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Empire BlueCross BlueShield HealthPlus – New York Essential Plan - Lista de medicamentos

Índice

NOTA: No todos los medicamentos y no todos los planes están sujetos a autorización previa y límites de

cantidad. Para obtener más información con respecto a autorización previa o límites de cantidad, póngase

en contacto con Servicios al Miembro al número telefónico que aparece en su tarjeta de identificación.

Lista de abreviaturas

Nivel 1: Los medicamentos del nivel 1 tienen el costo compartido más bajo. Estos medicamentos ofrecen el

mayor valor comparados con otros que tratan las mismas condiciones.

Nivel 2: El nivel 2 tiene un costo compartido medio. Pueden ser medicamentos preferidos, con base en su

efectividad y valor. Algunos son medicamentos genéricos más nuevos y más caros.

Nivel 3: Los medicamentos del nivel 3 tienen un costo compartido más alto. Pueden costar más que otros

usados para tratar la misma condición. El nivel 3 también puede incluir medicamentos que fueron

recientemente aprobados por la FDA.

Nivel 4: Los medicamentos especializados del nivel 4 tienen el costo compartido más alto. Pueden costar más

que otros usados para tratar la misma condición. Los medicamentos especializados son usados para tratar

condiciones complejas y crónicas y pueden necesitar manejo especial.

DO: SE REQUIERE OPTIMIZACIÓN DE DOSIS. Normalmente involucra la conversión de dosificación de

dos veces al día a un programa de dosificación de una vez al día.

PA: SE REQUIERE AUTORIZACIÓN PREVIA. La autorización previa es el proceso de obtener aprobación

de beneficios antes de que se puedan abastecer ciertas recetas.

QL: LÍMITES DE CANTIDAD. Ciertos medicamentos recetados tienen límites de calidad específicos por

receta o por mes.

ST: SE REQUIERE TERAPIA ESCALONADA. Tal vez deba usar un medicamento antes de que los

beneficios para el uso de otro medicamento se puedan autorizar. Tenga en cuenta: Foradil y Serevent son

ediciones de seguridad que evitan la duplicación de terapia.

www.empireblue.com/nyessentialplan

Empire BlueCross BlueShield HealthPlus es el nombre comercial de HealthPlus HP, LLC, licenciatario

independiente de Blue Cross and Blue Shield Association.

1

https://www.empireblue.com/nyessentialplan/

WEBMENY-0030-15

Revised 1/1/2016

2

Lista de medicamentos del New York

Essential Plan

Nombre del medicamento Nivel Notas

ANALGESICS

acetaminophen-codeine

oral solution 120 mg-12

mg /5 ml (5 ml), 120-12

mg/5 ml

Tier 1 QL


oral solution 240 mg-24

mg /10 ml (10 ml), 300

mg-30 mg /12.5 ml

Tier 1


oral tablet 300-15 mg,

300-30 mg, 300-60 mg

Tier 1 QL

almotriptan malate oral

tablet

Tier 1 QL

ascomp with codeine

oral capsule

Tier 1

buprenorphine hcl

injection solution

Tier 2

buprenorphine hcl

injection syringe

Tier 2

butalbital compound

w/codeine oral capsule

Tier 1

butalbital-acetaminop-

caf-cod oral capsule

Tier 1 QL

butalbital-

acetaminophen-caff oral

capsule

Tier 1

butalbital-

acetaminophen-caff oral

tablet

Tier 1

butalbital-aspirin-

caffeine oral capsule

Tier 1

butorphanol tartrate

nasal spray,non-aerosol

Tier 1 PA; QL

CAMBIA ORAL

POWDER IN

PACKET

Tier 3 QL

capacet oral capsule Tier 1

codeine sulfate oral

tablet 15 mg, 30 mg, 60

mg

Tier 1 QL

diclofenac potassium

oral tablet

Tier 1

diflunisal oral tablet

dihydroergotamine nasal

spray,non-aerosol

diskets oral tablet,

soluble

Tier 1

ELMIRON ORAL

CAPSULE

Tier 3

EMBEDA ORAL

CAPSULE,ORAL

ONLY,EXT.REL

PELL

Tier 3

endocet oral tablet Tier 1 QL

endodan oral tablet Tier 1

fentanyl transdermal

patch 72 hour

Tier 2 ST; QL

FROVA ORAL

TABLET

Tier 3 ST; QL

hydrocodone-

acetaminophen oral

solution 10-325 mg/15

ml(15 ml), 2.5-167 mg/5

ml, 5-163

mg/7.5ml(7.5ml)

Tier 1 QL

hydrocodone-

acetaminophen oral

tablet 10-300 mg, 10-325

mg, 2.5-325 mg, 5-300

mg, 5-325 mg, 7.5-300

mg, 7.5-325 mg

Tier 1 QL

hydromorphone oral

liquid

Tier 1 QL

hydromorphone oral

tablet 2 mg, 4 mg, 8 mg

Tier 1 QL

hydromorphone oral

tablet extended release

24 hr 12 mg, 16 mg, 32

mg, 8 mg

Tier 2 ST; QL

hydromorphone rectal

suppository

Tier 1

ibuprofen-oxycodone

oral tablet

Tier 1 QL

isometh-dichloral-

acetaminophn oral

capsule

Tier 1

ketorolac injection

cartridge 15 mg/ml, 30

mg/ml

Tier 2 QL

Nombre del medicamento

diflunisal oral tablet

dihydroergotamine nasal

spray,non-aerosol

Nivel

Tier 1

Tier 2

Notas

WEBMENY-0030-15

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3

ketorolac injection

solution 15 mg/ml, 30

mg/ml, 30 mg/ml (1 ml)

Tier 2 QL

ketorolac intramuscular

solution

Tier 2 QL

ketorolac oral tablet Tier 1 QL

levorphanol tartrate oral

tablet

Tier 2

margesic oral capsule Tier 1

marten-tab oral tablet Tier 1

mefenamic acid oral

capsule

Tier 1

meperidine oral solution Tier 1 QL

meperidine oral tablet

100 mg, 50 mg

Tier 1 QL

meperitab oral tablet Tier 1 QL

methadone intensol oral

concentrate

Tier 1 QL

methadone oral

concentrate

Tier 1 QL

methadone oral solution

10 mg/5 ml, 5 mg/5 ml

Tier 1 QL

methadone oral tablet 10

mg, 5 mg

Tier 1 QL

methadone oral

tablet,soluble

Tier 1

methadose oral

concentrate

Tier 1 QL

methadose oral

tablet,soluble

Tier 1

morphine concentrate

oral solution

Tier 1 QL

morphine oral

capsule,extend.release

pellets

Tier 2 QL

morphine oral solution

10 mg/5 ml, 20 mg/5 ml

Tier 1 QL

morphine oral tablet 15

mg, 30 mg

Tier 1 QL

morphine oral tablet

extended release 100 mg,

15 mg, 200 mg, 30 mg,

60 mg

Tier 2 QL


morphine rectal

suppository

Tier 1

nalbuphine injection

solution

Tier 2

naratriptan oral tablet Tier 1 QL

nodolor oral capsule Tier 1

NUCYNTA ER ORAL

TABLET EXTENDED

RELEASE 12 HR

Tier 3 ST; QL

NUCYNTA ORAL

TABLET 100 MG, 50

MG, 75 MG

Tier 3 QL

oxycodone oral capsule Tier 1 QL

oxycodone oral

concentrate

Tier 1 QL

oxycodone oral solution Tier 1 QL

oxycodone oral tablet 10

mg, 15 mg, 20 mg, 30

mg, 5 mg

Tier 1 QL

oxycodone-

acetaminophen oral

tablet

Tier 1 QL

oxycodone-aspirin oral

tablet

Tier 1 QL

OXYCONTIN ORAL

TABLET,ORAL

ONLY,EXT.REL.12

HR 10 MG, 15 MG, 20

MG, 30 MG, 40 MG, 60

MG, 80 MG

Tier 3 ST; QL

oxymorphone oral tablet

10 mg, 5 mg

Tier 1 QL

oxymorphone oral tablet

extended release 12 hr

10 mg, 15 mg, 20 mg, 30

mg, 40 mg, 5 mg, 7.5 mg

Tier 1 QL

RELPAX ORAL

TABLET

Tier 3 ST; QL

rizatriptan oral tablet Tier 1 QL

rizatriptan oral

tablet,disintegrating

Tier 1 QL

sumatriptan succinate

oral tablet

Tier 1 QL


subcutaneous cartridge

Tier 2 QL


WEBMENY-0030-15

Revised 1/1/2016

4


subcutaneous pen

injector

Tier 2 QL


subcutaneous solution

Tier 2 QL


subcutaneous syringe

Tier 2 QL

tramadol oral tablet Tier 1 QL

tramadol oral tablet


Tier 1 QL

tramadol oral tablet, er

multiphase 24 hr

Tier 1 QL

vicodin es oral tablet Tier 1 QL

vicodin hp oral tablet Tier 1 QL

vicodin oral tablet Tier 1 QL

zamicet oral solution Tier 1 QL

zebutal oral capsule Tier 2

ZIPSOR ORAL

CAPSULE

Tier 3

zolmitriptan oral tablet Tier 1 QL

zolmitriptan oral


Tier 1 QL


ANESTHETICS

lidocaine hcl mucous

membrane solution

Tier 1

lidocaine viscous

mucous membrane

solution

Tier 1

lidocaine-prilocaine

topical cream

Tier 1

lidocaine-prilocaine

topical kit

Tier 1

lta pre-attached

laryngotracheal solution

Tier 1

phenazopyridine oral

tablet

Tier 1

SYNERA TOPICAL

PATCH,

MEDICATED SELF-

HEATING

Tier 3

ANTIARTHRITICS

allopurinol oral tablet Tier 1

CALDOLOR

INTRAVENOUS

RECON SOLN

Tier 3

celecoxib oral capsule

100 mg, 200 mg, 400

mg, 50 mg

Tier 2 ST; QL

colchicine-probenecid

oral tablet

Tier 1

COLCRYS ORAL

TABLET

Tier 3 PA; QL

CUPRIMINE ORAL

CAPSULE

Tier 3

DAYPRO ORAL

TABLET

Tier 3

diclofenac sodium oral


24 hr

Tier 1

diclofenac sodium oral

tablet,delayed release

(dr/ec)

Tier 1

ENBREL

SUBCUTANEOUS

RECON SOLN

Tier 3 PA; QL

ENBREL

SUBCUTANEOUS

SYRINGE 25

MG/0.5ML (0.51), 50

MG/ML (0.98 ML)

Tier 3 PA; QL

ENBREL

SURECLICK

SUBCUTANEOUS

PEN INJECTOR

Tier 3 PA; QL

etodolac oral capsule Tier 1

etodolac oral tablet Tier 1

etodolac oral tablet


Tier 1

fenoprofen oral tablet Tier 1

flurbiprofen oral tablet Tier 1

HUMIRA PEDIATRIC

CROHN'S START

SUBCUTANEOUS

SYRINGE KIT

Tier 3 PA; QL

HUMIRA PEN

CROHN'S-UC-HS

START

SUBCUTANEOUS

PEN INJECTOR KIT

Tier 3 PA; QL


WEBMENY-0030-15

Revised 1/1/2016

5

HUMIRA PEN

PSORIASIS

STARTER

SUBCUTANEOUS

PEN INJECTOR KIT

Tier 3 PA; QL

HUMIRA PEN

SUBCUTANEOUS

PEN INJECTOR KIT

Tier 3 PA; QL

HUMIRA

SUBCUTANEOUS

SYRINGE KIT

Tier 3 PA; QL

ibuprofen oral

suspension

Tier 1

ibuprofen oral tablet Tier 1

indomethacin oral

capsule

Tier 1

indomethacin oral

capsule, extended release

Tier 1

ketoprofen oral capsule Tier 1

ketoprofen oral

capsule,ext rel. pellets 24

hr

Tier 1

KINERET

SUBCUTANEOUS

SYRINGE

Tier 3 PA

leflunomide oral tablet Tier 2

meclofenamate oral

capsule

Tier 1

meloxicam oral

suspension

Tier 1

meloxicam oral tablet Tier 1 QL

nabumetone oral tablet Tier 1

naproxen oral suspension Tier 1

naproxen oral tablet Tier 1

naproxen oral


(dr/ec)

Tier 1

naproxen sodium oral

tablet

Tier 1

ORENCIA (WITH

MALTOSE)

