Health Net Cal MediConnect Plan (Medicare-Medicaid Plan ...€¦ · Kung nagsasalita ka ng Tagalog, available sa inyo ang mga serbisyo ng tulog sa wika, nang walang singil. Tumawag

Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)

2018 Listahan ngMga Sinasaklaw na Gamot(Pormularyo)

Kung mayroon kang mga tanong pakitawagan ang Health Net Cal MediConnect sa 1-855-464-3571 para sa Los Angeles County o sa 1-855-464-3572 para sa San Diego County (TTY 711) mula 8 am hanggang 8 pm Lunes hanggang Biyernes Maaari kang mag-iwan ng mensahe pagkatapos ng mga oras ng negosyo weekend at sa holiday Tutugunan ang iyong tawag sa susunod na araw ng negosyo Libre ang tawag Para sa higit pang impormasyon bisitahin ang wwwhealthnetcomcalmediconnect

Paalala sa mga kasalukuyang miyembro Binago na ang pormularyong ito simula noong nakaraang taon Pakisuri ang dokumentong ito upang masiguradong naglalaman pa rin ito ng mga gamot na iniinom mo

PAKIBASA NAGLALAMAN ANG DOKUMENTONG ITO NG IMPORMASYON TUNGKOL SA MGA GAMOT NA SINASAKLAW NAMIN SA PLANONG ITO

Na-update noong 112018

HPMS Approved Formulary File Submission ID 18477 Version Number 17

H3237_18_LOD_TAG_Approved_08282017

Ito ang listahan ng mga gamot na maaaring makuha ng mga miyembro sa Health Net Cal MediConnect

Ang Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) ay isang planong pangkalusugan na nakikipagkontrata sa Medicare at Medi-Cal upang maipagkaloob ang mga benepisyo ng parehong programa sa mga nagpatala

Maaaring magbago ang Listahan ng Mga Sinasaklaw na Gamot ato mga network ng botika at provider sa buong taon Padadalhan ka namin ng isang abiso bago kami gumawa ng pagbabago na makakaapekto sa iyo

Maaaring magbago ang mga benepisyo ato copay tuwing Enero 1 ng bawat taon

Palagi mong matitingnan online ang pinakabagong Listahan ng Mga Sinasaklaw na Gamot ng Health Net Cal MediConnect sa wwwhealthnetcomcalmediconnect o sa pamamagitan ng pagtawag 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 am hanggang 8 pm Maaari kang mag-iwan ng mensahe tuwing pagkatapos ng oras ng negosyo sa mga weekend at holiday Tutugunan ang iyong tawag sa susunod na araw ng negosyo Libre ang tawag

Maaaring may nalalapat na mga limitasyon copay at paghihigpit Para sa higit pang impormasyon tumawag sa Mga Serbisyo sa Miyembro ng Health Net Cal MediConnect o basahin ang Handbook ng Miyembro ng Health Net Cal MediConnect

Maaaring mag-iba ang mga copay para sa mga inireresetang gamot batay sa antas ng Karagdagang Tulong na natatanggap mo Makipag-ugnayan sa plano para sa higit pang detalye

Si usted habla espantildeol hay servicios de asistencia de idiomas disponibles para usted sin cargo Llame al 1-855-464-3571 en Los Angeles County y al 1-855-464-3572 en San Diego County (TTY 711) de lunes a viernes de 8 am a 8 pm Despueacutes del horario de atencioacuten los fines de semana y los diacuteas feriados puede dejar un mensaje Le devolveremos la llamada el siguiente diacutea haacutebil La llamada es gratuita

如果您使用中文您可以免費獲得語言援助服務Los Angeles County 請撥 1-855-464-3571San Diego County 請撥 1-855-464-3572 (聽障專線711)週一至

週五上午8點到下午8點非營業時間週末及假日您可以留言我們會在下一個工作日給您回電此專線為免付費電話

في 3571-464-855-1قمبالر اتصل امجان اللغوية المساعدة خدمات لك تتوافر العربية تتحدث كنت إذا8 الساعة من )San Diego County)TTY 711 في3572-464-855-1 قملروا Los Angeles County

والعطلات الأجازات أيام الرسمي الدوام اتأوق غير في وللاتصال عةمالج إلى الاثنين يوم من مساء صباح ةمجاني المكالمة ذهھ التالي العمل يوم في مكالمتك على سنرد رسالة ركت يمكنك

8حتى ا

Kung mayroon kang mga tanong pakitawagan ang Health Net Cal MediConnect 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 am hanggang 8 pm Maaari kang mag-iwan ng mensahe tuwing pagkatapos ng oras ng negosyo sa mga weekend at holiday Tutugunan ang iyong tawag sa susunod na araw ng negosyo Libre ang tawag Para sa higit pang impormasyon bisitahin ang wwwhealthnetcomcalmediconnect

Եթե Հայերեն եք խոսում անվճար լեզվական օգնության ծառայություններ են հասնում Ձեզ Զանգահարեք 1-855-464-3571 հեռախոսահամարով Los Angeles County- և 1-855-464-3572 հեռախոսահամարով San Diego County-ի շրջաններին (TTYrsquo 711) երկուշաբթիից ուրբաթ կա 8-ից մինչեւ կհ 8-ը Հեռախոսազանգն անվճար է

េបើ ន ម ល គ ន ទ នងសនអកនយាយភាសាែខរ េសវាជនយភាសាឥតគតៃថ មានសរាបអក ទរសពេទៅេលខ 1-855-464-3571 កLos Angeles County នង 1-855-464-3572 កនង San Diego County (TTY 711) ពេមា ង 8 រពកដល 8 យប ៃថង ទ រហ ង ទ ប ងេធវការ េនៅច តយ ន ប កអាចទ ពទចន តៃថសរក បនា ពេមា ើ ងអាទ ងៃថង ណយ អន កសារស បាន អន ទ ង វការបនាប ឥត េចញ ៃថល យកនងរតវបានទរសពមកវញ េនៅៃថេធើ ទ េទៀត ការ េហៅ េនះ គ េឡើ

شماره با باشند می شما اراختي در رايگان طور به زبانی امداد خدمات دکني می صحبت فارسی به اگر San Diego County در 3572-464-855-1 شماره و Los Angeles County در 1-855-464-3571

و ھا ھفته آخر در اریک ساعات از بعد ) TTY 711( بگيريد تماس هجمع تا دوشنبه شب 8 تا صبح 8 ساعت از تماس اين شد خواھد داده پاسخ بعدی کاری روز در شما تلفنی تماس به بگذاريد پيام توانيد می میسر تعطيلات است رايگان

귀하께서 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다

Los Angeles County는 1-855-464-3571번 San Diego County는 1-855-464-

3572번으로 월요일 -금요일 오전 8시부터 오후 8시까지 전화하십시오 (TTY 711)

영업시간 이후 주말 및 공휴일에는 메시지를 남기실 수 있습니다 다음 영업일에

저희가 귀하께 전화를 드리겠습니다 안내전화는 무료입니다

Если вы говорите по-русски мы можем предложить вам бесплатные услуги переводчика Звоните по телефону 1-855-464-3571 в Los Angeles County или по телефону 1-855-464-3572 в San Diego County (TTY 711) Вы можете получить необходимую информацию непосредственно у сотрудника плана с понедельника по пятницу с 8 часов утра до 8 часов вечера В нерабочее время а также в выходные и праздничные дни вы можете оставить сообщение Вам перезвонят на следующий рабочий день Звонок бесплатный

Kung nagsasalita ka ng Tagalog available sa inyo ang mga serbisyo ng tulog sa wika nang walang singil Tumawag sa 1-855-464-3571 sa Los Angeles County at 1-855-464-3572 sa San Diego County (TTY 711) mula 8 am hanggang 8 pm Lunes hanggang Biyernes Paglipas ng mga oras ng negosyo tuwing Sabado at Linggo at sa pista opisyal maaari kang mag-iwan ng mensahe Ang iyong tawag ay ibabalik sa loob ng susunod na araw ng negosyo Libre ang tawag

Nếu quyacute vị noacutei tiếng Việt chuacuteng tocirci sẵn coacute dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho quyacute vị Xin gọi 1-855-464-3571 ở Los Angeles County vagrave 1-855-464-3572 ở San Diego County (TTY 711) từ 8 giờ saacuteng đến 8 giờ tối từ thứ Hai đến hết thứ Saacuteu Sau giờ lagravem việc vagraveo caacutec ngagravey cuối tuần vagrave ngagravey lễ quyacute vị coacute thể để lại tin nhắn Cuộc gọi của quyacute vị sẽ được hồi đaacutep vagraveo ngagravey lagravem việc hocircm sau Cuộc gọi nagravey miễn phiacute

Maaari mong makuha ang dokumentong ito nang libre sa iba pang format tulad ng malaking print braille o audio Tumawag 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 am hanggang 8 pm Maaari kang mag-iwan ng mensahe tuwing pagkatapos ng oras ng negosyo sa mga weekend at holiday Tutugunan ang iyong tawag sa susunod na araw ng negosyo Libre ang tawag

Kung gusto mong regular kang padalhan ng Health Net Cal MediConnect ng mga materyales para sa miyembro sa iba pang format tulad ng Braille o malaking print o sa wikang iba sa English makipag-ugnayan sa Mga Serbisyo sa Miyembro Ipaalam sa Mga Serbisyo sa Miyembro na gusto mong hilinging makuha ang iyong mga materyales sa ibang format o wika

Mga Madalas Itanong (Frequently Asked Questions FAQ)

Maghanap rito ng mga sagot sa tanong na mayroon ka tungkol sa Listahan ng Mga Sinasaklaw na Gamot na ito Mababasa mo ang lahat ng FAQ upang matuto pa o maghanap ng sagot at tanong

1 Anong mga inireresetang gamot ang nasa Listahan ng Mga Sinasaklaw na Gamot (Sa madaling salita tinatawag naming ldquoListahan ng Gamotrdquo ang Listahan ng Mga Sinasaklaw na Gamot)

Ang mga gamot sa Listahan ng Gamot ay mga gamot na sinasaklaw ng Health Net Cal MediConnect Available sa mga botika sa loob ng aming network ang mga gamot Nasa aming network ang isang botika kung nagkaroon kami ng kasunduan sa kanila upang makipagtulungan sa amin at magbigay sa iyo ng mga serbisyo Tinutukoy namin ang mga botikang ito bilang ldquomga botika sa networkrdquo

Sasaklawin ng Health Net Cal MediConnect ang lahat ng kinakailangang medikal na gamot sa Listahan ng Gamot kung

sinasabi ng iyong doktor o iba pang tagapagreseta na kailangan mo ang mga ito upang bumuti o manatiling malusog at

pinunan mo ang reseta sa botika sa network ng Health Net Cal MediConnect

Sa ilang sitwasyon may kailangan kang gawin bago mo makuha ang gamot (tingnan ang tanong 5 sa ibaba)

Maaari mo ring makita ang pinakabagong listahan ng mga gamot na sinasaklaw namin sa aming website sa wwwhealthnetcomcalmediconnect o tawagan ang Mga Serbisyo sa Miyembro 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 am hanggang 8 pm Maaari kang mag-iwan ng mensahe tuwing pagkatapos ng oras ng negosyo sa mga weekend at holiday Tutugunan ang iyong tawag sa susunod na araw ng negosyo Libre ang tawag

2 Nagbabago ba ang Listahan ng Gamot

Oo Maaaring magdagdag o mag-alis ang Health Net Cal MediConnect ng mga gamot sa Listahan ng Gamot sa loob ng isang taon Sa pangkalahatan magbabago lang ang Listahan ng Gamot kung

may murang gamot na dumating na kasing epektibo ng gamot na nasa Listahan ng Gamot sa ngayon o

nalaman naming hindi ligtas ang gamot na iyon

Maaari rin naming baguhin ang aming mga alintuntunin tungkol sa mga gamot Halimbawa maaari naming

Pagpasyahan kung kinakailangan o hindi kinakailangan ang paunang pag-apruba para sa isang gamot (Ang paunang pag-apruba ay pahintulot mula sa Health Net Cal MediConnect bago ka makakakuha ng gamot)

Dagdagan o baguhin ang halaga ng gamot na makukuha mo (tinatawag na ldquomga limitasyon sa damirdquo)

Dagdagan o baguhin ang mga paghihigpit sa step therapy sa gamot (Nangangahulugan ang Step therapy na dapat mo munang subukan ang isang gamot bago namin saklawin ang isa pang gamot)

(Para sa higit pang impormasyon sa mga alintuntunin sa gamot na ito tingnan ang pahina iv)

Ipapaalam namin sa iyo kapag inalis sa Listahan ng Gamot ang gamot na iniinom mo Ipapaalam din namin sa iyo kapag nagbago kami ng aming mga alintuntunin para sa pagsaklaw ng isang gamot May higit pang impormasyon ang mga tanong 3 4 at 7 sa ibaba ukol sa kung ano ang mangyayari kapag may mga pagbabago sa Listahan ng Gamot

Palagi mong matitingnan online ang pinakabagong Listahan ng Gamot ng Health Net Cal MediConnect sa wwwhealthnetcomcalmediconnect Maaari mo ring tawagan ang Mga Serbisyo sa Miyembro upang tingnan ang kasalakuyang Listahan ng Gamot 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 am hanggang 8 pm Maaari kang mag-iwan ng mensahe tuwing pagkatapos ng oras ng negosyo sa mga weekend at holiday Tutugunan ang iyong tawag sa susunod na araw ng negosyo Libre ang tawag

3 Ano ang mangyayari kapag may murang gamot na dumating na kasing epektibo ng gamot na nasa Listahan ng Gamot sa ngayon

Kung aalisin ang gamot na iniinom mo dahil may dumating na gamot na kasing epektibo rin ipapaalam namin sa iyo Ipapaalam namin sa iyo nang hindi bababa sa 60 araw bago namin ito alisin sa Listahan ng Gamot o kapag humingi ka ng refill Pagkatapos ay makakakuha ka ng 60 araw na supply ng gamot bago alisin ang gamot sa listahan ng gamot Padadalhan ka namin ng liham na nagbibigay-alam sa iyo ng tungkol sa pagbabagong ito Ilalagay din namin ang mga pagbabagong ito sa aming website sa wwwhealthnetcomcalmediconnect

4 Ano ang mangyayari kapag nalaman naming hindi ligtas ang isang gamot

Kung sinasabi ng Food and Drug Administration (FDA) na hindi ligtas ang gamot na iniinom mo aalisin namin ito kaagad sa Listahan ng Gamot Papadalhan ka rin namin ng liham na nagpapaalam sa iyo ukol diyan Kung matanggap mo ang isa sa mga liham na ito pakitawagan ang iyong doktor upang pag-usapan ang tungkol sa iba pang pagpipiliang gamot

5 May anumang paghihigpit o limitasyon ba sa pagsaklaw ng gamot O may anumang kinakailangang gawing pagkilos upang makakuha ng ilang partikular na gamot

Oo may ilang gamot na mayroong mga alintuntunin sa pagsaklaw o may mga limitasyon sa halagang maaari mong makuha Sa ilang sitwasyon dapat ay may gawin ka o ang iyong doktor o ang iba pang tagapagreseta bago mo makuha ang gamot Halimbawa

Paunang pag-apruba (o paunang pagpapahintulot) Para sa ilang gamot dapat ay kumuha ka o ang iyong doktor o ang iba pang tagapagreseta ng pag-apruba mula sa Health Net Cal MediConnect bago mo punan ang iyong reseta Kung hindi ka makakakuha ng pag-apruba maaaring hindi saklawin ng Health Net Cal MediConnect ang gamot

Mga limitasyon sa dami Nililimitahan kung minsan ng Health Net Cal MediConnect ang dami ng gamot na maaari mong makuha

Step therapy Hihingilin sa iyo kung minsan ng Health Net Cal MediConnect na gawin ang step therapy Nangangahulugan ito na kailangan mong subukan ang mga gamot sa isang partikular na ayos para sa iyong kundisyong medikal Maaaring kailanganin mong subukan ang isang gamot bago namin saklawin ang isa pang gamot Kung sa tingin ng iyong doktor ay hindi umeepekto sa iyo ang unang gamot kami na ang sasaklaw sa pangalawa

Maaari mong malaman kung may anumang karagdagang kinakailangan o limitasyon ang iyong gamot sa pamamagitan ng pagtingin sa mga talahayanan sa mga pahina 1 - Index 1 Makakakuha ka rin ng higit pang impormasyon sa pamamagitan ng pagbisita sa aming website sa wwwhealthnetcomcalmediconnect Nag-post kami ng mga online na dokumentong nagpapaliwanag ng aming paunang pagpapahintulot at mga paghihigpit sa step therapy Maaari mo ring hilingin sa aming padahalan ka ng kopya

Maaari ka ring humiling ng ldquoexceptionrdquo sa mga limitasyong ito Pakitingnan ang Tanong 11 para sa higit pang impormasyon sa mga exception

Kung ikaw ay nasa isang nursing home o iba pang pasilidad para sa pangmatagalang pangangalaga at kailangan ng gamot na wala sa Listahan ng Gamot o kung hindi mo madaling makukuha ang gamot na kailangan mo makakatulong kami Sasaklawin namin ang 31 araw na supply ng pang-emergency na gamot na kailangan mo (maliban kung may reseta ka para sa mas kaunting araw) ikaw man ay bagong miyembro ng Health Net Cal MediConnect o hindi Bibigyan ka nito ng panahon upang makipag-usap sa iyong doktor o iba pang tagapagreseta Matutulungan ka niyang magpasya kung may katulad bang gamot sa Listahan ng Gamot na maaari mong inumin o kung hihiling ng exception Pakitingnan ang Tanong 11 para sa higit pang impormasyon tungkol sa mga exception

6 Paano mo malalaman kung may mga limitasyon ang gamot na iyong iniinom o kung may mga kinakailangang gawing pagkilos upang makuha ang gamot

May column ang Listahan ng Mga Sinasaklaw na Gamot sa pahina 1 na may label na ldquoMga kinakailangang pagkilos paghihigpit o limitasyon sa paggamitrdquo

7 Ano ang mangyayari kung babaguhin namin ang mga alintutunin sa kung paano namin sasaklawin ang ilan sa mga gamot Halimbawa kung magdaragdag kami ng paunang pagpapahintulot (pag-apruba) mga limitasyon sa dami ato paghihigpit sa step therapy sa isang gamot

Ipapaalam namin sa iyo kung magdaragdag kami ng paunang pag-apruba mga limitasyon sa dami ato mga paghihigpit sa step therapy sa isang gamot Ipapaalam namin sa iyo nang hindi bababa sa 60 araw bago idagdag ang paghihigpit o sa susunod na hihingi ka ng refill sa iyong botika Pagkatapos makakakuha ka ng 60 araw na supply ng gamot bago gawin ang pagbabago sa mga alintuntunin sa pagsaklaw Bibigyan ka nito ng panahon upang makipag-usap sa iyong doktor o iba pang tagapagreseta tungkol sa kung ano ang susunod na gagawin

8 Paano ka makakahanap ng gamot sa Listahan ng Gamot

May dalawang paraan upang maghanap ng gamot

Maaari kang maghanap nang ayon sa alpabeto (kung alam mo kung paano i-spell ang gamot) o

Maaari kang maghanap ayon sa kundisyong medikal

Upang maghanap ayon sa titik pumunta sa seksyong Listahang Nakaayos ayon sa Titik Mahahanap mo ito sa Index na nagsisimula sa pahinang Index 1

Upang maghanap ayon sa kundisyong medikal hanapin ang seksyong may label na ldquoListahan ng mga gamot ayon sa kundisyong medikalrdquo sa pahina 1 Pinagpangkat-pangkat ang mga gamot sa seksyong ito sa mga kategorya depende sa uri ng mga kundisyong medikal kung saan ginagamit ang mga ito bilang panggamot Halimbawa kung may kundisyon ka sa puso dapat ay hanapin mo ang kategoryang Mga CARDIOVASCULAR AGENT - IBA PA - Mga Gamot para sa Mga Kundisyon sa Puso at Circulation Doon mo mahahanap ang mga gamot na ginagamit sa mga kundisyon 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 Mga Serbisyo sa Miyembro 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 am hanggang 8 pm at magtanong tungkol dito Kung malaman mong hindi sasaklawin ng Health Net Cal MediConnect ang gamot maaari mong gawin ang isa sa mga hakbang na ito

Humiling sa Mga Serbisyo sa Miyembro ng listahan ng mga gamot katulad ng gusto mong inumin Pagkatapos ay ipakita ang listahan sa iyong doktor o iba pang tagapagreseta Maaari niyang ireseta ang gamot sa Listahan ng Gamot na katulad ng gusto mong inumin O

Maaari mong hilingin sa planong pangkalusugan na gumawa ng exception upang saklawin ang iyong gamot Pakitingnan ang tanong 11 para sa higit pang impormasyon tungkol sa mga exception

10 Paano kung bago kang miyembro ng Health Net Cal MediConnect at hindi mo mahanap ang iyong gamot sa Listahan ng Gamot o may problema ka sa pagkuha ng iyong gamot

Makakatulong kami Maaari naming saklawin ang pansamantalang 30 araw na supply ng iyong gamot sa loob ng unang 90 araw na miyembro ka ng Health Net Cal MediConnect Bibigyan ka nito ng panahon upang makipag-usap sa iyong doktor o iba pang tagapagreseta Matutulungan ka niyang magpasya kung may katulad bang gamot sa Listahan ng Gamot na maaari mong inumin o kung hihiling ng exception

Sasaklawin namin ang 30 araw na supply ng gamot kung

kung umiinom ka ng gamot na wala sa aming Listahan ng Gamot o

hindi ka hinahayaan ng mga alintuntunin ng planong pangkalusugan na makuha ang halagang na-order ng iyong tagapagreseta o

kinakailangan ng gamot ang paunang pag-apruba ng Health Net Cal MediConnect o

ang iniinom mong gamot ay bahagi ng paghihigpit sa step therapy

Kung nakatira ka sa isang nursing home o sa iba pang pasilidad para sa pangmatagalang pangangalaga maaari mong i-refill ang iyong reseta sa loob ng 98 araw Maaari mong i-refill ang gamot nang maraming beses sa loob ng iyong unang 90 araw sa plano Binibigyan nito ng panahon ang iyong tagapagreseta na baguhin ang mga gamot mo na nasa Listahan ng Gamot o humiling ng exception

Mga Pagbabago sa Antas ng Pangangalaga

Kung nagbago ang iyong antas ng pangangalaga sasaklawin namin ang supply ng paglipat ng iyong mga gamot Nangyayari ang pagbabago sa antas ng pangangalaga kapag inilabas ka mula sa ospital Nangyayari rin ito kapag lumipat ka papunta sa o mula sa isang pasilidad para sa pangmatagalang pangangalaga

Kung lumipat ka sa bahay mula sa isang pasilidad o ospital para sa pangmatagalang pangangalaga at kailangan mo ng supply sa paglipat sasaklawin namin ang 30 araw na supply Kung isinulat ang iyong reseta para sa mas kaunting araw papayagan namin ang mga pag-refill upang magbigay ng hanggang sa kabuuan ng 30 araw na supply

Kung lumipat mula sa bahay o sa ospital papunta sa isang pasilidad para sa pangmatagalang pangangalaga sasaklawin namin ang 31 araw na supply Kung isinulat ang iyong reseta para sa mas kaunting araw papayagan namin ang mga pag-refill upang magbigay ng hanggang sa kabuuan ng 31 araw na supply

11 Maaari ka bang humiling ng exception upang saklawin ang iyong gamot

Oo Maaari kang humiling sa Health Net Cal MediConnect na gumawa ng exception upang saklawin ang gamot na wala sa Listahan ng Gamot

Maaari mo ring hilingin sa aming baguhin ang mga alintuntunin sa iyong gamot

Halimbawa maaaring limitahan ng Health Net Cal MediConnect ang halaga ng gamot na sasaklawin namin Kung may limitasyon ang iyong gamot maaari mong hilingin sa aming baguhin ang limitasyon at magsaklaw pa

Iba pang halimbawa Maaari mo ring hilingin sa aming alisin ang mga paghihigpit sa step therapy o ang mga kinakailangan sa paunang pag-apruba

12 Gaano katagal upang makakuha ng exception

Una dapat ay may makuha kaming pahayag mula sa iyong tagapagreseta na sumusuporta sa kahilingan mo para sa exception Pagkatapos naming makuha ang pahayag ibibigay namin sa iyo ang pagpapasya sa kahilingan mo sa exception sa loob ng 72 oras

Kung sa tingin mo o ng iyong tagapagreseta ay manganganib ang iyong kalusugan kung maghihintay ka nang 72 oras para sa pagpapasya maaari kang humiling ng pinabilis na exception Mas mabilis itong pagpapasya Kung sinusuportahan ng iyong tagapagreseta ang kahilingan mo ibibigay namin sa iyo ang pagpapasya sa loob ng 24 na oras simula nang pagkakakuha ng pahayag ng pagsuporta ng tagapagreseta mo

13 Paano ka makakahiling ng exception

Upang humiling ng exception tawagan ang Mga Serbisyo sa Miyembro Makikipagtulungan sa iyo at sa provider angMga Serbisyo sa Miyembro upang tumulong sa paghiling ng exception

14 Ano ang mga generic na gamot

Gawa ang mga generic na gamot sa parehong mga sangkap na katulad sa mga branded na gamot Kadalasang mas mura ang mga ito kaysa sa mga branded na gamot at mas karaniwang hindi kilala ang mga pangalan nito Aprubado ng Food and Drug Administration (FDA) ang mga generic na gamot

Sinasaklaw ng Health Net Cal MediConnect ang parehong mga gamot na branded at generic

15 Ano ang mga OTC na gamot

Tumutukoy ang OTC sa ldquoover-the-counterrdquo Sinasaklaw ng Health Net Cal MediConnect ang ilan sa OTC na gamot kapag isinulat ang mga ito bilang mga inirereseta ng iyong provider

Maaari mong basahin ang Listahan ng Gamot ng Health Net Cal MediConnect upang makita kung anong mga OTC na gamot ang sinasaklaw

16 Sinasaklaw ba ng Health Net Cal MediConnect ang mga OTC naproduktong hindi gamot

Sinasaklaw ng Health Net Cal MediConnect ang ilan sa OTC na produktong hindi gamot kapag isinulat ang mga ito bilang mga inirereseta ng iyong provider

Maaari mong basahin ang Listahan ng Gamot ng Health Net Cal MediConnect upang makita kung anong mga OTC na produktong hindi gamot ang sinasaklaw

17 Ano ang iyong copay

Maaari mong basahin ang Listahan ng Gamot ng Health Net Cal MediConnect upang matuto tungkol sa copay para sa bawat gamot

Walang copay ang mga miyembro ng Health Net Cal MediConnect na nakatira sa mga nursing home o iba pang pasilidad para sa pangmatagalang pangangalaga Wala ring copay ang ilang miyembro sa komunidad na kumukuha ng pangmatagalang pangangalaga

Inililista ang mga copay ayon sa tier Ang mga tier ay mga pangkat ng gamot na may parehong copay

May mababang copay ang mga gamot sa tier 1 Mga generic na gamot ito Mula $000 hanggang $335 ang copay Nakadepende ito sa antas ng iyong kita

Mas mataas ang copay ng mga gamot sa tier 2 Mga branded na gamot ito Mula $000 hanggang $835 ang copay Nakadepende ito sa antas ng iyong kita

May copay na $000 ang mga gamot sa tier 3 Ito ang mga gamot na inirereseta at OTC na sinasaklaw ng Medi-Cal

Listahan ng Mga Sinasaklaw na Gamot

Ang listahan ng mga sinasaklaw na gamot na nagsisimula sa pahina 1 ay nagbibigay sa iyo ng impormasyon tungkol sa mga gamot na sinasaklaw ng Health Net Cal MediConnect Kung nagkakaproblema ka sa paghahanap ng iyong gamot sa listahan pumunta sa Index na nagsisimula sa pahina Index 1

Inililista sa unang column ng chart ang pangalan ng gamot Naka-capitalize ang mga branded na gamot (hal ELIQUIS TABS) at nakalista sa mas maliliit na titik nang naka-italics ang mga generic na gamot (hal warfarin sodium tabs)

Ipinapaalam sa iyo ng impormasyon sa column na ldquoMga kinakailangang pagkilos paghihigpit o limitasyon sa paggamitrdquo kung may anumang alintuntunin ang Health Net Cal MediConnect para sa pagsaklaw ng gamot mo Narito ang mga kahulugan ng mga code na ginagamit sa column na ldquoMga kinakailangang pagkilos paghihigpit o limitasyon sa paggamitrdquo

Abbreviation Ano ang ibig sabihin nito

Paano ito tumatalab

AL Age Limit (Limitasyon sa Edad)

Maaaring kailangan ng gamot na ito ang paunang pagpapahintulot kung hindi nakakatugon ang iyong edad sa mga patnubay ng gumagawa ng gamot ng FDA o ng klinika

BD Medicare Part B vs Part D

Maaaring kailangan ng gamot na ito ang paunang pagpapahintulot upang pagpasyahan kung dapat ba itong saklawin sa ilalim ng Medicare Part B or Part D Isa itong tuntunin ng Medicare Maaaring kailanganin ng iyong doktor o iba pang tagapagreseta na magbigay ng higit pang ebidensya upang tulungan kaming gawin ang pagpapasyang ito

LA Limited Access (Limitadong Access)

Maaaring available lang ang resetang ito sa ilang partikular na botika Para sa higit pang impormasyon kumonsulta sa iyong Direktoryo ng Botika o tumawag sa Mga Serbisyo sa Miyembro 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 am hanggang 8 pm Maaari kang mag-iwan ng mensahe tuwing pagkatapos ng oras ng negosyo sa mga weekend at holiday Tutugunan ang iyong tawag sa susunod na araw ng negosyo Libre ang tawag

Paano ito tumatalab

MO Mail Order Available ang gamot na ito hanggang sa 90 araw na supply sa isang botikang mail order bukod pa sa ilang iba pang botika sa network Isaalang-alang ang pagkuha ng 90 araw na supply para sa iyong mga pangmatagalang (maintenance) gamot (tulad ng mga gamot para sa altapresyon) Maaaring mas naaangkop ang mga retail na botika sa network para sa mga panandaliang reseta (tulad ng mga antibiotic)

NF Not Covered (Hindi Sinasaklaw)

Hindi sinasaklaw ang gamot na ito sa Listahan ng Gamot Maaari kang humiling ng exception para saklawin ang gamot

NT Not Part D (Hindi Part D)

Hindi ldquogamot ng Part Drdquo ang gamot na ito Hindi mo kinakailangang magbayad ng copay para sa mga gamot na ito

PA Prior Authorization (Paunang Pagpapahintulot)

Nangangailangan ang gamot na ito ng paunang pagpapahintulot Nangangahulugan itong dapat kang humingi o ang iyong doktor ng pag-apruba mula sa amin bago mo punan ang iyong reseta Kung hindi ka makakakuha ng pag-apruba maaaring hindi namin saklawin ang gamot

QL Quantity Limit (Limitasyon sa Dami)

May limitasyon ang gamot na ito sa halagang sasaklawin ng aming plano

RXOTC Prescription and Over-the-Counter (Reseta at OTC)

Ginawa ang gamot na ito sa parehong form ng reseta at OTC

Paano ito tumatalab

SL Safety Limit (Limitasyon sa Kaligtasan)

May maximum na limitasyon ang pang-araw-araw na dosis ng gamot na ito na sinusuportahan ng FDA Nangangahulugan itong hindi namin sasaklawin ang higit pa sa maximum na pang-araw-araw na dosis Halimbawa ang maximum na pang-araw-araw na dosis ng FDA sa ibuprofen ay 3200 mg Samakatuwid sasaklawin lang namin ang apat na tableta bawat araw para sa ibuprofen 800 mg

ST Step Therapy Nangangailangan ang gamot na ito ng step therapy Nangangahulugan ito na kailangan mong subukan ang mga gamot sa isang partikular na ayos para sa iyong kundisyong medikal Maaaring kailanganin mong subukan ang isang gamot bago namin saklawin ang isa pang gamot Kung sa tingin ng iyong doktor ay hindi umeepekto sa iyo ang unang gamot kami na ang sasaklaw sa pangalawa

Tandaan Tumutukoy ang NT sa tabi ng isang gamot na hindi ito ldquoGamot ng Part Drdquo Hindi mo kinakailangang magbayad ng copay para sa mga gamot na ito May ibat iba ring alintuntunin para sa mga pag-apela ang mga gamot na ito Ang pag-apela ay isang pormal na paraan ng paghiling sa amin upang suriin ang pagpapasyang ginawa namin tungkol sa iyong pagsaklaw at upang baguhin ito kung sa tingin mo ay nagkamali kami Halimbawa maaaring pagpasyahan naming ang gamot na gusto mo ay hindi sinasaklaw o hindi na sinasaklaw ng Medicare o Medi-Cal Kung hindi kayo sumasang-ayon ng doktor mo sa aming pagpapasya maaari kang mag-apela Kung mayroon kang tanong tawagan ang Mga Serbisyo sa Miyembro 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 am hanggang 8 pm Maaari kang mag-iwan ng mensahe tuwing pagkatapos ng oras ng negosyo sa mga weekend at holiday Tutugunan ang iyong tawag sa susunod na araw ng negosyo Libre ang tawag Maaari mo ring basahin ang Handbook ng Miyembro upang malaman kung paano mag-apela ng pasya

Listahan ng Mga Gamot ayon sa Kundsiyong Medikal

Pinagpangkat-pangkat ang mga gamot sa seksyong ito sa mga kategorya depende sa uri ng mga kundisyong medikal kung saan ginagamit ang mga ito bilang panggamot Halimbawa kung may kundisyon ka sa puso dapat ay hanapin mo ang kategoryang Mga CARDIOVASCULAR

AGENT - IBA PA - Mga Gamot para sa Mga Kundisyon sa Puso at Circulation Doon mo mahahanap ang mga gamot na ginagamit sa mga kundisyon sa puso

Health Net Cal MediConnect Member Notice

Health Net Community Solutions Inc (Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Health Net Cal MediConnect does not exclude people or treat them differently because of race color national origin age disability or sex

Health Net Cal MediConnect

bull Provides free aids and services to people with disabilities to communicate effectively with us such as qualified sign language interpreters and written information in other formats (large print accessible electronic formats other formats)

bull Provides free language services to people whose primary language is not English such as qualified interpreters and information written in other languages

If you need these services contact the Health Net Cal MediConnect Customer Contact Center at 1-855-464-3571 (Los Angeles) 1-855-464-3572 (San Diego) (TTY 711) A live person is here to talk with you Monday through Friday 800 am to 800 pm At other times ndash including Saturday Sunday and federal holidays ndash you can leave a voicemail We will return your call the following business day The call is free If you believe that Health Net Cal MediConnect has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance by calling the number above and telling them you need help filing a grievance the Health Net Cal MediConnect Customer Contact Center is available to help you

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800ndash368ndash1019 (TDD 1-800ndash537ndash7697) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

CA_MMP_2017_NDL_LP_Compliance Approved_06012017 CMC Nondiscrimination Notice_LP FLY012656EO00 (517)

Multi-Language Insert Multi-language Interpreter Services

English ATTENTION If you do not 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 ATENCIOacuteN Si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica 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 注意如果您說中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)（TTY 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)

Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-855-464-3571 (Los Angeles) 1-855-464-3572 (San Diego) (TTY 711)

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) (TTY 711)

Arabic ملحوظة إذا كنت تتحدث العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان اتصل بالرقم(TTY 711) (San Diego) 1-855-464-3572 (Los Angeles) 1-855-464-3571

Hindi धयान द दद आप बोलत भयाषया सहयातया स ह तो आपक ललए मफत म वयाए उपलबध ह 1-855-464-3571 (Los Angeles) 1-855-464-3572 (San Diego) (TTY 711) पर कॉल कर

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 گان برای شما فراهم می باشد بايلات زبانی بصورت رايد تسهيتوجه اگر به زبان فارسی گفتگو می کن(TTY 711) 1-855-464-3572 (San Diego) 1-855-464-3571 (Los Angeles)

Thai เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-855-464-3571 (Los Angeles) 1-855-464-3572 (San Diego) (TTY 711)

H3237_17_MLI_Accepted_09092017

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 711)

Cambodian បរយ សនជាអនកនយាយ ភាសាខមែរ បសវាជនយខ ន នគតឈលតន បរើ កភាសា បោយម ន គអាចមានសរាររបរអនក ចរ ទរសពទ 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)

Punjabi ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪ ਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧਿਚ ਸਹਾਇਤਾ ਸਿਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ1-855-464-3571 (Los Angeles) 1-855-464-3572 (San Diego) (TTY 711) lsquoਤ ਕਾਲ ਕਰ

Laotian ໂປດຊາບ ຖາທານເວາພາສາອງກດ ການຊວຍເຫອດານພາສາທບເສຍຄາມພອມໃຫທານ ກະລນາໂທ 1-855-464-3571 (Los Angeles) 1-855-464-3572 (San Diego) (TTY 711)

Cal MediConnect Member Multi-Language Insert FLY015174ZO00 (817)

Name of drug

What the

drugwill cost you(tier

level)

Necessaryactions restrictions or limits on use

ADHDANTI-NARCOLEPSYANTI-OBESITYANOREXIANTS - Drugs to TreatADHD Sleep and Eating Disorders

Amphetamines

amphetamine-dextroamphetamine cp24

$0-$335 (Tier

amphetamine-dextroamphetamine tabs

$0-$335 (Tier

dextroamphetamine sulfatecp24 5 mg 10 mg 15 mg

$0-$335 (Tier

dextroamphetamine sulfatetabs 5 mg 10 mg

$0-$335 (Tier

methamphetamine hcl tabs

$0-$335 (Tier

Anorexiants Non-Amphetamine

DIETHYLPROPION HCL ER TB24

$0 (Tier

PA MO NT

diethylpropion hcl tabs 25 mg

$0 (Tier

PA MO NT

diethylpropion hcl tb24 75 mg

$0 (Tier

PA MO NT

LOMAIRA TABS $0

(Tier 3)

phentermine hcl caps $0

(Tier 3)

