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Select Drug List Drug list — Five Tier Drug Plan Your plan includes coverage for medications you’ll find on this drug list. The drug list includes brand-name and generic prescription medications approved by the FDA. Drugs that are not on this list may cost you more out of pocket. You and your doctor can use this list as a guide to choose the medications that are best for you. Your coverage has limitations and exclusions. It’s best to refer to your Certificate/Evidence of Coverage or Summary Plan Description (SPD) for details about what’s covered and what’s not. Inside you will find more information about how this drug list works with your prescription drug coverage.

For the most up to date information, including newly added medications, generics and more, you can visit

anthem.com/pharmacyinformation. For additional information, please call the Member Services number

on your ID card.

05277OHMENABS

What is a drug list? The drug list (also called a formulary) is a list of prescription medications approved by the U.S. Food and Drug Administration (FDA). The list is made up of hundreds of brand-name and generic medications that have been reviewed and recommended for their quality and effectiveness through our Pharmacy and Therapeutics (P&T) process. Our P&T process involves an independent group of practicing doctors, pharmacists, and other health care professionals responsible for the research and decisions surrounding our drug lists. This group meets regularly to review new and existing drugs and chooses the top medications for our drug lists, based on their safety, effectiveness and value. The drug list is organized in tiers; medications on Tier 1 have the lowest member cost share while members pay more for drugs on higher tiers. How will I know about changes to the drug list? Drugs on our list are reviewed regularly. Sometimes this results in drugs being added or removed. We will always try to notify you of changes to the drug list that impact you. Now and then, it’s a good idea to check the status of any medications you are taking. On our website, you can view and search the drug list to see which drugs are covered and at what tier level, as well as information on dosage/strength options and prior authorization or step therapy requirements. You can also see if a brand-name drug has a generic equivalent. What’s the difference between brand-name and generic medications? A brand-name drug is usually available from only one manufacturer and may have patent protection. A generic drug is also FDA-approved and has the same active ingredients as its brand-name counterpart, but a generic is typically available only after the brand-name drug’s patent protection expires. Although it may look different, a generic drug works the same as its brand-name counterpart.

Is this a complete listing of all covered drugs? Yes, this is a complete listing of all drugs on the drug list; however, a drug(s) may be excluded based on your plan's benefit design. If a medication isn’t on this list, this means your plan doesn’t cover the medication(s), so you may have to pay out of pocket or switch to a covered prescription medication or an over the counter (OTC) option. If my medication is not included on the drug list, what are my options? The drug list includes many brand-name and generic drugs. You may have to pay the full cost of a medication that isn’t included on the drug list. When you visit our website, you can get more information about generic equivalent options, if available; however, OTC options will not be displayed. If an alternative isn’t listed, please talk to your doctor or pharmacist about whether another medication that is included on the drug list or an OTC may be right for you. Only you and your doctor can decide what drugs are right for you. If a medication you’re taking is not covered, your doctor can ask us to keep covering the drug(s) you take now by submitting a request for an exception. This process, called prior authorization, requires your doctor to call the member services number on your member ID card or go to our website to download and submit the prior authorization form. How will I know how much my drug will cost? Medications on the drug list are grouped into tiers. Your cost will depend on what tier the medication your doctor prescribes for you falls in and could be a set cost or a percentage of the total drug cost. In general, drugs on the lowest tier have the lowest member cost share, which is what you pay. Drugs on a higher tier may cost you more. Several factors determine what tier a drug is placed in, including:

• Clinical considerations. • Cost of the drug in comparison to other

drugs used for the same type of treatment.

• Availability of over-the-counter options.

Select Drug List

What types of drugs can I expect to find in the different tiers? Tier 1 drugs have the lowest member cost share. These are typically generic drugs that offer the greatest value compared to others that treat the same conditions. Tier 2 drugs have a medium cost share. They may be preferred brand drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs. Tier 3 drugs have a higher cost share. They will most likely include non-preferred brand and generic drugs. They may cost more than others used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA. Tier 4 specialty drugs have a higher cost share and typically consist of preferred Specialty (brand and generic) drugs. They may cost more than others that are used to treat the same condition. Tier 4 may also include drugs that were recently approved by the FDA or Specialty drugs are used to treat complex, chronic conditions and may need special handling. Tier 5 drugs have the highest cost share. Drugs in this category are typically Non-Preferred Specialty (brand and generic). Tier 5 may also include drugs that were recently approved by the FDA, or drugs that are used to treat complex, chronic conditions and may need special handling.

Member cost share amount for certain abuse-deterrent opioid analgesics may be lower due to state law requirements.

We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA).

In selecting medications for the prescription drug formulary, the therapeutic efficacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the formulary by at least one medication. When a closed formulary is in effect, only medications that are included on the formulary are a covered service. In certain clinical situations, a member may require use of a non-formulary product. Anthem has criteria that permits a member to obtain a non-formulary medication in a closed formulary plan. If specific criteria are met, a member can receive a non-formulary drug for a formulary copay. The criteria preserves the clinical integrity of the drug formulary and provides a process by which deviations from the formulary may be allowed. An appeals process is in place for any medications that do not meet the criteria.

2017 Ohio Select Drug List

Table of Contents

Table of Contents

ANALGESICS ........................................................................................................................................................................................................................................................................................... 6ANESTHETICS ........................................................................................................................................................................................................................................................................................ 8ANTIARTHRITICS ................................................................................................................................................................................................................................................................................ 8ANTIASTHMATICS ............................................................................................................................................................................................................................................................................. 9ANTIBIOTICS ........................................................................................................................................................................................................................................................................................ 10ANTICOAGULANTS ...................................................................................................................................................................................................................................................................... 15ANTIDOTES ............................................................................................................................................................................................................................................................................................ 16ANTIFUNGALS .................................................................................................................................................................................................................................................................................... 16ANTIHISTAMINE AND DECONGESTANT COMBINATION ................................................................................................................................................................. 18ANTIHISTAMINES ............................................................................................................................................................................................................................................................................ 18ANTIHYPERGLYCEMICS ........................................................................................................................................................................................................................................................ 18ANTIINFECTIVES ............................................................................................................................................................................................................................................................................. 20ANTIINFECTIVES/MISCELLANEOUS ........................................................................................................................................................................................................................ 20ANTINEOPLASTICS ...................................................................................................................................................................................................................................................................... 20ANTI-OBESITY DRUGS ............................................................................................................................................................................................................................................................. 22ANTIPARKINSON DRUGS ..................................................................................................................................................................................................................................................... 22ANTIPLATELET DRUGS .......................................................................................................................................................................................................................................................... 23ANTIVIRALS ........................................................................................................................................................................................................................................................................................... 23AUTONOMIC DRUGS .................................................................................................................................................................................................................................................................. 25BIOLOGICALS ..................................................................................................................................................................................................................................................................................... 25BLOOD ......................................................................................................................................................................................................................................................................................................... 28CARDIAC DRUGS ............................................................................................................................................................................................................................................................................ 28CARDIOVASCULAR ...................................................................................................................................................................................................................................................................... 29CNS DRUGS ........................................................................................................................................................................................................................................................................................... 32COLONY STIMULATING FACTORS ............................................................................................................................................................................................................................ 33CONTRACEPTIVES ....................................................................................................................................................................................................................................................................... 33COUGH/COLD PREPARATIONS .................................................................................................................................................................................................................................... 36DIAGNOSTIC ......................................................................................................................................................................................................................................................................................... 37DIURETICS .............................................................................................................................................................................................................................................................................................. 37EENT PREPS ......................................................................................................................................................................................................................................................................................... 37ELECT/CALORIC/H2O ................................................................................................................................................................................................................................................................ 38GASTROINTESTINAL .................................................................................................................................................................................................................................................................. 40HORMONES ........................................................................................................................................................................................................................................................................................... 42IMMUNOSUPPRESANT ............................................................................................................................................................................................................................................................. 44MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ............................................................................................................................................ 44MUSCLE RELAXANTS ............................................................................................................................................................................................................................................................... 45PRE-NATAL VITAMINS .............................................................................................................................................................................................................................................................. 45PSYCHOTHERAPEUTIC DRUGS ................................................................................................................................................................................................................................... 47SEDATIVE/HYPNOTICS ............................................................................................................................................................................................................................................................ 49SKIN PREPS .......................................................................................................................................................................................................................................................................................... 49SMOKING DETERRENTS ........................................................................................................................................................................................................................................................ 52THYROID PREPS .............................................................................................................................................................................................................................................................................. 52UNCLASSIFIED DRUG PRODUCTS ............................................................................................................................................................................................................................ 53VITAMINS .................................................................................................................................................................................................................................................................................................. 54

4

2017 Ohio Select Drug List

CURRENT AS OF 1/1/2017

Drug Status Notes

ANALGESICS

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

Tier 1 QL

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

Tier 1

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

Tier 1 QL

almotriptan malate oral tablet

Tier 1 QL

asa-butalb-caff-cod #3 capsule

Tier 1

ascomp with codeine oral capsule

Tier 1

buprenorphine hcl injection solution

Tier 2

buprenorphine hcl injection syringe

Tier 2

butalbital compound w/codeine oral capsule

Tier 1

butalbital-acetaminop-caf-cod oral capsule

Tier 1 QL

butalbital-acetaminophen-caff oral capsule

Tier 1

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

Tier 1

butalbital-aspirin-caffeine oral capsule

Tier 1

butorphanol tartrate nasal spray,non-aerosol

Tier 1 PA; QL

BUTRANS TRANSDERMAL PATCH WEEKLY

Tier 3 QL

CAMBIA ORAL POWDER IN PACKET

Tier 3 QL

capacet oral capsule Tier 1

Drug Status Notes

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

Tier 1 QL

diclofenac potassium oral tablet

Tier 1

diflunisal oral tablet Tier 1

dihydroergotamine nasal spray,non-aerosol

Tier 2 QL

diskets oral tablet,soluble Tier 1

ELMIRON ORAL CAPSULE

Tier 3

EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL

Tier 3 PA; QL

endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Tier 2 QL

ERGOMAR SUBLINGUAL TABLET

Tier 3

fentanyl citrate buccal lozenge on a handle

Tier 1 PA; QL

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

Tier 2 ST; QL

frovatriptan oral tablet Tier 2 QL

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

Tier 1 QL

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

Tier 1 QL

hydrocodone-ibuprofen oral tablet 10-200 mg, 7.5-200 mg

Tier 1

hydrocodone-ibuprofen oral tablet 5-200 mg

Tier 1 QL

hydromorphone oral liquid Tier 1 QL

hydromorphone oral tablet 2 mg, 4 mg, 8 mg

Tier 1 QL

hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 32 mg, 8 mg

Tier 2 QL

hydromorphone rectal suppository

Tier 2

6

Drug Status Notes

HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

Tier 3 PA; QL

ibuprofen-oxycodone oral tablet

Tier 1 QL

isometh-dichloral-acetaminophn oral capsule

Tier 1

ketorolac injection cartridge 15 mg/ml, 30 mg/ml

Tier 1 QL

ketorolac injection solution 15 mg/ml, 30 mg/ml, 30 mg/ml (1 ml)

Tier 1 QL

ketorolac injection syringe Tier 1

ketorolac intramuscular solution

Tier 1 QL

ketorolac intramuscular syringe

Tier 1

ketorolac oral tablet Tier 1 QL

levorphanol tartrate oral tablet

Tier 2

margesic oral capsule Tier 1

marten-tab oral tablet Tier 1

mefenamic acid oral capsule

Tier 1

meperidine oral solution Tier 1 QL

meperidine oral tablet 100 mg, 50 mg

Tier 1 QL

methadone intensol oral concentrate

Tier 1 QL

methadone oral concentrate

Tier 1 QL

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

Tier 1 QL

methadone oral tablet 10 mg, 5 mg

Tier 1 QL

methadone oral tablet,soluble

Tier 1 QL

methadose oral concentrate

Tier 1 QL

methadose oral tablet,soluble

Tier 1

migergot rectal suppository

Tier 1

morphine concentrate oral solution

Tier 1 QL

Drug Status Notes

morphine oral capsule,extend.release pellets

Tier 2 QL

morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml)

Tier 1 QL

morphine oral tablet 15 mg, 30 mg

Tier 1 QL

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

Tier 2 QL

morphine rectal suppository

Tier 1

nalbuphine injection solution

Tier 1

naratriptan oral tablet Tier 1 QL

nodolor oral capsule Tier 1

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3 ST; QL

NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG

Tier 3 QL

oxycodone oral capsule Tier 1 QL

oxycodone oral concentrate

Tier 1 QL

oxycodone oral solution Tier 1 QL

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

Tier 1 QL

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Tier 1 QL

oxycodone-aspirin oral tablet

Tier 1 QL

oxymorphone oral tablet 10 mg, 5 mg

Tier 1 QL

oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg

Tier 1 QL

pentazocine-naloxone oral tablet

Tier 1

RELPAX ORAL TABLET Tier 3 ST; QL

rizatriptan oral tablet Tier 1 QL

rizatriptan oral tablet,disintegrating

Tier 1 QL

7

Drug Status Notes

sumatriptan nasal spray,non-aerosol

Tier 1 QL

sumatriptan succinate oral tablet

Tier 1 QL

sumatriptan succinate subcutaneous cartridge

Tier 1 QL

sumatriptan succinate subcutaneous pen injector

Tier 1 QL

sumatriptan succinate subcutaneous solution

Tier 1 QL

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml

Tier 1 QL

TALWIN INJECTION SOLUTION

Tier 3

tencon oral tablet 50-325 mg

Tier 1

tramadol oral tablet Tier 1 QL

tramadol oral tablet extended release 24 hr

Tier 1 QL

tramadol oral tablet, er multiphase 24 hr

Tier 1 QL

vicodin es oral tablet Tier 2 QL

vicodin hp oral tablet Tier 2 QL

vicodin oral tablet Tier 2 QL

XARTEMIS XR ORAL TAB,ORAL ONLY,IR - ER, BIPHASE

Tier 3 ST

zamicet oral solution Tier 1 QL

zebutal oral capsule 50-325-40 mg

Tier 1

ZIPSOR ORAL CAPSULE Tier 3

zolmitriptan oral tablet Tier 1 QL

zolmitriptan oral tablet,disintegrating

Tier 1 QL

ANESTHETICS

lidocaine hcl mucous membrane solution 2 %

Tier 1

lidocaine viscous mucous membrane solution

Tier 1

lidocaine-prilocaine topical cream

Tier 1

lidocaine-prilocaine topical kit

Tier 1

lta pre-attached laryngotracheal solution

Tier 1

phenazopyridine oral tablet 100 mg, 200 mg

Tier 1

Drug Status Notes

SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING

Tier 3

ANTIARTHRITICS

allopurinol oral tablet Tier 1

CALDOLOR INTRAVENOUS RECON SOLN

Tier 3

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

Tier 2 ST; QL

colchicine-probenecid oral tablet

Tier 1

COLCRYS ORAL TABLET

Tier 3 PA; QL

CUPRIMINE ORAL CAPSULE

Tier 3

diclofenac sodium oral tablet extended release 24 hr

Tier 1

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

Tier 1

ENBREL SUBCUTANEOUS RECON SOLN

Tier 4 PA; QL

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

Tier 4 PA; QL

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; QL

etodolac oral capsule Tier 1

etodolac oral tablet Tier 1

etodolac oral tablet extended release 24 hr

Tier 1

fenoprofen oral tablet Tier 1

flurbiprofen oral tablet Tier 1

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT

Tier 4 PA; QL

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

Tier 4 PA; QL

8

Drug Status Notes

HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT

Tier 4 PA; QL

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT

Tier 4 PA; QL

HUMIRA SUBCUTANEOUS SYRINGE KIT

Tier 4 PA; QL

ibuprofen oral suspension Tier 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

Tier 1

indomethacin oral capsule Tier 1

indomethacin oral capsule, extended release

Tier 1

ketoprofen oral capsule Tier 1

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

Tier 1

KINERET SUBCUTANEOUS SYRINGE

Tier 5 PA

meclofenamate oral capsule

Tier 1

meloxicam oral suspension

Tier 1 QL

meloxicam oral tablet Tier 1 QL

nabumetone oral tablet Tier 1

naproxen oral suspension Tier 1

naproxen oral tablet Tier 1

naproxen oral tablet,delayed release (dr/ec)

