1 Formulario Comprensivo de 2016 Lista de Medicamentos Cubiertos [PDF]

Formulario Comprensivo de 2016 Lista de Medicamentos Cubiertos

POR FAVOR, LEA: ESTE DOCUMENTO LLEVA INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN H5141_00016069_Comprehensive Formulary_SP Version 16

Se actualizó el formulario el 25/10/2016. Para información más reciente u otras preguntas, comuníquese, por favor, con el Servicio al Cliente de Clover Health al (888) 657-1207 o, para los usuarios de TTY, al 711 (llamada gratuita), 7 días a la semana/24 horas al da, o visite www.cloverhealth.com. Nota a los miembros actuales: El formulario cambió después del año pasado. Por favor, repase el documento y asegure que aún tiene los medicamentos que toma. Cuando se dice “nosotros”, “a nosotros” o “nuestro” en el formulario, se refiere a Clover Health. Cuando se dice “plan” o “nuestro plan”, se refiere a Clover Health. Nuestra información de contacto, juntamente con la fecha de la última actualización del formulario, se encuentran en la portada y la contraportada. Debe acudir a farmacias de la red para usar el beneficio de medicamentos recetados. Los beneficios, el formulario, la red de farmacias y/o los copagos/coaseguro podrían cambiar para el 1° de enero de 2016 y de vez en cuando a lo largo del año.

¿Qué es el Formulario de Clover Health? El formulario es una lista de medicamentos cubiertos seleccionados por Clover Health con la asesoría de un equipo de proveedores de atención de salud. La lista representa las terapias recetadas que se consideran una parte necesaria de un programa de tratamiento de calidad. Clover Health por lo general cubre los medicamentos enumerados en el formulario siempre y cuando el medicamento se necesite medicamente, la receta se surta en una farmacia de la red de Clover Health y se sigan las otras reglas del plan. Para información de cómo surtir recetas, repase, por favor, la Evidencia de Cobertura. 1

¿Puede cambiar el Formulario (lista de medicamentos? Por lo general, si toma un medicamento del formulario de 2016 que se cubría al comienzo del año, no descontinuaremos y reduciremos la obertura durante el año de cobertura de 2016 a menos que se disponga de un medicamento genérico nuevo y menos costoso o se divulgue nueva información adversa sobre la seguridad o efectividad del medicamento. Otros tipos de cambio de formulario, por ejemplo, la eliminación de un medicamento del formulario, no afectan a los miembros que actualmente toman el medicamento. Estará disponible por el mismo costo compartido a lo largo del resto del año de cobertura para los miembros que actualmente lo toman. Sentimos que es importante que tenga acceso no interrumpido por el resto del año de cobertura a los medicamentos del formulario que le estaban disponibles cuando escogió nuestro plan, a excepción de los casos en los cuales puede ahorrar más dinero o podemos asegurar su seguridad. Si eliminamos medicamentos del formulario, agregamos la autorización previa, límites de cantidad y/o terapia escalonada, restricciones sobre el medicamento o pasamos el medicamento a un nivel más alto de costos compartidos, tenemos que avisar a los miembros afectados del cambio con al menos 60 días de anticipación antes de la efectuación del cambio, o al momento que el miembro pida una reposición del medicamento. En ese momento, el miembro recibe un surtido de 60 días. Si la Administración de Alimentos y Medicamentos considera que un medicamento del formulario no es seguro o el fabricante del medicamento lo quita del mercado, inmediatamente lo quitamos del formulario y avisamos a los miembros que lo toman. El formulario adjunto se actualizó el 25/10/2016. Para información actualizada sobre los medicamentos cubiertos por Clover Health, comuníquese, por favor, con nosotros. Nuestra información de contacto aparece en la portada y contraportada. Cualquier cambio o actualización de formulario se le mandarán por correo. El sitio WEB de Clover Health se actualiza mensualmente con una lista revisada del

¿Cómo utilizo el Formulario? Hay dos maneras de encontrar sus medicamentos en el formulario: Condición Médica El formulario empieza en la página 8. Los medicamentos en el formulario se agrupan en clasificaciones a base del tipo de condición médica para las cuales se usan. Por ejemplo, los medicamentos usados para tratar una condición cardiaca se encuentran en la clasificación, CARDIOVASCULAR. Si sabe para qué se usa el medicamento, busque la clasificación en la lista que empieza en la página 8 a continuación. Entonces, busque el medicamento en esa clasificación. Lista Alfabética Si no sabe en qué clasificación buscar, debe buscar el medicamento en el Índice que empieza en la página 8. El Índice da una lista alfabética de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los medicamentos genéricos figuran en 2

el Índice. Busque en el Índice y encuentre su medicamento. Al lado del medicamento, se ve el número de la página donde se da la información de cobertura. Pase a la página indicada en el Índice y encuentre el nombre del medicamento en la primera columna de la lista. ¿Qué son los medicamentos genéricos? Clover Health cubre medicamentos de marca y medicamentos genéricos. Un medicamento genérico es aprobado por la FDA y lleva el mismo ingrediente activo que el medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los medicamentos de marca. ¿Hay restricciones sobre mi cobertura? Podría haber más requisitos o límites de cobertura en cuanto a ciertos medicamentos. Dichos requisitos y límites podrían incluir:

•   Autorización Previa: Clover Health requiere que Ud. [o su médico] reciban autorización previa para ciertos medicamentos. Eso significa que necesita recibir aprobación de Clover Health antes de surtir la receta. Si no obtiene la aprobación, Clover Haealth posiblemente no le cubra el medicamento. •   Límites de Cantidad: Para ciertos medicamentos, Clover Health limita la cantidad del medicamento que cubre. Por ejemplo, Clover Health proporciona 120 por receta de GLIMEPIRIDE. Podría ser una cantidad adicional al surtido estándar de un mes o tres meses. •   Terapia Escalonada: En dados casos, Clover Health requiere que primero pruebe ciertos medicamentos para tratar una condición médica antes de cubrirle otro medicamento para la condición. Por ejemplo, si tanto el Medicamento A como el Medicamento B tratan la condición médica, Clover Health posiblemente no cubra el Medicamento B sin que pruebe primero el Medicamento A. Si el Medicamento A no funciona, luego Clover Health cubre el Medicamento B. Puede averiguar si el medicamento tiene requisitos adicionales o límites consultando el formulario que empieza en la página 7. También puede recibir más información sobre las restricciones correspondiendo a ciertos medicamentos visitando el sitio WEB. Allí colocamos documentos en línea explicando las restricciones de autorización previa y terapia escalonada. También puede pedir que le enviemos una copia. Le puede pedir a Clover Health una excepción a las restricciones y límites o una lista de otros medicamentos parecidos que tratan la condición de salud. Consulte la sección, “Cómo pido una excepción al Formulario de Clover Health” en la página 4 para información sobre la manera de pedir una excepción. 3

¿Qué hago si mi medicamento no está en el Formulario? Si su medicamento no está en el formulario (lista de medicamentos cubiertos), primero debe comunicarse con el Servicio al Cliente para preguntar si se cubre, o no. Para más información, comuníquese, por favor, con nosotros. Nuestra información de contacto, juntamente con la fecha de la última actualización del formulario, se da en la portada y contraportada. En caso de enterarse que Clover Health no le cubre el medicamento, tiene dos opciones: •   Puede pedir al Servicio al Cliente una lista de medicamentos parecidos cubiertos por Clover Health. Al recibir la lista, enséñesela al médico y pídale que le recete un medicamento parecido cubierto por Clover Health. •   Puede pedir que Clover Health le conceda una excepción y le cubra el medicamento. Consulte la información a continuación de cómo pedir una excepción.

¿Cómo pido una excepción al Formulario de Clover Health? Puede pedirle a Clover Health una excepción a las reglas de cobertura. Hay diferentes clases de excepción que puede pedir. •   Puede pedir que le cubramos el medicamento aun si no figura en el formulario. Si se aprueba, dicho medicamento se cubre a un nivel predeterminado de costos compartidos. No nos puede pedir que le demos el medicamento a un nivel de costos compartidos más bajo. •   Puede pedir que le cubramos el medicamento a un nivel de costos compartidos más bajo si el medicamento no está en el nivel de especialidades. Si se aprueba, se reduce la cantidad que debe pagar por el medicamento. •   Puede pedir que obviemos restricciones de cobertura o límites sobre el medicamento. Por ejemplo, para dados medicamentos, Clover Health limita la cantidad del medicamento que cubrimos. Si su medicamento tiene un límite de cantidad, puede pedir que anulemos el límite y que le cubramos una cantidad mayor. Por lo general, Clover Health sólo aprueba peticiones de excepciones si los medicamentos alternativos están en el formulario del plan, el medicamento de un costo compartido más bajo y las restricciones sobre el uso adicionales no serían tan eficaces para tratar la condición y/o provocarían efectos médicos adversos. Comuníquese con nosotros para pedir una decisión de cobertura inicial sobre una excepción de formulario, nivel de costo compartido o utilización. Cuando pide una excepción de nivel de costos compartidos o restricción de utilización en el formulario, debe entregar una declaración escrita del recetador o médico respaldando la petición. Por lo general, tenemos que tomar una decisión dentro de 72 horas después de recibir la declaración sustentadora del recetador. Puede pedir una excepción acelerada (rápida) si Ud. o el médico creen que la demora 4

de 72 horas para una decisión podría ser de daño grave a la salud. Si se concede la petición de acelerar, tenemos que darle una decisión a más tardar dentro de 24 horas después de recibir la declaración sustentadora de su médico u otro recetador. ¿Qué hago antes de poder hablar con mi médico sobre cambiar mis medicamentos o pedir una excepción? Como miembro nuevo o actual en nuestro plan, posiblemente tome medicamentos que no figuran en el formulario. O, puede estar tomando un medicamento del formulario pero está limitada su capacidad de obtenerlo. Por ejemplo, a lo mejor necesite autorización previa antes de surtir la receta. Hable con el médico a ver si debe cambiar a un medicamento adecuado que cubrimos o pedir una excepción al formulario para que cubramos el medicamento que toma. Mientras hable con el médico para decidir el mejor camino a seguir, posiblemente cubramos el medicamento por los primeros 90 días de su membrecía en el plan en ciertos casos. Para cada uno de los medicamentos que no figuran en la lista o en caso de una capacidad limitada para obtener los medicamento, cubrimos un surtido temporal de 30 días (a menos que tenga una receta escrita por menos días) cuando acude a una farmacia de la red. Después del primer suministro de 30 días, no pagamos los medicamentos, aun si tiene menos de 90 días de membrecía en el plan. Si reside en una instalación de atención a largo plazo, permitiremos que surta la receta hasta que hayamos proporcionado un surtido de transición de por lo menos 91 y hasta 98 días, consecuente con el suministro incremental (a menos que tenga una receta escrita por menos días). Cubrimos más de una reposición de dichos medicamentos durante los primeros 90 días de su membrecía en el plan. Si necesita un medicamento que no está en el formulario o si su capacidad de obtener el medicamento está limitada, y ya han pasado los primeros 90 días de su membrecía en el plan, le cubriremos un surtido de emergencia de 31 días del medicamento (a menos que tenga una receta escrita por menos días) mientras busque una excepción al formulario. Si experimenta un cambio en el sitio donde recibe atención (por ejemplo, si le dan de alta o le internan en una instalación de atención a largo plazo), el médico o la farmacia pueden pedir un permiso único de receta. El permiso único le proporciona cobertura temporal (un surtido de hasta 30 días) para el/los medicamento(s) correspondiente(s). Para más información Para más información detallada sobre la cobertura de medicamentos recetados de Clover Health, repase, por favor, la Evidencia de Cobertura y otros materiales del plan. En caso de preguntas sobre Clover Health, comuníquese con nosotros, por favor. Nuestra información de contacto, juntamente con la fecha de la última actualización del formulario, se da en la portada y contraportada. En caso de preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame, por favor, a Medicare al 1-800-MEDICARE (1-800-633-4227) 24 horas al día, 7 días a la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O, visite http://www.medicare.gov. 5

El Formulario de Clover Health El formulario a continuación lleva información sobre los medicamentos cubiertos por Clover Health. Si tiene problemas buscando su medicamento en la lista, pase al Índice que empieza en la página 92. La primera columna de la tabla da el nombre del medicamento. Los nombres de medicamentos de marca se escriben con mayúsculas (p.ej., ADVAIR DISKUS) y los medicamentos genéricos se escriben con minúsculas en bastardilla (p.ej., omeprazole). La información en la columna de Requisitos/Límites le avisa de cualquier requisito especial respecto a la cobertura del medicamento que haya puesto Clover Health. Se usan las siguientes abreviaturas: B/D: Parte B versus Parte D. Este medicamento recetado tienen un requisito de autorización previa administrativa de la Parte B versus Parte D. El medicamento lo pueden cubrir la Parte B o D de Medicare, de acuerdo con las circunstancias. Posiblemente sea necesario presentar información describiendo el uso y el lugar donde se usa el medicamento para determinar. LA: Acceso Limitado. Dichas recetas están disponibles únicamente en dadas farmacias. Para más información, consulte el Directorio de Farmacias o comuníquese con Servicio al Cliente de Clover Health al (888) 657-1207 o, para los usuarios de TTY, al 771 (llamada gratuita), 7 días a la semana, 24 horas al día. NM: No está disponible por pedido de correo. PA: Autorización Previa. Clover Health requiere que Ud. o su médico obtengan autorización previa para ciertos medicamentos. Eso significa que necesita recibir aprobación de Clover Health antes de surtir la receta. Si no recibe la aprobación, posiblemente Clover Health no le cubra el medicamento. QL: Límites de Cantidad. Para ciertos medicamentos, Clover Health limita la cantidad que cubre. Por ejemplo, Clover Health proporciona 120 de CLIMEPIRIDE. Esta cantidad puede ser adicional al surtido estándar de un mes o tres meses. ST: Terapia Escalonada. En dados casos, Clover Health requiere que primero pruebe ciertos medicamentos para tratar una condición médica antes de cubrirle otro medicamento para la condición. Por ejemplo, si tanto el Medicamento A como el Medicamento B tratan la condición médica, Clover Health posiblemente no cubra el Medicamento B sin que pruebe primero el Medicamento A. Si el Medicamento A no funciona, luego Clover Health cubre el Medicamento B. Niveles de copago de medicamentos Este formulario comprensivo de 2016 es una lista de medicamentos de marca y medicamentos genéricos. El Formulario de Clover Health de 2016 cubre la mayoría de los medicamentos identificados por Medicare como medicamentos de la Parte D, y el copago puede variar según el nivel en que se encuentra el medicamento. 6

A continuación se dan los niveles de copago por los medicamentos recetados cubiertos. Los porcentajes de copago y coaseguro para cada nivel varían según el plan. Consulte el resumen de Beneficios o la Evidencia de cobertura para ver las cantidades correspondientes de copago y coaseguro.

Nivel de Copago Nivel 1 Nivel 2 Nivel 3 Nivel 4 Nivel 5

Tipo de Medicamento Medicamentos Genéricos Preferidos Medicamentos Genéricos Medicamentos de Marca Preferidos Medicamentos de Marco no Preferidos Medicamentos de Especialidad

Clover Health, en ciertos casos, combina medicamentos genéricos de un costo superior en los niveles de medicamentos de marca. Consulte la lista de medicamentos para determinar el nivel de cobertura para cada medicamento que toma.

7

BG_CY16_Gen_Strat_5T_STND eff 11/01/2016 Drug Name

Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol tab

1

colchicine w/ probenecid

3

COLCRYS

3

probenecid

3

ULORIC

3

ST

celecoxib CAPS

4

QL (60 caps / 30 days)

diclofenac potassium

2

diclofenac sodium TB24

3

diclofenac sodium TBEC

2

diflunisal

3

etodolac CAPS; TABS

3

etodolac TB24

4

flurbiprofen TABS

2

ibuprofen SUSP

3

ibuprofen TABS 400mg, 600mg, 800mg

1

ketoprofen CAPS

2

MELOXICAM SUSP

4

meloxicam TABS

1

nabumetone TABS

2

naproxen SUSP

3

naproxen TABS

1

naproxen TBEC

2

naproxen sodium TABS 275mg, 550mg

1

piroxicam CAPS

3

QL (120 tabs / 30 days)

NSAIDS

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

8  

Drug Name sulindac TABS

Drug Tier

Requirements/Limits

2

OPIOID ANALGESICS acetaminophen w/ codeine SOLN

2

QL (5000 mL / 30 days)

acetaminophen w/ codeine TABS

2

QL (400 tabs / 30 days)

butorphanol tartrate SOLN 1mg/ml, 2mg/ml 4 nalbuphine hcl SOLN

4

tramadol hcl TABS

2

QL (240 tabs / 30 days)

tramadol-acetaminophen

3

QL (240 tabs / 30 days)

DURAMORPH

3

B/D

endocet

3

QL (360 tabs / 30 days)

fentanyl citrate LPOP

5

QL (120 lozenges / 30 days), PA

fentanyl patch 12 mcg/hr

4

QL (10 patches / 30 days)

fentanyl patch 25 mcg/hr

4

QL (10 patches / 30 days)

fentanyl patch 50 mcg/hr

4

QL (10 patches / 30 days), PA

fentanyl patch 75 mcg/hr

4

QL (10 patches / 30 days), PA

fentanyl patch 100 mcg/hr

4

QL (10 patches / 30 days), PA

FENTORA

5

QL (120 tabs / 30 days), PA

hydroco/apap tab 5-325mg

2

QL (360 tabs / 30 days)

hydroco/apap tab 7.5-325

2

QL (360 tabs / 30 days)

hydroco/apap tab 10-325mg

2

QL (360 tabs / 30 days)

hydrocodone-acetaminophen 7.5-325 mg/15ml

4

QL (5400 mL / 30 days)

hydrocodone-ibuprofen tab 7.5-200 mg

3

QL (150 tabs / 30 days)

hydromorphon inj 10mg/ml

4

B/D

hydromorphone hcl LIQD

4

OPIOID ANALGESICS, CII

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

9  

Drug Name

Drug Tier

Requirements/Limits

hydromorphone hcl TABS

3

QL (270 tabs / 30 days)

lorcet hd tab 10-325mg

2

QL (360 tabs / 30 days)

lorcet plus tab 7.5-325

2

QL (360 tabs / 30 days)

lorcet tab 5-325mg

2

QL (360 tabs / 30 days)

lortab tab 5-325mg

2

QL (360 tabs / 30 days)

lortab tab 7.5-325

2

QL (360 tabs / 30 days)

lortab tab 10-325mg

2

QL (360 tabs / 30 days)

methadone hcl CONC

3

QL (120 mL / 30 days)

methadone hcl SOLN 5mg/5ml, 10mg/5ml

3

QL (600 mL / 30 days)

methadone hcl TABS

2

QL (240 tabs / 30 days)

morphine ext-rel tab 15mg, 30mg, 60mg, 100mg

4

QL (90 tabs / 30 days)

morphine ext-rel tab 200mg

4

QL (60 tabs / 30 days)

MORPHINE SUL INJ 1MG/ML

3

B/D

MORPHINE SUL INJ 4MG/ML

3

B/D

MORPHINE SUL INJ 10MG/ML

3

B/D

MORPHINE SUL INJ 15MG/ML

3

B/D

morphine sulfate CP24 10mg, 20mg, 30mg, 4 50mg, 60mg

QL (60 caps / 30 days)

morphine sulfate CP24 80mg, 100mg

5

QL (60 caps / 30 days)

MORPHINE SULFATE SOLN 2mg/ml, 8mg/ml

3

B/D

morphine sulfate SOLN .5mg/ml, 1mg/ml, 4mg/ml, 8mg/ml

3

B/D

MORPHINE SULFATE TABS

3

QL (180 tabs / 30 days)

morphine sulfate beads

4

QL (60 caps / 30 days)

MORPHINE SULFATE ORAL SOL

3

oxycodone hcl CAPS

4

oxycodone hcl CONC

4

OXYCODONE HCL SOLN

4

QL (180 caps / 30 days)

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

10  

Drug Name

Drug Tier

Requirements/Limits

oxycodone hcl TABS

3

QL (180 tabs / 30 days)

oxycodone w/ acetaminophen 2.5-325mg

3

QL (360 tabs / 30 days)

oxycodone w/ acetaminophen 5-325mg

3

QL (360 tabs / 30 days)

oxycodone w/ acetaminophen 7.5-325mg

3

QL (360 tabs / 30 days)

oxycodone w/ acetaminophen 10-325mg

3

QL (360 tabs / 30 days)

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

3

QL (1800 mL / 30 days)

lidocaine hcl (local anesth.)

2

B/D

lidocaine inj 0.5%

2

B/D

lidocaine inj 1%

2

B/D

lidocaine inj 1.5%

2

B/D

lidocaine inj 2%

2

B/D

ANESTHETICS LOCAL ANESTHETICS

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN

3

gentamicin in saline

2

gentamicin sulfate SOLN

2

neomycin sulfate TABS

3

paromomycin sulfate CAPS

4

streptomycin sulfate SOLR

4

sulfadiazine TABS

4

tobramycin NEBU

5

tobramycin sulfate SOLN

3

tobramycin sulfate SOLR

4

B/D, NM

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA

4

ALINIA

4

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

11  

Drug Name

Drug Tier

atovaquone SUSP

5

AZACTAM/DEX INJ 1GM

4

AZACTAM/DEX INJ 2GM

5

aztreonam

3

BILTRICIDE

3

CAYSTON

5

clindamycin cap 75mg

1

clindamycin cap 300 mg

1

clindamycin hcl cap 150 mg

1

clindamycin phosphate SOLN

2

clindamycin phosphate in d5w

3

clindamycin phosphate inj

2

clindamycin soln

4

colistimethate sodium SOLR

4

CUBICIN

5

dapsone TABS

3

daptomycin

5

DARAPRIM

4

emverm

4

imipenem-cilastatin

4

INVANZ

4

ivermectin TABS

3

linezolid SOLN

5

LINEZOLID SUSR; TABS

5

LINEZOLID IN SODIUM CHLORIDE

5

meropenem

4

methenamine hippurate

3

metronidazole TABS

2

metronidazole in nacl

2

Requirements/Limits

NM, LA, PA

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

12  

Drug Name

Drug Tier

Requirements/Limits

NEBUPENT

4

B/D

nitrofurantoin macrocrystal 50mg, 100mg

4

PA; PA applies if 65 years and older after a 90 day supply in a calendar year

nitrofurantoin monohyd macro

4

PA; PA applies if 65 years and older after a 90 day supply in a calendar year

PENTAM 300

4

SIVEXTRO

5

sulfamethoxazole-trimethoprim SUSP

3

sulfamethoxazole-trimethoprim TABS

1

sulfamethoxazole-trimethoprim inj

4

SYNERCID

5

trimethoprim TABS

2

TYGACIL

5

vancomycin hcl CAPS

5

vancomycin hcl SOLR

3

VANCOMYCIN IN NACL

4

ZYVOX TABS

5

ANTIFUNGALS ABELCET

5

B/D

AMBISOME

5

B/D

amphotericin b SOLR

4

B/D

CANCIDAS

5

fluconazole SUSR

3

fluconazole TABS

2

fluconazole in dextrose

3

fluconazole in nacl

3

fluconazole in nacl 0.9% inj

3

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

13  

Drug Name

Drug Tier

Requirements/Limits

flucytosine CAPS

5

griseofulvin microsize SUSP

3

griseofulvin microsize TABS

4

griseofulvin ultramicrosize

4

itraconazole CAPS

4

PA

ketoconazole TABS

3

PA

MYCAMINE

5

NOXAFIL SUSP; TBEC

5

nystatin TABS

3

terbinafine hcl TABS

2

voriconazole SOLR

4

voriconazole SUSR; TABS

5

QL (90 tabs / 365 days)

ANTIMALARIALS atovaquone-proguanil hcl

4

chloroquine phosphate TABS

3

COARTEM

4

mefloquine hcl

3

PRIMAQUINE PHOSPHATE

3

quinine sulfate CAPS

4

PA

ANTIRETROVIRAL AGENTS abacavir sulfate

3

APTIVUS

5

CRIXIVAN

4

didanosine

4

EDURANT

5

EMTRIVA

3

FUZEON

5

INTELENCE 25mg

4

INTELENCE 100mg, 200mg

5

NM

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

14  

Drug Name

Drug Tier

INVIRASE

5

ISENTRESS CHEW 25mg

3

ISENTRESS CHEW 100mg

5

ISENTRESS PACK

3

ISENTRESS TABS

5

lamivudine

3

LEXIVA SUSP

4

LEXIVA TABS

5

NEVIRAPINE SUSP

4

nevirapine TB24

4

nevirapine tab 200mg

3

NORVIR

3

PREZISTA SUSP

5

PREZISTA TABS 75mg, 150mg

3

PREZISTA TABS 600mg, 800mg

5

RESCRIPTOR

4

RETROVIR IV INFUSION

3

REYATAZ

5

SELZENTRY

5

stavudine

4

SUSTIVA CAPS

3

SUSTIVA TABS

5

TIVICAY 10mg

3

TIVICAY 25mg, 50mg

5

TYBOST

3

VIDEX PEDIATRIC

4

VIRACEPT

5

VIRAMUNE XR 100mg

4

VIREAD

5

Requirements/Limits

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

15  

Drug Name

Drug Tier

VITEKTA

5

ZIAGEN SOLN

3

zidovudine

3

Requirements/Limits

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine

5

ATRIPLA

5

COMPLERA

5

DESCOVY

5

EPZICOM

5

EVOTAZ

5

GENVOYA

5

KALETRA SOL

5

KALETRA TAB 100-25MG

3

KALETRA TAB 200-50MG

5

lamivudine-zidovudine

5

ODEFSEY

5

PREZCOBIX

5

STRIBILD

5

TRIUMEQ

5

TRUVADA TAB 100-150

5

QL (60 tabs / 30 days)

