riverspringmap.org · 2019 . formulario (lista de fármacos cubiertos) riverspring map (hmo snp)...

2019 Formulario (Lista de fármacos cubiertos)

RiverSpring MAP (HMO SNP)

RiverSpring Star (HMO SNP)

Para obtener información más reciente o si tiene otras preguntas, comuníquese con el Servicio al Cliente al 1 800 771 0088 (TTY: 711). Atendemos los 7 días de la semana, de

8:00 a. m. a 8:00 p. m. O bien visite RiverSpringHealthplans.org.

IMPORTANTE: Este documento contiene información sobre los fármacos que cubrimos en este plan. No hemos hecho cambios en este formulario integral desde el 08/2018. Identificación de presentación del archivo del formulario aprobado por el Sistema de Gestión de Plan de Salud (Health Plan Management System, HPMS): 00019578; versión número 5.

RiverSpring MAP (HMO SNP)

RiverSpring Star (HMO SNP)

Formulario 2019

Lista de fármacos cubiertos

IMPORTANTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS FÁRMACOS QUE CUBRIMOS EN ESTE PLAN

Identificación de presentación del formulario aprobado por el HPMS: 000919578; versión número 5

No hemos hecho cambios en este formulario desde el 8/23/2018. Para obtener información más reciente o si tiene otras preguntas, comuníquese con el Servicio al Cliente de ElderServe al 1 800 771 0088, o al 711 para usuarios de TTY, los 7 días de la semana de 8:00 a. m. a 8:00 p.m., hora del este, o visite www.RiverSpringhealthplans.org.

Nota para los asegurados existentes: este formulario ha cambiado desde el año anterior. Revise este documento para asegurarse de que todavía contiene los fármacos que toma.

Cuando esta lista de fármacos (formulario) dice “nosotros”, “nos” o “nuestro”, se refiere a ElderServe Health, Inc. Cuando dice “plan” o “nuestro plan”, se refiere a RiverSpring MAP y a RiverSpring Star.

Este documento incluye una lista de fármacos (formulario) para nuestro plan que entró en vigencia el 8/23/2018. Para obtener el formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en que actualizamos el formulario por última vez, aparece en la portada y contraportada.

Generalmente, debe utilizar farmacias de la red para acceder a su beneficio de fármacos recetados. Los beneficios, el formulario, la red de farmacias y los copagos o coseguros pueden cambiar el 1 de enero de 2019 y ocasionalmente durante el año.

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http://www.riverspringhealthplans.org/

http://www.riverspringhealthplans.org/

¿Qué es el Formulario de RiverSpring MAP y RiverSpring Star?

Un formulario es una lista de fármacos cubiertos seleccionados por nuestro plan en consulta con un equipo de proveedores de atención médica, que incluye las terapias con receta que se consideran una parte necesaria de un programa de tratamiento de calidad. Generalmente, nuestro plan cubrirá los fármacos incluidos en nuestro formulario, siempre y cuando el fármaco se considere médicamente necesario, la receta se surta en una farmacia de la red de nuestro plan y se cumplan las demás normas del plan. Para obtener más información sobre cómo surtir sus recetas, revise su Evidencia de Cobertura.

¿Puede cambiar el formulario (lista de fármacos)?

Por lo general, si está tomando un fármaco de nuestro formulario de 2019 que estaba cubierto al inicio del año, no interrumpiremos ni reduciremos la cobertura del fármaco durante el año de cobertura 2019, excepto cuando se encuentre disponible un fármaco genérico nuevo y menos costoso, cuando se divulgue información nueva con respecto a la seguridad o eficacia del fármaco, o cuando el fármaco sea retirado del mercado. (Vea las viñetas de abajo para obtener más información sobre los cambios que afectan a los asegurados que toman actualmente el fármaco). Otros tipos de cambios, como la eliminación de un fármaco de nuestro formulario, no afectarán a los asegurados que actualmente toman el fármaco. Continuará estando disponible al mismo costo compartido para aquellos asegurados que lo tomen durante el resto del año de cobertura. A continuación, se detallan los cambios en la lista de fármacos que también afectarán a los asegurados que toman actualmente el fármaco:

• Los fármacos son retirados del mercado. Si la Administración de Alimentos y Medicamentos (Food and Drug Administration, FDA) considera que un fármaco de nuestro formulario es inseguro o si el fabricante del fármaco lo retira del mercado, eliminaremos el fármaco de nuestro formulario de inmediato y le enviaremos un aviso a los asegurados que lo toman.

• Otros cambios. Podemos hacer otros cambios que afecten a los asegurados que toman actualmente un fármaco. Por ejemplo, podemos agregar un nuevo fármaco genérico para reemplazar un fármaco de marca que se encuentra actualmente en el formulario, o agregar nuevas restricciones para el fármaco de marca o moverlo a otro nivel de costo compartido. También podemos hacer cambios basados en nuevas pautas clínicas. Si eliminamos fármacos de nuestro formulario o agregamos requisitos de autorización previa, límites de cantidad o restricciones de terapia escalonada a un fármaco, debemos notificar el cambio a los asegurados afectados al menos 30 días antes de que el cambio entre en vigencia, o bien en el momento en que el asegurado solicite que le surtan el fármaco, en cuyo caso el asegurado recibirá un suministro de 31 días de dicho fármaco.

El formulario adjunto entró en vigencia el 8/23/2018. Para obtener información actualizada sobre los fármacos cubiertos por nuestro plan, comuníquese con nosotros. Nuestra información de contacto aparece en la portada y contraportada.

¿Cómo utilizo el formulario? Existen dos maneras de buscar su fármaco en el formulario:

Afección médica El formulario comienza en la página 1. Los fármacos de este formulario se agrupan en categorías según el tipo de afección médica que traten. Por ejemplo, los fármacos que se utilizan para tratar una afección cardíaca se incluyen en la categoría “Agentes cardiovasculares”. Si usted sabe para qué se utiliza su fármaco, busque el nombre de la categoría en la lista que comienza a continuación. Luego busque su fármaco en el nombre de la categoría.

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Lista alfabética

Si no está seguro de la categoría a la que pertenece su fármaco, debe buscarlo en el Índice que comienza en la página 109. En el Índice se proporciona una lista alfabética de todos los fármacos incluidos en este documento. Tanto los fármacos de marca como los genéricos están incluidos en el Índice. Busque en el Índice y encuentre su fármaco. Junto a su fármaco, verá el número de página en la que puede encontrar la información de cobertura. Consulte la página que figura en el Índice y busque el nombre de su fármaco en la primera columna de la lista.

¿Qué son los fármacos genéricos?

Nuestro plan cubre tanto fármacos genéricos como de marca. Un fármaco genérico está aprobado por la FDA por contener el mismo ingrediente activo que el fármaco de marca. Por lo general, los fármacos genéricos son menos costosos que los de marca.

¿Existen restricciones en mi cobertura?

Es posible que algunos fármacos cubiertos tengan requisitos adicionales o límites en la cobertura. Estos requisitos y límites pueden incluir los siguientes:

• Autorización previa: nuestro plan requiere que usted o su médico obtengan una autorización previa para determinados fármacos. Esto significa que deberá obtener la aprobación de nuestro plan antes de surtir sus recetas. Si no obtiene la aprobación, es posible que nuestro plan no cubra el fármaco.

• Límites de cantidad: en ciertos fármacos, nuestro plan limita la cantidad de fármaco que cubrirá. Por ejemplo, nuestro plan suministra 30 gramos cada 30 días por cada receta de Elidel crema tópica al 1 %. Esto puede ser además de un suministro estándar para un mes o tres meses.

• Terapia escalonada: en algunos casos, nuestro plan requiere que primero pruebe determinados fármacos para tratar su afección médica antes de cubrir otro fármaco para esa afección. Por ejemplo, si el fármaco A y el fármaco B tratan su afección médica, es posible que nuestro plan no cubra el fármaco B, a menos que pruebe el fármaco A primero. Si el fármaco A no funciona para su afección, nuestro plan cubrirá entonces el fármaco B.

Puede verificar si su fármaco tiene requisitos límites adicionales en el formulario que comienza en la página 1. También puede visitar nuestro sitio web para obtener más información sobre las restricciones que se aplican a fármacos cubiertos específicos. Hemos publicado documentos en línea donde se explican nuestras restricciones de terapia escalonada y autorización previa. También puede solicitarnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha en que actualizamos el formulario por última vez, aparece en la portada y contraportada.

Puede solicitarle a nuestro plan que haga una excepción a estas restricciones o límites, o que le proporcione una lista de otros fármacos similares que pueden tratar su afección médica. Consulte la sección “¿Cómo solicito una excepción al formulario de nuestro plan?” en la página IV para obtener información sobre cómo solicitar una excepción.

¿Qué son los fármacos de venta libre (OTC)?

Los fármacos de venta libre (over-the counter, OTC) son fármacos sin receta que normalmente no son cubiertos por un plan de fármacos con receta de Medicare. Nuestro plan paga ciertos fármacos OTC. Nuestro plan

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proveerá estos fármacos OTC sin ningún costo para usted. El costo de estos fármacos OTC para nuestro plan no se cuenta dentro de sus costos totales de fármacos de la Parte D (es decir, el costo de los fármacos OTC no se cuenta para el lapso en la cobertura).

¿Qué sucede si mi fármaco no está en el formulario?

Si su fármaco no está incluido en este formulario (lista de fármacos cubiertos), debe comunicarse primero con el Servicio al Cliente y preguntar si su fármaco está cubierto.

Si le informan que nuestro plan no cubre su fármaco, tiene dos opciones:

• Puede solicitarle al Servicio al Cliente una lista de fármacos similares que estén cubiertos por nuestro plan. Cuando reciba la lista, muéstresela a su médico y solicítele que le recete un fármaco similar que esté cubierto por nuestro plan.

• Puede solicitar a nuestro plan que haga una excepción y cubra el fármaco. Consulte la sección a continuación para obtener información sobre cómo solicitar una excepción.

¿Cómo solicito una excepción al formulario de RiverSpring MAP y RiverSpring Star?

Puede solicitar a nuestro plan que haga una excepción en nuestras normas de cobertura. Existen diversos tipos de excepciones que puede solicitarnos.

• Puede solicitarnos que cubramos un fármaco aunque no se encuentre en nuestro formulario. Si se aprueba, este fármaco estará cubierto a un nivel de costos compartidos predeterminado y usted no podrá solicitarnos que proporcionemos el fármaco a un nivel de costos compartidos más bajo.

• Puede solicitarnos que anulemos las restricciones o los límites de cobertura de su fármaco. Por ejemplo, para determinados fármacos, nuestro plan limita la cantidad de fármaco que cubrirá. Si su fármaco tiene un límite de cantidad, puede solicitarnos que anulemos el límite y que cubramos una cantidad mayor.

Generalmente, nuestro plan solo aprobará su solicitud de excepción si los fármacos alternativos incluidos en el formulario del plan o las restricciones de utilización adicionales no fuesen tan eficaces para tratar su afección o le ocasionaran efectos médicos adversos.

Para solicitar una decisión de cobertura inicial para una excepción al formulario o a las restricciones de utilización, debe comunicarse con nosotros. Cuando solicita una excepción al formulario o a las restricciones de utilización, debe presentar una declaración de parte del profesional o médico que receta para respaldar su solicitud. Generalmente, debemos tomar una decisión en un plazo de 72 horas a partir de la fecha en que recibimos la declaración de respaldo del profesional que receta. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que su salud podría verse gravemente perjudicada si espera 72 horas para conocer la decisión. Si le otorgan la solicitud de excepción acelerada, debemos informarle nuestra decisión no después de 24 horas a partir de la fecha en que recibimos la declaración de respaldo de su médico u otro profesional que receta.

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¿Qué debo hacer antes poder hablar con mi médico sobre cambiar mis fármacos o solicitar una excepción?

Como asegurado nuevo o que continúa con la cobertura de nuestro plan, es posible que tome fármacos que no se encuentren en nuestro formulario. O bien quizás esté tomando un fármaco que se encuentra en nuestro formulario, pero sus posibilidades de obtenerlo son limitadas. Por ejemplo, quizás necesite una autorización previa nuestra antes de poder surtir su receta. Debe consultar a su médico para decidir si debería cambiar el fármaco por uno adecuado que cubramos o si debería solicitar una excepción al formulario para que cubramos el fármaco que toma. Mientras habla con su médico para determinar la forma de proceder correcta para usted, es posible que, en ciertos casos, cubramos su fármaco durante los primeros 90 días a partir de la fecha en que se convierte en asegurado de nuestro plan.

Para cada uno de sus fármacos que no se encuentren en nuestro formulario o si sus posibilidades de obtener los fármacos son limitadas, cubriremos un suministro temporal de 31 días. Si su receta se emite para menos días, permitiremos resurtidos para brindarle hasta un máximo de 31 días de fármaco. Después de su primer suministro para 31 días, no pagaremos por estos fármacos, aunque haya sido un asegurado del plan durante menos de 90 días.

Si usted necesita un fármaco que no se encuentra en nuestro formulario o si sus posibilidades de obtener sus fármacos son limitadas, pero ya transcurrieron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia para 31 días de ese fármaco mientras solicita una excepción al formulario.

Política de transición para participantes con cambios en el nivel de atención

Los cambios en el nivel de atención se producen cuando el asegurado pasa de un entorno de tratamiento a otro. Si alguno de los siguientes escenarios de cambio en el nivel de atención se aplica a usted, podría tener derecho a un suministro de transición de los fármacos que está tomando actualmente:

• Abandona un hospital u otro entorno e ingresa en un centro de atención a largo plazo. • Abandona un centro de atención a largo plazo para irse a su casa. • Le dan el alta en el hospital para irse a una casa. • Le dan el alta en un centro de enfermería especializada. • Su estado cambia de enfermo terminal o no terminal. • Le dan el alta en un hospital psiquiátrico con un plan de medicamentos personalizado.

Para obtener más información, comuníquese con Servicios para el participante al 1-800-771-0088 (TTY: 711). Los representantes están disponibles los siete días de la semana, de 8:00 a. m. a 8:00 p. m.

Para obtener más información

Para obtener información más detallada sobre la cobertura de fármacos con receta de nuestro plan, revise su Evidencia de Cobertura y otros materiales del plan.

Si tiene preguntas sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en que actualizamos el formulario por última vez, aparece en la portada y contraportada.

Si tiene preguntas generales sobre la cobertura de fármacos con receta de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O bien visite http://www.medicare.gov.

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http://www.medicare.gov/

Formulario de nuestros planes El formulario que comienza en la siguiente página proporciona información de cobertura sobre los fármacos cubiertos por nuestro plan. Si tiene dificultades para encontrar su fármaco en la lista, diríjase al Índice, que comienza en la página 109.

En la primera columna del cuadro se menciona el nombre del fármaco. Los fármacos de marca aparecen en letra mayúscula (p. ej., ZOCOR) y los fármacos genéricos aparecen en letra minúscula cursiva (p. ej., simvastatina).

La información en la columna Requisitos/Límites le indica si nuestro plan tiene algún requisito especial para la cobertura de su fármaco.

Símbolo Descripción Explicación

LA Fármaco de acceso limitado

Este fármaco con receta puede estar disponible solo en ciertas farmacias. Para obtener más información, consulte el Directorio de farmacias o llame a Servicio al Cliente al 1-800-711-0088 (TTY: 711), los 7 días de la semana, de 8:00 a. m. a 8:00 p. m.

MO Pedido por correo Este fármaco con receta también puede estar disponible por correo.

NDS Suministro diario no extendido

Estos fármacos no están disponibles para el suministro diario extendido.

PA Autorización previa

Usted (o su médico) debe obtener la autorización previa de nuestro plan para poder surtir la receta del fármaco. Sin autorización previa, es posible que nuestro plan no cubra el fármaco.

PA BvD Cubierto por la Parte B o D de Medicare

Ciertos fármacos pueden estar cubiertos por la Parte B o D de Medicare según las circunstancias. Es necesario enviar información que describa el uso y el entorno donde se administra el fármaco para tomar una determinación.

PA NSO Autorización previa para nuevos inicios únicamente

Si no ha surtido una receta de este fármaco en los últimos 108 días, usted (o su médico) debe obtener la autorización previa de nuestro plan para poder surtir la receta de dicho fármaco. Sin autorización previa, es posible que nuestro plan no cubra el fármaco.

QL Límite de cantidad Nuestro plan limita la cantidad de fármaco que se cubre por receta o en un período específico. El límite para dispensar fármacos es de 30 días, a menos que se especifique otra cosa.

ST Terapia escalonada Antes de que el plan cubra el fármaco, usted debe probar primero otros fármacos para tratar su afección médica. El fármaco solo se podrá cubrir si los otros fármacos no funcionan para su afección.

ST-NS Terapia escalonada para nuevos inicios únicamente

Los requisitos de terapia escalonada se aplican a nuevos inicios únicamente.

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Aviso de no discriminación de ElderServe Health, Inc.

ElderServe Health, Inc. cumple con las leyes federales de derechos civiles vigentes y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. ElderServe Health, Inc. no excluye a las personas ni las trata de manera diferente por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

ElderServe Health, Inc.:

• Ofrece ayuda y servicios gratuitos a personas con discapacidades para que puedan comunicarse efectivamente con nosotros, como por ejemplo:

o Intérpretes calificados de lenguaje de señas.

o Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos).

• Ofrece servicios lingüísticos gratuitos a personas cuyo idioma principal no es el inglés, como por ejemplo:

o Intérpretes calificados.

o Información escrita en otros idiomas.

Si necesita estos servicios, comuníquese con el coordinador de derechos civiles. Si considera que ElderServe Health, Inc. no le ha proporcionado estos servicios o usted ha sido discriminado de alguna otra manera por motivos de raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a:

Civil Rights Coordinator 80 West 225th Street Bronx, NY, 10463 Teléfono: 1-347-842-3660, TTY 711 Fax: 1-888-341-5009

Puede presentar un reclamo en persona o por correo postal, teléfono o fax. Si necesita ayuda para presentar un reclamo, el coordinador de derechos civiles está a su disposición.

También puede presentar un reclamo de derechos civiles ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de los Estados Unidos a través de su portal de quejas de la Oficina de Derechos Civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo postal o por teléfono a:

U.S. Department of Health and Human Services 200 Independence Avenue, SW, Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 1-800-537-7697 (TDD)

Los formularios de reclamos se encuentran disponibles en http://www.hhs.gov/ocr/office/file/index.html.

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http://www.hhs.gov/ocr/office/file/index.html

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1- 800-771-0088 (TTY 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1- 800-711-0088 (TTY 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-711-0088（TTY 711)。

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-711-0088 (TTY 711)..

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-711- 0088 (TTY 711).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-711- 0088 (TTY 711).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-711-0088 (TTY 711).

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-711-0088 (TTY 711).번으로 전화해 주십시오.

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-711-0088 (телетайп: 711).

-800-1ناجم ال ب ك ل.ت م قر ب لص تا ةظوحل میة ر فاوت:وغ ل ال ةدعاس م ال تامدخ نإ ف ،ةغ ل ال ر كذا ثدحتت تن ك اذإ م قر .(117) :ف تاھ مص ال مك ب الو 711-0088

ध्यान द: यद आप हदी बोलते ह तो आपके ि◌ लए मफ्◌ु त म भाषा सहायता सेवाएं उपलब्ध ह। 1-800-711-0088 (TTY 711). पर कॉल कर।

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-711-0088 (TTY 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-711- 0088 (TTY 711).

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-711- 0088 (TTY 711).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-711-0088 (TTY 711).

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-711-0088 (TTY 711). まで、お電話にてご連絡ください。

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2019 RS SNP List of Covered Drugs

Table of Contents Analgesics ............................................................................................................................................. 3 Anesthetics ............................................................................................................................................ 6 Anti-Addiction/ Substance Abuse Treatment Agents ........................................................................ 7 Antibacterials ........................................................................................................................................ 8 Anticonvulsants ................................................................................................................................ 15 Antidementia Agents ........................................................................................................................ 18 Antidepressants ................................................................................................................................ 19 Antiemetics ........................................................................................................................................ 23 Antifungals ........................................................................................................................................ 24 Antigout Agents ................................................................................................................................ 26 Anti-Inflammatory Agents ................................................................................................................ 26 Antimigraine Agents ......................................................................................................................... 29 Antimyasthenic Agents .................................................................................................................... 30 Antimycobacterials ........................................................................................................................... 30 Antineoplastics ................................................................................................................................. 30 Antiparasitics .................................................................................................................................... 35 Antiparkinson Agents ....................................................................................................................... 36 Antipsychotics .................................................................................................................................. 37 Antispasticity Agents ....................................................................................................................... 40 Antivirals ............................................................................................................................................ 40 Anxiolytics ......................................................................................................................................... 46 Bipolar Agents ................................................................................................................................... 48 Blood Glucose Regulators ............................................................................................................... 50 Blood Products/ Modifiers/ Volume Expanders ............................................................................. 54 Cardiovascular Agents ..................................................................................................................... 56 Central Nervous System Agents ...................................................................................................... 64 Dental And Oral Agents .................................................................................................................... 66 Dermatological Agents ..................................................................................................................... 66 Electrolytes/Minerals/Metals/Vitamins ............................................................................................ 68 Gastrointestinal Agents .................................................................................................................... 74 Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment .............................................. 76 Genitourinary Agents ....................................................................................................................... 77 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) ................................................ 78 Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) ............................................... 81 Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins) .................................... 81 Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) ................... 81 Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) ................................................ 88 Hormonal Agents, Suppressant (Adrenal) ...................................................................................... 88 Hormonal Agents, Suppressant (Pituitary) ..................................................................................... 88 Hormonal Agents, Suppressant (Thyroid) ...................................................................................... 89 Immunological Agents ...................................................................................................................... 90 Inflammatory Bowel Disease Agents .............................................................................................. 95 Metabolic Bone Disease Agents ...................................................................................................... 97 Ophthalmic Agents ........................................................................................................................... 98 Otic Agents ...................................................................................................................................... 101

Respiratory Tract/ Pulmonary Agents ........................................................................................... 101

1

Skeletal Muscle Relaxants ............................................................................................................. 106 Sleep Disorder Agents .................................................................................................................... 106

2019 RS SNP

List of Covered Drugs

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Analgesics Analgesics acetaminophen-codeine oral solution 120-12 mg/5 ml

$0 (Tier 1)

NDS; QL (4500 per 30 days)

acetaminophen-codeine oral tablet 300-15 mg

$0 (Tier 1)



$0 (Tier 1)



$0 (Tier 1)


ASCOMP WITH CODEINE ORAL CAPSULE 30-50-325-40 MG

$0 (Tier 1)


butalbital-acetaminophen-caff oral capsule 50-300-40 mg, 50-325-40 mg

$0 (Tier 1)

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

$0 (Tier 1)

NDS

carisoprodol-asa-codeine oral tablet 200- 325-16 mg

$0 (Tier 1)


carisoprodol-aspirin oral tablet 200-325 mg $0 (Tier 1) NDS; QL (240 per 30 days) ENDOCET ORAL TABLET 10-325 MG, 5- 325 MG, 7.5-325 MG

$0 (Tier 1)

QL (360 per 30 days)

ESGIC ORAL TABLET 50-325-40 MG $0 (Tier 1) NDS FIORINAL ORAL CAPSULE 50-325-40 MG $0 (Tier 1) NDS hydrocodone-acetaminophen oral tablet 10- 325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

$0 (Tier 1)


hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

$0 (Tier 1)


LORCET (HYDROCODONE) ORAL TABLET 5-325 MG

$0 (Tier 1)


LORCET PLUS ORAL TABLET 7.5-325 MG $0 (Tier 1) NDS; QL (240 per 30 days) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 7.5-325 mg

$0 (Tier 1)

QL (360 per 30 days)

oxycodone-acetaminophen oral tablet 5-325 mg

$0 (Tier 1)


tramadol-acetaminophen oral tablet 37.5-325 mg

$0 (Tier 1)


You can find information on what the symbols and abbreviations on this table mean by going to page VI.

3

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Nonsteroidal Anti-Inflammatory Drugs

celecoxib oral capsule 100 mg, 200 mg, 50 mg

$0 (Tier 1)

MO; QL (60 per 30 days)

celecoxib oral capsule 400 mg $0 (Tier 1) MO; QL (30 per 30 days) diclofenac potassium oral tablet 50 mg $0 (Tier 1) NDS diclofenac sodium oral tablet extended release 24 hr 100 mg

$0 (Tier 1)

NDS

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg

$0 (Tier 1)

NDS

diclofenac sodium topical gel 3 % $0 (Tier 1)

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 50-200 mg-mcg, 75-200 mg-mcg

$0 (Tier 1)

NDS

diflunisal oral tablet 500 mg $0 (Tier 1) NDS etodolac oral capsule 200 mg, 300 mg $0 (Tier 1) MO etodolac oral tablet 400 mg, 500 mg $0 (Tier 1) MO etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg

$0 (Tier 1)

MO

fenoprofen oral tablet 600 mg $0 (Tier 1) NDS flurbiprofen oral tablet 100 mg $0 (Tier 1) NDS flurbiprofen oral tablet 50 mg $0 (Tier 1) NDS; MO ibuprofen oral suspension 100 mg/5 ml $0 (Tier 1) MO ibuprofen oral tablet 400 mg, 600 mg, 800 mg

$0 (Tier 1)

MO

ibuprofen-oxycodone oral tablet 400-5 mg $0 (Tier 1) NDS; QL (120 per 30 days) indomethacin oral capsule 25 mg, 50 mg $0 (Tier 1) NDS indomethacin oral capsule, extended release 75 mg

$0 (Tier 1)

NDS

ketoprofen oral capsule 75 mg $0 (Tier 1) NDS ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

$0 (Tier 1)

NDS; MO

ketorolac oral tablet 10 mg $0 (Tier 1) NDS meclofenamate oral capsule 100 mg $0 (Tier 1) NDS meclofenamate oral capsule 50 mg $0 (Tier 1) NDS; MO mefenamic acid oral capsule 250 mg $0 (Tier 1) NDS meloxicam oral tablet 15 mg, 7.5 mg $0 (Tier 1) MO nabumetone oral tablet 500 mg, 750 mg $0 (Tier 1) NDS naproxen oral suspension 125 mg/5 ml $0 (Tier 1) MO naproxen oral tablet 250 mg, 375 mg, 500 mg

$0 (Tier 1)

MO


4

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS naproxen sodium oral tablet 275 mg, 550 mg $0 (Tier 1) MO naproxen sodium oral tablet, er multiphase 24 hr 500 mg

$0 (Tier 1)

MO

oxaprozin oral tablet 600 mg $0 (Tier 1) NDS piroxicam oral capsule 10 mg, 20 mg $0 (Tier 1) NDS sulindac oral tablet 150 mg, 200 mg $0 (Tier 1) NDS tolmetin oral capsule 400 mg $0 (Tier 1) NDS tolmetin oral tablet 600 mg $0 (Tier 1) NDS; MO Opioid Analgesics, Long-Acting

buprenorphine hcl sublingual tablet 2 mg, 8 mg

$0 (Tier 1)

PA; NDS

DURAMORPH (PF) INJECTION SOLUTION 1 MG/ML

$0 (Tier 1)

NDS

fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

$0 (Tier 1)

PA; NDS; QL (120 per 30 days)

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour

$0 (Tier 1)


levorphanol tartrate oral tablet 2 mg $0 (Tier 1) NDS; QL (180 per 30 days) methadone oral solution 10 mg/5 ml, 5 mg/5 ml

$0 (Tier 1)

NDS

methadone oral tablet 10 mg, 5 mg $0 (Tier 1) NDS; QL (180 per 30 days) morphine concentrate oral solution 100 mg/5 ml (20 mg/ml)

$0 (Tier 1)

NDS

morphine oral capsule, er multiphase 24 hr 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg

$0 (Tier 1)


morphine oral capsule,extend.release pellets 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg

$0 (Tier 1)


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

$0 (Tier 1)

NDS

morphine oral tablet 15 mg, 30 mg $0 (Tier 1) NDS; QL (120 per 30 days) morphine oral tablet extended release 100 mg, 30 mg, 60 mg

$0 (Tier 1)


morphine oral tablet extended release 15 mg, 200 mg

$0 (Tier 1)

QL (90 per 30 days)

oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg

$0 (Tier 1)

QL (60 per 30 days)


5

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg

$0 (Tier 1)


tramadol oral tablet extended release 24 hr 100 mg

$0 (Tier 1)


tramadol oral tablet extended release 24 hr 200 mg

$0 (Tier 1)


tramadol oral tablet, er multiphase 24 hr 300 mg

$0 (Tier 1)


Opioid Analgesics, Short-Acting

butorphanol tartrate nasal spray,non-aerosol 10 mg/ml

$0 (Tier 1)

NDS; QL (2.5 per 14 days)

codeine sulfate oral tablet 15 mg, 30 mg $0 (Tier 1) NDS; QL (360 per 30 days) codeine sulfate oral tablet 60 mg $0 (Tier 1) NDS; QL (180 per 30 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

$0 (Tier 1)


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

$0 (Tier 1)


hydrocodone-acetaminophen oral tablet 2.5- 325 mg

$0 (Tier 1)


hydromorphone oral liquid 1 mg/ml $0 (Tier 1) NDS; QL (900 per 30 days) hydromorphone oral tablet 2 mg, 4 mg, 8 mg $0 (Tier 1) NDS; QL (180 per 30 days) LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY

$0 (Tier 1)


meperidine oral tablet 100 mg, 50 mg $0 (Tier 1) NDS; QL (360 per 30 days) morphine concentrate oral solution 100 mg/5 ml (20 mg/ml)

$0 (Tier 1)

NDS

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

$0 (Tier 1)

NDS

morphine oral tablet 15 mg, 30 mg $0 (Tier 1) NDS; QL (120 per 30 days) oxycodone oral solution 5 mg/5 ml $0 (Tier 1) NDS; QL (2400 per 30 days) oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg

$0 (Tier 1)


oxymorphone oral tablet 10 mg, 5 mg $0 (Tier 1) QL (180 per 30 days) tramadol oral tablet 50 mg $0 (Tier 1) NDS; QL (240 per 30 days) Anesthetics Local Anesthetics lidocaine hcl mucous membrane jelly 2 % $0 (Tier 1) NDS; QL (60 per 30 days)


6

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS lidocaine hcl mucous membrane solution 4 % (40 mg/ml)

$0 (Tier 1)


lidocaine topical adhesive patch,medicated 5 %

$0 (Tier 1)


lidocaine topical ointment 5 % $0 (Tier 1) NDS; QL (36 per 30 days) lidocaine-prilocaine topical cream 2.5-2.5 % $0 (Tier 1) NDS; QL (30 per 30 days) Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/Anti-Craving acamprosate oral tablet,delayed release (dr/ec) 333 mg

$0 (Tier 1)

MO

disulfiram oral tablet 250 mg, 500 mg $0 (Tier 1) MO naltrexone oral tablet 50 mg $0 (Tier 1) NDS Opioid Dependence Treatments

buprenorphine hcl sublingual tablet 2 mg, 8 mg

$0 (Tier 1)

PA; NDS

buprenorphine-naloxone sublingual tablet 2- 0.5 mg

$0 (Tier 1)


buprenorphine-naloxone sublingual tablet 8-2 mg

$0 (Tier 1)


LUCEMYRA ORAL TABLET 0.18 MG $0 (Tier 1) QL (224 per 14 days) naltrexone oral tablet 50 mg $0 (Tier 1) NDS Opioid Reversal Agents

naloxone injection syringe 0.4 mg/ml, 1 mg/ml

$0 (Tier 1)

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

$0 (Tier 1)

NDS

Smoking Cessation Agents

bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg

$0 (Tier 1)

CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG

$0 (Tier 1)

ST; NDS

CHANTIX ORAL TABLET 0.5 MG, 1 MG $0 (Tier 1) ST; NDS CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)

$0 (Tier 1)

ST; NDS

NICOTROL INHALATION CARTRIDGE 10 MG

$0 (Tier 1)

NDS

NICOTROL NS NASAL SPRAY,NON- AEROSOL 10 MG/ML

$0 (Tier 1)

ST; NDS


7

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Antibacterials Aminoglycosides amikacin injection solution 500 mg/2 ml $0 (Tier 1) PA BvD; NDS GENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM)

$0 (Tier 1)

NDS

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 80 mg/50 ml

$0 (Tier 1)