INTRAVENOUS

RECON SOLN

Tier 3 PA; QL


ORENCIA

SUBCUTANEOUS

SYRINGE

Tier 3 PA; QL

oxaprozin oral tablet Tier 1

piroxicam oral capsule Tier 1

probenecid oral tablet Tier 1

SIMPONI ARIA

INTRAVENOUS

SOLUTION

Tier 3 PA

SIMPONI

SUBCUTANEOUS

PEN INJECTOR

Tier 3 PA; QL

SIMPONI

SUBCUTANEOUS

SYRINGE

Tier 3 PA; QL

sulindac oral tablet Tier 1

tolmetin oral capsule Tier 1

tolmetin oral tablet Tier 1

ULORIC ORAL

TABLET

Tier 3 ST


ANTIASTHMATICS

acetylcysteine solution Tier 2

ADVAIR DISKUS

INHALATION

BLISTER WITH

DEVICE

Tier 2 QL

ADVAIR HFA

INHALATION HFA

AEROSOL INHALER

Tier 2 QL

albuterol sulfate

inhalation solution for

nebulization

Tier 1

albuterol sulfate oral

syrup

Tier 1

ASMANEX

TWISTHALER

INHALATION

AEROSOL POWDR

BREATH

ACTIVATED

Tier 2 QL

BROVANA

INHALATION

SOLUTION FOR

NEBULIZATION

Tier 3 QL

WEBMENY-0030-15

Revised 1/1/2016

6

budesonide inhalation

suspension for

nebulization 0.25 mg/2

ml, 0.5 mg/2 ml

Tier 1 QL

budesonide inhalation

suspension for

nebulization 1 mg/2 ml

Tier 1

cromolyn inhalation

solution for nebulization

Tier 1

DALIRESP ORAL

TABLET

Tier 3 QL

DULERA

INHALATION HFA

AEROSOL INHALER

Tier 2 QL

FLOVENT DISKUS

INHALATION

BLISTER WITH

DEVICE 100

MCG/ACTUATION,

250

MCG/ACTUATION,

50 MCG/ACTUATION

Tier 2 QL

FLOVENT HFA

INHALATION HFA

AEROSOL INHALER

110

MCG/ACTUATION,

220

MCG/ACTUATION,

44 MCG/ACTUATION

Tier 2 QL

ipratropium bromide

inhalation solution

Tier 1 QL

levalbuterol hcl

inhalation solution for

nebulization

Tier 2

metaproterenol oral

syrup

Tier 1

metaproterenol oral

tablet

Tier 1

montelukast oral

granules in packet

Tier 1 QL

montelukast oral tablet Tier 1 QL

montelukast oral

tablet,chewable

Tier 1 QL

PERFOROMIST

INHALATION

SOLUTION FOR

NEBULIZATION

Tier 3 QL


PROAIR HFA

INHALATION HFA

AEROSOL INHALER

Tier 2 QL

PROVENTIL HFA

INHALATION HFA

AEROSOL INHALER

Tier 3 QL

PULMICORT

FLEXHALER

INHALATION

AEROSOL POWDR

BREATH

ACTIVATED

Tier 2 QL

QVAR INHALATION

AEROSOL 40

MCG/ACTUATION,

80 MCG/ACTUATION

Tier 2 QL

SEREVENT DISKUS

INHALATION

BLISTER WITH

DEVICE

Tier 2 QL

SPIRIVA RESPIMAT

INHALATION MIST

1.25

MCG/ACTUATION

Tier 3

SPIRIVA RESPIMAT

INHALATION MIST

2.5

MCG/ACTUATION

Tier 3 QL

SPIRIVA WITH

HANDIHALER

INHALATION

CAPSULE,

W/INHALATION

DEVICE

Tier 3 QL

SYMBICORT

INHALATION HFA

AEROSOL INHALER

Tier 2 QL

terbutaline oral tablet Tier 1

theochron oral tablet


Tier 1

theophylline oral tablet

extended release

Tier 1

theophylline oral tablet


Tier 1

VENTOLIN HFA

INHALATION HFA

AEROSOL INHALER

Tier 3 QL


WEBMENY-0030-15

Revised 1/1/2016

7

XOPENEX HFA

INHALATION HFA

AEROSOL INHALER

Tier 3 QL

zafirlukast oral tablet Tier 1

ZYFLO CR ORAL

TABLET, ER

MULTIPHASE 12 HR

Tier 3 PA

ZYFLO ORAL

TABLET

Tier 3 PA


ANTIBIOTICS

ak-poly-bac ophthalmic

ointment

Tier 1

amoxicillin oral capsule Tier 1

amoxicillin oral

suspension for

reconstitution

Tier 1

amoxicillin oral tablet Tier 1

amoxicillin oral

tablet,chewable

Tier 1

amoxicillin-pot

clavulanate oral

suspension for

reconstitution

Tier 1

amoxicillin-pot

clavulanate oral tablet

Tier 1

amoxicillin-pot

clavulanate oral tablet


Tier 1

amoxicillin-pot

clavulanate oral

tablet,chewable

Tier 1

ampicillin oral capsule Tier 1

ampicillin oral

suspension for

reconstitution

Tier 1

avar topical cleanser Tier 1

avidoxy oral tablet Tier 1

azithromycin oral packet Tier 1 QL

azithromycin oral

suspension for

reconstitution 100 mg/5

ml, 200 mg/5 ml

Tier 1 QL

azithromycin oral tablet

250 mg, 500 mg, 600 mg

Tier 1 QL

bacitracin ophthalmic

ointment

Tier 1

bacitracin-polymyxin b

ophthalmic ointment

Tier 1

BESIVANCE

OPHTHALMIC

DROPS,SUSPENSION

Tier 3

bp 10-1 topical cleanser Tier 1

cefaclor oral capsule Tier 1

cefaclor oral suspension

for reconstitution

Tier 1

cefaclor oral tablet


Tier 1

cefadroxil oral capsule Tier 1

cefadroxil oral

suspension for

reconstitution

Tier 1

cefadroxil oral tablet Tier 1

cefazolin in dextrose

(iso-os) intravenous

piggyback

Tier 2

cefazolin injection recon

soln

Tier 2

cefazolin intravenous

recon soln

Tier 2

cefdinir oral capsule Tier 1

cefdinir oral suspension

for reconstitution

Tier 1

cefditoren pivoxil oral

tablet

Tier 1

cefotaxime injection

recon soln

Tier 2

cefpodoxime oral

suspension for

reconstitution

Tier 2

cefpodoxime oral tablet Tier 2

cefprozil oral suspension

for reconstitution

Tier 1

cefprozil oral tablet Tier 1

ceftibuten oral capsule Tier 2

ceftibuten oral

suspension for

reconstitution

Tier 2


WEBMENY-0030-15

Revised 1/1/2016

8

ceftriaxone in

dextrose,iso-os

intravenous piggyback

Tier 2

ceftriaxone injection

recon soln

Tier 2

ceftriaxone intravenous

recon soln

Tier 2

cefuroxime axetil oral

tablet

Tier 1

cephalexin oral capsule Tier 1

cephalexin oral

suspension for

reconstitution

Tier 1

cephalexin oral tablet Tier 1

chloramphenicol sod

succinate intravenous

recon soln

Tier 2

CIPRO HC OTIC

DROPS,SUSPENSION

Tier 3

CIPRODEX OTIC

DROPS,SUSPENSION

Tier 3 PA

ciprofloxacin (mixture)

oral tablet, er multiphase

24 hr 1,000 mg, 500 mg

Tier 1 QL

ciprofloxacin hcl

ophthalmic drops

Tier 1

ciprofloxacin hcl oral

tablet

Tier 1 QL

ciprofloxacin hcl otic

dropperette

Tier 1

ciprofloxacin in 5 %

dextrose intravenous

piggyback

Tier 2

ciprofloxacin lactate

intravenous solution

Tier 2

clarithromycin oral

suspension for

reconstitution

Tier 1

clarithromycin oral tablet Tier 1

clarithromycin oral tablet


Tier 1

cleansing wash topical

cleanser

Tier 1

CLINDACIN ETZ

TOPICAL KIT

Tier 3


clindacin etz topical

swab

Tier 1

clindacin p topical swab Tier 1

CLINDACIN PAC

TOPICAL KIT

Tier 3

clindamycin hcl oral

capsule

Tier 1

clindamycin palmitate

hcl oral recon soln

Tier 1

clindamycin pediatric

oral recon soln

Tier 1

clindamycin phosphate

topical foam

Tier 1


topical gel

Tier 1


topical lotion

Tier 1


topical solution

Tier 1


topical swab

Tier 1


vaginal cream

Tier 1

COLY-MYCIN S

OTIC

DROPS,SUSPENSION

Tier 3

CORTISPORIN

TOPICAL CREAM

Tier 3

CORTISPORIN

TOPICAL

OINTMENT

Tier 3

DAPSONE ORAL

TABLET

Tier 3

demeclocycline oral

tablet

Tier 2

dicloxacillin oral capsule Tier 1

DIFICID ORAL

TABLET

Tier 3 PA

doxycycline hyclate oral

capsule

Tier 1


tablet

Tier 1



(dr/ec)

Tier 1 PA


WEBMENY-0030-15

Revised 1/1/2016

9

doxycycline

monohydrate oral

capsule

Tier 1

doxycycline

monohydrate oral

suspension for

reconstitution

Tier 1

doxycycline

monohydrate oral tablet

Tier 1

e.e.s. 400 oral tablet Tier 1

ery pads topical swab Tier 1

erygel topical gel Tier 1

ery-tab oral


(dr/ec)

Tier 1

erythrocin (as stearate)

oral tablet

Tier 1

erythromycin

ethylsuccinate oral tablet

Tier 1

erythromycin ophthalmic

ointment

Tier 1

erythromycin oral

capsule,delayed

release(dr/ec)

Tier 1

erythromycin oral tablet Tier 1

erythromycin with

ethanol topical gel

Tier 1

erythromycin with

ethanol topical solution

Tier 1

erythromycin with

ethanol topical swab

Tier 1

erythromycin-benzoyl

peroxide topical gel

Tier 1

ethambutol oral tablet Tier 1

FACTIVE ORAL

TABLET

Tier 3 QL

garamycin ophthalmic

drops

Tier 1

gatifloxacin ophthalmic

drops

Tier 1

gentak ophthalmic

ointment

Tier 1

gentamicin ophthalmic

drops

Tier 1


gentamicin ophthalmic

ointment

Tier 1

isoniazid oral solution Tier 1

isoniazid oral tablet Tier 1

KETEK ORAL

TABLET

Tier 3

levofloxacin oral tablet Tier 1 QL

LINCOCIN

INJECTION

SOLUTION

Tier 3

linezolid oral tablet Tier 2 PA; QL

meropenem intravenous

recon soln

Tier 2

methenamine hippurate

oral tablet

Tier 2

methenamine mandelate

oral tablet

Tier 1

metronidazole oral

capsule

Tier 1

metronidazole oral tablet Tier 1

metronidazole vaginal

gel

Tier 1

minocycline oral capsule Tier 1

minocycline oral tablet Tier 1

minocycline oral tablet


Tier 1 PA

MORGIDOX 1X100

KIT

Tier 3

MORGIDOX 2X100

KIT

Tier 3

morgidox oral capsule Tier 1

mupirocin topical

ointment

Tier 1

neomycin oral tablet Tier 1

neomycin-bacitracin-

poly-hc ophthalmic

ointment

Tier 1

neomycin-bacitracin-

polymyxin ophthalmic

ointment

Tier 1

neomycin-polymyxin b-

dexameth ophthalmic

drops,suspension

Tier 1


WEBMENY-0030-15

Revised 1/1/2016

10

neomycin-polymyxin b-

dexameth ophthalmic

ointment

Tier 1

neomycin-polymyxin-

gramicidin ophthalmic

drops

Tier 1

neomycin-polymyxin-hc

ophthalmic

drops,suspension

Tier 1


otic drops,suspension

Tier 1


otic solution

Tier 1

neo-polycin hc

ophthalmic ointment

Tier 1

neo-polycin ophthalmic

ointment

Tier 1

nitrofurantoin

macrocrystal oral

capsule

Tier 1

nitrofurantoin

monohyd/m-cryst oral

capsule

Tier 1

nitrofurantoin oral

suspension

Tier 1

ofloxacin ophthalmic

drops

Tier 1

ofloxacin oral tablet Tier 1 QL

ofloxacin otic drops Tier 1

ORACEA ORAL

CAPSULE,IR &

DELAY

REL,BIPHASE

Tier 3

penicillin v potassium

oral recon soln

Tier 1

penicillin v potassium

oral tablet

Tier 1

piperacillin-tazobactam

intravenous recon soln

Tier 1

polycin ophthalmic

ointment

Tier 1

polymyxin b sulf-

trimethoprim ophthalmic

drops

Tier 1


PRED-G

OPHTHALMIC

DROPS,SUSPENSION

Tier 3

PRED-G S.O.P.

OPHTHALMIC

OINTMENT

Tier 3

PRIMSOL ORAL

SOLUTION

Tier 3

pyrazinamide oral tablet Tier 1

rifabutin oral capsule Tier 2

rifampin oral capsule Tier 1

RIFATER ORAL

TABLET

Tier 3

silver sulfadiazine

topical cream

Tier 1

ssd topical cream Tier 1

sss 10-5 topical cream Tier 1

sss 10-5 topical foam Tier 1

sulfacetamide sodium

ophthalmic drops

Tier 1


ophthalmic ointment

Tier 1

sulfacetamide sodium-

sulfur topical cleanser

Tier 1


sulfur topical cream

Tier 1


sulfur topical foam

Tier 1


sulfur topical lotion

Tier 1


sulfur topical pads,

medicated

Tier 1


sulfur topical suspension

Tier 1

sulfacetamide sod-sulfur-

urea topical cleanser

Tier 1

sulfacetamide-

prednisolone ophthalmic

drops

Tier 1

sulfacetamide-sulfur-

cleansr23 topical kit

Tier 1

sulfacleanse 8-4 topical

suspension

Tier 1


WEBMENY-0030-15

Revised 1/1/2016

11

sulfadiazine oral tablet Tier 2

sulfamethoxazole-

trimethoprim oral

suspension

Tier 1

sulfamethoxazole-

trimethoprim oral tablet

Tier 1

SULFAMYLON

TOPICAL CREAM

Tier 3

sulfatrim oral suspension Tier 1

SUPRAX ORAL

CAPSULE

Tier 3

SUPRAX ORAL

SUSPENSION FOR

RECONSTITUTION

Tier 3

tetracycline oral capsule Tier 1

THALOMID ORAL

CAPSULE

Tier 3 PA

thermazene topical

cream

Tier 1

tobramycin in 0.225 %

nacl inhalation solution

for nebulization

Tier 3

tobramycin ophthalmic

drops

Tier 1

tobramycin-

dexamethasone

ophthalmic

drops,suspension

Tier 1

trimethoprim oral tablet Tier 1

vancomycin oral capsule Tier 2 PA

vandazole vaginal gel Tier 1

VIBATIV

INTRAVENOUS

RECON SOLN

Tier 3

VIGAMOX

OPHTHALMIC

DROPS

Tier 3

zencia topical cleanser Tier 1

ZYVOX ORAL

SUSPENSION FOR

RECONSTITUTION

Tier 3 PA; QL


ANTICOAGULANTS

enoxaparin subcutaneous

solution

Tier 3 PA

enoxaparin subcutaneous

syringe

Tier 3 PA

fondaparinux

subcutaneous syringe

Tier 3 PA

FRAGMIN

SUBCUTANEOUS

SOLUTION

Tier 3 PA

FRAGMIN

SUBCUTANEOUS

SYRINGE

Tier 3 PA

hep flush-10 (pf)


Tier 2

heparin (porcine) in 5 %

dex intravenous

parenteral solution

Tier 2

heparin (porcine) in nacl

(pf) intravenous

parenteral solution

Tier 2

heparin (porcine)

injection cartridge

Tier 2

heparin (porcine)

injection solution

Tier 2

heparin flush intravenous

kit

Tier 2

heparin flush(porcine)-

0.9nacl intravenous kit

Tier 2

heparin lock flush

(porcine) intravenous

solution

Tier 2

heparin lock flush

(porcine) intravenous

syringe

Tier 2

heparin lock flush


Tier 2

heparin lock flush

intravenous syringe

Tier 2

heparin lock intravenous

solution

Tier 2

heparin

lockflush(porcine)(pf)

intravenous syringe

Tier 2

heparin(porcine) in

0.45% nacl intravenous

parenteral solution

Tier 2

heparin, porcine (pf)

injection solution

Tier 2


WEBMENY-0030-15

Revised 1/1/2016

12


injection syringe

Tier 2



Tier 2


intravenous syringe

Tier 2

jantoven oral tablet Tier 1

monoject prefill (pf)

intravenous syringe

Tier 2

monoject prefill

advanced (pf)

intravenous syringe

Tier 2

PRADAXA ORAL

CAPSULE

Tier 3 QL

warfarin oral tablet Tier 1

XARELTO ORAL

TABLET 10 MG, 15

MG, 20 MG

Tier 3 PA; QL

XARELTO ORAL

TABLETS,DOSE

PACK

Tier 3 PA


ANTIDOTES

depade oral tablet Tier 1

naltrexone oral tablet Tier 1

RELISTOR

SUBCUTANEOUS

SOLUTION

Tier 3 PA

RELISTOR

SUBCUTANEOUS

SYRINGE

Tier 3 PA

ANTIFUNGALS

CANCIDAS

INTRAVENOUS

RECON SOLN

Tier 3

CICLODAN KIT

TOPICAL COMBO

PACK

Tier 3

CICLODAN KIT

TOPICAL SOLUTION

Tier 3

ciclodan topical cream Tier 1

ciclodan topical solution Tier 1

ciclopirox topical cream Tier 1

ciclopirox topical gel Tier 1

ciclopirox topical

shampoo

Tier 1

ciclopirox topical

solution

Tier 1

ciclopirox topical

suspension

Tier 1

clotrimazole mucous

membrane troche

Tier 1

clotrimazole topical

cream

Tier 1

clotrimazole topical

solution

Tier 1

clotrimazole-

betamethasone topical

cream

Tier 1

clotrimazole-


lotion

Tier 1

econazole topical cream Tier 1

ERAXIS(WATER

DILUENT)

