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Prescription BlueSM PDP Options A & B

2018 Comprehensive Formulary. List of covered drugs

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

This formulary was updated on June 1, 2018. For more recent information or other questions, please contact us, Prescription Blue PDP Customer Service, at 1‑800‑565‑1770 or, for TTY users 711, Monday through Friday, 8 a.m. to 9 p.m. Eastern time. From October 1 through February 14, hours are from 8 a.m. to 9 p.m., Eastern time, seven days a week, or visit www.bcbsm.com/medicare.

The formulary and pharmacy network may change at any time. You will receive notice when necessary.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and/or copayments/co‑insurance may change on January 1 of each year.

Updated: 06/01/2018 Formulary 18094, Version 15

Prescription Blue is a PDP plan with a Medicare contract. Enrollment in Prescription Blue depends on contract renewal.

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Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Blue Cross Blue Shield. When it refers to “plan” or “our plan,” it means Prescription Blue Group PDP.

This document includes a list of the drugs (formulary) for our plan which is current as of June 1, 2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year.

What is the Prescription Blue PDP Options A & B Formulary? A formulary is a list of covered drugs selected by Prescription Blue PDP in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Prescription Blue PDP will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Prescription Blue PDP network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost‑sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost‑sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60‑day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of June 1, 2018. To get updated information about the drugs covered by Prescription Blue PDP, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid‑year non‑maintenance formulary change, we will send out an errata sheet to notify you of this change.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page Index 1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand‑name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Prescription Blue PDP covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand‑name drug. Generally, generic drugs cost less than brand‑name drugs.

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Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Prescription Blue PDP requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Prescription Blue PDP before you fill your prescriptions. If you don’t get approval, Prescription Blue PDP may not cover the drug.

• Quantity Limits: For certain drugs, Prescription Blue PDP limits the amount of the drug that Prescription Blue PDP will cover. For example, Prescription Blue PDP provides thirty‑one tablets per prescription for simvastatin. This may be in addition to a standard one‑month or three‑month supply.

• Step Therapy: In some cases, Prescription Blue PDP requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Prescription Blue PDP may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Prescription Blue PDP will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Prescription Blue PDP to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Prescription Blue PDP’s formulary?” on page ii for information about how to request an exception.

What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Prescription Blue PDP does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by Prescription Blue PDP. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Prescription Blue PDP.

• You can ask Prescription Blue PDP to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Prescription Blue PDP Options A & B Formulary? You can ask Prescription Blue PDP to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre‑determined cost‑sharing level, and you would not be able to ask us to provide the drug at a lower cost‑sharing level.

• You can ask us to cover a formulary drug at a lower cost‑sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Prescription Blue PDP limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Prescription Blue PDP will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost‑sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

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You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31‑day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31‑day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long‑term care facility, we will allow you to refill your prescription until we have provided you with a 93‑day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31‑day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

If you move into (or out of) a long‑term care facility, you will continue to have access to your medications during the transition. If needed, limits on early prescription refills will be waived to assure that your medications are available through a new pharmacy provider when you are moving to or from a long‑term care facility. Contact Customer Service if you require assistance in your transition. For more detailed information about our Transition Policy, refer to your Evidence of Coverage or visit our website at www.bcbsm.com/medicare/help/ forms‑documents.html.

For more information For more detailed information about your Prescription Blue PDP prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Prescription Blue PDP, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1‑800‑MEDICARE (1‑800‑633‑4227) 24 hours a day, 7 days a week. TTY users should call 1‑877‑486‑2048. Or, visit www.medicare.gov.

Prescription Blue PDP Options A & B Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Prescription Blue PDP. If you have trouble finding your drug in the list, turn to the Index that begins on page Index 1.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIVALO®) and generic drugs are listed in lower‑case italics (e.g., simvastatin).

The information in the Requirements/Limits column tells you if Prescription Blue PDP has any special requirements for coverage of your drug.

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http://www.bcbsm.com/medicare/help/forms-documents.html

Tier Descriptions

Medicare Plus Blue PPO Drug Tier Costs

Tier Drug Description

Up to a 31‑day supply Up to a 90‑day supply**

Standard retail and standard

mail‑order cost‑sharing (in‑network)

Preferred retail and preferred mail/order

cost‑sharing (in‑network)

Long‑term care (LTC)

cost‑sharing

Out‑of network

cost‑sharing

Standard retail and standard

mail‑order cost‑sharing (in‑network)

Preferred retail and preferred mail/order

cost‑sharing (in‑network)

Tier 1 Preferred Generic

See your Medical or Prescription Benefits Chart for member cost‑share details Tier 2 Generic

Tier 3 Preferred Brand‑Name

Tier 4 Non‑Preferred Drugs

Tier 5 Specialty See your Medical or Prescription Benefits Chart for member cost‑share details

90‑day supply is not available

*Out‑of‑network pharmacy coverage is limited to certain situations. Consult your Evidence of Coverage for details.

**Most pharmacies will fill a 90‑day supply of medication. Check with your pharmacist.

Drug Notes Code Definitions

Symbol Definition B/D This prescription drug may be covered under Medicare Part B or D depending on the circumstances.

Information may need to be submitted describing the use and setting of the drug to make the determination.

EX This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count toward your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.

LA Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, call Prescription Blue Group PDP Customer Service at 1‑800‑565‑1770, Monday through Friday, 8 a.m. to 9 p.m. Eastern time. From October 1 through February 14, hours are from 8 a.m. to 9 p.m., Eastern time, seven days a week. TTY users should call 711.

PA Prior Authorization. The plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, we may not cover the drug.

QL Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover.

ST Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

NEDS Non‑Extended Day Supply. These drugs are not offered at a 90‑day supply. They are offered up to a 31‑day supply.

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Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug

5-Specialty Drugs

Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only LA - Limited Availability

NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step

Therapy

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.

1

Drug Name Drug

Tier

Requirements

/Limits

ANALGESICS

ANALGESICS, OTHER

diclofenac-

misoprostol oral

tablet,ir,delayed

rel,biphasic 50-200

mg-mcg

2

PRIALT

INTRATHECAL

SOLUTION

4

NONSTEROIDAL ANTI-

INFLAMMATORY DRUGS

CALDOLOR

INTRAVENOUS

RECON SOLN 800

MG/8 ML (100

MG/ML)

3

celecoxib oral

capsule 100 mg

4 QL (270 per

90 days)

celecoxib oral

capsule 200 mg, 400

mg

4 QL (180 per

90 days)

celecoxib oral

capsule 50 mg

4 QL (540 per

90 days)

diclofenac potassium

oral tablet

2

diclofenac sodium

oral tablet extended

release 24 hr

2

diclofenac sodium

oral tablet,delayed

release (dr/ec)

2

diclofenac sodium

topical gel 1 %

2 QL (1000 per

31 days)

diclofenac-

misoprostol oral

tablet,ir,delayed

rel,biphasic 75-200

mg-mcg

2

diflunisal oral tablet 2

etodolac oral

capsule 200 mg

2

etodolac oral tablet 2

etodolac oral tablet

extended release 24

hr

2

fenoprofen oral

tablet

4

flurbiprofen oral

tablet

2

ibu oral tablet 2

ibuprofen oral

suspension

2

ibuprofen oral tablet

400 mg, 600 mg, 800

mg

2

ketoprofen oral

capsule

2

ketoprofen oral

capsule,ext rel.

pellets 24 hr 200 mg

2 QL (90 per 90

days)

meclofenamate oral

capsule

4

mefenamic acid oral

capsule

4

meloxicam oral

tablet

2

nabumetone oral

tablet

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


2

naproxen oral

suspension

2

naproxen oral tablet 2

naproxen oral

tablet,delayed

release (dr/ec)

2

naproxen sodium

oral tablet 275 mg,

550 mg

2

oxaprozin oral tablet 2

piroxicam oral

capsule

2

profeno oral tablet 4

salsalate oral tablet

750 mg

2

sulindac oral tablet 2

tolmetin oral capsule 2

tolmetin oral tablet 2

OPIOID ANALGESICS, LONG-

ACTING

BUPRENEX

INJECTION

SOLUTION

4 QL (801 per

90 days)

buprenorphine hcl

injection solution

4 QL (801 per

90 days)

buprenorphine hcl

injection syringe

4 QL (801 per

90 days)

BUPRENORPHINE

TRANSDERMAL

PATCH WEEKLY

4 QL (12 per 84

days)

BUTRANS

TRANSDERMAL

PATCH WEEKLY

4 QL (12 per 84

days)

Drug Name Drug

Tier

Requirements

/Limits

fentanyl transdermal

patch 72 hour 100

mcg/hr, 12 mcg/hr,

25 mcg/hr, 50

mcg/hr, 75 mcg/hr

2 QL (45 per 90

days)

levorphanol tartrate

oral tablet

2 QL (360 per

90 days)

methadone intensol

oral concentrate

2

methadone oral

concentrate

2

methadone oral

solution

2

methadone oral

tablet

2

morphine oral tablet

extended release 100

mg, 15 mg, 30 mg,

60 mg

4 QL (270 per

90 days)

morphine oral tablet

extended release 200

mg

4 QL (90 per 90

days)

OXYCODONE

ORAL SYRINGE

4 QL (540 per

90 days)

oxymorphone oral

tablet extended

release 12 hr

4 QL (180 per

90 days)

tramadol oral tablet

extended release 24

hr

4 QL (90 per 90

days)

tramadol oral tablet,

er multiphase 24 hr

4 QL (90 per 90

days)

OPIOID ANALGESICS, SHORT-

ACTING

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


3

ABSTRAL

SUBLINGUAL

TABLET

5 PA; QL (124

per 31 days);

NEDS

acetaminophen-

codeine oral solution

120 mg-12 mg /5 ml

(5 ml), 120-12 mg/5

ml, 300 mg-30 mg

/12.5 ml

2 QL (5167 per

31 days)

acetaminophen-

codeine oral tablet

300-15 mg, 300-30

mg

2 QL (1080 per

90 days)

acetaminophen-

codeine oral tablet

300-60 mg

2 QL (540 per

90 days)

butorphanol tartrate

injection solution 1

mg/ml

4 QL (2160 per

90 days)



mg/ml

4 QL (1080 per

90 days)


nasal spray,non-

aerosol

2 QL (15 per 90

days)

codeine sulfate oral

tablet 15 mg

2 QL (2160 per

90 days)


tablet 30 mg

2 QL (1080 per

90 days)


tablet 60 mg

2 QL (540 per

90 days)

duramorph (pf)

injection solution 0.5

mg/ml

4 QL (4133 per

31 days)

Drug Name Drug

Tier

Requirements

/Limits

duramorph (pf)


mg/ml

4 QL (6000 per

90 days)

endocet oral tablet

10-325 mg, 2.5-325

mg, 5-325 mg, 7.5-

325 mg

2 QL (1080 per

90 days)

fentanyl citrate (pf)

injection solution

2

fentanyl citrate

buccal lozenge on a

handle

5 PA; QL (124

per 31 days);

NEDS

FENTORA

BUCCAL TABLET,

EFFERVESCENT

5 PA; QL (124

per 31 days);

NEDS

hydrocodone-

acetaminophen oral

solution 7.5-325

mg/15 ml

2 QL (5735 per

31 days)

hydrocodone-

acetaminophen oral

tablet 10-325 mg,

2.5-325 mg, 5-325

mg, 7.5-325 mg

2 QL (1080 per

90 days)

hydrocodone-

ibuprofen oral tablet

10-200 mg, 5-200

mg, 7.5-200 mg

2 QL (450 per

90 days)

hydromorphone (pf)

injection solution

4

hydromorphone

injection solution

4

HYDROMORPHO

NE INJECTION

SYRINGE 0.5

MG/0.5 ML

4

Drug Name Drug

Tier

Requirements

/Limits

Drug Tier: 1-Preferred Generic

5-Specialty Drugs

2-Generic 3-Preferred Brand 4-Non-Preferred Drug



Therapy


4

hydromorphone

injection syringe 1

mg/ml, 2 mg/ml, 4

mg/ml

4

hydromorphone oral

liquid

2 QL (4500 per

90 days)

hydromorphone oral

tablet 2 mg

2 QL (1350 per

90 days)

hydromorphone oral

tablet 4 mg

2 QL (720 per

90 days)

hydromorphone oral

tablet 8 mg

2 QL (360 per

90 days)

ibuprofen-oxycodone

oral tablet

2 QL (360 per

90 days)

LAZANDA NASAL

SPRAY,NON-

AEROSOL

5 PA; QL (31

per 31 days);

NEDS

lorcet (hydrocodone)

oral tablet

2 QL (1080 per

90 days)

lorcet hd oral tablet 2 QL (1080 per

90 days)

lorcet plus oral

tablet 7.5-325 mg

2 QL (1080 per

90 days)

morphine (pf)


mg/ml, 1 mg/ml

4

morphine

concentrate oral

solution

2 QL (900 per

90 days)

morphine

intravenous

cartridge 10 mg/ml,

2 mg/ml, 4 mg/ml

4

Drug Name Drug

Tier

Requirements

/Limits

morphine

intravenous solution

10 mg/ml

4

morphine oral

solution

2 QL (2700 per

90 days)

morphine oral tablet 2 QL (540 per

90 days)

nalbuphine injection

solution 10 mg/ml

4 QL (600 per

90 days)

nalbuphine injection

solution 20 mg/ml

4 QL (300 per

90 days)

NUCYNTA ORAL

TABLET 100 MG

4 QL (543 per

90 days)

NUCYNTA ORAL

TABLET 50 MG

4 QL (1086 per

90 days)

NUCYNTA ORAL

TABLET 75 MG

4 QL (726 per

90 days)

oxycodone oral

capsule

2 QL (1080 per

90 days)

oxycodone oral

concentrate

4 QL (540 per

90 days)

oxycodone oral

solution

4 QL (3600 per

90 days)

oxycodone oral

tablet 10 mg, 15 mg,

20 mg, 30 mg

2 QL (540 per

90 days)

oxycodone oral

tablet 5 mg

2 QL (1080 per

90 days)

oxycodone-

acetaminophen oral

tablet 10-325 mg,

2.5-325 mg, 5-325

mg, 7.5-325 mg

2 QL (1080 per

90 days)

oxycodone-aspirin

oral tablet

2 QL (1080 per

90 days)

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


5

oxymorphone oral

tablet

4 QL (540 per

90 days)

SUBSYS

SUBLINGUAL

SPRAY,NON-

AEROSOL

5 PA; QL (124

per 31 days);

NEDS

tramadol oral tablet 2 QL (720 per

90 days)

tramadol-

acetaminophen oral

tablet

2 QL (1080 per

90 days)

xylon 10 oral tablet 2 QL (450 per

90 days)

Drug Name Drug

Tier

Requirements

/Limits

ANESTHETICS

LOCAL ANESTHETICS

chloroprocaine (pf)

injection solution

4

glydo mucous

membrane jelly in

applicator

2

lidocaine (pf)

injection solution

4

lidocaine (pf)


4

lidocaine (pf)

intravenous syringe

4

lidocaine hcl

injection solution

4

lidocaine hcl

laryngotracheal

solution

4

lidocaine hcl mucous

membrane jelly

2


membrane jelly in

applicator

2


membrane solution 4

% (40 mg/ml)

4

lidocaine topical

adhesive

patch,medicated

4 PA; QL (270

per 90 days)

lidocaine topical

ointment

4

lidocaine viscous

mucous membrane

solution

2

lidocaine-

epinephrine


%-1:200,000

4

lidocaine-prilocaine

topical cream

2

NAROPIN (PF)

INJECTION

SOLUTION

4

polocaine injection

solution 1 % (10

mg/ml)

4

polocaine-mpf

injection solution

4

xylocaine dental-

epinephrine

injection cartridge

4

Drug Name Drug

Tier

Requirements

/Limits

ANTI -

ADDICTION/SUBSTANCE

ABUSE TREATMENT AGENTS


5-Specialty Drugs



Therapy


6

ALCOHOL DETERRENTS/ANTI-

CRAVING

acamprosate oral

tablet,delayed

release (dr/ec)

2

disulfiram oral

tablet

2

OPIOID DEPENDENCE

TREATMENTS

buprenorphine hcl

sublingual tablet

2

buprenorphine-

naloxone sublingual

tablet

2

naltrexone oral

tablet

2

SUBOXONE

SUBLINGUAL

FILM

3

VIVITROL

INTRAMUSCULA

R

SUSPENSION,EXT

ENDED REL

RECON

5 NEDS

OPIOID REVERSAL AGENTS

EVZIO INJECTION

AUTO-INJECTOR

4

naloxone injection

solution

2

naloxone injection

syringe

2

Drug Name Drug

Tier

Requirements

/Limits

NARCAN NASAL

SPRAY,NON-

AEROSOL 4

MG/ACTUATION

4

SMOKING CESSATION AGENTS

bupropion hcl

(smoking deter) oral

tablet extended

release 12 hr

2

CHANTIX

CONTINUING

MONTH BOX

ORAL TABLET

3

CHANTIX ORAL

TABLET

3

CHANTIX

STARTING

MONTH BOX

ORAL

TABLETS,DOSE

PACK

3

NICOTROL

INHALATION

CARTRIDGE

4

NICOTROL NS

NASAL

SPRAY,NON-

AEROSOL

4

Drug Name Drug

Tier

Requirements

/Limits

ANTIBACTERIALS

AMINOGLYCOSIDES

amikacin injection

solution 1,000 mg/4

ml, 500 mg/2 ml

4

Drug Tier: 1-Preferred Generic 2-Generic

5-Specialty Drugs

3-Preferred Brand 4-Non-Preferred Drug



Therapy


7

BETHKIS

INHALATION

SOLUTION FOR

NEBULIZATION

5 B/D PA;

NEDS

gentak ophthalmic

(eye) ointment

2

gentamicin in nacl

(iso-osm)

intravenous

piggyback 100

mg/100 ml, 60 mg/50

ml, 70 mg/50 ml, 80

mg/100 ml, 80 mg/50

ml, 90 mg/100 ml

4

GENTAMICIN IN

NACL (ISO-OSM)

INTRAVENOUS

PIGGYBACK 100

MG/50 ML, 120

MG/100 ML

4

gentamicin injection

solution

4

gentamicin

ophthalmic (eye)

drops

2

gentamicin sulfate

(ped) (pf) injection

solution

4

gentamicin sulfate

(pf) intravenous

solution 100 mg/10

ml

4

GENTAMICIN

SULFATE (PF)

INTRAVENOUS

SOLUTION 60

MG/6 ML

4

Drug Name Drug

Tier

Requirements

/Limits

gentamicin topical

cream

2

gentamicin topical

ointment

2

neomycin oral tablet 2

paromomycin oral

capsule

2

STREPTOMYCIN

INTRAMUSCULA

R RECON SOLN

4

tobramycin in 0.225

% nacl inhalation

solution for

nebulization

5 B/D PA;

NEDS

tobramycin

ophthalmic (eye)

drops

1

tobramycin sulfate

injection recon soln

4

tobramycin sulfate

injection solution

4

ANTIBACTERIALS, OTHER

acetic acid otic (ear)

solution

2

AVC VAGINAL

CREAM

4

baciim

intramuscular recon

soln

4

bacitracin

intramuscular recon

soln

4

bacitracin

ophthalmic (eye)

ointment

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


8

BACTROBAN

NASAL

OINTMENT

4

BENZNIDAZOLE

ORAL TABLET

4

chloramphenicol sod

succinate

intravenous recon

soln

4

CLEOCIN

VAGINAL

SUPPOSITORY

4

clindacin etz topical

swab

2

clindacin p topical

swab

2

clindamycin hcl oral

capsule

2

CLINDAMYCIN IN

0.9 % SOD CHLOR

INTRAVENOUS

PIGGYBACK

4

clindamycin in 5 %

dextrose intravenous

piggyback

4

clindamycin

palmitate hcl oral

recon soln

4

clindamycin

pediatric oral recon

soln

4

clindamycin

phosphate injection

solution

4

Drug Name Drug

Tier

Requirements

/Limits

clindamycin

phosphate


4

clindamycin

phosphate topical

gel

2

clindamycin

phosphate topical

lotion

2

clindamycin

phosphate topical

solution

2

clindamycin

phosphate topical

swab

2

clindamycin

phosphate vaginal

cream

2

CLINDESSE

VAGINAL

CREAM,EXTENDE

D RELEASE

4

colistin

(colistimethate na)


4

DALVANCE

INTRAVENOUS

SOLUTION

5 NEDS

daptomycin

intravenous recon

soln

4

lincomycin injection

solution

4

linezolid in dextrose

5% intravenous

parenteral solution

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


9

linezolid oral

suspension for

reconstitution

2

linezolid oral tablet 2

linezolid-0.9%

sodium chloride

intravenous

parenteral solution

5 NEDS

mafenide acetate

topical packet

2

methenamine

hippurate oral tablet

2

metro i.v.

intravenous

piggyback

4

metronidazole in

nacl (iso-os)

intravenous

piggyback

4

metronidazole oral

capsule

2

metronidazole oral

tablet

2

metronidazole

topical cream

2

metronidazole

topical gel

2

metronidazole

topical gel with

pump

2

metronidazole

topical lotion

2

metronidazole

vaginal gel

2

Drug Name Drug

Tier

Requirements

/Limits

mupirocin calcium

topical cream

2

mupirocin topical

ointment

2

neomycin-

bacitracin-poly-hc

ophthalmic (eye)

ointment

2

neomycin-polymyxin

b gu irrigation

solution

4

neomycin-

polymyxin-

gramicidin

ophthalmic (eye)

drops

2

neomycin-

polymyxin-hc

ophthalmic (eye)

drops,suspension

2

neo-polycin hc

ophthalmic (eye)

ointment

2

nitrofurantoin

macrocrystal oral

capsule

2

nitrofurantoin

monohyd/m-cryst

oral capsule

2

nitrofurantoin oral

suspension

2

polymyxin b sulfate


4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


10

polymyxin b sulf-

trimethoprim

ophthalmic (eye)

drops

2

SYNERCID

INTRAVENOUS

RECON SOLN

5 NEDS

tigecycline

intravenous recon

soln

4

tinidazole oral tablet 2

trimethoprim oral

tablet

2

TYGACIL

INTRAVENOUS

RECON SOLN

4

VANCOMYCIN IN

0.9 % SODIUM

CHL

INTRAVENOUS

PIGGYBACK

4

VANCOMYCIN IN

DEXTROSE 5 %

INTRAVENOUS

PIGGYBACK

4

vancomycin

intravenous recon

soln 1,000 mg, 10

gram, 5 gram, 500

mg

4

VANCOMYCIN

INTRAVENOUS

RECON SOLN 750

MG

4

vancomycin oral

capsule

4

Drug Name Drug

Tier

Requirements

/Limits

vandazole vaginal

gel

2

XIFAXAN ORAL

TABLET 550 MG

4 QL (180 per

90 days)

BETA-LACTAM,

CEPHALOSPORINS

cefaclor oral capsule 2

cefaclor oral tablet

extended release 12

hr

2

cefadroxil oral

capsule

2

cefadroxil oral

suspension for

reconstitution 250

mg/5 ml, 500 mg/5

ml

2

cefadroxil oral tablet 2

cefazolin in dextrose

(iso-os) intravenous

piggyback 1 gram/50

ml

4

cefazolin injection

recon soln

4

cefazolin

intravenous recon

soln

4

cefdinir oral capsule 2

cefdinir oral

suspension for

reconstitution

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


11

CEFEPIME IN

DEXTROSE 5 %

INTRAVENOUS

PIGGYBACK 1

GRAM/50 ML

4

cefepime in

dextrose,iso-osm

intravenous

piggyback

4

cefepime injection

recon soln 1 gram

4

cefixime oral

suspension for

reconstitution

2

cefotaxime injection

recon soln 1 gram, 2

gram, 500 mg

4

CEFOTETAN IN

DEXTROSE, ISO-

OSM

INTRAVENOUS

PIGGYBACK

4

cefotetan injection

recon soln

4

cefoxitin in dextrose,

iso-osm intravenous

piggyback

4

cefoxitin intravenous

recon soln

4

cefpodoxime oral

suspension for

reconstitution

2

cefpodoxime oral

tablet

2

Drug Name Drug

Tier

Requirements

/Limits

cefprozil oral

suspension for

reconstitution

2

cefprozil oral tablet 2

CEFTAZIDIME IN

D5W

INTRAVENOUS

PIGGYBACK

4

ceftazidime injection

recon soln

4

ceftriaxone in

dextrose,iso-os

intravenous

piggyback

4

ceftriaxone injection

recon soln 1 gram,

10 gram, 2 gram,

250 mg, 500 mg

4

CEFTRIAXONE

INJECTION

RECON SOLN 100

GRAM

4

ceftriaxone

intravenous recon

soln

4

cefuroxime axetil

oral tablet

2

cefuroxime sodium


750 mg

4

cefuroxime sodium

intravenous recon

soln

4

cephalexin oral

capsule 250 mg, 500

mg

1

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


12

cephalexin oral

suspension for

reconstitution

2

cephalexin oral

tablet

1

FORTAZ

INJECTION

RECON SOLN 1

GRAM

4

FORTAZ

INTRAVENOUS

RECON SOLN

4

SUPRAX ORAL

CAPSULE

4

SUPRAX ORAL

SUSPENSION FOR

RECONSTITUTIO

N 500 MG/5 ML

4

SUPRAX ORAL

TABLET,CHEWAB

LE

4

TAZICEF

INJECTION

RECON SOLN

4

TAZICEF

INTRAVENOUS

RECON SOLN

4

TEFLARO

INTRAVENOUS

RECON SOLN

4

ZERBAXA

INTRAVENOUS

RECON SOLN

4

BETA-LACTAM, OTHER

Drug Name Drug

Tier

Requirements

/Limits

AZACTAM IN

DEXTROSE (ISO-

OSM)

INTRAVENOUS

PIGGYBACK 2

GRAM/50 ML

4

AZACTAM

INJECTION

RECON SOLN 2

GRAM

4

aztreonam injection

recon soln 1 gram

4

imipenem-cilastatin

intravenous recon

soln

4

INVANZ

INJECTION

RECON SOLN

4

INVANZ

INTRAVENOUS

RECON SOLN

4

meropenem

intravenous recon

soln

4

MEROPENEM-

0.9% SODIUM

CHLORIDE

INTRAVENOUS

PIGGYBACK

4

BETA-LACTAM, PENICILLINS

amoxicillin oral

capsule

1

amoxicillin oral

suspension for

reconstitution

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


13

amoxicillin oral

tablet

1

amoxicillin oral

tablet,chewable 125

mg, 250 mg

2

amoxicillin-pot

clavulanate oral

suspension for

reconstitution

2

amoxicillin-pot

clavulanate oral

tablet

2

amoxicillin-pot

clavulanate oral

tablet extended

release 12 hr

4

amoxicillin-pot

clavulanate oral

tablet,chewable

2

ampicillin oral

capsule

2

ampicillin sodium


4

ampicillin sodium

intravenous recon

soln

4

ampicillin-sulbactam


4

ampicillin-sulbactam

intravenous recon

soln

4

BICILLIN C-R

INTRAMUSCULA

R SYRINGE

4

Drug Name Drug

Tier

Requirements

/Limits

BICILLIN L-A

INTRAMUSCULA

R SYRINGE

4

dicloxacillin oral

capsule

2

nafcillin in dextrose

iso-osm intravenous

piggyback 1 gram/50

ml

4

nafcillin injection

recon soln

4

nafcillin intravenous

recon soln

4

oxacillin in

dextrose(iso-osm)

intravenous

piggyback

4

oxacillin injection

recon soln 10 gram,

2 gram

4

PENICILLIN G

POT IN

DEXTROSE

INTRAVENOUS

PIGGYBACK

4

penicillin g

potassium injection

recon soln

4

penicillin g procaine

intramuscular

syringe

4

penicillin g sodium


4

penicillin v

potassium oral recon

soln

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


14

penicillin v

potassium oral tablet

1

pfizerpen-g injection

recon soln 5 million

unit

4

piperacillin-

tazobactam

intravenous recon

soln 2.25 gram,

3.375 gram, 4.5

gram, 40.5 gram

4

ZOSYN IN

DEXTROSE (ISO-

OSM)

INTRAVENOUS

PIGGYBACK

4

ZOSYN

INTRAVENOUS

RECON SOLN 2.25

GRAM, 3.375

GRAM

4

MACROLIDES

AZASITE

OPHTHALMIC

(EYE) DROPS

4

azithromycin

intravenous recon

soln

4

azithromycin oral

packet

2

azithromycin oral

suspension for

reconstitution

2

azithromycin oral

tablet

2

Drug Name Drug

Tier

Requirements

/Limits

clarithromycin oral

suspension for

reconstitution

4

clarithromycin oral

tablet

2

clarithromycin oral

tablet extended

release 24 hr

4 QL (180 per

90 days)

DIFICID ORAL

TABLET

5 QL (20 per 10

days); NEDS

e.e.s. 400 oral tablet 2

ery pads topical

swab

2

ery-tab oral

tablet,delayed

release (dr/ec) 250

mg, 333 mg

4

ERY-TAB ORAL

TABLET,DELAYE

D RELEASE

(DR/EC) 500 MG

4

erythrocin (as

stearate) oral tablet

250 mg

2

ERYTHROCIN

INTRAVENOUS

RECON SOLN 500

MG

4

erythromycin

ethylsuccinate oral

suspension for

reconstitution

2

erythromycin

ethylsuccinate oral

tablet

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


15

erythromycin

ophthalmic (eye)

ointment

2

erythromycin oral

capsule,delayed

release(dr/ec)

2

erythromycin oral

tablet

2

erythromycin with

ethanol topical

solution

2

erythromycin with

ethanol topical swab

2

QUINOLONES

BAXDELA

INTRAVENOUS

RECON SOLN

5 NEDS

BAXDELA ORAL

TABLET

5 NEDS

CETRAXAL OTIC

(EAR)

