Idea Transcript
Medicare Plus Blue PPO SM
® every card. Confidence comes with
Essential, Vitality, Signature & Assure
2017 Plus Comprehensive Formulary List of covered drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This formulary was updated on December 1, 2017. For more recent information or other questions, please contact us, Medicare Plus Blue PPO Customer Service, at 1‑877‑241‑2583, Monday through Friday, 8 a.m. to 9 p.m. Eastern time. From October 1 through February 14, hours are from 8 a.m. to 9 p.m., Eastern time, seven days a week. TTY users should call 711 or visit www.bcbsm.com/medicare. The formulary may change at any time. You will receive notice when necessary
Medicare Plus Blue is a PPO plan with a Medicare contract. Enrollment in Medicare Plus Blue depends on contract renewal. bcbsm.com/medicare
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us,” or “our,” it means Blue Cross Blue Shield. When it refers to “plan” or “our plan,” it means Medicare Plus Blue PPO. This document includes a list of the drugs (formulary) for our plan which is current as of December 1, 2017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2018, and from time to time during the year.
What is the Medicare Plus Blue PPO Essential, Vitality, Signature & Assure Plus Formulary?
How do I use the Formulary?
A formulary is a list of covered drugs selected by Medicare Plus Blue PPO in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Medicare Plus Blue PPO will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Medicare Plus Blue PPO network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular, Hypertension, Cholesterol.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.
Can the Formulary (drug list) change?
Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page Index 1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand‑name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost‑sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60‑day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of December 1, 2017. To get updated information about the drugs covered by Medicare Plus Blue PPO, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid‑year non‑maintenance formulary change, we will send out an errata sheet to notify you of this change.
There are two ways to find your drug within the formulary:
What are generic drugs? Medicare Plus Blue PPO cover both brand‑name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand‑name drug. Generally, generic drugs cost less than brand‑name drugs.
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Are there any restrictions on my coverage?
What if my drug is not on the Formulary?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
If your drug is not included in this formulary (list of drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Medicare Plus Blue PPO does not cover your drug, you have two options:
• Prior Authorization: Medicare Plus Blue PPO requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Medicare Plus Blue PPO before you fill your prescriptions. If you don’t get approval, Medicare Plus Blue PPO may not cover the drug. • Quantity Limits: For certain drugs, Medicare Plus Blue PPO limits the amount of the drug that Medicare Plus Blue PPO will cover. For example, Medicare Plus Blue PPO provides thirty‑one tablets per prescription for Simvastatin. This may be in addition to a standard one‑month or three‑month supply. • Step Therapy: In some cases, Medicare Plus Blue PPO requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Medicare Plus Blue PPO may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Medicare Plus Blue PPO will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Medicare Plus Blue PPO to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Medicare Plus Blue PPO formulary?” on page ii for information about how to request an exception.
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• You can ask Customer Service for a list of similar drugs that are covered by Medicare Plus Blue PPO. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Medicare Plus Blue PPO. • You can ask Medicare Plus Blue PPO to make an exception and cover your drug. See below for information about how to request an exception.
How do I request an exception to the
Medicare Plus Blue PPO Essential, Vitality,
Signature & Assure Plus Formulary?
You can ask Medicare Plus Blue PPO to make an
exception to our coverage rules. There are several types of exceptions that you can ask us to make. • You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will be covered at a pre‑determined cost‑sharing level, and you would not be able to ask us to provide the drug at a lower cost‑sharing level. • For Medicare Plus Blue PPO Signature and Assure only: You can ask us to cover a formulary drug at a lower cost‑sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Medicare Plus Blue PPO limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Medicare Plus Blue PPO will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost‑sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31‑day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31‑day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long‑term care facility, we will allow you to refill your prescription until we have provided you with a 93‑day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31‑day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
If you move into (or out of) a long‑term care facility, you will continue to have access to your medications during the transition. If needed, limits on early prescription refills will be waived to assure that your medications are available through a new pharmacy provider when you are moving to or from a long‑term care facility. Contact Customer Service if you require assistance in your transition. For more detailed information about our Transition Policy, refer to your Evidence of Coverage or visit our website at www.bcbsm.com/medicare/help/ forms‑documents.html.
For more information For more detailed information about your Medicare Plus Blue PPO prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Medicare Plus Blue PPO, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1‑800‑MEDICARE (1‑800‑633‑4227) 24 hours a day, 7 days a week. TTY users should call 1‑877‑486‑2048. Or, visit www.medicare.gov.
Medicare Plus Blue PPO Essential, Vitality, Signature & Assure Plus Formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by Medicare Plus Blue PPO. If you have trouble finding your drug in the list, turn to the Index that begins on page Index 1. The first column of the chart lists the drug name. Brand‑name drugs are capitalized (e.g., VYTORIN) and generic drugs are listed in lower‑case italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if Medicare Plus Blue PPO have any special requirements for coverage of your drug.
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Tier Descriptions
Medicare Plus Blue PPO Drug Tier Costs Up to a 31‑day supply
Tier
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Drug Description
At long term care, preferred retail cost‑ sharing (in‑network), and standard retail cost‑ sharing (in‑network) pharmacies
Preferred Generic Generic Preferred Brand‑Name Non‑Preferred Drugs Specialty
At out‑of‑ network pharmacies*
At the plan’s mail order service
Up to a 90‑day supply**
At preferred retail cost‑ sharing (in‑network) pharmacies or the plan’s mail order service
At standard retail cost sharing (in‑network) pharmacies
See your Evidence of Coverage Chart for member cost‑share details
See your Evidence of Coverage Chart for member cost‑share details
90‑day supply is not available
*Out‑of‑network pharmacy coverage is limited to certain situations. Consult your Evidence of Coverage for details. **Most pharmacies will fill a 90‑day supply of medication. Check with your pharmacist.
Drug Notes Code Definitions Symbol Definition B/D This prescription drug may be covered under Medicare Part B or D depending on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. EX This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count toward your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. LA Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, call Medicare Plus Blue PPO Customer Service at 1‑877‑241‑2583, Monday through Friday, 8 a.m. to 9 p.m. Eastern time. From October 1 through February 14, hours are from 8 a.m. to 9 p.m., Eastern time, seven days a week. TTY users should call 711. PA Prior Authorization. The plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, we may not cover the drug. QL Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. NEDS Non‑Extended Day Supply. These drugs are not offered at a 90‑day supply. They are offered up to a 31‑day supply. iv
Drug Name
Drug Tier
Requirements /Limits
ANTI-INFECTIVES AMINOGLYCOSIDES
Drug Name
Drug Requirements Tier /Limits
GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML
4
STREPTOMYCIN INTRAMUSCULA R RECON SOLN
4
TOBI PODHALER INHALATION CAPSULE
4
TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE
5
NEDS
tobramycin in 0.225 % nacl inhalation solution for nebulization
5
B/D PA; NEDS
tobramycin sulfate injection recon soln
2
tobramycin sulfate injection solution
2
amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml
2
BETHKIS INHALATION SOLUTION FOR NEBULIZATION
5
gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml
2
GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML
4
gentamicin injection solution
2
gentamicin sulfate (ped) (pf) injection solution
2
ABELCET INTRAVENOUS SUSPENSION
5
B/D PA; NEDS
gentamicin sulfate (pf) intravenous solution 100 mg/10 ml
2
AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTIO N
5
B/D PA; NEDS
amphotericin b injection recon soln
2
B/D PA
B/D PA; NEDS
ANTIFUNGALS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 1
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
CANCIDAS INTRAVENOUS RECON SOLN
4
B/D PA
griseofulvin ultramicrosize oral tablet
2
CASPOFUNGIN INTRAVENOUS RECON SOLN
4
B/D PA
itraconazole oral capsule
4 2
clotrimazole mucous membrane troche
2
ketoconazole oral tablet
NEDS
4
NOXAFIL INTRAVENOUS SOLUTION
5
ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN
NOXAFIL ORAL SUSPENSION
5
NEDS
fluconazole in dextrose(iso-o) intravenous piggyback
4
NOXAFIL ORAL TABLET,DELAYE D RELEASE (DR/EC)
5
QL (93 per 31 days); NEDS
fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml
2
nystatin oral suspension
2
nystatin oral tablet
2 4
fluconazole oral suspension for reconstitution
2
ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET SPORANOX ORAL SOLUTION
3
fluconazole oral tablet
2
voriconazole intravenous solution
2
flucytosine oral capsule
2
4
griseofulvin microsize oral suspension
2
voriconazole oral suspension for reconstitution voriconazole oral tablet
4
griseofulvin microsize oral tablet
2
ANTIMALARIALS
atovaquoneproguanil oral tablet
2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 2
Drug Name
Drug Tier
chloroquine phosphate oral tablet
2
COARTEM ORAL TABLET
3
DARAPRIM ORAL TABLET
3
hydroxychloroquine oral tablet
1
mefloquine oral tablet
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
ANTIRETROVIRALS abacavir oral solution
2
abacavir oral tablet
4
abacavir-lamivudine oral tablet
5
NEDS
5
NEDS
2
abacavirlamivudinezidovudine oral tablet
NEDS
3
APTIVUS ORAL CAPSULE
5
PRIMAQUINE ORAL TABLET
NEDS
2
APTIVUS ORAL SOLUTION
5
quinine sulfate oral capsule
ATRIPLA ORAL TABLET
5
NEDS
COMPLERA ORAL TABLET
5
NEDS
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
3
DESCOVY ORAL TABLET
5
didanosine oral capsule,delayed release(dr/ec)
2
5
ANTIPARASITICS/ANTHELMINTIC S ALBENZA ORAL TABLET
4
ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N
3
ALINIA ORAL TABLET
3
atovaquone oral suspension
5
BILTRICIDE ORAL TABLET
3
EDURANT ORAL TABLET
3
ivermectin oral tablet
2
EMTRIVA ORAL CAPSULE
3
paromomycin oral capsule
2
EMTRIVA ORAL SOLUTION
4
tinidazole oral tablet
2
EPIVIR HBV ORAL SOLUTION
NEDS
NEDS
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 3
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
EPZICOM ORAL TABLET
5
NEDS
KALETRA ORAL SOLUTION
5
EVOTAZ ORAL TABLET
5
NEDS
4
fosamprenavir oral tablet
5
NEDS
KALETRA ORAL TABLET 100-25 MG
5
FUZEON SUBCUTANEOUS RECON SOLN
5
KALETRA ORAL TABLET 200-50 MG
2
GENVOYA ORAL TABLET
5
lamivudine oral solution
2
INTELENCE ORAL TABLET 100 MG, 200 MG
5
lamivudine oral tablet
2
INTELENCE ORAL TABLET 25 MG
3
lamivudinezidovudine oral tablet
4
INVIRASE ORAL CAPSULE
5
LEXIVA ORAL SUSPENSION
5
NEDS
INVIRASE ORAL TABLET
5
LEXIVA ORAL TABLET
5
NEDS
ISENTRESS HD ORAL TABLET
5
lopinavir-ritonavir oral solution
2
ISENTRESS ORAL POWDER IN PACKET
3
nevirapine oral suspension nevirapine oral tablet
2
ISENTRESS ORAL TABLET
5
NEDS
2
ISENTRESS ORAL TABLET,CHEWAB LE 100 MG
5
NEDS
nevirapine oral tablet extended release 24 hr NORVIR ORAL CAPSULE
3
ISENTRESS ORAL TABLET,CHEWAB LE 25 MG
3
NORVIR ORAL SOLUTION
3
NORVIR ORAL TABLET
3
NEDS
NEDS NEDS
NEDS NEDS NEDS
NEDS
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 4
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
ODEFSEY ORAL TABLET
5
NEDS
stavudine oral capsule
2
PREZCOBIX ORAL TABLET
5
NEDS
STRIBILD ORAL TABLET
5
PREZISTA ORAL SUSPENSION
5
NEDS
SUSTIVA ORAL CAPSULE
3
PREZISTA ORAL TABLET 150 MG, 75 MG
4
SUSTIVA ORAL TABLET
3
5
TIVICAY ORAL TABLET 10 MG
4
PREZISTA ORAL TABLET 600 MG, 800 MG
5
NEDS
RESCRIPTOR ORAL TABLET
3
TIVICAY ORAL TABLET 25 MG, 50 MG
5
NEDS
RESCRIPTOR ORAL TABLET, DISPERSIBLE
3
TRIUMEQ ORAL TABLET TRUVADA ORAL TABLET
5
NEDS
RETROVIR INTRAVENOUS SOLUTION
4
TYBOST ORAL TABLET
3
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG
5
NEDS
VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN
3
REYATAZ ORAL POWDER IN PACKET
5
NEDS
VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN
3
SELZENTRY ORAL SOLUTION
5
NEDS
VIRACEPT ORAL TABLET
5
NEDS
SELZENTRY ORAL TABLET 150 MG, 300 MG, 75 MG
5
NEDS
VIREAD ORAL POWDER
5
NEDS
VIREAD ORAL TABLET
3
SELZENTRY ORAL TABLET 25 MG
4
ZERIT ORAL RECON SOLN
5
NEDS
NEDS
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 5
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
ZIAGEN ORAL SOLUTION
3
rifampin intravenous recon soln
4
zidovudine oral capsule
2
rifampin oral capsule
2
zidovudine oral syrup
2
RIFATER ORAL TABLET
4
zidovudine oral tablet
2
SIRTURO ORAL TABLET
5
TRECATOR ORAL TABLET
4
ANTITUBERCULARS CAPASTAT INJECTION RECON SOLN
4
CYCLOSERINE ORAL CAPSULE
4
dapsone oral tablet
2
ethambutol oral tablet
2
isoniazid injection solution
2
isoniazid oral solution
2
isoniazid oral tablet
2
PASER ORAL GRANULES DR FOR SUSP IN PACKET
4
PRIFTIN ORAL TABLET
Requirements /Limits
PA; NEDS
ANTIVIRALS
acyclovir oral capsule
2
acyclovir oral suspension 200 mg/5 ml
2
acyclovir oral tablet
2
acyclovir sodium intravenous recon soln 500 mg
2
B/D PA
acyclovir sodium intravenous solution
2
B/D PA
acyclovir topical ointment
4
adefovir oral tablet
5 2
4
amantadine hcl oral capsule
2
amantadine hcl oral solution
2
pyrazinamide oral tablet
2
rifabutin oral capsule
4
amantadine hcl oral tablet BARACLUDE ORAL SOLUTION
4
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 6
Drug Name
Drug Tier
Requirements /Limits
cidofovir intravenous solution
2
DAKLINZA ORAL TABLET
5
entecavir oral tablet
5
NEDS
EPCLUSA ORAL TABLET
5
PA; NEDS
famciclovir oral tablet
2
foscarnet intravenous solution
2
ganciclovir sodium intravenous recon soln
Drug Name
Drug Tier
Requirements /Limits
oseltamivir oral capsule 45 mg, 75 mg
2
REBETOL ORAL SOLUTION
3
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE
4
B/D PA
ribasphere oral capsule
4
4
B/D PA
ribasphere oral tablet
4 NEDS
5
PA; NEDS
ribasphere ribapak oral tablets,dose pack
5
HARVONI ORAL TABLET MAVYRET ORAL TABLET
5
PA; NEDS
ribavirin inhalation recon soln
5
NEDS
moderiba dose pack oral tablets,dose pack 200 mg (7)400 mg (7), 600 mg (7)- 400 mg (7)
2
ribavirin oral capsule
4
ribavirin oral tablet 200 mg
4
moderiba dose pack oral tablets,dose pack 400 mg (7)400 mg (7), 600 mg (7)- 600 mg (7)
5
rimantadine oral tablet
2
SOVALDI ORAL TABLET
5
PA; NEDS
2
TAMIFLU ORAL CAPSULE 30 MG
3
moderiba oral tablet
QL (56 per 180 days)
OLYSIO ORAL CAPSULE
5
PA; NEDS
3
QL (28 per 180 days)
oseltamivir oral capsule 30 mg
2
QL (56 per 180 days)
TAMIFLU ORAL CAPSULE 45 MG, 75 MG
PA; NEDS
NEDS
QL (28 per 180 days)
QL (180 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 7
Drug Name
Drug Tier
Requirements /Limits
Drug Name cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml
2
cefadroxil oral tablet
2
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml
2
cefazolin injection recon soln
2
cefazolin intravenous recon soln
2
cefdinir oral capsule
2
cefdinir oral suspension for reconstitution
2
CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK
4
cefepime in dextrose,iso-osm intravenous piggyback
2
cefepime injection recon soln
2
cefixime oral suspension for reconstitution
2
cefotaxime injection recon soln
2
TAMIFLU ORAL SUSPENSION FOR RECONSTITUTIO N
3
QL (360 per 180 days)
TECHNIVIE ORAL TABLET
5
PA; NEDS
valacyclovir oral tablet
2
VALCYTE ORAL RECON SOLN
5
NEDS
valganciclovir oral recon soln
5
NEDS
valganciclovir oral tablet
5
NEDS
VIEKIRA PAK ORAL TABLETS,DOSE PACK
5
PA; NEDS
VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR
5
VIRAZOLE INHALATION RECON SOLN
5
ZEPATIER ORAL TABLET
5
CEPHALOSPORINS cefaclor oral capsule
2
cefaclor oral tablet extended release 12 hr
2
cefadroxil oral capsule
2
PA; NEDS
NEDS
PA; NEDS
Drug Tier
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 8
Drug Name
Drug Tier
CEFOTETAN IN DEXTROSE, ISOOSM INTRAVENOUS PIGGYBACK
4
cefotetan injection recon soln
2
cefotetan intravenous recon soln
Requirements /Limits
Drug Name
Drug Tier
ceftriaxone in dextrose,iso-os intravenous piggyback
2
ceftriaxone injection recon soln 1 gram, 2 gram
2
2
ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg
4
cefoxitin in dextrose, iso-osm intravenous piggyback
2
4
cefoxitin intravenous recon soln
2
CEFTRIAXONE INJECTION RECON SOLN 100 GRAM
2
cefpodoxime oral suspension for reconstitution
2
ceftriaxone intravenous recon soln
2
cefpodoxime oral tablet
2
cefuroxime axetil oral tablet
2
cefprozil oral suspension for reconstitution
2
cefuroxime sodium injection recon soln 750 mg
2
cefprozil oral tablet
2
cefuroxime sodium intravenous recon soln
CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK
4
cephalexin oral capsule 250 mg, 500 mg
1
ceftazidime injection recon soln
2
cephalexin oral suspension for reconstitution
1
ceftibuten oral capsule
2
cephalexin oral tablet
1
ceftibuten oral suspension for reconstitution
2
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 9
Drug Name
Drug Tier
FORTAZ IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK
4
FORTAZ INJECTION RECON SOLN 1 GRAM, 2 GRAM, 6 GRAM
4
FORTAZ INTRAVENOUS RECON SOLN
4
MAXIPIME INTRAVENOUS RECON SOLN
4
SUPRAX ORAL CAPSULE
4
SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 100 MG/5 ML, 500 MG/5 ML
4
SUPRAX ORAL TABLET,CHEWAB LE
4
TAZICEF INJECTION RECON SOLN
4
TAZICEF INTRAVENOUS RECON SOLN TEFLARO INTRAVENOUS RECON SOLN
Requirements /Limits
Drug Name
Drug Tier
ZERBAXA INTRAVENOUS RECON SOLN
4
ZINACEF IN STERILE WATER INTRAVENOUS PIGGYBACK
4
ZINACEF INTRAVENOUS RECON SOLN 1.5 GRAM, 750 MG
4
Requirements /Limits
MACROLIDES
azithromycin intravenous recon soln
2
azithromycin oral packet
2
azithromycin oral suspension for reconstitution
2
azithromycin oral tablet
2
clarithromycin oral suspension for reconstitution
2
clarithromycin oral tablet
2
4
clarithromycin oral tablet extended release 24 hr
2
QL (180 per 90 days)
4
DIFICID ORAL TABLET
5
QL (20 per 10 days); NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 10
Drug Name
Drug Tier
E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTIO N
4
ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTIO N
4
ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTIO N
4
ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg
4
ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG
4
erythrocin (as stearate) oral tablet 250 mg
Requirements /Limits
Drug Name
Drug Tier
erythromycin oral capsule,delayed release(dr/ec)
2
erythromycin oral tablet
2
ZMAX ORAL SUSPENSION,EXT ENDED REL RECON
4
Requirements /Limits
MISCELLANEOUS ANTIINFECTIVES AZACTAM IN DEXTROSE (ISOOSM) INTRAVENOUS PIGGYBACK
4
AZACTAM INJECTION RECON SOLN
4
aztreonam injection recon soln 1 gram
4
aztreonam injection recon soln 2 gram
2
2
2
ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG
4
baciim intramuscular recon soln bacitracin intramuscular recon soln
2
erythromycin ethylsuccinate oral suspension for reconstitution
2
CAYSTON INHALATION SOLUTION FOR NEBULIZATION
5
erythromycin ethylsuccinate oral tablet
2
PA; QL (84 per 28 days); NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 11
Drug Name
Drug Tier
chloramphenicol sod succinate intravenous recon soln
2
clindamycin hcl oral capsule
2
clindamycin in 5 % dextrose intravenous piggyback
Requirements /Limits
Drug Name
Drug Tier
imipenem-cilastatin intravenous recon soln
2
INVANZ INJECTION RECON SOLN
4
2
INVANZ INTRAVENOUS RECON SOLN
4
clindamycin palmitate hcl oral recon soln
4
lincomycin injection solution
2 5
clindamycin pediatric oral recon soln
4
linezolid intravenous parenteral solution
2
clindamycin phosphate injection solution
2
linezolid oral suspension for reconstitution linezolid oral tablet
2
clindamycin phosphate intravenous solution
2
linezolid-0.9% sodium chloride intravenous parenteral solution
5
colistin (colistimethate na) injection recon soln
2
meropenem intravenous recon soln 1 gram
2
CUBICIN INTRAVENOUS RECON SOLN
4
meropenem intravenous recon soln 500 mg
4
CUBICIN RF INTRAVENOUS RECON SOLN
4
2
DALVANCE INTRAVENOUS SOLUTION
5
MEROPENEM0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 1 GRAM/50 ML
daptomycin intravenous recon soln
4
NEDS
Requirements /Limits
NEDS
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 12
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK
4
vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg
2
2
VANCOMYCIN INTRAVENOUS RECON SOLN 750 MG
4
metronidazole oral capsule
2
vancomycin oral capsule
4
metronidazole oral tablet
2
3
NEBUPENT INHALATION RECON SOLN
4
VIBATIV INTRAVENOUS RECON SOLN 750 MG
4
neomycin oral tablet
2
XIFAXAN ORAL TABLET 200 MG
PENTAM INJECTION RECON SOLN
4
XIFAXAN ORAL TABLET 550 MG
4
QL (180 per 90 days)
5
NEDS
polymyxin b sulfate injection recon soln
2
ZYVOX INTRAVENOUS PARENTERAL SOLUTION
SYNERCID INTRAVENOUS RECON SOLN
5
TYGACIL INTRAVENOUS RECON SOLN VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK
MEROPENEM0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 500 MG/50 ML
4
metro i.v. intravenous piggyback
2
metronidazole in nacl (iso-os) intravenous piggyback
B/D PA
NEDS
PENICILLINS 1
4
amoxicillin oral capsule
1
4
amoxicillin oral suspension for reconstitution amoxicillin oral tablet
1
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 13
Drug Name
Drug Tier
amoxicillin oral tablet,chewable 125 mg, 250 mg
1
amoxicillin-pot clavulanate oral suspension for reconstitution
2
amoxicillin-pot clavulanate oral tablet
2
amoxicillin-pot clavulanate oral tablet extended release 12 hr
2
amoxicillin-pot clavulanate oral tablet,chewable
2
ampicillin oral capsule
2
ampicillin sodium injection recon soln
2
ampicillin sodium intravenous recon soln
Requirements /Limits
Drug Name
Drug Tier
dicloxacillin oral capsule
2
nafcillin in dextrose iso-osm intravenous piggyback
2
nafcillin injection recon soln
2
nafcillin intravenous recon soln
2
oxacillin in dextrose(iso-osm) intravenous piggyback
2
oxacillin injection recon soln
2
oxacillin intravenous recon soln
2 4
2
PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK
2
ampicillin-sulbactam injection recon soln
2
penicillin g potassium injection recon soln
2
ampicillin-sulbactam intravenous recon soln 1.5 gram
2
penicillin g procaine intramuscular syringe 1.2 million unit/2 ml
BICILLIN C-R INTRAMUSCULA R SYRINGE
4
4
BICILLIN L-A INTRAMUSCULA R SYRINGE
4
penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium injection recon soln
2
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 14
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
penicillin v potassium oral recon soln
1
ciprofloxacin lactate intravenous solution 400 mg/40 ml
2
penicillin v potassium oral tablet
1
2
pfizerpen-g injection recon soln
2
ciprofloxacin oral suspension,microcap sule recon
2
piperacillintazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram
2
levofloxacin in d5w intravenous piggyback levofloxacin intravenous solution
2
levofloxacin oral solution
2
ZOSYN IN DEXTROSE (ISOOSM) INTRAVENOUS PIGGYBACK
4
levofloxacin oral tablet
2 4
ZOSYN INTRAVENOUS RECON SOLN 2.25 GRAM, 3.375 GRAM
4
moxifloxacin in nacl (iso-osm) intravenous piggyback moxifloxacin oral tablet
2
ofloxacin oral tablet 300 mg, 400 mg
2
QUINOLONES
ciprofloxacin (mixture) oral tablet, er multiphase 24 hr
2
ciprofloxacin hcl oral tablet
2
ciprofloxacin in 5 % dextrose intravenous piggyback ciprofloxacin lactate intravenous solution 200 mg/20 ml
QL (14 per 14 days)
Requirements /Limits
SULFONAMIDES AND COMBINATIONS sulfadiazine oral tablet
2 2
2
sulfamethoxazoletrimethoprim intravenous solution
1
1
sulfamethoxazoletrimethoprim oral suspension
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 15
Drug Name
Drug Tier
sulfamethoxazoletrimethoprim oral tablet
1
sulfatrim oral suspension
1
TETRACYCLINES
Requirements /Limits
Drug Name
Drug Tier
mondoxyne nl oral capsule
2
morgidox oral capsule
2
VIBRAMYCIN ORAL SYRUP
4
Requirements /Limits
ARESTIN DENTAL CARTRIDGE
4
URINARY TRACT AGENTS
4
methenamine hippurate oral tablet
2
demeclocycline oral tablet
2
doxy-100 intravenous recon soln
2
methenamine mandelate oral tablet
2
doxycycline hyclate oral capsule
2
nitrofurantoin macrocrystal oral capsule
doxycycline hyclate oral tablet 100 mg, 20 mg
2
nitrofurantoin monohyd/m-cryst oral capsule
2
doxycycline hyclate oral tablet,delayed release (dr/ec)
2
nitrofurantoin oral suspension
2
2
PRIMSOL ORAL SOLUTION
4
doxycycline monohydrate oral capsule 75 mg
trimethoprim oral tablet
2
doxycycline monohydrate oral suspension for reconstitution
2
MINOCIN INTRAVENOUS RECON SOLN
4
minocycline oral capsule
2
minocycline oral tablet
2
ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS ADJUVANT THERAPY FUSILEV INTRAVENOUS RECON SOLN
5
leucovorin calcium injection recon soln
2
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 16
Drug Name
Drug Tier
leucovorin calcium oral tablet
2
LEUKINE INJECTION RECON SOLN
5
levoleucovorin intravenous recon soln 50 mg
2
levoleucovorin intravenous solution
2
MESNEX ORAL TABLET
4
Requirements /Limits
NEDS
ALKYLATING AGENTS BENDEKA INTRAVENOUS SOLUTION
5
BICNU INTRAVENOUS RECON SOLN
4
busulfan intravenous solution
4
BUSULFEX INTRAVENOUS SOLUTION
4
cyclophosphamide intravenous recon soln
2
CYCLOPHOSPHA MIDE ORAL CAPSULE
4
dacarbazine intravenous recon soln
2
PA; NEDS
B/D PA
B/D PA
Drug Name
Drug Tier
Requirements /Limits
EVOMELA INTRAVENOUS RECON SOLN
5
PA; NEDS
GLEOSTINE ORAL CAPSULE
3
HEXALEN ORAL CAPSULE
5
NEDS
ifosfamide intravenous recon soln 1 gram
2
B/D PA
LEUKERAN ORAL TABLET
3
melphalan hcl intravenous recon soln
2
melphalan oral tablet
4
MUSTARGEN INJECTION RECON SOLN
4
thiotepa injection recon soln
2
TREANDA INTRAVENOUS RECON SOLN 100 MG
5
PA; NEDS
VALCHLOR TOPICAL GEL
5
NEDS
ZANOSAR INTRAVENOUS RECON SOLN
4
B/D PA
ANTIMETABOLITES
adrucil intravenous solution
2
B/D PA
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 17
Drug Name
Drug Tier
Requirements /Limits
ALIMTA INTRAVENOUS RECON SOLN
4
cladribine intravenous solution
2
clofarabine intravenous solution
4
CLOLAR INTRAVENOUS SOLUTION
4
cytarabine (pf) injection solution
2
B/D PA
cytarabine injection solution
2
B/D PA
floxuridine injection recon soln
2
fludarabine intravenous recon soln
2
fludarabine intravenous solution
2
fluorouracil intravenous solution 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml
2
gemcitabine intravenous recon soln
5
gemcitabine intravenous solution
5
LONSURF ORAL TABLET
5
mercaptopurine oral tablet
2
B/D PA
Drug Name
Drug Tier
methotrexate sodium (pf) injection recon soln
2
methotrexate sodium (pf) injection solution
2
methotrexate sodium injection solution
2
methotrexate sodium oral tablet
1
NIPENT INTRAVENOUS RECON SOLN
4
PURIXAN ORAL SUSPENSION
5
TABLOID ORAL TABLET
3
XATMEP ORAL SOLUTION
5
Requirements /Limits
B/D PA
NEDS
B/D PA; NEDS
HORMONAL AGENTS
anastrozole oral tablet
2
bicalutamide oral tablet
2
EMCYT ORAL CAPSULE
3
exemestane oral tablet
2
NEDS
FARESTON ORAL TABLET
3
PA; NEDS
FASLODEX INTRAMUSCULA R SYRINGE
5
B/D PA
NEDS
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 18