INTRAVENOUS

RECON SOLN

Tier 3

ERTACZO TOPICAL

CREAM

Tier 3

EXELDERM

TOPICAL CREAM

Tier 3

EXELDERM

TOPICAL SOLUTION

Tier 3

fluconazole oral

suspension for

reconstitution

Tier 1

fluconazole oral tablet Tier 1

flucytosine oral capsule Tier 1

griseofulvin microsize

oral suspension

Tier 1

griseofulvin microsize

oral tablet

Tier 1

griseofulvin

ultramicrosize oral tablet

Tier 1

itraconazole oral capsule Tier 2 PA

ketoconazole oral tablet Tier 1

ketoconazole topical

cream

Tier 1


WEBMENY-0030-15

Revised 1/1/2016

13


foam

Tier 1


shampoo

Tier 1

MENTAX TOPICAL

CREAM

Tier 3

miconazole-3 vaginal

suppository

Tier 1

NAFTIN TOPICAL

CREAM

Tier 3

NAFTIN TOPICAL

GEL

Tier 3

NATACYN

OPHTHALMIC

DROPS,SUSPENSION

Tier 3

nyamyc topical powder Tier 1

nystatin oral powder Tier 1

nystatin oral suspension Tier 1

nystatin oral tablet Tier 1

nystatin topical cream Tier 1

nystatin topical ointment Tier 1

nystatin topical powder Tier 1

nystatin-triamcinolone

topical cream

Tier 1

nystatin-triamcinolone

topical ointment

Tier 1

nystop topical powder Tier 1

OXISTAT TOPICAL

CREAM

Tier 3

OXISTAT TOPICAL

LOTION

Tier 3

terbinafine hcl oral tablet Tier 1 PA

terconazole vaginal

cream

Tier 1

terconazole vaginal

suppository

Tier 1


ANTIHISTAMINE AND DECONGESTANT

COMBINATION

promethazine vc oral

syrup

Tier 1

ANTIHISTAMINES

arbinoxa oral liquid Tier 1

arbinoxa oral tablet Tier 1

azelastine ophthalmic

drops

Tier 1 QL

BEPREVE

OPHTHALMIC

DROPS

Tier 3 PA; QL

carbinoxamine maleate

oral liquid

Tier 1

carbinoxamine maleate

oral tablet

Tier 1

cetirizine oral solution Tier 1 QL

clemastine oral tablet Tier 1

cyproheptadine oral

tablet

Tier 1

desloratadine oral tablet Tier 1 QL

desloratadine oral


Tier 1 QL

diphenhydramine hcl

injection solution

Tier 2

diphenhydramine hcl

injection syringe

Tier 2

diphenhydramine hcl

oral capsule

Tier 1

EMADINE

OPHTHALMIC

DROPS

Tier 3 PA; QL

epinastine ophthalmic

drops

Tier 1 QL

fexofenadine oral tablet Tier 1 QL

hydroxyzine hcl oral

tablet

Tier 1

hydroxyzine pamoate

oral capsule

Tier 1

LASTACAFT

OPHTHALMIC

DROPS

Tier 3 QL

PATADAY

OPHTHALMIC

DROPS

Tier 3 PA; QL

PATANOL

OPHTHALMIC

DROPS

Tier 3 PA; QL

promethazine oral syrup Tier 1

promethazine oral tablet Tier 1


WEBMENY-0030-15

Revised 1/1/2016

14


ANTIHYPERGLYCEMICS

acarbose oral tablet Tier 1

APIDRA SOLOSTAR

SUBCUTANEOUS

INSULIN PEN

Tier 3 ST

APIDRA

SUBCUTANEOUS

SOLUTION

Tier 3 ST

BYDUREON

SUBCUTANEOUS

PEN INJECTOR

Tier 3 ST; QL

BYDUREON

SUBCUTANEOUS

SUSPENSION,EXTEN

DED REL RECON

Tier 3 ST; QL

chlorpropamide oral

tablet

Tier 1

glimepiride oral tablet Tier 1

glipizide oral tablet Tier 1

glipizide oral tablet

extended release 24hr

Tier 1

glipizide-metformin oral

tablet

Tier 1

glyburide oral tablet Tier 1

glyburide-metformin oral

tablet

Tier 1

GLYSET ORAL

TABLET

Tier 3

HUMALOG

KWIKPEN

SUBCUTANEOUS

INSULIN PEN

Tier 2

HUMALOG MIX 50-

50 KWIKPEN

SUBCUTANEOUS

INSULIN PEN

Tier 2

HUMALOG MIX 50-

50 SUBCUTANEOUS

SUSPENSION

Tier 2

HUMALOG MIX 75-

25 KWIKPEN

SUBCUTANEOUS

INSULIN PEN

Tier 2

HUMALOG MIX 75-

25 SUBCUTANEOUS

SUSPENSION

Tier 2

HUMALOG

SUBCUTANEOUS

CARTRIDGE

Tier 2

HUMALOG

SUBCUTANEOUS

SOLUTION

Tier 2

HUMULIN 70/30

KWIKPEN

SUBCUTANEOUS

INSULIN PEN

Tier 2

HUMULIN 70/30

SUBCUTANEOUS

SUSPENSION

Tier 2

HUMULIN N

KWIKPEN

SUBCUTANEOUS

INSULIN PEN

Tier 2

HUMULIN N

SUBCUTANEOUS

SUSPENSION

Tier 2

HUMULIN R

INJECTION

SOLUTION

Tier 2

HUMULIN R U-500

(CONCENTRATED)

SUBCUTANEOUS

SOLUTION

Tier 2

JANUMET ORAL

TABLET

Tier 3 ST; QL

JANUMET XR ORAL

TABLET, ER

MULTIPHASE 24 HR

100-1,000 MG, 50-1,000

MG, 50-500 MG

Tier 3 ST; QL

JANUVIA ORAL

TABLET

Tier 3 ST; QL

JARDIANCE ORAL

TABLET

Tier 3 ST

LANTUS SOLOSTAR

SUBCUTANEOUS

INSULIN PEN

Tier 2

LANTUS

SUBCUTANEOUS

SOLUTION

Tier 2

LEVEMIR

FLEXTOUCH

SUBCUTANEOUS

INSULIN PEN

Tier 2


WEBMENY-0030-15

Revised 1/1/2016

15

LEVEMIR

SUBCUTANEOUS

SOLUTION

Tier 2

metformin oral tablet Tier 1

metformin oral tablet


Tier 1

metformin oral tablet


Tier 1

nateglinide oral tablet Tier 2 PA

NOVOLIN 70/30

SUBCUTANEOUS

SUSPENSION

Tier 2

NOVOLIN N

SUBCUTANEOUS

SUSPENSION

Tier 2

NOVOLIN R

INJECTION

SOLUTION

Tier 2

NOVOLOG FLEXPEN

SUBCUTANEOUS

INSULIN PEN

Tier 2

NOVOLOG MIX 70-30

FLEXPEN

SUBCUTANEOUS

INSULIN PEN

Tier 2

NOVOLOG MIX 70-30

SUBCUTANEOUS

SOLUTION

Tier 2

NOVOLOG PENFILL

SUBCUTANEOUS

CARTRIDGE

Tier 2

NOVOLOG

SUBCUTANEOUS

SOLUTION

Tier 2

ONGLYZA ORAL

TABLET 2.5 MG

Tier 3 ST; DO

ONGLYZA ORAL

TABLET 5 MG

Tier 3 ST; QL

pioglitazone oral tablet Tier 1 QL

repaglinide oral tablet Tier 2

SYMLINPEN 120

SUBCUTANEOUS

PEN INJECTOR

Tier 3 PA

SYMLINPEN 60

SUBCUTANEOUS

PEN INJECTOR

Tier 3 PA


tolazamide oral tablet Tier 1

tolbutamide oral tablet Tier 1

TRADJENTA ORAL

TABLET

Tier 3 ST; DO

VICTOZA 2-PAK

SUBCUTANEOUS

PEN INJECTOR

Tier 3 ST; QL

VICTOZA 3-PAK

SUBCUTANEOUS

PEN INJECTOR

Tier 3 ST; QL


ANTIINFECTIVES/MISCELLANEOUS

ALBENZA ORAL

TABLET

Tier 3

ALINIA ORAL

SUSPENSION FOR

RECONSTITUTION

Tier 3

ALINIA ORAL

TABLET

Tier 3

atovaquone oral

suspension

Tier 2

atovaquone-proguanil

oral tablet

Tier 1

BILTRICIDE ORAL

TABLET

Tier 3

chloroquine phosphate

oral tablet

Tier 1

COARTEM ORAL

TABLET

Tier 3

DARAPRIM ORAL

TABLET

Tier 3

hydroxychloroquine oral

tablet

Tier 1

ivermectin oral tablet Tier 1

mefloquine oral tablet Tier 1

paromomycin oral

capsule

Tier 1

PRIMAQUINE ORAL

TABLET

Tier 3

quinine sulfate oral

capsule

Tier 1 PA; QL

ANTIINFECTIVES

ARESTIN DENTAL

CARTRIDGE

Tier 3

WEBMENY-0030-15

Revised 1/1/2016

16


ANTINEOPLASTICS

AFINITOR DISPERZ

ORAL TABLET FOR

SUSPENSION

Tier 3 PA

AFINITOR ORAL

TABLET

Tier 3 PA

ALFERON N

INJECTION

SOLUTION

Tier 3

ALKERAN ORAL

TABLET

Tier 3

anastrozole oral tablet Tier 3 PA

bexarotene oral capsule Tier 3 PA; QL

bicalutamide oral tablet Tier 3

BOSULIF ORAL

TABLET

Tier 3 PA

capecitabine oral tablet Tier 3 PA

CAPRELSA ORAL

TABLET

Tier 3 PA

COMETRIQ ORAL

CAPSULE 100

MG/DAY(80 MG[1]-20

MG[1]), 140

MG/DAY(80 MG[1]-20

MG[3]), 60 MG/DAY

(20 MG [3]/DAY)

Tier 3 PA; QL

CYCLOPHOSPHAMI

DE ORAL CAPSULE

Tier 3

diclofenac sodium

topical gel

Tier 2 PA

EMCYT ORAL

CAPSULE

Tier 3 PA

ERIVEDGE ORAL

CAPSULE

Tier 3 PA

etoposide oral capsule Tier 3

exemestane oral tablet Tier 3 PA

FARESTON ORAL

TABLET

Tier 3

FIRMAGON KIT W

DILUENT SYRINGE

SUBCUTANEOUS

RECON SOLN

Tier 3 PA

FIRMAGON

SUBCUTANEOUS

RECON SOLN

Tier 3 PA

FLUOROPLEX

TOPICAL CREAM

Tier 3

fluorouracil topical

cream

Tier 1

fluorouracil topical

solution

Tier 1

flutamide oral capsule Tier 3

GILOTRIF ORAL

TABLET

Tier 3 QL

GLEEVEC ORAL

TABLET

Tier 3 PA

HEXALEN ORAL

CAPSULE

Tier 3

HYCAMTIN ORAL

CAPSULE

Tier 3

hydroxyurea oral capsule Tier 3

ICLUSIG ORAL

TABLET 15 MG, 45

MG

Tier 3 PA; QL

INLYTA ORAL

TABLET

Tier 3 PA

INTRON A

INJECTION RECON

SOLN

Tier 3 PA

INTRON A

INJECTION

SOLUTION

Tier 3 PA

IRESSA ORAL

TABLET

Tier 3

JAKAFI ORAL

TABLET

Tier 3 PA

letrozole oral tablet Tier 3

LEUKERAN ORAL

TABLET

Tier 3

leuprolide subcutaneous

kit

Tier 3 PA

LOMUSTINE ORAL

CAPSULE

Tier 3

LYSODREN ORAL

TABLET

Tier 3

MATULANE ORAL

CAPSULE

Tier 3

MEKINIST ORAL

TABLET 0.5 MG, 2

MG

Tier 3 PA; QL


WEBMENY-0030-15

Revised 1/1/2016

17

mercaptopurine oral

tablet

Tier 3

methotrexate sodium

oral tablet

Tier 3

mitoxantrone

intravenous concentrate

Tier 3

MYLERAN ORAL

TABLET

Tier 3

NEXAVAR ORAL

TABLET

Tier 3 PA

NILANDRON ORAL

TABLET

Tier 3

PANRETIN TOPICAL

GEL

Tier 3

POMALYST ORAL

CAPSULE 1 MG, 2

MG, 3 MG, 4 MG

Tier 3 QL

REVLIMID ORAL

CAPSULE

Tier 3 PA; QL

RITUXAN

INTRAVENOUS

CONCENTRATE

Tier 3 PA

SPRYCEL ORAL

TABLET

Tier 3 PA

STIVARGA ORAL

TABLET

Tier 3 PA

SUTENT ORAL

CAPSULE

Tier 3 PA

TABLOID ORAL

TABLET

Tier 3

TAFINLAR ORAL

CAPSULE

Tier 3

tamoxifen oral tablet Tier 3

TARCEVA ORAL

TABLET

Tier 3 PA

TARGRETIN

TOPICAL GEL

Tier 3 PA

TASIGNA ORAL

CAPSULE

Tier 3 PA

temozolomide oral

capsule

Tier 3 PA

TORISEL

INTRAVENOUS

RECON SOLN

Tier 3


TRELSTAR DEPOT

INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION

Tier 3 PA

TRELSTAR

INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION

Tier 3 PA

TRELSTAR

INTRAMUSCULAR

SYRINGE

Tier 3 PA

TRELSTAR LA

INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION

Tier 3 PA

tretinoin (chemotherapy)

oral capsule

Tier 3

TYKERB ORAL

TABLET

Tier 3 PA

VOTRIENT ORAL

TABLET

Tier 3 PA

XALKORI ORAL

CAPSULE

Tier 3 PA

XTANDI ORAL

CAPSULE

Tier 3 PA

ZANOSAR

INTRAVENOUS

RECON SOLN

Tier 3

ZELBORAF ORAL

TABLET

Tier 3 PA

ZOLINZA ORAL

CAPSULE

Tier 3 PA

ZYTIGA ORAL

TABLET

Tier 3 PA


ANTIPARKINSON DRUGS

amantadine hcl oral

capsule

Tier 1

amantadine hcl oral

solution

Tier 1

amantadine hcl oral

tablet

Tier 1

AZILECT ORAL

TABLET

Tier 3

benztropine oral tablet Tier 1

bromocriptine oral

capsule

Tier 1

WEBMENY-0030-15

Revised 1/1/2016

18

bromocriptine oral tablet Tier 1

carbidopa oral tablet Tier 2

carbidopa-levodopa oral

tablet

Tier 1



Tier 1



Tier 1

entacapone oral tablet Tier 2

pramipexole oral tablet Tier 1

ropinirole oral tablet Tier 1

ropinirole oral tablet


Tier 1

selegiline hcl oral

capsule

Tier 1

selegiline hcl oral tablet Tier 1

tolcapone oral tablet Tier 2

trihexyphenidyl oral

elixir

Tier 1

trihexyphenidyl oral

tablet

Tier 1


ANTIPLATELET DRUGS

anagrelide oral capsule Tier 3

aspirin-dipyridamole oral

capsule, er multiphase 12

hr

Tier 2

BRILINTA ORAL

TABLET 60 MG, 90

MG

Tier 3 QL

cilostazol oral tablet Tier 2

clopidogrel oral tablet

300 mg

Tier 1

clopidogrel oral tablet 75

mg

Tier 1 QL

dipyridamole oral tablet Tier 1

EFFIENT ORAL

TABLET 10 MG

Tier 3 QL

EFFIENT ORAL

TABLET 5 MG

Tier 3 DO

ticlopidine oral tablet Tier 1

ANTIVIRALS

abacavir oral tablet Tier 3

abacavir-lamivudine-

zidovudine oral tablet

Tier 3

acyclovir oral capsule Tier 1

acyclovir oral suspension Tier 1

acyclovir oral tablet Tier 1

adefovir oral tablet Tier 3

APTIVUS ORAL

CAPSULE

Tier 3

APTIVUS ORAL

SOLUTION

Tier 3

ATRIPLA ORAL

TABLET

Tier 3

BARACLUDE ORAL

SOLUTION

Tier 3 PA

CRIXIVAN ORAL

CAPSULE

Tier 3

DAKLINZA ORAL

TABLET

Tier 1 QL

didanosine oral

capsule,delayed

release(dr/ec)

