page 20: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

10

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

metronidazole tabs 250mg 1

metronidazole tabs 500mg 1

MONUROL PACK 5.631GM 1

mupirocin crea 2% 1

mupirocin oint 2% 1

neo-polycin hc oint 400unit/gm; 1%; 3.5mg/gm; 10000unit/gm 1

neomycin/polymyxin/bacitracin/hydrocortisone oint

400unit/gm; 1%; 0.5%; 10000unit/gm

1

neomycin/polymyxin/gramicidin soln 0.025mg/ml; 1.75mg/ml;

10000unit/ml

1

neomycin/polymyxin/hydrocortisone susp 1%; 3.5mg/ml;

10000unit/ml

1

nitrofurantoin macrocrystals caps 100mg 1 QL (360 EA per 365 days)

nitrofurantoin macrocrystals caps 25mg 1

nitrofurantoin macrocrystals caps 50mg 1 QL (720 EA per 365 days)

nitrofurantoin monohydrate/macrocrystals caps 100mg 1 QL (180 EA per 365 days)

nitrofurantoin monohydrate caps 100mg 1 QL (180 EA per 365 days)

nitrofurantoin susp 25mg/5ml 1 QL (7200 ML per 365 days)

ORBACTIV INJ 400MG 1

polymyxin b sulfate inj 500000unit 1

rosadan kit kit 0.75% 1

rosadan kit kit 0.75% 1

rosadan crea 0.75% 1

rosadan gel 0.75% 1

silver sulfadiazine crea 1% 1

SIVEXTRO INJ 200MG 1 QL (6 EA per 30 days)

SIVEXTRO TABS 200MG 1 QL (6 EA per 30 days)

ssd crea 1% 1

SULFAMYLON CREA 85MG/GM 1

SYNERCID INJ 350MG; 150MG 1

trimethoprim tabs 100mg 1

TYGACIL INJ 50MG 1

vancomycin hcl in dextrose inj 0; 1gm/200ml 1

vancomycin hcl in dextrose inj 0; 500mg/100ml 1

vancomycin hcl in dextrose inj 0; 750mg/150ml 1

vancomycin hcl caps 125mg 1

vancomycin hcl caps 250mg 1

vancomycin hcl inj 0.9%; 1gm/200ml 1

vancomycin hcl inj 1000mg 1

vancomycin hcl inj 10gm 1

vancomycin hcl inj 500mg 1

vancomycin hcl inj 750mg 1

vancomycin hydrochloride/dextrose inj 5%; 1gm/100ml 1

vancomycin hydrochloride/dextrose inj 5%; 1gm/250ml 1

vancomycin hydrochloride/dextrose inj 5%; 2gm/500ml 1

vancomycin hydrochloride/nacl inj 0.9%; 1.5gm/150ml 1

vancomycin hydrochloride/sodium chloride inj 0.9%;

1.25gm/250ml

1

Page 21: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

11

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

vancomycin hydrochloride/sodium chloride inj 0.9%;

1.25gm/250ml

1

vancomycin hydrochloride/sodium chloride inj 0.9%;

1.5gm/250ml

1

vancomycin hydrochloride/sodium chloride inj 0.9%;

1.5gm/500ml

1

vancomycin hydrochloride/sodium chloride inj 0.9%;

1gm/150ml

1

vancomycin hydrochloride/sodium chloride inj 0.9%;

1gm/250ml

1

vancomycin hydrochloride inj 5%; 1.5gm/250ml 1

vancomycin inj 0.9%; 500mg/100ml 1

vancomycin inj 0.9%; 750mg/150ml 1

vandazole gel 0.75% 1

XIFAXAN TABS 200MG 1 PA

XIFAXAN TABS 550MG 1 PA MO

ZYVOX SUSR 100MG/5ML 1 QL (2400 ML per 30 days)

Beta-lactam, Cephalosporins

AVYCAZ INJ 0.5GM; 2GM 1

cefaclor er tb12 500mg 1

cefaclor caps 250mg 1

cefaclor caps 500mg 1

cefaclor susr 125mg/5ml 1

cefaclor susr 250mg/5ml 1

cefaclor susr 375mg/5ml 1

cefadroxil caps 500mg 1

cefadroxil susr 250mg/5ml 1

cefadroxil susr 500mg/5ml 1

cefadroxil tabs 1gm 1

cefazolin sodium inj 100gm 1

cefazolin sodium inj 10gm 1

cefazolin sodium inj 1gm 1

cefazolin sodium inj 1gm 1

cefazolin sodium inj 20gm 1

cefazolin sodium inj 300gm 1

cefazolin sodium inj 500mg 1

cefazolin/d5w inj 3gm/100ml; 5% 1

cefazolin/dextrose inj 2gm/100ml; 5% 1

cefazolin/sodium chloride inj 2gm/100ml; 0.9% 1

cefazolin/sodium chloride inj 2gm/50ml; 0.9% 1

cefazolin inj 2gm/100ml; 4% 1

cefdinir caps 300mg 1

cefdinir susr 125mg/5ml 1

cefdinir susr 250mg/5ml 1

cefepime/dextrose inj 1gm/50ml; 5% 1

cefepime inj 1gm 1

cefepime inj 2gm/50ml; 5% 1

cefepime inj 2gm 1

Page 22: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

12

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

cefixime susr 100mg/5ml 1

cefixime susr 200mg/5ml 1

cefotaxime sodium inj 10gm 1

cefotaxime sodium inj 1gm 1

cefotaxime sodium inj 2gm 1

cefotaxime sodium inj 500mg 1

cefoxitin sodium inj 10gm 1

cefoxitin sodium inj 1gm 1

cefoxitin sodium inj 1gm; 4% 1

cefoxitin sodium inj 2gm 1

cefoxitin sodium inj 2gm; 2.2% 1

cefpodoxime proxetil susr 100mg/5ml 1

cefpodoxime proxetil susr 50mg/5ml 1

cefpodoxime proxetil tabs 100mg 1

cefpodoxime proxetil tabs 200mg 1

cefprozil susr 125mg/5ml 1

cefprozil susr 250mg/5ml 1

cefprozil tabs 250mg 1

cefprozil tabs 500mg 1

ceftazidime inj 1gm 1

ceftazidime inj 2gm 1

ceftazidime inj 6gm 1

ceftriaxone sodium inj 10gm 1

ceftriaxone sodium inj 1gm 1

ceftriaxone sodium inj 250mg 1

ceftriaxone sodium inj 2gm 1

ceftriaxone sodium inj 500mg 1

cefuroxime axetil tabs 250mg 1

cefuroxime axetil tabs 500mg 1

cefuroxime sodium inj 1.5gm 1

cefuroxime sodium inj 7.5gm 1

cefuroxime sodium inj 7.5gm 1

cefuroxime sodium inj 750mg 1

cefuroxime sodium inj 75gm 1

cephalexin caps 250mg 1

cephalexin caps 500mg 1

cephalexin caps 750mg 1

cephalexin susr 125mg/5ml 1

cephalexin susr 250mg/5ml 1

cephalexin tabs 250mg 1

cephalexin tabs 500mg 1

SUPRAX CAPS 400MG 1

SUPRAX CHEW 100MG 1

SUPRAX CHEW 200MG 1

SUPRAX SUSR 500MG/5ML 1

tazicef inj 1gm 1

tazicef inj 1gm 1

tazicef inj 2gm 1

Page 23: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

13

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

tazicef inj 2gm 1

tazicef inj 6gm 1

TEFLARO INJ 400MG 1

TEFLARO INJ 600MG 1

Beta-lactam, Other

aztreonam inj 1gm 1

cefotetan inj 10gm 1

cefotetan inj 1gm 1

cefotetan inj 2gm 1

DORIBAX INJ 250MG 1

DORIBAX INJ 500MG 1

imipenem/cilastatin inj 250mg; 250mg 1

imipenem/cilastatin inj 500mg; 500mg 1

INVANZ INJ 1GM 1

INVANZ INJ 1GM 1

meropenem/sodium chloride inj 1gm/50ml; 0.9% 1

meropenem/sodium chloride inj 500mg/50ml; 0.9% 1

meropenem inj 500mg 1

Beta-lactam, Penicillins

amoxicillin/clavulanate potassium er tb12 1000mg; 62.5mg 1

amoxicillin/clavulanate potassium chew 200mg; 28.5mg 1

amoxicillin/clavulanate potassium chew 400mg; 57mg 1

amoxicillin/clavulanate potassium susr 200mg/5ml;

28.5mg/5ml

1

amoxicillin/clavulanate potassium susr 250mg/5ml;

62.5mg/5ml

1

amoxicillin/clavulanate potassium susr 400mg/5ml; 57mg/5ml 1

amoxicillin/clavulanate potassium susr 600mg/5ml;

42.9mg/5ml

1

amoxicillin/clavulanate potassium tabs 250mg; 125mg 1

amoxicillin/clavulanate potassium tabs 500mg; 125mg 1

amoxicillin/clavulanate potassium tabs 875mg; 125mg 1

amoxicillin caps 250mg 1

amoxicillin caps 500mg 1

amoxicillin chew 125mg 1

amoxicillin chew 250mg 1

amoxicillin susr 125mg/5ml 1

amoxicillin susr 200mg/5ml 1

amoxicillin susr 250mg/5ml 1

amoxicillin susr 400mg/5ml 1

amoxicillin tabs 500mg 1

amoxicillin tabs 875mg 1

ampicillin sodium inj 10gm 1

ampicillin sodium inj 10gm 1

ampicillin sodium inj 125mg 1

ampicillin sodium inj 1gm 1

ampicillin sodium inj 2gm 1

ampicillin-sulbactam inj 10gm; 5gm 1

Page 24: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

14

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

ampicillin-sulbactam inj 1gm; 0.5gm 1

ampicillin-sulbactam inj 2gm; 1gm 1

ampicillin caps 250mg 1

ampicillin caps 500mg 1

BICILLIN C-R INJ 300000UNIT/ML; 300000UNIT/ML 1

BICILLIN C-R INJ 900000UNIT/2ML; 300000UNIT/2ML 1

BICILLIN L-A INJ 1200000UNIT/2ML 1

BICILLIN L-A INJ 2400000UNIT/4ML 1

BICILLIN L-A INJ 600000UNIT/ML 1

dicloxacillin sodium caps 250mg 1

dicloxacillin sodium caps 500mg 1

nafcillin sodium inj 10gm 1

nafcillin sodium inj 1gm 1

nafcillin sodium inj 1gm 1

nafcillin sodium inj 2gm 1

nafcillin sodium inj 2gm 1

PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE INJ 0; 20000UNIT/ML

1

PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE INJ 0; 40000UNIT/ML

1

PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE INJ 0; 60000UNIT/ML

1

penicillin g potassium inj 20000000unit 1

penicillin g potassium inj 5000000unit 1

penicillin g sodium inj 5000000unit 1

penicillin v potassium solr 125mg/5ml 1

penicillin v potassium solr 250mg/5ml 1

penicillin v potassium tabs 250mg 1

penicillin v potassium tabs 500mg 1

pfizerpen-g inj 20mu 1

pfizerpen-g inj 5000000unit 1

piperacillin sodium/ tazobactam sodium inj 36gm; 4.5gm 1

piperacillin sodium/tazobactam sodium inj 2gm; 0.25gm 1

piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm 1

piperacillin/tazobactam inj 2gm; 0.25gm 1

piperacillin/tazobactam inj 2gm; 0.25gm 1

piperacillin/tazobactam inj 36gm; 4.5gm 1

piperacillin/tazobactam inj 36gm; 4.5gm 1

piperacillin/tazobactam inj 4gm; 0.5gm 1

Macrolides

AKNE-MYCIN OINT 2% 1

AZASITE SOLN 1% 1

azithromycin inj 500mg 1

azithromycin inj 500mg 1

azithromycin pack 1gm 1

azithromycin susr 100mg/5ml 1

azithromycin susr 200mg/5ml 1

azithromycin tabs 250mg 1

Page 25: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

15

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

azithromycin tabs 250mg 1

azithromycin tabs 500mg 1

azithromycin tabs 600mg 1

clarithromycin er tb24 500mg 1

clarithromycin susr 125mg/5ml 1

clarithromycin susr 250mg/5ml 1

clarithromycin tabs 250mg 1

clarithromycin tabs 500mg 1

DIFICID TABS 200MG 1 QL (20 EA per 10 days) ST

e.e.s. 400 tabs 400mg 1

E.E.S. GRANULES SUSR 200MG/5ML 1

ERY-TAB TBEC 250MG 1

ERY-TAB TBEC 333MG 1

ERY-TAB TBEC 500MG 1

ery pads 2% 1

ERYPED 200 SUSR 200MG/5ML 1

ERYPED 400 SUSR 400MG/5ML 1

ERYTHROCIN LACTOBIONATE INJ 500MG 1

ERYTHROCIN STEARATE TABS 250MG 1

erythromycin base tabs 250mg 1

erythromycin base tabs 500mg 1

erythromycin ethylsuccinate tabs 400mg 1

erythromycin cpep 250mg 1

erythromycin gel 2% 1

erythromycin oint 5mg/gm 1

erythromycin pads 2% 1

erythromycin soln 2% 1

ilotycin oint 5mg/gm 1

romycin oint 5mg/gm 1

Quinolones

BESIVANCE SUSP 0.6% 1

CILOXAN OINT 0.3% 1

CIPRO HC SUSP 0.2%; 1% 1

CIPRODEX SUSP 0.3%; 0.1% 1

ciprofloxacin er tb24 1000mg; 0 1

ciprofloxacin er tb24 500mg; 0 1

ciprofloxacin hcl soln 0.3% 1

ciprofloxacin hcl tabs 100mg 1

ciprofloxacin hcl tabs 250mg 1

ciprofloxacin hcl tabs 500mg 1

ciprofloxacin hcl tabs 750mg 1

ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5% 1

ciprofloxacin inj 400mg/40ml 1

ciprofloxacin susr 250mg/5ml 1

ciprofloxacin susr 500mg/5ml 1

gatifloxacin soln 0.5% 1

levofloxacin in d5w inj 5%; 500mg/100ml 1

levofloxacin in d5w inj 5%; 750mg/150ml 1

Page 26: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

16

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

levofloxacin inj 25mg/ml 1

levofloxacin soln 0.5% 1

levofloxacin soln 25mg/ml 1

levofloxacin tabs 250mg 1

levofloxacin tabs 500mg 1

levofloxacin tabs 750mg 1

MOXEZA SOLN 0.5% 1

moxifloxacin hcl inj 400mg/250ml 1

moxifloxacin hcl tabs 400mg 1

ofloxacin soln 0.3% 1

ofloxacin soln 0.3% 1

ofloxacin tabs 400mg 1

Sulfonamides

BLEPHAMIDE S.O.P. OINT 0.2%; 10% 1

BLEPHAMIDE SUSP 0.2%; 10% 1

sodium sulfacetamide soln 10% 1

sulfacetamide sodium/prednisolone sodium phosphate soln

0.23%; 10%

1

sulfacetamide sodium oint 10% 1

sulfadiazine tabs 500mg 1

sulfamethoxazole/trimethoprim ds tabs 800mg; 160mg 1

sulfamethoxazole/trimethoprim inj 400mg/5ml; 80mg/5ml 1

sulfamethoxazole/trimethoprim susp 200mg/5ml; 40mg/5ml 1

sulfamethoxazole/trimethoprim tabs 400mg; 80mg 1

sulfatrim pediatric susp 200mg/5ml; 40mg/5ml 1

Tetracyclines

avidoxy tabs 100mg 1

demeclocycline hcl tabs 150mg 1

demeclocycline hcl tabs 300mg 1

doxy 100 inj 100mg 1

doxycycline hyclate dr tbec 100mg 1

doxycycline hyclate dr tbec 150mg 1

doxycycline hyclate dr tbec 200mg 1

doxycycline hyclate dr tbec 50mg 1

doxycycline hyclate dr tbec 75mg 1

doxycycline hyclate caps 100mg 1

doxycycline hyclate caps 50mg 1

doxycycline hyclate inj 100mg 1

doxycycline hyclate tabs 100mg 1

doxycycline hyclate tabs 20mg 1

doxycycline monohydrate caps 100mg 1

doxycycline monohydrate caps 50mg 1

doxycycline monohydrate tabs 100mg 1

doxycycline monohydrate tabs 150mg 1

doxycycline monohydrate tabs 50mg 1

doxycycline monohydrate tabs 50mg 1

doxycycline monohydrate tabs 75mg 1

doxycycline caps 100mg 1

Page 27: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

17

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

doxycycline caps 150mg 1

doxycycline caps 75mg 1

doxycycline susr 25mg/5ml 1

minocycline hcl caps 100mg 1

minocycline hcl caps 50mg 1

minocycline hcl caps 75mg 1

minocycline hcl tabs 100mg 1

minocycline hcl tabs 50mg 1

minocycline hcl tabs 75mg 1

mondoxyne nl caps 100mg 1

mondoxyne nl caps 50mg 1

mondoxyne nl caps 75mg 1

morgidox 1x100mg caps 100mg 1

morgidox 1x100mg kit 0; 100mg; 0 1

morgidox 1x50mg kit kit 0; 50mg; 0 1

morgidox 1x50mg caps 50mg 1

morgidox 2x100mg caps 100mg 1

morgidox 2x100mg kit 0; 100mg; 0 1

tetracycline hcl caps 250mg 1

tetracycline hcl caps 500mg 1

tetracycline hydrochloride caps 250mg 1

tetracycline hydrochloride caps 500mg 1

Anticonvulsants

Anticonvulsants, Other

APTIOM TABS 200MG 1 MO

APTIOM TABS 400MG 1 MO

APTIOM TABS 600MG 1 MO

APTIOM TABS 800MG 1 MO

BRIVIACT INJ 50MG/5ML 1

BRIVIACT SOLN 10MG/ML 1 MO

BRIVIACT TABS 100MG 1 MO

BRIVIACT TABS 10MG 1 MO

BRIVIACT TABS 25MG 1 MO

BRIVIACT TABS 50MG 1 MO

BRIVIACT TABS 75MG 1 MO

FYCOMPA SUSP 0.5MG/ML 1 MO

FYCOMPA TABS 10MG 1 MO

FYCOMPA TABS 12MG 1 MO

FYCOMPA TABS 2MG 1 MO

FYCOMPA TABS 4MG 1 MO

FYCOMPA TABS 6MG 1 MO

FYCOMPA TABS 8MG 1 MO

levetiracetam er tb24 500mg 1 MO

levetiracetam er tb24 750mg 1 MO

levetiracetam inj 1000mg/100ml; 750mg/100ml 1

levetiracetam inj 1500mg/100ml; 540mg/100ml 1

levetiracetam inj 500mg/100ml; 820mg/100ml 1

levetiracetam inj 500mg/5ml 1

Page 28: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

18

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

levetiracetam soln 100mg/ml 1 MO

levetiracetam tabs 1000mg 1 MO

levetiracetam tabs 250mg 1 MO

levetiracetam tabs 500mg 1 MO

levetiracetam tabs 750mg 1 MO

magnesium sulfate/dextrose inj 5%; 3gm/50ml 1

magnesium sulfate/dextros inj 5%; 2gm/50ml 1

magnesium sulfate/sodium chloride inj 2gm/50ml; 0.9% 1

magnesium sulfate/sodium chloride inj 40gm/l; 0.9% 1

phenobarbital elix 20mg/5ml 1 MO

phenobarbital tabs 100mg 1 MO

phenobarbital tabs 15mg 1 MO

phenobarbital tabs 16.2mg 1 MO

phenobarbital tabs 30mg 1 MO

phenobarbital tabs 32.4mg 1 MO

phenobarbital tabs 60mg 1 MO

phenobarbital tabs 64.8mg 1 MO

phenobarbital tabs 97.2mg 1 MO

POTIGA TABS 200MG 1 MO

POTIGA TABS 300MG 1 MO

POTIGA TABS 400MG 1 MO

POTIGA TABS 50MG 1 MO

roweepra tabs 500mg 1 MO

SPRITAM TB3D 1000MG 1 MO

SPRITAM TB3D 250MG 1 MO

SPRITAM TB3D 500MG 1 MO

SPRITAM TB3D 750MG 1 MO

Calcium Channel Modifying Agents

CELONTIN CAPS 300MG 1 MO

ethosuximide caps 250mg 1 MO

ethosuximide soln 250mg/5ml 1 MO

LYRICA CAPS 100MG 1 MO

LYRICA CAPS 150MG 1 MO

LYRICA CAPS 200MG 1 MO

LYRICA CAPS 225MG 1 MO

LYRICA CAPS 25MG 1 MO

LYRICA CAPS 300MG 1 MO

LYRICA CAPS 50MG 1 MO

LYRICA CAPS 75MG 1 MO

LYRICA SOLN 20MG/ML 1 MO

zonisamide caps 100mg 1 MO

zonisamide caps 25mg 1 MO

zonisamide caps 50mg 1 MO

Gamma-aminobutyric Acid (GABA) Augmenting Agents

clonazepam odt tbdp 0.125mg 1 MO

clonazepam odt tbdp 0.25mg 1 MO

clonazepam odt tbdp 0.5mg 1 MO

clonazepam odt tbdp 1mg 1 MO

Page 29: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

19

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

clonazepam odt tbdp 2mg 1 MO

clonazepam tabs 0.5mg 1 MO

clonazepam tabs 1mg 1 MO

clonazepam tabs 2mg 1 MO

DIAZEPAM GEL 10MG 1

DIAZEPAM GEL 2.5MG 1

DIAZEPAM GEL 20MG 1

divalproex sodium dr tbec 125mg 1 MO

divalproex sodium dr tbec 250mg 1 MO

divalproex sodium dr tbec 500mg 1 MO

divalproex sodium er tb24 250mg 1 MO

divalproex sodium er tb24 500mg 1 MO

divalproex sodium csdr 125mg 1 MO

gabapentin caps 100mg 1 MO

gabapentin caps 300mg 1 MO

gabapentin caps 400mg 1 MO

gabapentin soln 250mg/5ml 1 MO

gabapentin tabs 600mg 1 MO

gabapentin tabs 800mg 1 MO

GABITRIL TABS 12MG 1 MO

GABITRIL TABS 16MG 1 MO

ONFI SUSP 2.5MG/ML 1 MO

ONFI TABS 10MG 1 MO

ONFI TABS 20MG 1 MO

primidone tabs 250mg 1 MO

primidone tabs 50mg 1 MO

SABRIL PACK 500MG 1 MO

SABRIL TABS 500MG 1 MO

STAVZOR CPDR 125MG 1 MO

STAVZOR CPDR 250MG 1 MO

STAVZOR CPDR 500MG 1 MO

tiagabine hydrochloride tabs 2mg 1 MO

tiagabine hydrochloride tabs 4mg 1 MO

valproate sodium inj 500mg/5ml 1

valproic acid syrp 250mg/5ml 1 MO

Glutamate Reducing Agents

felbamate susp 600mg/5ml 1 MO

felbamate tabs 400mg 1 MO

felbamate tabs 600mg 1 MO

lamotrigine er tb24 100mg 1 MO

lamotrigine er tb24 200mg 1 MO

lamotrigine er tb24 250mg 1 MO

lamotrigine er tb24 25mg 1 MO

lamotrigine er tb24 300mg 1 MO

lamotrigine er tb24 50mg 1 MO

lamotrigine odt tbdp 100mg 1 MO

lamotrigine odt tbdp 200mg 1 MO

lamotrigine odt tbdp 25mg 1 MO

Page 30: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

20

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

lamotrigine odt tbdp 50mg 1 MO

lamotrigine chew 25mg 1 MO

lamotrigine chew 5mg 1 MO

lamotrigine tabs 100mg 1 MO

lamotrigine tabs 150mg 1 MO

lamotrigine tabs 200mg 1 MO

lamotrigine tabs 25mg 1 MO

topiragen tabs 100mg 1 MO

topiragen tabs 200mg 1 MO

topiragen tabs 25mg 1 MO

topiragen tabs 50mg 1 MO

topiramate cpsp 15mg 1 MO

topiramate cpsp 25mg 1 MO

topiramate tabs 100mg 1 MO

topiramate tabs 200mg 1 MO

topiramate tabs 25mg 1 MO

topiramate tabs 50mg 1 MO

TROKENDI XR CP24 100MG 1 MO

TROKENDI XR CP24 200MG 1 MO

TROKENDI XR CP24 25MG 1 MO

TROKENDI XR CP24 50MG 1 MO

Sodium Channel Agents

BANZEL SUSP 40MG/ML 1 MO

BANZEL TABS 200MG 1 MO

BANZEL TABS 400MG 1 MO

carbamazepine er cp12 100mg 1 MO

carbamazepine er cp12 200mg 1 MO

carbamazepine er cp12 300mg 1 MO

carbamazepine er tb12 100mg 1 MO

carbamazepine er tb12 200mg 1 MO

carbamazepine er tb12 400mg 1 MO

carbamazepine chew 100mg 1 MO

carbamazepine susp 100mg/5ml 1 MO

carbamazepine tabs 200mg 1 MO

CARBATROL CP12 100MG 1 MO

CARBATROL CP12 200MG 1 MO

CARBATROL CP12 300MG 1 MO

CEREBYX INJ 500MG PE/10ML 1

DILANTIN INFATABS CHEW 50MG 1 MO

DILANTIN-125 SUSP 125MG/5ML 1 MO

DILANTIN CAPS 100MG 1 MO

DILANTIN CAPS 30MG 1 MO

epitol tabs 200mg 1 MO

EQUETRO CP12 100MG 1 MO

EQUETRO CP12 200MG 1 MO

EQUETRO CP12 300MG 1 MO

fosphenytoin sodium inj 100mg pe/2ml 1

fosphenytoin sodium inj 500mg pe/10ml 1

Page 31: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

21

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

oxcarbazepine susp 300mg/5ml 1 MO

oxcarbazepine tabs 150mg 1 MO

oxcarbazepine tabs 300mg 1 MO

oxcarbazepine tabs 600mg 1 MO

PEGANONE TABS 250MG 1 MO

PHENYTEK CAPS 200MG 1 MO

PHENYTEK CAPS 300MG 1 MO

phenytoin sodium extended caps 100mg 1 MO

phenytoin sodium extended caps 200mg 1 MO

phenytoin sodium extended caps 300mg 1 MO

phenytoin chew 50mg 1 MO

phenytoin susp 125mg/5ml 1 MO

TEGRETOL-XR TB12 100MG 1 MO

TEGRETOL-XR TB12 200MG 1 MO

TEGRETOL-XR TB12 400MG 1 MO

TEGRETOL SUSP 100MG/5ML 1 MO

TEGRETOL TABS 200MG 1 MO

VIMPAT INJ 200MG/20ML 1

VIMPAT SOLN 10MG/ML 1 MO

VIMPAT TABS 100MG 1 MO

VIMPAT TABS 150MG 1 MO

VIMPAT TABS 200MG 1 MO

VIMPAT TABS 50MG 1 MO

Antidementia Agents

Antidementia Agents, Other

ergoloid mesylates tabs 1mg 1 PA MO

NAMZARIC CP24 10MG; 21MG 1 QL (30 EA per 30 days) MO

NAMZARIC CP24 10MG; 7MG 1 QL (30 EA per 30 days) MO

Cholinesterase Inhibitors

donepezil hcl tabs 10mg 1 MO

donepezil hcl tabs 23mg 1 MO

donepezil hcl tabs 5mg 1 MO

donepezil hcl tbdp 10mg 1 MO

donepezil hcl tbdp 5mg 1 MO

EXELON PT24 13.3MG/24HR 1 MO

EXELON PT24 4.6MG/24HR 1 MO

EXELON PT24 9.5MG/24HR 1 MO

galantamine hydrobromide cp24 16mg 1 MO

galantamine hydrobromide cp24 24mg 1 MO

galantamine hydrobromide cp24 8mg 1 MO

galantamine hydrobromide soln 4mg/ml 1 MO

galantamine hydrobromide tabs 12mg 1 MO

galantamine hydrobromide tabs 4mg 1 MO

galantamine hydrobromide tabs 8mg 1 MO

rivastigmine tartrate caps 1.5mg 1 MO

rivastigmine tartrate caps 3mg 1 MO

rivastigmine tartrate caps 4.5mg 1 MO

rivastigmine tartrate caps 6mg 1 MO

Page 32: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

22

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

rivastigmine transdermal system pt24 13.3mg/24hr 1 MO

rivastigmine transdermal system pt24 4.6mg/24hr 1 MO

rivastigmine transdermal system pt24 9.5mg/24hr 1 MO

N-methyl-D-aspartate (NMDA) Receptor Antagonist

memantine hcl titration pak tabs 0 1

memantine hcl tabs 10mg 1 MO

memantine hcl tabs 5mg 1 MO

memantine hydrochloride soln 2mg/ml 1 MO

NAMENDA TITRATION PAK TABS 0 1

NAMENDA XR TITRATION PACK CP24 0 1 QL (56 EA per 365 days)

NAMENDA XR CP24 14MG 1 QL (30 EA per 30 days) MO

NAMENDA XR CP24 21MG 1 QL (30 EA per 30 days) MO

NAMENDA XR CP24 28MG 1 QL (30 EA per 30 days) MO

NAMENDA XR CP24 7MG 1 QL (30 EA per 30 days) MO

NAMENDA SOLN 10MG/5ML 1 MO

NAMENDA TABS 10MG 1 MO

NAMENDA TABS 5MG 1 MO

Antidepressants

Antidepressants, Other

APLENZIN TB24 174MG 1 QL (30 EA per 30 days) ST MO

APLENZIN TB24 348MG 1 QL (30 EA per 30 days) ST MO

APLENZIN TB24 522MG 1 QL (30 EA per 30 days) ST MO

BRINTELLIX TABS 10MG 1 QL (30 EA per 30 days) ST MO

BRINTELLIX TABS 20MG 1 QL (30 EA per 30 days) ST MO

BRINTELLIX TABS 5MG 1 QL (30 EA per 30 days) ST MO

bupropion hcl er tb12 100mg 1 MO

bupropion hcl er tb12 150mg 1 MO

bupropion hcl sr tb12 100mg 1 MO

bupropion hcl sr tb12 150mg 1 MO

bupropion hcl sr tb12 200mg 1 MO

bupropion hcl xl tb24 150mg 1 MO

bupropion hcl xl tb24 300mg 1 MO

bupropion hcl tabs 100mg 1 MO

bupropion hcl tabs 75mg 1 MO

FORFIVO XL TB24 450MG 1 QL (30 EA per 30 days) ST MO

maprotiline hcl tabs 25mg 1 MO

maprotiline hcl tabs 50mg 1 MO

maprotiline hcl tabs 75mg 1 MO

mirtazapine odt tbdp 15mg 1 MO

mirtazapine odt tbdp 30mg 1 MO

mirtazapine odt tbdp 45mg 1 MO

mirtazapine tabs 15mg 1 MO

mirtazapine tabs 30mg 1 MO

mirtazapine tabs 45mg 1 MO

mirtazapine tabs 7.5mg 1 MO

nefazodone hcl tabs 100mg 1 MO

nefazodone hcl tabs 150mg 1 MO

nefazodone hcl tabs 200mg 1 MO

Page 33: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

23

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

nefazodone hcl tabs 250mg 1 MO

nefazodone hcl tabs 50mg 1 MO

trazodone hcl tabs 100mg 1 MO

trazodone hcl tabs 150mg 1 MO

trazodone hcl tabs 300mg 1 MO

trazodone hcl tabs 50mg 1 MO

TRINTELLIX TABS 10MG 1 QL (30 EA per 30 days) ST MO

TRINTELLIX TABS 20MG 1 QL (30 EA per 30 days) ST MO

TRINTELLIX TABS 5MG 1 QL (30 EA per 30 days) ST MO

Monoamine Oxidase Inhibitors

EMSAM PT24 12MG/24HR 1 QL (30 EA per 30 days) MO

EMSAM PT24 6MG/24HR 1 QL (30 EA per 30 days) MO

EMSAM PT24 9MG/24HR 1 QL (30 EA per 30 days) MO

MARPLAN TABS 10MG 1 MO

phenelzine sulfate tabs 15mg 1 MO

tranylcypromine sulfate tabs 10mg 1 MO

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin

and Norepinephrine Reuptake Inhibitor

citalopram hydrobromide soln 10mg/5ml 1 MO

citalopram hydrobromide tabs 10mg 1 MO

citalopram hydrobromide tabs 20mg 1 MO

citalopram hydrobromide tabs 40mg 1 MO

DESVENLAFAXINE ER TB24 100MG 1 QL (30 EA per 30 days) ST MO

DESVENLAFAXINE ER TB24 100MG 1 QL (30 EA per 30 days) ST MO

DESVENLAFAXINE ER TB24 50MG 1 QL (30 EA per 30 days) ST MO

DESVENLAFAXINE ER TB24 50MG 1 QL (30 EA per 30 days) ST MO

duloxetine hcl cpep 20mg 1 QL (60 EA per 30 days) MO

duloxetine hcl cpep 30mg 1 QL (90 EA per 30 days) MO

duloxetine hcl cpep 40mg 1 QL (60 EA per 30 days) MO

duloxetine hcl cpep 60mg 1 QL (60 EA per 30 days) MO

escitalopram oxalate soln 5mg/5ml 1 MO

escitalopram oxalate tabs 10mg 1 MO

escitalopram oxalate tabs 20mg 1 MO

escitalopram oxalate tabs 5mg 1 MO

FETZIMA TITRATION PACK C4PK 0 1 QL (56 EA per 365 days) ST

FETZIMA CP24 120MG 1 QL (30 EA per 30 days) ST MO

FETZIMA CP24 20MG 1 QL (30 EA per 30 days) ST MO

FETZIMA CP24 40MG 1 QL (30 EA per 30 days) ST MO

FETZIMA CP24 80MG 1 QL (30 EA per 30 days) ST MO

fluoxetine dr cpdr 90mg 1 QL (4 EA per 28 days) MO

fluoxetine hcl caps 10mg 1 MO

fluoxetine hcl caps 20mg 1 MO

fluoxetine hcl caps 40mg 1 MO

fluoxetine hcl soln 20mg/5ml 1 MO

fluoxetine hcl tabs 10mg 1 MO

fluoxetine hcl tabs 20mg 1 MO

fluoxetine hcl tabs 60mg 1 MO

fluoxetine caps 10mg 1 MO

Page 34: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

24

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

fluoxetine caps 20mg 1 MO

fluvoxamine maleate er cp24 100mg 1 QL (60 EA per 30 days) MO

fluvoxamine maleate er cp24 150mg 1 QL (60 EA per 30 days) MO

fluvoxamine maleate tabs 100mg 1 MO

fluvoxamine maleate tabs 25mg 1 MO

fluvoxamine maleate tabs 50mg 1 MO

IRENKA CPEP 40MG 1 QL (60 EA per 30 days) MO

olanzapine/fluoxetine caps 25mg; 12mg 1 QL (30 EA per 30 days) MO

olanzapine/fluoxetine caps 25mg; 3mg 1 QL (30 EA per 30 days) MO

olanzapine/fluoxetine caps 25mg; 6mg 1 QL (90 EA per 30 days) MO

olanzapine/fluoxetine caps 50mg; 12mg 1 QL (30 EA per 30 days) MO

olanzapine/fluoxetine caps 50mg; 6mg 1 QL (30 EA per 30 days) MO

paroxetine hcl er tb24 12.5mg 1 MO

paroxetine hcl er tb24 25mg 1 MO

paroxetine hcl er tb24 37.5mg 1 MO

paroxetine hcl tabs 10mg 1 MO

paroxetine hcl tabs 20mg 1 MO

paroxetine hcl tabs 30mg 1 MO

paroxetine hcl tabs 40mg 1 MO

PAXIL SUSP 10MG/5ML 1 MO

PEXEVA TABS 10MG 1 QL (30 EA per 30 days) ST MO

PEXEVA TABS 20MG 1 QL (30 EA per 30 days) ST MO

PEXEVA TABS 30MG 1 QL (60 EA per 30 days) ST MO

PEXEVA TABS 40MG 1 QL (30 EA per 30 days) ST MO

PRISTIQ TB24 100MG 1 QL (120 EA per 30 days) ST MO

PRISTIQ TB24 25MG 1 QL (30 EA per 30 days) ST MO

PRISTIQ TB24 50MG 1 QL (120 EA per 30 days) ST MO

sertraline hcl conc 20mg/ml 1 MO

sertraline hcl tabs 100mg 1 MO

sertraline hcl tabs 25mg 1 MO

sertraline hcl tabs 50mg 1 MO

venlafaxine hcl er cp24 150mg 1 MO

venlafaxine hcl er cp24 37.5mg 1 MO

venlafaxine hcl er cp24 75mg 1 MO

venlafaxine hcl er tb24 150mg 1 MO

venlafaxine hcl er tb24 225mg 1 MO

venlafaxine hcl er tb24 37.5mg 1 MO

venlafaxine hcl er tb24 75mg 1 MO

venlafaxine hcl tabs 100mg 1 MO

venlafaxine hcl tabs 25mg 1 MO

venlafaxine hcl tabs 37.5mg 1 MO

venlafaxine hcl tabs 50mg 1 MO

venlafaxine hcl tabs 75mg 1 MO

VIIBRYD STARTER PACK KIT 0 1 QL (30 EA per 30 days) ST

VIIBRYD KIT 0 1 QL (30 EA per 30 days) ST

VIIBRYD TABS 10MG 1 QL (30 EA per 30 days) ST MO

VIIBRYD TABS 20MG 1 QL (30 EA per 30 days) ST MO

VIIBRYD TABS 40MG 1 QL (30 EA per 30 days) ST MO

Page 35: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

25

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

Tricyclics

amitriptyline hcl tabs 100mg 1 PA MO

amitriptyline hcl tabs 10mg 1 PA MO

amitriptyline hcl tabs 150mg 1 PA MO

amitriptyline hcl tabs 25mg 1 PA MO

amitriptyline hcl tabs 50mg 1 PA MO

amitriptyline hcl tabs 75mg 1 PA MO

amoxapine tabs 100mg 1 MO

amoxapine tabs 150mg 1 MO

amoxapine tabs 25mg 1 MO

amoxapine tabs 50mg 1 MO

chlordiazepoxide/amitriptyline tabs 12.5mg; 5mg 1 PA MO

chlordiazepoxide/amitriptyline tabs 25mg; 10mg 1 PA MO

clomipramine hcl caps 25mg 1 PA MO

clomipramine hcl caps 50mg 1 PA MO

clomipramine hcl caps 75mg 1 PA MO

desipramine hcl tabs 100mg 1 MO

desipramine hcl tabs 10mg 1 MO

desipramine hcl tabs 150mg 1 MO

desipramine hcl tabs 25mg 1 MO

desipramine hcl tabs 50mg 1 MO

desipramine hcl tabs 75mg 1 MO

imipramine hcl tabs 10mg 1 PA MO

imipramine hcl tabs 25mg 1 PA MO

imipramine hcl tabs 50mg 1 PA MO

nortriptyline hcl caps 10mg 1 MO

nortriptyline hcl caps 25mg 1 MO

nortriptyline hcl caps 50mg 1 MO

nortriptyline hcl caps 75mg 1 MO

nortriptyline hcl soln 10mg/5ml 1 MO

perphenazine/amitriptyline tabs 10mg; 2mg 1 PA MO

perphenazine/amitriptyline tabs 10mg; 4mg 1 PA MO

perphenazine/amitriptyline tabs 25mg; 2mg 1 PA MO

perphenazine/amitriptyline tabs 25mg; 4mg 1 PA MO

perphenazine/amitriptyline tabs 50mg; 4mg 1 PA MO

protriptyline hcl tabs 10mg 1 MO

protriptyline hcl tabs 5mg 1 MO

SURMONTIL CAPS 100MG 1 PA MO

SURMONTIL CAPS 25MG 1 PA MO

SURMONTIL CAPS 50MG 1 PA MO

trimipramine maleate caps 100mg 1 PA MO

trimipramine maleate caps 25mg 1 PA MO

trimipramine maleate caps 50mg 1 PA MO

Antiemetics

Antiemetics, Other

meclizine hcl tabs 12.5mg 1

meclizine hcl tabs 25mg 1

phenadoz supp 12.5mg 1 PA

Page 36: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

26

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

phenadoz supp 25mg 1 PA

phenergan supp 12.5mg 1 PA

phenergan supp 25mg 1 PA

phenergan supp 50mg 1 PA

promethazine hcl inj 25mg/ml 1 PA

promethazine hcl inj 50mg/ml 1 PA

promethazine hcl supp 12.5mg 1 PA

promethazine hcl supp 25mg 1 PA

promethazine hcl supp 50mg 1 PA

promethazine hcl syrp 6.25mg/5ml 1 PA

promethazine hcl tabs 12.5mg 1 PA

promethazine hcl tabs 25mg 1 PA

promethazine hcl tabs 50mg 1 PA

promethegan supp 12.5mg 1 PA

promethegan supp 25mg 1 PA

promethegan supp 50mg 1 PA

TRANSDERM-SCOP PT72 1MG/3DAYS 1

trimethobenzamide hcl caps 300mg 1 PA

Emetogenic Therapy Adjuncts

ALOXI INJ 0.25MG/5ML 1

DRONABINOL CAPS 10MG 1 QL (60 EA per 30 days) PA

dronabinol caps 2.5mg 1 QL (60 EA per 30 days) PA

dronabinol caps 5mg 1 QL (60 EA per 30 days) PA

EMEND CAPS 0 1 QL (6 EA per 30 days) B/D

EMEND CAPS 125MG 1 QL (2 EA per 30 days) B/D

EMEND CAPS 40MG 1 QL (1 EA per 30 days) B/D

EMEND CAPS 80MG 1 QL (8 EA per 30 days) B/D

EMEND INJ 150MG 1

EMEND SUSR 125MG 1 QL (6 EA per 30 days) B/D

granisetron hcl tabs 1mg 1 QL (30 EA per 30 days) B/D

ondansetron hcl inj 40mg/20ml 1

ondansetron hcl inj 4mg/2ml 1 QL (144 ML per 28 days)

ondansetron hcl inj 4mg/2ml 1 QL (144 ML per 28 days)

ondansetron hcl soln 4mg/5ml 1 QL (450 ML per 30 days) B/D

ondansetron hcl tabs 24mg 1 QL (14 EA per 28 days) B/D

ondansetron hcl tabs 4mg 1 B/D

ondansetron hcl tabs 8mg 1 B/D

ondansetron hydrochloride/sodium chloride inj 12mg/50ml;

0.9%

1

ondansetron hydrochloride/sodium chloride inj 16mg/50ml;

0.9%

1

ondansetron hydrochloride/sodium chloride inj 8mg/50ml;

0.9%

1

ondansetron odt tbdp 4mg 1 B/D

ondansetron odt tbdp 8mg 1 B/D

SANCUSO PTCH 3.1MG/24HR 1 QL (4 EA per 28 days)

