your guide to prescription drug beneits - health insurance€¦ · your guide to prescription drug...

Your Guide to Prescription Drug Benefits 2018 ESSENTIAL FORMULARY WITH PREVENTIVE DRUG COPAYS

Applies to the following Small Group plans:

• BlueCross SG Bronze 19 • BlueCross SG Silver 25 • BlueCross SG Gold 24

• BlueCross SG Bronze 20 • BlueCross SG Silver 41 • BlueCross SG Gold 25

• BlueCross SG Silver 23 • BlueCross SG Silver 52 • BlueCross SG Gold 26

2018 Essential Formulary with Preventive Copays

Table of Contents

Abbreviations and Key to Drug Tiers ……………………………………………………………………….....2

Anti - Infectives.................................................................................................................................................... 6 Antineoplastic & Immunosuppressant Drugs ....................................................................................................15 Autonomic & Cns Drugs, Neurology & Psych ..................................................................................................19 Cardiovascular, Hypertension & Lipids.............................................................................................................36 Dermatologicals/Topical Therapy......................................................................................................................46 Diagnostics & Miscellaneous Agents ................................................................................................................55 Ear, Nose & Throat Medications........................................................................................................................60 Endocrine/Diabetes ............................................................................................................................................ 61 Gastroenterology ................................................................................................................................................ 73 Immunology, Vaccines & Biotechnology..........................................................................................................79 Musculoskeletal & Rheumatology.....................................................................................................................86 Obstetrics & Gynecology................................................................................................................................... 87 Ophthalmology................................................................................................................................................... 95 Respiratory, Allergy, Cough & Cold ...............................................................................................................101 Urologicals ....................................................................................................................................................... 107 Vitamins, Hematinics & Electrolytes...............................................................................................................109 Index of Drugs.................................................................................................................................................. 117

Updated 7/2018

Requirements/Limits

AGE-A = Age edit is applicable. Prior authorization is required for members 17 years of age and younger. Your network provider must call Express Scripts at 1-877-916-2271 to request a coverage review.

ACA = Affordable Care Act. The products with the ACA indicator are available to you at no out-of-pocket cost based on the Affordable Care Act (ACA) $0 Copay Preventive List.

LD = Limited Distribution. This medication may be available only at certain pharmacies. For more information, please call BlueCross BlueShield Member Services at the phone number listed on your BlueCross BlueShield of Tennessee member ID card.

PA = Prior Authorization. The plan requires your physician to obtain prior authorization for certain drugs. This means that you will need to get approval before you may fill your prescription. Your network provider must call Express Scripts at 1-877-916-2271 to request a coverage review for a drug that requires prior authorization.

QL = Quantity Limit. For certain drugs, the plan limits the amount of the drug that will be covered.

SPRx = Specialty Medication. Includes high-cost medications for chronic, serious diseases such as hepatitis C, multiple sclerosis, arthritis, hemophilia and other conditions. Some plans may cover specialty medications at different benefit levels or may require the use of a preferred specialty pharmacy.

ST = Step Therapy. In some cases, your plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Your network provider must call Express Scripts at 1-877-916-2271 to request a coverage review. Please refer to the Step Therapy list included within this guidebook on page 3 for medications that require step therapy and the agents that are required to be taken first.

lowercase italics= Generic drugs UPPERCASE BOLD= Brand name drugs

2

Updated 7/2018

Step Therapy

Medication(s) Requiring Step Therapy Step Therapy Requirements

Edarbi Edarbyclor Trial and failure of generic ARB

Non-preferred diabetic test strips (e.g., Accu-Chek, Freestyle) QL

Trial and failure of preferred products made by Lifescan (OneTouch) QL or Ascensia (Contour or Breeze2) QL

Zioptan Trial and failure of latanoprost, Lumigan, or Travatan Z

Admelog Admelog SoloStar Apidra Apidra SoloStar Humalog Humalog KwikPen Humalog Junior KwikPen

Trial and failure of Fiasp, Fiasp FlexTouch, or Novolog

Humulin Trial and failure of Novolin

Proventil HFA QL

Ventolin HFA QL

Xopenex HFA QL Trial and failure of ProAir HFA QL or ProAir Respiclick QL

Nevanac Trial and failure of Prolensa

Alocril Alomide Bepreve Trial and failure of Pazeo Emadine Lastacaft

Azopt Betimol Betoptic S Cosopt PF Trial and failure of Alphagan P 0.1 % or Combigan

Istalol Simbrinza

Osphena Premarin Cream Trial and failure of Estrace 0.01% cream or estradiol 0.01% cream

3

Updated 7/2018

For drugs used to treat various inflammatory immune conditions, preferred drugs are required to be used before other non-preferred drugs based on a specific medical condition. A trial of one or two preferred agents will be required before a non-preferred drug will be covered. Below is a table of preferred and non-preferred agents based on various medical conditions.

Medical Condition Preferred Agents Non-Preferred Agents (directed to ONE Preferred agent)

Non-Preferred Agents (directed to TWO Preferred agents)

Rheumatoid arthritis

Actemra SC Enbrel Humira Xeljanz/XR

Cimzia Orencia SC Simponi SC Kevzara Kineret

Ankylosing spondylitis Cosentyx Enbrel Humira

Cimzia Simponi SC

Juvenile idiopathic arthritis

Enbrel Humira Orencia SC

Psoriatic arthritis

Cosentyx Enbrel Humira Stelara SC

Otezla

Cimzia Orencia SC Simponi SC Taltz Xeljanz/XR

Psoriasis

Cosentyx Humira Otezla Stelara SC

Enbrel* Tremfya*

Siliq Taltz

Crohn’s disease Humira Stelara SC

Cimzia

Ulcerative colitis Humira Simponi SC

SC – subcutaneous

* For the treatment of Psoriasis, you must try Humira first before Enbrel or Tremfya is approved. Cosentyx, Otezla or Stelara SC do not meet the requirement for coverage of Enbrel or Tremfya for Psoriasis.

4

Updated 7/2018

Drug Tiers

Tier 1= Generic Drugs with copay- based on the BlueCross Preventive Drug List

Tier 2= Preferred Brand Drugs with copay- based on the BlueCross Preventive Drug List

Tier 3= Non-Preferred Brand Drugs with copay- based on the BlueCross Preventive Drug List

Tier 4= Specialty Drugs with Deductible/Coinsurance

Tier 5= Drugs with $0 Cost Share- per Affordable Care Act (ACA) $0 Copay Preventive List

Tier 6= Generic or Brand Non-Specialty Drugs with Deductible/Coinsurance

Pharmacy Appeals To appeal a denial based on the prior authorization criteria or to request a medical exception to the quantity limit, please FAX a written request to:

Pharmacy Management Appeals BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN 37402-2555 Fax: 1-888-343-4232

Please provide the following information with your written request:

1. Patient name and cardholder ID number 2. Physician name and phone number 3. Drug and diagnosis information

This list is subject to change. Please call Member Services at the phone number listed on your BlueCross BlueShield of Tennessee member ID card or visit our website at bcbst.com for the most up‐to‐date information.

5

https://bcbst.com

6

Updated 7/2018

Drug Name Drug Tier Requirements/Limits

Anti - Infectives Antifungal Agents clotrimazole mucous membrane troche Tier 6

CRESEMBA ORAL CAPSULE Tier 6

fluconazole oral suspension for reconstitution Tier 6

fluconazole oral tablet Tier 6

flucytosine oral capsule Tier 6

griseofulvin microsize oral suspension Tier 6

griseofulvin microsize oral tablet Tier 6

griseofulvin ultramicrosize oral tablet Tier 6

itraconazole oral capsule Tier 6

ketoconazole oral tablet Tier 6

NOXAFIL ORAL SUSPENSION Tier 6

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 6

nystatin oral powder Tier 6

nystatin oral suspension Tier 6

nystatin oral tablet Tier 6

ONMEL ORAL TABLET Tier 6

ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET

Tier 6

SPORANOX ORAL SOLUTION Tier 6

terbinafine hcl oral tablet Tier 6

voriconazole oral suspension for reconstitution Tier 6

voriconazole oral tablet Tier 6

Antivirals abacavir oral solution Tier 6

abacavir oral tablet Tier 6

abacavir-lamivudine oral tablet Tier 4 SPRx

abacavir-lamivudine-zidovudine oral tablet Tier 6

acyclovir oral capsule Tier 6

acyclovir oral suspension 200 mg/5 ml Tier 6

7

Updated 7/2018

acyclovir oral tablet Tier 6

adefovir oral tablet Tier 6

amantadine hcl oral capsule Tier 6

amantadine hcl oral solution Tier 6

amantadine hcl oral tablet Tier 6

APTIVUS ORAL CAPSULE Tier 6

APTIVUS ORAL SOLUTION Tier 6

atazanavir oral capsule Tier 4 SPRx

ATRIPLA ORAL TABLET Tier 4 SPRx

BARACLUDE ORAL SOLUTION Tier 6

CIMDUO ORAL TABLET Tier 4 SPRx

COMPLERA ORAL TABLET Tier 4 SPRx

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

Tier 6

DESCOVY ORAL TABLET Tier 4 SPRx

didanosine oral capsule,delayed release(dr/ec) Tier 6

EDURANT ORAL TABLET Tier 6

efavirenz oral capsule Tier 6

efavirenz oral tablet Tier 6

EMTRIVA ORAL CAPSULE Tier 6

EMTRIVA ORAL SOLUTION Tier 6

entecavir oral tablet Tier 6

EPCLUSA ORAL TABLET Tier 4 PA; SPRx

EPIVIR HBV ORAL SOLUTION Tier 6

EPZICOM ORAL TABLET Tier 4 SPRx

EVOTAZ ORAL TABLET Tier 4 SPRx

famciclovir oral tablet Tier 6

fosamprenavir oral tablet Tier 6

FUZEON SUBCUTANEOUS RECON SOLN Tier 4 SPRx

GENVOYA ORAL TABLET Tier 4 SPRx

HARVONI ORAL TABLET Tier 4 PA; SPRx

INTELENCE ORAL TABLET Tier 6

INVIRASE ORAL CAPSULE Tier 6

8

Updated 7/2018

INVIRASE ORAL TABLET Tier 6

ISENTRESS HD ORAL TABLET Tier 4 SPRx

ISENTRESS ORAL POWDER IN PACKET Tier 4 SPRx

ISENTRESS ORAL TABLET Tier 4 SPRx

ISENTRESS ORAL TABLET,CHEWABLE Tier 4 SPRx

JULUCA ORAL TABLET Tier 4 SPRx

KALETRA ORAL SOLUTION Tier 6

KALETRA ORAL TABLET Tier 6

lamivudine oral solution Tier 6

lamivudine oral tablet Tier 6

lamivudine-zidovudine oral tablet Tier 6

LEXIVA ORAL SUSPENSION Tier 6

LEXIVA ORAL TABLET Tier 6

lopinavir-ritonavir oral solution Tier 6

MAVYRET ORAL TABLET Tier 4 PA; SPRx

nevirapine oral suspension Tier 6

nevirapine oral tablet Tier 6

nevirapine oral tablet extended release 24 hr Tier 6

NORVIR ORAL CAPSULE Tier 6

NORVIR ORAL SOLUTION Tier 6

NORVIR ORAL TABLET Tier 6

ODEFSEY ORAL TABLET Tier 4 SPRx

oseltamivir oral capsule 30 mg Tier 6 QL (20 EA per 180 days)

oseltamivir oral capsule 45 mg, 75 mg Tier 6 QL (10 EA per 180 days)

oseltamivir oral suspension for reconstitution Tier 6 QL (180 ML per 180 days)

PREZCOBIX ORAL TABLET Tier 4 SPRx

PREZISTA ORAL SUSPENSION Tier 4 SPRx

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

Tier 4 SPRx

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

Tier 6 QL (20 EA per 180 days)

RESCRIPTOR ORAL TABLET Tier 6

9

Updated 7/2018

RESCRIPTOR ORAL TABLET, DISPERSIBLE

Tier 6

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

Tier 4 SPRx

REYATAZ ORAL POWDER IN PACKET Tier 4 SPRx

rimantadine oral tablet Tier 6

ritonavir oral tablet Tier 6

SELZENTRY ORAL SOLUTION Tier 6

SELZENTRY ORAL TABLET Tier 6

stavudine oral capsule Tier 6

stavudine oral recon soln Tier 6

STRIBILD ORAL TABLET Tier 4 SPRx

SUSTIVA ORAL CAPSULE Tier 6

SUSTIVA ORAL TABLET Tier 6

SYMFI LO ORAL TABLET Tier 4 SPRx

SYMFI ORAL TABLET Tier 4 SPRx

TAMIFLU ORAL CAPSULE 30 MG Tier 6 QL (20 EA per 180 days)

TAMIFLU ORAL CAPSULE 45 MG, 75 MG Tier 6 QL (10 EA per 180 days)

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION

Tier 6 QL (180 ML per 180 days)

tenofovir disoproxil fumarate oral tablet Tier 6

TIVICAY ORAL TABLET Tier 4 SPRx

TRIUMEQ ORAL TABLET Tier 4 SPRx

TRUVADA ORAL TABLET Tier 4 SPRx

TYBOST ORAL TABLET Tier 6

TYZEKA ORAL TABLET Tier 6

valacyclovir oral tablet Tier 6

valganciclovir oral recon soln Tier 6

valganciclovir oral tablet Tier 6

VEMLIDY ORAL TABLET Tier 4 LD; SPRx

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN

Tier 6

VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN

Tier 6

10

Updated 7/2018

VIRACEPT ORAL TABLET Tier 6

VIREAD ORAL POWDER Tier 6

VIREAD ORAL TABLET Tier 6

VITEKTA ORAL TABLET Tier 4 SPRx

VOSEVI ORAL TABLET Tier 4 PA; SPRx

ZIAGEN ORAL SOLUTION Tier 6

zidovudine oral capsule Tier 6

zidovudine oral syrup Tier 6

zidovudine oral tablet Tier 6

Cephalosporins cefaclor oral capsule Tier 6

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

Tier 6

cefaclor oral tablet extended release 12 hr Tier 6

cefadroxil oral capsule Tier 6

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

Tier 6

cefadroxil oral tablet Tier 6

cefdinir oral capsule Tier 6

cefdinir oral suspension for reconstitution Tier 6

cefditoren pivoxil oral tablet Tier 6

cefixime oral suspension for reconstitution Tier 6

cefpodoxime oral suspension for reconstitution Tier 6

cefpodoxime oral tablet Tier 6

cefprozil oral suspension for reconstitution Tier 6

cefprozil oral tablet Tier 6

ceftibuten oral capsule Tier 6

ceftibuten oral suspension for reconstitution Tier 6

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION

Tier 6

cefuroxime axetil oral tablet Tier 6

cephalexin oral capsule Tier 6

cephalexin oral suspension for reconstitution Tier 6

11

Updated 7/2018

cephalexin oral tablet Tier 6

SUPRAX ORAL CAPSULE Tier 6

SUPRAX ORAL TABLET,CHEWABLE Tier 6

Erythromycins & Other Macrolides azithromycin oral packet Tier 6

azithromycin oral suspension for reconstitution Tier 6

azithromycin oral tablet Tier 6

clarithromycin oral suspension for reconstitution Tier 6

clarithromycin oral tablet Tier 6

clarithromycin oral tablet extended release 24 hr Tier 6

DIFICID ORAL TABLET Tier 6

E.E.S. 400 ORAL TABLET Tier 6

E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION

Tier 6

ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION

Tier 6

ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION

Tier 6

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 6

ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG

Tier 6

erythromycin ethylsuccinate oral tablet Tier 6

erythromycin oral capsule,delayed release(dr/ec) Tier 6

erythromycin oral tablet Tier 6

PCE ORAL TABLET, PARTICLES/CRYSTALS

Tier 6

ZMAX ORAL SUSPENSION,EXTENDED REL RECON

Tier 6

Miscellaneous Antiinfectives ALINIA ORAL SUSPENSION FOR RECONSTITUTION

Tier 6

ALINIA ORAL TABLET Tier 6

atovaquone oral suspension Tier 6

atovaquone-proguanil oral tablet Tier 6

12

Updated 7/2018

BILTRICIDE ORAL TABLET Tier 6

CAYSTON INHALATION SOLUTION FOR NEBULIZATION

Tier 4 PA; SPRx

chloroquine phosphate oral tablet Tier 6

clindamycin hcl oral capsule Tier 6

clindamycin palmitate hcl oral recon soln Tier 6

CLINDAMYCIN PEDIATRIC ORAL RECON SOLN

Tier 6

COARTEM ORAL TABLET Tier 6

cycloserine oral capsule Tier 6

dapsone oral tablet Tier 6

DARAPRIM ORAL TABLET Tier 4 PA; LD; SPRx

EMVERM ORAL TABLET,CHEWABLE Tier 6

ethambutol oral tablet Tier 6

FLAGYL ER ORAL TABLET EXTENDED RELEASE

Tier 6

hydroxychloroquine oral tablet Tier 6

isoniazid oral solution Tier 6

isoniazid oral tablet Tier 6

ivermectin oral tablet Tier 6

KETEK ORAL TABLET Tier 6

KITABIS PAK INHALATION SOLUTION FOR NEBULIZATION

Tier 4 SPRx; QL (56 ML per 30 days)

linezolid oral suspension for reconstitution Tier 6 QL (14 day supply per 30 days)

linezolid oral tablet Tier 6 QL (14 day supply per 30 days)

mefloquine oral tablet Tier 6

MEPRON ORAL SUSPENSION Tier 6

metronidazole oral capsule Tier 6

metronidazole oral tablet Tier 6

NEBUPENT INHALATION RECON SOLN Tier 6

neomycin oral tablet Tier 6

paromomycin oral capsule Tier 6

praziquantel oral tablet Tier 6

PRIFTIN ORAL TABLET Tier 6

13

Updated 7/2018

primaquine oral tablet Tier 6

pyrazinamide oral tablet Tier 6

quinine sulfate oral capsule Tier 6

rifabutin oral capsule Tier 6

RIFAMATE ORAL CAPSULE Tier 6

rifampin oral capsule Tier 6

RIFATER ORAL TABLET Tier 6

SIRTURO ORAL TABLET Tier 4 LD; SPRx

tinidazole oral tablet Tier 6

tobramycin in 0.225 % nacl inhalation solution for nebulization

Tier 4 SPRx; QL (56 ML per 30 days)

TRECATOR ORAL TABLET Tier 6

XIFAXAN ORAL TABLET Tier 6

Penicillins amoxicillin oral capsule Tier 6

amoxicillin oral suspension for reconstitution Tier 6

amoxicillin oral tablet Tier 6

amoxicillin oral tablet,chewable 125 mg, 250 mg Tier 6

amoxicillin-pot clavulanate oral suspension for reconstitution

Tier 6

amoxicillin-pot clavulanate oral tablet Tier 6

amoxicillin-pot clavulanate oral tablet extended release 12 hr

Tier 6

amoxicillin-pot clavulanate oral tablet,chewable Tier 6

ampicillin oral capsule Tier 6

ampicillin oral suspension for reconstitution Tier 6

dicloxacillin oral capsule Tier 6

penicillin v potassium oral recon soln Tier 6

penicillin v potassium oral tablet Tier 6

Quinolones ciprofloxacin (mixture) oral tablet, er multiphase 24 hr

Tier 6

ciprofloxacin hcl oral tablet Tier 6

14

Updated 7/2018

ciprofloxacin oral suspension,microcapsule recon Tier 6

FACTIVE ORAL TABLET Tier 6

levofloxacin oral solution Tier 6

levofloxacin oral tablet Tier 6

moxifloxacin oral tablet Tier 6

ofloxacin oral tablet 400 mg Tier 6

Sulfa's & Related Agents sulfadiazine oral tablet Tier 6

sulfamethoxazole-trimethoprim oral suspension Tier 6

sulfamethoxazole-trimethoprim oral tablet 800160 mg

Tier 6

SULFATRIM ORAL SUSPENSION Tier 6

Tetracyclines demeclocycline oral tablet Tier 6

doxycycline hyclate oral capsule Tier 6

doxycycline hyclate oral tablet 100 mg, 20 mg Tier 6

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

Tier 6

doxycycline monohydrate oral capsule Tier 6

doxycycline monohydrate oral suspension for reconstitution

Tier 6

doxycycline monohydrate oral tablet Tier 6

minocycline oral capsule Tier 6

minocycline oral tablet Tier 6

soloxide oral tablet,delayed release (dr/ec) Tier 6

tetracycline oral capsule Tier 6

VIBRAMYCIN ORAL SYRUP Tier 6

Urinary Tract Agents methenamine hippurate oral tablet Tier 6

methenamine mandelate oral tablet Tier 6

MONUROL ORAL PACKET Tier 6

nitrofurantoin macrocrystal oral capsule Tier 6

nitrofurantoin monohyd/m-cryst oral capsule Tier 6

15

Updated 7/2018

nitrofurantoin oral suspension Tier 6

PRIMSOL ORAL SOLUTION Tier 6

trimethoprim oral tablet Tier 6

Vancomycin FIRVANQ ORAL RECON SOLN Tier 6

vancomycin oral capsule Tier 6

Antineoplastic & Immunosuppressant Drugs Adjunctive Agents leucovorin calcium oral tablet Tier 6

MESNEX ORAL TABLET Tier 6

Antineoplastic & Immunosuppressant Drugs AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION

Tier 4 PA; SPRx

AFINITOR ORAL TABLET Tier 4 PA; SPRx

ALECENSA ORAL CAPSULE Tier 4 PA; SPRx

ALKERAN ORAL TABLET Tier 6

ALUNBRIG ORAL TABLET Tier 4 PA; SPRx

ALUNBRIG ORAL TABLETS,DOSE PACK Tier 4 PA; SPRx

anastrozole oral tablet Tier 6

ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 4 SPRx

azathioprine oral tablet Tier 6

bexarotene oral capsule Tier 4 SPRx

bicalutamide oral tablet Tier 6

BOSULIF ORAL TABLET Tier 4 PA; SPRx

CABOMETYX ORAL TABLET Tier 4 PA; SPRx

CALQUENCE ORAL CAPSULE Tier 4 PA; LD; SPRx

capecitabine oral tablet Tier 4 SPRx

CAPRELSA ORAL TABLET Tier 4 PA; LD; SPRx

COMETRIQ ORAL CAPSULE Tier 4 LD; SPRx

COTELLIC ORAL TABLET Tier 4 PA; SPRx

cyclophosphamide oral capsule Tier 6

16

Updated 7/2018

cyclosporine modified oral capsule Tier 6

cyclosporine modified oral solution Tier 6

cyclosporine oral capsule Tier 6

DROXIA ORAL CAPSULE Tier 6

EMCYT ORAL CAPSULE Tier 6

ERIVEDGE ORAL CAPSULE Tier 4 PA; SPRx

ERLEADA ORAL TABLET Tier 4 PA; SPRx

etoposide oral capsule Tier 6

exemestane oral tablet Tier 6

FARESTON ORAL TABLET Tier 6

FARYDAK ORAL CAPSULE Tier 4 PA; SPRx

flutamide oral capsule Tier 6

GENGRAF ORAL CAPSULE 100 MG, 25 MG Tier 6

GENGRAF ORAL SOLUTION Tier 6

GILOTRIF ORAL TABLET Tier 4 PA; SPRx

GLEOSTINE ORAL CAPSULE Tier 6

HEXALEN ORAL CAPSULE Tier 6

HYCAMTIN ORAL CAPSULE Tier 4 SPRx

hydroxyurea oral capsule Tier 6

IBRANCE ORAL CAPSULE Tier 4 PA; SPRx

ICLUSIG ORAL TABLET Tier 4 PA; LD; SPRx

IDHIFA ORAL TABLET Tier 4 PA; LD; SPRx

imatinib oral tablet Tier 4 SPRx

IMBRUVICA ORAL CAPSULE Tier 4 PA; LD; SPRx

IMBRUVICA ORAL TABLET Tier 4 PA; LD; SPRx

INLYTA ORAL TABLET Tier 4 PA; SPRx

IRESSA ORAL TABLET Tier 4 PA; SPRx

JAKAFI ORAL TABLET Tier 4 PA; SPRx

KISQALI ORAL TABLET Tier 4 PA; SPRx

LENVIMA ORAL CAPSULE Tier 4 PA; SPRx

letrozole oral tablet Tier 6

LEUKERAN ORAL TABLET Tier 6

17

Updated 7/2018

leuprolide subcutaneous kit Tier 4 PA; SPRx

LONSURF ORAL TABLET Tier 4 PA; SPRx

LYNPARZA ORAL CAPSULE Tier 4 PA; SPRx

LYNPARZA ORAL TABLET Tier 4 PA; LD; SPRx

LYSODREN ORAL TABLET Tier 6

MATULANE ORAL CAPSULE Tier 4 LD; SPRx

megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml

Tier 6

megestrol oral tablet Tier 6

MEKINIST ORAL TABLET Tier 4 PA; SPRx

melphalan oral tablet Tier 6

mercaptopurine oral tablet Tier 6

methotrexate sodium (pf) injection recon soln Tier 6

methotrexate sodium (pf) injection solution Tier 6

methotrexate sodium injection solution Tier 6

methotrexate sodium oral tablet Tier 6

mycophenolate mofetil oral capsule Tier 6

mycophenolate mofetil oral suspension for reconstitution

Tier 6

mycophenolate mofetil oral tablet Tier 6

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

Tier 6

MYLERAN ORAL TABLET Tier 6

NERLYNX ORAL TABLET Tier 4 PA; LD; SPRx

NEXAVAR ORAL TABLET Tier 4 PA; SPRx

nilutamide oral tablet Tier 4 SPRx

NINLARO ORAL CAPSULE Tier 4 PA; SPRx

octreotide acetate injection solution Tier 4 SPRx

octreotide acetate injection syringe Tier 4 SPRx

ODOMZO ORAL CAPSULE Tier 4 PA; SPRx

PURIXAN ORAL SUSPENSION Tier 4 LD; SPRx

RAPAMUNE ORAL SOLUTION Tier 6

RUBRACA ORAL TABLET Tier 4 PA; LD; SPRx

18

Updated 7/2018

SANDIMMUNE ORAL SOLUTION Tier 6

SIGNIFOR SUBCUTANEOUS SOLUTION Tier 4 PA; SPRx

sirolimus oral tablet Tier 6

SOLTAMOX ORAL SOLUTION Tier 5 ACA

SPRYCEL ORAL TABLET Tier 4 SPRx

STIVARGA ORAL TABLET Tier 4 PA; SPRx

SUTENT ORAL CAPSULE Tier 4 PA; SPRx

TABLOID ORAL TABLET Tier 6

tacrolimus oral capsule Tier 6

TAFINLAR ORAL CAPSULE Tier 4 PA; SPRx

TAGRISSO ORAL TABLET Tier 4 PA; SPRx

tamoxifen oral tablet Tier 5 ACA

TARCEVA ORAL TABLET Tier 4 PA; SPRx

TARGRETIN TOPICAL GEL Tier 4 SPRx

TASIGNA ORAL CAPSULE Tier 4 SPRx

temozolomide oral capsule Tier 4 PA; SPRx

THALOMID ORAL CAPSULE Tier 4 PA; SPRx

tretinoin (chemotherapy) oral capsule Tier 6

TYKERB ORAL TABLET Tier 4 PA; SPRx

VENCLEXTA ORAL TABLET Tier 4 PA; LD; SPRx

VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK

Tier 4 PA; LD; SPRx

VERZENIO ORAL TABLET Tier 4 PA; SPRx

VOTRIENT ORAL TABLET Tier 4 PA; SPRx

XALKORI ORAL CAPSULE Tier 4 PA; SPRx

XERMELO ORAL TABLET Tier 4 PA; LD; SPRx

XTANDI ORAL CAPSULE Tier 4 SPRx

ZEJULA ORAL CAPSULE Tier 4 PA; LD; SPRx

ZELBORAF ORAL TABLET Tier 4 PA; SPRx

ZOLINZA ORAL CAPSULE Tier 4 SPRx

ZORTRESS ORAL TABLET Tier 4 SPRx

ZYDELIG ORAL TABLET Tier 4 PA; LD; SPRx

ZYKADIA ORAL CAPSULE Tier 4 PA; SPRx

19

Updated 7/2018

ZYTIGA ORAL TABLET Tier 4 SPRx

Autonomic & Cns Drugs, Neurology & Psych Agents For Narcotic Withdrawal BUNAVAIL BUCCAL FILM Tier 6 QL (90 EA per 30 days)

buprenorphine hcl injection syringe Tier 6

buprenorphine-naloxone sublingual tablet Tier 6 QL (90 EA per 30 days)

SUBOXONE SUBLINGUAL FILM Tier 6 QL (90 EA per 30 days)

ZUBSOLV SUBLINGUAL TABLET Tier 6 QL (90 EA per 30 days)