PA MO NT

Name of drug

What the

level)

phentermine hcl tabs $0

(Tier 3)

PA MO NT

QSYMIA CP24 $0

(Tier 3)

Anti-Obesity Agents

ALLI CAPS $0

(Tier 3)

BELVIQ XR TB24 $0

(Tier 3)

XENICAL CAPS $0

(Tier 3)

PA MO NT

Attention-DeficitHyperactivity Disorder (ADHD)

atomoxetine hcl caps 10 mg

$0-$335 (Tier

SL(10 ea daily)MO

$0-$335 (Tier

SL(1 ea daily)MO

$0-$335 (Tier

SL(555 eadaily) MO

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(25 eadaily) MO

$0-$335 (Tier

SL(166 eadaily) MO

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

2018 Health Net Cal MediConnect Drug List Updated 11012018 1

Name of drug

What the

level)

$0-$335 (Tier

SL(125 eadaily) MO

clonidine hcl (adhd) tb12

$0-$335 (Tier

guanfacine hcl (adhd) tb24

$0-$335 (Tier

AL(Up to 64 yrsold) MO

Stimulants - Misc

CONCERTA TBCR

$0-$835 (Tier

dexmethylphenidate hclcp24 10 mg 15 mg 20 mg

$0-$335 (Tier

dexmethylphenidate hcltabs 5 mg 10 mg 25 mg

$0-$335 (Tier

methylphenidate hcl cp24or 20 mg 30 mg 40 mg60 mg

$0-$335 (Tier

methylphenidate hcl cpcr or10 mg 40 mg 50 mg 60 mg

$0-$335 (Tier

QL(1 ea daily)MO

methylphenidate hcl cpcr or20 mg

$0-$335 (Tier

QL(2 ea daily)MO

$0-$335 (Tier

Name of drug

What the

level)

methylphenidate hcl tabs or5 mg 10 mg 20 mg

$0-$335 (Tier

QL(3 ea daily)MO

methylphenidate hcl tb24 or27 mg 36 mg

$0-$335 (Tier

Non-Osmotic Release

methylphenidate hcl tbcr or18 mg 27 mg 36 mg 54 mg

$0-$335 (Tier

methylphenidate hcl tbcr or20 mg

$0-$335 (Tier

QL(3 ea daily)MO

modafinil tabs 100 mg

$0-$335 (Tier

PA QL(1 eadaily) MO

RITALIN LA CP24 60 MG

$0-$835 (Tier

ALLERGENIC EXTRACTSBIOLOGICALS MISC

Biologicals Misc

ADAGEN SOLN

$0-$835 (Tier

AMINOGLYCOSIDES - Drugs to Treat BacterialInfections

Aminoglycosides

amikacin sulfate soln ij 1gm4ml 500 mg2ml

$0-$335 (Tier

Name of drug

What the

level)

BETHKIS NEBU

$0-$835 (Tier

gentamicin in saline soln09-1mgml

$0-$335 (Tier

gentamicin sulfate soln ij40 mgml

$0-$335 (Tier

KITABIS PAK NEBU

$0-$835 (Tier

neomycin sulfate tabs or $0-

$335 (Tier

paromomycin sulfate caps

$0-$335 (Tier

TOBI PODHALER CAPS

$0-$835 (Tier

tobramycin nebu in

$0-$335 (Tier

tobramycin sulfate soln ij40 mgml 80 mg2ml 12gm30ml

$0-$335 (Tier

tobramycin sulfate solr ij12 gm

$0-$335 (Tier

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain Swelling Muscle and JointConditions

Name of drug

What the

level)

Anti-TNF-alpha - Monoclonal Antibodies

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT

$0-$835 (Tier

HUMIRA PEN PNKT

$0-$835 (Tier

HUMIRA PEN-CDUCHSSTARTER PNKT

$0-$835 (Tier

HUMIRA PEN-PSUVSTARTER PNKT

$0-$835 (Tier

HUMIRA PSKT

$0-$835 (Tier

SIMPONI ARIA SOLN

$0-$835 (Tier

SIMPONI SOAJ

$0-$835 (Tier

SIMPONI SOSY

$0-$835 (Tier

Antirheumatic - Enzyme Inhibitors

XELJANZ TABS

$0-$835 (Tier

Antirheumatic Antimetabolites

Name of drug

What the

level)

OTREXUP SOAJ 10 MG04ML 15 MG04ML20 MG04ML 25MG04ML 125MG04ML 175MG04ML 225 MG04ML

$0-$835 (Tier

RASUVO SOAJ 10 MG02ML 15 MG03ML20 MG04ML 25MG05ML 30 MG06ML75 MG015ML 125MG025ML 175MG035ML 225MG045ML

$0-$835 (Tier

Gold Compounds

RIDAURA CAPS

$0-$835 (Tier

Interleukin-1 Blockers

ARCALYST SOLR

$0-$835 (Tier

Interleukin-1 Receptor Antagonist (IL-1Ra)

KINERET SOSY

$0-$835 (Tier

Interleukin-1beta Blockers

ILARIS SOLN

$0-$835 (Tier

ILARIS SOLR

$0-$835 (Tier

Interleukin-6 Receptor Inhibitors

Name of drug

What the

level)

ACTEMRA SOLN

$0-$835 (Tier

ACTEMRA SOSY

$0-$835 (Tier

KEVZARA SOAJ

$0-$835 (Tier

KEVZARA SOSY

$0-$835 (Tier

Nonsteroidal Anti-inflammatory Agents (NSAIDs)

celecoxib caps

$0-$335 (Tier

CHILDRENS ADVIL SUSP (Ibuprofen)

$0 (Tier

RXOTC MONT

CHILDRENS MOTRIN SUSP (Ibuprofen)

$0 (Tier

RXOTC MONT

diclofenac potassium tabs

$0-$335 (Tier

diclofenac sodium tb24 or 100 mg

$0-$335 (Tier

diclofenac sodium tbec or 25 mg 50 mg 75 mg

$0-$335 (Tier

diclofenac w misoprostoltbec

$0-$335 (Tier

Name of drug

What the

level)

etodolac caps

$0-$335 (Tier

etodolac tabs

$0-$335 (Tier

etodolac tb24

$0-$335 (Tier

flurbiprofen tabs or 50 mg100 mg

$0-$335 (Tier

ibuprofen caps or 200 mg $0

(Tier 3)

ibuprofen chew or 100 mg $0

(Tier 3)

ibuprofen susp or 100mg5ml

$0 (Tier

Over-the-counterRXOTC MO NT

$0-$335 (Tier

RXOTC MO

ibuprofen susp or 40mgml 50 mg125ml

$0 (Tier

ibuprofen tabs or 100 mg $0

(Tier 3)

ibuprofen tabs or 400 mg

$0-$335 (Tier

SL(8 ea daily)MO

Name of drug

What the

level)

$0-$335 (Tier

SL(533 eadaily) MO

$0-$335 (Tier

SL(4 ea daily)MO

indomethacin caps or 25mg 50 mg

$0-$335 (Tier

indomethacin cpcr or 75 mg

$0-$335 (Tier

ketoprofen caps 50 mg 75 mg

$0-$335 (Tier

ketorolac tromethamine soln ij 15 mgml 30 mgml

$0-$335 (Tier

ketorolac tromethamine soln im 30 mgml 60mg2ml

$0-$335 (Tier

mefenamic acid caps or $0-

$335 (Tier

meloxicam tabs or 15 mg75 mg

$0-$335 (Tier

nabumetone tabs

$0-$335 (Tier

naproxen sodium caps or220 mg

$0 (Tier

Name of drug

What the

level)

naproxen sodium tabs or275 mg 550 mg

$0-$335 (Tier

naproxen tabs or 250 mg375 mg 500 mg

$0-$335 (Tier

naproxen tbec or 375 mg500 mg

$0-$335 (Tier

oxaprozin tabs

$0-$335 (Tier

piroxicam caps or 10 mg20 mg

$0-$335 (Tier

sulindac tabs or 150 mg200 mg

$0-$335 (Tier

tolmetin sodium caps 400 mg

$0-$335 (Tier

tolmetin sodium tabs 200 mg

$0-$335 (Tier

Phosphodiesterase 4 (PDE4) Inhibitors

OTEZLA TABS

$0-$835 (Tier

OTEZLA TBPK

$0-$835 (Tier

Pyrimidine Synthesis Inhibitors

Name of drug

What the

level)

leflunomide tabs or 10 mg20 mg

$0-$335 (Tier

Selective Costimulation Modulators

ORENCIA CLICKJECT SOAJ

$0-$835 (Tier

ORENCIA SOLR

$0-$835 (Tier

ORENCIA SOSY

$0-$835 (Tier

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL MINI SOCT

$0-$835 (Tier

ENBREL SOLR

$0-$835 (Tier

ENBREL SOSY

$0-$835 (Tier

ENBREL SURECLICK SOAJ

$0-$835 (Tier

ANALGESICS - NonNarcotic - Drugs to TreatPain Muscle and Joint Conditions

Analgesics Other

acetaminophen chew or160 mg

$0 (Tier

Name of drug

What the

level)

acetaminophen chew or 80 mg

$0 (Tier

acetaminophen liqd or 160mg5ml

$0 (Tier

acetaminophen soln or 160mg5ml 650 mg203ml325 mg1015ml

$0 (Tier

acetaminophen supp re120 mg

$0 (Tier

acetaminophen susp or160 mg5ml 80 mg25ml

$0 (Tier

acetaminophen susp or 80mg08ml

$0 (Tier

acetaminophen tbdp or 160 mg

$0 (Tier

FEVERALL INFANTS SUPP

$0 (Tier

NORTEMP INFANTS SUSP

$0 (Tier

Salicylates

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

$0 (Tier

ASPIRIN SUPP RE 300 MG 600 MG

$0 (Tier

aspirin supp re 300 mg600 mg

$0 (Tier

Name of drug

What the

level)

aspirin tabs or 325 mg $0

(Tier 3)

aspirin tbec or 81 mg 324mg 325 mg

$0 (Tier

BUFFERIN LOW DOSE TABS

$0 (Tier

diflunisal tabs

$0-$335 (Tier

ANALGESICS - OPIOID - Drugs to Treat PainMuscle and Joint Conditions

Opioid Agonists

fentanyl citrate lpop bu 200 mcg

$0-$335 (Tier

PA QL(8 eadaily) MO

fentanyl citrate lpop bu 400mcg 600 mcg 800 mcg1200 mcg 1600 mcg

$0-$335 (Tier

PA QL(4 eadaily) MO

fentanyl pt72 100 mcghr $0-

$335 (Tier

QL(05 eadaily) MO

$335 (Tier

Limit 43 patches permonthQL(144ea daily) MO

$335 (Tier

QL(094 eadaily) MO

fentanyl pt72 50 mcghr 75mcghr

$0-$335 (Tier

Name of drug

What the

level)

hydromorphone hcl liqd or1 mgml

$0-$335 (Tier

QL(50 mldaily) MO

hydromorphone hcl soln ij10 mgml 50 mg5ml 500mg50ml

$0-$335 (Tier

hydromorphone hcl soln ij 2mgml

$0-$335 (Tier

Preservative Free

$0-$335 (Tier

hydromorphone hcl tabs or2 mg

$0-$335 (Tier

QL(25 eadaily) MO

$0-$335 (Tier

QL(125 eadaily) MO

$0-$335 (Tier

QL(625 eadaily) MO

HYDROMORPHONE HYDROCHLORIDE SOLN 2 MGML

$0-$835 (Tier

Preservative Free

LAZANDA SOLN 100 MCGACT

$0-$835 (Tier

PA QL(1 eadaily) MO

$0-$835 (Tier

PA QL(05 eadaily) MO

Name of drug

What the

level)

$0-$835 (Tier

meperidine hcl soln ij 25mgml

$0-$335 (Tier

AL(Up to 64 yrsold)

meperidine hcl soln ij 50mgml 100 mgml

$0-$335 (Tier

methadone hcl conc or 10 mgml

$0-$335 (Tier

QL(667 mldaily) MO

methadone hcl soln or 10 mg5ml

$0-$335 (Tier

QL(3334 mldaily) MO

$0-$335 (Tier

QL(6667 mldaily) MO

methadone hcl tabs or 10 mg

$0-$335 (Tier

QL(667 eadaily) MO

$0-$335 (Tier

QL(1334 eadaily) MO

morphine sulfate cp24 or10 mg

$0-$335 (Tier

QL(20 eadaily) MO

$0-$335 (Tier

QL(2 ea daily)MO

Name of drug

What the

level)

$0-$335 (Tier

QL(10 eadaily) MO

$0-$335 (Tier

QL(667 eadaily) MO

$0-$335 (Tier

QL(4 ea daily)MO

$0-$335 (Tier

QL(334 eadaily) MO

$0-$335 (Tier

QL(25 eadaily) MO

morphine sulfate soln ij 05mgml

$0-$335 (Tier

morphine sulfate soln or 10mg5ml

$0-$335 (Tier

QL(100 mldaily) MO

$0-$335 (Tier

QL(50 mldaily) MO

morphine sulfate soln or 20mgml 100 mg5ml

$0-$335 (Tier

QL(10 mldaily) MO

Name of drug

What the

level)

MORPHINE SULFATE TABS OR 15 MG

$0-$835 (Tier

QL(1334 eadaily) MO

$0-$835 (Tier

QL(667 eadaily) MO

morphine sulfate tbcr or100 mg 200 mg

$0-$335 (Tier

QL(2 ea daily)MO

morphine sulfate tbcr or 15 mg

$0-$335 (Tier

QL(1334 eadaily) MO

$0-$335 (Tier

QL(667 eadaily) MO

$0-$335 (Tier

QL(334 eadaily) MO

oxycodone hcl caps or 5 mg

$0-$335 (Tier

QL(2667 eadaily) MO

oxycodone hcl conc or 100mg5ml

$0-$335 (Tier

QL(667 mldaily) MO

oxycodone hcl tabs or 10 mg

$0-$335 (Tier

QL(133 eadaily) MO

$0-$335 (Tier

QL(89 eadaily) MO

Name of drug

What the

level)

$0-$335 (Tier

QL(665 eadaily) MO

$0-$335 (Tier

QL(444 eadaily) MO

$0-$335 (Tier

QL(2667 eadaily) MO

oxymorphone hcl tabs 10 mg

$0-$335 (Tier

QL(667 eadaily) MO

$0-$335 (Tier

QL(1334 eadaily) MO

oxymorphone hcl tb12 15 mg

$0-$335 (Tier

QL(444 eadaily) MO

$0-$335 (Tier

QL(889 eadaily) MO

SUBSYS LIQD 100 MCG

$0-$835 (Tier

SUBSYS LIQD 1200 MCG

$0-$835 (Tier

PA QL(2 eadaily)

SUBSYS LIQD 200 MCG

$0-$835 (Tier

PA QL(8 eadaily) MO

Name of drug

What the

level)

SUBSYS LIQD 400 MCG 600 MCG 800 MCG 1600 MCG

$0-$835 (Tier

PA QL(4 eadaily) MO

tramadol hcl tabs or 50 mg

$0-$335 (Tier

SL(8 ea daily)MO

tramadol hcl tb24 or 100 mg

$0-$335 (Tier

SL(3 ea daily)MO

$0-$335 (Tier

SL(15 eadaily) MO

$0-$335 (Tier

SL(1 ea daily)MO

ZOHYDRO ER C12A 10 MG

$0-$835 (Tier

Name of drug

What the

level)

$0-$835 (Tier

Opioid Combinations

acetaminophen w codeinesoln 120mg5ml-12mg5ml

$0-$335 (Tier

SL(150 mldaily) MO

acetaminophen w codeinetabs 300mg-15mg

$0-$335 (Tier

SL(133 eadaily) MO

$0-$335 (Tier

SL(12 ea daily)MO

$0-$335 (Tier

SL(6 ea daily)MO

butalbital-aspirin-caffeinewcod caps

$0-$335 (Tier

AL(Up to 64 yrsold) SL(6 eadaily) MO

hydrocodone-acetaminophen soln25mg5ml-108mg5ml5mg10ml-217mg10ml75mg15ml-325mg15ml

$0-$335 (Tier

Limit 5535mls permonthSL(1845 ml daily) MO

hydrocodone- $0- SL(133 eaacetaminophen tabs 5mg- $335 daily) MO300mg 10mg-300mg (Tier75mg-300mg 1) hydrocodone- $0- SL(123 eaacetaminophen tabs 5mg- $335 daily) MO325mg 10mg-325mg (Tier 75mg-325mg 1)

hydrocodone-ibuprofentabs

$0-$335 (Tier

Name of drug

What the

level)

oxycodone wacetaminophen tabs

$0-$335 (Tier

SL(123 eadaily) MO

oxycodone-aspirin tabs

$0-$335 (Tier

tramadol-acetaminophentabs

$0-$335 (Tier

SL(8 ea daily)MO

Opioid Partial Agonists

buprenorphine hcl soln ij03 mgml

$0-$335 (Tier

buprenorphine hcl subl sl 2 mg

$0-$335 (Tier

PA QL(4 eadaily) MO

buprenorphine hcl-naloxone hcl dihydrate subl8mg-2mg 2mg-05mg

$0-$335 (Tier

butorphanol tartrate soln ij2 mgml

$0-$335 (Tier

butorphanol tartrate soln na10 mgml

$0-$335 (Tier

Limit 210mls per monthQL(7ml daily) MO

nalbuphine hcl soln ij 10mgml 20 mgml

$0-$335 (Tier

Name of drug

What the

level)

ANDROGENS-ANABOLIC - Drugs to RegulateHormones

Anabolic Steroids

ANADROL-50 TABS

$0-$835 (Tier

oxandrolone tabs or 10 mg25 mg

$0-$335 (Tier

Androgens

ANDRODERM PT24

$0-$835 (Tier

ANDROGEL GEL 405 MG25GM 2025MG125GM (Testosterone)

$0-$835 (Tier

ANDROGEL PUMP GEL (Testosterone)

$0-$835 (Tier

AVEED SOLN

$0-$835 (Tier

danazol caps or 50 mg100 mg 200 mg

$0-$335 (Tier

fluoxymesterone tabs

$0-$335 (Tier

methyltestosterone caps or $0-

$335 (Tier

Name of drug

What the

level)

testosterone cypionate soln

$0-$335 (Tier

testosterone enanthate soln im

$0-$335 (Tier

testosterone gel 1 162 50 mg5gm 25mg25gm 405 mg25gm2025 mg125gm

$0-$335 (Tier

TESTOSTERONE GEL 1 50 MG5GM 25MG25GM

$0-$835 (Tier

TESTOSTERONE PUMP GEL

$0-$835 (Tier

VOGELXO GEL

$0-$835 (Tier

VOGELXO PUMP GEL

$0-$835 (Tier

ANORECTAL AGENTS - Rectal Drugs to TreatPain Swelling and Itching

Intrarectal Steroids

hydrocortisone (intrarectal) enem

$0-$335 (Tier

UCERIS FOAM RE 2 MGACT

$0-$835 (Tier

Rectal Steroids

Name of drug

What the

level)

hydrocortisone (rectal) crea

$0-$335 (Tier

Vasodilating Agents

RECTIV OINT

$0-$835 (Tier

ANTACIDS

Antacid Combinations alum amp mag hydrox-simethicone chew 200mg-25mg-200mg

$0 (Tier

alum amp mag hydrox-simethicone liqd200mg5ml-20mg5ml-200mg5ml 400mg5ml-40mg5ml-400mg5ml

$0 (Tier

alum amp mag hydrox-simethicone susp200mg5ml-20mg5ml-200mg5ml 400mg5ml-40mg5ml-400mg5ml200mg5ml-200mg5ml-20mg5ml-20mg5ml-200mg5ml-200mg5ml400mg5ml-400mg5ml-40mg5ml-40mg5ml-400mg5ml-400mg5ml

$0 (Tier

aluminum hydroxide-magtrisil chew

$0 (Tier

Antacids - Aluminum Salts

ALUMINUM HYDROXIDE SUSP OR

$0 (Tier

Antacids - Calcium Salts calcium carbonate (antacid) chew 500 mg750 mg

$0 (Tier

Name of drug

What the

level)

calcium carbonate (antacid)tabs 648 mg

$0 (Tier

CALCIUM CARBONATE TABS OR 648 MG

$0 (Tier

ANTHELMINTICS - Drugs to Treat WormInfections

Anthelmintics

albendazole tabs or $0-

$335 (Tier

ALBENZA TABS (Albendazole)

$0-$835 (Tier

ivermectin tabs or $0-

$335 (Tier

pyrantel pamoate susp or $0

(Tier 3)

ANTI-INFECTIVE AGENTS - MISC - Drugs toTreat Bacterial Infections

Anti-infective Agents - Misc

colistimethate sodium solr ij $0-

$335 (Tier

IMPAVIDO CAPS

$0-$835 (Tier

metronidazole caps or 375 mg

$0-$335 (Tier

SL(106 eadaily) MO

Name of drug

What the

level)

metronidazole in nacl soln

$0-$335 (Tier

metronidazole tabs or 250 mg

$0-$335 (Tier

SL(16 ea daily)MO

$0-$335 (Tier

SL(8 ea daily)MO

NEBUPENT SOLR

$0-$835 (Tier

PENTAM 300 SOLR

$0-$835 (Tier

tinidazole tabs or 250 mg500 mg

$0-$335 (Tier

trimethoprim tabs or $0-

$335 (Tier

XIFAXAN TABS 200 MG

$0-$835 (Tier

XIFAXAN TABS 550 MG

$0-$835 (Tier

QL(3 ea daily)MO

Anti-infective Misc - Combinations

sulfamethoxazole-trimethoprim soln

$0-$335 (Tier

Name of drug

What the

level)

sulfamethoxazole-trimethoprim susp

$0-$335 (Tier

sulfamethoxazole-trimethoprim tabs

$0-$335 (Tier

Antiprotozoal Agents

ALINIA TABS 500 MG

$0-$835 (Tier

atovaquone susp

$0-$335 (Tier

Carbapenems

ertapenem sodium solr $0-

$335 (Tier

imipenem-cilastatin solr $0-

$335 (Tier

INVANZ SOLR IJ (Ertapenem Sodium)

$0-$835 (Tier

meropenem solr 1 gm

$0-$335 (Tier

meropenem solr 500 mg

$0-$335 (Tier

VABOMERE SOLR

$0-$835 (Tier

Name of drug

What the

level)

Chloramphenicols

chloramphenicol sodiumsuccinate solr

$0-$335 (Tier

Cyclic Lipopeptides

daptomycin solr 500 mg

$0-$335 (Tier

Glycopeptides

ORBACTIV SOLR

$0-$835 (Tier

vancomycin hcl caps or125 mg 250 mg

$0-$335 (Tier

VANCOMYCIN HCL IN DEXTROSE SOLN 5-1GM200ML 5-500MG100ML 5-750MG150ML

$0-$835 (Tier

vancomycin hcl solr iv 1gm 5 gm 10 gm

$0-$335 (Tier

vancomycin hcl solr iv 500 mg

$0-$335 (Tier

Glycylcyclines

TIGECYCLINE SOLR

$0-$835 (Tier

tigecycline solr $0-

$335 (Tier

Name of drug

What the

level)

TYGACIL SOLR (Tigecycline)

$0-$835 (Tier

Leprostatics

dapsone tabs or 25 mg100 mg

$0-$335 (Tier

Lincosamides

CLEOCIN PHOSPHATE SOLN IV 600 MG4ML(Clindamycin Phosphate)

$0-$835 (Tier

clindamycin hcl caps or 75mg 150 mg 300 mg

$0-$335 (Tier

clindamycin palmitatehydrochloride solr

$0-$335 (Tier

clindamycin phosphate ind5w soln

$0-$335 (Tier

clindamycin phosphate solnij 150 mgml 9000 mg60ml

$0-$335 (Tier

clindamycin phosphate solnij 600 mg4ml 900 mg6ml

$0-$335 (Tier

clindamycin phosphate solniv 600 mg4ml

$0-$335 (Tier

lincomycin hcl soln ij $0-

$335 (Tier

Name of drug

What the

level)

Monobactams

aztreonam solr $0-

$335 (Tier

CAYSTON SOLR

$0-$835 (Tier

Oxazolidinones

linezolid soln iv 600 mg300ml

$0-$335 (Tier

LINEZOLID SOLN IV 600MG300ML-09

$0-$835 (Tier

linezolid susr or 100 mg5ml

$0-$335 (Tier

linezolid tabs or 600 mg

$0-$335 (Tier

SIVEXTRO SOLR IV

$0-$835 (Tier

SIVEXTRO TABS OR

$0-$835 (Tier

ZYVOX SOLN IV 200 MG100ML

$0-$835 (Tier

Polymyxins

Name of drug

What the

level)

polymyxin b sulfate solr ij $0-

$335 (Tier

Streptogramins

SYNERCID SOLR

$0-$835 (Tier

ANTIANGINAL AGENTS - Drugs to Treat ChestPain

Antianginals-Other

RANEXA TB12

$0-$835 (Tier

Nitrates

isosorbide dinitrate tabs

$0-$335 (Tier

isosorbide dinitrate tbcr $0-

$335 (Tier

isosorbide mononitrate tabs 10 mg 20 mg

$0-$335 (Tier

isosorbide mononitrate tb24 30 mg 60 mg 120 mg

$0-$335 (Tier

NITROGLYCERIN LINGUAL AERS

$0-$835 (Tier

nitroglycerin pt24 td 01mghr 02 mghr 04mghr 06 mghr

$0-$335 (Tier

Name of drug

What the

level)

nitroglycerin soln tl 04mgspray

$0-$335 (Tier

nitroglycerin subl sl 03 mg04 mg 06 mg

$0-$335 (Tier

NITROSTAT SUBL (Nitroglycerin)

$0-$835 (Tier

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc

buspirone hcl tabs or 5 mg10 mg 15 mg 30 mg 75 mg

$0-$335 (Tier

hydroxyzine hcl soln im 50mgml

$0-$335 (Tier

hydroxyzine hcl syrp or 10mg5ml

$0-$335 (Tier

hydroxyzine hcl tabs or 10mg 25 mg 50 mg

$0-$335 (Tier

hydroxyzine pamoate capsor 25 mg 50 mg

$0-$335 (Tier

Benzodiazepines

alprazolam tabs or 025mg 05 mg 1 mg 2 mg

$0-$335 (Tier

Name of drug

What the

level)

alprazolam tb24 or 05 mg1 mg 2 mg 3 mg

$0-$335 (Tier

alprazolam tbdp or 025mg 05 mg 1 mg 2 mg

$0-$335 (Tier

clorazepate dipotassiumtabs

$0-$335 (Tier

diazepam conc or 5 mgml $0-

$335 (Tier

diazepam soln or 5 mg5ml $0-

$335 (Tier

diazepam tabs or 2 mg 5mg 10 mg

$0-$335 (Tier

lorazepam conc or 2 mgml $0-

$335 (Tier

lorazepam soln ij 2 mgml4 mgml 20 mg10ml

$0-$335 (Tier

lorazepam tabs or 05 mg1 mg 2 mg

$0-$335 (Tier

oxazepam caps 10 mg 15mg 30 mg

$0-$335 (Tier

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythms

Name of drug

What the

level)

Antiarrhythmics Type I-A

disopyramide phosphate caps

$0-$335 (Tier

quinidine gluconate tbcr or324 mg

$0-$335 (Tier

quinidine sulfate tabs

$0-$335 (Tier

Antiarrhythmics Type I-B

mexiletine hcl caps

$0-$335 (Tier

Antiarrhythmics Type I-C

flecainide acetate tabs 100 mg

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(266 eadaily) MO

$0-$335 (Tier

SL(8 ea daily)MO

propafenone hcl cp12

$0-$335 (Tier

propafenone hcl tabs

$0-$335 (Tier

Antiarrhythmics Type III

Name of drug

What the

level)

amiodarone hcl tabs or 100 mg 200 mg 400 mg

$0-$335 (Tier

dofetilide caps

$0-$335 (Tier

MULTAQ TABS

$0-$835 (Tier

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions

Anti-Inflammatory Agents

cromolyn sodium nebu in

$0-$335 (Tier

Antiasthmatic - Monoclonal Antibodies

CINQAIR SOLN

$0-$835 (Tier

FASENRA SOSY

$0-$835 (Tier

NUCALA SOLR

$0-$835 (Tier

XOLAIR SOLR

$0-$835 (Tier

Bronchodilators - Anticholinergics

ATROVENT HFA AERS

$0-$835 (Tier

Limit 2 inhalers permonthQL(086gm daily) MO

Name of drug

What the

level)

ipratropium bromide soln in

$0-$335 (Tier

SPIRIVA HANDIHALER CAPS

$0-$835 (Tier

QL(1 ea daily)MO

SPIRIVA RESPIMAT AERS

$0-$835 (Tier

Limit 1 inhaler per month (60actuations)SL(014 gm daily)MO

TUDORZA PRESSAIR AEPB

$0-$835 (Tier

Limit 2 inhalers per month (30actuations)QL(007 ea daily)MO

$0-$835 (Tier

Limit 1 inhaler per month (60actuations)QL(004 ea daily)MO

Leukotriene Modulators

montelukast sodium chew 4 mg 5 mg

$0-$335 (Tier

montelukast sodium tabs 10 mg

$0-$335 (Tier

zafirlukast tabs

$0-$335 (Tier

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP TABS

$0-$835 (Tier

QL(1 ea daily)MO

Steroid Inhalants

Name of drug

What the

level)

AEROSPAN AERS

$0-$835 (Tier

Limit 2 inhalers per month (120actuations)SL(06 gm daily)

budesonide (inhalation)susp 025 mg2ml 05mg2ml

$0-$335 (Tier

FLOVENT DISKUS AEPB 100 MCGBLIST

$0-$835 (Tier

SL(20 ea daily)MO

$0-$835 (Tier

SL(8 ea daily)MO

$0-$835 (Tier

SL(40 ea daily)MO

FLOVENT HFA AERO 110 MCGACT 220 MCGACT

$0-$835 (Tier

FLOVENT HFA AERO 44 MCGACT

$0-$835 (Tier

Limit 1 inhaler permonthQL(036gm daily) MO

QVAR AERS

$0-$835 (Tier

Sympathomimetics

ADVAIR DISKUS AEPB

$0-$835 (Tier

ADVAIR HFA AERO

$0-$835 (Tier

QL(4 gm daily)MO

Name of drug

What the

level)

albuterol sulfate nebu in 063 mg3ml 0083 05 125 mg3ml

$0-$335 (Tier

albuterol sulfate syrp or 2mg5ml

$0-$335 (Tier

albuterol sulfate tabs or 2 mg 4 mg

$0-$335 (Tier

albuterol sulfate tb12 or 4 mg 8 mg

$0-$335 (Tier

ANORO ELLIPTA AEPB

$0-$835 (Tier

QL(2 ea daily)MO

BREO ELLIPTA AEPB 25MCGINH-100MCGINH25MCGINH-200MCGINH

$0-$835 (Tier

Limit 2 inhalers per month(InstitutionalPack)SL(2 eadaily) MO

$0-$835 (Tier

Limit 1 inhaler per monthSL(2ea daily) MO

COMBIVENT RESPIMAT AERS

$0-$835 (Tier

Limit 1 inhaler permonthSL(02gm daily) MO

DULERA AERO

$0-$835 (Tier

QL(4 gm daily)MO

ipratropium-albuterol soln

$0-$335 (Tier

Name of drug

What the

level)

levalbuterol hcl nebu in 031 mg3ml 063 mg3ml125 mg3ml 125mg05ml

$0-$335 (Tier

PROAIR HFA AERS

$0-$835 (Tier

PROAIR RESPICLICK AEPB

$0-$835 (Tier

PROVENTIL HFA AERS

$0-$835 (Tier

SEREVENT DISKUS AEPB

$0-$835 (Tier

QL(2 ea daily)MO

STIOLTO RESPIMAT AERS

$0-$835 (Tier

STRIVERDI RESPIMAT AERS

$0-$835 (Tier

terbutaline sulfate tabs or 5 mg 25 mg

$0-$335 (Tier

TRELEGY ELLIPTA AEPB

$0-$835 (Tier

UTIBRON NEOHALER CAPS

$0-$835 (Tier

Xanthines

Name of drug

What the

level)

aminophylline soln

$0-$335 (Tier

theophylline tb12 100 mg200 mg 300 mg 450 mg

$0-$335 (Tier

theophylline tb24 400 mg600 mg

$0-$335 (Tier

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants

warfarin sodium tabs

$0-$335 (Tier

Direct Factor Xa Inhibitors

BEVYXXA CAPS

$0-$835 (Tier

QL(1 ea daily)

ELIQUIS STARTER PACK TABS

$0-$835 (Tier

ELIQUIS TABS

$0-$835 (Tier

XARELTO STARTER PACK TBPK

$0-$835 (Tier

XARELTO TABS 10 MG 15 MG 20 MG

$0-$835 (Tier

Heparins And Heparinoid-Like Agents

Name of drug

What the

level)

enoxaparin sodium soln

$0-$335 (Tier

fondaparinux sodium soln

$0-$335 (Tier

FRAGMIN SOLN

$0-$835 (Tier

heparin sodium (porcine)soln

$0-$335 (Tier

Thrombin Inhibitors

argatroban soln 250mg25ml

$0-$335 (Tier

IPRIVASK SOLR

$0-$835 (Tier

PRADAXA CAPS

$0-$835 (Tier

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists

FYCOMPA SUSP

$0-$835 (Tier

FYCOMPA TABS

$0-$835 (Tier

Anticonvulsants - Benzodiazepines

Name of drug

What the

level)

clonazepam tabs or 05 mg

$0-$335 (Tier

SL(40 ea daily)MO

$0-$335 (Tier

SL(20 ea daily)MO

$0-$335 (Tier

SL(10 ea daily)MO

clonazepam tbdp or 0125mg 025 mg 05 mg 1 mg2 mg

$0-$335 (Tier

DIASTAT ACUDIAL GEL

$0-$835 (Tier

DIASTAT PEDIATRIC GEL

$0-$835 (Tier

diazepam (anticonvulsant)gel

$0-$835 (Tier

DIAZEPAM GEL RE 20 MG 25 MG

$0-$835 (Tier

DIAZEPAM RECTAL GEL GEL

$0-$835 (Tier

ONFI SUSP

$0-$835 (Tier

Name of drug

What the

level)

ONFI TABS

$0-$835 (Tier

Anticonvulsants - Misc

APTIOM TABS

$0-$835 (Tier

BANZEL SUSP

$0-$835 (Tier

BANZEL TABS

$0-$835 (Tier

BRIVIACT SOLN IV 50 MG5ML

$0-$835 (Tier

SL(20 ml daily)

BRIVIACT SOLN OR 10 MGML

$0-$835 (Tier

PA SL(20 mldaily) MO

BRIVIACT TABS OR 10 MG

$0-$835 (Tier

PA SL(20 eadaily) MO

$0-$835 (Tier

PA SL(2 eadaily) MO

$0-$835 (Tier

PA SL(8 eadaily) MO

$0-$835 (Tier

PA SL(4 eadaily) MO

Name of drug

What the

level)

$0-$835 (Tier

carbamazepine chew or100 mg

$0-$335 (Tier

carbamazepine cp12 or100 mg 200 mg 300 mg

$0-$335 (Tier

carbamazepine susp or100 mg5ml

$0-$335 (Tier

carbamazepine tabs or 200 mg

$0-$335 (Tier

carbamazepine tb12 or 100mg 200 mg 400 mg

$0-$335 (Tier

gabapentin caps or 100mg 300 mg 400 mg

$0-$335 (Tier

gabapentin soln or 250mg5ml 300 mg6ml

$0-$335 (Tier

gabapentin tabs or 600 mg800 mg

$0-$335 (Tier

LAMICTAL XR KIT

$0-$835 (Tier

Name of drug

What the

level)

lamotrigine chew 5 mg 25 mg

$0-$335 (Tier

lamotrigine tabs 25 mg100 mg 150 mg 200 mg

$0-$335 (Tier

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

$0-$335 (Tier

levetiracetam in sodium chloride soln

$0-$335 (Tier

levetiracetam soln iv 500 mg5ml

$0-$335 (Tier

levetiracetam soln or 100 mgml 500 mg5ml

$0-$335 (Tier

levetiracetam tabs or 250 mg 500 mg 750 mg 1000 mg

$0-$335 (Tier

levetiracetam tb24 or 500 mg 750 mg

$0-$335 (Tier

LYRICA CAPS 150 MG 200 MG 225 MG

$0-$835 (Tier

QL(2 ea daily)MO

LYRICA CAPS 25 MG 50 MG 75 MG 100 MG

$0-$835 (Tier

QL(3 ea daily)MO

Name of drug

What the

level)

LYRICA CAPS 300 MG

$0-$835 (Tier

SL(2 ea daily)MO

LYRICA SOLN 20 MGML

$0-$835 (Tier

SL(30 ml daily)MO

oxcarbazepine susp

$0-$335 (Tier

oxcarbazepine tabs

$0-$335 (Tier

POTIGA TABS 200 MG

$0-$835 (Tier

SL(6 ea daily)MO

POTIGA TABS 400 MG

$0-$835 (Tier

SL(3 ea daily)MO

POTIGA TABS 50 MG

$0-$835 (Tier

SL(24 ea daily)MO

primidone tabs or 50 mg250 mg

$0-$335 (Tier

SPRITAM TB3D 1000 MG

$0-$835 (Tier

PA SL(3 eadaily) MO

SPRITAM TB3D 250 MG

$0-$835 (Tier

Name of drug

What the

level)