NDS

gentamicin injection solution 40 mg/ml $0 (Tier 1) NDS gentamicin ophthalmic (eye) drops 0.3 % $0 (Tier 1) NDS gentamicin topical cream 0.1 % $0 (Tier 1) NDS gentamicin topical ointment 0.1 % $0 (Tier 1) NDS neomycin oral tablet 500 mg $0 (Tier 1) NDS paromomycin oral capsule 250 mg $0 (Tier 1) NDS streptomycin intramuscular recon soln 1 gram

$0 (Tier 1)

NDS

TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 %

$0 (Tier 1)

NDS

tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml

$0 (Tier 1)

PA NSO; MO

tobramycin ophthalmic (eye) drops 0.3 % $0 (Tier 1) NDS tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml

$0 (Tier 1)

NDS

TOBREX OPHTHALMIC (EYE) DROPS 0.3 %

$0 (Tier 1)

NDS

TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 %

$0 (Tier 1)

NDS

Antibacterials, Other

acetic acid otic (ear) solution 2 % $0 (Tier 1) NDS alcohol pads topical pads, medicated $0 (Tier 1) NDS bacitracin ophthalmic (eye) ointment 500 unit/gram

$0 (Tier 1)

NDS

BACTROBAN NASAL NASAL OINTMENT 2 %

$0 (Tier 1)

NDS

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

$0 (Tier 1)

NDS

clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml

$0 (Tier 1)

NDS

clindamycin palmitate hcl oral recon soln 75 mg/5 ml

$0 (Tier 1)

NDS


8

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS clindamycin phosphate topical gel 1 % $0 (Tier 1) NDS clindamycin phosphate topical lotion 1 % $0 (Tier 1) NDS clindamycin phosphate topical solution 1 % $0 (Tier 1) NDS clindamycin phosphate vaginal cream 2 % $0 (Tier 1) NDS colistin (colistimethate na) injection recon soln 150 mg

$0 (Tier 1)

NDS

daptomycin intravenous recon soln 500 mg $0 (Tier 1)

linezolid in dextrose 5% intravenous piggyback 600 mg/300 ml

$0 (Tier 1)

NDS

linezolid oral suspension for reconstitution 100 mg/5 ml

$0 (Tier 1)


linezolid oral tablet 600 mg $0 (Tier 1) PA; NDS; QL (28 per 14 days) methenamine hippurate oral tablet 1 gram $0 (Tier 1) NDS metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml

$0 (Tier 1)

NDS

metronidazole oral capsule 375 mg $0 (Tier 1) NDS metronidazole oral tablet 250 mg, 500 mg $0 (Tier 1) NDS metronidazole topical cream 0.75 % $0 (Tier 1) NDS metronidazole topical gel 0.75 %, 1 % $0 (Tier 1) NDS metronidazole topical lotion 0.75 % $0 (Tier 1) NDS metronidazole vaginal gel 0.75 % $0 (Tier 1) NDS mupirocin calcium topical cream 2 % $0 (Tier 1) NDS mupirocin topical ointment 2 % $0 (Tier 1) NDS nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg

$0 (Tier 1)

NDS

nitrofurantoin macrocrystal oral capsule 50 mg

$0 (Tier 1)


nitrofurantoin monohyd/m-cryst oral capsule 100 mg

$0 (Tier 1)

NDS

nitrofurantoin oral suspension 25 mg/5 ml $0 (Tier 1) NDS tigecycline intravenous recon soln 50 mg $0 (Tier 1)

tinidazole oral tablet 250 mg, 500 mg $0 (Tier 1) NDS trimethoprim oral tablet 100 mg $0 (Tier 1) NDS TYGACIL INTRAVENOUS RECON SOLN 50 MG

$0 (Tier 1)

vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg

$0 (Tier 1)

NDS

vancomycin oral capsule 125 mg, 250 mg $0 (Tier 1) NDS; QL (112 per 4 days) XIFAXAN ORAL TABLET 200 MG $0 (Tier 1)


9

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS XIFAXAN ORAL TABLET 550 MG $0 (Tier 1) MO ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML

$0 (Tier 1)


Antibacterials

colistin (colistimethate na) injection recon soln 150 mg

$0 (Tier 1)

NDS

Beta-Lactam, Cephalosporins

cefaclor oral capsule 250 mg, 500 mg $0 (Tier 1) NDS cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

$0 (Tier 1)

NDS

cefaclor oral tablet extended release 12 hr 500 mg

$0 (Tier 1)

NDS

cefadroxil oral capsule 500 mg $0 (Tier 1) NDS cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

$0 (Tier 1)

NDS

cefadroxil oral tablet 1 gram $0 (Tier 1) NDS cefazolin injection recon soln 1 gram, 10 gram, 500 mg

$0 (Tier 1)

NDS

cefdinir oral capsule 300 mg $0 (Tier 1) NDS cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

$0 (Tier 1)

NDS

cefepime injection recon soln 1 gram, 2 gram $0 (Tier 1)

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

$0 (Tier 1)

NDS

cefotaxime injection recon soln 1 gram, 2 gram, 500 mg

$0 (Tier 1)

NDS

cefotetan injection recon soln 1 gram, 2 gram $0 (Tier 1) NDS cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram

$0 (Tier 1)

NDS

cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml

$0 (Tier 1)

NDS

cefpodoxime oral tablet 100 mg, 200 mg $0 (Tier 1) NDS cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

$0 (Tier 1)

NDS

cefprozil oral tablet 250 mg, 500 mg $0 (Tier 1) NDS ceftazidime injection recon soln 1 gram, 2 gram, 6 gram

$0 (Tier 1)

NDS

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

$0 (Tier 1)

NDS

cefuroxime axetil oral tablet 250 mg, 500 mg $0 (Tier 1) NDS


10

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS cefuroxime sodium injection recon soln 750 mg

$0 (Tier 1)

NDS

cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram

$0 (Tier 1)

NDS

cephalexin oral capsule 250 mg, 500 mg, 750 mg

$0 (Tier 1)

NDS

cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

$0 (Tier 1)

NDS

cephalexin oral tablet 250 mg, 500 mg $0 (Tier 1) NDS SUPRAX ORAL CAPSULE 400 MG $0 (Tier 1)

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 200 MG/5 ML, 500 MG/5 ML

$0 (Tier 1)

SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG

$0 (Tier 1)

NDS

TAZICEF INJECTION RECON SOLN 1 GRAM, 2 GRAM, 6 GRAM

$0 (Tier 1)

NDS

TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG

$0 (Tier 1)

NDS

ZERBAXA INTRAVENOUS RECON SOLN 1.5 GRAM

$0 (Tier 1)

NDS

Beta-Lactam, Other

AZACTAM INJECTION RECON SOLN 1 GRAM, 2 GRAM

$0 (Tier 1)

NDS

aztreonam injection recon soln 1 gram $0 (Tier 1) NDS CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML

$0 (Tier 1)

PA; NDS

doripenem intravenous recon soln 500 mg $0 (Tier 1)

imipenem-cilastatin intravenous recon soln 250 mg, 500 mg

$0 (Tier 1)

PA; NDS

INVANZ INJECTION RECON SOLN 1 GRAM

$0 (Tier 1)

NDS

meropenem intravenous recon soln 1 gram $0 (Tier 1)

meropenem intravenous recon soln 500 mg $0 (Tier 1) NDS Beta-Lactam, Penicillins

amoxicillin oral capsule 250 mg, 500 mg $0 (Tier 1) NDS amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

$0 (Tier 1)

NDS

amoxicillin oral tablet 500 mg, 875 mg $0 (Tier 1) NDS


11

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS amoxicillin oral tablet,chewable 125 mg, 250 mg

$0 (Tier 1)

NDS

amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml

$0 (Tier 1)

NDS

amoxicillin-pot clavulanate oral tablet 250- 125 mg, 500-125 mg, 875-125 mg

$0 (Tier 1)

NDS

amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg

$0 (Tier 1)

NDS

amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 mg

$0 (Tier 1)

NDS

ampicillin oral capsule 500 mg $0 (Tier 1) NDS ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg

$0 (Tier 1)

NDS

ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram

$0 (Tier 1)

NDS

BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML

$0 (Tier 1)

NDS

dicloxacillin oral capsule 250 mg, 500 mg $0 (Tier 1) NDS nafcillin injection recon soln 1 gram, 10 gram $0 (Tier 1) NDS oxacillin injection recon soln 10 gram $0 (Tier 1) NDS penicillin g sodium injection recon soln 5 million unit

$0 (Tier 1)

NDS

penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml

$0 (Tier 1)

NDS

penicillin v potassium oral tablet 250 mg, 500 mg

$0 (Tier 1)

NDS

piperacillin-tazobactam intravenous recon soln 2.25 gram

$0 (Tier 1)

piperacillin-tazobactam intravenous recon soln 3.375 gram, 4.5 gram, 40.5 gram

$0 (Tier 1)

NDS

Macrolides

AZASITE OPHTHALMIC (EYE) DROPS 1 % $0 (Tier 1) NDS azithromycin intravenous recon soln 500 mg $0 (Tier 1) NDS azithromycin oral packet 1 gram $0 (Tier 1) NDS azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml

$0 (Tier 1)

NDS

azithromycin oral tablet 250 mg, 500 mg, 600 mg

$0 (Tier 1)

NDS


12

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

$0 (Tier 1)

NDS

clarithromycin oral tablet 250 mg, 500 mg $0 (Tier 1) NDS clarithromycin oral tablet extended release 24 hr 500 mg

$0 (Tier 1)

NDS

E.E.S. 400 ORAL TABLET 400 MG $0 (Tier 1) NDS E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML

$0 (Tier 1)

NDS

ERY PADS TOPICAL SWAB 2 % $0 (Tier 1) NDS ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG

$0 (Tier 1)

NDS

ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG

$0 (Tier 1)

NDS

erythromycin ethylsuccinate oral tablet 400 mg

$0 (Tier 1)

NDS

erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %)

$0 (Tier 1)

NDS

erythromycin with ethanol topical gel 2 % $0 (Tier 1) NDS erythromycin with ethanol topical solution 2 %

$0 (Tier 1)

NDS

ZITHROMAX ORAL TABLET 250 MG $0 (Tier 1) NDS Quinolones

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

$0 (Tier 1)

NDS

ciprofloxacin hcl ophthalmic (eye) drops 0.3 %

$0 (Tier 1)

NDS

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg

$0 (Tier 1)

NDS

ciprofloxacin hcl otic (ear) dropperette 0.2 % $0 (Tier 1)

ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml

$0 (Tier 1)

NDS

ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml

$0 (Tier 1)

NDS

gatifloxacin ophthalmic (eye) drops 0.5 % $0 (Tier 1) NDS levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml

$0 (Tier 1)

NDS

levofloxacin ophthalmic (eye) drops 0.5 % $0 (Tier 1) NDS levofloxacin oral solution 250 mg/10 ml $0 (Tier 1) NDS levofloxacin oral tablet 250 mg, 500 mg, 750 mg

$0 (Tier 1)

NDS


13

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS moxifloxacin in nacl (iso-osm) intravenous piggyback 400 mg/250 ml

$0 (Tier 1)

NDS

moxifloxacin ophthalmic (eye) drops 0.5 % $0 (Tier 1)

moxifloxacin oral tablet 400 mg $0 (Tier 1) NDS ofloxacin oral tablet 400 mg $0 (Tier 1) NDS VIGAMOX OPHTHALMIC (EYE) DROPS 0.5 %

$0 (Tier 1)

NDS

Sulfonamides

silver sulfadiazine topical cream 1 % $0 (Tier 1) NDS SSD TOPICAL CREAM 1 % $0 (Tier 1) NDS sulfacetamide sodium (acne) topical suspension 10 %

$0 (Tier 1)

NDS

sulfacetamide sodium ophthalmic (eye) drops 10 %

$0 (Tier 1)

NDS

sulfacetamide sodium ophthalmic (eye) ointment 10 %

$0 (Tier 1)

NDS

sulfadiazine oral tablet 500 mg $0 (Tier 1) NDS sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml

$0 (Tier 1)

NDS

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

$0 (Tier 1)

NDS

Tetracyclines

demeclocycline oral tablet 150 mg, 300 mg $0 (Tier 1) NDS DOXY-100 INTRAVENOUS RECON SOLN 100 MG

$0 (Tier 1)

NDS

doxycycline hyclate oral capsule 100 mg, 50 mg

$0 (Tier 1)

NDS

doxycycline hyclate oral tablet 100 mg, 20 mg

$0 (Tier 1)

NDS

doxycycline monohydrate oral capsule 100 mg, 50 mg

$0 (Tier 1)

NDS

doxycycline monohydrate oral tablet 150 mg, 50 mg

$0 (Tier 1)

NDS

minocycline oral capsule 100 mg, 50 mg, 75 mg

$0 (Tier 1)

NDS

minocycline oral tablet 100 mg, 50 mg, 75 mg

$0 (Tier 1)

NDS

minocycline oral tablet extended release 24 hr 135 mg, 45 mg, 90 mg

$0 (Tier 1)

NDS

tetracycline oral capsule 250 mg, 500 mg $0 (Tier 1) NDS


14

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Anticonvulsants Anticonvulsants, Other BRIVIACT ORAL SOLUTION 10 MG/ML $0 (Tier 1) MO BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG

$0 (Tier 1)

MO

DIASTAT ACUDIAL RECTAL KIT 12.5-15- 17.5-20 MG, 5-7.5-10 MG

$0 (Tier 1)

DIASTAT RECTAL KIT 2.5 MG $0 (Tier 1)

diazepam intensol oral concentrate 5 mg/ml $0 (Tier 1) PA NSO; NDS diazepam oral solution 5 mg/5 ml (1 mg/ml) $0 (Tier 1) NDS diazepam oral tablet 10 mg, 2 mg, 5 mg $0 (Tier 1) NDS levetiracetam oral solution 100 mg/ml $0 (Tier 1) MO levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg

$0 (Tier 1)

MO

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

$0 (Tier 1)

MO

ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG

$0 (Tier 1)

MO

SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG, 750 MG

$0 (Tier 1)

MO

Calcium Channel Modifying Agents

CELONTIN ORAL CAPSULE 300 MG $0 (Tier 1) MO ethosuximide oral capsule 250 mg $0 (Tier 1) MO ethosuximide oral solution 250 mg/5 ml $0 (Tier 1) MO LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 330 MG, 82.5 MG

$0 (Tier 1)

MO

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

$0 (Tier 1)

MO

LYRICA ORAL SOLUTION 20 MG/ML $0 (Tier 1) MO ZARONTIN ORAL CAPSULE 250 MG $0 (Tier 1) MO ZARONTIN ORAL SOLUTION 250 MG/5 ML $0 (Tier 1) MO zonisamide oral capsule 100 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

Gamma-Aminobutyric Acid (Gaba) Augmenting Agents

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) MO clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

$0 (Tier 1)

MO


15

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg

$0 (Tier 1)

NDS

DEPAKENE ORAL CAPSULE 250 MG $0 (Tier 1) MO DEPAKENE ORAL SOLUTION 250 MG/5 ML

$0 (Tier 1)

MO


$0 (Tier 1)


diazepam intensol oral concentrate 5 mg/ml $0 (Tier 1) PA NSO; NDS diazepam oral solution 5 mg/5 ml (1 mg/ml) $0 (Tier 1) NDS diazepam oral tablet 10 mg, 2 mg, 5 mg $0 (Tier 1) NDS divalproex oral capsule, delayed rel sprinkle 125 mg

$0 (Tier 1)

MO

divalproex oral tablet extended release 24 hr 250 mg, 500 mg

$0 (Tier 1)

MO

divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg

$0 (Tier 1)

MO

gabapentin oral capsule 100 mg, 300 mg, 400 mg

$0 (Tier 1)

MO

gabapentin oral solution 250 mg/5 ml $0 (Tier 1) MO gabapentin oral tablet 600 mg, 800 mg $0 (Tier 1) MO GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG

$0 (Tier 1)

MO

KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG

$0 (Tier 1)

MO

lamotrigine oral tablet,disintegrating 100 mg, 200 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) NDS ONFI ORAL SUSPENSION 2.5 MG/ML $0 (Tier 1) MO; QL (480 per 30 days) ONFI ORAL TABLET 10 MG, 20 MG $0 (Tier 1) MO; QL (60 per 30 days) phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) $0 (Tier 1) PA NSO; MO phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

$0 (Tier 1)

PA NSO; MO

primidone oral tablet 250 mg, 50 mg $0 (Tier 1) MO SABRIL ORAL POWDER IN PACKET 500 MG

$0 (Tier 1)

PA NSO; LA; NDS; MO

SABRIL ORAL TABLET 500 MG $0 (Tier 1) PA NSO; LA; NDS tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg

$0 (Tier 1)

MO


16

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS valproic acid (as sodium salt) oral solution 250 mg/5 ml

$0 (Tier 1)

MO

valproic acid oral capsule 250 mg $0 (Tier 1) MO vigabatrin oral powder in packet 500 mg $0 (Tier 1) MO Glutamate Reducing Agents

felbamate oral suspension 600 mg/5 ml $0 (Tier 1) MO felbamate oral tablet 400 mg, 600 mg $0 (Tier 1) MO FYCOMPA ORAL SUSPENSION 0.5 MG/ML $0 (Tier 1) PA NSO; MO FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

$0 (Tier 1)

PA NSO; MO

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

$0 (Tier 1)

MO

lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

$0 (Tier 1)

MO

lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg

$0 (Tier 1)

MO

lamotrigine oral tablets,dose pack 25 mg (35), 25 mg (42) -100 mg (7), 25 mg (84) - 100 mg (14)

$0 (Tier 1)

QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 100 MG, 150 MG, 200 MG, 25 MG, 50 MG

$0 (Tier 1)

MO

topiramate oral capsule, sprinkle 15 mg, 25 mg

$0 (Tier 1)

MO

topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

Sodium Channel Agents

APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG

$0 (Tier 1)

MO

BANZEL ORAL SUSPENSION 40 MG/ML $0 (Tier 1) PA NSO; MO BANZEL ORAL TABLET 200 MG, 400 MG $0 (Tier 1) PA NSO; MO carbamazepine oral suspension 100 mg/5 ml $0 (Tier 1) MO carbamazepine oral tablet 200 mg $0 (Tier 1) MO carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg

$0 (Tier 1)

MO

carbamazepine oral tablet,chewable 100 mg $0 (Tier 1) MO


17

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG

$0 (Tier 1)

MO

DILANTIN EXTENDED ORAL CAPSULE 100 MG

$0 (Tier 1)

MO

DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG

$0 (Tier 1)

MO

DILANTIN ORAL CAPSULE 30 MG $0 (Tier 1) MO DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML

$0 (Tier 1)

MO

EPITOL ORAL TABLET 200 MG $0 (Tier 1) MO EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG

$0 (Tier 1)

MO

oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml)

$0 (Tier 1)

MO

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg

$0 (Tier 1)

MO

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG

$0 (Tier 1)

MO

PEGANONE ORAL TABLET 250 MG $0 (Tier 1) MO PHENYTEK ORAL CAPSULE 200 MG, 300 MG

$0 (Tier 1)

MO

phenytoin oral suspension 125 mg/5 ml $0 (Tier 1) MO phenytoin oral tablet,chewable 50 mg $0 (Tier 1) MO phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

$0 (Tier 1)

MO

VIMPAT ORAL SOLUTION 10 MG/ML $0 (Tier 1) MO; QL (1200 per 30 days) VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG

$0 (Tier 1)


VIMPAT ORAL TABLET 50 MG $0 (Tier 1) MO; QL (180 per 30 days) Antidementia Agents Antidementia Agents, Other ergoloid oral tablet 1 mg $0 (Tier 1) MO Cholinesterase Inhibitors

donepezil oral tablet 10 mg, 23 mg $0 (Tier 1) MO; QL (30 per 30 days) donepezil oral tablet 5 mg $0 (Tier 1) MO; QL (60 per 30 days) donepezil oral tablet,disintegrating 10 mg $0 (Tier 1) MO; QL (30 per 30 days) donepezil oral tablet,disintegrating 5 mg $0 (Tier 1) MO; QL (60 per 30 days)


18

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg

$0 (Tier 1)


galantamine oral solution 4 mg/ml $0 (Tier 1) MO galantamine oral tablet 12 mg, 4 mg, 8 mg $0 (Tier 1) MO rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

$0 (Tier 1)


rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr

$0 (Tier 1)


N-Methyl-D-Aspartate (Nmda) Receptor Antagonist

memantine oral solution 2 mg/ml $0 (Tier 1) MO; QL (360 per 30 days) memantine oral tablet 10 mg, 5 mg $0 (Tier 1) MO; QL (60 per 30 days) memantine oral tablets,dose pack 5-10 mg $0 (Tier 1) NDS; QL (49 per 28 days) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7-14-21-28 MG

$0 (Tier 1)

NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG

$0 (Tier 1)

NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG

$0 (Tier 1)

MO

Antidepressants Antidepressants, Other ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG

$0 (Tier 1)

MO

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG

$0 (Tier 1)

MO

amitriptyline-chlordiazepoxide oral tablet 12.5-5 mg, 25-10 mg

$0 (Tier 1)

MO

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG, 348 MG, 522 MG

$0 (Tier 1)

MO

aripiprazole oral solution 1 mg/ml $0 (Tier 1) MO; QL (900 per 30 days) aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

$0 (Tier 1)


aripiprazole oral tablet,disintegrating 10 mg, 15 mg

$0 (Tier 1)


bupropion hcl oral tablet 100 mg, 75 mg $0 (Tier 1) MO bupropion hcl oral tablet extended release 12 hr 100 mg, 200 mg

$0 (Tier 1)

MO


19

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS bupropion hcl oral tablet extended release 12 hr 150 mg

$0 (Tier 1)

NDS; MO

bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg

$0 (Tier 1)

MO

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG

$0 (Tier 1)

MO

maprotiline oral tablet 25 mg, 50 mg, 75 mg $0 (Tier 1) MO mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg

$0 (Tier 1)

MO

mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg

$0 (Tier 1)

MO

nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

$0 (Tier 1)

MO

perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg

$0 (Tier 1)

MO

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

$0 (Tier 1)


quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 400 mg, 50 mg

$0 (Tier 1)


REMERON ORAL TABLET 15 MG, 30 MG $0 (Tier 1) MO REMERON SOLTAB ORAL TABLET,DISINTEGRATING 15 MG, 30 MG, 45 MG

$0 (Tier 1)

MO

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG

$0 (Tier 1)

MO

trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg

$0 (Tier 1)

MO

WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG

$0 (Tier 1)

MO

Antidepressants

amitriptyline-chlordiazepoxide oral tablet 12.5-5 mg, 25-10 mg

$0 (Tier 1)

MO

fluoxetine oral tablet 60 mg $0 (Tier 1) MO olanzapine-fluoxetine oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-50 mg

$0 (Tier 1)


olanzapine-fluoxetine oral capsule 6-25 mg $0 (Tier 1) MO perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg

$0 (Tier 1)

MO

SYMBYAX ORAL CAPSULE 12-25 MG, 12- 50 MG, 3-25 MG, 6-25 MG, 6-50 MG

$0 (Tier 1)

MO


20

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Monoamine Oxidase Inhibitors

EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR

$0 (Tier 1)

MO

MARPLAN ORAL TABLET 10 MG $0 (Tier 1) MO NARDIL ORAL TABLET 15 MG $0 (Tier 1) MO PARNATE ORAL TABLET 10 MG $0 (Tier 1) MO phenelzine oral tablet 15 mg $0 (Tier 1) MO tranylcypromine oral tablet 10 mg $0 (Tier 1) MO Ssris/ Snris

BRISDELLE ORAL CAPSULE 7.5 MG $0 (Tier 1) MO CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG

$0 (Tier 1)

MO

citalopram oral solution 10 mg/5 ml $0 (Tier 1) MO citalopram oral tablet 10 mg, 20 mg, 40 mg $0 (Tier 1) MO desvenlafaxine oral tablet extended release 24 hr 100 mg, 50 mg

$0 (Tier 1)

MO

desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 40 mg, 60 mg

$0 (Tier 1)


escitalopram oxalate oral solution 5 mg/5 ml $0 (Tier 1) MO; QL (600 per 30 days) escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg

$0 (Tier 1)


FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)

$0 (Tier 1)

NDS

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG

$0 (Tier 1)


FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG

$0 (Tier 1)


FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG

$0 (Tier 1)


fluoxetine oral capsule 10 mg, 20 mg, 40 mg $0 (Tier 1) MO fluoxetine oral capsule,delayed release(dr/ec) 90 mg

$0 (Tier 1)

MO

fluoxetine oral solution 20 mg/5 ml (4 mg/ml) $0 (Tier 1) MO fluoxetine oral tablet 10 mg, 20 mg $0 (Tier 1) MO fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg

$0 (Tier 1)

MO


21

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS fluvoxamine oral tablet 100 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 50 MG

$0 (Tier 1)

MO

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

$0 (Tier 1)

MO

paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg

$0 (Tier 1)

MO

paroxetine mesylate(menop.sym) oral capsule 7.5 mg

$0 (Tier 1)

MO

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 12.5 MG, 25 MG, 37.5 MG

$0 (Tier 1)

MO

PAXIL ORAL SUSPENSION 10 MG/5 ML $0 (Tier 1) MO PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG

$0 (Tier 1)

MO

PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG

$0 (Tier 1)

MO

SARAFEM ORAL TABLET 10 MG, 20 MG $0 (Tier 1) MO sertraline oral concentrate 20 mg/ml $0 (Tier 1) MO sertraline oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO TRINTELLIX ORAL TABLET 10 MG, 20 MG $0 (Tier 1) MO; QL (30 per 30 days) TRINTELLIX ORAL TABLET 5 MG $0 (Tier 1) MO; QL (60 per 30 days) venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg

$0 (Tier 1)

MO

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

$0 (Tier 1)

MO

venlafaxine oral tablet extended release 24hr 150 mg, 225 mg, 37.5 mg, 75 mg

$0 (Tier 1)

MO

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG

$0 (Tier 1)


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

$0 (Tier 1)

NDS

ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG

$0 (Tier 1)

MO

Tricyclics

amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

$0 (Tier 1)

MO

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

ANAFRANIL ORAL CAPSULE 25 MG, 50 MG, 75 MG

$0 (Tier 1)

MO


22

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS clomipramine oral capsule 25 mg, 50 mg, 75 mg

$0 (Tier 1)

MO

desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

$0 (Tier 1)

MO

doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

$0 (Tier 1)

PA NSO; MO

doxepin oral concentrate 10 mg/ml $0 (Tier 1) PA NSO; MO imipramine hcl oral tablet 10 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg

$0 (Tier 1)

MO

NORPRAMIN ORAL TABLET 10 MG, 25 MG $0 (Tier 1) MO nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg

$0 (Tier 1)

MO

nortriptyline oral solution 10 mg/5 ml $0 (Tier 1) MO PAMELOR ORAL CAPSULE 10 MG, 25 MG, 50 MG, 75 MG

$0 (Tier 1)

MO

protriptyline oral tablet 10 mg, 5 mg $0 (Tier 1) MO SILENOR ORAL TABLET 3 MG, 6 MG $0 (Tier 1)

SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG

$0 (Tier 1)

MO

TOFRANIL ORAL TABLET 10 MG, 25 MG, 50 MG

$0 (Tier 1)

MO

trimipramine oral capsule 100 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

Antiemetics Antiemetics, Other chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

COMPRO RECTAL SUPPOSITORY 25 MG $0 (Tier 1) NDS hydroxyzine hcl oral solution 10 mg/5 ml $0 (Tier 1) PA NSO; NDS hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg

$0 (Tier 1)

PA NSO; NDS

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg

$0 (Tier 1)

PA NSO; NDS

meclizine oral tablet 12.5 mg, 25 mg $0 (Tier 1) NDS metoclopramide hcl oral solution 5 mg/5 ml $0 (Tier 1) NDS metoclopramide hcl oral tablet 10 mg, 5 mg $0 (Tier 1) NDS perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg

$0 (Tier 1)

MO


23

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS PHENADOZ RECTAL SUPPOSITORY 12.5 MG

$0 (Tier 1)

NDS

prochlorperazine maleate oral tablet 10 mg, 5 mg

$0 (Tier 1)

NDS

prochlorperazine rectal suppository 25 mg $0 (Tier 1) NDS promethazine oral syrup 6.25 mg/5 ml $0 (Tier 1) PA NSO; NDS promethazine oral tablet 12.5 mg, 25 mg, 50 mg

$0 (Tier 1)

PA NSO; NDS

promethazine rectal suppository 12.5 mg, 25 mg

$0 (Tier 1)

PA NSO; NDS

promethazine rectal suppository 50 mg $0 (Tier 1) NDS PROMETHEGAN RECTAL SUPPOSITORY 25 MG, 50 MG

$0 (Tier 1)

NDS

scopolamine base transdermal patch 3 day 1 mg over 3 days

$0 (Tier 1)

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1 MG OVER 3 DAYS

$0 (Tier 1)

NDS

Emetogenic Therapy Adjuncts

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg $0 (Tier 1) PA BvD; NDS EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG

$0 (Tier 1) PA BvD; NDS; QL (6 per 30

days) granisetron hcl oral tablet 1 mg $0 (Tier 1) PA BvD; NDS ondansetron hcl oral solution 4 mg/5 ml $0 (Tier 1) PA BvD; NDS ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg

$0 (Tier 1)

PA BvD; NDS

ondansetron oral tablet,disintegrating 4 mg, 8 mg

$0 (Tier 1)

PA BvD; NDS

Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 MG/ML

$0 (Tier 1)

PA NSO; NDS

AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG

$0 (Tier 1)

PA NSO; NDS

amphotericin b injection recon soln 50 mg $0 (Tier 1) PA BvD; NDS CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG

$0 (Tier 1)

PA NSO; NDS

caspofungin intravenous recon soln 50 mg, 70 mg

$0 (Tier 1)

PA NSO

ciclopirox topical cream 0.77 % $0 (Tier 1) NDS ciclopirox topical gel 0.77 % $0 (Tier 1) NDS


24

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ciclopirox topical shampoo 1 % $0 (Tier 1) NDS ciclopirox topical solution 8 % $0 (Tier 1) NDS ciclopirox topical suspension 0.77 % $0 (Tier 1) NDS clotrimazole mucous membrane troche 10 mg

$0 (Tier 1)

NDS

clotrimazole topical cream 1 % $0 (Tier 1) NDS clotrimazole topical solution 1 % $0 (Tier 1) NDS econazole topical cream 1 % $0 (Tier 1) NDS ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG

$0 (Tier 1)

NDS

EXELDERM TOPICAL CREAM 1 % $0 (Tier 1) NDS EXELDERM TOPICAL SOLUTION 1 % $0 (Tier 1) NDS fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml

$0 (Tier 1)

PA NSO; NDS

fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml

$0 (Tier 1)

NDS

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg

$0 (Tier 1)

NDS

flucytosine oral capsule 250 mg, 500 mg $0 (Tier 1) NDS griseofulvin microsize oral suspension 125 mg/5 ml

$0 (Tier 1)

NDS

griseofulvin microsize oral tablet 500 mg $0 (Tier 1) NDS griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

$0 (Tier 1)

NDS

itraconazole oral capsule 100 mg $0 (Tier 1) NDS ketoconazole oral tablet 200 mg $0 (Tier 1) NDS ketoconazole topical cream 2 % $0 (Tier 1) NDS ketoconazole topical foam 2 % $0 (Tier 1) NDS ketoconazole topical shampoo 2 % $0 (Tier 1) NDS MENTAX TOPICAL CREAM 1 % $0 (Tier 1) NDS miconazole-3 vaginal suppository 200 mg $0 (Tier 1) NDS MYCAMINE INTRAVENOUS RECON SOLN 100 MG, 50 MG

$0 (Tier 1)

NDS

naftifine topical cream 1 % $0 (Tier 1) NDS NAFTIN TOPICAL CREAM 2 % $0 (Tier 1) NDS NAFTIN TOPICAL GEL 1 %, 2 % $0 (Tier 1) NDS NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 %

$0 (Tier 1)

NDS


25

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML)

$0 (Tier 1)

NDS

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG

$0 (Tier 1)


NYAMYC TOPICAL POWDER 100,000 UNIT/GRAM

$0 (Tier 1)

nystatin oral suspension 100,000 unit/ml $0 (Tier 1) NDS nystatin oral tablet 500,000 unit $0 (Tier 1) NDS nystatin topical cream 100,000 unit/gram $0 (Tier 1) NDS nystatin topical ointment 100,000 unit/gram $0 (Tier 1) NDS nystatin topical powder 100,000 unit/gram $0 (Tier 1) NDS NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM

$0 (Tier 1)

OXISTAT TOPICAL CREAM 1 % $0 (Tier 1) NDS OXISTAT TOPICAL LOTION 1 % $0 (Tier 1) NDS terbinafine hcl oral tablet 250 mg $0 (Tier 1) NDS terconazole vaginal cream 0.4 %, 0.8 % $0 (Tier 1) NDS terconazole vaginal suppository 80 mg $0 (Tier 1) NDS voriconazole intravenous solution 200 mg $0 (Tier 1) PA NSO; NDS voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml)

$0 (Tier 1)

NDS

voriconazole oral tablet 200 mg, 50 mg $0 (Tier 1) NDS ZOLINZA ORAL CAPSULE 100 MG

$0 (Tier 1) PA NSO; NDS; QL (120 per 30

days) Antigout Agents Antigout Agents allopurinol oral tablet 100 mg, 300 mg $0 (Tier 1) MO colchicine oral capsule 0.6 mg $0 (Tier 1) MO colchicine oral tablet 0.6 mg $0 (Tier 1) MO COLCRYS ORAL TABLET 0.6 MG $0 (Tier 1) MO probenecid oral tablet 500 mg $0 (Tier 1) MO probenecid-colchicine oral tablet 500-0.5 mg $0 (Tier 1) NDS; MO ULORIC ORAL TABLET 40 MG, 80 MG $0 (Tier 1) MO Anti-Inflammatory Agents Glucocorticoids betamethasone dipropionate topical cream 0.05 %

$0 (Tier 1)

NDS

betamethasone dipropionate topical lotion 0.05 %

$0 (Tier 1)

NDS


26

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS betamethasone dipropionate topical ointment 0.05 %

$0 (Tier 1)

NDS

betamethasone valerate topical cream 0.1 % $0 (Tier 1) NDS betamethasone valerate topical foam 0.12 % $0 (Tier 1) NDS betamethasone valerate topical lotion 0.1 % $0 (Tier 1) NDS betamethasone valerate topical ointment 0.1 %

$0 (Tier 1)

NDS

betamethasone, augmented topical cream 0.05 %

$0 (Tier 1)

NDS

betamethasone, augmented topical gel 0.05 %

$0 (Tier 1)

NDS

betamethasone, augmented topical lotion 0.05 %

$0 (Tier 1)

NDS

BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION 10-

$0 (Tier 1)

NDS

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT 10-0.2 %

$0 (Tier 1)

NDS

cortisone oral tablet 25 mg $0 (Tier 1) NDS DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML

$0 (Tier 1)

NDS

dexamethasone oral elixir 0.5 mg/5 ml $0 (Tier 1) PA BvD; NDS dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

$0 (Tier 1)

PA BvD; NDS

hydrocortisone oral tablet 20 mg, 5 mg $0 (Tier 1) MO methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

$0 (Tier 1)

PA BvD; NDS

PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 %

$0 (Tier 1)

NDS

prednisolone acetate ophthalmic (eye) drops,suspension 1 %

$0 (Tier 1)

NDS

prednisolone oral solution 15 mg/5 ml $0 (Tier 1) PA BvD; NDS prednisolone sodium phosphate ophthalmic (eye) drops 1 %

$0 (Tier 1)

NDS

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

$0 (Tier 1)

PA BvD; NDS

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML

$0 (Tier 1)

PA BvD; NDS

prednisone oral solution 5 mg/5 ml $0 (Tier 1) PA BvD; NDS prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

$0 (Tier 1)

PA BvD; NDS


27

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS triamcinolone acetonide topical aerosol 0.147 mg/gram

$0 (Tier 1)

NDS

VERIPRED 20 ORAL SOLUTION 20 MG/5 ML (4 MG/ML)

$0 (Tier 1)

PA BvD; NDS

Nonsteroidal Anti-Inflammatory Drugs

celecoxib oral capsule 100 mg, 200 mg, 50 mg

$0 (Tier 1)


celecoxib oral capsule 400 mg $0 (Tier 1) MO; QL (30 per 30 days) diclofenac potassium oral tablet 50 mg $0 (Tier 1) NDS diclofenac sodium oral tablet extended release 24 hr 100 mg

$0 (Tier 1)

NDS

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg

$0 (Tier 1)

NDS

diflunisal oral tablet 500 mg $0 (Tier 1) NDS etodolac oral capsule 200 mg $0 (Tier 1) MO etodolac oral tablet 400 mg, 500 mg $0 (Tier 1) MO etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg

$0 (Tier 1)

MO

fenoprofen oral tablet 600 mg $0 (Tier 1) NDS flurbiprofen oral tablet 100 mg $0 (Tier 1) NDS flurbiprofen oral tablet 50 mg $0 (Tier 1) NDS; MO ibuprofen oral suspension 100 mg/5 ml $0 (Tier 1) MO ibuprofen oral tablet 400 mg, 600 mg, 800 mg

$0 (Tier 1)

MO

ibuprofen-oxycodone oral tablet 400-5 mg $0 (Tier 1) NDS; QL (120 per 30 days) indomethacin oral capsule 25 mg, 50 mg $0 (Tier 1) NDS indomethacin oral capsule, extended release 75 mg

$0 (Tier 1)

NDS

ketoprofen oral capsule 75 mg $0 (Tier 1) NDS ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

$0 (Tier 1)

NDS; MO

ketorolac oral tablet 10 mg $0 (Tier 1) NDS meclofenamate oral capsule 100 mg $0 (Tier 1) NDS meclofenamate oral capsule 50 mg $0 (Tier 1) NDS; MO mefenamic acid oral capsule 250 mg $0 (Tier 1) NDS meloxicam oral tablet 15 mg, 7.5 mg $0 (Tier 1) MO nabumetone oral tablet 500 mg, 750 mg $0 (Tier 1) NDS naproxen oral suspension 125 mg/5 ml $0 (Tier 1) MO


28

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS naproxen oral tablet 250 mg, 375 mg, 500 mg

$0 (Tier 1)

MO

naproxen sodium oral tablet 275 mg, 550 mg $0 (Tier 1) MO naproxen sodium oral tablet, er multiphase 24 hr 500 mg

$0 (Tier 1)

MO

oxaprozin oral tablet 600 mg $0 (Tier 1) NDS piroxicam oral capsule 10 mg, 20 mg $0 (Tier 1) NDS sulindac oral tablet 150 mg, 200 mg $0 (Tier 1) NDS tolmetin oral capsule 400 mg $0 (Tier 1) NDS tolmetin oral tablet 600 mg $0 (Tier 1) NDS; MO Antimigraine Agents Ergot Alkaloids dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml)

$0 (Tier 1)

NDS

MIGERGOT RECTAL SUPPOSITORY 2-100 MG

$0 (Tier 1)

NDS

Prophylactic


$0 (Tier 1)

MO

divalproex oral capsule, delayed rel sprinkle 125 mg

$0 (Tier 1)

MO


$0 (Tier 1)

MO


$0 (Tier 1)

MO

timolol maleate oral tablet 10 mg, 20 mg, 5 mg

$0 (Tier 1)

MO

topiramate oral capsule, sprinkle 15 mg, 25 mg

$0 (Tier 1)

MO

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

valproic acid (as sodium salt) oral solution 250 mg/5 ml

$0 (Tier 1)

MO

valproic acid oral capsule 250 mg $0 (Tier 1) MO Serotonin (5-Ht) 1B/1D Receptor Agonists

naratriptan oral tablet 1 mg, 2.5 mg $0 (Tier 1) NDS; QL (18 per 30 days) rizatriptan oral tablet 10 mg, 5 mg $0 (Tier 1) NDS; QL (18 per 30 days) rizatriptan oral tablet,disintegrating 10 mg $0 (Tier 1) NDS; QL (18 per 30 days)


29

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation

$0 (Tier 1)


sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg

$0 (Tier 1)


sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml

$0 (Tier 1)


Antimyasthenic Agents Parasympathomimetics guanidine oral tablet 125 mg $0 (Tier 1) NDS MESTINON ORAL SYRUP 60 MG/5 ML $0 (Tier 1) MO MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 180 MG

$0 (Tier 1)

MO

pyridostigmine bromide oral tablet 60 mg $0 (Tier 1) MO pyridostigmine bromide oral tablet extended release 180 mg

$0 (Tier 1)

MO

Antimycobacterials Antimycobacterials, Other dapsone oral tablet 100 mg, 25 mg $0 (Tier 1) MO PRIFTIN ORAL TABLET 150 MG $0 (Tier 1) NDS rifabutin oral capsule 150 mg $0 (Tier 1) NDS Antituberculars

ethambutol oral tablet 100 mg, 400 mg $0 (Tier 1) NDS; MO isoniazid oral solution 50 mg/5 ml $0 (Tier 1) NDS; MO isoniazid oral tablet 100 mg, 300 mg $0 (Tier 1) NDS PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM

$0 (Tier 1)

NDS; MO

pyrazinamide oral tablet 500 mg $0 (Tier 1) NDS rifampin intravenous recon soln 600 mg $0 (Tier 1) NDS rifampin oral capsule 150 mg, 300 mg $0 (Tier 1) NDS RIFATER ORAL TABLET 50-120-300 MG $0 (Tier 1) NDS SIRTURO ORAL TABLET 100 MG $0 (Tier 1) PA NSO; NDS TRECATOR ORAL TABLET 250 MG $0 (Tier 1) NDS Antineoplastics Alkylating Agents cyclophosphamide oral capsule 25 mg, 50 mg

$0 (Tier 1)

PA NSO; NDS

HEXALEN ORAL CAPSULE 50 MG $0 (Tier 1) PA NSO; NDS LEUKERAN ORAL TABLET 2 MG $0 (Tier 1) NDS MATULANE ORAL CAPSULE 50 MG $0 (Tier 1) PA NSO; LA; NDS


30

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS VALCHLOR TOPICAL GEL 0.016 % $0 (Tier 1) PA NSO; MO Antiandrogens

bicalutamide oral tablet 50 mg $0 (Tier 1) MO CASODEX ORAL TABLET 50 MG $0 (Tier 1) MO ERLEADA ORAL TABLET 60 MG $0 (Tier 1) PA NSO; MO flutamide oral capsule 125 mg $0 (Tier 1) MO nilutamide oral tablet 150 mg $0 (Tier 1) MO

XTANDI ORAL CAPSULE 40 MG

$0 (Tier 1) PA NSO; LA; MO; QL (120 per

30 days) YONSA ORAL TABLET 125 MG

$0 (Tier 1) PA NSO; MO; QL (120 per 30

days) ZYTIGA ORAL TABLET 250 MG


30 days) ZYTIGA ORAL TABLET 500 MG


days) Antiangiogenic Agents

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG

$0 (Tier 1)

PA NSO; LA; MO

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG

$0 (Tier 1)

PA NSO; LA; MO

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

$0 (Tier 1)

PA NSO; MO

Antiestrogens/Modifiers

EMCYT ORAL CAPSULE 140 MG $0 (Tier 1) NDS FARESTON ORAL TABLET 60 MG $0 (Tier 1) PA NSO; MO SOLTAMOX ORAL SOLUTION 10 MG/5 ML $0 (Tier 1) PA NSO; MO tamoxifen oral tablet 10 mg, 20 mg $0 (Tier 1) MO Antimetabolites

DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

$0 (Tier 1)

MO

HYDREA ORAL CAPSULE 500 MG $0 (Tier 1) MO hydroxyurea oral capsule 500 mg $0 (Tier 1) MO LONSURF ORAL TABLET 15-6.14 MG, 20- 8.19 MG

$0 (Tier 1)

PA NSO; NDS

PURIXAN ORAL SUSPENSION 20 MG/ML $0 (Tier 1) NDS; MO TABLOID ORAL TABLET 40 MG $0 (Tier 1) PA NSO; NDS Antineoplastics, Other

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

$0 (Tier 1)

NDS


31

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS REVLIMID ORAL CAPSULE 2.5 MG $0 (Tier 1) PA NSO; LA; MO REVLIMID ORAL CAPSULE 20 MG $0 (Tier 1) MO SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG

$0 (Tier 1)

MO

SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG

$0 (Tier 1)

PA NSO; MO

Antineoplastics

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

$0 (Tier 1)

NDS

LYNPARZA ORAL CAPSULE 50 MG $0 (Tier 1) PA NSO; NDS LYNPARZA ORAL TABLET 100 MG, 150 MG

$0 (Tier 1)

PA NSO; MO

MESNEX ORAL TABLET 400 MG $0 (Tier 1) NDS NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG

$0 (Tier 1)

PA NSO; NDS

RUBRACA ORAL TABLET 200 MG, 300 MG $0 (Tier 1)

RUBRACA ORAL TABLET 250 MG $0 (Tier 1) MO VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG

$0 (Tier 1)

MO

VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG

$0 (Tier 1)

ZEJULA ORAL CAPSULE 100 MG $0 (Tier 1) MO Aromatase Inhibitors, 3Rd Generation

anastrozole oral tablet 1 mg $0 (Tier 1) MO; QL (30 per 30 days) ARIMIDEX ORAL TABLET 1 MG $0 (Tier 1) MO AROMASIN ORAL TABLET 25 MG $0 (Tier 1) MO exemestane oral tablet 25 mg $0 (Tier 1) MO FEMARA ORAL TABLET 2.5 MG $0 (Tier 1) MO letrozole oral tablet 2.5 mg $0 (Tier 1) MO Enzyme Inhibitors

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG

$0 (Tier 1)

PA NSO; NDS

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG

$0 (Tier 1)

PA NSO; MO

IDHIFA ORAL TABLET 100 MG, 50 MG $0 (Tier 1) MO KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG

$0 (Tier 1)

PA NSO; MO


32

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3)

$0 (Tier 1)

PA NSO; MO

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

$0 (Tier 1)

PA NSO; MO

ZOLINZA ORAL CAPSULE 100 MG


days) ZYDELIG ORAL TABLET 100 MG, 150 MG $0 (Tier 1) PA NSO; NDS Molecular Target Inhibitors

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

$0 (Tier 1)

PA NSO; MO

ALECENSA ORAL CAPSULE 150 MG $0 (Tier 1) PA NSO; MO ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG

$0 (Tier 1)

MO

ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (23)

$0 (Tier 1)

BOSULIF ORAL TABLET 100 MG


days) BOSULIF ORAL TABLET 400 MG $0 (Tier 1) MO

BOSULIF ORAL TABLET 500 MG


days) CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG

$0 (Tier 1)

PA NSO

CALQUENCE ORAL CAPSULE 100 MG $0 (Tier 1) MO CAPRELSA ORAL TABLET 100 MG

$0 (Tier 1) PA NSO; NDS; MO; QL (60 per

30 days) CAPRELSA ORAL TABLET 300 MG

$0 (Tier 1) PA NSO; NDS; MO; QL (30 per

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

$0 (Tier 1)

PA NSO; LA; NDS; MO

COTELLIC ORAL TABLET 20 MG $0 (Tier 1) NDS ERIVEDGE ORAL CAPSULE 150 MG


30 days) GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG


30 days) ICLUSIG ORAL TABLET 15 MG $0 (Tier 1) MO ICLUSIG ORAL TABLET 45 MG $0 (Tier 1) PA NSO; MO imatinib oral tablet 100 mg, 400 mg $0 (Tier 1) PA NSO; MO


33

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS IMBRUVICA ORAL CAPSULE 140 MG

$0 (Tier 1) PA NSO; LA; NDS; QL (120 per

30 days) IMBRUVICA ORAL CAPSULE 70 MG


days) IMBRUVICA ORAL TABLET 140 MG


days) IMBRUVICA ORAL TABLET 280 MG


days) IMBRUVICA ORAL TABLET 420 MG, 560 MG


days) INLYTA ORAL TABLET 1 MG


30 days) INLYTA ORAL TABLET 5 MG


30 days) IRESSA ORAL TABLET 250 MG


days) JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG


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

$0 (Tier 1)

PA NSO; MO

LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1- 4 MG X2), 8 MG/DAY (4 MG X 2)

$0 (Tier 1)

MO

MEKINIST ORAL TABLET 0.5 MG


30 days) MEKINIST ORAL TABLET 2 MG


30 days) NERLYNX ORAL TABLET 40 MG $0 (Tier 1) MO

NEXAVAR ORAL TABLET 200 MG


30 days) ODOMZO ORAL CAPSULE 200 MG $0 (Tier 1) MO OFEV ORAL CAPSULE 100 MG, 150 MG $0 (Tier 1) PA; MO RYDAPT ORAL CAPSULE 25 MG $0 (Tier 1) MO SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG

$0 (Tier 1)

PA NSO; MO

STIVARGA ORAL TABLET 40 MG


30 days) SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

$0 (Tier 1)

PA NSO; NDS

tafinlar oral capsule 50 mg, 75 mg $0 (Tier 1) PA NSO; LA; NDS


34

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS TAGRISSO ORAL TABLET 40 MG, 80 MG $0 (Tier 1) PA NSO; NDS TARCEVA ORAL TABLET 100 MG, 25 MG $0 (Tier 1) PA NSO; LA; MO

TARCEVA ORAL TABLET 150 MG


30 days) TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG


days) TYKERB ORAL TABLET 250 MG


30 days) VOTRIENT ORAL TABLET 200 MG

$0 (Tier 1) PA NSO; LA; NDS; MO; QL

(120 per 30 days) XALKORI ORAL CAPSULE 200 MG


30 days) XALKORI ORAL CAPSULE 250 MG $0 (Tier 1) MO

ZELBORAF ORAL TABLET 240 MG


30 days) ZYKADIA ORAL CAPSULE 150 MG $0 (Tier 1) PA NSO; NDS Retinoids

AVITA TOPICAL CREAM 0.025 % $0 (Tier 1) NDS AVITA TOPICAL GEL 0.025 % $0 (Tier 1) NDS bexarotene oral capsule 75 mg $0 (Tier 1) PA NSO; MO PANRETIN TOPICAL GEL 0.1 % $0 (Tier 1) PA NSO; NDS TARGRETIN ORAL CAPSULE 75 MG $0 (Tier 1) PA NSO; MO TARGRETIN TOPICAL GEL 1 % $0 (Tier 1) PA NSO; NDS tretinoin (chemotherapy) oral capsule 10 mg $0 (Tier 1) NDS tretinoin topical cream 0.025 %, 0.05 %, 0.1 %

$0 (Tier 1)

PA; NDS

tretinoin topical gel 0.01 %, 0.025 % $0 (Tier 1) PA; NDS Treatment Adjuncts

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

$0 (Tier 1)

NDS

Antiparasitics Anthelmintics ALBENZA ORAL TABLET 200 MG $0 (Tier 1) NDS BILTRICIDE ORAL TABLET 600 MG $0 (Tier 1) NDS ivermectin oral tablet 3 mg $0 (Tier 1) NDS Antiprotozoals

ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML

$0 (Tier 1)


ALINIA ORAL TABLET 500 MG $0 (Tier 1) NDS; QL (6 per 3 days)


35

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS atovaquone oral suspension 750 mg/5 ml $0 (Tier 1) NDS atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg

$0 (Tier 1)

NDS

chloroquine phosphate oral tablet 250 mg, 500 mg

$0 (Tier 1)

MO

COARTEM ORAL TABLET 20-120 MG $0 (Tier 1) NDS DARAPRIM ORAL TABLET 25 MG $0 (Tier 1) NDS hydroxychloroquine oral tablet 200 mg $0 (Tier 1) MO mefloquine oral tablet 250 mg $0 (Tier 1) NDS NEBUPENT INHALATION RECON SOLN 300 MG

$0 (Tier 1)

PA BvD; NDS; MO

PENTAM INJECTION RECON SOLN 300 MG

$0 (Tier 1)

NDS

primaquine oral tablet 26.3 mg $0 (Tier 1)

quinine sulfate oral capsule 324 mg $0 (Tier 1) NDS Pediculicides/Scabicides

lindane topical shampoo 1 % $0 (Tier 1) NDS malathion topical lotion 0.5 % $0 (Tier 1) NDS permethrin topical cream 5 % $0 (Tier 1) NDS Antiparkinson Agents Anticholinergics benztropine oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) PA NSO; MO trihexyphenidyl oral elixir 0.4 mg/ml $0 (Tier 1) MO trihexyphenidyl oral tablet 2 mg, 5 mg $0 (Tier 1) MO Antiparkinson Agents, Other

amantadine hcl oral capsule 100 mg $0 (Tier 1) MO amantadine hcl oral solution 50 mg/5 ml $0 (Tier 1) MO amantadine hcl oral tablet 100 mg $0 (Tier 1) MO carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100- 200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

$0 (Tier 1)

MO

entacapone oral tablet 200 mg $0 (Tier 1) MO tolcapone oral tablet 100 mg $0 (Tier 1) MO Antiparkinson Agents

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100- 200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

$0 (Tier 1)

MO


36

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Dopamine Agonists

APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML

$0 (Tier 1)

NDS; MO

bromocriptine oral capsule 5 mg $0 (Tier 1) MO bromocriptine oral tablet 2.5 mg $0 (Tier 1) MO NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR

$0 (Tier 1)

MO

pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

$0 (Tier 1)

MO

pramipexole oral tablet extended release 24 hr 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

$0 (Tier 1)

MO

ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

$0 (Tier 1)

MO

ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg

$0 (Tier 1)

MO

Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

$0 (Tier 1)

MO

carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 mg

$0 (Tier 1)

MO

carbidopa-levodopa oral tablet,disintegrating 10-100 mg, 25-100 mg, 25-250 mg

$0 (Tier 1)

MO

Monoamine Oxidase B (Mao-B) Inhibitors

rasagiline oral tablet 0.5 mg, 1 mg $0 (Tier 1) MO selegiline hcl oral capsule 5 mg $0 (Tier 1) MO selegiline hcl oral tablet 5 mg $0 (Tier 1) MO ZELAPAR ORAL TABLET,DISINTEGRATING 1.25 MG

$0 (Tier 1)

MO

Antipsychotics 1St Generation/Typical chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

fluphenazine decanoate injection solution 25 mg/ml

$0 (Tier 1)

NDS; MO

fluphenazine hcl injection solution 2.5 mg/ml $0 (Tier 1) NDS fluphenazine hcl oral concentrate 5 mg/ml $0 (Tier 1) NDS fluphenazine hcl oral elixir 2.5 mg/5 ml $0 (Tier 1) MO


37

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

$0 (Tier 1)

MO

HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/ML

$0 (Tier 1)

MO

HALDOL INJECTION SOLUTION 5 MG/ML $0 (Tier 1)

haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml

$0 (Tier 1)

MO

haloperidol lactate injection solution 5 mg/ml $0 (Tier 1) NDS haloperidol lactate intramuscular syringe 5 mg/ml

$0 (Tier 1)

haloperidol lactate oral concentrate 2 mg/ml $0 (Tier 1) MO haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

$0 (Tier 1)

MO

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

$0 (Tier 1)

MO

ORAP ORAL TABLET 1 MG $0 (Tier 1) MO perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg

$0 (Tier 1)

MO

pimozide oral tablet 1 mg, 2 mg $0 (Tier 1) MO prochlorperazine maleate oral tablet 10 mg, 5 mg

$0 (Tier 1)

NDS

thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg

$0 (Tier 1)

PA NSO; MO

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg

$0 (Tier 1)

MO

trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg

$0 (Tier 1)

MO

2Nd Generation/Atypical

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG

$0 (Tier 1)

MO

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG

$0 (Tier 1)

MO

aripiprazole oral solution 1 mg/ml $0 (Tier 1) MO; QL (900 per 30 days) aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

$0 (Tier 1)


aripiprazole oral tablet,disintegrating 10 mg, 15 mg

$0 (Tier 1)



38

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML, 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML

$0 (Tier 1)

MO

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

$0 (Tier 1)


FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)

$0 (Tier 1)

NDS

GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.)

$0 (Tier 1)


GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG

$0 (Tier 1)

MO

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML

$0 (Tier 1)

MO

LATUDA ORAL TABLET 120 MG $0 (Tier 1) MO; QL (30 per 30 days) LATUDA ORAL TABLET 20 MG, 40 MG, 60 MG, 80 MG

$0 (Tier 1)


NUPLAZID ORAL TABLET 17 MG $0 (Tier 1) PA NSO; MO olanzapine intramuscular recon soln 10 mg $0 (Tier 1) NDS olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

$0 (Tier 1)


olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg

$0 (Tier 1)


paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg

$0 (Tier 1)


paliperidone oral tablet extended release 24hr 6 mg

$0 (Tier 1)



$0 (Tier 1)



$0 (Tier 1)


REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG

$0 (Tier 1)


REXULTI ORAL TABLET 3 MG, 4 MG $0 (Tier 1) MO; QL (30 per 30 days) RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML

$0 (Tier 1)

MO

risperidone oral solution 1 mg/ml $0 (Tier 1) MO risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

$0 (Tier 1)

MO


39

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

$0 (Tier 1)

MO

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG

$0 (Tier 1)



$0 (Tier 1)

MO

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG

$0 (Tier 1)

PA NSO; MO

VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6)

$0 (Tier 1)

PA NSO

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

$0 (Tier 1)


ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG

$0 (Tier 1)

MO

Treatment-Resistant

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg

$0 (Tier 1)


CLOZARIL ORAL TABLET 100 MG, 25 MG $0 (Tier 1) MO FAZACLO ORAL TABLET,DISINTEGRATING 100 MG, 12.5 MG, 150 MG, 200 MG, 25 MG

$0 (Tier 1)

MO

VERSACLOZ ORAL SUSPENSION 50 MG/ML

$0 (Tier 1)

MO

Antispasticity Agents Antispasticity Agents baclofen oral tablet 10 mg, 20 mg $0 (Tier 1) MO dantrolene oral capsule 100 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

tizanidine oral tablet 2 mg, 4 mg $0 (Tier 1) MO Antivirals Anti-Cytomegalovirus (Cmv) Agents valganciclovir oral tablet 450 mg $0 (Tier 1) MO ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % $0 (Tier 1) NDS Anti-Hepatitis B (Hbv) Agents

adefovir oral tablet 10 mg $0 (Tier 1) NDS BARACLUDE ORAL SOLUTION 0.05 MG/ML

$0 (Tier 1)

MO


40

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS entecavir oral tablet 0.5 mg, 1 mg $0 (Tier 1) MO EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML)

$0 (Tier 1)

MO

EPIVIR ORAL SOLUTION 10 MG/ML $0 (Tier 1) MO EPIVIR ORAL TABLET 150 MG, 300 MG $0 (Tier 1) MO INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML)

$0 (Tier 1)

PA NSO; NDS

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML

$0 (Tier 1)

PA NSO


$0 (Tier 1)

PA NSO; NDS

lamivudine oral solution 10 mg/ml $0 (Tier 1) MO lamivudine oral tablet 100 mg, 150 mg, 300 mg

$0 (Tier 1)

MO

REBETOL ORAL SOLUTION 40 MG/ML $0 (Tier 1) PA; NDS RIBASPHERE ORAL CAPSULE 200 MG $0 (Tier 1) NDS RIBASPHERE ORAL TABLET 200 MG $0 (Tier 1) NDS RIBASPHERE ORAL TABLET 400 MG, 600 MG

$0 (Tier 1)

PA; NDS

ribavirin oral capsule 200 mg $0 (Tier 1) PA; NDS ribavirin oral tablet 200 mg $0 (Tier 1) PA; NDS tenofovir disoproxil fumarate oral tablet 300 mg

$0 (Tier 1)

MO

VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM)

$0 (Tier 1)

MO

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG

$0 (Tier 1)

MO

Anti-Hepatitis C (Hcv) Agents, Direct Acting

DAKLINZA ORAL TABLET 30 MG, 60 MG $0 (Tier 1) PA; NDS EPCLUSA ORAL TABLET 400-100 MG $0 (Tier 1) PA HARVONI ORAL TABLET 90-400 MG $0 (Tier 1) PA; NDS MAVYRET ORAL TABLET 100-40 MG $0 (Tier 1) PA SOVALDI ORAL TABLET 400 MG $0 (Tier 1) PA; MO TECHNIVIE ORAL TABLET 12.5-75-50 MG $0 (Tier 1) PA; NDS Anti-Hepatitis C (Hcv) Agents, Others

DAKLINZA ORAL TABLET 30 MG, 60 MG $0 (Tier 1) PA; NDS EPCLUSA ORAL TABLET 400-100 MG $0 (Tier 1) PA HARVONI ORAL TABLET 90-400 MG $0 (Tier 1) PA; NDS


41

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

$0 (Tier 1)

PA NSO; NDS


$0 (Tier 1)

PA NSO; NDS

MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 400-400 MG (28)- MG (28), 600-600 MG (28)-MG (28)

$0 (Tier 1)

NDS

MODERIBA ORAL TABLET 200 MG $0 (Tier 1) NDS PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML

$0 (Tier 1)

NDS

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML

$0 (Tier 1)

PA; NDS

REBETOL ORAL SOLUTION 40 MG/ML $0 (Tier 1) PA; NDS RIBASPHERE ORAL CAPSULE 200 MG $0 (Tier 1) NDS RIBASPHERE ORAL TABLET 200 MG $0 (Tier 1) NDS RIBASPHERE ORAL TABLET 400 MG, 600 MG

$0 (Tier 1)

PA; NDS

RIBASPHERE RIBAPAK ORAL TABLETS,DOSE PACK 400-400 MG (28)- MG (28), 600-400 MG (28)-MG (28), 600-600 MG (28)-MG (28)

$0 (Tier 1)

NDS

ribavirin oral capsule 200 mg $0 (Tier 1) PA; NDS ribavirin oral tablet 200 mg $0 (Tier 1) PA; NDS SOVALDI ORAL TABLET 400 MG $0 (Tier 1) PA; MO SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG

$0 (Tier 1)

MO

TECHNIVIE ORAL TABLET 12.5-75-50 MG $0 (Tier 1) PA; NDS Antiherpetic Agents

acyclovir oral capsule 200 mg $0 (Tier 1) MO acyclovir oral suspension 200 mg/5 ml $0 (Tier 1) MO acyclovir oral tablet 400 mg, 800 mg $0 (Tier 1) MO acyclovir sodium intravenous solution 50 mg/ml

$0 (Tier 1)

PA BvD; NDS

acyclovir topical ointment 5 % $0 (Tier 1) NDS DENAVIR TOPICAL CREAM 1 % $0 (Tier 1) NDS famciclovir oral tablet 125 mg, 250 mg, 500 mg

$0 (Tier 1)

NDS; MO

trifluridine ophthalmic (eye) drops 1 % $0 (Tier 1) NDS valacyclovir oral tablet 1 gram, 500 mg $0 (Tier 1) MO


42

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ZOVIRAX TOPICAL CREAM 5 % $0 (Tier 1) NDS Anti-Hiv Agents, Integrase Inhibitors (Insti)

BIKTARVY ORAL TABLET 50-200-25 MG $0 (Tier 1) MO GENVOYA ORAL TABLET 150-150-200-10 MG

$0 (Tier 1)

MO

ISENTRESS HD ORAL TABLET 600 MG $0 (Tier 1) MO; QL (60 per 30 days) ISENTRESS ORAL POWDER IN PACKET 100 MG

$0 (Tier 1)

MO

ISENTRESS ORAL TABLET 400 MG $0 (Tier 1) MO; QL (60 per 30 days) ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG

$0 (Tier 1)

MO

STRIBILD ORAL TABLET 150-150-200-300 MG

$0 (Tier 1)


TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG

$0 (Tier 1)

MO

Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (Nnrti)

COMPLERA ORAL TABLET 200-25-300 MG $0 (Tier 1) MO EDURANT ORAL TABLET 25 MG $0 (Tier 1) MO efavirenz oral capsule 200 mg, 50 mg $0 (Tier 1) MO efavirenz oral tablet 600 mg $0 (Tier 1) MO INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG

$0 (Tier 1)

MO

nevirapine oral tablet 200 mg $0 (Tier 1) MO nevirapine oral tablet extended release 24 hr 100 mg, 400 mg

$0 (Tier 1)

MO

RESCRIPTOR ORAL TABLET 200 MG $0 (Tier 1) MO RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG

$0 (Tier 1)

MO

SUSTIVA ORAL CAPSULE 200 MG, 50 MG $0 (Tier 1) MO SUSTIVA ORAL TABLET 600 MG $0 (Tier 1) MO VIRAMUNE ORAL SUSPENSION 50 MG/5 ML

$0 (Tier 1)

