Health Net Cal MediConnect Plan (Medicare-Medicaid Plan ... · 4. Ano ang mangyayari kapag nalaman naming hindi ligtas ang isang gamot? Kung sinabi ng Food and Drug Administration

Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)

2017 Listahan ng Mga Gamot na Sakop ng (Formulary)

Isinapanahon ang listahan ng gamot na ito noong 12/01/201 . Kung mayroon kayong katanungan, mangyaring tawagan ang Health Net Cal MediConnect sa 1-855-464-3571 para sa Los Angeles County o 1-855-464-3572 para sa San Diego County (TTY: 711). May taong naririto para makipag-usap sa iyo mula Lunes hanggang Biyernes, 8:00 a.m. hanggang 8:00 p.m. Sa ibang panahon - kabilang ang Sabado, Linggo at pederal na mga pista opisyal - maaari kang mag-iwan ng voicemail. Tatawagan ka namin sa susunod na araw ng negosyo. Libre ang tawag. Para sa karagdagang impormasyon, pumunta sa www.healthnet.com/calmediconnect.

Aprubadong ID sa Pagsusumite ng Formulary File ng HPMS: 17404 Numero ng Bersyon: 21H3237_2017_0020_TAG CMS Approved 07132016

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? Kung mayroon kayong mga katanungan, mangyaring tawagan ang Health Net Cal MediConnect sa 1-855-464-3571 para sa Los Angeles County o 1-855-464-3572 para sa San Diego County (TTY: 711), Lunes hanggang Biyernes, 8:00 a.m. hanggang 8:00 p.m. Libre ang tawag. Para sa karagdagang impormasyon, pumunta sa www.healthnet.com/calmediconnect.

Listahan ito ng mga gamot na makukuha ng mga miyembro sa Health Net Cal MediConnect.

Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) ay isang planong pangkalusugan na nakakontrata kapwa sa Medicare at Medi-Cal upang magbigay ng mga benepisyo ng kapwang mga programa sa mga naka-enroll.

Ang Listahan ng mga Sakop na Gamot at/o parmasya at mga network ng tagapagbigay serbisyo ay maaaring magbago sa buong taon. Magpapadala kami ng isang pabatid bago kami gumawa ng isang pagbabago na makakaapekto sa iyo.

Ang mga benepisyo at/o mga copayment ay maaaring magbago sa Enero 1 ng bawat taon.

Anumang oras ay matitingnan mo online ang nasasapanahong Listahan ng Mga Sakop na Gamot ng Health Net Cal MediConnect sa www.healthnet.com/calmediconnect o sa pamamagitan ng pagtawag sa 1-855-464-3571 para sa Los Angeles County o 1-855-464-3572 para sa San Diego County (TTY: 711), Lunes hanggang Biyernes, 8:00 a.m. hanggang 8:00 p.m.

Ang mga limitasyon, mga copay, at paghihigpit ay maaaring gamitin. Para sa karagdagang impormasyon, tawagan ang Health Net Cal MediConnect Member Services o basahin ang Handbook ng Miyembro ng Health Net Cal MediConnect.

Ang mga copay para sa mga iniresetang gamot ay maaaring mag-iba batay sa antas ng Dagdag na Tulong na inyong natatanggap. Mangyaring makipag-ugnayan sa plano para sa mga detalye.

You can get this information for free in other languages. Call 1-855-464-3571 for Los Angeles County or 1-855-464-3572 for San Diego County (TTY: 711), Monday through Friday, 8:00 a.m. to 8:00 p.m. The call is free.Usted puede obtener esta información de forma gratuita en otros idiomas. Llame al 1-855-464-3571 para el condado de Los Angeles o al 1-855-464-3572 para el condado de San Diego (TTY: 711), de lunes a viernes de 8.00 a.m. a 8.00 p.m. La llamada es gratuita.

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لوس لمقاطعة 1-855-464-3571 الرقم على اتصل أخرى. بلغات مجاًنا المعلومات هذه على الحصول تستطيع الجمعة، إلى اإلثنين يوم من (،711 النصي: )الهاتف ديغو، سان لمقاطعة 1-855-464-3572 الرقم أو أنجلوس،

مجانية. المكالمة مساًء. 8:00 إلى صباًحا 8:00 الساعة من

លោកអ្នកអាចទទួលបានព័ត៌មានលនេះជាភាសាដទទលទៀតលោយឥតគិតទលៃ។ សូមទូរស័ពទលៅលលខ 1 855 464 3571 សម្រមាប់ លោនធី Los Angeles ឬលលខ 1 855 464 3572 សម្រមាប់ លោនធី San Diego (TTY: 711) ពីទលៃច័នទ ដល់ទលៃសុម្រក លមា៉ោ ង 8:00 ម្រពឹក ដល់លមា៉ោ ង 8:00 យប។់ ការលៅទូរសព័ទគឥឺតគិតទលៃ។

برای 3571-464-855-1 شماره با .کنید دریافت دیگر های زبان به رایگان طور به را اطالعات این توانید می شما و ،روزها(TTY: 711 کاربران) بگیرید، تماس دیگو سن بخش ببرای 1-855-464-3572 یا آنجلس، لس بخش .است رایگان تماسها . شب 08:00 تا صبح 8:000 جمعه، تا دوشنبه از تماس ساعت

Maaari mong hingin ang impormasyon na ito nang libre sa ibang mga ayos, tulad ng nasa malaking lathalain, braille o audio. Call 1-855-464-3571 for Los Angeles County or 1-855-464-3572 for San Diego County (TTY: 711), Monday through Friday, 8:00 a.m. to 8:00 p.m. Libre ang tawag.

Kung nais mong padalhan ka ng Health Net Cal MediConnect ng mga materyales ng miyembro sa isang patuloy na batayan sa iba pang mga ayos, tulad ng Braille o malalaking letra, o sa isang wika maliban sa Ingles, mangyaring kontakin ang Mga Serbisyo sa Miyembro. Sabihan ang Mga Serbisyo sa Miyembro na nais mong gumawa ng isang kahilingan upang makakuha ng iyong mga materyales sa ibang ayos o wika.

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Mga Madalas Itanong(FAQ)Maghanap ng mga sagot dito sa mga tanong na mayroon ka tungkol sa Listahan ng mga Sakop na Gamot na ito. Mababasa mo ang lahat ng FAQ para matuto pa, o maghanap ng tanong at sagot.

1. Anong mga de-resetang gamot ang nasa Listahan ng Mga Sakop na Gamot? (Tinatawag namin ang Listahan ng Mga Sakop na Gamot na maikling pangalang “Listahan ng Gamot”.)

Ang mga gamot sa Listahan ng Gamot ay ang mga gamot na sakop ng Health Net Cal MediConnect. Mabibili ang mga gamot sa mga parmasya sa loob ng aming network. Ang parmasya ay nasa network namin kung mayroon kaming kasunduan sa kanila na magtrabaho nang kasama kami at maglaan ng mga serbisyo sa iyo. Tinutukoy namin ang mga parmasyang ito bilang “mga parmasya ng network.”

Sasakupin ng Health Net Cal MediConnect lahat ng medikal na kailangang gamot sa Listahan ng Gamot kung:

■ sinabi ng iyong doktor o nagreseta na kailangan mo ito para gumaling o manatiling malusog, at

■ pinunan mo ang reseta sa isang parmasya ng network ng Health Net Cal MediConnect.Sa ilang mga kaso, may kailangan kang gawin bago ka makakuha ng gamot (tingnan ang tanong #5 sa ibaba).

Matitingnan mo rin sa aming website ang nasasapanahong listahan na mga gamot na aming sinasakop sa www.healthnet.com/calmediconnect o tumawag sa Member Services sa 1-855-464-3571 para Los Angeles County o 1-855-464-3572 para sa San Diego County (TTY: 711), Lunes hanggang Biyernes, 8:00 a.m. hanggang 8:00 p.m.

2. Nagbabago ba ang Listahan ng Gamot?Oo. Maaaring magdagdag o mag-alis ng mga gamot ang Health Net Cal MediConnect sa Listahan ng Gamot sa taon. Sa pangkalahatan, magbabago lang ang Listahan ng Gamot kung:

■ mayroong mas murang gamot na dumating na kasing-bisa ng isang gamot na nasa Listahan ng Gamot ngayon, o

■ nalaman namin na hindi ligtas ang isang gamot. Maaari rin naming baguhin ang mga patakaran tungkol sa mga gamot. Halimbawa, maaari kaming:

■ Magpasyang iatas o hindi iatas ang paunang pahintulot para sa isang gamot. (Ang paunang pahintulot ay pahintulot mula sa Health Net Cal MediConnect bago ka makakuha ng gamot.)

■ Magdagdag o magbago ng dami ng gamot na makukuha mo (tinatawag na “mga limitasyon sa dami”).

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■ Magdagdag o magbago ng mga restriksiyon ng step therapy sa isang gamot. (Ang kahulugan ng step therapy ay kailangan mong subukan ang isang gamot bago namin sakupin ang ibang gamot.)

(Para sa dagdag na impormasyon sa mga patakaran sa gamot na ito, tingnan ang pahina iv.)

Sasabihin namin sa iyo kapag ang gamot na iniinom mo ay inalis mula sa Listahan ng Gamot. Sasabihin din namin sa iyo kapag binago namin ang mga patakaran namin sa pagsakop ng isang gamot. Ang mga tanong 3, 4 at 7 sa ibaba ay may mas maraming impormasyon tungkol sa kung ano ang mangyayari kapag nagbago ang Listahan ng Gamot.

Anumang oras ay maaari mong tingnan ang online na nasasapanahong Listahan ng Gamot ng Health Net Cal MediConnect sa www.healthnet.com/calmediconnect. Maaari ka ring tumawwag sa Member Services para tingnan ang kasalukuyang Listahan ng Gamot sa 1-855-464-3571 para sa Los Angeles County o 1-855-464-3572 para sa San Diego County (TTY: 711), Lunes hanggang Biyernes, 8:00 a.m. hanggang 8:00 p.m.

3. Ano ang mangyayari kapag may mas murang gamot na dumating na kasing-bisa ng gamot na nasa Listahan ng Gamot ngayon?

Kung umiinom ka ng gamot na inalis dahil may mas murang gamot na kasing bisa ang dumating, sasabihin namin sa iyo. Sasabihin namin sa iyo nang hindi bababa sa 60 araw bago namin ito alisin mula sa Listahan ng Gamot o kung humingi ka ng isang refill. Pagkatapos ay makakakuha ka ng 60-araw na supply ng gamot bago alisin ang gamot mula sa listahan ng gamot. Padadalhan ka namin ng isang sulat na nagsasabi sa iyo tungkol sa pagbabagong ito. Ilalagay din namin ang mga uri ng mga pagbabagong ito sa aming website sa www.healthnet.com/calmediconnect.

4. Ano ang mangyayari kapag nalaman naming hindi ligtas ang isang gamot?Kung sinabi ng Food and Drug Administration (FDA) na hindi ligtas ang gamot na iniinom mo, aalisin namin ito kaagad sa Listahan ng Gamot. Magpapadala din kami ng sulat sa iyo na iyan ang sinasabi. Kung makatanggap ka ng isa sa mga liham na ito, mangyaring tawagan ang doktor mo para pag-usapan ang mga ibang opsyon sa gamot.

5. Mayroon bang anumang mga restriksiyon o mga limitasyon sa sakop sa gamot? O may anubang inaatas na pagkilos na gagawin upang makuha ang ilang mga gamot?

Oo, ang ilang mga gamot ay may mga patakaran sa sakop o may mga limitasyon sa dami ng makukuha mo. Sa ilang mga kaso, ikaw o ang iyong doktor ay may dapat gawin bago mo makuha ang gamot. Halimbawa:

■ Paunang pag-apruba (o paunang awtorisasyon): Para sa ilang mga gamot, ikaw o ang iyong doktor o ibang nagreseta ay dapat kumuha ng pahintulot mula sa Health Net Cal MediConnect bago mo punan ang iyong reseta. Kapag hindi ka nakakuha ang pahintulot, maaaring hindi sakupin ng Health Net Cal MediConnect ang gamot.

■ Mga limitasyon sa dami: Minsan, nililimita ng Health Net Cal MediConnect ang dami ng gamot na makukuha mo.

■ Step therapy: Minsan, aatasan ka ng Health Net Cal MediConnect na gumawa ng step therapy. Nangangahulugan ito na kakailanganin mong subukan ang mga gamot sa partikular na pagkakasunod-sunod para sa iyong medikal na kalagayan. Maaaring kailanganin mong subukan ang isang gamot bago namin sasakupin ang ibang gamot. Kung sa palagay ng doktor mo ay hindi gumagana ang unang gamot para sa iyo, sasakupin namin ang pangalawa.

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Malalaman mo kung ang gamot mo ay may anumang mga karagdagang iniaatas o mga limitasyon sa pamamagitan ng pagtingin sa mga talahanayan sa mga pahina 1 - Indiks 1. Maaari ka ring bumisita sa aming website sa www.healthnet.com/calmediconnect. Nagpaskil kami ng mga online na dokumento na nagpapaliwanag sa aming paunang pahintulot at mga restriksiyon sa step therapy. Maaari mo rin kaming hilingan na padalhan ka ng kopya.

Maaari ka ring humingi ng “eksepsyon” mula sa mga limitasyong ito. Mangyaring tingnan ang Tanong 11 para sa higit pang impormasyon sa mga hindi pagsama.

Kung ikaw ay nasa isang nursing home o ibang pasilidad sa pangmatagalang pag-aalaga at kailangan ng gamot na wala sa Listahan ng Gamot, o kung hindi mo madaling makuha ang kailangan mong gamot, makakatulong kami. Sasakupin namin ang 31-araw na emerhensiyang supply ng kailangan ninyong gamot (maliban kung mayroon kang gamot para sa ilang araw), ikaw man ay bagong miyembro o hindi ng Health Net Cal MediConnect. Bibigyan ka nito ng oras para makipag-usap sa iyong doktor o ibang nagrereseta. Matutulungan ka niyang magdesisyon kung mayroong katulad na gamot sa Listahan ng Gamot na maaari mong inumin sa halip o kung hihiling ng hindi pagsasama. Mangyaring tingnan ang Tanong 11 para sa karagdagang impormasyon tungkol sa mga eksepsyon.

6. Paano mo malalaman kung ang ninanais mong gamot ay mayroong mga limitasyon o kung mayroong mga kailangang gawin na pagkilos para makakuha ang gamot?

Ang Listahan ng mga Sakop na Gamot sa pahina 1 ay may hanay na may markang “Mga kinakailangang pagkilos, paghihigpit o limitasyon sa paggamit.”

7. Ano ang mangyayari kung babaguhin namin ang aming mga tuntunin sa kung paano namin sinasakop ang ilan sa mga gamot? Halimbawa, kung magdadagdag kami ng paunang pahintulot (pag-apruba), mga limitasyon sa dami at/o mga paghihigpit ng step therapy sa isang gamot.

Sasabihin namin sa iyo kung magdadagdag kami ng paunang pag-apruba, mga limitasyon sa dami, at/o mga paghihigpit ng step therapy sa isang gamot. Sasabihin namin sa iyo nang hindi bababa sa 60 araw bago idagdag ang paghihigpit o sa susunod na humingi ka ng refill sa iyong parmasya. Pagkatapos, maaari kang makakuha ng 60-araw na supply ng gamot bago gawin ang pagbabago sa mga tuntunin ng pagsakop. Binibigyan ka nito na oras para makipag-usap sa iyong doktor o ibang nagrereseta tungkol sa kung ano ang susunod na dapat gawin.

8. Paano ka makakahanap ng gamot sa Listahan ng Gamot?May dalawang paraan para maghanap ng gamot:

■ Maaari kang maghanap nang nakaayos sa alpabeto (kung alam mo kung paano baybayin ang gamot), o

■ Maaari kang maghanap sa pamamagitan ng medikal na kondisyon.Para maghanap nang nakaayos sa alpabeto, pumunta sa seksyon ng Listahan na Nakaayos sa Alpabeto. Makikita mo ito sa Index na nagsisimula sa pahina Index 1.

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Para maghanap nang ayon sa kondisyong medikal, hanapin ang seksyon na may markang “Listahan ng mga gamot nang ayon sa kondisyong medikal” sa pahina 1. Ang mga gamot sa seksyon na ito ay ginrupo nang ayon sa mga kategoriya batay sa uri ng mga kondisyong medikal na pinaggamitan sa kanila upang gamutin. Halimbawa, kung mayroon kang karamdaman sa puso, kailangan mong maghanap sa kategorya na, CARDIOVASCULAR AGENTS - MISC. –Mga Gamot para Gamutin ang mga Kondisyon sa Puso at Sirkulasyon. Doon mo mahahanap ang mga gamot na gumagamot sa mga karamdaman sa puso.

9. Paano kung ang gamot na gusto mong inumin ay wala sa Listahan ng Gamot?Kung hindi mo makita ang iyong gamot sa Listahan ng Gamot, tawagan ang Member Services sa 1-855-464-3571 para sa Los Angeles County o 1-855-464-3572 para sa San Diego County, TTY: 711), Lunes hanggang Biyernes, 8:00 a.m. hanggang 8:00 p.m. at magtanong tungkol dito. Kung malalaman mo na hindi sasakupin ng Health Net Cal MediConnect ang gamot, maaari mong gawin ang isa sa mga bagay na ito:

■ Humingi ng mga listahan ng mga gamot sa Member Services katulad ng isa na gusto mong inumin. Pagkatapos ipakita ang lisahan sa iyong doktor o ibang nagrereseta. Maaari siyang magreseta ng gamot na nasa Listahan ng Gamot na katulad ng isa na gusto mong inumin. O

■ Maaari mong hilingin sa planong pangkalusugan na gumawa ng hindi pagsasama para sakupin ang iyong gamot. Mangyaring tingnan ang Tanong 11 para sa karagdagang impormasyon tungkol sa mga eksepsyon.

10. Paano kung isa kang bagong miyembro ng Health Net Cal MediConnect at hindi mahanap ang iyong gamot sa Listahan ng Gamot o mayroong problema sa pagkuha ng iyong gamot?

Makakatulong kami. Maaari naming sakupin ang pansamantalang 30-araw na supply ng iyong gamot sa panahon ng unang 90 araw na miyembro kayo ng Health Net Cal MediConnect. Bibigyan ka nito ng oras para makipag-usap sa iyong doktor o ibang nagrereseta. Matutulungan ka niyang magdesisyon kung mayroong katulad na gamot sa Listahan ng Gamot na maaari mong inumin sa halip o kung hihiling ng hindi pagsasama.

Sasakupin namin ang 30-araw na supply ng iyong gamot kung:

■ umiinom ka ng gamot na wala sa aming Listahan ng Gamot, o■ hindi ka pinapayagan ng mga tuntunin ng planong pangkalusugan na makuha ang dami ng

iniutos ng nagrereseta sa iyo, o■ ang gamot ay nangangailangan ng paunang pag-apruba ng Health Net Cal MediConnect, o■ umiinom ka ng gamot na bahagi ng paghihigpit ng step therapy.

Kung nakatira ka sa isang nursing home o ibang pasilidad para sa pangmatagalang pangangalaga, maaari mong ipa-refill ang inyong reseta nang kasing haba ng 98 araw. Maaari mong ipa-refill ang gamot nang maramihang beses sa panahon ng iyong unang 90 araw sa plano. Binibigyan nito ng panahon ang nagrereseta sa iyo na palitan ang mga gamot mo ng mga nasa Listahan ng Gamot o humiling ng hindi pagsasama.

Mga Pagbabago sa Antas ng PangangalagaKung magbabago ang antas ng iyong pangangalaga, sasakupin namin ang supply ng mga iyong mga gamot para sa paglipat. Nangyayari ang pagbabago sa antas ng pangangalaga kapag ikaw ay pinalabas sa isang ospital. Nangyayari rin ito kapag ikaw ay lumipat sa o nanggaling sa isang pasilidad ng pangmatagalang pangangalaga.

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• Kunglilipatkasabahaymulasaisangpasilidadngpangmatagalangpangangalagaoospitalat kailangan ng supply para sa paglipat, sasakupin namin ang isang 30-araw na supply. Kung isinulat ang iyong reseta para sa mas kaunting araw, pahihintulutan namin ang mga muling pagpupuno para magbigay ng hanggang sa 30-araw na supply.

• Kunglilipatkamulasabahayoisangospitalpapuntasaisangpasilidadngpangmatagalangpangangalaga at kailangan ng supply para sa paglipat, sasakupin namin ang isang 31-araw na supply. Kung isinulat ang iyong reseta para sa mas kaunting araw, pahihintulutan namin ang mga muling pagpupuno para magbigay ng hanggang sa 31-araw na supply.

11. Maaari ka bang humingi ng hindi pagsasama para sakupin ang iyong gamot?Oo. Maaari mong hilingin sa Health Net Cal MediConnect na gumawa ng hindi pagsasama para sakupin ang gamot na wala sa Listahan ng Gamot.

Maaari mo ring hilingin sa amin na baguhin ang mga tuntunin sa iyong gamot.

■ Halimbawa, maaaring limitahan ng Health Net Cal MediConnect ang dami ng gamot na aming sasakupin. Kung may limitasyon ang iyong gamot, maaari mong hilingin sa amin na baguhin ang limitasyon at dagdagan ang pagsakop.

■ Ibang mga halimbawa: Maaari mong hilingin sa amin na alisin ang mga paghihigpit ng step therapy o mga pangangailangan ng paunang pag-apruba.

12. Gaano katagal ang pagkuha ng hindi pagsasama?Una, kailangan makatanggap kami ng pahayag mula sa nagrereseta sa iyo na sumusuporta sa iyong kahilingan para sa isang eksepsyon. Pagkatapos namin matanggap ang pahayag, bibigyan ka namin ng desisyon sa iyong hiniling na hindi pagsasama sa loob ng 72 oras.

Kung sa iyong palagay o ng nagrereseta sa iyo na ang iyong kalusugan ay maaaring mapinsala kung kailangan ninyong maghintay ng 72 oras para sa desisyon, maaari kang humiling ng pinabilis na eksepsyon. Ito ay mas mabilis na desisyon. Kung sinusuportahan ng nagrereseta sa iyo ang iyong kahilingan, bibigyan ka namin ng desisyon sa loob ng 24 oras na matanggap ang pahayag ng pagsuporta ng nagrereseta sa inyo.

13. Paano ka hihiling ng hindi pagsasama?Para humiling ng isang eksepsyon, tawagan ang Member Services. Ang Member Services ay maaaring makipagtulungan sa iyo at sa iyong tagapaglaan upang tulungan kang humiling ng isang hindi pagsasama.

14. Ano ang mga generic na gamot?Ang mga generic na gamot ay binubuo ng parehong mga sangkap katulad ng mga gamot na may tatak. Karaniwan mas mura ang mga ito kaysa sa gamot na may tatak at ang kanilang mga pangalan ay hindi masyadong kilala. Ang mga generic na gamot ay aprubado ng Food and Drug Administration (FDA).

Sinasakop ng Health Net Cal MediConnect ang parehong mga gamot na may tatak at generic.

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Abbreviation Ano ang kahulugan nito Paano ito gumaganaAL Limitasyon ng Edad Ang ilang mga gamot ay maaaring kailangan ng

paunang pahintulot kung hindi umabot ang edad mo sa gabay ng gumawa ng gamot, ng FDA o klinika.

B/D Medicare Bahagi B vs. Bahagi D

Ang ilang mga gamot at nangangailangan ng paunang pahintulot para magpasya kung ang gamot ay dapat sakupin sa ilalim ng Medicare Bahagi B o Bahagi D. Ito ay patakaran ng Medicare. Ang doktor mo o ang ibang nagreseta ay maaaring kailangang magbigay ng mas marami pang katotohanan para tulungan kaming gawin ang pasyang ito.

GL Limitasyon sa Kasarian Ang ilang mga gamot ay maaaring ligtas lang sa mga lalaki o mga babae.

15. Ano ang mga OTC na gamot? Ang OTC ay nangangahulugang “over-the-counter”. Sinasakop ng Health Net Cal MediConnect ang ilang mga OTC na gamot kapag isinulat ang mga ito ng inyong tagapaglaan bilang mga reseta.

Maaari mong basahin ang Listahan ng Gamot ng Health Net Cal MediConnect para makita kung anu-anong mga OTC na gamot ang sinasakop.

16. Sakop ba ng Health Net Cal MediConnect ang mga OTC na hindi gamot na produkto? Sinasakop ng Health Net Cal MediConnect ang ilang mga OTC na hindi gamot na produkto kapag isinulat ang mga ito ng inyong tagapaglaan bilang mga reseta.

Maaari mong basahin ang Listahan ng Gamot ng Health Net Cal MediConnect para makita kung anu-anong mga OTC na hindi gamot na produkto ang sinasakop.

17. Ano ang iyong co-pay?Maaari mong basahin ang Listahan ng Gamot ng Health Net Cal MediConnect para malaman ang tungkol sa co-pay para sa bawat gamot.

Ang mga miyembro ng Health Net Cal MediConnect na nakatira sa mga nursing home o ibang mga pasilidad para sa pangmatagalang pangangalaga ay walang mga co-pay. Ang ilang mga miyembro na nakakakuha ng pangmatagalang pangangalaga sa komunidad ay wala ring mga copay.

Ang mga co-pay ay nakalista sa ayon sa mga antas. Ang mga Antas ay mga pangkat ng gamot na may parehong co-pay.

■ Ang mga gamot na nasa Antas 1 ay may mababang copay. Ang mga ito ay mga generic na gamot. Ang copay ay mula $0.00 hanggang $3.30. Depende ito sa iyong antas ng pagsakop ng Medi-Cal.

■ Ang mga gamot na nasa Antas 2 ay may mas mataas na copay. Ang mga ito ay mga gamot na may tatak. Ang copay ay mula $0.00 hanggang $8.25. Depende ito sa iyong antas ng pagsakop ng Medi-Cal.

■ Ang mga gamot na nasa Antas 3 ay may $0.00 na co-pay. Ang mga ito ay mga inireseta at OTC na gamot na sinasakop ng Medi-Cal.

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Abbreviation Ano ang kahulugan nito Paano ito gumaganaLA Limitadong Access Ang ilang mga gamot ay maaaring mahanap lang

sa isa o sa ilang mga parmasya, dahil:

■ Nililimita ng FDA ang gamot sa ilang mga pasilidad, parmasya o mga nagrereseta, o

■ Ang ilang mga gamot ay nangangailangan ng espesyal na pag-aalaga o pagsasanay sa pasyente na hindi maibibigay sa tingiang parmasya.

Dapat mong kausapin ang iyong doktor o ibang nagrereseta tungkol sa pagkuha ng ilang gamot na limitado ang access.

MO Mail Order Makukuha mo ang gamot na ito sa mail order na parmasya ng Health Net Cal MediConnect.

NF Hindi Sakop Hindi sakop ang gamot na ito sa Listahan ng Gamot. Maaari kang humingi ng hindi pagsama para masakop ang gamot.

NT Hindi Bahagi D Ang gamot na ito ay hindi isang “Bahagi D na gamot.” Hindi ka aatasang magbayad ng copay para sa mga gamot na ito.

PA Paunang Pahintulot Ang gamot na ito ay nangangailangan ng paunang awtorisasyon. Nangangahulugan ito na ikaw o ang iyong doktor ay dapat magpa-apruba muna sa Health Net Cal MediConnect bago mo punan ang iyong reseta. Kapag hindi ka nakakuhan ang pahintulot, maaaring hindi namin sakupin ang gamot.

QL Limitasyon sa Dami May hangganang sasakupin ang Health Net Cal MediConnect sa gamot na ito.

RX/OTC Inireseta at Over-the-Counter (OTC) o Mabibili nang Walang Reseta

Ang ilang mga gamot ay ginagawa sa kapwa de-resetang uri at OTC na uri.

SL Pangkaligtasang Limitasyon (Safety Limit)

Ang gamot na ito ay may pinakamataas na limitasyon sa araw-araw na dosis para sa kaligtasan na suportado ng FDA. Nangangahulugan ito na hindi sasakupin ng Health Net ang mas higit sa pinakamataas na araw-araw na dosis. Halimbawa, ang pinakamataas na dosis araw-araw ng FDA ng simvastatin ay 80 mg. Samakatuwid, sasakupin lang namin ang hanggang dalawang tableta bawat araw para sa simvastatin 40 mg.

x

Abbreviation Ano ang kahulugan nito Paano ito gumaganaST Step Therapy Ang gamot na ito ay nangangailangan ng step

therapy. Nangangahulugan ito na kakailanganin mong subukan ang mga gamot sa partikular na pagkakasunod-sunod para sa iyong medikal na kalagayan. Maaaring kailanganin mong subukan ang isang gamot bago namin sasakupin ang ibang gamot. Kung sa palagay ng doktor mo ay hindi gumagana ang unang gamot para sa iyo, sasakupin namin ang pangalawa.

xi


Listahan ng mga Sakop na GamotAng Listahan ng mga Sakop na Gamot na nagsimula sa pahina 1 ay magbibigay sa iyo ng impormasyon tungkol sa mga gamot na sakop ng Health Net Cal MediConnect. Kung mayroon kang problema sa paghahanap ng iyong gamot sa listahan, pumunta sa Indise na nagsisimula sa pahina Indise 1.

Inililista ng unang hanay ng tsart ang pangalan ng gamot. Nakasulat sa malalaking letra ang mga gamot na may tatak (hal., LIPITOR) at nakalista ang mga gamot na generic sa maliliit na italics (hal., atorvastatin calcium).

Ang impormasyon sa hanay ng “Mga kinakailangan na pagkilos, paghihigpit, o limitasyon sa paggamit” ay sinasabi sa iyo kung ang Health Net Cal MediConnect ay mayroong anumang mga tuntunin para sa pagsakop ng iyong gamot. Narito ang mga kahulugan ng mga code na ginamit sa column na "Kinakailangang mga aksyon, paghihigpit, o limitasyon sa paggamit":

Tandaan: Ang NT sa tabi ng isang gamot ay nangangahulugan na ang gamot ay hindi isang “Bahagi D na gamot.” Hindi ka aatasang magbayad ng copay para sa mga gamot na ito. May magkakaiba ring mga tuntunin ang mga gamot na ito para sa mga apela. Ang isang apela ay isang pormal na paraan ng paghiling sa amin na suriin ang isang desisyon na ginawa namin tungkol sa pagsakop sa iyo at paghiling sa amin na palitan kung sa iyong palagay kami ay nagkamali. Halimbawa, maaari kaming magdesisyon na ang isang gamot na ninanais mo ay hindi sasakupin o hindi na sinasakop ng Medicare o ng Medi-Cal. Kung ang iyong doktor o ibang tagapaglaan ay hindi sumasang-ayon sa aming pagpapasiya, maaari kang umapela. Kung mayroon kang katanungan, tawagan ang Member Services sa 1-855-464-3571 para sa Los Angeles County o sa 1-855-464-3572 para sa San Diego County, (TTY: 711), Lunes hanggang Biyernes, 8:00 a.m. hanggang 8:00 p.m.. Maaari mo ring basahin ang Handbook ng Miyembro para malaman kung paano umapela sa isang desisyon.

Listahan ng mga Gamot nang Ayon sa Kondisyong Medikal Ang mga gamot sa seksyon na ito ay ginrupo nang ayon sa mga kategoriya batay sa uri ng mga kondisyong medikal na pinaggamitan sa kanila upang gamutin. Halimbawa, kung mayroon kang karamdaman sa puso, kailangan mong maghanap sa kategoriyang, CARDIOVASCULAR AGENTS – MISC. –Mga Gamot para Gamutin ang mga Kondisyon sa Puso at Sirkulasyon. Doon mo mahahanap ang mga gamot na gumagamot sa mga karamdaman sa puso.

xii

Walang Diskriminasyon na Abiso Ang Health Net Cal MediConnect ay sumusunod sa mga batas na angkop sa federal na mga karapatang sibil at hindi nagdidiskrimina batay sa lahi, kulay, bansang pinagmulan, edad, kapansanan, o kasarian. Ang Health Net Cal MediConnect ay hindi nagbubukod ng mga tao o tinatrato ang mga ito sa ibang paraan dahil sa lahi, kulay, bansang pinagmulan, edad, kapansanan, o kasarian.

Health Net Cal MediConnect:

•Nagbibigaynglibrengtulongatserbisyosamgataongmaykapansananupangepektibong makipag-usap sa amin, tulad ng mga kwalipikadong mga taga-interpret ng sign language at nakasulat na impormasyon sa iba pang mga ayos (malaki ang print, naa-akses na mga elektronikong format, iba pang mga format).

•NagbibigaynglibrengserbisyosawikasamgataongangpangunahingwikaayhindiIngles, tulad ng kwalipikadong mga taga-interpret at impormasyon na nakasulat sa ibang mga wika.

Kung kailangan mo ang mga serbisyong ito, makipag-ugnayan sa Health Net Cal MediConnect Customer Contact Center sa Los Angeles County: 1-855-464-3571/San Diego County: 1-855-464-3572 (TTY: 711), Lunes hanggang Biyernes, 8:00 a.m. hanggang 8:00 p.m. Sa ibang panahon - kabilang ang Sabado, Linggo at pederal na mga pista opisyal - maaari kang mag-iwan ng voicemail. Tatawagan ka namin sa susunod na araw ng negosyo. Libre ang tawag.

Kung naniniwala ka na ang Health Net Cal MediConnect ay nabigong magbigay ng mga serbisyong ito o nadiskrimina sa ibang paraan batay sa lahi, kulay, bansang pinagmulan, edad, kapansanan, o kasarian, maaari kang magsampa ng reklamo sa pamamagitan ng pagtawag sa numero sa itaas at sabihan sila na kailangan mong magharap ng reklamo; ang Health Net Cal MediConnect Customer Contact Center ay magagamit para makatulong sa iyo.

Maaari ka ring magsampa ng reklamo sa mga karapatang sibil sa U.S. Department of Health at Human Services, Office for Civil Rights, sa elektronikong paraan sa pamamagitan ng Office for Civil Rights Complaint Portal, na makukuha sa https://ocrportal.hhs.gov/ocr/portal/lobby.jsf o sa pamamagitan ng koreo o telepono sa: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800-537-7697).

Ang mga form sa reklamo ay makukuha sa http://www.hhs.gov/ocr/office/file/index.html.

xiii

Multi-Language Insert Multi-language Interpreter Services

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). Chinese Mandarin: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

Chinese Cantonese: 注意：如果您說英文，您可獲得免費的語言協助服務。請致電 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego)（聽障專線：711）。

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). French: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). H3237_2017_xxxx

Mga Serbisyo sa Taga-interpret ng Maramihang Wika

xiv


Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). 번으로 전화해 주십시오. Russian:

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (телетайп: 711).

Arabic: - ,(San Diego) 3572-464-855-1 ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم

1-855-464-3571 (Los Angeles) :(.711)رقم هاتف الصم والبكم Hindi: ध्यान दें: यदद आप बोलत ेहैं तो आपके ललए मफु्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). पर कॉल करें।.

Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). Portugués: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

xiv

xv

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). 번으로 전화해 주십시오. Russian:

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (телетайп: 711).

Arabic: - ,(San Diego) 3572-464-855-1 ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم

1-855-464-3571 (Los Angeles) :(.711)رقم هاتف الصم والبكم Hindi: ध्यान दें: यदद आप बोलत ेहैं तो आपके ललए मफु्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). पर कॉल करें।.

Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). Portugués: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). まで、お電話にてご連絡ください。

Farsi:

. باشدی م فراهم شمای برا گانيرا بصورتی زبان التیتسه د،یکنی م گفتگو فارسی زبان به اگر: توجه .ديریبگ تماس 1-855-464-3571 (Los Angeles) (TTY: 711) ,(San Diego) 3572-464-855-1 با

Armenian: ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY (հեռատիպ)՝ 711): Cambodian: ប្រយ័ត្ន៖ បរើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា បោយមិនគិត្ឈ្នួល គអឺាចមានសរំារ់រំបរើអ្នក។ ចូរ ទូរស័ព្ទ 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

Hmong: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersAmphetaminesADDERALL XR CP24(Amphetamine-Dextroamphetamine)

NFMO

amphetamine-dextroamphetamine cp243.75mg-3.75mg-3.75mg-3.75mg, 6.25mg-6.25mg-6.25mg-6.25mg, 2.5mg-2.5mg-2.5mg-2.5mg, 5mg-5mg-5mg-5mg, 1.25mg-1.25mg-1.25mg-1.25mg,7.5mg-7.5mg-7.5mg-7.5mg

$0-$3.30(Tier

1)

MO

amphetamine-dextroamphetamine tabs3.125mg-3.125mg-3.125mg-3.125mg,1.875mg-1.875mg-1.875mg-1.875mg, 5mg-5mg-5mg-5mg, 1.25mg-1.25mg-1.25mg-1.25mg,3.75mg-3.75mg-3.75mg-3.75mg, 2.5mg-2.5mg-2.5mg-2.5mg, 7.5mg-7.5mg-7.5mg-7.5mg

$0-$3.30(Tier

1)

MO

DESOXYN TABS(Methamphetamine HCl) NF PA; MO

DEXEDRINE CP24(DextroamphetamineSulfate)

NFMO

dextroamphetamine sulfatecp24 5 mg, 15 mg, 10 mg

$0-$3.30(Tier

1)

MO

dextroamphetamine sulfatetabs 5 mg, 10 mg

$0-$3.30(Tier

1)

MO

methamphetamine hcl tabs$0-

$3.30(Tier

1)

PA; MO

Anorexiants Non-AmphetamineADIPEX-P CAPS(Phentermine HCl) NF PA; MO; NT

Drug Name DrugTier

Requirements/Limits

ADIPEX-P TABS(Phentermine HCl) NF PA; MO; NT

diethylpropion hcl tabs 25mg

$0(Tier

3)

PA; MO; NT

DIETHYLPROPION HCLTABS 25 MG(Diethylpropion HCl)

NFPA; MO; NT

diethylpropion hcl tb24 75mg

$0(Tier

3)

PA; MO; NT

LOMAIRA TABS$0

(Tier3)

PA; MO; NT

phentermine hcl caps$0

(Tier3)

PA; MO; NT

phentermine hcl tabs$0

(Tier3)

PA; MO; NT

QSYMIA CP24$0

(Tier3)

PA; NT

SUPRENZA TBDP 30 MG,15 MG

$0(Tier

3)

PA; MO; NT

SUPRENZA TBDP 37.5MG

$0(Tier

3)

MO; NT

Anti-Obesity Agents

ALLI CAPS$0

(Tier3)

PA; NT

BELVIQ XR TB24$0

(Tier3)

PA; MO; NT

XENICAL CAPS$0

(Tier3)

PA; MO; NT

Attention-Deficit/Hyperactivity Disorder (ADHD)

atomoxetine hcl caps 10mg

$0-$3.30(Tier

1)

SL(10 ea daily);MO

You can find information on what the symbols and abbreviations on this table mean by going topage viii.

2017 Health Net Cal MediConnect Drug List Updated 12/1/2017

1

Drug Name DrugTier

Requirements/Limits


$0-$3.30(Tier

1)

SL(1 ea daily);MO


$0-$3.30(Tier

1)

SL(5.55 eadaily); MO


$0-$3.30(Tier

1)

SL(4 ea daily);MO


$0-$3.30(Tier

1)

SL(2.5 eadaily); MO


$0-$3.30(Tier

1)



$0-$3.30(Tier

1)


clonidine hcl (adhd) tb12$0-

$3.30(Tier

1)

MO

guanfacine hcl (adhd) tb24$0-

$3.30(Tier

1)

AL; Up to 64yrs old; MO

INTUNIV TB24(Guanfacine HCl (ADHD)) NF AL; Up to 64

yrs old; MOKAPVAY TB12 (ClonidineHCl (ADHD)) NF MO

STRATTERA CAPS 10 MG(Atomoxetine HCl)

$0-$8.25(Tier

2)

SL(10 ea daily);MO

STRATTERA CAPS 100MG (Atomoxetine HCl)

$0-$8.25(Tier

2)

SL(1 ea daily);MO


$0-$8.25(Tier

2)


Drug Name DrugTier

Requirements/Limits


$0-$8.25(Tier

2)

SL(4 ea daily);MO


$0-$8.25(Tier

2)

SL(2.5 eadaily); MO


$0-$8.25(Tier

2)



$0-$8.25(Tier

2)


Stimulants - Misc.

CONCERTA TBCR$0-

$8.25(Tier

2)

MO

dexmethylphenidate hclcp24 15 mg, 20 mg, 10 mg

$0-$3.30(Tier

1)

MO

dexmethylphenidate hcltabs 10 mg, 2.5 mg, 5 mg

$0-$3.30(Tier

1)

MO

FOCALIN TABS(Dexmethylphenidate HCl) NF MO

FOCALIN XR CP24 10MG, 15 MG, 20 MG(Dexmethylphenidate HCl)

NFMO

METADATE CD CPCR(Methylphenidate HCl) NF MO

methylphenidate hcl cp24or 20 mg, 60 mg, 40 mg, 30mg

$0-$3.30(Tier

1)

MO

methylphenidate hcl cpcr or10 mg, 50 mg, 60 mg, 20mg, 40 mg, 30 mg

$0-$3.30(Tier

1)

MO

methylphenidate hcl tabs or20 mg, 5 mg, 10 mg

$0-$3.30(Tier

1)

MO



2

Drug Name DrugTier

Requirements/Limits

methylphenidate hcl tb24or 36 mg, 27 mg

$0-$3.30(Tier

1)

Non-OsmoticRelease

methylphenidate hcl tbcr or54 mg, 20 mg, 36 mg, 27mg, 18 mg

$0-$3.30(Tier

1)

MO

modafinil tabs$0-

$3.30(Tier

1)

PA; MO

PROVIGIL TABS(Modafinil) NF PA; MO

RITALIN LA CP24 30 MG,20 MG, 40 MG(Methylphenidate HCl)

NFMO

RITALIN LA CP24 60 MG$0-

$8.25(Tier

2)

MO

RITALIN TABS(Methylphenidate HCl) NF MO

ALLERGENIC EXTRACTS/BIOLOGICALS MISC

Biologicals Misc

ADAGEN SOLN$0-

$8.25(Tier

2)

LA

AMINOGLYCOSIDES - Drugs to Treat BacterialInfectionsAminoglycosides

amikacin sulfate soln ij 1gm/4ml, 500 mg/2ml

$0-$3.30(Tier

1)

MO

BETHKIS NEBU$0-

$8.25(Tier

2)

B/D

gentamicin in saline soln0.9%-1mg/ml

$0-$3.30(Tier

1)

Drug Name DrugTier

Requirements/Limits

gentamicin sulfate soln ij 40mg/ml

$0-$3.30(Tier

1)

MO

KITABIS PAK NEBU$0-

$8.25(Tier

2)

B/D

neomycin sulfate tabs or$0-

$3.30(Tier

1)

MO

paromomycin sulfate caps$0-

$3.30(Tier

1)

MO

TOBI NEBU (Tobramycin) NF B/D

TOBI PODHALER CAPS$0-

$8.25(Tier

2)

tobramycin nebu in$0-

$3.30(Tier

1)

B/D

tobramycin sulfate soln ij80 mg/2ml, 40 mg/ml, 1.2gm/30ml

$0-$3.30(Tier

1)

MO

tobramycin sulfate solr ij1.2 gm

$0-$3.30(Tier

1)

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditionsAnti-TNF-alpha - Monoclonal Antibodies

HUMIRA PEDIATRICCROHNS DISEASESTARTER PACK PSKT

$0-$8.25(Tier

2)

PA

HUMIRA PEN PNKT$0-

$8.25(Tier

2)

PA



3

Drug Name DrugTier

Requirements/Limits

HUMIRA PEN-CROHNSDISEASESTARTER PNKT

$0-$8.25(Tier

2)

PA

HUMIRA PEN-PSORIASISSTARTER PNKT

$0-$8.25(Tier

2)

PA

HUMIRA PSKT$0-

$8.25(Tier

2)

PA

SIMPONI ARIA SOLN$0-

$8.25(Tier

2)

PA

SIMPONI SOAJ$0-

$8.25(Tier

2)

PA

SIMPONI SOSY$0-

$8.25(Tier

2)

PA

Antirheumatic - Enzyme Inhibitors

XELJANZ TABS$0-

$8.25(Tier

2)

PA

Antirheumatic Antimetabolites

OTREXUP SOAJ$0-

$8.25(Tier

2)

PA

RASUVO SOAJ 17.5MG/0.35ML, 30 MG/0.6ML,20 MG/0.4ML, 7.5MG/0.15ML, 10 MG/0.2ML,22.5 MG/0.45ML, 25MG/0.5ML, 12.5MG/0.25ML, 15 MG/0.3ML

$0-$8.25(Tier

2)

PA

Gold Compounds

RIDAURA CAPS$0-

$8.25(Tier

2)

MO

Interleukin-1 Blockers

Drug Name DrugTier

Requirements/Limits

ARCALYST SOLR$0-

$8.25(Tier

2)

LA

Interleukin-1 Receptor Antagonist (IL-1Ra)

KINERET SOSY$0-

$8.25(Tier

2)

PA

Interleukin-1beta Blockers

ILARIS SOLN 150 MG/ML$0-

$8.25(Tier

2)

PA

ILARIS SOLR 180 MG$0-

$8.25(Tier

2)

LA

Interleukin-6 Receptor Inhibitors

ACTEMRA SOLN$0-

$8.25(Tier

2)

PA

ACTEMRA SOSY$0-

$8.25(Tier

2)

PA

Nonsteroidal Anti-inflammatory Agents (NSAIDs)ADVIL CAPS (Ibuprofen) NF MO; NT

ADVIL MIGRAINE CAPS(Ibuprofen) NF MO; NT

ADVIL TABS (Ibuprofen) NF MO; NT

ALEVE CAPS (NaproxenSodium) NF NT

ANAPROX DS TABS(Naproxen Sodium) NF MO

ARTHROTEC 50 TBEC(Diclofenac w/ Misoprostol) NF MO

ARTHROTEC 75 TBEC(Diclofenac w/ Misoprostol) NF MO

CELEBREX CAPS(Celecoxib) NF MO



4

Drug Name DrugTier

Requirements/Limits

celecoxib caps$0-

$3.30(Tier

1)

MO

CHILDRENS ADVIL SUSP(Ibuprofen)

$0(Tier

3)

RX/OTC; MO;NT

CHILDRENS MOTRINSUSP (Ibuprofen)

$0(Tier

3)

RX/OTC; MO;NT

DAYPRO TABS(Oxaprozin) NF MO

diclofenac potassium tabs$0-

$3.30(Tier

1)

MO

diclofenac sodium tb24 or100 mg

$0-$3.30(Tier

1)

MO

diclofenac sodium tbec or25 mg, 75 mg, 50 mg

$0-$3.30(Tier

1)

MO

diclofenac w/ misoprostoltbec

$0-$3.30(Tier

1)

MO

EC-NAPROSYN TBEC(Naproxen) NF MO

etodolac caps 300 mg, 200mg

$0-$3.30(Tier

1)

MO

etodolac tabs 400 mg, 500mg

$0-$3.30(Tier

1)

MO

etodolac tb24 500 mg, 400mg, 600 mg

$0-$3.30(Tier

1)

MO

FELDENE CAPS(Piroxicam) NF MO

flurbiprofen tabs or 50 mg,100 mg

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

ibuprofen caps or 200 mg$0

(Tier3)

MO; NT

ibuprofen chew or 100 mg$0

(Tier3)

MO; NT

ibuprofen susp or 100mg/5ml

$0-$3.30(Tier

1)

RX/OTC; MO

ibuprofen susp or 100mg/5ml

$0(Tier

3)

Over-the-counter;RX/OTC; MO; NT

ibuprofen susp or 40mg/ml, 50 mg/1.25ml

$0(Tier

3)

NT

ibuprofen tabs or 100 mg$0

(Tier3)

NT

ibuprofen tabs or 200 mg$0

(Tier3)

MO; NT

ibuprofen tabs or 400 mg$0-

$3.30(Tier

1)

SL(8 ea daily);MO


$3.30(Tier

1)



$3.30(Tier

1)

SL(4 ea daily);MO

indomethacin caps or 50mg, 25 mg

$0-$3.30(Tier

1)


indomethacin cpcr or 75mg

$0-$3.30(Tier

1)


INFANTS ADVIL SUSP(Ibuprofen) NF NT

ketoprofen caps or 75 mg,50 mg

$0-$3.30(Tier

1)

MO



5

Drug Name DrugTier

Requirements/Limits

ketorolac tromethaminesoln ij 15 mg/ml, 30 mg/ml

$0-$3.30(Tier

1)


ketorolac tromethaminesoln im 30 mg/ml, 60mg/2ml

$0-$3.30(Tier

1)


mefenamic acid caps or$0-

$3.30(Tier

1)

MO

meloxicam tabs or 15 mg,7.5 mg

$0-$3.30(Tier

1)

MO

MOBIC TABS 7.5 MG, 15MG (Meloxicam) NF MO

MOTRIN INFANTSDROPS SUSP (Ibuprofen) NF NT

nabumetone tabs$0-

$3.30(Tier

1)

MO

NAPROSYN TABS 500MG (Naproxen) NF MO

naproxen sodium caps or220 mg

$0(Tier

3)

NT

naproxen sodium tabs or275 mg, 550 mg

$0-$3.30(Tier

1)

MO

naproxen tabs or 375 mg,250 mg, 500 mg

$0-$3.30(Tier

1)

MO

naproxen tbec or 500 mg,375 mg

$0-$3.30(Tier

1)

MO

oxaprozin tabs$0-

$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

piroxicam caps or 10 mg,20 mg

$0-$3.30(Tier

1)

MO

PONSTEL CAPS(Mefenamic Acid) NF MO

sulindac tabs or 200 mg,150 mg

$0-$3.30(Tier

1)

MO

tolmetin sodium caps 400mg

$0-$3.30(Tier

1)

MO

tolmetin sodium tabs 200mg

$0-$3.30(Tier

1)

Phosphodiesterase 4 (PDE4) Inhibitors

OTEZLA TABS$0-

$8.25(Tier

2)

PA

OTEZLA TBPK$0-

$8.25(Tier

2)

PA

Pyrimidine Synthesis InhibitorsARAVA TABS(Leflunomide) NF MO

leflunomide tabs or 20 mg,10 mg

$0-$3.30(Tier

1)

MO

Selective Costimulation Modulators

ORENCIA CLICKJECTSOAJ

$0-$8.25(Tier

2)

PA

ORENCIA SOLR$0-

$8.25(Tier

2)

PA

ORENCIA SOSY$0-

$8.25(Tier

2)

PA



6

Drug Name DrugTier

Requirements/Limits

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL SOLR$0-

$8.25(Tier

2)

PA

ENBREL SOSY$0-

$8.25(Tier

2)

PA

ENBREL SURECLICKSOAJ

$0-$8.25(Tier

2)

PA

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint ConditionsAnalgesics Other

acetaminophen chew or160 mg

$0(Tier

3)

NT

acetaminophen chew or 80mg

$0(Tier

3)

MO; NT

acetaminophen liqd or 160mg/5ml

$0(Tier

3)

MO; NT

acetaminophen soln or 160mg/5ml, 325 mg/10.15ml,650 mg/20.3ml

$0(Tier

3)

MO; NT

acetaminophen supp re120 mg

$0(Tier

3)

MO; NT

acetaminophen susp or160 mg/5ml, 80 mg/2.5ml

$0(Tier

3)

MO; NT

acetaminophen susp or 80mg/0.8ml

$0(Tier

3)

NT

acetaminophen tbdp or 160mg

$0(Tier

3)

MO; NT

acetaminophen tbdp or 80mg

$0(Tier

3)

NT

FEVERALL INFANTSSUPP

$0(Tier

3)

NT

Drug Name DrugTier

Requirements/Limits

TYLENOL CHILDRENSSUSP (Acetaminophen) NF MO; NT

TYLENOL INFANTSPAIN+FEVER SUSP(Acetaminophen)

NFMO; NT

TYLENOL INFANTS SUSP(Acetaminophen) NF MO; NT

Salicylates

aspirin buffered (cal carb-mag carb-mag oxide) tabs

$0(Tier

3)

MO; NT

aspirin supp re 300 mg,600 mg

$0(Tier

3)

NT

aspirin tabs or 325 mg$0

(Tier3)

MO; NT

aspirin tbec or 81 mg, 325mg, 324 mg

$0(Tier

3)

MO; NT

BUFFERIN LOW DOSETABS

$0(Tier

3)

NT

BUFFERIN TABS (AspirinBuffered (Cal Carb-MagCarb-Mag Oxide))

NFMO; NT

diflunisal tabs$0-

$3.30(Tier

1)

MO

ECOTRIN REGULARSTRENGTH TBEC(Aspirin)

NFMO; NT

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint ConditionsOpioid AgonistsACTIQ LPOP 1200 MCG,800 MCG, 600 MCG, 1600MCG, 400 MCG (FentanylCitrate)