Tier 1

naproxen sodium oral tablet 275 mg, 550 mg

Tier 1

ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN

Tier 5 PA; QL

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR

Tier 5 PA; QL

ORENCIA SUBCUTANEOUS SYRINGE

Tier 5 PA; QL

OTEZLA ORAL TABLET Tier 5 PA; QL

OTEZLA STARTER ORAL TABLETS,DOSE PACK

Tier 5 PA; QL

Drug Status Notes

oxaprozin oral tablet Tier 1

piroxicam oral capsule Tier 1

probenecid oral tablet Tier 1

RIDAURA ORAL CAPSULE

Tier 3

SIMPONI ARIA INTRAVENOUS SOLUTION

Tier 4 PA

SIMPONI SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; QL

SIMPONI SUBCUTANEOUS SYRINGE

Tier 4 PA; QL

sulindac oral tablet Tier 1

tolmetin oral capsule Tier 1

tolmetin oral tablet Tier 1

ULORIC ORAL TABLET Tier 3 ST

XELJANZ ORAL TABLET Tier 5 PA; QL

ANTIASTHMATICS

acetylcysteine solution Tier 2

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE

Tier 2 QL

ADVAIR HFA INHALATION HFA AEROSOL INHALER

Tier 2 QL

albuterol sulfate inhalation solution for nebulization

Tier 1

albuterol sulfate oral syrup Tier 1

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 3 QL

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 3 QL

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2 QL

BREO ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 3 QL

BROVANA INHALATION SOLUTION FOR NEBULIZATION

Tier 3 QL

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

Tier 1 QL

9

Drug Status Notes

cromolyn inhalation solution for nebulization

Tier 2

DALIRESP ORAL TABLET

Tier 3 QL

DULERA INHALATION HFA AEROSOL INHALER

Tier 2 QL

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

Tier 2 QL

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

Tier 2 QL

ipratropium bromide inhalation solution

Tier 1 QL

ipratropium-albuterol inhalation solution for nebulization

Tier 2

levalbuterol hcl inhalation solution for nebulization

Tier 1

metaproterenol oral syrup Tier 1

metaproterenol oral tablet Tier 1

montelukast oral granules in packet

Tier 1 QL

montelukast oral tablet Tier 1 QL

montelukast oral tablet,chewable

Tier 1 QL

PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION

Tier 3 QL

PROAIR HFA INHALATION HFA AEROSOL INHALER

Tier 2 QL

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2 QL

PROVENTIL HFA INHALATION HFA AEROSOL INHALER

Tier 3 QL

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2 QL

Drug Status Notes

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

Tier 2 QL

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

Tier 2 QL

SPIRIVA RESPIMAT INHALATION MIST

Tier 3 QL

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 3 QL

STRIVERDI RESPIMAT INHALATION MIST

Tier 3 QL

SYMBICORT INHALATION HFA AEROSOL INHALER

Tier 2 QL

terbutaline oral tablet Tier 2

theochron oral tablet extended release 12 hr

Tier 1

theophylline oral elixir Tier 1

theophylline oral solution Tier 1

theophylline oral tablet extended release 12 hr

Tier 1

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 3 QL

VENTOLIN HFA INHALATION HFA AEROSOL INHALER

Tier 3 QL

XOPENEX HFA INHALATION HFA AEROSOL INHALER

Tier 3 QL

zafirlukast oral tablet Tier 1

ZYFLO CR ORAL TABLET, ER MULTIPHASE 12 HR

Tier 3 PA

ZYFLO ORAL TABLET Tier 3 PA

ANTIBIOTICS

amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml

Tier 2

amoxicillin oral capsule Tier 1

amoxicillin oral suspension for reconstitution

Tier 1

amoxicillin oral tablet Tier 1

10

Drug Status Notes

amoxicillin oral tablet,chewable 125 mg, 250 mg

Tier 1

amoxicillin-pot clavulanate oral suspension for reconstitution

Tier 1

amoxicillin-pot clavulanate oral tablet

Tier 1

amoxicillin-pot clavulanate oral tablet extended release 12 hr

Tier 1

amoxicillin-pot clavulanate oral tablet,chewable

Tier 1

ampicillin oral capsule Tier 1

ampicillin oral suspension for reconstitution

Tier 1

ampicillin sodium injection recon soln

Tier 1

ampicillin sodium intravenous recon soln

Tier 1

ampicillin-sulbactam injection recon soln

Tier 2

ampicillin-sulbactam intravenous recon soln

Tier 2

avar topical cleanser Tier 1

avidoxy oral tablet Tier 1

AZASITE OPHTHALMIC DROPS

Tier 3

azithromycin oral packet Tier 1 QL

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

Tier 1 QL

azithromycin oral tablet 250 mg, 500 mg, 600 mg

Tier 1 QL

aztreonam injection recon soln

Tier 2

bacitracin ophthalmic ointment

Tier 1

bacitracin-polymyxin b ophthalmic ointment

Tier 1

BESIVANCE OPHTHALMIC DROPS,SUSPENSION

Tier 3

bp 10-1 topical cleanser Tier 1

CAPASTAT INJECTION RECON SOLN

Tier 3

CAYSTON INHALATION SOLUTION FOR NEBULIZATION

Tier 5

Drug Status Notes

cefaclor oral capsule Tier 1

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

Tier 1

cefaclor oral tablet extended release 12 hr

Tier 2

cefadroxil oral capsule Tier 1

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

Tier 1

cefadroxil oral tablet Tier 1

cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml

Tier 1

cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml

Tier 2

cefazolin injection recon soln 1 gram, 10 gram, 20 gram, 500 mg

Tier 1

cefazolin injection recon soln 100 gram, 300 g

Tier 2

cefazolin intravenous recon soln

Tier 1

cefdinir oral capsule Tier 1

cefdinir oral suspension for reconstitution

Tier 1

cefditoren pivoxil oral tablet

Tier 2

CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK

Tier 2

cefepime in dextrose,iso-osm intravenous piggyback

Tier 2

cefepime injection recon soln

Tier 2

cefotaxime injection recon soln

Tier 2

CEFOTETAN IN DEXTROSE, ISO-OSM INTRAVENOUS PIGGYBACK

Tier 2

cefotetan injection recon soln

Tier 2

cefotetan intravenous recon soln

Tier 2

11

Drug Status Notes

cefoxitin in dextrose, iso-osm intravenous piggyback

Tier 1

cefoxitin intravenous recon soln

Tier 1

cefpodoxime oral suspension for reconstitution

Tier 2

cefpodoxime oral tablet Tier 2

cefprozil oral suspension for reconstitution

Tier 1

cefprozil oral tablet Tier 1

ceftazidime injection recon soln

Tier 2

ceftibuten oral capsule Tier 1

ceftibuten oral suspension for reconstitution

Tier 1

ceftriaxone in dextrose,iso-os intravenous piggyback

Tier 2

ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg

Tier 2

ceftriaxone intravenous recon soln

Tier 2

cefuroxime axetil oral tablet

Tier 1

cephalexin oral capsule Tier 1

cephalexin oral suspension for reconstitution

Tier 1

cephalexin oral tablet Tier 1

chloramphenicol sod succinate intravenous recon soln

Tier 2

CIPRO HC OTIC DROPS,SUSPENSION

Tier 3

CIPRODEX OTIC DROPS,SUSPENSION

Tier 3 PA

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

Tier 1 QL

ciprofloxacin hcl ophthalmic drops

Tier 1

ciprofloxacin hcl oral tablet Tier 1 QL

ciprofloxacin hcl otic dropperette

Tier 1

ciprofloxacin in 5 % dextrose intravenous piggyback

Tier 1

Drug Status Notes

ciprofloxacin lactate intravenous solution

Tier 2

clarithromycin oral suspension for reconstitution

Tier 1

clarithromycin oral tablet Tier 1

clarithromycin oral tablet extended release 24 hr

Tier 1

cleansing wash topical cleanser

Tier 1

CLINDACIN ETZ TOPICAL KIT

Tier 3

clindacin etz topical swab Tier 1

clindacin p topical swab Tier 1

CLINDACIN PAC TOPICAL KIT

Tier 3

clindamycin hcl oral capsule

Tier 1

clindamycin palmitate hcl oral recon soln

Tier 1

clindamycin pediatric oral recon soln

Tier 1

clindamycin phosphate topical foam

Tier 1

clindamycin phosphate topical gel

Tier 1

clindamycin phosphate topical lotion

Tier 1

clindamycin phosphate topical solution

Tier 1

clindamycin phosphate topical swab

Tier 1

clindamycin phosphate vaginal cream

Tier 1

COLY-MYCIN S OTIC DROPS,SUSPENSION

Tier 3

CORTISPORIN TOPICAL CREAM

Tier 3

CORTISPORIN TOPICAL OINTMENT

Tier 3

CUBICIN INTRAVENOUS RECON SOLN

Tier 3

CYCLOSERINE ORAL CAPSULE

Tier 3

DAPSONE ORAL TABLET

Tier 2

demeclocycline oral tablet Tier 2

dicloxacillin oral capsule Tier 1

DIFICID ORAL TABLET Tier 3 PA

12

Drug Status Notes

DORIBAX INTRAVENOUS RECON SOLN

Tier 3

doxycycline hyclate oral capsule

Tier 1

doxycycline hyclate oral tablet 100 mg

Tier 1

doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg

Tier 1 PA

doxycycline monohydrate oral capsule

Tier 1

doxycycline monohydrate oral suspension for reconstitution

Tier 1

doxycycline monohydrate oral tablet

Tier 1

e.e.s. 400 oral tablet Tier 1

ery pads topical swab Tier 1

erygel topical gel Tier 1

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

Tier 1

erythrocin (as stearate) oral tablet 250 mg

Tier 1

erythromycin ethylsuccinate oral tablet

Tier 2

erythromycin ophthalmic ointment

Tier 1

erythromycin oral capsule,delayed release(dr/ec)

Tier 2

erythromycin oral tablet Tier 2

erythromycin with ethanol topical gel

Tier 1

erythromycin with ethanol topical solution

Tier 1

erythromycin with ethanol topical swab

Tier 1

erythromycin-benzoyl peroxide topical gel

Tier 1

ethambutol oral tablet Tier 1

FACTIVE ORAL TABLET Tier 3 QL

gatifloxacin ophthalmic drops

Tier 1

gentak ophthalmic ointment

Tier 1

Drug Status Notes

gentamicin ophthalmic drops

Tier 1

gentamicin ophthalmic ointment

Tier 1

gentamicin topical cream Tier 1

gentamicin topical ointment

Tier 1

imipenem-cilastatin intravenous recon soln

Tier 2

INVANZ INJECTION RECON SOLN

Tier 3

INVANZ INTRAVENOUS RECON SOLN

Tier 3

isoniazid oral solution Tier 1

isoniazid oral tablet Tier 1

KETEK ORAL TABLET Tier 3

levofloxacin ophthalmic drops

Tier 1

levofloxacin oral tablet Tier 2 QL

LINCOCIN INJECTION SOLUTION

Tier 3

lincomycin injection solution

Tier 2

linezolid oral tablet Tier 2 PA; QL

meropenem intravenous recon soln

Tier 2

methenamine hippurate oral tablet

Tier 1

methenamine mandelate oral tablet

Tier 1

metronidazole oral capsule

Tier 1

metronidazole oral tablet Tier 1

metronidazole vaginal gel Tier 1

minocycline oral capsule Tier 1

minocycline oral tablet Tier 1

minocycline oral tablet extended release 24 hr

Tier 1 PA

MONUROL ORAL PACKET

Tier 3

MORGIDOX 1X 50 KIT Tier 3

MORGIDOX 1X100 KIT Tier 3

MORGIDOX 2X100 KIT Tier 3

morgidox oral capsule 100 mg

Tier 1

13

Drug Status Notes

MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR

Tier 3

mupirocin topical ointment Tier 1

nafcillin in dextrose iso-osm intravenous piggyback

Tier 2

nafcillin injection recon soln

Tier 2

nafcillin intravenous recon soln

Tier 2

neomycin oral tablet Tier 1

neomycin-bacitracin-poly-hc ophthalmic ointment

Tier 1

neomycin-bacitracin-polymyxin ophthalmic ointment

Tier 1

neomycin-polymyxin b-dexameth ophthalmic drops,suspension

Tier 1

neomycin-polymyxin b-dexameth ophthalmic ointment

Tier 1

neomycin-polymyxin-gramicidin ophthalmic drops

Tier 1

neomycin-polymyxin-hc ophthalmic drops,suspension

Tier 1

neomycin-polymyxin-hc otic drops,suspension

Tier 1

neomycin-polymyxin-hc otic solution

Tier 1

neo-polycin hc ophthalmic ointment

Tier 1

neo-polycin ophthalmic ointment

Tier 1

NEO-SYNALAR KIT TOPICAL CREAM

Tier 3

NEO-SYNALAR TOPICAL CREAM

Tier 3

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

Tier 1

nitrofurantoin monohyd/m-cryst oral capsule

Tier 1

nitrofurantoin oral suspension

Tier 1

ofloxacin ophthalmic drops Tier 1

ofloxacin oral tablet 400 mg

Tier 1 QL

Drug Status Notes

ofloxacin otic drops Tier 1

ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE

Tier 3

oxacillin injection recon soln

Tier 2

oxacillin intravenous recon soln

Tier 2

PASER ORAL GRANULES DR FOR SUSP IN PACKET

Tier 3

penicillin g potassium injection recon soln 20 million unit

Tier 1

penicillin g potassium injection recon soln 5 million unit

Tier 2

penicillin g sodium injection recon soln

Tier 1

penicillin v potassium oral recon soln

Tier 1

penicillin v potassium oral tablet

Tier 1

pfizerpen-g injection recon soln

Tier 1

piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram

Tier 1

polycin ophthalmic ointment

Tier 1

polymyxin b sulfate injection recon soln

Tier 1

polymyxin b sulf-trimethoprim ophthalmic drops

Tier 1

PRED-G OPHTHALMIC DROPS,SUSPENSION

Tier 3

PRED-G S.O.P. OPHTHALMIC OINTMENT

Tier 3

PRIFTIN ORAL TABLET Tier 3

PRIMSOL ORAL SOLUTION

Tier 3

pyrazinamide oral tablet Tier 1

rifabutin oral capsule Tier 2

rifampin oral capsule Tier 1

RIFATER ORAL TABLET Tier 3

silver sulfadiazine topical cream

Tier 1

14

Drug Status Notes

SIRTURO ORAL TABLET Tier 3

SIVEXTRO ORAL TABLET

Tier 3 PA

ssd topical cream Tier 1

sss 10-5 topical cream Tier 1

sss 10-5 topical foam Tier 1

STREPTOMYCIN INTRAMUSCULAR RECON SOLN

Tier 3

sulfacetamide sodium ophthalmic drops

Tier 1

sulfacetamide sodium ophthalmic ointment

Tier 1

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w), 9-4 %, 9-4.5 %

Tier 1

sulfacetamide sodium-sulfur topical cream

Tier 1

sulfacetamide sodium-sulfur topical foam

Tier 1

sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w)

Tier 1

sulfacetamide sodium-sulfur topical pads, medicated 10-4 %

Tier 1

sulfacetamide sodium-sulfur topical suspension

Tier 1

sulfacetamide sod-sulfur-urea topical cleanser

Tier 1

sulfacetamide-prednisolone ophthalmic drops

Tier 1

sulfacetamide-sulfur-cleansr23 topical kit

Tier 1

sulfacleanse 8-4 topical suspension

Tier 1

sulfadiazine oral tablet Tier 2

sulfamethoxazole-trimethoprim oral suspension

Tier 1

sulfamethoxazole-trimethoprim oral tablet

Tier 1

SULFAMYLON TOPICAL CREAM

Tier 3

sulfatrim oral suspension Tier 1

Drug Status Notes

SUPRAX ORAL CAPSULE

Tier 3

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

TEFLARO INTRAVENOUS RECON SOLN

Tier 3

tetracycline oral capsule Tier 1

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

Tier 4 PA

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

Tier 4 PA; QL

thermazene topical cream Tier 1

TOBRADEX OPHTHALMIC OINTMENT

Tier 3

tobramycin in 0.225 % nacl inhalation solution for nebulization

Tier 4

tobramycin ophthalmic drops

Tier 1

tobramycin-dexamethasone ophthalmic drops,suspension

Tier 1

TRECATOR ORAL TABLET

Tier 3

trimethoprim oral tablet Tier 1

TYGACIL INTRAVENOUS RECON SOLN

Tier 3

vancomycin oral capsule Tier 2 PA

vandazole vaginal gel Tier 1

VIBATIV INTRAVENOUS RECON SOLN

Tier 3

VIGAMOX OPHTHALMIC DROPS

Tier 3

XIFAXAN ORAL TABLET200 MG, 550 MG

Tier 3 PA; QL

zencia topical cleanser Tier 1

ANTICOAGULANTS

ELIQUIS ORAL TABLET2.5 MG, 5 MG

Tier 3 PA; QL

enoxaparin subcutaneous solution

Tier 4

enoxaparin subcutaneous syringe

Tier 4

15

Drug Status Notes

fondaparinux subcutaneous syringe

Tier 4 PA

FRAGMIN SUBCUTANEOUS SOLUTION

Tier 4

FRAGMIN SUBCUTANEOUS SYRINGE

Tier 4

hep flush-10 (pf) intravenous solution

Tier 2

heparin (porcine) in 0.9% nacl intravenous parenteral solution 25,000 unit/250 ml, 250 unit/250 ml (1 unit/ml), 4000 unit/1000 ml (4 unit/ml), 5,000 unit/1,000 ml, 5,000 unit/500 ml (10 unit/ml), 6,000 unit/1000 ml (6 unit/ml)