Tier 3

EDURANT ORAL

TABLET

Tier 3

EMTRIVA ORAL

CAPSULE

Tier 3

EMTRIVA ORAL

SOLUTION

Tier 3

entecavir oral tablet Tier 3 PA

EPIVIR HBV ORAL

SOLUTION

Tier 3 PA

EPZICOM ORAL

TABLET

Tier 3

famciclovir oral tablet Tier 1

foscarnet intravenous

solution

Tier 2

FUZEON

SUBCUTANEOUS

RECON SOLN

Tier 3

ganciclovir sodium


Tier 3

HARVONI ORAL

TABLET

Tier 3 PA; QL


WEBMENY-0030-15

Revised 1/1/2016

19

INTELENCE ORAL

TABLET

Tier 3

INVIRASE ORAL

CAPSULE

Tier 3

INVIRASE ORAL

TABLET

Tier 3

ISENTRESS ORAL

TABLET

Tier 3

ISENTRESS ORAL

TABLET,CHEWABLE

Tier 3

KALETRA ORAL

SOLUTION

Tier 3

KALETRA ORAL

TABLET

Tier 3

lamivudine oral tablet Tier 3

lamivudine-zidovudine

oral tablet

Tier 3

LEXIVA ORAL

SUSPENSION

Tier 3

LEXIVA ORAL

TABLET

Tier 3

moderiba dose pack oral

tablets,dose pack

Tier 2

moderiba oral tablet Tier 2

nevirapine oral

suspension

Tier 3

nevirapine oral tablet Tier 3

NORVIR ORAL

CAPSULE

Tier 3

NORVIR ORAL

SOLUTION

Tier 3

NORVIR ORAL

TABLET

Tier 3

PEGASYS

PROCLICK

SUBCUTANEOUS

PEN INJECTOR

Tier 3 PA; QL

PEGASYS

SUBCUTANEOUS

SOLUTION

Tier 3 PA; QL

PEGASYS

SUBCUTANEOUS

SYRINGE

Tier 3 PA; QL


PEGINTRON

REDIPEN

SUBCUTANEOUS

PEN INJECTOR KIT

Tier 3 PA

PEGINTRON

SUBCUTANEOUS

KIT

Tier 3 PA

PREZISTA ORAL

SUSPENSION

Tier 3

PREZISTA ORAL

TABLET

Tier 3

RELENZA

DISKHALER

INHALATION

BLISTER WITH

DEVICE

Tier 2 QL

RESCRIPTOR ORAL

TABLET

Tier 3

RESCRIPTOR ORAL

TABLET,

DISPERSIBLE

Tier 3

REYATAZ ORAL

CAPSULE

Tier 3

ribasphere oral capsule Tier 3 PA

ribasphere oral tablet Tier 3 PA

ribasphere ribapak oral

tablets,dose pack

Tier 3 PA

ribavirin oral capsule Tier 3 PA

ribavirin oral tablet Tier 3 PA

rimantadine oral tablet Tier 1

SELZENTRY ORAL

TABLET

Tier 3

stavudine oral capsule Tier 3

stavudine oral recon soln Tier 3

SUSTIVA ORAL

CAPSULE

Tier 3

SUSTIVA ORAL

TABLET

Tier 3

TAMIFLU ORAL

CAPSULE 30 MG, 45

MG, 75 MG

Tier 2 QL

TAMIFLU ORAL

SUSPENSION FOR

RECONSTITUTION

Tier 2 QL


WEBMENY-0030-15

Revised 1/1/2016

20

trifluridine ophthalmic

drops

Tier 1

TRUVADA ORAL

TABLET

Tier 3

TYZEKA ORAL

TABLET

Tier 3 PA

valacyclovir oral tablet Tier 1

VEREGEN TOPICAL

OINTMENT

Tier 3

VIRACEPT ORAL

TABLET

Tier 3

VIREAD ORAL

TABLET

Tier 3 PA

zidovudine oral capsule Tier 3

zidovudine oral syrup Tier 3

zidovudine oral tablet Tier 3

ZIRGAN

OPHTHALMIC GEL

Tier 3


AUTONOMIC DRUGS

amphetamine salt combo

oral tablet

Tier 1 PA

bethanechol chloride oral

tablet

Tier 2

cevimeline oral capsule Tier 2

dextroamphetamine oral


Tier 1 PA


solution

Tier 1 PA


tablet

Tier 1 PA

dextroamphetamine-

amphetamine oral

capsule,extended release

24hr

Tier 1 PA

donepezil oral tablet Tier 1 QL

donepezil oral


Tier 1 QL

epinephrine injection

auto-injector

Tier 2

EPIPEN 2-PAK

INJECTION AUTO-

INJECTOR

Tier 2

EPIPEN JR 2-PAK

INJECTION AUTO-

INJECTOR

Tier 2

galantamine oral


hr 16 mg, 24 mg

Tier 2 QL

galantamine oral


hr 8 mg

Tier 2 DO

galantamine oral solution Tier 2 QL

galantamine oral tablet

12 mg, 4 mg

Tier 2 DO

galantamine oral tablet 8

mg

Tier 2 QL

guanidine oral tablet Tier 1

methamphetamine oral

tablet

Tier 1 PA

midodrine oral tablet Tier 1

phenoxybenzamine oral

capsule

Tier 2

pilocarpine hcl oral

tablet

Tier 2

procentra oral solution Tier 1 PA

rivastigmine tartrate oral

capsule 1.5 mg, 3 mg

Tier 2 DO

rivastigmine tartrate oral

capsule 4.5 mg, 6 mg

Tier 2 QL

zenzedi oral tablet Tier 1 PA


BIOLOGICALS

ACTHIB (PF)

INTRAMUSCULAR

RECON SOLN

Tier 3

ADACEL(TDAP

ADOLESN/ADULT)(P

F) INTRAMUSCULAR

SUSPENSION

Tier 3

ADACEL(TDAP

ADOLESN/ADULT)(P

F) INTRAMUSCULAR

SYRINGE

Tier 3

BOOSTRIX TDAP

INTRAMUSCULAR

SUSPENSION

Tier 3

WEBMENY-0030-15

Revised 1/1/2016

21

BOOSTRIX TDAP

INTRAMUSCULAR

SYRINGE

Tier 3

CERVARIX

VACCINE (PF)

INTRAMUSCULAR

SYRINGE

Tier 2

COMVAX (PF)

INTRAMUSCULAR

SUSPENSION

Tier 3

DAPTACEL (DTAP

PEDIATRIC) (PF)

INTRAMUSCULAR

SUSPENSION

Tier 3

ENGERIX-B (PF)

INTRAMUSCULAR

SUSPENSION

Tier 3

ENGERIX-B (PF)

INTRAMUSCULAR

SYRINGE

Tier 3

ENGERIX-B

PEDIATRIC (PF)

INTRAMUSCULAR

SUSPENSION

Tier 3

ENGERIX-B

PEDIATRIC (PF)

INTRAMUSCULAR

SYRINGE

Tier 3

FLUARIX QUAD

2015-2016 (PF)

INTRAMUSCULAR

SYRINGE

Tier 1 QL

FLUMIST QUAD

2015-2016 NASAL

NASAL SPRAY

SYRINGE

Tier 1

FLUZONE 2015-2016

INTRAMUSCULAR

SUSPENSION

Tier 1 QL

FLUZONE HIGH-

DOSE 2015-16 (PF)

INTRAMUSCULAR

SYRINGE

Tier 1 QL

FLUZONE

INTRADERM QUAD

2015-16

INTRADERMAL

SYRINGE

Tier 1 QL


FLUZONE QUAD

2015-2016 (PF)

INTRAMUSCULAR

SUSPENSION

Tier 1 QL

FLUZONE QUAD

2015-2016 (PF)

INTRAMUSCULAR

SYRINGE

Tier 1 QL

FLUZONE QUAD

2015-2016

INTRAMUSCULAR

SUSPENSION

Tier 1 QL

FLUZONE QUAD

PEDI 2015-16 (PF)

INTRAMUSCULAR

SYRINGE

Tier 1 QL

GAMASTAN S/D

INTRAMUSCULAR

SOLUTION

Tier 3

GARDASIL (PF)

INTRAMUSCULAR

SUSPENSION

Tier 2

GARDASIL (PF)

INTRAMUSCULAR

SYRINGE

Tier 2

GARDASIL 9 (PF)

INTRAMUSCULAR

SUSPENSION

Tier 2

GARDASIL 9 (PF)

INTRAMUSCULAR

SYRINGE

Tier 2

HAVRIX (PF)

INTRAMUSCULAR

SUSPENSION

Tier 3

HAVRIX (PF)

INTRAMUSCULAR

SYRINGE

Tier 3

IMOVAX RABIES

VACCINE (PF)

INTRAMUSCULAR

RECON SOLN

Tier 3

INFANRIX (DTAP)

(PF)

INTRAMUSCULAR

SUSPENSION

Tier 3

INFANRIX (DTAP)

(PF)

INTRAMUSCULAR

SYRINGE

Tier 3


WEBMENY-0030-15

Revised 1/1/2016

22

IPOL INJECTION

SUSPENSION

Tier 3

IXIARO (PF)

INTRAMUSCULAR

SYRINGE

Tier 3

KINRIX (PF)

INTRAMUSCULAR

SUSPENSION

Tier 3

KINRIX (PF)

INTRAMUSCULAR

SYRINGE

Tier 3

MENACTRA (PF)

INTRAMUSCULAR

SOLUTION

Tier 3

MENHIBRIX (PF)

INTRAMUSCULAR

RECON SOLN

Tier 3

MENOMUNE -

A/C/Y/W-135 (PF)

SUBCUTANEOUS

RECON SOLN

Tier 3

MENOMUNE -

A/C/Y/W-135

SUBCUTANEOUS

RECON SOLN

Tier 3

MENVEO A-C-Y-W-

135-DIP (PF)

INTRAMUSCULAR

KIT

Tier 3

M-M-R II (PF)

SUBCUTANEOUS

RECON SOLN

Tier 3

PEDIARIX (PF)

INTRAMUSCULAR

SYRINGE

Tier 3

PEDVAX HIB (PF)

INTRAMUSCULAR

SOLUTION

Tier 3

PENTACEL (PF)

INTRAMUSCULAR

KIT

Tier 3

PNEUMOVAX 23

INJECTION

SOLUTION

Tier 2

PNEUMOVAX 23

INJECTION

SYRINGE

Tier 2


PREVNAR 13 (PF)

INTRAMUSCULAR

SYRINGE

Tier 2

PROQUAD (PF)

SUBCUTANEOUS

SUSPENSION FOR

RECONSTITUTION

Tier 3

RABAVERT (PF)

INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION

Tier 3

RECOMBIVAX HB

(PF)

INTRAMUSCULAR

SUSPENSION

Tier 3

RECOMBIVAX HB

(PF)

INTRAMUSCULAR

SYRINGE

Tier 3

ROTARIX ORAL

SUSPENSION FOR

RECONSTITUTION

Tier 3

ROTATEQ VACCINE

ORAL SUSPENSION

Tier 3

TENIVAC (PF)

INTRAMUSCULAR

SUSPENSION

Tier 3

TENIVAC (PF)

INTRAMUSCULAR

SYRINGE

Tier 3

TETANUS,DIPHTHE

RIA TOX PED(PF)

INTRAMUSCULAR

SUSPENSION

Tier 3

TETANUS-

DIPHTHERIA

TOXOIDS-TD

INTRAMUSCULAR

SUSPENSION

Tier 3

TRUMENBA

INTRAMUSCULAR

SYRINGE

Tier 2

TWINRIX (PF)

INTRAMUSCULAR

SUSPENSION

Tier 3

TWINRIX (PF)

INTRAMUSCULAR

SYRINGE

Tier 3


WEBMENY-0030-15

Revised 1/1/2016

23

TYPHIM VI

INTRAMUSCULAR

SOLUTION

Tier 3

TYPHIM VI

INTRAMUSCULAR

SYRINGE

Tier 3

VAQTA (PF)

INTRAMUSCULAR

SUSPENSION

Tier 3

VAQTA (PF)

INTRAMUSCULAR

SYRINGE

Tier 3

VARIVAX (PF)

SUBCUTANEOUS

SUSPENSION FOR

RECONSTITUTION

Tier 3

VIVOTIF BERNA

VACCINE ORAL

CAPSULE,DELAYED

RELEASE(DR/EC)

Tier 2

YF-VAX (PF)

SUBCUTANEOUS

SUSPENSION FOR

RECONSTITUTION

Tier 3

ZOSTAVAX (PF)