SUSTOL INJ 10MG/0.4ML 1

Antifungals

Page 37: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

27

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

Antifungals

ABELCET INJ 5MG/ML 1 B/D

AMBISOME INJ 50MG 1 B/D

amphotericin b inj 50mg 1 B/D

CANCIDAS INJ 50MG 1

CANCIDAS INJ 70MG 1

ciclodan cream kit kit 0.77%; 0; 0 1

ciclodan solution kit kit 0; 8%; 0 1

ciclodan crea 0.77% 1

ciclodan soln 8% 1

ciclopirox nail lacquer soln 8% 1

ciclopirox olamine crea 0.77% 1

ciclopirox treatment kit 0; 8%; 0 1

ciclopirox gel 0.77% 1

ciclopirox sham 1% 1

ciclopirox susp 0.77% 1

clotrimazole soln 1% 1

clotrimazole troc 10mg 1

CRESEMBA CAPS 186MG 1

CRESEMBA INJ 372MG 1

econazole nitrate crea 1% 1

EXELDERM CREA 1% 1 ST

EXELDERM SOLN 1% 1 ST

fluconazole in dextrose inj 56mg/ml; 200mg/100ml 1

fluconazole in dextrose inj 56mg/ml; 400mg/200ml 1

fluconazole in nacl inj 100mg/50ml; 0.9% 1

fluconazole in nacl inj 200mg/100ml; 0.9% 1

fluconazole in nacl inj 400mg/200ml; 0.9% 1

fluconazole susr 10mg/ml 1

fluconazole susr 40mg/ml 1

fluconazole tabs 100mg 1

fluconazole tabs 150mg 1

fluconazole tabs 200mg 1

fluconazole tabs 50mg 1

flucytosine caps 250mg 1

flucytosine caps 500mg 1

griseofulvin microsize susp 125mg/5ml 1

griseofulvin microsize tabs 500mg 1

griseofulvin ultramicrosize tabs 125mg 1

griseofulvin ultramicrosize tabs 250mg 1

itraconazole caps 100mg 1 PA

ketoconazole crea 2% 1

ketoconazole foam 2% 1

ketoconazole sham 2% 1

ketoconazole tabs 200mg 1

ketodan foam 2% 1

loprox kit 0.77%; 0; 0 1

MENTAX CREA 1% 1 ST

Page 38: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

28

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

miconazole 3 supp 200mg 1

MYCAMINE INJ 100MG 1

MYCAMINE INJ 50MG 1

naftifine hcl crea 1% 1

naftifine hydrochloride crea 2% 1

NAFTIN CREA 2% 1 ST

NAFTIN GEL 1% 1 ST

NAFTIN GEL 2% 1 ST

NATACYN SUSP 5% 1

NOXAFIL INJ 300MG/16.7ML 1 MO

NOXAFIL SUSP 40MG/ML 1 PA MO

NOXAFIL TBEC 100MG 1 PA MO

nyamyc powd 100000unit/gm 1

nystatin/triamcinolone crea 100000unit/gm; 0.1% 1

nystatin/triamcinolone oint 100000unit/gm; 0.1% 1

nystatin crea 100000unit/gm 1

nystatin oint 100000unit/gm 1

nystatin powd 100000unit/gm 1

nystatin susp 100000unit/ml 1

nystatin tabs 500000unit 1

nystop powd 100000unit/gm 1

ONMEL TABS 200MG 1 PA

oxiconazole nitrate crea 1% 1

OXISTAT CREA 1% 1 ST

OXISTAT LOTN 1% 1 ST

SPORANOX SOLN 10MG/ML 1 PA

terbinafine hcl tabs 250mg 1 QL (84 EA per 168 days)

terconazole crea 0.4% 1

terconazole crea 0.8% 1

terconazole supp 80mg 1

voriconazole inj 200mg 1

voriconazole susr 40mg/ml 1

voriconazole tabs 200mg 1

voriconazole tabs 50mg 1

zazole crea 0.4% 1

zazole crea 0.8% 1

zazole supp 80mg 1

Antigout Agents

Antigout Agents

allopurinol tabs 100mg 1 MO

allopurinol tabs 300mg 1 MO

colchicine tabs 0.6mg 1

probenecid/colchicine tabs 0.5mg; 500mg 1 MO

probenecid tabs 500mg 1 MO

ULORIC TABS 40MG 1 MO

ULORIC TABS 80MG 1 MO

Antimigraine Agents

Ergot Alkaloids

Page 39: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

29

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

dihydroergotamine mesylate inj 1mg/ml 1

dihydroergotamine mesylate soln 4mg/ml 1 QL (8 ML per 28 days)

MIGERGOT SUPP 100MG; 2MG 1

Prophylactic

timolol maleate tabs 10mg 1 MO

timolol maleate tabs 20mg 1 MO

timolol maleate tabs 5mg 1 MO

valproic acid caps 250mg 1 MO

Serotonin (5-HT) 1b/1d Receptor Agonists

almotriptan malate tabs 12.5mg 1 QL (12 EA per 30 days)

almotriptan malate tabs 6.25mg 1 QL (12 EA per 30 days)

AXERT TABS 12.5MG 1 QL (12 EA per 30 days) ST

AXERT TABS 6.25MG 1 QL (12 EA per 30 days) ST

FROVA TABS 2.5MG 1 QL (9 EA per 30 days) ST

frovatriptan succinate tabs 2.5mg 1 QL (9 EA per 30 days)

naratriptan hcl tabs 1mg 1 QL (9 EA per 30 days)

naratriptan hcl tabs 2.5mg 1 QL (9 EA per 30 days)

RELPAX TABS 20MG 1 QL (9 EA per 30 days)

RELPAX TABS 40MG 1 QL (9 EA per 30 days)

rizatriptan benzoate odt tbdp 10mg 1 QL (18 EA per 30 days)

rizatriptan benzoate odt tbdp 5mg 1 QL (18 EA per 30 days)

rizatriptan benzoate tabs 10mg 1 QL (18 EA per 30 days)

rizatriptan benzoate tabs 5mg 1 QL (18 EA per 30 days)

sumatriptan succinate refill inj 4mg/0.5ml 1 QL (8 ML per 30 days)

sumatriptan succinate refill inj 6mg/0.5ml 1 QL (8 ML per 30 days)

sumatriptan succinate inj 4mg/0.5ml 1 QL (8 ML per 30 days)

sumatriptan succinate inj 6mg/0.5ml 1 QL (8 ML per 30 days)

sumatriptan succinate inj 6mg/0.5ml 1 QL (10 ML per 30 days)

sumatriptan succinate inj 6mg/0.5ml 1 QL (8 ML per 30 days)

sumatriptan succinate inj 6mg/0.5ml 1 QL (8 ML per 30 days)

sumatriptan succinate tabs 100mg 1 QL (18 EA per 30 days)

sumatriptan succinate tabs 25mg 1 QL (18 EA per 30 days)

sumatriptan succinate tabs 50mg 1 QL (18 EA per 30 days)

sumatriptan soln 20mg/act 1 QL (18 EA per 30 days)

sumatriptan soln 5mg/act 1 QL (18 EA per 30 days)

zolmitriptan odt tbdp 2.5mg 1 QL (12 EA per 30 days)

zolmitriptan odt tbdp 5mg 1 QL (12 EA per 30 days)

zolmitriptan tabs 2.5mg 1 QL (12 EA per 30 days)

zolmitriptan tabs 5mg 1 QL (12 EA per 30 days)

ZOMIG NASAL SPRAY SOLN 5MG 1 QL (18 EA per 30 days) ST

ZOMIG SOLN 2.5MG 1 QL (18 EA per 30 days) ST

Antimyasthenic Agents

Parasympathomimetics

guanidine hcl tabs 125mg 1

MESTINON TIMESPAN TBCR 180MG 1

MESTINON SYRP 60MG/5ML 1

pyridostigmine bromide er tbcr 180mg 1

pyridostigmine bromide tabs 60mg 1

Page 40: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

30

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

Antimycobacterials

Antimycobacterials, Other

dapsone tabs 100mg 1 MO

dapsone tabs 25mg 1 MO

rifabutin caps 150mg 1

Antituberculars

CAPASTAT SULFATE INJ 1GM 1

ethambutol hcl tabs 100mg 1

ethambutol hcl tabs 400mg 1

isoniazid tabs 100mg 1 MO

isoniazid tabs 300mg 1 MO

paser pack 4gm 1

PRIFTIN TABS 150MG 1

pyrazinamide tabs 500mg 1

rifampin caps 150mg 1

rifampin caps 300mg 1

rifampin inj 600mg 1

RIFATER TABS 50MG; 300MG; 120MG 1

SIRTURO TABS 100MG 1

TRECATOR TABS 250MG 1

Antineoplastics

Alkylating Agents

BENDEKA INJ 100MG/4ML 1 PA

cyclophosphamide caps 25mg 1 B/D

cyclophosphamide caps 50mg 1 B/D

cyclophosphamide tabs 25mg 1 B/D

cyclophosphamide tabs 50mg 1 B/D

EVOMELA INJ 50MG 1

GLEOSTINE CAPS 100MG 1

GLEOSTINE CAPS 10MG 1

GLEOSTINE CAPS 40MG 1

GLEOSTINE CAPS 5MG 1

HEXALEN CAPS 50MG 1 PA

LEUKERAN TABS 2MG 1

lomustine caps 100mg 1

lomustine caps 10mg 1

lomustine caps 40mg 1

MATULANE CAPS 50MG 1

MUSTARGEN INJ 10MG 1

thiotepa inj 15mg 1

TREANDA INJ 100MG 1

TREANDA INJ 180MG/2ML 1

TREANDA INJ 45MG/0.5ML 1

VALCHLOR GEL 0.016% 1 PA

YONDELIS INJ 1MG 1

Antiandrogens

bicalutamide tabs 50mg 1

flutamide caps 125mg 1

Page 41: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

31

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

NILANDRON TABS 150MG 1

nilutamide tabs 150mg 1

XTANDI CAPS 40MG 1 PA

ZYTIGA TABS 250MG 1 PA

Antiangiogenic Agents

CAPRELSA TABS 100MG 1 QL (60 EA per 30 days) PA

CAPRELSA TABS 300MG 1 PA

REVLIMID CAPS 10MG 1 PA

REVLIMID CAPS 15MG 1 PA

REVLIMID CAPS 2.5MG 1 PA

REVLIMID CAPS 20MG 1 PA

REVLIMID CAPS 25MG 1 PA

REVLIMID CAPS 5MG 1 PA

THALOMID CAPS 100MG 1 PA MO

THALOMID CAPS 150MG 1 PA MO

THALOMID CAPS 200MG 1 PA MO

THALOMID CAPS 50MG 1 PA MO

Antiestrogens/Modifiers

EMCYT CAPS 140MG 1

FARESTON TABS 60MG 1 MO

FASLODEX INJ 250MG/5ML 1

SOLTAMOX SOLN 10MG/5ML 1 MO

tamoxifen citrate tabs 10mg 1 MO

tamoxifen citrate tabs 20mg 1 MO

Antimetabolites

adrucil inj 2.5gm/50ml 1 B/D

adrucil inj 500mg/10ml 1 B/D

adrucil inj 5gm/100ml 1 B/D

ALIMTA INJ 500MG 1

cytarabine aqueous inj 100mg/ml 1 B/D

cytarabine aqueous inj 20mg/ml 1 B/D

DROXIA CAPS 200MG 1 MO

DROXIA CAPS 300MG 1 MO

DROXIA CAPS 400MG 1 MO

ELITEK INJ 7.5MG 1

fluorouracil inj 1gm/20ml 1 B/D

fluorouracil inj 2.5gm/50ml 1 B/D

fluorouracil inj 500mg/10ml 1 B/D

fluorouracil inj 500mg/10ml 1 B/D

fluorouracil inj 5gm/100ml 1 B/D

fluorouracil inj 5gm/100ml 1 B/D

GEMCITABINE HCL INJ 1GM 1

gemcitabine hcl inj 200mg 1

gemcitabine hcl inj 2gm 1

gemcitabine inj 1gm/26.3ml 1

gemcitabine inj 200mg/5.26ml 1

gemcitabine inj 200mg/5.26ml 1

gemcitabine inj 2gm/52.6ml 1

Page 42: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

32

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

hydroxyurea caps 500mg 1

LONSURF TABS 6.14MG; 15MG 1 PA

LONSURF TABS 8.19MG; 20MG 1 PA

mercaptopurine tabs 50mg 1

PURIXAN SUSP 2000MG/100ML 1

TABLOID TABS 40MG 1

Antineoplastics, Other

amifostine inj 500mg 1

ARRANON INJ 5MG/ML 1

azacitidine inj 100mg 1 PA

BELEODAQ INJ 500MG 1 PA

BLEO 15K INJ 15UNIT 1 B/D

bleomycin sulfate inj 15unit 1 B/D

bleomycin sulfate inj 30unit 1 B/D

carboplatin inj 150mg/15ml 1

carboplatin inj 450mg/45ml 1

carboplatin inj 50mg/5ml 1

carboplatin inj 600mg/60ml 1

COMETRIQ KIT 0 1 PA

COMETRIQ KIT 0 1 PA

COMETRIQ KIT 20MG 1 PA

COTELLIC TABS 20MG 1 QL (90 EA per 30 days) PA

DAUNOXOME INJ 2MG/ML 1

decitabine inj 50mg 1 PA

DEXRAZOXANE INJ 250MG 1

dexrazoxane inj 500mg 1

docetaxel (non-alcohol formula) inj 160mg/8ml 1

docetaxel (non-alcohol formula) inj 20mg/ml 1

docetaxel (non-alcohol formula) inj 80mg/4ml 1

docetaxel inj 160mg/16ml 1

DOCETAXEL INJ 200MG/20ML 1

docetaxel inj 20mg/0.5ml 1

docetaxel inj 20mg/2ml 1

docetaxel inj 20mg/2ml 1

docetaxel inj 80mg/2ml 1

docetaxel inj 80mg/4ml 1

DOCETAXEL INJ 80MG/8ML 1

doxorubicin hcl liposome inj 2mg/ml 1 B/D

doxorubicin hcl inj 10mg 1 B/D

doxorubicin hcl inj 2mg/ml 1 B/D

doxorubicin hcl inj 50mg 1 B/D

ERIVEDGE CAPS 150MG 1 PA

ERWINAZE INJ 10000UNIT 1 PA

FARYDAK CAPS 10MG 1 QL (6 EA per 21 days) PA

FARYDAK CAPS 15MG 1 QL (6 EA per 21 days) PA

FARYDAK CAPS 20MG 1 QL (6 EA per 21 days) PA

GILOTRIF TABS 20MG 1 PA

GILOTRIF TABS 30MG 1 PA

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

GILOTRIF TABS 40MG 1 PA

IBRANCE CAPS 100MG 1 PA

IBRANCE CAPS 125MG 1 PA

IBRANCE CAPS 75MG 1 PA

ICLUSIG TABS 15MG 1 QL (60 EA per 30 days) PA

ICLUSIG TABS 45MG 1 PA

irinotecan inj 100mg/5ml 1

irinotecan inj 40mg/2ml 1

irinotecan inj 500mg/25ml 1

IXEMPRA KIT INJ 45MG 1 PA

JAKAFI TABS 10MG 1 PA

JAKAFI TABS 15MG 1 PA

JAKAFI TABS 20MG 1 PA

JAKAFI TABS 25MG 1 PA

JAKAFI TABS 5MG 1 PA

JEVTANA INJ 60MG/1.5ML 1 PA

leucovorin calcium inj 100mg 1

leucovorin calcium inj 350mg 1

leucovorin calcium tabs 10mg 1

leucovorin calcium tabs 15mg 1

leucovorin calcium tabs 25mg 1

leucovorin calcium tabs 5mg 1

LEVOLEUCOVORIN CALCIUM INJ 175MG/17.5ML 1

LEVOLEUCOVORIN INJ 175MG/17.5ML 1

levoleucovorin inj 250mg/25ml 1

lipodox 50 inj 2mg/ml 1 B/D

lipodox inj 2mg/ml 1 B/D

LYNPARZA CAPS 50MG 1 PA

MEKINIST TABS 0.5MG 1 PA

MEKINIST TABS 2MG 1 PA

MENEST TABS 0.3MG 1 PA MO

MENEST TABS 0.625MG 1 PA MO

MENEST TABS 1.25MG 1 PA MO

MENEST TABS 2.5MG 1 PA MO

mesna inj 100mg/ml 1

MESNEX TABS 400MG 1

mitomycin inj 20mg 1

mitoxantrone hcl inj 2mg/ml 1

mitoxantrone hcl inj 2mg/ml 1

mitoxantrone hcl inj 2mg/ml 1

NINLARO CAPS 2.3MG 1 PA

NINLARO CAPS 3MG 1 PA

NINLARO CAPS 4MG 1 PA

ODOMZO CAPS 200MG 1 PA

ONCASPAR INJ 750UNIT/ML 1

ONIVYDE INJ 43MG/10ML 1

oxaliplatin inj 100mg/20ml 1

oxaliplatin inj 50mg 1

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

paclitaxel inj 100mg/16.7ml 1

paclitaxel inj 150mg/25ml 1

paclitaxel inj 300mg/50ml 1

paclitaxel inj 30mg/5ml 1

POMALYST CAPS 1MG 1 PA

POMALYST CAPS 2MG 1 PA

POMALYST CAPS 3MG 1 PA

POMALYST CAPS 4MG 1 PA

PORTRAZZA INJ 800MG/50ML 1 PA

SYLATRON INJ 200MCG 1 PA MO

SYLATRON INJ 300MCG 1 PA MO

SYLATRON INJ 600MCG 1 PA MO

SYNRIBO INJ 3.5MG 1 PA

TAFINLAR CAPS 50MG 1 PA

TAFINLAR CAPS 75MG 1 PA

TAGRISSO TABS 40MG 1 QL (30 EA per 30 days) PA

TAGRISSO TABS 80MG 1 QL (30 EA per 30 days) PA

VELCADE INJ 3.5MG 1 PA

VENCLEXTA STARTING PACK TBPK 0 1 PA

VENCLEXTA TABS 100MG 1 PA

VENCLEXTA TABS 10MG 1 PA

VENCLEXTA TABS 50MG 1 PA

vincasar pfs inj 1mg/ml 1 B/D

vincristine sulfate inj 1mg/ml 1 B/D

ZALTRAP INJ 100MG/4ML 1 PA

ZOLINZA CAPS 100MG 1 PA

ZYKADIA CAPS 150MG 1 PA

Aromatase Inhibitors, 3rd Generation

anastrozole tabs 1mg 1 MO

exemestane tabs 25mg 1 MO

letrozole tabs 2.5mg 1 MO

Enzyme Inhibitors

etoposide inj 100mg/5ml 1

etoposide inj 100mg/5ml 1

etoposide inj 1gm/50ml 1

etoposide inj 500mg/25ml 1

KYPROLIS INJ 30MG 1 PA

KYPROLIS INJ 60MG 1 PA

toposar inj 1gm/50ml 1

toposar inj 500mg/25ml 1

toposar inj 500mg/25ml 1

topotecan hcl inj 4mg/4ml 1

topotecan hcl inj 4mg 1

ZYDELIG TABS 100MG 1 PA

ZYDELIG TABS 150MG 1 PA

Molecular Target Inhibitors

AFINITOR DISPERZ TBSO 2MG 1 PA

AFINITOR DISPERZ TBSO 3MG 1 PA

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

AFINITOR DISPERZ TBSO 5MG 1 PA

AFINITOR TABS 10MG 1 PA

AFINITOR TABS 2.5MG 1 PA

AFINITOR TABS 5MG 1 PA

AFINITOR TABS 7.5MG 1 PA

ALECENSA CAPS 150MG 1 QL (240 EA per 30 days) PA

BOSULIF TABS 100MG 1 PA

BOSULIF TABS 500MG 1 PA

CABOMETYX TABS 20MG 1 PA

CABOMETYX TABS 40MG 1 PA

CABOMETYX TABS 60MG 1 PA

GLEEVEC TABS 100MG 1 PA

GLEEVEC TABS 400MG 1 PA

imatinib mesylate tabs 100mg 1 PA

imatinib mesylate tabs 400mg 1 PA

IMBRUVICA CAPS 140MG 1 PA

INLYTA TABS 1MG 1 PA

INLYTA TABS 5MG 1 PA

IRESSA TABS 250MG 1 PA

LENVIMA 10 MG DAILY DOSE CPPK 10MG 1 PA

LENVIMA 14 MG DAILY DOSE CPPK 0 1 PA

LENVIMA 18 MG DAILY DOSE CPPK 0 1 PA

LENVIMA 20 MG DAILY DOSE CPPK 10MG 1 PA

LENVIMA 24 MG DAILY DOSE CPPK 0 1 PA

LENVIMA 8 MG DAILY DOSE CPPK 4MG 1 PA

LENVIMA 8 MG DAILY DOSE CPPK 4MG 1 PA

NEXAVAR TABS 200MG 1 PA

SPRYCEL TABS 100MG 1 PA

SPRYCEL TABS 140MG 1 PA

SPRYCEL TABS 20MG 1 PA

SPRYCEL TABS 50MG 1 PA

SPRYCEL TABS 70MG 1 PA

SPRYCEL TABS 80MG 1 PA

STIVARGA TABS 40MG 1 PA

SUTENT CAPS 12.5MG 1 PA

SUTENT CAPS 25MG 1 PA

SUTENT CAPS 37.5MG 1 PA

SUTENT CAPS 50MG 1 PA

TARCEVA TABS 100MG 1 PA

TARCEVA TABS 150MG 1 PA

TARCEVA TABS 25MG 1 PA

TASIGNA CAPS 150MG 1 PA

TASIGNA CAPS 200MG 1 PA

TYKERB TABS 250MG 1 PA

VOTRIENT TABS 200MG 1 PA

XALKORI CAPS 200MG 1 PA

XALKORI CAPS 250MG 1 PA

ZELBORAF TABS 240MG 1 PA

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36

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

Monoclonal Antibodies

ARZERRA INJ 1000MG/50ML 1 PA

ARZERRA INJ 100MG/5ML 1 PA

AVASTIN INJ 100MG/4ML 1 PA

AVASTIN INJ 400MG/16ML 1 PA

CYRAMZA INJ 100MG/10ML 1 PA

CYRAMZA INJ 500MG/50ML 1 PA

DARZALEX INJ 100MG/5ML 1 PA

DARZALEX INJ 400MG/20ML 1 PA

EMPLICITI INJ 300MG 1 PA

EMPLICITI INJ 400MG 1 PA

ERBITUX INJ 100MG/50ML 1 PA

HERCEPTIN INJ 440MG 1 PA

KADCYLA INJ 100MG 1 PA

KEYTRUDA INJ 100MG/4ML 1 PA

KEYTRUDA INJ 50MG 1 PA

OPDIVO INJ 100MG/10ML 1 PA

OPDIVO INJ 40MG/4ML 1 PA

PERJETA INJ 420MG/14ML 1 PA

RITUXAN INJ 500MG/50ML 1 PA

SYLVANT INJ 100MG 1 PA

SYLVANT INJ 400MG 1 PA

TECENTRIQ INJ 1200MG/20ML 1 PA

UNITUXIN INJ 17.5MG/5ML 1

VECTIBIX INJ 100MG/5ML 1 PA

YERVOY INJ 50MG/10ML 1 PA

Retinoids

bexarotene caps 75mg 1 PA

PANRETIN GEL 0.1% 1

TARGRETIN CAPS 75MG 1 PA

TARGRETIN GEL 1% 1 PA

tretinoin caps 10mg 1

Antiparasitics

Anthelmintics

ALBENZA TABS 200MG 1

BILTRICIDE TABS 600MG 1

ivermectin tabs 3mg 1

Antiprotozoals

ALINIA TABS 500MG 1

atovaquone/proguanil hcl tabs 250mg; 100mg 1

atovaquone/proguanil hcl tabs 62.5mg; 25mg 1

atovaquone susp 750mg/5ml 1

chloroquine phosphate tabs 250mg 1 MO

chloroquine phosphate tabs 500mg 1 MO

COARTEM TABS 20MG; 120MG 1

DARAPRIM TABS 25MG 1

hydroxychloroquine sulfate tabs 200mg 1 MO

mefloquine hcl tabs 250mg 1 MO

Page 47: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

NEBUPENT SOLR 300MG 1 B/D

PENTAM 300 INJ 300MG 1

PRIMAQUINE PHOSPHATE TABS 26.3MG 1

quinine sulfate caps 324mg 1 PA

tinidazole tabs 250mg 1

tinidazole tabs 500mg 1

Pediculicides/Scabicides

EURAX CREA 10% 1

EURAX LOTN 10% 1

lindane lotn 1% 1

lindane sham 1% 1

malathion lotn 0.5% 1

permethrin crea 5% 1

SKLICE LOTN 0.5% 1

Antiparkinson Agents

Anticholinergics

benztropine mesylate inj 1mg/ml 1

benztropine mesylate tabs 0.5mg 1 PA MO

benztropine mesylate tabs 1mg 1 PA MO

benztropine mesylate tabs 2mg 1 PA MO

trihexyphenidyl hcl tabs 2mg 1 PA MO

trihexyphenidyl hcl tabs 5mg 1 PA MO

Antiparkinson Agents, Other

entacapone tabs 200mg 1 MO

tolcapone tabs 100mg 1 MO

Dopamine Agonists

APOKYN INJ 10MG/ML 1 PA

bromocriptine mesylate caps 5mg 1 MO

bromocriptine mesylate tabs 2.5mg 1 MO

NEUPRO PT24 1MG/24HR 1 ST MO

NEUPRO PT24 2MG/24HR 1 ST MO

NEUPRO PT24 3MG/24HR 1 ST MO

NEUPRO PT24 4MG/24HR 1 ST MO

NEUPRO PT24 6MG/24HR 1 ST MO

NEUPRO PT24 8MG/24HR 1 ST MO

pramipexole dihydrochloride tabs 0.125mg 1 MO

pramipexole dihydrochloride tabs 0.25mg 1 MO

pramipexole dihydrochloride tabs 0.5mg 1 MO

pramipexole dihydrochloride tabs 0.75mg 1 MO

pramipexole dihydrochloride tabs 1.5mg 1 MO

pramipexole dihydrochloride tabs 1mg 1 MO

ropinirole er tb24 12mg 1 MO

ropinirole er tb24 2mg 1 MO

ropinirole er tb24 4mg 1 MO

ropinirole er tb24 6mg 1 MO

ropinirole er tb24 8mg 1 MO

ropinirole hcl tabs 0.25mg 1 MO

ropinirole hcl tabs 0.5mg 1 MO

Page 48: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

38

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

ropinirole hcl tabs 1mg 1 MO

ropinirole hcl tabs 2mg 1 MO

ropinirole hcl tabs 3mg 1 MO

ropinirole hcl tabs 4mg 1 MO

ropinirole hcl tabs 5mg 1 MO

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors

carbidopa/levodopa er tbcr 25mg; 100mg 1 MO

carbidopa/levodopa er tbcr 50mg; 200mg 1 MO

carbidopa/levodopa odt tbdp 10mg; 100mg 1 MO

carbidopa/levodopa odt tbdp 25mg; 100mg 1 MO

carbidopa/levodopa odt tbdp 25mg; 250mg 1 MO

carbidopa/levodopa/entacapone tabs 12.5mg; 200mg; 50mg 1 MO

carbidopa/levodopa/entacapone tabs 18.75mg; 200mg; 75mg 1 MO

carbidopa/levodopa/entacapone tabs 25mg; 200mg; 100mg 1 MO

carbidopa/levodopa/entacapone tabs 31.25mg; 200mg;

125mg

1 MO

carbidopa/levodopa/entacapone tabs 37.5mg; 200mg; 150mg 1 MO

carbidopa/levodopa/entacapone tabs 50mg; 200mg; 200mg 1 MO

carbidopa/levodopa tabs 10mg; 100mg 1 MO

carbidopa/levodopa tabs 25mg; 100mg 1 MO

carbidopa/levodopa tabs 25mg; 250mg 1 MO

carbidopa tabs 25mg 1 MO

Monoamine Oxidase B (MAO-B) Inhibitors

AZILECT TABS 0.5MG 1 MO

AZILECT TABS 1MG 1 MO

selegiline hcl caps 5mg 1 MO

selegiline hcl tabs 5mg 1 MO

ZELAPAR TBDP 1.25MG 1 MO

Antipsychotics

1st Generation/Typical

chlorpromazine hcl inj 50mg/2ml 1

chlorpromazine hcl tabs 100mg 1 MO

chlorpromazine hcl tabs 10mg 1 MO

chlorpromazine hcl tabs 200mg 1 MO

chlorpromazine hcl tabs 25mg 1 MO

chlorpromazine hcl tabs 50mg 1 MO

compro supp 25mg 1

fluphenazine decanoate inj 25mg/ml 1

fluphenazine hcl conc 5mg/ml 1 MO

fluphenazine hcl elix 2.5mg/5ml 1 MO

fluphenazine hcl inj 2.5mg/ml 1

fluphenazine hcl tabs 10mg 1 MO

fluphenazine hcl tabs 1mg 1 MO

fluphenazine hcl tabs 2.5mg 1 MO

fluphenazine hcl tabs 5mg 1 MO

haloperidol decanoate inj 100mg/ml 1

haloperidol decanoate inj 50mg/ml 1

haloperidol lactate inj 5mg/ml 1

Page 49: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

39

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

haloperidol conc 2mg/ml 1 MO

haloperidol tabs 0.5mg 1 MO

haloperidol tabs 10mg 1 MO

haloperidol tabs 1mg 1 MO

haloperidol tabs 20mg 1 MO

haloperidol tabs 2mg 1 MO

haloperidol tabs 5mg 1 MO

loxapine succinate caps 10mg 1 MO

loxapine succinate caps 25mg 1 MO

loxapine succinate caps 50mg 1 MO

loxapine succinate caps 5mg 1 MO

ORAP TABS 1MG 1 MO

ORAP TABS 2MG 1 MO

perphenazine tabs 16mg 1 MO

perphenazine tabs 2mg 1 MO

perphenazine tabs 4mg 1 MO

perphenazine tabs 8mg 1 MO

pimozide tabs 1mg 1 MO

pimozide tabs 2mg 1 MO

prochlorperazine edisylate inj 5mg/ml 1

prochlorperazine maleate tabs 10mg 1 MO

prochlorperazine maleate tabs 5mg 1 MO

prochlorperazine supp 25mg 1

thioridazine hcl tabs 100mg 1 PA MO

thioridazine hcl tabs 10mg 1 PA MO

thioridazine hcl tabs 25mg 1 PA MO

thioridazine hcl tabs 50mg 1 PA MO

thiothixene caps 10mg 1 MO

thiothixene caps 1mg 1 MO

thiothixene caps 2mg 1 MO

thiothixene caps 5mg 1 MO

trifluoperazine hcl tabs 10mg 1 MO

trifluoperazine hcl tabs 1mg 1 MO

trifluoperazine hcl tabs 2mg 1 MO

trifluoperazine hcl tabs 5mg 1 MO

2nd Generation/Atypical

ABILIFY DISCMELT TBDP 10MG 1 QL (60 EA per 30 days) ST MO

ABILIFY DISCMELT TBDP 15MG 1 QL (60 EA per 30 days) ST MO

ABILIFY MAINTENA INJ 300MG 1 ST MO

ABILIFY MAINTENA INJ 300MG 1 ST MO

ABILIFY MAINTENA INJ 400MG 1 ST MO

ABILIFY INJ 9.75MG/1.3ML 1 QL (900 ML per 30 days)

ABILIFY SOLN 1MG/ML 1 QL (900 ML per 30 days) ST MO

aripiprazole odt tbdp 10mg 1 QL (60 EA per 30 days) MO

aripiprazole odt tbdp 15mg 1 QL (60 EA per 30 days) MO

aripiprazole soln 1mg/ml 1 QL (900 ML per 30 days) MO

aripiprazole tabs 10mg 1 QL (30 EA per 30 days) MO

aripiprazole tabs 15mg 1 QL (30 EA per 30 days) MO

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40

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

aripiprazole tabs 20mg 1 QL (30 EA per 30 days) MO

aripiprazole tabs 2mg 1 QL (60 EA per 30 days) MO

aripiprazole tabs 30mg 1 QL (30 EA per 30 days) MO

aripiprazole tabs 5mg 1 QL (60 EA per 30 days) MO

ARISTADA INJ 441MG/1.6ML 1 MO

ARISTADA INJ 662MG/2.4ML 1 MO

ARISTADA INJ 882MG/3.2ML 1 MO

FANAPT TITRATION PACK TABS 0 1 QL (8 EA per 180 days) ST

FANAPT TABS 10MG 1 QL (60 EA per 30 days) ST

FANAPT TABS 12MG 1 QL (60 EA per 30 days) ST

FANAPT TABS 1MG 1 QL (60 EA per 30 days) ST

FANAPT TABS 2MG 1 QL (60 EA per 30 days) ST

FANAPT TABS 4MG 1 QL (60 EA per 30 days) ST

FANAPT TABS 6MG 1 QL (60 EA per 30 days) ST

FANAPT TABS 8MG 1 QL (60 EA per 30 days) ST

GEODON INJ 20MG 1

INVEGA SUSTENNA INJ 117MG/0.75ML 1

INVEGA SUSTENNA INJ 156MG/ML 1

INVEGA SUSTENNA INJ 234MG/1.5ML 1

INVEGA SUSTENNA INJ 39MG/0.25ML 1

INVEGA SUSTENNA INJ 78MG/0.5ML 1

INVEGA TRINZA INJ 273MG/0.875ML 1 MO

INVEGA TRINZA INJ 410MG/1.315ML 1 MO

INVEGA TRINZA INJ 546MG/1.75ML 1 MO

INVEGA TRINZA INJ 819MG/2.625ML 1 MO

INVEGA TB24 1.5MG 1 QL (30 EA per 30 days) ST MO

INVEGA TB24 3MG 1 QL (30 EA per 30 days) ST MO

INVEGA TB24 6MG 1 QL (60 EA per 30 days) ST MO

INVEGA TB24 9MG 1 QL (30 EA per 30 days) ST MO

LATUDA TABS 120MG 1 QL (30 EA per 30 days) ST MO

LATUDA TABS 20MG 1 QL (30 EA per 30 days) ST MO

LATUDA TABS 40MG 1 QL (30 EA per 30 days) ST MO

LATUDA TABS 60MG 1 QL (30 EA per 30 days) ST MO

LATUDA TABS 80MG 1 QL (60 EA per 30 days) ST MO

NUPLAZID TABS 17MG 1 QL (60 EA per 30 days) PA MO

olanzapine odt tbdp 10mg 1 QL (30 EA per 30 days) MO

olanzapine odt tbdp 15mg 1 QL (30 EA per 30 days) MO

olanzapine odt tbdp 20mg 1 QL (30 EA per 30 days) MO

olanzapine odt tbdp 5mg 1 QL (30 EA per 30 days) MO

olanzapine inj 10mg 1

olanzapine tabs 10mg 1 QL (30 EA per 30 days) MO

olanzapine tabs 15mg 1 QL (30 EA per 30 days) MO

olanzapine tabs 2.5mg 1 QL (30 EA per 30 days) MO

olanzapine tabs 20mg 1 QL (30 EA per 30 days) MO

olanzapine tabs 5mg 1 QL (30 EA per 30 days) MO

olanzapine tabs 7.5mg 1 QL (30 EA per 30 days) MO

paliperidone er tb24 1.5mg 1 QL (30 EA per 30 days) MO

paliperidone er tb24 3mg 1 QL (30 EA per 30 days) MO

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

paliperidone er tb24 6mg 1 QL (60 EA per 30 days) MO

paliperidone er tb24 9mg 1 QL (30 EA per 30 days) MO

quetiapine fumarate tabs 100mg 1 QL (60 EA per 30 days) MO

quetiapine fumarate tabs 200mg 1 QL (60 EA per 30 days) MO

quetiapine fumarate tabs 25mg 1 QL (90 EA per 30 days) MO

quetiapine fumarate tabs 300mg 1 QL (60 EA per 30 days) MO

quetiapine fumarate tabs 400mg 1 QL (60 EA per 30 days) MO

quetiapine fumarate tabs 50mg 1 QL (90 EA per 30 days) MO

REXULTI TABS 0.25MG 1 QL (30 EA per 30 days) ST MO

REXULTI TABS 0.5MG 1 QL (30 EA per 30 days) ST MO

REXULTI TABS 1MG 1 QL (30 EA per 30 days) ST MO

REXULTI TABS 2MG 1 QL (30 EA per 30 days) ST MO

REXULTI TABS 3MG 1 QL (30 EA per 30 days) ST MO

REXULTI TABS 4MG 1 QL (30 EA per 30 days) ST MO

RISPERDAL CONSTA INJ 12.5MG 1

RISPERDAL CONSTA INJ 25MG 1

RISPERDAL CONSTA INJ 37.5MG 1

RISPERDAL CONSTA INJ 50MG 1

risperidone m-tab tbdp 0.5mg 1 QL (60 EA per 30 days) MO

risperidone m-tab tbdp 1mg 1 QL (60 EA per 30 days) MO

risperidone m-tab tbdp 2mg 1 QL (60 EA per 30 days) MO

risperidone m-tab tbdp 3mg 1 QL (60 EA per 30 days) MO

risperidone m-tab tbdp 4mg 1 QL (60 EA per 30 days) MO

risperidone odt tbdp 0.25mg 1 QL (60 EA per 30 days) MO

risperidone odt tbdp 0.5mg 1 QL (60 EA per 30 days) MO

risperidone odt tbdp 1mg 1 QL (60 EA per 30 days) MO

risperidone odt tbdp 2mg 1 QL (60 EA per 30 days) MO

risperidone odt tbdp 3mg 1 QL (60 EA per 30 days) MO

risperidone odt tbdp 4mg 1 QL (60 EA per 30 days) MO

risperidone soln 1mg/ml 1 QL (240 ML per 30 days) MO

risperidone tabs 0.25mg 1 QL (60 EA per 30 days) MO

risperidone tabs 0.5mg 1 QL (60 EA per 30 days) MO

risperidone tabs 1mg 1 QL (60 EA per 30 days) MO

risperidone tabs 2mg 1 QL (60 EA per 30 days) MO

risperidone tabs 3mg 1 QL (60 EA per 30 days) MO

risperidone tabs 4mg 1 QL (60 EA per 30 days) MO

SAPHRIS SUBL 10MG 1 QL (60 EA per 30 days) ST MO

SAPHRIS SUBL 2.5MG 1 QL (60 EA per 30 days) ST MO

SAPHRIS SUBL 5MG 1 QL (60 EA per 30 days) ST MO

SEROQUEL XR TB24 150MG 1 QL (30 EA per 30 days) MO

SEROQUEL XR TB24 200MG 1 QL (30 EA per 30 days) MO

SEROQUEL XR TB24 300MG 1 QL (60 EA per 30 days) MO

SEROQUEL XR TB24 400MG 1 QL (60 EA per 30 days) MO

SEROQUEL XR TB24 50MG 1 QL (60 EA per 30 days) MO

VRAYLAR CAPS 1.5MG 1 QL (30 EA per 30 days) ST MO

VRAYLAR CAPS 3MG 1 QL (30 EA per 30 days) ST MO

VRAYLAR CAPS 4.5MG 1 QL (30 EA per 30 days) ST MO

VRAYLAR CAPS 6MG 1 QL (30 EA per 30 days) ST MO

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

VRAYLAR CPPK 0 1 QL (14 EA per 365 days) ST

ziprasidone hcl caps 20mg 1 QL (60 EA per 30 days) MO

ziprasidone hcl caps 40mg 1 QL (60 EA per 30 days) MO

ziprasidone hcl caps 60mg 1 QL (60 EA per 30 days) MO

ziprasidone hcl caps 80mg 1 QL (60 EA per 30 days) MO

ZYPREXA RELPREVV INJ 210MG 1

ZYPREXA RELPREVV INJ 300MG 1

ZYPREXA RELPREVV INJ 300MG 1

ZYPREXA RELPREVV INJ 405MG 1

ZYPREXA RELPREVV INJ 405MG 1

Antipsychotics

molindone hydrochloride tabs 10mg 1 MO

molindone hydrochloride tabs 25mg 1 MO

molindone hydrochloride tabs 5mg 1 MO

Treatment-Resistant

clozapine odt tbdp 100mg 1 QL (270 EA per 30 days)

clozapine odt tbdp 12.5mg 1 QL (90 EA per 30 days)

clozapine odt tbdp 150mg 1 QL (180 EA per 30 days)

clozapine odt tbdp 200mg 1 QL (120 EA per 30 days)

clozapine odt tbdp 25mg 1 QL (270 EA per 30 days)

clozapine tabs 100mg 1 QL (270 EA per 30 days)

clozapine tabs 200mg 1 QL (120 EA per 30 days)

clozapine tabs 25mg 1 QL (270 EA per 30 days)

clozapine tabs 50mg 1 QL (180 EA per 30 days)

VERSACLOZ SUSP 50MG/ML 1 QL (540 ML per 30 days) ST

Antispasticity Agents

Antispasticity Agents

baclofen tabs 10mg 1 MO

baclofen tabs 20mg 1 MO

dantrolene sodium caps 100mg 1

dantrolene sodium caps 25mg 1

dantrolene sodium caps 50mg 1

tizanidine hcl caps 2mg 1 MO

tizanidine hcl caps 4mg 1 MO

tizanidine hcl caps 6mg 1 MO

tizanidine hcl tabs 2mg 1 MO

tizanidine hcl tabs 4mg 1 MO

Antivirals

Anti-cytomegalovirus (CMV) Agents

cidofovir inj 75mg/ml 1

ganciclovir inj 500mg 1 B/D

valganciclovir tabs 450mg 1 MO

ZIRGAN GEL 0.15% 1

Anti-hepatitis B (HBV) Agents

adefovir dipivoxil tabs 10mg 1 QL (30 EA per 30 days) PA MO

BARACLUDE SOLN 0.05MG/ML 1 QL (630 ML per 30 days) PA MO

entecavir tabs 0.5mg 1 QL (30 EA per 30 days) PA MO

entecavir tabs 1mg 1 QL (30 EA per 30 days) PA MO

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

INTRON A W/DILUENT INJ 10MU 1 PA MO

INTRON A W/DILUENT INJ 18MU 1 PA MO

INTRON A W/DILUENT INJ 50MU 1 PA MO

INTRON A INJ 10MU 1 PA MO

INTRON A INJ 18MU 1 PA MO

INTRON A INJ 50MU 1 PA MO

INTRON A INJ 6000000UNIT/ML 1 PA MO

TYZEKA TABS 600MG 1 QL (30 EA per 30 days) PA MO

Anti-hepatitis C (HCV) Agents

DAKLINZA TABS 30MG 1 QL (168 EA per 365 days) PA

DAKLINZA TABS 60MG 1 QL (168 EA per 365 days) PA

DAKLINZA TABS 90MG 1 QL (168 EA per 365 days) PA

EPCLUSA TABS 400MG; 100MG 1 QL (84 EA per 365 days) PA

HARVONI TABS 90MG; 400MG 1 QL (168 EA per 365 days) PA

moderiba 1200 dose pack tabs 600mg 1

MODERIBA 800 DOSE PACK TABS 400MG 1

MODERIBA MISC 0 1

MODERIBA MISC 0 1

moderiba tabs 200mg 1

OLYSIO CAPS 150MG 1 PA

PEG-INTRON REDIPEN PAK 4 INJ 120MCG/0.5ML 1 PA

PEG-INTRON REDIPEN PAK 4 INJ 150MCG/0.5ML 1 PA

PEG-INTRON REDIPEN PAK 4 INJ 50MCG/0.5ML 1 PA

PEG-INTRON REDIPEN PAK 4 INJ 80MCG/0.5ML 1 PA

PEG-INTRON REDIPEN INJ 120MCG/0.5ML 1 PA

PEG-INTRON REDIPEN INJ 150MCG/0.5ML 1 PA

PEG-INTRON REDIPEN INJ 50MCG/0.5ML 1 PA

PEG-INTRON REDIPEN INJ 80MCG/0.5ML 1 PA

PEGASYS PROCLICK INJ 135MCG/0.5ML 1 PA

PEGASYS PROCLICK INJ 180MCG/0.5ML 1 PA

PEGASYS INJ 180MCG/0.5ML 1 PA

PEGASYS INJ 180MCG/ML 1 PA

PEGINTRON INJ 120MCG/0.5ML 1 PA

PEGINTRON INJ 150MCG/0.5ML 1 PA

PEGINTRON INJ 50MCG/0.5ML 1 PA

PEGINTRON INJ 80MCG/0.5ML 1 PA

RIBASPHERE RIBAPAK TABS 0 1

RIBASPHERE RIBAPAK TABS 0 1

RIBASPHERE RIBAPAK TABS 400MG 1

RIBASPHERE RIBAPAK TABS 600MG 1

ribasphere caps 200mg 1

ribasphere tabs 200mg 1

RIBASPHERE TABS 400MG 1

RIBASPHERE TABS 600MG 1

RIBATAB MISC 0 1

RIBATAB TABS 400MG 1

ribavirin caps 200mg 1

ribavirin tabs 200mg 1

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

SOVALDI TABS 400MG 1 PA

TECHNIVIE TABS 12.5MG; 75MG; 50MG 1 QL (168 EA per 365 days) PA

VIEKIRA PAK TBPK 250MG; 12.5MG; 75MG; 50MG 1 QL (672 EA per 365 days) PA

VIEKIRA XR TB24 200MG; 8.33MG; 50MG; 33.33MG 1 QL (504 EA per 365 days) PA

Anti-HIV Agents, Integrase Inhibitors (INSTI)