TRUVADA TAB 133-200

5

QL (30 tabs / 30 days)

TRUVADA TAB 167-250

5

QL (30 tabs / 30 days)

TRUVADA TAB 200-300

5

QL (30 tabs / 30 days)

ANTITUBERCULAR AGENTS CAPASTAT SULFATE

4

cycloserine CAPS

5

ethambutol hcl TABS

3

isoniazid TABS

1

isoniazid inj 100 mg/ml

3

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

16  

Drug Name

Drug Tier

isoniazid syp 50mg/5ml

4

paser d/r

3

PRIFTIN

4

pyrazinamide TABS

4

rifabutin

4

rifampin CAPS

3

rifampin SOLR

4

RIFATER

4

SIRTURO

5

TRECATOR

4

Requirements/Limits

LA, PA

ANTIVIRALS acyclovir CAPS; TABS

2

acyclovir SUSP

4

acyclovir sodium SOLN

4

B/D

acyclovir sodium SOLR 500mg

4

B/D

adefovir dipivoxil

5

BARACLUDE SOLN

3

DAKLINZA

5

entecavir

5

EPIVIR HBV SOLN

4

famciclovir TABS

4

ganciclovir inj 500mg

3

B/D

HARVONI

5

NM, PA

lamivudine (hbv)

4

moderiba 800 dose pack

5

NM

moderiba pak 600/day

5

NM

moderiba pak 1000/day

5

NM

MODERIBA PAK 1200/DAY

5

NM

moderiba tab 200mg

3

NM

NM, PA

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

17  

Drug Name

Drug Tier

Requirements/Limits

PEG-INTRON REDIPEN

5

NM, PA

PEGASYS

5

NM, PA

PEGASYS PROCLICK

5

NM, PA

PEGINTRON

5

NM, PA

REBETOL SOLN

5

NM

RELENZA DISKHALER

3

ribapak mis 600/day

5

NM

ribasphere CAPS

3

NM

ribasphere TABS 200mg

3

NM

ribasphere TABS 400mg

4

NM

ribasphere TABS 600mg

5

NM

ribasphere ribapak 800

5

NM

ribasphere ribapak 1000

5

NM

ribasphere ribapak 1200

5

NM

ribavirin cap 200mg

3

NM

ribavirin tab 200mg

3

NM

rimantadine hydrochloride

3

SOVALDI

5

TAMIFLU

3

TYZEKA

5

valacyclovir hcl TABS

3

VALCYTE SOLR

5

valganciclovir hcl

5

NM, PA

CEPHALOSPORINS cefaclor CAPS

3

cefaclor SUSR

4

cefaclor er tab 500mg

4

cefadroxil CAPS

1

cefadroxil SUSR

3

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

18  

Drug Name

Drug Tier

cefadroxil TABS

4

cefazolin in dextrose 1gm/50ml-5%

3

CEFAZOLIN IN DEXTROSE 2GM/100ML4%

3

cefazolin inj

3

cefazolin sodium 1gm, 20gm

3

cefdinir CAPS

3

cefdinir SUSR

4

cefepime hcl

4

cefixime

3

cefotaxime sodium 1gm, 2gm, 500mg

4

cefoxitin sodium

4

cefpodoxime proxetil

4

cefprozil

3

ceftazidime

4

CEFTAZIDIME/DEXTROSE

4

Requirements/Limits

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 3 250mg, 500mg cefuroxime axetil

3

cefuroxime sodium 1.5gm, 7.5gm, 750mg

3

cephalexin CAPS 250mg, 500mg

1

cephalexin SUSR

3

SUPRAX CAPS

3

suprax CHEW

4

SUPRAX SUSR 500mg/5ml

3

tazicef SOLR

4

tazicef vial

4

TEFLARO

4

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK

3

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

19  

Drug Name

Drug Tier

azithromycin SOLR; SUSR

3

azithromycin TABS

1

clarithromycin TABS

4

clarithromycin er

3

clarithromycin for susp

4

DIFICID

5

e.e.s.

4

ery-tab

4

erythrocin lactobionate

4

erythrocin stearate

4

erythromycin base

4

erythromycin cap 250mg ec

4

erythromycin ethylsuccinate

4

Requirements/Limits

FLUOROQUINOLONES ciprofloxacin SUSR

4

ciprofloxacin er

4

ciprofloxacin hcl tab

1

ciprofloxacin in d5w

4

ciprofloxacin inj 200mg/20ml

4

ciprofloxacin inj 400mg/40ml

4

levofloxacin TABS

1

levofloxacin in d5w

3

levofloxacin inj 25mg/ml

4

levofloxacin oral soln 25 mg/ml

4

PENICILLINS amoxicillin CAPS; SUSR; TABS

1

amoxicillin CHEW

2

amoxicillin & pot clavulanate CHEW; SUSR 3 amoxicillin & pot clavulanate TABS

2

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

20  

Drug Name

Drug Tier

amoxicillin & pot clavulanate TB12

4

ampicillin & sulbactam sodium

4

ampicillin cap

1

ampicillin inj

4

ampicillin sodium

4

ampicillin sus

3

BICILLIN L-A

4

dicloxacillin sodium

3

nafcillin sodium 1gm

4

nafcillin sodium 2gm, 10gm

5

oxacillin sodium 1gm, 2gm

4

oxacillin sodium 10gm

5

PENICILLIN G POT IN DEXTROSE

4

penicillin g procaine

4

penicillin g sodium

4

penicillin gk inj 5mu

4

penicillin gk inj 20mu

4

penicillin v potassium

1

pfizerpen-g inj 5mu

4

piperacillin sodium-tazobactam sodium

4

Requirements/Limits

TETRACYCLINES doxy

4

doxycycline (monohydrate) CAPS 50mg, 100mg

2

doxycycline (monohydrate) TABS

3

doxycycline hyclate CAPS; TABS

3

doxycycline hyclate SOLR

4

minocycline hcl CAPS

2

morgidox

3

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

21  

Drug Name

Drug Tier

Requirements/Limits

BENDEKA

5

B/D, NM

BICNU

4

B/D

BUSULFEX

5

B/D

CYCLOPHOSPHAMIDE CAPS

4

B/D

cyclophosphamide SOLR 1gm, 500mg

5

B/D

cyclophosphamide SOLR 2gm

4

B/D

dacarbazine

3

B/D

EMCYT

4

GLEOSTINE

4

HEXALEN

5

IFEX INJ 3GM

4

B/D

ifosfamide inj 1gm

4

B/D

ifosfamide inj 1gm/20ml

3

B/D

IFOSFAMIDE INJ 3GM

4

B/D

ifosfamide inj 3gm/60ml

3

B/D

LEUKERAN

4

melphalan hcl

5

B/D, NM

MUSTARGEN

4

B/D

TREANDA

5

B/D, NM

daunorubicin hcl

3

B/D

doxorubicin hcl 50mg

3

B/D

doxorubicin hcl liposomal inj 2mg/ml

5

B/D

doxorubicin inj 50mg

3

B/D

epirubicin hcl

4

B/D

idarubicin hcl

5

B/D

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS

ANTHRACYCLINES

ANTIBIOTICS PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

22  

Drug Name

Drug Tier

Requirements/Limits

bleomycin sulfate

3

B/D

mitomycin SOLR

4

B/D

adrucil

3

B/D

adrucil inj

3

B/D

ALIMTA

5

B/D

azacitidine

5

B/D, NM

cladribine

5

B/D

cytarabine 20mg/ml

3

B/D

fludarabine phosphate

4

B/D

fluorouracil SOLN

3

B/D

GEMCITABINE HCL SOLN

5

B/D

gemcitabine hcl SOLR

5

B/D

mercaptopurine TABS

3

METHOTREXATE SODIUM 50mg/2ml

2

B/D

methotrexate sodium 50mg/2ml, 100mg/4ml, 2 200mg/8ml, 250mg/10ml

B/D

methotrexate sodium inj

2

B/D

NIPENT

5

B/D

PURIXAN

5

NM

TABLOID

4

ANTIMETABOLITES

ANTIMITOTIC, TAXOIDS ABRAXANE

5

B/D

DOCETAXEL CONC 20mg/ml, 80mg/4ml

5

B/D

docetaxel CONC 140mg/7ml

5

B/D

DOCETAXEL SOLN 20mg/2ml

4

B/D

DOCETAXEL SOLN 160mg/16ml, 200mg/20ml

5

B/D

DOCETAXEL SOLN 80MG/8ML

5

B/D

paclitaxel

4

B/D

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

23  

Drug Name

Drug Tier

Requirements/Limits

vinblastine sulfate

3

B/D

vincasar

2

B/D

vincristine sulfate

2

B/D

vinorelbine tartrate

3

B/D

AVASTIN

5

B/D, NM, LA

BELEODAQ

5

NM, PA

ERIVEDGE

5

NM, LA, PA

FARYDAK

5

NM, LA, PA

HERCEPTIN

5

B/D, NM

IBRANCE

5

NM, LA, PA

ISTODAX

5

B/D, NM

KADCYLA

5

B/D, NM

KEYTRUDA

5

NM, PA

LYNPARZA

5

NM, LA, PA

NINLARO

5

NM, PA

PROLEUKIN

5

B/D, NM

RITUXAN

5

NM, LA, PA

TECENTRIQ

5

NM, LA, PA

VELCADE

5

B/D, NM

VENCLEXTA 10mg, 50mg

4

NM, LA, PA

VENCLEXTA 100mg

5

NM, LA, PA

VENCLEXTA STARTING PACK

5

NM, LA, PA

YERVOY

5

NM, PA

ZOLINZA

5

NM, PA

ANTIMITOTIC, VINCA ALKALOIDS

BIOLOGIC RESPONSE MODIFIERS

HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS

2

bicalutamide

3

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

24  

Drug Name

Drug Tier

Requirements/Limits

DEPO-PROVERA INJ 400/ML

4

B/D

exemestane

4

FARESTON

5

FASLODEX

5

flutamide

4

hydroxyprogesterone caproate (antineoplastic)

4

letrozole TABS

3

leuprolide inj 1mg/0.2

3

NM, PA

LUPR DEP-PED INJ 11.25MG (3-MONTH)

5

NM, PA

LUPRON DEP-PED INJ 7.5MG

5

NM, PA

LUPRON DEP-PED INJ 11.25MG

5

NM, PA

LUPRON DEP-PED INJ 15MG

5

NM, PA

LUPRON DEP-PED INJ 30MG (3-MONTH) 5

NM, PA

LUPRON DEPOT 3.75mg

5

NM, PA

LYSODREN

3

megestrol ac sus 40mg/ml

4

PA; PA if 65 years and older

megestrol ac tab 20mg

4

PA; PA if 65 years and older

megestrol ac tab 40mg

4

PA; PA if 65 years and older

MEGESTROL SUS 625MG/5ML

5

PA

NILANDRON

5

nilutamide

5

SOLTAMOX

4

tamoxifen citrate TABS

1

TRELSTAR DEP INJ 3.75MG

5

NM, PA

TRELSTAR LA INJ 11.25MG

5

NM, PA

XTANDI

5

NM, LA, PA

B/D

B/D

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

25  

Drug Name

Drug Tier

Requirements/Limits

5

NM, LA, PA

AFINITOR

5

NM, PA

AFINITOR DISPERZ

5

NM, PA

ALECENSA

5

NM, LA, PA

BOSULIF

5

NM, PA

CABOMETYX

5

NM, LA, PA

CAPRELSA

5

NM, LA, PA

COMETRIQ

5

NM, LA, PA

COTELLIC

5

NM, LA, PA

GILOTRIF TAB 20MG

5

NM, LA, PA

GILOTRIF TAB 30MG

5

NM, LA, PA

GILOTRIF TAB 40MG

5

NM, LA, PA

ICLUSIG

5

NM, LA, PA

imatinib mesylate

5

NM, PA

IMBRUVICA CAP 140MG

5

NM, LA, PA

INLYTA

5

NM, LA, PA

IRESSA

5

NM, LA, PA

JAKAFI

5

NM, LA, PA

LENVIMA 8 MG DAILY DOSE

5

NM, LA, PA

LENVIMA 10 MG DAILY DOSE

5

NM, LA, PA

LENVIMA 14 MG DAILY DOSE

5

NM, LA, PA

LENVIMA 18 MG DAILY DOSE

5

NM, LA, PA

LENVIMA 20 MG DAILY DOSE

5

NM, LA, PA

LENVIMA 24 MG DAILY DOSE

5

NM, LA, PA

MEKINIST

5

NM, LA, PA

NEXAVAR

5

NM, LA, PA

SPRYCEL

5

NM, PA

STIVARGA

5

NM, LA, PA

ZYTIGA KINASE INHIBITORS

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

26  

Drug Name

Drug Tier

Requirements/Limits

SUTENT

5

NM, PA

TAFINLAR

5

NM, LA, PA

TAGRISSO

5

NM, LA, PA

TARCEVA

5

NM, LA, PA

TASIGNA

5

NM, PA

TYKERB

5

NM, LA, PA

VOTRIENT

5

NM, LA, PA

XALKORI

5

NM, LA, PA

ZELBORAF

5

NM, LA, PA

ZYDELIG

5

NM, LA, PA

ZYKADIA

5

NM, LA, PA

bexarotene

5

NM, PA

DROXIA

3

hydroxyurea CAPS

3

LONSURF

5

NM, PA

MATULANE

5

LA

mitoxantrone hcl

3

B/D, NM

ODOMZO

5

NM, LA, PA

POMALYST CAP 1MG

5

NM, LA, PA

POMALYST CAP 2MG

5

NM, LA, PA

POMALYST CAP 3MG

5

NM, LA, PA

POMALYST CAP 4MG

5

NM, LA, PA

SYLATRON KIT 200MCG

5

NM, PA

SYLATRON KIT 300MCG

5

NM, PA

SYLATRON KIT 600MCG

5

NM, PA

SYNRIBO

5

NM, PA

tretinoin (chemotherapy)

5

TRISENOX

5

MISCELLANEOUS

B/D

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

27  

Drug Name

Drug Tier

Requirements/Limits

carboplatin

4

B/D

cisplatin

3

B/D

oxaliplatin

5

B/D

amifostine crystalline

5

B/D

dexrazoxane 250mg

5

B/D

ELITEK

5

B/D

FUSILEV

5

B/D, NM

leucovorin calcium SOLR

4

B/D

leucovorin calcium TABS

3

leucovorin calcium for inj 500 mg

4

B/D

levoleucovorin calcium

5

B/D, NM

mesna

4

B/D

MESNEX TABS

5

PLATINUM-BASED AGENTS

PROTECTIVE AGENTS

TOPOISOMERASE INHIBITORS etoposide SOLN 500mg/25ml

3

B/D

irinotecan inj 40mg/2ml

4

B/D

irinotecan inj 100/5ml

4

B/D

irinotecan inj 500mg/25ml

4

B/D

toposar 1gm/50ml

3

B/D

topotecan hcl SOLR

5

B/D

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5- 1 10 mg

QL (30 caps / 30 days)

amlodipine besylate-benazepril hcl cap 5-10 1 mg

QL (30 caps / 30 days)

amlodipine besylate-benazepril hcl cap 5-20 1 mg

QL (30 caps / 30 days)

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

28  

Drug Name

Drug Tier

Requirements/Limits

amlodipine besylate-benazepril hcl cap 5-40 1 mg

QL (30 caps / 30 days)

amlodipine besylate-benazepril hcl cap 10-20 1 mg

QL (30 caps / 30 days)

amlodipine besylate-benazepril hcl cap 10-40 1 mg benazepril & hydrochlorothiazide

1

captopril & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide

1

fosinopril sodium & hydrochlorothiazide

1

lisinopril & hydrochlorothiazide

1

moexipril-hydrochlorothiazide

1

quinapril-hydrochlorothiazide

1

ACE INHIBITORS benazepril hcl TABS

1

captopril TABS

1

enalapril maleate TABS

1

fosinopril sodium

1

lisinopril TABS

1

moexipril hcl

1

perindopril erbumine

1

quinapril hcl

1

ramipril

1

trandolapril

1

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone

4

spironolactone TABS

1

ALPHA BLOCKERS doxazosin mesylate 1mg, 2mg, 4mg

3

doxazosin mesylate 8mg

3

QL (30 tabs / 30 days)

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

29  

Drug Name

Drug Tier

prazosin hcl

2

terazosin hcl

1

Requirements/Limits

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab 5-160 mg 1

QL (30 tabs / 30 days)

amlodipine besylate-valsartan tab 5-320 mg 1

QL (30 tabs / 30 days)

amlodipine besylate-valsartan tab 10-160 mg 1

QL (30 tabs / 30 days)

amlodipine besylate-valsartan tab 10-320 mg 1 amlodipine-valsartan-hydrochlorothiazide 5- 1 160-12.5mg

QL (30 tabs / 30 days)

amlodipine-valsartan-hydrochlorothiazide 5- 1 160-25mg

QL (60 tabs / 30 days)

amlodipine-valsartan-hydrochlorothiazide 10- 1 160-12.5mg

QL (30 tabs / 30 days)

amlodipine-valsartan-hydrochlorothiazide 10- 1 160-25mg

QL (30 tabs / 30 days)

amlodipine-valsartan-hydrochlorothiazide 10- 1 320-25mg AZOR 10-40MG

3

AZOR TAB 5-20MG

3

QL (30 tabs / 30 days)

AZOR TAB 5-40MG

3

QL (30 tabs / 30 days)

AZOR TAB 10-20MG

3

QL (30 tabs / 30 days)

BENICAR HCT 40-25MG

3

BENICAR HCT TAB 20-12.5MG

3

BENICAR HCT TAB 40-12.5MG

3

ENTRESTO

4

irbesartan-hydrochlorothiazide

1

losartan-hydrochlorothiazide

1

TRIBENZOR TAB 20-5-12.5MG

3

QL (30 tabs / 30 days)

TRIBENZOR TAB 40-5-12.5MG

3

QL (30 tabs / 30 days)

TRIBENZOR TAB 40-5-25MG

3

QL (30 tabs / 30 days)

TRIBENZOR TAB 40-10-12.5

3

QL (30 tabs / 30 days)

PA

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

30  

Drug Name

Drug Tier

TRIBENZOR TAB 40-10-25MG

3

valsartan & hctz tab 80-12.5mg

1

valsartan & hctz tab 160-12.5mg

1

valsartan & hctz tab 160-25mg

1

valsartan & hctz tab 320-12.5mg

1

valsartan & hctz tab 320-25mg

1

Requirements/Limits

ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR

3

irbesartan

1

losartan potassium

1

valsartan

1

ANTIARRHYTHMICS amiodarone hcl SOLN

2

amiodarone hcl TABS 100mg, 400mg

4

amiodarone hcl TABS 200mg

1

disopyramide phosphate

4

PA; PA if 65 years and older

dofetilide

4

NM

flecainide acetate

3

mexiletine hcl

4

MULTAQ

4

NORPACE CR

4

pacerone 100mg, 400mg

4

pacerone 200mg

1

propafenone hcl CP12

4

propafenone hcl TABS

3

propafenone hcl 12hr CP12

4

propafenone hcl 12hr TABS

3

quinidine gluconate TBCR

4

PA; PA if 65 years and older

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

31  

Drug Name

Drug Tier

quinidine sulfate TABS

2

sorine

2

sotalol hcl

2

sotalol hcl (afib/afl)

3

TIKOSYN

4

Requirements/Limits

NM

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium TABS

1

QL (30 tabs / 30 days)

CRESTOR

1

QL (30 tabs / 30 days)

lovastatin 10mg

1

QL (30 tabs / 30 days)

lovastatin 20mg

1

QL (120 tabs / 30 days)

lovastatin 40mg

1

QL (60 tabs / 30 days)

pravastatin sodium

1

QL (30 tabs / 30 days)

rosuvastatin calcium

1

QL (30 tabs / 30 days)

simvastatin TABS

1

QL (30 tabs / 30 days)

ANTILIPEMICS, MISCELLANEOUS cholestyramine

4

cholestyramine light

4

choline fenofibrate cap dr 45 mg

4

choline fenofibrate cap dr 135 mg

4

colestipol hcl GRAN; PACK

4

colestipol hcl TABS

3

fenofibrate TABS 48mg, 145mg

4

fenofibrate TABS 54mg, 160mg

3

fenofibrate micronized 67mg, 134mg, 200mg3 gemfibrozil TABS

2

JUXTAPID

5

NM, LA, PA

KYNAMRO

5

NM, PA

niacin er (antihyperlipidemic) 500mg

4

QL (90 tabs / 30 days)

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

32  

Drug Name

Drug Tier

niacin er (antihyperlipidemic) 750mg, 1000mg

4

niacor

3

omega-3-acid ethyl esters

4

PRALUENT

5

prevalite

4

VASCEPA 1gm

4

WELCHOL

3

ZETIA TAB 10MG

3

Requirements/Limits

NM, PA

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone

3

bisoprolol & hydrochlorothiazide

1

metoprolol & hydrochlorothiazide

3

propranolol & hydrochlorothiazide

3

BETA-BLOCKERS acebutolol hcl CAPS

2

atenolol TABS

1

bisoprolol fumarate

3

BYSTOLIC

4

carvedilol

1

labetalol hcl TABS

3

metoprolol succinate 25mg, 50mg

3

QL (60 tabs / 30 days)

metoprolol succinate 100mg

3

QL (45 tabs / 30 days)

metoprolol succinate 200mg

3

metoprolol tartrate SOLN

3

metoprolol tartrate TABS 25mg, 50mg, 100mg

1

nadolol TABS

4

pindolol

3

propranolol cap er

4

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

33  

Drug Name

Drug Tier

propranolol hcl SOLN

3

propranolol hcl TABS

1

timolol maleate TABS

3

Requirements/Limits

CALCIUM CHANNEL BLOCKERS afeditab cr 30mg

3

QL (60 tabs / 30 days)

afeditab cr 60mg

3

amlodipine besylate TABS 2.5mg, 5mg

1

amlodipine besylate TABS 10mg

1

cartia xt cap 120/24hr

3

cartia xt cap 180/24hr

3

cartia xt cap 240/24hr

3

cartia xt cap 300/24hr

3

dilt-xr cap

3

diltiazem cap

3

diltiazem cap 120mg/24hr

3

diltiazem cap 240mg/24hr

3

diltiazem cap er/12hr

3

diltiazem hcl SOLN; TABS

2

diltiazem hcl coated beads CP24

3

felodipine 2.5mg

3

QL (30 tabs / 30 days)

felodipine 5mg

3

QL (60 tabs / 30 days)

felodipine 10mg

3

isradipine

4

nicardipine hcl CAPS

4

nifedical 30mg

3

nifedical 60mg

3

nifedipine TB24 30mg

3

nifedipine TB24 60mg, 90mg

3

nifedipine er 30mg

3

QL (45 tabs / 30 days)

QL (30 tabs / 30 days)

QL (60 tabs / 30 days)

QL (30 tabs / 30 days)

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

34  

Drug Name

Drug Tier

nifedipine er 60mg, 90mg

3

nimodipine CAPS

5

NYMALIZE

5

taztia xt

3

verapamil cap er 100mg, 120mg, 180mg, 200mg, 240mg, 300mg

3

VERAPAMIL CAP ER 360mg

3

verapamil hcl SOLN

4

verapamil hcl TABS

1

verapamil hcl TBCR

2

verapamil tab er

2

Requirements/Limits

DIGITALIS GLYCOSIDES digitek .25mg

3

PA; PA if 65 years and older

digitek .125mg

3

QL (30 tabs / 30 days)

digox 125mcg

3

QL (30 tabs / 30 days)

digox 250mcg

3

PA; PA if 65 years and older

digoxin TABS 125mcg

3

QL (30 tabs / 30 days)

digoxin TABS 250mcg

3

PA; PA if 65 years and older

digoxin inj

3

DIGOXIN SOL 50MCG/ML

3

PA; PA if 65 years and older

TEKTURNA 150mg

3

QL (30 tabs / 30 days)