SUBCUTANEOUS

SUSPENSION FOR

RECONSTITUTION

Tier 2


BLOOD

DROXIA ORAL

CAPSULE

Tier 3

pentoxifylline oral tablet

extended release

Tier 1

tranexamic acid


Tier 2

tranexamic acid oral

tablet

Tier 1

CARDIAC DRUGS

afeditab cr oral tablet

extended release 30 mg

Tier 1 DO

afeditab cr oral tablet


Tier 1 QL

amlodipine oral tablet 10

mg

Tier 1 QL

amlodipine oral tablet

2.5 mg, 5 mg

Tier 1 DO

cartia xt oral


24hr 120 mg, 180 mg

Tier 1 DO

cartia xt oral


24hr 240 mg, 300 mg

Tier 1 QL

digox oral tablet Tier 1

digoxin oral solution Tier 1

digoxin oral tablet Tier 1

diltiazem hcl oral


120 mg, 180 mg

Tier 1 DO

diltiazem hcl oral


240 mg, 300 mg, 360

mg, 420 mg

Tier 1 QL

diltiazem hcl oral

capsule,ext release

degradable 120 mg, 180

mg

Tier 1 DO

diltiazem hcl oral

capsule,ext release

degradable 240 mg

Tier 1 QL

diltiazem hcl oral


12 hr 120 mg, 90 mg

Tier 1 QL

diltiazem hcl oral


12 hr 60 mg

Tier 1 DO

diltiazem hcl oral


24hr 120 mg, 180 mg

Tier 1 DO

diltiazem hcl oral


24hr 240 mg, 300 mg,

360 mg

Tier 1 QL

diltiazem hcl oral tablet Tier 1

diltiazem hcl oral tablet


180 mg

Tier 1 DO

diltiazem hcl oral tablet


240 mg, 300 mg, 360

mg, 420 mg

Tier 1

dilt-xr oral capsule,ext

release degradable 120

mg, 180 mg

Tier 1 DO


WEBMENY-0030-15

Revised 1/1/2016

24

dilt-xr oral capsule,ext

release degradable 240

mg

Tier 1 QL

disopyramide phosphate

oral capsule

Tier 1

felodipine oral tablet


10 mg

Tier 1 QL

felodipine oral tablet


2.5 mg, 5 mg

Tier 1 DO

flecainide oral tablet Tier 2

isosorbide dinitrate oral

tablet

Tier 1

isosorbide dinitrate oral


Tier 1

isosorbide mononitrate

oral tablet

Tier 1

isosorbide mononitrate

oral tablet extended

release 24 hr

Tier 1

isradipine oral capsule Tier 1

LANOXIN ORAL

TABLET

Tier 3

matzim la oral tablet


180 mg

Tier 1 DO

matzim la oral tablet


240 mg, 300 mg, 360

mg, 420 mg

Tier 1 QL

mexiletine oral capsule Tier 2

MULTAQ ORAL

TABLET

Tier 3

nicardipine oral capsule Tier 1

nifedical xl oral tablet

extended release 24hr 30

mg

Tier 1 DO

nifedical xl oral tablet


mg

Tier 1 QL

nifedipine oral capsule Tier 1

nifedipine oral tablet


mg

Tier 1 DO




mg, 90 mg

Tier 1 QL



Tier 1 DO



90 mg

Tier 1 QL

nimodipine oral capsule Tier 2

nisoldipine oral tablet


17 mg, 20 mg, 8.5 mg

Tier 1 DO

nisoldipine oral tablet


25.5 mg, 30 mg, 34 mg,

40 mg

Tier 1 QL

nitro-bid transdermal

ointment

Tier 1

nitroglycerin oral


Tier 1

nitroglycerin translingual

aerosol,spray

Tier 2

nitroglycerin translingual

spray,non-aerosol

Tier 2

NITROSTAT

SUBLINGUAL

TABLET

Tier 2

nitro-time oral capsule,

extended release

Tier 1

procainamide injection

solution

Tier 2

propafenone oral


12 hr

Tier 2

propafenone oral tablet Tier 2

quinidine sulfate oral

tablet

Tier 1

quinidine sulfate oral


Tier 1

RANEXA ORAL

TABLET EXTENDED

RELEASE 12 HR

Tier 3

taztia xt oral capsule,


180 mg

Tier 1 DO


WEBMENY-0030-15

Revised 1/1/2016

25

taztia xt oral capsule,


300 mg, 360 mg

Tier 1 QL

TIKOSYN ORAL

CAPSULE

Tier 3

verapamil oral capsule,

24 hr er pellet ct 100 mg

Tier 1 DO

verapamil oral capsule,

24 hr er pellet ct 200 mg,

300 mg

Tier 1 QL

verapamil oral


hr

Tier 1

verapamil oral tablet 120

mg, 80 mg

Tier 1 QL

verapamil oral tablet 40

mg

Tier 1

verapamil oral tablet

extended release

Tier 1


CARDIOVASCULAR

acebutolol oral capsule Tier 1

ADCIRCA ORAL

TABLET

Tier 3 PA

amlodipine-atorvastatin

oral tablet 10-10 mg, 10-

20 mg, 10-40 mg, 10-80

mg, 5-80 mg

Tier 1 QL

amlodipine-atorvastatin

oral tablet 2.5-10 mg,

2.5-20 mg, 2.5-40 mg, 5-

10 mg, 5-20 mg, 5-40

mg

Tier 1 DO

amlodipine-benazepril

oral capsule

Tier 1

atenolol oral tablet Tier 1

atenolol-chlorthalidone

oral tablet

Tier 1

atorvastatin oral tablet 10

mg, 20 mg, 40 mg

Tier 1 DO

atorvastatin oral tablet 80

mg

Tier 1 QL

benazepril oral tablet Tier 1

benazepril-

hydrochlorothiazide oral

tablet

Tier 1

BENICAR HCT ORAL

TABLET 20-12.5 MG

Tier 3 DO

BENICAR HCT ORAL

TABLET 40-12.5 MG,

40-25 MG

Tier 3 QL

BENICAR ORAL

TABLET 20 MG

Tier 3 DO

BENICAR ORAL

TABLET 40 MG

Tier 3 QL

BENICAR ORAL

TABLET 5 MG

Tier 3 DO; QL

betaxolol oral tablet Tier 1

bisoprolol fumarate oral

tablet

Tier 1

bisoprolol-


tablet

Tier 1

BYSTOLIC ORAL

TABLET

Tier 3

candesartan oral tablet

16 mg, 32 mg

Tier 1 QL

candesartan oral tablet 4

mg, 8 mg

Tier 1 DO; QL

candesartan-

hydrochlorothiazid oral

tablet 16-12.5 mg

Tier 1 DO

candesartan-


tablet 32-12.5 mg

Tier 1 QL

candesartan-


tablet 32-25 mg

Tier 1

captopril oral tablet Tier 1

carvedilol oral tablet Tier 1

cholestyramine (with

sugar) oral powder

Tier 1

cholestyramine (with

sugar) oral powder in

packet

Tier 1

cholestyramine light oral

powder

Tier 1

cholestyramine light oral

powder in packet

Tier 1

clonidine hcl oral tablet Tier 1

colestipol oral granules Tier 1


WEBMENY-0030-15

Revised 1/1/2016

26

colestipol oral packet Tier 1

colestipol oral tablet Tier 1

CRESTOR ORAL

TABLET 10 MG, 20

MG, 5 MG

Tier 3 ST; DO

CRESTOR ORAL

TABLET 40 MG

Tier 3 ST; QL

doxazosin oral tablet Tier 1

EDARBI ORAL

TABLET 40 MG

Tier 3 DO

EDARBI ORAL

TABLET 80 MG

Tier 3 QL

enalapril maleate oral

tablet

Tier 1

enalapril-


tablet

Tier 1

eprosartan oral tablet Tier 1 QL

ergoloid oral tablet Tier 2

fenofibrate micronized

oral capsule

Tier 1

fenofibrate

nanocrystallized oral

tablet

Tier 1

fenofibrate oral tablet Tier 1

fenofibric acid (choline)

oral capsule,delayed

release(dr/ec)

Tier 1

fenofibric acid oral tablet Tier 1

fluvastatin oral capsule Tier 1 DO

fosinopril oral tablet Tier 1

fosinopril-


tablet

Tier 1

gemfibrozil oral tablet Tier 1

guanfacine oral tablet Tier 1

hydralazine injection

solution

Tier 2

hydralazine oral tablet Tier 1

indomethacin sodium


Tier 2

irbesartan oral tablet 150

mg, 75 mg

Tier 1 DO


irbesartan oral tablet 300

mg

Tier 1 QL

irbesartan-


tablet 150-12.5 mg

Tier 1 QL

irbesartan-


tablet 300-12.5 mg

Tier 1

labetalol oral tablet Tier 1

LETAIRIS ORAL

TABLET

Tier 3 PA

LEVATOL ORAL

TABLET

Tier 3

lisinopril oral tablet Tier 1

lisinopril-


tablet

Tier 1

LIVALO ORAL

TABLET 1 MG, 2 MG

Tier 3 ST; DO

LIVALO ORAL

TABLET 4 MG

Tier 3 ST; QL

losartan oral tablet 100

mg

Tier 1 QL

losartan oral tablet 25

mg, 50 mg

Tier 1 DO

losartan-


tablet 100-12.5 mg, 100-

25 mg

Tier 1 QL

losartan-


tablet 50-12.5 mg

Tier 1 DO

lovastatin oral tablet 10

mg, 20 mg

Tier 1 DO

lovastatin oral tablet 40

mg

Tier 1 QL

methyldopa oral tablet Tier 1

methyldopa-


tablet

Tier 1

metoprolol succinate oral


24 hr

Tier 1

metoprolol ta-

hydrochlorothiaz oral

tablet

Tier 1


WEBMENY-0030-15

Revised 1/1/2016

27

metoprolol tartrate oral

tablet

Tier 1

minoxidil oral tablet Tier 1

moexipril oral tablet Tier 1

moexipril-


tablet

Tier 1

nadolol oral tablet Tier 1

nadolol-

bendroflumethiazide oral

tablet

Tier 1

niacin oral tablet


1,000 mg, 500 mg, 750

mg

Tier 1 QL

perindopril erbumine

oral tablet

Tier 1

pindolol oral tablet Tier 1

pravastatin oral tablet 10

mg, 20 mg, 40 mg

Tier 1 DO

pravastatin oral tablet 80

mg

Tier 1 QL

prazosin oral capsule Tier 1

prevalite oral powder Tier 1

prevalite oral powder in

packet

Tier 1

propranolol oral


24 hr

Tier 1

propranolol oral solution Tier 1

propranolol oral tablet Tier 1

propranolol-


tablet

Tier 1

quinapril oral tablet Tier 1

quinapril-


tablet

Tier 1

ramipril oral capsule Tier 1

REMODULIN

INJECTION

SOLUTION

Tier 3 PA

sildenafil oral tablet Tier 3 PA


simvastatin oral tablet 10

mg, 20 mg, 40 mg, 5 mg

Tier 1 DO

simvastatin oral tablet 80

mg

Tier 1 PA; QL

sorine oral tablet Tier 2

sotalol af oral tablet Tier 2

sotalol oral tablet Tier 2

TEKTURNA ORAL

TABLET 150 MG

Tier 3 DO

TEKTURNA ORAL

TABLET 300 MG

Tier 3 QL

telmisartan oral tablet 20

mg, 40 mg

Tier 1 DO

telmisartan oral tablet 80

mg

Tier 1 QL

terazosin oral capsule Tier 1

timolol maleate oral

tablet

Tier 1

trandolapril oral tablet Tier 1

trandolapril-verapamil

oral tablet, ir & er,

biphasic 24hr

Tier 1

valsartan oral tablet 160

mg, 320 mg

Tier 1 QL

valsartan oral tablet 40

mg, 80 mg

Tier 1 DO; QL

valsartan-


tablet 160-12.5 mg, 80-

12.5 mg

Tier 1 DO

valsartan-


tablet 160-25 mg, 320-

12.5 mg, 320-25 mg

Tier 1 QL

VENTAVIS

INHALATION

SOLUTION FOR

NEBULIZATION

Tier 3 PA

WELCHOL ORAL

POWDER IN

PACKET

Tier 3

WELCHOL ORAL

TABLET

Tier 3

ZETIA ORAL

TABLET

Tier 3 PA; QL


WEBMENY-0030-15

Revised 1/1/2016

28


CNS DRUGS

AUBAGIO ORAL

TABLET

Tier 3 PA; QL

carbamazepine oral

capsule, er multiphase 12

hr

Tier 1

carbamazepine oral

suspension

Tier 1

carbamazepine oral

tablet

Tier 1

carbamazepine oral


12 hr

Tier 1

carbamazepine oral

tablet,chewable

Tier 1

CELONTIN ORAL

CAPSULE

Tier 3

clonazepam oral tablet Tier 1

clonazepam oral


Tier 1

divalproex oral capsule,

sprinkle

Tier 1

divalproex oral tablet


Tier 1

divalproex oral


(dr/ec)

Tier 1

epitol oral tablet Tier 1

ethosuximide oral

capsule

Tier 1

ethosuximide oral

solution

Tier 1

EXTAVIA

SUBCUTANEOUS

KIT

Tier 3 PA

EXTAVIA

SUBCUTANEOUS

RECON SOLN

Tier 3 PA

felbamate oral

suspension

Tier 1

felbamate oral tablet Tier 1

fosphenytoin injection

solution

Tier 2

gabapentin oral capsule Tier 2

gabapentin oral solution Tier 2

gabapentin oral tablet Tier 2

HORIZANT ORAL

TABLET EXTENDED

RELEASE

Tier 3 PA

lamotrigine oral tablet Tier 1

lamotrigine oral tablet,

chewable dispersible

Tier 1

levetiracetam oral

solution

Tier 2

levetiracetam oral tablet Tier 2

levetiracetam oral tablet


500 mg, 750 mg

Tier 2 PA; QL

LYRICA ORAL

CAPSULE 100 MG,

150 MG, 200 MG, 225

MG, 25 MG, 300 MG,

50 MG, 75 MG

Tier 3 PA; QL

LYRICA ORAL

SOLUTION

Tier 3 PA; QL

memantine oral tablet Tier 2

memantine oral

tablets,dose pack

Tier 2

NAMENDA ORAL

SOLUTION

Tier 3 QL

NUEDEXTA ORAL

CAPSULE

Tier 3

oxcarbazepine oral

suspension

Tier 1

oxcarbazepine oral tablet Tier 1

PEGANONE ORAL

TABLET

Tier 3

phenytoin sodium

extended oral capsule

Tier 1

primidone oral tablet Tier 1

REBIF (WITH

ALBUMIN)

SUBCUTANEOUS

SYRINGE

Tier 3 PA

REBIF REBIDOSE

SUBCUTANEOUS

PEN INJECTOR

Tier 3 PA


WEBMENY-0030-15

Revised 1/1/2016

29

REBIF TITRATION

PACK

SUBCUTANEOUS

SYRINGE

Tier 3 PA

riluzole oral tablet Tier 3

SABRIL ORAL

POWDER IN

PACKET

Tier 3

SABRIL ORAL

TABLET

Tier 3

tiagabine oral tablet Tier 2

topiramate oral capsule,

sprinkle

Tier 1 PA

topiramate oral tablet Tier 1 PA

valproic acid (as sodium

salt) oral solution

Tier 1

valproic acid oral

capsule

Tier 1

XENAZINE ORAL

TABLET

Tier 3 PA

zonisamide oral capsule Tier 2


COLONY STIMULATING FACTORS

ARANESP (IN

POLYSORBATE)

INJECTION

SOLUTION

Tier 3 PA

ARANESP (IN

POLYSORBATE)

INJECTION

SYRINGE

Tier 3 PA

LEUKINE

INJECTION RECON

SOLN

Tier 3 PA

MOZOBIL

SUBCUTANEOUS

SOLUTION

Tier 3 PA

NEULASTA

SUBCUTANEOUS

SYRINGE

Tier 3 PA; QL

NEUPOGEN

INJECTION

SOLUTION

Tier 3 PA

NEUPOGEN

INJECTION

SYRINGE

Tier 3 PA

PROCRIT

INJECTION

SOLUTION

Tier 3 PA

PROMACTA ORAL

TABLET

Tier 3 PA

ZARXIO INJECTION

SYRINGE

Tier 1


CONTRACEPTIVES

altavera (28) oral tablet Tier 1

alyacen 1/35 (28) oral

tablet

Tier 1

alyacen 7/7/7 (28) oral

tablet

Tier 1

amethia lo oral

tablets,dose pack,3

month

Tier 1

amethia oral tablets,dose

pack,3 month

Tier 1

amethyst oral tablet Tier 1

apri oral tablet Tier 1

aranelle (28) oral tablet Tier 1

ashlyna oral tablets,dose

pack,3 month

Tier 1

aubra oral tablet Tier 1

aviane oral tablet Tier 1

azurette (28) oral tablet Tier 1

balziva (28) oral tablet Tier 1

BEYAZ ORAL

TABLET

Tier 3

briellyn oral tablet Tier 1

camila oral tablet Tier 1

camrese lo oral

tablets,dose pack,3

month

Tier 1

camrese oral tablets,dose

pack,3 month

Tier 1

caziant (28) oral tablet Tier 1

chateal oral tablet Tier 1

cryselle (28) oral tablet Tier 1

cyclafem 1/35 (28) oral

tablet

Tier 1

WEBMENY-0030-15

Revised 1/1/2016

30

cyclafem 7/7/7 (28) oral

tablet

Tier 1

cyred oral tablet Tier 1

dasetta 1/35 (28) oral

tablet

Tier 1

dasetta 7/7/7 (28) oral

tablet

Tier 1

daysee oral tablets,dose

pack,3 month

Tier 1

deblitane oral tablet Tier 1

delyla (28) oral tablet Tier 1

desog-

e.estradiol/e.estradiol

oral tablet

Tier 1

desogestrel-ethinyl

estradiol oral tablet

Tier 1

drospirenone-ethinyl


Tier 1

elinest oral tablet Tier 1

ELLA ORAL TABLET Tier 3

emoquette oral tablet Tier 1

enpresse oral tablet Tier 1

enskyce oral tablet Tier 1

errin oral tablet Tier 1

estarylla oral tablet Tier 1

falmina (28) oral tablet Tier 1

gianvi (28) oral tablet Tier 1

gildagia oral tablet Tier 1

gildess 24 fe oral tablet Tier 1

gildess fe oral tablet Tier 1

gildess oral tablet Tier 1

heather oral tablet Tier 1

introvale oral

tablets,dose pack,3

month

Tier 1

jencycla oral tablet Tier 1

jolessa oral tablets,dose

pack,3 month

Tier 1

jolivette oral tablet Tier 1

junel 1.5/30 (21) oral

tablet

Tier 1


junel 1/20 (21) oral

tablet

Tier 1

junel fe 1.5/30 (28) oral

tablet

Tier 1

junel fe 1/20 (28) oral

tablet

Tier 1

junel fe 24 oral tablet Tier 1

kariva (28) oral tablet Tier 1

kelnor 1/35 (28) oral

tablet

Tier 1

kimidess (28) oral tablet Tier 1

kurvelo oral tablet Tier 1

l norgest/e.estradiol-

e.estrad oral tablets,dose

pack,3 month

Tier 1

larin 1.5/30 (21) oral

tablet

Tier 1

larin 1/20 (21) oral tablet Tier 1

larin 24 fe oral tablet Tier 1

larin fe oral tablet Tier 1

layolis fe oral

tablet,chewable

Tier 1

leena 28 oral tablet Tier 1

lessina oral tablet Tier 1

levonest (28) oral tablet Tier 1

levonorgestrel oral tablet Tier 1

levonorgestrel-ethinyl

estrad oral tablet

Tier 1

levonorgestrel-ethinyl

estrad oral tablets,dose

pack,3 month

Tier 1

LEVORA 0.15/30 (28)

ORAL TABLET

Tier 1

levora-28 oral tablet Tier 1

LO LOESTRIN FE

ORAL TABLET

Tier 3

lomedia 24 fe oral tablet Tier 1

loryna (28) oral tablet Tier 1

low-ogestrel (28) oral

tablet

Tier 1

lutera (28) oral tablet Tier 1


WEBMENY-0030-15

Revised 1/1/2016

31

lyza oral tablet Tier 1

marlissa oral tablet Tier 1

medroxyprogesterone

intramuscular suspension

Tier 1

medroxyprogesterone

intramuscular syringe

Tier 1

microgestin 1.5/30 (21)

oral tablet

Tier 1

microgestin 1/20 (21)

oral tablet

Tier 1

microgestin fe 1.5/30

(28) oral tablet

Tier 1

microgestin fe 1/20 (28)

oral tablet

Tier 1

MINASTRIN 24 FE

ORAL

TABLET,CHEWABLE

Tier 3

MIRENA

INTRAUTERINE

INTRAUTERINE

DEVICE

Tier 2

mono-linyah oral tablet Tier 1

mononessa (28) oral

tablet

Tier 1

my way oral tablet Tier 1

myzilra oral tablet Tier 1

NATAZIA ORAL

TABLET

Tier 3

necon 0.5/35 (28) oral

tablet

Tier 1

necon 1/35 (28) oral

tablet

Tier 1


tablet

Tier 1


tablet

Tier 1

necon 7/7/7 (28) oral

tablet

Tier 1

next choice one dose oral

tablet

Tier 1 QL

nikki (28) oral tablet Tier 1

nora-be oral tablet Tier 1


noreth-ethinyl estradiol-

iron oral tablet,chewable

Tier 1

norethindrone

(contraceptive) oral

tablet

Tier 1

norethindrone ac-eth


Tier 1

norethindrone-

e.estradiol-iron oral

tablet

Tier 1

norgestimate-ethinyl


Tier 1

norgestrel-ethinyl


Tier 1

norlyroc oral tablet Tier 1

nortrel 0.5/35 (28) oral

tablet

Tier 1

nortrel 1/35 (21) oral

tablet

Tier 1

nortrel 1/35 (28) oral

tablet

Tier 1

nortrel 7/7/7 (28) oral

tablet

Tier 1

NUVARING

VAGINAL RING

Tier 3

ocella oral tablet Tier 1

ogestrel (28) oral tablet Tier 1

orsythia oral tablet Tier 1

ORTHO TRI-

CYCLEN LO (28)