Tier 1

heparin (porcine) in 0.9% nacl intravenous syringe

Tier 1

heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml

Tier 2

heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

Tier 1

heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml

Tier 1

heparin (porcine) injection cartridge

Tier 1

heparin (porcine) injection solution

Tier 1

heparin flush intravenous kit

Tier 1

heparin flush(porcine)-0.9nacl intravenous kit

Tier 1

heparin lock flush (porcine) intravenous solution

Tier 1

heparin lock flush (porcine) intravenous syringe

Tier 1

Drug Status Notes

heparin lock flush intravenous solution

Tier 1

heparin lock flush intravenous syringe

Tier 1

heparin lock intravenous solution

Tier 1

heparin lockflush(porcine)(pf) intravenous syringe

Tier 1

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml, 5,000 unit/1,000 ml

Tier 1

heparin, porcine (pf) injection solution

Tier 1

heparin, porcine (pf) injection syringe

Tier 1

heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml)

Tier 1

heparin, porcine (pf) intravenous syringe

Tier 1

jantoven oral tablet Tier 1

monoject prefill (pf) intravenous syringe

Tier 2

PRADAXA ORAL CAPSULE

Tier 3 QL

warfarin oral tablet Tier 1

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG

Tier 3 PA; QL

XARELTO ORAL TABLETS,DOSE PACK

Tier 3 PA

ANTIDOTES

naloxone injection solution Tier 1

naloxone injection syringe Tier 1

naltrexone oral tablet Tier 1

RELISTOR SUBCUTANEOUS SOLUTION

Tier 3 PA

RELISTOR SUBCUTANEOUS SYRINGE

Tier 3 PA

ANTIFUNGALS

amphotericin b injection recon soln

Tier 2

CICLODAN KIT TOPICAL COMBO PACK

Tier 3

16

Drug Status Notes

CICLODAN KIT TOPICAL SOLUTION

Tier 3

ciclodan topical cream Tier 1

ciclodan topical solution Tier 1

ciclopirox topical cream Tier 1

ciclopirox topical gel Tier 1

ciclopirox topical shampoo Tier 1

ciclopirox topical solution Tier 1

ciclopirox topical suspension

Tier 1

clotrimazole mucous membrane troche

Tier 2

clotrimazole topical cream Tier 1

clotrimazole topical solution

Tier 1

clotrimazole-betamethasone topical cream

Tier 1

clotrimazole-betamethasone topical lotion

Tier 1

econazole topical cream Tier 1

ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN

Tier 3

ERTACZO TOPICAL CREAM

Tier 3

EXELDERM TOPICAL CREAM

Tier 3

EXELDERM TOPICAL SOLUTION

Tier 3

fluconazole oral suspension for reconstitution

Tier 1

fluconazole oral tablet Tier 1

flucytosine oral capsule Tier 1

griseofulvin microsize oral suspension

Tier 1

griseofulvin microsize oral tablet

Tier 1

griseofulvin ultramicrosize oral tablet

Tier 1

GYNAZOLE-1 VAGINAL CREAM

Tier 3

itraconazole oral capsule Tier 2 PA

JUBLIA TOPICAL SOLUTION WITH APPLICATOR

Tier 3

Drug Status Notes

KERYDIN TOPICAL SOLUTION WITH APPLICATOR

Tier 3

ketoconazole oral tablet Tier 1

ketoconazole topical cream

Tier 1

ketoconazole topical foam Tier 1

ketoconazole topical shampoo

Tier 1

LUZU TOPICAL CREAM Tier 3

MENTAX TOPICAL CREAM

Tier 3

miconazole-3 vaginal suppository

Tier 1

MYCAMINE INTRAVENOUS RECON SOLN

Tier 3

naftifine topical cream 2 % Tier 2

NAFTIN TOPICAL GEL Tier 3

NATACYN OPHTHALMIC DROPS,SUSPENSION

Tier 3

NOXAFIL ORAL SUSPENSION

Tier 3

nyamyc topical powder Tier 1

nystatin oral powder Tier 1

nystatin oral suspension Tier 1

nystatin oral tablet Tier 1

nystatin topical cream Tier 1

nystatin topical ointment Tier 1

nystatin topical powder Tier 1

nystatin-triamcinolone topical cream

Tier 1

nystatin-triamcinolone topical ointment

Tier 1

nystop topical powder Tier 1

ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET

Tier 3

oxiconazole topical cream Tier 2

OXISTAT TOPICAL LOTION

Tier 3

terbinafine hcl oral tablet Tier 1 PA

terconazole vaginal cream Tier 1

terconazole vaginal suppository

Tier 1

17

Drug Status Notes

voriconazole oral suspension for reconstitution

Tier 2

voriconazole oral tablet Tier 2

ANTIHISTAMINE AND DECONGESTANT COMBINATION

promethazine vc oral syrup

Tier 1

ANTIHISTAMINES

arbinoxa oral liquid Tier 1

arbinoxa oral tablet Tier 1

azelastine ophthalmic drops

Tier 1 QL

BEPREVE OPHTHALMIC DROPS

Tier 3 PA; QL

carbinoxamine maleate oral liquid

Tier 1

carbinoxamine maleate oral tablet

Tier 1

cetirizine oral solution 1 mg/ml

Tier 1 QL

clemastine oral tablet 2.68 mg

Tier 1

cyproheptadine oral tablet Tier 1

desloratadine oral tablet Tier 1 QL

desloratadine oral tablet,disintegrating

Tier 1 QL

diphenhydramine hcl injection solution 50 mg/ml

Tier 1

diphenhydramine hcl injection syringe

Tier 1

diphenhydramine hcl oral capsule 50 mg

Tier 1

EMADINE OPHTHALMIC DROPS

Tier 3 ST; QL

epinastine ophthalmic drops

Tier 1 QL

fexofenadine oral tablet 180 mg

Tier 1 QL

hydroxyzine hcl oral tablet Tier 1

hydroxyzine pamoate oral capsule

Tier 1

LASTACAFT OPHTHALMIC DROPS

Tier 3 PA; QL

levocetirizine oral solution Tier 1 QL

levocetirizine oral tablet Tier 1 QL

Drug Status Notes

olopatadine ophthalmic drops

Tier 2 PA; QL

promethazine oral syrup Tier 1

promethazine oral tablet Tier 1

ANTIHYPERGLYCEMICS

acarbose oral tablet Tier 1

APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN

Tier 3 ST

APIDRA SUBCUTANEOUS SOLUTION

Tier 3 ST

AVANDIA ORAL TABLET2 MG, 4 MG

Tier 3 ST; QL

BYDUREON SUBCUTANEOUS PEN INJECTOR

Tier 3 ST; QL

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON

Tier 3 ST; QL

chlorpropamide oral tablet Tier 1

CYCLOSET ORAL TABLET

Tier 3

FARXIGA ORAL TABLET Tier 3 ST; QL

glimepiride oral tablet Tier 1

glipizide oral tablet Tier 1

glipizide oral tablet extended release 24hr

Tier 1

glipizide-metformin oral tablet

Tier 1

glyburide micronized oral tablet

Tier 1

glyburide oral tablet Tier 1

glyburide-metformin oral tablet

Tier 1

HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION

Tier 2

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

18

Drug Status Notes

HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION

Tier 2

HUMALOG SUBCUTANEOUS CARTRIDGE

Tier 2

HUMALOG SUBCUTANEOUS SOLUTION

Tier 2

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION

Tier 2

HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMULIN N SUBCUTANEOUS SUSPENSION

Tier 2

HUMULIN R INJECTION SOLUTION

Tier 2

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

Tier 2

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION

Tier 2

INVOKAMET ORAL TABLET

Tier 3 ST; QL

INVOKANA ORAL TABLET

Tier 3 ST; QL

JANUMET ORAL TABLET

Tier 2 QL

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR100-1,000 MG, 50-1,000 MG, 50-500 MG

Tier 2 QL

JANUVIA ORAL TABLET Tier 2 QL

JARDIANCE ORAL TABLET

Tier 2 QL

JENTADUETO ORAL TABLET

Tier 2 ST; QL

LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN

Tier 2

Drug Status Notes

LANTUS SUBCUTANEOUS SOLUTION

Tier 2

LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN

Tier 2

LEVEMIR SUBCUTANEOUS SOLUTION

Tier 2

metformin oral tablet Tier 1

metformin oral tablet extended release 24 hr

Tier 1

metformin oral tablet extended release 24hr

Tier 1

miglitol oral tablet Tier 2

nateglinide oral tablet Tier 2 PA

NESINA ORAL TABLET Tier 3 ST; QL

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN N SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN R INJECTION SOLUTION

Tier 2

NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION

Tier 2

NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE

Tier 2

NOVOLOG SUBCUTANEOUS SOLUTION

Tier 2

ONGLYZA ORAL TABLET 2.5 MG

Tier 3 ST; DO

ONGLYZA ORAL TABLET 5 MG

Tier 3 ST; QL

pioglitazone oral tablet Tier 1 QL

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR

Tier 3 PA

19

Drug Status Notes

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR

Tier 3 PA

SYNJARDY ORAL TABLET 12.5-1,000 MG, 5-1,000 MG

Tier 2 ST; QL

SYNJARDY ORAL TABLET 12.5-500 MG, 5-500 MG

Tier 2 ST

TANZEUM SUBCUTANEOUS PEN INJECTOR

Tier 3 ST

tolazamide oral tablet Tier 1

tolbutamide oral tablet Tier 1

TRADJENTA ORAL TABLET

Tier 2 DO

TRULICITY SUBCUTANEOUS PEN INJECTOR

Tier 3 ST; QL

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR

Tier 3 ST; QL

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR

Tier 3 ST; QL

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR

Tier 3 ST

ANTIINFECTIVES/MISCELLANEOUS

ALBENZA ORAL TABLET

Tier 3

ALINIA ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ALINIA ORAL TABLET Tier 3

atovaquone oral suspension

Tier 2

atovaquone-proguanil oral tablet

Tier 1

BILTRICIDE ORAL TABLET

Tier 3

chloroquine phosphate oral tablet

Tier 1

COARTEM ORAL TABLET

Tier 3

DARAPRIM ORAL TABLET

Tier 3 PA

hydroxychloroquine oral tablet

Tier 1

Drug Status Notes

ivermectin oral tablet Tier 1

mefloquine oral tablet Tier 1

NEBUPENT INHALATION RECON SOLN

Tier 4

paromomycin oral capsule Tier 1

PRIMAQUINE ORAL TABLET

Tier 3

quinine sulfate oral capsule

Tier 1 PA; QL

ANTIINFECTIVES

ARESTIN DENTAL CARTRIDGE

Tier 3

ANTINEOPLASTICS

ACTIMMUNE SUBCUTANEOUS SOLUTION

Tier 5 PA; QL

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

Tier 4 PA; QL

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

Tier 4 PA; QL

ALKERAN ORAL TABLET

Tier 4

anastrozole oral tablet Tier 4 PA; QL

bexarotene oral capsule Tier 4 PA; QL

bicalutamide oral tablet Tier 4

BOSULIF ORAL TABLET100 MG, 500 MG

Tier 4 PA; QL

capecitabine oral tablet 150 mg, 500 mg

Tier 4 PA; QL

CAPRELSA ORAL TABLET 100 MG, 300 MG

Tier 4 PA; QL

CARAC TOPICAL CREAM

Tier 2

COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)

Tier 4 PA; QL

CYCLOPHOSPHAMIDE ORAL CAPSULE

Tier 4

diclofenac sodium topical gel 3 %

Tier 1 QL

EMCYT ORAL CAPSULE Tier 4 PA

20

Drug Status Notes

ERIVEDGE ORAL CAPSULE

Tier 4 PA; QL

ETOPOPHOS INTRAVENOUS RECON SOLN

Tier 4

etoposide oral capsule Tier 4

exemestane oral tablet Tier 4 PA; QL

FARESTON ORAL TABLET

Tier 4 QL

FARYDAK ORAL CAPSULE

Tier 4 PA; QL

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN

Tier 4 PA

fludarabine intravenous recon soln

Tier 4

fludarabine intravenous solution

Tier 4

fluorouracil topical cream 5 %

Tier 1

fluorouracil topical solution Tier 1

flutamide oral capsule Tier 1

GILOTRIF ORAL TABLET

Tier 4 PA; QL

HEXALEN ORAL CAPSULE

Tier 4

HYCAMTIN ORAL CAPSULE

Tier 4

hydroxyurea oral capsule Tier 1

IBRANCE ORAL CAPSULE

Tier 4 PA; QL

ICLUSIG ORAL TABLET15 MG, 45 MG

Tier 4 PA; QL

imatinib oral tablet 100 mg, 400 mg

Tier 4 PA; QL

IMBRUVICA ORAL CAPSULE

Tier 4 PA; QL

INLYTA ORAL TABLET 1 MG, 5 MG

Tier 4 PA; QL

INTRON A INJECTION RECON SOLN

Tier 5 PA

INTRON A INJECTION SOLUTION

Tier 5 PA

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

Tier 4 PA; QL

Drug Status Notes

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1)

Tier 4 PA; QL

LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2), 8 MG/DAY (4 MG X 2)

Tier 4 PA

letrozole oral tablet Tier 4 QL

LEUKERAN ORAL TABLET

Tier 4

leuprolide subcutaneous kit

Tier 4 PA

LYNPARZA ORAL CAPSULE

Tier 4 PA; QL

LYSODREN ORAL TABLET

Tier 4 QL

MATULANE ORAL CAPSULE

Tier 4

MEKINIST ORAL TABLET 0.5 MG, 2 MG

Tier 4 PA; QL

melphalan hcl intravenous recon soln

Tier 4

mercaptopurine oral tablet Tier 4

methotrexate sodium oral tablet

Tier 1

MYLERAN ORAL TABLET

Tier 4

NEXAVAR ORAL TABLET

Tier 4 PA; QL

NILANDRON ORAL TABLET

Tier 4 QL

nilutamide oral tablet Tier 4 QL

ODOMZO ORAL CAPSULE

Tier 4 PA; QL

PANRETIN TOPICAL GEL

Tier 3

PICATO TOPICAL GEL Tier 3 PA; QL

POMALYST ORAL CAPSULE 1 MG

Tier 4 QL

POMALYST ORAL CAPSULE 2 MG, 3 MG, 4 MG

Tier 4 PA; QL

REVLIMID ORAL CAPSULE

Tier 4 PA; QL

21

Drug Status Notes

RITUXAN INTRAVENOUS CONCENTRATE

Tier 4 PA

SPRYCEL ORAL TABLET

Tier 4 PA; QL

STIVARGA ORAL TABLET

Tier 4 PA; QL

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

Tier 4 PA; QL

SYNRIBO SUBCUTANEOUS RECON SOLN

Tier 4

TABLOID ORAL TABLET Tier 4

TAFINLAR ORAL CAPSULE

Tier 4 QL

tamoxifen oral tablet Tier 1 $0

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG

Tier 4 PA; QL

TARGRETIN TOPICAL GEL

Tier 4 PA

TASIGNA ORAL CAPSULE

Tier 4 PA; QL

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

Tier 4 PA; QL

topotecan intravenous recon soln

Tier 4

topotecan intravenous solution

Tier 4

TORISEL INTRAVENOUS RECON SOLN

Tier 4

TRELSTAR DEPOT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 4 PA; QL

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 4 PA; QL

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

Tier 4 PA; QL

TRELSTAR LA INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 4 PA; QL

Drug Status Notes

tretinoin (chemotherapy) oral capsule

Tier 4

TYKERB ORAL TABLET Tier 4 PA; QL

VOTRIENT ORAL TABLET

Tier 4 PA; QL

XALKORI ORAL CAPSULE

Tier 4 PA

XTANDI ORAL CAPSULE Tier 4 PA; QL

YERVOY INTRAVENOUS SOLUTION

Tier 4 PA

ZANOSAR INTRAVENOUS RECON SOLN

Tier 4

ZELBORAF ORAL TABLET

Tier 4 PA; QL

ZOLINZA ORAL CAPSULE

Tier 4 PA; QL

ZYDELIG ORAL TABLET Tier 4 PA; QL

ZYKADIA ORAL CAPSULE

Tier 4 PA

ZYTIGA ORAL TABLET250 MG

Tier 4 PA

ZYTIGA ORAL TABLET250 MG

Tier 4 PA; QL

ANTI-OBESITY DRUGS

CONTRAVE ORAL TABLET EXTENDED RELEASE

Tier 3 PA

ANTIPARKINSON DRUGS

amantadine hcl oral capsule

Tier 2

amantadine hcl oral solution

Tier 2

amantadine hcl oral tablet Tier 2

APOKYN SUBCUTANEOUS CARTRIDGE

Tier 5

AZILECT ORAL TABLET Tier 3

benztropine oral tablet Tier 1

bromocriptine oral capsule Tier 1

bromocriptine oral tablet Tier 1

carbidopa oral tablet Tier 2

carbidopa-levodopa oral tablet

Tier 1

carbidopa-levodopa oral tablet extended release

Tier 1

22

Drug Status Notes

carbidopa-levodopa oral tablet,disintegrating

Tier 1

entacapone oral tablet Tier 2

pramipexole oral tablet Tier 2

ropinirole oral tablet Tier 1

ropinirole oral tablet extended release 24 hr

Tier 2

selegiline hcl oral capsule Tier 1

selegiline hcl oral tablet Tier 1

tolcapone oral tablet Tier 2

trihexyphenidyl oral elixir Tier 1

trihexyphenidyl oral tablet Tier 1

ANTIPLATELET DRUGS

anagrelide oral capsule Tier 2

aspirin-dipyridamole oral capsule, er multiphase 12 hr

Tier 2 QL

BRILINTA ORAL TABLET

Tier 3 QL

cilostazol oral tablet Tier 1

clopidogrel oral tablet 300 mg

Tier 2

clopidogrel oral tablet 75 mg

Tier 2 QL

dipyridamole oral tablet Tier 1

EFFIENT ORAL TABLET10 MG

Tier 3 QL

EFFIENT ORAL TABLET5 MG

Tier 3 DO

ticlopidine oral tablet Tier 1

ZONTIVITY ORAL TABLET

Tier 3 QL

ANTIVIRALS

abacavir oral tablet Tier 4

abacavir-lamivudine-zidovudine oral tablet

Tier 4

acyclovir oral capsule Tier 1

acyclovir oral suspension 200 mg/5 ml

Tier 1

acyclovir oral tablet Tier 1

acyclovir topical ointment Tier 3

adefovir oral tablet Tier 4

APTIVUS ORAL CAPSULE

Tier 4

APTIVUS ORAL SOLUTION

Tier 4

Drug Status Notes

BARACLUDE ORAL SOLUTION

Tier 5 PA

cidofovir intravenous solution

Tier 2

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

Tier 4

DENAVIR TOPICAL CREAM

Tier 3

didanosine oral capsule,delayed release(dr/ec)