Anticonvulsants APTIOM ORAL TABLET Tier 3

BANZEL ORAL SUSPENSION Tier 3

BANZEL ORAL TABLET Tier 3

carbamazepine oral capsule, er multiphase 12 hr Tier 1

carbamazepine oral suspension Tier 1

carbamazepine oral tablet Tier 1

carbamazepine oral tablet extended release 12 hr Tier 1

carbamazepine oral tablet,chewable Tier 1

CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR

Tier 3

CELONTIN ORAL CAPSULE 300 MG Tier 3

clonazepam oral tablet Tier 1

clonazepam oral tablet,disintegrating Tier 1

DEPAKENE ORAL CAPSULE Tier 3

DEPAKENE ORAL SOLUTION Tier 3

DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE

Tier 3

DIASTAT ACUDIAL RECTAL KIT Tier 3

DIASTAT RECTAL KIT Tier 3

diazepam rectal kit Tier 1

20

Updated 7/2018

DILANTIN EXTENDED ORAL CAPSULE Tier 2

DILANTIN INFATABS ORAL TABLET,CHEWABLE

Tier 2

DILANTIN KAPSEAL ORAL CAPSULE Tier 2

DILANTIN ORAL CAPSULE Tier 2

DILANTIN-125 ORAL SUSPENSION Tier 2

divalproex oral capsule, delayed rel sprinkle Tier 1

divalproex oral tablet extended release 24 hr Tier 1

divalproex oral tablet,delayed release (dr/ec) Tier 1

EPITOL ORAL TABLET Tier 1

EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR

Tier 6

ethosuximide oral capsule Tier 1

ethosuximide oral solution Tier 1

felbamate oral suspension Tier 1

felbamate oral tablet Tier 1

FELBATOL ORAL SUSPENSION Tier 3

FELBATOL ORAL TABLET Tier 3

FYCOMPA ORAL TABLET Tier 3

gabapentin oral capsule Tier 1

gabapentin oral solution Tier 1

gabapentin oral tablet 600 mg, 800 mg Tier 1

GABITRIL ORAL TABLET Tier 3

KEPPRA ORAL SOLUTION Tier 3

KEPPRA ORAL TABLET Tier 3

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

KLONOPIN ORAL TABLET Tier 3

LAMICTAL ODT ORAL TABLET,DISINTEGRATING

Tier 3

LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK

Tier 3

21

Updated 7/2018

LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK

Tier 3

LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK

Tier 3

LAMICTAL ORAL TABLET Tier 3

LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG

Tier 3

LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK

Tier 3

LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK

Tier 3

LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK

Tier 3

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR

Tier 3

LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK

Tier 3

LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK

Tier 3

LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK

Tier 3

lamotrigine oral tablet Tier 1

lamotrigine oral tablet disintegrating, dose pk Tier 1

lamotrigine oral tablet extended release 24hr Tier 1

lamotrigine oral tablet, chewable dispersible Tier 1

lamotrigine oral tablet,disintegrating Tier 1

lamotrigine oral tablets,dose pack Tier 1

levetiracetam oral solution Tier 1

levetiracetam oral tablet Tier 1

levetiracetam oral tablet extended release 24 hr Tier 1

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 6

LYRICA ORAL CAPSULE Tier 6

LYRICA ORAL SOLUTION Tier 6

22

Updated 7/2018

MYSOLINE ORAL TABLET Tier 3

NEURONTIN ORAL CAPSULE Tier 3

NEURONTIN ORAL SOLUTION Tier 3

NEURONTIN ORAL TABLET Tier 3

ONFI ORAL SUSPENSION Tier 3

ONFI ORAL TABLET 10 MG, 20 MG Tier 3

oxcarbazepine oral suspension Tier 1

oxcarbazepine oral tablet Tier 1

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 2

PEGANONE ORAL TABLET Tier 3

phenobarbital oral elixir Tier 1

phenobarbital oral tablet Tier 1

PHENYTEK ORAL CAPSULE Tier 3

phenytoin oral suspension Tier 1

phenytoin oral tablet,chewable Tier 1

phenytoin sodium extended oral capsule Tier 1

primidone oral tablet Tier 1

QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR

Tier 2

roweepra oral tablet Tier 1

roweepra xr oral tablet extended release 24 hr Tier 1

SABRIL ORAL POWDER IN PACKET Tier 3

SABRIL ORAL TABLET Tier 3

SPRITAM ORAL TABLET FOR SUSPENSION

Tier 3

TEGRETOL ORAL SUSPENSION Tier 3

TEGRETOL ORAL TABLET Tier 3

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

tiagabine oral tablet Tier 1

TOPAMAX ORAL CAPSULE, SPRINKLE Tier 3

TOPAMAX ORAL TABLET Tier 3

topiramate oral capsule, sprinkle Tier 1

23

Updated 7/2018

topiramate oral capsule,sprinkle,er 24hr Tier 6

topiramate oral tablet Tier 1

TRILEPTAL ORAL SUSPENSION Tier 3

TRILEPTAL ORAL TABLET Tier 3

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 2

valproic acid (as sodium salt) oral solution Tier 1

valproic acid oral capsule Tier 1

vigabatrin oral powder in packet Tier 1

VIMPAT ORAL SOLUTION Tier 2

VIMPAT ORAL TABLET Tier 2

ZARONTIN ORAL CAPSULE Tier 3

ZARONTIN ORAL SOLUTION Tier 3

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG

Tier 3

zonisamide oral capsule Tier 1

Antiparkinsonism Agents APOKYN SUBCUTANEOUS CARTRIDGE Tier 4 SPRx

benztropine oral tablet Tier 6

bromocriptine oral capsule Tier 6

bromocriptine oral tablet Tier 1

carbidopa oral tablet Tier 6

carbidopa-levodopa oral tablet Tier 6

carbidopa-levodopa oral tablet extended release Tier 6

carbidopa-levodopa oral tablet,disintegrating Tier 6

carbidopa-levodopa-entacapone oral tablet Tier 6

DUOPA J-TUBE INTESTINAL PUMP SUSPENSION

Tier 4 PA; SPRx

entacapone oral tablet Tier 6

NEUPRO TRANSDERMAL PATCH 24 HOUR

Tier 6

pramipexole oral tablet Tier 6

pramipexole oral tablet extended release 24 hr Tier 6

24

Updated 7/2018

rasagiline oral tablet Tier 6

ropinirole oral tablet Tier 6

ropinirole oral tablet extended release 24 hr Tier 6

selegiline hcl oral capsule Tier 6

selegiline hcl oral tablet Tier 6

tolcapone oral tablet Tier 6

trihexyphenidyl oral elixir Tier 6

trihexyphenidyl oral tablet Tier 6

ZELAPAR ORAL TABLET,DISINTEGRATING

Tier 6

Migraine & Cluster Headache Therapy almotriptan malate oral tablet Tier 6 QL (18 EA per 30 days)

dihydroergotamine injection solution Tier 6

dihydroergotamine nasal spray,non-aerosol Tier 6 QL (8 ML per 30 days)

eletriptan oral tablet Tier 6 QL (18 EA per 30 days)

ergotamine-caffeine oral tablet Tier 6

frovatriptan oral tablet Tier 6

isometh-dichloral-acetaminophn oral capsule Tier 6

MIGERGOT RECTAL SUPPOSITORY Tier 6

naratriptan oral tablet Tier 6 QL (18 EA per 30 days)

NODOLOR ORAL CAPSULE Tier 6

RELPAX ORAL TABLET Tier 6 QL (18 EA per 30 days)

rizatriptan oral tablet Tier 6 QL (18 EA per 30 days)

rizatriptan oral tablet,disintegrating Tier 6 QL (18 EA per 30 days)

sumatriptan nasal spray,non-aerosol Tier 6 QL (12 EA per 30 days)

sumatriptan succinate oral tablet Tier 6 QL (18 EA per 30 days)

sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml


sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml


sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml


sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml


25

Updated 7/2018

sumatriptan succinate subcutaneous solution Tier 6 QL (8 ML per 30 days)

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml


SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML


SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML


zolmitriptan oral tablet Tier 6 QL (18 EA per 30 days)

zolmitriptan oral tablet,disintegrating Tier 6 QL (18 EA per 30 days)

ZOMIG NASAL SPRAY,NON-AEROSOL Tier 6

Miscellaneous Neurological Therapy AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR

Tier 4 PA; SPRx

AUSTEDO ORAL TABLET Tier 4 PA; LD; SPRx

donepezil oral tablet Tier 6

donepezil oral tablet,disintegrating Tier 6

galantamine oral capsule,ext rel. pellets 24 hr Tier 6

galantamine oral solution Tier 6

galantamine oral tablet Tier 6

HORIZANT ORAL TABLET EXTENDED RELEASE

Tier 6

KEVEYIS ORAL TABLET Tier 4 PA; LD; SPRx

memantine oral capsule,sprinkle,er 24hr Tier 6

memantine oral solution Tier 6

memantine oral tablet Tier 6

memantine oral tablets,dose pack Tier 6

NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK

Tier 6

NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK

Tier 6

NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR

Tier 6

NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK

Tier 6

26

Updated 7/2018

NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR

Tier 6

NUEDEXTA ORAL CAPSULE Tier 6

rivastigmine tartrate oral capsule Tier 6

rivastigmine transdermal patch 24 hour Tier 6

tetrabenazine oral tablet Tier 4 PA; SPRx

Muscle Relaxants & Antispasmodic Therapy baclofen oral tablet 10 mg, 20 mg Tier 6

carisoprodol oral tablet Tier 6

carisoprodol-asa-codeine oral tablet Tier 6

carisoprodol-aspirin oral tablet Tier 6

chlorzoxazone oral tablet Tier 6

cyclobenzaprine oral tablet Tier 6

dantrolene oral capsule Tier 6

meprobamate oral tablet Tier 6

MESTINON ORAL SYRUP Tier 6

metaxalone oral tablet 800 mg Tier 6

methocarbamol oral tablet Tier 6

orphenadrine citrate oral tablet extended release Tier 6

pyridostigmine bromide oral tablet Tier 6

pyridostigmine bromide oral tablet extended release

Tier 6

tizanidine oral capsule Tier 6

tizanidine oral tablet Tier 6

Narcotic Analgesics acetaminophen-caff-dihydrocod oral capsule Tier 6 QL (120 EA per 30 days)

acetaminophen-codeine oral solution 120-12 mg/5 ml


acetaminophen-codeine oral tablet Tier 6 QL (180 EA per 30 days)

ASCOMP WITH CODEINE ORAL CAPSULE Tier 6 QL (120 EA per 30 days)

aspirin-caffeine-dihydrocodein oral capsule Tier 6 QL (240 EA per 30 days)

butalbital compound w/codeine oral capsule Tier 6 QL (120 EA per 30 days)

butalbital-acetaminop-caf-cod oral capsule Tier 6 QL (120 EA per 30 days)

27

Updated 7/2018

butalbital-acetaminophen oral tablet Tier 6 QL (120 EA per 30 days)

butalbital-acetaminophen-caff oral capsule Tier 6 QL (120 EA per 30 days)

butalbital-acetaminophen-caff oral tablet 50-32540 mg


butalbital-aspirin-caffeine oral capsule Tier 6 QL (120 EA per 30 days)

butorphanol tartrate nasal spray,non-aerosol Tier 6 QL (5 ML per 28 days)

BUTRANS TRANSDERMAL PATCH WEEKLY

Tier 6 PA; QL (4 EA per 28 days)

CAPACET ORAL CAPSULE Tier 6 QL (120 EA per 30 days)

codeine sulfate oral tablet Tier 6 QL (180 EA per 30 days)

codeine-butalbital-asa-caff oral capsule Tier 6 QL (120 EA per 30 days)

diskets oral tablet,soluble Tier 6 PA; QL (50 EA per 30 days)

ENDOCET ORAL TABLET 10-325 MG, 2.5325 MG, 5-325 MG, 7.5-325 MG


fentanyl citrate buccal lozenge on a handle 1,200 mcg


fentanyl citrate buccal lozenge on a handle 1,600 mcg


fentanyl citrate buccal lozenge on a handle 200 mcg








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


hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml)


hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml


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


hydrocodone-ibuprofen oral tablet 10-200 mg, 5200 mg, 7.5-200 mg


28

Updated 7/2018

hydromorphone oral liquid Tier 6 QL (30 ML per 30 days)

hydromorphone oral tablet Tier 6 QL (120 EA per 30 days)

hydromorphone rectal suppository Tier 6 QL (60 EA per 30 days)

ibuprofen-oxycodone oral tablet Tier 6 QL (28 EA per 30 days)

KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG, 40 MG


levorphanol tartrate oral tablet Tier 6 QL (120 EA per 30 days)

LORCET (HYDROCODONE) ORAL TABLET


LORCET HD ORAL TABLET Tier 6 QL (120 EA per 30 days)

LORCET PLUS ORAL TABLET 7.5-325 MG Tier 6 QL (120 EA per 30 days)

LORTAB ELIXIR ORAL SOLUTION 10-300 MG/15 ML


meperidine oral solution Tier 6 QL (480 ML per 30 days)

meperidine oral tablet Tier 6 QL (120 EA per 30 days)

METHADONE INTENSOL ORAL CONCENTRATE

Tier 6 PA; QL (120 ML per 30 days)

methadone oral concentrate Tier 6 PA; QL (120 ML per 30 days)

methadone oral solution 10 mg/5 ml Tier 6 PA; QL (480 ML per 30 days)

methadone oral solution 5 mg/5 ml Tier 6 PA; QL (960 ML per 30 days)

methadone oral tablet Tier 6 PA; QL (120 EA per 30 days)

methadone oral tablet,soluble Tier 6 PA; QL (50 EA per 30 days)

METHADOSE ORAL CONCENTRATE Tier 6 PA; QL (120 ML per 30 days)

METHADOSE ORAL TABLET,SOLUBLE Tier 6 PA; QL (50 EA per 30 days)

morphine concentrate oral solution Tier 6 QL (300 ML per 30 days)

morphine oral capsule, er multiphase 24 hr 120 mg


morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg


morphine oral capsule,extend.release pellets Tier 6 PA; QL (60 EA per 30 days)

morphine oral solution Tier 6 QL (900 ML per 30 days)

morphine oral tablet Tier 6 QL (120 EA per 30 days)

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


29

Updated 7/2018

morphine oral tablet extended release 200 mg Tier 6 PA; QL (30 EA per 30 days)

morphine rectal suppository Tier 6 QL (120 EA per 30 days)

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR


NUCYNTA ORAL TABLET Tier 6 QL (120 EA per 30 days)

oxycodone oral capsule Tier 6 QL (120 EA per 30 days)

oxycodone oral concentrate Tier 6 QL (120 ML per 30 days)

oxycodone oral solution Tier 6 QL (480 ML per 30 days)

oxycodone oral tablet Tier 6 QL (120 EA per 30 days)

oxycodone-acetaminophen oral solution Tier 6 QL (480 ML per 30 days)

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


oxycodone-aspirin oral tablet Tier 6 QL (120 EA per 30 days)

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG


OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG


oxymorphone oral tablet Tier 6 QL (120 EA per 30 days)

oxymorphone oral tablet extended release 12 hr Tier 6 PA; QL (60 EA per 30 days)

pentazocine-naloxone oral tablet Tier 6 QL (120 EA per 30 days)

phrenilin forte(with caffeine) oral capsule Tier 6 QL (120 EA per 30 days)

REPREXAIN ORAL TABLET Tier 6 QL (120 EA per 30 days)

TENCON ORAL TABLET 50-325 MG Tier 6 QL (120 EA per 30 days)

tramadol oral tablet Tier 6 QL (240 EA per 30 days)

tramadol oral tablet extended release 24 hr Tier 6 PA; QL (30 EA per 30 days)

tramadol oral tablet, er multiphase 24 hr Tier 6 PA; QL (30 EA per 30 days)

tramadol-acetaminophen oral tablet Tier 6 QL (240 EA per 30 days)

VERDROCET ORAL TABLET Tier 6 QL (120 EA per 30 days)

VICODIN ES ORAL TABLET Tier 6 QL (120 EA per 30 days)

VICODIN HP ORAL TABLET Tier 6 QL (120 EA per 30 days)

VICODIN ORAL TABLET Tier 6 QL (120 EA per 30 days)

XYLON 10 ORAL TABLET Tier 6 QL (150 EA per 30 days)

ZAMICET ORAL SOLUTION Tier 6 QL (480 ML per 30 days)

30

Updated 7/2018

ZEBUTAL ORAL CAPSULE 50-325-40 MG Tier 6 QL (120 EA per 30 days)

Non-Narcotic Analgesics celecoxib oral capsule Tier 6

diclofenac potassium oral tablet Tier 6

diclofenac sodium oral tablet extended release 24 hr

Tier 6

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

Tier 6

diclofenac sodium topical gel 1 % Tier 6 QL (500 GM per 30 days)

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic

Tier 6

diflunisal oral tablet Tier 6

etodolac oral capsule Tier 6

etodolac oral tablet Tier 6

etodolac oral tablet extended release 24 hr Tier 6

fenoprofen oral tablet Tier 6

flurbiprofen oral tablet Tier 6

ibu oral tablet Tier 6

ibuprofen oral suspension Tier 6

ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 6

INDOCIN ORAL SUSPENSION Tier 6

indomethacin oral capsule Tier 6

indomethacin oral capsule, extended release Tier 6

ketoprofen oral capsule Tier 6

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

Tier 6

ketorolac oral tablet Tier 6

meclofenamate oral capsule Tier 6

mefenamic acid oral capsule Tier 6

meloxicam oral suspension Tier 6

meloxicam oral tablet Tier 6

nabumetone oral tablet Tier 6

naproxen oral suspension Tier 6

31

Updated 7/2018

naproxen oral tablet Tier 6

naproxen oral tablet,delayed release (dr/ec) Tier 6

naproxen sodium oral tablet 275 mg, 550 mg Tier 6

oxaprozin oral tablet Tier 6

piroxicam oral capsule Tier 6

salsalate oral tablet Tier 6

SPRIX NASAL SPRAY,NON-AEROSOL Tier 4 LD; SPRx

sulindac oral tablet Tier 6

tolmetin oral capsule Tier 6

tolmetin oral tablet Tier 6

Opiate/Narcotic Reversal Agents - Opiate Antagonists naloxone injection solution Tier 6 QL (2 units per 1 claim)

naloxone injection syringe Tier 6 QL (2 units per 1 claim)

naltrexone oral tablet Tier 6

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

Tier 6 QL (2 units per 1 claim)

Psychotherapeutic Drugs ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

Tier 4 SPRx; AGE-A

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

Tier 4 SPRx; AGE-A

ALPRAZOLAM INTENSOL ORAL CONCENTRATE

Tier 6

alprazolam oral tablet Tier 6

alprazolam oral tablet extended release 24 hr Tier 6

alprazolam oral tablet,disintegrating Tier 6

amitriptyline oral tablet Tier 1

amitriptyline-chlordiazepoxide oral tablet Tier 1

amoxapine oral tablet Tier 1

aripiprazole oral solution Tier 1 AGE-A

aripiprazole oral tablet Tier 1 AGE-A

aripiprazole oral tablet,disintegrating Tier 1 AGE-A

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

Tier 4 LD; SPRx; AGE-A

32

Updated 7/2018

armodafinil oral tablet Tier 6 PA

atomoxetine oral capsule Tier 6

bupropion hcl oral tablet Tier 1

bupropion hcl oral tablet extended release 12 hr Tier 1

bupropion hcl oral tablet extended release 24 hr Tier 1

buspirone oral tablet Tier 6

chlordiazepoxide hcl oral capsule Tier 6

chlorpromazine oral tablet Tier 1

citalopram oral solution Tier 1

citalopram oral tablet Tier 1

clomipramine oral capsule Tier 1

clonidine hcl oral tablet extended release 12 hr Tier 6

clorazepate dipotassium oral tablet Tier 6

clozapine oral tablet Tier 1 AGE-A

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

Tier 1 AGE-A

CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 200 MG

Tier 6 AGE-A

DAYTRANA TRANSDERMAL PATCH 24 HOUR

Tier 6

desipramine oral tablet Tier 1

desvenlafaxine succinate oral tablet extended release 24 hr

Tier 1

DEXEDRINE ORAL TABLET Tier 6

dexmethylphenidate oral capsule,er biphasic 5050

Tier 6

dexmethylphenidate oral tablet Tier 6

dextroamphetamine oral capsule, extended release Tier 6

dextroamphetamine oral solution Tier 6

dextroamphetamine oral tablet Tier 6

dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg

Tier 6

dextroamphetamine-amphetamine oral tablet Tier 6

33

Updated 7/2018

DIAZEPAM INTENSOL ORAL CONCENTRATE

Tier 6

diazepam oral solution 5 mg/5 ml (1 mg/ml) Tier 6

diazepam oral tablet Tier 6

doxepin oral capsule Tier 1

doxepin oral concentrate Tier 1

duloxetine oral capsule,delayed release(dr/ec) Tier 1

EMSAM TRANSDERMAL PATCH 24 HOUR Tier 6

ergoloid oral tablet Tier 6

escitalopram oxalate oral solution Tier 1

escitalopram oxalate oral tablet Tier 1

estazolam oral tablet Tier 6

eszopiclone oral tablet Tier 6

FANAPT ORAL TABLET Tier 6 AGE-A

FANAPT ORAL TABLETS,DOSE PACK Tier 6 AGE-A

FAZACLO ORAL TABLET,DISINTEGRATING 150 MG, 200 MG

Tier 6 AGE-A

fluoxetine oral capsule Tier 1

fluoxetine oral capsule,delayed release(dr/ec) Tier 1

fluoxetine oral solution Tier 1

fluoxetine oral tablet Tier 1

fluphenazine hcl oral concentrate Tier 1

fluphenazine hcl oral elixir Tier 1

fluphenazine hcl oral tablet Tier 1

flurazepam oral capsule Tier 6

fluvoxamine oral capsule,extended release 24hr Tier 1

fluvoxamine oral tablet Tier 1

guanfacine oral tablet extended release 24 hr Tier 6

guanidine oral tablet Tier 6

haloperidol lactate oral concentrate Tier 1

haloperidol oral tablet Tier 1

imipramine hcl oral tablet Tier 1

34

Updated 7/2018

imipramine pamoate oral capsule Tier 1

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

Tier 4 SPRx; AGE-A

INVEGA TRINZA INTRAMUSCULAR SYRINGE

Tier 4 SPRx; AGE-A

LATUDA ORAL TABLET Tier 2 AGE-A

lithium carbonate oral capsule Tier 6

lithium carbonate oral tablet Tier 6

lithium carbonate oral tablet extended release Tier 6

lithium citrate oral solution 8 meq/5 ml Tier 6

LORAZEPAM INTENSOL ORAL CONCENTRATE

Tier 6

lorazepam oral concentrate Tier 6

lorazepam oral tablet Tier 6

loxapine succinate oral capsule Tier 1

maprotiline oral tablet Tier 1

MARPLAN ORAL TABLET Tier 6

METADATE ER ORAL TABLET EXTENDED RELEASE

Tier 6

methamphetamine oral tablet Tier 6

methylphenidate hcl oral capsule, er biphasic 3070

Tier 6

methylphenidate hcl oral capsule,er biphasic 5050

Tier 6

methylphenidate hcl oral solution Tier 6

methylphenidate hcl oral tablet Tier 6

methylphenidate hcl oral tablet extended release Tier 6

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

Tier 6

methylphenidate hcl oral tablet,chewable Tier 6

midazolam oral syrup 2 mg/ml Tier 6

mirtazapine oral tablet Tier 1

mirtazapine oral tablet,disintegrating Tier 1

modafinil oral tablet Tier 6 PA

35

Updated 7/2018

molindone oral tablet Tier 6

nefazodone oral tablet Tier 1

nortriptyline oral capsule Tier 1

nortriptyline oral solution Tier 1

NUPLAZID ORAL TABLET Tier 4 PA; SPRx

olanzapine oral tablet Tier 1 AGE-A

olanzapine oral tablet,disintegrating Tier 1 AGE-A

olanzapine-fluoxetine oral capsule Tier 1 AGE-A

oxazepam oral capsule Tier 6

paliperidone oral tablet extended release 24hr Tier 1 AGE-A

paroxetine hcl oral tablet Tier 1

paroxetine hcl oral tablet extended release 24 hr Tier 1

PAXIL ORAL SUSPENSION Tier 6

perphenazine oral tablet Tier 1

perphenazine-amitriptyline oral tablet Tier 1

phenelzine oral tablet Tier 1

pimozide oral tablet Tier 1

PROCENTRA ORAL SOLUTION Tier 6

protriptyline oral tablet Tier 1

quazepam oral tablet Tier 6

quetiapine oral tablet Tier 1 AGE-A

quetiapine oral tablet extended release 24 hr Tier 1 AGE-A

QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON

Tier 6

RISPERDAL CONSTA INTRAMUSCULAR SYRINGE

Tier 4 SPRx; AGE-A

risperidone oral solution Tier 1 AGE-A

risperidone oral tablet Tier 1 AGE-A

risperidone oral tablet,disintegrating Tier 1 AGE-A

ROZEREM ORAL TABLET Tier 6

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET

Tier 6 AGE-A

SARAFEM ORAL TABLET 10 MG, 20 MG Tier 6

36

Updated 7/2018

sertraline oral concentrate Tier 1

sertraline oral tablet Tier 1

STRATTERA ORAL CAPSULE Tier 6

temazepam oral capsule Tier 6

thioridazine oral tablet Tier 1

thiothixene oral capsule Tier 1

tranylcypromine oral tablet Tier 1

trazodone oral tablet Tier 1

triazolam oral tablet Tier 6

trifluoperazine oral tablet Tier 1

trimipramine oral capsule Tier 1

TRINTELLIX ORAL TABLET Tier 3

venlafaxine oral capsule,extended release 24hr Tier 1

venlafaxine oral tablet Tier 1

VIIBRYD ORAL TABLET Tier 2

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)

Tier 2

VRAYLAR ORAL CAPSULE Tier 3 AGE-A

VRAYLAR ORAL CAPSULE,DOSE PACK Tier 3 AGE-A

VYVANSE ORAL CAPSULE Tier 6

VYVANSE ORAL TABLET,CHEWABLE Tier 6

XYREM ORAL SOLUTION Tier 4 PA; LD; SPRx

zaleplon oral capsule Tier 6

ZENZEDI ORAL TABLET Tier 6

ziprasidone hcl oral capsule Tier 1 AGE-A

zolpidem oral tablet Tier 6

zolpidem oral tablet,ext release multiphase Tier 6

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 4 SPRx; AGE-A

Cardiovascular, Hypertension & Lipids Antiarrhythmic Agents amiodarone oral tablet Tier 1

disopyramide phosphate oral capsule Tier 1

37

Updated 7/2018

dofetilide oral capsule Tier 6

flecainide oral tablet Tier 1

mexiletine oral capsule Tier 1

MULTAQ ORAL TABLET Tier 6

NORPACE CR ORAL CAPSULE, EXTENDED RELEASE

Tier 6

PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG

Tier 1

propafenone oral capsule,extended release 12 hr Tier 1

propafenone oral tablet Tier 1

quinidine gluconate oral tablet extended release Tier 1

quinidine sulfate oral tablet Tier 1

SORINE ORAL TABLET Tier 1

SOTALOL AF ORAL TABLET Tier 1

sotalol oral tablet Tier 1

SOTYLIZE ORAL SOLUTION Tier 6

Antihypertensive Therapy acebutolol oral capsule Tier 1

AFEDITAB CR ORAL TABLET EXTENDED RELEASE

Tier 1

amiloride oral tablet Tier 1

amiloride-hydrochlorothiazide oral tablet Tier 1

amlodipine oral tablet Tier 1

amlodipine-benazepril oral capsule Tier 1

amlodipine-olmesartan oral tablet Tier 1

amlodipine-valsartan oral tablet Tier 6

amlodipine-valsartan-hcthiazid oral tablet Tier 6

atenolol oral tablet Tier 1

atenolol-chlorthalidone oral tablet Tier 1

benazepril oral tablet Tier 1

benazepril-hydrochlorothiazide oral tablet Tier 1

betaxolol oral tablet Tier 1

BIDIL ORAL TABLET Tier 6

38

Updated 7/2018

bisoprolol fumarate oral tablet Tier 1

bisoprolol-hydrochlorothiazide oral tablet Tier 1

bumetanide oral tablet Tier 1

BYSTOLIC ORAL TABLET Tier 2

candesartan oral tablet Tier 1

candesartan-hydrochlorothiazid oral tablet Tier 1

captopril oral tablet Tier 1

captopril-hydrochlorothiazide oral tablet Tier 1

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG

Tier 6

CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR

Tier 6

CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 1

carvedilol oral tablet Tier 1

carvedilol phosphate oral capsule, er multiphase 24 hr

Tier 1

chlorothiazide oral tablet Tier 1

chlorthalidone oral tablet 25 mg, 50 mg Tier 1

clonidine hcl oral tablet Tier 1

clonidine transdermal patch weekly Tier 6

CLORPRES ORAL TABLET 0.1-15 MG, 0.215 MG

Tier 1

CLORPRES ORAL TABLET 0.3-15 MG Tier 6

COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR

Tier 2

diltiazem hcl oral capsule,ext.rel 24h degradable Tier 1

diltiazem hcl oral capsule,extended release 12 hr Tier 1

diltiazem hcl oral capsule,extended release 24 hr Tier 1

diltiazem hcl oral capsule,extended release 24hr Tier 1

diltiazem hcl oral tablet Tier 1

diltiazem hcl oral tablet extended release 24 hr Tier 1

DILT-XR ORAL CAPSULE,EXT.REL 24H DEGRADABLE

Tier 1

39

Updated 7/2018

DIURIL ORAL SUSPENSION Tier 6

doxazosin oral tablet Tier 1

DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR

Tier 6

DYRENIUM ORAL CAPSULE Tier 6

EDARBI ORAL TABLET Tier 6 ST

EDARBYCLOR ORAL TABLET Tier 6 ST

enalapril maleate oral tablet Tier 1

enalapril-hydrochlorothiazide oral tablet Tier 1

EPANED ORAL RECON SOLN Tier 6

EPANED ORAL SOLUTION Tier 6

eplerenone oral tablet Tier 1

epoprostenol (glycine) intravenous recon soln Tier 4 PA; SPRx

eprosartan oral tablet Tier 1

ethacrynic acid oral tablet Tier 6

felodipine oral tablet extended release 24 hr Tier 1

FLOLAN INTRAVENOUS RECON SOLN Tier 4 PA; SPRx

fosinopril oral tablet Tier 1

fosinopril-hydrochlorothiazide oral tablet Tier 1

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

Tier 1

furosemide oral tablet Tier 1

guanfacine oral tablet Tier 1

hydralazine oral tablet Tier 1

hydrochlorothiazide oral capsule Tier 1

hydrochlorothiazide oral tablet Tier 1

indapamide oral tablet Tier 1

irbesartan oral tablet Tier 1

irbesartan-hydrochlorothiazide oral tablet Tier 1

isradipine oral capsule Tier 1

labetalol oral tablet Tier 1

LEVATOL ORAL TABLET Tier 6

lisinopril oral tablet Tier 1

40

Updated 7/2018

lisinopril-hydrochlorothiazide oral tablet Tier 1

losartan oral tablet Tier 1

losartan-hydrochlorothiazide oral tablet Tier 1

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR

Tier 1

methyclothiazide oral tablet Tier 1

methyldopa oral tablet Tier 1

methyldopa-hydrochlorothiazide oral tablet Tier 1

metolazone oral tablet Tier 1

metoprolol succinate oral tablet extended release 24 hr

Tier 1

metoprolol ta-hydrochlorothiaz oral tablet Tier 1

metoprolol tartrate oral tablet Tier 1

minoxidil oral tablet Tier 1

moexipril oral tablet Tier 1

moexipril-hydrochlorothiazide oral tablet Tier 1

nadolol oral tablet Tier 1

nadolol-bendroflumethiazide oral tablet Tier 1

nicardipine oral capsule Tier 1

nifedipine oral capsule Tier 1

nifedipine oral tablet extended release Tier 1

nifedipine oral tablet extended release 24hr Tier 1

nimodipine oral capsule Tier 1

nisoldipine oral tablet extended release 24 hr Tier 1

olmesartan oral tablet Tier 1

olmesartan-amlodipin-hcthiazid oral tablet Tier 1

olmesartan-hydrochlorothiazide oral tablet Tier 1

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG

Tier 4 PA; SPRx

ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG

Tier 4 PA; LD; SPRx

perindopril erbumine oral tablet Tier 1

phenoxybenzamine oral capsule Tier 6

pindolol oral tablet Tier 1

41

Updated 7/2018

prazosin oral capsule Tier 1

propranolol oral capsule,extended release 24 hr Tier 1

propranolol oral solution Tier 1

propranolol oral tablet Tier 1

propranolol-hydrochlorothiazid oral tablet Tier 1

quinapril oral tablet Tier 1

quinapril-hydrochlorothiazide oral tablet Tier 1

ramipril oral capsule Tier 1

REMODULIN INJECTION SOLUTION Tier 4 PA; SPRx

spironolactone oral tablet Tier 1

spironolacton-hydrochlorothiaz oral tablet Tier 1

TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR

Tier 1

TEKTURNA HCT ORAL TABLET Tier 6

TEKTURNA ORAL TABLET Tier 6

telmisartan oral tablet Tier 1

telmisartan-amlodipine oral tablet Tier 1

telmisartan-hydrochlorothiazid oral tablet Tier 1

terazosin oral capsule Tier 1

timolol maleate oral tablet Tier 1

torsemide oral tablet Tier 1

trandolapril oral tablet Tier 1

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

Tier 1

triamterene-hydrochlorothiazid oral capsule Tier 1

triamterene-hydrochlorothiazid oral tablet Tier 1

valsartan oral tablet Tier 1

valsartan-hydrochlorothiazide oral tablet Tier 1

VELETRI INTRAVENOUS RECON SOLN Tier 4 PA; SPRx

verapamil oral capsule, 24 hr er pellet ct Tier 1

verapamil oral capsule,ext rel. pellets 24 hr Tier 1

verapamil oral tablet Tier 1

verapamil oral tablet extended release Tier 1

42

Updated 7/2018

Cardiac Glycosides DIGITEK ORAL TABLET Tier 1

DIGOX ORAL TABLET Tier 1

digoxin oral solution Tier 1

digoxin oral tablet Tier 1

LANOXIN ORAL TABLET Tier 2

Coagulation Therapy ADVATE INTRAVENOUS RECON SOLN Tier 4 SPRx

ALPHANATE INTRAVENOUS RECON SOLN

Tier 4 SPRx

ALPHANINE SD INTRAVENOUS RECON SOLN

Tier 4 SPRx

ALPROLIX INTRAVENOUS RECON SOLN Tier 4 SPRx

AMICAR ORAL SOLUTION Tier 6

AMICAR ORAL TABLET Tier 6

aspirin-dipyridamole oral capsule, er multiphase 12 hr

Tier 1

BEBULIN INTRAVENOUS RECON SOLN Tier 4 SPRx

BENEFIX INTRAVENOUS RECON SOLN Tier 4 SPRx

BRILINTA ORAL TABLET Tier 2

cilostazol oral tablet Tier 1

clopidogrel oral tablet Tier 1

COAGADEX INTRAVENOUS RECON SOLN Tier 4 LD; SPRx

CORIFACT INTRAVENOUS RECON SOLN Tier 4 SPRx

COUMADIN ORAL TABLET Tier 3

dipyridamole oral tablet Tier 1

ELIQUIS ORAL TABLET Tier 2

ELIQUIS ORAL TABLETS,DOSE PACK Tier 2

enoxaparin subcutaneous solution Tier 1 QL (42 ML per 365 days)

enoxaparin subcutaneous syringe Tier 1 QL (42 ML per 365 days)