ORAL TABLET

Tier 3

PARAGARD T 380A

INTRAUTERINE

INTRAUTERINE

DEVICE

Tier 2

philith oral tablet Tier 1

pimtrea (28) oral tablet Tier 1

pirmella oral tablet Tier 1

portia oral tablet Tier 1

previfem oral tablet Tier 1

QUARTETTE ORAL

TABLETS,DOSE

PACK,3 MONTH

Tier 3


WEBMENY-0030-15

Revised 1/1/2016

32

quasense oral

tablets,dose pack,3

month

Tier 1

reclipsen (28) oral tablet Tier 1

SAFYRAL ORAL

TABLET

Tier 3

setlakin oral tablets,dose

pack,3 month

Tier 1

sharobel oral tablet Tier 1

sprintec (28) oral tablet Tier 1

sronyx oral tablet Tier 1

syeda oral tablet Tier 1

tarina fe oral tablet Tier 1

tilia fe oral tablet Tier 1

tri-estarylla oral tablet Tier 1

tri-legest fe oral tablet Tier 1

tri-linyah oral tablet Tier 1

trinessa (28) oral tablet Tier 1

tri-previfem (28) oral

tablet

Tier 1

tri-sprintec (28) oral

tablet

Tier 1

trivora (28) oral tablet Tier 1

velivet triphasic regimen

(28) oral tablet

Tier 1

vestura (28) oral tablet Tier 1

viorele (28) oral tablet Tier 1

vyfemla (28) oral tablet Tier 1

wera (28) oral tablet Tier 1

wymzya fe oral

tablet,chewable

Tier 1

xulane transdermal patch

weekly

Tier 1

zarah oral tablet Tier 1

zenchent (28) oral tablet Tier 1

zenchent fe oral

tablet,chewable

Tier 1

zeosa oral

tablet,chewable

Tier 1

zovia 1/35e (28) oral

tablet

Tier 1


zovia 1/50e (28) oral

tablet

Tier 1


COUGH/COLD PREPARATIONS

benzonatate oral capsule Tier 1

cheratussin ac oral liquid Tier 1

guaifenesin ac oral liquid Tier 1

iophen c-nr oral liquid Tier 1

promethazine vc-codeine

oral syrup

Tier 1

promethazine-codeine

oral syrup

Tier 1

promethazine-dm oral

syrup

Tier 1

promethazine-

phenyleph-codeine oral

syrup

Tier 1

DIAGNOSTIC

ACCU-CHEK

ACTIVE TEST STRIP

Tier 2 QL

ACCU-CHEK AVIVA

PLUS TEST STRP

STRIP

Tier 2 QL

ACCU-CHEK

COMPACT PLUS

TEST STRIP

Tier 2 QL

ACCU-CHEK

COMPACT TEST

STRIP

Tier 2 QL

ACCU-CHEK

SMARTVIEW TEST

STRIP STRIP

Tier 2 QL

ACCUTREND

GLUCOSE STRIP

Tier 2 QL

dipyridamole


Tier 2

GLUCAGEN

DIAGNOSTIC KIT

INJECTION RECON

SOLN

Tier 2

ONETOUCH ULTRA

TEST STRIP

Tier 2 QL

ONETOUCH VERIO

STRIP

Tier 2 QL

DIURETICS

WEBMENY-0030-15

Revised 1/1/2016

33

acetazolamide oral


Tier 1

acetazolamide oral tablet Tier 1

amiloride oral tablet Tier 1

AMMONIUM

CHLORIDE

INTRAVENOUS

SOLUTION

Tier 3

bumetanide oral tablet Tier 1

chlorothiazide oral tablet Tier 1

chlorthalidone oral tablet Tier 1

DYRENIUM ORAL

CAPSULE

Tier 3

EDECRIN ORAL

TABLET

Tier 3

eplerenone oral tablet Tier 2

furosemide oral solution Tier 1

furosemide oral tablet Tier 1


capsule

Tier 1


tablet

Tier 1

indapamide oral tablet Tier 1

methazolamide oral

tablet

Tier 1

methyclothiazide oral

tablet

Tier 1

SAMSCA ORAL

TABLET

Tier 3

spironolactone oral tablet Tier 1

torsemide oral tablet Tier 1

triamterene-


capsule

Tier 1

triamterene-


tablet

Tier 1


EENT PREPS

acetasol hc otic drops Tier 1

acetic acid otic solution Tier 1

acetic acid-aluminum

acetate otic drops

Tier 1

ALOCRIL

OPHTHALMIC

DROPS

Tier 3 PA; QL

ALOMIDE

OPHTHALMIC

DROPS

Tier 3 PA; QL

apraclonidine ophthalmic

drops

Tier 1

azelastine nasal

aerosol,spray

Tier 1 QL

AZOPT

OPHTHALMIC

DROPS,SUSPENSION

Tier 3

betaxolol ophthalmic

drops

Tier 1

bimatoprost ophthalmic

drops

Tier 2

brimonidine ophthalmic

drops

Tier 1

bromfenac ophthalmic

drops

Tier 2

carteolol ophthalmic

drops

Tier 1

COMBIGAN

OPHTHALMIC

DROPS

Tier 3

cromolyn ophthalmic

drops

Tier 1 QL

dexamethasone sodium

phosphate ophthalmic

drops

Tier 1

diclofenac sodium

ophthalmic drops

Tier 1

dorzolamide ophthalmic

drops

Tier 1

dorzolamide-timolol

ophthalmic drops

Tier 1

DUREZOL

OPHTHALMIC

DROPS

Tier 3 QL

flunisolide nasal

spray,non-aerosol

Tier 1 ST; QL

fluocinolone acetonide

oil otic drops

Tier 1


WEBMENY-0030-15

Revised 1/1/2016

34

fluorometholone

ophthalmic

drops,suspension

Tier 1

flurbiprofen sodium

ophthalmic drops

Tier 1

fluticasone nasal

spray,suspension

Tier 1 QL

FML S.O.P.

OPHTHALMIC

OINTMENT

Tier 3

hydrocortisone-acetic

acid otic drops

Tier 1

ketorolac ophthalmic

drops

Tier 1

LACRISERT

OPHTHALMIC

INSERT

Tier 3

latanoprost ophthalmic

drops

Tier 1

levobunolol ophthalmic

drops

Tier 1

LOTEMAX

OPHTHALMIC

DROPS,GEL

Tier 3

LOTEMAX

OPHTHALMIC

DROPS,SUSPENSION

Tier 3

LOTEMAX

OPHTHALMIC

OINTMENT

Tier 3

LUMIGAN

OPHTHALMIC

DROPS

Tier 3

metipranolol ophthalmic

drops

Tier 1

naphazoline ophthalmic

drops

Tier 1

NEVANAC

OPHTHALMIC

DROPS,SUSPENSION

Tier 3

olopatadine nasal

spray,non-aerosol

Tier 1 QL

OMNARIS NASAL

SPRAY,NON-

AEROSOL

Tier 3 ST; QL


PHOSPHOLINE

IODIDE

OPHTHALMIC

DROPS

Tier 3

pilocarpine hcl

ophthalmic drops

Tier 1

prednisolone acetate

ophthalmic

drops,suspension

Tier 1

prednisolone sodium

phosphate ophthalmic

drops

Tier 1

RESTASIS

OPHTHALMIC

DROPPERETTE

Tier 3

timolol maleate

ophthalmic drops

Tier 1

timolol maleate

ophthalmic gel forming

solution

Tier 1

TRAVATAN Z

OPHTHALMIC

DROPS

Tier 3

triamcinolone acetonide

nasal aerosol,spray

Tier 1 QL

tropicamide ophthalmic

drops

Tier 1

TYZINE NASAL

DROPS

Tier 3

TYZINE NASAL

SPRAY,NON-

AEROSOL

Tier 3

VEXOL

OPHTHALMIC

DROPS,SUSPENSION

Tier 3

ZIOPTAN (PF)

OPHTHALMIC

DROPPERETTE

Tier 3


ELECT/CALORIC/H2O

calcium acetate oral

tablet

Tier 2

denta 5000 plus dental

cream

Tier 1

dentagel dental gel Tier 1

WEBMENY-0030-15

Revised 1/1/2016

35

EFFER-K ORAL

TABLET,

EFFERVESCENT

Tier 3

eliphos oral tablet Tier 2 PA

fe c plus oral tablet Tier 1

fluoridex daily defense

dental gel

Tier 1

FLUORIDEX

SENSITIVITY

RELIEF DENTAL

GEL

Tier 3

fluoritab oral

tablet,chewable

Tier 1

FOSRENOL ORAL

POWDER IN

PACKET

Tier 3 PA

FOSRENOL ORAL

TABLET,CHEWABLE

Tier 3 PA

GLUCAGEN

HYPOKIT

INJECTION RECON

SOLN

Tier 2

ISOLYTE S PH 7.4

INTRAVENOUS

PARENTERAL

SOLUTION

Tier 3

ISOLYTE-S

INTRAVENOUS

PARENTERAL

SOLUTION

Tier 3

kionex oral powder Tier 1

kionex oral suspension Tier 1

klor-con 10 oral tablet

extended release

Tier 1

klor-con 8 oral tablet

extended release

Tier 1

klor-con m10 oral

tablet,er

particles/crystals

Tier 1

klor-con m15 oral

tablet,er

particles/crystals

Tier 1

klor-con m20 oral

tablet,er

particles/crystals

Tier 1


ludent fluoride oral

tablet,chewable

Tier 1

magnesium sulfate

injection syringe

Tier 2

NORMOSOL-R

INTRAVENOUS

PARENTERAL

SOLUTION

Tier 3

NORMOSOL-R PH 7.4

INTRAVENOUS

PARENTERAL

SOLUTION

Tier 3

NUTRAMINE ORAL

POWDER

Tier 3

PLASMA-LYTE 148

INTRAVENOUS

PARENTERAL

SOLUTION

Tier 3

PLASMA-LYTE A

INTRAVENOUS

PARENTERAL

SOLUTION

Tier 3

potassium chloride in

0.9%nacl intravenous

parenteral solution

Tier 2

potassium chloride oral


Tier 1



Tier 1


tablet,er

particles/crystals

Tier 1

potassium chloride-0.45

% nacl intravenous

parenteral solution

Tier 2

potassium citrate oral


Tier 1

PREVIDENT 5000

BOOSTER PLUS

DENTAL PASTE

Tier 3

PROGLYCEM ORAL

SUSPENSION

Tier 3

RENVELA ORAL

POWDER IN

PACKET

Tier 3 PA

RENVELA ORAL

TABLET

Tier 3 PA


WEBMENY-0030-15

Revised 1/1/2016

36

sf 5000 plus dental

cream

Tier 1

sf dental gel Tier 1

sodium chloride 0.45 %

intravenous parenteral

solution

Tier 2



Tier 2



solution

Tier 2



Tier 2

sodium chloride 3 %


solution

Tier 2

sodium chloride 5 %


solution

Tier 2

sodium chloride


solution

Tier 2

sodium fluoride dental

solution

Tier 1

sodium fluoride oral

drops

Tier 1

sodium fluoride oral

tablet,chewable

Tier 1

sodium polystyrene (sorb

free) oral suspension

Tier 1

sodium polystyrene

sulfonate oral powder

Tier 1

sodium polystyrene

sulfonate oral suspension

Tier 1

sodium polystyrene

sulfonate rectal enema

Tier 1

sps oral suspension Tier 1

sps rectal enema Tier 1


GASTROINTESTINAL

alosetron oral tablet Tier 2

ALOXI

INTRAVENOUS

SOLUTION

Tier 3

AMITIZA ORAL

CAPSULE

Tier 3

anaspaz oral


Tier 2

anucort-hc rectal

suppository

Tier 1

ANZEMET ORAL

TABLET 100 MG, 50

MG

Tier 3 QL

APRISO ORAL

CAPSULE,EXTENDE

D RELEASE 24HR

Tier 3

balsalazide oral capsule Tier 1

BUPHENYL ORAL

TABLET

Tier 3 PA

CANTIL ORAL

TABLET

Tier 3

carafate oral suspension Tier 1

CESAMET ORAL

CAPSULE

Tier 3

cimetidine hcl oral

solution

Tier 1

cimetidine oral tablet Tier 1

CIMZIA POWDER

FOR RECONST

SUBCUTANEOUS

KIT

Tier 3 PA; QL

CIMZIA STARTER

KIT

SUBCUTANEOUS

SYRINGE KIT

Tier 3 PA; QL

CIMZIA

SUBCUTANEOUS

SYRINGE KIT

Tier 3 PA; QL

COMPAZINE ORAL

TABLET

Tier 1

constulose oral solution Tier 1

DEXILANT ORAL

CAPSULE,BIPHASE

DELAYED RELEAS

Tier 3 PA; QL

dicyclomine oral capsule Tier 1

dicyclomine oral

solution

Tier 1

dicyclomine oral tablet Tier 1

DIPENTUM ORAL

CAPSULE

Tier 3


WEBMENY-0030-15

Revised 1/1/2016

37

diphenoxylate-atropine

oral liquid

Tier 1

diphenoxylate-atropine

oral tablet

Tier 1

enulose oral solution Tier 1

esomeprazole

magnesium oral

capsule,delayed

release(dr/ec)

Tier 2 PA; QL

famotidine oral

suspension

Tier 1

famotidine oral tablet Tier 1

gavilyte-c oral recon soln Tier 1

gavilyte-g oral recon

soln

Tier 1

gavilyte-n oral recon

soln

Tier 1

generlac oral solution Tier 1

granisetron hcl oral

tablet

Tier 2 QL

grx hicort 25 rectal

suppository

Tier 1

hydrocortisone acetate

rectal suppository

Tier 1

hydrocortisone-pramox-

e-pram#1 rectal

kit,cream and towelette

Tier 1

hydrocortisone-

pramoxine rectal cream

Tier 1

lactulose oral solution Tier 1

lansoprazole oral

capsule,delayed

release(dr/ec)

Tier 1 QL

lidocaine hcl-

hydrocortison ac rectal

cream

Tier 1

lidocaine hcl-

hydrocortison ac rectal

kit

Tier 1

lidocaine-

hydrocortisone-aloe

rectal gel

Tier 1

lidocaine-

hydrocortisone-aloe

rectal kit

Tier 1


LOVAZA ORAL

CAPSULE

Tier 3 QL

meclizine oral tablet Tier 1

methscopolamine oral

tablet

Tier 1

metoclopramide hcl oral

solution

Tier 1

metoclopramide hcl oral

tablet

Tier 1

misoprostol oral tablet Tier 1

MOTOFEN ORAL

TABLET

Tier 3

MOVIPREP ORAL

POWDER IN

PACKET

Tier 3

NEXIUM PACKET

ORAL GRANULES

DR FOR SUSP IN

PACKET

Tier 3 PA; QL

nizatidine oral capsule Tier 1

nizatidine oral solution Tier 1

omega-3 acid ethyl esters

oral capsule

Tier 1 QL

omeprazole oral

capsule,delayed

release(dr/ec)

Tier 1 QL

ondansetron hcl oral

solution

Tier 2 QL

ondansetron hcl oral

tablet 24 mg, 4 mg, 8 mg

Tier 2 QL

ondansetron oral

tablet,disintegrating 4

mg, 8 mg

Tier 2 QL

pancrelipase 5000 oral

capsule,delayed

release(dr/ec)