ATRIPLA TABS 600MG; 200MG; 300MG 1 QL (30 EA per 30 days) MO

GENVOYA TABS 150MG; 150MG; 200MG; 10MG 1 QL (30 EA per 30 days) MO

ISENTRESS CHEW 100MG 1 MO

ISENTRESS CHEW 25MG 1 MO

ISENTRESS PACK 100MG 1 MO

ISENTRESS TABS 400MG 1 QL (60 EA per 30 days) MO

TIVICAY TABS 10MG 1 MO

TIVICAY TABS 25MG 1 MO

TIVICAY TABS 50MG 1 MO

VITEKTA TABS 150MG 1 QL (30 EA per 30 days) MO

VITEKTA TABS 85MG 1 QL (30 EA per 30 days) MO

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase

Inhibitors (NNRTI)

COMPLERA TABS 200MG; 25MG; 300MG 1 QL (30 EA per 30 days) MO

EDURANT TABS 25MG 1 MO

INTELENCE TABS 100MG 1 QL (120 EA per 30 days) MO

INTELENCE TABS 200MG 1 QL (60 EA per 30 days) MO

INTELENCE TABS 25MG 1 MO

nevirapine er tb24 100mg 1 MO

nevirapine er tb24 400mg 1 MO

nevirapine susp 50mg/5ml 1 MO

nevirapine tabs 200mg 1 MO

ODEFSEY TABS 200MG; 25MG; 25MG 1 QL (30 EA per 30 days) MO

RESCRIPTOR TABS 100MG 1 MO

RESCRIPTOR TABS 200MG 1 MO

STRIBILD TABS 150MG; 150MG; 200MG; 300MG 1 QL (30 EA per 30 days) MO

SUSTIVA CAPS 200MG 1 MO

SUSTIVA CAPS 50MG 1 MO

SUSTIVA TABS 600MG 1 MO

VIRAMUNE XR TB24 100MG 1 MO

Anti-HIV Agents, Nucleoside and Nucleotide Reverse

Transcriptase Inhibitors (NRTI)

abacavir sulfate/lamivudine/zidovudine tabs 300mg; 150mg;

300mg

1 QL (60 EA per 30 days) MO

abacavir tabs 300mg 1 MO

DESCOVY TABS 200MG; 25MG 1 QL (30 EA per 30 days) MO

didanosine cpdr 125mg 1 MO

didanosine cpdr 200mg 1 MO

didanosine cpdr 250mg 1 MO

didanosine cpdr 400mg 1 MO

EMTRIVA CAPS 200MG 1 MO

EMTRIVA SOLN 10MG/ML 1 MO

EPIVIR HBV SOLN 5MG/ML 1 MO

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

EPZICOM TABS 600MG; 300MG 1 MO

lamivudine/zidovudine tabs 150mg; 300mg 1 MO

lamivudine soln 10mg/ml 1 MO

lamivudine tabs 100mg 1 MO

lamivudine tabs 150mg 1 MO

lamivudine tabs 300mg 1 MO

RETROVIR IV INFUSION INJ 10MG/ML 1

stavudine caps 15mg 1 MO

stavudine caps 20mg 1 MO

stavudine caps 30mg 1 MO

stavudine caps 40mg 1 MO

stavudine solr 1mg/ml 1 MO

TRIUMEQ TABS 600MG; 50MG; 300MG 1 QL (30 EA per 30 days) MO

TRUVADA TABS 100MG; 150MG 1 QL (30 EA per 30 days) MO

TRUVADA TABS 133MG; 200MG 1 QL (30 EA per 30 days) MO

TRUVADA TABS 167MG; 250MG 1 QL (30 EA per 30 days) MO

TRUVADA TABS 200MG; 300MG 1 QL (30 EA per 30 days) MO

VIDEX PEDIATRIC SOLR 2GM 1 MO

VIDEX PEDIATRIC SOLR 4GM 1 MO

VIREAD POWD 40MG/GM 1 MO

VIREAD TABS 150MG 1 MO

VIREAD TABS 200MG 1 MO

VIREAD TABS 250MG 1 MO

VIREAD TABS 300MG 1 MO

ZIAGEN SOLN 20MG/ML 1 MO

zidovudine caps 100mg 1 MO

zidovudine syrp 50mg/5ml 1 MO

zidovudine tabs 300mg 1 MO

Anti-HIV Agents, Other

FUZEON INJ 90MG 1 QL (60 EA per 30 days) MO

SELZENTRY TABS 150MG 1 QL (60 EA per 30 days) MO

SELZENTRY TABS 300MG 1 QL (120 EA per 30 days) MO

TYBOST TABS 150MG 1 MO

Anti-HIV Agents, Protease Inhibitors

APTIVUS CAPS 250MG 1 QL (120 EA per 30 days) MO

APTIVUS SOLN 100MG/ML 1 MO

CRIXIVAN CAPS 200MG 1 MO

CRIXIVAN CAPS 400MG 1 MO

EVOTAZ TABS 300MG; 150MG 1 QL (30 EA per 30 days) MO

INVIRASE CAPS 200MG 1 MO

INVIRASE TABS 500MG 1 MO

KALETRA SOLN 400MG/5ML; 100MG/5ML 1 MO

KALETRA TABS 100MG; 25MG 1 MO

KALETRA TABS 200MG; 50MG 1 MO

LEXIVA SUSP 50MG/ML 1 MO

LEXIVA TABS 700MG 1 MO

NORVIR CAPS 100MG 1 MO

NORVIR SOLN 80MG/ML 1 MO

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

NORVIR TABS 100MG 1 MO

PREZCOBIX TABS 150MG; 800MG 1 QL (30 EA per 30 days) MO

PREZISTA SUSP 100MG/ML 1 MO

PREZISTA TABS 150MG 1 MO

PREZISTA TABS 600MG 1 MO

PREZISTA TABS 75MG 1 MO

PREZISTA TABS 800MG 1 MO

REYATAZ CAPS 150MG 1 MO

REYATAZ CAPS 200MG 1 MO

REYATAZ CAPS 300MG 1 MO

REYATAZ PACK 50MG 1 MO

VIRACEPT TABS 250MG 1 MO

VIRACEPT TABS 625MG 1 MO

Anti-influenza Agents

amantadine hcl caps 100mg 1 MO

amantadine hcl syrp 50mg/5ml 1 MO

amantadine hcl tabs 100mg 1 MO

RELENZA DISKHALER AEPB 5MG/BLISTER 1 QL (112 EA per 365 days)

rimantadine hcl tabs 100mg 1

TAMIFLU CAPS 30MG 1 QL (112 EA per 365 days)

TAMIFLU CAPS 45MG 1 QL (60 EA per 365 days)

TAMIFLU CAPS 75MG 1 QL (110 EA per 365 days)

TAMIFLU SUSR 6MG/ML 1 QL (720 ML per 365 days)

Antiherpetic Agents

acyclovir sodium inj 50mg/ml 1 B/D

acyclovir caps 200mg 1

acyclovir oint 5% 1

acyclovir susp 200mg/5ml 1

acyclovir tabs 400mg 1

acyclovir tabs 800mg 1

DENAVIR CREA 1% 1

famciclovir tabs 125mg 1

famciclovir tabs 250mg 1

famciclovir tabs 500mg 1

trifluridine soln 1% 1

valacyclovir hcl tabs 1000mg 1 QL (90 EA per 30 days)

valacyclovir hcl tabs 500mg 1 QL (60 EA per 30 days)

ZOVIRAX CREA 5% 1

Antivirals

ZEPATIER TABS 50MG; 100MG 1 QL (112 EA per 365 days) PA

Anxiolytics

Anxiolytics, Other

buspirone hcl tabs 10mg 1

buspirone hcl tabs 15mg 1

buspirone hcl tabs 30mg 1

buspirone hcl tabs 5mg 1

buspirone hcl tabs 7.5mg 1

doxepin hcl caps 100mg 1 PA MO

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47

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

doxepin hcl caps 10mg 1 PA MO

doxepin hcl caps 150mg 1 PA MO

doxepin hcl caps 25mg 1 PA MO

doxepin hcl caps 50mg 1 PA MO

doxepin hcl caps 75mg 1 PA MO

doxepin hcl conc 10mg/ml 1 PA MO

Benzodiazepines

alprazolam tabs 0.25mg 1 PA

alprazolam tabs 0.5mg 1 PA

alprazolam tabs 1mg 1 PA

alprazolam tabs 2mg 1 PA

clorazepate dipotassium tabs 15mg 1

clorazepate dipotassium tabs 3.75mg 1

clorazepate dipotassium tabs 7.5mg 1

diazepam soln 1mg/ml 1

diazepam tabs 10mg 1

diazepam tabs 2mg 1

diazepam tabs 5mg 1

lorazepam tabs 0.5mg 1 PA

lorazepam tabs 1mg 1 PA

lorazepam tabs 2mg 1 PA

oxazepam caps 10mg 1 PA

oxazepam caps 15mg 1 PA

oxazepam caps 30mg 1 PA

temazepam caps 15mg 1 PA

temazepam caps 22.5mg 1 PA

temazepam caps 30mg 1 PA

temazepam caps 7.5mg 1 PA

Bipolar Agents

Mood Stabilizers

lithium carbonate er tbcr 300mg 1 MO

lithium carbonate er tbcr 450mg 1 MO

lithium carbonate caps 150mg 1 MO

lithium carbonate caps 300mg 1 MO

lithium carbonate caps 600mg 1 MO

lithium carbonate tabs 300mg 1 MO

lithium soln 8meq/5ml 1 MO

Blood Glucose Regulators

Antidiabetic Agents

acarbose tabs 100mg 1 MO

acarbose tabs 25mg 1 MO

acarbose tabs 50mg 1 MO

AVANDIA TABS 2MG 1 QL (120 EA per 30 days) MO

AVANDIA TABS 4MG 1 QL (60 EA per 30 days) MO

AVANDIA TABS 8MG 1 QL (30 EA per 30 days) MO

BYDUREON PEN INJ 2MG 1 MO

BYDUREON INJ 2MG 1 MO

BYETTA INJ 10MCG/0.04ML 1 MO

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

BYETTA INJ 5MCG/0.02ML 1 MO

CYCLOSET TABS 0.8MG 1 MO

glimepiride tabs 1mg 1 QL (240 EA per 30 days) MO

glimepiride tabs 2mg 1 QL (120 EA per 30 days) MO

glimepiride tabs 4mg 1 QL (60 EA per 30 days) MO

glipizide er tb24 10mg 1 QL (60 EA per 30 days) MO

glipizide er tb24 2.5mg 1 QL (240 EA per 30 days) MO

glipizide er tb24 5mg 1 QL (120 EA per 30 days) MO

glipizide xl tb24 10mg 1 QL (60 EA per 30 days) MO

glipizide xl tb24 2.5mg 1 QL (240 EA per 30 days) MO

glipizide xl tb24 5mg 1 QL (120 EA per 30 days) MO

glipizide/metformin hcl tabs 2.5mg; 250mg 1 QL (240 EA per 30 days) MO

glipizide/metformin hcl tabs 2.5mg; 500mg 1 QL (120 EA per 30 days) MO

glipizide/metformin hcl tabs 5mg; 500mg 1 QL (120 EA per 30 days) MO

glipizide tabs 10mg 1 QL (120 EA per 30 days) MO

glipizide tabs 5mg 1 QL (240 EA per 30 days) MO

glyburide micronized tabs 1.5mg 1 QL (240 EA per 30 days) PA MO

glyburide micronized tabs 3mg 1 QL (120 EA per 30 days) PA MO

glyburide micronized tabs 6mg 1 QL (60 EA per 30 days) PA MO

glyburide/metformin hcl tabs 1.25mg; 250mg 1 QL (240 EA per 30 days) PA MO

glyburide/metformin hcl tabs 2.5mg; 500mg 1 QL (120 EA per 30 days) PA MO

glyburide/metformin hcl tabs 5mg; 500mg 1 QL (120 EA per 30 days) PA MO

glyburide tabs 1.25mg 1 QL (480 EA per 30 days) PA MO

glyburide tabs 2.5mg 1 QL (240 EA per 30 days) PA MO

glyburide tabs 5mg 1 QL (120 EA per 30 days) PA MO

GLYSET TABS 100MG 1 MO

GLYSET TABS 25MG 1 MO

GLYSET TABS 50MG 1 MO

INVOKAMET XR TB24 150MG; 1000MG 1 QL (60 EA per 30 days) ST MO

INVOKAMET XR TB24 150MG; 500MG 1 QL (60 EA per 30 days) ST MO

INVOKAMET XR TB24 50MG; 1000MG 1 QL (60 EA per 30 days) ST MO

INVOKAMET XR TB24 50MG; 500MG 1 QL (60 EA per 30 days) ST MO

INVOKAMET TABS 150MG; 1000MG 1 MO

INVOKAMET TABS 150MG; 500MG 1 MO

INVOKAMET TABS 50MG; 1000MG 1 MO

INVOKAMET TABS 50MG; 500MG 1 MO

INVOKANA TABS 100MG 1 MO

INVOKANA TABS 300MG 1 MO

JANUMET XR TB24 1000MG; 100MG 1 QL (30 EA per 30 days) MO

JANUMET XR TB24 1000MG; 50MG 1 QL (60 EA per 30 days) MO

JANUMET XR TB24 500MG; 50MG 1 QL (60 EA per 30 days) MO

JANUMET TABS 1000MG; 50MG 1 QL (60 EA per 30 days) MO

JANUMET TABS 500MG; 50MG 1 QL (120 EA per 30 days) MO

JANUVIA TABS 100MG 1 MO

JANUVIA TABS 25MG 1 MO

JANUVIA TABS 50MG 1 MO

JARDIANCE TABS 10MG 1 ST MO

JARDIANCE TABS 25MG 1 ST MO

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

JENTADUETO XR TB24 2.5MG; 1000MG 1 ST MO

JENTADUETO XR TB24 5MG; 1000MG 1 ST MO

JENTADUETO TABS 2.5MG; 1000MG 1 QL (60 EA per 30 days) ST MO

JENTADUETO TABS 2.5MG; 500MG 1 QL (60 EA per 30 days) ST MO

JENTADUETO TABS 2.5MG; 850MG 1 QL (60 EA per 30 days) ST MO

KOMBIGLYZE XR TB24 1000MG; 2.5MG 1 QL (60 EA per 30 days) MO

KOMBIGLYZE XR TB24 1000MG; 5MG 1 QL (60 EA per 30 days) MO

KOMBIGLYZE XR TB24 500MG; 5MG 1 QL (120 EA per 30 days) MO

metformin hcl er tb24 1000mg 1 QL (60 EA per 30 days) MO

metformin hcl er tb24 500mg 1 QL (120 EA per 30 days) MO

metformin hcl er tb24 500mg 1 QL (120 EA per 30 days) MO

metformin hcl er tb24 750mg 1 QL (60 EA per 30 days) MO

metformin hcl tabs 1000mg 1 QL (60 EA per 30 days) MO

metformin hcl tabs 500mg 1 QL (150 EA per 30 days) MO

metformin hcl tabs 850mg 1 QL (90 EA per 30 days) MO

miglitol tabs 100mg 1 MO

miglitol tabs 25mg 1 MO

miglitol tabs 50mg 1 MO

nateglinide tabs 120mg 1 MO

nateglinide tabs 60mg 1 MO

ONGLYZA TABS 2.5MG 1 MO

ONGLYZA TABS 5MG 1 MO

pioglitazone hcl-glimepiride tabs 2mg; 30mg 1 QL (45 EA per 30 days) MO

pioglitazone hcl-glimepiride tabs 4mg; 30mg 1 QL (45 EA per 30 days) MO

pioglitazone hcl/metformin hcl tabs 500mg; 15mg 1 QL (90 EA per 30 days) MO

pioglitazone hcl/metformin hcl tabs 850mg; 15mg 1 QL (90 EA per 30 days) MO

pioglitazone hcl tabs 15mg 1 QL (60 EA per 30 days) MO

pioglitazone hcl tabs 30mg 1 QL (45 EA per 30 days) MO

pioglitazone hcl tabs 45mg 1 QL (30 EA per 30 days) MO

PRANDIMET TABS 500MG; 1MG 1 QL (150 EA per 30 days) MO

PRANDIMET TABS 500MG; 2MG 1 QL (150 EA per 30 days) MO

repaglinide/metformin hydrochloride tabs 500mg; 1mg 1 QL (150 EA per 30 days) MO

repaglinide/metformin hydrochloride tabs 500mg; 2mg 1 QL (150 EA per 30 days) MO

repaglinide tabs 0.5mg 1 MO

repaglinide tabs 1mg 1 MO

repaglinide tabs 2mg 1 MO

SYMLINPEN 120 INJ 2700MCG/2.7ML 1 PA MO

SYMLINPEN 60 INJ 1500MCG/1.5ML 1 PA MO

SYNJARDY TABS 12.5MG; 1000MG 1 QL (60 EA per 30 days) MO

SYNJARDY TABS 12.5MG; 500MG 1 QL (120 EA per 30 days) MO

SYNJARDY TABS 5MG; 1000MG 1 QL (60 EA per 30 days) MO

SYNJARDY TABS 5MG; 500MG 1 QL (120 EA per 30 days) MO

tolazamide tabs 250mg 1 QL (120 EA per 30 days) MO

tolazamide tabs 500mg 1 QL (60 EA per 30 days) MO

tolbutamide tabs 500mg 1 QL (180 EA per 30 days) MO

TRADJENTA TABS 5MG 1 ST MO

VICTOZA INJ 18MG/3ML 1 QL (9 ML per 30 days) ST MO

XIGDUO XR TB24 10MG; 1000MG 1 ST MO

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

XIGDUO XR TB24 10MG; 500MG 1 ST MO

XIGDUO XR TB24 5MG; 1000MG 1 ST MO

XIGDUO XR TB24 5MG; 500MG 1 ST MO

Glycemic Agents

dextrose 10% inj 10% 1

dextrose 5% inj 5% 1

GLUCAGEN HYPOKIT INJ 1MG 1

GLUCAGON EMERGENCY KIT INJ 1MG 1

PROGLYCEM SUSP 50MG/ML 1 MO

Insulins

APIDRA SOLOSTAR INJ 100UNIT/ML 1 MO

APIDRA INJ 100UNIT/ML 1 MO

HUMALOG KWIKPEN INJ 100UNIT/ML 1 MO

HUMALOG KWIKPEN INJ 100UNIT/ML 1 MO

HUMALOG KWIKPEN INJ 200UNIT/ML 1 MO

HUMALOG MIX 50/50 KWIKPEN INJ 50UNIT/ML;

50UNIT/ML

1 MO

HUMALOG MIX 50/50 INJ 50UNIT/ML; 50UNIT/ML 1 MO

HUMALOG MIX 75/25 KWIKPEN INJ 25UNIT/ML;

75UNIT/ML

1 MO

HUMALOG MIX 75/25 INJ 25UNIT/ML; 75UNIT/ML 1 MO

HUMALOG INJ 100UNIT/ML 1 MO

HUMALOG INJ 100UNIT/ML 1 MO

HUMULIN 70/30 KWIKPEN INJ 30UNIT/ML; 70UNIT/ML 1 MO

HUMULIN 70/30 INJ 30UNIT/ML; 70UNIT/ML 1 MO

HUMULIN N KWIKPEN INJ 100UNIT/ML 1 MO

HUMULIN N INJ 100UNIT/ML 1 MO

HUMULIN R U-500 (CONCENTRATED) INJ 500UNIT/ML 1 MO

HUMULIN R U-500 KWIKPEN INJ 500UNIT/ML 1 MO

HUMULIN R INJ 100UNIT/ML 1 MO

LANTUS SOLOSTAR INJ 100UNIT/ML 1 MO

LANTUS INJ 100UNIT/ML 1 MO

LEVEMIR FLEXTOUCH INJ 100UNIT/ML 1 MO

LEVEMIR INJ 100UNIT/ML 1 MO

NOVOLIN 70/30 RELION INJ 30UNIT/ML; 70UNIT/ML 1 MO

NOVOLIN 70/30 INJ 30UNIT/ML; 70UNIT/ML 1 MO

NOVOLIN N RELION INJ 100UNIT/ML 1 MO

NOVOLIN N INJ 100UNIT/ML 1 MO

NOVOLIN R RELION INJ 100UNIT/ML 1 MO

NOVOLIN R INJ 100UNIT/ML 1 MO

NOVOLOG FLEXPEN INJ 100UNIT/ML 1 MO

NOVOLOG MIX 70/30 PREFILLED FLEXPEN INJ

30UNIT/ML; 70UNIT/ML

1 MO

NOVOLOG MIX 70/30 INJ 30UNIT/ML; 70UNIT/ML 1 MO

NOVOLOG PENFILL INJ 100UNIT/ML 1 MO

NOVOLOG INJ 100UNIT/ML 1 MO

RELION R INJ 100UNIT/ML 1 MO

Blood Products/Modifiers/Volume Expanders

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51

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

Anticoagulants

COUMADIN TABS 10MG 1 MO

COUMADIN TABS 1MG 1 MO

COUMADIN TABS 2.5MG 1 MO

COUMADIN TABS 2MG 1 MO

COUMADIN TABS 3MG 1 MO

COUMADIN TABS 4MG 1 MO

COUMADIN TABS 5MG 1 MO

COUMADIN TABS 6MG 1 MO

COUMADIN TABS 7.5MG 1 MO

ELIQUIS TABS 2.5MG 1 QL (60 EA per 30 days) MO

ELIQUIS TABS 5MG 1 QL (60 EA per 30 days) MO

ENOXAPARIN SODIUM INJ 100MG/ML 1 QL (35 ML per 90 days)

ENOXAPARIN SODIUM INJ 120MG/0.8ML 1 QL (28 ML per 90 days)

ENOXAPARIN SODIUM INJ 150MG/ML 1 QL (35 ML per 90 days)

enoxaparin sodium inj 300mg/3ml 1 QL (105 ML per 90 days)

enoxaparin sodium inj 30mg/0.3ml 1 QL (10.5 ML per 90 days)

enoxaparin sodium inj 40mg/0.4ml 1 QL (14 ML per 90 days)

enoxaparin sodium inj 60mg/0.6ml 1 QL (21 ML per 90 days)

enoxaparin sodium inj 80mg/0.8ml 1 QL (28 ML per 90 days)

FONDAPARINUX SODIUM INJ 10MG/0.8ML 1 QL (28 ML per 90 days)

fondaparinux sodium inj 2.5mg/0.5ml 1 QL (17.5 ML per 90 days)

FONDAPARINUX SODIUM INJ 5MG/0.4ML 1 QL (14 ML per 90 days)

FONDAPARINUX SODIUM INJ 7.5MG/0.6ML 1 QL (21 ML per 90 days)

FRAGMIN INJ 10000UNIT/ML 1 QL (35 ML per 90 days)

FRAGMIN INJ 12500UNIT/0.5ML 1 QL (17.5 ML per 90 days)

FRAGMIN INJ 15000UNIT/0.6ML 1 QL (21 ML per 90 days)

FRAGMIN INJ 18000UNT/0.72ML 1 QL (25.3 ML per 90 days)

FRAGMIN INJ 25000UNIT/ML 1 QL (22.8 ML per 90 days)

FRAGMIN INJ 2500UNIT/0.2ML 1 QL (7 ML per 90 days)

FRAGMIN INJ 5000UNIT/0.2ML 1 QL (7 ML per 90 days)

FRAGMIN INJ 7500UNIT/0.3ML 1 QL (10.5 ML per 90 days)

FRAGMIN INJ 95000UNIT/3.8ML 1 QL (22.8 ML per 90 days)

heparin sodium/d5w inj 5%; 100unit/ml 1

heparin sodium/d5w inj 5%; 40unit/ml 1

heparin sodium/d5w inj 5%; 50unit/ml 1

heparin sodium/nacl 0.45% inj 100unit/ml; 0.45% 1

heparin sodium/nacl 0.45% inj 50unit/ml; 0.45% 1

heparin sodium/nacl 0.9% inj 2unit/ml; 0.9% 1

heparin sodium/nacl inj 4000unit/l; 0.9% 1

heparin sodium/sodium ch loride inj 500unit/250ml; 0.45% 1

heparin sodium/sodium chloride 0.9% premix inj 2unit/ml;

0.9%

1

heparin sodium/sodium chloride 0.9% inj 2unit/ml; 0.9% 1

heparin sodium/sodium chloride 0.9% inj 2unit/ml; 0.9% 1

heparin sodium/sodium chloride pf inj 50unit/50ml; 0.45% 1

heparin sodium/sodium chloride inj 20unit/20ml; 0.9% 1

heparin sodium/sodium chloride inj 25000unit/250ml; 0.45% 1

Page 62: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

heparin sodium/sodium chloride inj 30000unit/l; 0.9% 1 B/D

heparin sodium inj 10000unit/10ml 1

heparin sodium inj 10000unit/ml 1

heparin sodium inj 1000unit/ml 1

heparin sodium inj 20000unit/ml 1

heparin sodium inj 2000unit/ml 1

heparin sodium inj 2500unit/ml 1

heparin sodium inj 3000unit/3ml 1 B/D

heparin sodium inj 5000unit/5ml 1 B/D

heparin sodium inj 5000unit/ml 1

jantoven tabs 10mg 1 MO

jantoven tabs 1mg 1 MO

jantoven tabs 2.5mg 1 MO

jantoven tabs 2mg 1 MO

jantoven tabs 3mg 1 MO

jantoven tabs 4mg 1 MO

jantoven tabs 5mg 1 MO

jantoven tabs 6mg 1 MO

jantoven tabs 7.5mg 1 MO

PRADAXA CAPS 110MG 1 QL (60 EA per 30 days) MO

PRADAXA CAPS 150MG 1 QL (60 EA per 30 days) MO

PRADAXA CAPS 75MG 1 QL (60 EA per 30 days) MO

SAVAYSA TABS 15MG 1 QL (30 EA per 30 days) MO

SAVAYSA TABS 30MG 1 QL (30 EA per 30 days) MO

SAVAYSA TABS 60MG 1 QL (30 EA per 30 days) MO

warfarin sodium tabs 10mg 1 MO

warfarin sodium tabs 1mg 1 MO

warfarin sodium tabs 2.5mg 1 MO

warfarin sodium tabs 2mg 1 MO

warfarin sodium tabs 3mg 1 MO

warfarin sodium tabs 4mg 1 MO

warfarin sodium tabs 5mg 1 MO

warfarin sodium tabs 6mg 1 MO

warfarin sodium tabs 7.5mg 1 MO

XARELTO STARTER PACK TBPK 0 1 QL (102 EA per 365 days)

XARELTO TABS 10MG 1 QL (30 EA per 30 days) MO

XARELTO TABS 15MG 1 QL (60 EA per 30 days) MO

XARELTO TABS 20MG 1 QL (30 EA per 30 days) MO

Blood Formation Modifiers

anagrelide hydrochloride caps 0.5mg 1 MO

anagrelide hydrochloride caps 1mg 1 MO

ARANESP ALBUMIN FREE INJ 100MCG/0.5ML 1 PA

ARANESP ALBUMIN FREE INJ 100MCG/ML 1 PA

ARANESP ALBUMIN FREE INJ 10MCG/0.4ML 1 PA

ARANESP ALBUMIN FREE INJ 150MCG/0.3ML 1 PA

ARANESP ALBUMIN FREE INJ 200MCG/0.4ML 1 PA

ARANESP ALBUMIN FREE INJ 200MCG/ML 1 PA

ARANESP ALBUMIN FREE INJ 25MCG/0.42ML 1 PA

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

ARANESP ALBUMIN FREE INJ 25MCG/ML 1 PA

ARANESP ALBUMIN FREE INJ 300MCG/0.6ML 1 PA

ARANESP ALBUMIN FREE INJ 300MCG/ML 1 PA

ARANESP ALBUMIN FREE INJ 40MCG/0.4ML 1 PA

ARANESP ALBUMIN FREE INJ 40MCG/ML 1 PA

ARANESP ALBUMIN FREE INJ 500MCG/ML 1 PA

ARANESP ALBUMIN FREE INJ 60MCG/0.3ML 1 PA

ARANESP ALBUMIN FREE INJ 60MCG/ML 1 PA

LEUKINE INJ 250MCG 1 PA

MOZOBIL INJ 24MG/1.2ML 1 QL (9.6 ML per 30 days) PA

NEULASTA ONPRO KIT INJ 6MG/0.6ML 1 PA

NEULASTA INJ 6MG/0.6ML 1 PA

NEUMEGA INJ 5MG 1 PA

NEUPOGEN INJ 300MCG/0.5ML 1 PA

NEUPOGEN INJ 300MCG/ML 1 PA

NEUPOGEN INJ 480MCG/0.8ML 1 PA

NEUPOGEN INJ 480MCG/1.6ML 1 PA

PROCRIT INJ 10000UNIT/ML 1 PA

PROCRIT INJ 20000UNIT/ML 1 PA

PROCRIT INJ 2000UNIT/ML 1 PA

PROCRIT INJ 3000UNIT/ML 1 PA

PROCRIT INJ 40000UNIT/ML 1 PA

PROCRIT INJ 4000UNIT/ML 1 PA

PROMACTA TABS 12.5MG 1 PA MO

PROMACTA TABS 25MG 1 PA MO

PROMACTA TABS 50MG 1 PA MO

PROMACTA TABS 75MG 1 PA MO

ZARXIO INJ 300MCG/0.5ML 1 PA

ZARXIO INJ 480MCG/0.8ML 1 PA

Coagulants

tranexamic acid inj 1000mg/10ml 1

tranexamic acid tabs 650mg 1

Platelet Modifying Agents

AGGRENOX CP12 25MG; 200MG 1 MO

aspirin/dipyridamole cp12 25mg; 200mg 1 MO

BRILINTA TABS 60MG 1 MO

BRILINTA TABS 90MG 1 MO

cilostazol tabs 100mg 1 MO

cilostazol tabs 50mg 1 MO

clopidogrel tabs 300mg 1

clopidogrel tabs 75mg 1 MO

dipyridamole tabs 25mg 1 PA MO

dipyridamole tabs 50mg 1 PA MO

dipyridamole tabs 75mg 1 PA MO

EFFIENT TABS 10MG 1 MO

EFFIENT TABS 5MG 1 MO

ticlopidine hcl tabs 250mg 1 PA MO

Cardiovascular Agents

Page 64: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

54

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

Alpha-adrenergic Agonists

clonidine hcl er tb12 0.1mg 1 MO

clonidine hcl ptwk 0.1mg/24hr 1 MO

clonidine hcl ptwk 0.2mg/24hr 1 MO

clonidine hcl ptwk 0.3mg/24hr 1 MO

clonidine hcl tabs 0.1mg 1 MO

clonidine hcl tabs 0.2mg 1 MO

clonidine hcl tabs 0.3mg 1 MO

CLORPRES TABS 15MG; 0.1MG 1 MO

CLORPRES TABS 15MG; 0.2MG 1 MO

CLORPRES TABS 15MG; 0.3MG 1 MO

guanfacine hcl tabs 1mg 1 PA MO

guanfacine hcl tabs 2mg 1 PA MO

methyldopa/hydrochlorothiazide tabs 15mg; 250mg 1 PA MO

methyldopa/hydrochlorothiazide tabs 25mg; 250mg 1 PA MO

methyldopa tabs 250mg 1 PA MO

methyldopa tabs 500mg 1 PA MO

midodrine hcl tabs 10mg 1

midodrine hcl tabs 2.5mg 1

midodrine hcl tabs 5mg 1

phenylephrine hydrochloride/dextrose inj 5%; 50mg/500ml 1

phenylephrine/sodium chloride inj 10mg/250ml; 0.9% 1

Alpha-adrenergic Blocking Agents

DIBENZYLINE CAPS 10MG 1

phenoxybenzamine hydrochloride caps 10mg 1

prazosin hcl caps 1mg 1 MO

prazosin hcl caps 2mg 1 MO

prazosin hcl caps 5mg 1 MO

reserpine tabs 0.1mg 1 QL (30 EA per 30 days) MO

Angiotensin II Receptor Antagonists

BENICAR HCT TABS 12.5MG; 20MG 1 MO

BENICAR HCT TABS 12.5MG; 40MG 1 MO

BENICAR HCT TABS 25MG; 40MG 1 MO

BENICAR TABS 20MG 1 MO

BENICAR TABS 40MG 1 MO

BENICAR TABS 5MG 1 MO

candesartan cilexetil tabs 16mg 1 MO

candesartan cilexetil tabs 32mg 1 MO

candesartan cilexetil tabs 4mg 1 MO

candesartan cilexetil tabs 8mg 1 MO

EDARBI TABS 40MG 1 ST MO

EDARBI TABS 80MG 1 ST MO

EDARBYCLOR TABS 40MG; 12.5MG 1 ST MO

EDARBYCLOR TABS 40MG; 25MG 1 ST MO

ENTRESTO TABS 24MG; 26MG 1 QL (60 EA per 30 days) PA MO

ENTRESTO TABS 49MG; 51MG 1 QL (60 EA per 30 days) PA MO

ENTRESTO TABS 97MG; 103MG 1 QL (60 EA per 30 days) PA MO

eprosartan mesylate tabs 600mg 1 MO

Page 65: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

55

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

irbesartan/hydrochlorothiazide tabs 12.5mg; 150mg 1 MO

irbesartan/hydrochlorothiazide tabs 12.5mg; 300mg 1 MO

irbesartan tabs 150mg 1 MO

irbesartan tabs 300mg 1 MO

irbesartan tabs 75mg 1 MO

losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg 1 MO

losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg 1 MO

losartan potassium/hydrochlorothiazide tabs 25mg; 100mg 1 MO

losartan potassium tabs 100mg 1 MO

losartan potassium tabs 25mg 1 MO

losartan potassium tabs 50mg 1 MO

telmisartan/amlodipine tabs 10mg; 40mg 1 MO

telmisartan/amlodipine tabs 10mg; 80mg 1 MO

telmisartan/amlodipine tabs 5mg; 40mg 1 MO

telmisartan/amlodipine tabs 5mg; 80mg 1 MO

telmisartan/hydrochlorothiazide tabs 12.5mg; 40mg 1 MO

telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg 1 MO

telmisartan/hydrochlorothiazide tabs 25mg; 80mg 1 MO

telmisartan tabs 20mg 1 MO

telmisartan tabs 40mg 1 MO

telmisartan tabs 80mg 1 MO

valsartan/hydrochlorothiazide tabs 12.5mg; 160mg 1 MO

valsartan/hydrochlorothiazide tabs 12.5mg; 320mg 1 MO

valsartan/hydrochlorothiazide tabs 12.5mg; 80mg 1 MO

valsartan/hydrochlorothiazide tabs 25mg; 160mg 1 MO

valsartan/hydrochlorothiazide tabs 25mg; 320mg 1 MO

valsartan tabs 160mg 1 MO

valsartan tabs 320mg 1 MO

valsartan tabs 40mg 1 MO

valsartan tabs 80mg 1 MO

Angiotensin-converting Enzyme (ACE) Inhibitors

benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg 1 MO

benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg 1 MO

benazepril hcl/hydrochlorothiazide tabs 20mg; 25mg 1 MO

benazepril hcl/hydrochlorothiazide tabs 5mg; 6.25mg 1 MO

benazepril hcl tabs 10mg 1 MO

benazepril hcl tabs 20mg 1 MO

benazepril hcl tabs 40mg 1 MO

benazepril hcl tabs 5mg 1 MO

captopril/hydrochlorothiazide tabs 25mg; 15mg 1 MO

captopril/hydrochlorothiazide tabs 25mg; 25mg 1 MO

captopril/hydrochlorothiazide tabs 50mg; 15mg 1 MO

captopril/hydrochlorothiazide tabs 50mg; 25mg 1 MO

captopril tabs 100mg 1 MO

captopril tabs 12.5mg 1 MO

captopril tabs 25mg 1 MO

captopril tabs 50mg 1 MO

enalapril maleate/hydrochlorothiazide tabs 10mg; 25mg 1 MO

Page 66: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

56

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

enalapril maleate/hydrochlorothiazide tabs 5mg; 12.5mg 1 MO

enalapril maleate tabs 10mg 1 MO

enalapril maleate tabs 2.5mg 1 MO

enalapril maleate tabs 20mg 1 MO

enalapril maleate tabs 5mg 1 MO

fosinopril sodium/hydrochlorothiazide tabs 10mg; 12.5mg 1 MO

fosinopril sodium/hydrochlorothiazide tabs 20mg; 12.5mg 1 MO

fosinopril sodium tabs 10mg 1 MO

fosinopril sodium tabs 20mg 1 MO

fosinopril sodium tabs 40mg 1 MO

lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg 1 MO

lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg 1 MO

lisinopril/hydrochlorothiazide tabs 25mg; 20mg 1 MO

lisinopril tabs 10mg 1 MO

lisinopril tabs 2.5mg 1 MO

lisinopril tabs 20mg 1 MO

lisinopril tabs 30mg 1 MO

lisinopril tabs 40mg 1 MO

lisinopril tabs 5mg 1 MO

moexipril hcl tabs 15mg 1 MO

moexipril hcl tabs 7.5mg 1 MO

moexipril/hydrochlorothiazide tabs 12.5mg; 15mg 1 MO

moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg 1 MO

moexipril/hydrochlorothiazide tabs 25mg; 15mg 1 MO

perindopril erbumine tabs 2mg 1 MO

perindopril erbumine tabs 4mg 1 MO

perindopril erbumine tabs 8mg 1 MO

quinapril hcl tabs 10mg 1 MO

quinapril hcl tabs 20mg 1 MO

quinapril hcl tabs 40mg 1 MO

quinapril hcl tabs 5mg 1 MO

quinapril/hydrochlorothiazide tabs 12.5mg; 10mg 1 MO

quinapril/hydrochlorothiazide tabs 12.5mg; 20mg 1 MO

quinapril/hydrochlorothiazide tabs 25mg; 20mg 1 MO

ramipril caps 1.25mg 1 MO

ramipril caps 10mg 1 MO

ramipril caps 2.5mg 1 MO

ramipril caps 5mg 1 MO

trandolapril/verapamil hcl er tbcr 1mg; 240mg 1 MO

trandolapril/verapamil hcl er tbcr 2mg; 180mg 1 MO

trandolapril/verapamil hcl er tbcr 2mg; 240mg 1 MO

trandolapril/verapamil hcl er tbcr 4mg; 240mg 1 MO

trandolapril/verapamil hcl tbcr 1mg; 240mg 1 MO

trandolapril/verapamil hcl tbcr 2mg; 180mg 1 MO

trandolapril/verapamil hcl tbcr 2mg; 240mg 1 MO

trandolapril/verapamil hcl tbcr 4mg; 240mg 1 MO

trandolapril tabs 1mg 1 MO

trandolapril tabs 2mg 1 MO

Page 67: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

57

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

trandolapril tabs 4mg 1 MO

Antiarrhythmics

amiodarone hcl tabs 100mg 1 MO

amiodarone hcl tabs 200mg 1 MO

amiodarone hcl tabs 400mg 1 MO

disopyramide phosphate caps 100mg 1 PA MO

disopyramide phosphate caps 150mg 1 PA MO

dofetilide caps 125mcg 1 MO

dofetilide caps 250mcg 1 MO

dofetilide caps 500mcg 1 MO

flecainide acetate tabs 100mg 1 MO

flecainide acetate tabs 150mg 1 MO

flecainide acetate tabs 50mg 1 MO

lidocaine hcl inj 10mg/ml 1

lidocaine hcl inj 20mg/ml 1

mexiletine hcl caps 150mg 1 MO

mexiletine hcl caps 200mg 1 MO

mexiletine hcl caps 250mg 1 MO

MULTAQ TABS 400MG 1 MO

NORPACE CR CP12 100MG 1 PA MO

NORPACE CR CP12 150MG 1 PA MO

pacerone tabs 100mg 1 MO

pacerone tabs 200mg 1 MO

pacerone tabs 400mg 1 MO

propafenone hcl er cp12 225mg 1 MO

propafenone hcl er cp12 325mg 1 MO

propafenone hcl er cp12 425mg 1 MO

propafenone hcl tabs 150mg 1 MO

propafenone hcl tabs 225mg 1 MO

propafenone hcl tabs 300mg 1 MO

quinidine gluconate cr tbcr 324mg 1 MO

quinidine gluconate er tbcr 324mg 1 MO

quinidine sulfate er tbcr 300mg 1 MO

quinidine sulfate tabs 200mg 1 MO

quinidine sulfate tabs 300mg 1 MO

sorine tabs 120mg 1 MO

sorine tabs 160mg 1 MO

sorine tabs 240mg 1 MO

sorine tabs 80mg 1 MO

sotalol hcl (af) tabs 120mg 1 MO

sotalol hcl (af) tabs 160mg 1 MO

sotalol hcl (af) tabs 80mg 1 MO

sotalol hcl tabs 120mg 1 MO

sotalol hcl tabs 160mg 1 MO

sotalol hcl tabs 240mg 1 MO

sotalol hcl tabs 80mg 1 MO

TIKOSYN CAPS 125MCG 1 MO

TIKOSYN CAPS 250MCG 1 MO

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58

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

TIKOSYN CAPS 500MCG 1 MO

Beta-adrenergic Blocking Agents

acebutolol hcl caps 200mg 1 MO

acebutolol hcl caps 400mg 1 MO

atenolol/chlorthalidone tabs 100mg; 25mg 1 MO

atenolol/chlorthalidone tabs 50mg; 25mg 1 MO

atenolol tabs 100mg 1 MO

atenolol tabs 25mg 1 MO

atenolol tabs 50mg 1 MO

betaxolol hcl tabs 10mg 1 MO

betaxolol hcl tabs 20mg 1 MO

bisoprolol fumarate/hydrochlorothiazide tabs 10mg; 6.25mg 1 MO

bisoprolol fumarate/hydrochlorothiazide tabs 2.5mg; 6.25mg 1 MO

bisoprolol fumarate/hydrochlorothiazide tabs 5mg; 6.25mg 1 MO

bisoprolol fumarate tabs 10mg 1 MO

bisoprolol fumarate tabs 5mg 1 MO

BYSTOLIC TABS 10MG 1 MO

BYSTOLIC TABS 2.5MG 1 MO

BYSTOLIC TABS 20MG 1 MO

BYSTOLIC TABS 5MG 1 MO

carvedilol tabs 12.5mg 1 MO

carvedilol tabs 25mg 1 MO

carvedilol tabs 3.125mg 1 MO

carvedilol tabs 6.25mg 1 MO

DUTOPROL TB24 12.5MG; 100MG 1 MO

DUTOPROL TB24 12.5MG; 25MG 1 MO

DUTOPROL TB24 12.5MG; 50MG 1 MO

INDERAL XL CP24 120MG 1 MO

INDERAL XL CP24 80MG 1 MO

INNOPRAN XL CP24 120MG 1 MO

INNOPRAN XL CP24 80MG 1 MO

labetalol hcl tabs 100mg 1 MO

labetalol hcl tabs 200mg 1 MO

labetalol hcl tabs 300mg 1 MO

LEVATOL TABS 20MG 1 MO

metoprolol succinate er tb24 100mg 1 MO

metoprolol succinate er tb24 200mg 1 MO

metoprolol succinate er tb24 25mg 1 MO

metoprolol succinate er tb24 50mg 1 MO

metoprolol tartrate inj 1mg/ml 1

metoprolol tartrate inj 1mg/ml 1

metoprolol tartrate tabs 100mg 1 MO

metoprolol tartrate tabs 25mg 1 MO

metoprolol tartrate tabs 37.5mg 1 MO

metoprolol tartrate tabs 37.5mg 1 MO

metoprolol tartrate tabs 50mg 1 MO

metoprolol tartrate tabs 75mg 1 MO

metoprolol tartrate tabs 75mg 1 MO

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59

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

metoprolol/hydrochlorothiazide tabs 25mg; 100mg 1 MO

metoprolol/hydrochlorothiazide tabs 25mg; 50mg 1 MO

metoprolol/hydrochlorothiazide tabs 50mg; 100mg 1 MO

nadolol/bendroflumethiazide tabs 5mg; 40mg 1 MO

nadolol/bendroflumethiazide tabs 5mg; 80mg 1 MO

nadolol tabs 20mg 1 MO

nadolol tabs 40mg 1 MO

nadolol tabs 80mg 1 MO

pindolol tabs 10mg 1 MO

pindolol tabs 5mg 1 MO

propranolol hcl er cp24 120mg 1 MO

propranolol hcl er cp24 160mg 1 MO

propranolol hcl er cp24 60mg 1 MO

propranolol hcl er cp24 80mg 1 MO

propranolol hcl tabs 10mg 1 MO

propranolol hcl tabs 20mg 1 MO

propranolol hcl tabs 40mg 1 MO

propranolol hcl tabs 60mg 1 MO

propranolol hcl tabs 80mg 1 MO

propranolol/hydrochlorothiazide tabs 25mg; 40mg 1 MO

propranolol/hydrochlorothiazide tabs 25mg; 80mg 1 MO

Calcium Channel Blocking Agents

afeditab cr tb24 30mg 1 MO

afeditab cr tb24 60mg 1 MO

amlodipine besylate/atorvastatin calcium tabs 10mg; 10mg 1 MO

amlodipine besylate/atorvastatin calcium tabs 10mg; 20mg 1 MO

amlodipine besylate/atorvastatin calcium tabs 10mg; 40mg 1 MO

amlodipine besylate/atorvastatin calcium tabs 10mg; 80mg 1 MO

amlodipine besylate/atorvastatin calcium tabs 2.5mg; 10mg 1 MO

amlodipine besylate/atorvastatin calcium tabs 2.5mg; 20mg 1 MO

amlodipine besylate/atorvastatin calcium tabs 2.5mg; 40mg 1 MO

amlodipine besylate/atorvastatin calcium tabs 5mg; 10mg 1 MO

amlodipine besylate/atorvastatin calcium tabs 5mg; 20mg 1 MO

amlodipine besylate/atorvastatin calcium tabs 5mg; 40mg 1 MO

amlodipine besylate/atorvastatin calcium tabs 5mg; 80mg 1 MO

amlodipine besylate/benazepril hydrochloride caps 10mg;