MO

VIRAMUNE ORAL TABLET 200 MG $0 (Tier 1) MO VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 400 MG

$0 (Tier 1)

MO


43

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (Nrti)

abacavir oral solution 20 mg/ml $0 (Tier 1) MO abacavir oral tablet 300 mg $0 (Tier 1) MO abacavir-lamivudine oral tablet 600-300 mg $0 (Tier 1) MO abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

$0 (Tier 1)

MO

ATRIPLA ORAL TABLET 600-200-300 MG $0 (Tier 1) MO COMBIVIR ORAL TABLET 150-300 MG $0 (Tier 1) MO DESCOVY ORAL TABLET 200-25 MG $0 (Tier 1) MO didanosine oral capsule,delayed release(dr/ec) 200 mg, 250 mg, 400 mg

$0 (Tier 1)

MO

EMTRIVA ORAL CAPSULE 200 MG $0 (Tier 1) MO EMTRIVA ORAL SOLUTION 10 MG/ML $0 (Tier 1) MO EPIVIR ORAL SOLUTION 10 MG/ML $0 (Tier 1) MO EPIVIR ORAL TABLET 150 MG, 300 MG $0 (Tier 1) MO JULUCA ORAL TABLET 50-25 MG $0 (Tier 1) MO lamivudine oral solution 10 mg/ml $0 (Tier 1) MO lamivudine oral tablet 100 mg, 150 mg, 300 mg

$0 (Tier 1)

MO

lamivudine-zidovudine oral tablet 150-300 mg

$0 (Tier 1)

MO

ODEFSEY ORAL TABLET 200-25-25 MG $0 (Tier 1) MO RETROVIR ORAL CAPSULE 100 MG $0 (Tier 1) MO RETROVIR ORAL SYRUP 10 MG/ML $0 (Tier 1) MO stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg

$0 (Tier 1)

MO

SYMFI LO ORAL TABLET 400-300-300 MG $0 (Tier 1) MO SYMFI ORAL TABLET 600-300-300 MG $0 (Tier 1) MO tenofovir disoproxil fumarate oral tablet 300 mg

$0 (Tier 1)

MO

TRIZIVIR ORAL TABLET 300-150-300 MG $0 (Tier 1) MO TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG

$0 (Tier 1)

MO

VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL)

$0 (Tier 1)

MO

VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 125 MG, 200 MG, 250 MG, 400 MG

$0 (Tier 1)

MO


44

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM)

$0 (Tier 1)

MO

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG

$0 (Tier 1)

MO

ZERIT ORAL CAPSULE 15 MG, 20 MG, 30 MG, 40 MG

$0 (Tier 1)

MO

ZERIT ORAL RECON SOLN 1 MG/ML $0 (Tier 1) MO ZIAGEN ORAL SOLUTION 20 MG/ML $0 (Tier 1) MO ZIAGEN ORAL TABLET 300 MG $0 (Tier 1) MO zidovudine oral capsule 100 mg $0 (Tier 1) MO zidovudine oral syrup 10 mg/ml $0 (Tier 1) MO zidovudine oral tablet 300 mg $0 (Tier 1) MO Anti-Hiv Agents, Other

FUZEON SUBCUTANEOUS RECON SOLN 90 MG

$0 (Tier 1)

MO

SELZENTRY ORAL SOLUTION 20 MG/ML $0 (Tier 1) MO SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG

$0 (Tier 1)

MO

TRIUMEQ ORAL TABLET 600-50-300 MG $0 (Tier 1) MO TYBOST ORAL TABLET 150 MG $0 (Tier 1) MO Anti-Hiv Agents, Protease Inhibitors

APTIVUS ORAL CAPSULE 250 MG $0 (Tier 1) MO APTIVUS ORAL SOLUTION 100 MG/ML $0 (Tier 1) MO atazanavir oral capsule 150 mg, 200 mg, 300 mg

$0 (Tier 1)

MO

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

$0 (Tier 1)

MO

EVOTAZ ORAL TABLET 300-150 MG $0 (Tier 1) MO; QL (30 per 30 days) fosamprenavir oral tablet 700 mg $0 (Tier 1) MO INVIRASE ORAL CAPSULE 200 MG $0 (Tier 1) MO INVIRASE ORAL TABLET 500 MG $0 (Tier 1) MO KALETRA ORAL SOLUTION 400-100 MG/5 ML

$0 (Tier 1)

MO

KALETRA ORAL TABLET 100-25 MG, 200- 50 MG

$0 (Tier 1)

MO

LEXIVA ORAL SUSPENSION 50 MG/ML $0 (Tier 1) MO LEXIVA ORAL TABLET 700 MG $0 (Tier 1) MO lopinavir-ritonavir oral solution 400-100 mg/5 ml

$0 (Tier 1)

MO


45

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS NORVIR ORAL CAPSULE 100 MG $0 (Tier 1) MO NORVIR ORAL POWDER IN PACKET 100 MG

$0 (Tier 1)

MO

NORVIR ORAL SOLUTION 80 MG/ML $0 (Tier 1) MO NORVIR ORAL TABLET 100 MG $0 (Tier 1) MO PREZCOBIX ORAL TABLET 800-150 MG- MG

$0 (Tier 1)


PREZISTA ORAL SUSPENSION 100 MG/ML

$0 (Tier 1)

MO

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

$0 (Tier 1)

MO

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

$0 (Tier 1)

MO

REYATAZ ORAL POWDER IN PACKET 50 MG

$0 (Tier 1)

MO

ritonavir oral tablet 100 mg $0 (Tier 1) MO VIRACEPT ORAL TABLET 250 MG, 625 MG $0 (Tier 1) MO Anti-Influenza Agents

amantadine hcl oral capsule 100 mg $0 (Tier 1) MO amantadine hcl oral solution 50 mg/5 ml $0 (Tier 1) MO amantadine hcl oral tablet 100 mg $0 (Tier 1) MO oseltamivir oral suspension for reconstitution 6 mg/ml

$0 (Tier 1)

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION

$0 (Tier 1)

NDS

rimantadine oral tablet 100 mg $0 (Tier 1) NDS Anxiolytics Anxiolytics, Other buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

$0 (Tier 1)

MO

doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

$0 (Tier 1)

PA NSO; MO

doxepin oral concentrate 10 mg/ml $0 (Tier 1) PA NSO; MO hydroxyzine hcl oral solution 10 mg/5 ml $0 (Tier 1) PA NSO; NDS hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg

$0 (Tier 1)

PA NSO; NDS


$0 (Tier 1)

PA NSO; NDS

meprobamate oral tablet 200 mg, 400 mg $0 (Tier 1)

oxazepam oral capsule 10 mg, 15 mg, 30 mg $0 (Tier 1) NDS


46

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS SILENOR ORAL TABLET 3 MG, 6 MG $0 (Tier 1)

triazolam oral tablet 0.125 mg $0 (Tier 1) NDS Benzodiazepines

alprazolam oral tablet 0.25 mg, 1 mg, 2 mg $0 (Tier 1) NDS alprazolam oral tablet 0.5 mg $0 (Tier 1)

alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg

$0 (Tier 1)

NDS

alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg

$0 (Tier 1)

NDS

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) MO clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

$0 (Tier 1)

MO

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg

$0 (Tier 1)

NDS


$0 (Tier 1)


diazepam intensol oral concentrate 5 mg/ml $0 (Tier 1) PA NSO; NDS diazepam oral solution 5 mg/5 ml (1 mg/ml) $0 (Tier 1) NDS diazepam oral tablet 10 mg, 2 mg, 5 mg $0 (Tier 1) NDS KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG

$0 (Tier 1)

MO

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) NDS Ssris/ Snris


$0 (Tier 1)


escitalopram oxalate oral solution 5 mg/5 ml $0 (Tier 1) MO; QL (600 per 30 days) escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg

$0 (Tier 1)


paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

$0 (Tier 1)

MO

paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg

$0 (Tier 1)

MO

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 12.5 MG, 25 MG, 37.5 MG

$0 (Tier 1)

MO

PAXIL ORAL SUSPENSION 10 MG/5 ML $0 (Tier 1) MO PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG

$0 (Tier 1)

MO

PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG

$0 (Tier 1)

MO


47

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS sertraline oral concentrate 20 mg/ml $0 (Tier 1) MO sertraline oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg

$0 (Tier 1)

MO

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

$0 (Tier 1)

MO

venlafaxine oral tablet extended release 24hr 150 mg, 225 mg, 37.5 mg, 75 mg

$0 (Tier 1)

MO

ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG

$0 (Tier 1)

MO

Bipolar Agents Bipolar Agents, Other GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.)

$0 (Tier 1)


GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG

$0 (Tier 1)

MO

olanzapine intramuscular recon soln 10 mg $0 (Tier 1) NDS olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

$0 (Tier 1)


olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg

$0 (Tier 1)



$0 (Tier 1)



$0 (Tier 1)


RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML

$0 (Tier 1)

MO

risperidone oral solution 1 mg/ml $0 (Tier 1) MO risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

$0 (Tier 1)

MO

risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

$0 (Tier 1)

MO

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG

$0 (Tier 1)



$0 (Tier 1)

MO

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG

$0 (Tier 1)

PA NSO; MO


48

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6)

$0 (Tier 1)

PA NSO

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

$0 (Tier 1)


ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG

$0 (Tier 1)

MO

Mood Stabilizers

carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg

$0 (Tier 1)

MO

carbamazepine oral suspension 100 mg/5 ml $0 (Tier 1) MO carbamazepine oral tablet 200 mg $0 (Tier 1) MO carbamazepine oral tablet extended release 12 hr 100 mg

$0 (Tier 1)

MO

carbamazepine oral tablet,chewable 100 mg $0 (Tier 1) MO CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG

$0 (Tier 1)

MO


$0 (Tier 1)

MO

divalproex oral capsule, delayed rel sprinkle 125 mg

$0 (Tier 1)

MO


$0 (Tier 1)

MO


$0 (Tier 1)

MO

EPITOL ORAL TABLET 200 MG $0 (Tier 1) MO EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG

$0 (Tier 1)

MO

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

$0 (Tier 1)

MO

lamotrigine oral tablet extended release 24hr 50 mg

$0 (Tier 1)

MO

lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg

$0 (Tier 1)

MO

lamotrigine oral tablet,disintegrating 100 mg, 200 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

lamotrigine oral tablets,dose pack 25 mg (35), 25 mg (42) -100 mg (7), 25 mg (84) - 100 mg (14)

$0 (Tier 1)


49

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

$0 (Tier 1)

MO

lithium carbonate oral tablet 300 mg $0 (Tier 1) MO lithium carbonate oral tablet extended release 300 mg, 450 mg

$0 (Tier 1)

MO

lithium citrate oral solution 8 meq/5 ml $0 (Tier 1) MO valproic acid (as sodium salt) oral solution 250 mg/5 ml

$0 (Tier 1)

MO

valproic acid oral capsule 250 mg $0 (Tier 1) MO Blood Glucose Regulators Antidiabetic Agents acarbose oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO AVANDIA ORAL TABLET 2 MG, 4 MG $0 (Tier 1) MO BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML

$0 (Tier 1)

ST; MO; QL (4 per 28 days)

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG

$0 (Tier 1)

ST; MO; QL (4 per 28 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML

$0 (Tier 1)

ST; MO

colesevelam oral tablet 625 mg $0 (Tier 1) MO FARXIGA ORAL TABLET 10 MG, 5 MG $0 (Tier 1) MO; QL (30 per 30 days) glimepiride oral tablet 1 mg, 2 mg, 4 mg $0 (Tier 1) MO glipizide oral tablet 10 mg $0 (Tier 1) MO; QL (120 per 30 days) glipizide oral tablet 5 mg $0 (Tier 1) MO; QL (240 per 30 days) glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg

$0 (Tier 1)

MO

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg $0 (Tier 1) MO GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG

$0 (Tier 1)

MO

INVOKANA ORAL TABLET 100 MG, 300 MG

$0 (Tier 1)

MO

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG

$0 (Tier 1)


JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG

$0 (Tier 1)

MO

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG

$0 (Tier 1)

MO

metformin oral tablet 1,000 mg $0 (Tier 1) MO; QL (60 per 30 days)


50

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS metformin oral tablet 500 mg $0 (Tier 1) MO; QL (150 per 30 days) metformin oral tablet 850 mg $0 (Tier 1) MO; QL (90 per 30 days) metformin oral tablet extended release 24 hr 500 mg

$0 (Tier 1)


metformin oral tablet extended release 24 hr 750 mg

$0 (Tier 1)


nateglinide oral tablet 120 mg, 60 mg $0 (Tier 1) MO ONGLYZA ORAL TABLET 2.5 MG, 5 MG $0 (Tier 1) ST; MO pioglitazone oral tablet 15 mg, 30 mg, 45 mg $0 (Tier 1) MO; QL (30 per 30 days) repaglinide oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) MO SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML

$0 (Tier 1)

PA; MO

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML

$0 (Tier 1)

PA; MO

tolazamide oral tablet 250 mg, 500 mg $0 (Tier 1) MO tolbutamide oral tablet 500 mg $0 (Tier 1) MO TRADJENTA ORAL TABLET 5 MG $0 (Tier 1) MO TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML

$0 (Tier 1)

MO

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)

$0 (Tier 1)


WELCHOL ORAL POWDER IN PACKET 3.75 GRAM

$0 (Tier 1)

MO

WELCHOL ORAL TABLET 625 MG $0 (Tier 1) MO Blood Glucose Regulators

glipizide-metformin oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

$0 (Tier 1)

MO

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

$0 (Tier 1)

MO

JANUMET ORAL TABLET 50-1,000 MG, 50- 500 MG

$0 (Tier 1)


JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG

$0 (Tier 1)


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

$0 (Tier 1)


JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG

$0 (Tier 1)

MO

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG

$0 (Tier 1)

MO


51

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg

$0 (Tier 1)

MO

pioglitazone-metformin oral tablet 15-500 mg, 15-850 mg

$0 (Tier 1)


Glycemic Agents

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG

$0 (Tier 1)

NDS

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG

$0 (Tier 1)

NDS

KORLYM ORAL TABLET 300 MG $0 (Tier 1) PA; MO PROGLYCEM ORAL SUSPENSION 50 MG/ML

$0 (Tier 1)

MO

Insulins

ADMELOG SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML

$0 (Tier 1)

MO

ADMELOG U-100 INSULIN LISPRO SUBCUTANEOUS SOLUTION 100 UNIT/ML

$0 (Tier 1)

MO

APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML

$0 (Tier 1)

MO

APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML

$0 (Tier 1)

MO

assure id insulin safety syringe 1 ml 29 gauge x 1/2"

$0 (Tier 1)

MO

BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

$0 (Tier 1)

MO

gauze pad topical bandage 2 x 2 " $0 (Tier 1) NDS; QL (100 per 30 days) HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML (3 ML)

$0 (Tier 1)

MO

HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50)

$0 (Tier 1)

MO

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50)

$0 (Tier 1)

MO

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25)

$0 (Tier 1)

MO


52

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25)

$0 (Tier 1)

MO

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML

$0 (Tier 1)

MO

HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML

$0 (Tier 1)

MO

HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

$0 (Tier 1)

MO

HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

$0 (Tier 1)

MO

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML

$0 (Tier 1)

ST; MO

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML)

$0 (Tier 1)

ST; MO

insulin syringe-needle u-100 syringe 0.3 ml 29 gauge, 1 ml 29 gauge x 1/2", 1/2 ml 28 gauge

$0 (Tier 1)

NDS; MO; QL (200 per 30 days)

LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

$0 (Tier 1)

MO

LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML

$0 (Tier 1)

MO

LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

$0 (Tier 1)

MO

LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML

$0 (Tier 1)

MO

NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)

$0 (Tier 1)

MO

NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML

$0 (Tier 1)

MO

NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML

$0 (Tier 1)

MO

NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML

$0 (Tier 1)

MO


53

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30)

$0 (Tier 1)

MO

NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

$0 (Tier 1)

MO

NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML

$0 (Tier 1)

MO

NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML

$0 (Tier 1)

MO

pen needle, diabetic needle 29 gauge x 1/2"

$0 (Tier 1) NDS; MO; QL (200 per 30

days) TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML)

$0 (Tier 1)

MO

Blood Products/ Modifiers/ Volume Expanders Anticoagulants COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

$0 (Tier 1)

MO

ELIQUIS ORAL TABLET 2.5 MG, 5 MG $0 (Tier 1) MO enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml

$0 (Tier 1)

fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

$0 (Tier 1)

NDS

heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml

$0 (Tier 1)

PA BvD; NDS

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

$0 (Tier 1)

MO

PRADAXA ORAL CAPSULE 150 MG, 75 MG $0 (Tier 1) MO warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

$0 (Tier 1)

MO

XARELTO ORAL TABLET 10 MG $0 (Tier 1) NDS XARELTO ORAL TABLET 15 MG, 20 MG $0 (Tier 1) MO Blood Formation Modifiers

anagrelide oral capsule 0.5 mg, 1 mg $0 (Tier 1) MO


54

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

$0 (Tier 1)

PA BvD; MO

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML

$0 (Tier 1)

PA BvD; MO

DOPTELET ORAL TABLET 20 MG, 20 MG (15 PACK)

$0 (Tier 1)

PA

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

$0 (Tier 1)

PA BvD; MO

LEUKINE INJECTION RECON SOLN 250 MCG

$0 (Tier 1)

PA; NDS

MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML

$0 (Tier 1)

PA BvD; MO

NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML

$0 (Tier 1)

PA; NDS

NEUPOGEN INJECTION SOLUTION 300 MCG/ML

$0 (Tier 1)


NEUPOGEN INJECTION SOLUTION 480 MCG/1.6 ML

$0 (Tier 1)

PA; NDS; QL (11.2 per 7 days)

NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML

$0 (Tier 1)


NEUPOGEN INJECTION SYRINGE 480 MCG/0.8 ML

$0 (Tier 1)


PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML

$0 (Tier 1)

PA BvD; MO

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG

$0 (Tier 1)

PA; MO

ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

$0 (Tier 1)

Hemostasis Agents

tranexamic acid oral tablet 650 mg $0 (Tier 1) MO Platelet Modifying Agents

aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg

$0 (Tier 1)


BRILINTA ORAL TABLET 60 MG $0 (Tier 1) MO


55

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS BRILINTA ORAL TABLET 90 MG $0 (Tier 1) MO; QL (90 per 30 days) cilostazol oral tablet 100 mg, 50 mg $0 (Tier 1) MO clopidogrel oral tablet 75 mg $0 (Tier 1) MO; QL (30 per 30 days) dipyridamole oral tablet 25 mg, 50 mg, 75 mg $0 (Tier 1) MO prasugrel oral tablet 10 mg, 5 mg $0 (Tier 1) MO Cardiovascular Agents Alpha-Adrenergic Agonists clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg

$0 (Tier 1)

MO

clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr

$0 (Tier 1)

MO

midodrine oral tablet 10 mg, 2.5 mg, 5 mg $0 (Tier 1) NDS NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG

$0 (Tier 1)

PA NSO; MO

Alpha-Adrenergic Blocking Agents

doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg $0 (Tier 1) MO prazosin oral capsule 1 mg, 2 mg, 5 mg $0 (Tier 1) MO terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg

$0 (Tier 1)

MO

Angiotensin Ii Receptor Antagonists

candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg

$0 (Tier 1)

MO

DIOVAN ORAL TABLET 160 MG, 320 MG $0 (Tier 1) MO ENTRESTO ORAL TABLET 24-26 MG, 49- 51 MG, 97-103 MG

$0 (Tier 1)

MO

eprosartan oral tablet 600 mg $0 (Tier 1) MO irbesartan oral tablet 150 mg, 300 mg, 75 mg $0 (Tier 1) MO losartan oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO olmesartan oral tablet 20 mg, 40 mg, 5 mg $0 (Tier 1) MO telmisartan oral tablet 20 mg, 40 mg, 80 mg $0 (Tier 1) MO valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

$0 (Tier 1)

MO

Angiotensin-Converting Enzyme (Ace) Inhibitors

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

$0 (Tier 1)

MO

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg

$0 (Tier 1)

MO


56

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

$0 (Tier 1)

MO

fosinopril oral tablet 10 mg, 20 mg, 40 mg $0 (Tier 1) MO lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

$0 (Tier 1)

MO

moexipril oral tablet 15 mg, 7.5 mg $0 (Tier 1) MO perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg

$0 (Tier 1)

MO

quinapril oral tablet 10 mg, 20 mg, 5 mg $0 (Tier 1) MO ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

$0 (Tier 1)

MO

trandolapril oral tablet 1 mg, 2 mg, 4 mg $0 (Tier 1) MO Antiarrhythmics

amiodarone oral tablet 200 mg, 400 mg $0 (Tier 1) MO disopyramide phosphate oral capsule 100 mg, 150 mg

$0 (Tier 1)

MO

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg

$0 (Tier 1)

MO

flecainide oral tablet 100 mg, 150 mg, 50 mg $0 (Tier 1) MO mexiletine oral capsule 150 mg, 200 mg, 250 mg

$0 (Tier 1)

MO

MULTAQ ORAL TABLET 400 MG $0 (Tier 1) MO PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG

$0 (Tier 1)

MO

propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 mg

$0 (Tier 1)

MO

propafenone oral tablet 150 mg, 225 mg, 300 mg

$0 (Tier 1)

MO

quinidine gluconate oral tablet extended release 324 mg

$0 (Tier 1)

MO

quinidine sulfate oral tablet 200 mg, 300 mg $0 (Tier 1) MO sotalol af oral tablet 120 mg $0 (Tier 1) MO sotalol oral tablet 160 mg, 240 mg, 80 mg $0 (Tier 1) MO Beta-Adrenergic Blocking Agents

acebutolol oral capsule 200 mg, 400 mg $0 (Tier 1) MO atenolol oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO betaxolol oral tablet 10 mg, 20 mg $0 (Tier 1) MO bisoprolol fumarate oral tablet 10 mg, 5 mg $0 (Tier 1) MO BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG

$0 (Tier 1)

MO


57

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

$0 (Tier 1)

MO

labetalol oral tablet 100 mg, 200 mg, 300 mg $0 (Tier 1) MO metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

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

$0 (Tier 1)

MO

nadolol oral tablet 40 mg, 80 mg $0 (Tier 1) MO pindolol oral tablet 10 mg, 5 mg $0 (Tier 1) MO propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg

$0 (Tier 1)

MO

propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml)

$0 (Tier 1)

MO

propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

$0 (Tier 1)

MO

TENORMIN ORAL TABLET 100 MG $0 (Tier 1) MO timolol maleate oral tablet 10 mg, 20 mg, 5 mg

$0 (Tier 1)

MO

Calcium Channel Blocking Agents

AFEDITAB CR ORAL TABLET EXTENDED RELEASE 30 MG, 60 MG

$0 (Tier 1)

MO

amlodipine oral tablet 10 mg, 2.5 mg, 5 mg $0 (Tier 1) MO CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG, 240 MG, 300 MG

$0 (Tier 1)

MO

diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg

$0 (Tier 1)

MO

diltiazem hcl oral capsule,extended release 24 hr 360 mg, 420 mg

$0 (Tier 1)

MO

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg

$0 (Tier 1)

MO

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

$0 (Tier 1)

MO

DILT-XR ORAL CAPSULE,EXT.REL 24H DEGRADABLE 120 MG, 180 MG, 240 MG

$0 (Tier 1)

MO

felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg

$0 (Tier 1)

MO

isradipine oral capsule 2.5 mg, 5 mg $0 (Tier 1) MO MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

$0 (Tier 1)

MO


58

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS nicardipine oral capsule 20 mg, 30 mg $0 (Tier 1) MO nifedipine oral capsule 10 mg, 20 mg $0 (Tier 1) MO nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg

$0 (Tier 1)

MO

nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg

$0 (Tier 1)

MO

nimodipine oral capsule 30 mg $0 (Tier 1) NDS TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

$0 (Tier 1)

MO

verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg

$0 (Tier 1)

MO

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg

$0 (Tier 1)

MO

verapamil oral tablet 120 mg, 40 mg, 80 mg $0 (Tier 1) MO verapamil oral tablet extended release 120 mg, 180 mg, 240 mg

$0 (Tier 1)

MO

Cardiovascular Agents, Other

CORLANOR ORAL TABLET 5 MG, 7.5 MG $0 (Tier 1) MO DIGITEK ORAL TABLET 125 MCG, 250 MCG

$0 (Tier 1)

MO

digoxin oral tablet 125 mcg, 250 mcg $0 (Tier 1) MO LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG

$0 (Tier 1)

MO

pentoxifylline oral tablet extended release 400 mg

$0 (Tier 1)

MO

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG

$0 (Tier 1)

PA; MO

TEKTURNA ORAL TABLET 150 MG, 300 MG

$0 (Tier 1)

MO

UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

$0 (Tier 1)

PA; MO

UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60)

$0 (Tier 1)

PA

Cardiovascular Agents

amiloride-hydrochlorothiazide oral tablet 5-50 mg

$0 (Tier 1)

MO

amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

$0 (Tier 1)

MO


59

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg

$0 (Tier 1)

MO

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

$0 (Tier 1)

MO

benazepril-hydrochlorothiazide oral tablet 10- 12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

$0 (Tier 1)

MO

bisoprolol-hydrochlorothiazide oral tablet 10- 6.25 mg, 2.5-6.25 mg, 5-6.25 mg

$0 (Tier 1)

MO

candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg

$0 (Tier 1)

MO

captopril-hydrochlorothiazide oral tablet 25- 15 mg, 25-25 mg, 50-15 mg, 50-25 mg

$0 (Tier 1)

MO

DEMSER ORAL CAPSULE 250 MG $0 (Tier 1) NDS enalapril-hydrochlorothiazide oral tablet 10- 25 mg, 5-12.5 mg

$0 (Tier 1)

MO

fosinopril-hydrochlorothiazide oral tablet 10- 12.5 mg, 20-12.5 mg

$0 (Tier 1)

MO

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

$0 (Tier 1)

MO

lisinopril-hydrochlorothiazide oral tablet 10- 12.5 mg, 20-12.5 mg, 20-25 mg

$0 (Tier 1)

MO

losartan-hydrochlorothiazide oral tablet 100- 12.5 mg, 100-25 mg, 50-12.5 mg

$0 (Tier 1)

MO

metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, 100-50 mg, 50-25 mg

$0 (Tier 1)

MO

moexipril-hydrochlorothiazide oral tablet 15- 12.5 mg, 15-25 mg, 7.5-12.5 mg

$0 (Tier 1)

MO

propranolol-hydrochlorothiazid oral tablet 40- 25 mg, 80-25 mg

$0 (Tier 1)

MO

quinapril-hydrochlorothiazide oral tablet 10- 12.5 mg, 20-12.5 mg, 20-25 mg

$0 (Tier 1)

MO

spironolacton-hydrochlorothiaz oral tablet 25- 25 mg

$0 (Tier 1)

MO

TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG

$0 (Tier 1)

ST; MO

telmisartan-hydrochlorothiazid oral tablet 40- 12.5 mg, 80-12.5 mg, 80-25 mg

$0 (Tier 1)

MO

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg

$0 (Tier 1)

MO

triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 mg

$0 (Tier 1)

MO


60

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS valsartan-hydrochlorothiazide oral tablet 160- 12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

$0 (Tier 1)


Diuretics, Carbonic Anhydrase Inhibitors

acetazolamide oral capsule, extended release 500 mg

$0 (Tier 1)

MO

acetazolamide oral tablet 125 mg, 250 mg $0 (Tier 1) MO keveyis oral tablet 50 mg $0 (Tier 1) MO methazolamide oral tablet 25 mg, 50 mg $0 (Tier 1) MO Diuretics, Loop

bumetanide injection solution 0.25 mg/ml $0 (Tier 1) NDS bumetanide oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) MO furosemide injection solution 10 mg/ml $0 (Tier 1) NDS furosemide injection syringe 10 mg/ml $0 (Tier 1) NDS furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

$0 (Tier 1)

MO

furosemide oral tablet 20 mg, 40 mg, 80 mg $0 (Tier 1) MO torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg

$0 (Tier 1)

MO

Diuretics, Potassium-Sparing

amiloride oral tablet 5 mg $0 (Tier 1) MO DYRENIUM ORAL CAPSULE 100 MG, 50 MG

$0 (Tier 1)

MO

eplerenone oral tablet 25 mg, 50 mg $0 (Tier 1) MO spironolactone oral tablet 100 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

Diuretics, Thiazide

chlorothiazide oral tablet 250 mg, 500 mg $0 (Tier 1) MO chlorthalidone oral tablet 25 mg, 50 mg $0 (Tier 1) MO hydrochlorothiazide oral capsule 12.5 mg $0 (Tier 1) MO hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

indapamide oral tablet 1.25 mg, 2.5 mg $0 (Tier 1) MO irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg

$0 (Tier 1)

MO

methyclothiazide oral tablet 5 mg $0 (Tier 1) MO metolazone oral tablet 10 mg, 2.5 mg, 5 mg $0 (Tier 1) MO


61

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Dyslipidemics, Fibric Acid Derivatives

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg

$0 (Tier 1)

MO

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg

$0 (Tier 1)

MO

fenofibrate oral capsule 150 mg, 50 mg $0 (Tier 1) MO fenofibrate oral tablet 120 mg, 160 mg, 54 mg

$0 (Tier 1)

MO

gemfibrozil oral tablet 600 mg $0 (Tier 1) MO Dyslipidemics, Hmg Coa Reductase Inhibitors

atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg

$0 (Tier 1)

MO

fluvastatin oral capsule 20 mg, 40 mg $0 (Tier 1) MO fluvastatin oral tablet extended release 24 hr 80 mg

$0 (Tier 1)

MO

lovastatin oral tablet 10 mg, 20 mg, 40 mg $0 (Tier 1) MO pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg

$0 (Tier 1)

MO

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

$0 (Tier 1)


simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg

$0 (Tier 1)


Dyslipidemics, Other

CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM

$0 (Tier 1)

MO

colesevelam oral tablet 625 mg $0 (Tier 1) MO colestipol oral packet 5 gram $0 (Tier 1) MO colestipol oral tablet 1 gram $0 (Tier 1) MO ezetimibe oral tablet 10 mg $0 (Tier 1) MO JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG

$0 (Tier 1)

PA NSO; MO

JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG

$0 (Tier 1)

PA; MO

KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML

$0 (Tier 1)

PA NSO; MO

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

$0 (Tier 1)

MO

NIACOR ORAL TABLET 500 MG $0 (Tier 1) MO


62

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS omega-3 acid ethyl esters oral capsule 1 gram

$0 (Tier 1)

MO

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML

$0 (Tier 1)

PA; MO

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML

$0 (Tier 1)

PA; MO

REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML

$0 (Tier 1)

PA; MO

WELCHOL ORAL POWDER IN PACKET 3.75 GRAM

$0 (Tier 1)

MO

WELCHOL ORAL TABLET 625 MG $0 (Tier 1) MO Vasodilators, Direct-Acting Arterial/ Venous

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

$0 (Tier 1)

MO

isosorbide dinitrate oral tablet extended release 40 mg

$0 (Tier 1)

MO

isosorbide mononitrate oral tablet 10 mg, 20 mg

$0 (Tier 1)

MO

isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg

$0 (Tier 1)

MO

MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

$0 (Tier 1)

MO

NITRO-BID TRANSDERMAL OINTMENT 2 %

$0 (Tier 1)

MO

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

$0 (Tier 1)

MO

nitroglycerin sublingual tablet 0.4 mg $0 (Tier 1) MO nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

$0 (Tier 1)

MO

nitroglycerin translingual spray,non-aerosol 400 mcg/spray

$0 (Tier 1)

MO

NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG

$0 (Tier 1)

NDS; MO

NITROSTAT SUBLINGUAL TABLET 0.6 MG $0 (Tier 1) MO RECTIV RECTAL OINTMENT 0.4 % (W/W) $0 (Tier 1) NDS Vasodilators, Direct-Acting Arterial

hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg

$0 (Tier 1)

MO

minoxidil oral tablet 10 mg, 2.5 mg $0 (Tier 1) MO


63

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines adderall oral tablet 20 mg, 5 mg, 7.5 mg $0 (Tier 1) MO; QL (90 per 30 days) dextroamphetamine oral tablet 10 mg, 5 mg $0 (Tier 1) MO; QL (180 per 30 days) dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

$0 (Tier 1)


VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

$0 (Tier 1)