Drug Name
Drug Tier
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN
4
flutamide oral capsule
2
letrozole oral tablet
2
leuprolide subcutaneous kit
2
LUPRON DEPOT (3 MONTH) INTRAMUSCULA R SYRINGE KIT 22.5 MG
5
LUPRON DEPOT (4 MONTH) INTRAMUSCULA R SYRINGE KIT
5
LUPRON DEPOT (6 MONTH) INTRAMUSCULA R SYRINGE KIT
5
LUPRON DEPOT INTRAMUSCULA R SYRINGE KIT 7.5 MG
5
LUPRON DEPOTPED INTRAMUSCULA R KIT 11.25 MG, 15 MG
5
megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml), 625 mg/5 ml
4
Requirements /Limits
NEDS
NEDS
NEDS
NEDS
NEDS
Drug Name
Drug Tier
Requirements /Limits
megestrol oral tablet
2
PA
NILANDRON ORAL TABLET
3
nilutamide oral tablet
2
SOLTAMOX ORAL SOLUTION
4
SUPPRELIN LA IMPLANT KIT
5
tamoxifen oral tablet
2
TRELSTAR INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N
5
NEDS
TRELSTAR INTRAMUSCULA R SYRINGE 22.5 MG/2 ML
5
NEDS
VANTAS IMPLANT KIT
4
XTANDI ORAL CAPSULE
5
PA; NEDS
ZOLADEX SUBCUTANEOUS IMPLANT
4
QL (1.2 per 30 days)
ZYTIGA ORAL TABLET
5
PA; NEDS
NEDS
IMMUNOMODULATORS
PA
ARCALYST SUBCUTANEOUS RECON SOLN
5
PA; NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 19
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
B/D PA
GAZYVA INTRAVENOUS SOLUTION
5
PA; NEDS
gengraf oral capsule
2
B/D PA
gengraf oral solution
2
B/D PA
ILARIS (PF) SUBCUTANEOUS RECON SOLN
5
PA; NEDS
ILARIS (PF) SUBCUTANEOUS SOLUTION
5
PA; NEDS
mycophenolate mofetil hcl intravenous recon soln
2
B/D PA
mycophenolate mofetil oral capsule
2
B/D PA
mycophenolate mofetil oral suspension for reconstitution
5
B/D PA; NEDS
ASTAGRAF XL ORAL CAPSULE,EXTEN DED RELEASE 24HR 0.5 MG, 1 MG
4
ASTAGRAF XL ORAL CAPSULE,EXTEN DED RELEASE 24HR 5 MG
5
AZASAN ORAL TABLET
4
azathioprine oral tablet
2
B/D PA
azathioprine sodium injection recon soln
4
B/D PA
CELLCEPT INTRAVENOUS RECON SOLN
4
cyclosporine intravenous solution
2
B/D PA
cyclosporine modified oral capsule
2
B/D PA
mycophenolate mofetil oral tablet
2
B/D PA
4
B/D PA
cyclosporine modified oral solution
2
B/D PA
mycophenolate sodium oral tablet,delayed release (dr/ec)
cyclosporine oral capsule
2
B/D PA
NULOJIX INTRAVENOUS RECON SOLN
5
B/D PA; NEDS
ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR
4
B/D PA
POMALYST ORAL CAPSULE
5
PA; QL (31 per 31 days); NEDS
B/D PA; NEDS
B/D PA
B/D PA
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 20
Drug Name
Drug Tier
Requirements /Limits
Drug Name adriamycin intravenous solution
2
B/D PA
AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION
5
PA; NEDS
AFINITOR ORAL TABLET
5
PA; NEDS
ALECENSA ORAL CAPSULE
5
PA; NEDS
ALUNBRIG ORAL TABLET
5
PA; NEDS
amifostine crystalline intravenous recon soln
5
NEDS
Drug Tier
Requirements /Limits
PROGRAF INTRAVENOUS SOLUTION
4
B/D PA
RAPAMUNE ORAL SOLUTION
4
B/D PA
REVLIMID ORAL CAPSULE
5
PA; LA; NEDS
RITUXAN HYCELA SUBCUTANEOUS SOLUTION
5
RITUXAN INTRAVENOUS CONCENTRATE
5
SANDIMMUNE ORAL SOLUTION
4
B/D PA
SIMULECT INTRAVENOUS RECON SOLN
5
B/D PA; NEDS
ARRANON INTRAVENOUS SOLUTION
4
sirolimus oral tablet
4
B/D PA
3
PA
tacrolimus oral capsule
2
B/D PA
ARZERRA INTRAVENOUS SOLUTION
TECFIDERA ORAL CAPSULE,DELAY ED RELEASE(DR/EC)
5
PA; QL (62 per 31 days); NEDS
AVASTIN INTRAVENOUS SOLUTION
5
NEDS
5
NEDS
THALOMID ORAL CAPSULE
5
azacitidine injection recon soln BAVENCIO INTRAVENOUS SOLUTION
5
PA; NEDS
BELEODAQ INTRAVENOUS RECON SOLN
5
PA; NEDS
bexarotene oral capsule
5
PA; NEDS
PA; NEDS
PA; NEDS
PA; NEDS
MISCELLANEOUS ANTINEOPLASTIC AGENTS ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTIO N
4
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 21
Drug Name
Drug Tier
Requirements /Limits
Drug Name decitabine intravenous recon soln
5
dexrazoxane hcl intravenous recon soln
2
docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)
5
NEDS
DOCETAXEL INTRAVENOUS SOLUTION 20 MG/ML
5
NEDS
doxorubicin intravenous recon soln
2
B/D PA
Drug Tier
Requirements /Limits
bleo 15k injection recon soln
2
B/D PA
bleomycin injection recon soln
2
B/D PA
BLINCYTO INTRAVENOUS KIT
5
BOSULIF ORAL TABLET
5
PA; NEDS
CABOMETYX ORAL TABLET
5
PA; NEDS
CAMPTOSAR INTRAVENOUS SOLUTION 300 MG/15 ML
4
CAPRELSA ORAL TABLET
5
carboplatin intravenous solution
2
cisplatin intravenous solution
2
COMETRIQ ORAL CAPSULE
5
PA; NEDS
doxorubicin intravenous solution
2
B/D PA
COTELLIC ORAL TABLET
5
PA; LA; NEDS
2
B/D PA
CYRAMZA INTRAVENOUS SOLUTION
5
PA; NEDS
doxorubicin, pegliposomal intravenous suspension
4
DARZALEX INTRAVENOUS SOLUTION
5
DROXIA ORAL CAPSULE
4
daunorubicin intravenous solution
2
ELLENCE INTRAVENOUS SOLUTION EMPLICITI INTRAVENOUS RECON SOLN
5
B/D PA; NEDS
NEDS
PA; LA; NEDS
NEDS
PA; NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 22
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
epirubicin intravenous solution
2
IDHIFA ORAL TABLET
5
PA; NEDS
ERBITUX INTRAVENOUS SOLUTION
3
4
B/D PA
ERIVEDGE ORAL CAPSULE
5
IFEX INTRAVENOUS RECON SOLN 3 GRAM
2
B/D PA
ERWINAZE INJECTION RECON SOLN
5
ifosfamide intravenous recon soln 3 gram
2
B/D PA
ETOPOPHOS INTRAVENOUS RECON SOLN
4
ifosfamide intravenous solution imatinib oral tablet
5
NEDS
5
PA; NEDS
etoposide intravenous solution
2
IMBRUVICA ORAL CAPSULE
PA; NEDS
5
PA; NEDS
IMFINZI INTRAVENOUS SOLUTION
5
FARYDAK ORAL CAPSULE GILOTRIF ORAL TABLET
5
PA; QL (31 per 31 days); NEDS
INLYTA ORAL TABLET
5
PA; NEDS
IRESSA ORAL TABLET
5
NEDS
irinotecan intravenous solution
2
ISTODAX INTRAVENOUS RECON SOLN
5
B/D PA; NEDS
5
NEDS
PA; NEDS NEDS
HALAVEN INTRAVENOUS SOLUTION
5
NEDS
HERCEPTIN INTRAVENOUS RECON SOLN
5
hydroxyurea oral capsule
2
IBRANCE ORAL CAPSULE
5
PA; NEDS
IXEMPRA INTRAVENOUS RECON SOLN
PA; NEDS
5
PA; NEDS
JAKAFI ORAL TABLET
5
ICLUSIG ORAL TABLET
5
PA; NEDS
idarubicin intravenous solution
2
JEVTANA INTRAVENOUS SOLUTION
B/D PA; NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 23
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
KADCYLA INTRAVENOUS RECON SOLN
5
B/D PA; NEDS
mitomycin intravenous recon soln 20 mg, 5 mg
4
KEYTRUDA INTRAVENOUS RECON SOLN
5
NEDS
mitomycin intravenous recon soln 40 mg
5
KEYTRUDA INTRAVENOUS SOLUTION
5
NEDS
mitoxantrone intravenous concentrate
2
KISQALI FEMARA CO-PACK ORAL TABLET
5
PA; NEDS
NERLYNX ORAL TABLET
5
PA; NEDS
5
PA; NEDS
KISQALI ORAL TABLET
5
PA; NEDS
NEXAVAR ORAL TABLET
PA; NEDS
5
PA; NEDS
NINLARO ORAL CAPSULE
5
KYPROLIS INTRAVENOUS RECON SOLN
ODOMZO ORAL CAPSULE
5
PA; LA; NEDS
LARTRUVO INTRAVENOUS SOLUTION
5
PA; NEDS
ONCASPAR INJECTION SOLUTION
5
NEDS
LENVIMA ORAL CAPSULE
5
PA; NEDS
5
NEDS
LYNPARZA ORAL CAPSULE
5
PA; NEDS
OPDIVO INTRAVENOUS SOLUTION
NEDS
5
PA; NEDS
oxaliplatin intravenous recon soln
5
LYNPARZA ORAL TABLET LYSODREN ORAL TABLET
3
4
MATULANE ORAL CAPSULE
5
oxaliplatin intravenous solution 100 mg/20 ml
5
MEKINIST ORAL TABLET
5
oxaliplatin intravenous solution 50 mg/10 ml (5 mg/ml)
mesna intravenous solution
2
NEDS PA; NEDS
NEDS
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 24
Drug Name
Drug Tier
paclitaxel intravenous concentrate
2
PERJETA INTRAVENOUS SOLUTION
5
PROLEUKIN INTRAVENOUS RECON SOLN
5
RUBRACA ORAL TABLET
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
toposar intravenous solution
2
topotecan intravenous recon soln
2
2
NEDS
topotecan intravenous solution
5
PA; NEDS
5
PA; NEDS
TORISEL INTRAVENOUS RECON SOLN
PA; NEDS
5
PA; NEDS
SPRYCEL ORAL TABLET
5
PA; NEDS
TREANDA INTRAVENOUS RECON SOLN 25 MG
5
RYDAPT ORAL CAPSULE
5
NEDS
STIVARGA ORAL TABLET
5
NEDS
SUTENT ORAL CAPSULE
5
PA; NEDS
TRELSTAR INTRAMUSCULA R SYRINGE 11.25 MG/2 ML, 3.75 MG/2 ML
NEDS
5
NEDS
tretinoin (chemotherapy) oral capsule
5
SYNRIBO SUBCUTANEOUS RECON SOLN
5
PA; NEDS
TRISENOX INTRAVENOUS SOLUTION
4
TAFINLAR ORAL CAPSULE TAGRISSO ORAL TABLET
5
PA; LA; NEDS
TYKERB ORAL TABLET
5
NEDS
TARCEVA ORAL TABLET
5
PA; NEDS
5
NEDS
TASIGNA ORAL CAPSULE
5
PA; NEDS
VALSTAR INTRAVESICAL SOLUTION
5
NEDS
TECENTRIQ INTRAVENOUS SOLUTION
5
VECTIBIX INTRAVENOUS SOLUTION VELCADE INJECTION RECON SOLN
4
NEDS
PA; NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 25
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
VENCLEXTA ORAL TABLET 10 MG, 50 MG
4
PA
YONDELIS INTRAVENOUS RECON SOLN
5
PA; NEDS
VENCLEXTA ORAL TABLET 100 MG
5
PA; NEDS
ZALTRAP INTRAVENOUS SOLUTION
5
NEDS
VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK
5
PA; NEDS
ZEJULA ORAL CAPSULE
5
PA; NEDS
ZELBORAF ORAL TABLET
5
PA; QL (248 per 31 days); NEDS
vinblastine intravenous solution
2
B/D PA
4
vincasar pfs intravenous solution
2
B/D PA
ZINECARD (AS HCL) INTRAVENOUS RECON SOLN
vincristine intravenous solution
2
B/D PA
ZOLINZA ORAL CAPSULE
5
PA; NEDS
vinorelbine intravenous solution
2
ZORTRESS ORAL TABLET 0.25 MG
3
B/D PA
VOTRIENT ORAL TABLET
5
PA; NEDS
5
B/D PA; NEDS
VYXEOS INTRAVENOUS RECON SOLN
5
NEDS
ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG ZYDELIG ORAL TABLET
5
PA; NEDS
XALKORI ORAL CAPSULE
5
PA; QL (62 per 31 days); NEDS
ZYKADIA ORAL CAPSULE
5
PA; NEDS
XGEVA SUBCUTANEOUS SOLUTION
5
PA; NEDS
CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL
YERVOY INTRAVENOUS SOLUTION
5
PA; NEDS
ACE-INHIBITORS AND COMBINATIONS benazepril oral tablet
1
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 26
Drug Name
Drug Tier
benazeprilhydrochlorothiazide oral tablet
1
captopril oral tablet
1
captoprilhydrochlorothiazide oral tablet
1
enalapril maleate oral tablet
Requirements /Limits
Drug Name trandolapril oral tablet
Drug Tier
Requirements /Limits
1
ALPHA-ADRENERGIC AGENTS
CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR
4
1
clonidine (pf) epidural solution
2
enalaprilat intravenous solution
2
clonidine hcl oral tablet
2
enalaprilhydrochlorothiazide oral tablet
1
clonidine transdermal patch weekly
1
fosinopril oral tablet
1
doxazosin oral tablet
2
fosinoprilhydrochlorothiazide oral tablet
1
prazosin oral capsule
2
1
terazosin oral capsule
2
lisinopril oral tablet lisinoprilhydrochlorothiazide oral tablet
1
moexipril oral tablet
1
moexiprilhydrochlorothiazide oral tablet
QL (90 per 90 days)
QL (12 per 84 days)
ANGIOTENSIN II RECEPTOR BLOCKERS AND COMBINATIONS amlodipinevalsartan oral tablet
1
1
amlodipinevalsartan-hcthiazid oral tablet
1
perindopril erbumine oral tablet
1
BENICAR HCT ORAL TABLET
3
quinapril oral tablet
1
3
quinaprilhydrochlorothiazide oral tablet
1
BENICAR ORAL TABLET candesartan oral tablet
1
ramipril oral capsule
1
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 27
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
candesartanhydrochlorothiazid oral tablet
1
valsartanhydrochlorothiazide oral tablet
EDARBI ORAL TABLET
4
ANTI-COAGULANTS/HEMOSTASIS AGENTS
EDARBYCLOR ORAL TABLET
4
3
eprosartan oral tablet
1
AGGRENOX ORAL CAPSULE, ER MULTIPHASE 12 HR
irbesartan oral tablet
1
AMICAR ORAL TABLET 1,000 MG
4
irbesartanhydrochlorothiazide oral tablet
1
aminocaproic acid intravenous solution
2 2
losartan oral tablet
1
anagrelide oral capsule
losartanhydrochlorothiazide oral tablet
1
aspirin-dipyridamole oral capsule, er multiphase 12 hr
4
olmesartan oral tablet
1
BRILINTA ORAL TABLET
3
olmesartanhydrochlorothiazide oral tablet
1
cilostazol oral tablet
2
clopidogrel oral tablet
2
telmisartan oral tablet
1
COUMADIN ORAL TABLET
4
telmisartanamlodipine oral tablet
1
EFFIENT ORAL TABLET
3
1
ELIQUIS ORAL TABLET
3
telmisartanhydrochlorothiazid oral tablet
4
valsartan oral tablet
1
enoxaparin subcutaneous solution
1
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 28
Drug Name
Drug Tier
enoxaparin subcutaneous syringe
4
eptifibatide intravenous solution
2
fondaparinux subcutaneous syringe
4
FRAGMIN SUBCUTANEOUS SOLUTION
4
FRAGMIN SUBCUTANEOUS SYRINGE
4
heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)
2
heparin (porcine) injection cartridge
2
heparin (porcine) injection solution 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml
2
heparin (porcine) injection syringe 5,000 unit/ml
2
Requirements /Limits
Drug Name
Drug Tier
heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml
2
heparin, porcine (pf) injection solution 5,000 unit/0.5 ml
2
heparin, porcine (pf) injection syringe
2
INTEGRILIN INTRAVENOUS SOLUTION 2 MG/ML
4
IPRIVASK SUBCUTANEOUS RECON SOLN
5
jantoven oral tablet
1
pentoxifylline oral tablet extended release
2
PRADAXA ORAL CAPSULE
3
prasugrel oral tablet
2
warfarin oral tablet
1
XARELTO ORAL TABLET
3
XARELTO ORAL TABLETS,DOSE PACK
3
Requirements /Limits
NEDS
BETA BLOCKERS AND COMBINATIONS acebutolol oral capsule
2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 29
Drug Name
Drug Tier
Requirements /Limits
atenolol oral tablet
1
atenololchlorthalidone oral tablet
1
betaxolol oral tablet
1
bisoprolol fumarate oral tablet
1
bisoprololhydrochlorothiazide oral tablet
1
BYSTOLIC ORAL TABLET 10 MG
4
ST; QL (360 per 90 days)
BYSTOLIC ORAL TABLET 2.5 MG, 5 MG
4
ST; QL (90 per 90 days)
BYSTOLIC ORAL TABLET 20 MG
4
carvedilol oral tablet
1
COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR
4
INNOPRAN XL ORAL CAPSULE,EXTEN DED RELEASE 24HR
4
labetalol intravenous solution
1
labetalol intravenous syringe 20 mg/4 ml (5 mg/ml)
1
labetalol oral tablet
1
ST; QL (180 per 90 days) QL (90 per 90 days)
Drug Name
Drug Tier
metoprolol succinate oral tablet extended release 24 hr
1
metoprolol tahydrochlorothiaz oral tablet
1
metoprolol tartrate intravenous solution
2
metoprolol tartrate intravenous syringe
1
metoprolol tartrate oral tablet
1
nadolol oral tablet
1
nadololbendroflumethiazide oral tablet
1
pindolol oral tablet
1
propranolol intravenous solution
2
propranolol oral capsule,extended release 24 hr
1
propranolol oral solution
2
propranolol oral tablet
1
propranololhydrochlorothiazid oral tablet
1
sotalol af oral tablet 160 mg, 80 mg
2
SOTALOL INTRAVENOUS SOLUTION
4
Requirements /Limits QL (180 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 30
Drug Name
Drug Tier
sotalol oral tablet 120 mg
2
timolol maleate oral tablet
1
Requirements /Limits
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS afeditab cr oral tablet extended release
1
amlodipine oral tablet
1
amlodipineatorvastatin oral tablet
1
amlodipinebenazepril oral capsule
1
amlodipineolmesartan oral tablet
1
AZOR ORAL TABLET
4
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG
4
cartia xt oral capsule,extended release 24hr
1
CLEVIPREX INTRAVENOUS EMULSION
4
QL (90 per 90 days)
QL (90 per 90 days)
QL (90 per 90 days) QL (90 per 90 days)
Drug Name
Drug Tier
diltiazem hcl intravenous recon soln
2
diltiazem hcl intravenous solution
2
diltiazem hcl oral capsule,ext.rel 24h degradable
1
diltiazem hcl oral capsule,extended release 12 hr
1
diltiazem hcl oral capsule,extended release 24 hr
1
diltiazem hcl oral capsule,extended release 24hr
1
diltiazem hcl oral tablet
1
diltiazem hcl oral tablet extended release 24 hr
1
dilt-xr oral capsule,ext.rel 24h degradable
1
felodipine oral tablet extended release 24 hr
1
isradipine oral capsule
2
matzim la oral tablet extended release 24 hr
1
nicardipine intravenous solution
2
Requirements /Limits
QL (90 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 31
Drug Name
Drug Tier
Requirements /Limits
nicardipine oral capsule
1
nifedipine oral tablet extended release
1
QL (90 per 90 days)
nifedipine oral tablet extended release 24hr
1
QL (90 per 90 days)
nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 25.5 mg, 34 mg, 40 mg, 8.5 mg
4
nisoldipine oral tablet extended release 24 hr 30 mg
4
taztia xt oral capsule,extended release 24 hr
1
trandolaprilverapamil oral tablet, ir - er, biphasic 24hr
1
verapamil intravenous solution
Drug Name
Drug Tier
Requirements /Limits
CARBONIC ANHYDRASE INHIBITORS
QL (90 per 90 days)
QL (180 per 90 days)
acetazolamide oral capsule, extended release
2
acetazolamide oral tablet
2
acetazolamide sodium injection recon soln
2
methazolamide oral tablet
4
CARDIOVASCULAR TREATMENT ADENOCARD INTRAVENOUS SYRINGE
4
adenosine intravenous solution
2
adenosine intravenous syringe
2
amiodarone intravenous solution
2
2 1
amiodarone intravenous syringe
2
verapamil intravenous syringe
1
amiodarone oral tablet
2
verapamil oral capsule, 24 hr er pellet ct
CORLANOR ORAL TABLET
4
QL (180 per 90 days)
verapamil oral capsule,ext rel. pellets 24 hr
1
digitek oral tablet 125 mcg
2
QL (90 per 90 days)
verapamil oral tablet
1
digitek oral tablet 250 mcg
2
verapamil oral tablet extended release
1
digox oral tablet 125 mcg
1
QL (90 per 90 days)
QL (90 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 32
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
digox oral tablet 250 mcg
1
phenoxybenzamine oral capsule
2
digoxin injection solution
2
phentolamine injection recon soln
2
digoxin oral solution 50 mcg/ml
2
procainamide injection solution
2
digoxin oral tablet 125 mcg
2
2
digoxin oral tablet 250 mcg
2
propafenone oral capsule,extended release 12 hr
2
dofetilide oral capsule
2
propafenone oral tablet
2
flecainide oral tablet
2
quinidine gluconate injection solution
mexiletine oral capsule
2
quinidine gluconate oral tablet extended release
2
midodrine oral tablet
2
quinidine sulfate oral tablet
2
milrinone intravenous solution
2
4
MULTAQ ORAL TABLET
3
RANEXA ORAL TABLET EXTENDED RELEASE 12 HR
norepinephrine bitartrate intravenous solution
2
REMODULIN INJECTION SOLUTION
5
NORPACE CR ORAL CAPSULE, EXTENDED RELEASE
4
sodium nitroprusside intravenous solution
2
sorine oral tablet
2
NORTHERA ORAL CAPSULE
5
sotalol af oral tablet 120 mg
2
pacerone oral tablet 100 mg, 200 mg, 400 mg
2
sotalol oral tablet 160 mg, 240 mg, 80 mg
2
QL (90 per 90 days)
QL (180 per 90 days)
NEDS
Requirements /Limits
B/D PA; NEDS
DIURETICS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 33
Drug Name
Drug Tier
amiloride oral tablet
2
amiloridehydrochlorothiazide oral tablet
1
bumetanide injection solution
Requirements /Limits
Drug Name
Drug Tier
indapamide oral tablet
1
methyclothiazide oral tablet
2
1
metolazone oral tablet
2
bumetanide oral tablet
1
spironolactone oral tablet
1
chlorothiazide oral tablet
1
2
chlorothiazide sodium intravenous recon soln
2
spironolactonhydrochlorothiaz oral tablet torsemide oral tablet
2
1
triamterenehydrochlorothiazid oral capsule
1
chlorthalidone oral tablet 25 mg, 50 mg eplerenone oral tablet
2
1
ethacrynate sodium intravenous recon soln
2
triamterenehydrochlorothiazid oral tablet
furosemide injection solution
2
furosemide injection syringe
Requirements /Limits
LIPID-LOWERING AGENTS
atorvastatin oral tablet 10 mg, 20 mg, 40 mg
1
2
atorvastatin oral tablet 80 mg
1
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)
1
cholestyramine (with sugar) oral powder
2 2
furosemide oral tablet
1
cholestyramine (with sugar) oral powder in packet
1
cholestyramine light oral powder
2
hydrochlorothiazide oral capsule
2
hydrochlorothiazide oral tablet
1
cholestyramine light oral powder in packet
QL (90 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 34
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits QL (90 per 90 days)
COLESTID FLAVORED ORAL PACKET
4
FENOGLIDE ORAL TABLET 120 MG
4
colestipol oral granules
2
4
colestipol oral packet
2
FENOGLIDE ORAL TABLET 40 MG
1
colestipol oral tablet
2
fluvastatin oral capsule 20 mg
QL (360 per 90 days)
ezetimibe oral tablet
2
QL (90 per 90 days)
fluvastatin oral capsule 40 mg
1
QL (180 per 90 days)
ezetimibesimvastatin oral tablet
4
ST; QL (90 per 90 days)
fluvastatin oral tablet extended release 24 hr
1
QL (90 per 90 days)
fenofibrate micronized oral capsule
2
QL (90 per 90 days)
gemfibrozil oral tablet
2 5
PA; NEDS
fenofibrate nanocrystallized oral tablet
2
JUXTAPID ORAL CAPSULE
5
PA; NEDS
fenofibrate oral tablet 120 mg, 40 mg
2
KYNAMRO SUBCUTANEOUS SYRINGE
4
fenofibrate oral tablet 160 mg, 54 mg
4
LIPOFEN ORAL CAPSULE
4
ST
fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg
2
LIVALO ORAL TABLET lovastatin oral tablet 10 mg, 20 mg
1
QL (270 per 90 days)
lovastatin oral tablet 40 mg
1
QL (180 per 90 days)
fenofibric acid (choline) oral capsule,delayed release(dr/ec) 45 mg
2
niacin oral tablet extended release 24 hr
2
fenofibric acid oral tablet
2
NIACOR ORAL TABLET
4
QL (90 per 90 days) QL (90 per 90 days) QL (90 per 90 days)
QL (270 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 35
Drug Name
Drug Tier
omega-3 acid ethyl esters oral capsule
2
pravastatin oral tablet
1
prevalite oral powder
2
prevalite oral powder in packet
2
REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR
5
REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR
5
REPATHA SYRINGE SUBCUTANEOUS SYRINGE
5
rosuvastatin oral tablet
2
simvastatin oral tablet
Requirements /Limits
QL (90 per 90 days)
PA; NEDS
Drug Name
Drug Tier
Requirements /Limits
VYTORIN 10-40 ORAL TABLET
4
ST; QL (90 per 90 days)
VYTORIN 10-80 ORAL TABLET
4
ST; QL (90 per 90 days)
WELCHOL ORAL POWDER IN PACKET
3
WELCHOL ORAL TABLET
3
ZETIA ORAL TABLET
3
QL (90 per 90 days)
MISCELLANEOUS ANTIHYPERTENSIVES PA; NEDS
DEMSER ORAL CAPSULE
4
epoprostenol (glycine) intravenous recon soln
5
NEDS
5
NEDS
QL (90 per 90 days)
FLOLAN INTRAVENOUS RECON SOLN
1
QL (90 per 90 days)
hydralazine injection solution
2
TRIGLIDE ORAL TABLET 160 MG
4
QL (90 per 90 days)
hydralazine oral tablet
2
triklo oral capsule
2
minoxidil oral tablet
2
VASCEPA ORAL CAPSULE
4
olmesartanamlodipin-hcthiazid oral tablet
1
VYTORIN 10-10 ORAL TABLET
4
ST; QL (90 per 90 days)
4
VYTORIN 10-20 ORAL TABLET
4
ST; QL (90 per 90 days)
PROGLYCEM ORAL SUSPENSION
PA; NEDS
QL (90 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 36
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
TEKTURNA HCT ORAL TABLET
3
QL (90 per 90 days)
2
TEKTURNA ORAL TABLET
3
QL (90 per 90
days)
nitro-bid transdermal ointment
4
VECAMYL ORAL TABLET
5
PA; NEDS
NITRO-DUR TRANSDERMAL PATCH 24 HOUR
veletri intravenous recon soln
5
NEDS
nitroglycerin intravenous solution
2
VENTAVIS INHALATION
SOLUTION FOR NEBULIZATION
5
B/D PA;
NEDS
nitroglycerin oral capsule, extended release
2
nitroglycerin sublingual tablet
2
nitroglycerin transdermal patch 24 hour
2
nitroglycerin translingual aerosol,spray
4
nitroglycerin translingual spray,non-aerosol
4
NITROSTAT SUBLINGUAL TABLET
4
NITRATES AND COMBINATIONS
BIDIL ORAL TABLET
3
ISORDIL ORAL TABLET
4
ISORDIL TITRADOSE ORAL TABLET 5 MG
4
isosorbide dinitrate oral tablet
2
isosorbide dinitrate oral tablet extended release
2
isosorbide mononitrate oral tablet
2
isosorbide mononitrate oral tablet extended release 24 hr
2
Requirements /Limits
CENTRAL NERVOUS SYSTEM ANTICONVULSANTS APTIOM ORAL TABLET
4
BANZEL ORAL SUSPENSION
3
BANZEL ORAL TABLET
3
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 37
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
PA
diazepam rectal kit
4
DILANTIN 30 MG ORAL CAPSULE
3
divalproex oral capsule, delayed rel sprinkle
2
2
BRIVIACT INTRAVENOUS SOLUTION
4
BRIVIACT ORAL SOLUTION
4
PA; QL (1800 per 90 days)
BRIVIACT ORAL TABLET
4
PA; QL (180 per 90 days)
carbamazepine oral capsule, er multiphase 12 hr
2
divalproex oral tablet extended release 24 hr
2
carbamazepine oral suspension 100 mg/5 ml
2
divalproex oral tablet,delayed release (dr/ec) epitol oral tablet
2
carbamazepine oral tablet
2
ethosuximide oral capsule
2
carbamazepine oral tablet extended release 12 hr
2
ethosuximide oral solution
2
carbamazepine oral tablet,chewable
2
felbamate oral suspension
4
CELONTIN ORAL CAPSULE 300 MG
3
felbamate oral tablet
4 2
CEREBYX INJECTION SOLUTION
4
fosphenytoin injection solution FYCOMPA ORAL SUSPENSION
4
clonazepam oral tablet
2
4
clonazepam oral tablet,disintegrating
2
FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG, 8 MG
2
DIASTAT ACUDIAL RECTAL KIT
4
gabapentin oral capsule gabapentin oral solution
2
DIASTAT RECTAL KIT
4
gabapentin oral tablet 600 mg, 800 mg
2
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 38
Drug Name
Drug Tier
GABITRIL ORAL TABLET 12 MG, 16 MG
3
KEPPRA INTRAVENOUS SOLUTION
4
LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING , DOSE PK
4
LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING , DOSE PK
4
LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING , DOSE PK
4
LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK
3
LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK
3
Requirements /Limits
Drug Name
Drug Tier
LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK
3
lamotrigine oral tablet
4
lamotrigine oral tablet disintegrating, dose pk
2
lamotrigine oral tablet extended release 24hr
4
lamotrigine oral tablet, chewable dispersible
4
lamotrigine oral tablet,disintegrating
4
lamotrigine oral tablets,dose pack
2
LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK
4
levetiracetam intravenous solution
2
levetiracetam oral solution
2
levetiracetam oral tablet
2
levetiracetam oral tablet extended release 24 hr
2
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 39
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
LYRICA ORAL CAPSULE
4
primidone oral tablet
2
LYRICA ORAL SOLUTION
4
roweepra oral tablet
2 NEDS
4
QL (1440 per 90 days)
SABRIL ORAL POWDER IN PACKET
5
ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 20 MG
4
QL (180 per 90 days)
SABRIL ORAL TABLET
5
NEDS
2
SPRITAM ORAL TABLET FOR SUSPENSION
4
oxcarbazepine oral suspension oxcarbazepine oral tablet
2
3
OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR
4
TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG tiagabine oral tablet
4
PEGANONE ORAL TABLET
3
topiramate oral capsule, sprinkle
2
PA
phenobarbital oral elixir
2
topiramate oral tablet
2
PA
phenobarbital oral tablet
2
valproate sodium intravenous solution
2
phenytoin oral suspension
2
2
phenytoin oral tablet,chewable
2
valproic acid (as sodium salt) oral solution
2
phenytoin sodium extended oral capsule
2
valproic acid oral capsule vigabatrin oral powder in packet
5
phenytoin sodium intravenous solution
2
4
phenytoin sodium intravenous syringe
2
VIMPAT INTRAVENOUS SOLUTION
ST
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 40
Drug Name
Drug Tier
VIMPAT ORAL SOLUTION
3
VIMPAT ORAL TABLET
3
zonisamide oral capsule
2
Requirements /Limits
PA
ANTIDEPRESSANTS amitriptyline oral tablet
2
amoxapine oral tablet
2
bupropion hcl oral tablet
2
bupropion hcl oral tablet extended release 12 hr
2
bupropion hcl oral tablet extended release 24 hr
2
citalopram oral solution
2
citalopram oral tablet
2
clomipramine oral capsule
4
desipramine oral tablet
4
DESVENLAFAXIN E FUMARATE ORAL TABLET EXTENDED RELEASE 24HR
4
ST
Drug Name
Drug Tier
Requirements /Limits
DESVENLAFAXIN E ORAL TABLET EXTENDED RELEASE 24 HR
4
ST
DESVENLAFAXIN E ORAL TABLET EXTENDED RELEASE 24HR
4
ST
desvenlafaxine succinate oral tablet extended release 24 hr
4
doxepin oral capsule
2
doxepin oral concentrate
2
duloxetine oral capsule,delayed release(dr/ec)
2
EMSAM TRANSDERMAL PATCH 24 HOUR
4
escitalopram oxalate oral solution
2
escitalopram oxalate oral tablet
2
FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK
4
ST
FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR
4
ST
fluoxetine oral capsule
4
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 41
Drug Name
Drug Tier
fluoxetine oral capsule,delayed release(dr/ec)
4
fluoxetine oral solution
4
fluoxetine oral tablet 10 mg, 20 mg
Requirements /Limits
Drug Name
Drug Tier
paroxetine hcl oral tablet
2
paroxetine hcl oral tablet extended release 24 hr
2
4
PAXIL ORAL SUSPENSION
4
FLUOXETINE ORAL TABLET 60 MG
4
PEXEVA ORAL TABLET
4 2
fluvoxamine oral capsule,extended release 24hr
2
phenelzine oral tablet protriptyline oral tablet
2
fluvoxamine oral tablet
2
sertraline oral concentrate
2
imipramine hcl oral tablet
2
sertraline oral tablet
2
imipramine pamoate oral capsule
2
tranylcypromine oral tablet
4
maprotiline oral tablet
2
trazodone oral tablet
1 2
MARPLAN ORAL TABLET
4
trimipramine oral capsule
4
mirtazapine oral tablet
1
TRINTELLIX ORAL TABLET
2
mirtazapine oral tablet,disintegrating
1
venlafaxine oral capsule,extended release 24hr
nefazodone oral tablet
2
venlafaxine oral tablet
2
nortriptyline oral capsule
2
4
nortriptyline oral solution
2
venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg VIIBRYD ORAL TABLET
4
Requirements /Limits
ST
ST
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 42
Drug Name
Drug Tier
VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)20 MG (23)
4
Requirements /Limits
Drug Name
ST
aripiprazole oral tablet
4
aripiprazole oral tablet,disintegrating
2
ARISTADA INTRAMUSCULA R SUSPENSION,EXT ENDED REL SYRING
5
chlorpromazine injection solution
2
chlorpromazine oral tablet
4
clozapine oral tablet
2
clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg
2
CLOZAPINE ORAL TABLET,DISINTE GRATING 150 MG
4
CLOZAPINE ORAL TABLET,DISINTE GRATING 200 MG
5
FANAPT ORAL TABLET
4
FANAPT ORAL TABLETS,DOSE PACK
4
FAZACLO ORAL TABLET,DISINTE GRATING 150 MG, 200 MG
5
ANTIEMETICS droperidol injection solution
2
ANTIPSYCHOTICS
ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON 300 MG
5
ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON 400 MG
5
ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL SYRING
5
ADASUVE INHALATION AEROSOL POWDR BREATH ACTIVATED
5