NF

PA; QL(4 eadaily); MO

ACTIQ LPOP 200 MCG(Fentanyl Citrate) NF PA; QL(8 ea

daily); MODEMEROL SOLN IJ 25MG/ML (Meperidine HCl) NF AL; Up to 64

yrs old



7

Drug Name DrugTier

Requirements/Limits

DEMEROL SOLN IJ 50MG/ML, 100 MG/ML(Meperidine HCl)

NFAL; Up to 64yrs old; MO

DILAUDID LIQD OR 1MG/ML (HydromorphoneHCl)

NFQL(50 mldaily); MO

DILAUDID SOLN IJ 2MG/ML

$0-$8.25(Tier

2)

PreservativeFree

DILAUDID SOLN IJ 2MG/ML (HydromorphoneHCl)

NFMO

DILAUDID TABS OR 2 MG(Hydromorphone HCl) NF QL(25 ea

daily); MODILAUDID TABS OR 4 MG(Hydromorphone HCl) NF QL(12.5 ea

daily); MODILAUDID TABS OR 8 MG(Hydromorphone HCl) NF QL(6.25 ea

daily); MODILAUDID-HP SOLN(Hydromorphone HCl) NF

DOLOPHINE TABS 10 MG(Methadone HCl) NF QL(6.67 ea

daily); MODOLOPHINE TABS 5 MG(Methadone HCl) NF QL(13.34 ea

daily); MODURAGESIC PT72 100MCG/HR (Fentanyl) NF QL(0.5 ea

daily); MO

DURAGESIC PT72 12MCG/HR (Fentanyl) NF

Limit 43patches permonth;QL(1.44ea daily); MO

DURAGESIC PT72 25MCG/HR (Fentanyl) NF QL(0.94 ea

daily); MO

DURAGESIC PT72 50MCG/HR, 75 MCG/HR(Fentanyl)

NF


fentanyl citrate lpop bu1600 mcg, 800 mcg, 600mcg, 1200 mcg, 400 mcg

$0-$3.30(Tier

1)


fentanyl citrate lpop bu 200mcg

$0-$3.30(Tier

1)


Drug Name DrugTier

Requirements/Limits

fentanyl pt72 100 mcg/hr$0-

$3.30(Tier

1)

QL(0.5 eadaily); MO


$3.30(Tier

1)



$3.30(Tier

1)

QL(0.94 eadaily); MO

fentanyl pt72 75 mcg/hr, 50mcg/hr

$0-$3.30(Tier

1)


hydromorphone hcl liqd or1 mg/ml

$0-$3.30(Tier

1)

QL(50 mldaily); MO

hydromorphone hcl soln ij 2mg/ml

$0-$3.30(Tier

1)

MO

hydromorphone hcl soln ij500 mg/50ml, 50 mg/5ml,10 mg/ml

$0-$3.30(Tier

1)

hydromorphone hcl tabs or2 mg

$0-$3.30(Tier

1)

QL(25 eadaily); MO


$0-$3.30(Tier

1)



$0-$3.30(Tier

1)


KADIAN CP24 10 MG(Morphine Sulfate) NF QL(20 ea

daily); MOKADIAN CP24 100 MG(Morphine Sulfate) NF QL(2 ea daily);

MOKADIAN CP24 20 MG(Morphine Sulfate) NF QL(10 ea

daily); MOKADIAN CP24 30 MG(Morphine Sulfate) NF QL(6.67 ea

daily); MO



8

Drug Name DrugTier

Requirements/Limits

KADIAN CP24 50 MG(Morphine Sulfate) NF QL(4 ea daily);

MOKADIAN CP24 60 MG(Morphine Sulfate) NF QL(3.34 ea

daily); MOKADIAN CP24 80 MG(Morphine Sulfate) NF QL(2.5 ea

daily); MO

LAZANDA SOLN 100MCG/ACT

$0-$8.25(Tier

2)



$0-$8.25(Tier

2)

PA; QL(0.5 eadaily); MO


$0-$8.25(Tier

2)


meperidine hcl soln ij 25mg/ml

$0-$3.30(Tier

1)

AL; Up to 64yrs old

meperidine hcl soln ij 50mg/ml, 100 mg/ml

$0-$3.30(Tier

1)


methadone hcl conc or 10mg/ml

$0-$3.30(Tier

1)

QL(6.67 mldaily); MO

methadone hcl soln or 10mg/5ml

$0-$3.30(Tier

1)


methadone hcl soln or 5mg/5ml

$0-$3.30(Tier

1)


methadone hcl tabs or 10mg

$0-$3.30(Tier

1)


methadone hcl tabs or 5mg

$0-$3.30(Tier

1)


METHADOSE CONC(Methadone HCl) NF QL(6.67 ml

daily); MO

Drug Name DrugTier

Requirements/Limits

METHADOSE SUGAR-FREE CONC (MethadoneHCl)

NFQL(6.67 mldaily); MO

morphine sulfate cp24 or10 mg

$0-$3.30(Tier

1)

QL(20 eadaily); MO


$0-$3.30(Tier

1)

QL(2 ea daily);MO


$0-$3.30(Tier

1)

QL(10 eadaily); MO


$0-$3.30(Tier

1)



$0-$3.30(Tier

1)

QL(4 ea daily);MO


$0-$3.30(Tier

1)



$0-$3.30(Tier

1)

QL(2.5 eadaily); MO

morphine sulfate soln ij 0.5mg/ml

$0-$3.30(Tier

1)

morphine sulfate soln ij 1mg/ml

$0-$3.30(Tier

1)

MO

morphine sulfate soln or 10mg/5ml

$0-$3.30(Tier

1)

QL(100 mldaily); MO

morphine sulfate soln or 20mg/5ml

$0-$3.30(Tier

1)

QL(50 mldaily); MO



9

Drug Name DrugTier

Requirements/Limits

morphine sulfate soln or 20mg/ml, 100 mg/5ml

$0-$3.30(Tier

1)

QL(10 mldaily); MO

MORPHINE SULFATETABS OR 15 MG

$0-$8.25(Tier

2)


MORPHINE SULFATETABS OR 30 MG

$0-$8.25(Tier

2)


morphine sulfate tbcr or100 mg, 200 mg

$0-$3.30(Tier

1)

QL(2 ea daily);MO

morphine sulfate tbcr or 15mg

$0-$3.30(Tier

1)



$0-$3.30(Tier

1)



$0-$3.30(Tier

1)


MS CONTIN TBCR 100MG, 200 MG (MorphineSulfate)

NFQL(2 ea daily);MO

MS CONTIN TBCR 15 MG(Morphine Sulfate) NF QL(13.34 ea

daily); MOMS CONTIN TBCR 30 MG(Morphine Sulfate) NF QL(6.67 ea

daily); MOMS CONTIN TBCR 60 MG(Morphine Sulfate) NF QL(3.34 ea

daily); MOOPANA TABS OR 10 MG(Oxymorphone HCl) NF QL(6.67 ea

daily); MOOPANA TABS OR 5 MG(Oxymorphone HCl) NF QL(13.34 ea

daily); MO

oxycodone hcl caps or 5mg

$0-$3.30(Tier

1)


Drug Name DrugTier

Requirements/Limits

oxycodone hcl conc or 100mg/5ml

$0-$3.30(Tier

1)


oxycodone hcl tabs or 15mg

$0-$3.30(Tier

1)

QL(8.9 eadaily); MO

oxycodone hcl tabs or 30mg

$0-$3.30(Tier

1)


oxycodone hcl tabs or 5 mg$0-

$3.30(Tier

1)


oxymorphone hcl tabs 10mg

$0-$3.30(Tier

1)


oxymorphone hcl tabs 5 mg$0-

$3.30(Tier

1)


oxymorphone hcl tb12 15mg

$0-$3.30(Tier

1)


oxymorphone hcl tb12 7.5mg

$0-$3.30(Tier

1)


ROXICODONE TABS 15MG (Oxycodone HCl) NF QL(8.9 ea

daily); MOROXICODONE TABS 30MG (Oxycodone HCl) NF QL(4.44 ea

daily); MOROXICODONE TABS 5MG (Oxycodone HCl) NF QL(26.67 ea

daily); MO

SUBSYS LIQD 100 MCG$0-

$8.25(Tier

2)



$8.25(Tier

2)

PA; QL(2 eadaily)



10

Drug Name DrugTier

Requirements/Limits


$8.25(Tier

2)


SUBSYS LIQD 400 MCG,600 MCG, 1600 MCG, 800MCG

$0-$8.25(Tier

2)


tramadol hcl tabs or 50 mg$0-

$3.30(Tier

1)

SL(8 ea daily);MO

tramadol hcl tb24 or 100mg

$0-$3.30(Tier

1)

SL(3 ea daily);MO


$0-$3.30(Tier

1)

SL(1.5 eadaily); MO


$0-$3.30(Tier

1)

SL(1 ea daily);MO

ULTRAM ER TB24 100MG (Tramadol HCl) NF SL(3 ea daily);

MOULTRAM ER TB24 200MG (Tramadol HCl) NF SL(1.5 ea

daily); MOULTRAM ER TB24 300MG (Tramadol HCl) NF SL(1 ea daily);

MOULTRAM TABS (TramadolHCl) NF SL(8 ea daily);

MO

ZOHYDRO ER C12A 10MG

$0-$8.25(Tier

2)



$0-$8.25(Tier

2)



$0-$8.25(Tier

2)



$0-$8.25(Tier

2)


Drug Name DrugTier

Requirements/Limits


$0-$8.25(Tier

2)



$0-$8.25(Tier

2)


Opioid Combinations

acetaminophen w/ codeinesoln 120mg/5ml-12mg/5ml

$0-$3.30(Tier

1)

SL(150 mldaily); MO

acetaminophen w/ codeinetabs 300mg-15mg

$0-$3.30(Tier

1)



$0-$3.30(Tier

1)

SL(12 ea daily);MO


$0-$3.30(Tier

1)

SL(6 ea daily);MO

butalbital-aspirin-caffeinew/cod caps

$0-$3.30(Tier

1)

AL; Up to 64yrs old; SL(6 eadaily); MO

FIORINAL/CODEINE #3CAPS (Butalbital-Aspirin-Caffeine w/Cod)

NFAL; Up to 64yrs old; SL(6 eadaily); MO

hydrocodone-acetaminophen soln5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml,2.5mg/5ml-108mg/5ml

$0-$3.30(Tier

1)

Limit 5535mlspermonth;SL(184.5 ml daily); MO

hydrocodone-acetaminophen tabs 10mg-300mg, 7.5mg-300mg,5mg-300mg

$0-$3.30(Tier

1)


hydrocodone-acetaminophen tabs 10mg-325mg, 7.5mg-325mg,5mg-325mg

$0-$3.30(Tier

1)




11

Drug Name DrugTier

Requirements/Limits

hydrocodone-ibuprofentabs 200mg-2.5mg

$0-$3.30(Tier

1)

hydrocodone-ibuprofentabs 200mg-7.5mg,200mg-5mg, 200mg-10mg

$0-$3.30(Tier

1)

MO

oxycodone w/acetaminophen soln5mg/5ml-325mg/5ml

$0-$3.30(Tier

1)

Limit 1845mlspermonth;SL(61.5ml daily)

oxycodone w/acetaminophen tabs 10mg-325mg, 2.5mg-325mg,5mg-325mg, 7.5mg-325mg

$0-$3.30(Tier

1)


oxycodone-aspirin tabs$0-

$3.30(Tier

1)

MO

tramadol-acetaminophentabs

$0-$3.30(Tier

1)

SL(8 ea daily);MO

ULTRACET TABS(Tramadol-Acetaminophen) NF SL(8 ea daily);

MOVICOPROFEN TABS(Hydrocodone-Ibuprofen) NF MO

Opioid Partial AgonistsBUPRENEX SOLN(Buprenorphine HCl) NF MO

buprenorphine hcl soln ij0.3 mg/ml

$0-$3.30(Tier

1)

MO

buprenorphine hcl subl sl 2mg

$0-$3.30(Tier

1)


buprenorphine hcl subl sl 8mg

$0-$3.30(Tier

1)


buprenorphine hcl-naloxone hcl dihydrate subl2mg-0.5mg

$0-$3.30(Tier

1)


Drug Name DrugTier

Requirements/Limits

buprenorphine hcl-naloxone hcl dihydrate subl8mg-2mg

$0-$3.30(Tier

1)


butorphanol tartrate soln ij2 mg/ml

$0-$3.30(Tier

1)

MO

butorphanol tartrate soln na10 mg/ml

$0-$3.30(Tier

1)

Limit 210mlsper month;QL(7ml daily); MO

nalbuphine hcl soln ij 10mg/ml, 20 mg/ml

$0-$3.30(Tier

1)

MO

ANDROGENS-ANABOLIC - Drugs to RegulateHormonesAnabolic Steroids

ANADROL-50 TABS$0-

$8.25(Tier

2)

MO

OXANDRIN TABS(Oxandrolone) NF MO

oxandrolone tabs or 2.5mg, 10 mg

$0-$3.30(Tier

1)

MO

Androgens

ANDRODERM PT24$0-

$8.25(Tier

2)

MO

ANDROGEL GEL 40.5MG/2.5GM, 20.25MG/1.25GM

$0-$8.25(Tier

2)

MO

ANDROGEL GEL 50MG/5GM, 25 MG/2.5GM(Testosterone)

$0-$8.25(Tier

2)

MO

ANDROGEL PUMP GEL$0-

$8.25(Tier

2)

MO



12

Drug Name DrugTier

Requirements/Limits

AVEED SOLN$0-

$8.25(Tier

2)

LA

danazol caps or 100 mg,50 mg, 200 mg

$0-$3.30(Tier

1)

MO

fluoxymesterone tabs or$0-

$3.30(Tier

1)

MO

methyltestosterone caps or$0-

$3.30(Tier

1)

MO

TESTIM GEL(Testosterone) NF MO

testosterone cypionate soln$0-

$3.30(Tier

1)

MO

testosterone enanthatesoln im

$0-$3.30(Tier

1)

MO

TESTOSTERONE GEL TD1 %, 25 MG/2.5GM, 50MG/5GM

$0-$8.25(Tier

2)

MO

testosterone gel td 50mg/5gm, 1 %, 25mg/2.5gm

$0-$3.30(Tier

1)

MO

TESTOSTERONE PUMPGEL

$0-$8.25(Tier

2)

MO

VOGELXO GEL$0-

$8.25(Tier

2)

MO

VOGELXO PUMP GEL$0-

$8.25(Tier

2)

MO

ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and Itching

Drug Name DrugTier

Requirements/Limits

Intrarectal SteroidsCORTENEMA ENEM(Hydrocortisone(Intrarectal))

NFMO

hydrocortisone (intrarectal)enem

$0-$3.30(Tier

1)

MO

UCERIS FOAM RE 2MG/ACT

$0-$8.25(Tier

2)

MO

Rectal Steroids

hydrocortisone (rectal) crea$0-

$3.30(Tier

1)

MO

PROCTOCORT CREA 1 %(Hydrocortisone (Rectal)) NF MO

Vasodilating Agents

RECTIV OINT$0-

$8.25(Tier

2)

MO

ANTACIDS - Ulcer and Stomach Acid Drugs

Antacid Combinationsalum & mag hydrox-simethicone chew 200mg-25mg-200mg

$0(Tier

3)

NT

alum & mag hydrox-simethicone liqd200mg/5ml-20mg/5ml-200mg/5ml, 400mg/5ml-40mg/5ml-400mg/5ml

$0(Tier

3)

MO; NT

alum & mag hydrox-simethicone susp200mg/5ml-20mg/5ml-200mg/5ml, 400mg/5ml-40mg/5ml-400mg/5ml,400mg/5ml-400mg/5ml-40mg/5ml-40mg/5ml-400mg/5ml-400mg/5ml,200mg/5ml-200mg/5ml-20mg/5ml-20mg/5ml-200mg/5ml-200mg/5ml

$0(Tier

3)

MO; NT



13

Drug Name DrugTier

Requirements/Limits

aluminum hydroxide-magtrisil chew

$0(Tier

3)

NT

GELUSIL CHEW 200MG-25MG-200MG (Alum &Mag Hydrox-Simethicone)

NFNT

HYVEE ADVANCEDANTACID MAXIMUMSTRENGTH SUSP (Alum& Mag Hydrox-Simethicone)

NF

MO; NT

Antacids - Aluminum Salts

ALUMINUM HYDROXIDESUSP OR

$0(Tier

3)

NT

Antacids - Calcium Saltscalcium carbonate(antacid) chew 750 mg,500 mg

$0(Tier

3)

MO; NT

calcium carbonate(antacid) tabs 648 mg

$0(Tier

3)

MO; NT

CALCIUM CARBONATETABS OR 648 MG

$0(Tier

3)

MO; NT

TUMS CHEW (CalciumCarbonate (Antacid)) NF MO; NT

TUMS CHEWY BITESCHEW (Calcium Carbonate(Antacid))

NFMO; NT

TUMS E-X 750 CHEW(Calcium Carbonate(Antacid))

NFMO; NT

TUMS EXTRA STRENGTH750 CHEW (CalciumCarbonate (Antacid))

NFMO; NT

TUMS KIDS CHEW(Calcium Carbonate(Antacid))

NFMO; NT

TUMS LASTING EFFECTSCHEW (Calcium Carbonate(Antacid))

NFMO; NT

TUMS SMOOTHIESCHEW (Calcium Carbonate(Antacid))

NFMO; NT

ANTHELMINTICS - Drugs to Treat WormInfections

Drug Name DrugTier

Requirements/Limits

Anthelmintics

ALBENZA TABS$0-

$8.25(Tier

2)

MO

ivermectin tabs or$0-

$3.30(Tier

1)

MO

pyrantel pamoate susp or$0

(Tier3)

NT

STROMECTOL TABS(Ivermectin)

$0-$8.25(Tier

2)

MO

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial InfectionsAnti-infective Agents - Misc.AZACTAM SOLR(Aztreonam) NF MO

aztreonam solr$0-

$3.30(Tier

1)

MO

CAYSTON SOLR$0-

$8.25(Tier

2)

LA

colistimethate sodium solr ij$0-

$3.30(Tier

1)

MO

COLY-MYCIN M SOLR(Colistimethate Sodium) NF MO

FLAGYL CAPS 375 MG(Metronidazole) NF SL(10.6 ea

daily); MOFLAGYL TABS 250 MG(Metronidazole) NF SL(16 ea daily);

MOFLAGYL TABS 500 MG(Metronidazole) NF SL(8 ea daily);

MO

metronidazole caps or 375mg

$0-$3.30(Tier

1)




14

Drug Name DrugTier

Requirements/Limits

metronidazole in nacl soln$0-

$3.30(Tier

1)

metronidazole tabs or 250mg

$0-$3.30(Tier

1)

SL(16 ea daily);MO

metronidazole tabs or 500mg

$0-$3.30(Tier

1)

SL(8 ea daily);MO

NEBUPENT SOLR$0-

$8.25(Tier

2)

B/D; MO

ORBACTIV SOLR$0-

$8.25(Tier

2)

PENTAM 300 SOLR$0-

$8.25(Tier

2)

MO

TINDAMAX TABS(Tinidazole) NF MO

tinidazole tabs or 250 mg,500 mg

$0-$3.30(Tier

1)

MO

trimethoprim tabs or$0-

$3.30(Tier

1)

MO

VANCOCIN HCL CAPS(Vancomycin HCl) NF PA; MO

vancomycin hcl caps or125 mg, 250 mg

$0-$3.30(Tier

1)

PA; MO

VANCOMYCIN HCL INDEXTROSE SOLN500MG/100ML-5%,1GM/200ML-5%, 5%-750MG/150ML

$0-$8.25(Tier

2)

vancomycin hcl solr iv 500mg

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

vancomycin hcl solr iv 5000mg, 10 gm, 1000 mg

$0-$3.30(Tier

1)

XIFAXAN TABS$0-

$8.25(Tier

2)

MO

Anti-infective Misc. - CombinationsBACTRIM DS TABS(Sulfamethoxazole-Trimethoprim)

NFMO

BACTRIM TABS(Sulfamethoxazole-Trimethoprim)

NFMO

sulfamethoxazole-trimethoprim soln

$0-$3.30(Tier

1)

MO

sulfamethoxazole-trimethoprim susp

$0-$3.30(Tier

1)

MO

sulfamethoxazole-trimethoprim tabs

$0-$3.30(Tier

1)

MO

Antiprotozoal Agents

ALINIA TABS 500 MG$0-

$8.25(Tier

2)

MO

atovaquone susp$0-

$3.30(Tier

1)

MO

MEPRON SUSP(Atovaquone) NF MO

Carbapenems

imipenem-cilastatin solr$0-

$3.30(Tier

1)

MO

INVANZ SOLR IJ$0-

$8.25(Tier

2)

MO



15

Drug Name DrugTier

Requirements/Limits

meropenem solr$0-

$3.30(Tier

1)

MO

MERREM SOLR(Meropenem) NF MO

PRIMAXIN IV SOLR(Imipenem-Cilastatin) NF MO

Chloramphenicols

chloramphenicol sodiumsuccinate solr

$0-$3.30(Tier

1)

Cyclic Lipopeptides

CUBICIN RF SOLR(Daptomycin)

$0-$8.25(Tier

2)

CUBICIN SOLR(Daptomycin)

$0-$8.25(Tier

2)

daptomycin solr$0-

$3.30(Tier

1)

Glycylcyclines

TIGECYCLINE SOLR$0-

$8.25(Tier

2)

TYGACIL SOLR$0-

$8.25(Tier

2)

Leprostatics

dapsone tabs or 25 mg,100 mg

$0-$3.30(Tier

1)

MO

LincosamidesCLEOCIN CAPS OR 300MG, 75 MG, 150 MG(Clindamycin HCl)

NFMO

Drug Name DrugTier

Requirements/Limits

CLEOCIN IN D5W SOLN(Clindamycin Phosphate inD5W)

NF

CLEOCIN PHOSPHATESOLN IJ 900 MG/6ML, 600MG/4ML (ClindamycinPhosphate)

NF

MO

CLEOCIN PHOSPHATESOLN IV 600MG/50ML-5%, 300MG/50ML-5%,900MG/50ML-5%(Clindamycin Phosphate inD5W)

NF

clindamycin hcl caps or 75mg, 300 mg, 150 mg

$0-$3.30(Tier

1)

MO

clindamycin palmitatehydrochloride solr

$0-$3.30(Tier

1)

MO

clindamycin phosphate ind5w soln

$0-$3.30(Tier

1)

clindamycin phosphate solnij 600 mg/4ml, 900 mg/6ml

$0-$3.30(Tier

1)

MO

clindamycin phosphate solnij 9000 mg/60ml, 150 mg/ml

$0-$3.30(Tier

1)

clindamycin phosphate solniv 600 mg/4ml

$0-$3.30(Tier

1)

LINCOCIN SOLN(Lincomycin HCl)

$0-$8.25(Tier

2)

MO

lincomycin hcl soln ij$0-

$3.30(Tier

1)

MO

Oxazolidinones



16

Drug Name DrugTier

Requirements/Limits

linezolid soln iv 600mg/300ml

$0-$3.30(Tier

1)

LINEZOLID SOLN IV600MG/300ML-0.9%

$0-$8.25(Tier

2)

linezolid susr or 100mg/5ml

$0-$3.30(Tier

1)

MO

linezolid tabs or 600 mg$0-

$3.30(Tier

1)

MO

SIVEXTRO SOLR IV$0-

$8.25(Tier

2)

SIVEXTRO TABS OR$0-

$8.25(Tier

2)

MO

ZYVOX SOLN IV 200MG/100ML

$0-$8.25(Tier

2)

ZYVOX SOLN IV 600MG/300ML (Linezolid)

$0-$8.25(Tier

2)

ZYVOX SUSR OR 100MG/5ML (Linezolid)

$0-$8.25(Tier

2)

MO

ZYVOX TABS OR 600 MG(Linezolid)

$0-$8.25(Tier

2)

MO

Polymyxins

polymyxin b sulfate solr ij$0-

$3.30(Tier

1)

Streptogramins

Drug Name DrugTier

Requirements/Limits

SYNERCID SOLR$0-

$8.25(Tier

2)

ANTIANGINAL AGENTS - Drugs to Treat ChestPainAntianginals-Other

RANEXA TB12$0-

$8.25(Tier

2)

PA; MO

NitratesISORDIL TITRADOSETABS 5 MG (IsosorbideDinitrate)

NFMO

isosorbide dinitrate tabs$0-

$3.30(Tier

1)

MO

isosorbide dinitrate tbcr$0-

$3.30(Tier

1)

MO

isosorbide mononitrate tabs10 mg, 20 mg

$0-$3.30(Tier

1)

MO

isosorbide mononitratetb24 60 mg, 120 mg, 30 mg

$0-$3.30(Tier

1)

MO

NITRO-DUR PT24 0.6MG/HR, 0.2 MG/HR, 0.4MG/HR, 0.1 MG/HR(Nitroglycerin)

NF

MO

NITROGLYCERINLINGUAL AERS

$0-$8.25(Tier

2)

MO

nitroglycerin pt24 td 0.6mg/hr, 0.4 mg/hr, 0.2mg/hr, 0.1 mg/hr

$0-$3.30(Tier

1)

MO

nitroglycerin soln tl 0.4mg/spray

$0-$3.30(Tier

1)

MO



17

Drug Name DrugTier

Requirements/Limits

nitroglycerin subl sl 0.4 mg,0.6 mg, 0.3 mg

$0-$3.30(Tier

1)

MO

NITROLINGUALPUMPSPRAY SOLN(Nitroglycerin)

NFMO

NITROMIST AERS$0-

$8.25(Tier

2)

MO

NITROSTAT SUBL(Nitroglycerin)

$0-$8.25(Tier

2)

MO

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.

buspirone hcl tabs or 10mg, 15 mg, 7.5 mg, 5 mg,30 mg

$0-$3.30(Tier

1)

MO

hydroxyzine hcl soln im 50mg/ml

$0-$3.30(Tier

1)


hydroxyzine hcl syrp or 10mg/5ml

$0-$3.30(Tier

1)


hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg

$0-$3.30(Tier

1)


hydroxyzine pamoate capsor 50 mg, 25 mg

$0-$3.30(Tier

1)


VISTARIL CAPS(Hydroxyzine Pamoate) NF AL; Up to 64

yrs old; MOBenzodiazepines

alprazolam tabs or 0.25mg, 2 mg, 0.5 mg, 1 mg

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

alprazolam tb24 or 1 mg, 3mg, 0.5 mg, 2 mg

$0-$3.30(Tier

1)

MO

alprazolam tbdp or 0.5 mg,0.25 mg, 2 mg, 1 mg

$0-$3.30(Tier

1)

MO

ATIVAN SOLN IJ 2 MG/ML(Lorazepam) NF MO

ATIVAN SOLN IJ 4 MG/ML(Lorazepam) NF

ATIVAN TABS OR 1 MG, 2MG, 0.5 MG (Lorazepam) NF MO

clorazepate dipotassiumtabs

$0-$3.30(Tier

1)

MO

diazepam conc or 5 mg/ml$0-

$3.30(Tier

1)

MO

diazepam soln or 1 mg/ml$0-

$3.30(Tier

1)

MO

diazepam tabs or 2 mg, 5mg, 10 mg

$0-$3.30(Tier

1)

MO

lorazepam conc or 2 mg/ml$0-

$3.30(Tier

1)

MO

lorazepam soln ij 2 mg/ml,20 mg/10ml

$0-$3.30(Tier

1)

MO

lorazepam soln ij 4 mg/ml$0-

$3.30(Tier

1)

lorazepam tabs or 2 mg,0.5 mg, 1 mg

$0-$3.30(Tier

1)

MO



18

Drug Name DrugTier

Requirements/Limits

oxazepam caps$0-

$3.30(Tier

1)

MO

TRANXENE T TABS(Clorazepate Dipotassium) NF MO

VALIUM TABS (Diazepam) NF MO

XANAX TABS (Alprazolam) NF MO

XANAX XR TB24(Alprazolam) NF MO

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythmsAntiarrhythmics Type I-A

disopyramide phosphatecaps

$0-$3.30(Tier

1)


NORPACE CAPS(Disopyramide Phosphate) NF AL; Up to 64

yrs old; MO

quinidine gluconate tbcr or324 mg

$0-$3.30(Tier

1)

MO

quinidine sulfate tabs$0-

$3.30(Tier

1)

MO

Antiarrhythmics Type I-B

mexiletine hcl caps$0-

$3.30(Tier

1)

MO

Antiarrhythmics Type I-C

flecainide acetate tabs 100mg

$0-$3.30(Tier

1)

SL(4 ea daily);MO


$0-$3.30(Tier

1)



$0-$3.30(Tier

1)

SL(8 ea daily);MO

Drug Name DrugTier

Requirements/Limits

propafenone hcl cp12$0-

$3.30(Tier

1)

MO

propafenone hcl tabs$0-

$3.30(Tier

1)

MO

RYTHMOL SR CP12(Propafenone HCl) NF MO

RYTHMOL TABS(Propafenone HCl) NF MO

Antiarrhythmics Type III

amiodarone hcl tabs or 200mg, 400 mg, 100 mg

$0-$3.30(Tier

1)

MO

CORDARONE TABS(Amiodarone HCl) NF MO

dofetilide caps$0-

$3.30(Tier

1)

MULTAQ TABS$0-

$8.25(Tier

2)

MO

TIKOSYN CAPS(Dofetilide)

$0-$8.25(Tier

2)

ANTIASTHMATIC AND BRONCHODILATORAGENTS - Drugs to Treat Lung ConditionsAnti-Inflammatory Agents

cromolyn sodium nebu in$0-

$3.30(Tier

1)

B/D; MO

Antiasthmatic - Monoclonal Antibodies

CINQAIR SOLN$0-

$8.25(Tier

2)

PA; LA

NUCALA SOLR$0-

$8.25(Tier

2)

PA; LA



19

Drug Name DrugTier

Requirements/Limits

XOLAIR SOLR$0-

$8.25(Tier

2)

PA; LA

Bronchodilators - Anticholinergics

ATROVENT HFA AERS$0-

$8.25(Tier

2)

Limit 2 inhalerspermonth;QL(0.86gm daily); MO

ipratropium bromide soln in$0-

$3.30(Tier

1)

B/D; MO

SPIRIVA HANDIHALERCAPS

$0-$8.25(Tier

2)

QL(1 ea daily);MO

SPIRIVA RESPIMATAERS

$0-$8.25(Tier

2)

Limit 1 inhalerper month (60actuations);SL(0.14 gm daily);MO

TUDORZA PRESSAIRAEPB

$0-$8.25(Tier

2)

Limit 2 inhalersper month (30actuations);QL(0.07 ea daily);MO

TUDORZA PRESSAIRAEPB

$0-$8.25(Tier

2)

Limit 1 inhalerper month (60actuations);QL(0.04 ea daily);MO

Leukotriene ModulatorsACCOLATE TABS(Zafirlukast) NF MO

montelukast sodium chew4 mg, 5 mg

$0-$3.30(Tier

1)

MO

montelukast sodium tabs10 mg

$0-$3.30(Tier

1)

MO

SINGULAIR CHEW 4 MG,5 MG (MontelukastSodium)

NFMO

SINGULAIR TABS 10 MG(Montelukast Sodium) NF MO

Drug Name DrugTier

Requirements/Limits

zafirlukast tabs$0-

$3.30(Tier

1)

MO

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP TABS$0-

$8.25(Tier

2)

QL(1 ea daily);MO

Steroid Inhalants

AEROSPAN AERS$0-

$8.25(Tier

2)

Limit 2 inhalersper month (120actuations);SL(0.6 gm daily);MO

AEROSPAN AERS$0-

$8.25(Tier

2)

Limit 4 inhalersper month(institutionalpack);SL(0.68gm daily); MO

budesonide (inhalation)susp 0.5 mg/2ml, 0.25mg/2ml

$0-$3.30(Tier

1)

B/D; MO

FLOVENT DISKUS AEPB100 MCG/BLIST

$0-$8.25(Tier

2)

SL(20 ea daily);MO


$0-$8.25(Tier

2)

SL(8 ea daily);MO


$0-$8.25(Tier

2)

SL(40 ea daily);MO

FLOVENT HFA AERO 220MCG/ACT, 110 MCG/ACT

$0-$8.25(Tier

2)


FLOVENT HFA AERO 44MCG/ACT

$0-$8.25(Tier

2)

Limit 1 inhalerpermonth;QL(0.36gm daily); MO

PULMICORT SUSP 0.25MG/2ML, 0.5 MG/2ML(Budesonide (Inhalation))

NFB/D; MO



20

Drug Name DrugTier

Requirements/Limits

QVAR AERS$0-

$8.25(Tier

2)


Sympathomimetics

ADVAIR DISKUS AEPB$0-

$8.25(Tier

2)

MO

ADVAIR HFA AERO$0-

$8.25(Tier

2)

QL(4 gm daily);MO

albuterol sulfate nebu in0.083 %, 1.25 mg/3ml, 0.5%, 0.63 mg/3ml

$0-$3.30(Tier

1)

B/D; MO

albuterol sulfate syrp or 2mg/5ml

$0-$3.30(Tier

1)

MO

albuterol sulfate tabs or 4mg, 2 mg

$0-$3.30(Tier

1)

MO

albuterol sulfate tb12 or 8mg, 4 mg

$0-$3.30(Tier

1)

MO

ANORO ELLIPTA AEPB$0-

$8.25(Tier

2)

QL(2 ea daily);MO

BREO ELLIPTA AEPB25MCG/INH-100MCG/INH,25MCG/INH-200MCG/INH

$0-$8.25(Tier

2)

Limit 1 inhalerper month;SL(2ea daily); MO

BREO ELLIPTA AEPB25MCG/INH-200MCG/INH,25MCG/INH-100MCG/INH

$0-$8.25(Tier

2)

Limit 2 inhalersper month(InstitutionalPack);SL(2 eadaily); MO

COMBIVENT RESPIMATAERS

$0-$8.25(Tier

2)

Limit 1 inhalerpermonth;SL(0.2gm daily); MO

Drug Name DrugTier

Requirements/Limits

DULERA AERO$0-

$8.25(Tier

2)

QL(4 gm daily);MO

ipratropium-albuterol soln$0-

$3.30(Tier

1)

B/D; MO

levalbuterol hcl nebu in0.63 mg/3ml, 0.31 mg/3ml,1.25 mg/3ml, 1.25mg/0.5ml

$0-$3.30(Tier

1)

B/D; MO

PROAIR HFA AERS$0-

$8.25(Tier

2)

MO

PROAIR RESPICLICKAEPB

$0-$8.25(Tier

2)

MO

PROVENTIL HFA AERS$0-

$8.25(Tier

2)

MO

SEREVENT DISKUSAEPB

$0-$8.25(Tier

2)

QL(2 ea daily);MO

STIOLTO RESPIMATAERS

$0-$8.25(Tier

2)

Limit 1 inhalerpermonth;QL(0.14gm daily); MO

STRIVERDI RESPIMATAERS

$0-$8.25(Tier

2)

Limit 1 inhalerper month (60actuations);SL(0.14 gm daily);MO

terbutaline sulfate tabs or2.5 mg, 5 mg

$0-$3.30(Tier

1)

MO

XOPENEXCONCENTRATE NEBU(Levalbuterol HCl)

NFB/D; MO

XOPENEX NEBU(Levalbuterol HCl) NF B/D; MO

Xanthines



21

Drug Name DrugTier

Requirements/Limits

aminophylline soln$0-

$3.30(Tier

1)

theophylline tb12 300 mg,100 mg, 450 mg, 200 mg

$0-$3.30(Tier

1)

MO

theophylline tb24 400 mg,600 mg

$0-$3.30(Tier

1)

MO

ANTICOAGULANTS - Blood Thinners

Coumarin AnticoagulantsCOUMADIN TABS(Warfarin Sodium) NF MO

warfarin sodium tabs$0-

$3.30(Tier

1)

MO

Direct Factor Xa Inhibitors

ELIQUIS TABS$0-

$8.25(Tier

2)

MO

XARELTO STARTERPACK TBPK

$0-$8.25(Tier

2)

MO

XARELTO TABS$0-

$8.25(Tier

2)

MO

Heparins And Heparinoid-Like AgentsARIXTRA SOLN(Fondaparinux Sodium) NF MO

enoxaparin sodium soln$0-

$3.30(Tier

1)

MO

fondaparinux sodium soln$0-

$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

FRAGMIN SOLN$0-

$8.25(Tier

2)

MO

heparin sodium (porcine)soln

$0-$3.30(Tier

1)

MO

LOVENOX SOLN(Enoxaparin Sodium) NF MO

Thrombin Inhibitors

argatroban soln 250mg/2.5ml

$0-$3.30(Tier

1)

MO

IPRIVASK SOLR$0-

$8.25(Tier

2)

PRADAXA CAPS$0-

$8.25(Tier

2)

MO

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists

FYCOMPA SUSP$0-

$8.25(Tier

2)

MO

FYCOMPA TABS$0-

$8.25(Tier

2)

MO

Anticonvulsants - Benzodiazepines

clonazepam tabs or 0.5 mg$0-

$3.30(Tier

1)

SL(40 ea daily);MO

clonazepam tabs or 1 mg$0-

$3.30(Tier

1)

SL(20 ea daily);MO

clonazepam tabs or 2 mg$0-

$3.30(Tier

1)

SL(10 ea daily);MO



22

Drug Name DrugTier

Requirements/Limits

clonazepam tbdp or 1 mg,2 mg, 0.5 mg, 0.25 mg,0.125 mg

$0-$3.30(Tier

1)

MO

DIASTAT ACUDIAL GEL$0-

$8.25(Tier

2)

MO

DIASTAT PEDIATRIC GEL$0-

$8.25(Tier

2)

MO

DIAZEPAM GEL RE 20MG, 2.5 MG, 10 MG

$0-$8.25(Tier

2)

MO

DIAZEPAM RECTAL GELGEL

$0-$8.25(Tier

2)

MO

KLONOPIN TABS 0.5 MG(Clonazepam) NF SL(40 ea daily);

MOKLONOPIN TABS 1 MG(Clonazepam) NF SL(20 ea daily);

MOKLONOPIN TABS 2 MG(Clonazepam) NF SL(10 ea daily);

MO

ONFI SUSP$0-

$8.25(Tier

2)

MO

ONFI TABS$0-

$8.25(Tier

2)

MO

Anticonvulsants - Misc.

APTIOM TABS$0-

$8.25(Tier

2)

MO

BANZEL SUSP$0-

$8.25(Tier

2)

MO

BANZEL TABS$0-

$8.25(Tier

2)

MO

Drug Name DrugTier

Requirements/Limits

BRIVIACT SOLN IV 50MG/5ML

$0-$8.25(Tier

2)

SL(20 ml daily)

BRIVIACT SOLN OR 10MG/ML

$0-$8.25(Tier

2)

PA; SL(20 mldaily); MO

BRIVIACT TABS OR 10MG

$0-$8.25(Tier

2)

PA; SL(20 eadaily); MO


$0-$8.25(Tier

2)



$0-$8.25(Tier

2)



$0-$8.25(Tier

2)



$0-$8.25(Tier

2)

PA; SL(2.67 eadaily); MO

carbamazepine chew or100 mg

$0-$3.30(Tier

1)

MO

carbamazepine cp12 or200 mg, 300 mg, 100 mg

$0-$3.30(Tier

1)

MO

carbamazepine susp or100 mg/5ml

$0-$3.30(Tier

1)

MO

carbamazepine tabs or 200mg

$0-$3.30(Tier

1)

MO

carbamazepine tb12 or 400mg, 200 mg, 100 mg

$0-$3.30(Tier

1)

MO



23

Drug Name DrugTier

Requirements/Limits

CARBATROL CP12(Carbamazepine) NF MO

gabapentin caps or 300mg, 400 mg, 100 mg

$0-$3.30(Tier

1)

MO

gabapentin soln or 250mg/5ml, 300 mg/6ml

$0-$3.30(Tier

1)

MO

gabapentin tabs or 800 mg,600 mg

$0-$3.30(Tier

1)

MO

KEPPRA SOLN(Levetiracetam) NF MO

KEPPRA TABS(Levetiracetam) NF MO

KEPPRA XR TB24(Levetiracetam) NF MO

LAMICTAL CHEWABLEDISPERSIBLE CHEW(Lamotrigine)

NFMO

LAMICTAL TABS(Lamotrigine) NF MO

LAMICTAL XR KIT$0-

$8.25(Tier

2)

MO

LAMICTAL XR TB24 25MG, 250 MG, 100 MG, 200MG, 50 MG, 300 MG(Lamotrigine)

NF

MO

lamotrigine chew 25 mg, 5mg

$0-$3.30(Tier

1)

MO

lamotrigine tabs 100 mg,200 mg, 150 mg, 25 mg

$0-$3.30(Tier

1)

MO

lamotrigine tb24 300 mg,50 mg, 250 mg, 100 mg, 25mg, 200 mg

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

levetiracetam in sodiumchloride soln

$0-$3.30(Tier

1)LEVETIRACETAM SOLNIV 1000MG/100ML-750MG/100ML,500MG/100ML-820MG/100ML,1500MG/100ML-540MG/100ML(Levetiracetam in SodiumChloride)

$0-$8.25(Tier

2)

levetiracetam soln iv 500mg/5ml

$0-$3.30(Tier

1)

MO

levetiracetam soln or 100mg/ml, 500 mg/5ml

$0-$3.30(Tier

1)

MO

levetiracetam tabs or 500mg, 1000 mg, 750 mg, 250mg

$0-$3.30(Tier

1)

MO

levetiracetam tb24 or 500mg, 750 mg

$0-$3.30(Tier

1)

MO

LYRICA CAPS 100 MG$0-

$8.25(Tier

2)

SL(6 ea daily);MO


$8.25(Tier

2)

SL(4 ea daily);MO


$8.25(Tier

2)

SL(3 ea daily);MO


$8.25(Tier

2)



$8.25(Tier

2)

SL(24 ea daily);MO



24

Drug Name DrugTier

Requirements/Limits


$8.25(Tier

2)

SL(2 ea daily);MO


$8.25(Tier

2)

SL(12 ea daily);MO


$8.25(Tier

2)

SL(8 ea daily);MO

LYRICA SOLN 20 MG/ML$0-

$8.25(Tier

2)

SL(30 ml daily);MO

MYSOLINE TABS(Primidone) NF MO

NEURONTIN CAPS(Gabapentin) NF MO

NEURONTIN SOLN(Gabapentin) NF MO

NEURONTIN TABS(Gabapentin) NF MO

oxcarbazepine susp$0-

$3.30(Tier

1)

MO

oxcarbazepine tabs$0-

$3.30(Tier

1)

MO

POTIGA TABS 200 MG$0-

$8.25(Tier

2)

SL(6 ea daily);MO


$8.25(Tier

2)

SL(4 ea daily);MO


$8.25(Tier

2)

SL(3 ea daily);MO


$8.25(Tier

2)

SL(24 ea daily);MO

Drug Name DrugTier

Requirements/Limits

primidone tabs or 250 mg,50 mg

$0-$3.30(Tier

1)

MO

SPRITAM TB3D 1000 MG$0-

$8.25(Tier

2)



$8.25(Tier

2)



$8.25(Tier

2)



$8.25(Tier

2)


TEGRETOL SUSP(Carbamazepine) NF MO

TEGRETOL TABS(Carbamazepine) NF MO

TEGRETOL-XR TB12 100MG (Carbamazepine)

$0-$8.25(Tier

2)

MO

TEGRETOL-XR TB12 200MG, 400 MG(Carbamazepine)

NFMO

TOPAMAX SPRINKLECPSP (Topiramate) NF MO

TOPAMAX TABS(Topiramate) NF MO

topiramate cpsp or 25 mg,15 mg

$0-$3.30(Tier

1)

MO

topiramate tabs or 100 mg,200 mg, 25 mg, 50 mg

$0-$3.30(Tier

1)

MO

TRILEPTAL SUSP(Oxcarbazepine) NF MO

TRILEPTAL TABS(Oxcarbazepine) NF MO



25

Drug Name DrugTier

Requirements/Limits

VIMPAT SOLN IV 200MG/20ML

$0-$8.25(Tier

2)

VIMPAT SOLN OR 10MG/ML

$0-$8.25(Tier

2)

MO

VIMPAT TABS OR 50 MG,200 MG, 100 MG, 150 MG

$0-$8.25(Tier

2)

MO

ZONEGRAN CAPS(Zonisamide) NF MO

zonisamide caps$0-

$3.30(Tier

1)

MO

Carbamates

felbamate susp$0-

$3.30(Tier

1)

MO

felbamate tabs$0-

$3.30(Tier

1)

MO

FELBATOL SUSP(Felbamate) NF MO

FELBATOL TABS(Felbamate) NF MO

GABA Modulators

GABITRIL TABS 16 MG,12 MG

$0-$8.25(Tier

2)

MO

GABITRIL TABS 2 MG, 4MG (Tiagabine HCl) NF MO

SABRIL PACK (Vigabatrin)

$0-$8.25(Tier

2)

LA

SABRIL TABS$0-

$8.25(Tier

2)

LA

Drug Name DrugTier

Requirements/Limits

tiagabine hcl tabs$0-

$3.30(Tier

1)

MO

vigabatrin pack$0-

$3.30(Tier

1)

LA

HydantoinsCEREBYX SOLN 100 MGPE/2ML (FosphenytoinSodium)

NF

CEREBYX SOLN 500 MGPE/10ML (FosphenytoinSodium)

NFMO

DILANTIN-125 SUSP(Phenytoin) NF MO

fosphenytoin sodium soln100 mg pe/2ml

$0-$3.30(Tier

1)

fosphenytoin sodium soln500 mg pe/10ml

$0-$3.30(Tier

1)

MO

PEGANONE TABS$0-

$8.25(Tier

2)

MO

phenytoin chew or 50 mg$0-

$3.30(Tier

1)

MO

phenytoin sodium extendedcaps 30 mg, 300 mg, 100mg, 200 mg

$0-$3.30(Tier

1)

MO

phenytoin sodium soln ij$0-

$3.30(Tier

1)

phenytoin susp or 125mg/5ml

$0-$3.30(Tier

1)

MO

Succinimides



26

Drug Name DrugTier

Requirements/Limits

CELONTIN CAPS$0-

$8.25(Tier

2)

MO

ethosuximide caps or 250mg

$0-$3.30(Tier

1)

MO

ethosuximide soln or 250mg/5ml

$0-$3.30(Tier

1)

MO

ZARONTIN CAPS(Ethosuximide) NF MO

Valproic AcidDEPACON SOLN(Valproate Sodium) NF

DEPAKENE CAPS(Valproic Acid) NF MO

DEPAKENE SOLN(Valproate Sodium) NF MO

DEPAKOTE ER TB24(Divalproex Sodium) NF MO

DEPAKOTE SPRINKLESCSDR (Divalproex Sodium) NF MO

DEPAKOTE TBEC(Divalproex Sodium) NF MO

divalproex sodium csdr$0-

$3.30(Tier

1)

MO

divalproex sodium tb24$0-

$3.30(Tier

1)

MO

divalproex sodium tbec$0-

$3.30(Tier

1)

MO

valproate sodium soln iv500 mg/5ml, 100 mg/ml

$0-$3.30(Tier

1)

valproate sodium soln or250 mg/5ml

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

valproic acid caps or$0-

$3.30(Tier

1)

MO

ANTIDEPRESSANTS - Drugs to Treat Depression

Alpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tabs$0-

$3.30(Tier

1)

MO

mirtazapine tbdp$0-

$3.30(Tier

1)

MO

REMERON SOLTAB TBDP(Mirtazapine) NF MO

REMERON TABS(Mirtazapine) NF MO

Antidepressants - Misc.

bupropion hcl tabs or 100mg

$0-$3.30(Tier

1)

SL(4.5 eadaily); MO

bupropion hcl tabs or 75mg

$0-$3.30(Tier

1)

SL(6 ea daily);MO

bupropion hcl tb12 or 100mg

$0-$3.30(Tier

1)

SL(4 ea daily);MO


$0-$3.30(Tier

1)



$0-$3.30(Tier

1)

SL(2 ea daily);MO


$0-$3.30(Tier

1)

SL(3 ea daily);MO


$0-$3.30(Tier

1)

SL(1.5 eadaily); MO



27

Drug Name DrugTier

Requirements/Limits

FORFIVO XL TB24$0-

$8.25(Tier

2)

ST; MO

maprotiline hcl tabs$0-

$3.30(Tier

1)

MO

WELLBUTRIN SR TB12100 MG (Bupropion HCl) NF SL(4 ea daily);

MOWELLBUTRIN SR TB12150 MG (Bupropion HCl) NF SL(2.66 ea

daily); MOWELLBUTRIN SR TB12200 MG (Bupropion HCl) NF SL(2 ea daily);

MOWELLBUTRIN TABS 100MG (Bupropion HCl) NF SL(4.5 ea

daily); MOWELLBUTRIN TABS 75MG (Bupropion HCl) NF SL(6 ea daily);

MOWELLBUTRIN XL TB24150 MG (Bupropion HCl) NF SL(3 ea daily);

MOWELLBUTRIN XL TB24300 MG (Bupropion HCl) NF SL(1.5 ea

daily); MOMonoamine Oxidase Inhibitors (MAOIs)

EMSAM PT24$0-

$8.25(Tier

2)

MO

MARPLAN TABS$0-

$8.25(Tier

2)

MO

NARDIL TABS (PhenelzineSulfate) NF MO

PARNATE TABS(Tranylcypromine Sulfate) NF MO

phenelzine sulfate tabs or$0-

$3.30(Tier

1)

MO

tranylcypromine sulfatetabs

$0-$3.30(Tier

1)

MO

Selective Serotonin Reuptake Inhibitors (SSRIs)CELEXA TABS 10 MG(Citalopram Hydrobromide) NF SL(4 ea daily);

MO

Drug Name DrugTier

Requirements/Limits

CELEXA TABS 20 MG(Citalopram Hydrobromide) NF SL(2 ea daily);

MOCELEXA TABS 40 MG(Citalopram Hydrobromide) NF SL(1 ea daily);

MO

citalopram hydrobromidesoln 10 mg/5ml

$0-$3.30(Tier

1)

SL(20 ml daily);MO

citalopram hydrobromidetabs 10 mg

$0-$3.30(Tier

1)

SL(4 ea daily);MO


$0-$3.30(Tier

1)

SL(2 ea daily);MO


$0-$3.30(Tier

1)

SL(1 ea daily);MO

escitalopram oxalate soln$0-

$3.30(Tier

1)

MO

escitalopram oxalate tabs$0-

$3.30(Tier

1)

MO

fluoxetine hcl caps or 10mg, 40 mg, 20 mg

$0-$3.30(Tier

1)

MO

fluoxetine hcl cpdr or 90 mg$0-

$3.30(Tier

1)

MO

fluoxetine hcl soln or 20mg/5ml

$0-$3.30(Tier

1)

MO

fluoxetine hcl tabs or 10mg, 20 mg

$0-$3.30(Tier

1)

MO

fluvoxamine maleate cp24$0-

$3.30(Tier

1)

MO



28

Drug Name DrugTier

Requirements/Limits

fluvoxamine maleate tabs$0-

$3.30(Tier

1)

MO

LEXAPRO SOLN(Escitalopram Oxalate) NF MO

LEXAPRO TABS(Escitalopram Oxalate) NF MO

paroxetine hcl tabs$0-

$3.30(Tier

1)

MO

paroxetine hcl tb24$0-

$3.30(Tier

1)

MO

PAXIL CR TB24(Paroxetine HCl) NF MO

PAXIL SUSP 10 MG/5ML$0-

$8.25(Tier

2)

MO

PAXIL TABS 20 MG, 40MG, 30 MG, 10 MG(Paroxetine HCl)

NFMO

PROZAC CAPS(Fluoxetine HCl) NF MO

PROZAC WEEKLY CPDR(Fluoxetine HCl) NF MO

sertraline hcl conc or 20mg/ml

$0-$3.30(Tier

1)

MO

sertraline hcl tabs or 100mg, 25 mg, 50 mg

$0-$3.30(Tier

1)

MO

ZOLOFT CONC (SertralineHCl) NF MO

ZOLOFT TABS (SertralineHCl) NF MO

Serotonin Modulators

BRINTELLIX TABS 10 MG$0-

$8.25(Tier

2)

ST; QL(2 eadaily); MO

Drug Name DrugTier

Requirements/Limits


$8.25(Tier

2)



$8.25(Tier

2)


nefazodone hcl tabs$0-

$3.30(Tier

1)

MO

trazodone hcl tabs or 50mg, 100 mg, 300 mg, 150mg

$0-$3.30(Tier

1)

MO

TRINTELLIX TABS 10 MG$0-

$8.25(Tier

2)



$8.25(Tier

2)



$8.25(Tier

2)


VIIBRYD STARTER PACKKIT

$0-$8.25(Tier

2)

ST; MO

VIIBRYD TABS$0-

$8.25(Tier

2)

ST; MO

Serotonin-Norepinephrine Reuptake InhibitorsCYMBALTA CPEP(Duloxetine HCl) NF MO

DESVENLAFAXINE ERTB24 50 MG, 100 MG

$0-$8.25(Tier

2)

ST; MO

desvenlafaxine succinatetb24

$0-$3.30(Tier

1)

