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_00016067_Comprehensive Formulary_Version 16_SP

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 1

Clover Health y se sigan las otras reglas del plan. Para información de cómo surtir recetas, repase, por favor, la Evidencia de Cobertura. ¿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.

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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 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 8. 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. 3

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 5 para información sobre la manera de pedir una excepción. ¿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. 4

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 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.

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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.

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 125. 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. GC: Intervalo sin Cobertura. Damos cobertura adicional del medicamento recetado durante el intervalo sin cobertura. Por favor, consulte la Evidencia de Cobertura para más información sobre dicha cobertura. 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 6

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. 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.

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CH_BG_CY16_5T_PERFORMANCE_SPSX_PRINT eff 11/01/2016 Drug Name

Drug Tier

Requirements/Limits

allopurinol tab

1

GC

ALOPRIM

4

colchicine w/ probenecid

2

GC

COLCRYS

3

QL (120 tabs / 30 days)

probenecid

2

GC

ULORIC

3

ST

ZURAMPIC

4

PA

diclofenac w/ misoprostol

2

GC

DUEXIS

5

VIMOVO

5

ANALGESICS GOUT

MISCELLANEOUS

NSAIDS celecoxib CAPS

2

GC

diclofenac potassium

2

GC

diclofenac sodium TB24

2

GC

diclofenac sodium TBEC

2

GC

diflunisal

2

GC

etodolac

2

GC

etodolac er

2

GC

FENOPROFEN CALCIUM CAPS 400mg

2

GC

fenoprofen calcium TABS

2

GC

flurbiprofen TABS

2

GC

ibuprofen SUSP

2

GC

ibuprofen TABS 400mg, 600mg, 800mg

1

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

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Drug Name

Drug Tier

Requirements/Limits

ketoprofen CAPS; CP24

2

GC

mefenamic acid CAPS

2

GC

MELOXICAM SUSP

2

GC

meloxicam tabs

1

GC

nabumetone TABS

2

GC

NAPRELAN 375mg, 750mg

5

naproxen SUSP

2

GC

naproxen TABS; TBEC

1

GC

naproxen sodium TABS 275mg, 550mg

1

GC

naproxen sodium TB24 375mg

5

NAPROXEN SODIUM TB24 500mg

5

oxaprozin

2

GC

piroxicam CAPS

2

GC

sulindac TABS

1

GC

tolmetin sodium

2

GC

VIVLODEX

4

ZIPSOR

4

ZORVOLEX

4

OPIOID ANALGESICS acetaminophen w/ codeine SOLN

2

GC, QL (5000 mL / 30 days)

acetaminophen w/ codeine TABS

2

GC, QL (400 tabs / 30 days)

acetaminophen-caff-dihydrocod

2

GC, QL (360 caps / 30 days)

ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP 356.4-30-16 MG

2

GC, QL (360 caps / 30 days)

BELBUCA 75mcg, 150mcg, 300mcg, 450mcg

4

QL (120 buccal 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

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Drug Name

Drug Tier

Requirements/Limits

BELBUCA 600mcg, 750mcg, 900mcg

4

QL (60 buccal films / 30 days), PA

butorphanol nasal spray

2

GC, QL (10 mL / 30 days)

butorphanol tartrate SOLN

2

GC

BUTRANS 5mcg/hr

3

QL (16 patches / 28 days)

BUTRANS 7.5mcg/hr, 10mcg/hr

3

QL (8 patches / 28 days)

BUTRANS 15mcg/hr, 20mcg/hr

3

QL (4 patches / 28 days)

capital and codeine

4

QL (5000 mL / 30 days)

CONZIP 100mg

4

QL (90 caps / 30 days)

CONZIP 200mg

4

QL (60 caps / 30 days)

CONZIP 300mg

4

QL (30 caps / 30 days)

nalbuphine hcl SOLN

2

GC

TRAMADOL HCL CP24 100mg

2

GC, QL (90 caps / 30 days)

TRAMADOL HCL CP24 200mg

2

GC, QL (60 caps / 30 days)

TRAMADOL HCL CP24 300mg

2

GC, QL (30 caps / 30 days)

tramadol hcl er TB24 100mg

2

GC, QL (90 tabs / 30 days)

tramadol hcl er TB24 200mg

2

GC, QL (30 tabs / 30 days)

TRAMADOL HCL ER TB24 300mg

2

GC, QL (30 tabs / 30 days)

tramadol hcl er (biphasic) 100mg

2

GC, QL (90 tabs / 30 days)

tramadol hcl er (biphasic) 200mg

2

GC, QL (30 tabs / 30 days)

tramadol hcl er (biphasic) 300mg

2

GC, 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

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Drug Name

Drug Tier

Requirements/Limits

tramadol hcl tab 50 mg

2

GC, QL (240 tabs / 30 days)

tramadol-acetaminophen

2

GC, QL (240 tabs / 30 days)

trezix

4

QL (360 caps / 30 days)

ABSTRAL

5

QL (120 tabs / 30 days), PA

CODEINE SULFATE 15mg

2

GC, QL (720 tabs / 30 days)

CODEINE SULFATE 30mg

2

GC, QL (360 tabs / 30 days)

CODEINE SULFATE 60mg

2

GC, QL (180 tabs / 30 days)

DILAUDID-HP INJ 250MG

4

B/D

DURAMORPH

2

GC, B/D

EMBEDA

4

QL (60 caps / 30 days)

endocet

2

GC, QL (360 tabs / 30 days)

fentanyl citrate LPOP

5

QL (120 lozenges / 30 days), PA

fentanyl patch 12 mcg/hr

2

GC, QL (10 patches / 30 days)

fentanyl patch 25 mcg/hr

2

GC, QL (10 patches / 30 days)

fentanyl patch 50 mcg/hr

2

GC, QL (10 patches / 30 days), PA

fentanyl patch 75 mcg/hr

2

GC, QL (10 patches / 30 days), PA

fentanyl patch 100 mcg/hr

2

GC, QL (10 patches / 30 days), PA

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

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Drug Name

Drug Tier

Requirements/Limits

FENTORA

5

QL (120 tabs / 30 days), PA

hydrocodone-acetaminophen 2.5-325mg

2

GC, QL (360 tabs / 30 days)

hydrocodone-acetaminophen 5-300mg

2

GC, QL (400 tabs / 30 days)

hydrocodone-acetaminophen 5-325mg

2

GC, QL (360 tabs / 30 days)

hydrocodone-acetaminophen 7.5-300mg

2

GC, QL (400 tabs / 30 days)

hydrocodone-acetaminophen 7.5-325 mg/15ml

2

GC, QL (5400 mL / 30 days)

hydrocodone-acetaminophen 7.5-325mg

2

GC, QL (360 tabs / 30 days)

hydrocodone-acetaminophen 10-300mg

2

GC, QL (400 tabs / 30 days)

hydrocodone-acetaminophen tab 10-325mg 2

GC, QL (360 tabs / 30 days)

hydrocodone-ibuprofen tab 2.5-200mg

2

GC, QL (150 tabs / 30 days)

hydrocodone-ibuprofen tab 5-200mg

2

GC, QL (150 tabs / 30 days)

hydrocodone-ibuprofen tab 7.5-200 mg

2

GC, QL (150 tabs / 30 days)

hydrocodone-ibuprofen tab 10-200mg

2

GC, QL (150 tabs / 30 days)

hydromorphone hcl LIQD

2

GC

HYDROMORPHONE HCL SOLN 1mg/ml, 2mg/ml, 4mg/ml

2

GC, B/D

hydromorphone hcl SOLN 500mg/50ml

2

GC, B/D

hydromorphone hcl TABS

2

GC, QL (270 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

12  

Drug Name

Drug Tier

Requirements/Limits

hydromorphone tab 8mg er

2

GC, QL (60 tabs / 30 days)

hydromorphone tab 12mg er

2

GC, QL (60 tabs / 30 days)

hydromorphone tab 16mg er

5

QL (60 tabs / 30 days)

HYDROMORPHONE TABS 32MG

5

QL (60 tabs / 30 days)

HYSINGLA ER 20mg, 30mg, 40mg, 60mg

4

QL (60 tabs / 30 days)

HYSINGLA ER 80mg, 100mg, 120mg

5

QL (30 tabs / 30 days)

ibudone tab 5-200mg

2

GC, QL (150 tabs / 30 days)

ibudone tab 10-200mg

2

GC, QL (150 tabs / 30 days)

INFUMORPH 200

4

B/D

INFUMORPH 500

4

B/D

KADIAN 40mg, 200mg

5

QL (60 caps / 30 days)

LAZANDA

5

QL (30 bottles / 30 days), PA

levorphanol tartrate TABS

2

GC, QL (180 tabs / 30 days)

lorcet hd tab 10-325mg

2

GC, QL (360 tabs / 30 days)

lorcet plus tab 7.5-325

2

GC, QL (360 tabs / 30 days)

lorcet tab 5-325mg

2

GC, QL (360 tabs / 30 days)

lortab tab 5-325mg

2

GC, QL (360 tabs / 30 days)

lortab tab 7.5-325

2

GC, QL (360 tabs / 30 days)

lortab tab 10-325mg

2

GC, QL (360 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

13  

Drug Name

Drug Tier

Requirements/Limits

methadone hcl CONC

2

GC, QL (120 mL / 30 days)

methadone hcl SOLN

2

GC, QL (600 mL / 30 days)

methadone hcl TABS

2

GC, QL (240 tabs / 30 days)

METHADONE INJ 10MG/ML

4

MORPHINE SUL 20MG/ML ORAL SOL

2

GC

MORPHINE SUL INJ 1MG/ML

2

GC, B/D

MORPHINE SUL INJ 4MG/ML

2

GC, B/D

MORPHINE SUL INJ 10MG/ML

2

GC, B/D

MORPHINE SUL INJ 15MG/ML

2

GC, B/D

morphine sulfate CP24 10mg, 20mg, 30mg, 2 50mg, 60mg

GC, QL (60 caps / 30 days)

morphine sulfate CP24 80mg, 100mg

5

QL (60 caps / 30 days)

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

2

GC, B/D

MORPHINE SULFATE SOLN 10mg/5ml, 20mg/5ml

2

GC

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

2

GC, B/D

MORPHINE SULFATE TABS

2

GC, QL (180 tabs / 30 days)

morphine sulfate beads

2

GC, QL (60 caps / 30 days)

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

2

GC, QL (90 tabs / 30 days)

morphine sulfate ext-rel tab 200mg

2

GC, QL (60 tabs / 30 days)

NUCYNTA 50mg

4

QL (360 tabs / 30 days)

NUCYNTA 75mg

4

QL (240 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

14  

Drug Name

Drug Tier

Requirements/Limits

NUCYNTA 100mg

4

QL (180 tabs / 30 days)

NUCYNTA ER 50mg, 100mg

4

QL (120 tabs / 30 days)

NUCYNTA ER 150mg, 200mg, 250mg

4

QL (60 tabs / 30 days)

OPANA ER (CRUSH RESISTANT 5mg, 7.5mg, 10mg, 15mg, 20mg

4

QL (120 tabs / 30 days)

OPANA ER (CRUSH RESISTANT 30mg, 40mg

5

QL (120 tabs / 30 days)

oxycodone hcl CAPS

2

GC, QL (180 caps / 30 days)

oxycodone hcl CONC

2

GC

OXYCODONE HCL SOLN

2

GC

oxycodone hcl TABS

2

GC, QL (180 tabs / 30 days)

oxycodone w/ acetaminophen 2.5-325mg

2

GC, QL (360 tabs / 30 days)

oxycodone w/ acetaminophen 5-325mg

2

GC, QL (360 tabs / 30 days)

oxycodone w/ acetaminophen 7.5-325mg

2

GC, QL (360 tabs / 30 days)

oxycodone w/ acetaminophen 10-325mg

2

GC, QL (360 tabs / 30 days)

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

2

GC, QL (1800 mL / 30 days)

oxycodone-aspirin

2

GC, QL (360 tabs / 30 days)

oxycodone-ibuprofen

2

GC, QL (28 tabs / 30 days)

OXYCONTIN 10mg, 15mg, 20mg, 30mg, 40mg

4

QL (120 tabs / 30 days)

OXYCONTIN 60mg, 80mg

5

QL (120 tabs / 30 days)

oxymorphone hcl TABS

2

GC, QL (180 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

15  

Drug Name

Drug Tier

Requirements/Limits

reprexain tab 10-200mg

2

GC, QL (150 tabs / 30 days)

SUBSYS

5

QL (120 sprays / 30 days), PA

vicodin

2

GC, QL (400 tabs / 30 days)

vicodin es

2

GC, QL (400 tabs / 30 days)

vicodin hp

2

GC, QL (400 tabs / 30 days)

XARTEMIS XR

4

QL (120 tabs / 30 days)

XTAMPZA ER 9mg, 13.5mg, 18mg, 27mg

4

QL (120 caps / 30 days)

XTAMPZA ER 36mg

4

QL (240 caps / 30 days)

xylon tab 10-200mg

2

GC, QL (150 tabs / 30 days)

zamicet

2

GC, QL (5400 mL / 30 days)

ZOHYDRO ER (ABUSE DETERRENT) 10mg, 15mg, 20mg

4

QL (120 caps / 30 days)

ZOHYDRO ER (ABUSE DETERRENT) 30mg, 40mg, 50mg

4

QL (60 caps / 30 days)

lidocaine hcl (local anesth.) 4%

2

GC

lidocaine hcl (local anesth.) .5%, 1%

2

GC, B/D

lidocaine inj 0.5%

2

GC, B/D

lidocaine inj 1%

2

GC, B/D

lidocaine inj 1.5%

2

GC, B/D

lidocaine inj 2%

2

GC, B/D

ANESTHETICS LOCAL ANESTHETICS

ANTI-INFECTIVES 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

16  

Drug Name

Drug Tier

Requirements/Limits

amikacin sulfate SOLN

2

GC

BETHKIS

5

B/D, NM

gentamicin in saline

2

GC

gentamicin sulfate SOLN

2

GC

neomycin sulfate TABS

2

GC

paromomycin sulfate CAPS

2

GC

streptomycin sulfate SOLR

2

GC

sulfadiazine TABS

4

TOBI PODHALER

5

NM, LA, PA

tobramycin NEBU

5

B/D, NM

tobramycin sulfate SOLN; SOLR

2

GC

ANTI-BACTERIALS - MISCELLANEOUS

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA

4

ALINIA

4

atovaquone SUSP

5

AZACTAM/DEX INJ 1GM

4

AZACTAM/DEX INJ 2GM

5

aztreonam

2

BILTRICIDE

3

CAYSTON

5

NM, LA, PA

clindamycin hcl CAPS

1

GC

clindamycin palmitate hydrochloride

2

GC

clindamycin phosphate SOLN

2

GC

clindamycin phosphate in d5w

2

GC

colistimethate sodium SOLR

2

GC

CUBICIN

5

DALVANCE

5

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

17  

Drug Name

Drug Tier

Requirements/Limits

dapsone TABS

2

GC

daptomycin

5

DARAPRIM

4

DORIBAX

4

emverm

4

imipenem-cilastatin

2

INVANZ

4

ivermectin TABS

2

linezolid SOLN

5

LINEZOLID SUSR; TABS

5

LINEZOLID IN SODIUM CHLORIDE

5

MACRODANTIN 25mg

4

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

meropenem

2

GC

MEROPENEM/SODIUM CHLORIDE

2

GC

methenamine hippurate

2

GC

METRO IV

3

metronidazole CAPS

2

GC

metronidazole TABS

1

GC

metronidazole inj

2

GC

NEBUPENT

4

B/D

nitrofurantoin SUSP

2

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

nitrofurantoin macrocrystal

4

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

GC

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

18  

Drug Name

Drug Tier

Requirements/Limits

nitrofurantoin monohyd macro

4

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

PENTAM 300

4

polymyxin b sulfate SOLR

2

PRIMSOL

4

SIVEXTRO

5

sulfamethoxazole-trimethop SUSP

2

GC

sulfamethoxazole-trimethop TABS

1

GC

sulfamethoxazole-trimethoprim inj

2

GC

SYNERCID

5

trimethoprim TABS

1

TYGACIL

5

vancomycin hcl CAPS

5

vancomycin hcl SOLR

2

VANCOMYCIN IN NACL

4

XIFAXAN TAB 200MG

5

ZYVOX TABS

5

GC

GC

GC

ANTIFUNGALS ABELCET

5

B/D

AMBISOME

5

B/D

amphotericin b SOLR

2

GC, B/D

CANCIDAS

5

CRESEMBA

5

ERAXIS

5

fluconazole SUSR; TABS

2

GC

fluconazole in dextrose

2

GC

fluconazole in nacl

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

19  

Drug Name

Drug Tier

Requirements/Limits

flucytosine CAPS

5

griseofulvin microsize

2

GC

griseofulvin ultramicrosize

2

GC

itraconazole CAPS

2

GC, PA

ketoconazole TABS

2

GC, PA

LAMISIL PACK

4

MYCAMINE

5

NOXAFIL

5

nystatin TABS

2

GC

ONMEL

5

PA

SPORANOX SOL 10MG/ML

5

terbinafine hcl TABS

1

voriconazole SUSR; TABS

5

voriconazole inj 200mg

2

GC

atovaquone-proguanil hcl tab 62.5-25 mg

2

GC

atovaquone-proguanil hcl tab 250-100 mg

2

GC

chloroquine phosphate TABS

2

GC

COARTEM

4

mefloquine hcl

2

PRIMAQUINE PHOSPHATE

3

quinine sulfate CAPS

2

GC, PA

abacavir sulfate

2

GC

APTIVUS

5

CRIXIVAN

4

didanosine

2

GC, QL (90 tabs / 365 days)

ANTIMALARIALS

GC

ANTIRETROVIRAL AGENTS

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

20  

Drug Name

Drug Tier

Requirements/Limits

EDURANT

5

EMTRIVA

3

FUZEON

5

INTELENCE 25mg

4

INTELENCE 100mg, 200mg

5

INVIRASE

5

ISENTRESS CHEW 25mg

3

ISENTRESS CHEW 100mg

5

ISENTRESS PACK

3

ISENTRESS TABS

5

lamivudine

2

LEXIVA SUSP

4

LEXIVA TABS

5

NEVIRAPINE SUSP

2

GC

nevirapine TABS; TB24

2

GC

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

2

SUSTIVA CAPS

3

SUSTIVA TABS

5

TIVICAY 10mg

3

TIVICAY 25mg, 50mg

5

NM

GC

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

21  

Drug Name

Drug Tier

TYBOST

3

VIDEX PEDIATRIC

4

VIRACEPT

5

VIRAMUNE XR 100mg

4

VIREAD

5

VITEKTA

5

ZIAGEN SOLN

3

zidovudine

2

Requirements/Limits

GC

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)

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

22  

Drug Name

Drug Tier

Requirements/Limits

ANTITUBERCULAR AGENTS CAPASTAT SULFATE

4

cycloserine CAPS

5

ethambutol hcl TABS

2

GC

isoniazid SOLN; SYRP

2

GC

isoniazid tabs

1

GC

paser d/r

3

PRIFTIN

4

pyrazinamide TABS

2

GC

rifabutin

2

GC

rifamate

4

rifampin CAPS; SOLR

2

RIFATER

4

SIRTURO

5

TRECATOR

4

GC

LA, PA

ANTIVIRALS acyclovir CAPS; TABS

1

GC

acyclovir SUSP

2

GC

acyclovir sodium SOLN

2

GC, B/D

acyclovir sodium SOLR 500mg

2

GC, B/D

adefovir dipivoxil

5

BARACLUDE SOLN

3

cidofovir

5

DAKLINZA

5

entecavir

5

EPIVIR HBV SOLN

4

famciclovir TABS

2

GC

ganciclovir inj 500mg

2

GC, B/D

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

23  

Drug Name

Drug Tier

Requirements/Limits

HARVONI

5

NM, PA

lamivudine (hbv)

2

GC

moderiba pak MISC

5

NM

moderiba pak TABS 400mg

5

NM

MODERIBA PAK TABS 600mg

5

NM

moderiba tab 200mg

2

GC, NM

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

2

GC, NM

ribasphere TABS 200mg, 400mg

2

GC, NM

ribasphere TABS 600mg

5

NM

ribasphere ribapak 800

5

NM

ribasphere ribapak 1000

5

NM

ribasphere ribapak 1200

5

NM

ribavirin 200mg

2

GC, NM

rimantadine hydrochloride

2

GC

SOVALDI

5

NM, PA

TAMIFLU

3

TYZEKA

5

valacyclovir hcl TABS

2

VALCYTE SOLR

5

valganciclovir hcl

5

GC

CEPHALOSPORINS 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

24  

Drug Name

Drug Tier

Requirements/Limits

AVYCAZ

5

cefaclor

2

cefaclor er tab 500mg

3

cefadroxil CAPS

1

GC

cefadroxil SUSR; TABS

2

GC

cefazolin in dextrose 1gm/50ml-5%

3

CEFAZOLIN IN DEXTROSE 2GM/100ML4%

3

cefazolin inj

2

GC

cefazolin sodium 1gm, 20gm

2

GC

cefdinir

2

GC

CEFEPIME 1GM SOLN

4

CEFEPIME 2GM SOLN

4

CEFEPIME HCL AND DEXTROSE

4

cefepime inj 1gm

2

GC

cefepime inj 2gm

2

GC

cefixime

2

GC

cefotaxime sodium 1gm, 2gm, 500mg

2

GC

cefotetan disodium

2

cefoxitin sodium

2

CEFOXITIN SODIUM IN DEXTROSE

4

cefpodoxime proxetil

2

GC

cefprozil

2

GC

ceftazidime

2

GC

CEFTAZIDIME/DEXTROSE

4

CEFTIBUTEN

2

CEFTIN SUSR

4

GC

GC

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

25  

Drug Name

Drug Tier

Requirements/Limits

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 2 250mg, 500mg

GC

cefuroxime axetil

2

GC

cefuroxime sodium 1.5gm, 7.5gm, 750mg

2

GC

cephalexin CAPS 250mg, 500mg

1

GC

cephalexin CAPS 750mg

2

GC

cephalexin SUSR

2

GC

cephalexin TABS

2

GC

claforan 1gm, 2gm

4

CLAFORAN/D5W

4

FORTAZ SOLN

4

FORTAZ SOLR 500mg

4

MAXIPIME

4

SUPRAX CAPS

3

suprax CHEW

4

SUPRAX SUSR 500mg/5ml

3

tazicef SOLR

2

GC

tazicef vial

2

GC

TEFLARO

4

ZERBAXA

5

ZINACEF SOLR 750mg

4

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK

2

GC

azithromycin SOLR; SUSR

2

GC

azithromycin TABS

1

GC

clarithromycin SUSR; TABS; TB24

2

GC

DIFICID

5

e.e.s. 400 tab 400mg

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

26  

Drug Name

Drug Tier

Requirements/Limits

E.E.S. GRANULES

4

ery-tab

2

ERYPED 200

4

ERYPED 400

4

erythrocin lactobionate

4

erythrocin stearate

2

GC

erythromycin base

2

GC

erythromycin cap 250mg ec

2

GC

erythromycin ethylsuccinate

2

GC

PCE

4

ZMAX

4

FLUOROQUINOLONES AVELOX SOLN

4

ciprofloxacin SUSR

2

GC

ciprofloxacin er

2

GC

ciprofloxacin hcl TABS

1

GC

ciprofloxacin in d5w

2

GC

ciprofloxacin inj 200mg/20ml

2

GC

ciprofloxacin inj 400mg/40ml

2

GC

levofloxacin SOLN

2

GC

levofloxacin TABS

1

GC

levofloxacin in d5w

2

GC

MOXIFLOXACIN HCL SOLN

4

moxifloxacin hcl TABS

2

GC

amoxicillin

1

GC

amoxicillin & pot clavulanate

2

GC

ampicillin & sulbactam sodium

2

GC

PENICILLINS

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

27  

Drug Name

Drug Tier

Requirements/Limits

ampicillin cap 250mg

1

GC

ampicillin cap 500 mg

1

GC

ampicillin inj

2

GC

ampicillin sodium

2

GC

ampicillin susp

2

GC

AUGMENTIN SUSR

4

BACTOCILL INJ DEX 1GM

4

BACTOCILL INJ DEX 2GM

5

BICILLIN C-R

4

BICILLIN L-A

4

dicloxacillin sodium

2

MOXATAG

4

NAFCILLIN

4

nafcillin sodium 1gm

2

nafcillin sodium 2gm, 10gm

5

NAFCILLIN SODIUM IN DEXTROSE

4

oxacillin sodium 1gm, 2gm

2

oxacillin sodium 10gm

5

PENICILLIN G POT IN DEXTROSE

4

PENICILLIN G POTASSIUM IN

4

penicillin g procaine

3

penicillin g sodium

2

GC

penicillin gk inj 5mu

2

GC

penicillin gk inj 20mu

2

GC

penicillin v potassium

1

GC

pfizerpen-g inj 5mu

2

GC

pfizerpen-g inj 20mu

2

GC

piperacillin sodium-tazobactam sodium

2

GC

GC

GC

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

28  

Drug Name ZOSYN SOLN

Drug Tier

Requirements/Limits

4

TETRACYCLINES demeclocycline hcl

2

GC

doxy

2

GC

doxycycline (monohydrate)

2

GC

doxycycline hyclate CAPS; SOLR; TABS; TBEC

2

GC

doxycycline hyclate tab 75 mg dr

2

GC

doxycycline hyclate tab 100 mg dr

2

GC

doxycycline hyclate tab 150 mg dr

2

GC

minocycline hcl CAPS; TABS; TB24

2

GC

morgidox

2

GC

SOLODYN

5

TETRACYCLINE HCL CAPS

2

VIBRAMYCIN SYRP

4

GC

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS 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

2

GC, B/D

dacarbazine

2

GC, B/D

EMCYT

4

GLEOSTINE

4

HEXALEN

5

IFEX INJ 3GM

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

29  

Drug Name

Drug Tier

Requirements/Limits

ifosfamide inj 1gm

2

GC, B/D

ifosfamide inj 1gm/20ml

2

GC, B/D

IFOSFAMIDE INJ 3GM

4

B/D

ifosfamide inj 3gm/60ml

2

GC, B/D

LEUKERAN

4

melphalan hcl

5

B/D, NM

MUSTARGEN

4

B/D

thiotepa SOLR

5

B/D

TREANDA

5

B/D, NM

ZANOSAR

4

B/D

daunorubicin hcl

2

GC, B/D

doxorubicin hcl 50mg

2

GC, B/D

ANTHRACYCLINES

doxorubicin hcl liposomal inj (for iv infusion) 25 mg/ml

B/D

doxorubicin inj 50mg

2

GC, B/D

epirubicin inj 50mg/25ml

2

GC, B/D

epirubicin inj 200mg

2

GC, B/D

idarubicin hcl

5

B/D

bleomycin sulfate

2

GC, B/D

COSMEGEN

5

B/D

mitomycin SOLR

2

GC, B/D

adrucil

2

GC, B/D

ALIMTA

5

B/D

ARRANON

5

B/D

azacitidine

5

B/D, NM

ANTIBIOTICS

ANTIMETABOLITES

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

30  

Drug Name

Drug Tier

Requirements/Limits

cladribine

5

B/D

CLOLAR

5

B/D

cytarabine inj

2

GC, B/D

decitabine

5

B/D, NM

fludarabine phosphate

2

GC, B/D

fluorouracil SOLN

2

GC, B/D

GEMCITABINE HCL SOLN

5

B/D

gemcitabine hcl SOLR

5

B/D

mercaptopurine TABS

2

GC

METHOTREXATE SODIUM 50mg/2ml

2

GC, B/D

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

GC, B/D

methotrexate sodium inj

2

GC, B/D

NIPENT

5

B/D

PURIXAN

5

NM

TABLOID

4

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

2

GC, B/D

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

5

B/D

DOCETAXEL SOLN 80MG/8ML

5

B/D

paclitaxel

2

GC, B/D

vinblastine sulfate

3

B/D

vincasar

2

GC, B/D

ANTIMITOTIC, VINCA ALKALOIDS

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

31  

Drug Name

Drug Tier

Requirements/Limits

vincristine sulfate

2

GC, B/D

vinorelbine tartrate

2

GC, B/D

ARZERRA

5

B/D, NM

AVASTIN

5

B/D, NM, LA

BELEODAQ

5

NM, PA

ERBITUX

5

B/D, NM

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

PERJETA

5

NM, PA

PROLEUKIN

5

B/D, NM

RITUXAN

5

NM, LA, PA

TECENTRIQ

5

NM, LA, PA

TORISEL

5

B/D, NM

VECTIBIX

5

B/D, NM

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

BIOLOGIC RESPONSE MODIFIERS

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

32  

Drug Name

Drug Tier

Requirements/Limits

anastrozole TABS

2

GC

bicalutamide

2

GC

DEPO-PROVERA INJ 400/ML

4

B/D

ELIGARD INJ 7.5MG

4

B/D, NM

ELIGARD INJ 22.5MG

4

B/D, NM

ELIGARD INJ 30MG

4

B/D, NM

ELIGARD INJ 45MG

4

B/D, NM

exemestane

2

GC

FARESTON

5

FASLODEX

5

B/D

FIRMAGON 80mg

4

B/D, NM

FIRMAGON 120mg

5

B/D, NM

flutamide

2

GC

hydroxyprogesterone caproate (antineoplastic)