aripiprazole oral solution
2
ST; NEDS
NEDS
ST; NEDS
NEDS
Drug Tier
Requirements /Limits
ST; NEDS
NEDS
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 43
Drug Name
Drug Tier
fluphenazine decanoate injection solution
2
fluphenazine hcl injection solution
2
fluphenazine hcl oral concentrate
2
fluphenazine hcl oral elixir
2
fluphenazine hcl oral tablet
2
GEODON INTRAMUSCULA R RECON SOLN
4
haloperidol decanoate intramuscular solution
2
haloperidol lactate injection solution
2
haloperidol lactate oral concentrate
2
haloperidol oral tablet
2
INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 78 MG/0.5 ML
5
Requirements /Limits
ST; NEDS
Drug Name
Drug Tier
Requirements /Limits
INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 MG/0.25 ML
4
ST
INVEGA TRINZA INTRAMUSCULA R SYRINGE
5
PA; NEDS
LATUDA ORAL TABLET
4
ST
loxapine succinate oral capsule
2
NUPLAZID ORAL TABLET
5
olanzapine intramuscular recon soln
2
olanzapine oral tablet
2
olanzapine oral tablet,disintegrating
2
olanzapinefluoxetine oral capsule
4
ORAP ORAL TABLET 2 MG
3
paliperidone oral tablet extended release 24hr
2
perphenazine oral tablet
2
pimozide oral tablet
2
quetiapine oral tablet
2
PA; NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 44
Drug Name
Drug Tier
Requirements /Limits
quetiapine oral tablet extended release 24 hr
2
REXULTI ORAL TABLET
5
ST; NEDS
RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 12.5 MG/2 ML, 25 MG/2 ML
4
ST
RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 MG/2 ML, 50 MG/2 ML
5
risperidone oral solution
2
risperidone oral tablet
2
risperidone oral tablet,disintegrating
2
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET
4
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR
4
thioridazine oral tablet
2
thiothixene oral capsule
2
ST; NEDS
ST
Drug Name
Drug Tier
Requirements /Limits
trifluoperazine oral tablet
2
VERSACLOZ ORAL SUSPENSION
5
NEDS
VRAYLAR ORAL CAPSULE
5
ST; NEDS
VRAYLAR ORAL CAPSULE,DOSE PACK
4
ST
ziprasidone hcl oral capsule
2
ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 210 MG
4
ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 300 MG, 405 MG
5
NEDS
ANXIOLYTICS alprazolam intensol oral concentrate
2
alprazolam oral tablet
2
buspirone oral tablet
2
clorazepate dipotassium oral tablet
2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 45
Drug Name
Drug Tier
diazepam intensol oral concentrate
2
diazepam oral concentrate
2
diazepam oral solution 5 mg/5 ml (1 mg/ml)
2
diazepam oral tablet
2
lorazepam intensol oral concentrate
2
lorazepam oral concentrate
2
lorazepam oral tablet
2
Requirements /Limits
CNS STIMULANTS armodafinil oral tablet
4
atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg, 60 mg
4
atomoxetine oral capsule 100 mg, 80 mg
4
clonidine hcl oral tablet extended release 12 hr
2
dextroamphetamine oral solution
2
dextroamphetamineamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
2
PA; QL (90 per 90 days) ST; QL (180 per 90 days)
ST; QL (90 per 90 days) QL (360 per 90 days)
QL (270 per 90 days)
Drug Name
Drug Tier
Requirements /Limits
dextroamphetamineamphetamine oral tablet 30 mg
2
QL (180 per 90 days)
guanfacine oral tablet extended release 24 hr
2
methylphenidate hcl oral capsule, er biphasic 30-70
2
methylphenidate hcl oral capsule,er biphasic 50-50 20 mg, 40 mg
2
methylphenidate hcl oral solution
2
methylphenidate hcl oral tablet
2
QL (270 per 90 days)
modafinil oral tablet
4
PA; QL (180 per 90 days)
STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG, 60 MG
4
ST; QL (180 per 90 days)
STRATTERA ORAL CAPSULE 100 MG, 80 MG
4
ST; QL (90 per 90 days)
MIGRAINE THERAPY almotriptan malate oral tablet
4
ST; QL (36 per 90 days)
butorphanol tartrate nasal spray,nonaerosol
2
QL (15 per 90 days)
dihydroergotamine nasal spray,nonaerosol
2
QL (24 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 46
Drug Tier
Requirements /Limits
Drug Name
eletriptan hbr oral tablet
4
ST; QL (18 per 90 days)
4
ERGOMAR SUBLINGUAL TABLET
3
QL (60 per 90 days)
sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml
4
frovatriptan oral tablet
4
TREXIMET ORAL TABLET 85-500 MG
QL (30 per 90 days)
MIGERGOT RECTAL SUPPOSITORY
4
zolmitriptan oral tablet
2
QL (18 per 90 days)
2
naratriptan oral tablet
2
zolmitriptan oral tablet,disintegrating
QL (18 per 90 days)
4
RELPAX ORAL TABLET
4
ST; QL (18 per 90 days)
ZOMIG NASAL SPRAY,NONAEROSOL
ST; QL (36 per 90 days)
rizatriptan oral tablet
2
ST; QL (36 per 90 days)
rizatriptan oral tablet,disintegrating
2
ST; QL (36 per 90 days)
sumatriptan nasal spray,non-aerosol
4
QL (36 per 90 days)
sumatriptan succinate oral tablet
2
sumatriptan succinate subcutaneous cartridge
4
sumatriptan succinate subcutaneous pen injector
4
sumatriptan succinate subcutaneous solution
4
Drug Name
ST; QL (36 per 90 days)
QL (27 per 90 days)
Drug Tier
Requirements /Limits
MISCELLANEOUS CNS bupivacaine (pf) injection solution 0.25 % (2.5 mg/ml), 0.75 % (7.5 mg/ml)
2
chloroprocaine (pf) injection solution
4
donepezil oral tablet
4
QL (90 per 90 days)
donepezil oral tablet,disintegrating
4
QL (90 per 90 days)
ergoloid oral tablet
2
galantamine oral capsule,ext rel. pellets 24 hr
2
galantamine oral solution
2
galantamine oral tablet
2
QL (90 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 47
Drug Name
Drug Tier
glydo mucous membrane jelly in applicator
2
GRALISE 30-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 24 HR
4
GRALISE ORAL TABLET EXTENDED RELEASE 24 HR
4
guanidine oral tablet
2
lidocaine (pf) injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %)
2
lidocaine (pf) intravenous syringe
2
lidocaine hcl injection solution 10 mg/ml (1 %), 5 mg/ml (0.5 %)
2
lidocaine hcl laryngotracheal solution
2
LIDOCAINEEPINEPHRINE BIT INJECTION CARTRIDGE
4
lidocaineepinephrine injection solution 1.5 %-1:200,000
2
Requirements /Limits
PA
PA
Drug Name
Drug Tier
Requirements /Limits
lithium carbonate oral capsule
1
lithium carbonate oral tablet
1
lithium carbonate oral tablet extended release
1
lithium citrate oral solution 8 meq/5 ml
2
memantine oral solution
2
QL (900 per 90 days)
memantine oral tablet
2
QL (180 per 90 days)
MEMANTINE ORAL TABLETS,DOSE PACK
3
QL (147 per 84 days)
MESTINON ORAL SYRUP
3
NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK
3
QL (147 per 84 days)
NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK
4
QL (84 per 84 days)
NAMENDA XR ORAL CAPSULE,SPRINK LE,ER 24HR
4
QL (90 per 90 days)
NAROPIN (PF) INJECTION SOLUTION
4
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 48
Drug Name
Drug Tier
Requirements /Limits
neostigmine methylsulfate intravenous solution
2
nimodipine oral capsule
4
NUEDEXTA ORAL CAPSULE
3
PRIALT INTRATHECAL SOLUTION
4
pyridostigmine bromide oral tablet
2
pyridostigmine bromide oral tablet extended release
2
RADICAVA INTRAVENOUS PIGGYBACK
5
riluzole oral tablet
2
rivastigmine tartrate oral capsule
2
rivastigmine transdermal patch 24 hour
4
ropivacaine (pf) injection solution 2 mg/ml (0.2 %), 5 mg/ml (0.5 %)
2
SAVELLA ORAL TABLET
3
PA; QL (180 per 90 days)
SAVELLA ORAL TABLETS,DOSE PACK
4
PA; QL (165 per 84 days)
QL (180 per 90 days)
Drug Name
Drug Tier
Requirements /Limits
SENSORCAINEMPF/EPINEPHRIN E INJECTION SOLUTION 0.5 %1:200,000
4
tetrabenazine oral tablet 12.5 mg
5
PA; QL (248 per 31 days); NEDS
tetrabenazine oral tablet 25 mg
5
PA; QL (124 per 31 days); NEDS
xylocaine dentalepinephrine injection cartridge
2
NARCOTIC ANTAGONISTS
PA; NEDS
QL (90 per 90 days)
BUPRENEX INJECTION SOLUTION
4
QL (801 per 90 days)
buprenorphine hcl injection solution
2
QL (801 per 90 days)
buprenorphine hcl injection syringe
2
QL (801 per 90 days)
buprenorphine hcl sublingual tablet 2 mg
2
QL (900 per 90 days)
buprenorphine hcl sublingual tablet 8 mg
2
QL (180 per 90 days)
BUPRENORPHINE TRANSDERMAL PATCH WEEKLY
4
QL (12 per 84 days)
buprenorphinenaloxone sublingual tablet
2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 49
Drug Tier
Requirements /Limits
Drug Name
BUTRANS TRANSDERMAL PATCH WEEKLY
4
QL (12 per 84 days)
nalbuphine injection solution 20 mg/ml
2
QL (300 per 90 days)
tramadol oral tablet
2
EVZIO INJECTION AUTO-INJECTOR
4
QL (720 per 90 days)
2
tramadol oral tablet extended release 24 hr
2
naloxone injection solution
QL (90 per 90 days)
naloxone injection syringe
2
tramadol oral tablet, er multiphase 24 hr
2
QL (90 per 90 days)
naltrexone oral tablet
2
2
QL (1080 per 90 days)
NARCAN NASAL SPRAY,NONAEROSOL 4 MG/ACTUATION
4
tramadolacetaminophen oral tablet
SUBOXONE SUBLINGUAL FILM
3
VIVITROL INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON
5
Drug Name
Drug Tier
Requirements /Limits
NARCOTIC/ANALGESIC COMBINATIONS
NEDS
NARCOTIC MIXED AGONIST/ANTAGONIST butorphanol tartrate injection solution 1 mg/ml
2
butorphanol tartrate injection solution 2 mg/ml
2
nalbuphine injection solution 10 mg/ml
2
QL (2160 per 90 days) QL (1080 per 90 days) QL (600 per 90 days)
acetaminophen-caffdihydrocod oral capsule
2
acetaminophencodeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml
2
QL (5167 per 31 days)
acetaminophencodeine oral tablet 300-15 mg, 300-30 mg
2
QL (1080 per 90 days)
acetaminophencodeine oral tablet 300-60 mg
2
QL (540 per 90 days)
endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5325 mg
2
QL (1080 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 50
Drug Tier
Requirements /Limits
Drug Name
hydrocodoneacetaminophen oral solution 7.5-325 mg/15 ml
2
QL (5735 per 31 days)
hydrocodoneacetaminophen oral tablet 10-300 mg, 5300 mg, 7.5-300 mg
2
hydrocodoneacetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
2
hydrocodoneibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg
2
IBUDONE ORAL TABLET 5-200 MG
4
ibuprofen-oxycodone oral tablet
2
QL (360 per 90 days)
LAZANDA NASAL SPRAY,NONAEROSOL
5
PA; QL (31 per 31 days); NEDS
lorcet (hydrocodone) oral tablet
2
QL (1080 per 90 days)
lorcet hd oral tablet
2
QL (1080 per 90 days)
Drug Name
QL (1080 per 90 days)
QL (450 per 90 days)
lorcet plus oral tablet 7.5-325 mg
2
QL (1080 per 90 days)
oxycodoneacetaminophen oral solution
2
QL (1891 per 31 days)
Drug Tier
Requirements /Limits
oxycodoneacetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
2
QL (1080 per 90 days)
oxycodone-aspirin oral tablet
2
QL (1080 per 90 days)
xylon 10 oral tablet
2
NARCOTICS
ABSTRAL SUBLINGUAL TABLET
5
PA; QL (124 per 31 days); NEDS
codeine sulfate oral tablet 15 mg
2
QL (2160 per 90 days)
codeine sulfate oral tablet 30 mg
2
QL (1080 per 90 days)
codeine sulfate oral tablet 60 mg
2
QL (540 per 90 days)
diskets oral tablet,soluble
2
duramorph (pf) injection solution 0.5 mg/ml
2
QL (4133 per 31 days)
duramorph (pf) injection solution 1 mg/ml
2
QL (6000 per 90 days)
fentanyl citrate (pf) injection solution
2
FENTANYL CITRATE (PF) INTRAVENOUS SYRINGE 100 MCG/2 ML (50 MCG/ML)
3
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 51
Drug Name
Drug Tier
Requirements /Limits
Drug Name KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 200 MG
4
QL (180 per 90 days)
levorphanol tartrate oral tablet
2
QL (360 per 90 days)
methadone injection solution
2
QL (480 per 90 days)
methadone intensol oral concentrate
2
Drug Tier
Requirements /Limits
fentanyl citrate buccal lozenge on a handle
5
PA; QL (124 per 31 days); NEDS
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
2
QL (45 per 90 days)
FENTORA BUCCAL TABLET, EFFERVESCENT
5
hydromorphone (pf) injection solution
2
methadone oral concentrate
2
hydromorphone injection solution
2
methadone oral solution 10 mg/5 ml
2
QL (1800 per 90 days)
HYDROMORPHO NE INJECTION SYRINGE 0.5 MG/0.5 ML
4
methadone oral solution 5 mg/5 ml
2
QL (3600 per 90 days)
methadone oral tablet 10 mg
2
QL (360 per 90 days)
hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 mg/ml
2
methadone oral tablet 5 mg
2
QL (720 per 90 days)
methadone oral tablet,soluble
2
hydromorphone oral liquid
2
QL (4500 per 90 days)
methadose oral tablet,soluble
2
hydromorphone oral tablet 2 mg
2
QL (1350 per 90 days)
2
hydromorphone oral tablet 4 mg
2
QL (720 per 90 days)
morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml
2
hydromorphone oral tablet 8 mg
2
INFUMORPH P/F INJECTION SOLUTION
4
morphine (pf) intravenous patient control.analgesia soln morphine concentrate oral solution
2
PA; QL (124 per 31 days); NEDS
QL (360 per 90 days)
QL (900 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 52
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
morphine injection syringe 10 mg/ml
2
NUCYNTA ORAL TABLET 75 MG
4
QL (726 per 90 days)
morphine intravenous cartridge 10 mg/ml, 2 mg/ml, 4 mg/ml
2
OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR
4
QL (180 per 90 days)
morphine intravenous solution 10 mg/ml
2
OPANA INJECTION SOLUTION
4
MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML
4
oxycodone oral capsule
2
QL (1080 per 90 days)
oxycodone oral concentrate
4
QL (540 per 90 days)
morphine oral capsule,extend.relea se pellets 10 mg, 20 mg, 30 mg
4
oxycodone oral solution
4
QL (3600 per 90 days)
4
morphine oral capsule,extend.relea se pellets 100 mg, 50 mg, 60 mg, 80 mg
4
OXYCODONE ORAL SYRINGE
QL (540 per 90 days)
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg
2
QL (540 per 90 days)
morphine oral solution
2
QL (2700 per 90 days)
oxycodone oral tablet 5 mg
2
QL (1080 per 90 days)
morphine oral tablet
2
QL (540 per 90 days)
oxymorphone oral tablet
4
QL (540 per 90 days)
morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg
4
QL (270 per 90 days)
oxymorphone oral tablet extended release 12 hr
4
QL (180 per 90 days)
4
QL (90 per 90 days)
SUBSYS SUBLINGUAL SPRAY,NONAEROSOL
5
morphine oral tablet extended release 200 mg
PA; QL (124 per 31 days); NEDS
NUCYNTA ORAL TABLET 100 MG
4
QL (543 per
90 days)
NON-STEROIDAL ANTIINFLAMMATORY
NUCYNTA ORAL TABLET 50 MG
4
QL (1086 per 90 days)
celecoxib oral capsule 100 mg
QL (90 per 90 days)
QL (180 per 90 days)
2
QL (270 per
90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 53
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
celecoxib oral capsule 200 mg, 400 mg
2
QL (180 per 90 days)
ketoprofen oral capsule
2
2
QL (540 per 90 days)
ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg
2
celecoxib oral capsule 50 mg diclofenac potassium oral tablet
2
meclofenamate oral capsule
4
diclofenac sodium oral tablet extended release 24 hr
2
mefenamic acid oral capsule
4 2
diclofenac sodium oral tablet,delayed release (dr/ec)
2
meloxicam oral tablet nabumetone oral tablet
2
diclofenacmisoprostol oral tablet,ir,delayed rel,biphasic
2
naproxen oral suspension
2
naproxen oral tablet
2
diflunisal oral tablet
2
2
etodolac oral capsule
2
naproxen oral tablet,delayed release (dr/ec)
etodolac oral tablet
2
2
etodolac oral tablet extended release 24 hr
2
naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet
2
fenoprofen oral tablet
2
piroxicam oral capsule
2
flurbiprofen oral tablet
2
salsalate oral tablet
2
sulindac oral tablet
2
ibuprofen oral suspension
2
tolmetin oral capsule
2
tolmetin oral tablet
2
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
2
Requirements /Limits
QL (90 per 90 days)
PARKINSONS DISEASE AND RELATED DISORDERS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 54
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
NEDS
HORIZANT ORAL TABLET EXTENDED RELEASE
4
NEUPRO TRANSDERMAL PATCH 24 HOUR
4
pramipexole oral tablet
2
pramipexole oral tablet extended release 24 hr
4
rasagiline oral tablet
2
ropinirole oral tablet
2
ropinirole oral tablet extended release 24 hr
2
APOKYN SUBCUTANEOUS CARTRIDGE
5
AZILECT ORAL TABLET
3
benztropine injection solution
2
benztropine oral tablet
2
bromocriptine oral capsule
2
bromocriptine oral tablet
2
cabergoline oral tablet
2
carbidopa oral tablet
2
carbidopa-levodopa oral tablet
2
selegiline hcl oral capsule
2
carbidopa-levodopa oral tablet extended release
2
selegiline hcl oral tablet
2
tolcapone oral tablet
2
carbidopa-levodopa oral tablet,disintegrating
2
trihexyphenidyl oral elixir
2 2
carbidopa-levodopaentacapone oral tablet
2
trihexyphenidyl oral tablet
4
DUOPA J-TUBE INTESTINAL PUMP SUSPENSION
4
ZELAPAR ORAL TABLET,DISINTE GRATING
entacapone oral tablet
2
PA
Requirements /Limits
SEDATIVE/HYPNOTICS
ROZEREM ORAL TABLET
3
QL (90 per 90 days)
XYREM ORAL SOLUTION
5
PA; LA; NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 55
Drug Name
Drug Tier
Requirements /Limits
Drug Name
zaleplon oral capsule
2
QL (90 per 90 days)
clindacin etz topical swab
2
zolpidem oral tablet
4
QL (90 per 90 days)
clindacin p topical swab
2
zolpidem oral tablet,ext release multiphase
4
QL (90 per 90 days)
CLINDAGEL TOPICAL GEL
4 2
zolpidem sublingual tablet
4
QL (90 per 90 days)
clindamycin phosphate topical foam clindamycin phosphate topical gel
2
clindamycin phosphate topical lotion
2
clindamycin phosphate topical solution
2
clindamycin phosphate topical swab
2
clindamycin-benzoyl peroxide topical gel
2
clindamycin-benzoyl peroxide topical gel with pump
2
4
SKELETAL MUSCLE RELAXANTS baclofen oral tablet
2
cyclobenzaprine oral tablet
2
dantrolene oral capsule
2
metaxall oral tablet
2
tizanidine oral capsule
2
tizanidine oral tablet
2
DERMATOLOGY ACNE TREATMENT
Drug Tier
adapalene topical cream
2
adapalene topical gel
2
adapalene topical gel with pump
2
DIFFERIN TOPICAL GEL WITH PUMP
amnesteem oral capsule
2
DIFFERIN TOPICAL LOTION
4
AZELEX TOPICAL CREAM
4
erythromycinbenzoyl peroxide topical gel
2
claravis oral capsule
4
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 56
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
FINACEA TOPICAL GEL
4
calcipotriene topical ointment
4
metronidazole topical cream
2
4
metronidazole topical gel
2
calcipotrienebetamethasone topical ointment
2
metronidazole topical lotion
2
calcitrene topical ointment
4
neuac topical gel
2
calcitriol topical ointment
sulfacetamide sodium (acne) topical suspension
2
methoxsalen oral capsule,liqdfilled,rapid rel
5
TAZORAC TOPICAL CREAM
4
selenium sulfide topical lotion
2
TAZORAC TOPICAL GEL
4
TACLONEX TOPICAL SUSPENSION
4
tretinoin microspheres topical gel
2
tazarotene topical cream
4
tretinoin microspheres topical gel with pump
2
tretinoin topical cream tretinoin topical gel
NEDS
MISCELLANEOUS DERMATOLOGICALS 2
2
ammonium lactate topical cream
2
2
ammonium lactate topical lotion CARAC TOPICAL CREAM
3
ANTIPSORIATIC/ANTISEBORRHEI C
Requirements /Limits
acitretin oral capsule
4
CONDYLOX TOPICAL GEL
3
calcipotriene scalp solution
4
diclofenac sodium topical drops
2
calcipotriene topical cream
4
diclofenac sodium topical gel 1 %
2
QL (1000 per 31 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 57
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
diclofenac sodium topical gel 3 %
2
TARGRETIN TOPICAL GEL
5
doxepin topical cream
2
4
ELIDEL TOPICAL CREAM
3
VEREGEN TOPICAL OINTMENT
4
FLECTOR TRANSDERMAL PATCH 12 HOUR
4
VOLTAREN GEL TOPICAL GEL 1 %
fluorouracil intravenous solution 1 gram/20 ml
2
FLUOROURACIL TOPICAL CREAM 0.5 %
3
fluorouracil topical cream 5 %
PA
Requirements /Limits PA; NEDS
QL (1000 per 31 days)
SCABICIDES/PEDICULICIDES EURAX TOPICAL CREAM
3
EURAX TOPICAL LOTION
3
lindane topical shampoo
2
2
malathion topical lotion
4
fluorouracil topical solution
2
permethrin topical cream
2
imiquimod topical cream in packet
2
SKLICE TOPICAL LOTION
4
PANRETIN TOPICAL GEL
3
spinosad topical suspension
2
PICATO TOPICAL GEL 0.015 %
5
QL (3 per 31 days); NEDS
ULESFIA TOPICAL LOTION
4
PICATO TOPICAL GEL 0.05 %
5
QL (2 per 31 days); NEDS
podofilox topical solution
2
prudoxin topical cream
2
tacrolimus topical ointment
4
B/D PA
TOPICAL ANESTHETICS bupivacaine (pf) injection solution 0.5 % (5 mg/ml)
2
lidocaine (pf) injection solution 15 mg/ml (1.5 %)
2
lidocaine (pf) intravenous solution
2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 58
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
lidocaine hcl injection solution 20 mg/ml (2 %)
2
CORTISPORIN TOPICAL OINTMENT
4
lidocaine hcl mucous membrane jelly
2
ery pads topical swab
2
lidocaine hcl mucous membrane jelly in applicator
2
erygel topical gel
2
erythromycin with ethanol topical gel
2
lidocaine hcl mucous membrane solution 4 % (40 mg/ml)
2
erythromycin with ethanol topical solution
2
lidocaine hcl urethral gel
2
erythromycin with ethanol topical swab
2
lidocaine topical adhesive patch,medicated
4
gentamicin topical cream
2
lidocaine topical ointment
4
gentamicin topical ointment
2
lidocaine viscous mucous membrane solution
2
metronidazole topical gel with pump
2
lidocaine-prilocaine topical cream
2
mupirocin calcium topical cream
2
relador pak plus topical kit
2
mupirocin topical ointment
2
relador pak topical kit
2
SULFAMYLON TOPICAL CREAM
4
PA; QL (270 per 90 days)
TOPICAL ANTIBACTERIALS BACTROBAN NASAL OINTMENT
3
CORTISPORIN TOPICAL CREAM
4
Requirements /Limits
TOPICAL ANTIFUNGALS ciclodan topical cream
2
ciclodan topical solution
2
ciclopirox topical cream
2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 59
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
ciclopirox topical gel
2
MENTAX TOPICAL CREAM
4
ciclopirox topical shampoo
2
naftifine topical cream
2
ciclopirox topical solution
2
NAFTIN TOPICAL GEL
4
ciclopirox topical suspension
2
nyamyc topical powder
2
clotrimazole topical cream
2
nyata topical powder
2
2
nystatin topical cream
2
clotrimazole topical solution
2
clotrimazolebetamethasone topical cream
2
nystatin topical ointment nystatin topical powder
2
clotrimazolebetamethasone topical lotion
2
nystatintriamcinolone topical cream
2
econazole topical cream
4
2
ERTACZO TOPICAL CREAM
4
nystatintriamcinolone topical ointment
2
EXELDERM TOPICAL CREAM
4
nystop topical powder
4
oxiconazole topical cream
2
EXELDERM TOPICAL SOLUTION
OXISTAT TOPICAL LOTION
4
ketoconazole topical cream
2
ketoconazole topical foam
2
DENAVIR TOPICAL CREAM
4
ketoconazole topical shampoo
2
XERESE TOPICAL CREAM
4
Requirements /Limits
TOPICAL ANTIVIRALS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 60
Drug Name ZOVIRAX TOPICAL CREAM
Drug Tier
Requirements /Limits
4
TOPICAL CORTICOSTEROIDS ala-cort topical cream 2.5 %
2
alclometasone topical cream
2
alclometasone topical ointment
2
amcinonide topical cream
4
amcinonide topical lotion
4
amcinonide topical ointment
4
apexicon e topical cream
4
betamethasone dipropionate topical cream
2
betamethasone dipropionate topical lotion
2
betamethasone dipropionate topical ointment
2
betamethasone valerate topical cream
2
betamethasone valerate topical foam
2
Drug Name
Drug Tier
betamethasone valerate topical lotion
2
betamethasone valerate topical ointment
2
betamethasone, augmented topical cream
2
betamethasone, augmented topical gel
2
betamethasone, augmented topical lotion
2
betamethasone, augmented topical ointment
2
CAPEX TOPICAL SHAMPOO
3
clobetasol scalp solution
4
clobetasol topical cream
4
clobetasol topical foam
4
clobetasol topical gel
4
clobetasol topical lotion
4
clobetasol topical ointment
4
clobetasol topical
shampoo
4
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 61
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
clobetasol topical spray,non-aerosol
4
fluocinolone topical oil
2
clobetasol-emollient topical cream
4
fluocinolone topical ointment
2
clobetasol-emollient topical foam
4
fluocinolone topical solution
2
clodan topical shampoo
4
fluocinonide topical cream
4
CORDRAN TAPE LARGE ROLL TOPICAL TAPE
3
fluocinonide topical gel
4 4
cormax scalp solution
2
fluocinonide topical ointment
4
fluocinonide topical solution
4
desonide topical cream
4
desonide topical lotion
4
fluocinonide-e topical cream
4
fluocinonideemollient topical cream
4
desonide topical ointment desoximetasone topical cream
4
fluticasone topical cream
2
desoximetasone topical gel
2
fluticasone topical lotion
2
desoximetasone topical ointment
4
fluticasone topical ointment
2
diflorasone topical cream
4
2
diflorasone topical ointment
4
halobetasol propionate topical cream
2
fluocinolone and shower cap scalp oil
2
halobetasol propionate topical ointment
fluocinolone topical cream
2
HALOG TOPICAL CREAM
4
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 62
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
HALOG TOPICAL OINTMENT
4
LOCOID TOPICAL LOTION
4
hydrocortisone butyrate topical cream
2
mometasone topical cream
2
2
mometasone topical ointment
2
hydrocortisone butyrate topical ointment
mometasone topical solution
2
hydrocortisone butyrate topical solution
2
nolix topical lotion
4 4
hydrocortisone butyr-emollient topical cream
2
PANDEL TOPICAL CREAM prednicarbate topical cream
2
hydrocortisone topical cream 1 %, 2.5 %
2
prednicarbate topical ointment
2 3
hydrocortisone topical lotion 2.5 %
2
TEXACORT TOPICAL SOLUTION
hydrocortisone topical ointment 1 %, 2.5 %
2
4
hydrocortisone valerate topical cream
2
TOPICORT TOPICAL SPRAY,NONAEROSOL
2
hydrocortisone valerate topical ointment
2
triamcinolone acetonide topical aerosol
2
hydrocortisone-min oil-wht pet topical ointment
2
triamcinolone acetonide topical cream
2
LOCOID LIPOCREAM TOPICAL CREAM
4
triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %
2
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 63
Drug Name
Drug Tier
trianex topical ointment
2
triderm topical cream
2
TRIDESILON TOPICAL CREAM
4
Requirements /Limits
WOUND AND BURN THERAPY REGRANEX TOPICAL GEL
5
SANTYL TOPICAL OINTMENT
3
silver sulfadiazine topical cream
2
ssd topical cream
2
NEDS
DIAGNOSTIC AND OTHER MISCELLANEOUS DIAGNOSTIC AND OTHER MISCELLANEOUS PA
Drug Name
Drug Tier
Requirements /Limits
CARNITOR (SUGAR-FREE) ORAL SOLUTION
4
cevimeline oral capsule
2
CHEMET ORAL CAPSULE
3
chlorhexidine gluconate mucous membrane mouthwash
2
CINRYZE INTRAVENOUS RECON SOLN
5
deferoxamine injection recon soln
2
DESFERAL INJECTION RECON SOLN
4
disulfiram oral tablet
2 5
NEDS
NEDS
acamprosate oral tablet,delayed release (dr/ec)
2
acetylcysteine intravenous solution
2
EXJADE ORAL TABLET, DISPERSIBLE
5
NEDS
AURYXIA ORAL TABLET
5
FERRIPROX ORAL SOLUTION
NEDS
4
FERRIPROX ORAL TABLET
5
CALCIUM DISODIUM VERSENATE INJECTION SOLUTION
FIRAZYR SUBCUTANEOUS SYRINGE
5
PA; NEDS
CARBAGLU ORAL TABLET, DISPERSIBLE
5
FOSRENOL ORAL POWDER IN PACKET
4
NEDS
LA; NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 64
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
FOSRENOL ORAL TABLET,CHEWAB LE
4
KUVAN ORAL POWDER IN PACKET
5
NEDS
gavilyte-c oral recon soln
2
5
NEDS
gavilyte-g oral recon soln
2
KUVAN ORAL TABLET,SOLUBL E
2
gavilyte-n oral recon soln
2
lactated ringers irrigation solution
4
glycine urologic irrigation solution
2
lanthanum oral tablet,chewable
2
GOLYTELY ORAL POWDER IN PACKET
4
levocarnitine (with sugar) oral solution levocarnitine oral tablet
2
HAEGARDA SUBCUTANEOUS RECON SOLN
5
md-gastroview oral solution
2 3
HESPAN 6 % IN NS INTRAVENOUS SOLUTION
4
METOPIRONE ORAL CAPSULE MOVIPREP ORAL POWDER IN PACKET
4
HETLIOZ ORAL CAPSULE
5
PA; QL (31 per 31 days); NEDS
neomycin-polymyxin b gu irrigation solution
2
JADENU ORAL TABLET
5
NEDS
4
KALBITOR SUBCUTANEOUS SOLUTION
5
PA; NEDS
NEOSPORIN GU IRRIGANT IRRIGATION SOLUTION oralone dental paste
2
kionex (with sorbitol) oral suspension
2
ORFADIN ORAL CAPSULE
5
NEDS
kionex oral powder
2
ORFADIN ORAL SUSPENSION
5
NEDS
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 65
Drug Name
Drug Tier
OSMOPREP ORAL TABLET
4
paroex oral rinse mucous membrane mouthwash
2
peg 3350electrolytes oral recon soln
2
peg-electrolyte soln oral recon soln
2
periogard mucous membrane mouthwash
Requirements /Limits
Drug Name
Drug Tier
sevelamer carbonate oral powder in packet
2
sevelamer carbonate oral tablet
2
sodium chloride irrigation solution
2
sodium polystyrene (sorb free) oral suspension
2
2
sodium polystyrene sulfonate oral powder
2
pilocarpine hcl oral tablet
2
2
polyethylene glycol 3350 oral powder
2
sodium polystyrene sulfonate oral suspension
2
polyethylene glycol 3350 oral powder in packet
2
sodium polystyrene sulfonate rectal enema 30 gram/120 ml
RAVICTI ORAL LIQUID
5
4
RENAGEL ORAL TABLET
4
SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML
RENVELA ORAL POWDER IN PACKET
3
sps (with sorbitol) oral suspension
2 2
RENVELA ORAL TABLET
3
sps (with sorbitol) rectal enema
2
SUPREP BOWEL PREP KIT ORAL RECON SOLN
4
ringer's irrigation solution SAMSCA ORAL TABLET
5
TEMODAR INTRAVENOUS RECON SOLN
4
PA; NEDS
PA; NEDS
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 66
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
tis-u-sol pentalyte irrigation solution
2
dexamethasone intensol oral drops
2
tranexamic acid intravenous solution
2
dexamethasone oral elixir
1
tranexamic acid oral tablet
2
dexamethasone oral solution
1
triamcinolone acetonide dental paste
2
dexamethasone oral tablet
1
2
fludrocortisone oral tablet
2
trilyte with flavor packets oral recon soln
hydrocortisone oral tablet
1
UVADEX INJECTION SOLUTION
4
methylprednisolone acetate injection suspension
2
VELTASSA ORAL POWDER IN PACKET
4
methylprednisolone oral tablet
1