Tier 4

EDURANT ORAL TABLET

Tier 4

EMTRIVA ORAL CAPSULE

Tier 4

EMTRIVA ORAL SOLUTION

Tier 4

entecavir oral tablet Tier 4

EPCLUSA ORAL TABLET

Tier 4 PA; QL

EPIVIR HBV ORAL SOLUTION

Tier 5

EPZICOM ORAL TABLET Tier 4

EVOTAZ ORAL TABLET Tier 4

famciclovir oral tablet Tier 1

foscarnet intravenous solution

Tier 2

FUZEON SUBCUTANEOUS RECON SOLN

Tier 4

ganciclovir sodium intravenous recon soln

Tier 4

HARVONI ORAL TABLET

Tier 4 PA; QL

INTELENCE ORAL TABLET

Tier 4

INVIRASE ORAL CAPSULE

Tier 4

INVIRASE ORAL TABLET

Tier 4

ISENTRESS ORAL TABLET

Tier 4

ISENTRESS ORAL TABLET,CHEWABLE

Tier 4

KALETRA ORAL SOLUTION

Tier 4

KALETRA ORAL TABLET

Tier 4

23

Drug Status Notes

lamivudine oral tablet 150 mg, 300 mg

Tier 4

lamivudine-zidovudine oral tablet

Tier 4

moderiba dose pack oral tablets,dose pack

Tier 4

moderiba oral tablet Tier 4

nevirapine oral suspension Tier 4

nevirapine oral tablet Tier 4

NORVIR ORAL CAPSULE

Tier 4

NORVIR ORAL SOLUTION

Tier 4

NORVIR ORAL TABLET Tier 4

OLYSIO ORAL CAPSULE

Tier 5 PA; QL

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; QL

PEGASYS SUBCUTANEOUS SOLUTION

Tier 4 PA; QL

PEGASYS SUBCUTANEOUS SYRINGE

Tier 4 PA; QL

PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT

Tier 5 PA

PEGINTRON SUBCUTANEOUS KIT

Tier 5 PA

PREZISTA ORAL SUSPENSION

Tier 4

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

Tier 4

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

Tier 2 QL

RESCRIPTOR ORAL TABLET

Tier 4

RESCRIPTOR ORAL TABLET, DISPERSIBLE

Tier 4

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

Tier 4

ribasphere oral capsule Tier 4

ribasphere oral tablet Tier 4

ribasphere ribapak oral tablets,dose pack

Tier 4

Drug Status Notes

ribavirin oral capsule Tier 4

ribavirin oral tablet 200 mg Tier 4

rimantadine oral tablet Tier 1

SELZENTRY ORAL TABLET

Tier 4

SOVALDI ORAL TABLET Tier 4 PA; QL

stavudine oral capsule Tier 4

stavudine oral recon soln Tier 4

STRIBILD ORAL TABLET

Tier 4

SUSTIVA ORAL CAPSULE

Tier 4

SUSTIVA ORAL TABLET Tier 4

TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG

Tier 2 QL

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION

Tier 2 QL

TECHNIVIE ORAL TABLET

Tier 5 PA; QL

TIVICAY ORAL TABLET Tier 4

trifluridine ophthalmic drops

Tier 1

TRIUMEQ ORAL TABLET

Tier 4

TRUVADA ORAL TABLET

Tier 4

TYZEKA ORAL TABLET Tier 5 PA

valacyclovir oral tablet Tier 1

VALCYTE ORAL RECON SOLN

Tier 3

valganciclovir oral tablet Tier 2

VEREGEN TOPICAL OINTMENT

Tier 3

VIEKIRA PAK ORAL TABLETS,DOSE PACK

Tier 5 PA; QL

VIRACEPT ORAL TABLET

Tier 4

VIREAD ORAL TABLET Tier 4

zidovudine oral capsule Tier 4

zidovudine oral syrup Tier 4

zidovudine oral tablet Tier 4

ZIRGAN OPHTHALMIC GEL

Tier 3

24

Drug Status Notes

AUTONOMIC DRUGS

bethanechol chloride oral tablet

Tier 2

BOTOX INJECTION RECON SOLN

Tier 5 PA

cevimeline oral capsule Tier 2

dextroamphetamine oral capsule, extended release

Tier 1 PA

dextroamphetamine oral solution

Tier 1 PA

dextroamphetamine oral tablet

Tier 1 PA

dextroamphetamine-amphetamine oral capsule,extended release 24hr

Tier 1 PA

dextroamphetamine-amphetamine oral tablet

Tier 1 PA

donepezil oral tablet Tier 2 QL

donepezil oral tablet,disintegrating

Tier 2 QL

epinephrine injection auto-injector

Tier 1

EPIPEN 2-PAK INJECTION AUTO-INJECTOR

Tier 2

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR

Tier 2

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

Tier 2 QL

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

Tier 2 DO

galantamine oral solution Tier 2 QL

galantamine oral tablet 12 mg, 4 mg

Tier 2 DO

galantamine oral tablet 8 mg

Tier 2 QL

guanidine oral tablet Tier 1

methamphetamine oral tablet

Tier 2 PA

midodrine oral tablet Tier 1

NORTHERA ORAL CAPSULE

Tier 3

phenoxybenzamine oral capsule

Tier 2

pilocarpine hcl oral tablet Tier 2

Drug Status Notes

procentra oral solution Tier 1 PA

pyridostigmine bromide oral tablet

Tier 1

rivastigmine tartrate oral capsule 1.5 mg, 3 mg

Tier 2 DO

rivastigmine tartrate oral capsule 4.5 mg, 6 mg

Tier 2 QL

zenzedi oral tablet 10 mg, 5 mg

Tier 1 PA

BIOLOGICALS

ACTHIB (PF) INTRAMUSCULAR RECON SOLN

Tier 3 $0

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

Tier 3 $0

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

Tier 3 $0

AFLURIA 2016-2017 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

AFLURIA 2016-2017 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

AFLURIA QUAD 2016-2017 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0

AFLURIA QUAD 2016-2017 INTRAMUSCULAR SUSPENSION

Tier 1 $0

ATGAM INTRAVENOUS SOLUTION

Tier 4

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION

Tier 3 $0

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

Tier 3 $0

CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE

Tier 2 $0

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

25

Drug Status Notes

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

EZ FLU 2016-17 (AFLURIA) (PF) INTRAMUSCULAR SYRINGE KIT

Tier 1 $0

EZ FLU 2016-17 (FLUVIRIN) (PF) INTRAMUSCULAR SYRINGE KIT

Tier 1 $0

FLUAD 2016-2017 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLUARIX QUAD 2016-2017 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLUBLOK 2016-2017 (PF) INTRAMUSCULAR SOLUTION

Tier 1 $0; QL

FLUCELVAX QUAD 2016-2017 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLULAVAL QUAD 2016-2017 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLULAVAL QUAD 2016-2017 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

FLUVIRIN 2016-2017 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLUVIRIN 2016-2017 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

FLUZONE HIGH-DOSE 2016-17 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

Drug Status Notes

FLUZONE INTRADERM QUAD 2016-17 INTRADERMAL SYRINGE

Tier 1 $0; QL

FLUZONE QUAD 2016-2017 (PF) INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

FLUZONE QUAD 2016-2017 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLUZONE QUAD 2016-2017 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