4

B/D

letrozole TABS

2

GC

leuprolide acetate KIT

2

GC, NM, PA

LUPRON DEP INJ 11.25MG

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, 7.5mg

5

NM, PA

LUPRON DEPOT INJ 22.5MG (3-MONTH)

5

NM, PA

LUPRON DEPOT INJ 30MG (3-MONTH)

5

NM, PA

LYSODREN

3

HORMONAL ANTINEOPLASTIC 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

33  

Drug Name

Drug Tier

Requirements/Limits

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

GC

TRELSTAR MIXJECT

5

NM, PA

XTANDI

5

NM, LA, PA

ZYTIGA

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

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

34  

Drug Name

Drug Tier

Requirements/Limits

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

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

HALAVEN

5

MISCELLANEOUS

B/D, 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

35  

Drug Name

Drug Tier

Requirements/Limits

hydroxyurea CAPS

2

GC

IXEMPRA KIT

5

B/D, NM

LONSURF

5

NM, PA

MATULANE

5

LA

mitoxantrone hcl

2

GC, B/D, NM

ODOMZO

5

NM, LA, PA

POMALYST

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 CAPS

5

TRISENOX

5

B/D

UVADEX

4

B/D

carboplatin

2

GC, B/D

cisplatin

2

GC, B/D

ELOXATIN

5

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

KEPIVANCE

5

B/D

leucovor ca inj

2

GC, B/D

leucovorin calcium SOLR

2

GC, B/D

leucovorin calcium TABS

2

GC

PLATINUM-BASED AGENTS

PROTECTIVE 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

36  

Drug Name

Drug Tier

Requirements/Limits

leucovorin calcium 500 mg

2

GC, B/D

levoleucovorin calcium

5

B/D, NM

mesna

2

GC, B/D

MESNEX TABS

5

TOPOISOMERASE INHIBITORS CAMPTOSAR 300mg/15ml

4

B/D

ETOPOPHOS

4

B/D

etoposide SOLN 500mg/25ml

2

GC, B/D

irinotecan inj 40mg/2ml

2

GC, B/D

irinotecan inj 100/5ml

2

GC, B/D

irinotecan inj 500mg/25ml

2

GC, B/D

toposar 1gm/50ml

2

GC, B/D

topotecan hcl SOLR

5

B/D

amlodipine besylate-benazepril hcl

1

GC

benazepril & hydrochlorothiazide

1

GC

captopril & hydrochlorothiazide

1

GC

enalapril maleate & hydrochlorothiazide

1

GC

fosinopril sodium & hydrochlorothiazide

1

GC

lisinopril & hydrochlorothiazide

1

GC

moexipril-hydrochlorothiazide

1

GC

quinapril-hydrochlorothiazide

1

GC

trandolapril-verapamil hcl

1

GC

benazepril hcl TABS

1

GC

captopril TABS

1

GC

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS

ACE 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

37  

Drug Name

Drug Tier

Requirements/Limits

enalapril maleate TABS

1

GC

fosinopril sodium

1

GC

lisinopril TABS

1

GC

moexipril hcl

1

GC

perindopril erbumine

1

GC

QBRELIS

4

quinapril hcl

1

GC

ramipril

1

GC

trandolapril

1

GC

eplerenone

2

GC

spironolactone TABS

1

GC

doxazosin mesylate

2

GC

prazosin hcl

2

GC

terazosin hcl

1

GC

ALDOSTERONE RECEPTOR ANTAGONISTS

ALPHA BLOCKERS

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

GC

amlodipine besylate-valsartan tab 5-320 mg 1

GC

amlodipine besylate-valsartan tab 10-160 mg 1

GC

amlodipine besylate-valsartan tab 10-320 mg 1

GC

amlodipine-valsartan-hydrochlorothiazide 5- 1 160-12.5mg

GC

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

GC

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

GC

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

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

38  

Drug Name

Drug Tier

amlodipine-valsartan-hydrochlorothiazide 10- 1 320-25mg

Requirements/Limits GC

AZOR

3

BENICAR HCT

3

candesartan cilexetil-hydrochlorothiazide

1

EDARBYCLOR

4

ENTRESTO

4

PA

irbesartan-hydrochlorothiazide

1

GC

losartan-hydrochlorothiazide

1

GC

telmisartan-amlodipine

1

GC

telmisartan-hydrochlorothiazide

1

GC

TRIBENZOR

3

valsartan-hydrochlorothiazide

1

GC

GC

ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR

3

candesartan cilexetil

1

EDARBI

4

eprosartan mesylate

1

GC

irbesartan

1

GC

losartan potassium

1

GC

telmisartan

1

GC

valsartan

1

GC

amiodarone hcl SOLN

2

GC

amiodarone hcl TABS 100mg, 400mg

2

GC

amiodarone hcl TABS 200mg

1

GC

amiodarone inj 50mg/ml

2

GC

GC

ANTIARRHYTHMICS

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

39  

Drug Name

Drug Tier

Requirements/Limits

disopyramide phosphate

4

PA; PA if 65 years and older

dofetilide

2

GC, NM

flecainide acetate

2

GC

mexiletine hcl

2

GC

MULTAQ

4

NORPACE CR

4

PA; PA if 65 years and older

pacerone 100mg, 400mg

2

GC

pacerone 200mg

1

GC

propafenone hcl

2

GC

propafenone hcl 12hr

2

GC

quinidine gluconate TBCR

2

GC

quinidine sulfate TABS

2

GC

sorine

2

GC

sotalol hcl

1

GC

sotalol hcl (afib/afl)

2

GC

TIKOSYN

4

NM

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV

4

atorvastatin calcium TABS

1

CRESTOR

1

fluvastatin sodium cap 20 mg

1

GC

fluvastatin sodium cap 40 mg

1

GC

fluvastatin sodium tab sr 24 hr 80 mg

1

GC

LESCOL XL

4

LIVALO

4

lovastatin

1

GC

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

40  

Drug Name

Drug Tier

Requirements/Limits

pravastatin sodium

1

GC

rosuvastatin calcium

1

GC

simvastatin TABS 5mg, 10mg, 20mg, 40mg 1

GC

simvastatin TABS 80mg

GC, QL (30 tabs / 30 days)

1

ANTILIPEMICS, MISCELLANEOUS ANTARA

4

cholestyramine

2

GC

cholestyramine light

2

GC

choline fenofibrate

2

GC

colestipol hcl

2

GC

FENOFIBRATE CAPS

2

GC

FENOFIBRATE TABS 40mg, 120mg

2

GC

fenofibrate TABS 48mg, 54mg, 145mg, 160mg

2

GC

fenofibrate micronized

2

GC

FENOFIBRIC ACID

2

GC

FENOGLIDE

4

gemfibrozil TABS

1

GC

JUXTAPID

5

NM, LA, PA

KYNAMRO

5

NM, PA

niacin er (antihyperlipidemic)

2

GC

niacor

2

GC

omega-3-acid ethyl esters

2

GC

PRALUENT

5

NM, PA

prevalite

2

GC

TRIGLIDE

4

VASCEPA 1gm

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

41  

Drug Name

Drug Tier

Requirements/Limits

VYTORIN

4

ST

WELCHOL

3

ZETIA TAB 10MG

3

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone

2

GC

bisoprolol & hydrochlorothiazide

1

GC

DUTOPROL

4

metoprolol & hctz tab 50-25mg

2

GC

metoprolol & hctz tab 100-25mg

2

GC

metoprolol & hctz tab 100-50mg

2

GC

nadolol & bendroflumethiazide

2

GC

propranolol & hydrochlorothiazide

2

GC

acebutolol hcl CAPS

1

GC

atenolol TABS

1

GC

betaxolol hcl

2

GC

bisoprolol fumarate

2

GC

BYSTOLIC

4

carvedilol

1

COREG CR

4

labetalol hcl SOLN; TABS

2

GC

metoprolol succinate

2

GC

metoprolol tartrate SOLN

2

GC

metoprolol tartrate TABS 25mg, 50mg, 100mg

1

GC

nadolol TABS

2

GC

pindolol

2

GC

propranolol hcl er

2

GC

BETA-BLOCKERS

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

42  

Drug Name

Drug Tier

Requirements/Limits

propranolol inj 1mg/ml

2

GC

propranolol sol

2

GC

propranolol tab

1

GC

SOTYLIZE

5

timolol maleate TABS

2

GC

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate/atorv

1

GC

afeditab cr

2

GC

amlodipine besylate TABS

1

GC

CARDIZEM LA 120mg

4

cartia xt

2

GC

dilt-xr cap

2

GC

diltiazem cap 120mg/24hr

2

GC

diltiazem cap 240mg/24hr

2

GC

diltiazem cap er/12hr

2

GC

diltiazem hcl TABS

1

GC

diltiazem hcl coated beads

2

GC

diltiazem hcl er

2

GC

diltiazem hcl extended release beads

2

GC

diltiazem inj 25mg/5ml

2

GC

diltiazem inj 50/10ml

2

GC

diltiazem inj 100mg

4

diltiazem inj 125/25ml

2

GC

felodipine

2

GC

isradipine

2

GC

matzim la

2

GC

nicardipine hcl CAPS

2

GC

CALCIUM CHANNEL BLOCKERS

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

43  

Drug Name

Drug Tier

Requirements/Limits

nifedical

2

GC

nifedipine TB24

2

GC

nifedipine er

2

GC

nimodipine CAPS

5

nisoldipine

2

NYMALIZE

5

taztia xt

2

GC

verapamil hcl CP24 100mg, 120mg, 180mg, 2 200mg, 240mg, 300mg

GC

VERAPAMIL HCL CP24 360mg

2

GC

verapamil hcl SOLN

2

GC

verapamil hcl TABS

1

GC

verapamil hcl TBCR

1

GC

digitek .25mg

2

GC, PA; PA if 65 years and older

digitek .125mg

2

GC, QL (30 tabs / 30 days)

digox 125mcg

2

GC, QL (30 tabs / 30 days)

digox 250mcg

2

GC, PA; PA if 65 years and older

digoxin TABS 125mcg

2

GC, QL (30 tabs / 30 days)

digoxin TABS 250mcg

2

GC, PA; PA if 65 years and older

digoxin inj

2

GC

DIGOXIN SOL 50MCG/ML

2

GC, PA; PA if 65 years and older

LANOXIN TABS 62.5mcg

4

QL (60 tabs / 30 days)

GC

DIGITALIS GLYCOSIDES

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

44  

Drug Name

Drug Tier

Requirements/Limits

LANOXIN TABS 187.5mcg

4

PA; PA if 65 years and older

LANOXIN PEDIATRIC

4

DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA

3

TEKTURNA HCT

3

DIURETICS acetazolamide CP12; TABS

2

GC

acetazolamide sodium

2

GC

ALDACTAZIDE TAB 50/50

4

amiloride & hydrochlorothiazide

1

GC

amiloride hcl TABS

2

GC

bumetanide

2

GC

chlorothiazide tabs

2

GC

chlorthalidone 25mg, 50mg

2

GC

DIURIL SUS 250/5ML

4

DYRENIUM

4

EDECRIN

4

ethacrynic acid

2

GC

furosemide SOLN; TABS

1

GC

furosemide inj 10mg/ml

2

GC

FUROSEMIDE INJ 10mg/ml

2

GC

furosemide oral soln 8 mg/ml

1

GC

hydrochlorothiazide CAPS; TABS

1

GC

indapamide

1

GC

methazolamide TABS

2

GC

methyclothiazide

2

GC

metolazone

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

45  

Drug Name

Drug Tier

Requirements/Limits

spironolactone & hydrochlorothiazide

2

GC

torsemide inj 50mg/5ml

2

GC

torsemide tabs

1

GC

triamt/hctz cap 37.5-25

1

GC

triamt/hctz cap 50-25mg

1

GC

triamt/hctz tab 37.5-25

1

GC

triamt/hctz tab 75-50mg

1

GC

MISCELLANEOUS BIDIL

3

clonidine hcl PTWK

2

GC

clonidine hcl TABS

1

GC

clorpres

2

GC

CORLANOR

4

DEMSER

5

DIBENZYLINE

5

hydralazine hcl SOLN; TABS

2

GC

KEVEYIS

5

NM, PA

midodrine hcl

2

GC

minoxidil TABS

2

GC

phenoxybenzamine hcl CAPS

5

RANEXA

3

NITRATES DILATRATE SR

4

ISORDIL TITRADOSE 40mg

4

isosorbide dinitrate

2

GC

isosorbide dinitrate er

2

GC

isosorbide mononitrate

1

GC

isosorbide mononitrate er

1

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

46  

Drug Name

Drug Tier

Requirements/Limits

minitran

2

GC

nitro-bid

3

NITRO-DUR .3mg/hr, .8mg/hr

4

nitroglycerin SOLN .4mg/spray

2

GC

nitroglycerin SUBL

2

GC

NITROGLYCERIN LINGUAL

2

GC

nitroglycerin patches

2

GC

NITROSTAT

3

PULMONARY ARTERIAL HYPERTENSION ADCIRCA

5

NM, PA

ADEMPAS

5

NM, LA, PA

LETAIRIS

5

NM, LA, PA

OPSUMIT

5

NM, LA, PA

ORENITRAM TAB 0.25MG

5

NM, LA, PA

ORENITRAM TAB 0.125MG

4

NM, LA, PA

ORENITRAM TAB 1MG

5

NM, LA, PA

ORENITRAM TAB 2.5MG

5

NM, LA, PA

REMODULIN

5

B/D, NM, LA

REVATIO SUSR

5

NM, PA

sildenafil citrate (pulmonary hypertension) TABS

2

GC, NM, PA

TRACLEER

5

NM, LA, PA

TYVASO

5

B/D, NM

UPTRAVI

5

NM, LA, PA

VENTAVIS

5

B/D, NM

CENTRAL NERVOUS SYSTEM ANTIANXIETY

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

47  

Drug Name

Drug Tier

Requirements/Limits

alprazolam CONC

2

GC, QL (300 mL / 30 days)

alprazolam TABS 1mg

1

GC, QL (120 tabs / 30 days)

alprazolam TABS 2mg

1

GC, QL (150 tabs / 30 days)

alprazolam TABS .5mg

1

GC, QL (240 tabs / 30 days)

alprazolam TABS .25mg

1

GC, QL (480 tabs / 30 days)

buspirone hcl TABS

2

GC

fluvoxamine maleate 25mg, 50mg

2

GC, QL (45 tabs / 30 days)

fluvoxamine maleate 100mg

2

GC

fluvoxamine maleate er 100mg

2

GC, QL (90 caps / 30 days)

fluvoxamine maleate er 150mg

2

GC, QL (60 caps / 30 days)

lorazepam CONC

2

GC, QL (150 mL / 30 days)

lorazepam SOLN

2

GC

lorazepam TABS

1

GC, QL (150 tabs / 30 days)

ANTICONVULSANTS APTIOM 200mg

4

APTIOM 400mg, 600mg, 800mg

5

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

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

48  

Drug Name

Drug Tier

Requirements/Limits

BRIVIACT TABS

5

PA

carbamazepine CHEW; CP12; SUSP; TABS; TB12

2

GC

CELONTIN

4

clonazepam TABS 1mg

1

GC, QL (120 tabs / 30 days)

clonazepam TABS 2mg

1

GC, QL (300 tabs / 30 days)

clonazepam TABS .5mg

1

GC, QL (240 tabs / 30 days)

clonazepam TBDP 1mg

2

GC, QL (120 tabs / 30 days)

clonazepam TBDP 2mg

2

GC, QL (300 tabs / 30 days)

clonazepam TBDP .5mg

2

GC, QL (240 tabs / 30 days)

clonazepam TBDP .25mg

2

GC, QL (480 tabs / 30 days)

clonazepam TBDP .125mg

2

GC, QL (960 tabs / 30 days)

clorazepate dipotassium 3.75mg, 7.5mg

2

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

clorazepate dipotassium 15mg

2

GC, QL (180 tabs / 30 days), PA

diazepam CONC

2

GC, QL (240 mL / 30 days), PA

diazepam SOLN 1mg/ml

2

GC, QL (1200 mL / 30 days), PA

diazepam SOLN 5mg/ml

2

GC

diazepam TABS

1

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

DIAZEPAM GEL (ANTICONVULSANT)

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

49  

Drug Name

Drug Tier

Requirements/Limits

dilantin

3

DILANTIN-125

3

divalproex sodium

2

GC

epitol

2

GC

ethosuximide CAPS; SOLN

2

GC

felbamate SUSP

5

felbamate TABS

2

GC

FYCOMPA

4

PA

gabapentin CAPS 100mg

1

GC, QL (1080 caps / 30 days)

gabapentin CAPS 300mg

1

GC, QL (360 caps / 30 days)

gabapentin CAPS 400mg

1

GC, QL (270 caps / 30 days)

gabapentin SOLN

2

GC, QL (2160 mL / 30 days)

gabapentin TABS 600mg

2

GC, QL (180 tabs / 30 days)

gabapentin TABS 800mg

2

GC, QL (120 tabs / 30 days)

GABITRIL 12mg, 16mg

4

LAMICTAL ODT KIT

4

LAMICTAL STARTER

4

LAMICTAL XR KIT

4

lamotrigine CHEW; KIT; TB24; TBDP

2

GC

lamotrigine TABS

1

GC

levetiracetam SOLN; TABS; TB24

2

GC

LEVETIRACETAM IV

4

levetiracetam oral soln 100 mg/ml

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

50  

Drug Name

Drug Tier

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

2

GC

OXTELLAR XR

4

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

2

GC

phenytoin inj 50mg/ml

2

GC

phenytoin sodium extended

2

GC

POTIGA 50mg

4

POTIGA 200mg

5

QL (180 tabs / 30 days)

POTIGA 300mg, 400mg

5

QL (90 tabs / 30 days)

primidone TABS

2

GC

roweepra

2

GC

SABRIL PACK

5

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

SABRIL TABS

5

QL (180 tabs / 30 days), 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

51  

Drug Name

Drug Tier

Requirements/Limits

SPRITAM

4

TEGRETOL

4

TEGRETOL-XR

4

tiagabine hcl

2

GC

topiramate CPSP

2

GC

TOPIRAMATE CS24

2

GC

topiramate TABS

1

GC

TROKENDI XR 25mg, 50mg, 100mg

4

TROKENDI XR 200mg

5

valproate sodium SOLN; SYRP

2

GC

valproic acid

2

GC

VIMPAT SOLN

4

VIMPAT TABS 50mg

4

VIMPAT TABS 100mg, 150mg, 200mg

5

zonisamide CAPS

2

GC

donepezil odt 5mg

2

GC

donepezil odt 10mg

2

GC

donepezil tab hcl 23mg

2

GC

donepezil tabs 5mg

2

GC

donepezil tabs 10mg

2

GC

EXELON PATCHES

2

galantamine hydrobromide

2

GC

galantamine hydrobromide er

2

GC

memantine hcl

2

GC, 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

ANTIDEMENTIA

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

52  

Drug Name

Drug Tier

Requirements/Limits

2

GC

amitriptyline hcl TABS

4

PA; PA if 65 years and older

amoxapine

2

GC

APLENZIN

5

BRINTELLIX

4

bupropion hcl TABS; TB12; TB24

2

GC

citalopram hydrobromide SOLN

2

GC

citalopram hydrobromide TABS

1

GC

clomipramine hcl CAPS

4

PA; PA if 65 years and older

desipramine hcl TABS

2

GC

doxepin hcl CAPS; CONC

4

PA; PA if 65 years and older

duloxetine hcl CPEP 20mg, 30mg, 60mg

2

GC

EMSAM

5

PA

escitalopram oxalate

2

GC

FETZIMA

4

FETZIMA TITRATION PACK

4

fluoxetine cap 10mg

1

GC

fluoxetine cap 20mg

1

GC

fluoxetine cap 40mg

1

GC

fluoxetine hcl CPDR

2

GC

fluoxetine hcl SOLN

2

GC

fluoxetine hcl TABS 10mg, 20mg

2

GC

FLUOXETINE HCL TABS 60mg

4

FORFIVO XL

4

rivastigmine tartrate ANTIDEPRESSANTS

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

53  

Drug Name

Drug Tier

Requirements/Limits

imipramine hcl TABS

4

PA; PA if 65 years and older

imipramine pamoate

4

PA; PA if 65 years and older

maprotiline hcl

2

GC

MARPLAN

4

mirtazapine TABS

1

GC

mirtazapine TBDP

2

GC

nefazodone hcl

2

GC

nortriptyline hcl CAPS

1

GC

nortriptyline hcl SOLN

2

GC

paroxetine er tab

2

GC

paroxetine hcl tabs

1

GC

PAXIL SUSP

4

PEXEVA

4

phenelzine sulfate TABS

2

PRISTIQ

3

protriptyline hcl

2

GC

sertraline hcl CONC

2

GC

sertraline hcl TABS

1

GC

SURMONTIL

4

PA; PA if 65 years and older

tranylcypromine sulfate

2

GC

trazodone hcl TABS 50mg, 100mg, 150mg 1

GC

trazodone hcl TABS 300mg

2

GC

trimipramine maleate CAPS

4

PA; PA if 65 years and older

TRINTELLIX

4

venlafaxine cap er

2

GC

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

54  

Drug Name

Drug Tier

Requirements/Limits

venlafaxine hcl

2

GC

venlafaxine tab

2

GC

VENLAFAXINE TAB 225MG ER

2

GC

venlafaxine tab er

2

GC

VIIBRYD

4

VIIBRYD STARTER PACK

4

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS

2

GC

APOKYN

5

NM, LA, PA

AZILECT

3

BENZTROPINE MESYLATE SOLN

2

GC

benztropine mesylate TABS

4

PA; PA if 65 years and older

bromocriptine mesylate CAPS; TABS

2

GC

carbidopa TABS

5

carbidopa-levodopa

2

GC

CARBIDOPA/LEVODOPA/ENTACAPONE

2

GC

DUOPA

4

B/D, NM

ENTACAPONE

2

GC

MIRAPEX .75mg

4

MIRAPEX ER .375mg, 2.25mg, 3mg, 3.75mg, 4.5mg

4

NEUPRO

4

pramipexole dihydrochloride

2

GC

ropinirole hydrochloride

2

GC

RYTARY

4

selegiline hcl CAPS; TABS

2

ZELAPAR

5

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

55  

Drug Name

Drug Tier

Requirements/Limits

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)

ARISTADA

5

QL (1 syringe / 28 days)

chlorpromazine hcl TABS

2

GC

chlorpromazine inj

4

clozapine TABS 25mg, 50mg

2

GC

clozapine TABS 100mg

2

GC, QL (270 tabs / 30 days)

clozapine TABS 200mg

2

GC, QL (135 tabs / 30 days)

CLOZAPINE TBDP 150mg

5

QL (180 tabs / 30 days), PA

CLOZAPINE TBDP 200mg

5

QL (135 tabs / 30 days), PA

CLOZAPINE ODT 12.5mg, 25mg

2

GC, PA

CLOZAPINE ODT 100mg

2

GC, QL (270 tabs / 30 days), PA

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

2

GC

fluphenazine hcl

2

GC

ANTIPSYCHOTICS

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

56  

Drug Name

Drug Tier

Requirements/Limits

GEODON INJ

4

QL (6 mL / 3 days)

haloperidol TABS

2

GC

haloperidol decanoate SOLN

2

GC

haloperidol lactate

2

GC

haloperidol lactate inj 5 mg/ml

2

GC

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)

LATUDA 60mg, 80mg

4

QL (60 tabs / 30 days)

loxapine succinate

2

GC

molindone hcl

2

GC

NUPLAZID

5

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

olanzapine SOLR

2

GC, QL (3 vials / 1 day)

olanzapine TABS 2.5mg, 5mg, 7.5mg

2

GC, QL (30 tabs / 30 days)

olanzapine TABS 10mg, 15mg, 20mg

2

GC, QL (60 tabs / 30 days)

olanzapine odt 5mg

2

GC, QL (30 tabs / 30 days)

olanzapine odt 10mg, 15mg, 20mg

2

GC, QL (60 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

57  

Drug Name

Drug Tier

Requirements/Limits

paliperidone 1.5mg, 3mg, 9mg

2

GC, QL (30 tabs / 30 days)

paliperidone 6mg

2

GC, QL (60 tabs / 30 days)

perphenazine TABS

2

GC

pimozide

2

GC

quetiapine fumarate

2

GC, 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)

RISPERDAL INJ 50MG

5

QL (2 injections / 28 days)

risperidone SOLN

2

GC, QL (240 mL / 30 days)

risperidone TABS 1mg, 2mg, 3mg

2

GC, QL (60 tabs / 30 days)

risperidone TABS 4mg

2

GC, 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

58  

Drug Name

Drug Tier

Requirements/Limits

risperidone TABS .25mg, .5mg

2

GC, QL (90 tabs / 30 days)

risperidone odt 1mg, 2mg, 3mg

2

GC, QL (60 tabs / 30 days)

risperidone odt 4mg

2

GC, QL (120 tabs / 30 days)

risperidone odt .25mg, .5mg

2

GC, 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

2

GC

trifluoperazine hcl

2

GC

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

2

GC, QL (60 caps / 30 days)

ziprasidone hcl 60mg, 80mg

2

GC, QL (90 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

59  

Drug Name

Drug Tier

Requirements/Limits

ZYPREXA RELPREVV 300mg

5

QL (2 vials / 28 days), PA

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 cap 10mg er

2

GC, QL (90 caps / 30 days)

amphetamine cap 15mg er

2

GC, QL (30 caps / 30 days)

amphetamine cap 20mg er

2

GC, QL (30 caps / 30 days)

amphetamine cap 25mg er

2

GC, QL (30 caps / 30 days)

amphetamine cap 30mg er

2

GC, QL (30 caps / 30 days)

amphetamine-dextroamphetamine cap sr 24hr 5 mg

2

GC, QL (90 caps / 30 days)

amphetamine-dextroamphetamine tab 5 mg 2

GC, QL (360 tabs / 30 days)

amphetamine-dextroamphetamine tab 7.5 mg

2

GC, QL (240 tabs / 30 days)

amphetamine-dextroamphetamine tab 10 mg 2

GC, QL (180 tabs / 30 days)

amphetamine-dextroamphetamine tab 12.5 mg

2

GC, QL (144 tabs / 30 days)

amphetamine-dextroamphetamine tab 15 mg 2

GC, QL (120 tabs / 30 days)

amphetamine-dextroamphetamine tab 20 mg 2

GC, QL (90 tabs / 30 days)

amphetamine-dextroamphetamine tab 30 mg 2

GC, QL (60 tabs / 30 days)

APTENSIO XR 10mg, 15mg, 20mg, 30mg

4

QL (60 caps / 30 days)

APTENSIO XR 40mg, 50mg, 60mg

4

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

60  

Drug Name

Drug Tier

Requirements/Limits

DAYTRANA

4

QL (30 patches / 30 days)

guanfacine er (adhd)

4

PA; PA if 65 years and older

metadate er tab 20mg

2

GC, QL (90 tabs / 30 days)

methylphenidate hcl CHEW

2

GC, QL (180 tabs / 30 days)

methylphenidate hcl CP24 20mg

2

GC, QL (60 caps / 30 days)