MO

Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines

atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg

$0 (Tier 1)

MO

clonidine hcl oral tablet extended release 12 hr 0.1 mg

$0 (Tier 1)

MO

dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 20 mg, 5 mg

$0 (Tier 1)


dexmethylphenidate oral capsule,er biphasic 50-50 15 mg, 30 mg, 40 mg


days) dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg

$0 (Tier 1)

PA NSO; MO

guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg

$0 (Tier 1)

MO

METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG

$0 (Tier 1)

MO

methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60

$0 (Tier 1)


methylphenidate hcl oral solution 10 mg/5 ml $0 (Tier 1) MO; QL (900 per 30 days) methylphenidate hcl oral solution 5 mg/5 ml $0 (Tier 1) MO; QL (450 per 30 days) methylphenidate hcl oral tablet 10 mg $0 (Tier 1) MO; QL (180 per 30 days) methylphenidate hcl oral tablet 20 mg, 5 mg $0 (Tier 1) MO; QL (90 per 30 days) methylphenidate hcl oral tablet extended release 10 mg, 20 mg

$0 (Tier 1)


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

$0 (Tier 1)


methylphenidate hcl oral tablet,chewable 10 mg

$0 (Tier 1)


methylphenidate hcl oral tablet,chewable 2.5 mg, 5 mg

$0 (Tier 1)



64

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Central Nervous System, Other

estazolam oral tablet 1 mg, 2 mg $0 (Tier 1) NDS NUEDEXTA ORAL CAPSULE 20-10 MG $0 (Tier 1) PA NSO; NDS riluzole oral tablet 50 mg $0 (Tier 1) MO tetrabenazine oral tablet 12.5 mg $0 (Tier 1) PA; MO; QL (90 per 30 days) tetrabenazine oral tablet 25 mg $0 (Tier 1) PA; MO; QL (120 per 30 days) Fibromyalgia Agents


$0 (Tier 1)


LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 330 MG, 82.5 MG

$0 (Tier 1)

MO

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

$0 (Tier 1)

MO

LYRICA ORAL SOLUTION 20 MG/ML $0 (Tier 1) MO SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG

$0 (Tier 1)


SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42)

$0 (Tier 1)

NDS

Multiple Sclerosis Agents

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG

$0 (Tier 1)

PA; MO

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG

$0 (Tier 1)

PA; MO

AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML

$0 (Tier 1)

PA; MO

BETASERON SUBCUTANEOUS KIT 0.3 MG

$0 (Tier 1)

PA; MO

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML

$0 (Tier 1)

MO

EXTAVIA SUBCUTANEOUS KIT 0.3 MG $0 (Tier 1) PA; MO GILENYA ORAL CAPSULE 0.5 MG $0 (Tier 1) PA; MO glatiramer subcutaneous syringe 20 mg/ml, 40 mg/ml

$0 (Tier 1)

PA; MO

GLATOPA SUBCUTANEOUS SYRINGE 20 MG/ML

$0 (Tier 1)

PA; MO

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML

$0 (Tier 1)

PA; MO

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6)

$0 (Tier 1)

PA; MO


65

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)

$0 (Tier 1)

MO

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

$0 (Tier 1)

MO

Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg $0 (Tier 1) MO chlorhexidine gluconate mucous membrane mouthwash 0.12 %

$0 (Tier 1)

NDS

doxycycline hyclate oral capsule 100 mg, 50 mg

$0 (Tier 1)

NDS

doxycycline hyclate oral tablet 100 mg, 20 mg

$0 (Tier 1)

NDS

doxycycline monohydrate oral tablet 150 mg $0 (Tier 1) NDS minocycline oral capsule 100 mg, 50 mg, 75 mg

$0 (Tier 1)

NDS

minocycline oral tablet 100 mg, 50 mg, 75 mg

$0 (Tier 1)

NDS

minocycline oral tablet extended release 24 hr 135 mg, 45 mg, 90 mg

$0 (Tier 1)

NDS

PERIOGARD MUCOUS MEMBRANE MOUTHWASH 0.12 %

$0 (Tier 1)

NDS

pilocarpine hcl oral tablet 5 mg, 7.5 mg $0 (Tier 1) MO triamcinolone acetonide dental paste 0.1 % $0 (Tier 1) NDS Dermatological Agents Dermatological Agents acitretin oral capsule 10 mg, 17.5 mg, 25 mg $0 (Tier 1) NDS adapalene topical cream 0.1 % $0 (Tier 1) NDS adapalene topical gel 0.1 % $0 (Tier 1) NDS ammonium lactate topical cream 12 % $0 (Tier 1) NDS ammonium lactate topical lotion 12 % $0 (Tier 1) NDS AVITA TOPICAL CREAM 0.025 % $0 (Tier 1) NDS AVITA TOPICAL GEL 0.025 % $0 (Tier 1) NDS AZELEX TOPICAL CREAM 20 % $0 (Tier 1) NDS betamethasone dipropionate topical lotion 0.05 %

$0 (Tier 1)

NDS

calcipotriene scalp solution 0.005 % $0 (Tier 1) NDS calcipotriene topical cream 0.005 % $0 (Tier 1) NDS


66

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS calcipotriene topical ointment 0.005 % $0 (Tier 1) NDS calcipotriene-betamethasone topical ointment 0.005-0.064 %

$0 (Tier 1)

NDS

CARAC TOPICAL CREAM 0.5 % $0 (Tier 1)

CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

$0 (Tier 1)

NDS

clindamycin-benzoyl peroxide topical gel 1-5 %

$0 (Tier 1)

NDS

clotrimazole-betamethasone topical cream 1- 0.05 %

$0 (Tier 1)

NDS

clotrimazole-betamethasone topical lotion 1- 0.05 %

$0 (Tier 1)

NDS

CORTISPORIN TOPICAL CREAM 3.5- 10,000-0.5 MG/G-UNIT/G-%

$0 (Tier 1)

NDS

CORTISPORIN TOPICAL OINTMENT 1 % $0 (Tier 1) NDS diclofenac sodium topical gel 1 % $0 (Tier 1) MO diclofenac sodium topical gel 3 % $0 (Tier 1)

doxycycline hyclate oral capsule 50 mg $0 (Tier 1) NDS doxycycline monohydrate oral capsule 100 mg, 50 mg

$0 (Tier 1)

NDS

doxycycline monohydrate oral tablet 50 mg $0 (Tier 1) NDS EFUDEX TOPICAL CREAM 5 % $0 (Tier 1)

ELIDEL TOPICAL CREAM 1 % $0 (Tier 1) NDS; QL (60 per 30 days) erythromycin-benzoyl peroxide topical gel 3-5 %

$0 (Tier 1)

NDS

FINACEA TOPICAL FOAM 15 % $0 (Tier 1) NDS FINACEA TOPICAL GEL 15 % $0 (Tier 1) NDS fluocinonide topical cream 0.1 % $0 (Tier 1) NDS fluorouracil topical cream 0.5 %, 5 % $0 (Tier 1) NDS fluorouracil topical solution 2 %, 5 % $0 (Tier 1) NDS fluticasone topical cream 0.05 % $0 (Tier 1) NDS fluticasone topical ointment 0.005 % $0 (Tier 1) NDS imiquimod topical cream in packet 5 % $0 (Tier 1) NDS KERYDIN TOPICAL SOLUTION WITH APPLICATOR 5 %

$0 (Tier 1)

NDS

methoxsalen oral capsule,liqd-filled,rapid rel 10 mg

$0 (Tier 1)

PA NSO; NDS

MYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

$0 (Tier 1)

NDS


67

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS NEUAC TOPICAL GEL 1.2 %(1 % BASE) -5 %

$0 (Tier 1)

NDS

nystatin-triamcinolone topical cream 100,000-0.1 unit/g-%

$0 (Tier 1)

NDS

nystatin-triamcinolone topical ointment 100,000-0.1 unit/gram-%

$0 (Tier 1)

NDS

OXSORALEN ULTRA ORAL CAPSULE,LIQD-FILLED,RAPID REL 10 MG

$0 (Tier 1)

PA NSO; NDS

PICATO TOPICAL GEL 0.015 %, 0.05 % $0 (Tier 1) NDS podofilox topical solution 0.5 % $0 (Tier 1) NDS prednicarbate topical cream 0.1 % $0 (Tier 1) NDS REGRANEX TOPICAL GEL 0.01 % $0 (Tier 1) NDS SANTYL TOPICAL OINTMENT 250 UNIT/GRAM

$0 (Tier 1)

NDS

selenium sulfide topical lotion 2.5 % $0 (Tier 1) NDS tacrolimus topical ointment 0.03 % $0 (Tier 1) NDS; QL (30 per 30 days) tacrolimus topical ointment 0.1 % $0 (Tier 1) NDS; QL (30 per 31 days) tazarotene topical cream 0.1 % $0 (Tier 1)

TAZORAC TOPICAL CREAM 0.05 %, 0.1 % $0 (Tier 1) NDS TAZORAC TOPICAL GEL 0.05 %, 0.1 % $0 (Tier 1) NDS TOLAK TOPICAL CREAM 4 % $0 (Tier 1)

tretinoin topical cream 0.025 %, 0.05 %, 0.1 %

$0 (Tier 1)

PA; NDS

tretinoin topical gel 0.01 %, 0.025 %, 0.05 % $0 (Tier 1) PA; NDS VALCHLOR TOPICAL GEL 0.016 % $0 (Tier 1) PA NSO; MO ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

$0 (Tier 1)

NDS

Electrolytes/Minerals/Metals/Vitamins Electrolyte/ Mineral Replacement CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG

$0 (Tier 1)

PA NSO; MO

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION

$0 (Tier 1)

NDS

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ

$0 (Tier 1)

MO


$0 (Tier 1)

MO

KLOR-CON M10 ORAL TABLET,ER PARTICLES/CRYSTALS 10 MEQ

$0 (Tier 1)

MO


68

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS KLOR-CON M15 ORAL TABLET,ER PARTICLES/CRYSTALS 15 MEQ

$0 (Tier 1)

MO


$0 (Tier 1)

MO

KLOR-CON SPRINKLE ORAL CAPSULE, EXTENDED RELEASE 10 MEQ, 8 MEQ

$0 (Tier 1)

MO

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ, 8 MEQ

$0 (Tier 1)

MO

magnesium sulfate injection solution 4 meq/ml (50 %)

$0 (Tier 1)

NDS

NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION

$0 (Tier 1)

NDS

OSMOPREP ORAL TABLET 1.5 GRAM $0 (Tier 1) NDS potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

$0 (Tier 1)

NDS

potassium chloride in water intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 40 meq/100 ml

$0 (Tier 1)

NDS

potassium chloride intravenous solution 2 meq/ml

$0 (Tier 1)

NDS

potassium chloride oral capsule, extended release 10 meq, 8 meq

$0 (Tier 1)

MO

potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml

$0 (Tier 1)

MO

potassium chloride oral tablet extended release 10 meq, 20 meq, 8 meq

$0 (Tier 1)

MO

potassium chloride oral tablet,er particles/crystals 10 meq, 20 meq

$0 (Tier 1)

MO

potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l

$0 (Tier 1)

NDS

sodium chloride 0.45 % intravenous parenteral solution 0.45 %

$0 (Tier 1)

PA BvD; NDS

sodium chloride 0.9 % intravenous parenteral solution

$0 (Tier 1)

PA BvD; NDS

sodium chloride 3 % intravenous parenteral solution 3 %

$0 (Tier 1)

PA BvD; NDS

sodium chloride 5 % intravenous parenteral solution 5 %

$0 (Tier 1)

PA BvD; NDS

sodium chloride intravenous parenteral solution 2.5 meq/ml

$0 (Tier 1)

PA BvD; NDS

sodium chloride irrigation solution 0.9 % $0 (Tier 1) NDS


69

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS SUPREP BOWEL PREP KIT ORAL RECON SOLN 17.5-3.13-1.6 GRAM

$0 (Tier 1)

Electrolyte/Mineral/Metal Modifiers

AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 %

$0 (Tier 1)

PA BvD; NDS

AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 %

$0 (Tier 1)

PA BvD; NDS

DEPEN TITRATABS ORAL TABLET 250 MG $0 (Tier 1) MO EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG

$0 (Tier 1)

PA; LA; MO

FERRIPROX ORAL TABLET 500 MG $0 (Tier 1) PA; NDS FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 %

$0 (Tier 1)

PA BvD; NDS

KIONEX (WITH SORBITOL) ORAL SUSPENSION 15-19.3 GRAM/60 ML

$0 (Tier 1)

NDS

PLENAMINE INTRAVENOUS PARENTERAL SOLUTION 15 %

$0 (Tier 1)

PA BvD; NDS

sodium polystyrene sulfonate oral powder $0 (Tier 1) NDS SYPRINE ORAL CAPSULE 250 MG $0 (Tier 1) NDS VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM

$0 (Tier 1)

MO

Electrolytes/Minerals/Metals/Vitamins

AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 %

$0 (Tier 1)

PA BvD; NDS

AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %

$0 (Tier 1)

PA BvD; NDS

AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 %

$0 (Tier 1)

PA BvD; NDS

AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 %

$0 (Tier 1)

PA BvD; NDS

AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 %

$0 (Tier 1)

PA BvD; NDS

AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 %

$0 (Tier 1)

PA BvD; NDS

AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %

$0 (Tier 1)

PA BvD; NDS

AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7 %

$0 (Tier 1)

PA BvD; NDS


70

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

$0 (Tier 1)

PA BvD; NDS

CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

$0 (Tier 1)

PA BvD; NDS

CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 %

$0 (Tier 1)

PA BvD; NDS

CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

$0 (Tier 1)

PA BvD; NDS

CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

$0 (Tier 1)

PA BvD; NDS

CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

$0 (Tier 1)

PA BvD; NDS

CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

$0 (Tier 1)

PA BvD; NDS

CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 %

$0 (Tier 1)

PA BvD; NDS

CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 %

$0 (Tier 1)

PA BvD; NDS

CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 %

$0 (Tier 1)

PA BvD; NDS


$0 (Tier 1)

PA BvD; NDS


$0 (Tier 1)

PA BvD; NDS

CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

$0 (Tier 1)

PA BvD; NDS

CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

$0 (Tier 1)

PA BvD; NDS


71

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

$0 (Tier 1)

PA BvD; NDS

CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

$0 (Tier 1)

PA BvD; NDS

CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 %

$0 (Tier 1)

PA BvD; NDS

d10 %-0.45 % sodium chloride intravenous parenteral solution

$0 (Tier 1)

PA BvD; NDS

d2.5 %-0.45 % sodium chloride intravenous parenteral solution

$0 (Tier 1)

PA BvD; NDS

d5 % and 0.9 % sodium chloride intravenous parenteral solution

$0 (Tier 1)

PA BvD; NDS

d5 %-0.45 % sodium chloride intravenous parenteral solution

$0 (Tier 1)

PA BvD; NDS

dextrose 10 % and 0.2 % nacl intravenous parenteral solution

$0 (Tier 1)

PA BvD; NDS

dextrose 10 % in water (d10w) intravenous parenteral solution 10 %

$0 (Tier 1)

PA BvD; NDS

dextrose 5 % in water (d5w) intravenous parenteral solution

$0 (Tier 1)

PA BvD; NDS

dextrose 5%-0.2 % sod chloride intravenous parenteral solution

$0 (Tier 1)

PA BvD; NDS

dextrose 5%-0.3 % sod.chloride intravenous parenteral solution

$0 (Tier 1)

PA BvD; NDS

HEPATAMINE 8% INTRAVENOUS PARENTERAL SO O %

$0 (Tier 1)

PA BvD; NDS

ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %

$0 (Tier 1)

NDS

levocarnitine (with sugar) oral solution 100 mg/ml

$0 (Tier 1)

PA BvD; MO

levocarnitine oral tablet 330 mg $0 (Tier 1) PA BvD; MO NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 %

$0 (Tier 1)

PA BvD; NDS

NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

$0 (Tier 1)

NDS

NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %

$0 (Tier 1)

NDS


72

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS NUTRILIPID INTRAVENOUS EMULSION 20 %

$0 (Tier 1)

PA BvD; NDS

PLENAMINE INTRAVENOUS PARENTERAL SOLUTION 15 %

$0 (Tier 1)

PA BvD; NDS

potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l

$0 (Tier 1)

NDS

potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l

$0 (Tier 1)

NDS

potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l

$0 (Tier 1)

NDS

potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l

$0 (Tier 1)

NDS

potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l

$0 (Tier 1)

NDS

potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

$0 (Tier 1)

NDS

PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %

$0 (Tier 1)

PA BvD; NDS

PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 %

$0 (Tier 1)

PA BvD; NDS

PRENATAL VITAMIN PLUS LOW IRON ORAL TABLET 27 MG IRON- 1 MG

$0 (Tier 1)

MO

PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 %

$0 (Tier 1)

PA BvD; NDS

PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION

$0 (Tier 1)

PA BvD

sodium lactate intravenous solution 5 meq/ml $0 (Tier 1) NDS TPN ELECTROLYTES INTRAVENOUS SOLUTION 35-20-5 MEQ/20 ML

$0 (Tier 1)

NDS

TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %

$0 (Tier 1)

PA BvD; NDS

TROPHAMINE 10 % INTRAVENOUS PARENTERAL SO O %

$0 (Tier 1)

PA BvD; NDS

TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 %

$0 (Tier 1)

PA BvD; NDS

Vitamins

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg

$0 (Tier 1)

PA BvD; MO


$0 (Tier 1)

MO


73

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ

$0 (Tier 1)

MO


$0 (Tier 1)

MO


$0 (Tier 1)

MO


$0 (Tier 1)

MO

KLOR-CON SPRINKLE ORAL CAPSULE, EXTENDED RELEASE 10 MEQ, 8 MEQ

$0 (Tier 1)

MO

Gastrointestinal Agents Antispasmodics, Gastrointestinal dicyclomine oral capsule 10 mg $0 (Tier 1) NDS; MO dicyclomine oral solution 10 mg/5 ml $0 (Tier 1) NDS dicyclomine oral tablet 20 mg $0 (Tier 1) NDS; MO glycopyrrolate oral tablet 1 mg, 2 mg $0 (Tier 1) NDS; MO methscopolamine oral tablet 2.5 mg, 5 mg $0 (Tier 1) NDS scopolamine base transdermal patch 3 day 1 mg over 3 days

$0 (Tier 1)

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1 MG OVER 3 DAYS

$0 (Tier 1)

NDS

Gastrointestinal Agents, Other

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml

$0 (Tier 1)

NDS

diphenoxylate-atropine oral tablet 2.5-0.025 mg

$0 (Tier 1)

NDS

GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG

$0 (Tier 1)

MO

loperamide oral capsule 2 mg $0 (Tier 1) MO metoclopramide hcl oral solution 5 mg/5 ml $0 (Tier 1) NDS metoclopramide hcl oral tablet 10 mg, 5 mg $0 (Tier 1) NDS PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %

$0 (Tier 1)

RELISTOR ORAL TABLET 150 MG $0 (Tier 1) PA RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML

$0 (Tier 1)

PA; NDS

RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML, 8 MG/0.4 ML

$0 (Tier 1)

PA; NDS

ursodiol oral capsule 300 mg $0 (Tier 1) MO ursodiol oral tablet 250 mg, 500 mg $0 (Tier 1) MO


74

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS XIFAXAN ORAL TABLET 200 MG $0 (Tier 1)

Histamine2 (H2) Receptor Antagonists

cimetidine hcl oral solution 300 mg/5 ml $0 (Tier 1) MO cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg

$0 (Tier 1)

MO

famotidine oral suspension 40 mg/5 ml (8 mg/ml)

$0 (Tier 1)

MO

famotidine oral tablet 20 mg, 40 mg $0 (Tier 1) MO nizatidine oral capsule 150 mg, 300 mg $0 (Tier 1) MO ranitidine hcl oral syrup 15 mg/ml $0 (Tier 1) MO ranitidine hcl oral tablet 150 mg, 300 mg $0 (Tier 1) MO Irritable Bowel Syndrome Agents

alosetron oral tablet 0.5 mg, 1 mg $0 (Tier 1) NDS AMITIZA ORAL CAPSULE 24 MCG, 8 MCG $0 (Tier 1) MO; QL (60 per 30 days) budesonide oral capsule,delayed,extend.release 3 mg

$0 (Tier 1)

NDS

budesonide oral tablet,delayed and ext.release 9 mg

$0 (Tier 1)

DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG

$0 (Tier 1)

MO

GIAZO ORAL TABLET 1.1 GRAM $0 (Tier 1) NDS LINZESS ORAL CAPSULE 145 MCG, 290 MCG

$0 (Tier 1)


LINZESS ORAL CAPSULE 72 MCG $0 (Tier 1) MO Laxatives

CONSTULOSE ORAL SOLUTION 10 GRAM/15 ML

$0 (Tier 1)

MO

ENULOSE ORAL SOLUTION 10 GRAM/15 ML

$0 (Tier 1)

MO

GAVILYTE-C ORAL RECON SOLN 240- 22.72-6.72 -5.84 GRAM

$0 (Tier 1)

NDS

GAVILYTE-G ORAL RECON SOLN 236- 22.74-6.74 -5.86 GRAM

$0 (Tier 1)

NDS

GAVILYTE-N ORAL RECON SOLN 420 GRAM

$0 (Tier 1)

NDS

GENERLAC ORAL SOLUTION 10 GRAM/15 ML

$0 (Tier 1)

MO

lactulose oral solution 10 gram/15 ml $0 (Tier 1) MO peg 3350-electrolytes oral recon soln 240- 22.72-6.72 -5.84 gram

$0 (Tier 1)


75

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS peg-electrolyte soln oral recon soln 420 gram $0 (Tier 1) NDS polyethylene glycol 3350 oral powder 17 gram/dose

$0 (Tier 1)

NDS

Protectants

CARAFATE ORAL SUSPENSION 100 MG/ML

$0 (Tier 1)

MO

misoprostol oral tablet 100 mcg, 200 mcg $0 (Tier 1) MO sucralfate oral tablet 1 gram $0 (Tier 1) MO Proton Pump Inhibitors

esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg, 40 mg

$0 (Tier 1)

MO

lansoprazole oral capsule,delayed release(dr/ec) 15 mg, 30 mg

$0 (Tier 1)

MO

omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg

$0 (Tier 1)

MO

pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg

$0 (Tier 1)

MO

rabeprazole oral tablet,delayed release (dr/ec) 20 mg

$0 (Tier 1)

MO

Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment CERDELGA ORAL CAPSULE 84 MG $0 (Tier 1) PA; MO CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000- 9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT

$0 (Tier 1)

MO

CYSTAGON ORAL CAPSULE 150 MG, 50 MG

$0 (Tier 1)

PA NSO; MO

KUVAN ORAL TABLET,SOLUBLE 100 MG $0 (Tier 1) PA NSO; MO miglustat oral capsule 100 mg $0 (Tier 1) PA NSO; MO ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG

$0 (Tier 1)

MO

RAVICTI ORAL LIQUID 1.1 GRAM/ML $0 (Tier 1) PA NSO; MO SUCRAID ORAL SOLUTION 8,500 UNIT/ML $0 (Tier 1) MO ZAVESCA ORAL CAPSULE 100 MG $0 (Tier 1) PA; MO


76

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 20,000-63,000- 84,000 UNIT, 40,000- 126,000- 168,000 UNIT

$0 (Tier 1)

MO

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 25,000-85,000- 136,000 UNIT, 5,000-17,000 -27,000 UNIT

$0 (Tier 1)

Genitourinary Agents Antispasmodics, Urinary flavoxate oral tablet 100 mg $0 (Tier 1) MO MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG

$0 (Tier 1)


oxybutynin chloride oral syrup 5 mg/5 ml $0 (Tier 1) MO oxybutynin chloride oral tablet 5 mg $0 (Tier 1) MO oxybutynin chloride oral tablet extended release 24hr 10 mg

$0 (Tier 1)


oxybutynin chloride oral tablet extended release 24hr 15 mg, 5 mg

$0 (Tier 1)


tolterodine oral capsule,extended release 24hr 2 mg, 4 mg

$0 (Tier 1)

MO

tolterodine oral tablet 1 mg, 2 mg $0 (Tier 1) MO trospium oral capsule,extended release 24hr 60 mg

$0 (Tier 1)


trospium oral tablet 20 mg $0 (Tier 1) MO Benign Prostatic Hypertrophy Agents

alfuzosin oral tablet extended release 24 hr 10 mg

$0 (Tier 1)


CIALIS ORAL TABLET 2.5 MG, 5 MG $0 (Tier 1) PA; MO doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg $0 (Tier 1) MO dutasteride oral capsule 0.5 mg $0 (Tier 1) MO; QL (30 per 30 days) finasteride oral tablet 5 mg $0 (Tier 1) MO prazosin oral capsule 1 mg, 2 mg, 5 mg $0 (Tier 1) MO tamsulosin oral capsule 0.4 mg $0 (Tier 1) MO terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg

$0 (Tier 1)

MO

Genitourinary Agents, Other

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

$0 (Tier 1)

NDS

DEPEN TITRATABS ORAL TABLET 250 MG $0 (Tier 1) MO ELMIRON ORAL CAPSULE 100 MG $0 (Tier 1) NDS


77

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg)

$0 (Tier 1)

MO

Phosphate Binders

AURYXIA ORAL TABLET 210 MG IRON $0 (Tier 1) MO calcium acetate oral capsule 667 mg $0 (Tier 1) MO lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 mg

$0 (Tier 1)

MO

RENAGEL ORAL TABLET 800 MG $0 (Tier 1) MO RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM

$0 (Tier 1)

MO

RENVELA ORAL TABLET 800 MG $0 (Tier 1) MO sevelamer carbonate oral powder in packet 0.8 gram, 2.4 gram

$0 (Tier 1)

MO

sevelamer carbonate oral tablet 800 mg $0 (Tier 1) MO Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) alclometasone topical cream 0.05 % $0 (Tier 1) NDS alclometasone topical ointment 0.05 % $0 (Tier 1) NDS amcinonide topical cream 0.1 % $0 (Tier 1) NDS amcinonide topical lotion 0.1 % $0 (Tier 1) NDS amcinonide topical ointment 0.1 % $0 (Tier 1) NDS betamethasone dipropionate topical cream 0.05 %

$0 (Tier 1)

NDS

betamethasone dipropionate topical ointment 0.05 %

$0 (Tier 1)

NDS

betamethasone valerate topical cream 0.1 % $0 (Tier 1) NDS betamethasone valerate topical foam 0.12 % $0 (Tier 1) NDS betamethasone valerate topical lotion 0.1 % $0 (Tier 1) NDS betamethasone valerate topical ointment 0.1 %

$0 (Tier 1)

NDS

betamethasone, augmented topical cream 0.05 %

$0 (Tier 1)

NDS

betamethasone, augmented topical gel 0.05 %

$0 (Tier 1)

NDS

betamethasone, augmented topical lotion 0.05 %

$0 (Tier 1)

NDS

clobetasol scalp solution 0.05 % $0 (Tier 1) NDS


78

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS clobetasol topical foam 0.05 % $0 (Tier 1) NDS clobetasol topical gel 0.05 % $0 (Tier 1) NDS clobetasol topical lotion 0.05 % $0 (Tier 1) NDS clobetasol topical ointment 0.05 % $0 (Tier 1) NDS clobetasol topical shampoo 0.05 % $0 (Tier 1) NDS clobetasol-emollient topical cream 0.05 % $0 (Tier 1) NDS CLODAN TOPICAL SHAMPOO 0.05 % $0 (Tier 1) NDS CORDRAN TAPE LARGE ROLL TOPICAL TAPE 4 MCG/CM2

$0 (Tier 1)

NDS

cortisone oral tablet 25 mg $0 (Tier 1) NDS desonide topical lotion 0.05 % $0 (Tier 1) NDS desoximetasone topical cream 0.05 %, 0.25 %

$0 (Tier 1)

NDS

desoximetasone topical gel 0.05 % $0 (Tier 1) NDS desoximetasone topical ointment 0.05 %, 0.25 %

$0 (Tier 1)

NDS

DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML

$0 (Tier 1)

NDS


$0 (Tier 1)

PA BvD; NDS

diflorasone topical cream 0.05 % $0 (Tier 1) NDS diflorasone topical ointment 0.05 % $0 (Tier 1) NDS fludrocortisone oral tablet 0.1 mg $0 (Tier 1) MO fluocinolone acetonide oil otic (ear) drops 0.01 %

$0 (Tier 1)

NDS

fluocinolone and shower cap scalp oil 0.01 % $0 (Tier 1) NDS fluocinolone topical cream 0.01 %, 0.025 % $0 (Tier 1) NDS fluocinolone topical ointment 0.025 % $0 (Tier 1) NDS fluocinolone topical solution 0.01 % $0 (Tier 1) NDS fluocinonide topical cream 0.1 % $0 (Tier 1) NDS fluocinonide topical gel 0.05 % $0 (Tier 1) NDS fluocinonide topical ointment 0.05 % $0 (Tier 1) NDS fluocinonide topical solution 0.05 % $0 (Tier 1) NDS fluocinonide-e topical cream 0.05 % $0 (Tier 1)

fluticasone topical cream 0.05 % $0 (Tier 1) NDS fluticasone topical ointment 0.005 % $0 (Tier 1) NDS halobetasol propionate topical cream 0.05 % $0 (Tier 1) NDS


79

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS HALOG TOPICAL CREAM 0.1 % $0 (Tier 1) NDS HALOG TOPICAL OINTMENT 0.1 % $0 (Tier 1) NDS hydrocortisone oral tablet 10 mg, 20 mg, 5 mg

$0 (Tier 1)

MO

hydrocortisone topical cream 1 %, 2.5 % $0 (Tier 1) NDS hydrocortisone topical lotion 2.5 % $0 (Tier 1) NDS hydrocortisone topical ointment 1 %, 2.5 % $0 (Tier 1) NDS methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

$0 (Tier 1)

PA BvD; NDS

methylprednisolone oral tablets,dose pack 4 mg

$0 (Tier 1)

NDS

mometasone topical cream 0.1 % $0 (Tier 1) NDS mometasone topical ointment 0.1 % $0 (Tier 1) NDS mometasone topical solution 0.1 % $0 (Tier 1) NDS prednicarbate topical ointment 0.1 % $0 (Tier 1) NDS prednisolone oral solution 15 mg/5 ml $0 (Tier 1) PA BvD; NDS prednisolone sodium phosphate oral solution 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

$0 (Tier 1)

PA BvD; NDS


$0 (Tier 1)

PA BvD; NDS


$0 (Tier 1)

PA BvD; NDS

PROCTO-PAK TOPICAL CREAM WITH PERINEAL APPLICATOR 1 %

$0 (Tier 1)

NDS

PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %

$0 (Tier 1)

triamcinolone acetonide nasal aerosol,spray 55 mcg

$0 (Tier 1)

triamcinolone acetonide topical aerosol 0.147 mg/gram

$0 (Tier 1)

NDS

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

$0 (Tier 1)

NDS

triamcinolone acetonide topical lotion 0.025 %, 0.1 %

$0 (Tier 1)

NDS

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

$0 (Tier 1)

NDS

TRIDERM TOPICAL CREAM 0.1 % $0 (Tier 1) NDS


80

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS VERIPRED 20 ORAL SOLUTION 20 MG/5 ML (4 MG/ML)

$0 (Tier 1)

PA BvD; NDS

Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml)

$0 (Tier 1)

MO

desmopressin oral tablet 0.1 mg, 0.2 mg $0 (Tier 1) MO EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG

$0 (Tier 1)

MO

INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML

$0 (Tier 1)

PA NSO; NDS

MYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.)

