cigna-healthspring comprehensive drug list · cigna-healthspring rx covers both brand name drugs...

Plan covered / Plan en coberturaCigna-HealthSpring Rx℠ Secure-Xtra (PDP)

This drug list was updated on August 2014. For more recent information or other questions, please contact Cigna-HealthSpring Rx Customer Service, at 1-800-222-6700 or, for TTY users, 711, 8 a.m. – 8 p.m., local time, 7 days a week. (From February 15 – September 30, Monday – Friday 8 a.m. – 8 p.m. local time, Saturday and Sunday 10 a.m. – 6 p.m., EST, customer service agents available. Messaging service used weekends after hours). Or visit www.cignahealthspring.com. Esta lista de medicamentos se actualizó en agosto de 2014. Para información más reciente u otras preguntas, favor de contactar al Departamento de servicio al cliente de Cigna-HealthSpring Rx, al 1-800-222-6700 o, para los usuarios de TTY, 711, de 8 a.m. a 8 p.m., hora local, 7 días de la semana. (Del 15 de febrero al 30 de septiembre, de lunes a viernes, de 8 a.m. a 8 p.m. hora local; y los sábados y domingos, de 10 a.m. a 6 p.m., Hora del este, nuestros representantes de servicio al cliente estás disponibles. Si llama los fines de semana, o fuera del horario de servicio, entrará el servicio de contestadora automática). O visite www.cignahealthspring.com.Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal. Cigna-HealthSpring tiene contrato con Medicare para planes PDP, y planes HMO y PPO en ciertos estados, y con ciertos programas estatales de Medicaid. La inscripción en Cigna-HealthSpring depende de la renovación de contrato. HPMS Approved Formulary File Submission ID 15150, Version Number 6 Y0036_15_18973bBL_Final_6 Approved 08152014

2015CIGNA-HEALTHSPRING® COMPREHENSIVE DRUG LIST(Formulary)

Lista de medicamentos completa de Cigna-HealthSpring (Formulario)Please read: This document contains information about all of the drugs we cover in this plan.Favor de leer: Este documento incluye información sobre todos los medicamentos que se cubren con este plan.

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Note to existing customers: This drug list 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 Cigna-HealthSpring Rx. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Rx Secure-Xtra (PDP).

This document includes a list of the drugs for our plan which is current as of August 2014. For an updated drug list, please contact us. Our contact information, along with the date we last updated the drug list, 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, 2016, and from time to time during the year. What is the Cigna-HealthSpring Rx Comprehensive Drug List? A drug list is a list of covered drugs selected by Cigna-HealthSpring Rx 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. Cigna-HealthSpring Rx will generally cover the drugs listed in our drug list as long as the drug is medically necessary, the prescription is filled at a Cigna-HealthSpring Rx 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 Drug List (formulary) change?

Generally, if you are taking a drug on our 2015 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 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 drug list changes, such as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the same cost-sharing for those customers 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 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 drug list, 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 customers of the change at least 60 days before the change becomes effective, or at the time the customer requests a refill of the drug, at which time the customer will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug. The enclosed drug list is current as of August 2014. To get updated information about the drugs covered by Cigna-HealthSpring Rx, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List?

There are two ways to find your drug within the drug list: Medical Condition The drug list begins on page 32. The drugs in this drug list 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 32. 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 Alphabetical Drug List section that begins on page 1. The Alphabetical Drug List provides a list of all of the drugs included in this document. Both brand name drugs and generic drugs are in the Drug List. Look in the Alphabetical Drug List section of the document and find your drug. Next to your

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drug, you will see the drug tier, requirements/limits (Reqs./Limits), and page number where you can find coverage information. Turn to the page listed in the Alphabetical Drug List section and find the name of your drug in the first column of the list.

What are generic drugs?

Cigna-HealthSpring Rx 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.

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: Cigna-HealthSpring Rx requires you or your doctor to get prior authorization for certain drugs. This

means that you will need to get approval from Cigna-HealthSpring Rx before you fill your prescriptions. If you don’t get approval, Cigna-HealthSpring Rx may not cover the drug.

Quantity Limits: For certain drugs, Cigna-HealthSpring Rx limits the amount of the drug that Cigna-HealthSpring Rx will cover. For example, Cigna-HealthSpring Rx provides 30 (tablets) per prescription for CRESTOR. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, Cigna-HealthSpring Rx 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, Cigna-HealthSpring Rx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Cigna-HealthSpring Rx will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain 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 drug list, appears on the front and back cover pages. You can ask Cigna-HealthSpring Rx 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 Cigna-HealthSpring Rx’s drug list?” on page A4 for information about how to request an exception.

Options for Maintenance Medications

Taking the medications prescribed by your doctor is important to your health.

We are committed to helping you achieve control of chronic conditions by making it easy for you to receive your maintenance medications. As part of our commitment to coordinating your healthcare needs, we have set a goal of helping you take your medications at least 80% of the time. There are several ways we can work together to accomplish this goal:

Talk with your doctor about whether a 90 day supply of your ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for your overall health, and getting 90 day prescriptions of these medications can ensure that you don’t miss a dose.

You can receive a 90-day supply at most retail pharmacies or through one of our mail-order pharmacies.

Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications.

How can I use my prescription drug coverage to save money on my medications?

There may be opportunities for you to save money on your medications using your Cigna-HealthSpring Rx coverage.

Ask your doctor if there are any lower-cost generic alternatives available for any of your current medications.

Explore whether the ‘CMS extra help’ program may offer additional financial support for your medications.

If your medication is not covered on the Cigna-HealthSpring Rx drug list, talk with your doctor about alternative medications which are covered in the drug list.

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What if my drug is not in the Drug List?

If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn that Cigna-HealthSpring Rx does not cover your drug, you have two options:

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

You can ask Cigna-HealthSpring Rx 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 Cigna-HealthSpring Rx’s Drug List?

You can ask Cigna-HealthSpring Rx 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 in our drug list. 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 waive coverage restrictions or limits on your drug. For example, for certain drugs, Cigna-HealthSpring Rx 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.

You can ask us to provide a tiering exception for a higher cost-sharing drug to be covered at a lower cost-sharing tier. If your drug is contained in our Non-Preferred Brand tier or the Non-Preferred Generic tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the respective Preferred Brand or Preferred Generic tier instead. This would lower the amount you must pay for your drug. If your drug is contained in our Brand tier you can ask to cover it at the cost-sharing amount that applies to drugs in the respective Generic tier if all generic alternatives in the lower cost tier used to treat the same condition/disease are determined to be not as effective as the Brand. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.

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

You should contact us to ask us for an initial coverage decision for a drug list, tiering or utilization restriction exception. When you request a drug list, tiering or utilization restriction exception you should submit a statement from your prescriber or doctor 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 customer in our plan you may be taking drugs that are not in our drug list. Or, you may be taking a drug that is on our drug list 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 drug list 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 customer of our plan. For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a customer of the plan less than 90 days.

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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 customer of our plan. If you need a drug that is not in our drug list 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 drug list exception.

In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna-HealthSpring Rx will allow a one-time 31-day supply (unless the prescription is written for fewer days).

For more information

For more detailed information about your Cigna-HealthSpring Rx prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Cigna-HealthSpring Rx, please contact us. Our contact information, along with the date we last updated the drug list, 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 http://www.medicare.gov.

Cigna-HealthSpring Rx’s Drug List

The comprehensive drug list provides coverage information about all of the drugs covered by Cigna-HealthSpring Rx. If you have trouble finding your drug in the list, turn to the Alphabetical Drug List that begins on page 1.

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

The information in the Requirements/Limits column tells you if Cigna-HealthSpring Rx has any special requirements for coverage of your drug.

We provide quantity limits on certain drugs which are indicated with a QL in the Alphabetical Drug list on page 1 along with the amount dispensed per the days supplied. (For example: CRESTOR 30/30; this means the drug CRESTOR is limited to 30 tablets per 30 days). Key: B/D = This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances. Information may need to be submitted describing use and setting of the drug to make the determination. PA = This drug requires prior authorization QL = This drug has quantity limits ST = This drug has step therapy requirements Generally all medications in the drug list are available through mail order, except when special circumstances or situations prohibit mailing a particular medication to your home.

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Nota para los clientes: Esta lista de medicamentos ha cambiado desde el año pasado. Favor de revisar el documento y asegurarse de que los medicamentos que toma aún se encuentren en la lista.

Cuando esta lista de medicamentos (formulario) se refiera a “nosotros”, “nos”, o “nuestro”, esto significa Cigna-HealthSpring Rx. Cuando se refiera al “plan” o “nuestro plan”, significa Cigna-HealthSpring Rx Secure-Xtra (PDP). Este documento incluye una lista de los medicamentos para nuestro plan, la cual se actualizó en agosto de 2014. Para una versión actualizada de la lista de medicamentos, por favor póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización de la lista de medicamentos, aparece en la portada y al reverso de este folleto.

Por lo general, debe acudir a farmacias de la red para usar su beneficio de medicamentos recetados. Es posible que los beneficios, el formulario, las farmacias de la red, y/o copagos/coseguros cambien el 1 de enero de 2016, y de vez en cuando durante el año.

¿Qué es la Lista de medicamentos completa de Cigna-HealthSpring Rx? Una lista de medicamentos es una lista de medicamentos que selecciona Cigna-HealthSpring Rx, en conjunto con un equipo de proveedores de servicios de atención médica, y que representa las terapias con medicamentos recetados que se considera son una parte esencial de un programa de tratamiento de calidad. En general, Cigna-HealthSpring Rx cubre los medicamentos incluidos en nuestra lista de medicamentos, siempre que sean médicamente necesarios, la receta se surta en una farmacia de la red de Cigna-HealthSpring Rx y se respeten las otras reglas del plan. Para más información sobre cómo surtir sus recetas, consulte la Evidencia de cobertura.

¿Puede cambiar la Lista de medicamentos (Formulario)? Por lo general, si está tomando un medicamento que se encontraba en nuestra Lista de medicamentos del 2015 a principios del año, no dejaremos, ni reduciremos la cobertura del medicamento durante el año de cobertura del 2015, a menos que ponga a la venta un medicamento genérico más económico o se presente información adversa sobre la seguridad o efectividad del medicamento. Otros tipos de cambios que se hagan a la lista de medicamentos, como el retiro de algún medicamento, no afectaran a clientes que estén tomando dicho medicamento. Éste seguirá estando disponible y al mismo costo compartido para dichos clientes, por el resto del año de cobertura. Creemos que es muy importante que tenga acceso continuo durante el año de cobertura a los medicamentos que estaban disponibles cuando seleccionó nuestro plan, a menos que se presente la opción de que ahorre dinero o podamos garantizar su seguridad.

Si quitamos medicamentos de la lista de medicamentos, agregamos previa autorización, límites de cantidad y/o restricciones de terapia escalonada a un medicamento o movemos un medicamento a un nivel de costo compartido más alto, debemos notificar a los clientes que tomen dicho medicamento con al menos 60 días de anticipación a la fecha en que entre en vigencia el cambio o cuando el cliente renueve el medicamento, momento en que recibirá un suministro de 60 días. Si la Food and Drug Administration considera que un medicamento de nuestra lista de medicamentos es poco seguro o el fabricante lo retira del mercado, retiraremos inmediatamente el medicamento de la lista de medicamentos y daremos aviso a los clientes que lo tomen. La lista de medicamentos adjunta se actualizó en agosto de 2014. Para obtener información actualizada sobre los medicamentos que cubre Cigna-HealthSpring Rx, por favor póngase en contacto con nosotros. Nuestra información aparece en la portada y al reverso de este folleto. En caso de que se hagan cambios importantes a la lista de medicamentos impresa dentro del año en cobertura, es posible que se le avise por correo sobre cuáles son los cambios. La lista de medicamentos de nuestra página de internet se revisa y actualiza cada mes. ¿Cómo utilizo la Lista de medicamentos?

Existen dos formas de encontrar un medicamento en la lista de medicamentos:

Problema médico

La lista de medicamentos comienza en la página 32. Los medicamentos de esta lista de medicamentos están agrupados en categorías por tipo de problema médico que tratan. Por ejemplo, los medicamentos para tratar una afección cardíaca se incluyen

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dentro de la categoría, “AGENTES CARDIOVASCULARES”. Si sabe para lo que se utiliza el medicamento, busque la categoría en la lista que comienza en la página 32. Después, busque el medicamento bajo dicha categoría. Lista por orden alfabético

Si no está seguro de la categoría bajo la cual debe buscar, busque el medicamento en la sección de la Lista por orden alfabético de medicamentos que comienza en la página 1. La lista por orden alfabético de medicamentos proporciona un listado de todos los medicamentos que aparecen en el documento. Tanto los medicamentos de marca como los genéricos están en la Lista de medicamentos. Busque en la sección de la Lista por orden alfabético de medicamentos del documento y encuentre su medicamento. Junto al medicamento, encontrará el nivel del medicamento, los límites/requisitos y el número de la página donde puede encontrar información sobre la cobertura. Vaya a la página indicada en la sección de la Lista por orden alfabético de medicamentos y localice el nombre del medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos?

Cigna-HealthSpring Rx cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado por la FDA por tener el mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos cuestan menos que los de marca. ¿Existe alguna restricción en la cobertura?

Algunos medicamentos que entran en cobertura pueden tener requisitos o límites adicionales de cobertura. Estos requisitos y límites pueden incluir:

Autorización previa: Cigna-HealthSpring Rx exige que usted o su médico obtengan una autorización previa para ciertos medicamentos. Esto significa que necesitará de la aprobación de Cigna-HealthSpring Rx antes de surtir sus recetas médicas. Si no obtiene la aprobación, es posible que Cigna-HealthSpring Rx no cubra el medicamento.

Límites de cantidad: Para ciertos medicamentos, Cigna-HealthSpring Rx limita la cantidad de medicamento que entran en cobertura. Por ejemplo, Cigna-HealthSpring Rx proporciona 30 (tabletas) por receta médica de CRESTOR. Esto puede ser, además de un suministro normal de un mes ó tres meses.

Terapia escalonada: En algunos casos, Cigna-HealthSpring Rx le pedirá que pruebe primero con determinados medicamentos para tratar su enfermedad, antes de cubrir otros. Por ejemplo, si un medicamento A y un medicamento B sirven para tratar su condición médica, es posible que Cigna-HealthSpring Rx no cubra el medicamento B a menos que usted pruebe el medicamento A, primero. Si el medicamento A no funciona, entonces Cigna-HealthSpring Rx cubrirá el medicamento B.

Para saber si un medicamento tiene algún requisito o límite adicional, consulte la lista de medicamentos que comienza en la página 1. Puede obtener más información sobre las restricciones que se aplican a ciertos medicamentos visitando nuestra página de Internet. Hemos publicado documentos en línea que explican nuestras restricciones de autorización previa y terapia escalonada. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización de la lista de medicamentos, aparece en la portada y al reverso de este folleto.

Puede solicitarle a Cigna-HealthSpring Rx que haga una excepción a estas restricciones o límites, o pedirle una lista de otros medicamentos similares que pueden tratar su condición de salud. Consulte la sección “¿Cómo solicito una excepción para la Lista de medicamentos de Cigna-HealthSpring Rx?" en la página A8 para obtener información sobre cómo solicitar una excepción.

Opciones para Medicamentos de Mantenimiento

Tomar los medicamentos que le receta su médico es importante para su salud.

Estamos comprometidos a ayudarle a que logre controlar sus enfermedades crónicas facilitándole la obtención de sus medicamentos de mantenimiento. Como parte de nuestro compromiso para coordinar sus necesidades de atención médica, nos

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propusimos la meta de ayudarle a tomar sus medicamentos al menos el 80% del tiempo. Hay varias maneras en las que podemos trabajar juntos para lograr esta meta:

Hablar con su médico para saber si sería apropiado un suministro de 90 días de sus medicamentos fijos y regulares. Tomar estos medicamentos todos los días exactamente como se los receta el médico es importante para su salud en general, y recibir recetas por 90 días de estos medicamentos puede garantizar que usted no pierda ninguna dosis.

Puede recibir un suministro de 90 días en la mayoría de las farmacias de venta al menudeo o a través de una de nuestras farmacias de orden por correo.

Hablar con su farmacéutico en caso de que tenga dificultades con sus medicamentos de mantenimiento.

¿Cómo puedo usar mi cobertura de medicamentos recetados para ahorrar dinero en la compra de mis medicamentos?

Es posible que haya oportunidades para que ahorre dinero en la compra de sus medicamentos al usar su cobertura de Cigna-HealthSpring Rx.

Pregúntele a su médico si hay algunas alternativas genéricas de bajo costo disponibles para algunos de sus medicamentos actuales.

Investigue si el programa de ‘ayuda adicional de CMS’ puede ofrecer ayuda financiera adicional para sus medicamentos.

Si su medicamento no entra en cobertura de la lista de medicamentos de Cigna-HealthSpring Rx, hable con su médico sobre medicamentos alternos que entren en cobertura en la lista de medicamentos.

¿Qué pasa si mi medicamento no se encuentra la Lista de medicamentos? En caso de que su medicamento no se incluya en esta lista de medicamentos, debe primero contactar al Departamento de servicio al cliente y preguntar si su medicamento entra en cobertura. En caso de que le confirmen que Cigna-HealthSpring Rx no cubre su medicamento, tiene dos opciones:

Puede solicitar al Departamento de servicio al cliente una lista de medicamentos similares que entren en la cobertura de Cigna-HealthSpring Rx. Cuando la reciba, muéstresela a su médico y pídale que le recete un medicamento similar que entre en la cobertura de Cigna-HealthSpring Rx.

Puede pedirle a Cigna-HealthSpring Rx que haga una excepción y cubra su medicamento. Consulte a continuación la información sobre cómo solicitar una excepción.

¿Cómo solicito una excepción a la Lista de medicamentos de Cigna-HealthSpring Rx?

Puede pedirle a Cigna-HealthSpring Rx que haga una excepción a sus reglas de cobertura. Existen varios tipos de excepciones que puede solicitar que hagamos.

Puede solicitarnos que cubramos un medicamento, incluso si no se encuentra en nuestra lista de medicamentos. Si lo aprobamos, el medicamento se cubrirá a un nivel de costo compartido predeterminado, y no podrá solicitarnos que le brindemos el medicamento a un nivel de costo compartido menor.

Puede solicitarnos que retiremos las restricciones o los límites de cobertura de su medicamento. Por ejemplo, para ciertos medicamentos, Cigna-HealthSpring Rx limita la cantidad de medicamento que cubrirá. Si su medicamento tiene un límite de cantidad, puede solicitarnos que no apliquemos el límite y cubramos una cantidad mayor.