METHYLPHENIDATE HCL CP24 30mg

2

GC, QL (60 caps / 30 days)

methylphenidate hcl CP24 40mg

2

GC, QL (30 caps / 30 days)

methylphenidate hcl CPCR 10mg, 20mg, 30mg

2

GC, QL (60 caps / 30 days)

methylphenidate hcl CPCR 40mg, 50mg, 60mg

2

GC, QL (30 caps / 30 days)

methylphenidate hcl SOLN 5mg/5ml

2

GC, QL (1800 mL / 30 days)

methylphenidate hcl SOLN 10mg/5ml

2

GC, QL (900 mL / 30 days)

methylphenidate hcl TABS 5mg, 10mg

2

GC, QL (180 tabs / 30 days)

methylphenidate hcl TABS 20mg

2

GC, QL (90 tabs / 30 days)

methylphenidate hcl TB24

2

GC, QL (60 tabs / 30 days)

methylphenidate hcl TBCR

2

GC, QL (90 tabs / 30 days)

methylphenidate hcl er TB24 27mg, 36mg

2

GC, QL (60 tabs / 30 days)

methylphenidate hcl er TB24 54mg

2

GC, 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

61  

Drug Name

Drug Tier

Requirements/Limits

QUILLICHEW ER 20mg

4

QL (90 tabs / 30 days)

QUILLICHEW ER 30mg

4

QL (60 tabs / 30 days)

QUILLICHEW ER 40mg

4

QL (30 tabs / 30 days)

QUILLIVANT XR

4

QL (360 mL / 30 days)

RITALIN LA 10mg

4

QL (180 tabs / 30 days)

RITALIN LA 60mg

4

QL (30 caps / 30 days)

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)

VYVANSE 10mg, 20mg, 30mg

4

QL (60 caps / 30 days)

VYVANSE 40mg, 50mg, 60mg, 70mg

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

GC, 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

GC, 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

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

62  

Drug Name

Drug Tier

Requirements/Limits

almotriptan malate

2

GC, QL (12 tabs / 30 days)

AXERT

4

QL (12 tabs / 30 days), ST

cafergot tab 1-100mg

4

dihydroergotamine mesylate 1mg/ml

2

GC

DIHYDROERGOTAMINE MESYLATE 4mg/ml

5

QL (8 mL / 30 days)

ergomar

4

FROVA TAB 2.5MG

4

QL (18 tabs / 30 days), ST

frovatriptan succinate

2

GC, QL (18 tabs / 30 days)

migergot

5

naratriptan hcl

2

GC, QL (9 tabs / 30 days)

ONZETRA XSAIL

4

QL (8 pouches / 30 days), ST

RELPAX

3

QL (12 tabs / 30 days)

rizatriptan benzoate

2

GC, QL (18 tabs / 30 days)

sumatriptan inj 4mg/0.5ml SOAJ

2

GC, QL (12 injections / 30 days)

SUMATRIPTAN INJ 4MG/0.5ML SOCT

2

GC, QL (12 injections / 30 days)

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

2

GC, QL (12 injections / 30 days)

SUMATRIPTAN INJ 6MG/0.5ML SOCT

2

GC, QL (12 injections / 30 days)

SUMATRIPTAN SUCCINATE SOLN 5mg/act

2

GC, QL (24 inhalers / 30 days)

MIGRAINE

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

63  

Drug Name

Drug Tier

Requirements/Limits

SUMATRIPTAN SUCCINATE SOLN 20mg/act

2

GC, QL (12 inhalers / 30 days)

sumatriptan succinate TABS

2

GC, QL (9 tabs / 30 days)

SUMAVEL DOSEPRO

5

QL (12 injections / 30 days)

TREXIMET

5

QL (9 tabs / 30 days), ST

ZEMBRACE SYMTOUCH

4

QL (24 injections / 30 days), ST

zolmitriptan TABS

2

GC, QL (12 tabs / 30 days)

zolmitriptan odt

2

GC, QL (12 tabs / 30 days)

ZOMIG NASAL SPRAY

4

QL (12 inhalers / 30 days)

MISCELLANEOUS BRISDELLE

4

EQUETRO

4

GRALISE 300mg

3

QL (180 tabs / 30 days)

GRALISE 600mg

3

QL (90 tabs / 30 days)

GRALISE STARTER

3

HORIZANT

4

lithium carbonate CAPS; TABS

1

GC

lithium carbonate TBCR

2

GC

LITHIUM SOLN 8MEQ/5ML

3

MESTINON SYRUP

4

MESTINON TIMESPAN

4

NUEDEXTA

3

PA

pyridostigmine bromide TABS; TBCR

2

GC

riluzole

2

GC

SAVELLA 12.5mg

4

QL (480 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

64  

Drug Name

Drug Tier

Requirements/Limits

SAVELLA 25mg

4

QL (240 tabs / 30 days)

SAVELLA 50mg

4

QL (120 tabs / 30 days)

SAVELLA 100mg

4

QL (60 tabs / 30 days)

SAVELLA TITRATION PACK

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

AUBAGIO

5

QL (30 tabs / 30 days), 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

EXTAVIA

5

QL (15 syringes / 30 days), NM, PA

GILENYA CAP 0.5MG

5

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

LEMTRADA

5

NM, LA, PA

REBIF

5

QL (6 mL / 28 days), NM, PA

REBIF REBIDOSE

5

QL (6 mL / 28 days), NM, PA

REBIF REBIDOSE TITRATION

5

QL (6 mL / 28 days), NM, PA

REBIF TITRATION PACK

5

QL (6 mL / 30 days), NM, 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

65  

Drug Name

Drug Tier

Requirements/Limits

TECFIDERA CAP 120MG

5

QL (14 caps / 7 days), NM, LA, PA

TECFIDERA CAP 240MG

5

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

TECFIDERA MIS STARTER

5

NM, LA, PA

TYSABRI

5

NM, LA, PA

baclofen TABS

2

GC

BOTOX INJ 100UNIT

5

NM, PA

BOTOX INJ 200UNIT

5

NM, PA

dantrolene sodium CAPS

2

GC

tizanidine

2

GC

XEOMIN 50UNIT

4

NM, PA

XEOMIN 100UNIT

5

NM, PA

XEOMIN 200UNIT

5

NM, PA

modafinil 100mg

2

GC, QL (30 tabs / 30 days), PA

modafinil 200mg

5

QL (60 tabs / 30 days), PA

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

2

GC

MUSCULOSKELETAL THERAPY AGENTS

NARCOLEPSY/CATAPLEXY

PSYCHOTHERAPEUTIC-MISC acamprosate calcium

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

66  

Drug Name

Drug Tier

Requirements/Limits

BUNAVAIL MIS 2.1-0.3MG

4

QL (120 buccal films / 30 days), PA

BUNAVAIL MIS 4.2-0.7MG

4

QL (120 buccal films / 30 days), PA

BUNAVAIL MIS 6.3-1MG

4

QL (60 buccal films / 30 days), PA

buprenorphine hcl SUBL

2

GC, PA

buprenorphine hcl-naloxone hcl sl

2

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

buproban tab (smoking deterrent)

2

GC

bupropion hcl (smoking deterrent)

2

GC

CHANTIX

4

PA

CHANTIX CONTINUING MONTH

4

PA

CHANTIX STARTER PACK

4

PA

disulfiram TABS

2

GC

naloxone inj 0.4mg/ml

2

GC

naloxone inj 1mg/ml

2

GC

naltrexone hcl TABS

2

GC

NICOTROL INHALER

4

NICOTROL NS

4

SARAFEM

4

SUBOXONE MIS 2-0.5MG

4

QL (120 SL films / 30 days), PA

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

VIVITROL

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

67  

Drug Name

Drug Tier

Requirements/Limits

ZUBSOLV SUB 1.4-0.36MG

4

QL (120 tabs / 30 days), PA

ZUBSOLV SUB 2.9-0.71MG

4

QL (120 tabs / 30 days), PA

ZUBSOLV SUB 5.7-1.4MG

4

QL (120 tabs / 30 days), PA

ZUBSOLV SUB 8.6-2.1MG

4

QL (60 tabs / 30 days), PA

ZUBSOLV SUB 11.4-2.9MG

4

QL (60 tabs / 30 days), PA

ANDRODERM

4

QL (30 patches / 30 days), PA

ANDROGEL 20.25mg/1.25gm, 40.5mg/2.5gm

4

QL (150 grams / 30 days), PA

ANDROGEL 25mg/2.5gm

4

QL (300 grams / 30 days), PA

ANDROGEL 1%

4

QL (300 grams / 30 days), PA

ANDROGEL 1.62%

4

QL (150 grams / 30 days), PA

AXIRON

3

QL (440 mL / 30 days), PA

depo-testosterone 100mg/ml

4

PA

FORTESTA

4

QL (120 grams / 30 days), PA

oxandrolone TABS 2.5mg

2

GC, PA

oxandrolone TABS 10mg

5

PA

STRIANT

4

QL (60 buccal systems / 30 days), PA

ENDOCRINE AND METABOLIC ANDROGENS

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

68  

Drug Name

Drug Tier

Requirements/Limits

TESTIM

4

QL (300 grams / 30 days), PA

TESTOSTERONE GEL 1%, 25mg/2.5gm

2

GC, QL (300 grams / 30 days), PA

TESTOSTERONE GEL 10mg/act

2

GC, QL (120 grams / 30 days), PA

testosterone cypionate SOLN

2

GC, PA

testosterone enanthate SOLN

2

GC, PA

VOGELXO

4

QL (300 grams / 30 days), PA

VOGELXO PUMP

4

QL (300 grams / 30 days), PA

ANTIDIABETICS, INJECTABLE ALCOHOL SWABS

3

APIDRA

4

APIDRA SOLOSTAR

4

BYDUREON

3

QL (4 vials / 28 days)

BYDUREON PEN

3

QL (4 pens / 28 days)

BYETTA

4

QL (1 pen / 30 days)

GAUZE PADS 2X2

3

HUMALOG

4

HUMALOG KWIKPEN

4

HUMALOG MIX 50/50

4

HUMALOG MIX 50/50 KWIKPEN

4

HUMALOG MIX 75/25

4

HUMALOG MIX 75/25 KWIKPEN

4

HUMULIN 70/30

4

HUMULIN 70/30 KWIKPEN

4

HUMULIN N

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

69  

Drug Name

Drug Tier

HUMULIN N KWIKPEN

4

HUMULIN R

4

HUMULIN R U-500 KWIKPEN

5

HUMULIN R U-500 VIAL (CONCENTRATE) 5

Requirements/Limits

B/D

INSULIN PEN NEEDLES

3

INSULIN SAFETY NEEDLES

3

INSULIN SYRINGES

3

LANTUS

3

LANTUS SOLOSTAR

3

LEVEMIR

3

LEVEMIR FLEXTOUCH

3

NOVOLIN 70/30

3

NOVOLIN 70/30 RELION

4

NOVOLIN N

3

NOVOLIN N RELION

4

NOVOLIN R

3

NOVOLIN R RELION

4

NOVOLOG

3

NOVOLOG FLEXPEN

3

NOVOLOG MIX 70/30

3

NOVOLOG MIX 70/30 PREFILL

3

NOVOLOG PENFILL

3

SYMLINPEN 60

4

PA

SYMLINPEN 120

5

PA

TANZEUM

4

QL (4 pens / 28 days)

TOUJEO SOLOSTAR

3

TRESIBA FLEXTOUCH

3

TRULICITY

4

QL (4 pens / 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

70  

Drug Name

Drug Tier

Requirements/Limits

3

QL (3 pens / 30 days)

acarbose

2

GC

ACTOPLUS MET XR 15-1000MG

4

QL (60 tabs / 30 days)

ACTOPLUS MET XR 30-1000MG

4

QL (30 tabs / 30 days)

FARXIGA 5mg

3

QL (60 tabs / 30 days)

FARXIGA 10mg

3

QL (30 tabs / 30 days)

glimepiride 1mg

1

GC, QL (240 tabs / 30 days)

glimepiride 2mg

1

GC, QL (120 tabs / 30 days)

glimepiride 4mg

1

GC, QL (60 tabs / 30 days)

glipizide TABS 5mg

1

GC, QL (240 tabs / 30 days)

glipizide TABS 10mg

1

GC, QL (120 tabs / 30 days)

glipizide er 2.5mg

1

GC, QL (240 tabs / 30 days)

glipizide er 5mg

1

GC, QL (120 tabs / 30 days)

glipizide er 10mg

1

GC, QL (60 tabs / 30 days)

GLIPIZIDE XL TB24 2.5MG

1

GC, QL (240 tabs / 30 days)

GLIPIZIDE XL TB24 5MG

1

GC, QL (120 tabs / 30 days)

glipizide-metformin 2.5-250 mg

1

GC, QL (240 tabs / 30 days)

glipizide-metformin 2.5-500 mg

1

GC, QL (120 tabs / 30 days)

VICTOZA ANTIDIABETICS, ORAL

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

71  

Drug Name

Drug Tier

Requirements/Limits

glipizide-metformin 5-500mg

1

GC, QL (120 tabs / 30 days)

GLUMETZA 500mg

4

QL (120 tabs / 30 days)

GLUMETZA 1000mg

4

QL (60 tabs / 30 days)

GLYSET

4

GLYXAMBI

4

QL (30 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 TAB 100MG

3

QL (90 tabs / 30 days)

INVOKANA TAB 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)

JARDIANCE 10mg

4

QL (60 tabs / 30 days)

JARDIANCE 25mg

4

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)

KAZANO

4

QL (60 tabs / 30 days)

KOMBIGLYZE XR 2.5-1000MG

4

QL (60 tabs / 30 days)

KOMBIGLYZE XR 5-500MG

4

QL (30 tabs / 30 days)

KOMBIGLYZE XR 5-1000MG

4

QL (30 tabs / 30 days)

metformin er 500mg

1

GC, 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

72  

Drug Name

Drug Tier

Requirements/Limits

metformin er 750mg

1

GC, QL (60 tabs / 30 days)

metformin hcl TABS 500mg

1

GC, QL (150 tabs / 30 days)

metformin hcl TABS 850mg

1

GC, QL (90 tabs / 30 days)

metformin hcl TABS 1000mg

1

GC, QL (75 tabs / 30 days)

metformin hcl TB24 500mg

1

GC, QL (120 tabs / 30 days)

metformin hcl TB24 1000mg

1

GC, QL (60 tabs / 30 days)

metformin hcl osmotic 500mg

1

GC, QL (150 tabs / 30 days)

metformin hcl osmotic 1000mg

1

GC, QL (75 tabs / 30 days)

miglitol

2

GC

nateglinide

1

GC, QL (90 tabs / 30 days)

NESINA 6.25mg

4

QL (120 tabs / 30 days)

NESINA 12.5mg

4

QL (60 tabs / 30 days)

NESINA 25mg

4

QL (30 tabs / 30 days)

ONGLYZA

4

QL (30 tabs / 30 days)

OSENI TAB 12.5-15MG

4

QL (60 tabs / 30 days)

OSENI TAB 12.5-30MG

4

QL (30 tabs / 30 days)

OSENI TAB 12.5-45MG

4

QL (30 tabs / 30 days)

OSENI TAB 25-15MG

4

QL (30 tabs / 30 days)

OSENI TAB 25-30MG

4

QL (30 tabs / 30 days)

OSENI TAB 25-45MG

4

QL (30 tabs / 30 days)

pioglitazone hcl

1

GC, 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

73  

Drug Name

Drug Tier

Requirements/Limits

pioglitazone hcl-glimepiride

1

GC, QL (30 tabs / 30 days)

pioglitazone hcl-metformin hcl

1

GC, QL (90 tabs / 30 days)

PRANDIMET

4

QL (150 tabs / 30 days)

repaglinide 2mg

1

GC, QL (240 tabs / 30 days)

repaglinide .5mg, 1mg

1

GC, QL (120 tabs / 30 days)

repaglinide-metformin hcl

1

GC, QL (150 tabs / 30 days)

RIOMET

4

QL (946 mL / 30 days)

SYNJARDY TAB 5-500MG

4

QL (120 tabs / 30 days)

SYNJARDY TAB 5-1000MG

4

QL (60 tabs / 30 days)

SYNJARDY TAB 12.5-500

4

QL (60 tabs / 30 days)

SYNJARDY TAB 12.5-1000

4

QL (60 tabs / 30 days)

TRADJENTA

3

QL (30 tabs / 30 days)

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)

alendronate sodium SOLN

2

GC, QL (300 mL / 28 days)

alendronate sodium TABS

1

GC

BINOSTO

4

FOSAMAX PLUS D

4

ST

ibandronate sodium

2

GC, B/D, QL (1 injection / 90 days)

ibandronate tab 150mg

2

GC, B/D

BISPHOSPHONATES

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

74  

Drug Name pamidronate disodium SOLN

Drug Tier

Requirements/Limits

2

GC, B/D

RISEDRONATE SODIUM TABS 5mg, 30mg 2

GC

risedronate sodium TABS 35mg, 150mg

2

GC

risedronate sodium TBEC

2

GC

zoledronic inj 4mg/5ml

2

GC, B/D, NM

zoledronic inj 5/100ml

2

GC, B/D, NM

ZOMETA SOLN

5

B/D, NM

SENSIPAR 30mg

3

NM

SENSIPAR 60mg, 90mg

5

NM

CALCIUM RECEPTOR AGONISTS

CHELATING AGENTS CHEMET

4

DEPEN TITRATABS

5

EXJADE

5

NM, LA, PA

FERRIPROX

5

NM, LA, PA

JADENU

5

NM, PA

kionex

2

GC

sodium polystyrene sulfonate

2

GC

sps

2

GC

SYPRINE

5

VELTASSA

4

NM, LA

altavera

2

GC

amethia 91 day

2

GC

amethyst 28 day

2

GC

apri 28 day

2

GC

aranelle 28

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

75  

Drug Name

Drug Tier

Requirements/Limits

ashlyna 91 day

2

GC

aubra 28 day

2

GC

aviane 28

2

GC

balziva 28 day

2

GC

bekyree 28 day

2

GC

BEYAZ

4

blisovi 21 fe 1.5/30 28 day pack

2

GC

blisovi 21 fe 1/20 28 day pack

2

GC

blisovi 24 fe 1/20 28 day

2

GC

briellyn 28 day

2

GC

camila 28 day

2

GC

CAMRESE LO TAB

2

GC

caziant 28 day

2

GC

cryselle 28

2

GC

cyclafem 1/35 28 day

2

GC

cyclafem 7/7/7 28 day

2

GC

cyred tab

2

GC

deblitane 28 day

2

GC

delyla 28 day

2

GC

DEPO-SUBQ PROVERA 104

4

desogestrel-ethinyl estradiol (biphasic)

2

GC

drospirenone-ethinyl estradiol

2

GC

ELLA

4

emoquette

2

GC

enpresse 28 day

2

GC

errin 28 day

2

GC

estarylla tab 0.25-35

2

GC

falmina 28 day

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

76  

Drug Name

Drug Tier

Requirements/Limits

GIANVI TAB 3-0.02MG

2

GC

gildagia

2

GC

gildess 1.5/30 21 day

2

GC

gildess 24 fe 28 day

2

GC

heather

2

GC

introvale 91 day

2

GC

JOLESSA TAB 0.15-0.03 MG

2

GC

JOLIVETTE

2

GC

juleber 28 day

2

GC

junel 1.5/30 21 day

2

GC

junel 1/20 21 day

2

GC

junel fe 1.5/30 28 day

2

GC

junel fe 1/20 28 day

2

GC

junel fe 24 1/20 28 day

2

GC

kaitlib fe 28 day

2

GC

kariva 28 day

2

GC

kelnor 1/35 28 day

2

GC

kimidess 28 day

2

GC

larin 1.5/30

2

GC

larin 1/20

2

GC

larin fe 1.5/30

2

GC

larin fe 1/20

2

GC

larissia 28 day pack

2

GC

LAYOLIS FE CHW

2

GC

leena tab

2

GC

lessina 28 day

2

GC

levonest 28 day

2

GC

levonor/ethi tab

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

77  

Drug Name

Drug Tier

Requirements/Limits

levonorgestrel & eth estradiol

2

GC

levonorgestrel (emergency oc)

2

GC

levonorgestrel-ethinyl estradiol (91-day)

2

GC

levonorgestrel-ethinyl estradiol (continuous) 2

GC

levora 0.15/30 28 day

2

GC

LO LOESTRIN FE

4

lomedia 24 fe

2

GC

loryna 28 day

2

GC

low-ogestrel

2

GC

lutera 28 day

2

GC

lyza

2

GC

marlissa 28 day

2

GC

medroxyprogesterone acetate (contraceptive) SUSP

2

GC

MEDROXYPROGESTERONE ACETATE (CONTRACEPTIVE) SUSY

2

GC

MICROGESTIN 1.5/30

2

GC

MICROGESTIN 1/20

2

GC

MICROGESTIN FE 1.5/30

2

GC

MICROGESTIN FE 1/20

2

GC

MINASTRIN 24 FE

4

mono-linyah tab 0.25-35

2

GC

MONONESSA

2

GC

myzilra

2

GC

necon 0.5/35 28 day

2

GC

necon 1/35 28 day

2

GC

NECON 7/7/7

2

GC

necon 10/11 28 day

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

78  

Drug Name

Drug Tier

Requirements/Limits

NECON TAB 1/50-28

2

GC

nikki 28 day

2

GC

NORA-BE TAB

2

GC

norethin acet & estrad-fe

2

GC

norethindrone & ethinyl estradiol-fe

2

GC

norethindrone (contraceptive)

2

GC

norgest/ethi tab 0.25/35

2

GC

norgestimate-ethinyl estradiol (triphasic)

2

GC

norlyroc 28 day

2

GC

nortrel 0.5/35 28 day

2

GC

nortrel 1/35 21 day

2

GC

nortrel 1/35 28 day

2

GC

nortrel 7/7/7 28 day

2

GC

NUVARING

4

OCELLA TAB 3-0.03MG

2

GC

ogestrel 28 day

2

GC

orsythia 28 day

2

GC

ORTHO TRI-CYCLEN LO

4

philith

2

GC

pimtrea pack

2

GC

pirmella 1/35 28 day

2

GC

portia 28 day

2

GC

previfem 28 day

2

GC

QUARTETTE

4

quasense 91 day

2

GC

reclipsen 28 day

2

GC

setlakin tab

2

GC

sharobel 28 day

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

79  

Drug Name

Drug Tier

Requirements/Limits

sprintec 28 day

2

GC

sronyx 28 day

2

GC

syeda

2

GC

tarina fe 1/20 28 day

2

GC

tri-legest 28 day

2

GC

tri-linyah tab

2

GC

tri-lo- estarylla 28 day

2

GC

tri-lo- tab marzia

2

GC

tri-lo-sprintec 28 day

2

GC

tri-previfem 28 day

2

GC

tri-sprintec 28 day

2

GC

TRINESSA

2

GC

TRINESSA LO TAB

2

GC

trivora 28 day

2

GC

velivet 28 day

2

GC

vestura

2

GC

vienva 28 day

2

GC

viorele

2

GC

vyfemla 28 day

2

GC

wymzya fe

2

GC

xulane dis 150-35

2

GC

zarah

2

GC

zenchent fe 28 day

2

GC

zenchent tab

2

GC

zovia 1/35e 28 day

2

GC

zovia 1/50e 28 day

2

GC

2

GC

ENDOMETRIOSIS danazol CAPS

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

80  

Drug Name

Drug Tier

Requirements/Limits

LUPANETA PACK

5

NM, PA

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

ELAPRASE

5

NM, LA, PA

ELELYSO

5

NM, PA

FABRAZYME

5

NM, LA, PA

KUVAN

5

NM, LA, PA

levocarnitine (metabolic modifiers)

2

GC, B/D

LUMIZYME

5

NM, LA, PA

MYOZYME

5

NM, LA, PA

NAGLAZYME

5

NM, LA, PA

ORFADIN

5

NM, LA, PA

PROCYSBI

5

NM, LA, PA

RAVICTI

5

NM, PA

sodium phenylbutyrate

5

NM

VIMIZIM

5

NM, PA

VPRIV

5

NM, PA

ZAVESCA

5

NM, LA, PA

ESTROGENS

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

81  

Drug Name

Drug Tier

Requirements/Limits

ALORA

4

PA; PA if 65 years and older

DELESTROGEN 10mg/ml

4

depo-estradiol

4

estrace CREA

4

estradiol PTTW; PTWK; TABS

4

PA; PA if 65 years and older

estradiol valerate OIL

2

GC

ESTRING

4

FEMRING

4

fyavolv tab 1 mg-5 mcg

4

PA; PA if 65 years and older

jinteli

4

PA; PA if 65 years and older

MENOSTAR

4

PA; PA if 65 years and older

MINIVELLE

4

PA; PA if 65 years and older

norethindrone acetate-ethinyl estradiol

4

PA; PA if 65 years and older

PREMARIN CREAM

4

PREMARIN INJ

4

VAGIFEM

4

GLUCOCORTICOIDS a-hydrocort

2

GC

cortisone acetate TABS

2

GC

DEPO-MEDROL INJ 20MG/ML

4

B/D

dexamethasone CONC; ELIX; SOLN

2

GC

dexamethasone TABS

1

GC

dexamethasone sodium phosphate

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

82  

Drug Name

Drug Tier

Requirements/Limits

dexpak 6 day

4

dexpak 10 day

4

dexpak taperpak 13 day

4

fludrocortisone acetate TABS

2

GC

hydrocortisone TABS

2

GC

MEDROL TAB 2MG

4

B/D

methylpr ace inj 40mg/ml

2

GC, B/D

methylpr ace inj 80mg/ml

2

GC, B/D

methylpr ss inj 1gm

2

GC, B/D

methylpr ss inj 40mg

2

GC, B/D

methylpr ss inj 125mg

2

GC, B/D

methylpred pak 4mg

2

GC

methylpred tab 4mg

2

GC, B/D

methylpred tab 8mg

2

GC, B/D

methylpred tab 16mg

2

GC, B/D

methylpred tab 32mg

2

GC, B/D

millipred

4

B/D

millipred dp

4

pred sod pho sol 5mg/5ml

2

GC, B/D

prednisolone sodium phosphate

2

GC, B/D

prednisolone sol 15mg/5ml

2

GC, B/D

prednisolone sol 25mg/5ml

2

GC, B/D

prednisolone syrup 15 mg/5ml

1

GC, B/D

prednisone con 5mg/ml

3

B/D

prednisone pak 5mg

2

GC

prednisone pak 10mg

2

GC

prednisone sol 5mg/5ml

2

GC, B/D

prednisone tab 1mg

1

GC, 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

83  

Drug Name

Drug Tier

Requirements/Limits

prednisone tab 2.5mg

1

GC, B/D

prednisone tab 5mg

1

GC, B/D

prednisone tab 10mg

1

GC, B/D

prednisone tab 20mg

1

GC, B/D

prednisone tab 50mg

1

GC, B/D

RAYOS TAB 1MG

5

B/D

RAYOS TAB 2MG

5

B/D

RAYOS TAB 5MG

5

B/D

SOLU-CORTEF 100MG

4

SOLU-CORTEF 250MG

4

SOLU-CORTEF 500MG

4

SOLU-CORTEF 1000MG

4

SOLU-MEDROL INJ 2GM

4

B/D

veripred

4

B/D

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT

3

GLUCAGON EMERGENCY KIT

3

KORLYM

5

PROGLYCEM SUS 50MG/ML

4

NM, LA, PA

HUMAN GROWTH HORMONES GENOTROPIN

5

NM, PA

GENOTROPIN MINIQUICK .2mg

4

NM, PA

GENOTROPIN MINIQUICK .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg

5

NM, PA

HUMATROPE

5

NM, PA

HUMATROPE COMBO PACK

5

NM, PA

NORDITROPIN FLEXPRO

5

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

84  

Drug Name

Drug Tier

Requirements/Limits

NUTROPIN AQ INJ 20MG/2ML

5

NM, LA, PA

NUTROPIN AQ NUSPIN 5

5

NM, LA, PA

NUTROPIN AQ NUSPIN 10

5

NM, LA, PA

NUTROPIN AQ NUSPIN 20

5

NM, LA, PA

NUTROPIN AQ PEN

5

NM, LA, PA

OMNITROPE 5.8MG

5

NM, LA, PA

OMNITROPE 5MG

5

NM, LA, PA

OMNITROPE 10MG

5

NM, LA, PA

SAIZEN

5

NM, LA, PA

SAIZEN CLICK.EASY

5

NM, LA, PA

SEROSTIM

5

NM, LA, PA

ZOMACTON

5

NM, PA

ZORBTIVE

5

NM, PA

MISCELLANEOUS AFREZZA

4

cabergoline

2

GC

calcitonin (salmon) nasal spray

2

GC

CHORIONIC GONADOTROPIN SOLR

2

GC, NM, PA

EGRIFTA 1mg

5

NM, LA, PA

FORTICAL SPR 200/ACT

3

H.P. ACTHAR

5

QL (1.5 ml / 1 day), NM, LA, PA

INCRELEX

5

NM, LA, PA

methylergonovine maleate TABS

2

GC

MIACALCIN INJ 200U/ML

5

B/D

NOVAREL INJ 10000UNT

2

GC, NM, PA

octreotide acetate 50mcg/ml, 100mcg/ml

2

GC, 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

85  

Drug Name

Drug Tier

Requirements/Limits

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

5

NM, PA

PREGNYL W/DILUENT BENZYL

2

GC, NM, PA

PROLIA

4

QL (1 syringe / 180 days), NM

raloxifene hcl

2

GC

SAMSCA

5

NM, PA

SANDOSTATIN LAR DEPOT

5

NM, PA

SIGNIFOR

5

NM, LA, PA

SIGNIFOR LAR

5

NM, LA, PA

SOMATULINE DEPOT

5

NM, PA

SOMAVERT

5

NM, LA, PA

XGEVA

5

NM, PA

FORTEO

5

NM, PA

NATPARA

5

NM, PA

PARATHYROID HORMONES

PHOSPHATE BINDER AGENTS AURYXIA

5

calcium acetate (phosphate binder)