SPRITAM TB3D 500 MG

$0-$835 (Tier

PA SL(6 eadaily) MO

SPRITAM TB3D 750 MG

$0-$835 (Tier

PA SL(4 eadaily) MO

topiramate cpsp or 15 mg25 mg

$0-$335 (Tier

topiramate tabs or 25 mg50 mg 100 mg 200 mg

$0-$335 (Tier

VIMPAT SOLN IV 200 MG20ML

$0-$835 (Tier

VIMPAT SOLN OR 10 MGML

$0-$835 (Tier

VIMPAT TABS OR 50 MG 100 MG 150 MG 200 MG

$0-$835 (Tier

zonisamide caps

$0-$335 (Tier

Carbamates

felbamate susp

$0-$335 (Tier

felbamate tabs

$0-$335 (Tier

GABA Modulators

Name of drug

What the

level)

GABITRIL TABS 12 MG 16 MG (Tiagabine HCl)

$0-$835 (Tier

SABRIL PACK (Vigabatrin)

$0-$835 (Tier

SABRIL TABS

$0-$835 (Tier

tiagabine hcl tabs

$0-$335 (Tier

vigabatrin pack

$0-$335 (Tier

Hydantoins

fosphenytoin sodium soln100 mg pe2ml

$0-$335 (Tier

PEGANONE TABS

$0-$835 (Tier

phenytoin chew or 50 mg

$0-$335 (Tier

phenytoin sodium extendedcaps 30 mg 100 mg 200mg 300 mg

$0-$335 (Tier

Name of drug

What the

level)

phenytoin sodium soln ij $0-

$335 (Tier

phenytoin susp or 125mg5ml

$0-$335 (Tier

Succinimides

CELONTIN CAPS

$0-$835 (Tier

ethosuximide caps or 250 mg

$0-$335 (Tier

ethosuximide soln or 250 mg5ml

$0-$335 (Tier

Valproic Acid

divalproex sodium csdr $0-

$335 (Tier

divalproex sodium tb24

$0-$335 (Tier

divalproex sodium tbec

$0-$335 (Tier

valproate sodium soln iv100 mgml 500 mg5ml

$0-$335 (Tier

valproate sodium soln or250 mg5ml

$0-$335 (Tier

Name of drug

What the

level)

valproic acid caps

$0-$335 (Tier

ANTIDEPRESSANTS - Drugs to TreatDepression

Alpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tabs

$0-$335 (Tier

mirtazapine tbdp

$0-$335 (Tier

Antidepressants - Misc

bupropion hcl tabs or 100 mg

$0-$335 (Tier

SL(45 eadaily) MO

$0-$335 (Tier

SL(6 ea daily)MO

bupropion hcl tb12 or 100 mg

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(266 eadaily) MO

$0-$335 (Tier

SL(2 ea daily)MO

$0-$335 (Tier

SL(3 ea daily)MO

Name of drug

What the

level)

$0-$335 (Tier

SL(15 eadaily) MO

BUPROPION HYDROCHLORIDE ER TB24

$0-$835 (Tier

FORFIVO XL TB24

$0-$835 (Tier

maprotiline hcl tabs

$0-$335 (Tier

Monoamine Oxidase Inhibitors (MAOIs)

EMSAM PT24

$0-$835 (Tier

MARPLAN TABS

$0-$835 (Tier

phenelzine sulfate tabs or $0-

$335 (Tier

tranylcypromine sulfatetabs

$0-$335 (Tier

Selective Serotonin Reuptake Inhibitors (SSRIs)

citalopram hydrobromidesoln 10 mg5ml

$0-$335 (Tier

SL(20 ml daily)MO

citalopram hydrobromidetabs 10 mg

$0-$335 (Tier

SL(4 ea daily)MO

Name of drug

What the

level)

$0-$335 (Tier

SL(2 ea daily)MO

$0-$335 (Tier

SL(1 ea daily)MO

escitalopram oxalate soln

$0-$335 (Tier

escitalopram oxalate tabs

$0-$335 (Tier

fluoxetine hcl caps or 10mg 20 mg 40 mg

$0-$335 (Tier

fluoxetine hcl cpdr or 90 mg

$0-$335 (Tier

fluoxetine hcl soln or 20 mg5ml

$0-$335 (Tier

fluoxetine hcl tabs or 10 mg 20 mg

$0-$335 (Tier

fluvoxamine maleate cp24

$0-$335 (Tier

fluvoxamine maleate tabs

$0-$335 (Tier

Name of drug

What the

level)

paroxetine hcl tabs

$0-$335 (Tier

paroxetine hcl tb24

$0-$335 (Tier

PAXIL SUSP 10 MG5ML

$0-$835 (Tier

sertraline hcl conc or 20 mgml

$0-$335 (Tier

sertraline hcl tabs or 25 mg 50 mg 100 mg

$0-$335 (Tier

Serotonin Modulators

nefazodone hcl tabs 50 mg100 mg 150 mg 200 mg250 mg

$0-$335 (Tier

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

$0-$335 (Tier

TRINTELLIX TABS 10 MG

$0-$835 (Tier

ST QL(2 eadaily) MO

$0-$835 (Tier

ST QL(1 eadaily) MO

$0-$835 (Tier

ST QL(4 eadaily) MO

Name of drug

What the

level)

VIIBRYD STARTER PACK KIT

$0-$835 (Tier

VIIBRYD TABS

$0-$835 (Tier

Serotonin-Norepinephrine Reuptake Inhibitors

DESVENLAFAXINE ER TB24 50 MG 100 MG

$0-$835 (Tier

desvenlafaxine succinate tb24

$0-$335 (Tier

duloxetine hcl cpep 20 mg30 mg 60 mg

$0-$335 (Tier

FETZIMA CP24 20 MG

$0-$835 (Tier

ST QL(2 eadaily) MO

FETZIMA CP24 40 MG 80 MG 120 MG

$0-$835 (Tier

ST QL(1 eadaily) MO

FETZIMA TITRATION PACK C4PK

$0-$835 (Tier

KHEDEZLA TB24

$0-$835 (Tier

venlafaxine hcl cp24 150 mg

$0-$335 (Tier

SL(15 eadaily) MO

Name of drug

What the

level)

$0-$335 (Tier

SL(6 ea daily)MO

$0-$335 (Tier

SL(3 ea daily)MO

venlafaxine hcl tabs 100 mg

$0-$335 (Tier

SL(375 eadaily) MO

$0-$335 (Tier

SL(15 ea daily)MO

$0-$335 (Tier

SL(10 ea daily)MO

$0-$335 (Tier

SL(75 eadaily) MO

$0-$335 (Tier

SL(5 ea daily)MO

venlafaxine hcl tb24 150 mg

$0-$335 (Tier

SL(15 eadaily) MO

$0-$335 (Tier

ST SL(1 eadaily) MO

$0-$335 (Tier

SL(6 ea daily)MO

Name of drug

What the

level)

$0-$335 (Tier

SL(3 ea daily)MO

Tricyclic Agents

amitriptyline hcl tabs

$0-$335 (Tier

amoxapine tabs

$0-$335 (Tier

clomipramine hcl caps or25 mg 50 mg 75 mg

$0-$335 (Tier

desipramine hcl tabs or 10mg 25 mg 50 mg 75 mg100 mg 150 mg

$0-$335 (Tier

doxepin hcl caps or 10 mg25 mg 50 mg 75 mg 100mg 150 mg

$0-$335 (Tier

doxepin hcl conc or 10mgml

$0-$335 (Tier

imipramine hcl tabs or 10mg 25 mg 50 mg

$0-$335 (Tier

imipramine pamoate caps

$0-$335 (Tier

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

$0-$335 (Tier

Name of drug

What the

level)

nortriptyline hcl soln or 10mg5ml

$0-$335 (Tier

protriptyline hcl tabs

$0-$335 (Tier

SURMONTIL CAPS (Trimipramine Maleate)

$0-$835 (Tier

trimipramine maleate capsor 25 mg 50 mg 100 mg

$0-$335 (Tier

ANTIDIABETICS - Drugs to Regulate BloodSugar Alpha-Glucosidase Inhibitors

acarbose tabs

$0-$335 (Tier

QL(3 ea daily)MO

miglitol tabs

$0-$335 (Tier

QL(3 ea daily)MO

Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN

$0-$835 (Tier

PA Limit 12mls permonthQL(04ml daily) MO

SYMLINPEN 60 SOPN

$0-$835 (Tier

Antidiabetic Combinations

alogliptin-metformin hcltabs

$0-$835 (Tier

PA SL(2 eadaily) MO

Name of drug

What the

level)

alogliptin-pioglitazone tabs125mg-15mg

$0-$835 (Tier

PA SL(2 eadaily) MO

$0-$835 (Tier

alogliptin-pioglitazone tabs25mg-15mg 25mg-30mg25mg-45mg 125mg-45mg

$0-$835 (Tier

PA SL(1 eadaily) MO

glipizide-metformin hcl tabs25mg-250mg

$0-$335 (Tier

SL(8 ea daily)MO

glipizide-metformin hcl tabs5mg-500mg 25mg-500mg

$0-$335 (Tier

SL(4 ea daily)MO

glyburide-metformin tabs125mg-250mg

$0-$335 (Tier

glyburide-metformin tabs5mg-500mg 25mg-500mg

$0-$335 (Tier

INVOKAMET TABS 150MG-500MG 50MG-1000MG 150MG-1000MG

$0-$835 (Tier

SL(2 ea daily)MO

INVOKAMET TABS 50MG-500MG

$0-$835 (Tier

SL(4 ea daily)MO

INVOKAMET XR TB24 150MG-500MG 50MG-1000MG 150MG-1000MG

$0-$835 (Tier

SL(2 ea daily)MO

Name of drug

What the

level)

INVOKAMET XR TB24 50MG-500MG

$0-$835 (Tier

SL(4 ea daily)MO

JANUMET TABS

$0-$835 (Tier

SL(2 ea daily)MO

JANUMET XR TB24 100MG-1000MG

$0-$835 (Tier

SL(1 ea daily)MO

JANUMET XR TB24 50MG-500MG 50MG-1000MG

$0-$835 (Tier

SL(2 ea daily)MO

JENTADUETO TABS

$0-$835 (Tier

SL(2 ea daily)MO

JENTADUETO XR TB24 25MG-1000MG

$0-$835 (Tier

SL(2 ea daily)MO

$0-$835 (Tier

SL(1 ea daily)MO

KAZANO TABS

$0-$835 (Tier

PA SL(2 eadaily) MO

KOMBIGLYZE XR TB24 25MG-1000MG

$0-$835 (Tier

PA SL(2 eadaily) MO

KOMBIGLYZE XR TB24 5MG-500MG 5MG-1000MG

$0-$835 (Tier

PA SL(1 eadaily) MO

Name of drug

What the

level)

OSENI TABS 125MG-15MG

$0-$835 (Tier

PA SL(2 eadaily) MO

$0-$835 (Tier

OSENI TABS 25MG-15MG 25MG-30MG 25MG-45MG 125MG-45MG

$0-$835 (Tier

PA SL(1 eadaily) MO

pioglitazone hcl-glimepiridetabs

$0-$335 (Tier

SL(15 eadaily) MO

pioglitazone hcl-metforminhcl tabs

$0-$335 (Tier

SL(3 ea daily)MO

REPAGLINIDEMETFORMIN HYDROCHLORIDE TABS

$0-$835 (Tier

SL(5 ea daily)MO

SYNJARDY TABS 5MG-1000MG 125MG-1000MG

$0-$835 (Tier

SL(2 ea daily)MO

$0-$835 (Tier

SL(4 ea daily)MO

SYNJARDY XR TB24 25MG-1000MG

$0-$835 (Tier

SL(1 ea daily)MO

SYNJARDY XR TB24 5MG-1000MG 10MG-1000MG 125MG-1000MG

$0-$835 (Tier

SL(2 ea daily)MO

Biguanides

Name of drug

What the

level)

metformin hcl tabs or 1000 mg

$0-$335 (Tier

SL(255 eadaily) MO

$0-$335 (Tier

SL(51 eadaily) MO

$0-$335 (Tier

SL(3 ea daily)MO

metformin hcl tb24 or 1000 mg

$0-$335 (Tier

OsmoticSL(25ea daily) MO

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(266 eadaily) MO

Diabetic Other

GLUCAGEN HYPOKIT SOLR

$0-$835 (Tier

GLUCAGON EMERGENCY KIT KIT

$0-$835 (Tier

KORLYM TABS

$0-$835 (Tier

PA SL(4 eadaily) LA MO

Name of drug

What the

level)

PROGLYCEM SUSP

$0-$835 (Tier

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

alogliptin benzoate tabs125 mg

$0-$835 (Tier

PA QL(2 eadaily) MO

alogliptin benzoate tabs 25 mg

$0-$835 (Tier

PA QL(1 eadaily) MO

$0-$835 (Tier

PA QL(4 eadaily) MO

JANUVIA TABS 100 MG

$0-$835 (Tier

QL(1 ea daily)MO

JANUVIA TABS 25 MG

$0-$835 (Tier

QL(4 ea daily)MO

JANUVIA TABS 50 MG

$0-$835 (Tier

QL(2 ea daily)MO

NESINA TABS 125 MG

$0-$835 (Tier

PA QL(2 eadaily) MO

NESINA TABS 25 MG

$0-$835 (Tier

PA QL(1 eadaily) MO

NESINA TABS 625 MG

$0-$835 (Tier

PA QL(4 eadaily) MO

Name of drug

What the

level)

ONGLYZA TABS 25 MG

$0-$835 (Tier

PA QL(2 eadaily) MO

ONGLYZA TABS 5 MG

$0-$835 (Tier

PA QL(1 eadaily) MO

TRADJENTA TABS

$0-$835 (Tier

QL(1 ea daily)MO

Dopamine Receptor Agonists - Antidiabetic

CYCLOSET TABS

$0-$835 (Tier

QL(6 ea daily)MO

Incretin Mimetic Agents (GLP-1 Receptor

BYDUREON BCISE AUIJ

$0-$835 (Tier

BYDUREON PEN PEN

$0-$835 (Tier

BYDUREON SRER

$0-$835 (Tier

BYETTA SOPN

$0-$835 (Tier

VICTOZA SOPN

$0-$835 (Tier

ST Limit 9mls permonthQL(03ml daily) MO

Insulin Sensitizing Agents

Name of drug

What the

level)

AVANDIA TABS 2 MG

$0-$835 (Tier

SL(4 ea daily)MO

AVANDIA TABS 4 MG

$0-$835 (Tier

SL(2 ea daily)MO

pioglitazone hcl tabs 15 mg

$0-$335 (Tier

SL(3 ea daily)MO

$0-$335 (Tier

SL(15 eadaily) MO

$0-$335 (Tier

SL(1 ea daily)MO

Insulin

HUMALOG JUNIOR KWIKPEN SOPN

$0-$835 (Tier

Limit 45mls permonthQL(15ml daily) MO

HUMALOG KWIKPEN SOPN

$0-$835 (Tier

HUMALOG MIX 5050KWIKPEN SUPN

$0-$835 (Tier

HUMALOG MIX 5050SUSP

$0-$835 (Tier

Name of drug

What the

level)

$0-$835 (Tier

HUMALOG SOCT

$0-$835 (Tier

HUMALOG SOLN

$0-$835 (Tier

HUMULIN 7030 KWIKPENSUPN

$0-$835 (Tier

HUMULIN 7030 SUSP

$0-$835 (Tier

HUMULIN N KWIKPEN SUPN

$0-$835 (Tier

HUMULIN N SUSP

$0-$835 (Tier

HUMULIN R SOLN

$0-$835 (Tier

HUMULIN R U-500 (CONCENTRATED) SOLN

$0-$835 (Tier

HUMULIN R U-500 KWIKPEN SOPN

$0-$835 (Tier

Name of drug

What the

level)

LANTUS SOLN

$0-$835 (Tier

LANTUS SOLOSTAR SOPN

$0-$835 (Tier

LEVEMIR FLEXTOUCH SOPN

$0-$835 (Tier

LEVEMIR SOLN

$0-$835 (Tier

TOUJEO MAX SOLOSTAR SOPN

$0-$835 (Tier

TOUJEO SOLOSTAR SOPN

$0-$835 (Tier

TRESIBA FLEXTOUCH SOPN 100 UNITML

$0-$835 (Tier

Meglitinide Analogues

nateglinide tabs

$0-$335 (Tier

QL(3 ea daily)MO

repaglinide tabs 05 mg

$0-$335 (Tier

SL(32 ea daily)MO

Name of drug

What the

level)

$0-$335 (Tier

SL(16 ea daily)MO

$0-$335 (Tier

SL(8 ea daily)MO

Sodium-Glucose Co-Transporter 2 (SGLT2)

INVOKANA TABS

$0-$835 (Tier

JARDIANCE TABS

$0-$835 (Tier

Sulfonylureas

glimepiride tabs 1 mg

$0-$335 (Tier

SL(8 ea daily)MO

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(2 ea daily)MO

glipizide tabs or 10 mg

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(8 ea daily)MO

glipizide tb24 or 10 mg

$0-$335 (Tier

SL(2 ea daily)MO

Name of drug

What the

level)

$0-$335 (Tier

SL(8 ea daily)MO

$0-$335 (Tier

SL(4 ea daily)MO

glyburide micronized tabs15 mg

$0-$335 (Tier

glyburide micronized tabs 3 mg

$0-$335 (Tier

glyburide tabs or 125 mg

$0-$335 (Tier

tolazamide tabs 250 mg

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(2 ea daily)MO

Name of drug

What the

level)

tolbutamide tabs

$0-$335 (Tier

SL(6 ea daily)MO

ANTIDIARRHEALPROBIOTIC AGENTS - Drugsto Treat Diarrhea

AntidiarrhealProbiotic Agents - Misc

bismuth subsalicylate chewor 262 mg

$0 (Tier

bismuth subsalicylate suspor 262 mg15ml 525mg30ml 527 mg30ml

$0 (Tier

bismuth subsalicylate suspor 525 mg15ml

$0 (Tier

bismuth subsalicylate tabsor 262 mg

$0 (Tier

Antiperistaltic Agents

diphenoxylate w atropinetabs

$0-$335 (Tier

loperamide hcl caps or 2 mg

$0-$335 (Tier

RXOTC MO

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents

EXJADE TBSO

$0-$835 (Tier

FERRIPROX TABS 500 MG

$0-$835 (Tier

PA LA MO

Name of drug

What the

level)

JADENU SPRINKLE PACK

$0-$835 (Tier

JADENU TABS

$0-$835 (Tier

Antidotes and Specific Antagonists

VISTOGARD PACK

$0-$835 (Tier

Opioid Antagonists

naloxone hcl sosy ij 2mg2ml

$0-$335 (Tier

naltrexone hcl tabs or $0-

$335 (Tier

ANTIEMETICS - Drugs to Treat Nausea andVomiting

5-HT3 Receptor Antagonists

granisetron hcl tabs or 1 mg

$0-$335 (Tier

ondansetron hcl soln ij 4mg2ml 40 mg20ml

$0-$335 (Tier

ondansetron hcl soln or 4 mg5ml

$0-$335 (Tier

ondansetron hcl tabs or 24 mg

$0-$335 (Tier

Name of drug

What the

level)

ondansetron hcl tabs or 4 mg 8 mg

$0-$335 (Tier

ondansetron tbdp

$0-$335 (Tier

Antiemetics - Anticholinergic

meclizine hcl chew or 25 mg

$0 (Tier

meclizine hcl tabs or 25 mg 125 mg

$0-$335 (Tier

RXOTC MO

$0 (Tier

scopolamine pt72

$0-$335 (Tier

TIGAN SOLN IM 100 MGML

$0-$835 (Tier

TRANSDERM-SCOP PT72

$0-$835 (Tier

TRANSDERM-SCOP PT72 (Scopolamine)

$0-$835 (Tier

Antiemetics - Miscellaneous

CESAMET CAPS

$0-$835 (Tier

Name of drug

What the

level)

dronabinol caps

$0-$335 (Tier

SYNDROS SOLN

$0-$835 (Tier

Substance PNeurokinin 1 (NK1) Receptor

aprepitant caps 40 mg

$0-$335 (Tier

aprepitant caps 80 mg 125 mg

$0-$335 (Tier

VARUBI TABS OR 90 MG

$0-$835 (Tier

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungal - Glucan Synthesis Inhibitors

CANCIDAS SOLR 50 MG (Caspofungin Acetate)

$0-$835 (Tier

caspofungin acetate solr 50 mg

$0-$335 (Tier

CASPOFUNGIN ACETATE SOLR 50 MG

$0-$835 (Tier

Name of drug

What the

level)

$0-$835 (Tier

$0-$335 (Tier

ERAXIS SOLR 100 MG

$0-$835 (Tier

MYCAMINE SOLR 100 MG

$0-$835 (Tier

MYCAMINE SOLR 50 MG

$0-$835 (Tier

Antifungals

ABELCET SUSP

$0-$835 (Tier

AMBISOME SUSR

$0-$835 (Tier

amphotericin b solr ij 50 mg

$0-$335 (Tier

flucytosine caps 500 mg

$0-$335 (Tier

griseofulvin microsize susp

$0-$335 (Tier

Name of drug

What the

level)

griseofulvin microsize tabs

$0-$335 (Tier

griseofulvin ultramicrosizetabs

$0-$335 (Tier

nystatin tabs

$0-$335 (Tier

terbinafine hcl tabs or $0-

$335 (Tier

Imidazole-Related Antifungals

CRESEMBA CAPS OR 186 MG

$0-$835 (Tier

CRESEMBA SOLR IV 372 MG

$0-$835 (Tier

2) fluconazole in dextrose soln 200mg100ml-56mgml 400mg200ml-56mgml

$0-$335 (Tier

fluconazole in nacl soln 200mg100ml-09400mg200ml-09

$0-$335 (Tier

fluconazole susr or 10 mgml 40 mgml

$0-$335 (Tier

fluconazole tabs or 50 mg100 mg 150 mg 200 mg

$0-$335 (Tier

Name of drug

What the

level)

itraconazole caps or 100 mg

$0-$335 (Tier

ketoconazole tabs or $0-

$335 (Tier

NOXAFIL SOLN IV 300 MG167ML

$0-$835 (Tier

NOXAFIL SUSP OR 40 MGML

$0-$835 (Tier

NOXAFIL TBEC OR 100 MG

$0-$835 (Tier

voriconazole solr iv 200 mg

$0-$335 (Tier

voriconazole susr or 40 mgml

$0-$335 (Tier

voriconazole tabs or 50 mg200 mg

$0-$335 (Tier

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines

chlorpheniramine maleatesyrp or 2 mg5ml

$0 (Tier

AL(Up to 64 yrsold) NT

chlorpheniramine maleatetabs or 4 mg

$0 (Tier

AL(Up to 64 yrsold) MO NT

Name of drug

What the

level)

ED CHLORPED LIQD $0

(Tier 3)

Antihistamines - Ethanolamines

carbinoxamine maleate soln 4 mg5ml

$0-$335 (Tier

carbinoxamine maleate tabs 4 mg

$0-$335 (Tier

clemastine fumarate tabs or 268 mg

$0-$335 (Tier

diphenhydramine hcl capsor 25 mg

$0 (Tier

RXOTC MONT

diphenhydramine hcl elix or125 mg5ml

$0-$335 (Tier

AL(Up to 64 yrsold) RXOTC

diphenhydramine hcl liqd or25 mg10ml 50 mg20ml125 mg5ml

$0 (Tier

diphenhydramine hcl soln ij50 mgml

$0-$335 (Tier

diphenhydramine hcl tabsor 25 mg

$0 (Tier

SILPHEN COUGH SYRP $0

(Tier 3)

Antihistamines - Non-Sedating

Name of drug

What the

level)

cetirizine hcl chew 5 mg 10 mg

$0 (Tier

cetirizine hcl soln 1 mgml5 mg5ml

$0-$335 (Tier

RXOTC MO

cetirizine hcl tabs 5 mg 10 mg

$0 (Tier

desloratadine tabs

$0-$335 (Tier

desloratadine tbdp

$0-$335 (Tier

levocetirizine dihydrochloride soln 25mg5ml

$0-$335 (Tier

RXOTC MO

levocetirizine dihydrochloride tabs 5 mg

$0-$335 (Tier

RXOTC MO

loratadine soln or 5 mg5ml $0

(Tier 3)

loratadine syrp or 5 mg5ml $0

(Tier 3)

loratadine tabs or 10 mg $0

(Tier 3)

QL(1 ea daily)MO NT

loratadine tbdp or 10 mg $0

(Tier 3)

Antihistamines - Phenothiazines

Name of drug

What the

level)

promethazine hcl soln ij 25mgml 50 mgml

$0-$335 (Tier

promethazine hcl soln or625 mg5ml

$0-$335 (Tier

promethazine hcl supp re25 mg 125 mg

$0-$335 (Tier

promethazine hcl syrp or625 mg5ml

$0-$335 (Tier

promethazine hcl tabs or25 mg 50 mg 125 mg

$0-$335 (Tier

Antihistamines - Piperidines

cyproheptadine hcl syrp or2 mg5ml

$0-$335 (Tier

cyproheptadine hcl tabs or4 mg

$0-$335 (Tier

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Antihyperlipidemics - Misc

KYNAMRO SOSY

$0-$835 (Tier

omega-3-acid ethyl esters caps

$0-$335 (Tier

Name of drug

What the

level)

VASCEPA CAPS

$0-$835 (Tier

Bile Acid Sequestrants

cholestyramine light pack

$0-$335 (Tier

cholestyramine light powd

$0-$335 (Tier

cholestyramine pack or 4 gm

$0-$335 (Tier

cholestyramine powd or 4gmdose

$0-$335 (Tier

colesevelam hcl pack

$0-$335 (Tier

colesevelam hcl tabs

$0-$335 (Tier

colestipol hcl gran

$0-$335 (Tier

colestipol hcl pack

$0-$335 (Tier

colestipol hcl tabs

$0-$335 (Tier

Name of drug

What the

level)

WELCHOL PACK (Colesevelam HCl)

$0-$835 (Tier

WELCHOL TABS (Colesevelam HCl)

$0-$835 (Tier

Fibric Acid Derivatives

ANTARA CAPS 30 MG

$0-$835 (Tier

SL(433 eadaily) MO

ANTARA CAPS 90 MG

$0-$835 (Tier

SL(144 eadaily) MO

choline fenofibrate cpdr $0-

$335 (Tier

fenofibrate micronized caps130 mg

$0-$335 (Tier

SL(1 ea daily)MO

$0-$335 (Tier

SL(302 eadaily) MO

fenofibrate micronized caps67 mg 134 mg 200 mg

$0-$335 (Tier

fenofibrate tabs 48 mg 54mg 145 mg 160 mg

$0-$335 (Tier

gemfibrozil tabs or $0-

$335 (Tier

Name of drug

What the

level)

TRIGLIDE TABS

$0-$835 (Tier

HMG CoA Reductase Inhibitors

atorvastatin calcium tabs

$0-$335 (Tier

fluvastatin sodium caps 20 mg

$0-$335 (Tier

QL(3 ea daily)MO

$0-$335 (Tier

QL(2 ea daily)MO

fluvastatin sodium tb24 80 mg

$0-$335 (Tier

lovastatin tabs 10 mg 20 mg

$0-$335 (Tier

QL(1 ea daily)MO

lovastatin tabs 40 mg

$0-$335 (Tier

QL(2 ea daily)MO

pravastatin sodium tabs

$0-$335 (Tier

QL(1 ea daily)MO

rosuvastatin calcium tabs

$0-$335 (Tier

QL(1 ea daily)MO

simvastatin tabs or 5 mg10 mg 20 mg 40 mg

$0-$335 (Tier

QL(1 ea daily)MO

Name of drug

What the

level)

simvastatin tabs or 80 mg

$0-$335 (Tier

SL(1 ea daily)MO

Intestinal Cholesterol Absorption Inhibitors

ezetimibe tabs

$0-$335 (Tier

QL(1 ea daily)MO

Microsomal Triglyceride Transfer Protein (MTP)

JUXTAPID CAPS 10 MG

$0-$835 (Tier

JUXTAPID CAPS 20 MG

$0-$835 (Tier

JUXTAPID CAPS 30 MG

$0-$835 (Tier

JUXTAPID CAPS 40 MG

$0-$835 (Tier

JUXTAPID CAPS 5 MG

$0-$835 (Tier

JUXTAPID CAPS 60 MG

$0-$835 (Tier

Nicotinic Acid Derivatives

niacin (antihyperlipidemic)tbcr

$0-$335 (Tier

Proprotein Convertase SubtilisinKexin Type 9

Name of drug

What the

level)

PRALUENT SOPN 150 MGML

$0-$835 (Tier

PA Limit 2mls per 28daysSL(008ml daily)

$0-$835 (Tier

PRALUENT SOSY 150 MGML

$0-$835 (Tier

REPATHA PUSHTRONEX SYSTEM SOCT

$0-$835 (Tier

REPATHA SOSY

$0-$835 (Tier

REPATHA SURECLICK SOAJ

$0-$835 (Tier

ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure

ACE Inhibitors

benazepril hcl tabs or 5 mg10 mg 20 mg 40 mg

$0-$335 (Tier

captopril tabs or 25 mg 50mg 100 mg 125 mg

$0-$335 (Tier

Name of drug

What the

level)

enalapril maleate tabs or10 mg

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(16 ea daily)MO

$0-$335 (Tier

SL(2 ea daily)MO

enalapril maleate tabs or 5 mg

$0-$335 (Tier

SL(8 ea daily)MO

fosinopril sodium tabs

$0-$335 (Tier

lisinopril tabs or 5 mg 10mg 20 mg 30 mg 40 mg25 mg

$0-$335 (Tier

moexipril hcl tabs

$0-$335 (Tier

perindopril erbumine tabs 2 mg

$0-$335 (Tier

SL(8 ea daily)MO

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(2 ea daily)MO

Name of drug

What the

level)

quinapril hcl tabs

$0-$335 (Tier

ramipril caps

$0-$335 (Tier

trandolapril tabs

$0-$335 (Tier

Agents for Pheochromocytoma

DEMSER CAPS

$0-$835 (Tier

phenoxybenzamine hcl caps or

$0-$335 (Tier

Angiotensin II Receptor Antagonists

candesartan cilexetil tabs

$0-$335 (Tier

DIOVAN TABS (Valsartan)

$0-$835 (Tier

eprosartan mesylate tabs

$0-$335 (Tier

irbesartan tabs

$0-$335 (Tier

losartan potassium tabs

$0-$335 (Tier

Name of drug

What the

level)

valsartan tabs

$0-$335 (Tier

Antiadrenergic Antihypertensives

clonidine hcl tabs or 01 mg 02 mg 03 mg

$0-$335 (Tier

clonidine ptwk

$0-$335 (Tier

doxazosin mesylate tabs

$0-$335 (Tier

guanfacine hcl tabs

$0-$335 (Tier

prazosin hcl caps

$0-$335 (Tier

terazosin hcl caps

$0-$335 (Tier

Antihypertensive Combinations

amlodipine besylate-benazepril hcl caps

$0-$335 (Tier

atenolol amp chlorthalidone tabs

$0-$335 (Tier

benazepril amphydrochlorothiazide tabs

$0-$335 (Tier

Name of drug

What the

level)

bisoprolol amphydrochlorothiazide tabs

$0-$335 (Tier

candesartan cilexetil-hydrochlorothiazide tabs

$0-$335 (Tier

captopril amphydrochlorothiazide tabs

$0-$335 (Tier

CORZIDE TABS 80MG-5MG

$0-$835 (Tier

DIOVAN HCT TABS (Valsartan-Hydrochlorothiazide)

$0-$835 (Tier

enalapril maleate amphydrochlorothiazide tabs

$0-$335 (Tier

fosinopril sodium amphydrochlorothiazide tabs

$0-$335 (Tier

irbesartan-hydrochlorothiazide tabs

$0-$335 (Tier

lisinopril amphydrochlorothiazide tabs

$0-$335 (Tier

losartan potassium amphydrochlorothiazide tabs

$0-$335 (Tier

Name of drug

What the

level)

metoprolol amphydrochlorothiazide tabs50mg-25mg 100mg-25mg100mg-50mg

$0-$335 (Tier

moexipril-hydrochlorothiazide tabs

$0-$335 (Tier

nadolol amp bendroflumethiazide tabs

$0-$335 (Tier

quinapril-hydrochlorothiazide tabs

$0-$335 (Tier

TEKTURNA HCT TABS

$0-$835 (Tier

valsartan-hydrochlorothiazide tabs

$0-$335 (Tier

Direct Renin Inhibitors

TEKTURNA TABS

$0-$835 (Tier

Selective Aldosterone Receptor Antagonists

eplerenone tabs

$0-$335 (Tier

Vasodilators

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

$0-$335 (Tier

Name of drug

What the

level)

minoxidil tabs or 10 mg 25 mg

$0-$335 (Tier

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

atovaquone-proguanil hcltabs 250mg-100mg

$0-$335 (Tier

COARTEM TABS

$0-$835 (Tier

Antimalarials

chloroquine phosphate tabsor 250 mg 500 mg

$0-$335 (Tier

DARAPRIM TABS

$0-$835 (Tier

hydroxychloroquine sulfatetabs or

$0-$335 (Tier

mefloquine hcl tabs

$0-$335 (Tier

primaquine phosphate tabs

$0-$335 (Tier

PRIMAQUINE PHOSPHATE TABS

$0-$835 (Tier

Name of drug

What the

level)

quinine sulfate caps or $0-

$335 (Tier

ANTIMYASTHENICCHOLINERGIC AGENTS

AntimyasthenicCholinergic Agents

GUANIDINE HCL TABS

$0-$835 (Tier

pyridostigmine bromidetabs or 60 mg

$0-$335 (Tier

pyridostigmine bromidetbcr or 180 mg

$0-$335 (Tier

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

isoniazid amp rifampin caps

$0-$335 (Tier

RIFATER TABS

$0-$835 (Tier

Antimycobacterial Agents

aminosalicylic acid pack or $0-

$335 (Tier

CAPASTAT SULFATE SOLR

$0-$835 (Tier

Name of drug

What the

level)

ethambutol hcl tabs or 100 mg 400 mg

$0-$335 (Tier

isoniazid tabs or 100 mg300 mg

$0-$335 (Tier

PRIFTIN TABS

$0-$835 (Tier

pyrazinamide tabs or $0-

$335 (Tier

rifabutin caps

$0-$335 (Tier

rifampin caps or 150 mg300 mg

$0-$335 (Tier

rifampin solr iv 600 mg

$0-$335 (Tier

SIRTURO TABS

$0-$835 (Tier

TRECATOR TABS

$0-$835 (Tier

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents

Name of drug

What the

level)

ALKERAN TABS OR 2 MG (Melphalan)

$0-$835 (Tier

BENDEKA SOLN

$0-$835 (Tier

BICNU SOLR (Carmustine)

$0-$835 (Tier

busulfan soln

$0-$335 (Tier

carboplatin soln

$0-$335 (Tier

carmustine solr $0-

$335 (Tier

cisplatin soln 50 mg50ml100 mg100ml 200mg200ml

$0-$335 (Tier

cyclophosphamide caps or25 mg 50 mg

$0-$335 (Tier

CYCLOPHOSPHAMIDE CAPS OR 25 MG 50 MG (Cyclophosphamide)

$0-$835 (Tier

EVOMELA SOLR

$0-$835 (Tier

Name of drug

What the

level)

GLEOSTINE CAPS 10 MG

$0-$835 (Tier

GLEOSTINE CAPS 40 MG 100 MG

$0-$835 (Tier

HEXALEN CAPS

$0-$835 (Tier

IFEX SOLR 3 GM

$0-$835 (Tier

ifosfamide soln 1 gm20ml3 gm60ml

$0-$335 (Tier

ifosfamide solr 1 gm

$0-$335 (Tier

IFOSFAMIDE SOLR 3 GM

$0-$835 (Tier

LEUKERAN TABS

$0-$835 (Tier

melphalan hcl solr $0-

$335 (Tier

melphalan tabs

$0-$335 (Tier

Name of drug

What the

level)

MUSTARGEN SOLR

$0-$835 (Tier

oxaliplatin soln

$0-$335 (Tier

oxaliplatin solr $0-

$335 (Tier

TEMODAR SOLR

$0-$835 (Tier

thiotepa solr ij $0-

$335 (Tier

TREANDA SOLR

$0-$835 (Tier

YONDELIS SOLR

$0-$835 (Tier

ZANOSAR SOLR

$0-$835 (Tier

Antimetabolites

ALIMTA SOLR

$0-$835 (Tier

ARRANON SOLN

$0-$835 (Tier

Name of drug

What the

level)

azacitidine susr $0-

$335 (Tier

cladribine soln

$0-$335 (Tier

clofarabine soln

$0-$335 (Tier

cytarabine soln

$0-$335 (Tier

decitabine solr $0-

$335 (Tier

fludarabine phosphate solr50 mg

$0-$335 (Tier

fluorouracil soln iv 1 gm20ml 5 gm100ml 25gm50ml 500 mg10ml

$0-$335 (Tier

FOLOTYN SOLN

$0-$835 (Tier

gemcitabine hcl soln

$0-$335 (Tier

gemcitabine hcl solr $0-

$335 (Tier

Name of drug

What the

level)

GEMCITABINE HYDROCHLORIDE SOLN 2 GM20ML 200 MG2ML

$0-$835 (Tier

mercaptopurine tabs or $0-

$335 (Tier

methotrexate sodium soln ij1 gm40ml 50 mg2ml 250mg10ml

$0-$335 (Tier

methotrexate sodium solr ij1 gm

$0-$335 (Tier

methotrexate sodium tabs or 5 mg 10 mg 15 mg 25mg 75 mg

$0-$335 (Tier

PURIXAN SUSP

$0-$835 (Tier

TABLOID TABS

$0-$835 (Tier

XATMEP SOLN

$0-$835 (Tier

Antineoplastic - Angiogenesis Inhibitors

AVASTIN SOLN

$0-$835 (Tier

CYRAMZA SOLN

$0-$835 (Tier

Name of drug

What the

level)