20mg

1 MO

amlodipine besylate/benazepril hydrochloride caps 10mg;

40mg

1 MO

amlodipine besylate/benazepril hydrochloride caps 2.5mg;

10mg

1 MO

amlodipine besylate/benazepril hydrochloride caps 5mg;

10mg

1 MO

amlodipine besylate/benazepril hydrochloride caps 5mg;

20mg

1 MO

amlodipine besylate/benazepril hydrochloride caps 5mg;

40mg

1 MO

amlodipine besylate tabs 10mg 1 MO

Page 70: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

60

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

amlodipine besylate tabs 2.5mg 1 MO

amlodipine besylate tabs 5mg 1 MO

AZOR TABS 10MG; 20MG 1 MO

AZOR TABS 10MG; 40MG 1 MO

AZOR TABS 5MG; 20MG 1 MO

AZOR TABS 5MG; 40MG 1 MO

CARDIZEM LA TB24 120MG 1 MO

cartia xt cp24 120mg 1 MO

cartia xt cp24 180mg 1 MO

cartia xt cp24 240mg 1 MO

cartia xt cp24 300mg 1 MO

dilt-xr cp24 120mg 1 MO

dilt-xr cp24 180mg 1 MO

dilt-xr cp24 240mg 1 MO

diltiazem cd cp24 120mg 1 MO

diltiazem cd cp24 180mg 1 MO

diltiazem cd cp24 240mg 1 MO

diltiazem cd cp24 300mg 1 MO

diltiazem hcl cd cp24 360mg 1 MO

diltiazem hcl er cp12 120mg 1 MO

diltiazem hcl er cp12 60mg 1 MO

diltiazem hcl er cp12 90mg 1 MO

diltiazem hcl er cp24 120mg 1 MO

diltiazem hcl er cp24 120mg 1 MO

diltiazem hcl er cp24 120mg 1 MO

diltiazem hcl er cp24 180mg 1 MO

diltiazem hcl er cp24 180mg 1 MO

diltiazem hcl er cp24 180mg 1 MO

diltiazem hcl er cp24 240mg 1 MO

diltiazem hcl er cp24 240mg 1 MO

diltiazem hcl er cp24 300mg 1 MO

diltiazem hcl er cp24 360mg 1 MO

diltiazem hcl er cp24 360mg 1 MO

diltiazem hcl er cp24 420mg 1 MO

diltiazem hcl er tb24 180mg 1 MO

diltiazem hcl er tb24 240mg 1 MO

diltiazem hcl er tb24 300mg 1 MO

diltiazem hcl er tb24 360mg 1 MO

diltiazem hcl er tb24 420mg 1 MO

diltiazem hcl inj 100mg 1

diltiazem hcl inj 5%; 125mg/125ml 1

diltiazem hcl tabs 120mg 1 MO

diltiazem hcl tabs 30mg 1 MO

diltiazem hcl tabs 60mg 1 MO

diltiazem hcl tabs 90mg 1 MO

diltiazem hydrochloride/sodium chloride inj 100mg/100ml;

0.9%

1

felodipine er tb24 10mg 1 MO

Page 71: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

61

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

felodipine er tb24 2.5mg 1 MO

felodipine er tb24 5mg 1 MO

isradipine caps 2.5mg 1 MO

isradipine caps 5mg 1 MO

matzim la tb24 180mg 1 MO

matzim la tb24 240mg 1 MO

matzim la tb24 300mg 1 MO

matzim la tb24 360mg 1 MO

matzim la tb24 420mg 1 MO

nicardipine hcl caps 20mg 1 MO

nicardipine hcl caps 30mg 1 MO

nifedical xl tb24 30mg 1 MO

nifedical xl tb24 60mg 1 MO

nifedipine er tb24 30mg 1 MO

nifedipine er tb24 30mg 1 MO

nifedipine er tb24 60mg 1 MO

nifedipine er tb24 60mg 1 MO

nifedipine er tb24 90mg 1 MO

nifedipine er tb24 90mg 1 MO

nifedipine caps 10mg 1 PA MO

nifedipine caps 20mg 1 PA MO

nimodipine caps 30mg 1 MO

nisoldipine er tb24 25.5mg 1 MO

nisoldipine tb24 17mg 1 MO

nisoldipine tb24 20mg 1 MO

nisoldipine tb24 30mg 1 MO

nisoldipine tb24 34mg 1 MO

nisoldipine tb24 40mg 1 MO

nisoldipine tb24 8.5mg 1 MO

taztia xt cp24 120mg 1 MO

taztia xt cp24 180mg 1 MO

taztia xt cp24 240mg 1 MO

taztia xt cp24 300mg 1 MO

taztia xt cp24 360mg 1 MO

TRIBENZOR TABS 10MG; 12.5MG; 40MG 1 MO

TRIBENZOR TABS 10MG; 25MG; 40MG 1 MO

TRIBENZOR TABS 5MG; 12.5MG; 20MG 1 MO

TRIBENZOR TABS 5MG; 12.5MG; 40MG 1 MO

TRIBENZOR TABS 5MG; 25MG; 40MG 1 MO

verapamil hcl er cp24 100mg 1 MO

verapamil hcl er cp24 120mg 1 MO

verapamil hcl er cp24 180mg 1 MO

verapamil hcl er cp24 200mg 1 MO

verapamil hcl er cp24 240mg 1 MO

verapamil hcl er cp24 300mg 1 MO

verapamil hcl er tbcr 120mg 1 MO

verapamil hcl er tbcr 120mg 1 MO

verapamil hcl er tbcr 180mg 1 MO

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62

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

verapamil hcl er tbcr 240mg 1 MO

verapamil hcl sr cp24 120mg 1 MO

verapamil hcl sr cp24 180mg 1 MO

verapamil hcl sr cp24 240mg 1 MO

verapamil hcl sr cp24 360mg 1 MO

verapamil hcl tabs 120mg 1 MO

verapamil hcl tabs 40mg 1 MO

verapamil hcl tabs 80mg 1 MO

Cardiovascular Agents, Other

AMTURNIDE TABS 150MG; 5MG; 12.5MG 1 MO

AMTURNIDE TABS 300MG; 10MG; 12.5MG 1 MO

AMTURNIDE TABS 300MG; 10MG; 25MG 1 MO

AMTURNIDE TABS 300MG; 5MG; 12.5MG 1 MO

AMTURNIDE TABS 300MG; 5MG; 25MG 1 MO

DEMSER CAPS 250MG 1

digitek tabs 0.125mg 1 QL (30 EA per 30 days) MO

digitek tabs 0.25mg 1 PA MO

digoxin soln 0.05mg/ml 1 MO

digoxin tabs 125mcg 1 QL (30 EA per 30 days) MO

digoxin tabs 250mcg 1 PA MO

digox tabs 125mcg 1 QL (30 EA per 30 days) MO

digox tabs 250mcg 1 PA MO

LANOXIN TABS 125MCG 1 QL (30 EA per 30 days) MO

LANOXIN TABS 62.5MCG 1 MO

NORTHERA CAPS 100MG 1 PA

NORTHERA CAPS 200MG 1 PA

NORTHERA CAPS 300MG 1 PA

pentoxifylline er tbcr 400mg 1 MO

PRALUENT INJ 150MG/ML 1 QL (2 ML per 28 days) PA MO

PRALUENT INJ 150MG/ML 1 QL (2 ML per 28 days) PA MO

PRALUENT INJ 75MG/ML 1 QL (2 ML per 28 days) PA MO

PRALUENT INJ 75MG/ML 1 QL (2 ML per 28 days) PA MO

RANEXA TB12 1000MG 1 PA MO

RANEXA TB12 500MG 1 PA MO

REPATHA PUSHTRONEX SYSTEM INJ 420MG/3.5ML 1 QL (3.5 ML per 28 days) PA MO

REPATHA SURECLICK INJ 140MG/ML 1 QL (3 ML per 28 days) PA MO

REPATHA INJ 140MG/ML 1 QL (3 ML per 28 days) PA MO

TEKAMLO TABS 150MG; 10MG 1 MO

TEKAMLO TABS 150MG; 5MG 1 MO

TEKAMLO TABS 300MG; 10MG 1 MO

TEKAMLO TABS 300MG; 5MG 1 MO

TEKTURNA HCT TABS 150MG; 12.5MG 1 MO

TEKTURNA HCT TABS 150MG; 25MG 1 MO

TEKTURNA HCT TABS 300MG; 12.5MG 1 MO

TEKTURNA HCT TABS 300MG; 25MG 1 MO

TEKTURNA TABS 150MG 1 MO

TEKTURNA TABS 300MG 1 MO

Cardiovascular Agents

Page 73: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

63

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

norepinephrine bitartrate/dextrose inj 5%; 4mg/250ml 1

norepinephrine bitartrate/dextrose inj 5%; 4mg/500ml 1

norepinephrine bitartrate/dextrose inj 5%; 8mg/250ml 1

norepinephrine bitartrate/sodium chloride inj 0.08mg/10ml;

0.9%

1

norepinephrine bitartrate/sodium chloride inj 4mg/250ml;

0.9%

1

norepinephrine/sodium chloride inj 8mg/250ml; 0.9% 1

Diuretics, Carbonic Anhydrase Inhibitors

acetazolamide sodium inj 500mg 1

acetazolamide tabs 125mg 1 MO

acetazolamide tabs 250mg 1 MO

methazolamide tabs 25mg 1 MO

methazolamide tabs 50mg 1 MO

Diuretics, Loop

bumetanide inj 0.25mg/ml 1

bumetanide tabs 0.5mg 1 MO

bumetanide tabs 1mg 1 MO

bumetanide tabs 2mg 1 MO

EDECRIN TABS 25MG 1 MO

ethacrynic acid tabs 25mg 1 MO

furosemide inj 10mg/ml 1

furosemide inj 10mg/ml 1

furosemide soln 10mg/ml 1 MO

furosemide soln 8mg/ml 1 MO

furosemide tabs 20mg 1 MO

furosemide tabs 40mg 1 MO

furosemide tabs 80mg 1 MO

torsemide tabs 100mg 1 MO

torsemide tabs 10mg 1 MO

torsemide tabs 20mg 1 MO

torsemide tabs 5mg 1 MO

Diuretics, Potassium-sparing

ALDACTAZIDE TABS 50MG; 50MG 1 MO

amiloride hcl tabs 5mg 1 MO

amiloride/hydrochlorothiazide tabs 5mg; 50mg 1 MO

DYRENIUM CAPS 0; 100MG 1 MO

DYRENIUM CAPS 50MG 1 MO

eplerenone tabs 25mg 1 MO

eplerenone tabs 50mg 1 MO

spironolactone/hydrochlorothiazide tabs 25mg; 25mg 1 MO

spironolactone tabs 100mg 1 MO

spironolactone tabs 25mg 1 MO

spironolactone tabs 50mg 1 MO

triamterene/hydrochlorothiazide caps 25mg; 37.5mg 1 MO

triamterene/hydrochlorothiazide caps 25mg; 50mg 1 MO

triamterene/hydrochlorothiazide tabs 25mg; 37.5mg 1 MO

triamterene/hydrochlorothiazide tabs 50mg; 75mg 1 MO

Page 74: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

64

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

Diuretics, Thiazide

candesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg 1 MO

candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg 1 MO

candesartan cilexetil/hydrochlorothiazide tabs 32mg; 25mg 1 MO

chlorothiazide sodium inj 500mg 1

chlorothiazide tabs 250mg 1 MO

chlorothiazide tabs 500mg 1 MO

chlorthalidone tabs 25mg 1 MO

chlorthalidone tabs 50mg 1 MO

hydrochlorothiazide caps 12.5mg 1 MO

hydrochlorothiazide tabs 12.5mg 1 MO

hydrochlorothiazide tabs 25mg 1 MO

hydrochlorothiazide tabs 50mg 1 MO

indapamide tabs 1.25mg 1 MO

indapamide tabs 2.5mg 1 MO

methyclothiazide tabs 5mg 1 MO

metolazone tabs 10mg 1 MO

metolazone tabs 2.5mg 1 MO

metolazone tabs 5mg 1 MO

Dyslipidemics, Fibric Acid Derivatives

fenofibrate micronized caps 134mg 1 MO

fenofibrate micronized caps 200mg 1 MO

fenofibrate micronized caps 67mg 1 MO

fenofibrate caps 130mg 1 MO

fenofibrate caps 150mg 1 MO

fenofibrate caps 43mg 1 MO

fenofibrate caps 50mg 1 MO

fenofibrate tabs 120mg 1 MO

fenofibrate tabs 145mg 1 MO

fenofibrate tabs 160mg 1 MO

fenofibrate tabs 40mg 1 MO

fenofibrate tabs 48mg 1 MO

fenofibrate tabs 54mg 1 MO

fenofibric acid dr cpdr 135mg 1 MO

fenofibric acid dr cpdr 45mg 1 MO

fenofibric acid tabs 105mg 1 MO

fenofibric acid tabs 35mg 1 MO

gemfibrozil tabs 600mg 1 MO

Dyslipidemics, HMG CoA Reductase Inhibitors

atorvastatin calcium tabs 10mg 1 MO

atorvastatin calcium tabs 20mg 1 MO

atorvastatin calcium tabs 40mg 1 MO

atorvastatin calcium tabs 80mg 1 MO

CRESTOR TABS 10MG 1 MO

CRESTOR TABS 20MG 1 MO

CRESTOR TABS 40MG 1 MO

CRESTOR TABS 5MG 1 MO

fluvastatin sodium er tb24 80mg 1 MO

Page 75: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

65

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

fluvastatin caps 20mg 1 MO

fluvastatin caps 40mg 1 MO

LESCOL XL TB24 80MG 1 ST MO

LIVALO TABS 1MG 1 ST MO

LIVALO TABS 2MG 1 ST MO

LIVALO TABS 4MG 1 ST MO

lovastatin tabs 10mg 1 MO

lovastatin tabs 20mg 1 MO

lovastatin tabs 40mg 1 MO

pravastatin sodium tabs 10mg 1 MO

pravastatin sodium tabs 20mg 1 MO

pravastatin sodium tabs 40mg 1 MO

pravastatin sodium tabs 80mg 1 MO

rosuvastatin calcium tabs 10mg 1 MO

rosuvastatin calcium tabs 20mg 1 MO

rosuvastatin calcium tabs 40mg 1 MO

rosuvastatin calcium tabs 5mg 1 MO

SIMCOR TB24 1000MG; 20MG 1 ST MO

SIMCOR TB24 1000MG; 40MG 1 ST MO

SIMCOR TB24 500MG; 20MG 1 ST MO

SIMCOR TB24 500MG; 40MG 1 ST MO

SIMCOR TB24 750MG; 20MG 1 ST MO

simvastatin tabs 10mg 1 MO

simvastatin tabs 20mg 1 MO

simvastatin tabs 40mg 1 MO

simvastatin tabs 5mg 1 MO

simvastatin tabs 80mg 1 PA MO

Dyslipidemics, Other

cholestyramine light pack 4gm 1 MO

cholestyramine light powd 4gm/dose 1 MO

cholestyramine powd 4gm/dose 1 MO

colestipol hcl gran 5gm 1 MO

colestipol hcl tabs 1gm 1 MO

JUXTAPID CAPS 10MG 1 QL (30 EA per 30 days) PA MO

JUXTAPID CAPS 20MG 1 QL (30 EA per 30 days) PA MO

JUXTAPID CAPS 30MG 1 QL (30 EA per 30 days) PA MO

JUXTAPID CAPS 40MG 1 QL (30 EA per 30 days) PA MO

JUXTAPID CAPS 5MG 1 QL (30 EA per 30 days) PA MO

JUXTAPID CAPS 60MG 1 QL (30 EA per 30 days) PA MO

KYNAMRO INJ 200MG/ML 1 QL (4 ML per 28 days) MO

niacin er tbcr 1000mg 1 MO

niacin er tbcr 500mg 1 MO

niacin er tbcr 750mg 1 MO

niacor tabs 500mg 1

omega-3-acid ethyl esters caps 375mg; 465mg; 1gm 1 MO

prevalite pack 4gm 1 MO

prevalite powd 4gm/dose 1 MO

VASCEPA CAPS 0.5GM 1 MO

Page 76: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

66

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

VASCEPA CAPS 1GM 1 MO

VYTORIN TABS 10MG; 10MG 1 ST MO

VYTORIN TABS 10MG; 20MG 1 ST MO

VYTORIN TABS 10MG; 40MG 1 ST MO

VYTORIN TABS 10MG; 80MG 1 PA MO

ZETIA TABS 10MG 1 MO

Vasodilators, Direct-acting Arterial/Venous

DILATRATE SR CPCR 40MG 1 MO

ISORDIL TITRADOSE TABS 40MG 1 MO

isosorbide dinitrate er tbcr 40mg 1 MO

isosorbide dinitrate tabs 10mg 1 MO

isosorbide dinitrate tabs 20mg 1 MO

isosorbide dinitrate tabs 30mg 1 MO

isosorbide dinitrate tabs 5mg 1 MO

isosorbide mononitrate er tb24 120mg 1 MO

isosorbide mononitrate er tb24 30mg 1 MO

isosorbide mononitrate er tb24 60mg 1 MO

isosorbide mononitrate tabs 10mg 1 MO

isosorbide mononitrate tabs 20mg 1 MO

minitran pt24 0.1mg/hr 1 MO

minitran pt24 0.2mg/hr 1 MO

minitran pt24 0.4mg/hr 1 MO

minitran pt24 0.6mg/hr 1 MO

NITRO-BID OINT 2% 1 MO

NITRO-DUR PT24 0.3MG/HR 1 MO

NITRO-DUR PT24 0.8MG/HR 1 MO

nitroglycerin lingual aers 400mcg/spray 1 MO

nitroglycerin lingual soln 0.4mg/spray 1 MO

nitroglycerin transdermal pt24 0.1mg/hr 1 MO

nitroglycerin transdermal pt24 0.2mg/hr 1 MO

nitroglycerin transdermal pt24 0.4mg/hr 1 MO

nitroglycerin transdermal pt24 0.6mg/hr 1 MO

nitroglycerin subl 0.3mg 1 MO

nitroglycerin subl 0.4mg 1 MO

nitroglycerin subl 0.6mg 1 MO

NITROMIST AERS 400MCG/SPRAY 1 MO

NITROSTAT SUBL 0.3MG 1 MO

NITROSTAT SUBL 0.4MG 1 MO

NITROSTAT SUBL 0.6MG 1 MO

Vasodilators, Direct-acting Arterial

hydralazine hcl tabs 100mg 1 MO

hydralazine hcl tabs 10mg 1 MO

hydralazine hcl tabs 25mg 1 MO

hydralazine hcl tabs 50mg 1 MO

minoxidil tabs 10mg 1 MO

minoxidil tabs 2.5mg 1 MO

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

Page 77: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

67

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg;

1.25mg; 1.25mg

1 QL (30 EA per 30 days) MO

amphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg;

2.5mg

1 QL (30 EA per 30 days) MO

amphetamine/dextroamphetamine cp24 3.75mg; 3.75mg;

3.75mg; 3.75mg

1 QL (30 EA per 30 days) MO

amphetamine/dextroamphetamine cp24 5mg; 5mg; 5mg; 5mg 1 QL (30 EA per 30 days) MO

amphetamine/dextroamphetamine cp24 6.25mg; 6.25mg;

6.25mg; 6.25mg

1 QL (30 EA per 30 days) MO

amphetamine/dextroamphetamine cp24 7.5mg; 7.5mg; 7.5mg;

7.5mg

1 QL (30 EA per 30 days) MO

amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg;

1.25mg; 1.25mg

1 QL (60 EA per 30 days) MO

amphetamine/dextroamphetamine tabs 1.875mg; 1.875mg;

1.875mg; 1.875mg

1 QL (60 EA per 30 days) MO

amphetamine/dextroamphetamine tabs 2.5mg; 2.5mg; 2.5mg;

2.5mg

1 QL (60 EA per 30 days) MO

amphetamine/dextroamphetamine tabs 3.125mg; 3.125mg;

3.125mg; 3.125mg

1 QL (60 EA per 30 days) MO

amphetamine/dextroamphetamine tabs 3.75mg; 3.75mg;

3.75mg; 3.75mg

1 QL (60 EA per 30 days) MO

amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg 1 QL (60 EA per 30 days) MO

amphetamine/dextroamphetamine tabs 7.5mg; 7.5mg; 7.5mg;

7.5mg

1 QL (60 EA per 30 days) MO

dextroamphetamine sulfate er cp24 10mg 1 QL (180 EA per 30 days) MO

dextroamphetamine sulfate er cp24 15mg 1 QL (120 EA per 30 days) MO

dextroamphetamine sulfate er cp24 5mg 1 QL (90 EA per 30 days) MO

dextroamphetamine sulfate soln 5mg/5ml 1 QL (1800 ML per 30 days) MO

dextroamphetamine sulfate tabs 10mg 1 QL (180 EA per 30 days) MO

dextroamphetamine sulfate tabs 5mg 1 QL (90 EA per 30 days) MO

methamphetamine hcl tabs 5mg 1 QL (150 EA per 30 days) MO

zenzedi tabs 10mg 1 QL (180 EA per 30 days) MO

zenzedi tabs 15mg 1 QL (90 EA per 30 days) MO

zenzedi tabs 2.5mg 1 QL (90 EA per 30 days) MO

zenzedi tabs 20mg 1 QL (90 EA per 30 days) MO

zenzedi tabs 30mg 1 QL (60 EA per 30 days) MO

zenzedi tabs 5mg 1 QL (90 EA per 30 days) MO

zenzedi tabs 7.5mg 1 QL (90 EA per 30 days) MO

Attention Deficit Hyperactivity Disorder Agents,

Non-amphetamines

DAYTRANA PTCH 10MG/9HR 1 QL (30 EA per 30 days) ST MO

DAYTRANA PTCH 15MG/9HR 1 QL (30 EA per 30 days) ST MO

DAYTRANA PTCH 20MG/9HR 1 QL (30 EA per 30 days) ST MO

DAYTRANA PTCH 30MG/9HR 1 QL (30 EA per 30 days) ST MO

dexmethylphenidate hcl er cp24 10mg 1 QL (30 EA per 30 days) MO

dexmethylphenidate hcl er cp24 15mg 1 QL (30 EA per 30 days) MO

dexmethylphenidate hcl er cp24 20mg 1 QL (60 EA per 30 days) MO

dexmethylphenidate hcl er cp24 30mg 1 QL (30 EA per 30 days) MO

Page 78: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

68

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

dexmethylphenidate hcl er cp24 40mg 1 QL (30 EA per 30 days) MO

dexmethylphenidate hcl er cp24 5mg 1 QL (30 EA per 30 days) MO

dexmethylphenidate hcl tabs 10mg 1 QL (60 EA per 30 days) MO

dexmethylphenidate hcl tabs 2.5mg 1 QL (60 EA per 30 days) MO

dexmethylphenidate hcl tabs 5mg 1 QL (60 EA per 30 days) MO

guanfacine er tb24 1mg 1 MO

guanfacine er tb24 2mg 1 MO

guanfacine er tb24 3mg 1 MO

guanfacine er tb24 4mg 1 MO

metadate er tbcr 20mg 1 QL (90 EA per 30 days) MO

methylphenidate hcl cd cpcr 10mg 1 QL (60 EA per 30 days) MO

methylphenidate hcl cd cpcr 20mg 1 QL (60 EA per 30 days) MO

methylphenidate hcl cd cpcr 30mg 1 QL (60 EA per 30 days) MO

methylphenidate hcl cd cpcr 40mg 1 QL (30 EA per 30 days) MO

methylphenidate hcl cd cpcr 50mg 1 QL (30 EA per 30 days) MO

methylphenidate hcl cd cpcr 60mg 1 QL (30 EA per 30 days) MO

methylphenidate hcl er cp24 20mg 1 QL (60 EA per 30 days) MO

methylphenidate hcl er cp24 30mg 1 QL (60 EA per 30 days) MO

methylphenidate hcl er cp24 40mg 1 QL (30 EA per 30 days) MO

methylphenidate hcl er tb24 18mg 1 QL (120 EA per 30 days) MO

methylphenidate hcl er tb24 27mg 1 QL (30 EA per 30 days) MO

methylphenidate hcl er tb24 36mg 1 QL (60 EA per 30 days) MO

methylphenidate hcl er tb24 54mg 1 QL (30 EA per 30 days) MO

methylphenidate hcl er tbcr 10mg 1 QL (180 EA per 30 days) MO

methylphenidate hcl er tbcr 18mg 1 QL (120 EA per 30 days) MO

methylphenidate hcl er tbcr 20mg 1 QL (90 EA per 30 days) MO

methylphenidate hcl chew 10mg 1 QL (180 EA per 30 days) MO

methylphenidate hcl chew 2.5mg 1 QL (90 EA per 30 days) MO

methylphenidate hcl chew 5mg 1 QL (90 EA per 30 days) MO

methylphenidate hcl tabs 10mg 1 QL (90 EA per 30 days) MO

methylphenidate hcl tabs 20mg 1 QL (90 EA per 30 days) MO

methylphenidate hcl tabs 5mg 1 QL (90 EA per 30 days) MO

methylphenidate hydrochloride soln 10mg/5ml 1 MO

methylphenidate hydrochloride soln 5mg/5ml 1 MO

STRATTERA CAPS 100MG 1 QL (30 EA per 30 days) ST MO

STRATTERA CAPS 10MG 1 QL (30 EA per 30 days) ST MO

STRATTERA CAPS 18MG 1 QL (30 EA per 30 days) ST MO

STRATTERA CAPS 25MG 1 QL (30 EA per 30 days) ST MO

STRATTERA CAPS 40MG 1 QL (30 EA per 30 days) ST MO

STRATTERA CAPS 60MG 1 QL (30 EA per 30 days) ST MO

STRATTERA CAPS 80MG 1 QL (30 EA per 30 days) ST MO

Central Nervous System, Other

butalbital/acetaminophen/caffeine/codeine caps 300mg;

50mg; 40mg; 30mg

1 QL (180 EA per 30 days) PA

butalbital/acetaminophen/caffeine/codeine caps 325mg;

50mg; 40mg; 30mg

1 QL (180 EA per 30 days) PA

HETLIOZ CAPS 20MG 1 QL (30 EA per 30 days) PA MO

NUEDEXTA CAPS 20MG; 10MG 1 MO

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69

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

riluzole tabs 50mg 1 QL (60 EA per 30 days) PA MO

tetrabenazine tabs 12.5mg 1 PA MO

tetrabenazine tabs 25mg 1 PA MO

XENAZINE TABS 12.5MG 1 PA MO

XENAZINE TABS 25MG 1 PA MO

Fibromyalgia Agents

SAVELLA TITRATION PACK MISC 0 1 QL (55 EA per 28 days) PA

SAVELLA TABS 100MG 1 QL (60 EA per 30 days) PA MO

SAVELLA TABS 12.5MG 1 QL (60 EA per 30 days) PA MO

SAVELLA TABS 25MG 1 QL (60 EA per 30 days) PA MO

SAVELLA TABS 50MG 1 QL (60 EA per 30 days) PA MO

Multiple Sclerosis Agents

AMPYRA TB12 10MG 1 QL (60 EA per 30 days) PA MO

AUBAGIO TABS 14MG 1 QL (30 EA per 30 days) PA MO

AUBAGIO TABS 7MG 1 QL (30 EA per 30 days) PA MO

AVONEX PEN INJ 30MCG/0.5ML 1 QL (2 EA per 28 days) PA MO

AVONEX INJ 30MCG/0.5ML 1 QL (2 EA per 28 days) PA MO

AVONEX INJ 30MCG/VIAL 1 QL (2 EA per 28 days) PA MO

BETASERON INJ 0.3MG 1 QL (15 EA per 30 days) PA MO

COPAXONE INJ 40MG/ML 1 QL (12 ML per 28 days) PA MO

EXTAVIA INJ 0.3MG 1 QL (15 EA per 30 days) PA MO

GILENYA CAPS 0.5MG 1 QL (28 EA per 28 days) PA MO

glatopa inj 20mg/ml 1 QL (30 ML per 30 days) PA MO

LEMTRADA INJ 12MG/1.2ML 1 PA

PLEGRIDY STARTER PACK INJ 0 1 QL (2 ML per 365 days) PA

PLEGRIDY STARTER PACK INJ 0 1 QL (2 ML per 365 days) PA

PLEGRIDY INJ 125MCG/0.5ML 1 QL (2 ML per 28 days) PA MO

PLEGRIDY INJ 125MCG/0.5ML 1 QL (2 ML per 28 days) PA MO

REBIF REBIDOSE TITRATION PACK INJ 0 1 QL (4.2 ML per 28 days) PA MO

REBIF REBIDOSE INJ 22MCG/0.5ML 1 QL (6 ML per 28 days) PA MO

REBIF REBIDOSE INJ 44MCG/0.5ML 1 QL (6 ML per 28 days) PA MO

REBIF TITRATION PACK INJ 0 1 QL (4.2 ML per 28 days) PA MO

REBIF INJ 22MCG/0.5ML 1 QL (6 ML per 28 days) PA MO

REBIF INJ 44MCG/0.5ML 1 QL (6 ML per 28 days) PA MO

TYSABRI INJ 300MG/15ML 1 QL (15 ML per 28 days) PA

ZINBRYTA INJ 150MG/ML 1 QL (1 ML per 28 days) PA MO

Dental and Oral Agents

Dental and Oral Agents

cevimeline hcl caps 30mg 1 MO

chlorhexidine gluconate soln 0.12% 1

oralone pste 0.1% 1

paroex soln 0.12% 1

periogard soln 0.12% 1

pilocarpine hcl tabs 7.5mg 1 MO

pilocarpine hydrochloride tabs 5mg 1 MO

triamcinolone acetonide pste 0.1% 1

triamcinolone in orabase pste 0.1% 1

Dermatological Agents

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

Dermatological Agents

acitretin caps 10mg 1 PA

acitretin caps 17.5mg 1 PA

acitretin caps 25mg 1 PA

ACZONE GEL 5% 1

adapalene pump gel 0.3% 1 PA

adapalene crea 0.1% 1 PA

adapalene gel 0.1% 1 PA

adapalene gel 0.3% 1 PA

alclometasone dipropionate crea 0.05% 1

alclometasone dipropionate oint 0.05% 1

alphatrex gel 0.05% 1

amcinonide crea 0.1% 1

amcinonide lotn 0.1% 1

amcinonide oint 0.1% 1

AMELUZ GEL 10% 1

ammonium lactate crea 12% 1

ammonium lactate lotn 12% 1

amnesteem caps 10mg 1

amnesteem caps 20mg 1

amnesteem caps 40mg 1

apexicon e crea 0.05% 1

augmented betamethasone dipropionate crea 0.05% 1

augmented betamethasone dipropionate gel 0.05% 1

augmented betamethasone dipropionate lotn 0.05% 1

augmented betamethasone dipropionate oint 0.05% 1

avita crea 0.025% 1 PA

avita gel 0.025% 1 PA

AZELEX CREA 20% 1

betamethasone dipropionate crea 0.05% 1

betamethasone dipropionate lotn 0.05% 1

betamethasone dipropionate oint 0.05% 1

betamethasone valerate crea 0.1% 1

betamethasone valerate foam 0.12% 1

betamethasone valerate lotn 0.1% 1

betamethasone valerate oint 0.1% 1

calcipotriene/betamethasone dipropionate oint 0.064%;

0.005%

1 QL (400 GM per 28 days) PA

calcipotriene crea 0.005% 1

calcipotriene oint 0.005% 1

calcipotriene soln 0.005% 1

calcitrene oint 0.005% 1

calcitriol oint 3mcg/gm 1

CAPEX SHAM 0.01% 1

claravis caps 10mg 1

claravis caps 20mg 1

claravis caps 30mg 1

claravis caps 40mg 1

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

clindacin etz pledgets swab 1% 1

clindacin-p swab 1% 1

clindamax gel 1% 1

clindamycin phosphate foam 1% 1

clindamycin phosphate gel 1% 1

clindamycin phosphate lotn 1% 1

clindamycin phosphate soln 1% 1

clindamycin phosphate swab 1% 1

clindamycin/benzoyl peroxide gel 5%; 1% 1

clindamycin/benzoyl peroxide gel 5%; 1.2% 1

clobetasol propionate e crea 0.05% 1

clobetasol propionate emollient foam 0.05% 1

clobetasol propionate crea 0.05% 1

clobetasol propionate foam 0.05% 1

clobetasol propionate foam 0.05% 1

clobetasol propionate foam 0.05% 1

clobetasol propionate gel 0.05% 1

clobetasol propionate liqd 0.05% 1

clobetasol propionate lotn 0.05% 1

clobetasol propionate oint 0.05% 1

clobetasol propionate sham 0.05% 1

clobetasol propionate soln 0.05% 1

clodan kit kit 0.05% 1

clodan sham 0.05% 1

CONDYLOX GEL 0.5% 1

CORDRAN TAPE TAPE 4MCG/SQCM 1

cormax scalp application soln 0.05% 1

cormax soln 0.05% 1

COSENTYX SENSOREADY PEN INJ 150MG/ML 1 PA MO

COSENTYX INJ 150MG/ML 1 PA MO

CURITY GAUZE PADS 2"X2" PADS 1

DESONATE GEL 0.05% 1

desonide crea 0.05% 1

desonide lotn 0.05% 1

desonide oint 0.05% 1

desoximetasone crea 0.05% 1

desoximetasone crea 0.25% 1

desoximetasone gel 0.05% 1

desoximetasone oint 0.05% 1

desoximetasone oint 0.25% 1

diclofenac sodium gel 1% 1

diclofenac sodium soln 1.5% 1

diflorasone diacetate crea 0.05% 1

diflorasone diacetate oint 0.05% 1

doxepin hydrochloride crea 5% 1

ELIDEL CREA 1% 1 ST

erythromycin/benzoyl peroxide gel 5%; 3% 1

fluocinolone acetonide body oil 0.01% 1

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

fluocinolone acetonide scalp oil 0.01% 1

fluocinolone acetonide scalp oil 0.01% 1

fluocinolone acetonide crea 0.01% 1

fluocinolone acetonide crea 0.025% 1

fluocinolone acetonide oint 0.025% 1

fluocinolone acetonide soln 0.01% 1

fluocinonide-e crea 0.05% 1

fluocinonide crea 0.05% 1

fluocinonide crea 0.1% 1

fluocinonide gel 0.05% 1

fluocinonide oint 0.05% 1

fluocinonide soln 0.05% 1

fluorouracil crea 0.5% 1

fluorouracil crea 5% 1

fluorouracil soln 2% 1

fluorouracil soln 5% 1

fluticasone propionate crea 0.05% 1

fluticasone propionate lotn 0.05% 1

fluticasone propionate oint 0.005% 1

halobetasol propionate crea 0.05% 1

halobetasol propionate oint 0.05% 1

HALOG CREA 0.1% 1

HALOG OINT 0.1% 1

hydrocortisone butyrate (lipid) crea 0.1% 1

hydrocortisone butyrate (lipophilic) crea 0.1% 1

hydrocortisone butyrate crea 0.1% 1

hydrocortisone butyrate oint 0.1% 1

hydrocortisone butyrate soln 0.1% 1

hydrocortisone valerate crea 0.2% 1

hydrocortisone valerate oint 0.2% 1

hydrocortisone crea 2.5% 1

hydrocortisone lotn 2.5% 1

hydrocortisone oint 2.5% 1

imiquimod crea 5% 1

klofensaid ii soln 1.5% 1

LOCOID LIPOCREAM CREA 0.1% 1

lokara lotn 0.05% 1

methoxsalen caps 10mg 1

mometasone furoate crea 0.1% 1

mometasone furoate oint 0.1% 1

mometasone furoate soln 0.1% 1

myorisan caps 10mg 1

myorisan caps 20mg 1

myorisan caps 30mg 1

myorisan caps 40mg 1

neuac kit kit 5%; 1.2% 1

neuac gel 5%; 1.2% 1

PANDEL CREA 0.1% 1

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

podofilox soln 0.5% 1

prednicarbate crea 0.1% 1

prednicarbate oint 0.1% 1

prudoxin crea 5% 1

SANTYL OINT 250UNIT/GM 1

selenium sulfide lotn 2.5% 1

STELARA INJ 45MG/0.5ML 1 PA MO

STELARA INJ 90MG/ML 1 PA MO

sulfacetamide sodium susp 10% 1

SYNALAR OINTMENT KIT KIT 0.025% 1

SYNALAR CREA 0.025% 1

synalar oint 0.025% 1

TACLONEX SUSP 0.064%; 0.005% 1 QL (420 GM per 28 days) PA

tacrolimus oint 0.03% 1

tacrolimus oint 0.1% 1

TALTZ INJ 80MG/ML 1 PA MO

TALTZ INJ 80MG/ML 1 PA MO

TAZORAC CREA 0.05% 1 QL (100 GM per 30 days) PA

TAZORAC CREA 0.1% 1 QL (100 GM per 30 days) PA

TAZORAC GEL 0.05% 1 QL (100 GM per 30 days) PA

TAZORAC GEL 0.1% 1 QL (100 GM per 30 days) PA

TOLAK CREA 4% 1

tretinoin microsphere pump gel 0.04% 1 PA

tretinoin microsphere pump gel 0.1% 1 PA

tretinoin microsphere gel 0.04% 1 PA

tretinoin microsphere gel 0.1% 1 PA

tretinoin crea 0.025% 1 PA

tretinoin crea 0.05% 1 PA

tretinoin crea 0.1% 1 PA

tretinoin gel 0.01% 1 PA

tretinoin gel 0.025% 1 PA

tretinoin gel 0.05% 1 PA

triamcinolone acetonide aers 0.147mg/gm 1

triamcinolone acetonide crea 0.025% 1

triamcinolone acetonide crea 0.1% 1

triamcinolone acetonide crea 0.5% 1

triamcinolone acetonide lotn 0.025% 1

triamcinolone acetonide lotn 0.1% 1

triamcinolone acetonide oint 0.025% 1

triamcinolone acetonide oint 0.1% 1

triamcinolone acetonide oint 0.5% 1

trianex oint 0.05% 1

triderm crea 0.1% 1

VEREGEN OINT 15% 1

VOLTAREN GEL 1% 1

zenatane caps 10mg 1

zenatane caps 20mg 1

zenatane caps 30mg 1

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

zenatane caps 40mg 1

ZONALON CREA 5% 1

ZYCLARA PUMP CREA 2.5% 1

ZYCLARA PUMP CREA 3.75% 1

ZYCLARA CREA 3.75% 1

Enzyme Replacement/Modifiers

Enzyme Replacement/Modifiers

ADAGEN INJ 250UNIT/ML 1 PA

ALDURAZYME INJ 2.9MG/5ML 1 PA

BUPHENYL TABS 500MG 1 MO

CARBAGLU TABS 200MG 1 PA MO

CERDELGA CAPS 84MG 1 PA MO

CEREZYME INJ 400UNIT 1 PA

CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT 1 MO

CREON CPEP 15000UNIT; 3000UNIT; 9500UNIT 1 MO

CREON CPEP 180000UNIT; 36000UNIT; 114000UNIT 1 MO

CREON CPEP 30000UNIT; 6000UNIT; 19000UNIT 1 MO

CREON CPEP 60000UNIT; 12000UNIT; 38000UNIT 1 MO

FABRAZYME INJ 35MG 1 PA

KANUMA INJ 20MG/10ML 1 PA

KUVAN PACK 100MG 1 PA MO

KUVAN PACK 500MG 1 PA MO

KUVAN TBSO 100MG 1 PA MO

LUMIZYME INJ 50MG 1 PA

MYOZYME INJ 50MG 1 PA

NAGLAZYME INJ 1MG/ML 1 PA

PANCREAZE CPEP 17500UNIT; 4200UNIT; 10000UNIT 1 MO

PANCREAZE CPEP 43750UNIT; 10500UNIT; 25000UNIT 1 MO

PANCREAZE CPEP 61000UNIT; 21000UNIT; 37000UNIT 1 MO

PANCREAZE CPEP 70000UNIT; 16800UNIT; 40000UNIT 1 MO

PANCRELIPASE CPEP 27000UNIT; 5000UNIT;