FEIBA NF INTRAVENOUS RECON SOLN Tier 4 SPRx

fondaparinux subcutaneous syringe Tier 1 QL (42 ML per 365 days)

FRAGMIN SUBCUTANEOUS SOLUTION Tier 3 QL (42 ML per 365 days)

43

Updated 7/2018

FRAGMIN SUBCUTANEOUS SYRINGE Tier 3 QL (42 ML per 365 days)

HELIXATE FS INTRAVENOUS RECON SOLN

Tier 4 SPRx

HEMOFIL M HIGH INTRAVENOUS RECON SOLN

Tier 4 SPRx

HEMOFIL M LOW INTRAVENOUS RECON SOLN

Tier 4 SPRx

HEMOFIL M MID INTRAVENOUS RECON SOLN

Tier 4 SPRx

HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN

Tier 4 SPRx

HEP FLUSH-10 (PF) INTRAVENOUS SOLUTION

Tier 1

heparin (porcine) injection solution Tier 1

heparin lock flush (porcine) intravenous solution 100 unit/ml

Tier 1

heparin lock flush (porcine) intravenous syringe Tier 6

HEPARIN LOCK FLUSH INTRAVENOUS SOLUTION

Tier 1

HEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS SYRINGE

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

HUMATE-P INTRAVENOUS RECON SOLN Tier 4 SPRx

JANTOVEN ORAL TABLET Tier 1

KOATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT

Tier 4 SPRx

KOATE-DVI INTRAVENOUS RECON SOLN Tier 4 SPRx

KOGENATE FS INTRAVENOUS RECON SOLN

Tier 4 SPRx

MEPHYTON ORAL TABLET Tier 6

MONOCLATE-P INTRAVENOUS RECON SOLN

Tier 4 SPRx

44

Updated 7/2018

NOVOEIGHT INTRAVENOUS RECON SOLN

Tier 4 SPRx

NOVOSEVEN RT INTRAVENOUS RECON SOLN

Tier 4 SPRx

pentoxifylline oral tablet extended release Tier 1

PRADAXA ORAL CAPSULE Tier 3

prasugrel oral tablet Tier 1

PROFILNINE INTRAVENOUS RECON SOLN

Tier 4 SPRx

PROMACTA ORAL TABLET Tier 4 SPRx

RECOMBINATE INTRAVENOUS RECON SOLN

Tier 4 SPRx

RIXUBIS INTRAVENOUS RECON SOLN Tier 4 SPRx

ticlopidine oral tablet Tier 1

warfarin oral tablet Tier 1

WILATE INTRAVENOUS RECON SOLN Tier 4 SPRx

XARELTO ORAL TABLET Tier 2

XARELTO ORAL TABLETS,DOSE PACK Tier 2

XYNTHA INTRAVENOUS SOLUTION Tier 4 SPRx

XYNTHA SOLOFUSE INTRAVENOUS SYRINGE

Tier 4 SPRx

ZONTIVITY ORAL TABLET Tier 6

Lipid/Cholesterol Lowering Agents amlodipine-atorvastatin oral tablet Tier 1

ANTARA ORAL CAPSULE 30 MG, 90 MG Tier 6

atorvastatin oral tablet 10 mg, 20 mg Tier 5 ACA

atorvastatin oral tablet 40 mg, 80 mg Tier 1

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

COLESTID FLAVORED ORAL PACKET Tier 6

45

Updated 7/2018

colestipol oral granules Tier 1

colestipol oral packet Tier 1

colestipol oral tablet Tier 1

ezetimibe oral tablet Tier 1

ezetimibe-simvastatin oral tablet Tier 1

fenofibrate micronized oral capsule Tier 1

fenofibrate nanocrystallized oral tablet Tier 1

fenofibrate oral tablet Tier 1

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

Tier 1

fenofibric acid oral tablet Tier 1

fluvastatin oral capsule Tier 5 ACA

fluvastatin oral tablet extended release 24 hr Tier 5 ACA

gemfibrozil oral tablet Tier 1

KYNAMRO SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

LIPOFEN ORAL CAPSULE Tier 6

LIVALO ORAL TABLET Tier 6

lovastatin oral tablet Tier 5 ACA

niacin oral tablet extended release 24 hr Tier 1

NIACOR ORAL TABLET Tier 6

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SPRx

PRALUENT SYRINGE SUBCUTANEOUS SYRINGE

Tier 4 PA; SPRx

pravastatin oral tablet Tier 5 ACA

PREVALITE ORAL POWDER Tier 1

PREVALITE ORAL POWDER IN PACKET Tier 1

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR

Tier 4 PA; SPRx

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SPRx

REPATHA SYRINGE SUBCUTANEOUS SYRINGE

Tier 4 PA; SPRx

rosuvastatin oral tablet 10 mg, 5 mg Tier 5 ACA

46

Updated 7/2018

rosuvastatin oral tablet 20 mg, 40 mg Tier 1

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

simvastatin oral tablet 80 mg Tier 1

TRIGLIDE ORAL TABLET 160 MG Tier 6

WELCHOL ORAL POWDER IN PACKET Tier 6

WELCHOL ORAL TABLET Tier 6

Miscellaneous Cardiovascular Agents CORLANOR ORAL TABLET Tier 6

ENTRESTO ORAL TABLET Tier 6

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR

Tier 6

Nitrates DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE

Tier 6

ISORDIL ORAL TABLET Tier 6

isosorbide dinitrate oral tablet Tier 1

isosorbide dinitrate oral tablet extended release Tier 1

isosorbide mononitrate oral tablet Tier 1

isosorbide mononitrate oral tablet extended release 24 hr

Tier 1

MINITRAN TRANSDERMAL PATCH 24 HOUR

Tier 6

NITRO-BID TRANSDERMAL OINTMENT Tier 1

NITRO-DUR TRANSDERMAL PATCH 24 HOUR

Tier 6

nitroglycerin oral capsule, extended release Tier 1

nitroglycerin sublingual tablet Tier 1

nitroglycerin transdermal patch 24 hour Tier 1

nitroglycerin translingual aerosol,spray Tier 1

nitroglycerin translingual spray,non-aerosol Tier 1

NITROSTAT SUBLINGUAL TABLET Tier 6

NITRO-TIME ORAL CAPSULE, EXTENDED RELEASE

Tier 1

Dermatologicals/Topical Therapy

47

Updated 7/2018

Antipsoriatic / Antiseborrheic acitretin oral capsule Tier 6

calcipotriene scalp solution Tier 6

calcipotriene topical cream Tier 6

calcipotriene topical ointment Tier 6

calcipotriene-betamethasone topical ointment Tier 6

CALCITRENE TOPICAL OINTMENT Tier 6

calcitriol topical ointment Tier 6

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE

Tier 4 PA; SPRx

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SPRx

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SPRx

COSENTYX SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

DRITHOCREME HP TOPICAL CREAM Tier 6

ENSTILAR TOPICAL FOAM Tier 6

hydrocortisone-pramoxine topical cream Tier 6

SEB-PREV TOPICAL CLEANSER Tier 6

selenium sulfide topical lotion Tier 6

selenium sulfide topical shampoo 2.25 % Tier 6

SILIQ SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

STELARA SUBCUTANEOUS SYRINGE Tier 4 PA; LD; SPRx

sulfacetamide sodium topical cleanser Tier 6

sulfacetamide sodium topical shampoo Tier 6

TACLONEX TOPICAL SUSPENSION Tier 6

TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR

Tier 4 PA; SPRx

TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR

Tier 4 PA; SPRx

TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR

Tier 4 PA; SPRx

TALTZ SYRINGE (2 PACK) SUBCUTANEOUS SYRINGE

Tier 4 PA; SPRx

48

Updated 7/2018

TALTZ SYRINGE (3 PACK) SUBCUTANEOUS SYRINGE

Tier 4 PA; SPRx

TALTZ SYRINGE SUBCUTANEOUS SYRINGE

Tier 4 PA; SPRx

TREMFYA SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

Burn Therapy silver sulfadiazine topical cream Tier 6

SSD TOPICAL CREAM Tier 6

THERMAZENE TOPICAL CREAM Tier 6

Keratolytics PODOCON TOPICAL LIQUID Tier 6

potassium hydroxide topical solution Tier 6

salicylic acid er-ceramides topical combo pack Tier 6

salicylic acid topical cream Tier 6

salicylic acid topical cream,extended release Tier 6

salicylic acid topical film forming liquid w/appl Tier 6

salicylic acid topical liquid 26 % Tier 6

salicylic acid topical lotion Tier 6

salicylic acid topical shampoo Tier 6

Miscellaneous Dermatologicals ammonium lactate topical cream Tier 6

diclofenac sodium topical gel 3 % Tier 6 QL (100 GM per 30 days)

doxepin topical cream Tier 6

DUPIXENT SUBCUTANEOUS SYRINGE Tier 4 PA; LD; SPRx; QL (2 ML per 30 days)

ELIDEL TOPICAL CREAM Tier 6

EUCRISA TOPICAL OINTMENT Tier 6

fluorouracil topical cream 5 % Tier 6

fluorouracil topical solution Tier 6

methoxsalen oral capsule,liqd-filled,rapid rel Tier 6

PICATO TOPICAL GEL Tier 6

podofilox topical solution Tier 6

PRUCLAIR TOPICAL CREAM Tier 6

49

Updated 7/2018

REGRANEX TOPICAL GEL Tier 6

silver nitrate applicators topical stick Tier 6

silver nitrate topical solution 10 % Tier 6

tacrolimus topical ointment Tier 6

VALCHLOR TOPICAL GEL Tier 4 PA; SPRx

VEREGEN TOPICAL OINTMENT Tier 6

Therapy For Acne ACANYA TOPICAL GEL WITH PUMP Tier 6

adapalene topical cream Tier 6

adapalene topical gel Tier 6

adapalene topical gel with pump Tier 6

adapalene-benzoyl peroxide topical gel with pump Tier 6

amnesteem oral capsule Tier 6

AVITA TOPICAL CREAM Tier 6 PA

benzoyl peroxide topical cleanser 7 % Tier 6

benzoyl peroxide topical foam 9.8 % Tier 6

CLARAVIS ORAL CAPSULE Tier 6

clindamycin phosphate topical foam Tier 6

clindamycin phosphate topical gel Tier 6

clindamycin phosphate topical lotion Tier 6

clindamycin phosphate topical solution Tier 6

clindamycin phosphate topical swab Tier 6

clindamycin-benzoyl peroxide topical gel Tier 6

clindamycin-benzoyl peroxide topical gel with pump

Tier 6

EPIDUO FORTE TOPICAL GEL WITH PUMP

Tier 6

EPIDUO TOPICAL GEL Tier 6

EPIDUO TOPICAL GEL WITH PUMP Tier 6

ERY PADS TOPICAL SWAB Tier 6

ERYGEL TOPICAL GEL Tier 6

erythromycin with ethanol topical gel Tier 6

erythromycin with ethanol topical solution Tier 6

50

Updated 7/2018

erythromycin with ethanol topical swab Tier 6

erythromycin-benzoyl peroxide topical gel Tier 6

FINACEA TOPICAL FOAM Tier 6

FINACEA TOPICAL GEL Tier 6

metronidazole topical cream Tier 6

metronidazole topical gel Tier 6

metronidazole topical gel with pump Tier 6

metronidazole topical lotion Tier 6

MIRVASO TOPICAL GEL Tier 6

MIRVASO TOPICAL GEL WITH PUMP Tier 6

MYORISAN ORAL CAPSULE Tier 6

SSS 10-5 TOPICAL CREAM Tier 6

SSS 10-5 TOPICAL FOAM Tier 6

sulfacetamide sodium-sulfur topical cleanser Tier 6

sulfacetamide sodium-sulfur topical cream Tier 6

sulfacetamide sodium-sulfur topical lotion Tier 6

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

Tier 6

sulfacetamide sodium-sulfur topical suspension Tier 6

sulfacetamide sod-sulfur-urea topical cleanser Tier 6

tazarotene topical cream Tier 6 PA

TAZORAC TOPICAL CREAM 0.05 % Tier 6 PA

TAZORAC TOPICAL GEL Tier 6 PA

tretinoin microspheres topical gel 0.04 % Tier 6 PA

tretinoin topical cream Tier 6 PA

tretinoin topical gel Tier 6 PA

VANOXIDE-HC TOPICAL SUSPENSION Tier 6

ZENATANE ORAL CAPSULE Tier 6

Topical Anesthetics GLYDO MUCOUS MEMBRANE JELLY IN APPLICATOR

Tier 6

lidocaine hcl mucous membrane jelly Tier 6

lidocaine hcl mucous membrane jelly in applicator Tier 6

51

Updated 7/2018

lidocaine hcl mucous membrane solution 4 % (40 mg/ml)

Tier 6

lidocaine hcl-hydrocortison ac topical cream Tier 6

lidocaine topical adhesive patch,medicated Tier 6 QL (90 EA per 30 days)

lidocaine topical ointment Tier 6 QL (100 GM per 30 days)

LIDOCAINE VISCOUS MUCOUS MEMBRANE SOLUTION

Tier 6

lidocaine-prilocaine topical cream Tier 6 QL (60 GM per 30 days)

SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING

Tier 6

Topical Antibacterials ALTABAX TOPICAL OINTMENT Tier 6

CORTISPORIN TOPICAL CREAM Tier 6

CORTISPORIN TOPICAL OINTMENT Tier 6

gentamicin topical cream Tier 6

gentamicin topical ointment Tier 6

mupirocin calcium topical cream Tier 6

mupirocin topical ointment Tier 6

sulfacetamide sodium (acne) topical suspension Tier 6

SULFAMYLON TOPICAL CREAM Tier 6

SULFAMYLON TOPICAL PACKET Tier 6

Topical Antifungals CICLODAN TOPICAL CREAM Tier 6

CICLODAN TOPICAL SOLUTION Tier 6

ciclopirox topical cream Tier 6

ciclopirox topical gel Tier 6

ciclopirox topical shampoo Tier 6

ciclopirox topical solution Tier 6

ciclopirox topical suspension Tier 6

ciclopirox-ure-camph-menth-euc topical solution Tier 6

clotrimazole-betamethasone topical cream Tier 6

clotrimazole-betamethasone topical lotion Tier 6

econazole topical cream Tier 6

52

Updated 7/2018

ERTACZO TOPICAL CREAM Tier 6

EXELDERM TOPICAL CREAM Tier 6

EXELDERM TOPICAL SOLUTION Tier 6

ketoconazole topical cream Tier 6

ketoconazole topical foam Tier 6

ketoconazole topical shampoo Tier 6

naftifine topical cream Tier 6

NAFTIN TOPICAL GEL Tier 6

NYAMYC TOPICAL POWDER Tier 6

NYATA TOPICAL POWDER Tier 6

nystatin topical cream Tier 6

nystatin topical ointment Tier 6

nystatin topical powder Tier 6

nystatin-triamcinolone topical cream Tier 6

nystatin-triamcinolone topical ointment Tier 6

NYSTOP TOPICAL POWDER Tier 6

oxiconazole topical cream Tier 6

VUSION TOPICAL OINTMENT Tier 6

Topical Antivirals acyclovir topical ointment Tier 6

DENAVIR TOPICAL CREAM Tier 6

ZOVIRAX TOPICAL CREAM Tier 6

Topical Corticosteroids ALA-CORT TOPICAL CREAM 2.5 % Tier 6

alclometasone topical cream Tier 6

alclometasone topical ointment Tier 6

amcinonide topical cream Tier 6

amcinonide topical lotion Tier 6

amcinonide topical ointment Tier 6

APEXICON E TOPICAL CREAM Tier 6

AQUA GLYCOLIC HC TOPICAL COMBO PACK

Tier 6

53

Updated 7/2018

betamethasone dipropionate topical cream Tier 6

betamethasone dipropionate topical lotion Tier 6

betamethasone dipropionate topical ointment Tier 6

betamethasone valerate topical cream Tier 6

betamethasone valerate topical foam Tier 6

betamethasone valerate topical lotion Tier 6

betamethasone valerate topical ointment Tier 6

betamethasone, augmented topical cream Tier 6

betamethasone, augmented topical gel Tier 6

betamethasone, augmented topical lotion Tier 6

betamethasone, augmented topical ointment Tier 6

clobetasol scalp solution Tier 6

clobetasol topical cream Tier 6

clobetasol topical foam Tier 6

clobetasol topical gel Tier 6

clobetasol topical lotion Tier 6

clobetasol topical ointment Tier 6

clobetasol topical shampoo Tier 6

clobetasol topical spray,non-aerosol Tier 6

clobetasol-emollient topical cream Tier 6

clobetasol-emollient topical foam Tier 6

CLODERM TOPICAL CREAM Tier 6

desonide topical cream Tier 6

desonide topical lotion Tier 6

desonide topical ointment Tier 6

desoximetasone topical cream Tier 6

desoximetasone topical gel Tier 6

desoximetasone topical ointment Tier 6

diflorasone topical cream Tier 6

diflorasone topical ointment Tier 6

fluocinolone and shower cap scalp oil Tier 6

fluocinolone topical cream Tier 6

54

Updated 7/2018

fluocinolone topical oil Tier 6

fluocinolone topical ointment Tier 6

fluocinolone topical solution Tier 6

fluocinonide topical cream Tier 6

fluocinonide topical gel Tier 6

fluocinonide topical ointment Tier 6

fluocinonide topical solution Tier 6

FLUOCINONIDE-E TOPICAL CREAM Tier 6

flurandrenolide topical cream Tier 6

flurandrenolide topical lotion Tier 6

flurandrenolide topical ointment Tier 6

fluticasone topical cream Tier 6

fluticasone topical lotion Tier 6

fluticasone topical ointment Tier 6

halobetasol propionate topical cream Tier 6

halobetasol propionate topical ointment Tier 6

HALOG TOPICAL CREAM Tier 6

HALOG TOPICAL OINTMENT Tier 6

hydrocortisone butyrate topical cream Tier 6

hydrocortisone butyrate topical ointment Tier 6

hydrocortisone butyrate topical solution Tier 6

hydrocortisone butyr-emollient topical cream Tier 6

hydrocortisone topical cream 2.5 % Tier 6

hydrocortisone topical lotion 2.5 % Tier 6

hydrocortisone topical ointment 2.5 % Tier 6

hydrocortisone valerate topical cream Tier 6

hydrocortisone valerate topical ointment Tier 6

hydrocortisone-min oil-wht pet topical ointment Tier 6

mometasone topical cream Tier 1

mometasone topical ointment Tier 1

mometasone topical solution Tier 1

prednicarbate topical cream Tier 6

55

Updated 7/2018

prednicarbate topical ointment Tier 6

triamcinolone acetonide topical aerosol Tier 6

triamcinolone acetonide topical cream Tier 6

triamcinolone acetonide topical lotion Tier 6

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

Tier 6

TRIDERM TOPICAL CREAM 0.5 % Not Covered

ULTRAVATE X TOPICAL COMBO PACK Tier 6

ULTRAVATE X TOPICAL COMBO PACK,OINTMENT AND CREAM

Tier 6

Topical Enzymes SANTYL TOPICAL OINTMENT Tier 6

Topical Scabicides / Pediculicides EURAX TOPICAL CREAM Tier 6

EURAX TOPICAL LOTION Tier 6

lindane topical shampoo Tier 6

malathion topical lotion Tier 6

permethrin topical cream Tier 6

SKLICE TOPICAL LOTION Tier 6

spinosad topical suspension Tier 6

ULESFIA TOPICAL LOTION Tier 6

Diagnostics & Miscellaneous Agents Irrigating Solutions neomycin-polymyxin b gu irrigation solution Tier 6

sorbitol irrigation solution Tier 6

sorbitol-mannitol urethral solution Tier 6

TIS-U-SOL PENTALYTE IRRIGATION SOLUTION

Tier 6

Miscellaneous Agents acamprosate oral tablet,delayed release (dr/ec) Tier 6

acetic acid irrigation solution Tier 6

alendronate oral tablet 40 mg Tier 6

anagrelide oral capsule Tier 1

56

Updated 7/2018

BD PRE-FILLED NORMAL SALINE INJECTION SYRINGE

Tier 6

BUPHENYL ORAL TABLET Tier 6

caffeine citrate oral solution Tier 6

CARBAGLU ORAL TABLET, DISPERSIBLE Tier 6

cevimeline oral capsule Tier 6

CHEMET ORAL CAPSULE Tier 6

disulfiram oral tablet Tier 6

etidronate disodium oral tablet Tier 6

EXJADE ORAL TABLET, DISPERSIBLE Tier 4 SPRx

FERRIPROX ORAL TABLET Tier 4 LD; SPRx

finasteride oral tablet 1 mg Tier 6

JADENU ORAL TABLET Tier 4 SPRx

levocarnitine (with sugar) oral solution Tier 6

levocarnitine oral tablet Tier 6

METOPIRONE ORAL CAPSULE Tier 6

midodrine oral tablet Tier 6

MONOJECT 0.9% SODIUM CHLORIDE INJECTION SYRINGE

Tier 6

MONOJECT PREFILL ADVANCED NS INJECTION SYRINGE

Tier 6

MONOJECT PREFILL SALINE FLUSH INJECTION SYRINGE

Tier 6

NITYR ORAL TABLET Tier 4 LD; SPRx

NORMAL SALINE FLUSH INJECTION SYRINGE

Tier 6

NORTHERA ORAL CAPSULE Tier 4 PA; SPRx

ORFADIN ORAL CAPSULE Tier 4 LD; SPRx

pilocarpine hcl oral tablet 5 mg Tier 6

RADIOGARDASE ORAL CAPSULE Tier 6

RAVICTI ORAL LIQUID Tier 4 SPRx

riluzole oral tablet Tier 6

risedronate oral tablet 30 mg Tier 1

sodium chlor 0.9% bacteriostat injection solution Tier 6

57

Updated 7/2018

sodium chloride 0.9 % injection syringe Tier 6

sodium chloride irrigation solution Tier 6

sodium phenylbutyrate oral powder Tier 6

sodium phenylbutyrate oral tablet Tier 6

SYREX SODIUM CHLORIDE 0.9 % INJECTION SYRINGE

Tier 6

THIOLA ORAL TABLET Tier 4 LD; SPRx

water for irrigation, sterile irrigation solution Tier 6

Phenylketonuria (Pku) Nutritional Products CAMINO PRO 15 PE PKU ORAL LIQUID IN PACKET

Tier 6

EAA SUPPLEMENT ORAL POWDER IN PACKET

Tier 6

GLYTACTIN 10 PE COMPLETE ORAL BAR Tier 6

GLYTACTIN 15 PE BETTERMILK ORAL POWDER IN PACKET

Tier 6

GLYTACTIN 15 PE COMPLETE ORAL BAR Tier 6

GLYTACTIN 20PE BETTERMILK LITE ORAL POWDER IN PACKET

Tier 6

GLYTACTIN BUILD 10 PE ORAL POWDER IN PACKET

Tier 6

GLYTACTIN RESTORE 10 PE LITE ORAL LIQUID

Tier 6

GLYTACTIN RESTORE 10 PE LITE ORAL POWDER IN PACKET

Tier 6

GLYTACTIN RESTORE 10 PE ORAL LIQUID

Tier 6

GLYTACTIN RESTORE 5 PE ORAL POWDER IN PACKET

Tier 6

GLYTACTIN RTD 10 PE ORAL LIQUID Tier 6

GLYTACTIN RTD 15 PE ORAL LIQUID Tier 6

GLYTACTIN SWIRL 15 PE ORAL POWDER IN PACKET

Tier 6

LANAFLEX ORAL POWDER IN PACKET Tier 6

LOPHLEX ORAL POWDER IN PACKET Tier 6

PERIFLEX ADVANCE ORAL POWDER Tier 6

58

Updated 7/2018

PERIFLEX INFANT ORAL POWDER Tier 6

PERIFLEX JUNIOR ORAL POWDER Tier 6

PERIFLEX LQ PKU ORAL LIQUID Tier 6

PHENACTIN AA PLUS 20 PE ORAL LIQUID Tier 6

PHENEX-1 ORAL POWDER Tier 6

PHENEX-2 ORAL POWDER Tier 6

PHENYLADE 40 ORAL POWDER IN PACKET

Tier 6

PHENYLADE 60 ORAL POWDER Tier 6

PHENYLADE 60 ORAL POWDER IN PACKET

Tier 6

PHENYLADE AMINO ACID ORAL BAR Tier 6

PHENYLADE AMINO ACIDS ORAL POWDER

Tier 6

PHENYLADE AMINO ACIDS ORAL POWDER IN PACKET

Tier 6

PHENYLADE DRINK MIX ORAL POWDER Tier 6

PHENYLADE ESSENTIAL ORAL POWDER Tier 6

PHENYLADE ESSENTIAL ORAL POWDER IN PACKET

Tier 6

PHENYLADE GMP MIX-IN ORAL POWDER IN PACKET

Tier 6

PHENYLADE GMP ORAL POWDER Tier 6

PHENYLADE GMP ORAL POWDER IN PACKET

Tier 6

PHENYLADE MTE AMINO ACIDS ORAL POWDER

Tier 6

PHENYLADE MTE AMINO ACIDS ORAL POWDER IN PACKET

Tier 6

PHENYLADE PHEBLOC ORAL POWDER IN PACKET

Tier 6

phenylade phebloc oral tablet Tier 6

PHENYLADE RTD PKU 10 ORAL LIQUID Tier 6

PHENYL-FREE 1 ORAL POWDER Tier 6

PHENYL-FREE 2 PKU ORAL POWDER Tier 6

59

Updated 7/2018

PHENYL-FREE 2HP PKU ORAL POWDER Tier 6

PHLEXY-10 DRINK MIX POWDER ORAL POWDER IN PACKET

Tier 6

PHLEXY-10 ORAL TABLET 8.33 GRAM-35 KCAL/10

Tier 6

PKU 2 ORAL POWDER Tier 6

PKU 3 ORAL POWDER Tier 6

PKU AIR15 ORAL LIQUID IN PACKET Tier 6

PKU AIR20 ORAL LIQUID IN PACKET Tier 6

PKU COOLER 10 ORAL SUSPENSION Tier 6



PKU EASY MICROTABS ORAL GRANULES DELAYED RELEASE

Tier 6

PKU EXPRESS15 ORAL POWDER IN PACKET

Tier 6

PKU EXPRESS20 ORAL POWDER IN PACKET

Tier 6

PKU GEL POWDER ORAL POWDER IN PACKET

Tier 6

PKU LOPHLEX ORAL LIQUID IN PACKET Tier 6

PKU PERIFLEX EARLY YEARS ORAL POWDER

Tier 6

PKU PERIFLEX JUNIOR PLUS ORAL POWDER

Tier 6

PKU SPHERE20 ORAL POWDER IN PACKET

Tier 6

PKU TRIO ORAL POWDER Tier 6

XPHE MAXAMAID ORAL POWDER Tier 6

xphe maxamum oral powder Tier 6

XPHE MAXAMUM ORAL POWDER IN PACKET

Tier 6

Smoking Deterrents bupropion hcl (smoking deter) oral tablet extended release 12 hr

Tier 5 ACA

60

Updated 7/2018

CHANTIX CONTINUING MONTH BOX ORAL TABLET

Tier 5 ACA

CHANTIX ORAL TABLET Tier 5 ACA

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

Tier 5 ACA

NICODERM CQ TRANSDERMAL PATCH 24 HOUR

Tier 5 ACA

NICORETTE BUCCAL GUM Tier 5 ACA

NICORETTE BUCCAL LOZENGE Tier 5 ACA

NICORETTE BUCCAL MINI LOZENGE Tier 5 ACA

nicotine (polacrilex) buccal gum Tier 5 ACA

nicotine (polacrilex) buccal lozenge Tier 5 ACA

nicotine (polacrilex) buccal mini lozenge Tier 5 ACA

nicotine transdermal patch 24 hour Tier 5 ACA

nicotine transdermal patch, td daily, sequential Tier 5 ACA

NICOTROL INHALATION CARTRIDGE Tier 5 ACA

NICOTROL NS NASAL SPRAY,NONAEROSOL

Tier 5 ACA

nts step 1 transdermal patch 24 hour Tier 5 ACA

ZYBAN ORAL TABLET EXTENDED RELEASE 12 HR

Tier 5 ACA

Ear, Nose & Throat Medications Miscellaneous Agents azelastine nasal aerosol,spray Tier 6

azelastine nasal spray,non-aerosol Tier 6

BACTROBAN NASAL NASAL OINTMENT Tier 6

chlorhexidine gluconate mucous membrane mouthwash

Tier 6

DENTA 5000 PLUS DENTAL CREAM Tier 6

DENTAGEL DENTAL GEL Tier 6

ipratropium bromide nasal spray,non-aerosol Tier 1

olopatadine nasal spray,non-aerosol Tier 6

PERIOGARD MUCOUS MEMBRANE MOUTHWASH

Tier 6

61

Updated 7/2018

pilocarpine hcl oral tablet 7.5 mg Tier 6

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE

Tier 6

PREVIDENT 5000 DRY MOUTH DENTAL GEL

Tier 6

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE

Tier 6

PREVIDENT 5000 SENSITIVE DENTAL PASTE

Tier 6

SF 5000 PLUS DENTAL CREAM Tier 6

SF DENTAL GEL Tier 6

triamcinolone acetonide dental paste Tier 6

Miscellaneous Otic Preparations acetic acid otic (ear) solution Tier 6

acetic acid-aluminum acetate otic (ear) drops Tier 6

ciprofloxacin hcl otic (ear) dropperette Tier 6

fluocinolone acetonide oil otic (ear) drops Tier 6

hydrocortisone-acetic acid otic (ear) drops Tier 6

ofloxacin otic (ear) drops Tier 6

Otic Steroid / Antibiotic CIPRO HC OTIC (EAR) DROPS,SUSPENSION

Tier 6

CIPRODEX OTIC (EAR) DROPS,SUSPENSION

Tier 6

COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION

Tier 6

neomycin-polymyxin-hc otic (ear) drops,suspension

Tier 6

neomycin-polymyxin-hc otic (ear) solution Tier 6

OTOVEL OTIC (EAR) SOLUTION Tier 6

Endocrine/Diabetes Adrenal Hormones ACTHAR H.P. INJECTION GEL Tier 4 PA; SPRx

cortisone oral tablet Tier 6

62

Updated 7/2018

decadron oral tablet Tier 6

DELTASONE ORAL TABLET 20 MG Tier 6

DEXAMETHASONE INTENSOL ORAL DROPS

Tier 6

dexamethasone oral elixir Tier 6

dexamethasone oral solution Tier 6

dexamethasone oral tablet Tier 6

EMFLAZA ORAL SUSPENSION Tier 4 PA; LD; SPRx

EMFLAZA ORAL TABLET Tier 4 PA; LD; SPRx

fludrocortisone oral tablet Tier 6

hydrocortisone oral tablet Tier 6

methylprednisolone oral tablet Tier 6

methylprednisolone oral tablets,dose pack Tier 6

millipred dp oral tablets,dose pack Tier 6

millipred oral tablet Tier 6

prednisolone oral solution 15 mg/5 ml Tier 6

prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

Tier 6

prednisolone sodium phosphate oral tablet,disintegrating

Tier 6

PREDNISONE INTENSOL ORAL CONCENTRATE

Tier 6

prednisone oral solution Tier 6

prednisone oral tablet Tier 6

prednisone oral tablets,dose pack Tier 6

VERIPRED 20 ORAL SOLUTION Tier 6

Antithyroid Agents methimazole oral tablet 10 mg, 5 mg Tier 1

propylthiouracil oral tablet Tier 1

SSKI ORAL SOLUTION Tier 6

Blood Glucose Monitoring Devices & Supplies

63

Updated 7/2018

ACCU-CHEK AVIVA PLUS TEST STRP STRIP

Tier 3 ST; QL (102 EA per 30 days)