MO



29

Drug Name DrugTier

Requirements/Limits

duloxetine hcl cpep 20 mg,60 mg, 30 mg

$0-$3.30(Tier

1)

MO

EFFEXOR XR CP24 150MG (Venlafaxine HCl) NF SL(1.5 ea

daily); MOEFFEXOR XR CP24 37.5MG (Venlafaxine HCl) NF SL(6 ea daily);

MOEFFEXOR XR CP24 75MG (Venlafaxine HCl) NF SL(3 ea daily);

MO

FETZIMA CP24 20 MG$0-

$8.25(Tier

2)


FETZIMA CP24 80 MG,120 MG, 40 MG

$0-$8.25(Tier

2)


FETZIMA TITRATIONPACK C4PK

$0-$8.25(Tier

2)

ST; MO

KHEDEZLA TB24$0-

$8.25(Tier

2)

ST; MO

PRISTIQ TB24(Desvenlafaxine Succinate)

$0-$8.25(Tier

2)

MO

venlafaxine hcl cp24 150mg

$0-$3.30(Tier

1)

SL(1.5 eadaily); MO

venlafaxine hcl cp24 37.5mg

$0-$3.30(Tier

1)

SL(6 ea daily);MO

venlafaxine hcl cp24 75 mg$0-

$3.30(Tier

1)

SL(3 ea daily);MO

VENLAFAXINE HCL ERTB24

$0-$8.25(Tier

2)

ST; SL(1 eadaily); MO

Drug Name DrugTier

Requirements/Limits

venlafaxine hcl tabs 100mg

$0-$3.30(Tier

1)


venlafaxine hcl tabs 25 mg$0-

$3.30(Tier

1)

SL(15 ea daily);MO

venlafaxine hcl tabs 37.5mg

$0-$3.30(Tier

1)

SL(10 ea daily);MO


$3.30(Tier

1)

SL(7.5 eadaily); MO


$3.30(Tier

1)

SL(5 ea daily);MO

venlafaxine hcl tb24 150mg

$0-$3.30(Tier

1)

SL(1.5 eadaily); MO

venlafaxine hcl tb24 225mg

$0-$3.30(Tier

1)

ST; SL(1 eadaily); MO

venlafaxine hcl tb24 37.5mg

$0-$3.30(Tier

1)

SL(6 ea daily);MO

venlafaxine hcl tb24 75 mg$0-

$3.30(Tier

1)

SL(3 ea daily);MO

Tricyclic Agents

amitriptyline hcl tabs$0-

$3.30(Tier

1)


amoxapine tabs$0-

$3.30(Tier

1)

MO

ANAFRANIL CAPS(Clomipramine HCl) NF AL; Up to 64

yrs old; MO



30

Drug Name DrugTier

Requirements/Limits

clomipramine hcl caps or25 mg, 75 mg, 50 mg

$0-$3.30(Tier

1)


desipramine hcl tabs or 50mg, 100 mg, 150 mg, 10mg, 25 mg, 75 mg

$0-$3.30(Tier

1)

MO

doxepin hcl caps or 150mg, 25 mg, 50 mg, 10 mg,100 mg, 75 mg

$0-$3.30(Tier

1)


doxepin hcl conc or 10mg/ml

$0-$3.30(Tier

1)


ELAVIL TABS(Amitriptyline HCl) NF AL; Up to 64

yrs old; MO

imipramine hcl tabs or 25mg, 50 mg, 10 mg

$0-$3.30(Tier

1)


imipramine pamoate caps$0-

$3.30(Tier

1)


NORPRAMIN TABS(Desipramine HCl) NF MO

nortriptyline hcl caps or 50mg, 25 mg, 10 mg, 75 mg

$0-$3.30(Tier

1)

MO

nortriptyline hcl soln or 10mg/5ml

$0-$3.30(Tier

1)

MO

PAMELOR CAPS(Nortriptyline HCl) NF MO

protriptyline hcl tabs$0-

$3.30(Tier

1)

MO

SURMONTIL CAPS$0-

$8.25(Tier

2)


TOFRANIL-PM CAPS(Imipramine Pamoate) NF AL; Up to 64

yrs old; MO

Drug Name DrugTier

Requirements/Limits

trimipramine maleate capsor 100 mg, 50 mg, 25 mg

$0-$3.30(Tier

1)


ANTIDIABETICS - Drugs to Regulate Blood Sugar

Alpha-Glucosidase Inhibitors

acarbose tabs$0-

$3.30(Tier

1)

QL(3 ea daily);MO

GLYSET TABS (Miglitol)$0-

$8.25(Tier

2)

QL(3 ea daily);MO

miglitol tabs$0-

$3.30(Tier

1)

QL(3 ea daily);MO

PRECOSE TABS(Acarbose) NF QL(3 ea daily);

MOAntidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN$0-

$8.25(Tier

2)

Limit 12mls permonth;QL(0.4ml daily); MO

SYMLINPEN 60 SOPN$0-

$8.25(Tier

2)


Antidiabetic CombinationsACTOPLUS MET TABS(Pioglitazone HCl-Metformin HCl)

NFSL(3 ea daily);MO

ALOGLIPTIN/METFORMINHCL TABS

$0-$8.25(Tier

2)


ALOGLIPTIN/PIOGLITAZONE TABS 12.5MG-15MG

$0-$8.25(Tier

2)


ALOGLIPTIN/PIOGLITAZONE TABS 12.5MG-30MG

$0-$8.25(Tier

2)




31

Drug Name DrugTier

Requirements/Limits

ALOGLIPTIN/PIOGLITAZONE TABS 25MG-30MG,25MG-15MG, 25MG-45MG, 12.5MG-45MG

$0-$8.25(Tier

2)


DUETACT TABS(Pioglitazone HCl-Glimepiride)

NFSL(1.5 eadaily); MO

glipizide-metformin hcl tabs2.5mg-250mg

$0-$3.30(Tier

1)

SL(8 ea daily);MO

glipizide-metformin hcl tabs5mg-500mg, 2.5mg-500mg

$0-$3.30(Tier

1)

SL(4 ea daily);MO

GLUCOVANCE TABS(Glyburide-Metformin) NF


glyburide-metformin tabs1.25mg-250mg

$0-$3.30(Tier

1)


glyburide-metformin tabs2.5mg-500mg, 5mg-500mg

$0-$3.30(Tier

1)


INVOKAMET TABS150MG-1000MG, 150MG-500MG, 50MG-1000MG

$0-$8.25(Tier

2)

SL(2 ea daily);MO

INVOKAMET TABS 50MG-500MG

$0-$8.25(Tier

2)

SL(4 ea daily);MO

INVOKAMET XR TB24150MG-500MG, 150MG-1000MG, 50MG-1000MG

$0-$8.25(Tier

2)

SL(2 ea daily);MO

INVOKAMET XR TB2450MG-500MG

$0-$8.25(Tier

2)

SL(4 ea daily);MO

JANUMET TABS$0-

$8.25(Tier

2)

SL(2 ea daily);MO

Drug Name DrugTier

Requirements/Limits

JANUMET XR TB24100MG-1000MG

$0-$8.25(Tier

2)

SL(1 ea daily);MO

JANUMET XR TB2450MG-500MG, 50MG-1000MG

$0-$8.25(Tier

2)

SL(2 ea daily);MO

JENTADUETO TABS$0-

$8.25(Tier

2)

SL(2 ea daily);MO

JENTADUETO XR TB242.5MG-1000MG

$0-$8.25(Tier

2)

SL(2 ea daily);MO

JENTADUETO XR TB245MG-1000MG

$0-$8.25(Tier

2)

SL(1 ea daily);MO

KAZANO TABS$0-

$8.25(Tier

2)


KOMBIGLYZE XR TB242.5MG-1000MG

$0-$8.25(Tier

2)


KOMBIGLYZE XR TB245MG-1000MG, 5MG-500MG

$0-$8.25(Tier

2)


OSENI TABS 12.5MG-15MG

$0-$8.25(Tier

2)


OSENI TABS 12.5MG-30MG

$0-$8.25(Tier

2)


OSENI TABS 12.5MG-45MG, 25MG-15MG,25MG-45MG, 25MG-30MG

$0-$8.25(Tier

2)


pioglitazone hcl-glimepiridetabs

$0-$3.30(Tier

1)

SL(1.5 eadaily); MO



32

Drug Name DrugTier

Requirements/Limits

pioglitazone hcl-metforminhcl tabs

$0-$3.30(Tier

1)

SL(3 ea daily);MO

repaglinide-metformin hcltabs

$0-$3.30(Tier

1)

SL(5 ea daily);MO

SYNJARDY TABS 5MG-1000MG, 12.5MG-1000MG

$0-$8.25(Tier

2)

SL(2 ea daily);MO

SYNJARDY TABS 5MG-500MG, 12.5MG-500MG

$0-$8.25(Tier

2)

SL(4 ea daily);MO

SYNJARDY XR TB2410MG-1000MG, 5MG-1000MG

$0-$8.25(Tier

2)

SL(2 ea daily)

SYNJARDY XR TB2412.5MG-1000MG

$0-$8.25(Tier

2)

SL(2 ea daily);MO

SYNJARDY XR TB2425MG-1000MG

$0-$8.25(Tier

2)

SL(1 ea daily)

BiguanidesFORTAMET TB24 1000MG (Metformin HCl) NF Osmotic;SL(2.5

ea daily); MOFORTAMET TB24 500 MG(Metformin HCl) NF Osmotic;SL(5

ea daily); MOGLUCOPHAGE TABS1000 MG (Metformin HCl) NF SL(2.55 ea

daily); MOGLUCOPHAGE TABS 500MG (Metformin HCl) NF SL(5.1 ea

daily); MOGLUCOPHAGE TABS 850MG (Metformin HCl) NF SL(3 ea daily);

MOGLUCOPHAGE XR TB24500 MG (Metformin HCl) NF SL(4 ea daily);

MOGLUCOPHAGE XR TB24750 MG (Metformin HCl) NF SL(2.66 ea

daily); MO

metformin hcl tabs or 1000mg

$0-$3.30(Tier

1)


Drug Name DrugTier

Requirements/Limits


$0-$3.30(Tier

1)

SL(5.1 eadaily); MO


$0-$3.30(Tier

1)

SL(3 ea daily);MO

metformin hcl tb24 or 1000mg

$0-$3.30(Tier

1)

Osmotic;SL(2.5ea daily); MO


$0-$3.30(Tier

1)

Osmotic;SL(5ea daily); MO


$0-$3.30(Tier

1)

SL(4 ea daily);MO


$0-$3.30(Tier

1)


Diabetic Other

GLUCAGEN HYPOKITSOLR

$0-$8.25(Tier

2)

MO

GLUCAGONEMERGENCY KIT KIT

$0-$8.25(Tier

2)

MO

KORLYM TABS$0-

$8.25(Tier

2)

SL(4 ea daily);LA

PROGLYCEM SUSP$0-

$8.25(Tier

2)

MO

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

ALOGLIPTIN TABS 12.5MG

$0-$8.25(Tier

2)




33

Drug Name DrugTier

Requirements/Limits

ALOGLIPTIN TABS 25 MG$0-

$8.25(Tier

2)


ALOGLIPTIN TABS 6.25MG

$0-$8.25(Tier

2)


JANUVIA TABS 100 MG$0-

$8.25(Tier

2)

QL(1 ea daily);MO


$8.25(Tier

2)

QL(4 ea daily);MO


$8.25(Tier

2)

QL(2 ea daily);MO

NESINA TABS 12.5 MG$0-

$8.25(Tier

2)


NESINA TABS 25 MG$0-

$8.25(Tier

2)


NESINA TABS 6.25 MG$0-

$8.25(Tier

2)


ONGLYZA TABS 2.5 MG$0-

$8.25(Tier

2)


ONGLYZA TABS 5 MG$0-

$8.25(Tier

2)


TRADJENTA TABS$0-

$8.25(Tier

2)

QL(1 ea daily);MO

Dopamine Receptor Agonists - Antidiabetic

Drug Name DrugTier

Requirements/Limits

CYCLOSET TABS$0-

$8.25(Tier

2)

QL(6 ea daily);MO

Incretin Mimetic Agents (GLP-1 Receptor

BYDUREON PEN PEN$0-

$8.25(Tier

2)

ST; MO

BYDUREON SRER$0-

$8.25(Tier

2)

ST; MO

BYETTA SOPN$0-

$8.25(Tier

2)

ST; MO

VICTOZA SOPN$0-

$8.25(Tier

2)

ST; Limit 9mlspermonth;QL(0.3ml daily); MO

Insulin Sensitizing AgentsACTOS TABS 15 MG(Pioglitazone HCl) NF SL(3 ea daily);

MOACTOS TABS 30 MG(Pioglitazone HCl) NF SL(1.5 ea

daily); MOACTOS TABS 45 MG(Pioglitazone HCl) NF SL(1 ea daily);

MO

AVANDIA TABS 2 MG$0-

$8.25(Tier

2)

SL(4 ea daily);MO

AVANDIA TABS 4 MG$0-

$8.25(Tier

2)

SL(2 ea daily);MO

pioglitazone hcl tabs 15 mg$0-

$3.30(Tier

1)

SL(3 ea daily);MO


$3.30(Tier

1)

SL(1.5 eadaily); MO


$3.30(Tier

1)

SL(1 ea daily);MO



34

Drug Name DrugTier

Requirements/Limits

Insulin

HUMALOG JUNIORKWIKPEN SOPN

$0-$8.25(Tier

2)


HUMALOG KWIKPENSOPN

$0-$8.25(Tier

2)


HUMALOG MIX 50/50KWIKPEN SUPN

$0-$8.25(Tier

2)


HUMALOG MIX 50/50SUSP

$0-$8.25(Tier

2)


HUMALOG MIX 75/25KWIKPEN SUPN

$0-$8.25(Tier

2)


HUMALOG MIX 75/25SUSP

$0-$8.25(Tier

2)


HUMALOG SOCT$0-

$8.25(Tier

2)


HUMALOG SOLN$0-

$8.25(Tier

2)


HUMULIN 70/30 KWIKPENSUPN

$0-$8.25(Tier

2)


HUMULIN 70/30 SUSP$0-

$8.25(Tier

2)


HUMULIN N KWIKPENSUPN

$0-$8.25(Tier

2)


Drug Name DrugTier

Requirements/Limits

HUMULIN N SUSP$0-

$8.25(Tier

2)


HUMULIN R SOLN$0-

$8.25(Tier

2)


HUMULIN R U-500(CONCENTRATED) SOLN

$0-$8.25(Tier

2)


HUMULIN R U-500KWIKPEN SOPN

$0-$8.25(Tier

2)


LANTUS SOLN$0-

$8.25(Tier

2)


LANTUS SOLOSTARSOPN

$0-$8.25(Tier

2)


LEVEMIR FLEXTOUCHSOPN

$0-$8.25(Tier

2)


LEVEMIR SOLN$0-

$8.25(Tier

2)


TOUJEO SOLOSTARSOPN

$0-$8.25(Tier

2)


TRESIBA FLEXTOUCHSOPN 100 UNIT/ML

$0-$8.25(Tier

2)


TRESIBA FLEXTOUCHSOPN 200 UNIT/ML

$0-$8.25(Tier

2)


Meglitinide Analogues



35

Drug Name DrugTier

Requirements/Limits

nateglinide tabs$0-

$3.30(Tier

1)

QL(3 ea daily);MO

PRANDIN TABS 0.5 MG(Repaglinide) NF SL(32 ea daily);

MOPRANDIN TABS 1 MG(Repaglinide) NF SL(16 ea daily);

MOPRANDIN TABS 2 MG(Repaglinide) NF SL(8 ea daily);

MO

repaglinide tabs 0.5 mg$0-

$3.30(Tier

1)

SL(32 ea daily);MO

repaglinide tabs 1 mg$0-

$3.30(Tier

1)

SL(16 ea daily);MO

repaglinide tabs 2 mg$0-

$3.30(Tier

1)

SL(8 ea daily);MO

STARLIX TABS(Nateglinide) NF QL(3 ea daily);

MOSodium-Glucose Co-Transporter 2 (SGLT2)

INVOKANA TABS$0-

$8.25(Tier

2)

MO

JARDIANCE TABS$0-

$8.25(Tier

2)

MO

SulfonylureasAMARYL TABS 1 MG(Glimepiride) NF SL(8 ea daily);

MOAMARYL TABS 2 MG(Glimepiride) NF SL(4 ea daily);

MOAMARYL TABS 4 MG(Glimepiride) NF SL(2 ea daily);

MO

DIABETA TABS 1.25 MG(Glyburide)

$0-$8.25(Tier

2)

AL; Up to 64yrs old; SL(16ea daily); MO

Drug Name DrugTier

Requirements/Limits

DIABETA TABS 2.5 MG(Glyburide)

$0-$8.25(Tier

2)


DIABETA TABS 5 MG(Glyburide)

$0-$8.25(Tier

2)


glimepiride tabs 1 mg$0-

$3.30(Tier

1)

SL(8 ea daily);MO


$3.30(Tier

1)

SL(4 ea daily);MO


$3.30(Tier

1)

SL(2 ea daily);MO

glipizide tabs or 10 mg$0-

$3.30(Tier

1)

SL(4 ea daily);MO

glipizide tabs or 5 mg$0-

$3.30(Tier

1)

SL(8 ea daily);MO

glipizide tb24 or 10 mg$0-

$3.30(Tier

1)

SL(2 ea daily);MO

glipizide tb24 or 2.5 mg$0-

$3.30(Tier

1)

SL(8 ea daily);MO

glipizide tb24 or 5 mg$0-

$3.30(Tier

1)

SL(4 ea daily);MO

GLUCOTROL TABS 10MG (Glipizide) NF SL(4 ea daily);

MOGLUCOTROL TABS 5 MG(Glipizide) NF SL(8 ea daily);

MOGLUCOTROL XL TB24 10MG (Glipizide) NF SL(2 ea daily);

MOGLUCOTROL XL TB24 2.5MG (Glipizide) NF SL(8 ea daily);

MO



36

Drug Name DrugTier

Requirements/Limits

GLUCOTROL XL TB24 5MG (Glipizide) NF SL(4 ea daily);

MO

glyburide micronized tabs1.5 mg

$0-$3.30(Tier

1)


glyburide micronized tabs 3mg

$0-$3.30(Tier

1)


glyburide micronized tabs 6mg

$0-$3.30(Tier

1)


glyburide tabs or 1.25 mg$0-

$3.30(Tier

1)

AL; Up to 64yrs old; SL(16ea daily); MO

glyburide tabs or 2.5 mg$0-

$3.30(Tier

1)


glyburide tabs or 5 mg$0-

$3.30(Tier

1)


GLYNASE TABS 1.5 MG(Glyburide Micronized) NF


GLYNASE TABS 3 MG(Glyburide Micronized) NF


GLYNASE TABS 6 MG(Glyburide Micronized) NF


tolazamide tabs 250 mg$0-

$3.30(Tier

1)

SL(4 ea daily);MO

tolazamide tabs 500 mg$0-

$3.30(Tier

1)

SL(2 ea daily);MO

tolbutamide tabs$0-

$3.30(Tier

1)

SL(6 ea daily);MO

Drug Name DrugTier

Requirements/Limits

ANTIDIARRHEALS - Drugs to Treat Diarrhea

Antidiarrheal Agents - Misc.

bismuth subsalicylate chewor 262 mg

$0(Tier

3)

MO; NT

bismuth subsalicylate suspor 525 mg/15ml

$0(Tier

3)

NT

bismuth subsalicylate suspor 525 mg/30ml, 262mg/15ml, 527 mg/30ml

$0(Tier

3)

MO; NT

bismuth subsalicylate tabsor 262 mg

$0(Tier

3)

NT

PEPTO BISMOL TABS(Bismuth Subsalicylate) NF NT

PEPTO-BISMOL CHEW262 MG (BismuthSubsalicylate)

NFMO; NT

PEPTO-BISMOLINSTACOOL CHEW(Bismuth Subsalicylate)

NFMO; NT

PEPTO-BISMOL MAXSTRENGTH SUSP(Bismuth Subsalicylate)

NFNT

PEPTO-BISMOL SUSP262 MG/15ML (BismuthSubsalicylate)

NFMO; NT

PEPTO-BISMOL TO-GOCHEW (BismuthSubsalicylate)

NFMO; NT

Antiperistaltic Agents

diphenoxylate w/ atropinetabs

$0-$3.30(Tier

1)

MO

IMODIUM A-D CAPS 2 MG(Loperamide HCl) NF RX/OTC; MO;

NTLOMOTIL TABS(Diphenoxylate w/ Atropine) NF MO

loperamide hcl caps or 2mg

$0-$3.30(Tier

1)

RX/OTC; MO

ANTIDOTES AND SPECIFIC ANTAGONISTS



37

Drug Name DrugTier

Requirements/Limits

Antidotes - Chelating Agents

EXJADE TBSO$0-

$8.25(Tier

2)

LA

FERRIPROX TABS 500MG

$0-$8.25(Tier

2)

PA; LA

JADENU TABS$0-

$8.25(Tier

2)

Opioid Antagonists

naloxone hcl sosy ij 2mg/2ml

$0-$3.30(Tier

1)

MO

naltrexone hcl tabs or$0-

$3.30(Tier

1)

MO

ANTIEMETICS - Drugs to Treat Nausea andVomiting5-HT3 Receptor Antagonists

granisetron hcl tabs or 1mg

$0-$3.30(Tier

1)

B/D; MO

ondansetron hcl soln ij 4mg/2ml, 40 mg/20ml

$0-$3.30(Tier

1)

MO

ondansetron hcl soln or 4mg/5ml

$0-$3.30(Tier

1)

B/D; MO

ondansetron hcl tabs or 8mg, 24 mg, 4 mg

$0-$3.30(Tier

1)

B/D; MO

ondansetron tbdp$0-

$3.30(Tier

1)

B/D; MO

ZOFRAN ODT TBDP(Ondansetron) NF B/D; MO

Drug Name DrugTier

Requirements/Limits

ZOFRAN SOLN(Ondansetron HCl) NF B/D; MO

ZOFRAN TABS(Ondansetron HCl) NF B/D; MO

Antiemetics - Anticholinergic

meclizine hcl chew or 25mg

$0(Tier

3)

MO; NT

meclizine hcl tabs or 25mg, 12.5 mg

$0-$3.30(Tier

1)

RX/OTC; MO

meclizine hcl tabs or 25mg, 12.5 mg

$0(Tier

3)


scopolamine pt72$0-

$3.30(Tier

1)

MO

TIGAN SOLN IM 100MG/ML

$0-$8.25(Tier

2)


TRANSDERM-SCOP PT72$0-

$8.25(Tier

2)

MO

TRANSDERM-SCOP PT72(Scopolamine)

$0-$8.25(Tier

2)

MO

Antiemetics - Miscellaneous

CESAMET CAPS$0-

$8.25(Tier

2)

B/D; MO

dronabinol caps$0-

$3.30(Tier

1)

B/D; MO

MARINOL CAPS(Dronabinol) NF B/D; MO

SYNDROS SOLN$0-

$8.25(Tier

2)

B/D

Substance P/Neurokinin 1 (NK1) Receptor



38

Drug Name DrugTier

Requirements/Limits

aprepitant caps 40 mg$0-

$3.30(Tier

1)

PA; MO

aprepitant caps 80 mg, 125mg,

$0-$3.30(Tier

1)

B/D; MO

EMEND CAPS OR 40 MG(Aprepitant)

$0-$8.25(Tier

2)

PA; MO

EMEND CAPS OR 80 MG,125 MG (Aprepitant)

$0-$8.25(Tier

2)

B/D; MO

EMEND TRIPACK CAPS(Aprepitant)

$0-$8.25(Tier

2)

B/D; MO

VARUBI TABS OR 90 MG$0-

$8.25(Tier

2)

B/D

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungal - Glucan Synthesis Inhibitors

CANCIDAS SOLR(Caspofungin Acetate)

$0-$8.25(Tier

2)

MO

caspofungin acetate solr 50mg, 70 mg

$0-$3.30(Tier

1)

MO

CASPOFUNGIN ACETATESOLR 70 MG

$0-$8.25(Tier

2)

MO

ERAXIS SOLR 100 MG$0-

$8.25(Tier

2)

MYCAMINE SOLR$0-

$8.25(Tier

2)

MO

Antifungals

Drug Name DrugTier

Requirements/Limits

ABELCET SUSP$0-

$8.25(Tier

2)

PA

AMBISOME SUSR$0-

$8.25(Tier

2)

PA

amphotericin b solr ij 50 mg$0-

$3.30(Tier

1)

PA; MO

ANCOBON CAPS 500 MG(Flucytosine) NF MO

flucytosine caps 500 mg$0-

$3.30(Tier

1)

MO

GRIS-PEG TABS(GriseofulvinUltramicrosize)

NFMO

griseofulvin microsize susp$0-

$3.30(Tier

1)

MO

griseofulvin microsize tabs$0-

$3.30(Tier

1)

MO

griseofulvin ultramicrosizetabs

$0-$3.30(Tier

1)

MO

LAMISIL TABS 250 MG(Terbinafine HCl) NF MO

nystatin tabs$0-

$3.30(Tier

1)

MO

terbinafine hcl tabs or$0-

$3.30(Tier

1)

MO

Imidazole-Related Antifungals

CRESEMBA CAPS OR186 MG

$0-$8.25(Tier

2)

MO



39

Drug Name DrugTier

Requirements/Limits

CRESEMBA SOLR IV 372MG

$0-$8.25(Tier

2)DIFLUCAN SUSR(Fluconazole) NF MO

DIFLUCAN TABS(Fluconazole) NF MO

fluconazole in dextrosesoln

$0-$3.30(Tier

1)

fluconazole in nacl soln400mg/200ml-0.9%,200mg/100ml-0.9%

$0-$3.30(Tier

1)

fluconazole susr or 10mg/ml, 40 mg/ml

$0-$3.30(Tier

1)

MO

fluconazole tabs or 100mg, 50 mg, 150 mg, 200mg

$0-$3.30(Tier

1)

MO

itraconazole caps or$0-

$3.30(Tier

1)

MO

ketoconazole tabs or$0-

$3.30(Tier

1)

MO

NOXAFIL SOLN IV 300MG/16.7ML

$0-$8.25(Tier

2)

NOXAFIL SUSP OR 40MG/ML

$0-$8.25(Tier

2)

MO

NOXAFIL TBEC OR 100MG

$0-$8.25(Tier

2)

MO

SPORANOX CAPS 100MG (Itraconazole) NF MO

SPORANOX PULSEPAKCAPS (Itraconazole) NF MO

Drug Name DrugTier

Requirements/Limits

VFEND IV SOLR(Voriconazole) NF

VFEND SUSR(Voriconazole) NF MO

VFEND TABS(Voriconazole) NF MO

voriconazole solr iv 200 mg$0-

$3.30(Tier

1)

voriconazole susr or 40mg/ml

$0-$3.30(Tier

1)

MO

voriconazole tabs or 200mg, 50 mg

$0-$3.30(Tier

1)

MO

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - AlkylaminesCHLOR-TRIMETON SYRP2 MG/5ML(ChlorpheniramineMaleate)

NF

AL; Up to 64yrs old; NT

CHLOR-TRIMETON TABS4 MG (ChlorpheniramineMaleate)

NFAL; Up to 64yrs old; MO; NT

chlorpheniramine maleatesyrp or 2 mg/5ml

$0(Tier

3)


chlorpheniramine maleatetabs or 4 mg

$0(Tier

3)

AL; Up to 64yrs old; MO; NT

ED CHLORPED LIQD$0

(Tier3)


Antihistamines - EthanolaminesBENADRYL ALLERGYCAPS (DiphenhydramineHCl)


BENADRYL ALLERGYCHILDRENS LIQD 12.5MG/5ML (DiphenhydramineHCl)

NF




40

Drug Name DrugTier

Requirements/Limits

BENADRYL ALLERGYTABS (DiphenhydramineHCl)


carbinoxamine maleatesoln

$0-$3.30(Tier

1)


carbinoxamine maleatetabs

$0-$3.30(Tier

1)


clemastine fumarate tabsor 2.68 mg

$0-$3.30(Tier

1)


diphenhydramine hcl capsor 25 mg

$0(Tier

3)


diphenhydramine hcl capsor 50 mg

$0(Tier

3)

RX/OTC; MO;NT

diphenhydramine hcl elix or12.5 mg/5ml

$0-$3.30(Tier

1)

AL; Up to 64yrs old;RX/OTC

diphenhydramine hcl liqd or25 mg/10ml, 12.5 mg/5ml,50 mg/20ml

$0(Tier

3)


diphenhydramine hcl soln ij50 mg/ml

$0-$3.30(Tier

1)

MO

diphenhydramine hcl syrpor 12.5 mg/5ml

$0(Tier

3)


diphenhydramine hcl tabsor 25 mg

$0(Tier

3)


SILPHEN COUGH SYRP$0

(Tier3)


Antihistamines - Non-Sedating

cetirizine hcl chew 5 mg,10 mg

$0(Tier

3)

MO; NT

Drug Name DrugTier

Requirements/Limits

cetirizine hcl soln 1 mg/ml$0-

$3.30(Tier

1)

RX/OTC; MO

cetirizine hcl syrp 1 mg/ml$0-

$3.30(Tier

1)

RX/OTC; MO

cetirizine hcl tabs 10 mg, 5mg

$0(Tier

3)

MO; NT

CLARINEX TABS 5 MG(Desloratadine) NF MO

CLARITIN REDITABSTBDP 10 MG (Loratadine) NF MO; NT

CLARITIN SYRP 5MG/5ML (Loratadine) NF MO; NT

CLARITIN TABS 10 MG(Loratadine) NF QL(1 ea daily);

MO; NT

desloratadine tabs$0-

$3.30(Tier

1)

MO

desloratadine tbdp$0-

$3.30(Tier

1)

MO

levocetirizinedihydrochloride soln

$0-$3.30(Tier

1)

RX/OTC; MO

levocetirizinedihydrochloride tabs

$0-$3.30(Tier

1)

RX/OTC; MO

loratadine soln or 5 mg/5ml$0

(Tier3)

MO; NT

loratadine syrp or 5 mg/5ml$0

(Tier3)

MO; NT

loratadine tabs or 10 mg$0

(Tier3)

QL(1 ea daily);MO; NT

loratadine tbdp or 10 mg$0

(Tier3)

MO; NT



41

Drug Name DrugTier

Requirements/Limits

XYZAL SOLN(LevocetirizineDihydrochloride)

NFRX/OTC; MO

XYZAL TABS(LevocetirizineDihydrochloride)

NFRX/OTC; MO

ZYRTEC ALLERGY TABS(Cetirizine HCl) NF MO; NT

ZYRTEC CHILDRENSALLERGY SYRP(Cetirizine HCl)

NFRX/OTC; MO;NT

Antihistamines - Phenothiazines

promethazine hcl soln ij 50mg/ml, 25 mg/ml

$0-$3.30(Tier

1)


promethazine hcl soln or6.25 mg/5ml

$0-$3.30(Tier

1)


promethazine hcl supp re12.5 mg, 25 mg

$0-$3.30(Tier

1)


promethazine hcl syrp or6.25 mg/5ml

$0-$3.30(Tier

1)


promethazine hcl tabs or25 mg, 50 mg, 12.5 mg

$0-$3.30(Tier

1)


Antihistamines - Piperidines

cyproheptadine hcl syrp or2 mg/5ml

$0-$3.30(Tier

1)


cyproheptadine hcl tabs or4 mg

$0-$3.30(Tier

1)


ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterolAntihyperlipidemics - Misc.

Drug Name DrugTier

Requirements/Limits

KYNAMRO SOSY$0-

$8.25(Tier

2)

PA; LA

LOVAZA CAPS (Omega-3-acid Ethyl Esters) NF MO

omega-3-acid ethyl esterscaps

$0-$3.30(Tier

1)

MO

VASCEPA CAPS$0-

$8.25(Tier

2)

ST; MO

Bile Acid Sequestrants

cholestyramine light pack$0-

$3.30(Tier

1)

MO

cholestyramine light powd$0-

$3.30(Tier

1)

MO

cholestyramine pack or 4gm

$0-$3.30(Tier

1)

MO

cholestyramine powd or 4gm/dose

$0-$3.30(Tier

1)

MO

COLESTID FLAVOREDGRAN 5 GM (ColestipolHCl)

NFMO

COLESTID GRAN(Colestipol HCl) NF MO

COLESTID PACK(Colestipol HCl) NF MO

COLESTID TABS(Colestipol HCl) NF MO

colestipol hcl gran$0-

$3.30(Tier

1)

MO

colestipol hcl pack$0-

$3.30(Tier

1)

MO



42

Drug Name DrugTier

Requirements/Limits

colestipol hcl tabs$0-

$3.30(Tier

1)

MO

WELCHOL PACK$0-

$8.25(Tier

2)

MO

WELCHOL TABS$0-

$8.25(Tier

2)

MO

Fibric Acid Derivatives

ANTARA CAPS 30 MG$0-

$8.25(Tier

2)


ANTARA CAPS 90 MG$0-

$8.25(Tier

2)


choline fenofibrate cpdr$0-

$3.30(Tier

1)

MO

fenofibrate micronized caps130 mg

$0-$3.30(Tier

1)

SL(1 ea daily);MO

fenofibrate micronized caps134 mg, 200 mg, 67 mg

$0-$3.30(Tier

1)

MO

fenofibrate micronized caps43 mg

$0-$3.30(Tier

1)


fenofibrate tabs 145 mg, 54mg, 160 mg, 48 mg

$0-$3.30(Tier

1)

MO

gemfibrozil tabs or$0-

$3.30(Tier

1)

MO

LOPID TABS (Gemfibrozil) NF MO

Drug Name DrugTier

Requirements/Limits

TRICOR TABS(Fenofibrate) NF MO

TRIGLIDE TABS$0-

$8.25(Tier

2)

MO

TRILIPIX CPDR (CholineFenofibrate) NF MO

HMG CoA Reductase Inhibitors

atorvastatin calcium tabs$0-

$3.30(Tier

1)

MO

CRESTOR TABS(Rosuvastatin Calcium) NF MO

fluvastatin sodium caps$0-

$3.30(Tier

1)

MO

fluvastatin sodium tb24$0-

$3.30(Tier

1)

MO

LESCOL XL TB24(Fluvastatin Sodium) NF MO

LIPITOR TABS(Atorvastatin Calcium) NF MO

lovastatin tabs$0-

$3.30(Tier

1)

MO

MEVACOR TABS(Lovastatin) NF MO

PRAVACHOL TABS(Pravastatin Sodium) NF MO

pravastatin sodium tabs$0-

$3.30(Tier

1)

MO

rosuvastatin calcium tabs$0-

$3.30(Tier

1)

MO

simvastatin tabs or 10 mg$0-

$3.30(Tier

1)

SL(8 ea daily);MO



43

Drug Name DrugTier

Requirements/Limits


$3.30(Tier

1)

SL(4 ea daily);MO


$3.30(Tier

1)

SL(2 ea daily);MO


$3.30(Tier

1)

SL(16 ea daily);MO


$3.30(Tier

1)

SL(1 ea daily);MO

ZOCOR TABS 10 MG(Simvastatin) NF SL(8 ea daily);

MOZOCOR TABS 20 MG(Simvastatin) NF SL(4 ea daily);




MOIntestinal Cholesterol Absorption Inhibitors

ezetimibe tabs$0-

$3.30(Tier

1)

MO

ZETIA TABS (Ezetimibe)

$0-$8.25(Tier

2)

MO

Microsomal Triglyceride Transfer Protein (MTP)

JUXTAPID CAPS 10 MG$0-

$8.25(Tier

2)

PA; SL(6 eadaily); LA


$8.25(Tier

2)


Drug Name DrugTier

Requirements/Limits


$8.25(Tier

2)



$8.25(Tier

2)

PA; SL(1.5 eadaily); LA


$8.25(Tier

2)



$8.25(Tier

2)


Nicotinic Acid Derivatives

niacin (antihyperlipidemic)tbcr

$0-$3.30(Tier

1)

MO

NIASPAN TBCR (Niacin(Antihyperlipidemic)) NF MO

Proprotein Convertase Subtilisin/Kexin Type 9

PRALUENT SOPN 150MG/ML

$0-$8.25(Tier

2)

PA; Limit 2mlsper 28days;SL(0.08ml daily)

PRALUENT SOPN 75MG/ML

$0-$8.25(Tier

2)


PRALUENT SOSY 150MG/ML

$0-$8.25(Tier

2)


PRALUENT SOSY 75MG/ML

$0-$8.25(Tier

2)


REPATHA PUSHTRONEXSYSTEM SOCT

$0-$8.25(Tier

2)

PA

REPATHA SOSY$0-

$8.25(Tier

2)

PA



44

Drug Name DrugTier

Requirements/Limits

REPATHA SURECLICKSOAJ

$0-$8.25(Tier

2)

PA

ANTIHYPERTENSIVES - Drugs to Treat HighBlood PressureACE InhibitorsACCUPRIL TABS(Quinapril HCl) NF MO

ACEON TABS 4 MG(Perindopril Erbumine) NF SL(4 ea daily);

MOACEON TABS 8 MG(Perindopril Erbumine) NF SL(2 ea daily);

MO

ALTACE CAPS (Ramipril) NF MO

benazepril hcl tabs or 5mg, 20 mg, 40 mg, 10 mg

$0-$3.30(Tier

1)

MO

captopril tabs or 12.5 mg,100 mg, 50 mg, 25 mg

$0-$3.30(Tier

1)

MO

enalapril maleate tabs or10 mg

$0-$3.30(Tier

1)

SL(4 ea daily);MO

enalapril maleate tabs or2.5 mg

$0-$3.30(Tier

1)

SL(16 ea daily);MO

enalapril maleate tabs or20 mg

$0-$3.30(Tier

1)

SL(2 ea daily);MO

enalapril maleate tabs or 5mg

$0-$3.30(Tier

1)

SL(8 ea daily);MO

fosinopril sodium tabs$0-

$3.30(Tier

1)

MO

lisinopril tabs or 20 mg, 5mg, 40 mg, 10 mg, 30 mg,2.5 mg

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

LOTENSIN TABS(Benazepril HCl) NF MO

MAVIK TABS (Trandolapril) NF MO

moexipril hcl tabs$0-

$3.30(Tier

1)

MO

perindopril erbumine tabs 2mg

$0-$3.30(Tier

1)

SL(8 ea daily);MO


$0-$3.30(Tier

1)

SL(4 ea daily);MO


$0-$3.30(Tier

1)

SL(2 ea daily);MO

PRINIVIL TABS (Lisinopril) NF MO

quinapril hcl tabs$0-

$3.30(Tier

1)

MO

ramipril caps$0-

$3.30(Tier

1)

MO

trandolapril tabs$0-

$3.30(Tier

1)

MO

VASOTEC TABS 10 MG(Enalapril Maleate) NF SL(4 ea daily);

MOVASOTEC TABS 2.5 MG(Enalapril Maleate) NF SL(16 ea daily);

MOVASOTEC TABS 20 MG(Enalapril Maleate) NF SL(2 ea daily);

MOVASOTEC TABS 5 MG(Enalapril Maleate) NF SL(8 ea daily);

MO

ZESTRIL TABS (Lisinopril) NF MO

Agents for Pheochromocytoma



45

Drug Name DrugTier

Requirements/Limits

DEMSER CAPS$0-

$8.25(Tier

2)

MO

DIBENZYLINE CAPS(Phenoxybenzamine HCl)

$0-$8.25(Tier

2)

MO

phenoxybenzamine hclcaps or

$0-$3.30(Tier

1)

MO

Angiotensin II Receptor AntagonistsATACAND TABS(Candesartan Cilexetil) NF MO

AVAPRO TABS(Irbesartan) NF MO

candesartan cilexetil tabs$0-

$3.30(Tier

1)

MO

COZAAR TABS (LosartanPotassium) NF MO

DIOVAN TABS (Valsartan) NF MO

eprosartan mesylate tabs$0-

$3.30(Tier

1)

MO

irbesartan tabs$0-

$3.30(Tier

1)

MO

losartan potassium tabs$0-

$3.30(Tier

1)

MO

valsartan tabs$0-

$3.30(Tier

1)

MO

Antiadrenergic AntihypertensivesCARDURA TABS(Doxazosin Mesylate) NF MO

CATAPRES TABS(Clonidine HCl) NF MO

Drug Name DrugTier

Requirements/Limits

CATAPRES-TTS-1 PTWK(Clonidine HCl) NF MO



clonidine hcl ptwk td 0.1mg/24hr, 0.3 mg/24hr, 0.2mg/24hr

$0-$3.30(Tier

1)

MO

clonidine hcl tabs or 0.1mg, 0.3 mg, 0.2 mg

$0-$3.30(Tier

1)

MO

doxazosin mesylate tabs$0-

$3.30(Tier

1)

MO

guanfacine hcl tabs$0-

$3.30(Tier

1)


MINIPRESS CAPS(Prazosin HCl) NF MO

prazosin hcl caps$0-

$3.30(Tier

1)

MO

TENEX TABS (GuanfacineHCl) NF AL; Up to 64

yrs old; MO

terazosin hcl caps$0-

$3.30(Tier

1)

MO

Antihypertensive CombinationsACCURETIC TABS(Quinapril-Hydrochlorothiazide)

NFMO

amlodipine besylate-benazepril hcl caps

$0-$3.30(Tier

1)

MO

ATACAND HCT TABS(Candesartan Cilexetil-Hydrochlorothiazide)

NFMO



46

Drug Name DrugTier

Requirements/Limits

atenolol & chlorthalidonetabs

$0-$3.30(Tier

1)

MO

AVALIDE TABS(Irbesartan-Hydrochlorothiazide)

NFMO

benazepril &hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

bisoprolol &hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

candesartan cilexetil-hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

captopril &hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

CORZIDE TABS (Nadolol& Bendroflumethiazide) NF MO

DIOVAN HCT TABS(Valsartan-Hydrochlorothiazide)

NFMO

enalapril maleate &hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

fosinopril sodium &hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

HYZAAR TABS (LosartanPotassium &Hydrochlorothiazide)

NFMO

irbesartan-hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

lisinopril &hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

LOPRESSOR HCT TABS(Metoprolol &Hydrochlorothiazide)

NFMO

losartan potassium &hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

LOTENSIN HCT TABS(Benazepril &Hydrochlorothiazide)

NFMO

LOTREL CAPS(Amlodipine Besylate-Benazepril HCl)

NFMO

metoprolol &hydrochlorothiazide tabs100mg-50mg, 100mg-25mg, 50mg-25mg

$0-$3.30(Tier

1)

MO

moexipril-hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

nadolol &bendroflumethiazide tabs

$0-$3.30(Tier

1)

MO

quinapril-hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

TEKTURNA HCT TABS$0-

$8.25(Tier

2)

MO

TENORETIC 100 TABS(Atenolol & Chlorthalidone) NF MO

TENORETIC 50 TABS(Atenolol & Chlorthalidone) NF MO

valsartan-hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

VASERETIC TABS(Enalapril Maleate &Hydrochlorothiazide)

NFMO

ZESTORETIC TABS(Lisinopril &Hydrochlorothiazide)

NFMO



47

Drug Name DrugTier

Requirements/Limits

ZIAC TABS (Bisoprolol &Hydrochlorothiazide) NF MO

Direct Renin Inhibitors

TEKTURNA TABS$0-

$8.25(Tier

2)

MO

Selective Aldosterone Receptor Antagonists

eplerenone tabs$0-

$3.30(Tier

1)

MO

INSPRA TABS(Eplerenone) NF MO

Vasodilators

hydralazine hcl tabs or 50mg, 100 mg, 25 mg, 10 mg

$0-$3.30(Tier

1)

MO

minoxidil tabs or 10 mg, 2.5mg

$0-$3.30(Tier

1)

MO

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections)Antimalarial Combinations

atovaquone-proguanil hcltabs 250mg-100mg

$0-$3.30(Tier

1)

MO

COARTEM TABS$0-

$8.25(Tier

2)

MO

MALARONE TABS250MG-100MG(Atovaquone-ProguanilHCl)

NF

MO

Antimalarials

chloroquine phosphatetabs or 250 mg, 500 mg

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

DARAPRIM TABS$0-

$8.25(Tier

2)

hydroxychloroquine sulfatetabs or

$0-$3.30(Tier

1)

MO

mefloquine hcl tabs$0-

$3.30(Tier

1)

MO

PLAQUENIL TABS(HydroxychloroquineSulfate)

NFMO

PRIMAQUINEPHOSPHATE TABS

$0-$8.25(Tier

2)

MO

primaquine phosphate tabs$0-

$3.30(Tier

1)

MO

QUALAQUIN CAPS(Quinine Sulfate) NF PA; MO

quinine sulfate caps or$0-

$3.30(Tier

1)

PA; MO

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agents

GUANIDINE HCL TABS$0-

$8.25(Tier

2)MESTINON TABS 60 MG(Pyridostigmine Bromide) NF MO

MESTINON TIMESPANTBCR (PyridostigmineBromide)

NFMO

pyridostigmine bromidetabs or 60 mg

$0-$3.30(Tier

1)

MO



48

Drug Name DrugTier

Requirements/Limits

pyridostigmine bromidetbcr or 180 mg

$0-$3.30(Tier

1)

MO

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections)Anti TB Combinations

isoniazid & rifampin caps$0-

$3.30(Tier

1)

MO

RIFATER TABS$0-

$8.25(Tier

2)

MO

Antimycobacterial Agents

aminosalicylic acid pack or$0-

$3.30(Tier

1)

MO

CAPASTAT SULFATESOLR

$0-$8.25(Tier

2)

ethambutol hcl tabs or 400mg, 100 mg

$0-$3.30(Tier

1)

MO

isoniazid tabs or 300 mg,100 mg

$0-$3.30(Tier

1)

MO

MYAMBUTOL TABS(Ethambutol HCl) NF MO

MYCOBUTIN CAPS(Rifabutin) NF MO

PRIFTIN TABS$0-

$8.25(Tier

2)

MO

pyrazinamide tabs or$0-

$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

rifabutin caps$0-

$3.30(Tier

1)

MO

RIFADIN CAPS (Rifampin) NF MO

RIFADIN SOLR (Rifampin) NF MO

rifampin caps or 300 mg,150 mg

$0-$3.30(Tier

1)

MO

rifampin solr iv 600 mg$0-

$3.30(Tier

1)

MO

SIRTURO TABS$0-

$8.25(Tier

2)

TRECATOR TABS$0-

$8.25(Tier

2)

MO

ANTINEOPLASTICS AND ADJUNCTIVETHERAPIES - Drugs to Treat CancerAlkylating AgentsALKERAN SOLR IV 50 MG(Melphalan HCl) NF

ALKERAN TABS OR 2 MG(Melphalan)

$0-$8.25(Tier

2)

B/D; MO

BENDEKA SOLN$0-

$8.25(Tier

2)

BICNU SOLR$0-

$8.25(Tier

2)

busulfan soln$0-

$3.30(Tier

1)



49

Drug Name DrugTier

Requirements/Limits

BUSULFEX SOLN(Busulfan)

$0-$8.25(Tier

2)

carboplatin soln$0-

$3.30(Tier

1)

cisplatin soln 200mg/200ml, 100 mg/100ml,50 mg/50ml

$0-$3.30(Tier

1)

CYCLOPHOSPHAMIDECAPS OR 25 MG, 50 MG

$0-$8.25(Tier

2)

B/D; MO

EVOMELA SOLR$0-

$8.25(Tier

2)

GLEOSTINE CAPS$0-

$8.25(Tier

2)

HEXALEN CAPS$0-

$8.25(Tier

2)

MO

IFEX SOLR 1 GM(Ifosfamide) NF

IFEX SOLR 3 GM$0-

$8.25(Tier

2)

ifosfamide soln 1 gm/20ml,3 gm/60ml

$0-$3.30(Tier

1)

ifosfamide solr 1 gm$0-

$3.30(Tier

1)

IFOSFAMIDE SOLR 3 GM$0-

$8.25(Tier

2)

Drug Name DrugTier

Requirements/Limits

LEUKERAN TABS$0-

$8.25(Tier

2)

MO

melphalan hcl solr$0-

$3.30(Tier

1)

melphalan tabs$0-

$3.30(Tier

1)

B/D; MO

MUSTARGEN SOLR$0-

$8.25(Tier

2)

oxaliplatin soln$0-

$3.30(Tier

1)

oxaliplatin solr$0-

$3.30(Tier

1)

TEMODAR SOLR$0-

$8.25(Tier

2)

thiotepa solr ij$0-

$3.30(Tier

1)

TREANDA SOLR 100 MG,25 MG

$0-$8.25(Tier

2)

YONDELIS SOLR$0-

$8.25(Tier

2)

LA

ZANOSAR SOLR$0-

$8.25(Tier

2)

MO

Antimetabolites



50

Drug Name DrugTier

Requirements/Limits

ALIMTA SOLR 100 MG$0-

$8.25(Tier

2)

ALIMTA SOLR 500 MG$0-

$8.25(Tier

2)

MO

ARRANON SOLN$0-

$8.25(Tier

2)

azacitidine susr$0-

$3.30(Tier

1)

cladribine soln$0-

$3.30(Tier

1)

PA

clofarabine soln$0-

$3.30(Tier

1)

CLOLAR SOLN(Clofarabine)

$0-$8.25(Tier

2)

cytarabine soln$0-

$3.30(Tier

1)

PA

DACOGEN SOLR(Decitabine) NF

decitabine solr$0-

$3.30(Tier

1)

fludarabine phosphate solr50 mg

$0-$3.30(Tier

1)

fluorouracil soln iv 1gm/20ml

$0-$3.30(Tier

1)

Drug Name DrugTier

Requirements/Limits

fluorouracil soln iv 2.5gm/50ml, 500 mg/10ml

$0-$3.30(Tier

1)

PA

FOLOTYN SOLN$0-

$8.25(Tier

2)

gemcitabine hcl soln$0-

$3.30(Tier

1)

gemcitabine hcl solr$0-

$3.30(Tier

1)GEMZAR SOLR(Gemcitabine HCl) NF

mercaptopurine tabs or$0-

$3.30(Tier

1)

MO

methotrexate sodium soln ij200 mg/8ml, 1 gm/40ml,250 mg/10ml, 100 mg/4ml,50 mg/2ml

$0-$3.30(Tier

1)

methotrexate sodium solr ij1 gm

$0-$3.30(Tier

1)

methotrexate sodium tabsor 5 mg, 7.5 mg, 10 mg, 2.5mg, 15 mg

$0-$3.30(Tier

1)

MO

PURIXAN SUSP$0-

$8.25(Tier

2)

PA

TABLOID TABS$0-

$8.25(Tier

2)

MO

VIDAZA SUSR(Azacitidine) NF

XATMEP SOLN$0-

$8.25(Tier

2)

PA



51

Drug Name DrugTier

Requirements/Limits

Antineoplastic - Angiogenesis Inhibitors

AVASTIN SOLN$0-

$8.25(Tier

2)

CYRAMZA SOLN$0-

$8.25(Tier

2)

LA

ZALTRAP SOLN$0-

$8.25(Tier

2)

Antineoplastic - Antibodies

ARZERRA CONC$0-

$8.25(Tier

2)

BAVENCIO SOLN$0-

$8.25(Tier

2)

LA

BESPONSA SOLR$0-

$8.25(Tier

2)

BLINCYTO SOLR$0-

$8.25(Tier

2)

CAMPATH SOLN$0-

$8.25(Tier

2)

DARZALEX SOLN$0-

$8.25(Tier

2)

LA

EMPLICITI SOLR$0-

$8.25(Tier

2)

ERBITUX SOLN$0-

$8.25(Tier

2)

Drug Name DrugTier

Requirements/Limits

GAZYVA SOLN$0-

$8.25(Tier

2)

LA

HERCEPTIN SOLR$0-

$8.25(Tier

2)

IMFINZI SOLN$0-

$8.25(Tier

2)

LA

KADCYLA SOLR$0-

$8.25(Tier

2)

KEYTRUDA SOLN$0-

$8.25(Tier

2)

KEYTRUDA SOLR$0-

$8.25(Tier

2)

LARTRUVO SOLN$0-

$8.25(Tier

2)

LA

MYLOTARG SOLR$0-

$8.25(Tier

2)

OPDIVO SOLN$0-

$8.25(Tier

2)

PERJETA SOLN$0-

$8.25(Tier

2)

PORTRAZZA SOLN$0-

$8.25(Tier

2)

RITUXAN SOLN$0-

$8.25(Tier

2)



52

Drug Name DrugTier

Requirements/Limits

TECENTRIQ SOLN$0-

$8.25(Tier

2)

VECTIBIX SOLN$0-

$8.25(Tier

2)

YERVOY SOLN$0-

$8.25(Tier

2)

Antineoplastic - BCL-2 Inhibitors

VENCLEXTA STARTINGPACK TBPK

$0-$8.25(Tier

2)

PA; LA

VENCLEXTA TABS$0-

$8.25(Tier

2)

PA; LA

Antineoplastic - Hedgehog Pathway Inhibitors

ERIVEDGE CAPS$0-

$8.25(Tier

2)