$0 (Tier 1)

MO

NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)

$0 (Tier 1)

PA; MO

NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 5 MG/2 ML (2.5 MG/ML)

$0 (Tier 1)

PA; MO

Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins) Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins) misoprostol oral tablet 200 mcg $0 (Tier 1) MO Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) Anabolic Steroids ANADROL-50 ORAL TABLET 50 MG $0 (Tier 1) NDS oxandrolone oral tablet 10 mg, 2.5 mg $0 (Tier 1) MO Androgens

danazol oral capsule 100 mg, 200 mg, 50 mg $0 (Tier 1) NDS testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml

$0 (Tier 1)

MO

testosterone enanthate intramuscular oil 200 mg/ml

$0 (Tier 1)

NDS

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

$0 (Tier 1)

MO


81

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS testosterone transdermal gel in packet 1 % (25 mg/2.5gram)

$0 (Tier 1)

MO

Estrogens

ALORA TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR

$0 (Tier 1)

MO

DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML

$0 (Tier 1)

NDS

DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML

$0 (Tier 1)

NDS

DUAVEE ORAL TABLET 0.45-20 MG $0 (Tier 1) MO ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM)

$0 (Tier 1)

MO

estradiol oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) PA NSO; MO estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

$0 (Tier 1)

PA NSO; MO

estradiol vaginal cream 0.01 % (0.1 mg/gram)

$0 (Tier 1)

MO

estradiol vaginal tablet 10 mcg $0 (Tier 1) MO estradiol valerate intramuscular oil 20 mg/ml $0 (Tier 1) NDS ESTRING VAGINAL RING 2 MG (7.5 MCG /24 HOUR)

$0 (Tier 1)


estropipate oral tablet 0.75 mg $0 (Tier 1) MO estropipate oral tablet 1.5 mg $0 (Tier 1)

FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR

$0 (Tier 1)

MO

MARLISSA ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

$0 (Tier 1)

MO

MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG/24 HR

$0 (Tier 1)

PA NSO; MO

MINIVELLE TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.0375 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR

$0 (Tier 1)

MO

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

$0 (Tier 1)

MO

YUVAFEM VAGINAL TABLET 10 MCG $0 (Tier 1) MO


82

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)

AMETHIA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7)

$0 (Tier 1)

MO

ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5- 1 MG

$0 (Tier 1)

MO

APRI ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO ARANELLE (28) ORAL TABLET 0.5/1/0.5-35 MG-MCG

$0 (Tier 1)

MO

ASHLYNA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7)

$0 (Tier 1)

MO

AUBRA ORAL TABLET 0.1-20 MG-MCG $0 (Tier 1) MO AVIANE ORAL TABLET 0.1-20 MG-MCG $0 (Tier 1) MO BALZIVA (28) ORAL TABLET 0.4-35 MG- MCG

$0 (Tier 1)

MO

BLISOVI 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)

$0 (Tier 1)

MO

BLISOVI FE 1/20 (28) ORAL TABLET 1 MG- 20 MCG (21)/75 MG (7)

$0 (Tier 1)

MO

BRIELLYN ORAL TABLET 0.4-35 MG-MCG $0 (Tier 1) MO budesonide oral capsule,delayed,extend.release 3 mg

$0 (Tier 1)

NDS


$0 (Tier 1)

CRYSELLE (28) ORAL TABLET 0.3-30 MG- MCG

$0 (Tier 1)

MO

CYCLAFEM 1/35 (28) ORAL TABLET 1-35 MG-MCG

$0 (Tier 1)

MO

CYCLAFEM 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG

$0 (Tier 1)

MO

DEBLITANE ORAL TABLET 0.35 MG $0 (Tier 1) MO DELYLA (28) ORAL TABLET 0.1-20 MG- MCG

$0 (Tier 1)

MO

desogestrel-ethinyl estradiol oral tablet 0.15- 0.03 mg

$0 (Tier 1)

MO

drospirenone-ethinyl estradiol oral tablet 3- 0.02 mg, 3-0.03 mg

$0 (Tier 1)

MO

EMOQUETTE ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO ENPRESSE ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10)

$0 (Tier 1)

MO


83

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS estradiol valerate intramuscular oil 40 mg/ml $0 (Tier 1) NDS estradiol-norethindrone acet oral tablet 0.5- 0.1 mg, 1-0.5 mg

$0 (Tier 1)

MO

ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg

$0 (Tier 1)

MO

FALMINA (28) ORAL TABLET 0.1-20 MG- MCG

$0 (Tier 1)

MO

GIANVI (28) ORAL TABLET 3-0.02 MG $0 (Tier 1) MO INTROVALE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG

$0 (Tier 1)

MO

JINTELI ORAL TABLET 1-5 MG-MCG $0 (Tier 1) MO JULEBER ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO JUNEL 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

$0 (Tier 1)

MO

JUNEL 1/20 (21) ORAL TABLET 1-20 MG- MCG

$0 (Tier 1)

MO

JUNEL FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)

$0 (Tier 1)

MO

JUNEL FE 1/20 (28) ORAL TABLET 1 MG- 20 MCG (21)/75 MG (7)

$0 (Tier 1)

MO

JUNEL FE 24 ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)

$0 (Tier 1)

MO

KARIVA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

$0 (Tier 1)

MO

KELNOR 1/35 (28) ORAL TABLET 1-35 MG- MCG

$0 (Tier 1)

MO

KIMIDESS (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

$0 (Tier 1)

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg

$0 (Tier 1)

MO

LARIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

$0 (Tier 1)

MO

LARIN 1/20 (21) ORAL TABLET 1-20 MG- MCG

$0 (Tier 1)

MO

LARIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)

$0 (Tier 1)

MO

LARIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)

$0 (Tier 1)

MO

LAYOLIS FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4)

$0 (Tier 1)

MO


84

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS LEENA 28 ORAL TABLET 0.5/1/0.5-35 MG- MCG

$0 (Tier 1)

MO

LESSINA ORAL TABLET 0.1-20 MG-MCG $0 (Tier 1) MO LEVONEST (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10)

$0 (Tier 1)

MO

levonorgestrel-ethinyl estrad oral tablet 0.15- 0.03 mg, 90-20 mcg

$0 (Tier 1)

MO

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg

$0 (Tier 1)

MO

LEVORA-28 ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO LORYNA (28) ORAL TABLET 3-0.02 MG $0 (Tier 1) MO LUTERA (28) ORAL TABLET 0.1-20 MG- MCG

$0 (Tier 1)

MO

MARLISSA ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO MICROGESTIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

$0 (Tier 1)

MO

MICROGESTIN 1/20 (21) ORAL TABLET 1- 20 MG-MCG

$0 (Tier 1)

MO

MICROGESTIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)

$0 (Tier 1)

MO

MIMVEY LO ORAL TABLET 0.5-0.1 MG $0 (Tier 1) MO MIMVEY ORAL TABLET 1-0.5 MG $0 (Tier 1) MO MINASTRIN 24 FE ORAL TABLET,CHEWABLE 1 MG-20 MCG(24) /75 MG (4)

$0 (Tier 1)

MO

MONONESSA (28) ORAL TABLET 0.25-35 MG-MCG

$0 (Tier 1)

MO

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

$0 (Tier 1)

MO

NECON 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG

$0 (Tier 1)

MO

NIKKI (28) ORAL TABLET 3-0.02 MG $0 (Tier 1) MO NORA-BE ORAL TABLET 0.35 MG $0 (Tier 1) MO noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)

$0 (Tier 1)

MO

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

$0 (Tier 1)

MO

norethindrone-e.estradiol-iron oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4)

$0 (Tier 1)

MO


85

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg

$0 (Tier 1)

MO

NORLYROC ORAL TABLET 0.35 MG $0 (Tier 1) MO NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

$0 (Tier 1)

MO

NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG

$0 (Tier 1)

MO

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG

$0 (Tier 1)

MO

NORTREL 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG

$0 (Tier 1)

MO

OGESTREL (28) ORAL TABLET 0.5-50 MG- MCG

$0 (Tier 1)

MO

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG $0 (Tier 1) MO PIMTREA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

$0 (Tier 1)

MO

PIRMELLA ORAL TABLET 1-35 MG-MCG $0 (Tier 1) MO PORTIA ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG-5MG(14)

$0 (Tier 1)

MO

PREVIFEM ORAL TABLET 0.25-35 MG- MCG

$0 (Tier 1)

MO

QUARTETTE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG

$0 (Tier 1)

MO

QUASENSE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG

$0 (Tier 1)

MO

RECLIPSEN (28) ORAL TABLET 0.15-0.03 MG

$0 (Tier 1)

MO

SETLAKIN ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG

$0 (Tier 1)

MO

SHAROBEL ORAL TABLET 0.35 MG $0 (Tier 1) MO SPRINTEC (28) ORAL TABLET 0.25-35 MG- MCG

$0 (Tier 1)

MO

SRONYX ORAL TABLET 0.1-20 MG-MCG $0 (Tier 1) MO TARINA FE 1/20 (28) ORAL TABLET 1 MG- 20 MCG (21)/75 MG (7)

$0 (Tier 1)

MO

TRI-LEGEST FE ORAL TABLET 1-20(5)/1- 30(7) /1MG-35MCG (9)

$0 (Tier 1)

MO

TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

$0 (Tier 1)

MO


86

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS TRI-PREVIFEM (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

$0 (Tier 1)

MO

TRI-SPRINTEC (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

$0 (Tier 1)

MO

TRIVORA (28) ORAL TABLET 50-30 (6)/75- 40 (5)/125-30(10)

$0 (Tier 1)

MO

VELIVET TRIPHASIC REGIMEN (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG

$0 (Tier 1)

MO

VYFEMLA (28) ORAL TABLET 0.4-35 MG- MCG

$0 (Tier 1)

MO

WYMZYA FE ORAL TABLET,CHEWABLE 0.4MG-35MCG(21) AND 75 MG (7)

$0 (Tier 1)

MO

XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24 HR

$0 (Tier 1)

MO

ZENCHENT (28) ORAL TABLET 0.4-35 MG- MCG

$0 (Tier 1)

MO

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG- MCG

$0 (Tier 1)

MO

Progestins

CAMILA ORAL TABLET 0.35 MG $0 (Tier 1) MO DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML, 400 MG/ML

$0 (Tier 1)

MO

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG/0.65 ML

$0 (Tier 1)

MO

ERRIN ORAL TABLET 0.35 MG $0 (Tier 1) MO JOLIVETTE ORAL TABLET 0.35 MG $0 (Tier 1) MO LYZA ORAL TABLET 0.35 MG $0 (Tier 1) MO MARLISSA ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO medroxyprogesterone intramuscular syringe 150 mg/ml

$0 (Tier 1)

MO

medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg

$0 (Tier 1)

MO

MEGACE ES ORAL SUSPENSION 625 MG/5 ML

$0 (Tier 1)

MO

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

$0 (Tier 1)

PA NSO; MO

megestrol oral tablet 20 mg, 40 mg $0 (Tier 1) PA NSO; NDS norethindrone (contraceptive) oral tablet 0.35 mg

$0 (Tier 1)

MO

norethindrone acetate oral tablet 5 mg $0 (Tier 1) MO


87

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS progesterone micronized oral capsule 100 mg, 200 mg

$0 (Tier 1)

MO

Selective Estrogen Receptor Modifying Agents

DUAVEE ORAL TABLET 0.45-20 MG $0 (Tier 1) MO raloxifene oral tablet 60 mg $0 (Tier 1) MO Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

$0 (Tier 1)

MO

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

$0 (Tier 1)

MO

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg

$0 (Tier 1)

MO

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

$0 (Tier 1)

MO

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG

$0 (Tier 1)

MO

Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) LYSODREN ORAL TABLET 500 MG $0 (Tier 1) NDS Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) bromocriptine oral capsule 5 mg $0 (Tier 1) MO bromocriptine oral tablet 2.5 mg $0 (Tier 1) MO cabergoline oral tablet 0.5 mg $0 (Tier 1) MO ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG

$0 (Tier 1)

PA NSO; NDS

ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG

$0 (Tier 1)

PA NSO; NDS

ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG

$0 (Tier 1)

PA NSO; NDS


88

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH)

$0 (Tier 1)

PA NSO; NDS

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG

$0 (Tier 1)

PA NSO; NDS

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG

$0 (Tier 1)

PA NSO; MO

leuprolide subcutaneous kit 1 mg/0.2 ml $0 (Tier 1) PA; NDS LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG

$0 (Tier 1)

PA NSO; NDS

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 22.5 MG

$0 (Tier 1)

PA NSO; NDS; MO

LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG

$0 (Tier 1)

PA NSO; NDS

LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG

$0 (Tier 1)

PA NSO; NDS

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG

$0 (Tier 1)

PA NSO; NDS

octreotide acetate injection solution 1,000 mcg/ml

$0 (Tier 1)

PA; MO

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML)

$0 (Tier 1)

PA NSO; MO

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 90 MG/0.3 ML

$0 (Tier 1)

PA NSO; MO

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG/0.2 ML

$0 (Tier 1) PA NSO; MO; QL (0.2 per 28

days) SOMAVERT SUBCUTANEOUS RECON SOLN 15 MG, 20 MG, 25 MG, 30 MG

$0 (Tier 1)

PA NSO; MO

SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML

$0 (Tier 1)

NDS

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

$0 (Tier 1)

PA NSO; NDS; MO

TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML

$0 (Tier 1)

MO

Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole oral tablet 10 mg, 5 mg $0 (Tier 1) MO propylthiouracil oral tablet 50 mg $0 (Tier 1) MO


89

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Immunological Agents Angioedema Agents CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)

$0 (Tier 1)

PA; MO

FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML

$0 (Tier 1)

PA; NDS

Immune Suppressants

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

$0 (Tier 1)

PA NSO; MO

AFINITOR ORAL TABLET 2.5 MG $0 (Tier 1) PA NSO; MO ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG

$0 (Tier 1)

PA BvD; MO

AZASAN ORAL TABLET 100 MG, 75 MG $0 (Tier 1) PA BvD; MO azathioprine oral tablet 50 mg $0 (Tier 1) PA BvD; MO CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)

$0 (Tier 1)

PA; MO

CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)

$0 (Tier 1)

PA; MO

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

$0 (Tier 1)

PA BvD; MO

cyclosporine modified oral solution 100 mg/ml

$0 (Tier 1)

PA BvD; MO

cyclosporine oral capsule 100 mg, 25 mg $0 (Tier 1) PA BvD; MO DEPEN TITRATABS ORAL TABLET 250 MG $0 (Tier 1) MO ELIDEL TOPICAL CREAM 1 % $0 (Tier 1) NDS; QL (60 per 30 days) ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)

$0 (Tier 1)

PA; MO

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

$0 (Tier 1)

PA; MO

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML)

$0 (Tier 1)

PA; MO

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG

$0 (Tier 1)

PA BvD; MO

GENGRAF ORAL CAPSULE 100 MG, 25 MG

$0 (Tier 1)

PA BvD; MO

GENGRAF ORAL SOLUTION 100 MG/ML $0 (Tier 1) PA BvD; MO HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 80 MG/0.8 ML

$0 (Tier 1)

PA; MO


90

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML

$0 (Tier 1)

PA

HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

$0 (Tier 1)

PA; MO

HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

$0 (Tier 1)

PA; MO

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML, 40 MG/0.8 ML

$0 (Tier 1)

PA; MO

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 10 MG/0.2 ML, 20 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.4 ML, 40 MG/0.8 ML

$0 (Tier 1)

PA; MO

IMURAN ORAL TABLET 50 MG $0 (Tier 1) PA BvD; MO KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML

$0 (Tier 1)

PA; MO

mercaptopurine oral tablet 50 mg $0 (Tier 1) NDS methotrexate sodium (pf) injection solution 25 mg/ml

$0 (Tier 1)

PA BvD; NDS

methotrexate sodium injection solution 25 mg/ml

$0 (Tier 1)

methotrexate sodium oral tablet 2.5 mg $0 (Tier 1) PA BvD; MO mycophenolate mofetil oral capsule 250 mg $0 (Tier 1) PA BvD; MO mycophenolate mofetil oral suspension for reconstitution 200 mg/ml

$0 (Tier 1)

PA BvD; MO

mycophenolate mofetil oral tablet 500 mg $0 (Tier 1) PA BvD; MO mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg

$0 (Tier 1)

PA BvD; MO

MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC) 180 MG, 360 MG

$0 (Tier 1)

PA BvD; MO

NEORAL ORAL CAPSULE 100 MG, 25 MG $0 (Tier 1) PA BvD; MO NEORAL ORAL SOLUTION 100 MG/ML $0 (Tier 1) PA BvD; MO ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML

$0 (Tier 1)

PA; MO

OTEZLA ORAL TABLET 30 MG $0 (Tier 1) PA; MO OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)

$0 (Tier 1)

PA; NDS

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG

$0 (Tier 1)

PA BvD; MO


91

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS RAPAMUNE ORAL SOLUTION 1 MG/ML $0 (Tier 1) PA BvD; MO RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG

$0 (Tier 1)

PA BvD; MO

SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG

$0 (Tier 1)

PA BvD; MO

SANDIMMUNE ORAL SOLUTION 100 MG/ML

$0 (Tier 1)

PA BvD; MO

SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML

$0 (Tier 1)

PA; MO

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) PA BvD; MO tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg $0 (Tier 1) PA BvD; MO TREXALL ORAL TABLET 10 MG, 5 MG, 7.5 MG

$0 (Tier 1)

PA BvD; MO

TREXALL ORAL TABLET 15 MG $0 (Tier 1) MO XATMEP ORAL SOLUTION 2.5 MG/ML $0 (Tier 1) MO XELJANZ ORAL TABLET 5 MG $0 (Tier 1) PA; MO XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG

$0 (Tier 1)

PA; MO

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG

$0 (Tier 1)

PA BvD; MO

Immunizing Agents, Passive

BIVIGAM INTRAVENOUS SOLUTION 10 % $0 (Tier 1) PA BvD; MO CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM

$0 (Tier 1)

PA; MO

FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %

$0 (Tier 1)

PA BvD; MO

GAMMAGARD LIQUID INJECTION SOLUTION 10 %

$0 (Tier 1)

PA BvD; MO

GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %)

$0 (Tier 1)

PA BvD; MO

GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 %

$0 (Tier 1)

PA BvD; MO

GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %)

$0 (Tier 1)

PA BvD; MO

OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 %

$0 (Tier 1)

PA BvD; MO

PRIVIGEN INTRAVENOUS SOLUTION 10 %

$0 (Tier 1)

PA BvD; MO

Immunomodulators

ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML

$0 (Tier 1)

PA


92

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ARCALYST SUBCUTANEOUS RECON SOLN 220 MG

$0 (Tier 1)

MO

leflunomide oral tablet 10 mg, 20 mg $0 (Tier 1) MO RIDAURA ORAL CAPSULE 3 MG $0 (Tier 1) MO SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML

$0 (Tier 1)

PA; MO

Vaccines

ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML

$0 (Tier 1)

NDS

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5- 5-3-5 MCG)-5LF/0.5 ML

$0 (Tier 1)

NDS

bcg vaccine, live (pf) percutaneous suspension for reconstitution 50 mg

$0 (Tier 1)

BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML

$0 (Tier 1)

NDS

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML

$0 (Tier 1)

NDS

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML

$0 (Tier 1)

NDS

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF/0.5ML

$0 (Tier 1)

NDS

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML

$0 (Tier 1)

PA BvD; NDS

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML

$0 (Tier 1)

PA BvD

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML

$0 (Tier 1)

NDS

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML

$0 (Tier 1)

NDS

HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML

$0 (Tier 1)

NDS

HAVRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT/0.5 ML

$0 (Tier 1)

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML

$0 (Tier 1)

HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML

$0 (Tier 1)

NDS

HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML

$0 (Tier 1)


93

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT

$0 (Tier 1)

PA BvD; NDS

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF/0.5ML

$0 (Tier 1)

NDS

IPOL INJECTION SUSPENSION 40-8-32 UNIT/0.5 ML

$0 (Tier 1)

NDS

IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML

$0 (Tier 1)

NDS

KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML

$0 (Tier 1)

KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML

$0 (Tier 1)

MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML

$0 (Tier 1)

NDS

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML

$0 (Tier 1)

NDS

M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML

$0 (Tier 1)

NDS

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML

$0 (Tier 1)

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML

$0 (Tier 1)

NDS

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5

$0 (Tier 1)

NDS

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML

$0 (Tier 1)

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT

$0 (Tier 1)

NDS

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML

$0 (Tier 1)

PA BvD; NDS

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML

$0 (Tier 1)

PA BvD; NDS

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML

$0 (Tier 1)

NDS

ROTATEQ VACCINE ORAL SOLUTION 2 ML

$0 (Tier 1)

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML

$0 (Tier 1)

QL (1 per 1 day)


94

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML

$0 (Tier 1)

NDS

tetanus,diphtheria tox ped(pf) intramuscular suspension 5-25 lf unit/0.5 ml

$0 (Tier 1)

NDS

tetanus-diphtheria toxoids-td intramuscular suspension 2-2 lf unit/0.5 ml

$0 (Tier 1)

TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML

$0 (Tier 1)

TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML

$0 (Tier 1)

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML

$0 (Tier 1)

NDS

TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML

$0 (Tier 1)

NDS

VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML

$0 (Tier 1)

VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML

$0 (Tier 1)

NDS

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML

$0 (Tier 1)

NDS

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML

$0 (Tier 1)

NDS

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML

$0 (Tier 1)


Inflammatory Bowel Disease Agents Aminosalicylates APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR 0.375 GRAM

$0 (Tier 1)

MO

ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG

$0 (Tier 1)

MO

balsalazide oral capsule 750 mg $0 (Tier 1) NDS CANASA RECTAL SUPPOSITORY 1,000 MG

$0 (Tier 1)

MO

DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG

$0 (Tier 1)

MO

DIPENTUM ORAL CAPSULE 250 MG $0 (Tier 1) MO LIALDA ORAL TABLET,DELAYED RELEASE ( / C) G

$0 (Tier 1)

MO


95

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

$0 (Tier 1)

MO

mesalamine rectal enema 4 gram/60 ml $0 (Tier 1) MO PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG, 500 MG

$0 (Tier 1)

MO

Glucocorticoids

budesonide oral capsule,delayed,extend.release 3 mg

$0 (Tier 1)

NDS


$0 (Tier 1)

COLOCORT RECTAL ENEMA 100 MG/60 ML

$0 (Tier 1)

NDS

cortisone oral tablet 25 mg $0 (Tier 1) NDS DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML

$0 (Tier 1)

NDS


$0 (Tier 1)

PA BvD; NDS

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg

$0 (Tier 1)

MO

hydrocortisone rectal enema 100 mg/60 ml $0 (Tier 1) NDS methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

$0 (Tier 1)

PA BvD; NDS

methylprednisolone oral tablets,dose pack 4 mg

$0 (Tier 1)

NDS


$0 (Tier 1)

NDS

prednisolone oral solution 15 mg/5 ml $0 (Tier 1) PA BvD; NDS prednisolone sodium phosphate oral solution 5 mg base/5 ml (6.7 mg/5 ml)

$0 (Tier 1)

PA BvD; NDS


$0 (Tier 1)

PA BvD; NDS


$0 (Tier 1)

PA BvD; NDS

PROCTOSOL HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %

$0 (Tier 1)

NDS

VERIPRED 20 ORAL SOLUTION 20 MG/5 ML (4 MG/ML)

$0 (Tier 1)

PA BvD; NDS

Sulfonamides

sulfasalazine oral tablet 500 mg $0 (Tier 1) MO


96

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS sulfasalazine oral tablet,delayed release (dr/ec) 500 mg

$0 (Tier 1)

MO

Metabolic Bone Disease Agents Metabolic Bone Disease Agents ACTONEL ORAL TABLET 30 MG $0 (Tier 1) ST; NDS alendronate oral tablet 10 mg, 40 mg, 5 mg $0 (Tier 1) MO; QL (30 per 30 days) alendronate oral tablet 35 mg, 70 mg $0 (Tier 1) MO; QL (4 per 28 days) calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation

$0 (Tier 1)

PA BvD; MO

calcitriol oral capsule 0.25 mcg, 0.5 mcg $0 (Tier 1) PA BvD; MO calcitriol oral solution 1 mcg/ml $0 (Tier 1) PA BvD; MO doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg

$0 (Tier 1)

PA BvD; MO

etidronate disodium oral tablet 200 mg, 400 mg

$0 (Tier 1)

MO

FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML

$0 (Tier 1)

PA; MO; QL (2.4 per 28 days)

FOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT, 70 MG- 5,600 UNIT

$0 (Tier 1)


ibandronate oral tablet 150 mg

$0 (Tier 1) PA BvD; MO; QL (1 per 30

days) NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE

$0 (Tier 1)

PA; MO

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg $0 (Tier 1) PA BvD; MO PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML

$0 (Tier 1)

PA; MO

risedronate oral tablet 150 mg $0 (Tier 1) MO; QL (1 per 28 days) risedronate oral tablet 30 mg $0 (Tier 1) NDS; QL (30 per 30 days) risedronate oral tablet 35 mg $0 (Tier 1) MO; QL (4 per 28 days) risedronate oral tablet 5 mg $0 (Tier 1) MO; QL (30 per 30 days) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG

$0 (Tier 1) PA BvD; MO; QL (120 per 30

days) XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7 ML (70 MG/ML)

$0 (Tier 1)

PA; NDS

ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG $0 (Tier 1) PA BvD; MO


97

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Ophthalmic Agents Ophthalmic Agents, Other CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 %

$0 (Tier 1)

MO

LACRISERT OPHTHALMIC (EYE) INSERT 5 MG

$0 (Tier 1)

NDS

proparacaine ophthalmic (eye) drops 0.5 % $0 (Tier 1) NDS RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 %

$0 (Tier 1)

MO


$0 (Tier 1)

NDS

Ophthalmic Agents

bacitracin-polymyxin b ophthalmic (eye) ointment 500-10,000 unit/gram

$0 (Tier 1)

NDS

BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION 10-

%

$0 (Tier 1)

NDS

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT 10-0.2 %

$0 (Tier 1)

NDS

neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 3.5-400-10,000 mg-unit/g-1%

$0 (Tier 1)

NDS

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g

$0 (Tier 1)

NDS

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 %

$0 (Tier 1)

NDS

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 %

$0 (Tier 1)

NDS

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-10,000-10 mg-unit- mg/ml

$0 (Tier 1)

NDS

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml

$0 (Tier 1)

NDS


$0 (Tier 1)

NDS

tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 %

$0 (Tier 1)

NDS

Ophthalmic Anti-Allergy Agents

ALOCRIL OPHTHALMIC (EYE) DROPS 2 % $0 (Tier 1) NDS azelastine ophthalmic (eye) drops 0.05 % $0 (Tier 1) NDS cromolyn ophthalmic (eye) drops 4 % $0 (Tier 1) NDS epinastine ophthalmic (eye) drops 0.05 % $0 (Tier 1) NDS


98

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS olopatadine ophthalmic (eye) drops 0.2 % $0 (Tier 1)

Ophthalmic Antiglaucoma Agents

acetazolamide oral tablet 125 mg, 250 mg $0 (Tier 1) MO ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %

$0 (Tier 1)

MO

AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION 1 %

$0 (Tier 1)

MO

betaxolol ophthalmic (eye) drops 0.5 % $0 (Tier 1) MO BETIMOL OPHTHALMIC (EYE) DROPS 0.25 %, 0.5 %

$0 (Tier 1)

MO

BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 %

$0 (Tier 1)

MO

bimatoprost ophthalmic (eye) drops 0.03 % $0 (Tier 1) MO brimonidine ophthalmic (eye) drops 0.15 %, 0.2 %

$0 (Tier 1)

MO

carteolol ophthalmic (eye) drops 1 % $0 (Tier 1) MO COMBIGAN OPHTHALMIC (EYE) DROPS 0.2-0.5 %

$0 (Tier 1)

MO

dorzolamide ophthalmic (eye) drops 2 % $0 (Tier 1) MO dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 mg/ml

$0 (Tier 1)

MO

IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1 %

$0 (Tier 1)

NDS

IOPIDINE OPHTHALMIC (EYE) DROPS 0.5 %

$0 (Tier 1)

NDS

ISTALOL OPHTHALMIC (EYE) DROPS, ONCE DAILY 0.5 %

$0 (Tier 1)

MO

levobunolol ophthalmic (eye) drops 0.5 % $0 (Tier 1) MO methazolamide oral tablet 25 mg, 50 mg $0 (Tier 1) MO metipranolol ophthalmic (eye) drops 0.3 % $0 (Tier 1) MO pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %

$0 (Tier 1)

MO

timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 %

$0 (Tier 1)

MO

timolol maleate ophthalmic (eye) drops, once daily 0.5 %

$0 (Tier 1)

MO

timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 %

$0 (Tier 1)

MO


99

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Ophthalmic Anti-Inflammatories

ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 %

$0 (Tier 1)

NDS

DUREZOL OPHTHALMIC (EYE) DROPS 0.05 %

$0 (Tier 1)

NDS

fluorometholone ophthalmic (eye) drops,suspension 0.1 %

$0 (Tier 1)

NDS

flurbiprofen sodium ophthalmic (eye) drops 0.03 %

$0 (Tier 1)

NDS

FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 %

$0 (Tier 1)

NDS

FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 %

$0 (Tier 1)

NDS

ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3 %

$0 (Tier 1)

NDS

ketorolac ophthalmic (eye) drops 0.4 %, 0.5 %

$0 (Tier 1)

NDS

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 0.5 %

$0 (Tier 1)

NDS

LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 %

$0 (Tier 1)

NDS

LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 %

$0 (Tier 1)

NDS

MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 %

$0 (Tier 1)

NDS

NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 %

$0 (Tier 1)

NDS

PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 %

$0 (Tier 1)

NDS


$0 (Tier 1)

NDS

prednisolone sodium phosphate ophthalmic (eye) drops 1 %

$0 (Tier 1)

NDS

Ophthalmic Prostaglandin And Prostamide Analogs

bimatoprost ophthalmic (eye) drops 0.03 % $0 (Tier 1) MO latanoprost ophthalmic (eye) drops 0.005 % $0 (Tier 1) MO LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %

$0 (Tier 1)

MO

TRAVATAN Z OPHTHALMIC (EYE) DROPS 0.004 %

$0 (Tier 1)

MO

100


DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Otic Agents Otic Agents CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.2-1 %

$0 (Tier 1)

NDS

CIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 %

$0 (Tier 1)

NDS

hydrocortisone-acetic acid otic (ear) drops 1- 2 %

$0 (Tier 1)

neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 mg/ml- unit/ml-%

$0 (Tier 1)

NDS

neomycin-polymyxin-hc otic (ear) solution 3.5-10,000-1 mg/ml-unit/ml-%

$0 (Tier 1)

NDS

Respiratory Tract/ Pulmonary Agents Antihistamines azelastine nasal aerosol,spray 137 mcg (0.1 %)

$0 (Tier 1)

MO

azelastine nasal spray,non-aerosol 0.15 % (205.5 mcg)

$0 (Tier 1)

MO

carbinoxamine maleate oral liquid 4 mg/5 ml $0 (Tier 1) NDS carbinoxamine maleate oral tablet 4 mg $0 (Tier 1) NDS cetirizine oral solution 1 mg/ml $0 (Tier 1) NDS clemastine oral tablet 2.68 mg $0 (Tier 1) NDS cyproheptadine oral tablet 4 mg $0 (Tier 1)

desloratadine oral tablet 5 mg $0 (Tier 1) MO; QL (30 per 30 days) desloratadine oral tablet,disintegrating 2.5 mg, 5 mg

$0 (Tier 1)


hydroxyzine hcl oral solution 10 mg/5 ml $0 (Tier 1) PA NSO; NDS hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg

$0 (Tier 1)

PA NSO; NDS


$0 (Tier 1)

PA NSO; NDS

levocetirizine oral solution 2.5 mg/5 ml $0 (Tier 1) MO; QL (300 per 30 days) levocetirizine oral tablet 5 mg $0 (Tier 1) MO; QL (30 per 30 days) promethazine oral syrup 6.25 mg/5 ml $0 (Tier 1) PA NSO; NDS promethazine oral tablet 12.5 mg, 25 mg, 50 mg

$0 (Tier 1)

PA NSO; NDS


101

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Anti-Inflammatories, Inhaled Corticosteroids

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

$0 (Tier 1)

MO

ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION

$0 (Tier 1)

MO

BECONASE AQ NASAL SPRAY,NON- AEROSOL 42 MCG (0.042 %)

$0 (Tier 1)

MO

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

$0 (Tier 1)

PA BvD; MO

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

$0 (Tier 1)

MO

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

$0 (Tier 1)

MO

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

$0 (Tier 1)

MO

fluticasone nasal spray,suspension 50 mcg/actuation

$0 (Tier 1)

MO

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION

$0 (Tier 1)

MO

PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML

$0 (Tier 1)

PA BvD; MO

Antileukotrienes

montelukast oral granules in packet 4 mg $0 (Tier 1) MO; QL (30 per 30 days) montelukast oral tablet 10 mg $0 (Tier 1) MO; QL (30 per 30 days) montelukast oral tablet,chewable 4 mg, 5 mg $0 (Tier 1) MO; QL (30 per 30 days) zafirlukast oral tablet 10 mg, 20 mg $0 (Tier 1) MO; QL (60 per 30 days) Bronchodilators, Anticholinergic

ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION

$0 (Tier 1)

MO

ipratropium bromide inhalation solution 0.02 %

$0 (Tier 1)

PA BvD; MO

102


DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ipratropium bromide nasal spray,non-aerosol 0.03 %

$0 (Tier 1)

MO

ipratropium bromide nasal spray,non-aerosol 42 mcg (0.06 %)

$0 (Tier 1)

NDS

SPIRIVA RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION

$0 (Tier 1)


SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG

$0 (Tier 1)


TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION

$0 (Tier 1)


Bronchodilators, Sympathomimetic


$0 (Tier 1)

MO

ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION

$0 (Tier 1)

MO

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %)

$0 (Tier 1)

PA BvD; MO

albuterol sulfate oral syrup 2 mg/5 ml $0 (Tier 1) MO albuterol sulfate oral tablet 2 mg, 4 mg $0 (Tier 1) MO albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg

$0 (Tier 1)

MO

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG

$0 (Tier 1)

MO

BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE

$0 (Tier 1)


BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG/2 ML

$0 (Tier 1)

PA BvD; MO

epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml

$0 (Tier 1)

NDS

EPIPEN 2-PAK INJECTION AUTO- INJECTOR 0.3 MG/0.3 ML

$0 (Tier 1)

NDS

EPIPEN JR 2-PAK INJECTION AUTO- INJECTOR 0.15 MG/0.3 ML

$0 (Tier 1)

NDS


103

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS fluticasone-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation

$0 (Tier 1)

MO

levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml

$0 (Tier 1)

PA BvD; MO

metaproterenol oral syrup 10 mg/5 ml $0 (Tier 1) MO metaproterenol oral tablet 10 mg, 20 mg $0 (Tier 1) MO PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG/2 ML

$0 (Tier 1)

PA BvD; MO

PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION

$0 (Tier 1)

MO

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE

$0 (Tier 1)


terbutaline oral tablet 2.5 mg, 5 mg $0 (Tier 1) MO VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION

$0 (Tier 1)


Cystic Fibrosis Agents

CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML

$0 (Tier 1)

PA; NDS

KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG

$0 (Tier 1)

PA; MO

KALYDECO ORAL TABLET 150 MG $0 (Tier 1) PA; MO ORKAMBI ORAL TABLET 100-125 MG, 200- 125 MG

$0 (Tier 1)

PA; MO

PULMOZYME INHALATION SOLUTION 1 MG/ML

$0 (Tier 1)

PA BvD; MO

Mast Cell Stabilizers

cromolyn inhalation solution for nebulization 20 mg/2 ml

$0 (Tier 1)

PA BvD; MO

cromolyn oral concentrate 100 mg/5 ml $0 (Tier 1) NDS GASTROCROM ORAL CONCENTRATE 100 MG/5 ML

$0 (Tier 1)

Phosphodiesterase Inhibitors, Airways Disease

DALIRESP ORAL TABLET 500 MCG $0 (Tier 1) PA; MO theophylline oral solution 80 mg/15 ml $0 (Tier 1) MO theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg

$0 (Tier 1)

MO

104


DRUG NAME DRUG TIER REQUIREMENTS/LIMITS theophylline oral tablet extended release 24 hr 400 mg, 600 mg

$0 (Tier 1)

MO

Pulmonary Antihypertensives

ADCIRCA ORAL TABLET 20 MG $0 (Tier 1) PA; MO ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG

$0 (Tier 1)

PA; MO

LETAIRIS ORAL TABLET 10 MG, 5 MG $0 (Tier 1) PA; MO OPSUMIT ORAL TABLET 10 MG $0 (Tier 1) PA; MO REVATIO ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML

$0 (Tier 1)

PA

REVATIO ORAL TABLET 20 MG $0 (Tier 1) PA sildenafil (antihypertensive) oral tablet 20 mg $0 (Tier 1) PA; NDS; MO TRACLEER ORAL TABLET 125 MG, 62.5 MG

$0 (Tier 1)

PA; LA; MO

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML

$0 (Tier 1)

PA BvD; MO

Pulmonary Fibrosis Agents

ESBRIET ORAL CAPSULE 267 MG $0 (Tier 1) PA NSO; MO OFEV ORAL CAPSULE 100 MG, 150 MG $0 (Tier 1) PA; MO Respiratory Tract Agents, Other

acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %)

$0 (Tier 1)

PA BvD; NDS

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION

$0 (Tier 1)


ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG

$0 (Tier 1)

PA; MO

GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML (2 %)

$0 (Tier 1)

PA; MO

PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG

$0 (Tier 1)

PA; MO

STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION

$0 (Tier 1)

MO

ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG

$0 (Tier 1)

PA; MO

Respiratory Tract/ Pulmonary Agents


$0 (Tier 1)

MO


105

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION

$0 (Tier 1)

MO

COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION

$0 (Tier 1)

MO

ESBRIET ORAL CAPSULE 267 MG $0 (Tier 1) PA NSO; MO ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml

$0 (Tier 1)

PA BvD; MO

OFEV ORAL CAPSULE 100 MG, 150 MG $0 (Tier 1) PA; MO promethazine vc oral syrup 6.25-5 mg/5 ml $0 (Tier 1) NDS PULMOZYME INHALATION SOLUTION 1 MG/ML

$0 (Tier 1)

PA BvD; MO

SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION

$0 (Tier 1)


SYMBICORT INHALATION HFA AEROSOL INHALER 80-4.5 MCG/ACTUATION

$0 (Tier 1)

MO; QL (13.8 per 30 days)

XOLAIR SUBCUTANEOUS RECON SOLN 150 MG

$0 (Tier 1)

PA; MO

Skeletal Muscle Relaxants Skeletal Muscle Relaxants

carisoprodol oral tablet 350 mg


days) chlorzoxazone oral tablet 500 mg $0 (Tier 1) NDS cyclobenzaprine oral tablet 10 mg, 5 mg, 7.5 mg

$0 (Tier 1)

PA NSO; NDS

METAXALL ORAL TABLET 800 MG $0 (Tier 1) NDS metaxalone oral tablet 400 mg, 800 mg $0 (Tier 1) NDS methocarbamol oral tablet 500 mg, 750 mg $0 (Tier 1) PA NSO; NDS orphenadrine citrate oral tablet extended release 100 mg

$0 (Tier 1)

PA NSO; NDS

tizanidine oral tablet 2 mg, 4 mg $0 (Tier 1) MO Sleep Disorder Agents Gaba Receptor Modulators temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg

$0 (Tier 1)

NDS

zaleplon oral capsule 10 mg, 5 mg $0 (Tier 1) NDS zolpidem oral tablet 10 mg, 5 mg $0 (Tier 1)

106


DRUG NAME DRUG TIER REQUIREMENTS/LIMITS Sleep Disorders, Other

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg

$0 (Tier 1)

PA; MO

doxepin oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg

$0 (Tier 1)

PA NSO; MO

doxepin oral concentrate 10 mg/ml $0 (Tier 1) PA NSO; MO HETLIOZ ORAL CAPSULE 20 MG $0 (Tier 1) PA NSO; MO modafinil oral tablet 100 mg, 200 mg $0 (Tier 1) PA; MO ROZEREM ORAL TABLET 8 MG $0 (Tier 1) NDS; QL (30 per 30 days)

XYREM ORAL SOLUTION 500 MG/ML

$0 (Tier 1) PA; LA; NDS; QL (540 per 30

days)


107

108


Index Index Index Index

abacavir .............................. 44 ALREX .............................. 100 APLENZIN ........................... 19 abacavir-lamivudine ............ 44 ALUNBRIG .......................... 33 APOKYN ............................. 37 abacavir-lamivudine- amantadine hcl................ 36, 46 APRI .................................... 83 zidovudine ........................... 44 AMBISOME ......................... 24 APRISO ............................... 95 ABELCET ............................ 24 amcinonide .......................... 78 APTIOM .............................. 17 ABILIFY MAINTENA....... 19, 38 AMETHIA ............................ 83 APTIVUS ............................. 45 acamprosate ........................... 7 amikacin .................................. 8 ARALAST NP .................... 105 acarbose ............................. 50 amiloride ............................. 61 ARANELLE (28) .................. 83 acebutolol ............................ 57 amiloride-hydrochlorothiazide59 ARANESP (IN acetaminophen-codeine .......... 3 AMINOSYN 7 % WITH POLYSORBATE) ................ 55 acetazolamide ................. 61, 99 ELECTROLYTES ................ 70 ARCALYST ......................... 93 acetic acid ............................... 8 AMINOSYN 8.5 %- ARCAPTA NEOHALER .... 103 acetylcysteine ................... 105 ELECTROLYTES ................ 70 ARIMIDEX ........................... 32 acitretin ............................... 66 AMINOSYN II 10 % ............. 70 aripiprazole ......................19, 38 ACTHIB (PF) ....................... 93 AMINOSYN II 15 % ............. 70 ARISTADA .......................... 39 ACTIMMUNE ...................... 92 AMINOSYN II 8.5 % ............ 70 armodafinil ......................... 107 ACTONEL ........................... 97 AMINOSYN II 8.5 %- AROMASIN ......................... 32 acyclovir .............................. 42 ELECTROLYTES ................ 70 ASACOL HD ....................... 95 acyclovir sodium ................. 42 AMINOSYN-HBC 7% .......... 70 ASCOMP WITH CODEINE ... 3 ADACEL(TDAP AMINOSYN-PF 10 % .......... 70 ASHLYNA ........................... 83 ADOLESN/ADULT)(PF) ...... 93 AMINOSYN-PF 7 % aspirin-dipyridamole ............ 55 adapalene ........................... 66 (SULFITE-FREE) ................ 70 assure id insulin safety ........ 52 ADCIRCA .......................... 105 AMINOSYN-RF 5.2 % ......... 70 ASTAGRAF XL ................... 90 adderall ............................... 64 amiodarone ......................... 57 atazanavir ............................ 45 adefovir ............................... 40 AMITIZA .............................. 75 atenolol ............................... 57 ADEMPAS ........................ 105 amitriptyline ......................... 22 atenolol-chlorthalidone ........ 60 ADMELOG SOLOSTAR U- amitriptyline- atomoxetine ......................... 64 100 INSULIN ....................... 52 chlordiazepoxide ............. 19, 20 atorvastatin .......................... 62 ADMELOG U-100 INSULIN amlodipine ........................... 58 atovaquone ......................... 36 LISPRO ............................... 52 amlodipine-benazepril ......... 59 atovaquone-proguanil ......... 36 ADVAIR DISKUS.102, 103, 105 amlodipine-valsartan ........... 60 ATRIPLA ............................. 44 ADVAIR HFA.......102, 103, 106 ammonium lactate ............... 66 ATROVENT HFA .............. 102 AFEDITAB CR .................... 58 amoxapine .......................... 22 AUBRA ................................ 83 AFINITOR........................33, 90 amoxicillin ........................11, 12 AURYXIA ............................ 78 AFINITOR DISPERZ ........... 90 amoxicillin-pot clavulanate .. 12 AVANDIA ............................ 50 ALBENZA ............................ 35 amphotericin b ..................... 24 AVIANE ............................... 83 albuterol sulfate ................. 103 ampicillin ............................. 12 AVITA.............................. 35, 66 alclometasone ..................... 78 ampicillin sodium ................. 12 AVONEX ............................. 65 alcohol pads ............................ 8 ampicillin-sulbactam ............ 12 AVONEX (WITH ALBUMIN)..65 ALECENSA ......................... 33 AMPYRA ............................. 65 AZACTAM ........................... 11 alendronate ......................... 97 ANADROL-50 ...................... 81 AZASAN .............................. 90 alfuzosin .............................. 77 ANAFRANIL ........................ 22 AZASITE ............................. 12 ALINIA ................................. 35 anagrelide ........................... 54 azathioprine ......................... 90 allopurinol ............................ 26 anastrozole .......................... 32 azelastine ...................... 98, 101 ALOCRIL ............................. 98 ANGELIQ ............................ 83 AZELEX .............................. 66 ALORA ................................ 82 ANORO ELLIPTA .............. 105 azithromycin ........................ 12 alosetron ............................. 75 APIDRA SOLOSTAR U-100 AZOPT ................................ 99 ALPHAGAN P ..................... 99 INSULIN .............................. 52 aztreonam ........................... 11 alprazolam .......................... 47 APIDRA U-100 INSULIN ..... 52 bacitracin ............................... 8


109

Index

bacitracin-polymyxin b ......... 98 baclofen .............................. 40 BACTROBAN NASAL ........... 8 balsalazide .......................... 95 BALZIVA (28) ...................... 83 BANZEL .............................. 17 BARACLUDE ...................... 40 BASAGLAR KWIKPEN U- 100 INSULIN ....................... 52 bcg vaccine, live (pf) ........... 93 BECONASE AQ ................ 102 benazepril ........................... 56 benazepril- hydrochlorothiazide ............. 60 benztropine ......................... 36 betamethasone dipropionate .............................26, 27, 66, 78 betamethasone valerate ..27, 78 betamethasone, augmented .........................................27, 78 BETASERON ........................ 65 betaxolol.......................... 57, 99 bethanechol chloride ............. 77 BETIMOL .............................. 99 BETOPTIC S ......................... 99 bexarotene ............................ 35 BEXSERO ............................. 93 bicalutamide .......................... 31 BICILLIN L-A ......................... 12 BIKTARVY ............................ 43 BILTRICIDE .......................... 35 bimatoprost....................99, 100 bisoprolol fumarate ................ 57 bisoprolol- hydrochlorothiazide ............... 60 BIVIGAM ............................... 92 BLEPHAMIDE................. 27, 98 BLEPHAMIDE S.O.P.......27, 98 BLISOVI 24 FE ...................... 83 BLISOVI FE 1/20 (28) ........... 83 BOOSTRIX TDAP ................. 93 BOSULIF ............................... 33 BREO ELLIPTA ................... 103 BRIELLYN ............................. 83 BRILINTA........................ 55, 56 brimonidine............................ 99 BRISDELLE .......................... 21 BRIVIACT.............................. 15 bromocriptine ...................37, 88 BROVANA........................... 103

Index

budesonide........75, 83, 96, 102 bumetanide ......................... 61 buprenorphine hcl................5, 7 buprenorphine-naloxone ....... 7 bupropion hcl...................19, 20 bupropion hcl (smoking deter) ..................................... 7 buspirone ............................ 46 butalbital-acetaminophen- caff ........................................ 3 butorphanol tartrate ............... 6 BYDUREON ........................ 50 BYETTA .............................. 50 BYSTOLIC .......................... 57 cabergoline ......................... 88 CABOMETYX ...................... 33 calcipotriene .................... 66, 67 calcipotriene-betamethasone 67 calcitonin (salmon) .............. 97 calcitriol ............................... 97 calcium acetate ................... 78 CALQUENCE ...................... 33 CAMILA ............................... 87 CANASA ............................. 95 CANCIDAS ......................... 24 candesartan ........................ 56 candesartan- hydrochlorothiazid ............... 60 CAPRELSA ......................... 33 captopril .............................. 56 captopril-hydrochlorothiazide 60 CARAC ............................... 67 CARAFATE ......................... 76 CARBAGLU ........................ 68 carbamazepine ................17, 49 CARBATROL.................. 18, 49 carbidopa-levodopa ............. 37 carbidopa-levodopa- entacapone ......................... 36 carbinoxamine maleate ..... 101 CARIMUNE NF NANOFILTERED ................ 92 carisoprodol ...................... 106 carisoprodol-asa-codeine ...... 3 carisoprodol-aspirin ............... 3 carteolol .............................. 99 CARTIA XT ......................... 58 carvedilol ............................. 58 CASODEX .......................... 31 caspofungin ......................... 24

Index

CAYSTON..................... 11, 104 cefaclor .................................. 10 cefadroxil ............................... 10 cefazolin ................................ 10 cefdinir ................................... 10 cefepime ................................ 10 cefixime ................................. 10 cefotaxime ............................. 10 cefotetan ............................... 10 cefoxitin ................................. 10 cefpodoxime .......................... 10 cefprozil ................................. 10 ceftazidime ............................ 10 ceftriaxone ............................. 10 cefuroxime axetil ................... 10 cefuroxime sodium ................ 11 celecoxib ........................... 4, 28 CELEXA ................................ 21 CELONTIN ............................ 15 cephalexin ............................. 11 CERDELGA .......................... 76 cetirizine .............................. 101 cevimeline ............................. 66 CHANTIX ................................ 7 CHANTIX CONTINUING MONTH BOX .......................... 7 CHANTIX STARTING MONTH BOX .......................... 7 chlorhexidine gluconate ......... 66 chloroquine phosphate .......... 36 chlorothiazide ........................ 61 chlorpromazine ................23, 37 chlorthalidone ........................ 61 chlorzoxazone ..................... 106 CHOLESTYRAMINE LIGHT. 62 CIALIS ................................... 77 ciclopirox......................... 24, 25 cilostazol ............................... 56 cimetidine .............................. 75 cimetidine hcl ........................ 75 CIMZIA .................................. 90 CIMZIA POWDER FOR RECONST ............................. 90 CINRYZE .............................. 90 CIPRO HC ........................... 101 CIPRODEX ......................... 101 ciprofloxacin .......................... 13 ciprofloxacin (mixture) ........... 13 ciprofloxacin hcl ..................... 13 ciprofloxacin in 5 % dextrose .13

110


Index

Index

Index

citalopram ........................... 21 clopidogrel ........................... 56 DALIRESP ........................ 104 CLARAVIS .......................... 67 clorazepate dipotassium..16, 47 danazol ............................... 81 clarithromycin ...................... 13 clotrimazole ......................... 25 dantrolene ........................... 40 clemastine ......................... 101 clotrimazole-betamethasone . 67 dapsone .............................. 30 clindamycin hcl ........................ 8 clozapine ............................. 40 DAPTACEL (DTAP clindamycin in 5 % dextrose .... 8 CLOZARIL ........................... 40 PEDIATRIC) (PF) ................ 93 clindamycin palmitate hcl ........ 8 COARTEM .......................... 36 daptomycin ............................ 9 clindamycin phosphate ............ 9 codeine sulfate ........................ 6 DARAPRIM ......................... 36 clindamycin-benzoyl colchicine ............................ 26 DEBLITANE ........................ 83 peroxide .............................. 67 COLCRYS ........................... 26 DELESTROGEN ................. 82 CLINIMIX 5%/D15W colesevelam.................... 50, 62 DELYLA (28) ....................... 83 SULFITE FREE ................... 71 colestipol ............................. 62 DELZICOL.......................75, 95 CLINIMIX 5%/D25W colistin (colistimethate na). 9, 10 demeclocycline .................... 14 SULFITE-FREE .................. 71 COLOCORT ........................ 96 DEMSER ............................. 60 CLINIMIX 2.75%/D5W COMBIGAN ......................... 99 DENAVIR ............................ 42 SULFIT FREE ..................... 71 COMBIVENT RESPIMAT . 106 DEPAKENE...............16, 29, 49 CLINIMIX 4.25%/D10W COMBIVIR .......................... 44 DEPEN TITRATABS. 70, 77, 90 SULF FREE ........................ 71 COMETRIQ ......................... 33 DEPO-ESTRADIOL ............ 82 CLINIMIX 4.25%/D5W COMPLERA ........................ 43 DEPO-PROVERA ............... 87 SULFIT FREE ..................... 71 COMPRO ............................ 23 DEPO-SUBQ PROVERA CLINIMIX 4.25%-D20W CONSTULOSE ................... 75 104........................................ 87 SULF-FREE ........................ 71 COPAXONE ........................ 65 DESCOVY ........................... 44 CLINIMIX 4.25%-D25W CORDRAN TAPE LARGE desipramine ......................... 23 SULF-FREE ........................ 71 ROLL ................................... 79 desloratadine ..................... 101 CLINIMIX 5%- CORLANOR ........................ 59 desmopressin ...................... 81 D20W(SULFITE-FREE) ...... 71 cortisone ....................27, 79, 96 desogestrel-ethinyl estradiol..83 CLINIMIX E 2.75%/D10W CORTISPORIN ................... 67 desonide .............................. 79 SUL FREE .......................... 71 COTELLIC ........................... 33 desoximetasone .................. 79 CLINIMIX E 2.75%/D5W COUMADIN ......................... 54 desvenlafaxine .................... 21 SULF FREE ........................ 71 CREON ............................... 76 desvenlafaxine succinate .... 21 CLINIMIX E 4.25%/D10W CRIXIVAN ........................... 45 dexamethasone .........27, 79, 96 SUL FREE .......................... 71 cromolyn ........................98, 104 DEXAMETHASONE CLINIMIX E 4.25%/D25W CRYSELLE (28) .................. 83 INTENSOL................ 27, 79, 96 SUL FREE .......................... 71 CYCLAFEM 1/35 (28) ......... 83 dexmethylphenidate ............ 64 CLINIMIX E 4.25%/D5W CYCLAFEM 7/7/7 (28) ........ 83 dextroamphetamine ............ 64 SULF FREE ........................ 71 cyclobenzaprine ................ 106 dextroamphetamine- CLINIMIX E 5%/D15W cyclophosphamide .............. 30 amphetamine ...................... 64 SULFIT FREE ..................... 71 cyclosporine ........................ 90 dextrose 10 % and 0.2 % CLINIMIX E 5%/D20W cyclosporine modified .......... 90 nacl ..................................... 72 SULFIT FREE ..................... 72 cyproheptadine .................. 101 dextrose 10 % in water CLINIMIX E 5%/D25W CYSTAGON ........................ 76 (d10w) ................................. 72 SULFIT FREE ..................... 72 CYSTARAN ......................... 98 dextrose 5 % in water (d5w)..72 CLINISOL SF 15 % ............. 72 d10 %-0.45 % sodium dextrose 5%-0.2 % sod clobetasol........................ 78, 79 chloride ............................... 72 chloride ............................... 72 clobetasol-emollient ............ 79 d2.5 %-0.45 % sodium dextrose 5%-0.3 % CLODAN ............................. 79 chloride ............................... 72 sod.chloride ......................... 72 clomipramine ....................... 23 d5 % and 0.9 % sodium DIASTAT................... 15, 16, 47 clonazepam..................... 15, 47 chloride ............................... 72 DIASTAT ACUDIAL...15, 16, 47 clonidine .............................. 56 d5 %-0.45 % sodium chloride 72 diazepam...................15, 16, 47 clonidine hcl.....................56, 64 DAKLINZA ........................... 41 diazepam intensol..... 15, 16, 47


111

Index

Index

Index

diclofenac potassium.........4, 28 EDURANT ........................... 43 ERYTHROCIN (AS diclofenac sodium........4, 28, 67 efavirenz ............................. 43 STEARATE) ........................ 13 diclofenac-misoprostol ............ 4 EFUDEX ............................. 67 erythromycin ........................ 13 dicloxacillin .......................... 12 EGRIFTA ............................ 81 erythromycin ethylsuccinate .. 13 dicyclomine ......................... 74 ELIDEL............................ 67, 90 erythromycin with ethanol .... 13 didanosine ........................... 44 ELIGARD ............................ 89 erythromycin-benzoyl diflorasone .......................... 79 ELIGARD (3 MONTH) ......... 88 peroxide .............................. 67 diflunisal............................ 4, 28 ELIGARD (4 MONTH) ......... 88 ESBRIET..................... 105, 106 DIGITEK .............................. 59 ELIGARD (6 MONTH) ......... 88 escitalopram oxalate....... 21, 47 digoxin ................................. 59 ELIQUIS .............................. 54 ESGIC ................................... 3 dihydroergotamine .............. 29 ELMIRON ............................ 77 esomeprazole magnesium .. 76 DILANTIN ............................ 18 EMCYT ............................... 31 estazolam ............................ 65 DILANTIN EXTENDED ....... 18 EMEND ............................... 24 ESTRACE ........................... 82 DILANTIN INFATABS ......... 18 EMOQUETTE ..................... 83 estradiol ............................... 82 DILANTIN-125 .................... 18 EMSAM ............................... 21 estradiol valerate ............. 82, 84 diltiazem hcl ........................ 58 EMTRIVA ............................ 44 estradiol-norethindrone acet..84 DILT-XR .............................. 58 enalapril maleate ................. 57 ESTRING ............................ 82 DIOVAN .............................. 56 enalapril-hydrochlorothiazide 60 estropipate .......................... 82 DIPENTUM ......................... 95 ENBREL .............................. 90 ethambutol .......................... 30 diphenoxylate-atropine ........ 74 ENBREL SURECLICK ........ 90 ethosuximide ....................... 15 dipyridamole ........................ 56 ENDOCET ............................... 3 ethynodiol diac-eth estradiol..84 disopyramide phosphate ..... 57 ENGERIX-B (PF) ................ 93 etidronate disodium ............. 97 disulfiram ................................. 7 ENGERIX-B PEDIATRIC etodolac.............................4, 28 divalproex.................. 16, 29, 49 (PF) ..................................... 93 EVOTAZ .............................. 45 dofetilide .............................. 57 enoxaparin .......................... 54 EXELDERM ........................ 25 donepezil ............................. 18 ENPRESSE ......................... 83 exemestane ......................... 32 DOPTELET ......................... 55 entacapone ......................... 36 EXJADE .............................. 70 doripenem ........................... 11 entecavir ............................. 41 EXTAVIA ............................. 65 dorzolamide ........................ 99 ENTRESTO ......................... 56 ezetimibe ............................. 62 dorzolamide-timolol ............. 99 ENULOSE ........................... 75 FALMINA (28) ..................... 84 doxazosin ........................ 56, 77 ENVARSUS XR .................. 90 famciclovir ........................... 42 doxepin ....................23, 46, 107 EPCLUSA ........................... 41 famotidine ............................ 75 doxercalciferol................. 73, 97 epinastine ............................ 98 FANAPT .............................. 39 DOXY-100 ........................... 14 epinephrine ....................... 103 FARESTON ......................... 31 doxycycline hyclate... 14, 66, 67 EPIPEN 2-PAK .................. 103 FARXIGA ............................ 50 doxycycline monohydrate EPIPEN JR 2-PAK ............ 103 FARYDAK ........................... 32 ...................................14, 66, 67 EPITOL............................18, 49 FAZACLO ............................ 40 dronabinol ........................... 24 EPIVIR.............................41, 44 felbamate ............................ 17 drospirenone-ethinyl EPIVIR HBV ........................ 41 felodipine ............................. 58 estradiol .............................. 83 eplerenone .......................... 61 FEMARA ............................. 32 DROXIA .............................. 31 EPOGEN ............................. 55 FEMRING ............................ 82 DUAVEE..........................82, 88 eprosartan ........................... 56 fenofibrate ........................... 62 duloxetine .................. 21, 47, 65 EQUETRO.......................18, 49 fenofibrate micronized ......... 62 DURAMORPH (PF) ................. 5 ERAXIS(WATER DILUENT). 25 fenofibrate nanocrystallized ...62 DUREZOL ......................... 100 ergoloid ............................... 18 fenoprofen ......................... 4, 28 dutasteride .......................... 77 ERIVEDGE .......................... 33 fentanyl................................5, 6 DYRENIUM ......................... 61 ERLEADA ........................... 31 fentanyl citrate ..................... 5, 6 E.E.S. 400 ........................... 13 ERRIN ................................. 87 FERRIPROX ....................... 70 E.E.S. GRANULES ............. 13 ERY PADS .......................... 13 FETZIMA ............................. 21 econazole ............................ 25 ERYTHROCIN .................... 13 FINACEA ............................. 67

112


Index

Index

Index

finasteride ........................... 77 GAMMAPLEX (WITH HAVRIX (PF) ....................... 93 FIORINAL................................ 3 SORBITOL) ......................... 92 heparin (porcine) ................. 54 FIRAZYR ............................. 90 GAMUNEX-C ...................... 92 HEPATAMINE 8% ............... 72 FIRMAGON KIT W DILUENT GARDASIL 9 (PF) ............... 93 HETLIOZ ........................... 107 SYRINGE ............................ 89 GASTROCROM ................ 104 HEXALEN ........................... 30 flavoxate .............................. 77 gatifloxacin .......................... 13 HIBERIX (PF) ...................... 93 FLEBOGAMMA DIF ............ 92 GATTEX 30-VIAL ................ 74 HUMALOG KWIKPEN flecainide ............................. 57 gauze pad ........................... 52 INSULIN .............................. 52 FLOVENT DISKUS ........... 102 GAVILYTE-C ....................... 75 HUMALOG MIX 50-50 FLOVENT HFA ................. 102 GAVILYTE-G ....................... 75 INSULN U-100 .................... 52 fluconazole .......................... 25 GAVILYTE-N ....................... 75 HUMALOG MIX 50-50 fluconazole in nacl (iso-osm).25 gemfibrozil ........................... 62 KWIKPEN ............................ 52 flucytosine ........................... 25 GENERLAC ........................ 75 HUMALOG MIX 75-25 fludrocortisone .................... 79 GENGRAF .......................... 90 KWIKPEN ............................ 52 flunisolide .......................... 102 GENTAK ................................. 8 HUMALOG MIX 75-25(U- fluocinolone ......................... 79 gentamicin ............................... 8 100)INSULN ........................ 53 fluocinolone acetonide oil .... 79 gentamicin in nacl (iso-osm) .... 8 HUMALOG U-100 INSULIN.. 53 fluocinolone and shower cap.79 GENVOYA .......................... 43 HUMIRA .............................. 91 fluocinonide..................... 67, 79 GEODON........................ 39, 48 HUMIRA PEDIATRIC fluocinonide-e ...................... 79 GIANVI (28) ......................... 84 CROHN'S START........... 90, 91 fluorometholone ................ 100 GIAZO ................................. 75 HUMIRA PEN ...................... 91 fluorouracil .......................... 67 GILENYA ............................ 65 HUMIRA PEN CROHN'S- fluoxetine ......................... 20, 21 GILOTRIF ........................... 33 UC-HS START .................... 91 fluphenazine decanoate ...... 37 GLASSIA ........................... 105 HUMIRA PEN PSORIASIS- fluphenazine hcl.............. 37, 38 glatiramer ............................ 65 UVEITIS .............................. 91 flurbiprofen ........................ 4, 28 GLATOPA ........................... 65 HUMULIN 70/30 U-100 flurbiprofen sodium ............ 100 GLEOSTINE ........................ 32 KWIKPEN ............................ 53 flutamide ............................. 31 glimepiride ........................... 50 HUMULIN N NPH INSULIN fluticasone ............... 67, 79, 102 glipizide ............................... 50 KWIKPEN ............................ 53 fluticasone-salmeterol ....... 104 glipizide-metformin .............. 51 HUMULIN R U-500 (CONC) fluvastatin ............................ 62 GLUCAGEN HYPOKIT ....... 52 INSULIN .............................. 53 fluvoxamine ..................... 21, 22 GLUCAGON EMERGENCY HUMULIN R U-500 (CONC) FML FORTE ...................... 100 KIT (HUMAN) ...................... 52 KWIKPEN ............................ 53 FML S.O.P. ....................... 100 glyburide ............................. 50 hydralazine .......................... 63 fondaparinux ....................... 54 glyburide-metformin ............ 51 HYDREA ............................. 31 FORFIVO XL ....................... 20 glycopyrrolate ...................... 74 hydrochlorothiazide ............. 61 FORTEO ............................. 97 GLYSET .............................. 50 hydrocodone-acetaminophen FOSAMAX PLUS D ............. 97 granisetron hcl ..................... 24 .............................................3, 6 fosamprenavir ..................... 45 griseofulvin microsize .......... 25 hydrocodone-ibuprofen ......... 3 fosinopril .............................. 57 griseofulvin ultramicrosize ... 25 hydrocortisone ...........27, 80, 96 fosinopril-hydrochlorothiazide 60 guanfacine .......................... 64 hydrocortisone-acetic acid ...101 FREAMINE HBC 6.9 % ....... 70 guanidine ............................ 30 hydromorphone ..................... 6 furosemide .......................... 61 HALDOL .............................. 38 hydroxychloroquine ............. 36 FUZEON ............................. 45 HALDOL DECANOATE ...... 38 hydroxyurea ........................ 31 FYCOMPA .......................... 17 halobetasol propionate ........ 79 hydroxyzine hcl........23, 46, 101 gabapentin .......................... 16 HALOG ............................... 80 hydroxyzine pamoate GABITRIL ............................ 16 haloperidol .......................... 38 .................................23, 46, 101 galantamine ........................ 19 haloperidol decanoate ......... 38 ibandronate ......................... 97 GAMMAGARD LIQUID ....... 92 haloperidol lactate ............... 38 IBRANCE ............................ 32 GAMMAKED ....................... 92 HARVONI ............................ 41 ibuprofen ........................... 4, 28