water for irrigation, sterile irrigation solution
2
methylprednisolone oral tablets,dose pack
1
XIAFLEX INJECTION RECON SOLN
5
methylprednisolone sodium succ injection recon soln 125 mg, 40 mg
2
2
QL (90 per 63 days)
PA; QL (1 per 30 days); NEDS
ENDOCRINOLOGY a-hydrocort injection recon soln
2
methylprednisolone sodium succ intravenous recon soln
4
millipred dp oral tablets,dose pack
2
budesonide oral capsule,delayed,exte nd.release
MILLIPRED ORAL SOLUTION
4
cortisone oral tablet
2 2
prednisolone oral solution 15 mg/5 ml
2
deltasone oral tablet 20 mg
ADRENOCORTICAL STEROIDS
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 67
Drug Name
Drug Tier
Requirements /Limits
Drug Name
prednisolone sodium phosphate oral solution 10 mg/5 ml
4
triamcinolone acetonide injection suspension
prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
2
ANDROGENS
prednisolone sodium phosphate oral tablet,disintegrating
2
prednisone intensol oral concentrate
2
prednisone oral solution
1
prednisone oral tablet
1
prednisone oral tablets,dose pack
1
SOLU-CORTEF INJECTION RECON SOLN
4
SOLU-MEDROL (PF) INJECTION RECON SOLN
4
SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN
4
SOLU-MEDROL INTRAVENOUS RECON SOLN
4
Drug Tier
Requirements /Limits
2
ANADROL-50 ORAL TABLET
4
PA
ANDRODERM TRANSDERMAL PATCH 24 HOUR
3
PA; QL (90 per 90 days)
ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)
3
PA; QL (450 per 90 days)
ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM)
3
PA; QL (900 per 90 days)
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM)
3
PA; QL (225 per 90 days)
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM)
3
PA; QL (450 per 90 days)
ANDROID ORAL CAPSULE
4
danazol oral capsule
2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 68
Drug Name
Drug Tier
METHITEST ORAL TABLET
4
methyltestosterone oral capsule
2
oxandrolone oral tablet
2
TESTIM TRANSDERMAL GEL
4
testosterone cypionate intramuscular oil
2
testosterone enanthate intramuscular oil
2
testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)
2
testosterone transdermal gel in packet 1 % (25 mg/2.5gram)
2
testosterone transdermal gel in packet 1 % (50 mg/5 gram)
2
TESTRED ORAL CAPSULE
4
ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg
2
propylthiouracil oral tablet
2
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
GLUCOCORTICOIDS 2
PA
dexamethasone sodium phosphate injection solution 4 mg/ml
2
PA; QL (900 per 90 days)
dexamethasone sodium phosphate injection syringe SOLU-CORTEF (PF) INJECTION RECON SOLN
4
GROWTH HORMONE AND RELATED PRODUCTS
PA
PA; QL (900 per 90 days)
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML
4
PA
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML
5
PA; NEDS
GENOTROPIN SUBCUTANEOUS CARTRIDGE
5
PA; NEDS
HUMATROPE INJECTION CARTRIDGE
5
PA; NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 69
Drug Name
Drug Tier
Requirements /Limits
Drug Name APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN
4
APIDRA SUBCUTANEOUS SOLUTION
4
gauze pads 2 x 2
2
HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS INSULIN PEN, HALF-UNIT
3
HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN
3
Drug Tier
HUMATROPE INJECTION RECON SOLN
5
PA; NEDS
NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR
5
PA; NEDS
NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR
5
OMNITROPE SUBCUTANEOUS CARTRIDGE
4
OMNITROPE SUBCUTANEOUS RECON SOLN
5
PA; NEDS
SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE
5
PA; NEDS
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN
3
SAIZEN SAIZENPREP SUBCUTANEOUS CARTRIDGE
5
PA; NEDS
HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION
3
SAIZEN SUBCUTANEOUS RECON SOLN
5
PA; NEDS
3
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG
5
PA; NEDS
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION
3
HUMALOG SUBCUTANEOUS CARTRIDGE
3
INSULINS alcohol pads topical pads, medicated
1
PA; NEDS
PA
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 70
Drug Name
Drug Tier
HUMALOG SUBCUTANEOUS SOLUTION
3
HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN
3
HUMULIN 70/30 SUBCUTANEOUS SUSPENSION
3
HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN
3
HUMULIN N SUBCUTANEOUS SUSPENSION
3
HUMULIN R U-100 INJECTION SOLUTION
3
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN
3
HUMULIN R U-500 (CONCENTRATED ) SUBCUTANEOUS SOLUTION
3
insulin pen needle
1
insulin syringe (disp) u-100 0.3 ml, 1 ml, 1/2 ml
1
Requirements /Limits
Drug Name
Drug Tier
LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN
3
LANTUS SUBCUTANEOUS SOLUTION
3
LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN
3
LEVEMIR SUBCUTANEOUS SOLUTION
3
needles, insulin disp.,safety
1
NOVOFINE 30 NEEDLE
1
NOVOFINE 32 NEEDLE
1
NOVOFINE PLUS NEEDLE
1
NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION
3
NOVOLIN N SUBCUTANEOUS SUSPENSION
3
NOVOLIN R INJECTION SOLUTION
3
NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN
3
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 71
Drug Name
Drug Tier
NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN
3
NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION
3
NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE
3
NOVOLOG SUBCUTANEOUS SOLUTION
3
NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN
1
NOVOTWIST NEEDLE 32 GAUGE X 1/5"
1
TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN
3
VGO 20 DEVICE
1
VGO 30 DEVICE
1
VGO 40 DEVICE
1
Requirements /Limits
MISCELLANEOUS ENDOCRINE ALDURAZYME INTRAVENOUS SOLUTION
5
BUPHENYL ORAL POWDER
4
NEDS
Drug Name
Drug Tier
Requirements /Limits
BUPHENYL ORAL TABLET
4
CERDELGA ORAL CAPSULE
5
NEDS
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT
5
NEDS
CHOLBAM ORAL CAPSULE
5
PA; NEDS
chorionic gonadotropin, human intramuscular recon soln
4
PA
CYSTADANE ORAL POWDER
4
desmopressin injection solution
2
desmopressin nasal aerosol,spray
4
desmopressin nasal solution
4
desmopressin nasal spray,non-aerosol
4
desmopressin oral tablet
2
EGRIFTA SUBCUTANEOUS RECON SOLN
5
NEDS
ELAPRASE INTRAVENOUS SOLUTION
5
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 72
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
ELELYSO INTRAVENOUS RECON SOLN
5
NEDS
NATPARA SUBCUTANEOUS CARTRIDGE
5
PA; NEDS
ELITEK INTRAVENOUS RECON SOLN
5
NEDS
novarel intramuscular recon soln 10,000 unit
4
PA
FABRAZYME INTRAVENOUS RECON SOLN
5
NEDS
4
PA
GLUCAGEN HYPOKIT INJECTION RECON SOLN
3
NOVAREL INTRAMUSCULA R RECON SOLN 5,000 UNIT
5
NEDS
GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT
3
octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml
4
INCRELEX SUBCUTANEOUS SOLUTION
5
octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml octreotide acetate injection syringe
5
KANUMA INTRAVENOUS SOLUTION
5
PA; NEDS
pamidronate intravenous recon soln
2
KORLYM ORAL TABLET
5
PA; NEDS
pamidronate intravenous solution
2
LUMIZYME INTRAVENOUS RECON SOLN
5
B/D PA; NEDS
5
PA; NEDS
MYALEPT SUBCUTANEOUS RECON SOLN
5
PA; NEDS
PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE
5
NEDS
NAGLAZYME INTRAVENOUS SOLUTION
5
SANDOSTATIN LAR DEPOT INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON
PA; NEDS
NEDS
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 73
Drug Name
Drug Tier
Requirements /Limits
SENSIPAR ORAL TABLET
3
SIGNIFOR LAR INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N
5
SIGNIFOR SUBCUTANEOUS SOLUTION
5
sodium phenylbutyrate oral powder
2
sodium phenylbutyrate oral tablet
4
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE
5
NEDS
SOMAVERT SUBCUTANEOUS RECON SOLN
5
PA; NEDS
STIMATE NASAL SPRAY,NONAEROSOL
3
STRENSIQ SUBCUTANEOUS SOLUTION
5
SYPRINE ORAL CAPSULE VIMIZIM INTRAVENOUS SOLUTION
NEDS
Drug Name
Drug Tier
Requirements /Limits
VPRIV INTRAVENOUS RECON SOLN
5
NEDS
ZAVESCA ORAL CAPSULE
5
NEDS
NON-INSULIN HYPOGLYCEMIC AGENTS BYDUREON SUBCUTANEOUS PEN INJECTOR
3
PA; QL (12 per 84 days)
BYDUREON SUBCUTANEOUS SUSPENSION,EXT ENDED REL RECON
3
PA; QL (12 per 84 days)
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML
4
PA; QL (7.2 per 84 days)
BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML
4
PA; QL (3.6 per 84 days)
CYCLOSET ORAL TABLET
4
QL (540 per 90 days)
PA; NEDS
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR
4
5
NEDS
4
5
PA; NEDS
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR
3
NEDS
PA; QL (27 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 74
Drug Name VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR
Drug Tier 3
Requirements /Limits
Drug Name
PA; QL (27 per 90 days)
JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR
3
JANUVIA ORAL TABLET
3
JENTADUETO ORAL TABLET
4
KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR
3
metformin oral tablet
1
metformin oral tablet extended release 24 hr 500 mg
1
QL (360 per 90 days)
metformin oral tablet extended release 24 hr 750 mg
1
QL (180 per 90 days)
metformin oral tablet extended release (osm) 24 hr 1,000 mg
1
metformin oral tablet extended release (osm) 24 hr 500 mg
1
QL (360 per 90 days)
metformin oral tablet,er gast.retention 24 hr 500 mg
1
QL (360 per 90 days)
miglitol oral tablet
2
nateglinide oral tablet
1
ORAL HYPOGLYCEMIC AGENTS
acarbose oral tablet
2
ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR
4
FARXIGA ORAL TABLET
3
glimepiride oral tablet
1
glipizide oral tablet
1
glipizide oral tablet extended release 24hr 10 mg
1
glipizide oral tablet extended release 24hr 2.5 mg, 5 mg
1
glipizide-metformin oral tablet
1
INVOKAMET ORAL TABLET
3
ST
INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR
3
ST
INVOKANA ORAL TABLET
3
JANUMET ORAL TABLET
3
ST
QL (180 per 90 days) QL (270 per 90 days)
ST
Drug Tier
Requirements /Limits
QL (180 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 75
Drug Name
Drug Tier
Requirements /Limits
ONGLYZA ORAL TABLET
3
pioglitazone oral tablet
1
QL (90 per 90 days)
pioglitazoneglimepiride oral tablet
1
QL (90 per 90 days)
pioglitazonemetformin oral tablet
1
repaglinide oral tablet
Drug Name
Drug Tier
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
1
liothyronine intravenous solution
2
liothyronine oral tablet
2
1
SYNTHROID ORAL TABLET
4
repaglinidemetformin oral tablet
1
thyroid (pork) oral tablet
2 3
tolazamide oral tablet
1
THYROLAR-1 ORAL TABLET
3
tolbutamide oral tablet
1
THYROLAR-1/2 ORAL TABLET
3
TRADJENTA ORAL TABLET
4
THYROLAR-1/4 ORAL TABLET
3
XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR
3
THYROLAR-2 ORAL TABLET THYROLAR-3 ORAL TABLET
3
unithroid oral tablet
1
THYROID HORMONES
levothyroxine intravenous recon
soln 200 mcg, 500
mcg
1
levothyroxine oral
tablet
1
QL (270 per 90 days)
ST
Requirements /Limits
GASTROINTESTINAL AGENTS ANTIDIARRHEALS AND ANTISPASMODICS atropine injection syringe 0.05 mg/ml, 0.1 mg/ml
2
chlordiazepoxideclidinium oral capsule
2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 76
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
dicyclomine oral capsule
2
dronabinol oral capsule
4
dicyclomine oral solution
2
4
dicyclomine oral tablet
2
EMEND (FOSAPREPITANT ) INTRAVENOUS RECON SOLN
diphenoxylateatropine oral liquid
2
EMEND INTRAVENOUS RECON SOLN
4
diphenoxylateatropine oral tablet
2
EMEND ORAL CAPSULE
3
B/D PA
glycopyrrolate injection solution
2
3
B/D PA
glycopyrrolate oral tablet 1 mg, 2 mg
2
EMEND ORAL CAPSULE,DOSE PACK
B/D PA
2
methscopolamine oral tablet
2
EMEND ORAL SUSPENSION FOR RECONSTITUTIO N
3
loperamide oral capsule
granisetron (pf) intravenous solution
2
granisetron hcl intravenous solution
2
granisetron hcl oral tablet
2
meclizine oral tablet 12.5 mg, 25 mg
2
ondansetron hcl (pf) injection solution
2
ondansetron hcl (pf) injection syringe
2
ondansetron hcl intravenous solution
2
ondansetron hcl oral solution
4
ANTIEMETICS
AKYNZEO ORAL CAPSULE
4
ALOXI INTRAVENOUS SOLUTION
4
ANZEMET ORAL TABLET
4
aprepitant oral capsule
2
aprepitant oral capsule,dose pack
2
compro rectal suppository
2
B/D PA
B/D PA B/D PA B/D PA
B/D PA
B/D PA
B/D PA
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 77
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
CREON ORAL CAPSULE,DELAY ED RELEASE(DR/EC)
3
PANCREAZE ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10,500-35,50061,500 UNIT, 16,800-56,80098,400 UNIT, 2,6006,200- 10,850 UNIT, 21,000-54,70083,900 UNIT, 4,20014,200- 24,600 UNIT
3
4
ondansetron hcl oral tablet
2
B/D PA
ondansetron oral tablet,disintegrating
2
B/D PA
phenadoz rectal suppository 25 mg
2
PA
prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml)
2
prochlorperazine maleate oral tablet
2
prochlorperazine rectal suppository
2
promethazine injection solution
2
PA
promethazine oral syrup
2
PA
promethazine oral tablet
2
PA
PERTZYE ORAL CAPSULE,DELAY ED RELEASE(DR/EC)
promethazine rectal suppository
2
PA
VIOKACE ORAL TABLET
4
SANCUSO TRANSDERMAL PATCH WEEKLY
5
QL (4 per 28 days); NEDS
4
scopolamine base transdermal patch 3 day
2
TRANSDERMSCOP TRANSDERMAL PATCH 3 DAY
3
ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10,000-34,000 55,000 UNIT, 15,000-51,000 82,000 UNIT, 20,000-68,000 109,000 UNIT, 25,000-85,000136,000 UNIT, 3,000-10,00016,000 UNIT
DIGESTIVE ENZYMES
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 78
Drug Name ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 40,000-136,000218,000 UNIT
Drug Tier 5
Requirements /Limits
Drug Name
NEDS
AMITIZA ORAL CAPSULE
4
APRISO ORAL CAPSULE,EXTEN DED RELEASE 24HR
4
ASACOL HD ORAL TABLET,DELAYE D RELEASE (DR/EC)
3
balsalazide oral capsule
2
CANASA RECTAL SUPPOSITORY
3
colocort rectal enema
2
constulose oral solution
2
CORTIFOAM RECTAL FOAM
3
CUVPOSA ORAL SOLUTION
4
DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS)
3
DIPENTUM ORAL CAPSULE
4
ENTEREG ORAL CAPSULE
4
enulose oral solution
2
GATTEX 30-VIAL SUBCUTANEOUS KIT
5
H2-RECEPTOR ANTAGONISTS famotidine (pf) intravenous solution
2
famotidine (pf)-nacl (iso-os) intravenous piggyback
2
famotidine intravenous solution
2
famotidine oral suspension
2
famotidine oral tablet 20 mg, 40 mg
2
nizatidine oral capsule
2
nizatidine oral solution
2
ranitidine hcl injection solution
2
ranitidine hcl oral capsule
1
ranitidine hcl oral syrup
1
ranitidine hcl oral tablet 150 mg, 300 mg
1
MISCELLANEOUS GASTROINTESTINAL AGENTS alosetron oral tablet
4
PA
Drug Tier
Requirements /Limits PA; QL (180 per 90 days)
PA; NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 79
Drug Name
Drug Tier
GATTEX ONEVIAL SUBCUTANEOUS KIT
5
generlac oral solution
2
hydrocortisone rectal enema
2
hydrocortisone topical cream with perineal applicator
2
KRISTALOSE ORAL PACKET
3
lactulose oral solution
2
LIALDA ORAL TABLET,DELAYE D RELEASE (DR/EC)
4
LINZESS ORAL CAPSULE
3
mesalamine oral tablet,delayed release (dr/ec) 1.2 gram
4
MESALAMINE ORAL TABLET,DELAYE D RELEASE (DR/EC) 800 MG
3
mesalamine rectal enema
4
mesalamine with cleansing wipe rectal enema kit
4
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
PA; NEDS
metoclopramide hcl injection solution
2
metoclopramide hcl injection syringe
2
metoclopramide hcl oral solution
2
metoclopramide hcl oral tablet
2
metoclopramide hcl oral tablet,disintegrating
2
MOVANTIK ORAL TABLET
4
NUTRESTORE ORAL POWDER IN PACKET
4
opium tincture oral tincture
2
paregoric oral liquid
2
PENTASA ORAL CAPSULE, EXTENDED RELEASE
3
proctozone-hc topical cream with perineal applicator
2
RELISTOR ORAL TABLET
4
PA
RELISTOR SUBCUTANEOUS SOLUTION
4
PA; QL (16.8 per 28 days)
RELISTOR SUBCUTANEOUS SYRINGE
4
PA
PA
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 80
Drug Name
Drug Tier
SUCRAID ORAL SOLUTION
5
sulfasalazine oral tablet
1
sulfasalazine oral tablet,delayed release (dr/ec)
2
ursodiol oral capsule
2
ursodiol oral tablet
2
Requirements /Limits
Drug Name
NEDS
omeprazole oral capsule,delayed release(dr/ec)
2
omeprazole-sodium bicarbonate oral capsule
4
omeprazole-sodium bicarbonate oral packet
4
pantoprazole intravenous recon soln
4
pantoprazole oral tablet,delayed release (dr/ec)
2
rabeprazole oral tablet,delayed release (dr/ec)
2
OTHER ULCER THERAPY
amoxicilclarithromylansopraz oral combo pack
4
carafate oral suspension
2
misoprostol oral tablet
2
PYLERA ORAL CAPSULE
4
sucralfate oral tablet
2
PROTON PUMP INHIBITORS
Drug Tier
Requirements /Limits
IMMUNOLOGY AND HEMATOLOGY ALPHA 1-PROTEINASE INHIBITOR ARALAST NP INTRAVENOUS RECON SOLN
5
PA; NEDS
GLASSIA INTRAVENOUS SOLUTION
5
PA; NEDS
esomeprazole magnesium oral capsule,delayed release(dr/ec)
4
PA; NEDS
2
PROLASTIN-C INTRAVENOUS RECON SOLN
5
esomeprazole sodium intravenous recon soln
PA
2
ZEMAIRA INTRAVENOUS RECON SOLN
4
lansoprazole oral capsule,delayed release(dr/ec) omeppi oral capsule
4
COLONY STIMULATING FACTORS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 81
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML
5
PA; NEDS
EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML
4
PA
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML
4
PA
NEULASTA SUBCUTANEOUS SYRINGE
5
QL (1.2 per 28 days); NEDS
5
QL (1.2 per 28 days); NEDS
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML
4
NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR NEUPOGEN INJECTION SOLUTION
5
NEDS
5
NEDS
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML, 60 MCG/0.3 ML
5
NEUPOGEN INJECTION SYRINGE PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML
4
PA
PROCRIT INJECTION SOLUTION 20,000 UNIT/2 ML
3
PA
PA
PA; NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 82
Drug Name
Drug Tier
PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML
5
ZARXIO INJECTION SYRINGE
5
Requirements /Limits
Drug Name
PA; NEDS
GAMMAGARD LIQUID INJECTION SOLUTION
5
PA; NEDS
GAMMAGARD SD (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN
5
PA; NEDS
GAMMAKED INJECTION SOLUTION
4
PA
GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION
5
PA; NEDS
GAMMAPLEX INTRAVENOUS SOLUTION
5
PA; NEDS
GAMUNEX-C INJECTION SOLUTION
5
PA; NEDS
HEPAGAM B INJECTION SOLUTION
4
HIZENTRA SUBCUTANEOUS SOLUTION
5
HYPERHEP B S/D INTRAMUSCULA R SOLUTION
4
HYPERHEP B S/D INTRAMUSCULA R SYRINGE
4
NEDS
IMMUNOGLOBULINS
ADAGEN INTRAMUSCULA R SOLUTION
5
NEDS
BIVIGAM INTRAVENOUS SOLUTION
5
PA; NEDS
CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM
5
PA; NEDS
CUVITRU SUBCUTANEOUS SOLUTION
5
CYTOGAM INTRAVENOUS SOLUTION 50 MG/ML
4
FLEBOGAMMA DIF INTRAVENOUS SOLUTION
5
GAMASTAN S/D INTRAMUSCULA R SOLUTION
3
PA; NEDS
PA; NEDS
PA
Drug Tier
Requirements /Limits
PA; NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 83
Drug Name
Drug Tier
HYPERHEP B S-D NEONATAL INTRAMUSCULA R SYRINGE
4
HYPERRAB S/D (PF) INTRAMUSCULA R SOLUTION
3
HYPERTET S/D (PF) INTRAMUSCULA R SYRINGE
4
HYQVIA SUBCUTANEOUS SOLUTION
5
IMOGAM RABIESHT (PF) INTRAMUSCULA R SOLUTION
4
NABI-HB INTRAMUSCULA R SOLUTION
4
OCTAGAM INTRAVENOUS SOLUTION
5
PRIVIGEN INTRAVENOUS SOLUTION
5
RHOPHYLAC INJECTION SYRINGE
4
SYNAGIS INTRAMUSCULA R SOLUTION 50 MG/0.5 ML
5
Requirements /Limits
Drug Name
Drug Tier
THYMOGLOBULI N INTRAVENOUS RECON SOLN
5
VARIZIG INTRAMUSCULA R SOLUTION
3
WINRHO SDF INJECTION SOLUTION
4
Requirements /Limits NEDS
INTERFERONS AND MS THERAPY
B/D PA; NEDS
PA; NEDS
PA; NEDS
NEDS
ACTIMMUNE SUBCUTANEOUS SOLUTION
5
NEDS
AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR
5
PA; QL (62 per 31 days); NEDS
AUBAGIO ORAL TABLET
5
PA; NEDS
AVONEX (WITH ALBUMIN) INTRAMUSCULA R KIT
5
PA; NEDS
AVONEX INTRAMUSCULA R PEN INJECTOR KIT
5
PA; NEDS
AVONEX INTRAMUSCULA R SYRINGE KIT
5
PA; NEDS
BETASERON SUBCUTANEOUS KIT
5
PA; NEDS
COPAXONE SUBCUTANEOUS SYRINGE
5
PA; NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 84
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML
5
QL (4 per 28 days); NEDS
PLEGRIDY SUBCUTANEOUS PEN INJECTOR
5
PA; NEDS
PLEGRIDY SUBCUTANEOUS SYRINGE
5
PA; NEDS
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE
5
PA; NEDS
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR
5
PA; NEDS
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE
5
PA; NEDS
SYLATRON SUBCUTANEOUS KIT
5
NEDS
EXTAVIA SUBCUTANEOUS KIT
5
PA; NEDS
EXTAVIA SUBCUTANEOUS RECON SOLN
5
PA; NEDS
GILENYA ORAL CAPSULE
5
glatopa subcutaneous syringe
5
INTRON A INJECTION RECON SOLN
5
NEDS
INTRON A INJECTION SOLUTION
5
NEDS
LEMTRADA INTRAVENOUS SOLUTION
5
PA; QL (6 per 365 days); NEDS
PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR
5
QL (4 per 28 days); NEDS
PEGASYS SUBCUTANEOUS SOLUTION
5
QL (4 per 28 days); NEDS
MISCELLANEOUS IMMUNOLOGIC AND HEMATOLOGIC AGENTS 5
NEDS
PEGASYS SUBCUTANEOUS SYRINGE
5
QL (4 per 28 days); NEDS
BENLYSTA INTRAVENOUS RECON SOLN
5
NEDS
PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML
5
QL (4 per 28 days); NEDS
BENLYSTA SUBCUTANEOUS AUTO-INJECTOR BENLYSTA SUBCUTANEOUS SYRINGE
5
NEDS
PA; NEDS NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 85
Drug Name
Drug Tier
Requirements /Limits
Drug Name
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT
5
PA; NEDS
CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT
5
PA; NEDS
CIMZIA SUBCUTANEOUS SYRINGE KIT
5
ENBREL SUBCUTANEOUS RECON SOLN
5
ENBREL SUBCUTANEOUS SYRINGE
5
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR
5
ENDARI ORAL POWDER IN PACKET
5
FLEXBUMIN 5 % INTRAVENOUS PARENTERAL SOLUTION
4
HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT
5
PA; NEDS
QL (16 per 28 days); NEDS QL (8 per 28 days); NEDS QL (8 per 28 days); NEDS
NEDS
QL (5.6 per 28 days); NEDS
Drug Tier
Requirements /Limits
HUMIRA PEN PSORIASISUVEITIS SUBCUTANEOUS PEN INJECTOR KIT
5
QL (5.6 per 28 days); NEDS
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT
5
QL (5.6 per 28 days); NEDS
HUMIRA SUBCUTANEOUS SYRINGE KIT
5
QL (5.6 per 28 days); NEDS
INFLECTRA INTRAVENOUS RECON SOLN
5
NEDS
KINERET SUBCUTANEOUS SYRINGE
5
PA; QL (18.8 per 28 days); NEDS
MOZOBIL SUBCUTANEOUS SOLUTION
5
PA; NEDS
NPLATE SUBCUTANEOUS RECON SOLN
5
PA; NEDS
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR
5
PA; NEDS
ORENCIA SUBCUTANEOUS SYRINGE
5
PA; NEDS
OTEZLA ORAL TABLET
5
PA; NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 86
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
OTEZLA STARTER ORAL TABLETS,DOSE PACK
5
PA; NEDS
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR
PROMACTA ORAL TABLET
5
PA; NEDS
VACCINES
5
NEDS
ACTHIB (PF) INTRAMUSCULA R RECON SOLN
3
REMICADE INTRAVENOUS RECON SOLN
5
PA; NEDS
SIMPONI SUBCUTANEOUS SYRINGE
5
PA; NEDS
ADACEL(TDAP ADOLESN/ADULT )(PF) INTRAMUSCULA R SUSPENSION
3
SIMPONI SUBCUTANEOUS PEN INJECTOR
3
SOLIRIS INTRAVENOUS SOLUTION
5
NEDS
ADACEL(TDAP ADOLESN/ADULT )(PF) INTRAMUSCULA R SYRINGE
STELARA INTRAVENOUS SOLUTION
5
PA; NEDS
3
STELARA SUBCUTANEOUS SOLUTION
5
PA; NEDS
BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTIO N
5
PA; NEDS
BEXSERO INTRAMUSCULA R SYRINGE
3
STELARA SUBCUTANEOUS SYRINGE
5
PA; NEDS
BOOSTRIX TDAP INTRAMUSCULA R SUSPENSION
3
SYLVANT INTRAVENOUS RECON SOLN
5
PA; LA; NEDS
BOOSTRIX TDAP INTRAMUSCULA R SYRINGE
3
TYSABRI INTRAVENOUS SOLUTION
XELJANZ ORAL TABLET
5
5
Requirements /Limits PA; NEDS
3 DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULA R SUSPENSION Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 87
PA; NEDS
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
INFANRIX (DTAP) (PF) INTRAMUSCULA R SUSPENSION
3
INFANRIX (DTAP) (PF) INTRAMUSCULA R SYRINGE
3
IPOL INJECTION SUSPENSION
3
IXIARO (PF) INTRAMUSCULA R SYRINGE
3
3
ENGERIX-B (PF) INTRAMUSCULA R SUSPENSION
3
B/D PA
ENGERIX-B (PF) INTRAMUSCULA R SYRINGE
3
B/D PA
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SUSPENSION
3
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SYRINGE
3
GARDASIL 9 (PF) INTRAMUSCULA R SUSPENSION
3
KINRIX (PF) INTRAMUSCULA R SUSPENSION
3
GARDASIL 9 (PF) INTRAMUSCULA R SYRINGE
3
KINRIX (PF) INTRAMUSCULA R SYRINGE
3
HAVRIX (PF) INTRAMUSCULA R SUSPENSION
3
MENACTRA (PF) INTRAMUSCULA R SOLUTION
3
MENHIBRIX (PF) INTRAMUSCULA R RECON SOLN
3
HAVRIX (PF) INTRAMUSCULA R SYRINGE
3
MENOMUNE A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN
3
HIBERIX (PF) INTRAMUSCULA R RECON SOLN IMOVAX RABIES VACCINE (PF) INTRAMUSCULA R RECON SOLN
3
MENOMUNE A/C/Y/W-135 SUBCUTANEOUS RECON SOLN
3
B/D PA
B/D PA
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 88
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
MENVEO A-C-YW-135-DIP (PF) INTRAMUSCULA R KIT
3
RECOMBIVAX HB (PF) INTRAMUSCULA R SUSPENSION
3
B/D PA
M-M-R II (PF) SUBCUTANEOUS RECON SOLN
3
3
B/D PA
PEDIARIX (PF) INTRAMUSCULA R SYRINGE
3
RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE
3
PEDVAX HIB (PF) INTRAMUSCULA R SOLUTION
3
ROTARIX ORAL SUSPENSION FOR RECONSTITUTIO N
3
PENTACEL (PF) INTRAMUSCULA R KIT
4
ROTATEQ VACCINE ORAL SOLUTION
3
PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULA R RECON SOLN
3
STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTIO N
4
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTIO N
3
TENIVAC (PF) INTRAMUSCULA R SUSPENSION TENIVAC (PF) INTRAMUSCULA R SYRINGE
3
QUADRACEL (PF) INTRAMUSCULA R SUSPENSION
3
3
RABAVERT (PF) INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N
3
TETANUS,DIPHTH ERIA TOX PED(PF) INTRAMUSCULA R SUSPENSION TETANUSDIPHTHERIA TOXOIDS-TD INTRAMUSCULA R SUSPENSION
3
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 89
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTIO N
4
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTIO N
TRUMENBA INTRAMUSCULA R SYRINGE
3
LIFESTYLE MODIFICATION
TWINRIX (PF) INTRAMUSCULA R SUSPENSION
3
TWINRIX (PF) INTRAMUSCULA R SYRINGE
3
TYPHIM VI INTRAMUSCULA R SOLUTION
3
TYPHIM VI INTRAMUSCULA R SYRINGE
3
VAQTA (PF) INTRAMUSCULA R SUSPENSION
3
VAQTA (PF) INTRAMUSCULA R SYRINGE
3
SMOKING CESSATION bupropion hcl (smoking deter) oral tablet extended release 12 hr
2
CHANTIX CONTINUING MONTH BOX ORAL TABLET
3
CHANTIX ORAL TABLET
3
CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK
3
3
NICOTROL INHALATION CARTRIDGE
4
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTIO N
3
NICOTROL NS NASAL SPRAY,NONAEROSOL
4
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTIO N
3
OPHTHALMOLOGY MISCELLANEOUS OPHTHALMIC AGENTS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 90
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
ALOCRIL OPHTHALMIC (EYE) DROPS
3
LUCENTIS INTRAVITREAL SYRINGE
5
ALOMIDE OPHTHALMIC (EYE) DROPS
3
olopatadine ophthalmic (eye) drops
2
atropine ophthalmic (eye) drops
2
3
azelastine ophthalmic (eye) drops
2
PATADAY OPHTHALMIC (EYE) DROPS
3
BEPREVE OPHTHALMIC (EYE) DROPS
4
PAZEO OPHTHALMIC (EYE) DROPS
3
cromolyn ophthalmic (eye) drops
2
RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS
3
CYSTARAN OPHTHALMIC (EYE) DROPS
5
RESTASIS OPHTHALMIC (EYE) DROPPERETTE
EMADINE OPHTHALMIC (EYE) DROPS
4
OPHTHALMIC ANTIINFECTIVE/STEROID COMBINATIONS
epinastine ophthalmic (eye) drops
2
3
EYLEA INTRAVITREAL SOLUTION
5
BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSI ON
3
LACRISERT OPHTHALMIC (EYE) INSERT
3
BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT
LUCENTIS INTRAVITREAL SOLUTION
5
neomycinbacitracin-poly-hc ophthalmic (eye) ointment
2
NEDS
NEDS
NEDS
Requirements /Limits NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 91
Drug Name
Drug Tier
neo-polycin hc ophthalmic (eye) ointment
2
sulfacetamideprednisolone ophthalmic (eye) drops
1
TOBRADEX OPHTHALMIC (EYE) OINTMENT
3
TOBRADEX ST OPHTHALMIC (EYE) DROPS,SUSPENSI ON
3
tobramycindexamethasone ophthalmic (eye) drops,suspension
2
ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSI ON
4
Requirements /Limits
Drug Name
Drug Tier
BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSI ON
4
BLEPH-10 OPHTHALMIC (EYE) DROPS
4
CILOXAN OPHTHALMIC (EYE) OINTMENT
3
ciprofloxacin hcl ophthalmic (eye) drops
2
erythromycin ophthalmic (eye) ointment
2
gatifloxacin ophthalmic (eye) drops
2
gentak ophthalmic (eye) ointment
2 2
OPHTHALMIC ANTI-INFECTIVES
gentamicin ophthalmic (eye) drops
AZASITE OPHTHALMIC (EYE) DROPS
4
gentamicin ophthalmic (eye) ointment
2
bacitracin ophthalmic (eye) ointment
2
levofloxacin ophthalmic (eye) drops
2
bacitracinpolymyxin b ophthalmic (eye) ointment
2
MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS
4
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 92
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
moxifloxacin ophthalmic (eye) drops
2
sulfacetamide sodium ophthalmic (eye) drops
2
NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSI ON
3
sulfacetamide sodium ophthalmic (eye) ointment
2
1
neomycinbacitracinpolymyxin ophthalmic (eye) ointment
2
tobramycin ophthalmic (eye) drops trifluridine ophthalmic (eye) drops
2
neomycinpolymyxingramicidin ophthalmic (eye) drops
2
VIGAMOX OPHTHALMIC (EYE) DROPS
3
3
neo-polycin ophthalmic (eye) ointment
2
ZIRGAN OPHTHALMIC (EYE) GEL
ofloxacin ophthalmic (eye) drops
2
polycin ophthalmic (eye) ointment
2
polymyxin b sulftrimethoprim ophthalmic (eye) drops
2
PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSI ON
4
PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT
4
Requirements /Limits
OPHTHALMIC ANTIINFLAMMATORY AGENTS ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE
4
bromfenac ophthalmic (eye) drops
2
diclofenac sodium ophthalmic (eye) drops
1
flurbiprofen sodium ophthalmic (eye) drops
2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 93
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSI ON
4
TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) DROPPERETTE
4
ketorolac ophthalmic (eye) drops
2
TIMOPTIC OPHTHALMIC (EYE) DROPS
4
NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSI ON
4
OPHTHALMIC STEROIDS
OPHTHALMIC BETA BLOCKERS BETIMOL OPHTHALMIC (EYE) DROPS
4
carteolol ophthalmic (eye) drops
2
ISTALOL OPHTHALMIC (EYE) DROPS, ONCE DAILY
4
levobunolol ophthalmic (eye) drops 0.5 %
2
metipranolol ophthalmic (eye) drops
2
timolol maleate ophthalmic (eye) drops
1
timolol maleate ophthalmic (eye) gel forming solution
1
ALREX OPHTHALMIC (EYE) DROPS,SUSPENSI ON
4
dexamethasone sodium phosphate ophthalmic (eye) drops
2
DUREZOL OPHTHALMIC (EYE) DROPS
3
FLAREX OPHTHALMIC (EYE) DROPS,SUSPENSI ON
4
fluorometholone ophthalmic (eye) drops,suspension
2
FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSI ON
4
Requirements /Limits
FML S.O.P. 4 OPHTHALMIC (EYE) OINTMENT Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 94
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
LOTEMAX OPHTHALMIC (EYE) DROPS,GEL
4
OTHER GLAUCOMA AGENTS 3
LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSI ON
4
ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % apraclonidine ophthalmic (eye) drops
2
LOTEMAX OPHTHALMIC (EYE) OINTMENT
4
3
MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSI ON
4
AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSI ON betaxolol ophthalmic (eye) drops
1
OZURDEX INTRAVITREAL IMPLANT
5
3
PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSI ON
3
BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSI ON bimatoprost ophthalmic (eye) drops
4
prednisolone acetate ophthalmic (eye) drops,suspension
2
brimonidine ophthalmic (eye) drops
2
prednisolone sodium phosphate ophthalmic (eye) drops
2
COMBIGAN OPHTHALMIC (EYE) DROPS
4
4
RETISERT INTRAVITREAL IMPLANT
5
COSOPT (PF) OPHTHALMIC (EYE) DROPPERETTE
TRIESENCE (PF) INTRAOCULAR SUSPENSION
4
dorzolamide ophthalmic (eye) drops
2
NEDS
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 95
Drug Name
Drug Tier
dorzolamide-timolol ophthalmic (eye) drops
2
IOPIDINE OPHTHALMIC (EYE) DROPPERETTE
4
latanoprost ophthalmic (eye) drops
2
LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %
3
PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS
3
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %
2
SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSI ON
3
TRAVATAN Z OPHTHALMIC (EYE) DROPS
3
ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE
4
Requirements /Limits
Drug Name
Drug Tier
BECONASE AQ NASAL SPRAY,NONAEROSOL
4
budesonide nasal spray,non-aerosol
2
flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)
2
fluticasone nasal spray,suspension
2
mometasone nasal spray,non-aerosol
2
NASONEX NASAL SPRAY,NONAEROSOL
4
olopatadine nasal spray,non-aerosol
2
OMNARIS NASAL SPRAY,NONAEROSOL
4
triamcinolone acetonide nasal aerosol,spray
2
Requirements /Limits
OTIC PREPARATIONS
OTIC AND NASAL PREPARATIONS
acetic acid irrigation solution
2
acetic acid otic (ear) solution
2
CIPRO HC OTIC (EAR) DROPS,SUSPENSI ON
4
NASAL PREPARATIONS Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 96
Drug Name
Drug Tier
CIPRODEX OTIC (EAR) DROPS,SUSPENSI ON
3
ciprofloxacin hcl otic (ear) dropperette
2
COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSI ON
4
floxin otic (ear) drops
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
azelastine nasal aerosol,spray
2
azelastine nasal spray,non-aerosol
2
cetirizine oral solution 1 mg/ml
2
cyproheptadine oral syrup
2
cyproheptadine oral tablet
2
2
desloratadine oral tablet
2
QL (90 per 90 days)
fluocinolone acetonide oil otic (ear) drops
2
desloratadine oral tablet,disintegrating
2
QL (90 per 90 days)
2
hydrocortisoneacetic acid otic (ear) drops
2
diphenhydramine hcl injection solution 50 mg/ml
2
neomycinpolymyxin-hc ophthalmic (eye) drops,suspension
2
diphenhydramine hcl injection syringe hydroxyzine hcl oral solution 10 mg/5 ml
2
neomycinpolymyxin-hc otic (ear) drops,suspension
2
hydroxyzine hcl oral tablet
2 2
neomycinpolymyxin-hc otic (ear) solution
2
hydroxyzine pamoate oral capsule 25 mg, 50 mg
2
ofloxacin otic (ear) drops
2
levocetirizine oral solution levocetirizine oral tablet
2
RESPIRATORY AND ALLERGY ANTIHISTAMINES
QL (90 per 90 days)
EPINEPHRINE
adrenalin injection solution
2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 97
Drug Name
Drug Tier
AUVI-Q INJECTION AUTOINJECTOR
3
EPINEPHRINE INJECTION AUTOINJECTOR 0.15 MG/0.15 ML, 0.3 %, 0.3 MG/0.3 ML
4
EPINEPHRINE INJECTION AUTOINJECTOR 0.15 MG/0.3 ML
3
EPIPEN 2-PAK INJECTION AUTOINJECTOR
4
EPIPEN INJECTION AUTOINJECTOR
4
EPIPEN JR 2-PAK INJECTION AUTOINJECTOR
3
EPIPEN JR INJECTION AUTOINJECTOR
3
Requirements /Limits
INHALED BETA-AGONISTS albuterol sulfate inhalation solution for nebulization
1
B/D PA
ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE
4
QL (90 per 90 days)
Drug Name
Drug Tier
Requirements /Limits
BROVANA INHALATION SOLUTION FOR NEBULIZATION
4
B/D PA; QL (360 per 90 days)
levalbuterol hcl inhalation solution for nebulization
2
B/D PA
LEVALBUTEROL TARTRATE INHALATION HFA AEROSOL INHALER
4
QL (90 per 90 days)
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION
4
B/D PA
PROAIR HFA INHALATION HFA AEROSOL INHALER
3
QL (102 per 90 days)
PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED
3
QL (12 per 90 days)
PROVENTIL HFA INHALATION HFA AEROSOL INHALER
4
QL (80 per 90 days)
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE
3
QL (180 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 98
Drug Name
Drug Tier
Requirements /Limits
Drug Name
STRIVERDI RESPIMAT INHALATION MIST
3
QL (12 per 90 days)
3
VENTOLIN HFA INHALATION HFA AEROSOL INHALER
3
QL (216 per 90 days)
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES)
XOPENEX HFA INHALATION HFA AEROSOL INHALER
4
QL (90 per 90 days)
budesonide inhalation suspension for nebulization
4
B/D PA
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE
3
QL (360 per 90 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION , 220 MCG/ACTUATION
3
QL (72 per 90 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION
3
QL (32 per 90 days)
PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED
3
QVAR INHALATION AEROSOL
3
INHALED STEROIDS ALVESCO INHALATION HFA AEROSOL INHALER
3
QL (37 per 90 days)
ASMANEX HFA INHALATION HFA AEROSOL INHALER
3
QL (39 per 90 days)
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)
3
QL (3 per 90 days)
Drug Tier
Requirements /Limits
QL (53 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 99
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
MISCELLANEOUS PULMONARY AGENTS
ESBRIET ORAL CAPSULE
5
PA; NEDS
acetylcysteine solution
2
B/D PA
ESBRIET ORAL TABLET
5
PA; NEDS
ADCIRCA ORAL TABLET
5
PA; QL (62 per 31 days); NEDS
ipratropium bromide inhalation solution
1
B/D PA
ipratropium bromide nasal spray,nonaerosol
1
ADEMPAS ORAL TABLET
5
PA; NEDS
ADVAIR DISKUS INHALATION BLISTER WITH DEVICE
3
QL (180 per 90 days)
ipratropiumalbuterol inhalation solution for nebulization
2
B/D PA
ADVAIR HFA INHALATION HFA AEROSOL INHALER
3
QL (36 per 90 days)
KALYDECO ORAL GRANULES IN PACKET
5
PA; NEDS
5
PA; NEDS
ATROVENT HFA INHALATION HFA AEROSOL INHALER
3
KALYDECO ORAL TABLET LETAIRIS ORAL TABLET
5
PA; NEDS
COMBIVENT RESPIMAT INHALATION MIST
4
montelukast oral granules in packet
2
QL (90 per 90 days)
montelukast oral tablet
2
QL (90 per 90 days)
cromolyn inhalation solution for nebulization
2
montelukast oral tablet,chewable
2
QL (90 per 90 days)
5
PA; NEDS
cromolyn oral concentrate
4
OFEV ORAL CAPSULE
5
PA; NEDS
DALIRESP ORAL TABLET
4
OPSUMIT ORAL TABLET ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG
4
PA
B/D PA
3 QL (39 per 90 DULERA days) INHALATION HFA AEROSOL INHALER Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 100
Drug Name
Drug Tier
Requirements /Limits
Drug Name
PA; NEDS
SYMBICORT INHALATION HFA AEROSOL INHALER
3
terbutaline subcutaneous solution
2
TRACLEER ORAL TABLET
5
PA; LA; NEDS
TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED
4
QL (3 per 90 days)
TYVASO INHALATION SOLUTION FOR NEBULIZATION
5
B/D PA; NEDS
TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION
5
B/D PA; NEDS
TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION
5
B/D PA; NEDS
TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION
5
B/D PA; NEDS
UPTRAVI ORAL TABLET
5
PA; NEDS
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG
5
ORKAMBI ORAL TABLET
5
PULMOZYME INHALATION SOLUTION
5
REVATIO ORAL SUSPENSION FOR RECONSTITUTIO N
5
PA; QL (180 per 30 days); NEDS
sildenafil intravenous solution
5
PA; QL (1163 per 31 days); NEDS
sildenafil oral tablet
2
PA; QL (270 per 90 days)
PA; NEDS B/D PA; NEDS
SPIRIVA RESPIMAT INHALATION MIST
3
QL (12 per 90 days)
SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE
3
QL (90 per 90 days)
STIOLTO RESPIMAT INHALATION MIST
3
QL (12 per 90 days)
Drug Tier
Requirements /Limits QL (30.6 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 101
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
UPTRAVI ORAL TABLETS,DOSE PACK
5
PA; NEDS
aminophylline intravenous solution 500 mg/20 ml
4
XOLAIR SUBCUTANEOUS RECON SOLN
5
PA; NEDS
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML
4
zafirlukast oral tablet
2
QL (180 per 90 days)
2
zileuton oral tablet, er multiphase 12 hr
4
QL (360 per 90 days)
theophylline oral tablet extended release 12 hr
2
ZYFLO CR ORAL TABLET, ER MULTIPHASE 12 HR
4
theophylline oral tablet extended release 24 hr
ZYFLO ORAL TABLET
4
QL (360 per 90 days)
Requirements /Limits
RHEUMATOLOGY AND MUSCULOSKELETAL
ORAL BETA-AGONISTS
GOUT THERAPY allopurinol oral tablet
1 2
albuterol sulfate oral syrup
1
albuterol sulfate oral tablet
1
allopurinol sodium intravenous recon soln
1
COLCRYS ORAL TABLET
3
albuterol sulfate oral tablet extended release 12 hr
QL (360 per 90 days)
5
NEDS
metaproterenol oral syrup
2
KRYSTEXXA INTRAVENOUS SOLUTION
2
probenecid oral tablet
2
metaproterenol oral tablet
2
probenecidcolchicine oral tablet
2
terbutaline oral tablet
ULORIC ORAL TABLET
3
ST; QL (90 per 90 days)
ZURAMPIC ORAL TABLET
4
PA
XANTHINES
aminophylline intravenous solution
250 mg/10 ml
2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 102
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
MISCELLANEOUS RHEUMATOLOGIC AGENTS
alendronate oral solution
2
ACTEMRA SUBCUTANEOUS SYRINGE
5
alendronate oral tablet 10 mg, 40 mg, 5 mg
2
QL (90 per 90 days)
DEPEN TITRATABS ORAL TABLET
4
alendronate oral tablet 35 mg, 70 mg
2
QL (12 per 84 days)
4
B/D PA
leflunomide oral tablet
2
BONIVA INTRAVENOUS SYRINGE
OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML
4
calcitonin (salmon) nasal spray,nonaerosol
2
etidronate disodium oral tablet
2
FORTEO SUBCUTANEOUS PEN INJECTOR
5
PA; QL (3 per 28 days); NEDS
4
RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML
4
FOSAMAX PLUS D ORAL TABLET
QL (12 per 84 days)
ibandronate intravenous solution
2
B/D PA
ibandronate intravenous syringe
2
ibandronate oral tablet
2
MIACALCIN INJECTION SOLUTION
4
RIDAURA ORAL CAPSULE
3
PROLIA SUBCUTANEOUS SYRINGE
4
PA
raloxifene oral tablet
1
QL (90 per 90 days)
OSTEOPOROSIS/BONE RESORPTION
PA; NEDS
QL (90 per 90 days)
QL (3 per 84 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 103
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
risedronate oral tablet 150 mg
2
QL (3 per 84 days)
finasteride oral tablet 5 mg
2
risedronate oral tablet 30 mg, 5 mg
2
QL (90 per 90 days)
2
risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack)
2
QL (12 per 84 days)
tamsulosin oral capsule,extended release 24hr
risedronate oral tablet,delayed release (dr/ec)
2
TYMLOS SUBCUTANEOUS PEN INJECTOR
3
zoledronic acid intravenous recon soln
4
zoledronic acid intravenous solution
4
zoledronic acidmannitol-water intravenous piggyback
4
ZOMETA INTRAVENOUS PIGGYBACK
5
QL (12 per 84 days)
Requirements /Limits
QL (180 per 90 days)
MISCELLANEOUS UROLOGICALS
bethanechol chloride oral tablet
2
CYSTAGON ORAL CAPSULE
4
ELMIRON ORAL CAPSULE
3
K-PHOS NO 2 ORAL TABLET
4
K-PHOS ORIGINAL ORAL TABLET,SOLUBL E
4
potassium citrate oral tablet extended release
2
URINARY ANTISPASMODICS
NEDS
UROLOGY BPH TREATMENT alfuzosin oral tablet extended release 24 hr
2
dutasteride oral capsule
2
QL (90 per 90 days) QL (90 per 90 days)
flavoxate oral tablet
2
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR
3
oxybutynin chloride oral syrup
2
oxybutynin chloride oral tablet
2
oxybutynin chloride oral tablet extended release 24hr
2
QL (180 per 90 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 104
Drug Name
Drug Tier
tolterodine oral capsule,extended release 24hr
2
tolterodine oral tablet
2
TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR
3
trospium oral capsule,extended release 24hr
2
trospium oral tablet
2
VESICARE ORAL TABLET
3
Requirements /Limits
QL (90 per 90 days)
VITAMINS AND SUPPLEMENTS ELECTROLYTES AND MISC. NUTRIENTS calcium chloride intravenous solution
2
calcium chloride intravenous syringe
2
calcium gluconate intravenous solution
2
cysteine (l-cysteine) intravenous solution
2
electrolyte-48 in d5w intravenous parenteral solution
2
HYPERLYTE CR INTRAVENOUS SOLUTION
4
B/D PA
Drug Name
Drug Tier
ISOLYTE S PH 7.4 INTRAVENOUS PARENTERAL SOLUTION
4
ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION
4
ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION
4
magnesium chloride injection solution
2
magnesium sulfate injection solution
2
magnesium sulfate injection syringe
2
NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION
4
NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION
4
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION
4
PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION
4
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 105
Drug Name
Drug Tier
sodium acetate intravenous solution
2
sodium lactate intravenous solution
2
sodium phosphate intravenous solution
2
Requirements /Limits
IV FAT EMULSIONS
intralipid intravenous emulsion 20 %
4
B/D PA
INTRALIPID INTRAVENOUS EMULSION 30 %
4
B/D PA
SMOFLIPID INTRAVENOUS EMULSION
4
B/D PA
IV SOLUTIONS: DEXTROSE AND LACTATED RINGERS
Drug Name
Drug Tier
d10 %-0.45 % sodium chloride intravenous parenteral solution
2
d2.5 %-0.45 % sodium chloride intravenous parenteral solution
2
d5 % and 0.9 % sodium chloride intravenous parenteral solution
2
d5 %-0.45 % sodium chloride intravenous parenteral solution
2
dextrose 10 % and 0.2 % nacl intravenous parenteral solution
2
dextrose 5%-0.2 % sod chloride intravenous parenteral solution
2
dextrose 5%-0.3 % sod.chloride intravenous parenteral solution
2
2
Requirements /Limits
dextrose 5 %lactated ringers intravenous parenteral solution
2
lactated ringers intravenous parenteral solution
2
potassium chloride in lr-d5 intravenous parenteral solution
2
dextrose with sodium chloride intravenous parenteral solution
ringer's intravenous parenteral solution
2
IV SOLUTIONS: DEXTROSEWATER
IV SOLUTIONS: DEXTROSESALINE
dextrose 10 % in water (d10w) intravenous parenteral solution
2
B/D PA
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 106
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
dextrose 20 % in water (d20w) intravenous parenteral solution
2
B/D PA
lmd 10 % in 0.9 % sodium chlor intravenous parenteral solution
2
dextrose 25 % in water (d25w) intravenous syringe
2
B/D PA
lmd 10 % in 5 % dextrose intravenous parenteral solution
2
dextrose 30 % in water (d30w) intravenous parenteral solution
2
B/D PA
IV SOLUTIONS: SALINE
dextrose 40 % in water (d40w) intravenous parenteral solution
2
dextrose 5 % in water (d5w) intravenous parenteral solution
2
dextrose 5 % in water (d5w) intravenous piggyback
2
dextrose 50 % in water (d50w) intravenous parenteral solution
2
dextrose 50 % in water (d50w) intravenous syringe
2
dextrose 70 % in water (d70w) intravenous parenteral solution
2
Requirements /Limits
sodium chloride 0.45 % intravenous parenteral solution
2
sodium chloride 0.45 % intravenous piggyback
2
sodium chloride 0.9 % intravenous parenteral solution
2
sodium chloride 0.9 % intravenous piggyback
2
sodium chloride 3 % intravenous parenteral solution
2
sodium chloride 5 % intravenous parenteral solution
2
B/D PA
sodium chloride intravenous parenteral solution
2
B/D PA
POTASSIUM REPLACEMENT
B/D PA
B/D PA
dextrose-kcl-nacl intravenous solution
2
effer-k oral tablet, effervescent 25 meq
2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 107
Drug Name
Drug Tier
k-effervescent oral tablet, effervescent
2
klor-con 10 oral tablet extended release
2
klor-con 8 oral tablet extended release
2
klor-con m10 oral tablet,er particles/crystals
2
klor-con m15 oral tablet,er particles/crystals
2
klor-con m20 oral tablet,er particles/crystals
2
klor-con oral packet
2
KLOR-CON/25 ORAL PACKET
Requirements /Limits
Drug Name
Drug Tier
potassium bicarbcitric acid oral tablet, effervescent
2
potassium chloridd5-0.45%nacl intravenous parenteral solution
2
potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l
2
potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l
2
2
4
potassium chloride intravenous piggyback
klor-con/ef oral tablet, effervescent
2
potassium chloride intravenous solution
2
K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ
4
potassium chloride oral capsule, extended release
2
2
k-tab oral tablet extended release 8 meq
2
potassium chloride oral liquid potassium chloride oral packet
2
potassium acetate intravenous solution 2 meq/ml
2
potassium chloride oral tablet extended release
2
potassium bicarb and chloride oral tablet, effervescent
2
potassium chloride oral tablet,er particles/crystals
2
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 108
Drug Name
Drug Tier
potassium chloride0.45 % nacl intravenous parenteral solution
2
potassium chlorided5-0.2%nacl intravenous parenteral solution 20 meq/l
2
potassium chlorided5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l
4
potassium chlorided5-0.3%nacl intravenous parenteral solution 20 meq/l
2
potassium chlorided5-0.9%nacl intravenous parenteral solution
2
potassium phosphate m-/d-basic intravenous solution
2
Requirements /Limits
PROTEIN REPLACEMENT amino acids 15 % intravenous parenteral solution
4
B/D PA
AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
Drug Name
Drug Tier
Requirements /Limits
AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
AMINOSYN II 8.5 %ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 109
Drug Name
Drug Tier
Requirements /Limits
Drug Name CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
CLINIMIX 4.25%D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
CLINIMIX 4.25%D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
CLINIMIX 5%D20W(SULFITEFREE) INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
freamine iii 10 % intravenous parenteral solution
2
B/D PA
AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
AMINOSYN-PF 7 % (SULFITEFREE) INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION
4
CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION
4
CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION
4
CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION
4
CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
Drug Tier
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 110
Drug Name
Drug Tier
Requirements /Limits
Drug Name calcitriol intravenous solution 1 mcg/ml
2
calcitriol oral capsule
2
calcitriol oral solution
2
calcium acetate oral capsule
2
calcium acetate oral tablet 667 mg
2
denta 5000 plus dental cream
2
dentagel dental gel
2
eliphos oral tablet
2
ESCAVITE ORAL TABLET,CHEWAB LE
4
FLUORABON ORAL DROPS
4 2
Drug Tier
HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
KABIVEN INTRAVENOUS EMULSION
4
B/D PA
NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION
4
PERIKABIVEN INTRAVENOUS EMULSION
4
premasol 10 % intravenous parenteral solution
4
PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION
4
travasol 10 % intravenous parenteral solution
4
TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
fluor-a-day (with xylitol) oral tablet,chewable 0.25 mg f (0.55 mg)236.79mg, 1 mg f (2.2 mg)-236.79 mg
TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION
4
B/D PA
FLUOR-A-DAY ORAL DROPS
4
fluoride (sodium) oral drops
2
fluoride (sodium) oral tablet
2
fluoride (sodium) oral tablet,chewable
2
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
VITAMINS AND MINERALS BERINERT INTRAVENOUS KIT
5
PA; NEDS
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 111
Drug Name
Drug Tier
fluoritab oral tablet,chewable
2
HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML (1 ML)
4
ludent fluoride oral tablet,chewable
2
multi-vit with fluoride-iron oral drops
2
multi-vitamin with fluoride oral drops
2
multivitamin with fluoride oral tablet,chewable
2
multivitamins with fluoride oral tablet,chewable
2
mvc-fluoride oral tablet,chewable
2
NEUT INTRAVENOUS SOLUTION
4
PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION
4
PARICALCITOL INTRAVENOUS SOLUTION
4
paricalcitol oral capsule
2
PHOSLYRA ORAL SOLUTION
4
Requirements /Limits
Drug Name
Drug Tier
POLY-VI-FLOR ORAL TABLET,CHEWAB LE
2
POLY-VI-FLOR WITH IRON ORAL TABLET,CHEWAB LE
2
prenatal vitamin oral tablet
2
PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE
4
PREVIDENT 5000 DRY MOUTH DENTAL GEL
4
PREVIDENT 5000 SENSITIVE DENTAL PASTE
4
sf 5000 plus dental cream
2
sf dental gel
2
triple vitamin with fluoride oral drops
2
tri-vit with fluoride and iron oral drops
2
tri-vitamin with fluoride oral drops
2
vitamins a,c,d and fluoride oral drops
2
ZEMPLAR INTRAVENOUS SOLUTION
4
Requirements /Limits
WOMEN'S HEALTH
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 112
Drug Name
Drug Tier
Requirements /Limits
CONTRACEPTIVES
Drug Name
Drug Tier
Requirements /Limits
camrese lo oral tablets,dose pack,3 month
2
QL (91 per 91 days)
camrese oral tablets,dose pack,3 month
2
QL (91 per 91 days)
caziant (28) oral tablet
2
chateal oral tablet
2
cryselle (28) oral tablet
2
cyclafem 1/35 (28) oral tablet
2
altavera (28) oral tablet
2
alyacen 1/35 (28) oral tablet
2
alyacen 7/7/7 (28) oral tablet
2
amethia lo oral tablets,dose pack,3 month
2
amethia oral tablets,dose pack,3 month
4
amethyst oral tablet
2
cyred oral tablet
2
apri oral tablet
2
2
aviane oral tablet
2
dasetta 1/35 (28) oral tablet
azurette (28) oral tablet
2
dasetta 7/7/7 (28) oral tablet
2
balziva (28) oral tablet
2
daysee oral tablets,dose pack,3 month
2
bekyree (28) oral tablet
2
desogestrel-ethinyl estradiol oral tablet
2
BEYAZ ORAL TABLET
4
2
blisovi 24 fe oral tablet
2
drospirenonee.estradiol-lm.fa oral tablet elinest oral tablet
2
blisovi fe 1.5/30 (28) oral tablet
2
ELLA ORAL TABLET
3
blisovi fe 1/20 (28) oral tablet
2
emoquette oral tablet
2
camila oral tablet
2
enpresse oral tablet
2
enskyce oral tablet
2
QL (91 per 91 days) QL (91 per 91 days)
QL (91 per 91 days)
QL (6 per 84 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 113
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
l norgest/e.estradiole.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7)
2
QL (91 per 91 days)
errin oral tablet
2
estarylla oral tablet
2
ethynodiol diac-eth estradiol oral tablet
2
falmina (28) oral tablet
2
larin 24 fe oral tablet
2
femynor oral tablet
2
2
gianvi (28) oral tablet
2
larin fe 1.5/30 (28) oral tablet
2
heather oral tablet
2
larin fe 1/20 (28) oral tablet
isibloom oral tablet
2
layolis fe oral tablet,chewable
2
jencycla oral tablet
2
leena 28 oral tablet
2
jolessa oral tablets,dose pack,3 month
2
levonorgestrelethinyl estrad oral tablet 0.15-0.03 mg
2
jolivette oral tablet
2 2
junel 1/20 (21) oral tablet
2
levonorgestrelethinyl estrad oral tablets,dose pack,3 month
2
juleber oral tablet
junel fe 1/20 (28) oral tablet
2
levora-28 oral tablet
2
lillow oral tablet
2
kaitlib fe oral tablet,chewable
2
LO LOESTRIN FE ORAL TABLET
4
kariva (28) oral tablet
2
loryna (28) oral tablet
2
kelnor 1/35 (28) oral tablet
2
low-ogestrel (28) oral tablet
2
kimidess (28) oral tablet
2
lutera (28) oral tablet
2
kurvelo oral tablet
2
lyza oral tablet
2
microgestin 1/20 (21) oral tablet
2
QL (91 per 91 days)
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 114
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
microgestin fe 1.5/30 (28) oral tablet
2
nortrel 7/7/7 (28) oral tablet
2
microgestin fe 1/20 (28) oral tablet
2
ocella oral tablet
2
philith oral tablet
2
mono-linyah oral tablet
2
2
mononessa (28) oral tablet
2
pirmella oral tablet 0.5/0.75/1 mg- 35 mcg portia oral tablet
2
myzilra oral tablet
2 4
quasense oral tablets,dose pack,3 month
2
NATAZIA ORAL TABLET necon 7/7/7 (28) oral tablet
2
rajani oral tablet
2 2
next choice one dose oral tablet
2
reclipsen (28) oral tablet
2
SAFYRAL ORAL TABLET
4
nora-be oral tablet noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)
2
setlakin oral tablets,dose pack,3 month
2
sharobel oral tablet
2
norethindrone (contraceptive) oral tablet
2
sprintec (28) oral tablet
2
sronyx oral tablet
2
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg
2
syeda oral tablet
2
tilia fe oral tablet
2
norethindronee.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7)
2
tri femynor oral tablet
2
tri-estarylla oral tablet
2
norgestimate-ethinyl estradiol oral tablet
2
tri-linyah oral tablet
2 2
norlyda oral tablet
2
tri-lo-estarylla oral tablet
Requirements /Limits
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 115
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
tri-lo-marzia oral tablet
2
MENEST ORAL TABLET 1.25 MG
4
PA
tri-lo-sprintec oral tablet
2
NUVARING VAGINAL RING
4
QL (3 per 84 days)
trinessa (28) oral tablet
2
ESTROGENS
2
DEPO-ESTRADIOL INTRAMUSCULA R OIL
4
trinessa lo oral tablet tri-previfem (28) oral tablet
2
4
tri-sprintec (28) oral tablet
2
DIVIGEL TRANSDERMAL GEL IN PACKET
3
trivora (28) oral tablet
2
ESTRACE VAGINAL CREAM estradiol oral tablet
2
velivet triphasic regimen (28) oral tablet
2
estradiol vaginal tablet
2
2
viorele (28) oral tablet
2
estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml
2
vienva oral tablet
3
wera (28) oral tablet
2
ESTRING VAGINAL RING
QL (1 per 90 days)
xulane transdermal patch weekly
2
FEMRING VAGINAL RING
3
QL (1 per 90 days)
zarah oral tablet
2
PREMARIN VAGINAL CREAM
3
zenchent (28) oral tablet
2
VAGIFEM VAGINAL TABLET
3
yuvafem vaginal tablet
2
ESTROGEN/PROGESTIN COMBINATIONS amabelz oral tablet
2
PA
fyavolv oral tablet
2
PA
jinteli oral tablet
2
PA
PA
MISCELLANEOUS WOMEN'S HEALTH AVC VAGINAL VAGINAL CREAM
4
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 116
Drug Name
Drug Tier
BRISDELLE ORAL CAPSULE
3
LUPRON DEPOT (3 MONTH) INTRAMUSCULA R SYRINGE KIT 11.25 MG
5
LUPRON DEPOT INTRAMUSCULA R SYRINGE KIT 3.75 MG
5
LUPRON DEPOTPED (3 MONTH) INTRAMUSCULA R SYRINGE KIT
5
LUPRON DEPOTPED INTRAMUSCULA R KIT 7.5 MG (PED)
5
METHYLERGONO VINE INJECTION SOLUTION
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
hydroxyprogesterone caproate intramuscular oil
2
MAKENA INTRAMUSCULA R OIL
5
medroxyprogesteron e intramuscular suspension
2
medroxyprogesteron e intramuscular syringe
2
medroxyprogesteron e oral tablet
2
norethindrone acetate oral tablet
2
progesterone in oil intramuscular oil
2 2
4
progesterone intramuscular oil
2
paroxetine mesylate oral capsule
2
progesterone micronized oral capsule
SYNAREL NASAL SPRAY,NONAEROSOL
3
VAGINAL ANTI-INFECTIVE/ANTIFUNGAL
PROGESTINS
NEDS
NEDS
NEDS
NEDS
CLEOCIN VAGINAL SUPPOSITORY
4
DEPO-PROVERA INTRAMUSCULA R SOLUTION
3
clindamycin phosphate vaginal cream
2
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE
4
CLINDESSE VAGINAL CREAM,EXTENDE D RELEASE
4
NEDS
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 117
Drug Name
Drug Tier
metronidazole vaginal gel
2
miconazole-3 vaginal suppository
2
terconazole vaginal cream
2
terconazole vaginal suppository
2
Requirements /Limits
Drug Name vandazole vaginal gel
Drug Tier
Requirements /Limits
2
Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 118
Index A abacavir ..................................3
abacavir-lamivudine ...............3
abacavir-lamivudinezidovudine ..........................3
ABELCET..............................1
ABILIFY MAINTENA........43
ABRAXANE........................21
ABSTRAL............................51
acamprosate..........................64
acarbose................................75
acebutolol .............................29
acetaminophen-caffdihydrocod........................50
acetaminophen-codeine........50
acetazolamide .......................32
acetazolamide sodium ..........32
acetic acid.............................96
acetylcysteine ............... 64, 100