Puede pedirnos que le demos una excepción de nivel para que cubramos un medicamento que tenga un costo compartido mayor a un nivel de costo compartido menor. En caso de que su medicamento se encuentre en nuestro nivel de medicamentos de marca no preferida o el nivel de medicamentos genéricos no preferidos, puede solicitarnos la cobertura de su medicamento a la cantidad de pago compartido que se aplique al medicamento de marca preferida o medicamentos genéricos preferidos. De esta manera se reduciría la cantidad que deba pagar por su medicamento. En

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caso de que su medicamento se encuentre en nuestro nivel de medicamentos de marca, puede solicitarnos la cobertura de su medicamento a la cantidad de pago compartido que se aplique a los medicamentos en el nivel genérico respectivo si todas las alternativas genéricas en el nivel de costo compartido menor usadas para tratar la misma condición/enfermedad no son tan efectivas como el medicamento de marca. Recuerde que si aceptamos su solicitud para cubrir un medicamento que no se encuentre en nuestra lista de medicamentos, es posible que no pueda pedirnos que le demos un nivel más alto de cobertura para el medicamento. Además, es posible que no pueda pedirnos un nivel más alto de cobertura por medicamentos que se encuentren en el nivel de medicamentos especiales.

Por lo general, Cigna-HealthSpring Rx sólo aprobará su solicitud de excepción si los medicamentos alternativos incluidos en la lista de medicamentos del plan, los medicamentos de un costo compartido más bajo o aquellos a los que se les aplican restricciones de uso adicionales, no tuviesen la misma efectividad para tratar su enfermedad y/o le ocasionaran efectos médicos adversos.

Póngase en contacto con nosotros para solicitar una decisión sobre la cobertura inicial en el caso de una excepción a la lista de medicamentos, al nivel o a la restricción de uso. Cuando solicite una excepción a la lista de medicamentos, al nivel o a la restricción de uso, debe presentar una declaración de su médico o la persona que le recete, que respalde su solicitud. Por lo general, debemos tomar una decisión en un plazo de 72 horas, a partir del momento en que presente la declaración del médico que le hizo la receta. Puede solicitar una respuesta más expedita (rápida) si usted o su médico creen que su salud resultaría afectada por la espera del plazo de 72 horas para obtener una respuesta. En caso de que se autorice la respuesta rápida, le daremos una respuesta en un término de 24 horas después de que recibamos la declaración de su médico o de la persona que realizó la receta médica. ¿Qué debo hacer antes de decirle a mi médico que quiero cambiar mis medicamentos o solicitar una excepción?

Como cliente nuevo o continuo de nuestro plan, puede estar tomando medicamentos que no se encuentran en nuestra lista de medicamentos. O bien, es posible que esté tomando un medicamento que se encuentre en nuestra lista de medicamentos, pero su capacidad para obtenerlo es limitada. Por ejemplo, puede requerir de nuestra autorización previa antes de surtir sus recetas. Hable con su médico para determinar si debe cambiar a un medicamento que entre en cobertura o solicitar una excepción a la lista de medicamentos para que se cubra el medicamento que está tomando. Mientras habla con su médico para determinar la medida correcta a seguir, podremos cubrir su medicamento en ciertos casos durante los primeros 90 días que sea cliente de nuestro plan.

Para cada uno de los medicamentos que no se encuentran en nuestra lista de medicamentos, o que están limitados, daremos una cobertura temporal de un suministro de 30 días (a menos que su receta indique un suministro de menos días) cuando acuda a surtir su receta en un farmacia de la red. Después de su suministro de 30 días, dejaremos de cubrir el costo de estos medicamentos, incluso si usted ha sido cliente de este plan por menos de 90 días.

Si usted vive en un centro de atención médica de largo plazo, le permitiremos volver a surtir su receta hasta que le hayamos proporcionado un suministro de transición temporal de 93 días, consistente con el incremento de dispensación, (a menos que su receta indique un suministro de menos días). Cubriremos más de un relleno (refill) de dichos medicamentos por los primeros 90 días que usted sea cliente de nuestro plan. En caso de que necesite de un medicamento que no se encuentre en la lista de medicamentos o que esté limitado, y ya tenga más 90 días de su membresía en nuestro plan, cubriremos un suministro de emergencia de 31 días del medicamento (a menos que su receta indique un suministro de menos días) mientras solicita que se haga una excepción a la lista de medicamentos.

Para adaptar transiciones inesperadas de nuestros clientes que no permiten hacer planes con anticipación, como los cambios de nivel de atención para pasar de un hospital a un centro de enfermería especializada o al hogar, Cigna-HealthSpring Rx permitirá un único suministro de 31 días (a menos que la receta sea por menos días). Para más información

Para obtener información más detallada sobre su cobertura de medicamentos recetados de Cigna-HealthSpring Rx, consulte su Evidencia de cobertura y otros materiales del plan.

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Si tiene alguna pregunta sobre Cigna-HealthSpring Rx, por favor póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización de la lista de medicamentos, aparece en la portada y al reverso de este folleto.

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

Lista de medicamentos de Cigna-HealthSpring Rx

La lista de medicamentos completa siguiente ofrece información sobre la cobertura de todos los medicamentos que cubre Cigna-HealthSpring Rx. En caso de que tenga problemas para encontrar su medicamento en la lista, consulte la Lista por orden alfabético de medicamentos que comienza en la página 1.

La primera columna de la tabla indica el nombre del medicamento. Los nombres de los medicamentos de marca están en mayúscula (p. ej. CRESTOR) y los de medicamentos genéricos en minúscula y cursiva (p. ej. simvastatin).

La información en la columna de Requisitos/Límites indica si Cigna-HealthSpring Rx tiene algún requisito especial para la cobertura de su medicamento.

Brindamos límites de cantidad para ciertos medicamentos que están indicados con QL en la lista por orden alfabético que comienza en la página 1 junto con la cantidad despachada para los días suministrados. (Por ejemplo: CRESTOR 30/30; esto significa que el medicamento CRESTOR está limitado a 30 cápsulas por 30 días).

Clave:

B/D = Este medicamento tiene un requisito de autorización de la Parte B vs la Parte D. El medicamento puede entrar en cobertura con la Parte B o la D de Medicare, dependiendo de las circunstancias. Debe enviarse información que describa el uso y la base del medicamento para tomar esta decisión.

PA = Este medicamento requiere de autorización previa. QL = Este medicamento tiene límite de cantidad. ST = Este medicamento tiene requerimientos de terapia escalonada.

Generalmente todos los medicamentos de la lista de medicamentos están disponibles a través de la orden por correo, excepto cuando existan situaciones o circunstancias especiales que prohíban el envío por correo de un medicamento en particular.

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Drug Tier and Cost-Share Table

The following table represents the plan name, plan service area, the drug tier number as it appears in the drug list, and the cost-share amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Non-Preferred Generic drugs. Tier number 3 is for Preferred Brand drugs. Tier number 4 is for Non-Preferred Brand drugs. Tier 5 is for Specialty tier drugs. You may also refer to your Evidence of Coverage document for additional details. To locate your drug cost, please refer to the table(s) below to find your service area and the Prescription Drug plan in which you are currently enrolled or would like to enroll. Cigna-HealthSpring Rx Secure-Xtra (PDP) has pharmacies with preferred cost-shares. See your Pharmacy Directory for information on which stores with preferred cost-shares are near you.

Tabla del nivel del medicamento y costo compartido

La siguiente tabla representa el nombre del plan, el área de servicio del plan, el número de nivel de medicamento, tal y como aparece en la lista de medicamentos, y la cantidad de costo compartido para ese número de nivel. El nivel 1 es para los medicamentos genéricos preferidos. El nivel 2 es el nivel para los medicamentos genéricos no preferidos. El nivel 3 es para los medicamentos de marca preferida. El nivel 4 es el nivel para los medicamentos de marca no preferida. El nivel 5 es para los medicamentos de especialidad. Su plan tiene un nivel llamado “Medicamentos en cobertura”. Por favor consulte la siguiente tabla.] Para obtener más detalles, puede también consultar su Evidencia de cobertura

Para localizar el costo de su medicamento, por favor consulte la (s) tabla (s) que están a continuación para encontrar su área de servicio y el plan de Medicamentos recetados en el que actualmente está inscrito o en el que le gustaría inscribirse.

Cigna-HealthSpring Rx Secure-Xtra (PDP) tiene farmacias con costos compartidos preferidos. Consulte su Directorio de farmacias para información sobre las tiendas con costos compartidos preferidos que están cerca de usted.

A12

All States Todos los estados

Preferred Retail Cost-Sharing

30, 60, 90 Days

Costo compartido al menudeo

preferido 30, 60, 90 días

Standard Retail Cost-Sharing

30, 60, 90 Days

Costo compartido al

menudeo estándar

30, 60, 90 días

Preferred Mail Order

Cost-Sharing 30 and 90 Days

Costo

compartido orden por

correo preferido

30 y 90 días

Standard Mail Order

Cost-Sharing

30 and 90 Days

Costo

compartido orden por

correo estándar

30 y 90 días

Long-Term Care - 31 DaysOut-of-Network

- 30 Days*

Atención a largo plazo - 31

días Fuera de la red

- 30 días*

Cigna-HealthSpring Rx Secure-Xtra (PDP)

30/60/90 Days 30/60/90 días

30/60/90 Days 30/60/90 días

30/90 Days 30/90 días

30/90 Days 30/90 días

Tier 1: Preferred Generic Drugs Nivel 1: Medicamentos genéricos preferidos

$1/$2/$3 $4/$8/$12 $1/$3 $4/$12 $4

Tier 2: Non-Preferred Generic Drugs Nivel 2: Medicamentos genéricos no preferidos

$4/$8/$12 $10/$20/$30 $4/$12 $10/$30 $10

Tier 3: Preferred Brand Drugs Nivel 3: Medicamentos de marca preferida

20% 22% 20% 22% 22%

Tier 4: Non-Preferred Brand Drugs Nivel 4: Medicamentos de marca no preferida

35% 40% 35% 40% 40%

Tier 5: Specialty Tier Nivel 5: Medicamentos de especialidad

33% 33% 33% 33% 33%

*You will pay the copay or percentage of the drug cost shown above plus the difference between the Out–of–Network pharmacy billed charge and our typical Standard Retail pharmacy billed costs. *Pagará el copago o porcentaje del costo del medicamento que se menciona en la tabla, más la diferencia entre el monto que cobra la farmacia fuera de la red y el costo típico de nuestra farmacia de venta al menudeo estándar.

A13

My Medications In this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service, at 1-800-222-6700 or, for TTY users, 711, 8 am–8 pm, local time, 7 days a week. (From February 15–September 30, Monday–Friday 8 am–8 pm local time, Saturday and Sunday 10 am–6 pm, EST, customer service agents available. Messaging service used weekends after hours.) Or visit www.cignahealthspring.com.

Mis medicamentos En esta sección puede escribir todos los medicamentos que toma actualmente; de esta manera, puede encontrar su medicamento en las siguientes páginas de la lista de medicamentos, así como buscar y ver en qué nivel está su medicamento. Una vez que encuentre el nivel en el que está su medicamento, puede buscar en las tablas anteriores a esta página y localizar su costo compartido para ese medicamento. Si necesita ayuda para localizar sus medicamentos y el costo compartido, por favor llame al Departamento de servicio al cliente al 1-800-222-6700 o, para los usuarios de TTY, 711, de 8 am a 8 pm, hora local, 7 días de la semana. (Del 15 de febrero al 30 de septiembre, de lunes a viernes, de 8 a.m. a 8 p.m. hora local; y los sábados y domingos, de 10 a.m. a 6 p.m., Hora del este, nuestros representantes de servicio al cliente estás disponibles. Si llama los fines de semana, o fuera del horario de servicio, entrará el servicio de contestadora automática). O visite www.cignahealthspring.com.

My Medications

Mis medicamentos

Page Number in the Drug List

Número de página en la Lista de medicamentos

Cost-Share through Cigna-HealthSpring Rx

Costo compartido a través de

Cigna-HealthSpring Rx

Drug Name Drug Tier

Reqs./Limits Page Drug Name Drug Tier

Reqs./Limits Page

Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;

B/D= Drugs covered under Medicare Part B or Part D

Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;

ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D

1

A

abacavir 2 42

abacavir sulfate/lamivudine/zidovudine

5 42

ABELCET 5 PA 38

ABILIFY INJ 4 ST 41

ABILIFY ORAL SOLN 4 QL(900/30) ST 41

ABILIFY TABS 5 QL(30/30) ST 41

ABILIFY DISCMELT 5 QL(60/30) ST 41

ABILIFY MAINTENA INJ 300MG

5 QL(1.5/30) 41


5 QL(2/30) 41

ABRAXANE 5 B/D PA 39

acamprosate calcium dr 2 PA 33

acarbose 2 QL(90/30) 43

ACCUPRIL 4 45

ACCURETIC 4 45

acebutolol hcl 2 46

ACEON 4 45

acetaminophen/codeine oral soln

2 QL(5000/30) 32

acetaminophen/codeine tabs 300mg 60mg

2 QL(240/30) 32

acetaminophen/codeine tabs 300mg 15mg

2 QL(360/30) 32

acetaminophen/codeine #2 2 QL(360/30) 32



acetasol hc 2 55

acetazolamide 2 47

acetazolamide er 2 54

acetazolamide sodium 4 47

acetic acid 2 55

acetylcysteine inhalation soln 2 B/D PA 56

acitretin 5 PA 48

ACTHIB 4 53

acticin 2 40

ACTIMMUNE 5 PA 53

ACTONEL TABS 35MG 3 QL(4/28) 54

ACTONEL TABS 30MG, 5MG 3 QL(30/30) 54

acyclovir 2 43

acyclovir sodium inj 1000mg, 50mg/ml

4 43

ADACEL 4 53

ADAGEN 5 PA 48

ADEFOVIR DIPIVOXIL 5 QL(30/30) 42

adriamycin 2 B/D PA 39

adrucil inj 2.5gm/50ml 4 B/D PA 39

afeditab cr 2 46

AFINITOR 5 PA QL(30/30) 40

AFINITOR DISPERZ 5 PA QL(60/30) 40

AGGRENOX 4 QL(60/30) 45

a-hydrocort 4 50

ak-poly-bac 2 33

ala cort 1 50

ALA SCALP 3 50

ALBENZA 3 40

albuterol sulfate nebu 0.63mg/3ml, 1.25mg/3ml

2 B/D PA QL(375/30)

55

albuterol sulfate nebu 0.5% 1 B/D PA QL(360/30)

55

albuterol sulfate nebu 0.083% 1 B/D PA QL(375/30)

55

albuterol sulfate syrp 1 55

albuterol sulfate tabs 1 55

albuterol sulfate er 2 55

alclometasone dipropionate 2 50

alcohol preps pads 1 33

ALDURAZYME 5 PA 48

alendronate sodium tabs 35mg, 70mg

1 QL(4/28) 54

alendronate sodium tabs 10mg, 40mg, 5mg

2 QL(30/30) 54

ALIMTA INJ 500MG 5 B/D PA 39

ALINIA 3 40

allopurinol 1 38

ALOCRIL 3 54

ALORA 3 PA QL(8/28) 51

alphatrex 2 50

alprazolam tabs 0.25mg, 0.5mg

2 QL(90/30) 43

alprazolam tabs 1mg 2 QL(120/30) 43

alprazolam tabs 2mg 2 QL(150/30) 43

Nombre del medicamento

Nivel del medicamento

Requ./

Límites

Página



Requ./

Límites

Página




ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D;

2

alprazolam odt tbdp 0.25mg, 0.5mg

2 QL(90/30) 43

alprazolam odt tbdp 1mg 2 QL(120/30) 43

alprazolam odt tbdp 2mg 2 QL(150/30) 43

ALTACE 4 45

altavera 2 51

alyacen 1/35 2 51

alyacen 7/7/7 2 51

amantadine hcl 2 43

AMBISOME 4 PA 38

amcinonide 2 50

a-methapred 4 50

amifostine 5 B/D PA 39

amikacin sulfate inj 500mg/2ml 4 33

amiloride hcl 2 47

amiloride/hydrochlorothiazide 1 47

AMINO ACIDS 4 B/D PA 56

aminophylline 4 56

AMINOSYN 4 B/D PA 56

AMINOSYN 7%/ELECTROLYTES

4 B/D PA 56

AMINOSYN 8.5%/ELECTROLYTES

4 B/D PA 56

AMINOSYN II 4 B/D PA 56

AMINOSYN II 8.5%/ELECTROLYTES

4 B/D PA 56

AMINOSYN M 4 B/D PA 56

AMINOSYN-HBC 4 B/D PA 56

AMINOSYN-HF 4 B/D PA 56

AMINOSYN-PF 4 B/D PA 56

AMINOSYN-PF 7% 4 B/D PA 56

amiodarone hcl inj 50mg/ml 4 46

amiodarone hcl tabs 2 46

AMITIZA 3 QL(60/30) 49

amitriptyline hcl tabs 150mg 2 PA 37

amitriptyline hcl tabs 100mg, 10mg, 25mg, 50mg, 75mg

1 PA 37

amlodipine besylate 1 46

amlodipine besylate/benazepril hcl

2 46

amlodipine besylate/benazepril hydrochloride

2 46

ammonium lactate 2 48

amnesteem 2 48

amoxapine 2 37

amoxicillin caps 1 34

amoxicillin chew 2 34

amoxicillin susr 1 34

amoxicillin tabs 2 34

amoxicillin/clavulanate potassium

2 34

amoxicillin/clavulanate potassium er

2 34

amphetamine/dextroamphetamine cp24

2 QL(60/30) 47

amphetamine/dextroamphetamine tabs

2 QL(90/30) 47

AMPHOTEC INJ 50MG 4 PA 38

amphotericin b 4 PA 38

ampicillin 2 34

ampicillin sodium 4 34

ampicillin-sulbactam inj 10gm 5gm, 2gm 1gm

4 34

AMPYRA 5 PA QL(60/30) 48

AMTURNIDE 3 ST 46

ANADROL-50 5 PA 51

anagrelide hydrochloride 2 45

anastrozole 2 QL(30/30) 40

ANDROXY 3 PA 51

apexicon 2 50

APOKYN 5 PA QL(60/30) 40

apraclonidine 2 54

apri 2 51

APRISO 3 53

APTIOM TABS 200MG, 400MG, 800MG

4 QL(30/30) ST 35

APTIOM TABS 600MG 4 QL(60/30) ST 36

APTIVUS 5 42

ARALAST NP INJ 1000MG 5 B/D PA 56

aranelle 2 51

ARANESP ALBUMIN FREE INJ 25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/0.3ML, 60MCG/ML