LA

ODOMZO CAPS$0-

$8.25(Tier

2)

LA

Antineoplastic - Hormonal and Related Agents

anastrozole tabs or$0-

$3.30(Tier

1)

MO

ARIMIDEX TABS(Anastrozole) NF MO

AROMASIN TABS(Exemestane) NF MO

bicalutamide tabs$0-

$3.30(Tier

1)

MO

CASODEX TABS(Bicalutamide) NF MO

Drug Name DrugTier

Requirements/Limits

DEPO-PROVERA SUSP$0-

$8.25(Tier

2)

MO

ELIGARD KIT$0-

$8.25(Tier

2)

EMCYT CAPS$0-

$8.25(Tier

2)

MO

exemestane tabs$0-

$3.30(Tier

1)

MO

FARESTON TABS$0-

$8.25(Tier

2)

MO

FASLODEX SOLN$0-

$8.25(Tier

2)

FEMARA TABS (Letrozole) NF MO

FIRMAGON SOLR$0-

$8.25(Tier

2)

flutamide caps$0-

$3.30(Tier

1)

MO

HYDROXYPROGESTERONE CAPROATE SOLN IM

$0-$8.25(Tier

2)

letrozole tabs$0-

$3.30(Tier

1)

MO

leuprolide acetate kit ij$0-

$3.30(Tier

1)



53

Drug Name DrugTier

Requirements/Limits

LUPRON DEPOT (1-MONTH) KIT

$0-$8.25(Tier

2)


$0-$8.25(Tier

2)


$0-$8.25(Tier

2)


$0-$8.25(Tier

2)

LYSODREN TABS$0-

$8.25(Tier

2)

MO

MEGACE ORAL SUSP(Megestrol Acetate) NF AL; Up to 64

yrs old; MO

megestrol acetate susp or40 mg/ml, 400 mg/10ml

$0-$3.30(Tier

1)


megestrol acetate tabs or20 mg, 40 mg

$0-$3.30(Tier

1)


NILANDRON TABS(Nilutamide)

$0-$8.25(Tier

2)

MO

nilutamide tabs$0-

$3.30(Tier

1)

MO

SOLTAMOX SOLN$0-

$8.25(Tier

2)

MO

tamoxifen citrate tabs or 20mg, 10 mg

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

TRELSTAR MIXJECTSUSR

$0-$8.25(Tier

2)

TRELSTAR SUSR$0-

$8.25(Tier

2)

VANTAS KIT$0-

$8.25(Tier

2)

XTANDI CAPS$0-

$8.25(Tier

2)

PA; LA

ZOLADEX IMPL$0-

$8.25(Tier

2)

ZYTIGA TABS$0-

$8.25(Tier

2)

Antineoplastic - Immunomodulators

POMALYST CAPS$0-

$8.25(Tier

2)

LA

Antineoplastic Antibiotics

bleomycin sulfate solr 15unit

$0-$3.30(Tier

1)

bleomycin sulfate solr 30unit

$0-$3.30(Tier

1)

PA

COSMEGEN SOLR$0-

$8.25(Tier

2)

daunorubicin hcl inj$0-

$3.30(Tier

1)DOXIL INJ (DoxorubicinHCl Liposomal) NF



54

Drug Name DrugTier

Requirements/Limits

doxorubicin hcl liposomalinj

$0-$3.30(Tier

1)

doxorubicin hcl soln$0-

$3.30(Tier

1)

doxorubicin hcl solr$0-

$3.30(Tier

1)ELLENCE SOLN(Epirubicin HCl) NF

epirubicin hcl soln$0-

$3.30(Tier

1)IDAMYCIN PFS SOLN(Idarubicin HCl) NF

idarubicin hcl soln$0-

$3.30(Tier

1)

mitomycin solr iv 20 mg, 5mg, 40 mg

$0-$3.30(Tier

1)

MO

mitoxantrone hcl conc$0-

$3.30(Tier

1)

VALSTAR SOLN$0-

$8.25(Tier

2)

Antineoplastic Combinations

KISQALI FEMARA 200DOSE TBPK

$0-$8.25(Tier

2)

PA


$0-$8.25(Tier

2)

PA

Drug Name DrugTier

Requirements/Limits


$0-$8.25(Tier

2)

PA

LONSURF TABS$0-

$8.25(Tier

2)

PA

RITUXAN HYCELA SOLN$0-

$8.25(Tier

2)

VYXEOS SUSR$0-

$8.25(Tier

2)

Antineoplastic Enzyme Inhibitors

AFINITOR DISPERZ TBSO$0-

$8.25(Tier

2)

AFINITOR TABS$0-

$8.25(Tier

2)

ALECENSA CAPS$0-

$8.25(Tier

2)

PA; LA

ALIQOPA SOLR$0-

$8.25(Tier

2)

ALUNBRIG TABS$0-

$8.25(Tier

2)

PA; LA

BELEODAQ SOLR$0-

$8.25(Tier

2)

BOSULIF TABS$0-

$8.25(Tier

2)

PA



55

Drug Name DrugTier

Requirements/Limits

CABOMETYX TABS$0-

$8.25(Tier

2)

PA

CAPRELSA TABS$0-

$8.25(Tier

2)

LA

COMETRIQ KIT$0-

$8.25(Tier

2)

LA

COTELLIC TABS$0-

$8.25(Tier

2)

LA

FARYDAK CAPS$0-

$8.25(Tier

2)

PA; LA

GILOTRIF TABS$0-

$8.25(Tier

2)

LA

GLEEVEC TABS (ImatinibMesylate)

$0-$8.25(Tier

2)

IBRANCE CAPS$0-

$8.25(Tier

2)

LA

ICLUSIG TABS$0-

$8.25(Tier

2)

LA

imatinib mesylate tabs$0-

$3.30(Tier

1)

IMBRUVICA CAPS$0-

$8.25(Tier

2)

PA; LA

INLYTA TABS$0-

$8.25(Tier

2)

PA; LA

Drug Name DrugTier

Requirements/Limits

IRESSA TABS$0-

$8.25(Tier

2)

LA; MO

ISTODAX (OVERFILL)SOLR

$0-$8.25(Tier

2)

ISTODAX SOLR$0-

$8.25(Tier

2)

JAKAFI TABS$0-

$8.25(Tier

2)

LA

KISQALI TABS$0-

$8.25(Tier

2)

PA

KYPROLIS SOLR$0-

$8.25(Tier

2)

LENVIMA 10 MG DAILYDOSE CPPK

$0-$8.25(Tier

2)

PA


$0-$8.25(Tier

2)

PA


$0-$8.25(Tier

2)

PA


$0-$8.25(Tier

2)

PA


$0-$8.25(Tier

2)

PA


$0-$8.25(Tier

2)

PA



56

Drug Name DrugTier

Requirements/Limits

LYNPARZA CAPS 50 MG$0-

$8.25(Tier

2)

PA; LA

MEKINIST TABS$0-

$8.25(Tier

2)

NERLYNX TABS$0-

$8.25(Tier

2)

PA; LA

NEXAVAR TABS$0-

$8.25(Tier

2)

LA

NINLARO CAPS$0-

$8.25(Tier

2)

PA

RUBRACA TABS$0-

$8.25(Tier

2)

PA; LA

RYDAPT CAPS$0-

$8.25(Tier

2)

PA

SPRYCEL TABS$0-

$8.25(Tier

2)

STIVARGA TABS$0-

$8.25(Tier

2)

PA; LA

SUTENT CAPS$0-

$8.25(Tier

2)

TAFINLAR CAPS$0-

$8.25(Tier

2)

TAGRISSO TABS$0-

$8.25(Tier

2)

LA

Drug Name DrugTier

Requirements/Limits

TARCEVA TABS$0-

$8.25(Tier

2)

TASIGNA CAPS$0-

$8.25(Tier

2)

TORISEL SOLN$0-

$8.25(Tier

2)

TYKERB TABS$0-

$8.25(Tier

2)

VELCADE SOLR$0-

$8.25(Tier

2)

VOTRIENT TABS$0-

$8.25(Tier

2)

XALKORI CAPS$0-

$8.25(Tier

2)

ZEJULA CAPS$0-

$8.25(Tier

2)

PA

ZELBORAF TABS$0-

$8.25(Tier

2)

LA

ZOLINZA CAPS$0-

$8.25(Tier

2)

ZYDELIG TABS$0-

$8.25(Tier

2)

PA; LA

ZYKADIA CAPS$0-

$8.25(Tier

2)

PA; LA



57

Drug Name DrugTier

Requirements/Limits

Antineoplastic Enzymes

ERWINAZE SOLR$0-

$8.25(Tier

2)

ONCASPAR SOLN$0-

$8.25(Tier

2)

Antineoplastics Misc.

ACTIMMUNE SOLN$0-

$8.25(Tier

2)

LA

bexarotene caps$0-

$3.30(Tier

1)

dacarbazine solr$0-

$3.30(Tier

1)HYDREA CAPS(Hydroxyurea) NF MO

hydroxyurea caps or$0-

$3.30(Tier

1)

MO

INTRON A SOLN$0-

$8.25(Tier

2)

INTRON A SOLR$0-

$8.25(Tier

2)

INTRON A W/DILUENTSOLR

$0-$8.25(Tier

2)

MATULANE CAPS$0-

$8.25(Tier

2)

LA

NIPENT SOLR$0-

$8.25(Tier

2)

Drug Name DrugTier

Requirements/Limits

PROLEUKIN SOLR$0-

$8.25(Tier

2)

SYLATRON KIT$0-

$8.25(Tier

2)

SYNRIBO SOLR$0-

$8.25(Tier

2)

TARGRETIN CAPS OR 75MG (Bexarotene)

$0-$8.25(Tier

2)

TICE BCG SUSR$0-

$8.25(Tier

2)

tretinoin (chemotherapy)caps

$0-$3.30(Tier

1)

MO

TRISENOX SOLN$0-

$8.25(Tier

2)

UVADEX SOLN$0-

$8.25(Tier

2)

Chemotherapy Adjuncts

ELITEK SOLR$0-

$8.25(Tier

2)

KEPIVANCE SOLR$0-

$8.25(Tier

2)

Chemotherapy Rescue/Antidote Agents

amifostine solr$0-

$3.30(Tier

1)

MO



58

Drug Name DrugTier

Requirements/Limits

dexrazoxane solr 500 mg,250 mg

$0-$3.30(Tier

1)

FUSILEV SOLR(Levoleucovorin Calcium)

$0-$8.25(Tier

2)

leucovorin calcium solr ij100 mg, 350 mg

$0-$3.30(Tier

1)

MO

leucovorin calcium solr ij200 mg, 50 mg, 500 mg

$0-$3.30(Tier

1)

leucovorin calcium tabs or5 mg, 25 mg, 10 mg, 15 mg

$0-$3.30(Tier

1)

MO

levoleucovorin calcium soln$0-

$3.30(Tier

1)

levoleucovorin calcium solr$0-

$3.30(Tier

1)

LEVOLEUCOVORIN SOLN$0-

$8.25(Tier

2)

LEVOLEUCOVORIN SOLR$0-

$8.25(Tier

2)

mesna soln$0-

$3.30(Tier

1)

MO

MESNEX SOLN IV 100MG/ML (Mesna) NF MO

MESNEX TABS OR 400MG

$0-$8.25(Tier

2)

MO

ZINECARD SOLR(Dexrazoxane) NF

Drug Name DrugTier

Requirements/Limits

Mitotic Inhibitors

ABRAXANE SUSR$0-

$8.25(Tier

2)

MO

docetaxel conc 20 mg/ml,80 mg/4ml

$0-$3.30(Tier

1)

DOCETAXEL CONC 80MG/4ML, 20 MG/ML

$0-$8.25(Tier

2)

DOCETAXEL SOLN 20MG/2ML, 160 MG/16ML,80 MG/8ML

$0-$8.25(Tier

2)

ETOPOPHOS SOLR$0-

$8.25(Tier

2)

etoposide soln iv 1gm/50ml, 500 mg/25ml,100 mg/5ml

$0-$3.30(Tier

1)

HALAVEN SOLN$0-

$8.25(Tier

2)

IXEMPRA KIT SOLR$0-

$8.25(Tier

2)

JEVTANA SOLN$0-

$8.25(Tier

2)

MARQIBO SUSP$0-

$8.25(Tier

2)NAVELBINE SOLN(Vinorelbine Tartrate) NF MO

paclitaxel conc 100mg/16.7ml, 150 mg/25ml

$0-$3.30(Tier

1)



59

Drug Name DrugTier

Requirements/Limits

paclitaxel conc 30 mg/5ml,300 mg/50ml

$0-$3.30(Tier

1)

MO

TAXOL CONC (Paclitaxel) NF MO

TAXOTERE CONC(Docetaxel)

$0-$8.25(Tier

2)

vinblastine sulfate soln$0-

$3.30(Tier

1)

PA; MO

vincristine sulfate soln$0-

$3.30(Tier

1)

PA; MO

vinorelbine tartrate soln$0-

$3.30(Tier

1)

MO

Topoisomerase I Inhibitors

CAMPTOSAR SOLN 300MG/15ML

$0-$8.25(Tier

2)CAMPTOSAR SOLN 40MG/2ML, 100 MG/5ML(Irinotecan HCl)

NF

HYCAMTIN SOLR(Topotecan HCl) NF MO

irinotecan hcl soln$0-

$3.30(Tier

1)

ONIVYDE INJ$0-

$8.25(Tier

2)

TOPOTECAN HCL SOLN4 MG/4ML

$0-$8.25(Tier

2)

topotecan hcl solr 4 mg$0-

$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

ANTIPARKINSON AGENTS - Drugs to TreatParkinson's DiseaseAntiparkinson Adjuvants

carbidopa tabs or$0-

$3.30(Tier

1)

MO

LODOSYN TABS(Carbidopa) NF MO

Antiparkinson Anticholinergics

benztropine mesylate solnij 1 mg/ml

$0-$3.30(Tier

1)

MO

benztropine mesylate tabsor 1 mg, 2 mg, 0.5 mg

$0-$3.30(Tier

1)


COGENTIN SOLN(Benztropine Mesylate) NF MO

trihexyphenidyl hcl elix$0-

$3.30(Tier

1)


trihexyphenidyl hcl tabs$0-

$3.30(Tier

1)


Antiparkinson COMT InhibitorsCOMTAN TABS(Entacapone) NF SL(8 ea daily);

MO

entacapone tabs$0-

$3.30(Tier

1)

SL(8 ea daily);MO

TASMAR TABS(Tolcapone)

$0-$8.25(Tier

2)

MO

tolcapone tabs$0-

$3.30(Tier

1)

MO

Antiparkinson Dopaminergics



60

Drug Name DrugTier

Requirements/Limits

amantadine hcl caps or100 mg

$0-$3.30(Tier

1)

MO

amantadine hcl syrp or 50mg/5ml

$0-$3.30(Tier

1)

MO

amantadine hcl tabs or 100mg

$0-$3.30(Tier

1)

MO

APOKYN SOCT$0-

$8.25(Tier

2)

LA

bromocriptine mesylatecaps or 5 mg

$0-$3.30(Tier

1)

MO

bromocriptine mesylatetabs or 2.5 mg

$0-$3.30(Tier

1)

MO

carbidopa-levodopa tabs$0-

$3.30(Tier

1)

MO

carbidopa-levodopa tbcr$0-

$3.30(Tier

1)

MO

carbidopa-levodopa tbdp$0-

$3.30(Tier

1)

MO

DUOPA SUSP$0-

$8.25(Tier

2)

B/D

MIRAPEX TABS(PramipexoleDihydrochloride)

NFMO

NEUPRO PT24$0-

$8.25(Tier

2)

MO

PARLODEL CAPS(Bromocriptine Mesylate) NF MO

Drug Name DrugTier

Requirements/Limits

PARLODEL TABS(Bromocriptine Mesylate) NF MO

pramipexoledihydrochloride tabs 0.5mg, 1.5 mg, 1 mg, 0.25 mg,0.75 mg, 0.125 mg

$0-$3.30(Tier

1)

MO

REQUIP TABS (RopiniroleHydrochloride) NF MO

REQUIP XL TB24(Ropinirole Hydrochloride) NF MO

ropinirole hydrochloridetabs

$0-$3.30(Tier

1)

MO

ropinirole hydrochloridetb24

$0-$3.30(Tier

1)

MO

RYTARY CPCR$0-

$8.25(Tier

2)

MO

SINEMET CR TBCR(Carbidopa-Levodopa) NF MO

SINEMET TABS(Carbidopa-Levodopa) NF MO

Antiparkinson Monoamine Oxidase Inhibitors

AZILECT TABS (RasagilineMesylate)

$0-$8.25(Tier

2)

MO

ELDEPRYL CAPS(Selegiline HCl) NF MO

rasagiline mesylate tabs$0-

$3.30(Tier

1)

MO

selegiline hcl caps or$0-

$3.30(Tier

1)

MO

selegiline hcl tabs or$0-

$3.30(Tier

1)

MO

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood Disorders



61

Drug Name DrugTier

Requirements/Limits

Antimanic Agents

lithium carbonate caps or300 mg, 600 mg, 150 mg

$0-$3.30(Tier

1)

MO

LITHIUM CARBONATECAPS OR 600 MG (LithiumCarbonate)

NFMO

lithium carbonate tabs or300 mg

$0-$3.30(Tier

1)

MO

lithium carbonate tbcr or450 mg, 300 mg

$0-$3.30(Tier

1)

MO

LITHIUM SOLN$0-

$8.25(Tier

2)

MO

LITHOBID TBCR (LithiumCarbonate) NF MO

Antipsychotics - Misc.

EQUETRO CP12$0-

$8.25(Tier

2)

MO

GEODON CAPS OR 80MG, 60 MG, 20 MG, 40 MG(Ziprasidone HCl)

NFMO

GEODON SOLR IM 20 MG$0-

$8.25(Tier

2)

MO

LATUDA TABS 120 MG$0-

$8.25(Tier

2)



$8.25(Tier

2)

SL(8 ea daily);MO


$8.25(Tier

2)

SL(4 ea daily);MO

Drug Name DrugTier

Requirements/Limits


$8.25(Tier

2)



$8.25(Tier

2)

SL(2 ea daily);MO

NUPLAZID TABS$0-

$8.25(Tier

2)

PA; LA

VRAYLAR CAPS 1.5 MG$0-

$8.25(Tier

2)


VRAYLAR CAPS 3 MG$0-

$8.25(Tier

2)


VRAYLAR CAPS 4.5 MG$0-

$8.25(Tier

2)


VRAYLAR CAPS 6 MG$0-

$8.25(Tier

2)


VRAYLAR CPPK$0-

$8.25(Tier

2)

PA; MO

ziprasidone hcl caps$0-

$3.30(Tier

1)

MO

Benzisoxazoles

FANAPT TABS$0-

$8.25(Tier

2)

MO

INVEGA SUSTENNASUSP

$0-$8.25(Tier

2)

MO



62

Drug Name DrugTier

Requirements/Limits

INVEGA TB24 1.5 MG(Paliperidone)

$0-$8.25(Tier

2)

SL(8 ea daily);MO

INVEGA TB24 3 MG(Paliperidone)

$0-$8.25(Tier

2)

SL(4 ea daily);MO


$0-$8.25(Tier

2)

SL(2 ea daily);MO


$0-$8.25(Tier

2)


INVEGA TRINZA SUSP$0-

$8.25(Tier

2)

paliperidone tb24 1.5 mg$0-

$3.30(Tier

1)

SL(8 ea daily);MO

paliperidone tb24 3 mg$0-

$3.30(Tier

1)

SL(4 ea daily);MO


$3.30(Tier

1)

SL(2 ea daily);MO


$3.30(Tier

1)


RISPERDAL CONSTASUSR 12.5 MG

$0-$8.25(Tier

2)

Limit 8 vials per28days;SL(0.29ea daily); MO

RISPERDAL CONSTASUSR 25 MG

$0-$8.25(Tier

2)


RISPERDAL CONSTASUSR 37.5 MG

$0-$8.25(Tier

2)

Limit 4 vials per42 days;SL(0.1ea daily); MO

Drug Name DrugTier

Requirements/Limits

RISPERDAL CONSTASUSR 50 MG

$0-$8.25(Tier

2)


RISPERDAL M-TAB TBDP(Risperidone) NF MO

RISPERDAL SOLN(Risperidone) NF MO

RISPERDAL TABS(Risperidone) NF MO

risperidone soln$0-

$3.30(Tier

1)

MO

risperidone tabs$0-

$3.30(Tier

1)

MO

risperidone tbdp$0-

$3.30(Tier

1)

MO

ButyrophenonesHALDOL DECANOATE100 SOLN (HaloperidolDecanoate)

NFMO

HALDOL DECANOATE 50SOLN (HaloperidolDecanoate)

NFMO

HALDOL SOLN(Haloperidol Lactate) NF MO

haloperidol decanoate solnim 50 mg/ml, 100 mg/ml

$0-$3.30(Tier

1)

MO

haloperidol lactate conc$0-

$3.30(Tier

1)

MO

haloperidol lactate soln$0-

$3.30(Tier

1)

MO

haloperidol tabs$0-

$3.30(Tier

1)

MO



63

Drug Name DrugTier

Requirements/Limits

Dibenzapines

CLOZAPINE ODT TBDP$0-

$8.25(Tier

2)

clozapine tabs$0-

$3.30(Tier

1)

clozapine tbdp$0-

$3.30(Tier

1)CLOZARIL TABS(Clozapine) NF

FAZACLO TBDP 100 MG,25 MG (Clozapine) NF

FAZACLO TBDP 150 MG,200 MG, 12.5 MG

$0-$8.25(Tier

2)

loxapine succinate caps$0-

$3.30(Tier

1)

MO

olanzapine solr$0-

$3.30(Tier

1)

MO

olanzapine tabs$0-

$3.30(Tier

1)

MO

olanzapine tbdp$0-

$3.30(Tier

1)

MO

quetiapine fumarate tabs100 mg, 300 mg, 50 mg,400 mg, 200 mg, 25 mg

$0-$3.30(Tier

1)

MO

SAPHRIS SUBL 10 MG$0-

$8.25(Tier

2)

SL(2 ea daily);MO

Drug Name DrugTier

Requirements/Limits

SAPHRIS SUBL 2.5 MG$0-

$8.25(Tier

2)

SL(8 ea daily);MO

SAPHRIS SUBL 5 MG$0-

$8.25(Tier

2)

SL(4 ea daily);MO

SEROQUEL TABS(Quetiapine Fumarate) NF MO

VERSACLOZ SUSP$0-

$8.25(Tier

2)

PA; SL(18 mldaily)

ZYPREXA RELPREVVSUSR 210 MG

$0-$8.25(Tier

2)ZYPREXA SOLR(Olanzapine) NF MO

ZYPREXA TABS(Olanzapine) NF MO

ZYPREXA ZYDIS TBDP(Olanzapine) NF MO

Dihydroindolones

molindone hcl tabs$0-

$3.30(Tier

1)

MO

Phenothiazines

chlorpromazine hcl soln ij25 mg/ml

$0-$3.30(Tier

1)

MO

chlorpromazine hcl soln ij50 mg/2ml

$0-$3.30(Tier

1)

chlorpromazine hcl tabs or50 mg, 10 mg, 100 mg, 25mg, 200 mg

$0-$3.30(Tier

1)

MO

fluphenazine decanoatesoln ij

$0-$3.30(Tier

1)

MO



64

Drug Name DrugTier

Requirements/Limits

fluphenazine hcl conc or 5mg/ml

$0-$3.30(Tier

1)

MO

fluphenazine hcl soln ij 2.5mg/ml

$0-$3.30(Tier

1)

MO

fluphenazine hcl tabs or 1mg, 10 mg, 2.5 mg, 5 mg

$0-$3.30(Tier

1)

MO

perphenazine tabs or 16mg, 4 mg, 2 mg, 8 mg

$0-$3.30(Tier

1)

MO

prochlorperazine edisylatesoln ij

$0-$3.30(Tier

1)

MO

prochlorperazine maleatetabs or

$0-$3.30(Tier

1)

MO

prochlorperazine supp$0-

$3.30(Tier

1)

MO

thioridazine hcl tabs or 100mg, 25 mg, 10 mg, 50 mg

$0-$3.30(Tier

1)


trifluoperazine hcl tabs$0-

$3.30(Tier

1)

MO

Quinolinone Derivatives

ABILIFY MAINTENA PRSY$0-

$8.25(Tier

2)

ABILIFY MAINTENA SRER$0-

$8.25(Tier

2)

Drug Name DrugTier

Requirements/Limits

ABILIFY TABS 10 MG(Aripiprazole)

$0-$8.25(Tier

2)

SL(3 ea daily);MO


$0-$8.25(Tier

2)

SL(2 ea daily);MO


$0-$8.25(Tier

2)

SL(15 ea daily);MO


$0-$8.25(Tier

2)

SL(1.5 eadaily); MO


$0-$8.25(Tier

2)

SL(1 ea daily);MO


$0-$8.25(Tier

2)

SL(6 ea daily);MO

aripiprazole soln 1 mg/ml$0-

$3.30(Tier

1)

SL(30 ml daily);MO

aripiprazole tabs 10 mg$0-

$3.30(Tier

1)

SL(3 ea daily);MO


$3.30(Tier

1)

SL(2 ea daily);MO


$3.30(Tier

1)

SL(15 ea daily);MO


$3.30(Tier

1)

SL(1.5 eadaily); MO


$3.30(Tier

1)

SL(1 ea daily);MO



65

Drug Name DrugTier

Requirements/Limits


$3.30(Tier

1)

SL(6 ea daily);MO

aripiprazole tbdp 10 mg$0-

$3.30(Tier

1)

SL(3 ea daily);MO

aripiprazole tbdp 15 mg$0-

$3.30(Tier

1)

SL(2 ea daily);MO

ARISTADA PRSY$0-

$8.25(Tier

2)

REXULTI TABS 0.25 MG$0-

$8.25(Tier

2)


REXULTI TABS 0.5 MG$0-

$8.25(Tier

2)


REXULTI TABS 1 MG$0-

$8.25(Tier

2)



$8.25(Tier

2)



$8.25(Tier

2)



$8.25(Tier

2)


Thioxanthenes

thiothixene caps$0-

$3.30(Tier

1)

MO

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals

Drug Name DrugTier

Requirements/Limits

abacavir sulfate soln$0-

$3.30(Tier

1)

MO

abacavir sulfate tabs$0-

$3.30(Tier

1)

MO

abacavir sulfate-lamivudinetabs

$0-$3.30(Tier

1)

MO

abacavir sulfate-lamivudine-zidovudine tabs

$0-$3.30(Tier

1)

MO

APTIVUS CAPS 250 MG$0-

$8.25(Tier

2)

MO

APTIVUS SOLN 100MG/ML

$0-$8.25(Tier

2)

ATRIPLA TABS$0-

$8.25(Tier

2)

MO

COMBIVIR TABS(Lamivudine-Zidovudine) NF MO

COMPLERA TABS$0-

$8.25(Tier

2)

MO

CRIXIVAN CAPS$0-

$8.25(Tier

2)

MO

DESCOVY TABS$0-

$8.25(Tier

2)

MO

didanosine cpdr$0-

$3.30(Tier

1)

MO



66

Drug Name DrugTier

Requirements/Limits

EDURANT TABS$0-

$8.25(Tier

2)

MO

EMTRIVA CAPS$0-

$8.25(Tier

2)

MO

EMTRIVA SOLN$0-

$8.25(Tier

2)

MO

EPIVIR SOLN 10 MG/ML(Lamivudine)

$0-$8.25(Tier

2)

MO

EPIVIR TABS 300 MG, 150MG (Lamivudine) NF MO

EPZICOM TABS (AbacavirSulfate-Lamivudine)

$0-$8.25(Tier

2)

MO

EVOTAZ TABS$0-

$8.25(Tier

2)

MO

fosamprenavir calcium tabs$0-

$3.30(Tier

1)

MO

FUZEON SOLR$0-

$8.25(Tier

2)

GENVOYA TABS$0-

$8.25(Tier

2)

MO

INTELENCE TABS 200MG, 100 MG

$0-$8.25(Tier

2)

MO

INTELENCE TABS 25 MG$0-

$8.25(Tier

2)

Drug Name DrugTier

Requirements/Limits

INVIRASE CAPS$0-

$8.25(Tier

2)

MO

INVIRASE TABS$0-

$8.25(Tier

2)

MO

ISENTRESS CHEW 100MG

$0-$8.25(Tier

2)

SL(6 ea daily);MO

ISENTRESS CHEW 25 MG$0-

$8.25(Tier

2)

SL(24 ea daily);MO

ISENTRESS HD TABS$0-

$8.25(Tier

2)

ISENTRESS PACK 100MG

$0-$8.25(Tier

2)

SL(2 ea daily)

ISENTRESS TABS 400MG

$0-$8.25(Tier

2)

MO

KALETRA SOLN400MG/5ML-100MG/5ML(Lopinavir-Ritonavir)

$0-$8.25(Tier

2)

MO

KALETRA TABS 100MG-25MG, 200MG-50MG

$0-$8.25(Tier

2)

MO

lamivudine soln$0-

$3.30(Tier

1)

MO

lamivudine tabs$0-

$3.30(Tier

1)

MO

lamivudine-zidovudine tabs$0-

$3.30(Tier

1)

MO



67

Drug Name DrugTier

Requirements/Limits

LEXIVA SUSP 50 MG/ML$0-

$8.25(Tier

2)

MO

LEXIVA TABS 700 MG(Fosamprenavir Calcium)

$0-$8.25(Tier

2)

MO

lopinavir-ritonavir soln$0-

$3.30(Tier

1)

MO

NEVIRAPINE SUSP 50MG/5ML

$0-$8.25(Tier

2)

MO

nevirapine tabs 200 mg$0-

$3.30(Tier

1)

MO

nevirapine tb24 100 mg,400 mg

$0-$3.30(Tier

1)

MO

NORVIR CAPS 100 MG$0-

$8.25(Tier

2)

NORVIR SOLN 80 MG/ML$0-

$8.25(Tier

2)

MO

NORVIR TABS 100 MG$0-

$8.25(Tier

2)

MO

ODEFSEY TABS$0-

$8.25(Tier

2)

MO

PREZCOBIX TABS$0-

$8.25(Tier

2)

MO

PREZISTA SUSP$0-

$8.25(Tier

2)

MO

Drug Name DrugTier

Requirements/Limits

PREZISTA TABS$0-

$8.25(Tier

2)

MO

RESCRIPTOR TABS$0-

$8.25(Tier

2)

MO

RETROVIR CAPS(Zidovudine) NF MO

RETROVIR IV INFUSIONSOLN

$0-$8.25(Tier

2)RETROVIR SYRP(Zidovudine) NF MO

REYATAZ CAPS$0-

$8.25(Tier

2)

MO

REYATAZ PACK$0-

$8.25(Tier

2)

MO

SELZENTRY SOLN 20MG/ML

$0-$8.25(Tier

2)

SELZENTRY TABS 25MG, 75 MG

$0-$8.25(Tier

2)

SELZENTRY TABS 300MG, 150 MG

$0-$8.25(Tier

2)

MO

stavudine caps 20 mg, 40mg, 30 mg, 15 mg

$0-$3.30(Tier

1)

MO

STRIBILD TABS$0-

$8.25(Tier

2)

MO

SUSTIVA CAPS$0-

$8.25(Tier

2)

MO



68

Drug Name DrugTier

Requirements/Limits

SUSTIVA TABS$0-

$8.25(Tier

2)

MO

TIVICAY TABS$0-

$8.25(Tier

2)

MO

TRIUMEQ TABS$0-

$8.25(Tier

2)

MO

TRIZIVIR TABS (AbacavirSulfate-Lamivudine-Zidovudine)

NFMO

TRUVADA TABS$0-

$8.25(Tier

2)

MO

TYBOST TABS$0-

$8.25(Tier

2)

MO

VIDEX EC CPDR 125 MG(Didanosine)

$0-$8.25(Tier

2)

MO

VIDEX EC CPDR 250 MG,200 MG, 400 MG(Didanosine)

NFMO

VIDEXPEDIATRIC SOLR$0-

$8.25(Tier

2)

MO

VIRACEPT TABS$0-

$8.25(Tier

2)

MO

VIRAMUNE SUSP 50MG/5ML

$0-$8.25(Tier

2)

MO

VIRAMUNE TABS 200 MG(Nevirapine) NF MO

VIRAMUNE XR TB24 100MG (Nevirapine)

$0-$8.25(Tier

2)

MO

Drug Name DrugTier

Requirements/Limits

VIRAMUNE XR TB24 400MG (Nevirapine) NF MO

VIREAD POWD$0-

$8.25(Tier

2)

MO

VIREAD TABS$0-

$8.25(Tier

2)

MO

ZERIT CAPS 30 MG, 20MG, 40 MG, 15 MG(Stavudine)

NFMO

ZERIT SOLR 1 MG/ML$0-

$8.25(Tier

2)

MO

ZIAGEN SOLN 20 MG/ML(Abacavir Sulfate)

$0-$8.25(Tier

2)

MO

ZIAGEN TABS 300 MG(Abacavir Sulfate) NF MO

zidovudine caps$0-

$3.30(Tier

1)

MO

zidovudine syrp$0-

$3.30(Tier

1)

MO

zidovudine tabs$0-

$3.30(Tier

1)

MO

CMV Agents

cidofovir soln$0-

$3.30(Tier

1)CYTOVENE SOLR(Ganciclovir Sodium) NF PA; MO

ganciclovir sodium solr$0-

$3.30(Tier

1)

PA; MO



69

Drug Name DrugTier

Requirements/Limits

VALCYTE TABS 450 MG(Valganciclovir HCl)

$0-$8.25(Tier

2)

MO

valganciclovir hcl tabs 450mg

$0-$3.30(Tier

1)

MO

Hepatitis Agents

adefovir dipivoxil tabs$0-

$3.30(Tier

1)

MO

BARACLUDE SOLN 0.05MG/ML

$0-$8.25(Tier

2)

MO

BARACLUDE TABS 0.5MG, 1 MG (Entecavir)

$0-$8.25(Tier

2)

MO

COPEGUS TABS(Ribavirin (Hepatitis C)) NF

DAKLINZA TABS$0-

$8.25(Tier

2)

PA

entecavir tabs$0-

$3.30(Tier

1)

MO

EPCLUSA TABS$0-

$8.25(Tier

2)

PA

EPIVIR HBV SOLN 5MG/ML

$0-$8.25(Tier

2)

MO

EPIVIR HBV TABS 100MG (Lamivudine (HBV)) NF MO

HARVONI TABS$0-

$8.25(Tier

2)

PA

HEPSERA TABS (AdefovirDipivoxil) NF MO

Drug Name DrugTier

Requirements/Limits

lamivudine (hbv) tabs$0-

$3.30(Tier

1)

MO

OLYSIO CAPS$0-

$8.25(Tier

2)

PA

PEG-INTRON REDIPENKIT

$0-$8.25(Tier

2)

PEG-INTRON REDIPENPAK 4 KIT

$0-$8.25(Tier

2)

PEGASYS PROCLICKSOLN

$0-$8.25(Tier

2)

PEGASYS SOLN$0-

$8.25(Tier

2)

PEGINTRON KIT$0-

$8.25(Tier

2)REBETOL CAPS 200 MG(Ribavirin (Hepatitis C)) NF

ribavirin (hepatitis c) caps$0-

$3.30(Tier

1)

ribavirin (hepatitis c) tabs$0-

$3.30(Tier

1)

SOVALDI TABS$0-

$8.25(Tier

2)

PA

TECHNIVIE TABS$0-

$8.25(Tier

2)

PA



70

Drug Name DrugTier

Requirements/Limits

TYZEKA TABS$0-

$8.25(Tier

2)

VEMLIDY TABS$0-

$8.25(Tier

2)

ST; MO

VICTRELIS CAPS$0-

$8.25(Tier

2)

PA

VIEKIRA PAK TBPK$0-

$8.25(Tier

2)

PA

ZEPATIER TABS$0-

$8.25(Tier

2)

PA

Herpes Agents

acyclovir caps or 200 mg$0-

$3.30(Tier

1)

MO

acyclovir sodium soln 50mg/ml

$0-$3.30(Tier

1)

PA

acyclovir sodium solr 500mg

$0-$3.30(Tier

1)

MO

acyclovir susp or 200mg/5ml

$0-$3.30(Tier

1)

MO

acyclovir tabs or 800 mg,400 mg

$0-$3.30(Tier

1)

MO

famciclovir tabs$0-

$3.30(Tier

1)

MO

FAMVIR TABS(Famciclovir) NF MO

Drug Name DrugTier

Requirements/Limits

valacyclovir hcl tabs or1000 mg, 1 gm, 500 mg

$0-$3.30(Tier

1)

MO

VALTREX TABS(Valacyclovir HCl) NF MO

ZOVIRAX CAPS OR 200MG (Acyclovir) NF MO

ZOVIRAX SUSP OR 200MG/5ML (Acyclovir) NF MO

ZOVIRAX TABS OR 800MG, 400 MG (Acyclovir) NF MO

Influenza AgentsFLUMADINE TABS(RimantadineHydrochloride)

NFMO

oseltamivir phosphate caps$0-

$3.30(Tier

1)

MO

oseltamivir phosphate susr$0-

$3.30(Tier

1)

MO

RELENZA DISKHALERAEPB

$0-$8.25(Tier

2)

MO

rimantadine hydrochloridetabs

$0-$3.30(Tier

1)

MO

TAMIFLU CAPS(Oseltamivir Phosphate)

$0-$8.25(Tier

2)

MO

TAMIFLU SUSR(Oseltamivir Phosphate)

$0-$8.25(Tier

2)

MO

Respiratory Syncytial Virus (RSV) Agents

ribavirin solr in$0-

$3.30(Tier

1)



71

Drug Name DrugTier

Requirements/Limits

VIRAZOLE SOLR(Ribavirin)

$0-$8.25(Tier

2)

BETA BLOCKERS - Drugs to Treat High BloodPressureAlpha-Beta Blockers

carvedilol phosphate cp24$0-

$3.30(Tier

1)

MO

carvedilol tabs 12.5 mg$0-

$3.30(Tier

1)

SL(8 ea daily);MO

carvedilol tabs 25 mg$0-

$3.30(Tier

1)

SL(4 ea daily);MO


$3.30(Tier

1)

SL(32 ea daily);MO


$3.30(Tier

1)

SL(16 ea daily);MO

COREG CR CP24(Carvedilol Phosphate)

$0-$8.25(Tier

2)

MO

COREG TABS 12.5 MG(Carvedilol) NF SL(8 ea daily);

MOCOREG TABS 25 MG(Carvedilol) NF SL(4 ea daily);

MOCOREG TABS 3.125 MG(Carvedilol) NF SL(32 ea daily);

MOCOREG TABS 6.25 MG(Carvedilol) NF SL(16 ea daily);

MO

labetalol hcl tabs or 300mg, 200 mg, 100 mg

$0-$3.30(Tier

1)

MO

Beta Blockers Cardio-Selective

Drug Name DrugTier

Requirements/Limits

acebutolol hcl caps or 400mg, 200 mg

$0-$3.30(Tier

1)

MO

atenolol tabs or 50 mg, 25mg, 100 mg

$0-$3.30(Tier

1)

MO

betaxolol hcl tabs$0-

$3.30(Tier

1)

MO

bisoprolol fumarate tabs$0-

$3.30(Tier

1)

MO

LOPRESSOR TABS(Metoprolol Tartrate) NF MO

metoprolol succinate tb24$0-

$3.30(Tier

1)

MO

metoprolol tartrate tabs or50 mg, 25 mg, 100 mg

$0-$3.30(Tier

1)

MO

METOPROLOLTARTRATE TABS OR 75MG, 37.5 MG

$0-$8.25(Tier

2)

MO

SECTRAL CAPS(Acebutolol HCl) NF MO

TENORMIN TABS(Atenolol) NF MO

TOPROL XL TB24(Metoprolol Succinate) NF MO

ZEBETA TABS (BisoprololFumarate) NF MO

Beta Blockers Non-SelectiveBETAPACE AF TABS(Sotalol HCl (AFIB/AFL)) NF MO

BETAPACE TABS (SotalolHCl) NF tabs;MO

CORGARD TABS(Nadolol) NF MO

INDERAL LA CP24(Propranolol HCl) NF MO



72

Drug Name DrugTier

Requirements/Limits

nadolol tabs or 80 mg, 20mg, 40 mg

$0-$3.30(Tier

1)

MO

pindolol tabs$0-

$3.30(Tier

1)

MO

propranolol hcl cp24 or 120mg, 80 mg, 160 mg, 60 mg

$0-$3.30(Tier

1)

MO

propranolol hcl tabs or 80mg, 10 mg, 60 mg, 40 mg,20 mg

$0-$3.30(Tier

1)

MO

sotalol hcl (afib/afl) tabs$0-

$3.30(Tier

1)

MO

Sotalol Hcl IV Soln NF

sotalol hcl tabs$0-

$3.30(Tier

1)

tabs;MO

SOTYLIZE SOLN$0-

$8.25(Tier

2)

MO

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood PressureCalcium Channel BlockersADALAT CC TB24(Nifedipine) NF MO

amlodipine besylate tabs or10 mg

$0-$3.30(Tier

1)

SL(1 ea daily);MO

amlodipine besylate tabs or2.5 mg

$0-$3.30(Tier

1)

SL(4 ea daily);MO

amlodipine besylate tabs or5 mg

$0-$3.30(Tier

1)

SL(2 ea daily);MO

Drug Name DrugTier

Requirements/Limits

CALAN SR TBCR(Verapamil HCl) NF MO

CALAN TABS (VerapamilHCl) NF MO

CARDIZEM CD CP24(Diltiazem HCl CoatedBeads)

NFMO

CARDIZEM LA TB24 240MG, 300 MG, 420 MG, 360MG, 180 MG (DiltiazemHCl Coated Beads)

NF

MO

CARDIZEM TABS(Diltiazem HCl) NF MO

diltiazem hcl coated beadscp24

$0-$3.30(Tier

1)

MO

diltiazem hcl coated beadstb24

$0-$3.30(Tier

1)

MO

diltiazem hcl cp12 or 60mg, 90 mg, 120 mg

$0-$3.30(Tier

1)

MO

diltiazem hcl cp24 or 180mg, 120 mg, 240 mg

$0-$3.30(Tier

1)

MO

diltiazem hcl extendedrelease beads cp24

$0-$3.30(Tier

1)

MO

diltiazem hcl tabs or 90 mg,30 mg, 60 mg, 120 mg

$0-$3.30(Tier

1)

MO

felodipine tb24$0-

$3.30(Tier

1)

MO

nicardipine hcl caps or 20mg, 30 mg

$0-$3.30(Tier

1)

MO



73

Drug Name DrugTier

Requirements/Limits

nifedipine tb24 or 90 mg,30 mg, 60 mg

$0-$3.30(Tier

1)

MO

nimodipine caps or 30 mg,30mg

$0-$3.30(Tier

1)

MO

nisoldipine tb24$0-

$3.30(Tier

1)

MO

NORVASC TABS 10 MG(Amlodipine Besylate) NF SL(1 ea daily);

MONORVASC TABS 2.5 MG(Amlodipine Besylate) NF SL(4 ea daily);

MONORVASC TABS 5 MG(Amlodipine Besylate) NF SL(2 ea daily);

MO

NYMALIZE SOLN$0-

$8.25(Tier

2)PROCARDIA XL TB24(Nifedipine) NF MO

SULAR TB24 (Nisoldipine) NF MO

TIAZAC CP24 (DiltiazemHCl Extended ReleaseBeads)

NFMO

verapamil hcl cp24 or 120mg, 100 mg, 300 mg, 360mg, 180 mg, 200 mg, 240mg

$0-$3.30(Tier

1)

MO

verapamil hcl tabs or 40mg, 120 mg, 80 mg

$0-$3.30(Tier

1)

MO

verapamil hcl tbcr or 120mg, 180 mg, 240 mg

$0-$3.30(Tier

1)

MO

VERELAN CP24(Verapamil HCl) NF MO

VERELAN PM CP24(Verapamil HCl) NF MO

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm

Drug Name DrugTier

Requirements/Limits

Cardiac Glycosides

DIGOXIN SOLN OR 0.05MG/ML

$0-$8.25(Tier

2)

MO

digoxin tabs or 250 mcg,0.125 mg, 0.25 mg, 125mcg

$0-$3.30(Tier

1)

MO

LANOXIN TABS OR 187.5MCG, 62.5 MCG

$0-$8.25(Tier

2)

MO

LANOXIN TABS OR 250MCG, 125 MCG (Digoxin) NF MO

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation ConditionsCardiovascular Agents Misc. - Combinations

amlodipine besylate-atorvastatin calcium tabs

$0-$3.30(Tier

1)

MO

CADUET TABS(Amlodipine Besylate-Atorvastatin Calcium)

NFMO

ENTRESTO TABS$0-

$8.25(Tier

2)

PA; MO

Prostaglandin Vasodilators

REMODULIN SOLN$0-

$8.25(Tier

2)

B/D; LA

TYVASO REFILL SOLN$0-

$8.25(Tier

2)

B/D; LA

TYVASO SOLN$0-

$8.25(Tier

2)

B/D; LA

TYVASO STARTER SOLN$0-

$8.25(Tier

2)

B/D; LA



74

Drug Name DrugTier

Requirements/Limits

VENTAVIS SOLN$0-

$8.25(Tier

2)

B/D; LA

Pulmonary Hypertension - Endothelin Receptor

LETAIRIS TABS$0-

$8.25(Tier

2)

LA

OPSUMIT TABS$0-

$8.25(Tier

2)

TRACLEER TABS$0-

$8.25(Tier

2)

LA

Pulmonary Hypertension - Phosphodiesterase

ADCIRCA TABS$0-

$8.25(Tier

2)

PA

REVATIO SOLN IV 10MG/12.5ML (SildenafilCitrate (PulmonaryHypertension))

$0-$8.25(Tier

2)

PA

REVATIO TABS OR 20MG (Sildenafil Citrate(Pulmonary Hypertension))

NFPA

sildenafil citrate (pulmonaryhypertension) soln

$0-$3.30(Tier

1)

PA

sildenafil citrate (pulmonaryhypertension) tabs

$0-$3.30(Tier

1)

PA

Pulmonary Hypertension - Prostacyclin Receptor

UPTRAVI TABS$0-

$8.25(Tier

2)

PA; LA

UPTRAVI TBPK$0-

$8.25(Tier

2)

PA; LA

Pulmonary Hypertension - Sol Guanylate Cyclase

Drug Name DrugTier

Requirements/Limits

ADEMPAS TABS 0.5 MG$0-

$8.25(Tier

2)

PA; SL(15 eadaily)

ADEMPAS TABS 1 MG$0-

$8.25(Tier

2)

PA; SL(7.5 eadaily)


$8.25(Tier

2)

PA; SL(5 eadaily)

ADEMPAS TABS 2 MG$0-

$8.25(Tier

2)

PA; SL(3.75 eadaily)


$8.25(Tier

2)

PA; SL(3 eadaily)

Sinus Node Inhibitors

CORLANOR TABS 5 MG$0-

$8.25(Tier

2)

SL(3 ea daily);MO

CORLANOR TABS 7.5 MG$0-

$8.25(Tier

2)

SL(2 ea daily);MO

CEPHALOSPORINS - Drugs to Treat BacterialInfectionsCephalosporins - 1st Generation

cefadroxil caps 500 mg$0-

$3.30(Tier

1)

MO

cefadroxil susr 500 mg/5ml$0-

$3.30(Tier

1)

MO

cefadroxil tabs 1 gm$0-

$3.30(Tier

1)

MO

cefazolin sodium solr ij 10gm, 1 gm, 500 mg

$0-$3.30(Tier

1)

MO



75

Drug Name DrugTier

Requirements/Limits

cephalexin caps 750 mg,500 mg, 250 mg

$0-$3.30(Tier

1)

MO

cephalexin susr 250mg/5ml, 125 mg/5ml

$0-$3.30(Tier

1)

MO

KEFLEX CAPS(Cephalexin) NF MO

Cephalosporins - 2nd Generation

cefaclor caps 250 mg, 500mg

$0-$3.30(Tier

1)

MO

cefoxitin sodium solr ij 10gm

$0-$3.30(Tier

1)

cefoxitin sodium solr iv 1gm

$0-$3.30(Tier

1)

MO

cefoxitin sodium solr iv 2gm

$0-$3.30(Tier

1)

cefprozil susr 250 mg/5ml$0-

$3.30(Tier

1)

MO

cefprozil tabs 250 mg, 500mg

$0-$3.30(Tier

1)

MO

CEFTIN TABS 500 MG,250 MG (CefuroximeAxetil)

NFMO

cefuroxime axetil tabs$0-

$3.30(Tier

1)

MO

cefuroxime sodium solr ij1.5 gm

$0-$3.30(Tier

1)ZINACEF SOLR IJ 1.5 GM(Cefuroxime Sodium) NF

Drug Name DrugTier

Requirements/Limits

Cephalosporins - 3rd Generation

cefdinir caps$0-

$3.30(Tier

1)

MO

cefdinir susr$0-

$3.30(Tier

1)

MO

cefixime chew$0-

$3.30(Tier

1)

MO

cefixime susr$0-

$3.30(Tier

1)

MO

cefpodoxime proxetil susr100 mg/5ml

$0-$3.30(Tier

1)

MO

cefpodoxime proxetil tabs100 mg, 200 mg

$0-$3.30(Tier

1)

MO

ceftazidime solr ij 1 gm, 2gm

$0-$3.30(Tier

1)

MO

ceftazidime solr ij 6 gm$0-

$3.30(Tier

1)

ceftriaxone sodium solr ij 1gm

$0-$3.30(Tier

1)

SL(4 ea daily)

ceftriaxone sodium solr ij 2gm

$0-$3.30(Tier

1)

SL(2 ea daily);MO

ceftriaxone sodium solr ij250 mg

$0-$3.30(Tier

1)

SL(16 ea daily);MO



76

Drug Name DrugTier

Requirements/Limits

ceftriaxone sodium solr ij500 mg

$0-$3.30(Tier

1)

SL(8 ea daily);MO

ceftriaxone sodium solr iv 1gm

$0-$3.30(Tier

1)

SL(4 ea daily)

ceftriaxone sodium solr iv10 gm

$0-$3.30(Tier

1)

MO

FORTAZ SOLR IJ 2 GM, 1GM (Ceftazidime) NF MO

FORTAZ SOLR IJ 6 GM(Ceftazidime) NF

SUPRAX CAPS 400 MG$0-

$8.25(Tier

2)

MO

Cephalosporins - 4th Generation

cefepime hcl solr$0-

$3.30(Tier

1)

MO

CEFEPIME SOLN 2GM/100ML

$0-$8.25(Tier

2)MAXIPIME SOLR IJ 1 GM,2 GM (Cefepime HCl) NF MO

Cephalosporins - 5th Generation

TEFLARO SOLR 600 MG$0-

$8.25(Tier

2)

CONTRACEPTIVES - Drugs to PreventPregnancyCombination Contraceptives - OralBREVICON-28 TABS(Norethindrone & EthEstradiol)

NFMO

DESOGEN TABS(Desogestrel & EthinylEstradiol)

NFMO

Drug Name DrugTier

Requirements/Limits

desogestrel & ethinylestradiol tabs

$0-$3.30(Tier

1)

MO

desogestrel-ethinylestradiol (biphasic) tabs

$0-$3.30(Tier

1)

MO

drospirenone-ethinylestradiol tabs

$0-$3.30(Tier

1)

MO

ethynodiol diacet & ethestrad tabs 1mg-35mcg

$0-$3.30(Tier

1)

MO

FEMCON FE CHEW(Norethindrone & EthinylEstradiol-Fe)

NFMO

levonorgestrel & ethestradiol tabs

$0-$3.30(Tier

1)

MO

levonorgestrel-eth estradiol(triphasic) tabs

$0-$3.30(Tier

1)

MO

levonorgestrel-ethinylestradiol (91-day) tabs

$0-$3.30(Tier

1)

MO

LOSEASONIQUE TABS(Levonorgestrel-EthinylEstradiol (91-Day))

NFMO

MODICON TABS(Norethindrone & EthEstradiol)

NFMO

norethin acet & estrad-fetabs 75mg-20mcg-1mg,75mg-30mcg-1.5mg

$0-$3.30(Tier

1)

MO

norethindrone & ethestradiol tabs

$0-$3.30(Tier

1)

MO

norethindrone & ethinylestradiol-fe chew 0.4mg-35mcg

$0-$3.30(Tier

1)

MO



77

Drug Name DrugTier

Requirements/Limits

norethindrone acet & ethestra tabs 30mcg-1.5mg,20mcg-1mg

$0-$3.30(Tier

1)

MO

norethindrone-eth estradiol(triphasic) tabs

$0-$3.30(Tier

1)

MO

norgestimate-ethinylestradiol (triphasic) tabs

$0-$3.30(Tier

1)

MO

norgestimate-ethinylestradiol tabs

$0-$3.30(Tier

1)

MO

norgestrel & ethinylestradiol tabs

$0-$3.30(Tier

1)