ACCU-CHEK COMPACT PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ACCU-CHEK GUIDE STRIP Tier 3 ST; QL (102 EA per 30 days)

ACCU-CHEK SMARTVIEW TEST STRIP STRIP


ACCUTREND GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

ADVANCED GLUC METER TEST STRIP STRIP


ADVOCATE REDI-CODE STRIP Tier 3 ST; QL (102 EA per 30 days)

ADVOCATE TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

AGAMATRIX AMP TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

ASSURE 4 STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

ASSURE PLATINUM STRIP Tier 3 ST; QL (102 EA per 30 days)

ASSURE PRISM MULTI STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

BIONIME RIGHTEST TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

BLOOD GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

BREEZE 2 TEST STRIPS STRIP Tier 2 QL (102 EA per 30 days)

CARESENS N TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

CARETOUCH TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE MICRO TEST STRIP STRIP


CLEVER CHOICE PRO STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE TALK TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE VOICE+ TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

CONTOUR NEXT TEST STRIPS STRIP Tier 2 QL (102 EA per 30 days)

CONTOUR TEST STRIPS STRIP Tier 2 QL (102 EA per 30 days)

COOL GLUCOSE TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

DIATRUE PLUS TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY PLUS II TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY STEP STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY TALK GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY TOUCH TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

64

Updated 7/2018

EASY TRAK GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASYGLUCO PLUS STRIP Tier 3 ST; QL (102 EA per 30 days)

EASYGLUCO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASYMAX STRIP Tier 3 ST; QL (102 EA per 30 days)

ELEMENT COMPACT TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

ELEMENT TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

EMBRACE BLOOD GLUCOSE SYSTEM STRIP


EMBRACE EVO TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

EMBRACE PRO TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

EVENCARE G2 STRIP Tier 3 ST; QL (102 EA per 30 days)

EVENCARE G3 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EVENCARE MINI GLUCOSE TEST STR STRIP


EVOLUTION TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

EZ SMART PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EZ SMART TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FIFTY50 TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA D15G STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA D20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA D40-G31 TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA G20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA G30-PREMIUM V10 TEST STRP STRIP


FORA GD50 TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA TN'G VOICE TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA V10 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA V12 GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA V20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORACARE GD20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORACARE GD40 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORTISCARE GLUCOSE TEST STRIPS STRIP


65

Updated 7/2018

FREESTYLE INSULINX STRIP Tier 3 ST; QL (102 EA per 30 days)

FREESTYLE INSULINX TEST STRIPS STRIP


FREESTYLE LITE STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

FREESTYLE PRECISION NEO STRIPS STRIP


FREESTYLE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

GE100 BLOOD GLUCOSE TEST STRIP STRIP


GENSTRIP TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCO NAVII TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD 01 SENSOR PLUS STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD EXPRESSION STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD SHINE TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD VITAL SENSOR STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD VITAL TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCOM GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

GM100 STRIP Tier 3 ST; QL (102 EA per 30 days)

HEALTHPRO TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

IGLUCOSE TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

INFINITY TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

INFINITY VOICE TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

MICRO BLOOD GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

MICRODOT BLOOD GLUCOSE SYSTEM STRIP


MYGLUCOHEALTH STRIP Tier 3 ST; QL (102 EA per 30 days)

NEUTEK 2TEK TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

NOVA MAX GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ON CALL EXPRESS TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

ON CALL PLUS TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

ON CALL VIVID TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

ONETOUCH ULTRA TEST STRIP Tier 2 QL (102 EA per 30 days)

ONETOUCH VERIO STRIP Tier 2 ST; QL (102 EA per 30 days)

OPTIUM EZ STRIP Tier 3 ST; QL (102 EA per 30 days)

66

Updated 7/2018

OPTIUM TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

OPTUMRX STRIP Tier 3 ST; QL (102 EA per 30 days)

PHARMACIST CHOICE STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION PCX PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION PCX TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION POINT OF CARE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION Q-I-D TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION XTRA TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PREMIER TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

PREMIUM V10 STRIP Tier 3 ST; QL (102 EA per 30 days)

PRODIGY NO CODING STRIP Tier 3 ST; QL (102 EA per 30 days)

QUINTET AC STRIP Tier 3 ST; QL (102 EA per 30 days)

REFUAH PLUS STRIP Tier 3 ST; QL (102 EA per 30 days)

RELION CONFIRM-MICRO STRIP Tier 3 ST; QL (102 EA per 30 days)

RELION PRIME TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

REVEAL TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

RIGHTEST GS550 TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

SMART SENSE TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

SMARTEST TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

SURE-TEST EASYPLUS MINI STRIP Tier 3 ST; QL (102 EA per 30 days)

TELCARE TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

TEST N'GO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

TRUE METRIX GLUCOSE TEST STRIP STRIP


TRUETEST TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

TRUETRACK TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ULTIMA TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

ULTRATRAK STRIP Tier 3 ST; QL (102 EA per 30 days)

ULTRATRAK ULTIMATE STRIP Tier 3 ST; QL (102 EA per 30 days)

UNISTRIP1 TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

VERASENS TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

WAVESENSE JAZZ STRIP Tier 3 ST; QL (102 EA per 30 days)

WAVESENSE PRESTO STRIP Tier 3 ST; QL (102 EA per 30 days)

67

Updated 7/2018

Diabetes, Supplies, & Durable Medical Equipment GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN

Tier 6

Glucose Elevating Agents GLUCAGEN HYPOKIT INJECTION RECON SOLN

Tier 6

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT

Tier 6

Insulin Syringes/Miscellaneous Durable Medical Equ insulin syringe-needle u-100 syringe 0.5 ml 29 gauge x 1/2"


lancets 30 gauge Tier 2

NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN

Tier 6

pen needle, diabetic needle 29 gauge x 1/2" Tier 2 QL (1000 EA per 30 days)

VGO 20 DEVICE Tier 6



Insulin Therapy ADMELOG SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

ADMELOG U-100 INSULIN LISPRO SUBCUTANEOUS SOLUTION

Tier 3 ST

AFREZZA INHALATION CARTRIDGE WITH INHALER

Tier 3

APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 3 ST

FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 2

HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALFUNIT

Tier 3 ST

68

Updated 7/2018

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION

Tier 3 ST

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION

Tier 3 ST

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE

Tier 3 ST

HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 3 ST

HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 3 ST

HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 3 ST

HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION

Tier 3 ST

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION

Tier 2

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

Tier 2

LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 2

LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN

Tier 2

LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 2

NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 2

69

Updated 7/2018

NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION

Tier 2

NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION

Tier 2

NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE

Tier 2

NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION

Tier 2

SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN

Tier 2

TOUJEO MAX SOLOSTAR SUBCUTANEOUS INSULIN PEN

Tier 2

TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN

Tier 2

TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN

Tier 2

XULTOPHY 100/3.6 SUBCUTANEOUS INSULIN PEN

Tier 2

Miscellaneous Hormones ANADROL-50 ORAL TABLET Tier 6 PA

ANDRODERM TRANSDERMAL PATCH 24 HOUR

Tier 6 PA

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

Tier 6 PA

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

Tier 6 PA

ANDROXY ORAL TABLET Tier 6 PA

cabergoline oral tablet Tier 6

70

Updated 7/2018

calcitonin (salmon) nasal spray,non-aerosol Tier 1

calcitriol oral capsule Tier 6

calcitriol oral solution Tier 6

CERDELGA ORAL CAPSULE Tier 4 PA; SPRx

danazol oral capsule Tier 6

DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MG/ML

Tier 6 PA

desmopressin nasal solution Tier 6

desmopressin nasal spray,non-aerosol Tier 6

desmopressin oral tablet Tier 6

doxercalciferol oral capsule Tier 6

KORLYM ORAL TABLET Tier 4 PA; LD; SPRx

KUVAN ORAL POWDER IN PACKET Tier 4 SPRx

KUVAN ORAL TABLET,SOLUBLE Tier 4 SPRx

methyltestosterone oral capsule Tier 6 PA

MIACALCIN INJECTION SOLUTION Tier 2

miglustat oral capsule Tier 4 SPRx

MYALEPT SUBCUTANEOUS RECON SOLN Tier 4 PA; SPRx

NATPARA SUBCUTANEOUS CARTRIDGE Tier 4 PA; SPRx

oxandrolone oral tablet Tier 6 PA

paricalcitol oral capsule Tier 6

SAMSCA ORAL TABLET Tier 4 SPRx

SENSIPAR ORAL TABLET Tier 4 SPRx

SOMAVERT SUBCUTANEOUS RECON SOLN

Tier 4 SPRx

STIMATE NASAL SPRAY,NON-AEROSOL Tier 4 SPRx

STRENSIQ SUBCUTANEOUS SOLUTION Tier 4 PA; LD; SPRx

SYNAREL NASAL SPRAY,NON-AEROSOL Tier 6

testosterone cypionate intramuscular oil Tier 6 PA

testosterone enanthate intramuscular oil Tier 6 PA

testosterone transdermal gel Tier 6 PA

testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)

Tier 6 PA

71

Updated 7/2018

testosterone transdermal gel in packet Tier 6 PA

ZAVESCA ORAL CAPSULE Tier 4 SPRx

Non-Insulin Hypoglycemic Agents acarbose oral tablet Tier 1

ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR

Tier 3

AVANDIA ORAL TABLET 2 MG, 4 MG Tier 3

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR

Tier 2

BYDUREON SUBCUTANEOUS PEN INJECTOR

Tier 2

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON

Tier 2

BYETTA SUBCUTANEOUS PEN INJECTOR Tier 2

chlorpropamide oral tablet Tier 1

CYCLOSET ORAL TABLET Tier 3

FARXIGA ORAL TABLET Tier 2

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

GLYXAMBI ORAL TABLET Tier 2

INVOKAMET ORAL TABLET Tier 2

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

Tier 2

INVOKANA ORAL TABLET Tier 2

JANUMET ORAL TABLET Tier 2

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR

Tier 2

JANUVIA ORAL TABLET Tier 2

JENTADUETO ORAL TABLET Tier 2

72

Updated 7/2018

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

Tier 2

metformin oral tablet Tier 1

metformin oral tablet extended release 24 hr Tier 1

miglitol oral tablet Tier 1

nateglinide oral tablet Tier 1

pioglitazone oral tablet Tier 1

pioglitazone-glimepiride oral tablet Tier 1

pioglitazone-metformin oral tablet Tier 1

repaglinide oral tablet Tier 1

repaglinide-metformin oral tablet Tier 1

RIOMET ORAL SOLUTION Tier 3

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR

Tier 3

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR

Tier 3

tolazamide oral tablet Tier 1

tolbutamide oral tablet Tier 1

TRADJENTA ORAL TABLET Tier 2

TRULICITY SUBCUTANEOUS PEN INJECTOR

Tier 2

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

Tier 2

Thyroid Hormones ARMOUR THYROID ORAL TABLET Tier 6

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

NATURE-THROID ORAL TABLET Tier 1

np thyroid oral tablet 120 mg Tier 1

NP THYROID ORAL TABLET 15 MG, 30 MG, 60 MG, 90 MG

Tier 1

73

Updated 7/2018

SYNTHROID ORAL TABLET Tier 6

thyroid (pork) oral tablet Tier 1

THYROLAR-1 ORAL TABLET Tier 6

THYROLAR-1/2 ORAL TABLET Tier 6

THYROLAR-1/4 ORAL TABLET Tier 6



UNITHROID ORAL TABLET Tier 1

WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG

Tier 1

WP THYROID ORAL TABLET 130 MG, 32.5 MG, 65 MG, 81.25 MG

Tier 6

Gastroenterology Antidiarrheals & Antispasmodics chlordiazepoxide-clidinium oral capsule Tier 6

dicyclomine oral capsule Tier 6

dicyclomine oral solution Tier 6

dicyclomine oral tablet Tier 6

diphenoxylate-atropine oral liquid Tier 6

diphenoxylate-atropine oral tablet Tier 6

DONNATAL ORAL TABLET Tier 6

FULYZAQ ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 6

glycopyrrolate oral tablet 1 mg, 2 mg Tier 6

hyoscyamine sulfate oral drops Tier 6

hyoscyamine sulfate oral elixir Tier 6

hyoscyamine sulfate oral tablet Tier 6

hyoscyamine sulfate oral tablet extended release 12 hr

Tier 6

hyoscyamine sulfate oral tablet,disintegrating Tier 6

hyoscyamine sulfate sublingual tablet Tier 6

methscopolamine oral tablet Tier 6

MYTESI ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 6

74

Updated 7/2018

paregoric oral liquid Tier 6

propantheline oral tablet Tier 6

Miscellaneous Gastrointestinal Agents alosetron oral tablet Tier 6

AMITIZA ORAL CAPSULE Tier 6

ANUCORT-HC RECTAL SUPPOSITORY Tier 6

ANZEMET ORAL TABLET Tier 6

aprepitant oral capsule Tier 6

aprepitant oral capsule,dose pack Tier 6

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 6

AURYXIA ORAL TABLET Tier 6

balsalazide oral capsule Tier 6

bisacodyl oral tablet,delayed release (dr/ec) Tier 5 ACA

budesonide oral capsule,delayed,extend.release Tier 1

calcium acetate oral capsule Tier 6

calcium acetate oral tablet 667 mg Tier 6

CANASA RECTAL SUPPOSITORY Tier 6

CESAMET ORAL CAPSULE Tier 6

CHENODAL ORAL TABLET Tier 4 LD; SPRx

CIMZIA SUBCUTANEOUS SYRINGE KIT Tier 4 PA; SPRx

CITRATE OF MAGNESIA ORAL SOLUTION

Tier 5 ACA

CLENPIQ ORAL SOLUTION Tier 5 ACA

COLOCORT RECTAL ENEMA Tier 6

COMPRO RECTAL SUPPOSITORY Tier 6

CONSTULOSE ORAL SOLUTION Tier 6

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 6

cromolyn oral concentrate Tier 1

CYSTADANE ORAL POWDER Tier 4 LD; SPRx

DIPENTUM ORAL CAPSULE Tier 6

dronabinol oral capsule 2.5 mg, 5 mg Tier 6

75

Updated 7/2018

ELIPHOS ORAL TABLET Tier 6

ENULOSE ORAL SOLUTION Tier 6

FOSRENOL ORAL POWDER IN PACKET Tier 6

FOSRENOL ORAL TABLET,CHEWABLE Tier 6

GATTEX 30-VIAL SUBCUTANEOUS KIT Tier 4 PA; SPRx

gavilyte-c oral recon soln Tier 5 ACA

gavilyte-g oral recon soln Tier 5 ACA

gavilyte-h and bisacodyl oral kit Tier 5 ACA

gavilyte-n oral recon soln Tier 5 ACA

GENERLAC ORAL SOLUTION Tier 6

GOLYTELY ORAL POWDER IN PACKET Tier 5 ACA

granisetron hcl oral tablet Tier 6

HEMMOREX-HC RECTAL SUPPOSITORY Tier 6

hydrocortisone acetate rectal suppository Tier 6

hydrocortisone rectal enema Tier 6

hydrocortisone topical cream with perineal applicator

Tier 6

hydrocortisone-pramoxine rectal cream Tier 6

KIONEX (WITH SORBITOL) ORAL SUSPENSION

Tier 6

KIONEX ORAL POWDER Tier 6

KRISTALOSE ORAL PACKET Tier 6

lactulose oral solution 10 gram/15 ml Tier 6

lanthanum oral tablet,chewable Tier 6

laxaclear oral powder Tier 5 ACA

laxative peg 3350 oral powder Tier 5 ACA

LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 6

lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %

Tier 6

lidocaine-hydrocortisone-aloe rectal gel Tier 6

LINZESS ORAL CAPSULE Tier 6

meclizine oral tablet 25 mg Tier 6

76

Updated 7/2018

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

Tier 6

mesalamine rectal enema Tier 6

metoclopramide hcl oral solution Tier 6

metoclopramide hcl oral tablet Tier 6

MILK OF MAGNESIA CONCENTRATED ORAL SUSPENSION

Tier 5 ACA

MOVIPREP ORAL POWDER IN PACKET Tier 5 ACA

OCALIVA ORAL TABLET Tier 4 PA; LD; SPRx

ondansetron hcl oral solution Tier 6

ondansetron hcl oral tablet Tier 6

ondansetron oral tablet,disintegrating Tier 6

OSMOPREP ORAL TABLET Tier 5 ACA

peg 3350-electrolytes oral recon soln Tier 5 ACA

peg-3350 with flavor packs oral recon soln Tier 5 ACA

peg-electrolyte soln oral recon soln Tier 5 ACA

peg-prep oral kit Tier 5 ACA

PENTASA ORAL CAPSULE, EXTENDED RELEASE

Tier 6

PHOSLYRA ORAL SOLUTION Tier 6

PHOSPHATE LAXATIVE ORAL LIQUID Tier 5 ACA

polyethylene glycol 3350 oral powder Tier 5 ACA

polyethylene glycol 3350 oral powder in packet Tier 5 ACA

PRAMCORT RECTAL CREAM Tier 6

PREPOPIK ORAL POWDER IN PACKET Tier 5 ACA

prochlorperazine maleate oral tablet Tier 6

prochlorperazine rectal suppository Tier 6

PROCTO-MED HC TOPICAL CREAM WITH PERINEAL APPLICATOR

Tier 6

PROCTO-PAK TOPICAL CREAM WITH PERINEAL APPLICATOR

Tier 6

PROCTOSOL HC TOPICAL CREAM WITH PERINEAL APPLICATOR

Tier 6

77

Updated 7/2018

PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR

Tier 6

RELISTOR SUBCUTANEOUS SOLUTION Tier 6

RELISTOR SUBCUTANEOUS SYRINGE Tier 6

RENAGEL ORAL TABLET Tier 6

RENVELA ORAL POWDER IN PACKET Tier 6

RENVELA ORAL TABLET Tier 6

scopolamine base transdermal patch 3 day Tier 6

sevelamer carbonate oral powder in packet Tier 6

sevelamer carbonate oral tablet Tier 6

sodium polystyrene sulfonate oral powder Tier 6

sodium polystyrene sulfonate oral suspension Tier 6

sodium polystyrene sulfonate rectal enema 50 gram/200 ml

Tier 6

SOLESTA IMPLANT GEL FOR IMPLANT IN SYRINGE

Tier 6

SPS (WITH SORBITOL) ORAL SUSPENSION

Tier 6

SUCRAID ORAL SOLUTION Tier 6

sulfasalazine oral tablet Tier 6

sulfasalazine oral tablet,delayed release (dr/ec) Tier 6

SUPREP BOWEL PREP KIT ORAL RECON SOLN

Tier 5 ACA

SYNDROS ORAL SOLUTION Tier 6

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY

Tier 6

trilyte with flavor packets oral recon soln Tier 5 ACA

trimethobenzamide oral capsule Tier 6

UCERIS ORAL TABLET,DELAYED AND EXT.RELEASE

Tier 6

ursodiol oral capsule Tier 6

ursodiol oral tablet Tier 6

VELPHORO ORAL TABLET,CHEWABLE Tier 6

VIBERZI ORAL TABLET Tier 6

78

Updated 7/2018

women's gentle laxative(bisac) oral tablet,delayed release (dr/ec)

Tier 5 ACA

women's laxative (bisacodyl) oral tablet Tier 5 ACA

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 10,000-34,000 -55,000 UNIT, 15,00047,000 -63,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-63,000- 84,000 UNIT, 20,00068,000 -109,000 UNIT, 25,000-79,000- 105,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,00010,000- 16,000 UNIT, 40,000-126,000- 168,000 UNIT, 40,000-136,000- 218,000 UNIT, 5,00017,000 -27,000 UNIT, 5,000-17,000- 24,000 UNIT

Tier 6

Ulcer Therapy amoxicil-clarithromy-lansopraz oral combo pack Tier 6

cimetidine hcl oral solution Tier 6

cimetidine oral tablet 300 mg, 400 mg, 800 mg Tier 6

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS

Tier 6

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

Tier 6

famotidine oral suspension Tier 6

famotidine oral tablet 40 mg Tier 6

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

Tier 6

lansoprazole oral tablet,disintegrat, delay rel Tier 6

misoprostol oral tablet Tier 6

NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET

Tier 6

nizatidine oral capsule Tier 6

nizatidine oral solution Tier 6

OMECLAMOX-PAK ORAL COMBO PACK Tier 6

omeprazole oral capsule,delayed release(dr/ec) Tier 6

pantoprazole oral tablet,delayed release (dr/ec) Tier 6

PREVACID SOLUTAB ORAL TABLET,DISINTEGRAT, DELAY REL

Tier 6

79

Updated 7/2018

PYLERA ORAL CAPSULE Tier 6

rabeprazole oral tablet,delayed release (dr/ec) Tier 6

ranitidine hcl oral capsule Tier 6

ranitidine hcl oral syrup Tier 6

ranitidine hcl oral tablet 300 mg Tier 6

sucralfate oral suspension Tier 6

sucralfate oral tablet Tier 6

Immunology, Vaccines & Biotechnology Biotechnology Drugs ARANESP (IN POLYSORBATE) INJECTION SOLUTION

Tier 4 PA; SPRx

ARANESP (IN POLYSORBATE) INJECTION SYRINGE

Tier 4 PA; SPRx

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

Tier 4 PA; SPRx

MIRCERA INJECTION SYRINGE Tier 4 PA; LD; SPRx

MOZOBIL SUBCUTANEOUS SOLUTION Tier 4 SPRx

NEULASTA SUBCUTANEOUS SYRINGE Tier 4 SPRx

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR

Tier 4 SPRx

NEUPOGEN INJECTION SOLUTION Tier 4 SPRx

NEUPOGEN INJECTION SYRINGE Tier 4 SPRx

PROCRIT INJECTION SOLUTION Tier 4 PA; SPRx

ZARXIO INJECTION SYRINGE Tier 4 SPRx

Growth Hormones NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SPRx

Interferons AUBAGIO ORAL TABLET Tier 4 PA; SPRx

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT

Tier 4 SPRx

AVONEX INTRAMUSCULAR PEN INJECTOR KIT

Tier 4 SPRx

80

Updated 7/2018

AVONEX INTRAMUSCULAR SYRINGE KIT Tier 4 SPRx

BETASERON SUBCUTANEOUS KIT Tier 4 SPRx

COPAXONE SUBCUTANEOUS SYRINGE Tier 4 SPRx

EXTAVIA SUBCUTANEOUS KIT Tier 4 SPRx

EXTAVIA SUBCUTANEOUS RECON SOLN Tier 4 SPRx

GILENYA ORAL CAPSULE 0.5 MG Tier 4 SPRx

glatiramer subcutaneous syringe Tier 4 SPRx

glatopa subcutaneous syringe Tier 4 SPRx

moderiba dose pack oral tablets,dose pack Tier 4 PA; SPRx

moderiba oral tablet Tier 4 PA; SPRx

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR

Tier 4 SPRx

PEGASYS SUBCUTANEOUS SOLUTION Tier 4 SPRx

PEGASYS SUBCUTANEOUS SYRINGE Tier 4 SPRx

PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT

Tier 4 PA; SPRx

PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 80 MCG/0.5 ML

Tier 4 PA; SPRx

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML

Tier 4 SPRx

PLEGRIDY SUBCUTANEOUS PEN INJECTOR

Tier 4 SPRx

PLEGRIDY SUBCUTANEOUS SYRINGE Tier 4 SPRx

POMALYST ORAL CAPSULE Tier 4 PA; SPRx

REBETOL ORAL SOLUTION Tier 4 PA; SPRx

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

Tier 4 SPRx

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR

Tier 4 SPRx

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

Tier 4 SPRx

REVLIMID ORAL CAPSULE Tier 4 PA; SPRx

ribasphere oral capsule Tier 4 PA; SPRx

ribasphere oral tablet Tier 4 PA; SPRx

81

Updated 7/2018

ribavirin oral capsule Tier 4 PA; SPRx

ribavirin oral tablet 200 mg Tier 4 PA; SPRx

SYLATRON SUBCUTANEOUS KIT Tier 4 SPRx

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 4 SPRx

ZINBRYTA SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

Interleukins ACTIMMUNE SUBCUTANEOUS SOLUTION

Tier 4 SPRx

ARCALYST SUBCUTANEOUS RECON SOLN

Tier 4 SPRx

imiquimod topical cream in packet Tier 6

INTRON A INJECTION RECON SOLN Tier 4 SPRx

INTRON A INJECTION SOLUTION Tier 4 SPRx

KINERET SUBCUTANEOUS SYRINGE Tier 4 PA; LD; SPRx

Vaccines & Miscellaneous Immunologicals ACTHIB (PF) INTRAMUSCULAR RECON SOLN

Tier 5 ACA

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

Tier 5 ACA

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

Tier 5 ACA

AFLURIA 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

AFLURIA 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 5 ACA

AFLURIA QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

AFLURIA QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 5 ACA

bcg vaccine, live (pf) percutaneous suspension for reconstitution

Tier 5 ACA

BEXSERO INTRAMUSCULAR SYRINGE Tier 5 ACA

BIOTHRAX INTRAMUSCULAR SUSPENSION

Tier 5 ACA

82

Updated 7/2018

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION

Tier 5 ACA

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

Tier 5 ACA

CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

CUVITRU SUBCUTANEOUS SOLUTION Tier 4 PA; SPRx

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUAD 2017-2018 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUARIX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUBLOK 2017-2018 (PF) INTRAMUSCULAR SOLUTION

Tier 5 ACA

FLUBLOK QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUCELVAX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUCELVAX QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 5 ACA

FLULAVAL QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLULAVAL QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 5 ACA

FLUMIST QUAD 2017-2018 NASAL NASAL SPRAY SYRINGE

Tier 5 ACA

FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

83

Updated 7/2018

FLUVIRIN 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 5 ACA

FLUZONE HIGH-DOSE 2017-18 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUZONE INTRADERM QUAD 2017-18 INTRADERMAL SYRINGE

Tier 5 ACA

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUZONE QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 5 ACA

FLUZONE QUAD PEDI 2017-18 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

GAMMAGARD LIQUID INJECTION SOLUTION

Tier 4 PA; SPRx

GAMUNEX-C INJECTION SOLUTION Tier 4 PA; SPRx

GARDASIL (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

GRASTEK SUBLINGUAL TABLET Tier 6 PA

HAVRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

HAVRIX (PF) INTRAMUSCULAR SYRINGE Tier 5 ACA

HEPLISAV-B INTRAMUSCULAR SOLUTION

Tier 5 ACA

HIZENTRA SUBCUTANEOUS SOLUTION Tier 4 PA; SPRx

HYQVIA SUBCUTANEOUS SOLUTION Tier 4 PA; SPRx

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN

Tier 5 ACA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

84

Updated 7/2018

IPOL INJECTION SUSPENSION Tier 5 ACA

IXIARO (PF) INTRAMUSCULAR SYRINGE Tier 5 ACA

KINRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

KINRIX (PF) INTRAMUSCULAR SYRINGE Tier 5 ACA

MENACTRA (PF) INTRAMUSCULAR SOLUTION

Tier 5 ACA

MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN

Tier 5 ACA

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

Tier 5 ACA

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

Tier 5 ACA

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

Tier 5 ACA

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

Tier 5 ACA

ODACTRA SUBLINGUAL TABLET Tier 6 PA

ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY

Tier 4 PA; LD; SPRx

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION

Tier 5 ACA

PENTACEL (PF) INTRAMUSCULAR KIT Tier 5 ACA

PNEUMOVAX 23 INJECTION SOLUTION Tier 5 ACA

PNEUMOVAX 23 INJECTION SYRINGE Tier 5 ACA

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

RAGWITEK SUBLINGUAL TABLET Tier 6 PA

85

Updated 7/2018

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

ROTATEQ VACCINE ORAL SOLUTION Tier 5 ACA

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

TENIVAC (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

TENIVAC (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

tetanus,diphtheria tox ped(pf) intramuscular suspension

Tier 5 ACA

tetanus-diphtheria toxoids-td intramuscular suspension

Tier 5 ACA

TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

TRUMENBA INTRAMUSCULAR SYRINGE Tier 5 ACA

TWINRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

TWINRIX (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

TYPHIM VI INTRAMUSCULAR SOLUTION Tier 5 ACA

TYPHIM VI INTRAMUSCULAR SYRINGE Tier 5 ACA

VAQTA (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

VAQTA (PF) INTRAMUSCULAR SYRINGE Tier 5 ACA

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

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

Tier 5 ACA

86

Updated 7/2018

VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 5 ACA

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

Musculoskeletal & Rheumatology Gout Therapy allopurinol oral tablet Tier 6

COLCRYS ORAL TABLET Tier 6

probenecid oral tablet Tier 6

probenecid-colchicine oral tablet Tier 6

ULORIC ORAL TABLET Tier 6

Osteoporosis Therapy alendronate oral solution Tier 1

alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg Tier 1

FORTEO SUBCUTANEOUS PEN INJECTOR Tier 4 SPRx

FOSAMAX PLUS D ORAL TABLET Tier 3

ibandronate oral tablet Tier 1

raloxifene oral tablet Tier 5 ACA

risedronate oral tablet 150 mg, 35 mg, 5 mg Tier 1

risedronate oral tablet,delayed release (dr/ec) Tier 1

TYMLOS SUBCUTANEOUS PEN INJECTOR Tier 6

Other Rheumatologicals ACTEMRA SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

BENLYSTA SUBCUTANEOUS AUTOINJECTOR

Tier 4 PA; LD; SPRx

BENLYSTA SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

DEPEN TITRATABS ORAL TABLET Tier 6

ENBREL MINI SUBCUTANEOUS CARTRIDGE

Tier 4 PA; SPRx

ENBREL SUBCUTANEOUS RECON SOLN Tier 4 PA; SPRx

ENBREL SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

87

Updated 7/2018

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SPRx

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT

Tier 4 PA; SPRx; QL (2 EA per 30 days)

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


HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT


HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT


HUMIRA SUBCUTANEOUS SYRINGE KIT Tier 4 PA; SPRx; QL (2 EA per 30 days)

KEVZARA SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

leflunomide oral tablet Tier 6

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML

Tier 4 PA; SPRx; QL (4 ML per 30 days)

ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML, 87.5 MG/0.7 ML

Tier 4 PA; LD; SPRx; QL (4 ML per 28 days)

OTEZLA ORAL TABLET Tier 4 PA; SPRx

OTEZLA STARTER ORAL TABLETS,DOSE PACK

Tier 4 PA; SPRx

RIDAURA ORAL CAPSULE Tier 6

SAVELLA ORAL TABLET Tier 6

SAVELLA ORAL TABLETS,DOSE PACK Tier 6

SIMPONI SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SPRx

SIMPONI SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

XELJANZ ORAL TABLET Tier 4 PA; SPRx

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 4 PA; SPRx

Obstetrics & Gynecology Estrogens & Progestins ALORA TRANSDERMAL PATCH SEMIWEEKLY