ZALTRAP SOLN

$0-$835 (Tier

Antineoplastic - Antibodies

ARZERRA CONC

$0-$835 (Tier

BAVENCIO SOLN

$0-$835 (Tier

BESPONSA SOLR

$0-$835 (Tier

BLINCYTO SOLR

$0-$835 (Tier

CAMPATH SOLN

$0-$835 (Tier

DARZALEX SOLN

$0-$835 (Tier

EMPLICITI SOLR

$0-$835 (Tier

ERBITUX SOLN

$0-$835 (Tier

GAZYVA SOLN

$0-$835 (Tier

Name of drug

What the

level)

HERCEPTIN SOLR

$0-$835 (Tier

IMFINZI SOLN

$0-$835 (Tier

KADCYLA SOLR

$0-$835 (Tier

KEYTRUDA SOLN

$0-$835 (Tier

LARTRUVO SOLN

$0-$835 (Tier

MYLOTARG SOLR

$0-$835 (Tier

OPDIVO SOLN

$0-$835 (Tier

PERJETA SOLN

$0-$835 (Tier

PORTRAZZA SOLN

$0-$835 (Tier

POTELIGEO SOLN

$0-$835 (Tier

Name of drug

What the

level)

RITUXAN SOLN

$0-$835 (Tier

TECENTRIQ SOLN

$0-$835 (Tier

VECTIBIX SOLN

$0-$835 (Tier

YERVOY SOLN

$0-$835 (Tier

Antineoplastic - BCL-2 Inhibitors

VENCLEXTA STARTING PACK TBPK

$0-$835 (Tier

PA LA MO

VENCLEXTA TABS

$0-$835 (Tier

PA LA MO

Antineoplastic - Hedgehog Pathway Inhibitors

ERIVEDGE CAPS

$0-$835 (Tier

ODOMZO CAPS

$0-$835 (Tier

Antineoplastic - Hormonal and Related Agents

anastrozole tabs or $0-

$335 (Tier

Name of drug

What the

level)

bicalutamide tabs

$0-$335 (Tier

DEPO-PROVERA SUSP

$0-$835 (Tier

ELIGARD KIT

$0-$835 (Tier

EMCYT CAPS

$0-$835 (Tier

ERLEADA TABS

$0-$835 (Tier

exemestane tabs

$0-$335 (Tier

FARESTON TABS

$0-$835 (Tier

FASLODEX SOLN

$0-$835 (Tier

FIRMAGON SOLR

$0-$835 (Tier

flutamide caps

$0-$335 (Tier

Name of drug

What the

level)

HYDROXYPROGESTERO NE CAPROATE SOLN IM 125 GM5ML

$0-$835 (Tier

letrozole tabs

$0-$335 (Tier

leuprolide acetate kit ij $0-

$335 (Tier

LUPRON DEPOT (1-MONTH) KIT

$0-$835 (Tier

LYSODREN TABS

$0-$835 (Tier

megestrol acetate susp or40 mgml 400 mg10ml

$0-$335 (Tier

megestrol acetate tabs or20 mg 40 mg

$0-$335 (Tier

Name of drug

What the

level)

nilutamide tabs

$0-$335 (Tier

SOLTAMOX SOLN

$0-$835 (Tier

tamoxifen citrate tabs or 10 mg 20 mg

$0-$335 (Tier

TRELSTAR MIXJECT SUSR

$0-$835 (Tier

TRELSTAR SUSR

$0-$835 (Tier

VANTAS KIT

$0-$835 (Tier

XTANDI CAPS

$0-$835 (Tier

YONSA TABS

$0-$835 (Tier

ZOLADEX IMPL

$0-$835 (Tier

ZYTIGA TABS

$0-$835 (Tier

Antineoplastic - Immunomodulators

Name of drug

What the

level)

POMALYST CAPS

$0-$835 (Tier

Antineoplastic Antibiotics

bleomycin sulfate solr $0-

$335 (Tier

COSMEGEN SOLR

$0-$835 (Tier

dactinomycin solr $0-

$335 (Tier

daunorubicin hcl soln

$0-$335 (Tier

DAUNORUBICIN HYDROCHLORIDE SOLN

$0-$835 (Tier

doxorubicin hcl liposomalinj

$0-$335 (Tier

doxorubicin hcl soln 2 mgml

$0-$335 (Tier

doxorubicin hcl solr 10 mg50 mg

$0-$335 (Tier

epirubicin hcl soln

$0-$335 (Tier

Name of drug

What the

level)

idarubicin hcl soln

$0-$335 (Tier

mitomycin solr iv 5 mg 20mg 40 mg

$0-$335 (Tier

mitoxantrone hcl conc

$0-$335 (Tier

VALSTAR SOLN

$0-$835 (Tier

Antineoplastic Combinations

KISQALI FEMARA 200 DOSE TBPK

$0-$835 (Tier

LONSURF TABS

$0-$835 (Tier

RITUXAN HYCELA SOLN

$0-$835 (Tier

VYXEOS SUSR

$0-$835 (Tier

Antineoplastic Enzyme Inhibitors

Name of drug

What the

level)

AFINITOR DISPERZ TBSO

$0-$835 (Tier

AFINITOR TABS

$0-$835 (Tier

ALECENSA CAPS

$0-$835 (Tier

ALIQOPA SOLR

$0-$835 (Tier

ALUNBRIG TABS

$0-$835 (Tier

ALUNBRIG TBPK

$0-$835 (Tier

BELEODAQ SOLR

$0-$835 (Tier

BORTEZOMIB SOLR

$0-$835 (Tier

BOSULIF TABS

$0-$835 (Tier

BRAFTOVI CAPS

$0-$835 (Tier

Name of drug

What the

level)

CABOMETYX TABS

$0-$835 (Tier

CALQUENCE CAPS

$0-$835 (Tier

PA LA MO

CAPRELSA TABS

$0-$835 (Tier

PA LA MO

COMETRIQ KIT

$0-$835 (Tier

PA LA MO

COTELLIC TABS

$0-$835 (Tier

FARYDAK CAPS

$0-$835 (Tier

GILOTRIF TABS

$0-$835 (Tier

PA LA MO

GLEEVEC TABS 400 MG (Imatinib Mesylate)

$0-$835 (Tier

IBRANCE CAPS

$0-$835 (Tier

ICLUSIG TABS

$0-$835 (Tier

PA LA MO

Name of drug

What the

level)

IDHIFA TABS

$0-$835 (Tier

imatinib mesylate tabs

$0-$335 (Tier

IMBRUVICA CAPS 140 MG

$0-$835 (Tier

PA LA MO

$0-$835 (Tier

IMBRUVICA TABS 140 MG 280 MG 420 MG 560 MG

$0-$835 (Tier

INLYTA TABS

$0-$835 (Tier

IRESSA TABS

$0-$835 (Tier

ISTODAX (OVERFILL) SOLR

$0-$835 (Tier

JAKAFI TABS

$0-$835 (Tier

KISQALI TABS

$0-$835 (Tier

Name of drug

What the

level)

KYPROLIS SOLR

$0-$835 (Tier

LENVIMA 10 MG DAILY DOSE CPPK

$0-$835 (Tier

LENVIMA 12MG DAILY DOSE CPPK

$0-$835 (Tier

LYNPARZA CAPS

$0-$835 (Tier

PA LA MO

Name of drug

What the

level)

LYNPARZA TABS

$0-$835 (Tier

PA LA MO

MEKINIST TABS

$0-$835 (Tier

MEKTOVI TABS

$0-$835 (Tier

NERLYNX TABS

$0-$835 (Tier

NEXAVAR TABS

$0-$835 (Tier

NINLARO CAPS

$0-$835 (Tier

ROMIDEPSIN SOLR

$0-$835 (Tier

RUBRACA TABS

$0-$835 (Tier

RYDAPT CAPS

$0-$835 (Tier

SPRYCEL TABS

$0-$835 (Tier

Name of drug

What the

level)

STIVARGA TABS

$0-$835 (Tier

SUTENT CAPS

$0-$835 (Tier

TAFINLAR CAPS

$0-$835 (Tier

TAGRISSO TABS

$0-$835 (Tier

TARCEVA TABS

$0-$835 (Tier

TASIGNA CAPS

$0-$835 (Tier

temsirolimus soln

$0-$335 (Tier

TORISEL SOLN (Temsirolimus)

$0-$835 (Tier

TYKERB TABS

$0-$835 (Tier

VELCADE SOLR

$0-$835 (Tier

Name of drug

What the

level)

VERZENIO TABS

$0-$835 (Tier

VOTRIENT TABS

$0-$835 (Tier

XALKORI CAPS

$0-$835 (Tier

ZEJULA CAPS

$0-$835 (Tier

PA LA MO

ZELBORAF TABS

$0-$835 (Tier

ZOLINZA CAPS

$0-$835 (Tier

ZYDELIG TABS

$0-$835 (Tier

ZYKADIA CAPS

$0-$835 (Tier

Antineoplastic Enzymes

ERWINAZE SOLR

$0-$835 (Tier

ONCASPAR SOLN

$0-$835 (Tier

Antineoplastics Misc

Name of drug

What the

level)

ACTIMMUNE SOLN

$0-$835 (Tier

ARSENIC TRIOXIDE SOLN IV

$0-$835 (Tier

bexarotene caps

$0-$335 (Tier

dacarbazine solr $0-

$335 (Tier

hydroxyurea caps or $0-

$335 (Tier

INTRON A SOLN

$0-$835 (Tier

INTRON A SOLR

$0-$835 (Tier

MATULANE CAPS

$0-$835 (Tier

NIPENT SOLR

$0-$835 (Tier

PROLEUKIN SOLR

$0-$835 (Tier

Name of drug

What the

level)

SYLATRON KIT

$0-$835 (Tier

SYNRIBO SOLR

$0-$835 (Tier

TICE BCG SUSR

$0-$835 (Tier

tretinoin (chemotherapy) caps

$0-$335 (Tier

TRISENOX SOLN

$0-$835 (Tier

UVADEX SOLN

$0-$835 (Tier

Chemotherapy Adjuncts

ELITEK SOLR

$0-$835 (Tier

KEPIVANCE SOLR

$0-$835 (Tier

Chemotherapy RescueAntidote Agents

amifostine solr $0-

$335 (Tier

dexrazoxane solr $0-

$335 (Tier

Name of drug

What the

level)

ETHYOL SOLR

$0-$835 (Tier

leucovorin calcium solr ij 50mg 100 mg 200 mg 350mg 500 mg

$0-$335 (Tier

leucovorin calcium tabs or 5 mg 10 mg 15 mg 25 mg

$0-$335 (Tier

levoleucovorin calcium soln

$0-$335 (Tier

levoleucovorin calcium solr $0-

$335 (Tier

LEVOLEUCOVORIN SOLN 250 MG25ML(Levoleucovorin Calcium)

$0-$835 (Tier

LEVOLEUCOVORIN SOLR 175 MG

$0-$835 (Tier

mesna soln

$0-$335 (Tier

MESNEX TABS OR 400 MG

$0-$835 (Tier

TOTECT SOLR

$0-$835 (Tier

Mitotic Inhibitors

Name of drug

What the

level)

ABRAXANE SUSR

$0-$835 (Tier

$0-DOCETAXEL CONC 20 $835 MGML 80 MG4ML (Tier

2) $0-

docetaxel conc 20 mgml $335 80 mg4ml (Tier

1) $0-

docetaxel soln 20 mg2ml $335 80 mg8ml 160 mg16ml (Tier

DOCETAXEL SOLN 20 MG2ML 80 MG8ML 160MG16ML

$0-$835 (Tier

DOCETAXEL SOLN 20 MG2ML 80 MG8ML 160MG16ML (Docetaxel)

$0-$835 (Tier

ETOPOPHOS SOLR

$0-$835 (Tier

etoposide soln iv 1gm50ml 100 mg5ml 500mg25ml

$0-$335 (Tier

HALAVEN SOLN

$0-$835 (Tier

IXEMPRA KIT SOLR

$0-$835 (Tier

Name of drug

What the

level)

JEVTANA SOLN

$0-$835 (Tier

MARQIBO SUSP

$0-$835 (Tier

paclitaxel conc

$0-$335 (Tier

vinblastine sulfate soln

$0-$335 (Tier

vincristine sulfate soln

$0-$335 (Tier

vinorelbine tartrate soln 10 mgml

$0-$335 (Tier

vinorelbine tartrate soln 50 mg5ml

$0-$335 (Tier

Topoisomerase I Inhibitors

CAMPTOSAR SOLN 300 MG15ML

$0-$835 (Tier

irinotecan hcl soln

$0-$335 (Tier

ONIVYDE INJ

$0-$835 (Tier

Name of drug

What the

level)

TOPOTECAN HCL SOLN 4 MG4ML

$0-$835 (Tier

topotecan hcl soln 4mg4ml

$0-$335 (Tier

TOPOTECAN HCL SOLN 4 MG4ML (Topotecan HCl)

$0-$835 (Tier

topotecan hcl solr 4 mg

$0-$335 (Tier

ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinsons Disease

Antiparkinson Adjuvants

carbidopa tabs or $0-

$335 (Tier

Antiparkinson Anticholinergics

benztropine mesylate solnij 1 mgml

$0-$335 (Tier

benztropine mesylate tabsor 05 mg 1 mg 2 mg

$0-$335 (Tier

trihexyphenidyl hcl elix

$0-$335 (Tier

trihexyphenidyl hcl tabs

$0-$335 (Tier

Antiparkinson COMT Inhibitors

Name of drug

What the

level)

entacapone tabs

$0-$335 (Tier

SL(8 ea daily)MO

tolcapone tabs

$0-$335 (Tier

Antiparkinson Dopaminergics

amantadine hcl caps or100 mg

$0-$335 (Tier

amantadine hcl syrp or 50mg5ml

$0-$335 (Tier

amantadine hcl tabs or 100 mg

$0-$335 (Tier

APOKYN SOCT

$0-$835 (Tier

bromocriptine mesylatecaps or 5 mg

$0-$335 (Tier

bromocriptine mesylatetabs or 25 mg

$0-$335 (Tier

carbidopa-levodopa tabs

$0-$335 (Tier

carbidopa-levodopa tbcr $0-

$335 (Tier

Name of drug

What the

level)

carbidopa-levodopa tbdp

$0-$335 (Tier

DUOPA SUSP

$0-$835 (Tier

NEUPRO PT24

$0-$835 (Tier

pramipexoledihydrochloride tabs 0125mg 025 mg 075 mg 05mg 1 mg 15 mg

$0-$335 (Tier

ropinirole hydrochloridetabs

$0-$335 (Tier

ropinirole hydrochloridetb24

$0-$335 (Tier

RYTARY CPCR

$0-$835 (Tier

Antiparkinson Monoamine Oxidase Inhibitors

rasagiline mesylate tabs

$0-$335 (Tier

selegiline hcl caps or $0-

$335 (Tier

selegiline hcl tabs or $0-

$335 (Tier

Name of drug

What the

level)

ANTIPSYCHOTICSANTIMANIC AGENTS -Drugs to Treat Mood Disorders

Antimanic Agents

lithium carbonate caps or150 mg 300 mg 600 mg

$0-$335 (Tier

lithium carbonate tabs or 300 mg

$0-$335 (Tier

lithium carbonate tbcr or 300 mg 450 mg

$0-$335 (Tier

LITHIUM SOLN

$0-$835 (Tier

Antipsychotics - Misc

EQUETRO CP12

$0-$835 (Tier

GEODON SOLR IM 20 MG

$0-$835 (Tier

LATUDA TABS 120 MG

$0-$835 (Tier

LATUDA TABS 20 MG

$0-$835 (Tier

PA SL(8 eadaily) MO

LATUDA TABS 40 MG

$0-$835 (Tier

PA SL(4 eadaily) MO

Name of drug

What the

level)

LATUDA TABS 60 MG

$0-$835 (Tier

LATUDA TABS 80 MG

$0-$835 (Tier

PA SL(2 eadaily) MO

NUPLAZID CAPS

$0-$835 (Tier

NUPLAZID TABS

$0-$835 (Tier

VRAYLAR CAPS 15 MG

$0-$835 (Tier

PA SL(4 eadaily) MO

VRAYLAR CAPS 3 MG

$0-$835 (Tier

PA SL(2 eadaily) MO

VRAYLAR CAPS 45 MG

$0-$835 (Tier

VRAYLAR CAPS 6 MG

$0-$835 (Tier

PA SL(1 eadaily) MO

VRAYLAR CPPK

$0-$835 (Tier

ziprasidone hcl caps

$0-$335 (Tier

Benzisoxazoles

Name of drug

What the

level)

FANAPT TABS

$0-$835 (Tier

INVEGA SUSTENNA SUSP

$0-$835 (Tier

INVEGA TRINZA SUSP

$0-$835 (Tier

paliperidone tb24 15 mg

$0-$335 (Tier

SL(8 ea daily)MO

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(2 ea daily)MO

$0-$335 (Tier

SL(133 eadaily) MO

RISPERDAL CONSTA SUSR 125 MG

$0-$835 (Tier

Limit 8 vials per28 daysSL(029ea daily) MO

$0-$835 (Tier

Name of drug

What the

level)

$0-$835 (Tier

risperidone soln 1 mgml $0-

$335 (Tier

risperidone tabs 025 mg05 mg 1 mg 2 mg 3 mg4 mg

$0-$335 (Tier

risperidone tbdp 025 mg05 mg 1 mg 2 mg 3 mg4 mg

$0-$335 (Tier

Butyrophenones

haloperidol decanoate solnim 50 mgml 100 mgml

$0-$335 (Tier

haloperidol lactate conc

$0-$335 (Tier

haloperidol lactate soln

$0-$335 (Tier

haloperidol tabs

$0-$335 (Tier

Dibenzapines

CLOZAPINE ODT TBDP

$0-$835 (Tier

clozapine tabs

$0-$335 (Tier

Name of drug

What the

level)

clozapine tbdp

$0-$335 (Tier

FAZACLO TBDP 125 MG (Clozapine)

$0-$835 (Tier

FAZACLO TBDP 150 MG 200 MG

$0-$835 (Tier

loxapine succinate caps

$0-$335 (Tier

olanzapine solr $0-

$335 (Tier

olanzapine tabs

$0-$335 (Tier

olanzapine tbdp

$0-$335 (Tier

quetiapine fumarate tabs25 mg 50 mg 100 mg 200mg 300 mg 400 mg

$0-$335 (Tier

SAPHRIS SUBL 10 MG

$0-$835 (Tier

SL(2 ea daily)MO

SAPHRIS SUBL 25 MG

$0-$835 (Tier

SL(8 ea daily)MO

Name of drug

What the

level)

SAPHRIS SUBL 5 MG

$0-$835 (Tier

SL(4 ea daily)MO

VERSACLOZ SUSP

$0-$835 (Tier

PA SL(18 mldaily)

ZYPREXA RELPREVV SUSR 210 MG

$0-$835 (Tier

Phenothiazines

chlorpromazine hcl soln ij25 mgml

$0-$335 (Tier

chlorpromazine hcl soln ij50 mg2ml

$0-$335 (Tier

chlorpromazine hcl tabs or10 mg 25 mg 50 mg 100mg 200 mg

$0-$335 (Tier

fluphenazine decanoatesoln ij

$0-$335 (Tier

fluphenazine hcl conc or 5mgml

$0-$335 (Tier

fluphenazine hcl soln ij 25mgml

$0-$335 (Tier

fluphenazine hcl tabs or 1mg 5 mg 10 mg 25 mg

$0-$335 (Tier

Name of drug

What the

level)

perphenazine tabs or 2 mg4 mg 8 mg 16 mg

$0-$335 (Tier

prochlorperazine edisylatesoln ij

$0-$335 (Tier

prochlorperazine maleatetabs or 5 mg 10 mg

$0-$335 (Tier

prochlorperazine supp

$0-$335 (Tier

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

$0-$335 (Tier

trifluoperazine hcl tabs

$0-$335 (Tier

Quinolinone Derivatives

ABILIFY MAINTENA PRSY

$0-$835 (Tier

ABILIFY MAINTENA SRER

$0-$835 (Tier

aripiprazole soln 1 mgml $0-

$335 (Tier

SL(30 ml daily)MO

aripiprazole tabs 10 mg

$0-$335 (Tier

SL(3 ea daily)MO

Name of drug

What the

level)

$0-$335 (Tier

SL(2 ea daily)MO

$0-$335 (Tier

SL(15 ea daily)MO

$0-$335 (Tier

SL(15 eadaily) MO

$0-$335 (Tier

SL(1 ea daily)MO

$0-$335 (Tier

SL(6 ea daily)MO

aripiprazole tbdp 10 mg

$0-$335 (Tier

SL(3 ea daily)MO

$0-$335 (Tier

SL(2 ea daily)MO

ARISTADA INITIO PRSY

$0-$835 (Tier

ARISTADA PRSY

$0-$835 (Tier

REXULTI TABS 025 MG

$0-$835 (Tier

Name of drug

What the

level)

REXULTI TABS 05 MG

$0-$835 (Tier

PA SL(8 eadaily) MO

REXULTI TABS 1 MG

$0-$835 (Tier

PA SL(4 eadaily) MO

REXULTI TABS 2 MG

$0-$835 (Tier

PA SL(2 eadaily) MO

REXULTI TABS 3 MG

$0-$835 (Tier

REXULTI TABS 4 MG

$0-$835 (Tier

PA SL(1 eadaily) MO

Thioxanthenes

thiothixene caps

$0-$335 (Tier

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals

abacavir sulfate soln

$0-$335 (Tier

abacavir sulfate tabs

$0-$335 (Tier

abacavir sulfate-lamivudine tabs

$0-$335 (Tier

Name of drug

What the

level)

abacavir sulfate-lamivudine-zidovudine tabs

$0-$335 (Tier

APTIVUS CAPS 250 MG

$0-$835 (Tier

APTIVUS SOLN 100 MGML

$0-$835 (Tier

atazanavir sulfate caps

$0-$335 (Tier

ATRIPLA TABS

$0-$835 (Tier

BIKTARVY TABS

$0-$835 (Tier

CIMDUO TABS

$0-$835 (Tier

COMPLERA TABS

$0-$835 (Tier

CRIXIVAN CAPS

$0-$835 (Tier

DELSTRIGO TABS

$0-$835 (Tier

Name of drug

What the

level)

DESCOVY TABS

$0-$835 (Tier

didanosine cpdr $0-

$335 (Tier

EDURANT TABS

$0-$835 (Tier

efavirenz caps

$0-$335 (Tier

efavirenz tabs

$0-$335 (Tier

EMTRIVA CAPS

$0-$835 (Tier

EMTRIVA SOLN

$0-$835 (Tier

EVOTAZ TABS

$0-$835 (Tier

fosamprenavir calcium tabs

$0-$335 (Tier

FUZEON SOLR

$0-$835 (Tier

Name of drug

What the

level)

GENVOYA TABS

$0-$835 (Tier

INTELENCE TABS 100 MG 200 MG

$0-$835 (Tier

INTELENCE TABS 25 MG

$0-$835 (Tier

INVIRASE CAPS

$0-$835 (Tier

INVIRASE TABS

$0-$835 (Tier

ISENTRESS CHEW 100 MG

$0-$835 (Tier

SL(6 ea daily)MO

$0-$835 (Tier

SL(24 ea daily)MO

ISENTRESS HD TABS

$0-$835 (Tier

ISENTRESS PACK 100 MG

$0-$835 (Tier

SL(2 ea daily)MO

ISENTRESS TABS 400 MG

$0-$835 (Tier

Name of drug

What the

level)

JULUCA TABS

$0-$835 (Tier

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

$0-$835 (Tier

lamivudine soln

$0-$335 (Tier

lamivudine tabs

$0-$335 (Tier

lamivudine-zidovudine tabs

$0-$335 (Tier

LEXIVA SUSP 50 MGML

$0-$835 (Tier

LEXIVA TABS 700 MG (Fosamprenavir Calcium)

$0-$835 (Tier

lopinavir-ritonavir soln

$0-$335 (Tier

nevirapine susp

$0-$335 (Tier

nevirapine tabs

$0-$335 (Tier

Name of drug

What the

level)

nevirapine tb24

$0-$335 (Tier

NORVIR CAPS 100 MG

$0-$835 (Tier

NORVIR PACK 100 MG

$0-$835 (Tier

NORVIR SOLN 80 MGML

$0-$835 (Tier

NORVIR TABS 100 MG (Ritonavir)

$0-$835 (Tier

ODEFSEY TABS

$0-$835 (Tier

PIFELTRO TABS

$0-$835 (Tier

PREZCOBIX TABS

$0-$835 (Tier

PREZISTA SUSP

$0-$835 (Tier

PREZISTA TABS

$0-$835 (Tier

Name of drug

What the

level)

RESCRIPTOR TABS

$0-$835 (Tier

RETROVIR IV INFUSION SOLN

$0-$835 (Tier

REYATAZ CAPS 150 MG 200 MG 300 MG (Atazanavir Sulfate)

$0-$835 (Tier

REYATAZ PACK 50 MG

$0-$835 (Tier

ritonavir tabs

$0-$335 (Tier

SELZENTRY SOLN 20 MGML

$0-$835 (Tier

SELZENTRY TABS 150 MG 300 MG

$0-$835 (Tier

stavudine caps

$0-$335 (Tier

STRIBILD TABS

$0-$835 (Tier

Name of drug

What the

level)

SUSTIVA CAPS (Efavirenz)

$0-$835 (Tier

SUSTIVA TABS (Efavirenz)

$0-$835 (Tier

SYMFI LO TABS

$0-$835 (Tier

SYMFI TABS

$0-$835 (Tier

SYMTUZA TABS

$0-$835 (Tier

tenofovir disoproxilfumarate tabs

$0-$335 (Tier

TIVICAY TABS

$0-$835 (Tier

TRIUMEQ TABS

$0-$835 (Tier

TROGARZO SOLN

$0-$835 (Tier

TRUVADA TABS

$0-$835 (Tier

Name of drug

What the

level)

TYBOST TABS

$0-$835 (Tier

VIDEX EC CPDR 125 MG

$0-$835 (Tier

VIDEXPEDIATRIC SOLR

$0-$835 (Tier

VIRACEPT TABS

$0-$835 (Tier

VIRAMUNE SUSP 50 MG5ML (Nevirapine)

$0-$835 (Tier

VIREAD POWD 40 MGGM

$0-$835 (Tier

VIREAD TABS 150 MG 200 MG 250 MG

$0-$835 (Tier

VIREAD TABS 300 MG (Tenofovir DisoproxilFumarate)

$0-$835 (Tier

ZERIT SOLR 1 MGML

$0-$835 (Tier

ZIAGEN SOLN 20 MGML(Abacavir Sulfate)

$0-$835 (Tier

Name of drug

What the

level)

zidovudine caps

$0-$335 (Tier

zidovudine syrp

$0-$335 (Tier

zidovudine tabs

$0-$335 (Tier

CMV Agents

cidofovir soln

$0-$335 (Tier

ganciclovir sodium solr $0-

$335 (Tier

PREVYMIS SOLN IV 240 MG12ML 480 MG24ML

$0-$835 (Tier

PREVYMIS TABS OR 240 MG 480 MG

$0-$835 (Tier

valganciclovir hcl tabs 450 mg

$0-$335 (Tier

Hepatitis Agents

adefovir dipivoxil tabs

$0-$335 (Tier

BARACLUDE SOLN 005 MGML

$0-$835 (Tier

Name of drug

What the

level)

DAKLINZA TABS

$0-$835 (Tier

entecavir tabs

$0-$335 (Tier

EPCLUSA TABS

$0-$835 (Tier

EPIVIR HBV SOLN 5 MGML

$0-$835 (Tier

HARVONI TABS

$0-$835 (Tier

lamivudine (hbv) tabs

$0-$335 (Tier

MAVYRET TABS

$0-$835 (Tier

PEG-INTRON REDIPEN KIT

$0-$835 (Tier

PEGASYS PROCLICK SOLN

$0-$835 (Tier

PEGASYS SOLN

$0-$835 (Tier

Name of drug

What the

level)

PEGINTRON KIT

$0-$835 (Tier

ribavirin (hepatitis c) caps

$0-$335 (Tier

ribavirin (hepatitis c) tabs

$0-$335 (Tier

SOVALDI TABS

$0-$835 (Tier

VEMLIDY TABS

$0-$835 (Tier

VOSEVI TABS

$0-$835 (Tier

ZEPATIER TABS

$0-$835 (Tier

Herpes Agents

acyclovir caps or 200 mg

$0-$335 (Tier

acyclovir sodium soln 50mgml

$0-$335 (Tier

acyclovir susp or 200mg5ml

$0-$335 (Tier

Name of drug

What the

level)

acyclovir tabs or 400 mg800 mg

$0-$335 (Tier

famciclovir tabs

$0-$335 (Tier

valacyclovir hcl tabs or 1gm 500 mg 1000 mg

$0-$335 (Tier

Influenza Agents

oseltamivir phosphate capsor 30 mg

$0-$335 (Tier

QL(4 ea daily)MO

oseltamivir phosphate capsor 45 mg 75 mg

$0-$335 (Tier

oseltamivir phosphate susror 6 mgml

$0-$335 (Tier

RELENZA DISKHALER AEPB

$0-$835 (Tier

rimantadine hydrochloridetabs

$0-$335 (Tier

TAMIFLU SUSR 6 MGML(Oseltamivir Phosphate)

$0-$835 (Tier

Respiratory Syncytial Virus (RSV) Agents

ribavirin solr in

$0-$335 (Tier

Name of drug

What the

level)

BETA BLOCKERS - Drugs to Treat High BloodPressure

Alpha-Beta Blockers

carvedilol phosphate cp24

$0-$335 (Tier

carvedilol tabs 125 mg

$0-$335 (Tier

SL(8 ea daily)MO

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(32 ea daily)MO

$0-$335 (Tier

SL(16 ea daily)MO

COREG CR CP24 (Carvedilol Phosphate)

$0-$835 (Tier

labetalol hcl tabs or 100 mg 200 mg 300 mg

$0-$335 (Tier

Beta Blockers Cardio-Selective

acebutolol hcl caps or 200mg 400 mg

$0-$335 (Tier

atenolol tabs or 25 mg 50mg 100 mg

$0-$335 (Tier

Name of drug

What the

level)

betaxolol hcl tabs

$0-$335 (Tier

bisoprolol fumarate tabs

$0-$335 (Tier

metoprolol succinate tb24

$0-$335 (Tier

metoprolol tartrate tabs or25 mg 50 mg 100 mg

$0-$335 (Tier

METOPROLOL TARTRATE TABS OR 75 MG 375 MG

$0-$835 (Tier

Beta Blockers Non-Selective

nadolol tabs or 20 mg 40mg 80 mg

$0-$335 (Tier

pindolol tabs

$0-$335 (Tier

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

$0-$335 (Tier

propranolol hcl tabs or 10mg 20 mg 40 mg 60 mg80 mg

$0-$335 (Tier

sotalol hcl (afibafl) tabs

$0-$335 (Tier

Name of drug

What the

level)

sotalol hcl tabs

$0-$335 (Tier

tabsMO

SOTYLIZE SOLN

$0-$835 (Tier

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure

Calcium Channel Blockers

amlodipine besylate tabs or10 mg

$0-$335 (Tier

SL(1 ea daily)MO

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(2 ea daily)MO

diltiazem hcl coated beads cp24

$0-$335 (Tier

diltiazem hcl coated beads tb24

$0-$335 (Tier

diltiazem hcl cp12 or 60mg 90 mg 120 mg

$0-$335 (Tier

Name of drug

What the

level)

diltiazem hcl extended release beads cp24

$0-$335 (Tier

diltiazem hcl tabs or 30 mg60 mg 90 mg 120 mg

$0-$335 (Tier

felodipine tb24

$0-$335 (Tier

nicardipine hcl caps or 20mg 30 mg

$0-$335 (Tier

nifedipine tb24 or 30 mg60 mg 90 mg

$0-$335 (Tier

nimodipine caps or 30mg30 mg

$0-$335 (Tier

nisoldipine tb24

$0-$335 (Tier

NYMALIZE SOLN

$0-$835 (Tier

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

$0-$335 (Tier

verapamil hcl tabs or 40mg 80 mg 120 mg

$0-$335 (Tier

Name of drug

What the

level)

verapamil hcl tbcr or 120mg 180 mg 240 mg

$0-$335 (Tier

VERELAN CP24 360 MG

$0-$835 (Tier

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm

Cardiac Glycosides

DIGOXIN SOLN OR 005 MGML

$0-$835 (Tier

digoxin tabs or 0125 mg025 mg 125 mcg 250 mcg

$0-$335 (Tier

LANOXIN TABS OR 625 MCG 1875 MCG

$0-$835 (Tier

CARDIOVASCULAR AGENTS - MISC - Drugs toTreat Heart and Circulation Conditions

Cardiovascular Agents Misc - Combinations

amlodipine besylate-atorvastatin calcium tabs

$0-$335 (Tier

ENTRESTO TABS

$0-$835 (Tier

Prostaglandin Vasodilators

REMODULIN SOLN

$0-$835 (Tier

Name of drug

What the

level)

TYVASO REFILL SOLN

$0-$835 (Tier

TYVASO SOLN

$0-$835 (Tier

TYVASO STARTER SOLN

$0-$835 (Tier

VENTAVIS SOLN

$0-$835 (Tier

Pulmonary Hypertension - Endothelin Receptor

LETAIRIS TABS

$0-$835 (Tier

OPSUMIT TABS

$0-$835 (Tier

TRACLEER TABS 125 MG 625 MG

$0-$835 (Tier

TRACLEER TBSO 32 MG

$0-$835 (Tier

Pulmonary Hypertension - Phosphodiesterase

ADCIRCA TABS (Tadalafil (Pulmonary Hypertension))

$0-$835 (Tier

sildenafil citrate (pulmonaryhypertension) soln

$0-$335 (Tier

Name of drug

What the

level)

sildenafil citrate (pulmonaryhypertension) tabs

$0-$335 (Tier

tadalafil (pulmonaryhypertension) tabs

$0-$335 (Tier

Pulmonary Hypertension - Prostacyclin Receptor

UPTRAVI TABS

$0-$835 (Tier

UPTRAVI TBPK

$0-$835 (Tier

Pulmonary Hypertension - Sol Guanylate Cyclase

ADEMPAS TABS 05 MG

$0-$835 (Tier

PA SL(15 eadaily)

ADEMPAS TABS 1 MG

$0-$835 (Tier

PA SL(75 eadaily)

ADEMPAS TABS 15 MG

$0-$835 (Tier

PA SL(5 eadaily)

ADEMPAS TABS 2 MG

$0-$835 (Tier

PA SL(375 eadaily)

ADEMPAS TABS 25 MG

$0-$835 (Tier

PA SL(3 eadaily)

Sinus Node Inhibitors

Name of drug

What the

level)

CORLANOR TABS 5 MG

$0-$835 (Tier

SL(3 ea daily)MO

CORLANOR TABS 75 MG

$0-$835 (Tier

SL(2 ea daily)MO

CEPHALOSPORINS - Drugs to Treat BacterialInfections

Cephalosporins - 1st Generation

cefadroxil caps 500 mg

$0-$335 (Tier

cefadroxil susr 500 mg5ml $0-

$335 (Tier

cefadroxil tabs 1 gm

$0-$335 (Tier

cefazolin sodium solr ij 1gm 10 gm 500 mg

$0-$335 (Tier

cephalexin caps 250 mg500 mg 750 mg

$0-$335 (Tier

cephalexin susr 125mg5ml 250 mg5ml

$0-$335 (Tier

Cephalosporins - 2nd Generation

cefaclor caps 250 mg 500 mg

$0-$335 (Tier

Name of drug

What the

level)

cefoxitin sodium solr ij 10 gm

$0-$335 (Tier

cefoxitin sodium solr iv 1 gm 2 gm

$0-$335 (Tier

cefprozil susr 250 mg5ml $0-

$335 (Tier

cefprozil tabs 250 mg 500 mg

$0-$335 (Tier

cefuroxime axetil tabs

$0-$335 (Tier

cefuroxime sodium solr iv 15 gm

$0-$335 (Tier

Cephalosporins - 3rd Generation

cefdinir caps

$0-$335 (Tier

cefdinir susr $0-

$335 (Tier

cefixime chew

$0-$335 (Tier

cefixime susr $0-

$335 (Tier

Name of drug

What the

level)

cefpodoxime proxetil susr100 mg5ml

$0-$335 (Tier

cefpodoxime proxetil tabs100 mg 200 mg

$0-$335 (Tier

ceftazidime solr ij 1 gm 2 gm

$0-$335 (Tier

ceftazidime solr ij 6 gm

$0-$335 (Tier

ceftriaxone sodium solr ij 1 gm

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(2 ea daily)MO

ceftriaxone sodium solr ij250 mg

$0-$335 (Tier

SL(16 ea daily)MO

$0-$335 (Tier

SL(8 ea daily)MO

ceftriaxone sodium solr iv 1 gm

$0-$335 (Tier

SL(4 ea daily)

$0-$335 (Tier

Name of drug

What the

level)