17000UNIT

1 MO

PERTZYE CPEP 30250UNIT; 8000UNIT; 28750UNIT 1 MO

PERTZYE CPEP 60500UNIT; 16000UNIT; 57500UNIT 1 MO

RAVICTI LIQD 1.1GM/ML 1 PA MO

sodium phenylbutyrate powd 3gm/tsp 1 MO

STRENSIQ INJ 18MG/0.45ML 1 PA MO

STRENSIQ INJ 28MG/0.7ML 1 PA MO

STRENSIQ INJ 40MG/ML 1 PA MO

STRENSIQ INJ 80MG/0.8ML 1 PA MO

ULTRESA CPEP 27600UNIT; 13800UNIT; 27600UNIT 1 MO

ULTRESA CPEP 41400UNIT; 20700UNIT; 41400UNIT 1 MO

ULTRESA CPEP 46000UNIT; 23000UNIT; 46000UNIT 1 MO

VIMIZIM INJ 5MG/5ML 1 PA

VIOKACE TABS 39150UNIT; 10440UNIT; 39150UNIT 1 MO

VIOKACE TABS 78300UNIT; 20880UNIT; 78300UNIT 1 MO

VPRIV INJ 400UNIT 1 PA

ZAVESCA CAPS 100MG 1 PA MO

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

ZENPEP CPEP 109000UNIT; 20000UNIT; 68000UNIT 1 MO

ZENPEP CPEP 136000UNIT; 25000UNIT; 85000UNIT 1 MO

ZENPEP CPEP 16000UNIT; 3000UNIT; 10000UNIT 1 MO

ZENPEP CPEP 218000UNIT; 40000UNIT; 136000UNIT 1 MO

ZENPEP CPEP 27000UNIT; 5000UNIT; 17000UNIT 1 MO

ZENPEP CPEP 55000UNIT; 10000UNIT; 34000UNIT 1 MO

ZENPEP CPEP 82000UNIT; 15000UNIT; 51000UNIT 1 MO

Gastrointestinal Agents

Antispasmodics, Gastrointestinal

dicyclomine hcl caps 10mg 1

dicyclomine hcl inj 10mg/ml 1

dicyclomine hcl soln 10mg/5ml 1

dicyclomine hcl tabs 20mg 1

ENTYVIO INJ 300MG 1 PA

glycopyrrolate inj 0.4mg/2ml 1

glycopyrrolate inj 0.6mg/3ml 1

glycopyrrolate inj 1mg/5ml 1

glycopyrrolate inj 1mg/5ml 1

glycopyrrolate inj 4mg/20ml 1

glycopyrrolate tabs 1mg 1

glycopyrrolate tabs 2mg 1

methscopolamine bromide tabs 2.5mg 1

methscopolamine bromide tabs 5mg 1

Gastrointestinal Agents, Other

CHENODAL TABS 250MG 1

CHOLBAM CAPS 250MG 1 MO

CHOLBAM CAPS 50MG 1 MO

cromolyn sodium conc 100mg/5ml 1 MO

diphenoxylate/atropine liqd 0.025mg/5ml; 2.5mg/5ml 1

diphenoxylate/atropine tabs 0.025mg; 2.5mg 1

GATTEX INJ 5MG 1 PA MO

gavilyte-h kit 5mg; 210gm; 0.74gm; 2.86gm; 5.6gm 1

lofene tabs 0.025mg; 2.5mg 1

loperamide hcl caps 2mg 1

metoclopramide hcl inj 5mg/ml 1

metoclopramide hcl soln 5mg/5ml 1

metoclopramide hcl tabs 10mg 1

metoclopramide hcl tabs 5mg 1

OCALIVA TABS 10MG 1 QL (30 EA per 30 days) PA MO

OCALIVA TABS 5MG 1 QL (30 EA per 30 days) PA MO

OSMOPREP TABS 0.398GM; 1.102GM 1

peg-prep kit 5mg; 210gm; 0.74gm; 2.86gm; 5.6gm 1

PYLERA CAPS 140MG; 125MG; 125MG 1

RECTIV OINT 0.4% 1

RELISTOR INJ 12MG/0.6ML 1 PA

RELISTOR INJ 12MG/0.6ML 1 PA

RELISTOR INJ 8MG/0.4ML 1 PA

RELISTOR TABS 150MG 1 QL (90 EA per 30 days) PA

Page 86: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

76

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

ursodiol caps 300mg 1 MO

ursodiol tabs 250mg 1 MO

ursodiol tabs 500mg 1 MO

Histamine2 (H2) Receptor Antagonists

cimetidine hcl soln 300mg/5ml 1 MO

cimetidine tabs 200mg 1

cimetidine tabs 300mg 1 MO

cimetidine tabs 400mg 1 MO

cimetidine tabs 800mg 1 MO

famotidine inj 200mg/20ml 1

famotidine inj 20mg/2ml 1

famotidine inj 40mg/4ml 1

famotidine inj 40mg/4ml 1

famotidine inj 500mg/50ml 1

famotidine susr 40mg/5ml 1 MO

famotidine tabs 20mg 1 MO

famotidine tabs 40mg 1 MO

nizatidine caps 150mg 1 MO

nizatidine caps 300mg 1 MO

nizatidine soln 15mg/ml 1 MO

ranitidine hcl caps 150mg 1 MO

ranitidine hcl caps 300mg 1 MO

ranitidine hcl syrp 15mg/ml 1 MO

ranitidine hcl tabs 150mg 1 MO

ranitidine hcl tabs 300mg 1 MO

Irritable Bowel Syndrome Agents

alosetron hydrochloride tabs 0.5mg 1 MO

alosetron hydrochloride tabs 1mg 1 MO

AMITIZA CAPS 24MCG 1 QL (60 EA per 30 days) PA MO

AMITIZA CAPS 8MCG 1 QL (60 EA per 30 days) PA MO

LINZESS CAPS 145MCG 1 QL (30 EA per 30 days) PA MO

LINZESS CAPS 290MCG 1 QL (30 EA per 30 days) PA MO

VIBERZI TABS 100MG 1 QL (60 EA per 30 days) PA MO

VIBERZI TABS 75MG 1 QL (60 EA per 30 days) PA MO

Laxatives

constulose soln 10gm/15ml 1 MO

enulose soln 10gm/15ml 1 MO

gavilyte-c solr 240gm; 2.98gm; 6.72gm; 5.84gm; 22.72gm 1

gavilyte-g solr 236gm; 2.97gm; 6.74gm; 5.86gm; 22.74gm 1

gavilyte-n/flavor pack solr 420gm; 1.48gm; 5.72gm; 11.2gm 1

generlac soln 10gm/15ml 1 MO

GOLYTELY SOLR 227.1GM; 2.82GM; 6.36GM; 5.53GM;

21.5GM

1

KRISTALOSE PACK 10GM 1 MO

KRISTALOSE PACK 20GM 1 MO

lactulose soln 10gm/15ml 1 MO

lactulose soln 10gm/15ml 1 MO

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

MOVIPREP SOLR 4.7GM; 100GM; 1.015GM; 5.9GM;

2.691GM; 7.5GM

1

peg 3350/electrolytes solr 240gm; 2.98gm; 6.72gm; 5.84gm;

22.72gm

1

peg-3350/electrolytes solr 236gm; 2.97gm; 6.74gm; 5.86gm;

22.74gm

1

peg-3350/nacl/na bicarbonate/kcl solr 420gm; 1.48gm;

5.72gm; 11.2gm

1

pegylax powd 0 1

polyethylene glycol 3350 pack 0 1

polyethylene glycol 3350 powd 0 1

PREPOPIK PACK 12GM; 3.5GM; 10MG 1

SUPREP BOWEL PREP SOLN 1.6GM/180ML;

3.13GM/180ML; 17.5GM/180ML

1

trilyte solr 420gm; 1.48gm; 5.72gm; 11.2gm 1

Protectants

CARAFATE SUSP 1GM/10ML 1 MO

misoprostol tabs 100mcg 1 MO

misoprostol tabs 200mcg 1 MO

sucralfate tabs 1gm 1 MO

Proton Pump Inhibitors

DEXILANT CPDR 30MG 1 QL (30 EA per 30 days) ST MO

DEXILANT CPDR 60MG 1 QL (30 EA per 30 days) ST MO

esomeprazole magnesium cpdr 20mg 1 QL (30 EA per 30 days) MO

esomeprazole magnesium cpdr 40mg 1 QL (30 EA per 30 days) MO

esomeprazole sodium inj 20mg 1

esomeprazole sodium inj 40mg 1

lansoprazole cpdr 15mg 1 QL (30 EA per 30 days) MO

lansoprazole cpdr 30mg 1 QL (30 EA per 30 days) MO

omeprazole cpdr 10mg 1 QL (30 EA per 30 days) MO

omeprazole cpdr 20mg 1 QL (30 EA per 30 days) MO

omeprazole cpdr 40mg 1 QL (30 EA per 30 days) MO

pantoprazole sodium inj 40mg 1

pantoprazole sodium tbec 20mg 1 QL (30 EA per 30 days) MO

pantoprazole sodium tbec 40mg 1 QL (30 EA per 30 days) MO

rabeprazole sodium tbec 20mg 1 QL (30 EA per 30 days) MO

Genitourinary Agents

Antispasmodics, Urinary

darifenacin hydrobromide er tb24 15mg 1 MO

darifenacin hydrobromide er tb24 7.5mg 1 MO

ENABLEX TB24 15MG 1 ST MO

ENABLEX TB24 7.5MG 1 ST MO

flavoxate hcl tabs 100mg 1 MO

GELNIQUE GEL 10% 1 MO

MYRBETRIQ TB24 25MG 1 MO

MYRBETRIQ TB24 50MG 1 MO

oxybutynin chloride er tb24 10mg 1 MO

oxybutynin chloride er tb24 15mg 1 MO

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

oxybutynin chloride er tb24 5mg 1 MO

oxybutynin chloride syrp 5mg/5ml 1 MO

oxybutynin chloride tabs 5mg 1 MO

OXYTROL PTTW 3.9MG/24HR 1 QL (8 EA per 28 days) MO

tolterodine tartrate er cp24 2mg 1 MO

tolterodine tartrate er cp24 4mg 1 MO

tolterodine tartrate tabs 1mg 1 MO

tolterodine tartrate tabs 2mg 1 MO

TOVIAZ TB24 4MG 1 MO

TOVIAZ TB24 8MG 1 MO

trospium chloride er cp24 60mg 1 MO

trospium chloride tabs 20mg 1 MO

VESICARE TABS 10MG 1 MO

VESICARE TABS 5MG 1 MO

Benign Prostatic Hypertrophy Agents

alfuzosin hcl er tb24 10mg 1 MO

AVODART CAPS 0.5MG 1 MO

doxazosin mesylate tabs 1mg 1 MO

doxazosin mesylate tabs 2mg 1 MO

doxazosin mesylate tabs 8mg 1 MO

doxazosin tabs 4mg 1 MO

dutasteride/tamsulosin hydrochloride caps 0.5mg; 0.4mg 1 MO

dutasteride caps 0.5mg 1 MO

finasteride tabs 5mg 1 MO

JALYN CAPS 0.5MG; 0.4MG 1 MO

RAPAFLO CAPS 4MG 1 MO

RAPAFLO CAPS 8MG 1 MO

tamsulosin hcl caps 0.4mg 1 MO

terazosin hcl caps 10mg 1 MO

terazosin hcl caps 1mg 1 MO

terazosin hcl caps 2mg 1 MO

terazosin hcl caps 5mg 1 MO

Genitourinary Agents, Other

bethanechol chloride tabs 10mg 1

bethanechol chloride tabs 25mg 1

bethanechol chloride tabs 50mg 1

bethanechol chloride tabs 5mg 1

ELMIRON CAPS 100MG 1

Phosphate Binders

calcium acetate caps 667mg 1 MO

calcium acetate tabs 667mg 1 MO

eliphos tabs 667mg 1 MO

FOSRENOL CHEW 1000MG 1 MO

FOSRENOL CHEW 500MG 1 MO

FOSRENOL CHEW 750MG 1 MO

FOSRENOL PACK 1000MG 1 MO

FOSRENOL PACK 750MG 1 MO

PHOSLYRA SOLN 667MG/5ML 1 MO

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

a-hydrocort inj 100mg 1

ala cort crea 1% 1

baycadron elix 0.5mg/5ml 1

clotrimazole/betamethasone dipropionate crea 0.05%; 1% 1

clotrimazole/betamethasone dipropionate lotn 0.05%; 1% 1

cortisone acetate tabs 25mg 1

CORTISPORIN CREA 0.5%; 3.5MG/GM; 10000UNIT/GM 1

deltasone tabs 20mg 1

dexamethasone intensol conc 1mg/ml 1

dexamethasone sodium phosphate inj 10mg/ml 1

dexamethasone sodium phosphate inj 120mg/30ml 1

dexamethasone sodium phosphate inj 20mg/5ml 1

dexamethasone elix 0.5mg/5ml 1

dexamethasone soln 0.5mg/5ml 1

dexamethasone tabs 0.5mg 1

dexamethasone tabs 0.75mg 1

dexamethasone tabs 1.5mg 1

dexamethasone tabs 1mg 1

dexamethasone tabs 2mg 1

dexamethasone tabs 4mg 1

dexamethasone tabs 6mg 1

fludrocortisone acetate tabs 0.1mg 1 MO

fluocinolone acetonide ear drops oil 0.01% 1

fluocinolone acetonide oil 0.01% 1

flurandrenolide crea 0.05% 1

hydrocortisone crea 1% 1

hydrocortisone crea 2.5% 1

hydrocortisone tabs 10mg 1

hydrocortisone tabs 20mg 1

hydrocortisone tabs 5mg 1

methylprednisolone acetate inj 40mg/ml 1

methylprednisolone acetate inj 80mg/ml 1

methylprednisolone dose pack tbpk 4mg 1

methylprednisolone pf inj 40mg/ml 1

methylprednisolone pf inj 80mg/ml 1

methylprednisolone pf inj 80mg/ml 1

methylprednisolone sodiumsuccinate inj 125mg 1

methylprednisolone sodiumsuccinate inj 40mg 1

methylprednisolone inj 100mg/ml 1

methylprednisolone tabs 16mg 1

methylprednisolone tabs 32mg 1

methylprednisolone tabs 4mg 1

methylprednisolone tabs 8mg 1

MILLIPRED SOLN 10MG/5ML 1

MILLIPRED TABS 5MG 1

prednisolone sodium phosphate soln 15mg/5ml 1

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80

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

prednisolone sodium phosphate soln 25mg/5ml 1

prednisolone sodium phosphate soln 5mg/5ml 1

prednisolone soln 15mg/5ml 1

prednisone intensol conc 5mg/ml 1

prednisone soln 5mg/5ml 1

prednisone tabs 10mg 1

prednisone tabs 1mg 1

prednisone tabs 2.5mg 1

prednisone tabs 20mg 1

prednisone tabs 50mg 1

prednisone tabs 5mg 1

prednisone tbpk 10mg 1

prednisone tbpk 10mg 1

prednisone tbpk 5mg 1

prednisone tbpk 5mg 1

procto-med hc crea 2.5% 1

procto-pak crea 1% 1

proctosol hc crea 2.5% 1

proctozone-hc crea 2.5% 1

SOLU-CORTEF INJ 100MG 1

SOLU-CORTEF INJ 250MG 1

VERIPRED 20 SOLN 20MG/5ML 1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

chorionic gonadotropin inj 10000unit 1 PA

desmopressin acetate inj 4mcg/ml 1

desmopressin acetate soln 0.01% 1 MO

desmopressin acetate soln 0.01% 1 MO

desmopressin acetate tabs 0.1mg 1 MO

desmopressin acetate tabs 0.2mg 1 MO

GENOTROPIN MINIQUICK INJ 0.2MG 1 PA MO

GENOTROPIN MINIQUICK INJ 0.4MG 1 PA MO

GENOTROPIN MINIQUICK INJ 0.6MG 1 PA MO

GENOTROPIN MINIQUICK INJ 0.8MG 1 PA MO

GENOTROPIN MINIQUICK INJ 1.2MG 1 PA MO

GENOTROPIN MINIQUICK INJ 1.4MG 1 PA MO

GENOTROPIN MINIQUICK INJ 1.6MG 1 PA MO

GENOTROPIN MINIQUICK INJ 1.8MG 1 PA MO

GENOTROPIN MINIQUICK INJ 1MG 1 PA MO

GENOTROPIN MINIQUICK INJ 2MG 1 PA MO

GENOTROPIN INJ 12MG 1 PA MO

GENOTROPIN INJ 5MG 1 PA MO

H.P. ACTHAR INJ 80UNIT/ML 1 PA

HUMATROPE COMBO PACK INJ 5MG 1 PA MO

HUMATROPE INJ 12MG 1 PA MO

HUMATROPE INJ 24MG 1 PA MO

HUMATROPE INJ 6MG 1 PA MO

INCRELEX INJ 40MG/4ML 1 MO

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81

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

NORDITROPIN FLEXPRO INJ 10MG/1.5ML 1 PA MO

NORDITROPIN FLEXPRO INJ 15MG/1.5ML 1 PA MO

NORDITROPIN FLEXPRO INJ 30MG/3ML 1 PA MO

NORDITROPIN FLEXPRO INJ 5MG/1.5ML 1 PA MO

novarel inj 10000unit 1 PA

NUTROPIN AQ NUSPIN 10 INJ 10MG/2ML 1 PA MO

NUTROPIN AQ NUSPIN 20 INJ 20MG/2ML 1 PA MO

NUTROPIN AQ NUSPIN 5 INJ 5MG/2ML 1 PA MO

NUTROPIN AQ PEN INJ 10MG/2ML 1 PA MO

NUTROPIN AQ PEN INJ 20MG/2ML 1 PA MO

OMNITROPE INJ 10MG/1.5ML 1 PA MO

OMNITROPE INJ 5.8MG 1 PA MO

OMNITROPE INJ 5MG/1.5ML 1 PA MO

pregnyl w/diluent benzyl alcohol/nacl inj 10000unit 1 PA

SAIZEN CLICK.EASY INJ 8.8MG 1 PA MO

SAIZEN INJ 5MG 1 PA MO

SAIZEN INJ 8.8MG 1 PA MO

SEROSTIM INJ 4MG 1 PA MO

SEROSTIM INJ 5MG 1 PA MO

SEROSTIM INJ 6MG 1 PA MO

SIGNIFOR LAR INJ 20MG 1 QL (1 EA per 28 days) PA MO

SIGNIFOR LAR INJ 40MG 1 QL (1 EA per 28 days) PA MO

SIGNIFOR LAR INJ 60MG 1 QL (1 EA per 28 days) PA MO

TEV-TROPIN INJ 5MG 1 PA MO

vasopressin/sodium chloride inj 0.9%; 40unit/100ml 1

vasopressin/sodium chloride inj 0.9%; 50unit/50ml 1

ZOMACTON INJ 10MG 1 PA MO

ZOMACTON INJ 5MG 1 PA MO

ZORBTIVE INJ 8.8MG 1 PA MO

Hormonal Agents, Stimulant/Replacement/Modifying

(Prostaglandins)

Hormonal Agents, Stimulant/Replacement/Modifying

(Prostaglandins)

KORLYM TABS 300MG 1 QL (120 EA per 30 days) PA MO

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers)

Anabolic Steroids

ANADROL-50 TABS 50MG 1

oxandrolone tabs 10mg 1 QL (60 EA per 30 days) PA

oxandrolone tabs 2.5mg 1 QL (120 EA per 30 days) PA

Androgens

ANDROGEL PUMP GEL 1.62% 1 PA MO

ANDROGEL GEL 20.25MG/1.25GM 1 PA MO

ANDROGEL GEL 40.5MG/2.5GM 1 PA MO

ANDROXY TABS 10MG 1 MO

danazol caps 100mg 1

danazol caps 200mg 1

danazol caps 50mg 1

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82

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

METHITEST TABS 10MG 1 MO

methyltestosterone caps 10mg 1 MO

testosterone cypionate inj 100mg/ml 1

testosterone cypionate inj 200mg/ml 1

testosterone enanthate inj 200mg/ml 1

testosterone pump gel 1% 1 PA MO

testosterone gel 1% 1 PA MO

testosterone gel 10mg/act 1 PA MO

testosterone gel 25mg/2.5gm 1 PA MO

TESTRED CAPS 10MG 1 MO

Estrogens

ALORA PTTW 0.025MG/24HR 1 PA MO

ALORA PTTW 0.05MG/24HR 1 PA MO

ALORA PTTW 0.075MG/24HR 1 PA MO

ALORA PTTW 0.1MG/24HR 1 PA MO

alyacen 1/35 tabs 35mcg; 1mg 1 MO

alyacen 7/7/7 tabs 0; 0 1 MO

amabelz tabs 0.5mg; 0.1mg 1 PA MO

amabelz tabs 1mg; 0.5mg 1 PA MO

amethia lo tabs 0; 0 1 QL (91 EA per 91 days) MO

amethia tabs 0; 0 1 QL (91 EA per 91 days) MO

amethyst tabs 20mcg; 90mcg 1 MO

apri tabs 0.15mg; 30mcg 1 MO

aranelle tabs 0; 0 1 MO

ashlyna tabs 0; 0 1 QL (91 EA per 91 days) MO

aubra tabs 20mcg; 0.1mg 1 MO

aviane tabs 20mcg; 0.1mg 1 MO

azurette tabs 0; 0 1 MO

balziva tabs 35mcg; 0.4mg 1 MO

bekyree tabs 0; 0 1 MO

blisovi 24 fe tabs 20mcg; 75mg; 1mg 1 MO

blisovi fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 MO

blisovi fe 1/20 tabs 20mcg; 75mg; 1mg 1 MO

briellyn tabs 35mcg; 0.4mg 1 MO

camrese lo tabs 0; 0 1 QL (91 EA per 91 days) MO

camrese tabs 0; 0 1 QL (91 EA per 91 days) MO

caziant tabs 0; 0 1 MO

chateal tabs 0.03mg; 0.15mg 1 MO

CLIMARA PRO PTWK 0.045MG/DAY; 0.015MG/DAY 1 PA MO

COMBIPATCH PTTW 0.05MG/DAY; 0.14MG/DAY 1 PA MO

COMBIPATCH PTTW 0.05MG/DAY; 0.25MG/DAY 1 PA MO

cryselle-28 tabs 30mcg; 0.3mg 1 MO

cyclafem 1/35 tabs 35mcg; 1mg 1 MO

cyclafem 7/7/7 tabs 0; 0 1 MO

dasetta 1/35 tabs 35mcg; 1mg 1 MO

dasetta 7/7/7 tabs 0; 0 1 MO

dasetta 7/7/7 tabs 0; 0 1 MO

daysee tabs 0; 0 1 QL (91 EA per 91 days) MO

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83

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

delyla tabs 20mcg; 0.1mg 1 MO

DEPO-ESTRADIOL INJ 5MG/ML 1

desogestrel/ethinyl estradiol tabs 0.15mg; 30mcg 1 MO

desogestrel/ethinyl estradiol tabs 0; 0 1 MO

DIVIGEL GEL 0.25MG/0.25GM 1 MO

DIVIGEL GEL 0.5MG/0.5GM 1 MO

DIVIGEL GEL 1MG/GM 1 MO

drospirenone/ethinyl estradiol tabs 3mg; 0.02mg 1 MO

drospirenone/ethinyl estradiol tabs 3mg; 0.03mg 1 MO

ELESTRIN GEL 0.06% 1 PA MO

elinest tabs 30mcg; 0.3mg 1 MO

elinest tabs 30mcg; 0.3mg 1 MO

emoquette tabs 0.15mg; 30mcg 1 MO

ENJUVIA TABS 0.3MG 1 PA MO

ENJUVIA TABS 0.45MG 1 PA MO

ENJUVIA TABS 0.625MG 1 PA MO

ENJUVIA TABS 0.9MG 1 PA MO

ENJUVIA TABS 1.25MG 1 PA MO

enpresse-28 tabs 0; 0 1 MO

enskyce tabs 0.15mg; 30mcg 1 MO

estarylla tabs 35mcg; 0.25mg 1 MO

ESTRACE CREA 0.1MG/GM 1 MO

estradiol valerate inj 20mg/ml 1

estradiol valerate inj 40mg/ml 1

estradiol/norethindrone acetate tabs 0.5mg; 0.1mg 1 PA MO

estradiol/norethindrone acetate tabs 1mg; 0.5mg 1 PA MO

estradiol pttw 0.025mg/24hr 1 PA MO

estradiol pttw 0.0375mg/24hr 1 PA MO

estradiol pttw 0.05mg/24hr 1 PA MO

estradiol pttw 0.075mg/24hr 1 PA MO

estradiol pttw 0.1mg/24hr 1 PA MO

estradiol ptwk 0.025mg/24hr 1 PA MO

estradiol ptwk 0.05mg/24hr 1 PA MO

estradiol ptwk 0.06mg/24hr 1 PA MO

estradiol ptwk 0.075mg/24hr 1 PA MO

estradiol ptwk 0.1mg/24hr 1 PA MO

estradiol ptwk 37.5mcg/24hr 1 PA MO

estradiol tabs 0.5mg 1 PA MO

estradiol tabs 1mg 1 PA MO

estradiol tabs 2mg 1 PA MO

ESTRING RING 2MG 1 QL (1 EA per 90 days) MO

estropipate tabs 0.75mg 1 PA MO

estropipate tabs 1.5mg 1 PA MO

estropipate tabs 3mg 1 PA MO

EVAMIST SOLN 1.53MG/SPRAY 1 MO

falmina tabs 20mcg; 0.1mg 1 MO

FEMRING RING 0.05MG/24HR 1 QL (1 EA per 90 days) MO

FEMRING RING 0.1MG/24HR 1 QL (1 EA per 90 days) MO

Page 94: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

84

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

fyavolv tabs 2.5mcg; 0.5mg 1 PA MO

fyavolv tabs 5mcg; 1mg 1 PA MO

gianvi tabs 3mg; 0.02mg 1 MO

gildagia tabs 35mcg; 0.4mg 1 MO

gildess 1.5/30 tabs 30mcg; 1.5mg 1 MO

gildess 1/20 tabs 20mcg; 1mg 1 MO

gildess 1/20 tabs 20mcg; 1mg 1 MO

gildess 24 fe tabs 20mcg; 75mg; 1mg 1 MO

gildess fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 MO

gildess fe 1/20 tabs 20mcg; 75mg; 1mg 1 MO

introvale tabs 0.03mg; 0.15mg 1 QL (91 EA per 91 days) MO

jevantique lo tabs 2.5mcg; 0.5mg 1 PA MO

jinteli tabs 5mcg; 1mg 1 PA MO

jolessa tabs 0.03mg; 0.15mg 1 QL (91 EA per 91 days) MO

juleber tabs 0.15mg; 30mcg 1 MO

junel 1.5/30 tabs 30mcg; 1.5mg 1 MO

junel 1/20 tabs 20mcg; 1mg 1 MO

junel fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 MO

junel fe 1/20 tabs 20mcg; 75mg; 1mg 1 MO

junel fe 24 tabs 20mcg; 75mg; 1mg 1 MO

kaitlib fe chew 25mcg; 75mg; 0.8mg 1 MO

kariva tabs 0; 0 1 MO

kelnor 1/35 tabs 35mcg; 1mg 1 MO

kimidess tabs 0; 0 1 MO

kurvelo tabs 0.03mg; 0.15mg 1 MO

larin 1.5/30 tabs 30mcg; 1.5mg 1 MO

larin 1/20 tabs 20mcg; 1mg 1 MO

larin 24 fe tabs 20mcg; 75mg; 1mg 1 MO

larin 24 fe tabs 20mcg; 75mg; 1mg 1 MO

larin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 MO

larin fe 1/20 tabs 20mcg; 75mg; 1mg 1 MO

larissia tabs 20mcg; 0.1mg 1 MO

layolis fe chew 25mcg; 75mg; 0.8mg 1 MO

leena tabs 0; 0 1 MO

lessina tabs 20mcg; 0.1mg 1 MO

levonest tabs 0; 0 1 MO

levonorgestrel and ethinyl estradiol tabs 0; 0 1 QL (91 EA per 91 days) MO

levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg 1 MO

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg 1 MO

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg 1 QL (91 EA per 91 days) MO

levonorgestrel/ethinyl estradiol tabs 0; 0 1 QL (91 EA per 91 days) MO

levonorgestrel/ethinyl estradiol tabs 0; 0 1 MO

levonorgestrel/ethinyl estradiol tabs 20mcg; 0.1mg 1 MO

levora 0.15/30-28 tabs 0.03mg; 0.15mg 1 MO

lomedia 24 fe tabs 20mcg; 75mg; 1mg 1 MO

lopreeza tabs 0.5mg; 0.1mg 1 PA MO

lopreeza tabs 1mg; 0.5mg 1 PA MO

loryna tabs 3mg; 0.02mg 1 MO

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85

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

low-ogestrel tabs 30mcg; 0.3mg 1 MO

lutera tabs 20mcg; 0.1mg 1 MO

marlissa tabs 0.03mg; 0.15mg 1 MO

MENOSTAR PTWK 14MCG/24HR 1 PA MO

microgestin 1.5/30 tabs 30mcg; 1.5mg 1 MO

microgestin 1/20 tabs 20mcg; 1mg 1 MO

microgestin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 MO

microgestin fe tabs 20mcg; 75mg; 1mg 1 MO

mimvey lo tabs 0.5mg; 0.1mg 1 PA MO

mimvey tabs 1mg; 0.5mg 1 PA MO

MINIVELLE PTTW 0.025MG/24HR 1 PA MO

MINIVELLE PTTW 0.0375MG/24HR 1 PA MO

MINIVELLE PTTW 0.05MG/24HR 1 PA MO

MINIVELLE PTTW 0.075MG/24HR 1 PA MO

MINIVELLE PTTW 0.1MG/24HR 1 PA MO

mono-linyah tabs 35mcg; 0.25mg 1 MO

mono-linyah tabs 35mcg; 0.25mg 1 MO

mononessa tabs 35mcg; 0.25mg 1 MO

myzilra tabs 0; 0 1 MO

myzilra tabs 0; 0 1 MO

necon 0.5/35-28 tabs 35mcg; 0.5mg 1 MO

necon 1/35 tabs 35mcg; 1mg 1 MO

necon 10/11-28 tabs 35mcg; 0 1 MO

necon 7/7/7 tabs 0; 0 1 MO

nikki tabs 3mg; 0.02mg 1 MO

norethindrone & ethinyl estradiol ferrous fumarate chew

25mcg; 75mg; 0.8mg

1 MO

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs

20mcg; 75mg; 1mg

1 MO

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs

20mcg; 75mg; 1mg

1 MO

norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg 1 PA MO

norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg 1 MO

norethindrone acetate/ethinyl estradiol tabs 5mcg; 1mg 1 PA MO

norgestimate/ethinyl estradiol tabs 0; 0 1 MO

norgestimate/ethinyl estradiol tabs 0; 0 1 MO

norgestimate/ethinyl estradiol tabs 35mcg; 0.25mg 1 MO

norgestimate/ethinyl estradiol tabs 35mcg; 0.25mg 1 MO

nortrel 0.5/35 (28) tabs 35mcg; 0.5mg 1 MO

nortrel 1/35 tabs 35mcg; 1mg 1 MO

nortrel 1/35 tabs 35mcg; 1mg 1 MO

nortrel 7/7/7 tabs 0; 0 1 MO

ocella tabs 3mg; 0.03mg 1 MO

ogestrel tabs 50mcg; 0.5mg 1 MO

orsythia tabs 20mcg; 0.1mg 1 MO

ortho-est tabs 0.75mg 1 PA MO

ortho-est tabs 1.5mg 1 PA MO

philith tabs 35mcg; 0.4mg 1 MO

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86

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

pimtrea tabs 0; 0 1 MO

pirmella 1/35 tabs 35mcg; 1mg 1 MO

pirmella 7/7/7 tabs 0; 0 1 MO

pirmella 7/7/7 tabs 0; 0 1 MO

portia-28 tabs 0.03mg; 0.15mg 1 MO

PREFEST TABS 0; 0 1 PA MO

PREMARIN CREA 0.625MG/GM 1 MO

PREMARIN TABS 0.3MG 1 PA MO

PREMARIN TABS 0.45MG 1 PA MO

PREMARIN TABS 0.625MG 1 PA MO

PREMARIN TABS 0.9MG 1 PA MO

PREMARIN TABS 1.25MG 1 PA MO

PREMPHASE TABS 0.625MG; 5MG 1 PA MO

PREMPRO TABS 0.3MG; 1.5MG 1 PA MO

PREMPRO TABS 0.45MG; 1.5MG 1 PA MO

PREMPRO TABS 0.625MG; 2.5MG 1 PA MO

PREMPRO TABS 0.625MG; 5MG 1 PA MO

previfem tabs 35mcg; 0.25mg 1 MO

quasense tabs 0.03mg; 0.15mg 1 QL (91 EA per 91 days) MO

reclipsen tabs 0.15mg; 30mcg 1 MO

setlakin tabs 0.03mg; 0.15mg 1 QL (91 EA per 91 days) MO

sprintec 28 tabs 35mcg; 0.25mg 1 MO

sronyx tabs 20mcg; 0.1mg 1 MO

syeda tabs 3mg; 0.03mg 1 MO

tarina fe 1/20 tabs 20mcg; 75mg; 1mg 1 MO

tilia fe tabs 0; 75mg; 1mg 1 MO

tri-estarylla tabs 0; 0 1 MO

tri-legest fe tabs 0; 75mg; 1mg 1 MO

tri-linyah tabs 0; 0 1 MO

tri-linyah tabs 0; 0 1 MO

tri-lo-estarylla tabs 0; 0 1 MO

tri-lo-marzia tabs 0; 0 1 MO

tri-lo-marzia tabs 0; 0 1 MO

tri-lo-sprintec tabs 0; 0 1 MO

tri-previfem tabs 0; 0 1 MO

tri-sprintec tabs 0; 0 1 MO

trinessa lo tabs 0; 0 1 MO

trinessa lo tabs 0; 0 1 MO

trinessa tabs 0; 0 1 MO

trivora-28 tabs 0; 0 1 MO

VAGIFEM TABS 10MCG 1 MO

velivet tabs 0; 0 1 MO

vestura tabs 3mg; 0.02mg 1 MO

vienva tabs 20mcg; 0.1mg 1 MO

viorele tabs 0; 0 1 MO

vyfemla tabs 35mcg; 0.4mg 1 MO

wera tabs 35mcg; 0.5mg 1 MO

wymzya fe chew 35mcg; 0; 0.4mg 1 MO

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87

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

xulane ptwk 35mcg/24hr; 150mcg/24hr 1 MO

zarah tabs 3mg; 0.03mg 1 MO

zenchent fe chew 35mcg; 0; 0.4mg 1 MO

zenchent tabs 35mcg; 0.4mg 1 MO

zovia 1/35e tabs 35mcg; 1mg 1 MO

zovia 1/50e tabs 50mcg; 1mg 1 MO

Progesterone Agonists/Antagonists

ELLA TABS 30MG 1 QL (4 EA per 365 days)

Progestins

camila tabs 0.35mg 1 MO

CRINONE GEL 4% 1

CRINONE GEL 8% 1

deblitane tabs 0.35mg 1 MO

DEPO-PROVERA INJ 400MG/ML 1

DEPO-SUBQ PROVERA 104 INJ 104MG/0.65ML 1 QL (0.65 ML per 84 days)

errin tabs 0.35mg 1 MO

heather tabs 0.35mg 1 MO

hydroxyprogesterone caproate inj 1.25gm/5ml 1

jencycla tabs 0.35mg 1 MO

jolivette tabs 0.35mg 1 MO

lyza tabs 0.35mg 1 MO

medroxyprogesterone acetate inj 150mg/ml 1

medroxyprogesterone acetate tabs 10mg 1 MO

medroxyprogesterone acetate tabs 2.5mg 1 MO

medroxyprogesterone acetate tabs 5mg 1 MO

megestrol acetate susp 40mg/ml 1 PA

megestrol acetate susp 625mg/5ml 1 PA MO

megestrol acetate tabs 20mg 1 PA

megestrol acetate tabs 40mg 1 PA

nora-be tabs 0.35mg 1 MO

norethindrone acetate tabs 5mg 1 MO

norethindrone tabs 0.35mg 1 MO

norlyroc tabs 0.35mg 1 MO

progesterone caps 100mg 1 MO

progesterone caps 200mg 1 MO

sharobel tabs 0.35mg 1 MO

Selective Estrogen Receptor Modifying Agents

DUAVEE TABS 20MG; 0.45MG 1 MO

raloxifene hydrochloride tabs 60mg 1 MO

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

levothyroxine sodium inj 100mcg 1

levothyroxine sodium inj 200mcg 1

levothyroxine sodium inj 500mcg 1

levothyroxine sodium tabs 100mcg 1 MO

levothyroxine sodium tabs 112mcg 1 MO

levothyroxine sodium tabs 125mcg 1 MO

levothyroxine sodium tabs 137mcg 1 MO

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88

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

levothyroxine sodium tabs 150mcg 1 MO

levothyroxine sodium tabs 175mcg 1 MO

levothyroxine sodium tabs 200mcg 1 MO

levothyroxine sodium tabs 25mcg 1 MO

levothyroxine sodium tabs 300mcg 1 MO

levothyroxine sodium tabs 50mcg 1 MO

levothyroxine sodium tabs 75mcg 1 MO

levothyroxine sodium tabs 88mcg 1 MO

levoxyl tabs 100mcg 1 MO

levoxyl tabs 112mcg 1 MO

levoxyl tabs 125mcg 1 MO

levoxyl tabs 137mcg 1 MO

levoxyl tabs 150mcg 1 MO

levoxyl tabs 175mcg 1 MO

levoxyl tabs 200mcg 1 MO

levoxyl tabs 25mcg 1 MO

levoxyl tabs 50mcg 1 MO

levoxyl tabs 75mcg 1 MO

levoxyl tabs 88mcg 1 MO

liothyronine sodium tabs 25mcg 1 MO

liothyronine sodium tabs 50mcg 1 MO

liothyronine sodium tabs 5mcg 1 MO

SYNTHROID TABS 100MCG 1 MO

SYNTHROID TABS 112MCG 1 MO

SYNTHROID TABS 125MCG 1 MO

SYNTHROID TABS 137MCG 1 MO

SYNTHROID TABS 150MCG 1 MO

SYNTHROID TABS 175MCG 1 MO

SYNTHROID TABS 200MCG 1 MO

SYNTHROID TABS 25MCG 1 MO

SYNTHROID TABS 300MCG 1 MO

SYNTHROID TABS 50MCG 1 MO

SYNTHROID TABS 75MCG 1 MO

SYNTHROID TABS 88MCG 1 MO

THYROLAR-1/2 TABS 30MG 1 MO

THYROLAR-1/4 TABS 15MG 1 MO

THYROLAR-1 TABS 60MG 1 MO

THYROLAR-2 TABS 120MG 1 MO

THYROLAR-3 TABS 180MG 1 MO

TIROSINT CAPS 100MCG 1 MO

TIROSINT CAPS 112MCG 1 MO

TIROSINT CAPS 125MCG 1 MO

TIROSINT CAPS 137MCG 1 MO

TIROSINT CAPS 13MCG 1 MO

TIROSINT CAPS 150MCG 1 MO

TIROSINT CAPS 25MCG 1 MO

TIROSINT CAPS 50MCG 1 MO

TIROSINT CAPS 75MCG 1 MO

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89

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

TIROSINT CAPS 88MCG 1 MO

unithroid direct tabs 100mcg 1 MO

unithroid direct tabs 112mcg 1 MO

unithroid direct tabs 125mcg 1 MO

unithroid direct tabs 150mcg 1 MO

unithroid direct tabs 175mcg 1 MO

unithroid direct tabs 200mcg 1 MO

unithroid direct tabs 25mcg 1 MO

unithroid direct tabs 300mcg 1 MO

unithroid direct tabs 50mcg 1 MO

unithroid direct tabs 75mcg 1 MO

unithroid direct tabs 88mcg 1 MO

unithroid tabs 100mcg 1 MO

unithroid tabs 112mcg 1 MO

unithroid tabs 125mcg 1 MO

unithroid tabs 137mcg 1 MO

unithroid tabs 150mcg 1 MO

unithroid tabs 175mcg 1 MO

unithroid tabs 200mcg 1 MO

unithroid tabs 25mcg 1 MO

unithroid tabs 300mcg 1 MO

unithroid tabs 50mcg 1 MO

unithroid tabs 75mcg 1 MO

unithroid tabs 88mcg 1 MO

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)

LYSODREN TABS 500MG 1

Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Parathyroid)

SENSIPAR TABS 30MG 1 MO

SENSIPAR TABS 60MG 1 MO

SENSIPAR TABS 90MG 1 MO

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)

cabergoline tabs 0.5mg 1

ELIGARD INJ 22.5MG 1 QL (1 EA per 84 days) PA

ELIGARD INJ 30MG 1 QL (1 EA per 112 days) PA

ELIGARD INJ 45MG 1 QL (1 EA per 168 days) PA

ELIGARD INJ 7.5MG 1 QL (1 EA per 28 days) PA

FIRMAGON INJ 120MG 1 QL (6 EA per 365 days) PA

FIRMAGON INJ 80MG 1 QL (4 EA per 28 days) PA

leuprolide acetate inj 1mg/0.2ml 1 PA

LUPANETA PACK KIT 11.25MG; 5MG 1 QL (1 EA per 84 days) PA

LUPANETA PACK KIT 3.75MG; 5MG 1 QL (1 EA per 28 days) PA

LUPRON DEPOT-PED INJ 11.25MG 1 QL (1 EA per 84 days)

LUPRON DEPOT-PED INJ 11.25MG 1 QL (1 EA per 28 days)

LUPRON DEPOT-PED INJ 15MG 1 QL (1 EA per 28 days)

LUPRON DEPOT-PED INJ 30MG 1 QL (1 EA per 84 days)

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90

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

LUPRON DEPOT-PED INJ 7.5MG 1 QL (1 EA per 28 days)