2

FOSRENOL

5

PHOSLYRA

4

RENAGEL 400mg

4

RENAGEL 800mg

5

RENVELA PAK

5

RENVELA TAB 800MG

5

VELPHORO

5

GC

PROGESTINS CRINONE

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

86  

Drug Name

Drug Tier

Requirements/Limits

medroxyprogesterone acetate

1

GC

norethindrone acetate TABS

2

GC

progesterone micronized CAPS

2

GC

levothyroxine sodium TABS

1

GC

LEVOXYL

1

GC

liothyronine sodium SOLN; TABS

2

GC

methimazole TABS

1

GC

propylthiouracil TABS

2

GC

SYNTHROID

4

TIROSINT

4

UNITHROID

1

GC

DESMOPRESSIN ACETATE SOLN

2

GC

desmopressin acetate TABS

2

GC

desmopressin acetate inj

2

GC

desmopressin acetate spray

2

GC

desmopressin acetate spray refrigerated

2

GC

STIMATE

5

NM

AKYNZEO

4

B/D

ALOXI

5

CESAMET

5

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

compro supp

2

GC

dronabinol 2.5mg, 5mg

2

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

THYROID AGENTS

VASOPRESSINS

GASTROINTESTINAL ANTIEMETICS

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

87  

Drug Name

Drug Tier

Requirements/Limits

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

2

GC

granisetron hcl TABS

2

GC, B/D

meclizine hcl TABS

2

GC

metoclopramide hcl SOLN; TABS

1

GC

metoclopramide hcl TBDP

2

GC

metoclopramide hcl inj 5 mg/ml

2

GC

metoclopramide odt

2

GC

ondansetron hcl TABS

2

GC, B/D

ondansetron hcl inj

2

GC

ondansetron hcl oral soln

2

GC, B/D

ondansetron odt

2

GC, B/D

phenadoz

4

PA; PA if 65 years and older

phenergan SUPP

4

PA; PA if 65 years and older

prochlorperazine inj 5 mg/ml

2

GC

prochlorperazine maleate TABS

1

GC

prochlorperazine supp

2

GC

promethazine hcl SOLN; SUPP; SYRP; TABS

4

PA; PA if 65 years and older

promethegan

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

88  

Drug Name

Drug Tier

Requirements/Limits

SANCUSO

5

QL (4 patches / 30 days)

SUSTOL

4

TRANSDERM-SCOP

4

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

VARUBI

4

B/D

ZUPLENZ

5

B/D

ATROPINE SULFATE SOLN .05mg/ml, .1mg/ml

2

GC

BENTYL SOLN

4

CANTIL

4

CUVPOSA

4

dicyclomine hcl CAPS; TABS

1

GC

dicyclomine hcl SOLN

2

GC

glycopyrrolate SOLN; TABS

2

GC

methscopolamine bromide TABS

2

GC

cimetidine TABS

2

GC

cimetidine sol 300/5ml

2

GC

famotidine SUSR

2

GC

famotidine TABS 20mg, 40mg

1

GC

famotidine inj

2

GC

nizatidine

2

GC

ranitidine hcl CAPS

2

GC

ranitidine hcl SOLN

2

GC

ranitidine hcl SYRP

2

GC

ranitidine hcl TABS 150mg, 300mg

1

GC

ranitidine hcl inj

2

GC

ANTISPASMODICS

H2-RECEPTOR ANTAGONISTS

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

89  

Drug Name

Drug Tier

Requirements/Limits

INFLAMMATORY BOWEL DISEASE APRISO

3

ASACOL HD

4

balsalazide disodium

2

budesonide CPEP

5

CANASA

5

colocort

2

DELZICOL

4

DIPENTUM

5

ENTYVIO

5

GIAZO

5

HYDROCORTISONE (INTRARECTAL)

2

LIALDA

4

MESALAMINE TBEC

2

GC

mesalamine enema

2

GC

PENTASA

4

SF-ROWASA

5

sulfasalazine dr

2

GC

sulfasalazine ir

2

GC

UCERIS FOAM

4

UCERIS TB24

5

GC

GC

NM, PA

GC

LAXATIVES COLYTE-FLAVOR PACKS 227.1 GM

4

constulose

2

GC

enulose

2

GC

gaviltye-g

1

GC

gavilyte-c

1

GC

gavilyte-h

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

90  

Drug Name

Drug Tier

Requirements/Limits

gavilyte-n

2

GC

generlac

2

GC

GOLYTELY

3

kristalose

3

lactulose

2

GC

lactulose (encephalopathy)

2

GC

MOVIPREP

4

NULYTELY/FLAVOR PACKS

3

OSMOPREP

4

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

1

GC

peg 3350-potassium chloride-sod bicarbonate-sod chloride

2

GC

polyethylene glycol 3350 PACK; POWD

2

GC

PREPOPIK

4

RELISTOR SOLN

5

SUCLEAR

4

SUPREP BOWEL PREP

4

trilyte

2

GC

alosetron hcl

5

PA

AMITIZA

3

amoxicillin-clarithromycin w/ lansoprazole

2

CARAFATE SUSP

4

cromolyn sodium (mastocytosis)

5

diphenoxylate w/ atropine

2

GC

GATTEX

5

NM, LA, PA

LINZESS

3

PA

MISCELLANEOUS

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

91  

Drug Name

Drug Tier

Requirements/Limits

loperamide hcl CAPS

1

GC

misoprostol TABS

2

GC

MOVANTIK

3

OMECLAMOX-PAK

4

PYLERA

5

SUCRAID

5

LA

sucralfate TABS

2

GC

ursodiol CAPS; TABS

2

GC

VIBERZI

5

PA

XIFAXAN TAB 550MG

5

PA

PANCREATIC ENZYMES CREON

3

PANCREAZE

4

PERTZYE

4

ULTRESA

4

VIOKACE 10

4

VIOKACE 20

5

ZENPEP

4

PROTON PUMP INHIBITORS ACIPHEX SPR CAP 5MG

4

ACIPHEX SPR CAP 10MG

4

QL (60 caps / 30 days)

DEXILANT

3

QL (30 caps / 30 days)

esomeprazole sodium inj

2

GC

lansoprazole CPDR

2

GC, QL (30 caps / 30 days)

NEXIUM CAP 20MG

2

GC, QL (30 caps / 30 days)

NEXIUM CAP 40MG

2

GC, 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

92  

Drug Name

Drug Tier

Requirements/Limits

NEXIUM GRA 2.5MG DR

3

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

GC, QL (30 caps / 30 days)

omeprazole CPDR 20mg

1

GC, QL (60 caps / 30 days)

OMEPRAZOLE-SODIUM BICARBONATE CAPS

2

GC, QL (30 caps / 30 days)

OMEPRAZOLE-SODIUM BICARBONATE PACK

4

QL (30 packets / 30 days)

pantoprazole sodium SOLR

2

GC

pantoprazole sodium TBEC

1

GC, QL (30 tabs / 30 days)

PREVACID SOLUTAB

4

QL (30 tabs / 30 days)

PRILOSEC PACK

3

PROTONIX PACK

4

QL (30 packets / 30 days)

rabeprazole sodium

2

GC, QL (30 tabs / 30 days)

ZEGERID PACK

4

QL (30 packets / 30 days)

alfuzosin hcl

2

GC

CARDURA XL

4

dutasteride

2

GC

dutasteride-tamsulosin hcl

2

GC

finasteride TABS 5mg

1

GC

RAPAFLO

4

ST

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

93  

Drug Name

Drug Tier

Requirements/Limits

2

GC

bethanechol chloride TABS

2

GC

ELMIRON

4

potassium citrate (alkalinizer) 15meq

2

GC

POTASSIUM CITRATE (ALKALINIZER) 540mg, 1080mg

2

GC

DARIFENACIN HYDROBROMIDE

2

GC

ENABLEX

4

ST

GELNIQUE

4

ST

MYRBETRIQ

4

oxybutynin chloride SYRP

1

GC

oxybutynin chloride TABS; TB24

2

GC

OXYTROL

4

tolterodine tartrate er

2

GC

tolterodine tartrate tab 1 mg

2

GC

tolterodine tartrate tab 2 mg

2

GC

TOVIAZ

3

trospium chloride

2

GC

trospium chloride er

2

GC

VESICARE

4

tamsulosin hcl MISCELLANEOUS

URINARY ANTISPASMODICS

VAGINAL ANTI-INFECTIVES AVC

4

CLEOCIN VAG SUPP 100MG

4

clindamycin cre 2% vag

2

CLINDESSE

4

metronidazole vaginal

2

GC

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

94  

Drug Name

Drug Tier

Requirements/Limits

miconazole 3 sup 200mg

2

GC

NUVESSA

4

terconazole vaginal

2

GC

VANDAZOLE

2

GC

ZAZOLE CRE 0.8%

2

GC

HEMATOLOGIC ANTICOAGULANTS COUMADIN

4

ELIQUIS TAB 2.5MG

3

ELIQUIS TAB 5MG

3

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

2

GC

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

2

GC

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

5

FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml

4

FRAGMIN 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 95000unit/3.8ml

5

HEP SOD/NACL INJ 25000

3

HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML

3

heparin sod inj 1000u/ml

2

GC, B/D

heparin sod inj 5000u/0.5ml

2

GC, B/D

heparin sod inj 5000u/ml

2

GC, B/D

heparin sod inj 10000u/ml

2

GC, B/D

heparin sod inj 20000u/ml

2

GC, 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

95  

Drug Name

Drug Tier

HEPARIN SODIUM/D5W

3

HEPARIN SODIUM/NACL 0.45%

3

jantoven

1

PRADAXA

3

SAVAYSA

4

warfarin sodium

1

XARELTO

3

XARELTO STARTER PACK

3

Requirements/Limits

GC

GC

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE SOLN 10mcg/0.4ml, 25mcg/ml, 40mcg/ml, 60mcg/ml

3

NM, PA

ARANESP ALBUMIN FREE SOLN 100mcg/ml, 150mcg/0.75ml, 200mcg/ml, 300mcg/ml

5

NM, PA

ARANESP ALBUMIN FREE SOSY 25mcg/0.42ml, 40mcg/0.4ml, 60mcg/0.3ml

3

NM, PA

ARANESP ALBUMIN FREE SOSY 100mcg/0.5ml, 150mcg/0.3ml, 200mcg/0.4ml, 300mcg/0.6ml, 500mcg/ml

5

NM, PA

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

4

NM, PA

EPOGEN 20000unit/ml

5

NM, PA

GRANIX

5

NM, PA

LEUKINE

5

NM, PA

MIRCERA

4

NM, PA

MOZOBIL

5

NM, PA

NEULASTA

5

NM, PA

NEULASTA ONPRO KIT

5

NM, PA

NEUMEGA

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

96  

Drug Name

Drug Tier

Requirements/Limits

NEUPOGEN

5

NM, PA

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

3

NM, PA

PROCRIT 20000unit/ml, 40000unit/ml

5

NM, PA

anagrelide hcl

2

GC

cilostazol

2

GC

CINRYZE

5

NM, LA, PA

FIRAZYR

5

NM, PA

pentoxifylline TBCR

2

GC

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

RUCONEST

5

NM, PA

tranexamic acid SOLN; TABS

2

GC

AGGRENOX

2

GC

BRILINTA

3

clopidogrel bisulfate 75mg

1

GC

clopidogrel bisulfate 300mg

2

GC

DURLAZA

4

EFFIENT

4

ZONTIVITY

4

MISCELLANEOUS

PLATELET AGGREGATION INHIBITORS

IMMUNOLOGIC 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

97  

Drug Name

Drug Tier

Requirements/Limits

DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA

5

NM, PA

CIMZIA

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 STARTER KIT

5

NM, PA

HUMIRA PEN-PSORIASIS STARTER KIT

5

NM, PA

hydroxychloroquine sulfate

2

GC

KINERET

5

NM, PA

leflunomide TABS

2

GC

methotrexate sodium tabs

2

GC

ORENCIA

5

NM, PA

ORENCIA CLICKJECT

5

NM, PA

OTEZLA

5

NM, PA

REMICADE

5

NM, PA

RHEUMATREX

4

SIMPONI

5

NM, PA

SIMPONI ARIA

5

NM, PA

trexall

4

B/D

XELJANZ

5

NM, PA

XELJANZ XR

5

NM, PA

BIVIGAM

5

NM, PA

CARIMUNE NANOFILTERED

5

NM, PA

FLEBOGAMMA

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

98  

Drug Name

Drug Tier

Requirements/Limits

FLEBOGAMMA DIF

5

NM, PA

GAMASTAN S/D

3

B/D, NM

GAMMAGARD LIQUID

5

NM, PA

GAMMAGARD S/D

5

NM, PA

GAMMAGARD S/D IGA LESS TH

5

NM, PA

GAMMAKED

5

NM, PA

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

GRASTEK

4

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

RAGWITEK

4

PA

REVLIMID

5

NM, LA, PA

THALOMID

5

NM, PA

ASTAGRAF XL 5mg

5

B/D

ASTAGRAF XL .5mg, 1mg

4

B/D

ATGAM

5

B/D

azasan

4

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

99  

Drug Name

Drug Tier

Requirements/Limits

azathioprine SOLR; TABS

2

GC, B/D

BENLYSTA

5

NM, PA

CELLCEPT INTRAVENOUS

4

B/D

cyclosporine CAPS; SOLN

2

GC, B/D

cyclosporine modified (for microemulsion)

2

GC, B/D

ENVARSUS XR

4

B/D

gengraf

2

GC, B/D

mycophenolate mofetil CAPS; TABS

2

GC, B/D

mycophenolate mofetil SUSR

5

B/D

mycophenolate sodium 180mg

2

GC, B/D

mycophenolate sodium 360mg

5

B/D

NEORAL

3

B/D

NULOJIX

5

B/D

PROGRAF CAPS 5mg

5

B/D

PROGRAF CAPS .5mg, 1mg

4

B/D

PROGRAF SOLN

4

B/D

RAPAMUNE SOLN

5

B/D

SANDIMMUNE SOLN

3

B/D

SIMULECT 10mg

4

B/D

SIMULECT 20mg

5

B/D

SIROLIMUS TABS 2mg

5

B/D

sirolimus TABS .5mg, 1mg

2

GC, B/D

tacrolimus CAPS 5mg

5

B/D

tacrolimus CAPS .5mg, 1mg

2

GC, B/D

THYMOGLOBULIN

5

B/D

ZORTRESS TAB 0.5MG

5

B/D

ZORTRESS TAB 0.25MG

4

B/D

ZORTRESS TAB 0.75MG

5

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

100  

Drug Name

Drug Tier

Requirements/Limits

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

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

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

101  

Drug Name

Drug Tier

Requirements/Limits

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

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN

4

KLOR-CON 8

2

GC

KLOR-CON 10

2

GC

klor-con m10

2

GC

klor-con m15

2

GC

klor-con m20

2

GC

klor-con pow 20meq

2

GC

klor-con spr cap 8meq

2

GC

klor-con spr cap 10meq

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

102  

Drug Name

Drug Tier

Requirements/Limits

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

2

GC

MAGNESIUM SULFATE IN D5W

3

MAGNESIUM SULFATE INJ 50%

2

GC

POTASSIUM CHLORIDE SOLN 10%, 20% 2

GC

potassium chloride TBCR 8meq

2

GC

POTASSIUM CHLORIDE TBCR 20meq

2

GC

potassium chloride caps er

2

GC

potassium chloride microencapsulated crystals cr

2

GC

POTASSIUM CHLORIDE TAB CR 10 MEQ 2

GC

SODIUM CHLORIDE SOLN 2.5meq/ml

2

GC

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

2

GC

TPN ELECTROLYTES

4

B/D

AMINOSYN

4

B/D

AMINOSYN 7%/ELECTROLYTES

4

B/D

AMINOSYN II

4

B/D

AMINOSYN II 8.5%/ELECTROL

4

B/D

AMINOSYN INJ 8.5/LYTE

4

B/D

AMINOSYN M

4

B/D

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

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

103  

Drug Name

Drug Tier

Requirements/Limits

CLINIMIX 4.25%/DEXTROSE 5%

4

B/D

CLINIMIX 4.25%/DEXTROSE 10%

4

B/D

CLINIMIX 4.25%/DEXTROSE 20%

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 E 2.75%/DEXTROSE 5%

4

B/D

CLINIMIX E 2.75%/DEXTROSE 10%

4

B/D

CLINIMIX E 4.25%/D10

4

B/D

CLINIMIX E 4.25%/DEXTROSE 5%

4

B/D

CLINIMIX E 4.25%/DEXTROSE 25%

4

B/D

CLINIMIX E 5%/DEXTROSE 15%

4

B/D

CLINIMIX E 5%/DEXTROSE 20%

4

B/D

CLINIMIX E 5%/DEXTROSE 25%

4

B/D

clinisol 15

2

GC, 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

LIPOSYN III

4

B/D

NEPHRAMINE

4

B/D

NUTRILIPID INJ 20%

4

B/D

plenamine

2

GC, B/D

premasol 6%

2

GC, B/D

premasol 10%

4

B/D

PROCALAMINE

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

104  

Drug Name

Drug Tier

Requirements/Limits

PROSOL

4

B/D

SMOFLIPID

4

B/D

TRAVASOL

4

B/D

TROPHAMINE INJ 10%

4

B/D

DEXTROSE SOLN

2

GC

DEXTROSE 2.5%/NACL 0.45%

2

GC

DEXTROSE 5%

2

GC

DEXTROSE 5% /ELECTROLYTE

3

DEXTROSE 5%/LACTATED RING

2

GC

DEXTROSE 5%/NACL 0.2%

2

GC

DEXTROSE 5%/NACL 0.3%

2

GC

DEXTROSE 5%/NACL 0.9%

2

GC

DEXTROSE 5%/NACL 0.33%

2

GC

DEXTROSE 5%/NACL 0.45%

2

GC

DEXTROSE 5%/NACL 0.225%

2

GC

DEXTROSE 5%/POTASSIUM CHL

2

GC

DEXTROSE 10% FLEX CONTAIN

2

GC

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

3

DEXTROSE 10%/NACL 0.45%

2

ELECTROLYTE-R IN DEXTROSE

4

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

IV REPLACEMENT SOLUTIONS

GC

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

105  

Drug Name

Drug Tier

Requirements/Limits

KCL 0.3%/D5W/LR IV LAC RI

4

KCL 0.3%/D5W/NACL 0.9%

2

GC

KCL 0.3%/D5W/NACL 0.45%

2

GC

KCL 0.15%/D5W/LR

4

KCL 0.15%/D5W/NACL 0.9%

2

GC

KCL 0.075%/D5W/NACL 0.45%

2

GC

KCL IN NACL INJ .15-0.45

2

GC

KCL/D5W/NACL INJ 0.22%/0.45%

2

GC

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

2

GC

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

2

GC

KCL/NACL INJ 0.15%-0.9%

2

GC

LACTATED RINGERS VIAFLEX

2

GC

NORMOSOL-M IN D5W

2

GC

NORMOSOL-R

4

PLASMA-LYTE A

4

PLASMA-LYTE-56/D5W

4

PLASMA-LYTE-148

4

pot chloride inj 2meq/ml

2

GC

POTASSIUM CHLORIDE SOLN .4meq/ml, 2 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

GC

POTASSIUM CHLORIDE 0.3%/D

2

GC

potassium chloride in nacl

2

GC

POTASSIUM CHLORIDE IN NACL

2

GC

RINGER'S

2

GC

SODIUM CHLORIDE SOLN .9%, 3%, 5%

2

GC

SODIUM CHLORIDE 0.45% VIA

2

GC

VITAMINS 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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

106  

Drug Name

Drug Tier

Requirements/Limits

calcitriol CAPS; SOLN

2

GC, B/D

doxercalciferol CAPS 1mcg, 2.5mcg

5

B/D

doxercalciferol CAPS .5mcg

2

GC, B/D

doxercalciferol SOLN

2

GC, B/D

HECTOROL SOLN 2mcg/ml

4

B/D

paricalcitol CAPS

2

GC, B/D

PARICALCITOL SOLN

2

GC, B/D

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG 2 (GENERIC)

GC

ZEMPLAR SOLN 2mcg/ml

4

B/D

bacitracin-poly-neomycin-hc

2

GC

blephamide OINT

4

BLEPHAMIDE SUSP

4

neomycin-polymy-dexameth

2

GC

neomycin-polymyxin-hc (ophth)

2

GC

PRED-G

4

PRED-G S.O.P.

4

sulfacetamide sod-prednisolone

2

TOBRADEX OINT

3

TOBRADEX ST

3

tobramycin-dexamethasone

2

ZYLET

3

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY

GC

GC

ANTI-INFECTIVES AZASITE

4

bacitracin (ophthalmic)

2

GC

bacitracin-polymyxin b (ophth)

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

107  

Drug Name

Drug Tier

Requirements/Limits

BESIVANCE

3

CILOXAN OIN 0.3% OP

3

ciprofloxacin hcl (ophth)

2

GC

erythromycin (ophth)

1

GC

gatifloxacin (ophth)

2

GC

gentak

2

GC

gentamicin sulfate (ophth) OINT

2

GC

gentamicin sulfate (ophth) SOLN

1

GC

ilotycin

1

GC

levofloxacin (ophth)

2

GC

MOXEZA

3

NATACYN

4

neomycin-bacitracin zn-polymyxin

2

GC

neomycin-polymyxin-gramicidin

2

GC

ofloxacin (ophth)

2

GC

polymyxin b-trimethoprim

1

GC

sulfacet sod oin 10% op

2

GC

sulfacetamide sodium (ophth)

2

GC

tobramycin (ophth)

1

GC

TOBREX OINT 0.3%

4

trifluridine SOLN

2

VIGAMOX

3

ZIRGAN

4

GC

ANTI-INFLAMMATORIES ACUVAIL

4

ALREX

3

bromfenac sodium (ophth)

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

108  

Drug Name

Drug Tier

Requirements/Limits

BROMFENAC SODIUM (OPHTH)(ONCEDAILY)

2

GC

dexamethasone sodium phosphate (ophth)

2

GC

diclofenac sodium (ophth)

2

GC

DUREZOL

3

FLAREX

4

FLUOROMETHOLONE (OPHTH)

2

GC

flurbiprofen sodium

1

GC

FML

4

FML FORTE

4

ILEVRO

3

ketorolac tromethamine (ophth)

2

LOTEMAX

3

MAXIDEX

3

PRED MILD

4

PREDNISOLONE ACETATE (OPHTH)

2

prednisolone sodium phosphate (ophth)

3

VEXOL

4

GC

GC

ANTIALLERGICS ALOCRIL

4

ALOMIDE

4

azelastine drop 0.05%

2

BEPREVE

3

cromolyn sodium (ophth)

1

EMADINE

4

epinastine hcl (ophth)

2

LASTACAFT

4

olopatadine hcl

2

GC

GC

GC

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

109  

Drug Name

Drug Tier

PATADAY

3

PATANOL

4

PAZEO

3

Requirements/Limits

ANTIGLAUCOMA ALPHAGAN P 0.1%

3

AZOPT

3

betaxolol hcl (ophth)

2

BETIMOL

4

BETOPTIC-S

3

brimonidine sol 0.2%

1

GC

BRIMONIDINE SOL 0.15%

2

GC

carteolol hcl (ophth)

1

GC

COMBIGAN

3

COSOPT PF

4

dorzolamide hcl

2

GC

dorzolamide hcl-timolol maleate

2

GC

ISTALOL

3

latanoprost SOLN

1

GC

levobunolol hcl

2

GC

LUMIGAN

3

metipranolol

2

PHOSPHOLINE IODIDE

4

PILOCARPINE HCL SOLN

2

SIMBRINZA SUS 1-0.2%

3

timolol maleate (ophth)

1

GC

TIMOLOL MALEATE GEL

2

GC

TIMOPTIC OCUDOSE

4

TRAVATAN Z

3

GC

GC

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

110  

Drug Name ZIOPTAN

Drug Tier

Requirements/Limits

4

ST

MISCELLANEOUS LACRISERT

4

naphazoline hcl SOLN

1

PROLENSA

3

proparacaine hcl SOLN

1

RESTASIS

3

GC

GC

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER 62.5-25

3

QL (60 inhalations / 30 days)

COMBIVENT RESPIMAT

4

QL (2 inhalers / 30 days)

ipratropium-albuterol

2

GC, B/D

STIOLTO RESPIMAT

4

QL (1 inhaler / 30 days)

UTIBRON NEOHALER

4

QL (60 caps / 30 days)

ATROVENT HFA

4

QL (2 inhalers / 30 days)

INCRUSE ELLIPTA

3

QL (1 inhaler / 30 days)

ipratropium bromide (nasal)

2

GC

ipratropium sol inhal

2

GC, B/D

SEEBRI NEOHALER

4

QL (60 caps / 30 days)

SPIRIVA HANDIHALER

4

QL (30 caps / 30 days)

SPIRIVA RESPIMAT

4

QL (1 inhaler / 30 days)

TUDORZA PRESSAIR

4

QL (1 inhaler / 30 days)

TUDORZA PRESSAIR (INSTITUTIONAL PACK)

4

QL (2 inhalers / 30 days)

ANTICHOLINERGICS

ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB 2.5-120

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

111  

Drug Name

Drug Tier

Requirements/Limits

DYMISTA SPR 137-50

4

QL (1 bottle / 30 days)

SEMPREX-D

4

ANTIHISTAMINES ASTEPRO

3

azelastine spr 0.1%

2

GC

azelastine spr 0.15%

2

GC

cetirizine syrup

2

GC

CLARINEX SYRP

4

desloratadine

2

GC

diphenhydram inj 50mg/ml

2

GC

hydroxyzine hcl SOLN

4

PA; PA if 65 years and older

levocetirizine soln 2.5mg/5ml

2

GC

levocetirizine tab 5 mg

2

GC

olopatadine hcl (nasal)

2

GC

albuterol sulfate NEBU

2

GC, B/D

albuterol sulfate SYRP

1

GC

albuterol sulfate TABS

2

GC

albuterol sulfate er

2

GC

ARCAPTA NEOHALER

4

QL (30 caps / 30 days)

BROVANA

4

B/D

FORADIL AEROLIZER

4

QL (60 caps / 30 days)

levalbuterol conc 1.25mg/0.5ml

2

GC, B/D

LEVALBUTEROL HCL NEBU 1.25mg/3ml

2

GC, B/D

levalbuterol hcl NEBU .31mg/3ml, .63mg/3ml

2

GC, B/D

PERFOROMIST

4

B/D

BETA AGONISTS

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

112  

Drug Name

Drug Tier

Requirements/Limits

PROAIR HFA

4

QL (2 inhalers / 30 days)

PROAIR RESPICLICK

4

QL (2 inhalers / 30 days)

PROVENTIL HFA

4

QL (2 inhalers / 30 days)

SEREVENT DISKUS

3

QL (60 inhalations / 30 days)