acitretin.................................57
ACTEMRA ........................103
ACTHIB (PF).......................87
ACTIMMUNE .....................84
ACTOPLUS MET XR .........75
ACUVAIL (PF)....................93
acyclovir .................................6
acyclovir sodium ....................6
ADACEL(TDAP
ADOLESN/ADULT)(PF) 87
ADAGEN .............................83
adapalene..............................56
ADASUVE...........................43
ADCIRCA..........................100
adefovir...................................6
ADEMPAS.........................100
ADENOCARD.....................32
adenosine..............................32
adrenalin ...............................97
adriamycin............................21
adrucil...................................17
ADVAIR DISKUS .............100
ADVAIR HFA ...................100
afeditab cr.............................31
AFINITOR ...........................21
AFINITOR DISPERZ ..........21
AGGRENOX .......................28
a-hydrocort ...........................67
AKYNZEO...........................77
ala-cort..................................61
ALBENZA .............................3
albuterol sulfate ............98, 102
alclometasone .......................61
alcohol pads..........................70
ALDURAZYME ..................72
ALECENSA .........................21
alendronate .........................103
alfuzosin .............................104
ALIMTA ..............................18
ALINIA ..................................3
allopurinol ..........................102
allopurinol sodium..............102
almotriptan malate................46
ALOCRIL.............................91
ALOMIDE............................91
alosetron ...............................79
ALOXI..................................77
ALPHAGAN P.....................95
alprazolam ............................45
alprazolam intensol...............45
ALREX.................................94
altavera (28)........................113
ALUNBRIG .........................21
ALVESCO............................99
alyacen 1/35 (28) ................113
alyacen 7/7/7 (28)...............113
amabelz...............................116
amantadine hcl........................6
AMBISOME ..........................1
amcinonide ...........................61
amethia ...............................113
amethia lo ...........................113
amethyst..............................113
AMICAR ..............................28
amifostine crystalline ...........21
amikacin .................................1
amiloride...............................34
amiloride-hydrochlorothiazide
..........................................34
amino acids 15 % ...............109
aminocaproic acid.................28
aminophylline.....................102
AMINOSYN 10 % .............109
AMINOSYN 7 % WITH
ELECTROLYTES..........109
Index 1
AMINOSYN 8.5 % ............109
AMINOSYN II 10 %..........109
AMINOSYN II 15 %..........109
AMINOSYN II 7 %............109
AMINOSYN II 8.5 %.........109
AMINOSYN II 8.5 %ELECTROLYTES..........109
AMINOSYN-HBC 7%.......109
AMINOSYN-PF 10 % .......110
AMINOSYN-PF 7 %
(SULFITE-FREE) ..........110
AMINOSYN-RF 5.2 % ......110
amiodarone ...........................32
AMITIZA .............................79
amitriptyline .........................41
amlodipine ............................31
amlodipine-atorvastatin ........31
amlodipine-benazepril ..........31
amlodipine-olmesartan .........31
amlodipine-valsartan ............27
amlodipine-valsartan-hcthiazid
..........................................27
ammonium lactate ................57
amnesteem ............................56
amoxapine.............................41
amoxicil-clarithromy-lansopraz
..........................................81
amoxicillin......................13, 14
amoxicillin-pot clavulanate ..14
amphotericin b ........................1
ampicillin..............................14
ampicillin sodium .................14
ampicillin-sulbactam ............14
AMPYRA .............................84
ANADROL-50 .....................68
anagrelide .............................28
anastrozole ............................18
ANDRODERM ....................68
ANDROGEL ........................68
ANDROID............................68
ANZEMET ...........................77
apexicon e.............................61
APIDRA ...............................70
APIDRA SOLOSTAR..........70
APOKYN .............................55
apraclonidine ........................95
aprepitant ..............................77
apri...................................... 113
APRISO................................79
APTIOM...............................37
APTIVUS ...............................3
ARALAST NP .....................81
ARANESP (IN
POLYSORBATE)............82
ARCALYST.........................19
ARCAPTA NEOHALER.....98
ARESTIN .............................16
aripiprazole...........................43
ARISTADA..........................43
armodafinil ...........................46
ARRANON ..........................21
ARZERRA ...........................21
ASACOL HD .......................79
ASMANEX HFA .................99
ASMANEX TWISTHALER 99
aspirin-dipyridamole ............28
ASTAGRAF XL ..................20
atenolol ................................. 30
atenolol-chlorthalidone.........30
atomoxetine ..........................46
atorvastatin ...........................34
atovaquone .............................3
atovaquone-proguanil.............2
ATRIPLA ...............................3
atropine...........................76, 91
ATROVENT HFA .............100
AUBAGIO ...........................84
AURYXIA ...........................64
AUVI-Q................................98
AVASTIN ............................21
AVC VAGINAL ................116
aviane ................................. 113
AVONEX .............................84
AVONEX (WITH ALBUMIN)
.......................................... 84
azacitidine.............................21
AZACTAM ..........................11
AZACTAM IN DEXTROSE
(ISO-OSM).......................11
AZASAN..............................20
AZASITE .............................92
azathioprine ..........................20
azathioprine sodium .............20
azelastine ........................91, 97
AZELEX ..............................56
AZILECT .............................55
azithromycin.........................10
AZOPT .................................95
AZOR ...................................31
aztreonam .............................11
azurette (28)........................113
B baciim ...................................11
bacitracin ........................11, 92
bacitracin-polymyxin b.........92
baclofen ................................56
BACTROBAN NASAL .......59
balsalazide ............................79
balziva (28).........................113
BANZEL ..............................37
BARACLUDE........................6
BAVENCIO .........................21
BCG VACCINE, LIVE (PF) 87
BECONASE AQ ..................96
bekyree (28)........................113
BELEODAQ ........................21
benazepril .............................26
benazepril-hydrochlorothiazide
..........................................27
BENDEKA...........................17
BENICAR ............................27
BENICAR HCT ...................27
BENLYSTA .........................85
benztropine ...........................55
BEPREVE ............................91
BERINERT ........................111
BESIVANCE........................92
betamethasone dipropionate .61
betamethasone valerate.........61
betamethasone, augmented...61
BETASERON ......................84
betaxolol .........................30, 95
bethanechol chloride...........104
BETHKIS ...............................1
BETIMOL ............................94
BETOPTIC S........................95
bexarotene ............................21
BEXSERO............................87
BEYAZ...............................113
bicalutamide .........................18
BICILLIN C-R .....................14
BICILLIN L-A .....................14
BICNU..................................17
BIDIL ...................................37
BILTRICIDE..........................3
Index 2
bimatoprost ...........................95
bisoprolol fumarate...............30
bisoprolol-hydrochlorothiazide
..........................................30
BIVIGAM.............................83
bleo 15k ................................22
bleomycin .............................22
BLEPH-10 ............................92
BLEPHAMIDE ....................91
BLEPHAMIDE S.O.P. .........91
BLINCYTO ..........................22
blisovi 24 fe ........................113
blisovi fe 1.5/30 (28) ..........113
blisovi fe 1/20 (28) .............113
BONIVA.............................103
BOOSTRIX TDAP...............87
BOSULIF .............................22
BRILINTA ...........................28
brimonidine...........................95
BRISDELLE.......................117
BRIVIACT ...........................38
bromfenac .............................93
bromocriptine .......................55
BROVANA ..........................98
budesonide ................67, 96, 99
bumetanide ...........................34
BUPHENYL.........................72
bupivacaine (pf)..............47, 58
BUPRENEX .........................49
BUPRENORPHINE .............49
buprenorphine hcl .................49
buprenorphine-naloxone.......49
bupropion hcl........................41
bupropion hcl (smoking deter)
..........................................90
buspirone ..............................45
busulfan ................................17
BUSULFEX .........................17
butorphanol tartrate ........46, 50
BUTRANS ...........................50
BYDUREON ........................74
BYETTA ..............................74
BYSTOLIC...........................30
C cabergoline ...........................55
CABOMETYX.....................22
calcipotriene .........................57
calcipotriene-betamethasone 57
calcitonin (salmon) .............103
calcitrene ..............................57
calcitriol........................57, 111
calcium acetate ...................111
calcium chloride .................105
CALCIUM DISODIUM
VERSENATE...................64
calcium gluconate...............105
camila ................................. 113
CAMPTOSAR .....................22
camrese...............................113
camrese lo...........................113
CANASA .............................79
CANCIDAS ...........................2
candesartan ...........................27
candesartan-hydrochlorothiazid
.......................................... 28
CAPASTAT ...........................6
CAPEX................................. 61
CAPRELSA .........................22
captopril................................27
captopril-hydrochlorothiazide
.......................................... 27
CARAC ................................57
carafate ................................. 81
CARBAGLU........................64
carbamazepine......................38
carbidopa ..............................55
carbidopa-levodopa ..............55
carbidopa-levodopaentacapone........................55
carboplatin............................22
CARDIZEM LA...................31
CARDURA XL ....................27
CARIMUNE NF
NANOFILTERED ...........83
CARNITOR (SUGAR-FREE)
.......................................... 64
carteolol................................94
cartia xt................................. 31
carvedilol..............................30
CASPOFUNGIN....................2
CAYSTON ...........................11
caziant (28).........................113
cefaclor ................................... 8
cefadroxil................................8
cefazolin ................................. 8
cefazolin in dextrose (iso-os) .8
cefdinir ................................... 8
cefepime ................................. 8
CEFEPIME IN DEXTROSE 5
%.........................................8
cefepime in dextrose,iso-osm .8
cefixime ..................................8
cefotaxime ..............................8
cefotetan .................................9
CEFOTETAN IN
DEXTROSE, ISO-OSM.....9
cefoxitin..................................9
cefoxitin in dextrose, iso-osm 9
cefpodoxime ...........................9
cefprozil..................................9
ceftazidime .............................9
CEFTAZIDIME IN D5W ......9
ceftibuten ................................9
ceftriaxone ..............................9
CEFTRIAXONE ....................9
ceftriaxone in dextrose,iso-os.9
cefuroxime axetil....................9
cefuroxime sodium .................9
celecoxib.........................53, 54
CELLCEPT INTRAVENOUS
..........................................20
CELONTIN ..........................38
cephalexin...............................9
CERDELGA.........................72
CEREBYX ...........................38
CEREZYME ........................72
cetirizine ...............................97
cevimeline ............................64
CHANTIX ............................90
CHANTIX CONTINUING
MONTH BOX..................90
CHANTIX STARTING
MONTH BOX..................90
chateal.................................113
CHEMET..............................64
chloramphenicol sod succinate
..........................................12
chlordiazepoxide-clidinium..76
chlorhexidine gluconate .......64
chloroprocaine (pf) ...............47
chloroquine phosphate............3
chlorothiazide .......................34
chlorothiazide sodium ..........34
chlorpromazine.....................43
chlorthalidone.......................34
CHOLBAM ..........................72
cholestyramine (with sugar) .34
Index 3
cholestyramine light .............34
chorionic gonadotropin, human
..........................................72
ciclodan.................................59
ciclopirox ........................59, 60
cidofovir .................................7
cilostazol...............................28
CILOXAN ............................92
CIMZIA ................................86
CIMZIA POWDER FOR
RECONST........................86
CIMZIA STARTER KIT .....86
CINRYZE.............................64
CIPRO HC............................96
CIPRODEX ..........................97
ciprofloxacin.........................15
ciprofloxacin (mixture).........15
ciprofloxacin hcl .......15, 92, 97
ciprofloxacin in 5 % dextrose
..........................................15
ciprofloxacin lactate .............15
cisplatin.................................22
citalopram .............................41
cladribine ..............................18
claravis..................................56
clarithromycin.......................10
CLEOCIN...........................117
CLEVIPREX ........................31
clindacin etz..........................56
clindacin p ............................56
CLINDAGEL .......................56
clindamycin hcl ....................12
clindamycin in 5 % dextrose 12
clindamycin palmitate hcl.....12
clindamycin pediatric ...........12
clindamycin phosphate ..12, 56,
117
clindamycin-benzoyl peroxide
..........................................56
CLINDESSE.......................117
CLINIMIX 5%/D15W
SULFITE FREE .............110
CLINIMIX 5%/D25W
SULFITE-FREE .............110
CLINIMIX 2.75%/D5W
SULFIT FREE................110
CLINIMIX 4.25%/D10W
SULF FREE....................110
CLINIMIX 4.25%/D5W SULFIT FREE................110
CLINIMIX 4.25%-D20W
SULF-FREE ...................110
CLINIMIX 4.25%-D25W
SULF-FREE ...................110
CLINIMIX 5%D20W(SULFITE-FREE)110 CLINIMIX E 4.25%/D10W SUL FREE......................110
clobetasol........................61, 62
clobetasol-emollient .............62
clodan ................................... 62
clofarabine............................18
CLOLAR..............................18
clomipramine........................41
clonazepam...........................38
clonidine ...............................27
clonidine (pf) ........................27
clonidine hcl ...................27, 46
clopidogrel............................28
clorazepate dipotassium .......45
clotrimazole......................2, 60
clotrimazole-betamethasone.60
clozapine...............................43
CLOZAPINE........................43
COARTEM ............................3
codeine sulfate......................51
COLCRYS .........................102
COLESTID FLAVORED ....35
colestipol ..............................35
colistin (colistimethate na) ...12
colocort................................. 79
COLY-MYCIN S .................97
COMBIGAN ........................95
COMBIVENT RESPIMAT100
COMETRIQ .........................22
COMPLERA ..........................3
compro..................................77
CONDYLOX .......................57
constulose .............................79
COPAXONE ........................84
CORDRAN TAPE LARGE
ROLL ...............................62
COREG CR ..........................30
CORLANOR........................32
cormax..................................62
CORTIFOAM ......................79
cortisone ...............................67
CORTISPORIN....................59
COSOPT (PF).......................95
COTELLIC...........................22
COUMADIN ........................28
CREON ................................78
CRIXIVAN ............................3
cromolyn.......................91, 100
cryselle (28)........................113
CUBICIN..............................12
CUBICIN RF........................12
CUVITRU ............................83
CUVPOSA ...........................79
cyclafem 1/35 (28)..............113
cyclobenzaprine....................56
cyclophosphamide ................17
CYCLOPHOSPHAMIDE ....17
CYCLOSERINE ....................6
CYCLOSET .........................74
cyclosporine..........................20
cyclosporine modified ..........20
cyproheptadine .....................97
CYRAMZA ..........................22
cyred ...................................113
CYSTADANE......................72
CYSTAGON ......................104
CYSTARAN ........................91
cysteine (l-cysteine)............105
cytarabine .............................18
cytarabine (pf) ......................18
CYTOGAM..........................83
D d10 %-0.45 % sodium chloride ........................................106
d2.5 %-0.45 % sodium
chloride...........................106
d5 % and 0.9 % sodium
chloride...........................106
d5 %-0.45 % sodium chloride
........................................106
dacarbazine...........................17
DAKLINZA ...........................7
DALIRESP.........................100
DALVANCE ........................12
danazol..................................68
dantrolene .............................56
dapsone...................................6
DAPTACEL (DTAP
PEDIATRIC) (PF)............87
daptomycin ...........................12
Index 4
DARAPRIM ...........................3
DARZALEX.........................22
dasetta 1/35 (28) .................113
dasetta 7/7/7 (28) ................113
daunorubicin .........................22
daysee .................................113
decitabine..............................22
deferoxamine ........................64
deltasone ...............................67
DELZICOL...........................79
demeclocycline .....................16
DEMSER..............................36
DENAVIR ............................60
denta 5000 plus...................111
dentagel...............................111
DEPEN TITRATABS ........103
DEPO-ESTRADIOL ..........116
DEPO-PROVERA..............117
DEPO-SUBQ PROVERA 104
........................................117
DESCOVY .............................3
DESFERAL..........................64
desipramine...........................41
desloratadine.........................97
desmopressin ........................72
desogestrel-ethinyl estradiol
........................................113
desonide................................62
desoximetasone.....................62
DESVENLAFAXINE ..........41
DESVENLAFAXINE
FUMARATE ....................41
desvenlafaxine succinate ......41
dexamethasone .....................67
dexamethasone intensol........67
dexamethasone sodium
phosphate ....................69, 94
dexrazoxane hcl ....................22
dextroamphetamine ..............46
dextroamphetamineamphetamine.....................46
dextrose 10 % and 0.2 % nacl
........................................106
dextrose 10 % in water (d10w)
........................................106
dextrose 20 % in water (d20w)
........................................107
dextrose 25 % in water (d25w)
........................................107
dextrose 30 % in water (d30w) ........................................ 107
dextrose 40 % in water (d40w)
........................................ 107
dextrose 5 % in water (d5w)
........................................ 107
dextrose 5 %-lactated ringers
........................................ 106
dextrose 5%-0.2 % sod
chloride...........................106
dextrose 5%-0.3 %
sod.chloride ....................106
dextrose 50 % in water (d50w)
........................................ 107
dextrose 70 % in water (d70w)
........................................ 107
dextrose with sodium chloride
........................................ 106
dextrose-kcl-nacl ................107
DIASTAT.............................38
DIASTAT ACUDIAL..........38
diazepam.........................38, 46
diazepam intensol.................46
diclofenac potassium ............54
diclofenac sodium ...54, 57, 58,
93
diclofenac-misoprostol .........54
dicloxacillin..........................14
dicyclomine ..........................77
didanosine...............................3
DIFFERIN............................56
DIFICID ...............................10
diflorasone............................62
diflunisal...............................54
digitek................................... 32
digox...............................32, 33
digoxin..................................33
dihydroergotamine ...............46
DILANTIN 30 MG ..............38
diltiazem hcl .........................31
dilt-xr....................................31
DIPENTUM .........................79
diphenhydramine hcl ............97
diphenoxylate-atropine.........77
diskets................................... 51
disulfiram .............................64
divalproex.............................38
DIVIGEL............................116
docetaxel...............................22
DOCETAXEL ......................22
dofetilide...............................33
donepezil ..............................47
dorzolamide ..........................95
dorzolamide-timolol .............96
doxazosin..............................27
doxepin ...........................41, 58
doxorubicin...........................22
doxorubicin, peg-liposomal..22
doxy-100...............................16
doxycycline hyclate..............16
doxycycline monohydrate ....16
dronabinol.............................77
droperidol .............................43
drospirenone-e.estradiol-lm.fa
........................................113
DROXIA ..............................22
DULERA............................100
duloxetine .............................41
DUOPA ................................55
duramorph (pf) .....................51
DUREZOL ...........................94
dutasteride ..........................104
E
E.E.S. GRANULES..............11
econazole ..............................60
EDARBI ...............................28
EDARBYCLOR...................28
EDURANT.............................3
effer-k .................................107
EFFIENT ..............................28
EGRIFTA .............................72
ELAPRASE..........................72
electrolyte-48 in d5w..........105
ELELYSO ............................73
eletriptan hbr.........................47
ELIDEL ................................58
elinest..................................113
eliphos ................................111
ELIQUIS ..............................28
ELITEK ................................73
ELIXOPHYLLIN ...............102
ELLA..................................113
ELLENCE ............................22
ELMIRON..........................104
EMADINE............................91
EMCYT ................................18
EMEND................................77
Index 5
EMEND (FOSAPREPITANT) ..........................................77
emoquette ...........................113
EMPLICITI ..........................22
EMSAM ...............................41
EMTRIVA ..............................3
enalapril maleate...................27
enalaprilat .............................27
enalapril-hydrochlorothiazide
..........................................27
ENBREL...............................86
ENBREL SURECLICK .......86
ENDARI ...............................86
endocet..................................50
ENGERIX-B (PF) ................88
ENGERIX-B PEDIATRIC
(PF) ...................................88
enoxaparin ......................28, 29
enpresse ..............................113
enskyce ...............................113
entacapone ............................55
entecavir .................................7
ENTEREG ............................79
enulose..................................79
ENVARSUS XR ..................20
EPCLUSA ..............................7
epinastine ..............................91
EPINEPHRINE ....................98
EPIPEN.................................98
EPIPEN 2-PAK ....................98
EPIPEN JR ...........................98
EPIPEN JR 2-PAK ...............98
epirubicin ..............................23
epitol .....................................38
EPIVIR HBV..........................3
eplerenone.............................34
EPOGEN ..............................82
epoprostenol (glycine) ..........36
eprosartan .............................28
eptifibatide ............................29
EPZICOM...............................4
ERAXIS(WATER DILUENT)
............................................2
ERBITUX.............................23
ergoloid.................................47
ERGOMAR ..........................47
ERIVEDGE ..........................23
errin.....................................114
ERTACZO............................60
ERWINAZE .........................23
ery pads ................................59
erygel....................................59
ERYPED 200 .......................11
ERYPED 400 .......................11
ery-tab................................... 11
ERY-TAB.............................11
ERYTHROCIN ....................11
erythrocin (as stearate) .........11
erythromycin ..................11, 92
erythromycin ethylsuccinate 11
erythromycin with ethanol ...59
erythromycin-benzoyl peroxide
.......................................... 56
ESBRIET............................100
ESCAVITE.........................111
escitalopram oxalate.............41
esomeprazole magnesium ....81
esomeprazole sodium ...........81
estarylla ..............................114
ESTRACE ..........................116
estradiol ..............................116
estradiol valerate ................116
ESTRING ...........................116
ethacrynate sodium...............34
ethambutol..............................6
ethosuximide ........................38
ethynodiol diac-eth estradiol
........................................ 114
etidronate disodium ............103
etodolac ................................54
ETOPOPHOS.......................23
etoposide...............................23
EURAX ................................58
EVOMELA ..........................17
EVOTAZ................................4
EVZIO..................................50
EXELDERM ........................60
exemestane ...........................18
EXJADE...............................64
EXTAVIA ............................85
EYLEA................................. 91
ezetimibe ..............................35
ezetimibe-simvastatin...........35
F
FABRAZYME .....................73
falmina (28) ........................114
famciclovir .............................7
famotidine.............................79
famotidine (pf)......................79
famotidine (pf)-nacl (iso-os)79
FANAPT ..............................43
FARESTON .........................18
FARXIGA ............................75
FARYDAK...........................23
FASLODEX .........................18
FAZACLO............................43
felbamate ..............................38
felodipine..............................31
FEMRING ..........................116
femynor ..............................114
fenofibrate ............................35
fenofibrate micronized .........35
fenofibrate nanocrystallized .35
fenofibric acid.......................35
fenofibric acid (choline) .......35
FENOGLIDE........................35
fenoprofen ............................54