TEKTURNA 300mg

3

TEKTURNA HCT TAB 150-12.5MG

3

QL (30 tabs / 30 days)

TEKTURNA HCT TAB 150-25MG

3

QL (60 tabs / 30 days)

TEKTURNA HCT TAB 300-12.5MG

3

QL (30 tabs / 30 days)

DIRECT RENIN INHIBITORS/COMBINATIONS

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

35  

Drug Name TEKTURNA HCT TAB 300-25MG

Drug Tier

Requirements/Limits

3

DIURETICS acetazolamide CP12; TABS

3

amiloride & hydrochlorothiazide

2

amiloride hcl TABS

3

bumetanide inj 0.25/ml

3

bumetanide tab

3

chlorothiazide tabs

3

chlorthalidone 25mg, 50mg

3

furosemide SOLN

2

furosemide TABS

1

furosemide inj 10mg/ml

2

FUROSEMIDE INJ 10mg/ml

2

hydrochlorothiazide CAPS; TABS

1

indapamide

2

methazolamide TABS

4

methyclothiazide

3

metolazone

3

spironolactone & hydrochlorothiazide

3

torsemide inj

2

torsemide tabs

2

triamterene & hydrochlorothiazide TABS

1

triamterene & hydrochlorothiazide cap 37.5- 1 25 mg MISCELLANEOUS clonidine hcl PTWK

4

clonidine hcl TABS

1

DEMSER

5

hydralazine hcl SOLN

3

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

36  

Drug Name

Drug Tier

hydralazine hcl TABS

2

midodrine hcl

4

minoxidil TABS

2

RANEXA

3

Requirements/Limits

NITRATES isosorb mononitrate tab

2

isosorbide dinitrate

3

isosorbide dinitrate er

3

isosorbide mononitrate er

2

minitran

3

nitro-bid

3

NITRO-DUR DIS 0.3MG/HR

4

NITRO-DUR DIS 0.8MG/HR

4

nitroglycer dis 0.1mg/hr

3

nitroglycer dis 0.2mg/hr

3

nitroglycer dis 0.4mg/hr

3

nitroglycer dis 0.6mg/hr

3

nitroglycerin SUBL

3

NITROSTAT

3

PULMONARY ARTERIAL HYPERTENSION ADEMPAS

5

QL (90 tabs / 30 days), NM, LA, PA

LETAIRIS

5

QL (30 tabs / 30 days), NM, LA, PA

OPSUMIT

5

QL (30 tabs / 30 days), NM, LA, PA

REMODULIN

5

B/D, NM, LA

REVATIO SUSR

5

QL (224 mL / 30 days), NM, PA

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

37  

Drug Name

Drug Tier

Requirements/Limits

sildenafil citrate (pulmonary hypertension) TABS

3

QL (90 tabs / 30 days), NM, PA

TRACLEER 62.5mg

5

QL (120 tabs / 30 days), NM, LA, PA

TRACLEER 125mg

5

QL (60 tabs / 30 days), NM, LA, PA

UPTRAVI TABS 200mcg

5

QL (480 tabs / 30 days), NM, LA, PA

UPTRAVI TABS 400mcg

5

QL (240 tabs / 30 days), NM, LA, PA

UPTRAVI TABS 600mcg

5

QL (150 tabs / 30 days), NM, LA, PA

UPTRAVI TABS 800mcg

5

QL (120 tabs / 30 days), NM, LA, PA

UPTRAVI TABS 1000mcg

5

QL (90 tabs / 30 days), NM, LA, PA

UPTRAVI TABS 1200mcg, 1400mcg, 1600mcg

5

QL (60 tabs / 30 days), NM, LA, PA

UPTRAVI TBPK

5

NM, LA, PA

alprazolam tab 0.5mg

1

QL (240 tabs / 30 days)

alprazolam tab 0.25mg

1

QL (480 tabs / 30 days)

alprazolam tab 1mg

1

QL (120 tabs / 30 days)

alprazolam tab 2 mg

1

QL (150 tabs / 30 days)

buspirone hcl TABS

3

fluvoxamine maleate TABS 25mg, 50mg

3

fluvoxamine maleate TABS 100mg

3

lorazepam CONC

3

lorazepam SOLN

2

lorazepam TABS

1

CENTRAL NERVOUS SYSTEM ANTIANXIETY

QL (45 tabs / 30 days)

QL (150 mL / 30 days)

QL (150 tabs / 30 days)

ANTICONVULSANTS PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

38  

Drug Name

Drug Tier

Requirements/Limits

APTIOM 200mg

4

QL (180 tabs / 30 days)

APTIOM 400mg

5

QL (90 tabs / 30 days)

APTIOM 600mg

5

QL (60 tabs / 30 days)

APTIOM 800mg

5

QL (30 tabs / 30 days)

BANZEL SUS 40MG/ML

5

PA

BANZEL TAB 200MG

4

PA

BANZEL TAB 400MG

5

PA

BRIVIACT INJ

4

PA

BRIVIACT SOLN 10MG/ML

5

PA

BRIVIACT TABS

5

PA

carbamazepine CHEW; TABS

3

carbamazepine CP12; SUSP; TB12

4

CELONTIN

4

clonazepam TABS 1mg

1

QL (120 tabs / 30 days)

clonazepam TABS 2mg

1

QL (300 tabs / 30 days)

clonazepam TABS .5mg

1

QL (240 tabs / 30 days)

clonazepam TBDP 1mg

3

QL (120 tabs / 30 days)

clonazepam TBDP 2mg

3

QL (300 tabs / 30 days)

clonazepam TBDP .5mg

3

QL (240 tabs / 30 days)

clonazepam TBDP .25mg

3

QL (480 tabs / 30 days)

clonazepam TBDP .125mg

3

QL (960 tabs / 30 days)

clorazepate dipotassium 3.75mg, 7.5mg

2

QL (120 tabs / 30 days), PA

clorazepate dipotassium 15mg

2

QL (180 tabs / 30 days), PA

diazepam CONC

3

QL (240 mL / 30 days), PA

diazepam SOLN

3

QL (1200 mL / 30 days), PA

diazepam TABS

1

QL (120 tabs / 30 days), PA

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

39  

Drug Name

Drug Tier

Requirements/Limits

DIAZEPAM GEL

4

diazepam inj

3

dilantin

3

DILANTIN-125 SUS 125/5ML

3

divalproex sodium CSDR; TB24

4

divalproex sodium TBEC

2

epitol

3

ethosuximide CAPS; SOLN

4

felbamate SUSP

5

felbamate TABS

4

FYCOMPA SUSP

4

QL (720 mL / 30 days), PA

FYCOMPA TABS 2mg

4

QL (180 tabs / 30 days), PA

FYCOMPA TABS 4mg

4

QL (90 tabs / 30 days), PA

FYCOMPA TABS 6mg

4

QL (60 tabs / 30 days), PA

FYCOMPA TABS 8mg, 10mg, 12mg

4

QL (30 tabs / 30 days), PA

gabapentin CAPS 100mg

2

QL (1080 caps / 30 days)

gabapentin CAPS 300mg

2

QL (360 caps / 30 days)

gabapentin CAPS 400mg

2

QL (270 caps / 30 days)

gabapentin SOLN

3

QL (2160 mL / 30 days)

gabapentin TABS 600mg

3

QL (180 tabs / 30 days)

gabapentin TABS 800mg

3

QL (120 tabs / 30 days)

GABITRIL 12mg, 16mg

4

lamotrigine CHEW

3

lamotrigine TABS

2

lamotrigine TB24

4

levetiracetam TABS

3

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

40  

Drug Name

Drug Tier

levetiracetam TB24

4

levetiracetam inj

4

LEVETIRACETAM IV

4

levetiracetam oral soln 100 mg/ml

3

Requirements/Limits

LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 3 150mg

QL (120 caps / 30 days)

LYRICA CAPS 200mg

3

QL (90 caps / 30 days)

LYRICA CAPS 225mg, 300mg

3

QL (60 caps / 30 days)

LYRICA SOLN

3

QL (946 mL / 30 days)

ONFI SUSP

5

PA

ONFI TABS 10mg

4

PA

ONFI TABS 20mg

5

PA

oxcarbazepine SUSP

4

oxcarbazepine TABS

3

PEGANONE

4

phenobarbital ELIX; TABS

4

PA; PA if 65 years and older

PHENOBARBITAL SODIUM SOLN 65mg/ml 4

PA; PA if 65 years and older

phenobarbital sodium SOLN 130mg/ml

4

PA; PA if 65 years and older

phenytek

3

phenytoin CHEW; SUSP

3

phenytoin sodium SOLN

3

phenytoin sodium extended

3

POTIGA 50mg

4

POTIGA 200mg

5

QL (180 tabs / 30 days)

POTIGA 300mg, 400mg

5

QL (90 tabs / 30 days)

primidone TABS

2

roweepra

3

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

41  

Drug Name

Drug Tier

Requirements/Limits

SABRIL PACK

5

QL (180 packets / 30 days), NM, LA, PA

SABRIL TABS

5

QL (180 tabs / 30 days), NM, LA, PA

SPRITAM

4

TEGRETOL

4

TEGRETOL-XR

4

tiagabine hcl

4

topiramate CPSP

4

topiramate TABS

2

valproate sodium SOLN

4

valproate sodium SYRP

2

valproic acid

3

VIMPAT SOLN 10mg/ml

4

VIMPAT SOLN 200mg/20ml

4

VIMPAT TABS 50mg

4

QL (180 tabs / 30 days)

VIMPAT TABS 100mg, 150mg, 200mg

5

QL (60 tabs / 30 days)

zonisamide CAPS

3

QL (1200 mL / 30 days)

ANTIDEMENTIA donepezil hydrochloride TABS 5mg

2

QL (30 tabs / 30 days)

donepezil hydrochloride TABS 10mg

2

donepezil hydrochloride TABS 23mg

4

donepezil hydrochloride TBDP 5mg

4

donepezil hydrochloride TBDP 10mg

4

EXELON PATCHES

2

galantamine hydrobromide SOLN

4

galantamine hydrobromide TABS 4mg

4

QL (180 tabs / 30 days)

galantamine hydrobromide TABS 8mg

4

QL (90 tabs / 30 days)

galantamine hydrobromide TABS 12mg

4

galantamine hydrobromide er 8mg, 16mg

4

QL (30 tabs / 30 days)

QL (30 patches / 30 days)

QL (30 caps / 30 days)

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

42  

Drug Name

Drug Tier

Requirements/Limits

galantamine hydrobromide er 24mg

4

memantine hcl SOLN

3

PA; PA if < 30 yrs

memantine hcl TABS

4

PA; PA if < 30 yrs

NAMENDA XR

4

PA; PA if < 30 yrs

NAMENDA XR TITRATION PACK

4

PA; PA if < 30 yrs

NAMZARIC

4

rivastigmine tartrate

4

ANTIDEPRESSANTS amitriptyline hcl TABS

4

PA; PA if 65 years and older

amoxapine

3

BRINTELLIX 5mg

4

QL (120 tabs / 30 days)

BRINTELLIX 10mg

4

QL (60 tabs / 30 days)

BRINTELLIX 20mg

4

QL (30 tabs / 30 days)

bupropion hcl TABS

3

bupropion hcl TB12

2

bupropion hcl TB24 150mg

3

QL (90 tabs / 30 days)

bupropion hcl TB24 300mg

3

QL (30 tabs / 30 days)

citalopram hydrobromide SOLN

3

citalopram hydrobromide TABS 10mg, 20mg 1

QL (45 tabs / 30 days)

citalopram hydrobromide TABS 40mg

1

QL (30 tabs / 30 days)

clomipramine hcl CAPS

4

PA; PA if 65 years and older

desipramine hcl TABS

4

doxepin hcl CAPS; CONC

4

PA; PA if 65 years and older

duloxetine hcl CPEP 20mg, 30mg, 60mg

4

QL (60 caps / 30 days)

EMSAM

5

QL (30 patches / 30 days), PA

escitalopram oxalate SOLN

4

QL (600 mL / 30 days)

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

43  

Drug Name

Drug Tier

Requirements/Limits

escitalopram oxalate TABS 5mg, 10mg

2

QL (45 tabs / 30 days)

escitalopram oxalate TABS 20mg

2

QL (60 tabs / 30 days)

FETZIMA 20mg

4

QL (180 caps / 30 days)

FETZIMA 40mg

4

QL (90 caps / 30 days)

FETZIMA 80mg, 120mg

4

QL (30 caps / 30 days)

FETZIMA TITRATION PACK

4

fluoxetine cap 10mg

1

QL (30 caps / 30 days)

fluoxetine cap 20mg

1

QL (120 caps / 30 days)

fluoxetine cap 40mg

1

fluoxetine hcl SOLN

3

fluoxetine hcl TABS 10mg

3

fluoxetine hcl TABS 20mg

3

imipramine hcl TABS

4

maprotiline hcl

4

MARPLAN TAB 10MG

4

QL (180 tabs / 30 days)

mirtazapine TABS 7.5mg, 15mg

2

QL (45 tabs / 30 days)

mirtazapine TABS 30mg, 45mg

2

mirtazapine TBDP 15mg

3

mirtazapine TBDP 30mg, 45mg

3

nefazodone hcl

4

nortriptyline hcl CAPS

1

nortriptyline hcl SOLN

4

paroxetine hcl tabs 10mg, 20mg, 40mg

1

QL (45 tabs / 30 days)

paroxetine hcl tabs 30mg

1

QL (60 tabs / 30 days)

PAXIL SUSP

4

QL (900 mL / 30 days)

phenelzine sulfate TABS

3

PRISTIQ

3

protriptyline hcl

4

QL (45 tabs / 30 days)

PA; PA if 65 years and older

QL (30 tabs / 30 days)

QL (30 tabs / 30 days)

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

44  

Drug Name

Drug Tier

Requirements/Limits

sertraline hcl CONC

3

sertraline hcl TABS 25mg, 50mg

1

sertraline hcl TABS 100mg

1

SURMONTIL CAP 25MG

4

QL (240 caps / 30 days), PA; PA if 65 years and older

SURMONTIL CAP 50MG

4

QL (120 caps / 30 days), PA; PA if 65 years and older

SURMONTIL CAP 100MG

4

QL (60 caps / 30 days), PA; PA if 65 years and older

tranylcypromine sulfate

4

QL (45 tabs / 30 days)

trazodone hcl TABS 50mg, 100mg, 150mg 1 trimipramine maleate CAPS 25mg

4

QL (240 caps / 30 days), PA; PA if 65 years and older

trimipramine maleate CAPS 50mg

4

QL (120 caps / 30 days), PA; PA if 65 years and older

trimipramine maleate CAPS 100mg

4

QL (60 caps / 30 days), PA; PA if 65 years and older

TRINTELLIX 5mg

4

QL (120 tabs / 30 days)

TRINTELLIX 10mg

4

QL (60 tabs / 30 days)

TRINTELLIX 20mg

4

QL (30 tabs / 30 days)

venlafaxine hcl CP24 37.5mg, 75mg

2

QL (30 caps / 30 days)

venlafaxine hcl CP24 150mg

2

QL (60 caps / 30 days)

venlafaxine hcl TABS

3

VIIBRYD KIT

4

VIIBRYD TABS

4

VIIBRYD STARTER PACK

4

QL (30 tabs / 30 days)

ANTIPARKINSONIAN AGENTS PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

45  

Drug Name

Drug Tier

amantadine hcl CAPS; TABS

4

amantadine hcl SYRP

2

APOKYN

5

AZILECT

3

BENZTROPINE MESYLATE SOLN

3

benztropine mesylate TABS

4

bromocriptine mesylate CAPS; TABS

4

carbidopa-levodopa TABS; TBDP

2

carbidopa-levodopa TBCR

3

CARBIDOPA/LEVODOPA/ENTACAPONE

4

ENTACAPONE

4

NEUPRO

4

pramipexole dihydrochloride TABS

2

ropinirole hydrochloride TABS

2

selegiline hcl CAPS; TABS

4

Requirements/Limits

NM, LA, PA

PA; PA if 65 years and older

ANTIPSYCHOTICS ABILIFY DISCMELT TAB 10MG

5

QL (60 tabs / 30 days)

ABILIFY MAINTENA

5

QL (1 injection / 28 days)

aripiprazole

5

QL (60 tabs / 30 days)

aripiprazole oral solution 1 mg/ml

5

QL (900ml / 30 days)

aripiprazole tabs

5

QL (30 tabs / 30 days)

chlorpromazine hcl TABS

4

chlorpromazine inj

4

clozapine TABS 100mg

4

QL (270 tabs / 30 days)

clozapine TABS 200mg

4

QL (135 tabs / 30 days)

CLOZAPINE TBDP 12.5mg, 25mg

4

PA

CLOZAPINE TBDP 100mg

4

QL (270 tabs / 30 days), PA

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

46  

Drug Name

Drug Tier

Requirements/Limits

CLOZAPINE TBDP 150mg

5

QL (180 tabs / 30 days), PA

CLOZAPINE TBDP 200mg

5

QL (135 tabs / 30 days), PA

clozapine tab 25mg

3

clozapine tab 50mg

3

FANAPT

4

QL (60 tabs / 30 days), ST

FANAPT TITRATION PACK

4

ST

FAZACLO 150mg

5

QL (180 tabs / 30 days), PA

FAZACLO 200mg

5

QL (135 tabs / 30 days), PA

fluphenazine decanoate SOLN

4

fluphenazine hcl CONC; ELIX; SOLN

4

fluphenazine hcl TABS

2

GEODON SOLR

4

haloperidol TABS

3

haloperidol con lactate

3

haloperidol decanoate SOLN

3

haloperidol lactate inj 5 mg/ml

3

INVEGA 1.5mg, 3mg, 9mg

4

QL (30 tabs / 30 days)

INVEGA 6mg

4

QL (60 tabs / 30 days)

INVEGA SUST INJ 39 MG/0.25 ML

4

QL (1 injection / 28 days)

INVEGA SUST INJ 78 MG/0.5 ML

5

QL (1 injection / 28 days)

INVEGA SUST INJ 117 MG/0.75 ML

5

QL (1 injection / 28 days)

INVEGA SUST INJ 156MG/ML

5

QL (1 injection / 28 days)

INVEGA SUST INJ 234 MG/1.5 ML

5

QL (1 injection / 28 days)

INVEGA TRINZA

5

QL (1 syringe / 90 days)

LATUDA 20mg

4

QL (240 tabs / 30 days)

LATUDA 40mg, 120mg

4

QL (30 tabs / 30 days)

QL (6 mL / 3 days)

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

47  

Drug Name

Drug Tier

Requirements/Limits

LATUDA 60mg, 80mg

4

QL (60 tabs / 30 days)

loxapine succinate

3

molindone hcl

4

NUPLAZID

5

QL (60 tabs / 30 days), NM, LA, PA

olanzapine SOLR

4

QL (3 vials / 1 day)

olanzapine TABS 2.5mg, 5mg, 7.5mg

3

QL (30 tabs / 30 days)

olanzapine TABS 10mg, 15mg, 20mg

3

QL (60 tabs / 30 days)

olanzapine TBDP 5mg

4

QL (30 tabs / 30 days)

olanzapine TBDP 10mg, 15mg, 20mg

4

QL (60 tabs / 30 days)

paliperidone 1.5mg, 3mg, 9mg

4

QL (30 tabs / 30 days)

paliperidone 6mg

4

QL (60 tabs / 30 days)

perphenazine TABS

4

pimozide

4

quetiapine fumarate

3

QL (90 tabs / 30 days)

REXULTI 1mg

5

QL (90 tabs / 30 days), ST

REXULTI 2mg

5

QL (60 tabs / 30 days), ST

REXULTI 3mg, 4mg

5

QL (30 tabs / 30 days), ST

REXULTI .5mg

5

QL (180 tabs / 30 days), ST

REXULTI .25mg

5

QL (360 tabs / 30 days), ST

RISPERDAL INJ 12.5MG

4

QL (2 injections / 28 days)

RISPERDAL INJ 25MG

4

QL (2 injections / 28 days)

RISPERDAL INJ 37.5MG

5

QL (2 injections / 28 days)

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

48  

Drug Name

Drug Tier

Requirements/Limits

RISPERDAL INJ 50MG

5

QL (2 injections / 28 days)

risperidone SOLN

4

QL (240 mL / 30 days)

risperidone TABS 1mg, 2mg, 3mg

2

QL (60 tabs / 30 days)

risperidone TABS 4mg

2

QL (120 tabs / 30 days)

risperidone TABS .25mg, .5mg

2

QL (90 tabs / 30 days)

risperidone TBDP 1mg, 2mg, 3mg

4

QL (60 tabs / 30 days)

risperidone TBDP 4mg

4

QL (120 tabs / 30 days)

risperidone TBDP .25mg, .5mg

4

QL (90 tabs / 30 days)

SAPHRIS 2.5mg

4

QL (240 tabs / 30 days)

SAPHRIS 5mg

4

QL (120 tabs / 30 days)

SAPHRIS 10mg

4

QL (60 tabs / 30 days)

SEROQUEL XR 50mg

4

QL (120 tabs / 30 days)

SEROQUEL XR 150mg, 200mg

4

QL (30 tabs / 30 days)

SEROQUEL XR 300mg, 400mg

4

QL (60 tabs / 30 days)

thioridazine hcl TABS

4

PA; PA if 65 years and older

thiothixene

3

trifluoperazine hcl

3

VERSACLOZ

5

QL (600 mL / 30 days), PA

VRAYLAR CAPS 1.5mg

5

QL (120 caps / 30 days), ST

VRAYLAR CAPS 3mg

5

QL (60 caps / 30 days), ST

VRAYLAR CAPS 4.5mg, 6mg

5

QL (30 caps / 30 days), ST

VRAYLAR CPPK

4

ST

ziprasidone hcl 20mg, 40mg

4

QL (60 caps / 30 days)

ziprasidone hcl 60mg, 80mg

4

QL (90 caps / 30 days)

ZYPREXA RELPREVV 300mg

5

QL (2 vials / 28 days), PA

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

49  

Drug Name

Drug Tier

Requirements/Limits

ZYPREXA RELPREVV 405mg

5

QL (1 vial / 28 days), PA

ZYPREXA RELPREVV INJ 210MG

5

QL (2 vials / 28 days), PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap sr 24hr 5 mg

4

QL (90 caps / 30 days)

amphetamine-dextroamphetamine cap sr 24hr 10 mg

4

QL (90 caps / 30 days)

amphetamine-dextroamphetamine cap sr 24hr 15 mg

4

QL (30 caps / 30 days)

amphetamine-dextroamphetamine cap sr 24hr 20 mg

4

QL (30 caps / 30 days)

amphetamine-dextroamphetamine cap sr 24hr 25 mg

4

QL (30 caps / 30 days)

amphetamine-dextroamphetamine cap sr 24hr 30 mg

4

QL (30 caps / 30 days)

amphetamine-dextroamphetamine tab 5 mg 3

QL (360 tabs / 30 days)

amphetamine-dextroamphetamine tab 7.5 mg

3

QL (240 tabs / 30 days)

amphetamine-dextroamphetamine tab 10 mg 3

QL (180 tabs / 30 days)

amphetamine-dextroamphetamine tab 12.5 mg

3

QL (144 tabs / 30 days)

amphetamine-dextroamphetamine tab 15 mg 3

QL (120 tabs / 30 days)

amphetamine-dextroamphetamine tab 20 mg 3

QL (90 tabs / 30 days)

amphetamine-dextroamphetamine tab 30 mg 3

QL (60 tabs / 30 days)

guanfacine er (adhd)

4

PA; PA if 65 years and older

metadate er tab 20mg

4

QL (90 tabs / 30 days)

methylphenidate hcl TABS 5mg, 10mg

3

QL (180 tabs / 30 days)

methylphenidate hcl TABS 20mg

3

QL (90 tabs / 30 days)

methylphenidate hcl TBCR

4

QL (90 tabs / 30 days)

methylphenidate hcl oral soln 5mg/5ml

4

QL (1800 mL / 30 days)

methylphenidate hcl oral soln 10mg/5ml

4

QL (900 mL / 30 days)

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

50  

Drug Name

Drug Tier

Requirements/Limits

STRATTERA 10mg, 18mg, 25mg

4

QL (120 caps / 30 days)

STRATTERA 40mg

4

QL (60 caps / 30 days)

STRATTERA 60mg, 80mg, 100mg

4

QL (30 caps / 30 days)

HETLIOZ

5

NM, LA, PA

ROZEREM

4

QL (30 tabs / 30 days)

SILENOR 3mg

3

QL (60 tabs / 30 days)