STRIVERDI RESPIMAT

4

QL (1 inhaler / 30 days)

terbutaline sulfate SOLN

5

terbutaline sulfate TABS

2

GC

VENTOLIN HFA

3

QL (2 inhalers / 30 days)

XOPENEX HFA

3

QL (2 inhalers / 30 days)

montelukast sodium CHEW; PACK; TABS

2

GC

zafirlukast

2

GC

ZYFLO CR

5

LEUKOTRIENE RECEPTOR ANTAGONISTS

MAST CELL STABILIZERS cromolyn sodium NEBU

2

GC, B/D

acetylcysteine SOLN 10%, 20%

2

GC, B/D

ARALAST NP

5

NM, LA, PA

CINQAIR

5

NM, LA, PA

DALIRESP

4

EPINEPHRINE SOAJ

2

EPIPEN 2-PAK

3

EPIPEN-JR 2-PAK

3

ESBRIET

5

NM, PA

GLASSIA

5

NM, LA, PA

KALYDECO

5

NM, PA

NUCALA

5

NM, LA, PA

MISCELLANEOUS

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

113  

Drug Name

Drug Tier

Requirements/Limits

OFEV

5

NM, PA

ORKAMBI

5

NM, PA

PROLASTIN-C

5

NM, LA, PA

PULMOZYME

5

B/D, NM

tyzine .05%

4

XOLAIR

5

NM, LA, PA

ZEMAIRA

5

NM, LA, PA

BECONASE AQ

4

QL (2 inhalers / 30 days)

budesonide (nasal)

2

GC, QL (2 bottles / 30 days)

flunisolide (nasal)

2

GC, QL (2 bottles / 30 days)

fluticasone propionate (nasal)

2

GC, QL (1 bottle / 30 days)

NASONEX

4

QL (2 inhalers / 30 days)

OMNARIS

4

QL (1 inhaler / 30 days)

QNASL

4

QL (1 inhaler / 30 days)

QNASL CHILDRENS

4

QL (1 inhaler / 30 days)

TRIAMCINOLONE ACETONIDE (NASAL)

2

GC, QL (1 bottle / 30 days)

VERAMYST

4

QL (1 bottle / 30 days)

ZETONNA

4

QL (1 inhaler / 30 days)

AEROSPAN

4

QL (2 inhalers / 30 days)

ALVESCO

4

QL (2 inhalers / 30 days)

ARNUITY ELLIPTA

3

QL (30 inhalations / 30 days)

ASMANEX

4

QL (2 inhalers / 30 days)

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

114  

Drug Name

Drug Tier

Requirements/Limits

ASMANEX HFA 100mcg/act

4

QL (2 inhalers / 30 days)

ASMANEX HFA 200mcg/act

4

QL (1 inhaler / 30 days)

budesonide (inhalation)

2

GC, B/D

FLOVENT DISKUS 50mcg/blist, 100mcg/blist

3

QL (120 inhalations / 30 days)

FLOVENT DISKUS 250mcg/blist

3

QL (240 inhalations / 30 days)

FLOVENT HFA

3

QL (2 inhalers / 30 days)

PULMICORT FLEXHALER

3

QL (2 inhalers / 30 days)

PULMICORT INH SUSP 1MG/2ML

5

B/D

QVAR 40mcg/act

4

QL (1 inhaler / 30 days)

QVAR 80mcg/act

4

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)

DULERA

4

QL (1 inhaler / 30 days)

SYMBICORT

3

QL (1 inhaler / 30 days)

aminophylline inj

2

GC

elixophyllin

4

theo-24

4

theophylline

2

STEROID/BETA-AGONIST COMBINATIONS

XANTHINES

GC

TOPICAL DERMATOLOGY, ACNE ABSORICA

5

ACANYA

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

115  

Drug Name

Drug Tier

Requirements/Limits

ACZONE

4

adapalene CREA; GEL

2

GC

amnesteem

2

GC

ATRALIN

4

AVITA

2

AZELEX

4

benzoyl peroxide-erythromycin

2

GC

claravis

2

GC

clindacin-p

2

GC

CLINDAGEL

4

clindamax

2

GC

clindamycin phosphate (topical)

2

GC

clindamycin phosphate-benzoyl peroxide

2

GC

clindamycin phosphate-benzoyl peroxide (refrigerate)

2

GC

clindamycin phosphate-tretinoin

2

GC

DIFFERIN LOTN

4

EPIDUO

4

EPIDUO FORTE

4

ery pad 2%

2

GC

erythromycin (acne aid)

2

GC

FABIOR

4

myorisan

2

GC

neuac gel 1.2-5%

2

GC

ONEXTON

4

RETIN-A MICRO PUMP .08%

4

sulfacetamide sodium (acne)

2

tretin-x CREA

4

GC

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

116  

Drug Name

Drug Tier

Requirements/Limits

tretinoin CREA

2

GC

TRETINOIN GEL .01%

2

GC

tretinoin GEL .025%, .05%

2

GC

TRETINOIN MICROSPHERE

2

GC

VELTIN

4

zenatane

2

ZIANA

4

GC

DERMATOLOGY, ANTIBIOTICS BACTROBAN NASAL

4

CENTANY

4

CORTISPORIN

4

gentamicin sulfate (topical)

2

GC

mupirocin OINT

1

GC

mupirocin calcium (topical)

2

GC

SILVER SULFADIAZINE CREA

2

GC

SSD

2

GC

SULFAMYLON CREA

4

SULFAMYLON PACK

5

DERMATOLOGY, ANTIFUNGALS ciclopirox GEL

2

GC

ciclopirox cre 0.77%

2

GC

ciclopirox shampoo 1%

2

GC

ciclopirox sus 0.77%

2

GC

clotrimazole (topical)

2

GC

econazole nitrate CREA

2

GC

ERTACZO

4

EXELDERM

4

ketoconazole (topical)

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

117  

Drug Name

Drug Tier

Requirements/Limits

ketodan aer 2%

2

GC

LUZU

4

MENTAX

4

NAFTIFINE HCL 1%

2

GC

naftifine hcl 2%

2

GC

NAFTIN

4

nyamyc

2

GC

nystatin (topical)

2

GC

nystatin pow 100000

2

GC

nystop

2

GC

oxiconazole nitrate cream

2

GC

OXISTAT

4

DERMATOLOGY, ANTIPRURITIC CORTIFOAM

4

DOXEPIN HCL (ANTIPRURITIC)

2

GC

procto-med

2

GC

procto-pak

2

GC

proctosol hc 2.5 %

2

GC

proctozone hc

2

GC

PRUDOXIN CRE 5%

2

GC

acitretin

5

PA

calcipotriene CREA; OINT; SOLN

2

GC

calcitrene oin 0.005%

2

GC

CALCITRIOL OINT

2

GC

COSENTYX

5

NM, PA

COSENTYX SENSOREADY PEN

5

NM, PA

methoxsalen rapid

5

DERMATOLOGY, ANTIPSORIATICS

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

118  

Drug Name

Drug Tier

Requirements/Limits

8-MOP

4

SORILUX

4

STELARA SOSY

5

NM, PA

TAZORAC

4

PA

ketoconazole shampoo

1

GC

selenium sulfide LOTN

1

GC

ala-cort

1

GC

alclometasone dipropionate

2

GC

amcinonide CREA; LOTN

2

GC

amcinonide OINT

4

apexicon e cream

4

betamethasone dipropionate (topical)

2

GC

betamethasone dipropionate augmented

2

GC

betamethasone valerate CREA; FOAM; LOTN; OINT

2

GC

calcipotriene/betamethasone

5

CAPEX

4

clobetasol e cream 0.05%

2

GC

clobetasol propionate CREA; FOAM; GEL; LIQD; LOTN; OINT; SHAM; SOLN

2

GC

clobetasol propionate emulsion

2

GC

CLOCORTOLONE PIVALATE

2

GC

clodan sha 0.05%

2

GC

CORDRAN TAPE

4

cormax

2

DESONATE

4

DERMATOLOGY, ANTISEBORRHEICS

DERMATOLOGY, CORTICOSTEROIDS

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

119  

Drug Name

Drug Tier

Requirements/Limits

DESONIDE CREA

2

GC

desonide LOTN; OINT

2

GC

desoximetasone CREA

2

GC

desoximetasone GEL

2

GC

DESOXIMETASONE OINT .05%

2

GC

desoximetasone OINT .25%

2

GC

diflorasone diacetate

2

GC

ENSTILAR

5

fluocinolone acetonide CREA; OIL; OINT; SOLN

2

fluocinonide CREA .1%

5

fluocinonide CREA .05%

2

GC

fluocinonide GEL

2

GC

fluocinonide OINT

2

GC

fluocinonide SOLN

2

GC

fluocinonide-e 0.05% cream

2

GC

flurandrenolide CREA

2

GC

fluticasone propionate CREA; LOTN; OINT 2

GC

halobetasol propionate

2

GC

HALOG

4

hydrocortisone (topical) CREA; OINT

1

GC

hydrocortisone (topical) LOTN

2

GC

hydrocortisone butyrate

2

GC

hydrocortisone butyrate hydrophilic lipo base 2

GC

hydrocortisone valerate

2

GC

LOCOID LOTN

4

lokara

2

GC

mometasone furoate CREA; OINT; SOLN

2

GC

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

120  

Drug Name

Drug Tier

Requirements/Limits

PANDEL

4

PREDNICARBATE CREA

2

GC

prednicarbate OINT

2

GC

SERNIVO

5

TACLONEX SUSP

5

texacort

4

TOPICORT SPRAY 0.25%

4

triamcinolone acetonide (topical) AERS; LOTN

2

GC

triamcinolone acetonide (topical) CREA; OINT

1

GC

trianex

4

triderm

1

ULTRAVATE LOTN

4

GC

DERMATOLOGY, LOCAL ANESTHETICS lidocaine OINT

2

GC

lidocaine PTCH

2

GC, PA

lidocaine hcl GEL

2

GC

lidocaine hcl SOLN 4%

1

GC

lidocaine-prilocaine

2

GC, B/D

SYNERA

4

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical

2

GC

ammonium lactate CREA; LOTN

2

GC

CONDYLOX GEL

4

DENAVIR

5

diclofenac sodium (actinic keratoses)

5

PA

diclofenac sodium (topical) 1.5% soln

2

GC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

121  

Drug Name

Drug Tier

Requirements/Limits

DOXYCYCLINE (ROSACEA)

2

GC

ELIDEL

4

PA

FINACEA AER 15%

4

FINACEA GEL 15%

4

fluorouracil (topical) CREA 5%

2

FLUOROURACIL (TOPICAL) CREA .5%

5

fluorouracil (topical) SOLN

2

GC

imiquimod CREA

2

GC

metronidazole (topical)

2

GC

NORITATE

5

ORACEA

4

PANRETIN

5

PENNSAID SOL 2%

4

PICATO

5

podofilox SOLN

2

RECTIV

4

rosadan cre 0.75%

2

SOOLANTRA

4

tacrolimus (topical)

2

GC, PA

TARGRETIN GEL

5

NM, PA

TOLAK

4

VALCHLOR

5

VOLTAREN GEL 1%

3

XERESE

5

ZOVIRAX CREA

5

ZYCLARA

5

GC

GC

GC

NM, LA, PA

DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

122  

Drug Name

Drug Tier

Requirements/Limits

malathion

2

GC

permethrin

2

GC

SKLICE

4

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25%

1

GC

neomycin/polymyxin b gu

2

GC

REGRANEX

5

PA

SANTYL

4

SODIUM CHLORIDE 0.9%

1

GC

STERILE WATER IRRIGATION

2

GC

cevimeline hcl

2

GC

chlorhexidine gluconate (mouth-throat)

1

GC

clotrimazole TROC

2

GC

lidocaine hcl (mouth-throat)

1

GC

nystatin (mouth-throat)

2

GC

ORAVIG

5

paroex sol 0.12%

1

GC

periogard soln 0.12%

1

GC

PILOCARPINE HCL (ORAL) 5mg

2

GC

pilocarpine hcl (oral) 7.5mg

2

GC

triamcinolone acetonide (mouth)

2

GC

acetasol hc

2

GC

acetic acid (otic)

2

GC

acetic acid sol/hc

2

GC

acetic acid-aluminum acetate

2

GC

MOUTH/THROAT/DENTAL AGENTS

OTIC

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

123  

Drug Name

Drug Tier

Requirements/Limits

CIPRO HC

4

CIPRODEX

3

COLY-MYCIN S

4

CORTISPORIN-TC

4

fluocinolone acetonide (otic)

2

GC

neomycin-polymyxin-hc (otic)

2

GC

ofloxacin (otic)

2

GC

OTOVEL

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        GC  -­  We  provide  coverage  of  this  prescription  drug  in  the  coverage  gap.   Please  refer  to  our  Evidence  of  Coverage  for  more  information  about  this   coverage.          

124  

Index 8   8-MOP ........................................... 119 A   abacavir sulfate .................................. 20 abacavir sulfate-lamivudine-zidovudine ...... 22 ABELCET ......................................... 19 ABILIFY DISCMELT TAB 10MG .............. 56 ABILIFY MAINTENA ............................ 56 ABRAXANE....................................... 31 ABSORICA ..................................... 115 ABSTRAL ......................................... 11 acamprosate calcium............................ 66 ACANYA ........................................ 115 acarbose .......................................... 71 acebutolol hcl ..................................... 42 acetaminophen w/ codeine ...................... 9 acetaminophen-caff-dihydrocod ................ 9 acetasol hc ...................................... 123 acetazolamide .................................... 45 acetazolamide sodium .......................... 45 acetic acid....................................... 123 acetic acid (otic) ................................ 123 acetic acid sol/hc............................... 123 acetic acid-aluminum acetate ................ 123 acetylcysteine .................................. 113 ACIPHEX SPR CAP 10MG .................... 92 ACIPHEX SPR CAP 5MG ...................... 92 acitretin .......................................... 118 ACTEMRA ........................................ 98 ACTHIB ......................................... 101 ACTIMMUNE ..................................... 99 ACTOPLUS MET XR 15-1000MG ............ 71 ACTOPLUS MET XR 30-1000MG ............ 71 ACUVAIL ........................................ 108 acyclovir ........................................... 23 acyclovir sodium ................................. 23 acyclovir topical ................................ 121 ACZONE ........................................ 116 ADACEL......................................... 101 ADAGEN .......................................... 81 adapalene ....................................... 116 ADCIRCA ......................................... 47

adefovir dipivoxil ................................. 23 ADEMPAS ........................................ 47 adrucil ............................................. 30 ADVAIR DISKUS .............................. 115 ADVAIR HFA ................................... 115 AEROSPAN .................................... 114 afeditab cr ......................................... 43 AFINITOR ......................................... 34 AFINITOR DISPERZ ............................ 34 AFREZZA ......................................... 85 AGGRENOX ...................................... 97 a-hydrocort ........................................ 82 AKYNZEO ........................................ 87 ala-cort .......................................... 119 ALBENZA ......................................... 17 albuterol sulfate ................................ 112 albuterol sulfate er ............................. 112 alclometasone dipropionate .................. 119 ALCOHOL SWABS .............................. 69 ALDACTAZIDE TAB 50/50 ..................... 45 ALDURAZYME ................................... 81 ALECENSA ....................................... 34 alendronate sodium ............................. 74 alfuzosin hcl ...................................... 93 ALIMTA............................................ 30 ALINIA ............................................. 17 allopurinol tab ..................................... 8 almotriptan malate ............................... 63 ALOCRIL ........................................ 109 ALOMIDE ....................................... 109 ALOPRIM .......................................... 8 ALORA ............................................ 82 alosetron hcl ...................................... 91 ALOXI ............................................. 87 ALPHAGAN P 0.1% ........................... 110 alprazolam ........................................ 48 ALREX .......................................... 108 altavera ............................................ 75 ALTOPREV ....................................... 40 ALVESCO....................................... 114 amantadine hcl ................................... 55 AMBISOME ....................................... 19 125  

amcinonide ..................................... 119 amethia 91 day ................................... 75 amethyst 28 day ................................. 75 amifostine crystalline ............................ 36 amikacin sulfate .................................. 17 amiloride & hydrochlorothiazide ............... 45 amiloride hcl ...................................... 45 aminophylline inj ............................... 115 AMINOSYN ..................................... 103 AMINOSYN 7%/ELECTROLYTES .......... 103 AMINOSYN II................................... 103 AMINOSYN II 8.5%/ELECTROL ............ 103 AMINOSYN INJ 8.5/LYTE .................... 103 AMINOSYN M .................................. 103 AMINOSYN-HBC .............................. 103 AMINOSYN-PF 7% ............................ 103 AMINOSYN-PF INJ 10% ..................... 103 AMINOSYN-RF ................................ 103 amiodarone hcl ................................... 39 amiodarone inj 50mg/ml ........................ 39 AMITIZA ........................................... 91 amitriptyline hcl................................... 53 amlodipine besylate ............................. 43 amlodipine besylate/atorv ...................... 43 amlodipine besylate-benazepril hcl ........... 37 amlodipine besylate-valsartan tab 10-160 mg ...................................................... 38 amlodipine besylate-valsartan tab 10-320 mg ...................................................... 38 amlodipine besylate-valsartan tab 5-160 mg 38 amlodipine besylate-valsartan tab 5-320 mg 38 amlodipine-valsartan-hydrochlorothiazide 10160-12.5mg ....................................... 38 amlodipine-valsartan-hydrochlorothiazide 10160-25mg ......................................... 38 amlodipine-valsartan-hydrochlorothiazide 10320-25mg ......................................... 39 amlodipine-valsartan-hydrochlorothiazide 5160-12.5mg ....................................... 38 amlodipine-valsartan-hydrochlorothiazide 5160-25mg ......................................... 38 ammonium chloride............................ 102 ammonium lactate ............................. 121 amnesteem ..................................... 116 amoxapine ........................................ 53

amoxicillin ......................................... 27 amoxicillin & pot clavulanate ................... 27 amoxicillin-clarithromycin w/ lansoprazole ... 91 amphetamine cap 10mg er ..................... 60 amphetamine cap 15mg er ..................... 60 amphetamine cap 20mg er ..................... 60 amphetamine cap 25mg er ..................... 60 amphetamine cap 30mg er ..................... 60 amphetamine-dextroamphetamine cap sr 24hr 5 mg ............................................... 60 amphetamine-dextroamphetamine tab 10 mg ...................................................... 60 amphetamine-dextroamphetamine tab 12.5 mg ...................................................... 60 amphetamine-dextroamphetamine tab 15 mg ...................................................... 60 amphetamine-dextroamphetamine tab 20 mg ...................................................... 60 amphetamine-dextroamphetamine tab 30 mg ...................................................... 60 amphetamine-dextroamphetamine tab 5 mg 60 amphetamine-dextroamphetamine tab 7.5 mg ...................................................... 60 amphotericin b ................................... 19 ampicillin & sulbactam sodium ................. 27 ampicillin cap 250mg ............................ 28 ampicillin cap 500 mg ........................... 28 ampicillin inj ....................................... 28 ampicillin sodium................................. 28 ampicillin susp .................................... 28 AMPYRA .......................................... 65 anagrelide hcl .................................... 97 anastrozole ....................................... 33 ANDRODERM ................................... 68 ANDROGEL ...................................... 68 ANDROGEL 1.62%.............................. 68 ANDROGEL 1% ................................. 68 ANORO ELLIPT AER 62.5-25 ............... 111 ANTARA .......................................... 41 apexicon e cream .............................. 119 APIDRA ........................................... 69 APIDRA SOLOSTAR............................ 69 APLENZIN ........................................ 53 APOKYN .......................................... 55 apri 28 day ........................................ 75 126  

APRISO ........................................... 90 APTENSIO XR ................................... 60 APTIOM ........................................... 48 APTIVUS .......................................... 20 ARALAST NP .................................. 113 aranelle 28 ........................................ 75 ARANESP ALBUMIN FREE ................... 96 ARCALYST ....................................... 99 ARCAPTA NEOHALER ....................... 112 aripiprazole ....................................... 56 aripiprazole oral solution 1 mg/ml ............. 56 aripiprazole tabs ................................. 56 ARISTADA ........................................ 56 ARNUITY ELLIPTA ............................ 114 ARRANON ........................................ 30 ARZERRA ........................................ 32 ASACOL HD ...................................... 90 ashlyna 91 day ................................... 76 ASMANEX ...................................... 114 ASMANEX HFA ................................ 115 ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP 356.4-30-16 MG ............................ 9 ASTAGRAF XL................................... 99 ASTEPRO ...................................... 112 atenolol ............................................ 42 atenolol & chlorthalidone ....................... 42 ATGAM ............................................ 99 atorvastatin calcium ............................. 40 atovaquone ....................................... 17 atovaquone-proguanil hcl tab 250-100 mg ... 20 atovaquone-proguanil hcl tab 62.5-25 mg ... 20 ATRALIN ........................................ 116 ATRIPLA .......................................... 22 ATROPINE SULFATE .......................... 89 ATROVENT HFA .............................. 111 AUBAGIO ......................................... 65 aubra 28 day ..................................... 76 AUGMENTIN ..................................... 28 AURYXIA ......................................... 86 AVASTIN .......................................... 32 AVC ................................................ 94 AVELOX .......................................... 27 aviane 28.......................................... 76 AVITA............................................ 116 AVYCAZ........................................... 25

AXERT ............................................ 63 AXIRON ........................................... 68 azacitidine......................................... 30 AZACTAM/DEX INJ 1GM ...................... 17 AZACTAM/DEX INJ 2GM ...................... 17 azasan ............................................. 99 AZASITE ........................................ 107 azathioprine..................................... 100 azelastine drop 0.05% ........................ 109 azelastine spr 0.1%............................ 112 azelastine spr 0.15% .......................... 112 AZELEX ......................................... 116 AZILECT .......................................... 55 AZITHROMYCIN................................. 26 AZOPT .......................................... 110 AZOR .............................................. 39 aztreonam......................................... 17 B   bacitracin (ophthalmic) ........................ 107 bacitracin-polymyxin b (ophth) ............... 107 bacitracin-poly-neomycin-hc ................. 107 baclofen ........................................... 66 BACTOCILL INJ DEX 1GM .................... 28 BACTOCILL INJ DEX 2GM .................... 28 BACTROBAN NASAL ......................... 117 balsalazide disodium ............................ 90 balziva 28 day .................................... 76 BANZEL SUS 40MG/ML........................ 48 BANZEL TAB 200MG ........................... 48 BANZEL TAB 400MG ........................... 48 BARACLUDE ..................................... 23 BCG VACCINE................................. 101 BECONASE AQ ............................... 114 bekyree 28 day ................................... 76 BELBUCA ..................................... 9, 10 BELEODAQ ...................................... 32 benazepril & hydrochlorothiazide .............. 37 benazepril hcl..................................... 37 BENDEKA ........................................ 29 BENICAR ......................................... 39 BENICAR HCT ................................... 39 BENLYSTA ..................................... 100 BENTYL ........................................... 89 benzoyl peroxide-erythromycin .............. 116 BENZTROPINE MESYLATE................... 55 127  

BEPREVE....................................... 109 BESIVANCE .................................... 108 betamethasone dipropionate (topical) ...... 119 betamethasone dipropionate augmented .. 119 betamethasone valerate ...................... 119 BETASERON..................................... 65 betaxolol hcl ...................................... 42 betaxolol hcl (ophth) ........................... 110 bethanechol chloride ............................ 94 BETHKIS .......................................... 17 BETIMOL ....................................... 110 BETOPTIC-S ................................... 110 bexarotene ........................................ 35 BEXSERO ...................................... 101 BEYAZ ............................................ 76 bicalutamide ...................................... 33 BICILLIN C-R ..................................... 28 BICILLIN L-A ..................................... 28 BICNU ............................................. 29 BIDIL ............................................... 46 BILTRICIDE ...................................... 17 BINOSTO ......................................... 74 bisoprolol & hydrochlorothiazide............... 42 bisoprolol fumarate .............................. 42 BIVIGAM .......................................... 98 bleomycin sulfate ................................ 30 blephamide ..................................... 107 blisovi 21 fe 1.5/30 28 day pack ............... 76 blisovi 21 fe 1/20 28 day pack ................. 76 blisovi 24 fe 1/20 28 day ........................ 76 BOOSTRIX ..................................... 101 BOSULIF .......................................... 34 BOTOX INJ 100UNIT ........................... 66 BOTOX INJ 200UNIT ........................... 66 BREO ELLIPTA ................................ 115 briellyn 28 day .................................... 76 BRILINTA ......................................... 97 BRIMONIDINE SOL 0.15% .................. 110 brimonidine sol 0.2% .......................... 110 BRINTELLIX ...................................... 53 BRISDELLE ...................................... 64 BRIVIACT INJ .................................... 48 BRIVIACT SOLN 10MG/ML .................... 48 BRIVIACT TABS ................................. 49 bromfenac sodium (ophth) ................... 108

BROMFENAC SODIUM (OPHTH)(ONCEDAILY) ........................................... 109 bromocriptine mesylate ......................... 55 BROVANA ...................................... 112 budesonide ....................................... 90 budesonide (inhalation) ....................... 115 budesonide (nasal) ............................ 114 bumetanide ....................................... 45 BUNAVAIL MIS 2.1-0.3MG..................... 67 BUNAVAIL MIS 4.2-0.7MG..................... 67 BUNAVAIL MIS 6.3-1MG ....................... 67 BUPHENYL ....................................... 81 buprenorphine hcl ............................... 67 buprenorphine hcl-naloxone hcl sl ............ 67 buproban tab (smoking deterrent) ............. 67 bupropion hcl ..................................... 53 bupropion hcl (smoking deterrent) ............ 67 buspirone hcl ..................................... 48 BUSULFEX ....................................... 29 butorphanol nasal spray ........................ 10 butorphanol tartrate.............................. 10 BUTRANS ........................................ 10 BYDUREON ...................................... 69 BYDUREON PEN................................ 69 BYETTA ........................................... 69 BYSTOLIC ........................................ 42 C   cabergoline ....................................... 85 CABOMETYX .................................... 34 cafergot tab 1-100mg ........................... 63 calcipotriene .................................... 118 calcipotriene/betamethasone ................ 119 calcitonin (salmon) nasal spray ................ 85 calcitrene oin 0.005% ......................... 118 calcitriol................................... 107, 118 calcium acetate (phosphate binder)........... 86 camila 28 day..................................... 76 CAMPTOSAR .................................... 37 CAMRESE LO TAB ............................. 76 CANASA .......................................... 90 CANCIDAS ....................................... 19 candesartan cilexetil ............................. 39 candesartan cilexetil-hydrochlorothiazide .... 39 CANTIL ............................................ 89 CAPASTAT SULFATE .......................... 23 128  

CAPEX .......................................... 119 capital and codeine .................................... 10 CAPRELSA ....................................... 34 captopril ........................................... 37 captopril & hydrochlorothiazide ................ 37 CARAFATE ....................................... 91 CARBAGLU ...................................... 81 carbamazepine ................................... 49 carbidopa ......................................... 55 CARBIDOPA/LEVODOPA/ENTACAPONE .. 55 carbidopa-levodopa ............................. 55 carboplatin ........................................ 36 CARDIZEM LA ................................... 43 CARDURA XL .................................... 93 CARIMUNE NANOFILTERED ................. 98 carteolol hcl (ophth) ........................... 110 cartia xt ............................................ 43 carvedilol .......................................... 42 CAYSTON ........................................ 17 caziant 28 day .................................... 76 cefaclor ............................................ 25 cefaclor er tab 500mg ........................... 25 cefadroxil .......................................... 25 cefazolin in dextrose 1gm/50ml-5% ........... 25 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ...................................................... 25 cefazolin inj ....................................... 25 cefazolin sodium ................................. 25 cefdinir ............................................. 25 CEFEPIME 1GM SOLN ........................ 25 CEFEPIME 2GM SOLN ........................ 25 CEFEPIME HCL AND DEXTROSE ........... 25 cefepime inj 1gm ................................. 25 cefepime inj 2gm ................................. 25 cefixime ........................................... 25 cefotaxime sodium............................... 25 cefotetan disodium .............................. 25 cefoxitin sodium .................................. 25 CEFOXITIN SODIUM IN DEXTROSE ........ 25 cefpodoxime proxetil ............................ 25 cefprozil ........................................... 25 ceftazidime ........................................ 25 CEFTAZIDIME/DEXTROSE ................... 25 CEFTIBUTEN .................................... 25