MO

NORINYL 1+35 TABS(Norethindrone & EthEstradiol)

NFMO

ORTHO TRI-CYCLENTABS (Norgestimate-Ethinyl Estradiol(Triphasic))

NF

MO

ORTHO-CYCLEN TABS(Norgestimate-EthinylEstradiol)

NFMO

ORTHO-NOVUM 1/35TABS (Norethindrone &Eth Estradiol)

NFMO

ORTHO-NOVUM 7/7/7TABS (Norethindrone-EthEstradiol (Triphasic))

NFMO

SEASONIQUE TABS(Levonorgestrel-EthinylEstradiol (91-Day))

NFMO

YASMIN 28 TABS(Drospirenone-EthinylEstradiol)

NFMO

YAZ TABS (Drospirenone-Ethinyl Estradiol) NF MO

Combination Contraceptives - Transdermal

Drug Name DrugTier

Requirements/Limits

norelgestromin-ethinylestradiol ptwk

$0-$3.30(Tier

1)

MO

Combination Contraceptives - Vaginal

NUVARING RING$0-

$8.25(Tier

2)

MO

Emergency Contraceptives

ELLA TABS$0-

$8.25(Tier

2)

levonorgestrel (emergencyoc) tabs

$0(Tier

3)

NT

PLAN B ONE-STEP TABS(Levonorgestrel(Emergency OC))

NFNT

Progestin Contraceptives - InjectableDEPO-PROVERACONTRACEPTIVE SUSP(MedroxyprogesteroneAcetate (Contraceptive))

NF

MO

DEPO-PROVERACONTRACEPTIVE SUSY(MedroxyprogesteroneAcetate (Contraceptive))

NF

MO

medroxyprogesteroneacetate (contraceptive)susp

$0-$3.30(Tier

1)

MO

medroxyprogesteroneacetate (contraceptive)susy

$0-$3.30(Tier

1)

MO

Progestin Contraceptives - OralNOR-QD TABS(Norethindrone(Contraceptive))

NFMO

norethindrone(contraceptive) tabs

$0-$3.30(Tier

1)

MO



78

Drug Name DrugTier

Requirements/Limits

ORTHO MICRONORTABS (Norethindrone(Contraceptive))

NFMO

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling ConditionsGlucocorticosteroids

betamethasone sodphosphate & acetate susp

$0-$3.30(Tier

1)

MO

budesonide cpep or$0-

$3.30(Tier

1)

MO

CELESTONE-SOLUSPANSUSP (BetamethasoneSod Phosphate & Acetate)

NFMO

CORTEF TABS(Hydrocortisone) NF MO

cortisone acetate tabs or$0-

$3.30(Tier

1)

MO

DEPO-MEDROL SUSP 20MG/ML

$0-$8.25(Tier

2)

MO

DEPO-MEDROL SUSP 80MG/ML, 40 MG/ML(MethylprednisoloneAcetate)

NF

MO

dexamethasone elix or 0.5mg/5ml

$0-$3.30(Tier

1)

MO

dexamethasone sodiumphosphate soln ij 10 mg/ml

$0-$3.30(Tier

1)

PreservativeFree;MO

dexamethasone sodiumphosphate soln ij 10 mg/ml

$0-$3.30(Tier

1)dexamethasone sodiumphosphate soln ij 100mg/10ml, 4 mg/ml, 20mg/5ml, 120 mg/30ml

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

dexamethasone soln or 0.5mg/5ml

$0-$3.30(Tier

1)

MO

dexamethasone tabs or0.75 mg, 4 mg, 2 mg, 6 mg,1 mg, 1.5 mg, 0.5 mg

$0-$3.30(Tier

1)

MO

dexamethasone tbpk or 1.5mg

$0-$3.30(Tier

1)

MO

EMFLAZA SUSP$0-

$8.25(Tier

2)

PA; LA

EMFLAZA TABS$0-

$8.25(Tier

2)

PA; LA

ENTOCORT EC CPEP(Budesonide) NF MO

hydrocortisone tabs or 5mg, 20 mg, 10 mg

$0-$3.30(Tier

1)

MO

KENALOG-10 SUSP$0-

$8.25(Tier

2)

MO

KENALOG-40 SUSP$0-

$8.25(Tier

2)

MO

LOCORT 11-DAY TBPK$0-

$8.25(Tier

2)

LOCORT 7-DAY TBPK$0-

$8.25(Tier

2)MEDROL DOSEPAK TBPK(Methylprednisolone) NF MO

MEDROL TABS 2 MG$0-

$8.25(Tier

2)

MO



79

Drug Name DrugTier

Requirements/Limits

MEDROL TABS 32 MG, 4MG, 16 MG, 8 MG(Methylprednisolone)

NFMO

methylprednisolone acetatesusp ij 80 mg/ml, 40 mg/ml

$0-$3.30(Tier

1)

MO

methylprednisolone sodsucc solr

$0-$3.30(Tier

1)

MO

methylprednisolone tabs or16 mg, 8 mg, 4 mg, 32 mg

$0-$3.30(Tier

1)

MO

methylprednisolone tbpk or4 mg

$0-$3.30(Tier

1)

MO

ORAPRED ODT TBDP(Prednisolone SodiumPhosphate)

NFMO

prednisolone sodiumphosphate soln or 15mg/5ml, 5 mg/5ml, 6.7mg/5ml

$0-$3.30(Tier

1)

MO

prednisolone sodiumphosphate tbdp or 10 mg,30 mg, 15 mg

$0-$3.30(Tier

1)

MO

prednisolone soln or 15mg/5ml

$0-$3.30(Tier

1)

MO

prednisolone syrp or 15mg/5ml

$0-$3.30(Tier

1)

MO

prednisolone tabs or 5 mg$0-

$3.30(Tier

1)

MO

prednisone conc or 5mg/ml

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

prednisone soln or 5mg/5ml

$0-$3.30(Tier

1)

MO

prednisone tabs or 5 mg,2.5 mg, 1 mg, 10 mg, 20mg, 50 mg

$0-$3.30(Tier

1)

MO

prednisone tbpk or 5 mg$0-

$3.30(Tier

1)

Dose Pack;MO

prednisone tbpk or 5 mg,10 mg

$0-$3.30(Tier

1)

MO

SOLU-CORTEF SOLR1000 MG

$0-$8.25(Tier

2)

SOLU-CORTEF SOLR 500MG, 100 MG, 250 MG

$0-$8.25(Tier

2)

MO

SOLU-MEDROL SOLR 125MG, 1000 MG, 40 MG(Methylprednisolone SodSucc)

NF

MO

SOLU-MEDROL SOLR 500MG

$0-$8.25(Tier

2)

MO

ZODEX 6-DAY TBPK$0-

$8.25(Tier

2)

MO

ZONACORT 11 DAY TBPK$0-

$8.25(Tier

2)

ZONACORT 7 DAY TBPK$0-

$8.25(Tier

2)

Mineralocorticoids



80

Drug Name DrugTier

Requirements/Limits

fludrocortisone acetatetabs or

$0-$3.30(Tier

1)

MO

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy SymptomsAntitussives

benzonatate caps 200 mg,100 mg

$0(Tier

3)

MO; NT

hydrocodone w/homatropine syrp

$0(Tier

3)

MO; NT

hydrocodone w/homatropine tabs

$0(Tier

3)

MO; NT

TESSALON PERLESCAPS (Benzonatate) NF MO; NT

Cough/Cold/Allergy Combinationsbrompheniramine &phenyleph elix 1mg/5ml-1mg/5ml-2.5mg/5ml-2.5mg/5ml, 1mg/5ml-2.5mg/5ml

$0(Tier

3)


brompheniramine &pseudoeph elix

$0(Tier

3)


brompheniramine &pseudoeph liqd

$0(Tier

3)


cetirizine-pseudoephedrinetb12

$0(Tier

3)

MO; NT

CHILDRENS PLUS COLDSUSP

$0(Tier

3)


chlorpheniramine &phenylephrine tabs 4mg-10mg

$0(Tier

3)


CLARITIN-D 24 HOURTB24 (Loratadine &Pseudoephedrine)

NFMO; NT

DIMETAPP COLD &ALLERGY ELIX 1MG/5ML-2.5MG/5ML(Brompheniramine &Phenyleph)

NF


Drug Name DrugTier

Requirements/Limits

diphenhydramine-phenylephrine-acetaminophen susp12.5mg/5ml-160mg/5ml-2.5mg/5ml

$0(Tier

3)


ED CHLORPED D LIQD$0

(Tier3)


ENTRE-HIST PSE LIQD$0

(Tier3)


guaifenesin-codeine liqd100mg/5ml-10mg/5ml

$0(Tier

3)

MO; NT

guaifenesin-codeine soln100mg/5ml-10mg/5ml

$0(Tier

3)

MO; NT

guaifenesin-codeine syrp100mg/5ml-10mg/5ml

$0(Tier

3)

MO; NT

hydrocodone polistirex-chlorpheniramine polistirexsuer

$0(Tier

3)


loratadine &pseudoephedrine tb2410mg-10mg-240mg-240mg, 10mg-240mg

$0(Tier

3)

MO; NT

NEXAFED SINUSPRESSURE +PAIN TABS

$0(Tier

3)

NT

PHENYLHISTINE DH LIQD$0

(Tier3)

NT

promethazine w/codeinesyrp

$0(Tier

3)


promethazine-dm syrp$0

(Tier3)


promethazine-phenylephrine-codeine syrp

$0(Tier

3)


pseudoephedrine-ibuprofensusp 100mg/5ml-15mg/5ml

$0(Tier

3)

NT

RYMED TABS$0

(Tier3)




81

Drug Name DrugTier

Requirements/Limits

triprolidine &pseudoephedrine tabs

$0(Tier

3)


TUSSIONEXPENNKINETICEXTENDED RELEASESUER (HydrocodonePolistirex-ChlorpheniraminePolistirex)

NF


ZYRTEC-DALLERGY/CONGESTIONTB12 (Cetirizine-Pseudoephedrine)

NF

MO; NT

Misc. Respiratory Inhalants

sodium chloride (inhalant)aers

$0(Tier

3)

NT

Mucolytics

acetylcysteine soln in 20%, 10 %

$0-$3.30(Tier

1)

B/D; MO

DERMATOLOGICALS - Drugs to Treat SkinConditionsAcne Products

ABSORICA CAPS$0-

$8.25(Tier

2)

ACNE MEDICATION 10LOTN

$0(Tier

3)

NT

adapalene crea 0.1 %$0-

$3.30(Tier

1)

MO

adapalene gel 0.1 %$0-

$3.30(Tier

1)

RX/OTC; MO

AVAR-E LS CREA(Sulfacetamide Sodium w/Sulfur)

NFMO; NT

BENZAC AC WASH LIQD(Benzoyl Peroxide) NF RX/OTC; MO;

NT

Drug Name DrugTier

Requirements/Limits

BENZACLIN GEL(Clindamycin Phosphate-Benzoyl Peroxide)

NFMO

BENZACLIN WITH PUMPGEL (ClindamycinPhosphate-BenzoylPeroxide)

NF

MO

BENZAMYCIN GEL(Benzoyl Peroxide-Erythromycin)

NFMO

BENZEFOAM FOAM(Benzoyl Peroxide) NF RX/OTC; MO;

NT

benzoyl peroxide gel ex 10%

$0(Tier

3)

RX/OTC; MO;NT

BENZOYL PEROXIDEGEL EX 2.5 %

$0(Tier

3)

MO; NT

benzoyl peroxide gel ex 5%

$0(Tier

3)

MO; NT

benzoyl peroxide liqd ex 10%, 5 %

$0(Tier

3)

RX/OTC; MO;NT

benzoyl peroxide-erythromycin gel

$0-$3.30(Tier

1)

MO

CLEOCIN-T GEL(Clindamycin Phosphate(Topical))

NFMO

CLEOCIN-T LOTN(Clindamycin Phosphate(Topical))

NFMO

CLEOCIN-T SOLN(Clindamycin Phosphate(Topical))

NFMO

CLEOCIN-T SWAB(Clindamycin Phosphate(Topical))

NFMO

CLINDAGEL GEL$0-

$8.25(Tier

2)

MO

clindamycin phosphate(topical) foam

$0-$3.30(Tier

1)

MO



82

Drug Name DrugTier

Requirements/Limits

clindamycin phosphate(topical) gel

$0-$3.30(Tier

1)

MO

clindamycin phosphate(topical) lotn

$0-$3.30(Tier

1)

MO

clindamycin phosphate(topical) soln

$0-$3.30(Tier

1)

MO

clindamycin phosphate(topical) swab

$0-$3.30(Tier

1)

MO

clindamycin phosphate-benzoyl peroxide(refrigerate) gel

$0-$3.30(Tier

1)

MO

clindamycin phosphate-benzoyl peroxide gel

$0-$3.30(Tier

1)

MO

DESQUAM-X WASH LIQD(Benzoyl Peroxide) NF RX/OTC; MO;

NTDIFFERIN CREA 0.1 %(Adapalene) NF MO

DIFFERIN GEL 0.1 %(Adapalene) NF RX/OTC; MO

DUAC GEL (ClindamycinPhosphate-BenzoylPeroxide (Refrigerate))

NFMO

erythromycin (acne aid)soln

$0-$3.30(Tier

1)

MO

EVOCLIN FOAM(Clindamycin Phosphate(Topical))

NFMO

isotretinoin caps or 20 mg,30 mg, 10 mg, 40 mg

$0-$3.30(Tier

1)KLARON LOTN(Sulfacetamide Sodium(Acne))

NFMO

Drug Name DrugTier

Requirements/Limits

PLEXION CLEANSERLIQD (SulfacetamideSodium w/ Sulfur)

NFMO; NT

RETIN-A CREA (Tretinoin) NF MO

RETIN-A GEL (Tretinoin) NF MO

RETIN-A MICRO GEL(Tretinoin Microsphere) NF MO

RETIN-A MICRO PUMPGEL 0.04 %, 0.1 %(Tretinoin Microsphere)

NFMO

sulfacetamide sodium(acne) lotn

$0-$3.30(Tier

1)

MO

sulfacetamide sodium(acne) susp

$0-$3.30(Tier

1)

MO

tretinoin crea ex 0.025 %,0.1 %, 0.05 %

$0-$3.30(Tier

1)

MO

tretinoin gel ex 0.025 %,0.01 %

$0-$3.30(Tier

1)

MO

tretinoin microsphere gel$0-

$3.30(Tier

1)

MO

Anti-inflammatory Agents - Topical

diclofenac sodium (topical)gel 1 %

$0-$3.30(Tier

1)

MO

FLECTOR PTCH$0-

$8.25(Tier

2)

PA; MO

VOLTAREN GEL(Diclofenac Sodium(Topical))

$0-$8.25(Tier

2)

MO

Antibiotics - TopicalBACIGUENT OINT(Bacitracin (Topical)) NF MO; NT



83

Drug Name DrugTier

Requirements/Limits

bacitracin (topical) oint$0

(Tier3)

MO; NT

bacitracin zinc oint ex$0

(Tier3)

MO; NT

bacitracin-polymyxin b oint$0

(Tier3)

MO; NT

BACTROBAN CREA(Mupirocin Calcium(Topical))

NFMO

BACTROBAN OINT(Mupirocin) NF MO

CENTANY OINT$0-

$8.25(Tier

2)

MO

gentamicin sulfate (topical)crea

$0-$3.30(Tier

1)

MO

gentamicin sulfate (topical)oint

$0-$3.30(Tier

1)

MO

mupirocin calcium (topical)crea

$0-$3.30(Tier

1)

MO

mupirocin oint ex$0-

$3.30(Tier

1)

MO

POLYSPORIN OINT(Bacitracin-Polymyxin B) NF MO; NT

Antifungals - Topical

ALEVAZOL OINT$0

(Tier3)

NT

ciclopirox gel 0.77 %$0-

$3.30(Tier

1)

MO

ciclopirox olamine crea ex$0-

$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

ciclopirox olamine susp ex$0-

$3.30(Tier

1)

MO

ciclopirox sham 1 %$0-

$3.30(Tier

1)

MO

ciclopirox soln 8 %$0-

$3.30(Tier

1)

MO

clotrimazole (topical) crea$0

(Tier3)


clotrimazole (topical) crea$0-

$3.30(Tier

1)

RX/OTC; MO

clotrimazole (topical) soln$0

(Tier3)


clotrimazole (topical) soln$0-

$3.30(Tier

1)

RX/OTC; MO

clotrimazole w/betamethasone crea

$0-$3.30(Tier

1)

MO

clotrimazole w/betamethasone lotn

$0-$3.30(Tier

1)

MO

econazole nitrate crea$0-

$3.30(Tier

1)

MO

EXTINA FOAM(Ketoconazole (Topical)) NF MO

ketoconazole (topical) crea$0-

$3.30(Tier

1)

MO

ketoconazole (topical) foam$0-

$3.30(Tier

1)

MO



84

Drug Name DrugTier

Requirements/Limits

ketoconazole (topical)sham

$0-$3.30(Tier

1)

MO

LAMISIL AT CREA(Terbinafine HCl (Topical)) NF MO; NT

LAMISIL AT JOCK ITCHCREA (Terbinafine HCl(Topical))

NFMO; NT

LAMISIL AT SPRAY SOLN$0

(Tier3)

NT

LOPROX CREA 0.77 %(Ciclopirox Olamine) NF MO

LOPROX SHAMPOOSHAM (Ciclopirox) NF MO

LOPROX SUSP 0.77 %(Ciclopirox Olamine) NF MO

LOTRIMIN AF CREA 1 %(Clotrimazole (Topical))

$0(Tier

3)

RX/OTC; MO;NT

LOTRIMIN AF FOR HERCREA (Clotrimazole(Topical))

$0(Tier

3)

RX/OTC; MO;NT

LOTRIMIN AF JOCK ITCHCREA (Clotrimazole(Topical))

$0(Tier

3)

RX/OTC; MO;NT

LOTRISONE CREA(Clotrimazole w/Betamethasone)

NFMO

MICATIN CREA(Miconazole Nitrate(Topical))

NFMO; NT

miconazole nitrate (topical)crea

$0(Tier

3)

MO; NT

naftifine hcl crea 2 %$0-

$3.30(Tier

1)

MO

NAFTIN CREA 2 %(Naftifine HCl)

$0-$8.25(Tier

2)

MO

NAFTIN GEL 2 %$0-

$8.25(Tier

2)

MO

Drug Name DrugTier

Requirements/Limits

NIZORAL SHAM(Ketoconazole (Topical)) NF MO

nystatin (topical) crea$0-

$3.30(Tier

1)

MO

nystatin (topical) oint$0-

$3.30(Tier

1)

MO

nystatin (topical) powd$0-

$3.30(Tier

1)

MO

nystatin-triamcinolone crea$0-

$3.30(Tier

1)

MO

nystatin-triamcinolone oint$0-

$3.30(Tier

1)

MO

PENLAC NAIL LACQUERSOLN (Ciclopirox) NF MO

terbinafine hcl (topical) crea$0

(Tier3)

MO; NT

TINACTIN CREA(Tolnaftate) NF MO; NT

TINACTIN JOCK ITCHCREA (Tolnaftate) NF MO; NT

tolnaftate crea ex$0

(Tier3)

MO; NT

tolnaftate liqd ex$0

(Tier3)

MO; NT

tolnaftate soln ex$0

(Tier3)

MO; NT

Antineoplastic or Premalignant Lesion Agents -

CARAC CREA$0-

$8.25(Tier

2)

MO



85

Drug Name DrugTier

Requirements/Limits

diclofenac sodium (actinickeratoses) gel

$0-$3.30(Tier

1)

MO

EFUDEX CREA(Fluorouracil (Topical)) NF MO

fluorouracil (topical) crea$0-

$3.30(Tier

1)

MO

fluorouracil (topical) soln$0-

$3.30(Tier

1)

MO

FLUOROURACIL CREAEX 0.5 %

$0-$8.25(Tier

2)

MO

PANRETIN GEL$0-

$8.25(Tier

2)

MO

PICATO GEL$0-

$8.25(Tier

2)

MO

SOLARAZE GEL(Diclofenac Sodium (ActinicKeratoses))

NFMO

TARGRETIN GEL EX 1 %$0-

$8.25(Tier

2)

VALCHLOR GEL$0-

$8.25(Tier

2)

PA

Antipsoriatics

acitretin caps$0-

$3.30(Tier

1)

MO

calcipotriene crea$0-

$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

calcipotriene oint$0-

$3.30(Tier

1)

MO

calcipotriene soln$0-

$3.30(Tier

1)

MO

COSENTYXSENSOREADY PEN SOAJ

$0-$8.25(Tier

2)

PA; LA

COSENTYX SOSY$0-

$8.25(Tier

2)

PA; LA

DOVONEX CREA(Calcipotriene) NF MO

methoxsalen rapid caps$0-

$3.30(Tier

1)

MO

OXSORALEN ULTRACAPS (Methoxsalen Rapid)

$0-$8.25(Tier

2)

MO

SILIQ SOSY$0-

$8.25(Tier

2)

PA

SORIATANE CAPS(Acitretin) NF MO

STELARA SOSY SC 90MG/ML, 45 MG/0.5ML

$0-$8.25(Tier

2)

PA

TALTZ SOAJ$0-

$8.25(Tier

2)

PA

TALTZ SOSY$0-

$8.25(Tier

2)

PA

tazarotene crea$0-

$3.30(Tier

1)

MO



86

Drug Name DrugTier

Requirements/Limits

TAZORAC CREA 0.05 %$0-

$8.25(Tier

2)

MO

TAZORAC CREA 0.1 %(Tazarotene)

$0-$8.25(Tier

2)

MO

TAZORAC GEL 0.05 %,0.1 %

$0-$8.25(Tier

2)

MO

Antiseborrheic ProductsOVACE PLUS WASH LIQD(Sulfacetamide Sodium) NF MO; NT

OVACE WASH LIQD(Sulfacetamide Sodium) NF MO; NT

selenium sulfide lotn ex 1%

$0(Tier

3)

MO; NT

selenium sulfide lotn ex 2.5%

$0-$3.30(Tier

1)

MO

selenium sulfide sham ex 1%

$0(Tier

3)

MO; NT

SELSUN BLUE DAILYLOTN (Selenium Sulfide) NF MO; NT

SELSUN BLUE LOTN(Selenium Sulfide) NF MO; NT

SELSUN BLUEMEDICATED LOTN(Selenium Sulfide)

NFMO; NT

SELSUN BLUEMOISTURIZING LOTN(Selenium Sulfide)

NFMO; NT

Antivirals - Topical

ABREVA CREA$0

(Tier3)

MO; NT

acyclovir topical oint$0-

$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

DENAVIR CREA$0-

$8.25(Tier

2)

MO

ZOVIRAX CREA EX 5 %$0-

$8.25(Tier

2)

MO

ZOVIRAX OINT EX 5 %(Acyclovir Topical) NF MO

Burn Products

mafenide acetate pack ex$0-

$3.30(Tier

1)

MO

SILVADENE CREA (SilverSulfadiazine) NF MO

silver sulfadiazine crea ex$0-

$3.30(Tier

1)

MO

SULFAMYLON CREA 85MG/GM

$0-$8.25(Tier

2)

MO

SULFAMYLON PACK 5 %(Mafenide Acetate)

$0-$8.25(Tier

2)

MO

Corticosteroids - Topical

alclometasone dipropionatecrea

$0-$3.30(Tier

1)

MO

alclometasone dipropionateoint

$0-$3.30(Tier

1)

MO

amcinonide crea$0-

$3.30(Tier

1)

MO

betamethasonedipropionate (topical) crea

$0-$3.30(Tier

1)

MO



87

Drug Name DrugTier

Requirements/Limits

betamethasonedipropionate (topical) lotn

$0-$3.30(Tier

1)

MO

betamethasonedipropionate (topical) oint

$0-$3.30(Tier

1)

MO

betamethasonedipropionate augmentedcrea

$0-$3.30(Tier

1)

MO

betamethasonedipropionate augmentedgel

$0-$3.30(Tier

1)

MO

betamethasonedipropionate augmentedlotn

$0-$3.30(Tier

1)

MO

betamethasonedipropionate augmentedoint

$0-$3.30(Tier

1)

MO

betamethasone valeratecrea ex 0.1 %

$0-$3.30(Tier

1)

MO

betamethasone valeratefoam ex 0.12 %

$0-$3.30(Tier

1)

MO

betamethasone valeratelotn ex 0.1 %

$0-$3.30(Tier

1)

MO

betamethasone valerateoint ex 0.1 %

$0-$3.30(Tier

1)

MO

clobetasol propionate creaex

$0-$3.30(Tier

1)

MO

clobetasol propionateemollient base crea

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

clobetasol propionateemulsion foam

$0-$3.30(Tier

1)

MO

clobetasol propionate foamex

$0-$3.30(Tier

1)

MO

clobetasol propionate gelex

$0-$3.30(Tier

1)

MO

clobetasol propionate lotnex

$0-$3.30(Tier

1)

MO

clobetasol propionate ointex

$0-$3.30(Tier

1)

MO

clobetasol propionate shamex

$0-$3.30(Tier

1)

MO

clobetasol propionate solnex

$0-$3.30(Tier

1)

MO

CLOBEX LOTN(Clobetasol Propionate) NF MO

CLOBEX SHAM(Clobetasol Propionate) NF MO

CUTIVATE CREA(Fluticasone Propionate) NF MO

CUTIVATE LOTN(Fluticasone Propionate) NF MO

DERMA-SMOOTHE/FSBODY OIL (FluocinoloneAcetonide)

NFMO

DERMA-SMOOTHE/FSSCALP OIL (FluocinoloneAcetonide)

NFMO

DERMATOP CREA(Prednicarbate) NF MO

desonide crea ex$0-

$3.30(Tier

1)

MO



88

Drug Name DrugTier

Requirements/Limits

desonide lotn ex$0-

$3.30(Tier

1)

MO

desonide oint ex$0-

$3.30(Tier

1)

MO

DESOWEN CREA(Desonide) NF MO

desoximetasone crea ex0.25 %

$0-$3.30(Tier

1)

MO

desoximetasone gel ex0.05 %

$0-$3.30(Tier

1)

MO

desoximetasone oint ex0.25 %

$0-$3.30(Tier

1)

MO

diflorasone diacetate oint$0-

$3.30(Tier

1)

MO

DIPROLENE AF CREA(BetamethasoneDipropionate Augmented)

NFMO

DIPROLENE LOTN(BetamethasoneDipropionate Augmented)

NFMO

DIPROLENE OINT(BetamethasoneDipropionate Augmented)

NFMO

ELOCON CREA(Mometasone Furoate) NF MO

ELOCON OINT(Mometasone Furoate) NF MO

fluocinolone acetonide creaex 0.025 %, 0.01 %

$0-$3.30(Tier

1)

MO

fluocinolone acetonide oilex 0.01 %

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

fluocinolone acetonide ointex 0.025 %

$0-$3.30(Tier

1)

MO

fluocinolone acetonide solnex 0.01 %

$0-$3.30(Tier

1)

MO

fluocinonide crea ex 0.05 %$0-

$3.30(Tier

1)

MO

fluocinonide emulsifiedbase crea

$0-$3.30(Tier

1)

MO

fluocinonide gel ex 0.05 %$0-

$3.30(Tier

1)

MO

fluocinonide oint ex 0.05 %$0-

$3.30(Tier

1)

MO

fluocinonide soln ex 0.05 %$0-

$3.30(Tier

1)

MO

fluticasone propionate creaex 0.05 %

$0-$3.30(Tier

1)

MO

fluticasone propionate lotnex 0.05 %

$0-$3.30(Tier

1)

MO

fluticasone propionate ointex 0.005 %

$0-$3.30(Tier

1)

MO

halobetasol propionatecrea

$0-$3.30(Tier

1)

MO

halobetasol propionate oint$0-

$3.30(Tier

1)

MO



89

Drug Name DrugTier

Requirements/Limits

hydrocortisone (topical)crea 0.5 %

$0(Tier

3)

MO; NT

hydrocortisone (topical)crea 1 %

$0-$3.30(Tier

1)

RX/OTC; MO

hydrocortisone (topical)crea 1 %, 1%

$0(Tier

3)


hydrocortisone (topical)crea 2.5 %

$0-$3.30(Tier

1)

MO

hydrocortisone (topical)lotn 1 %

$0(Tier

3)

MO; NT

hydrocortisone (topical)lotn 2.5 %

$0-$3.30(Tier

1)

MO

hydrocortisone (topical)oint 0.5 %

$0(Tier

3)

MO; NT

hydrocortisone (topical)oint 1 %

$0(Tier

3)


hydrocortisone (topical)oint 1 %

$0-$3.30(Tier

1)

RX/OTC; MO

hydrocortisone (topical)oint 2.5 %

$0-$3.30(Tier

1)

MO

hydrocortisone (topical)soln 1 %

$0(Tier

3)

NT

hydrocortisone butyratecrea

$0-$3.30(Tier

1)

MO

hydrocortisone butyratehydrophilic lipo base crea

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

hydrocortisone butyrateoint

$0-$3.30(Tier

1)

MO

hydrocortisone butyratesoln

$0-$3.30(Tier

1)

MO

hydrocortisone valeratecrea

$0-$3.30(Tier

1)

MO

hydrocortisone valerate oint$0-

$3.30(Tier

1)

MO

hydrocortisone-aloe veracrea

$0(Tier

3)

NT

KENALOG AERS(Triamcinolone Acetonide(Topical))

NFMO

LOCOID CREA(Hydrocortisone Butyrate) NF MO

LOCOID LIPOCREAMCREA (HydrocortisoneButyrate Hydrophilic LipoBase)

NF

MO

LOCOID OINT(Hydrocortisone Butyrate) NF MO

LOCOID SOLN(Hydrocortisone Butyrate) NF MO

LUXIQ FOAM(Betamethasone Valerate)

$0-$8.25(Tier

2)

MO

mometasone furoate creaex

$0-$3.30(Tier

1)

MO

mometasone furoate ointex

$0-$3.30(Tier

1)

MO

mometasone furoate solnex

$0-$3.30(Tier

1)

MO



90

Drug Name DrugTier

Requirements/Limits

MONISTAT SOOTHINGCARE ITCH RELIEF CREA(Hydrocortisone (Topical))

$0(Tier

3)

RX/OTC; MO;NT

OLUX FOAM (ClobetasolPropionate) NF MO

OLUX-E FOAM (ClobetasolPropionate Emulsion) NF MO

prednicarbate crea$0-

$3.30(Tier

1)

MO

SYNALAR CREA(Fluocinolone Acetonide) NF MO

SYNALAR OINT(Fluocinolone Acetonide) NF MO

SYNALAR SOLN(Fluocinolone Acetonide) NF MO

TEMOVATE CREA(Clobetasol Propionate) NF MO

TEMOVATE E CREA(Clobetasol PropionateEmollient Base)

NFMO

TEMOVATE GEL(Clobetasol Propionate) NF MO

TEMOVATE OINT(Clobetasol Propionate) NF MO

TEMOVATE SOLN(Clobetasol Propionate) NF MO

triamcinolone acetonide(topical) aers 0.147 mg/gm

$0-$3.30(Tier

1)

MO

triamcinolone acetonide(topical) crea 0.5 %, 0.1 %,0.025 %

$0-$3.30(Tier

1)

MO

triamcinolone acetonide(topical) lotn 0.1 %, 0.025%

$0-$3.30(Tier

1)

MO

triamcinolone acetonide(topical) oint 0.1 %, 0.025%

$0-$3.30(Tier

1)

MO

TRIDESILON CREA(Desonide) NF MO

Drug Name DrugTier

Requirements/Limits

ULTRAVATE CREA(Halobetasol Propionate) NF MO

ULTRAVATE OINT(Halobetasol Propionate) NF MO

WESTCORT OINT(Hydrocortisone Valerate) NF MO

Emollient/Keratolytic AgentsURAMAXIN GEL 45 %(Urea) NF MO; NT

URAMAXIN GT GEL(Urea) NF MO; NT

URAMAXIN LOTN 45 %(Urea) NF MO; NT

EmollientsLAC-HYDRIN CREA(Lactic Acid (AmmoniumLactate))

NFRX/OTC; MO

LAC-HYDRIN LOTN (LacticAcid (Ammonium Lactate)) NF RX/OTC; MO

LAC-HYDRIN TWELVELOTN (Lactic Acid(Ammonium Lactate))

$0(Tier

3)

RX/OTC; MO;NT

lactic acid (ammoniumlactate) crea 12 %

$0-$3.30(Tier

1)

RX/OTC; MO

lactic acid (ammoniumlactate) crea 12 %

$0(Tier

3)


lactic acid (ammoniumlactate) lotn 12 %

$0(Tier

3)


lactic acid (ammoniumlactate) lotn 12 %

$0-$3.30(Tier

1)

RX/OTC; MO

Enzymes - Topical

SANTYL OINT$0-

$8.25(Tier

2)

MO

Immunomodulating Agents - TopicalALDARA CREA(Imiquimod) NF MO



91

Drug Name DrugTier

Requirements/Limits

imiquimod crea ex$0-

$3.30(Tier

1)

MO

ZYCLARA CREA$0-

$8.25(Tier

2)

MO

ZYCLARA PUMP CREA$0-

$8.25(Tier

2)

MO

Immunosuppressive Agents - Topical

ELIDEL CREA$0-

$8.25(Tier

2)

MO

PROTOPIC OINT(Tacrolimus (Topical)) NF MO

tacrolimus (topical) oint$0-

$3.30(Tier

1)

MO

Keratolytic/Antimitotic AgentsCONDYLOX SOLN(Podofilox) NF MO

podofilox soln ex$0-

$3.30(Tier

1)

MO

VIRASAL LIQD (SalicylicAcid) NF MO

Local Anesthetics - TopicalLENZAPATCH PTCH(Lidocaine-Menthol) NF RX/OTC; NT

lidocaine hcl gel ex 2 %$0-

$3.30(Tier

1)

RX/OTC; MO

lidocaine hcl soln ex 4 %$0-

$3.30(Tier

1)

MO

lidocaine oint ex 5 %$0-

$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

lidocaine ptch ex 5 %$0-

$3.30(Tier

1)

PA; MO

lidocaine-prilocaine crea$0-

$3.30(Tier

1)

MO

LIDOCAREARM/NECK/LEG PTCH(Lidocaine)

NFNT

LIDOCAREBACK/SHOULDER PTCH(Lidocaine)

NFNT

LIDODERM PTCH(Lidocaine) NF PA; MO

XYLOCAINE SOLN EX 4% (Lidocaine HCl) NF MO

Misc. Topical

CALAMINE LOTN EX$0

(Tier3)

NT

CALAMINE LOTN EX$0

(Tier3)

Calamine-ZincOxideLotion;MO; NT

GNP CALAMINE LOTN$0

(Tier3)


HM CALAMINE LOTN$0

(Tier3)


MEIJER CALAMINE LOTN$0

(Tier3)

NT

PX CALAMINE LOTN$0

(Tier3)


QC CALAMINE LOTN$0

(Tier3)

NT

RA CALAMINE LOTN6.971%-6.971%

$0(Tier

3)


SM CALAMINE LOTN$0

(Tier3)

NT

Rosacea Agents



92

Drug Name DrugTier

Requirements/Limits

FINACEA GEL$0-

$8.25(Tier

2)

MO

METROCREAM CREA(Metronidazole (Topical)) NF MO

METROGEL GEL(Metronidazole (Topical)) NF MO

METROLOTION LOTN(Metronidazole (Topical)) NF MO

metronidazole (topical)crea

$0-$3.30(Tier

1)

MO

metronidazole (topical) gel$0-

$3.30(Tier

1)

MO

metronidazole (topical) lotn$0-

$3.30(Tier

1)

MO

MIRVASO GEL$0-

$8.25(Tier

2)

PA; MO

Scabicides & Pediculicides

lindane lotn$0-

$3.30(Tier

1)

malathion lotn$0-

$3.30(Tier

1)

MO

NIX CREME RINSE LIQD(Permethrin) NF MO; NT

permethrin crea ex 5 %$0-

$3.30(Tier

1)

MO

permethrin liqd ex 1 %$0

(Tier3)

MO; NT

permethrin lotn ex 1 %$0

(Tier3)

NT

Drug Name DrugTier

Requirements/Limits

pyrethrins-piperonylbutoxide liqd 0.33%-4%

$0(Tier

3)

NT

pyrethrins-piperonylbutoxide sham 0.33%-4%

$0(Tier

3)

NT

pyrethrins-piperonylbutoxide sham 0.33%-4%,0.3%-0.33%-4%

$0(Tier

3)

MO; NT

RID LIQD EX 0.33%-4%(Pyrethrins-PiperonylButoxide)

NFNT

Wound Care Products

REGRANEX GEL$0-

$8.25(Tier

2)

MO

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymesDigestive Enzymes

CREON CPEP$0-

$8.25(Tier

2)

MO

PANCREAZE CPEP$0-

$8.25(Tier

2)

MO

SUCRAID SOLN$0-

$8.25(Tier

2)

LA

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood PressureCarbonic Anhydrase Inhibitors

acetazolamide cp12 or 500mg

$0-$3.30(Tier

1)

MO

acetazolamide tabs or 250mg

$0-$3.30(Tier

1)

MO

DIAMOX CP12(Acetazolamide) NF MO



93

Drug Name DrugTier

Requirements/Limits

methazolamide tabs or 50mg, 25 mg

$0-$3.30(Tier

1)

MO

Diuretic CombinationsALDACTAZIDE TABS25MG-25MG(Spironolactone &Hydrochlorothiazide)

NF

MO

amiloride &hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

DYAZIDE CAPS(Triamterene &Hydrochlorothiazide)

NFMO

MAXZIDE TABS(Triamterene &Hydrochlorothiazide)

NFMO

MAXZIDE-25 TABS(Triamterene &Hydrochlorothiazide)

NFMO

spironolactone &hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

triamterene &hydrochlorothiazide caps

$0-$3.30(Tier

1)

MO

triamterene &hydrochlorothiazide tabs

$0-$3.30(Tier

1)

MO

Loop Diuretics

bumetanide tabs or 0.5 mg,2 mg, 1 mg

$0-$3.30(Tier

1)

MO

BUMEX TABS(Bumetanide) NF MO

DEMADEX TABS(Torsemide) NF MO

furosemide soln ij 10 mg/ml$0-

$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

furosemide soln or 10mg/ml

$0-$3.30(Tier

1)

MO

furosemide tabs or 80 mg,20 mg, 40 mg

$0-$3.30(Tier

1)

MO

LASIX TABS (Furosemide) NF MO

torsemide tabs$0-

$3.30(Tier

1)

MO

Potassium Sparing DiureticsALDACTONE TABS(Spironolactone) NF MO

amiloride hcl tabs or$0-

$3.30(Tier

1)

MO

spironolactone tabs or 50mg, 25 mg, 100 mg

$0-$3.30(Tier

1)

MO

Thiazides and Thiazide-Like Diuretics

chlorothiazide tabs 500 mg$0-

$3.30(Tier

1)

MO

chlorthalidone tabs 25 mg$0-

$3.30(Tier

1)

MO

hydrochlorothiazide caps or12.5 mg

$0-$3.30(Tier

1)

MO

hydrochlorothiazide tabs or50 mg, 12.5 mg, 25 mg

$0-$3.30(Tier

1)

MO

indapamide tabs$0-

$3.30(Tier

1)

MO



94

Drug Name DrugTier

Requirements/Limits

metolazone tabs$0-

$3.30(Tier

1)

MO

MICROZIDE CAPS(Hydrochlorothiazide) NF MO

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate HormonesBone Density Regulators

alendronate sodium tabs35 mg, 70 mg

$0-$3.30(Tier

1)


alendronate sodium tabs 5mg, 10 mg

$0-$3.30(Tier

1)

MO

BONIVA SOLN IV 3MG/3ML (IbandronateSodium)

NFQL(0.04 mldaily); MO

BONIVA TABS OR 150 MG(Ibandronate Sodium) NF

Limit 1 tab per28 days (3 per84);QL(0.036ea daily); MO

calcitonin (salmon) soln$0-

$3.30(Tier

1)

MO

FORTEO SOLN$0-

$8.25(Tier

2)

Limit 2.4mlsper 28days;QL(0.09ml daily)

FORTICAL SOLN$0-

$8.25(Tier

2)

MO

FOSAMAX TABS(Alendronate Sodium) NF QL(0.15 ea

daily); MO

ibandronate sodium soln iv3 mg/3ml

$0-$3.30(Tier

1)


ibandronate sodium tabs or150 mg

$0-$3.30(Tier

1)

Limit 1 tab per28 days (3 per84);QL(0.036ea daily); MO

Drug Name DrugTier

Requirements/Limits

MIACALCIN SOLN IJ 200UNIT/ML

$0-$8.25(Tier

2)

MO

MIACALCIN SOLN NA 200UNIT/ACT (Calcitonin(Salmon))

NFMO

NATPARA CART$0-

$8.25(Tier

2)

PA; LA

PROLIA SOLN$0-

$8.25(Tier

2)

QL(0.01 mldaily)

RECLAST SOLN(Zoledronic Acid) NF QL(0.28 ml

daily)

TYMLOS SOPN$0-

$8.25(Tier

2)

PA

XGEVA SOLN$0-

$8.25(Tier

2)

Limit 6.8mlsper 28days;QL(0.243ml daily)

zoledronic acid conc 4mg/5ml

$0-$3.30(Tier

1)

zoledronic acid soln 5mg/100ml

$0-$3.30(Tier

1)

QL(0.28 mldaily)

ZOMETA CONC 4MG/5ML (Zoledronic Acid) NF

Corticotropin

H.P. ACTHAR GEL$0-

$8.25(Tier

2)

PA; LA

Fertility Regulators

chorionic gonadotropin solrim

$0-$3.30(Tier

1)

PA

Growth Hormone Receptor Antagonists



95

Drug Name DrugTier

Requirements/Limits

SOMAVERT SOLR$0-

$8.25(Tier

2)

LA

Growth Hormones

GENOTROPIN MINIQUICKSOLR 0.4 MG

$0-$8.25(Tier

2)

PA

GENOTROPIN SOLR 5MG

$0-$8.25(Tier

2)

PA

HUMATROPE COMBOPACK SOLR

$0-$8.25(Tier

2)

PA

HUMATROPE SOLR 12MG, 6 MG, 24 MG

$0-$8.25(Tier

2)

PA

NORDITROPIN FLEXPROSOLN 5 MG/1.5ML, 10MG/1.5ML

$0-$8.25(Tier

2)

PA

NUTROPIN AQ NUSPIN20 SOLN

$0-$8.25(Tier

2)

PA

OMNITROPE SOLN 10MG/1.5ML, 5 MG/1.5ML

$0-$8.25(Tier

2)

PA

SEROSTIM SOLR 4 MG, 6MG

$0-$8.25(Tier

2)

PA

ZOMACTON SOLR 5 MG$0-

$8.25(Tier

2)

PA

Hormone Receptor ModulatorsEVISTA TABS (RaloxifeneHCl) NF QL(1 ea daily);

MO

raloxifene hcl tabs$0-

$3.30(Tier

1)

QL(1 ea daily);MO

Drug Name DrugTier

Requirements/Limits

Insulin-Like Growth Factors (Somatomedins)

INCRELEX SOLN$0-

$8.25(Tier

2)

LA

LHRH/GnRH Agonist Analog Pituitary

LUPRON DEPOT-PED (1-MONTH) KIT

$0-$8.25(Tier

2)

LUPRON DEPOT-PED (3-MONTH) KIT 11.25 MG

$0-$8.25(Tier

2)

3 month kit

LUPRON DEPOT-PED (3-MONTH) KIT 30 MG

$0-$8.25(Tier

2)

SYNAREL SOLN$0-

$8.25(Tier

2)

MO

Metabolic Modifiers

calcitriol caps or 0.25 mcg,0.5 mcg

$0-$3.30(Tier

1)

MO

calcitriol soln or 1 mcg/ml$0-

$3.30(Tier

1)

MO

CARBAGLU TABS$0-

$8.25(Tier

2)

LA

CARNITOR TABS OR 330MG (Levocarnitine(Metabolic Modifiers))

NFRX/OTC; MO

FABRAZYME SOLR 35MG

$0-$8.25(Tier

2)

LA

KANUMA SOLN$0-

$8.25(Tier

2)

LA



96

Drug Name DrugTier

Requirements/Limits

KUVAN PACK$0-

$8.25(Tier

2)

LA

KUVAN TBSO$0-

$8.25(Tier

2)

LA

levocarnitine (metabolicmodifiers) tabs 330 mg

$0-$3.30(Tier

1)

RX/OTC; MO

LUMIZYME SOLR$0-

$8.25(Tier

2)

LA

MYALEPT SOLR$0-

$8.25(Tier

2)

LA

NAGLAZYME SOLN$0-

$8.25(Tier

2)

LA

ORFADIN CAPS 5 MG, 20MG, 2 MG, 10 MG

$0-$8.25(Tier

2)

LA

paricalcitol caps or 2 mcg,4 mcg, 1 mcg

$0-$3.30(Tier

1)

MO

RAVICTI LIQD$0-

$8.25(Tier

2)

LA

RAYALDEE CPCR$0-

$8.25(Tier

2)

PA; MO

ROCALTROL CAPS(Calcitriol) NF MO

ROCALTROL SOLN(Calcitriol) NF MO

SENSIPAR TABS$0-

$8.25(Tier

2)

Drug Name DrugTier

Requirements/Limits

STRENSIQ SOLN$0-

$8.25(Tier

2)

PA; LA

VIMIZIM SOLN$0-

$8.25(Tier

2)

LA

ZEMPLAR CAPS OR 1MCG, 2 MCG (Paricalcitol) NF MO

Posterior Pituitary HormonesDDAVP SOLN(Desmopressin AcetateRefrigerated)

NFMO

DDAVP SOLN(Desmopressin AcetateSpray)

NFMO

DDAVP SOLN(Desmopressin Acetate) NF MO

DDAVP TABS(Desmopressin Acetate) NF MO

desmopressin acetaterefrigerated soln

$0-$3.30(Tier

1)

MO

desmopressin acetate solnij 4 mcg/ml

$0-$3.30(Tier

1)

MO

desmopressin acetatespray refrigerated soln

$0-$3.30(Tier

1)

MO

desmopressin acetatespray soln

$0-$3.30(Tier

1)

MO

desmopressin acetate tabsor 0.1 mg, 0.2 mg

$0-$3.30(Tier

1)

MO

Prolactin Inhibitors

cabergoline tabs$0-

$3.30(Tier

1)

MO

Somatostatic Agents



97

Drug Name DrugTier

Requirements/Limits

octreotide acetate soln 200mcg/ml, 50 mcg/ml, 100mcg/ml

$0-$3.30(Tier

1)

SANDOSTATIN LARDEPOT KIT 20 MG, 30 MG

$0-$8.25(Tier

2)SANDOSTATIN SOLN 50MCG/ML, 100 MCG/ML,200 MCG/ML (OctreotideAcetate)

NF

SIGNIFOR LAR SRER 20MG

$0-$8.25(Tier

2)

Limit 3 vials per28days;SL(0.11ea daily); LA


$0-$8.25(Tier

2)

Limit 3 vials per56days;SL(0.054ea daily); LA


$0-$8.25(Tier

2)

Limit 1 vial per28days;SL(0.036ea daily); LA

SIGNIFOR SOLN$0-

$8.25(Tier

2)

LA

SOMATULINE DEPOTSOLN

$0-$8.25(Tier

2)

Vasopressin Receptor Antagonists

SAMSCA TABS$0-

$8.25(Tier

2)

ESTROGENS - Hormone Replacement/ModifyingDrugsEstrogen CombinationsACTIVELLA TABS(Estradiol & NorethindroneAcetate)


estradiol & norethindroneacetate tabs

$0-$3.30(Tier

1)


Drug Name DrugTier

Requirements/Limits

FEMHRT LOW DOSETABS (NorethindroneAcetate-Ethinyl Estradiol)


norethindrone acetate-ethinyl estradiol tabs2.5mcg-0.5mg

$0-$3.30(Tier

1)


PREMPHASE TABS$0-

$8.25(Tier

2)


PREMPRO TABS$0-

$8.25(Tier

2)


EstrogensCLIMARA PTWK(Estradiol) NF AL; Up to 64

yrs old; MO

DELESTROGEN OIL 10MG/ML

$0-$8.25(Tier

2)

MO

DELESTROGEN OIL 40MG/ML, 20 MG/ML(Estradiol Valerate)

NFMO

DIVIGEL GEL$0-

$8.25(Tier

2)


estradiol ptwk td 0.025mg/24hr, 37.5 mcg/24hr,0.1 mg/24hr, 0.075mg/24hr, 0.06 mg/24hr,0.05 mg/24hr

$0-$3.30(Tier

1)


estradiol tabs or 2 mg, 0.5mg, 1 mg

$0-$3.30(Tier

1)


estradiol valerate oil im 40mg/ml, 20 mg/ml

$0-$3.30(Tier

1)

MO

estropipate tabs 1.5 mg,0.75 mg

$0-$3.30(Tier

1)




98

Drug Name DrugTier

Requirements/Limits

PREMARIN TABS OR 0.45MG, 1.25 MG, 0.9 MG,0.625 MG, 0.3 MG

$0-$8.25(Tier

2)


FLUOROQUINOLONES - Drugs to Treat BacterialInfectionsFluoroquinolonesCIPRO I.V.-IN D5W SOLN(Ciprofloxacin in D5W) NF MO

CIPRO TABS 500 MG, 250MG (Ciprofloxacin HCl) NF MO

CIPRO XR TB24(Ciprofloxacin-CiprofloxacinHCl)

NFMO

ciprofloxacin hcl tabs or500 mg, 100 mg, 750 mg,250 mg

$0-$3.30(Tier

1)

MO

ciprofloxacin in d5w soln200mg/100ml-5%

$0-$3.30(Tier

1)

ciprofloxacin in d5w soln400mg/200ml-5%

$0-$3.30(Tier

1)

MO

ciprofloxacin soln iv 400mg/40ml

$0-$3.30(Tier

1)

MO

ciprofloxacin-ciprofloxacinhcl tb24

$0-$3.30(Tier

1)

MO

LEVAQUIN TABS(Levofloxacin) NF MO

levofloxacin in d5w soln$0-

$3.30(Tier

1)

levofloxacin soln iv 25mg/ml

$0-$3.30(Tier

1)

levofloxacin soln or 25mg/ml

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

levofloxacin tabs or 250mg, 750 mg, 500 mg

$0-$3.30(Tier

1)

MO

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal DrugsAntiflatulentsGAS-X EXTRASTRENGTH CHEW 125MG (Simethicone)

NFMO; NT

simethicone caps or125mg, 125 mg

$0(Tier

3)

MO; NT

simethicone chew or 125mg

$0(Tier

3)

MO; NT

Farnesoid X Receptor (FXR) Agonists

OCALIVA TABS 10 MG$0-

$8.25(Tier

2)

PA; SL(1 eadaily)

OCALIVA TABS 5 MG$0-

$8.25(Tier

2)

PA; SL(2 eadaily)

Gallstone Solubilizing AgentsACTIGALL CAPS(Ursodiol) NF MO

chenodiol tabs$0-

$3.30(Tier

1)

LA

URSO 250 TABS(Ursodiol) NF MO

URSO FORTE TABS(Ursodiol) NF MO

ursodiol caps or 300 mg$0-

$3.30(Tier

1)

MO

ursodiol tabs or 500 mg,250 mg

$0-$3.30(Tier

1)

MO

Gastrointestinal Antiallergy Agents



99

Drug Name DrugTier

Requirements/Limits

cromolyn sodium(mastocytosis) conc

$0-$3.30(Tier

1)

MO

GASTROCROM CONC(Cromolyn Sodium(Mastocytosis))

NFMO

Gastrointestinal Stimulants

metoclopramide hcl soln ij5 mg/ml

$0-$3.30(Tier

1)

MO

metoclopramide hcl soln or10 mg/10ml, 5 mg/5ml

$0-$3.30(Tier

1)

MO

metoclopramide hcl tabs or5 mg, 10 mg

$0-$3.30(Tier

1)

MO

REGLAN TABS(Metoclopramide HCl) NF MO

Inflammatory Bowel Agents

APRISO CP24$0-

$8.25(Tier

2)

MO

ASACOL HD TBEC$0-

$8.25(Tier

2)

MO

AZULFIDINE EN-TABSTBEC (Sulfasalazine) NF MO

AZULFIDINE TABS(Sulfasalazine) NF MO

balsalazide disodium caps$0-

$3.30(Tier

1)

MO

CIMZIA KIT$0-

$8.25(Tier

2)

PA

CIMZIA STARTER KIT KIT$0-

$8.25(Tier

2)

PA

Drug Name DrugTier

Requirements/Limits

COLAZAL CAPS(Balsalazide Disodium) NF MO

DELZICOL CPDR$0-

$8.25(Tier

2)

MO

DIPENTUM CAPS$0-

$8.25(Tier

2)

MO

ENTYVIO SOLR$0-

$8.25(Tier

2)

PA

INFLECTRA SOLR$0-

$8.25(Tier

2)

PA

MESALAMINE DR TBEC$0-

$8.25(Tier

2)