4 PA 45

Drug Name Drug Tier


Reqs./Limits Page





3

ARANESP ALBUMIN FREE INJ 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML

5 PA 45

ARCALYST 5 PA 53

ARRANON 4 39

ARZERRA 5 B/D PA 40

ascomp/codeine 2 PA QL(180/30) 32

ASTAGRAF XL 4 B/D PA 53

atenolol 1 46

atenolol/chlorthalidone 1 46

ATGAM 4 B/D PA 53

atorvastatin calcium 2 QL(30/30) 47

ATOVAQUONE 5 40

atovaquone/proguanil hcl 2 40

ATRIPLA 5 42

atropine sulfate inj 0.05mg/ml, 0.1mg/ml

4 49

ATROVENT HFA 3 QL(26/30) 55

aubra 2 51

augmented betamethasone dipropionate

2 50

AUGMENTIN SUSR 125MG/5ML 31.25MG/5ML

3 34

AVALIDE 4 45

AVASTIN INJ 100MG/4ML 5 B/D PA 40

AVELOX INJ 4 35

aviane 2 51

AVODART 3 49

AVONEX 5 PA QL(4/28) 48

AVONEX PEN 5 PA QL(4/28) 48

AZACITIDINE 5 B/D PA 39

AZACTAM IN ISO-OSMOTIC DEXTROSE

4 34

AZASAN 3 B/D PA 53

AZASITE 3 35

azathioprine 2 B/D PA 53

azelastine hcl ophthalmic soln 2 54

azelastine hcl nasal soln 2 QL(60/30) 55

AZILECT 3 41

azithromycin inj 500mg 4 35

AZITHROMYCIN PACK 3 QL(3/30) 35

azithromycin susr 200mg/5ml 2 QL(75/30) 35

azithromycin susr 100mg/5ml 2 QL(150/30) 35

azithromycin tabs 2 QL(12/28) 35

AZOPT 3 ST 54

aztreonam 4 34

azurette 2 51

B

baciim 4 33

BACITRACIN INJ 4 33

bacitracin ophthalmic oint 2 33

bacitracin/polymyxin b 2 33

baclofen tabs 10mg 1 42

baclofen tabs 20mg 2 42

BACTROBAN NASAL 3 33

balsalazide disodium 2 53

balziva 2 51

BANZEL SUSP 5 PA 36

BANZEL TABS 400MG 5 PA 36

BANZEL TABS 200MG 4 PA 36

BARACLUDE ORAL SOLN 3 42

BARACLUDE TABS 5 42

benazepril hcl 1 45

benazepril hcl/hydrochlorothiazide

2 45

BENICAR 3 QL(30/30) ST 45

BENICAR HCT 3 QL(30/30) ST 45

benztropine mesylate inj 4 PA 40

benztropine mesylate tabs 2mg

1 PA 40

benztropine mesylate tabs 0.5mg, 1mg

2 PA 40

betamethasone dipropionate 2 50

betamethasone valerate 2 50

betaxolol hcl 2 46

betaxolol hcl 2 54

bethanechol chloride 2 49

bicalutamide 2 39

BICILLIN L-A 4 34

BICNU 4 B/D PA 39



Requ./

Límites

Página



Requ./

Límites

Página





4

bisoprolol fumarate 2 46

bisoprolol fumarate/hydrochlorothiazide

1 46

BIVIGAM 4 B/D PA 53

bleomycin sulfate 4 B/D PA 39

BLEPHAMIDE 3 35

blephamide s.o.p. 2 35

BOOSTRIX 4 53

BOSULIF 5 PA 40

briellyn 2 51

BRILINTA 4 QL(60/30) 45

brimonidine tartrate ophthalmic soln 0.2%

2 54

BRIMONIDINE TARTRATE OPHTHALMIC SOLN 0.15%

3 54

BRINTELLIX 4 QL(30/30) ST 36

bromfenac 2 54

bromocriptine mesylate 2 41

budesonide cp24 2 50

budesonide susp 32mcg/act 2 QL(17.2/30) 55

budesonide susp 0.25mg/2ml, 0.5mg/2ml

2 B/D PA QL(120/30)

55

bumetanide inj 4 47

bumetanide tabs 0.5mg, 1mg 1 47

bumetanide tabs 2mg 2 47

BUPHENYL TABS 5 48

buprenorphine hcl inj 4 PA 33

buprenorphine hcl subl 2 PA QL(24/30) 33

buprenorphine hcl/naloxone hcl

2 PA QL(90/30) 33

buproban 2 QL(60/30) 33

bupropion hcl 2 36

bupropion hcl er tb12 100mg, 200mg

2 QL(60/30) 36

bupropion hcl er tb12 150mg 2 QL(90/30) 37

bupropion hcl sr tb12 150mg 2 QL(60/30) 33

bupropion hcl sr tb12 100mg, 200mg

2 QL(60/30) 37

bupropion hcl sr tb12 150mg 2 QL(90/30) 37

bupropion hcl xl tb24 300mg 2 QL(30/30) 37

bupropion hcl xl tb24 150mg 2 QL(90/30) 37

buspirone hcl tabs 10mg, 5mg 1 43

buspirone hcl tabs 15mg, 30mg, 7.5mg

2 43

BUSULFEX 5 B/D PA 39

butal/asa/caff 2 PA QL(180/30) 32

butalbital/acetaminophen/caffeine

2 PA QL(180/30) 32

butalbital/acetaminophen/caffeine/codeine caps 325mg 50mg 40mg 30mg

2 PA QL(180/30) 48

butalbital/aspirin/caffeine/codeine

2 PA QL(180/30) 32

butorphanol tartrate inj 4 32

butorphanol tartrate nasal soln 2 QL(6/30) 32

BYDUREON 3 QL(2.6/28) 43

BYETTA 3 QL(2.4/30) 43

C

cabergoline 2 52

cafergot 2 38

calcipotriene crea 2 48

calcipotriene external soln 2 48

calcipotriene oint 2 QL(120/30) 48

calcitonin-salmon 2 QL(3.7/30) 54

calcitrene 2 QL(120/30) 48

CALCITRIOL OINT 3 48

calcitriol caps 2 54

calcitriol inj 4 B/D PA 54

calcitriol oral soln 2 54

calcium acetate caps 2 56

calcium acetate tabs 667mg 2 56

calcium folinate 4 39

camila 2 52

CANCIDAS 5 PA 38

candesartan cilexetil 2 45

candesartan cilexetil/hydrochlorothiazide

2 47

CAPASTAT SULFATE 4 38

CAPRELSA 5 PA 39

captopril 1 45

captopril/hydrochlorothiazide 2 45

CARAC 3 48

CARAFATE SUSP 3 49

CARBAGLU 5 56

Drug Name Drug Tier


Reqs./Limits Page





5

carbamazepine 2 36

carbamazepine er 2 36

carbidopa 2 41

carbidopa/levodopa 2 41

carbidopa/levodopa er 2 41

carbidopa/levodopa odt 2 41

CARBIDOPA/LEVODOPA/ENTACAPONE

3 41

carboplatin 4 B/D PA 39

carteolol hcl 2 54

cartia xt 2 46

carvedilol 1 46

caziant 2 51

cefaclor caps 2 34

cefaclor er 2 34

cefadroxil 2 34

cefazolin sodium inj 10gm, 1gm, 1gm 5%, 500mg

4 34

cefazolin sodium/dextrose inj 2gm 3%

4 34

cefdinir 2 34

cefepime inj 1gm, 1gm/50ml 5%, 2gm, 2gm/100ml, 2gm/50ml 5%

4 34

cefotaxime sodium 4 34

cefotetan 4 34

cefoxitin sodium inj 10gm, 1gm, 2gm

4 34

cefpodoxime proxetil 2 34

cefprozil 2 34

ceftazidime inj 1gm, 2gm, 6gm 4 34

ceftazidime/dextrose 4 34

ceftriaxone in iso-osmotic dextrose

4 34

ceftriaxone sodium 4 34

cefuroxime axetil 2 34

cefuroxime sodium inj 1.5gm, 7.5gm, 750mg

4 34

CELLCEPT SUSR 3 B/D PA 53

CELLCEPT INTRAVENOUS 4 B/D PA 53

CELONTIN 3 36

cephalexin caps 250mg, 1 34

500mg

cephalexin susr 2 34

cephalexin tabs 2 34

CEREZYME INJ 400UNIT 5 B/D PA 48

CERVARIX 4 53

CHANTIX 3 PA QL(336/365) 33

CHANTIX CONTINUING MONTH PAK

3 PA QL(336/365) 33

CHANTIX STARTING MONTH PAK

3 PA QL(106/365) 33

chateal 2 51

CHEMET 3 56

chloramphenicol sodium succinate

1 33

chlorhexidine gluconate oral rinse

1 48

chloroquine phosphate 2 40

chlorothiazide 2 47

chlorothiazide sodium 4 47

chlorpromazine hcl inj 4 41

chlorpromazine hcl tabs 2 41

chlorthalidone tabs 25mg, 50mg

1 47

chlorzoxazone 2 PA 56

cholestyramine 2 47

cholestyramine light 2 47

chorionic gonadotropin 4 PA 51

ciclopirox sham 2 38

ciclopirox susp 2 38

ciclopirox nail lacquer 2 38

ciclopirox olamine 2 38

cidofovir 5 42

cilostazol 2 45

CILOXAN OINT 3 35

cimetidine 2 49

cimetidine hcl 2 49

CINRYZE 5 PA 52

CIPRO HC 3 35

CIPRODEX 3 35

ciprofloxacin inj 400mg/40ml 4 35

ciprofloxacin susr 2 35

ciprofloxacin er 2 35



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ciprofloxacin hcl ophthalmic soln

2 35

ciprofloxacin hcl tabs 100mg, 750mg

2 35


1 35

ciprofloxacin i.v.-in d5w 4 35

cisplatin inj 100mg/100ml 4 B/D PA 39

citalopram hydrobromide oral soln

1 QL(600/30) 37

citalopram hydrobromide tabs 40mg

1 QL(30/30) 37

citalopram hydrobromide tabs 10mg, 20mg

1 QL(60/30) 37

cladribine 4 B/D PA 39

claravis 2 48

clarithromycin 2 35

clarithromycin er 2 QL(60/30) 35

clindacin etz pledgets 2 48

clindacin-p 2 48

clindamax 2 33

clindamycin hcl 2 33

clindamycin phosphate crea 2 33

clindamycin phosphate inj 150mg/ml

4 34

clindamycin phosphate external soln

2 48

clindamycin phosphate gel 2 48

clindamycin phosphate lotn 2 48

clindamycin phosphate swab 2 48

clindamycin phosphate add-vantage

4 33

CLINDAMYCIN PHOSPHATE IN D5W

4 33

CLINIMIX 2.75%/DEXTROSE 5%

4 B/D PA 56

clinimix 4.25%/dextrose 10% 4 B/D PA 56




4 B/D PA 56

CLINIMIX 5%/DEXTROSE 15%

4 B/D PA 43


4 B/D PA 43


4 B/D PA 56

CLINIMIX E 4.25%/DEXTROSE 25%

3 B/D PA 43

clinisol sf 15% 4 B/D PA 56

clobetasol propionate crea 2 50

clobetasol propionate external soln

2 50

clobetasol propionate foam 2 50

clobetasol propionate gel 2 50

clobetasol propionate oint 2 50

clobetasol propionate e 2 50

clobetasol propionate emollient crea

2 50

CLOLAR 4 B/D PA 39

clomipramine hcl 2 PA 37

clonazepam tabs 0.5mg, 1mg 2 QL(90/30) 36

clonazepam tabs 2mg 2 QL(300/30) 36

clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg

2 QL(90/30) 36

clonazepam odt tbdp 2mg 2 QL(300/30) 36

clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr

2 QL(4/28) 45

clonidine hcl ptwk 0.3mg/24hr 2 QL(8/28) 45

clonidine hcl tabs 0.3mg 2 45

clonidine hcl tabs 0.1mg, 0.2mg

1 45

clonidine hcl er 2 45

clopidogrel tabs 300mg 2 QL(1/30) 45

clopidogrel tabs 75mg 2 QL(30/30) 45

clorazepate dipotassium tabs 3.75mg, 7.5mg

2 QL(90/30) 43

clorazepate dipotassium tabs 15mg

2 QL(120/30) 43

clotrimazole external crea 2 38

clotrimazole external soln 2 38

clotrimazole troc 2 38

clotrimazole/betamethasone dipropionate

2 50

clozapine 2 42

CLOZAPINE ODT 3 42

Drug Name Drug Tier


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7

COARTEM 3 40

COLCRYS 3 38

colestipol hcl 2 47

colistimethate sodium 4 34

colocort 2 50

COLY-MYCIN S 3 55

COMBIGAN 3 54

COMBIVENT RESPIMAT 3 QL(8/30) 55

COMETRIQ 5 PA 39

compazine supp 2 41

COMPLERA 5 42

compro 2 41

COMVAX 4 53

constulose 1 49

COPAXONE INJ 20MG/ML 5 QL(30/30) 48

COREG CR 4 46

cormax scalp application 2 50

cortisone acetate 2 50

CORTISPORIN-TC 3 55

COSMEGEN 5 B/D PA 39

COUMADIN 4 44

COZAAR TABS 100MG 4 QL(30/30) 45

COZAAR TABS 25MG, 50MG 4 QL(60/30) 45

CREON 3 48

CRESTOR 3 QL(30/30) 47

CRIXIVAN 3 43

cromolyn sodium conc 2 49

cromolyn sodium ophthalmic soln

2 54

cromolyn sodium nebu 2 B/D PA 56

cryselle-28 2 51

CUBICIN 5 B/D PA 34

CUPRIMINE 5 56

curity gauze pads 2x2 2 48

cyclafem 1/35 2 51

cyclafem 7/7/7 2 51

cyclobenzaprine hcl tabs 10mg, 5mg

2 PA 56

CYCLOPHOSPHAMIDE CAPS

3 B/D PA 39

cyclophosphamide inj 4 B/D PA 39

cyclophosphamide tabs 2 B/D PA 39

cycloserine 2 38

cyclosporine caps 2 B/D PA 53

cyclosporine inj 4 B/D PA 53

cyclosporine modified 2 B/D PA 53

CYSTADANE 5 48

CYSTAGON 3 48

cytarabine 4 B/D PA 39

cytarabine aqueous 4 B/D PA 39

D

dacarbazine 4 B/D PA 39

DALIRESP 3 PA QL(30/30) 56

danazol 2 51

dantrolene sodium 2 42

dapsone 2 38

DAPTACEL 4 53

DARAPRIM 3 40

dasetta 1/35 2 51

dasetta 7/7/7 2 51

daunorubicin hcl 4 B/D PA 39

DAUNOXOME 5 B/D PA 39

decitabine 5 39

DELZICOL 3 53

demeclocycline hcl 2 35

DEMSER 5 46

DENAVIR 3 43

DEPEN TITRATABS 3 56

DEPO-ESTRADIOL 4 51

DEPO-MEDROL INJ 20MG/ML

4 50

DEPO-PROVERA 4 52

desipramine hcl 2 37

desloratadine 2 QL(30/30) 55

desloratadine odt 2 QL(30/30) 55

desmopressin acetate inj 4 51

desmopressin acetate nasal soln 0.01%

2 51

DESMOPRESSIN ACETATE NASAL SOLN 0.01%

3 51

desmopressin acetate tabs 2 51

desogestrel/ethinyl estradiol 2 51



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tabs 0.15mg 30mcg

desonide lotn 2 50

desonide oint 2 50

desoximetasone crea 2 50

desoximetasone gel 2 50

desoximetasone oint 0.25% 2 50

dexamethasone elix 2 50

dexamethasone tabs 0.5mg, 0.75mg, 4mg

1 50

dexamethasone tabs 1.5mg, 1mg, 2mg, 6mg

2 50

DEXAMETHASONE INTENSOL

3 50

dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml

4 50

dexamethasone sodium phosphate ophthalmic soln

2 54

dexmethylphenidate hcl 2 QL(60/30) 48

dexrazoxane inj 250mg 4 B/D PA 39

dextroamphetamine sulfate oral soln

2 QL(1800/30) 48

dextroamphetamine sulfate tabs 5mg

2 QL(90/30) 48


2 QL(180/30) 48

dextroamphetamine sulfate er cp24 10mg, 5mg

2 QL(90/30) 48

dextroamphetamine sulfate er cp24 15mg

2 QL(120/30) 48

dextrose 10%/nacl 0.45% 4 B/D PA 44

dextrose 5% /electrolyte #48 viaflex

4 B/D PA 56

dextrose 10% flex container 4 B/D PA 44


dextrose 2.5%/nacl 0.45% 4 B/D PA 44

dextrose 2.5%/sodium chloride 0.45%

4 B/D PA 44

dextrose 5% 4 B/D PA 44






dextrose 5%/potassium chloride 0.15%

4 B/D PA 56

dextrose 5%/sodium chloride 0.2%

4 B/D PA 44


4 B/D PA 44

DIAZEPAM GEL 3 36

diazepam oral soln 2 QL(1200/30) 43

diazepam tabs 2 QL(120/30) 43

DIBENZYLINE 3 45

diclofenac potassium 2 32

diclofenac sodium ophthalmic soln

2 54

diclofenac sodium dr tbec 25mg, 50mg

2 32

diclofenac sodium dr tbec 75mg

1 32

diclofenac sodium er 2 32

dicloxacillin sodium 2 34

dicyclomine hcl caps 1 49

dicyclomine hcl oral soln 2 49

dicyclomine hcl tabs 1 49

didanosine 2 42

diflorasone diacetate 2 50

diflunisal 2 32

digox tabs 125mcg 1 QL(30/30) 46

digox tabs 250mcg 1 PA 46

digoxin inj 4 PA 46

digoxin tabs 125mcg 1 QL(30/30) 46

digoxin tabs 250mcg 1 PA 46

dihydroergotamine mesylate inj

2 38

dilantin caps 30mg 2 36

DILANTIN CAPS 100MG 4 36

DILANTIN INFATABS 4 36

diltiazem cd 2 46

diltiazem hcl inj 100mg, 25mg/5ml, 50mg/10ml

4 46

diltiazem hcl tabs 1 46

diltiazem hcl er cp12 2 46

diltiazem hcl er cp24 2 46

dilt-xr 2 46

Drug Name Drug Tier


Reqs./Limits Page





9

diphenhydramine hcl inj 4 55

diphenoxylate/atropine 2 49

DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

4 53

dipyridamole tabs 2 PA 45

disulfiram 2 33

divalproex sodium 2 36

divalproex sodium dr 2 36

divalproex sodium er 2 36

DOCEFREZ 5 B/D PA 39

docetaxel inj 140mg/7ml, 20mg/ml, 80mg/4ml, 80mg/8ml

5 B/D PA 39

donepezil hcl tabs 23mg, 5mg 2 QL(30/30) 36

donepezil hcl tabs 10mg 2 QL(60/30) 36

donepezil hcl tbdp 5mg 2 QL(30/30) 36

donepezil hcl tbdp 10mg 2 QL(60/30) 36

dorzolamide hcl 2 54

dorzolamide hcl/timolol maleate

2 54

doxazosin mesylate tabs 1mg, 2mg, 4mg

1 QL(30/30) 49

doxazosin mesylate tabs 8mg 1 QL(60/30) 49

doxepin hcl 2 PA 37

doxercalciferol caps 2 54

doxercalciferol inj 4 B/D PA 54

doxorubicin hcl inj 2mg/ml 2 B/D PA 39

DOXORUBICIN HCL LIPOSOME

5 B/D PA 39

doxycycline caps 75mg 2 35

doxycycline susr 2 35

doxycycline hyclate caps 1 35

doxycycline hyclate inj 4 35

doxycycline hyclate tabs 100mg

1 35

doxycycline hyclate tabs 20mg 2 35

doxycycline monohydrate 2 35

dronabinol 2 PA QL(90/30) 38

DROXIA 3 39

DULERA 3 QL(13/30) 55

duloxetine hcl cpep 20mg, 2 QL(60/30) 37

60mg

duloxetine hcl cpep 30mg 2 QL(90/30) 37

duramorph 4 32

DUREZOL 3 54

E

e.e.s. 400 2 35

E.E.S. GRANULES 3 35

e.s.p. 2 35

econazole nitrate 2 38

EDECRIN 3 47

EDURANT 3 42

ELAPRASE 5 PA 48

ELIDEL 3 48

ELIGARD INJ 30MG 4 PA QL(1/120) 52

ELIGARD INJ 45MG 4 PA QL(1/180) 52

ELIGARD INJ 7.5MG 4 PA QL(1/30) 52

ELIGARD INJ 22.5MG 4 PA QL(1/90) 52

elinest 2 51

ELIQUIS 3 PA QL(60/30) 44

ELITEK 5 B/D PA 39

ELLA 3 52

ELLENCE INJ 200MG/100ML 4 B/D PA 39

ELMIRON 3 49

EMCYT 3 39

EMEND CAPS 40MG 3 B/D PA QL(2/30) 38



EMEND CAPS 3 B/D PA QL(12/30)