CEFTIN............................................ 25 ceftriaxone sodium .............................. 26 cefuroxime axetil ................................. 26 cefuroxime sodium .............................. 26 celecoxib ........................................... 8 CELLCEPT INTRAVENOUS ................. 100 CELONTIN ........................................ 49 CENTANY ...................................... 117 cephalexin ........................................ 26 CERDELGA ...................................... 81 CEREZYME ...................................... 81 CERVARIX ..................................... 101 CESAMET ........................................ 87 cetirizine syrup ................................. 112 cevimeline hcl .................................. 123 CHANTIX ......................................... 67 CHANTIX CONTINUING MONTH ............ 67 CHANTIX STARTER PACK .................... 67 CHEMET .......................................... 75 chlorhexidine gluconate (mouth-throat) .... 123 chloroquine phosphate .......................... 20 chlorothiazide tabs............................... 45 chlorpromazine hcl .............................. 56 chlorpromazine inj ............................... 56 chlorthalidone .................................... 45 cholestyramine ................................... 41 cholestyramine light ............................. 41 choline fenofibrate ............................... 41 CHORIONIC GONADOTROPIN .............. 85 ciclopirox ........................................ 117 ciclopirox cre 0.77% ........................... 117 ciclopirox shampoo 1% ....................... 117 ciclopirox sus 0.77% .......................... 117 cidofovir ........................................... 23 cilostazol .......................................... 97 CILOXAN OIN 0.3% OP ...................... 108 cimetidine ......................................... 89 cimetidine sol 300/5ml .......................... 89 CIMZIA ............................................ 98 CINQAIR ........................................ 113 CINRYZE ......................................... 97 CIPRO HC ...................................... 124 CIPRODEX ..................................... 124 ciprofloxacin ...................................... 27 ciprofloxacin er ................................... 27 129  

ciprofloxacin hcl .................................. 27 ciprofloxacin hcl (ophth) ...................... 108 ciprofloxacin in d5w.............................. 27 ciprofloxacin inj 200mg/20ml ................... 27 ciprofloxacin inj 400mg/40ml ................... 27 cisplatin............................................ 36 citalopram hydrobromide ....................... 53 cladribine .......................................... 31 claforan ............................................ 26 CLAFORAN/D5W ................................ 26 claravis .......................................... 116 CLARINEX ...................................... 112 CLARINEX-D TAB 2.5-120 ................... 111 clarithromycin..................................... 26 CLEOCIN VAG SUPP 100MG ................. 94 clindacin-p ...................................... 116 CLINDAGEL .................................... 116 clindamax ....................................... 116 clindamycin cre 2% vag ......................... 94 clindamycin hcl ................................... 17 clindamycin palmitate hydrochloride .......... 17 clindamycin phosphate.......................... 17 clindamycin phosphate (topical) ............. 116 clindamycin phosphate in d5w ................. 17 clindamycin phosphate-benzoyl peroxide .. 116 clindamycin phosphate-benzoyl peroxide (refrigerate) ..................................... 116 clindamycin phosphate-tretinoin ............. 116 CLINDESSE ...................................... 94 CLINIMIX 2.75%/DEXTROSE 5% .......... 103 CLINIMIX 4.25%/DEXTROSE 10% ......... 104 CLINIMIX 4.25%/DEXTROSE 20% ......... 104 CLINIMIX 4.25%/DEXTROSE 25% ......... 104 CLINIMIX 4.25%/DEXTROSE 5% .......... 104 CLINIMIX 5%/DEXTROSE 15% ............. 104 CLINIMIX 5%/DEXTROSE 20% ............. 104 CLINIMIX 5%/DEXTROSE 25% ............. 104 CLINIMIX E 2.75%/DEXTROSE 10% ...... 104 CLINIMIX E 2.75%/DEXTROSE 5% ........ 104 CLINIMIX E 4.25%/D10 ....................... 104 CLINIMIX E 4.25%/DEXTROSE 25% ...... 104 CLINIMIX E 4.25%/DEXTROSE 5% ........ 104 CLINIMIX E 5%/DEXTROSE 15% .......... 104 CLINIMIX E 5%/DEXTROSE 20% .......... 104 CLINIMIX E 5%/DEXTROSE 25% .......... 104

clinisol 15 ....................................... 104 clobetasol e cream 0.05% .................... 119 clobetasol propionate ......................... 119 clobetasol propionate emulsion .............. 119 CLOCORTOLONE PIVALATE............... 119 clodan sha 0.05% .............................. 119 CLOLAR........................................... 31 clomipramine hcl ................................. 53 clonazepam ....................................... 49 clonidine hcl ...................................... 46 clopidogrel bisulfate ............................. 97 clorazepate dipotassium ........................ 49 clorpres ............................................ 46 clotrimazole ..................................... 123 clotrimazole (topical) .......................... 117 clozapine .......................................... 56 CLOZAPINE ODT ............................... 56 COARTEM ........................................ 20 codeine and capital ..................................... 10 CODEINE SULFATE ............................ 11 colchicine w/ probenecid......................... 8 COLCRYS ......................................... 8 colestipol hcl ...................................... 41 colistimethate sodium ........................... 17 colocort ............................................ 90 COLY-MYCIN S ................................ 124 COLYTE-FLAVOR PACKS 227.1 GM ........ 90 COMBIGAN..................................... 110 COMBIVENT RESPIMAT .................... 111 COMETRIQ ....................................... 34 COMPLERA ...................................... 22 compro supp ...................................... 87 COMVAX ........................................ 101 CONDYLOX .................................... 121 constulose ........................................ 90 CONZIP ........................................... 10 COPAXONE INJ 20MG/ML .................... 65 COPAXONE INJ 40MG/ML .................... 65 CORDRAN ...................................... 119 COREG CR ....................................... 42 CORLANOR ...................................... 46 cormax .......................................... 119 CORTIFOAM ................................... 118 cortisone acetate................................. 82 130  

CORTISPORIN ................................ 117 CORTISPORIN-TC ............................ 124 COSENTYX .................................... 118 COSENTYX SENSOREADY PEN .......... 118 COSMEGEN ..................................... 30 COSOPT PF .................................... 110 COTELLIC ........................................ 34 COUMADIN....................................... 95 CREON............................................ 92 CRESEMBA ...................................... 19 CRESTOR ........................................ 40 CRINONE ......................................... 86 CRIXIVAN......................................... 20 cromolyn sodium ............................... 113 cromolyn sodium (mastocytosis) .............. 91 cromolyn sodium (ophth) ..................... 109 cryselle 28 ........................................ 76 CUBICIN .......................................... 17 CUVPOSA ........................................ 89 cyclafem 1/35 28 day............................ 76 cyclafem 7/7/7 28 day ........................... 76 CYCLOPHOSPHAMIDE ........................ 29 cycloserine ........................................ 23 cyclosporine .................................... 100 cyclosporine modified (for microemulsion) . 100 cyred tab .......................................... 76 CYSTADANE ..................................... 81 CYSTAGON ...................................... 81 cytarabine inj ..................................... 31 D   dacarbazine....................................... 29 DAKLINZA ........................................ 23 DALIRESP ...................................... 113 DALVANCE ....................................... 17 danazol ............................................ 80 dantrolene sodium ............................... 66 dapsone ........................................... 18 DAPTACEL ..................................... 101 daptomycin ....................................... 18 DARAPRIM ....................................... 18 DARIFENACIN HYDROBROMIDE ........... 94 daunorubicin hcl ................................. 30 DAYTRANA....................................... 61 deblitane 28 day ................................. 76 decitabine ......................................... 31

DELESTROGEN ................................. 82 delyla 28 day ..................................... 76 DELZICOL ........................................ 90 demeclocycline hcl .............................. 29 DEMSER .......................................... 46 DENAVIR ....................................... 121 DEPEN TITRATABS ............................ 75 depo-estradiol .................................... 82 DEPO-MEDROL INJ 20MG/ML ............... 82 DEPO-PROVERA INJ 400/ML................. 33 DEPO-SUBQ PROVERA 104 ................. 76 depo-testosterone ............................... 68 DESCOVY ........................................ 22 desipramine hcl .................................. 53 desloratadine ................................... 112 DESMOPRESSIN ACETATE .................. 87 desmopressin acetate inj ....................... 87 desmopressin acetate spray ................... 87 desmopressin acetate spray refrigerated .... 87 desogestrel-ethinyl estradiol (biphasic) ....... 76 DESONATE .................................... 119 DESONIDE ..................................... 120 desoximetasone ............................... 120 dexamethasone .................................. 82 dexamethasone sodium phosphate ........... 82 dexamethasone sodium phosphate (ophth) 109 DEXILANT ........................................ 92 dexpak 10 day .................................... 83 dexpak 6 day ..................................... 83 dexpak taperpak 13 day ........................ 83 dexrazoxane ...................................... 36 DEXTROSE .................................... 105 DEXTROSE 10% FLEX CONTAIN ......... 105 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% ............................................. 105 DEXTROSE 10%/NACL 0.45% ............. 105 DEXTROSE 2.5%/NACL 0.45% ............. 105 DEXTROSE 5% ................................ 105 DEXTROSE 5% /ELECTROLYTE .......... 105 DEXTROSE 5%/LACTATED RING ......... 105 DEXTROSE 5%/NACL 0.2%................. 105 DEXTROSE 5%/NACL 0.225% ............. 105 DEXTROSE 5%/NACL 0.3%................. 105 DEXTROSE 5%/NACL 0.33% ............... 105 DEXTROSE 5%/NACL 0.45% ............... 105 131  

DEXTROSE 5%/NACL 0.9%................. 105 DEXTROSE 5%/POTASSIUM CHL ........ 105 diazepam.......................................... 49 DIAZEPAM GEL (ANTICONVULSANT)...... 49 DIBENZYLINE ................................... 46 diclofenac potassium ............................. 8 diclofenac sodium ................................ 8 diclofenac sodium (actinic keratoses) ...... 121 diclofenac sodium (ophth) .................... 109 diclofenac sodium (topical) 1.5% soln ...... 121 diclofenac w/ misoprostol ........................ 8 dicloxacillin sodium .............................. 28 dicyclomine hcl ................................... 89 didanosine ........................................ 20 DIFFERIN ....................................... 116 DIFICID............................................ 26 diflorasone diacetate .......................... 120 diflunisal ............................................ 8 digitek.............................................. 44 digox ............................................... 44 digoxin ............................................. 44 digoxin inj ......................................... 44 DIGOXIN SOL 50MCG/ML ..................... 44 dihydroergotamine mesylate ................... 63 dilantin ............................................. 50 DILANTIN-125 ................................... 50 DILATRATE SR .................................. 46 DILAUDID-HP INJ 250MG ..................... 11 diltiazem cap 120mg/24hr ...................... 43 diltiazem cap 240mg/24hr ...................... 43 diltiazem cap er/12hr ............................ 43 diltiazem hcl ...................................... 43 diltiazem hcl coated beads ..................... 43 diltiazem hcl er ................................... 43 diltiazem hcl extended release beads ........ 43 diltiazem inj 100mg .............................. 43 diltiazem inj 125/25ml ........................... 43 diltiazem inj 25mg/5ml .......................... 43 diltiazem inj 50/10ml ............................. 43 dilt-xr cap .......................................... 43 DIPENTUM ....................................... 90 diphenhydram inj 50mg/ml ................... 112 diphenoxylate w/ atropine ...................... 91 DIPHTHERIA/TETANUS TOXOID .......... 101 disopyramide phosphate........................ 40

disulfiram .......................................... 67 DIURIL SUS 250/5ML ........................... 45 divalproex sodium ............................... 50 DOCETAXEL ..................................... 31 DOCETAXEL SOLN 80MG/8ML .............. 31 dofetilide .......................................... 40 donepezil odt 10mg.............................. 52 donepezil odt 5mg ............................... 52 donepezil tab hcl 23mg ......................... 52 donepezil tabs 10mg ............................ 52 donepezil tabs 5mg .............................. 52 DORIBAX ......................................... 18 dorzolamide hcl ................................ 110 dorzolamide hcl-timolol maleate ............. 110 doxazosin mesylate ............................. 38 doxepin hcl ........................................ 53 DOXEPIN HCL (ANTIPRURITIC) ........... 118 doxercalciferol .................................. 107 doxorubicin hcl ................................... 30 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml .............................................. 30 doxorubicin inj 50mg ............................ 30 doxy ................................................ 29 doxycycline (monohydrate) ..................... 29 DOXYCYCLINE (ROSACEA) ................ 122 doxycycline hyclate .............................. 29 doxycycline hyclate tab 100 mg dr ............ 29 doxycycline hyclate tab 150 mg dr ............ 29 doxycycline hyclate tab 75 mg dr .............. 29 dronabinol ................................... 87, 88 drospirenone-ethinyl estradiol ................. 76 DROXIA ........................................... 35 DUEXIS ............................................ 8 DULERA ........................................ 115 duloxetine hcl ..................................... 53 DUOPA ............................................ 55 DURAMORPH ................................... 11 DUREZOL ...................................... 109 DURLAZA ......................................... 97 dutasteride ........................................ 93 dutasteride-tamsulosin hcl...................... 93 DUTOPROL ...................................... 42 DYMISTA SPR 137-50........................ 112 DYRENIUM ....................................... 45 132  

E   e.e.s. 400 tab 400mg ............................ 26 E.E.S. GRANULES .............................. 27 econazole nitrate............................... 117 EDARBI ........................................... 39 EDARBYCLOR................................... 39 EDECRIN ......................................... 45 EDURANT ........................................ 21 EFFIENT .......................................... 97 EGRIFTA .......................................... 85 ELAPRASE ....................................... 81 ELECTROLYTE-R IN DEXTROSE ......... 105 ELELYSO ......................................... 81 ELIDEL .......................................... 122 ELIGARD INJ 22.5MG .......................... 33 ELIGARD INJ 30MG ............................ 33 ELIGARD INJ 45MG ............................ 33 ELIGARD INJ 7.5MG............................ 33 ELIQUIS TAB 2.5MG............................ 95 ELIQUIS TAB 5MG .............................. 95 ELITEK ............................................ 36 elixophyllin ...................................... 115 ELLA ............................................... 76 ELMIRON ......................................... 94 ELOXATIN ........................................ 36 EMADINE ....................................... 109 EMBEDA .......................................... 11 EMCYT ............................................ 29 EMEND............................................ 88 EMEND CAP 125MG ........................... 88 EMEND CAP 40MG ............................. 88 EMEND CAP 80MG ............................. 88 EMEND PAK 80 & 125.......................... 88 emoquette......................................... 76 EMSAM ........................................... 53 EMTRIVA ......................................... 21 emverm............................................ 18 ENABLEX ......................................... 94 enalapril maleate................................. 38 enalapril maleate & hydrochlorothiazide ..... 37 endocet ............................................ 11 ENGERIX-B .................................... 101 enoxaparin sodium .............................. 95 enpresse 28 day ................................. 76 ENSTILAR ...................................... 120

ENTACAPONE................................... 55 entecavir .......................................... 23 ENTRESTO....................................... 39 ENTYVIO ......................................... 90 enulose ............................................ 90 ENVARSUS XR ................................ 100 EPIDUO ......................................... 116 EPIDUO FORTE ............................... 116 epinastine hcl (ophth) ......................... 109 EPINEPHRINE ................................. 113 EPIPEN 2-PAK ................................. 113 EPIPEN-JR 2-PAK ............................ 113 epirubicin inj 200mg ............................. 30 epirubicin inj 50mg/25ml ........................ 30 epitol ............................................... 50 EPIVIR HBV ...................................... 23 eplerenone ........................................ 38 EPOGEN .......................................... 96 eprosartan mesylate ............................. 39 EPZICOM ......................................... 22 EQUETRO ........................................ 64 ERAXIS ........................................... 19 ERBITUX .......................................... 32 ergomar ........................................... 63 ERIVEDGE ....................................... 32 errin 28 day ....................................... 76 ERTACZO ...................................... 117 ery pad 2% ...................................... 116 ERYPED 200 ..................................... 27 ERYPED 400 ..................................... 27 ery-tab ............................................. 27 erythrocin lactobionate .......................... 27 erythrocin stearate ............................... 27 erythromycin (acne aid) ....................... 116 erythromycin (ophth) .......................... 108 erythromycin base ............................... 27 erythromycin cap 250mg ec .................... 27 erythromycin ethylsuccinate.................... 27 ESBRIET ........................................ 113 escitalopram oxalate ............................ 53 esomeprazole sodium inj ....................... 92 estarylla tab 0.25-35 ............................. 76 estrace ............................................ 82 estradiol ........................................... 82 estradiol valerate................................. 82 133  

ESTRING ......................................... 82 ethacrynic acid ................................... 45 ethambutol hcl .................................... 23 ethosuximide ..................................... 50 etodolac ............................................ 8 etodolac er ......................................... 8 ETOPOPHOS .................................... 37 etoposide.......................................... 37 EURAX .......................................... 122 EVOTAZ........................................... 22 EXELDERM .................................... 117 EXELON PATCHES ............................. 52 exemestane....................................... 33 EXJADE ........................................... 75 EXTAVIA .......................................... 65 F   FABIOR ......................................... 116 FABRAZYME ..................................... 81 falmina 28 day .................................... 76 famciclovir......................................... 23 famotidine ......................................... 89 famotidine inj ..................................... 89 FANAPT ........................................... 56 FANAPT TITRATION PACK ................... 56 FARESTON....................................... 33 FARXIGA ......................................... 71 FARYDAK......................................... 32 FASLODEX ....................................... 33 FAZACLO ......................................... 56 felbamate ......................................... 50 felodipine .......................................... 43 FEMRING ......................................... 82 FENOFIBRATE .................................. 41 fenofibrate micronized .......................... 41 FENOFIBRIC ACID.............................. 41 FENOGLIDE ...................................... 41 FENOPROFEN CALCIUM ...................... 8 fentanyl citrate .................................... 11 fentanyl patch 100 mcg/hr ...................... 11 fentanyl patch 12 mcg/hr ....................... 11 fentanyl patch 25 mcg/hr ....................... 11 fentanyl patch 50 mcg/hr ....................... 11 fentanyl patch 75 mcg/hr ....................... 11 FENTORA ........................................ 12 FERRIPROX ..................................... 75

FETZIMA .......................................... 53 FETZIMA TITRATION PACK .................. 53 FINACEA AER 15% ........................... 122 FINACEA GEL 15% ........................... 122 finasteride ......................................... 93 FIRAZYR .......................................... 97 FIRMAGON ....................................... 33 FLAREX ......................................... 109 FLEBOGAMMA .................................. 98 FLEBOGAMMA DIF ............................. 99 flecainide acetate ................................ 40 FLOVENT DISKUS ............................ 115 FLOVENT HFA................................. 115 fluconazole ........................................ 19 fluconazole in dextrose ......................... 19 fluconazole in nacl ............................... 19 flucytosine......................................... 20 fludarabine phosphate .......................... 31 fludrocortisone acetate .......................... 83 flunisolide (nasal) .............................. 114 fluocinolone acetonide ........................ 120 fluocinolone acetonide (otic) ................. 124 fluocinonide ..................................... 120 fluocinonide-e 0.05% cream ................. 120 FLUOROMETHOLONE (OPHTH) .......... 109 fluorouracil ........................................ 31 fluorouracil (topical)............................ 122 fluoxetine cap 10mg ............................. 53 fluoxetine cap 20mg ............................. 53 fluoxetine cap 40mg ............................. 53 fluoxetine hcl ..................................... 53 fluphenazine decanoate ........................ 56 fluphenazine hcl .................................. 56 flurandrenolide ................................. 120 flurbiprofen ......................................... 8 flurbiprofen sodium ............................ 109 flutamide .......................................... 33 fluticasone propionate ......................... 120 fluticasone propionate (nasal) ............... 114 fluvastatin sodium cap 20 mg .................. 40 fluvastatin sodium cap 40 mg .................. 40 fluvastatin sodium tab sr 24 hr 80 mg ........ 40 fluvoxamine maleate ............................ 48 fluvoxamine maleate er ......................... 48 FML .............................................. 109 134  

FML FORTE .................................... 109 fondaparinux sodium ............................ 95 FORADIL AEROLIZER ....................... 112 FORFIVO XL ..................................... 53 FORTAZ........................................... 26 FORTEO .......................................... 86 FORTESTA ....................................... 68 FORTICAL SPR 200/ACT ...................... 85 FOSAMAX PLUS D ............................. 74 fosinopril sodium ................................. 38 fosinopril sodium & hydrochlorothiazide ...... 37 FOSRENOL ...................................... 86 FRAGMIN ......................................... 95 FREAMINE HBC 6.9% ........................ 104 FREAMINE III .................................. 104 FROVA TAB 2.5MG ............................. 63 frovatriptan succinate ........................... 63 furosemide ........................................ 45 furosemide inj .................................... 45 furosemide oral soln 8 mg/ml .................. 45 FUSILEV .......................................... 36 FUZEON .......................................... 21 fyavolv tab 1 mg-5 mcg ......................... 82 FYCOMPA ........................................ 50 G   gabapentin ........................................ 50 GABITRIL ......................................... 50 galantamine hydrobromide ..................... 52 galantamine hydrobromide er .................. 52 GAMASTAN S/D ................................. 99 GAMMAGARD LIQUID ......................... 99 GAMMAGARD S/D .............................. 99 GAMMAGARD S/D IGA LESS TH ............ 99 GAMMAKED ..................................... 99 GAMMAPLEX .................................... 99 GAMUNEX-C ..................................... 99 ganciclovir inj 500mg ............................ 23 GARDASIL ...................................... 101 GARDASIL 9 ................................... 101 gatifloxacin (ophth) ............................ 108 GATTEX........................................... 91 GAUZE PADS 2X2 .............................. 69 gaviltye-g .......................................... 90 gavilyte-c .......................................... 90 gavilyte-h .......................................... 90

gavilyte-n .......................................... 91 GELNIQUE ....................................... 94 GEMCITABINE HCL ............................ 31 gemfibrozil ........................................ 41 generlac ........................................... 91 gengraf .......................................... 100 GENOTROPIN ................................... 84 GENOTROPIN MINIQUICK .................... 84 gentak ........................................... 108 gentamicin in saline ............................. 17 gentamicin sulfate ............................... 17 gentamicin sulfate (ophth) .................... 108 gentamicin sulfate (topical) ................... 117 GENVOYA ........................................ 22 GEODON INJ .................................... 57 GIANVI TAB 3-0.02MG ......................... 77 GIAZO ............................................. 90 gildagia ............................................ 77 gildess 1.5/30 21 day............................ 77 gildess 24 fe 28 day ............................. 77 GILENYA CAP 0.5MG .......................... 65 GILOTRIF TAB 20MG .......................... 34 GILOTRIF TAB 30MG .......................... 34 GILOTRIF TAB 40MG .......................... 34 GLASSIA ........................................ 113 GLEOSTINE ...................................... 29 glimepiride ........................................ 71 glipizide............................................ 71 glipizide er ........................................ 71 GLIPIZIDE XL TB24 2.5MG .................... 71 GLIPIZIDE XL TB24 5MG ...................... 71 glipizide-metformin 2.5-250 mg ................ 71 glipizide-metformin 2.5-500 mg ................ 71 glipizide-metformin 5-500mg ................... 72 GLUCAGEN HYPOKIT ......................... 84 GLUCAGON EMERGENCY KIT .............. 84 GLUMETZA....................................... 72 glycopyrrolate .................................... 89 GLYSET ........................................... 72 GLYXAMBI ....................................... 72 GOLYTELY ....................................... 91 GRALISE .......................................... 64 GRALISE STARTER ............................ 64 granisetron hcl ................................... 88 GRANIX ........................................... 96 135  

GRASTEK ........................................ 99 griseofulvin microsize ........................... 20 griseofulvin ultramicrosize ...................... 20 guanfacine er (adhd) ............................ 61 H   H.P. ACTHAR .................................... 85 HALAVEN ......................................... 35 halobetasol propionate ........................ 120 HALOG .......................................... 120 haloperidol ........................................ 57 haloperidol decanoate .......................... 57 haloperidol lactate ............................... 57 haloperidol lactate inj 5 mg/ml ................. 57 HARVONI ......................................... 24 HAVRIX ......................................... 101 heather ............................................ 77 HECTOROL .................................... 107 HEP SOD/NACL INJ 25000 .................... 95 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML .......................................... 95 heparin sod inj 10000u/ml ...................... 95 heparin sod inj 1000u/ml........................ 95 heparin sod inj 20000u/ml ...................... 95 heparin sod inj 5000u/0.5ml .................... 95 heparin sod inj 5000u/ml........................ 95 HEPARIN SODIUM/D5W ....................... 96 HEPARIN SODIUM/NACL 0.45% ............. 96 HEPATAMINE .................................. 104 HERCEPTIN ...................................... 32 HETLIOZ .......................................... 62 HEXALEN ......................................... 29 HIBERIX......................................... 101 HORIZANT ....................................... 64 HUMALOG ........................................ 69 HUMALOG KWIKPEN .......................... 69 HUMALOG MIX 50/50 .......................... 69 HUMALOG MIX 50/50 KWIKPEN ............. 69 HUMALOG MIX 75/25 .......................... 69 HUMALOG MIX 75/25 KWIKPEN ............. 69 HUMATROPE .................................... 84 HUMATROPE COMBO PACK................. 84 HUMIRA INJ 10MG/0.2ML ..................... 98 HUMIRA KIT 20MG/0.4ML ..................... 98 HUMIRA KIT 40MG/0.8ML ..................... 98 HUMIRA PEDIATRIC CROHNS............... 98

HUMIRA PEN .................................... 98 HUMIRA PEN-CROHNS STARTER KIT ..... 98 HUMIRA PEN-PSORIASIS STARTER KIT .. 98 HUMULIN 70/30 ................................. 69 HUMULIN 70/30 KWIKPEN .................... 69 HUMULIN N ...................................... 69 HUMULIN N KWIKPEN ......................... 70 HUMULIN R ...................................... 70 HUMULIN R U-500 KWIKPEN................. 70 HUMULIN R U-500 VIAL (CONCENTRATE) 70 hydralazine hcl ................................... 46 hydrochlorothiazide .............................. 45 hydrocodone-acetaminophen 10-300mg ..... 12 hydrocodone-acetaminophen 2.5-325mg .... 12 hydrocodone-acetaminophen 5-300mg ...... 12 hydrocodone-acetaminophen 5-325mg ...... 12 hydrocodone-acetaminophen 7.5-300mg .... 12 hydrocodone-acetaminophen 7.5-325 mg/15ml ...................................................... 12 hydrocodone-acetaminophen 7.5-325mg .... 12 hydrocodone-acetaminophen tab 10-325mg 12 hydrocodone-ibuprofen tab 10-200mg ....... 12 hydrocodone-ibuprofen tab 2.5-200mg ....... 12 hydrocodone-ibuprofen tab 5-200mg ......... 12 hydrocodone-ibuprofen tab 7.5-200 mg ...... 12 hydrocortisone ................................... 83 HYDROCORTISONE (INTRARECTAL)...... 90 hydrocortisone (topical) ....................... 120 hydrocortisone butyrate ....................... 120 hydrocortisone butyrate hydrophilic lipo base .................................................... 120 hydrocortisone valerate ....................... 120 hydromorphone hcl .............................. 12 hydromorphone tab 12mg er ................... 13 hydromorphone tab 16mg er ................... 13 hydromorphone tab 8mg er .................... 13 HYDROMORPHONE TABS 32MG ........... 13 hydroxychloroquine sulfate ..................... 98 hydroxyprogesterone caproate (antineoplastic) ...................................................... 33 hydroxyurea ...................................... 36 hydroxyzine hcl................................. 112 HYSINGLA ER ................................... 13 I   ibandronate sodium ............................. 74 136  

ibandronate tab 150mg ......................... 74 IBRANCE ......................................... 32 ibudone tab 10-200mg .......................... 13 ibudone tab 5-200mg............................ 13 ibuprofen ........................................... 8 ICLUSIG........................................... 34 idarubicin hcl ..................................... 30 IFEX INJ 3GM .................................... 29 ifosfamide inj 1gm ............................... 30 ifosfamide inj 1gm/20ml ......................... 30 IFOSFAMIDE INJ 3GM ......................... 30 ifosfamide inj 3gm/60ml ......................... 30 ILEVRO ......................................... 109 ilotycin ........................................... 108 imatinib mesylate ................................ 34 IMBRUVICA CAP 140MG ...................... 34 imipenem-cilastatin .............................. 18 imipramine hcl .................................... 54 imipramine pamoate ............................. 54 imiquimod ....................................... 122 IMOVAX RABIES (H.D.C.V.)................. 101 INCRELEX ........................................ 85 INCRUSE ELLIPTA ........................... 111 indapamide ....................................... 45 INFANRIX ....................................... 101 INFUMORPH 200................................ 13 INFUMORPH 500................................ 13 INLYTA ............................................ 35 INSULIN PEN NEEDLES ....................... 70 INSULIN SAFETY NEEDLES .................. 70 INSULIN SYRINGES ............................ 70 INTELENCE ...................................... 21 INTRALIPID INJ 20% ......................... 104 INTRALIPID INJ 30% ......................... 104 INTRON-A INJ 10MU ........................... 99 INTRON-A INJ 18MU ........................... 99 INTRON-A INJ 25MU ........................... 99 INTRON-A INJ 50MU ........................... 99 introvale 91 day .................................. 77 INVANZ ........................................... 18 INVEGA ........................................... 57 INVEGA SUST INJ 117 MG/0.75 ML ......... 57 INVEGA SUST INJ 156MG/ML ................ 57 INVEGA SUST INJ 234 MG/1.5 ML .......... 57 INVEGA SUST INJ 39 MG/0.25 ML .......... 57