FLUZONE QUAD PEDI 2016-17 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

GAMASTAN S/D INTRAMUSCULAR SOLUTION

Tier 5 PA

GARDASIL (PF) INTRAMUSCULAR SUSPENSION

Tier 2 $0

GARDASIL (PF) INTRAMUSCULAR SYRINGE

Tier 2 $0

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION

Tier 2 $0

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

Tier 2 $0

HAVRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

HAVRIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

HYQVIA SUBCUTANEOUS SOLUTION

Tier 4 PA

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN

Tier 3

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

26

Drug Status Notes

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

IPOL INJECTION SUSPENSION

Tier 3 $0

IXIARO (PF) INTRAMUSCULAR SYRINGE

Tier 3

KINRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

KINRIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

MENACTRA (PF) INTRAMUSCULAR SOLUTION

Tier 3 $0

MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN

Tier 3 $0

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

Tier 3 $0

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

Tier 3 $0

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

Tier 3 $0

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

Tier 3 $0

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION

Tier 3 $0

PENTACEL (PF) INTRAMUSCULAR KIT

Tier 3 $0

PNEUMOVAX 23 INJECTION SOLUTION

Tier 2 $0

PNEUMOVAX 23 INJECTION SYRINGE

Tier 2 $0

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE

Tier 2 $0

Drug Status Notes

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 $0

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 3

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION

Tier 3 $0

ROTATEQ VACCINE ORAL SUSPENSION

Tier 3 $0

TENIVAC (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

TENIVAC (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION

Tier 3 $0

TRUMENBA INTRAMUSCULAR SYRINGE

Tier 2 $0

TWINRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

TWINRIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

TYPHIM VI INTRAMUSCULAR SOLUTION

Tier 3

TYPHIM VI INTRAMUSCULAR SYRINGE

Tier 3

VAQTA (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

27

Drug Status Notes

VAQTA (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 $0

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

Tier 2

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 2 $0

BLOOD

DROXIA ORAL CAPSULE

Tier 4

pentoxifylline oral tablet extended release

Tier 1

tranexamic acid intravenous solution

Tier 2

tranexamic acid oral tablet Tier 1

CARDIAC DRUGS

afeditab cr oral tablet extended release 30 mg

Tier 1 DO

afeditab cr oral tablet extended release 60 mg

Tier 1 QL

amiodarone oral tablet Tier 1

amlodipine oral tablet 10 mg

Tier 1 QL

amlodipine oral tablet 2.5 mg, 5 mg

Tier 1 DO

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

Tier 1 DO

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

Tier 1 QL

digox oral tablet Tier 1

digoxin oral solution 50 mcg/ml

Tier 1

digoxin oral tablet Tier 1

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

Tier 1 DO

Drug Status Notes

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

Tier 1 QL

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

Tier 1 DO

diltiazem hcl oral capsule,ext release degradable 240 mg

Tier 1 QL

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

Tier 2 QL

diltiazem hcl oral capsule,extended release 12 hr 60 mg

Tier 2 DO; QL

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

Tier 1 DO

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

Tier 1 QL

diltiazem hcl oral tablet Tier 1 QL

diltiazem hcl oral tablet extended release 24 hr 180 mg

Tier 1 DO

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

Tier 1 QL

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

Tier 1 DO

dilt-xr oral capsule,ext release degradable 240 mg

Tier 1 QL

disopyramide phosphate oral capsule

Tier 1

dofetilide oral capsule Tier 2

felodipine oral tablet extended release 24 hr 10 mg

Tier 1 QL

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

Tier 1 DO

flecainide oral tablet Tier 2

isosorbide dinitrate oral tablet

Tier 1

isosorbide dinitrate oral tablet extended release

Tier 1

28

Drug Status Notes

isosorbide mononitrate oral tablet

Tier 1

isosorbide mononitrate oral tablet extended release 24 hr

Tier 1

isradipine oral capsule 2.5 mg, 5 mg

Tier 1 QL

LANOXIN ORAL TABLET Tier 3

matzim la oral tablet extended release 24 hr 180 mg

Tier 1 DO

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

Tier 1 QL

mexiletine oral capsule Tier 2

MULTAQ ORAL TABLET Tier 3

nicardipine oral capsule 20 mg, 30 mg

Tier 2 QL

nifedical xl oral tablet extended release 24hr 30 mg

Tier 1 DO

nifedical xl oral tablet extended release 24hr 60 mg

Tier 1 QL

nifedipine oral capsule Tier 1 QL

nifedipine oral tablet extended release 24hr 30 mg

Tier 1 DO

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

Tier 1 QL

nifedipine oral tablet extended release 30 mg

Tier 1 DO

nifedipine oral tablet extended release 60 mg, 90 mg

Tier 1 QL

nimodipine oral capsule Tier 2

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

Tier 1 DO

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

Tier 1 QL

nitro-bid transdermal ointment

Tier 1

nitroglycerin oral capsule, extended release

Tier 2

Drug Status Notes

nitroglycerin translingual aerosol,spray

Tier 2

nitroglycerin translingual spray,non-aerosol

Tier 2

NITROSTAT SUBLINGUAL TABLET

Tier 2

nitro-time oral capsule, extended release

Tier 1

pacerone oral tablet 100 mg, 200 mg, 400 mg

Tier 2

procainamide injection solution

Tier 2

propafenone oral capsule,extended release 12 hr

Tier 2

propafenone oral tablet Tier 2

quinidine sulfate oral tablet Tier 1

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

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

Tier 1 DO

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

Tier 1 QL

verapamil oral capsule, 24 hr er pellet ct 100 mg

Tier 1 DO

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

Tier 1 QL

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

Tier 1

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

Tier 1 QL

verapamil oral tablet 120 mg, 40 mg, 80 mg

Tier 1 QL

verapamil oral tablet 40 mg

Tier 1

verapamil oral tablet extended release

Tier 1 QL

CARDIOVASCULAR

acebutolol oral capsule Tier 1

ADCIRCA ORAL TABLET

Tier 4 PA; QL

ADEMPAS ORAL TABLET

Tier 4 PA

29

Drug Status Notes

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

Tier 1 QL

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

Tier 1 DO

amlodipine-benazepril oral capsule

Tier 1

atenolol oral tablet Tier 1

atenolol-chlorthalidone oral tablet

Tier 1

atorvastatin oral tablet 10 mg, 20 mg, 40 mg

Tier 1 DO

atorvastatin oral tablet 80 mg

Tier 1 QL

benazepril oral tablet Tier 1

benazepril-hydrochlorothiazide oral tablet

Tier 1

BENICAR ORAL TABLET20 MG

Tier 3 DO


Tier 3 QL


Tier 3 DO; QL

betaxolol oral tablet Tier 1

bisoprolol fumarate oral tablet

Tier 1

bisoprolol-hydrochlorothiazide oral tablet

Tier 1

BYSTOLIC ORAL TABLET

Tier 3

candesartan oral tablet 16 mg, 32 mg

Tier 1 QL

candesartan oral tablet 4 mg, 8 mg

Tier 1 DO; QL

candesartan-hydrochlorothiazid oral tablet 16-12.5 mg

Tier 1 DO; QL

candesartan-hydrochlorothiazid oral tablet 32-12.5 mg

Tier 1 QL

candesartan-hydrochlorothiazid oral tablet 32-25 mg

Tier 1

captopril oral tablet Tier 2

captopril-hydrochlorothiazide oral tablet

Tier 2

carvedilol oral tablet Tier 1

Drug Status Notes

cholestyramine (with sugar) oral powder

Tier 1

cholestyramine (with sugar) oral powder in packet

Tier 1

cholestyramine light oral powder

Tier 1

cholestyramine light oral powder in packet

Tier 1

clonidine hcl oral tablet Tier 1

colestipol oral granules Tier 1

colestipol oral packet Tier 1

colestipol oral tablet Tier 1

doxazosin oral tablet Tier 1

EDARBI ORAL TABLET40 MG

Tier 3 DO

EDARBI ORAL TABLET80 MG

Tier 3 QL

enalapril maleate oral tablet

Tier 1

enalapril-hydrochlorothiazide oral tablet

Tier 1

eprosartan oral tablet Tier 1 QL

ergoloid oral tablet Tier 2

fenofibrate micronized oral capsule

Tier 1

fenofibrate nanocrystallized oral tablet

Tier 1

fenofibrate oral tablet 160 mg, 54 mg

Tier 1

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

Tier 1

fenofibric acid oral tablet Tier 1

fluvastatin oral capsule Tier 1 DO

fosinopril oral tablet Tier 1

fosinopril-hydrochlorothiazide oral tablet

Tier 1

gemfibrozil oral tablet Tier 1

guanfacine oral tablet Tier 1

HEMANGEOL ORAL SOLUTION

Tier 4

hydralazine oral tablet Tier 1

indomethacin sodium intravenous recon soln

Tier 2

irbesartan oral tablet 150 mg, 75 mg

Tier 1 DO

30

Drug Status Notes

irbesartan oral tablet 300 mg

Tier 1 QL

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

Tier 1 QL

labetalol oral tablet Tier 1

LETAIRIS ORAL TABLET Tier 4 PA

LEVATOL ORAL TABLET

Tier 3

lisinopril oral tablet Tier 1

lisinopril-hydrochlorothiazide oral tablet

Tier 1

LIVALO ORAL TABLET 1 MG, 2 MG

Tier 3 ST; DO

LIVALO ORAL TABLET 4 MG

Tier 3 ST; QL

losartan oral tablet 100 mg Tier 1 QL

losartan oral tablet 25 mg, 50 mg

Tier 1 DO; QL

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

Tier 1 QL

losartan-hydrochlorothiazide oral tablet 50-12.5 mg

Tier 1 DO

lovastatin oral tablet 10 mg, 20 mg

Tier 1 DO

lovastatin oral tablet 40 mg

Tier 1 QL

methyldopa oral tablet Tier 1

methyldopa-hydrochlorothiazide oral tablet

Tier 1

methyldopate intravenous solution

Tier 2

metoprolol succinate oral tablet extended release 24 hr

Tier 1

metoprolol ta-hydrochlorothiaz oral tablet

Tier 1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

Tier 1

minoxidil oral tablet Tier 1

moexipril oral tablet Tier 1

moexipril-hydrochlorothiazide oral tablet

Tier 1

nadolol oral tablet Tier 1

nadolol-bendroflumethiazide oral tablet

Tier 1

Drug Status Notes

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

Tier 1 QL

OPSUMIT ORAL TABLET Tier 4 PA

ORENITRAM ORAL TABLET EXTENDED RELEASE

Tier 5 PA

perindopril erbumine oral tablet

Tier 1

pindolol oral tablet Tier 1

pravastatin oral tablet 10 mg, 20 mg, 40 mg

Tier 1 DO

pravastatin oral tablet 80 mg

Tier 1 QL

prazosin oral capsule Tier 1

prevalite oral powder Tier 1

prevalite oral powder in packet

Tier 1

propranolol oral capsule,extended release 24 hr

Tier 1

propranolol oral solution Tier 1

propranolol oral tablet Tier 1

propranolol-hydrochlorothiazid oral tablet

Tier 1

quinapril oral tablet Tier 1

quinapril-hydrochlorothiazide oral tablet

Tier 1

ramipril oral capsule Tier 1

REMODULIN INJECTION SOLUTION

Tier 5 PA

rosuvastatin oral tablet Tier 2 QL

sildenafil oral tablet Tier 4 PA; QL

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

Tier 1 DO

simvastatin oral tablet 80 mg

Tier 1 PA; QL

sorine oral tablet Tier 1

sotalol af oral tablet Tier 2

sotalol oral tablet Tier 2

TEKTURNA ORAL TABLET 150 MG

Tier 3 DO

TEKTURNA ORAL TABLET 300 MG

Tier 3 QL

telmisartan oral tablet 20 mg, 40 mg

Tier 1 DO

telmisartan oral tablet 80 mg

Tier 1 QL

31

Drug Status Notes

terazosin oral capsule Tier 1

timolol maleate oral tablet Tier 1

TRACLEER ORAL TABLET

Tier 4 PA

trandolapril oral tablet Tier 1

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

Tier 1

valsartan oral tablet 160 mg, 320 mg

Tier 1 QL

valsartan oral tablet 40 mg, 80 mg

Tier 1 DO; QL

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

Tier 1 DO

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

Tier 1 QL

VECAMYL ORAL TABLET

Tier 3

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION

Tier 5 PA

WELCHOL ORAL POWDER IN PACKET

Tier 3

WELCHOL ORAL TABLET

Tier 3

ZETIA ORAL TABLET Tier 3 ST; QL

CNS DRUGS

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR

Tier 5 PA; QL

APTIOM ORAL TABLET Tier 3

AUBAGIO ORAL TABLET

Tier 5 PA; QL

BANZEL ORAL SUSPENSION

Tier 3 QL

BANZEL ORAL TABLET200 MG, 400 MG

Tier 3 QL

carbamazepine oral capsule, er multiphase 12 hr

Tier 1

carbamazepine oral suspension 100 mg/5 ml

Tier 1

carbamazepine oral tablet Tier 1

carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg

Tier 1

carbamazepine oral tablet,chewable

Tier 1

Drug Status Notes

CELONTIN ORAL CAPSULE 300 MG

Tier 3

clonazepam oral tablet Tier 1

clonazepam oral tablet,disintegrating

Tier 1

COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML

Tier 5 PA

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML

Tier 4 PA

diazepam rectal kit Tier 2 QL

divalproex oral capsule, sprinkle

Tier 2

divalproex oral tablet extended release 24 hr

Tier 2

divalproex oral tablet,delayed release (dr/ec)

Tier 2

epitol oral tablet Tier 1

ethosuximide oral capsule Tier 1

ethosuximide oral solution Tier 1

EXTAVIA SUBCUTANEOUS KIT

Tier 5 PA

EXTAVIA SUBCUTANEOUS RECON SOLN

Tier 5 PA

felbamate oral suspension Tier 1

felbamate oral tablet Tier 1

fosphenytoin injection solution

Tier 2

FYCOMPA ORAL TABLET

Tier 3

gabapentin oral capsule Tier 2

gabapentin oral solution Tier 2

gabapentin oral tablet 600 mg, 800 mg

Tier 2

GILENYA ORAL CAPSULE

Tier 4 PA; QL

HORIZANT ORAL TABLET EXTENDED RELEASE

Tier 3 PA

lamotrigine oral tablet Tier 1

lamotrigine oral tablet, chewable dispersible

Tier 1

levetiracetam oral solution Tier 2

levetiracetam oral tablet Tier 2

32

Drug Status Notes

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

Tier 2 PA; QL

LYRICA ORAL CAPSULE100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

Tier 3 PA; QL

LYRICA ORAL SOLUTION

Tier 3 PA; QL

memantine oral solution Tier 2

memantine oral tablet Tier 2

memantine oral tablets,dose pack

Tier 2

NUEDEXTA ORAL CAPSULE

Tier 3

ONFI ORAL SUSPENSION

Tier 3

ONFI ORAL TABLET 10 MG, 20 MG

Tier 3

oxcarbazepine oral suspension

Tier 2

oxcarbazepine oral tablet Tier 2

PEGANONE ORAL TABLET

Tier 3

phenytoin sodium extended oral capsule

Tier 1

PLEGRIDY SUBCUTANEOUS PEN INJECTOR

Tier 4 PA

PLEGRIDY SUBCUTANEOUS SYRINGE

Tier 4 PA

POTIGA ORAL TABLET200 MG, 300 MG, 400 MG, 50 MG

Tier 3 QL

primidone oral tablet Tier 1

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

Tier 5 PA

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR

Tier 5 PA

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

Tier 5 PA

riluzole oral tablet Tier 4

SABRIL ORAL POWDER IN PACKET

Tier 3

SABRIL ORAL TABLET Tier 3

Drug Status Notes

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG

Tier 4 PA; QL

tiagabine oral tablet Tier 2

topiramate oral capsule, sprinkle

Tier 1

topiramate oral tablet Tier 1

valproic acid (as sodium salt) oral solution

Tier 1

valproic acid oral capsule Tier 1

VIMPAT ORAL SOLUTION

Tier 3 QL

VIMPAT ORAL TABLET Tier 3 QL

zonisamide oral capsule Tier 2

COLONY STIMULATING FACTORS

ARANESP (IN POLYSORBATE) INJECTION SOLUTION

Tier 4 PA

ARANESP (IN POLYSORBATE) INJECTION SYRINGE

Tier 4 PA

LEUKINE INJECTION RECON SOLN

Tier 5 PA

MOZOBIL SUBCUTANEOUS SOLUTION

Tier 5 PA

NEULASTA SUBCUTANEOUS SYRINGE

Tier 5 PA; QL

NEUPOGEN INJECTION SOLUTION

Tier 4 PA

NEUPOGEN INJECTION SYRINGE

Tier 4 PA

PROCRIT INJECTION SOLUTION

Tier 4 PA

PROMACTA ORAL TABLET

Tier 5 PA

CONTRACEPTIVES

altavera (28) oral tablet Tier 1 $0

alyacen 1/35 (28) oral tablet

Tier 1 $0

alyacen 7/7/7 (28) oral tablet

Tier 1 $0

amethia lo oral tablets,dose pack,3 month

Tier 1 $0

33

Drug Status Notes

amethia oral tablets,dose pack,3 month

Tier 1 $0

amethyst oral tablet Tier 1 $0

apri oral tablet Tier 1 $0

aranelle (28) oral tablet Tier 1 $0

ashlyna oral tablets,dose pack,3 month

Tier 1 $0

aubra oral tablet Tier 1 $0

aviane oral tablet Tier 1 $0

azurette (28) oral tablet Tier 1 $0

balziva (28) oral tablet Tier 1 $0

BEKYREE (28) ORAL TABLET

Tier 1 $0

BEYAZ ORAL TABLET Tier 3 $0

BLISOVI 24 FE ORAL TABLET

Tier 1 $0

BLISOVI FE 1.5/30 (28) ORAL TABLET

Tier 1 $0

BLISOVI FE 1/20 (28) ORAL TABLET

Tier 1 $0

briellyn oral tablet Tier 1 $0

camila oral tablet Tier 1 $0

camrese lo oral tablets,dose pack,3 month

Tier 1 $0

camrese oral tablets,dose pack,3 month

Tier 1 $0

caziant (28) oral tablet Tier 1 $0

chateal oral tablet Tier 1 $0

cryselle (28) oral tablet Tier 1 $0

cyclafem 1/35 (28) oral tablet

Tier 1 $0

cyclafem 7/7/7 (28) oral tablet

Tier 1 $0

cyred oral tablet Tier 1 $0

dasetta 1/35 (28) oral tablet

Tier 1 $0

dasetta 7/7/7 (28) oral tablet

Tier 1 $0

daysee oral tablets,dose pack,3 month

Tier 1 $0

deblitane oral tablet Tier 1 $0

delyla (28) oral tablet Tier 1 $0

desog-e.estradiol/e.estradiol oral tablet

Tier 1 $0

desogestrel-ethinyl estradiol oral tablet

Tier 1 $0

Drug Status Notes

drospirenone-ethinyl estradiol oral tablet

Tier 1 $0

elinest oral tablet Tier 1 $0

ELLA ORAL TABLET Tier 3 $0

emoquette oral tablet Tier 1 $0

enpresse oral tablet Tier 1 $0

enskyce oral tablet Tier 1 $0

errin oral tablet Tier 1 $0

estarylla oral tablet Tier 1 $0

falmina (28) oral tablet Tier 1 $0

gianvi (28) oral tablet Tier 1 $0

gildagia oral tablet Tier 1 $0

gildess 1.5/30 (21) oral tablet

Tier 1 $0

gildess 1/20 (21) oral tablet

Tier 1 $0

gildess 24 fe oral tablet Tier 1 $0

gildess fe 1.5/30 (28) oral tablet

Tier 1 $0

gildess fe 1/20 (28) oral tablet

Tier 1 $0

heather oral tablet Tier 1 $0

introvale oral tablets,dose pack,3 month

Tier 1 $0

jencycla oral tablet Tier 1 $0

jolessa oral tablets,dose pack,3 month

Tier 1 $0

jolivette oral tablet Tier 1 $0

JULEBER ORAL TABLET

Tier 1 $0

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

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

junel fe 1.5/30 (28) oral tablet

Tier 1 $0

junel fe 1/20 (28) oral tablet

Tier 1 $0

junel fe 24 oral tablet Tier 1 $0

KAITLIB FE ORAL TABLET,CHEWABLE

Tier 1 $0

kariva (28) oral tablet Tier 1 $0

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

kimidess (28) oral tablet Tier 1 $0

kurvelo oral tablet Tier 1 $0

34

Drug Status Notes

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

Tier 1 $0

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

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

larin 24 fe oral tablet Tier 1 $0

larin fe 1.5/30 (28) oral tablet

Tier 1 $0

larin fe 1/20 (28) oral tablet

Tier 1 $0

LARISSIA ORAL TABLET

Tier 1 $0

layolis fe oral tablet,chewable

Tier 1 $0

leena 28 oral tablet Tier 1 $0

lessina oral tablet Tier 1 $0

levonest (28) oral tablet Tier 1 $0

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg

Tier 1 $0

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

Tier 1 $0

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

Tier 1 $0

levora-28 oral tablet Tier 1 $0

LO LOESTRIN FE ORAL TABLET

Tier 3 $0

lomedia 24 fe oral tablet Tier 1 $0

loryna (28) oral tablet Tier 1 $0

low-ogestrel (28) oral tablet

Tier 1 $0

lutera (28) oral tablet Tier 1 $0

lyza oral tablet Tier 1 $0

marlissa oral tablet Tier 1 $0

medroxyprogesterone intramuscular suspension

Tier 1 $0

medroxyprogesterone intramuscular syringe

Tier 1 $0

microgestin 1.5/30 (21) oral tablet

Tier 1 $0

microgestin 1/20 (21) oral tablet

Tier 1 $0

microgestin fe 1.5/30 (28) oral tablet

Tier 1 $0

Drug Status Notes

microgestin fe 1/20 (28) oral tablet

Tier 1 $0

MINASTRIN 24 FE ORAL TABLET,CHEWABLE

Tier 3 $0

mono-linyah oral tablet Tier 1 $0

mononessa (28) oral tablet Tier 1 $0

my way oral tablet 1.5 mg Tier 1 $0

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

myzilra oral tablet Tier 1 $0

NATAZIA ORAL TABLET Tier 3 $0

necon 0.5/35 (28) oral tablet

Tier 1 $0

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

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

necon 10/11 (28) oral tablet

Tier 1 $0

necon 7/7/7 (28) oral tablet

Tier 1 $0

next choice one dose oral tablet

Tier 1 $0; QL

nikki (28) oral tablet Tier 1 $0

nora-be oral tablet Tier 1 $0

noreth-ethinyl estradiol-iron oral tablet,chewable

Tier 1 $0

norethindrone (contraceptive) oral tablet

Tier 1 $0

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg

Tier 1 $0

norethindrone-e.estradiol-iron oral tablet

Tier 1 $0

norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28)

