plus drug formulary (dmhc) · the blue shield plus drug formulary is a list of medications that are...
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Plus Drug Formulary January 2020
Blue Shield of California
This formulary corresponds with the following plans:
Shield Spectrum PPO℠, Full PPO, Full PPO Savings, Access+ HMO®, Added Advantage POS℠, Local Access+
HMO®, Tandem PPO, Trio HMO
This formulary was last updated on 10/01/2019. This formulary is subject to change and all previous versions of
the formulary no longer apply. For the most current information about the Plus Drug Formulary, visit
www.blueshieldca.com/pharmacy.
You can find information about specific prescription drug benefits and drug benefit exclusions in the Blue Shield
Summary of Benefits and Evidence of Coverage. For plan and coverage documents, visit
https://www.blueshieldca.com/bsca/bsc/wcm/connect/employer/employer_contents_en/policies. For
additional information about your plan, call the customer service number on your Blue Shield member ID card.
blueshieldca.com
http://www.blueshieldca.com/pharmacyhttps://www.blueshieldca.com/bsca/bsc/wcm/connect/employer/employer_contents_en/policies
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Introduction to the formulary drug list
The Blue Shield Plus Drug Formulary is a list of medications that are approved by the Food and Drug
Administration (FDA) and are selected based on safety, effectiveness, and cost. This list of generic and
brand drugs is covered by your health insurance policy under the prescription drug benefit of the policy.
Definitions The following words and definitions will be used throughout the formulary drug list.
Term
“Brand name drug” is a drug that is marketed under a proprietary, trademark protected name. The
brand name drug shall be listed in all CAPITAL letters.
“Coinsurance” is a percentage of the cost of a covered health care benefit that an enrollee pays after
the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the
prescription drug benefit.
“Copayment” is a fixed dollar amount that an enrollee pays for a covered health care benefit after the
enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the
prescription drug benefit.
“Deductible” is the amount an enrollee pays for covered health care benefits before the enrollee's
health plan begins payment for all or part of the cost of the health care benefit under the terms of the
policy.
“Drug Tier” is a group of prescription drugs that corresponds to a specified cost sharing tier in the health
plan's prescription drug coverage. The tier in which a prescription drug is placed determines the
enrollee's portion of the cost for the drug.
“Enrollee” is a person enrolled in a health plan who is entitled to receive services from the plan. All
references to enrollees in this this formulary template shall also include subscriber as defined in this
section below.
“Exception request” is a request for coverage of a prescription drug. If an enrollee, his or her designee,
or prescribing health care provider submits an exception request for coverage of a prescription drug,
the health plan must cover the prescription drug when the drug is determined to be medically
necessary to treat the enrollee's condition.
“Exigent circumstances” are when an enrollee is suffering from a health condition that may seriously
jeopardize the enrollee's life, health, or ability to regain maximum function, or when an enrollee is
undergoing a current course of treatment using a non-formulary drug.
“Formulary” is the complete list of drugs preferred for use and eligible for coverage under a health plan
product, and includes all drugs covered under the outpatient prescription drug benefit of the health
plan product. Formulary is also known as a prescription drug list.
“Generic drug” is the same drug as its brand name equivalent in dosage, safety, strength, how it is
taken, quality, performance, and intended use. A generic drug is listed in bold and italicized lowercase
letters.
“Non-formulary drug” is a prescription drug that is not listed on the health plan's formulary.
“Out-of-pocket costs” are copayments, coinsurance, and the applicable deductible, plus all costs for
health care services that are not covered by the health plan.
“Prescribing provider” is a health care provider authorized to write a prescription to treat a medical
condition for a health plan enrollee.
“Prescription” is an oral, written, or electronic order by a prescribing provider for a specific enrollee that
contains the name of the prescription drug, the quantity of the prescribed drug, the date of issue, the
name and contact information of the prescribing provider, the signature of the prescribing provider if
the prescription is in writing, and if requested by the enrollee, the medical condition or purpose for
which the drug is being prescribed.
“Prescription drug” is a drug that is prescribed by the enrollee's prescribing provider and requires a
prescription under applicable law.
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Term
“Prior authorization” is a health plan's requirement that the enrollee or the enrollee's prescribing
provider obtain the health plan's authorization for a prescription drug before the health plan will cover
the drug. The health plan shall grant a prior authorization when it is medically necessary for the enrollee
to obtain the drug.
“Step therapy” is a process specifying the sequence in which different prescription drugs for a given
medical condition and medically appropriate for a particular patient are prescribed. The health plan
may require the enrollee to try one or more drugs to treat the enrollee's medical condition before the
health plan will cover a particular drug for the condition pursuant to a step therapy request. If the
enrollee's prescribing provider submits a request for step therapy exception, the health plans shall make
exceptions to step therapy when the criteria is met.
“Subscriber” means the person who is responsible for payment to a plan or whose employment or other
status, except for family dependency, is the basis for eligibility for membership in the plan.
How do I find a drug on this list? The drugs are listed alphabetically under the column titled “Prescription Drug Name” by its brand or
generic name under the therapeutic category and class to which it belongs. You can search this list using
the brand or generic name of the drug by:
• Searching for the category or class to which the drug belongs and search for the name of the
drug in alphabetical order or
• Searching the Alphabetical Index of Drugs by the name of the drug.
Listing a drug on the formulary does not guarantee that it will be prescribed by your doctor or prescriber.
How do I know if the drug listed is a brand or generic drug? • A generic name for a brand name drug is listed after the brand name of the drug in all lowercase
bold italics
o If a generic equivalent for a brand name drug is both available and covered, the
generic drug will be listed separately from the brand name drug in all lowercase bold
italics
o When a generic drug is marketed with a brand name, the brand name will be listed after
the generic name in parentheses in all CAPITALS.
• A brand name drug is listed in all CAPITALS followed by the generic name in parentheses in
lowercase bold italics.
Example
Drug Type How the drug name will appear in the
formulary drug list
generic drug atorvastatin calcium
generic drug marketed with a brand name oxycodone/acetaminophen (ENDOCET)
brand drug LIPITOR (atorvastatin calcium)
What are drug tiers? Drugs are placed into drug tiers based on defined categories. The amount you pay for drugs in different tiers
will vary. You can find information about what you pay by drug tier in the Summary of Benefits of your Blue
Shield Evidence of Coverage (EOC).
The column titled “Drug Tier” is the cost level you pay for a drug.
Drug
Tier† Description
1 Most generic drugs or low-cost, preferred brand drugs
2 Non-preferred generic drugs, preferred brand drugs, or drugs recommended by the P&T
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Committee based on drug safety, efficacy, and cost
3 Non-preferred brand drugs; drugs recommended by the P&T Committee based on safety,
efficacy, and cost; or drugs that generally have a preferred and often less costly therapeutic
alternative at a lower tier
4 Drugs that are biologics; drugs that the FDA or drug manufacturer requires to be distributed by
specialty pharmacies; drugs that require training or clinical monitoring for self-administration; or
drugs with a plan cost (net of rebates) greater than $600 for a one-month supply
† Affordable Care Act (ACA) drugs are preventive health drugs, including
contraceptive drugs and devices. These drugs are covered at $0 when specific criteria
are met.
Note about multi-source brand drugs: If you or your doctor choose a brand drug when a generic drug
equivalent is available, you will pay the difference in cost, plus the Tier 1 copayment or coinsurance. You or
your doctor can ask for an exception to the difference in cost through the Blue Shield prior authorization
process. (See “What is the prior authorization/exception request process?” below for more information.)
You can find information about specific prescription drug benefits and drug benefit exclusions in the Blue
Shield Evidence of Coverage. For additional information about specific plans, call the customer service
number on your Blue Shield member ID card.
Note: Blue Shield drug formularies apply to outpatient prescription drug benefits available through plans
underwritten by Blue Shield of California (individually and collectively referred to as Blue Shield throughout this
document).
How to read the formulary The column titled “Coverage Requirements and Limits” identifies coverage restrictions or limits for drugs when
applicable.
Coverage Requirements and Limits Description
AL1 Age Limit Prior authorization may be required if your age does not fall within
the FDA, manufacturer, or treatment guideline recommendations.
GL Gender Limit Prior authorization may be required if the FDA, manufacturer, or
treatment guidelines do not recommend the drug for a gender.
OAC Oral Anti-Cancer There is a maximum limit on the copayment/coinsurance amount for
orally administered anti-cancer drugs. Please see your Summary of
Benefits for more detailed information.
PA Prior Authorization Prior authorization is required to determine coverage.
PH Preventive Drugs Affordable Care Act (ACA) preventive health drugs, including
contraceptive drugs and devices, are covered at $0 when specific
criteria are met.*
QLC Quantity Limit The prescription quantity covered is limited. Prior authorization is
required for amounts greater than the limit.
RO Retail Only This prescription can be dispensed at retail pharmacies only. It is not
covered through mail service.
C Short Cycle Blue Shield’s Short Cycle Specialty Drug Program allows initial
prescriptions for select specialty drugs to be filled for a 15-day
supply. When this occurs, the copayment or coinsurance will be
prorated.
SP Specialty Pharmacy These drugs are available exclusively through select
specialty pharmacies.
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* Does not apply to grandfathered plans, plans purchased on or before March 23, 2010.
How often will the formulary change? This formulary is subject to change monthly. Formulary changes that may not have prior notice include the
following:
• A brand name drug may be moved to a higher tier or removed from the formulary if a new
generic drug is added to the formulary,
• A drug may be removed from the formulary when is it removed from the market because the
Food and Drug Administration (FDA) deems a drug to be unsafe or the drug’s manufacturer
removes the drug from the market, or
• A drug is added to the formulary, moved to a lower tier, or has a utilization management
requirement removed.
Formulary changes that will have at least 30-day prior notice to an affected insured before the change is
effective include the following:
• Moving a drug or dosage form to a higher tier,
• Removal of a drug or dosage form from the formulary,
• Adding or changing utilization management requirements or limits for a drug.
o When a step therapy utilization management requirement changes, the new requirement
will not require you to repeat the step therapy if you are already taking the drug for your
condition as long as the drugs is still appropriate, your provider continues to prescribe the
drug, and the drug is still considered safe and effective for your condition.
When a drug or dosage form is removed from the formulary and a drug was previously approved for
coverage for your medical condition, coverage for the drug will continue if your provider continues to
prescribe the drug for your condition and the drug is prescribed appropriately and is safe and effective for
your condition.
For the most current information about the Blue Shield Plus Drug Formulary, visit
blueshieldca.com/pharmacy.
What is a medical benefit drug versus a drug covered under the Outpatient
Prescription Drug Benefit? A medical benefit drug is a drug that is not generally self-administered and administered by a health care
professional. The outpatient prescription drug benefit includes FDA-approved drugs that are self-
administered, commonly oral or self-injectable drugs, not otherwise excluded from coverage.
For additional information, check your Blue Shield Evidence of Coverage or call the customer service
number on your Blue Shield member ID card.
What are preventive health drugs? Preventive health drugs are select drugs required by health reform legislation to be covered at no charge
to the insured.* Preventive health drugs are determined based on evidence-based recommendations by
the United States Preventive Services Task Force. For more details about preventive health drugs, visit
blueshieldca.com/pharmacy.
What is a contraceptive drug or device? Contraceptives are drugs or devices, such as diaphragms or cervical caps, that help prevent pregnancy.
Most generic drug contraceptives and contraceptive devices are covered at no charge to the insured.* Most
ST Step Therapy A specific sequence in which prescription drugs for a
particular medical condition must be tried. If a drug is
subject to step therapy in this formulary, you may have
to try one or more other drugs before your health
insurance policy will cover that drug for your medical
condition.
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brand drug contraceptives require a copayment, which may be waived based on medical necessity. Physicians
or members may provide medical necessity information using the prior authorization process by calling or faxing
a form to Blue Shield Pharmacy Services. (See “What is the prior authorization/exception request process?”
below.)