38

emoquette 2 51

EMSAM 3 37

EMTRIVA 3 42

enalapril maleate 1 45

enalapril maleate/hydrochlorothiazide

1 45

ENBREL 5 PA QL(8/28) 53

ENBREL SURECLICK 5 PA QL(8/28) 53

endocet tabs 325mg 10mg, 325mg 5mg, 325mg 7.5mg

2 QL(360/30) 32

ENGERIX-B 4 B/D PA 53

enoxaparin sodium inj 120mg/0.8ml

5 QL(24/30) 44



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enoxaparin sodium inj 100mg/ml, 150mg/ml

5 QL(30/30) 44


4 QL(9/30) 44


4 QL(12/30) 44


4 QL(18/30) 44


4 QL(24/30) 44

enoxaparin sodium inj 300mg/3ml

4 QL(90/30) 44

enpresse-28 2 51

enskyce 2 51

entacapone 2 40

enulose 1 49

epinastine hcl 2 54

EPINEPHRINE HCL INJ 0.1MG/ML

4 55

epinephrine hcl inj 1mg/ml 4 55

EPIPEN 2-PAK 3 QL(2/30) 55

EPIPEN-JR 2-PAK 3 QL(2/30) 55

epirubicin hcl inj 50mg/25ml 4 B/D PA 39

epirubicin hcl inj 200mg/100ml 5 B/D PA 39

epitol 2 36

EPIVIR ORAL SOLN 3 42

EPIVIR HBV ORAL SOLN 3 42

EPZICOM 5 42

ERBITUX 5 B/D PA 40

ergoloid mesylates 2 PA 36

ERIVEDGE 5 PA QL(30/30) 39

errin 2 52

ERWINAZE 5 B/D PA 39

ery 2 35

ERYPED 200 3 35

ERYPED 400 3 35

ERY-TAB 3 35

ERYTHROCIN LACTOBIONATE

4 35

erythrocin stearate 2 35

erythromycin external soln 2 35

erythromycin gel 2 35

erythromycin oint 2 35

erythromycin pads 2 35

erythromycin base 2 35

erythromycin ethylsuccinate 2 35

erythromycin/benzoyl peroxide 2 48

escitalopram oxalate oral soln 2 QL(600/30) 37

escitalopram oxalate tabs 2 QL(60/30) 37

ESOMEPRAZOLE SODIUM 4 49

estarylla 2 51

estradiol ptwk 2 PA QL(4/28) 51

estradiol tabs 2 PA 51

estradiol valerate 4 51

estradiol/norethindrone acetate

2 PA 51

ESTRING 3 QL(1/90) 51

ethambutol hcl 2 38

ethosuximide 2 36

etidronate disodium 2 54

etodolac 2 32

etodolac er 2 32

ETOPOPHOS 4 B/D PA 40

ETOPOSIDE INJ 3 B/D PA 40

EXELON PT24 3 QL(30/30) 36

exemestane 2 40

EXFORGE 3 46

EXFORGE HCT 3 46

EXJADE 5 56

F

FABRAZYME 5 B/D PA 49

falmina 2 51

famciclovir 2 QL(21/7) 43

famotidine inj 20mg/2ml 4 49

famotidine tabs 20mg 1 49

famotidine tabs 40mg 2 49

famotidine premixed 4 49

FANAPT TABS 10MG, 12MG, 6MG, 8MG

5 QL(60/30) ST 41

FANAPT TABS 1MG, 2MG, 4MG

4 QL(60/30) ST 41

FANAPT TITRATION PACK 4 QL(16/30) ST 41

FARESTON 5 39

FASLODEX 5 B/D PA 39

FAZACLO 4 ST 42

Drug Name Drug Tier


Reqs./Limits Page





11

felbamate 2 36

felodipine er 2 46

FEMRING 3 51

fenofibrate caps 130mg, 43mg 2 47

fenofibrate tabs 2 47

fenofibrate micronized 2 47

fenofibric acid dr 2 47

fenoprofen calcium 2 32

fentanyl 2 QL(15/30) 32

fentanyl citrate 4 B/D PA 32

FENTANYL CITRATE ORAL TRANSMUCOSAL

5 PA QL(120/30) 32

FETZIMA 4 QL(30/30) ST 37

FETZIMA TITRATION PACK 4 QL(28/28) ST 37

finasteride tabs 5mg 2 QL(30/30) 49

FIRAZYR 5 PA 53

firmagon inj 80mg 4 B/D PA QL(4/28) 52

FIRMAGON INJ 120MG 5 B/D PA QL(6/365)

52

flavoxate hcl 2 49

FLEBOGAMMA DIF 4 B/D PA 53

flecainide acetate 2 46

FLOVENT DISKUS AEPB 250MCG/BLIST, 50MCG/BLIST

3 QL(120/30) 55

FLOVENT DISKUS AEPB 100MCG/BLIST

3 QL(180/30) 55

FLOVENT HFA AERO 44MCG/ACT

3 QL(22/30) 55

FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT

3 QL(24/30) 55

fluconazole susr 2 38

fluconazole tabs 100mg, 200mg, 50mg

2 38

fluconazole tabs 150mg 1 QL(8/30) 38

fluconazole in dextrose 4 38

fluconazole in nacl 4 38

FLUCYTOSINE 5 38

fludarabine phosphate 4 B/D PA 39

fludrocortisone acetate 2 50

flunisolide 1 55

fluocinolone acetonide crea 2 50

fluocinolone acetonide external soln

1 50

fluocinolone acetonide oint 2 50

fluocinolone acetonide oil 2 55

fluocinonide 2 50

fluocinonide-e 2 50

fluoride chew 0.25mg, 1.1mg, 2.2mg

1 56

fluoritab chew 1 56

FLUOROMETHOLONE 3 54

FLUOROPLEX 3 48

fluorouracil inj 2.5gm/50ml 4 B/D PA 39

fluorouracil crea 2 48

fluorouracil external soln 2 48

fluoxetine dr 2 37

fluoxetine hcl caps 2 37

fluoxetine hcl oral soln 2 37

fluoxetine hcl tabs 10mg, 20mg

2 37

fluphenazine decanoate 4 41

fluphenazine hcl conc 2 41

fluphenazine hcl elix 2 41

fluphenazine hcl inj 4 41

fluphenazine hcl tabs 1mg 1 41

fluphenazine hcl tabs 10mg, 2.5mg, 5mg

2 41

flurbiprofen 2 32

flurbiprofen sodium 2 54

flutamide 2 39

fluticasone propionate crea 2 50

fluticasone propionate oint 2 50

fluticasone propionate susp 2 QL(16/30) 55

fluvastatin caps 20mg 2 QL(30/30) 47

fluvastatin caps 40mg 2 QL(60/30) 47

fluvoxamine maleate 2 37

fluvoxamine maleate er cp24 150mg

2 QL(60/30) 37


2 QL(90/30) 37

FOLOTYN 5 B/D PA 39

fomepizole 5 54

fondaparinux sodium inj 4 QL(15/30) 44



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2.5mg/0.5ml

fondaparinux sodium inj 5mg/0.4ml

5 QL(12/30) 44

fondaparinux sodium inj 7.5mg/0.6ml

5 QL(18/30) 44


5 QL(24/30) 44

FORADIL AEROLIZER 3 QL(60/30) 55

FORTEO 5 PA QL(2.4/28) 54

foscarnet sodium 4 42

fosinopril sodium 2 45

fosinopril sodium/hydrochlorothiazide

2 45

fosphenytoin sodium 4 36

FOSRENOL 5 ST 50

FREAMINE III 4 B/D PA 56

FREAMINE III 3% 4 B/D PA 56

furosemide inj 4 47

furosemide oral soln 2 47

furosemide tabs 1 47

FUSILEV 5 39

FUZEON 5 QL(60/30) 42

FYCOMPA 4 ST 36

G

gabapentin 2 36

GABITRIL TABS 16MG 3 QL(90/30) ST 36

GABITRIL TABS 12MG 3 QL(120/30) ST 36

galantamine 2 QL(60/30) 36

galantamine hydrobromide cp24

2 QL(30/30) 36

galantamine hydrobromide oral soln

2 QL(200/30) 36

galantamine hydrobromide tabs

2 QL(60/30) 36

gamastan s/d 4 B/D PA 53

GAMMAGARD LIQUID 4 B/D PA 53

GAMMAKED 4 B/D PA 53

GAMMAPLEX INJ 10GM/200ML, 2.5GM/50ML, 5GM/100ML

4 B/D PA 53

GAMUNEX-C 4 B/D PA 53

ganciclovir 4 B/D PA 42

GARDASIL 4 53

gavilyte-c 2 49

gavilyte-n/flavor pack 2 49

GAZYVA 5 PA 40

gemcitabine 4 B/D PA 39

gemcitabine hcl 5 B/D PA 39

gemfibrozil 2 47

generlac 1 49

gengraf 2 B/D PA 53

gentak 2 33

gentamicin sulfate crea 2 33

gentamicin sulfate inj 4 33

gentamicin sulfate oint 2 33

gentamicin sulfate ophthalmic soln

4 33

gentamicin sulfate pediatric 4 33

gentamicin sulfate/0.9% sodium chloride

4 33

gentamicin sulfate/sodium chloride

4 33

GEODON INJ 4 QL(60/30) 41

gildagia 2 51

gildess 1.5/30 2 51

gildess 1/20 2 51

gildess fe 1.5/30 2 51

gildess fe 1/20 2 51

GILOTRIF 5 PA QL(30/30) 40

GLEEVEC 5 PA QL(60/30) 40

glimepiride tabs 1mg, 2mg 1 QL(30/30) 43

glimepiride tabs 4mg 1 QL(60/30) 43

glipizide 1 43

glipizide er 1 43

glipizide/metformin hcl 1 43

GLUCAGEN HYPOKIT 4 44

glyburide/metformin hcl 2 PA 43

glycopyrrolate inj 4mg/20ml 4 49

glycopyrrolate tabs 2 49

GLYSET 3 43

granisetron hcl inj 0.1mg/ml, 1mg/ml

4 B/D PA 38

granisetron hcl tabs 2 B/D PA QL(60/30)

38

griseofulvin microsize 2 38

Drug Name Drug Tier


Reqs./Limits Page





13

griseofulvin ultramicrosize 2 38

GUANIDINE HCL 3 38

H

HALAVEN 5 PA 39

halobetasol propionate 2 50

haloperidol conc 2 41

haloperidol tabs 0.5mg, 1mg, 2mg, 5mg

1 41

haloperidol tabs 10mg, 20mg 2 41

haloperidol decanoate 4 41

haloperidol lactate 4 41

HAVRIX 4 53

heather 2 52

hecoria 2 B/D PA 53

heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 2000unit/ml, 2500unit/ml, 5000unit/ml

4 44

heparin sodium/d5w 4 44

heparin sodium/nacl 0.9% 4 44

hepatamine 4 B/D PA 56

HEPATASOL 4 B/D PA 56

HERCEPTIN 5 B/D PA 40

HEXALEN 5 39

HUMALOG 3 44

HUMALOG KWIKPEN 3 44

HUMALOG MIX 50/50 3 44

HUMALOG MIX 50/50 KWIKPEN

3 44

HUMALOG MIX 75/25 3 44


3 44

HUMIRA INJ 20MG/0.4ML 5 PA QL(2/28) 53

HUMIRA INJ 40MG/0.8ML 5 PA QL(6/28) 53

HUMIRA PEN 5 PA QL(6/28) 53

HUMIRA PEN-CROHNS DISEASESTARTER

5 PA QL(6/28) 53

HUMULIN 70/30 3 44

HUMULIN 70/30 KWIKPEN 3 44

HUMULIN 70/30 PEN 3 44

HUMULIN N 3 44

HUMULIN N KWIKPEN 3 44

HUMULIN N U-100 PEN 3 44

HUMULIN R 3 44

HUMULIN R U-500 (CONCENTRATED)

3 44

hydralazine hcl inj 4 47

hydralazine hcl tabs 2 47

hydrochlorothiazide caps 1 47

hydrochlorothiazide tabs 25mg, 50mg

1 47

hydrochlorothiazide tabs 12.5mg

2 47

hydrocodone bitartrate/acetaminophen oral soln

2 QL(5400/30) 32

hydrocodone bitartrate/acetaminophen tabs 325mg 2.5mg

2 QL(360/30) 32

hydrocodone bitartrate/acetaminophen tabs 300mg 10mg, 300mg 5mg, 300mg 7.5mg

2 QL(390/30) 32

hydrocodone/acetaminophen tabs

2 QL(360/30) 32

hydrocodone/ibuprofen tabs 7.5mg 200mg

2 QL(150/30) 32

hydrocortisone crea 1%, 2.5% 1 50

hydrocortisone lotn 2.5% 2 50

hydrocortisone oint 1%, 2.5% 2 50

hydrocortisone tabs 2 50

hydrocortisone butyrate 2 50

hydrocortisone butyrate (lipophilic)

2 50

hydrocortisone in absorbase 2 50

hydrocortisone valerate 2 50

hydrocortisone/acetic acid 2 55

HYDROMORPHONE HCL INJ 1MG/ML, 2MG/ML

4 32

hydromorphone hcl inj 2mg/ml, 500mg/50ml

4 32

hydromorphone hcl liqd 2 QL(1200/30) 32

hydromorphone hcl tabs 2 QL(240/30) 32

hydroxychloroquine sulfate 2 40

hydroxyurea 2 39



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HYZAAR TABS 12.5MG 100MG, 25MG 100MG