LUPRON DEPOT INJ 11.25MG 1 QL (1 EA per 84 days) PA

LUPRON DEPOT INJ 22.5MG 1 QL (1 EA per 84 days) PA

LUPRON DEPOT INJ 3.75MG 1 QL (1 EA per 28 days) PA

LUPRON DEPOT INJ 30MG 1 QL (1 EA per 112 days) PA

LUPRON DEPOT INJ 45MG 1 QL (1 EA per 168 days) PA

LUPRON DEPOT INJ 7.5MG 1 QL (1 EA per 28 days) PA

OCTREOTIDE ACETATE INJ 1000MCG/ML 1 PA MO

octreotide acetate inj 100mcg/ml 1 PA MO

octreotide acetate inj 200mcg/ml 1 PA MO

OCTREOTIDE ACETATE INJ 500MCG/ML 1 PA MO

octreotide acetate inj 50mcg/ml 1 PA MO

SANDOSTATIN LAR DEPOT INJ 10MG 1 PA

SANDOSTATIN LAR DEPOT INJ 20MG 1 PA

SANDOSTATIN LAR DEPOT INJ 30MG 1 PA

SIGNIFOR INJ 0.3MG/ML 1 QL (60 ML per 30 days) PA MO

SIGNIFOR INJ 0.6MG/ML 1 QL (60 ML per 30 days) PA MO

SIGNIFOR INJ 0.9MG/ML 1 QL (60 ML per 30 days) PA MO

SOMATULINE DEPOT INJ 120MG/0.5ML 1 PA

SOMATULINE DEPOT INJ 60MG/0.2ML 1 PA

SOMATULINE DEPOT INJ 90MG/0.3ML 1 PA

SOMAVERT INJ 10MG 1 PA MO

SOMAVERT INJ 15MG 1 PA MO

SOMAVERT INJ 20MG 1 PA MO

SOMAVERT INJ 25MG 1 PA MO

SOMAVERT INJ 30MG 1 PA MO

SYNAREL SOLN 2MG/ML 1

TRELSTAR MIXJECT INJ 11.25MG 1 QL (1 EA per 84 days) PA

TRELSTAR MIXJECT INJ 22.5MG 1 QL (1 EA per 168 days) PA

TRELSTAR MIXJECT INJ 3.75MG 1 QL (1 EA per 28 days) PA

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

methimazole tabs 10mg 1 MO

methimazole tabs 5mg 1 MO

propylthiouracil tabs 50mg 1 MO

Immunological Agents

Angioedema (HAE) Agents

CINRYZE INJ 500UNIT 1 PA

FIRAZYR INJ 30MG/3ML 1 PA

Immune Suppressants

ASTAGRAF XL CP24 0.5MG 1 B/D MO

ASTAGRAF XL CP24 1MG 1 B/D MO

ASTAGRAF XL CP24 5MG 1 B/D MO

AZASAN TABS 100MG 1 B/D MO

AZASAN TABS 75MG 1 B/D MO

azathioprine inj 100mg 1 B/D

azathioprine tabs 50mg 1 B/D MO

BENLYSTA INJ 120MG 1 PA

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

BENLYSTA INJ 400MG 1 PA

CIMZIA INJ 200MG/ML 1 PA MO

CIMZIA INJ 200MG 1 PA

cyclosporine modified caps 100mg 1 B/D MO

cyclosporine modified caps 25mg 1 B/D MO

cyclosporine modified caps 50mg 1 B/D MO

cyclosporine modified soln 100mg/ml 1 B/D MO

cyclosporine caps 100mg 1 B/D MO

cyclosporine caps 25mg 1 B/D MO

cyclosporine inj 50mg/ml 1 B/D

ENBREL SURECLICK INJ 50MG/ML 1 PA MO

ENBREL INJ 25MG/0.5ML 1 PA MO

ENBREL INJ 25MG 1 PA MO

ENBREL INJ 50MG/ML 1 PA MO

ENVARSUS XR TB24 0.75MG 1 B/D MO

ENVARSUS XR TB24 1MG 1 B/D MO

ENVARSUS XR TB24 4MG 1 B/D MO

gengraf caps 100mg 1 B/D MO

gengraf caps 25mg 1 B/D MO

gengraf caps 50mg 1 B/D MO

gengraf soln 100mg/ml 1 B/D MO

hecoria caps 0.5mg 1 B/D MO

hecoria caps 1mg 1 B/D MO

hecoria caps 5mg 1 B/D MO

HUMIRA PEDIATRIC CROHNS DISEASE STARTER

PACK INJ 40MG/0.8ML

1 PA MO

HUMIRA PEDIATRIC CROHNS DISEASE STARTER

PACK INJ 40MG/0.8ML

1 PA MO

HUMIRA PEN-CROHNS DISEASESTARTER INJ

40MG/0.8ML

1 PA MO

HUMIRA PEN-PSORIASIS STARTER INJ 40MG/0.8ML 1 PA MO

HUMIRA PEN INJ 40MG/0.8ML 1 PA MO

HUMIRA INJ 10MG/0.2ML 1 PA MO

HUMIRA INJ 20MG/0.4ML 1 PA MO

HUMIRA INJ 40MG/0.8ML 1 PA MO

KINERET INJ 100MG/0.67ML 1 PA MO

methotrexate sodium inj 1gm/40ml 1

methotrexate sodium inj 250mg/10ml 1

methotrexate tabs 2.5mg 1

mycophenolate mofetil caps 250mg 1 B/D MO

mycophenolate mofetil susr 200mg/ml 1 B/D MO

mycophenolate mofetil tabs 500mg 1 B/D MO

mycophenolic acid dr tbec 180mg 1 B/D MO

mycophenolic acid dr tbec 360mg 1 B/D MO

NULOJIX INJ 250MG 1 PA

ORENCIA CLICKJECT INJ 125MG/ML 1 PA MO

ORENCIA INJ 125MG/ML 1 PA MO

ORENCIA INJ 250MG 1 PA MO

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92

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

RAPAMUNE SOLN 1MG/ML 1 B/D MO

REMICADE INJ 100MG 1 PA

SIMPONI ARIA INJ 50MG/4ML 1 PA MO

SIMPONI INJ 100MG/ML 1 PA MO

SIMPONI INJ 100MG/ML 1 PA MO

SIMPONI INJ 50MG/0.5ML 1 PA MO

SIMPONI INJ 50MG/0.5ML 1 PA MO

sirolimus tabs 0.5mg 1 B/D MO

sirolimus tabs 1mg 1 B/D MO

sirolimus tabs 2mg 1 B/D MO

tacrolimus caps 0.5mg 1 B/D MO

tacrolimus caps 1mg 1 B/D MO

tacrolimus caps 5mg 1 B/D MO

ZORTRESS TABS 0.25MG 1 PA MO

ZORTRESS TABS 0.5MG 1 PA MO

ZORTRESS TABS 0.75MG 1 PA MO

Immunizing Agents, Passive

ATGAM INJ 50MG/ML 1 B/D

BIVIGAM INJ 10GM/100ML 1 PA

BIVIGAM INJ 5GM/50ML 1 PA

CARIMUNE NANOFILTERED INJ 6GM 1 PA

FLEBOGAMMA DIF INJ 0.5GM/10ML 1 PA

FLEBOGAMMA DIF INJ 10% 1 PA

FLEBOGAMMA DIF INJ 10% 1 PA

FLEBOGAMMA DIF INJ 10% 1 PA

FLEBOGAMMA DIF INJ 10GM/200ML 1 PA

FLEBOGAMMA DIF INJ 2.5GM/50ML 1 PA

FLEBOGAMMA DIF INJ 20GM/400ML 1 PA

FLEBOGAMMA DIF INJ 5GM/100ML 1 PA

GAMASTAN S/D INJ 0 1 PA

GAMMAGARD LIQUID INJ 1GM/10ML 1 PA

GAMMAGARD LIQUID INJ 2.5GM/25ML 1 PA

GAMMAKED INJ 10GM/100ML 1 PA

GAMMAKED INJ 1GM/10ML 1 PA

GAMMAKED INJ 2.5GM/25ML 1 PA

GAMMAKED INJ 20GM/200ML 1 PA

GAMMAKED INJ 5GM/50ML 1 PA

GAMMAPLEX INJ 10GM/200ML 1 PA

GAMMAPLEX INJ 2.5GM/50ML 1 PA

GAMMAPLEX INJ 20GM/400ML 1 PA

GAMMAPLEX INJ 5GM/100ML 1 PA

GAMMAPLEX INJ 5GM/100ML 1 PA

GAMUNEX-C INJ 1GM/10ML 1 PA

GAMUNEX-C INJ 40GM/400ML 1 PA

HYPERRAB S/D INJ 150UNIT/ML 1 B/D

HYPERRAB S/D INJ 150UNIT/ML 1 B/D

HYQVIA INJ 10GM/100ML; 800UNIT/5ML 1 PA

HYQVIA INJ 2.5GM/25ML; 200UNT/1.25ML 1 PA

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93

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

HYQVIA INJ 20GM/200ML; 1600UNIT/10ML 1 PA

HYQVIA INJ 30GM/300ML; 2400UNIT/15ML 1 PA

HYQVIA INJ 5GM/50ML; 400UNIT/2.5ML 1 PA

IMOGAM RABIES-HT INJ 150UNIT/ML 1 B/D

IMOGAM RABIES-HT INJ 150UNIT/ML 1 B/D

OCTAGAM INJ 10GM/100ML 1 PA

OCTAGAM INJ 10GM/200ML 1 PA

OCTAGAM INJ 1GM/20ML 1 PA

OCTAGAM INJ 2.5GM/50ML 1 PA

OCTAGAM INJ 20GM/200ML 1 PA

OCTAGAM INJ 2GM/20ML 1 PA

OCTAGAM INJ 5GM/100ML 1 PA

OCTAGAM INJ 5GM/50ML 1 PA

PRIVIGEN INJ 10GM/100ML 1 PA

PRIVIGEN INJ 20GM/200ML 1 PA

PRIVIGEN INJ 40GM/400ML 1 PA

PRIVIGEN INJ 5GM/50ML 1 PA

Immunomodulators

ACTEMRA INJ 162MG/0.9ML 1 QL (4 ML per 28 days) PA MO

ACTEMRA INJ 200MG/10ML 1 PA

ACTEMRA INJ 400MG/20ML 1 PA

ACTEMRA INJ 80MG/4ML 1 PA

ACTIMMUNE INJ 2000000UNIT/0.5ML 1 MO

ARCALYST INJ 220MG 1 PA MO

ILARIS INJ 180MG 1 PA

leflunomide tabs 10mg 1 MO

leflunomide tabs 20mg 1 MO

OTEZLA TABS 30MG 1 PA MO

OTEZLA TBPK 0 1 QL (110 EA per 365 days) PA

RIDAURA CAPS 3MG 1 MO

STELARA INJ 130MG/26ML 1 PA

SYNAGIS INJ 100MG/ML 1

SYNAGIS INJ 50MG/0.5ML 1

TECFIDERA STARTER PACK MISC 0 1 QL (60 EA per 30 days) PA

TECFIDERA CPDR 120MG 1 QL (60 EA per 30 days) PA MO

TECFIDERA CPDR 240MG 1 QL (60 EA per 30 days) PA MO

XELJANZ XR TB24 11MG 1 QL (30 EA per 30 days) PA MO

XELJANZ TABS 5MG 1 PA MO

Vaccines

ACTHIB INJ 0 1

ADACEL INJ 15.5MCG/0.5ML; 2LF/0.5ML; 5LF/0.5ML 1

BCG VACCINE INJ 0 1

BEXSERO INJ 0 1

BOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML;

5LF/0.5ML

1

BOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML;

5LF/0.5ML

1

CERVARIX INJ 0 1

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94

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

COMVAX INJ 7.5MCG/0.5ML; 5MCG/0.5ML 1

DAPTACEL INJ 10MCG/0.5ML; 15LF/0.5ML; 5LF/0.5ML 1

DIPHTHERIA/TETANUS TOXOIDS ADSORBED

PEDIATRIC INJ 25LFU/0.5ML; 5LFU/0.5ML

1

ENGERIX-B INJ 10MCG/0.5ML 1 B/D

ENGERIX-B INJ 10MCG/0.5ML 1 B/D

ENGERIX-B INJ 10MCG/0.5ML 1 B/D

ENGERIX-B INJ 20MCG/ML 1 B/D

ENGERIX-B INJ 20MCG/ML 1 B/D

GARDASIL 9 INJ 0 1

GARDASIL 9 INJ 0 1

GARDASIL INJ 0 1

GARDASIL INJ 0 1

HAVRIX INJ 1440ELU/ML 1

HAVRIX INJ 720ELU/0.5ML 1

HIBERIX INJ 10MCG 1

IMOVAX RABIES (H.D.C.V.) INJ 2.5UNIT/ML 1 B/D

INFANRIX INJ 58MCG/0.5ML; 25LFU/0.5ML;

10LFU/0.5ML

1

IPOL INACTIVATED IPV INJ 0 1

IXIARO INJ 0 1

KINRIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 0;

10LFU/0.5ML

1

KINRIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 0;

10LFU/0.5ML

1

M-M-R II INJ 0; 0; 0 1

MENACTRA INJ 0 1

MENHIBRIX INJ 2.5MCG; 5MCG; 5MCG 1

MENOMUNE-A/C/Y/W-135 INJ 0 1

MENVEO INJ 0 1

PEDVAX HIB INJ 7.5MCG/0.5ML 1

PROQUAD INJ 0; 0; 0; 0 1

QUADRACEL INJ 48MCG/0.5ML; 15LFU/0.5ML; 0;

5LFU/0.5ML

1

RABAVERT INJ 0 1 B/D

RECOMBIVAX HB INJ 10MCG/ML 1 B/D

RECOMBIVAX HB INJ 10MCG/ML 1 B/D

RECOMBIVAX HB INJ 40MCG/ML 1 B/D

RECOMBIVAX HB INJ 5MCG/0.5ML 1 B/D

ROTARIX SUSR 0 1

ROTATEQ SOLN 0 1

TENIVAC INJ 2LFU; 5LFU 1

TETANUS/DIPHTHERIA TOXOIDS-ADSORBED INJ

2LF/0.5ML; 2LF/0.5ML

1

TRUMENBA INJ 0 1

TWINRIX INJ 720ELU/ML; 20MCG/ML 1 B/D

TYPHIM VI INJ 25MCG/0.5ML 1

TYPHIM VI INJ 25MCG/0.5ML 1

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

VAQTA INJ 25UNIT/0.5ML 1

VAQTA INJ 50UNIT/ML 1

VARIVAX INJ 1350PFU/0.5ML 1

VARIZIG INJ 125UNIT/1.2ML 1 PA

YF-VAX INJ 0 1

ZOSTAVAX INJ 19400UNT/0.65ML 1 QL (1 EA per 365 days)

Inflammatory Bowel Disease Agents

Aminosalicylates

APRISO CP24 0.375GM 1 MO

ASACOL HD TBEC 800MG 1

balsalazide disodium caps 750mg 1

CANASA SUPP 1000MG 1

DIPENTUM CAPS 250MG 1 MO

LIALDA TBEC 1.2GM 1

mesalamine dr tbec 800mg 1

mesalamine enem 4gm 1

mesalamine kit 4gm 1

PENTASA CPCR 250MG 1 MO

PENTASA CPCR 500MG 1 MO

Glucocorticoids

budesonide cpep 3mg 1

colocort enem 100mg/60ml 1

hydrocortisone enem 100mg/60ml 1

UCERIS FOAM 2MG/ACT 1

UCERIS TB24 9MG 1

Sulfonamides

sulfasalazine tabs 500mg 1 MO

sulfasalazine tbec 500mg 1 MO

Metabolic Bone Disease Agents

Metabolic Bone Disease Agents

alendronate sodium soln 70mg/75ml 1 MO

alendronate sodium tabs 10mg 1 MO

alendronate sodium tabs 35mg 1 QL (4 EA per 28 days) MO

alendronate sodium tabs 40mg 1

alendronate sodium tabs 5mg 1 MO

alendronate sodium tabs 70mg 1 QL (4 EA per 28 days) MO

calcitonin-salmon soln 200unit/act 1 QL (3.7 ML per 30 days) MO

calcitriol caps 0.25mcg 1 MO

calcitriol caps 0.5mcg 1 MO

calcitriol inj 1mcg/ml 1

calcitriol soln 1mcg/ml 1 MO

doxercalciferol caps 0.5mcg 1 MO

doxercalciferol caps 1mcg 1 MO

doxercalciferol caps 2.5mcg 1 MO

doxercalciferol inj 4mcg/2ml 1

etidronate disodium tabs 200mg 1

etidronate disodium tabs 400mg 1

FORTEO INJ 600MCG/2.4ML 1 QL (2.4 ML per 28 days) PA MO

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

fortical soln 200unit/act 1 QL (3.7 ML per 30 days) MO

FOSAMAX PLUS D TABS 70MG; 2800UNIT 1 QL (4 EA per 28 days) ST MO

FOSAMAX PLUS D TABS 70MG; 5600UNIT 1 QL (4 EA per 28 days) ST MO

ibandronate sodium inj 3mg/3ml 1

ibandronate sodium tabs 150mg 1 MO

MIACALCIN INJ 200UNIT/ML 1

pamidronate disodium inj 30mg/10ml 1

PAMIDRONATE DISODIUM INJ 30MG 1

pamidronate disodium inj 6mg/ml 1

pamidronate disodium inj 90mg/10ml 1

PAMIDRONATE DISODIUM INJ 90MG 1

paricalcitol caps 1mcg 1 MO

paricalcitol caps 2mcg 1 MO

paricalcitol caps 4mcg 1 MO

paricalcitol inj 2mcg/ml 1

paricalcitol inj 5mcg/ml 1

PROLIA INJ 60MG/ML 1 QL (2 ML per 365 days) PA

risedronate sodium dr tbec 35mg 1 QL (4 EA per 28 days) MO

risedronate sodium tabs 150mg 1 QL (1 EA per 28 days) MO

risedronate sodium tabs 30mg 1

risedronate sodium tabs 35mg 1 QL (4 EA per 28 days) MO

risedronate sodium tabs 35mg 1 QL (4 EA per 28 days) MO

risedronate sodium tabs 35mg 1 QL (4 EA per 28 days) MO

risedronate sodium tabs 5mg 1 MO

XGEVA INJ 120MG/1.7ML 1 PA

ZOLEDRONIC ACID INJ 4MG/100ML 1 PA

zoledronic acid inj 4mg/5ml 1 PA

zoledronic acid inj 4mg 1 PA

zoledronic acid inj 5mg/100ml 1 PA

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agents

argyle sterile saline 100ml soln 0.9% 1

BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2"

MISC

1 QL (200 EA per 30 days)

BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16"

MISC

1 QL (200 EA per 30 days)

BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2"

MISC

1 QL (200 EA per 30 days)

BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16"

MISC

1 QL (200 EA per 30 days)

BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM MISC 1 QL (200 EA per 30 days)

BOTOX INJ 100UNIT 1 PA

BOTOX INJ 200UNIT 1 PA

curity sterile saline soln 0.9% 1

DROPLET PEN NEEDLES 29GX10MM MISC 1 QL (200 EA per 30 days)

EXONDYS 51 INJ 100MG/2ML 1 PA

EXONDYS 51 INJ 500MG/10ML 1 PA

FERRIPROX SOLN 100MG/ML 1 PA MO

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97

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

INSUPEN 33GX4MM MISC 1 QL (200 EA per 30 days)

intralipid inj 20gm/100ml 1 B/D

KEVEYIS TABS 50MG 1 QL (120 EA per 30 days) PA

lactated ringers irrigation soln 3meq/l; 109meq/l; 28meq/l;

4meq/l; 130meq/l

1

levocarnitine inj 200mg/ml 1

levocarnitine soln 1gm/10ml 1 MO

levocarnitine tabs 330mg 1 MO

liposyn iii inj 2.5%; 30% 1 B/D

methergine tabs 0.2mg 1

methylergonovine maleate tabs 0.2mg 1

MYALEPT INJ 11.3MG 1 PA MO

NATPARA INJ 100MCG 1 QL (2 EA per 28 days) PA MO

NATPARA INJ 25MCG 1 QL (2 EA per 28 days) PA MO

NATPARA INJ 50MCG 1 QL (2 EA per 28 days) PA MO

NATPARA INJ 75MCG 1 QL (2 EA per 28 days) PA MO

nutrilipid inj 20gm/100ml 1 B/D

nutrilipid inj 20gm/100ml 1 B/D

ORFADIN CAPS 10MG 1 MO

ORFADIN CAPS 20MG 1 MO

ORFADIN CAPS 2MG 1 MO

ORFADIN CAPS 5MG 1 MO

ORFADIN SUSP 4MG/ML 1 MO

oxytocin/lactated ringers inj 0.1gm/500ml; 30unit/500ml;

0.15gm/500ml; 3gm/500ml; 1.55gm/500ml

1

sodium chloride 0.9% soln 0.9% 1

sterile water irrigation soln 0 1

VISTOGARD PACK 10GM 1

VISTOGARD PACK 10GM 1

XEOMIN INJ 200UNIT 1 PA

XEOMIN INJ 50UNIT 1 PA

XURIDEN PACK 2GM 1 QL (120 EA per 30 days) PA MO

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogs

bimatoprost soln 0.03% 1 QL (5 ML per 30 days) MO

COMBIGAN SOLN 0.2%; 0.5% 1 MO

latanoprost soln 0.005% 1 QL (2.5 ML per 25 days) MO

LUMIGAN SOLN 0.01% 1 QL (2.5 ML per 25 days) MO

TRAVATAN Z SOLN 0.004% 1 QL (2.5 ML per 25 days) MO

travoprost soln 0.004% 1 QL (2.5 ML per 25 days) MO

Ophthalmic Agents, Other

ak-poly-bac oint 500unit/gm; 10000unit/gm 1

atropine sulfate soln 1% 1 MO

atropine-care soln 1% 1 MO

bacitracin/polymyxin b oint 500unit/gm; 10000unit/gm 1

CYSTARAN SOLN 0.44% 1 QL (60 ML per 28 days) PA MO

neo-polycin oint 400unit/gm; 3.5mg/gm; 10000unit/gm 1

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98

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

neomycin/bacitracin/polymyxin oint 400unit/gm; 5mg/gm;

10000unit/gm

1

parcaine soln 0.5% 1

polycin b oint 500unit/gm; 10000unit/gm 1

polycin oint 500unit/gm; 10000unit/gm 1

polymyxin b sulfate/trimethoprim sulfate soln 10000unit/ml;

0.1%

1

PROCYSBI CPDR 25MG 1 PA MO

PROCYSBI CPDR 75MG 1 PA MO

proparacaine hcl soln 0.5% 1

RESTASIS EMUL 0.05% 1 QL (60 EA per 30 days) MO

trimethoprim sulfate/polymyxin b sulfate soln 10000unit/ml;

0.1%

1

Ophthalmic Anti-allergy Agents

ALOCRIL SOLN 2% 1

azelastine hcl soln 0.05% 1

BEPREVE SOLN 1.5% 1

cromolyn sodium soln 4% 1

EMADINE SOLN 0.05% 1

epinastine hcl soln 0.05% 1

LASTACAFT SOLN 0.25% 1

olopatadine hcl soln 0.1% 1

PATADAY SOLN 0.2% 1

PATANOL SOLN 0.1% 1

Ophthalmic Anti-inflammatories

ACUVAIL SOLN 0.45% 1

ALOMIDE SOLN 0.1% 1

ALREX SUSP 0.2% 1

bromfenac soln 0.09% 1

bromfenac soln 0.09% 1

dexamethasone sodium phosphate soln 0.1% 1

diclofenac sodium soln 0.1% 1

DUREZOL EMUL 0.05% 1

FLAREX SUSP 0.1% 1

fluorometholone susp 0.1% 1

flurbiprofen sodium soln 0.03% 1

FML FORTE SUSP 0.25% 1

FML OINT 0.1% 1

ILEVRO SUSP 0.3% 1

ketorolac tromethamine soln 0.4% 1

ketorolac tromethamine soln 0.5% 1

LOTEMAX GEL 0.5% 1

LOTEMAX OINT 0.5% 1

LOTEMAX SUSP 0.5% 1

MAXIDEX SUSP 0.1% 1

neomycin/polymyxin/dexamethasone oint 0.1%; 3.5mg/gm;

10000unit/gm

1

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99

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

neomycin/polymyxin/dexamethasone susp 0.1%; 3.5mg/ml;

10000unit/ml

1

NEVANAC SUSP 0.1% 1

poly-dex oint 0.1%; 3.5mg/gm; 10000unit/gm 1

PRED MILD SUSP 0.12% 1

PRED-G S.O.P. OINT 0.3%; 0.6% 1

PRED-G SUSP 0.3%; 1% 1

prednisolone acetate susp 1% 1

prednisolone sodium phosphate soln 1% 1

PROLENSA SOLN 0.07% 1

TOBRADEX ST SUSP 0.05%; 0.3% 1

TOBRADEX OINT 0.1%; 0.3% 1

tobramycin/dexamethasone susp 0.1%; 0.3% 1

VEXOL SUSP 1% 1

Ophthalmic Antiglaucoma Agents

acetazolamide er cp12 500mg 1 MO

ALPHAGAN P SOLN 0.1% 1 MO

apraclonidine soln 0.5% 1

AZOPT SUSP 1% 1 MO

betaxolol hcl soln 0.5% 1 MO

BETIMOL SOLN 0.25% 1 MO

BETIMOL SOLN 0.5% 1 MO

BETOPTIC-S SUSP 0.25% 1 MO

brimonidine tartrate soln 0.15% 1 MO

brimonidine tartrate soln 0.2% 1 MO

carteolol hcl soln 1% 1 MO

dorzolamide hcl/timolol maleate soln 22.3mg/ml; 6.8mg/ml 1 MO

dorzolamide hcl soln 2% 1 MO

IOPIDINE SOLN 1% 1

ISTALOL SOLN 0.5% 1 MO

levobunolol hcl soln 0.5% 1 MO

metipranolol soln 0.3% 1 MO

PHOSPHOLINE IODIDE SOLR 0.125% 1 MO

pilocarpine hcl soln 1% 1 MO

pilocarpine hcl soln 2% 1 MO

pilocarpine hcl soln 4% 1 MO

SIMBRINZA SUSP 0.2%; 1% 1 MO

timolol maleate ophthalmic gel forming solg 0.25% 1 MO

timolol maleate ophthalmic gel forming solg 0.5% 1 MO

timolol maleate soln 0.25% 1 MO

timolol maleate soln 0.5% 1 MO

Otic Agents

Otic Agents

acetasol hc soln 2%; 1% 1

acetic acid/aluminum acetate soln 2%; 0 1

acetic acid soln 2% 1

COLY-MYCIN S SUSP 3MG/ML; 10MG/ML; 3.3MG/ML;

0.5MG/ML

1

Page 110: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

100

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

CORTISPORIN-TC SUSP 3MG/ML; 10MG/ML;

3.3MG/ML; 0.5MG/ML

1

hydrocortisone/acetic acid soln 2%; 1% 1

neomycin/polymyxin/hc soln 1%; 3.5mg/ml; 10000unit/ml 1

neomycin/polymyxin/hydrocortisone soln 1%; 3.5mg/ml;

10000unit/ml

1

neomycin/polymyxin/hydrocortisone susp 1%; 3.5mg/ml;

10000unit/ml

1

Respiratory Tract/Pulmonary Agents

Anti-inflammatories, Inhaled Corticosteroids

ADVAIR DISKUS AEPB 100MCG/DOSE; 50MCG/DOSE 1 QL (60 EA per 30 days) ST MO

ADVAIR DISKUS AEPB 250MCG/DOSE; 50MCG/DOSE 1 QL (60 EA per 30 days) ST MO

ADVAIR DISKUS AEPB 500MCG/DOSE; 50MCG/DOSE 1 QL (60 EA per 30 days) ST MO

ADVAIR HFA AERO 115MCG/ACT; 21MCG/ACT 1 QL (16 GM per 30 days) ST MO

ADVAIR HFA AERO 230MCG/ACT; 21MCG/ACT 1 QL (16 GM per 30 days) ST MO

ADVAIR HFA AERO 45MCG/ACT; 21MCG/ACT 1 QL (16 GM per 30 days) ST MO

ALVESCO AERS 160MCG/ACT 1 QL (12.2 GM per 30 days) MO

ALVESCO AERS 80MCG/ACT 1 QL (12.2 GM per 30 days) MO

ASMANEX HFA AERO 100MCG/ACT 1 QL (26 GM per 30 days) MO

ASMANEX HFA AERO 200MCG/ACT 1 QL (26 GM per 30 days) MO

ASMANEX TWISTHALER 120 METERED DOSES AEPB

220MCG/INH

1 QL (2 EA per 30 days) MO

ASMANEX TWISTHALER 14 METERED DOSES AEPB

220MCG/INH

1 QL (2 EA per 30 days) MO

ASMANEX TWISTHALER 30 METERED DOSES AEPB

110MCG/INH

1 QL (2 EA per 30 days) MO

ASMANEX TWISTHALER 30 METERED DOSES AEPB

220MCG/INH

1 QL (2 EA per 30 days) MO

ASMANEX TWISTHALER 60 METERED DOSES AEPB

220MCG/INH

1 QL (2 EA per 30 days) MO

ASMANEX TWISTHALER 7 METERED DOSES AEPB

110MCG/INH

1 QL (2 EA per 30 days) MO

BREO ELLIPTA AEPB 100MCG/INH; 25MCG/INH 1 QL (60 EA per 30 days) ST MO

BREO ELLIPTA AEPB 200MCG/INH; 25MCG/INH 1 QL (60 EA per 30 days) ST MO

BUDESONIDE SUSP 0.25MG/2ML 1 QL (120 ML per 30 days) B/D MO

BUDESONIDE SUSP 0.5MG/2ML 1 QL (120 ML per 30 days) B/D MO

budesonide susp 1mg/2ml 1 QL (120 ML per 30 days) B/D MO

budesonide susp 32mcg/act 1 QL (17.2 GM per 30 days)

DULERA AERO 5MCG/ACT; 100MCG/ACT 1 QL (17.6 GM per 30 days) MO

DULERA AERO 5MCG/ACT; 200MCG/ACT 1 QL (17.6 GM per 30 days) MO

FLOVENT DISKUS AEPB 100MCG/BLIST 1 QL (60 EA per 30 days) MO

FLOVENT DISKUS AEPB 250MCG/BLIST 1 QL (240 EA per 30 days) MO

FLOVENT DISKUS AEPB 50MCG/BLIST 1 QL (60 EA per 30 days) MO

FLOVENT HFA AERO 110MCG/ACT 1 QL (24 GM per 30 days) MO

FLOVENT HFA AERO 220MCG/ACT 1 QL (24 GM per 30 days) MO

FLOVENT HFA AERO 44MCG/ACT 1 QL (21.2 GM per 30 days) MO

flunisolide soln 0.025% 1 QL (50 ML per 30 days)

fluticasone propionate susp 50mcg/act 1 QL (16 GM per 30 days)

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101

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

mometasone furoate susp 50mcg/act 1 QL (34 GM per 30 days)

NASONEX SUSP 50MCG/ACT 1 QL (34 GM per 30 days) ST

PULMICORT FLEXHALER AEPB 180MCG/ACT 1 QL (1 EA per 30 days) MO

PULMICORT FLEXHALER AEPB 90MCG/ACT 1 QL (1 EA per 30 days) MO

PULMICORT SUSP 1MG/2ML 1 QL (120 ML per 30 days) B/D MO

QVAR AERS 40MCG/ACT 1 QL (17.4 GM per 30 days) MO

QVAR AERS 80MCG/ACT 1 QL (17.4 GM per 30 days) MO

SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT 1 QL (12 GM per 30 days) MO

SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT 1 QL (13.8 GM per 30 days) MO

triamcinolone acetonide aero 55mcg/act 1 QL (16.5 GM per 30 days)

VERAMYST SUSP 27.5MCG/SPRAY 1 QL (10 GM per 30 days) ST

Antihistamines

arbinoxa soln 4mg/5ml 1 PA

arbinoxa tabs 4mg 1 PA

azelastine hcl soln 0.1% 1 QL (60 ML per 30 days)

azelastine hcl soln 0.15% 1 QL (60 ML per 30 days)

carbinoxamine maleate soln 4mg/5ml 1 PA

carbinoxamine maleate tabs 4mg 1 PA

cetirizine hcl syrp 1mg/ml 1

cyproheptadine hcl syrp 2mg/5ml 1 PA

cyproheptadine hcl tabs 4mg 1 PA

desloratadine odt tbdp 2.5mg 1

desloratadine odt tbdp 5mg 1

desloratadine tabs 5mg 1

diphenhydramine hcl inj 50mg/ml 1

DYMISTA SUSP 137MCG/ACT; 50MCG/ACT 1 QL (23 GM per 30 days) ST

hydroxyzine hcl inj 25mg/ml 1 PA

hydroxyzine hcl inj 50mg/ml 1 PA

hydroxyzine hcl syrp 10mg/5ml 1 PA

hydroxyzine hcl tabs 10mg 1 PA

hydroxyzine hcl tabs 25mg 1 PA

hydroxyzine hcl tabs 50mg 1 PA

hydroxyzine pamoate caps 100mg 1 PA

hydroxyzine pamoate caps 25mg 1 PA

hydroxyzine pamoate caps 50mg 1 PA

levocetirizine dihydrochloride soln 2.5mg/5ml 1

levocetirizine dihydrochloride tabs 5mg 1

olopatadine hcl soln 0.6% 1 QL (30.5 GM per 30 days)

pharbedryl caps 50mg 1 PA

Antileukotrienes

montelukast sodium chew 4mg 1 MO

montelukast sodium chew 5mg 1 MO

montelukast sodium pack 4mg 1 MO

montelukast sodium tabs 10mg 1 MO

zafirlukast tabs 10mg 1 MO

zafirlukast tabs 20mg 1 MO

ZYFLO CR TB12 600MG 1 MO

Bronchodilators, Anticholinergic

Page 112: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

102

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

ATROVENT HFA AERS 17MCG/ACT 1 QL (25.8 GM per 30 days) MO

COMBIVENT RESPIMAT AERS 100MCG/ACT;

20MCG/ACT

1 QL (8 GM per 30 days) MO

ipratropium bromide/albuterol sulfate soln 2.5mg/3ml;

0.5mg/3ml

1 QL (540 ML per 30 days) B/D MO

ipratropium bromide soln 0.02% 1 QL (312.5 ML per 30 days) B/D MO

ipratropium bromide soln 0.03% 1 QL (60 ML per 30 days) MO

ipratropium bromide soln 0.06% 1 QL (30 ML per 30 days) MO

SPIRIVA HANDIHALER CAPS 18MCG 1 QL (30 EA per 30 days) MO

SPIRIVA RESPIMAT AERS 1.25MCG/ACT 1 QL (4 GM per 28 days) MO

SPIRIVA RESPIMAT AERS 2.5MCG/ACT 1 QL (4 GM per 30 days) MO

TUDORZA PRESSAIR AEPB 400MCG/ACT 1 QL (60 EA per 30 days) MO

TUDORZA PRESSAIR AEPB 400MCG/ACT 1 QL (60 EA per 30 days) MO

Bronchodilators, Sympathomimetic

adrenaclick inj 0.15mg/0.15ml 1

adrenaclick inj 0.3mg/0.3ml 1

ADRENALIN INJ 1MG/ML 1

ADRENALIN INJ 30MG/30ML 1

albuterol sulfate er tb12 4mg 1 MO

albuterol sulfate er tb12 8mg 1 MO

albuterol sulfate nebu 0.083% 1 QL (525 ML per 30 days) B/D MO

albuterol sulfate nebu 0.5% 1 QL (100 ML per 30 days) B/D MO

albuterol sulfate nebu 0.63mg/3ml 1 QL (375 ML per 30 days) B/D MO

albuterol sulfate nebu 1.25mg/3ml 1 QL (375 ML per 30 days) B/D MO

albuterol sulfate syrp 2mg/5ml 1 MO

albuterol sulfate tabs 2mg 1 MO

albuterol sulfate tabs 4mg 1 MO

albuterol tabs 4mg 1 MO

ANORO ELLIPTA AEPB 62.5MCG/INH; 25MCG/INH 1 QL (60 EA per 30 days) MO

ARCAPTA NEOHALER CAPS 75MCG 1 QL (30 EA per 30 days) MO

BROVANA NEBU 15MCG/2ML 1 QL (120 ML per 30 days) B/D MO

epinephrine inj 0.15mg/0.15ml 1

epinephrine inj 0.3mg/0.3ml 1

EPIPEN 2-PAK INJ 0.3MG/0.3ML 1

EPIPEN-JR 2-PAK INJ 0.15MG/0.3ML 1

FORADIL AEROLIZER CAPS 12MCG 1 QL (60 EA per 30 days) MO

levalbuterol hcl nebu 0.31mg/3ml 1 QL (540 ML per 30 days) B/D MO

levalbuterol hcl nebu 0.63mg/3ml 1 QL (540 ML per 30 days) B/D MO

levalbuterol hcl nebu 1.25mg/3ml 1 QL (270 ML per 30 days) B/D MO

levalbuterol nebu 1.25mg/0.5ml 1 QL (45 EA per 30 days) B/D MO

METAPROTERENOL SULFATE SYRP 10MG/5ML 1 MO

PERFOROMIST NEBU 20MCG/2ML 1 QL (120 ML per 30 days) B/D MO

PROAIR HFA AERS 108MCG/ACT 1 QL (17 GM per 30 days) MO

PROAIR RESPICLICK AEPB 108MCG/ACT 1 QL (2 EA per 30 days) MO

PROVENTIL HFA AERS 108MCG/ACT 1 QL (13.4 GM per 30 days) MO

SEREVENT DISKUS AEPB 50MCG/DOSE 1 QL (60 EA per 30 days) MO

terbutaline sulfate inj 1mg/ml 1

terbutaline sulfate tabs 2.5mg 1 MO

Page 113: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

103

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

terbutaline sulfate tabs 5mg 1 MO

VENTOLIN HFA AERS 108MCG/ACT 1 QL (48 GM per 30 days) MO

XOPENEX HFA AERO 45MCG/ACT 1 QL (30 GM per 30 days) MO

Cystic Fibrosis Agents

CAYSTON SOLR 75MG 1 PA

KALYDECO PACK 50MG 1 PA MO

KALYDECO PACK 75MG 1 PA MO

KALYDECO TABS 150MG 1 PA MO

ORKAMBI TABS 125MG; 100MG 1 QL (112 EA per 28 days) PA MO

ORKAMBI TABS 125MG; 200MG 1 QL (112 EA per 28 days) PA MO

PULMOZYME SOLN 1MG/ML 1 PA MO

TOBI PODHALER CAPS 28MG 1 QL (224 EA per 56 days) PA

tobramycin inhalation solution pak nebu 300mg/5ml 1 PA

tobramycin nebu 300mg/5ml 1 PA

Mast Cell Stabilizers

cromolyn sodium nebu 20mg/2ml 1 B/D MO

Phosphodiesterase Inhibitors, Airways Disease

aminophylline inj 25mg/ml 1

DALIRESP TABS 500MCG 1 PA MO

ELIXOPHYLLIN ELIX 80MG/15ML 1 MO

LUFYLLIN TABS 200MG 1 MO

LUFYLLIN TABS 400MG 1 MO

theochron tb12 100mg 1 MO

theochron tb12 200mg 1 MO

theochron tb12 300mg 1 MO

theophylline cr tb12 100mg 1 MO

theophylline cr tb12 200mg 1 MO

theophylline er tb12 100mg 1 MO

theophylline er tb12 200mg 1 MO

theophylline er tb12 300mg 1 MO

theophylline er tb12 450mg 1 MO

theophylline er tb24 400mg 1 MO

theophylline er tb24 600mg 1 MO

theophylline soln 80mg/15ml 1 MO

Pulmonary Antihypertensives

ADCIRCA TABS 20MG 1 QL (60 EA per 30 days) PA MO

ADEMPAS TABS 0.5MG 1 QL (90 EA per 30 days) PA MO

ADEMPAS TABS 1.5MG 1 QL (90 EA per 30 days) PA MO

ADEMPAS TABS 1MG 1 QL (90 EA per 30 days) PA MO

ADEMPAS TABS 2.5MG 1 QL (90 EA per 30 days) PA MO

ADEMPAS TABS 2MG 1 QL (90 EA per 30 days) PA MO

LETAIRIS TABS 10MG 1 QL (30 EA per 30 days) PA MO

LETAIRIS TABS 5MG 1 QL (30 EA per 30 days) PA MO

OPSUMIT TABS 10MG 1 QL (30 EA per 30 days) PA MO

ORENITRAM TBCR 0.125MG 1 PA MO

ORENITRAM TBCR 0.25MG 1 PA MO

ORENITRAM TBCR 1MG 1 PA MO

ORENITRAM TBCR 2.5MG 1 PA MO

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104

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

REVATIO SUSR 10MG/ML 1 PA MO

SILDENAFIL INJ 10MG/12.5ML 1 QL (1125 ML per 30 days) PA

sildenafil tabs 20mg 1 QL (90 EA per 30 days) PA MO

TRACLEER TABS 125MG 1 QL (60 EA per 30 days) PA MO

TRACLEER TABS 62.5MG 1 QL (60 EA per 30 days) PA MO

TYVASO SOLN 0.6MG/ML 1 QL (87 ML per 30 days) PA MO

UPTRAVI TABS 1000MCG 1 QL (60 EA per 30 days) PA MO

UPTRAVI TABS 1200MCG 1 QL (60 EA per 30 days) PA MO

UPTRAVI TABS 1400MCG 1 QL (60 EA per 30 days) PA MO

UPTRAVI TABS 1600MCG 1 QL (60 EA per 30 days) PA MO

UPTRAVI TABS 200MCG 1 QL (150 EA per 30 days) PA MO

UPTRAVI TABS 400MCG 1 QL (60 EA per 30 days) PA MO

UPTRAVI TABS 600MCG 1 QL (60 EA per 30 days) PA MO

UPTRAVI TABS 800MCG 1 QL (60 EA per 30 days) PA MO

UPTRAVI TBPK 0 1 QL (400 EA per 365 days) PA

VENTAVIS SOLN 10MCG/ML 1 QL (270 ML per 30 days) PA MO

VENTAVIS SOLN 20MCG/ML 1 QL (270 ML per 30 days) PA MO

Respiratory Tract Agents, Other

acetylcysteine soln 10% 1 B/D

acetylcysteine soln 20% 1 B/D

ARALAST NP INJ 500MG 1 PA

ESBRIET CAPS 267MG 1 PA MO

OFEV CAPS 100MG 1 PA MO

OFEV CAPS 150MG 1 PA MO

PROLASTIN-C INJ 1000MG 1 PA

PROLASTIN-C INJ 1000MG 1 PA

promethazine vc plain syrp 5mg/5ml; 6.25mg/5ml 1 PA

promethazine vc syrp 5mg/5ml; 6.25mg/5ml 1 PA

promethazine/phenylephrine syrp 5mg/5ml; 6.25mg/5ml 1 PA

TYZINE PEDIATRIC NASAL DROPS SOLN 0.05% 1

TYZINE SOLN 0.1% 1

VIRAZOLE SOLR 6GM 1

XOLAIR INJ 150MG 1 PA

ZEMAIRA INJ 1000MG 1 PA

Skeletal Muscle Relaxants

Skeletal Muscle Relaxants

carisoprodol/aspirin tabs 325mg; 200mg 1 PA

carisoprodol tabs 350mg 1 PA

chlorzoxazone tabs 500mg 1 PA

cyclobenzaprine hcl tabs 10mg 1 PA

cyclobenzaprine hcl tabs 5mg 1 PA

cyclobenzaprine hcl tabs 7.5mg 1 PA

methocarbamol tabs 500mg 1 PA

methocarbamol tabs 750mg 1 PA

orphenadrine citrate er tb12 100mg 1 PA

orphenadrine citrate inj 30mg/ml 1 PA

Sleep Disorder Agents

GABA Receptor Modulators

Page 115: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

105

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

zaleplon caps 10mg 1 QL (60 EA per 30 days) PA

zaleplon caps 5mg 1 QL (30 EA per 30 days) PA

zolpidem tartrate er tbcr 12.5mg 1 QL (30 EA per 30 days) PA

zolpidem tartrate er tbcr 6.25mg 1 QL (30 EA per 30 days) PA

zolpidem tartrate tabs 10mg 1 QL (30 EA per 30 days) PA

zolpidem tartrate tabs 5mg 1 QL (30 EA per 30 days) PA

Sleep Disorders, Other

armodafinil tabs 150mg 1 QL (30 EA per 30 days) PA MO

armodafinil tabs 200mg 1 QL (30 EA per 30 days) PA MO

armodafinil tabs 250mg 1 QL (30 EA per 30 days) PA MO

armodafinil tabs 50mg 1 QL (60 EA per 30 days) PA MO

modafinil tabs 100mg 1 QL (30 EA per 30 days) PA MO

modafinil tabs 200mg 1 QL (30 EA per 30 days) PA MO

NUVIGIL TABS 150MG 1 QL (30 EA per 30 days) PA MO

NUVIGIL TABS 200MG 1 QL (30 EA per 30 days) PA MO

NUVIGIL TABS 250MG 1 QL (30 EA per 30 days) PA MO

NUVIGIL TABS 50MG 1 QL (60 EA per 30 days) PA MO

ROZEREM TABS 8MG 1 QL (30 EA per 30 days) MO

SILENOR TABS 3MG 1 QL (30 EA per 30 days) MO

SILENOR TABS 6MG 1 QL (30 EA per 30 days) MO

XYREM SOLN 500MG/ML 1 QL (540 ML per 30 days) PA

Therapeutic Nutrients/Minerals/Electrolytes

Electrolyte/Mineral Modifiers

DEPEN TITRATABS TABS 250MG 1

EXJADE TBSO 125MG 1 PA MO

EXJADE TBSO 250MG 1 PA MO

EXJADE TBSO 500MG 1 PA MO

FERRIPROX TABS 500MG 1 PA MO

JADENU TABS 180MG 1 PA MO

JADENU TABS 360MG 1 PA MO

JADENU TABS 90MG 1 PA MO

kionex powd 0 1

kionex susp 15gm/60ml 1

kionex susp 15gm/60ml 1

SAMSCA TABS 15MG 1

SAMSCA TABS 30MG 1

sodium polystyrene sulfonate powd 0 1

sodium polystyrene sulfonate powd 0 1

sodium polystyrene sulfonate powd 0 1

sodium polystyrene sulfonate susp 15gm/60ml 1

sodium polystyrene sulfonate susp 30gm/120ml 1

sodium polystyrene sulfonate susp 50gm/200ml 1

sps susp 15gm/60ml 1

SYPRINE CAPS 250MG 1

Electrolyte/Mineral Replacement

Page 116: Trillium Advantage Dual SNP (HMO) Trillium Advantage TLC ... · Trillium Advantage TLC ISNP (HMO) Trillium Advantage TLC Community ISNP (HMO) 2016 Formulary (List of Covered Drugs)

106

H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

AMINOSYN 7%/ELECTROLYTES INJ 124MEQ/L;

900MG/100ML; 690MG/100ML; 96MEQ/L; 900MG/100ML;

210MG/100ML; 510MG/100ML; 660MG/100ML;

510MG/100ML; 10MEQ/L; 280MG/100ML; 310MG/100ML;

30MMOLE/L; 65MEQ/L; 610MG/100ML; 300MG/100ML;