Tier 1 $0

norgestimate-ethinyl estradiol oral tablet 0.25-35 mg-mcg

Tier 1 $0

norlyroc oral tablet Tier 1 $0

nortrel 0.5/35 (28) oral tablet

Tier 1 $0

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

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

nortrel 7/7/7 (28) oral tablet

Tier 1 $0

35

Drug Status Notes

NUVARING VAGINAL RING

Tier 3 $0

ocella oral tablet Tier 1 $0

ogestrel (28) oral tablet Tier 1 $0

orsythia oral tablet Tier 1 $0

philith oral tablet Tier 1 $0

pimtrea (28) oral tablet Tier 1 $0

pirmella oral tablet Tier 1 $0

PLAN B ONE-STEP ORAL TABLET 1.5 MG

Tier 1

PLAN B ONE-STEP ORAL TABLET 1.5 MG

Tier 1 QL

portia oral tablet Tier 1 $0

previfem oral tablet Tier 1 $0

QUARTETTE ORAL TABLETS,DOSE PACK,3 MONTH

Tier 3 $0

quasense oral tablets,dose pack,3 month

Tier 1 $0

REACT ORAL TABLET Tier 1

reclipsen (28) oral tablet Tier 1 $0

SAFYRAL ORAL TABLET

Tier 3 $0

setlakin oral tablets,dose pack,3 month

Tier 1 $0

sharobel oral tablet Tier 1 $0

sprintec (28) oral tablet Tier 1 $0

sronyx oral tablet Tier 1 $0

syeda oral tablet Tier 1 $0

tarina fe 1/20 (28) oral tablet

Tier 1 $0

tilia fe oral tablet Tier 1 $0

tri-estarylla oral tablet Tier 1 $0

tri-legest fe oral tablet Tier 1 $0

tri-linyah oral tablet Tier 1 $0

TRI-LO-ESTARYLLA ORAL TABLET

Tier 1 $0

TRI-LO-SPRINTEC ORAL TABLET

Tier 1 $0

trinessa (28) oral tablet Tier 1 $0

TRINESSA LO ORAL TABLET

Tier 1 $0

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

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

trivora (28) oral tablet Tier 1 $0

Drug Status Notes

velivet triphasic regimen (28) oral tablet

Tier 1 $0

vestura (28) oral tablet Tier 1 $0

VIENVA ORAL TABLET Tier 1 $0

viorele (28) oral tablet Tier 1 $0

vyfemla (28) oral tablet Tier 1 $0

wera (28) oral tablet Tier 1 $0

wymzya fe oral tablet,chewable

Tier 1 $0

xulane transdermal patch weekly

Tier 1 $0

zarah oral tablet Tier 1 $0

zenchent (28) oral tablet Tier 1 $0

zenchent fe oral tablet,chewable

Tier 1 $0

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

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

COUGH/COLD PREPARATIONS

benzonatate oral capsule 100 mg, 200 mg

Tier 1

cheratussin ac oral liquid Tier 1

FLOWTUSS ORAL SOLUTION

Tier 3

guaifenesin ac oral liquid Tier 1

HYCOFENIX ORAL SOLUTION

Tier 3

hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr

Tier 1

hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

Tier 1

iophen c-nr oral liquid Tier 1

OBREDON ORAL SOLUTION

Tier 3

promethazine vc-codeine oral syrup

Tier 1

promethazine-codeine oral syrup

Tier 1

promethazine-dm oral syrup

Tier 1

promethazine-phenyleph-codeine oral syrup

Tier 1

VITUZ ORAL SOLUTION Tier 3

36

Drug Status Notes

DIAGNOSTIC

ACCU-CHEK AVIVA PLUS TEST STRP STRIP

Tier 2 QL

ACCU-CHEK COMPACT PLUS TEST STRIP

Tier 2 QL

ACCU-CHEK COMPACT TEST STRIP

Tier 2 QL

ACCU-CHEK SMARTVIEW TEST STRIP STRIP

Tier 2 QL

ACCUTREND GLUCOSE STRIP

Tier 2 QL

dipyridamole intravenous solution

Tier 2

GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN

Tier 2

ONETOUCH ULTRA TEST STRIP

Tier 2 QL

ONETOUCH VERIO STRIP

Tier 2 QL

DIURETICS

acetazolamide oral capsule, extended release

Tier 1

acetazolamide oral tablet Tier 1

amiloride oral tablet Tier 1

AMMONIUM CHLORIDE INTRAVENOUS SOLUTION

Tier 3

bumetanide oral tablet Tier 1

chlorothiazide oral tablet Tier 1

chlorthalidone oral tablet 25 mg, 50 mg

Tier 1

DYRENIUM ORAL CAPSULE

Tier 3

EDECRIN ORAL TABLET Tier 3

eplerenone oral tablet Tier 2

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

Tier 1

furosemide oral tablet Tier 1

hydrochlorothiazide oral capsule

Tier 1

hydrochlorothiazide oral tablet

Tier 1

indapamide oral tablet Tier 1

methazolamide oral tablet Tier 1

Drug Status Notes

methyclothiazide oral tablet

Tier 1

metolazone oral tablet Tier 1

SAMSCA ORAL TABLET Tier 3

spironolactone oral tablet Tier 1

torsemide oral tablet Tier 1

triamterene-hydrochlorothiazid oral capsule

Tier 1

triamterene-hydrochlorothiazid oral tablet

Tier 1

EENT PREPS

acetasol hc otic drops Tier 2

acetic acid otic solution Tier 1

acetic acid-aluminum acetate otic drops

Tier 1

ALOCRIL OPHTHALMIC DROPS

Tier 3 PA; QL

ALOMIDE OPHTHALMIC DROPS

Tier 3 PA; QL

apraclonidine ophthalmic drops

Tier 1

azelastine nasal aerosol,spray

Tier 1 QL

AZOPT OPHTHALMIC DROPS,SUSPENSION

Tier 3

betaxolol ophthalmic drops Tier 1

bimatoprost ophthalmic drops

Tier 2

brimonidine ophthalmic drops

Tier 1

bromfenac ophthalmic drops

Tier 2

carteolol ophthalmic drops Tier 1

COMBIGAN OPHTHALMIC DROPS

Tier 3

cromolyn ophthalmic drops

Tier 1 QL

CYSTARAN OPHTHALMIC DROPS

Tier 3

dexamethasone sodium phosphate ophthalmic drops

Tier 1

diclofenac sodium ophthalmic drops

Tier 1

dorzolamide ophthalmic drops

Tier 1

dorzolamide-timolol ophthalmic drops

Tier 1

37

Drug Status Notes

DUREZOL OPHTHALMIC DROPS

Tier 3 QL

DYMISTA NASAL SPRAY,NON-AEROSOL

Tier 3 QL

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)

Tier 1 ST; QL

fluocinolone acetonide oil otic drops

Tier 1

fluorometholone ophthalmic drops,suspension

Tier 1

flurbiprofen sodium ophthalmic drops

Tier 1

fluticasone nasal spray,suspension

Tier 1 QL

FML S.O.P. OPHTHALMIC OINTMENT

Tier 3

hydrocortisone-acetic acid otic drops

Tier 1

ketorolac ophthalmic drops

Tier 1

LACRISERT OPHTHALMIC INSERT

Tier 3

latanoprost ophthalmic drops

Tier 1

levobunolol ophthalmic drops 0.5 %

Tier 1

LOTEMAX OPHTHALMIC DROPS,GEL

Tier 3

LOTEMAX OPHTHALMIC DROPS,SUSPENSION

Tier 3

LOTEMAX OPHTHALMIC OINTMENT

Tier 3

LUMIGAN OPHTHALMIC DROPS 0.01 %

Tier 3

metipranolol ophthalmic drops

Tier 1

NEVANAC OPHTHALMIC DROPS,SUSPENSION

Tier 3

olopatadine nasal spray,non-aerosol

Tier 1 QL

OMNARIS NASAL SPRAY,NON-AEROSOL

Tier 3 ST; QL

PHOSPHOLINE IODIDE OPHTHALMIC DROPS

Tier 3

pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 %

Tier 1

Drug Status Notes

prednisolone acetate ophthalmic drops,suspension

Tier 1

prednisolone sodium phosphate ophthalmic drops

Tier 1

RESTASIS OPHTHALMIC DROPPERETTE

Tier 3

SIMBRINZA OPHTHALMIC DROPS,SUSPENSION

Tier 3

timolol maleate ophthalmic drops

Tier 1

timolol maleate ophthalmic gel forming solution

Tier 1

TRAVATAN Z OPHTHALMIC DROPS

Tier 3

triamcinolone acetonide nasal aerosol,spray

Tier 1 QL

tropicamide ophthalmic drops

Tier 1

TYZINE NASAL DROPS Tier 3

TYZINE NASAL SPRAY,NON-AEROSOL

Tier 3

VEXOL OPHTHALMIC DROPS,SUSPENSION

Tier 3

ZIOPTAN (PF) OPHTHALMIC DROPPERETTE

Tier 3

ELECT/CALORIC/H2O

calcium acetate oral tablet 667 mg

Tier 2

cytra k crystals oral packet Tier 1

cytra-k oral solution Tier 1

denta 5000 plus dental cream

Tier 1

dentagel dental gel Tier 1

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

Tier 3

effer-k oral tablet, effervescent 25 meq

Tier 1

eliphos oral tablet Tier 1 PA

fe c plus oral tablet Tier 1

fluoridex daily defense dental gel

Tier 1

38

Drug Status Notes

FLUORIDEX SENSITIVITY RELIEF DENTAL GEL

Tier 3

fluoritab oral tablet,chewable

Tier 1

FOSRENOL ORAL POWDER IN PACKET

Tier 3 PA

FOSRENOL ORAL TABLET,CHEWABLE

Tier 3 PA

GLUCAGEN HYPOKIT INJECTION RECON SOLN

Tier 2

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT

Tier 2

ISOLYTE S PH 7.4 INTRAVENOUS PARENTERAL SOLUTION

Tier 3

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION

Tier 3

k-effervescent oral tablet, effervescent

Tier 1

kionex (with sorbitol) oral suspension

Tier 1

kionex oral powder Tier 1

klor-con 10 oral tablet extended release

Tier 1

klor-con 8 oral tablet extended release

Tier 1

klor-con m10 oral tablet,er particles/crystals

Tier 1


Tier 1


Tier 1

klor-con/ef oral tablet, effervescent

Tier 1

ludent fluoride oral tablet,chewable

Tier 1

magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %)

Tier 1

magnesium sulfate in water intravenous parenteral solution 40 gram/1,000 ml (4 %)

Tier 2

Drug Status Notes

magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %)

Tier 2

magnesium sulfate in water intravenous piggyback 4 gram/50 ml (8 %)

Tier 1

magnesium sulfate injection solution

Tier 1

magnesium sulfate injection syringe

Tier 1

NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION

Tier 3

NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION

Tier 3

NUTRAMINE ORAL POWDER

Tier 3

PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION

Tier 3

PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION

Tier 3

potassium bicarb-citric acid oral tablet, effervescent

Tier 1

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

Tier 2

potassium chloride intravenous piggyback

Tier 1

potassium chloride intravenous solution

Tier 1

potassium chloride oral capsule, extended release

Tier 1

potassium chloride oral tablet extended release 10 meq, 8 meq

Tier 1

potassium chloride oral tablet,er particles/crystals

Tier 1

potassium chloride-0.45 % nacl intravenous parenteral solution

Tier 2

39

Drug Status Notes

potassium citrate oral tablet extended release

Tier 2

potassium citrate-citric acid oral solution

Tier 1

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE

Tier 3

PROGLYCEM ORAL SUSPENSION

Tier 3

RENVELA ORAL POWDER IN PACKET

Tier 3

RENVELA ORAL TABLET

Tier 3

sf 5000 plus dental cream Tier 1

sf dental gel Tier 1

SHOHL'S MODIFIED ORAL SOLUTION

Tier 3

sodium chloride 0.45 % intravenous parenteral solution

Tier 1

sodium chloride 0.45 % intravenous piggyback

Tier 1

sodium chloride 0.9 % injection solution

Tier 1

sodium chloride 0.9 % injection syringe

Tier 1

sodium chloride 0.9 % intravenous parenteral solution

Tier 1

sodium chloride 0.9 % intravenous piggyback

Tier 2

sodium chloride 3 % intravenous parenteral solution

Tier 1

sodium chloride 5 % intravenous parenteral solution

Tier 1

sodium chloride intravenous parenteral solution 2.5 meq/ml

Tier 1

sodium fluoride dental solution

Tier 1

sodium fluoride oral drops Tier 1

sodium fluoride oral tablet,chewable

Tier 1

sodium polystyrene (sorb free) oral suspension

Tier 1

sodium polystyrene sulfonate oral powder

Tier 1

Drug Status Notes

sodium polystyrene sulfonate oral suspension

Tier 1

sodium polystyrene sulfonate rectal enema 30 gram/120 ml

Tier 1

sps (with sorbitol) oral suspension

Tier 1

sps (with sorbitol) rectal enema

Tier 1

SSKI ORAL SOLUTION Tier 3

VELPHORO ORAL TABLET,CHEWABLE

Tier 3 PA

GASTROINTESTINAL

AKYNZEO ORAL CAPSULE

Tier 3 QL

alosetron oral tablet Tier 2

ALOXI INTRAVENOUS SOLUTION

Tier 3

AMITIZA ORAL CAPSULE

Tier 3

anaspaz oral tablet,disintegrating

Tier 2

anucort-hc rectal suppository

Tier 1

ANZEMET ORAL TABLET

Tier 3 QL

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml

Tier 1

balsalazide oral capsule Tier 1

BUPHENYL ORAL TABLET

Tier 3 PA

carafate oral suspension Tier 1

CESAMET ORAL CAPSULE

Tier 3 ST

CHOLBAM ORAL CAPSULE

Tier 3 PA; QL

cimetidine hcl oral solution Tier 1

cimetidine oral tablet Tier 1

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT

Tier 5 PA; QL

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT

Tier 5 PA; QL

40

Drug Status Notes

CIMZIA SUBCUTANEOUS SYRINGE KIT

Tier 5 PA; QL

COMPAZINE ORAL TABLET

Tier 1

constulose oral solution Tier 1

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS

Tier 3 PA; QL

dicyclomine oral capsule Tier 1

dicyclomine oral solution Tier 1

dicyclomine oral tablet Tier 1

DIPENTUM ORAL CAPSULE

Tier 3

diphenoxylate-atropine oral liquid

Tier 1

diphenoxylate-atropine oral tablet

Tier 1

dronabinol oral capsule Tier 2

EMEND ORAL CAPSULE125 MG, 40 MG, 80 MG

Tier 3 QL

EMEND ORAL CAPSULE,DOSE PACK

Tier 3 QL

enulose oral solution Tier 1

esomeprazole magnesium oral capsule,delayed release(dr/ec)

Tier 2 PA; QL

famotidine oral suspension Tier 1

famotidine oral tablet 20 mg, 40 mg

Tier 1

gavilyte-c oral recon soln Tier 1

gavilyte-g oral recon soln Tier 1

gavilyte-n oral recon soln Tier 1

generlac oral solution Tier 1

glycopyrrolate oral tablet Tier 1

granisetron hcl oral tablet Tier 2 QL

hydrocortisone acetate rectal suppository

Tier 1

hydrocortisone-pramoxine rectal cream

Tier 1

KEPIVANCE INTRAVENOUS RECON SOLN

Tier 5

lactulose oral solution Tier 1

lansoprazole oral capsule,delayed release(dr/ec)

Tier 1 QL

Drug Status Notes

lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %

Tier 1

lidocaine hcl-hydrocortison ac rectal kit

Tier 1

lidocaine-hydrocortisone-aloe rectal gel

Tier 1

lidocaine-hydrocortisone-aloe rectal kit 3-2.5 % (7 gram)

Tier 1

LINZESS ORAL CAPSULE

Tier 2

LOVAZA ORAL CAPSULE

Tier 3 QL

meclizine oral tablet 12.5 mg, 25 mg

Tier 1

methscopolamine oral tablet

Tier 1

metoclopramide hcl oral solution

Tier 1

metoclopramide hcl oral tablet

Tier 1

misoprostol oral tablet Tier 1

MOTOFEN ORAL TABLET

Tier 3

MOVIPREP ORAL POWDER IN PACKET

Tier 3

NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET

Tier 3 PA; QL

nizatidine oral capsule Tier 1

nizatidine oral solution Tier 1

omega-3 acid ethyl esters oral capsule

Tier 1 QL

omeprazole oral capsule,delayed release(dr/ec)

Tier 1 QL

ondansetron hcl oral solution

Tier 2 QL

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

Tier 2 QL

ondansetron oral tablet,disintegrating 4 mg, 8 mg

Tier 2 QL

OSMOPREP ORAL TABLET

Tier 3

pantoprazole oral tablet,delayed release (dr/ec)

Tier 2 QL

peg 3350-electrolytes oral recon soln

Tier 1

41

Drug Status Notes

peg-3350 with flavor packs oral recon soln

Tier 1

phenadoz rectal suppository

Tier 1

pramcort rectal cream Tier 1

PREPOPIK ORAL POWDER IN PACKET

Tier 3

prochlorperazine maleate oral tablet

Tier 1

proctosol hc rectal cream Tier 1

proctozone-hc rectal cream

Tier 1

promethazine rectal suppository

Tier 1

promethegan rectal suppository

Tier 1

rabeprazole oral tablet,delayed release (dr/ec)

Tier 2 QL

ranitidine hcl oral capsule Tier 1

ranitidine hcl oral syrup Tier 1

ranitidine hcl oral tablet 150 mg, 300 mg

Tier 1

RECTIV RECTAL OINTMENT

Tier 3

REMICADE INTRAVENOUS RECON SOLN

Tier 4 PA

SANCUSO TRANSDERMAL PATCH WEEKLY

Tier 3 QL

SCOPOLAMINE HBR INJECTION SOLUTION

Tier 3

sucralfate oral tablet Tier 1

sulfasalazine oral tablet Tier 1

sulfasalazine oral tablet,delayed release (dr/ec)

Tier 1

sulfazine oral tablet Tier 1

SUPREP BOWEL PREP KIT ORAL RECON SOLN

Tier 3

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY

Tier 3

trilyte with flavor packets oral recon soln

Tier 1

trimethobenzamide oral capsule

Tier 1

ursodiol oral capsule Tier 2

Drug Status Notes

ursodiol oral tablet Tier 2

VARUBI ORAL TABLET Tier 3

VASCEPA ORAL CAPSULE

Tier 3 QL

VIBERZI ORAL TABLET Tier 3 PA

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)10,000-34,000 -55,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-68,000 -109,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000- 16,000 UNIT, 40,000-136,000- 218,000 UNIT

Tier 2

HORMONES

ANADROL-50 ORAL TABLET

Tier 3

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP20.25 MG/1.25 GRAM (1.62 %)