SILENOR 6mg

3

QL (30 tabs / 30 days)

temazepam 7.5mg

2

QL (30 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year

temazepam 15mg

2

QL (60 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year

zolpidem tartrate TABS

4

QL (30 tabs / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year

HYPNOTICS

MIGRAINE dihydroergotamine mesylate 1mg/ml

3

naratriptan hcl

3

QL (9 tabs / 30 days)

RELPAX

3

QL (12 tabs / 30 days)

rizatriptan benzoate

3

QL (18 tabs / 30 days)

SUMATRIPTAN SOLN 5mg/act

4

QL (24 inhalers / 30 days)

SUMATRIPTAN SOLN 20mg/act

4

QL (12 inhalers / 30 days)

sumatriptan inj 4mg/0.5ml SOAJ

4

QL (12 injections / 30 days)

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

51  

Drug Name

Drug Tier

Requirements/Limits

SUMATRIPTAN INJ 4MG/0.5ML SOCT

4

QL (12 injections / 30 days)

sumatriptan inj 6mg/0.5ml SOAJ; SOLN; SOSY

4

QL (12 injections / 30 days)

SUMATRIPTAN INJ 6MG/0.5ML SOCT

4

QL (12 injections / 30 days)

sumatriptan succinate TABS

2

QL (9 tabs / 30 days)

zolmitriptan TABS

4

QL (12 tabs / 30 days)

zolmitriptan odt

4

QL (12 tabs / 30 days)

MISCELLANEOUS lithium carbonate CAPS

1

lithium carbonate TABS

2

lithium carbonate er

2

LITHIUM SOLN 8MEQ/5ML

3

NUEDEXTA

3

pyridostigmine bromide TABS

3

riluzole

4

tetrabenazine 12.5mg

5

QL (240 tabs / 30 days), NM, PA

tetrabenazine 25mg

5

QL (120 tabs / 30 days), NM, PA

AMPYRA

5

NM, LA, PA

BETASERON

5

QL (14 syringes / 28 days), NM, PA

COPAXONE INJ 20MG/ML

5

QL (30 syringes / 30 days), NM, PA

COPAXONE INJ 40MG/ML

5

QL (12 syringes / 28 days), NM, PA

GILENYA

5

QL (28 caps / 28 days), NM, PA

TYSABRI

5

NM, LA, PA

PA

MULTIPLE SCLEROSIS AGENTS

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

52  

Drug Name

Drug Tier

Requirements/Limits

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS

2

dantrolene sodium CAPS

4

tizanidine hcl TABS

2

NARCOLEPSY/CATAPLEXY NUVIGIL 50mg

3

QL (150 tabs / 30 days), PA

NUVIGIL 150mg

3

QL (60 tabs / 30 days), PA

NUVIGIL 200mg, 250mg

3

QL (30 tabs / 30 days), PA

XYREM

5

QL (540 mL / 30 days), LA, PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium

4

buprenorphine hcl SUBL

4

PA

buprenorphine hcl-naloxone hcl sl

4

QL (120 tabs / 30 days), PA

buproban tab (smoking deterrent)

3

bupropion hcl (smoking deterrent)

3

CHANTIX

4

PA

CHANTIX CONTINUING MONTH

4

PA

CHANTIX STARTER PACK

4

PA

disulfiram TABS

4

naloxone inj 0.4mg/ml

3

naloxone inj 1mg/ml

3

naltrexone hcl TABS

3

NICOTROL INHALER

4

NICOTROL NS

4

SUBOXONE MIS 2-0.5MG

4

QL (120 SL films / 30 days), PA

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

53  

Drug Name

Drug Tier

Requirements/Limits

SUBOXONE MIS 4-1MG

4

QL (120 SL films / 30 days), PA

SUBOXONE MIS 8-2MG

4

QL (120 SL films / 30 days), PA

SUBOXONE MIS 12-3MG

4

QL (60 SL films / 30 days), PA

ANDRODERM

4

QL (30 patches / 30 days), PA

AXIRON

3

QL (440 mL / 30 days), PA

oxandrolone tab 2.5mg

3

PA

oxandrolone tab 10mg

5

PA

testosterone cypionate SOLN

3

PA

testosterone enanthate SOLN

3

PA

ENDOCRINE AND METABOLIC ANDROGENS

ANTIDIABETICS, INJECTABLE ALCOHOL SWABS

3

BYDUREON

3

QL (4 vials / 28 days)

BYDUREON PEN

3

QL (4 pens / 28 days)

BYETTA

4

QL (1 pen / 30 days)

GAUZE PADS 2" X 2"

3

HUMULIN R U-500 KWIKPEN

5

HUMULIN R U-500 VIAL (CONCENTRATE) 5 INSULIN PEN NEEDLE

3

INSULIN SAFETY NEEDLES

3

INSULIN SYRINGE

3

LANTUS

3

LANTUS SOLOSTAR

3

LEVEMIR

3

B/D

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

54  

Drug Name

Drug Tier

Requirements/Limits

LEVEMIR FLEXTOUCH

3

NOVOLIN 70/30

3

(brand RELION not covered)

NOVOLIN N

3

(brand RELION not covered)

NOVOLIN R

3

(brand RELION not covered)

NOVOLOG

3

NOVOLOG FLEXPEN

3

NOVOLOG MIX 70/30

3

NOVOLOG MIX 70/30 PREFILL

3

NOVOLOG PENFILL

3

SYMLINPEN 60

4

QL (8 pens / 30 days), PA

SYMLINPEN 120

5

QL (4 pens / 30 days), PA

TOUJEO SOLOSTAR

3

TRESIBA FLEXTOUCH

3

TRULICITY

4

QL (4 pens / 28 days)

VICTOZA

3

QL (3 pens / 30 days)

ANTIDIABETICS, ORAL acarbose

3

FARXIGA 5mg

3

QL (60 tabs / 30 days)

FARXIGA 10mg

3

QL (30 tabs / 30 days)

glimepiride 1mg

1

QL (240 tabs / 30 days)

glimepiride 2mg

1

QL (120 tabs / 30 days)

glimepiride 4mg

1

QL (60 tabs / 30 days)

glip/metform tab 5-500mg

1

QL (120 tabs / 30 days)

glipizide TABS 5mg

1

QL (240 tabs / 30 days)

glipizide TABS 10mg

1

QL (120 tabs / 30 days)

glipizide TB24 2.5mg

1

QL (240 tabs / 30 days)

glipizide TB24 5mg

1

QL (120 tabs / 30 days)

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

55  

Drug Name

Drug Tier

Requirements/Limits

glipizide TB24 10mg

1

QL (60 tabs / 30 days)

GLIPIZIDE XL TB24 2.5MG

1

QL (240 tabs / 30 days)

GLIPIZIDE XL TB24 5MG

1

QL (120 tabs / 30 days)

glipizide-metformin hcl tab 2.5-250 mg

1

QL (240 tabs / 30 days)

glipizide-metformin hcl tab 2.5-500 mg

1

QL (120 tabs / 30 days)

INVOKAMET TAB 50-500MG

3

QL (120 tabs / 30 days)

INVOKAMET TAB 50-1000

3

QL (60 tabs / 30 days)

INVOKAMET TAB 150-500

3

QL (60 tabs / 30 days)

INVOKAMET TAB 150-1000

3

QL (60 tabs / 30 days)

INVOKANA 100mg

3

QL (90 tabs / 30 days)

INVOKANA 300mg

3

QL (30 tabs / 30 days)

JANUMET

3

QL (60 tabs / 30 days)

JANUMET XR TAB 50-500MG

3

QL (60 tabs / 30 days)

JANUMET XR TAB 50-1000

3

QL (60 tabs / 30 days)

JANUMET XR TAB 100-1000

3

QL (30 tabs / 30 days)

JANUVIA

3

QL (30 tabs / 30 days)

JENTADUETO

3

QL (60 tabs / 30 days)

JENTADUETO XR 2.5-1000MG

3

QL (60 tabs / 30 days)

JENTADUETO XR 5-1000MG

3

QL (30 tabs / 30 days)

metformin er 500mg

1

QL (120 tabs / 30 days)

metformin er 750mg

1

QL (60 tabs / 30 days)

metformin hcl TABS 500mg

1

QL (150 tabs / 30 days)

metformin hcl TABS 850mg

1

QL (90 tabs / 30 days)

metformin hcl TABS 1000mg

1

QL (75 tabs / 30 days)

nateglinide

1

QL (90 tabs / 30 days)

pioglitazone hcl

1

QL (30 tabs / 30 days)

repaglinide 2mg

1

QL (240 tabs / 30 days)

repaglinide .5mg, 1mg

1

QL (120 tabs / 30 days)

TRADJENTA

3

QL (30 tabs / 30 days)

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

56  

Drug Name

Drug Tier

Requirements/Limits

XIGDUO XR TAB 5-500MG

3

QL (60 tabs / 30 days)

XIGDUO XR TAB 5-1000MG

3

QL (60 tabs / 30 days)

XIGDUO XR TAB 10-500MG

3

QL (30 tabs / 30 days)

XIGDUO XR TAB 10-1000MG

3

QL (30 tabs / 30 days)

BISPHOSPHONATES alendronate sodium TABS 5mg, 10mg, 40mg

1

alendronate sodium TABS 35mg, 70mg

1

QL (4 tabs / 28 days)

ibandronate tab 150mg

4

B/D, QL (1 tab / 30 days)

pamidronate disodium SOLN

3

B/D

zoledronic acid SOLN 5mg/100ml

4

B/D, NM

zoledronic inj 4mg/5ml

4

B/D, NM

SENSIPAR 30mg

3

QL (120 tabs / 30 days), NM

SENSIPAR 60mg

5

QL (60 tabs / 30 days), NM

SENSIPAR 90mg

5

QL (120 tabs / 30 days), NM

CALCIUM RECEPTOR AGONISTS

CHELATING AGENTS CHEMET

4

DEPEN TITRATABS

5

EXJADE

5

NM, LA, PA

FERRIPROX

5

NM, LA, PA

kionex powder

4

sodium polystyrene sulfonate POWD

4

sodium polystyrene sulfonate SUSP

3

sps

3

SYPRINE

5

CONTRACEPTIVES PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

57  

Drug Name

Drug Tier

altavera

3

apri 28 day

3

aranelle 28

3

aubra 28 day

3

aviane 28

3

balziva 28 day

3

bekyree 28 day

3

blisovi 21 fe 1.5/30 28 day pack

3

blisovi 21 fe 1/20 28 day pack

2

briellyn 28 day

3

camila 28 day

3

caziant 28 day

3

cryselle 28

3

cyclafem 1/35 28 day

3

cyclafem 7/7/7 28 day

3

cyred tab

3

deblitane 28 day

3

delyla 28 day

3

desogestrel-ethinyl estradiol (biphasic)

3

drospirenone-ethinyl estradiol

3

ELLA

4

emoquette

3

enpresse 28 day

2

errin 28 day

3

estarylla tab 0.25-35

3

falmina 28 day

3

GIANVI TAB 3-0.02MG

3

gildagia

3

gildess 1.5/30 21 day

3

Requirements/Limits

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

58  

Drug Name

Drug Tier

heather

3

introvale 91 day

3

JOLESSA TAB 0.15-0.03 MG

3

JOLIVETTE

3

juleber 28 day

3

junel 1.5/30 21 day

3

junel 1/20 21 day

3

junel fe 1.5/30 28 day

3

junel fe 1/20 28 day

2

kariva 28 day

3

kelnor 1/35 28 day

3

kimidess 28 day

3

larin 1.5/30

3

larin 1/20

3

larin fe 1.5/30

3

larin fe 1/20

2

larissia 28 day pack

3

leena tab

3

lessina 28 day

3

levonest 28 day

2

levonor/ethi tab

2

levonorgestrel & eth estradiol

3

levonorgestrel (emergency oc)

3

levonorgestrel-ethinyl estradiol (91-day)

3

levora 0.15/30 28 day

3

loryna 28 day

3

low-ogestrel

3

lutera 28 day

3

lyza

3

Requirements/Limits

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

59  

Drug Name

Drug Tier

marlissa 28 day

3

medroxyprogesterone acetate 150 mg/ml

2

MEDROXYPROGESTERONE ACETATE (CONTRACEPTIVE)

2

MICROGESTIN 1.5/30

3

MICROGESTIN 1/20

3

MICROGESTIN FE 1.5/30

3

MICROGESTIN FE 1/20

2

mono-linyah tab 0.25-35

3

MONONESSA

3

myzilra

2

necon 0.5/35 28 day

3

necon 1/35 28 day

3

NECON 1/50-28

3

NECON 7/7/7

3

necon 10/11 28 day

3

nikki 28 day

3

NORA-BE TAB 0.35MG

3

norethindrone (contraceptive)

3

norgest/ethi tab 0.25/35

3

norgestimate-ethinyl estradiol (triphasic)

2

norlyroc 28 day

3

nortrel 0.5/35 28 day

3

nortrel 1/35 21 day

3

nortrel 1/35 28 day

3

nortrel 7/7/7 28 day

3

NUVARING

4

OCELLA TAB 3-0.03MG

3

orsythia 28 day

3

Requirements/Limits

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

60  

Drug Name

Drug Tier

philith

3

pimtrea pack

3

pirmella 1/35 28 day

3

portia 28 day

3

previfem 28 day

3

quasense 91 day

3

reclipsen 28 day

3

setlakin tab

3

sharobel 28 day

3

sprintec 28 day

3

sronyx

3

syeda

3

tarina fe 1/20 28 day

2

tri-legest 28 day

3

tri-linyah tab

2

tri-previfem 28 day

2

tri-sprintec 28 day

2

TRINESSA

2

trivora 28 day

2

velivet 28 day

3

vestura

3

vienva 28 day

3

viorele

3

vyfemla 28 day

3

xulane dis 150-35

4

zarah

3

zenchent 28 day

3

zovia 1/35e 28 day

3

zovia 1/50e 28 day

3

Requirements/Limits

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

61  

Drug Name

Drug Tier

Requirements/Limits

ENDOMETRIOSIS danazol CAPS

4

SYNAREL

5

ENZYME REPLACEMENTS ADAGEN

5

NM, LA, PA

ALDURAZYME

5

NM, LA, PA

BUPHENYL TABS

5

NM, LA, PA

CARBAGLU

5

NM, LA, PA

CERDELGA

5

NM, PA

CEREZYME

5

NM, LA, PA

CYSTADANE

5

NM, LA

CYSTAGON

4

NM, LA, PA

FABRAZYME

5

NM, LA, PA

KUVAN

5

NM, LA, PA

levocarnitine (metabolic modifiers)

3

B/D

LUMIZYME

5

NM, LA, PA

MYOZYME

5

NM, LA, PA

NAGLAZYME

5

NM, LA, PA

ORFADIN

5

NM, LA, PA

RAVICTI

5

NM, PA

sodium phenylbutyrate

5

NM

ZAVESCA

5

NM, LA, PA

ESTROGENS DELESTROGEN 10mg/ml

4

estrace CREA

4

estrad val inj 20mg/ml

3

estrad val inj 40mg/ml

3

estradiol PTWK

4

PA; PA if 65 years and older

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

62  

Drug Name

Drug Tier

Requirements/Limits

estradiol TABS

4

PA; PA if 65 years and older

fyavolv tab 1 mg-5 mcg

4

PA; PA if 65 years and older

jinteli

4

PA; PA if 65 years and older

norethindrone acetate-ethinyl estradiol

4

PA; PA if 65 years and older

VAGIFEM

4

GLUCOCORTICOIDS a-hydrocort

2

cortisone acetate TABS

4

dexamethasone CONC; ELIX; SOLN

3

dexamethasone TABS

2

dexamethasone sodium phosphate

2

fludrocortisone acetate TABS

2

hydrocortisone TABS

3

methylpr ace inj 40mg/ml

2

B/D

methylpr ace inj 80mg/ml

2

B/D

methylpr ss inj 1gm

3

B/D

methylpr ss inj 40mg

3

B/D

methylpr ss inj 125 mg

3

B/D

methylpred pak 4mg

3

methylpred tab 4mg

3

B/D

methylpred tab 8mg

3

B/D

methylpred tab 16mg

3

B/D

methylpred tab 32mg

3

B/D

pred sod pho sol 5mg/5ml

2

B/D

prednisolone sol 15mg/5ml

2

B/D

prednisolone sol 25mg/5ml

2

B/D

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

63  

Drug Name

Drug Tier

Requirements/Limits

prednisolone syp 15mg/5ml

1

B/D

prednisone con 5mg/ml

3

B/D

prednisone pak 5mg

2

prednisone pak 10mg

2

prednisone sol 5mg/5ml

3

B/D

prednisone tab 1mg

1

B/D

prednisone tab 2.5mg

1

B/D

prednisone tab 5mg

1

B/D

prednisone tab 10mg

1

B/D

prednisone tab 20mg

1

B/D

prednisone tab 50mg

1

B/D

SOLU-CORTEF 250mg

4

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT

3

GLUCAGON EMERGENCY KIT

3

KORLYM

5

PROGLYCEM SUS 50MG/ML

4

NM, LA, PA

HUMAN GROWTH HORMONES NORDITROPIN FLEXPRO

5

NM, PA

MISCELLANEOUS cabergoline

4

calcitonin (salmon)

3

FORTICAL

3

INCRELEX

5

methylergonovine maleate TABS

4

MIACALCIN 200unit/ml

5

B/D

octreotide acetate 50mcg/ml, 100mcg/ml

4

NM, PA

octreotide acetate 200mcg/ml, 500mcg/ml, 1000mcg/ml

5

NM, PA

NM, LA, PA

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

64  

Drug Name

Drug Tier

Requirements/Limits

PROLIA

4

QL (1 syringe / 180 days), NM

raloxifene tab 60mg

3

SANDOSTATIN LAR DEPOT

5

NM, PA

SIGNIFOR

5

NM, LA, PA

SOMATULINE DEPOT

5

NM, PA

SOMAVERT

5

NM, LA, PA

XGEVA

5

NM, PA

FORTEO

5

QL (1 pen / 28 days), NM, PA

NATPARA

5

NM, PA

PARATHYROID HORMONES

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder)

3

RENVELA PAK

5

RENVELA TAB 800MG

5

PROGESTINS medroxyprogesterone acetate tab

1

norethindrone acetate TABS

3

THYROID AGENTS levothyroxine sodium TABS

2

LEVOXYL

2

liothyronine sodium TABS

3

methimazole TABS

2

propylthiouracil TABS

3

SYNTHROID

4

UNITHROID

2

VASOPRESSINS desmopressin acetate spray

4

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

65  

Drug Name

Drug Tier

desmopressin acetate spray refrigerated

4

desmopressin acetate tabs

3

desmopressin inj 4mcg/ml

4

DESMOPRESSIN SOL 0.01%

4

Requirements/Limits

GASTROINTESTINAL ANTIEMETICS compro supp

4

dronabinol 2.5mg, 5mg

4

B/D, QL (60 caps / 30 days)

dronabinol 10mg

5

B/D, QL (60 caps / 30 days)

EMEND SUSR

4

B/D

EMEND CAP 40MG

4

B/D

EMEND CAP 80MG

4

B/D

EMEND CAP 125MG

4

B/D

EMEND PAK 80 & 125

4

B/D

granisetron hcl SOLN

3

granisetron hcl TABS

4

meclizine hcl TABS

2

metoclopramide hcl SOLN

2

metoclopramide hcl TABS

1

metoclopramide inj

2

ondansetron hcl TABS

3

ondansetron hcl inj

3

ondansetron hcl oral soln

4

B/D

ondansetron odt

2

B/D

phenadoz

4

PA; PA if 65 years and older

phenergan SUPP

4

PA; PA if 65 years and older

B/D

B/D

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

66  

Drug Name

Drug Tier

Requirements/Limits

prochlorperazine inj

3

prochlorperazine maleate TABS

1

prochlorperazine supp

4

promethazine hcl SOLN; SUPP; SYRP; TABS

4

PA; PA if 65 years and older

promethegan

4

PA; PA if 65 years and older

TRANSDERM-SCOP

4

QL (10 patches / 30 days), PA; PA if 65 years and older

ANTISPASMODICS CUVPOSA

4

dicyclomine hcl CAPS

1

dicyclomine hcl SOLN 10mg/5ml

3

dicyclomine hcl TABS

1

glycopyrrolate TABS

3

glycopyrrolate inj

4

H2-RECEPTOR ANTAGONISTS famotidine SUSR

4

famotidine TABS 20mg, 40mg

1

famotidine inj

2

ranitidine hcl SOLN

2

ranitidine hcl TABS 150mg, 300mg

1

ranitidine hcl inj

3

ranitidine syrup

3

INFLAMMATORY BOWEL DISEASE APRISO

3

ASACOL HD

4

balsalazide disodium

4

budesonide ec

5

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

67  

Drug Name

Drug Tier

CANASA

5

colocort

4

DELZICOL

4

DIPENTUM

5

HYDROCORTISONE (INTRARECTAL)

4

MESALAMINE TBEC

4

mesalamine enema

4

mesalamine w/ cleanser

4

sulfasalazine TABS

3

sulfasalazine ec

3

UCERIS TB24

5

Requirements/Limits

LAXATIVES constulose

2

enulose

2

gaviltye-g

2

gavilyte-c

2

gavilyte-h

2

gavilyte-n

2

generlac

2

GOLYTELY

3

lactulose

2

lactulose (encephalopathy)

2

MOVIPREP

4

NULYTELY/FLAVOR PACKS

3

PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE

2

peg 3350-potassium chloride-sod bicarbonate-sod chloride

2

PEG 3350/ELECTROLYTES

2

polyethylene glycol 3350 PACK; POWD

2

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

68  

Drug Name

Drug Tier

Requirements/Limits

RELISTOR SOLN

5

PA

SUPREP BOWEL PREP

4

trilyte

2

MISCELLANEOUS alosetron hcl

5

PA

AMITIZA CAP 8MCG

3

QL (60 caps / 30 days)

AMITIZA CAP 24MCG

3

QL (60 caps / 30 days)

cromolyn sodium (mastocytosis)

5

diphenoxylate w/ atropine

3

GATTEX

5

NM, LA, PA

LINZESS 145mcg

3

QL (60 caps / 30 days)

LINZESS 290mcg

3

QL (30 caps / 30 days)

loperamide hcl CAPS

2

misoprostol TABS

3

MOVANTIK 12.5mg

3

QL (60 tabs / 30 days)

MOVANTIK 25mg

3

QL (30 tabs / 30 days)

SUCRAID

5

LA

sucralfate TABS

3

ursodiol CAPS; TABS

4

XIFAXAN 550mg

5

PA

PANCREATIC ENZYMES CREON

3

ZENPEP

4

PROTON PUMP INHIBITORS DEXILANT

3

QL (30 caps / 30 days)

esomeprazole sodium inj

4

NEXIUM CAP 20MG

2

QL (30 caps / 30 days)

NEXIUM CAP 40MG

2

QL (30 caps / 30 days)

NEXIUM GRA 2.5MG DR

3

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

69  

Drug Name

Drug Tier

Requirements/Limits

NEXIUM GRA 5MG DR

3

NEXIUM GRA 10MG DR

3

QL (30 packets / 30 days)

NEXIUM GRA 20MG DR

3

QL (30 packets / 30 days)

NEXIUM GRA 40MG DR

3

QL (30 packets / 30 days)

omeprazole CPDR 10mg, 40mg

1

QL (30 caps / 30 days)

omeprazole CPDR 20mg

1

QL (60 caps / 30 days)

pantoprazole sodium tbec

2

QL (30 tabs / 30 days)

alfuzosin hcl

2

QL (30 tabs / 30 days)

dutasteride

4

QL (30 caps / 30 days)

dutasteride-tamsulosin hcl

4

QL (30 caps / 30 days)

finasteride TABS 5mg

2

tamsulosin hcl

3

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA

MISCELLANEOUS bethanechol chloride TABS

3

ELMIRON

4

potassium citrate (alkalinizer) 15meq

4

POTASSIUM CITRATE (ALKALINIZER) 540mg, 1080mg

4

URINARY ANTISPASMODICS MYRBETRIQ 25mg

4

QL (60 tabs / 30 days)

MYRBETRIQ 50mg

4

QL (30 tabs / 30 days)

oxybutynin chloride SYRP

1

oxybutynin chloride TABS

3

oxybutynin chloride TB24 5mg

3

QL (30 tabs / 30 days)

oxybutynin chloride TB24 10mg, 15mg

3

QL (60 tabs / 30 days)

tolterodine tartrate CP24

4

QL (30 caps / 30 days)

tolterodine tartrate TABS

4

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

70  

Drug Name

Drug Tier

Requirements/Limits

TOVIAZ

3

QL (30 tabs / 30 days)

trospium chloride TABS

4

QL (60 tabs / 30 days)

VESICARE

4

QL (30 tabs / 30 days)

VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal

4

metronidazole vaginal

3

terconazole vaginal CREA

3

terconazole vaginal SUPP

4

VANDAZOLE

3

ZAZOLE CRE 0.8%

3

HEMATOLOGIC ANTICOAGULANTS COUMADIN

4

ELIQUIS

3

enoxaparin sodium 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml

4

enoxaparin sodium 100mg/ml, 120mg/0.8ml, 5 150mg/ml fondaparinux sodium 2.5mg/0.5ml

4

fondaparinux sodium 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

5

HEPARIN SOD (PORCINE) IN D5W

3

heparin sod inj 1000/ml

3

B/D

heparin sod inj 5000/ml

3

B/D

heparin sod inj 10000/ml

3

B/D

heparin sod inj 20000/ml

3

B/D

HEPARIN SODIUM/D5W

3

HEPARIN SODIUM/NACL 0.45%

3

jantoven

1

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

71  

Drug Name

Drug Tier

PRADAXA

3

warfarin sodium

1

XARELTO

3

XARELTO STARTER PACK

3

Requirements/Limits

HEMATOPOIETIC GROWTH FACTORS GRANIX

5

NM, PA

LEUKINE

5

NM, PA

MOZOBIL

5

NM, PA

NEUMEGA

5

NM

NEUPOGEN

5

NM, PA

PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

3

NM, PA

PROCRIT 20000unit/ml, 40000unit/ml

5

NM, PA

MISCELLANEOUS anagrelide hcl

4

cilostazol

2

CINRYZE

5

NM, LA, PA

FIRAZYR

5

NM, PA

pentoxifylline TBCR

3

PROMACTA 12.5mg

5

QL (360 tabs / 30 days), NM, LA, PA

PROMACTA 25mg

5

QL (180 tabs / 30 days), NM, LA, PA

PROMACTA 50mg

5

QL (90 tabs / 30 days), NM, LA, PA

PROMACTA 75mg

5

QL (60 tabs / 30 days), NM, LA, PA

tranexamic acid SOLN

3

tranexamic acid TABS

4

PLATELET AGGREGATION INHIBITORS PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

72  

Drug Name

Drug Tier

AGGRENOX

2

BRILINTA

3

clopidogrel tab 75mg

2

EFFIENT

4

ZONTIVITY

4

Requirements/Limits

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) CIMZIA

5

NM, PA

CIMZIA STARTER KIT

5

NM, PA

HUMIRA INJ 10MG/0.2ML

5

NM, PA

HUMIRA KIT 20MG/0.4ML

5

NM, PA

HUMIRA KIT 40MG/0.8ML

5

NM, PA

HUMIRA PEDIATRIC CROHNS

5

NM, PA

HUMIRA PEN

5

NM, PA

HUMIRA PEN-CROHNS DISEASE

5

NM, PA

HUMIRA PEN-PSORIASIS STAR

5

NM, PA

hydroxychloroquine sulfate

4

leflunomide TABS

3

methotrexate sodium tabs

3

REMICADE

5

NM, PA

BIVIGAM

5

NM, PA

CARIMUNE NANOFILTERED

5

NM, PA

FLEBOGAMMA

5

NM, PA

FLEBOGAMMA DIF

5

NM, PA

GAMASTAN S/D

3

B/D, NM

GAMMAGARD LIQUID

5

NM, PA

GAMMAGARD S/D

5

NM, PA

GAMMAKED

5

NM, PA

IMMUNOGLOBULINS

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

73  

Drug Name

Drug Tier

Requirements/Limits

GAMMAPLEX 2.5gm/50ml, 5gm/100ml, 10gm/200ml

5

NM, PA

GAMUNEX-C

5

NM, PA

OCTAGAM 1gm/20ml, 2gm/20ml, 2.5gm/50ml, 5gm/100ml, 10gm/200ml, 25gm/500ml

5

NM, PA

PRIVIGEN

5

NM, PA

ACTIMMUNE

5

NM, LA, PA

ARCALYST

5

NM, PA

INTRON-A INJ 10MU

5

B/D, NM

INTRON-A INJ 18MU

5

B/D, NM

INTRON-A INJ 25MU

5

B/D, NM

INTRON-A INJ 50MU

5

B/D, NM

REVLIMID

5

NM, LA, PA

THALOMID

5

NM, PA

azathioprine SOLR

4

B/D

azathioprine TABS

3

B/D

BENLYSTA

5

NM, PA

cyclosporine CAPS; SOLN

4

B/D

cyclosporine modified (for microemulsion)

3

B/D

gengraf

3

B/D

mycophenolate mofetil CAPS; TABS

4

B/D

mycophenolate mofetil SUSR

5

B/D

mycophenolate sodium 180mg

4

B/D

mycophenolate sodium 360mg

5

B/D

NEORAL

3

B/D

NULOJIX

5

B/D

PROGRAF CAPS 5mg

5

B/D

IMMUNOMODULATORS

IMMUNOSUPPRESSANTS

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

74  

Drug Name

Drug Tier

Requirements/Limits

PROGRAF CAPS .5mg, 1mg

4

B/D

RAPAMUNE SOLN

5

B/D

SANDIMMUNE SOLN 100mg/ml

3

B/D

SIROLIMUS TABS 2mg

5

B/D

sirolimus TABS .5mg, 1mg

4

B/D

tacrolimus CAPS 5mg

5

B/D

tacrolimus CAPS .5mg, 1mg

4

B/D

ZORTRESS TAB 0.5MG

5

B/D

ZORTRESS TAB 0.25MG

4

B/D

ZORTRESS TAB 0.75MG

5

B/D

VACCINES ACTHIB

3

ADACEL

3

BCG VACCINE

3

BEXSERO

3

BOOSTRIX

3

CERVARIX

3

COMVAX

3

DAPTACEL

3

DIPHTHERIA/TETANUS TOXOID

3

B/D

ENGERIX-B SUSP

3

B/D

GARDASIL

3

GARDASIL 9

3

HAVRIX

3

HIBERIX

3

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

3

INFANRIX

3

IPOL INACTIVATED IPV

3

IXIARO

3

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

75  

Drug Name

Drug Tier

Requirements/Limits

KINRIX

3

M-M-R II

3

MENACTRA

3

MENHIBRIX

3

MENOMUNE-A/C/Y/W-135

3

MENVEO

3

PEDIARIX

3

PEDVAX HIB

3

PENTACEL

3

PROQUAD

3

QUADRACEL

3

RABAVERT

3

RECOMBIVAX HB

3

ROTARIX

3

ROTATEQ

3

SYNAGIS

5

NM

TENIVAC

3

B/D

TETANUS/DIPHTHERIA TOXOID

3

B/D

TRUMENBA

3

TWINRIX INJ

3

TYPHIM VI

3

VAQTA

3

VARIVAX

3

YF-VAX

3

ZOSTAVAX

3

B/D

QL (1 vial per lifetime)

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES KLOR-CON 8

3

KLOR-CON 10

3

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

76  

Drug Name

Drug Tier

klor-con m10

2

klor-con m15

2

klor-con m20

2

klor-con pow 20meq

4

klor-con spr cap 8meq

3

klor-con spr cap 10meq

3

Requirements/Limits

MAGNESIUM SULFATE SOLN 2gm/50ml, 3 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml magnesium sulfate SOLN 2gm/50ml, 50%

2

MAGNESIUM SULFATE SOLN 50%

2

MAGNESIUM SULFATE IN D5W

3

potassium chloride CPCR

3

POTASSIUM CHLORIDE SOLN 10%, 20% 3 potassium chloride TBCR 8meq

3

POTASSIUM CHLORIDE TBCR 20meq

3

potassium chloride microencapsulated crystals cr

2

POTASSIUM CHLORIDE TAB CR 10 MEQ 3 SODIUM CHLORIDE SOLN 2.5meq/ml

2

SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN

2

TPN ELECTROLYTES

4

B/D

AMINOSYN

4

B/D

AMINOSYN 7%/ELECTROLYTES

4

B/D

AMINOSYN 8.5%/ELECTROLYTE

4

B/D

AMINOSYN II

4

B/D

AMINOSYN II 8.5%/ELECTROL

4

B/D

AMINOSYN M

4

B/D

IV NUTRITION

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

77  

Drug Name

Drug Tier

Requirements/Limits

AMINOSYN-HBC

4

B/D

AMINOSYN-PF 7%

4

B/D

AMINOSYN-PF INJ 10%

4

B/D

AMINOSYN-RF

4

B/D

CLINIMIX 2.75%/DEXTROSE 5%

4

B/D

CLINIMIX 4.25%/DEXTROSE 5%

4

B/D

CLINIMIX 4.25%/DEXTROSE 25%

4

B/D

CLINIMIX 5%/DEXTROSE 15%

4

B/D

CLINIMIX 5%/DEXTROSE 20%

4

B/D

CLINIMIX 5%/DEXTROSE 25%

4

B/D

CLINIMIX INJ 4.25/D10

4

B/D

CLINIMIX INJ 4.25/D20

4

B/D

FREAMINE HBC 6.9%

4

B/D

FREAMINE III

4

B/D

HEPATAMINE

4

B/D

INTRALIPID INJ 20%

4

B/D

INTRALIPID INJ 30%

4

B/D

NEPHRAMINE

4

B/D

NUTRILIPID INJ 20%

4

B/D

premasol 6%

2

B/D

premasol 10%

4

B/D

PROCALAMINE

4

B/D

PROSOL

4

B/D

TRAVASOL

4

B/D

TROPHAMINE INJ 10%

4

B/D

IV REPLACEMENT SOLUTIONS DEXTROSE 2.5%/NACL 0.45%

2

DEXTROSE 5%

2

DEXTROSE 5% /ELECTROLYTE

3

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

78  

Drug Name

Drug Tier

DEXTROSE 5%/LACTATED RING

2

DEXTROSE 5%/NACL 0.2%

2

DEXTROSE 5%/NACL 0.3%

2

DEXTROSE 5%/NACL 0.9%

2

DEXTROSE 5%/NACL 0.33%

2

DEXTROSE 5%/NACL 0.45%

2

DEXTROSE 5%/NACL 0.225%

2

DEXTROSE 5%/POTASSIUM CHL

2

DEXTROSE 10% FLEX CONTAIN

2

DEXTROSE 10%/NACL 0.2%

3

DEXTROSE 10%/NACL 0.45%

2

DEXTROSE 50%

2

DEXTROSE INJ 70%

2

IONOSOL-B/DEXTROSE 5%

4

IONOSOL-MB/DEXTROSE 5%

4

ISOLYTE P

4

ISOLYTE S

4

KCL0.15%/D5W/NACL0.2%

2

KCL0.15%/D5W/NACL0.225%

3

KCL 0.3%/D5W/NACL 0.9%

2

KCL 0.3%/D5W/NACL 0.45%

2

KCL 0.15%/D5W/NACL 0.9%

2

KCL 0.075%/D5W/NACL 0.45%

2

KCL IN NACL INJ .15-0.45

2

KCL/D5W INJ 0.3%

2

KCL/D5W/NACL INJ 0.22%/0.45%

2

KCL/D5W/NACL INJ .15/.33%

2

KCL/D5W/NACL INJ .15/.45%

2

KCL/NACL INJ 0.3-0.9

2

Requirements/Limits

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

79  

Drug Name

Drug Tier

KCL/NACL INJ 0.15%-0.9%

2

LACTATED RINGER'S INJ

2

NORMOSOL-M IN D5W

4

NORMOSOL-R

4

NORMOSOL-R IN D5W

4

PLASMA-LYTE A

4

PLASMA-LYTE-56/D5W

4

PLASMA-LYTE-148

4

pot chloride inj 2meq/ml

2

Requirements/Limits

POTASSIUM CHLORIDE SOLN .4meq/ml, 2 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml potassium chloride in nacl

2

RINGER'S

2

SODIUM CHLORIDE SOLN 3%, 5%

2

SODIUM CHLORIDE 0.45% VIA

2

SODIUM CHLORIDE INJ 0.9%

2

VITAMINS calcitriol CAPS

3

B/D

calcitriol inj

4

B/D

calcitriol oral soln 1 mcg/ml

4

B/D

paricalcitol CAPS

4

B/D

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG 2 (GENERIC) OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc

3

blephamide OINT

4

neomycin-polymy-dexameth

2

neomycin-polymyxin-hc (ophth)

4

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

80  

Drug Name

Drug Tier

sulfacetamide sod-prednisolone

2

TOBRADEX OINT

3

TOBRADEX ST

3

tobramycin-dexamethasone

4

ZYLET

3

Requirements/Limits

ANTI-INFECTIVES bacitracin (ophthalmic)

3

bacitracin-polymyxin b (ophth)

2

BESIVANCE

3

CILOXAN OINT

3

ciprofloxacin hcl (ophth)

2

erythromycin (ophth)

2

gatifloxacin (ophth)

4

gentak

2

gentamicin sulfate (ophth)

2

ilotycin

2

MOXEZA

3

NATACYN

4

neomycin-bacitracin zn-polymyxin

3

neomycin-polymyxin-gramicidin

3

ofloxacin (ophth)

2

polymyxin b-trimethoprim

2

sulfacet sod oin 10% op

3

sulfacetamide sodium (ophth)

3

tobramycin (ophth)

2

TOBREX OINT

4

trifluridine SOLN

4

VIGAMOX

3

ZIRGAN

4

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

81  

Drug Name

Drug Tier

Requirements/Limits

ANTI-INFLAMMATORIES ALREX

3

bromfenac sodium (ophth)

4

BROMFENAC SODIUM (OPHTH)(ONCEDAILY)

4

dexamethasone sodium phosphate (ophth)

2

diclofenac sodium (ophth)

2

DUREZOL

3

FLUOROMETHOLONE

3

flurbiprofen sodium

2

ILEVRO

3

ketorolac tromethamine (ophth)

3

LOTEMAX

3

MAXIDEX

3

PREDNISOLONE ACETATE (OPHTH)

3

prednisolone sodium phosphate (ophth)

3

ANTIALLERGICS azelastine drop 0.05%

3

BEPREVE

3

cromolyn sodium (ophth)

2

LASTACAFT

4

PATADAY

3

PAZEO

3

ANTIGLAUCOMA ALPHAGAN P SOL 0.1%

3

AZOPT

3

betaxolol hcl (ophth)

3

BETOPTIC-S

3

brimonidine sol 0.2%

2

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

82  

Drug Name

Drug Tier

BRIMONIDINE SOL 0.15%

3

carteolol hcl (ophth)

2

COMBIGAN

3

dorzolamide hcl

3

dorzolamide hcl-timolol maleate

3

ISTALOL

3

latanoprost SOLN

2

levobunolol hcl

3

LUMIGAN

3

metipranolol

3

PHOSPHOLINE IODIDE

4

PILOCARPINE HCL SOLN

3

SIMBRINZA

3

timolol maleate (ophth)

1

TIMOLOL MALEATE GEL

4

TRAVATAN Z

3

Requirements/Limits

MISCELLANEOUS naphazoline hcl SOLN

1

PROLENSA

3

proparacaine hcl SOLN

2

RESTASIS

3

QL (64 vials / 30 days)

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA

3

QL (60 inhalations / 30 days)

COMBIVENT RESPIMAT

4

QL (2 inhalers / 30 days)

ipratropium-albuterol nebu

3

B/D

4

QL (2 inhalers / 30 days)

ANTICHOLINERGICS ATROVENT HFA

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

83  

Drug Name

Drug Tier

Requirements/Limits

INCRUSE ELLIPTA

3

QL (1 inhaler / 30 days)

ipratropium bromide SOLN

2

B/D

ipratropium bromide (nasal)

3

ANTIHISTAMINES ASTEPRO

3

azelastine spr 0.1%

3

azelastine spr 0.15%

3

cetirizine syrup

3

diphenhydramine hcl inj

2

hydroxyzine hcl SOLN

4

levocetirizine dihydrochloride SOLN

4

levocetirizine dihydrochloride TABS

3

olopatadine hcl (nasal)

4

PA; PA if 65 years and older

BETA AGONISTS albuterol sulfate NEBU

2

B/D

albuterol sulfate SYRP

1

albuterol sulfate TABS; TB12

4

levalbuterol conc 1.25mg/0.5ml

4

B/D

PERFOROMIST

4

B/D

SEREVENT DISKUS

3

QL (60 inhalations / 30 days)

terbutaline sulfate SOLN

5

terbutaline sulfate TABS

3

VENTOLIN HFA

3

QL (2 inhalers / 30 days)

XOPENEX HFA

3

QL (2 inhalers / 30 days)

LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW; TABS

3

montelukast sodium PACK

4

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

84  

Drug Name zafirlukast

Drug Tier

Requirements/Limits

4

MAST CELL STABILIZERS cromolyn sod neb 20mg/2ml

3

B/D

acetylcysteine SOLN 10%, 20%

3

B/D

ARALAST NP

5

NM, LA, PA

DALIRESP

4

EPIPEN 2-PAK

3

EPIPEN-JR 2-PAK

3

ESBRIET

5

NM, PA

KALYDECO

5

NM, PA

OFEV

5

NM, PA

ORKAMBI

5

NM, PA

PROLASTIN-C

5

NM, LA, PA

PULMOZYME

5

B/D, NM

XOLAIR

5

NM, LA, PA

ZEMAIRA

5

NM, LA, PA

flunisolide (nasal)

3

QL (2 bottles / 30 days)

fluticasone propionate (nasal)

2

QL (1 bottle / 30 days)

NASONEX

3

QL (2 inhalers / 30 days)

ARNUITY ELLIPTA

3

QL (30 inhalations / 30 days)

budesonide (inhalation) .25mg/2ml, .5mg/2ml

4

B/D

FLOVENT DISKUS 50mcg/blist, 100mcg/blist

3

QL (120 inhalations / 30 days)

FLOVENT DISKUS 250mcg/blist

3

QL (240 inhalations / 30 days)

MISCELLANEOUS

NASAL STEROIDS

STEROID INHALANTS

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

85  

Drug Name

Drug Tier

Requirements/Limits

FLOVENT HFA

3

QL (2 inhalers / 30 days)

PULMICORT FLEXHALER

3

QL (2 inhalers / 30 days)

ADVAIR DISKUS

3

QL (60 inhalations / 30 days)

ADVAIR HFA

3

QL (1 inhaler / 30 days)

BREO ELLIPTA

3

QL (60 blisters / 30 days)

SYMBICORT

3

QL (1 inhaler / 30 days)

STEROID/BETA-AGONIST COMBINATIONS

XANTHINES aminophylline inj

3

elixophyllin

4

theo-24

4

theophylline SOLN

4

theophylline TB12; TB24

3

TOPICAL DERMATOLOGY, ACNE adapalene CREA

4

adapalene GEL .1%

4

amnesteem

4

AVITA

4

benzoyl peroxide-erythromycin

4

claravis

4

clindacin-p

3

clindamax

4

clindamycin phosphate (topical) GEL; LOTN 4 clindamycin phosphate (topical) SOLN; SWAB

3

ery pad 2%

3

erythromycin (acne aid)

3

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

86  

Drug Name

Drug Tier

myorisan

4

sulfacetamide sodium (acne)

3

tretinoin CREA

4

TRETINOIN GEL .01%

4

tretinoin GEL .025%

4

zenatane

4

Requirements/Limits

DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical)

3

mupirocin OINT

2

SILVER SULFADIAZINE CREA

2

SSD

2

SULFAMYLON CREA

4

SULFAMYLON PACK

5

DERMATOLOGY, ANTIFUNGALS ciclopirox CREA; SUSP

3

ciclopirox GEL

4

ciclopirox shampoo 1%

4

clotrimazole (topical)

3

econazole nitrate CREA

4

ketoconazole cream

3

nyamyc

3

nystatin (topical)

3

nystop

3

DERMATOLOGY, ANTIPRURITIC DOXEPIN HCL (ANTIPRURITIC)

4

procto-med

2

procto-pak

2

proctosol hc cre 2.5%

2

proctozone hc

2

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

87  

Drug Name PRUDOXIN CRE 5%

Drug Tier

Requirements/Limits

4

DERMATOLOGY, ANTIPSORIATICS acitretin

5

calcipotriene CREA; OINT; SOLN

4

calcitrene oin 0.005%

4

8-MOP

4

TAZORAC CREA

4

PA

PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo

2

selenium sulfide LOTN

2

DERMATOLOGY, CORTICOSTEROIDS ala-cort

1

alclometasone dipropionate

3

betamethasone dipropionate (topical) CREA;3 LOTN betamethasone dipropionate (topical) OINT 4 betamethasone dipropionate augmented CREA

3

betamethasone dipropionate augmented GEL; LOTN; OINT

4

betamethasone valerate CREA; LOTN; OINT

3

clobetasol e cream 0.05%

4

clobetasol propionate CREA

4

clobetasol propionate GEL

4

clobetasol propionate OINT

4

clobetasol propionate SOLN

4

cormax

4

DESONIDE CREA

4

desonide LOTN; OINT

4

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

88  

Drug Name

Drug Tier

desoximetasone CREA

4

desoximetasone GEL

4

DESOXIMETASONE OINT .05%

4

desoximetasone OINT .25%

4

diflorasone diacetate

4

fluocinolone acetonide CREA; OINT

3

fluocinolone acetonide OIL; SOLN

4

fluocinonide CREA .05%

4

fluocinonide GEL

3

fluocinonide OINT

4

fluocinonide SOLN

4

fluocinonide-e 0.05% cream

4

fluticasone propionate CREA

2

fluticasone propionate OINT

2

halobetasol propionate

4

hydrocortisone (topical) CREA; OINT

1

hydrocortisone (topical) LOTN

3

hydrocortisone butyrate

4

hydrocortisone valerate

4

lokara

4

mometasone furoate CREA; OINT; SOLN

3

texacort soln 2.5%

4

triamcinolone acetonide (topical) CREA; OINT

2

triamcinolone acetonide (topical) LOTN

3

triderm

2

Requirements/Limits

DERMATOLOGY, LOCAL ANESTHETICS lidocaine PTCH

4

lidocaine hcl GEL

2

QL (3 patches / 1 day), PA

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

89  

Drug Name

Drug Tier

lidocaine hcl SOLN 4%

1

lidocaine oint 5%

4

lidocaine-prilocaine

3

Requirements/Limits

B/D

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical

4

ammonium lactate CREA

3

ammonium lactate LOTN

2

ELIDEL

4

fluorouracil (topical) CREA 5%

4

fluorouracil (topical) SOLN

4

imiquimod CREA

4

metronidazole (topical) CREA; LOTN

4

metronidazole gel 0.75%

4

PANRETIN

5

podofilox SOLN

3

rosadan cre 0.75%

4

tacrolimus (topical)

4

PA

TARGRETIN GEL

5

NM, PA

VALCHLOR

5

NM, LA, PA

VOLTAREN

3

PA

DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX

4

malathion

4

permethrin

3

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25%

2

REGRANEX

5

SANTYL

4

SODIUM CHLORIDE 0.9%

1

PA

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

90  

Drug Name STERILE WATER IRRIGATION

Drug Tier

Requirements/Limits

3

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl

4

chlorhexidine gluconate (mouth-throat)

1

clotrimazole TROC

4

lidocaine hcl (mouth-throat)

1

nystatin (mouth-throat)

3

paroex sol 0.12%

1

periogard

1

PILOCARPINE HCL (ORAL) 5mg

4

pilocarpine hcl (oral) 7.5mg

4

triamcinolone acetonide (mouth)

3

OTIC acetic acid (otic)

3

acetic acid-aluminum acetate

3

CIPRODEX

3

fluocinolone acetonide (otic)

4

neomycin-polymyxin-hc (otic)

2

ofloxacin (otic)

2

PA  -­  Prior  Authorization        QL  -­  Quantity  Limits        ST  -­  Step  Therapy        NM  -­  Not   available  at  mail-­order        B/D  -­  Covered  under  Medicare  B  or  D        LA  -­  Limited   Access          

91  

Index 8   8-MOP ............................................. 88 A   abacavir sulfate .................................. 14 abacavir sulfate-lamivudine-zidovudine ...... 16 ABELCET ......................................... 13 ABILIFY DISCMELT TAB 10MG .............. 46 ABILIFY MAINTENA ............................ 46 ABRAXANE....................................... 23 acamprosate calcium............................ 53 acarbose .......................................... 55 acebutolol hcl ..................................... 33 acetaminophen w/ codeine ...................... 9 acetazolamide .................................... 36 acetic acid......................................... 90 acetic acid (otic) .................................. 91 acetic acid-aluminum acetate .................. 91 acetylcysteine .................................... 85 acitretin ............................................ 88 ACTHIB ........................................... 75 ACTIMMUNE ..................................... 74 acyclovir ........................................... 17 acyclovir sodium ................................. 17 acyclovir topical .................................. 90 ADACEL........................................... 75 ADAGEN .......................................... 62 adapalene ......................................... 86 adefovir dipivoxil ................................. 17 ADEMPAS ........................................ 37 adrucil ............................................. 23 adrucil inj .......................................... 23 ADVAIR DISKUS ................................ 86 ADVAIR HFA ..................................... 86 afeditab cr ......................................... 34 AFINITOR ......................................... 26 AFINITOR DISPERZ ............................ 26 AGGRENOX ...................................... 73 a-hydrocort ........................................ 63 ala-cort ............................................ 88 ALBENZA ......................................... 11 albuterol sulfate .................................. 84 alclometasone dipropionate .................... 88