Tier 1

pantoprazole oral


(dr/ec)

Tier 2 QL

peg 3350-electrolytes

oral recon soln

Tier 1

peg-3350 with flavor

packs oral recon soln

Tier 1

phenadoz rectal

suppository

Tier 1


WEBMENY-0030-15

Revised 1/1/2016

38

pramcort rectal cream Tier 1

prochlorperazine maleate

oral tablet

Tier 1

proctosol hc rectal cream Tier 1

proctozone-hc rectal

cream

Tier 1

promethazine rectal

suppository

Tier 1

promethegan rectal

suppository

Tier 1

rabeprazole oral


(dr/ec)

Tier 2 QL

ranitidine hcl oral

capsule

Tier 1

ranitidine hcl oral syrup Tier 1

ranitidine hcl oral tablet Tier 1

RECTIV RECTAL

OINTMENT

Tier 3

REMICADE

INTRAVENOUS

RECON SOLN

Tier 3 PA

sucralfate oral tablet Tier 1

sulfasalazine oral tablet Tier 1

sulfasalazine oral


(dr/ec)

Tier 1

sulfazine ec oral


(dr/ec)

Tier 1

sulfazine oral tablet Tier 1

SUPREP BOWEL

PREP KIT ORAL

RECON SOLN

Tier 3

TRANSDERM-SCOP

TRANSDERMAL

PATCH 3 DAY

Tier 3

trilyte with flavor

packets oral recon soln

Tier 1

trimethobenzamide oral

capsule

Tier 1

ursodiol oral capsule Tier 2

ursodiol oral tablet Tier 2


ZENPEP ORAL

CAPSULE,DELAYED

RELEASE(DR/EC)

Tier 2


HORMONES

ANADROL-50 ORAL

TABLET

Tier 3

ANDROGEL

TRANSDERMAL GEL

IN METERED-DOSE

PUMP

Tier 3 PA; QL

ANDROGEL

TRANSDERMAL GEL

IN PACKET 1.62 %

(20.25 MG/1.25

GRAM), 1.62 % (40.5

MG/2.5 GRAM)

Tier 3 PA; QL

androxy oral tablet Tier 1

budesonide oral

capsule,delayed,extend.r

elease

Tier 2

cabergoline oral tablet Tier 1

calcitonin (salmon) nasal

spray,non-aerosol

Tier 2 QL

chorionic gonadotropin,

human intramuscular

recon soln

Tier 3

cortisone oral tablet Tier 1

covaryx h.s. oral tablet Tier 1

covaryx oral tablet Tier 1

danazol oral capsule Tier 2

desmopressin injection

solution

Tier 1

desmopressin nasal

aerosol,spray

Tier 1

desmopressin nasal

solution

Tier 1

desmopressin nasal

spray,non-aerosol

Tier 1

desmopressin oral tablet Tier 1

dexamethasone intensol

oral drops

Tier 1

dexamethasone oral

elixir

Tier 1

dexamethasone oral

solution

Tier 1

WEBMENY-0030-15

Revised 1/1/2016

39

dexamethasone oral

tablet

Tier 1

eemt hs oral tablet Tier 1

eemt oral tablet Tier 1

ENJUVIA ORAL

TABLET

Tier 3

estradiol oral tablet Tier 1

estradiol transdermal

patch semiweekly

Tier 1 QL

estradiol transdermal

patch weekly

Tier 1 QL

estradiol-norethindrone

acet oral tablet

Tier 1

ESTRING VAGINAL

RING

Tier 3

estrogens-

methyltestosterone oral

tablet

Tier 1

estropipate oral tablet Tier 1

fludrocortisone oral

tablet

Tier 1

fortical nasal spray,non-

aerosol

Tier 2 QL

hydrocortisone oral

tablet

Tier 1

hydrocortisone rectal

enema

Tier 1

INCRELEX

SUBCUTANEOUS

SOLUTION

Tier 3 PA

jinteli oral tablet Tier 1

medroxyprogesterone

oral tablet

Tier 1

MENEST ORAL

TABLET

Tier 3

METHITEST ORAL

TABLET

Tier 3

methylergonovine oral

tablet

Tier 1

methylprednisolone oral

tablet

Tier 1

methylprednisolone oral

tablets,dose pack

Tier 1


millipred dp oral

tablets,dose pack

Tier 1

millipred oral tablet Tier 1

mimvey oral tablet Tier 1

norethindrone acetate

oral tablet

Tier 1

OMNITROPE

SUBCUTANEOUS

CARTRIDGE

Tier 3 PA

OMNITROPE

SUBCUTANEOUS

RECON SOLN

Tier 3 PA

oxandrolone oral tablet Tier 2 PA

prednisolone oral

solution

Tier 1

prednisolone sodium

phosphate oral solution

Tier 1

prednisone intensol oral

concentrate

Tier 1

prednisone oral solution Tier 1

prednisone oral tablet Tier 1

prednisone oral

tablets,dose pack

Tier 1

PREMARIN ORAL

TABLET

Tier 3

PREMARIN

VAGINAL CREAM

Tier 3

PREMPHASE ORAL

TABLET

Tier 3

PREMPRO ORAL

TABLET

Tier 3

progesterone micronized

oral capsule

Tier 1

SOMATULINE

DEPOT

SUBCUTANEOUS

SYRINGE

Tier 3

SYNAREL NASAL

SPRAY,NON-

AEROSOL

Tier 3 PA

testosterone cypionate

intramuscular oil

Tier 1

testosterone transdermal

gel in metered-dose

pump

Tier 2 PA; QL


WEBMENY-0030-15

Revised 1/1/2016

40

testosterone transdermal

gel in packet 1 % (25

mg/2.5gram), 1 % (50

mg/5 gram)

Tier 2 PA; QL

VAGIFEM VAGINAL

TABLET

Tier 3

veripred 20 oral solution Tier 1


IMMUNOSUPPRESANT

azathioprine oral tablet Tier 3

cyclosporine modified

oral capsule

Tier 3

cyclosporine modified

oral solution

Tier 3

cyclosporine oral capsule Tier 3

ELIDEL TOPICAL

CREAM

Tier 3 PA

gengraf oral capsule Tier 3

gengraf oral solution Tier 3

mycophenolate mofetil

oral capsule

Tier 3

mycophenolate mofetil

oral tablet

Tier 3

mycophenolate sodium

oral tablet,delayed

release (dr/ec)

Tier 3

RAPAMUNE ORAL

SOLUTION

Tier 3

sirolimus oral tablet Tier 3

tacrolimus oral capsule Tier 3

tacrolimus topical

ointment

Tier 1 PA

ZORTRESS ORAL

TABLET

Tier 3 PA

MUSCLE RELAXANTS

baclofen oral tablet Tier 1

carisoprodol oral tablet Tier 1

chlorzoxazone oral tablet Tier 1

cyclobenzaprine oral

tablet

Tier 1

dantrolene oral capsule Tier 2

metaxalone oral tablet Tier 1

methocarbamol oral

tablet

Tier 1

orphenadrine citrate oral


Tier 1

tizanidine oral capsule Tier 1

tizanidine oral tablet Tier 1


PRE-NATAL VITAMINS

bal-care dha oral combo

pack,tablet & cap,dr

Tier 1

c-nate dha oral capsule Tier 1

complete natal dha oral

combo pack

Tier 1

completenate oral

tablet,chewable

Tier 1

elite-ob 400 oral capsule Tier 1

elite-ob oral capsule Tier 1

elite-ob oral tablet Tier 1

folbecal oral tablet, er

multiphase 24 hr

Tier 1

folivane-ob oral capsule Tier 1

hemenatal ob + dha oral

combo pack

Tier 1

hemenatal ob oral tablet Tier 1

inatal advance oral tablet Tier 1

inatal ultra oral tablet Tier 1

levomefolate dha oral

capsule

Tier 1

macnatal cn dha oral

capsule

Tier 1

mynatal advance oral

tablet

Tier 1

mynatal oral capsule Tier 1

mynatal oral tablet Tier 1

mynatal plus oral tablet Tier 1

mynatal-z oral tablet Tier 1

mynate 90 plus oral


Tier 1

obstetrix dha oral combo


Tier 1

pnv ob+dha oral combo

pack

Tier 1

WEBMENY-0030-15

Revised 1/1/2016

41

pnv-dha + docusate oral

capsule

Tier 1

pnv-dha oral capsule Tier 1

pnv-ferrous fumarate-

docu-fa oral tablet

Tier 1

pnv-omega oral capsule Tier 1

pnv-select oral tablet Tier 1

pr natal 400 ec oral

combo pack,tablet &

cap,dr

Tier 1

pr natal 400 oral combo

pack

Tier 1

pr natal 430 ec oral

combo pack,tablet &

cap,dr

Tier 1

pr natal 430 oral combo

pack

Tier 1

prenaissance next oral

tablet

Tier 1

prenaissance oral capsule Tier 1

prenaissance plus oral

capsule

Tier 1

prenatabs fa oral tablet Tier 1

prenatabs rx oral tablet Tier 1

PRENATAL 19 (WITH

DOCUSATE) ORAL

TABLET

Tier 1

PRENATAL 19 ORAL

TABLET,CHEWABLE

Tier 1

prenatal low iron oral

tablet

Tier 1

prenatal plus (calcium

carb) oral tablet

Tier 1

prenatal plus oral tablet Tier 1

prenatal-u oral capsule Tier 1

preplus oral tablet Tier 1

relnate dha oral capsule Tier 1

se-natal 19 (with

docusate) oral tablet

Tier 1

se-natal 19 oral

tablet,chewable

Tier 1

se-tan dha oral capsule Tier 1


taron-bc oral tablets,

sequential

Tier 1

taron-c dha oral capsule Tier 1

taron-prex prenatal-dha

oral capsule

Tier 1

tl-select oral capsule Tier 1

triadvance oral tablet Tier 1

trinatal gt oral tablet Tier 1

trinatal rx 1 oral tablet Tier 1

trinate oral tablet Tier 1

tri-tabs dha oral combo

pack

Tier 1

triveen-duo dha oral

combo pack

Tier 1

triveen-one oral capsule Tier 1

triveen-prx rnf oral

capsule

Tier 1

triveen-u oral capsule Tier 1

trust natal dha oral

combo pack

Tier 1

ultimatecare one nf oral

capsule

Tier 1

ultimatecare one oral

capsule

Tier 1

vemavite-prx-2 oral

capsule

Tier 1

vena-bal dha oral combo


Tier 1

venatal complete dha

oral combo pack,tablet &

cap,dr

Tier 1

vinacal oral tablet Tier 1

vinate care oral

tablet,chewable

Tier 1

vinate dha oral capsule Tier 1

vinate gt oral tablet Tier 1

vinate ii oral tablet Tier 1

vinate m oral tablet Tier 1

vinate one oral tablet Tier 1

vinate pn care oral tablet Tier 1

vinate ultra oral tablet Tier 1


WEBMENY-0030-15

Revised 1/1/2016

42

virt-pn dha oral capsule Tier 1

virt-pn oral tablet Tier 1

virt-pn plus oral capsule Tier 1

virt-select oral capsule Tier 1

vitafol-ob oral tablet Tier 1

vitaspire oral tablet Tier 1

vol-nate oral tablet Tier 1

vol-tab rx oral tablet Tier 1

vp-ch plus oral capsule Tier 1

vp-ch-pnv oral capsule Tier 1

vp-ggr-b6 oral tablet Tier 1

vp-heme ob + dha oral

combo pack

Tier 1

vp-heme ob oral tablet Tier 1

vp-heme one oral

capsule

Tier 1

zatean-ch oral capsule Tier 1

zatean-pn dha oral

capsule

Tier 1

zatean-pn plus oral

capsule

Tier 1

zingiber oral tablet Tier 1


PSYCHOTHERAPEUTIC DRUGS

alprazolam oral tablet Tier 1

amitriptyline oral tablet Tier 1

amoxapine oral tablet Tier 1

aripiprazole oral solution Tier 2 PA

aripiprazole oral tablet Tier 2 PA

bupropion hcl oral tablet

100 mg

Tier 1 QL


75 mg

Tier 1



Tier 1 DO



200 mg

Tier 1 QL



150 mg

Tier 1 DO



300 mg

Tier 1 QL

buspirone oral tablet Tier 1

chlorpromazine oral

tablet

Tier 1 PA

citalopram oral solution Tier 1 QL

citalopram oral tablet 10

mg, 20 mg

Tier 1 DO

citalopram oral tablet 40

mg

Tier 1 QL

clomipramine oral

capsule

Tier 1

clonidine hcl oral tablet


Tier 1 PA

clozapine oral tablet Tier 2 PA

clozapine oral


Tier 2 PA

desipramine oral tablet Tier 2

dexmethylphenidate oral

capsule,er biphasic 50-50

Tier 1 PA

dexmethylphenidate oral

tablet

Tier 1 PA

diazepam intensol oral

concentrate

Tier 1

diazepam oral

concentrate

Tier 1

diazepam oral solution Tier 1

diazepam oral tablet Tier 1

doxepin oral capsule Tier 1

doxepin oral concentrate Tier 1

duloxetine oral

capsule,delayed

release(dr/ec) 20 mg, 60

mg

Tier 2 PA; QL

duloxetine oral

capsule,delayed

release(dr/ec) 30 mg

Tier 2 PA; DO

duloxetine oral

capsule,delayed

release(dr/ec) 40 mg

Tier 2 PA

EMSAM

TRANSDERMAL

PATCH 24 HOUR

Tier 3 QL


WEBMENY-0030-15

Revised 1/1/2016

43

escitalopram oxalate oral

solution

Tier 1 QL


tablet 10 mg, 5 mg

Tier 1 DO


tablet 20 mg

Tier 1 QL

FANAPT ORAL

TABLET

Tier 3 PA

FANAPT ORAL

TABLETS,DOSE

PACK

Tier 3 PA

fluoxetine oral capsule

10 mg, 20 mg

Tier 1 DO

fluoxetine oral capsule

40 mg

Tier 1 QL

fluoxetine oral

capsule,delayed

release(dr/ec)

Tier 1 QL

fluoxetine oral solution Tier 1 QL

fluoxetine oral tablet Tier 1 DO

fluphenazine hcl oral

concentrate

Tier 1 PA


elixir

Tier 1 PA


tablet

Tier 1 PA

fluvoxamine oral tablet

100 mg

Tier 1 QL

fluvoxamine oral tablet

25 mg, 50 mg

Tier 1 DO

FOCALIN XR ORAL

CAPSULE,ER

BIPHASIC 50-50

Tier 3 PA

guanfacine oral tablet


Tier 1 PA

haloperidol oral tablet Tier 1 PA

imipramine hcl oral

tablet

Tier 1

INVEGA ORAL

TABLET EXTENDED

RELEASE 24HR

Tier 3 PA

LATUDA ORAL

TABLET

Tier 3 PA

lithium carbonate oral

capsule

Tier 1



tablet

Tier 1



Tier 1

lithium citrate oral

solution

Tier 1

loxapine succinate oral

capsule

Tier 1 PA

maprotiline oral tablet Tier 1

MARPLAN ORAL

TABLET

Tier 3

meprobamate oral tablet Tier 1

metadate er oral tablet

extended release

Tier 1 PA

methylphenidate oral

capsule, er biphasic 30-

70

Tier 1 PA


capsule,er biphasic 50-50

Tier 1 PA


solution

Tier 1 PA


tablet

Tier 1 PA



Tier 1 PA



24hr

Tier 1 PA

mirtazapine oral tablet Tier 1

mirtazapine oral


Tier 1

modafinil oral tablet 100

mg

Tier 1 PA; DO

modafinil oral tablet 200

mg

Tier 1 PA; QL

nefazodone oral tablet Tier 1

nortriptyline oral capsule Tier 1

nortriptyline oral

solution

Tier 1

NUVIGIL ORAL

TABLET 150 MG, 250

MG, 50 MG

Tier 3 PA; QL

olanzapine oral tablet Tier 2 PA


WEBMENY-0030-15

Revised 1/1/2016

44

olanzapine oral


Tier 2 PA

ORAP ORAL

TABLET

Tier 3 PA

paliperidone oral tablet


Tier 2 PA

paroxetine hcl oral tablet

10 mg, 20 mg

Tier 1 DO


30 mg, 40 mg

Tier 1 QL



12.5 mg

Tier 1 DO



25 mg, 37.5 mg

Tier 1 QL

perphenazine oral tablet Tier 1 PA

phenelzine oral tablet Tier 1

pimozide oral tablet Tier 2 PA

PRISTIQ ORAL

TABLET EXTENDED

RELEASE 24 HR 100

MG

Tier 3 QL

PRISTIQ ORAL

TABLET EXTENDED

RELEASE 24 HR 25

MG

Tier 3

PRISTIQ ORAL

TABLET EXTENDED

RELEASE 24 HR 50

MG

Tier 3 DO

protriptyline oral tablet Tier 1

quetiapine oral tablet Tier 1 PA

risperidone oral solution Tier 1 PA

risperidone oral tablet Tier 1 PA

risperidone oral


Tier 1 PA

SAPHRIS (BLACK

CHERRY)