DROPPERETTE

3

CILOXAN

OPHTHALMIC

(EYE) OINTMENT

3

ciprofloxacin hcl

ophthalmic (eye)

drops

2

ciprofloxacin hcl

oral tablet

2

ciprofloxacin hcl

otic (ear)

dropperette

2

Drug Name Drug

Tier

Requirements

/Limits

ciprofloxacin in 5 %

dextrose intravenous

piggyback 200

mg/100 ml

4

ciprofloxacin lactate


400 mg/40 ml

4

ciprofloxacin oral

suspension,microcap

sule recon

2

floxin otic (ear)

drops

2

gatifloxacin

ophthalmic (eye)

drops

2

levofloxacin in d5w

intravenous

piggyback

4

levofloxacin


4

levofloxacin

ophthalmic (eye)

drops

2

levofloxacin oral

solution

2

levofloxacin oral

tablet

2

moxifloxacin in nacl

(iso-osm)

intravenous

piggyback

4

moxifloxacin

ophthalmic (eye)

drops

2

moxifloxacin oral

tablet

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


16

ofloxacin ophthalmic

(eye) drops

2

ofloxacin oral tablet

300 mg, 400 mg

2

ofloxacin otic (ear)

drops

2

VIGAMOX

OPHTHALMIC

(EYE) DROPS

3

SULFONAMIDES

silver sulfadiazine

topical cream

2

ssd topical cream 2

sulfacetamide

sodium (acne)

topical suspension

2

sulfacetamide

sodium ophthalmic

(eye) drops

2

sulfacetamide

sodium ophthalmic

(eye) ointment

2

sulfadiazine oral

tablet

2

sulfamethoxazole-

trimethoprim


4

sulfamethoxazole-

trimethoprim oral

suspension

2

sulfamethoxazole-

trimethoprim oral

tablet

1

sulfatrim oral

suspension

2

Drug Name Drug

Tier

Requirements

/Limits

TETRACYCLINES

demeclocycline oral

tablet

4

doxy-100

intravenous recon

soln

4

doxycycline hyclate

oral capsule

2

doxycycline hyclate

oral tablet 100 mg,

20 mg

2

doxycycline hyclate

oral tablet,delayed

release (dr/ec) 200

mg, 50 mg

2

doxycycline

monohydrate oral

suspension for

reconstitution

2

minocycline oral

capsule

2

minocycline oral

tablet

2

morgidox oral

capsule

2

VIBRAMYCIN

ORAL SYRUP

4

Drug Name Drug

Tier

Requirements

/Limits

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

BRIVIACT

INTRAVENOUS

SOLUTION

4 PA

BRIVIACT ORAL

SOLUTION

4 PA; QL (1800

per 90 days)


5-Specialty Drugs



Therapy


17

BRIVIACT ORAL

TABLET

4 PA; QL (180

per 90 days)

KEPPRA

INTRAVENOUS

SOLUTION

4

levetiracetam in nacl


piggyback

4

levetiracetam


4

levetiracetam oral

solution

2

levetiracetam oral

tablet

2

levetiracetam oral

tablet extended

release 24 hr

2

roweepra oral tablet 2

roweepra xr oral

tablet extended

release 24 hr

2

SPRITAM ORAL

TABLET FOR

SUSPENSION

4

CALCIUM CHANNEL MODIFYING

AGENTS

CELONTIN ORAL

CAPSULE 300 MG

3

ethosuximide oral

capsule

2

ethosuximide oral

solution

2

LYRICA ORAL

CAPSULE

4

Drug Name Drug

Tier

Requirements

/Limits

LYRICA ORAL

SOLUTION

4

zonisamide oral

capsule

2

GAMMA-AMINOBUTYRIC ACID

(GABA) AUGMENTING AGENTS

DIASTAT

ACUDIAL

RECTAL KIT

4

DIASTAT RECTAL

KIT

4

diazepam rectal kit 4

divalproex oral

capsule, delayed rel

sprinkle

2

divalproex oral

tablet extended

release 24 hr

2

divalproex oral

tablet,delayed

release (dr/ec)

2

gabapentin oral

capsule

2

gabapentin oral

solution

2

gabapentin oral

tablet 600 mg, 800

mg

2

GABITRIL ORAL

TABLET 12 MG, 16

MG

3

ONFI ORAL

SUSPENSION

4 QL (1440 per

90 days)

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


18

ONFI ORAL

TABLET 10 MG, 20

MG

4 QL (180 per

90 days)

phenobarbital oral

elixir

4

phenobarbital oral

tablet

4

primidone oral

tablet

2

SABRIL ORAL

POWDER IN

PACKET

5 NEDS

SABRIL ORAL

TABLET

5 NEDS

tiagabine oral tablet 4

valproate sodium


4

valproic acid (as

sodium salt) oral

solution

2

valproic acid oral

capsule

2

vigabatrin oral

powder in packet

5 NEDS

GLUTAMATE REDUCING AGENTS

felbamate oral

suspension

4

felbamate oral tablet 4

FYCOMPA ORAL

SUSPENSION

4

FYCOMPA ORAL

TABLET 2 MG, 4

MG, 6 MG, 8 MG

4

Drug Name Drug

Tier

Requirements

/Limits

LAMICTAL

STARTER (BLUE)

KIT ORAL

TABLETS,DOSE

PACK

3

LAMICTAL

STARTER

(GREEN) KIT

ORAL

TABLETS,DOSE

PACK

3

LAMICTAL

STARTER

(ORANGE) KIT

ORAL

TABLETS,DOSE

PACK

3

lamotrigine oral

tablet

4

lamotrigine oral

tablet extended

release 24hr

4

lamotrigine oral

tablet, chewable

dispersible

4

lamotrigine oral

tablet,disintegrating

4

lamotrigine oral

tablets,dose pack

2

topiramate oral

capsule, sprinkle

2

topiramate oral

tablet

2

SODIUM CHANNEL AGENTS

APTIOM ORAL

TABLET

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


19

BANZEL ORAL

SUSPENSION

4

BANZEL ORAL

TABLET

4

carbamazepine oral

capsule, er

multiphase 12 hr

2

carbamazepine oral

suspension 100 mg/5

ml

2

carbamazepine oral

tablet

2

carbamazepine oral

tablet extended

release 12 hr

2

carbamazepine oral

tablet,chewable

2

CEREBYX

INJECTION

SOLUTION 500

MG PE/10 ML

4

DILANTIN 30 MG

ORAL CAPSULE

3

epitol oral tablet 2

fosphenytoin

injection solution

100 mg pe/2 ml

4

fosphenytoin

injection solution

500 mg pe/10 ml

2

oxcarbazepine oral

suspension

2

oxcarbazepine oral

tablet

2

Drug Name Drug

Tier

Requirements

/Limits

OXTELLAR XR

ORAL TABLET

EXTENDED

RELEASE 24 HR

4 ST

PEGANONE ORAL

TABLET

3

phenytoin oral

suspension

2

phenytoin oral

tablet,chewable

2

phenytoin sodium

extended oral

capsule

2

phenytoin sodium


4

phenytoin sodium

intravenous syringe

4

VIMPAT

INTRAVENOUS

SOLUTION

4

VIMPAT ORAL

SOLUTION

3

VIMPAT ORAL

TABLET

3

Drug Name Drug

Tier

Requirements

/Limits

ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHER

ergoloid oral tablet 2

CHOLINESTERASE INHIBITORS

donepezil oral tablet 4 QL (90 per 90

days)

donepezil oral


4 QL (90 per 90

days)


5-Specialty Drugs



Therapy


20

galantamine oral

capsule,ext rel.

pellets 24 hr

2 QL (90 per 90

days)

galantamine oral

solution

2

galantamine oral

tablet

2

rivastigmine tartrate

oral capsule

2

rivastigmine

transdermal patch

24 hour

4 QL (90 per 90

days)

N-METHYL-D-ASPARTATE (NMDA)

RECEPTOR ANTAGONIST

memantine oral

capsule,sprinkle,er

24hr

4 QL (90 per 90

days)

memantine oral

solution

2 QL (900 per

90 days)

memantine oral

tablet

2 QL (180 per

90 days)

MEMANTINE

ORAL

TABLETS,DOSE

PACK

3 QL (147 per

84 days)

NAMENDA

TITRATION PAK

ORAL

TABLETS,DOSE

PACK

3 QL (147 per

84 days)

NAMENDA XR

ORAL

CAP,SPRINKLE,ER

24HR DOSE PACK

4 QL (84 per 84

days)

Drug Name Drug

Tier

Requirements

/Limits

NAMENDA XR

ORAL

CAPSULE,SPRINK

LE,ER 24HR

4 QL (90 per 90

days)

Drug Name Drug

Tier

Requirements

/Limits

ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

bupropion hcl oral

tablet

2

bupropion hcl oral

tablet extended

release 12 hr

2

bupropion hcl oral

tablet extended

release 24 hr

2

mirtazapine oral

tablet

2

mirtazapine oral


2

olanzapine-

fluoxetine oral

capsule

4

MONOAMINE OXIDASE

INHIBITORS

EMSAM

TRANSDERMAL

PATCH 24 HOUR

4

MARPLAN ORAL

TABLET

4

phenelzine oral

tablet

2

tranylcypromine

oral tablet

4


5-Specialty Drugs




Therapy


21

SELECTIVE SEROTONIN

REUPTAKE

INHIBITORS/SEROTONIN AND

NOREPINEPHRINE REUPTAKE

INHIBITORS

BRISDELLE ORAL

CAPSULE

3

citalopram oral

solution

2

citalopram oral

tablet

2

DESVENLAFAXIN

E ORAL TABLET

EXTENDED

RELEASE 24 HR

4 ST

DESVENLAFAXIN

E ORAL TABLET

EXTENDED

RELEASE 24HR

4 ST

desvenlafaxine

succinate oral tablet

extended release 24

hr

4

duloxetine oral

capsule,delayed

release(dr/ec)

2

escitalopram oxalate

oral solution

2

escitalopram oxalate

oral tablet

2

FETZIMA ORAL

CAPSULE,EXT

REL 24HR DOSE

PACK

4 ST

Drug Name Drug

Tier

Requirements

/Limits

FETZIMA ORAL

CAPSULE,EXTEN

DED RELEASE 24

HR

4 ST

fluoxetine oral

capsule

4

fluoxetine oral

capsule,delayed

release(dr/ec)

4

fluoxetine oral

solution

4

fluoxetine oral tablet

10 mg, 20 mg

4

FLUOXETINE

ORAL TABLET 60

MG

4

fluvoxamine oral

capsule,extended

release 24hr

2

fluvoxamine oral

tablet

2

maprotiline oral

tablet

2

nefazodone oral

tablet

2

paroxetine hcl oral

tablet

2

paroxetine hcl oral

tablet extended

release 24 hr

2

paroxetine

mesylate(menop.sym

) oral capsule

2

PAXIL ORAL

SUSPENSION

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


22

sertraline oral

concentrate

2

sertraline oral tablet 2

trazodone oral tablet 2

TRINTELLIX

ORAL TABLET

4 ST

venlafaxine oral

capsule,extended

release 24hr

2

venlafaxine oral

tablet

2

VIIBRYD ORAL

TABLET

4 ST

VIIBRYD ORAL

TABLETS,DOSE

PACK 10 MG (7)-

20 MG (23)

4 ST

TRICYCLICS

amitriptyline oral

tablet

2

amoxapine oral

tablet

2

clomipramine oral

capsule

4

desipramine oral

tablet

4

doxepin oral capsule 2

doxepin oral

concentrate

2

imipramine hcl oral

tablet

2

imipramine pamoate

oral capsule

4

Drug Name Drug

Tier

Requirements

/Limits

nortriptyline oral

capsule

2

nortriptyline oral

solution

2

protriptyline oral

tablet

2

trimipramine oral

capsule

2

Drug Name Drug

Tier

Requirements

/Limits

ANTIEMETICS

ANTIEMETICS, OTHER

compro rectal

suppository

2

droperidol injection

solution

2

meclizine oral tablet

12.5 mg, 25 mg

2

metoclopramide hcl

injection syringe

4

phenadoz rectal

suppository

2

phenergan rectal

suppository

2

prochlorperazine

rectal suppository

2

promethazine oral

syrup

2

promethazine oral

tablet

2

promethazine rectal

suppository

2

promethegan rectal

suppository 25 mg,

50 mg

2


5-Specialty Drugs



Therapy


23

scopolamine base

transdermal patch 3

day

2

TRANSDERM-

SCOP

TRANSDERMAL

PATCH 3 DAY

3

EMETOGENIC THERAPY

ADJUNCTS

ANZEMET ORAL

TABLET

4 B/D PA

aprepitant oral

capsule

2 B/D PA

aprepitant oral

capsule,dose pack

2 B/D PA

dronabinol oral

capsule

4 B/D PA

EMEND ORAL

CAPSULE 125 MG,

40 MG

3 B/D PA

EMEND ORAL

SUSPENSION FOR

RECONSTITUTIO

N

3 B/D PA

granisetron hcl oral

tablet

2 B/D PA

ondansetron hcl (pf)

injection solution

4

ondansetron hcl (pf)

injection syringe

4

ondansetron hcl


4

ondansetron hcl oral

solution

4 B/D PA

Drug Name Drug

Tier

Requirements

/Limits

ondansetron hcl oral

tablet

2 B/D PA

ondansetron oral


2 B/D PA

SANCUSO

TRANSDERMAL

PATCH WEEKLY

5 QL (4 per 28

days); NEDS

Drug Name Drug

Tier

Requirements

/Limits

ANTIFUNGALS

ANTIFUNGALS

ABELCET

INTRAVENOUS

SUSPENSION

5 B/D PA;

NEDS

AMBISOME

INTRAVENOUS

SUSPENSION FOR

RECONSTITUTIO

N

5 B/D PA;

NEDS

amphotericin b


4 B/D PA

CANCIDAS

INTRAVENOUS

RECON SOLN

4 B/D PA

caspofungin

intravenous recon

soln 50 mg

4 B/D PA

CASPOFUNGIN

INTRAVENOUS

RECON SOLN 70

MG

4 B/D PA

ciclodan topical

cream

2

ciclodan topical

solution

2

ciclopirox topical

cream

2


5-Specialty Drugs



Therapy


24

ciclopirox topical

gel

2

ciclopirox topical

shampoo

2

ciclopirox topical

solution

2

ciclopirox topical

suspension

2

clotrimazole mucous

membrane troche

2

clotrimazole topical

cream

2

clotrimazole topical

solution

2

clotrimazole-

betamethasone

topical cream

2

clotrimazole-

betamethasone

topical lotion

2

econazole topical

cream

4

ERAXIS(WATER

DILUENT)

INTRAVENOUS

RECON SOLN

4

EXELDERM

TOPICAL CREAM

4

EXELDERM

TOPICAL

SOLUTION

4

fluconazole in

dextrose(iso-o)

intravenous

piggyback

4

Drug Name Drug

Tier

Requirements

/Limits

fluconazole in nacl

(iso-osm)

intravenous

piggyback 200

mg/100 ml, 400

mg/200 ml

4

fluconazole oral

suspension for

reconstitution

2

fluconazole oral

tablet

2

flucytosine oral

capsule

2

griseofulvin

microsize oral

suspension

2

griseofulvin

microsize oral tablet

2

griseofulvin

ultramicrosize oral

tablet

2

itraconazole oral

capsule

4

ketoconazole oral

tablet

2

ketoconazole topical

cream

2


foam

4


shampoo

2

MENTAX

TOPICAL CREAM

4

miconazole-3

vaginal suppository

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


25

naftifine topical

cream

4

NAFTIN TOPICAL

GEL

4

NATACYN

OPHTHALMIC

(EYE)

DROPS,SUSPENSI

ON

3

NOXAFIL ORAL

SUSPENSION

5 NEDS

NOXAFIL ORAL

TABLET,DELAYE

D RELEASE

(DR/EC)

5 QL (93 per 31

days); NEDS

nyamyc topical

powder

2

nystatin oral

suspension

2

nystatin oral tablet 2

nystatin topical

cream

2

nystatin topical

ointment

2

nystatin topical

powder

2

nystatin-

triamcinolone

topical cream

2

nystatin-

triamcinolone

topical ointment

2

nystop topical

powder

2

Drug Name Drug

Tier

Requirements

/Limits

oxiconazole topical

cream

4

OXISTAT

TOPICAL LOTION

4

SPORANOX ORAL

SOLUTION

3

terconazole vaginal

cream

2

terconazole vaginal

suppository

2

voriconazole


4

voriconazole oral

suspension for

reconstitution

4

voriconazole oral

tablet

4

Drug Name Drug

Tier

Requirements

/Limits

ANTIGOUT AGENTS

ANTIGOUT AGENTS

allopurinol oral

tablet

1

COLCHICINE

ORAL TABLET

4 QL (360 per

90 days)

DUZALLO ORAL

TABLET 200-300

MG

4

probenecid oral

tablet

2

probenecid-

colchicine oral

tablet

2

ULORIC ORAL

TABLET

3 ST; QL (90 per

90 days)


5-Specialty Drugs



Therapy


26

ZURAMPIC ORAL

TABLET

4 PA

Drug Name Drug

Tier

Requirements

/Limits

ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS

dihydroergotamine

nasal spray,non-

aerosol

2 QL (24 per 90

days)

migergot rectal

suppository

4

SEROTONIN (5-HT) 1B/1D

RECEPTOR AGONISTS

almotriptan malate

oral tablet

4 ST; QL (36 per

90 days)

eletriptan oral tablet 4 ST; QL (18 per

90 days)

frovatriptan oral

tablet

4 ST; QL (36 per

90 days)

naratriptan oral

tablet

2 QL (27 per 90

days)

RELPAX ORAL

TABLET

4 ST; QL (18 per

90 days)

rizatriptan oral

tablet

2 ST; QL (36 per

90 days)

rizatriptan oral


2 ST; QL (36 per

90 days)

sumatriptan nasal

spray,non-aerosol

4 QL (36 per 90

days)

sumatriptan

succinate oral tablet

2

sumatriptan

succinate

subcutaneous

cartridge

4

sumatriptan

succinate

subcutaneous pen

injector

4

sumatriptan

succinate

subcutaneous

solution

4

zolmitriptan oral

tablet

2 QL (18 per 90

days)

zolmitriptan oral


2 QL (18 per 90

days)

Drug Name Drug

Tier

Requirements

/Limits

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

guanidine oral tablet 2

MESTINON ORAL

SYRUP

3

pyridostigmine

bromide oral tablet

2

pyridostigmine

bromide oral tablet

extended release

2

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone oral tablet 2

rifabutin oral

capsule

4

ANTITUBERCULARS

CAPASTAT

INJECTION

RECON SOLN

4

ethambutol oral

tablet

2


5-Specialty Drugs



Therapy


27

isoniazid injection

solution

4

isoniazid oral

solution

2

isoniazid oral tablet 2

PASER ORAL

GRANULES DR

FOR SUSP IN

PACKET

4

PRIFTIN ORAL

TABLET

4

pyrazinamide oral

tablet

2

rifampin intravenous

recon soln

4

rifampin oral

capsule

2

RIFATER ORAL

TABLET

4

SIRTURO ORAL

TABLET

5 PA; NEDS

TRECATOR ORAL

TABLET

4

Drug Name Drug

Tier

Requirements

/Limits

ANTINEOPLASTICS

ALKYLATING AGENTS

BENDEKA

INTRAVENOUS

SOLUTION

5 PA; NEDS

BICNU

INTRAVENOUS

RECON SOLN

4

busulfan intravenous

solution

4

cyclophosphamide

intravenous recon

soln

2 B/D PA

CYCLOPHOSPHA

MIDE ORAL

CAPSULE

4 B/D PA

dacarbazine

intravenous recon

soln 100 mg

2

dacarbazine

intravenous recon

soln 200 mg

4

EVOMELA

INTRAVENOUS

RECON SOLN

5 PA; NEDS

GLEOSTINE ORAL

CAPSULE

3

HEXALEN ORAL

CAPSULE

5 NEDS

IFEX

INTRAVENOUS

RECON SOLN 3

GRAM

4 B/D PA

ifosfamide

intravenous recon

soln 1 gram

4 B/D PA

ifosfamide

intravenous recon

soln 3 gram

2 B/D PA

ifosfamide


2 B/D PA

LEUKERAN ORAL

TABLET

3

MATULANE

ORAL CAPSULE

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


28

melphalan hcl

intravenous recon

soln

4

melphalan oral

tablet

4 B/D PA

MUSTARGEN

INJECTION

RECON SOLN

4

thiotepa injection

recon soln

4

TREANDA

INTRAVENOUS

RECON SOLN

5 PA; NEDS

VALCHLOR

TOPICAL GEL

5 NEDS

YONDELIS

INTRAVENOUS

RECON SOLN

5 PA; NEDS

ZANOSAR

INTRAVENOUS

RECON SOLN

4

ANTIANDROGENS

bicalutamide oral

tablet

2

ERLEADA ORAL

TABLET

5 PA; NEDS

flutamide oral

capsule

2

nilutamide oral

tablet

2

XTANDI ORAL

CAPSULE

5 PA; NEDS

ZYTIGA ORAL

TABLET

5 PA; NEDS

Drug Name Drug

Tier

Requirements

/Limits

ANTIANGIOGENIC AGENTS

POMALYST ORAL

CAPSULE

5 PA; QL (31

per 31 days);

NEDS

REVLIMID ORAL

CAPSULE

5 PA; LA;

NEDS

THALOMID ORAL

CAPSULE

5 PA; NEDS

ANTIESTROGENS/MODIFIERS

EMCYT ORAL

CAPSULE

3

FARESTON ORAL

TABLET

3

FASLODEX

INTRAMUSCULA

R SYRINGE

5 NEDS

SOLTAMOX

ORAL SOLUTION

4

tamoxifen oral tablet 2

ANTIMETABOLITES

adrucil intravenous

solution 2.5 gram/50

ml, 5 gram/100 ml

2 B/D PA

adrucil intravenous

solution 500 mg/10

ml

4 B/D PA

ALIMTA

INTRAVENOUS

RECON SOLN

4

ARRANON

INTRAVENOUS

SOLUTION

4

cladribine


4 B/D PA

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


29

clofarabine


4

CLOLAR

INTRAVENOUS

SOLUTION

4

cytarabine (pf)

injection solution

100 mg/5 ml (20

mg/ml)

2 B/D PA

cytarabine (pf)


gram/20 ml (100

mg/ml), 20 mg/ml

4 B/D PA

cytarabine injection

solution

4 B/D PA

DROXIA ORAL

CAPSULE

4

ELITEK

INTRAVENOUS

RECON SOLN

5 NEDS

floxuridine injection

recon soln

2

fluorouracil


2.5 gram/50 ml, 5

gram/100 ml

4 B/D PA

fluorouracil


500 mg/10 ml

2 B/D PA

gemcitabine

intravenous recon

soln

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits

gemcitabine


1 gram/26.3 ml (38

mg/ml), 2 gram/52.6

ml (38 mg/ml), 200

mg/5.26 ml (38

mg/ml)

5 NEDS

hydroxyurea oral

capsule

2

mercaptopurine oral

tablet

2

NIPENT

INTRAVENOUS

RECON SOLN

4

PURIXAN ORAL

SUSPENSION

5 NEDS

TABLOID ORAL

TABLET

3

ANTINEOPLASTICS, OTHER

ABRAXANE

INTRAVENOUS

SUSPENSION FOR

RECONSTITUTIO

N

4

adriamycin


10 mg/5 ml, 2 mg/ml,

50 mg/25 ml

2 B/D PA

adriamycin


20 mg/10 ml

4 B/D PA

amifostine

crystalline

intravenous recon

soln

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


30

azacitidine injection

recon soln

5 NEDS

bleomycin injection

recon soln 15 unit

2 B/D PA

bleomycin injection

recon soln 30 unit

4 B/D PA

BORTEZOMIB

INTRAVENOUS

RECON SOLN

4

carboplatin


4

cisplatin intravenous

solution

4

dactinomycin

intravenous recon

soln

4

daunorubicin


4

decitabine

intravenous recon

soln

5 NEDS

dexrazoxane hcl

intravenous recon

soln 250 mg

4

dexrazoxane hcl

intravenous recon

soln 500 mg

2

Drug Name Drug

Tier

Requirements

/Limits

docetaxel


160 mg/16 ml (10

mg/ml), 160 mg/8 ml

(20 mg/ml), 20 mg/2

ml (10 mg/ml), 20

mg/ml (1 ml), 80

mg/4 ml (20 mg/ml),

80 mg/8 ml (10

mg/ml)

5 NEDS

DOCETAXEL

INTRAVENOUS

SOLUTION 20

MG/ML

5 NEDS

doxorubicin

intravenous recon

soln

2 B/D PA

doxorubicin


10 mg/5 ml, 2 mg/ml,

20 mg/10 ml

2 B/D PA

doxorubicin


50 mg/25 ml

4 B/D PA

doxorubicin, peg-

liposomal

intravenous

suspension

4 B/D PA

ELLENCE

INTRAVENOUS

SOLUTION

4

epirubicin


200 mg/100 ml

4

epirubicin


50 mg/25 ml

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


31

ERWINAZE

INJECTION

RECON SOLN

5 NEDS

ETHYOL

INTRAVENOUS

RECON SOLN

5 NEDS

fludarabine

intravenous recon

soln

4

fludarabine


2

HALAVEN

INTRAVENOUS

SOLUTION

5 NEDS

idarubicin


4

irinotecan


100 mg/5 ml

4

irinotecan


40 mg/2 ml, 500

mg/25 ml

2

ISTODAX

INTRAVENOUS

RECON SOLN

5 B/D PA;

NEDS

IXEMPRA

INTRAVENOUS

RECON SOLN

5 NEDS

KISQALI FEMARA

CO-PACK ORAL

TABLET

5 PA; NEDS

KISQALI ORAL

TABLET

5 PA; NEDS

Drug Name Drug

Tier

Requirements

/Limits

KYPROLIS

INTRAVENOUS

RECON SOLN

5 PA; NEDS

leucovorin calcium


4

leucovorin calcium

oral tablet

2

LONSURF ORAL

TABLET

5 PA; NEDS

mitomycin

intravenous recon

soln 20 mg, 5 mg

4

mitomycin

intravenous recon

soln 40 mg

5 NEDS

mitoxantrone

intravenous

concentrate

4

NINLARO ORAL

CAPSULE

5 PA; NEDS

ONCASPAR

INJECTION

SOLUTION

5 NEDS

oxaliplatin

intravenous recon

soln

5 NEDS

oxaliplatin


100 mg/20 ml

4

oxaliplatin


50 mg/10 ml (5

mg/ml)

5 NEDS

paclitaxel

intravenous

concentrate

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


32

PROLEUKIN

INTRAVENOUS

RECON SOLN

5 NEDS

ROMIDEPSIN

INTRAVENOUS

RECON SOLN

5 B/D PA;

NEDS

SUPPRELIN LA

IMPLANT KIT

5 NEDS

SYNRIBO

SUBCUTANEOUS

RECON SOLN

5 NEDS

TEMODAR

INTRAVENOUS

RECON SOLN

4

TOTECT

INTRAVENOUS

RECON SOLN 500

MG

3

TRISENOX

INTRAVENOUS

SOLUTION 2

MG/ML

4

VALSTAR

INTRAVESICAL

SOLUTION

5 NEDS

VANTAS

IMPLANT KIT

4

VELCADE

INJECTION

RECON SOLN

4

vinblastine


4 B/D PA

vincasar pfs


1 mg/ml

4 B/D PA

Drug Name Drug

Tier

Requirements

/Limits

vincasar pfs


2 mg/2 ml

2 B/D PA

vincristine


1 mg/ml

4 B/D PA

vincristine


2 mg/2 ml

2 B/D PA

vinorelbine


10 mg/ml

2

vinorelbine


50 mg/5 ml

4

VYXEOS

INTRAVENOUS

RECON SOLN

5 NEDS

ZOLINZA ORAL

CAPSULE

5 PA; NEDS

AROMATASE INHIBITORS, 3RD

GENERATION

anastrozole oral

tablet

2

exemestane oral

tablet

2

letrozole oral tablet 2

ENZYME INHIBITORS

ETOPOPHOS

INTRAVENOUS

RECON SOLN

4

etoposide


2

toposar intravenous

solution

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


33

topotecan

intravenous recon

soln

4

topotecan


2

MOLECULAR TARGET

INHIBITORS

AFINITOR

DISPERZ ORAL

TABLET FOR

SUSPENSION

5 PA; NEDS

AFINITOR ORAL

TABLET

5 PA; NEDS

ALECENSA ORAL

CAPSULE

5 PA; NEDS

ALIQOPA

INTRAVENOUS

RECON SOLN

5 PA; NEDS

ALUNBRIG ORAL

TABLET

5 PA; NEDS

BELEODAQ

INTRAVENOUS

RECON SOLN

5 PA; NEDS

BOSULIF ORAL

TABLET

5 PA; NEDS

CABOMETYX

ORAL TABLET

5 PA; NEDS

CALQUENCE

ORAL CAPSULE

5 PA; NEDS

CAMPTOSAR

INTRAVENOUS

SOLUTION 300

MG/15 ML

4

CAPRELSA ORAL

TABLET

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits

COMETRIQ ORAL

CAPSULE

5 PA; NEDS

COTELLIC ORAL

TABLET

5 PA; LA;

NEDS

ERIVEDGE ORAL

CAPSULE

5 PA; NEDS

FARYDAK ORAL

CAPSULE

5 PA; NEDS

GILOTRIF ORAL

TABLET

5 PA; QL (31

per 31 days);

NEDS

IBRANCE ORAL

CAPSULE

5 PA; NEDS

ICLUSIG ORAL

TABLET

5 PA; NEDS

IDHIFA ORAL

TABLET

5 PA; NEDS

imatinib oral tablet 5 NEDS

IMBRUVICA

ORAL CAPSULE

5 PA; NEDS

IMBRUVICA

ORAL TABLET

5 PA; NEDS

INLYTA ORAL

TABLET

5 PA; NEDS

IRESSA ORAL

TABLET

5 NEDS

JAKAFI ORAL

TABLET

5 PA; NEDS

LENVIMA ORAL

CAPSULE

5 PA; NEDS

LYNPARZA ORAL

CAPSULE

5 PA; NEDS

LYNPARZA ORAL

TABLET

5 PA; NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


34

MEKINIST ORAL

TABLET

5 PA; NEDS

NERLYNX ORAL

TABLET

5 PA; NEDS

NEXAVAR ORAL

TABLET

5 PA; NEDS

ODOMZO ORAL

CAPSULE

5 PA; LA;

NEDS

RUBRACA ORAL

TABLET

5 PA; NEDS

RYDAPT ORAL

CAPSULE

5 PA; NEDS

SPRYCEL ORAL

TABLET

5 PA; NEDS

STIVARGA ORAL

TABLET

5 NEDS

SUTENT ORAL

CAPSULE

5 PA; NEDS

TAFINLAR ORAL

CAPSULE

5 PA; NEDS

TAGRISSO ORAL

TABLET

5 PA; LA;

NEDS

TARCEVA ORAL

TABLET

5 PA; NEDS

TASIGNA ORAL

CAPSULE

5 PA; NEDS

TYKERB ORAL

TABLET

5 NEDS

VENCLEXTA

ORAL TABLET 10

MG, 50 MG

4 PA

VENCLEXTA

ORAL TABLET

100 MG

5 PA; NEDS

Drug Name Drug

Tier

Requirements

/Limits

VENCLEXTA

STARTING PACK

ORAL

TABLETS,DOSE

PACK

5 PA; NEDS

VERZENIO ORAL

TABLET

5 PA; NEDS

VOTRIENT ORAL

TABLET

5 PA; NEDS

XALKORI ORAL

CAPSULE

5 PA; QL (62

per 31 days);