Tier 6

amabelz oral tablet Tier 6

ANGELIQ ORAL TABLET Tier 6

camila oral tablet Tier 5 ACA

88

Updated 7/2018

CLIMARA PRO TRANSDERMAL PATCH WEEKLY

Tier 6

COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY

Tier 6

covaryx h.s. oral tablet Tier 6

covaryx oral tablet Tier 6

CRINONE VAGINAL GEL 4 % Tier 6

deblitane oral tablet Tier 5 ACA

DEPO-ESTRADIOL INTRAMUSCULAR OIL Tier 6

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE

Tier 5 ACA

DIVIGEL TRANSDERMAL GEL IN PACKET

Tier 6

DUAVEE ORAL TABLET Tier 6

eemt hs oral tablet Tier 6

eemt oral tablet Tier 6

ELESTRIN TRANSDERMAL GEL IN METERED-DOSE PUMP

Tier 6

errin oral tablet Tier 5 ACA

ESTRACE VAGINAL CREAM Tier 6

estradiol oral tablet Tier 6

estradiol transdermal patch semiweekly Tier 6

estradiol transdermal patch weekly Tier 6

estradiol vaginal cream Tier 6

estradiol vaginal tablet Tier 6

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

Tier 6

estradiol-norethindrone acet oral tablet Tier 6

ESTRING VAGINAL RING Tier 6

ESTROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP

Tier 6

estrogens-methyltestosterone oral tablet Tier 6

estropipate oral tablet Tier 6

EVAMIST TRANSDERMAL SPRAY,NONAEROSOL

Tier 6

89

Updated 7/2018

FEMRING VAGINAL RING Tier 6

fyavolv oral tablet Tier 5 ACA

heather oral tablet Tier 5 ACA

jencycla oral tablet Tier 5 ACA

jevantique lo oral tablet Tier 5 ACA

jinteli oral tablet Tier 5 ACA

jolivette oral tablet Tier 5 ACA

lopreeza oral tablet Tier 6

lyza oral tablet Tier 5 ACA

medroxyprogesterone intramuscular suspension Tier 5 ACA

medroxyprogesterone intramuscular syringe Tier 5 ACA

medroxyprogesterone oral tablet Tier 6

MENEST ORAL TABLET Tier 6

MENOSTAR TRANSDERMAL PATCH WEEKLY

Tier 6

mimvey lo oral tablet Tier 6

mimvey oral tablet Tier 6

MINIVELLE TRANSDERMAL PATCH SEMIWEEKLY

Tier 6

nora-be oral tablet Tier 5 ACA

norethindrone (contraceptive) oral tablet Tier 5 ACA

norethindrone acetate oral tablet Tier 6

norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

Tier 5 ACA

norlyda oral tablet Tier 5 ACA

norlyroc oral tablet Tier 5 ACA

PREFEST ORAL TABLET Tier 6

PREMARIN ORAL TABLET Tier 6

PREMARIN VAGINAL CREAM Tier 6 ST

PREMPHASE ORAL TABLET Tier 6

PREMPRO ORAL TABLET Tier 6

progesterone micronized oral capsule Tier 6

sharobel oral tablet Tier 5 ACA

90

Updated 7/2018

VIVELLE-DOT TRANSDERMAL PATCH SEMIWEEKLY

Tier 6

yuvafem vaginal tablet Tier 6

Miscellaneous Ob/Gyn AVC VAGINAL VAGINAL CREAM Tier 6

CLEOCIN VAGINAL SUPPOSITORY Tier 6

clindamycin phosphate vaginal cream Tier 6

fem ph vaginal gel Tier 6

GYNAZOLE-1 VAGINAL CREAM Tier 6

INTRAROSA VAGINAL INSERT Tier 6

LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET

Tier 4 PA; SPRx

LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET

Tier 4 PA; SPRx

metronidazole vaginal gel Tier 6

miconazole-3 vaginal suppository Tier 6

NUVARING VAGINAL RING Tier 5 ACA

OSPHENA ORAL TABLET Tier 6 ST

terconazole vaginal cream Tier 6

terconazole vaginal suppository Tier 6

tranexamic acid oral tablet Tier 6

vandazole vaginal gel Tier 6

xulane transdermal patch weekly Tier 5 ACA

Oral Contraceptives & Related Agents altavera (28) oral tablet Tier 5 ACA

alyacen 1/35 (28) oral tablet Tier 5 ACA

alyacen 7/7/7 (28) oral tablet Tier 5 ACA

amethia lo oral tablets,dose pack,3 month Tier 5 ACA

amethia oral tablets,dose pack,3 month Tier 5 ACA

amethyst oral tablet Tier 5 ACA

apri oral tablet Tier 5 ACA

aranelle (28) oral tablet Tier 5 ACA

ashlyna oral tablets,dose pack,3 month Tier 5 ACA

91

Updated 7/2018

aubra oral tablet Tier 5 ACA

aviane oral tablet Tier 5 ACA

azurette (28) oral tablet Tier 5 ACA

BALCOLTRA ORAL TABLET Tier 5 ACA

balziva (28) oral tablet Tier 5 ACA

bekyree (28) oral tablet Tier 5 ACA

blisovi 24 fe oral tablet Tier 5 ACA

blisovi fe 1.5/30 (28) oral tablet Tier 5 ACA

blisovi fe 1/20 (28) oral tablet Tier 5 ACA

briellyn oral tablet Tier 5 ACA

camrese lo oral tablets,dose pack,3 month Tier 5 ACA

camrese oral tablets,dose pack,3 month Tier 5 ACA

caziant (28) oral tablet Tier 5 ACA

chateal oral tablet Tier 5 ACA

cryselle (28) oral tablet Tier 5 ACA

cyclafem 1/35 (28) oral tablet Tier 5 ACA

cyclafem 7/7/7 (28) oral tablet Tier 5 ACA

cyred oral tablet Tier 5 ACA

dasetta 1/35 (28) oral tablet Tier 5 ACA

dasetta 7/7/7 (28) oral tablet Tier 5 ACA

daysee oral tablets,dose pack,3 month Tier 5 ACA

delyla (28) oral tablet Tier 5 ACA

desog-e.estradiol/e.estradiol oral tablet Tier 5 ACA

desogestrel-ethinyl estradiol oral tablet Tier 5 ACA

drospirenone-e.estradiol-lm.fa oral tablet 3-0.020.451 mg (24) (4)

Tier 5 ACA

drospirenone-ethinyl estradiol oral tablet Tier 5 ACA

econtra ez oral tablet Tier 5 ACA; QL (2 EA per 30 days)

econtra one-step oral tablet Tier 5 ACA; QL (2 EA per 30 days)

elinest oral tablet Tier 5 ACA

ELLA ORAL TABLET Tier 5 ACA; QL (2 EA per 30 days)

emoquette oral tablet Tier 5 ACA

enpresse oral tablet Tier 5 ACA

92

Updated 7/2018

enskyce oral tablet Tier 5 ACA

estarylla oral tablet Tier 5 ACA

ethynodiol diac-eth estradiol oral tablet Tier 5 ACA

falmina (28) oral tablet Tier 5 ACA

fayosim oral tablets,dose pack,3 month Tier 5 ACA

femynor oral tablet Tier 5 ACA

gianvi (28) oral tablet Tier 5 ACA

gildagia oral tablet Tier 5 ACA

introvale oral tablets,dose pack,3 month Tier 5 ACA

isibloom oral tablet Tier 5 ACA

jolessa oral tablets,dose pack,3 month Tier 5 ACA

juleber oral tablet Tier 5 ACA

junel 1.5/30 (21) oral tablet Tier 5 ACA

junel 1/20 (21) oral tablet Tier 5 ACA

junel fe 1.5/30 (28) oral tablet Tier 5 ACA

junel fe 1/20 (28) oral tablet Tier 5 ACA

junel fe 24 oral tablet Tier 5 ACA

kaitlib fe oral tablet,chewable Tier 5 ACA

kariva (28) oral tablet Tier 5 ACA

kelnor 1/35 (28) oral tablet Tier 5 ACA

kimidess (28) oral tablet Tier 5 ACA

kurvelo oral tablet Tier 5 ACA

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

Tier 5 ACA

larin 1.5/30 (21) oral tablet Tier 5 ACA

larin 1/20 (21) oral tablet Tier 5 ACA

larin 24 fe oral tablet Tier 5 ACA

larin fe 1.5/30 (28) oral tablet Tier 5 ACA

larin fe 1/20 (28) oral tablet Tier 5 ACA

larissia oral tablet Tier 5 ACA

layolis fe oral tablet,chewable Tier 5 ACA

leena 28 oral tablet Tier 5 ACA

lessina oral tablet Tier 5 ACA

93

Updated 7/2018

levonest (28) oral tablet Tier 5 ACA

levonorgestrel-ethinyl estrad oral tablet Tier 5 ACA

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

Tier 5 ACA

levonorg-eth estrad triphasic oral tablet Tier 5 ACA

levora 0.15/30 (28) oral tablet Tier 5 ACA

levora-28 oral tablet Tier 5 ACA

lillow oral tablet Tier 5 ACA

LO LOESTRIN FE ORAL TABLET Tier 5 ACA

lomedia 24 fe oral tablet Tier 5 ACA

loryna (28) oral tablet Tier 5 ACA

low-ogestrel (28) oral tablet Tier 5 ACA

lutera (28) oral tablet Tier 5 ACA

marlissa oral tablet Tier 5 ACA

melodetta 24 fe oral tablet,chewable Tier 5 ACA

mibelas 24 fe oral tablet,chewable Tier 5 ACA

microgestin 1.5/30 (21) oral tablet Tier 5 ACA

microgestin 1/20 (21) oral tablet Tier 5 ACA

microgestin fe 1.5/30 (28) oral tablet Tier 5 ACA

microgestin fe 1/20 (28) oral tablet Tier 5 ACA

mono-linyah oral tablet Tier 5 ACA

mononessa (28) oral tablet Tier 5 ACA

my choice oral tablet Tier 5 ACA; QL (2 EA per 30 days)

my way oral tablet Tier 5 ACA; QL (2 EA per 30 days)

myzilra oral tablet Tier 5 ACA

NATAZIA ORAL TABLET Tier 5 ACA

necon 0.5/35 (28) oral tablet Tier 5 ACA

necon 1/50 (28) oral tablet Tier 5 ACA

necon 10/11 (28) oral tablet Tier 5 ACA

necon 7/7/7 (28) oral tablet Tier 5 ACA

next choice one dose oral tablet Tier 5 ACA; QL (2 EA per 30 days)

nikki (28) oral tablet Tier 5 ACA

noreth-ethinyl estradiol-iron oral tablet,chewable Tier 5 ACA

94

Updated 7/2018

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

Tier 5 ACA

norethindrone-e.estradiol-iron oral tablet Tier 5 ACA

norgestimate-ethinyl estradiol oral tablet Tier 5 ACA

norgestrel-ethinyl estradiol oral tablet Tier 5 ACA

nortrel 0.5/35 (28) oral tablet Tier 5 ACA

nortrel 1/35 (21) oral tablet Tier 5 ACA

nortrel 1/35 (28) oral tablet Tier 5 ACA

nortrel 7/7/7 (28) oral tablet Tier 5 ACA

ocella oral tablet Tier 5 ACA

ogestrel (28) oral tablet Tier 5 ACA

opcicon one-step oral tablet Tier 5 ACA; QL (2 EA per 30 days)

option-2 oral tablet Tier 5 ACA; QL (2 EA per 30 days)

orsythia oral tablet Tier 5 ACA

philith oral tablet Tier 5 ACA

pimtrea (28) oral tablet Tier 5 ACA

pirmella oral tablet Tier 5 ACA

portia oral tablet Tier 5 ACA

previfem oral tablet Tier 5 ACA

quasense oral tablets,dose pack,3 month Tier 5 ACA

rajani oral tablet Tier 5 ACA

reclipsen (28) oral tablet Tier 5 ACA

rivelsa oral tablets,dose pack,3 month Tier 5 ACA

SAFYRAL ORAL TABLET Tier 5 ACA

setlakin oral tablets,dose pack,3 month Tier 5 ACA

sprintec (28) oral tablet Tier 5 ACA

sronyx oral tablet Tier 5 ACA

syeda oral tablet Tier 5 ACA

tarina fe 1/20 (28) oral tablet Tier 5 ACA

tilia fe oral tablet Tier 5 ACA

tri femynor oral tablet Tier 5 ACA

tri-estarylla oral tablet Tier 5 ACA

tri-legest fe oral tablet Tier 5 ACA

95

Updated 7/2018

tri-linyah oral tablet Tier 5 ACA

tri-lo-estarylla oral tablet Tier 5 ACA

tri-lo-marzia oral tablet Tier 5 ACA

tri-lo-sprintec oral tablet Tier 5 ACA

trinessa (28) oral tablet Tier 5 ACA

trinessa lo oral tablet Tier 5 ACA

tri-previfem (28) oral tablet Tier 5 ACA

tri-sprintec (28) oral tablet Tier 5 ACA

trivora (28) oral tablet Tier 5 ACA

tri-vylibra oral tablet Tier 5 ACA

tydemy oral tablet Tier 5 ACA

velivet triphasic regimen (28) oral tablet Tier 5 ACA

vestura (28) oral tablet Tier 5 ACA

vienva oral tablet Tier 5 ACA

viorele (28) oral tablet Tier 5 ACA

vyfemla (28) oral tablet Tier 5 ACA

vylibra oral tablet Tier 5 ACA

wera (28) oral tablet Tier 5 ACA

wymzya fe oral tablet,chewable Tier 5 ACA

zarah oral tablet Tier 5 ACA

zenchent (28) oral tablet Tier 5 ACA

zenchent fe oral tablet,chewable Tier 5 ACA

zovia 1/35e (28) oral tablet Tier 5 ACA

zovia 1/50e (28) oral tablet Tier 5 ACA

Ophthalmology Antibiotics AZASITE OPHTHALMIC (EYE) DROPS Tier 6

bacitracin ophthalmic (eye) ointment Tier 6

bacitracin-polymyxin b ophthalmic (eye) ointment Tier 6

BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 6

BETADINE OPHTHALMIC PREP OPHTHALMIC (EYE) SOLUTION

Tier 6

96

Updated 7/2018

CILOXAN OPHTHALMIC (EYE) OINTMENT

Tier 6

ciprofloxacin hcl ophthalmic (eye) drops Tier 6

erythromycin ophthalmic (eye) ointment Tier 6

gatifloxacin ophthalmic (eye) drops Tier 6

gentamicin ophthalmic (eye) drops Tier 6

gentamicin ophthalmic (eye) ointment Tier 6

levofloxacin ophthalmic (eye) drops Tier 6

MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS

Tier 6

moxifloxacin ophthalmic (eye) drops Tier 6

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 6

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment

Tier 6

neomycin-polymyxin-gramicidin ophthalmic (eye) drops

Tier 6

NEO-POLYCIN OPHTHALMIC (EYE) OINTMENT

Tier 6

ofloxacin ophthalmic (eye) drops Tier 6

POLYCIN OPHTHALMIC (EYE) OINTMENT

Tier 6

polymyxin b sulf-trimethoprim ophthalmic (eye) drops

Tier 6

tobramycin ophthalmic (eye) drops Tier 6

TOBREX OPHTHALMIC (EYE) OINTMENT Tier 6

VIGAMOX OPHTHALMIC (EYE) DROPS Tier 6

Antivirals trifluridine ophthalmic (eye) drops Tier 6

ZIRGAN OPHTHALMIC (EYE) GEL Tier 6

Beta-Blockers betaxolol ophthalmic (eye) drops Tier 6

BETIMOL OPHTHALMIC (EYE) DROPS Tier 6 ST

BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 6 ST

97

Updated 7/2018

carteolol ophthalmic (eye) drops Tier 6

ISTALOL OPHTHALMIC (EYE) DROPS, ONCE DAILY

Tier 6 ST

levobunolol ophthalmic (eye) drops 0.5 % Tier 6

metipranolol ophthalmic (eye) drops Tier 6

timolol maleate ophthalmic (eye) drops Tier 6

timolol maleate ophthalmic (eye) drops, once daily Tier 6

timolol maleate ophthalmic (eye) gel forming solution

Tier 6

TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) DROPPERETTE

Tier 6

Cholinesterase Inhibitor Miotics PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS

Tier 6

Cycloplegic Mydriatics atropine ophthalmic (eye) drops Tier 6

atropine ophthalmic (eye) ointment Tier 6

cyclopentolate ophthalmic (eye) drops Tier 6

homatropine hbr ophthalmic (eye) drops Tier 6

tropicamide ophthalmic (eye) drops Tier 6

Direct Acting Miotics MIOCHOL-E INTRAOCULAR KIT Tier 6

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %

Tier 6

Miscellaneous Ophthalmologics AKTEN (PF) OPHTHALMIC (EYE) GEL Tier 6

ALOCRIL OPHTHALMIC (EYE) DROPS Tier 6 ST

ALOMIDE OPHTHALMIC (EYE) DROPS Tier 6 ST

azelastine ophthalmic (eye) drops Tier 6

BEPREVE OPHTHALMIC (EYE) DROPS Tier 6 ST

cromolyn ophthalmic (eye) drops Tier 6

CYSTARAN OPHTHALMIC (EYE) DROPS Tier 4 LD; SPRx

EMADINE OPHTHALMIC (EYE) DROPS Tier 6 ST

98

Updated 7/2018

epinastine ophthalmic (eye) drops Tier 6

FLUCAINE OPHTHALMIC (EYE) DROPS Tier 6

fluorescein-proparacaine ophthalmic (eye) drops Tier 6

LACRISERT OPHTHALMIC (EYE) INSERT Tier 6

LASTACAFT OPHTHALMIC (EYE) DROPS Tier 6 ST

olopatadine ophthalmic (eye) drops Tier 6

PATADAY OPHTHALMIC (EYE) DROPS Tier 6

PAZEO OPHTHALMIC (EYE) DROPS Tier 6

proparacaine ophthalmic (eye) drops Tier 6

RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS

Tier 6

RESTASIS OPHTHALMIC (EYE) DROPPERETTE

Tier 6

tetracaine hcl (pf) ophthalmic (eye) drops Tier 6

tetracaine hcl ophthalmic (eye) drops Tier 6

Non-Steroidal Anti-Inflammatory Agents bromfenac ophthalmic (eye) drops Tier 6

diclofenac sodium ophthalmic (eye) drops Tier 6

flurbiprofen sodium ophthalmic (eye) drops Tier 6

ketorolac ophthalmic (eye) drops Tier 6

NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 6 ST

PROLENSA OPHTHALMIC (EYE) DROPS Tier 6

Oral Drugs For Glaucoma acetazolamide oral capsule, extended release Tier 1

acetazolamide oral tablet Tier 1

methazolamide oral tablet Tier 1

Other Glaucoma Drugs AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 6 ST

bimatoprost ophthalmic (eye) drops Tier 6

COMBIGAN OPHTHALMIC (EYE) DROPS Tier 6

99

Updated 7/2018

COSOPT (PF) OPHTHALMIC (EYE) DROPPERETTE

Tier 6 ST

dorzolamide ophthalmic (eye) drops Tier 6

dorzolamide-timolol ophthalmic (eye) drops Tier 6

latanoprost ophthalmic (eye) drops Tier 6

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %

Tier 6

SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 6 ST

TRAVATAN Z OPHTHALMIC (EYE) DROPS

Tier 6

ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE

Tier 6 ST

Steroid-Antibiotic Combinations neomycin-bacitracin-poly-hc ophthalmic (eye) ointment

Tier 6

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension

Tier 6

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment

Tier 6

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension

Tier 6

NEO-POLYCIN HC OPHTHALMIC (EYE) OINTMENT

Tier 6

PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 6

PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT

Tier 6

TOBRADEX OPHTHALMIC (EYE) OINTMENT

Tier 6

TOBRADEX ST OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 6

tobramycin-dexamethasone ophthalmic (eye) drops,suspension

Tier 6

Steroids dexamethasone sodium phosphate ophthalmic (eye) drops

Tier 6

100

Updated 7/2018

DUREZOL OPHTHALMIC (EYE) DROPS Tier 6

fluorometholone ophthalmic (eye) drops,suspension

Tier 6

FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 6

FML S.O.P. OPHTHALMIC (EYE) OINTMENT

Tier 6

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL

Tier 6

LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 6

LOTEMAX OPHTHALMIC (EYE) OINTMENT

Tier 6

PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 6

prednisolone acetate ophthalmic (eye) drops,suspension

Tier 6

prednisolone sodium phosphate ophthalmic (eye) drops

Tier 6

VEXOL OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 6

Steroid-Sulfonamide Combinations BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 6

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT

Tier 6

sulfacetamide-prednisolone ophthalmic (eye) drops

Tier 6

Sulfonamides sulfacetamide sodium ophthalmic (eye) drops Tier 6

sulfacetamide sodium ophthalmic (eye) ointment Tier 6

Sympathomimetics ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %

Tier 6

apraclonidine ophthalmic (eye) drops Tier 6

brimonidine ophthalmic (eye) drops Tier 6

101

Updated 7/2018

Vasoconstrictor Decongestants CYCLOMYDRIL OPHTHALMIC (EYE) DROPS

Tier 6

naphazoline ophthalmic (eye) drops Tier 6

phenylephrine hcl ophthalmic (eye) drops Tier 6

Respiratory, Allergy, Cough & Cold Antihistamine & Antiallergenic Agents carbinoxamine maleate oral liquid Tier 6

carbinoxamine maleate oral tablet 4 mg Tier 6

CLARINEX ORAL SYRUP Tier 6

clemastine oral tablet 2.68 mg Tier 6

cyproheptadine oral syrup Tier 6

cyproheptadine oral tablet Tier 6

desloratadine oral tablet Tier 6

desloratadine oral tablet,disintegrating Tier 6

diphenhydramine hcl injection solution 50 mg/ml Tier 6

diphenhydramine hcl injection syringe Tier 6

EPINEPHRINE INJECTION AUTOINJECTOR


epinephrine injection solution Tier 6

epinephrine injection syringe 0.1 mg/ml Tier 6

EPIPEN 2-PAK INJECTION AUTOINJECTOR


EPIPEN INJECTION AUTO-INJECTOR Tier 6 QL (4 EA per 30 days)

EPIPEN JR 2-PAK INJECTION AUTOINJECTOR


EPIPEN JR INJECTION AUTO-INJECTOR Tier 6 QL (4 EA per 30 days)

hydroxyzine hcl oral solution 10 mg/5 ml Tier 6

hydroxyzine hcl oral tablet Tier 6

hydroxyzine pamoate oral capsule Tier 6

levocetirizine oral solution Tier 6

levocetirizine oral tablet Tier 6

PHENADOZ RECTAL SUPPOSITORY Tier 6

102

Updated 7/2018

PHENERGAN RECTAL SUPPOSITORY Tier 6

promethazine oral syrup Tier 6

promethazine oral tablet Tier 6

promethazine rectal suppository Tier 6

PROMETHEGAN RECTAL SUPPOSITORY Tier 6

Cough & Cold Therapy benzonatate oral capsule Tier 6

brompheniramine-pseudoeph-dm oral syrup Tier 6

CHERATUSSIN AC ORAL LIQUID Tier 6

codeine-guaifenesin oral liquid Tier 6

GUAIFENESIN AC ORAL LIQUID Tier 6

GUAIFENESIN DAC ORAL SYRUP Tier 6

hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr

Tier 6

hydrocodone-cpm-pseudoephed oral solution Tier 6

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

Tier 6

hydrocodone-homatropine oral tablet Tier 6

HYDROMET ORAL SYRUP Tier 6

MAR-COF BP ORAL LIQUID Tier 6

MAR-COF CG ORAL LIQUID Tier 6

M-CLEAR WC ORAL LIQUID Tier 6

PROMETHAZINE VC ORAL SYRUP Tier 6

PROMETHAZINE VC-CODEINE ORAL SYRUP

Tier 6

promethazine-codeine oral syrup Tier 6

promethazine-dm oral syrup Tier 6

promethazine-phenyleph-codeine oral syrup Tier 6

REZIRA ORAL SOLUTION Tier 6

ROBAFEN AC ORAL LIQUID Tier 6

SEMPREX-D ORAL CAPSULE Tier 6

TUSSIGON ORAL TABLET Tier 6

VIRTUSSIN AC ORAL LIQUID Tier 6

103

Updated 7/2018

ZODRYL AC 25 ORAL SUSPENSION Tier 6







ZODRYL DAC 25 ORAL SUSPENSION Tier 6







ZODRYL DEC 25 ORAL SUSPENSION Tier 6







Z-TUSS AC ORAL LIQUID Tier 6

Pulmonary Agents acetylcysteine solution Tier 6

ADCIRCA ORAL TABLET Tier 4 PA; SPRx

ADEMPAS ORAL TABLET Tier 4 PA; SPRx

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE

Tier 2

ADVAIR HFA INHALATION HFA AEROSOL INHALER

Tier 2

AEROSPAN INHALATION HFA AEROSOL INHALER

Tier 6

104

Updated 7/2018

albuterol sulfate inhalation solution for nebulization

Tier 1

albuterol sulfate oral syrup Tier 1

albuterol sulfate oral tablet Tier 1

albuterol sulfate oral tablet extended release 12 hr Tier 1

ALVESCO INHALATION HFA AEROSOL INHALER

Tier 6

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 2

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 2

ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION

Tier 2

ASMANEX HFA INHALATION HFA AEROSOL INHALER

Tier 2

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2

ATROVENT HFA INHALATION HFA AEROSOL INHALER

Tier 6

BERINERT INTRAVENOUS KIT Tier 4 PA; SPRx

BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER

Tier 2

BREO ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 2

BROVANA INHALATION SOLUTION FOR NEBULIZATION

Tier 2

budesonide inhalation suspension for nebulization Tier 1

budesonide nasal spray,non-aerosol Tier 6

CINRYZE INTRAVENOUS RECON SOLN Tier 4 PA; SPRx

COMBIVENT RESPIMAT INHALATION MIST

Tier 2

cromolyn inhalation solution for nebulization Tier 1

DALIRESP ORAL TABLET Tier 6

DULERA INHALATION HFA AEROSOL INHALER

Tier 2

ESBRIET ORAL CAPSULE Tier 4 PA; SPRx

105

Updated 7/2018

ESBRIET ORAL TABLET Tier 4 PA; SPRx

FIRAZYR SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE

Tier 2

FLOVENT HFA INHALATION HFA AEROSOL INHALER

Tier 2

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

Tier 6

fluticasone nasal spray,suspension Tier 6

HAEGARDA SUBCUTANEOUS RECON SOLN

Tier 4 PA; LD; SPRx

ipratropium bromide inhalation solution Tier 1

ipratropium-albuterol inhalation solution for nebulization

Tier 1

KALYDECO ORAL GRANULES IN PACKET

Tier 4 PA; SPRx

KALYDECO ORAL TABLET Tier 4 PA; SPRx

levalbuterol hcl inhalation solution for nebulization

Tier 1

LONHALA MAGNAIR REFILL INHALATION SOLUTION FOR NEBULIZATION

Tier 2

LONHALA MAGNAIR STARTER INHALATION SOLUTION FOR NEBULIZATION

Tier 2

metaproterenol oral syrup Tier 1

metaproterenol oral tablet Tier 1

mometasone nasal spray,non-aerosol Tier 6

montelukast oral granules in packet Tier 1

montelukast oral tablet Tier 1

montelukast oral tablet,chewable Tier 1

OFEV ORAL CAPSULE Tier 4 PA; SPRx

OPSUMIT ORAL TABLET Tier 4 PA; SPRx

ORKAMBI ORAL TABLET Tier 4 PA; SPRx

PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION

Tier 2

106

Updated 7/2018

PROAIR HFA INHALATION HFA AEROSOL INHALER


PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED


PROVENTIL HFA INHALATION HFA AEROSOL INHALER


PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 3

PULMOSAL INHALATION SOLUTION FOR NEBULIZATION

Tier 6

PULMOZYME INHALATION SOLUTION Tier 4 SPRx

QVAR INHALATION AEROSOL Tier 2

QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED

Tier 2

REVATIO INTRAVENOUS SOLUTION Tier 4 PA; SPRx

REVATIO ORAL SUSPENSION FOR RECONSTITUTION

Tier 4 PA; SPRx

RUCONEST INTRAVENOUS RECON SOLN Tier 4 PA; SPRx

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

Tier 2

sildenafil (antihypertensive) intravenous solution Tier 4 PA; SPRx

sildenafil (antihypertensive) oral tablet Tier 4 PA; SPRx

sodium chloride inhalation solution for nebulization

Tier 6

SPIRIVA RESPIMAT INHALATION MIST Tier 2

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 2

STIOLTO RESPIMAT INHALATION MIST Tier 2

STRIVERDI RESPIMAT INHALATION MIST

Tier 2

SYMBICORT INHALATION HFA AEROSOL INHALER

Tier 2

SYMDEKO ORAL TABLETS, SEQUENTIAL Tier 4 PA; SPRx

terbutaline oral tablet Tier 1

terbutaline subcutaneous solution Tier 1

107

Updated 7/2018

THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HR

Tier 6

theophylline oral solution Tier 6

theophylline oral tablet extended release 12 hr Tier 6

theophylline oral tablet extended release 24 hr Tier 6

TRACLEER ORAL TABLET Tier 4 PA; SPRx

TRACLEER ORAL TABLET FOR SUSPENSION

Tier 4 PA; SPRx

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 2

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2

TYVASO INHALATION SOLUTION FOR NEBULIZATION

Tier 4 PA; SPRx

TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION

Tier 4 PA; SPRx

TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION

Tier 4 PA; SPRx

TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION

Tier 4 PA; SPRx

UTIBRON NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 3

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION

Tier 4 PA; SPRx

VENTOLIN HFA INHALATION HFA AEROSOL INHALER


XOPENEX HFA INHALATION HFA AEROSOL INHALER


zafirlukast oral tablet Tier 1

zileuton oral tablet, er multiphase 12 hr Tier 1 PA

Urologicals Anticholinergics & Antispasmodics darifenacin oral tablet extended release 24 hr Tier 6

flavoxate oral tablet Tier 6

108

Updated 7/2018

GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 100 MG/GRAM (10 %)

Tier 6

GELNIQUE TRANSDERMAL GEL IN PACKET

Tier 6

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

Tier 6

oxybutynin chloride oral syrup Tier 6

oxybutynin chloride oral tablet Tier 6

oxybutynin chloride oral tablet extended release 24hr

Tier 6

tolterodine oral capsule,extended release 24hr Tier 6

tolterodine oral tablet Tier 6

trospium oral capsule,extended release 24hr Tier 6

trospium oral tablet Tier 6

VESICARE ORAL TABLET Tier 6

Benign Prostatic Hyperplasia (Bph) Therapy alfuzosin oral tablet extended release 24 hr Tier 6

CIALIS ORAL TABLET 2.5 MG, 5 MG Tier 6 PA

dutasteride oral capsule Tier 6

dutasteride-tamsulosin oral capsule, er multiphase 24 hr

Tier 6

finasteride oral tablet 5 mg Tier 6

RAPAFLO ORAL CAPSULE Tier 6

tamsulosin oral capsule,extended release 24hr Tier 6

Cholinergic Stimulants bethanechol chloride oral tablet Tier 6

Miscellaneous Urologicals alprostadil injection solution Tier 6

CYSTAGON ORAL CAPSULE Tier 4 LD; SPRx

ELMIRON ORAL CAPSULE Tier 6

K-PHOS NO 2 ORAL TABLET Tier 6

K-PHOS ORIGINAL ORAL TABLET,SOLUBLE

Tier 6

109

Updated 7/2018

potassium citrate oral tablet extended release Tier 6

potassium citrate-citric acid oral packet Tier 6

PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE

Tier 4 PA; SPRx

PROSTIN VR PEDIATRIC INJECTION SOLUTION

Tier 6

Urinary Anesthetics phenazopyridine oral tablet 100 mg, 200 mg Tier 6

Vitamins, Hematinics & Electrolytes Electrolytes calcium 500 with d oral tablet Tier 5 ACA

calcium 600 with vitamin d3 oral capsule 600 mg(1,500mg) -500 unit

Tier 5 ACA

calcium carb and citrate-vitd3 oral tablet extended release

Tier 5 ACA

calcium carbonate-vitamin d3 oral tablet 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -400 unit