Tier 3 PA; QL

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

Tier 3 PA; QL

androxy oral tablet Tier 1

budesonide oral capsule,delayed,extend.release

Tier 2

cabergoline oral tablet Tier 1

calcitonin (salmon) nasal spray,non-aerosol

Tier 1 QL

chorionic gonadotropin, human intramuscular recon soln

Tier 4 PA

cortisone oral tablet Tier 1

covaryx h.s. oral tablet Tier 1

covaryx oral tablet Tier 1

danazol oral capsule Tier 2

desmopressin injection solution

Tier 1

desmopressin nasal aerosol,spray

Tier 2

desmopressin nasal solution

Tier 2

42

Drug Status Notes

desmopressin nasal spray,non-aerosol

Tier 2

desmopressin oral tablet Tier 1

dexamethasone intensol oral drops

Tier 1

dexamethasone oral elixir Tier 1

dexamethasone oral solution

Tier 1

dexamethasone oral tablet Tier 1

DUAVEE ORAL TABLET Tier 3

eemt hs oral tablet Tier 1

eemt oral tablet Tier 1

ESTRACE VAGINAL CREAM

Tier 3

estradiol oral tablet Tier 1

estradiol transdermal patch semiweekly

Tier 1 QL

estradiol transdermal patch weekly

Tier 1 QL

estradiol-norethindrone acet oral tablet

Tier 1

ESTRING VAGINAL RING

Tier 3

estrogens-methyltestosterone oral tablet

Tier 1

estropipate oral tablet Tier 1

fludrocortisone oral tablet Tier 1

fortical nasal spray,non-aerosol

Tier 2 QL

GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR

Tier 3 PA

GONAL-F RFF SUBCUTANEOUS RECON SOLN

Tier 3 PA

GONAL-F SUBCUTANEOUS RECON SOLN

Tier 3 PA

hydrocortisone oral tablet Tier 1

hydrocortisone rectal enema

Tier 2

jinteli oral tablet Tier 1

LOPREEZA ORAL TABLET

Tier 1

LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET

Tier 5 PA

Drug Status Notes

LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET

Tier 5 PA

medroxyprogesterone oral tablet

Tier 1

MENEST ORAL TABLET Tier 3

METHITEST ORAL TABLET

Tier 3

methylergonovine oral tablet

Tier 1

methylprednisolone oral tablet

Tier 1

methylprednisolone oral tablets,dose pack

Tier 1

millipred dp oral tablets,dose pack

Tier 1

millipred oral tablet Tier 1

mimvey lo oral tablet Tier 1

mimvey oral tablet Tier 1

MYALEPT SUBCUTANEOUS RECON SOLN

Tier 5

norethindrone acetate oral tablet

Tier 1

NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR

Tier 4 PA

NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 10 MG/2 ML (5 MG/ML)

Tier 4 PA

oxandrolone oral tablet Tier 2 PA

prednisolone oral solution 15 mg/5 ml

Tier 1

prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

Tier 1

prednisone intensol oral concentrate

Tier 1

prednisone oral solution Tier 1

prednisone oral tablet Tier 1

prednisone oral tablets,dose pack

Tier 1

PREMARIN ORAL TABLET

Tier 3

PREMARIN VAGINAL CREAM

Tier 3

43

Drug Status Notes

PREMPHASE ORAL TABLET

Tier 3

PREMPRO ORAL TABLET

Tier 3

progesterone micronized oral capsule

Tier 1

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT10 MG, 20 MG, 30 MG

Tier 5 PA; QL

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG

Tier 5 PA; QL

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 5 PA

SIGNIFOR SUBCUTANEOUS SOLUTION

Tier 5 PA

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE

Tier 5

SYNAREL NASAL SPRAY,NON-AEROSOL

Tier 5 PA

testosterone cypionate intramuscular oil

Tier 1

testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %)

Tier 1 PA; QL

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

Tier 1 PA; QL

VAGIFEM VAGINAL TABLET

Tier 3

veripred 20 oral solution Tier 1

IMMUNOSUPPRESANT

ACTEMRA INTRAVENOUS SOLUTION

Tier 5 PA; QL

ACTEMRA SUBCUTANEOUS SYRINGE

Tier 5 PA; QL

azathioprine oral tablet Tier 2

CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN

Tier 4

Drug Status Notes

cyclosporine modified oral capsule

Tier 4

cyclosporine modified oral solution

Tier 4

cyclosporine oral capsule Tier 4

ELIDEL TOPICAL CREAM

Tier 3 PA

gengraf oral capsule 100 mg, 25 mg

Tier 4

GENGRAF ORAL CAPSULE 50 MG

Tier 4

gengraf oral solution Tier 4

mycophenolate mofetil oral capsule

Tier 4

mycophenolate mofetil oral tablet

Tier 4

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

Tier 4

RAPAMUNE ORAL SOLUTION

Tier 4

SIMULECT INTRAVENOUS RECON SOLN

Tier 4

sirolimus oral tablet Tier 4

STELARA SUBCUTANEOUS SYRINGE

Tier 4 PA; QL

tacrolimus oral capsule Tier 4

tacrolimus topical ointment Tier 1 PA

MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG

ACCU-CHEK AVIVA CONNECT METER

Tier 2

ACCU-CHEK AVIVA CONTROL SOLN SOLUTION

Tier 2

ACCU-CHEK AVIVA PLUS METER

Tier 2

ACCU-CHEK COMP BLUE CONT, M-H SOLUTION

Tier 2

ACCU-CHEK COMPACT PLUS CARE KIT

Tier 2

ACCU-CHEK COMPACT PLUS CONTROL SOLUTION

Tier 2

ACCU-CHEK FASTCLIX Tier 2

44

Drug Status Notes

ACCU-CHEK FASTCLIX KIT

Tier 2

ACCU-CHEK MULTICLIX LANCET

Tier 2

ACCU-CHEK MULTICLIX LANCET KIT

Tier 2

ACCU-CHEK NANO Tier 2

ACCU-CHEK SAFE-T-PRO PLUS

Tier 2

ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION

Tier 2

ACCU-CHEK SOFT DEV LANCETS KIT

Tier 2

ACCU-CHEK SOFTCLIX LANCET DEV

Tier 2

ACCU-CHEK SOFTCLIX LANCETS

Tier 2

ACCU-CHEK VOICEMATE KIT

Tier 2

acti-lance lancets 28 gauge

Tier 1

e-z ject lancets Tier 1

ONETOUCH DELICA LANC DEVICE KIT

Tier 2

ONETOUCH DELICA LANCETS

Tier 2

ONETOUCH SURESOFT LANCING DEV

Tier 2

ONETOUCH ULTRA CONTROL SOLUTION

Tier 2

ONETOUCH ULTRA2 KIT Tier 2

ONETOUCH ULTRAMINI KIT

Tier 2

ONETOUCH ULTRASOFT LANCETS

Tier 2

ONETOUCH VERIO HIGH CONTROL SOLUTION

Tier 2

ONETOUCH VERIO IQ METER

Tier 2

ONETOUCH VERIO SYNC KIT

Tier 2

ONETOUCH VERIO SYSTEM

Tier 2

MUSCLE RELAXANTS

baclofen oral tablet Tier 2

carisoprodol oral tablet Tier 1

chlorzoxazone oral tablet Tier 1

Drug Status Notes

cyclobenzaprine oral tablet Tier 1

dantrolene oral capsule Tier 2

metaxalone oral tablet Tier 1

methocarbamol oral tablet Tier 1

orphenadrine citrate oral tablet extended release

Tier 1

tizanidine oral capsule Tier 1

tizanidine oral tablet Tier 1

PRE-NATAL VITAMINS

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

Tier 1

c-nate dha oral capsule Tier 1

complete natal dha oral combo pack

Tier 1

completenate oral tablet,chewable

Tier 1

elite-ob 400 oral capsule Tier 1

elite-ob oral capsule Tier 1

folbecal oral tablet, er multiphase 24 hr

Tier 1

folivane-ob oral capsule Tier 1

hemenatal ob + dha oral combo pack

Tier 1

hemenatal ob oral tablet Tier 1

inatal advance oral tablet Tier 1

inatal ultra oral tablet Tier 1

levomefolate dha oral capsule

Tier 1

macnatal cn dha oral capsule

Tier 1

mynatal advance oral tablet

Tier 1

mynatal oral capsule Tier 1

mynatal oral tablet Tier 1

mynatal plus oral tablet Tier 1

mynatal-z oral tablet Tier 1

mynate 90 plus oral tablet extended release

Tier 1

obstetrix dha oral combo pack,tablet and cap,dr

Tier 1

pnv ob+dha oral combo pack 27-1-50-250 mg

Tier 1

pnv-dha + docusate oral capsule

Tier 1

pnv-dha oral capsule Tier 1

45

Drug Status Notes

pnv-ferrous fumarate-docu-fa oral tablet

Tier 1

pnv-omega oral capsule Tier 1

pnv-select oral tablet Tier 1

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

Tier 1

pr natal 400 oral combo pack

Tier 1

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

Tier 1

pr natal 430 oral combo pack

Tier 1

prenaissance next oral tablet

Tier 1

prenaissance oral capsule Tier 1

prenaissance plus oral capsule

Tier 1

prenatabs fa oral tablet Tier 1

prenatabs rx oral tablet Tier 1

PRENATAL 19 (WITH DOCUSATE) ORAL TABLET

Tier 1

prenatal low iron oral tablet

Tier 1

prenatal plus (calcium carb) oral tablet

Tier 1

prenatal plus oral tablet Tier 1

prenatal-u oral capsule Tier 1

preplus oral tablet Tier 1

relnate dha oral capsule Tier 1

se-natal 19 (with docusate) oral tablet

Tier 1

se-natal 19 oral tablet,chewable

Tier 1

se-tan dha oral capsule Tier 1

taron-c dha oral capsule Tier 1

taron-prex prenatal-dha oral capsule

Tier 1

tl-select oral capsule Tier 1

triadvance oral tablet Tier 1

trinatal gt oral tablet Tier 1

trinatal rx 1 oral tablet Tier 1

trinate oral tablet Tier 1

tri-tabs dha oral combo pack

Tier 1

Drug Status Notes

triveen-duo dha oral combo pack

Tier 1

triveen-one oral capsule Tier 1

triveen-prx rnf oral capsule Tier 1

trust natal dha oral combo pack

Tier 1

ultimatecare one nf oral capsule

Tier 1

ultimatecare one oral capsule

Tier 1

vemavite-prx-2 oral capsule

Tier 1

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

Tier 1

vinacal oral tablet Tier 1

vinate care oral tablet,chewable

Tier 1

vinate dha oral capsule Tier 1

vinate gt oral tablet Tier 1

vinate ii oral tablet Tier 1

vinate m oral tablet Tier 1

vinate one oral tablet Tier 1

vinate pn care oral tablet Tier 1

vinate ultra oral tablet Tier 1

VIRT-NATE DHA ORAL CAPSULE

Tier 1

virt-pn dha oral capsule Tier 1

virt-pn oral tablet Tier 1

virt-pn plus oral capsule Tier 1

virt-select oral capsule Tier 1

vitafol-ob oral tablet Tier 1

vol-nate oral tablet Tier 1

vol-tab rx oral tablet Tier 1

vp-ch plus oral capsule Tier 1

vp-ch-pnv oral capsule Tier 1

vp-ggr-b6 oral tablet Tier 1

vp-heme ob oral tablet Tier 1

vp-heme one oral capsule Tier 1

zatean-ch oral capsule Tier 1

zatean-pn dha oral capsule

Tier 1

zatean-pn plus oral capsule

Tier 1

zingiber oral tablet Tier 1

46

Drug Status Notes

PSYCHOTHERAPEUTIC DRUGS

ADDYI ORAL TABLET Tier 3 PA; QL

alprazolam oral tablet Tier 1

amitriptyline oral tablet Tier 1

amoxapine oral tablet Tier 1

aripiprazole oral solution Tier 2

aripiprazole oral tablet Tier 2

armodafinil oral tablet Tier 2 QL

bupropion hcl oral tablet 100 mg

Tier 1 QL

bupropion hcl oral tablet 75 mg

Tier 1

bupropion hcl oral tablet extended release 100 mg

Tier 1 DO


Tier 1 $0; QL


Tier 1 QL

bupropion hcl oral tablet extended release 24 hr 150 mg

Tier 1 DO

bupropion hcl oral tablet extended release 24 hr 300 mg

Tier 1 QL

buspirone oral tablet Tier 1

chlorpromazine oral tablet Tier 2

citalopram oral solution Tier 1 QL

citalopram oral tablet 10 mg, 20 mg

Tier 1 DO

citalopram oral tablet 40 mg

Tier 1 QL

clomipramine oral capsule Tier 2

clonidine hcl oral tablet extended release 12 hr

Tier 1 PA

clozapine oral tablet Tier 2

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

Tier 2

desipramine oral tablet Tier 1

dexmethylphenidate oral capsule,er biphasic 50-50

Tier 1 PA

dexmethylphenidate oral tablet

Tier 1 PA

diazepam intensol oral concentrate

Tier 1

diazepam oral concentrate Tier 1

Drug Status Notes

diazepam oral solution Tier 1

diazepam oral tablet Tier 1

doxepin oral capsule Tier 1

doxepin oral concentrate Tier 1

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 40 mg, 60 mg

Tier 2 PA; QL

duloxetine oral capsule,delayed release(dr/ec) 30 mg

Tier 2 PA; DO

EMSAM TRANSDERMAL PATCH 24 HOUR

Tier 3 QL

escitalopram oxalate oral solution

Tier 1 QL

escitalopram oxalate oral tablet 10 mg, 5 mg

Tier 1 DO

escitalopram oxalate oral tablet 20 mg

Tier 1 QL

FANAPT ORAL TABLET Tier 3

FANAPT ORAL TABLETS,DOSE PACK

Tier 3

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK

Tier 3 ST; QL

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR

Tier 3 ST; QL

fluoxetine oral capsule 10 mg, 20 mg

Tier 1 DO

fluoxetine oral capsule 40 mg

Tier 1 QL

fluoxetine oral capsule,delayed release(dr/ec)

Tier 1 QL

fluoxetine oral solution Tier 1 QL

fluoxetine oral tablet 10 mg, 20 mg

Tier 1 DO

fluphenazine hcl oral concentrate

Tier 1

fluphenazine hcl oral elixir Tier 1

fluphenazine hcl oral tablet Tier 1

fluvoxamine oral tablet 100 mg

Tier 1 QL

fluvoxamine oral tablet 25 mg, 50 mg

Tier 1 DO

FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50 10 MG

Tier 3

47

Drug Status Notes

FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50 25 MG, 35 MG

Tier 3 PA

guanfacine oral tablet extended release 24 hr

Tier 1 PA

haloperidol oral tablet Tier 1

imipramine hcl oral tablet Tier 1

LATUDA ORAL TABLET Tier 3

lithium carbonate oral capsule

Tier 1

lithium carbonate oral tablet

Tier 1

lithium carbonate oral tablet extended release

Tier 1

lithium citrate oral solution Tier 1

loxapine succinate oral capsule

Tier 1

maprotiline oral tablet Tier 1

MARPLAN ORAL TABLET

Tier 3

meprobamate oral tablet Tier 1

metadate er oral tablet extended release

Tier 1 PA

methylphenidate oral capsule, er biphasic 30-70

Tier 1 PA

methylphenidate oral capsule,er biphasic 50-50

Tier 1 PA

methylphenidate oral solution

Tier 1 PA

methylphenidate oral tablet

Tier 1 PA

methylphenidate oral tablet extended release

Tier 1 PA

methylphenidate oral tablet extended release 24hr

Tier 1 PA

mirtazapine oral tablet Tier 1

mirtazapine oral tablet,disintegrating

Tier 1

modafinil oral tablet 100 mg

Tier 1 PA; DO

modafinil oral tablet 200 mg

Tier 1 PA; QL

nefazodone oral tablet Tier 1

nortriptyline oral capsule Tier 1

nortriptyline oral solution Tier 1

olanzapine oral tablet Tier 2

Drug Status Notes

olanzapine oral tablet,disintegrating

Tier 2

paliperidone oral tablet extended release 24hr

Tier 2

paroxetine hcl oral tablet 10 mg, 20 mg

Tier 1 DO

paroxetine hcl oral tablet 30 mg, 40 mg

Tier 1 QL

paroxetine hcl oral tablet extended release 24 hr 12.5 mg

Tier 1 DO

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

Tier 1 QL

perphenazine oral tablet Tier 1

phenelzine oral tablet Tier 1

pimozide oral tablet Tier 2

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG

Tier 3 QL


Tier 3


Tier 3 DO

protriptyline oral tablet Tier 1

quetiapine oral tablet Tier 1

risperidone oral solution Tier 1

risperidone oral tablet Tier 1

risperidone oral tablet,disintegrating

Tier 1

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET

Tier 3

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

sertraline oral concentrate Tier 1 QL

sertraline oral tablet 100 mg

Tier 1 QL

sertraline oral tablet 25 mg, 50 mg

Tier 1 DO

STRATTERA ORAL CAPSULE

Tier 3 PA

thioridazine oral tablet Tier 1

thiothixene oral capsule Tier 1

tranylcypromine oral tablet Tier 1

trazodone oral tablet Tier 1

48

Drug Status Notes

trifluoperazine oral tablet Tier 1

trimipramine oral capsule Tier 1

TRINTELLIX ORAL TABLET

Tier 3 ST

venlafaxine oral capsule,extended release 24hr 150 mg

Tier 1 QL

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

Tier 1 DO

venlafaxine oral tablet Tier 1 QL

VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 150 MG, 225 MG

Tier 1 QL

VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 37.5 MG, 75 MG

Tier 1 DO

VIIBRYD ORAL TABLET10 MG, 20 MG

Tier 3 ST

VIIBRYD ORAL TABLET40 MG

Tier 3 ST; QL

VIIBRYD ORAL TABLETS,DOSE PACK10 MG (7)- 20 MG (23)