What diabetes care drugs and products are covered under the Outpatient
Prescription Drug Benefit? FDA-approved drugs for the treatment of diabetes are included in the formulary drug list. Diabetic testing
supplies such as blood glucose test strips, urine test strips, lancets, insulin syringes/pens covered under the
Outpatient Prescription Drug Benefit are also included in the formulary drug list.
What is step therapy? Step therapy means a specific sequence in which prescription drugs for a particular medical condition must be
tried. If a drug is subject to step therapy in this formulary, you may have to try one or more other drugs before
your health insurance policy will cover that drug for your medical condition.
Step therapy requirements are based on how the FDA recommends that a drug should be used, nationally
recognized treatment guidelines, medical studies, information from the drug manufacturer, and the relative cost
of treatment for a condition. Your provider may submit a request for an exception to the step therapy
requirement.
To request an exception, please call the customer service number on your Blue Shield member ID card. You,
your representative, or your doctor may submit an exception request to Blue Shield.
What is the prior authorization/exception request process? Drug prior authorization involves getting advance approval of coverage for a prescription medication based on
medical necessity. Some drugs require review of the patient’s prescription and medical history to determine
coverage.
The exception process involves requesting coverage of a non-formulary drug. A formulary exception, which
allows coverage of a non-formulary drug is based on medical necessity.
To request prior authorization or a non-formulary coverage exception, please call the customer service
number on your Blue Shield member ID card. You, your representative, or your doctor may submit an
exception request to Blue Shield.
Once we receive all the needed supporting information, we will approve or deny the exception request
based on medical necessity within 72 hours for non-urgent requests, or within 24 hours in urgent or exigent
circumstances. If Blue Shield denies a request for prior authorization or an exception request, the member, an
authorized representative, or the provider can file an appeal/grievance with Blue Shield, as described in the
“Grievance Process” section of the EOC.
Participating retail pharmacies You can fill prescriptions at any participating (network) pharmacy, unless it is a prescription for a specialty
drug. Blue Shield contracts with a wide network of retail pharmacies. To find a network pharmacy, visit
blueshieldca.com/pharmacy.
What are specialty drugs? Specialty drugs are drugs that may require coordination of care, close monitoring, or extensive patient training
for self- administration. These requirements generally cannot be met by a retail pharmacy. Specialty drugs
may also require special handling or manufacturing processes (such as biotechnology), restriction to certain
physicians or pharmacies, or reporting of certain clinical events to the FDA. Specialty drugs are usually high-
cost.
Specialty drugs may require prior authorization for medical necessity by Blue Shield. Most specialty drugs are
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available exclusively from a Network Specialty Pharmacy. If coverage is approved, a Network Specialty
Pharmacy can provide specialty drugs by mail or, upon your request, can transfer the specialty drug to an
associated retail store for pickup. Call the customer service number on your Blue Shield member ID card or
visit blueshieldca.com/pharmacy if you have questions about specialty drugs.
Mail service pharmacy Blue Shield offers an easy-to-use mail service prescription drug program through our contracted mail service
pharmacy. You can save time and money using the mail service drug program. It can be a convenient way to
fill maintenance medications for up to a 90-day supply. Maintenance medications are drugs that doctors
prescribe on an ongoing, regular basis to maintain health. For more information on using the mail service
prescription benefit, visit blueshieldca.com/pharmacy.
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Table of ContentsANALGESICS (Drugs for Pain) 1
ANESTHETICS (Drugs for Numbing) 14
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS (Drugs for Addiction/Substance Abuse) 14
ANTIBACTERIALS (Drugs for Bacterial Infections) 16
ANTICONVULSANTS (Drugs for Seizures) 25
ANTIDEMENTIA AGENTS (Drugs for Alzheimer's Disease and Dementia) 30
ANTIDEPRESSANTS (Drugs for Depression) 31
ANTIEMETICS (Drugs for Nausea and Vomiting) 35
ANTIFUNGALS (Drugs for Fungal Infections) 37
ANTIGOUT AGENTS (Drugs for Gout) 39
ANTIMIGRAINE AGENTS (Drugs for Migraine) 40
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis) 42
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections) 42
ANTINEOPLASTICS (Drugs for Cancer) 43
ANTIPARASITICS (Drugs for Parasitic Infections) 51
ANTIPARKINSON AGENTS (Drugs for Parkinson's Disease) 52
ANTIPSYCHOTICS (Drugs for Mental Health) 55
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm) 57
ANTIVIRALS (Drugs for Viral Infections) 57
ANXIOLYTICS (Drugs for Anxiety) 66
BIPOLAR AGENTS (Drugs for Bipolar Disorder) 67
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes) 68
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS (Drugs for Blood Disorders) 74
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation) 77
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions) 94
DENTAL AND ORAL AGENTS (Drugs for the Mouth) 103
DERMATOLOGICAL AGENTS (Drugs for the Skin) 104
ELECTROLYTES/MINERALS/METALS/VITAMINS 112
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach) 122
GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT (Drugs for Genetic or
Enzyme Disorders) 128
GENITOURINARY AGENTS (Drugs for the Genital, Bladder, and Kidney) 130
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) (Drugs for
Replacing/Stimulating Adrenal Gland Hormones) 134
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) (Drugs for
Replacing/Stimulating Pituitary Gland Hormones) 140
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) (Drugs
for Replacing/Stimulating Sex Hormones) 141
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) (Drugs for the Thyroid) 155
HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (Drugs for Suppressing Hormones from the Pituitary
Gland) 156
HORMONAL AGENTS, SUPPRESSANT (THYROID) (Drugs for the Thyroid) 157
LAST UPDATED 10/01/2019
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IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing the Immune System) 157
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for Inflammatory Bowel Disease) 160
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone) 161
MISCELLANEOUS THERAPEUTIC AGENTS 163
OPHTHALMIC AGENTS (Drugs for the Eyes) 165
OTIC AGENTS (Drugs for the Ears) 171
RESPIRATORY TRACT/PULMONARY AGENTS (Drugs for the Lungs) 171
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles) 182
SLEEP DISORDER AGENTS (Drugs for Insomnia) 183
LAST UPDATED 10/01/2019
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITS
ANALGESICS (Drugs for Pain)
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (Pain and ArthritisDrugs)
ANAPROX (naproxen sodium) TIER 3
ANAPROX DS (naproxen sodium) TIER 3
ARTHROTEC 50 (diclofenacsodium/misoprostol)
TIER 3
ARTHROTEC 75 (diclofenacsodium/misoprostol)
TIER 3
butalbital/aspirin/caffeine 50-325-40capsule
TIER 1 QLC (6 caps/day)
butalbital/aspirin/caffeine 50-325-40tablet
TIER 1 QLC (6 tabs/day)
CAMBIA (diclofenac potassium) TIER 3 PA, QLC (9 packs/month)
CELEBREX (celecoxib) 400 MG CAPSULE TIER 3 QLC (1 cap/day)
CELEBREX (celecoxib) 50 MG CAPSULE,100 MG CAPSULE, 200 MG CAPSULE
TIER 3 QLC (2 caps/day)
celecoxib 400 mg capsule TIER 1 QLC (1 cap/day)
celecoxib 50 mg capsule, 100 mgcapsule, 200 mg capsule
TIER 1 QLC (2 caps/day)
DAYPRO (oxaprozin) TIER 3
diclofenac epolamine TIER 1 PA, QLC (2 patches/day)
diclofenac potassium TIER 1
diclofenac sodium (KLOFENSAID II) TIER 1 PA, QLC (1 bottle/month)
diclofenac sodium 1.5 % drops TIER 1 PA, QLC (1 bottle/month)
diclofenac sodium 25 mg tablet dr, 50 mgtablet dr, 75 mg tablet dr, 100 mg tab er24h
TIER 1
diclofenac sodium/misoprostol TIER 1
diflunisal TIER 1