SUPRAX CAPS 400 MG

$0-$835 (Tier

Cephalosporins - 4th Generation

cefepime hcl solr $0-

$335 (Tier

CEFEPIME SOLN 2 GM100ML

$0-$835 (Tier

TEFLARO SOLR 600 MG

$0-$835 (Tier

CONTRACEPTIVES - Drugs to PreventPregnancy

Combination Contraceptives - Oral

desogestrel amp ethinylestradiol tabs

$0-$335 (Tier

desogestrel-ethinylestradiol (biphasic) tabs

$0-$335 (Tier

drospirenone-ethinylestradiol tabs

$0-$335 (Tier

ethynodiol diacet amp ethestrad tabs 1mg-35mcg

$0-$335 (Tier

levonorgestrel amp ethestradiol tabs

$0-$335 (Tier

Name of drug

What the

level)

levonorgestrel-eth estradiol(triphasic) tabs

$0-$335 (Tier

levonorgestrel-ethinylestradiol (91-day) tabs

$0-$335 (Tier

biphasicMO

norethin acet amp estrad-fe tabs 75mg-20mcg-1mg75mg-30mcg-15mg

$0-$335 (Tier

norethindrone amp eth estradiol tabs

$0-$335 (Tier

norethindrone amp ethinylestradiol-fe chew 04mg-35mcg

$0-$335 (Tier

norethindrone acet amp eth estra tabs

$0-$335 (Tier

norethindrone-eth estradiol (triphasic) tabs

$0-$335 (Tier

norgestimate-ethinylestradiol (triphasic) tabs

$0-$335 (Tier

norgestimate-ethinylestradiol tabs

$0-$335 (Tier

norgestrel amp ethinylestradiol tabs

$0-$335 (Tier

Combination Contraceptives - Transdermal

Name of drug

What the

level)

norelgestromin-ethinylestradiol ptwk

$0-$335 (Tier

Combination Contraceptives - Vaginal

NUVARING RING

$0-$835 (Tier

Emergency Contraceptives

ELLA TABS

$0-$835 (Tier

levonorgestrel (emergencyoc) tabs

$0 (Tier

Progestin Contraceptives - Injectable

medroxyprogesteroneacetate (contraceptive) susp

$0-$335 (Tier

medroxyprogesteroneacetate (contraceptive) susy

$0-$335 (Tier

Progestin Contraceptives - Oral

norethindrone (contraceptive) tabs

$0-$335 (Tier

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions

Glucocorticosteroids

betamethasone sod phosphate amp acetate susp

$0-$335 (Tier

Name of drug

What the

level)

budesonide cpep or 3 mg

$0-$335 (Tier

cortisone acetate tabs or $0-

$335 (Tier

DEPO-MEDROL SUSP 20 MGML

$0-$835 (Tier

dexamethasone elix or 05 mg5ml

$0-$335 (Tier

dexamethasone sodium phosphate soln ij 10 mgml

$0-$335 (Tier

Preservative FreeMO

$0-$335 (Tier

1) dexamethasone sodium phosphate soln ij 4 mgml20 mg5ml 100 mg10ml120 mg30ml

$0-$335 (Tier

dexamethasone soln or 05 mg5ml

$0-$335 (Tier

dexamethasone tabs or 075 mg 05 mg 1 mg 2mg 4 mg 6 mg 15 mg

$0-$335 (Tier

dexamethasone tbpk or 15 mg

$0-$335 (Tier

Name of drug

What the

level)

EMFLAZA SUSP

$0-$835 (Tier

PA LA MO

EMFLAZA TABS

$0-$835 (Tier

PA LA MO

hydrocortisone tabs or 5mg 10 mg 20 mg

$0-$335 (Tier

KENALOG-10 SUSP

$0-$835 (Tier

KENALOG-40 SUSP (Triamcinolone Acetonide)

$0-$835 (Tier

MEDROL TABS 2 MG

$0-$835 (Tier

methylprednisolone acetatesusp ij 40 mgml 80 mgml

$0-$335 (Tier

methylprednisolone sodsucc solr

$0-$335 (Tier

methylprednisolone tabs or4 mg 8 mg 16 mg 32 mg

$0-$335 (Tier

methylprednisolone tbpk or4 mg

$0-$335 (Tier

Name of drug

What the

level)

prednisolone sodiumphosphate soln or 5mg5ml 15 mg5ml

$0-$335 (Tier

prednisolone sodiumphosphate tbdp or 10 mg15 mg 30 mg

$0-$335 (Tier

prednisolone soln or 15mg5ml

$0-$335 (Tier

prednisolone syrp or 15mg5ml

$0-$335 (Tier

prednisolone tabs or 5 mg

$0-$335 (Tier

prednisone conc or 5mgml

$0-$335 (Tier

prednisone soln or 5mg5ml

$0-$335 (Tier

prednisone tabs or 1 mg 5mg 10 mg 20 mg 50 mg25 mg

$0-$335 (Tier

prednisone tbpk or 5 mg

$0-$335 (Tier

Dose PackMO

prednisone tbpk or 5 mg10 mg

$0-$335 (Tier

Name of drug

What the

level)

SOLU-CORTEF SOLR 100 MG 250 MG 500 MG

$0-$835 (Tier

SOLU-CORTEF SOLR 1000 MG

$0-$835 (Tier

SOLU-MEDROL SOLR 500 MG

$0-$835 (Tier

TAPERDEX 6-DAY TBPK

$0-$835 (Tier

triamcinolone acetonide susp ij 40 mgml

$0-$335 (Tier

Mineralocorticoids

fludrocortisone acetate tabs or

$0-$335 (Tier

COUGHCOLDALLERGY - Drugs to TreatCough Cold and Allergy Symptoms

Antitussives

benzonatate caps 100 mg200 mg

$0 (Tier

hydrocodone whomatropine syrp

$0 (Tier

hydrocodone whomatropine tabs

$0 (Tier

CoughColdAllergy Combinations

Name of drug

What the

level)

brompheniramine ampphenyleph elix 1mg5ml-25mg5ml 1mg5ml-1mg5ml-25mg5ml-25mg5ml

$0 (Tier

brompheniramine amppseudoeph elix

$0 (Tier

brompheniramine amppseudoeph liqd

$0 (Tier

cetirizine-pseudoephedrinetb12

$0 (Tier

chlorpheniramine ampphenylephrine tabs 4mg-10mg

$0 (Tier

ED CHLORPED D LIQD $0

(Tier 3)

ENTRE-HIST PSE LIQD $0

(Tier 3)

guaifenesin-codeine liqd100mg5ml-10mg5ml

$0 (Tier

guaifenesin-codeine soln100mg5ml-10mg5ml

$0 (Tier

guaifenesin-codeine syrp100mg5ml-10mg5ml

$0 (Tier

hydrocodone polistirex-chlorpheniramine polistirex suer

$0 (Tier

loratadine amp pseudoephedrine tb2410mg-240mg 10mg-10mg-240mg-240mg

$0 (Tier

NEXAFED SINUS PRESSURE +PAIN TABS

$0 (Tier

Name of drug

What the

level)

PHENYLHISTINE DH LIQD $0

(Tier 3)

promethazine ampphenylephrine soln

$0-$335 (Tier

promethazine ampphenylephrine syrp

$0-$335 (Tier

promethazine wcodeinesoln

$0 (Tier

promethazine wcodeine syrp

$0 (Tier

promethazine-dm syrp $0

(Tier 3)

promethazine-phenylephrine-codeine syrp

$0 (Tier

RYMED TABS $0

(Tier 3)

triprolidine amppseudoephedrine tabs

$0 (Tier

Misc Respiratory Inhalants

sodium chloride (inhalant) aers

$0 (Tier

Mucolytics

acetylcysteine soln in 10 20

$0-$335 (Tier

DERMATOLOGICALS - Drugs to Treat SkinConditions

Acne Products

Name of drug

What the

level)

ABSORICA CAPS

$0-$835 (Tier

ACNE MEDICATION 10 LOTN

$0 (Tier

adapalene crea 01

$0-$335 (Tier

adapalene gel 01

$0-$335 (Tier

RXOTC MO

benzoyl peroxide gel ex 10

$0 (Tier

RXOTC MONT

BENZOYL PEROXIDE GEL EX 25

$0 (Tier

benzoyl peroxide liqd ex 5 10

$0 (Tier

RXOTC MONT

benzoyl peroxide-erythromycin gel

$0-$335 (Tier

CLINDAGEL GEL

$0-$835 (Tier

clindamycin phosphate(topical) foam

$0-$335 (Tier

clindamycin phosphate(topical) gel

$0-$335 (Tier

Name of drug

What the

level)

clindamycin phosphate(topical) lotn

$0-$335 (Tier

clindamycin phosphate(topical) soln

$0-$335 (Tier

clindamycin phosphate(topical) swab

$0-$335 (Tier

clindamycin phosphate-benzoyl peroxide(refrigerate) gel

$0-$335 (Tier

clindamycin phosphate-benzoyl peroxide gel

$0-$335 (Tier

erythromycin (acne aid)soln

$0-$335 (Tier

isotretinoin caps or 10 mg20 mg 30 mg 40 mg

$0-$335 (Tier

sulfacetamide sodium (acne) lotn

$0-$335 (Tier

tretinoin crea ex 0025 005 01

$0-$335 (Tier

tretinoin gel ex 0025 001

$0-$335 (Tier

Name of drug

What the

level)

tretinoin microsphere gel $0-

$335 (Tier

Anti-inflammatory Agents - Topical

diclofenac sodium (topical)gel 1

$0-$335 (Tier

FLECTOR PTCH

$0-$835 (Tier

Antibiotics - Topical

bacitracin (topical) oint $0

(Tier 3)

bacitracin zinc oint ex $0

(Tier 3)

bacitracin-polymyxin b oint $0

(Tier 3)

CENTANY OINT

$0-$835 (Tier

gentamicin sulfate (topical) crea

$0-$335 (Tier

gentamicin sulfate (topical)oint

$0-$335 (Tier

mupirocin calcium (topical) crea

$0-$335 (Tier

Name of drug

What the

level)

mupirocin oint ex

$0-$335 (Tier

Antifungals - Topical

ALEVAZOL OINT $0

(Tier 3)

ciclopirox gel 077

$0-$335 (Tier

ciclopirox olamine crea ex

$0-$335 (Tier

ciclopirox olamine susp ex

$0-$335 (Tier

ciclopirox sham 1

$0-$335 (Tier

ciclopirox soln 8

$0-$335 (Tier

clotrimazole (topical) crea

$0-$335 (Tier

RXOTC MO

clotrimazole (topical) crea $0

(Tier 3)

clotrimazole (topical) soln

$0-$335 (Tier

RXOTC MO

clotrimazole (topical) soln $0

(Tier 3)

Name of drug

What the

level)

clotrimazole wbetamethasone crea

$0-$335 (Tier

clotrimazole wbetamethasone lotn

$0-$335 (Tier

econazole nitrate crea

$0-$335 (Tier

ketoconazole (topical) crea

$0-$335 (Tier

ketoconazole (topical) foam

$0-$335 (Tier

ketoconazole (topical)sham

$0-$335 (Tier

LAMISIL AT SPRAY SOLN $0

(Tier 3)

LOTRIMIN AF CREA 1 (Clotrimazole (Topical))

$0 (Tier

RXOTC MONT

LOTRIMIN AF FOR HER CREA (Clotrimazole (Topical))

$0 (Tier

RXOTC MONT

LOTRIMIN AF JOCK ITCH CREA (Clotrimazole (Topical))

$0 (Tier

RXOTC MONT

miconazole nitrate (topical) crea

$0 (Tier

naftifine hcl crea 2

$0-$335 (Tier

Name of drug

What the

level)

NAFTIN GEL 2

$0-$835 (Tier

nystatin (topical) crea

$0-$335 (Tier

nystatin (topical) oint $0-

$335 (Tier

nystatin (topical) powd

$0-$335 (Tier

nystatin-triamcinolone crea

$0-$335 (Tier

nystatin-triamcinolone oint $0-

$335 (Tier

terbinafine hcl (topical) crea $0

(Tier 3)

tolnaftate crea ex $0

(Tier 3)

tolnaftate liqd ex $0

(Tier 3)

tolnaftate soln ex $0

(Tier 3)

Antineoplastic or Premalignant Lesion Agents -

CARAC CREA

$0-$835 (Tier

Name of drug

What the

level)

diclofenac sodium (actinickeratoses) gel

$0-$335 (Tier

fluorouracil (topical) crea

$0-$335 (Tier

fluorouracil (topical) soln

$0-$335 (Tier

FLUOROURACIL CREA EX 05

$0-$835 (Tier

PANRETIN GEL

$0-$835 (Tier

PICATO GEL

$0-$835 (Tier

TARGRETIN GEL EX 1

$0-$835 (Tier

VALCHLOR GEL

$0-$835 (Tier

Antipsoriatics

acitretin caps

$0-$335 (Tier

calcipotriene crea

$0-$335 (Tier

Name of drug

What the

level)

calcipotriene oint $0-

$335 (Tier

calcipotriene soln

$0-$335 (Tier

COSENTYX SENSOREADY PEN SOAJ

$0-$835 (Tier

COSENTYX SOSY

$0-$835 (Tier

methoxsalen rapid caps

$0-$335 (Tier

SILIQ SOSY

$0-$835 (Tier

STELARA SOSY SC 90 MGML 45 MG05ML

$0-$835 (Tier

TALTZ SOAJ

$0-$835 (Tier

TALTZ SOSY

$0-$835 (Tier

tazarotene crea

$0-$335 (Tier

Name of drug

What the

level)

TAZORAC CREA 005

$0-$835 (Tier

TAZORAC GEL 005 01

$0-$835 (Tier

TREMFYA SOSY

$0-$835 (Tier

Antiseborrheic Products

selenium sulfide lotn ex 1

$0 (Tier

$0-$335 (Tier

selenium sulfide sham ex 1

$0 (Tier

Antivirals - Topical

ABREVA CREA $0

(Tier 3)

acyclovir topical oint $0-

$335 (Tier

DENAVIR CREA

$0-$835 (Tier

ZOVIRAX CREA EX 5

$0-$835 (Tier

Burn Products

Name of drug

What the

level)

mafenide acetate pack ex

$0-$335 (Tier

silver sulfadiazine crea ex

$0-$335 (Tier

SULFAMYLON CREA 85 MGGM

$0-$835 (Tier

SULFAMYLON PACK 5 (Mafenide Acetate)

$0-$835 (Tier

Corticosteroids - Topical

alclometasone dipropionate crea

$0-$335 (Tier

alclometasone dipropionateoint

$0-$335 (Tier

amcinonide crea

$0-$335 (Tier

betamethasone dipropionate (topical) crea

$0-$335 (Tier

betamethasone dipropionate (topical) lotn

$0-$335 (Tier

betamethasone dipropionate (topical) oint

$0-$335 (Tier

Name of drug

What the

level)

betamethasone dipropionate augmented crea

$0-$335 (Tier

betamethasone dipropionate augmentedgel

$0-$335 (Tier

betamethasone dipropionate augmentedlotn

$0-$335 (Tier

betamethasone dipropionate augmentedoint

$0-$335 (Tier

betamethasone valerate crea ex 01

$0-$335 (Tier

betamethasone valerate foam ex 012

$0-$335 (Tier

betamethasone valerate lotn ex 01

$0-$335 (Tier

betamethasone valerate oint ex 01

$0-$335 (Tier

clobetasol propionate crea ex

$0-$335 (Tier

clobetasol propionateemollient base crea

$0-$335 (Tier

Name of drug

What the

level)

clobetasol propionateemulsion foam

$0-$335 (Tier

clobetasol propionate foam ex

$0-$335 (Tier

clobetasol propionate gel ex

$0-$335 (Tier

clobetasol propionate lotn ex

$0-$335 (Tier

clobetasol propionate oint ex

$0-$335 (Tier

clobetasol propionate sham ex

$0-$335 (Tier

clobetasol propionate soln ex

$0-$335 (Tier

desonide crea ex

$0-$335 (Tier

desonide lotn ex

$0-$335 (Tier

desonide oint ex

$0-$335 (Tier

Name of drug

What the

level)

desoximetasone crea ex 025

$0-$335 (Tier

desoximetasone gel ex005

$0-$335 (Tier

desoximetasone oint ex 025

$0-$335 (Tier

diflorasone diacetate oint $0-

$335 (Tier

fluocinolone acetonide crea ex 0025 001

$0-$335 (Tier

fluocinolone acetonide oil ex 001

$0-$335 (Tier

fluocinolone acetonide oint ex 0025

$0-$335 (Tier

fluocinolone acetonide soln ex 001

$0-$335 (Tier

fluocinonide crea ex 005

$0-$335 (Tier

fluocinonide emulsified base crea

$0-$335 (Tier

Name of drug

What the

level)

fluocinonide gel ex 005

$0-$335 (Tier

fluocinonide oint ex 005

$0-$335 (Tier

fluocinonide soln ex 005

$0-$335 (Tier

fluticasone propionate creaex 005

$0-$335 (Tier

fluticasone propionate lotnex 005

$0-$335 (Tier

fluticasone propionate ointex 0005

$0-$335 (Tier

halobetasol propionate crea

$0-$335 (Tier

halobetasol propionate oint $0-

$335 (Tier

hydrocortisone (topical)crea 05

$0 (Tier

$0-$335 (Tier

RXOTC MO

hydrocortisone (topical)crea 1 1

$0 (Tier

Name of drug

What the

level)

$0-$335 (Tier

hydrocortisone (topical)lotn 1

$0 (Tier

$0-$335 (Tier

hydrocortisone (topical)oint 05

$0 (Tier

$0-$335 (Tier

RXOTC MO

$0 (Tier

$0-$335 (Tier

hydrocortisone (topical)soln 1

$0 (Tier

hydrocortisone butyrate crea

$0-$335 (Tier

hydrocortisone butyratehydrophilic lipo base crea

$0-$335 (Tier

hydrocortisone butyrateoint

$0-$335 (Tier

Name of drug

What the

level)

hydrocortisone butyratesoln

$0-$335 (Tier

hydrocortisone valerate crea

$0-$335 (Tier

hydrocortisone valerate oint $0-

$335 (Tier

hydrocortisone-aloe vera crea

$0 (Tier

mometasone furoate crea ex

$0-$335 (Tier

mometasone furoate oint ex

$0-$335 (Tier

mometasone furoate soln ex

$0-$335 (Tier

MONISTAT SOOTHING CARE ITCH RELIEF CREA (Hydrocortisone (Topical))

$0 (Tier

RXOTC MONT

prednicarbate crea

$0-$335 (Tier

triamcinolone acetonide (topical) aers 0147 mggm

$0-$335 (Tier

triamcinolone acetonide (topical) crea 0025 01 05

$0-$335 (Tier

Name of drug

What the

level)

triamcinolone acetonide (topical) lotn 0025 01

$0-$335 (Tier

triamcinolone acetonide (topical) oint 0025 01

$0-$335 (Tier

Emollients LAC-HYDRIN TWELVE LOTN (Lactic Acid (Ammonium Lactate))

$0 (Tier

RXOTC MONT

lactic acid (ammoniumlactate) crea 12

$0 (Tier

$0-$335 (Tier

RXOTC MO

lactic acid (ammoniumlactate) lotn 12

$0-$335 (Tier

RXOTC MO

$0 (Tier

Enzymes - Topical

SANTYL OINT

$0-$835 (Tier

Immunomodulating Agents - Topical

imiquimod crea ex

$0-$335 (Tier

IMIQUIMOD PUMP CREA

$0-$835 (Tier

Name of drug

What the

level)

ZYCLARA CREA

$0-$835 (Tier

ZYCLARA PUMP CREA 25 375

$0-$835 (Tier

Immunosuppressive Agents - Topical

ELIDEL CREA

$0-$835 (Tier

tacrolimus (topical) oint $0-

$335 (Tier

KeratolyticAntimitotic Agents

podofilox soln ex

$0-$335 (Tier

Local Anesthetics - Topical

lidocaine hcl gel ex 2

$0-$335 (Tier

RXOTC MO

lidocaine hcl soln ex 4

$0-$335 (Tier

lidocaine oint ex 5

$0-$335 (Tier

lidocaine ptch ex 5

$0-$335 (Tier

Name of drug

What the

level)

lidocaine-prilocaine crea

$0-$335 (Tier

Misc Topical

CALAMINE LOTN EX $0

(Tier 3)

CALAMINE LOTN EX $0

(Tier 3)

Calamine-Zinc Oxide LotionMO NT

GNP CALAMINE LOTN $0

(Tier 3)

HM CALAMINE LOTN $0

(Tier 3)

MEIJER CALAMINE LOTN $0

(Tier 3)

PX CALAMINE LOTN $0

(Tier 3)

QC CALAMINE LOTN $0

(Tier 3)

RA CALAMINE LOTN 6971-6971

$0 (Tier

SM CALAMINE LOTN $0

(Tier 3)

Rosacea Agents

FINACEA GEL

$0-$835 (Tier

metronidazole (topical) crea

$0-$335 (Tier

Name of drug

What the

level)

metronidazole (topical) gel $0-

$335 (Tier

metronidazole (topical) lotn

$0-$335 (Tier

MIRVASO GEL

$0-$835 (Tier

Scabicides amp Pediculicides

malathion lotn

$0-$335 (Tier

permethrin crea ex 5

$0-$335 (Tier

permethrin liqd ex 1 $0

(Tier 3)

permethrin lotn ex 1 $0

(Tier 3)

pyrethrins-piperonylbutoxide liqd 033-4

$0 (Tier

pyrethrins-piperonylbutoxide sham 03-033-4 033-4

$0 (Tier

pyrethrins-piperonylbutoxide sham 033-4

$0 (Tier

Wound Care Products

REGRANEX GEL

$0-$835 (Tier

Name of drug

What the

level)

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes

Digestive Enzymes

CREON CPEP

$0-$835 (Tier

PANCREAZE CPEP

$0-$835 (Tier

SUCRAID SOLN

$0-$835 (Tier

DIURETICS - Drugs to Treat Heart CirculationConditions and Blood Pressure

Carbonic Anhydrase Inhibitors

acetazolamide cp12 or 500 mg

$0-$335 (Tier

acetazolamide tabs or 250 mg

$0-$335 (Tier

methazolamide tabs or 25 mg 50 mg

$0-$335 (Tier

Diuretic Combinations

amiloride amp hydrochlorothiazide tabs

$0-$335 (Tier

spironolactone amphydrochlorothiazide tabs

$0-$335 (Tier

Name of drug

What the

level)

triamterene amp hydrochlorothiazide caps375mg-25mg

$0-$335 (Tier

triamterene amp hydrochlorothiazide tabs75mg-50mg 375mg-25mg

$0-$335 (Tier

Loop Diuretics

bumetanide tabs or 05 mg1 mg 2 mg

$0-$335 (Tier

furosemide soln ij 10 mgml $0-

$335 (Tier

furosemide soln or 10 mgml

$0-$335 (Tier

furosemide tabs or 20 mg40 mg 80 mg

$0-$335 (Tier

torsemide tabs

$0-$335 (Tier

Potassium Sparing Diuretics

amiloride hcl tabs or $0-

$335 (Tier

spironolactone tabs or 25mg 50 mg 100 mg

$0-$335 (Tier

Name of drug

What the

level)

Thiazides and Thiazide-Like Diuretics

chlorothiazide tabs 500 mg

$0-$335 (Tier

chlorthalidone tabs 25 mg

$0-$335 (Tier

hydrochlorothiazide caps or125 mg

$0-$335 (Tier

hydrochlorothiazide tabs or25 mg 50 mg 125 mg

$0-$335 (Tier

indapamide tabs

$0-$335 (Tier

metolazone tabs

$0-$335 (Tier

ENDOCRINE AND METABOLIC AGENTS -MISC - Drugs to Treat Bone Disease andRegulate Hormones

Bone Density Regulators

alendronate sodium tabs 35 mg 70 mg

$0-$335 (Tier

QL(015 eadaily) MO

$0-$335 (Tier

calcitonin (salmon) soln

$0-$335 (Tier

Name of drug

What the

level)

FORTEO SOLN

$0-$835 (Tier

PA Limit 24mls per 28daysQL(009ml daily)

ibandronate sodium soln iv 3 mg3ml

$0-$335 (Tier

QL(004 mldaily) MO

ibandronate sodium tabs or 150 mg

$0-$335 (Tier

Limit 1 tab per28 days (3 per84)QL(0036ea daily) MO

MIACALCIN SOLN IJ 200 UNITML

$0-$835 (Tier

NATPARA CART

$0-$835 (Tier

PROLIA SOLN

$0-$835 (Tier

PA QL(001 mldaily)

TYMLOS SOPN

$0-$835 (Tier

XGEVA SOLN

$0-$835 (Tier

Limit 68mls per 28daysQL(0243ml daily)

zoledronic acid conc 4 mg5ml

$0-$335 (Tier

zoledronic acid soln 5 mg100ml

$0-$335 (Tier

QL(028 mldaily)

Corticotropin

Name of drug

What the

level)

HP ACTHAR GEL

$0-$835 (Tier

Fertility Regulators

chorionic gonadotropin solrim

$0-$335 (Tier

NOVAREL SOLR

$0-$835 (Tier

Growth Hormone Receptor Antagonists

SOMAVERT SOLR

$0-$835 (Tier

Growth Hormones

GENOTROPIN MINIQUICK SOLR 04 MG

$0-$835 (Tier

GENOTROPIN SOLR 5 MG

$0-$835 (Tier

HUMATROPE COMBO PACK SOLR

$0-$835 (Tier

HUMATROPE SOLR 6 MG 12 MG 24 MG

$0-$835 (Tier

NORDITROPIN FLEXPRO SOLN 5 MG15ML 10MG15ML

$0-$835 (Tier

Name of drug

What the

level)

NUTROPIN AQ NUSPIN 20 SOLN

$0-$835 (Tier

OMNITROPE SOLN 5 MG15ML 10 MG15ML

$0-$835 (Tier

SEROSTIM SOLR 4 MG 6 MG

$0-$835 (Tier

ZOMACTON SOLR 5 MG

$0-$835 (Tier

Hormone Receptor Modulators

raloxifene hcl tabs

$0-$335 (Tier

QL(1 ea daily)MO

Insulin-Like Growth Factors (Somatomedins)

INCRELEX SOLN

$0-$835 (Tier

LHRHGnRH Agonist Analog Pituitary

LUPRON DEPOT-PED (1-MONTH) KIT

$0-$835 (Tier

LUPRON DEPOT-PED (3-MONTH) KIT 1125 MG

$0-$835 (Tier

3 month kit

$0-$835 (Tier

Name of drug

What the

level)

SYNAREL SOLN

$0-$835 (Tier

TRIPTODUR SRER

$0-$835 (Tier

Metabolic Modifiers

calcitriol caps or 025 mcg05 mcg

$0-$335 (Tier

calcitriol soln or 1 mcgml $0-

$335 (Tier

CARBAGLU TABS

$0-$835 (Tier

FABRAZYME SOLR 35 MG

$0-$835 (Tier

KANUMA SOLN

$0-$835 (Tier

KUVAN PACK

$0-$835 (Tier

KUVAN TBSO

$0-$835 (Tier

levocarnitine (metabolicmodifiers) tabs 330 mg

$0-$335 (Tier

RXOTC MO

Name of drug

What the

level)

LUMIZYME SOLR

$0-$835 (Tier

MYALEPT SOLR

$0-$835 (Tier

NAGLAZYME SOLN

$0-$835 (Tier

ORFADIN CAPS 2 MG 5 MG 10 MG 20 MG

$0-$835 (Tier

paricalcitol caps or 1 mcg2 mcg 4 mcg

$0-$335 (Tier

RAVICTI LIQD

$0-$835 (Tier

RAYALDEE CPCR

$0-$835 (Tier

SENSIPAR TABS

$0-$835 (Tier

STRENSIQ SOLN

$0-$835 (Tier

PA LA MO

VIMIZIM SOLN

$0-$835 (Tier

Name of drug

What the

level)

XURIDEN PACK

$0-$835 (Tier

SL(4 ea daily)MO

Posterior Pituitary Hormones

DDAVP SOLN NA 001

$0-$835 (Tier

desmopressin acetate solnij 4 mcgml

$0-$335 (Tier

desmopressin acetatespray refrigerated soln

$0-$335 (Tier

desmopressin acetatespray soln

$0-$335 (Tier

desmopressin acetate tabsor 01 mg 02 mg

$0-$335 (Tier

Prolactin Inhibitors

cabergoline tabs

$0-$335 (Tier

Somatostatic Agents

octreotide acetate soln 50 mcgml 100 mcgml 200mcgml

$0-$335 (Tier

SANDOSTATIN LAR DEPOT KIT 20 MG 30 MG

$0-$835 (Tier

Name of drug

What the

level)

SIGNIFOR LAR SRER 10 MG

$0-$835 (Tier

Limit 6 vials per28 daysSL(021ea daily) LAMO

$0-$835 (Tier

Limit 1 vial per28 daysSL(0036ea daily) LAMO

SIGNIFOR SOLN

$0-$835 (Tier

SOMATULINE DEPOT SOLN

$0-$835 (Tier

Vasopressin Receptor Antagonists

JYNARQUE TBPK

$0-$835 (Tier

SAMSCA TABS

$0-$835 (Tier

Name of drug

What the

level)

ESTROGENS - Hormone ReplacementModifyingDrugs

Estrogen Combinations

estradiol amp norethindrone acetate tabs

$0-$335 (Tier

norethindrone acetate-ethinyl estradiol tabs25mcg-05mg

$0-$335 (Tier

PREMPHASE TABS

$0-$835 (Tier

PREMPRO TABS

$0-$835 (Tier

Estrogens

DELESTROGEN OIL 10 MGML

$0-$835 (Tier

DIVIGEL GEL

$0-$835 (Tier

estradiol ptwk td 0025mg24hr 0075 mg24hr005 mg24hr 006mg24hr 01 mg24hr 375mcg24hr

$0-$335 (Tier

estradiol tabs or 05 mg 1mg 2 mg

$0-$335 (Tier

estradiol valerate oil im 20 mgml 40 mgml

$0-$335 (Tier

Name of drug

What the

level)

estropipate tabs 075 mg15 mg

$0-$335 (Tier

PREMARIN TABS OR 0625 MG 045 MG 03 MG 09 MG 125 MG

$0-$835 (Tier

FLUOROQUINOLONES - Drugs to Treat BacterialInfections

Fluoroquinolones

BAXDELA SOLR IV 300 MG

$0-$835 (Tier

BAXDELA TABS OR 450 MG

$0-$835 (Tier

ciprofloxacin hcl tabs or100 mg 250 mg 500 mg750 mg

$0-$335 (Tier

ciprofloxacin in d5w soln200mg100ml-5

$0-$335 (Tier

ciprofloxacin soln iv 400mg40ml

$0-$335 (Tier

ciprofloxacin-ciprofloxacinhcl tb24

$0-$335 (Tier

Name of drug

What the

level)

levofloxacin in d5w soln

$0-$335 (Tier

levofloxacin soln iv 25 mgml

$0-$335 (Tier

levofloxacin soln or 25 mgml

$0-$335 (Tier

levofloxacin tabs or 250 mg 500 mg 750 mg

$0-$335 (Tier

QL(1 ea daily)MO

GASTROINTESTINAL AGENTS - MISC -Miscellaneous Gastrointestinal Drugs

Antiflatulents

simethicone caps or125mg 125 mg

$0 (Tier

simethicone chew or 125 mg

$0 (Tier

Farnesoid X Receptor (FXR) Agonists

OCALIVA TABS 10 MG

$0-$835 (Tier

PA SL(1 eadaily)

OCALIVA TABS 5 MG

$0-$835 (Tier

PA SL(2 eadaily)

Gallstone Solubilizing Agents

chenodiol tabs

$0-$335 (Tier

Name of drug

What the

level)

ursodiol caps or 300 mg

$0-$335 (Tier

ursodiol tabs or 250 mg500 mg

$0-$335 (Tier

Gastrointestinal Antiallergy Agents

cromolyn sodium(mastocytosis) conc

$0-$335 (Tier

Gastrointestinal Stimulants

metoclopramide hcl soln ij5 mgml

$0-$335 (Tier

metoclopramide hcl soln or5 mg5ml 10 mg10ml

$0-$335 (Tier

metoclopramide hcl tabs or5 mg 10 mg

$0-$335 (Tier

Inflammatory Bowel Agents

APRISO CP24

$0-$835 (Tier

ASACOL HD TBEC

$0-$835 (Tier

ASACOL HD TBEC (Mesalamine)

$0-$835 (Tier

Name of drug

What the

level)

balsalazide disodium caps

$0-$335 (Tier

CIMZIA KIT

$0-$835 (Tier

CIMZIA STARTER KIT KIT

$0-$835 (Tier

DELZICOL CPDR

$0-$835 (Tier

DIPENTUM CAPS

$0-$835 (Tier

ENTYVIO SOLR

$0-$835 (Tier

INFLECTRA SOLR

$0-$835 (Tier

mesalamine enem re 4 gm

$0-$335 (Tier

mesalamine tbec or 800 mg

$0-$335 (Tier

mesalamine w cleanser kit $0-

$335 (Tier

Name of drug

What the

level)

REMICADE SOLR

$0-$835 (Tier

STELARA SOLN IV 130 MG26ML

$0-$835 (Tier

sulfasalazine tabs or $0-

$335 (Tier

sulfasalazine tbec or $0-

$335 (Tier

Intestinal Acidifiers

lactulose (encephalopathy)soln

$0-$335 (Tier

Irritable Bowel Syndrome (IBS) Agents

alosetron hcl tabs

$0-$335 (Tier

LINZESS CAPS

$0-$835 (Tier

VIBERZI TABS

$0-$835 (Tier

Peripheral Opioid Receptor Antagonists

MOVANTIK TABS

$0-$835 (Tier

Name of drug

What the

level)

RELISTOR SOLN SC 8 MG04ML 12 MG06ML

$0-$835 (Tier

Phosphate Binder Agents

calcium acetate (phosphatebinder) caps

$0-$335 (Tier

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

$0-$835 (Tier

lanthanum carbonate chew

$0-$335 (Tier

RENVELA TABS 800 MG (Sevelamer Carbonate)

$0-$835 (Tier

sevelamer carbonate pack24 gm

$0-$335 (Tier

sevelamer carbonate tabs 800 mg

$0-$335 (Tier

Short Bowel Syndrome (SBS) Agents

GATTEX KIT

$0-$835 (Tier

Tryptophan Hydroxylase Inhibitors

XERMELO TABS

$0-$835 (Tier

PA LA MO

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

Name of drug

What the

level)

Alkalinizers

potassium citrate(alkalinizer) tbcr 540 mg1080 mg

$0-$335 (Tier

Cystinosis Agents

CYSTAGON CAPS

$0-$835 (Tier

Genitourinary Irrigants

acetic acid soln

$0-$335 (Tier

neomycinpolymyxin b gusoln

$0-$335 (Tier

sodium chloride (guirrigant) soln

$0-$335 (Tier

Prostatic Hypertrophy Agents

alfuzosin hcl tb24

$0-$335 (Tier

dutasteride caps

$0-$335 (Tier

dutasteride-tamsulosin hcl caps

$0-$335 (Tier

finasteride tabs or $0-

$335 (Tier

Name of drug

What the

level)

tamsulosin hcl caps

$0-$335 (Tier

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations

colchicine w probenecidtabs

$0-$335 (Tier

Gout Agents

allopurinol tabs or 100 mg

$0-$335 (Tier

SL(8 ea daily)MO

$0-$335 (Tier

SL(266 eadaily) MO

colchicine tabs or $0-

$835 (Tier

COLCRYS TABS

$0-$835 (Tier

Uricosurics

probenecid tabs

$0-$335 (Tier

HEMATOLOGICAL AGENTS - MISC - Drugs toTreat Blood Disorders

Bradykinin B2 Receptor Antagonists

FIRAZYR SOLN

$0-$835 (Tier

Complement Inhibitors

Name of drug

What the

level)

BERINERT KIT

$0-$835 (Tier

CINRYZE SOLR

$0-$835 (Tier

HAEGARDA SOLR

$0-$835 (Tier

RUCONEST SOLR

$0-$835 (Tier

Hemataologic - Tyrosine Kinase Inhibitors

TAVALISSE TABS

$0-$835 (Tier

Hematorheologic Agents

pentoxifylline tbcr or $0-

$335 (Tier

Plasma Kallikrein Inhibitors

KALBITOR SOLN

$0-$835 (Tier

Platelet Aggregation Inhibitors

anagrelide hcl caps

$0-$335 (Tier

aspirin-dipyridamole cp12

$0-$335 (Tier

Name of drug

What the

level)

BRILINTA TABS

$0-$835 (Tier

cilostazol tabs

$0-$335 (Tier

clopidogrel bisulfate tabs300 mg

$0-$335 (Tier

dipyridamole tabs or 25mg 50 mg 75 mg

$0-$335 (Tier

EFFIENT TABS (PrasugrelHCl)

$0-$835 (Tier

prasugrel hcl tabs

$0-$335 (Tier

ZONTIVITY TABS

$0-$835 (Tier

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders

Agents for Gaucher Disease

CERDELGA CAPS

$0-$835 (Tier

Name of drug

What the

level)

CEREZYME SOLR

$0-$835 (Tier

ELELYSO SOLR

$0-$835 (Tier

miglustat caps

$0-$335 (Tier

VPRIV SOLR

$0-$835 (Tier

ZAVESCA CAPS (Miglustat)

$0-$835 (Tier

Agents for Sickle Cell Anemia

DROXIA CAPS

$0-$835 (Tier

ENDARI PACK

$0-$835 (Tier

Cobalamins

cyanocobalamin tabs or100 mcg

$0 (Tier

cyanocobalamin tabs or 50 mcg

$0 (Tier

Folic AcidFolates

folic acid caps or 08 mg800 mcg

$0 (Tier

Name of drug

What the

level)

FOLIC ACID CAPS OR 20 MG

$0 (Tier

folic acid tabs or 1 mg $0

(Tier 3)

RXOTC MONT

folic acid tabs or 400 mcg800 mcg

$0 (Tier

Hematopoietic Growth Factors

ARANESP ALBUMIN FREE SOLN

$0-$835 (Tier

ARANESP ALBUMIN FREE SOSY

$0-$835 (Tier

EPOGEN SOLN

$0-$835 (Tier

GRANIX SOSY

$0-$835 (Tier

LEUKINE SOLR

$0-$835 (Tier

NEULASTA ONPRO KIT PSKT

$0-$835 (Tier

NEULASTA SOSY

$0-$835 (Tier

NEUPOGEN SOLN

$0-$835 (Tier

Name of drug

What the

level)