MO

mesalamine enem re 4 gm$0-

$3.30(Tier

1)

MO

mesalamine w/ cleanser kit$0-

$3.30(Tier

1)

MO

REMICADE SOLR$0-

$8.25(Tier

2)

PA

ROWASA KIT (Mesalaminew/ Cleanser) NF MO

STELARA SOLN IV 130MG/26ML

$0-$8.25(Tier

2)

PA

sulfasalazine tabs or$0-

$3.30(Tier

1)

MO

sulfasalazine tbec or$0-

$3.30(Tier

1)

MO



100

Drug Name DrugTier

Requirements/Limits

Intestinal Acidifiers

lactulose (encephalopathy)soln

$0-$3.30(Tier

1)

MO

Irritable Bowel Syndrome (IBS) Agents

alosetron hcl tabs$0-

$3.30(Tier

1)

MO

LINZESS CAPS$0-

$8.25(Tier

2)

MO

LOTRONEX TABS(Alosetron HCl)

$0-$8.25(Tier

2)

MO

VIBERZI TABS$0-

$8.25(Tier

2)

PA; MO

Peripheral Opioid Receptor Antagonists

MOVANTIK TABS$0-

$8.25(Tier

2)

MO

RELISTOR SOLN SC 8MG/0.4ML, 12 MG/0.6ML

$0-$8.25(Tier

2)

MO

Phosphate Binder Agents

calcium acetate (phosphatebinder) caps

$0-$3.30(Tier

1)

MO

FOSRENOL CHEW 500MG, 750 MG, 1000 MG(Lanthanum Carbonate)

$0-$8.25(Tier

2)

MO

lanthanum carbonate chew$0-

$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

RENVELA PACK 2.4 GM(Sevelamer Carbonate)

$0-$8.25(Tier

2)

MO

RENVELA TABS 800 MG(Sevelamer Carbonate)

$0-$8.25(Tier

2)

MO

sevelamer carbonate pack2.4 gm

$0-$3.30(Tier

1)

MO

sevelamer carbonate tabs800 mg

$0-$3.30(Tier

1)

MO

Short Bowel Syndrome (SBS) Agents

GATTEX KIT$0-

$8.25(Tier

2)

PA; LA

Tryptophan Hydroxylase Inhibitors

XERMELO TABS$0-

$8.25(Tier

2)

PA; LA

GENITOURINARY AGENTS - MISCELLANEOUS- Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary SystemAlkalinizers

potassium citrate(alkalinizer) tbcr 540 mg,1080 mg

$0-$3.30(Tier

1)

MO

UROCIT-K 10 TBCR(Potassium Citrate(Alkalinizer))

$0-$8.25(Tier

2)

MO

UROCIT-K 5 TBCR(Potassium Citrate(Alkalinizer))

$0-$8.25(Tier

2)

MO

Cystinosis Agents

CYSTAGON CAPS$0-

$8.25(Tier

2)



101

Drug Name DrugTier

Requirements/Limits

Genitourinary Irrigants

acetic acid soln$0-

$3.30(Tier

1)

MO

neomycin/polymyxin b gusoln

$0-$3.30(Tier

1)

MO

sodium chloride (guirrigant) soln

$0-$3.30(Tier

1)

MO

Prostatic Hypertrophy Agents

alfuzosin hcl tb24$0-

$3.30(Tier

1)

MO

AVODART CAPS(Dutasteride) NF MO

dutasteride caps$0-

$3.30(Tier

1)

MO

dutasteride-tamsulosin hclcaps

$0-$3.30(Tier

1)

MO

finasteride tabs or$0-

$3.30(Tier

1)

MO

FLOMAX CAPS(Tamsulosin HCl) NF MO

JALYN CAPS (Dutasteride-Tamsulosin HCl) NF MO

PROSCAR TABS(Finasteride) NF MO

tamsulosin hcl caps$0-

$3.30(Tier

1)

MO

UROXATRAL TB24(Alfuzosin HCl) NF MO

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations

Drug Name DrugTier

Requirements/Limits

colchicine w/ probenecidtabs

$0-$3.30(Tier

1)

MO

Gout Agents

allopurinol tabs or 100 mg$0-

$3.30(Tier

1)

SL(8 ea daily);MO

allopurinol tabs or 300 mg$0-

$3.30(Tier

1)


COLCHICINE TABS OR$0-

$8.25(Tier

2)

MO

COLCRYS TABS$0-

$8.25(Tier

2)

MO

ZYLOPRIM TABS 100 MG(Allopurinol) NF SL(8 ea daily);

MOZYLOPRIM TABS 300 MG(Allopurinol) NF SL(2.66 ea

daily); MOUricosurics

probenecid tabs$0-

$3.30(Tier

1)

MO

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood DisordersBradykinin B2 Receptor Antagonists

FIRAZYR SOLN$0-

$8.25(Tier

2)

Complement Inhibitors

BERINERT KIT$0-

$8.25(Tier

2)

LA

CINRYZE SOLR$0-

$8.25(Tier

2)

LA



102

Drug Name DrugTier

Requirements/Limits

RUCONEST SOLR$0-

$8.25(Tier

2)

Hematorheologic Agents

pentoxifylline tbcr or$0-

$3.30(Tier

1)

MO

Plasma Kallikrein Inhibitors

KALBITOR SOLN$0-

$8.25(Tier

2)

Platelet Aggregation Inhibitors

AGGRENOX CP12(Aspirin-Dipyridamole)

$0-$8.25(Tier

2)

MO

AGRYLIN CAPS(Anagrelide HCl) NF MO

anagrelide hcl caps$0-

$3.30(Tier

1)

MO

aspirin-dipyridamole cp12$0-

$3.30(Tier

1)

MO

BRILINTA TABS$0-

$8.25(Tier

2)

MO

cilostazol tabs$0-

$3.30(Tier

1)

MO

clopidogrel bisulfate tabs300 mg

$0-$3.30(Tier

1)

clopidogrel bisulfate tabs75 mg

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

dipyridamole tabs or 50mg, 25 mg, 75 mg

$0-$3.30(Tier

1)


EFFIENT TABS (PrasugrelHCl)

$0-$8.25(Tier

2)

MO

PERSANTINE TABS(Dipyridamole) NF AL; Up to 64

yrs old; MOPLAVIX TABS 300 MG(Clopidogrel Bisulfate) NF

PLAVIX TABS 75 MG(Clopidogrel Bisulfate) NF MO

PLETAL TABS (Cilostazol) NF MO

prasugrel hcl tabs$0-

$3.30(Tier

1)

MO

ZONTIVITY TABS$0-

$8.25(Tier

2)

MO

HEMATOPOIETIC AGENTS - Drugs to TreatBlood DisordersAgents for Gaucher Disease

CERDELGA CAPS$0-

$8.25(Tier

2)

PA

CEREZYME SOLR$0-

$8.25(Tier

2)

LA

ELELYSO SOLR$0-

$8.25(Tier

2)

VPRIV SOLR$0-

$8.25(Tier

2)

ZAVESCA CAPS$0-

$8.25(Tier

2)

LA



103

Drug Name DrugTier

Requirements/Limits

Agents for Sickle Cell Anemia

DROXIA CAPS$0-

$8.25(Tier

2)

MO

Folic Acid/Folates

folic acid caps or 0.8 mg,800 mcg

$0(Tier

3)

NT

FOLIC ACID CAPS OR 20MG

$0(Tier

3)

NT

folic acid tabs or 1 mg$0

(Tier3)

RX/OTC; MO;NT

folic acid tabs or 400 mcg,800 mcg

$0(Tier

3)

MO; NT

Hematopoietic Growth Factors

ARANESP ALBUMINFREE SOLN

$0-$8.25(Tier

2)

PA

ARANESP ALBUMINFREE SOSY

$0-$8.25(Tier

2)

PA

EPOGEN SOLN$0-

$8.25(Tier

2)

PA

GRANIX SOSY$0-

$8.25(Tier

2)

PA

LEUKINE SOLR$0-

$8.25(Tier

2)

PA

NEULASTA ONPRO KITPSKT

$0-$8.25(Tier

2)

PA

NEULASTA SOSY$0-

$8.25(Tier

2)

PA

Drug Name DrugTier

Requirements/Limits

NEUPOGEN SOLN$0-

$8.25(Tier

2)

PA

NEUPOGEN SOSY$0-

$8.25(Tier

2)

PA

PROCRIT SOLN 40000UNIT/ML, 2000 UNIT/ML,20000 UNIT/ML, 10000UNIT/ML, 3000 UNIT/ML,4000 UNIT/ML

$0-$8.25(Tier

2)

PA

PROMACTA TABS 12.5MG

$0-$8.25(Tier

2)

SL(12 ea daily);LA

PROMACTA TABS 25 MG$0-

$8.25(Tier

2)

SL(6 ea daily);LA


$8.25(Tier

2)

SL(3 ea daily);LA


$8.25(Tier

2)

SL(2 ea daily);LA

ZARXIO SOSY$0-

$8.25(Tier

2)

PA

IronFER-IN-SOL SOLN(Ferrous Sulfate) NF MO; NT

FERROUS GLUCONATETABS OR 225 MG

$0(Tier

3)

NT

ferrous sulfate elix or 220mg/5ml

$0(Tier

3)

MO; NT

FERROUS SULFATE LIQDOR 220 MG/5ML

$0(Tier

3)

NT

ferrous sulfate soln or 15mg/ml

$0(Tier

3)

MO; NT



104

Drug Name DrugTier

Requirements/Limits

FERROUS SULFATESYRP OR 300 MG/5ML

$0(Tier

3)

NT

ferrous sulfate tabs or 65mg, 325 mg

$0(Tier

3)

MO; NT

FERROUS SULFATETBEC OR 324 MG

$0(Tier

3)

MO; NT

ferrous sulfate tbec or 325mg

$0(Tier

3)

NT

IRON CHEWS PEDIATRICCHEW

$0(Tier

3)

MO; NT

polysaccharide ironcomplex caps 150 mg

$0(Tier

3)

MO; NT

Stem Cell Mobilizers

MOZOBIL SOLN$0-

$8.25(Tier

2)

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood DisordersHemostatics - Systemic

AMICAR SOLN 0.25GM/ML

$0-$8.25(Tier

2)

MO

AMICAR TABS 500 MG$0-

$8.25(Tier

2)

MO

CYKLOKAPRON SOLN(Tranexamic Acid) NF

LYSTEDA TABS(Tranexamic Acid) NF MO

tranexamic acid soln iv1000 mg/10ml

$0-$3.30(Tier

1)

tranexamic acid tabs or650 mg

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTSBarbiturate Hypnotics

BUTISOL SODIUM TABS$0-

$8.25(Tier

2)


phenobarbital elix or 20mg/5ml

$0-$3.30(Tier

1)


phenobarbital soln or 20mg/5ml

$0-$3.30(Tier

1)


phenobarbital tabs or 64.8mg, 32.4 mg, 30 mg, 16.2mg, 15 mg, 97.2 mg, 100mg, 60 mg

$0-$3.30(Tier

1)


Hypnotics - Tricyclic Agents

SILENOR TABS 3 MG$0-

$8.25(Tier

2)

QL(2 ea daily);MO

SILENOR TABS 6 MG$0-

$8.25(Tier

2)

QL(1 ea daily);MO

Non-Barbiturate Hypnotics

AMBIEN CR TBCR 12.5MG (Zolpidem Tartrate) NF


AMBIEN CR TBCR 6.25MG (Zolpidem Tartrate) NF


AMBIEN TABS 10 MG(Zolpidem Tartrate) NF


AMBIEN TABS 5 MG(Zolpidem Tartrate) NF


HALCION TABS(Triazolam) NF MO

RESTORIL CAPS(Temazepam) NF MO



105

Drug Name DrugTier

Requirements/Limits

SONATA CAPS (Zaleplon) NF AL; Up to 64yrs old; MO

temazepam caps$0-

$3.30(Tier

1)

MO

TRIAZOLAM TABS 0.125MG

$0-$8.25(Tier

2)

MO

triazolam tabs 0.25 mg$0-

$3.30(Tier

1)

MO

zaleplon caps$0-

$3.30(Tier

1)


zolpidem tartrate tabs or 10mg

$0-$3.30(Tier

1)


zolpidem tartrate tabs or 5mg

$0-$3.30(Tier

1)


zolpidem tartrate tbcr or12.5 mg

$0-$3.30(Tier

1)


zolpidem tartrate tbcr or6.25 mg

$0-$3.30(Tier

1)


Orexin Receptor Antagonists

BELSOMRA TABS 10 MG$0-

$8.25(Tier

2)



$8.25(Tier

2)



$8.25(Tier

2)


Drug Name DrugTier

Requirements/Limits


$8.25(Tier

2)


Selective Melatonin Receptor Agonists

HETLIOZ CAPS$0-

$8.25(Tier

2)

PA

ROZEREM TABS$0-

$8.25(Tier

2)

MO

LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives

calcium polycarbophil tabs$0

(Tier3)

MO; NT

CITRUCEL FIBERLAXATIVE POWD(Methylcellulose (Laxative))

NFMO; NT

CVS NATURAL FIBERSUPPLEMENT PACK

$0(Tier

3)

NT

EQUALACTIN CHEW$0

(Tier3)

MO; NT

EVAC POWD (Psyllium) NF MO; NT

FIBERCON TABS (CalciumPolycarbophil) NF MO; NT

HYDROCIL INSTANTPACK

$0(Tier

3)

MO; NT

HYDROCIL INSTANTPOWD (Psyllium) NF MO; NT

KONSYL PACK 100 %$0

(Tier3)

MO; NT

KONSYL PACK 28.3 %,60.3 %

$0(Tier

3)

NT

KONSYL POWD 100 %(Psyllium) NF MO; NT



106

Drug Name DrugTier

Requirements/Limits

KONSYL POWD 71.67 %,60.3 %

$0(Tier

3)

NT

KONSYL-D POWD$0

(Tier3)

NT

METAMUCIL CAPS 0.52GM (Psyllium) NF MO; NT

METAMUCILMULTIHEALTH FIBERPOWD 55.46 %

$0(Tier

3)

NT

METAMUCIL ORIGINALTEXTURE POWD(Psyllium)

NFMO; NT

METAMUCIL POWD 48.57% (Psyllium) NF MO; NT

METAMUCIL SMOOTHTEXTUREFIBER SINGLESPACK

$0(Tier

3)

MO; NT

methylcellulose (laxative)powd 2 gm/10.2gm, 2gm/19gm,

$0(Tier

3)

MO; NT

psyllium caps 0.52 gm, 520mg

$0(Tier

3)

MO; NT

psyllium powd 58.6 %, 100%, 95 %, 48.57 %,

$0(Tier

3)

MO; NT

psyllium powd 68 %, 30.9%, 28.3 %, 33 %

$0(Tier

3)

NT

Laxative Combinations

bisacodyl-peg 3350-potchloride-sod bicarb-sodchloride kit

$0-$3.30(Tier

1)COLYTE-FLAVOR PACKSSOLR (PEG 3350-KCl-SodBicarb-Sod Chloride-SodSulfate)

NF

MO

GOLYTELY SOLR 236GM-22.74GM-5.86GM-2.97GM-6.74GM (PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

NF

MO

Drug Name DrugTier

Requirements/Limits

NULYTELY/FLAVORPACKS SOLR (PEG 3350-Potassium Chloride-SodBicarbonate-Sod Chloride)

NF

MO

peg 3350-kcl-sod bicarb-sod chloride-sod sulfatesolr

$0-$3.30(Tier

1)

MO

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr

$0-$3.30(Tier

1)

MO

SUPREP BOWEL PREPKIT SOLN

$0-$8.25(Tier

2)

MO

Laxatives - Miscellaneous

FLEET LIQUID GLYCERINSUPPOSITORIES ENEM

$0(Tier

3)

MO; NT

lactulose soln$0-

$3.30(Tier

1)

MO

MIRALAX PACK(Polyethylene Glycol 3350)

$0(Tier

3)

RX/OTC; MO;NT

MIRALAX POWD(Polyethylene Glycol 3350)

$0(Tier

3)

RX/OTC; MO;NT

polyethylene glycol 3350pack or

$0-$3.30(Tier

1)

RX/OTC; MO

polyethylene glycol 3350pack or

$0(Tier

3)


polyethylene glycol 3350powd or

$0-$3.30(Tier

1)

RX/OTC; MO

polyethylene glycol 3350powd or

$0(Tier

3)


Saline Laxatives

MILK OF MAGNESIACONCENTRATE SUSP

$0(Tier

3)

MO; NT



107

Drug Name DrugTier

Requirements/Limits

Stimulant Laxatives

bisacodyl supp re 10 mg$0

(Tier3)

MO; NT

bisacodyl tbec or 5 mg$0

(Tier3)

MO; NT

DULCOLAX SUPP(Bisacodyl) NF MO; NT

DULCOLAX TBEC(Bisacodyl) NF MO; NT

EX-LAX TABS(Sennosides) NF MO; NT

FLEET BISACODYL ENEM$0

(Tier3)

MO; NT

sennosides tabs 15 mg$0

(Tier3)

MO; NT

Surfactant LaxativesCOLACE CAPS (DocusateSodium) NF MO; NT

docusate calcium caps$0

(Tier3)

MO; NT

docusate sodium caps or100 mg, 250 mg

$0(Tier

3)

MO; NT

docusate sodium liqd or 50mg/5ml, 150 mg/15ml

$0(Tier

3)

MO; NT

docusate sodium syrp or60 mg/15ml

$0(Tier

3)

MO; NT

docusate sodium tabs or100 mg

$0(Tier

3)

NT

DOCUSOL MINI ENEM$0

(Tier3)

MO; NT

DOCUSOL PLUS MINI-ENEMA ENEM

$0(Tier

3)

MO; NT

ENEMEEZ MINI ENEM$0

(Tier3)

MO; NT

Drug Name DrugTier

Requirements/Limits

ENEMEEZ PLUS ENEM$0

(Tier3)

MO; NT

LOCAL ANESTHETICS-Parenteral - Drugs forNumbingLocal Anesthetics - Amides

lidocaine hcl (local anesth.)soln 1 %, 2 %

$0-$3.30(Tier

1)XYLOCAINE SOLN IJ 1 %,2 % (Lidocaine HCl (LocalAnesth.))

NF

XYLOCAINE-MPF SOLN 1% (Lidocaine HCl (LocalAnesth.))

NF

MACROLIDES - Drugs to Treat BacterialInfectionsAzithromycin

azithromycin solr iv 500 mg$0-

$3.30(Tier

1)

MO

azithromycin susr or 100mg/5ml, 200 mg/5ml

$0-$3.30(Tier

1)

MO

azithromycin tabs or 600mg, 500 mg, 250 mg

$0-$3.30(Tier

1)

MO

ZITHROMAX SOLR IV 500MG (Azithromycin) NF MO

ZITHROMAX SUSR OR100 MG/5ML, 200 MG/5ML(Azithromycin)

NFMO

ZITHROMAX TABS OR600 MG, 500 MG, 250 MG(Azithromycin)

NFMO

ZITHROMAX TRI-PAKTABS (Azithromycin) NF MO

ZITHROMAX Z-PAK TABS(Azithromycin) NF MO

ClarithromycinBIAXIN TABS 250 MG, 500MG (Clarithromycin) NF MO



108

Drug Name DrugTier

Requirements/Limits

clarithromycin susr or 250mg/5ml

$0-$3.30(Tier

1)

MO

clarithromycin tabs or 500mg, 250 mg

$0-$3.30(Tier

1)

MO

clarithromycin tb24 or 500mg

$0-$3.30(Tier

1)

MO

Erythromycins

erythromycin base tabs250 mg

$0-$3.30(Tier

1)

SL(16 ea daily);MO

erythromycin base tabs500 mg

$0-$3.30(Tier

1)

SL(8 ea daily);MO

erythromycinethylsuccinate tabs or 400mg

$0-$3.30(Tier

1)

SL(10 ea daily);MO

erythromycin lactobionatesolr

$0-$3.30(Tier

1)

SL(8 ea daily)

erythromycin stearate tabs$0-

$3.30(Tier

1)

SL(16 ea daily);MO

Fidaxomicin

DIFICID TABS$0-

$8.25(Tier

2)

MO

MEDICAL DEVICES AND SUPPLIES

Bandages-Dressings-Tape

gauze pads 2" x 2"$0-

$3.30(Tier

1)

RX/OTC; MO

Contraceptives

Drug Name DrugTier

Requirements/Limits

FC FEMALE CONDOMMISC

$0(Tier

3)

NT

FC2 FEMALE CONDOMMISC

$0(Tier

3)

NT

LATEX CONDOMS$0

(Tier3)

NON-LATEX CONDOMS NF

Misc. Devices

ALCOHOL PADS$0-

$8.25(Tier

2)

RX/OTC; MO

Parenteral Therapy Supplies

INSULIN SYRINGES ANDPEN NEEDLES

$0-$8.25(Tier

2)

RX/OTC; MO

Respiratory Therapy Supplies

AIRZONE PEAK FLOWMETER DEVI

$0(Tier

3)

RX/OTC; MO;NT

ASSESS FULL RANGEPEAK FLOW METER DEVI

$0(Tier

3)

RX/OTC; MO;NT

ASSESS LOW RANGEPEAK FLOW METER DEVI

$0(Tier

3)

RX/OTC; MO;NT

ASSESS PEAK FLOWMETER FULL RANGEDEVI

$0(Tier

3)

RX/OTC; MO;NT

ASSESS PEAK FLOWMETER LOW RANGEDEVI

$0(Tier

3)

RX/OTC; MO;NT

ASTHMA CHECK METER-ZONE SYSTEM DEVI

$0(Tier

3)

RX/OTC; MO;NT

ASTHMAMENTOR DEVI$0

(Tier3)

RX/OTC; MO;NT

MICROLIFE DIGITALPEAK FLOW METER DEVI

$0(Tier

3)

RX/OTC; MO;NT



109

Drug Name DrugTier

Requirements/Limits

MINI WRIGHT AFS PEAKFLOWMETER LOWRANGE DEVI

$0(Tier

3)

RX/OTC; MO;NT

MINI WRIGHT PEAKFLOW METER DEVI

$0(Tier

3)

RX/OTC; MO;NT

PEAK AIR PEAK FLOWMETERADULT/PEDIATRIC DEVI

$0(Tier

3)

RX/OTC; MO;NT

PEAK FLOW METER DEVI$0

(Tier3)

RX/OTC; MO;NT

PERSONAL BEST FULLRANGE DEVI

$0(Tier

3)

RX/OTC; MO;NT

PERSONAL BEST LOWRANGE DEVI

$0(Tier

3)

RX/OTC; MO;NT

PIKO 1 ELECTRONICDEVI

$0(Tier

3)

RX/OTC; MO;NT

POCKET PEAK FLOWMETER DEVI

$0(Tier

3)

RX/OTC; MO;NT

POCKETPEAK PEAKFLOW METER LOWRANGE DEVI

$0(Tier

3)

RX/OTC; MO;NT

POCKETPEAK PEAKFLOWMETER/UNIVERSALRANGE 50-720 LPM DEVI

$0(Tier

3)

RX/OTC; MO;NT

POCKETPEAK PEAKFLOWMETER/UNIVERSALRANGE DEVI

$0(Tier

3)

RX/OTC; MO;NT

TRUZONE PEAK FLOWMETER DEVI

$0(Tier

3)

RX/OTC; MO;NT

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadachesMigraine Combinations

ergotamine w/ caffeinesupp re 2mg-100mg

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

TREXIMET TABS$0-

$8.25(Tier

2)

MO

Migraine ProductsD.H.E. 45 SOLN(DihydroergotamineMesylate)

NFMO

dihydroergotaminemesylate soln ij 1 mg/ml

$0-$3.30(Tier

1)

MO

DIHYDROERGOTAMINEMESYLATE SOLN NA 4MG/ML

$0-$8.25(Tier

2)

MO

ergotamine tartrate subl sl$0-

$3.30(Tier

1)

MIGRANAL SOLN$0-

$8.25(Tier

2)

MO

Serotonin Agonists

almotriptan malate tabs$0-

$3.30(Tier

1)

MO

AMERGE TABS(Naratriptan HCl) NF QL(0.3 ea

daily); MOAXERT TABS (AlmotriptanMalate) NF MO

IMITREX SOLN SC 6MG/0.5ML (SumatriptanSuccinate)

NFLimit 8mls permonth;QL(0.27ml daily); MO

IMITREX STATDOSEREFILL SOCT 4 MG/0.5ML(Sumatriptan Succinate)


IMITREX STATDOSEREFILL SOCT 6 MG/0.5ML(Sumatriptan Succinate)


IMITREX STATDOSESYSTEM SOAJ 4MG/0.5ML (SumatriptanSuccinate)

NF




110

Drug Name DrugTier

Requirements/Limits

IMITREX STATDOSESYSTEM SOAJ 6MG/0.5ML (SumatriptanSuccinate)

NF


IMITREX TABS OR 100MG (SumatriptanSuccinate)

NFQL(0.3 eadaily); MO

IMITREX TABS OR 25 MG(Sumatriptan Succinate) NF QL(0.9 ea

daily); MOIMITREX TABS OR 50 MG(Sumatriptan Succinate) NF QL(0.6 ea

daily); MOMAXALT TABS 10 MG(Rizatriptan Benzoate) NF QL(0.4 ea

daily); MOMAXALT TABS 5 MG(Rizatriptan Benzoate) NF QL(0.8 ea

daily); MOMAXALT-MLT TBDP 10MG (Rizatriptan Benzoate) NF QL(0.4 ea

daily); MOMAXALT-MLT TBDP 5 MG(Rizatriptan Benzoate) NF QL(0.8 ea

daily); MO

naratriptan hcl tabs$0-

$3.30(Tier

1)

QL(0.3 eadaily); MO

rizatriptan benzoate tabs10 mg

$0-$3.30(Tier

1)

QL(0.4 eadaily); MO

rizatriptan benzoate tabs 5mg

$0-$3.30(Tier

1)

QL(0.8 eadaily); MO

rizatriptan benzoate tbdp10 mg

$0-$3.30(Tier

1)

QL(0.4 eadaily); MO

rizatriptan benzoate tbdp 5mg

$0-$3.30(Tier

1)

QL(0.8 eadaily); MO

sumatriptan succinate soajsc 4 mg/0.5ml

$0-$3.30(Tier

1)


sumatriptan succinate soajsc 6 mg/0.5ml

$0-$3.30(Tier

1)


Drug Name DrugTier

Requirements/Limits

sumatriptan succinate soctsc 4 mg/0.5ml

$0-$3.30(Tier

1)


sumatriptan succinate soctsc 6 mg/0.5ml

$0-$3.30(Tier

1)


sumatriptan succinate solnsc 6 mg/0.5ml

$0-$3.30(Tier

1)


sumatriptan succinate tabsor 100 mg

$0-$3.30(Tier

1)

QL(0.3 eadaily); MO


$0-$3.30(Tier

1)

QL(0.9 eadaily); MO


$0-$3.30(Tier

1)

QL(0.6 eadaily); MO

zolmitriptan tabs 2.5 mg$0-

$3.30(Tier

1)

SL(4 ea daily);MO

zolmitriptan tabs 5 mg$0-

$3.30(Tier

1)

SL(2 ea daily);MO

zolmitriptan tbdp 2.5 mg$0-

$3.30(Tier

1)

SL(4 ea daily);MO

zolmitriptan tbdp 5 mg$0-

$3.30(Tier

1)

SL(2 ea daily);MO

ZOMIG TABS OR 2.5 MG(Zolmitriptan) NF SL(4 ea daily);

MOZOMIG TABS OR 5 MG(Zolmitriptan) NF SL(2 ea daily);

MOZOMIG ZMT TBDP 2.5 MG(Zolmitriptan) NF SL(4 ea daily);

MOZOMIG ZMT TBDP 5 MG(Zolmitriptan) NF SL(2 ea daily);

MO



111

Drug Name DrugTier

Requirements/Limits

MINERALS & ELECTROLYTES

Bicarbonates

sodium bicarbonate soln iv8.4 %

$0-$3.30(Tier

1)

MO

Calcium

CALCI-CHEW CHEW$0

(Tier3)

NT

calcium & phosphorus w/vitamin d tabs 105mg-81mg-120unit

$0(Tier

3)

NT

calcium carbonate tabs or1500 mg, 600 mg, 600mg,500 mg, 1250 mg

$0(Tier

3)

MO; NT

calcium carbonate-cholecalciferol caps600mg-500unit

$0(Tier

3)

MO; NT

calcium carbonate-cholecalciferol chew500mg-400unit, 500mg-100unit

$0(Tier

3)

MO; NT

calcium carbonate-cholecalciferol tabs 500mg-600unit

$0(Tier

3)

NT

calcium carbonate-cholecalciferol tabs 600mg-400unit, 500mg-200unit

$0(Tier

3)

MO; NT

calcium carbonate-ergocalciferol tabs

$0(Tier

3)

NT

calcium carbonate-vitamind tabs 125unit-500mg,500mg-125unit, 125unit-250mg, 250mg-125unit,600mg-400unit, 400unit-600mg

$0(Tier

3)

NT

calcium carbonate-vitamind tabs 200unit-500mg,500mg-200unit, 500mg-500mg-200unit-200unit

$0(Tier

3)

MO; NT

CALCIUM CITRATEMALATE/VITAMIN D TABS

$0(Tier

3)

NT

Drug Name DrugTier

Requirements/Limits

calcium citrate tabs or 200mg, 950 mg

$0(Tier

3)

MO; NT

calcium citrate-vitamin dtabs 250mg-200unit

$0(Tier

3)

NT

calcium citrate-vitamin dtabs 315mg-200unit

$0(Tier

3)

MO; NT

CALCIUM GLUCONATETABS OR 500 MG

$0(Tier

3)

NT

CALCIUM TABS 600MG-200UNIT

$0(Tier

3)

NT

calcium w/ vitamin d tabs$0

(Tier3)

NT

EQL CALCIUM/VITAMIN DCAPS

$0(Tier

3)

NT

GNP VITAMIN D-400TABS

$0(Tier

3)

NT

oyster shell tabs$0

(Tier3)

MO; NT

RA OYSTER SHELLCALCIUM/VITAMIN DTABS

$0(Tier

3)

NT

RISACAL-D TABS$0

(Tier3)

NT

Electrolyte Mixtures

dextrose in lactated ringerssoln

$0-$3.30(Tier

1)

dextrose w/ sodiumchloride soln 0.45%-5%,0.45%-2.5%

$0-$3.30(Tier

1)

dextrose w/ sodiumchloride soln 0.9%-5%

$0-$3.30(Tier

1)

MO



112

Drug Name DrugTier

Requirements/Limits

lactated ringer's soln$0-

$3.30(Tier

1)

parenteral electrolytes conc$0-

$3.30(Tier

1)

B/D

parenteral electrolytes soln$0-

$3.30(Tier

1)

B/D

potassium chloride indextrose & sodium chloridesoln 0.45%-20meq/l-5%

$0-$3.30(Tier

1)

Iodine Products

POTASSIUM IODIDETABS OR 32.5 MG

$0(Tier

3)

NT

Magnesium

MAG64 TBCR$0

(Tier3)

MO; NT

MAGDELAY TBEC$0

(Tier3)

NT

magnesium sulfate soln ij50 %

$0-$3.30(Tier

1)

MO

PotassiumK-TAB TBCR 10 MEQ(Potassium Chloride) NF MO

K-TAB TBCR 20 MEQ, 8MEQ

$0-$8.25(Tier

2)

MO

MICRO-K CPCR(Potassium Chloride) NF MO

potassium chloride cpcr or10 meq, 8 meq

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

POTASSIUM CHLORIDEER TBCR

$0-$8.25(Tier

2)

MO

potassium chloridemicroencapsulated crystalser tbcr

$0-$3.30(Tier

1)

MO

potassium chloride soln iv 2meq/ml

$0-$3.30(Tier

1)

MO

potassium chloride soln or10 %, 20 %

$0-$3.30(Tier

1)

MO

potassium chloride tbcr or10 meq, 8 meq, 20 meq

$0-$3.30(Tier

1)

MO

Sodium

sodium chloride soln iv0.45 %

$0-$3.30(Tier

1)

sodium chloride soln iv 0.9%

$0-$3.30(Tier

1)

MO

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents

CUPRIMINE CAPS$0-

$8.25(Tier

2)

MO

DEPEN TITRATABS TABS$0-

$8.25(Tier

2)

MO

SYPRINE CAPS$0-

$8.25(Tier

2)

MO

Immunomodulators



113

Drug Name DrugTier

Requirements/Limits

REVLIMID CAPS$0-

$8.25(Tier

2)

LA

THALOMID CAPS$0-

$8.25(Tier

2)

Immunosuppressive Agents

ASTAGRAF XL CP24$0-

$8.25(Tier

2)

B/D; MO

AZATHIOPRINE SOLR IJ100 MG

$0-$8.25(Tier

2)

B/D

azathioprine tabs or 100mg, 75 mg, 50 mg

$0-$3.30(Tier

1)

B/D; MO

CELLCEPT CAPS 250 MG(Mycophenolate Mofetil) NF B/D; MO

CELLCEPTINTRAVENOUS SOLR(Mycophenolate MofetilHCl)

$0-$8.25(Tier

2)

B/D

CELLCEPT SUSR 200MG/ML (MycophenolateMofetil)

$0-$8.25(Tier

2)

B/D; MO

CELLCEPT TABS 500 MG(Mycophenolate Mofetil) NF B/D; MO

cyclosporine caps or 25mg, 100 mg

$0-$3.30(Tier

1)

B/D; MO

cyclosporine modified (formicroemulsion) caps 50mg, 100 mg, 25 mg

$0-$3.30(Tier

1)

B/D; MO

cyclosporine soln iv 50mg/ml

$0-$3.30(Tier

1)

B/D

Drug Name DrugTier

Requirements/Limits

ENVARSUS XR TB24$0-

$8.25(Tier

2)

B/D; MO

IMURAN TABS(Azathioprine) NF B/D; MO

mycophenolate mofetilcaps

$0-$3.30(Tier

1)

B/D; MO

mycophenolate mofetil hclsolr

$0-$3.30(Tier

1)

B/D

mycophenolate mofetil susr$0-

$3.30(Tier

1)

B/D; MO

mycophenolate mofetil tabs$0-

$3.30(Tier

1)

B/D; MO

mycophenolate sodiumtbec

$0-$3.30(Tier

1)

B/D; MO

MYFORTIC TBEC(Mycophenolate Sodium) NF B/D; MO

NEORAL CAPS 100 MG,25 MG (CyclosporineModified (ForMicroemulsion))

NF

B/D; MO

NULOJIX SOLR$0-

$8.25(Tier

2)

B/D

PROGRAF CAPS OR 0.5MG, 5 MG, 1 MG(Tacrolimus)

NFB/D; MO

PROGRAF SOLN IV 5MG/ML

$0-$8.25(Tier

2)

B/D

RAPAMUNE SOLN 1MG/ML

$0-$8.25(Tier

2)

B/D; MO



114

Drug Name DrugTier

Requirements/Limits

RAPAMUNE TABS 0.5 MG(Sirolimus) NF B/D; MO

RAPAMUNE TABS 2 MG,1 MG (Sirolimus)

$0-$8.25(Tier

2)

B/D; MO

SANDIMMUNE CAPS OR25 MG, 100 MG(Cyclosporine)

NFB/D; MO

SANDIMMUNE SOLN IV50 MG/ML (Cyclosporine) NF B/D

SANDIMMUNE SOLN OR100 MG/ML

$0-$8.25(Tier

2)

B/D; MO

SIMULECT SOLR$0-

$8.25(Tier

2)

B/D

sirolimus tabs$0-

$3.30(Tier

1)

B/D; MO

tacrolimus caps or 0.5 mg,1 mg, 5 mg

$0-$3.30(Tier

1)

B/D; MO

THYMOGLOBULIN SOLR$0-

$8.25(Tier

2)

B/D

ZORTRESS TABS$0-

$8.25(Tier

2)

B/D; MO

Irrigation Solutions

irrigation solutions,physiological soln

$0-$3.30(Tier

1)

water for irrigation, sterilesoln

$0-$3.30(Tier

1)

MO

Potassium Removing AgentsKAYEXALATE POWD(Sodium PolystyreneSulfonate)

NFMO

Drug Name DrugTier

Requirements/Limits

sodium polystyrenesulfonate powd or

$0-$3.30(Tier

1)

MO

sodium polystyrenesulfonate susp or 15gm/60ml

$0-$3.30(Tier

1)

MO

VELTASSA PACK 16.8 GM$0-

$8.25(Tier

2)

ST; SL(1.5 eadaily); LA; MO


$8.25(Tier

2)

ST; SL(1 eadaily); LA; MO


$8.25(Tier

2)

ST; SL(3 eadaily); LA; MO

Systemic Lupus Erythematosus Agents

BENLYSTA SOLR IV 120MG

$0-$8.25(Tier

2)

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Oral

lidocaine hcl (mouth-throat)soln

$0-$3.30(Tier

1)

MO

Anti-infectives - Throat

clotrimazole lozg mt$0-

$3.30(Tier

1)

MO

clotrimazole troc mt$0-

$3.30(Tier

1)

MO

nystatin (mouth-throat)susp

$0-$3.30(Tier

1)

MO

Antiseptics - Mouth/Throat



115

Drug Name DrugTier

Requirements/Limits

chlorhexidine gluconate(mouth-throat) soln

$0-$3.30(Tier

1)

MO

PERIDEX SOLN(Chlorhexidine Gluconate(Mouth-Throat))

NFMO

Dental ProductsGEL-KAM ORAL CARERINSE CONC (StannousFluoride)

NFRX/OTC; MO;NT

Steroids - Mouth/Throat

triamcinolone acetonide(mouth) pste

$0-$3.30(Tier

1)

MO

Throat Products - Misc.

cevimeline hcl caps$0-

$3.30(Tier

1)

MO

EVOXAC CAPS(Cevimeline HCl) NF MO

pilocarpine hcl (oral) tabs$0-

$3.30(Tier

1)

MO

SALAGEN TABS(Pilocarpine HCl (Oral)) NF MO

MULTIVITAMINS

Pediatric Vitamins

BPROTECTED PEDIATRI-VITE SOLN

$0(Tier

3)

MO; NT

pediatric vitamins adc soln$0

(Tier3)

MO; NT

TRI-VI-SOL SOLN$0

(Tier3)

MO; NT

Prenatal Vitamins

CENTRUM SPECIALISTPRENATAL MISC

$0(Tier

3)

NT

Drug Name DrugTier

Requirements/Limits

CLASSIC PRENATALTABS

$0(Tier

3)

MO; NT

CVS PRENATALMULTI+DHA CAPS

$0(Tier

3)

NT

CVS PRENATAL TABS$0

(Tier3)

MO; NT

ENFAMIL EXPECTA MISC$0

(Tier3)

MO; NT

EQL PRENATALFORMULA TABS

$0(Tier

3)

MO; NT

EZFE FORTE CAPS$0

(Tier3)

NT

GNP DAILY PRENATALMISC

$0(Tier

3)

NT

GNP PRENATAL TABS$0

(Tier3)

MO; NT

GOODSENSE PRENATALVITAMINS TABS

$0(Tier

3)

MO; NT

HM ONE DAILYPRENATAL COMBO MISC

$0(Tier

3)

NT

HM PRENATAL TABS$0

(Tier3)

MO; NT

KP PRENATALMULTIVITAMINS TABS

$0(Tier

3)

MO; NT

KPN PRENATAL TABS$0

(Tier3)

NT

MULTI PRENATAL TABS$0

(Tier3)

MO; NT

NAT-RUL PRENATALVITAMINS TABS

$0(Tier

3)

MO; NT

ONE A DAY WOMENSPRENATAL1 CAPS

$0(Tier

3)

NT



116

Drug Name DrugTier

Requirements/Limits

ONE-A-DAY WOMENSPRENATAL MISC

$0(Tier

3)

NT

PRENATAL FORMULA A-FREE TABS

$0(Tier

3)

NT

PRENATAL FORMULATABS 30UNIT-200MG-4000UNIT-25MG-1.8MG-28MG-20MG-1.7MG-8MCG-800MCG-2.6MG-120MG-400UNIT

$0(Tier

3)

MO; NT

PRENATAL LOW IRONTABS

$0(Tier

3)

MO; NT

PRENATAL MULTI + DHACAPS

$0(Tier

3)

NT

PRENATALMULTIVITAMIN + DHAMISC

$0(Tier

3)

MO; NT

PRENATALMULTIVITAMIN PLUSDHA CAPS

$0(Tier

3)

NT

PRENATALMULTIVITAMIN TABS

$0(Tier

3)

MO; NT

PRENATAL ONE DAILYTABS

$0(Tier

3)

MO; NT

PRENATAL TABS3.75UNIT-0.5MG-50MG-0.5MG-25MG-15MG-3.75MG-6.75MG-2.5MG-5MG-0.75MG-500UNIT-2.5MCG-0.5MG-200MCG-25MCG-0.75MG-100UNIT

$0(Tier

3)

NT

Drug Name DrugTier

Requirements/Limits

PRENATAL TABS 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-0.8MG-2.6MG-120MG,11UNIT-263MG-25MG-1.5MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG, 4000UNIT-30UNIT-200MG-25MG-1.8MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG,30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG, 160MG-11UNIT-200MG-25MG-1.84MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-800MCG-2.6MG-100MG,30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-4000UNIT-8MCG-400UNIT-800MCG-2.6MG-120MG, 4000UNIT-30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG

$0(Tier

3)

MO; NT

PRENATAL VITAMIN &MINERAL TABS

$0(Tier

3)

MO; NT

PRENATAL VITAMINTABS

$0(Tier

3)

MO; NT

PRENATALVITAMIN/IRON TABS

$0(Tier

3)

MO; NT

PRENATAL VITAMINSTABS 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG

$0(Tier

3)

MO; NT

PROFE FORTE CAPS$0

(Tier3)

NT



117

Drug Name DrugTier

Requirements/Limits

PX PRENATALMULTIVITAMINS TABS

$0(Tier

3)

MO; NT

QC PRENATAL TABS$0

(Tier3)

MO; NT

RA ONE DAILY MISC$0

(Tier3)

NT

RA PRENATALFORMULA/FOLICACIDTABS

$0(Tier

3)

MO; NT

RA PRENATAL TABS$0

(Tier3)

MO; NT

RIGHT STEP PRENATALTABS

$0(Tier

3)

MO; NT

SIMILAC PRENATALEARLY SHIELD MISC

$0(Tier

3)

NT

SM ONE DAILYPRENATAL MISC

$0(Tier

3)

NT

SM PRENATAL VITAMINSTABS

$0(Tier

3)

MO; NT

STUART ONE CAPS$0

(Tier3)

NT

THERANATALCOMPLETE MISC

$0(Tier

3)

NT

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat SpasmsCentral Muscle Relaxants

baclofen tabs or 10 mg$0-

$3.30(Tier

1)

SL(8 ea daily);MO

baclofen tabs or 20 mg$0-

$3.30(Tier

1)

SL(4 ea daily);MO

Drug Name DrugTier

Requirements/Limits

carisoprodol tabs or 350mg

$0-$3.30(Tier

1)


chlorzoxazone tabs 500 mg$0-

$3.30(Tier

1)


cyclobenzaprine hcl tabs or10 mg, 5 mg

$0-$3.30(Tier

1)


metaxalone tabs$0-

$3.30(Tier

1)


methocarbamol tabs or 750mg, 500 mg

$0-$3.30(Tier

1)


PARAFON FORTE DSCTABS (Chlorzoxazone) NF AL; Up to 64

yrs old; MOROBAXIN TABS OR 500MG (Methocarbamol) NF AL; Up to 64

yrs old; MOROBAXIN-750 TABS(Methocarbamol) NF AL; Up to 64

yrs old; MOSKELAXIN TABS(Metaxalone) NF AL; Up to 64

yrs old; MOSOMA TABS 350 MG(Carisoprodol) NF AL; Up to 64

yrs old; MO

tizanidine hcl caps or 2 mg$0-

$3.30(Tier

1)

SL(18 ea daily);MO


$3.30(Tier

1)

SL(9 ea daily);MO


$3.30(Tier

1)

SL(6 ea daily);MO

tizanidine hcl tabs or 2 mg$0-

$3.30(Tier

1)

SL(18 ea daily);MO



118

Drug Name DrugTier

Requirements/Limits

tizanidine hcl tabs or 4 mg$0-

$3.30(Tier

1)

SL(9 ea daily);MO

ZANAFLEX CAPS 2 MG(Tizanidine HCl) NF SL(18 ea daily);

MOZANAFLEX CAPS 4 MG(Tizanidine HCl) NF SL(9 ea daily);

MOZANAFLEX CAPS 6 MG(Tizanidine HCl) NF SL(6 ea daily);

MOZANAFLEX TABS 4 MG(Tizanidine HCl) NF SL(9 ea daily);

MODirect Muscle RelaxantsDANTRIUM CAPS(Dantrolene Sodium) NF MO

dantrolene sodium caps or100 mg, 50 mg, 25 mg

$0-$3.30(Tier

1)

MO

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or SinusNasal Agents - Misc.OCEAN NASAL SPRAYSOLN (Saline) NF MO; NT

saline soln na 0.65%-0.002%, 0.65 %, 0.65%

$0(Tier

3)

MO; NT

Nasal Antiallergy

azelastine hcl soln 137mcg/spray, 0.1 %

$0-$3.30(Tier

1)

MO

cromolyn sodium (nasal)aers

$0(Tier

3)

MO; NT

NASALCROM AERS(Cromolyn Sodium (Nasal)) NF MO; NT

olopatadine hcl (nasal) soln$0-

$3.30(Tier

1)

MO

PATANASE SOLN(Olopatadine HCl (Nasal)) NF MO

Nasal Anticholinergics

Drug Name DrugTier

Requirements/Limits

ATROVENT SOLN(Ipratropium Bromide(Nasal))

NFMO

ipratropium bromide (nasal)soln

$0-$3.30(Tier

1)

MO

Nasal Steroids

budesonide (nasal) susp$0-

$3.30(Tier

1)

RX/OTC; MO

FLONASE ALLERGYRELIEF CHILDRENSSUSP (FluticasonePropionate (Nasal))

$0(Tier

3)

RX/OTC; MO;NT

FLONASE ALLERGYRELIEF SUSP (FluticasonePropionate (Nasal))

$0(Tier

3)

RX/OTC; MO;NT

flunisolide (nasal) soln$0-

$3.30(Tier

1)

MO

fluticasone propionate(nasal) susp

$0(Tier

3)


fluticasone propionate(nasal) susp

$0-$3.30(Tier

1)

RX/OTC; MO

NASACORT ALLERGY24HR AERO(Triamcinolone Acetonide(Nasal))

NF

RX/OTC; MO;NT

NASACORT ALLERGY24HR CHILDRENS AERO(Triamcinolone Acetonide(Nasal))

NF

RX/OTC; MO;NT

triamcinolone acetonide(nasal) aero

$0-$3.30(Tier

1)

RX/OTC; MO

Sympathomimetic Decongestants

NASAL DECONGESTANTLIQD

$0(Tier

3)

MO; NT



119

Drug Name DrugTier

Requirements/Limits

NASAL DECONGESTANTSYRP

$0(Tier

3)

NT

pseudoephedrine hcl liqdor 15 mg/5ml

$0(Tier

3)

MO; NT

pseudoephedrine hcl tabsor 60 mg, 30 mg

$0(Tier

3)

MO; NT

SUDAFED CHILDRENSLIQD (PseudoephedrineHCl)

NFMO; NT

SUDAFED CONGESTIONTABS (PseudoephedrineHCl)

NFMO; NT

SUDAFED NASALDECONGESTANTMAXIMUM STRENGTHTABS (PseudoephedrineHCl)

NF

MO; NT

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze MusclesALS Agents

RADICAVA SOLN$0-

$8.25(Tier

2)

PA

RILUTEK TABS (Riluzole) NF MO

riluzole tabs$0-

$3.30(Tier

1)

MO

Muscular Dystrophy Agents

EXONDYS 51 SOLN$0-

$8.25(Tier

2)

PA; LA

Neuromuscular Blocking Agent - Neurotoxins

BOTOX SOLR$0-

$8.25(Tier

2)

PA

XEOMIN SOLR$0-

$8.25(Tier

2)

PA

Drug Name DrugTier

Requirements/Limits

NUTRIENTS

Carbohydrates

DEXTROSE ANHYDROUSGRAN

$0(Tier

3)

NT

dextrose soln iv 10 %$0-

$3.30(Tier

1)

B/D

dextrose soln iv 5 %$0-

$3.30(Tier

1)

B/D; MO

Lipids

fat emulsion emul$0-

$3.30(Tier

1)

B/D

Misc. Nutritional Substances

ATABEX DHA CAPS$0

(Tier3)

NT

Proteins

amino acid electrolyteinfusion soln

$0-$3.30(Tier

1)

B/D

amino acid infusion 15%$0-

$3.30(Tier

1)

B/D

AMINOSYN II 15% (Useamino acid infusion) NF B/D

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants

polyvinyl alcohol soln op$0

(Tier3)

MO; NT

REFRESH PLUS SOLN(CarboxymethylcelluloseSodium (Ophth))

NFNT

Beta-blockers - OphthalmicBETAGAN SOLN(Levobunolol HCl) NF MO



120

Drug Name DrugTier

Requirements/Limits

betaxolol hcl (ophth) soln$0-

$3.30(Tier

1)

MO

carteolol hcl (ophth) soln$0-

$3.30(Tier

1)

MO

COSOPT SOLN(Dorzolamide HCl-TimololMaleate)

NFMO

dorzolamide hcl-timololmaleate soln

$0-$3.30(Tier

1)

MO

levobunolol hcl soln$0-

$3.30(Tier

1)

MO

timolol maleate (ophth)solg

$0-$3.30(Tier

1)

MO

timolol maleate (ophth)soln

$0-$3.30(Tier

1)

MO

TIMOPTIC SOLN (TimololMaleate (Ophth)) NF MO

TIMOPTIC-XE SOLG(Timolol Maleate (Ophth)) NF MO

Cycloplegic Mydriatics

cyclopentolate hcl soln op1 %

$0-$3.30(Tier

1)

MO

Miotics

ISOPTO CARPINE SOLN(Pilocarpine HCl)

$0-$8.25(Tier

2)

MO

PHOSPHOLINE IODIDESOLR

$0-$8.25(Tier

2)

Drug Name DrugTier

Requirements/Limits

pilocarpine hcl soln op 4 %,1 %, 2 %

$0-$3.30(Tier

1)

MO

Ophthalmic Adrenergic Agents

ALPHAGAN P SOLN 0.1 %$0-

$8.25(Tier

2)

MO

ALPHAGAN P SOLN 0.15% (Brimonidine Tartrate) NF MO

apraclonidine hcl soln$0-

$3.30(Tier

1)

MO

brimonidine tartrate soln$0-

$3.30(Tier

1)

MO

IOPIDINE SOLN 0.5 %(Apraclonidine HCl) NF MO

Ophthalmic Anti-infectives

AZASITE SOLN$0-

$8.25(Tier

2)

MO

bacitracin (ophthalmic) oint$0-

$3.30(Tier

1)

MO

bacitracin-polymyxin b(ophth) oint

$0-$3.30(Tier

1)

MO

BLEPH-10 SOLN(Sulfacetamide Sodium(Ophth))

NFMO

CILOXAN SOLN(Ciprofloxacin HCl (Ophth)) NF MO

ciprofloxacin hcl (ophth)soln

$0-$3.30(Tier

1)

MO

erythromycin (ophth) oint$0-

$3.30(Tier

1)

MO



121

Drug Name DrugTier

Requirements/Limits

gatifloxacin (ophth) soln$0-

$3.30(Tier

1)

MO

gentamicin sulfate (ophth)oint

$0-$3.30(Tier

1)

MO

gentamicin sulfate (ophth)soln

$0-$3.30(Tier

1)

MO

levofloxacin (ophth) soln$0-

$3.30(Tier

1)

MO

moxifloxacin hcl (ophth)soln

$0-$3.30(Tier

1)

MO

neomycin-bacitracin zn-polymyxin oint

$0-$3.30(Tier

1)

MO

neomycin-polymyxin-gramicidin soln

$0-$3.30(Tier

1)

MO

OCUFLOX SOLN(Ofloxacin (Ophth)) NF MO

ofloxacin (ophth) soln$0-

$3.30(Tier

1)

MO

polymyxin b-trimethoprimsoln

$0-$3.30(Tier

1)

MO

POLYTRIM SOLN(Polymyxin B-Trimethoprim)

NFMO

sulfacetamide sodium(ophth) soln

$0-$3.30(Tier

1)

MO

tobramycin (ophth) soln$0-

$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

TOBREX SOLN(Tobramycin (Ophth)) NF MO

trifluridine soln op$0-

$3.30(Tier

1)

MO

VIGAMOX SOLN(Moxifloxacin HCl (Ophth))

$0-$8.25(Tier

2)

MO

VIROPTIC SOLN(Trifluridine) NF MO

ZIRGAN GEL$0-

$8.25(Tier

2)