DISALCID (salsalate) TIER 3
DUEXIS (ibuprofen/famotidine) TIER 4 PA, QLC (3 tabs/day)
EC-NAPROSYN (naproxen) TIER 3
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSetodolac TIER 1
FELDENE (piroxicam) TIER 3
fenoprofen calcium (FENORTHO) TIER 3 PA, QLC (4 caps/day)
fenoprofen calcium (PROFENO) TIER 3 PA, QLC (4 tabs/day)
fenoprofen calcium 200 mg capsule TIER 3 PA, QLC (4 caps/day)
fenoprofen calcium 400 mg capsule TIER 3 PA, QLC (8 caps/day)
fenoprofen calcium 600 mg tablet TIER 3 PA, QLC (4 tabs/day)
FENORTHO (fenoprofen calcium) 200 MGCAPSULE
TIER 3 PA, QLC (4 caps/day)
FENORTHO (fenoprofen calcium) 400 MGCAPSULE
TIER 3 PA, QLC (8 caps/day)
FIORINAL (butalbital/aspirin/caffeine) TIER 3 QLC (6 caps/day)
FLECTOR (diclofenac epolamine) TIER 3 PA, QLC (2 patches/day)
flurbiprofen TIER 1
ibuprofen (IBU) TIER 1
ibuprofen 400 mg tablet, 600 mg tablet,800 mg tablet
TIER 1
INDOCIN (indomethacin) TIER 3
indomethacin TIER 1
ketoprofen TIER 1
ketorolac tromethamine 10 mg tablet TIER 1 QLC (4 tabs/day, not to exceed20 tabs/30 days)
LODINE (etodolac) TIER 3
meclofenamate sodium TIER 1
mefenamic acid TIER 1
meloxicam TIER 1
MOBIC (meloxicam) TIER 3
nabumetone TIER 1
NALFON (fenoprofen calcium) 400 MGCAPSULE
TIER 3 PA, QLC (8 caps/day)
NALFON (fenoprofen calcium) 600 MGTABLET
TIER 3 PA, QLC (4 tabs/day)
NAPRELAN (naproxen sodium) CR 375 MGTABLET
TIER 4 ST, QLC (1 tab/day)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSNAPRELAN (naproxen sodium) CR 500 MGTABLET, CR 750 MG TABLET
TIER 4 ST, QLC (2 tabs/day)
NAPROSYN (naproxen) TIER 3
naproxen TIER 1
naproxen sodium 275 mg tablet, 550 mgtablet
TIER 1
naproxen sodium 375 mg tbmp 24hr TIER 4 ST, QLC (1 tab/day)
naproxen sodium 500 mg tbmp 24hr TIER 4 ST, QLC (2 tabs/day)
oxaprozin TIER 1
PENNSAID (diclofenac sodium) TIER 4 PA, QLC (1 bottle/month)
piroxicam TIER 1
PONSTEL (mefenamic acid) TIER 3
QMIIZ ODT (meloxicam) TIER 3 PA, QLC (1 tab/day)
salsalate TIER 1
SPRIX (ketorolac tromethamine) TIER 4 PA, QLC (5 bottles/month)
sulindac TIER 1
TIVORBEX (indomethacin, submicronized) TIER 3 ST, QLC (3 caps/day)
tolmetin sodium TIER 1
VIMOVO (naproxen/esomeprazolemagnesium)
TIER 4 PA, QLC (2 tabs/day)
VIVLODEX (meloxicam, submicronized) TIER 3 PA, QLC (1 cap/day)
VOLTAREN-XR (diclofenac sodium) TIER 3
ZIPSOR (diclofenac potassium) TIER 4 ST, QLC (4 caps/day)
ZORVOLEX (diclofenac submicronized) TIER 3 ST, QLC (3 caps/day)
OPIOID ANALGESICS, LONG-ACTING (Long-acting Narcotic PainRelievers)
ARYMO ER (morphine sulfate) TIER 3 PA, QLC (3 tabs/day)
BELBUCA (buprenorphine hcl) TIER 3 PA, QLC (2 films/day)
buprenorphine TIER 1 PA, QLC (4 patches/28 days)
BUTRANS (buprenorphine) TIER 3 PA, QLC (4 patches/28 days)
CONZIP (tramadol hcl) TIER 3 ST, QLC (1 cap/day)
DISKETS (methadone hcl) TIER 3 PA, QLC (5 tabs/day)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSDOLOPHINE HCL (methadone hcl) 10 MGTABLET
TIER 3 PA, QLC (18 tabs/day)
DOLOPHINE HCL (methadone hcl) 5 MGTABLET
TIER 3 PA, QLC (36 tabs/day)
DURAGESIC (fentanyl) TIER 3 PA, QLC (20 patches/month)
EMBEDA (morphine sulfate/naltrexonehcl) ER 20-0.8 MG CAPSULE
TIER 3 PA, QLC (4 caps/day)
EMBEDA (morphine sulfate/naltrexonehcl) ER 30-1.2 MG CAPSULE, ER 50-2 MGCAPSULE, ER 60-2.4 MG CAPSULE
TIER 3 PA, QLC (2 caps/day)
EMBEDA (morphine sulfate/naltrexonehcl) ER 80-3.2 MG CAPSULE, ER 100-4 MGCAPSULE
TIER 3 PA, QLC (1 cap/day)
EXALGO (hydromorphone hcl) ER 12 MGTABLET
TIER 3 PA, QLC (5 tabs/day)
EXALGO (hydromorphone hcl) ER 16 MGTABLET
TIER 3 PA, QLC (4 tabs/day)
EXALGO (hydromorphone hcl) ER 32 MGTABLET
TIER 3 PA, QLC (2 tabs/day)
EXALGO (hydromorphone hcl) ER 8 MGTABLET
TIER 3 PA, QLC (1 tab/day)
fentanyl 12 mcg/hr patch, 25 mcg/hrpatch, 50mcg/hr patch, 75mcg/hr patch,100 mcg/hr patch
TIER 1 PA, QLC (20 patches/month)
fentanyl 37.5mcg/hr patch, 62.5mcg/hrpatch, 87.5mcg/hr patch
TIER 4 PA, QLC (10 patches/month)
hydromorphone hcl 12 mg tab er 24h TIER 1 PA, QLC (5 tabs/day)
hydromorphone hcl 16 mg tab er 24h TIER 1 PA, QLC (4 tabs/day)
hydromorphone hcl 32 mg tab er 24h TIER 1 PA, QLC (2 tabs/day)
hydromorphone hcl 8 mg tab er 24h TIER 1 PA, QLC (1 tab/day)
HYSINGLA ER (hydrocodone bitartrate) ER20 MG TABLET, ER 30 MG TABLET, ER 40 MGTABLET, ER 60 MG TABLET
TIER 3 PA, QLC (1 cap/day)
HYSINGLA ER (hydrocodone bitartrate) ER80 MG TABLET, ER 100 MG TABLET, ER 120MG TABLET
TIER 4 PA, QLC (1 cap/day)
KADIAN (morphine sulfate) ER 10 MGCAPSULE, ER 30 MG CAPSULE, ER 40 MGCAPSULE, ER 50 MG CAPSULE, ER 100 MGCAPSULE
TIER 3 PA, QLC (2 caps/day)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
4
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSKADIAN (morphine sulfate) ER 20 MGCAPSULE
TIER 3 PA, QLC (4 caps/day)
KADIAN (morphine sulfate) ER 60 MGCAPSULE, ER 80 MG CAPSULE, ER 200 MGCAPSULE
TIER 3 PA, QLC (3 caps/day)
levorphanol tartrate 2 mg tablet TIER 4 PA, QLC (9 tabs/day)
levorphanol tartrate 3 mg tablet TIER 4 PA, QLC (4 tabs/day)
methadone hcl (METHADONE INTENSOL) TIER 2 PA, QLC (18 ml/day)
methadone hcl (METHADOSE) TIER 2 PA, QLC (5 tabs/day)
methadone hcl 10 mg tablet TIER 2 PA, QLC (18 tabs/day)
methadone hcl 10 mg/5 ml solution TIER 2 PA, QLC (90 ml/day)
methadone hcl 10 mg/ml oral conc TIER 2 PA, QLC (18 ml/day)
methadone hcl 40 mg tablet sol TIER 2 PA, QLC (5 tabs/day)
methadone hcl 5 mg tablet TIER 2 PA, QLC (36 tabs/day)
methadone hcl 5 mg/5 ml solution TIER 2 PA, QLC (180 ml/day)
METHADOSE (methadone hcl) TIER 3 PA, QLC (18 ml/day)
MORPHABOND ER (morphine sulfate) TIER 3 PA, QLC (2 tabs/day)
morphine sulfate 10 mg cap er, 30 mgcap er, 50 mg cap er, 100 mg cap er
TIER 1 PA, QLC (2 caps/day)
morphine sulfate 100 mg tablet er, 200mg tablet er
TIER 1 QLC (3 tabs/day)
morphine sulfate 120 mg cpmp 24hr TIER 1 PA, QLC (13 caps/day)
morphine sulfate 15 mg tablet er, 30 mgtablet er
TIER 1 QLC (6 tabs/day)
morphine sulfate 20 mg cap er pel TIER 1 PA, QLC (4 caps/day)
morphine sulfate 30 mg, 45 mg, 60 mg, 75mg
TIER 1 PA, QLC (1 cap/day)
morphine sulfate 40 mg cap er pel TIER 1 PA, QLC (2 caps/day)
morphine sulfate 60 mg cap er pel, 80 mgcap er pel, 90 mg cpmp 24hr
TIER 1 PA, QLC (3 caps/day)
morphine sulfate 60 mg tablet er TIER 1 QLC (5 tabs/day)
MS CONTIN (morphine sulfate) ER 100 MGTABLET, ER 200 MG TABLET
TIER 3 QLC (3 tabs/day)
MS CONTIN (morphine sulfate) ER 15 MGTABLET, ER 30 MG TABLET
TIER 3 QLC (6 tabs/day)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
5
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSMS CONTIN (morphine sulfate) ER 60 MGTABLET
TIER 3 QLC (5 tabs/day)
NUCYNTA ER (tapentadol hcl) TIER 3 PA, QLC (2 tabs/day)
OPANA ER (oxymorphone hcl) 40 MGTABLET
TIER 3 PA, QLC (4 tabs/day)
OPANA ER (oxymorphone hcl) ER 5 MGTABLET, ER 7.5 MG TABLET, ER 10 MGTABLET, ER 15 MG TABLET, ER 20 MGTABLET, ER 30 MG TABLET
TIER 3 PA, QLC (2 tabs/day)
oxycodone hcl 10 mg tab er 12h TIER 1 PA, QLC (9 tabs/day)
oxycodone hcl 15 mg tab er, 20 mg taber, 30 mg tab er
TIER 1 PA, QLC (6 tabs/day)
oxycodone hcl 40 mg tab er, 80 mg taber
TIER 1 PA, QLC (4 tabs/day)
oxycodone hcl 60 mg tab er 12h TIER 1 PA, QLC (2 tabs/day)
OXYCONTIN (oxycodone hcl) ER 10 MGTABLET
TIER 3 PA, QLC (9 tabs/day)
OXYCONTIN (oxycodone hcl) ER 15 MGTABLET, ER 20 MG TABLET, ER 30 MG TABLET
TIER 3 PA, QLC (6 tabs/day)
OXYCONTIN (oxycodone hcl) ER 40 MGTABLET, ER 80 MG TABLET
TIER 3 PA, QLC (4 tabs/day)
OXYCONTIN (oxycodone hcl) ER 60 MGTABLET
TIER 3 PA, QLC (2 tabs/day)
oxymorphone hcl 40 mg tab er 12h TIER 1 PA, QLC (4 tabs/day)
oxymorphone hcl 5 mg tab er, 7.5 mg taber, 10 mg tab er, 15 mg tab er, 20 mg taber, 30 mg tab er
TIER 1 PA, QLC (2 tabs/day)
tramadol hcl 100 mg 25-75, 200 mg 25-75,300 mg 17-83
TIER 1 ST, QLC (1 cap/day)
tramadol hcl 100 mg tab er 24h TIER 1 ST, QLC (3 tabs/day)
tramadol hcl 100 mg tbmp 24hr, 200 mgtbmp 24hr, 200 mg tab er 24h, 300 mg taber 24h, 300 mg tbmp 24hr
TIER 1 ST, QLC (1 tab/day)
tramadol hcl 150 mg cpbp 25-75 TIER 1 ST, QLC (2 caps/day)
ULTRAM ER (tramadol hcl) 100 MG TABLET TIER 3 ST, QLC (3 tabs/day)
ULTRAM ER (tramadol hcl) ER 200 MGTABLET, ER 300 MG TABLET
TIER 3 ST, QLC (1 tab/day)
XTAMPZA ER (oxycodone myristate) TIER 3 PA, QLC (2 caps/day)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
6
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSZOHYDRO ER (hydrocodone bitartrate) TIER 3 PA, QLC (2 caps/day)
OPIOID ANALGESICS, SHORT-ACTING (Short-acting Narcotic PainRelievers)
ABSTRAL (fentanyl citrate) 100 MCG TABSUBLINGUAL