NEUPOGEN SOSY

$0-$835 (Tier

PROCRIT SOLN 2000 UNITML 3000 UNITML4000 UNITML 10000UNITML 20000 UNITML40000 UNITML

$0-$835 (Tier

PROMACTA TABS 125 MG

$0-$835 (Tier

PA SL(12 eadaily) LA

PROMACTA TABS 25 MG

$0-$835 (Tier

PA SL(6 eadaily) LA

PROMACTA TABS 50 MG

$0-$835 (Tier

PA SL(3 eadaily) LA

PROMACTA TABS 75 MG

$0-$835 (Tier

PA SL(2 eadaily) LA

ZARXIO SOSY

$0-$835 (Tier

ferrous sulfate elix or 220 mg5ml

$0 (Tier

FERROUS SULFATE LIQD OR 220 MG5ML

$0 (Tier

ferrous sulfate soln or 15 mgml

$0 (Tier

FERROUS SULFATE SYRP OR 300 MG5ML

$0 (Tier

Name of drug

What the

level)

ferrous sulfate tabs or 65 mg 325 mg

$0 (Tier

FERROUS SULFATE TBEC OR 324 MG

$0 (Tier

ferrous sulfate tbec or 325 mg

$0 (Tier

IRON CHEWS PEDIATRIC CHEW

$0 (Tier

polysaccharide ironcomplex caps

$0 (Tier

Stem Cell Mobilizers

MOZOBIL SOLN

$0-$835 (Tier

HEMOSTATICS - Drugs to Stop BleedingTreatBlood Disorders

Hemostatics - Systemic

AMICAR SOLN 025 GMML

$0-$835 (Tier

AMICAR TABS 500 MG

$0-$835 (Tier

tranexamic acid soln iv 1000 mg10ml

$0-$335 (Tier

tranexamic acid tabs or 650 mg

$0-$335 (Tier

HYPNOTICSSEDATIVESSLEEP DISORDERAGENTS

Name of drug

What the

level)

Barbiturate Hypnotics

BUTISOL SODIUM TABS

$0-$835 (Tier

phenobarbital elix or 20mg5ml

$0-$335 (Tier

phenobarbital soln or 20mg5ml

$0-$335 (Tier

phenobarbital tabs or 15mg 30 mg 60 mg 100 mg162 mg 324 mg 648 mg972 mg

$0-$335 (Tier

Hypnotics - Tricyclic Agents

SILENOR TABS 3 MG

$0-$835 (Tier

QL(2 ea daily)MO

SILENOR TABS 6 MG

$0-$835 (Tier

QL(1 ea daily)MO

Non-Barbiturate Hypnotics

temazepam caps

$0-$335 (Tier

TRIAZOLAM TABS 0125 MG

$0-$835 (Tier

triazolam tabs 025 mg

$0-$335 (Tier

Name of drug

What the

level)

zaleplon caps

$0-$335 (Tier

zolpidem tartrate tabs or 10 mg

$0-$335 (Tier

zolpidem tartrate tbcr or125 mg

$0-$335 (Tier

Orexin Receptor Antagonists

BELSOMRA TABS 10 MG

$0-$835 (Tier

PA SL(2 eadaily) MO

BELSOMRA TABS 15 MG

$0-$835 (Tier

BELSOMRA TABS 20 MG

$0-$835 (Tier

PA SL(1 eadaily) MO

BELSOMRA TABS 5 MG

$0-$835 (Tier

PA SL(4 eadaily) MO

Selective Melatonin Receptor Agonists

HETLIOZ CAPS

$0-$835 (Tier

Name of drug

What the

level)

ROZEREM TABS

$0-$835 (Tier

LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives

calcium polycarbophil tabs $0

(Tier 3)

CVS NATURAL FIBER SUPPLEMENT PACK

$0 (Tier

EQUALACTIN CHEW $0

(Tier 3)

HYDROCIL INSTANT PACK

$0 (Tier

KONSYL DAILY FIBER PACK 100

$0 (Tier

KONSYL DAILY FIBER POWD 603

$0 (Tier

KONSYL PACK $0

(Tier 3)

KONSYL POWD $0

(Tier 3)

KONSYL-D POWD $0

(Tier 3)

METAMUCIL SMOOTH TEXTUREFIBER SINGLES PACK

$0 (Tier

Name of drug

What the

level)

methylcellulose (laxative)powd

$0 (Tier

psyllium caps 052 gm 520 mg

$0 (Tier

psyllium powd 33 68 309

$0 (Tier

psyllium powd 95 100 283 586 4857

$0 (Tier

Laxative Combinations

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

$0-$335 (Tier

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate solr

$0-$335 (Tier

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr

$0-$335 (Tier

SUPREP BOWEL PREP KIT SOLN

$0-$835 (Tier

Laxatives - Miscellaneous

FLEET LIQUID GLYCERIN SUPPOSITORIES ENEM

$0 (Tier

lactulose soln 10 gm15ml20 gm30ml

$0-$335 (Tier

MIRALAX PACK (Polyethylene Glycol 3350)

$0 (Tier

RXOTC MONT

Name of drug

What the

level)

MIRALAX POWD (Polyethylene Glycol 3350)

$0 (Tier

RXOTC MONT

polyethylene glycol 3350pack or

$0-$335 (Tier

RXOTC MO

$0 (Tier

polyethylene glycol 3350powd or

$0 (Tier

$0-$335 (Tier

RXOTC MO

Saline Laxatives

MILK OF MAGNESIA CONCENTRATE SUSP

$0 (Tier

Stimulant Laxatives

bisacodyl supp re 10 mg $0

(Tier 3)

bisacodyl tbec or 5 mg $0

(Tier 3)

FLEET BISACODYL ENEM $0

(Tier 3)

sennosides tabs 15 mg $0

(Tier 3)

Surfactant Laxatives

docusate calcium caps $0

(Tier 3)

docusate sodium caps or100 mg 250 mg

$0 (Tier

Name of drug

What the

level)

docusate sodium liqd or 50mg5ml 150 mg15ml

$0 (Tier

docusate sodium syrp or60 mg15ml

$0 (Tier

docusate sodium tabs or 100 mg

$0 (Tier

DOCUSOL MINI ENEM $0

(Tier 3)

DOCUSOL PLUS MINI-ENEMA ENEM

$0 (Tier

ENEMEEZ MINI ENEM $0

(Tier 3)

ENEMEEZ PLUS ENEM $0

(Tier 3)

LOCAL ANESTHETICS-Parenteral - Drugs forNumbing

Local Anesthetics - Amides

lidocaine hcl (local anesth)soln 1 2

$0-$335 (Tier

MACROLIDES - Drugs to Treat BacterialInfections

Azithromycin

azithromycin solr iv 500 mg

$0-$335 (Tier

azithromycin susr or 100mg5ml

$0-$335 (Tier

QL(3 ml daily)MO

Name of drug

What the

level)

$0-$335 (Tier

QL(45 mldaily) MO

azithromycin tabs or 250 mg

$0-$335 (Tier

QL(12 eadaily) MO

$0-$335 (Tier

QL(1 ea daily)MO

$0-$335 (Tier

QL(029 eadaily) MO

Clarithromycin

clarithromycin susr or 250mg5ml

$0-$335 (Tier

clarithromycin tabs or 250mg 500 mg

$0-$335 (Tier

clarithromycin tb24 or 500 mg

$0-$335 (Tier

Erythromycins

erythromycin base tabs 250 mg

$0-$335 (Tier

SL(16 ea daily)MO

$0-$335 (Tier

SL(8 ea daily)MO

erythromycinethylsuccinate tabs or 400 mg

$0-$335 (Tier

SL(10 ea daily)MO

Name of drug

What the

level)

erythromycin lactobionatesolr

$0-$335 (Tier

SL(8 ea daily)

erythromycin stearate tabs

$0-$335 (Tier

SL(16 ea daily)MO

Fidaxomicin

DIFICID TABS

$0-$835 (Tier

MEDICAL DEVICES AND SUPPLIES

Bandages-Dressings-Tape

gauze pads 2x2 $0-

$335 (Tier

RXOTC MO

Contraceptives

FC FEMALE CONDOM MISC

$0 (Tier

FC2 FEMALE CONDOM MISC

$0 (Tier

LATEX CONDOMS $0

(Tier 3)

Misc Devices

ALCOHOL PADS

$0-$835 (Tier

RXOTC MO

Parenteral Therapy Supplies

INSULIN SYRINGES AND PEN NEEDLES

$0-$835 (Tier

RXOTC MO

Respiratory Therapy Supplies

Name of drug

What the

level)

AIRZONE PEAK FLOW METER DEVI

$0 (Tier

RXOTC MONT

ASSESS FULL RANGE PEAK FLOW METER DEVI

$0 (Tier

RXOTC MONT

ASSESS LOW RANGE PEAK FLOW METER DEVI

$0 (Tier

RXOTC MONT

ASSESS PEAK FLOW METER FULL RANGE DEVI

$0 (Tier

RXOTC MONT

ASSESS PEAK FLOW METER LOW RANGE DEVI

$0 (Tier

RXOTC MONT

ASTHMA CHECK METER-ZONE SYSTEM DEVI

$0 (Tier

RXOTC MONT

ASTHMAMENTOR DEVI $0

(Tier 3)

RXOTC MONT

LUNG PERFORMANCE PEAK FLOW METER DEVI

$0 (Tier

RXOTC MONT

MICROLIFE DIGITAL PEAK FLOW METER DEVI

$0 (Tier

RXOTC MONT

MINI WRIGHT AFS PEAK FLOWMETER LOW RANGE DEVI

$0 (Tier

RXOTC MONT

MINI WRIGHT PEAK FLOW METER DEVI

$0 (Tier

RXOTC MONT

PEAK AIR PEAK FLOW METERADULTPEDIATRIC DEVI

$0 (Tier

RXOTC MONT

PERSONAL BEST FULL RANGE DEVI

$0 (Tier

RXOTC MONT

PERSONAL BEST LOW RANGE DEVI

$0 (Tier

RXOTC MONT

Name of drug

What the

level)

PIKO 1 ELECTRONIC DEVI

$0 (Tier

RXOTC MONT

POCKET PEAK FLOW METER DEVI

$0 (Tier

RXOTC MONT

POCKETPEAK PEAK FLOW METER LOW RANGE DEVI

$0 (Tier

RXOTC MONT

POCKETPEAK PEAK FLOW METERUNIVERSALRANGE 50-720 LPM DEVI

$0 (Tier

RXOTC MONT

TRUZONE PEAK FLOW METER DEVI

$0 (Tier

RXOTC MONT

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches

Migraine Combinations

ergotamine w caffeinesupp re 2mg-100mg

$0-$335 (Tier

sumatriptan-naproxensodium tabs

$0-$335 (Tier

TREXIMET TABS 10MG-60MG

$0-$835 (Tier

TREXIMET TABS 85MG-500MG (Sumatriptan-Naproxen Sodium)

$0-$835 (Tier

Migraine Products - Monoclonal Antibodies

AIMOVIG SOAJ

$0-$835 (Tier

Migraine Products

Name of drug

What the

level)

dihydroergotaminemesylate soln ij 1 mgml

$0-$335 (Tier

dihydroergotaminemesylate soln na 4 mgml

$0-$835 (Tier

ergotamine tartrate subl sl $0-

$335 (Tier

MIGRANAL SOLN

$0-$835 (Tier

Serotonin Agonists

almotriptan malate tabs

$0-$335 (Tier

naratriptan hcl tabs

$0-$335 (Tier

QL(03 eadaily) MO

rizatriptan benzoate tabs

$0-$335 (Tier

QL(04 eadaily) MO

rizatriptan benzoate tbdp

$0-$335 (Tier

QL(04 eadaily) MO

sumatriptan succinate soajsc 4 mg05ml 6 mg05ml

$0-$335 (Tier

sumatriptan succinate soctsc 4 mg05ml 6 mg05ml

$0-$335 (Tier

Name of drug

What the

level)

sumatriptan succinate solnsc 6 mg05ml

$0-$335 (Tier

sumatriptan succinate tabsor 25 mg 50 mg 100 mg

$0-$335 (Tier

QL(03 eadaily) MO

zolmitriptan tabs 25 mg

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(2 ea daily)MO

zolmitriptan tbdp 25 mg

$0-$335 (Tier

SL(4 ea daily)MO

$0-$335 (Tier

SL(2 ea daily)MO

MINERALS amp ELECTROLYTES

Calcium

CALCI-CHEW CHEW $0

(Tier 3)

calcium carbonate tabs or 500 mg 1250 mg

$0 (Tier

calcium carbonate tabs or 600mg 600 mg 1500 mg

$0 (Tier

calcium carbonate-cholecalciferol caps600mg-500unit

$0 (Tier

calcium carbonate-cholecalciferol chew 500mg-100unit 500mg-400unit

$0 (Tier

Name of drug

What the

level)

calcium carbonate-cholecalciferol tabs 500mg-200unit 600mg-400unit600mg-800unit 600mg-600mg-800unit-400unit

$0 (Tier

calcium carbonate-cholecalciferol tabs 500mg-600unit

$0 (Tier

calcium carbonate-vitamin d tabs 125unit-250mg125unit-500mg 250mg-125unit 400unit-600mg500mg-125unit 600mg-400unit

$0 (Tier

calcium carbonate-vitamin d tabs 200unit-500mg500mg-200unit 500mg-500mg-200unit-200unit

$0 (Tier

CALCIUM CITRATE MALATEVITAMIN D TABS

$0 (Tier

calcium citrate tabs or 200 mg 950 mg

$0 (Tier

calcium citrate-vitamin d tabs 250mg-200unit

$0 (Tier

CALCIUM GLUCONATE TABS OR 500 MG

$0 (Tier

EQL CALCIUMVITAMIN DCAPS

$0 (Tier

oyster shell tabs $0

(Tier 3)

RA OYSTER SHELL CALCIUMVITAMIN DTABS

$0 (Tier

Name of drug

What the

level)

RISACAL-D TABS $0

(Tier 3)

Electrolyte Mixtures

dextrose in lactated ringerssoln

$0-$335 (Tier

dextrose w sodiumchloride soln 045-25045-5

$0-$335 (Tier

dextrose w sodiumchloride soln 09-5

$0-$335 (Tier

lactated ringers soln

$0-$335 (Tier

1) parenteral electrolytes soln20meq20ml-5meq20ml-35meq20ml-35meq20ml-45meq20ml-295meq20ml

$0-$335 (Tier

potassium chloride indextrose amp sodium chloride soln 045-20meql-5

$0-$335 (Tier

Magnesium

MAGDELAY TBEC $0

(Tier 3)

MAGNESIUM SULFATE SOLN IJ 50

$0-$835 (Tier

magnesium sulfate soln ij50

$0-$335 (Tier

Name of drug

What the

level)

magnesium sulfate soln iv2 gm50ml 4 gm50ml 4gm100ml 20 gm500ml40 gm1000ml

$0-$335 (Tier

1) MAGNESIUM SULFATE SOLN IV 2 GM50ML 4GM50ML 4 GM100ML20 GM500ML 40GM1000ML (MagnesiumSulfate)

$0-$835 (Tier

Phosphate

sodium phosphates(sodium phosphate dibasicamp monobasic) soln

$0-$335 (Tier

Potassium

K-TAB TBCR 8 MEQ 20 MEQ

$0-$835 (Tier

potassium chloride cpcr or8 meq 10 meq

$0-$335 (Tier

POTASSIUM CHLORIDE ER TBCR

$0-$835 (Tier

potassium chloridemicroencapsulated crystalser tbcr

$0-$335 (Tier

potassium chloride soln iv 2meqml

$0-$335 (Tier

POTASSIUM CHLORIDE SOLN IV 2 MEQML

$0-$835 (Tier

Name of drug

What the

level)

potassium chloride soln or10 20

$0-$335 (Tier

potassium chloride tbcr or8 meq 10 meq

$0-$335 (Tier

Sodium

sodium chloride soln iv 045

$0-$335 (Tier

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents

CUPRIMINE CAPS

$0-$835 (Tier

DEPEN TITRATABS TABS

$0-$835 (Tier

SYPRINE CAPS (Trientine HCl)

$0-$835 (Tier

trientine hcl caps

$0-$335 (Tier

Immunomodulators

REVLIMID CAPS

$0-$835 (Tier

Name of drug

What the

level)

THALOMID CAPS

$0-$835 (Tier

Immunosuppressive Agents

ASTAGRAF XL CP24

$0-$835 (Tier

AZATHIOPRINE SOLR IJ 100 MG

$0-$835 (Tier

azathioprine tabs or 50 mg75 mg 100 mg

$0-$335 (Tier

cyclosporine caps or 25mg 100 mg

$0-$335 (Tier

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

$0-$335 (Tier

cyclosporine soln iv 50mgml

$0-$335 (Tier

ENVARSUS XR TB24

$0-$835 (Tier

mycophenolate mofetil caps

$0-$335 (Tier

mycophenolate mofetil hclsolr

$0-$335 (Tier

Name of drug

What the

level)

mycophenolate mofetil susr $0-

$335 (Tier

mycophenolate mofetil tabs

$0-$335 (Tier

mycophenolate sodiumtbec

$0-$335 (Tier

NULOJIX SOLR

$0-$835 (Tier

PROGRAF SOLN IV 5 MGML

$0-$835 (Tier

RAPAMUNE SOLN 1 MGML

$0-$835 (Tier

SANDIMMUNE SOLN OR 100 MGML

$0-$835 (Tier

SIMULECT SOLR

$0-$835 (Tier

sirolimus tabs

$0-$335 (Tier

tacrolimus caps or 05 mg1 mg 5 mg

$0-$335 (Tier

Name of drug

What the

level)

THYMOGLOBULIN SOLR

$0-$835 (Tier

ZORTRESS TABS

$0-$835 (Tier

Irrigation Solutions

irrigation solutionsphysiological soln

$0-$335 (Tier

water for irrigation sterilesoln

$0-$335 (Tier

Potassium Removing Agents

sodium polystyrenesulfonate powd or

$0-$335 (Tier

sodium polystyrenesulfonate susp or 15gm60ml

$0-$335 (Tier

VELTASSA PACK 168 GM

$0-$835 (Tier

ST SL(15 eadaily) LA MO

$0-$835 (Tier

VELTASSA PACK 84 GM

$0-$835 (Tier

Systemic Lupus Erythematosus Agents

Name of drug

What the

level)

BENLYSTA SOAJ SC 200 MGML

$0-$835 (Tier

BENLYSTA SOLR IV 120 MG

$0-$835 (Tier

BENLYSTA SOSY SC 200 MGML

$0-$835 (Tier

MOUTHTHROATDENTAL AGENTS

Anesthetics Topical Oral

lidocaine hcl (mouth-throat)soln

$0-$335 (Tier

Anti-infectives - Throat

clotrimazole lozg mt $0-

$335 (Tier

clotrimazole troc mt $0-

$335 (Tier

nystatin (mouth-throat) susp

$0-$335 (Tier

Antiseptics - MouthThroat

chlorhexidine gluconate(mouth-throat) soln

$0-$335 (Tier

Steroids - MouthThroat

triamcinolone acetonide (mouth) pste

$0-$335 (Tier

Name of drug

What the

level)

Throat Products - Misc

cevimeline hcl caps

$0-$335 (Tier

pilocarpine hcl (oral) tabs

$0-$335 (Tier

MULTIVITAMINS

Pediatric Vitamins

pediatric vitamins adc soln $0

(Tier 3)

TRI-VI-SOL SOLN (Pediatric Vitamins ADC)

$0 (Tier

Prenatal Vitamins

CENTRUM SPECIALIST PRENATAL MISC

$0 (Tier

CLASSIC PRENATAL TABS

$0 (Tier

CVS PRENATAL MULTI+DHA CAPS

$0 (Tier

CVS PRENATAL TABS $0

(Tier 3)

ENFAMIL EXPECTA MISC $0

(Tier 3)

EQL PRENATAL FORMULA TABS

$0 (Tier

EZFE FORTE CAPS $0

(Tier 3)

Name of drug

What the

level)

GNP DAILY PRENATAL MISC

$0 (Tier

GNP PRENATAL TABS $0

(Tier 3)

GOODSENSE PRENATAL VITAMINS TABS

$0 (Tier

HM ONE DAILY PRENATAL COMBO MISC

$0 (Tier

HM PRENATAL TABS $0

(Tier 3)

KP PRENATAL MULTIVITAMINS TABS

$0 (Tier

KPN PRENATAL TABS $0

(Tier 3)

MULTI PRENATAL TABS $0

(Tier 3)

NAT-RUL PRENATAL VITAMINS TABS

$0 (Tier

NEONATAL VITAMIN TABS

$0 (Tier

NESTABS TABS

$0-$835 (Tier

ONE A DAY WOMENS PRENATAL1 CAPS

$0 (Tier

ONE-A-DAY WOMENS PRENATAL MISC

$0 (Tier

Name of drug

What the

level)

PRENATAL FORMULA A-FREE TABS

$0 (Tier

PRENATAL LOW IRON TABS

$0 (Tier

PRENATAL MULTI + DHA CAPS 250MG-11UNIT-4000UNIT-25MG-15MG-38MG-27MG-18MG-17MG-4MCG-400UNIT-800MCG-26MG-60MG

$0 (Tier

PRENATAL MULTIVITAMIN + DHA MISC

$0 (Tier

PRENATAL MULTIVITAMIN PLUS DHA CAPS 250MG-11UNIT-4000UNIT-25MG-15MG-38MG-27MG-18MG-17MG-4MCG-400UNIT-800MCG-26MG-60MG

$0 (Tier

PRENATAL MULTIVITAMIN TABS

$0 (Tier

PRENATAL ONE DAILY TABS

$0 (Tier

Name of drug

What the

level)

PRENATAL TABS 11UNIT- MO NT 263MG-25MG-15MG-27MG-4000UNIT-18MG-17MG-4MCG-400UNIT-08MG-26MG-100MG 30UNIT-4000UNIT-25MG-18MG-200MG-28MG-20MG-17MG-8MCG-400UNIT-08MG-26MG-120MG 30UNIT-25MG-18MG-200MG-28MG-20MG-17MG-4000UNIT-8MCG-400UNIT-800MCG-26MG-120MG 30UNIT-4000UNIT-25MG-18MG-200MG-28MG-20MG-17MG-8MCG-400UNIT-800MCG-26MG-120MG

$0 (Tier

4000UNIT-30UNIT-200MG-25MG-18MG-28MG-20MG-17MG-8MCG-400UNIT-800MCG-26MG-120MG 4000UNIT-30UNIT-25MG-18MG-200MG-28MG-20MG-17MG-8MCG-400UNIT-800MCG-26MG-120MG 160MG-11UNIT-200MG-25MG-184MG-27MG-4000UNIT-18MG-17MG-4MCG-400UNIT-800MCG-26MG-100MG PRENATAL TABS NT 375UNIT-05MG-50MG-05MG-25MG-15MG- $0 375MG-675MG-25MG- (Tier 5MG-075MG-500UNIT- 3) 25MCG-05MG-200MCG-25MCG-075MG-100UNIT

PRENATAL VITAMIN amp MINERAL TABS

$0 (Tier

PRENATAL VITAMIN TABS

$0 (Tier

Name of drug

What the

level)

PRENATAL VITAMINIRON TABS

$0 (Tier

PRENATAL VITAMINS TABS

$0 (Tier

PRENATE AM TABS

$0-$835 (Tier

PRENATE CHEW

$0-$835 (Tier

PX PRENATAL MULTIVITAMINS TABS

$0 (Tier

QC PRENATAL TABS $0

(Tier 3)

RA ONE DAILY MISC $0

(Tier 3)

RA PRENATAL FORMULAFOLICACIDTABS

$0 (Tier

RA PRENATAL TABS $0

(Tier 3)

RIGHT STEP PRENATAL TABS

$0 (Tier

SIMILAC PRENATAL EARLY SHIELD MISC

$0 (Tier

SM ONE DAILY PRENATAL MISC

$0 (Tier

SM PRENATAL VITAMINS TABS

$0 (Tier

Name of drug

What the

level)

STUART ONE CAPS $0

(Tier 3)

THERANATAL COMPLETE MISC

$0 (Tier

VIRT-PN DHA CAPS 600MCG-330MG-300MG-45MG-140MG-27MG-12MCG-200UNIT-400MCG-10UNIT-25MG-85MG

$0-$835 (Tier

ZATEAN-PN DHA CAPS

$0-$835 (Tier

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms

Central Muscle Relaxants

baclofen tabs or 10 mg

$0-$335 (Tier

SL(8 ea daily)MO

$0-$335 (Tier

SL(4 ea daily)MO

BACLOFEN TABS OR 5 MG

$0-$835 (Tier

SL(16 ea daily)

carisoprodol tabs or 350 mg

$0-$335 (Tier

chlorzoxazone tabs 500 mg

$0-$335 (Tier

Name of drug

What the

level)

cyclobenzaprine hcl tabs or5 mg 10 mg

$0-$335 (Tier

metaxalone tabs

$0-$335 (Tier

methocarbamol tabs or 500 mg 750 mg

$0-$335 (Tier

tizanidine hcl caps or 2 mg

$0-$335 (Tier

SL(18 ea daily)MO

$0-$335 (Tier

SL(9 ea daily)MO

$0-$335 (Tier

SL(6 ea daily)MO

tizanidine hcl tabs or 2 mg

$0-$335 (Tier

SL(18 ea daily)MO

$0-$335 (Tier

SL(9 ea daily)MO

Direct Muscle Relaxants

dantrolene sodium caps or25 mg 50 mg 100 mg

$0-$335 (Tier

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus

Nasal Agents - Misc

Name of drug

What the

level)

saline soln na 065-0002 065 065

$0 (Tier

Nasal Antiallergy

azelastine hcl soln 01 137 mcgspray

$0-$335 (Tier

cromolyn sodium (nasal) aers

$0 (Tier

olopatadine hcl (nasal) soln

$0-$335 (Tier

Nasal Anticholinergics

ipratropium bromide (nasal)soln

$0-$335 (Tier

Nasal Steroids

budesonide (nasal) susp

$0-$335 (Tier

RXOTC MO

FLONASE ALLERGY RELIEF CHILDRENS SUSP (Fluticasone Propionate (Nasal))

$0 (Tier

RXOTC MONT

FLONASE ALLERGY RELIEF SUSP (Fluticasone Propionate (Nasal))

$0 (Tier

RXOTC MONT

flunisolide (nasal) soln

$0-$335 (Tier

fluticasone propionate(nasal) susp

$0 (Tier

Name of drug

What the

level)

$0-$335 (Tier

RXOTC MO

triamcinolone acetonide (nasal) aero

$0-$335 (Tier

RXOTC MO

Sympathomimetic Decongestants

NASAL DECONGESTANT LIQD

$0 (Tier

NASAL DECONGESTANT SYRP

$0 (Tier

pseudoephedrine hcl liqd or15 mg5ml

$0 (Tier

pseudoephedrine hcl tabsor 30 mg 60 mg

$0 (Tier

NEUROMUSCULAR AGENTS - Drugs toRelaxParalyze Muscles

ALS Agents

RADICAVA SOLN

$0-$835 (Tier

riluzole tabs

$0-$335 (Tier

Muscular Dystrophy Agents

EXONDYS 51 SOLN

$0-$835 (Tier

PA LA MO

Neuromuscular Blocking Agent - Neurotoxins

Name of drug

What the

level)

BOTOX SOLR

$0-$835 (Tier

XEOMIN SOLR

$0-$835 (Tier

NUTRIENTS

Carbohydrates

DEXTROSE ANHYDROUS GRAN

$0 (Tier

dextrose soln iv 10

$0-$335 (Tier

dextrose soln iv 5

$0-$335 (Tier

Lipids

fat emulsion emul $0-

$335 (Tier

Misc Nutritional Substances

ATABEX DHA CAPS $0

(Tier 3)

Proteins

amino acid electrolyteinfusion soln

$0-$335 (Tier

amino acid infusion 15

$0-$335 (Tier

Name of drug

What the

level)

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants

polyvinyl alcohol soln op $0

(Tier 3)

Beta-blockers - Ophthalmic

betaxolol hcl (ophth) soln

$0-$335 (Tier

carteolol hcl (ophth) soln

$0-$335 (Tier

dorzolamide hcl-timolol maleate soln 2-05223mgml-68mgml

$0-$335 (Tier

levobunolol hcl soln

$0-$335 (Tier

timolol maleate (ophth) solg025 05

$0-$335 (Tier

timolol maleate (ophth) soln025 05

$0-$335 (Tier

TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG

$0-$835 (Tier

Cycloplegic Mydriatics

cyclopentolate hcl soln op 1

$0-$335 (Tier

Miotics

Name of drug

What the

level)

PHOSPHOLINE IODIDE SOLR

$0-$835 (Tier

pilocarpine hcl soln op 1 2 4

$0-$335 (Tier

Ophthalmic Adrenergic Agents

ALPHAGAN P SOLN 01

$0-$835 (Tier

apraclonidine hcl soln

$0-$335 (Tier

brimonidine tartrate soln

$0-$335 (Tier

Ophthalmic Anti-infectives

AZASITE SOLN

$0-$835 (Tier

bacitracin (ophthalmic) oint $0-

$335 (Tier

bacitracin-polymyxin b(ophth) oint

$0-$335 (Tier

ciprofloxacin hcl (ophth)soln

$0-$335 (Tier

erythromycin (ophth) oint $0-

$335 (Tier

Name of drug

What the

level)

gatifloxacin (ophth) soln

$0-$335 (Tier

gentamicin sulfate (ophth)oint

$0-$335 (Tier

gentamicin sulfate (ophth)soln

$0-$335 (Tier

levofloxacin (ophth) soln

$0-$335 (Tier

moxifloxacin hcl (ophth)soln

$0-$335 (Tier

NATACYN SUSP

$0-$835 (Tier

neomycin-bacitracin zn-polymyxin oint

$0-$335 (Tier

neomycin-polymyxin-gramicidin soln

$0-$335 (Tier

ofloxacin (ophth) soln

$0-$335 (Tier

polymyxin b-trimethoprimsoln

$0-$335 (Tier

Name of drug

What the

level)

sulfacetamide sodium (ophth) soln

$0-$335 (Tier

tobramycin (ophth) soln

$0-$335 (Tier

trifluridine soln op

$0-$335 (Tier

VIGAMOX SOLN (Moxifloxacin HCl (Ophth))

$0-$835 (Tier

ZIRGAN GEL

$0-$835 (Tier

Ophthalmic Decongestants naphazoline wpheniramine soln 0025-03

$0 (Tier

Ophthalmic Immunomodulators

RESTASIS EMUL

$0-$835 (Tier

RESTASIS MULTIDOSE EMUL

$0-$835 (Tier

Ophthalmic Local Anesthetics

proparacaine hcl soln op

$0-$335 (Tier

Ophthalmic Steroids

Name of drug

What the

level)

bacitracin-poly-neomycin-hc oint

$0-$335 (Tier

dexamethasone sodium phosphate (ophth) soln

$0-$335 (Tier

DUREZOL EMUL

$0-$835 (Tier

fluorometholone (ophth) susp

$0-$335 (Tier

LOTEMAX OINT

$0-$835 (Tier

neomycin-polymy-dexameth oint

$0-$335 (Tier

neomycin-polymy-dexameth susp

$0-$335 (Tier

prednisolone acetate(ophth) susp

$0-$335 (Tier

sulfacetamide sod-prednisolone soln

$0-$335 (Tier

tobramycin-dexamethasone susp

$0-$335 (Tier

Ophthalmics - Misc

Name of drug

What the

level)

azelastine hcl (ophth) soln

$0-$335 (Tier

AZOPT SUSP

$0-$835 (Tier

bromfenac sodium (ophth)soln

$0-$335 (Tier

Once dailydosingMO

cromolyn sodium (ophth)soln

$0-$335 (Tier

CYSTARAN SOLN

$0-$835 (Tier

Limit 60mls per28 daysQL(215ml daily) LAMO

diclofenac sodium (ophth)soln

$0-$335 (Tier

dorzolamide hcl soln

$0-$335 (Tier

epinastine hcl (ophth) soln

$0-$335 (Tier

flurbiprofen sodium soln

$0-$335 (Tier

ILEVRO SUSP

$0-$835 (Tier

Name of drug

What the

level)

ketorolac tromethamine (ophth) soln

$0-$335 (Tier

ketotifen fumarate (ophth)soln

$0 (Tier

MURO 128 SOLN 2 $0

(Tier 3)

NEVANAC SUSP

$0-$835 (Tier

olopatadine hcl soln 02

$0-$335 (Tier

ophthalmic irrigationsolution soln

$0 (Tier

sodium chloride hypertonicoint

$0 (Tier

sodium chloride hypertonicsoln

$0 (Tier

Prostaglandins - Ophthalmic

bimatoprost soln

$0-$335 (Tier

latanoprost soln

$0-$335 (Tier

LUMIGAN SOLN

$0-$835 (Tier

Name of drug

What the

level)

TRAVATAN Z SOLN

$0-$835 (Tier

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous

acetic acid (otic) soln

$0-$335 (Tier

carbamide peroxide (otic)soln

$0 (Tier

Otic Anti-infectives

ofloxacin (otic) soln

$0-$335 (Tier

Otic Combinations

CIPRODEX SUSP

$0-$835 (Tier

neomycin-polymyxin-hc(otic) soln

$0-$335 (Tier

neomycin-polymyxin-hc(otic) susp

$0-$335 (Tier

Otic Steroids

fluocinolone acetonide (otic) oil

$0-$335 (Tier

hydrocortisone waceticacid soln

$0-$335 (Tier

Name of drug

What the

level)

OXYTOCICS - Drugs to PreventControl UterineBleeding

Oxytocics

methylergonovine maleatetabs or 02 mg

$0-$335 (Tier

PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low ImmuneSystem

Immune Serums

BIVIGAM SOLN

$0-$835 (Tier

CUVITRU SOLN

$0-$835 (Tier

FLEBOGAMMA DIF SOLN 10

$0-$835 (Tier

GAMASTAN INJ

$0-$835 (Tier

GAMASTAN SD INJ

$0-$835 (Tier

GAMMAGARD LIQUID SOLN

$0-$835 (Tier

GAMMAKED SOLN

$0-$835 (Tier

Name of drug

What the

level)

GAMMAPLEX SOLN 5 GM50ML 10GM100ML20 GM200ML

$0-$835 (Tier

GAMUNEX-C SOLN

$0-$835 (Tier

HIZENTRA SOLN

$0-$835 (Tier

HYPERRAB SD SOLN

$0-$835 (Tier

IMOGAM RABIES-HT SOLN 300 UNIT2ML

$0-$835 (Tier

KEDRAB SOLN

$0-$835 (Tier

OCTAGAM SOLN 2 GM20ML 5 GM50ML 10GM100ML 20 GM200ML

$0-$835 (Tier

PRIVIGEN SOLN

$0-$835 (Tier

VARIZIG SOLN

$0-$835 (Tier

Monoclonal Antibodies

SYNAGIS SOLN 50 MG05ML

$0-$835 (Tier

Name of drug

What the

level)

ZINPLAVA SOLN

$0-$835 (Tier

Passive Immunizing Agents - Combinations

HYQVIA KIT

$0-$835 (Tier

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins

amoxicillin caps 250 mg500 mg

$0-$335 (Tier

amoxicillin susr 125 mg5ml 200 mg5ml 250mg5ml 400 mg5ml

$0-$335 (Tier

amoxicillin tabs 500 mg875 mg

$0-$335 (Tier

ampicillin caps 250 mg

$0-$335 (Tier

ampicillin sodium solr ij 1gm 2 gm

$0-$335 (Tier

ampicillin sodium solr iv 10 gm

$0-$335 (Tier

Natural Penicillins

Name of drug

What the

level)

BICILLIN L-A SUSP

$0-$835 (Tier

penicillin g potassium solr $0-

$335 (Tier

penicillin v potassium solr250 mg5ml

$0-$335 (Tier

penicillin v potassium tabs250 mg 500 mg

$0-$335 (Tier

Penicillin Combinations

amoxicillin amp potclavulanate chew

$0-$335 (Tier

amoxicillin amp potclavulanate susr

$0-$335 (Tier

amoxicillin amp potclavulanate tabs

$0-$335 (Tier

amoxicillin amp potclavulanate tb12

$0-$335 (Tier

ampicillin amp sulbactamsodium solr ij 1gm-2gm

$0-$335 (Tier

Name of drug

What the

level)

ampicillin amp sulbactamsodium solr iv 5gm-10gm

$0-$335 (Tier

BICILLIN C-R SUSP 300000UNITML-300000UNITML

$0-$835 (Tier

BICILLIN C-R SUSP 900000UNIT2ML-300000UNIT2ML

$0-$835 (Tier

piperacillin sodium-tazobactam sodium solr

$0-$335 (Tier

Penicillinase-Resistant Penicillins

dicloxacillin sodium caps

$0-$335 (Tier

NAFCILLIN SODIUM SOLR IJ 10 GM

$0-$835 (Tier

nafcillin sodium solr ij 2 gm

$0-$335 (Tier

nafcillin sodium solr iv 10 gm

$0-$335 (Tier

oxacillin sodium solr 10 gm

$0-$335 (Tier

Name of drug

What the

level)

PROGESTINS - Hormone ReplacementModifyingDrugs

Progestins

medroxyprogesteroneacetate tabs or 5 mg 10mg 25 mg

$0-$335 (Tier

megestrol acetate(appetite) susp

$0-$335 (Tier

norethindrone acetate tabs or

$0-$335 (Tier

progesterone micronized caps

$0-$335 (Tier

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC - Drugs to Treat Mental andEmotional Conditions