NEDS

ZEJULA ORAL

CAPSULE

5 PA; NEDS

ZELBORAF ORAL

TABLET

5 PA; QL (248

per 31 days);

NEDS

ZYDELIG ORAL

TABLET

5 PA; NEDS

ZYKADIA ORAL

CAPSULE

5 PA; NEDS

MONOCLONAL

ANTIBODIES/ANTIBODY-DRUG

CONJUGATE

ARZERRA

INTRAVENOUS

SOLUTION

3 PA

AVASTIN

INTRAVENOUS

SOLUTION

5 NEDS

BAVENCIO

INTRAVENOUS

SOLUTION

5 PA; NEDS

BESPONSA

INTRAVENOUS

RECON SOLN

5 PA; NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


35

BLINCYTO

INTRAVENOUS

KIT

5 B/D PA;

NEDS

CYRAMZA

INTRAVENOUS

SOLUTION

5 PA; NEDS

DARZALEX

INTRAVENOUS

SOLUTION

5 PA; LA;

NEDS

EMPLICITI

INTRAVENOUS

RECON SOLN

5 PA; NEDS

ERBITUX

INTRAVENOUS

SOLUTION 100

MG/50 ML

4

ERBITUX

INTRAVENOUS

SOLUTION 200

MG/100 ML

3

GAZYVA

INTRAVENOUS

SOLUTION

5 PA; NEDS

HERCEPTIN

INTRAVENOUS

RECON SOLN

5 B/D PA;

NEDS

IMFINZI

INTRAVENOUS

SOLUTION

5 PA; NEDS

JEVTANA

INTRAVENOUS

SOLUTION

5 PA; NEDS

KADCYLA

INTRAVENOUS

RECON SOLN

5 B/D PA;

NEDS

Drug Name Drug

Tier

Requirements

/Limits

KEYTRUDA

INTRAVENOUS

SOLUTION

5 NEDS

LARTRUVO

INTRAVENOUS

SOLUTION

5 PA; NEDS

MYLOTARG

INTRAVENOUS

RECON SOLN

5 PA; NEDS

OPDIVO

INTRAVENOUS

SOLUTION

5 NEDS

PERJETA

INTRAVENOUS

SOLUTION

5 NEDS

RITUXAN

HYCELA

SUBCUTANEOUS

SOLUTION

5 PA; NEDS

RITUXAN

INTRAVENOUS

CONCENTRATE

5 PA; NEDS

TECENTRIQ

INTRAVENOUS

SOLUTION

5 PA; NEDS

VECTIBIX

INTRAVENOUS

SOLUTION

5 NEDS

YERVOY

INTRAVENOUS

SOLUTION

5 PA; NEDS

ZALTRAP

INTRAVENOUS

SOLUTION

5 NEDS

RETINOIDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


36

bexarotene oral

capsule

5 PA; NEDS

PANRETIN

TOPICAL GEL

3

TARGRETIN

TOPICAL GEL

5 PA; NEDS

tretinoin

(chemotherapy) oral

capsule

5 NEDS

TREATMENT ADJUNCTS

allopurinol sodium

intravenous recon

soln

4

aloprim intravenous

recon soln

4

FUSILEV

INTRAVENOUS

RECON SOLN

5 NEDS

levoleucovorin

intravenous recon

soln 50 mg

2

levoleucovorin


4

mesna intravenous

solution

4

MESNEX ORAL

TABLET

4

SYLATRON

SUBCUTANEOUS

KIT

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits

ANTIPARASITICS

ANTHELMINTICS

ALBENZA ORAL

TABLET

4

BILTRICIDE

ORAL TABLET

3

ivermectin oral

tablet

2

praziquantel oral

tablet

2

ANTIHELMINTICS

SKLICE TOPICAL

LOTION

4

ANTIPROTOZOALS

ALINIA ORAL

SUSPENSION FOR

RECONSTITUTIO

N

3

ALINIA ORAL

TABLET

3

atovaquone oral

suspension

5 NEDS

atovaquone-

proguanil oral tablet

2

chloroquine

phosphate oral

tablet

2

COARTEM ORAL

TABLET

3

DARAPRIM ORAL

TABLET

3

hydroxychloroquine

oral tablet

1

mefloquine oral

tablet

2

NEBUPENT

INHALATION

RECON SOLN

4 B/D PA

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


37

PENTAM

INJECTION

RECON SOLN

4

PRIMAQUINE

ORAL TABLET

3

quinine sulfate oral

capsule

2

PEDICULICIDES/SCABICIDES

EURAX TOPICAL

LOTION

3

lindane topical

shampoo

2

malathion topical

lotion

4

permethrin topical

cream

2

Drug Name Drug

Tier

Requirements

/Limits

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine injection

solution

4

benztropine oral

tablet

2

trihexyphenidyl oral

elixir

2

trihexyphenidyl oral

tablet

2

ANTIPARKINSON AGENTS, OTHER

entacapone oral

tablet

2

tolcapone oral tablet 2

DOPAMINE AGONISTS

APOKYN

SUBCUTANEOUS

CARTRIDGE

5 NEDS

bromocriptine oral

capsule

2

bromocriptine oral

tablet

2

NEUPRO

TRANSDERMAL

PATCH 24 HOUR

4

pramipexole oral

tablet

2

pramipexole oral

tablet extended

release 24 hr

4

ropinirole oral tablet 2

ropinirole oral tablet

extended release 24

hr

2

DOPAMINE PRECURSORS/ L-

AMINO ACID DECARBOXYLASE

INHIBITORS

carbidopa oral

tablet

2

carbidopa-levodopa

oral tablet

2

carbidopa-levodopa


release

2

carbidopa-levodopa

oral


2

carbidopa-levodopa-

entacapone oral

tablet

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


38

MONOAMINE OXIDASE B (MAO-B)

INHIBITORS

rasagiline oral tablet 2

selegiline hcl oral

capsule

2

selegiline hcl oral

tablet

2

ZELAPAR ORAL

TABLET,DISINTE

GRATING

4

Drug Name Drug

Tier

Requirements

/Limits

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

ADASUVE

INHALATION AEROSOL POWDR

BREATH ACTIVATED

5

NEDS

chlorpromazine

injection solution

4

chlorpromazine oral

tablet

4

fluphenazine

decanoate injection

solution

4

fluphenazine hcl

injection solution

4

fluphenazine hcl oral

concentrate

2


elixir

2


tablet

2

haloperidol

decanoate

intramuscular

solution

4

haloperidol lactate

injection solution

4

haloperidol lactate

intramuscular

syringe

4

haloperidol lactate

oral concentrate

2

haloperidol oral

tablet

2

loxapine succinate

oral capsule

2

perphenazine oral

tablet

2

pimozide oral tablet 2

prochlorperazine

edisylate injection

solution 10 mg/2 ml

(5 mg/ml)

4

prochlorperazine

maleate oral tablet

2

thioridazine oral

tablet

2

thiothixene oral

capsule

2

trifluoperazine oral

tablet

2

2ND GENERATION/ATYPICAL

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


39

ABILIFY

MAINTENA

INTRAMUSCULA

R

SUSPENSION,EXT

ENDED REL

RECON

5 ST; NEDS

ABILIFY

MAINTENA

INTRAMUSCULA

R

SUSPENSION,EXT

ENDED REL

SYRING

5 ST; NEDS

aripiprazole oral

solution

4

aripiprazole oral

tablet

4

aripiprazole oral


2

ARISTADA

INTRAMUSCULA

R

SUSPENSION,EXT

ENDED REL

SYRING

5 ST; NEDS

FANAPT ORAL

TABLET

4

FANAPT ORAL

TABLETS,DOSE

PACK

4

GEODON

INTRAMUSCULA

R RECON SOLN

4

Drug Name Drug

Tier

Requirements

/Limits

INVEGA

SUSTENNA

INTRAMUSCULA

R SYRINGE 117

MG/0.75 ML, 156

MG/ML, 234

MG/1.5 ML, 78

MG/0.5 ML

5 ST; NEDS

INVEGA

SUSTENNA

INTRAMUSCULA

R SYRINGE 39

MG/0.25 ML

4 ST

INVEGA TRINZA

INTRAMUSCULA

R SYRINGE

5 PA; NEDS

LATUDA ORAL

TABLET

4 ST

NUPLAZID ORAL

TABLET

5 PA; NEDS

olanzapine

intramuscular recon

soln

4

olanzapine oral

tablet

2

olanzapine oral


2

paliperidone oral

tablet extended

release 24hr

2

quetiapine oral

tablet

2

quetiapine oral

tablet extended

release 24 hr

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


40

REXULTI ORAL

TABLET

5 ST; NEDS

RISPERDAL

CONSTA

INTRAMUSCULA

R SYRINGE 12.5

MG/2 ML, 25 MG/2

ML

4 ST

RISPERDAL

CONSTA

INTRAMUSCULA

R SYRINGE 37.5

MG/2 ML, 50 MG/2

ML

5 ST; NEDS

risperidone oral

solution

2

risperidone oral

tablet

2

risperidone oral


2

SAPHRIS (BLACK

CHERRY)

SUBLINGUAL

TABLET

4 ST

VRAYLAR ORAL

CAPSULE

5 ST; NEDS

VRAYLAR ORAL

CAPSULE,DOSE

PACK

4 ST

ziprasidone hcl oral

capsule

2

Drug Name Drug

Tier

Requirements

/Limits

ZYPREXA

RELPREVV

INTRAMUSCULA

R SUSPENSION

FOR

RECONSTITUTIO

N

5 NEDS

TREATMENT-RESISTANT

clozapine oral tablet 2

clozapine oral


100 mg, 12.5 mg, 25

mg

2

CLOZAPINE

ORAL

TABLET,DISINTE

GRATING 150 MG

4

CLOZAPINE

ORAL

TABLET,DISINTE

GRATING 200 MG

5 NEDS

FAZACLO ORAL

TABLET,DISINTE

GRATING 150 MG,

200 MG

5 NEDS

VERSACLOZ

ORAL

SUSPENSION

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits

ANTISPASTICITY AGENTS

ANTISPASTICITY AGENTS

baclofen oral tablet

10 mg, 20 mg

2

dantrolene oral

capsule

2

tizanidine oral tablet 2


5-Specialty Drugs



Therapy


41

Drug Name Drug

Tier

Requirements

/Limits

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV)

AGENTS

cidofovir


4

foscarnet


2 B/D PA

ganciclovir sodium

intravenous recon

soln

4 B/D PA

ganciclovir sodium


4 B/D PA

valganciclovir oral

recon soln

5 NEDS

valganciclovir oral

tablet

5 NEDS

ZIRGAN

OPHTHALMIC

(EYE) GEL

3

ANTI-HEPATITIS B (HBV) AGENTS

adefovir oral tablet 5 NEDS

BARACLUDE

ORAL SOLUTION

4

entecavir oral tablet 5 NEDS

EPIVIR HBV

ORAL SOLUTION

4

INTRON A

INJECTION

RECON SOLN

5 NEDS

INTRON A

INJECTION

SOLUTION

5 NEDS

lamivudine oral

tablet 100 mg

2

ANTI-HEPATITIS C (HCV) AGENTS,

DIRECT ACTING AGENTS

EPCLUSA ORAL

TABLET

5 PA; NEDS

HARVONI ORAL

TABLET

5 PA; NEDS

SOVALDI ORAL

TABLET

5 PA; NEDS

VOSEVI ORAL

TABLET

5 PA; NEDS

ANTI-HEPATITIS C (HCV) AGENTS,

OTHER

moderiba dose pack

oral tablets,dose

pack 200 mg (28)-

400 mg (28), 400 mg

(7)- 400 mg (7), 600

mg (7)- 600 mg (7)

5 NEDS

ribasphere ribapak

oral tablets,dose

pack 200 mg (28)-

400 mg (28), 400 mg

(7)- 400 mg (7), 600

mg (7)- 400 mg (7),

600 mg (7)- 600 mg

(7)

5 NEDS

ANTI-HEPATITIS C (HCV) AGENTS

moderiba dose pack

oral tablets,dose

pack 400-400 mg

(28)-mg (28), 600-

400 mg (28)-mg

(28), 600-600 mg

(28)-mg (28)

5 NEDS

moderiba oral tablet 4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


42

PEGASYS

PROCLICK

SUBCUTANEOUS

PEN INJECTOR

5 QL (4 per 28

days); NEDS

PEGASYS

SUBCUTANEOUS

SOLUTION

5 QL (4 per 28

days); NEDS

PEGASYS

SUBCUTANEOUS

SYRINGE

5 QL (4 per 28

days); NEDS

PEGINTRON

SUBCUTANEOUS

KIT 50 MCG/0.5

ML

5 QL (4 per 28

days); NEDS

REBETOL ORAL

SOLUTION

3

ribasphere oral

capsule

4

ribasphere oral

tablet

4

ribasphere ribapak

oral tablets,dose

pack 200 mg (7)-

400 mg (7), 400-400

mg (28)-mg (28),

600-400 mg (28)-mg

(28), 600-600 mg

(28)-mg (28)

5 NEDS

ribavirin oral

capsule

4

ribavirin oral tablet

200 mg

4

ANTIHERPETIC AGENTS

acyclovir oral

capsule

2

Drug Name Drug

Tier

Requirements

/Limits

acyclovir oral

suspension 200 mg/5

ml

2

acyclovir oral tablet 2

acyclovir sodium


4 B/D PA

acyclovir topical

ointment

4

DENAVIR

TOPICAL CREAM

4

famciclovir oral

tablet

2

trifluridine

ophthalmic (eye)

drops

2

valacyclovir oral

tablet

2

ZOVIRAX

TOPICAL CREAM

4

ANTI-HIV AGENTS, INTEGRASE

INHIBITORS (INSTI)

BIKTARVY ORAL

TABLET

5 NEDS

GENVOYA ORAL

TABLET

5 NEDS

ISENTRESS HD

ORAL TABLET

5 NEDS

ISENTRESS ORAL

POWDER IN

PACKET

5 NEDS

ISENTRESS ORAL

TABLET

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


43

ISENTRESS ORAL

TABLET,CHEWAB

LE 100 MG

5 NEDS

ISENTRESS ORAL

TABLET,CHEWAB

LE 25 MG

3

JULUCA ORAL

TABLET

5 NEDS

STRIBILD ORAL

TABLET

5 NEDS

TIVICAY ORAL

TABLET 10 MG

4

TIVICAY ORAL

TABLET 25 MG, 50

MG

5 NEDS

ANTI-HIV AGENTS, NON-

NUCLEOSIDE REVERSE

TRANSCRIPTASE INHIBITORS

(NNRTI)

ATRIPLA ORAL

TABLET

5 NEDS

COMPLERA ORAL

TABLET

5 NEDS

DESCOVY ORAL

TABLET

5 NEDS

EDURANT ORAL

TABLET

5 NEDS

efavirenz oral

capsule 200 mg

4

efavirenz oral

capsule 50 mg

2

efavirenz oral tablet 5 NEDS

INTELENCE ORAL

TABLET 100 MG,

200 MG

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits

INTELENCE ORAL

TABLET 25 MG

3

nevirapine oral

tablet

2

nevirapine oral

tablet extended

release 24 hr

2

RESCRIPTOR

ORAL TABLET

4

RESCRIPTOR

ORAL TABLET,

DISPERSIBLE

4

SUSTIVA ORAL

CAPSULE 200 MG

5 NEDS

SUSTIVA ORAL

CAPSULE 50 MG

3

SUSTIVA ORAL

TABLET

5 NEDS

VIRAMUNE ORAL

SUSPENSION

4

ANTI-HIV AGENTS, NUCLEOSIDE

AND NUCLEOTIDE REVERSE

TRANSCRIPTASE INHIBITORS

(NRTI)

abacavir oral

solution

2

abacavir oral tablet 4

abacavir-lamivudine

oral tablet

5 NEDS

abacavir-

lamivudine-

zidovudine oral

tablet

5 NEDS

CIMDUO ORAL

TABLET

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


44

didanosine oral

capsule,delayed

release(dr/ec) 200

mg, 250 mg, 400 mg

2

EMTRIVA ORAL

CAPSULE

3

EMTRIVA ORAL

SOLUTION

3

lamivudine oral

solution

2

lamivudine oral

tablet 150 mg, 300

mg

2

lamivudine-

zidovudine oral

tablet

2

ODEFSEY ORAL

TABLET

5 NEDS

RETROVIR

INTRAVENOUS

SOLUTION

4

stavudine oral

capsule

2

SYMFI LO ORAL

TABLET

5 NEDS

SYMFI ORAL

TABLET

5 NEDS

tenofovir disoproxil

fumarate oral tablet

5 NEDS

TRIUMEQ ORAL

TABLET

5 NEDS

TRUVADA ORAL

TABLET

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits

VIDEX 2 GRAM

PEDIATRIC ORAL

RECON SOLN

3

VIDEX 4 GRAM

PEDIATRIC ORAL

RECON SOLN

3

VIDEX EC ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

125 MG

3

VIREAD ORAL

POWDER

5 NEDS

VIREAD ORAL

TABLET

5 NEDS

ZERIT ORAL

RECON SOLN

5 NEDS

ZIAGEN ORAL

SOLUTION

3

zidovudine oral

capsule

2

zidovudine oral

syrup

2

zidovudine oral

tablet

2

ANTI-HIV AGENTS, OTHER

FUZEON

SUBCUTANEOUS

RECON SOLN

5 NEDS

SELZENTRY

ORAL SOLUTION

5 NEDS

SELZENTRY

ORAL TABLET

150 MG, 300 MG,

75 MG

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


45

SELZENTRY

ORAL TABLET 25

MG

4

TROGARZO

INTRAVENOUS

SOLUTION

5 NEDS

TYBOST ORAL

TABLET

3

ANTI-HIV AGENTS, PROTEASE

INHIBITORS

APTIVUS ORAL

CAPSULE

5 NEDS

APTIVUS ORAL

SOLUTION

5 NEDS

atazanavir oral

capsule 150 mg, 200

mg

4

atazanavir oral

capsule 300 mg

5 NEDS

CRIXIVAN ORAL

CAPSULE 200 MG,

400 MG

3

EVOTAZ ORAL

TABLET

5 NEDS

fosamprenavir oral

tablet

5 NEDS

INVIRASE ORAL

CAPSULE

5 NEDS

INVIRASE ORAL

TABLET

5 NEDS

KALETRA ORAL

TABLET 100-25

MG

4

Drug Name Drug

Tier

Requirements

/Limits

KALETRA ORAL

TABLET 200-50

MG

5 NEDS

LEXIVA ORAL

SUSPENSION

4

LEXIVA ORAL

TABLET

5 NEDS

lopinavir-ritonavir

oral solution

5 NEDS

NORVIR ORAL

CAPSULE

3

NORVIR ORAL

SOLUTION

3

NORVIR ORAL

TABLET

3

PREZCOBIX

ORAL TABLET

5 NEDS

PREZISTA ORAL

SUSPENSION

5 NEDS

PREZISTA ORAL

TABLET 150 MG,

75 MG

4

PREZISTA ORAL

TABLET 600 MG,

800 MG

5 NEDS

REYATAZ ORAL

CAPSULE 150 MG,

200 MG, 300 MG

5 NEDS

REYATAZ ORAL

POWDER IN

PACKET

5 NEDS

ritonavir oral tablet 2

VIRACEPT ORAL

TABLET

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


46

ANTI-INFLUENZA AGENTS

amantadine hcl oral

capsule

2

amantadine hcl oral

solution

2

amantadine hcl oral

tablet

2

oseltamivir oral

capsule 30 mg

2 QL (56 per

180 days)

oseltamivir oral

capsule 45 mg, 75

mg

2 QL (28 per

180 days)

oseltamivir oral

suspension for

reconstitution

2 QL (360 per

180 days)

RELENZA

DISKHALER

INHALATION

BLISTER WITH

DEVICE

4 QL (180 per

90 days)

rimantadine oral

tablet

2

TAMIFLU ORAL

SUSPENSION FOR

RECONSTITUTIO

N

3 QL (360 per

180 days)

Drug Name Drug

Tier

Requirements

/Limits

ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone oral tablet 2

meprobamate oral

tablet

4

BENZODIAZEPINES

alprazolam intensol

oral concentrate

2

alprazolam oral

tablet

2

clonazepam oral

tablet

2

clonazepam oral


2

clorazepate

dipotassium oral

tablet

2

diazepam intensol

oral concentrate

2

diazepam oral

concentrate

2

diazepam oral

solution 5 mg/5 ml

(1 mg/ml)

2

diazepam oral tablet 2

estazolam oral tablet 4

lorazepam intensol

oral concentrate

2

lorazepam oral

concentrate

2

lorazepam oral

tablet

2

triazolam oral tablet 4

Drug Name Drug

Tier

Requirements

/Limits

BIPOLAR AGENTS

MOOD STABILIZERS

lithium carbonate

oral capsule

2

lithium carbonate

oral tablet

2


5-Specialty Drugs




Therapy


47

lithium carbonate


release

2

lithium citrate oral

solution 8 meq/5 ml

2

Drug Name Drug

Tier

Requirements

/Limits

BLOOD GLUCOSE

REGULATORS

ANTIDIABETIC AGENTS

acarbose oral tablet 2

BYDUREON

BCISE

SUBCUTANEOUS

AUTO-INJECTOR

3 PA; QL (10.2

per 84 days)

BYDUREON

SUBCUTANEOUS

PEN INJECTOR

3 PA; QL (12

per 84 days)

BYDUREON

SUBCUTANEOUS

SUSPENSION,EXT

ENDED REL

RECON

3 PA; QL (12

per 84 days)

BYETTA

SUBCUTANEOUS

PEN INJECTOR 10

MCG/DOSE(250

MCG/ML) 2.4 ML

4 PA; QL (7.2

per 84 days)

BYETTA

SUBCUTANEOUS

PEN INJECTOR 5

MCG/DOSE (250

MCG/ML) 1.2 ML

4 PA; QL (3.6

per 84 days)

CYCLOSET ORAL

TABLET

4 QL (540 per

90 days)

FARXIGA ORAL

TABLET

3 ST; QL (90 per

90 days)

glimepiride oral

tablet

1

glipizide oral tablet 1

glipizide oral tablet

extended release

24hr 10 mg

1 QL (180 per

90 days)

glipizide oral tablet

extended release

24hr 2.5 mg, 5 mg

1 QL (270 per

90 days)

glipizide-metformin

oral tablet

1

INVOKAMET

ORAL TABLET

150-1,000 MG, 150-

500 MG, 50-1,000

MG

3 ST; QL (180

per 90 days)

INVOKAMET

ORAL TABLET 50-

500 MG

3 ST; QL (360

per 90 days)

INVOKAMET XR

ORAL TABLET, IR

- ER, BIPHASIC

24HR 150-1,000

MG, 150-500 MG,

50-1,000 MG

3 ST; QL (180

per 90 days)

INVOKAMET XR

ORAL TABLET, IR

- ER, BIPHASIC

24HR 50-500 MG

3 ST; QL (360

per 90 days)

INVOKANA ORAL

TABLET 100 MG

3 ST; QL (180

per 90 days)

INVOKANA ORAL

TABLET 300 MG

3 ST; QL (90 per

90 days)

JANUMET ORAL

TABLET

3 QL (180 per

90 days)

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


48

JANUMET XR

ORAL TABLET,

ER MULTIPHASE

24 HR 100-1,000

MG

3 QL (90 per 90

days)

JANUMET XR

ORAL TABLET,

ER MULTIPHASE

24 HR 50-1,000

MG, 50-500 MG

3 QL (180 per

90 days)

JANUVIA ORAL

TABLET

3 QL (90 per 90

days)

KOMBIGLYZE XR

ORAL TABLET,

ER MULTIPHASE

24 HR 2.5-1,000

MG

3 QL (180 per

90 days)

KOMBIGLYZE XR

ORAL TABLET,

ER MULTIPHASE

24 HR 5-1,000 MG,

5-500 MG

3 QL (90 per 90

days)

metformin oral

tablet

1

metformin oral

tablet extended

release 24 hr 500 mg

1 QL (360 per

90 days)

metformin oral

tablet extended

release 24 hr 750 mg

1 QL (180 per

90 days)

metformin oral

tablet extended

release (osm) 24 hr

1,000 mg

1 QL (180 per

90 days)

Drug Name Drug

Tier

Requirements

/Limits

metformin oral

tablet extended

release (osm) 24 hr

500 mg

1 QL (450 per

90 days)

metformin oral

tablet,er

gast.retention 24 hr

500 mg

1 QL (360 per

90 days)

miglitol oral tablet 2

nateglinide oral

tablet

1

ONGLYZA ORAL

TABLET

3 QL (90 per 90

days)

pioglitazone oral

tablet

1 QL (90 per 90

days)

pioglitazone-

glimepiride oral

tablet

1 QL (90 per 90

days)

pioglitazone-

metformin oral

tablet

1 QL (270 per

90 days)

repaglinide oral

tablet

1

repaglinide-

metformin oral

tablet

1

SYMLINPEN 120

SUBCUTANEOUS

PEN INJECTOR

4

SYMLINPEN 60

SUBCUTANEOUS

PEN INJECTOR

4

tolazamide oral

tablet

1

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


49

tolbutamide oral

tablet

1

VICTOZA 2-PAK

SUBCUTANEOUS

PEN INJECTOR

3 PA; QL (27

per 90 days)

VICTOZA 3-PAK

SUBCUTANEOUS

PEN INJECTOR

3 PA; QL (27

per 90 days)

XIGDUO XR

ORAL TABLET, IR

- ER, BIPHASIC

24HR 10-1,000 MG,

10-500 MG

3 ST; QL (90 per

90 days)

XIGDUO XR

ORAL TABLET, IR

- ER, BIPHASIC

24HR 2.5-1,000

MG, 5-1,000 MG, 5-

500 MG

3 ST; QL (180

per 90 days)

GLYCEMIC AGENTS

GLUCAGEN

HYPOKIT

INJECTION

RECON SOLN

3

GLUCAGON

EMERGENCY KIT

(HUMAN)

INJECTION KIT

3

KORLYM ORAL

TABLET

5 PA; NEDS

PROGLYCEM

ORAL

SUSPENSION

4

INSULINS

Drug Name Drug

Tier

Requirements

/Limits

HUMALOG

KWIKPEN

INSULIN

SUBCUTANEOUS

INSULIN PEN 200

UNIT/ML (3 ML)

4 ST

HUMULIN R U-500

(CONC) INSULIN

SUBCUTANEOUS

SOLUTION

3

HUMULIN R U-500

(CONC) KWIKPEN

SUBCUTANEOUS

INSULIN PEN

3

LANTUS

SOLOSTAR U-100

INSULIN

SUBCUTANEOUS

INSULIN PEN

3

LANTUS U-100

INSULIN

SUBCUTANEOUS

SOLUTION

3

NOVOLIN 70/30 U-

100 INSULIN

SUBCUTANEOUS

SUSPENSION

3

NOVOLIN N NPH

U-100 INSULIN

SUBCUTANEOUS

SUSPENSION

3

NOVOLIN R

REGULAR U-100

INSULN

INJECTION

SOLUTION

3

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


50

NOVOLOG

FLEXPEN U-100

INSULIN

SUBCUTANEOUS

INSULIN PEN

3

NOVOLOG MIX

70-30 U-100

INSULN

SUBCUTANEOUS

SOLUTION

3

NOVOLOG MIX

70-30FLEXPEN U-

100

SUBCUTANEOUS

INSULIN PEN

3

NOVOLOG

PENFILL U-100

INSULIN

SUBCUTANEOUS

CARTRIDGE

3

NOVOLOG U-100

INSULIN ASPART

SUBCUTANEOUS

SOLUTION

3

TOUJEO MAX

SOLOSTAR

SUBCUTANEOUS

INSULIN PEN

3

TOUJEO

SOLOSTAR U-300

INSULIN

SUBCUTANEOUS

INSULIN PEN

3

Drug Name Drug

Tier

Requirements

/Limits

BLOOD

PRODUCTS/MODIFIERS/VOLU

ME EXPANDERS

ANTICOAGULANTS

BEVYXXA ORAL

CAPSULE

4

COUMADIN ORAL

TABLET

4

ELIQUIS ORAL

TABLET

3

enoxaparin

subcutaneous

solution

4

enoxaparin

subcutaneous

syringe

4

fondaparinux

subcutaneous

syringe

4

FRAGMIN

SUBCUTANEOUS

SOLUTION

4

FRAGMIN

SUBCUTANEOUS

SYRINGE

4

heparin (porcine) in

5 % dex intravenous

parenteral solution

4

heparin (porcine)

injection cartridge

4

heparin (porcine)

injection solution

4

heparin (porcine)

injection syringe

5,000 unit/ml

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


51

heparin(porcine) in

0.45% nacl

intravenous

parenteral solution

25,000 unit/250 ml,

25,000 unit/500 ml

4

heparin, porcine (pf)

injection solution

5,000 unit/0.5 ml

4

heparin, porcine (pf)

injection syringe

4

jantoven oral tablet 1

PRADAXA ORAL

CAPSULE

4

warfarin oral tablet 1

XARELTO ORAL

TABLET

3

XARELTO ORAL

TABLETS,DOSE

PACK

3

BLOOD FORMATION MODIFIERS

anagrelide oral

capsule

2

ARANESP (IN

POLYSORBATE)