TIER 3 PA, QLC (56 tabs/month)
ABSTRAL (fentanyl citrate) 200 MCG TABSUBLINGUAL
TIER 3 PA, QLC (42 tabs/month)
ABSTRAL (fentanyl citrate) 300 MCG TAB,400 MCG TAB
TIER 3 PA, QLC (28 tabs/month)
ABSTRAL (fentanyl citrate) 600 MCG TAB,800 MCG TAB
TIER 3 PA, QLC (14 tabs/month)
acetaminophen with codeine phosphate-15mg tablet, -30mg tablet
TIER 1 QLC (168 tabs/month)
acetaminophen with codeine phosphate120-12mg/5, 300mg/12.5
TIER 1 QLC (840 ml/month)
acetaminophen with codeine phosphate300mg-60mg tablet
TIER 1 QLC (84 tabs/month)
acetaminophen/caffeine/dihydrocodeine bitartrate (DVORAH)
TIER 3 PA, QLC (140 tabs/month)
acetaminophen/caffeine/dihydrocodeine bitartrate (PANLOR)
TIER 1 PA, QLC (140 tabs/month)
acetaminophen/caffeine/dihydrocodeine bitartrateacetaminophen/caff/dihydrocod 320.5-30mg capsule
TIER 1 PA, QLC (140 caps/month)
acetaminophen/caffeine/dihydrocodeine bitartrateacetaminophen/caff/dihydrocod 325-30-16 tablet
TIER 1 PA, QLC (140 tabs/month)
ACTIQ (fentanyl citrate) TIER 3 PA, QLC (56 lozenges/month)
APADAZ (benzhydrocodonehcl/acetaminophen) 4.08-325 MG TABLET
TIER 3 PA, QLC (12 tabs/day; not toexceed 168 tabs/30 days)
APADAZ (benzhydrocodonehcl/acetaminophen) 6.12-325 MG TABLET
TIER 3 PA, QLC (12 tabs/day; not toexceed 168 tabs/30 days)
APADAZ (benzhydrocodonehcl/acetaminophen) 8.16-325 MG TABLET
TIER 3 PA, QLC (9 tabs/day; not toexceed 126 tabs/30 days)
aspirin/caffeine/dihydrocodeinebitartrate
TIER 1 QLC (168 caps/month)
benzhydrocodone hcl/acetaminophenbenzhydrocodone/acetaminophen 4.08-325mg tablet
TIER 3 PA, QLC (12 tabs/day; not toexceed 168 tabs/30 days)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
7
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSbenzhydrocodone hcl/acetaminophenbenzhydrocodone/acetaminophen 6.12-325mg tablet
TIER 3 PA, QLC (12 tabs/day; not toexceed 168 tabs/30 days)
benzhydrocodone hcl/acetaminophenbenzhydrocodone/acetaminophen 8.16-325mg tablet
TIER 3 PA, QLC (9 tabs/day; not toexceed 126 tabs/30 days)
butalbital/acetaminophen/caffeine/codeine phosphate
TIER 1 QLC (84 caps/month)
butorphanol tartrate 10 mg/ml spray TIER 1 QLC (4 canisters/month at 2canisters/fill)
CAPITAL W-CODEINE (acetaminophenwith codeine phosphate)
TIER 3 QLC (2380 ml/month)
carisoprodol/aspirin/codeine phosphate TIER 1 AL1 (Up to 65 yrs old), QLC (8tabs/day)
codeinephosphate/butalbital/aspirin/caffeine
TIER 1 QLC (84 caps/month)
codeinephosphate/butalbital/aspirin/caffeine(ASCOMP WITH CODEINE)
TIER 1 QLC (84 caps/month)
codeine sulfate 15 mg tablet TIER 1 QLC (336 tabs/month)
codeine sulfate 30 mg tablet TIER 1 QLC (168 tabs/month)
codeine sulfate 60 mg tablet TIER 1 QLC (84 tabs/month)
DEMEROL (meperidine hcl) 100 MGTABLET
TIER 3 AL1 (Up to 65 yrs old), QLC (126tabs/month)
DEMEROL (meperidine hcl) 50 MG TABLET TIER 3 AL1 (Up to 65 yrs old), QLC (252tabs/month)
DILAUDID (hydromorphone hcl) 2 MGTABLET
TIER 3 QLC (154 tabs/month)
DILAUDID (hydromorphone hcl) 4 MGTABLET
TIER 3 QLC (84 tabs/month)
DILAUDID (hydromorphone hcl) 5 MG/5ML ORAL LIQUID
TIER 3 QLC (56 ml/month)
DILAUDID (hydromorphone hcl) 8 MGTABLET
TIER 3 QLC (42 tabs/month)
fentanyl citrate 100 mcg tablet eff TIER 1 PA, QLC (56 tabs/month)
fentanyl citrate 200 mcg tablet eff TIER 1 PA, QLC (42 tabs/month)
fentanyl citrate 200 mcg, 400 mcg, 600mcg, 800 mcg, 1200 mcg, 1600 mcg
TIER 1 PA, QLC (56 lozenges/month)
fentanyl citrate 400 mcg tablet eff TIER 1 PA, QLC (28 tabs/month)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
8
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSfentanyl citrate 600 mcg tablet, 800 mcgtablet
TIER 1 PA, QLC (14 tabs/month)
FENTORA (fentanyl citrate) 100 MCGBUCCAL TABLET
TIER 3 PA, QLC (56 tabs/month)
FENTORA (fentanyl citrate) 200 MCGBUCCAL TABLET
TIER 3 PA, QLC (42 tabs/month)
FENTORA (fentanyl citrate) 400 MCGBUCCAL TABLET
TIER 3 PA, QLC (28 tabs/month)
FENTORA (fentanyl citrate) 600 MCGTABLET, 800 MCG TABLET
TIER 3 PA, QLC (14 tabs/month)
FIORICET WITH CODEINE(butalbital/acetaminophen/caffeine/codeine phosphate)
TIER 3 QLC (84 caps/month)
FIORINAL WITH CODEINE #3 (codeinephosphate/butalbital/aspirin/caffeine)
TIER 3 QLC (84 caps/month)
HYCET (hydrocodonebitartrate/acetaminophen)
TIER 3 QLC (90 ml/day; max 1260 ml/30days)
hydrocodone bitartrate/acetaminophen(LORCET HD)
TIER 1 QLC (126 tabs/month)
hydrocodone bitartrate/acetaminophen(LORCET PLUS)
TIER 1 QLC (168 tabs/month)
hydrocodone bitartrate/acetaminophen(LORCET)
TIER 1 QLC (168 tabs/month)
hydrocodone bitartrate/acetaminophen(LORTAB) hydrocodone/acetaminophen10-300/15 solution
TIER 1 QLC (945 ml/month)
hydrocodone bitartrate/acetaminophen(LORTAB) hydrocodone/acetaminophen10mg-325mg tablet
TIER 1 QLC (126 tabs/month)
hydrocodone bitartrate/acetaminophen(LORTAB) hydrocodone/acetaminophen5 mg-325mg tablet,hydrocodone/acetaminophen 7.5-325mg tablet
TIER 1 QLC (168 tabs/month)
hydrocodone bitartrate/acetaminophen(VERDROCET)
TIER 1 QLC (168 tabs/month)
hydrocodone bitartrate/acetaminophen(VICODIN ES)
TIER 1 QLC (168 tabs/month)
hydrocodone bitartrate/acetaminophen(VICODIN HP)
TIER 1 QLC (126 tabs/month)
hydrocodone bitartrate/acetaminophen(VICODIN)
TIER 1 QLC (168 tabs/month)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
9
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITShydrocodone bitartrate/acetaminophenhydrocodone/acetaminophen -300mgtablet, hydrocodone/acetaminophen -325mg tablet
TIER 1 QLC (126 tabs/month)
hydrocodone bitartrate/acetaminophenhydrocodone/acetaminophen 10-325/15solution
TIER 1 PA, QLC (868 ml/month)
hydrocodone bitartrate/acetaminophenhydrocodone/acetaminophen 2.5-108/5,hydrocodone/acetaminophen 5-217mg/10
TIER 1 PA, QLC (90 ml/day; max 1260ml/30 days)
hydrocodone bitartrate/acetaminophenhydrocodone/acetaminophen 2.5-325mg tablet,hydrocodone/acetaminophen 5 mg-325mg tablet,hydrocodone/acetaminophen 5 mg-300mg tablet,hydrocodone/acetaminophen 7.5-325mg tablet,hydrocodone/acetaminophen 7.5-300mg tablet
TIER 1 QLC (168 tabs/month)
hydrocodone bitartrate/acetaminophenhydrocodone/acetaminophen 7.5-325/15solution
TIER 1 QLC (90 ml/day; max 1260 ml/30days)
hydrocodone/ibuprofen (IBUDONE) TIER 1 QLC (112 tabs/month)
hydrocodone/ibuprofen (XYLON 10) TIER 1 QLC (70 tabs/month)
hydrocodone/ibuprofen 5mg-200mgtablet
TIER 1 QLC (112 tabs/month)
hydrocodone/ibuprofen 7.5-200 mgtablet, 10mg-200mg tablet
TIER 1 QLC (70 tabs/month)
hydromorphone hcl 1 mg/ml liquid TIER 1 QLC (56 ml/month)
hydromorphone hcl 2 mg tablet TIER 1 QLC (154 tabs/month)
hydromorphone hcl 3 mg supp.rect TIER 1 QLC (112 suppositories/month)
hydromorphone hcl 4 mg tablet TIER 1 QLC (84 tabs/month)
hydromorphone hcl 8 mg tablet TIER 1 QLC (42 tabs/month)
IBUDONE (hydrocodone/ibuprofen) TIER 3 QLC (70 tabs/month)
ibuprofen/oxycodone hcl TIER 1 QLC (56 tabs/month)
LAZANDA (fentanyl citrate) TIER 3 PA, QLC (14 bottles/month)
meperidine hcl 100 mg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (126tabs/month)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
10
-
PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSmeperidine hcl 50 mg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (252
tabs/month)
meperidine hcl 50 mg/5 ml solution TIER 1 AL1 (Up to 65 yrs old), QLC (1260ml/month)
morphine sulfate 10 mg supp.rect TIER 1 QLC (126 suppositories/month)
morphine sulfate 10 mg/5 ml solution TIER 1 QLC (630 ml/month)
morphine sulfate 100 mg/5ml solution TIER 1 QLC (70 ml/month)
morphine sulfate 15 mg tablet TIER 1 QLC (84 tabs/month)
morphine sulfate 20 mg supp.rect TIER 1 QLC (70 suppositories/month)
morphine sulfate 20 mg/5 ml solution TIER 1 QLC (84 ml/month)
morphine sulfate 30 mg supp.rect TIER 1 QLC (42 suppositories/month)
morphine sulfate 30 mg tablet TIER 1 QLC (42 tabs/month)
morphine sulfate 5 mg supp.rect TIER 1 QLC (168 suppositories/month)
NORCO (hydrocodonebitartrate/acetaminophen) 10-325 TABLET
TIER 3 QLC (126 tabs/month)
NORCO (hydrocodonebitartrate/acetaminophen) 5-325 TABLET,7.5-325 TABLET
TIER 3 QLC (168 tabs/month)
NUCYNTA (tapentadol hcl) 50 MG TABLET TIER 3 PA, QLC (70 tabs/month)
NUCYNTA (tapentadol hcl) 75 MG TABLET,100 MG TABLET
TIER 3 PA, QLC (56 tabs/month)
OPANA (oxymorphone hcl) 10 MG TABLET TIER 3 PA, QLC (56 tabs/month)
OPANA (oxymorphone hcl) 5 MG TABLET TIER 3 PA, QLC (84 tabs/month)
OXAYDO (oxycodone hcl) 5 MG TABLET TIER 3 PA, QLC (168 tabs/month)
OXAYDO (oxycodone hcl) 7.5 MG TABLET TIER 3 PA, QLC (112 tabs/month)