ALCOHOL SWABS .............................. 54 ALDURAZYME ................................... 62 ALECENSA ....................................... 26 alendronate sodium ............................. 57 alfuzosin hcl ...................................... 70 ALIMTA............................................ 23 ALINIA ............................................. 11 allopurinol tab ..................................... 8 alosetron hcl ...................................... 69 ALPHAGAN P SOL 0.1% ....................... 82 alprazolam tab 0.25mg.......................... 38 alprazolam tab 0.5mg ........................... 38 alprazolam tab 1mg ............................. 38 alprazolam tab 2 mg ............................. 38 ALREX ............................................ 82 altavera ............................................ 58 amantadine hcl ................................... 46 AMBISOME ....................................... 13 amifostine crystalline ............................ 28 amikacin sulfate .................................. 11 amiloride & hydrochlorothiazide ............... 36 amiloride hcl ...................................... 36 aminophylline inj ................................. 86 AMINOSYN ....................................... 77 AMINOSYN 7%/ELECTROLYTES ............ 77 AMINOSYN 8.5%/ELECTROLYTE ........... 77 AMINOSYN II..................................... 77 AMINOSYN II 8.5%/ELECTROL .............. 77 AMINOSYN M .................................... 77 AMINOSYN-HBC ................................ 78 AMINOSYN-PF 7% .............................. 78 AMINOSYN-PF INJ 10% ....................... 78 AMINOSYN-RF .................................. 78 amiodarone hcl ................................... 31 AMITIZA CAP 24MCG .......................... 69 AMITIZA CAP 8MCG............................ 69 amitriptyline hcl................................... 43 amlodipine besylate ............................. 34 amlodipine besylate-benazepril hcl cap 10-20 mg .................................................. 29 amlodipine besylate-benazepril hcl cap 10-40 mg .................................................. 29 92  

amlodipine besylate-benazepril hcl cap 2.5-10 mg .................................................. 28 amlodipine besylate-benazepril hcl cap 5-10 mg .................................................. 28 amlodipine besylate-benazepril hcl cap 5-20 mg .................................................. 28 amlodipine besylate-benazepril hcl cap 5-40 mg .................................................. 29 amlodipine besylate-valsartan tab 10-160 mg ...................................................... 30 amlodipine besylate-valsartan tab 10-320 mg ...................................................... 30 amlodipine besylate-valsartan tab 5-160 mg 30 amlodipine besylate-valsartan tab 5-320 mg 30 amlodipine-valsartan-hydrochlorothiazide 10160-12.5mg ....................................... 30 amlodipine-valsartan-hydrochlorothiazide 10160-25mg ......................................... 30 amlodipine-valsartan-hydrochlorothiazide 10320-25mg ......................................... 30 amlodipine-valsartan-hydrochlorothiazide 5160-12.5mg ....................................... 30 amlodipine-valsartan-hydrochlorothiazide 5160-25mg ......................................... 30 ammonium lactate ............................... 90 amnesteem ....................................... 86 amoxapine ........................................ 43 amoxicillin ......................................... 20 amoxicillin & pot clavulanate ............. 20, 21 amphetamine-dextroamphetamine cap sr 24hr 10 mg .............................................. 50 amphetamine-dextroamphetamine cap sr 24hr 15 mg .............................................. 50 amphetamine-dextroamphetamine cap sr 24hr 20 mg .............................................. 50 amphetamine-dextroamphetamine cap sr 24hr 25 mg .............................................. 50 amphetamine-dextroamphetamine cap sr 24hr 30 mg .............................................. 50 amphetamine-dextroamphetamine cap sr 24hr 5 mg ............................................... 50 amphetamine-dextroamphetamine tab 10 mg ...................................................... 50 amphetamine-dextroamphetamine tab 12.5 mg ...................................................... 50

amphetamine-dextroamphetamine tab 15 mg ...................................................... 50 amphetamine-dextroamphetamine tab 20 mg ...................................................... 50 amphetamine-dextroamphetamine tab 30 mg ...................................................... 50 amphetamine-dextroamphetamine tab 5 mg 50 amphetamine-dextroamphetamine tab 7.5 mg ...................................................... 50 amphotericin b ................................... 13 ampicillin & sulbactam sodium ................. 21 ampicillin cap ..................................... 21 ampicillin inj ....................................... 21 ampicillin sodium................................. 21 ampicillin sus ..................................... 21 AMPYRA .......................................... 52 anagrelide hcl .................................... 72 anastrozole ....................................... 24 ANDRODERM ................................... 54 ANORO ELLIPTA ................................ 83 APOKYN .......................................... 46 apri 28 day ........................................ 58 APRISO ........................................... 67 APTIOM ........................................... 39 APTIVUS .......................................... 14 ARALAST NP .................................... 85 aranelle 28 ........................................ 58 ARCALYST ....................................... 74 aripiprazole ....................................... 46 aripiprazole oral solution 1 mg/ml ............. 46 aripiprazole tabs ................................. 46 ARNUITY ELLIPTA .............................. 85 ASACOL HD ...................................... 67 ASTEPRO ........................................ 84 atenolol ............................................ 33 atenolol & chlorthalidone ....................... 33 atorvastatin calcium ............................. 32 atovaquone ....................................... 12 atovaquone-proguanil hcl ....................... 14 ATRIPLA .......................................... 16 ATROVENT HFA ................................ 83 aubra 28 day ..................................... 58 AVASTIN .......................................... 24 aviane 28.......................................... 58 AVITA.............................................. 86 93  

AXIRON ........................................... 54 azacitidine......................................... 23 AZACTAM/DEX INJ 1GM ...................... 12 AZACTAM/DEX INJ 2GM ...................... 12 azathioprine....................................... 74 azelastine drop 0.05% .......................... 82 azelastine spr 0.1%.............................. 84 azelastine spr 0.15% ............................ 84 AZILECT .......................................... 46 AZITHROMYCIN........................... 19, 20 AZOPT ............................................ 82 AZOR 10-40MG .................................. 30 AZOR TAB 10-20MG............................ 30 AZOR TAB 5-20MG ............................. 30 AZOR TAB 5-40MG ............................. 30 aztreonam......................................... 12 B   bacitracin (ophthalmic) .......................... 81 bacitracin-polymyxin b (ophth) ................. 81 bacitracin-poly-neomycin-hc ................... 80 baclofen ........................................... 53 balsalazide disodium ............................ 67 balziva 28 day .................................... 58 BANZEL SUS 40MG/ML........................ 39 BANZEL TAB 200MG ........................... 39 BANZEL TAB 400MG ........................... 39 BARACLUDE ..................................... 17 BCG VACCINE................................... 75 bekyree 28 day ................................... 58 BELEODAQ ...................................... 24 benazepril & hydrochlorothiazide .............. 29 benazepril hcl..................................... 29 BENDEKA ........................................ 22 BENICAR ......................................... 31 BENICAR HCT 40-25MG ....................... 30 BENICAR HCT TAB 20-12.5MG .............. 30 BENICAR HCT TAB 40-12.5MG .............. 30 BENLYSTA ....................................... 74 benzoyl peroxide-erythromycin ................ 86 BENZTROPINE MESYLATE................... 46 BEPREVE......................................... 82 BESIVANCE ...................................... 81 betamethasone dipropionate (topical) ........ 88 betamethasone dipropionate augmented .... 88 betamethasone valerate ........................ 88

BETASERON..................................... 52 betaxolol hcl (ophth) ............................. 82 bethanechol chloride ............................ 70 BETOPTIC-S ..................................... 82 bexarotene ........................................ 27 BEXSERO ........................................ 75 bicalutamide ...................................... 24 BICILLIN L-A ..................................... 21 BICNU ............................................. 22 BILTRICIDE ...................................... 12 bisoprolol & hydrochlorothiazide............... 33 bisoprolol fumarate .............................. 33 BIVIGAM .......................................... 73 bleomycin sulfate ................................ 23 blephamide ....................................... 80 blisovi 21 fe 1.5/30 28 day pack ............... 58 blisovi 21 fe 1/20 28 day pack ................. 58 BOOSTRIX ....................................... 75 BOSULIF .......................................... 26 BREO ELLIPTA .................................. 86 briellyn 28 day .................................... 58 BRILINTA ......................................... 73 BRIMONIDINE SOL 0.15% .................... 83 brimonidine sol 0.2% ............................ 82 BRINTELLIX ...................................... 43 BRIVIACT INJ .................................... 39 BRIVIACT SOLN 10MG/ML .................... 39 BRIVIACT TABS ................................. 39 bromfenac sodium (ophth) ..................... 82 BROMFENAC SODIUM (OPHTH)(ONCEDAILY) ............................................. 82 bromocriptine mesylate ......................... 46 budesonide (inhalation) ......................... 85 budesonide ec .................................... 67 bumetanide inj 0.25/ml .......................... 36 bumetanide tab................................... 36 BUPHENYL ....................................... 62 buprenorphine hcl ............................... 53 buprenorphine hcl-naloxone hcl sl ............ 53 buproban tab (smoking deterrent) ............. 53 bupropion hcl ..................................... 43 bupropion hcl (smoking deterrent) ............ 53 buspirone hcl ..................................... 38 BUSULFEX ....................................... 22 butorphanol tartrate............................... 9 94  

BYDUREON ...................................... 54 BYDUREON PEN................................ 54 BYETTA ........................................... 54 BYSTOLIC ........................................ 33 C   cabergoline ....................................... 64 CABOMETYX .................................... 26 calcipotriene ...................................... 88 calcitonin (salmon)............................... 64 calcitrene oin 0.005% ........................... 88 calcitriol............................................ 80 calcitriol inj ........................................ 80 calcitriol oral soln 1 mcg/ml..................... 80 calcium acetate (phosphate binder)........... 65 camila 28 day..................................... 58 CANASA .......................................... 68 CANCIDAS ....................................... 13 CAPASTAT SULFATE .......................... 16 CAPRELSA ....................................... 26 captopril ........................................... 29 captopril & hydrochlorothiazide ................ 29 CARBAGLU ...................................... 62 carbamazepine ................................... 39 CARBIDOPA/LEVODOPA/ENTACAPONE .. 46 carbidopa-levodopa ............................. 46 carboplatin ........................................ 28 CARIMUNE NANOFILTERED ................. 73 carteolol hcl (ophth) ............................. 83 cartia xt cap 120/24hr ........................... 34 cartia xt cap 180/24hr ........................... 34 cartia xt cap 240/24hr ........................... 34 cartia xt cap 300/24hr ........................... 34 carvedilol .......................................... 33 CAYSTON ........................................ 12 caziant 28 day .................................... 58 cefaclor ............................................ 18 cefaclor er tab 500mg ........................... 18 cefadroxil .................................... 18, 19 cefazolin in dextrose 1gm/50ml-5% ........... 19 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ...................................................... 19 cefazolin inj ....................................... 19 cefazolin sodium ................................. 19 cefdinir ............................................. 19 cefepime hcl ...................................... 19

cefixime ........................................... 19 cefotaxime sodium............................... 19 cefoxitin sodium .................................. 19 cefpodoxime proxetil ............................ 19 cefprozil ........................................... 19 ceftazidime ........................................ 19 CEFTAZIDIME/DEXTROSE ................... 19 ceftriaxone sodium .............................. 19 cefuroxime axetil ................................. 19 cefuroxime sodium .............................. 19 celecoxib ........................................... 8 CELONTIN ........................................ 39 cephalexin ........................................ 19 CERDELGA ...................................... 62 CEREZYME ...................................... 62 CERVARIX ....................................... 75 cetirizine syrup ................................... 84 cevimeline hcl .................................... 91 CHANTIX ......................................... 53 CHANTIX CONTINUING MONTH ............ 53 CHANTIX STARTER PACK .................... 53 CHEMET .......................................... 57 chlorhexidine gluconate (mouth-throat) ...... 91 chloroquine phosphate .......................... 14 chlorothiazide tabs............................... 36 chlorpromazine hcl .............................. 46 chlorpromazine inj ............................... 46 chlorthalidone .................................... 36 cholestyramine ................................... 32 cholestyramine light ............................. 32 choline fenofibrate cap dr 135 mg ............. 32 choline fenofibrate cap dr 45 mg .............. 32 ciclopirox .......................................... 87 ciclopirox shampoo 1% ......................... 87 cilostazol .......................................... 72 CILOXAN ......................................... 81 CIMZIA ............................................ 73 CIMZIA STARTER KIT.......................... 73 CINRYZE ......................................... 72 CIPRODEX ....................................... 91 ciprofloxacin ...................................... 20 ciprofloxacin er ................................... 20 ciprofloxacin hcl (ophth) ........................ 81 ciprofloxacin hcl tab ............................. 20 ciprofloxacin in d5w.............................. 20 95  

ciprofloxacin inj 200mg/20ml ................... 20 ciprofloxacin inj 400mg/40ml ................... 20 cisplatin............................................ 28 citalopram hydrobromide ....................... 43 cladribine .......................................... 23 claravis ............................................ 86 clarithromycin..................................... 20 clarithromycin er ................................. 20 clarithromycin for susp .......................... 20 clindacin-p ........................................ 86 clindamax ......................................... 86 clindamycin cap 300 mg ........................ 12 clindamycin cap 75mg .......................... 12 clindamycin hcl cap 150 mg .................... 12 clindamycin phosphate.......................... 12 clindamycin phosphate (topical) ............... 86 clindamycin phosphate in d5w ................. 12 clindamycin phosphate inj ...................... 12 clindamycin phosphate vaginal ................ 71 clindamycin soln ................................. 12 CLINIMIX 2.75%/DEXTROSE 5% ............ 78 CLINIMIX 4.25%/DEXTROSE 25% ........... 78 CLINIMIX 4.25%/DEXTROSE 5% ............ 78 CLINIMIX 5%/DEXTROSE 15% ............... 78 CLINIMIX 5%/DEXTROSE 20% ............... 78 CLINIMIX 5%/DEXTROSE 25% ............... 78 CLINIMIX INJ 4.25/D10 ......................... 78 CLINIMIX INJ 4.25/D20 ......................... 78 clobetasol e cream 0.05% ...................... 88 clobetasol propionate ........................... 88 clomipramine hcl ................................. 43 clonazepam ....................................... 39 clonidine hcl ...................................... 36 clopidogrel tab 75mg ............................ 73 clorazepate dipotassium ........................ 39 clotrimazole ....................................... 91 clotrimazole (topical) ............................ 87 clozapine .................................... 46, 47 clozapine tab 25mg .............................. 47 clozapine tab 50mg .............................. 47 COARTEM ........................................ 14 colchicine w/ probenecid......................... 8 COLCRYS ......................................... 8 colestipol hcl ...................................... 32 colistimethate sodium ........................... 12

colocort ............................................ 68 COMBIGAN....................................... 83 COMBIVENT RESPIMAT ...................... 83 COMETRIQ ....................................... 26 COMPLERA ...................................... 16 compro supp ...................................... 66 COMVAX .......................................... 75 constulose ........................................ 68 COPAXONE INJ 20MG/ML .................... 52 COPAXONE INJ 40MG/ML .................... 52 cormax ............................................ 88 cortisone acetate................................. 63 COTELLIC ........................................ 26 COUMADIN....................................... 71 CREON............................................ 69 CRESTOR ........................................ 32 CRIXIVAN......................................... 14 cromolyn sod neb 20mg/2ml ................... 85 cromolyn sodium (mastocytosis) .............. 69 cromolyn sodium (ophth) ....................... 82 cryselle 28 ........................................ 58 CUBICIN .......................................... 12 CUVPOSA ........................................ 67 cyclafem 1/35 28 day............................ 58 cyclafem 7/7/7 28 day ........................... 58 CYCLOPHOSPHAMIDE ........................ 22 cycloserine ........................................ 16 cyclosporine ...................................... 74 cyclosporine modified (for microemulsion) ... 74 cyred tab .......................................... 58 CYSTADANE ..................................... 62 CYSTAGON ...................................... 62 cytarabine ......................................... 23 D   dacarbazine....................................... 22 DAKLINZA ........................................ 17 DALIRESP ........................................ 85 danazol ............................................ 62 dantrolene sodium ............................... 53 dapsone ........................................... 12 DAPTACEL ....................................... 75 daptomycin ....................................... 12 DARAPRIM ....................................... 12 daunorubicin hcl ................................. 22 deblitane 28 day ................................. 58 96  

DELESTROGEN ................................. 62 delyla 28 day ..................................... 58 DELZICOL ........................................ 68 DEMSER .......................................... 36 DEPEN TITRATABS ............................ 57 DEPO-PROVERA INJ 400/ML................. 25 DESCOVY ........................................ 16 desipramine hcl .................................. 43 desmopressin acetate spray ................... 65 desmopressin acetate spray refrigerated .... 66 desmopressin acetate tabs ..................... 66 desmopressin inj 4mcg/ml ...................... 66 DESMOPRESSIN SOL 0.01%................. 66 desogestrel-ethinyl estradiol (biphasic) ....... 58 DESONIDE ....................................... 88 desoximetasone ................................. 89 dexamethasone .................................. 63 dexamethasone sodium phosphate ........... 63 dexamethasone sodium phosphate (ophth) . 82 DEXILANT ........................................ 69 dexrazoxane ...................................... 28 DEXTROSE 10% FLEX CONTAIN ........... 79 DEXTROSE 10%/NACL 0.2% ................. 79 DEXTROSE 10%/NACL 0.45% ............... 79 DEXTROSE 2.5%/NACL 0.45% ............... 78 DEXTROSE 5% .................................. 78 DEXTROSE 5% /ELECTROLYTE ............ 78 DEXTROSE 5%/LACTATED RING ........... 79 DEXTROSE 5%/NACL 0.2%................... 79 DEXTROSE 5%/NACL 0.225% ............... 79 DEXTROSE 5%/NACL 0.3%................... 79 DEXTROSE 5%/NACL 0.33% ................. 79 DEXTROSE 5%/NACL 0.45% ................. 79 DEXTROSE 5%/NACL 0.9%................... 79 DEXTROSE 5%/POTASSIUM CHL .......... 79 DEXTROSE 50% ................................ 79 DEXTROSE INJ 70% ........................... 79 diazepam.......................................... 39 DIAZEPAM GEL ................................. 40 diazepam inj ...................................... 40 diclofenac potassium ............................. 8 diclofenac sodium ................................ 8 diclofenac sodium (ophth) ...................... 82 dicloxacillin sodium .............................. 21 dicyclomine hcl ................................... 67

didanosine ........................................ 14 DIFICID............................................ 20 diflorasone diacetate ............................ 89 diflunisal ............................................ 8 digitek.............................................. 35 digox ............................................... 35 digoxin ............................................. 35 digoxin inj ......................................... 35 DIGOXIN SOL 50MCG/ML ..................... 35 dihydroergotamine mesylate ................... 51 dilantin ............................................. 40 DILANTIN-125 SUS 125/5ML .................. 40 diltiazem cap ..................................... 34 diltiazem cap 120mg/24hr ...................... 34 diltiazem cap 240mg/24hr ...................... 34 diltiazem cap er/12hr ............................ 34 diltiazem hcl ...................................... 34 diltiazem hcl coated beads ..................... 34 dilt-xr cap .......................................... 34 DIPENTUM ....................................... 68 diphenhydramine hcl inj ......................... 84 diphenoxylate w/ atropine ...................... 69 DIPHTHERIA/TETANUS TOXOID ............ 75 disopyramide phosphate........................ 31 disulfiram .......................................... 53 divalproex sodium ............................... 40 DOCETAXEL ..................................... 23 DOCETAXEL SOLN 80MG/8ML .............. 23 dofetilide .......................................... 31 donepezil hydrochloride ........................ 42 dorzolamide hcl .................................. 83 dorzolamide hcl-timolol maleate ............... 83 doxazosin mesylate ............................. 29 doxepin hcl ........................................ 43 DOXEPIN HCL (ANTIPRURITIC) ............. 87 doxorubicin hcl ................................... 22 doxorubicin hcl liposomal inj 2mg/ml ......... 22 doxorubicin inj 50mg ............................ 22 doxy ................................................ 21 doxycycline (monohydrate) ..................... 21 doxycycline hyclate .............................. 21 dronabinol ......................................... 66 drospirenone-ethinyl estradiol ................. 58 DROXIA ........................................... 27 duloxetine hcl ..................................... 43 97  

DURAMORPH .................................... 9 DUREZOL ........................................ 82 dutasteride ........................................ 70 dutasteride-tamsulosin hcl...................... 70 E   e.e.s. ............................................... 20 econazole nitrate................................. 87 EDURANT ........................................ 14 EFFIENT .......................................... 73 ELIDEL ............................................ 90 ELIQUIS ........................................... 71 ELITEK ............................................ 28 elixophyllin ........................................ 86 ELLA ............................................... 58 ELMIRON ......................................... 70 EMCYT ............................................ 22 EMEND............................................ 66 EMEND CAP 125MG ........................... 66 EMEND CAP 40MG ............................. 66 EMEND CAP 80MG ............................. 66 EMEND PAK 80 & 125.......................... 66 emoquette......................................... 58 EMSAM ........................................... 43 EMTRIVA ......................................... 14 emverm............................................ 12 enalapril maleate................................. 29 enalapril maleate & hydrochlorothiazide ..... 29 endocet ............................................. 9 ENGERIX-B ...................................... 75 enoxaparin sodium .............................. 71 enpresse 28 day ................................. 58 ENTACAPONE................................... 46 entecavir .......................................... 17 ENTRESTO....................................... 30 enulose ............................................ 68 EPIPEN 2-PAK ................................... 85 EPIPEN-JR 2-PAK .............................. 85 epirubicin hcl ..................................... 22 epitol ............................................... 40 EPIVIR HBV ...................................... 17 eplerenone ........................................ 29 EPZICOM ......................................... 16 ERIVEDGE ....................................... 24 errin 28 day ....................................... 58 ery pad 2% ........................................ 86

ery-tab ............................................. 20 erythrocin lactobionate .......................... 20 erythrocin stearate ............................... 20 erythromycin (acne aid) ......................... 86 erythromycin (ophth) ............................ 81 erythromycin base ............................... 20 erythromycin cap 250mg ec .................... 20 erythromycin ethylsuccinate.................... 20 ESBRIET .......................................... 85 escitalopram oxalate ...................... 43, 44 esomeprazole sodium inj ....................... 69 estarylla tab 0.25-35 ............................. 58 estrace ............................................ 62 estrad val inj 20mg/ml ........................... 62 estrad val inj 40mg/ml ........................... 62 estradiol ..................................... 62, 63 ethambutol hcl .................................... 16 ethosuximide ..................................... 40 etodolac ............................................ 8 etoposide.......................................... 28 EURAX ............................................ 90 EVOTAZ........................................... 16 EXELON PATCHES ............................. 42 exemestane....................................... 25 EXJADE ........................................... 57 F   FABRAZYME ..................................... 62 falmina 28 day .................................... 58 famciclovir......................................... 17 famotidine ......................................... 67 famotidine inj ..................................... 67 FANAPT ........................................... 47 FANAPT TITRATION PACK ................... 47 FARESTON....................................... 25 FARXIGA ......................................... 55 FARYDAK......................................... 24 FASLODEX ....................................... 25 FAZACLO ......................................... 47 felbamate ......................................... 40 felodipine .......................................... 34 fenofibrate......................................... 32 fenofibrate micronized .......................... 32 fentanyl citrate ..................................... 9 fentanyl patch 100 mcg/hr ....................... 9 fentanyl patch 12 mcg/hr ........................ 9 98  

fentanyl patch 25 mcg/hr ........................ 9 fentanyl patch 50 mcg/hr ........................ 9 fentanyl patch 75 mcg/hr ........................ 9 FENTORA ......................................... 9 FERRIPROX ..................................... 57 FETZIMA .......................................... 44 FETZIMA TITRATION PACK .................. 44 finasteride ......................................... 70 FIRAZYR .......................................... 72 FLEBOGAMMA .................................. 73 FLEBOGAMMA DIF ............................. 73 flecainide acetate ................................ 31 FLOVENT DISKUS .............................. 85 FLOVENT HFA................................... 86 fluconazole ........................................ 13 fluconazole in dextrose ......................... 13 fluconazole in nacl ............................... 13 fluconazole in nacl 0.9% inj .................... 13 flucytosine......................................... 14 fludarabine phosphate .......................... 23 fludrocortisone acetate .......................... 63 flunisolide (nasal) ................................ 85 fluocinolone acetonide .......................... 89 fluocinolone acetonide (otic) ................... 91 fluocinonide ....................................... 89 fluocinonide-e 0.05% cream ................... 89 FLUOROMETHOLONE ......................... 82 fluorouracil ........................................ 23 fluorouracil (topical).............................. 90 fluoxetine cap 10mg ............................. 44 fluoxetine cap 20mg ............................. 44 fluoxetine cap 40mg ............................. 44 fluoxetine hcl ..................................... 44 fluphenazine decanoate ........................ 47 fluphenazine hcl .................................. 47 flurbiprofen ......................................... 8 flurbiprofen sodium .............................. 82 flutamide .......................................... 25 fluticasone propionate ........................... 89 fluticasone propionate (nasal) ................. 85 fluvoxamine maleate ............................ 38 fondaparinux sodium ............................ 71 FORTEO .......................................... 65 FORTICAL ........................................ 64 fosinopril sodium ................................. 29

fosinopril sodium & hydrochlorothiazide ...... 29 FREAMINE HBC 6.9% .......................... 78 FREAMINE III .................................... 78 furosemide ........................................ 36 furosemide inj .................................... 36 FUSILEV .......................................... 28 FUZEON .......................................... 14 fyavolv tab 1 mg-5 mcg ......................... 63 FYCOMPA ........................................ 40 G   gabapentin ........................................ 40 GABITRIL ......................................... 40 galantamine hydrobromide ..................... 42 galantamine hydrobromide er ............ 42, 43 GAMASTAN S/D ................................. 73 GAMMAGARD LIQUID ......................... 73 GAMMAGARD S/D .............................. 73 GAMMAKED ..................................... 73 GAMMAPLEX .................................... 74 GAMUNEX-C ..................................... 74 ganciclovir inj 500mg ............................ 17 GARDASIL ........................................ 75 GARDASIL 9 ..................................... 75 gatifloxacin (ophth) .............................. 81 GATTEX........................................... 69 GAUZE PADS 2" X 2" ........................... 54 gaviltye-g .......................................... 68 gavilyte-c .......................................... 68 gavilyte-h .......................................... 68 gavilyte-n .......................................... 68 GEMCITABINE HCL ............................ 23 gemfibrozil ........................................ 32 generlac ........................................... 68 gengraf ............................................ 74 gentak ............................................. 81 gentamicin in saline ............................. 11 gentamicin sulfate ............................... 11 gentamicin sulfate (ophth) ...................... 81 gentamicin sulfate (topical) ..................... 87 GENVOYA ........................................ 16 GEODON ......................................... 47 GIANVI TAB 3-0.02MG ......................... 58 gildagia ............................................ 58 gildess 1.5/30 21 day............................ 58 GILENYA .......................................... 52 99  