INJECTION

SOLUTION 100

MCG/ML, 200

MCG/ML, 300

MCG/ML, 60

MCG/ML

5 PA; NEDS

Drug Name Drug Tier

Requirements

/Limits

ARANESP (IN

POLYSORBATE)

INJECTION

SOLUTION 25

MCG/ML, 40

MCG/ML

4 PA

ARANESP (IN

POLYSORBATE)

INJECTION

SYRINGE 10

MCG/0.4 ML, 25

MCG/0.42 ML, 40

MCG/0.4 ML

4 PA

ARANESP (IN

POLYSORBATE)

INJECTION

SYRINGE 100

MCG/0.5 ML, 150

MCG/0.3 ML, 200

MCG/0.4 ML, 300

MCG/0.6 ML, 500

MCG/ML, 60

MCG/0.3 ML

5 PA; NEDS

EPOGEN

INJECTION

SOLUTION 10,000

UNIT/ML, 2,000

UNIT/ML, 20,000

UNIT/2 ML, 20,000

UNIT/ML, 3,000

UNIT/ML, 4,000

UNIT/ML

4 PA

LEUKINE

INJECTION

RECON SOLN

5 NEDS

MOZOBIL

SUBCUTANEOUS

SOLUTION

5 PA; NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


52

NEULASTA

SUBCUTANEOUS

SYRINGE

5 QL (1.2 per 28

days); NEDS

NEULASTA

SUBCUTANEOUS

SYRINGE, W/

WEARABLE

INJECTOR

5 QL (1.2 per 28

days); NEDS

NEUPOGEN

INJECTION

SOLUTION

5 NEDS

NEUPOGEN

INJECTION

SYRINGE

5 NEDS

NPLATE

SUBCUTANEOUS

RECON SOLN

5 PA; NEDS

PROCRIT

INJECTION

SOLUTION 10,000

UNIT/ML, 2,000

UNIT/ML, 20,000

UNIT/2 ML, 3,000

UNIT/ML, 4,000

UNIT/ML

4 PA

PROCRIT

INJECTION

SOLUTION 20,000

UNIT/ML, 40,000

UNIT/ML

5 PA; NEDS

PROMACTA

ORAL TABLET

5 PA; NEDS

ZARXIO

INJECTION

SYRINGE

5 NEDS

HEMOSTASIS AGENTS

Drug Name Drug Tier

Requirements

/Limits

AMICAR ORAL

TABLET 1,000 MG

4

tranexamic acid


4

tranexamic acid oral

tablet

2 QL (90 per 63

days)

PLATELET MODIFYING AGENTS

aspirin-dipyridamole

oral capsule, er

multiphase 12 hr

4

BRILINTA ORAL

TABLET

3

cilostazol oral tablet 2

clopidogrel oral

tablet 75 mg

2

EFFIENT ORAL

TABLET

3

prasugrel oral tablet 2

Drug Name Drug

Tier

Requirements

/Limits

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

clonidine (pf)

epidural solution

2

clonidine hcl oral

tablet

2

clonidine

transdermal patch

weekly

1 QL (12 per 84

days)

midodrine oral

tablet

2

ALPHA-ADRENERGIC BLOCKING

AGENTS

doxazosin oral tablet 2


5-Specialty Drugs



Therapy


53

prazosin oral

capsule

2

terazosin oral

capsule

2

ANGIOTENSIN II II RECEPTOR

ANTAGONISTS

candesartan oral

tablet

1

candesartan-

hydrochlorothiazid

oral tablet

2

eprosartan oral

tablet

1

irbesartan oral

tablet

1

irbesartan-

hydrochlorothiazide

oral tablet

2

losartan oral tablet 1

losartan-

hydrochlorothiazide

oral tablet

1

olmesartan oral

tablet

1

olmesartan-

hydrochlorothiazide

oral tablet

1

telmisartan oral

tablet

1

telmisartan-

hydrochlorothiazid

oral tablet

2

valsartan oral tablet 1

Drug Name Drug

Tier

Requirements

/Limits

valsartan-

hydrochlorothiazide

oral tablet

2

ANGIOTENSIN-CONVERTING

ENZYME (ACE) INHIBITORS

benazepril oral

tablet

1

benazepril-

hydrochlorothiazide

oral tablet

2

captopril oral tablet 1

captopril-

hydrochlorothiazide

oral tablet

2

enalapril maleate

oral tablet

1

enalapril-

hydrochlorothiazide

oral tablet

2

fosinopril oral tablet 1

fosinopril-

hydrochlorothiazide

oral tablet

2

lisinopril oral tablet 1

lisinopril-

hydrochlorothiazide

oral tablet

1

moexipril oral tablet 1

moexipril-

hydrochlorothiazide

oral tablet

2

perindopril

erbumine oral tablet

1

quinapril oral tablet 1

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


54

quinapril-

hydrochlorothiazide

oral tablet

2

ramipril oral

capsule

1

trandolapril oral

tablet

1

ANTIARRHYTHMICS

adenosine

intravenous syringe

4

amiodarone


4

amiodarone

intravenous syringe

4

amiodarone oral

tablet

2

dofetilide oral

capsule

2

flecainide oral tablet 2

mexiletine oral

capsule

2

MULTAQ ORAL

TABLET

3 QL (180 per

90 days)

NORPACE CR

ORAL CAPSULE,

EXTENDED

RELEASE

4

pacerone oral tablet

100 mg, 200 mg, 400

mg

2

procainamide

injection solution

4

Drug Name Drug

Tier

Requirements

/Limits

propafenone oral

capsule,extended

release 12 hr

4

propafenone oral

tablet

2

quinidine gluconate

injection solution

4

quinidine gluconate


release

4

quinidine sulfate

oral tablet

2

sorine oral tablet 2

sotalol af oral tablet 2

sotalol oral tablet 2

BETA-ADRENERGIC BLOCKING

AGENTS

acebutolol oral

capsule

2

atenolol oral tablet 1

atenolol-

chlorthalidone oral

tablet

2

betaxolol oral tablet 1

bisoprolol fumarate

oral tablet

1

bisoprolol-

hydrochlorothiazide

oral tablet

2

carvedilol oral tablet 1

carvedilol phosphate

oral capsule, er

multiphase 24 hr

2 QL (90 per 90

days)

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


55

COREG CR ORAL

CAPSULE, ER

MULTIPHASE 24

HR

4 QL (90 per 90

days)

labetalol


4

labetalol

intravenous syringe

20 mg/4 ml (5

mg/ml)

4

labetalol oral tablet 1

metoprolol succinate


release 24 hr

1 QL (180 per

90 days)

metoprolol ta-

hydrochlorothiaz

oral tablet

2

metoprolol tartrate


4

metoprolol tartrate

intravenous syringe

4

metoprolol tartrate

oral tablet 100 mg,

25 mg, 50 mg

1

nadolol oral tablet 1

pindolol oral tablet 1

propranolol


4

propranolol oral

capsule,extended

release 24 hr

1

propranolol oral

solution

2

propranolol oral

tablet

1

Drug Name Drug

Tier

Requirements

/Limits

propranolol-

hydrochlorothiazid

oral tablet

2

timolol maleate oral

tablet

1

CALCIUM CHANNEL BLOCKING

AGENTS

afeditab cr oral

tablet extended

release

2 QL (90 per 90

days)

amlodipine oral

tablet

1

cartia xt oral

capsule,extended

release 24hr

2

diltiazem hcl

intravenous recon

soln

4

diltiazem hcl


4

diltiazem hcl oral

capsule,ext.rel 24h

degradable

2

diltiazem hcl oral

capsule,extended

release 12 hr

2

diltiazem hcl oral

capsule,extended

release 24 hr

2

diltiazem hcl oral

capsule,extended

release 24hr

2

diltiazem hcl oral

tablet

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


56

diltiazem hcl oral

tablet extended

release 24 hr

1

dilt-xr oral

capsule,ext.rel 24h

degradable

2

felodipine oral tablet

extended release 24

hr

2 QL (90 per 90

days)

isradipine oral

capsule

2

matzim la oral tablet

extended release 24

hr

2

nicardipine


4

nicardipine oral

capsule

1

nifedipine oral tablet

extended release

2 QL (90 per 90

days)

nifedipine oral tablet

extended release

24hr

2 QL (90 per 90

days)

nimodipine oral

capsule

4

nisoldipine oral

tablet extended

release 24 hr 17 mg,

20 mg, 25.5 mg, 34

mg, 40 mg, 8.5 mg

4 QL (90 per 90

days)

nisoldipine oral

tablet extended

release 24 hr 30 mg

4 QL (180 per

90 days)

taztia xt oral

capsule,extended

release 24 hr

2

Drug Name Drug

Tier

Requirements

/Limits

verapamil


4

verapamil

intravenous syringe

4

verapamil oral

capsule, 24 hr er

pellet ct

2

verapamil oral

capsule,ext rel.

pellets 24 hr

2

verapamil oral tablet 1

verapamil oral tablet

extended release

2

CARDIOVASCULAR AGENTS,

OTHER

amlodipine-

atorvastatin oral

tablet

2 QL (90 per 90

days)

amlodipine-

benazepril oral

capsule

2

amlodipine-

olmesartan oral

tablet

2 QL (90 per 90

days)

amlodipine-

valsartan oral tablet

2

amlodipine-

valsartan-hcthiazid

oral tablet

2

BIDIL ORAL

TABLET

3

CORLANOR ORAL

TABLET

4 QL (180 per

90 days)

DEMSER ORAL

CAPSULE

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


57

digitek oral tablet

125 mcg

2 QL (90 per 90

days)

digitek oral tablet

250 mcg

2

digox oral tablet 125

mcg

2 QL (90 per 90

days)

digox oral tablet 250

mcg

2

digoxin injection

solution

4

digoxin oral solution

50 mcg/ml

2

digoxin oral tablet

125 mcg

2 QL (90 per 90

days)

digoxin oral tablet

250 mcg

2

ENTRESTO ORAL

TABLET

4

ezetimibe-

simvastatin oral

tablet

4 ST; QL (90 per

90 days)

nadolol-

bendroflumethiazide

oral tablet

2

NORTHERA ORAL

CAPSULE

5 NEDS

olmesartan-

amlodipin-hcthiazid

oral tablet

1 QL (90 per 90

days)

pentoxifylline oral

tablet extended

release

2

Drug Name Drug

Tier

Requirements

/Limits

RANEXA ORAL

TABLET

EXTENDED

RELEASE 12 HR

4

spironolacton-

hydrochlorothiaz

oral tablet

2

TEKTURNA HCT

ORAL TABLET

4 QL (90 per 90

days)

TEKTURNA ORAL

TABLET

4 QL (90 per 90

days)

telmisartan-

amlodipine oral

tablet

2

trandolapril-

verapamil oral

tablet, ir - er,

biphasic 24hr

2 QL (90 per 90

days)

triamterene-

hydrochlorothiazid

oral capsule

1

triamterene-

hydrochlorothiazid

oral tablet

1

VECAMYL ORAL

TABLET

5 PA; NEDS

DIURETICS, CARBONIC

ANHYDRASE INHIBITORS

acetazolamide oral

capsule, extended

release

2

acetazolamide oral

tablet

2

acetazolamide

sodium injection

recon soln

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


58

methazolamide oral

tablet

4

DIURETICS, LOOP

bumetanide injection

solution

4

bumetanide oral

tablet

1

ethacrynate sodium

intravenous recon

soln

4

furosemide injection

solution

4

furosemide injection

syringe

4

furosemide oral

solution 10 mg/ml,

40 mg/5 ml (8

mg/ml)

1

furosemide oral

tablet

1

torsemide oral tablet 2

DIURETICS, POTASSIUM-SPARING

amiloride oral tablet 2

amiloride-

hydrochlorothiazide

oral tablet

2

eplerenone oral

tablet

2

spironolactone oral

tablet

1

DIURETICS, THIAZIDE

chlorothiazide oral

tablet

1

Drug Name Drug

Tier

Requirements

/Limits

chlorothiazide

sodium intravenous

recon soln

4

chlorthalidone oral

tablet 25 mg, 50 mg

2

hydrochlorothiazide

oral capsule

1

hydrochlorothiazide

oral tablet

1

indapamide oral

tablet

1

methyclothiazide

oral tablet

2

metolazone oral

tablet

2

DYSLIPIDEMICS, FIBRIC ACID

DERIVATIVES

fenofibrate

micronized oral

capsule

4 QL (90 per 90

days)

fenofibrate

nanocrystallized

oral tablet

4

fenofibrate oral

tablet

4 QL (90 per 90

days)

fenofibric acid

(choline) oral

capsule,delayed

release(dr/ec) 135

mg

4 QL (90 per 90

days)

fenofibric acid

(choline) oral

capsule,delayed

release(dr/ec) 45 mg

4 QL (270 per

90 days)

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


59

fenofibric acid oral

tablet

4

gemfibrozil oral

tablet

2

TRIGLIDE ORAL

TABLET 160 MG

4 QL (90 per 90

days)

DYSLIPIDEMICS, HMG COA

REDUCTASE INHIBITORS

atorvastatin oral


40 mg

1

atorvastatin oral

tablet 80 mg

1 QL (90 per 90

days)

fluvastatin oral

capsule 20 mg

1 QL (360 per

90 days)

fluvastatin oral

capsule 40 mg

1 QL (180 per

90 days)

fluvastatin oral

tablet extended

release 24 hr

1 QL (90 per 90

days)

LIVALO ORAL

TABLET

4 ST

lovastatin oral tablet

10 mg, 20 mg

1 QL (270 per

90 days)

lovastatin oral tablet

40 mg

1 QL (180 per

90 days)

pravastatin oral

tablet

1 QL (90 per 90

days)

rosuvastatin oral

tablet

2 QL (90 per 90

days)

simvastatin oral

tablet

1 QL (90 per 90

days)

DYSLIPIDEMICS, OTHER

Drug Name Drug

Tier

Requirements

/Limits

cholestyramine (with

sugar) oral powder

4

cholestyramine (with

sugar) oral powder

in packet

4

cholestyramine light

oral powder

4

cholestyramine light

oral powder in

packet

4

colestipol oral

granules

4

colestipol oral

packet

4

colestipol oral tablet 4

ezetimibe oral tablet 2 QL (90 per 90

days)

JUXTAPID ORAL

CAPSULE

5 PA; NEDS

KYNAMRO

SUBCUTANEOUS

SYRINGE

5 PA; NEDS

niacin oral tablet

extended release 24

hr

4

omega-3 acid ethyl

esters oral capsule

4

PRALUENT PEN

SUBCUTANEOUS

PEN INJECTOR

5 PA; NEDS

prevalite oral

powder

4

prevalite oral

powder in packet

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


60

REPATHA

PUSHTRONEX

SUBCUTANEOUS

WEARABLE

INJECTOR

5 PA; NEDS

REPATHA

SUBCUTANEOUS

SYRINGE

5 PA; NEDS

REPATHA

SURECLICK

SUBCUTANEOUS

PEN INJECTOR

5 PA; NEDS

triklo oral capsule 4

VASCEPA ORAL

CAPSULE

4

WELCHOL ORAL

POWDER IN

PACKET

3

WELCHOL ORAL

TABLET

3

VASODILATORS, DIRECT-ACTING

ARTERIAL/VENOUS

epoprostenol

(glycine)

intravenous recon

soln

5 NEDS

FLOLAN

INTRAVENOUS

RECON SOLN

5 NEDS

isosorbide dinitrate

oral tablet

2

isosorbide dinitrate


release

2

Drug Name Drug

Tier

Requirements

/Limits

isosorbide

mononitrate oral

tablet

2

isosorbide

mononitrate oral

tablet extended

release 24 hr

2

nitro-bid

transdermal

ointment

4

NITRO-DUR

TRANSDERMAL

PATCH 24 HOUR

0.3 MG/HR, 0.8

MG/HR

4

nitroglycerin


4

nitroglycerin

sublingual tablet

2

nitroglycerin

transdermal patch

24 hour

2

nitroglycerin

translingual

spray,non-aerosol

4

veletri intravenous

recon soln

5 NEDS

VASODILATORS, DIRECT-ACTING

ARTERIAL

hydralazine injection

solution

4

hydralazine oral

tablet

2

minoxidil oral tablet 2

VASOPRESSORS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


61

norepinephrine

bitartrate


2

Drug Name Drug

Tier

Requirements

/Limits

CENTRAL NERVOUS SYSTEM

AGENTS

ATTENTION DEFICIT

HYPERACTIVITY DISORDER

AGENTS, AMPHETAMINES

dextroamphetamine

oral tablet

2 QL (540 per

90 days)

dextroamphetamine-

amphetamine oral

tablet 10 mg, 12.5

mg, 15 mg, 20 mg, 5

mg, 7.5 mg

2 QL (270 per

90 days)

dextroamphetamine-

amphetamine oral

tablet 30 mg

2 QL (180 per

90 days)

zenzedi oral tablet

10 mg, 5 mg

2 QL (540 per

90 days)

ATTENTION DEFICIT

HYPERACTIVITY DISORDER

AGENTS, NON-AMPHETAMINES

atomoxetine oral

capsule 10 mg, 18

mg, 25 mg, 40 mg,

60 mg

4 ST; QL (180

per 90 days)

atomoxetine oral

capsule 100 mg, 80

mg

4 ST; QL (90 per

90 days)

clonidine hcl oral

tablet extended

release 12 hr

2 QL (360 per

90 days)

guanfacine oral

tablet extended

release 24 hr

2

methylphenidate hcl

oral capsule, er

biphasic 30-70 20

mg, 40 mg

2

methylphenidate hcl

oral solution

2

methylphenidate hcl

oral tablet

2 QL (270 per

90 days)

CENTRAL NERVOUS SYSTEM,

OTHER

NUEDEXTA ORAL

CAPSULE

3 QL (180 per

90 days)

RADICAVA

INTRAVENOUS

PIGGYBACK

5 PA; NEDS

riluzole oral tablet 2

tetrabenazine oral

tablet 12.5 mg

5 PA; QL (248

per 31 days);

NEDS

tetrabenazine oral

tablet 25 mg

5 PA; QL (124

per 31 days);

NEDS

FIBROMYALGIA AGENTS

SAVELLA ORAL

TABLET

3 PA; QL (180

per 90 days)

SAVELLA ORAL

TABLETS,DOSE

PACK

4 PA; QL (165

per 84 days)

MULTIPLE SCLEROSIS AGENTS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


62

AMPYRA ORAL

TABLET

EXTENDED

RELEASE 12 HR

5 PA; QL (62

per 31 days);

NEDS

AUBAGIO ORAL

TABLET

5 PA; NEDS

AVONEX (WITH

ALBUMIN)

INTRAMUSCULA

R KIT

5 PA; NEDS

AVONEX

INTRAMUSCULA

R PEN INJECTOR

KIT

5 PA; NEDS

AVONEX

INTRAMUSCULA

R SYRINGE KIT

5 PA; NEDS

BETASERON

SUBCUTANEOUS

KIT

5 PA; NEDS

COPAXONE

SUBCUTANEOUS

SYRINGE 40

MG/ML

5 PA; NEDS

EXTAVIA

SUBCUTANEOUS

KIT

5 PA; NEDS

EXTAVIA

SUBCUTANEOUS

RECON SOLN

5 PA; NEDS

GILENYA ORAL

CAPSULE

5 PA; NEDS

glatiramer

subcutaneous

syringe

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits

glatopa

subcutaneous

syringe

5 NEDS

PLEGRIDY

SUBCUTANEOUS

PEN INJECTOR

5 PA; NEDS

PLEGRIDY

SUBCUTANEOUS

SYRINGE

5 PA; NEDS

REBIF (WITH

ALBUMIN)

SUBCUTANEOUS

SYRINGE

5 PA; NEDS

REBIF REBIDOSE

SUBCUTANEOUS

PEN INJECTOR

5 PA; NEDS

REBIF TITRATION

PACK

SUBCUTANEOUS

SYRINGE

5 PA; NEDS

TECFIDERA ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

5 PA; QL (62

per 31 days);

NEDS

TYSABRI

INTRAVENOUS

SOLUTION

5 PA; LA;

NEDS

Drug Name Drug

Tier

Requirements

/Limits

DENTAL AND ORAL AGENTS

DENTAL AND ORAL AGENTS

cevimeline oral

capsule

2

chlorhexidine

gluconate mucous

membrane

mouthwash

2

oralone dental paste 2


5-Specialty Drugs



Therapy


63

paroex oral rinse

mucous membrane

mouthwash

2

periogard mucous

membrane

mouthwash

2

pilocarpine hcl oral

tablet

2

triamcinolone

acetonide dental

paste

2

Drug Name Drug

Tier

Requirements

/Limits

DERMATOLOGICAL AGENTS

DERMATOLOGICAL AGENTS

acitretin oral

capsule

4

adapalene topical

cream

4

adapalene topical

gel 0.3 %

4

adapalene topical

gel with pump

4

ammonium lactate

topical cream

2

ammonium lactate

topical lotion

2

amnesteem oral

capsule

4

apexicon e topical

cream

4

avita topical cream 4

calcipotriene scalp

solution

4

calcipotriene topical

cream

4

calcipotriene topical

ointment

4

calcipotriene-

betamethasone

topical ointment

4

calcitrene topical

ointment

4

calcitriol topical

ointment

4

claravis oral capsule 4

clindamycin-benzoyl

peroxide topical gel

1.2 %(1 % base) -5

%

4

FINACEA

TOPICAL GEL

4

fluorouracil


1 gram/20 ml

2 B/D PA

FLUOROURACIL

TOPICAL CREAM

0.5 %

4

fluorouracil topical

cream 5 %

2

fluorouracil topical

solution

2

imiquimod topical

cream in packet

2

isotretinoin oral

capsule

2

methoxsalen oral

capsule,liqd-

filled,rapid rel

5 NEDS

myorisan oral

capsule

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


64

neuac topical gel 4

podofilox topical

solution

4

SANTYL TOPICAL

OINTMENT

4

selenium sulfide

topical lotion

2

STELARA

INTRAVENOUS

SOLUTION

5 PA; NEDS

STELARA

SUBCUTANEOUS

SOLUTION

5 PA; NEDS

STELARA

SUBCUTANEOUS

SYRINGE

5 PA; NEDS

TACLONEX

TOPICAL

SUSPENSION

4

tacrolimus topical

ointment

4

tazarotene topical

cream

4

TAZORAC

TOPICAL GEL

4

tretinoin topical

cream

4

tretinoin topical gel 4

UVADEX

INJECTION

SOLUTION

4

zenatane oral

capsule

4

Drug Name Drug

Tier

Requirements

/Limits

Drug Name Drug

Tier

Requirements

/Limits

ELECTROLYTES/MINERALS/

METALS/VITAMINS

ELECTROLYTE/MINERAL

REPLACEMENT

AMINOSYN 10 %

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

AMINOSYN 7 %

WITH

ELECTROLYTES

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

AMINOSYN 8.5 %

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

AMINOSYN II 10

% INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

AMINOSYN II 15

% INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

AMINOSYN II 7 %

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

AMINOSYN II 8.5

% INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA


5-Specialty Drugs



Therapy


65

AMINOSYN II 8.5

%-

ELECTROLYTES

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

AMINOSYN-HBC

7%

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

AMINOSYN-PF 10

% INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

AMINOSYN-PF 7

% (SULFITE-

FREE)

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

AMINOSYN-RF 5.2

% INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

calcium chloride


4

calcium chloride

intravenous syringe

4

calcium gluconate


4

CARBAGLU ORAL

TABLET,

DISPERSIBLE

5 LA; NEDS

Drug Name Drug

Tier

Requirements

/Limits

CLINIMIX

5%/D15W

SULFITE FREE

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

CLINIMIX

5%/D25W

SULFITE-FREE

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

CLINIMIX

2.75%/D5W

SULFIT FREE

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

CLINIMIX

4.25%/D10W SULF

FREE

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

CLINIMIX

4.25%/D5W

SULFIT FREE

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

CLINIMIX 4.25%-

D20W SULF-FREE

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


66

CLINIMIX 4.25%-

D25W SULF-FREE

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

CLINIMIX 5%-

D20W(SULFITE-

FREE)

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

CLINIMIX E

4.25%/D10W SUL

FREE

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

cysteine (l-cysteine)


2 B/D PA

d10 %-0.45 %

sodium chloride

intravenous

parenteral solution

4

d2.5 %-0.45 %

sodium chloride

intravenous

parenteral solution

4

d5 % and 0.9 %

sodium chloride

intravenous

parenteral solution

4

d5 %-0.45 % sodium

chloride intravenous

parenteral solution

4

denta 5000 plus

dental cream

2

Drug Name Drug

Tier

Requirements

/Limits

dextrose 10 % and

0.2 % nacl

intravenous

parenteral solution

4

dextrose 10 % in

water (d10w)

intravenous

parenteral solution

4 B/D PA

dextrose 20 % in

water (d20w)

intravenous

parenteral solution

4 B/D PA

dextrose 30 % in

water (d30w)

intravenous

parenteral solution

4 B/D PA

dextrose 40 % in

water (d40w)

intravenous

parenteral solution

4 B/D PA

dextrose 5 % in

water (d5w)

intravenous

parenteral solution

4

dextrose 5 % in

water (d5w)

intravenous

piggyback

4

dextrose 5 %-

lactated ringers

intravenous

parenteral solution

4

dextrose 5%-0.2 %

sod chloride

intravenous

parenteral solution

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


67

dextrose 5%-0.3 %

sod.chloride

intravenous

parenteral solution

4

dextrose 50 % in

water (d50w)

intravenous

parenteral solution

2 B/D PA

dextrose 70 % in

water (d70w)

intravenous

parenteral solution

4 B/D PA

dextrose with sodium

chloride intravenous

parenteral solution

4

fluoride (sodium)

oral tablet

2

fluoride (sodium)

oral tablet,chewable

2

fluoritab oral

tablet,chewable

2

HEPATAMINE 8%

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

intralipid

intravenous

emulsion 20 %

4 B/D PA

INTRALIPID

INTRAVENOUS

EMULSION 30 %

4 B/D PA

ISOLYTE S PH 7.4

INTRAVENOUS

PARENTERAL

SOLUTION

4

Drug Name Drug

Tier

Requirements

/Limits

ISOLYTE-P IN 5 %

DEXTROSE

INTRAVENOUS

PARENTERAL

SOLUTION

4

ISOLYTE-S

INTRAVENOUS

PARENTERAL

SOLUTION

4

KABIVEN

INTRAVENOUS

EMULSION

4 B/D PA

klor-con 10 oral

tablet extended

release

2

klor-con 8 oral

tablet extended

release

2

klor-con m10 oral

tablet,er

particles/crystals

2

klor-con m15 oral

tablet,er

particles/crystals

2

klor-con m20 oral

tablet,er

particles/crystals

2

klor-con sprinkle

oral capsule,

extended release

2

k-tab oral tablet

extended release 8

meq

2

lactated ringers

intravenous

parenteral solution

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


68

lactated ringers

irrigation solution

4

levocarnitine (with

sugar) oral solution

2

levocarnitine oral

tablet

2

ludent fluoride oral

tablet,chewable

2

magnesium chloride

injection solution

4

magnesium sulfate

injection solution

4

magnesium sulfate

injection syringe

4

multi-vit with

fluoride-iron oral

drops

2

multi-vitamin with

fluoride oral drops

0.5 mg/ml

2

multivitamins with

fluoride oral

tablet,chewable 0.25

mg, 1 mg

2

multivit-fluor (vit e

acetate) oral drops

2

NEPHRAMINE 5.4

% INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

NORMOSOL-R

INTRAVENOUS

PARENTERAL

SOLUTION

4

Drug Name Drug

Tier

Requirements

/Limits

NORMOSOL-R PH

7.4

INTRAVENOUS

PARENTERAL

SOLUTION

4

PERIKABIVEN

INTRAVENOUS

EMULSION

4 B/D PA

PLASMA-LYTE

148

INTRAVENOUS

PARENTERAL

SOLUTION

4

PLASMA-LYTE A

INTRAVENOUS

PARENTERAL

SOLUTION

4

plenamine

intravenous

parenteral solution

4 B/D PA

potassium acetate


2 meq/ml

4

potassium chlorid-

d5-0.45%nacl

intravenous

parenteral solution

4

potassium chloride

in 0.9%nacl

intravenous

parenteral solution

20 meq/l, 40 meq/l

4

potassium chloride

in 5 % dex

intravenous

parenteral solution

20 meq/l, 30 meq/l,

40 meq/l

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


69

potassium chloride

in lr-d5 intravenous

parenteral solution

4

potassium chloride

in water intravenous

piggyback

4

potassium chloride


4

potassium chloride

oral capsule,

extended release

2

potassium chloride

oral liquid

2

potassium chloride


release

2

potassium chloride

oral tablet,er

particles/crystals

2

potassium chloride-

0.45 % nacl

intravenous

parenteral solution

4

potassium chloride-

d5-0.2%nacl

intravenous

parenteral solution

20 meq/l, 30 meq/l,

40 meq/l

4

potassium chloride-

d5-0.3%nacl

intravenous

parenteral solution

20 meq/l

4

Drug Name Drug

Tier

Requirements

/Limits

potassium chloride-

d5-0.9%nacl

intravenous

parenteral solution

4

potassium citrate


release

2

potassium phosphate

m-/d-basic


4

premasol 10 %

intravenous

parenteral solution

4 B/D PA

PREMASOL 6 %

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

prenatal vitamin

oral tablet

2

PREVIDENT 5000

BOOSTER PLUS

DENTAL PASTE

4

PREVIDENT 5000

SENSITIVE

DENTAL PASTE

4

ringer's intravenous

parenteral solution

4

ringer's irrigation

solution

4

sf 5000 plus dental

cream

2

sodium acetate


4

sodium chloride 0.45

% intravenous

parenteral solution

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


70

sodium chloride 0.45

% intravenous

piggyback

4

sodium chloride 0.9

% intravenous

parenteral solution

4

sodium chloride 0.9

% intravenous

piggyback

4

sodium chloride 3 %

intravenous

parenteral solution

4

sodium chloride 5 %

intravenous

parenteral solution

4

sodium chloride

intravenous

parenteral solution

4

sodium chloride

irrigation solution

4

sodium lactate


4

sodium phosphate


4

travasol 10 %

intravenous

parenteral solution

4 B/D PA

TROPHAMINE 10

% INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

TROPHAMINE 6%

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

Drug Name Drug

Tier

Requirements

/Limits

ELECTROLYTE/MINERAL/METAL

MODIFIERS

CHEMET ORAL

CAPSULE

3

DEPEN

TITRATABS ORAL

TABLET

4

EXJADE ORAL

TABLET,

DISPERSIBLE

5 NEDS

FERRIPROX ORAL

SOLUTION

5 NEDS

FERRIPROX ORAL

TABLET

5 NEDS

FREAMINE HBC

6.9 %

INTRAVENOUS

PARENTERAL

SOLUTION

4 B/D PA

JADENU ORAL

TABLET

5 NEDS

kionex (with

sorbitol) oral

suspension

2

kionex oral powder 2

SAMSCA ORAL

TABLET

5 PA; NEDS

sodium polystyrene

(sorb free) oral

suspension

2

sodium polystyrene

sulfonate oral

powder

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


71

sodium polystyrene

sulfonate oral

suspension

2

sodium polystyrene

sulfonate rectal

enema 30 gram/120

ml

2

SODIUM

POLYSTYRENE

SULFONATE

RECTAL ENEMA

50 GRAM/200 ML

4

sps (with sorbitol)

oral suspension

2

sps (with sorbitol)

rectal enema

2

SYPRINE ORAL

CAPSULE

5 NEDS

trientine oral

capsule

5 NEDS

VELTASSA ORAL

POWDER IN

PACKET

4

VITAMINS

FLUORABON

ORAL DROPS

4

fluoride (sodium)

oral drops

2

Drug Name Drug

Tier

Requirements

/Limits

GASTROINTESTINAL AGENTS

ANTISPASMODICS,

GASTROINTESTINAL

dicyclomine oral

capsule

2

dicyclomine oral

solution

2

dicyclomine oral

tablet

2

glycopyrrolate oral

tablet 1 mg, 2 mg

2

methscopolamine

oral tablet

2

GASTROINTESTINAL AGENTS,

OTHER

chlordiazepoxide-

clidinium oral

capsule

2

diphenoxylate-

atropine oral liquid

2

diphenoxylate-

atropine oral tablet

2

ENDARI ORAL

POWDER IN

PACKET

5 NEDS

ENTEREG ORAL

CAPSULE

4

GATTEX 30-VIAL

SUBCUTANEOUS

KIT

5 PA; NEDS

GATTEX ONE-

VIAL

SUBCUTANEOUS

KIT

5 PA; NEDS

loperamide oral

capsule

2

metoclopramide hcl

injection solution

4

metoclopramide hcl

oral solution

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


72

metoclopramide hcl

oral tablet

2

metoclopramide hcl

oral


2

MOVANTIK ORAL

TABLET

4 PA

NUTRESTORE

ORAL POWDER IN

PACKET

4

RELISTOR ORAL

TABLET

4 PA

RELISTOR

SUBCUTANEOUS

SOLUTION

4 PA; QL (16.8

per 28 days)