113

Index

Index

Index

ibuprofen-oxycodone .........4, 28 JANUMET XR ..................... 51 lansoprazole ........................ 76 ICLUSIG .............................. 33 JANUVIA ............................. 50 lanthanum ........................... 78 IDHIFA ................................ 32 JENTADUETO................ 50, 51 LANTUS SOLOSTAR U-100 ILEVRO ............................. 100 JENTADUETO XR.......... 50, 51 INSULIN .............................. 53 imatinib ................................ 33 JINTELI ............................... 84 LANTUS U-100 INSULIN .... 53 IMBRUVICA ........................ 34 JOLIVETTE ......................... 87 LARIN 1.5/30 (21) ............... 84 imipenem-cilastatin ............. 11 JULEBER ............................ 84 LARIN 1/20 (21) .................. 84 imipramine hcl ..................... 23 JULUCA .............................. 44 LARIN FE 1.5/30 (28) .......... 84 imipramine pamoate ............ 23 JUNEL 1.5/30 (21) .............. 84 LARIN FE 1/20 (28) ............. 84 imiquimod ............................ 67 JUNEL 1/20 (21) ................. 84 latanoprost ........................ 100 IMOVAX RABIES VACCINE JUNEL FE 1.5/30 (28) ......... 84 LATUDA .............................. 39 (PF) ..................................... 94 JUNEL FE 1/20 (28) ............ 84 LAYOLIS FE ........................ 84 IMURAN .............................. 91 JUNEL FE 24 ...................... 84 LAZANDA .............................. 6 INCRELEX .......................... 81 JUXTAPID ........................... 62 LEENA 28 ........................... 85 indapamide ......................... 61 KALETRA ............................ 45 leflunomide .......................... 93 indomethacin ..................... 4, 28 KALYDECO ....................... 104 LENVIMA ............................ 34 INFANRIX (DTAP) (PF) ...... 94 KARIVA (28) ........................ 84 LESSINA ............................. 85 INLYTA ............................... 34 KELNOR 1/35 (28) .............. 84 LETAIRIS .......................... 105 insulin syringe-needle u-100 . 53 KERYDIN ............................ 67 letrozole ............................... 32 INTELENCE ........................ 43 ketoconazole ....................... 25 leucovorin calcium...........31, 35 INTRON A....................... 41, 42 ketoprofen ......................... 4, 28 LEUKERAN ......................... 30 INTROVALE ........................ 84 ketorolac....................4, 28, 100 LEUKINE ............................. 55 INVANZ ............................... 11 keveyis ................................ 61 leuprolide ............................. 89 INVEGA SUSTENNA .......... 39 KHEDEZLA ......................... 22 levalbuterol hcl .................. 104 INVIRASE ........................... 45 KIMIDESS (28) .................... 84 LEVEMIR FLEXTOUCH U- INVOKANA ......................... 50 KINERET ............................ 91 100 INSULN ........................ 53 IOPIDINE ............................ 99 KINRIX (PF) ........................ 94 LEVEMIR U-100 INSULIN ... 53 IPOL .................................... 94 KIONEX (WITH SORBITOL). 70 levetiracetam ....................... 15 ipratropium bromide .... 102, 103 KISQALI .............................. 33 levobunolol .......................... 99 ipratropium-albuterol ......... 106 KISQALI FEMARA CO- levocarnitine ........................ 72 irbesartan ............................ 56 PACK .................................. 32 levocarnitine (with sugar) .... 72 irbesartan- KLONOPIN......................16, 47 levocetirizine ..................... 101 hydrochlorothiazide ......... 60, 61 KLOR-CON 10................ 68, 73 levofloxacin ......................... 13 IRESSA ............................... 34 KLOR-CON 8.................. 68, 74 levofloxacin in d5w .............. 13 ISENTRESS ........................ 43 KLOR-CON M10............. 68, 74 LEVONEST (28) .................. 85 ISENTRESS HD .................. 43 KLOR-CON M15............. 69, 74 levonorgestrel-ethinyl estrad . 85 ISOLYTE-P IN 5 % KLOR-CON M20............. 69, 74 LEVORA-28 ........................ 85 DEXTROSE ........................ 72 KLOR-CON SPRINKLE...69, 74 levorphanol tartrate ............... 5 ISOLYTE-S ......................... 68 KORLYM ............................. 52 levothyroxine ....................... 88 isoniazid .............................. 30 K-TAB ................................. 69 LEVOXYL ............................ 88 isosorbide dinitrate .............. 63 KUVAN ................................ 76 LEXIVA ............................... 45 isosorbide mononitrate ........ 63 KYNAMRO .......................... 62 LIALDA ................................ 95 isradipine ............................. 58 l norgest/e.estradiol-e.estrad .84 lidocaine ................................ 7 ISTALOL ............................. 99 labetalol ............................... 58 lidocaine hcl.........................6, 7 itraconazole ......................... 25 LACRISERT ........................ 98 lidocaine-prilocaine ............... 7 ivermectin ............................ 35 lactulose .............................. 75 lindane ................................ 36 IXIARO (PF) ........................ 94 lamivudine ....................... 41, 44 linezolid ................................. 9 JAKAFI ................................ 34 lamivudine-zidovudine ......... 44 linezolid in dextrose 5% ........ 9 JANTOVEN ......................... 54 lamotrigine .................16, 17, 49 LINZESS ............................. 75 JANUMET ........................... 51 LANOXIN ............................ 59 liothyronine .......................... 88

114


Index

lisinopril ............................... 57 lisinopril-hydrochlorothiazide . 60 lithium carbonate .............................................. 50 lithium citrate .............................................. 50 LONSURF ........................... 31 loperamide .......................... 74 lopinavir-ritonavir ................. 45 lorazepam........................16, 47 LORCET (HYDROCODONE)..3 LORCET PLUS ................................................ 3 LORYNA (28) .............................................. 85 losartan ............................... 56 losartan-hydrochlorothiazide . 60 LOTEMAX ......................... 100 lovastatin ............................. 62 loxapine succinate .............................................. 38 LUCEMYRA .......................... 7 LUMIGAN .......................... 100 LUPRON DEPOT .............................................. 89 LUPRON DEPOT (3 MONTH) .............................. 89 LUPRON DEPOT (4 MONTH) .............................. 89 LUPRON DEPOT (6 MONTH) .............................. 89 LUTERA (28) .............................................. 85 LYNPARZA ......................... 32 LYRICA........................... 15, 65 LYRICA CR..................... 15, 65 LYSODREN ........................ 88 LYZA ................................... 87 magnesium sulfate .............................................. 69 malathion ............................ 36 maprotiline .......................... 20 MARLISSA................ 82, 85, 87 MARPLAN ........................... 21 MATULANE ........................ 30 MATZIM LA .............................................. 58 MAVYRET ........................... 41 MAXIDEX .......................... 100 meclizine ............................. 23

meclofenamate ..................4, 28 medroxyprogesterone ......... 87 mefenamic acid ................. 4, 28 mefloquine .......................... 36 MEGACE ES .............................................. 87 megestrol ............................ 87 MEKINIST ........................... 34 meloxicam......................... 4, 28 memantine .......................... 19

Index

MENACTRA (PF) .................. 94 MENEST ............................... 82 MENOSTAR .......................... 82 MENTAX ............................... 25 MENVEO A-C-Y-W-135-DIP (PF) .............................................. 94 meperidine .............................. 6 meprobamate ........................ 46 mercaptopurine ..................... 91 meropenem ......................... 11 mesalamine ......................... 96 MESNEX ............................... 32 MESTINON ........................... 30 MESTINON TIMESPAN ........ 30 METADATE ER ................... 64 metaproterenol .................. 104 METAXALL ....................... 106 metaxalone ........................ 106 metformin ........................ 50, 51 methadone .............................. 5 methazolamide ................ 61, 99 methenamine hippurate ........... 9 methimazole .......................... 89 methocarbamol ................... 106 methotrexate sodium ............. 91 methotrexate sodium (pf) ...... 91 methoxsalen .......................... 67 methscopolamine .................. 74 methyclothiazide ................... 61 methylphenidate hcl .............. 64 methylprednisolone... 27, 80, 96 metipranolol ........................... 99 metoclopramide hcl......... 23, 74 metolazone ............................ 61 metoprolol succinate ............. 58 metoprolol ta- hydrochlorothiaz .................... 60 metoprolol tartrate ................. 58 metronidazole .......................... 9 metronidazole in nacl (iso-os). 9 mexiletine .............................. 57 miconazole-3 ......................... 25 MICROGESTIN 1.5/30 (21)...85 MICROGESTIN 1/20 (21) ...... 85 MICROGESTIN FE 1.5/30 (28) .............................................. 85 midodrine .............................. 56 MIGERGOT ........................... 29 miglustat ................................ 76 MIMVEY ................................ 85

Index

MIMVEY LO ........................ 85 MINASTRIN 24 FE .............. 85 MINITRAN ........................... 63 MINIVELLE ......................... 82 minocycline ......................14, 66 minoxidil .............................. 63 MIRCERA ........................... 55 mirtazapine ......................... 20 misoprostol...................... 76, 81 M-M-R II (PF) ...................... 94 modafinil ............................ 107 MODERIBA ......................... 42 MODERIBA DOSE PACK ... 42 moexipril .............................. 57 moexipril-hydrochlorothiazide 60 mometasone .................. 80

MONONESSA (28) ............. 85 montelukast ....................... 102 morphine ............................. 5, 6 morphine concentrate ..........5, 6 moxifloxacin ........................ 14 moxifloxacin in nacl (iso- osm) .................................... 14 MULTAQ ............................. 57 mupirocin................................. 9 mupirocin calcium ................... 9 MYALEPT ........................... 81 MYCAMINE ......................... 25 mycophenolate mofetil ........ 91 mycophenolate sodium ....... 91 MYFORTIC ......................... 91 MYORISAN ......................... 67 MYRBETRIQ ....................... 77

nabumetone ...................... 4, 28 nadolol ................................ 58 nafcillin ................................ 12 naftifine ............................... 25 NAFTIN ............................... 25 naloxone .................................. 7 naltrexone ............................... 7 NAMENDA XR .................... 19 NAMZARIC ......................... 19 naproxen ..................... 4, 28, 29 naproxen sodium...............5, 29 naratriptan ........................... 29 NARCAN ................................. 7 NARDIL ............................... 21 NATACYN ........................... 25 nateglinide ........................... 51 NATPARA ........................... 97


115

NEBUPENT .......................... 36 NORLYROC ......................... 86 ésteres etílicos de ácidos NECON 0.5/35 (28) .............. 85 NORMOSOL-M IN 5 % omeprazol ............................ 76

NECON 7/7/7 (28) ................ 85 DEXTROSE ......................... 72 ondansetrón ......................... 24 nefazodona .......................... 20 NORMOSOL-R IN 5 % ondansetrón clorhidrato ........ 24 neomicina ................................ 8 DEXTROSE ......................... 72 ONFI ..................................... 16 neomicina-bacitracina-poli-hc..98 NORMOSOL-R PH 7.4 ......... 69 ONGLYZA ............................ 51 neomicina-bacitracina- NORPRAMIN ....................... 23 OPSUMIT ........................... 105 polimixina ............................. 98 NORTHERA ......................... 56 ORAP ................................... 38 neomicina-polimixina b- NORTREL 0.5/35 (28) .......... 86 ORENCIA ............................. 91 dexametasona ...................... 98 NORTREL 1/35 (21) ............. 86 ORFADIN ............................. 76 neomicina-polimixina-hc.98, 101 NORTREL 1/35 (28) ............. 86 ORKAMBI ........................... 104 NEORAL .............................. 91 NORTREL 7/7/7 (28) ............ 86 orfenadrina citrato .............. 106 NEPHRAMINE 5.4 % ........... 72 nortriptilina ............................ 23 ORSYTHIA ........................... 86 NERLYNX ............................ 34 NORVIR ............................... 46 oseltamivir ............................ 46 NEUAC ................................ 68 NOVOLIN 70/30 U-100 OSMOPREP ........................ 69 NEULASTA .......................... 55 INSULIN ............................... 53 OTEZLA ............................... 91 NEUPOGEN ......................... 55 NOVOLIN N NPH U-100 OTEZLA STARTER .............. 91 NEUPRO .............................. 37 INSULIN ............................... 53 oxacilina ............................... 12 NEVANAC .......................... 100 NOVOLIN R REGULAR U- oxandrolona ......................... 81 nevirapina ............................. 43 100 INSULN ......................... 53 oxaprozina...........................5,

NEXAVAR ............................ 34 NOVOLOG FLEXPEN U-100 oxazepam ............................. 46 niacina .................................. 62 INSULIN ............................... 53 oxcarbazepina ...................... 18 NIACOR ............................... 62 NOVOLOG MIX 70-30 U-100 OXISTAT .............................. 26 nicardipina ............................ 59 INSULN ................................ 54 OXSORALEN ULTRA .......... 68 NICOTROL.............................. 7 NOVOLOG MIX 70- OXTELLAR XR .................... 18 NICOTROL NS ........................ 7 30FLEXPEN U-100 .............. 54 cloruro de oxibutinina ........... 77 nifedipina .............................. 59 NOVOLOG PENFILL U-100 oxicodona........................... 5, 6 NIKKI (28) ............................ 85 INSULIN ............................... 54 oxicodona-acetaminofén ........ 3 nilutamida ............................. 31 NOVOLOG U-100 INSULIN oximorfona ............................. 6 nimodipina ............................ 59 ASPART ............................... 54 PACERONE ......................... 57 NINLARO ............................. 32 NOXAFIL .............................. 26 paliperidona .......................... 39 NITRO-BID ........................... 63 NUEDEXTA .......................... 65 PAMELOR ............................ 23 NITRO-DUR ......................... 63 NUPLAZID ........................... 39 PANRETIN ........................... 35 nitrofurantoína ......................... 9 NUTRILIPID ......................... 73 pantoprazol .......................... 76 nitrofurantoína macrocristales . 9 NUTROPIN AQ NUSPIN ...... 81 paricalcitol ............................ 97 nitrofurantoína

NYAMYC .............................. 26 PARNATE ............................ 21

cristales ................................... 9 nistatina ................................ 26 paromomicina ......................... 8 nitroglicerina ......................... 63 nistatina-triamcinolona ......... 68 paroxetina

NITROSTAT ......................... 63 NYSTOP .............................. 26 paroxetina nizatidina .............................. 75 OCTAGAM ........................... 92 mesilato (sínt. menop.) ......... 22 NORA-BE ............................. 85 octreótida acetato ................. 89 PASER ................................. 30 NORDITROPIN FLEXPRO... 81 ODEFSEY ............................ 44 PAXIL.............................. 22, 47 noretindrona-etinilestradiol-hierro

ODOMZO ............................. 34 PAXIL CR........................ 22, 47

noretindrona (anticonceptivo)87 OFEV.....................34, 105, 106 PEDIARIX (PF) .................... 94 noretindrona acetato ............ 87 ofloxacina ............................. 14 PEDVAX HIB (PF) ................ 94 noretindrona acetato-etinil OGESTREL (28) .................. 86 peg 3350-electrolitos ............ 75 estradiol ............................... 85 olanzapina....................... 39, 48 PEGANONE ......................... 18 noretindrona-e.estradiol- olanzapina-fluoxetina ........... 20 PEGASYS ............................ 42 hierro .................................... 85 olmesartán ........................... 56 PEGASYS PROCLICK ......... 42 norgestimato-etinilestradiol86 olopatadina ........................... 99 solución electrolítica de

polietilenglicol 76

Index Index Index

116

Index

Index

Index

pen needle, diabetic ............ 54 potassium chloride-d5- promethazine .................24, 101 penicillin g sodium ............... 12 0.3%nacl ............................. 73 promethazine vc ................ 106 penicillin v potassium .......... 12 potassium chloride-d5- PROMETHEGAN ................ 24 PENTAM ............................. 36 0.9%nacl ............................. 73 propafenone ........................ 57 PENTASA ........................... 96 potassium citrate ................. 78 proparacaine ....................... 98 pentoxifylline ....................... 59 PRADAXA ........................... 54 propranolol .......................... 58 PERFOROMIST ................ 104 PRALUENT PEN ................. 63 propranolol- perindopril erbumine ........... 57 pramipexole ......................... 37 hydrochlorothiazid ............... 60 PERIOGARD ...................... 66 prasugrel ............................. 56 propylthiouracil .................... 89 permethrin ........................... 36 pravastatin .......................... 62 PROQUAD (PF) .................. 94 perphenazine ...................23, 38 prazosin ...........................56, 77 PROSOL 20 % .................... 73 perphenazine-amitriptyline .. 20 PRED MILD...................27, 100 protriptyline .......................... 23 PEXEVA.......................... 22, 47 prednicarbate .................. 68, 80 PULMICORT ..................... 102 PHENADOZ ........................ 24 prednisolone ..............27, 80, 96 PULMICORT FLEXHALER. 102 phenelzine ........................... 21 prednisolone acetate PULMOZYME..............104, 106 phenobarbital ...................... 16 .................................27, 96, 100 PURIXAN ............................ 31 PHENYTEK ......................... 18 prednisolone sodium pyrazinamide ....................... 30 phenytoin ............................ 18 phosphate ..........27, 80, 96, 100 pyridostigmine bromide ....... 30 phenytoin sodium extended .. 18 prednisone .................27, 80, 96 QUADRACEL (PF) .............. 94 PICATO ............................... 68 PREDNISONE INTENSOL QUARTETTE ...................... 86 pilocarpine hcl................. 66, 99 ...................................27, 80, 96 QUASENSE ........................ 86 pimozide .............................. 38 PREMARIN ......................... 82 QUDEXY XR ....................... 17 PIMTREA (28) ..................... 86 PREMASOL 10 % ............... 73 quetiapine ..................20, 39, 48 pindolol ................................ 58 PREMASOL 6 % ................. 73 quinapril ............................... 57 pioglitazone ......................... 51 PREMPHASE ...................... 86 quinapril-hydrochlorothiazide 60 pioglitazone-glimepiride ...... 52 PRENATAL VITAMIN PLUS quinidine gluconate ............. 57 pioglitazone-metformin ........ 52 LOW IRON .......................... 73 quinidine sulfate .................. 57 piperacillin-tazobactam ....... 12 PREVIFEM .......................... 86 quinine sulfate ..................... 36 PIRMELLA .......................... 86 PREZCOBIX ....................... 46 RABAVERT (PF) ................. 94 piroxicam........................... 5, 29 PREZISTA ........................... 46 rabeprazole ......................... 76 PLENAMINE....................70, 73 PRIFTIN .............................. 30 raloxifene ............................. 88 podofilox .............................. 68 primaquine .......................... 36 ramipril ................................ 57 polyethylene glycol 3350 ..... 76 primidone ............................ 16 RANEXA ............................. 59 polymyxin b sulf-trimethoprim 98 PRIVIGEN ........................... 92 ranitidine hcl ........................ 75 POMALYST ........................ 31 PROAIR HFA .................... 104 RAPAMUNE ........................ 92 PORTIA ............................... 86 probenecid .......................... 26 rasagiline ............................. 37 potassium chlorid-d5- probenecid-colchicine ......... 26 RAVICTI .............................. 76 0.45%nacl ........................... 73 PROCALAMINE 3% ............ 73 REBETOL........................41, 42 potassium chloride .............. 69 prochlorperazine ................. 24 REBIF (WITH ALBUMIN) .... 65 potassium chloride in prochlorperazine maleate 24, 38 REBIF REBIDOSE .............. 65 0.9%nacl ............................. 69 PROCRIT ............................ 55 REBIF TITRATION PACK ... 66 potassium chloride in 5 % PROCTO-PAK .................... 80 RECLIPSEN (28) ................ 86 dex ...................................... 73 PROCTOSOL HC ............... 96 RECOMBIVAX HB (PF) ...... 94 potassium chloride in lr-d5 .. 73 PROCTOZONE-HC.........74, 80 RECTIV ............................... 63 potassium chloride in water...69 progesterone micronized ..... 88 REGRANEX ........................ 68 potassium chloride-0.45 % PROGLYCEM ..................... 52 RELENZA DISKHALER ...... 46 nacl ..................................... 69 PROGRAF .......................... 91 RELISTOR .......................... 74 potassium chloride-d5- PROLASTIN-C .................. 105 REMERON .......................... 20 0.2%nacl ............................. 73 PROLIA ............................... 97 REMERON SOLTAB ........... 20 PROMACTA ........................ 55 RENAGEL ........................... 78


117

Index

Index

Index

RENVELA ........................... 78 SETLAKIN ........................... 86 sumatriptan ......................... 30 repaglinide .......................... 51 sevelamer carbonate ........... 78 sumatriptan succinate ......... 30 REPATHA SURECLICK ...... 63 SHAROBEL ......................... 86 SUPRAX ............................. 11 REPATHA SYRINGE .......... 63 SHINGRIX (PF) ................... 94 SUPREP BOWEL PREP KIT 70 RESCRIPTOR .................... 43 SIGNIFOR ........................... 89 SURMONTIL ....................... 23 RESTASIS .......................... 98 sildenafil (antihypertensive).105 SUSTIVA ............................. 43 RETROVIR ......................... 44 SILENOR.........................23, 47 SUTENT .............................. 34 REVATIO .......................... 105 silver sulfadiazine ................ 14 SYLATRON..................... 32, 42 REVLIMID....................... 31, 32 SIMPONI......................... 92, 93 SYMBICORT ..................... 106 REXULTI ............................. 39 simvastatin .......................... 62 SYMBYAX ........................... 20 REYATAZ ........................... 46 sirolimus .............................. 92 SYMFI ................................. 44 RIBASPHERE................. 41, 42 SIRTURO ............................ 30 SYMFI LO ........................... 44 RIBASPHERE RIBAPAK .... 42 sodium chloride ................... 69 SYMLINPEN 120 ................ 51 ribavirin ............................41, 42 sodium chloride 0.45 % ....... 69 SYMLINPEN 60 .................. 51 RIDAURA ............................ 93 sodium chloride 0.9 % ......... 69 SYNAREL ........................... 89 rifabutin ............................... 30 sodium chloride 3 % ............ 69 SYNRIBO ............................ 32 rifampin ............................... 30 sodium chloride 5 % ............ 69 SYNTHROID ....................... 88 RIFATER ............................. 30 sodium lactate ..................... 73 SYPRINE ............................ 70 riluzole ................................. 65 sodium polystyrene sulfonate 70 TABLOID ............................. 31 rimantadine ......................... 46 SOLTAMOX ........................ 31 tacrolimus........................ 68, 92 risedronate .......................... 97 SOMATULINE DEPOT ....... 89 tafinlar ................................. 34 RISPERDAL CONSTA.... 39, 48 SOMAVERT ........................ 89 TAGRISSO .......................... 35 risperidone.................39, 40, 48 sotalol .................................. 57 tamoxifen ............................. 31 ritonavir ............................... 46 sotalol af .............................. 57 tamsulosin ........................... 77 rivastigmine ......................... 19 SOVALDI.........................41, 42 TARCEVA ........................... 35 rivastigmine tartrate ............. 19 SPIRIVA RESPIMAT ......... 103 TARGRETIN ....................... 35 rizatriptan ............................ 29 SPIRIVA WITH TARINA FE 1/20 (28) .......... 86 ropinirole ............................. 37 HANDIHALER ................... 103 TASIGNA ............................ 35 rosuvastatin ......................... 62 spironolactone ..................... 61 tazarotene ........................... 68 ROTARIX ............................ 94 spironolacton- TAZICEF ............................. 11 ROTATEQ VACCINE .......... 94 hydrochlorothiaz .................. 60 TAZORAC ........................... 68 ROWEEPRA ....................... 15 SPRINTEC (28) ................... 86 TAZTIA XT .......................... 59 ROZEREM ........................ 107 SPRITAM ............................ 15 TECFIDERA ........................ 66 RUBRACA .......................... 32 SPRYCEL ........................... 34 TECHNIVIE..................... 41, 42 RYDAPT ............................. 34 SRONYX ............................. 86 TEFLARO ............................ 11 SABRIL ............................... 16 SSD ..................................... 14 TEKTURNA ......................... 59 SANDIMMUNE ................... 92 stavudine ............................. 44 TEKTURNA HCT ................ 60 SANTYL .............................. 68 STIOLTO RESPIMAT ....... 105 telmisartan ........................... 56 SAPHRIS (BLACK STIVARGA .......................... 34 telmisartan- CHERRY)........................ 40, 48 streptomycin ............................ 8 hydrochlorothiazid ............... 60 SARAFEM ........................... 22 STRIBILD ............................ 43 temazepam ....................... 106 SAVELLA ............................ 65 SUCRAID ............................ 76 TENIVAC (PF) ..................... 95 scopolamine base ........... 24, 74 sucralfate ............................ 76 tenofovir disoproxil fumarate selegiline hcl ....................... 37 sulfacetamide sodium......14, 98 .........................................41, 44 selenium sulfide .................. 68 sulfacetamide sodium (acne) 14 TENORMIN ......................... 58 SELZENTRY ....................... 45 sulfadiazine ......................... 14 terazosin ..........................56, 77 SENSIPAR .......................... 97 sulfamethoxazole- terbinafine hcl ...................... 26 SEREVENT DISKUS ........ 104 trimethoprim ........................ 14 terbutaline ......................... 104 SEROQUEL XR........ 20, 40, 48 sulfasalazine ....................96, 97 terconazole .......................... 26 sertraline ..........................22, 48 sulindac............................. 5, 29 testosterone .....................81, 82

118


Index

Index

Index

testosterone cypionate ........ 81 triamcinolone acetonide VENCLEXTA STARTING testosterone enanthate ....... 81 ...................................28, 66, 80 PACK .................................. 32 tetanus,diphtheria tox ped(pf) 95 triamterene- venlafaxine ...................... 22, 48 tetanus-diphtheria toxoids-td . 95 hydrochlorothiazid ............... 60 VENTAVIS ........................ 105 tetrabenazine ...................... 65 triazolam ............................. 47 VENTOLIN HFA ................ 104 tetracycline .......................... 14 TRIDERM ............................ 80 verapamil ............................. 59 THALOMID ......................... 31 trifluoperazine ...................... 38 VERIPRED 20........... 28, 81, 96 theophylline................. 104, 105 trifluridine ............................ 42 VERSACLOZ ...................... 40 thioridazine .......................... 38 trihexyphenidyl .................... 36 VERZENIO .......................... 33 thiothixene ........................... 38 TRI-LEGEST FE ................. 86 VICTOZA 3-PAK ................. 51 tiagabine ............................. 16 trimethoprim ............................ 9 VIDEX 4 GRAM PEDIATRIC.44 tigecycline ............................... 9 trimipramine ........................ 23 VIDEX EC ........................... 44 timolol maleate .......... 29, 58, 99 TRINESSA (28) ................... 86 vigabatrin ............................. 17 tinidazole ................................. 9 TRINTELLIX ........................ 22 VIGAMOX ........................... 14 TIVICAY .............................. 43 TRI-PREVIFEM (28) ........... 87 VIIBRYD .............................. 22 tizanidine ....................... 40, 106 TRI-SPRINTEC (28) ............ 87 VIMPAT ............................... 18 TOBRADEX ............................ 8 TRIUMEQ ............................ 45 VIRACEPT .......................... 46 tobramycin............................... 8 TRIVORA (28) ..................... 87 VIRAMUNE ......................... 43 tobramycin in 0.225 % nacl ..... 8 TRIZIVIR ............................. 44 VIRAMUNE XR ................... 43 tobramycin sulfate ................... 8 TROPHAMINE 10 % ........... 73 VIREAD........................... 41, 45 tobramycin-dexamethasone .. 98 TROPHAMINE 6% .............. 73 voriconazole ........................ 26 TOBREX ................................. 8 trospium .............................. 77 VOTRIENT .......................... 35 TOFRANIL .......................... 23 TRULICITY .......................... 51 VRAYLAR..................40, 48, 49 TOLAK ................................ 68 TRUMENBA ........................ 95 VYFEMLA (28) .................... 87 tolazamide ........................... 51 TRUVADA ........................... 44 VYVANSE ........................... 64 tolbutamide ......................... 51 TUDORZA PRESSAIR ...... 103 warfarin ............................... 54 tolcapone ............................ 36 TWINRIX (PF) ..................... 95 WELCHOL.......................51, 63 tolmetin ..............................5, 29 TYBOST .............................. 45 WELLBUTRIN SR ............... 20 tolterodine ........................... 77 TYGACIL ................................. 9 WYMZYA FE ....................... 87 topiramate ....................... 17, 29 TYKERB .............................. 35 XALKORI ............................. 35 torsemide ............................ 61 TYPHIM VI .......................... 95 XARELTO ........................... 54 TOUJEO SOLOSTAR U-300 ULORIC .............................. 26 XATMEP ............................. 92 INSULIN .............................. 54 UNITHROID ........................ 88 XELJANZ ............................ 92 TPN ELECTROLYTES ........ 73 UPTRAVI ............................ 59 XELJANZ XR ...................... 92 TRACLEER ....................... 105 ursodiol ............................... 74 XGEVA ................................ 97 TRADJENTA ....................... 51 valacyclovir .......................... 42 XIFAXAN..................... 9, 10, 75 tramadol .................................. 6 VALCHLOR..................... 31, 68 XOLAIR ............................. 106 tramadol-acetaminophen ........ 3 valganciclovir ....................... 40 XTANDI ............................... 31 trandolapril .......................... 57 valproic acid .............. 17, 29, 50 XULANE .............................. 87 tranexamic acid ................... 55 valproic acid (as sodium salt) XYREM ............................. 107 TRANSDERM-SCOP...... 24, 74 ...................................17, 29, 50 YF-VAX (PF) ....................... 95 tranylcypromine ................... 21 valsartan ............................. 56 YONSA ................................ 31 TRAVASOL 10 % ................ 73 valsartan-hydrochlorothiazide61 YUVAFEM ........................... 82 TRAVATAN Z .................... 100 vancomycin ............................. 9 zafirlukast .......................... 102 trazodone ............................ 20 VAQTA (PF) ........................ 95 zaleplon ............................. 106 TRECATOR ........................ 30 VARIVAX (PF) ..................... 95 ZARONTIN .......................... 15 TRELSTAR ......................... 89 VELIVET TRIPHASIC ZARXIO ............................... 55 tretinoin............................35, 68 REGIMEN (28) .................... 87 ZAVESCA ........................... 76 tretinoin (chemotherapy) ..... 35 VELTASSA .......................... 70 ZEJULA ............................... 32 TREXALL ............................ 92 VENCLEXTA ....................... 32 ZELAPAR ............................ 37


119

Index

ZELBORAF ........................... 35 ZEMAIRA ............................ 105 ZEMPLAR ............................. 97 ZENATANE ........................... 68 ZENCHENT (28) ................... 87 ZENPEP ................................ 77 ZERBAXA ............................. 11 ZERIT .................................... 45 ZIAGEN ................................. 45 zidovudine ............................. 45 ziprasidone hcl................ 40, 49 ZIRGAN .............................. 40 ZITHROMAX ......................... 13 ZOLINZA......................... 26, 33 ZOLOFT.......................... 22, 48 zolpidem .............................. 106 zonisamide ............................ 15 ZORTRESS........................... 92 ZOSTAVAX (PF) ................... 95 ZOVIA 1/35E (28) .................. 87 ZOVIRAX .............................. 43 ZYDELIG ............................... 33 ZYKADIA ............................... 35 ZYPREXA RELPREVV... 40, 49 ZYTIGA ................................. 31 ZYVOX .................................. 10

120

Yo

u can find information

on what the symbols and abbreviations on this table mean by going to page VI.

RiverSpring Star (HMO SNP): resumen de beneficios

RiverSpring Health Plans

1-800-771-0088 (TTY 711) De 8:00 a. m. a 8:00 p. m., los 7 días de la semana.

RiverSpringHealthPlans.org IMPORTANTE: Este documento contiene información sobre los fármacos que cubrimos en este plan. No hemos hecho cambios en este formulario integral desde el 08/2018. Identificación de presentación del archivo del formulario aprobado por el HPMS: 00019578; versión número 5.

riverspringmap.org · 2019 . formulario (lista de fármacos cubiertos) riverspring map (hmo snp)...

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