Tier 5 ACA

calcium citrate + d oral tablet Tier 5 ACA

calcium citrate-vitamin d2 oral tablet Tier 5 ACA

calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit, 315-200 mg-unit

Tier 5 ACA

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

Tier 6

effer-k oral tablet, effervescent 25 meq Tier 6

GALZIN ORAL CAPSULE Tier 6

k-effervescent oral tablet, effervescent 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



klor-con oral packet Tier 1

klor-con sprinkle oral capsule, extended release Tier 1

klor-con/ef oral tablet, effervescent Tier 1

110

Updated 7/2018

K-PHOS-NEUTRAL ORAL TABLET Tier 6

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ

Tier 6

K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ

Tier 1

oyster shell calcium-vit d3 oral tablet 500 mg(1,250mg) -400 unit

Tier 5 ACA

PHOSPHA 250 NEUTRAL ORAL TABLET Tier 6

potassium bicarb and chloride oral tablet, effervescent

Tier 6

potassium bicarb-citric acid oral tablet, effervescent

Tier 1

potassium chloride oral capsule, extended release Tier 1

potassium chloride oral liquid Tier 1

potassium chloride oral packet Tier 1

potassium chloride oral tablet extended release Tier 1

potassium chloride oral tablet,er particles/crystals Tier 1

VIRT-PHOS 250 NEUTRAL ORAL TABLET Tier 6

Vitamins & Hematinics ANIMI-3 WITH VITAMIN D ORAL CAPSULE

Tier 6

b complex-vitamin b12 oral tablet Tier 5 ACA

b complex-vitamin c-folic acid oral tablet Tier 5 ACA

balanced b-100 complex oral tablet extended release 100 mg

Tier 5 ACA

b-complex with vitamin c oral tablet Tier 5 ACA

CALCIUM PNV ORAL CAPSULE Tier 1

CENTRATEX ORAL CAPSULE Tier 6

cholecalciferol (vitamin d3) oral capsule 50,000 unit

Tier 6

classic prenatal oral tablet Tier 5 ACA

C-NATE DHA ORAL CAPSULE Tier 1

COMPLETE NATAL DHA ORAL COMBO PACK

Tier 1

111

Updated 7/2018

COMPLETENATE ORAL TABLET,CHEWABLE

Tier 1

CORVITA 150 ORAL TABLET Tier 6

cyanocobalamin (vitamin b-12) injection solution Tier 6

DECARA ORAL CAPSULE 50,000 UNIT Tier 6

dialyvite 800 oral tablet Tier 5 ACA

DIALYVITE ORAL TABLET 100-1 MG Tier 6

DOTHELLE DHA ORAL CAPSULE Tier 1

elite-ob oral tablet 50 mg iron- 1.25 mg Tier 1

elite-ob oral tablet 50 mg iron- 1.25 mg Tier 6

ergocalciferol (vitamin d2) oral capsule Tier 6

FABB ORAL TABLET Tier 6

FERRALET 90 DUAL-IRON DELIVERY ORAL TABLET

Tier 6

FERRAPLUS 90 ORAL TABLET Tier 6

FERROCITE PLUS ORAL TABLET Tier 6

fluorabon oral drops Tier 5 ACA

fluor-a-day (with xylitol) oral tablet,chewable 0.25 mg f (0.55 mg)-236.79mg

Tier 5 ACA

fluoride (sodium) oral drops Tier 5 ACA

fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

Tier 5 ACA

fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)

Tier 5 ACA

flura-drops oral drops Tier 5 ACA

FOLBECAL ORAL TABLET, ER MULTIPHASE 24 HR

Tier 1

folic acid oral tablet 400 mcg, 800 mcg Tier 5 ACA

FOLIVANE-F ORAL CAPSULE Tier 6

FOLIVANE-OB ORAL CAPSULE Tier 1

foltabs 800 oral tablet Tier 5 ACA

full spectrum b-vitamin c oral tablet Tier 5 ACA

HEMATINIC PLUS VIT/MINERALS ORAL TABLET

Tier 6

112

Updated 7/2018

HEMATINIC/FOLIC ACID ORAL TABLET Tier 6

HEMATOGEN ORAL CAPSULE Tier 6

HEMENATAL OB + DHA ORAL COMBO PACK

Tier 1

HEMENATAL OB ORAL TABLET Tier 1

IROSPAN 24/6 ORAL TABLET Tier 6

ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

Tier 5 ACA

MULTI-VIT WITH FLUORIDE-IRON ORAL DROPS

Tier 5 ACA

multi-vitamin with fluoride oral drops Tier 5 ACA

multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

Tier 5 ACA

MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 1 MG

Tier 6

multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

Tier 5 ACA

multivitamins with fluoride oral tablet,chewable 1 mg

Tier 6

multivit-fluor (vit e acetate) oral drops Tier 5 ACA

mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg Tier 5 ACA

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

natural b-100 complex oral tablet Tier 5 ACA

NEWGEN ORAL TABLET Tier 1

OBSTETRIX DHA ORAL COMBO PACK,TABLET AND CAP,DR

Tier 1

one daily prenatal oral combo pack 28-800-440 mg-mcg-mg

Tier 5 ACA

perry prenatal oral capsule Tier 5 ACA

113

Updated 7/2018

PNV 29-1 ORAL TABLET Tier 1

PNV OB+DHA ORAL COMBO PACK 27-150-250 MG

Tier 1

PNV-DHA + DOCUSATE ORAL CAPSULE Tier 1

PNV-DHA ORAL CAPSULE Tier 1

PNV-OMEGA ORAL CAPSULE Tier 1

PNV-SELECT ORAL TABLET Tier 1

PNV-VP-U ORAL CAPSULE Tier 1

POLY-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC

Tier 6

POLY-VI-FLOR WITH IRON ORAL DROPS,SUSPENSION BIPHASIC

Tier 6

poly-vitamin with iron oral drops Tier 5 ACA

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

PRENA1 CHEW ORAL TABLET,CHEW,IR DR,BIPHASE

Tier 6

PRENA1 PEARL ORAL CAPSULE,IR DELAY REL,BIPHASE

Tier 6

PRENA1 TRUE ORAL COMBO PACK Tier 6

PRENAISSANCE ORAL CAPSULE Tier 1

PRENAISSANCE PLUS ORAL CAPSULE Tier 1

PRENATABS FA ORAL TABLET Tier 1

PRENATABS RX ORAL TABLET Tier 1

prenatal complete oral tablet Tier 5 ACA

PRENATAL LOW IRON ORAL TABLET Tier 1

prenatal multi-dha (algal oil) oral capsule Tier 5 ACA

prenatal one daily oral tablet Tier 5 ACA

prenatal oral tablet 28 mg iron- 800 mcg Tier 5 ACA

PRENATAL PLUS (CALCIUM CARB) ORAL TABLET

Tier 1

114

Updated 7/2018

PRENATAL PLUS ORAL TABLET Tier 1

prenatal vitamin oral tablet , 27 mg iron- 0.8 mg Tier 5 ACA

PRENATAL VITAMIN PLUS LOW IRON ORAL TABLET

Tier 1

prenatal vits96-iron fum-folic oral tablet Tier 5 ACA

PRENATAL-U ORAL CAPSULE Tier 1

PREPLUS ORAL TABLET Tier 1

PRETAB ORAL TABLET Tier 1

RELNATE DHA ORAL CAPSULE Tier 1

rena-vite oral tablet Tier 5 ACA

RENA-VITE RX ORAL TABLET Tier 6

RENO CAPS ORAL CAPSULE Tier 6

risacal-d oral tablet Tier 5 ACA

SE-NATAL 19 (WITH DOCUSATE) ORAL TABLET

Tier 1

SE-NATAL 19 ORAL TABLET,CHEWABLE Tier 1

SE-TAN PLUS ORAL CAPSULE Tier 6

STRESS FORMULA ORAL TABLET Tier 5 ACA

STRESS FORMULA WITH IRON ORAL TABLET

Tier 5 ACA

STRESS FORMULA WITH IRON(SULF) ORAL TABLET

Tier 5 ACA

TARON-C DHA ORAL CAPSULE Tier 1

TARON-PREX PRENATAL-DHA ORAL CAPSULE

Tier 1

THRIVITE-19 ORAL TABLET Tier 1

TL GARD RX ORAL TABLET Tier 6

TRICON ORAL CAPSULE Tier 6

TRINATAL GT ORAL TABLET Tier 1

TRINATAL RX 1 ORAL TABLET Tier 1

TRINATE ORAL TABLET Tier 1

TRI-TABS DHA ORAL COMBO PACK Tier 1

TRIVEEN-DUO DHA ORAL COMBO PACK Tier 1

TRIVEEN-ONE ORAL CAPSULE Tier 1

115

Updated 7/2018

TRIVEEN-PRX RNF ORAL CAPSULE Tier 1

TRI-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC

Tier 6

tri-vit with fluoride and iron oral drops Tier 5 ACA

tri-vitamin with fluoride oral drops Tier 5 ACA

TRUST NATAL DHA ORAL COMBO PACK Tier 1

UDAMIN SP ORAL TABLET Tier 6

ULTIMATECARE ONE NF ORAL CAPSULE Tier 1

ULTIMATECARE ONE ORAL CAPSULE Tier 1

V-C FORTE ORAL CAPSULE Tier 6

VEMAVITE-PRX-2 ORAL CAPSULE Tier 1

VINATE CARE ORAL TABLET,CHEWABLE

Tier 1

VINATE DHA ORAL CAPSULE Tier 1

VINATE II ORAL TABLET Tier 1

VINATE M ORAL TABLET Tier 1

VINATE ONE ORAL TABLET Tier 1

VINATE ULTRA ORAL TABLET Tier 1

VIRT-ADVANCE ORAL TABLET Tier 1

VIRT-C DHA ORAL CAPSULE Tier 1

VIRT-NATE DHA ORAL CAPSULE Tier 1

VIRT-NATE ORAL TABLET Tier 1

VIRT-PN DHA ORAL CAPSULE Tier 1

VIRT-PN ORAL TABLET Tier 1

VIRT-PN PLUS ORAL CAPSULE Tier 1

VIRT-SELECT ORAL CAPSULE Tier 1

VIRT-VITE GT ORAL TABLET Tier 1

VIRT-VITE ORAL TABLET Tier 6

VIRT-VITE PLUS ORAL TABLET Tier 6

vit b complex-folic acid oral tablet Tier 5 ACA

vitamin d3 oral tablet 400 unit Tier 5 ACA

vitamins a,c,d and fluoride oral drops Tier 5 ACA

VOL-NATE ORAL TABLET Tier 1

116

Updated 7/2018

VOL-PLUS ORAL TABLET Tier 1

VOL-TAB RX ORAL TABLET Tier 1

VP-CH PLUS ORAL CAPSULE Tier 1

VP-CH-PNV ORAL CAPSULE Tier 1

VP-GGR-B6 ORAL TABLET Tier 1

VP-HEME OB 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

Updated 7/2018

117

Index of Drugs

A abacavir ..................................6 abacavir-lamivudine ...............6 abacavir-lamivudine

zidovudine ..........................6 ABILIFY MAINTENA........31 acamprosate..........................55 ACANYA.............................49 acarbose................................71 ACCU-CHEK AVIVA PLUS

TEST STRP......................63 ACCU-CHEK COMPACT

PLUS TEST......................63 ACCU-CHEK GUIDE .........63 ACCU-CHEK SMARTVIEW

TEST STRIP ....................63 ACCUTREND GLUCOSE..63 acebutolol .............................37 acetaminophen-caff

dihydrocod........................26 acetaminophen-codeine........26 acetazolamide .......................98 acetic acid....................... 55, 61acetic acid-aluminum acetate61 acetylcysteine .....................103 acitretin.................................47 ACTEMRA ..........................86 ACTHAR H.P. .....................61 ACTHIB (PF).......................81 ACTIMMUNE .....................81 ACTOPLUS MET XR .........71 acyclovir ....................... 6, 7, 52 ADACEL(TDAP

ADOLESN/ADULT)(PF) 81 adapalene..............................49 adapalene-benzoyl peroxide. 49 ADCIRCA..........................103 adefovir...................................7 ADEMPAS.........................103 ADMELOG SOLOSTAR U

100 INSULIN...................67 ADMELOG U-100 INSULIN

LISPRO ............................67 ADVAIR DISKUS.............103 ADVAIR HFA ...................103

ADVANCED GLUC METER TEST STRIP.....................63

ADVATE..............................42 ADVOCATE REDI-CODE . 63 ADVOCATE TEST STRIPS63 AEROSPAN.......................103 AFEDITAB CR....................37 AFINITOR ...........................15 AFINITOR DISPERZ ..........15 AFLURIA 2017-2018 ..........81 AFLURIA 2017-2018 (PF) ..81 AFLURIA QUAD 2017-2018

..........................................81 AFLURIA QUAD 2017-2018

(PF)...................................81 AFREZZA ............................67 AGAMATRIX AMP TEST

STRIPS.............................63 AKTEN (PF) ........................97 ALA-CORT..........................52 albuterol sulfate ..................104 alclometasone .......................52 ALECENSA .........................15 alendronate ..................... 55, 86alfuzosin .............................108 ALINIA ................................11 ALKERAN...........................15 allopurinol ............................86 almotriptan malate................24 ALOCRIL.............................97 ALOMIDE............................97 ALORA ................................87 alosetron ...............................74 ALPHAGAN P...................100 ALPHANATE......................42 ALPHANINE SD.................42 alprazolam ............................31 ALPRAZOLAM INTENSOL

..........................................31 ALPROLIX ..........................42 alprostadil ...........................108 ALTABAX...........................51 altavera (28)..........................90 ALUNBRIG .........................15 ALVESCO..........................104

alyacen 1/35 (28) ..................90 alyacen 7/7/7 (28) .................90 amabelz.................................87 amantadine hcl........................7 amcinonide ...........................52 amethia .................................90 amethia lo .............................90 amethyst................................90 AMICAR ..............................42 amiloride...............................37 amiloride-hydrochlorothiazide

..........................................37 amiodarone ...........................36 AMITIZA .............................74 amitriptyline .........................31 amitriptyline-chlordiazepoxide

..........................................31 amlodipine ............................37 amlodipine-atorvastatin ........44 amlodipine-benazepril ..........37 amlodipine-olmesartan .........37 amlodipine-valsartan ............37 amlodipine-valsartan-hcthiazid

..........................................37 ammonium lactate ................48 amnesteem ............................49 amoxapine.............................31 amoxicil-clarithromy-lansopraz

..........................................78 amoxicillin............................13 amoxicillin-pot clavulanate ..13 ampicillin..............................13 AMPYRA.............................25 ANADROL-50 .....................69 anagrelide .............................55 anastrozole............................15 ANDRODERM ....................69 ANDROGEL ........................69 ANDROXY ..........................69 ANGELIQ ............................87 ANIMI-3 WITH VITAMIN D

........................................110 ANORO ELLIPTA.............104 ANTARA .............................44 ANUCORT-HC....................74

Updated 7/2018

118

ANZEMET...........................74 APEXICON E ......................52 APIDRA SOLOSTAR U-100

INSULIN..........................67 APIDRA U-100 INSULIN...67 APOKYN .............................23 apraclonidine ......................100 aprepitant ..............................74 apri........................................ 90 APRISO................................74 APTIOM...............................19 APTIVUS...............................7 AQUA GLYCOLIC HC.......52 aranelle (28)..........................90 ARANESP (IN

POLYSORBATE)............79 ARCALYST.........................81 ARCAPTA NEOHALER...104 aripiprazole...........................31 ARISTADA..........................31 armodafinil ...........................32 ARMOUR THYROID .........72 ARNUITY ELLIPTA.........104 ASCOMP WITH CODEINE26 ashlyna..................................90 ASMANEX HFA ...............104 ASMANEX TWISTHALER

........................................104 aspirin-caffeine-dihydrocodein

..........................................26 aspirin-dipyridamole ............42 ASSURE 4 STRIPS .............63 ASSURE PLATINUM.........63 ASSURE PRISM MULTI

STRIP ...............................63 ASTAGRAF XL ..................15 atazanavir ...............................7 atenolol .................................37 atenolol-chlorthalidone.........37 atomoxetine ..........................32 atorvastatin ...........................44 atovaquone ...........................11 atovaquone-proguanil...........11 ATRIPLA ...............................7 atropine.................................97 ATROVENT HFA .............104 AUBAGIO ...........................79 aubra .....................................91

AURYXIA............................74 AUSTEDO ...........................25 AVANDIA ...........................71 AVC VAGINAL ..................90 aviane....................................91 AVITA..................................49 AVONEX ....................... 79, 80 AVONEX (WITH ALBUMIN)

..........................................79 AZASITE .............................95 azathioprine ..........................15 azelastine ........................ 60, 97azithromycin.........................11 AZOPT .................................98 azurette (28)..........................91 B b complex-vitamin b12.......110 b complex-vitamin c-folic acid

........................................110 bacitracin ..............................95 bacitracin-polymyxin b.........95 baclofen ................................26 BACTROBAN NASAL.......60 balanced b-100 complex.....110 BALCOLTRA ......................91 balsalazide ............................74 balziva (28)...........................91 BANZEL ..............................19 BARACLUDE........................7 bcg vaccine, live (pf) ............81 b-complex with vitamin c...110 BD PRE-FILLED NORMAL

SALINE............................56 BEBULIN.............................42 bekyree (28)..........................91 benazepril .............................37 benazepril-hydrochlorothiazide

..........................................37 BENEFIX .............................42 BENLYSTA .........................86 benzonatate.........................102 benzoyl peroxide ..................49 benztropine ...........................23 BEPREVE ............................97 BERINERT ........................104 BESIVANCE........................95 BETADINE OPHTHALMIC

PREP ................................95

betamethasone dipropionate . 53 betamethasone valerate.........53 betamethasone, augmented...53 BETASERON.......................80 betaxolol ......................... 37, 96bethanechol chloride...........108 BETIMOL ............................96 BETOPTIC S........................96 BEVESPI AEROSPHERE . 104 bexarotene.............................15 BEXSERO............................81 bicalutamide .........................15 BIDIL ...................................37 BILTRICIDE........................12 bimatoprost ...........................98 BIONIME RIGHTEST TEST

STRIPS .............................63 BIOTHRAX .........................81 bisacodyl...............................74 bisoprolol fumarate...............38 bisoprolol-hydrochlorothiazide

..........................................38 BLEPHAMIDE ..................100 BLEPHAMIDE S.O.P. .......100 blisovi 24 fe ..........................91 blisovi fe 1.5/30 (28) ............91 blisovi fe 1/20 (28) ...............91 BLOOD GLUCOSE TEST ..63 BOOSTRIX TDAP...............82 BOSULIF .............................15 BREEZE 2 TEST STRIPS ...63 BREO ELLIPTA ................104 briellyn..................................91 BRILINTA ...........................42 brimonidine.........................100 bromfenac .............................98 bromocriptine .......................23 brompheniramine-pseudoeph

dm...................................102 BROVANA ........................104 budesonide.................... 74, 104bumetanide ...........................38 BUNAVAIL .........................19 BUPHENYL.........................56 buprenorphine hcl .................19 buprenorphine-naloxone.......19 bupropion hcl........................32

Updated 7/2018

119

bupropion hcl (smoking deter) ..........................................59

buspirone ..............................32 butalbital compound w/codeine

..........................................26 butalbital-acetaminop-caf-cod

..........................................26 butalbital-acetaminophen .....27 butalbital-acetaminophen-caff

..........................................27 butalbital-aspirin-caffeine ....27 butorphanol tartrate ..............27 BUTRANS ...........................27 BYDUREON........................71 BYDUREON BCISE ...........71 BYETTA ..............................71 BYSTOLIC ..........................38 C cabergoline ...........................69 CABOMETYX.....................15 caffeine citrate ......................56 calcipotriene .........................47 calcipotriene-betamethasone 47 calcitonin (salmon)...............70 CALCITRENE.....................47 calcitriol.......................... 47, 70calcium 500 with d .............109 calcium 600 with vitamin d3

........................................109 calcium acetate .....................74 calcium carb and citrate-vitd3

........................................109 calcium carbonate-vitamin d3

........................................109 calcium citrate + d ..............109 calcium citrate-vitamin d2..109 calcium citrate-vitamin d3..109 CALCIUM PNV ................110 CALQUENCE......................15 camila ...................................87 CAMINO PRO 15 PE PKU . 57 camrese.................................91 camrese lo.............................91 CANASA .............................74 candesartan ...........................38 candesartan-hydrochlorothiazid

..........................................38 CAPACET............................27

capecitabine ..........................15 CAPRELSA..........................15 captopril................................38 captopril-hydrochlorothiazide

..........................................38 CARBAGLU........................56 carbamazepine ......................19 CARBATROL......................19 carbidopa ..............................23 carbidopa-levodopa ..............23 carbidopa-levodopa

entacapone ........................23 carbinoxamine maleate.......101 CARDIZEM LA...................38 CARDURA XL ....................38 CARESENS N TEST STRIPS

..........................................63 CARETOUCH TEST STRIP

..........................................63 carisoprodol ..........................26 carisoprodol-asa-codeine......26 carisoprodol-aspirin..............26 carteolol ................................97 CARTIA XT.........................38 carvedilol ..............................38 carvedilol phosphate.............38 CAYSTON ...........................12 caziant (28) ...........................91 cefaclor .................................10 cefadroxil..............................10 cefdinir..................................10 cefditoren pivoxil .................10 cefixime................................10 cefpodoxime .........................10 cefprozil................................10 ceftibuten ..............................10 CEFTIN ................................10 cefuroxime axetil..................10 celecoxib...............................30 CELONTIN..........................19 CENTRATEX ....................110 cephalexin....................... 10, 11 CERDELGA.........................70 CERVARIX VACCINE (PF)

..........................................82 CESAMET ...........................74 cevimeline ............................56 CHANTIX............................60

CHANTIX CONTINUING MONTH BOX ..................60

CHANTIX STARTING MONTH BOX ..................60

chateal...................................91 CHEMET..............................56 CHENODAL ........................74 CHERATUSSIN AC ..........102 chlordiazepoxide hcl.............32 chlordiazepoxide-clidinium..73 chlorhexidine gluconate........60 chloroquine phosphate..........12 chlorothiazide .......................38 chlorpromazine .....................32 chlorpropamide.....................71 chlorthalidone .......................38 chlorzoxazone.......................26 cholecalciferol (vitamin d3)110 cholestyramine (with sugar) . 44 CHOLESTYRAMINE LIGHT

..........................................44 CIALIS ...............................108 CICLODAN .........................51 ciclopirox ..............................51 ciclopirox-ure-camph-menth

euc.....................................51 cilostazol...............................42 CILOXAN ............................96 CIMDUO................................7 cimetidine .............................78 cimetidine hcl .......................78 CIMZIA................................74 CINRYZE...........................104 CIPRO HC............................61 CIPRODEX ..........................61 ciprofloxacin.........................14 ciprofloxacin (mixture).........13 ciprofloxacin hcl ....... 13, 61, 96 citalopram .............................32 CITRATE OF MAGNESIA . 74 CLARAVIS ..........................49 CLARINEX........................101 clarithromycin.......................11 classic prenatal....................110 clemastine ...........................101 CLENPIQ .............................74 CLEOCIN.............................90

Updated 7/2018

120

CLEVER CHOICE MICRO TEST STRIP ....................63

CLEVER CHOICE PRO......63 CLEVER CHOICE TALK

TEST ................................63 CLEVER CHOICE TEST

STRIPS.............................63 CLEVER CHOICE VOICE+

TEST ................................63 CLIMARA PRO...................88 clindamycin hcl ....................12 clindamycin palmitate hcl ....12 CLINDAMYCIN PEDIATRIC

..........................................12 clindamycin phosphate... 49, 90 clindamycin-benzoyl peroxide

..........................................49 clobetasol..............................53 clobetasol-emollient .............53 CLODERM ..........................53 clomipramine........................32 clonazepam...........................19 clonidine ...............................38 clonidine hcl ................... 32, 38clopidogrel............................42 clorazepate dipotassium .......32 CLORPRES..........................38 clotrimazole............................6 clotrimazole-betamethasone. 51 clozapine...............................32 CLOZAPINE........................32 C-NATE DHA....................110 COAGADEX .......................42 COARTEM ..........................12 codeine sulfate......................27 codeine-butalbital-asa-caff ...27 codeine-guaifenesin............102 COLCRYS ...........................86 COLESTID FLAVORED ....44 colestipol ..............................45 COLOCORT ........................74 COLY-MYCIN S .................61 COMBIGAN ........................98 COMBIPATCH....................88 COMBIVENT RESPIMAT104 COMETRIQ.........................15 COMPLERA ..........................7

COMPLETE NATAL DHA ........................................110

COMPLETENATE ............111 COMPRO .............................74 CONSTULOSE....................74 CONTOUR NEXT TEST

STRIPS.............................63 CONTOUR TEST STRIPS..63 COOL GLUCOSE TEST

STRIP ...............................63 COPAXONE ........................80 COREG CR ..........................38 CORIFACT ..........................42 CORLANOR........................46 cortisone ...............................61 CORTISPORIN....................51 CORVITA 150 ...................111 COSENTYX.........................47 COSENTYX (2 SYRINGES)

..........................................47 COSENTYX PEN ................47 COSENTYX PEN (2 PENS)47 COSOPT (PF).......................99 COTELLIC...........................15 COUMADIN........................42 covaryx .................................88 covaryx h.s............................ 88 CREON ................................74 CRESEMBA ..........................6 CRINONE ............................88 CRIXIVAN ............................7 cromolyn................. 74, 97, 104 cryselle (28)..........................91 CUVITRU ............................82 cyanocobalamin (vitamin b-12)

........................................111 cyclafem 1/35 (28)................91 cyclafem 7/7/7 (28) ..............91 cyclobenzaprine....................26 CYCLOMYDRIL...............101 cyclopentolate.......................97 cyclophosphamide ................15 cycloserine............................12 CYCLOSET .........................71 cyclosporine..........................16 cyclosporine modified ..........16 cyproheptadine ...................101 cyred .....................................91

CYSTADANE......................74 CYSTAGON ......................108 CYSTARAN.........................97 D DALIRESP .........................104 danazol..................................70 dantrolene .............................26 dapsone .................................12 DAPTACEL (DTAP

PEDIATRIC) (PF)............82 DARAPRIM .........................12 darifenacin ..........................107 dasetta 1/35 (28) ...................91 dasetta 7/7/7 (28) ..................91 daysee ...................................91 DAYTRANA........................32 deblitane ...............................88 decadron ...............................62 DECARA............................111 DELTASONE.......................62 delyla (28).............................91 demeclocycline .....................14 DENAVIR ............................52 DENTA 5000 PLUS.............60 DENTAGEL.........................60 DEPAKENE .........................19 DEPAKOTE .........................19 DEPAKOTE ER...................19 DEPAKOTE SPRINKLES...19 DEPEN TITRATABS ..........86 DEPO-ESTRADIOL ............88 DEPO-SUBQ PROVERA 104

..........................................88 DEPO-TESTOSTERONE....70 DESCOVY .............................7 desipramine...........................32 desloratadine.......................101 desmopressin ........................70 desog-e.estradiol/e.estradiol .91desogestrel-ethinyl estradiol . 91 desonide................................53 desoximetasone.....................53 desvenlafaxine succinate ......32 dexamethasone .....................62 DEXAMETHASONE

INTENSOL.......................62 dexamethasone sodium

phosphate..........................99

Updated 7/2018

121

DEXEDRINE.......................32 DEXILANT..........................78 dexmethylphenidate .............32 dextroamphetamine ..............32 dextroamphetamine

amphetamine ....................32 DIALYVITE ......................111 dialyvite 800.......................111 DIASTAT.............................19 DIASTAT ACUDIAL..........19 DIATRUE PLUS TEST STRIP

..........................................63 diazepam......................... 19, 33 DIAZEPAM INTENSOL.....33 diclofenac potassium............30 diclofenac sodium .... 30, 48, 98diclofenac-misoprostol .........30 dicloxacillin..........................13 dicyclomine ..........................73 didanosine...............................7 DIFICID ...............................11 diflorasone............................53 diflunisal...............................30 DIGITEK..............................42 DIGOX.................................42 digoxin ..................................42 dihydroergotamine ...............24 DILANTIN...........................20 DILANTIN EXTENDED ....20 DILANTIN INFATABS ......20 DILANTIN KAPSEAL........20 DILANTIN-125 ...................20 DILATRATE-SR .................46 diltiazem hcl .........................38 DILT-XR..............................38 DIPENTUM .........................74 diphenhydramine hcl ..........101 diphenoxylate-atropine.........73 dipyridamole.........................42 diskets...................................27 disopyramide phosphate.......36 disulfiram .............................56 DIURIL ................................39 divalproex.............................20 DIVIGEL..............................88 dofetilide...............................37 donepezil ..............................25 DONNATAL........................73

dorzolamide ..........................99 dorzolamide-timolol .............99 DOTHELLE DHA .............111 doxazosin ..............................39 doxepin ........................... 33, 48 doxercalciferol......................70 doxycycline hyclate..............14 doxycycline monohydrate ....14 DRITHOCREME HP...........47 dronabinol.............................74 drospirenone-e.estradiol-lm.fa

..........................................91 drospirenone-ethinyl estradiol

..........................................91 DROXIA ..............................16 DUAVEE..............................88 DULERA............................104 duloxetine .............................33 DUOPA ................................23 DUPIXENT..........................48 DUREZOL .........................100 dutasteride ..........................108 dutasteride-tamsulosin........108 DUTOPROL.........................39 DYRENIUM ........................39 E E.E.S. 400 .............................11 E.E.S. GRANULES..............11 EAA SUPPLEMENT...........57 EASY PLUS II TEST...........63 EASY STEP .........................63 EASY TALK GLUCOSE

TEST ................................63 EASY TOUCH TEST STRIP

..........................................63 EASY TRAK GLUCOSE

TEST ................................64 EASYGLUCO PLUS...........64 EASYGLUCO TEST ...........64 EASYMAX ..........................64 econazole ..............................51 econtra ez..............................91 econtra one-step....................91 EDARBI ...............................39 EDARBYCLOR...................39 EDURANT.............................7 eemt ......................................88 eemt hs..................................88

efavirenz .................................7 effer-k .................................109 EFFER-K............................109 ELEMENT COMPACT TEST

STRIPS .............................64 ELEMENT TEST STRIPS...64 ELESTRIN ...........................88 eletriptan ...............................24 ELIDEL ................................48 elinest....................................91 ELIPHOS..............................75 ELIQUIS...............................42 elite-ob ................................111 ELLA....................................91 ELMIRON..........................108 EMADINE............................97 EMBRACE BLOOD

GLUCOSE SYSTEM.......64 EMBRACE EVO TEST

STRIPS .............................64 EMBRACE PRO TEST

STRIPS .............................64 EMCYT ................................16 EMFLAZA ...........................62 emoquette .............................91 EMSAM ...............................33 EMTRIVA..............................7 EMVERM.............................12 enalapril maleate...................39 enalapril-hydrochlorothiazide

..........................................39 ENBREL...............................86 ENBREL MINI ....................86 ENBREL SURECLICK .......87 ENDOCET ...........................27 ENGERIX-B (PF) ................82 ENGERIX-B PEDIATRIC

(PF) ...................................82 enoxaparin ............................42 enpresse ................................91 enskyce .................................92 ENSTILAR...........................47 entacapone ............................23 entecavir .................................7 ENTRESTO..........................46 ENULOSE............................75 EPANED ..............................39 EPCLUSA ..............................7

Updated 7/2018

122

EPIDUO ...............................49 EPIDUO FORTE..................49 epinastine..............................98 epinephrine .........................101 EPINEPHRINE ..................101 EPIPEN ..............................101 EPIPEN 2-PAK..................101 EPIPEN JR .........................101 EPIPEN JR 2-PAK.............101 EPITOL ................................20 EPIVIR HBV..........................7 eplerenone ............................39 EPOGEN ..............................79 epoprostenol (glycine)..........39 eprosartan .............................39 EPZICOM ..............................7 EQUETRO ...........................20 ergocalciferol (vitamin d2). 111 ergoloid.................................33 ergotamine-caffeine..............24 ERIVEDGE..........................16 ERLEADA ...........................16 errin ......................................88 ERTACZO ...........................52 ERY PADS...........................49 ERYGEL ..............................49 ERYPED 200 .......................11 ERYPED 400 .......................11 ERY-TAB.............................11 ERYTHROCIN (AS