4 QL(30/30) 45

HYZAAR TABS 12.5MG 50MG

4 QL(60/30) 45

I

ibandronate sodium tabs 2 QL(1/28) 54

ibuprofen susp 1 32

ibuprofen tabs 400mg, 600mg, 800mg

1 32

ICLUSIG 5 PA 39

idarubicin hcl inj 10mg/10ml 5 B/D PA 39

ifosfamide inj 1gm, 3gm 4 B/D PA 39

ifosfamide/mesna 5 B/D PA 39

ILARIS 5 PA 53

ilotycin 2 35

IMBRUVICA 5 PA QL(120/30) 40

imipenem/cilastatin 2 34

imipramine hcl 2 PA 37

imipramine pamoate 2 PA 37

imiquimod 2 48

IMOVAX RABIES (H.D.C.V.) 4 53

INCIVEK 5 PA QL(180/30) 42

INCRELEX 4 PA 51

indapamide 1 47

INFANRIX 4 53

infumorph 200 4 32

infumorph 500 4 32

INLYTA TABS 5MG 5 PA QL(120/30) 40

INLYTA TABS 1MG 5 PA QL(240/30) 40

INTELENCE TABS 200MG 5 QL(60/30) 42



intralipid inj 2.25% 20% 4 B/D PA 58

INTRON-A 5 42

INTRON-A W/DILUENT INJ 10MU, 18MU

5 42

introvale 2 51

INVANZ 4 34

INVEGA TB24 9MG 5 QL(30/30) ST 41

INVEGA TB24 1.5MG, 3MG 4 QL(30/30) ST 41

INVEGA TB24 6MG 4 QL(60/30) ST 41

INVEGA SUSTENNA INJ 4 QL(0.25/28) 41

39MG/0.25ML

INVEGA SUSTENNA INJ 78MG/0.5ML

4 QL(0.5/28) 41


5 QL(0.75/28) 41

INVEGA SUSTENNA INJ 156MG/ML

5 QL(1/28) 41


5 QL(1.5/28) 41

INVIRASE 5 43

IPOL INACTIVATED IPV 4 53

ipratropium bromide inhalation soln

2 B/D PA QL(300/30)

55

ipratropium bromide nasal soln 0.06%

2 QL(30/30) 55


2 QL(60/30) 55

ipratropium bromide/albuterol sulfate

2 B/D PA QL(540/30)

55

irbesartan 1 45

irbesartan/hydrochlorothiazide 1 45

irinotecan inj 100mg/5ml 4 B/D PA 39

ISENTRESS CHEW 25MG 3 QL(360/30) 42

ISENTRESS CHEW 100MG 5 QL(180/30) 42

ISENTRESS PACK 3 42

ISENTRESS TABS 5 QL(60/30) 42

isoditrate er 2 47

isolyte-m/dextrose 5% 4 B/D PA 57

isoniazid inj 4 38

isoniazid syrp 2 39

isoniazid tabs 100mg 2 39

isoniazid tabs 300mg 1 39

isosorbide dinitrate 2 47

isosorbide dinitrate er 2 47

isosorbide mononitrate 2 47

isosorbide mononitrate er 2 47

isotonic gentamicin inj 0.8mg/ml 0.9%, 1.2mg/ml 0.9%, 1.6mg/ml 0.9%, 1mg/ml 0.9%

4 33

isradipine 2 46

ISTODAX 5 PA 39

itraconazole 2 PA QL(120/30) 38

Drug Name Drug Tier


Reqs./Limits Page





15

IXEMPRA KIT 5 B/D PA 39

IXIARO 4 53

J

JAKAFI 5 PA QL(60/30) 39

JALYN 3 49

jantoven 1 44

JANUMET 3 QL(60/30) 43

JANUMET XR TB24 1000MG 100MG

3 QL(30/30) 43

JANUMET XR TB24 1000MG 50MG, 500MG 50MG

3 QL(60/30) 43

JANUVIA 3 QL(30/30) 43

jencycla 2 52

JENTADUETO 3 QL(60/30) 43

JEVTANA 5 B/D PA 39

junel 1.5/30 2 51

junel 1/20 2 51

junel fe 1.5/30 2 51

junel fe 1/20 2 51

K

KADCYLA 5 PA 40

KALETRA ORAL SOLN 5 43

KALETRA TABS 200MG 50MG

5 43

KALETRA TABS 100MG 25MG

4 43

kariva 2 51

kcl 0.075%/d5w/nacl 0.45% 4 B/D PA 44

kcl 0.15%/d5w/ nacl 0.3% 4 B/D PA 44

kcl 0.15%/d5w/lr 4 B/D PA 44

kcl 0.15%/d5w/nacl 0.2% 4 B/D PA 44

kcl 0.15%/d5w/nacl 0.45% 4 B/D PA 44

kcl 0.15%/d5w/nacl 0.9% 4 B/D PA 44

kcl 0.3%/d5w/nacl 0.45% 4 B/D PA 44

kelnor 1/35 2 51

KETEK 3 QL(20/30) 35

ketoconazole 2 38

ketoprofen 2 32

ketoprofen er 2 32

ketorolac tromethamine ophthalmic soln

2 54

kionex 2 56

klor-con 2 57

klor-con m10 1 57

klor-con m20 1 57

kurvelo 2 51

KUVAN 5 PA 49

k-vescent pack 2 57

KYPROLIS 5 PA QL(6/28) 39

L

labetalol hcl inj 4 46

labetalol hcl tabs 2 46

laclotion 2 48

LACRISERT 3 54

lactated ringers inj 3meq/l 109meq/l 28meq/l 4meq/l 130meq/l

4 57

lactated ringers dextrose 5% viaflex

4 57

lactated ringers irrigation 4 54

lactated ringers viaflex 4 57

lactulose 1 49

lamivudine 2 42

lamivudine/zidovudine 5 42

lamotrigine 2 36

lamotrigine er 2 36

LANOXIN TABS 125MCG 4 QL(30/30) 46

LANOXIN TABS 250MCG 4 PA 46

LANOXIN PEDIATRIC 4 PA 46

lansoprazole 2 QL(60/30) 49

lansoprazole/amoxicillin/clarithromycin

2 34

LANTUS 3 44

LANTUS SOLOSTAR 3 44

larin 1/20 2 51

larin fe 1.5/30 2 51

larin fe 1/20 2 51

latanoprost 2 QL(5/30) 54

LATUDA TABS 120MG, 20MG, 40MG, 60MG

4 QL(30/30) ST 41

LATUDA TABS 80MG 4 QL(60/30) ST 41

LAZANDA 5 PA QL(44/28) 32

leflunomide 2 QL(30/30) 53

lessina 2 51



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LETAIRIS 5 PA QL(30/30) 56

letrozole 2 QL(30/30) 40

leucovorin calcium inj 100mg, 350mg, 500mg, 50mg

4 39

leucovorin calcium tabs 2 39

LEUKERAN 3 39

LEUKINE 5 PA 45

leuprolide acetate 4 PA QL(30/30) 52

LEVEMIR 3 44

LEVEMIR FLEXPEN 3 44

levetiracetam inj 4 36

levetiracetam oral soln 2 36

levetiracetam tabs 2 36

levetiracetam er 2 36

LEVOBUNOLOL HCL OPHTHALMIC SOLN 0.25%

3 55

levobunolol hcl ophthalmic soln 0.5%

1 55

levocarnitine inj 4 B/D PA 54

levocarnitine oral soln 2 54

levocarnitine tabs 2 54

levocetirizine dihydrochloride oral soln

2 QL(300/30) 55

levocetirizine dihydrochloride tabs

2 QL(30/30) 55

levofloxacin inj 4 35

levofloxacin oral soln 2 35

levofloxacin tabs 2 35

levofloxacin in d5w 4 35

levonest 2 51

levonorgestrel/ethinyl estradiol 2 51

levora 0.15/30-28 2 51

levorphanol tartrate 2 QL(180/30) 32

levothyroxine sodium tabs 1 52

LEVOXYL 4 52

LEXIVA SUSP 4 43

LEXIVA TABS 5 43

lidocaine oint 2 33

lidocaine ptch 2 PA QL(90/30) 33

lidocaine hcl external soln 2 33

lidocaine hcl gel 2 33

lidocaine hcl inj 0.5%, 1%, 2% 4 33

lidocaine hcl inj 10mg/ml 4 46

lidocaine hcl jelly 2 33

lidocaine viscous 1 33

lidocaine/prilocaine crea 2 33

LINCOCIN 4 34

lindane 2 40

liothyronine sodium inj 4 52

liothyronine sodium tabs 2 52

LIPODOX 5 B/D PA 40

LIPODOX 50 5 B/D PA 40

LIPOFEN 3 47

liposyn iii inj 2.5% 30% 4 B/D PA 58

lisinopril 1 45

lisinopril/hydrochlorothiazide 1 46

lithium carbonate caps 300mg 1 43

lithium carbonate caps 150mg, 600mg

2 43

lithium carbonate tabs 2 43

lithium carbonate er 2 43

lofene 2 49

LOMUSTINE 3 39

lonox 2 49

loperamide hcl caps 2 49

lorazepam conc 2 QL(120/30) 43

lorazepam inj 2mg/ml, 4mg/ml 4 43

lorazepam tabs 2 QL(120/30) 43

lorcet 2 QL(360/30) 32

lorcet hd 2 QL(360/30) 32

lorcet plus 2 QL(360/30) 32

lortab tabs 2 QL(360/30) 32

losartan potassium tabs 100mg

1 QL(30/30) 45

losartan potassium tabs 50mg 1 QL(60/30) 45

losartan potassium tabs 25mg 1 QL(90/30) 45

losartan potassium/hydrochlorothiazide tabs 12.5mg 100mg, 25mg 100mg

1 QL(30/30) 45

losartan potassium/hydrochlorothiazide tabs 12.5mg 50mg

1 QL(60/30) 45

LOTENSIN 4 46

Drug Name Drug Tier


Reqs./Limits Page





17

LOTENSIN HCT 4 46

LOTRONEX 5 PA QL(60/30) 49

lovastatin tabs 40mg 2 QL(60/30) 47

lovastatin tabs 10mg, 20mg 1 QL(90/30) 47

low-ogestrel 2 51

loxapine 2 41

loxapine succinate 2 41

ludent 1 57

LUMIZYME 5 PA 49

LUPRON DEPOT 5 PA QL(1/30) 52

LUPRON DEPOT-PED 5 PA QL(1/30) 52

lutera 2 51

LYRICA CAPS 225MG, 25MG, 300MG

3 QL(60/30) 36

LYRICA CAPS 100MG, 150MG, 200MG, 50MG, 75MG

3 QL(90/30) 36

LYRICA ORAL SOLN 3 QL(900/30) 36

LYSODREN 3 52

lyza 2 52

M

magnesium sulfate inj 50% 4 B/D PA 57

MAKENA 5 52

malathion 2 40

maprotiline hcl 2 37

margesic 2 PA QL(180/30) 32

marlissa 2 51

MARPLAN 4 37

MATULANE 5 39

matzim la 2 46

MAVIK 4 46

meclizine hcl tabs 2 37

meclofenamate sodium 2 32

MEDROL TABS 2MG 3 50

medroxyprogesterone acetate inj

4 QL(1/90) 52

medroxyprogesterone acetate tabs

1 52

mefloquine hcl 2 40

megestrol acetate 2 PA 52

MEKINIST 5 PA 40

meloxicam tabs 1 32

melphalan hydrochloride 5 B/D PA 39

MENACTRA 4 53

MENEST 3 PA 40

MENOMUNE-A/C/Y/W-135 4 53

MENOSTAR 3 PA QL(4/28) 51

MENVEO 4 53

mercaptopurine 2 39

meropenem 2 34

mesalamine 2 53

mesna 2 B/D PA 40

MESNEX TABS 5 40

MESTINON TIMESPAN 3 38

metadate er 2 QL(90/30) 48

metaproterenol sulfate 2 55

metformin hcl 1 43

metformin hcl er tb24 500mg, 750mg

1 43

methadone hcl conc 2 QL(500/30) 32

methadone hcl inj 4 32

methadone hcl oral soln 10mg/5ml

2 QL(2000/30) 32


2 QL(4000/30) 32

methadone hcl tabs 2 QL(360/30) 32

methadose tabs 2 QL(360/30) 32

methazolamide 2 55

methenamine hippurate 2 34

methimazole 2 52

methotrexate 2 53

methotrexate sodium 4 53

methoxsalen 5 48

methscopolamine bromide 2 49

methyldopate hcl 2 PA 45

methylphenidate hcl 2 QL(90/30) 48

methylphenidate hcl er tbcr 20mg

2 QL(90/30) 48


2 QL(180/30) 48

methylphenidate hcl sr 2 QL(90/30) 48

methylprednisolone 2 50

methylprednisolone acetate 4 50

methylprednisolone dose pack 2 50



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methylprednisolone sodiumsuccinate inj 125mg, 40mg

4 50

metipranolol 2 55

metoclopramide hcl inj 4 49

metoclopramide hcl oral soln 1 49

metoclopramide hcl tabs 10mg 1 49

metoclopramide hcl tabs 5mg 2 49

metolazone 2 47

metoprolol succinate er 2 46

metoprolol tartrate inj 4 46

metoprolol tartrate tabs 1 46

metoprolol/hydrochlorothiazide 2 46

metronidazole crea 2 34

metronidazole gel 2 34

metronidazole lotn 2 34

metronidazole tabs 1 34

metronidazole in nacl 0.79% 4 34

metronidazole vaginal 2 34

mexiletine hcl 2 46

MIACALCIN INJ 4 54

microgestin 1.5/30 2 51

microgestin 1/20 2 51

microgestin fe 2 51

microgestin fe 1.5/30 2 51

midodrine hcl 2 45

migergot 2 38

mimvey 2 PA 51

mimvey lo 2 PA 51

minitran 2 47

MINIVELLE PTTW 0.1MG/24HR

3 PA QL(8/28) 51

minocycline hcl 2 35

minoxidil tabs 2 47

mirtazapine 2 QL(30/30) 37

mirtazapine odt 2 QL(30/30) 37

misoprostol 2 49

mitomycin 4 B/D PA 40

MITOXANTRONE HCL 3 B/D PA 40

M-M-R II W/DILUENT 10 DOSE

4 53

MODAFINIL TABS 100MG 4 PA QL(30/30) 56

modafinil tabs 200mg 5 PA QL(60/30) 56

MODERIBA MISC 5 PA 42

moderiba tabs 2 PA 42

MODERIBA 1200 DOSE PACK

5 PA 42

MODERIBA 800 DOSE PACK 5 PA 42

moexipril hcl 2 46

moexipril/hydrochlorothiazide 2 46

mometasone furoate 2 50

mono-linyah 2 51

montelukast sodium 2 QL(30/30) 55

morgidox 1x100mg caps 1 35

morgidox 2x100mg caps 1 35

morphine sulfate inj 0.5mg/ml, 10mg/ml, 1mg/ml, 5mg/ml

4 32

morphine sulfate oral soln 20mg/ml

2 QL(540/30) 32

morphine sulfate oral soln 20mg/5ml

2 QL(2700/30) 32


2 QL(5400/30) 33

MORPHINE SULFATE TABS 3 QL(360/30) 33

morphine sulfate er tbcr 2 QL(90/30) 32

MOVIPREP 4 49

MOXEZA 3 35

moxifloxacin hcl 2 35

MOZOBIL 5 QL(9.6/30) 57

MULTAQ 3 QL(60/30) 46

mupirocin 2 34

mupirocin calcium 2 34

MUSTARGEN 4 B/D PA 39

mycophenolate mofetil 2 B/D PA 53

mycophenolic acid dr 2 B/D PA 53

mydral 2 54

myorisan 2 48

myzilra 2 51

N

nabumetone 2 32

nadolol tabs 80mg 2 46

nadolol tabs 20mg, 40mg 1 46

nadolol/bendroflumethiazide 2 46

nafcillin sodium 4 34

Drug Name Drug Tier


Reqs./Limits Page





19

nafrinse 1 57

NAFTIN 3 38

NAGLAZYME 5 PA 49

nalbuphine hcl 4 33

naloxone hcl 2 33

naltrexone hcl 2 PA 33

NAMENDA ORAL SOLN 3 QL(300/30) 36

NAMENDA XR 3 QL(30/30) 36

NAMENDA XR TITRATION PACK

3 QL(28/28) 36

naphazoline hcl 2 54

naproxen susp 2 32

naproxen tabs 250mg 2 32

naproxen tabs 375mg, 500mg 1 32

naproxen dr 2 32

naproxen sodium tabs 275mg, 550mg

2 32

naratriptan hcl 2 QL(9/30) 38

NATACYN 3 38

nateglinide 2 QL(90/30) 43

NEBUPENT 3 B/D PA 40

necon 0.5/35-28 2 51

necon 1/35 2 51

necon 10/11-28 2 51

necon 7/7/7 2 51

nefazodone hcl 2 QL(60/30) 37

neomycin sulfate 2 33

neomycin/bacitracin/polymyxin 2 34

neomycin/polymyxin b sulfates 4 33

neomycin/polymyxin/bacitracin zinc

2 54

neomycin/polymyxin/bacitracin/hydrocortisone

2 34

neomycin/polymyxin/dexamethasone

2 54

neomycin/polymyxin/gramicidin

2 34

neomycin/polymyxin/hc 2 55

neomycin/polymyxin/hydrocortisone

2 34


2 55

neo-polycin 2 54

NEULASTA 5 PA 45

NEUMEGA 5 PA 45

NEUPOGEN INJ 300MCG/0.5ML, 480MCG/0.8ML, 480MCG/1.6ML

5 PA 45

NEUPRO 4 PA QL(30/30) 41

NEUTREXIN 5 40

NEVIRAPINE SUSP 3 42

nevirapine tabs 2 42

nevirapine er 2 42

NEXAVAR 5 PA 40

niacin er tbcr 500mg 2 QL(30/30) 47

niacin er tbcr 1000mg, 750mg 2 QL(60/30) 47

niacor 2 47

nicardipine hcl caps 2 46

nicardipine hcl inj 4 46

NICOTROL INHALER 3 PA QL(504/30) 33

NICOTROL NS 3 PA QL(40/30) 33

nifediac cc tb24 30mg, 60mg 2 46

nifedical xl 2 46

nifedipine er 2 46

NILANDRON 5 39

nimodipine 2 46

nisoldipine 2 46

nisoldipine er 2 46

nitrofurantoin 2 QL(900/365) 34

nitrofurantoin macrocrystals 2 QL(90/365) 34

nitrofurantoin monohydrate 2 QL(90/365) 34

nitroglycerin inj 4 47

nitroglycerin pt24 2 47

nitroglycerin lingual translingual soln

2 47

nitroglycerin transdermal 2 47

NITROSTAT 3 47

nizatidine caps 2 49

norethindrone 2 52

norethindrone acetate 2 52

norgestimate/ethinyl estradiol 2 51

NORITATE 3 34



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normosol-m in d5w 4 B/D PA 57

NORMOSOL-R 4 B/D PA 57

normosol-r in d5w 4 B/D PA 44

nortrel 0.5/35 (28) 2 51

nortrel 1/35 2 51

nortrel 7/7/7 2 51

nortriptyline hcl caps 1 37

nortriptyline hcl oral soln 2 37

NORVIR 3 43

novarel 4 PA 51

novofine 30gx8mm 2 QL(200/30) 54

novofine 31 2 QL(200/30) 54

novofine 32gx6mm 2 QL(200/30) 54

novofine autocover 30gx8mm 2 QL(200/30) 54

novotwist 30gx8mm 2 QL(200/30) 54

novotwist 32gx5mm 2 QL(200/30) 54

NOXAFIL SUSP 5 PA QL(600/30) 38

NOXAFIL TBEC 5 PA QL(93/30) 38

NUEDEXTA 3 PA 48

NULOJIX 5 PA 53

nyamyc 2 38

nystatin crea 2 38

nystatin oint 2 38

nystatin powd 100000unit/gm 2 38

nystatin susp 2 38

nystatin tabs 2 38

nystatin/triamcinolone 2 38

nystop 2 38

NEEDLES AND SYRINGES

bd insulin syringe safetyglide/1ml/29g x 1/2

2 QL(200/30) 59

bd insulin syringe ultrafine/0.3ml/31g x 5/16

2 QL(200/30) 59

bd insulin syringe ultrafine/0.5ml/30g x 1/2

2 QL(200/30) 59

bd insulin syringe ultrafine/1ml/31g x 5/16

2 QL(200/30) 59

bd insulin syringe ultrafine/u-100/0.3ml/31g x 15/64

2 QL(200/30) 59

bd insulin syringe ultrafine/u-100/0.5ml/31g x 15/64

2 QL(200/30) 59

bd insulin syringe ultrafine/u- 2 QL(200/30) 59

100/1ml/31g x 15/64

bd pen needle/mini/ultrafine/31g x 3/16

2 QL(200/30) 59

bd pen needle/nano/ultra fine/32g x 4mm

2 QL(200/30) 59

bd pen needle/ultrafine/29g x 12.7mm

2 QL(200/30) 59

monoject insulin syringe/detach needle/1ml/27g x 1/2

2 QL(200/30) 59

monoject insulin syringe/safety/perm needle/0.3ml/29g x 1/2

2 QL(200/30) 59

monoject insulin syringe/u-100/0.5ml/30g x 5/16

2 QL(200/30) 59

monoject insulin syringe/u-100/1ml/30g x 5/16

2 QL(200/30) 59

monoject ultra comfort insulin syringe/0.3ml/30g x 5/16

2 QL(200/30) 59


2 QL(200/30) 59


2 QL(200/30) 59

monoject ultra comfort insulin syringe/1ml/28g x 1/2

2 QL(200/30) 59

ulticare insulin syringe/u-100/0.3ml/30g x 1/2

2 QL(200/30) 59

ulticare insulin syringe/u-100/0.5ml/31g x 5/16

2 QL(200/30) 59

ulticare insulin syringe/u-100/1ml/30g x 1/2

2 QL(200/30) 59

O

OB COMPLETE 400 3 58

OB COMPLETE/DHA 3 58

OCTAGAM INJ 10GM/200ML, 2.5GM/50ML, 5GM/100ML

4 B/D PA 53

octreotide acetate inj 1000mcg/ml, 500mcg/ml

5 PA 52

octreotide acetate inj 100mcg/ml, 200mcg/ml, 50mcg/ml

4 PA 52

ofloxacin 2 35

ogestrel 2 51

Drug Name Drug Tier


Reqs./Limits Page





21

olanzapine inj 4 41

olanzapine tabs 2 QL(30/30) 41

olanzapine odt 2 QL(30/30) 41

olanzapine/fluoxetine 2 QL(30/30) 37

OLYSIO 5 PA QL(30/30) 42

omega-3-acid ethyl esters 2 QL(120/30) 47

omeprazole cpdr 2 QL(60/30) 49

ONCASPAR 5 B/D PA 40

ondansetron hcl inj 4mg/2ml 4 38

ondansetron hcl oral soln 2 B/D PA 38

ondansetron hcl tabs 24mg 2 B/D PA QL(5/30) 38

ondansetron hcl tabs 4mg, 8mg

2 B/D PA QL(90/30)

38

ondansetron odt 2 B/D PA QL(90/30)