fentanyl.................................52
fentanyl citrate......................52
fentanyl citrate (pf)...............51
FENTANYL CITRATE (PF)
..........................................51
FENTORA............................52
FERRIPROX ........................64
FETZIMA.............................41
FINACEA.............................57
finasteride ...........................104
FIRAZYR.............................64
FIRMAGON KIT W
DILUENT SYRINGE ......19
FLAREX ..............................94
flavoxate .............................104
FLEBOGAMMA DIF ..........83
flecainide ..............................33
FLECTOR ............................58
FLEXBUMIN 5 % ...............86
FLOLAN ..............................36
FLOVENT DISKUS ............99
FLOVENT HFA...................99
floxin ....................................97
floxuridine ............................18
fluconazole .............................2
fluconazole in dextrose(iso-o) 2
fluconazole in nacl (iso-osm) .2
flucytosine ..............................2
fludarabine............................18
fludrocortisone......................67
Index 6
flunisolide .............................96
fluocinolone ..........................62
fluocinolone acetonide oil ....97
fluocinolone and shower cap 62
fluocinonide ..........................62
fluocinonide-e.......................62
fluocinonide-emollient .........62
FLUORABON....................111
FLUOR-A-DAY.................111
fluor-a-day (with xylitol) ....111
fluoride (sodium) ................111
fluoritab ..............................112
fluorometholone ...................94
fluorouracil .....................18, 58
FLUOROURACIL ...............58
fluoxetine........................41, 42
FLUOXETINE .....................42
fluphenazine decanoate ........44
fluphenazine hcl....................44
flurbiprofen...........................54
flurbiprofen sodium ..............93
flutamide...............................19
fluticasone.......................62, 96
fluvastatin .............................35
fluvoxamine..........................42
FML FORTE ........................94
FML S.O.P............................94
fondaparinux.........................29
FORTAZ...............................10
FORTAZ IN DEXTROSE 5 %
..........................................10
FORTEO.............................103
FOSAMAX PLUS D ..........103
fosamprenavir .........................4
foscarnet .................................7
fosinopril...............................27
fosinopril-hydrochlorothiazide
..........................................27
fosphenytoin .........................38
FOSRENOL ...................64, 65
FRAGMIN............................29
FREAMINE HBC 6.9 % ....110
freamine iii 10 % ................110
frovatriptan ...........................47
furosemide ............................34
FUSILEV..............................16
FUZEON ................................4
fyavolv ................................116
FYCOMPA...........................38
G gabapentin ............................38
GABITRIL ...........................39
galantamine ..........................47
GAMASTAN S/D ................83
GAMMAGARD LIQUID ....83
GAMMAGARD S-D (IGA < 1
MCG/ML) ........................83
GAMMAKED......................83
GAMMAPLEX ....................83
GAMMAPLEX (WITH
SORBITOL) .....................83
GAMUNEX-C .....................83
ganciclovir sodium .................7
GARDASIL 9 (PF)...............88
gatifloxacin...........................92
GATTEX 30-VIAL ..............79
GATTEX ONE-VIAL..........80
gauze pad..............................70
gavilyte-c..............................65
gavilyte-g..............................65
gavilyte-n..............................65
GAZYVA .............................20
gemcitabine ..........................18
gemfibrozil ...........................35
generlac ................................80
gengraf..................................20
GENOTROPIN ....................69
GENOTROPIN MINIQUICK
.......................................... 69
gentak ................................... 92
gentamicin ..................1, 59, 92
gentamicin in nacl (iso-osm) ..1
GENTAMICIN IN NACL
(ISO-OSM).........................1
gentamicin sulfate (ped) (pf) ..1
gentamicin sulfate (pf) ...........1
GENTAMICIN SULFATE
(PF)..................................... 1
GENVOYA ............................4
GEODON .............................44
gianvi (28) ..........................114
GILENYA ............................85
GILOTRIF............................23
GLASSIA .............................81
glatopa ..................................85
GLEOSTINE........................17
glimepiride ...........................75
glipizide................................75
glipizide-metformin..............75
GLUCAGEN HYPOKIT .....73
GLUCAGON EMERGENCY
KIT (HUMAN).................73
glycine urologic....................65
glycopyrrolate.......................77
glydo.....................................48
GOLYTELY.........................65
GRALISE .............................48
GRALISE 30-DAY STARTER
PACK ...............................48
granisetron (pf) .....................77
granisetron hcl ......................77
griseofulvin microsize ............2
griseofulvin ultramicrosize.....2
guanfacine ............................46
guanidine ..............................48
H
HAEGARDA........................65
HALAVEN...........................23
halobetasol propionate..........62
HALOG ..........................62, 63
haloperidol............................44
haloperidol decanoate...........44
haloperidol lactate ................44
HARVONI..............................7
HAVRIX (PF) ......................88
heather ................................114
HECTOROL.......................112
HEPAGAM B.......................83
heparin (porcine) ..................29
heparin (porcine) in 5 % dex 29
heparin(porcine) in 0.45% nacl
..........................................29
heparin, porcine (pf) .............29
HEPATAMINE 8%............111
HERCEPTIN ........................23
HESPAN 6 % IN NS............65
HETLIOZ .............................65
HEXALEN ...........................17
HIBERIX (PF)......................88
HIZENTRA ..........................83
HORIZANT..........................55
HUMALOG....................70, 71
HUMALOG JUNIOR
KWIKPEN........................70
HUMALOG KWIKPEN ......70
HUMALOG MIX 50-50 ......70
Index 7
HUMALOG MIX 50-50
KWIKPEN........................70
HUMALOG MIX 75-25.......70
HUMALOG MIX 75-25
KWIKPEN........................70
HUMATROPE ...............69, 70
HUMIRA ..............................86
HUMIRA PEN .....................86
HUMIRA PEN CROHN'SUC-HS START ................86
HUMIRA PEN PSORIASISUVEITIS...........................86
HUMULIN 70/30 .................71
HUMULIN 70/30 KWIKPEN
..........................................71
HUMULIN N .......................71
HUMULIN N KWIKPEN ....71
HUMULIN R U-100 ............71
HUMULIN R U-500 (CONC)
KWIKPEN........................71
HUMULIN R U-500
(CONCENTRATED) .......71
hydralazine ...........................36
hydrochlorothiazide ..............34
hydrocodone-acetaminophen51
hydrocodone-ibuprofen ........51
hydrocortisone ..........63, 67, 80
hydrocortisone butyrate ........63
hydrocortisone butyr-emollient
..........................................63
hydrocortisone valerate ........63
hydrocortisone-acetic acid....97
hydrocortisone-min oil-wht pet
..........................................63
hydromorphone.....................52
HYDROMORPHONE .........52
hydromorphone (pf)..............52
hydroxychloroquine................3
hydroxyprogesterone caproate
........................................117
hydroxyurea ..........................23
hydroxyzine hcl ....................97
hydroxyzine pamoate............97
HYPERHEP B S/D...............83
HYPERHEP B S-D
NEONATAL ....................84
HYPERLYTE CR ..............105
HYPERRAB S/D (PF) .........84
HYPERTET S/D (PF) ..........84
HYQVIA ..............................84
I ibandronate .........................103
IBRANCE ............................23
IBUDONE............................51
ibuprofen ..............................54
ibuprofen-oxycodone ...........51
ICLUSIG ..............................23
idarubicin..............................23
IDHIFA ................................23
IFEX ..................................... 23
ifosfamide.......................17, 23
ILARIS (PF).........................20
ILEVRO ...............................94
imatinib................................. 23
IMBRUVICA .......................23
IMFINZI...............................23
imipenem-cilastatin ..............12
imipramine hcl......................42
imipramine pamoate.............42
imiquimod ............................58
IMOGAM RABIES-HT (PF)
.......................................... 84
IMOVAX RABIES VACCINE
(PF)................................... 88
INCRELEX ..........................73
indapamide ...........................34
INFANRIX (DTAP) (PF).....88
INFLECTRA........................86
INFUMORPH P/F................52
INLYTA ...............................23
INNOPRAN XL...................30
insulin pen needle.................71
insulin syringe (disp) u-100..71
INTEGRILIN .......................29
INTELENCE..........................4
intralipid .............................106
INTRALIPID .....................106
INTRON A...........................85
INVANZ...............................12
INVEGA SUSTENNA.........44
INVEGA TRINZA...............44
INVIRASE .............................4
INVOKAMET......................75
INVOKAMET XR ...............75
INVOKANA ........................75
IOPIDINE.............................96
IPOL .....................................88
ipratropium bromide...........100
ipratropium-albuterol..........100
IPRIVASK............................29
irbesartan ..............................28
irbesartan-hydrochlorothiazide
..........................................28
IRESSA ................................23
irinotecan ..............................23
ISENTRESS ...........................4
ISENTRESS HD ....................4
isibloom ..............................114
ISOLYTE S PH 7.4 ............105
ISOLYTE-P IN 5 %
DEXTROSE ...................105
ISOLYTE-S........................105
isoniazid..................................6
ISORDIL ..............................37
ISORDIL TITRADOSE .......37
isosorbide dinitrate ...............37
isosorbide mononitrate .........37
isradipine ..............................31
ISTALOL .............................94
ISTODAX ............................23
itraconazole ............................2
ivermectin...............................3
IXEMPRA ............................23
IXIARO (PF)........................88
J
JADENU ..............................65
JAKAFI ................................23
jantoven ................................29
JANUMET ...........................75
JANUMET XR.....................75
JANUVIA.............................75
jencycla...............................114
JENTADUETO ....................75
JEVTANA ............................23
jinteli...................................116
jolessa .................................114
jolivette...............................114
juleber.................................114
junel 1/20 (21) ....................114
junel fe 1/20 (28) ................114
JUXTAPID...........................35
K
KABIVEN ..........................111
KADCYLA ..........................24
KADIAN ..............................52
kaitlib fe..............................114
KALBITOR..........................65
Index 8
KALETRA .............................4
KALYDECO ......................100
KANUMA ............................73
kariva (28) ..........................114
k-effervescent .....................108
kelnor 1/35 (28) ..................114
KEPPRA...............................39
ketoconazole .....................2, 60
ketoprofen.............................54
ketorolac ...............................94
KEYTRUDA ........................24
kimidess (28) ......................114
KINERET .............................86
KINRIX (PF) ........................88
kionex ...................................65
kionex (with sorbitol) ...........65
KISQALI ..............................24
KISQALI FEMARA COPACK ...............................24
klor-con...............................108
klor-con 10..........................108
klor-con 8............................108
klor-con m10 ......................108
klor-con m15 ......................108
klor-con m20 ......................108
KLOR-CON/25 ..................108
klor-con/ef ..........................108
KOMBIGLYZE XR .............75
KORLYM.............................73
K-PHOS NO 2 ....................104
K-PHOS ORIGINAL .........104
KRISTALOSE......................80
KRYSTEXXA ....................102
k-tab....................................108
K-TAB................................108
kurvelo ................................114
KUVAN................................65
KYNAMRO .........................35
KYPROLIS...........................24
L l norgest/e.estradiol-e.estrad ........................................114
labetalol ................................30
LACRISERT ........................91
lactated ringers..............65, 106
lactulose................................80
LAMICTAL ODT STARTER
(BLUE) .............................39
LAMICTAL ODT STARTER (GREEN)..........................39
LAMICTAL ODT STARTER
(ORANGE).......................39
LAMICTAL STARTER
(BLUE) KIT .....................39
LAMICTAL STARTER
(GREEN) KIT ..................39
LAMICTAL STARTER
(ORANGE) KIT...............39
lamivudine..............................4
lamivudine-zidovudine...........4
lamotrigine ...........................39
lansoprazole..........................81
lanthanum .............................65
LANTUS ..............................71
LANTUS SOLOSTAR ........71
larin 24 fe ...........................114
larin fe 1.5/30 (28)..............114
larin fe 1/20 (28).................114
LARTRUVO ........................24
latanoprost ............................96
LATUDA .............................44
layolis fe .............................114
LAZANDA...........................51
leena 28 ..............................114
leflunomide.........................103
LEMTRADA........................85
LENVIMA ...........................24
LETAIRIS ..........................100
letrozole................................19
leucovorin calcium .........16, 17
LEUKERAN ........................17
LEUKINE.............................17
leuprolide..............................19
levalbuterol hcl.....................98
LEVALBUTEROL
TARTRATE .....................98
LEVEMIR ............................71
LEVEMIR FLEXTOUCH ...71
levetiracetam ........................39
LEVETIRACETAM IN NACL
(ISO-OS) ..........................39
levobunolol...........................94
levocarnitine .........................65
levocarnitine (with sugar).....65
levocetirizine ........................97
levofloxacin....................15, 92
levofloxacin in d5w..............15
levoleucovorin ......................17
levonorgestrel-ethinyl estrad
........................................114
levora-28.............................114
levorphanol tartrate...............52
levothyroxine........................76
levoxyl ..................................76
LEXIVA .................................4
LIALDA ...............................80
lidocaine ...............................59
lidocaine (pf) ..................48, 58
lidocaine hcl ...................48, 59
lidocaine viscous ..................59
lidocaine-epinephrine ...........48
LIDOCAINE-EPINEPHRINE
BIT....................................48
lidocaine-prilocaine ..............59
lillow...................................114
lincomycin ............................12
lindane ..................................58
linezolid ................................12
linezolid-0.9% sodium chloride
..........................................12
LINZESS ..............................80
liothyronine ..........................76
LIPOFEN..............................35
lisinopril................................27
lisinopril-hydrochlorothiazide
..........................................27
lithium carbonate..................48
lithium citrate .......................48
LIVALO ...............................35
lmd 10 % in 0.9 % sodium
chlor................................107
lmd 10 % in 5 % dextrose ..107
LO LOESTRIN FE.............114
LOCOID...............................63
LOCOID LIPOCREAM.......63
LONSURF............................18
loperamide ............................77
lopinavir-ritonavir ..................4
lorazepam .............................46
lorazepam intensol................46
lorcet (hydrocodone) ............51
lorcet hd................................51
lorcet plus .............................51
loryna (28) ..........................114
losartan .................................28
losartan-hydrochlorothiazide 28
Index 9
LOTEMAX...........................95
lovastatin...............................35
low-ogestrel (28) ................114
loxapine succinate ................44
LUCENTIS...........................91
ludent fluoride ....................112
LUMIGAN ...........................96
LUMIZYME.........................73
LUPRON DEPOT ........19, 117
LUPRON DEPOT (3
MONTH) ..................19, 117
LUPRON DEPOT (4
MONTH) ..........................19
LUPRON DEPOT (6
MONTH) ..........................19
LUPRON DEPOT-PED19, 117
LUPRON DEPOT-PED (3
MONTH) ........................117
lutera (28) ...........................114
LYNPARZA.........................24
LYRICA ...............................40
LYSODREN.........................24
lyza .....................................114
M
magnesium chloride............105
magnesium sulfate ..............105
MAKENA...........................117
malathion ..............................58
maprotiline............................42
MARPLAN...........................42
MATULANE........................24
matzim la ..............................31
MAVYRET ............................7
MAXIDEX ...........................95
MAXIPIME ..........................10
md-gastroview ......................65
meclizine...............................77
meclofenamate......................54
medroxyprogesterone .........117
mefenamic acid.....................54
mefloquine ..............................3
megestrol ..............................19
MEKINIST ...........................24
meloxicam ............................54
melphalan .............................17
melphalan hcl........................17
memantine ............................48
MEMANTINE......................48
MENACTRA (PF)................88
MENEST............................ 116
MENHIBRIX (PF) ............... 88
MENOMUNE - A/C/Y/W-135
.......................................... 88
MENOMUNE - A/C/Y/W-135
(PF)................................... 88
MENTAX.............................60
MENVEO A-C-Y-W-135-DIP
(PF)................................... 89
mercaptopurine.....................18
meropenem ...........................12
MEROPENEM-0.9%
SODIUM CHLORIDE....12,
13
mesalamine...........................80
MESALAMINE ...................80
mesalamine with cleansing
wipe ..................................80
mesna....................................24
MESNEX .............................17
MESTINON .........................48
metaproterenol....................102
metaxall ................................56
metformin .............................75
methadone ............................52
methadone intensol...............52
methadose.............................52
methazolamide .....................32
methenamine hippurate ........16
methenamine mandelate.......16
methimazole .........................69
METHITEST........................69
methotrexate sodium ............18
methotrexate sodium (pf) .....18
methoxsalen..........................57
methscopolamine..................77
methyclothiazide ..................34
METHYLERGONOVINE .117
methylphenidate hcl .............46
methylprednisolone ..............67
methylprednisolone acetate ..67
methylprednisolone sodium
succ................................... 67
methyltestosterone................69
metipranolol .........................94
metoclopramide hcl ..............80
metolazone ...........................34
METOPIRONE ....................65
metoprolol succinate ............30
metoprolol ta-hydrochlorothiaz ..........................................30
metoprolol tartrate ................30
metro i.v................................13
metronidazole ...13, 57, 59, 118
metronidazole in nacl (iso-os)
..........................................13
mexiletine .............................33
MIACALCIN .....................103
miconazole-3 ......................118
microgestin 1/20 (21) .........114
microgestin fe 1.5/30 (28) ..115
microgestin fe 1/20 (28) .....115
midodrine..............................33
MIGERGOT.........................47
miglitol .................................75
MILLIPRED.........................67
millipred dp ..........................67
milrinone ..............................33
MINOCIN ............................16
minocycline ..........................16
minoxidil ..............................36
mirtazapine ...........................42
misoprostol ...........................81
mitomycin.............................24
mitoxantrone.........................24
M-M-R II (PF)......................89
modafinil ..............................46
moderiba.................................7
moderiba dose pack ................7
moexipril ..............................27
moexipril-hydrochlorothiazide
..........................................27
mometasone....................63, 96
mondoxyne nl .......................16
mono-linyah........................115
mononessa (28)...................115
montelukast ........................100
morgidox ..............................16
morphine...............................53
MORPHINE .........................53
morphine (pf)........................52
morphine concentrate ...........52
MOVANTIK ........................80
MOVIPREP..........................65
MOXEZA.............................92
moxifloxacin...................15, 93
moxifloxacin in nacl (iso-osm)
..........................................15
Index 10
MOZOBIL ............................86
MULTAQ .............................33
multi-vit with fluoride-iron.112
multivitamin with fluoride..112
multi-vitamin with fluoride 112
multivitamins with fluoride 112
mupirocin..............................59
mupirocin calcium ................59
MUSTARGEN .....................17
mvc-fluoride .......................112
MYALEPT ...........................73
mycophenolate mofetil .........20
mycophenolate mofetil hcl ...20
mycophenolate sodium .........20
MYRBETRIQ.....................104
myzilra ................................115
N NABI-HB .............................84
nabumetone...........................54
nadolol ..................................30
nadolol-bendroflumethiazide30
nafcillin.................................14
nafcillin in dextrose iso-osm 14
naftifine.................................60
NAFTIN ...............................60
NAGLAZYME.....................73
nalbuphine ............................50
naloxone ...............................50
naltrexone .............................50
NAMENDA TITRATION
PAK ..................................48
NAMENDA XR ...................48
naproxen ...............................54
naproxen sodium ..................54
naratriptan.............................47
NARCAN .............................50
NAROPIN (PF) ....................48
NASONEX ...........................96
NATACYN...........................93
NATAZIA ..........................115
nateglinide ............................75
NATPARA ...........................73
NEBUPENT .........................13
necon 7/7/7 (28)..................115
needles, insulin disp.,safety ..71
nefazodone............................42
neomycin ..............................13
neomycin-bacitracin-poly-hc91
neomycin-bacitracinpolymyxin......................... 93
neomycin-polymyxin b gu ... 65
neomycin-polymyxingramicidin......................... 93
neomycin-polymyxin-hc ...... 97
neo-polycin........................... 93
neo-polycin hc ...................... 92
NEOSPORIN GU IRRIGANT
.......................................... 65
neostigmine methylsulfate....49
NEPHRAMINE 5.4 % .......111
NERLYNX...........................24
neuac..................................... 57
NEULASTA.........................82
NEUPOGEN ........................82
NEUPRO..............................55
NEUT ................................. 112
NEVANAC ..........................94
nevirapine ...............................4
NEXAVAR ..........................24
next choice one dose ..........115
niacin ....................................35
NIACOR...............................35
nicardipine......................31, 32
NICOTROL..........................90
NICOTROL NS....................90
nifedipine..............................32
NILANDRON ......................19
nilutamide.............................19
nimodipine............................49
NINLARO............................24
NIPENT................................18
nisoldipine ............................32
nitro-bid................................37
NITRO-DUR........................ 37
nitrofurantoin........................ 16
nitrofurantoin macrocrystal .. 16
nitrofurantoin monohyd/mcryst .................................. 16
nitroglycerin ......................... 37
NITROSTAT........................ 37
nizatidine .............................. 79
nolix...................................... 63
nora-be................................115
NORDITROPIN FLEXPRO 70
norepinephrine bitartrate ......33
noreth-ethinyl estradiol-iron
........................................ 115
norethindrone (contraceptive) ........................................115
norethindrone acetate .........117
norethindrone ac-eth estradiol
........................................115
norethindrone-e.estradiol-iron
........................................115
norgestimate-ethinyl estradiol
........................................115
norlyda................................115
NORMOSOL-R..................105
NORMOSOL-R PH 7.4 .....105
NORPACE CR .....................33
NORTHERA ........................33
nortrel 7/7/7 (28) ................115
nortriptyline ..........................42
NORVIR.................................4
novarel ..................................73
NOVAREL...........................73
NOVOFINE 30.....................71
NOVOFINE 32.....................71
NOVOFINE PLUS...............71
NOVOLIN 70/30..................71
NOVOLIN N........................71
NOVOLIN R ........................71
NOVOLOG ..........................72
NOVOLOG FLEXPEN........71
NOVOLOG MIX 70-30 .......72
NOVOLOG MIX 70-30
FLEXPEN ........................72
NOVOLOG PENFILL .........72
NOVOPEN ECHO ...............72
NOVOTWIST ......................72
NOXAFIL ..............................2
NPLATE...............................86
NUCYNTA ..........................53
NUEDEXTA ........................49
NULOJIX .............................20
NUPLAZID ..........................44
NUTRESTORE ....................80
NUTROPIN AQ NUSPIN....70
NUVARING.......................116
nyamyc .................................60
nyata .....................................60
nystatin .............................2, 60
nystatin-triamcinolone..........60
nystop ...................................60
O
ocella ..................................115
Index 11
OCTAGAM ..........................84
octreotide acetate ..................73
ODEFSEY ..............................5
ODOMZO.............................24
OFEV..................................100
ofloxacin ...................15, 93, 97
olanzapine.............................44
olanzapine-fluoxetine ...........44
olmesartan.............................28
olmesartan-amlodipinhcthiazid ...........................36
olmesartanhydrochlorothiazide ..........28
olopatadine .....................91, 96
OLYSIO .................................7
omega-3 acid ethyl esters .....36
omeppi ..................................81
omeprazole ...........................81
omeprazole-sodium
bicarbonate .......................81
OMNARIS............................96
OMNITROPE.......................70
ONCASPAR.........................24
ondansetron...........................78
ondansetron hcl...............77, 78
ondansetron hcl (pf)..............77