oxycodone hcl 10 mg tablet TIER 1 QLC (84 tabs/month)
oxycodone hcl 10mg/0.5ml syringe TIER 1 PA, QLC (3 ml/day)
oxycodone hcl 15 mg tablet TIER 1 QLC (56 tabs/month)
oxycodone hcl 20 mg tablet TIER 1 QLC (42 tabs/month)
oxycodone hcl 20 mg/ml oral conc TIER 1 QLC (42 ml/month)
oxycodone hcl 30 mg tablet TIER 1 QLC (28 tabs/month)
oxycodone hcl 5 mg capsule TIER 1 QLC (168 caps/month)
oxycodone hcl 5 mg tablet TIER 1 QLC (168 tabs/month)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
11
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSoxycodone hcl 5 mg/5 ml solution TIER 1 QLC (840 ml/month)
oxycodone hcl/acetaminophen(ENDOCET) 10mg-325mg tablet
TIER 1 QLC (84 tabs/month)
oxycodone hcl/acetaminophen(ENDOCET) 2.5-325 mg tablet, 5 mg-325mg tablet
TIER 1 QLC (168 tabs/month)
oxycodone hcl/acetaminophen(ENDOCET) 7.5-325 mg tablet
TIER 1 QLC (112 tabs/month)
oxycodone hcl/acetaminophen(NALOCET)
TIER 3 PA, QLC (12 tabs/day; not toexceed 168 tabs/month)
oxycodone hcl/acetaminophen(PRIMLEV) 10mg-300mg tablet
TIER 1 QLC (84 tabs/month)
oxycodone hcl/acetaminophen(PRIMLEV) 5 mg-300mg tablet
TIER 1 QLC (168 tabs/month)
oxycodone hcl/acetaminophen(PRIMLEV) 7.5-300 mg tablet
TIER 1 QLC (112 tabs/month)
oxycodone hcl/acetaminophen 10mg-325mg tablet
TIER 1 QLC (84 tabs/month)
oxycodone hcl/acetaminophen 2.5-325mg tablet, 5 mg-325mg tablet
TIER 1 QLC (168 tabs/month)
oxycodone hcl/acetaminophen 5-325/5ml solution
TIER 1 QLC (840 ml/month)
oxycodone hcl/acetaminophen 7.5-325mg tablet
TIER 1 QLC (112 tabs/month)
oxycodone hcl/aspirin TIER 1 QLC (168 tabs/month)
oxymorphone hcl 10 mg tablet TIER 1 PA, QLC (56 tabs/month)
oxymorphone hcl 5 mg tablet TIER 1 PA, QLC (84 tabs/month)
pentazocine hcl/naloxone hcl TIER 1 AL1 (Up to 65 yrs old), QLC (18tabs/day)
PERCOCET (oxycodonehcl/acetaminophen) 10-325 MG TABLET
TIER 3 QLC (84 tabs/month)
PERCOCET (oxycodonehcl/acetaminophen) 2.5-325 MG TABLET,5-325 MG TABLET
TIER 3 QLC (168 tabs/month)
PERCOCET (oxycodonehcl/acetaminophen) 7.5-325 MG TABLET
TIER 3 QLC (112 tabs/month)
ROXICODONE (oxycodone hcl) 15 MGTABLET
TIER 3 QLC (56 tabs/month)
ROXICODONE (oxycodone hcl) 30 MGTABLET
TIER 3 QLC (28 tabs/month)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
12
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSROXICODONE (oxycodone hcl) 5 MGTABLET
TIER 3 QLC (168 tabs/month)
ROXYBOND (oxycodone hcl) 15 MGTABLET
TIER 3 PA, QLC (56 tabs/month, not toexceed 4 tabs/day)
ROXYBOND (oxycodone hcl) 30 MGTABLET
TIER 3 PA, QLC (28 tabs/month, not toexceed 2 tabs/day)
ROXYBOND (oxycodone hcl) 5 MG TABLET TIER 3 PA, QLC (168 tabs/month; not toexceed 12 tabs/day)
SKYRIZI (2 SYRINGES) KIT (risankizumab-rzaa)
TIER 4 PA, SP, QLC (1 kit/84 days)
SUBSYS (fentanyl) 100 MCG SPRAY, 1,200MCG SPRAY, 1,600 MCG SPRAY
TIER 3 PA, QLC (56 doses/month)
SUBSYS (fentanyl) 200 MCG SPRAY TIER 3 PA, QLC (42 doses/month)
SUBSYS (fentanyl) 400 MCG SPRAY, 600MCG SPRAY, 800 MCG SPRAY
TIER 3 PA, QLC (14 doses/month)
SYNALGOS-DC(aspirin/caffeine/dihydrocodeinebitartrate)
TIER 3 QLC (168 caps/month)
tramadol hcl 50 mg tablet TIER 1 QLC (112 tabs/month)
tramadol hcl/acetaminophen TIER 1 QLC (112 tabs/month)
TREZIX(acetaminophen/caffeine/dihydrocodeine bitartrate)
TIER 3 PA, QLC (140 caps/month)
TYLENOL-CODEINE NO.3 (acetaminophenwith codeine phosphate)
TIER 3 QLC (168 tabs/month)
TYLENOL-CODEINE NO.4 (acetaminophenwith codeine phosphate)
TIER 3 QLC (84 tabs/month)
ULTRACET (tramadol hcl/acetaminophen) TIER 3 QLC (112 tabs/month)
ULTRAM (tramadol hcl) TIER 3
XARTEMIS XR (oxycodonehcl/acetaminophen)
TIER 3 PA, QLC (4 tabs/day)
XODOL 10-300 (hydrocodonebitartrate/acetaminophen)
TIER 3 QLC (126 tabs/month)
XODOL 5-300 (hydrocodonebitartrate/acetaminophen)
TIER 3 QLC (168 tabs/month)
XODOL 7.5-300 (hydrocodonebitartrate/acetaminophen)
TIER 3 QLC (168 tabs/month)
ZAMICET (hydrocodonebitartrate/acetaminophen)
TIER 3 QLC (1890 ml/month)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
13
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITS
ANESTHETICS (Drugs for Numbing)
LOCAL ANESTHETICS (Skin Numbing Drugs)lidocaine 5 % adh. patch TIER 1 QLC (90 patches/month)
lidocaine 5 % oint. (g) TIER 1 QLC (50 gm/month)
lidocaine hcl (GLYDO) TIER 1
lidocaine hcl 2 % jelly(ml), 2 % jel/pf app,2 % solution, 40 mg/ml solution
TIER 1
lidocaine/prilocaine 2.5 %-2.5% cream (g) TIER 1 QLC (30 gm/month)
LIDODERM (lidocaine) TIER 3 QLC (90 patches/month)
NAYZILAM (midazolam) TIER 3 QLC (2 sprayers/fill; max 5 fills/30days)
SYNERA (lidocaine/tetracaine) TIER 3 PA, QLC (1 patch/month)
XYLOCAINE (lidocaine hcl) 4% SOLUTION TIER 3
ZTLIDO (lidocaine) TIER 3 PA, QLC (3 patches/day)
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS (Drugs forAddiction/Substance Abuse)
ALCOHOL DETERRENTS/ANTI-CRAVING (Drugs for AlcoholDependence)
acamprosate calcium TIER 1
ANTABUSE (disulfiram) TIER 3
disulfiram TIER 1
naltrexone hcl TIER 1
OPIOID DEPENDENCE TREATMENTS (Drugs for Opioid Dependence)BUNAVAIL (buprenorphine hcl/naloxonehcl) 2.1-0.3 MG FILM
TIER 3 QLC (1 film/day)
BUNAVAIL (buprenorphine hcl/naloxonehcl) 4.2-0.7 MG FILM, 6.3-1 MG FILM
TIER 3 QLC (2 films/day)
buprenorphine hcl 2 mg tab subl TIER 1 QLC (12 tabs/day; not to exceed7 days therapy/90 days)
buprenorphine hcl 8 mg tab subl TIER 1 QLC (3 tabs/day; not to exceed 7days supply over 90 days)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
14
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSbuprenorphine hcl/naloxone hcl/naloxone 12 mg-3 mg film
TIER 1 QLC (2 films/day)
buprenorphine hcl/naloxone hcl/naloxone 2 mg-0.5mg tab subl
TIER 1 QLC (12 tabs/day)
buprenorphine hcl/naloxone hcl/naloxone 2 mg-0.5mg, /naloxone 4mg-1mg
TIER 1 QLC (5 films/day)
buprenorphine hcl/naloxone hcl/naloxone 8 mg-2 mg film
TIER 1 QLC (3 films/day)
buprenorphine hcl/naloxone hcl/naloxone 8 mg-2 mg tab subl
TIER 1 QLC (3 tabs/day)
LUCEMYRA (lofexidine hcl) TIER 3 PA, QLC (16 tabs/day, not toexceed 224 tabs/6 months)
SUBOXONE (buprenorphine hcl/naloxonehcl) 12 MG-3 MG SL FILM
TIER 3 QLC (2 films/day)
SUBOXONE (buprenorphine hcl/naloxonehcl) 2 MG-0.5 MG FILM, 4 MG-1 MG FILM
TIER 3 QLC (5 films/day)
SUBOXONE (buprenorphine hcl/naloxonehcl) 8 MG-2 MG SL FILM
TIER 3 QLC (3 films/day)
ZUBSOLV (buprenorphine hcl/naloxonehcl) 0.7-0.18 MG TABLET, 1.4-0.36 MGTABLET, 5.7-1.4 MG TABLET
TIER 3 QLC (3 tabs/day)
ZUBSOLV (buprenorphine hcl/naloxonehcl) 2.9-0.71 MG TABLET, 11.4-2.9 MGTABLET
TIER 3 QLC (1 tab/day)
ZUBSOLV (buprenorphine hcl/naloxonehcl) 8.6-2.1 MG TABLET SL
TIER 3 QLC (2 tabs/day)
OPIOID REVERSAL AGENTS (Drugs for Opioid Overdose)EVZIO (naloxone hcl) TIER 3 PA, QLC (2 injections [1 pack]/6
months)
naloxone hcl 0.4 mg/ml vial TIER 1 QLC (two 1 ml vials/month)
naloxone hcl 1 mg/ml syringe TIER 1 QLC (2 syringes/month)
NARCAN (naloxone hcl) TIER 2 QLC (2 doses/month)
SMOKING CESSATION AGENTS (Drugs to Help Quit Smoking)bupropion hcl 150 mg tab er 12h TIER 1 ACA (Preventive Health), QLC (2
tabs/day)
CHANTIX (varenicline tartrate) 0.5 MGTABLET, 1 MG TABLET, 1 MG CONT MONTHBOX
TIER 2 ACA (Preventive Health), QLC (2tabs/day)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
15
-
PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSCHANTIX (varenicline tartrate) STARTINGMONTH BOX
TIER 2 ACA (Preventive Health), QLC (1starting month box/28 days)
NICOTROL (nicotine) TIER 2 ACA (Preventive Health), QLC (16cartridges/day)
NICOTROL NS (nicotine) TIER 2 ACA (Preventive Health), QLC (2ml/day)
ZYBAN (bupropion hcl) TIER 3 ACA (Preventive Health), QLC (2tabs/day)
ANTIBACTERIALS (Drugs for Bacterial Infections)
AMINOGLYCOSIDESARIKAYCE (amikacin sulfate liposomalwith nebulizer accessories)
TIER 4 PA, SP, QLC (1 vial/day)
gentamicin sulfate (GENTAK) TIER 1
gentamicin sulfate 0.1 % oint. (g), 0.1 %cream (g), 0.3 % oint. (g), 0.3 % drops
TIER 1
neomycin sulfate TIER 1
paromomycin sulfate TIER 1
tobramycin TIER 1
TOBREX (tobramycin) 0.3% EYE DROP TIER 3
TOBREX (tobramycin) 0.3% EYE OINTMENT TIER 2
ANTIBACTERIALS, OTHERAEMCOLO (rifamycin sodium) TIER 3 PA, QLC (12 tabs/30 days)
AKTIPAK (erythromycin base/benzoylperoxide)
TIER 3
ALTABAX (retapamulin) TIER 3 ST
bacitracin 500 unit/g oint. (g) TIER 1
BACTROBAN (mupirocin calcium) TIER 3
BACTROBAN (mupirocin) TIER 3
BACTROBAN NASAL (mupirocin calcium) TIER 3
BENZAMYCIN (erythromycin base/benzoylperoxide)
TIER 3
CENTANY (mupirocin) TIER 3