SUBLINGUAL

TABLET

Tier 3 PA

SEROQUEL XR

ORAL TABLET

EXTENDED

RELEASE 24 HR

Tier 3 PA


sertraline oral

concentrate

Tier 1 QL

sertraline oral tablet 100

mg

Tier 1 QL

sertraline oral tablet 25

mg, 50 mg

Tier 1 DO

STRATTERA ORAL

CAPSULE

Tier 3 PA

thioridazine oral tablet Tier 1 PA

thiothixene oral capsule Tier 1 PA

tranylcypromine oral

tablet

Tier 1

trazodone oral tablet Tier 1

trifluoperazine oral tablet Tier 1 PA

trimipramine oral

capsule

Tier 1

venlafaxine oral


24hr 150 mg

Tier 1 QL

venlafaxine oral


24hr 37.5 mg, 75 mg

Tier 1 DO

venlafaxine oral tablet Tier 1

VENLAFAXINE

ORAL TABLET

EXTENDED

RELEASE 24HR 150

MG, 225 MG

Tier 1 QL

venlafaxine oral tablet


37.5 mg, 75 mg

Tier 1 DO

VIIBRYD ORAL

TABLET

Tier 3 ST

VIIBRYD ORAL

TABLETS,DOSE

PACK

Tier 3

VYVANSE ORAL

CAPSULE

Tier 3 PA

ziprasidone hcl oral

capsule

Tier 1 PA


SEDATIVE/HYPNOTICS

eszopiclone oral tablet 1

mg, 2 mg

Tier 1 QL

eszopiclone oral tablet 3

mg

Tier 1 PA; QL

WEBMENY-0030-15

Revised 1/1/2016

45

phenobarbital oral elixir Tier 1

phenobarbital oral tablet Tier 1

ROZEREM ORAL

TABLET

Tier 3 ST; QL

SILENOR ORAL

TABLET

Tier 3

XYREM ORAL

SOLUTION

Tier 3 PA; QL

zaleplon oral capsule Tier 1 QL

zolpidem oral tablet Tier 1 QL


SKIN PREPS

acitretin oral capsule Tier 2

ACZONE TOPICAL

GEL

Tier 3

adapalene topical cream Tier 1

adapalene topical gel Tier 1

adapalene topical gel

with pump

Tier 1

alclometasone topical

cream

Tier 1

alclometasone topical

ointment

Tier 1

ALTABAX TOPICAL

OINTMENT

Tier 3

amcinonide topical

cream

Tier 1

amcinonide topical

lotion

Tier 1

amcinonide topical

ointment

Tier 1

ammonium lactate

topical cream

Tier 1

ammonium lactate

topical lotion

Tier 1

amnesteem oral capsule Tier 1 PA

avita topical cream Tier 1 PA

AZELEX TOPICAL

CREAM

Tier 3 PA

benzoyl peroxide topical

cleanser

Tier 1

benzoyl peroxide topical

foam

Tier 1

betamethasone

dipropionate topical

cream

Tier 1

betamethasone


lotion

Tier 1

betamethasone


ointment

Tier 1

betamethasone valerate

topical cream

Tier 1


topical foam

Tier 1


topical lotion

Tier 1


topical ointment

Tier 1

betamethasone,

augmented topical cream

Tier 1

betamethasone,

augmented topical gel

Tier 1

betamethasone,

augmented topical lotion

Tier 1

betamethasone,

augmented topical

ointment

Tier 1

bpo topical gel Tier 1

bpo topical towelette Tier 1

calcipotriene topical

cream

Tier 1


ointment

Tier 1


solution

Tier 1

calcitrene topical

ointment

Tier 1

calcitriol topical

ointment

Tier 1

claravis oral capsule Tier 1 PA

clindamycin-benzoyl

peroxide topical gel

Tier 1

clobetasol topical cream Tier 1

clobetasol topical foam Tier 1

clobetasol topical gel Tier 1


WEBMENY-0030-15

Revised 1/1/2016

46

clobetasol topical lotion Tier 1

clobetasol topical

ointment

Tier 1

clobetasol topical

shampoo

Tier 1

clobetasol topical

solution

Tier 1

clobetasol-emollient

topical cream

Tier 1

CLODERM TOPICAL

CREAM

Tier 3

CORDRAN TAPE

LARGE ROLL

TOPICAL TAPE

Tier 3

CORDRAN TAPE

SMALL ROLL

TOPICAL TAPE

Tier 3

CORDRAN TOPICAL

CREAM

Tier 3

CORDRAN TOPICAL

LOTION

Tier 3

cormax topical solution Tier 1

dermazene topical cream Tier 1

desonide topical cream Tier 1

desonide topical lotion Tier 1

desonide topical

ointment

Tier 1

desoximetasone topical

cream

Tier 1


gel

Tier 1


ointment

Tier 1

DIFFERIN TOPICAL

LOTION

Tier 3

diflorasone topical cream Tier 1

diflorasone topical

ointment

Tier 1

EPIDUO TOPICAL

GEL

Tier 3

EPIDUO TOPICAL

GEL WITH PUMP

Tier 3


EURAX TOPICAL

CREAM

Tier 3

EURAX TOPICAL

LOTION

Tier 3

FINACEA TOPICAL

GEL

Tier 3

FLECTOR

TRANSDERMAL

PATCH 12 HOUR

Tier 3 ST

fluocinolone topical

cream

Tier 1

fluocinolone topical oil Tier 1


ointment

Tier 1


solution

Tier 1

fluocinolone-shower cap

topical oil

Tier 1

fluocinonide topical

cream

Tier 1

fluocinonide topical gel Tier 1


ointment

Tier 1


solution

Tier 1

fluocinonide-e topical

cream

Tier 1

fluticasone topical cream Tier 1

fluticasone topical lotion Tier 1

fluticasone topical

ointment

Tier 1

halobetasol propionate

topical cream

Tier 1

halobetasol propionate

topical ointment

Tier 1

HALOG TOPICAL

CREAM

Tier 3

HALOG TOPICAL

OINTMENT

Tier 3

hydrocortisone butyrate

topical cream

Tier 1


topical ointment

Tier 1


WEBMENY-0030-15

Revised 1/1/2016

47


topical solution

Tier 1

hydrocortisone topical

cream

Tier 1


lotion

Tier 1


ointment

Tier 1

hydrocortisone valerate

topical cream

Tier 1

hydrocortisone valerate

topical ointment

Tier 1

hydrocortisone-

pramoxine topical cream

Tier 1

imiquimod topical cream

in packet

Tier 1 PA; QL

IODOFLEX TOPICAL

PADS, MEDICATED

Tier 3

iodoquinol-hc topical

cream

Tier 1

lidocaine hcl-

hydrocortison ac topical

cream

Tier 1

lindane topical lotion Tier 1

lindane topical shampoo Tier 1

malathion topical lotion Tier 1

methoxsalen rapid oral

capsule

Tier 2 PA

metronidazole topical

cream

Tier 1

metronidazole topical gel Tier 1

metronidazole topical gel

with pump

Tier 1

metronidazole topical

lotion

Tier 1

mometasone topical

cream

Tier 1

mometasone topical

ointment

Tier 1

mometasone topical

solution

Tier 1

NUOX TOPICAL GEL Tier 3


OVACE PLUS

TOPICAL

CLEANSER,EXTEND

ED RELEASE

Tier 3

OVACE PLUS

TOPICAL CREAM

Tier 3

OVACE PLUS WASH

TOPICAL

CLEANSER,GEL

EXTENDED

RELEASE

Tier 3

OXSORALEN

TOPICAL LOTION

Tier 3

permethrin topical cream Tier 1

podofilox topical

solution

Tier 1

prednicarbate topical

cream

Tier 1

prednicarbate topical

ointment

Tier 1

prudoxin topical cream Tier 2

REGRANEX

TOPICAL GEL

Tier 3

rosadan topical cream Tier 1

rosadan topical gel Tier 1

ROSADAN TOPICAL

KIT, CLEANSER &

GEL

Tier 3

ROSADAN TOPICAL

KIT,CLEANSER AND

CREAM

Tier 3

salacyn topical cream Tier 1

salacyn topical lotion Tier 1

salicylic acid sr-

ceramides topical combo

pack

Tier 1

salicylic acid sr-

ceramides topical

kit,cleanser & cream er

Tier 1

salicylic acid topical

cream

Tier 1


cream,extended release

Tier 1

salicylic acid topical film

forming liquid w/appl

Tier 1


WEBMENY-0030-15

Revised 1/1/2016

48


foam

Tier 1

salicylic acid topical gel Tier 1


liquid

Tier 1


lotion

Tier 1


lotion,extended release

Tier 1


shampoo

Tier 1

salvax topical foam Tier 1

SANTYL TOPICAL

OINTMENT

Tier 3

seb-prev topical cleanser Tier 1

selenium sulfide topical

shampoo

Tier 1

selenium sulfide topical

suspension

Tier 1

sodium chloride

irrigation solution

Tier 2

spinosad topical

suspension

Tier 1


(acne) topical suspension

Tier 1


topical cleanser

Tier 1


topical shampoo

Tier 1

TAZORAC TOPICAL

CREAM

Tier 3 PA

TAZORAC TOPICAL

GEL

Tier 3 PA

tretinoin (emollient)

topical cream

Tier 1

tretinoin topical cream Tier 1 PA

tretinoin topical gel Tier 1 PA


topical cream

Tier 1


topical lotion

Tier 1


topical ointment

Tier 1


trianex topical ointment Tier 1

triderm topical cream Tier 1

ULESFIA TOPICAL

LOTION

Tier 3

VOLTAREN

TOPICAL GEL

Tier 3

zenatane oral capsule Tier 1 PA

ZIANA TOPICAL

GEL

Tier 3 PA


SMOKING DETERRENTS

buproban oral tablet

extended release

Tier 1 QL

CHANTIX

CONTINUING

MONTH BOX ORAL

TABLET

Tier 3 QL

CHANTIX

CONTINUING

MONTH PAK ORAL

TABLET

Tier 3 QL

CHANTIX ORAL

TABLET

Tier 3 QL

CHANTIX STARTING

MONTH BOX ORAL

TABLETS,DOSE

PACK

Tier 3 QL

CHANTIX STARTING

MONTH PAK ORAL

TABLETS,DOSE

PACK

Tier 3 QL

THYROID PREPS

levothyroxine oral tablet Tier 1

levoxyl oral tablet Tier 1

liothyronine oral tablet Tier 1

methimazole oral tablet Tier 1

nature-throid oral tablet Tier 1

np thyroid oral tablet Tier 1

propylthiouracil oral

tablet

Tier 1

THYROLAR-1 ORAL

TABLET

Tier 3

THYROLAR-1/2

ORAL TABLET

Tier 3

WEBMENY-0030-15

Revised 1/1/2016

49

THYROLAR-1/4

ORAL TABLET

Tier 3

THYROLAR-2 ORAL

TABLET

Tier 3

THYROLAR-3 ORAL

TABLET

Tier 3

unithroid oral tablet Tier 1

westhroid oral tablet Tier 1


UNCLASSIFIED DRUG PRODUCTS

acamprosate oral


(dr/ec)

Tier 2

alendronate oral solution Tier 1 QL

alendronate oral tablet 10

mg, 35 mg, 40 mg, 5 mg,

70 mg

Tier 1 QL

alfuzosin oral tablet


Tier 1

AVODART ORAL

CAPSULE

Tier 3 PA

buprenorphine hcl

sublingual tablet 2 mg, 8

mg

Tier 1 PA; QL

buprenorphine-naloxone

sublingual tablet 2-0.5

mg, 8-2 mg

Tier 1 PA; QL

calcipotriene-


ointment

Tier 1

CARBAGLU ORAL

TABLET,

DISPERSIBLE

Tier 3

CHEMET ORAL

CAPSULE

Tier 3

chlorhexidine gluconate

mucous membrane

mouthwash

Tier 1

CIALIS ORAL

TABLET

Tier 3 PA; QL

CYSTADANE ORAL

POWDER

Tier 3

disulfiram oral tablet Tier 1


tablet

Tier 1

dutasteride oral capsule Tier 2 PA

ENABLEX ORAL

TABLET EXTENDED

RELEASE 24 HR

Tier 3 ST

EXJADE ORAL

TABLET,

DISPERSIBLE

Tier 3 PA

FABRAZYME

INTRAVENOUS

RECON SOLN

Tier 3 PA

FERRIPROX ORAL

TABLET

Tier 3 PA

finasteride oral tablet Tier 1 PA

flavoxate oral tablet Tier 1

FORTEO

SUBCUTANEOUS

PEN INJECTOR

Tier 3 PA; QL

FOSAMAX PLUS D

ORAL TABLET

Tier 3 ST; QL

ibandronate oral tablet Tier 1 QL

JALYN ORAL

CAPSULE, ER

MULTIPHASE 24 HR

Tier 3

leucovorin calcium oral

tablet

Tier 3

levocarnitine (with

sugar) oral solution

Tier 2

levocarnitine oral tablet Tier 2

NYSTATIN (BULK)

POWDER

Tier 1

oralone dental paste Tier 1

ORFADIN ORAL

CAPSULE

Tier 3

oxybutynin chloride oral

syrup

Tier 1


tablet

Tier 1



24hr

Tier 1

paroex oral rinse mucous

membrane mouthwash

Tier 1

periogard mucous

membrane mouthwash

Tier 1


WEBMENY-0030-15

Revised 1/1/2016

50

PROLIA

SUBCUTANEOUS

SYRINGE

Tier 3 PA; QL

raloxifene oral tablet Tier 1

RAPAFLO ORAL

CAPSULE

Tier 3

risedronate oral tablet

150 mg, 30 mg, 5 mg

Tier 1 QL

risedronate oral tablet 35

mg

Tier 1

risedronate oral


(dr/ec)

Tier 1

SAVELLA ORAL

TABLET

Tier 3 QL

SAVELLA ORAL

TABLETS,DOSE

PACK

Tier 3 QL

SENSIPAR ORAL

TABLET

Tier 3

sodium chlor 0.9%

bacteriostat injection

solution

Tier 2

SUBOXONE

SUBLINGUAL FILM

12-3 MG, 2-0.5 MG, 4-1

MG, 8-2 MG

Tier 3 PA; QL

SYPRINE ORAL

CAPSULE

Tier 3

TACLONEX

TOPICAL

SUSPENSION

Tier 3

tamsulosin oral


24hr

Tier 1

tolterodine oral tablet Tier 1

TOVIAZ ORAL

TABLET EXTENDED

RELEASE 24 HR

Tier 3


dental paste

Tier 1

trospium oral


24hr

Tier 2


TYSABRI

INTRAVENOUS

SOLUTION

Tier 3 PA

VESICARE ORAL

TABLET

Tier 3

XIAFLEX

INJECTION RECON

SOLN

Tier 3 PA

ZEMAIRA

INTRAVENOUS

RECON SOLN

Tier 3

zoledronic acid


Tier 3

zoledronic acid-

mannitol-water


Tier 3 PA


VITAMINS

calcitriol oral capsule Tier 1

calcitriol oral solution Tier 1

cyanocobalamin (vitamin

b-12) injection solution

Tier 1

ergocalciferol (vitamin

d2) oral capsule

Tier 1

folic acid oral tablet Tier 1

vitamin d2 oral capsule Tier 1

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