GILOTRIF TAB 20MG .......................... 26 GILOTRIF TAB 30MG .......................... 26 GILOTRIF TAB 40MG .......................... 26 GLEOSTINE ...................................... 22 glimepiride ........................................ 55 glip/metform tab 5-500mg ...................... 55 glipizide...................................... 55, 56 GLIPIZIDE XL TB24 2.5MG .................... 56 GLIPIZIDE XL TB24 5MG ...................... 56 glipizide-metformin hcl tab 2.5-250 mg ....... 56 glipizide-metformin hcl tab 2.5-500 mg ....... 56 GLUCAGEN HYPOKIT ......................... 64 GLUCAGON EMERGENCY KIT .............. 64 glycopyrrolate .................................... 67 glycopyrrolate inj ................................. 67 GOLYTELY ....................................... 68 granisetron hcl ................................... 66 GRANIX ........................................... 72 griseofulvin microsize ........................... 14 griseofulvin ultramicrosize ...................... 14 guanfacine er (adhd) ............................ 50 H   halobetasol propionate .......................... 89 haloperidol ........................................ 47 haloperidol con lactate .......................... 47 haloperidol decanoate .......................... 47 haloperidol lactate inj 5 mg/ml ................. 47 HARVONI ......................................... 17 HAVRIX ........................................... 75 heather ............................................ 59 HEPARIN SOD (PORCINE) IN D5W ......... 71 heparin sod inj 1000/ml ......................... 71 heparin sod inj 10000/ml........................ 71 heparin sod inj 20000/ml........................ 71 heparin sod inj 5000/ml ......................... 71 HEPARIN SODIUM/D5W ....................... 71 HEPARIN SODIUM/NACL 0.45% ............. 71 HEPATAMINE .................................... 78 HERCEPTIN ...................................... 24 HETLIOZ .......................................... 51 HEXALEN ......................................... 22 HIBERIX........................................... 75 HUMIRA INJ 10MG/0.2ML ..................... 73 HUMIRA KIT 20MG/0.4ML ..................... 73 HUMIRA KIT 40MG/0.8ML ..................... 73

HUMIRA PEDIATRIC CROHNS............... 73 HUMIRA PEN .................................... 73 HUMIRA PEN-CROHNS DISEASE ........... 73 HUMIRA PEN-PSORIASIS STAR ............ 73 HUMULIN R U-500 KWIKPEN................. 54 HUMULIN R U-500 VIAL (CONCENTRATE) 54 hydralazine hcl ............................. 36, 37 hydrochlorothiazide .............................. 36 hydroco/apap tab 10-325mg .................... 9 hydroco/apap tab 5-325mg ...................... 9 hydroco/apap tab 7.5-325 ....................... 9 hydrocodone-acetaminophen 7.5-325 mg/15ml ....................................................... 9 hydrocodone-ibuprofen tab 7.5-200 mg ....... 9 hydrocortisone ................................... 63 HYDROCORTISONE (INTRARECTAL)...... 68 hydrocortisone (topical) ......................... 89 hydrocortisone butyrate ......................... 89 hydrocortisone valerate ......................... 89 hydromorphon inj 10mg/ml ...................... 9 hydromorphone hcl .......................... 9, 10 hydroxychloroquine sulfate ..................... 73 hydroxyprogesterone caproate (antineoplastic) ...................................................... 25 hydroxyurea ...................................... 27 hydroxyzine hcl................................... 84 I   ibandronate tab 150mg ......................... 57 IBRANCE ......................................... 24 ibuprofen ........................................... 8 ICLUSIG........................................... 26 idarubicin hcl ..................................... 22 IFEX INJ 3GM .................................... 22 ifosfamide inj 1gm ............................... 22 ifosfamide inj 1gm/20ml ......................... 22 IFOSFAMIDE INJ 3GM ......................... 22 ifosfamide inj 3gm/60ml ......................... 22 ILEVRO ........................................... 82 ilotycin ............................................. 81 imatinib mesylate ................................ 26 IMBRUVICA CAP 140MG ...................... 26 imipenem-cilastatin .............................. 12 imipramine hcl .................................... 44 imiquimod ......................................... 90 IMOVAX RABIES (H.D.C.V.)................... 75 100  

INCRELEX ........................................ 64 INCRUSE ELLIPTA ............................. 84 indapamide ....................................... 36 INFANRIX ......................................... 75 INLYTA ............................................ 26 INSULIN PEN NEEDLE ........................ 54 INSULIN SAFETY NEEDLES .................. 54 INSULIN SYRINGE.............................. 54 INTELENCE ...................................... 14 INTRALIPID INJ 20% ........................... 78 INTRALIPID INJ 30% ........................... 78 INTRON-A INJ 10MU ........................... 74 INTRON-A INJ 18MU ........................... 74 INTRON-A INJ 25MU ........................... 74 INTRON-A INJ 50MU ........................... 74 introvale 91 day .................................. 59 INVANZ ........................................... 12 INVEGA ........................................... 47 INVEGA SUST INJ 117 MG/0.75 ML ......... 47 INVEGA SUST INJ 156MG/ML ................ 47 INVEGA SUST INJ 234 MG/1.5 ML .......... 47 INVEGA SUST INJ 39 MG/0.25 ML .......... 47 INVEGA SUST INJ 78 MG/0.5 ML ............ 47 INVEGA TRINZA ................................ 47 INVIRASE ......................................... 15 INVOKAMET TAB 150-1000 ................... 56 INVOKAMET TAB 150-500 .................... 56 INVOKAMET TAB 50-1000 .................... 56 INVOKAMET TAB 50-500MG ................. 56 INVOKANA ....................................... 56 IONOSOL-B/DEXTROSE 5% .................. 79 IONOSOL-MB/DEXTROSE 5% ............... 79 IPOL INACTIVATED IPV ....................... 75 ipratropium bromide ............................. 84 ipratropium bromide (nasal) .................... 84 ipratropium-albuterol nebu ..................... 83 irbesartan ......................................... 31 irbesartan-hydrochlorothiazide................. 30 IRESSA ........................................... 26 irinotecan inj 100/5ml............................ 28 irinotecan inj 40mg/2ml ......................... 28 irinotecan inj 500mg/25ml ...................... 28 ISENTRESS ...................................... 15 ISOLYTE P ....................................... 79 ISOLYTE S ....................................... 79

isoniazid ........................................... 16 isoniazid inj 100 mg/ml .......................... 16 isoniazid syp 50mg/5ml ......................... 17 isosorb mononitrate tab ......................... 37 isosorbide dinitrate .............................. 37 isosorbide dinitrate er ........................... 37 isosorbide mononitrate er ...................... 37 isradipine .......................................... 34 ISTALOL .......................................... 83 ISTODAX ......................................... 24 itraconazole ....................................... 14 ivermectin ......................................... 12 IXIARO ............................................ 75 J   JAKAFI ............................................ 26 jantoven ........................................... 71 JANUMET......................................... 56 JANUMET XR TAB 100-1000 ................. 56 JANUMET XR TAB 50-1000 ................... 56 JANUMET XR TAB 50-500MG ................ 56 JANUVIA .......................................... 56 JENTADUETO ................................... 56 JENTADUETO XR 2.5-1000MG............... 56 JENTADUETO XR 5-1000MG ................. 56 jinteli ............................................... 63 JOLESSA TAB 0.15-0.03 MG ................. 59 JOLIVETTE ....................................... 59 juleber 28 day .................................... 59 junel 1.5/30 21 day .............................. 59 junel 1/20 21 day................................. 59 junel fe 1.5/30 28 day ........................... 59 junel fe 1/20 28 day.............................. 59 JUXTAPID ........................................ 32 K   KADCYLA ......................................... 24 KALETRA SOL ................................... 16 KALETRA TAB 100-25MG ..................... 16 KALETRA TAB 200-50MG ..................... 16 KALYDECO....................................... 85 kariva 28 day ..................................... 59 KCL 0.075%/D5W/NACL 0.45%............... 79 KCL 0.15%/D5W/NACL 0.9% .................. 79 KCL 0.3%/D5W/NACL 0.45% .................. 79 KCL 0.3%/D5W/NACL 0.9% ................... 79 KCL IN NACL INJ .15-0.45 ..................... 79 101  

KCL/D5W INJ 0.3% ............................. 79 KCL/D5W/NACL INJ .15/.33% ................. 79 KCL/D5W/NACL INJ .15/.45% ................. 79 KCL/D5W/NACL INJ 0.22%/0.45% ........... 79 KCL/NACL INJ 0.15%-0.9% ................... 80 KCL/NACL INJ 0.3-0.9 .......................... 79 KCL0.15%/D5W/NACL0.2% ................... 79 KCL0.15%/D5W/NACL0.225% ................ 79 kelnor 1/35 28 day ............................... 59 ketoconazole ..................................... 14 ketoconazole cream ............................. 87 ketoconazole shampoo ......................... 88 ketoprofen.......................................... 8 ketorolac tromethamine (ophth) ............... 82 KEYTRUDA....................................... 24 kimidess 28 day .................................. 59 KINRIX ............................................ 76 kionex powder .................................... 57 KLOR-CON 10 ................................... 76 KLOR-CON 8 ..................................... 76 klor-con m10 ...................................... 77 klor-con m15 ...................................... 77 klor-con m20 ...................................... 77 klor-con pow 20meq ............................. 77 klor-con spr cap 10meq ......................... 77 klor-con spr cap 8meq .......................... 77 KORLYM .......................................... 64 KUVAN ............................................ 62 KYNAMRO ........................................ 32 L   labetalol hcl ....................................... 33 LACTATED RINGER'S INJ .................... 80 lactulose ........................................... 68 lactulose (encephalopathy) ..................... 68 lamivudine ........................................ 15 lamivudine (hbv) ................................. 17 lamivudine-zidovudine .......................... 16 lamotrigine ........................................ 40 LANTUS ........................................... 54 LANTUS SOLOSTAR ........................... 54 larin 1.5/30 ........................................ 59 larin 1/20 .......................................... 59 larin fe 1.5/30 ..................................... 59 larin fe 1/20 ....................................... 59 larissia 28 day pack ............................. 59

LASTACAFT ...................................... 82 latanoprost ........................................ 83 LATUDA ..................................... 47, 48 leena tab .......................................... 59 leflunomide ....................................... 73 LENVIMA 10 MG DAILY DOSE ............... 26 LENVIMA 14 MG DAILY DOSE ............... 26 LENVIMA 18 MG DAILY DOSE ............... 26 LENVIMA 20 MG DAILY DOSE ............... 26 LENVIMA 24 MG DAILY DOSE ............... 26 LENVIMA 8 MG DAILY DOSE ................. 26 lessina 28 day .................................... 59 LETAIRIS ......................................... 37 letrozole ........................................... 25 leucovorin calcium ............................... 28 leucovorin calcium for inj 500 mg ............. 28 LEUKERAN ....................................... 22 LEUKINE .......................................... 72 leuprolide inj 1mg/0.2 ........................... 25 levalbuterol conc 1.25mg/0.5ml ............... 84 LEVEMIR ......................................... 54 LEVEMIR FLEXTOUCH ........................ 55 levetiracetam ............................... 40, 41 levetiracetam inj .................................. 41 LEVETIRACETAM IV ........................... 41 levetiracetam oral soln 100 mg/ml ............ 41 levobunolol hcl ................................... 83 levocarnitine (metabolic modifiers) ............ 62 levocetirizine dihydrochloride .................. 84 levofloxacin ....................................... 20 levofloxacin in d5w .............................. 20 levofloxacin inj 25mg/ml ........................ 20 levofloxacin oral soln 25 mg/ml ................ 20 levoleucovorin calcium .......................... 28 levonest 28 day .................................. 59 levonor/ethi tab ................................... 59 levonorgestrel (emergency oc) ................ 59 levonorgestrel & eth estradiol .................. 59 levonorgestrel-ethinyl estradiol (91-day) ..... 59 levora 0.15/30 28 day ........................... 59 levothyroxine sodium ............................ 65 LEVOXYL ......................................... 65 LEXIVA ............................................ 15 lidocaine ........................................... 89 lidocaine hcl ................................ 89, 90 102  

lidocaine hcl (local anesth.) .................... 11 lidocaine hcl (mouth-throat) .................... 91 lidocaine inj 0.5% ................................ 11 lidocaine inj 1.5% ................................ 11 lidocaine inj 1% .................................. 11 lidocaine inj 2% .................................. 11 lidocaine oint 5% ................................. 90 lidocaine-prilocaine .............................. 90 linezolid............................................ 12 LINEZOLID IN SODIUM CHLORIDE ......... 12 LINZESS .......................................... 69 liothyronine sodium .............................. 65 lisinopril............................................ 29 lisinopril & hydrochlorothiazide ................ 29 lithium carbonate................................. 52 lithium carbonate er ............................. 52 LITHIUM SOLN 8MEQ/5ML .................... 52 lokara .............................................. 89 LONSURF ........................................ 27 loperamide hcl .................................... 69 lorazepam ......................................... 38 lorcet hd tab 10-325mg ......................... 10 lorcet plus tab 7.5-325 .......................... 10 lorcet tab 5-325mg............................... 10 lortab tab 10-325mg ............................. 10 lortab tab 5-325mg .............................. 10 lortab tab 7.5-325 ................................ 10 loryna 28 day ..................................... 59 losartan potassium .............................. 31 losartan-hydrochlorothiazide ................... 30 LOTEMAX ........................................ 82 lovastatin .......................................... 32 low-ogestrel ....................................... 59 loxapine succinate ............................... 48 LUMIGAN ......................................... 83 LUMIZYME ....................................... 62 LUPR DEP-PED INJ 11.25MG (3-MONTH) . 25 LUPRON DEPOT ................................ 25 LUPRON DEP-PED INJ 11.25MG ............ 25 LUPRON DEP-PED INJ 15MG ................ 25 LUPRON DEP-PED INJ 30MG (3-MONTH) . 25 LUPRON DEP-PED INJ 7.5MG ............... 25 lutera 28 day ...................................... 59 LYNPARZA ....................................... 24 LYRICA............................................ 41

LYSODREN ...................................... 25 lyza ................................................. 59 M   MAGNESIUM SULFATE ....................... 77 MAGNESIUM SULFATE IN D5W ............. 77 malathion.......................................... 90 maprotiline hcl .................................... 44 marlissa 28 day .................................. 60 MARPLAN TAB 10MG .......................... 44 MATULANE....................................... 27 MAXIDEX ......................................... 82 meclizine hcl ...................................... 66 MEDROXYPROGESTERONE ACETATE (CONTRACEPTIVE) ............................ 60 medroxyprogesterone acetate 150 mg/ml ... 60 medroxyprogesterone acetate tab ............ 65 mefloquine hcl .................................... 14 megestrol ac sus 40mg/ml ..................... 25 megestrol ac tab 20mg.......................... 25 megestrol ac tab 40mg.......................... 25 MEGESTROL SUS 625MG/5ML .............. 25 MEKINIST......................................... 26 MELOXICAM ...................................... 8 melphalan hcl..................................... 22 memantine hcl .................................... 43 MENACTRA ...................................... 76 MENHIBRIX ...................................... 76 MENOMUNE-A/C/Y/W-135 .................... 76 MENVEO .......................................... 76 mercaptopurine .................................. 23 meropenem ....................................... 12 MESALAMINE ................................... 68 mesalamine enema.............................. 68 mesalamine w/ cleanser ........................ 68 mesna ............................................. 28 MESNEX .......................................... 28 metadate er tab 20mg ........................... 50 metformin er ...................................... 56 metformin hcl ..................................... 56 methadone hcl ................................... 10 methazolamide ................................... 36 methenamine hippurate ......................... 12 methimazole ...................................... 65 METHOTREXATE SODIUM ................... 23 methotrexate sodium inj ........................ 23 103  

methotrexate sodium tabs ...................... 73 methyclothiazide ................................. 36 methylergonovine maleate ..................... 64 methylphenidate hcl ............................. 50 methylphenidate hcl oral soln .................. 50 methylpr ace inj 40mg/ml ....................... 63 methylpr ace inj 80mg/ml ....................... 63 methylpr ss inj 125 mg .......................... 63 methylpr ss inj 1gm .............................. 63 methylpr ss inj 40mg ............................ 63 methylpred pak 4mg ............................. 63 methylpred tab 16mg ............................ 63 methylpred tab 32mg ............................ 63 methylpred tab 4mg ............................. 63 methylpred tab 8mg ............................. 63 metipranolol....................................... 83 metoclopramide hcl .............................. 66 metoclopramide inj .............................. 66 metolazone ....................................... 36 metoprolol & hydrochlorothiazide ............. 33 metoprolol succinate ............................ 33 metoprolol tartrate ............................... 33 metronidazole .................................... 12 metronidazole (topical) .......................... 90 metronidazole gel 0.75% ....................... 90 metronidazole in nacl............................ 12 metronidazole vaginal ........................... 71 mexiletine hcl ..................................... 31 MIACALCIN....................................... 64 MICROGESTIN 1.5/30 .......................... 60 MICROGESTIN 1/20 ............................ 60 MICROGESTIN FE 1.5/30 ..................... 60 MICROGESTIN FE 1/20 ........................ 60 midodrine hcl ..................................... 37 minitran ............................................ 37 minocycline hcl ................................... 21 minoxidil ........................................... 37 mirtazapine ....................................... 44 misoprostol ....................................... 69 mitomycin ......................................... 23 mitoxantrone hcl ................................. 27 M-M-R II ........................................... 76 moderiba 800 dose pack ....................... 17 moderiba pak 1000/day ......................... 17 MODERIBA PAK 1200/DAY ................... 17

moderiba pak 600/day .......................... 17 moderiba tab 200mg ............................ 17 moexipril hcl ...................................... 29 moexipril-hydrochlorothiazide .................. 29 molindone hcl..................................... 48 mometasone furoate ............................ 89 mono-linyah tab 0.25-35 ........................ 60 MONONESSA .................................... 60 montelukast sodium ............................. 84 morgidox .......................................... 21 morphine ext-rel tab ............................. 10 MORPHINE SUL INJ 10MG/ML ............... 10 MORPHINE SUL INJ 15MG/ML ............... 10 MORPHINE SUL INJ 1MG/ML ................ 10 MORPHINE SUL INJ 4MG/ML ................ 10 morphine sulfate ................................. 10 morphine sulfate beads ......................... 10 MORPHINE SULFATE ORAL SOL ........... 10 MOVANTIK ....................................... 69 MOVIPREP ....................................... 68 MOXEZA .......................................... 81 MOZOBIL ......................................... 72 MULTAQ .......................................... 31 mupirocin .......................................... 87 MUSTARGEN .................................... 22 MYCAMINE ....................................... 14 mycophenolate mofetil .......................... 74 mycophenolate sodium ......................... 74 myorisan .......................................... 87 MYOZYME ........................................ 62 MYRBETRIQ ..................................... 70 myzilra ............................................. 60 N   nabumetone ....................................... 8 nadolol ............................................. 33 nafcillin sodium ................................... 21 NAGLAZYME..................................... 62 nalbuphine hcl ..................................... 9 naloxone inj 0.4mg/ml ........................... 53 naloxone inj 1mg/ml ............................. 53 naltrexone hcl .................................... 53 NAMENDA XR ................................... 43 NAMENDA XR TITRATION PACK ............ 43 NAMZARIC ....................................... 43 naphazoline hcl .................................. 83 104  

naproxen ........................................... 8 naproxen sodium ................................. 8 naratriptan hcl .................................... 51 NASONEX ........................................ 85 NATACYN ........................................ 81 nateglinide ........................................ 56 NATPARA......................................... 65 NEBUPENT....................................... 13 necon 0.5/35 28 day ............................. 60 necon 1/35 28 day ............................... 60 NECON 1/50-28 ................................. 60 necon 10/11 28 day ............................. 60 NECON 7/7/7 ..................................... 60 nefazodone hcl ................................... 44 neomycin sulfate ................................. 11 neomycin-bacitracin zn-polymyxin ............ 81 neomycin-polymy-dexameth ................... 80 neomycin-polymyxin-gramicidin ............... 81 neomycin-polymyxin-hc (ophth) ............... 80 neomycin-polymyxin-hc (otic) .................. 91 NEORAL .......................................... 74 NEPHRAMINE ................................... 78 NEUMEGA ........................................ 72 NEUPOGEN ...................................... 72 NEUPRO .......................................... 46 NEVIRAPINE ..................................... 15 nevirapine tab 200mg ........................... 15 NEXAVAR ........................................ 26 NEXIUM CAP 20MG ............................ 69 NEXIUM CAP 40MG ............................ 69 NEXIUM GRA 10MG DR ....................... 70 NEXIUM GRA 2.5MG DR ...................... 69 NEXIUM GRA 20MG DR ....................... 70 NEXIUM GRA 40MG DR ....................... 70 NEXIUM GRA 5MG DR ......................... 70 niacin er (antihyperlipidemic)............. 32, 33 niacor .............................................. 33 nicardipine hcl .................................... 34 NICOTROL INHALER ........................... 53 NICOTROL NS ................................... 53 nifedical ........................................... 34 nifedipine .......................................... 34 nifedipine er................................. 34, 35 nikki 28 day ....................................... 60 NILANDRON ..................................... 25

nilutamide ......................................... 25 nimodipine ........................................ 35 NINLARO ......................................... 24 NIPENT ........................................... 23 nitro-bid............................................ 37 NITRO-DUR DIS 0.3MG/HR ................... 37 NITRO-DUR DIS 0.8MG/HR ................... 37 nitrofurantoin macrocrystal ..................... 13 nitrofurantoin monohyd macro ................. 13 nitroglycer dis 0.1mg/hr ......................... 37 nitroglycer dis 0.2mg/hr ......................... 37 nitroglycer dis 0.4mg/hr ......................... 37 nitroglycer dis 0.6mg/hr ......................... 37 nitroglycerin ....................................... 37 NITROSTAT ...................................... 37 NORA-BE TAB 0.35MG ........................ 60 NORDITROPIN FLEXPRO ..................... 64 norethindrone (contraceptive) .................. 60 norethindrone acetate ........................... 65 norethindrone acetate-ethinyl estradiol ....... 63 norgest/ethi tab 0.25/35 ......................... 60 norgestimate-ethinyl estradiol (triphasic) ..... 60 norlyroc 28 day ................................... 60 NORMOSOL-M IN D5W ........................ 80 NORMOSOL-R................................... 80 NORMOSOL-R IN D5W ........................ 80 NORPACE CR ................................... 31 nortrel 0.5/35 28 day ............................ 60 nortrel 1/35 21 day............................... 60 nortrel 1/35 28 day............................... 60 nortrel 7/7/7 28 day .............................. 60 nortriptyline hcl ................................... 44 NORVIR ........................................... 15 NOVOLIN 70/30 ................................. 55 NOVOLIN N ...................................... 55 NOVOLIN R ...................................... 55 NOVOLOG ........................................ 55 NOVOLOG FLEXPEN .......................... 55 NOVOLOG MIX 70/30 .......................... 55 NOVOLOG MIX 70/30 PREFILL .............. 55 NOVOLOG PENFILL ............................ 55 NOXAFIL .......................................... 14 NUEDEXTA....................................... 52 NULOJIX .......................................... 74 NULYTELY/FLAVOR PACKS ................. 68 105  