STEARATE) ....................11 erythromycin .................. 11, 96 erythromycin ethylsuccinate 11 erythromycin with ethanol ..49,

50 erythromycin-benzoyl peroxide

..........................................50 ESBRIET.................... 104, 105escitalopram oxalate.............33 esomeprazole magnesium ....78 estarylla ................................92 estazolam..............................33 ESTRACE ............................88 estradiol ................................88 estradiol valerate ..................88 estradiol-norethindrone acet . 88 ESTRING.............................88 ESTROGEL .........................88

estrogens-methyltestosterone88 estropipate ............................88 eszopiclone ...........................33 ethacrynic acid......................39 ethambutol ............................12 ethosuximide ........................20 ethynodiol diac-eth estradiol 92 etidronate disodium ..............56 etodolac ................................30 etoposide...............................16 EUCRISA.............................48 EURAX ................................55 EVAMIST ............................88 EVENCARE G2...................64 EVENCARE G3 TEST ........64 EVENCARE MINI

GLUCOSE TEST STR.....64 EVOLUTION TEST STRIPS

..........................................64 EVOTAZ................................7 EXELDERM ........................52 exemestane ...........................16 EXJADE...............................56 EXTAVIA ............................80 EZ SMART PLUS TEST.....64 EZ SMART TEST................64 ezetimibe ..............................45 ezetimibe-simvastatin...........45 F FABB..................................111 FACTIVE .............................14 falmina (28) ..........................92 famciclovir..............................7 famotidine.............................78 FANAPT ..............................33 FARESTON .........................16 FARXIGA ............................71 FARYDAK...........................16 fayosim .................................92 FAZACLO............................33 FEIBA NF ............................42 felbamate ..............................20 FELBATOL..........................20 felodipine..............................39 fem ph...................................90 FEMRING ............................89 femynor ................................92 fenofibrate ............................45

fenofibrate micronized..........45 fenofibrate nanocrystallized . 45 fenofibric acid.......................45 fenofibric acid (choline) .......45 fenoprofen.............................30 fentanyl .................................27 fentanyl citrate ......................27 FERRALET 90 DUAL-IRON

DELIVERY ....................111 FERRAPLUS 90 ................111 FERRIPROX ........................56 FERROCITE PLUS............111 FIASP FLEXTOUCH U-100

INSULIN ..........................67 FIASP U-100 INSULIN .......67 FIFTY50 TEST STRIP.........64 FINACEA.............................50 finasteride ..................... 56, 108FIRAZYR ...........................105 FIRVANQ ............................15 FLAGYL ER ........................12 flavoxate .............................107 flecainide ..............................37 FLOLAN ..............................39 FLOVENT DISKUS ..........105 FLOVENT HFA.................105 FLUAD 2017-2018 (65 YR

UP)(PF).............................82 FLUARIX QUAD 2017-2018

(PF) ...................................82 FLUBLOK 2017-2018 (PF) . 82 FLUBLOK QUAD 2017-2018

(PF) ...................................82 FLUCAINE ..........................98 FLUCELVAX QUAD 2017

2018 ..................................82 FLUCELVAX QUAD 2017

2018 (PF) ..........................82 fluconazole .............................6 flucytosine ..............................6 fludrocortisone......................62 FLULAVAL QUAD 2017

2018 ..................................82 FLULAVAL QUAD 2017

2018 (PF) ..........................82 FLUMIST QUAD 2017-2018

..........................................82 flunisolide ...........................105

Updated 7/2018

123

fluocinolone.................... 53, 54fluocinolone acetonide oil ....61 fluocinolone and shower cap 53 fluocinonide..........................54 FLUOCINONIDE-E ............54 fluorabon ............................111 fluor-a-day (with xylitol)....111 fluorescein-proparacaine ......98 fluoride (sodium)................111 fluoritab ..............................111 fluorometholone .................100 fluorouracil ...........................48 fluoxetine..............................33 fluphenazine hcl ...................33 flura-drops ..........................111 flurandrenolide .....................54 flurazepam............................33 flurbiprofen...........................30 flurbiprofen sodium..............98 flutamide...............................16 fluticasone .................... 54, 105fluvastatin .............................45 FLUVIRIN 2017-2018.........83 FLUVIRIN 2017-2018 (PF). 82 fluvoxamine..........................33 FLUZONE HIGH-DOSE

2017-18 (PF) ....................83 FLUZONE INTRADERM

QUAD 2017-18 ................83 FLUZONE QUAD 2017-2018

..........................................83 FLUZONE QUAD 2017-2018

(PF)...................................83 FLUZONE QUAD PEDI

2017-18 (PF) ....................83 FML FORTE......................100 FML S.O.P. ........................100 FOLBECAL .......................111 folic acid.............................111 FOLIVANE-F ....................111 FOLIVANE-OB.................111 foltabs 800 ..........................111 fondaparinux.........................42 FORA D15G ........................64 FORA D20 ...........................64 FORA D40-G31 TEST

STRIPS.............................64 FORA G20 ...........................64

FORA G30-PREMIUM V10 TEST STRP......................64

FORA GD50 TEST STRIPS 64 FORA TEST STRIP.............64 FORA TN'G VOICE TEST

STRIPS.............................64 FORA V10 ...........................64 FORA V12 GLUCOSE........64 FORA V20 ...........................64 FORACARE GD20..............64 FORACARE GD40..............64 FORTEO ..............................86 FORTISCARE GLUCOSE

TEST STRIPS ..................64 FOSAMAX PLUS D............86 fosamprenavir.........................7 fosinopril ..............................39 fosinopril-hydrochlorothiazide

..........................................39 FOSRENOL .........................75 FRAGMIN...................... 42, 43FREESTYLE INSULINX....65 FREESTYLE INSULINX

TEST STRIPS ..................65 FREESTYLE LITE STRIPS 65 FREESTYLE PRECISION

NEO STRIPS....................65 FREESTYLE TEST .............65 frovatriptan ...........................24 full spectrum b-vitamin c ...111 FULYZAQ ...........................73 furosemide ............................39 FUZEON ................................7 fyavolv ..................................89 FYCOMPA...........................20 G gabapentin ............................20 GABITRIL ...........................20 galantamine ..........................25 GALZIN .............................109 GAMMAGARD LIQUID ....83 GAMUNEX-C......................83 GARDASIL (PF)..................83 GARDASIL 9 (PF)...............83 gatifloxacin...........................96 GATTEX 30-VIAL ..............75 gavilyte-c ..............................75 gavilyte-g ..............................75

gavilyte-h and bisacodyl.......75 gavilyte-n ..............................75 GE100 BLOOD GLUCOSE

TEST STRIP.....................65 GELNIQUE........................108 gemfibrozil ...........................45 GENERLAC.........................75 GENGRAF ...........................16 GENSTRIP TEST STRIP.....65 gentamicin ...................... 51, 96 GENVOYA ............................7 gianvi (28) ............................92 gildagia .................................92 GILENYA ............................80 GILOTRIF............................16 glatiramer..............................80 glatopa ..................................80 GLEOSTINE ........................16 glimepiride............................71 glipizide ................................71 glipizide-metformin..............71 GLUCAGEN DIAGNOSTIC

KIT ...................................67 GLUCAGEN HYPOKIT......67 GLUCAGON EMERGENCY

KIT (HUMAN).................67 GLUCO NAVII TEST STRIP

..........................................65 GLUCOCARD 01 SENSOR

PLUS ................................65 GLUCOCARD EXPRESSION

..........................................65 GLUCOCARD SHINE TEST

STRIPS .............................65 GLUCOCARD VITAL

SENSOR...........................65 GLUCOCARD VITAL TEST

STRIPS .............................65 GLUCOCOM GLUCOSE....65 glyburide...............................71 glyburide micronized ............71 glyburide-metformin.............71 glycopyrrolate.......................73 GLYDO ................................50 GLYTACTIN 10 PE

COMPLETE .....................57 GLYTACTIN 15 PE

BETTERMILK.................57

Updated 7/2018

124

GLYTACTIN 15 PE COMPLETE.....................57

GLYTACTIN 20PE BETTERMILK LITE.......57

GLYTACTIN BUILD 10 PE57 GLYTACTIN RESTORE 10

PE .....................................57 GLYTACTIN RESTORE 10

PE LITE............................57 GLYTACTIN RESTORE 5 PE

..........................................57 GLYTACTIN RTD 10 PE ...57 GLYTACTIN RTD 15 PE ...57 GLYTACTIN SWIRL 15 PE

..........................................57 GLYXAMBI ........................71 GM100 .................................65 GOLYTELY.........................75 granisetron hcl ......................75 GRASTEK ...........................83 griseofulvin microsize ............6 griseofulvin ultramicrosize.....6 GUAIFENESIN AC...........102 GUAIFENESIN DAC........102 guanfacine ...................... 33, 39 guanidine ..............................33 GYNAZOLE-1.....................90 H HAEGARDA .....................105 halobetasol propionate..........54 HALOG................................54 haloperidol............................33 haloperidol lactate ................33 HARVONI .............................7 HAVRIX (PF) ......................83 HEALTHPRO TEST STRIPS

..........................................65 heather ..................................89 HELIXATE FS.....................43 HEMATINIC PLUS

VIT/MINERALS............111 HEMATINIC/FOLIC ACID

........................................112 HEMATOGEN...................112 HEMENATAL OB ............112 HEMENATAL OB + DHA112 HEMMOREX-HC................75 HEMOFIL M HIGH.............43

HEMOFIL M LOW..............43 HEMOFIL M MID...............43 HEMOFIL M SUPER HIGH43 HEP FLUSH-10 (PF) ...........43 heparin (porcine) ..................43 HEPARIN LOCK FLUSH ...43 heparin lock flush (porcine) . 43 HEPARIN

LOCKFLUSH(PORCINE)( PF) ....................................43

heparin, porcine (pf) .............43 HEPLISAV-B.......................83 HEXALEN ...........................16 HIZENTRA..........................83 homatropine hbr ...................97 HORIZANT..........................25 HUMALOG JUNIOR

KWIKPEN U-100 ............67 HUMALOG KWIKPEN

INSULIN ..........................68 HUMALOG MIX 50-50

INSULN U-100 ................68 HUMALOG MIX 50-50

KWIKPEN........................68 HUMALOG MIX 75-25

KWIKPEN........................68 HUMALOG MIX 75-25(U

100)INSULN....................68 HUMALOG U-100 INSULIN

..........................................68 HUMATE-P .........................43 HUMIRA..............................87 HUMIRA PEDIATRIC

CROHN'S START ...........87 HUMIRA PEN .....................87 HUMIRA PEN CROHN'S

UC-HS START ................87 HUMIRA PEN PSORIASIS

UVEITIS ..........................87 HUMULIN 70/30 U-100

INSULIN ..........................68 HUMULIN 70/30 U-100

KWIKPEN........................68 HUMULIN N NPH INSULIN

KWIKPEN........................68 HUMULIN N NPH U-100

INSULIN ..........................68

HUMULIN R REGULAR U100 INSULN ....................68

HUMULIN R U-500 (CONC) INSULIN ..........................68

HUMULIN R U-500 (CONC) KWIKPEN........................68

HYCAMTIN.........................16 hydralazine ...........................39 hydrochlorothiazide..............39 hydrocodone-acetaminophen27 hydrocodone-chlorpheniramine

........................................102 hydrocodone-cpm

pseudoephed ...................102 hydrocodone-homatropine..102 hydrocodone-ibuprofen ........27 hydrocortisone .......... 54, 62, 75 hydrocortisone acetate ..........75 hydrocortisone butyrate ........54 hydrocortisone butyr-emollient

..........................................54 hydrocortisone valerate ........54 hydrocortisone-acetic acid....61 hydrocortisone-min oil-wht pet

..........................................54 hydrocortisone-pramoxine...47,

75 HYDROMET .....................102 hydromorphone.....................28 hydroxychloroquine..............12 hydroxyurea ..........................16 hydroxyzine hcl ..................101 hydroxyzine pamoate..........101 hyoscyamine sulfate .............73 HYQVIA ..............................83 I ibandronate ...........................86 IBRANCE.............................16 ibu .........................................30 ibuprofen...............................30 ibuprofen-oxycodone............28 ICLUSIG ..............................16 IDHIFA.................................16 IGLUCOSE TEST STRIP....65 imatinib.................................16 IMBRUVICA .......................16 imipramine hcl......................33 imipramine pamoate .............34

Updated 7/2018

125

imiquimod ............................81 IMOVAX RABIES VACCINE

(PF)...................................83 indapamide ...........................39 INDOCIN .............................30 indomethacin ........................30 INFANRIX (DTAP) (PF).....83 INFINITY TEST STRIPS....65 INFINITY VOICE TEST

STRIP ...............................65 INLYTA ...............................16 insulin syringe-needle u-100 67 INTELENCE..........................7 INTRAROSA.......................90 INTRON A...........................81 introvale................................92 INVEGA SUSTENNA.........34 INVEGA TRINZA...............34 INVIRASE ......................... 7, 8INVOKAMET......................71 INVOKAMET XR ...............71 INVOKANA ........................71 IPOL.....................................84 ipratropium bromide..... 60, 105 ipratropium-albuterol .........105 irbesartan ..............................39 irbesartan-hydrochlorothiazide

..........................................39 IRESSA ................................16 IROSPAN 24/6...................112 ISENTRESS...........................8 ISENTRESS HD ....................8 isibloom................................92 isometh-dichloral

acetaminophn ...................24 isoniazid ...............................12 ISORDIL ..............................46 isosorbide dinitrate ...............46 isosorbide mononitrate .........46 isradipine ..............................39 ISTALOL .............................97 itraconazole ............................6 ivermectin.............................12 IXIARO (PF)........................84 J JADENU ..............................56 JAKAFI ................................16 JANTOVEN.........................43

JANUMET ...........................71 JANUMET XR.....................71 JANUVIA.............................71 jencycla.................................89 JENTADUETO ....................71 JENTADUETO XR..............72 jevantique lo .........................89 jinteli.....................................89 jolessa ...................................92 jolivette.................................89 juleber...................................92 JULUCA.................................8 junel 1.5/30 (21) ...................92 junel 1/20 (21) ......................92 junel fe 1.5/30 (28) ...............92 junel fe 1/20 (28) ..................92 junel fe 24.............................92 K KADIAN ..............................28 kaitlib fe................................92 KALETRA .............................8 KALYDECO......................105 kariva (28) ............................92 k-effervescent .....................109 kelnor 1/35 (28) ....................92 KEPPRA...............................20 KEPPRA XR ........................20 KETEK.................................12 ketoconazole..................... 6, 52ketoprofen.............................30 ketorolac ......................... 30, 98KEVEYIS.............................25 KEVZARA...........................87 kimidess (28) ........................92 KINERET.............................81 KINRIX (PF)........................84 KIONEX...............................75 KIONEX (WITH SORBITOL)

..........................................75 KISQALI..............................16 KITABIS PAK .....................12 KLONOPIN..........................20 klor-con ..............................109 klor-con 10 .........................109 klor-con 8 ...........................109 klor-con m10 ......................109 klor-con m15 ......................109 klor-con m20 ......................109

klor-con sprinkle.................109 klor-con/ef ..........................109 KOATE.................................43 KOATE-DVI ........................43 KOGENATE FS...................43 KORLYM.............................70 K-PHOS NO 2....................108 K-PHOS ORIGINAL .........108 K-PHOS-NEUTRAL..........110 KRISTALOSE......................75 K-TAB................................110 kurvelo ..................................92 KUVAN................................70 KYNAMRO .........................45 L l norgest/e.estradiol-e.estrad. 92 labetalol ................................39 LACRISERT ........................98 lactulose................................75 LAMICTAL .........................21 LAMICTAL ODT ................20 LAMICTAL ODT STARTER

(BLUE) .............................20 LAMICTAL ODT STARTER

(GREEN) ..........................21 LAMICTAL ODT STARTER

(ORANGE).......................21 LAMICTAL STARTER

(BLUE) KIT .....................21 LAMICTAL STARTER

(GREEN) KIT ..................21 LAMICTAL STARTER

(ORANGE) KIT ...............21 LAMICTAL XR...................21 LAMICTAL XR STARTER

(BLUE) .............................21 LAMICTAL XR STARTER

(GREEN) ..........................21 LAMICTAL XR STARTER

(ORANGE).......................21 lamivudine ..............................8 lamivudine-zidovudine ...........8 lamotrigine............................21 LANAFLEX .........................57 lancets ...................................67 LANOXIN............................42 lansoprazole..........................78 lanthanum .............................75

Updated 7/2018

126

LANTUS SOLOSTAR U-100 INSULIN.......................... 68

LANTUS U-100 INSULIN.. 68 larin 1.5/30 (21).................... 92 larin 1/20 (21)....................... 92 larin 24 fe ............................. 92 larin fe 1.5/30 (28)................ 92 larin fe 1/20 (28)................... 92 larissia................................... 92 LASTACAFT....................... 98 latanoprost ............................ 99 LATUDA ............................. 34 laxaclear ............................... 75 laxative peg 3350 ................. 75 layolis fe ............................... 92 leena 28 ................................ 92 leflunomide........................... 87 LENVIMA ........................... 16 lessina ................................... 92 letrozole................................ 16 leucovorin calcium ............... 15 LEUKERAN ........................ 16 leuprolide.............................. 17 levalbuterol hcl ................... 105 LEVATOL ........................... 39 LEVEMIR FLEXTOUCH U

100 INSULN .................... 68 LEVEMIR U-100 INSULIN 68 levetiracetam ........................ 21 levobunolol........................... 97 levocarnitine ......................... 56 levocarnitine (with sugar)..... 56 levocetirizine ...................... 101 levofloxacin.................... 14, 96 levonest (28)......................... 93 levonorgestrel-ethinyl estrad 93 levonorg-eth estrad triphasic 93 levora 0.15/30 (28) ............... 93 levora-28............................... 93 levorphanol tartrate .............. 28 levothyroxine........................ 72 LEVOXYL........................... 72 LEXIVA ................................. 8 LIALDA ............................... 75 lidocaine ............................... 51 lidocaine hcl ................... 50, 51 lidocaine hcl-hydrocortison ac

.................................... 51, 75

LIDOCAINE VISCOUS ...... 51 lidocaine-hydrocortisone-aloe

.......................................... 75 lidocaine-prilocaine .............. 51 lillow..................................... 93 lindane .................................. 55 linezolid ................................ 12 LINZESS.............................. 75 liothyronine .......................... 72 LIPOFEN.............................. 45 lisinopril................................ 39 lisinopril-hydrochlorothiazide

.......................................... 40 lithium carbonate.................. 34 lithium citrate ....................... 34 LIVALO ............................... 45 LO LOESTRIN FE............... 93 lomedia 24 fe ........................ 93 LONHALA MAGNAIR

REFILL .......................... 105 LONHALA MAGNAIR

STARTER ...................... 105 LONSURF............................ 17 LOPHLEX............................ 57 lopinavir-ritonavir .................. 8 lopreeza ................................ 89 lorazepam ............................. 34 LORAZEPAM INTENSOL. 34 LORCET (HYDROCODONE)

.......................................... 28 LORCET HD........................ 28 LORCET PLUS.................... 28 LORTAB ELIXIR................ 28 loryna (28) ............................ 93 losartan ................................. 40 losartan-hydrochlorothiazide40 LOTEMAX ........................ 100 lovastatin .............................. 45 low-ogestrel (28) .................. 93 loxapine succinate ................ 34 ludent fluoride .................... 112 LUMIGAN ........................... 99 LUPANETA PACK (1

MONTH) .......................... 90 LUPANETA PACK (3

MONTH) .......................... 90 lutera (28) ............................. 93 LYNPARZA......................... 17

LYRICA ............................... 21 LYRICA CR......................... 21 LYSODREN......................... 17 lyza ....................................... 89 M malathion .............................. 55 maprotiline............................ 34 MAR-COF BP .................... 102 MAR-COF CG ................... 102 marlissa................................. 93 MARPLAN........................... 34 MATULANE........................ 17 MATZIM LA........................ 40 MAVYRET ............................ 8 M-CLEAR WC................... 102 meclizine............................... 75 meclofenamate...................... 30 medroxyprogesterone ........... 89 mefenamic acid..................... 30 mefloquine............................ 12 megestrol .............................. 17 MEKINIST ........................... 17 melodetta 24 fe ..................... 93 meloxicam ............................ 30 melphalan ............................. 17 memantine ............................ 25 MENACTRA (PF)................ 84 MENEST .............................. 89 MENHIBRIX (PF) ............... 84 MENOMUNE - A/C/Y/W-135

.......................................... 84 MENOMUNE - A/C/Y/W-135

(PF) ................................... 84 MENOSTAR ........................ 89 MENVEO A-C-Y-W-135-DIP

(PF) ................................... 84 meperidine ............................ 28 MEPHYTON........................ 43 meprobamate ........................ 26 MEPRON ............................. 12 mercaptopurine ..................... 17 mesalamine ........................... 76 MESNEX.............................. 15 MESTINON ......................... 26 METADATE ER .................. 34 metaproterenol .................... 105 metaxalone............................ 26 metformin ............................. 72

Updated 7/2018

127

methadone ............................28 METHADONE INTENSOL 28 METHADOSE .....................28 methamphetamine ................34 methazolamide .....................98 methenamine hippurate ........14 methenamine mandelate.......14 methimazole .........................62 methocarbamol .....................26 methotrexate sodium ............17 methotrexate sodium (pf) .....17 methoxsalen..........................48 methscopolamine..................73 methyclothiazide ..................40 methyldopa ...........................40 methyldopa

hydrochlorothiazide..........40 methylphenidate hcl .............34 methylprednisolone ..............62 methyltestosterone................70 metipranolol .........................97 metoclopramide hcl ..............76 metolazone ...........................40 METOPIRONE ....................56 metoprolol succinate ............40 metoprolol ta-hydrochlorothiaz

..........................................40 metoprolol tartrate ................40 metronidazole ........... 12, 50, 90mexiletine.............................37 MIACALCIN .......................70 mibelas 24 fe ........................93 miconazole-3 ........................90 MICRO BLOOD GLUCOSE

..........................................65 MICRODOT BLOOD

GLUCOSE SYSTEM.......65 microgestin 1.5/30 (21) ........93 microgestin 1/20 (21) ...........93 microgestin fe 1.5/30 (28) ....93 microgestin fe 1/20 (28) .......93 midazolam ............................34 midodrine .............................56 MIGERGOT.........................24 miglitol .................................72 miglustat ...............................70 MILK OF MAGNESIA

CONCENTRATED..........76

millipred ...............................62 millipred dp ..........................62 mimvey.................................89 mimvey lo.............................89 MINITRAN ..........................46 MINIVELLE ........................89 minocycline ..........................14 minoxidil ..............................40 MIOCHOL-E........................97 MIRCERA............................79 mirtazapine ...........................34 MIRVASO............................50 misoprostol ...........................78 M-M-R II (PF)......................84 modafinil ..............................34 moderiba...............................80 moderiba dose pack ..............80 moexipril ..............................40 moexipril-hydrochlorothiazide

..........................................40 molindone.............................35 mometasone.................. 54, 105MONOCLATE-P .................43 MONOJECT 0.9% SODIUM

CHLORIDE......................56 MONOJECT PREFILL

ADVANCED NS .............56 MONOJECT PREFILL

SALINE FLUSH ..............56 mono-linyah..........................93 mononessa (28).....................93 montelukast ........................105 MONUROL..........................14 morphine......................... 28, 29 morphine concentrate ...........28 MOVIPREP..........................76 MOXEZA.............................96 moxifloxacin................... 14, 96MOZOBIL............................79 MULTAQ.............................37 MULTI-VIT WITH

FLUORIDE-IRON .........112 multi-vitamin with fluoride 112 MULTI-VITAMIN WITH

FLUORIDE ....................112 multivitamins with fluoride 112 multivit-fluor (vit e acetate)112 mupirocin..............................51

mupirocin calcium ................51 mvc-fluoride .......................112 my choice..............................93 my way .................................93 MYALEPT ...........................70 mycophenolate mofetil .........17 mycophenolate sodium.........17 MYGLUCOHEALTH..........65 MYLERAN ..........................17 MYNATAL ........................112 MYNATAL ADVANCE....112 MYNATAL PLUS .............112 MYNATAL-Z ....................112 MYNATE 90 PLUS ...........112 MYORISAN.........................50 MYRBETRIQ.....................108 MYSOLINE .........................22 MYTESI ...............................73 myzilra ..................................93 N nabumetone...........................30 nadolol ..................................40 nadolol-bendroflumethiazide40 naftifine.................................52 NAFTIN ...............................52 naloxone ...............................31 naltrexone .............................31 NAMENDA TITRATION

PAK ..................................25 NAMENDA XR ...................25 NAMZARIC................... 25, 26naphazoline.........................101 naproxen ......................... 30, 31 naproxen sodium ..................31 naratriptan.............................24 NARCAN .............................31 NATACYN...........................96 NATAZIA ............................93 nateglinide ............................72 NATPARA ...........................70 natural b-100 complex ........112 NATURE-THROID .............72 NEBUPENT .........................12 necon 0.5/35 (28)..................93 necon 1/50 (28).....................93 necon 10/11 (28)...................93 necon 7/7/7 (28)....................93 nefazodone............................35

Updated 7/2018

128

neomycin ..............................12 neomycin-bacitracin-poly-hc99 neomycin-bacitracin

polymyxin.........................96 neomycin-polymyxin b gu ...55 neomycin-polymyxin b

dexameth ..........................99 neomycin-polymyxin

gramicidin.........................96 neomycin-polymyxin-hc 61, 99 NEO-POLYCIN ...................96 NEO-POLYCIN HC ............99 NERLYNX...........................17 NEULASTA.........................79 NEUPOGEN ........................79 NEUPRO..............................23 NEURONTIN.......................22 NEUTEK 2TEK TEST

STRIPS.............................65 NEVANAC ..........................98 nevirapine ...............................8 NEWGEN...........................112 NEXAVAR ..........................17 NEXIUM PACKET .............78 next choice one dose ............93 niacin ....................................45 NIACOR...............................45 nicardipine............................40 NICODERM CQ..................60 NICORETTE........................60 nicotine .................................60 nicotine (polacrilex) .............60 NICOTROL..........................60 NICOTROL NS....................60 nifedipine..............................40 nikki (28) ..............................93 nilutamide.............................17 nimodipine............................40 NINLARO............................17 nisoldipine ............................40 NITRO-BID .........................46 NITRO-DUR........................46 nitrofurantoin ........................15 nitrofurantoin macrocrystal ..14 nitrofurantoin monohyd/m

cryst ..................................14 nitroglycerin .........................46 NITROSTAT........................46

NITRO-TIME.......................46 NITYR..................................56 nizatidine ..............................78 NODOLOR ..........................24 nora-be..................................89 NORDITROPIN FLEXPRO 79 noreth-ethinyl estradiol-iron. 93 norethindrone (contraceptive)

..........................................89 norethindrone acetate ...........89 norethindrone ac-eth estradiol

.................................... 89, 94 norethindrone-e.estradiol-iron

..........................................94 norgestimate-ethinyl estradiol

..........................................94 norgestrel-ethinyl estradiol...94 norlyda..................................89 norlyroc ................................89 NORMAL SALINE FLUSH56 NORPACE CR.....................37 NORTHERA ........................56 nortrel 0.5/35 (28).................94 nortrel 1/35 (21)....................94 nortrel 1/35 (28)....................94 nortrel 7/7/7 (28) ..................94 nortriptyline ..........................35 NORVIR.................................8 NOVA MAX GLUCOSE

TEST ................................65 NOVOEIGHT ......................44 NOVOLIN 70/30 U-100

INSULIN ..........................68 NOVOLIN N NPH U-100

INSULIN ..........................69 NOVOLIN R REGULAR U

100 INSULN ....................69 NOVOLOG FLEXPEN U-100

INSULIN ..........................69 NOVOLOG MIX 70-30 U-100

INSULN ...........................69 NOVOLOG MIX 70

30FLEXPEN U-100 .........69 NOVOLOG PENFILL U-100

INSULIN ..........................69 NOVOLOG U-100 INSULIN

ASPART...........................69 NOVOPEN ECHO...............67

NOVOSEVEN RT................44 NOXAFIL...............................6 np thyroid..............................72 NP THYROID ......................72 nts step 1 ...............................60 NUCYNTA...........................29 NUCYNTA ER ....................29 NUEDEXTA ........................26 NUPLAZID ..........................35 NUVARING.........................90 NYAMYC ............................52 NYATA ................................52 nystatin ............................. 6, 52 nystatin-triamcinolone ..........52 NYSTOP...............................52 O OBSTETRIX DHA ............112 OCALIVA ............................76 ocella.....................................94 octreotide acetate ..................17 ODACTRA...........................84 ODEFSEY ..............................8 ODOMZO.............................17 OFEV..................................105 ofloxacin ................... 14, 61, 96ogestrel (28)..........................94 olanzapine.............................35 olanzapine-fluoxetine ...........35 olmesartan.............................40 olmesartan-amlodipin

hcthiazid ...........................40 olmesartan

hydrochlorothiazide..........40 olopatadine ..................... 60, 98 OMECLAMOX-PAK...........78 omeprazole ...........................78 ON CALL EXPRESS TEST

STRIP ...............................65 ON CALL PLUS TEST STRIP

..........................................65 ON CALL VIVID TEST

STRIP ...............................65 ondansetron...........................76 ondansetron hcl.....................76 one daily prenatal ...............112 ONETOUCH ULTRA TEST

..........................................65 ONETOUCH VERIO...........65

Updated 7/2018

129

ONFI.....................................22 ONMEL..................................6 opcicon one-step...................94 OPSUMIT ..........................105 option-2 ................................94 OPTIUM EZ.........................65 OPTIUM TEST....................66 OPTUMRX ..........................66 ORALAIR ............................84 ORAVIG ................................6 ORENCIA ............................87 ORENITRAM ......................40 ORFADIN ............................56 ORKAMBI.........................105 orphenadrine citrate..............26 orsythia .................................94 oseltamivir..............................8 OSMOPREP.........................76 OSPHENA ...........................90 OTEZLA ..............................87 OTEZLA STARTER............87 OTOVEL..............................61 oxandrolone..........................70 oxaprozin..............................31 oxazepam..............................35 oxcarbazepine.......................22 oxiconazole...........................52 OXTELLAR XR ..................22 oxybutynin chloride............108 oxycodone ............................29 oxycodone-acetaminophen...29 oxycodone-aspirin ................29 OXYCONTIN ......................29 oxymorphone........................29 oyster shell calcium-vit d3 . 110 P PACERONE.........................37 paliperidone..........................35 pantoprazole .........................78 paregoric...............................74 paricalcitol ............................70 paromomycin........................12 paroxetine hcl .......................35 PATADAY...........................98 PAXIL ..................................35 PAZEO .................................98 PCE.......................................11 PEDIARIX (PF) ...................84

PEDVAX HIB (PF)..............84 peg 3350-electrolytes ...........76 peg-3350 with flavor packs ..76 PEGANONE ........................22 PEGASYS ............................80 PEGASYS PROCLICK .......80 peg-electrolyte soln ..............76 PEGINTRON .......................80 PEGINTRON REDIPEN .....80 peg-prep................................76 pen needle, diabetic ..............67 penicillin v potassium...........13 PENTACEL (PF) .................84 PENTASA............................76 pentazocine-naloxone...........29 pentoxifylline........................44 PERFOROMIST ................105 PERIFLEX ADVANCE.......57 PERIFLEX INFANT............58 PERIFLEX JUNIOR ............58 PERIFLEX LQ PKU............58 perindopril erbumine ............40 PERIOGARD .......................60 permethrin ............................55 perphenazine.........................35 perphenazine-amitriptyline...35 perry prenatal......................112 PHARMACIST CHOICE ....66 PHENACTIN AA PLUS 20