MO

ZYMAXID SOLN(Gatifloxacin (Ophth)) NF MO

Ophthalmic Decongestantsnaphazoline w/pheniramine soln 0.025%-0.3%

$0(Tier

3)

MO; NT

NAPHCON-A SOLN(Naphazoline w/Pheniramine)

NFMO; NT

Ophthalmic Immunomodulators

RESTASIS EMUL$0-

$8.25(Tier

2)

MO

RESTASIS MULTIDOSEEMUL

$0-$8.25(Tier

2)

MO

Ophthalmic Integrin Antagonists

XIIDRA SOLN$0-

$8.25(Tier

2)

PA; MO

Ophthalmic Local Anesthetics

proparacaine hcl soln op$0-

$3.30(Tier

1)

MO

Ophthalmic Steroids



122

Drug Name DrugTier

Requirements/Limits

bacitracin-poly-neomycin-hc oint

$0-$3.30(Tier

1)

MO

dexamethasone sodiumphosphate (ophth) soln

$0-$3.30(Tier

1)

MO

DUREZOL EMUL$0-

$8.25(Tier

2)

MO

fluorometholone (ophth)susp

$0-$3.30(Tier

1)

MO

FML LIQUIFILM SUSP(Fluorometholone (Ophth)) NF MO

LOTEMAX OINT$0-

$8.25(Tier

2)

MO

MAXITROL OINT(Neomycin-Polymy-Dexameth)

NFMO

MAXITROL SUSP(Neomycin-Polymy-Dexameth)

NFMO

neomycin-polymy-dexameth oint

$0-$3.30(Tier

1)

MO

neomycin-polymy-dexameth susp

$0-$3.30(Tier

1)

MO

OMNIPRED SUSP(Prednisolone Acetate(Ophth))

NFMO

PRED FORTE SUSP(Prednisolone Acetate(Ophth))

NFMO

prednisolone acetate(ophth) susp

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

sulfacetamide sod-prednisolone soln

$0-$3.30(Tier

1)

MO

TOBRADEX SUSP(Tobramycin-Dexamethasone)

NFMO

tobramycin-dexamethasone susp

$0-$3.30(Tier

1)

MO

Ophthalmics - Misc.ACULAR LS SOLN(Ketorolac Tromethamine(Ophth))

NFMO

ACULAR SOLN (KetorolacTromethamine (Ophth)) NF MO

azelastine hcl (ophth) soln$0-

$3.30(Tier

1)

MO

AZOPT SUSP$0-

$8.25(Tier

2)

MO

bromfenac sodium (ophth)soln

$0-$3.30(Tier

1)

Once dailydosing;MO

cromolyn sodium (ophth)soln

$0-$3.30(Tier

1)

MO

CYSTARAN SOLN$0-

$8.25(Tier

2)

Limit 60mls per28days;QL(2.15ml daily); LA

diclofenac sodium (ophth)soln

$0-$3.30(Tier

1)

MO

dorzolamide hcl soln$0-

$3.30(Tier

1)

MO

ELESTAT SOLN(Epinastine HCl (Ophth)) NF MO



123

Drug Name DrugTier

Requirements/Limits

epinastine hcl (ophth) soln$0-

$3.30(Tier

1)

MO

EYEAID IRRIGATINGSOLUTION SOLN(Ophthalmic IrrigationSolution)

NF

MO; NT

flurbiprofen sodium soln$0-

$3.30(Tier

1)

MO

ILEVRO SUSP$0-

$8.25(Tier

2)

MO

ketorolac tromethamine(ophth) soln

$0-$3.30(Tier

1)

MO

ketotifen fumarate (ophth)soln

$0(Tier

3)

MO; NT

MURO 128 OINT 5 %(Sodium ChlorideHypertonic)

NFMO; NT

MURO 128 SOLN 2 %$0

(Tier3)

MO; NT

MURO 128 SOLN 5 %(Sodium ChlorideHypertonic)

NFMO; NT

NEVANAC SUSP$0-

$8.25(Tier

2)

MO

OCUFEN SOLN(Flurbiprofen Sodium) NF MO

olopatadine hcl soln 0.2 %$0-

$3.30(Tier

1)

MO

ophthalmic irrigationsolution soln

$0(Tier

3)

MO; NT

Drug Name DrugTier

Requirements/Limits

PATADAY SOLN(Olopatadine HCl)

$0-$8.25(Tier

2)

MO

sodium chloride hypertonicoint

$0(Tier

3)

MO; NT

sodium chloride hypertonicsoln

$0(Tier

3)

MO; NT

TRUSOPT SOLN(Dorzolamide HCl) NF MO

ZADITOR SOLN (KetotifenFumarate (Ophth)) NF MO; NT

Prostaglandins - Ophthalmic

BIMATOPROST SOLN$0-

$8.25(Tier

2)

MO

latanoprost soln$0-

$3.30(Tier

1)

MO

LUMIGAN SOLN$0-

$8.25(Tier

2)

MO

TRAVATAN Z SOLN$0-

$8.25(Tier

2)

MO

XALATAN SOLN(Latanoprost) NF MO

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous

acetic acid (otic) soln$0-

$3.30(Tier

1)

MO

acetic acid-aluminumacetate soln

$0-$3.30(Tier

1)

MO

carbamide peroxide (otic)soln

$0(Tier

3)

MO; NT



124

Drug Name DrugTier

Requirements/Limits

DEBROX SOLN(Carbamide Peroxide(Otic))

NFMO; NT

Otic Anti-infectivesFLOXIN OTIC SOLN(Ofloxacin (Otic)) NF MO

ofloxacin (otic) soln$0-

$3.30(Tier

1)

MO

Otic Combinations

CIPRODEX SUSP$0-

$8.25(Tier

2)

MO

neomycin-polymyxin-hc(otic) soln

$0-$3.30(Tier

1)

MO

neomycin-polymyxin-hc(otic) susp

$0-$3.30(Tier

1)

MO

Otic SteroidsDERMOTIC OIL(Fluocinolone Acetonide(Otic))

NFMO

fluocinolone acetonide(otic) oil

$0-$3.30(Tier

1)

MO

hydrocortisone w/aceticacid soln

$0-$3.30(Tier

1)

MO

OXYTOCICS - Drugs to Prevent/Control UterineBleedingOxytocics

methylergonovine maleatetabs or 0.2 mg

$0-$3.30(Tier

1)

MO

PASSIVE IMMUNIZING AGENTS - AntibodyDrugs to Treat Low Immune SystemImmune Serums

Drug Name DrugTier

Requirements/Limits

BIVIGAM SOLN$0-

$8.25(Tier

2)

B/D

CUVITRU SOLN$0-

$8.25(Tier

2)

B/D

FLEBOGAMMA DIF SOLN10 %

$0-$8.25(Tier

2)

B/D

GAMASTAN S/D INJ$0-

$8.25(Tier

2)

B/D

GAMMAGARD LIQUIDSOLN

$0-$8.25(Tier

2)

B/D

GAMMAKED SOLN$0-

$8.25(Tier

2)

B/D

GAMMAPLEX SOLN10GM/100ML, 5 GM/50ML,20 GM/200ML

$0-$8.25(Tier

2)

B/D

GAMUNEX-C SOLN$0-

$8.25(Tier

2)

B/D

HIZENTRA SOLN$0-

$8.25(Tier

2)

B/D

OCTAGAM SOLN 2GM/20ML, 10 GM/100ML,20 GM/200ML, 5 GM/50ML

$0-$8.25(Tier

2)

B/D

PRIVIGEN SOLN$0-

$8.25(Tier

2)

B/D

VARIZIG SOLN$0-

$8.25(Tier

2)



125

Drug Name DrugTier

Requirements/Limits

Monoclonal Antibodies

SYNAGIS SOLN 50MG/0.5ML

$0-$8.25(Tier

2)

ZINPLAVA SOLN$0-

$8.25(Tier

2)

PA

Passive Immunizing Agents - Combinations

HYQVIA KIT$0-

$8.25(Tier

2)

B/D

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins

amoxicillin caps 500 mg,250 mg

$0-$3.30(Tier

1)

MO

amoxicillin susr 250mg/5ml, 125 mg/5ml, 200mg/5ml, 400 mg/5ml

$0-$3.30(Tier

1)

MO

amoxicillin tabs 500 mg,875 mg

$0-$3.30(Tier

1)

MO

ampicillin caps 250 mg,500 mg

$0-$3.30(Tier

1)

MO

ampicillin sodium solr ij 2gm, 1 gm

$0-$3.30(Tier

1)

MO

ampicillin sodium solr iv 10gm

$0-$3.30(Tier

1)

Natural Penicillins

BICILLIN L-A SUSP$0-

$8.25(Tier

2)

MO

Drug Name DrugTier

Requirements/Limits

penicillin g potassium solr5000000 unit, 20000000unit, 20 mu

$0-$3.30(Tier

1)

MO

penicillin v potassium solr250 mg/5ml

$0-$3.30(Tier

1)

MO

penicillin v potassium tabs500 mg, 250 mg

$0-$3.30(Tier

1)

MO

Penicillin Combinations

amoxicillin & potclavulanate chew

$0-$3.30(Tier

1)

MO

amoxicillin & potclavulanate susr

$0-$3.30(Tier

1)

MO

amoxicillin & potclavulanate tabs

$0-$3.30(Tier

1)

MO

amoxicillin & potclavulanate tb12

$0-$3.30(Tier

1)

MO

ampicillin & sulbactamsodium solr ij 1gm-2gm

$0-$3.30(Tier

1)

MO

ampicillin & sulbactamsodium solr iv 5gm-10gm

$0-$3.30(Tier

1)AUGMENTIN ES-600SUSR (Amoxicillin & PotClavulanate)

NFMO

AUGMENTIN SUSR250MG/5ML-62.5MG/5ML(Amoxicillin & PotClavulanate)

NF

MO

AUGMENTIN TABS500MG-125MG, 875MG-125MG (Amoxicillin & PotClavulanate)

NF

MO



126

Drug Name DrugTier

Requirements/Limits

AUGMENTIN XR TB12(Amoxicillin & PotClavulanate)

NFMO

BICILLIN C-R SUSP300000UNIT/ML-300000UNIT/ML

$0-$8.25(Tier

2)

MO

BICILLIN C-R SUSP900000UNIT/2ML-300000UNIT/2ML

$0-$8.25(Tier

2)

piperacillin sodium-tazobactam sodium solr

$0-$3.30(Tier

1)UNASYN SOLR 1GM-2GM(Ampicillin & SulbactamSodium)

NFMO

ZOSYN SOLR 0.375GM-3GM, 0.5GM-4GM, 4.5GM-36GM, 0.25GM-2GM(Piperacillin Sodium-Tazobactam Sodium)

NF

Penicillinase-Resistant Penicillins

dicloxacillin sodium caps$0-

$3.30(Tier

1)

MO

nafcillin sodium solr ij 10gm

$0-$3.30(Tier

1)

nafcillin sodium solr ij 2 gm$0-

$3.30(Tier

1)

MO

oxacillin sodium solr 10 gm$0-

$3.30(Tier

1)

oxacillin sodium solr 2 gm$0-

$3.30(Tier

1)

MO

PROGESTINS - Hormone Replacement/ModifyingDrugsProgestins

Drug Name DrugTier

Requirements/Limits

medroxyprogesteroneacetate tabs or 10 mg, 5mg, 2.5 mg

$0-$3.30(Tier

1)

MO

MEGACE ES SUSP(Megestrol Acetate(Appetite))

$0-$8.25(Tier

2)


megestrol acetate(appetite) susp

$0-$3.30(Tier

1)


norethindrone acetate tabsor

$0-$3.30(Tier

1)

MO

progesterone micronizedcaps

$0-$3.30(Tier

1)

MO

PROMETRIUM CAPS(Progesterone Micronized) NF MO

PROVERA TABS(MedroxyprogesteroneAcetate)

NFMO

PSYCHOTHERAPEUTIC AND NEUROLOGICALAGENTS - MISC. - Drugs to Treat Mental andEmotional ConditionsAgents for Chemical Dependency

acamprosate calcium tbec$0-

$3.30(Tier

1)

MO

disulfiram tabs or 250 mg,500 mg

$0-$3.30(Tier

1)

MO

Anti-Cataplectic Agents

XYREM SOLN$0-

$8.25(Tier

2)

LA

Antidementia AgentsARICEPT TABS (DonepezilHydrochloride) NF MO



127

Drug Name DrugTier

Requirements/Limits

donepezil hydrochloridetabs

$0-$3.30(Tier

1)

MO

donepezil hydrochloridetbdp

$0-$3.30(Tier

1)

MO

EXELON CAPS OR 6 MG,4.5 MG, 3 MG, 1.5 MG(Rivastigmine Tartrate)

NFMO

EXELON PT24 TD 13.3MG/24HR, 9.5 MG/24HR,4.6 MG/24HR(Rivastigmine)

$0-$8.25(Tier

2)

MO

galantamine hydrobromidecp24

$0-$3.30(Tier

1)

MO

galantamine hydrobromidesoln

$0-$3.30(Tier

1)

MO

galantamine hydrobromidetabs

$0-$3.30(Tier

1)

MO

memantine hcl soln 2mg/ml

$0-$3.30(Tier

1)

AL; At least 60yrs old; MO

memantine hcl tabs 5 mg, ,10 mg

$0-$3.30(Tier

1)

MO

NAMENDA SOLN 10MG/5ML (Memantine HCl)

$0-$8.25(Tier

2)


NAMENDA TABS 10 MG, 5MG (Memantine HCl)

$0-$8.25(Tier

2)

MO

NAMENDA TITRATIONPAK TABS (MemantineHCl)

$0-$8.25(Tier

2)

MO

Drug Name DrugTier

Requirements/Limits

NAMENDA XR CP24 14MG

$0-$8.25(Tier

2)

AL; At least 60yrs old; SL(2 eadaily); MO


$0-$8.25(Tier

2)

AL; At least 60yrs old; SL(1.33ea daily); MO


$0-$8.25(Tier

2)


NAMENDA XR CP24 7 MG$0-

$8.25(Tier

2)


NAMENDA XR TITRATIONPACK CP24

$0-$8.25(Tier

2)


RAZADYNE ER CP24(GalantamineHydrobromide)

NFMO

RAZADYNE TABS(GalantamineHydrobromide)

NFMO

rivastigmine pt24$0-

$3.30(Tier

1)

MO

rivastigmine tartrate caps$0-

$3.30(Tier

1)

MO

Combination Psychotherapeutics

chlordiazepoxide-amitriptyline tabs

$0-$3.30(Tier

1)


olanzapine-fluoxetine hclcaps

$0-$3.30(Tier

1)

MO

perphenazine-amitriptylinetabs

$0-$3.30(Tier

1)




128

Drug Name DrugTier

Requirements/Limits

SYMBYAX CAPS(Olanzapine-FluoxetineHCl)

NFMO

Movement Disorder Drug Therapy

AUSTEDO TABS 12 MG$0-

$8.25(Tier

2)

SL(4 ea daily);LA


$8.25(Tier

2)

SL(8 ea daily);LA


$8.25(Tier

2)

SL(5.33 eadaily); LA

tetrabenazine tabs$0-

$3.30(Tier

1)

XENAZINE TABS(Tetrabenazine)

$0-$8.25(Tier

2)

LA

Multiple Sclerosis Agents

AMPYRA TB12$0-

$8.25(Tier

2)

AUBAGIO TABS$0-

$8.25(Tier

2)

PA

AVONEX KIT$0-

$8.25(Tier

2)

PA

AVONEX PEN AJKT$0-

$8.25(Tier

2)

PA

AVONEX PSKT$0-

$8.25(Tier

2)

PA

Drug Name DrugTier

Requirements/Limits

BETASERON KIT$0-

$8.25(Tier

2)

PA

COPAXONE SOSY(Glatiramer Acetate)

$0-$8.25(Tier

2)

PA

EXTAVIA KIT$0-

$8.25(Tier

2)

PA

GILENYA CAPS$0-

$8.25(Tier

2)

PA

glatiramer acetate sosy$0-

$3.30(Tier

1)

PA

LEMTRADA SOLN$0-

$8.25(Tier

2)

PA; LA

OCREVUS SOLN$0-

$8.25(Tier

2)

PA

PLEGRIDY SOPN$0-

$8.25(Tier

2)

PA

PLEGRIDY SOSY$0-

$8.25(Tier

2)

PA

PLEGRIDY STARTERPACK SOPN

$0-$8.25(Tier

2)

PA

PLEGRIDY STARTERPACK SOSY

$0-$8.25(Tier

2)

PA

REBIF REBIDOSE SOAJ$0-

$8.25(Tier

2)

PA



129

Drug Name DrugTier

Requirements/Limits

REBIF REBIDOSETITRATIONPACK SOAJ

$0-$8.25(Tier

2)

PA

REBIF SOSY$0-

$8.25(Tier

2)

PA

REBIF TITRATION PACKSOSY

$0-$8.25(Tier

2)

PA

TECFIDERA CPDR$0-

$8.25(Tier

2)

PA

TECFIDERA STARTERPACK MISC

$0-$8.25(Tier

2)

PA

TYSABRI CONC$0-

$8.25(Tier

2)

PA

Premenstrual Dysphoric Disorder (PMDD) Agentsfluoxetine hcl (pmdd) cap10 mg, 20 mg NF

Pseudobulbar Affect (PBA) Agents

NUEDEXTA CAPS$0-

$8.25(Tier

2)

MO

Psychotherapeutic and Neurological Agents -

ergoloid mesylates tabs or$0-

$3.30(Tier

1)


ORAP TABS (Pimozide) NF MO

pimozide tabs$0-

$3.30(Tier

1)

MO

Smoking Deterrents

Drug Name DrugTier

Requirements/Limits

bupropion hcl (smokingdeterrent) tb12

$0-$3.30(Tier

1)

SL(2 ea daily);MO

CHANTIX CONTINUINGMONTHPAK TABS

$0-$8.25(Tier

2)

MO

CHANTIX STARTINGMONTH PAK TABS

$0-$8.25(Tier

2)

MO

CHANTIX TABS$0-

$8.25(Tier

2)

MO

NICODERM CQ PT24(Nicotine) NF MO; NT

NICORETTE GUM(Nicotine Polacrilex) NF MO; NT

NICORETTE LOZG(Nicotine Polacrilex) NF MO; NT

NICORETTE MINI LOZG(Nicotine Polacrilex) NF MO; NT

NICORETTE STARTERKIT GUM (NicotinePolacrilex)

NFMO; NT

nicotine polacrilex gum mt4 mg, 2 mg

$0(Tier

3)

MO; NT

nicotine polacrilex lozg mt 2mg, 4 mg

$0(Tier

3)

MO; NT

nicotine pt24$0

(Tier3)

MO; NT

NICOTINETRANSDERMAL SYSTEMKIT

$0(Tier

3)

NT

NICOTROL INHALERINHA

$0-$8.25(Tier

2)

SL(17 ea daily);MO

NICOTROL NS SOLN$0-

$8.25(Tier

2)

MO



130

Drug Name DrugTier

Requirements/Limits

ZYBAN TB12 (BupropionHCl (Smoking Deterrent)) NF SL(2 ea daily);

MOVasomotor Symptom Agents

BRISDELLE CAPS(Paroxetine Mesylate(Vasomotor))

$0-$8.25(Tier

2)

MO

paroxetine mesylate(vasomotor) caps

$0-$3.30(Tier

1)

MO

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung ConditionsAlpha-Proteinase Inhibitor (Human)

ARALAST NP SOLR 1000MG

$0-$8.25(Tier

2)

LA

PROLASTIN-C SOLR$0-

$8.25(Tier

2)

LA

ZEMAIRA SOLR$0-

$8.25(Tier

2)

LA

Cystic Fibrosis Agents

KALYDECO PACK$0-

$8.25(Tier

2)

PA

KALYDECO TABS$0-

$8.25(Tier

2)

PA

ORKAMBI TABS$0-

$8.25(Tier

2)

PA; LA

PULMOZYME SOLN$0-

$8.25(Tier

2)

B/D

Pulmonary Fibrosis Agents

Drug Name DrugTier

Requirements/Limits

ESBRIET CAPS$0-

$8.25(Tier

2)

PA; LA

ESBRIET TABS$0-

$8.25(Tier

2)

PA; LA

OFEV CAPS$0-

$8.25(Tier

2)

PA; LA

SULFONAMIDES - Drugs to Treat BacterialInfectionsSulfonamides

sulfadiazine tabs or$0-

$3.30(Tier

1)

MO

TETRACYCLINES - Drugs to Treat BacterialInfectionsTetracyclinesADOXA PAK 1/100 TABS(Doxycycline(Monohydrate))

NFMO

ADOXA PAK 1/150 TABS(Doxycycline(Monohydrate))

NFMO

ADOXA PAK 2/100 TABS(Doxycycline(Monohydrate))

NFMO

ADOXA TABS 75 MG, 100MG, 50 MG (Doxycycline(Monohydrate))

NFMO

demeclocycline hcl tabs$0-

$3.30(Tier

1)

MO

doxycycline (monohydrate)caps 100 mg, 50 mg, 75mg

$0-$3.30(Tier

1)

MO

doxycycline (monohydrate)susr 25 mg/5ml

$0-$3.30(Tier

1)

MO



131

Drug Name DrugTier

Requirements/Limits

doxycycline (monohydrate)tabs 100 mg, 50 mg, 75mg, 150 mg

$0-$3.30(Tier

1)

MO

doxycycline hyclate caps or100 mg, 50 mg

$0-$3.30(Tier

1)

MO

doxycycline hyclate solr iv100 mg

$0-$3.30(Tier

1)

MO

doxycycline hyclate tabs or100 mg, 20 mg

$0-$3.30(Tier

1)

MO

doxycycline hyclate tbec or150 mg

$0-$3.30(Tier

1)

MO

MINOCIN CAPS OR 100MG, 50 MG, 75 MG(Minocycline HCl)

NFMO

minocycline hcl caps or100 mg, 75 mg, 50 mg

$0-$3.30(Tier

1)

MO

minocycline hcl tabs or 50mg, 100 mg

$0-$3.30(Tier

1)

MO

MONODOX CAPS(Doxycycline(Monohydrate))

NFMO

tetracycline hcl caps or 500mg, 250 mg

$0-$3.30(Tier

1)

MO

TETRACYCLINE HCLCAPS OR 500 MG, 250MG (Tetracycline HCl)

$0-$8.25(Tier

2)

MO

VIBRAMYCIN CAPS 100MG (Doxycycline Hyclate) NF MO

VIBRAMYCIN SUSR 25MG/5ML (Doxycycline(Monohydrate))

NFMO

Drug Name DrugTier

Requirements/Limits

THYROID AGENTS - Drugs to Regulate ThyroidHormonesAntithyroid Agents

methimazole tabs or 10mg, 5 mg

$0-$3.30(Tier

1)

MO

propylthiouracil tabs or$0-

$3.30(Tier

1)

MO

Thyroid HormonesCYTOMEL TABS(Liothyronine Sodium) NF MO

levothyroxine sodium tabsor 125 mcg, 150 mcg, 300mcg, 175 mcg, 25 mcg, 75mcg, 50 mcg, 88 mcg, 100mcg, 200 mcg, 137 mcg,112 mcg

$0-$3.30(Tier

1)

MO

liothyronine sodium tabs or25 mcg, 50 mcg, 5 mcg

$0-$3.30(Tier

1)

MO

SYNTHROID TABS(Levothyroxine Sodium) NF MO

TOXOIDS

Toxoid Combinations

ADACEL SUSP$0-

$8.25(Tier

2)

BOOSTRIX SUSP$0-

$8.25(Tier

2)

DAPTACEL SUSP$0-

$8.25(Tier

2)

DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC SUSP

$0-$8.25(Tier

2)



132

Drug Name DrugTier

Requirements/Limits

INFANRIX SUSP$0-

$8.25(Tier

2)

KINRIX SUSP$0-

$8.25(Tier

2)

QUADRACEL SUSP$0-

$8.25(Tier

2)

TENIVAC INJ$0-

$8.25(Tier

2)

B/D

TETANUS/DIPHTHERIATOXOIDS-ADSORBEDSUSP

$0-$8.25(Tier

2)

ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach ConditionsAntispasmodicsBENTYL CAPS OR 10 MG(Dicyclomine HCl) NF MO

BENTYL TABS OR 20 MG(Dicyclomine HCl) NF MO

dicyclomine hcl caps or 10mg

$0-$3.30(Tier

1)

MO

dicyclomine hcl tabs or 20mg

$0-$3.30(Tier

1)

MO

glycopyrrolate soln ij 0.2mg/ml

$0-$3.30(Tier

1)

MO

glycopyrrolate tabs or 1 mg$0-

$3.30(Tier

1)

SL(8 ea daily);MO

glycopyrrolate tabs or 2 mg$0-

$3.30(Tier

1)

SL(4 ea daily);MO

Drug Name DrugTier

Requirements/Limits

LIBRAX CAPS(Chlordiazepoxide HCl-Clidinium Bromide)

NFMO

methscopolamine bromidetabs or 5 mg, 2.5 mg

$0-$3.30(Tier

1)

MO

PAMINE FORTE TABS(MethscopolamineBromide)

NFMO

PAMINE TABS(MethscopolamineBromide)

NFMO

ROBINUL FORTE TABS(Glycopyrrolate) NF SL(4 ea daily);

MOROBINUL SOLN IJ 0.2MG/ML (Glycopyrrolate) NF MO

ROBINUL TABS OR 1 MG(Glycopyrrolate) NF SL(8 ea daily);

MOH-2 Antagonists

cimetidine tabs or 200 mg$0

(Tier3)


cimetidine tabs or 200 mg$0-

$3.30(Tier

1)

RX/OTC; MO

cimetidine tabs or 400 mg,800 mg, 300 mg

$0-$3.30(Tier

1)

MO

famotidine soln iv 40mg/4ml, 20 mg/2ml, 200mg/20ml

$0-$3.30(Tier

1)

famotidine susr or 40mg/5ml

$0-$3.30(Tier

1)

MO

famotidine tabs or 10 mg$0

(Tier3)

MO; NT

famotidine tabs or 20 mg$0-

$3.30(Tier

1)

RX/OTC; MO



133

Drug Name DrugTier

Requirements/Limits

famotidine tabs or 20 mg$0

(Tier3)


famotidine tabs or 40 mg$0-

$3.30(Tier

1)

MO

nizatidine caps 300 mg,150 mg

$0-$3.30(Tier

1)

MO

PEPCID AC MAXIMUMSTRENGTH TABS(Famotidine)

$0(Tier

3)

RX/OTC; MO;NT

PEPCID AC TABS(Famotidine) NF MO; NT

PEPCID SUSR(Famotidine) NF MO

ranitidine hcl caps or 150mg, 300 mg

$0-$3.30(Tier

1)

MO

ranitidine hcl syrp or 75mg/5ml, 150 mg/10ml, 15mg/ml

$0-$3.30(Tier

1)

MO

ranitidine hcl tabs or 150mg

$0-$3.30(Tier

1)

RX/OTC; MO


$0(Tier

3)



$0-$3.30(Tier

1)

MO

ranitidine hcl tabs or 75 mg$0

(Tier3)

MO; NT

TAGAMET HB TABS(Cimetidine)

$0(Tier

3)

RX/OTC; MO;NT

ZANTAC 150 MAXIMUMSTRENGTH TABS(Ranitidine HCl)

$0(Tier

3)

RX/OTC; MO;NT

ZANTAC 75 TABS(Ranitidine HCl) NF MO; NT

Drug Name DrugTier

Requirements/Limits

ZANTAC TABS OR 150MG (Ranitidine HCl) NF RX/OTC; MO

ZANTAC TABS OR 300MG (Ranitidine HCl) NF MO

Misc. Anti-UlcerCARAFATE TABS 1 GM(Sucralfate) NF MO

sucralfate tabs or$0-

$3.30(Tier

1)

MO

Proton Pump Inhibitors

CVS OMEPRAZOLE TBEC$0

(Tier3)

MO; NT

DEXILANT CPDR$0-

$8.25(Tier

2)

ST; MO

EQ OMEPRAZOLE TBEC$0

(Tier3)

MO; NT

EQL OMEPRAZOLE TBEC$0

(Tier3)

MO; NT

esomeprazole magnesiumcpdr 20 mg

$0-$3.30(Tier

1)

RX/OTC; MO

esomeprazole magnesiumcpdr 40 mg

$0-$3.30(Tier

1)

MO

esomeprazole sodium solr40 mg

$0-$3.30(Tier

1)

GNP OMEPRAZOLETBEC

$0(Tier

3)

MO; NT

HM OMEPRAZOLE TBEC$0

(Tier3)

MO; NT

KLS OMEPRAZOLE TBEC$0

(Tier3)

MO; NT



134

Drug Name DrugTier

Requirements/Limits

lansoprazole cpdr or 15 mg$0

(Tier3)


lansoprazole cpdr or 15 mg$0-

$3.30(Tier

1)

RX/OTC; MO

lansoprazole cpdr or 30 mg$0-

$3.30(Tier

1)

MO

NEXIUM CPDR 20 MG(EsomeprazoleMagnesium)

NFRX/OTC; MO

NEXIUM CPDR 40 MG(EsomeprazoleMagnesium)

NFMO

NEXIUM I.V. SOLR(Esomeprazole Sodium) NF

NEXIUM PACK 20 MG, 10MG, 5 MG, 40 MG, 2.5 MG

$0-$8.25(Tier

2)

ST; MO

omeprazole cpdr or 40 mg,10 mg, 20 mg

$0-$3.30(Tier

1)

MO

OMEPRAZOLE TBEC OR20 MG

$0(Tier

3)

MO; NT

pantoprazole sodium solr iv40 mg

$0-$3.30(Tier

1)

pantoprazole sodium tbecor 20 mg, 40 mg

$0-$3.30(Tier

1)

MO

PREVACID 24HR CPDR(Lansoprazole)

$0(Tier

3)

RX/OTC; MO;NT

PREVACID CPDR 15 MG(Lansoprazole) NF RX/OTC; MO

PREVACID CPDR 30 MG(Lansoprazole) NF MO

PRILOSEC CPDR 20 MG,40 MG, 10 MG(Omeprazole)

NFMO

Drug Name DrugTier

Requirements/Limits

PRILOSEC OTC TBEC$0

(Tier3)

MO; NT

PROTONIX SOLR IV 40MG (Pantoprazole Sodium) NF

PROTONIX TBEC OR 20MG, 40 MG (PantoprazoleSodium)

NFMO

PX OMEPRAZOLE TBEC$0

(Tier3)

MO; NT

RA OMEPRAZOLE TBEC$0

(Tier3)

MO; NT

SB OMEPRAZOLE TBEC$0

(Tier3)

MO; NT

SM OMEPRAZOLE TBEC$0

(Tier3)

MO; NT

SW OMEPRAZOLE TBEC$0

(Tier3)

MO; NT

TGT OMEPRAZOLE TBEC$0

(Tier3)

MO; NT

Ulcer Drugs - ProstaglandinsCYTOTEC TABS(Misoprostol) NF MO

misoprostol tabs or 200mcg, 100 mcg

$0-$3.30(Tier

1)

MO

Ulcer Therapy Combinations

amoxicillin-clarithromycinw/ lansoprazole misc

$0-$3.30(Tier

1)

MO

OMECLAMOX-PAK MISC$0-

$8.25(Tier

2)

MO

omeprazole-sodiumbicarbonate caps 20mg-1100mg

$0-$3.30(Tier

1)

RX/OTC; MO



135

Drug Name DrugTier

Requirements/Limits

omeprazole-sodiumbicarbonate caps 40mg-1100mg

$0-$3.30(Tier

1)

MO

omeprazole-sodiumbicarbonate pack 20mg-1680mg

$0-$3.30(Tier

1)

ST; 20MG-1680 MG;MO

PREVPAC MISC(Amoxicillin-Clarithromycinw/ Lansoprazole)

NFMO

ZEGERID CAPS 20MG-1100MG (Omeprazole-Sodium Bicarbonate)

NFRX/OTC; MO

ZEGERID CAPS 40MG-1100MG (Omeprazole-Sodium Bicarbonate)

NFMO

ZEGERID OTC CAPS(Omeprazole-SodiumBicarbonate)

NFRX/OTC; MO;NT

ZEGERID PACK 20MG-1680MG (Omeprazole-Sodium Bicarbonate)

$0-$8.25(Tier

2)

ST; 20MG-1680 MG;MO

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney InfectionsUrinary Anti-infectivesHIPREX TABS(Methenamine Hippurate) NF MO

MACROBID CAPS(Nitrofurantoin MonohydMacro)

NFMO

MACRODANTIN CAPS 50MG, 100 MG(NitrofurantoinMacrocrystal)

NF


methenamine hippuratetabs

$0-$3.30(Tier

1)

MO

nitrofurantoin macrocrystalcaps or 100 mg, 50 mg

$0-$3.30(Tier

1)


nitrofurantoin monohydmacro caps

$0-$3.30(Tier

1)

MO

Drug Name DrugTier

Requirements/Limits

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder SpasmsUrinary Antispasmodic - AntimuscarinicsDETROL LA CP24(Tolterodine Tartrate) NF MO

DETROL TABS(Tolterodine Tartrate) NF MO

DITROPAN XL TB24(Oxybutynin Chloride) NF MO

oxybutynin chloride syrp$0-

$3.30(Tier

1)

MO

oxybutynin chloride tabs$0-

$3.30(Tier

1)

MO

oxybutynin chloride tb24$0-

$3.30(Tier

1)

MO

tolterodine tartrate cp24$0-

$3.30(Tier

1)

MO

tolterodine tartrate tabs$0-

$3.30(Tier

1)

MO

trospium chloride cp24$0-

$3.30(Tier

1)

MO

trospium chloride tabs$0-

$3.30(Tier

1)

MO

Urinary Antispasmodics - Beta-3 Adrenergic

MYRBETRIQ TB24$0-

$8.25(Tier

2)

MO

Urinary Antispasmodics - Cholinergic Agonists

bethanechol chloride tabs10 mg, 25 mg, 50 mg, 5 mg

$0-$3.30(Tier

1)

MO



136

Drug Name DrugTier

Requirements/Limits

Urinary Antispasmodics - Direct Muscle Relaxants

flavoxate hcl tabs$0-

$3.30(Tier

1)

MO

VACCINES

Bacterial Vaccines

ACTHIB SOLR$0-

$8.25(Tier

2)

BEXSERO SUSY$0-

$8.25(Tier

2)

HIBERIX SOLR$0-

$8.25(Tier

2)

MENACTRA INJ$0-

$8.25(Tier

2)

MENOMUNE-A/C/Y/W-135INJ

$0-$8.25(Tier

2)

MENVEO SOLR$0-

$8.25(Tier

2)

PEDVAX HIB SUSP$0-

$8.25(Tier

2)

TRUMENBA SUSY$0-

$8.25(Tier

2)

TYPHIM VI SOLN$0-

$8.25(Tier

2)

Viral Vaccines

Drug Name DrugTier

Requirements/Limits

ENGERIX-B SUSP IJ 20MCG/ML, 10 MCG/0.5ML

$0-$8.25(Tier

2)

B/D

GARDASIL 9 SUSP$0-

$8.25(Tier

2)

GARDASIL 9 SUSY$0-

$8.25(Tier

2)

GARDASIL SUSP$0-

$8.25(Tier

2)

HAVRIX SUSP$0-

$8.25(Tier

2)

IMOVAX RABIES(H.D.C.V.) INJ

$0-$8.25(Tier

2)

B/D

IPOL INACTIVATED IPVINJ

$0-$8.25(Tier

2)

IXIARO SUSP$0-

$8.25(Tier

2)

M-M-R II INJ$0-

$8.25(Tier

2)

PROQUAD INJ$0-

$8.25(Tier

2)

RABAVERT SUSR$0-

$8.25(Tier

2)

B/D

RECOMBIVAX HB SUSP$0-

$8.25(Tier

2)

B/D



137

Drug Name DrugTier

Requirements/Limits

ROTARIX SUSR$0-

$8.25(Tier

2)

ROTATEQ SOLN$0-

$8.25(Tier

2)

STAMARIL SUSR$0-

$8.25(Tier

2)

TWINRIX SUSP$0-

$8.25(Tier

2)

VAQTA SUSP$0-

$8.25(Tier

2)

VARIVAX INJ$0-

$8.25(Tier

2)

YF-VAX INJ$0-

$8.25(Tier

2)

ZOSTAVAX SUSR$0-

$8.25(Tier

2)

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low HormonesSpermicidesOPTIONS GYNOL IIVAGINALCONTRACEPTIVE GEL

$0(Tier

3)

MO; NT

VCF VAGINALCONTRACEPTIVE FOAMFOAM

$0(Tier

3)

NT

Vaginal Anti-infectivesCLEOCIN CREA VA 2 %(Clindamycin PhosphateVaginal)

NFMO

Drug Name DrugTier

Requirements/Limits

clindamycin phosphatevaginal crea

$0-$3.30(Tier

1)

MO

clotrimazole vaginal crea 1%

$0(Tier

3)

MO; NT

GYNE-LOTRIMIN CREA(Clotrimazole Vaginal) NF MO; NT

METROGEL-VAGINALGEL (MetronidazoleVaginal)

NFMO

metronidazole vaginal gel$0-

$3.30(Tier

1)

MO

miconazole nitrate vaginalcrea 2 %

$0(Tier

3)

MO; NT

miconazole nitrate vaginalcrea 4 %

$0(Tier

3)

NT

miconazole nitrate vaginalkit

$0(Tier

3)

NT

miconazole nitrate vaginalsupp 100 mg

$0(Tier

3)

MO; NT

MONISTAT 3COMBINATION PACK KIT(Miconazole NitrateVaginal)

NF

NT

MONISTAT 3 CREA(Miconazole NitrateVaginal)

NFNT

MONISTAT 7 SIMPLYCURE CREA (MiconazoleNitrate Vaginal)

NFMO; NT

TERAZOL 3 CREA(Terconazole Vaginal) NF MO

TERAZOL 7 CREA(Terconazole Vaginal) NF MO

terconazole vaginal crea$0-

$3.30(Tier

1)

MO



138

Drug Name DrugTier

Requirements/Limits

terconazole vaginal supp$0-

$3.30(Tier

1)

MO

tioconazole vaginal oint$0

(Tier3)

NT

VAGISTAT-1 OINT(Tioconazole Vaginal) NF NT

Vaginal Estrogens

estradiol vaginal crea 0.1mg/gm

$0-$3.30(Tier

1)

MO

PREMARIN CREA VA0.625 MG/GM

$0-$8.25(Tier

2)

MO

VASOPRESSORS - Drugs to Treat Heart andCirculation ConditionsAnaphylaxis Therapy Agents

epinephrine (anaphylaxis)soaj

$0-$8.25(Tier

2)

MO

EPIPEN 2-PAK SOAJ$0-

$8.25(Tier

2)

MO

EPIPEN-JR 2-PAK SOAJ$0-

$8.25(Tier

2)

MO

Neurogenic Orthostatic Hypotension (NOH) -

NORTHERA CAPS 100MG

$0-$8.25(Tier

2)

PA; SL(18 eadaily)

NORTHERA CAPS 200MG

$0-$8.25(Tier

2)

PA; SL(9 eadaily)

NORTHERA CAPS 300MG

$0-$8.25(Tier

2)

PA; SL(6 eadaily)

Vasopressors

Drug Name DrugTier

Requirements/Limits

dobutamine hcl soln$0-

$3.30(Tier

1)

midodrine hcl tabs$0-

$3.30(Tier

1)

MO

VITAMINS

Oil Soluble Vitaminscholecalciferol caps or5000 unit, 1000 unit, 2000unit

$0(Tier

3)

MO; NT

cholecalciferol tabs or 1000unit, 400 unit, 2000 unit

$0(Tier

3)

MO; NT

cholecalciferol tabs or 5000unit

$0(Tier

3)

NT

DRISDOL CAPS 50000UNIT (Ergocalciferol) NF MO; NT

ergocalciferol caps or50000 unit

$0(Tier

3)

MO; NT

MEPHYTON TABS$0

(Tier3)

MO; NT

phytonadione tabs or 100mcg

$0(Tier

3)

MO; NT

vitamin a caps or 10000unit

$0(Tier

3)

MO; NT

vitamin a caps or 8000 unit$0

(Tier3)

NT

Water Soluble Vitamins

niacin cpcr or 250 mg$0

(Tier3)

MO; NT

niacin tabs or 100 mg, 500mg, 50 mg

$0(Tier

3)

MO; NT

niacin tbcr or 500 mg$0

(Tier3)

MO; NT



139

Drug Name DrugTier

Requirements/Limits

pyridoxine hcl tabs or 25mg, 50 mg, 100 mg

$0(Tier

3)

MO; NT

SLO-NIACIN TBCR 500MG (Niacin) NF MO; NT



140

Indexabacavir sulfate 66abacavir sulfate-lamivudine 66abacavir sulfate-lamivudine-zidovudine 66ABELCET 39ABILIFY 65ABILIFY MAINTENA 65ABRAXANE 59ABREVA 87ABSORICA 82acamprosate calcium 127acarbose 31ACCOLATE 20ACCUPRIL 45ACCURETIC 46acebutolol hcl 72ACEON 45acetaminophen 7acetaminophen w/ codeine 11acetazolamide 93acetic acid 102acetic acid (otic) 124acetic acid-aluminumacetate 124acetylcysteine 82acitretin 86ACNE MEDICATION 10 82ACTEMRA 4ACTHIB 137ACTIGALL 99ACTIMMUNE 58ACTIQ 7ACTIVELLA 98ACTOPLUS MET 31ACTOS 34ACULAR 123ACULAR LS 123acyclovir 71acyclovir sodium 71acyclovir topical 87ADACEL 132ADAGEN 3ADALAT CC 73adapalene 82ADCIRCA 75ADDERALL XR 1adefovir dipivoxil 70

ADEMPAS 75ADIPEX-P 1ADOXA 131ADOXA PAK 1/100 131ADOXA PAK 1/150 131ADOXA PAK 2/100 131ADVAIR DISKUS 21ADVAIR HFA 21ADVIL 4ADVIL MIGRAINE 4AEROSPAN 20AFINITOR 55AFINITOR DISPERZ 55AGGRENOX 103AGRYLIN 103AIRZONE PEAK FLOWMETER 109ALBENZA 14albuterol sulfate 21alclometasonedipropionate 87ALCOHOL PADS 109ALDACTAZIDE 94ALDACTONE 94ALDARA 91ALECENSA 55alendronate sodium 95ALEVAZOL 84ALEVE 4alfuzosin hcl 102ALIMTA 51ALINIA 15ALIQOPA 55ALKERAN 49ALLI 1allopurinol 102almotriptan malate 110ALOGLIPTIN 33,34ALOGLIPTIN/METFORMINHCL 31ALOGLIPTIN/PIOGLITAZONE

31,32alosetron hcl 101ALPHAGAN P 121alprazolam 18ALTACE 45alum & mag hydrox-simethicone 13

ALUMINUM HYDROXIDE 14aluminum hydroxide-magtrisil 14ALUNBRIG 55amantadine hcl 61AMARYL 36AMBIEN 105AMBIEN CR 105AMBISOME 39amcinonide 87AMERGE 110AMICAR 105amifostine 58amikacin sulfate 3amiloride &hydrochlorothiazide 94amiloride hcl 94amino acid electrolyteinfusion 120amino acid infusion 15% 120aminophylline 22aminosalicylic acid 49AMINOSYN II 15% (Use aminoacid infusion) 120amiodarone hcl 19amitriptyline hcl 30amlodipine besylate 73amlodipine besylate-atorvastatincalcium 74amlodipine besylate-benazeprilhcl 46amoxapine 30amoxicillin 126amoxicillin & potclavulanate 126amoxicillin-clarithromycin w/lansoprazole 135amphetamine-dextroamphetamine 1amphotericin b 39ampicillin 126ampicillin & sulbactamsodium 126ampicillin sodium 126AMPYRA 129ANADROL-50 12ANAFRANIL 30anagrelide hcl 103ANAPROX DS 4anastrozole 53

Index 1

ANCOBON 39ANDRODERM 12ANDROGEL 12ANDROGEL PUMP 12ANORO ELLIPTA 21ANTARA 43APOKYN 61apraclonidine hcl 121aprepitant 39APRISO 100APTIOM 23APTIVUS 66ARALAST NP 131ARANESP ALBUMINFREE 104ARAVA 6ARCALYST 4argatroban 22ARICEPT 127ARIMIDEX 53aripiprazole 65,66ARISTADA 66ARIXTRA 22AROMASIN 53ARRANON 51ARTHROTEC 50 4ARTHROTEC 75 4ARZERRA 52ASACOL HD 100aspirin 7aspirin buffered (cal carb-magcarb-mag oxide) 7aspirin-dipyridamole 103ASSESS FULL RANGE PEAKFLOW METER 109ASSESS LOW RANGE PEAKFLOW METER 109ASSESS PEAK FLOW METERFULL RANGE 109ASSESS PEAK FLOW METERLOW RANGE 109ASTAGRAF XL 114ASTHMA CHECK METER-ZONESYSTEM 109ASTHMAMENTOR 109ATABEX DHA 120ATACAND 46ATACAND HCT 46atenolol 72

atenolol & chlorthalidone 47ATIVAN 18atomoxetine hcl 1,2atorvastatin calcium 43atovaquone 15atovaquone-proguanil hcl 48ATRIPLA 66ATROVENT 119ATROVENT HFA 20AUBAGIO 129AUGMENTIN 126AUGMENTIN ES-600 126AUGMENTIN XR 127AUSTEDO 129AVALIDE 47AVANDIA 34AVAPRO 46AVAR-E LS 82AVASTIN 52AVEED 13AVODART 102AVONEX 129AVONEX PEN 129AXERT 110azacitidine 51AZACTAM 14AZASITE 121AZATHIOPRINE 114azathioprine 114azelastine hcl 119azelastine hcl (ophth) 123AZILECT 61azithromycin 108AZOPT 123aztreonam 14AZULFIDINE 100AZULFIDINE EN-TABS 100BACIGUENT 83bacitracin (ophthalmic) 121bacitracin (topical) 84bacitracin zinc 84bacitracin-poly-neomycin-hc

123bacitracin-polymyxin b 84bacitracin-polymyxin b(ophth) 121baclofen 118

BACTRIM 15BACTRIM DS 15BACTROBAN 84balsalazide disodium 100BANZEL 23BARACLUDE 70BAVENCIO 52BELEODAQ 55BELSOMRA 106BELVIQ XR 1BENADRYL ALLERGY 40BENADRYL ALLERGYCHILDRENS 40benazepril &hydrochlorothiazide 47benazepril hcl 45BENDEKA 49BENLYSTA 115BENTYL 133BENZAC AC WASH 82BENZACLIN 82BENZACLIN WITH PUMP 82BENZAMYCIN 82BENZEFOAM 82benzonatate 81benzoyl peroxide 82BENZOYL PEROXIDE 82benzoyl peroxide 82benzoyl peroxide-erythromycin 82benztropine mesylate 60BERINERT 102BESPONSA 52BETAGAN 120betamethasone dipropionate(topical) 87betamethasone dipropionateaugmented 88betamethasone sod phosphate &acetate 79betamethasone valerate 88BETAPACE 72BETAPACE AF 72BETASERON 129betaxolol hcl 72betaxolol hcl (ophth) 121bethanechol chloride 136BETHKIS 3bexarotene 58

Index 2

BEXSERO 137BIAXIN 108bicalutamide 53BICILLIN C-R 127BICILLIN L-A 126BICNU 49BIMATOPROST 124bisacodyl 108bisacodyl-peg 3350-pot chloride-sod bicarb-sod chloride 107bismuth subsalicylate 37bisoprolol &hydrochlorothiazide 47bisoprolol fumarate 72BIVIGAM 125bleomycin sulfate 54BLEPH-10 121BLINCYTO 52BONIVA 95BOOSTRIX 132BOSULIF 55BOTOX 120BPROTECTED PEDIA TRI-VITE 116BREO ELLIPTA 21BREVICON-28 77BRILINTA 103brimonidine tartrate 121BRINTELLIX 29BRISDELLE 131BRIVIACT 23bromfenac sodium (ophth) 123bromocriptine mesylate 61brompheniramine &phenyleph 81brompheniramine &pseudoeph 81budesonide 79budesonide (inhalation) 20budesonide (nasal) 119BUFFERIN 7BUFFERIN LOW DOSE 7bumetanide 94BUMEX 94BUPRENEX 12buprenorphine hcl 12buprenorphine hcl-naloxone hcldihydrate 12bupropion hcl 27

bupropion hcl (smokingdeterrent) 130buspirone hcl 18busulfan 49BUSULFEX 50butalbital-aspirin-caffeinew/cod 11BUTISOL SODIUM 105butorphanol tartrate 12BYDUREON 34BYDUREON PEN 34BYETTA 34cabergoline 97CABOMETYX 56CADUET 74CALAMINE 92CALAN 73CALAN SR 73CALCI-CHEW 112calcipotriene 86calcitonin (salmon) 95calcitriol 96CALCIUM 112calcium & phosphorus w/vitamin d 112calcium acetate (phosphatebinder) 101CALCIUM CARBONATE 14calcium carbonate 112calcium carbonate(antacid) 14calcium carbonate-cholecalciferol 112calcium carbonate-ergocalciferol 112calcium carbonate-vitamind 112calcium citrate 112CALCIUM CITRATEMALATE/VITAMIN D 112calcium citrate-vitamin d 112CALCIUM GLUCONATE 112calcium polycarbophil 106calcium w/ vitamin d 112CAMPATH 52CAMPTOSAR 60CANCIDAS 39candesartan cilexetil 46candesartan cilexetil-hydrochlorothiazide 47

CAPASTAT SULFATE 49CAPRELSA 56captopril 45captopril &hydrochlorothiazide 47CARAC 85CARAFATE 134CARBAGLU 96carbamazepine 23carbamide peroxide (otic) 124CARBATROL 24carbidopa 60carbidopa-levodopa 61carbinoxamine maleate 41carboplatin 50CARDIZEM 73CARDIZEM CD 73CARDIZEM LA 73CARDURA 46carisoprodol 118CARNITOR 96carteolol hcl (ophth) 121carvedilol 72carvedilol phosphate 72CASODEX 53caspofungin acetate 39CASPOFUNGIN ACETATE 39CATAPRES 46CATAPRES-TTS-1 46CATAPRES-TTS-2 46CATAPRES-TTS-3 46CAYSTON 14cefaclor 76cefadroxil 75cefazolin sodium 75cefdinir 76CEFEPIME 77cefepime hcl 77cefixime 76cefoxitin sodium 76cefpodoxime proxetil 76cefprozil 76ceftazidime 76CEFTIN 76ceftriaxone sodium 76,77cefuroxime axetil 76

Index 3

cefuroxime sodium 76CELEBREX 4celecoxib 5CELESTONE-SOLUSPAN 79CELEXA 28CELLCEPT 114CELLCEPTINTRAVENOUS 114CELONTIN 27CENTANY 84CENTRUM SPECIALISTPRENATAL 116cephalexin 76CERDELGA 103CEREBYX 26CEREZYME 103CESAMET 38cetirizine hcl 41cetirizine-pseudoephedrine 81cevimeline hcl 116CHANTIX 130CHANTIX CONTINUINGMONTHPAK 130CHANTIX STARTING MONTHPAK 130chenodiol 99CHILDRENS ADVIL 5CHILDRENS MOTRIN 5CHILDRENS PLUS COLD 81CHLOR-TRIMETON 40chloramphenicol sodiumsuccinate 16chlordiazepoxide-amitriptyline

128chlorhexidine gluconate (mouth-throat) 116chloroquine phosphate 48chlorothiazide 94chlorpheniramine &phenylephrine 81chlorpheniramine maleate 40chlorpromazine hcl 64chlorthalidone 94chlorzoxazone 118cholecalciferol 139cholestyramine 42cholestyramine light 42choline fenofibrate 43chorionic gonadotropin 95ciclopirox 84

ciclopirox olamine 84cidofovir 69cilostazol 103CILOXAN 121cimetidine 133CIMZIA 100CIMZIA STARTER KIT 100CINQAIR 19CINRYZE 102CIPRO 99CIPRO I.V.-IN D5W 99CIPRO XR 99CIPRODEX 125ciprofloxacin 99ciprofloxacin hcl 99ciprofloxacin hcl (ophth) 121ciprofloxacin in d5w 99ciprofloxacin-ciprofloxacinhcl 99cisplatin 50citalopram hydrobromide 28CITRUCEL FIBERLAXATIVE 106cladribine 51CLARINEX 41clarithromycin 109CLARITIN 41CLARITIN REDITABS 41CLARITIN-D 24 HOUR 81CLASSIC PRENATAL 116clemastine fumarate 41CLEOCIN 16,138CLEOCIN IN D5W 16CLEOCIN PHOSPHATE 16CLEOCIN-T 82CLIMARA 98CLINDAGEL 82clindamycin hcl 16clindamycin palmitatehydrochloride 16clindamycin phosphate 16clindamycin phosphate(topical) 82clindamycin phosphate ind5w 16clindamycin phosphatevaginal 138clindamycin phosphate-benzoylperoxide 83

clindamycin phosphate-benzoylperoxide (refrigerate) 83clobetasol propionate 88clobetasol propionate emollientbase 88clobetasol propionateemulsion 88CLOBEX 88clofarabine 51CLOLAR 51clomipramine hcl 31clonazepam 22,23clonidine hcl 46clonidine hcl (adhd) 2clopidogrel bisulfate 103clorazepate dipotassium 18clotrimazole 115clotrimazole (topical) 84clotrimazole vaginal 138clotrimazole w/betamethasone 84clozapine 64CLOZAPINE ODT 64CLOZARIL 64COARTEM 48COGENTIN 60COLACE 108COLAZAL 100COLCHICINE 102colchicine w/ probenecid 102COLCRYS 102COLESTID 42COLESTID FLAVORED 42colestipol hcl 42colistimethate sodium 14COLY-MYCIN M 14COLYTE-FLAVOR PACKS 107COMBIVENT RESPIMAT 21COMBIVIR 66COMETRIQ 56COMPLERA 66COMTAN 60CONCERTA 2CONDYLOX 92COPAXONE 129COPEGUS 70CORDARONE 19COREG 72