Agents for Chemical Dependency

acamprosate calcium tbec

$0-$335 (Tier

disulfiram tabs or 250 mg500 mg

$0-$335 (Tier

Anti-Cataplectic Agents

XYREM SOLN

$0-$835 (Tier

Antidementia Agents

donepezil hydrochloridetabs

$0-$335 (Tier

Name of drug

What the

level)

donepezil hydrochloridetbdp

$0-$335 (Tier

galantamine hydrobromidecp24

$0-$335 (Tier

galantamine hydrobromidesoln

$0-$335 (Tier

galantamine hydrobromidetabs

$0-$335 (Tier

memantine hcl cp24 14 mg

$0-$335 (Tier

AL(At least 60yrs old) SL(2ea daily) MO

$0-$335 (Tier

AL(At least 60yrs old)SL(133 eadaily) MO

$0-$335 (Tier

memantine hcl soln 2 mgml

$0-$335 (Tier

AL(At least 60yrs old) MO

memantine hcl tabs 5 mg10 mg

$0-$335 (Tier

Name of drug

What the

level)

NAMENDA XR CP24 14 MG (Memantine HCl)

$0-$835 (Tier

NAMENDA XR TITRATION PACK CP24

$0-$835 (Tier

rivastigmine pt24

$0-$335 (Tier

rivastigmine tartrate caps

$0-$335 (Tier

Combination Psychotherapeutics

chlordiazepoxide-amitriptyline tabs

$0-$335 (Tier

olanzapine-fluoxetine hcl caps

$0-$335 (Tier

perphenazine-amitriptylinetabs

$0-$335 (Tier

Movement Disorder Drug Therapy

Name of drug

What the

level)

AUSTEDO TABS 12 MG

$0-$835 (Tier

SL(4 ea daily)LA

AUSTEDO TABS 6 MG

$0-$835 (Tier

SL(8 ea daily)LA

AUSTEDO TABS 9 MG

$0-$835 (Tier

SL(533 eadaily) LA

tetrabenazine tabs

$0-$335 (Tier

Multiple Sclerosis Agents

AMPYRA TB12 (Dalfampridine)

$0-$835 (Tier

AUBAGIO TABS

$0-$835 (Tier

AVONEX KIT

$0-$835 (Tier

AVONEX PEN AJKT

$0-$835 (Tier

AVONEX PSKT

$0-$835 (Tier

BETASERON KIT

$0-$835 (Tier

Name of drug

What the

level)

COPAXONE SOSY (Glatiramer Acetate)

$0-$835 (Tier

dalfampridine tb12

$0-$335 (Tier

EXTAVIA KIT

$0-$835 (Tier

GILENYA CAPS 05 MG

$0-$835 (Tier

glatiramer acetate sosy

$0-$335 (Tier

LEMTRADA SOLN

$0-$835 (Tier

OCREVUS SOLN

$0-$835 (Tier

PLEGRIDY SOPN

$0-$835 (Tier

PLEGRIDY SOSY

$0-$835 (Tier

PLEGRIDY STARTER PACK SOPN

$0-$835 (Tier

Name of drug

What the

level)

PLEGRIDY STARTER PACK SOSY

$0-$835 (Tier

REBIF REBIDOSE SOAJ

$0-$835 (Tier

REBIF REBIDOSE TITRATIONPACK SOAJ

$0-$835 (Tier

REBIF SOSY

$0-$835 (Tier

REBIF TITRATION PACK SOSY

$0-$835 (Tier

TECFIDERA CPDR

$0-$835 (Tier

TECFIDERA STARTER PACK MISC

$0-$835 (Tier

TYSABRI CONC

$0-$835 (Tier

Pseudobulbar Affect (PBA) Agents

NUEDEXTA CAPS

$0-$835 (Tier

Psychotherapeutic and Neurological Agents -

ergoloid mesylates tabs or $0-

$335 (Tier

Name of drug

What the

level)

pimozide tabs

$0-$335 (Tier

Smoking Deterrents

bupropion hcl (smokingdeterrent) tb12

$0-$335 (Tier

SL(2 ea daily)MO

CHANTIX CONTINUING MONTHPAK TABS

$0-$835 (Tier

CHANTIX STARTING MONTH PAK TABS

$0-$835 (Tier

CHANTIX TABS

$0-$835 (Tier

nicotine polacrilex gum mt2 mg 4 mg

$0 (Tier

nicotine polacrilex lozg mt2 mg 4 mg

$0 (Tier

nicotine pt24 $0

(Tier 3)

NICOTINE TRANSDERMAL SYSTEM KIT

$0 (Tier

NICOTROL INHALER INHA

$0-$835 (Tier

SL(17 ea daily)MO

NICOTROL NS SOLN

$0-$835 (Tier

Vasomotor Symptom Agents

Name of drug

What the

level)

BRISDELLE CAPS (Paroxetine Mesylate(Vasomotor))

$0-$835 (Tier

paroxetine mesylate(vasomotor) caps

$0-$335 (Tier

RESPIRATORY AGENTS - MISC - Drugs toTreat Lung Conditions

Alpha-Proteinase Inhibitor (Human)

ARALAST NP SOLR 1000 MG

$0-$835 (Tier

PROLASTIN-C SOLR 1000 MG

$0-$835 (Tier

ZEMAIRA SOLR

$0-$835 (Tier

Cystic Fibrosis Agents

KALYDECO PACK

$0-$835 (Tier

KALYDECO TABS

$0-$835 (Tier

ORKAMBI TABS 100MG-125MG 200MG-125MG

$0-$835 (Tier

PA LA MO

PULMOZYME SOLN

$0-$835 (Tier

Name of drug

What the

level)

SYMDEKO TBPK

$0-$835 (Tier

Pulmonary Fibrosis Agents

ESBRIET CAPS

$0-$835 (Tier

ESBRIET TABS

$0-$835 (Tier

OFEV CAPS

$0-$835 (Tier

SULFONAMIDES - Drugs to Treat BacterialInfections

Sulfonamides

sulfadiazine tabs or $0-

$335 (Tier

TETRACYCLINES - Drugs to Treat BacterialInfections

Tetracyclines

demeclocycline hcl tabs

$0-$335 (Tier

doxycycline (monohydrate)caps 50 mg 75 mg 100 mg

$0-$335 (Tier

doxycycline (monohydrate)susr 25 mg5ml

$0-$335 (Tier

Name of drug

What the

level)

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

$0-$335 (Tier

doxycycline hyclate caps or50 mg 100 mg

$0-$335 (Tier

doxycycline hyclate solr iv100 mg

$0-$335 (Tier

doxycycline hyclate tabs or20 mg 100 mg

$0-$335 (Tier

doxycycline hyclate tbec or150 mg

$0-$335 (Tier

minocycline hcl caps or 50mg 75 mg 100 mg

$0-$335 (Tier

minocycline hcl tabs or 50mg 100 mg

$0-$335 (Tier

tetracycline hcl caps or 250mg 500 mg

$0-$335 (Tier

THYROID AGENTS - Drugs to Regulate ThyroidHormones

Antithyroid Agents

methimazole tabs or 5 mg10 mg

$0-$335 (Tier

Name of drug

What the

level)

propylthiouracil tabs or $0-

$335 (Tier

Thyroid Hormones levothyroxine sodium tabsor 25 mcg 50 mcg 75mcg 88 mcg 100 mcg112 mcg 125 mcg 137mcg 150 mcg 175 mcg200 mcg 300 mcg

$0-$335 (Tier

liothyronine sodium tabs or5 mcg 25 mcg 50 mcg

$0-$335 (Tier

TOXOIDS

Toxoid Combinations

ADACEL SUSP

$0-$835 (Tier

BOOSTRIX SUSP

$0-$835 (Tier

DAPTACEL SUSP

$0-$835 (Tier

DIPHTHERIATETANUSTOXOIDS ADSORBED PEDIATRIC SUSP

$0-$835 (Tier

INFANRIX SUSP

$0-$835 (Tier

KINRIX SUSP

$0-$835 (Tier

Name of drug

What the

level)

PEDIARIX SUSP

$0-$835 (Tier

PENTACEL SUSR

$0-$835 (Tier

QUADRACEL SUSP

$0-$835 (Tier

TENIVAC INJ

$0-$835 (Tier

TETANUSDIPHTHERIATOXOIDS-ADSORBED SUSP

$0-$835 (Tier

ULCER DRUGS - Drugs to Treat Bowel Intestineand Stomach Conditions

Antispasmodics

dicyclomine hcl caps or 10 mg

$0-$335 (Tier

dicyclomine hcl tabs or 20 mg

$0-$335 (Tier

glycopyrrolate soln ij 02mgml

$0-$335 (Tier

glycopyrrolate tabs or 1 mg

$0-$335 (Tier

SL(8 ea daily)MO

Name of drug

What the

level)

$0-$335 (Tier

SL(4 ea daily)MO

methscopolamine bromidetabs or 5 mg 25 mg

$0-$335 (Tier

H-2 Antagonists

cimetidine tabs or 200 mg $0

(Tier 3)

cimetidine tabs or 200 mg

$0-$335 (Tier

RXOTC MO

cimetidine tabs or 300 mg400 mg 800 mg

$0-$335 (Tier

famotidine soln iv 20 mg2ml 40 mg4ml 200mg20ml

$0-$335 (Tier

famotidine susr or 40 mg5ml

$0-$335 (Tier

famotidine tabs or 10 mg $0

(Tier 3)

famotidine tabs or 20 mg

$0-$335 (Tier

RXOTC MO

$0-$335 (Tier

Name of drug

What the

level)

nizatidine caps 150 mg300 mg

$0-$335 (Tier

PEPCID AC MAXIMUM STRENGTH TABS (Famotidine)

$0 (Tier

RXOTC MONT

ranitidine hcl caps or 150mg 300 mg

$0-$335 (Tier

ranitidine hcl syrp or 15mgml 75 mg5ml 150mg10ml

$0-$335 (Tier

ranitidine hcl tabs or 150 mg

$0 (Tier

$0-$335 (Tier

RXOTC MO

$0-$335 (Tier

ranitidine hcl tabs or 75 mg $0

(Tier 3)

TAGAMET HB TABS (Cimetidine)

$0 (Tier

RXOTC MONT

ZANTAC 150 MAXIMUM STRENGTH TABS (Ranitidine HCl)

$0 (Tier

RXOTC MONT

Misc Anti-Ulcer

sucralfate tabs or $0-

$335 (Tier

Proton Pump Inhibitors

Name of drug

What the

level)

CVS OMEPRAZOLE TBEC $0

(Tier 3)

DEXILANT CPDR

$0-$835 (Tier

EQ OMEPRAZOLE TBEC $0

(Tier 3)

EQL OMEPRAZOLE TBEC $0

(Tier 3)

esomeprazole magnesiumcpdr 20 mg

$0-$335 (Tier

RXOTC MO

$0-$335 (Tier

esomeprazole sodium solr40 mg

$0-$335 (Tier

GNP OMEPRAZOLE TBEC

$0 (Tier

HM OMEPRAZOLE TBEC $0

(Tier 3)

KLS OMEPRAZOLE TBEC $0

(Tier 3)

lansoprazole cpdr or 15 mg

$0-$335 (Tier

RXOTC MO

lansoprazole cpdr or 15 mg $0

(Tier 3)

Name of drug

What the

level)

$0-$335 (Tier

NEXIUM PACK 5 MG 10 MG 20 MG 40 MG 25 MG

$0-$835 (Tier

omeprazole cpdr or 10 mg40 mg

$0-$335 (Tier

omeprazole cpdr or 20 mg

$0-$335 (Tier

RXOTC MO

OMEPRAZOLE TBEC OR 20 MG

$0 (Tier

pantoprazole sodium solr iv40 mg

$0-$335 (Tier

pantoprazole sodium tbecor 20 mg 40 mg

$0-$335 (Tier

PREVACID 24HR CPDR (Lansoprazole)

$0 (Tier

RXOTC MONT

PRILOSEC OTC TBEC $0

(Tier 3)

PX OMEPRAZOLE TBEC $0

(Tier 3)

RA OMEPRAZOLE TBEC $0

(Tier 3)

SB OMEPRAZOLE TBEC $0

(Tier 3)

Name of drug

What the

level)

SM OMEPRAZOLE TBEC $0

(Tier 3)

SW OMEPRAZOLE TBEC $0

(Tier 3)

TGT OMEPRAZOLE TBEC $0

(Tier 3)

Ulcer Drugs - Prostaglandins

misoprostol tabs or 100mcg 200 mcg

$0-$335 (Tier

Ulcer Therapy Combinations

amoxicillin-clarithromycinw lansoprazole misc

$0-$335 (Tier

OMECLAMOX-PAK MISC

$0-$835 (Tier

omeprazole-sodiumbicarbonate caps 20mg-1100mg

$0-$335 (Tier

RXOTC MO

$0-$335 (Tier

omeprazole-sodiumbicarbonate pack 20mg-1680mg

$0-$335 (Tier

ST 20MG-1680 MGMO

URINARY ANTI-INFECTIVES - Drugs to TreatBladderKidney Infections

Urinary Anti-infectives

Name of drug

What the

level)

methenamine hippuratetabs

$0-$335 (Tier

nitrofurantoin macrocrystalcaps or 50 mg 100 mg

$0-$335 (Tier

nitrofurantoin monohyd macro caps

$0-$335 (Tier

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms

Urinary Antispasmodic - Antimuscarinics

oxybutynin chloride syrp

$0-$335 (Tier

oxybutynin chloride tabs

$0-$335 (Tier

oxybutynin chloride tb24

$0-$335 (Tier

tolterodine tartrate cp24

$0-$335 (Tier

tolterodine tartrate tabs

$0-$335 (Tier

trospium chloride cp24

$0-$335 (Tier

Name of drug

What the

level)

trospium chloride tabs

$0-$335 (Tier

Urinary Antispasmodics - Beta-3 Adrenergic

MYRBETRIQ TB24

$0-$835 (Tier

Urinary Antispasmodics - Cholinergic Agonists

bethanechol chloride tabs

$0-$335 (Tier

Urinary Antispasmodics - Direct Muscle Relaxants

flavoxate hcl tabs

$0-$335 (Tier

VACCINES

Bacterial Vaccines

ACTHIB SOLR

$0-$835 (Tier

BCG VACCINE INJ

$0-$835 (Tier

BEXSERO SUSY

$0-$835 (Tier

HIBERIX SOLR

$0-$835 (Tier

MENACTRA INJ

$0-$835 (Tier

Name of drug

What the

level)

MENOMUNE-ACYW-135INJ

$0-$835 (Tier

MENVEO SOLR

$0-$835 (Tier

PEDVAX HIB SUSP

$0-$835 (Tier

TRUMENBA SUSY

$0-$835 (Tier

TYPHIM VI SOLN

$0-$835 (Tier

Viral Vaccines

ENGERIX-B SUSP IJ 20 MCGML 10 MCG05ML

$0-$835 (Tier

GARDASIL 9 SUSP

$0-$835 (Tier

GARDASIL 9 SUSY

$0-$835 (Tier

GARDASIL SUSP

$0-$835 (Tier

HAVRIX SUSP

$0-$835 (Tier

Name of drug

What the

level)

IMOVAX RABIES (HDCV) INJ

$0-$835 (Tier

IPOL INACTIVATED IPV INJ

$0-$835 (Tier

IXIARO SUSP

$0-$835 (Tier

M-M-R II INJ

$0-$835 (Tier

PROQUAD SUSR

$0-$835 (Tier

RABAVERT SUSR

$0-$835 (Tier

RECOMBIVAX HB SUSP

$0-$835 (Tier

ROTARIX SUSR

$0-$835 (Tier

ROTATEQ SOLN

$0-$835 (Tier

SHINGRIX SUSR

$0-$835 (Tier

Name of drug

What the

level)

STAMARIL SUSR

$0-$835 (Tier

TWINRIX SUSP

$0-$835 (Tier

VAQTA SUSP

$0-$835 (Tier

VARIVAX INJ

$0-$835 (Tier

YF-VAX INJ

$0-$835 (Tier

ZOSTAVAX SUSR

$0-$835 (Tier

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low Hormones

Spermicides OPTIONS GYNOL II VAGINALCONTRACEPTIV E GEL

$0 (Tier

VCF VAGINAL CONTRACEPTIVE FOAM FOAM

$0 (Tier

Vaginal Anti-infectives

clindamycin phosphatevaginal crea

$0-$335 (Tier

clotrimazole vaginal crea 1

$0 (Tier

Name of drug

What the

level)

metronidazole vaginal gel $0-

$335 (Tier

miconazole nitrate vaginalcrea 2

$0 (Tier

miconazole nitrate vaginalkit

$0 (Tier

miconazole nitrate vaginalsupp 100 mg

$0 (Tier

terconazole vaginal crea

$0-$335 (Tier

terconazole vaginal supp

$0-$335 (Tier

tioconazole vaginal oint $0

(Tier 3)

Vaginal Estrogens

estradiol vaginal crea 01mggm

$0-$335 (Tier

PREMARIN CREA VA 0625 MGGM

$0-$835 (Tier

VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions

Anaphylaxis Therapy Agents

Name of drug

What the

level)

epinephrine (anaphylaxis)soaj

$0-$835 (Tier

EPIPEN 2-PAK SOAJ

$0-$835 (Tier

EPIPEN-JR 2-PAK SOAJ

$0-$835 (Tier

Neurogenic Orthostatic Hypotension (NOH) -

NORTHERA CAPS 100 MG

$0-$835 (Tier

PA SL(18 eadaily)

$0-$835 (Tier

PA SL(9 eadaily)

$0-$835 (Tier

PA SL(6 eadaily)

Vasopressors

dobutamine hcl soln

$0-$335 (Tier

midodrine hcl tabs

$0-$335 (Tier

VITAMINS

Oil Soluble Vitamins cholecalciferol caps or1000 unit 2000 unit 5000unit

$0 (Tier

Name of drug

What the

level)

cholecalciferol tabs or 400 unit 1000 unit 2000 unit

$0 (Tier

cholecalciferol tabs or 5000 unit

$0 (Tier

ergocalciferol caps or50000 unit

$0 (Tier

MEPHYTON TABS (Phytonadione)

$0 (Tier

phytonadione tabs or 5 mg100 mcg

$0 (Tier

vitamin a caps or 10000unit

$0 (Tier

vitamin a caps or 8000 unit $0

(Tier 3)

vitamin e caps or 1000 unit $0

(Tier 3)

Water Soluble Vitamins ascorbic acid tabs or 500mg 500 mg 10mg-500mg 37mg-500mg14mg-25mg-500mg

$0 (Tier

niacin cpcr or 250 mg $0

(Tier 3)

niacin tabs or 50 mg 100mg 500 mg

$0 (Tier

niacin tbcr or 500 mg $0

(Tier 3)

pyridoxine hcl tabs or 25mg 50 mg 100 mg

$0 (Tier

Name of drug

What the

level)

riboflavin tabs or 100 mg $0

(Tier 3)

thiamine hcl tabs or 100 mg $0

(Tier 3)

Index abacavir sulfate 65 ALEVAZOL 82 amphotericin b 37 abacavir sulfate-lamivudine 65 abacavir sulfate-lamivudine-zidovudine 65 ABELCET 37 ABILIFY MAINTENA 64 ABRAXANE 58 ABREVA 85 ABSORICA 81 acamprosate calcium 125 acarbose 29 acebutolol hcl 71 acetaminophen 67 acetaminophen w codeine 11 acetazolamide 91 acetic acid 99 acetic acid (otic) 122

alfuzosin hcl ALIMTA ALINIA ALIQOPA ALKERAN ALLI allopurinol almotriptan malate alogliptin benzoate alogliptin-metformin hcl alogliptin-pioglitazone alosetron hcl ALPHAGAN P alprazolam alum amp mag hydrox-simethicone

99 48 14 53 47

1 100 108

32 29 30 98

119 17

ampicillin ampicillin amp sulbactamsodium ampicillin sodium AMPYRA ANADROL-50 anagrelide hcl anastrozole ANDRODERM ANDROGEL ANDROGEL PUMP ANORO ELLIPTA ANTARA APOKYN apraclonidine hcl aprepitant

124 123 126

12 100

50 12 12 12 20 41 60

119 37

acetylcysteine acitretin ACNE MEDICATION 10 ACTEMRA ACTHIB ACTIMMUNE acyclovir acyclovir sodium acyclovir topical ADACEL ADAGEN adapalene ADCIRCA adefovir dipivoxil ADEMPAS ADVAIR DISKUS ADVAIR HFA AEROSPAN AFINITOR AFINITOR DISPERZ AIMOVIG AIRZONE PEAK FLOW METER albendazole ALBENZA

80 84 81

57 7071

81 74 69 74 19 19 19 53 53

107 13 13

ALUMINUM HYDROXIDE 13 aluminum hydroxide-magtrisil 13 ALUNBRIG 53 amantadine hcl 60 AMBISOME 37 amcinonide 85 AMICAR 103 amifostine 57 amikacin sulfate 2 amiloride amp hydrochlorothiazide 91 amiloride hcl 91 amino acid electrolyteinfusion 118 amino acid infusion 15 118 aminophylline 21 aminosalicylic acid 46 amiodarone hcl 18 amitriptyline hcl 29 amlodipine besylate 72 amlodipine besylate-atorvastatin calcium 73 amlodipine besylate-benazeprilhcl 44 amoxapine 29 amoxicillin 123

APRISO 97 APTIOM 22 APTIVUS 65 ARALAST NP 128 ARANESP ALBUMIN FREE 102 ARCALYST 4 argatroban 21 aripiprazole 64 ARISTADA 64 ARISTADA INITIO 64 ARRANON 48 ARSENIC TRIOXIDE 57 ARZERRA 49 ASACOL HD 97 ascorbic acid 137 ASPIRIN 7 aspirin 7 aspirin buffered (cal carb-magcarb-mag oxide) 7 aspirin-dipyridamole 100 ASSESS FULL RANGE PEAK FLOW METER 107 ASSESS LOW RANGE PEAK FLOW METER 107 ASSESS PEAK FLOW METER FULL RANGE 107

albuterol sulfate 20 alclometasone dipropionate 85 ALCOHOL PADS 107 ALECENSA 53 alendronate sodium 92

amoxicillin amp potclavulanate 124 amoxicillin-clarithromycin wlansoprazole 133 amphetamine-dextroamphetamine 1

ASSESS PEAK FLOW METER LOW RANGE 107 ASTAGRAF XL 111 ASTHMA CHECK METER-ZONE SYSTEM 107 ASTHMAMENTOR 107

Index 1

ATABEX DHA 118 benazepril hcl 42 BREO ELLIPTA 20 atazanavir sulfate 65 BENDEKA 47 BRILINTA 101 atenolol 71 BENLYSTA 113 brimonidine tartrate 119 atenolol amp chlorthalidone 44 benzonatate 79 BRISDELLE 128 atomoxetine hcl 12 benzoyl peroxide 81 BRIVIACT 2223 atorvastatin calcium 41 BENZOYL PEROXIDE 81 bromfenac sodium (ophth) 121 atovaquone atovaquone-proguanil hcl ATRIPLA ATROVENT HFA AUBAGIO AUSTEDO AVANDIA AVASTIN AVEED AVONEX AVONEX PEN azacitidine AZASITE AZATHIOPRINE azathioprine azelastine hcl azelastine hcl (ophth) azithromycin AZOPT aztreonam

14 45 65 18

126 126

33 49 12

126 126

48 119 111 111 117 121 106 121

benzoyl peroxide 81 benzoyl peroxide-erythromycin 81 benztropine mesylate 59 BERINERT 100 BESPONSA 49 betamethasone dipropionate(topical) 85 betamethasone dipropionateaugmented 86 betamethasone sod phosphateamp acetate 77 betamethasone valerate 86 BETASERON 126 betaxolol hcl 72 betaxolol hcl (ophth) 118 bethanechol chloride 134 BETHKIS 3 BEVYXXA 21 bexarotene 57 BEXSERO 134 bicalutamide 51

bromocriptine mesylate 60 brompheniramine ampphenyleph 80 brompheniramine amppseudoeph 80 budesonide 78 budesonide (inhalation) 19 budesonide (nasal) 117 BUFFERIN LOW DOSE 7 bumetanide 91 buprenorphine hcl 11 buprenorphine hcl-naloxone hcldihydrate 11 bupropion hcl 26 bupropion hcl (smokingdeterrent) 128 BUPROPION HYDROCHLORIDE ER 26 buspirone hcl 17 busulfan 47 butalbital-aspirin-caffeinewcod 11 BUTISOL SODIUM 103

bacitracin (ophthalmic) bacitracin (topical)

119 82

BICILLIN C-R BICILLIN L-A

124 124

butorphanol tartrate BYDUREON

bacitracin zinc 82 bacitracin-poly-neomycin-hc

120 bacitracin-polymyxin b 82 bacitracin-polymyxin b(ophth) 119 baclofen 116 BACLOFEN 116 balsalazide disodium 98 BANZEL 22 BARACLUDE 69

BICNU BIKTARVY bimatoprost bisacodyl bisacodyl-peg 3350-potchloride-sod bicarb-sod chloride bismuth subsalicylate bisoprolol amphydrochlorothiazide bisoprolol fumarate

121 105

105 35

BYDUREON BCISE BYDUREON PEN BYETTA cabergoline CABOMETYX CALAMINE CALCI-CHEW calcipotriene calcitonin (salmon) calcitriol

32 32 32 95 54 90

109 84 92 94

BAVENCIO BAXDELA BCG VACCINE

BIVIGAM bleomycin sulfate BLINCYTO

122 52 49

calcium acetate (phosphatebinder) CALCIUM CARBONATE

BELEODAQ BELSOMRA BELVIQ XR benazepril amphydrochlorothiazide

53 104

BOOSTRIX BORTEZOMIB BOSULIF BOTOX BRAFTOVI

130 53 53

118 53

calcium carbonate 109 calcium carbonate (antacid) 13 calcium carbonate-cholecalciferol 109 calcium carbonate-vitamin d 109

Index 2

calcium citrate 109 cefuroxime axetil 75 CINQAIR 18 CALCIUM CITRATE cefuroxime sodium 75 CINRYZE 100 MALATEVITAMIN D calcium citrate-vitamin d CALCIUM GLUCONATE calcium polycarbophil CALQUENCE CAMPATH CAMPTOSAR

109 109 109 104

54 49 59

celecoxib 4 CELONTIN 25 CENTANY 82 CENTRUM SPECIALIST PRENATAL 113 cephalexin 75 CERDELGA 101

CIPRODEX ciprofloxacin ciprofloxacin hcl ciprofloxacin hcl (ophth) ciprofloxacin in d5w ciprofloxacin-ciprofloxacinhcl

122 96 96

119 96

96 CANCIDAS 37 CEREZYME 101 cisplatin 47 candesartan cilexetil candesartan cilexetil-

43 CESAMET cetirizine hcl

citalopram hydrobromide 2627 cladribine 48

hydrochlorothiazide 44 CAPASTAT SULFATE 46 CAPRELSA 54 captopril 42 captopril amphydrochlorothiazide 44 CARAC 83 CARBAGLU 94 carbamazepine 23 carbamide peroxide (otic) 122 carbidopa 59 carbidopa-levodopa 60 carbinoxamine maleate 39 carboplatin 47 carisoprodol 116 carmustine 47 carteolol hcl (ophth) 118 carvedilol 71 carvedilol phosphate 71 caspofungin acetate 37 CASPOFUNGIN ACETATE 37 caspofungin acetate 37 CAYSTON 16 cefaclor 75 cefadroxil 75 cefazolin sodium 75 cefdinir 75 CEFEPIME 76 cefepime hcl 76 cefixime 75 cefoxitin sodium 75 cefpodoxime proxetil 76 cefprozil 75 ceftazidime 76

cetirizine-pseudoephedrine80

cevimeline hcl 113 CHANTIX 128 CHANTIX CONTINUING MONTHPAK 128 CHANTIX STARTING MONTH PAK 128 chenodiol 97 CHILDRENS ADVIL 4 CHILDRENS MOTRIN 4 chloramphenicol sodiumsuccinate 15 chlordiazepoxide-amitriptyline

126 chlorhexidine gluconate(mouth-throat) 113 chloroquine phosphate 45 chlorothiazide 92 chlorpheniramine ampphenylephrine 80 chlorpheniramine maleate 38 chlorpromazine hcl 63 chlorthalidone 92 chlorzoxazone 116 cholecalciferol 136137 cholestyramine 40 cholestyramine light 40 choline fenofibrate 41 chorionic gonadotropin 93 ciclopirox 82 ciclopirox olamine 82 cidofovir 69 cilostazol 101 CIMDUO 65 cimetidine 131

clarithromycin 106 CLASSIC PRENATAL 113 clemastine fumarate 39 CLEOCIN PHOSPHATE 15 CLINDAGEL 81 clindamycin hcl 15 clindamycin palmitatehydrochloride 15 clindamycin phosphate 15 clindamycin phosphate(topical) 81 clindamycin phosphate ind5w 15 clindamycin phosphatevaginal 135 clindamycin phosphate-benzoylperoxide 81 clindamycin phosphate-benzoylperoxide (refrigerate) 81 clobetasol propionate 86 clobetasol propionate emollientbase 86 clobetasol propionateemulsion 86 clofarabine 48 clomipramine hcl 29 clonazepam 22 clonidine 44 clonidine hcl 44 clonidine hcl (adhd) 2 clopidogrel bisulfate 101 clorazepate dipotassium 17 clotrimazole 113 clotrimazole (topical) 82 clotrimazole vaginal 135 clotrimazole wbetamethasone 83

ceftriaxone sodium 76 CIMZIA 98 clozapine 62 CIMZIA STARTER KIT 98

Index 3

CLOZAPINE ODT COARTEM colchicine colchicine w probenecid COLCRYS colesevelam hcl colestipol hcl colistimethate sodium COMBIVENT RESPIMAT COMETRIQ

100 100 100

40 40 13 20 54

CYRAMZA CYSTAGON CYSTARAN cytarabine dacarbazine dactinomycin DAKLINZA dalfampridine DALIRESP danazol

121 48 57 52 70

127 19 12

dexamethasone sodium phosphate (ophth) 120 DEXILANT 132 dexmethylphenidate hcl 2 dexrazoxane 57 dextroamphetamine sulfate 1 dextrose 118 DEXTROSE ANHYDROUS 118 dextrose in lactated ringers 110 dextrose w sodiumchloride 110

COMPLERA 65 dantrolene sodium 116 DIASTAT ACUDIAL 22 CONCERTA 2 dapsone 15 DIASTAT PEDIATRIC 22 COPAXONE COREG CR

127 71

DAPTACEL daptomycin

130 15

diazepam DIAZEPAM

CORLANOR cortisone acetate

DARAPRIM DARZALEX

diazepam (anticonvulsant) DIAZEPAM RECTAL GEL

CORZIDE 44 COSENTYX 84 COSENTYX SENSOREADY PEN 84 COSMEGEN 52 COTELLIC 54 CREON 91 CRESEMBA 38

daunorubicin hcl DAUNORUBICIN HYDROCHLORIDE DDAVP decitabine DELESTROGEN DELSTRIGO DELZICOL

52 95 48 96 65 98

diclofenac potassium 4 diclofenac sodium 4 diclofenac sodium (actinickeratoses) 84 diclofenac sodium (ophth) 121 diclofenac sodium (topical) 82 diclofenac w misoprostol 4 dicloxacillin sodium 124

CRIXIVAN cromolyn sodium cromolyn sodium(mastocytosis) cromolyn sodium (nasal) cromolyn sodium (ophth) CUPRIMINE CUVITRU CVS NATURAL FIBER SUPPLEMENT CVS OMEPRAZOLE CVS PRENATAL CVS PRENATAL MULTI+DHA cyanocobalamin cyclobenzaprine hcl cyclopentolate hcl cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified (formicroemulsion) cyproheptadine hcl

97 117 121 111 122

104 132 113

113 101 116 118

47 47 32

111 40

demeclocycline hcl 129 DEMSER 43 DENAVIR 85 DEPEN TITRATABS 111 DEPO-MEDROL 78 DEPO-PROVERA 51 DESCOVY 66 desipramine hcl 29 desloratadine 39 desmopressin acetate 95 desmopressin acetate spray 95 desmopressin acetate sprayrefrigerated 95 desogestrel amp ethinylestradiol 76 desogestrel-ethinyl estradiol(biphasic) 76 desonide 86 desoximetasone 87 DESVENLAFAXINE ER 28 desvenlafaxine succinate 28 dexamethasone 78 dexamethasone sodium phosphate 78

dicyclomine hcl 130 didanosine 66 diethylpropion hcl 1 DIETHYLPROPION HCL ER 1 DIFICID 107 diflorasone diacetate 87 diflunisal 7 DIGOXIN 73 digoxin 73 dihydroergotaminemesylate 108 diltiazem hcl 7273 diltiazem hcl coated beads 72 diltiazem hcl extended release beads 73 DIOVAN 43 DIOVAN HCT 44 DIPENTUM 98 diphenhydramine hcl 39 diphenoxylate w atropine 35 DIPHTHERIATETANUSTOXOIDS ADSORBED PEDIATRIC 130 dipyridamole 101

Index 4

disopyramide phosphate 18 disulfiram 125 divalproex sodium 25 DIVIGEL 96 dobutamine hcl 136 DOCETAXEL 58 docetaxel 58 DOCETAXEL 58 docusate calcium 105 docusate sodium 105106 DOCUSOL MINI 106 DOCUSOL PLUS MINI-ENEMA 106 dofetilide 18 donepezil hydrochloride 125 dorzolamide hcl 121 dorzolamide hcl-timolol maleate 118 doxazosin mesylate 44 doxepin hcl 29 doxorubicin hcl 52 doxorubicin hcl liposomal 52 doxycycline (monohydrate) 129 doxycycline hyclate 129 dronabinol 37 drospirenone-ethinylestradiol 76 DROXIA 101 DULERA 20 duloxetine hcl 28 DUOPA 60 DUREZOL 120 dutasteride 99 dutasteride-tamsulosin hcl 99 econazole nitrate 83 ED CHLORPED 39 ED CHLORPED D 80 EDURANT 66 efavirenz 66 EFFIENT 101 ELELYSO 101 ELIDEL 89 ELIGARD 51 ELIQUIS 21 ELIQUIS STARTER PACK 21 ELITEK 57 ELLA 77

EMCYT 51 EMFLAZA 78 EMPLICITI 49 EMSAM 26 EMTRIVA 66 enalapril maleate 43 enalapril maleate amphydrochlorothiazide 44 ENBREL 6 ENBREL MINI 6 ENBREL SURECLICK 6 ENDARI 101 ENEMEEZ MINI 106 ENEMEEZ PLUS 106 ENFAMIL EXPECTA 113 ENGERIX-B 134 enoxaparin sodium 21 entacapone 60 entecavir 70 ENTRE-HIST PSE 80 ENTRESTO 73 ENTYVIO 98 ENVARSUS XR 111 EPCLUSA 70 epinastine hcl (ophth) 121 epinephrine (anaphylaxis)136 EPIPEN 2-PAK 136 EPIPEN-JR 2-PAK 136 epirubicin hcl 52 EPIVIR HBV 70 eplerenone 45 EPOGEN 102 eprosartan mesylate 43 EQ OMEPRAZOLE 132 EQL CALCIUMVITAMIND 109 EQL OMEPRAZOLE 132 EQL PRENATAL FORMULA 113 EQUALACTIN 104 EQUETRO 61 ERAXIS 37 ERBITUX 49 ergocalciferol 137 ergoloid mesylates 127 ergotamine tartrate 108 ergotamine w caffeine 108

ERIVEDGE 50 ERLEADA 51 ertapenem sodium 14 ERWINAZE 56 erythromycin (acne aid) 81 erythromycin (ophth) 119 erythromycin base 106 erythromycinethylsuccinate 106 erythromycin lactobionate 107 erythromycin stearate 107 ESBRIET 129 escitalopram oxalate 27 esomeprazole magnesium 132 esomeprazole sodium 132 estradiol 96 estradiol amp norethindrone acetate 96 estradiol vaginal 136 estradiol valerate 96 estropipate 96 ethambutol hcl 46 ethosuximide 25 ethynodiol diacet amp ethestrad 76 ETHYOL 58 etodolac 5 ETOPOPHOS 58 etoposide 58 EVOMELA 47 EVOTAZ 66 exemestane 51 EXJADE 35 EXONDYS 51 117 EXTAVIA 127 ezetimibe 42 EZFE FORTE 113 FABRAZYME 94 famciclovir 71 famotidine 131 FANAPT 62 FARESTON 51 FARYDAK 54 FASENRA 18 FASLODEX 51 fat emulsion 118 FAZACLO 63

Index 5

FC FEMALE CONDOM 107 fluorometholone (ophth) 120 GATTEX 99 FC2 FEMALE CONDOM 107 fluorouracil 48 gauze pads 2x2 107 felbamate 24 FLUOROURACIL 84 GAZYVA 49 felodipine fenofibrate

fluorouracil (topical) fluoxetine hcl

gemcitabine hcl GEMCITABINE

fenofibrate micronized 41 fentanyl 7 fentanyl citrate 7 FERRIPROX 35 ferrous sulfate 102 FERROUS SULFATE 102 ferrous sulfate 102 FERROUS SULFATE 102 ferrous sulfate 103 FERROUS SULFATE 103 ferrous sulfate 103 FETZIMA 28 FETZIMA TITRATION PACK28 FEVERALL INFANTS 7 FINACEA 90 finasteride 99 FIRAZYR 100 FIRMAGON 51 flavoxate hcl 134 FLEBOGAMMA DIF 122 flecainide acetate 18 FLECTOR 82 FLEET BISACODYL 105 FLEET LIQUID GLYCERIN SUPPOSITORIES 105 FLONASE ALLERGY

fluoxymesterone fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone propionate fluticasone propionate(nasal) fluvastatin sodium fluvoxamine maleate folic acid FOLIC ACID folic acid FOLOTYN fondaparinux sodium FORFIVO XL FORTEO fosamprenavir calcium fosinopril sodium fosinopril sodium amphydrochlorothiazide fosphenytoin sodium FOSRENOL FRAGMIN furosemide