INVEGA SUST INJ 78 MG/0.5 ML ............ 57 INVEGA TRINZA ................................ 57 INVIRASE ......................................... 21 INVOKAMET TAB 150-1000 ................... 72 INVOKAMET TAB 150-500 .................... 72 INVOKAMET TAB 50-1000 .................... 72 INVOKAMET TAB 50-500MG ................. 72 INVOKANA TAB 100MG ....................... 72 INVOKANA TAB 300MG ....................... 72 IONOSOL-B/DEXTROSE 5% ................ 105 IONOSOL-MB/DEXTROSE 5% ............. 105 IPOL INACTIVATED IPV ..................... 101 ipratropium bromide (nasal) .................. 111 ipratropium sol inhal ........................... 111 ipratropium-albuterol .......................... 111 irbesartan ......................................... 39 irbesartan-hydrochlorothiazide................. 39 IRESSA ........................................... 35 irinotecan inj 100/5ml............................ 37 irinotecan inj 40mg/2ml ......................... 37 irinotecan inj 500mg/25ml ...................... 37 ISENTRESS ...................................... 21 ISOLYTE P ..................................... 105 ISOLYTE S ..................................... 105 isoniazid ........................................... 23 isoniazid tabs ..................................... 23 ISORDIL TITRADOSE .......................... 46 isosorbide dinitrate .............................. 46 isosorbide dinitrate er ........................... 46 isosorbide mononitrate .......................... 46 isosorbide mononitrate er ...................... 46 isradipine .......................................... 43 ISTALOL ........................................ 110 ISTODAX ......................................... 32 itraconazole ....................................... 20 ivermectin ......................................... 18 IXEMPRA KIT .................................... 36 IXIARO .......................................... 101 J   JADENU........................................... 75 JAKAFI ............................................ 35 jantoven ........................................... 96 JANUMET......................................... 72 JANUMET XR TAB 100-1000 ................. 72 JANUMET XR TAB 50-1000 ................... 72 137  

JANUMET XR TAB 50-500MG ................ 72 JANUVIA .......................................... 72 JARDIANCE ...................................... 72 JENTADUETO ................................... 72 JENTADUETO XR 2.5-1000MG............... 72 JENTADUETO XR 5-1000MG ................. 72 jinteli ............................................... 82 JOLESSA TAB 0.15-0.03 MG ................. 77 JOLIVETTE ....................................... 77 juleber 28 day .................................... 77 junel 1.5/30 21 day .............................. 77 junel 1/20 21 day................................. 77 junel fe 1.5/30 28 day ........................... 77 junel fe 1/20 28 day.............................. 77 junel fe 24 1/20 28 day .......................... 77 JUXTAPID ........................................ 41 K   KADCYLA ......................................... 32 KADIAN ........................................... 13 kaitlib fe 28 day .................................. 77 KALETRA SOL ................................... 22 KALETRA TAB 100-25MG ..................... 22 KALETRA TAB 200-50MG ..................... 22 KALYDECO..................................... 113 kariva 28 day ..................................... 77 KAZANO .......................................... 72 KCL 0.075%/D5W/NACL 0.45%............. 106 KCL 0.15%/D5W/LR .......................... 106 KCL 0.15%/D5W/NACL 0.9% ................ 106 KCL 0.3%/D5W/LR IV LAC RI ............... 106 KCL 0.3%/D5W/NACL 0.45% ................ 106 KCL 0.3%/D5W/NACL 0.9% ................. 106 KCL IN NACL INJ .15-0.45 ................... 106 KCL/D5W/NACL INJ .15/.33% ............... 106 KCL/D5W/NACL INJ .15/.45% ............... 106 KCL/D5W/NACL INJ 0.22%/0.45% ......... 106 KCL/NACL INJ 0.15%-0.9% ................. 106 KCL0.15%/D5W/NACL0.2% ................. 105 KCL0.15%/D5W/NACL0.225% .............. 105 kelnor 1/35 28 day ............................... 77 KEPIVANCE ...................................... 36 ketoconazole ..................................... 20 ketoconazole (topical) ......................... 117 ketoconazole shampoo ....................... 119 ketodan aer 2% ................................ 118

ketoprofen.......................................... 9 ketorolac tromethamine (ophth) ............. 109 KEVEYIS .......................................... 46 KEYTRUDA....................................... 32 kimidess 28 day .................................. 77 KINERET .......................................... 98 KINRIX .......................................... 101 kionex.............................................. 75 KLOR-CON 10 ................................. 102 KLOR-CON 8 ................................... 102 klor-con m10 .................................... 102 klor-con m15 .................................... 102 klor-con m20 .................................... 102 klor-con pow 20meq ........................... 102 klor-con spr cap 10meq ....................... 102 klor-con spr cap 8meq ........................ 102 KOMBIGLYZE XR 2.5-1000MG ............... 72 KOMBIGLYZE XR 5-1000MG ................. 72 KOMBIGLYZE XR 5-500MG ................... 72 KORLYM .......................................... 84 kristalose .......................................... 91 KUVAN ............................................ 81 KYNAMRO ........................................ 41 L   labetalol hcl ....................................... 42 LACRISERT .................................... 111 LACTATED RINGERS VIAFLEX ............ 106 lactulose ........................................... 91 lactulose (encephalopathy) ..................... 91 LAMICTAL ODT ................................. 50 LAMICTAL STARTER .......................... 50 LAMICTAL XR ................................... 50 LAMISIL ........................................... 20 lamivudine ........................................ 21 lamivudine (hbv) ................................. 24 lamivudine-zidovudine .......................... 22 lamotrigine ........................................ 50 LANOXIN ................................... 44, 45 LANOXIN PEDIATRIC .......................... 45 lansoprazole ...................................... 92 LANTUS ........................................... 70 LANTUS SOLOSTAR ........................... 70 larin 1.5/30 ........................................ 77 larin 1/20 .......................................... 77 larin fe 1.5/30 ..................................... 77 138  

larin fe 1/20 ....................................... 77 larissia 28 day pack ............................. 77 LASTACAFT .................................... 109 latanoprost ...................................... 110 LATUDA ........................................... 57 LAYOLIS FE CHW .............................. 77 LAZANDA ......................................... 13 leena tab .......................................... 77 leflunomide ....................................... 98 LEMTRADA....................................... 65 LENVIMA 10 MG DAILY DOSE ............... 35 LENVIMA 14 MG DAILY DOSE ............... 35 LENVIMA 18 MG DAILY DOSE ............... 35 LENVIMA 20 MG DAILY DOSE ............... 35 LENVIMA 24 MG DAILY DOSE ............... 35 LENVIMA 8 MG DAILY DOSE ................. 35 LESCOL XL....................................... 40 lessina 28 day .................................... 77 LETAIRIS ......................................... 47 letrozole ........................................... 33 leucovor ca inj .................................... 36 leucovorin calcium ............................... 36 leucovorin calcium 500 mg ..................... 37 LEUKERAN ....................................... 30 LEUKINE .......................................... 96 leuprolide acetate ................................ 33 levalbuterol conc 1.25mg/0.5ml ............. 112 LEVALBUTEROL HCL ........................ 112 LEVEMIR ......................................... 70 LEVEMIR FLEXTOUCH ........................ 70 levetiracetam ..................................... 50 LEVETIRACETAM IV ........................... 50 levetiracetam oral soln 100 mg/ml ............ 50 levobunolol hcl ................................. 110 levocarnitine (metabolic modifiers) ............ 81 levocetirizine soln 2.5mg/5ml ................ 112 levocetirizine tab 5 mg ........................ 112 levofloxacin ....................................... 27 levofloxacin (ophth) ............................ 108 levofloxacin in d5w .............................. 27 levoleucovorin calcium .......................... 37 levonest 28 day .................................. 77 levonor/ethi tab ................................... 77 levonorgestrel (emergency oc) ................ 78 levonorgestrel & eth estradiol .................. 78

levonorgestrel-ethinyl estradiol (91-day) ..... 78 levonorgestrel-ethinyl estradiol (continuous) 78 levora 0.15/30 28 day ........................... 78 levorphanol tartrate .............................. 13 levothyroxine sodium ............................ 87 LEVOXYL ......................................... 87 LEXIVA ............................................ 21 LIALDA ............................................ 90 lidocaine ......................................... 121 lidocaine hcl .................................... 121 lidocaine hcl (local anesth.) .................... 16 lidocaine hcl (mouth-throat) .................. 123 lidocaine inj 0.5% ................................ 16 lidocaine inj 1.5% ................................ 16 lidocaine inj 1% .................................. 16 lidocaine inj 2% .................................. 16 lidocaine-prilocaine ............................ 121 linezolid............................................ 18 LINEZOLID IN SODIUM CHLORIDE ......... 18 LINZESS .......................................... 91 liothyronine sodium .............................. 87 LIPOSYN III..................................... 104 lisinopril............................................ 38 lisinopril & hydrochlorothiazide ................ 37 lithium carbonate................................. 64 LITHIUM SOLN 8MEQ/5ML .................... 64 LIVALO ............................................ 40 LO LOESTRIN FE ............................... 78 LOCOID ......................................... 120 lokara ............................................ 120 lomedia 24 fe ..................................... 78 LONSURF ........................................ 36 loperamide hcl .................................... 92 lorazepam ......................................... 48 lorcet hd tab 10-325mg ......................... 13 lorcet plus tab 7.5-325 .......................... 13 lorcet tab 5-325mg............................... 13 lortab tab 10-325mg ............................. 13 lortab tab 5-325mg .............................. 13 lortab tab 7.5-325 ................................ 13 loryna 28 day ..................................... 78 losartan potassium .............................. 39 losartan-hydrochlorothiazide ................... 39 LOTEMAX ...................................... 109 lovastatin .......................................... 40 139  

low-ogestrel ....................................... 78 loxapine succinate ............................... 57 LUMIGAN ....................................... 110 LUMIZYME ....................................... 81 LUPANETA PACK ............................... 81 LUPRON DEP INJ 11.25MG ................... 33 LUPRON DEPOT ................................ 33 LUPRON DEPOT INJ 22.5MG (3-MONTH) . 33 LUPRON DEPOT INJ 30MG (3-MONTH).... 33 LUPRON DEP-PED INJ 11.25MG ............ 33 LUPRON DEP-PED INJ 15MG ................ 33 LUPRON DEP-PED INJ 30MG (3-MONTH) . 33 LUPRON DEP-PED INJ 7.5MG ............... 33 lutera 28 day ...................................... 78 LUZU ............................................ 118 LYNPARZA ....................................... 32 LYRICA............................................ 51 LYSODREN ...................................... 33 lyza ................................................. 78 M   MACRODANTIN ................................. 18 MAGNESIUM SULFATE ..................... 103 MAGNESIUM SULFATE IN D5W ........... 103 MAGNESIUM SULFATE INJ 50% .......... 103 malathion........................................ 123 maprotiline hcl .................................... 54 marlissa 28 day .................................. 78 MARPLAN ........................................ 54 MATULANE....................................... 36 matzim la .......................................... 43 MAXIDEX ....................................... 109 MAXIPIME ........................................ 26 meclizine hcl ...................................... 88 MEDROL TAB 2MG ............................. 83 medroxyprogesterone acetate ................. 87 medroxyprogesterone acetate (contraceptive) ...................................................... 78 mefenamic acid ................................... 9 mefloquine hcl .................................... 20 megestrol ac sus 40mg/ml ..................... 34 megestrol ac tab 20mg.......................... 34 megestrol ac tab 40mg.......................... 34 MEGESTROL SUS 625MG/5ML .............. 34 MEKINIST......................................... 35 MELOXICAM ...................................... 9

meloxicam tabs ................................... 9 melphalan hcl..................................... 30 memantine hcl .................................... 52 MENACTRA .................................... 101 MENHIBRIX .................................... 101 MENOMUNE-A/C/Y/W-135 .................. 101 MENOSTAR ...................................... 82 MENTAX ........................................ 118 MENVEO ........................................ 101 mercaptopurine .................................. 31 meropenem ....................................... 18 MEROPENEM/SODIUM CHLORIDE ......... 18 MESALAMINE ................................... 90 mesalamine enema.............................. 90 mesna ............................................. 37 MESNEX .......................................... 37 MESTINON SYRUP ............................. 64 MESTINON TIMESPAN ........................ 64 metadate er tab 20mg ........................... 61 metformin er ................................ 72, 73 metformin hcl ..................................... 73 metformin hcl osmotic 1000mg ................ 73 metformin hcl osmotic 500mg .................. 73 methadone hcl ................................... 14 METHADONE INJ 10MG/ML .................. 14 methazolamide ................................... 45 methenamine hippurate ......................... 18 methimazole ...................................... 87 METHOTREXATE SODIUM ................... 31 methotrexate sodium inj ........................ 31 methotrexate sodium tabs ...................... 98 methoxsalen rapid ............................. 118 methscopolamine bromide ..................... 89 methyclothiazide ................................. 45 methylergonovine maleate ..................... 85 methylphenidate hcl ............................. 61 methylphenidate hcl er .......................... 61 methylpr ace inj 40mg/ml ....................... 83 methylpr ace inj 80mg/ml ....................... 83 methylpr ss inj 125mg ........................... 83 methylpr ss inj 1gm .............................. 83 methylpr ss inj 40mg ............................ 83 methylpred pak 4mg ............................. 83 methylpred tab 16mg ............................ 83 methylpred tab 32mg ............................ 83 140  

methylpred tab 4mg ............................. 83 methylpred tab 8mg ............................. 83 metipranolol..................................... 110 metoclopramide hcl .............................. 88 metoclopramide hcl inj 5 mg/ml ................ 88 metoclopramide odt ............................. 88 metolazone ....................................... 45 metoprolol & hctz tab 100-25mg............... 42 metoprolol & hctz tab 100-50mg............... 42 metoprolol & hctz tab 50-25mg ................ 42 metoprolol succinate ............................ 42 metoprolol tartrate ............................... 42 METRO IV ........................................ 18 metronidazole .................................... 18 metronidazole (topical) ........................ 122 metronidazole inj ................................. 18 metronidazole vaginal ........................... 94 mexiletine hcl ..................................... 40 MIACALCIN INJ 200U/ML ...................... 85 miconazole 3 sup 200mg ....................... 95 MICROGESTIN 1.5/30 .......................... 78 MICROGESTIN 1/20 ............................ 78 MICROGESTIN FE 1.5/30 ..................... 78 MICROGESTIN FE 1/20 ........................ 78 midodrine hcl ..................................... 46 migergot ........................................... 63 miglitol ............................................. 73 millipred ........................................... 83 millipred dp ....................................... 83 MINASTRIN 24 FE .............................. 78 minitran ............................................ 47 MINIVELLE ....................................... 82 minocycline hcl ................................... 29 minoxidil ........................................... 46 MIRAPEX ......................................... 55 MIRAPEX ER..................................... 55 MIRCERA ......................................... 96 mirtazapine ....................................... 54 misoprostol ....................................... 92 mitomycin ......................................... 30 mitoxantrone hcl ................................. 36 M-M-R II ......................................... 101 modafinil .......................................... 66 moderiba pak ..................................... 24 moderiba tab 200mg ............................ 24

moexipril hcl ...................................... 38 moexipril-hydrochlorothiazide .................. 37 molindone hcl..................................... 57 mometasone furoate .......................... 120 mono-linyah tab 0.25-35 ........................ 78 MONONESSA .................................... 78 montelukast sodium ........................... 113 morgidox .......................................... 29 MORPHINE SUL 20MG/ML ORAL SOL ..... 14 MORPHINE SUL INJ 10MG/ML ............... 14 MORPHINE SUL INJ 15MG/ML ............... 14 MORPHINE SUL INJ 1MG/ML ................ 14 MORPHINE SUL INJ 4MG/ML ................ 14 morphine sulfate ................................. 14 morphine sulfate beads ......................... 14 morphine sulfate ext-rel tab .................... 14 MOVANTIK ....................................... 92 MOVIPREP ....................................... 91 MOXATAG ........................................ 28 MOXEZA ........................................ 108 MOXIFLOXACIN HCL .......................... 27 MOZOBIL ......................................... 96 MULTAQ .......................................... 40 mupirocin ........................................ 117 mupirocin calcium (topical) ................... 117 MUSTARGEN .................................... 30 MYCAMINE ....................................... 20 mycophenolate mofetil ........................ 100 mycophenolate sodium ....................... 100 myorisan ........................................ 116 MYOZYME ........................................ 81 MYRBETRIQ ..................................... 94 myzilra ............................................. 78 N   nabumetone ....................................... 9 nadolol ............................................. 42 nadolol & bendroflumethiazide................. 42 NAFCILLIN ....................................... 28 nafcillin sodium ................................... 28 NAFCILLIN SODIUM IN DEXTROSE ........ 28 NAFTIFINE HCL ............................... 118 NAFTIN.......................................... 118 NAGLAZYME..................................... 81 nalbuphine hcl .................................... 10 naloxone inj 0.4mg/ml ........................... 67 141  

naloxone inj 1mg/ml ............................. 67 naltrexone hcl .................................... 67 NAMENDA XR ................................... 52 NAMENDA XR TITRATION PACK ............ 52 NAMZARIC ....................................... 52 naphazoline hcl ................................ 111 NAPRELAN ........................................ 9 naproxen ........................................... 9 naproxen sodium ................................. 9 naratriptan hcl .................................... 63 NASONEX ...................................... 114 NATACYN ...................................... 108 nateglinide ........................................ 73 NATPARA......................................... 86 NEBUPENT....................................... 18 necon 0.5/35 28 day ............................. 78 necon 1/35 28 day ............................... 78 necon 10/11 28 day ............................. 78 NECON 7/7/7 ..................................... 78 NECON TAB 1/50-28 ........................... 79 nefazodone hcl ................................... 54 neomycin sulfate ................................. 17 neomycin/polymyxin b gu ..................... 123 neomycin-bacitracin zn-polymyxin .......... 108 neomycin-polymy-dexameth ................. 107 neomycin-polymyxin-gramicidin ............. 108 neomycin-polymyxin-hc (ophth) ............. 107 neomycin-polymyxin-hc (otic) ................ 124 NEORAL ........................................ 100 NEPHRAMINE ................................. 104 NESINA ........................................... 73 neuac gel 1.2-5% .............................. 116 NEULASTA ....................................... 96 NEULASTA ONPRO KIT ....................... 96 NEUMEGA ........................................ 96 NEUPOGEN ...................................... 97 NEUPRO .......................................... 55 NEVIRAPINE ..................................... 21 NEXAVAR ........................................ 35 NEXIUM CAP 20MG ............................ 92 NEXIUM CAP 40MG ............................ 92 NEXIUM GRA 10MG DR ....................... 93 NEXIUM GRA 2.5MG DR ...................... 93 NEXIUM GRA 20MG DR ....................... 93 NEXIUM GRA 40MG DR ....................... 93

NEXIUM GRA 5MG DR ......................... 93 niacin er (antihyperlipidemic)................... 41 niacor .............................................. 41 nicardipine hcl .................................... 43 NICOTROL INHALER ........................... 67 NICOTROL NS ................................... 67 nifedical ........................................... 44 nifedipine .......................................... 44 nifedipine er....................................... 44 nikki 28 day ....................................... 79 NILANDRON ..................................... 34 nilutamide ......................................... 34 nimodipine ........................................ 44 NINLARO ......................................... 32 NIPENT ........................................... 31 nisoldipine......................................... 44 nitro-bid............................................ 47 NITRO-DUR ...................................... 47 nitrofurantoin ..................................... 18 nitrofurantoin macrocrystal ..................... 18 nitrofurantoin monohyd macro ................. 19 nitroglycerin ....................................... 47 NITROGLYCERIN LINGUAL .................. 47 nitroglycerin patches ............................ 47 NITROSTAT ...................................... 47 nizatidine .......................................... 89 NORA-BE TAB ................................... 79 NORDITROPIN FLEXPRO ..................... 84 norethin acet & estrad-fe ....................... 79 norethindrone (contraceptive) .................. 79 norethindrone & ethinyl estradiol-fe ........... 79 norethindrone acetate ........................... 87 norethindrone acetate-ethinyl estradiol ....... 82 norgest/ethi tab 0.25/35 ......................... 79 norgestimate-ethinyl estradiol (triphasic) ..... 79 NORITATE ...................................... 122 norlyroc 28 day ................................... 79 NORMOSOL-M IN D5W ...................... 106 NORMOSOL-R................................. 106 NORPACE CR ................................... 40 nortrel 0.5/35 28 day ............................ 79 nortrel 1/35 21 day............................... 79 nortrel 1/35 28 day............................... 79 nortrel 7/7/7 28 day .............................. 79 nortriptyline hcl ................................... 54 142  

NORVIR ........................................... 21 NOVAREL INJ 10000UNT ..................... 85 NOVOLIN 70/30 ................................. 70 NOVOLIN 70/30 RELION ...................... 70 NOVOLIN N ...................................... 70 NOVOLIN N RELION ........................... 70 NOVOLIN R ...................................... 70 NOVOLIN R RELION ........................... 70 NOVOLOG ........................................ 70 NOVOLOG FLEXPEN .......................... 70 NOVOLOG MIX 70/30 .......................... 70 NOVOLOG MIX 70/30 PREFILL .............. 70 NOVOLOG PENFILL ............................ 70 NOXAFIL .......................................... 20 NUCALA ........................................ 113 NUCYNTA .................................. 14, 15 NUCYNTA ER .................................... 15 NUEDEXTA....................................... 64 NULOJIX ........................................ 100 NULYTELY/FLAVOR PACKS ................. 91 NUPLAZID ........................................ 57 NUTRILIPID INJ 20% ......................... 104 NUTROPIN AQ INJ 20MG/2ML ............... 85 NUTROPIN AQ NUSPIN 10 ................... 85 NUTROPIN AQ NUSPIN 20 ................... 85 NUTROPIN AQ NUSPIN 5 ..................... 85 NUTROPIN AQ PEN ............................ 85 NUVARING ....................................... 79 NUVESSA ........................................ 95 NUVIGIL........................................... 66 nyamyc .......................................... 118 NYMALIZE ........................................ 44 nystatin ............................................ 20 nystatin (mouth-throat) ........................ 123 nystatin (topical) ............................... 118 nystatin pow 100000 .......................... 118 nystop ........................................... 118 O   OCELLA TAB 3-0.03MG........................ 79 OCTAGAM ........................................ 99 octreotide acetate .......................... 85, 86 ODEFSEY ........................................ 22 ODOMZO ......................................... 36 OFEV ............................................ 114 ofloxacin (ophth) ............................... 108

ofloxacin (otic) .................................. 124 ogestrel 28 day ................................... 79 olanzapine ........................................ 57 olanzapine odt .................................... 57 olopatadine hcl ................................. 109 olopatadine hcl (nasal) ........................ 112 OMECLAMOX-PAK ............................. 92 omega-3-acid ethyl esters ...................... 41 omeprazole ....................................... 93 OMEPRAZOLE-SODIUM BICARBONATE .. 93 OMNARIS ....................................... 114 OMNITROPE 10MG ............................. 85 OMNITROPE 5.8MG ............................ 85 OMNITROPE 5MG .............................. 85 ondansetron hcl .................................. 88 ondansetron hcl inj .............................. 88 ondansetron hcl oral soln ....................... 88 ondansetron odt .................................. 88 ONEXTON ...................................... 116 ONFI ............................................... 51 ONGLYZA ........................................ 73 ONMEL ............................................ 20 ONZETRA XSAIL ................................ 63 OPANA ER (CRUSH RESISTANT ............ 15 OPSUMIT ......................................... 47 ORACEA ........................................ 122 ORAVIG ......................................... 123 ORENCIA ......................................... 98 ORENCIA CLICKJECT ......................... 98 ORENITRAM TAB 0.125MG ................... 47 ORENITRAM TAB 0.25MG .................... 47 ORENITRAM TAB 1MG ........................ 47 ORENITRAM TAB 2.5MG ...................... 47 ORFADIN ......................................... 81 ORKAMBI ....................................... 114 orsythia 28 day ................................... 79 ORTHO TRI-CYCLEN LO ...................... 79 OSENI TAB 12.5-15MG ........................ 73 OSENI TAB 12.5-30MG ........................ 73 OSENI TAB 12.5-45MG ........................ 73 OSENI TAB 25-15MG ........................... 73 OSENI TAB 25-30MG ........................... 73 OSENI TAB 25-45MG ........................... 73 OSMOPREP ...................................... 91 OTEZLA ........................................... 98 143  

OTOVEL ........................................ 124 oxacillin sodium .................................. 28 oxaliplatin ......................................... 36 oxandrolone ...................................... 68 oxaprozin........................................... 9 oxcarbazepine .................................... 51 oxiconazole nitrate cream .................... 118 OXISTAT ........................................ 118 OXTELLAR XR................................... 51 oxybutynin chloride .............................. 94 oxycodone hcl .................................... 15 oxycodone w/ acetaminophen 10-325mg .... 15 oxycodone w/ acetaminophen 2.5-325mg ... 15 oxycodone w/ acetaminophen 5-325mg...... 15 oxycodone w/ acetaminophen 7.5-325mg ... 15 oxycodone w/ acetaminophen soln 5-325 mg/5ml ............................................ 15 oxycodone-aspirin ............................... 15 oxycodone-ibuprofen ............................ 15 OXYCONTIN ..................................... 15 oxymorphone hcl................................. 15 OXYTROL ........................................ 94 P   pacerone .......................................... 40 paclitaxel .......................................... 31 paliperidone....................................... 58 pamidronate disodium .......................... 75 PANCREAZE ..................................... 92 PANDEL......................................... 121 PANRETIN ...................................... 122 pantoprazole sodium ............................ 93 paricalcitol....................................... 107 paroex sol 0.12% .............................. 123 paromomycin sulfate ............................ 17 paroxetine er tab ................................. 54 paroxetine hcl tabs .............................. 54 paser d/r ........................................... 23 PATADAY ....................................... 110 PATANOL ....................................... 110 PAXIL .............................................. 54 PAZEO .......................................... 110 PCE ................................................ 27 PEDIARIX ....................................... 101 PEDVAX HIB ................................... 101 PEG 3350-KCL-SOD BICARB-SOD