RELISTOR

SUBCUTANEOUS

SYRINGE

4 PA

ursodiol oral

capsule

2

ursodiol oral tablet 2

HISTAMINE2 (H2) RECEPTOR

ANTAGONISTS

famotidine (pf)


4

famotidine (pf)-nacl


piggyback

4

famotidine


4

famotidine oral

suspension

2

famotidine oral

tablet 20 mg, 40 mg

2

Drug Name Drug

Tier

Requirements

/Limits

nizatidine oral

capsule

2

nizatidine oral

solution

2

ranitidine hcl

injection solution

4

ranitidine hcl oral

capsule

2

ranitidine hcl oral

syrup

2

ranitidine hcl oral

tablet 150 mg, 300

mg

2

IRRITABLE BOWEL SYNDROME

AGENTS

alosetron oral tablet 4 PA

AMITIZA ORAL

CAPSULE

4 PA; QL (180

per 90 days)

LINZESS ORAL

CAPSULE

3

LAXATIVES

constulose oral

solution

2

enulose oral solution 2

gavilyte-c oral recon

soln

2

gavilyte-g oral recon

soln

2

gavilyte-n oral recon

soln

2

generlac oral

solution

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


73

lactulose oral

solution

2

peg 3350-

electrolytes oral

recon soln

2

peg-electrolyte oral

recon soln

2

polyethylene glycol

3350 oral powder

2

polyethylene glycol

3350 oral powder in

packet

2

SUPREP BOWEL

PREP KIT ORAL

RECON SOLN

4

trilyte with flavor

packets oral recon

soln

2

PROTECTANTS

misoprostol oral

tablet

2

sucralfate oral tablet 2

PROTON PUMP INHIBITORS

esomeprazole

magnesium oral

capsule,delayed

release(dr/ec)

4

omeppi oral capsule 4

omeprazole oral

capsule,delayed

release(dr/ec)

2

pantoprazole

intravenous recon

soln

4

Drug Name Drug

Tier

Requirements

/Limits

pantoprazole oral

tablet,delayed

release (dr/ec)

2

Drug Name Drug

Tier

Requirements

/Limits

GENETIC OR ENZYME

DISORDER: REPLACEMENT,

MODIFIERS, TREATMENT

GENETIC OR ENZYME DISORDER:

REPLACEMENT, MODIFIERS,

TREATMENT

ADAGEN

INTRAMUSCULA

R SOLUTION

5 NEDS

ALDURAZYME

INTRAVENOUS

SOLUTION

5 NEDS

BUPHENYL ORAL

TABLET

4

CERDELGA ORAL

CAPSULE

5 NEDS

CEREZYME

INTRAVENOUS

RECON SOLN 400

UNIT

5 NEDS

CHOLBAM ORAL

CAPSULE

5 PA; NEDS

CREON ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

3

CYSTADANE

ORAL POWDER

4

CYSTAGON ORAL

CAPSULE

4


5-Specialty Drugs



Therapy


74

ELAPRASE

INTRAVENOUS

SOLUTION

5 NEDS

ELELYSO

INTRAVENOUS

RECON SOLN

5 NEDS

FABRAZYME

INTRAVENOUS

RECON SOLN

5 NEDS

KANUMA

INTRAVENOUS

SOLUTION

5 PA; NEDS

KUVAN ORAL

POWDER IN

PACKET

5 NEDS

KUVAN ORAL

TABLET,SOLUBL

E

5 NEDS

LUMIZYME

INTRAVENOUS

RECON SOLN

5 B/D PA;

NEDS

miglustat oral

capsule

5 NEDS

NAGLAZYME

INTRAVENOUS

SOLUTION

5 NEDS

ORFADIN ORAL

CAPSULE

5 NEDS

ORFADIN ORAL

SUSPENSION

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits

PANCREAZE

ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

10,500-35,500-

61,500 UNIT,

16,800-56,800-

98,400 UNIT, 2,600-

6,200- 10,850 UNIT,

21,000-54,700-

83,900 UNIT, 4,200-

14,200- 24,600

UNIT

3

PERTZYE ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

4

PROCYSBI ORAL

CAPSULE,

DELAYED REL

SPRINKLE

5 PA; NEDS

RAVICTI ORAL

LIQUID

5 PA; NEDS

sodium

phenylbutyrate oral

powder

2

sodium

phenylbutyrate oral

tablet

4

STRENSIQ

SUBCUTANEOUS

SOLUTION

5 PA; NEDS

SUCRAID ORAL

SOLUTION

5 NEDS

VPRIV

INTRAVENOUS

RECON SOLN

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


75

ZAVESCA ORAL

CAPSULE

5 NEDS

ZENPEP ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

10,000-32,000 -

42,000 UNIT,

10,000-34,000 -

55,000 UNIT,

15,000-51,000 -

82,000 UNIT,

20,000-63,000-

84,000 UNIT,

25,000-79,000-

105,000 UNIT,

25,000-85,000-

136,000 UNIT,

3,000-10,000-

16,000 UNIT, 5,000-

17,000- 24,000

UNIT

4

ZENPEP ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

40,000-126,000-

168,000 UNIT

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

flavoxate oral tablet 2

MYRBETRIQ

ORAL TABLET

EXTENDED

RELEASE 24 HR

3

oxybutynin chloride

oral syrup

2

oxybutynin chloride

oral tablet

2

oxybutynin chloride


release 24hr

2 QL (180 per

90 days)

tolterodine oral

capsule,extended

release 24hr

2

tolterodine oral

tablet

2

TOVIAZ ORAL

TABLET

EXTENDED

RELEASE 24 HR

3

trospium oral

capsule,extended

release 24hr

2 QL (90 per 90

days)

trospium oral tablet 2

VESICARE ORAL

TABLET

3

BENIGN PROSTATIC

HYPERTROPHY AGENTS

alfuzosin oral tablet

extended release 24

hr

2 QL (90 per 90

days)

dutasteride oral

capsule

2 QL (90 per 90

days)

finasteride oral

tablet 5 mg

2

tamsulosin oral

capsule,extended

release 24hr

2 QL (180 per

90 days)

GENITOURINARY AGENTS,

OTHER

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


76

bethanechol chloride

oral tablet

2

ELMIRON ORAL

CAPSULE

3

PHOSPHATE BINDERS

calcium acetate oral

capsule

2

calcium acetate oral

tablet 667 mg

2

eliphos oral tablet 2

FOSRENOL ORAL

POWDER IN

PACKET

4

FOSRENOL ORAL

TABLET,CHEWAB

LE

4

lanthanum oral

tablet,chewable

4

PHOSLYRA ORAL

SOLUTION

4

RENAGEL ORAL

TABLET

4

RENVELA ORAL

TABLET

3

sevelamer carbonate

oral powder in

packet

2

sevelamer carbonate

oral tablet

2

Drug Name Drug

Tier

Requirements

/Limits

HORMONAL AGENTS,

STIMULANT/REPLACEMENT/

MODIFYING (ADRENAL)

HORMONAL AGENTS,

STIMULANT/REPLACEMENT/MOD

IFYING (ADRENAL)

a-hydrocort


2

ala-cort topical

cream 2.5 %

2

alclometasone

topical cream

2

alclometasone

topical ointment

2

amcinonide topical

cream

4

amcinonide topical

lotion

4

amcinonide topical

ointment

4

betamethasone

dipropionate topical

cream

2

betamethasone


lotion

2

betamethasone


ointment

2

betamethasone

valerate topical

cream

2

betamethasone

valerate topical

lotion

2

betamethasone

valerate topical

ointment

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


77

betamethasone,

augmented topical

cream

2

betamethasone,

augmented topical

gel

2

betamethasone,

augmented topical

lotion

2

betamethasone,

augmented topical

ointment

2

budesonide oral

capsule,delayed,exte

nd.release

4

CAPEX TOPICAL

SHAMPOO

3

clobetasol scalp

solution

4

clobetasol topical

cream

4

clobetasol topical

gel

4

clobetasol topical

lotion

4

clobetasol topical

ointment

4

clobetasol topical

shampoo

4

clobetasol-emollient

topical cream

4

clobetasol-emollient

topical foam

4

clodan topical

shampoo

4

Drug Name Drug

Tier

Requirements

/Limits

cortisone oral tablet 2

decadron oral elixir 2

decadron oral tablet 2

deltasone oral tablet

20 mg

2

desonide topical

cream

4

desonide topical

lotion

4

desonide topical

ointment

4

desoximetasone

topical cream

4

desoximetasone

topical gel

4

desoximetasone

topical ointment

4

dexamethasone

intensol oral drops

2

dexamethasone oral

elixir

2

dexamethasone oral

solution

2

dexamethasone oral

tablet

2

dexamethasone

sodium phosphate


mg/ml

4

dexamethasone

sodium phosphate

injection syringe

4

diflorasone topical

cream

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


78

diflorasone topical

ointment

4

fludrocortisone oral

tablet

2

fluocinolone

acetonide oil otic

(ear) drops

2

fluocinolone and

shower cap scalp oil

2

fluocinolone topical

cream

2


oil

2


ointment

2


solution

2

fluocinonide topical

cream

4


gel

4


ointment

4


solution

4

fluocinonide-e

topical cream

4

fluocinonide-

emollient topical

cream

4

fluticasone topical

cream

2

fluticasone topical

ointment

2

Drug Name Drug

Tier

Requirements

/Limits

halobetasol

propionate topical

cream

2

halobetasol

propionate topical

ointment

2

hydrocortisone oral

tablet

2

hydrocortisone

topical cream 2.5 %

2

hydrocortisone

topical cream with

perineal applicator

2.5 %

2

hydrocortisone

topical lotion 2.5 %

2

hydrocortisone

topical ointment 1

%, 2.5 %

2

hydrocortisone

valerate topical

cream

2

hydrocortisone

valerate topical

ointment

2

hydrocortisone-min

oil-wht pet topical

ointment

2

methylprednisolone

acetate injection

suspension

4

methylprednisolone

oral tablet

2

methylprednisolone

oral tablets,dose

pack

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


79

methylprednisolone

sodium succ


125 mg, 40 mg

4

methylprednisolone

sodium succ

intravenous recon

soln

4

mometasone topical

cream

2

mometasone topical

ointment

2

mometasone topical

solution

2

nolix topical cream 4

prednicarbate

topical cream

2

prednicarbate

topical ointment

2

prednisolone oral

solution 15 mg/5 ml

2

prednisolone sodium

phosphate oral

solution 15 mg/5 ml

(3 mg/ml), 20 mg/5

ml (4 mg/ml), 25

mg/5 ml (5 mg/ml), 5

mg base/5 ml (6.7

mg/5 ml)

2

prednisone intensol

oral concentrate

2

prednisone oral

solution

2

prednisone oral

tablet

2

Drug Name Drug

Tier

Requirements

/Limits

prednisone oral

tablets,dose pack

2

procto-med hc

topical cream with

perineal applicator

2

proctosol hc topical

cream with perineal

applicator

2

proctozone-hc

topical cream with

perineal applicator

2

SOLU-CORTEF

(PF) INJECTION

RECON SOLN

4

SOLU-CORTEF

INJECTION

RECON SOLN

4

SOLU-MEDROL

INTRAVENOUS

RECON SOLN 2

GRAM

4

triamcinolone

acetonide nasal

aerosol,spray

2

triamcinolone

acetonide topical

cream

2

triamcinolone

acetonide topical

lotion

2

triamcinolone

acetonide topical

ointment 0.025 %,

0.1 %, 0.5 %

2

triderm topical

cream

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


80

veripred 20 oral

solution

2

Drug Name Drug

Tier

Requirements

/Limits

HORMONAL AGENTS,


MODIFYING (PITUITARY)

HORMONAL AGENTS,


IFYING (PITUITARY)

CHORIONIC

GONADOTROPIN,

HUMAN

INTRAMUSCULA

R RECON SOLN

4 PA

desmopressin

injection solution

4

desmopressin nasal

solution

4

desmopressin nasal

spray with pump

4

desmopressin nasal

spray,non-aerosol

4

desmopressin oral

tablet

2

EGRIFTA

SUBCUTANEOUS

RECON SOLN 1

MG

5 NEDS

GENOTROPIN

MINIQUICK

SUBCUTANEOUS

SYRINGE 0.2

MG/0.25 ML

4 PA

GENOTROPIN

MINIQUICK

SUBCUTANEOUS

SYRINGE 0.4

MG/0.25 ML, 0.6

MG/0.25 ML, 0.8

MG/0.25 ML, 1

MG/0.25 ML, 1.2

MG/0.25 ML, 1.4

MG/0.25 ML, 1.6

MG/0.25 ML, 1.8

MG/0.25 ML, 2

MG/0.25 ML

5 PA; NEDS

GENOTROPIN

SUBCUTANEOUS

CARTRIDGE

5 PA; NEDS

HUMATROPE

INJECTION

CARTRIDGE

5 PA; NEDS

HUMATROPE

INJECTION

RECON SOLN

5 PA; NEDS

INCRELEX

SUBCUTANEOUS

SOLUTION

5 PA; NEDS

MYALEPT

SUBCUTANEOUS

RECON SOLN

5 PA; NEDS

NORDITROPIN

FLEXPRO

SUBCUTANEOUS

PEN INJECTOR

5 PA; NEDS

NOVAREL

INTRAMUSCULA

R RECON SOLN

4 PA

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


81

NUTROPIN AQ

NUSPIN

SUBCUTANEOUS

PEN INJECTOR

5 PA; NEDS

OMNITROPE

SUBCUTANEOUS

CARTRIDGE

4 PA

OMNITROPE

SUBCUTANEOUS

RECON SOLN

5 PA; NEDS

PREGNYL

INTRAMUSCULA

R RECON SOLN

4 PA

SAIZEN

CLICK.EASY

SUBCUTANEOUS

CARTRIDGE

5 PA; NEDS

SAIZEN

SAIZENPREP

SUBCUTANEOUS

CARTRIDGE

5 PA; NEDS

SAIZEN

SUBCUTANEOUS

RECON SOLN

5 PA; NEDS

SEROSTIM

SUBCUTANEOUS

RECON SOLN 4

MG, 5 MG, 6 MG

5 PA; NEDS

STIMATE NASAL

SPRAY,NON-

AEROSOL

3

Drug Name Drug

Tier

Requirements

/Limits

HORMONAL AGENTS,


MODIFYING (SEX

HORMONES/MODIFIERS)

ANABOLIC STEROIDS

ANADROL-50

ORAL TABLET

4 PA

oxandrolone oral

tablet

2 PA

ANDROGENS

ANDRODERM

TRANSDERMAL

PATCH 24 HOUR

3 PA; QL (90

per 90 days)

ANDROGEL

TRANSDERMAL

GEL IN

METERED-DOSE

PUMP 20.25

MG/1.25 GRAM

(1.62 %)

3 PA; QL (450

per 90 days)

ANDROGEL

TRANSDERMAL

GEL IN PACKET 1

% (50 MG/5

GRAM)

3 PA; QL (900

per 90 days)

ANDROGEL

TRANSDERMAL

GEL IN PACKET

1.62 % (20.25

MG/1.25 GRAM)

3 PA; QL (225

per 90 days)

ANDROGEL

TRANSDERMAL

GEL IN PACKET

1.62 % (40.5

MG/2.5 GRAM)

3 PA; QL (450

per 90 days)

danazol oral capsule 4

METHITEST

ORAL TABLET

4

methyltestosterone

oral capsule

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


82

testosterone

cypionate

intramuscular oil

4

testosterone

enanthate

intramuscular oil

4

testosterone

transdermal gel in

packet 1 % (25

mg/2.5gram)

2 PA; QL (900

per 90 days)

ESTROGENS

amabelz oral tablet 2 PA

amethia lo oral

tablets,dose pack,3

month

2 QL (91 per 91

days)

amethia oral

tablets,dose pack,3

month

4 QL (91 per 91

days)

amethyst oral tablet 2

ashlyna oral

tablets,dose pack,3

month

4 QL (91 per 91

days)

camrese lo oral

tablets,dose pack,3

month

2 QL (91 per 91

days)

camrese oral

tablets,dose pack,3

month

4 QL (91 per 91

days)

caziant (28) oral

tablet

2

daysee oral

tablets,dose pack,3

month

4 QL (91 per 91

days)

Drug Name Drug

Tier

Requirements

/Limits

DIVIGEL

TRANSDERMAL

GEL IN PACKET

4

drospirenone-

e.estradiol-lm.fa

oral tablet

2

drospirenone-ethinyl

estradiol oral tablet

3-0.03 mg

2

ESTRACE

VAGINAL CREAM

3

estradiol oral tablet 2 PA

estradiol vaginal

cream

2

estradiol vaginal

tablet

2

estradiol valerate

intramuscular oil 20

mg/ml, 40 mg/ml

4

estradiol-

norethindrone acet

oral tablet

2 PA

ESTRING

VAGINAL RING

3 QL (1 per 90

days)

ethynodiol diac-eth


1-50 mg-mcg

2

FEMRING

VAGINAL RING

3 QL (1 per 90

days)

fyavolv oral tablet 4 PA

jinteli oral tablet 4 PA

kelnor 1-50 oral

tablet

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


83

l norgest/e.estradiol-

e.estrad oral

tablets,dose pack,3

month 0.10 mg-20

mcg (84)/10 mcg (7)

2 QL (91 per 91

days)

l norgest/e.estradiol-

e.estrad oral

tablets,dose pack,3

month 0.15 mg-30

mcg (84)/10 mcg (7)

4 QL (91 per 91

days)

lillow oral tablet 2

low-ogestrel (28)

oral tablet

2

MENEST ORAL

TABLET 1.25 MG

4 PA

mimvey lo oral

tablet

2 PA

mimvey oral tablet 2 PA

norethindrone ac-eth


0.5-2.5 mg-mcg, 1-5

mg-mcg

4 PA

ocella oral tablet 2

PREMARIN

VAGINAL CREAM

3

velivet triphasic

regimen (28) oral

tablet

2

yuvafem vaginal

tablet

2

zarah oral tablet 2

zovia 1/50e (28) oral

tablet

2

PROGESTINS

Drug Name Drug

Tier

Requirements

/Limits

camila oral tablet 2

deblitane oral tablet 2

DEPO-PROVERA

INTRAMUSCULA

R SUSPENSION

400 MG/ML

4

DEPO-SUBQ

PROVERA 104

SUBCUTANEOUS

SYRINGE

4

errin oral tablet 2

hydroxyprogesterone

caproate

intramuscular oil

4

jolivette oral tablet 2

lyza oral tablet 2

MAKENA (PF)

SUBCUTANEOUS

AUTO-INJECTOR

5 NEDS

MAKENA

INTRAMUSCULA

R OIL 250 MG/ML

(1 ML)

5 NEDS

medroxyprogesteron

e intramuscular

suspension

4

medroxyprogesteron

e intramuscular

syringe

4

medroxyprogesteron

e oral tablet

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


84

megestrol oral

suspension 400

mg/10 ml (10 ml),

400 mg/10 ml (40

mg/ml), 625 mg/5 ml

4

megestrol oral tablet 2

nora-be oral tablet 2

norethindrone

(contraceptive) oral

tablet

2

norethindrone

acetate oral tablet

2

norlyroc oral tablet 2

progesterone

micronized oral

capsule

2

sharobel oral tablet 2

SELECTIVE ESTROGEN

RECEPTOR MODIFYING AGENTS

raloxifene oral tablet 1 QL (90 per 90

days)

Drug Name Drug

Tier

Requirements

/Limits

HORMONAL AGENTS,


MODIFYING (THYROID)

HORMONAL AGENTS,


IFYING (THYROID)

levothyroxine

intravenous recon

soln 200 mcg, 500

mcg

1

levothyroxine oral

tablet

1

levoxyl oral tablet

100 mcg, 112 mcg,

125 mcg, 137 mcg,

150 mcg, 175 mcg,

200 mcg, 25 mcg, 50

mcg, 75 mcg, 88 mcg

1

liothyronine


4

liothyronine oral

tablet

2

SYNTHROID

ORAL TABLET

4

thyroid (pork) oral


90 mg

4

THYROLAR-1

ORAL TABLET

3

THYROLAR-1/2

ORAL TABLET

3

THYROLAR-1/4

ORAL TABLET

3

THYROLAR-2

ORAL TABLET

3

THYROLAR-3

ORAL TABLET

3

unithroid oral tablet 1

Drug Name Drug

Tier

Requirements

/Limits

HORMONAL AGENTS,

SUPPRESSANT (ADRENAL)

HORMONAL AGENTS,

SUPPRESSANT (ADRENAL)

LYSODREN ORAL

TABLET 3

HORMONAL AGENTS,

SUPPRESSANT (PITUITARY)


5-Specialty Drugs



Therapy


85

HORMONAL AGENTS,

SUPPRESSANT (PITUITARY)

cabergoline oral

tablet

2

FIRMAGON KIT W

DILUENT

SYRINGE

SUBCUTANEOUS

RECON SOLN

4

leuprolide

subcutaneous kit

2

LUPRON DEPOT

(3 MONTH)

INTRAMUSCULA

R SYRINGE KIT

5 NEDS

LUPRON DEPOT

(4 MONTH)

INTRAMUSCULA

R SYRINGE KIT

5 NEDS

LUPRON DEPOT

(6 MONTH)

INTRAMUSCULA

R SYRINGE KIT

5 NEDS

LUPRON DEPOT

INTRAMUSCULA

R SYRINGE KIT

5 NEDS

LUPRON DEPOT-

PED (3 MONTH)

INTRAMUSCULA

R SYRINGE KIT

5 NEDS

LUPRON DEPOT-

PED

INTRAMUSCULA

R KIT

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits

octreotide acetate

injection solution

1,000 mcg/ml, 500

mcg/ml

5 NEDS

octreotide acetate

injection solution

100 mcg/ml, 200

mcg/ml, 50 mcg/ml

4

SANDOSTATIN

LAR DEPOT

INTRAMUSCULA

R

SUSPENSION,EXT

ENDED REL

RECON

5 NEDS

SIGNIFOR LAR

INTRAMUSCULA

R SUSPENSION

FOR

RECONSTITUTIO

N

5 NEDS

SIGNIFOR

SUBCUTANEOUS

SOLUTION

5 NEDS

SOMATULINE

DEPOT

SUBCUTANEOUS

SYRINGE

5 NEDS

SOMAVERT

SUBCUTANEOUS

RECON SOLN

5 PA; NEDS

SYNAREL NASAL

SPRAY,NON-

AEROSOL

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


86

TRELSTAR

INTRAMUSCULA

R SUSPENSION

FOR

RECONSTITUTIO

N

5 NEDS

TRELSTAR

INTRAMUSCULA

R SYRINGE

5 NEDS

ZOLADEX

SUBCUTANEOUS

IMPLANT

4 QL (1.2 per 30

days)

Drug Name Drug

Tier

Requirements

/Limits

HORMONAL AGENTS,

SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole oral

tablet 10 mg, 5 mg

2

propylthiouracil oral

tablet

2

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTS

BERINERT

INTRAVENOUS

KIT

5 PA; NEDS

CINRYZE

INTRAVENOUS

RECON SOLN

5 NEDS

FIRAZYR

SUBCUTANEOUS

SYRINGE

5 PA; NEDS

HAEGARDA

SUBCUTANEOUS

RECON SOLN

5 NEDS

KALBITOR

SUBCUTANEOUS

SOLUTION

5 PA; NEDS

IMMUNE SUPPRESSANTS

ASTAGRAF XL

ORAL

CAPSULE,EXTEN

DED RELEASE

24HR 0.5 MG, 1

MG

4 B/D PA

ASTAGRAF XL

ORAL

CAPSULE,EXTEN

DED RELEASE

24HR 5 MG

5 B/D PA;

NEDS

azathioprine oral

tablet

2 B/D PA

azathioprine sodium


4 B/D PA

BENLYSTA

INTRAVENOUS

RECON SOLN

5 NEDS

BENLYSTA

SUBCUTANEOUS

AUTO-INJECTOR

5 NEDS

BENLYSTA

SUBCUTANEOUS

SYRINGE

5 NEDS

CELLCEPT

INTRAVENOUS

RECON SOLN

4 B/D PA

CIMZIA POWDER

FOR RECONST

SUBCUTANEOUS

KIT

5 PA; NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


87

CIMZIA STARTER

KIT

SUBCUTANEOUS

SYRINGE KIT

5 PA; NEDS

CIMZIA

SUBCUTANEOUS

SYRINGE KIT

5 PA; NEDS

cyclosporine


4 B/D PA

cyclosporine

modified oral

capsule

2 B/D PA

cyclosporine

modified oral

solution

2 B/D PA

cyclosporine oral

capsule

2 B/D PA

ENBREL MINI

SUBCUTANEOUS

CARTRIDGE

5 QL (8 per 28

days); NEDS

ENBREL

SUBCUTANEOUS

RECON SOLN

5 QL (16 per 28

days); NEDS

ENBREL

SUBCUTANEOUS

SYRINGE

5 QL (8 per 28

days); NEDS

ENBREL

SURECLICK

SUBCUTANEOUS

PEN INJECTOR

5 QL (8 per 28

days); NEDS

ENVARSUS XR

ORAL TABLET

EXTENDED

RELEASE 24 HR

4 B/D PA

gengraf oral capsule

100 mg, 25 mg

2 B/D PA

Drug Name Drug

Tier

Requirements

/Limits

gengraf oral solution 2 B/D PA

HUMIRA

PEDIATRIC

CROHN'S START

SUBCUTANEOUS

SYRINGE KIT

80MG/0.8ML

5 QL (2.8 per 28

days); NEDS

HUMIRA PEN

CROHN'S-UC-HS

START

SUBCUTANEOUS

PEN INJECTOR

KIT

5 QL (5.6 per 28

days); NEDS

HUMIRA PEN

PSORIASIS-

UVEITIS

SUBCUTANEOUS

PEN INJECTOR

KIT

5 QL (5.6 per 28

days); NEDS

HUMIRA PEN

SUBCUTANEOUS

PEN INJECTOR

KIT 40MG/0.8ML

5 QL (2.8 per 28

days); NEDS

HUMIRA

SUBCUTANEOUS

SYRINGE KIT 10

MG/0.2 ML, 20

MG/0.4 ML, 40

MG/0.8 ML

5 QL (5.6 per 28

days); NEDS

INFLECTRA

INTRAVENOUS

RECON SOLN

5 NEDS

KINERET

SUBCUTANEOUS

SYRINGE

5 PA; QL (18.8

per 28 days);

NEDS

methotrexate sodium

(pf) injection recon

soln

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


88

methotrexate sodium

(pf) injection

solution

4

methotrexate sodium

injection solution

4

methotrexate sodium

oral tablet

1 B/D PA

mycophenolate

mofetil hcl

intravenous recon

soln

4 B/D PA

mycophenolate

mofetil oral capsule

2 B/D PA

mycophenolate

mofetil oral

suspension for

reconstitution

5 B/D PA;

NEDS

mycophenolate

mofetil oral tablet

2 B/D PA

mycophenolate

sodium oral

tablet,delayed

release (dr/ec)

4 B/D PA

NULOJIX

INTRAVENOUS

RECON SOLN

5 B/D PA;

NEDS

ORENCIA

CLICKJECT

SUBCUTANEOUS

AUTO-INJECTOR

5 PA; NEDS

ORENCIA

SUBCUTANEOUS

SYRINGE

5 PA; NEDS

Drug Name Drug

Tier

Requirements

/Limits

OTREXUP (PF)