CLEOCIN (clindamycin phosphate) 100MG VAGINAL OVULE
TIER 2 QLC (3 suppositories/fill)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
16
-
PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSCLEOCIN (clindamycin phosphate) 2%VAGINAL CREAM
TIER 3
CLEOCIN HCL (clindamycin hcl) TIER 3
CLEOCIN PALMITATE (clindamycinpalmitate hcl)
TIER 3
CLEOCIN T (clindamycin phosphate) TIER 3
CLINDAGEL (clindamycin phosphate) TIER 3 PA, QLC (1 bottle/month)
clindamycin hcl TIER 1
clindamycin palmitate hcl TIER 1
clindamycin phosphate (CLINDACIN ETZ) TIER 1
clindamycin phosphate (CLINDACIN P) TIER 1
clindamycin phosphate 1 % foam TIER 1 QLC (1 can/month)
clindamycin phosphate 1 % gel (gram), 1% lotion, 1 % med. swab, 1 % solution, 2 %cream/appl
TIER 1
clindamycin phosphate 1 % gel daily TIER 3 PA, QLC (1 bottle/month)
CLINDESSE (clindamycin phosphate) TIER 2
erythromycin base/benzoyl peroxide TIER 1
EVOCLIN (clindamycin phosphate) TIER 3 QLC (1 can/month)
FIRVANQ (vancomycin hcl) 25 MG/MLSOLUTION
TIER 3 PA, QLC (300 ml/month)
FIRVANQ (vancomycin hcl) 50 MG/MLSOLUTION
TIER 3 PA, QLC (450 ml/30 days)
FLAGYL (metronidazole) TIER 3
FURADANTIN (nitrofurantoin) TIER 3
HIPREX (methenamine hippurate) TIER 3
linezolid TIER 1 PA
MACROBID (nitrofurantoinmonohydrate/macrocrystals)
TIER 3
MACRODANTIN (nitrofurantoinmacrocrystal)
TIER 3
mafenide acetate TIER 1
methenamine hippurate TIER 1
METROGEL-VAGINAL (metronidazole) TIER 3
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
17
-
PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSmetronidazole 0.75 % gel w/appl, 250 mgtablet, 375 mg capsule, 500 mg tablet
TIER 1
MONUROL (fosfomycin tromethamine) TIER 3 QLC (1 packet/month)
mupirocin TIER 1
mupirocin calcium TIER 1
neomycin sulfate/polymyxin b sulfate TIER 1 PA, QLC (1 ml/day)
NEOSPORIN G.U. IRRIGANT (neomycinsulfate/polymyxin b sulfate)
TIER 3 PA, QLC (1 ml/day)
nitrofurantoin TIER 1
nitrofurantoin macrocrystal TIER 1
nitrofurantoinmonohydrate/macrocrystals
TIER 1
NUVESSA (metronidazole) TIER 3 QLC (2 tubes/month)
PRIMSOL (trimethoprim) TIER 3
SIVEXTRO (tedizolid phosphate) 200 MGTABLET
TIER 4 PA, QLC (6 tabs/month)
SOLOSEC (secnidazole) TIER 3 PA, QLC (1 pack/month)
SULFAMYLON (mafenide acetate) TIER 3
TINDAMAX (tinidazole) TIER 3 QLC (20 tabs/fill)
tinidazole 250 mg tablet TIER 1 QLC (40 tabs/fill)
tinidazole 500 mg tablet TIER 1 QLC (20 tabs/fill)
trimethoprim TIER 1
TRIMPEX (trimethoprim) TIER 3
VANCOCIN HCL (vancomycin hcl) TIER 3
vancomycin hcl 125 mg capsule, 250 mgcapsule
TIER 1
vancomycin hcl 50 mg/ml soln recon TIER 1 PA, QLC (450 ml/30 days)
VANDAZOLE (metronidazole) TIER 3
XIFAXAN (rifaximin) 200 MG TABLET TIER 3 PA, QLC (8 tabs/day)
XIFAXAN (rifaximin) 550 MG TABLET TIER 3 PA, QLC (3 tabs/day)
ZYVOX (linezolid) TIER 3 PA
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
18
-
PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITS
BETA-LACTAM, CEPHALOSPORINSCEDAX (ceftibuten) TIER 3
cefaclor 125 mg/5ml susp recon, 250mg/5ml susp recon, 250 mg capsule, 375mg/5ml susp recon, 500 mg capsule
TIER 1
cefaclor 500 mg tab er 12h TIER 1 QLC (14 tabs/fill)
cefadroxil TIER 1
cefdinir TIER 1
cefditoren pivoxil TIER 1
cefixime TIER 1
cefpodoxime proxetil TIER 1
cefprozil TIER 1
ceftibuten TIER 1
CEFTIN (cefuroxime axetil) TIER 3
cefuroxime axetil TIER 1
cephalexin TIER 1
DAXBIA (cephalexin) TIER 3 PA, QLC (12 caps/day)
KEFLEX (cephalexin) TIER 3
SPECTRACEF (cefditoren pivoxil) TIER 3
SUPRAX (cefixime) TIER 3
BETA-LACTAM, PENICILLINSamoxicillin 125 mg/5ml susp recon, 125mg tab chew, 200 mg/5ml susp recon,250 mg tab chew, 250 mg/5ml susprecon, 250 mg capsule, 400 mg/5ml susprecon, 500 mg tablet, 500 mg capsule,875 mg tablet
TIER 1
amoxicillin 775 mg tbmp 24hr TIER 1 QLC (10 tabs/fill)
amoxicillin/potassium clavulanate 200-28.5/5 susp recon, 200-28.5mg tab chew,250-62.5/5 susp recon, 250-125 mg tablet,400-57mg/5 susp recon, 400-57mg tabchew, 500-125 mg tablet, 600-42.9/5 susprecon, 1000-62.5 tab er 12h
TIER 1
amoxicillin/potassium clavulanate 875-125 mg tablet
TIER 1 QLC (2 tabs/day)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
19
-
PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSampicillin trihydrate TIER 1
AUGMENTIN (amoxicillin/potassiumclavulanate) 125-31.25 MG/5 ML
TIER 2
AUGMENTIN (amoxicillin/potassiumclavulanate) 250-62.5 MG/5 ML, 500-125TABLET
TIER 3
AUGMENTIN (amoxicillin/potassiumclavulanate) 875-125 TABLET
TIER 3 QLC (2 tabs/day)
AUGMENTIN ES-600 (amoxicillin/potassiumclavulanate)
TIER 3
AUGMENTIN XR (amoxicillin/potassiumclavulanate)
TIER 3
dicloxacillin sodium TIER 1
MOXATAG (amoxicillin) TIER 3 QLC (10 tabs/fill)
penicillin v potassium TIER 1
MACROLIDESAZASITE (azithromycin) TIER 3
azithromycin 1 g packet, 100 mg/5ml susprecon, 200 mg/5ml susp recon, 250 mgtablet, 500 mg tablet, 600 mg tablet
TIER 1
BIAXIN (clarithromycin) 250 MG TABLET,500 MG TABLET
TIER 3 QLC (42 tabs/fill)
BIAXIN (clarithromycin) 250 MG/5 MLSUSPENSION
TIER 3
clarithromycin 125 mg/5ml, 250 mg/5ml TIER 1
clarithromycin 250 mg tablet, 500 mgtablet, 500 mg tab er 24h
TIER 1 QLC (42 tabs/fill)
DIFICID (fidaxomicin) TIER 3 PA, QLC (20 tabs/month)
E.E.S. 200 (erythromycin ethylsuccinate) TIER 3
E.E.S. 400 (erythromycin ethylsuccinate) TIER 3
ERY-TAB (erythromycin base) TIER 2
ERYGEL (erythromycin base in ethanol) TIER 1
ERYPED 200 (erythromycin ethylsuccinate) TIER 3
ERYPED 400 (erythromycin ethylsuccinate) TIER 3
ERYTHROCIN STEARATE (erythromycinstearate)
TIER 2
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
20
-
PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSerythromycin base TIER 1
erythromycin base in ethanol TIER 1
erythromycin base in ethanol (ERY) TIER 1
erythromycin ethylsuccinate TIER 1
KETEK (telithromycin) TIER 3 QLC (20 tabs/fill)
PCE (erythromycin base) TIER 3
ZITHROMAX (azithromycin) 1 GM POWDERPACKET, 100 MG/5 ML SUSP, 200 MG/5 MLSUSP, 250 MG TABLET, 250 MG Z-PAKTABLET, 500 MG TABLET, 600 MG TABLET
TIER 3
ZITHROMAX TRI-PAK (azithromycin) TIER 3
ZMAX (azithromycin) TIER 3 QLC (1 bottle/fill)
QUINOLONESAVELOX (moxifloxacin hcl) TIER 3 QLC (10 tabs/fill)
AVELOX ABC PACK (moxifloxacin hcl) TIER 3 QLC (10 tabs/fill)
BAXDELA (delafloxacin meglumine) 450MG TABLET
TIER 4 PA, QLC (28 tabs/month)
BESIVANCE (besifloxacin hcl) TIER 3 QLC (5 ml/month)
CETRAXAL (ciprofloxacin hcl) TIER 3
CILOXAN (ciprofloxacin hcl) 0.3% EYEDROPS
TIER 3
CILOXAN (ciprofloxacin hcl) 0.3%OINTMENT
TIER 2
CIPRO (ciprofloxacin hcl) TIER 3 QLC (2 tabs/day)
CIPRO (ciprofloxacin) 10% SUSPENSION TIER 3 QLC (3 bottles/fill)
CIPRO (ciprofloxacin) 5% SUSPENSION TIER 3 QLC (2 bottles/fill)
CIPRO XR (ciprofloxacin/ciprofloxacin hcl)1,000 MG TABLET
TIER 3 QLC (14 tabs/fill)
CIPRO XR (ciprofloxacin/ciprofloxacin hcl)500 MG TABLET
TIER 3 QLC (3 tabs/fill)
ciprofloxacin 250 mg/5ml sus mc rec TIER 1 QLC (2 bottles/fill)
ciprofloxacin 500 mg/5ml sus mc rec TIER 1 QLC (3 bottles/fill)
ciprofloxacin hcl 0.2 % droperette, 0.3 %drops
TIER 1
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
21
-
PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSciprofloxacin hcl 100 mg tablet, 250 mgtablet, 500 mg tablet, 750 mg tablet
TIER 1 QLC (2 tabs/day)
ciprofloxacin/ciprofloxacin hcl 1000 mgtbmp 24hr
TIER 1 QLC (14 tabs/fill)
ciprofloxacin/ciprofloxacin hcl 500 mgtbmp 24hr
TIER 1 QLC (3 tabs/fill)
FACTIVE (gemifloxacin mesylate) TIER 3 QLC (1 box/fill)
gatifloxacin TIER 1 QLC (one 2.5 ml bottle/month)
LEVAQUIN (levofloxacin) TIER 3 QLC (10 tabs/fill)
levofloxacin 0.5 % drops TIER 1
levofloxacin 250 mg tablet, 500 mg tablet,750 mg tablet
TIER 1 QLC (10 tabs/fill)
levofloxacin 250mg/10ml, 500mg/20ml TIER 1 QLC (300 ml/fill)
MOXEZA (moxifloxacin hcl) TIER 2
moxifloxacin hcl 0.5 % drops TIER 1
moxifloxacin hcl 400 mg tablet TIER 1 QLC (10 tabs/fill)
OCUFLOX (ofloxacin) TIER 3
ofloxacin TIER 1
VIGAMOX (moxifloxacin hcl) TIER 3
ZYMAXID (gatifloxacin) TIER 3 QLC (one 2.5 ml bottle/month)
SULFONAMIDESAVC (sulfanilamide) TIER 2
BACTRIM (sulfamethoxazole/trimethoprim) TIER 3
BACTRIM DS(sulfamethoxazole/trimethoprim)
TIER 3
BLEPH-10 (sulfacetamide sodium) TIER 3
KLARON (sulfacetamide sodium) TIER 3
SILVADENE (silver sulfadiazine) TIER 3
silver sulfadiazine TIER 1
SSD (silver sulfadiazine) TIER 3
sulfacetamide sodium 10 % suspension, 10% oint. (g), 10 % drops
TIER 1
sulfadiazine TIER 1
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
22
-
PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSsulfamethoxazole/trimethoprim 200-40mg/5 oral susp, 400mg-80mg tablet,800-160 mg tablet
TIER 1
sulfamethoxazole/trimethoprim 800-160/20 oral susp
TIER 1 PA
SULFATRIM(sulfamethoxazole/trimethoprim)
TIER 3
THERMAZENE (silver sulfadiazine) TIER 3
TETRACYCLINESACTICLATE (doxycycline hyclate) TIER 3 PA, QLC (1 tab/day)
ADOXA (doxycycline monohydrate) TIER 3
demeclocycline hcl TIER 1
DORYX (doxycycline hyclate) DR 200 MGTABLET
TIER 3 PA, QLC (1 tab/day)
DORYX (doxycycline hyclate) DR 50 MGTABLET
TIER 3 PA, QLC (2 tabs/day)
DORYX MPC (doxycycline hyclate) TIER 3 PA, QLC (2 tabs/day)
doxycycline hyclate (MORGIDOX) TIER 1
doxycycline hyclate (SOLOXIDE) TIER 1 PA, QLC (1 tab/day)
doxycycline hyclate 20 mg tablet TIER 1 QLC (2 tabs/day)
doxycycline hyclate 50 mg capsule, 100mg capsule, 100 mg tablet
TIER 1
doxycycline hyclate 50 mg tablet, 50 mgtablet dr
TIER 1 PA, QLC (2 tabs/day)
doxycycline hyclate 75 mg tablet dr, 100mg tablet dr
TIER 1 PA
doxycycline hyclate 75 mg tablet, 150 mgtablet dr, 150 mg tablet, 200 mg tablet dr
TIER 1 PA, QLC (1 tab/day)
doxycycline hyclate 80 mg tablet dr TIER 3 PA, QLC (2 tabs/day)
doxycycline monohydrate (AVIDOXY) TIER 1
doxycycline monohydrate (MONDOXYNENL)
TIER 1
doxycycline monohydrate (OKEBO) TIER 1
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
23
-
PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSdoxycycline monohydrate 25 mg/5 mlsusp recon, 50 mg capsule, 50 mg tablet,75 mg tablet, 75 mg capsule, 100 mgcapsule, 100 mg tablet, 150 mg capsule,150 mg tablet
TIER 1
doxycycline monohydrate 40 mg cap ir TIER 1 PA, QLC (1 cap/day; max 120caps/5 months)
MINOCIN (minocycline hcl) 50 MG CAP,75 MG CAP, 100 MG CAP
TIER 3
minocycline hcl (COREMINO) TIER 3 PA, QLC (1 tab/day)
minocycline hcl 45 mg tab er, 65 mg taber, 90 mg tab er, 115mg tab er, 135 mgtab er
TIER 3 PA, QLC (1 tab/day)
minocycline hcl 50 mg tablet, 50 mgcapsule, 75 mg capsule, 75 mg tablet,100 mg tablet, 100 mg capsule
TIER 1
minocycline hcl 55 mg tab er 24h TIER 3 PA, QLC (1 tab/day)
minocycline hcl 80 mg tab er, 105 mg taber
TIER 3 PA, QLC (1 tab/day)
MINOLIRA ER (minocycline hcl) TIER 3 PA, QLC (1 tab/day)
MONODOX (doxycycline monohydrate) TIER 3
NUZYRA (omadacycline tosylate) 150 MGTABLET
TIER 4 PA, QLC (6 tabs/28 days)
NUZYRA (omadacycline tosylate) 150 MGTABLET-7 DAY
TIER 4 PA, QLC (28 tabs/28 days)
NUZYRA (omadacycline tosylate) 150 MG-7 DAY WITH LOAD
TIER 4 PA, QLC (32 tabs/28 days)
ORACEA (doxycycline monohydrate) TIER 3 PA, QLC (1 cap/day; max 120caps/5 months)
SEYSARA (sarecycline hcl) TIER 4 PA, QLC (1 tab/day)
SOLODYN (minocycline hcl) TIER 3 PA, QLC (1 tab/day)
TARGADOX (doxycycline hyclate) TIER 3 PA, QLC (2 tabs/day)
tetracycline hcl TIER 1
VIBRAMYCIN (doxycycline calcium) TIER 2
VIBRAMYCIN (doxycycline hyclate) TIER 3
VIBRAMYCIN (doxycycline monohydrate) TIER 3
XIMINO (minocycline hcl) TIER 4 PA, QLC (1 cap/day)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
24
-
PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITS
ANTICONVULSANTS (Drugs for Seizures)
ANTICONVULSANTS, OTHER (Other Seizure Control Drugs)BRIVIACT (brivaracetam) 10 MG TABLET,25 MG TABLET, 50 MG TABLET, 75 MGTABLET, 100 MG TABLET
TIER 3 ST, QLC (2 tabs/day)
BRIVIACT (brivaracetam) 10 MG/ML ORALSOLN
TIER 3 ST, QLC (20 ml/day)
DIACOMIT (stiripentol) 250 MG CAPSULE TIER 4 PA, SP, QLC (3 caps/day)
DIACOMIT (stiripentol) 250 MG POWDERPACKET
TIER 4 PA, SP, QLC (3 packets/day)
DIACOMIT (stiripentol) 500 MG CAPSULE TIER 4 PA, SP, QLC (6 caps/day)
DIACOMIT (stiripentol) 500 MG POWDERPACKET
TIER 4 PA, SP, QLC (6 packets/day)
EPIDIOLEX (cannabidiol (cbd) extract) TIER 4 PA, SP, QLC (4 bottles/28 days)
KEPPRA (levetiracetam) 100 MG/ML ORALSOLN, 250 MG TABLET, 500 MG TABLET, 750MG TABLET, 1,000 MG TABLET
TIER 3
KEPPRA XR (levetiracetam) 500 MGTABLET
TIER 3 QLC (6 tabs/day)
KEPPRA XR (levetiracetam) 750 MGTABLET
TIER 3 QLC (4 tabs/day)
levetiracetam (ROWEEPRA XR) 500 mgtab er 24h
TIER 1 QLC (6 tabs/day)
levetiracetam (ROWEEPRA XR) 750 mgtab er 24h
TIER 1 QLC (4 tabs/day)
levetiracetam (ROWEEPRA) TIER 1
levetiracetam 100 mg/ml solution, 250 mgtablet, 500 mg tablet, 500 mg/5mlsolution, 750 mg tablet, 1000 mg tablet
TIER 1
levetiracetam 500 mg tab er 24h TIER 1 QLC (6 tabs/day)
levetiracetam 750 mg tab er 24h TIER 1 QLC (4 tabs/day)
POTIGA (ezogabine) 200 MG TABLET, 300MG TABLET, 400 MG TABLET
TIER 3 QLC (3 tabs/day)
POTIGA (ezogabine) 50 MG TABLET TIER 3 QLC (9 tabs/day)
SPRITAM (levetiracetam) 1,000 MG TABLET TIER 3 PA, QLC (3 tabs/day)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
25
-
PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSSPRITAM (levetiracetam) 250 MG TABLET,500 MG TABLET
TIER 3 PA, QLC (2 tabs/day)
SPRITAM (levetiracetam) 750 MG TABLET TIER 3 PA, QLC (4 tabs/day)
CALCIUM CHANNEL MODIFYING AGENTSCELONTIN (methsuximide) TIER 3
ethosuximide TIER 1
ZARONTIN (ethosuximide) TIER 3
ZONEGRAN (zonisamide) TIER 3
zonisamide TIER 1
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSclobazam 10 mg tablet, 20 mg tablet TIER 1 ST, QLC (2 tabs/day)
clobazam 2.5 mg/ml oral susp TIER 1 ST, QLC (16 ml/day)
DEPAKENE (valproic acid (as sodium salt)(valproate sodium))
TIER 3
DEPAKENE (valproic acid) TIER 3
DEPAKOTE (divalproex sodium) TIER 3
DEPAKOTE ER (divalproex sodium) TIER 3
DEPAKOTE SPRINKLE (divalproex sodium) TIER 3
DIASTAT (diazepam) TIER 3 QLC (1 kit [2 doses]/fill)
DIASTAT ACUDIAL (diazepam) TIER 3 QLC (1 kit [2 doses]/fill)
diazepam 2.5 mg, 5-7.5-10mg, 12.5-15-20 TIER 1 QLC (1 kit [2 doses]/fill)
divalproex sodium TIER 1
gabapentin 100 mg capsule, 300 mgcapsule, 400 mg capsule, 600 mg tablet,800 mg tablet
TIER 1
gabapentin 250 mg/5ml, 300 mg/6ml TIER 1 PA
GABITRIL (tiagabine hcl) TIER 3
GRALISE (gabapentin) 30-DAY STARTERPACK
TIER 3 PA, QLC (1 pack/month)
GRALISE (gabapentin) ER 300 MG TABLET TIER 3 PA, QLC (1 tab/day)
GRALISE (gabapentin) ER 600 MG TABLET TIER 3 PA, QLC (3 tabs/day)
MYSOLINE (primidone) TIER 3
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
26
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSNEURONTIN (gabapentin) TIER 3
ONFI (clobazam) 10 MG TABLET, 20 MGTABLET
TIER 3 ST, QLC (2 tabs/day)
ONFI (clobazam) 2.5 MG/ML SUSPENSION TIER 3 ST, QLC (16 ml/day)
phenobarbital TIER 1
primidone TIER 1
SABRIL (vigabatrin) 500 MG POWDERPACKET
TIER 4 PA, SP, QLC (6 packs/day)
SABRIL (vigabatrin) 500 MG TABLET TIER 4 PA, SP, QLC (6 tabs/day)
SYMPAZAN (clobazam) TIER 3 PA, QLC (2 films/day)
tiagabine hcl TIER 1
valproic acid TIER 1
valproic acid (as sodium salt) (valproatesodium) 250 mg/5ml, 500mg/10ml
TIER 1
vigabatrin (VIGADRONE) TIER 4 PA, SP, QLC (6 packs/day)
vigabatrin 500 mg powd pack TIER 4 PA, SP, QLC (6 packs/day)
vigabatrin 500 mg tablet TIER 4 PA, SP, QLC (6 tabs/day)
GLUTAMATE REDUCING AGENTSfelbamate TIER 1
FELBATOL (felbamate) TIER 3
FYCOMPA (perampanel) 0.5 MG/MLORAL SUSP
TIER 3 ST, QLC (24 ml/day)
FYCOMPA (perampanel) 2 MG TABLET TIER 3 ST, QLC (3 tabs/day)
FYCOMPA (perampanel) 4 MG TABLET, 6MG TABLET, 8 MG TABLET, 10 MG TABLET,12 MG TABLET
TIER 3 ST, QLC (1 tab/day)
LAMICTAL (BLUE) (lamotrigine) TIER 3
LAMICTAL (GREEN) (lamotrigine) TIER 3
LAMICTAL (lamotrigine) TIER 3
LAMICTAL (ORANGE) (lamotrigine) TIER 3
LAMICTAL ODT (BLUE) (lamotrigine) TIER 3 PA, QLC (1 starter kit/month)
LAMICTAL ODT (GREEN) (lamotrigine) TIER 3 PA, QLC (1 starter kit/month)
LAMICTAL ODT (lamotrigine) TIER 3 PA
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
27
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSLAMICTAL ODT (ORANGE) (lamotrigine) TIER 3 PA, QLC (1 starter kit/month)
LAMICTAL XR (BLUE) (lamotrigine) TIER 3 ST, QLC (1 kit/month)
LAMICTAL XR (GREEN) (lamotrigine) TIER 3 ST, QLC (1 kit/month)
LAMICTAL XR (lamotrigine) 200 MG TABLET TIER 3 ST, QLC (3 tabs/day)
LAMICTAL XR (lamotrigine) 25 MG TABLET,50 MG TABLET, 100 MG TABLET
TIER 3 ST, QLC (1 tab/day)
LAMICTAL XR (lamotrigine) 250 MGTABLET, 300 MG TABLET
TIER 3 ST, QLC (2 tabs/day)
LAMICTAL XR (ORANGE) (lamotrigine) TIER 3 ST, QLC (1 kit/month)
lamotrigine (SUBVENITE (BLUE)) TIER 1
lamotrigine (SUBVENITE (GREEN)) TIER 1
lamotrigine (SUBVENITE (ORANGE)) TIER 1
lamotrigine (SUBVENITE) TIER 1
lamotrigine 200 mg tab er 24 TIER 1 ST, QLC (3 tabs/day)
lamotrigine 25 mg tab er 24, 50 mg tab er24, 100 mg tab er 24
TIER 1 ST, QLC (1 tab/day)
lamotrigine 25 mg tab rapdis, 50 mg tabrapdis, 100 mg tab rapdis, 200 mg tabrapdis
TIER 1 PA