CHLORIDE-SOD SULFATE ................... 91 peg 3350-potassium chloride-sod bicarbonatesod chloride ....................................... 91 PEGANONE ...................................... 51 PEGASYS ........................................ 24 PEGASYS PROCLICK.......................... 24 PEGINTRON ..................................... 24 PEG-INTRON REDIPEN ....................... 24 PENICILLIN G POT IN DEXTROSE .......... 28 PENICILLIN G POTASSIUM IN ............... 28 penicillin g procaine ............................. 28 penicillin g sodium ............................... 28 penicillin gk inj 20mu ............................ 28 penicillin gk inj 5mu .............................. 28 penicillin v potassium............................ 28 PENNSAID SOL 2% .......................... 122 PENTACEL ..................................... 101 PENTAM 300 ..................................... 19 PENTASA ......................................... 90 pentoxifylline ...................................... 97 PERFOROMIST ............................... 112 perindopril erbumine ............................ 38 periogard soln 0.12%.......................... 123 PERJETA ......................................... 32 permethrin ...................................... 123 perphenazine ..................................... 58 PERTZYE ......................................... 92 PEXEVA .......................................... 54 pfizerpen-g inj 20mu ............................. 28 pfizerpen-g inj 5mu .............................. 28 phenadoz ......................................... 88 phenelzine sulfate ............................... 54 phenergan ........................................ 88 phenobarbital ..................................... 51 PHENOBARBITAL SODIUM ................... 51 phenoxybenzamine hcl ......................... 46 phenytek .......................................... 51 phenytoin.......................................... 51 phenytoin inj 50mg/ml ........................... 51 phenytoin sodium extended .................... 51 philith .............................................. 79 PHOSLYRA....................................... 86 PHOSPHOLINE IODIDE ..................... 110 PICATO ......................................... 122 PILOCARPINE HCL ........................... 110 144  

PILOCARPINE HCL (ORAL) ................. 123 pimozide .......................................... 58 pimtrea pack ...................................... 79 pindolol ............................................ 42 pioglitazone hcl................................... 73 pioglitazone hcl-glimepiride .................... 74 pioglitazone hcl-metformin hcl ................. 74 piperacillin sodium-tazobactam sodium ...... 28 pirmella 1/35 28 day ............................. 79 piroxicam ........................................... 9 PLASMA-LYTE A .............................. 106 PLASMA-LYTE-148 ........................... 106 PLASMA-LYTE-56/D5W ...................... 106 plenamine ....................................... 104 podofilox ........................................ 122 polyethylene glycol 3350 ....................... 91 polymyxin b sulfate .............................. 19 polymyxin b-trimethoprim ..................... 108 POMALYST....................................... 36 portia 28 day ...................................... 79 pot chloride inj 2meq/ml ...................... 106 POTASSIUM CHLORIDE ............. 103, 106 POTASSIUM CHLORIDE 0.3%/D........... 106 potassium chloride caps er ................... 103 potassium chloride in nacl .................... 106 potassium chloride microencapsulated crystals cr ................................................. 103 POTASSIUM CHLORIDE TAB CR 10 MEQ .................................................... 103 potassium citrate (alkalinizer) .................. 94 POTIGA ........................................... 51 PRADAXA ........................................ 96 PRALUENT ....................................... 41 pramipexole dihydrochloride ................... 55 PRANDIMET ..................................... 74 pravastatin sodium .............................. 41 prazosin hcl ....................................... 38 PRED MILD..................................... 109 pred sod pho sol 5mg/5ml ...................... 83 PRED-G ......................................... 107 PRED-G S.O.P. ................................ 107 PREDNICARBATE ............................ 121 PREDNISOLONE ACETATE (OPHTH) .... 109 prednisolone sodium phosphate............... 83 prednisolone sodium phosphate (ophth) ... 109

prednisolone sol 15mg/5ml ..................... 83 prednisolone sol 25mg/5ml ..................... 83 prednisolone syrup 15 mg/5ml ................. 83 prednisone con 5mg/ml ......................... 83 prednisone pak 10mg ........................... 83 prednisone pak 5mg ............................. 83 prednisone sol 5mg/5ml ........................ 83 prednisone tab 10mg ............................ 84 prednisone tab 1mg ............................. 83 prednisone tab 2.5mg ........................... 84 prednisone tab 20mg ............................ 84 prednisone tab 50mg ............................ 84 prednisone tab 5mg ............................. 84 PREGNYL W/DILUENT BENZYL ............. 86 PREMARIN CREAM ............................ 82 PREMARIN INJ .................................. 82 premasol 10% .................................. 104 premasol 6% ................................... 104 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) ..................................... 107 PREPOPIK ....................................... 91 PREVACID SOLUTAB .......................... 93 prevalite ........................................... 41 previfem 28 day .................................. 79 PREZCOBIX ...................................... 22 PREZISTA ........................................ 21 PRIFTIN ........................................... 23 PRILOSEC PACK ............................... 93 PRIMAQUINE PHOSPHATE .................. 20 primidone ......................................... 51 PRIMSOL ......................................... 19 PRISTIQ........................................... 54 PRIVIGEN ........................................ 99 PROAIR HFA ................................... 113 PROAIR RESPICLICK ........................ 113 probenecid ......................................... 8 PROCALAMINE ............................... 104 prochlorperazine inj 5 mg/ml ................... 88 prochlorperazine maleate ...................... 88 prochlorperazine supp .......................... 88 PROCRIT ......................................... 97 procto-med ...................................... 118 procto-pak....................................... 118 proctosol hc 2.5 % ............................. 118 proctozone hc .................................. 118 145  

PROCYSBI ....................................... 81 progesterone micronized ....................... 87 PROGLYCEM SUS 50MG/ML ................. 84 PROGRAF ...................................... 100 PROLASTIN-C ................................. 114 PROLENSA..................................... 111 PROLEUKIN ...................................... 32 PROLIA ........................................... 86 PROMACTA ...................................... 97 promethazine hcl................................. 88 promethegan ..................................... 88 propafenone hcl .................................. 40 propafenone hcl 12hr............................ 40 proparacaine hcl ............................... 111 propranolol & hydrochlorothiazide............. 42 propranolol hcl er ................................ 42 propranolol inj 1mg/ml .......................... 43 propranolol sol ................................... 43 propranolol tab ................................... 43 propylthiouracil ................................... 87 PROQUAD ...................................... 102 PROSOL ........................................ 105 PROTONIX ....................................... 93 protriptyline hcl ................................... 54 PROVENTIL HFA .............................. 113 PRUDOXIN CRE 5% .......................... 118 PULMICORT FLEXHALER................... 115 PULMICORT INH SUSP 1MG/2ML ......... 115 PULMOZYME .................................. 114 PURIXAN ......................................... 31 PYLERA ........................................... 92 pyrazinamide ..................................... 23 pyridostigmine bromide ......................... 64 Q   QBRELIS .......................................... 38 QNASL .......................................... 114 QNASL CHILDRENS.......................... 114 QUADRACEL .................................. 102 QUARTETTE ..................................... 79 quasense 91 day................................. 79 quetiapine fumarate ............................. 58 QUILLICHEW ER ................................ 62 QUILLIVANT XR ................................. 62 quinapril hcl ....................................... 38 quinapril-hydrochlorothiazide .................. 37

quinidine gluconate .............................. 40 quinidine sulfate .................................. 40 quinine sulfate .................................... 20 QVAR ............................................ 115 R   RABAVERT ..................................... 102 rabeprazole sodium ............................. 93 RAGWITEK ....................................... 99 raloxifene hcl ..................................... 86 ramipril ............................................ 38 RANEXA .......................................... 46 ranitidine hcl ...................................... 89 ranitidine hcl inj................................... 89 RAPAFLO ......................................... 93 RAPAMUNE .................................... 100 RAVICTI ........................................... 81 RAYOS TAB 1MG ............................... 84 RAYOS TAB 2MG ............................... 84 RAYOS TAB 5MG ............................... 84 REBETOL ......................................... 24 REBIF ............................................. 65 REBIF REBIDOSE .............................. 65 REBIF REBIDOSE TITRATION ............... 65 REBIF TITRATION PACK ...................... 65 reclipsen 28 day ................................. 79 RECOMBIVAX HB ............................. 102 RECTIV ......................................... 122 REGRANEX .................................... 123 RELENZA DISKHALER ........................ 24 RELISTOR ........................................ 91 RELPAX ........................................... 63 REMICADE ....................................... 98 REMODULIN ..................................... 47 RENAGEL ........................................ 86 RENVELA PAK .................................. 86 RENVELA TAB 800MG ......................... 86 repaglinide ........................................ 74 repaglinide-metformin hcl ....................... 74 reprexain tab 10-200mg ........................ 16 RESCRIPTOR ................................... 21 RESTASIS ...................................... 111 RETIN-A MICRO PUMP ...................... 116 RETROVIR IV INFUSION ...................... 21 REVATIO ......................................... 47 REVLIMID......................................... 99 146  

REXULTI .......................................... 58 REYATAZ ......................................... 21 RHEUMATREX .................................. 98 ribapak mis 600/day ............................. 24 ribasphere......................................... 24 ribasphere ribapak 1000 ........................ 24 ribasphere ribapak 1200 ........................ 24 ribasphere ribapak 800 ......................... 24 ribavirin 200mg ................................... 24 rifabutin ............................................ 23 rifamate............................................ 23 rifampin ............................................ 23 RIFATER .......................................... 23 riluzole ............................................. 64 rimantadine hydrochloride ...................... 24 RINGER'S ...................................... 106 RIOMET ........................................... 74 RISEDRONATE SODIUM ...................... 75 RISPERDAL INJ 12.5MG ...................... 58 RISPERDAL INJ 25MG ......................... 58 RISPERDAL INJ 37.5MG ...................... 58 RISPERDAL INJ 50MG ......................... 58 risperidone .................................. 58, 59 risperidone odt ................................... 59 RITALIN LA ....................................... 62 RITUXAN ......................................... 32 rivastigmine tartrate ............................. 53 rizatriptan benzoate ............................. 63 ropinirole hydrochloride ......................... 55 rosadan cre 0.75% ............................ 122 rosuvastatin calcium ............................. 41 ROTARIX ....................................... 102 ROTATEQ ...................................... 102 roweepra .......................................... 51 ROZEREM ........................................ 62 RUCONEST ...................................... 97 RYTARY .......................................... 55 S   SABRIL ............................................ 51 SAIZEN............................................ 85 SAIZEN CLICK.EASY ........................... 85 SAMSCA .......................................... 86 SANCUSO ........................................ 89 SANDIMMUNE SOLN ........................ 100 SANDOSTATIN LAR DEPOT .................. 86

SANTYL ......................................... 123 SAPHRIS ......................................... 59 SARAFEM ........................................ 67 SAVAYSA ......................................... 96 SAVELLA ................................... 64, 65 SAVELLA TITRATION PACK .................. 65 SEEBRI NEOHALER.......................... 111 selegiline hcl ...................................... 55 selenium sulfide ................................ 119 SELZENTRY ..................................... 21 SEMPREX-D ................................... 112 SENSIPAR ........................................ 75 SEREVENT DISKUS .......................... 113 SERNIVO ....................................... 121 SEROQUEL XR .................................. 59 SEROSTIM ....................................... 85 sertraline hcl ...................................... 54 setlakin tab ........................................ 79 SF-ROWASA ..................................... 90 sharobel 28 day .................................. 79 SIGNIFOR ........................................ 86 SIGNIFOR LAR .................................. 86 sildenafil citrate (pulmonary hypertension) ... 47 SILENOR ......................................... 62 SILVER SULFADIAZINE ..................... 117 SIMBRINZA SUS 1-0.2% ..................... 110 SIMPONI .......................................... 98 SIMPONI ARIA ................................... 98 SIMULECT ...................................... 100 simvastatin ........................................ 41 SIROLIMUS .................................... 100 SIRTURO ......................................... 23 SIVEXTRO ........................................ 19 SKLICE .......................................... 123 SMOFLIPID ..................................... 105 SODIUM CHLORIDE................... 103, 106 SODIUM CHLORIDE 0.45% VIA ............ 106 SODIUM CHLORIDE 0.9%................... 123 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN .................................. 103 sodium phenylbutyrate .......................... 81 sodium polystyrene sulfonate .................. 75 SOLODYN ........................................ 29 SOLTAMOX ...................................... 34 SOLU-CORTEF 1000MG ...................... 84 147  

SOLU-CORTEF 100MG ........................ 84 SOLU-CORTEF 250MG ........................ 84 SOLU-CORTEF 500MG ........................ 84 SOLU-MEDROL INJ 2GM ...................... 84 SOMATULINE DEPOT ......................... 86 SOMAVERT ...................................... 86 SOOLANTRA................................... 122 SORILUX ....................................... 119 sorine .............................................. 40 sotalol hcl ......................................... 40 sotalol hcl (afib/afl)............................... 40 SOTYLIZE ........................................ 43 SOVALDI .......................................... 24 SPIRIVA HANDIHALER ...................... 111 SPIRIVA RESPIMAT .......................... 111 spironolactone .................................... 38 spironolactone & hydrochlorothiazide ........ 46 SPORANOX SOL 10MG/ML ................... 20 sprintec 28 day ................................... 80 SPRITAM ......................................... 52 SPRYCEL ......................................... 35 sps ................................................. 75 sronyx 28 day .................................... 80 SSD .............................................. 117 stavudine .......................................... 21 STELARA ....................................... 119 STERILE WATER IRRIGATION............. 123 STIMATE .......................................... 87 STIOLTO RESPIMAT ......................... 111 STIVARGA ........................................ 35 STRATTERA ..................................... 62 streptomycin sulfate ............................. 17 STRIANT .......................................... 68 STRIBILD ......................................... 22 STRIVERDI RESPIMAT ...................... 113 SUBOXONE MIS 12-3MG...................... 67 SUBOXONE MIS 2-0.5MG ..................... 67 SUBOXONE MIS 4-1MG ....................... 67 SUBOXONE MIS 8-2MG ....................... 67 SUBSYS .......................................... 16 SUCLEAR......................................... 91 SUCRAID ......................................... 92 sucralfate.......................................... 92 sulfacet sod oin 10% op ...................... 108 sulfacetamide sodium (acne) ................ 116

sulfacetamide sodium (ophth) ............... 108 sulfacetamide sod-prednisolone ............. 107 sulfadiazine ....................................... 17 sulfamethoxazole-trimethop .................... 19 sulfamethoxazole-trimethoprim inj ............ 19 SULFAMYLON ................................. 117 sulfasalazine dr .................................. 90 sulfasalazine ir ................................... 90 sulindac ............................................ 9 sumatriptan inj 4mg/0.5ml ...................... 63 sumatriptan inj 6mg/0.5ml ...................... 63 SUMATRIPTAN SUCCINATE ........... 63, 64 SUMAVEL DOSEPRO .......................... 64 SUPRAX .......................................... 26 SUPREP BOWEL PREP ....................... 91 SURMONTIL ..................................... 54 SUSTIVA .......................................... 21 SUSTOL........................................... 89 SUTENT........................................... 35 syeda .............................................. 80 SYLATRON KIT 200MCG ...................... 36 SYLATRON KIT 300MCG ...................... 36 SYLATRON KIT 600MCG ...................... 36 SYMBICORT ................................... 115 SYMLINPEN 120 ................................ 70 SYMLINPEN 60 .................................. 70 SYNAGIS ....................................... 102 SYNAREL ......................................... 81 SYNERA ........................................ 121 SYNERCID ....................................... 19 SYNJARDY TAB 12.5-1000.................... 74 SYNJARDY TAB 12.5-500 ..................... 74 SYNJARDY TAB 5-1000MG ................... 74 SYNJARDY TAB 5-500MG..................... 74 SYNRIBO ......................................... 36 SYNTHROID ..................................... 87 SYPRINE ......................................... 75 T   TABLOID .......................................... 31 TACLONEX ..................................... 121 tacrolimus ....................................... 100 tacrolimus (topical) ............................ 122 TAFINLAR ........................................ 35 TAGRISSO ....................................... 35 TAMIFLU .......................................... 24 148  

tamoxifen citrate ................................. 34 tamsulosin hcl .................................... 94 TANZEUM ........................................ 70 TARCEVA......................................... 35 TARGRETIN .................................... 122 tarina fe 1/20 28 day ............................ 80 TASIGNA ......................................... 35 tazicef.............................................. 26 tazicef vial ......................................... 26 TAZORAC ...................................... 119 taztia xt ............................................ 44 TECENTRIQ ...................................... 32 TECFIDERA CAP 120MG ...................... 66 TECFIDERA CAP 240MG ...................... 66 TECFIDERA MIS STARTER ................... 66 TEFLARO ......................................... 26 TEGRETOL ....................................... 52 TEGRETOL-XR .................................. 52 TEKTURNA ....................................... 45 TEKTURNA HCT ................................ 45 telmisartan ........................................ 39 telmisartan-amlodipine .......................... 39 telmisartan-hydrochlorothiazide ............... 39 temazepam ....................................... 62 TENIVAC ........................................ 102 terazosin hcl ...................................... 38 terbinafine hcl .................................... 20 terbutaline sulfate .............................. 113 terconazole vaginal .............................. 95 TESTIM ........................................... 69 TESTOSTERONE ............................... 69 testosterone cypionate .......................... 69 testosterone enanthate ......................... 69 TETANUS/DIPHTHERIA TOXOID .......... 102 tetrabenazine ..................................... 65 TETRACYCLINE HCL .......................... 29 texacort .......................................... 121 THALOMID ....................................... 99 theo-24 .......................................... 115 theophylline ..................................... 115 thioridazine hcl ................................... 59 thiotepa ............................................ 30 thiothixene ........................................ 59 THYMOGLOBULIN ............................ 100 tiagabine hcl ...................................... 52

TIKOSYN ......................................... 40 timolol maleate ................................... 43 timolol maleate (ophth)........................ 110 TIMOLOL MALEATE GEL.................... 110 TIMOPTIC OCUDOSE ........................ 110 TIROSINT ......................................... 87 TIVICAY ........................................... 21 tizanidine .......................................... 66 TOBI PODHALER ............................... 17 TOBRADEX .................................... 107 TOBRADEX ST ................................ 107 tobramycin ........................................ 17 tobramycin (ophth)............................. 108 tobramycin sulfate ............................... 17 tobramycin-dexamethasone.................. 107 TOBREX OINT 0.3% .......................... 108 TOLAK .......................................... 122 tolmetin sodium ................................... 9 tolterodine tartrate er ............................ 94 tolterodine tartrate tab 1 mg .................... 94 tolterodine tartrate tab 2 mg .................... 94 TOPICORT SPRAY 0.25% ................... 121 topiramate......................................... 52 toposar ............................................ 37 topotecan hcl ..................................... 37 TORISEL .......................................... 32 torsemide inj 50mg/5ml ......................... 46 torsemide tabs ................................... 46 TOUJEO SOLOSTAR ........................... 70 TOVIAZ............................................ 94 TPN ELECTROLYTES........................ 103 TRACLEER ....................................... 47 TRADJENTA ..................................... 74 TRAMADOL HCL ................................ 10 tramadol hcl er ................................... 10 tramadol hcl er (biphasic) 100mg ............. 10 tramadol hcl er (biphasic) 200mg ............. 10 tramadol hcl er (biphasic) 300mg ............. 10 tramadol hcl tab 50 mg.......................... 11 tramadol-acetaminophen ....................... 11 trandolapril ........................................ 38 trandolapril-verapamil hcl ....................... 37 tranexamic acid .................................. 97 TRANSDERM-SCOP ........................... 89 tranylcypromine sulfate ......................... 54 149  

TRAVASOL ..................................... 105 TRAVATAN Z .................................. 110 trazodone hcl ..................................... 54 TREANDA ........................................ 30 TRECATOR ...................................... 23 TRELSTAR MIXJECT ........................... 34 TRESIBA FLEXTOUCH ........................ 70 tretinoin .................................... 36, 117 TRETINOIN MICROSPHERE ............... 117 tretin-x ........................................... 116 trexall .............................................. 98 TREXIMET ........................................ 64 trezix ............................................... 11 triamcinolone acetonide (mouth) ............ 123 TRIAMCINOLONE ACETONIDE (NASAL) 114 triamcinolone acetonide (topical) ............ 121 triamt/hctz cap 37.5-25.......................... 46 triamt/hctz cap 50-25mg ........................ 46 triamt/hctz tab 37.5-25 .......................... 46 triamt/hctz tab 75-50mg ......................... 46 trianex ........................................... 121 TRIBENZOR ...................................... 39 triderm ........................................... 121 trifluoperazine hcl ................................ 59 trifluridine ........................................ 108 TRIGLIDE ......................................... 41 tri-legest 28 day .................................. 80 tri-linyah tab....................................... 80 tri-lo- estarylla 28 day ........................... 80 tri-lo- tab marzia .................................. 80 tri-lo-sprintec 28 day ............................. 80 trilyte ............................................... 91 trimethoprim ...................................... 19 trimipramine maleate ............................ 54 TRINESSA ........................................ 80 TRINESSA LO TAB ............................. 80 TRINTELLIX ...................................... 54 tri-previfem 28 day ............................... 80 TRISENOX ....................................... 36 tri-sprintec 28 day ................................ 80 TRIUMEQ ......................................... 22 trivora 28 day ..................................... 80 TROKENDI XR ................................... 52 TROPHAMINE INJ 10% ...................... 105 trospium chloride................................. 94

trospium chloride er ............................. 94 TRULICITY ....................................... 70 TRUMENBA .................................... 102 TRUVADA TAB 100-150 ....................... 22 TRUVADA TAB 133-200 ....................... 22 TRUVADA TAB 167-250 ....................... 22 TRUVADA TAB 200-300 ....................... 22 TUDORZA PRESSAIR........................ 111 TUDORZA PRESSAIR (INSTITUTIONAL PACK) ........................................... 111 TWINRIX INJ ................................... 102 TYBOST........................................... 22 TYGACIL .......................................... 19 TYKERB........................................... 35 TYPHIM VI ...................................... 102 TYSABRI .......................................... 66 TYVASO .......................................... 47 TYZEKA ........................................... 24 tyzine ............................................ 114 U   UCERIS ........................................... 90 ULORIC ............................................ 8 ULTRAVATE ................................... 121 ULTRESA ......................................... 92 UNITHROID ...................................... 87 UPTRAVI .......................................... 47 ursodiol ............................................ 92 UTIBRON NEOHALER ....................... 111 UVADEX .......................................... 36 V   VAGIFEM ......................................... 82 valacyclovir hcl ................................... 24 VALCHLOR ..................................... 122 VALCYTE ......................................... 24 valganciclovir hcl ................................. 24 valproate sodium................................. 52 valproic acid ...................................... 52 valsartan .......................................... 39 valsartan-hydrochlorothiazide .................. 39 vancomycin hcl ................................... 19 VANCOMYCIN IN NACL ....................... 19 VANDAZOLE ..................................... 95 VAQTA .......................................... 102 VARIVAX ........................................ 102 VARUBI ........................................... 89 150  

VASCEPA......................................... 41 VECTIBIX ......................................... 32 VELCADE ......................................... 32 velivet 28 day ..................................... 80 VELPHORO ...................................... 86 VELTASSA ....................................... 75 VELTIN .......................................... 117 VENCLEXTA ..................................... 32 VENCLEXTA STARTING PACK .............. 32 venlafaxine cap er ............................... 54 venlafaxine hcl ................................... 55 venlafaxine tab ................................... 55 VENLAFAXINE TAB 225MG ER .............. 55 venlafaxine tab er ................................ 55 VENTAVIS ........................................ 47 VENTOLIN HFA ............................... 113 VERAMYST .................................... 114 verapamil hcl ..................................... 44 veripred............................................ 84 VERSACLOZ ..................................... 59 VESICARE ........................................ 94 vestura ............................................ 80 VEXOL .......................................... 109 VIBERZI ........................................... 92 VIBRAMYCIN .................................... 29 vicodin ............................................. 16 vicodin es ......................................... 16 vicodin hp ......................................... 16 VICTOZA .......................................... 71 VIDEX PEDIATRIC .............................. 22 vienva 28 day..................................... 80 VIGAMOX ....................................... 108 VIIBRYD........................................... 55 VIIBRYD STARTER PACK ..................... 55 VIMIZIM ........................................... 81 VIMOVO............................................ 8 VIMPAT ........................................... 52 vinblastine sulfate ................................ 31 vincasar ........................................... 31 vincristine sulfate ................................ 32 vinorelbine tartrate ............................... 32 VIOKACE 10 ..................................... 92 VIOKACE 20 ..................................... 92 viorele ............................................. 80 VIRACEPT ........................................ 22

VIRAMUNE XR .................................. 22 VIREAD ........................................... 22 VITEKTA .......................................... 22 VIVITROL ......................................... 67 VIVLODEX ......................................... 9 VOGELXO ........................................ 69 VOGELXO PUMP ............................... 69 VOLTAREN GEL 1% .......................... 122 voriconazole ...................................... 20 voriconazole inj 200mg ......................... 20 VOTRIENT ........................................ 35 VPRIV ............................................. 81 VRAYLAR ......................................... 59 vyfemla 28 day ................................... 80 VYTORIN ......................................... 42 VYVANSE......................................... 62 W   warfarin sodium .................................. 96 WELCHOL ........................................ 42 wymzya fe......................................... 80 X   XALKORI .......................................... 35 XARELTO ......................................... 96 XARELTO STARTER PACK ................... 96 XARTEMIS XR ................................... 16 XELJANZ ......................................... 98 XELJANZ XR ..................................... 98 XEOMIN 100UNIT ............................... 66 XEOMIN 200UNIT ............................... 66 XEOMIN 50UNIT ................................ 66 XERESE ........................................ 122 XGEVA ............................................ 86 XIFAXAN TAB 200MG .......................... 19 XIFAXAN TAB 550MG .......................... 92 XIGDUO XR TAB 10-1000MG ................. 74 XIGDUO XR TAB 10-500MG .................. 74 XIGDUO XR TAB 5-1000MG .................. 74 XIGDUO XR TAB 5-500MG .................... 74 XOLAIR ......................................... 114 XOPENEX HFA ................................ 113 XTAMPZA ER .................................... 16 XTANDI ........................................... 34 xulane dis 150-35 ................................ 80 xylon tab 10-200mg ............................. 16 XYREM ............................................ 66 151  

Y   YERVOY .......................................... 32 YF-VAX.......................................... 102 Z   zafirlukast ....................................... 113 zamicet ............................................ 16 ZANOSAR ........................................ 30 zarah ............................................... 80 ZAVESCA ......................................... 81 ZAZOLE CRE 0.8% ............................. 95 ZEGERID ......................................... 93 ZELAPAR ......................................... 55 ZELBORAF ....................................... 35 ZEMAIRA ....................................... 114 ZEMBRACE SYMTOUCH ...................... 64 ZEMPLAR....................................... 107 zenatane ........................................ 117 zenchent fe 28 day .............................. 80 zenchent tab ...................................... 80 ZENPEP........................................... 92 ZERBAXA ......................................... 26 ZETIA TAB 10MG ............................... 42 ZETONNA ...................................... 114 ZIAGEN ........................................... 22 ZIANA ........................................... 117 zidovudine ........................................ 22 ZINACEF .......................................... 26 ZIOPTAN ........................................ 111 ziprasidone hcl ................................... 59 ZIPSOR ............................................ 9 ZIRGAN ......................................... 108 ZMAX .............................................. 27 ZOHYDRO ER (ABUSE DETERRENT) ...... 16 zoledronic inj 4mg/5ml .......................... 75 zoledronic inj 5/100ml ........................... 75

ZOLINZA .......................................... 32 zolmitriptan ....................................... 64 zolmitriptan odt ................................... 64 zolpidem tartrate ................................. 62 ZOMACTON ...................................... 85 ZOMETA .......................................... 75 ZOMIG NASAL SPRAY ......................... 64 zonisamide ........................................ 52 ZONTIVITY ....................................... 97 ZORBTIVE ........................................ 85 ZORTRESS TAB 0.25MG .................... 100 ZORTRESS TAB 0.5MG ..................... 100 ZORTRESS TAB 0.75MG .................... 100 ZORVOLEX........................................ 9 ZOSTAVAX ..................................... 102 ZOSYN ............................................ 29 zovia 1/35e 28 day .............................. 80 zovia 1/50e 28 day .............................. 80 ZOVIRAX ....................................... 122 ZUBSOLV SUB 1.4-0.36MG ................... 68 ZUBSOLV SUB 11.4-2.9MG ................... 68 ZUBSOLV SUB 2.9-0.71MG ................... 68 ZUBSOLV SUB 5.7-1.4MG..................... 68 ZUBSOLV SUB 8.6-2.1MG..................... 68 ZUPLENZ ......................................... 89 ZURAMPIC ........................................ 8 ZYCLARA ....................................... 122 ZYDELIG .......................................... 35 ZYFLO CR ...................................... 113 ZYKADIA .......................................... 35 ZYLET ........................................... 107 ZYPREXA RELPREVV ......................... 60 ZYPREXA RELPREVV INJ 210MG........... 60 ZYTIGA............................................ 34 ZYVOX ............................................ 19

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. 152  

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

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