65MEQ/L; 370MG/100ML; 120MG/100ML; 44MG/100ML;

560MG/100ML

1 B/D

AMINOSYN 8.5%/ELECTROLYTES INJ 142MEQ/L;

1100MG/100ML; 850MG/100ML; 98MEQ/L;

1100MG/100ML; 260MG/100ML; 620MG/100ML;

810MG/100ML; 624MG/100ML; 10MEQ/L; 340MG/100ML;

380MG/100ML; 30MEQ/L; 65MEQ/L; 750MG/100ML;

370MG/100ML; 65MEQ/L; 460MG/100ML; 150MG/100ML;

44MG/100ML; 680MG/100ML

1 B/D

AMINOSYN II 8.5%/ELECTROLYTES INJ 61MEQ/L;

844MG/100ML; 865MG/100ML; 595MG/100ML; 86MEQ/L;

627MG/100ML; 425MG/100ML; 255MG/100ML;

561MG/100ML; 850MG/100ML; 893MG/100ML; 10MEQ/L;

146MG/100ML; 253MG/100ML; 30MMOLE/L; 66MEQ/L;

614MG/100ML; 450MG/100ML; 80MEQ/L; 340MG/100ML;

170MG/100ML; 230MG/100ML; 425MG/100ML

1 B/D

AMINOSYN II INJ 50.3MEQ/L; 695MG/100ML;

713MG/100ML; 490MG/100ML; 517MG/100ML;

350MG/100ML; 210MG/100ML; 462MG/100ML;

700MG/100ML; 735MG/100ML; 120MG/100ML;

209MG/100ML; 505MG/100ML; 371MG/100ML;

31.3MEQ/L; 280MG/100ML; 140MG/100ML;

189MG/100ML; 350MG/100ML

1 B/D

AMINOSYN II INJ 61.1MEQ/L; 844MG/100ML;

865MG/100ML; 595MG/100ML; 627MG/100ML;

425MG/100ML; 255MG/100ML; 561MG/100ML;

850MG/100ML; 893MG/100ML; 146MG/100ML;

253MG/100ML; 614MG/100ML; 450MG/100ML;

33.3MEQ/L; 340MG/100ML; 170MG/100ML;

230MG/100ML; 425MG/100ML

1 B/D

AMINOSYN II INJ 71.8MEQ/L; 993MG/100ML;

1018MG/100ML; 700MG/100ML; 738MG/100ML;

500MG/100ML; 300MG/100ML; 660MG/100ML;

1000MG/100ML; 1050MG/100ML; 172MG/100ML;

298MG/100ML; 722MG/100ML; 530MG/100ML;

45.3MEQ/L; 400MG/100ML; 200MG/100ML;

270MG/100ML; 500MG/100ML

1 B/D

AMINOSYN M INJ 65MEQ/L; 448MG/100ML;

343MG/100ML; 40MEQ/L; 448MG/100ML; 105MG/100ML;

252MG/100ML; 329MG/100ML; 252MG/100ML; 3MEQ/L;

140MG/100ML; 154MG/100ML; 3.5MMOLE/L; 13MEQ/L;

300MG/100ML; 147MG/100ML; 40MEQ/L; 182MG/100ML;

56MG/100ML; 31MG/100ML; 280MG/100ML

1 B/D

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Drug Name

Drug

Tier Requirements/Limits

AMINOSYN-HBC INJ 7.1MEQ/100ML; 660MG/100ML;

507MG/100ML; 4MEQ/100ML; 660MG/100ML;

154MG/100ML; 789MG/100ML; 1576MG/100ML;

265MG/100ML; 206MG/100ML; 1.12GM/100ML;

228MG/100ML; 448MG/100ML; 221MG/100ML;

272MG/100ML; 88MG/100ML; 33MG/100ML;

789MG/100ML

1 B/D

AMINOSYN-PF 7% INJ 32.5MEQ/L; 490MG/100ML;

861MG/100ML; 370MG/100ML; 576MG/100ML;

270MG/100ML; 220MG/100ML; 534MG/100ML;

831MG/100ML; 475MG/100ML; 125MG/100ML;

10.69GM/L; 300MG/100ML; 570MG/100ML; 70GM/L;

347MG/100ML; 50MG/100ML; 360MG/100ML;

125MG/100ML; 44MG/100ML; 452MG/100ML

1 B/D

AMINOSYN-PF INJ 46MEQ/L; 698MG/100ML;

1227MG/100ML; 527MG/100ML; 820MG/100ML;

385MG/100ML; 312MG/100ML; 760MG/100ML;

1200MG/100ML; 677MG/100ML; 180MG/100ML;

427MG/100ML; 812MG/100ML; 495MG/100ML;

3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML;

44MG/100ML; 673MG/100ML

1 B/D

AMINOSYN-RF INJ 113MEQ/L; 600MG/100ML;

429MG/100ML; 462MG/100ML; 726MG/100ML;

535MG/100ML; 726MG/100ML; 726MG/100ML;

330MG/100ML; 165MG/100ML; 528MG/100ML

1 B/D

AMINOSYN INJ 148MEQ/L; 1280MG/100ML;

980MG/100ML; 1280MG/100ML; 300MG/100ML;

720MG/100ML; 940MG/100ML; 720MG/100ML;

400MG/100ML; 440MG/100ML; 5.4MEQ/L;

860MG/100ML; 420MG/100ML; 520MG/100ML;

160MG/100ML; 44MG/100ML; 800MG/100ML

1 B/D

AMINOSYN INJ 90MEQ/L; 1100MG/100ML;

850MG/100ML; 35MEQ/L; 1100MG/100ML;

260MG/100ML; 620MG/100ML; 810MG/100ML;

624MG/100ML; 340MG/100ML; 380MG/100ML;

5.4MEQ/L; 750MG/100ML; 370MG/100ML;

460MG/100ML; 150MG/100ML; 44MG/100ML;

680MG/100ML

1 B/D

CLINIMIX 2.75%/DEXTROSE 5% INJ 24MEQ/1000ML;

570MG/100ML; 316MG/100ML; 11MEQ/1000ML;

5GM/100ML; 283MG/100ML; 132MG/100ML;

165MG/100ML; 201MG/100ML; 159MG/100ML;

110MG/100ML; 154MG/100ML; 187MG/100ML;

138MG/100ML; 116MG/100ML; 50MG/100ML;

11MG/100ML; 160MG/100ML

1 B/D

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Drug Name

Drug

Tier Requirements/Limits

CLINIMIX 4.25%/DEXTROSE 10% INJ 37MEQ/L;

880MG/100ML; 489MG/100ML; 17MEQ/L; 10GM/100ML;

438MG/100ML; 204MG/100ML; 255MG/100ML;

311MG/100ML; 247MG/100ML; 170MG/100ML;

238MG/100ML; 289MG/100ML; 213MG/100ML;

179MG/100ML; 77MG/100ML; 17MG/100ML;

247MG/100ML

1 B/D

CLINIMIX 4.25%/DEXTROSE 20% INJ 37MEQ/L;

880MG/100ML; 489MG/100ML; 17MEQ/L; 20GM/100ML;

438MG/100ML; 204MG/100ML; 255MG/100ML;

311MG/100ML; 247MG/100ML; 170MG/100ML;

238MG/100ML; 289MG/100ML; 213MG/100ML;

179MG/100ML; 77MG/100ML; 17MG/100ML;

247MG/100ML

1 B/D

CLINIMIX 4.25%/DEXTROSE 25% INJ 37MEQ/L;

880MG/100ML; 489MG/100ML; 17MEQ/L; 25GM/100ML;

438MG/100ML; 204MG/100ML; 255MG/100ML;

311MG/100ML; 247MG/100ML; 170MG/100ML;

238MG/100ML; 289MG/100ML; 213MG/100ML;

179MG/100ML; 77MG/100ML; 17MG/100ML;

247MG/100ML

1 B/D

CLINIMIX 4.25%/DEXTROSE 5% INJ 37MEQ/L;

880MG/100ML; 489MG/100ML; 17MEQ/L; 5GM/100ML;

438MG/100ML; 204MG/100ML; 255MG/100ML;

311MG/100ML; 247MG/100ML; 170MG/100ML;

238MG/100ML; 289MG/100ML; 213MG/100ML;

179MG/100ML; 77MG/100ML; 17MG/100ML;

247MG/100ML

1 B/D

CLINIMIX 5%/DEXTROSE 15% INJ 42MEQ/1000ML;

1035MG/100ML; 575MG/100ML; 20MEQ/1000ML;

15GM/100ML; 515MG/100ML; 240MG/100ML;

300MG/100ML; 365MG/100ML; 290MG/100ML;

200MG/100ML; 280MG/100ML; 340MG/100ML;

250MG/100ML; 210MG/100ML; 90MG/100ML;

20MG/100ML; 290MG/100ML

1 B/D

CLINIMIX 5%/DEXTROSE 20% INJ 42MEQ/L;

1035MG/100ML; 575MG/100ML; 20MEQ/L; 20GM/100ML;

515MG/100ML; 240MG/100ML; 300MG/100ML;

365MG/100ML; 290MG/100ML; 200MG/100ML;

280MG/100ML; 340MG/100ML; 250MG/100ML;

210MG/100ML; 90MG/100ML; 20MG/100ML;

290MG/100ML

1 B/D

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

CLINIMIX 5%/DEXTROSE 25% INJ 42MEQ/L;

1035MG/100ML; 575MG/100ML; 20MEQ/L; 25GM/100ML;

515MG/100ML; 240MG/100ML; 300MG/100ML;

365MG/100ML; 290MG/100ML; 200MG/100ML;

280MG/100ML; 340MG/100ML; 250MG/100ML;

210MG/100ML; 90MG/100ML; 20MG/100ML;

290MG/100ML

1 B/D

CLINIMIX E 2.75%/DEXTROSE 10% INJ 570MG/100ML;

316MG/100ML; 33MG/100ML; 10GM/100ML;

132MG/100ML; 165MG/100ML; 201MG/100ML;

159MG/100ML; 51MG/100ML; 110MG/100ML;

454MG/100ML; 154MG/100ML; 261MG/100ML;

187MG/100ML; 138MG/100ML; 217MG/100ML;

112MG/100ML; 116MG/100ML; 50MG/100ML;

11MG/100ML; 160MG/100ML

1 B/D

CLINIMIX E 2.75%/DEXTROSE 5% INJ 570MG/100ML;

316MG/100ML; 33MG/100ML; 5GM/100ML;

132MG/100ML; 165MG/100ML; 201MG/100ML;

159MG/100ML; 51MG/100ML; 110MG/100ML;

454MG/100ML; 154MG/100ML; 261MG/100ML;

187MG/100ML; 138MG/100ML; 217MG/100ML;

112MG/100ML; 116MG/100ML; 50MG/100ML;

11MG/100ML; 160MG/100ML

1 B/D

CLINIMIX E 4.25%/DEXTROSE 10% INJ 880MG/100ML;

489MG/100ML; 33MG/100ML; 10GM/100ML;

204MG/100ML; 255MG/100ML; 311MG/100ML;

247MG/100ML; 51MG/100ML; 170MG/100ML;

702MG/100ML; 238MG/100ML; 261MG/100ML;

289MG/100ML; 213MG/100ML; 297MG/100ML;

77MG/100ML; 179MG/100ML; 77MG/100ML;

17MG/100ML; 247MG/100ML

1 B/D

CLINIMIX E 4.25%/DEXTROSE 25% INJ 880MG/100ML;

489MG/100ML; 33MG/100ML; 25GM/100ML;

204MG/100ML; 255MG/100ML; 311MG/100ML;

247MG/100ML; 51MG/100ML; 170MG/100ML;

702MG/100ML; 238MG/100ML; 261MG/100ML;

289MG/100ML; 213MG/100ML; 297MG/100ML;

77MG/100ML; 179MG/100ML; 77MG/100ML;

17MG/100ML; 247MG/100ML

1 B/D

CLINIMIX E 4.25%/DEXTROSE 5% INJ 880MG/100ML;

489MG/100ML; 33MG/100ML; 5GM/100ML;

204MG/100ML; 255MG/100ML; 311MG/100ML;

247MG/100ML; 51MG/100ML; 170MG/100ML;

702MG/100ML; 238MG/100ML; 261MG/100ML;

289MG/100ML; 213MG/100ML; 297MG/100ML;

77MG/100ML; 179MG/100ML; 77MG/100ML;

17MG/100ML; 247MG/100ML

1 B/D

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Drug Name

Drug

Tier Requirements/Limits

CLINIMIX E 5%/DEXTROSE 15% INJ 1035MG/100ML;

575MG/100ML; 33MG/100ML; 15GM/100ML;

240MG/100ML; 300MG/100ML; 365MG/100ML;

290MG/100ML; 51MG/100ML; 200MG/100ML;

826MG/100ML; 280MG/100ML; 261MG/100ML;

340MG/100ML; 250MG/100ML; 340MG/100ML;

59MG/100ML; 210MG/100ML; 90MG/100ML;

20MG/100ML; 290MG/100ML

1 B/D

CLINIMIX E 5%/DEXTROSE 20% INJ 1035MG/100ML;

575MG/100ML; 33MG/100ML; 20GM/100ML;

240MG/100ML; 300MG/100ML; 365MG/100ML;

290MG/100ML; 51MG/100ML; 200MG/100ML;

826MG/100ML; 280MG/100ML; 261MG/100ML;

340MG/100ML; 250MG/100ML; 340MG/100ML;

59MG/100ML; 210MG/100ML; 90MG/100ML;

20MG/100ML; 290MG/100ML

1 B/D

CLINIMIX E 5%/DEXTROSE 25% INJ 1035MG/100ML;

575MG/100ML; 33MG/100ML; 25GM/100ML;

240MG/100ML; 300MG/100ML; 365MG/100ML;

290MG/100ML; 51MG/100ML; 200MG/100ML;

826MG/100ML; 280MG/100ML; 261MG/100ML;

340MG/100ML; 250MG/100ML; 340MG/100ML;

59MG/100ML; 210MG/100ML; 90MG/100ML;

20MG/100ML; 290MG/100ML

1 B/D

CLINISOL SF 15% INJ 151MEQ/L; 2170MG/100ML;

1470MG/100ML; 434MG/100ML; 749MG/100ML;

1040MG/100ML; 894MG/100ML; 749MG/100ML;

1040MG/100ML; 1180MG/100ML; 749MG/100ML;

1040MG/100ML; 894MG/100ML; 592MG/100ML;

749MG/100ML; 250MG/100ML; 39MG/100ML;

960MG/100ML

1 B/D

dextrose 10%/nacl 0.45% inj 10%; 0.45% 1

dextrose 10%/nacl 0.2% inj 10%; 0.2% 1

dextrose 10%/nacl 0.225% inj 10%; 0.225% 1

dextrose 2.5%/nacl 0.45% inj 2.5%; 0.45% 1

dextrose 20% inj 20% 1

dextrose 25% inj 250mg/ml 1

dextrose 30% partial fill inj 30% 1

dextrose 30% inj 30% 1

dextrose 40% inj 40% 1

dextrose 5%/lactated ringers inj 2.7meq/l; 109meq/l; 5%;

28meq/l; 4meq/l; 130meq/l

1

dextrose 5%/nacl 0.2% inj 5%; 0.2% 1

dextrose 5%/nacl 0.225% inj 5%; 0.225% 1

dextrose 5%/nacl 0.3% inj 5%; 0.3% 1

dextrose 5%/nacl 0.33% inj 5%; 0.33% 1

dextrose 5%/nacl 0.45% inj 5%; 0.45% 1

dextrose 5%/nacl 0.9% inj 5%; 0.9% 1

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Drug Name

Drug

Tier Requirements/Limits

dextrose 5%/potassium chloride 0.15% inj 5%; 20meq/l 1

dextrose 50% inj 50% 1

dextrose 70% inj 70% 1

FREAMINE HBC 6.9% INJ 59.3MEQ/L; 400MG/100ML;

580MG/100ML; 3MEQ/L; 14MG/100ML; 330MG/100ML;

160MG/100ML; 760MG/100ML; 1370MG/100ML;

410MG/100ML; 250MG/100ML; 320MG/100ML;

630MG/100ML; 330MG/100ML; 10MEQ/L; 200MG/100ML;

90MG/100ML; 880MG/100ML

1 B/D

FREAMINE III INJ 89MEQ/L; 710MG/100ML;

950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML;

280MG/100ML; 690MG/100ML; 910MG/100ML;

730MG/100ML; 530MG/100ML; 560MG/100ML;

10MMOLE/L; 120MG/100ML; 1120MG/100ML;

590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML;

660MG/100ML

1 B/D

HEPATAMINE INJ 62MEQ/L; 770MG/100ML;

600MG/100ML; 3MEQ/L; 20MG/100ML; 900MG/100ML;

240MG/100ML; 900MG/100ML; 1100MG/100ML;

610MG/100ML; 100MG/100ML; 100MG/100ML;

115MG/100ML; 800MG/100ML; 500MG/100ML;

100MG/100ML; 450MG/100ML; 66MG/100ML;

840MG/100ML

1 B/D

HEPATASOL INJ 0.77GM/100ML; 0.6GM/100ML;

0.02GM/100ML; 0.9GM/100ML; 0.24GM/100ML;

0.9GM/100ML; 1.1GM/100ML; 0.61GM/100ML;

0.1GM/100ML; 0.1GM/100ML; 0.115GM/100ML;

0.8GM/100ML; 0.5GM/100ML; 0.45GM/100ML;

0.065GM/100ML; 0.84GM/100ML

1 B/D

IONOSOL-B/DEXTROSE 5% INJ 49MEQ/L; 5%;

25MEQ/L; 5MEQ/L; 13MEQ/L; 25MEQ/L; 57MEQ/L

1

isolyte-m/dextrose 5% inj 20meq/l; 44meq/l; 5%; 15meq/l;

35meq/l; 38meq/l

1

ISOLYTE-P/DEXTROSE 5% INJ 23MEQ/L; 23MEQ/L; 5%;

3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L

1

k-sol soln 10% 1 MO

k-sol soln 20% 1 MO

kcl 0.075%/d5w/nacl 0.45% inj 5%; 10meq/l; 0.45% 1

kcl 0.15%/d5w/ nacl 0.3% inj 5%; 20meq/l; 0.33% 1

KCL 0.15%/D5W/LR INJ 3MEQ/L; 149MEQ/L; 5%;

28MEQ/L; 24MEQ/L; 130MEQ/L

1

kcl 0.15%/d5w/nacl 0.2% inj 5%; 20meq/l; 0.2% 1

kcl 0.15%/d5w/nacl 0.225% inj 5%; 20meq/l; 0.225% 1

kcl 0.15%/d5w/nacl 0.9% inj 5%; 20meq/l; 0.9% 1

KCL 0.3%/D5W/LR IV LAC RING INJ 3MEQ/L;

149MEQ/L; 5%; 28MEQ/L; 44MEQ/L; 130MEQ/L

1

kcl 0.3%/d5w/nacl 0.45% inj 5%; 40meq/l; 0.45% 1

kcl 0.3%/d5w/nacl 0.9% inj 5%; 40meq/l; 0.9% 1

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

klor-con 10 tbcr 10meq 1 MO

klor-con 8 tbcr 8meq 1 MO

KLOR-CON M15 TBCR 15MEQ 1 MO

klor-con m20 tbcr 20meq 1 MO

klor-con sprinkle cpcr 10meq 1 MO

klor-con sprinkle cpcr 8meq 1 MO

lactated ringers viaflex inj 3meq/l; 109meq/l; 28meq/l;

4meq/l; 130meq/l

1

magnesium sulfate inj 50% 1

magnesium sulfate inj 50% 1

NEPHRAMINE INJ 44MEQ/L; 20MG/100ML;

250MG/100ML; 560MG/100ML; 880MG/100ML;

640MG/100ML; 880MG/100ML; 880MG/100ML; 6MEQ/L;

400MG/100ML; 200MG/100ML; 640MG/100ML

1 B/D

normosol-m in d5w inj 16meq/l; 40meq/l; 5%; 3meq/l;

13meq/l; 40meq/l

1

normosol-r in d5w inj 27meq/l; 98meq/l; 5%; 23meq/l;

3meq/l; 5meq/l; 140meq/l

1

PLASMA-LYTE-148 INJ 27MEQ/L; 98MEQ/L; 23MEQ/L;

3MEQ/L; 5MEQ/L; 140MEQ/L

1

PLASMA-LYTE-56/D5W INJ 16MEQ/L; 40MEQ/L; 5%;

3MEQ/L; 13MEQ/L; 40MEQ/L

1

PLENAMINE INJ 151MEQ/L; 2170MG/100ML;

1470MG/100ML; 434MG/100ML; 749MG/100ML;

1040MG/100ML; 894MG/100ML; 749MG/100ML;

1040MG/100ML; 1180MG/100ML; 749MG/100ML;

1040MG/100ML; 894MG/100ML; 592MG/100ML;

749MG/100ML; 250MG/100ML; 39MG/100ML;

960MG/100ML

1 B/D

potassium chloride 0.15% /nacl 0.45% viaflex inj 20meq/l;

0.45%

1

potassium chloride 0.15% d5w/nacl 0.33% inj 5%; 20meq/l;

0.33%

1

potassium chloride 0.15% d5w/nacl 0.45% viaflex inj 5%;

20meq/l; 0.45%

1

potassium chloride 0.15% d5w/nacl 0.45% inj 5%; 20meq/l;

0.45%

1

potassium chloride 0.15% nacl 0.9% inj 20meq/l; 0.9% 1

potassium chloride 0.15%/nacl 0.9% inj 20meq/l; 0.9% 1

potassium chloride 0.22% d5w/nacl 0.45% inj 5%; 30meq/l;

0.45%

1

potassium chloride 0.3%/ nacl 0.9% inj 40meq/l; 0.9% 1

potassium chloride 0.3%/d5w inj 5%; 40meq/l 1

potassium chloride cr tbcr 10meq 1 MO

potassium chloride cr tbcr 10meq 1 MO

potassium chloride er cpcr 10meq 1 MO

potassium chloride er cpcr 8meq 1 MO

potassium chloride er tbcr 10meq 1 MO

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

potassium chloride er tbcr 10meq 1 MO

potassium chloride er tbcr 20meq 1 MO

potassium chloride er tbcr 20meq 1 MO

potassium chloride er tbcr 8meq 1 MO

potassium chloride sr tbcr 8meq 1 MO

potassium chloride/lidocaine hydrochloride inj 5%;

10mg/100ml; 20meq/100ml

1

potassium chloride inj 10meq/100ml 1

potassium chloride inj 20meq/100ml 1

potassium chloride inj 2meq/ml 1

potassium chloride inj 40meq/100ml 1

potassium chloride soln 10% 1 MO

potassium chloride soln 20% 1 MO

potassium citrate er tbcr 1080mg 1

potassium citrate er tbcr 15meq 1

potassium citrate er tbcr 540mg 1

PREMASOL INJ 52MEQ/L; 1760MG/100ML;

880MG/100ML; 34MEQ/L; 1760MG/100ML;

372MG/100ML; 406MG/100ML; 526MG/100ML;

492MG/100ML; 492MG/100ML; 526MG/100ML;

356MG/100ML; 356MG/100ML; 390MG/100ML;

34MG/100ML; 152MG/100ML

1 B/D

PREMASOL INJ 56MEQ/L; 320MG/100ML;

730MG/100ML; 190MG/100ML; 3MEQ/L; 20MG/100ML;

300MG/100ML; 220MG/100ML; 290MG/100ML;

490MG/100ML; 840MG/100ML; 490MG/100ML;

200MG/100ML; 290MG/100ML; 410MG/100ML;

230MG/100ML; 5MEQ/L; 15MG/100ML; 250MG/100ML;

120MG/100ML; 140MG/100ML; 470MG/100ML

1 B/D

PROCALAMINE INJ 47MEQ/L; 210MG/100ML;

290MG/100ML; 3MEQ/L; 41MEQ/L; 20MG/100ML;

420MG/100ML; 85MG/100ML; 210MG/100ML;

270MG/100ML; 220MG/100ML; 5MEQ/L; 160MG/100ML;

170MG/100ML; 7MMOLE/L; 24MEQ/L; 340MG/100ML;

180MG/100ML; 35MEQ/L; 120MG/100ML; 46MG/100ML;

200MG/100ML

1 B/D

PROSOL INJ 2.76GM/100ML; 1.96GM/100ML;

600MG/100ML; 1.02GM/100ML; 2.06GM/100ML;

1.18GM/100ML; 1.08GM/100ML; 1.08GM/100ML;

1.35GM/100ML; 760MG/100ML; 1GM/100ML;

1.34GM/100ML; 1.02GM/100ML; 980MG/100ML;

320MG/100ML; 50MG/100ML; 1.44GM/100ML

1 B/D

sodium chloride 0.45% inj 0.45% 1

sodium chloride inj 0.9% 1

sodium chloride inj 0.9% 1

sodium chloride inj 2.5meq/ml 1

sodium chloride inj 3% 1

sodium chloride inj 5% 1

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H2174_EK12V3 Accepted 8/13/2015

Drug Name

Drug

Tier Requirements/Limits

TRAVASOL INJ 52MEQ/L; 1760MG/100ML;

880MG/100ML; 34MEQ/L; 1760MG/100ML;

372MG/100ML; 406MG/100ML; 526MG/100ML;

492MG/100ML; 492MG/100ML; 526MG/100ML;

356MG/100ML; 356MG/100ML; 390MG/100ML;

34MG/100ML; 152MG/100ML

1 B/D

TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML;

1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML;

0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML;

1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML;

0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML;

5MEQ/L; 0.025GM/100ML; 0.42GM/100ML;

0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML

1 B/D

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Index Drug Name Page #

abacavir 44

abacavir sulfate/lamivudine/zidovudine 44

ABELCET 27

ABILIFY 39

ABILIFY DISCMELT 39

ABILIFY MAINTENA 39

ABSTRAL 3

acamprosate calcium dr 7

acarbose 47

acebutolol hcl 58

acetaminophen/codeine 4

acetaminophen/codeine #3 3

acetasol hc 99

acetazolamide 63

acetazolamide er 99

acetazolamide sodium 63

acetic acid 99

acetic acid/aluminum acetate 99

acetylcysteine 104

acitretin 70

ACTEMRA 93

ACTHIB 93

ACTIMMUNE 93

ACUVAIL 98

acyclovir 46

acyclovir sodium 46

ACZONE 70

ADACEL 93

ADAGEN 74

adapalene 70

adapalene pump 70

ADCIRCA 103

adefovir dipivoxil 42

ADEMPAS 103

adrenaclick 102

ADRENALIN 102

adrucil 31

ADVAIR DISKUS 100

ADVAIR HFA 100

afeditab cr 59

AFINITOR 35

AFINITOR DISPERZ 34

AGGRENOX 53

a-hydrocort 79

AKNE-MYCIN 14

ak-poly-bac 97

Drug Name Page #

ala cort 79

ALBENZA 36

albuterol 102

albuterol sulfate 102

albuterol sulfate er 102

alclometasone dipropionate 70

ALCOHOL PREP PADS 8

ALDACTAZIDE 63

ALDURAZYME 74

ALECENSA 35

alendronate sodium 95

alfuzosin hcl er 78

ALIMTA 31

ALINIA 36

allopurinol 28

almotriptan malate 29

ALOCRIL 98

ALOMIDE 98

ALORA 82

alosetron hydrochloride 76

ALOXI 26

ALPHAGAN P 99

alphatrex 70

alprazolam 47

ALREX 98

ALTABAX 8

ALVESCO 100

alyacen 1/35 82

alyacen 7/7/7 82

amabelz 82

amantadine hcl 46

AMBISOME 27

amcinonide 70

AMELUZ 70

amethia 82

amethia lo 82

amethyst 82

amifostine 32

amikacin sulfate 8

amiloride hcl 63

amiloride/hydrochlorothiazide 63

aminophylline 103

AMINOSYN 107

AMINOSYN 7%/ELECTROLYTES 106

AMINOSYN 8.5%/ELECTROLYTES 106

AMINOSYN II 106

AMINOSYN II 8.5%/ELECTROLYTES 106

AMINOSYN M 106

AMINOSYN-HBC 107

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Drug Name Page #

AMINOSYN-PF 107

AMINOSYN-PF 7% 107

AMINOSYN-RF 107

amiodarone hcl 57

AMITIZA 76

amitriptyline hcl 25

amlodipine besylate 59

amlodipine besylate/atorvastatin calcium 59

amlodipine besylate/benazepril

hydrochloride

59

ammonium lactate 70

amnesteem 70

amoxapine 25

amoxicillin 13

amoxicillin/clavulanate potassium 13

amoxicillin/clavulanate potassium er 13

amphetamine/dextroamphetamine 67

amphotericin b 27

ampicillin 14

ampicillin sodium 13

ampicillin-sulbactam 13

AMPYRA 69

AMTURNIDE 62

ANADROL-50 81

anagrelide hydrochloride 52

anastrozole 34

ANDROGEL 81

ANDROGEL PUMP 81

ANDROXY 81

ANORO ELLIPTA 102

apexicon e 70

APIDRA 50

APIDRA SOLOSTAR 50

APLENZIN 22

APOKYN 37

apraclonidine 99

apri 82

APRISO 95

APTIOM 17

APTIVUS 45

ARALAST NP 104

aranelle 82

ARANESP ALBUMIN FREE 52

arbinoxa 101

ARCALYST 93

ARCAPTA NEOHALER 102

argyle sterile saline 100ml 96

aripiprazole 39

aripiprazole odt 39

Drug Name Page #

ARISTADA 40

armodafinil 105

ARRANON 32

ARZERRA 36

ASACOL HD 95

ascomp/codeine 4

ashlyna 82

ASMANEX HFA 100

ASMANEX TWISTHALER 120

METERED DOSES

100

ASMANEX TWISTHALER 14 METERED

DOSES

100

ASMANEX TWISTHALER 30 METERED

DOSES

100

ASMANEX TWISTHALER 60 METERED

DOSES

100

ASMANEX TWISTHALER 7 METERED

DOSES

100

aspirin/dipyridamole 53

aspirin-caffeine-dihydrocodeine 4

ASTAGRAF XL 90

atenolol 58

atenolol/chlorthalidone 58

ATGAM 92

atorvastatin calcium 64

atovaquone 36

atovaquone/proguanil hcl 36

ATRIPLA 44

atropine sulfate 97

atropine-care 97

ATROVENT HFA 102

AUBAGIO 69

aubra 82

augmented betamethasone dipropionate 70

AVANDIA 47

AVASTIN 36

aviane 82

avidoxy 16

avita 70

AVODART 78

AVONEX 69

AVONEX PEN 69

AVYCAZ 11

AXERT 29

azacitidine 32

AZASAN 90

AZASITE 14

azathioprine 90

azelastine hcl 98

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Drug Name Page #

azelastine hcl 101

AZELEX 70

AZILECT 38

azithromycin 14

AZOPT 99

AZOR 60

aztreonam 13

azurette 82

baciim 8

bacitracin 8

bacitracin/polymyxin b 97

baclofen 42

BACTROBAN NASAL 8

balsalazide disodium 95

balziva 82

BANZEL 20

BARACLUDE 42

baycadron 79

BCG VACCINE 93

BD INSULIN SYRINGE

SAFETYGLIDE/1ML/29G X 1/2"

96

BD INSULIN SYRINGE

ULTRAFINE/0.3ML/31G X 5/16"

96

BD INSULIN SYRINGE

ULTRAFINE/0.5ML/30G X 1/2"

96

BD INSULIN SYRINGE

ULTRAFINE/1ML/31G X 5/16"