SUBCUTANEOUS

AUTO-INJECTOR

10 MG/0.4 ML, 12.5

MG/0.4 ML, 15

MG/0.4 ML, 17.5

MG/0.4 ML, 20

MG/0.4 ML, 22.5

MG/0.4 ML, 25

MG/0.4 ML

4

PROGRAF

INTRAVENOUS

SOLUTION

4 B/D PA

RAPAMUNE

ORAL SOLUTION

4 B/D PA

RASUVO (PF)

SUBCUTANEOUS

AUTO-INJECTOR

10 MG/0.2 ML, 12.5

MG/0.25 ML, 15

MG/0.3 ML, 17.5

MG/0.35 ML, 20

MG/0.4 ML, 22.5

MG/0.45 ML, 25

MG/0.5 ML, 30

MG/0.6 ML, 7.5

MG/0.15 ML

4

REMICADE

INTRAVENOUS

RECON SOLN

5 NEDS

SANDIMMUNE

ORAL SOLUTION

4 B/D PA

SIMPONI ARIA

INTRAVENOUS

SOLUTION

5 PA; NEDS

SIMPONI

SUBCUTANEOUS

PEN INJECTOR

5 PA; NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


89

SIMPONI

SUBCUTANEOUS

SYRINGE

5 PA; NEDS

sirolimus oral tablet 4 B/D PA

tacrolimus oral

capsule

2 B/D PA

TORISEL

INTRAVENOUS

RECON SOLN

5 PA; NEDS

XATMEP ORAL

SOLUTION

5 B/D PA;

NEDS

XELJANZ ORAL

TABLET

5 PA; NEDS

XELJANZ XR

ORAL TABLET

EXTENDED

RELEASE 24 HR

5 PA; NEDS

ZORTRESS ORAL

TABLET 0.25 MG

4 B/D PA

ZORTRESS ORAL

TABLET 0.5 MG,

0.75 MG

5 B/D PA;

NEDS

IMMUNIZING AGENTS, PASSIVE

BIVIGAM

INTRAVENOUS

SOLUTION

5 PA; NEDS

CARIMUNE NF

NANOFILTERED

INTRAVENOUS

RECON SOLN 6

GRAM

5 PA; NEDS

CUVITRU

SUBCUTANEOUS

SOLUTION

5 PA; NEDS

Drug Name Drug

Tier

Requirements

/Limits

CYTOGAM

INTRAVENOUS

SOLUTION 50

MG/ML

4

FLEBOGAMMA

DIF

INTRAVENOUS

SOLUTION

5 PA; NEDS

GAMASTAN S/D

INTRAMUSCULA

R SOLUTION

4 PA

GAMMAGARD

LIQUID

INJECTION

SOLUTION

5 PA; NEDS

GAMMAGARD S-

D (IGA < 1

MCG/ML)

INTRAVENOUS

RECON SOLN

5 PA; NEDS

GAMMAKED

INJECTION

SOLUTION

5 PA; NEDS

GAMMAPLEX

(WITH SORBITOL)

INTRAVENOUS

SOLUTION

5 PA; NEDS

GAMMAPLEX

INTRAVENOUS

SOLUTION

5 PA; NEDS

GAMUNEX-C

INJECTION

SOLUTION

5 PA; NEDS

HIZENTRA

SUBCUTANEOUS

SOLUTION

5 PA; NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


90

HYPERHEP B S/D

INTRAMUSCULA

R SOLUTION

4

HYPERHEP B S/D

INTRAMUSCULA

R SYRINGE

4

HYPERHEP B S-D

NEONATAL

INTRAMUSCULA

R SYRINGE

4

HYPERRAB (PF)

INTRAMUSCULA

R SOLUTION

4

HYPERRAB S/D

(PF)

INTRAMUSCULA

R SOLUTION

4

HYPERTET S/D

(PF)

INTRAMUSCULA

R SYRINGE

3

HYQVIA

SUBCUTANEOUS

SOLUTION

5 B/D PA;

NEDS

IMOGAM RABIES-

HT (PF)

INTRAMUSCULA

R SOLUTION

4

NABI-HB

INTRAMUSCULA

R SOLUTION

4

OCTAGAM

INTRAVENOUS

SOLUTION

5 PA; NEDS

PRIVIGEN

INTRAVENOUS

SOLUTION

5 PA; NEDS

Drug Name Drug

Tier

Requirements

/Limits

THYMOGLOBULI

N INTRAVENOUS

RECON SOLN

5 NEDS

VARIZIG

INTRAMUSCULA

R SOLUTION

3

IMMUNOMODULATORS

ACTEMRA

SUBCUTANEOUS

SYRINGE

5 PA; NEDS

ACTIMMUNE

SUBCUTANEOUS

SOLUTION

5 NEDS

ARCALYST

SUBCUTANEOUS

RECON SOLN

5 PA; NEDS

ILARIS (PF)

SUBCUTANEOUS

SOLUTION

5 PA; NEDS

leflunomide oral

tablet

2 QL (90 per 90

days)

LEMTRADA

INTRAVENOUS

SOLUTION

5 PA; QL (6 per

365 days);

NEDS

OTEZLA ORAL

TABLET

5 PA; NEDS

OTEZLA

STARTER ORAL

TABLETS,DOSE

PACK 10 MG (4)-

20 MG (4)-30 MG

(47)

5 PA; NEDS

RIDAURA ORAL

CAPSULE

3

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


91

SIMULECT

INTRAVENOUS

RECON SOLN

5 B/D PA;

NEDS

SYLVANT

INTRAVENOUS

RECON SOLN

5 PA; NEDS

SYNAGIS

INTRAMUSCULA

R SOLUTION

5 NEDS

XOLAIR

SUBCUTANEOUS

RECON SOLN

5 PA; NEDS

VACCINES

ACTHIB (PF)

INTRAMUSCULA

R RECON SOLN

3

ADACEL(TDAP

ADOLESN/ADULT

)(PF)

INTRAMUSCULA

R SUSPENSION

3

ADACEL(TDAP

ADOLESN/ADULT

)(PF)

INTRAMUSCULA

R SYRINGE

3

BCG VACCINE,

LIVE (PF)

PERCUTANEOUS

SUSPENSION FOR

RECONSTITUTIO

N

3

BEXSERO

INTRAMUSCULA

R SYRINGE

3

Drug Name Drug

Tier

Requirements

/Limits

BOOSTRIX TDAP

INTRAMUSCULA

R SUSPENSION

3

BOOSTRIX TDAP

INTRAMUSCULA

R SYRINGE

3

DAPTACEL (DTAP

PEDIATRIC) (PF)

INTRAMUSCULA

R SUSPENSION

3

ENGERIX-B (PF)

INTRAMUSCULA

R SUSPENSION

3 B/D PA

ENGERIX-B (PF)

INTRAMUSCULA

R SYRINGE

3 B/D PA

ENGERIX-B

PEDIATRIC (PF)

INTRAMUSCULA

R SYRINGE

3 B/D PA

GARDASIL 9 (PF)

INTRAMUSCULA

R SUSPENSION

3

GARDASIL 9 (PF)

INTRAMUSCULA

R SYRINGE

3

HAVRIX (PF)

INTRAMUSCULA

R SUSPENSION

3

HAVRIX (PF)

INTRAMUSCULA

R SYRINGE

3

HIBERIX (PF)

INTRAMUSCULA

R RECON SOLN

3

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


92

IMOVAX RABIES

VACCINE (PF) INTRAMUSCULA R RECON SOLN

3

INFANRIX (DTAP) (PF) INTRAMUSCULA R SUSPENSION

3

INFANRIX (DTAP) (PF) INTRAMUSCULA R SYRINGE

3

IPOL INJECTION SUSPENSION

3

IXIARO (PF)

INTRAMUSCULA R SYRINGE

3

KINRIX (PF)

INTRAMUSCULA

R SUSPENSION

3

KINRIX (PF)

INTRAMUSCULA

R SYRINGE

3

MENACTRA (PF) INTRAMUSCULA

R SOLUTION

3

MENVEO A-C-Y-

W-135-DIP (PF) INTRAMUSCULA

R KIT

3

M-M-R II (PF) SUBCUTANEOUS RECON SOLN

3

PEDIARIX (PF) INTRAMUSCULA R SYRINGE

3

Drug Name Drug

Tier

Requirements

/Limits

PEDVAX HIB (PF)

INTRAMUSCULA R SOLUTION

3

PENTACEL (PF) INTRAMUSCULA R KIT

3

PROQUAD (PF)

SUBCUTANEOUS SUSPENSION FOR RECONSTITUTIO N

3

QUADRACEL (PF) INTRAMUSCULA R SUSPENSION

3

RABAVERT (PF) INTRAMUSCULA R SUSPENSION

FOR

RECONSTITUTIO

N

3

RECOMBIVAX HB (PF)

INTRAMUSCULA

R SUSPENSION

3 B/D PA

RECOMBIVAX HB

(PF)

INTRAMUSCULA R SYRINGE

3 B/D PA

ROTARIX ORAL

SUSPENSION FOR

RECONSTITUTIO N

3

ROTATEQ

VACCINE ORAL SOLUTION

3

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


93

SHINGRIX (PF)

INTRAMUSCULA

R SUSPENSION

FOR

RECONSTITUTIO

N

3

STAMARIL (PF)

SUBCUTANEOUS

SUSPENSION FOR

RECONSTITUTIO

N

3

TENIVAC (PF)

INTRAMUSCULA

R SUSPENSION

3

TENIVAC (PF)

INTRAMUSCULA

R SYRINGE

3

TETANUS,DIPHTH

ERIA TOX

PED(PF)

INTRAMUSCULA

R SUSPENSION

3

TETANUS-

DIPHTHERIA

TOXOIDS-TD

INTRAMUSCULA

R SUSPENSION

3

TRUMENBA

INTRAMUSCULA

R SYRINGE

3

TWINRIX (PF)

INTRAMUSCULA

R SYRINGE

3

TYPHIM VI

INTRAMUSCULA

R SOLUTION

3

Drug Name Drug

Tier

Requirements

/Limits

TYPHIM VI

INTRAMUSCULA

R SYRINGE

3

VAQTA (PF)

INTRAMUSCULA

R SUSPENSION

3

VAQTA (PF)

INTRAMUSCULA

R SYRINGE

3

VARIVAX (PF)

SUBCUTANEOUS

SUSPENSION FOR

RECONSTITUTIO

N

3

YF-VAX (PF)

SUBCUTANEOUS

SUSPENSION FOR

RECONSTITUTIO

N

3

ZOSTAVAX (PF)

SUBCUTANEOUS

SUSPENSION FOR

RECONSTITUTIO

N

3

Drug Name Drug

Tier

Requirements

/Limits

INFLAMMATORY BOWEL

DISEASE AGENTS

AMINOSALICYLATES

ASACOL HD

ORAL

TABLET,DELAYE

D RELEASE

(DR/EC)

3

balsalazide oral

capsule

2

CANASA RECTAL

SUPPOSITORY

3


5-Specialty Drugs



Therapy


94

DELZICOL ORAL

CAPSULE (WITH

DEL REL

TABLETS)

3

DIPENTUM ORAL

CAPSULE

4

LIALDA ORAL

TABLET,DELAYE

D RELEASE

(DR/EC)

4

mesalamine oral

tablet,delayed

release (dr/ec) 1.2

gram

4

MESALAMINE

ORAL

TABLET,DELAYE

D RELEASE

(DR/EC) 800 MG

3

mesalamine rectal

enema

4

mesalamine with

cleansing wipe

rectal enema kit

4

PENTASA ORAL

CAPSULE,

EXTENDED

RELEASE

4

GLUCOCORTICOIDS

ANALPRAM-HC

RECTAL CREAM

1-1 %

4

colocort rectal

enema

2

hydrocortisone

rectal enema

2

Drug Name Drug

Tier

Requirements

/Limits

hydrocortisone-

pramoxine rectal

cream 1-1 %

4

SULFONAMIDES

sulfasalazine oral

tablet

1

sulfasalazine oral

tablet,delayed

release (dr/ec)

2

Drug Name Drug

Tier

Requirements

/Limits

METABOLIC BONE DISEASE

AGENTS

METABOLIC BONE DISEASE

AGENTS

alendronate oral

solution

2

alendronate oral


5 mg

2 QL (90 per 90

days)

alendronate oral

tablet 35 mg, 70 mg

2 QL (12 per 84

days)

calcitonin (salmon)

nasal spray,non-

aerosol

2

calcitriol


1 mcg/ml

4

calcitriol oral

capsule

2

calcitriol oral

solution

2

etidronate disodium

oral tablet

2


5-Specialty Drugs



Therapy


95

FORTEO

SUBCUTANEOUS

PEN INJECTOR

5 PA; QL (3 per

28 days);

NEDS

ibandronate


4 B/D PA

ibandronate

intravenous syringe

4 B/D PA

ibandronate oral

tablet

2 QL (3 per 84

days)

MIACALCIN

INJECTION

SOLUTION

4

NATPARA

SUBCUTANEOUS

CARTRIDGE

5 PA; NEDS

pamidronate


4

PARICALCITOL

HEMODIALYSIS

PORT INJECTION

SOLUTION

4

paricalcitol


4

paricalcitol oral

capsule

2

PROLIA

SUBCUTANEOUS

SYRINGE

4 PA

SENSIPAR ORAL

TABLET

3

TYMLOS

SUBCUTANEOUS

PEN INJECTOR

3

Drug Name Drug

Tier

Requirements

/Limits

XGEVA

SUBCUTANEOUS

SOLUTION

5 PA; NEDS

zoledronic acid


4

zoledronic acid-

mannitol-water

intravenous

piggyback

4

ZOMETA

INTRAVENOUS

PIGGYBACK

5 NEDS

Drug Name Drug

Tier

Requirements

/Limits

MISCELLANEOUS

THERAPEUTIC AGENTS

MISCELLANEOUS THERAPEUTIC

AGENTS

ACETADOTE

INTRAVENOUS

SOLUTION

3

acetylcysteine


2

alcohol pads topical

pads, medicated

1

CALCIUM

DISODIUM

VERSENATE

INJECTION

SOLUTION

4

clomiphene citrate

oral tablet

2 PA

deferoxamine


2


5-Specialty Drugs



Therapy


96

DESFERAL

INJECTION

RECON SOLN 500

MG

4

freamine iii 10 %

intravenous

parenteral solution

2 B/D PA

GAUZE PADS 2 X

2

2

INSULIN PEN

NEEDLE

1

INSULIN

SYRINGE (DISP)

U-100 0.3 ML, 1

ML, 1/2 ML

1

md-gastroview oral

solution

2

METHYLERGONO

VINE INJECTION

SOLUTION

4

METOPIRONE

ORAL CAPSULE

3

NEEDLES,

INSULIN

DISP.,SAFETY

1

NOVOFINE 32

NEEDLE

1

NOVOFINE PLUS

NEEDLE

1

NOVOPEN ECHO

SUBCUTANEOUS

INSULIN PEN

1

NOVOTWIST

NEEDLE 32

GAUGE X 1/5"

1

Drug Name Drug

Tier

Requirements

/Limits

VGO 20 DEVICE 1

VGO 30 DEVICE 1

VGO 40 DEVICE 1

VIMIZIM

INTRAVENOUS

SOLUTION

5 PA; NEDS

water for irrigation,

sterile irrigation

solution

4

XIAFLEX

INJECTION

RECON SOLN

5 PA; QL (1 per

30 days);

NEDS

Drug Name Drug

Tier

Requirements

/Limits

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

atropine ophthalmic

(eye) drops

2

bacitracin-

polymyxin b

ophthalmic (eye)

ointment

2

CYSTARAN

OPHTHALMIC

(EYE) DROPS

5 NEDS

LACRISERT

OPHTHALMIC

(EYE) INSERT

3

neomycin-

bacitracin-

polymyxin

ophthalmic (eye)

ointment

2

neo-polycin

ophthalmic (eye)

ointment

2


5-Specialty Drugs




Therapy


97

polycin ophthalmic

(eye) ointment

2

RESTASIS

MULTIDOSE

OPHTHALMIC

(EYE) DROPS

3

RESTASIS

OPHTHALMIC

(EYE)

DROPPERETTE

3

OPHTHALMIC ANTI-ALLERGY

AGENTS

azelastine

ophthalmic (eye)

drops

2

cromolyn

ophthalmic (eye)

drops

2

EMADINE

OPHTHALMIC

(EYE) DROPS

4

epinastine

ophthalmic (eye)

drops

2

olopatadine

ophthalmic (eye)

drops 0.1 %

2

PAZEO

OPHTHALMIC

(EYE) DROPS

3

OPHTHALMIC ANTIGLAUCOMA

AGENTS

ALPHAGAN P

OPHTHALMIC

(EYE) DROPS 0.1

%

3

Drug Name Drug

Tier

Requirements

/Limits

apraclonidine

ophthalmic (eye)

drops

2

AZOPT

OPHTHALMIC

(EYE)

DROPS,SUSPENSI

ON

3

betaxolol ophthalmic

(eye) drops

2

BETOPTIC S

OPHTHALMIC

(EYE)

DROPS,SUSPENSI

ON

3

bimatoprost

ophthalmic (eye)

drops

4

brimonidine

ophthalmic (eye)

drops

2

carteolol ophthalmic

(eye) drops

2

COMBIGAN

OPHTHALMIC

(EYE) DROPS

3

dorzolamide

ophthalmic (eye)

drops

2

dorzolamide-timolol

ophthalmic (eye)

drops

2

IOPIDINE

OPHTHALMIC

(EYE)

DROPPERETTE

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


98

levobunolol

ophthalmic (eye)

drops 0.5 %

2

metipranolol

ophthalmic (eye)

drops

2

PHOSPHOLINE

IODIDE

OPHTHALMIC

(EYE) DROPS

3

pilocarpine hcl

ophthalmic (eye)

drops 1 %, 2 %, 4 %

2

SIMBRINZA

OPHTHALMIC

(EYE)

DROPS,SUSPENSI

ON

3

timolol maleate

ophthalmic (eye)

drops

1

timolol maleate

ophthalmic (eye) gel

forming solution

2

OPHTHALMIC ANTI-

INFLAMMATORIES

ACUVAIL (PF)

OPHTHALMIC

(EYE)

DROPPERETTE

4

BLEPHAMIDE

S.O.P.

OPHTHALMIC

(EYE) OINTMENT

4

bromfenac

ophthalmic (eye)

drops

2

Drug Name Drug

Tier

Requirements

/Limits

dexamethasone

sodium phosphate

ophthalmic (eye)

drops

2

DUREZOL

OPHTHALMIC

(EYE) DROPS

3

fluorometholone

ophthalmic (eye)

drops,suspension

2

flurbiprofen sodium

ophthalmic (eye)

drops

2

FML S.O.P.

OPHTHALMIC

(EYE) OINTMENT

4

ILEVRO

OPHTHALMIC

(EYE)

DROPS,SUSPENSI

ON

4

ketorolac

ophthalmic (eye)

drops

2

NEVANAC

OPHTHALMIC

(EYE)

DROPS,SUSPENSI

ON

4

PRED MILD

OPHTHALMIC

(EYE)

DROPS,SUSPENSI

ON

4

PRED-G S.O.P.

OPHTHALMIC

(EYE) OINTMENT

4

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


99

prednisolone acetate

ophthalmic (eye)

drops,suspension

2

prednisolone sodium

phosphate

ophthalmic (eye)

drops

2

sulfacetamide-

prednisolone

ophthalmic (eye)

drops

2

TOBRADEX

OPHTHALMIC

(EYE) OINTMENT

3

TOBRADEX ST

OPHTHALMIC

(EYE)

DROPS,SUSPENSI

ON

3

tobramycin-

dexamethasone

ophthalmic (eye)

drops,suspension

2

OPHTHALMIC PROSTAGLANDIN

AND PROSTAMIDE ANALOGS

latanoprost

ophthalmic (eye)

drops

2

LUMIGAN

OPHTHALMIC

(EYE) DROPS 0.01

%

3

TRAVATAN Z

OPHTHALMIC

(EYE) DROPS

3

Drug Name Drug

Tier

Requirements

/Limits

OTIC AGENTS

OTIC AGENTS

CIPRO HC OTIC

(EAR)

DROPS,SUSPENSI

ON

4

CIPRODEX OTIC

(EAR)

DROPS,SUSPENSI

ON

3

COLY-MYCIN S

OTIC (EAR)

DROPS,SUSPENSI

ON

4

hydrocortisone-

acetic acid otic (ear)

drops

2

neomycin-

polymyxin-hc otic

(ear)

drops,suspension

2

neomycin-

polymyxin-hc otic

(ear) solution

2

Drug Name Drug

Tier

Requirements

/Limits

RESPIRATORY

TRACT/PULMONARY AGENTS

ANTIHISTAMINES

azelastine nasal

aerosol,spray

2

azelastine nasal

spray,non-aerosol

2

cetirizine oral

solution 1 mg/ml

2

cyproheptadine oral

syrup

2


5-Specialty Drugs



Therapy


100

cyproheptadine oral

tablet

2

desloratadine oral

tablet

2 QL (90 per 90

days)

desloratadine oral


2 QL (90 per 90

days)

diphenhydramine hcl


mg/ml

4

diphenhydramine hcl

injection syringe

4

hydroxyzine hcl

intramuscular

solution

4

hydroxyzine hcl oral

solution 10 mg/5 ml

2

hydroxyzine hcl oral

tablet

2

hydroxyzine

pamoate oral

capsule 25 mg, 50

mg

2

levocetirizine oral

solution

2

levocetirizine oral

tablet

2 QL (90 per 90

days)

olopatadine nasal

spray,non-aerosol

2

ANTI-INFLAMMATORIES,

INHALED CORTICOSTEROIDS

ALVESCO

INHALATION HFA

AEROSOL

INHALER

3 QL (37 per 90

days)

Drug Name Drug

Tier

Requirements

/Limits

ASMANEX HFA

AEROSOL

INHALER

3 QL (39 per 90

days)

ASMANEX

TWISTHALER

INHALATION

AEROSOL POWDR

BREATH

ACTIVATED 110

MCG (30 DOSES),

220 MCG (120

DOSES), 220 MCG

(30 DOSES), 220

MCG (60 DOSES)

3 QL (3 per 90

days)

BECONASE AQ

NASAL

SPRAY,NON-

AEROSOL

4

budesonide

inhalation

suspension for

nebulization

4 B/D PA

FLOVENT DISKUS

INHALATION

BLISTER WITH

DEVICE

3 QL (360 per

90 days)

FLOVENT HFA

AEROSOL

INHALER

3 QL (72 per 90

days)

flunisolide nasal

spray,non-aerosol

25 mcg (0.025 %)

2

fluticasone nasal

spray,suspension

2

mometasone nasal

spray,non-aerosol

2

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


101

PULMICORT

FLEXHALER

INHALATION

AEROSOL POWDR

BREATH

ACTIVATED

3

QVAR

INHALATION

AEROSOL

3 QL (53 per 90

days)

QVAR

REDIHALER

INHALATION HFA

AEROSOL

BREATH

ACTIVATED

3 QL (64 per 90

days)

ANTILEUKOTRIENES

montelukast oral

granules in packet

2 QL (90 per 90

days)

montelukast oral

tablet

2 QL (90 per 90

days)

montelukast oral

tablet,chewable

2 QL (90 per 90

days)

zafirlukast oral

tablet

2 QL (180 per

90 days)

zileuton oral tablet,

er multiphase 12 hr

4 QL (360 per

90 days)

ZYFLO ORAL

TABLET

4

BRONCHODILATORS,

ANTICHOLINERGIC

ATROVENT HFA

AEROSOL

INHALER

3

ipratropium bromide

inhalation solution

2 B/D PA

Drug Name Drug

Tier

Requirements

/Limits

ipratropium bromide

nasal spray,non-

aerosol

2

SPIRIVA

RESPIMAT

INHALATION

MIST

3 QL (12 per 90

days)

SPIRIVA WITH

HANDIHALER

INHALATION

CAPSULE,

W/INHALATION

DEVICE

3 QL (90 per 90

days)

TUDORZA

PRESSAIR

INHALATION

AEROSOL POWDR

BREATH

ACTIVATED

3 QL (3 per 90

days)

BRONCHODILATORS,

SYMPATHOMIMETIC

adrenalin injection

solution

4

albuterol sulfate

inhalation solution

for nebulization

1 B/D PA

albuterol sulfate oral

syrup

1

albuterol sulfate oral

tablet

4

AUVI-Q

INJECTION AUTO-

INJECTOR

3

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


102

EPINEPHRINE

INJECTION AUTO-

INJECTOR 0.15

MG/0.15 ML, 0.3

MG/0.3 ML

4

EPINEPHRINE

INJECTION AUTO-

INJECTOR 0.15

MG/0.3 ML

3

EPIPEN 2-PAK

INJECTION AUTO-

INJECTOR

4

EPIPEN

INJECTION AUTO-

INJECTOR

4

EPIPEN JR 2-PAK

INJECTION AUTO-

INJECTOR

3

EPIPEN JR

INJECTION AUTO-

INJECTOR

3

levalbuterol hcl

inhalation solution

for nebulization

2 B/D PA

LEVALBUTEROL

TARTRATE

INHALATION HFA

AEROSOL

INHALER

4 QL (90 per 90

days)

metaproterenol oral

syrup

4

metaproterenol oral

tablet

4

PERFOROMIST

INHALATION

SOLUTION FOR

NEBULIZATION

4 B/D PA

Drug Name Drug

Tier

Requirements

/Limits

PROAIR HFA

AEROSOL

INHALER

3 QL (102 per

90 days)

PROAIR

RESPICLICK

INHALATION

AEROSOL POWDR

BREATH

ACTIVATED

3 QL (12 per 90

days)

PROVENTIL HFA

AEROSOL

INHALER

3 QL (81 per 90

days)

SEREVENT

DISKUS

INHALATION

BLISTER WITH

DEVICE

3 QL (180 per

90 days)

STRIVERDI

RESPIMAT

INHALATION

MIST

3 QL (12 per 90

days)

terbutaline oral

tablet

2

terbutaline

subcutaneous

solution

4

VENTOLIN HFA

AEROSOL

INHALER

3 QL (216 per

90 days)

XOPENEX HFA

AEROSOL

INHALER

4 QL (90 per 90

days)

CYSTIC FIBROSIS AGENTS

CAYSTON

INHALATION

SOLUTION FOR

NEBULIZATION

5 PA; QL (84

per 28 days);

NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


103

KALYDECO ORAL

GRANULES IN

PACKET

5 PA; NEDS

KALYDECO ORAL

TABLET

5 PA; NEDS

ORKAMBI ORAL

TABLET

5 PA; NEDS

PULMOZYME

INHALATION

SOLUTION

5 B/D PA;

NEDS

TOBI PODHALER

INHALATION

CAPSULE

5 NEDS

TOBI PODHALER

INHALATION

CAPSULE,

W/INHALATION

DEVICE

5 NEDS

MAST CELL STABILIZERS

cromolyn inhalation

solution for

nebulization

2 B/D PA

cromolyn oral

concentrate

4

PHOSPHODIESTERASE

INHIBITORS, AIRWAYS DISEASE

aminophylline


4

DALIRESP ORAL

TABLET

4

ELIXOPHYLLIN

ORAL ELIXIR 80

MG/15 ML

4

Drug Name Drug

Tier

Requirements

/Limits

theophylline oral

tablet extended

release 12 hr

2

theophylline oral

tablet extended

release 24 hr

2

PULMONARY

ANTIHYPERTENSIVES

ADCIRCA ORAL

TABLET

5 PA; QL (62

per 31 days);

NEDS

ADEMPAS ORAL

TABLET

5 PA; NEDS

LETAIRIS ORAL

TABLET

5 PA; NEDS

OPSUMIT ORAL

TABLET

5 PA; NEDS

ORENITRAM

ORAL TABLET

EXTENDED

RELEASE 0.125

MG

4 PA

ORENITRAM

ORAL TABLET

EXTENDED

RELEASE 0.25 MG,

1 MG, 2.5 MG, 5

MG

5 PA; NEDS

REMODULIN

INJECTION

SOLUTION

5 B/D PA;

NEDS

REVATIO ORAL

SUSPENSION FOR

RECONSTITUTIO

N

5 PA; QL (180

per 30 days);

NEDS

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs




Therapy


104

sildenafil

(pulmonary arterial

hypertension)


10 mg/12.5 ml

5 PA; QL (1163

per 31 days);

NEDS

sildenafil

(pulmonary arterial

hypertension) oral

tablet 20 mg

2 PA; QL (270

per 90 days)

TRACLEER ORAL

TABLET

5 PA; LA;

NEDS

TRACLEER ORAL

TABLET FOR

SUSPENSION

5 PA; LA;

NEDS

TYVASO

INHALATION

SOLUTION FOR

NEBULIZATION

5 B/D PA;

NEDS

TYVASO

INSTITUTIONAL

START KIT

INHALATION

SOLUTION FOR

NEBULIZATION

5 B/D PA;

NEDS

TYVASO REFILL

KIT INHALATION

SOLUTION FOR

NEBULIZATION

5 B/D PA;

NEDS

TYVASO

STARTER KIT

INHALATION

SOLUTION FOR

NEBULIZATION

5 B/D PA;

NEDS

UPTRAVI ORAL

TABLET

5 PA; NEDS

Drug Name Drug

Tier

Requirements

/Limits

UPTRAVI ORAL

TABLETS,DOSE

PACK

5 PA; NEDS

VENTAVIS

INHALATION

SOLUTION FOR

NEBULIZATION

5 B/D PA;

NEDS

PULMONARY FIBROSIS AGENTS

ESBRIET ORAL

CAPSULE

5 PA; NEDS

ESBRIET ORAL

TABLET

5 PA; NEDS

OFEV ORAL

CAPSULE

5 PA; NEDS

RESPIRATORY TRACT AGENTS,

OTHER

acetylcysteine

solution

2 B/D PA

ADVAIR DISKUS

INHALATION

BLISTER WITH

DEVICE

3 QL (180 per

90 days)

ADVAIR HFA

AEROSOL

INHALER

3 QL (36 per 90

days)

ANORO ELLIPTA

INHALATION

BLISTER WITH

DEVICE

3 QL (180 per

90 days)

BREO ELLIPTA

INHALATION

BLISTER WITH

DEVICE

3 QL (180 per

90 days)