ONFI.....................................40
ONGLYZA...........................76
OPANA ................................53
OPANA ER ..........................53
OPDIVO ...............................24
opium tincture.......................80
OPSUMIT...........................100
oralone ..................................65
ORAP ...................................44
ORAVIG.................................2
ORENCIA ............................86
ORENCIA CLICKJECT ......86
ORENITRAM ............100, 101
ORFADIN ............................65
ORKAMBI .........................101
oseltamivir ..............................7
OSMOPREP .........................66
OTEZLA...............................86
OTEZLA STARTER............87
OTREXUP (PF)..................103
oxacillin ................................14
oxacillin in dextrose(iso-osm)
..........................................14
oxaliplatin............................. 24
oxandrolone.......................... 69
oxaprozin.............................. 54
oxcarbazepine....................... 40
oxiconazole........................... 60
OXISTAT............................. 60
OXTELLAR XR .................. 40
oxybutynin chloride............ 104
oxycodone ............................ 53
OXYCODONE..................... 53
oxycodone-acetaminophen... 51
oxycodone-aspirin ................ 51
oxymorphone........................ 53
OZURDEX........................... 95
P pacerone ............................... 33
paclitaxel .............................. 25
paliperidone.......................... 44
pamidronate.......................... 73
PANCREAZE ...................... 78
PANDEL .............................. 63
PANRETIN .......................... 58
pantoprazole ......................... 81
paregoric............................... 80
paricalcitol.......................... 112
PARICALCITOL ............... 112
paroex oral rinse ................... 66
paromomycin.......................... 3
paroxetine hcl ....................... 42
paroxetine mesylate............ 117
PASER ................................... 6
PATADAY...........................91
PAXIL ..................................42
PAZEO ................................. 91
PEDIARIX (PF) ...................89
PEDVAX HIB (PF)..............89
peg 3350-electrolytes ...........66
PEGANONE ........................40
PEGASYS ............................85
PEGASYS PROCLICK .......85
peg-electrolyte soln ..............66
PEGINTRON .......................85
PEGINTRON REDIPEN .....85
PENICILLIN G POT IN
DEXTROSE .....................14
penicillin g potassium...........14
penicillin g procaine .............14
penicillin g sodium ...............14
penicillin v potassium...........15
PENTACEL (PF) .................89
PENTACEL ACTHIB
COMPONENT (PF) .........89
PENTAM..............................13
PENTASA ............................80
pentoxifylline........................29
PERFOROMIST ..................98
PERIKABIVEN .................111
perindopril erbumine ............27
periogard...............................66
PERJETA .............................25
permethrin ............................58
perphenazine.........................44
PERTZYE ............................78
PEXEVA ..............................42
pfizerpen-g............................15
phenadoz...............................78
phenelzine.............................42
phenobarbital ........................40
phenoxybenzamine...............33
phentolamine ........................33
phenytoin ..............................40
phenytoin sodium .................40
phenytoin sodium extended..40
philith..................................115
PHOSLYRA.......................112
PHOSPHOLINE IODIDE....96
PICATO................................58
pilocarpine hcl ................66, 96
pimozide ...............................44
pindolol.................................30
pioglitazone ..........................76
pioglitazone-glimepiride ......76
pioglitazone-metformin ........76
piperacillin-tazobactam ........15
pirmella...............................115
piroxicam..............................54
PLASMA-LYTE 148 .........105
PLASMA-LYTE A ............105
PLEGRIDY ..........................85
podofilox ..............................58
polycin ..................................93
polyethylene glycol 3350 .....66
polymyxin b sulfate ..............13
polymyxin b sulf-trimethoprim
..........................................93
POLY-VI-FLOR ................112
POLY-VI-FLOR WITH IRON
........................................112
Index 12
POMALYST.........................20
portia...................................115
potassium acetate................108
potassium bicarb and chloride
........................................108
potassium bicarb-citric acid108
potassium chlorid-d50.45%nacl .......................108
potassium chloride..............108
potassium chloride in 0.9%nacl
........................................108
potassium chloride in 5 % dex
........................................108
potassium chloride in lr-d5 .106
potassium chloride-0.45 % nacl
........................................109
potassium chloride-d50.2%nacl .........................109
potassium chloride-d50.3%nacl .........................109
potassium chloride-d50.9%nacl .........................109
potassium citrate .................104
potassium phosphate m-/dbasic................................109
PRADAXA...........................29
pramipexole ..........................55
prasugrel ...............................29
pravastatin.............................36
prazosin.................................27
PRED MILD.........................95
PRED-G................................93
PRED-G S.O.P. ....................93
prednicarbate ........................63
prednisolone .........................67
prednisolone acetate .............95
prednisolone sodium phosphate
....................................68, 95
prednisone.............................68
prednisone intensol ...............68
PREMARIN .......................116
premasol 10 % ....................111
PREMASOL 6 % ...............111
prenatal vitamin oral tablet .112
prevalite ................................36
PREVIDENT 5000 BOOSTER
PLUS ..............................112
PREVIDENT 5000 DRY
MOUTH .........................112
PREVIDENT 5000
SENSITIVE.................... 112
PREZCOBIX.......................... 5
PREZISTA ............................. 5
PRIALT................................ 49
PRIFTIN................................. 6
PRIMAQUINE.......................3
primidone .............................40
PRIMSOL.............................16
PRIVIGEN ...........................84
PROAIR HFA ......................98
PROAIR RESPICLICK .......98
probenecid ..........................102
probenecid-colchicine ........102
procainamide ........................33
prochlorperazine...................78
prochlorperazine edisylate....78
prochlorperazine maleate oral
.......................................... 78
PROCRIT .......................82, 83
proctozone-hc .......................80
PROCYSBI ..........................73
progesterone .......................117
progesterone in oil..............117
progesterone micronized ....117
PROGLYCEM .....................36
PROGRAF ...........................21
PROLASTIN-C....................81
PROLEUKIN .......................25
PROLIA .............................103
PROMACTA........................87
promethazine ........................78
propafenone..........................33
propranolol ...........................30
propranolol-hydrochlorothiazid
.......................................... 30
propylthiouracil ....................69
PROQUAD (PF) ..................89
protriptyline..........................42
PROVENTIL HFA...............98
prudoxin ...............................58
PULMICORT FLEXHALER
.......................................... 99
PULMOZYME...................101
PURIXAN ............................18
PYLERA ..............................81
pyrazinamide ..........................6
pyridostigmine bromide .......49
Q QUADRACEL (PF) .............89
quasense..............................115
quetiapine .......................44, 45
quinapril................................27
quinapril-hydrochlorothiazide
..........................................27
quinidine gluconate ..............33
quinidine sulfate ...................33
quinine sulfate ........................3
QVAR...................................99
R
RABAVERT (PF) ................89
rabeprazole ...........................81
RADICAVA.........................49
rajani...................................115
raloxifene............................103
ramipril .................................27
RANEXA .............................33
ranitidine hcl.........................79
RAPAMUNE........................21
rasagiline ..............................55
RASUVO (PF) ...................103
RAVICTI..............................66
REBETOL ..............................7
REBIF (WITH ALBUMIN).85
REBIF REBIDOSE ..............85
REBIF TITRATION PACK.85
reclipsen (28)......................115
RECOMBIVAX HB (PF) ....89
REGRANEX ........................64
relador pak............................59
relador pak plus ....................59
RELENZA DISKHALER ......7
RELISTOR...........................80
RELPAX ..............................47
REMICADE .........................87
REMODULIN ......................33
RENAGEL ...........................66
RENVELA ...........................66
repaglinide ............................76
repaglinide-metformin..........76
REPATHA PUSHTRONEX 36
REPATHA SURECLICK ....36
REPATHA SYRINGE .........36
RESCRIPTOR........................5
RESTASIS............................91
RESTASIS MULTIDOSE ...91
RETISERT ...........................95
Index 13
RETROVIR ............................5
REVATIO...........................101
REVLIMID...........................21
REXULTI .............................45
REYATAZ .............................5
RHOPHYLAC......................84
ribasphere ...............................7
ribasphere ribapak ..................7
ribavirin ..................................7
RIDAURA ..........................103
rifabutin ..................................6
rifampin ..................................6
RIFATER ...............................6
riluzole..................................49
rimantadine .............................7
ringer's ..........................66, 106
risedronate ..........................104
RISPERDAL CONSTA .......45
risperidone ............................45
RITUXAN ............................21
RITUXAN HYCELA ...........21
rivastigmine ..........................49
rivastigmine tartrate..............49
rizatriptan..............................47
ropinirole ..............................55
ropivacaine (pf) ....................49
rosuvastatin...........................36
ROTARIX ............................89
ROTATEQ VACCINE.........89
roweepra ...............................40
ROZEREM ...........................55
RUBRACA...........................25
RYDAPT ..............................25
S SABRIL................................40
SAFYRAL..........................115
SAIZEN ................................70
SAIZEN CLICK.EASY .......70
SAIZEN SAIZENPREP .......70
salsalate.................................54
SAMSCA..............................66
SANCUSO ...........................78
SANDIMMUNE...................21
SANDOSTATIN LAR
DEPOT .............................73
SANTYL ..............................64
SAPHRIS (BLACK
CHERRY).........................45
SAVELLA ............................49
scopolamine base.................. 78
selegiline hcl......................... 55
selenium sulfide.................... 57
SELZENTRY ......................... 5
SENSIPAR ........................... 74
SENSORCAINEMPF/EPINEPHRINE ....... 49
SEREVENT DISKUS .......... 98
SEROQUEL XR .................. 45
SEROSTIM .......................... 70
sertraline ............................... 42
setlakin ............................... 115
sevelamer carbonate ............. 66
sf 112
sf 5000 plus ........................ 112
sharobel .............................. 115
SIGNIFOR ........................... 74
SIGNIFOR LAR .................. 74
sildenafil ............................. 101
silver sulfadiazine................. 64
SIMBRINZA........................ 96
SIMPONI ............................. 87
SIMULECT.......................... 21
simvastatin............................ 36
sirolimus ............................... 21
SIRTURO............................... 6
SKLICE................................ 58
SMOFLIPID....................... 106
sodium acetate .................... 106
sodium chloride ............ 66, 107
sodium chloride 0.45 %...... 107
sodium chloride 0.9 %........ 107
sodium chloride 3 %........... 107
sodium chloride 5 %........... 107
sodium lactate intravenous .106
sodium nitroprusside ............ 33
sodium phenylbutyrate ......... 74
sodium phosphate............... 106
sodium polystyrene (sorb free)
.......................................... 66
sodium polystyrene sulfonate
.......................................... 66
SODIUM POLYSTYRENE
SULFONATE...................66
SOLIRIS...............................87
SOLTAMOX........................19
SOLU-CORTEF...................68
SOLU-CORTEF (PF)...........69
SOLU-MEDROL .................68
SOLU-MEDROL (PF) .........68
SOMATULINE DEPOT ......74
SOMAVERT ........................74
sorine ....................................33
sotalol .............................31, 33
SOTALOL............................30
sotalol af .........................30, 33
SOVALDI ..............................7
spinosad ................................58
SPIRIVA RESPIMAT........101
SPIRIVA WITH
HANDIHALER..............101
spironolactone ......................34
spironolacton-hydrochlorothiaz
..........................................34
SPORANOX ..........................2
sprintec (28)........................115
SPRITAM.............................40
SPRYCEL ............................25
sps (with sorbitol).................66
sronyx .................................115
ssd.........................................64
STAMARIL (PF) .................89
stavudine.................................5
STELARA ............................87
STIMATE.............................74
STIOLTO RESPIMAT.......101
STIVARGA..........................25
STRATTERA.......................46
STRENSIQ...........................74
STREPTOMYCIN .................1
STRIBILD ..............................5
STRIVERDI RESPIMAT ....99
SUBOXONE ........................50
SUBSYS...............................53
SUCRAID ............................81
sucralfate ..............................81
sulfacetamide sodium ...........93
sulfacetamide sodium (acne) 57
sulfacetamide-prednisolone..92
sulfadiazine...........................15
sulfamethoxazole-trimethoprim
....................................15, 16
SULFAMYLON...................59
sulfasalazine .........................81
sulfatrim................................16
sulindac.................................54
sumatriptan ...........................47
sumatriptan succinate ...........47
Index 14
SUPPRELIN LA ..................19
SUPRAX ..............................10
SUPREP BOWEL PREP KIT
..........................................66
SUSTIVA ...............................5
SUTENT...............................25
syeda ...................................115
SYLATRON.........................85
SYLVANT ...........................87
SYMBICORT.....................101
SYMLINPEN 120 ................74
SYMLINPEN 60 ..................74
SYNAGIS.............................84
SYNAREL..........................117
SYNERCID ..........................13
SYNRIBO.............................25
SYNTHROID .......................76
SYPRINE .............................74
T
TABLOID.............................18
TACLONEX.........................57
tacrolimus .......................21, 58
TAFINLAR ..........................25
TAGRISSO...........................25
TAMIFLU ..........................7, 8
tamoxifen..............................19
tamsulosin...........................104
TARCEVA ...........................25
TARGRETIN .......................58
TASIGNA.............................25
tazarotene..............................57
TAZICEF..............................10
TAZORAC ...........................57
taztia xt .................................32
TECENTRIQ ........................25
TECFIDERA ........................21
TECHNIVIE...........................8
TEFLARO ............................10
TEGRETOL XR ...................40
TEKTURNA.........................37
TEKTURNA HCT................37
telmisartan ............................28
telmisartan-amlodipine .........28
telmisartan-hydrochlorothiazid
..........................................28
TEMODAR ..........................66
TENIVAC (PF) ....................89
terazosin................................27
terbutaline ...................101, 102
terconazole ......................... 118
TESTIM ............................... 69
testosterone........................... 69
testosterone cypionate .......... 69
testosterone enanthate .......... 69
TESTRED ............................ 69
TETANUS,DIPHTHERIA
TOX PED(PF) .................. 89
TETANUS-DIPHTHERIA
TOXOIDS-TD.................. 89
tetrabenazine......................... 49
TEXACORT......................... 63
THALOMID......................... 21
theophylline........................ 102
thioridazine........................... 45
thiotepa ................................. 17
thiothixene............................45
THYMOGLOBULIN...........84
thyroid (pork) .......................76
THYROLAR-1.....................76
THYROLAR-1/2..................76
THYROLAR-1/4..................76
THYROLAR-2.....................76
THYROLAR-3.....................76
tiagabine ...............................40
TICE BCG............................90
tilia fe..................................115
timolol maleate...............31, 94
TIMOPTIC ...........................94
TIMOPTIC OCUDOSE (PF)
.......................................... 94
tinidazole ................................3
tis-u-sol pentalyte ................. 67
TIVICAY ...............................5
tizanidine ..............................56
TOBI PODHALER ................1
TOBRADEX ........................92
TOBRADEX ST ..................92
tobramycin............................93
tobramycin in 0.225 % nacl ...1
tobramycin sulfate ..................1
tobramycin-dexamethasone..92
tolazamide ............................76
tolbutamide...........................76
tolcapone ..............................55
tolmetin................................. 54
tolterodine...........................105
TOPICORT ..........................63
topiramate.............................40
toposar ..................................25
topotecan ..............................25
TORISEL..............................25
torsemide ..............................34
TOUJEO SOLOSTAR .........72
TOVIAZ .............................105
TRACLEER .......................101
TRADJENTA.......................76
tramadol................................50
tramadol-acetaminophen ......50
trandolapril ...........................27
trandolapril-verapamil ..........32
tranexamic acid.....................67
TRANSDERM-SCOP ..........78
tranylcypromine....................42
travasol 10 % ......................111
TRAVATAN Z.....................96
trazodone ..............................42
TREANDA.....................17, 25
TRECATOR...........................6
TRELSTAR....................19, 25
tretinoin (chemotherapy) ......25
tretinoin microspheres ..........57
tretinoin topical.....................57
TREXIMET..........................47
tri femynor..........................115
triamcinolone acetonide 63, 67,
68, 96
triamterene-hydrochlorothiazid
..........................................34
trianex...................................64
triderm ..................................64
TRIDESILON ......................64
TRIESENCE (PF) ................95
tri-estarylla..........................115
trifluoperazine ......................45
trifluridine.............................93
TRIGLIDE............................36
trihexyphenidyl.....................55
triklo .....................................36
tri-linyah .............................115
tri-lo-estarylla .....................115
tri-lo-marzia........................116
tri-lo-sprintec ......................116
trilyte with flavor packets.....67
trimethoprim.........................16
trimipramine .........................42
trinessa (28) ........................116
trinessa lo............................116
Index 15
TRINTELLIX.......................42
triple vitamin with fluoride.112
tri-previfem (28) .................116
TRISENOX ..........................25
tri-sprintec (28) ...................116
TRIUMEQ ..............................5
tri-vit with fluoride and iron
........................................112
tri-vitamin with fluoride .....112
trivora (28)..........................116
TROPHAMINE 10 %.........111
TROPHAMINE 6%............111
trospium..............................105
TRUMENBA........................90
TRUVADA.............................5
TUDORZA PRESSAIR .....101
TWINRIX (PF).....................90
TYBOST.................................5
TYGACIL.............................13
TYKERB ..............................25
TYMLOS............................104
TYPHIM VI..........................90
TYSABRI .............................87
TYVASO ............................101
TYVASO INSTITUTIONAL
START KIT....................101
TYVASO REFILL KIT......101
TYVASO STARTER KIT .101
U
ULESFIA..............................58
ULORIC .............................102
unithroid ...............................76
UPTRAVI...................101, 102
ursodiol .................................81
UVADEX .............................67
V
VAGIFEM ..........................116
valacyclovir ............................8
VALCHLOR ........................17
VALCYTE .............................8
valganciclovir .........................8
valproate sodium ..................40
valproic acid .........................40
valproic acid (as sodium salt)
..........................................40
valsartan................................28
valsartan-hydrochlorothiazide
..........................................28
VALSTAR............................25
vancomycin .......................... 13
VANCOMYCIN .................. 13
VANCOMYCIN IN 0.9%
SODIUM CL .................... 13
VANCOMYCIN IN
DEXTROSE 5 %.............. 13
vandazole............................ 118
VANTAS.............................. 19
VAQTA (PF)........................ 90
VARIVAX (PF) ................... 90
VARIZIG ............................. 84
VASCEPA............................ 36
VECAMYL .......................... 37
VECTIBIX ........................... 25
VELCADE ........................... 25
veletri.................................... 37
velivet triphasic regimen (28)
........................................ 116
VELTASSA .........................67
VENCLEXTA......................26
VENCLEXTA STARTING
PACK ...............................26
venlafaxine ...........................42
VENTAVIS..........................37
VENTOLIN HFA.................99
verapamil..............................32
VEREGEN ...........................58
VERSACLOZ ......................45
VESICARE ........................105
VGO 20 ................................72
VGO 30 ................................72
VGO 40 ................................72
VIBATIV .............................13
VIBRAMYCIN ....................16
VICTOZA 2-PAK ................74
VICTOZA 3-PAK ................75
VIDEX 2 GRAM PEDIATRIC
............................................ 5
VIDEX 4 GRAM PEDIATRIC
............................................ 5
VIEKIRA PAK ......................8
VIEKIRA XR.........................8
vienva ................................. 116
vigabatrin..............................40
VIGAMOX...........................93
VIIBRYD .......................42, 43
VIMIZIM .............................74
VIMPAT.........................40, 41
vinblastine ............................26
vincasar pfs...........................26
vincristine .............................26
vinorelbine............................26
VIOKACE ............................78
viorele (28) .........................116
VIRACEPT ............................5
VIRAZOLE ............................8
VIREAD.................................5
vitamins a,c,d and fluoride .112
VIVITROL ...........................50
VOLTAREN GEL................58
voriconazole ...........................2
VOTRIENT ..........................26
VPRIV ..................................74
VRAYLAR...........................45
VYTORIN 10-10..................36
VYTORIN 10-20..................36
VYTORIN 10-40..................36
VYTORIN 10-80..................36
VYXEOS..............................26
W warfarin ................................29
water for irrigation, sterile....67
WELCHOL ..........................36
wera (28).............................116
WINRHO SDF .....................84
X
XALKORI ............................26
XARELTO ...........................29
XATMEP..............................18
XELJANZ ............................87
XELJANZ XR......................87
XERESE...............................60
XGEVA ................................26
XIAFLEX.............................67
XIFAXAN ............................13
XIGDUO XR........................76
XOLAIR.............................102
XOPENEX HFA ..................99
XTANDI...............................19
xulane .................................116
xylocaine dental-epinephrine49
xylon 10................................51
XYREM................................55
Y YERVOY .............................26
YF-VAX (PF).......................90
YONDELIS ..........................26
yuvafem ..............................116
Index 16
Z zafirlukast ...........................102
zaleplon.................................56
ZALTRAP ............................26
ZANOSAR ...........................17
zarah ...................................116
ZARXIO ...............................83
ZAVESCA............................74
ZEJULA ...............................26
ZELAPAR ............................55
ZELBORAF .........................26
ZEMAIRA ............................81
ZEMPLAR .........................112
zenchent (28) ......................116
ZENPEP .........................78, 79
ZEPATIER .............................8
ZERBAXA ...........................10
ZERIT.....................................5
ZETIA...................................36
ZIAGEN .................................6
zidovudine ..............................6
zileuton ...............................102
ZINACEF .............................10
ZINACEF IN STERILE
WATER............................10
ZINECARD (AS HCL) ........26
ZIOPTAN (PF) .....................96
ziprasidone hcl......................45
ZIRGAN ...............................93
ZMAX ..................................11
ZOLADEX ...........................19
zoledronic acid....................104
zoledronic acid-mannitol-water
........................................104
ZOLINZA.............................26
zolmitriptan...........................47
zolpidem ...............................56
ZOMETA ...........................104
ZOMIG .................................47
zonisamide............................41
ZORTRESS ..........................26
ZOSTAVAX (PF) ................90
ZOSYN.................................15
ZOSYN IN DEXTROSE (ISOOSM) ................................15
ZOVIRAX ............................61
ZURAMPIC .......................102
ZYDELIG.............................26
ZYFLO ...............................102
ZYFLO CR ......................... 102 ZYKADIA ............................ 26
ZYLET ................................. 92 ZYPREXA RELPREVV ...... 45
Index 17
ZYTIGA ............................... 19 ZYVOX ................................ 13
This formulary was updated on December 1, 2017. For more recent information or other questions, please contact us, Medicare Plus Blue PPO Customer Service, at 1‑877‑241‑2583, Monday through Friday, 8 a.m. to 9 p.m. Eastern time. From October 1 through February 14, hours are from 8 a.m. to 9 p.m., Eastern time, seven days a week. TTY users should call 711 or visit www.bcbsm.com/medicare.
Updated: 12/01/2017 Formulary 17093, Version 18 DB 16052 DEC 17
H9572_C_17CompFormEVSR1 CMS Accepted 09062016
R075318 EVS