NUPLAZID ........................................ 48 NUTRILIPID INJ 20% ........................... 78 NUVARING ....................................... 60 NUVIGIL........................................... 53 nyamyc ............................................ 87 NYMALIZE ........................................ 35 nystatin ............................................ 14 nystatin (mouth-throat) .......................... 91 nystatin (topical) ................................. 87 nystop ............................................. 87 O   OCELLA TAB 3-0.03MG........................ 60 OCTAGAM ........................................ 74 octreotide acetate ................................ 64 ODEFSEY ........................................ 16 ODOMZO ......................................... 27 OFEV .............................................. 85 ofloxacin (ophth) ................................. 81 ofloxacin (otic) .................................... 91 olanzapine ........................................ 48 olopatadine hcl (nasal) .......................... 84 omega-3-acid ethyl esters ...................... 33 omeprazole ....................................... 70 ondansetron hcl .................................. 66 ondansetron hcl inj .............................. 66 ondansetron hcl oral soln ....................... 66 ondansetron odt .................................. 66 ONFI ............................................... 41 OPSUMIT ......................................... 37 ORFADIN ......................................... 62 ORKAMBI ......................................... 85 orsythia 28 day ................................... 60 oxacillin sodium .................................. 21 oxaliplatin ......................................... 28 oxandrolone tab 10mg .......................... 54 oxandrolone tab 2.5mg ......................... 54 oxcarbazepine .................................... 41 oxybutynin chloride .............................. 70 oxycodone hcl .............................. 10, 11 oxycodone w/ acetaminophen 10-325mg .... 11 oxycodone w/ acetaminophen 2.5-325mg ... 11 oxycodone w/ acetaminophen 5-325mg...... 11 oxycodone w/ acetaminophen 7.5-325mg ... 11 oxycodone w/ acetaminophen soln 5-325 mg/5ml ............................................ 11

P   pacerone .......................................... 31 paclitaxel .......................................... 23 paliperidone....................................... 48 pamidronate disodium .......................... 57 PANRETIN ........................................ 90 pantoprazole sodium tbec ...................... 70 paricalcitol......................................... 80 paroex sol 0.12% ................................ 91 paromomycin sulfate ............................ 11 paroxetine hcl tabs .............................. 44 paser d/r ........................................... 17 PATADAY ......................................... 82 PAXIL .............................................. 44 PAZEO ............................................ 82 PEDIARIX ......................................... 76 PEDVAX HIB ..................................... 76 PEG 3350/ELECTROLYTES .................. 68 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE ................... 68 peg 3350-potassium chloride-sod bicarbonatesod chloride ....................................... 68 PEGANONE ...................................... 41 PEGASYS ........................................ 18 PEGASYS PROCLICK.......................... 18 PEGINTRON ..................................... 18 PEG-INTRON REDIPEN ....................... 18 PENICILLIN G POT IN DEXTROSE .......... 21 penicillin g procaine ............................. 21 penicillin g sodium ............................... 21 penicillin gk inj 20mu ............................ 21 penicillin gk inj 5mu .............................. 21 penicillin v potassium............................ 21 PENTACEL ....................................... 76 PENTAM 300 ..................................... 13 pentoxifylline ...................................... 72 PERFOROMIST ................................. 84 perindopril erbumine ............................ 29 periogard .......................................... 91 permethrin ........................................ 90 perphenazine ..................................... 48 pfizerpen-g inj 5mu .............................. 21 phenadoz ......................................... 66 phenelzine sulfate ............................... 44 phenergan ........................................ 66 106  

phenobarbital ..................................... 41 PHENOBARBITAL SODIUM ................... 41 phenytek .......................................... 41 phenytoin.......................................... 41 phenytoin sodium ................................ 41 phenytoin sodium extended .................... 41 philith .............................................. 61 PHOSPHOLINE IODIDE ....................... 83 PILOCARPINE HCL ............................. 83 PILOCARPINE HCL (ORAL) ................... 91 pimozide .......................................... 48 pimtrea pack ...................................... 61 pindolol ............................................ 33 pioglitazone hcl................................... 56 piperacillin sodium-tazobactam sodium ...... 21 pirmella 1/35 28 day ............................. 61 piroxicam ........................................... 8 PLASMA-LYTE A ................................ 80 PLASMA-LYTE-148 ............................. 80 PLASMA-LYTE-56/D5W ........................ 80 podofilox .......................................... 90 polyethylene glycol 3350 ....................... 68 polymyxin b-trimethoprim ....................... 81 POMALYST CAP 1MG ......................... 27 POMALYST CAP 2MG ......................... 27 POMALYST CAP 3MG ......................... 27 POMALYST CAP 4MG ......................... 27 portia 28 day ...................................... 61 pot chloride inj 2meq/ml ........................ 80 potassium chloride......................... 77, 80 potassium chloride in nacl ...................... 80 potassium chloride microencapsulated crystals cr ................................................... 77 POTASSIUM CHLORIDE TAB CR 10 MEQ . 77 potassium citrate (alkalinizer) .................. 70 POTIGA ........................................... 41 PRADAXA ........................................ 72 PRALUENT ....................................... 33 pramipexole dihydrochloride ................... 46 pravastatin sodium .............................. 32 prazosin hcl ....................................... 30 pred sod pho sol 5mg/5ml ...................... 63 PREDNISOLONE ACETATE (OPHTH) ...... 82 prednisolone sodium phosphate (ophth) ..... 82 prednisolone sol 15mg/5ml ..................... 63

prednisolone sol 25mg/5ml ..................... 63 prednisolone syp 15mg/5ml .................... 64 prednisone con 5mg/ml ......................... 64 prednisone pak 10mg ........................... 64 prednisone pak 5mg ............................. 64 prednisone sol 5mg/5ml ........................ 64 prednisone tab 10mg ............................ 64 prednisone tab 1mg ............................. 64 prednisone tab 2.5mg ........................... 64 prednisone tab 20mg ............................ 64 prednisone tab 50mg ............................ 64 prednisone tab 5mg ............................. 64 premasol 10% .................................... 78 premasol 6% ..................................... 78 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) ....................................... 80 prevalite ........................................... 33 previfem 28 day .................................. 61 PREZCOBIX ...................................... 16 PREZISTA ........................................ 15 PRIFTIN ........................................... 17 PRIMAQUINE PHOSPHATE .................. 14 primidone ......................................... 41 PRISTIQ........................................... 44 PRIVIGEN ........................................ 74 probenecid ......................................... 8 PROCALAMINE ................................. 78 prochlorperazine inj.............................. 67 prochlorperazine maleate ...................... 67 prochlorperazine supp .......................... 67 PROCRIT ......................................... 72 procto-med ........................................ 87 procto-pak......................................... 87 proctosol hc cre 2.5% ........................... 87 proctozone hc .................................... 87 PROGLYCEM SUS 50MG/ML ................. 64 PROGRAF .................................. 74, 75 PROLASTIN-C ................................... 85 PROLENSA....................................... 83 PROLEUKIN ...................................... 24 PROLIA ........................................... 65 PROMACTA ...................................... 72 promethazine hcl................................. 67 promethegan ..................................... 67 propafenone hcl .................................. 31 107  

propafenone hcl 12hr............................ 31 proparacaine hcl ................................. 83 propranolol & hydrochlorothiazide............. 33 propranolol cap er ............................... 33 propranolol hcl ................................... 34 propylthiouracil ................................... 65 PROQUAD ........................................ 76 PROSOL .......................................... 78 protriptyline hcl ................................... 44 PRUDOXIN CRE 5% ............................ 88 PULMICORT FLEXHALER..................... 86 PULMOZYME .................................... 85 PURIXAN ......................................... 23 pyrazinamide ..................................... 17 pyridostigmine bromide ......................... 52 Q   QUADRACEL .................................... 76 quasense 91 day................................. 61 quetiapine fumarate ............................. 48 quinapril hcl ....................................... 29 quinapril-hydrochlorothiazide .................. 29 quinidine gluconate .............................. 31 quinidine sulfate .................................. 32 quinine sulfate .................................... 14 R   RABAVERT ....................................... 76 raloxifene tab 60mg ............................. 65 ramipril ............................................ 29 RANEXA .......................................... 37 ranitidine hcl ...................................... 67 ranitidine hcl inj................................... 67 ranitidine syrup ................................... 67 RAPAMUNE ...................................... 75 RAVICTI ........................................... 62 REBETOL SOLN ................................ 18 reclipsen 28 day ................................. 61 RECOMBIVAX HB ............................... 76 REGRANEX ...................................... 90 RELENZA DISKHALER ........................ 18 RELISTOR ........................................ 69 RELPAX ........................................... 51 REMICADE ....................................... 73 REMODULIN ..................................... 37 RENVELA PAK .................................. 65 RENVELA TAB 800MG ......................... 65

repaglinide ........................................ 56 RESCRIPTOR ................................... 15 RESTASIS ........................................ 83 RETROVIR IV INFUSION ...................... 15 REVATIO ......................................... 37 REVLIMID......................................... 74 REXULTI .......................................... 48 REYATAZ ......................................... 15 ribapak mis 600/day ............................. 18 ribasphere......................................... 18 ribasphere ribapak 1000 ........................ 18 ribasphere ribapak 1200 ........................ 18 ribasphere ribapak 800 ......................... 18 ribavirin cap 200mg.............................. 18 ribavirin tab 200mg .............................. 18 rifabutin ............................................ 17 rifampin ............................................ 17 RIFATER .......................................... 17 riluzole ............................................. 52 rimantadine hydrochloride ...................... 18 RINGER'S ........................................ 80 RISPERDAL INJ 12.5MG ...................... 48 RISPERDAL INJ 25MG ......................... 48 RISPERDAL INJ 37.5MG ...................... 48 RISPERDAL INJ 50MG ......................... 49 risperidone ........................................ 49 RITUXAN ......................................... 24 rivastigmine tartrate ............................. 43 rizatriptan benzoate ............................. 51 ropinirole hydrochloride ......................... 46 rosadan cre 0.75% .............................. 90 rosuvastatin calcium ............................. 32 ROTARIX ......................................... 76 ROTATEQ ........................................ 76 roweepra .......................................... 41 ROZEREM ........................................ 51 S   SABRIL ............................................ 42 SANDIMMUNE ................................... 75 SANDOSTATIN LAR DEPOT .................. 65 SANTYL ........................................... 90 SAPHRIS ......................................... 49 selegiline hcl ...................................... 46 selenium sulfide .................................. 88 SELZENTRY ..................................... 15 108  

SENSIPAR ........................................ 57 SEREVENT DISKUS ............................ 84 SEROQUEL XR .................................. 49 sertraline hcl ...................................... 45 setlakin tab ........................................ 61 sharobel 28 day .................................. 61 SIGNIFOR ........................................ 65 sildenafil citrate (pulmonary hypertension) ... 38 SILENOR ......................................... 51 SILVER SULFADIAZINE ....................... 87 SIMBRINZA....................................... 83 simvastatin ........................................ 32 SIROLIMUS ...................................... 75 SIRTURO ......................................... 17 SIVEXTRO ........................................ 13 SODIUM CHLORIDE...................... 77, 80 SODIUM CHLORIDE 0.45% VIA .............. 80 SODIUM CHLORIDE 0.9%..................... 90 SODIUM CHLORIDE INJ 0.9% ................ 80 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN .................................... 77 sodium phenylbutyrate .......................... 62 sodium polystyrene sulfonate .................. 57 SOLTAMOX ...................................... 25 SOLU-CORTEF .................................. 64 SOMATULINE DEPOT ......................... 65 SOMAVERT ...................................... 65 sorine .............................................. 32 sotalol hcl ......................................... 32 sotalol hcl (afib/afl)............................... 32 SOVALDI .......................................... 18 spironolactone .................................... 29 spironolactone & hydrochlorothiazide ........ 36 sprintec 28 day ................................... 61 SPRITAM ......................................... 42 SPRYCEL ......................................... 26 sps ................................................. 57 sronyx ............................................. 61 SSD ................................................ 87 stavudine .......................................... 15 STERILE WATER IRRIGATION............... 91 STIVARGA ........................................ 26 STRATTERA ..................................... 51 streptomycin sulfate ............................. 11 STRIBILD ......................................... 16

SUBOXONE MIS 12-3MG...................... 54 SUBOXONE MIS 2-0.5MG ..................... 53 SUBOXONE MIS 4-1MG ....................... 54 SUBOXONE MIS 8-2MG ....................... 54 SUCRAID ......................................... 69 sucralfate.......................................... 69 sulfacet sod oin 10% op ........................ 81 sulfacetamide sodium (acne) .................. 87 sulfacetamide sodium (ophth) ................. 81 sulfacetamide sod-prednisolone ............... 81 sulfadiazine ....................................... 11 sulfamethoxazole-trimethoprim ................ 13 sulfamethoxazole-trimethoprim inj ............ 13 SULFAMYLON ................................... 87 sulfasalazine ...................................... 68 sulfasalazine ec .................................. 68 sulindac ............................................ 9 SUMATRIPTAN .................................. 51 sumatriptan inj 4mg/0.5ml ................ 51, 52 sumatriptan inj 6mg/0.5ml ...................... 52 sumatriptan succinate ........................... 52 SUPRAX .......................................... 19 SUPREP BOWEL PREP ....................... 69 SURMONTIL CAP 100MG ..................... 45 SURMONTIL CAP 25MG ....................... 45 SURMONTIL CAP 50MG ....................... 45 SUSTIVA .......................................... 15 SUTENT........................................... 27 syeda .............................................. 61 SYLATRON KIT 200MCG ...................... 27 SYLATRON KIT 300MCG ...................... 27 SYLATRON KIT 600MCG ...................... 27 SYMBICORT ..................................... 86 SYMLINPEN 120 ................................ 55 SYMLINPEN 60 .................................. 55 SYNAGIS ......................................... 76 SYNAREL ......................................... 62 SYNERCID ....................................... 13 SYNRIBO ......................................... 27 SYNTHROID ..................................... 65 SYPRINE ......................................... 57 T   TABLOID .......................................... 23 tacrolimus ......................................... 75 tacrolimus (topical) .............................. 90 109  

TAFINLAR ........................................ 27 TAGRISSO ....................................... 27 TAMIFLU .......................................... 18 tamoxifen citrate ................................. 25 tamsulosin hcl .................................... 70 TARCEVA......................................... 27 TARGRETIN ...................................... 90 tarina fe 1/20 28 day ............................ 61 TASIGNA ......................................... 27 tazicef.............................................. 19 tazicef vial ......................................... 19 TAZORAC ........................................ 88 taztia xt ............................................ 35 TECENTRIQ ...................................... 24 TEFLARO ......................................... 19 TEGRETOL ....................................... 42 TEGRETOL-XR .................................. 42 TEKTURNA ....................................... 35 TEKTURNA HCT TAB 150-12.5MG .......... 35 TEKTURNA HCT TAB 150-25MG ............ 35 TEKTURNA HCT TAB 300-12.5MG .......... 35 TEKTURNA HCT TAB 300-25MG ............ 36 temazepam ....................................... 51 TENIVAC .......................................... 76 terazosin hcl ...................................... 30 terbinafine hcl .................................... 14 terbutaline sulfate ................................ 84 terconazole vaginal .............................. 71 testosterone cypionate .......................... 54 testosterone enanthate ......................... 54 TETANUS/DIPHTHERIA TOXOID ............ 76 tetrabenazine ..................................... 52 texacort soln 2.5% ............................... 89 THALOMID ....................................... 74 theo-24 ............................................ 86 theophylline ....................................... 86 thioridazine hcl ................................... 49 thiothixene ........................................ 49 tiagabine hcl ...................................... 42 TIKOSYN ......................................... 32 timolol maleate ................................... 34 timolol maleate (ophth).......................... 83 TIMOLOL MALEATE GEL...................... 83 TIVICAY ........................................... 15 tizanidine hcl ...................................... 53

TOBRADEX ...................................... 81 TOBRADEX ST .................................. 81 tobramycin ........................................ 11 tobramycin (ophth)............................... 81 tobramycin sulfate ............................... 11 tobramycin-dexamethasone.................... 81 TOBREX .......................................... 81 tolterodine tartrate ............................... 70 topiramate......................................... 42 toposar ............................................ 28 topotecan hcl ..................................... 28 torsemide inj ...................................... 36 torsemide tabs ................................... 36 TOUJEO SOLOSTAR ........................... 55 TOVIAZ............................................ 71 TPN ELECTROLYTES.......................... 77 TRACLEER ....................................... 38 TRADJENTA ..................................... 56 tramadol hcl........................................ 9 tramadol-acetaminophen ........................ 9 trandolapril ........................................ 29 tranexamic acid .................................. 72 TRANSDERM-SCOP ........................... 67 tranylcypromine sulfate ......................... 45 TRAVASOL ....................................... 78 TRAVATAN Z .................................... 83 trazodone hcl ..................................... 45 TREANDA ........................................ 22 TRECATOR ...................................... 17 TRELSTAR DEP INJ 3.75MG ................. 25 TRELSTAR LA INJ 11.25MG .................. 25 TRESIBA FLEXTOUCH ........................ 55 tretinoin ............................................ 87 tretinoin (chemotherapy) ........................ 27 triamcinolone acetonide (mouth) .............. 91 triamcinolone acetonide (topical) .............. 89 triamterene & hydrochlorothiazide ............ 36 triamterene & hydrochlorothiazide cap 37.5-25 mg .................................................. 36 TRIBENZOR TAB 20-5-12.5MG............... 30 TRIBENZOR TAB 40-10-12.5 ................. 30 TRIBENZOR TAB 40-10-25MG ............... 31 TRIBENZOR TAB 40-5-12.5MG............... 30 TRIBENZOR TAB 40-5-25MG ................. 30 triderm ............................................. 89 110  

trifluoperazine hcl ................................ 49 trifluridine .......................................... 81 tri-legest 28 day .................................. 61 tri-linyah tab....................................... 61 trilyte ............................................... 69 trimethoprim ...................................... 13 trimipramine maleate ............................ 45 TRINESSA ........................................ 61 TRINTELLIX ...................................... 45 tri-previfem 28 day ............................... 61 TRISENOX ....................................... 27 tri-sprintec 28 day ................................ 61 TRIUMEQ ......................................... 16 trivora 28 day ..................................... 61 TROPHAMINE INJ 10% ........................ 78 trospium chloride................................. 71 TRULICITY ....................................... 55 TRUMENBA ...................................... 76 TRUVADA TAB 100-150 ....................... 16 TRUVADA TAB 133-200 ....................... 16 TRUVADA TAB 167-250 ....................... 16 TRUVADA TAB 200-300 ....................... 16 TWINRIX INJ ..................................... 76 TYBOST........................................... 15 TYGACIL .......................................... 13 TYKERB........................................... 27 TYPHIM VI ........................................ 76 TYSABRI .......................................... 52 TYZEKA ........................................... 18 U   UCERIS ........................................... 68 ULORIC ............................................ 8 UNITHROID ...................................... 65 UPTRAVI .......................................... 38 ursodiol ............................................ 69 V   VAGIFEM ......................................... 63 valacyclovir hcl ................................... 18 VALCHLOR ....................................... 90 VALCYTE ......................................... 18 valganciclovir hcl ................................. 18 valproate sodium................................. 42 valproic acid ...................................... 42 valsartan .......................................... 31 valsartan & hctz tab 160-12.5mg .............. 31

valsartan & hctz tab 160-25mg ................ 31 valsartan & hctz tab 320-12.5mg .............. 31 valsartan & hctz tab 320-25mg ................ 31 valsartan & hctz tab 80-12.5mg ............... 31 vancomycin hcl ................................... 13 VANCOMYCIN IN NACL ....................... 13 VANDAZOLE ..................................... 71 VAQTA ............................................ 76 VARIVAX .......................................... 76 VASCEPA......................................... 33 VELCADE ......................................... 24 velivet 28 day ..................................... 61 VENCLEXTA ..................................... 24 VENCLEXTA STARTING PACK .............. 24 venlafaxine hcl ................................... 45 VENTOLIN HFA ................................. 84 verapamil cap er ................................. 35 verapamil hcl ..................................... 35 verapamil tab er .................................. 35 VERSACLOZ ..................................... 49 VESICARE ........................................ 71 vestura ............................................ 61 VICTOZA .......................................... 55 VIDEX PEDIATRIC .............................. 15 vienva 28 day..................................... 61 VIGAMOX ......................................... 81 VIIBRYD........................................... 45 VIIBRYD STARTER PACK ..................... 45 VIMPAT ........................................... 42 vinblastine sulfate ................................ 24 vincasar ........................................... 24 vincristine sulfate ................................ 24 vinorelbine tartrate ............................... 24 viorele ............................................. 61 VIRACEPT ........................................ 15 VIRAMUNE XR .................................. 15 VIREAD ........................................... 15 VITEKTA .......................................... 16 VOLTAREN ....................................... 90 voriconazole ...................................... 14 VOTRIENT ........................................ 27 VRAYLAR ......................................... 49 vyfemla 28 day ................................... 61 W   warfarin sodium .................................. 72 111  

WELCHOL ........................................ 33 X   XALKORI .......................................... 27 XARELTO ......................................... 72 XARELTO STARTER PACK ................... 72 XGEVA ............................................ 65 XIFAXAN .......................................... 69 XIGDUO XR TAB 10-1000MG ................. 57 XIGDUO XR TAB 10-500MG .................. 57 XIGDUO XR TAB 5-1000MG .................. 57 XIGDUO XR TAB 5-500MG .................... 57 XOLAIR ........................................... 85 XOPENEX HFA .................................. 84 XTANDI ........................................... 25 xulane dis 150-35 ................................ 61 XYREM ............................................ 53 Y   YERVOY .......................................... 24 YF-VAX............................................ 76 Z   zafirlukast ......................................... 85 zarah ............................................... 61 ZAVESCA ......................................... 62 ZAZOLE CRE 0.8% ............................. 71 ZELBORAF ....................................... 27 ZEMAIRA ......................................... 85 zenatane .......................................... 87 zenchent 28 day ................................. 61

ZENPEP........................................... 69 ZETIA TAB 10MG ............................... 33 ZIAGEN ........................................... 16 zidovudine ........................................ 16 ziprasidone hcl ................................... 49 ZIRGAN ........................................... 81 zoledronic acid ................................... 57 zoledronic inj 4mg/5ml .......................... 57 ZOLINZA .......................................... 24 zolmitriptan ....................................... 52 zolmitriptan odt ................................... 52 zolpidem tartrate ................................. 51 zonisamide ........................................ 42 ZONTIVITY ....................................... 73 ZORTRESS TAB 0.25MG ...................... 75 ZORTRESS TAB 0.5MG ....................... 75 ZORTRESS TAB 0.75MG ...................... 75 ZOSTAVAX ....................................... 76 zovia 1/35e 28 day .............................. 61 zovia 1/50e 28 day .............................. 61 ZYDELIG .......................................... 27 ZYKADIA .......................................... 27 ZYLET ............................................. 81 ZYPREXA RELPREVV ................... 49, 50 ZYPREXA RELPREVV INJ 210MG........... 50 ZYTIGA............................................ 26 ZYVOX ............................................ 13

Este formulario se actualizó el 25 de octubre de 2016. Para información más reciente u otras preguntas, llame, por favor, a los Servicios para Miembros de Clover Health al(888) 657-1207 o, para los usuarios de TTY, al 711, gratis, 7 días a la semana, 24 horas al día, o visite www.cloverhealth.com. Clover Health es una Organización de Proveedores Preferidos (OPP) con un contrato de Medicare. La inscripción en Clover Health depende de la Renovación del Contrato. Esta información esta disponible de gratis en otros idiomas. Por favor llame a nuestro número de servicio al cliente al (888) 657-1207 o, para los usuarios de TTY, llame gratis al 771, 7 días a la semana y 24 horas al día. H5141_CP_Comprehensive Formulary_16_CMS Approved 112  

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