38

ONFI SUSP 3 QL(480/30) 36

ONFI TABS 10MG 3 QL(60/30) 36

ONFI TABS 20MG 3 QL(120/30) 36

oralone 2 48

ORAP 3 41

ORFADIN 5 49

orphenadrine citrate er 2 PA 56

orsythia 2 51

OSMOPREP 4 49

oxacillin sodium inj 10gm, 2gm 4 34

oxaliplatin inj 100mg/20ml 5 B/D PA 40

oxandrolone tabs 10mg 2 PA QL(60/30) 51

oxandrolone tabs 2.5mg 2 PA QL(120/30) 51

oxaprozin 2 32

oxazepam 2 QL(120/30) 43

oxcarbazepine 2 36

oxybutynin chloride 1 49

oxybutynin chloride er tb24 5mg

2 QL(30/30) 49

oxybutynin chloride er tb24 10mg, 15mg

2 QL(60/30) 49

oxycodone hcl caps 2 QL(240/30) 33

oxycodone hcl conc 2 QL(360/30) 33

oxycodone hcl oral soln 2 QL(1200/30) 33

oxycodone hcl tabs 2 QL(240/30) 33

oxycodone/acetaminophen tabs 325mg 10mg, 325mg

2 QL(360/30) 33

5mg, 325mg 7.5mg

oxycodone/aspirin 2 QL(360/30) 33

oxycodone/ibuprofen 2 QL(150/30) 32

OXYCONTIN 4 PA QL(60/30) 32

oxymorphone hydrochloride er 2 QL(60/30) 32

P

pacerone 2 46

paclitaxel inj 300mg/50ml 4 B/D PA 40

pamidronate disodium inj 30mg/10ml, 6mg/ml, 90mg/10ml

4 B/D PA 54

PANCRELIPASE 3 49

PANRETIN 5 40

pantoprazole sodium tbec 2 QL(60/30) 49

parcaine 2 54

paricalcitol 2 54

paromomycin sulfate 2 33

paroxetine hcl tabs 30mg, 40mg

2 QL(60/30) 37

paroxetine hcl tabs 10mg 1 QL(30/30) 37

paroxetine hcl tabs 20mg 1 QL(60/30) 37

paroxetine hcl er tb24 12.5mg 2 QL(30/30) 37

paroxetine hcl er tb24 37.5mg 2 QL(60/30) 37

paroxetine hcl er tb24 25mg 2 QL(90/30) 37

PASER 3 39

PATADAY 3 54

PATANOL 3 54

PAXIL SUSP 3 QL(900/30) 37

pedi-dri 2 38

PEDVAX HIB 4 53

peg 3350/electrolytes 2 49

peg-3350/nacl/na bicarbonate/kcl

2 49

PEGANONE 3 36

PEG-INTRON 5 PA 42

PEG-INTRON REDIPEN 5 PA 42

PEG-INTRON REDIPEN PAK 4

5 PA 42

penicillin g potassium inj 20000000unit, 5mu

4 35

penicillin v potassium oral soln 1 35

penicillin v potassium tabs 1 35



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250mg

penicillin v potassium tabs 500mg

2 35

PENTAM 300 3 40

pentoxifylline er 2 46

PERFOROMIST 3 B/D PA QL(120/30)

55

perindopril erbumine 1 46

periogard 1 48

PERJETA 5 PA 40

permethrin crea 2 40

perphenazine 2 41

perphenazine/amitriptyline 2 PA 37

PFIZERPEN-G INJ 5MU 4 35

phenadoz 2 PA 37

phenelzine sulfate 2 37

phenobarbital 2 36

phenytoin 2 36

phenytoin infatabs 2 36

phenytoin sodium 4 36

phenytoin sodium extended 2 36

philith 2 51

PHOSLYRA 4 57

PHOSPHOLINE IODIDE 4 55

physiolyte 4 B/D PA 54

physiosol irrigation 4 54

PICATO 4 ST 40

pilocarpine hcl tabs 2 48

PILOCARPINE HCL OPHTHALMIC SOLN

3 55

pilocarpine hydrochloride 2 48

pimtrea 2 51

pindolol 1 46

pioglitazone hcl 2 QL(30/30) 43

pioglitazone hcl/metformin hcl 2 QL(90/30) 43

pioglitazone hcl-glimepiride 2 QL(30/30) 43

piperacillin sodium/ tazobactam sodium

4 35

piperacillin sodium/tazobactam sodium

4 35

PIPERACILLIN/TAZOBACTAM

4 35

pirmella 1/35 2 51

pirmella 7/7/7 2 51

piroxicam 2 32

podofilox 2 48

polycin 2 54

polycin b 2 34

poly-dex 2 54

polyethylene glycol 3350 powd 2 49

polymyxin b sulfate 4 34

polymyxin b sulfate/trimethoprim sulfate

2 34

POMALYST 5 PA QL(21/28) 40

portia-28 2 51

potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml

4 B/D PA 57

potassium chloride liqd 2 57

potassium chloride pack 2 57

potassium chloride 0.15% d5w/nacl 0.33%

4 B/D PA 44


4 B/D PA 44

potassium chloride 0.15%/d5w 4 57

potassium chloride 0.15%/nacl 0.9%

4 B/D PA 57


4 B/D PA 44

potassium chloride 0.224%/d5w/nacl 0.45%

4 B/D PA 44

POTASSIUM CHLORIDE 0.3%/ NACL 0.9%

4 B/D PA 57

potassium chloride 0.3%/d5w 4 B/D PA 57

potassium chloride 0.3%/nacl 0.9%/viaflex

4 B/D PA 57

potassium chloride cr 1 57

potassium chloride er cpcr 2 57

POTASSIUM CHLORIDE ER TBCR 10MEQ

3 57

potassium chloride er tbcr 10meq, 20meq

1 57

POTASSIUM CHLORIDE SR 3 57

POTASSIUM CITRATE 3 57

POTIGA 3 PA QL(90/30) 36

Drug Name Drug Tier


Reqs./Limits Page





23

PRADAXA 3 PA QL(60/30) 44

pramipexole dihydrochloride 2 QL(90/30) 41

pravastatin sodium tabs 80mg 1 QL(30/30) 47

pravastatin sodium tabs 40mg 1 QL(60/30) 47

pravastatin sodium tabs 10mg, 20mg

1 QL(90/30) 47

prazosin hcl 1 45

PRED MILD 3 54

PRED-G 3 54

PRED-G S.O.P. 3 54

prednicarbate oint 2 50

PREDNISOLONE ACETATE 3 54

prednisolone sodium phosphate oral soln

2 50

prednisolone sodium phosphate ophthalmic soln

1 54

prednisone oral soln 2 50

prednisone tabs 50mg 2 50

prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg

1 50

PREDNISONE INTENSOL 3 50

pregnyl w/diluent benzyl alcohol/nacl

4 PA 51

PREMARIN CREA 3 52

PREMARIN INJ 4 52

PREMARIN TABS 4 PA QL(30/30) 52

PREMASOL INJ 52MEQ/L 1760MG/100ML 880MG/100ML 34MEQ/L 1760MG/100ML 372MG/100ML 406MG/100ML 526MG/100ML 492MG/100ML 492MG/100ML 526MG/100ML 356MG/100ML 356MG/100ML 390MG/100ML 34MG/100ML 152MG/100ML

4 B/D PA 57

premasol inj 56meq/l 320mg/100ml 730mg/100ml 190mg/100ml 3meq/l 20mg/100ml 300mg/100ml

4 B/D PA 57

220mg/100ml 290mg/100ml 490mg/100ml 840mg/100ml 490mg/100ml 200mg/100ml 290mg/100ml 410mg/100ml 230mg/100ml 5meq/l 15mg/100ml 250mg/100ml 120mg/100ml 140mg/100ml 470mg/100ml