12 63 63

117 41 27

101 102 102

48 21 26 92 66 43

44 25 99 21 91

HYDROCHLORIDE 49 gemfibrozil 41 GENOTROPIN 93 GENOTROPIN MINIQUICK 93 gentamicin in saline 3 gentamicin sulfate 3 gentamicin sulfate (ophth) 119 gentamicin sulfate (topical) 82 GENVOYA 66 GEODON 61 GILENYA 127 GILOTRIF 54 glatiramer acetate 127 GLEEVEC 54 GLEOSTINE 47 glimepiride 34 glipizide 3435 glipizide-metformin hcl 30 GLUCAGEN HYPOKIT 31 GLUCAGON EMERGENCY KIT 31 glyburide 35 glyburide micronized 35 glyburide-metformin 30 glycopyrrolate 130131 GNP CALAMINE 90

RELIEF 117 FUZEON 66 GNP DAILY PRENATAL 114 FLONASE ALLERGY RELIEF FYCOMPA 21 GNP OMEPRAZOLE 132 CHILDRENS FLOVENT DISKUS FLOVENT HFA fluconazole fluconazole in dextrose

117 19 19 38 38

gabapentin GABITRIL galantaminehydrobromide GAMASTAN

125 122

GNP PRENATAL 114 GOODSENSE PRENATAL VITAMINS 114 granisetron hcl 36 GRANIX 102

fluconazole in nacl 38 GAMASTAN SD 122 griseofulvin microsize 37 flucytosine 37 GAMMAGARD LIQUID 122 griseofulvin ultramicrosize 38 fludarabine phosphate 48 GAMMAKED 122 guaifenesin-codeine 80 fludrocortisone acetate 79 GAMMAPLEX 123 guanfacine hcl 44 flunisolide (nasal) 117 GAMUNEX-C 123 guanfacine hcl (adhd) 2 fluocinolone acetonide fluocinolone acetonide

87 ganciclovir sodium GARDASIL

69 134

GUANIDINE HCL HP ACTHAR

(otic) 122 fluocinonide 87 fluocinonide emulsified base 87

GARDASIL 9 gatifloxacin (ophth)

134 119

HAEGARDA HALAVEN

100 58

Index 6

halobetasol propionate 87 haloperidol 62 haloperidol decanoate 62 haloperidol lactate 62 HARVONI 70 HAVRIX 134 heparin sodium (porcine) 21 HERCEPTIN 50 HETLIOZ 104 HEXALEN 47 HIBERIX 134 HIZENTRA 123 HM CALAMINE 90 HM OMEPRAZOLE 132 HM ONE DAILY PRENATAL COMBO 114 HM PRENATAL 114 HUMALOG 33 HUMALOG JUNIOR

hydrocodone polistirex-chlorpheniramine polistirex 80 hydrocodone whomatropine 79 hydrocodone-acetaminophen 11 hydrocodone-ibuprofen 11 hydrocortisone 78 hydrocortisone (intrarectal) 12 hydrocortisone (rectal) 13 hydrocortisone (topical) 8788 hydrocortisone butyrate 88 hydrocortisone butyratehydrophilic lipo base 88 hydrocortisone valerate 88 hydrocortisone waceticacid 122 hydrocortisone-aloe vera 88 hydromorphone hcl 8 HYDROMORPHONE HYDROCHLORIDE 8

IMOVAX RABIES (HDCV) 135 IMPAVIDO 13 INCRELEX 93 indapamide 92 indomethacin 5 INFANRIX 130 INFLECTRA 98 INLYTA 54 INSULIN SYRINGES AND PEN NEEDLES 107 INTELENCE 66 INTRON A 57 INVANZ 14 INVEGA SUSTENNA 62 INVEGA TRINZA 62 INVIRASE 66 INVOKAMET 30 INVOKAMET XR 30

KWIKPEN HUMALOG KWIKPEN

hydroxychloroquine sulfate 45 HYDROXYPROGESTERONE

INVOKANA IPOL INACTIVATED IPV

34 135

HUMALOG MIX 5050 HUMALOG MIX 5050KWIKPEN HUMALOG MIX 7525 HUMALOG MIX 7525KWIKPEN HUMATROPE HUMATROPE COMBO PACK

CAPROATE hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERRAB SD HYQVIA ibandronate sodium IBRANCE

51 57 17 17

123 123

ipratropium bromide 19 ipratropium bromide (nasal)117 ipratropium-albuterol 20 IPRIVASK 21 irbesartan 43 irbesartan-hydrochlorothiazide

44 IRESSA 54

HUMIRA 3 HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK 3 HUMIRA PEN 3 HUMIRA PEN-CDUCHSSTARTER 3 HUMIRA PEN-PSUVSTARTER 3 HUMULIN 7030 33 HUMULIN 7030 KWIKPEN 33 HUMULIN N 33 HUMULIN N KWIKPEN 33 HUMULIN R 33 HUMULIN R U-500 (CONCENTRATED) 33 HUMULIN R U-500 KWIKPEN 33 hydralazine hcl 45 hydrochlorothiazide 92 HYDROCIL INSTANT 104

ibuprofen ICLUSIG idarubicin hcl IDHIFA IFEX ifosfamide IFOSFAMIDE ILARIS ILEVRO imatinib mesylate IMBRUVICA IMFINZI imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMIQUIMOD PUMP IMOGAM RABIES-HT

5 54 53 54 47 47 47

54 54 50 14 29 29 89 89

irinotecan hcl 59 IRON CHEWS PEDIATRIC 103 irrigation solutionsphysiological 112 ISENTRESS 66 ISENTRESS HD 66 isoniazid 46 isoniazid amp rifampin 46 isosorbide dinitrate 16 isosorbide mononitrate 16 isotretinoin 81 ISTODAX (OVERFILL) 54 itraconazole 38 ivermectin 13 IXEMPRA KIT 58 IXIARO 135 JADENU 36 JADENU SPRINKLE 36 JAKAFI 54

Index 7

JANUMET 30 KP PRENATAL LEUKERAN 47 JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR JEVTANA JULUCA JUXTAPID JYNARQUE K-TAB KADCYLA KALBITOR

30 32 34 30 30 59 67 42 95

110 50

MULTIVITAMINS 114 KPN PRENATAL 114 KUVAN 94 KYNAMRO 40 KYPROLIS 55 labetalol hcl 71 LAC-HYDRIN TWELVE 89 lactated ringers 110 lactic acid (ammoniumlactate) 89 lactulose 105 lactulose (encephalopathy)98 LAMICTAL XR 23

LEUKINE 102 leuprolide acetate 51 levalbuterol hcl 20 LEVEMIR 34 LEVEMIR FLEXTOUCH 34 levetiracetam 23 levetiracetam in sodium chloride 23 levobunolol hcl 118 levocarnitine (metabolicmodifiers) 94 levocetirizine dihydrochloride39 levofloxacin 97

KALETRA KALYDECO

67 128

LAMISIL AT SPRAY lamivudine

levofloxacin (ophth) levofloxacin in d5w

119 97

KANUMA KAZANO

lamivudine (hbv) lamivudine-zidovudine

LEVOLEUCOVORIN levoleucovorin calcium

KEDRAB KENALOG-10 KENALOG-40 KEPIVANCE ketoconazole ketoconazole (topical) ketoprofen ketorolac tromethamine ketorolac tromethamine (ophth) ketotifen fumarate (ophth) KEVZARA KEYTRUDA KHEDEZLA KINERET KINRIX

123 78 78 57 38 83

121 121

4 50 28

lamotrigine LANOXIN lansoprazole lanthanum carbonate LANTUS LANTUS SOLOSTAR LARTRUVO latanoprost LATEX CONDOMS LATUDA LAZANDA leflunomide LEMTRADA LENVIMA 10 MG DAILY DOSE LENVIMA 12MG DAILY

132 99 34 34 50

121 107

61 8 6

levonorgestrel amp ethestradiol 76 levonorgestrel (emergencyoc) 77 levonorgestrel-eth estradiol(triphasic) 77 levonorgestrel-ethinyl estradiol(91-day) 77 levothyroxine sodium 130 LEXIVA 67 lidocaine 89 lidocaine hcl 89 lidocaine hcl (local anesth) 106 lidocaine hcl (mouth-throat) 113 lidocaine-prilocaine 90 lincomycin hcl 15 linezolid 16

KISQALI KISQALI FEMARA 200 DOSE KISQALI FEMARA 400 DOSE KISQALI FEMARA 600 DOSE KITABIS PAK KLS OMEPRAZOLE KOMBIGLYZE XR KONSYL KONSYL DAILY FIBER KONSYL-D KORLYM

132 30

104 104 104

DOSE LENVIMA 14 MG DAILY DOSE LENVIMA 18 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE LENVIMA 24 MG DAILY DOSE LENVIMA 4 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE LETAIRIS letrozole leucovorin calcium

55 74 51 58

LINEZOLID linezolid LINZESS liothyronine sodium lisinopril lisinopril amphydrochlorothiazide LITHIUM lithium carbonate LOMAIRA LONSURF loperamide hcl lopinavir-ritonavir loratadine

16 16 98

130 43

44 61 61

1 53 35 67 39

Index 8

loratadine amp megestrol acetate 51 metoprolol amppseudoephedrine 80 megestrol acetate hydrochlorothiazide 45 lorazepam 17 (appetite) 125 metoprolol succinate 72 losartan potassium 43 losartan potassium amphydrochlorothiazide 44 LOTEMAX 120 LOTRIMIN AF 83 LOTRIMIN AF FOR HER 83 LOTRIMIN AF JOCK ITCH 83 lovastatin 41 loxapine succinate 63 LUMIGAN 121 LUMIZYME 94 LUNG PERFORMANCE PEAK FLOW METER 107 LUPRON DEPOT (1-MONTH) 51 LUPRON DEPOT (3-MONTH) 51 LUPRON DEPOT (4-MONTH) 51 LUPRON DEPOT (6-MONTH) 51 LUPRON DEPOT-PED (1-MONTH) 93 LUPRON DEPOT-PED (3-MONTH) 93 LYNPARZA 55 LYRICA 2324 LYSODREN 51 M-M-R II 135 mafenide acetate 85 MAGDELAY 110 MAGNESIUM SULFATE 110 magnesium sulfate 110 MAGNESIUM SULFATE 110 malathion 90 maprotiline hcl 26

MEIJER CALAMINE 90 MEKINIST 55 MEKTOVI 55 meloxicam 5 melphalan 47 melphalan hcl 47 memantine hcl 125 MENACTRA 134 MENOMUNE-ACYW-135

134 MENVEO 134 meperidine hcl 8 MEPHYTON 137 mercaptopurine 49 meropenem 14 mesalamine 98 mesalamine w cleanser 98 mesna 58 MESNEX 58 METAMUCIL SMOOTH TEXTUREFIBER SINGLES 104 metaxalone 116 metformin hcl 31 methadone hcl 8 methamphetamine hcl 1 methazolamide 91 methenamine hippurate 133 methimazole 129 methocarbamol 116 methotrexate sodium 49 methoxsalen rapid 84 methscopolaminebromide 131

metoprolol tartrate 72 METOPROLOL TARTRATE 72 metronidazole 1314 metronidazole (topical) 90 metronidazole in nacl 14 metronidazole vaginal 136 mexiletine hcl 18 MIACALCIN 92 miconazole nitrate (topical) 83 miconazole nitrate vaginal 136 MICROLIFE DIGITAL PEAK FLOW METER 107 midodrine hcl 136 miglitol 29 miglustat 101 MIGRANAL 108 MILK OF MAGNESIA CONCENTRATE 105 MINI WRIGHT AFS PEAK FLOWMETER LOW RANGE 107 MINI WRIGHT PEAK FLOW METER 107 minocycline hcl 129 minoxidil 45 MIRALAX 105 mirtazapine 26 MIRVASO 90 misoprostol 133 mitomycin 53 mitoxantrone hcl 53 modafinil 2 moexipril hcl 43 moexipril-hydrochlorothiazide

45 MARPLAN 26 MARQIBO 59 MATULANE 57 MAVYRET 70 meclizine hcl 36 MEDROL 78 medroxyprogesterone acetate 125 medroxyprogesterone acetate(contraceptive) 77 mefenamic acid 5 mefloquine hcl 45

methylcellulose (laxative) 105 methylergonovinemaleate 122 methylphenidate hcl 2 methylprednisolone 78 methylprednisolone acetate 78 methylprednisolone sod succ 78 methyltestosterone 12 metoclopramide hcl 97 metolazone 92

mometasone furoate 88 MONISTAT SOOTHING CARE ITCH RELIEF 88 montelukast sodium 19 morphine sulfate 89 MORPHINE SULFATE 9 morphine sulfate 9 MOVANTIK 98 moxifloxacin hcl (ophth) 119 MOZOBIL 103 MULTAQ 18

Index 9

MULTI PRENATAL 114 NEONATAL VITAMIN 114 norethindrone acetate 125 mupirocin 82 mupirocin calcium (topical) 82 MURO 128 121 MUSTARGEN 48 MYALEPT 94 MYCAMINE 37 mycophenolate mofetil 111 mycophenolate mofetil hcl 111

NERLYNX 55 NESINA 32 NESTABS 114 NEULASTA 102 NEULASTA ONPRO KIT 102 NEUPOGEN 102 NEUPRO 60 NEVANAC 121

norethindrone acetate-ethinylestradiol 96 norethindrone-eth estradiol (triphasic) 77 norgestimate-ethinylestradiol 77 norgestimate-ethinyl estradiol(triphasic) 77 norgestrel amp ethinyl estradiol 77 NORTEMP INFANTS 7

mycophenolate sodium 112 MYLOTARG 50 MYRBETRIQ 134 nabumetone 5 nadolol 72 nadolol amp bendroflumethiazide 45 NAFCILLIN SODIUM 124 nafcillin sodium 124 naftifine hcl 83 NAFTIN 83 NAGLAZYME 94 nalbuphine hcl 11 naloxone hcl 36 naltrexone hcl 36 NAMENDA XR 126 NAMENDA XR TITRATION

nevirapine 67 NEXAFED SINUS PRESSURE +PAIN 80 NEXAVAR 55 NEXIUM 132 niacin 137 niacin (antihyperlipidemic) 42 nicardipine hcl 73 nicotine 128 nicotine polacrilex 128 NICOTINE TRANSDERMAL SYSTEM 128 NICOTROL INHALER 128 NICOTROL NS 128 nifedipine 73 nilutamide 52 nimodipine 73

NORTHERA 136 nortriptyline hcl 29 NORVIR 67 NOVAREL 93 NOXAFIL 38 NUCALA 18 NUEDEXTA 127 NULOJIX 112 NUPLAZID 61 NUTROPIN AQ NUSPIN 20 93 NUVARING 77 NYMALIZE 73 nystatin 38 nystatin (mouth-throat) 113 nystatin (topical) 83 nystatin-triamcinolone 83

PACK 126 NINLARO 55 OCALIVA 97 naphazoline wpheniramine 120 naproxen 6 naproxen sodium 56 naratriptan hcl 108 NASAL DECONGESTANT 117 NAT-RUL PRENATAL VITAMINS 114 NATACYN 119 nateglinide 34 NATPARA 92 NEBUPENT 14 nefazodone hcl 27

NIPENT 57 nisoldipine 73 nitrofurantoin macrocrystal 133 nitrofurantoin monohyd macro 133 nitroglycerin 1617 NITROGLYCERIN LINGUAL 16 NITROSTAT 17 nizatidine 131 NORDITROPIN FLEXPRO 93 norelgestromin-ethinylestradiol 77

OCREVUS OCTAGAM octreotide acetate ODEFSEY ODOMZO OFEV ofloxacin (ophth) ofloxacin (otic) olanzapine olanzapine-fluoxetine hcl olopatadine hcl olopatadine hcl (nasal)

127 123

95 67 50

129 119 122

63 126 121 117

neomycin sulfate 3 neomycin-bacitracin zn-polymyxin 119 neomycin-polymy-dexameth 120 neomycin-polymyxin-gramicidin

119 neomycin-polymyxin-hc(otic) 122 neomycinpolymyxin b gu 99

norethin acet amp estrad-fe norethindrone amp eth estradiol norethindrone amp ethinylestradiol-fe norethindrone (contraceptive)norethindrone acet amp eth estra

OMECLAMOX-PAK omega-3-acid ethyl esters omeprazole OMEPRAZOLE omeprazole-sodiumbicarbonate OMNITROPE ONCASPAR

133 40

132 132

133 93 56

Index 10

ondansetron 36 ondansetron hcl 36 ONE A DAY WOMENS PRENATAL1 114 ONE-A-DAY WOMENS PRENATAL 114 ONFI 22 ONGLYZA 32 ONIVYDE 59 OPDIVO 50 ophthalmic irrigationsolution 121 OPSUMIT 74 OPTIONS GYNOL II VAGINALCONTRACEPTIVE

135 ORBACTIV 15 ORENCIA 6 ORENCIA CLICKJECT 6 ORFADIN 94 ORKAMBI 128 oseltamivir phosphate 71 OSENI 31 OTEZLA 6 OTREXUP 4 oxacillin sodium 124

PAXIL 27 PEAK AIR PEAK FLOW METERADULTPEDIATRIC

107 PEDIARIX 130 pediatric vitamins adc 113 PEDVAX HIB 134 peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 105 peg 3350-potassium chloride-sod bicarbonate-sod chloride 105 PEG-INTRON REDIPEN 70 PEGANONE 25 PEGASYS 70 PEGASYS PROCLICK 70 PEGINTRON 70 penicillin g potassium 124 penicillin v potassium 124 PENTACEL 130 PENTAM 300 14 pentoxifylline 100 PEPCID AC MAXIMUM STRENGTH 131 perindopril erbumine 43 PERJETA 50

pimozide 128 pindolol 72 pioglitazone hcl 33 pioglitazone hcl-glimepiride 31 pioglitazone hcl-metforminhcl 31 piperacillin sodium-tazobactamsodium 124 piroxicam 6 PLEGRIDY 127 PLEGRIDY STARTER PACK 127 POCKET PEAK FLOW METER 108 POCKETPEAK PEAK FLOW METER LOW RANGE 108 POCKETPEAK PEAK FLOW METERUNIVERSAL RANGE 50-720 LPM 108 podofilox 89 polyethylene glycol 3350 105 polymyxin b sulfate 16 polymyxin b-trimethoprim 119 polysaccharide ironcomplex 103 polyvinyl alcohol 118 POMALYST 52

oxaliplatin oxandrolone oxaprozin oxazepam oxcarbazepine oxybutynin chloride oxycodone hcl oxycodone wacetaminophen oxycodone-aspirin oxymorphone hcl oyster shell

6 17 24

133 910

11 11 10

permethrin 90 perphenazine 64 perphenazine-amitriptyline

126 PERSONAL BEST FULL RANGE 107 PERSONAL BEST LOW RANGE 107 phenelzine sulfate 26 phenobarbital 103 phenoxybenzamine hcl 43 phentermine hcl 1 PHENYLHISTINE DH 80

PORTRAZZA 50 potassium chloride 110 POTASSIUM CHLORIDE 110 potassium chloride 111 POTASSIUM CHLORIDE ER 110 potassium chloride in dextrose ampsodium chloride 110 potassium chloridemicroencapsulated crystals er 110 potassium citrate(alkalinizer) 99 POTELIGEO 50

paclitaxel 59 phenytoin 25 POTIGA 24 paliperidone PANCREAZE PANRETIN pantoprazole sodium parenteral electrolytes paricalcitol paromomycin sulfate paroxetine hcl paroxetine mesylate(vasomotor)

62 91 84

132 110

phenytoin sodium 25 phenytoin sodiumextended 25 PHOSPHOLINE IODIDE 119 phytonadione 137 PICATO 84 PIFELTRO 67 PIKO 1 ELECTRONIC 108 pilocarpine hcl 119 pilocarpine hcl (oral) 113

PRADAXA 21 PRALUENT 42 pramipexole dihydrochloride 60 prasugrel hcl 101 pravastatin sodium 41 prazosin hcl 44 prednicarbate 88 prednisolone 79 prednisolone acetate(ophth) 120

Index 11

prednisolone sodiumphosphate 79 prednisone 79 PREMARIN 96136 PREMPHASE 96 PREMPRO 96 PRENATAL 115 PRENATAL FORMULA A-FREE 114 PRENATAL LOW IRON 114 PRENATAL MULTI + DHA 114 PRENATAL MULTIVITAMIN 114 PRENATAL MULTIVITAMIN + DHA 114 PRENATAL MULTIVITAMIN PLUS DHA 114 PRENATAL ONE DAILY 114 PRENATAL VITAMIN 115 PRENATAL VITAMIN amp MINERAL 115 PRENATAL VITAMINIRON 115 PRENATAL VITAMINS 115 PRENATE 115

PROMACTA 102 promethazine ampphenylephrine 80 promethazine hcl 40 promethazine wcodeine 80 promethazine-dm 80 promethazine-phenylephrine-codeine 80 propafenone hcl 18 proparacaine hcl 120 propranolol hcl 72 propylthiouracil 130 PROQUAD 135 protriptyline hcl 29 PROVENTIL HFA 20 pseudoephedrine hcl 117 psyllium 105 PULMOZYME 128 PURIXAN 49 PX CALAMINE 90 PX OMEPRAZOLE 132 PX PRENATAL MULTIVITAMINS 115

RABAVERT RADICAVA raloxifene hcl ramipril RANEXA ranitidine hcl RAPAMUNE rasagiline mesylate RASUVO RAVICTI RAYALDEE REBIF REBIF REBIDOSE REBIF REBIDOSE TITRATIONPACK REBIF TITRATION PACK RECOMBIVAX HB RECTIV REGRANEX RELENZA DISKHALER RELISTOR REMICADE

135 117

93 43 16

131 112

127 127

127 127 135

13 90 71 99 98

PRENATE AM 115 PREVACID 24HR 132 PREVYMIS 69 PREZCOBIX 67 PREZISTA 67 PRIFTIN 46 PRILOSEC OTC 132 primaquine phosphate 45 PRIMAQUINE PHOSPHATE 45 primidone 24 PRIVIGEN 123 PROAIR HFA 20 PROAIR RESPICLICK 20

pyrantel pamoate 13 pyrazinamide 46 pyrethrins-piperonylbutoxide 90 pyridostigmine bromide 46 pyridoxine hcl 137 QC CALAMINE 90 QC PRENATAL 115 QSYMIA 1 QUADRACEL 130 quetiapine fumarate 63 quinapril hcl 43 quinapril-hydrochlorothiazide

REMODULIN 73 RENVELA 99 repaglinide 34 REPAGLINIDEMETFORMINHYDROCHLORIDE 31 REPATHA 42 REPATHA PUSHTRONEX SYSTEM 42 REPATHA SURECLICK 42 RESCRIPTOR 68 RESTASIS 120 RESTASIS MULTIDOSE 120 RETROVIR IV INFUSION 68 REVLIMID 111

probenecid prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT

100 64 64 64

quinidine gluconate quinidine sulfate quinine sulfate QVAR RA CALAMINE

18 18 46 19 90

REXULTI REYATAZ ribavirin ribavirin (hepatitis c) riboflavin

6465 68 71 70

progesterone micronized PROGLYCEM

125 32

RA OMEPRAZOLE RA ONE DAILY

132 115

RIDAURA rifabutin

PROGRAF PROLASTIN-C PROLEUKIN PROLIA

112 128

RA OYSTER SHELL CALCIUMVITAMIN D RA PRENATAL RA PRENATAL FORMULAFOLICACID

109 115

rifampin RIFATER RIGHT STEP PRENATAL riluzole

115 117

Index 12

rimantadine hydrochloride 71 SILIQ 84 STIVARGA 56 RISACAL-D 110 SILPHEN COUGH 39 STRENSIQ 94 RISPERDAL CONSTA 62 silver sulfadiazine 85 STRIBILD 68 risperidone 62 RITALIN LA 2

simethicone 97 SIMILAC PRENATAL EARLY

STRIVERDI RESPIMAT 20 STUART ONE 116

ritonavir 68 RITUXAN 50 RITUXAN HYCELA 53 rivastigmine 126 rivastigmine tartrate 126 rizatriptan benzoate 108 ROMIDEPSIN 55 ropinirole hydrochloride 60 rosuvastatin calcium 41 ROTARIX 135 ROTATEQ 135 ROZEREM 104

SHIELD 115 SIMPONI 3 SIMPONI ARIA 3 SIMULECT 112 simvastatin 4142 sirolimus 112 SIRTURO 46 SIVEXTRO 16 SM CALAMINE 90 SM OMEPRAZOLE 133 SM ONE DAILY PRENATAL 115 SM PRENATAL

SUBSYS 10 SUCRAID 91 sucralfate 131 sulfacetamide sod-prednisolone 120 sulfacetamide sodium (acne)81 sulfacetamide sodium (ophth) 120 sulfadiazine 129 sulfamethoxazole-trimethoprim

14 SULFAMYLON 85 sulfasalazine 98

RUBRACA 55 VITAMINS 115 sulindac 6

RUCONEST 100 RYDAPT 55 RYMED 80 RYTARY 60

sodium chloride 111 sodium chloride (guirrigant) 99 sodium chloride (inhalant) 80 sodium chloride

sumatriptan succinate 108109 sumatriptan-naproxensodium 108 SUPRAX 76 SUPREP BOWEL PREP

SABRIL 25 saline 117 SAMSCA 95 SANDIMMUNE 112 SANDOSTATIN LAR

hypertonic 121 sodium phosphates (sodiumphosphate dibasic ampmonobasic) 110 sodium polystyrenesulfonate 112

KIT 105 SURMONTIL 29 SUSTIVA 68 SUTENT 56 SW OMEPRAZOLE 133

DEPOT 95 SOLTAMOX 52 SYLATRON 57 SANTYL 89 SOLU-CORTEF 79 SYMDEKO 129 SAPHRIS 63 SOLU-MEDROL 79 SYMFI 68 SB OMEPRAZOLE 132 SOMATULINE DEPOT 95 SYMFI LO 68 scopolamine 36 SOMAVERT 93 SYMLINPEN 120 29 selegiline hcl 60 sotalol hcl 72 SYMLINPEN 60 29 selenium sulfide 85 sotalol hcl (afibafl) 72 SYMTUZA 68 SELZENTRY 68 SOTYLIZE 72 SYNAGIS 123 sennosides 105 SOVALDI 70 SYNAREL 94 SENSIPAR 94 SPIRIVA HANDIHALER 19 SYNDROS 37 SEREVENT DISKUS 20 SPIRIVA RESPIMAT 19 SYNERCID 16 SEROSTIM 93 sertraline hcl 27 sevelamer carbonate 99 SHINGRIX 135 SIGNIFOR 95 SIGNIFOR LAR 95 sildenafil citrate (pulmonaryhypertension) 74 SILENOR 103

spironolactone 91 spironolactone amphydrochlorothiazide 91 SPRITAM 24 SPRYCEL 55 STAMARIL 135 stavudine 68 STELARA 8498 STIOLTO RESPIMAT 20

SYNJARDY 31 SYNJARDY XR 31 SYNRIBO 57 SYPRINE 111 TABLOID 49 tacrolimus 112 tacrolimus (topical) 89 tadalafil (pulmonaryhypertension) 74

Index 13

TAFINLAR 56 thiotepa 48 TRECATOR 46 TAGAMET HB 131 thiothixene 65 TRELEGY ELLIPTA 20 TAGRISSO 56 THYMOGLOBULIN 112 TRELSTAR 52 TALTZ 84 tiagabine hcl 25 TRELSTAR MIXJECT 52 TAMIFLU 71 TICE BCG 57 TREMFYA 85 tamoxifen citrate 52 TIGAN 36 TRESIBA FLEXTOUCH 34 tamsulosin hcl 100 TIGECYCLINE 15 tretinoin 81 TAPERDEX 6-DAY 79 tigecycline 15 tretinoin (chemotherapy) 57 TARCEVA TARGRETIN

timolol maleate (ophth) TIMOLOL MALEATE

118 tretinoin microsphere TREXIMET

82 108

TASIGNA TAVALISSE tazarotene TAZORAC TECENTRIQ TECFIDERA TECFIDERA STARTER PACK

56 100

84 85 50

OPHTHALMIC GEL FORMING tinidazole tioconazole vaginal TIVICAY tizanidine hcl TOBI PODHALER tobramycin

118 14

136 68

116 3 3

TRI-VI-SOL triamcinolone acetonide triamcinolone acetonide (mouth)triamcinolone acetonide (nasal)triamcinolone acetonide (topical)triamterene amp

113 79

TEFLARO 76 TEKTURNA 45 TEKTURNA HCT 45 temazepam 103 TEMODAR 48 temsirolimus 56 TENIVAC 130 tenofovir disoproxil fumarate 68 terazosin hcl 44 terbinafine hcl 38 terbinafine hcl (topical) 83 terbutaline sulfate 20 terconazole vaginal 136

tobramycin (ophth) tobramycin sulfate tobramycin-dexamethasone tolazamide tolbutamide tolcapone tolmetin sodium tolnaftate tolterodine tartrate topiramate TOPOTECAN HCL topotecan hcl TORISEL

120 35 35 60

133 24 59 59 56

hydrochlorothiazide TRIAZOLAM triazolam trientine hcl trifluoperazine hcl trifluridine TRIGLIDE trihexyphenidyl hcl trimethoprim trimipramine maleate TRINTELLIX triprolidine amppseudoephedrine TRIPTODUR

91 103 103 111

64 120

41 59 14 29 27

testosterone TESTOSTERONE testosterone cypionate

12 12 12

torsemide TOTECT TOUJEO MAX

TRISENOX TRIUMEQ TROGARZO

57 68 68

testosterone enanthate TESTOSTERONE PUMP

SOLOSTAR TOUJEO SOLOSTAR

trospium chloride TRUMENBA

133 134

TETANUSDIPHTHERIATOXOIDS-ADSORBED tetrabenazine tetracycline hcl TGT OMEPRAZOLE THALOMID theophylline THERANATAL COMPLETE thiamine hcl thioridazine hcl

130 126 129 133 111

116 137

TRACLEER TRADJENTA tramadol hcl tramadol-acetaminophen trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine sulfate TRAVATAN Z trazodone hcl TREANDA

74 32 10 11 43

103 36 26

122 27 48

TRUVADA TRUZONE PEAK FLOW METER TUDORZA PRESSAIR TWINRIX TYBOST TYGACIL TYKERB TYMLOS TYPHIM VI TYSABRI

108 19

135 69 15 56 92

134 127

Index 14

TYVASO 74 VIIBRYD 28 ZALTRAP 49 TYVASO REFILL 74 VIIBRYD STARTER PACK 28 ZANOSAR 48 TYVASO STARTER 74 VIMIZIM 94 ZANTAC 150 MAXIMUM

UCERIS 12 UPTRAVI 74 ursodiol 97 UTIBRON NEOHALER 20 UVADEX 57 VABOMERE 14 valacyclovir hcl 71 VALCHLOR 84 valganciclovir hcl 69 valproate sodium 25 valproic acid 26 valsartan 44 valsartan-hydrochlorothiazide

45 VALSTAR 53 vancomycin hcl 15 VANCOMYCIN HCL IN DEXTROSE 15 VANTAS 52 VAQTA 135 VARIVAX 135 VARIZIG 123 VARUBI 37 VASCEPA 40 VCF VAGINAL CONTRACEPTIVE FOAM 135

VIMPAT 24 vinblastine sulfate 59 vincristine sulfate 59 vinorelbine tartrate 59 VIRACEPT 69 VIRAMUNE 69 VIREAD 69 VIRT-PN DHA 116 VISTOGARD 36 vitamin a 137 vitamin e 137 VOGELXO 12 VOGELXO PUMP 12 voriconazole 38 VOSEVI 70 VOTRIENT 56 VPRIV 101 VRAYLAR 61 VYXEOS 53 warfarin sodium 21 water for irrigation sterile 112 WELCHOL 41 XALKORI 56 XARELTO 21 XARELTO STARTER

STRENGTH ZARXIO ZATEAN-PN DHA ZAVESCA ZEJULA ZELBORAF ZEMAIRA ZEPATIER ZERIT ZIAGEN zidovudine ZINPLAVA ziprasidone hcl ZIRGAN ZOHYDRO ER ZOLADEX zoledronic acid ZOLINZA zolmitriptan zolpidem tartrate ZOMACTON zonisamide ZONTIVITY ZORTRESS ZOSTAVAX

131 102 116 101

128 70 69 69 69

123 61

120 1011

52 92 56

109 104

101 112 135

VECTIBIX 50 PACK 21 ZOVIRAX 85 VELCADE 56 XATMEP 49 ZYCLARA 89 VELTASSA 112 XELJANZ 3 ZYCLARA PUMP 89 VEMLIDY 70 XENICAL 1 ZYDELIG 56 VENCLEXTA 50 XEOMIN 118 ZYKADIA 56 VENCLEXTA STARTING XERMELO 99 ZYPREXA RELPREVV 63 PACK venlafaxine hcl VENTAVIS verapamil hcl VERELAN VERSACLOZ VERZENIO VIBERZI VICTOZA VIDEX EC VIDEXPEDIATRIC vigabatrin VIGAMOX

50 28 74 73 73 63 56 98 32 69 69 25

XGEVA XIFAXAN XOLAIR XTANDI XURIDEN XYREM YERVOY YF-VAX YONDELIS YONSA zafirlukast zaleplon

92 14 18 52 95

125 50

135 48 52 19

ZYTIGA ZYVOX

Index 15

Ang Health Net Community Solutions Inc ay isang sangay ng Health Net Inc Ang Health Net ay isang rehistradong marka ng serbisyo ng Health Net Inc Nakalaan ang lahat ng karapatan

DIR026142TN00

18477 CA MMP (10-23-18) November Final Review eff date 11012018 TAGpdf

Classes

ADHDANTI-NARCOLEPSYANTI-OBESITYANOREXIANTS - Drugs to Treat ADHD Sleep and Eating Disorders


AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections

ANALGESICS - ANTI-INFLAMMATORY - Drugs to Treat Pain Swelling Muscle and Joint Conditions

ANALGESICS - NonNarcotic - Drugs to Treat Pain Muscle and Joint Conditions

ANALGESICS - OPIOID - Drugs to Treat Pain Muscle and Joint Conditions

ANDROGENS-ANABOLIC - Drugs to Regulate Hormones

ANORECTAL AGENTS - Rectal Drugs to Treat Pain Swelling and Itching

ANTACIDS

ANTHELMINTICS - Drugs to Treat Worm Infections

ANTI-INFECTIVE AGENTS - MISC - Drugs to Treat Bacterial Infections

ANTIANGINAL AGENTS - Drugs to Treat Chest Pain


ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms




ANTIDEPRESSANTS - Drugs to Treat Depression

ANTIDIABETICS - Drugs to Regulate Blood Sugar

ANTIDIARRHEALPROBIOTIC AGENTS - Drugs to Treat Diarrhea


ANTIEMETICS - Drugs to Treat Nausea and Vomiting



ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol

ANTIHYPERTENSIVES - Drugs to Treat High Blood Pressure

ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections)


ANTIMYCOBACTERIAL AGENTS - Drugs to Treat Tuberculosis (Bacterial Infections)

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer


ANTIPSYCHOTICSANTIMANIC AGENTS - Drugs to Treat Mood Disorders


BETA BLOCKERS - Drugs to Treat High Blood Pressure

CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure

CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm

CARDIOVASCULAR AGENTS - MISC - Drugs to Treat Heart and Circulation Conditions

CEPHALOSPORINS - Drugs to Treat Bacterial Infections

CONTRACEPTIVES - Drugs to Prevent Pregnancy

CORTICOSTEROIDS - Steroid Hormone Drugs to Treat Systemic Swelling Conditions

COUGHCOLDALLERGY - Drugs to Treat Cough Cold and Allergy Symptoms

DERMATOLOGICALS - Drugs to Treat Skin Conditions

DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes

DIURETICS - Drugs to Treat Heart Circulation Conditions and Blood Pressure

ENDOCRINE AND METABOLIC AGENTS - MISC - Drugs to Treat Bone Disease and Regulate Hormones

ESTROGENS - Hormone ReplacementModifying Drugs

FLUOROQUINOLONES - Drugs to Treat Bacterial Infections

GASTROINTESTINAL AGENTS - MISC - Miscellaneous Gastrointestinal Drugs

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System


HEMATOLOGICAL AGENTS - MISC - Drugs to Treat Blood Disorders

HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders

HEMOSTATICS - Drugs to Stop BleedingTreat Blood Disorders

HYPNOTICSSEDATIVESSLEEP DISORDER AGENTS


LOCAL ANESTHETICS-Parenteral - Drugs for Numbing

MACROLIDES - Drugs to Treat Bacterial Infections


MIGRAINE PRODUCTS - Drugs to Treat Migraine Headaches




MULTIVITAMINS

MUSCULOSKELETAL THERAPY AGENTS - Drugs to Treat Spasms

NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus

NEUROMUSCULAR AGENTS - Drugs to RelaxParalyze Muscles

NUTRIENTS



OXYTOCICS - Drugs to PreventControl Uterine Bleeding

PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low Immune System


PROGESTINS - Hormone ReplacementModifying Drugs

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC - Drugs to Treat Mental and Emotional Conditions

RESPIRATORY AGENTS - MISC - Drugs to Treat Lung Conditions

SULFONAMIDES - Drugs to Treat Bacterial Infections

TETRACYCLINES - Drugs to Treat Bacterial Infections

THYROID AGENTS - Drugs to Regulate Thyroid Hormones

TOXOIDS

ULCER DRUGS - Drugs to Treat Bowel Intestine and Stomach Conditions

URINARY ANTI-INFECTIVES - Drugs to Treat BladderKidney Infections

URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms

VACCINES

VAGINAL PRODUCTS - Drugs to Treat Vaginal Infections and Low Hormones

VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions

VITAMINS