lamotrigine 25-50-100, 25(21)-50, 50(42)-100
TIER 1 PA, QLC (1 starter pack/month)
lamotrigine 250 mg tab er 24, 300 mg taber 24
TIER 1 ST, QLC (2 tabs/day)
lamotrigine 5 mg tb chw dsp, 25(84)-100tab ds pk, 25 mg tb chw dsp, 25 mgtablet, 25(42)-100 tab ds pk, 25mg (35)tab ds pk, 100 mg tablet, 150 mg tablet,200 mg tablet
TIER 1
QUDEXY XR (topiramate) 150 MGCAPSULE, 200 MG CAPSULE
TIER 3 PA, QLC (2 caps/day)
QUDEXY XR (topiramate) 25 MG CAPSULE,50 MG CAPSULE, 100 MG CAPSULE
TIER 3 PA, QLC (1 cap/day)
TOPAMAX (topiramate) TIER 3
topiramate 15 mg cap sprink, 25 mgtablet, 25 mg cap sprink, 50 mg tablet,100 mg tablet, 200 mg tablet
TIER 1
topiramate 150 mg cap 24, 200 mg cap24
TIER 1 PA, QLC (2 caps/day)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
28
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITStopiramate 25 mg cap 24, 50 mg cap 24,100 mg cap 24
TIER 1 PA, QLC (1 cap/day)
TROKENDI XR (topiramate) 200 MGCAPSULE
TIER 3 PA, QLC (2 caps/day)
TROKENDI XR (topiramate) 25 MGCAPSULE, 100 MG CAPSULE
TIER 3 PA, QLC (3 caps/day)
TROKENDI XR (topiramate) 50 MGCAPSULE
TIER 3 PA, QLC (7 caps/day)
SODIUM CHANNEL AGENTSAPTIOM (eslicarbazepine acetate) 200MG TABLET, 400 MG TABLET
TIER 3 ST, QLC (1 tab/day)
APTIOM (eslicarbazepine acetate) 600MG TABLET, 800 MG TABLET
TIER 3 ST, QLC (2 tabs/day)
BANZEL (rufinamide) 200 MG TABLET TIER 3 ST, QLC (2 tabs/day)
BANZEL (rufinamide) 40 MG/MLSUSPENSION
TIER 3 ST, QLC (80 ml/day)
BANZEL (rufinamide) 400 MG TABLET TIER 3 ST, QLC (8 tabs/day)
carbamazepine TIER 1
carbamazepine (EPITOL) TIER 1
CARBATROL (carbamazepine) TIER 3
DILANTIN (phenytoin sodium extended) TIER 2
DILANTIN (phenytoin) TIER 2
DILANTIN-125 (phenytoin) TIER 2
oxcarbazepine 150 mg tablet, 300 mgtablet
TIER 1 QLC (2 tabs/day)
oxcarbazepine 300 mg/5ml oral susp TIER 1 QLC (40 ml/day)
oxcarbazepine 600 mg tablet TIER 1 QLC (4 tabs/day)
OXTELLAR XR (oxcarbazepine) 150 MGTABLET, 300 MG TABLET
TIER 3 ST, QLC (1 tab/day)
OXTELLAR XR (oxcarbazepine) 600 MGTABLET
TIER 3 ST, QLC (4 tabs/day)
PEGANONE (ethotoin) TIER 3
PHENYTEK (phenytoin sodium extended) TIER 3
phenytoin TIER 1
phenytoin sodium extended TIER 1
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
29
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSTEGRETOL (carbamazepine) TIER 3
TEGRETOL XR (carbamazepine) TIER 3
TRILEPTAL (oxcarbazepine) 150 MGTABLET, 300 MG TABLET
TIER 3 QLC (2 tabs/day)
TRILEPTAL (oxcarbazepine) 300 MG/5 MLSUSP
TIER 3 QLC (40 ml/day)
TRILEPTAL (oxcarbazepine) 600 MG TABLET TIER 3 QLC (4 tabs/day)
VIMPAT (lacosamide) 10 MG/MLSOLUTION
TIER 3 ST, QLC (40 ml/day)
VIMPAT (lacosamide) 50 MG TABLET, 100MG TABLET, 150 MG TABLET, 200 MGTABLET
TIER 3 ST, QLC (2 tabs/day)
ANTIDEMENTIA AGENTS (Drugs for Alzheimer's Disease andDementia)
ANTIDEMENTIA AGENTS, OTHERergoloid mesylates TIER 1
CHOLINESTERASE INHIBITORSARICEPT (donepezil hcl) 23 MG TABLET TIER 3 ST, QLC (1 tab/day)
ARICEPT (donepezil hcl) 5 MG TABLET, 10MG TABLET
TIER 3
donepezil hcl 23 mg tablet TIER 1 ST, QLC (1 tab/day)
donepezil hcl 5 mg tab rapdis, 5 mgtablet, 10 mg tab rapdis, 10 mg tablet
TIER 1
EXELON (rivastigmine tartrate) TIER 3
EXELON (rivastigmine) TIER 3 QLC (1 patch/day)
galantamine hbr TIER 1
NAMZARIC (memantine hcl/donepezilhcl) 7 MG-10 MG CAPSULE, 14 MG-10 MGCAPSULE, 21 MG-10 MG CAPSULE, 28 MG-10 MG CAPSULE
TIER 2 QLC (1 cap/day)
NAMZARIC (memantine hcl/donepezilhcl) TITRATION PACK
TIER 2 QLC (1 dose-pack/6 months)
RAZADYNE (galantamine hbr) TIER 3
RAZADYNE ER (galantamine hbr) TIER 3
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
30
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSrivastigmine TIER 1 QLC (1 patch/day)
rivastigmine tartrate TIER 1
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl 2 mg/ml solution, 5 mg-10mg tab ds pk
TIER 1
memantine hcl 5 mg tablet, 10 mg tablet TIER 1 QLC (2 tabs/day)
memantine hcl 7 mg cap 24, 14 mg cap24, 21 mg cap 24, 28 mg cap 24
TIER 1 QLC (1 cap/day)
NAMENDA (memantine hcl) 2 MG/MLSOLUTION, 5-10 MG TITRATION PK
TIER 3
NAMENDA (memantine hcl) 5 MG TABLET,10 MG TABLET
TIER 3 QLC (2 tabs/day)
NAMENDA XR (memantine hcl) 7 MGCAPSULE, 14 MG CAPSULE, 21 MGCAPSULE, 28 MG CAPSULE
TIER 3 QLC (1 cap/day)
NAMENDA XR (memantine hcl) TITRATIONPACK
TIER 2 QLC (1 cap/day)
ANTIDEPRESSANTS (Drugs for Depression)
ANTIDEPRESSANTS, OTHERamitriptyline hcl/chlordiazepoxide TIER 1
APLENZIN (bupropion hbr) TIER 3 ST, QLC (1 tab/day)
bupropion hcl 100 mg tab sr 12h, 100 mgtablet
TIER 1 QLC (4 tabs/day)
bupropion hcl 150 mg tab sr 12h, 150 mgtab er 24h
TIER 1 QLC (3 tabs/day)
bupropion hcl 200 mg tab sr 12h TIER 1 QLC (2 tabs/day)
bupropion hcl 300 mg tab er 24h TIER 1 QLC (1 tab/day)
bupropion hcl 450 mg tab er 24h TIER 1 ST, QLC (1 tab/day)
bupropion hcl 75 mg tablet TIER 1 QLC (6 tabs/day)
FORFIVO XL (bupropion hcl) TIER 3 ST, QLC (1 tab/day)
mirtazapine TIER 1
olanzapine/fluoxetine hcl TIER 1
perphenazine/amitriptyline hcl TIER 1
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
31
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSREMERON (mirtazapine) TIER 3
SYMBYAX (olanzapine/fluoxetine hcl) TIER 3
WELLBUTRIN (bupropion hcl) 100 MGTABLET
TIER 3 QLC (4 tabs/day)
WELLBUTRIN (bupropion hcl) 75 MG TABLET TIER 3 QLC (6 tabs/day)
WELLBUTRIN SR (bupropion hcl) 100 MGTABLET
TIER 3 QLC (4 tabs/day)
WELLBUTRIN SR (bupropion hcl) 150 MGTABLET
TIER 3 QLC (3 tabs/day)
WELLBUTRIN SR (bupropion hcl) 200 MGTABLET
TIER 3 QLC (2 tabs/day)
WELLBUTRIN XL (bupropion hcl) 150 MGTABLET
TIER 3 QLC (3 tabs/day)
WELLBUTRIN XL (bupropion hcl) 300 MGTABLET
TIER 3 QLC (1 tab/day)
MONOAMINE OXIDASE INHIBITORSEMSAM (selegiline) TIER 3
MARPLAN (isocarboxazid) TIER 3
NARDIL (phenelzine sulfate) TIER 3
PARNATE (tranylcypromine sulfate) TIER 3
phenelzine sulfate TIER 1
tranylcypromine sulfate TIER 1
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKEINHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)
BRISDELLE (paroxetine mesylate) TIER 3 QLC (1 cap/day)
CELEXA (citalopram hydrobromide) 10MG TABLET
TIER 3 QLC (4 tabs/day)
CELEXA (citalopram hydrobromide) 20MG TABLET
TIER 3 QLC (2 tabs/day)
CELEXA (citalopram hydrobromide) 40MG TABLET
TIER 3 QLC (1 tab/day)
CITALOPRAM HBR (citalopramhydrobromide)
TIER 1 QLC (40 mg/day)
citalopram hydrobromide 10 mg tablet TIER 1 QLC (4 tabs/day)
citalopram hydrobromide 10 mg/5 mlsolution
TIER 1 QLC (40 mg/day)
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
32
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITScitalopram hydrobromide 20 mg tablet TIER 1 QLC (2 tabs/day)
citalopram hydrobromide 40 mg tablet TIER 1 QLC (1 tab/day)
desvenlafaxine TIER 3 ST, QLC (1 tab/day)
desvenlafaxine fumarate TIER 3 ST, QLC (1 tab/day)
desvenlafaxine succinate TIER 1 QLC (1 tab/day)
EFFEXOR XR (venlafaxine hcl) 37.5 MGCAPSULE, 150 MG CAPSULE
TIER 3 QLC (2 caps/day)
EFFEXOR XR (venlafaxine hcl) 75 MGCAPSULE
TIER 3 QLC (3 caps/day)
escitalopram oxalate 10 mg tablet TIER 1 QLC (4 tabs/day)
escitalopram oxalate 20 mg tablet TIER 1 QLC (2 tabs/day)
escitalopram oxalate 5 mg tablet TIER 1 QLC (8 tabs/day)
escitalopram oxalate 5 mg/5 ml solution TIER 1 QLC (24 ml/day)
FETZIMA (levomilnacipran hcl) TIER 3 PA, QLC (1 cap/day)
fluoxetine hcl 10 mg capsule, 10 mgtablet, 20 mg capsule, 20 mg tablet, 20mg/5 ml solution, 40 mg capsule
TIER 1
fluoxetine hcl 60 mg tablet TIER 3
fluoxetine hcl 90 mg capsule dr TIER 1 QLC (4 caps/month)
fluvoxamine maleate 100 mg cap er 24h TIER 1 ST, QLC (3 caps/day)
fluvoxamine maleate 150 mg cap er 24h TIER 1 ST, QLC (2 caps/day)
fluvoxamine maleate 25 mg tablet, 50 mgtablet, 100 mg tablet
TIER 1
KHEDEZLA (desvenlafaxine) TIER 3 ST, QLC (1 tab/day)
LEXAPRO (escitalopram oxalate) 10 MGTABLET
TIER 3 QLC (4 tabs/day)
LEXAPRO (escitalopram oxalate) 20 MGTABLET
TIER 3 QLC (2 tabs/day)
LEXAPRO (escitalopram oxalate) 5 MGTABLET
TIER 3 QLC (8 tabs/day)
LEXAPRO (escitalopram oxalate) 5 MG/5ML SOLUTION
TIER 3 QLC (24 ml/day)
maprotiline hcl TIER 1
nefazodone hcl TIER 1
paroxetine hcl TIER 1
LAST UPDATED 10/01/2019
AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;
SP – Specialty Pharmacy; ST – Step Therapy
33
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PRESCRIPTION DRUG NAME DRUGTIER
COVERAGEREQUIREMENTS AND
LIMITSparoxetine mesylate TIER 1 QLC (1 cap/day)
PAXIL (paroxetine hcl) 10 MG TABLET, 20MG TABLET, 30 MG TABLET, 40 MG TABLET
TIER 3
PAXIL (parox
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