Drug Name Drug

Tier

Requirements

/Limits


5-Specialty Drugs



Therapy


105

COMBIVENT

RESPIMAT

INHALATION

MIST

4

DULERA

INHALATION HFA

AEROSOL

INHALER

3 QL (39 per 90

days)

ipratropium-

albuterol inhalation

solution for

nebulization

2 B/D PA

PROLASTIN-C

INTRAVENOUS

RECON SOLN

5 PA; NEDS

PROLASTIN-C

INTRAVENOUS

SOLUTION

5 PA; NEDS

STIOLTO

RESPIMAT

INHALATION

MIST

3 QL (12 per 90

days)

SYMBICORT

INHALATION HFA

AEROSOL

INHALER

3 QL (30.6 per

90 days)

ZEMAIRA

INTRAVENOUS

RECON SOLN

5 PA; NEDS

Drug Name Drug

Tier

Requirements

/Limits

SKELETAL MUSCLE

RELAXANTS

SKELETAL MUSCLE RELAXANTS

cyclobenzaprine oral

tablet

2

methocarbamol oral

tablet

2

Drug Name Drug

Tier

Requirements

/Limits

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

zaleplon oral

capsule

2 QL (90 per 90

days)

zolpidem oral tablet 4 QL (90 per 90

days)

zolpidem oral

tablet,ext release

multiphase

4 QL (90 per 90

days)

zolpidem sublingual

tablet

4 QL (90 per 90

days)

SLEEP DISORDERS, OTHER

armodafinil oral

tablet

4 PA; QL (90

per 90 days)

HETLIOZ ORAL

CAPSULE

5 PA; QL (31

per 31 days);

NEDS

modafinil oral tablet 4 PA; QL (180

per 90 days)

ROZEREM ORAL

TABLET

3 QL (90 per 90

days)

XYREM ORAL

SOLUTION

5 PA; LA;

NEDS

Index 1

Index

A

abacavir ................................43 abacavir-lamivudine .............43 abacavir-lamivudine-

zidovudine ........................43 ABELCET............................23 ABILIFY MAINTENA........39 ABRAXANE........................29 ABSTRAL..............................3 acamprosate............................6 acarbose................................47 acebutolol .............................54 ACETADOTE......................95 acetaminophen-codeine..........3 acetazolamide .......................57 acetazolamide sodium ..........57 acetic acid...............................7 acetylcysteine ...............95, 104 acitretin.................................63 ACTEMRA ..........................90 ACTHIB (PF).......................91 ACTIMMUNE .....................90 ACUVAIL (PF)....................98 acyclovir ...............................42 acyclovir sodium ..................42 ADACEL(TDAP

ADOLESN/ADULT)(PF) 91 ADAGEN .............................73 adapalene..............................63 ADASUVE...........................38 ADCIRCA..........................103 adefovir.................................41 ADEMPAS.........................103 adenosine..............................54 adrenalin .............................101 adriamycin............................29 adrucil...................................28 ADVAIR DISKUS.............104 ADVAIR HFA ...................104 afeditab cr.............................55 AFINITOR ...........................33 AFINITOR DISPERZ ..........33 a-hydrocort ...........................76 ala-cort..................................76 ALBENZA ...........................36 albuterol sulfate ..................101 alclometasone .......................76

alcohol pads..........................95 ALDURAZYME ..................73 ALECENSA .........................33 alendronate ...........................94 alfuzosin ...............................75 ALIMTA ..............................28 ALINIA ................................36 ALIQOPA ............................33 allopurinol ............................25 allopurinol sodium................36 almotriptan malate................26 aloprim..................................36 alosetron ...............................72 ALPHAGAN P.....................97 alprazolam ............................46 alprazolam intensol...............46 ALUNBRIG .........................33 ALVESCO..........................100 amabelz.................................82 amantadine hcl......................46 AMBISOME ........................23 amcinonide ...........................76 amethia .................................82 amethia lo .............................82 amethyst................................82 AMICAR ..............................52 amifostine crystalline ...........29 amikacin .................................6 amiloride...............................58 amiloride-hydrochlorothiazide

..........................................58 aminophylline.....................103 AMINOSYN 10 % ...............64 AMINOSYN 7 % WITH

ELECTROLYTES............64 AMINOSYN 8.5 % ..............64 AMINOSYN II 10 % ...........64 AMINOSYN II 15 % ...........64 AMINOSYN II 7 % .............64 AMINOSYN II 8.5 % ..........64 AMINOSYN II 8.5 %-

ELECTROLYTES............65 AMINOSYN-HBC 7%.........65 AMINOSYN-PF 10 % .........65 AMINOSYN-PF 7 %

(SULFITE-FREE) ............65 AMINOSYN-RF 5.2 %........65

amiodarone ...........................54 AMITIZA .............................72 amitriptyline .........................22 amlodipine ............................55 amlodipine-atorvastatin ........56 amlodipine-benazepril ..........56 amlodipine-olmesartan .........56 amlodipine-valsartan ............56 amlodipine-valsartan-hcthiazid

..........................................56 ammonium lactate ................63 amnesteem ............................63 amoxapine.............................22 amoxicillin......................12, 13 amoxicillin-pot clavulanate ..13 amphotericin b ......................23 ampicillin..............................13 ampicillin sodium .................13 ampicillin-sulbactam ............13 AMPYRA .............................62 ANADROL-50 .....................81 anagrelide .............................51 ANALPRAM-HC.................94 anastrozole ............................32 ANDRODERM ....................81 ANDROGEL ........................81 ANORO ELLIPTA.............104 ANZEMET ...........................23 apexicon e.............................63 APOKYN .............................37 apraclonidine ........................97 aprepitant ..............................23 APTIOM...............................18 APTIVUS .............................45 ARANESP (IN

POLYSORBATE) ............51 ARCALYST .........................90 aripiprazole ...........................39 ARISTADA..........................39 armodafinil .........................105 ARRANON ..........................28 ARZERRA ...........................34 ASACOL HD .......................93 ashlyna ..................................82 ASMANEX HFA ...............100 ASMANEX TWISTHALER

........................................100

Index 2

aspirin-dipyridamole ............52 ASTAGRAF XL ..................86 atazanavir .............................45 atenolol .................................54 atenolol-chlorthalidone.........54 atomoxetine ..........................61 atorvastatin ...........................59 atovaquone ...........................36 atovaquone-proguanil...........36 ATRIPLA .............................43 atropine.................................96 ATROVENT HFA .............101 AUBAGIO ...........................62 AUVI-Q..............................101 AVASTIN ............................34 AVC .......................................7 avita ......................................63 AVONEX .............................62 AVONEX (WITH ALBUMIN)

..........................................62 azacitidine.............................30 AZACTAM ..........................12 AZACTAM IN DEXTROSE

(ISO-OSM).......................12 AZASITE .............................14 azathioprine ..........................86 azathioprine sodium .............86 azelastine ........................97, 99 azithromycin.........................14 AZOPT.................................97 aztreonam .............................12 B baciim.....................................7 bacitracin ................................7 bacitracin-polymyxin b ........96 baclofen ................................40 BACTROBAN NASAL.........8 balsalazide ............................93 BANZEL ..............................19 BARACLUDE .....................41 BAVENCIO .........................34 BAXDELA...........................15 BCG VACCINE, LIVE (PF) 91 BECONASE AQ ................100 BELEODAQ ........................33 benazepril .............................53 benazepril-hydrochlorothiazide

..........................................53 BENDEKA...........................27

BENLYSTA .........................86 BENZNIDAZOLE .................8 benztropine ...........................37 BERINERT ..........................86 BESPONSA..........................34 betamethasone dipropionate .76 betamethasone valerate.........76 betamethasone, augmented...77 BETASERON ......................62 betaxolol .........................54, 97 bethanechol chloride.............76 BETHKIS ...............................7 BETOPTIC S........................97 BEVYXXA ..........................50 bexarotene ............................36 BEXSERO............................91 bicalutamide .........................28 BICILLIN C-R .....................13 BICILLIN L-A .....................13 BICNU..................................27 BIDIL ...................................56 BIKTARVY .........................42 BILTRICIDE........................36 bimatoprost...........................97 bisoprolol fumarate...............54 bisoprolol-hydrochlorothiazide

..........................................54 BIVIGAM ............................89 bleomycin .............................30 BLEPHAMIDE S.O.P. .........98 BLINCYTO..........................35 BOOSTRIX TDAP...............91 BORTEZOMIB ....................30 BOSULIF .............................33 BREO ELLIPTA ................104 BRILINTA ...........................52 brimonidine ..........................97 BRISDELLE ........................21 BRIVIACT .....................16, 17 bromfenac.............................98 bromocriptine .......................37 budesonide....................77, 100 bumetanide ...........................58 BUPHENYL.........................73 BUPRENEX...........................2 BUPRENORPHINE...............2 buprenorphine hcl...............2, 6 buprenorphine-naloxone.........6 bupropion hcl........................20

bupropion hcl (smoking deter)6 buspirone ..............................46 busulfan ................................27 butorphanol tartrate ................3 BUTRANS .............................2 BYDUREON........................47 BYDUREON BCISE............47 BYETTA ..............................47 C

cabergoline 85 ...........................

CABOMETYX.....................33 calcipotriene .........................63 calcipotriene-betamethasone 63 calcitonin (salmon) ...............94 calcitrene...............................63 calcitriol ..........................63, 94 calcium acetate .....................76 calcium chloride ...................65 CALCIUM DISODIUM

VERSENATE...................95 calcium gluconate .................65 CALDOLOR ..........................1 CALQUENCE......................33 camila ...................................83 CAMPTOSAR......................33 camrese .................................82 camrese lo .............................82 CANASA..............................93 CANCIDAS..........................23 candesartan ...........................53 candesartan-hydrochlorothiazid

..........................................53 CAPASTAT .........................26 CAPEX .................................77 CAPRELSA..........................33 captopril ................................53 captopril-hydrochlorothiazide

..........................................53 CARBAGLU ........................65 carbamazepine ......................19 carbidopa ..............................37 carbidopa-levodopa ..............37 carbidopa-levodopa-

entacapone ........................37 carboplatin ............................30 CARIMUNE NF

NANOFILTERED............89 carteolol ................................97 cartia xt .................................55

Index 3

carvedilol ..............................54 carvedilol phosphate.............54 caspofungin ..........................23 CASPOFUNGIN..................23 CAYSTON.........................102 caziant (28)...........................82 cefaclor .................................10 cefadroxil..............................10 cefazolin ...............................10 cefazolin in dextrose (iso-os)10 cefdinir .................................10 cefepime ...............................11 CEFEPIME IN DEXTROSE 5

%.......................................11 cefepime in dextrose,iso-osm

..........................................11 cefixime................................11 cefotaxime ............................11 cefotetan ...............................11 CEFOTETAN IN

DEXTROSE, ISO-OSM...11 cefoxitin................................11 cefoxitin in dextrose, iso-osm

..........................................11 cefpodoxime.........................11 cefprozil................................11 ceftazidime ...........................11 CEFTAZIDIME IN D5W ....11 ceftriaxone............................11 CEFTRIAXONE ..................11 ceftriaxone in dextrose,iso-os

..........................................11 cefuroxime axetil..................11 cefuroxime sodium...............11 celecoxib.................................1 CELLCEPT INTRAVENOUS

..........................................86 CELONTIN..........................17 cephalexin.......................11, 12 CERDELGA.........................73 CEREBYX ...........................19 CEREZYME ........................73 cetirizine ...............................99 CETRAXAL.........................15 cevimeline ............................62 CHANTIX..............................6 CHANTIX CONTINUING

MONTH BOX....................6

CHANTIX STARTING

MONTH BOX....................6 CHEMET 70 ..............................

chloramphenicol sod succinate ............................................8

chlordiazepoxide-clidinium..71 chlorhexidine gluconate .......62 chloroprocaine (pf) .................5 chloroquine phosphate..........36 chlorothiazide .......................58 chlorothiazide sodium ..........58 chlorpromazine.....................38 chlorthalidone.......................58 CHOLBAM ..........................73 cholestyramine (with sugar) .59 cholestyramine light .............59 CHORIONIC

GONADOTROPIN,

HUMAN...........................80 ciclodan ................................23 ciclopirox........................23, 24 cidofovir ...............................41 cilostazol...............................52 CILOXAN ............................15 CIMDUO..............................43 CIMZIA................................87 CIMZIA POWDER FOR

RECONST........................86 CIMZIA STARTER KIT .....87 CINRYZE.............................86 CIPRO HC............................99 CIPRODEX ..........................99 ciprofloxacin.........................15 ciprofloxacin hcl...................15 ciprofloxacin in 5 % dextrose

..........................................15 ciprofloxacin lactate .............15 cisplatin ................................30 citalopram.............................21 cladribine ..............................28 claravis..................................63 clarithromycin ......................14 CLEOCIN...............................8 clindacin etz............................8 clindacin p ..............................8 clindamycin hcl ......................8 CLINDAMYCIN IN 0.9 %

SOD CHLOR .....................8 clindamycin in 5 % dextrose ..8

clindamycin palmitate hcl.......8 clindamycin pediatric .............8 clindamycin phosphate ...........8 clindamycin-benzoyl peroxide

..........................................63 CLINDESSE...........................8 CLINIMIX 5%/D15W

SULFITE FREE ...............65 CLINIMIX 5%/D25W

SULFITE-FREE ...............65 CLINIMIX 2.75%/D5W

SULFIT FREE..................65 CLINIMIX 4.25%/D10W

SULF FREE......................65 CLINIMIX 4.25%/D5W

SULFIT FREE..................65 CLINIMIX 4.25%-D20W

SULF-FREE .....................65 CLINIMIX 4.25%-D25W

SULF-FREE .....................66 CLINIMIX 5%-

D20W(SULFITE-FREE)..66 CLINIMIX E 4.25%/D10W

SUL FREE........................66 clobetasol ..............................77 clobetasol-emollient .............77 clodan ...................................77 clofarabine ............................29 CLOLAR ..............................29 clomiphene citrate ................95 clomipramine........................22 clonazepam ...........................46 clonidine ...............................52 clonidine (pf) ........................52 clonidine hcl ...................52, 61 clopidogrel ............................52 clorazepate dipotassium........46 clotrimazole ..........................24 clotrimazole-betamethasone .24 clozapine...............................40 CLOZAPINE........................40 COARTEM...........................36 codeine sulfate ........................3 COLCHICINE......................25 colestipol...............................59 colistin (colistimethate na) .....8 colocort .................................94 COLY-MYCIN S .................99 COMBIGAN ........................97

Index 4

COMBIVENT RESPIMAT105 COMETRIQ .........................33 COMPLERA ........................43 compro..................................22 constulose .............................72 COPAXONE ........................62 COREG CR..........................55 CORLANOR........................56 cortisone ...............................77 COTELLIC...........................33 COUMADIN........................50 CREON ................................73 CRIXIVAN ..........................45 cromolyn.......................97, 103 CUVITRU ............................89 cyclobenzaprine..................105 cyclophosphamide................27 CYCLOPHOSPHAMIDE....27 CYCLOSET .........................47 cyclosporine .........................87 cyclosporine modified ..........87 cyproheptadine .............99, 100 CYRAMZA..........................35 CYSTADANE......................73 CYSTAGON ........................73 CYSTARAN ........................96 cysteine (l-cysteine)..............66 cytarabine .............................29 cytarabine (pf) ......................29 CYTOGAM..........................89 D

d10 %-0.45 % sodium chloride

..........................................66 d2.5 %-0.45 % sodium

chloride.............................66 d5 % and 0.9 % sodium

chloride.............................66 d5 %-0.45 % sodium chloride

..........................................66 dacarbazine...........................27 dactinomycin ........................30 DALIRESP.........................103 DALVANCE..........................8 danazol .................................81 dantrolene .............................40 dapsone.................................26 DAPTACEL (DTAP

PEDIATRIC) (PF)............91 daptomycin .............................8

DARAPRIM.........................36 DARZALEX ........................35 daunorubicin.........................30 daysee ...................................82 deblitane ...............................83 decadron ...............................77 decitabine..............................30 deferoxamine ........................95 deltasone...............................77 DELZICOL ..........................94 demeclocycline.....................16 DEMSER..............................56 DENAVIR ............................42 denta 5000 plus.....................66 DEPEN TITRATABS ..........70 DEPO-PROVERA................83 DEPO-SUBQ PROVERA 104

..........................................83 DESCOVY ...........................43 DESFERAL..........................96 desipramine ..........................22 desloratadine.......................100 desmopressin ........................80 desonide................................77 desoximetasone ....................77 DESVENLAFAXINE ..........21 desvenlafaxine succinate ......21 dexamethasone .....................77 dexamethasone intensol........77 dexamethasone sodium

phosphate....................77, 98 dexrazoxane hcl ....................30 dextroamphetamine ..............61 dextroamphetamine-

amphetamine ....................61 dextrose 10 % and 0.2 % nacl

..........................................66 dextrose 10 % in water (d10w)




..........................................66 dextrose 5 % in water (d5w).66 dextrose 5 %-lactated ringers66 dextrose 5%-0.2 % sod

chloride.............................66

dextrose 5%-0.3 %

sod.chloride ......................67 dextrose 50 % in water (d50w)


..........................................67 dextrose with sodium chloride

..........................................67 DIASTAT .............................17 DIASTAT ACUDIAL ..........17 diazepam.........................17, 46 diazepam intensol .................46 diclofenac potassium ..............1 diclofenac sodium...................1 diclofenac-misoprostol ...........1 dicloxacillin ..........................13 dicyclomine ..........................71 didanosine.............................44 DIFICID ...............................14 diflorasone ......................77, 78 diflunisal .................................1 digitek ...................................57 digox .....................................57 digoxin..................................57 dihydroergotamine................26 DILANTIN 30 MG...............19 diltiazem hcl ...................55, 56 dilt-xr ....................................56 DIPENTUM .........................94 diphenhydramine hcl ..........100 diphenoxylate-atropine .........71 disulfiram................................6 divalproex .............................17 DIVIGEL..............................82 docetaxel...............................30 DOCETAXEL ......................30 dofetilide...............................54 donepezil...............................19 dorzolamide ..........................97 dorzolamide-timolol .............97 doxazosin..............................52 doxepin .................................22 doxorubicin...........................30 doxorubicin, peg-liposomal ..30 doxy-100...............................16 doxycycline hyclate ..............16 doxycycline monohydrate ....16 dronabinol.............................23 droperidol .............................22

Index 5

drospirenone-e.estradiol-lm.fa

..........................................82 drospirenone-ethinyl estradiol

..........................................82 DROXIA ..............................29 DULERA............................105 duloxetine.............................21 duramorph (pf) .......................3 DUREZOL ...........................98 dutasteride ............................75 DUZALLO ...........................25 E e.e.s. 400...............................14 econazole..............................24 EDURANT...........................43 efavirenz ...............................43 EFFIENT..............................52 EGRIFTA .............................80 ELAPRASE..........................74 ELELYSO ............................74 eletriptan...............................26 eliphos ..................................76 ELIQUIS ..............................50 ELITEK................................29 ELIXOPHYLLIN...............103 ELLENCE ............................30 ELMIRON............................76 EMADINE ...........................97 EMCYT................................28 EMEND................................23 EMPLICITI ..........................35 EMSAM ...............................20 EMTRIVA............................44 enalapril maleate ..................53 enalapril-hydrochlorothiazide

..........................................53 ENBREL ..............................87 ENBREL MINI ....................87 ENBREL SURECLICK .......87 ENDARI...............................71 endocet ...................................3 ENGERIX-B (PF) ................91 ENGERIX-B PEDIATRIC

(PF)...................................91 enoxaparin ............................50 entacapone............................37 entecavir ...............................41 ENTEREG............................71 ENTRESTO .........................57

enulose..................................72 ENVARSUS XR ..................87 EPCLUSA ............................41 epinastine..............................97 EPINEPHRINE ..................102 EPIPEN ..............................102 EPIPEN 2-PAK ..................102 EPIPEN JR .........................102 EPIPEN JR 2-PAK.............102 epirubicin..............................30 epitol.....................................19 EPIVIR HBV........................41 eplerenone ............................58 EPOGEN ..............................51 epoprostenol (glycine)..........60 eprosartan .............................53 ERAXIS(WATER DILUENT)

..........................................24 ERBITUX.............................35 ergoloid.................................19 ERIVEDGE ..........................33 ERLEADA ...........................28 errin ......................................83 ERWINAZE .........................31 ery pads.................................14 ery-tab...................................14 ERY-TAB.............................14 ERYTHROCIN ....................14 erythrocin (as stearate) .........14 erythromycin ........................15 erythromycin ethylsuccinate.14 erythromycin with ethanol....15 ESBRIET............................104 escitalopram oxalate .............21 esomeprazole magnesium.....73 estazolam..............................46 ESTRACE ............................82 estradiol ................................82 estradiol valerate...................82 estradiol-norethindrone acet .82 ESTRING .............................82 ethacrynate sodium...............58 ethambutol ............................26 ethosuximide ........................17 ethynodiol diac-eth estradiol 82 ETHYOL..............................31 etidronate disodium ..............94 etodolac ..................................1 ETOPOPHOS.......................32

etoposide...............................32 EURAX ................................37 EVOMELA...........................27 EVOTAZ ..............................45 EVZIO ....................................6 EXELDERM ........................24 exemestane ...........................32 EXJADE ...............................70 EXTAVIA ............................62 ezetimibe...............................59 ezetimibe-simvastatin ...........57 F

FABRAZYME .....................74 famciclovir............................42 famotidine.............................72 famotidine (pf)......................72 famotidine (pf)-nacl (iso-os)72 FANAPT...............................39 FARESTON .........................28 FARXIGA ............................47 FARYDAK...........................33 FASLODEX .........................28 FAZACLO............................40 felbamate ..............................18 felodipine..............................56 FEMRING ............................82 fenofibrate.............................58 fenofibrate micronized..........58 fenofibrate nanocrystallized .58 fenofibric acid.......................59 fenofibric acid (choline) .......58 fenoprofen...............................1 fentanyl ...................................2 fentanyl citrate ........................3 fentanyl citrate (pf) .................3 FENTORA..............................3 FERRIPROX ........................70 FETZIMA.............................21 FINACEA.............................63 finasteride .............................75 FIRAZYR .............................86 FIRMAGON KIT W

DILUENT SYRINGE ......85 flavoxate ...............................75 FLEBOGAMMA DIF ..........89 flecainide ..............................54 FLOLAN ..............................60 FLOVENT DISKUS 100 ..........

FLOVENT HFA.................100

Index 6

floxin ....................................15 floxuridine ............................29 fluconazole ...........................24 fluconazole in dextrose(iso-o)

..........................................24 fluconazole in nacl (iso-osm)24 flucytosine ............................24 fludarabine............................31 fludrocortisone .....................78 flunisolide...........................100 fluocinolone..........................78 fluocinolone acetonide oil ....78 fluocinolone and shower cap 78 fluocinonide..........................78 fluocinonide-e.......................78 fluocinonide-emollient .........78 FLUORABON .....................71 fluoride (sodium)............67, 71 fluoritab ................................67 fluorometholone ...................98 fluorouracil .....................29, 63 FLUOROURACIL...............63 fluoxetine..............................21 FLUOXETINE .....................21 fluphenazine decanoate ........38 fluphenazine hcl ...................38 flurbiprofen.............................1 flurbiprofen sodium..............98 flutamide...............................28 fluticasone ....................78, 100 fluvastatin .............................59 fluvoxamine..........................21 FML S.O.P. ..........................98 fondaparinux.........................50 FORTAZ ..............................12 FORTEO ..............................95 fosamprenavir.......................45 foscarnet ...............................41 fosinopril ..............................53 fosinopril-hydrochlorothiazide

..........................................53 fosphenytoin .........................19 FOSRENOL .........................76 FRAGMIN ...........................50 FREAMINE HBC 6.9 %......70 freamine iii 10 % ..................96 frovatriptan ...........................26 furosemide............................58 FUSILEV .............................36

FUZEON ..............................44 fyavolv..................................82 FYCOMPA...........................18 G

gabapentin ............................17 GABITRIL ...........................17 galantamine ..........................20 GAMASTAN S/D ................89 GAMMAGARD LIQUID ....89 GAMMAGARD S-D (IGA < 1

MCG/ML) ........................89 GAMMAKED......................89 GAMMAPLEX ....................89 GAMMAPLEX (WITH

SORBITOL) .....................89 GAMUNEX-C......................89 ganciclovir sodium ...............41 GARDASIL 9 (PF)...............91 gatifloxacin...........................15 GATTEX 30-VIAL ..............71 GATTEX ONE-VIAL..........71 GAUZE PAD .......................96 gavilyte-c ..............................72 gavilyte-g..............................72 gavilyte-n..............................72 GAZYVA .............................35 gemcitabine ..........................29 gemfibrozil ...........................59 generlac ................................72 gengraf..................................87 GENOTROPIN ....................80 GENOTROPIN MINIQUICK

..........................................80 gentak .....................................7 gentamicin ..............................7 gentamicin in nacl (iso-osm) ..7 GENTAMICIN IN NACL

(ISO-OSM).........................7 gentamicin sulfate (ped) (pf) ..7 gentamicin sulfate (pf)............7 GENTAMICIN SULFATE

(PF).....................................7 GENVOYA ..........................42 GEODON .............................39 GILENYA ............................62 GILOTRIF............................33 glatiramer..............................62 glatopa ..................................62 GLEOSTINE ........................27

glimepiride............................47 glipizide ................................47 glipizide-metformin..............47 GLUCAGEN HYPOKIT......49 GLUCAGON EMERGENCY

KIT (HUMAN).................49 glycopyrrolate.......................71 glydo .......................................5 granisetron hcl ......................23 griseofulvin microsize ..........24 griseofulvin ultramicrosize...24 guanfacine.............................61 guanidine ..............................26 H HAEGARDA........................86 HALAVEN...........................31 halobetasol propionate..........78 haloperidol ............................38 haloperidol decanoate ...........38 haloperidol lactate ................38 HARVONI............................41 HAVRIX (PF) ......................91 heparin (porcine) ..................50 heparin (porcine) in 5 % dex 50 heparin(porcine) in 0.45% nacl

..........................................51 heparin, porcine (pf) .............51 HEPATAMINE 8%..............67 HERCEPTIN ........................35 HETLIOZ ...........................105 HEXALEN ...........................27 HIBERIX (PF)......................91 HIZENTRA ..........................89 HUMALOG KWIKPEN

INSULIN ..........................49 HUMATROPE .....................80 HUMIRA..............................87 HUMIRA PEDIATRIC

CROHN'S START............87 HUMIRA PEN .....................87 HUMIRA PEN CROHN'S-

UC-HS START ................87 HUMIRA PEN PSORIASIS-

UVEITIS...........................87 HUMULIN R U-500 (CONC)

INSULIN ..........................49 HUMULIN R U-500 (CONC)

KWIKPEN........................49 hydralazine ...........................60

Index 7

hydrochlorothiazide..............58 hydrocodone-acetaminophen .3 hydrocodone-ibuprofen ..........3 hydrocortisone................78, 94 hydrocortisone valerate ........78 hydrocortisone-acetic acid....99 hydrocortisone-min oil-wht pet

..........................................78 hydrocortisone-pramoxine ...94 hydromorphone ..................3, 4 HYDROMORPHONE ...........3 hydromorphone (pf) ...............3 hydroxychloroquine .............36 hydroxyprogesterone caproate

..........................................83 hydroxyurea..........................29 hydroxyzine hcl ..................100 hydroxyzine pamoate .........100 HYPERHEP B S/D ..............90 HYPERHEP B S-D

NEONATAL ....................90 HYPERRAB (PF) ................90 HYPERRAB S/D (PF) .........90 HYPERTET S/D (PF) ..........90 HYQVIA ..............................90 I ibandronate ...........................95 IBRANCE ............................33 ibu...........................................1 ibuprofen ................................1 ibuprofen-oxycodone .............4 ICLUSIG ..............................33 idarubicin..............................31 IDHIFA ................................33 IFEX .....................................27 ifosfamide.............................27 ILARIS (PF).........................90 ILEVRO ...............................98 imatinib.................................33 IMBRUVICA .......................33 IMFINZI...............................35 imipenem-cilastatin ..............12 imipramine hcl......................22 imipramine pamoate.............22 imiquimod ............................63 IMOGAM RABIES-HT (PF)

..........................................90 IMOVAX RABIES VACCINE

(PF)...................................92

INCRELEX ..........................80 indapamide ...........................58 INFANRIX (DTAP) (PF).....92 INFLECTRA ........................87 INLYTA ...............................33 INSULIN PEN NEEDLE.....96 INSULIN SYRINGE (DISP)

U-100................................96 INTELENCE ........................43 intralipid ...............................67 INTRALIPID........................67 INTRON A...........................41 INVANZ...............................12 INVEGA SUSTENNA.........39 INVEGA TRINZA ...............39 INVIRASE ...........................45 INVOKAMET......................47 INVOKAMET XR ...............47 INVOKANA ........................47 IOPIDINE.............................97 IPOL .....................................92 ipratropium bromide...........101 ipratropium-albuterol..........105 irbesartan ..............................53 irbesartan-hydrochlorothiazide

..........................................53 IRESSA ................................33 irinotecan ..............................31 ISENTRESS ...................42, 43 ISENTRESS HD ..................42 ISOLYTE S PH 7.4 ..............67 ISOLYTE-P IN 5 %

DEXTROSE .....................67 ISOLYTE-S..........................67 isoniazid................................27 isosorbide dinitrate ...............60 isosorbide mononitrate .........60 isotretinoin............................63 isradipine ..............................56 ISTODAX ............................31 itraconazole ..........................24 ivermectin.............................36 IXEMPRA............................31 IXIARO (PF)........................92 J JADENU ..............................70 JAKAFI ................................33 jantoven ................................51 JANUMET ...........................47

JANUMET XR.....................48 JANUVIA.............................48 JEVTANA ............................35 jinteli.....................................82 jolivette .................................83 JULUCA...............................43 JUXTAPID ...........................59 K

KABIVEN ............................67 KADCYLA...........................35 KALBITOR..........................86 KALETRA ...........................45 KALYDECO ......................103 KANUMA ............................74 kelnor 1-50............................82 KEPPRA...............................17 ketoconazole .........................24 ketoprofen...............................1 ketorolac ...............................98 KEYTRUDA ........................35 KINERET .............................87 KINRIX (PF) ........................92 kionex ...................................70 kionex (with sorbitol) ...........70 KISQALI ..............................31 KISQALI FEMARA CO-