Tier 3 QL

VYVANSE ORAL CAPSULE

Tier 3 PA

ziprasidone hcl oral capsule

Tier 1

SEDATIVE/HYPNOTICS

estazolam oral tablet Tier 1

eszopiclone oral tablet 1 mg, 2 mg

Tier 1 QL

eszopiclone oral tablet 3 mg

Tier 1 PA; QL

HETLIOZ ORAL CAPSULE

Tier 5 PA; QL

phenobarbital oral elixir Tier 1

phenobarbital oral tablet Tier 1

ROZEREM ORAL TABLET

Tier 3 ST; QL

SILENOR ORAL TABLET Tier 3 QL

XYREM ORAL SOLUTION

Tier 3 PA; QL

zaleplon oral capsule Tier 1 QL

zolpidem oral tablet Tier 1 QL

SKIN PREPS

acitretin oral capsule Tier 2

Drug Status Notes

ACZONE TOPICAL GEL Tier 3

adapalene topical cream Tier 1

adapalene topical gel Tier 1

adapalene topical gel with pump

Tier 1

ADAPALENE TOPICAL LOTION

Tier 2

alclometasone topical cream

Tier 1

alclometasone topical ointment

Tier 1

ALTABAX TOPICAL OINTMENT

Tier 3

amcinonide topical cream Tier 1

amcinonide topical lotion Tier 1

amcinonide topical ointment

Tier 1

ammonium lactate topical cream

Tier 1

ammonium lactate topical lotion

Tier 1

avita topical cream Tier 1 PA

AZELEX TOPICAL CREAM

Tier 3 PA

benzoyl peroxide topical cleanser 3 %, 6 %, 7 %, 9 %

Tier 1

benzoyl peroxide topical foam

Tier 1

betamethasone dipropionate topical cream

Tier 1

betamethasone dipropionate topical lotion

Tier 1

betamethasone dipropionate topical ointment

Tier 1

betamethasone valerate topical cream

Tier 1

betamethasone valerate topical foam

Tier 1

betamethasone valerate topical lotion

Tier 1

betamethasone valerate topical ointment

Tier 1

betamethasone, augmented topical cream

Tier 1

betamethasone, augmented topical gel

Tier 1

49

Drug Status Notes

betamethasone, augmented topical lotion

Tier 1

betamethasone, augmented topical ointment

Tier 1

bpo topical gel Tier 1

bpo topical towelette 6 % Tier 1

calcipotriene scalp solution

Tier 1

calcipotriene topical cream Tier 1

calcipotriene topical ointment

Tier 1

calcipotriene-betamethasone topical ointment

Tier 1

calcitrene topical ointment Tier 1

calcitriol topical ointment Tier 1

claravis oral capsule Tier 1 PA

clindamycin-benzoyl peroxide topical gel

Tier 1

clindamycin-tretinoin topical gel

Tier 2

clobetasol scalp solution Tier 1

clobetasol topical cream Tier 1

clobetasol topical foam Tier 1

clobetasol topical gel Tier 1

clobetasol topical lotion Tier 1

clobetasol topical ointment Tier 1

clobetasol topical shampoo

Tier 1

clobetasol-emollient topical cream

Tier 1

CLODERM TOPICAL CREAM

Tier 3

CORDRAN TAPE LARGE ROLL TOPICAL TAPE

Tier 3

CORDRAN TAPE SMALL ROLL TOPICAL TAPE

Tier 3

CORDRAN TOPICAL LOTION

Tier 3

cormax scalp solution Tier 1

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE

Tier 5 PA; QL

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR

Tier 5 PA; QL

Drug Status Notes

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR

Tier 5 PA; QL

COSENTYX SUBCUTANEOUS SYRINGE

Tier 5 PA; QL

dermazene topical cream Tier 1

desonide topical cream Tier 1

desonide topical lotion Tier 1

desonide topical ointment Tier 1

desoximetasone topical cream

Tier 1

desoximetasone topical gel

Tier 1

desoximetasone topical ointment

Tier 1

diclofenac sodium topical gel 1 %

Tier 2

diflorasone topical cream Tier 1

diflorasone topical ointment

Tier 1

EPIDUO TOPICAL GEL Tier 3

EPIDUO TOPICAL GEL WITH PUMP

Tier 3

EURAX TOPICAL CREAM

Tier 3

EURAX TOPICAL LOTION

Tier 3

FINACEA TOPICAL GEL Tier 3

FLECTOR TRANSDERMAL PATCH 12 HOUR

Tier 3 ST

fluocinolone and shower cap scalp oil

Tier 1

fluocinolone topical cream Tier 1

fluocinolone topical oil Tier 1

fluocinolone topical ointment

Tier 1

fluocinolone topical solution

Tier 1

fluocinonide topical cream Tier 1

fluocinonide topical gel Tier 1

fluocinonide topical ointment

Tier 1

fluocinonide topical solution

Tier 1

fluocinonide-e topical cream

Tier 1

50

Drug Status Notes

flurandrenolide topical cream

Tier 2

fluticasone topical cream Tier 1

fluticasone topical lotion Tier 1

fluticasone topical ointment

Tier 1

halobetasol propionate topical cream

Tier 1

halobetasol propionate topical ointment

Tier 1

HALOG TOPICAL CREAM

Tier 3

HALOG TOPICAL OINTMENT

Tier 3

hydrocortisone butyrate topical cream

Tier 1

hydrocortisone butyrate topical ointment

Tier 1

hydrocortisone butyrate topical solution

Tier 1

hydrocortisone topical cream 2.5 %

Tier 1

hydrocortisone topical lotion 2.5 %

Tier 1

hydrocortisone topical ointment 2.5 %

Tier 1

hydrocortisone valerate topical cream

Tier 1

hydrocortisone valerate topical ointment

Tier 1

hydrocortisone-pramoxine topical cream

Tier 1

imiquimod topical cream in packet

Tier 1 PA; QL

IODOFLEX TOPICAL PADS, MEDICATED

Tier 3

iodoquinol-hc topical cream

Tier 1

lidocaine hcl-hydrocortison ac topical cream

Tier 1

lindane topical shampoo Tier 1

malathion topical lotion Tier 1

methoxsalen rapid oral capsule

Tier 2 PA

metronidazole topical cream

Tier 1

metronidazole topical lotion

Tier 1

MIRVASO TOPICAL GEL Tier 3

Drug Status Notes

MIRVASO TOPICAL GEL WITH PUMP

Tier 3

mometasone topical cream

Tier 1

mometasone topical ointment

Tier 1

mometasone topical solution

Tier 1

NUOX TOPICAL GEL Tier 3

OVACE PLUS TOPICAL CLEANSER,EXTENDED RELEASE

Tier 3

OVACE PLUS TOPICAL CREAM

Tier 3

OVACE PLUS WASH TOPICAL CLEANSER,GEL EXTENDED RELEASE

Tier 3

OXSORALEN TOPICAL LOTION

Tier 3

permethrin topical cream Tier 1

PHYSIOLYTE IRRIGATION SOLUTION

Tier 3

podofilox topical solution Tier 1

prednicarbate topical cream

Tier 1

prednicarbate topical ointment

Tier 1

prudoxin topical cream Tier 2

REGRANEX TOPICAL GEL

Tier 3

rosadan topical cream Tier 1

ROSADAN TOPICAL KIT, CLEANSER AND GEL

Tier 3

ROSADAN TOPICAL KIT,CLEANSER AND CREAM

Tier 3

salacyn topical cream Tier 1

salacyn topical lotion Tier 1

salicylic acid er-ceramides topical combo pack

Tier 1

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

Tier 1

salicylic acid topical cream Tier 1

salicylic acid topical cream,extended release

Tier 1

salicylic acid topical film forming liquid w/appl

Tier 1

51

Drug Status Notes

salicylic acid topical foam Tier 1

salicylic acid topical gel Tier 1

salicylic acid topical liquid 26 %

Tier 1

salicylic acid topical lotion Tier 1

salicylic acid topical lotion,extended release

Tier 1

salicylic acid topical shampoo

Tier 1

salvax topical foam Tier 1

SANTYL TOPICAL OINTMENT

Tier 3

seb-prev topical cleanser Tier 1

selenium sulfide topical shampoo 2.25 %

Tier 1

SKLICE TOPICAL LOTION

Tier 3

spinosad topical suspension

Tier 1

sulfacetamide sodium (acne) topical suspension

Tier 1

sulfacetamide sodium topical cleanser

Tier 1

sulfacetamide sodium topical shampoo

Tier 1

TACLONEX TOPICAL SUSPENSION

Tier 3

TAZORAC TOPICAL CREAM

Tier 3 PA

TAZORAC TOPICAL GEL Tier 3 PA

TIS-U-SOL PENTALYTE IRRIGATION SOLUTION

Tier 3

tretinoin (emollient) topical cream

Tier 1

tretinoin topical cream 0.025 %, 0.1 %

Tier 1 PA

tretinoin topical cream 0.05 %

Tier 1

tretinoin topical gel 0.01 %, 0.025 %

Tier 1 PA

triamcinolone acetonide topical cream

Tier 1

triamcinolone acetonide topical lotion

Tier 1

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

Tier 1

trianex topical ointment Tier 1

Drug Status Notes

triderm topical cream Tier 1

ULESFIA TOPICAL LOTION

Tier 3

zenatane oral capsule Tier 1 PA

ZIANA TOPICAL GEL Tier 3 PA

SMOKING DETERRENTS

CHANTIX CONTINUING MONTH BOX ORAL TABLET

Tier 3 $0; QL

CHANTIX ORAL TABLET Tier 3 $0; QL

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

Tier 3 $0; QL

NICOTROL INHALATION CARTRIDGE

Tier 3

NICOTROL NS NASAL SPRAY,NON-AEROSOL

Tier 3

THYROID PREPS

ARMOUR THYROID ORAL TABLET

Tier 1

levothyroxine oral tablet Tier 1

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

Tier 1

liothyronine oral tablet Tier 1

methimazole oral tablet 10 mg, 5 mg

Tier 1

nature-throid oral tablet Tier 1

np thyroid oral tablet Tier 1

propylthiouracil oral tablet Tier 1

SYNTHROID ORAL TABLET

Tier 1

THYROLAR-1 ORAL TABLET

Tier 3

THYROLAR-1/2 ORAL TABLET

Tier 3

THYROLAR-1/4 ORAL TABLET

Tier 3


Tier 3


Tier 3

unithroid oral tablet Tier 1

westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg

Tier 1

52

Drug Status Notes

WP THYROID ORAL TABLET

Tier 1

UNCLASSIFIED DRUG PRODUCTS

acamprosate oral tablet,delayed release (dr/ec)

Tier 2

ADAGEN INTRAMUSCULAR SOLUTION

Tier 5

ALDURAZYME INTRAVENOUS SOLUTION

Tier 5 PA

alendronate oral solution Tier 1 QL

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

Tier 1 QL

alfuzosin oral tablet extended release 24 hr

Tier 1

amifostine crystalline intravenous recon soln

Tier 4 PA

ARCALYST SUBCUTANEOUS RECON SOLN

Tier 5 PA; QL

BENLYSTA INTRAVENOUS RECON SOLN

Tier 5 PA

BERINERT INTRAVENOUS KIT

Tier 5 PA

BERINERT INTRAVENOUS RECON SOLN

Tier 4 PA

buprenorphine hcl sublingual tablet 2 mg, 8 mg

Tier 2 PA; QL

buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg

Tier 3 PA; QL

CARBAGLU ORAL TABLET, DISPERSIBLE

Tier 5

CERDELGA ORAL CAPSULE

Tier 5 PA

CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

Tier 5

CHEMET ORAL CAPSULE

Tier 3

chlorhexidine gluconate mucous membrane mouthwash

Tier 1

Drug Status Notes

CIALIS ORAL TABLET2.5 MG, 5 MG

Tier 3 PA; QL

CYSTADANE ORAL POWDER

Tier 3

darifenacin oral tablet extended release 24 hr

Tier 2

DEBACTEROL MUCOUS MEMBRANE SOLUTION

Tier 3

DEBACTEROL MUCOUS MEMBRANE SWAB

Tier 3

disulfiram oral tablet Tier 1

doxercalciferol oral capsule

Tier 2

doxycycline hyclate oral tablet 20 mg

Tier 1

dutasteride oral capsule Tier 2 PA

ELAPRASE INTRAVENOUS SOLUTION

Tier 5 PA

ELELYSO INTRAVENOUS RECON SOLN

Tier 5 PA

etidronate disodium oral tablet

Tier 2

EXJADE ORAL TABLET, DISPERSIBLE

Tier 5 PA

FABRAZYME INTRAVENOUS RECON SOLN

Tier 5 PA

FERRIPROX ORAL TABLET

Tier 5 PA

finasteride oral tablet 1 mg Tier 1

finasteride oral tablet 5 mg Tier 1 PA

flavoxate oral tablet Tier 1

FORTEO SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; QL

FOSAMAX PLUS D ORAL TABLET

Tier 3 ST; QL

ibandronate oral tablet Tier 1 QL

KALYDECO ORAL GRANULES IN PACKET

Tier 5 PA; QL

KALYDECO ORAL TABLET

Tier 5 PA; QL

KEVEYIS ORAL TABLET Tier 3 PA; QL

KUVAN ORAL TABLET,SOLUBLE

Tier 5 PA

leucovorin calcium oral tablet

Tier 4

53

Drug Status Notes

levocarnitine (with sugar) oral solution

Tier 2

levocarnitine oral tablet Tier 1

MYOZYME INTRAVENOUS RECON SOLN

Tier 5 PA

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3 ST

NAGLAZYME INTRAVENOUS SOLUTION

Tier 5 PA

NYSTATIN (BULK) POWDER 150 MILLION UNIT

Tier 1

oralone dental paste Tier 1

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG

Tier 5

ORFADIN ORAL CAPSULE 20 MG

Tier 4

OSPHENA ORAL TABLET

Tier 3 QL

oxybutynin chloride oral syrup

Tier 1

oxybutynin chloride oral tablet

Tier 1

oxybutynin chloride oral tablet extended release 24hr

Tier 1

pamidronate intravenous recon soln

Tier 4

pamidronate intravenous solution

Tier 4

paricalcitol oral capsule Tier 2

paroex oral rinse mucous membrane mouthwash

Tier 1

periogard mucous membrane mouthwash

Tier 1

PROLIA SUBCUTANEOUS SYRINGE

Tier 3 PA; QL

raloxifene oral tablet Tier 1 $0

RAPAFLO ORAL CAPSULE

Tier 3

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

Tier 1 QL

SAVELLA ORAL TABLET

Tier 3 QL

Drug Status Notes

SAVELLA ORAL TABLETS,DOSE PACK

Tier 3 QL

SENSIPAR ORAL TABLET

Tier 5

sodium chlor 0.9% bacteriostat injection solution

Tier 1

SOMAVERT SUBCUTANEOUS RECON SOLN

Tier 5 PA

SYPRINE ORAL CAPSULE

Tier 3

tamsulosin oral capsule,extended release 24hr

Tier 1

tolterodine oral tablet Tier 1

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

triamcinolone acetonide dental paste

Tier 1

trospium oral capsule,extended release 24hr

Tier 2

VESICARE ORAL TABLET

Tier 3

VIAGRA ORAL TABLET Tier 2 PA

VPRIV INTRAVENOUS RECON SOLN

Tier 5 PA

XIAFLEX INJECTION RECON SOLN

Tier 5 PA

ZAVESCA ORAL CAPSULE

Tier 5 PA

ZEMAIRA INTRAVENOUS RECON SOLN

Tier 5

zoledronic acid intravenous recon soln

Tier 4 PA

zoledronic acid intravenous solution

Tier 4 PA

zoledronic acid-mannitol-water intravenous solution

Tier 4 PA

VITAMINS

calcitriol oral capsule Tier 1

calcitriol oral solution Tier 1

cyanocobalamin (vitamin b-12) injection solution

Tier 1

ergocalciferol (vitamin d2) oral capsule

Tier 1

54

Drug Status Notes

folic acid oral tablet 1 mg Tier 1

tl gard rx oral tablet Tier 1

vitamin d2 oral capsule Tier 1

55

KEY Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled. QL = QUANTITY LIMITS. Certain prescription medications have specific quantity limits per prescription or per month. ST = STEP THERAPY REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized. DO = DOSE OPTIMIZATION REQUIRED. Normally this means switching from taking a drug twice a day to taking it once a day (at a higher strength). $0: PREVENTIVE DRUGS: For some members, this product may be covered at 100% with $0 cost share with a prescription from your provider if specified criteria are met.

Drug(s) may be excluded based on your plan's benefit design. If you have additional questions about your prescription benefits please call the Member Services number on your ID card.

For more information, please visit anthem.com/pharmacyinformation If you have additional questions about your prescription benefits please call the Member Services number on your ID card. Speech and hearing impaired (TDD/TTY users) should call 1-800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m. ET For the most current version of this prescription drug list, please visit anthem.com/pharmacyinformation.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans. Rev. 09/16

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