Index 4

COREG CR 72CORGARD 72CORLANOR 75CORTEF 79CORTENEMA 13cortisone acetate 79CORZIDE 47COSENTYX 86COSENTYX SENSOREADYPEN 86COSMEGEN 54COSOPT 121COTELLIC 56COUMADIN 22COZAAR 46CREON 93CRESEMBA 39,40CRESTOR 43CRIXIVAN 66cromolyn sodium 19cromolyn sodium(mastocytosis) 100cromolyn sodium (nasal) 119cromolyn sodium (ophth) 123CUBICIN 16CUBICIN RF 16CUPRIMINE 113CUTIVATE 88CUVITRU 125CVS NATURAL FIBERSUPPLEMENT 106CVS OMEPRAZOLE 134CVS PRENATAL 116CVS PRENATALMULTI+DHA 116cyclobenzaprine hcl 118cyclopentolate hcl 121CYCLOPHOSPHAMIDE 50CYCLOSET 34cyclosporine 114cyclosporine modified (formicroemulsion) 114CYKLOKAPRON 105CYMBALTA 29cyproheptadine hcl 42CYRAMZA 52CYSTAGON 101CYSTARAN 123

cytarabine 51CYTOMEL 132CYTOTEC 135CYTOVENE 69D.H.E. 45 110dacarbazine 58DACOGEN 51DAKLINZA 70DALIRESP 20danazol 13DANTRIUM 119dantrolene sodium 119dapsone 16DAPTACEL 132daptomycin 16DARAPRIM 48DARZALEX 52daunorubicin hcl 54DAYPRO 5DDAVP 97DEBROX 125decitabine 51DELESTROGEN 98DELZICOL 100DEMADEX 94demeclocycline hcl 131DEMEROL 7,8DEMSER 46DENAVIR 87DEPACON 27DEPAKENE 27DEPAKOTE 27DEPAKOTE ER 27DEPAKOTE SPRINKLES 27DEPEN TITRATABS 113DEPO-MEDROL 79DEPO-PROVERA 53DEPO-PROVERACONTRACEPTIVE 78DERMA-SMOOTHE/FSBODY 88DERMA-SMOOTHE/FSSCALP 88DERMATOP 88DERMOTIC 125DESCOVY 66desipramine hcl 31

desloratadine 41desmopressin acetate 97desmopressin acetaterefrigerated 97desmopressin acetate spray 97desmopressin acetate sprayrefrigerated 97DESOGEN 77desogestrel & ethinylestradiol 77desogestrel-ethinyl estradiol(biphasic) 77desonide 88DESOWEN 89desoximetasone 89DESOXYN 1DESQUAM-X WASH 83DESVENLAFAXINE ER 29desvenlafaxine succinate 29DETROL 136DETROL LA 136dexamethasone 79dexamethasone sodiumphosphate 79dexamethasone sodiumphosphate (ophth) 123DEXEDRINE 1DEXILANT 134dexmethylphenidate hcl 2dexrazoxane 59dextroamphetamine sulfate 1dextrose 120DEXTROSE ANHYDROUS 120dextrose in lactated ringers 112dextrose w/ sodiumchloride 112DIABETA 36DIAMOX 93DIASTAT ACUDIAL 23DIASTAT PEDIATRIC 23diazepam 18DIAZEPAM 23DIAZEPAM RECTAL GEL 23DIBENZYLINE 46diclofenac potassium 5diclofenac sodium 5diclofenac sodium (actinickeratoses) 86diclofenac sodium (ophth) 123diclofenac sodium (topical) 83

Index 5

diclofenac w/ misoprostol 5dicloxacillin sodium 127dicyclomine hcl 133didanosine 66diethylpropion hcl 1DIETHYLPROPION HCL 1diethylpropion hcl 1DIFFERIN 83DIFICID 109diflorasone diacetate 89DIFLUCAN 40diflunisal 7DIGOXIN 74digoxin 74dihydroergotaminemesylate 110DIHYDROERGOTAMINEMESYLATE 110DILANTIN-125 26DILAUDID 8DILAUDID-HP 8diltiazem hcl 73diltiazem hcl coated beads 73diltiazem hcl extended releasebeads 73DIMETAPP COLD &ALLERGY 81DIOVAN 46DIOVAN HCT 47DIPENTUM 100diphenhydramine hcl 41diphenhydramine-phenylephrine-acetaminophen 81diphenoxylate w/ atropine 37DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC 132DIPROLENE 89DIPROLENE AF 89dipyridamole 103disopyramide phosphate 19disulfiram 127DITROPAN XL 136divalproex sodium 27DIVIGEL 98dobutamine hcl 139docetaxel 59DOCETAXEL 59docusate calcium 108

docusate sodium 108DOCUSOL MINI 108DOCUSOL PLUS MINI-ENEMA 108dofetilide 19DOLOPHINE 8donepezil hydrochloride 128dorzolamide hcl 123dorzolamide hcl-timololmaleate 121DOVONEX 86doxazosin mesylate 46doxepin hcl 31DOXIL 54doxorubicin hcl 55doxorubicin hcl liposomal 55doxycycline(monohydrate) 131,132doxycycline hyclate 132DRISDOL 139dronabinol 38drospirenone-ethinylestradiol 77DROXIA 104DUAC 83DUETACT 32DULCOLAX 108DULERA 21duloxetine hcl 30DUOPA 61DURAGESIC 8DUREZOL 123dutasteride 102dutasteride-tamsulosinhcl 102DYAZIDE 94EC-NAPROSYN 5econazole nitrate 84ECOTRIN REGULARSTRENGTH 7ED CHLORPED 40ED CHLORPED D 81EDURANT 67EFFEXOR XR 30EFFIENT 103EFUDEX 86ELAVIL 31ELDEPRYL 61ELELYSO 103

ELESTAT 123ELIDEL 92ELIGARD 53ELIQUIS 22ELITEK 58ELLA 78ELLENCE 55ELOCON 89EMCYT 53EMEND 39EMEND TRIPACK 39EMFLAZA 79EMPLICITI 52EMSAM 28EMTRIVA 67enalapril maleate 45enalapril maleate &hydrochlorothiazide 47ENBREL 7ENBREL SURECLICK 7ENEMEEZ MINI 108ENEMEEZ PLUS 108ENFAMIL EXPECTA 116ENGERIX-B 137enoxaparin sodium 22entacapone 60entecavir 70ENTOCORT EC 79ENTRE-HIST PSE 81ENTRESTO 74ENTYVIO 100ENVARSUS XR 114EPCLUSA 70epinastine hcl (ophth) 124epinephrine (anaphylaxis) 139EPIPEN 2-PAK 139EPIPEN-JR 2-PAK 139epirubicin hcl 55EPIVIR 67EPIVIR HBV 70eplerenone 48EPOGEN 104eprosartan mesylate 46EPZICOM 67EQ OMEPRAZOLE 134EQL CALCIUM/VITAMIN D 112

Index 6

EQL OMEPRAZOLE 134EQL PRENATALFORMULA 116EQUALACTIN 106EQUETRO 62ERAXIS 39ERBITUX 52ergocalciferol 139ergoloid mesylates 130ergotamine tartrate 110ergotamine w/ caffeine 110ERIVEDGE 53ERWINAZE 58erythromycin (acne aid) 83erythromycin (ophth) 121erythromycin base 109erythromycinethylsuccinate 109erythromycin lactobionate 109erythromycin stearate 109ESBRIET 131escitalopram oxalate 28esomeprazole magnesium 134esomeprazole sodium 134estradiol 98estradiol & norethindroneacetate 98estradiol vaginal 139estradiol valerate 98estropipate 98ethambutol hcl 49ethosuximide 27ethynodiol diacet & ethestrad 77etodolac 5ETOPOPHOS 59etoposide 59EVAC 106EVISTA 96EVOCLIN 83EVOMELA 50EVOTAZ 67EVOXAC 116EX-LAX 108EXELON 128exemestane 53EXJADE 38EXONDYS 51 120

EXTAVIA 129EXTINA 84EYEAID IRRIGATINGSOLUTION 124ezetimibe 44EZFE FORTE 116FABRAZYME 96famciclovir 71famotidine 133,134FAMVIR 71FANAPT 62FARESTON 53FARYDAK 56FASLODEX 53fat emulsion 120FAZACLO 64FC FEMALE CONDOM 109FC2 FEMALE CONDOM 109felbamate 26FELBATOL 26FELDENE 5felodipine 73FEMARA 53FEMCON FE 77FEMHRT LOW DOSE 98fenofibrate 43fenofibrate micronized 43fentanyl 8fentanyl citrate 8FER-IN-SOL 104FERRIPROX 38FERROUS GLUCONATE104ferrous sulfate 104FERROUS SULFATE 104ferrous sulfate 104FERROUS SULFATE 105ferrous sulfate 105FERROUS SULFATE 105ferrous sulfate 105FETZIMA 30FETZIMA TITRATIONPACK 30FEVERALL INFANTS 7FIBERCON 106FINACEA 93finasteride 102FIORINAL/CODEINE #3 11

FIRAZYR 102FIRMAGON 53FLAGYL 14flavoxate hcl 137FLEBOGAMMA DIF 125flecainide acetate 19FLECTOR 83FLEET BISACODYL 108FLEET LIQUID GLYCERINSUPPOSITORIES 107FLOMAX 102FLONASE ALLERGYRELIEF 119FLONASE ALLERGY RELIEFCHILDRENS 119FLOVENT DISKUS 20FLOVENT HFA 20FLOXIN OTIC 125fluconazole 40fluconazole in dextrose 40fluconazole in nacl 40flucytosine 39fludarabine phosphate 51fludrocortisone acetate 81FLUMADINE 71flunisolide (nasal) 119fluocinolone acetonide 89fluocinolone acetonide(otic) 125fluocinonide 89fluocinonide emulsified base 89fluorometholone (ophth) 123fluorouracil 51FLUOROURACIL 86fluorouracil (topical) 86fluoxetine hcl 28fluoxetine hcl (PMDD) cap 10 mg,20 mg 130fluoxymesterone 13fluphenazine decanoate 64fluphenazine hcl 65flurbiprofen 5flurbiprofen sodium 124flutamide 53fluticasone propionate 89fluticasone propionate(nasal) 119fluvastatin sodium 43fluvoxamine maleate 28

Index 7

FML LIQUIFILM 123FOCALIN 2FOCALIN XR 2folic acid 104FOLIC ACID 104folic acid 104FOLOTYN 51fondaparinux sodium 22FORFIVO XL 28FORTAMET 33FORTAZ 77FORTEO 95FORTICAL 95FOSAMAX 95fosamprenavir calcium 67fosinopril sodium 45fosinopril sodium &hydrochlorothiazide 47fosphenytoin sodium 26FOSRENOL 101FRAGMIN 22furosemide 94FUSILEV 59FUZEON 67FYCOMPA 22gabapentin 24GABITRIL 26galantamine hydrobromide 128GAMASTAN S/D 125GAMMAGARD LIQUID 125GAMMAKED 125GAMMAPLEX 125GAMUNEX-C 125ganciclovir sodium 69GARDASIL 137GARDASIL 9 137GAS-X EXTRA STRENGTH 99GASTROCROM 100gatifloxacin (ophth) 122GATTEX 101gauze pads 2" X 2" 109GAZYVA 52GEL-KAM ORAL CARERINSE 116GELUSIL 14gemcitabine hcl 51gemfibrozil 43

GEMZAR 51GENOTROPIN 96GENOTROPINMINIQUICK 96gentamicin in saline 3gentamicin sulfate 3gentamicin sulfate(ophth) 122gentamicin sulfate (topical) 84GENVOYA 67GEODON 62GILENYA 129GILOTRIF 56glatiramer acetate 129GLEEVEC 56GLEOSTINE 50glimepiride 36glipizide 36glipizide-metformin hcl 32GLUCAGEN HYPOKIT 33GLUCAGON EMERGENCYKIT 33GLUCOPHAGE 33GLUCOPHAGE XR 33GLUCOTROL 36GLUCOTROL XL 36,37GLUCOVANCE 32glyburide 37glyburide micronized 37glyburide-metformin 32glycopyrrolate 133GLYNASE 37GLYSET 31GNP CALAMINE 92GNP DAILY PRENATAL 116GNP OMEPRAZOLE 134GNP PRENATAL 116GNP VITAMIN D-400 112GOLYTELY 107GOODSENSE PRENATALVITAMINS 116granisetron hcl 38GRANIX 104GRIS-PEG 39griseofulvin microsize 39griseofulvin ultramicrosize 39guaifenesin-codeine 81guanfacine hcl 46

guanfacine hcl (adhd) 2GUANIDINE HCL 48GYNE-LOTRIMIN 138H.P. ACTHAR 95HALAVEN 59HALCION 105HALDOL 63HALDOL DECANOATE 100 63HALDOL DECANOATE 50 63halobetasol propionate 89haloperidol 63haloperidol decanoate 63haloperidol lactate 63HARVONI 70HAVRIX 137heparin sodium (porcine) 22HEPSERA 70HERCEPTIN 52HETLIOZ 106HEXALEN 50HIBERIX 137HIPREX 136HIZENTRA 125HM CALAMINE 92HM OMEPRAZOLE 134HM ONE DAILY PRENATALCOMBO 116HM PRENATAL 116HUMALOG 35HUMALOG JUNIORKWIKPEN 35HUMALOG KWIKPEN 35HUMALOG MIX 50/50 35HUMALOG MIX 50/50KWIKPEN 35HUMALOG MIX 75/25 35HUMALOG MIX 75/25KWIKPEN 35HUMATROPE 96HUMATROPE COMBOPACK 96HUMIRA 4HUMIRA PEDIATRIC CROHNSDISEASE STARTER PACK 3HUMIRA PEN 3HUMIRA PEN-CROHNSDISEASESTARTER 4HUMIRA PEN-PSORIASISSTARTER 4HUMULIN 70/30 35

Index 8

HUMULIN 70/30 KWIKPEN 35HUMULIN N 35HUMULIN N KWIKPEN 35HUMULIN R 35HUMULIN R U-500(CONCENTRATED) 35HUMULIN R U-500KWIKPEN 35HYCAMTIN 60hydralazine hcl 48HYDREA 58hydrochlorothiazide 94HYDROCIL INSTANT 106hydrocodone polistirex-chlorpheniramine polistirex 81hydrocodone w/homatropine 81hydrocodone-acetaminophen 11hydrocodone-ibuprofen 12hydrocortisone 79hydrocortisone (intrarectal) 13hydrocortisone (rectal) 13hydrocortisone (topical) 90hydrocortisone butyrate 90hydrocortisone butyratehydrophilic lipo base 90hydrocortisone valerate 90hydrocortisone w/aceticacid 125hydrocortisone-aloe vera 90hydromorphone hcl 8hydroxychloroquine sulfate 48HYDROXYPROGESTERONECAPROATE 53hydroxyurea 58hydroxyzine hcl 18hydroxyzine pamoate 18HYQVIA 126HYVEE ADVANCED ANTACIDMAXIMUM STRENGTH 14HYZAAR 47ibandronate sodium 95IBRANCE 56ibuprofen 5ICLUSIG 56IDAMYCIN PFS 55idarubicin hcl 55IFEX 50ifosfamide 50

IFOSFAMIDE 50ILARIS 4ILEVRO 124imatinib mesylate 56IMBRUVICA 56IMFINZI 52imipenem-cilastatin 15imipramine hcl 31imipramine pamoate 31imiquimod 92IMITREX 110,111IMITREX STATDOSEREFILL 110IMITREX STATDOSESYSTEM 110,111IMODIUM A-D 37IMOVAX RABIES(H.D.C.V.) 137IMURAN 114INCRELEX 96indapamide 94INDERAL LA 72indomethacin 5INFANRIX 133INFANTS ADVIL 5INFLECTRA 100INLYTA 56INSPRA 48INSULIN SYRINGES AND PENNEEDLES 109INTELENCE 67INTRON A 58INTRON A W/DILUENT 58INTUNIV 2INVANZ 15INVEGA 63INVEGA SUSTENNA 62INVEGA TRINZA 63INVIRASE 67INVOKAMET 32INVOKAMET XR 32INVOKANA 36IOPIDINE 121IPOL INACTIVATED IPV 137ipratropium bromide 20ipratropium bromide(nasal) 119ipratropium-albuterol 21

IPRIVASK 22irbesartan 46irbesartan-hydrochlorothiazide

47IRESSA 56irinotecan hcl 60IRON CHEWS PEDIATRIC 105irrigation solutions,physiological 115ISENTRESS 67ISENTRESS HD 67isoniazid 49isoniazid & rifampin 49ISOPTO CARPINE 121ISORDIL TITRADOSE 17isosorbide dinitrate 17isosorbide mononitrate 17isotretinoin 83ISTODAX 56ISTODAX (OVERFILL) 56itraconazole 40ivermectin 14IXEMPRA KIT 59IXIARO 137JADENU 38JAKAFI 56JALYN 102JANUMET 32JANUMET XR 32JANUVIA 34JARDIANCE 36JENTADUETO 32JENTADUETO XR 32JEVTANA 59JUXTAPID 44K-TAB 113KADCYLA 52KADIAN 8,9KALBITOR 103KALETRA 67KALYDECO 131KANUMA 96KAPVAY 2KAYEXALATE 115KAZANO 32KEFLEX 76KENALOG 90

Index 9

KENALOG-10 79KENALOG-40 79KEPIVANCE 58KEPPRA 24KEPPRA XR 24ketoconazole 40ketoconazole (topical) 84ketoprofen 5ketorolac tromethamine 6ketorolac tromethamine(ophth) 124ketotifen fumarate (ophth) 124KEYTRUDA 52KHEDEZLA 30KINERET 4KINRIX 133KISQALI 56KISQALI FEMARA 200DOSE 55KISQALI FEMARA 400DOSE 55KISQALI FEMARA 600DOSE 55KITABIS PAK 3KLARON 83KLONOPIN 23KLS OMEPRAZOLE 134KOMBIGLYZE XR 32KONSYL 106,107KONSYL-D 107KORLYM 33KP PRENATALMULTIVITAMINS 116KPN PRENATAL 116KUVAN 97KYNAMRO 42KYPROLIS 56labetalol hcl 72LAC-HYDRIN 91LAC-HYDRIN TWELVE 91lactated ringer's 113lactic acid (ammoniumlactate) 91lactulose 107lactulose (encephalopathy) 101LAMICTAL 24LAMICTAL CHEWABLEDISPERSIBLE 24LAMICTAL XR 24

LAMISIL 39LAMISIL AT 85LAMISIL AT JOCK ITCH 85LAMISIL AT SPRAY 85lamivudine 67lamivudine (hbv) 70lamivudine-zidovudine 67lamotrigine 24LANOXIN 74lansoprazole 135lanthanum carbonate 101LANTUS 35LANTUS SOLOSTAR 35LARTRUVO 52LASIX 94latanoprost 124LATEX CONDOMS 109LATUDA 62LAZANDA 9leflunomide 6LEMTRADA 129LENVIMA 10 MG DAILYDOSE 56LENVIMA 14 MG DAILYDOSE 56LENVIMA 18 MG DAILYDOSE 56LENVIMA 20 MG DAILYDOSE 56LENVIMA 24 MG DAILYDOSE 56LENVIMA 8 MG DAILYDOSE 56LENZAPATCH 92LESCOL XL 43LETAIRIS 75letrozole 53leucovorin calcium 59LEUKERAN 50LEUKINE 104leuprolide acetate 53levalbuterol hcl 21LEVAQUIN 99LEVEMIR 35LEVEMIR FLEXTOUCH 35LEVETIRACETAM 24levetiracetam 24levetiracetam in sodiumchloride 24

levobunolol hcl 121levocarnitine (metabolicmodifiers) 97levocetirizine dihydrochloride41levofloxacin 99levofloxacin (ophth) 122levofloxacin in d5w 99LEVOLEUCOVORIN 59levoleucovorin calcium 59levonorgestrel & ethestradiol 77levonorgestrel (emergencyoc) 78levonorgestrel-eth estradiol(triphasic) 77levonorgestrel-ethinyl estradiol(91-day) 77levothyroxine sodium 132LEXAPRO 29LEXIVA 68LIBRAX 133lidocaine 92lidocaine hcl 92lidocaine hcl (local anesth.) 108lidocaine hcl (mouth-throat) 115lidocaine-prilocaine 92LIDOCAREARM/NECK/LEG 92LIDOCAREBACK/SHOULDER 92LIDODERM 92LINCOCIN 16lincomycin hcl 16lindane 93linezolid 17LINEZOLID 17linezolid 17LINZESS 101liothyronine sodium 132LIPITOR 43lisinopril 45lisinopril &hydrochlorothiazide 47LITHIUM 62lithium carbonate 62LITHIUM CARBONATE 62lithium carbonate 62LITHOBID 62LOCOID 90LOCOID LIPOCREAM 90

Index 10

LOCORT 11-DAY 79LOCORT 7-DAY 79LODOSYN 60LOMAIRA 1LOMOTIL 37LONSURF 55loperamide hcl 37LOPID 43lopinavir-ritonavir 68LOPRESSOR 72LOPRESSOR HCT 47LOPROX 85LOPROX SHAMPOO 85loratadine 41loratadine &pseudoephedrine 81lorazepam 18losartan potassium 46losartan potassium &hydrochlorothiazide 47LOSEASONIQUE 77LOTEMAX 123LOTENSIN 45LOTENSIN HCT 47LOTREL 47LOTRIMIN AF 85LOTRIMIN AF FOR HER 85LOTRIMIN AF JOCK ITCH 85LOTRISONE 85LOTRONEX 101lovastatin 43LOVAZA 42LOVENOX 22loxapine succinate 64LUMIGAN 124LUMIZYME 97LUPRON DEPOT (1-MONTH) 54LUPRON DEPOT (3-MONTH) 54LUPRON DEPOT (4-MONTH) 54LUPRON DEPOT (6-MONTH) 54LUPRON DEPOT-PED (1-MONTH) 96LUPRON DEPOT-PED (3-MONTH) 96LUXIQ 90LYNPARZA 57

LYRICA 24,25LYSODREN 54LYSTEDA 105M-M-R II 137MACROBID 136MACRODANTIN 136mafenide acetate 87MAG64 113MAGDELAY 113magnesium sulfate 113MALARONE 48malathion 93maprotiline hcl 28MARINOL 38MARPLAN 28MARQIBO 59MATULANE 58MAVIK 45MAXALT 111MAXALT-MLT 111MAXIPIME 77MAXITROL 123MAXZIDE 94MAXZIDE-25 94meclizine hcl 38MEDROL 79,80MEDROL DOSEPAK 79medroxyprogesteroneacetate 127medroxyprogesterone acetate(contraceptive) 78mefenamic acid 6mefloquine hcl 48MEGACE ES 127MEGACE ORAL 54megestrol acetate 54megestrol acetate(appetite) 127MEIJER CALAMINE 92MEKINIST 57meloxicam 6melphalan 50melphalan hcl 50memantine hcl 128MENACTRA 137MENOMUNE-A/C/Y/W-135

137MENVEO 137

meperidine hcl 9MEPHYTON 139MEPRON 15mercaptopurine 51meropenem 16MERREM 16mesalamine 100MESALAMINE DR 100mesalamine w/ cleanser 100mesna 59MESNEX 59MESTINON 48MESTINON TIMESPAN 48METADATE CD 2METAMUCIL 107METAMUCIL MULTIHEALTHFIBER 107METAMUCIL ORIGINALTEXTURE 107METAMUCIL SMOOTHTEXTUREFIBER SINGLES107metaxalone 118metformin hcl 33methadone hcl 9METHADOSE 9METHADOSE SUGAR-FREE 9methamphetamine hcl 1methazolamide 94methenamine hippurate 136methimazole 132methocarbamol 118methotrexate sodium 51methoxsalen rapid 86methscopolamine bromide 133methylcellulose (laxative) 107methylergonovine maleate 125methylphenidate hcl 2,3methylprednisolone 80methylprednisolone acetate 80methylprednisolone sodsucc 80methyltestosterone 13metoclopramide hcl 100metolazone 95metoprolol &hydrochlorothiazide 47metoprolol succinate 72metoprolol tartrate 72

Index 11

METOPROLOL TARTRATE 72METROCREAM 93METROGEL 93METROGEL-VAGINAL 138METROLOTION 93metronidazole 14,15metronidazole (topical) 93metronidazole in nacl 15metronidazole vaginal 138MEVACOR 43mexiletine hcl 19MIACALCIN 95MICATIN 85miconazole nitrate (topical) 85miconazole nitrate vaginal 138MICRO-K 113MICROLIFE DIGITAL PEAKFLOW METER 109MICROZIDE 95midodrine hcl 139miglitol 31MIGRANAL 110MILK OF MAGNESIACONCENTRATE 107MINI WRIGHT AFS PEAKFLOWMETER LOWRANGE 110MINI WRIGHT PEAK FLOWMETER 110MINIPRESS 46MINOCIN 132minocycline hcl 132minoxidil 48MIRALAX 107MIRAPEX 61mirtazapine 27MIRVASO 93misoprostol 135mitomycin 55mitoxantrone hcl 55MOBIC 6modafinil 3MODICON 77moexipril hcl 45moexipril-hydrochlorothiazide

47molindone hcl 64mometasone furoate 90

MONISTAT 3 138MONISTAT 3 COMBINATIONPACK 138MONISTAT 7 SIMPLYCURE 138MONISTAT SOOTHING CAREITCH RELIEF 91MONODOX 132montelukast sodium 20morphine sulfate 9,10MORPHINE SULFATE 10morphine sulfate 10MOTRIN INFANTS DROPS 6MOVANTIK 101moxifloxacin hcl (ophth) 122MOZOBIL 105MS CONTIN 10MULTAQ 19MULTI PRENATAL 116mupirocin 84mupirocin calcium (topical) 84MURO 128 124MUSTARGEN 50MYALEPT 97MYAMBUTOL 49MYCAMINE 39MYCOBUTIN 49mycophenolate mofetil 114mycophenolate mofetilhcl 114mycophenolate sodium 114MYFORTIC 114MYLOTARG 52MYRBETRIQ 136MYSOLINE 25nabumetone 6nadolol 73nadolol &bendroflumethiazide 47nafcillin sodium 127naftifine hcl 85NAFTIN 85NAGLAZYME 97nalbuphine hcl 12naloxone hcl 38naltrexone hcl 38NAMENDA 128NAMENDA TITRATIONPAK 128

NAMENDA XR 128NAMENDA XR TITRATIONPACK 128naphazoline w/pheniramine 122NAPHCON-A 122NAPROSYN 6naproxen 6naproxen sodium 6naratriptan hcl 111NARDIL 28NASACORT ALLERGY24HR 119NASACORT ALLERGY 24HRCHILDRENS 119NASAL DECONGESTANT 119NASALCROM 119NAT-RUL PRENATALVITAMINS 116nateglinide 36NATPARA 95NAVELBINE 59NEBUPENT 15nefazodone hcl 29neomycin sulfate 3neomycin-bacitracin zn-polymyxin 122neomycin-polymy-dexameth 123neomycin-polymyxin-gramicidin

122neomycin-polymyxin-hc(otic) 125neomycin/polymyxin b gu 102NEORAL 114NERLYNX 57NESINA 34NEULASTA 104NEULASTA ONPRO KIT 104NEUPOGEN 104NEUPRO 61NEURONTIN 25NEVANAC 124NEVIRAPINE 68nevirapine 68NEXAFED SINUS PRESSURE+PAIN 81NEXAVAR 57NEXIUM 135NEXIUM I.V. 135

Index 12

niacin 139niacin (antihyperlipidemic) 44NIASPAN 44nicardipine hcl 73NICODERM CQ 130NICORETTE 130NICORETTE MINI 130NICORETTE STARTERKIT 130nicotine 130nicotine polacrilex 130NICOTINE TRANSDERMALSYSTEM 130NICOTROL INHALER 130NICOTROL NS 130nifedipine 74NILANDRON 54nilutamide 54nimodipine 74NINLARO 57NIPENT 58nisoldipine 74NITRO-DUR 17nitrofurantoin macrocrystal 136nitrofurantoin monohydmacro 136nitroglycerin 17,18NITROGLYCERIN LINGUAL17NITROLINGUALPUMPSPRAY 18NITROMIST 18NITROSTAT 18NIX CREME RINSE 93nizatidine 134NIZORAL 85NON-LATEX CONDOMS 109NOR-QD 78NORDITROPIN FLEXPRO 96norelgestromin-ethinylestradiol 78norethin acet & estrad-fe 77norethindrone & eth estradiol77norethindrone & ethinyl estradiol-fe 77norethindrone(contraceptive) 78norethindrone acet & ethestra 78norethindrone acetate 127

norethindrone acetate-ethinylestradiol 98norethindrone-eth estradiol(triphasic) 78norgestimate-ethinylestradiol 78norgestimate-ethinyl estradiol(triphasic) 78norgestrel & ethinylestradiol 78NORINYL 1+35 78NORPACE 19NORPRAMIN 31NORTHERA 139nortriptyline hcl 31NORVASC 74NORVIR 68NOXAFIL 40NUCALA 19NUEDEXTA 130NULOJIX 114NULYTELY/FLAVORPACKS 107NUPLAZID 62NUTROPIN AQ NUSPIN20 96NUVARING 78NYMALIZE 74nystatin 39nystatin (mouth-throat) 115nystatin (topical) 85nystatin-triamcinolone 85OCALIVA 99OCEAN NASAL SPRAY 119OCREVUS 129OCTAGAM 125octreotide acetate 98OCUFEN 124OCUFLOX 122ODEFSEY 68ODOMZO 53OFEV 131ofloxacin (ophth) 122ofloxacin (otic) 125olanzapine 64olanzapine-fluoxetine hcl 128olopatadine hcl 124olopatadine hcl (nasal) 119OLUX 91

OLUX-E 91OLYSIO 70OMECLAMOX-PAK 135omega-3-acid ethyl esters 42omeprazole 135OMEPRAZOLE 135omeprazole-sodiumbicarbonate 135,136OMNIPRED 123OMNITROPE 96ONCASPAR 58ondansetron 38ondansetron hcl 38ONE A DAY WOMENSPRENATAL1 116ONE-A-DAY WOMENSPRENATAL 117ONFI 23ONGLYZA 34ONIVYDE 60OPANA 10OPDIVO 52ophthalmic irrigationsolution 124OPSUMIT 75OPTIONS GYNOL IIVAGINALCONTRACEPTIVE

138ORAP 130ORAPRED ODT 80ORBACTIV 15ORENCIA 6ORENCIA CLICKJECT 6ORFADIN 97ORKAMBI 131ORTHO MICRONOR 79ORTHO TRI-CYCLEN 78ORTHO-CYCLEN 78ORTHO-NOVUM 1/35 78ORTHO-NOVUM 7/7/7 78oseltamivir phosphate 71OSENI 32OTEZLA 6OTREXUP 4OVACE PLUS WASH 87OVACE WASH 87oxacillin sodium 127oxaliplatin 50

Index 13

OXANDRIN 12oxandrolone 12oxaprozin 6oxazepam 19oxcarbazepine 25OXSORALEN ULTRA 86oxybutynin chloride 136oxycodone hcl 10oxycodone w/acetaminophen 12oxycodone-aspirin 12oxymorphone hcl 10oyster shell 112paclitaxel 59,60paliperidone 63PAMELOR 31PAMINE 133PAMINE FORTE 133PANCREAZE 93PANRETIN 86pantoprazole sodium 135PARAFON FORTE DSC 118parenteral electrolytes 113paricalcitol 97PARLODEL 61PARNATE 28paromomycin sulfate 3paroxetine hcl 29paroxetine mesylate(vasomotor) 131PATADAY 124PATANASE 119PAXIL 29PAXIL CR 29PEAK AIR PEAK FLOWMETERADULT/PEDIATRIC

110PEAK FLOW METER 110pediatric vitamins adc 116PEDVAX HIB 137peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 107peg 3350-potassium chloride-sodbicarbonate-sod chloride 107PEG-INTRON REDIPEN 70PEG-INTRON REDIPEN PAK4 70PEGANONE 26PEGASYS 70

PEGASYS PROCLICK 70PEGINTRON 70penicillin g potassium 126penicillin v potassium 126PENLAC NAIL LACQUER 85PENTAM 300 15pentoxifylline 103PEPCID 134PEPCID AC 134PEPCID AC MAXIMUMSTRENGTH 134PEPTO BISMOL 37PEPTO-BISMOL 37PEPTO-BISMOLINSTACOOL 37PEPTO-BISMOL MAXSTRENGTH 37PEPTO-BISMOL TO-GO 37PERIDEX 116perindopril erbumine 45PERJETA 52permethrin 93perphenazine 65perphenazine-amitriptyline

128PERSANTINE 103PERSONAL BEST FULLRANGE 110PERSONAL BEST LOWRANGE 110phenelzine sulfate 28phenobarbital 105phenoxybenzamine hcl 46phentermine hcl 1PHENYLHISTINE DH 81phenytoin 26phenytoin sodium 26phenytoin sodiumextended 26PHOSPHOLINE IODIDE 121phytonadione 139PICATO 86PIKO 1 ELECTRONIC 110pilocarpine hcl 121pilocarpine hcl (oral) 116pimozide 130pindolol 73pioglitazone hcl 34pioglitazone hcl-glimepiride 32

pioglitazone hcl-metforminhcl 33piperacillin sodium-tazobactamsodium 127piroxicam 6PLAN B ONE-STEP 78PLAQUENIL 48PLAVIX 103PLEGRIDY 129PLEGRIDY STARTERPACK 129PLETAL 103PLEXION CLEANSER 83POCKET PEAK FLOWMETER 110POCKETPEAK PEAK FLOWMETER LOW RANGE 110POCKETPEAK PEAK FLOWMETER/UNIVERSALRANGE 110POCKETPEAK PEAK FLOWMETER/UNIVERSAL RANGE 50-720 LPM 110podofilox 92polyethylene glycol 3350 107polymyxin b sulfate 17polymyxin b-trimethoprim 122polysaccharide ironcomplex 105POLYSPORIN 84POLYTRIM 122polyvinyl alcohol 120POMALYST 54PONSTEL 6PORTRAZZA 52potassium chloride 113POTASSIUM CHLORIDEER 113potassium chloride in dextrose &sodium chloride 113potassium chloridemicroencapsulated crystalser 113potassium citrate(alkalinizer) 101POTASSIUM IODIDE 113POTIGA 25PRADAXA 22PRALUENT 44pramipexole dihydrochloride 61PRANDIN 36prasugrel hcl 103

Index 14

PRAVACHOL 43pravastatin sodium 43prazosin hcl 46PRECOSE 31PRED FORTE 123prednicarbate 91prednisolone 80prednisolone acetate(ophth) 123prednisolone sodiumphosphate 80prednisone 80PREMARIN 99,139PREMPHASE 98PREMPRO 98PRENATAL 117PRENATAL FORMULA 117PRENATAL FORMULA A-FREE 117PRENATAL LOW IRON 117PRENATAL MULTI + DHA 117PRENATALMULTIVITAMIN 117PRENATAL MULTIVITAMIN +DHA 117PRENATAL MULTIVITAMINPLUS DHA 117PRENATAL ONE DAILY 117PRENATAL VITAMIN 117PRENATAL VITAMIN &MINERAL 117PRENATALVITAMIN/IRON 117PRENATAL VITAMINS 117PREVACID 135PREVACID 24HR 135PREVPAC 136PREZCOBIX 68PREZISTA 68PRIFTIN 49PRILOSEC 135PRILOSEC OTC 135PRIMAQUINE PHOSPHATE48primaquine phosphate 48PRIMAXIN IV 16primidone 25PRINIVIL 45PRISTIQ 30PRIVIGEN 125PROAIR HFA 21

PROAIR RESPICLICK 21probenecid 102PROCARDIA XL 74prochlorperazine 65prochlorperazine edisylate 65prochlorperazine maleate 65PROCRIT 104PROCTOCORT 13PROFE FORTE 117progesterone micronized 127PROGLYCEM 33PROGRAF 114PROLASTIN-C 131PROLEUKIN 58PROLIA 95PROMACTA 104promethazine hcl 42promethazine w/codeine 81promethazine-dm 81promethazine-phenylephrine-codeine 81PROMETRIUM 127propafenone hcl 19proparacaine hcl 122propranolol hcl 73propylthiouracil 132PROQUAD 137PROSCAR 102PROTONIX 135PROTOPIC 92protriptyline hcl 31PROVENTIL HFA 21PROVERA 127PROVIGIL 3PROZAC 29PROZAC WEEKLY 29pseudoephedrine hcl 120pseudoephedrine-ibuprofen 81psyllium 107PULMICORT 20PULMOZYME 131PURIXAN 51PX CALAMINE 92PX OMEPRAZOLE 135PX PRENATALMULTIVITAMINS 118

pyrantel pamoate 14pyrazinamide 49pyrethrins-piperonyl butoxide93pyridostigmine bromide 48,49pyridoxine hcl 140QC CALAMINE 92QC PRENATAL 118QSYMIA 1QUADRACEL 133QUALAQUIN 48quetiapine fumarate 64quinapril hcl 45quinapril-hydrochlorothiazide

47quinidine gluconate 19quinidine sulfate 19quinine sulfate 48QVAR 21RA CALAMINE 92RA OMEPRAZOLE 135RA ONE DAILY 118RA OYSTER SHELLCALCIUM/VITAMIN D 112RA PRENATAL 118RA PRENATALFORMULA/FOLICACID 118RABAVERT 137RADICAVA 120raloxifene hcl 96ramipril 45RANEXA 17ranitidine hcl 134RAPAMUNE 114,115rasagiline mesylate 61RASUVO 4RAVICTI 97RAYALDEE 97RAZADYNE 128RAZADYNE ER 128REBETOL 70REBIF 130REBIF REBIDOSE 129REBIF REBIDOSETITRATIONPACK 130REBIF TITRATION PACK 130RECLAST 95RECOMBIVAX HB 137RECTIV 13

Index 15

REFRESH PLUS 120REGLAN 100REGRANEX 93RELENZA DISKHALER 71RELISTOR 101REMERON 27REMERON SOLTAB 27REMICADE 100REMODULIN 74RENVELA 101repaglinide 36repaglinide-metformin hcl 33REPATHA 44REPATHA PUSHTRONEXSYSTEM 44REPATHA SURECLICK 45REQUIP 61REQUIP XL 61RESCRIPTOR 68RESTASIS 122RESTASIS MULTIDOSE 122RESTORIL 105RETIN-A 83RETIN-A MICRO 83RETIN-A MICRO PUMP 83RETROVIR 68RETROVIR IV INFUSION 68REVATIO 75REVLIMID 114REXULTI 66REYATAZ 68ribavirin 71ribavirin (hepatitis c) 70RID 93RIDAURA 4rifabutin 49RIFADIN 49rifampin 49RIFATER 49RIGHT STEP PRENATAL 118RILUTEK 120riluzole 120rimantadine hydrochloride 71RISACAL-D 112RISPERDAL 63RISPERDAL CONSTA 63

RISPERDAL M-TAB 63risperidone 63RITALIN 3RITALIN LA 3RITUXAN 52RITUXAN HYCELA 55rivastigmine 128rivastigmine tartrate 128rizatriptan benzoate 111ROBAXIN 118ROBAXIN-750 118ROBINUL 133ROBINUL FORTE 133ROCALTROL 97ropinirole hydrochloride 61rosuvastatin calcium 43ROTARIX 138ROTATEQ 138ROWASA 100ROXICODONE 10ROZEREM 106RUBRACA 57RUCONEST 103RYDAPT 57RYMED 81RYTARY 61RYTHMOL 19RYTHMOL SR 19SABRIL 26SALAGEN 116saline 119SAMSCA 98SANDIMMUNE 115SANDOSTATIN 98SANDOSTATIN LARDEPOT 98SANTYL 91SAPHRIS 64SB OMEPRAZOLE 135scopolamine 38SEASONIQUE 78SECTRAL 72selegiline hcl 61selenium sulfide 87SELSUN BLUE 87SELSUN BLUE DAILY 87

SELSUN BLUEMEDICATED 87SELSUN BLUEMOISTURIZING 87SELZENTRY 68sennosides 108SENSIPAR 97SEREVENT DISKUS 21SEROQUEL 64SEROSTIM 96sertraline hcl 29sevelamer carbonate 101SIGNIFOR 98SIGNIFOR LAR 98sildenafil citrate (pulmonaryhypertension) 75SILENOR 105SILIQ 86SILPHEN COUGH 41SILVADENE 87silver sulfadiazine 87simethicone 99SIMILAC PRENATAL EARLYSHIELD 118SIMPONI 4SIMPONI ARIA 4SIMULECT 115simvastatin 43,44SINEMET 61SINEMET CR 61SINGULAIR 20sirolimus 115SIRTURO 49SIVEXTRO 17SKELAXIN 118SLO-NIACIN 140SM CALAMINE 92SM OMEPRAZOLE 135SM ONE DAILYPRENATAL 118SM PRENATAL VITAMINS 118sodium bicarbonate 112sodium chloride 113sodium chloride (guirrigant) 102sodium chloride (inhalant) 82sodium chloride hypertonic 124sodium polystyrenesulfonate 115

Index 16

SOLARAZE 86SOLTAMOX 54SOLU-CORTEF 80SOLU-MEDROL 80SOMA 118SOMATULINE DEPOT 98SOMAVERT 96SONATA 106SORIATANE 86sotalol hcl 73sotalol hcl (afib/afl) 73Sotalol Hcl IV Soln 73SOTYLIZE 73SOVALDI 70SPIRIVA HANDIHALER 20SPIRIVA RESPIMAT 20spironolactone 94spironolactone &hydrochlorothiazide 94SPORANOX 40SPORANOX PULSEPAK 40SPRITAM 25SPRYCEL 57STAMARIL 138STARLIX 36stavudine 68STELARA 86,100STIOLTO RESPIMAT 21STIVARGA 57STRATTERA 2STRENSIQ 97STRIBILD 68STRIVERDI RESPIMAT 21STROMECTOL 14STUART ONE 118SUBSYS 10,11SUCRAID 93sucralfate 134SUDAFED CHILDRENS 120SUDAFED CONGESTION 120SUDAFED NASALDECONGESTANT MAXIMUMSTRENGTH 120SULAR 74sulfacetamide sod-prednisolone 123sulfacetamide sodium (acne)83

sulfacetamide sodium(ophth) 122sulfadiazine 131sulfamethoxazole-trimethoprim

15SULFAMYLON 87sulfasalazine 100sulindac 6sumatriptan succinate 111SUPRAX 77SUPRENZA 1SUPREP BOWEL PREPKIT 107SURMONTIL 31SUSTIVA 68SUTENT 57SW OMEPRAZOLE 135SYLATRON 58SYMBYAX 129SYMLINPEN 120 31SYMLINPEN 60 31SYNAGIS 126SYNALAR 91SYNAREL 96SYNDROS 38SYNERCID 17SYNJARDY 33SYNJARDY XR 33SYNRIBO 58SYNTHROID 132SYPRINE 113TABLOID 51tacrolimus 115tacrolimus (topical) 92TAFINLAR 57TAGAMET HB 134TAGRISSO 57TALTZ 86TAMIFLU 71tamoxifen citrate 54tamsulosin hcl 102TARCEVA 57TARGRETIN 58,86TASIGNA 57TASMAR 60TAXOL 60TAXOTERE 60

tazarotene 86TAZORAC 87TECENTRIQ 53TECFIDERA 130TECFIDERA STARTERPACK 130TECHNIVIE 70TEFLARO 77TEGRETOL 25TEGRETOL-XR 25TEKTURNA 48TEKTURNA HCT 47temazepam 106TEMODAR 50TEMOVATE 91TEMOVATE E 91TENEX 46TENIVAC 133TENORETIC 100 47TENORETIC 50 47TENORMIN 72TERAZOL 3 138TERAZOL 7 138terazosin hcl 46terbinafine hcl 39terbinafine hcl (topical) 85terbutaline sulfate 21terconazole vaginal 138TESSALON PERLES 81TESTIM 13TESTOSTERONE 13testosterone 13testosterone cypionate 13testosterone enanthate 13TESTOSTERONE PUMP 13TETANUS/DIPHTHERIATOXOIDS-ADSORBED 133tetrabenazine 129tetracycline hcl 132TETRACYCLINE HCL 132TGT OMEPRAZOLE 135THALOMID 114theophylline 22THERANATALCOMPLETE 118thioridazine hcl 65thiotepa 50

Index 17

thiothixene 66THYMOGLOBULIN 115tiagabine hcl 26TIAZAC 74TICE BCG 58TIGAN 38TIGECYCLINE 16TIKOSYN 19timolol maleate (ophth) 121TIMOPTIC 121TIMOPTIC-XE 121TINACTIN 85TINACTIN JOCK ITCH 85TINDAMAX 15tinidazole 15tioconazole vaginal 139TIVICAY 69tizanidine hcl 118TOBI 3TOBI PODHALER 3TOBRADEX 123tobramycin 3tobramycin (ophth) 122tobramycin sulfate 3tobramycin-dexamethasone 123TOBREX 122TOFRANIL-PM 31tolazamide 37tolbutamide 37tolcapone 60tolmetin sodium 6tolnaftate 85tolterodine tartrate 136TOPAMAX 25TOPAMAX SPRINKLE 25topiramate 25TOPOTECAN HCL 60topotecan hcl 60TOPROL XL 72TORISEL 57torsemide 94TOUJEO SOLOSTAR 35TRACLEER 75TRADJENTA 34tramadol hcl 11

tramadol-acetaminophen 12trandolapril 45tranexamic acid 105TRANSDERM-SCOP 38TRANXENE T 19tranylcypromine sulfate 28TRAVATAN Z 124trazodone hcl 29TREANDA 50TRECATOR 49TRELSTAR 54TRELSTAR MIXJECT 54TRESIBA FLEXTOUCH 35tretinoin 83tretinoin (chemotherapy) 58tretinoin microsphere 83TREXIMET 110TRI-VI-SOL 116triamcinolone acetonide(mouth) 116triamcinolone acetonide(nasal) 119triamcinolone acetonide(topical) 91triamterene &hydrochlorothiazide 94TRIAZOLAM 106triazolam 106TRICOR 43TRIDESILON 91trifluoperazine hcl 65trifluridine 122TRIGLIDE 43trihexyphenidyl hcl 60TRILEPTAL 25TRILIPIX 43trimethoprim 15trimipramine maleate 31TRINTELLIX 29triprolidine &pseudoephedrine 82TRISENOX 58TRIUMEQ 69TRIZIVIR 69trospium chloride 136TRUMENBA 137TRUSOPT 124TRUVADA 69

TRUZONE PEAK FLOWMETER 110TUDORZA PRESSAIR 20TUMS 14TUMS CHEWY BITES 14TUMS E-X 750 14TUMS EXTRA STRENGTH750 14TUMS KIDS 14TUMS LASTING EFFECTS 14TUMS SMOOTHIES 14TUSSIONEX PENNKINETICEXTENDED RELEASE 82TWINRIX 138TYBOST 69TYGACIL 16TYKERB 57TYLENOL CHILDRENS 7TYLENOL INFANTS 7TYLENOL INFANTSPAIN+FEVER 7TYMLOS 95TYPHIM VI 137TYSABRI 130TYVASO 74TYVASO REFILL 74TYVASO STARTER 74TYZEKA 71UCERIS 13ULTRACET 12ULTRAM 11ULTRAM ER 11ULTRAVATE 91UNASYN 127UPTRAVI 75URAMAXIN 91URAMAXIN GT 91UROCIT-K 10 101UROCIT-K 5 101UROXATRAL 102URSO 250 99URSO FORTE 99ursodiol 99UVADEX 58VAGISTAT-1 139valacyclovir hcl 71VALCHLOR 86VALCYTE 70

Index 18

valganciclovir hcl 70VALIUM 19valproate sodium 27valproic acid 27valsartan 46valsartan-hydrochlorothiazide

47VALSTAR 55VALTREX 71VANCOCIN HCL 15vancomycin hcl 15VANCOMYCIN HCL INDEXTROSE 15VANTAS 54VAQTA 138VARIVAX 138VARIZIG 125VARUBI 39VASCEPA 42VASERETIC 47VASOTEC 45VCF VAGINALCONTRACEPTIVE FOAM 138VECTIBIX 53VELCADE 57VELTASSA 115VEMLIDY 71VENCLEXTA 53VENCLEXTA STARTINGPACK 53venlafaxine hcl 30VENLAFAXINE HCL ER 30VENTAVIS 75verapamil hcl 74VERELAN 74VERELAN PM 74VERSACLOZ 64VFEND 40VFEND IV 40VIBERZI 101VIBRAMYCIN 132VICOPROFEN 12VICTOZA 34VICTRELIS 71VIDAZA 51VIDEX EC 69VIDEXPEDIATRIC 69VIEKIRA PAK 71

vigabatrin 26VIGAMOX 122VIIBRYD 29VIIBRYD STARTER PACK29VIMIZIM 97VIMPAT 26vinblastine sulfate 60vincristine sulfate 60vinorelbine tartrate 60VIRACEPT 69VIRAMUNE 69VIRAMUNE XR 69VIRASAL 92VIRAZOLE 72VIREAD 69VIROPTIC 122VISTARIL 18vitamin a 139VOGELXO 13VOGELXO PUMP 13VOLTAREN 83voriconazole 40VOTRIENT 57VPRIV 103VRAYLAR 62VYXEOS 55warfarin sodium 22water for irrigation, sterile 115WELCHOL 43WELLBUTRIN 28WELLBUTRIN SR 28WELLBUTRIN XL 28WESTCORT 91XALATAN 124XALKORI 57XANAX 19XANAX XR 19XARELTO 22XARELTO STARTERPACK 22XATMEP 51XELJANZ 4XENAZINE 129XENICAL 1XEOMIN 120XERMELO 101

XGEVA 95XIFAXAN 15XIIDRA 122XOLAIR 20XOPENEX 21XOPENEX CONCENTRATE 21XTANDI 54XYLOCAINE 92,108XYLOCAINE-MPF 108XYREM 127XYZAL 42YASMIN 28 78YAZ 78YERVOY 53YF-VAX 138YONDELIS 50ZADITOR 124zafirlukast 20zaleplon 106ZALTRAP 52ZANAFLEX 119ZANOSAR 50ZANTAC 134ZANTAC 150 MAXIMUMSTRENGTH 134ZANTAC 75 134ZARONTIN 27ZARXIO 104ZAVESCA 103ZEBETA 72ZEGERID 136ZEGERID OTC 136ZEJULA 57ZELBORAF 57ZEMAIRA 131ZEMPLAR 97ZEPATIER 71ZERIT 69ZESTORETIC 47ZESTRIL 45ZETIA 44ZIAC 48ZIAGEN 69zidovudine 69ZINACEF 76ZINECARD 59

Index 19

ZINPLAVA 126ziprasidone hcl 62ZIRGAN 122ZITHROMAX 108ZITHROMAX TRI-PAK 108ZITHROMAX Z-PAK 108ZOCOR 44ZODEX 6-DAY 80ZOFRAN 38ZOFRAN ODT 38ZOHYDRO ER 11ZOLADEX 54zoledronic acid 95ZOLINZA 57zolmitriptan 111ZOLOFT 29zolpidem tartrate 106ZOMACTON 96ZOMETA 95ZOMIG 111ZOMIG ZMT 111ZONACORT 11 DAY 80ZONACORT 7 DAY 80ZONEGRAN 26zonisamide 26ZONTIVITY 103ZORTRESS 115ZOSTAVAX 138ZOSYN 127ZOVIRAX 71,87ZYBAN 131ZYCLARA 92ZYCLARA PUMP 92ZYDELIG 57ZYKADIA 57ZYLOPRIM 102ZYMAXID 122ZYPREXA 64ZYPREXA RELPREVV 64ZYPREXA ZYDIS 64ZYRTEC ALLERGY 42ZYRTEC CHILDRENSALLERGY 42ZYRTEC-DALLERGY/CONGESTION 82ZYTIGA 54ZYVOX 17

Index 20

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