PACK ...............................31 klor-con 10............................67 klor-con 8..............................67 klor-con m10 ........................67 klor-con m15 ........................67 klor-con m20 ........................67 klor-con sprinkle...................67 KOMBIGLYZE XR .............48 KORLYM.............................49 k-tab......................................67 KUVAN................................74 KYNAMRO .........................59 KYPROLIS...........................31 L

l norgest/e.estradiol-e.estrad.83 labetalol ................................55 LACRISERT ........................96 lactated ringers................67, 68 lactulose................................73 LAMICTAL STARTER

(BLUE) KIT .....................18 LAMICTAL STARTER

(GREEN) KIT ..................18

Index 8

LAMICTAL STARTER

(ORANGE) KIT...............18 lamivudine......................41, 44 lamivudine-zidovudine.........44 lamotrigine ...........................18 lanthanum.............................76 LANTUS SOLOSTAR U-100

INSULIN..........................49 LANTUS U-100 INSULIN..49 LARTRUVO ........................35 latanoprost ............................99 LATUDA .............................39 LAZANDA.............................4 leflunomide...........................90 LEMTRADA........................90 LENVIMA ...........................33 LETAIRIS ..........................103 letrozole................................32 leucovorin calcium ...............31 LEUKERAN ........................27 LEUKINE.............................51 leuprolide..............................85 levalbuterol hcl ...................102 LEVALBUTEROL

TARTRATE...................102 levetiracetam ........................17 levetiracetam in nacl (iso-os)17 levobunolol...........................98 levocarnitine .........................68 levocarnitine (with sugar).....68 levocetirizine ......................100 levofloxacin..........................15 levofloxacin in d5w..............15 levoleucovorin......................36 levorphanol tartrate ................2 levothyroxine........................84 levoxyl..................................84 LEXIVA ...............................45 LIALDA ...............................94 lidocaine .................................5 lidocaine (pf) ..........................5 lidocaine hcl ...........................5 lidocaine viscous ....................5 lidocaine-epinephrine .............5 lidocaine-prilocaine................5 lillow.....................................83 lincomycin..............................8 lindane ..................................37 linezolid..................................9

linezolid in dextrose 5% .........8 linezolid-0.9% sodium chloride

............................................9 LINZESS..............................72 liothyronine ..........................84 lisinopril................................53 lisinopril-hydrochlorothiazide

..........................................53 lithium carbonate............46, 47 lithium citrate .......................47 LIVALO ...............................59 LONSURF............................31 loperamide ............................71 lopinavir-ritonavir ................45 lorazepam .............................46 lorazepam intensol................46 lorcet (hydrocodone) ..............4 lorcet hd..................................4 lorcet plus ...............................4 losartan .................................53 losartan-hydrochlorothiazide 53 lovastatin ..............................59 low-ogestrel (28) ..................83 loxapine succinate ................38 ludent fluoride ......................68 LUMIGAN ...........................99 LUMIZYME ........................74 LUPRON DEPOT ................85 LUPRON DEPOT (3

MONTH) ..........................85 LUPRON DEPOT (4

MONTH) ..........................85 LUPRON DEPOT (6

MONTH) ..........................85 LUPRON DEPOT-PED .......85 LUPRON DEPOT-PED (3

MONTH) ..........................85 LYNPARZA.........................33 LYRICA ...............................17 LYSODREN.........................84 lyza .......................................83 M mafenide acetate .....................9 magnesium chloride .............68 magnesium sulfate................68 MAKENA ............................83 MAKENA (PF) ....................83 malathion ..............................37 maprotiline............................21

MARPLAN...........................20 MATULANE........................27 matzim la ..............................56 md-gastroview ......................96 meclizine...............................22 meclofenamate........................1 medroxyprogesterone ...........83 mefenamic acid.......................1 mefloquine............................36 megestrol ..............................84 MEKINIST ...........................34 meloxicam ..............................1 melphalan .............................28 melphalan hcl........................28 memantine ............................20 MEMANTINE......................20 MENACTRA (PF)................92 MENEST ..............................83 MENTAX .............................24 MENVEO A-C-Y-W-135-DIP

(PF) ...................................92 meprobamate ........................46 mercaptopurine .....................29 meropenem ...........................12 MEROPENEM-0.9%

SODIUM CHLORIDE .....12 mesalamine ...........................94 MESALAMINE ...................94 mesalamine with cleansing

wipe ..................................94 mesna....................................36 MESNEX..............................36 MESTINON .........................26 metaproterenol ....................102 metformin .............................48 methadone...............................2 methadone intensol .................2 methazolamide......................58 methenamine hippurate ..........9 methimazole .........................86 METHITEST........................81 methocarbamol ...................105 methotrexate sodium ............88 methotrexate sodium (pf)87, 88 methoxsalen..........................63 methscopolamine..................71 methyclothiazide...................58 METHYLERGONOVINE ...96 methylphenidate hcl..............61

Index 9

methylprednisolone ..............78 methylprednisolone acetate ..78 methylprednisolone sodium

succ...................................79 methyltestosterone................81 metipranolol .........................98 metoclopramide hcl ..22, 71, 72 metolazone ...........................58 METOPIRONE ....................96 metoprolol succinate ............55 metoprolol ta-hydrochlorothiaz

..........................................55 metoprolol tartrate ................55 metro i.v. ................................9 metronidazole .........................9 metronidazole in nacl (iso-os) 9 mexiletine.............................54 MIACALCIN .......................95 miconazole-3 ........................24 midodrine .............................52 migergot ...............................26 miglitol .................................48 miglustat ...............................74 mimvey.................................83 mimvey lo.............................83 minocycline ..........................16 minoxidil ..............................60 mirtazapine ...........................20 misoprostol ...........................73 mitomycin.............................31 mitoxantrone.........................31 M-M-R II (PF)......................92 modafinil ............................105 moderiba...............................41 moderiba dose pack..............41 moexipril ..............................53 moexipril-hydrochlorothiazide

..........................................53 mometasone..................79, 100 montelukast ........................101 morgidox ..............................16 morphine.............................2, 4 morphine (pf)..........................4 morphine concentrate .............4 MOVANTIK ........................72 moxifloxacin.........................15 moxifloxacin in nacl (iso-osm)

..........................................15 MOZOBIL............................51

MULTAQ.............................54 multi-vit with fluoride-iron ..68 multi-vitamin with fluoride ..68 multivitamins with fluoride ..68 multivit-fluor (vit e acetate) .68 mupirocin................................9 mupirocin calcium..................9 MUSTARGEN .....................28 MYALEPT ...........................80 mycophenolate mofetil .........88 mycophenolate mofetil hcl ...88 mycophenolate sodium.........88 MYLOTARG .......................35 myorisan ...............................63 MYRBETRIQ ......................75 N

NABI-HB .............................90 nabumetone ............................1 nadolol ..................................55 nadolol-bendroflumethiazide57 nafcillin.................................13 nafcillin in dextrose iso-osm 13 naftifine ................................25 NAFTIN ...............................25 NAGLAZYME.....................74 nalbuphine ..............................4 naloxone .................................6 naltrexone ...............................6 NAMENDA TITRATION

PAK..................................20 NAMENDA XR ...................20 naproxen .................................2 naproxen sodium ....................2 naratriptan.............................26 NARCAN ...............................6 NAROPIN (PF) ......................5 NATACYN ..........................25 nateglinide ............................48 NATPARA ...........................95 NEBUPENT .........................36 NEEDLES, INSULIN

DISP.,SAFETY ................96 nefazodone............................21 neomycin ................................7 neomycin-bacitracin-poly-hc..9 neomycin-bacitracin-

polymyxin.........................96 neomycin-polymyxin b gu......9

neomycin-polymyxin-

gramicidin...........................9 neomycin-polymyxin-hc...9, 99 neo-polycin ...........................96 neo-polycin hc ........................9 NEPHRAMINE 5.4 %..........68 NERLYNX ...........................34 neuac.....................................64 NEULASTA .........................52 NEUPOGEN.........................52 NEUPRO ..............................37 NEVANAC...........................98 nevirapine .............................43 NEXAVAR...........................34 niacin ....................................59 nicardipine ............................56 NICOTROL............................6 NICOTROL NS......................6 nifedipine..............................56 nilutamide .............................28 nimodipine............................56 NINLARO ............................31 NIPENT................................29 nisoldipine ............................56 nitro-bid ................................60 NITRO-DUR ........................60 nitrofurantoin ..........................9 nitrofurantoin macrocrystal ....9 nitrofurantoin monohyd/m-

cryst ....................................9 nitroglycerin .........................60 nizatidine ..............................72 nolix......................................79 nora-be ..................................84 NORDITROPIN FLEXPRO 80 norepinephrine bitartrate ......61 norethindrone (contraceptive)

..........................................84 norethindrone acetate............84 norethindrone ac-eth estradiol

..........................................83 norlyroc.................................84 NORMOSOL-R....................68 NORMOSOL-R PH 7.4........68 NORPACE CR .....................54 NORTHERA ........................57 nortriptyline ..........................22 NORVIR...............................45 NOVAREL ...........................80

Index 10

NOVOFINE 32 ....................96 NOVOFINE PLUS...............96 NOVOLIN 70/30 U-100

INSULIN..........................49 NOVOLIN N NPH U-100

INSULIN..........................49 NOVOLIN R REGULAR U-

100 INSULN ....................49 NOVOLOG FLEXPEN U-100

INSULIN..........................50 NOVOLOG MIX 70-30 U-100

INSULN ...........................50 NOVOLOG MIX 70-

30FLEXPEN U-100 .........50 NOVOLOG PENFILL U-100

INSULIN..........................50 NOVOLOG U-100 INSULIN

ASPART...........................50 NOVOPEN ECHO...............96 NOVOTWIST ......................96 NOXAFIL ............................25 NPLATE...............................52 NUCYNTA ............................4 NUEDEXTA ........................61 NULOJIX .............................88 NUPLAZID..........................39 NUTRESTORE....................72 NUTROPIN AQ NUSPIN ...81 nyamyc .................................25 nystatin .................................25 nystatin-triamcinolone..........25 nystop ...................................25 O ocella ....................................83 OCTAGAM..........................90 octreotide acetate..................85 ODEFSEY............................44 ODOMZO ............................34 OFEV .................................104 ofloxacin...............................16 olanzapine.............................39 olanzapine-fluoxetine ...........20 olmesartan ............................53 olmesartan-amlodipin-

hcthiazid ...........................57 olmesartan-

hydrochlorothiazide..........53 olopatadine ...................97, 100 omega-3 acid ethyl esters .....59

omeppi ..................................73 omeprazole ...........................73 OMNITROPE.......................81 ONCASPAR.........................31 ondansetron ..........................23 ondansetron hcl.....................23 ondansetron hcl (pf)..............23 ONFI...............................17, 18 ONGLYZA...........................48 OPDIVO...............................35 OPSUMIT ..........................103 oralone ..................................62 ORENCIA ............................88 ORENCIA CLICKJECT ......88 ORENITRAM ....................103 ORFADIN ............................74 ORKAMBI .........................103 oseltamivir ............................46 OTEZLA ..............................90 OTEZLA STARTER............90 OTREXUP (PF) ...................88 oxacillin ................................13 oxacillin in dextrose(iso-osm)

..........................................13 oxaliplatin.............................31 oxandrolone ..........................81 oxaprozin ................................2 oxcarbazepine.......................19 oxiconazole...........................25 OXISTAT.............................25 OXTELLAR XR ..................19 oxybutynin chloride..............75 oxycodone ..............................4 OXYCODONE.......................2 oxycodone-acetaminophen.....4 oxycodone-aspirin ..................4 oxymorphone......................2, 5 P pacerone................................54 paclitaxel ..............................31 paliperidone ..........................39 pamidronate ..........................95 PANCREAZE ......................74 PANRETIN ..........................36 pantoprazole .........................73 paricalcitol ............................95 PARICALCITOL .................95 paroex oral rinse ...................63 paromomycin..........................7

paroxetine hcl .......................21 paroxetine

mesylate(menop.sym).......21 PASER..................................27 PAXIL ..................................21 PAZEO .................................97 PEDIARIX (PF) ...................92 PEDVAX HIB (PF) ..............92 peg 3350-electrolytes............73 PEGANONE.........................19 PEGASYS ............................42 PEGASYS PROCLICK........42 peg-electrolyte ......................73 PEGINTRON .......................42 PENICILLIN G POT IN

DEXTROSE .....................13 penicillin g potassium...........13 penicillin g procaine .............13 penicillin g sodium ...............13 penicillin v potassium.....13, 14 PENTACEL (PF)..................92 PENTAM..............................37 PENTASA ............................94 pentoxifylline........................57 PERFOROMIST.................102 PERIKABIVEN ...................68 perindopril erbumine ............53 periogard...............................63 PERJETA .............................35 permethrin.............................37 perphenazine.........................38 PERTZYE.............................74 pfizerpen-g............................14 phenadoz...............................22 phenelzine.............................20 phenergan .............................22 phenobarbital ........................18 phenytoin ..............................19 phenytoin sodium .................19 phenytoin sodium extended..19 PHOSLYRA .........................76 PHOSPHOLINE IODIDE ....98 pilocarpine hcl ................63, 98 pimozide ...............................38 pindolol.................................55 pioglitazone ..........................48 pioglitazone-glimepiride.......48 pioglitazone-metformin ........48 piperacillin-tazobactam ........14

Index 11

piroxicam................................2 PLASMA-LYTE 148 ...........68 PLASMA-LYTE A ..............68 PLEGRIDY ..........................62 plenamine .............................68 podofilox ..............................64 polocaine ................................5 polocaine-mpf.........................5 polycin..................................97 polyethylene glycol 3350 .....73 polymyxin b sulfate................9 polymyxin b sulf-trimethoprim

..........................................10 POMALYST ........................28 potassium acetate..................68 potassium chlorid-d5-

0.45%nacl.........................68 potassium chloride 69 ................

potassium chloride in 0.9%nacl ..........................................68

potassium chloride in 5 % dex ..........................................68

potassium chloride in lr-d5...69 potassium chloride in water..69 potassium chloride-0.45 % nacl

..........................................69 potassium chloride-d5-

0.2%nacl ...........................69 potassium chloride-d5-

0.3%nacl ...........................69 potassium chloride-d5-

0.9%nacl ...........................69 potassium citrate...................69 potassium phosphate m-/d-

basic..................................69 PRADAXA...........................51 PRALUENT PEN ................59 pramipexole..........................37 prasugrel ...............................52 pravastatin ............................59 praziquantel ..........................36 prazosin ................................53 PRED MILD ........................98 PRED-G S.O.P. ....................98 prednicarbate ........................79 prednisolone .........................79 prednisolone acetate .............99 prednisolone sodium phosphate

....................................79, 99

prednisone ............................79 prednisone intensol...............79 PREGNYL............................81 PREMARIN .........................83 premasol 10 %......................69 PREMASOL 6 % .................69 prenatal vitamin oral tablet...69 prevalite ................................59 PREVIDENT 5000 BOOSTER

PLUS ................................69 PREVIDENT 5000

SENSITIVE......................69 PREZCOBIX........................45 PREZISTA ...........................45 PRIALT ..................................1 PRIFTIN...............................27 PRIMAQUINE.....................37 primidone..............................18 PRIVIGEN ...........................90 PROAIR HFA ....................102 PROAIR RESPICLICK .....102 probenecid ............................25 probenecid-colchicine ..........25 procainamide ........................54 prochlorperazine...................22 prochlorperazine edisylate....38 prochlorperazine maleate oral

..........................................38 PROCRIT .............................52 procto-med hc.......................79 proctosol hc ..........................79 proctozone-hc .......................79 PROCYSBI ..........................74 profeno....................................2 progesterone micronized ......84 PROGLYCEM .....................49 PROGRAF............................88 PROLASTIN-C ..................105 PROLEUKIN .......................32 PROLIA................................95 PROMACTA........................52 promethazine ........................22 promethegan .........................22 propafenone ..........................54 propranolol ...........................55 propranolol-hydrochlorothiazid

..........................................55 propylthiouracil ....................86 PROQUAD (PF)...................92

protriptyline ..........................22 PROVENTIL HFA.............102 PULMICORT FLEXHALER

........................................101 PULMOZYME...................103 PURIXAN ............................29 pyrazinamide ........................27 pyridostigmine bromide........26 Q QUADRACEL (PF) .............92 quetiapine .............................39 quinapril................................53 quinapril-hydrochlorothiazide

..........................................54 quinidine gluconate ..............54 quinidine sulfate ...................54 quinine sulfate ......................37 QVAR.................................101 QVAR REDIHALER .........101 R RABAVERT (PF) ................92 RADICAVA .........................61 raloxifene..............................84 ramipril .................................54 RANEXA .............................57 ranitidine hcl .........................72 RAPAMUNE........................88 rasagiline...............................38 RASUVO (PF)......................88 RAVICTI..............................74 REBETOL ............................42 REBIF (WITH ALBUMIN) .62 REBIF REBIDOSE ..............62 REBIF TITRATION PACK.62 RECOMBIVAX HB (PF).....92 RELENZA DISKHALER ....46 RELISTOR ...........................72 RELPAX...............................26 REMICADE .........................88 REMODULIN ....................103 RENAGEL ...........................76 RENVELA ...........................76 repaglinide ............................48 repaglinide-metformin..........48 REPATHA............................60 REPATHA PUSHTRONEX 60 REPATHA SURECLICK ....60 RESCRIPTOR......................43 RESTASIS............................97

Index 12

RESTASIS MULTIDOSE ...97 RETROVIR..........................44 REVATIO ..........................103 REVLIMID ..........................28 REXULTI.............................40 REYATAZ ...........................45 ribasphere .............................42 ribasphere ribapak ..........41, 42 ribavirin ................................42 RIDAURA............................90 rifabutin ................................26 rifampin ................................27 RIFATER .............................27 riluzole..................................61 rimantadine...........................46 ringer's ..................................69 RISPERDAL CONSTA .......40 risperidone............................40 ritonavir ................................45 RITUXAN............................35 RITUXAN HYCELA...........35 rivastigmine..........................20 rivastigmine tartrate..............20 rizatriptan .............................26 ROMIDEPSIN .....................32 ropinirole ..............................37 rosuvastatin...........................59 ROTARIX ............................92 ROTATEQ VACCINE ........92 roweepra ...............................17 roweepra xr...........................17 ROZEREM.........................105 RUBRACA...........................34 RYDAPT..............................34 S

SABRIL................................18 SAIZEN................................81 SAIZEN CLICK.EASY .......81 SAIZEN SAIZENPREP.......81 salsalate ..................................2 SAMSCA .............................70 SANCUSO ...........................23 SANDIMMUNE ..................88 SANDOSTATIN LAR

DEPOT.............................85 SANTYL ..............................64 SAPHRIS (BLACK

CHERRY) ........................40 SAVELLA............................61

scopolamine base..................23 selegiline hcl.........................38 selenium sulfide....................64 SELZENTRY .................44, 45 SENSIPAR ...........................95 SEREVENT DISKUS ........102 SEROSTIM ..........................81 sertraline ...............................22 sevelamer carbonate .............76 sf 5000 plus ..........................69 sharobel ................................84 SHINGRIX (PF)...................93 SIGNIFOR............................85 SIGNIFOR LAR...................85 sildenafil (pulmonary arterial

hypertension) ..................104 silver sulfadiazine.................16 SIMBRINZA ........................98 SIMPONI 88, 89 ........................

SIMPONI ARIA...................88 SIMULECT ..........................91 simvastatin............................59 sirolimus ...............................89 SIRTURO.............................27 SKLICE ................................36 sodium acetate ......................69 sodium chloride ....................70 sodium chloride 0.45 %..69, 70 sodium chloride 0.9 %..........70 sodium chloride 3 %.............70 sodium chloride 5 %.............70 sodium lactate intravenous ...70 sodium phenylbutyrate .........74 sodium phosphate .................70 sodium polystyrene (sorb free)

..........................................70 sodium polystyrene sulfonate

....................................70, 71 SODIUM POLYSTYRENE

SULFONATE...................71 SOLTAMOX........................28 SOLU-CORTEF...................79 SOLU-CORTEF (PF)...........79 SOLU-MEDROL .................79 SOMATULINE DEPOT ......85 SOMAVERT........................85 sorine ....................................54 sotalol ...................................54 sotalol af ...............................54

SOVALDI.............................41 SPIRIVA RESPIMAT........101 SPIRIVA WITH

HANDIHALER..............101 spironolactone.......................58 spironolacton-hydrochlorothiaz

..........................................57 SPORANOX.........................25 SPRITAM.............................17 SPRYCEL.............................34 sps (with sorbitol) .................71 ssd .........................................16 STAMARIL (PF)..................93 stavudine...............................44 STELARA ............................64 STIMATE.............................81 STIOLTO RESPIMAT.......105 STIVARGA..........................34 STRENSIQ ...........................74 STREPTOMYCIN .................7 STRIBILD ............................43 STRIVERDI RESPIMAT ..102 SUBOXONE ..........................6 SUBSYS .................................5 SUCRAID.............................74 sucralfate...............................73 sulfacetamide sodium ...........16 sulfacetamide sodium (acne) 16 sulfacetamide-prednisolone..99 sulfadiazine...........................16 sulfamethoxazole-trimethoprim

..........................................16 sulfasalazine .........................94 sulfatrim................................16 sulindac...................................2 sumatriptan ...........................26 sumatriptan succinate ...........26 SUPPRELIN LA ..................32 SUPRAX ..............................12 SUPREP BOWEL PREP KIT

..........................................73 SUSTIVA .............................43 SUTENT...............................34 SYLATRON.........................36 SYLVANT ...........................91 SYMBICORT.....................105 SYMFI..................................44 SYMFI LO............................44 SYMLINPEN 120 ................48

Index 13

SYMLINPEN 60 ..................48 SYNAGIS.............................91 SYNAREL ...........................85 SYNERCID..........................10 SYNRIBO ............................32 SYNTHROID.......................84 SYPRINE .............................71 T

TABLOID ............................29 TACLONEX ........................64 tacrolimus .......................64, 89 TAFINLAR ..........................34 TAGRISSO ..........................34 TAMIFLU ............................46 tamoxifen..............................28 tamsulosin.............................75 TARCEVA...........................34 TARGRETIN .......................36 TASIGNA ............................34 tazarotene .............................64 TAZICEF .............................12 TAZORAC...........................64 taztia xt .................................56 TECENTRIQ........................35 TECFIDERA........................62 TEFLARO............................12 TEKTURNA ........................57 TEKTURNA HCT ...............57 telmisartan ............................53 telmisartan-amlodipine.........57 telmisartan-hydrochlorothiazid

..........................................53 TEMODAR ..........................32 TENIVAC (PF) ....................93 tenofovir disoproxil fumarate

..........................................44 terazosin ...............................53 terbutaline...........................102 terconazole ...........................25 testosterone...........................82 testosterone cypionate ..........82 testosterone enanthate ..........82 TETANUS,DIPHTHERIA

TOX PED(PF) ..................93 TETANUS-DIPHTHERIA

TOXOIDS-TD..................93 tetrabenazine.........................61 THALOMID.........................28 theophylline........................103

thioridazine...........................38 thiotepa .................................28 thiothixene ............................38 THYMOGLOBULIN...........90 thyroid (pork) .......................84 THYROLAR-1.....................84 THYROLAR-1/2..................84 THYROLAR-1/4..................84 THYROLAR-2.....................84 THYROLAR-3.....................84 tiagabine ...............................18 tigecycline ............................10 timolol maleate ...............55, 98 tinidazole ..............................10 TIVICAY..............................43 tizanidine ..............................40 TOBI PODHALER ............103 TOBRADEX ........................99 TOBRADEX ST...................99 tobramycin..............................7 tobramycin in 0.225 % nacl....7 tobramycin sulfate ..................7 tobramycin-dexamethasone..99 tolazamide ............................48 tolbutamide...........................49 tolcapone ..............................37 tolmetin...................................2 tolterodine.............................75 topiramate.............................18 toposar ..................................32 topotecan ..............................33 TORISEL..............................89 torsemide ..............................58 TOTECT...............................32 TOUJEO MAX SOLOSTAR

..........................................50 TOUJEO SOLOSTAR U-300

INSULIN ..........................50 TOVIAZ ...............................75 TRACLEER .......................104 tramadol..............................2, 5 tramadol-acetaminophen ........5 trandolapril ...........................54 trandolapril-verapamil ..........57 tranexamic acid.....................52 TRANSDERM-SCOP..........23 tranylcypromine....................20 travasol 10 %........................70 TRAVATAN Z 99 .....................

trazodone ..............................22 TREANDA ...........................28 TRECATOR .........................27 TRELSTAR..........................86 tretinoin (chemotherapy) ......36 tretinoin topical.....................64 triamcinolone acetonide..63, 79 triamterene-hydrochlorothiazid

..........................................57 triazolam ...............................46 triderm ..................................79 trientine.................................71 trifluoperazine.......................38 trifluridine.............................42 TRIGLIDE............................59 trihexyphenidyl.....................37 triklo .....................................60 trilyte with flavor packets .....73 trimethoprim .........................10 trimipramine .........................22 TRINTELLIX.......................22 TRISENOX ..........................32 TRIUMEQ............................44 TROGARZO ........................45 TROPHAMINE 10 %...........70 TROPHAMINE 6%..............70 trospium................................75 TRUMENBA........................93 TRUVADA...........................44 TUDORZA PRESSAIR .....101 TWINRIX (PF).....................93 TYBOST...............................45 TYGACIL.............................10 TYKERB ..............................34 TYMLOS..............................95 TYPHIM VI..........................93 TYSABRI .............................62 TYVASO............................104 TYVASO INSTITUTIONAL

START KIT....................104 TYVASO REFILL KIT......104 TYVASO STARTER KIT .104 U ULORIC ...............................25 unithroid ...............................84 UPTRAVI...........................104 ursodiol .................................72 UVADEX .............................64

Index 14

V

valacyclovir ..........................42 VALCHLOR ........................28 valganciclovir .......................41 valproate sodium ..................18 valproic acid .........................18 valproic acid (as sodium salt)

..........................................18 valsartan ...............................53 valsartan-hydrochlorothiazide

..........................................53 VALSTAR ...........................32 vancomycin ..........................10 VANCOMYCIN ..................10 VANCOMYCIN IN 0.9 %

SODIUM CHL .................10 VANCOMYCIN IN

DEXTROSE 5 %..............10 vandazole..............................10 VANTAS..............................32 VAQTA (PF)........................93 VARIVAX (PF) ...................93 VARIZIG .............................90 VASCEPA............................60 VECAMYL ..........................57 VECTIBIX ...........................35 VELCADE ...........................32 veletri....................................60 velivet triphasic regimen (28)

..........................................83 VELTASSA .........................71 VENCLEXTA......................34 VENCLEXTA STARTING

PACK ...............................34 venlafaxine ...........................22 VENTAVIS........................104 VENTOLIN HFA...............102 verapamil ..............................56 veripred 20............................80 VERSACLOZ ......................40 VERZENIO..........................34 VESICARE ..........................75 VGO 20 ................................96 VGO 30 ................................96 VGO 40 ................................96 VIBRAMYCIN ....................16 VICTOZA 2-PAK ................49

VICTOZA 3-PAK ................49 VIDEX 2 GRAM PEDIATRIC

..........................................44 VIDEX 4 GRAM PEDIATRIC

..........................................44 VIDEX EC ...........................44 vigabatrin..............................18 VIGAMOX...........................16 VIIBRYD .............................22 VIMIZIM..............................96 VIMPAT...............................19 vinblastine ............................32 vincasar pfs...........................32 vincristine .............................32 vinorelbine............................32 VIRACEPT ..........................45 VIRAMUNE ........................43 VIREAD...............................44 VIVITROL .............................6 voriconazole .........................25 VOSEVI ...............................41 VOTRIENT ..........................34 VPRIV..................................74 VRAYLAR...........................40 VYXEOS..............................32 W warfarin ................................51 water for irrigation, sterile....96 WELCHOL ..........................60 X XALKORI............................34 XARELTO ...........................51 XATMEP..............................89 XELJANZ ............................89 XELJANZ XR......................89 XGEVA................................95 XIAFLEX.............................96 XIFAXAN ............................10 XIGDUO XR........................49 XOLAIR...............................91 XOPENEX HFA ................102 XTANDI...............................28 xylocaine dental-epinephrine .5 xylon 10..................................5 XYREM..............................105 Y

YERVOY .............................35

YF-VAX (PF).......................93 YONDELIS ..........................28 yuvafem ................................83 Z

zafirlukast ...........................101 zaleplon...............................105 ZALTRAP ............................35 ZANOSAR ...........................28 zarah .....................................83 ZARXIO ...............................52 ZAVESCA............................75 ZEJULA ...............................34 ZELAPAR ............................38 ZELBORAF .........................34 ZEMAIRA..........................105 zenatane ................................64 ZENPEP ...............................75 zenzedi..................................61 ZERBAXA ...........................12 ZERIT...................................44 ZIAGEN ...............................44 zidovudine ............................44 zileuton ...............................101 ziprasidone hcl......................40 ZIRGAN ...............................41 ZOLADEX ...........................86 zoledronic acid......................95 zoledronic acid-mannitol-water

..........................................95 ZOLINZA.............................32 zolmitriptan...........................26 zolpidem .............................105 ZOMETA .............................95 zonisamide............................17 ZORTRESS ..........................89 ZOSTAVAX (PF) ................93 ZOSYN.................................14 ZOSYN IN DEXTROSE (ISO-

OSM) ................................14 zovia 1/50e (28) ....................83 ZOVIRAX ............................42 ZURAMPIC .........................26 ZYDELIG.............................34 ZYFLO ...............................101 ZYKADIA............................34 ZYPREXA RELPREVV ......40 ZYTIGA ...............................28

This formulary was updated on June 1, 2018. For more recent information or other questions, please contact us, Prescription Blue PDP Customer Service, at 1‑800‑565‑1770 or, for TTY users 711, Monday through Friday, 8 a.m. to 9 p.m. Eastern time. From October 1 through February 14, hours are from 8 a.m. to 9 p.m., Eastern time, seven days a week, or visit www.bcbsm.com/medicare.

S5584_T_18CompFormABR1_FINAL_7_18 Populated Template 05252018

DB 16053 JUN 18 R076063 AB


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