96

BD PEN NEEDLE/ULTRAFINE/29G X

12.7MM

96

bekyree 82

BELEODAQ 32

benazepril hcl 55

benazepril hcl/hydrochlorothiazide 55

BENDEKA 30

BENICAR 54

BENICAR HCT 54

BENLYSTA 90

benztropine mesylate 37

BEPREVE 98

BESIVANCE 15

betamethasone dipropionate 70

betamethasone valerate 70

BETASERON 69

betaxolol hcl 58

betaxolol hcl 99

bethanechol chloride 78

BETIMOL 99

BETOPTIC-S 99

bexarotene 36

Drug Name Page #

BEXSERO 93

bicalutamide 30

BICILLIN C-R 14

BICILLIN L-A 14

BILTRICIDE 36

bimatoprost 97

bisoprolol fumarate 58

bisoprolol fumarate/hydrochlorothiazide 58

BIVIGAM 92

BLEO 15K 32

bleomycin sulfate 32

BLEPHAMIDE 16

BLEPHAMIDE S.O.P. 16

blisovi 24 fe 82

blisovi fe 1.5/30 82

blisovi fe 1/20 82

BOOSTRIX 93

BOSULIF 35

BOTOX 96

BREO ELLIPTA 100

briellyn 82

BRILINTA 53

brimonidine tartrate 99

BRINTELLIX 22

BRIVIACT 17

bromfenac 98

bromocriptine mesylate 37

BROVANA 102

budesonide 95

BUDESONIDE 100

bumetanide 63

BUPHENYL 74

buprenorphine hcl 7

buprenorphine hcl/naloxone hcl 7

buproban 7

bupropion hcl 22

bupropion hcl er 22

bupropion hcl sr 7

bupropion hcl sr 22

bupropion hcl xl 22

buspirone hcl 46

butalbital/acetaminophen/caffeine/codeine 68

butalbital/aspirin/caffeine/codeine 4

butorphanol tartrate 4

BUTRANS 7

BYDUREON 47

BYDUREON PEN 47

BYETTA 47

BYSTOLIC 58

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Drug Name Page #

cabergoline 89

CABOMETYX 35

calcipotriene 70

calcipotriene/betamethasone dipropionate 70

calcitonin-salmon 95

calcitrene 70

calcitriol 70

calcitriol 95

calcium acetate 78

camila 87

camrese 82

camrese lo 82

CANASA 95

CANCIDAS 27

candesartan cilexetil 54

candesartan cilexetil/hydrochlorothiazide 64

CAPASTAT SULFATE 30

CAPEX 70

CAPRELSA 31

captopril 55

captopril/hydrochlorothiazide 55

CARAFATE 77

CARBAGLU 74

carbamazepine 20

carbamazepine er 20

CARBATROL 20

carbidopa 38

carbidopa/levodopa 38

carbidopa/levodopa er 38

carbidopa/levodopa odt 38

carbidopa/levodopa/entacapone 38

carbinoxamine maleate 101

carboplatin 32

CARDIZEM LA 60

CARIMUNE NANOFILTERED 92

carisoprodol 104

carisoprodol/aspirin 104

carisoprodol/aspirin/codeine 4

carteolol hcl 99

cartia xt 60

carvedilol 58

CAYSTON 103

caziant 82

cefaclor 11

cefaclor er 11

cefadroxil 11

cefazolin 11

cefazolin sodium 11

cefazolin/d5w 11

Drug Name Page #

cefazolin/dextrose 11

cefazolin/sodium chloride 11

cefdinir 11

cefepime 11

cefepime/dextrose 11

cefixime 12

cefotaxime sodium 12

cefotetan 13

cefoxitin sodium 12

cefpodoxime proxetil 12

cefprozil 12

ceftazidime 12

ceftriaxone sodium 12

cefuroxime axetil 12

cefuroxime sodium 12

celecoxib 1

CELONTIN 18

centany 9

centany at 8

cephalexin 12

CERDELGA 74

CEREBYX 20

CEREZYME 74

CERVARIX 93

cetirizine hcl 101

cevimeline hcl 69

CHANTIX 8

CHANTIX CONTINUING MONTH PAK 7

CHANTIX STARTING MONTH PAK 7

chateal 82

CHENODAL 75

chloramphenicol sodium succinate 9

chlordiazepoxide/amitriptyline 25

chlorhexidine gluconate 69

chloroquine phosphate 36

chlorothiazide 64

chlorothiazide sodium 64

chlorpromazine hcl 38

chlorthalidone 64

chlorzoxazone 104

CHOLBAM 75

cholestyramine 65

cholestyramine light 65

chorionic gonadotropin 80

ciclodan 27

ciclodan cream kit 27

ciclodan solution kit 27

ciclopirox 27

ciclopirox nail lacquer 27

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Drug Name Page #

ciclopirox olamine 27

ciclopirox treatment 27

cidaleaze 6

cidofovir 42

cilostazol 53

CILOXAN 15

cimetidine 76

cimetidine hcl 76

CIMZIA 91

CINRYZE 90

CIPRO HC 15

CIPRODEX 15

ciprofloxacin 15

ciprofloxacin er 15

ciprofloxacin hcl 15

ciprofloxacin i.v.-in d5w 15

citalopram hydrobromide 23

claravis 70

clarithromycin 15

clarithromycin er 15

CLEOCIN 9

CLIMARA PRO 82

clindacin etz pledgets 71

clindacin-p 71

clindamax 71

clindamycin 9

clindamycin hcl 9

clindamycin palmitate hcl 9

clindamycin phosphate 9

clindamycin phosphate 71

clindamycin phosphate add-vantage 9

clindamycin phosphate in d5w 9

clindamycin phosphate pharmacy bulk

package

9

clindamycin/benzoyl peroxide 71

CLINIMIX 2.75%/DEXTROSE 5% 107

CLINIMIX 4.25%/DEXTROSE 10% 108

CLINIMIX 4.25%/DEXTROSE 20% 108

CLINIMIX 4.25%/DEXTROSE 25% 108

CLINIMIX 4.25%/DEXTROSE 5% 108

CLINIMIX 5%/DEXTROSE 15% 108

CLINIMIX 5%/DEXTROSE 20% 108

CLINIMIX 5%/DEXTROSE 25% 109

CLINIMIX E 2.75%/DEXTROSE 10% 109

CLINIMIX E 2.75%/DEXTROSE 5% 109

CLINIMIX E 4.25%/DEXTROSE 10% 109

CLINIMIX E 4.25%/DEXTROSE 25% 109

CLINIMIX E 4.25%/DEXTROSE 5% 109

CLINIMIX E 5%/DEXTROSE 15% 110

Drug Name Page #

CLINIMIX E 5%/DEXTROSE 20% 110

CLINIMIX E 5%/DEXTROSE 25% 110

CLINISOL SF 15% 110

clobetasol propionate 71

clobetasol propionate e 71

clobetasol propionate emollient 71

clodan 71

clodan kit 71

clomipramine hcl 25

clonazepam 19

clonazepam odt 18

clonidine hcl 54

clonidine hcl er 54

clopidogrel 53

clorazepate dipotassium 47

CLORPRES 54

clotrimazole 27

clotrimazole/betamethasone dipropionate 79

clozapine 42

clozapine odt 42

COARTEM 36

codeine sulfate 4

colchicine 28

colestipol hcl 65

colistimethate sodium 9

colocort 95

COLY-MYCIN S 99

COMBIGAN 97

COMBIPATCH 82

COMBIVENT RESPIMAT 102

COMETRIQ 32

COMPLERA 44

compro 38

COMVAX 94

CONDYLOX 71

constulose 76

COPAXONE 69

CORDRAN TAPE 71

cormax 71

cormax scalp application 71

cortisone acetate 79

CORTISPORIN 9

CORTISPORIN 79

CORTISPORIN-TC 100

COSENTYX 71

COSENTYX SENSOREADY PEN 71

COTELLIC 32

COUMADIN 51

CREON 74

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Drug Name Page #

CRESEMBA 27

CRESTOR 64

CRINONE 87

CRIXIVAN 45

cromolyn sodium 75

cromolyn sodium 98

cromolyn sodium 103

cryselle-28 82

CUBICIN 9

CUBICIN RF 9

CURITY GAUZE PADS 2"X2" 71

curity sterile saline 96

cyclafem 1/35 82

cyclafem 7/7/7 82

cyclobenzaprine hcl 104

cyclophosphamide 30

CYCLOSET 48

cyclosporine 91

cyclosporine modified 91

cyproheptadine hcl 101

CYRAMZA 36

CYSTARAN 97

cytarabine aqueous 31

DAKLINZA 43

DALIRESP 103

DALVANCE 9

danazol 81

dantrolene sodium 42

dapsone 30

DAPTACEL 94

daptomycin 9

DARAPRIM 36

darifenacin hydrobromide er 77

DARZALEX 36

dasetta 1/35 82

dasetta 7/7/7 82

DAUNOXOME 32

daysee 82

DAYTRANA 67

deblitane 87

decitabine 32

deltasone 79

delyla 83

demeclocycline hcl 16

DEMSER 62

DENAVIR 46

DEPEN TITRATABS 105

DEPO-ESTRADIOL 83

DEPO-PROVERA 87

Drug Name Page #

DEPO-SUBQ PROVERA 104 87

dermacinrx prizopak 6

DESCOVY 44

desipramine hcl 25

desloratadine 101

desloratadine odt 101

desmopressin acetate 80

desogestrel/ethinyl estradiol 83

DESONATE 71

desonide 71

desoximetasone 71

DESVENLAFAXINE ER 23

dexamethasone 79

dexamethasone intensol 79

dexamethasone sodium phosphate 79

dexamethasone sodium phosphate 98

DEXILANT 77

dexmethylphenidate hcl 68

dexmethylphenidate hcl er 67

DEXRAZOXANE 32

dextroamphetamine sulfate 67

dextroamphetamine sulfate er 67

dextrose 10%/nacl 0.45% 110

dextrose 10% 50

dextrose 10%/nacl 0.2% 110

dextrose 10%/nacl 0.225% 110

dextrose 2.5%/nacl 0.45% 110

dextrose 20% 110

dextrose 25% 110

dextrose 30% 110

dextrose 30% partial fill 110

dextrose 40% 110

dextrose 5% 50

dextrose 5%/lactated ringers 110

dextrose 5%/nacl 0.2% 110

dextrose 5%/nacl 0.225% 110

dextrose 5%/nacl 0.3% 110

dextrose 5%/nacl 0.33% 110

dextrose 5%/nacl 0.45% 110

dextrose 5%/nacl 0.9% 110

dextrose 5%/potassium chloride 0.15% 111

dextrose 50% 111

dextrose 70% 111

DIAZEPAM 19

diazepam 47

DIBENZYLINE 54

diclofenac potassium 1

diclofenac sodium 8

diclofenac sodium 71

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Drug Name Page #

diclofenac sodium 98

diclofenac sodium dr 1

diclofenac sodium er 1

diclofenac sodium/misoprostol 1

dicloxacillin sodium 14

dicyclomine hcl 75

didanosine 44

DIFICID 15

diflorasone diacetate 71

diflunisal 1

digitek 62

digox 62

digoxin 62

dihydroergotamine mesylate 29

DILANTIN 20

DILANTIN INFATABS 20

DILANTIN-125 20

DILATRATE SR 66

diltiazem cd 60

diltiazem hcl 60

diltiazem hcl cd 60

diltiazem hcl er 60

diltiazem hydrochloride/sodium chloride 60

dilt-xr 60

DIPENTUM 95

diphenhydramine hcl 101

diphenoxylate/atropine 75

DIPHTHERIA/TETANUS TOXOIDS

ADSORBED PEDIATRIC

94

dipyridamole 53

disopyramide phosphate 57

disulfiram 7

divalproex sodium 19

divalproex sodium dr 19

divalproex sodium er 19

DIVIGEL 83

docetaxel 32

docetaxel (non-alcohol formula) 32

dofetilide 57

donepezil hcl 21

DORIBAX 13

dorzolamide hcl 99

dorzolamide hcl/timolol maleate 99

doxazosin 78

doxazosin mesylate 78

doxepin hcl 46

doxepin hydrochloride 71

doxercalciferol 95

doxorubicin hcl 32

Drug Name Page #

doxorubicin hcl liposome 32

doxy 100 16

doxycycline 16

doxycycline hyclate 16

doxycycline hyclate dr 16

doxycycline monohydrate 16

DRONABINOL 26

DROPLET PEN NEEDLES 29GX10MM 96

drospirenone/ethinyl estradiol 83

DROXIA 31

DUAVEE 87

DULERA 100

duloxetine hcl 23

duramorph 4

DUREZOL 98

dutasteride 78

dutasteride/tamsulosin hydrochloride 78

DUTOPROL 58

DYMISTA 101

DYRENIUM 63

e.e.s. 400 15

E.E.S. GRANULES 15

econazole nitrate 27

EDARBI 54

EDARBYCLOR 54

EDECRIN 63

EDURANT 44

EFFIENT 53

ELESTRIN 83

ELIDEL 71

ELIGARD 89

elinest 83

eliphos 78

ELIQUIS 51

ELITEK 31

ELIXOPHYLLIN 103

ELLA 87

ELMIRON 78

EMADINE 98

EMCYT 31

EMEND 26

emoquette 83

EMPLICITI 36

EMSAM 23

EMTRIVA 44

ENABLEX 77

enalapril maleate 56

enalapril maleate/hydrochlorothiazide 55

ENBREL 91

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Drug Name Page #

ENBREL SURECLICK 91

endocet 4

endodan 4

ENGERIX-B 94

ENJUVIA 83

ENOXAPARIN SODIUM 51

enpresse-28 83

enskyce 83

entacapone 37

entecavir 42

ENTRESTO 54

ENTYVIO 75

enulose 76

ENVARSUS XR 91

EPCLUSA 43

epinastine hcl 98

epinephrine 102

EPIPEN 2-PAK 102

EPIPEN-JR 2-PAK 102

epitol 20

EPIVIR HBV 44

eplerenone 63

eprosartan mesylate 54

EPZICOM 45

EQUETRO 20

ERBITUX 36

ergoloid mesylates 21

ERIVEDGE 32

errin 87

ERWINAZE 32

ery 15

ERYPED 200 15

ERYPED 400 15

ERY-TAB 15

ERYTHROCIN LACTOBIONATE 15

ERYTHROCIN STEARATE 15

erythromycin 15

erythromycin base 15

erythromycin ethylsuccinate 15

erythromycin/benzoyl peroxide 71

ESBRIET 104

escitalopram oxalate 23

esomeprazole magnesium 77

esomeprazole sodium 77

estarylla 83

ESTRACE 83

estradiol 83

estradiol valerate 83

estradiol/norethindrone acetate 83

Drug Name Page #

ESTRING 83

estropipate 83

ethacrynic acid 63

ethambutol hcl 30

ethosuximide 18

etidronate disodium 95

etodolac 1

etodolac er 1

etoposide 34

EURAX 37

EVAMIST 83

EVOMELA 30

EVOTAZ 45

EXELDERM 27

EXELON 21

exemestane 34

EXJADE 105

EXONDYS 51 96

EXTAVIA 69

FABRAZYME 74

falmina 83

famciclovir 46

famotidine 76

FANAPT 40

FANAPT TITRATION PACK 40

FARESTON 31

FARYDAK 32

FASLODEX 31

felbamate 19

felodipine er 60

FEMRING 83

fenofibrate 64

fenofibrate micronized 64

fenofibric acid 64

fenofibric acid dr 64

fenoprofen calcium 1

fentanyl 2

fentanyl citrate oral transmucosal 4

fentanyl citrate/nacl 4

FENTORA 4

FERRIPROX 96

FERRIPROX 105

FETZIMA 23

FETZIMA TITRATION PACK 23

finasteride 78

FIRAZYR 90

FIRMAGON 89

FLAREX 98

flavoxate hcl 77

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Drug Name Page #

FLEBOGAMMA DIF 92

flecainide acetate 57

FLECTOR 1

FLOVENT DISKUS 100

FLOVENT HFA 100

fluconazole 27

fluconazole in dextrose 27

fluconazole in nacl 27

flucytosine 27

fludrocortisone acetate 79

flunisolide 100

fluocinolone acetonide 72

fluocinolone acetonide 79

fluocinolone acetonide body 71

fluocinolone acetonide ear drops 79

fluocinolone acetonide scalp 72

fluocinonide 72

fluocinonide-e 72

fluorometholone 98

fluorouracil 31

fluorouracil 72

fluoxetine 23

fluoxetine dr 23

fluoxetine hcl 23

fluphenazine decanoate 38

fluphenazine hcl 38

flurandrenolide 79

flurbiprofen 1

flurbiprofen sodium 98

flutamide 30

fluticasone propionate 72

fluticasone propionate 100

fluvastatin 65

fluvastatin sodium er 64

fluvoxamine maleate 24

fluvoxamine maleate er 24

FML 98

FML FORTE 98

FONDAPARINUX SODIUM 51

FORADIL AEROLIZER 102

FORFIVO XL 22

FORTEO 95

fortical 96

FOSAMAX PLUS D 96

fosinopril sodium 56

fosinopril sodium/hydrochlorothiazide 56

fosphenytoin sodium 20

FOSRENOL 78

FRAGMIN 51

Drug Name Page #

FREAMINE HBC 6.9% 111

FREAMINE III 111

FROVA 29

frovatriptan succinate 29

furosemide 63

FUZEON 45

fyavolv 84

FYCOMPA 17

gabapentin 19

GABITRIL 19

galantamine hydrobromide 21

GAMASTAN S/D 92

GAMMAGARD LIQUID 92

GAMMAKED 92

GAMMAPLEX 92

GAMUNEX-C 92

ganciclovir 42

garamycin 8

GARDASIL 94

GARDASIL 9 94

gatifloxacin 15

GATTEX 75

gavilyte-c 76

gavilyte-g 76

gavilyte-h 75

gavilyte-n/flavor pack 76

GELNIQUE 77

gemcitabine 31

GEMCITABINE HCL 31

gemfibrozil 64

generlac 76

gengraf 91

GENOTROPIN 80

GENOTROPIN MINIQUICK 80

gentak 8

gentamicin sulfate 8

gentamicin sulfate pediatric 8

gentamicin sulfate/0.9% sodium chloride 8

GENVOYA 44

GEODON 40

gianvi 84

gildagia 84

gildess 1.5/30 84

gildess 1/20 84

gildess 24 fe 84

gildess fe 1.5/30 84

gildess fe 1/20 84

GILENYA 69

GILOTRIF 32

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Drug Name Page #

glatopa 69

GLEEVEC 35

GLEOSTINE 30

glimepiride 48

glipizide 48

glipizide er 48

glipizide xl 48

glipizide/metformin hcl 48

GLUCAGEN HYPOKIT 50

GLUCAGON EMERGENCY KIT 50

glyburide 48

glyburide micronized 48

glyburide/metformin hcl 48

glycopyrrolate 75

glydo 6

GLYSET 48

GOLYTELY 76

granisetron hcl 26

griseofulvin microsize 27

griseofulvin ultramicrosize 27

guanfacine er 68

guanfacine hcl 54

guanidine hcl 29

H.P. ACTHAR 80

halobetasol propionate 72

HALOG 72

haloperidol 39

haloperidol decanoate 38

haloperidol lactate 38

HARVONI 43

HAVRIX 94

heather 87

hecoria 91

heparin sodium 52

heparin sodium/d5w 51

heparin sodium/nacl 51

heparin sodium/nacl 0.45% 51

heparin sodium/nacl 0.9% 51

heparin sodium/sodium ch loride 51

heparin sodium/sodium chloride 51

heparin sodium/sodium chloride 0.9% 51

heparin sodium/sodium chloride 0.9%

premix

51

heparin sodium/sodium chloride pf 51

HEPATAMINE 111

HEPATASOL 111

HERCEPTIN 36

HETLIOZ 68

HEXALEN 30

Drug Name Page #

HIBERIX 94

HUMALOG 50

HUMALOG KWIKPEN 50

HUMALOG MIX 50/50 50

HUMALOG MIX 50/50 KWIKPEN 50

HUMALOG MIX 75/25 50

HUMALOG MIX 75/25 KWIKPEN 50

HUMATROPE 80

HUMATROPE COMBO PACK 80

HUMIRA 91

HUMIRA PEDIATRIC CROHNS

DISEASE STARTER PACK

91

HUMIRA PEN 91

HUMIRA PEN-CROHNS

DISEASESTARTER

91

HUMIRA PEN-PSORIASIS STARTER 91

HUMULIN 70/30 50

HUMULIN 70/30 KWIKPEN 50

HUMULIN N 50

HUMULIN N KWIKPEN 50

HUMULIN R 50

HUMULIN R U-500 (CONCENTRATED) 50

HUMULIN R U-500 KWIKPEN 50

hydralazine hcl 66

hydrochlorothiazide 64

hydrocodone bitartrate/acetaminophen 4

hydrocodone/acetaminophen 4

hydrocodone/ibuprofen 4

hydrocortisone 72

hydrocortisone 79

hydrocortisone 95

hydrocortisone butyrate 72

hydrocortisone butyrate (lipid) 72

hydrocortisone butyrate (lipophilic) 72

hydrocortisone valerate 72

hydrocortisone/acetic acid 100

hydromorphone hcl 5

hydromorphone hcl er 2

hydromorphone hcl/nacl 5

hydromorphone hcl/sodium chloride 5

hydromorphone hydrochloride/ nacl 5

hydromorphone hydrochloride/nacl 5

hydromorphone hydrochloride/sodium

chloride

5

hydroxychloroquine sulfate 36

hydroxyprogesterone caproate 87

hydroxyurea 32

hydroxyzine hcl 101

hydroxyzine pamoate 101

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Drug Name Page #

HYPERRAB S/D 92

HYQVIA 92

ibandronate sodium 96

IBRANCE 33

ibudone 5

ibuprofen 1

ICLUSIG 33

ILARIS 93

ILEVRO 98

ilotycin 15

imatinib mesylate 35

IMBRUVICA 35

imipenem/cilastatin 13

imipramine hcl 25

imiquimod 72

IMOGAM RABIES-HT 93

IMOVAX RABIES (H.D.C.V.) 94

INCRELEX 80

indapamide 64

INDERAL XL 58

INDOCIN 1

indomethacin 1

indomethacin er 1

INFANRIX 94

INLYTA 35

INNOPRAN XL 58

INSUPEN 33GX4MM 97

INTELENCE 44

intralipid 97

INTRON A 43

INTRON A W/DILUENT 43

introvale 84

INVANZ 13

INVEGA 40

INVEGA SUSTENNA 40

INVEGA TRINZA 40

INVIRASE 45

INVOKAMET 48

INVOKAMET XR 48

INVOKANA 48

IONOSOL-B/DEXTROSE 5% 111

IOPIDINE 99

IPOL INACTIVATED IPV 94

ipratropium bromide 102

ipratropium bromide/albuterol sulfate 102

irbesartan 55

irbesartan/hydrochlorothiazide 55

IRENKA 24

IRESSA 35

Drug Name Page #

irinotecan 33

ISENTRESS 44

isolyte-m/dextrose 5% 111

ISOLYTE-P/DEXTROSE 5% 111

isoniazid 30

ISORDIL TITRADOSE 66

isosorbide dinitrate 66

isosorbide dinitrate er 66

isosorbide mononitrate 66

isosorbide mononitrate er 66

isotonic gentamicin 8

isradipine 61

ISTALOL 99

itraconazole 27

ivermectin 36

IXEMPRA KIT 33

IXIARO 94

JADENU 105

JAKAFI 33

JALYN 78

jantoven 52

JANUMET 48

JANUMET XR 48

JANUVIA 48

JARDIANCE 48

jencycla 87

JENTADUETO 49

JENTADUETO XR 49

jevantique lo 84

JEVTANA 33

jinteli 84

jolessa 84

jolivette 87

juleber 84

junel 1.5/30 84

junel 1/20 84

junel fe 1.5/30 84

junel fe 1/20 84

junel fe 24 84

JUXTAPID 65

KADCYLA 36

kaitlib fe 84

KALETRA 45

KALYDECO 103

KANUMA 74

kariva 84

kcl 0.075%/d5w/nacl 0.45% 111

kcl 0.15%/d5w/ nacl 0.3% 111

KCL 0.15%/D5W/LR 111

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Drug Name Page #

kcl 0.15%/d5w/nacl 0.2% 111

kcl 0.15%/d5w/nacl 0.225% 111

kcl 0.15%/d5w/nacl 0.9% 111

KCL 0.3%/D5W/LR IV LAC RING 111

kcl 0.3%/d5w/nacl 0.45% 111

kcl 0.3%/d5w/nacl 0.9% 111

kelnor 1/35 84

ketoconazole 27

ketodan 27

ketoprofen 1

ketoprofen er 1

ketorolac tromethamine 1

ketorolac tromethamine 98

KEVEYIS 97

KEYTRUDA 36

kimidess 84

KINERET 91

KINRIX 94

kionex 105

klofensaid ii 72

klor-con 10 112

klor-con 8 112

KLOR-CON M15 112

klor-con m20 112

klor-con sprinkle 112

KOMBIGLYZE XR 49

KORLYM 81

KRISTALOSE 76

k-sol 111

kurvelo 84

KUVAN 74

KYNAMRO 65

KYPROLIS 34

labetalol hcl 58

lactated ringers irrigation 97

lactated ringers viaflex 112

lactulose 76

lamivudine 45

lamivudine/zidovudine 45

lamotrigine 20

lamotrigine er 19

lamotrigine odt 19

LANOXIN 62

lansoprazole 77

lansoprazole/amoxicillin/clarithromycin 9

LANTUS 50

LANTUS SOLOSTAR 50

larin 1.5/30 84

larin 1/20 84

Drug Name Page #

larin 24 fe 84

larin fe 1.5/30 84

larin fe 1/20 84

larissia 84

LASTACAFT 98

latanoprost 97

LATUDA 40

layolis fe 84

LAZANDA 5

leena 84

leflunomide 93

LEMTRADA 69

LENVIMA 10 MG DAILY DOSE 35

LENVIMA 14 MG DAILY DOSE 35

LENVIMA 18 MG DAILY DOSE 35

LENVIMA 20 MG DAILY DOSE 35

LENVIMA 24 MG DAILY DOSE 35

LENVIMA 8 MG DAILY DOSE 35

LESCOL XL 65

lessina 84

LETAIRIS 103

letrozole 34

leucovorin calcium 33

LEUKERAN 30

LEUKINE 53

leuprolide acetate 89

levalbuterol 102

levalbuterol hcl 102

LEVATOL 58

LEVEMIR 50

LEVEMIR FLEXTOUCH 50

levetiracetam 17

levetiracetam er 17

levobunolol hcl 99

levocarnitine 97

levocetirizine dihydrochloride 101

levofloxacin 16

levofloxacin in d5w 15

LEVOLEUCOVORIN 33

LEVOLEUCOVORIN CALCIUM 33

levonest 84

levonorgestrel and ethinyl estradiol 84

levonorgestrel/ethinyl estradiol 84

levora 0.15/30-28 84

levothyroxine sodium 87

levoxyl 88

LEXIVA 45

LIALDA 95

lidocaine 7

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Drug Name Page #

lidocaine hcl 6

lidocaine hcl 57

lidocaine hcl jelly 6

lidocaine hcl viscous 6

lidocaine pak 7

lidocaine viscous 7

lidocaine/prilocaine 7

lidocaine-prilocaine-cream base 7

lidopin 7

LINCOCIN 9

lincomycin hcl 9

lindane 37

linezolid 9

LINZESS 76

liothyronine sodium 88

lipodox 33

lipodox 50 33

liposyn iii 97

lisinopril 56

lisinopril/hydrochlorothiazide 56

lithium 47

lithium carbonate 47

lithium carbonate er 47

LIVALO 65

livixil pak 7

LOCOID LIPOCREAM 72

lofene 75

lokara 72

lomedia 24 fe 84

lomustine 30

LONSURF 32

loperamide hcl 75

lopreeza 84

loprox 27

lorazepam 47

lorcet 5

lorcet hd 5

lorcet plus 5

lortab 5

loryna 84

losartan potassium 55

losartan potassium/hydrochlorothiazide 55

LOTEMAX 98

lovastatin 65

low-ogestrel 85

loxapine succinate 39

lp lite pak 7

LUFYLLIN 103

LUMIGAN 97

Drug Name Page #

LUMIZYME 74

LUPANETA PACK 89

LUPRON DEPOT 90

LUPRON DEPOT-PED 89

lutera 85

LYNPARZA 33

LYRICA 18

LYSODREN 89

lyza 87

mafenide acetate 9

magnesium sulfate 112

magnesium sulfate/dextros 18

magnesium sulfate/dextrose 18

magnesium sulfate/sodium chloride 18

malathion 37

maprotiline hcl 22

marlissa 85

MARPLAN 23

MATULANE 30

matzim la 61

MAXIDEX 98

meclizine hcl 25

meclofenamate sodium 1

medroxyprogesterone acetate 87

mefenamic acid 1

mefloquine hcl 36

megestrol acetate 87

MEKINIST 33

meloxicam 1

memantine hcl 22

memantine hcl titration pak 22

memantine hydrochloride 22

MENACTRA 94

MENEST 33

MENHIBRIX 94

MENOMUNE-A/C/Y/W-135 94

MENOSTAR 85

MENTAX 27

MENVEO 94

mercaptopurine 32

meropenem 13

meropenem/sodium chloride 13

mesalamine 95

mesalamine dr 95

mesna 33

MESNEX 33

MESTINON 29

MESTINON TIMESPAN 29

metadate er 68

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Drug Name Page #

METAPROTERENOL SULFATE 102

metformin hcl 49

metformin hcl er 49

methadone hcl 2

methadone hcl intensol 2

methadose 2

methadose sugar-free 2

methamphetamine hcl 67

methazolamide 63

methenamine hippurate 9

methenamine mandelate 9

methergine 97

methimazole 90

METHITEST 82

methocarbamol 104

methotrexate 91

methotrexate sodium 91

methoxsalen 72

methscopolamine bromide 75

methyclothiazide 64

methyldopa 54

methyldopa/hydrochlorothiazide 54

methylergonovine maleate 97

methylphenidate hcl 68

methylphenidate hcl cd 68

methylphenidate hcl er 68

methylphenidate hydrochloride 68

methylprednisolone 79

methylprednisolone acetate 79

methylprednisolone dose pack 79

methylprednisolone pf 79

methylprednisolone sodiumsuccinate 79

methyltestosterone 82

metipranolol 99

metoclopramide hcl 75

metolazone 64

metoprolol succinate er 58

metoprolol tartrate 58

metoprolol/hydrochlorothiazide 59

metro iv 9

metronidazole 9

metronidazole in nacl 0.79% 9

metronidazole vaginal 9

mexiletine hcl 57

MIACALCIN 96

miconazole 3 28

microgestin 1.5/30 85

microgestin 1/20 85

microgestin fe 85

Drug Name Page #

microgestin fe 1.5/30 85

midodrine hcl 54

MIGERGOT 29

miglitol 49

MILLIPRED 79

mimvey 85

mimvey lo 85

minitran 66

MINIVELLE 85

minocycline hcl 17

minoxidil 66

mirtazapine 22

mirtazapine odt 22

misoprostol 77

mitomycin 33

mitoxantrone hcl 33

M-M-R II 94

modafinil 105

MODERIBA 43

moderiba 1200 dose pack 43

MODERIBA 800 DOSE PACK 43

moexipril hcl 56

moexipril/hydrochlorothiazide 56

molindone hydrochloride 42

mometasone furoate 72

mometasone furoate 101

mondoxyne nl 17

mono-linyah 85

mononessa 85

montelukast sodium 101

MONUROL 10

morgidox 1x100mg 17

morgidox 1x50mg 17

morgidox 1x50mg kit 17

morgidox 2x100mg 17

morphine sulfate 3

morphine sulfate 5

morphine sulfate add-vantage 5

morphine sulfate er 2

morphine sulfate/sodium chloride 5

MOVIPREP 77

MOXEZA 16

moxifloxacin hcl 16

MOZOBIL 53

MULTAQ 57

mupirocin 10

MUSTARGEN 30

MYALEPT 97

MYCAMINE 28

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Drug Name Page #

mycophenolate mofetil 91

mycophenolic acid dr 91

myorisan 72

MYOZYME 74

MYRBETRIQ 77

myzilra 85

nabumetone 2

nadolol 59

nadolol/bendroflumethiazide 59

nafcillin sodium 14

naftifine hcl 28

naftifine hydrochloride 28

NAFTIN 28

NAGLAZYME 74

nalbuphine hcl 5

nalfon 2

naloxone hcl 7

naltrexone hcl 7

NAMENDA 22

NAMENDA TITRATION PAK 22

NAMENDA XR 22

NAMENDA XR TITRATION PACK 22

NAMZARIC 21

naproxen 2

naproxen dr 2

naproxen sodium 2

naproxen sodium cr 2

naproxen sodium er 2

naratriptan hcl 29

NASONEX 101

NATACYN 28

nateglinide 49

NATPARA 97

NEBUPENT 37

necon 0.5/35-28 85

necon 1/35 85

necon 10/11-28 85

necon 7/7/7 85

nefazodone hcl 22

neomycin sulfate 8

neomycin/bacitracin/polymyxin 98

neomycin/polymyxin b sulfates 8

neomycin/polymyxin/bacitracin/hydrocortis

one

10

neomycin/polymyxin/dexamethasone 98

neomycin/polymyxin/gramicidin 10

neomycin/polymyxin/hc 100

neomycin/polymyxin/hydrocortisone 10

neomycin/polymyxin/hydrocortisone 100

Drug Name Page #

neo-polycin 97

neo-polycin hc 10

NEPHRAMINE 112

neuac 72

neuac kit 72

NEULASTA 53

NEULASTA ONPRO KIT 53

NEUMEGA 53

NEUPOGEN 53

NEUPRO 37

NEVANAC 99

nevirapine 44

nevirapine er 44

NEXAVAR 35

niacin er 65

niacor 65

nicardipine hcl 61

NICOTROL NS 8

nifedical xl 61

nifedipine 61

nifedipine er 61

nikki 85

NILANDRON 31

nilutamide 31

nimodipine 61

NINLARO 33

nisoldipine 61

nisoldipine er 61

NITRO-BID 66

NITRO-DUR 66

nitrofurantoin 10

nitrofurantoin macrocrystals 10

nitrofurantoin monohydrate 10

nitrofurantoin monohydrate/macrocrystals 10

nitroglycerin 66

nitroglycerin lingual 66

nitroglycerin transdermal 66

NITROMIST 66

NITROSTAT 66

nizatidine 76

nora-be 87

NORDITROPIN FLEXPRO 81

norepinephrine bitartrate/dextrose 63

norepinephrine bitartrate/sodium chloride 63

norepinephrine/sodium chloride 63

norethindrone 87

norethindrone & ethinyl estradiol ferrous

fumarate

85

norethindrone acetate 87

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Drug Name Page #

norethindrone acetate/ethinyl estradiol 85

norethindrone acetate/ethinyl

estradiol/ferrous fumarate

85

norgestimate/ethinyl estradiol 85

norlyroc 87

normosol-m in d5w 112

normosol-r in d5w 112

NORPACE CR 57

NORTHERA 62

nortrel 0.5/35 (28) 85

nortrel 1/35 85

nortrel 7/7/7 85

nortriptyline hcl 25

NORVIR 45

novarel 81

NOVOLIN 70/30 50

NOVOLIN 70/30 RELION 50

NOVOLIN N 50

NOVOLIN N RELION 50

NOVOLIN R 50

NOVOLIN R RELION 50

NOVOLOG 50

NOVOLOG FLEXPEN 50

NOVOLOG MIX 70/30 50

NOVOLOG MIX 70/30 PREFILLED

FLEXPEN

50

NOVOLOG PENFILL 50

NOXAFIL 28

NUCYNTA 6

NUCYNTA ER 3

NUEDEXTA 68

NULOJIX 91

NUPLAZID 40

nutrilipid 97

NUTROPIN AQ NUSPIN 10 81

NUTROPIN AQ NUSPIN 20 81

NUTROPIN AQ NUSPIN 5 81

NUTROPIN AQ PEN 81

NUVIGIL 105

nyamyc 28

nystatin 28

nystatin/triamcinolone 28

nystop 28

OCALIVA 75

ocella 85

OCTAGAM 93

OCTREOTIDE ACETATE 90

ODEFSEY 44

ODOMZO 33

Drug Name Page #

OFEV 104

ofloxacin 16

ogestrel 85

olanzapine 40

olanzapine odt 40

olanzapine/fluoxetine 24

olopatadine hcl 98

olopatadine hcl 101

OLYSIO 43

omega-3-acid ethyl esters 65

omeprazole 77

OMNITROPE 81

ONCASPAR 33

ondansetron hcl 26

ondansetron hydrochloride/sodium chloride 26

ondansetron odt 26

ONFI 19

ONGLYZA 49

ONIVYDE 33

ONMEL 28

OPDIVO 36

OPSUMIT 103

oralone 69

ORAP 39

ORBACTIV 10

ORENCIA 91

ORENCIA CLICKJECT 91

ORENITRAM 103

ORFADIN 97

ORKAMBI 103

orphenadrine citrate 104

orphenadrine citrate er 104

orsythia 85

ortho-est 85

OSMOPREP 75

OTEZLA 93

oxaliplatin 33

oxandrolone 81

oxaprozin 2

oxazepam 47

oxcarbazepine 21

oxiconazole nitrate 28

OXISTAT 28

oxybutynin chloride 78

oxybutynin chloride er 77

oxycodone hcl 6

oxycodone hcl er 3

oxycodone/acetaminophen 6

oxycodone/aspirin 6

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Drug Name Page #

oxycodone/ibuprofen 2

oxymorphone hydrochloride 6

oxymorphone hydrochloride er 3

oxytocin/lactated ringers 97

OXYTROL 78

pacerone 57

paclitaxel 34

paliperidone er 40

pamidronate disodium 96

PANCREAZE 74

PANCRELIPASE 74

PANDEL 72

PANRETIN 36

pantoprazole sodium 77

parcaine 98

paricalcitol 96

paroex 69

paromomycin sulfate 8

paroxetine hcl 24

paroxetine hcl er 24

paser 30

PATADAY 98

PATANOL 98

PAXIL 24

PEDVAX HIB 94

peg 3350/electrolytes 77

peg-3350/electrolytes 77

peg-3350/nacl/na bicarbonate/kcl 77

PEGANONE 21

PEGASYS 43

PEGASYS PROCLICK 43

PEGINTRON 43

PEG-INTRON REDIPEN 43

PEG-INTRON REDIPEN PAK 4 43

peg-prep 75

pegylax 77

penicillin g potassium 14

PENICILLIN G POTASSIUM IN

ISO-OSMOTIC DEXTROSE

14

penicillin g sodium 14

penicillin v potassium 14

PENTAM 300 37

PENTASA 95

pentazocine/naloxone hcl 6

pentoxifylline er 62

PERFOROMIST 102

perindopril erbumine 56

periogard 69

PERJETA 36

Drug Name Page #

permethrin 37

perphenazine 39

perphenazine/amitriptyline 25

PERTZYE 74

PEXEVA 24

pfizerpen-g 14

pharbedryl 101

phenadoz 25

phenelzine sulfate 23

phenergan 26

phenobarbital 18

phenoxybenzamine hydrochloride 54

phenylephrine hydrochloride/dextrose 54

phenylephrine/sodium chloride 54

PHENYTEK 21

phenytoin 21

phenytoin sodium extended 21

philith 85

PHOSLYRA 78

PHOSPHOLINE IODIDE 99

pilocarpine hcl 69

pilocarpine hcl 99

pilocarpine hydrochloride 69

pimozide 39

pimtrea 86

pindolol 59

pioglitazone hcl 49

pioglitazone hcl/metformin hcl 49

pioglitazone hcl-glimepiride 49

piperacillin sodium/ tazobactam sodium 14

piperacillin sodium/tazobactam sodium 14

piperacillin/tazobactam 14

pirmella 1/35 86

pirmella 7/7/7 86

piroxicam 2

PLASMA-LYTE-148 112

PLASMA-LYTE-56/D5W 112

PLEGRIDY 69

PLEGRIDY STARTER PACK 69

PLENAMINE 112

podofilox 73

polycin 98

polycin b 98

poly-dex 99

polyethylene glycol 3350 77

polymyxin b sulfate 10

polymyxin b sulfate/trimethoprim sulfate 98

POMALYST 34

portia-28 86

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Drug Name Page #

PORTRAZZA 34

potassium chloride 113

potassium chloride 0.15% /nacl 0.45%

viaflex

112

potassium chloride 0.15% d5w/nacl 0.33% 112

potassium chloride 0.15% d5w/nacl 0.45% 112

potassium chloride 0.15% d5w/nacl 0.45%

viaflex

112

potassium chloride 0.15% nacl 0.9% 112

potassium chloride 0.15%/nacl 0.9% 112

potassium chloride 0.22% d5w/nacl 0.45% 112

potassium chloride 0.3%/ nacl 0.9% 112

potassium chloride 0.3%/d5w 112

potassium chloride cr 112

potassium chloride er 112

potassium chloride sr 113

potassium chloride/lidocaine hydrochloride 113

potassium citrate er 113

POTIGA 18

PRADAXA 52

PRALUENT 62

pramipexole dihydrochloride 37

PRANDIMET 49

pravastatin sodium 65

prazosin hcl 54

PRED MILD 99

PRED-G 99

PRED-G S.O.P. 99

prednicarbate 73

prednisolone 80

prednisolone acetate 99

prednisolone sodium phosphate 79

prednisolone sodium phosphate 99

prednisone 80

prednisone intensol 80

PREFEST 86

pregnyl w/diluent benzyl alcohol/nacl 81

PREMARIN 86

PREMASOL 113

premium lidocaine 7

PREMPHASE 86

PREMPRO 86

PREPOPIK 77

prevalite 65

previfem 86

PREZCOBIX 46

PREZISTA 46

PRIFTIN 30

PRIMAQUINE PHOSPHATE 37

Drug Name Page #

primidone 19

PRISTIQ 24

PRIVIGEN 93

PROAIR HFA 102

PROAIR RESPICLICK 102

probenecid 28

probenecid/colchicine 28

PROCALAMINE 113

prochlorperazine 39

prochlorperazine edisylate 39

prochlorperazine maleate 39

PROCRIT 53

procto-med hc 80

procto-pak 80

proctosol hc 80

proctozone-hc 80

PROCYSBI 98

progesterone 87

PROGLYCEM 50

PROLASTIN-C 104

PROLENSA 99

PROLIA 96

PROMACTA 53

promethazine hcl 26

promethazine vc 104

promethazine vc plain 104

promethazine/phenylephrine 104

promethegan 26

propafenone hcl 57

propafenone hcl er 57

proparacaine hcl 98

propranolol hcl 59

propranolol hcl er 59

propranolol/hydrochlorothiazide 59

propylthiouracil 90

PROQUAD 94

PROSOL 113

protriptyline hcl 25

PROVENTIL HFA 102

prudoxin 73

PULMICORT 101

PULMICORT FLEXHALER 101

PULMOZYME 103

PURIXAN 32

PYLERA 75

pyrazinamide 30

pyridostigmine bromide 29

pyridostigmine bromide er 29

QUADRACEL 94

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Drug Name Page #

quasense 86

quetiapine fumarate 41

quinapril hcl 56

quinapril/hydrochlorothiazide 56

quinidine gluconate cr 57

quinidine gluconate er 57

quinidine sulfate 57

quinidine sulfate er 57

quinine sulfate 37

QVAR 101

RABAVERT 94

rabeprazole sodium 77

raloxifene hydrochloride 87

ramipril 56

RANEXA 62

ranitidine hcl 76

RAPAFLO 78

RAPAMUNE 92

RAVICTI 74

REBIF 69

REBIF REBIDOSE 69

REBIF REBIDOSE TITRATION PACK 69

REBIF TITRATION PACK 69

reclipsen 86

RECOMBIVAX HB 94

RECTIV 75

relador pak 7

relador pak plus 7

RELENZA DISKHALER 46

RELION R 50

RELISTOR 75

RELPAX 29

REMICADE 92

repaglinide 49

repaglinide/metformin hydrochloride 49

REPATHA 62

REPATHA PUSHTRONEX SYSTEM 62

REPATHA SURECLICK 62

reprexain 6

RESCRIPTOR 44

reserpine 54

RESTASIS 98

RETROVIR IV INFUSION 45

REVATIO 104

REVLIMID 31

REXULTI 41

REYATAZ 46

ribasphere 43

RIBASPHERE RIBAPAK 43

Drug Name Page #

RIBATAB 43

ribavirin 43

RIDAURA 93

rifabutin 30

rifampin 30

RIFATER 30

riluzole 69

rimantadine hcl 46

risedronate sodium 96

risedronate sodium dr 96

RISPERDAL CONSTA 41

risperidone 41

risperidone m-tab 41

risperidone odt 41

RITUXAN 36

rivastigmine tartrate 21

rivastigmine transdermal system 22

rizatriptan benzoate 29

rizatriptan benzoate odt 29

romycin 15

ropinirole er 37

ropinirole hcl 37

rosadan 10

rosadan kit 10

rosuvastatin calcium 65

ROTARIX 94

ROTATEQ 94

roweepra 18

roxicet 6

ROZEREM 105

SABRIL 19

SAIZEN 81

SAIZEN CLICK.EASY 81

SAMSCA 105

SANCUSO 26

SANDOSTATIN LAR DEPOT 90

SANTYL 73

SAPHRIS 41

SAVAYSA 52

SAVELLA 69

SAVELLA TITRATION PACK 69

selegiline hcl 38

selenium sulfide 73

SELZENTRY 45

SENSIPAR 89

SEREVENT DISKUS 102

SEROQUEL XR 41

SEROSTIM 81

sertraline hcl 24

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Drug Name Page #

setlakin 86

sharobel 87

SIGNIFOR 90

SIGNIFOR LAR 81

SILDENAFIL 104

SILENOR 105

silver sulfadiazine 10

SIMBRINZA 99

SIMCOR 65

SIMPONI 92

SIMPONI ARIA 92

simvastatin 65

sirolimus 92

SIRTURO 30

SIVEXTRO 10

SKLICE 37

sodium chloride 113

sodium chloride 0.45% 113

sodium chloride 0.9% 97

sodium phenylbutyrate 74

sodium polystyrene sulfonate 105

sodium sulfacetamide 16

SOLTAMOX 31

SOLU-CORTEF 80

SOMATULINE DEPOT 90

SOMAVERT 90

sorine 57

sotalol hcl 57

sotalol hcl (af) 57

SOVALDI 44

SPIRIVA HANDIHALER 102

SPIRIVA RESPIMAT 102

spironolactone 63

spironolactone/hydrochlorothiazide 63

SPORANOX 28

sprintec 28 86

SPRITAM 18

SPRYCEL 35

sps 105

sronyx 86

ssd 10

stavudine 45

STAVZOR 19

STELARA 73

STELARA 93

sterile water irrigation 97

STIVARGA 35

STRATTERA 68

STRENSIQ 74

Drug Name Page #

streptomycin sulfate 8

STRIBILD 44

SUBOXONE 7

sucralfate 77

sulfacetamide sodium 16

sulfacetamide sodium 73

sulfacetamide sodium/prednisolone sodium

phosphate

16

sulfadiazine 16

sulfamethoxazole/trimethoprim 16

sulfamethoxazole/trimethoprim ds 16

SULFAMYLON 10

sulfasalazine 95

sulfatrim pediatric 16

sulindac 2

sumatriptan 29

sumatriptan succinate 29

sumatriptan succinate refill 29

SUPRAX 12

SUPREP BOWEL PREP 77

SURMONTIL 25

SUSTIVA 44

SUSTOL 26

SUTENT 35

syeda 86

SYLATRON 34

SYLVANT 36

SYMBICORT 101

SYMLINPEN 120 49

SYMLINPEN 60 49

SYNAGIS 93

SYNALAR 73

SYNALAR OINTMENT KIT 73

SYNALGOS-DC 6

SYNAREL 90

SYNERCID 10

SYNJARDY 49

SYNRIBO 34

SYNTHROID 88

SYPRINE 105

TABLOID 32

TACLONEX 73

tacrolimus 73

tacrolimus 92

TAFINLAR 34

TAGRISSO 34

TALTZ 73

TAMIFLU 46

tamoxifen citrate 31

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Drug Name Page #

tamsulosin hcl 78

TARCEVA 35

TARGRETIN 36

tarina fe 1/20 86

TASIGNA 35

tazicef 12

TAZORAC 73

taztia xt 61

TECENTRIQ 36

TECFIDERA 93

TECFIDERA STARTER PACK 93

TECHNIVIE 44

TEFLARO 13

TEGRETOL 21

TEGRETOL-XR 21

TEKAMLO 62

TEKTURNA 62

TEKTURNA HCT 62

telmisartan 55

telmisartan/amlodipine 55

telmisartan/hydrochlorothiazide 55

temazepam 47

TENIVAC 94

terazosin hcl 78

terbinafine hcl 28

terbutaline sulfate 102

terconazole 28

testosterone 82

testosterone cypionate 82

testosterone enanthate 82

testosterone pump 82

TESTRED 82

TETANUS/DIPHTHERIA

TOXOIDS-ADSORBED

94

tetrabenazine 69

tetracycline hcl 17

tetracycline hydrochloride 17

TEV-TROPIN 81

THALOMID 31

theochron 103

theophylline 103

theophylline cr 103

theophylline er 103

thioridazine hcl 39

thiotepa 30

thiothixene 39

THYROLAR-1 88

THYROLAR-1/2 88

THYROLAR-1/4 88

Drug Name Page #

THYROLAR-2 88

THYROLAR-3 88

tiagabine hydrochloride 19

ticlopidine hcl 53

TIKOSYN 57

tilia fe 86

timolol maleate 29

timolol maleate 99

timolol maleate ophthalmic gel forming 99

tinidazole 37

TIROSINT 88

TIVICAY 44

tizanidine hcl 42

TOBI PODHALER 103

TOBRADEX 99

TOBRADEX ST 99

tobramycin 103

tobramycin inhalation solution pak 103

tobramycin sulfate 8

tobramycin/dexamethasone 99

TOBREX 8

TOLAK 73

tolazamide 49

tolbutamide 49

tolcapone 37

tolmetin sodium 8

tolterodine tartrate 78

tolterodine tartrate er 78

topiragen 20

topiramate 20

toposar 34

topotecan hcl 34

torsemide 63

TOVIAZ 78

TRACLEER 104

TRADJENTA 49

tramadol hcl 6

tramadol hcl er 3

tramadol hydrochloride/acetaminophen 6

trandolapril 56

trandolapril/verapamil hcl 56

trandolapril/verapamil hcl er 56

tranexamic acid 53

TRANSDERM-SCOP 26

tranylcypromine sulfate 23

TRAVASOL 114

TRAVATAN Z 97

travoprost 97

trazodone hcl 23

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Drug Name Page #

TREANDA 30

TRECATOR 30

TRELSTAR MIXJECT 90

tretinoin 36

tretinoin 73

tretinoin microsphere 73

tretinoin microsphere pump 73

triamcinolone acetonide 69

triamcinolone acetonide 73

triamcinolone acetonide 101

triamcinolone in orabase 69

triamterene/hydrochlorothiazide 63

trianex 73

TRIBENZOR 61

triderm 73

tri-estarylla 86

trifluoperazine hcl 39

trifluridine 46

trihexyphenidyl hcl 37

tri-legest fe 86

tri-linyah 86

tri-lo-estarylla 86

tri-lo-marzia 86

tri-lo-sprintec 86

trilyte 77

trimethobenzamide hcl 26

trimethoprim 10

trimethoprim sulfate/polymyxin b sulfate 98

trimipramine maleate 25

trinessa 86

trinessa lo 86

TRINTELLIX 23

tri-previfem 86

tri-sprintec 86

TRIUMEQ 45

trivora-28 86

TROKENDI XR 20

TROPHAMINE 114

trospium chloride 78

trospium chloride er 78

TRUMENBA 94

TRUVADA 45

TUDORZA PRESSAIR 102

TWINRIX 94

TYBOST 45

TYGACIL 10

TYKERB 35

TYPHIM VI 94

TYSABRI 69

Drug Name Page #

TYVASO 104

TYZEKA 43

TYZINE 104

TYZINE PEDIATRIC NASAL DROPS 104

UCERIS 95

ULORIC 28

ULTRESA 74

unithroid 89

unithroid direct 89

UNITUXIN 36

UPTRAVI 104

ursodiol 76

VAGIFEM 86

valacyclovir hcl 46

VALCHLOR 30

valganciclovir 42

valproate sodium 19

valproic acid 19

valproic acid 29

valsartan 55

valsartan/hydrochlorothiazide 55

vancomycin 11

vancomycin hcl 10

vancomycin hcl in dextrose 10

vancomycin hydrochloride 11

vancomycin hydrochloride/dextrose 10

vancomycin hydrochloride/nacl 10

vancomycin hydrochloride/sodium chloride 10

vandazole 11

VAQTA 95

VARIVAX 95

VARIZIG 95

VASCEPA 65

vasopressin/sodium chloride 81

VECTIBIX 36

VELCADE 34

velivet 86

VENCLEXTA 34

VENCLEXTA STARTING PACK 34

venlafaxine hcl 24

venlafaxine hcl er 24

VENTAVIS 104

VENTOLIN HFA 103

VERAMYST 101

verapamil hcl 62

verapamil hcl er 61

verapamil hcl sr 62

verdrocet 6

VEREGEN 73

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Drug Name Page #

VERIPRED 20 80

VERSACLOZ 42

VESICARE 78

vestura 86

VEXOL 99

VIBERZI 76

vicodin 6

vicodin es 6

vicodin hp 6

VICTOZA 49

VIDEX PEDIATRIC 45

VIEKIRA PAK 44

VIEKIRA XR 44

vienva 86

VIIBRYD 24

VIIBRYD STARTER PACK 24

VIMIZIM 74

VIMPAT 21

vincasar pfs 34

vincristine sulfate 34

VIOKACE 74

viorele 86

VIRACEPT 46

VIRAMUNE XR 44

VIRAZOLE 104

VIREAD 45

VISTOGARD 97

VITEKTA 44

VOLTAREN 73

voriconazole 28

VOTRIENT 35

VPRIV 74

VRAYLAR 41

vyfemla 86

VYTORIN 66

warfarin sodium 52

wera 86

wymzya fe 86

XALKORI 35

XARELTO 52

XARELTO STARTER PACK 52

XELJANZ 93

XELJANZ XR 93

XENAZINE 69

XEOMIN 97

XGEVA 96

XIFAXAN 11

XIGDUO XR 49

XOLAIR 104

Drug Name Page #

XOPENEX HFA 103

XTANDI 31

xulane 87

XURIDEN 97

xylon 6

XYREM 105

YERVOY 36

YF-VAX 95

YONDELIS 30

zafirlukast 101

zaleplon 105

ZALTRAP 34

zamicet 6

zarah 87

ZARXIO 53

ZAVESCA 74

zazole 28

ZELAPAR 38

ZELBORAF 35

ZEMAIRA 104

zenatane 73

zenchent 87

zenchent fe 87

ZENPEP 75

zenzedi 67

ZEPATIER 46

ZETIA 66

ZIAGEN 45

zidovudine 45

ZINBRYTA 69

ziprasidone hcl 42

ZIRGAN 42

ZOLEDRONIC ACID 96

ZOLINZA 34

zolmitriptan 29

zolmitriptan odt 29

zolpidem tartrate 105

zolpidem tartrate er 105

ZOMACTON 81

ZOMIG 29

ZOMIG NASAL SPRAY 29

ZONALON 74

zonisamide 18

ZORBTIVE 81

ZORTRESS 92

ZOSTAVAX 95

zovia 1/35e 87

zovia 1/50e 87

ZOVIRAX 46

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Drug Name Page #

ZYCLARA 74

ZYCLARA PUMP 74

ZYDELIG 34

ZYFLO CR 101

ZYKADIA 34

ZYLET 8

ZYPREXA RELPREVV 42

ZYTIGA 31

ZYVOX 11

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This formulary was updated on November 1, 2016. For more recent information or other questions, please

contact us, Trillium Community Health Plan, at 1(844) 867-1156 or, for TTY users, 711, October 1 to

February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you

can call us Monday – Friday from 8 a.m. to 8 p.m. Alternate technologies, such as voice mail, will be used

after hours, on the weekends, and holidays from February 15 through September 30. Voice messages are

reviewed and responded to within one business day, or visit http://www.trilliumadvantage.com.