PE .....................................58 PHENADOZ ......................101 phenazopyridine .................109 phenelzine.............................35 PHENERGAN....................102 PHENEX-1...........................58 PHENEX-2...........................58 phenobarbital ........................22 phenoxybenzamine...............40 PHENYLADE 40 .................58 PHENYLADE 60 .................58 PHENYLADE AMINO ACID

..........................................58 PHENYLADE AMINO

ACIDS ..............................58 PHENYLADE DRINK MIX58 PHENYLADE ESSENTIAL58 PHENYLADE GMP ............58

PHENYLADE GMP MIX-IN ..........................................58

PHENYLADE MTE AMINO ACIDS ..............................58

phenylade phebloc ................58 PHENYLADE PHEBLOC...58 PHENYLADE RTD PKU 10

..........................................58 phenylephrine hcl ...............101 PHENYL-FREE 1 ................58 PHENYL-FREE 2 PKU .......58 PHENYL-FREE 2HP PKU ..59 PHENYTEK .........................22 phenytoin ..............................22 phenytoin sodium extended ..22 philith....................................94 PHLEXY-10 .........................59 PHLEXY-10 DRINK MIX

POWDER .........................59 PHOSLYRA .........................76 PHOSPHA 250 NEUTRAL

........................................110 PHOSPHATE LAXATIVE..76 PHOSPHOLINE IODIDE....97 phrenilin forte(with caffeine)29 PICATO................................48 pilocarpine hcl .......... 56, 61, 97 pimozide ...............................35 pimtrea (28) ..........................94 pindolol.................................40 pioglitazone ..........................72 pioglitazone-glimepiride.......72 pioglitazone-metformin ........72 pirmella.................................94 piroxicam..............................31 PKU 2 ...................................59 PKU 3 ...................................59 PKU AIR15 ..........................59 PKU AIR20 ..........................59 PKU COOLER 10 ................59 PKU COOLER 15 ................59 PKU COOLER 20 ................59 PKU EASY MICROTABS ..59 PKU EXPRESS15................59 PKU EXPRESS20................59 PKU GEL POWDER ...........59 PKU LOPHLEX...................59

Updated 7/2018

130

PKU PERIFLEX EARLY YEARS.............................59

PKU PERIFLEX JUNIOR PLUS ................................59

PKU SPHERE20..................59 PKU TRIO............................59 PLEGRIDY ..........................80 PNEUMOVAX 23 ...............84 PNV 29-1............................113 PNV OB+DHA ..................113 PNV-DHA..........................113 PNV-DHA + DOCUSATE 113 PNV-OMEGA....................113 PNV-SELECT....................113 PNV-VP-U .........................113 PODOCON...........................48 podofilox ..............................48 POLYCIN.............................96 polyethylene glycol 3350 .....76 polymyxin b sulf-trimethoprim

..........................................96 POLY-VI-FLOR ................113 POLY-VI-FLOR WITH IRON

........................................113 poly-vitamin with iron........113 POMALYST ........................80 portia.....................................94 potassium bicarb and chloride

........................................110 potassium bicarb-citric acid110 potassium chloride..............110 potassium citrate.................109 potassium citrate-citric acid109 potassium hydroxide ............48 PR NATAL 400 .................113 PR NATAL 400 EC ...........113 PR NATAL 430 .................113 PR NATAL 430 EC ...........113 PRADAXA...........................44 PRALUENT PEN ................45 PRALUENT SYRINGE.......45 PRAMCORT........................76 pramipexole..........................23 prasugrel ...............................44 pravastatin ............................45 praziquantel ..........................12 prazosin ................................41

PRECISION PCX PLUS TEST ..........................................66

PRECISION PCX TEST......66 PRECISION POINT OF

CARE TEST.....................66 PRECISION Q-I-D TEST....66 PRECISION XTRA TEST...66 PRED MILD.......................100 PRED-G................................99 PRED-G S.O.P. .................... 99 prednicarbate .................. 54, 55 prednisolone .........................62 prednisolone acetate ...........100 prednisolone sodium phosphate

.................................. 62, 100 prednisone ............................62 PREDNISONE INTENSOL. 62 PREFEST .............................89 PREMARIN .........................89 PREMIER TEST STRIP ......66 PREMIUM V10 ...................66 PREMPHASE ......................89 PREMPRO ...........................89 PRENA1 CHEW ................113 PRENA1 PEARL ...............113 PRENA1 TRUE .................113 PRENAISSANCE ..............113 PRENAISSANCE PLUS ...113 PRENATABS FA...............113 PRENATABS RX ..............113 prenatal ...............................113 prenatal complete ...............113 PRENATAL LOW IRON ..113 prenatal multi-dha (algal oil)

........................................113 prenatal one daily ...............113 PRENATAL PLUS ............114 PRENATAL PLUS

(CALCIUM CARB) .......113 prenatal vitamin..................114 PRENATAL VITAMIN PLUS

LOW IRON ....................114 prenatal vits96-iron fum-folic

........................................114 PRENATAL-U...................114 PREPLUS...........................114 PREPOPIK ...........................76 PRETAB.............................114

PREVACID SOLUTAB.......78 PREVALITE ........................45 PREVIDENT 5000 BOOSTER

PLUS ................................61 PREVIDENT 5000 DRY

MOUTH ...........................61 PREVIDENT 5000 ENAMEL

PROTECT ........................61 PREVIDENT 5000

SENSITIVE......................61 previfem................................94 PREVNAR 13 (PF) ..............84 PREZCOBIX..........................8 PREZISTA .............................8 PRIFTIN ...............................12 primaquine............................13 primidone..............................22 PRIMSOL.............................15 PROAIR HFA ....................106 PROAIR RESPICLICK......106 probenecid ............................86 probenecid-colchicine...........86 PROCENTRA ......................35 prochlorperazine ...................76 prochlorperazine maleate......76 PROCRIT .............................79 PROCTO-MED HC..............76 PROCTO-PAK.....................76 PROCTOSOL HC ................76 PROCTOZONE-HC.............77 PROCYSBI.........................109 PRODIGY NO CODING.....66 PROFILNINE.......................44 progesterone micronized ......89 PROLENSA .........................98 PROMACTA........................44 promethazine ......................102 PROMETHAZINE VC ......102 PROMETHAZINE VC

CODEINE.......................102 promethazine-codeine.........102 promethazine-dm................102 promethazine-phenyleph

codeine............................102 PROMETHEGAN..............102 propafenone ..........................37 propantheline ........................74 proparacaine .........................98

Updated 7/2018

131

propranolol ........................... 41 propranolol-hydrochlorothiazid

.......................................... 41 propylthiouracil .................... 62 PROQUAD (PF) .................. 84 PROSTIN VR PEDIATRIC

........................................ 109 protriptyline.......................... 35 PROVENTIL HFA............. 106 PRUCLAIR .......................... 48 PULMICORT FLEXHALER

........................................ 106 PULMOSAL ...................... 106 PULMOZYME................... 106 PURIXAN ............................ 17 PYLERA .............................. 79 pyrazinamide ........................ 13 pyridostigmine bromide ....... 26 Q QUADRACEL (PF) ............. 84 quasense ............................... 94 quazepam.............................. 35 QUDEXY XR ...................... 22 quetiapine ............................. 35 QUILLIVANT XR............... 35 quinapril ............................... 41 quinapril-hydrochlorothiazide

.......................................... 41 quinidine gluconate .............. 37 quinidine sulfate ................... 37 quinine sulfate ...................... 13 QUINTET AC...................... 66 QVAR................................. 106 QVAR REDIHALER......... 106 R RABAVERT (PF) ................ 84 rabeprazole ........................... 79 RADIOGARDASE .............. 56 RAGWITEK......................... 84 rajani..................................... 94 raloxifene.............................. 86 ramipril ................................. 41 RANEXA ............................. 46 ranitidine hcl......................... 79 RAPAFLO.......................... 108 RAPAMUNE ....................... 17 rasagiline .............................. 24 RAVICTI.............................. 56

REBETOL............................ 80 REBIF (WITH ALBUMIN). 80 REBIF REBIDOSE .............. 80 REBIF TITRATION PACK. 80 reclipsen (28)........................ 94 RECOMBINATE ................. 44 RECOMBIVAX HB (PF) .... 85 REFUAH PLUS ................... 66 REGRANEX ........................ 49 RELENZA DISKHALER ...... 8 RELION CONFIRM-MICRO

.......................................... 66 RELION PRIME TEST

STRIPS............................. 66 RELISTOR........................... 77 RELNATE DHA ................ 114 RELPAX .............................. 24 REMODULIN...................... 41 RENAGEL ........................... 77 rena-vite.............................. 114 RENA-VITE RX ................ 114 RENO CAPS ...................... 114 RENVELA ........................... 77 repaglinide ............................ 72 repaglinide-metformin.......... 72 REPATHA PUSHTRONEX 45 REPATHA SURECLICK .... 45 REPATHA SYRINGE ......... 45 REPREXAIN........................ 29 RESCRIPTOR.................... 8, 9 RESTASIS............................ 98 RESTASIS MULTIDOSE ... 98 REVATIO .......................... 106 REVEAL TEST STRIP........ 66 REVLIMID .......................... 80 REYATAZ ............................. 9 REZIRA.............................. 102 ribasphere ............................. 80 ribavirin ................................ 81 RIDAURA............................ 87 rifabutin ................................ 13 RIFAMATE.......................... 13 rifampin ................................ 13 RIFATER ............................. 13 RIGHTEST GS550 TEST

STRIPS............................. 66 riluzole.................................. 56 rimantadine............................. 9

RIOMET............................... 72 risacal-d .............................. 114 risedronate ...................... 56, 86 RISPERDAL CONSTA ....... 35 risperidone ............................ 35 ritonavir .................................. 9 rivastigmine .......................... 26 rivastigmine tartrate.............. 26 rivelsa ................................... 94 RIXUBIS .............................. 44 rizatriptan.............................. 24 ROBAFEN AC................... 102 ropinirole .............................. 24 rosuvastatin ..................... 45, 46 ROTARIX ............................ 85 ROTATEQ VACCINE......... 85 roweepra ............................... 22 roweepra xr ........................... 22 ROZEREM ........................... 35 RUBRACA........................... 17 RUCONEST....................... 106 S SABRIL................................ 22 SAFYRAL............................ 94 salicylic acid ......................... 48 salicylic acid er-ceramides ... 48 salsalate................................. 31 SAMSCA.............................. 70 SANDIMMUNE................... 18 SANTYL .............................. 55 SAPHRIS (BLACK

CHERRY)......................... 35 SARAFEM ........................... 35 SAVELLA............................ 87 scopolamine base.................. 77 SEB-PREV ........................... 47 selegiline hcl ......................... 24 selenium sulfide.................... 47 SELZENTRY ......................... 9 SEMPREX-D ..................... 102 SE-NATAL 19.................... 114 SE-NATAL 19 (WITH

DOCUSATE) ................. 114 SENSIPAR ........................... 70 SEREVENT DISKUS ........ 106 sertraline ............................... 36 SE-TAN PLUS ................... 114 setlakin.................................. 94

Updated 7/2018

132

sevelamer carbonate ............. 77 SF ......................................... 61 SF 5000 PLUS...................... 61 sharobel ................................ 89 SHINGRIX (PF)................... 85 SIGNIFOR ........................... 18 sildenafil (antihypertensive)

........................................ 106 SILIQ.................................... 47 silver nitrate.......................... 49 silver nitrate applicators ....... 49 silver sulfadiazine................. 48 SIMBRINZA........................ 99 SIMPONI ............................. 87 simvastatin............................ 46 sirolimus............................... 18 SIRTURO............................. 13 SKLICE................................ 55 SMART SENSE TEST

STRIPS............................. 66 SMARTEST TEST .............. 66 sodium chlor 0.9% bacteriostat

.......................................... 56 sodium chloride ............ 57, 106 sodium chloride 0.9 %.......... 57 sodium phenylbutyrate ......... 57 sodium polystyrene sulfonate

.......................................... 77 SOLESTA ............................ 77 SOLIQUA 100/33 ................ 69 soloxide ................................ 14 SOLTAMOX........................ 18 SOMAVERT........................ 70 sorbitol.................................. 55 sorbitol-mannitol .................. 55 SORINE ............................... 37 sotalol ................................... 37 SOTALOL AF...................... 37 SOTYLIZE........................... 37 spinosad ................................ 55 SPIRIVA RESPIMAT ....... 106 SPIRIVA WITH

HANDIHALER.............. 106 spironolactone ...................... 41 spironolacton-hydrochlorothiaz

.......................................... 41 SPORANOX .......................... 6 sprintec (28).......................... 94

SPRITAM............................. 22 SPRIX................................... 31 SPRYCEL ............................ 18 SPS (WITH SORBITOL)..... 77 sronyx ................................... 94 SSD....................................... 48 SSKI ..................................... 62 SSS 10-5............................... 50 STAMARIL (PF) ................. 85 stavudine................................. 9 STELARA ............................ 47 STIMATE............................. 70 STIOLTO RESPIMAT....... 106 STIVARGA.......................... 18 STRATTERA....................... 36 STRENSIQ........................... 70 STRESS FORMULA ......... 114 STRESS FORMULA WITH

IRON .............................. 114 STRESS FORMULA WITH

IRON(SULF).................. 114 STRIBILD.............................. 9 STRIVERDI RESPIMAT .. 106 SUBOXONE ........................ 19 SUCRAID ............................ 77 sucralfate .............................. 79 sulfacetamide sodium... 47, 100 sulfacetamide sodium (acne) 51 sulfacetamide sodium-sulfur 50 sulfacetamide sod-sulfur-urea

.......................................... 50 sulfacetamide-prednisolone 100 sulfadiazine........................... 14 sulfamethoxazole-trimethoprim

.......................................... 14 SULFAMYLON................... 51 sulfasalazine ......................... 77 SULFATRIM ....................... 14 sulindac................................. 31 sumatriptan ........................... 24 sumatriptan succinate ..... 24, 25 SUMAVEL DOSEPRO ....... 25 SUPRAX .............................. 11 SUPREP BOWEL PREP KIT

.......................................... 77 SURE-TEST EASYPLUS

MINI................................. 66 SUSTIVA ............................... 9

SUTENT............................... 18 syeda ..................................... 94 SYLATRON......................... 81 SYMBICORT..................... 106 SYMDEKO ........................ 106 SYMFI.................................... 9 SYMFI LO.............................. 9 SYMLINPEN 120 ................ 72 SYMLINPEN 60 .................. 72 SYNAREL............................ 70 SYNDROS ........................... 77 SYNERA .............................. 51 SYNTHROID ....................... 73 SYREX SODIUM

CHLORIDE 0.9 %............ 57 T TABLOID............................. 18 TACLONEX......................... 47 tacrolimus ....................... 18, 49 TAFINLAR .......................... 18 TAGRISSO........................... 18 TALTZ AUTOINJECTOR .. 47 TALTZ AUTOINJECTOR (2

PACK) .............................. 47 TALTZ AUTOINJECTOR (3

PACK) .............................. 47 TALTZ SYRINGE ............... 48 TALTZ SYRINGE (2 PACK)

.......................................... 47 TALTZ SYRINGE (3 PACK)

.......................................... 48 TAMIFLU .............................. 9 tamoxifen.............................. 18 tamsulosin........................... 108 TARCEVA ........................... 18 TARGRETIN ....................... 18 tarina fe 1/20 (28) ................. 94 TARON-C DHA................. 114 TARON-PREX PRENATAL

DHA ............................... 114 TASIGNA............................. 18 tazarotene.............................. 50 TAZORAC ........................... 50 TAZTIA XT ......................... 41 TECFIDERA ........................ 81 TEGRETOL ......................... 22 TEGRETOL XR................... 22 TEKTURNA......................... 41

Updated 7/2018

133

TEKTURNA HCT ............... 41 TELCARE TEST STRIPS ... 66 telmisartan ............................ 41 telmisartan-amlodipine......... 41 telmisartan-hydrochlorothiazid

.......................................... 41 temazepam............................ 36 temozolomide....................... 18 TENCON.............................. 29 TENIVAC (PF) .................... 85 tenofovir disoproxil fumarate. 9 terazosin ............................... 41 terbinafine hcl......................... 6 terbutaline........................... 106 terconazole ........................... 90 TEST N'GO TEST ............... 66 testosterone..................... 70, 71 testosterone cypionate .......... 70 testosterone enanthate .......... 70 tetanus,diphtheria tox ped(pf)

.......................................... 85 tetanus-diphtheria toxoids-td 85 tetrabenazine......................... 26 tetracaine hcl ........................ 98 tetracaine hcl (pf) ................. 98 tetracycline ........................... 14 THALOMID......................... 18 THEOCHRON ................... 107 theophylline........................ 107 THERMAZENE................... 48 THIOLA............................... 57 thioridazine........................... 36 thiothixene............................ 36 THRIVITE-19 .................... 114 thyroid (pork) ....................... 73 THYROLAR-1..................... 73 THYROLAR-1/2.................. 73 THYROLAR-1/4.................. 73 THYROLAR-2..................... 73 THYROLAR-3..................... 73 tiagabine ............................... 22 TICE BCG............................ 85 ticlopidine............................. 44 tilia fe.................................... 94 timolol maleate............... 41, 97 TIMOPTIC OCUDOSE (PF)

.......................................... 97 tinidazole .............................. 13

TIS-U-SOL PENTALYTE... 55 TIVICAY................................ 9 tizanidine .............................. 26 TL GARD RX .................... 114 TOBRADEX ........................ 99 TOBRADEX ST................... 99 tobramycin............................ 96 tobramycin in 0.225 % nacl.. 13 tobramycin-dexamethasone.. 99 TOBREX.............................. 96 tolazamide ............................ 72 tolbutamide........................... 72 tolcapone .............................. 24 tolmetin................................. 31 tolterodine........................... 108 TOPAMAX .......................... 22 topiramate....................... 22, 23 torsemide .............................. 41 TOUJEO MAX SOLOSTAR

.......................................... 69 TOUJEO SOLOSTAR U-300

INSULIN .......................... 69 TRACLEER ....................... 107 TRADJENTA....................... 72 tramadol................................ 29 tramadol-acetaminophen ...... 29 trandolapril ........................... 41 trandolapril-verapamil .......... 41 tranexamic acid..................... 90 TRANSDERM-SCOP.......... 77 tranylcypromine.................... 36 TRAVATAN Z..................... 99 trazodone .............................. 36 TRECATOR......................... 13 TRELEGY ELLIPTA......... 107 TREMFYA........................... 48 TRESIBA FLEXTOUCH U

100 .................................... 69 TRESIBA FLEXTOUCH U

200 .................................... 69 tretinoin ................................ 50 tretinoin (chemotherapy) ...... 18 tretinoin microspheres .......... 50 tri femynor............................ 94 triamcinolone acetonide . 55, 61 triamterene-hydrochlorothiazid

.......................................... 41 triazolam............................... 36

TRICON ............................. 114 TRIDERM ............................ 55 tri-estarylla............................ 94 trifluoperazine....................... 36 trifluridine............................. 96 TRIGLIDE............................ 46 trihexyphenidyl..................... 24 tri-legest fe............................ 94 TRILEPTAL......................... 23 tri-linyah ............................... 95 tri-lo-estarylla ....................... 95 tri-lo-marzia.......................... 95 tri-lo-sprintec ........................ 95 trilyte with flavor packets ..... 77 trimethobenzamide ............... 77 trimethoprim ......................... 15 trimipramine ......................... 36 TRINATAL GT.................. 114 TRINATAL RX 1............... 114 TRINATE ........................... 114 trinessa (28) .......................... 95 trinessa lo.............................. 95 TRINTELLIX....................... 36 tri-previfem (28) ................... 95 tri-sprintec (28) ..................... 95 TRI-TABS DHA ................ 114 TRIUMEQ.............................. 9 TRIVEEN-DUO DHA ....... 114 TRIVEEN-ONE ................. 114 TRIVEEN-PRX RNF ......... 115 TRI-VI-FLOR..................... 115 tri-vit with fluoride and iron

........................................ 115 tri-vitamin with fluoride ..... 115 trivora (28)............................ 95 tri-vylibra .............................. 95 TROKENDI XR ................... 23 tropicamide ........................... 97 trospium.............................. 108 TRUE METRIX GLUCOSE

TEST STRIP..................... 66 TRUETEST TEST STRIPS . 66 TRUETRACK TEST............ 66 TRULICITY ......................... 72 TRUMENBA........................ 85 TRUST NATAL DHA ....... 115 TRUVADA............................. 9 TUDORZA PRESSAIR ..... 107

Updated 7/2018

134

TUSSIGON ........................102 TWINRIX (PF) ....................85 TYBOST ................................9 tydemy..................................95 TYKERB..............................18 TYMLOS .............................86 TYPHIM VI .........................85 TYVASO............................107 TYVASO INSTITUTIONAL

START KIT....................107 TYVASO REFILL KIT .....107 TYVASO STARTER KIT . 107 TYZEKA................................9 U UCERIS................................77 UDAMIN SP......................115 ULESFIA .............................55 ULORIC ...............................86 ULTIMA TEST STRIPS......66 ULTIMATECARE ONE....115 ULTIMATECARE ONE NF

........................................115 ULTRATRAK......................66 ULTRATRAK ULTIMATE 66 ULTRAVATE X..................55 UNISTRIP1 TEST STRIP ...66 UNITHROID........................73 ursodiol.................................77 UTIBRON NEOHALER....107 V valacyclovir ............................9 VALCHLOR ........................49 valganciclovir .........................9 valproic acid .........................23 valproic acid (as sodium salt)

..........................................23 valsartan ...............................41 valsartan-hydrochlorothiazide

..........................................41 vancomycin ..........................15 vandazole..............................90 VANOXIDE-HC..................50 VAQTA (PF)........................85 VARIVAX (PF) ...................85 VAXCHORA VACCINE ....85 V-C FORTE .......................115 VELETRI .............................41

velivet triphasic regimen (28) ..........................................95

VELPHORO.........................77 VEMAVITE-PRX-2...........115 VEMLIDY..............................9 VENCLEXTA......................18 VENCLEXTA STARTING

PACK ...............................18 venlafaxine ...........................36 VENTAVIS ........................107 VENTOLIN HFA...............107 verapamil ..............................41 VERASENS TEST STRIP...66 VERDROCET......................29 VEREGEN ...........................49 VERIPRED 20 .....................62 VERZENIO..........................18 VESICARE ........................108 vestura (28)...........................95 VEXOL ..............................100 VGO 20 ................................67 VGO 30 ................................67 VGO 40 ................................67 VIBERZI ..............................77 VIBRAMYCIN ....................14 VICODIN .............................29 VICODIN ES .......................29 VICODIN HP .......................29 VIDEX 2 GRAM PEDIATRIC

............................................9 VIDEX 4 GRAM PEDIATRIC

............................................9 vienva ...................................95 vigabatrin..............................23 VIGAMOX...........................96 VIIBRYD .............................36 VIMPAT...............................23 VINATE CARE .................115 VINATE DHA ...................115 VINATE II .........................115 VINATE M.........................115 VINATE ONE....................115 VINATE ULTRA...............115 viorele (28) ...........................95 VIRACEPT ..........................10 VIREAD...............................10 VIRT-ADVANCE..............115 VIRT-C DHA.....................115

VIRT-NATE.......................115 VIRT-NATE DHA .............115 VIRT-PHOS 250 NEUTRAL

........................................110 VIRT-PN ............................115 VIRT-PN DHA...................115 VIRT-PN PLUS..................115 VIRT-SELECT...................115 VIRTUSSIN AC.................102 VIRT-VITE ........................115 VIRT-VITE GT ..................115 VIRT-VITE PLUS..............115 vit b complex-folic acid......115 vitamin d3...........................115 vitamins a,c,d and fluoride . 115 VITEKTA.............................10 VIVELLE-DOT....................90 VIVOTIF ..............................86 VIVOTIF BERNA VACCINE

..........................................85 VOL-NATE........................115 VOL-PLUS.........................116 VOL-TAB RX ....................116 voriconazole ...........................6 VOSEVI ...............................10 VOTRIENT ..........................18 VP-CH PLUS .....................116 VP-CH-PNV.......................116 VP-GGR-B6 .......................116 VP-HEME OB....................116 VP-HEME ONE .................116 VRAYLAR...........................36 VUSION ...............................52 vyfemla (28) .........................95 vylibra...................................95 VYVANSE ...........................36 W warfarin.................................44 water for irrigation, sterile ....57 WAVESENSE JAZZ............66 WAVESENSE PRESTO......66 WELCHOL...........................46 wera (28)...............................95 WESTHROID.......................73 WILATE...............................44 women's gentle laxative(bisac)

..........................................78 women's laxative (bisacodyl)78

Updated 7/2018

135

WP THYROID..................... 73 wymzya fe ............................ 95 X XALKORI............................ 18 XARELTO ........................... 44 XELJANZ ............................ 87 XELJANZ XR...................... 87 XERMELO........................... 18 XIFAXAN............................ 13 XIGDUO XR........................ 72 XOPENEX HFA ................ 107 XPHE MAXAMAID............ 59 xphe maxamum .................... 59 XPHE MAXAMUM ............ 59 XTANDI............................... 18 xulane ................................... 90 XULTOPHY 100/3.6 ........... 69 XYLON 10........................... 29 XYNTHA............................. 44 XYNTHA SOLOFUSE........ 44 XYREM ............................... 36 Y YF-VAX (PF)....................... 86 yuvafem................................ 90 Z zafirlukast ........................... 107 zaleplon ................................ 36 ZAMICET ............................ 29 zarah ..................................... 95 ZARONTIN ......................... 23 ZARXIO............................... 79

ZATEAN-CH ..................... 116 ZATEAN-PN DHA............ 116 ZATEAN-PN PLUS........... 116 ZAVESCA............................ 71 ZEBUTAL............................ 30 ZEJULA ............................... 18 ZELAPAR ............................ 24 ZELBORAF ......................... 18 ZENATANE......................... 50 zenchent (28) ........................ 95 zenchent fe............................ 95 ZENPEP ............................... 78 ZENZEDI ............................. 36 ZIAGEN ............................... 10 zidovudine ............................ 10 zileuton ............................... 107 ZINBRYTA.......................... 81 ZINGIBER ......................... 116 ZIOPTAN (PF)..................... 99 ziprasidone hcl...................... 36 ZIRGAN............................... 96 ZMAX .................................. 11 ZODRYL AC 25 ................ 103 ZODRYL AC 30 ................ 103 ZODRYL AC 35 ................ 103 ZODRYL AC 40 ................ 103 ZODRYL AC 50 ................ 103 ZODRYL AC 60 ................ 103 ZODRYL AC 80 ................ 103 ZODRYL DAC 25 ............. 103 ZODRYL DAC 30 ............. 103

ZODRYL DAC 35 ............. 103 ZODRYL DAC 40 ............. 103 ZODRYL DAC 50 ............. 103 ZODRYL DAC 60 ............. 103 ZODRYL DAC 80 ............. 103 ZODRYL DEC 25.............. 103 ZODRYL DEC 30.............. 103 ZODRYL DEC 35.............. 103 ZODRYL DEC 40.............. 103 ZODRYL DEC 50.............. 103 ZODRYL DEC 60.............. 103 ZODRYL DEC 80.............. 103 ZOLINZA............................. 18 zolmitriptan........................... 25 zolpidem ............................... 36 ZOMIG ................................. 25 ZONEGRAN ........................ 23 zonisamide............................ 23 ZONTIVITY......................... 44 ZORTRESS .......................... 18 ZOSTAVAX (PF) ................ 86 zovia 1/35e (28).................... 95 zovia 1/50e (28).................... 95 ZOVIRAX ............................ 52 Z-TUSS AC ........................ 103 ZUBSOLV............................ 19 ZYBAN ................................ 60 ZYDELIG............................. 18 ZYKADIA............................ 18 ZYPREXA RELPREVV ...... 36 ZYTIGA ............................... 19

BlueCross BlueShield of Tennessee 1 Cameron Hill Circle | Chattanooga, TN 37402 | bcbst.com

BlueCross BlueShield of Tennessee (BlueCross) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia complies with applicable Federal civil rights laws and lingüística. Llame al 1-800-565-9140 (TTY: 1-800-848-0298).does not discriminate on the basis of race, color, nationalorigin, age, disability or sex. BlueCross does not excludepeople or treat them differently because of race, color, national origin, age, disability or sex.

(رقم 1-9140-565-800 اتصل برقملمجان. لك باللغویة تتوافر لمساعدة اخدمات اللغة، فإن ملحوظة: إذا كنت تتحدث اذكر ا 1-0298-848-800).م: لبكلصم واھاتف ا

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-565-9140 (TTY:1-800-848-0298) 。

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-565-9140 (TTY:1-800-848-0298).

BlueCross: • Provides free aids and services to people withdisabilities to communicate effectively with us, suchas: (1) qualified interpreters and (2) written informationin other formats, such as large print, audio and accessible electronic formats.

• Provides free language services to people whoseprimary language is not English, such as: (1) qualifiedinterpreters and (2) written information in otherlanguages.

If you need these services, contact a consumer advisorat the number on the back of your Member ID card orcall 1-800-565-9140 (TTY: 1-800-848-0298 or 711). If you believe that BlueCross has failed to providethese services or discriminated in another way onthe basis of race, color, national origin, age, disabilityor sex, you can file a grievance (“NondiscriminationGrievance”). For help with preparing and submittingyour Nondiscrimination Grievance, contact a consumer advisor at the number on the back of your Member ID cardor call 1-800-565-9140 (TTY: 1-800-848-0298 or 711). They can provide you with the appropriate form to usein submitting a Nondiscrimination Grievance. You can file a Nondiscrimination Grievance in person or by mail, fax or email. Address your Nondiscrimination Grievanceto: Nondiscrimination Compliance Coordinator; c/oManager, Operations, Member Benefits Administration;1 Cameron Hill Circle, Suite 0019, Chattanooga, TN37402-0019; (423) 591-9208 (fax); [email protected] (email). You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.1-800-565-9140 (TTY: 1-800-848-0298) 번으로 전화해 주십시오.

ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-565-9140 (ATS : 1-800-848-0298).

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ,ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-800-565-9140(TTY: 1-800-848-0298).

ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-565-9140 (መስማት ለተሳናቸው: 1-800-848-0298).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-565-9140(TTY: 1-800-848-0298).

સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-800-565-9140 (TTY:1-800-848-0298)

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-565-9140 (TTY:1-800-848-0298) まで、お電話にてご連絡ください。

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-565-9140(TTY:1-800-848-0298).

ध्यान दें: यिद आप िहंदी बोलते हैं तो आपके िलए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-800-565-9140 (TTY:1-800-848-0298) पर कॉल करें।

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-565-9140 (телетайп: 1-800-848-0298).

انی بصورت رایگان برای شما فراهم می باشد. با توجه: اگر به زبان فارسی گفتگو می کنید، تسهیالت زب-1-800-565-9140 (TTY:1-800-848-0298) . تماس بگیرید.U.S. Department of Health and Human Services,

200 Independence Avenue SW., Room 509F, HHHBuilding, Washington, DC 20201, 1–800–368–1019,800–537–7697 (TDD). Complaint forms are available athttp://www.hhs.gov/ocr/office/file/index.html. BlueCross BlueShield of Tennessee is a QualifiedHealth Plan Issuer in the Health Insurance Marketplace. BlueCross BlueShield of Tennessee, Inc., anIndependent Licensee of the BlueCross BlueShieldAssociation.

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-565-9140 (TTY: 1-800-848-0298).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-565-9140 (TTY: 1-800-848-0298).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-565-9140 (TTY: 1-800-848-0298).

ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-565-9140 (TTY: 1-800-848-0298).

D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-565-9140 (TTY: 1-800-848-0298).

18PHM269415 RX-18_2018 (7/18)

Essential Formulary with Preventive Drug Copays

http://www.hhs.gov/ocr/office/file/index.html

https://bcbst.com

mailto:[email protected]

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

your guide to prescription drug beneits - health insurance€¦ · your guide to prescription drug...

Documents