PRENATABS OBN 3 58

prevalite 2 47

previfem 2 52

PREZISTA SUSP 5 QL(400/30) 43

PREZISTA TABS 800MG 5 QL(30/30) 43




PRIFTIN 3 39

PRIMAQUINE PHOSPHATE 3 40

primidone 2 36

PRIMSOL 3 34

PRINIVIL 4 46

PRISTIQ 4 QL(30/30) ST 37

PRIVIGEN INJ 10GM/100ML, 20GM/200ML, 5GM/50ML

4 B/D PA 53

PROAIR HFA 3 QL(17/30) 55

probenecid 2 38

probenecid/colchicine 2 38

PROCALAMINE 4 B/D PA 57

procentra 2 QL(1800/30) 48

prochlorperazine 2 41

prochlorperazine edisylate 4 41

prochlorperazine maleate tabs 10mg

1 41


2 41

PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML

5 PA 45

PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

4 PA 45

procto-pak 2 50

proctosol hc 2 50

proctozone-hc 2 50



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progesterone caps 2 52

PROGLYCEM 3 44

PROGRAF INJ 4 B/D PA 53

PROLASTIN-C 5 B/D PA 56

PROLEUKIN 5 B/D PA 40

PROLIA 4 QL(1/180) ST 54

PROMACTA 5 PA QL(30/30) 45

promethazine hcl supp 12.5mg, 25mg

2 PA 37

promethazine hcl inj 4 PA 55

promethazine hcl syrp 2 PA 55

promethazine hcl tabs 12.5mg, 50mg

2 PA 55

promethazine hcl tabs 25mg 1 PA 55

promethazine hcl plain 2 PA 37

promethegan 2 PA 37

propafenone hcl 2 46

propafenone hcl er 2 46

propantheline bromide 2 49

proparacaine hcl 2 54

propranolol hcl inj 4 46

propranolol hcl oral soln 2 46

propranolol hcl tabs 60mg 2 46

propranolol hcl tabs 10mg, 20mg, 40mg, 80mg

1 46

propranolol hcl er 2 46

propranolol/hydrochlorothiazide

2 46

propylthiouracil 2 52

PROQUAD 4 53

PROSOL 4 B/D PA 57

PROTOPIC 3 48

protriptyline hcl 2 37

PROVENGE 5 B/D PA 53

PRUDOXIN 3 48

PULMOZYME 5 B/D PA 56

pyrazinamide 2 39

pyridostigmine bromide 2 38

Q

quasense 2 52

quetiapine fumarate 2 QL(90/30) 41

quinapril hcl 1 46

quinapril/hydrochlorothiazide 2 46

quinidine sulfate 2 46

quinine sulfate 1 40

QVAR 3 QL(18/30) 55

R

RABAVERT 4 53

raloxifene hydrochloride 2 QL(30/30) 52

ramipril 1 46

RANEXA TB12 1000MG 3 QL(60/30) ST 46

RANEXA TB12 500MG 3 QL(120/30) ST 47

ranitidine hcl caps 2 49

ranitidine hcl inj 150mg/6ml 4 49

ranitidine hcl syrp 2 49

ranitidine hcl tabs 1 49

RAPAFLO 4 QL(30/30) 49

RAPAMUNE ORAL SOLN 3 B/D PA 53

RAPAMUNE TABS 1MG, 2MG

3 B/D PA 53

REBETOL ORAL SOLN 4 PA 42

REBIF 5 PA QL(6/28) 48

REBIF REBIDOSE 5 PA QL(6/28) 48

REBIF REBIDOSE TITRATION PACK

5 PA QL(4.2/28) 48

REBIF TITRATION PACK 5 PA QL(4.2/28) 48

reclipsen 2 52

RECOMBIVAX HB INJ 10MCG/ML, 40MCG/ML

4 B/D PA 53

regonol 4 38

REGRANEX 5 PA 48

RELISTOR INJ 8MG/0.4ML 4 PA QL(12/30) 49

RELISTOR INJ VIAL 12MG/0.6ML 4 PA QL(18/30) 49

RELISTOR INJ KIT 12MG/0.6ML 4 PA QL(28/28) 49

REMICADE 5 PA 53

REMODULIN 5 B/D PA 56

RENVELA PACK 2.4GM 5 QL(180/30) 50

RENVELA PACK 0.8GM 3 QL(180/30) 50

RENVELA TABS 3 QL(540/30) 50

repaglinide 2 43

RESCRIPTOR 3 42

RESTASIS 3 QL(64/30) 54

RETROVIR IV INFUSION 4 42

REVLIMID 5 PA QL(28/28) 39

Drug Name Drug Tier


Reqs./Limits Page





25

REYATAZ 5 43

ribasphere caps 2 PA 42

RIBASPHERE TABS 600MG 5 PA 42

ribasphere tabs 200mg 2 PA 42

RIBASPHERE TABS 400MG 4 PA 42

RIBASPHERE RIBAPAK 5 PA 42

RIBATAB 5 PA 42

ribavirin 2 PA 42

RIDAURA 5 53

rifabutin 2 38

rifampin caps 2 39

rifampin inj 4 39

RIFATER 3 39

riluzole 4 48

rimantadine hcl 2 43

ringers injection 4 57

ringers irrigation 4 54

RIOMET 3 43

risedronate sodium 2 QL(1/28) 54

RISPERDAL CONSTA INJ 12.5MG, 25MG

4 41


5 41

risperidone oral soln 2 QL(360/30) 41

risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg

2 QL(90/30) 42

risperidone tabs 4mg 2 QL(120/30) 42

risperidone m-tab tbdp 0.5mg, 1mg, 2mg, 3mg

2 QL(90/30) 41

risperidone m-tab tbdp 4mg 2 QL(120/30) 41

risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg

2 QL(90/30) 41

risperidone odt tbdp 4mg 2 QL(120/30) 41

RITUXAN 5 PA 40

rivastigmine tartrate 2 QL(60/30) 36

rizatriptan benzoate 2 QL(12/30) 38

rizatriptan benzoate odt 2 QL(12/30) 38

romycin 2 35

ropinirole hcl 2 41

rosadan gel 2 34

ROTARIX 3 53

ROTATEQ 3 53

roxicet tabs 2 QL(360/30) 33

ROZEREM 3 QL(30/30) 56

S

SABRIL PACK 5 PA QL(200/30) 36

SABRIL TABS 5 PA QL(180/30) 36

SAIZEN 5 PA 51

SAIZEN CLICK.EASY 5 PA 51

SAMSCA TABS 30MG 5 PA QL(60/30) 56

SAMSCA TABS 15MG 5 PA QL(90/30) 56

SANDOSTATIN LAR DEPOT 5 PA 52

SANTYL 3 48

SAPHRIS 3 QL(60/30) ST 42

selegiline hcl 2 41

selenium sulfide lotn 1 48

SELZENTRY TABS 150MG 5 QL(60/30) 42

SELZENTRY TABS 300MG 5 QL(120/30) 42

SENSIPAR TABS 30MG 3 QL(60/30) 52



SEREVENT DISKUS 3 QL(60/30) 55

sertraline hcl conc 2 QL(300/30) 37

sertraline hcl tabs 25mg 2 QL(30/30) 37



sildenafil 2 PA QL(90/30) 56

SILENOR 3 QL(30/30) 56

SILVER SULFADIAZINE 3 34

SIMULECT 5 B/D PA 53

simvastatin tabs 20mg, 40mg, 80mg

1 QL(30/30) 47

simvastatin tabs 10mg, 5mg 1 QL(90/30) 47

sirolimus 2 B/D PA 53

SIRTURO 4 PA 39

sodium bicarbonate inj 7.5%, 8.4%

4 56

sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5%

4 B/D PA 57

sodium chloride 0.45% viaflex 4 B/D PA 57

sodium chloride 0.9% 4 54

SODIUM EDECRIN 4 47

sodium fluoride chew 0.25mg, 0.5mg, 1mg, 2.2mg

1 57



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sodium fluoride tabs 1 57

sodium lactate 4 B/D PA 56

SODIUM PHENYLBUTYRATE 5 49

sodium polystyrene sulfonate powd

2 56

sodium polystyrene sulfonate susp 15gm/60ml

2 56

sodium sulfacetamide ophthalmic soln

2 35

SOLTAMOX 3 39

SOLU-CORTEF INJ 1000MG, 250MG, 500MG

4 50

SOMATULINE DEPOT 5 PA 52

SOMAVERT INJ 15MG, 20MG 5 PA QL(60/30) 52

SOMAVERT INJ 10MG 5 PA QL(90/30) 52

sorine 2 46

sotalol hcl 2 46

sotalol hcl (af) 2 46

SOVALDI 5 PA QL(30/30) 42

SPIRIVA HANDIHALER 3 QL(30/30) 55

spironolactone tabs 25mg 1 47

spironolactone tabs 100mg, 50mg

2 47

spironolactone/hydrochlorothiazide

2 47

SPORANOX ORAL SOLN 3 PA 38

sprintec 28 2 52

SPRYCEL 5 PA 40

sps 2 56

sronyx 2 52

SSD 3 34

stavudine 2 42

sterile water irrigation 4 54

STIMATE 3 51

STIVARGA 5 PA QL(84/21) 40

STRATTERA 3 48

streptomycin sulfate 4 33

STRIBILD 5 42

STROMECTOL 3 40

SUBOXONE 3 PA QL(90/30) 33

sucralfate 2 49

sulfacetamide sodium 2 35

ophthalmic soln

sulfacetamide sodium susp 2 48

sulfacetamide sodium/prednisolone sodium phosphate

2 35

sulfadiazine 2 35

sulfamethoxazole/trimethoprim inj

4 35

sulfamethoxazole/trimethoprim susp

1 35

sulfamethoxazole/trimethoprim tabs

1 35

sulfamethoxazole/trimethoprim ds

1 35

sulfasalazine tabs 2 53

sulfazine 2 53

sulfazine ec 2 53

sulindac 2 32

SUMATRIPTAN 3 QL(12/30) 38

sumatriptan succinate inj 4mg/0.5ml

2 QL(4/30) 38

sumatriptan succinate inj 4mg/0.5ml, 6mg/0.5ml

2 QL(8/30) 38

sumatriptan succinate tabs 2 QL(9/30) 38

sumatriptan succinate refill inj 6mg/0.5ml

2 QL(4/30) 38


2 QL(8/30) 38

SUPRAX SUSR 3 34

SUPRAX TABS 3 34

SURMONTIL 4 PA 37

SUSTIVA 3 42

SUTENT CAPS 12.5MG, 25MG, 50MG

5 PA 40

SYLATRON 5 PA 40

SYMBICORT AERO 160MCG/ACT 4.5MCG/ACT

3 QL(11/30) 55

SYMBICORT AERO 80MCG/ACT 4.5MCG/ACT

3 QL(14/30) 55

SYNAGIS INJ 50MG/0.5ML 5 PA 53

SYNAREL 5 PA 52

SYNERCID 4 34

SYNRIBO 5 PA 40

Drug Name Drug Tier


Reqs./Limits Page





27

SYNTHROID 4 52

SYPRINE 5 56

T

TABLOID 3 39

tacrolimus 2 B/D PA 53

TAFINLAR 5 PA 40

TAMIFLU CAPS 75MG 3 QL(56/365) 43



TAMIFLU SUSR 3 QL(700/365) 43

tamoxifen citrate 2 39

tamsulosin hcl 2 49

TARCEVA 5 PA 40

TARGRETIN 5 40

TASIGNA 5 PA 40

TASMAR 5 40

TAXOTERE 5 B/D PA 40

TAZICEF INJ 1GM/50ML 4.4%

4 34

tazicef inj 1gm, 2gm, 6gm 4 34

TAZORAC CREA 3 QL(120/30) 48

TAZORAC GEL 3 QL(100/30) 48

taztia xt 2 46

TEFLARO 4 34

TEGRETOL TABS 4 36

TEGRETOL-XR TB12 200MG, 400MG

4 36

TEGRETOL-XR TB12 100MG 3 36

TEKAMLO 3 ST 47

TEKTURNA 3 ST 47

TEKTURNA HCT 3 ST 47

telmisartan 2 QL(30/30) 45

telmisartan/amlodipine 2 QL(30/30) 45

telmisartan/hydrochloroth 2 QL(30/30) 45

telmisartan/hydrochlorothiazide

2 QL(30/30) 45

temazepam 2 QL(90/365) 43

TEMODAR INJ 5 B/D PA 39

tenivac 4 53

TERAZOL 3 CREA 4 38

TERAZOL 7 4 38

terazosin hcl caps 1mg, 5mg 1 QL(30/30) 49

terazosin hcl caps 10mg, 2mg 1 QL(60/30) 49

terbinafine hcl tabs 1 QL(180/365) 38

terbutaline sulfate inj 4 55

terbutaline sulfate tabs 2 55

terconazole 2 38

TESTIM 3 PA 51

testosterone cypionate 4 PA 51

testosterone enanthate 4 PA 51

tetanus toxoid adsorbed 4 53

tetanus/diphtheria toxoids-adsorbed adult

4 53

tetracycline hcl 1 35

TEXACORT 3 50

THALOMID CAPS 150MG, 200MG, 50MG

5 PA QL(60/30) 39

THALOMID CAPS 100MG 5 PA QL(90/30) 39

THEO-24 4 56

theochron 2 56

theophylline cr 2 56

theophylline er tb12 200mg, 300mg, 450mg

2 56

theophylline er tb24 2 56

THERMAZENE 3 34

thioridazine hcl 2 PA 41

thiothixene caps 10mg, 1mg, 5mg

2 41

thiothixene caps 2mg 1 41

THYMOGLOBULIN 3 B/D PA 53

THYROLAR-1 3 52

THYROLAR-1/2 3 52

THYROLAR-1/4 3 52

THYROLAR-2 3 52

THYROLAR-3 3 52

tiagabine hydrochloride tabs 2mg

2 QL(240/30) ST 36


2 QL(420/30) ST 36

TIKOSYN 3 46

tilia fe 2 52

TIMENTIN 4 35

timolol maleate tabs 2 46



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timolol maleate ophthalmic soln

1 55

tis-u-sol 4 54

TIVICAY 5 QL(60/30) 42

tizanidine hcl tabs 2 42

TOBI PODHALER 5 QL(1568/365) 56

TOBRADEX OINT 3 54

tobramycin 4 B/D PA 56

tobramycin sulfate inj 10mg/ml, 80mg/2ml

4 33

tobramycin sulfate inj 1.2gm 4 B/D PA 33

tobramycin sulfate ophthalmic soln

2 33

tobramycin/dexamethasone 2 54

TOBREX OINT 3 33

tolmetin sodium 2 32

tolterodine tartrate 1 49

topiragen 2 36

topiramate 2 36

TOPOSAR 3 B/D PA 40

topotecan hcl inj 4mg 5 40

TORISEL 3 B/D PA 53

torsemide tabs 2 47

tpn electrolytes 4 B/D PA 57

TRACLEER 5 PA QL(60/30) 56

TRADJENTA 3 QL(30/30) 43

tramadol hcl 2 QL(240/30) 33

tramadol hcl er tb24 2 QL(30/30) 32

tramadol hydrochloride/acetaminophen

2 QL(240/30) 33

trandolapril 2 46

tranexamic acid inj 2 PA 45

tranexamic acid tabs 2 45

TRANSDERM-SCOP 3 QL(12/36) 37

tranylcypromine sulfate 2 37

TRAVASOL 4 B/D PA 57

TRAVATAN Z 3 QL(5/30) ST 54

trazodone hcl tabs 300mg 2 37

trazodone hcl tabs 100mg, 150mg, 50mg

1 37

TREANDA 5 B/D PA 39

TRECATOR 3 39

TRELSTAR DEPOT 5 PA QL(1/28) 52

TRELSTAR DEPOT MIXJECT 5 PA QL(2/28) 52

TRELSTAR LA 5 PA QL(1/84) 52

TRELSTAR LA MIXJECT 5 PA QL(2/84) 52

TRELSTAR MIXJECT 5 PA QL(2/168) 52

TRETINOIN CAPS 5 40

tretinoin crea 2 PA QL(45/30) 48

tretinoin gel 2 PA QL(45/30) 48

tretinoin microsphere 2 PA QL(50/30) 48

tretinoin microsphere pump gel 0.04%

2 PA QL(50/30) 48

triamcinolone acetonide pste 2 48

triamcinolone acetonide crea 0.1%

1 50

triamcinolone acetonide crea 0.025%, 0.5%

2 51

triamcinolone acetonide lotn 2 51

triamcinolone acetonide oint 2 51

triamcinolone acetonide inha 2 QL(16.5/30) 55

triamcinolone in orabase 2 48

triamterene/hydrochlorothiazide caps 25mg 50mg

2 47

triamterene/hydrochlorothiazide caps 25mg 37.5mg

1 47

triamterene/hydrochlorothiazide tabs

1 47

triderm 1 51

tri-estarylla 2 52

trifluoperazine hcl 2 41

trifluridine 2 43

trihexyphenidyl hcl elix 2 PA 40

trihexyphenidyl hcl tabs 5mg 2 PA 40

trihexyphenidyl hcl tabs 2mg 1 PA 40

tri-legest fe 2 52

tri-linyah 2 52

trilyte 2 49

trimethoprim 2 34

trimethoprim sulfate/polymyxin b sulfate

2 54

tri-previfem 2 52

TRISENOX 4 B/D PA 40

tri-sprintec 2 52

Drug Name Drug Tier


Reqs./Limits Page





29

trivora-28 2 52

TROPHAMINE INJ 97MEQ/L 0.54GM/100ML 1.2GM/100ML 0.32GM/100ML 0 0 0.5GM/100ML 0.36GM/100ML 0.48GM/100ML 0.82GM/100ML 1.4GM/100ML 1.2GM/100ML 0.34GM/100ML 0.48GM/100ML 0.68GM/100ML 0.38GM/100ML 5MEQ/L 0.025GM/100ML 0.42GM/100ML 0.2GM/100ML 0.24GM/100ML 0.78GM/100ML

4 B/D PA 58

tropicamide 2 54

TRUVADA 5 42

TWINRIX 4 53

TYGACIL 5 34

TYKERB 5 PA 40

TYPHIM VI 4 53

TYSABRI 5 PA 48

TYZEKA 5 PA 42

TYZINE 3 56

TYZINE PEDIATRIC NASAL DROPS

3 56

U

u-cort 2 51

ULORIC 3 ST 38

UNIRETIC 4 46

UNITHROID 4 52

UNITHROID DIRECT 4 52

UNIVASC 4 46

ursodiol 2 49

UVADEX 4 B/D PA 48

V

valacyclovir hcl tabs 1000mg 2 QL(30/30) 43

valacyclovir hcl tabs 500mg 2 QL(60/30) 43

VALCHLOR 5 PA 39

VALCYTE 5 42

valproate sodium 4 36

valproic acid 2 36

valsartan/hydrochlorothiazide 2 45

VANCOMYCIN HCL CAPS 125MG

5 QL(40/10) 34


5 QL(80/10) 34

VANCOMYCIN HCL INJ 5000MG, 750MG

5 34

vancomycin hcl inj 1000mg, 10gm, 500mg

4 34

VANCOMYCIN HCL IN DEXTROSE

4 34

VAQTA 4 53

VARIVAX 4 53

VASERETIC 4 46

VASOTEC TABS 10MG, 2.5MG, 20MG

4 46

VECTIBIX INJ 100MG/5ML 3 B/D PA 40

VECTICAL 3 48

VELCADE 5 B/D PA 40

velivet 2 52

venlafaxine hcl 2 QL(120/30) 37

venlafaxine hcl er cp24 150mg, 37.5mg

2 QL(30/30) 37

venlafaxine hcl er cp24 75mg 2 QL(90/30) 37

venlafaxine hcl er tb24 150mg, 37.5mg

2 QL(30/30) 37

venlafaxine hcl er tb24 75mg 2 QL(90/30) 37

VENTOLIN HFA 4 QL(36/30) 55

verapamil hcl inj 4 46

verapamil hcl tabs 120mg, 80mg

1 46

verapamil hcl tabs 40mg 2 46

verapamil hcl er 2 46

VERSACLOZ 5 42

VESICARE 3 QL(30/30) 49

vicodin 2 QL(390/30) 33

vicodin es 2 QL(390/30) 33

vicodin hp 2 QL(390/30) 33

VICTRELIS 5 PA QL(360/30) 42



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VIDEX PEDIATRIC 3 42

VIGAMOX 3 35

VIIBRYD 4 QL(30/30) ST 37

VIMPAT INJ 4 QL(1200/30) ST 36

VIMPAT ORAL SOLN 3 QL(1200/30) ST 36

VIMPAT TABS 3 QL(60/30) ST 36

vinblastine sulfate inj 1mg/ml 4 B/D PA 40

vincasar pfs 4 B/D PA 40

vincristine sulfate 4 B/D PA 40

vinorelbine tartrate 4 B/D PA 40

viorele 2 52

VIRACEPT 5 43

VIRAMUNE XR TB24 100MG 3 42

VIRAZOLE 5 B/D PA 42

VIREAD 5 42

VIVELLE-DOT 3 PA QL(8/28) 52

VOLTAREN 3 QL(1000/30) ST 48

VORAXAZE 5 54

voriconazole inj 4 PA 38

voriconazole susr 5 PA 38

voriconazole tabs 5 PA 38

VOTRIENT 5 PA QL(120/30) 40

VPRIV 5 PA 49

vyfemla 2 52

W

warfarin sodium 1 44

WELCHOL 4 47

wera 2 52

X

XALKORI 5 PA QL(60/30) 40

XARELTO TABS 10MG, 20MG

3 PA QL(30/30) 44

XARELTO TABS 15MG 3 PA QL(60/30) 44

XENAZINE TABS 12.5MG 5 PA QL(90/30) 48

XENAZINE TABS 25MG 5 PA QL(120/30) 48

XGEVA 5 PA 54

XIFAXAN TABS 550MG 5 PA QL(60/30) 34

XIFAXAN TABS 200MG 4 PA QL(9/30) 34

XOLAIR 5 PA 56

XOLEGEL 3 38

XTANDI 5 PA QL(120/30) 39

XYREM 5 PA QL(540/30) 56

Y

YERVOY 5 B/D PA 40

yf-vax 4 53

Z

zafirlukast 2 55

zaleplon 2 QL(90/365) 56

ZALTRAP 5 PA 39

ZANOSAR 4 B/D PA 39

ZAVESCA 5 49

zazole supp 2 38

ZELBORAF 5 PA QL(240/30) 40

ZEMAIRA 5 B/D PA 56

zenatane 2 48

zenchent 2 52

ZENPEP 3 49

ZESTORETIC 4 46

ZESTRIL 4 46

ZETIA 3 QL(30/30) 47

ZIAGEN ORAL SOLN 3 42

zidovudine 2 42

ZINECARD INJ 250MG 4 B/D PA 40

ziprasidone hcl 2 QL(60/30) 42

ZIRGAN 3 ST 42

ZMAX 4 QL(60/30) 35

zoledronic acid inj 4mg/5ml 5 B/D PA 54

zoledronic acid inj 5mg/100ml 4 B/D PA 54

ZOLINZA 5 QL(120/30) 40

zolpidem tartrate 2 PA QL(90/365) 56

ZOMETA INJ 4MG/100ML 5 B/D PA 54

ZONALON 3 48

zonisamide 2 36

ZORTRESS TABS 0.25MG 4 B/D PA 53

ZORTRESS TABS 0.5MG, 0.75MG

5 B/D PA 53

ZOSTAVAX 4 53

ZOSYN INJ 5% 2GM/50ML 0.25GM/50ML, 5% 3GM/50ML 0.375GM/50ML

4 35

zovia 1/35e 2 52

zovia 1/50e 2 52

ZYCLARA 5 48

ZYKADIA 5 PA 40

Drug Name Drug Tier


Reqs./Limits Page





31

ZYLET 3 ST 33

ZYPREXA RELPREVV 5 42

ZYTIGA 5 PA QL(120/30) 39

ZYVOX 5 PA 34

Drug Name Drug Tier

Reqs/Limits

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Reqs/Limits

Drug Name Drug Tier

Reqs/Limits





32

ANALGESICS

ANALGESICS

butal/asa/caff 2 PA QL(180/30)

butalbital/acetaminophen/caffeine

2 PA QL(180/30)

margesic 2 PA QL(180/30)

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

diclofenac potassium

2

diclofenac sodium dr tbec 25mg, 50mg

2

diclofenac sodium dr tbec 75mg

1

diclofenac sodium er

2

diflunisal 2 etodolac 2 etodolac er 2 fenoprofen calcium 2 flurbiprofen 2 ibuprofen susp 1 ibuprofen tabs 400mg, 600mg, 800mg

1

ketoprofen 2 ketoprofen er 2 meclofenamate sodium

2

meloxicam tabs 1 nabumetone 2 naproxen dr 2 naproxen sodium tabs 275mg, 550mg

2

naproxen susp 2 naproxen tabs 250mg

2

naproxen tabs 375mg, 500mg

1

oxaprozin 2 oxycodone/ibuprofen

2 QL(150/30)

piroxicam 2 sulindac 2 tolmetin sodium 2

OPIOID ANALGESICS, LONG-ACTING

fentanyl 2 QL(15/30) infumorph 200 4 infumorph 500 4 levorphanol tartrate 2 QL(180/30) methadone hcl conc 2 QL(500/30) methadone hcl inj 4 methadone hcl oral soln 10mg/5ml

2 QL(2000/30)


2 QL(4000/30)

methadone hcl tabs 2 QL(360/30) methadose tabs 2 QL(360/30) morphine sulfate er tbcr

2 QL(90/30)

OXYCONTIN 4 PA QL(60/30)

oxymorphone hydrochloride er

2 QL(60/30)

tramadol hcl er tb24 2 QL(30/30)

OPIOID ANALGESICS, SHORT-ACTING

acetaminophen/codeine #2

2 QL(360/30)


2 QL(360/30)


2 QL(240/30)

acetaminophen/codeine oral soln

2 QL(5000/30)

acetaminophen/codeine tabs 300mg; 60mg

2 QL(240/30)

acetaminophen/codeine tabs 300mg; 15mg

2 QL(360/30)

ascomp/codeine 2 PA QL(180/30)

butalbital/aspirin/caffeine/codeine

2 PA QL(180/30)

butorphanol tartrate inj

4

butorphanol tartrate nasal soln

2 QL(6/30)

duramorph 4

endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg

2 QL(360/30)

fentanyl citrate 4 B/D PA FENTANYL CITRATE ORAL TRANSMUCOSAL

5 PA QL(120/30)

hydrocodone bitartrate/acetaminophen oral soln

2 QL(5400/30)

hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg

2 QL(360/30)

hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg

2 QL(390/30)

hydrocodone/acetaminophen tabs

2 QL(360/30)

hydrocodone/ibuprofen tabs 7.5mg; 200mg

2 QL(150/30)

HYDROMORPHONE HCL INJ 1MG/ML, 2MG/ML

4

hydromorphone hcl inj 2mg/ml, 500mg/50ml

4

hydromorphone hcl liqd

2 QL(1200/30)

hydromorphone hcl tabs

2 QL(240/30)

LAZANDA 5 PA QL(44/28)

lorcet 2 QL(360/30) lorcet hd 2 QL(360/30) lorcet plus 2 QL(360/30) lortab tabs 2 QL(360/30) morphine sulfate inj 0.5mg/ml, 10mg/ml, 1mg/ml, 5mg/ml

4

morphine sulfate oral soln 20mg/ml

2 QL(540/30)


2 QL(2700/30)



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2 QL(5400/30)

MORPHINE SULFATE TABS

3 QL(360/30)

nalbuphine hcl 4 oxycodone hcl caps 2 QL(240/30) oxycodone hcl conc 2 QL(360/30) oxycodone hcl oral soln

2 QL(1200/30)

oxycodone hcl tabs 2 QL(240/30) oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg

2 QL(360/30)

oxycodone/aspirin 2 QL(360/30) roxicet tabs 2 QL(360/30) tramadol hcl 2 QL(240/30) tramadol hydrochloride/acetaminophen

2 QL(240/30)

vicodin 2 QL(390/30) vicodin es 2 QL(390/30) vicodin hp 2 QL(390/30)

ANESTHETICS

LOCAL ANESTHETICS

lidocaine hcl external soln

2

lidocaine hcl gel 2 lidocaine hcl inj 0.5%, 1%, 2%

4

lidocaine hcl jelly 2 lidocaine oint 2 lidocaine ptch 2 PA

QL(90/30) lidocaine viscous 1 lidocaine/prilocaine crea

2

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium dr

2 PA

disulfiram 2

OPIOID DEPENDENCE TREATMENTS

buprenorphine hcl inj

4 PA

buprenorphine hcl subl

2 PA QL(24/30)

buprenorphine hcl/naloxone hcl

2 PA QL(90/30)

naltrexone hcl 2 PA SUBOXONE 3 PA

QL(90/30)

OPIOID REVERSAL AGENTS

naloxone hcl 2

SMOKING CESSATION AGENTS

buproban 2 QL(60/30) bupropion hcl sr tb12 150mg

2 QL(60/30)

CHANTIX 3 PA QL(336/365)

CHANTIX CONTINUING MONTH PAK

3 PA QL(336/365)

CHANTIX STARTING MONTH PAK

3 PA QL(106/365)

NICOTROL INHALER

3 PA QL(504/30)

NICOTROL NS 3 PA QL(40/30)

ANTIBACTERIALS

AMINOGLYCOSIDES

amikacin sulfate inj 500mg/2ml

4

gentak 2 gentamicin sulfate crea

2

gentamicin sulfate inj

4

gentamicin sulfate oint

2

gentamicin sulfate ophthalmic soln

4

gentamicin sulfate pediatric

4

gentamicin sulfate/0.9% sodium chloride

4

gentamicin sulfate/sodium chloride

4

isotonic gentamicin inj 0.8mg/ml; 0.9%, 1.2mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9%

4

neomycin sulfate 2 neomycin/polymyxin b sulfates

4

paromomycin sulfate

2

streptomycin sulfate 4 tobramycin sulfate inj 10mg/ml, 80mg/2ml

4

tobramycin sulfate inj 1.2gm

4 B/D PA

tobramycin sulfate ophthalmic soln

2

TOBREX OINT 3 ZYLET 3 ST

ANTIBACTERIALS, OTHER

ak-poly-bac 2 alcohol preps pads 1 baciim 4 BACITRACIN INJ 4 bacitracin ophthalmic oint

2

bacitracin/polymyxin b

2

BACTROBAN NASAL

3

chloramphenicol sodium succinate

1

clindamax 2 clindamycin hcl 2 clindamycin phosphate add-vantage

4

clindamycin phosphate crea

2

CLINDAMYCIN PHOSPHATE IN D5W

4

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits

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34

clindamycin phosphate inj 150mg/ml

4

colistimethate sodium

4

CUBICIN 5 B/D PA lansoprazole/amoxicillin/clarithromycin

2

LINCOCIN 4 methenamine hippurate

2

metronidazole crea 2 metronidazole gel 2 metronidazole in nacl 0.79%

4

metronidazole lotn 2 metronidazole tabs 1 metronidazole vaginal

2

mupirocin 2 mupirocin calcium 2 neomycin/bacitracin/polymyxin

2

neomycin/polymyxin/bacitracin/hydrocortisone

2

neomycin/polymyxin/gramicidin

2


2

nitrofurantoin 2 QL(900/365) nitrofurantoin macrocrystals

2 QL(90/365)

nitrofurantoin monohydrate

2 QL(90/365)

NORITATE 3 polycin b 2 polymyxin b sulfate 4 polymyxin b sulfate/trimethoprim sulfate

2

PRIMSOL 3 rosadan gel 2 SILVER SULFADIAZINE

3

SSD 3 SYNERCID 4 THERMAZENE 3

trimethoprim 2 TYGACIL 5 VANCOMYCIN HCL CAPS 125MG

5 QL(40/10)


5 QL(80/10)

VANCOMYCIN HCL IN DEXTROSE

4

VANCOMYCIN HCL INJ 5000MG, 750MG

5

vancomycin hcl inj 1000mg, 10gm, 500mg

4

XIFAXAN TABS 550MG

5 PA QL(60/30)

XIFAXAN TABS 200MG

4 PA QL(9/30)

ZYVOX 5 PA

BETA-LACTAM, CEPHALOSPORINS

cefaclor caps 2 cefaclor er 2 cefadroxil 2 cefazolin sodium inj 10gm, 1gm, 1gm; 5%, 500mg

4

cefazolin sodium/dextrose inj 2gm; 3%

4

cefdinir 2 cefepime inj 1gm, 1gm/50ml; 5%, 2gm, 2gm/100ml, 2gm/50ml; 5%

4

cefotaxime sodium 4 cefoxitin sodium inj 10gm, 1gm, 2gm

4

cefpodoxime proxetil

2

cefprozil 2 ceftazidime inj 1gm, 2gm, 6gm

4

ceftazidime/dextrose

4

ceftriaxone in iso-osmotic dextrose

4

ceftriaxone sodium 4

cefuroxime axetil 2 cefuroxime sodium inj 1.5gm, 7.5gm, 750mg

4

cephalexin caps 250mg, 500mg

1

cephalexin susr 2 cephalexin tabs 2 SUPRAX SUSR 3 SUPRAX TABS 3 TAZICEF INJ 1GM/50ML; 4.4%

4

tazicef inj 1gm, 2gm, 6gm

4

TEFLARO 4

BETA-LACTAM, OTHER

AZACTAM IN ISO-OSMOTIC DEXTROSE

4

aztreonam 4 cefotetan 4 imipenem/cilastatin 2 INVANZ 4 meropenem 2

BETA-LACTAM, PENICILLINS

amoxicillin caps 1 amoxicillin chew 2 amoxicillin susr 1 amoxicillin tabs 2 amoxicillin/clavulanate potassium

2

amoxicillin/clavulanate potassium er

2

ampicillin 2 ampicillin sodium 4 ampicillin-sulbactam inj 10gm; 5gm, 2gm; 1gm

4

AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML

3

BICILLIN L-A 4 dicloxacillin sodium 2 nafcillin sodium 4 oxacillin sodium inj 10gm, 2gm

4



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penicillin g potassium inj 20000000unit, 5mu

4

penicillin v potassium oral soln

1


1


2

PFIZERPEN-G INJ 5MU

4

piperacillin sodium/ tazobactam sodium

4

piperacillin sodium/tazobactam sodium

4

PIPERACILLIN/TAZOBACTAM

4

TIMENTIN 4 ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML

4

MACROLIDES

AZASITE 3 azithromycin inj 500mg

4

AZITHROMYCIN PACK

3 QL(3/30)

azithromycin susr 200mg/5ml

2 QL(75/30)

azithromycin susr 100mg/5ml

2 QL(150/30)

azithromycin tabs 2 QL(12/28) clarithromycin 2 clarithromycin er 2 QL(60/30) e.e.s. 400 2 E.E.S. GRANULES 3 e.s.p. 2 ery 2 ERY-TAB 3 ERYPED 200 3 ERYPED 400 3

ERYTHROCIN LACTOBIONATE

4

erythrocin stearate 2 erythromycin base 2 erythromycin ethylsuccinate

2

erythromycin external soln

2

erythromycin gel 2 erythromycin oint 2 erythromycin pads 2 ilotycin 2 KETEK 3 QL(20/30) romycin 2 ZMAX 4 QL(60/30)

QUINOLONES

AVELOX INJ 4 CILOXAN OINT 3 CIPRO HC 3 CIPRODEX 3 ciprofloxacin er 2 ciprofloxacin hcl ophthalmic soln

2


2


1

ciprofloxacin i.v.-in d5w

4

ciprofloxacin inj 400mg/40ml

4

ciprofloxacin susr 2 levofloxacin in d5w 4 levofloxacin inj 4 levofloxacin oral soln

2

levofloxacin tabs 2 MOXEZA 3 moxifloxacin hcl 2 ofloxacin 2 VIGAMOX 3

SULFONAMIDES

BLEPHAMIDE 3 blephamide s.o.p. 2

sodium sulfacetamide ophthalmic soln

2

sulfacetamide sodium ophthalmic soln

2

sulfacetamide sodium/prednisolone sodium phosphate

2

sulfadiazine 2 sulfamethoxazole/trimethoprim ds

1

sulfamethoxazole/trimethoprim inj

4

sulfamethoxazole/trimethoprim susp

1

sulfamethoxazole/trimethoprim tabs

1

TETRACYCLINES

demeclocycline hcl 2 doxycycline caps 75mg

2

doxycycline hyclate caps

1

doxycycline hyclate inj

4


1


2

doxycycline monohydrate

2

doxycycline susr 2 minocycline hcl 2 morgidox 1x100mg caps

1

morgidox 2x100mg caps

1

tetracycline hcl 1

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

APTIOM TABS 200MG, 400MG, 800MG

4 QL(30/30) ST

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36

APTIOM TABS 600MG

4 QL(60/30) ST

FYCOMPA 4 ST levetiracetam er 2 levetiracetam inj 4 levetiracetam oral soln

2

levetiracetam tabs 2 phenobarbital 2 POTIGA 3 PA

QL(90/30)

CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN 3 ethosuximide 2 LYRICA CAPS 225MG, 25MG, 300MG

3 QL(60/30)

LYRICA CAPS 100MG, 150MG, 200MG, 50MG, 75MG

3 QL(90/30)

LYRICA ORAL SOLN

3 QL(900/30)

zonisamide 2

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg

2 QL(90/30)

clonazepam odt tbdp 2mg

2 QL(300/30)

clonazepam tabs 0.5mg, 1mg

2 QL(90/30)

clonazepam tabs 2mg

2 QL(300/30)

DIAZEPAM GEL 3 divalproex sodium 2 divalproex sodium dr

2

divalproex sodium er

2

gabapentin 2 GABITRIL TABS 16MG

3 QL(90/30) ST

GABITRIL TABS 12MG

3 QL(120/30) ST

ONFI SUSP 3 QL(480/30) ONFI TABS 10MG 3 QL(60/30) ONFI TABS 20MG 3 QL(120/30) primidone 2 SABRIL PACK 5 PA

QL(200/30) SABRIL TABS 5 PA

QL(180/30) tiagabine hydrochloride tabs 2mg

2 QL(240/30) ST


2 QL(420/30) ST

valproate sodium 4 valproic acid 2

GLUTAMATE REDUCING AGENTS

felbamate 2 lamotrigine 2 lamotrigine er 2 topiragen 2 topiramate 2

SODIUM CHANNEL AGENTS

BANZEL SUSP 5 PA BANZEL TABS 400MG

5 PA

BANZEL TABS 200MG

4 PA

carbamazepine 2 carbamazepine er 2 dilantin caps 30mg 2 DILANTIN CAPS 100MG

4

DILANTIN INFATABS

4

epitol 2 fosphenytoin sodium

4

oxcarbazepine 2 PEGANONE 3 phenytoin 2 phenytoin infatabs 2 phenytoin sodium 4 phenytoin sodium extended

2

TEGRETOL TABS 4

TEGRETOL-XR TB12 200MG, 400MG

4

TEGRETOL-XR TB12 100MG

3

VIMPAT INJ 4 QL(1200/30) ST

VIMPAT ORAL SOLN

3 QL(1200/30) ST

VIMPAT TABS 3 QL(60/30) ST

ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHER

ergoloid mesylates 2 PA

CHOLINESTERASE INHIBITORS

donepezil hcl tabs 23mg, 5mg

2 QL(30/30)

donepezil hcl tabs 10mg

2 QL(60/30)

donepezil hcl tbdp 5mg

2 QL(30/30)

donepezil hcl tbdp 10mg

2 QL(60/30)

EXELON PT24 3 QL(30/30) galantamine 2 QL(60/30) galantamine hydrobromide cp24

2 QL(30/30)

galantamine hydrobromide oral soln

2 QL(200/30)

galantamine hydrobromide tabs

2 QL(60/30)

rivastigmine tartrate 2 QL(60/30)

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

NAMENDA ORAL SOLN

3 QL(300/30)

NAMENDA XR 3 QL(30/30) NAMENDA XR TITRATION PACK

3 QL(28/28)

ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

BRINTELLIX 4 QL(30/30) ST

bupropion hcl 2 bupropion hcl er tb12 100mg, 200mg

2 QL(60/30)



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bupropion hcl er tb12 150mg

2 QL(90/30)

bupropion hcl sr tb12 100mg, 200mg

2 QL(60/30)

bupropion hcl sr tb12 150mg

2 QL(90/30)

bupropion hcl xl tb24 300mg

2 QL(30/30)

bupropion hcl xl tb24 150mg

2 QL(90/30)

maprotiline hcl 2 mirtazapine 2 QL(30/30) mirtazapine odt 2 QL(30/30) nefazodone hcl 2 QL(60/30) trazodone hcl tabs 300mg

2

trazodone hcl tabs 100mg, 150mg, 50mg

1

MONOAMINE OXIDASE INHIBITORS

EMSAM 3 MARPLAN 4 phenelzine sulfate 2 tranylcypromine sulfate

2

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE

INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE

INHIBITOR

citalopram hydrobromide oral soln

1 QL(600/30)

citalopram hydrobromide tabs 40mg

1 QL(30/30)

citalopram hydrobromide tabs 10mg, 20mg

1 QL(60/30)

duloxetine hcl cpep 20mg, 60mg

2 QL(60/30)

duloxetine hcl cpep 30mg

2 QL(90/30)

escitalopram oxalate oral soln

2 QL(600/30)

escitalopram oxalate tabs

2 QL(60/30)

FETZIMA 4 QL(30/30) ST

FETZIMA TITRATION PACK

4 QL(28/28) ST

fluoxetine dr 2 fluoxetine hcl caps 2 fluoxetine hcl oral soln

2

fluoxetine hcl tabs 10mg, 20mg

2

fluvoxamine maleate

2


2 QL(60/30)


2 QL(90/30)

olanzapine/fluoxetine

2 QL(30/30)

paroxetine hcl er tb24 12.5mg

2 QL(30/30)

paroxetine hcl er tb24 37.5mg

2 QL(60/30)

paroxetine hcl er tb24 25mg

2 QL(90/30)

paroxetine hcl tabs 30mg, 40mg

2 QL(60/30)

paroxetine hcl tabs 10mg

1 QL(30/30)

paroxetine hcl tabs 20mg

1 QL(60/30)

PAXIL SUSP 3 QL(900/30) PRISTIQ 4 QL(30/30)

ST sertraline hcl conc 2 QL(300/30) sertraline hcl tabs 25mg

2 QL(30/30)

sertraline hcl tabs 100mg

2 QL(60/30)

sertraline hcl tabs 50mg

2 QL(90/30)

venlafaxine hcl 2 QL(120/30)

venlafaxine hcl er cp24 150mg, 37.5mg

2 QL(30/30)

venlafaxine hcl er cp24 75mg

2 QL(90/30)

venlafaxine hcl er tb24 150mg, 37.5mg

2 QL(30/30)

venlafaxine hcl er tb24 75mg

2 QL(90/30)

VIIBRYD 4 QL(30/30) ST

TRICYCLICS

amitriptyline hcl tabs 150mg

2 PA

amitriptyline hcl tabs 100mg, 10mg, 25mg, 50mg, 75mg

1 PA

amoxapine 2 clomipramine hcl 2 PA desipramine hcl 2 doxepin hcl 2 PA imipramine hcl 2 PA imipramine pamoate

2 PA

nortriptyline hcl caps

1

nortriptyline hcl oral soln

2

perphenazine/amitriptyline

2 PA

protriptyline hcl 2 SURMONTIL 4 PA

ANTIEMETICS

ANTIEMETICS, OTHER

meclizine hcl tabs 2 phenadoz 2 PA promethazine hcl plain

2 PA

promethazine hcl supp 12.5mg, 25mg

2 PA

promethegan 2 PA TRANSDERM-SCOP

3 QL(12/36)

EMETOGENIC THERAPY ADJUNCTS

Drug Name Drug Tier

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Drug Name Drug Tier

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Drug Name Drug Tier

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38

dronabinol 2 PA QL(90/30)

EMEND CAPS 40MG

3 B/D PA QL(2/30)

EMEND CAPS 125MG

3 B/D PA QL(4/30)

EMEND CAPS 80MG

3 B/D PA QL(8/30)

EMEND CAPS 3 B/D PA QL(12/30)

granisetron hcl inj 0.1mg/ml, 1mg/ml

4 B/D PA

granisetron hcl tabs 2 B/D PA QL(60/30)

ondansetron hcl inj 4mg/2ml

4

ondansetron hcl oral soln

2 B/D PA

ondansetron hcl tabs 24mg

2 B/D PA QL(5/30)

ondansetron hcl tabs 4mg, 8mg

2 B/D PA QL(90/30)

ondansetron odt 2 B/D PA QL(90/30)

ANTIFUNGALS

ANTIFUNGALS

ABELCET 5 PA AMBISOME 4 PA AMPHOTEC INJ 50MG

4 PA

amphotericin b 4 PA CANCIDAS 5 PA ciclopirox nail lacquer

2

ciclopirox olamine 2 ciclopirox sham 2 ciclopirox susp 2 clotrimazole external crea

2

clotrimazole external soln

2

clotrimazole troc 2 econazole nitrate 2 fluconazole in dextrose

4

fluconazole in nacl 4 fluconazole susr 2

fluconazole tabs 100mg, 200mg, 50mg

2

fluconazole tabs 150mg

1 QL(8/30)

FLUCYTOSINE 5 griseofulvin microsize

2

griseofulvin ultramicrosize

2

itraconazole 2 PA QL(120/30)

ketoconazole 2 NAFTIN 3 NATACYN 3 NOXAFIL SUSP 5 PA

QL(600/30) NOXAFIL TBEC 5 PA

QL(93/30) nyamyc 2 nystatin crea 2 nystatin oint 2 nystatin powd 100000unit/gm

2

nystatin susp 2 nystatin tabs 2 nystatin/triamcinolone

2

nystop 2 pedi-dri 2 SPORANOX ORAL SOLN

3 PA

TERAZOL 3 CREA 4 TERAZOL 7 4 terbinafine hcl tabs 1 QL(180/365) terconazole 2 voriconazole inj 4 PA voriconazole susr 5 PA voriconazole tabs 5 PA XOLEGEL 3 zazole supp 2

ANTIGOUT AGENTS

ANTIGOUT AGENTS

allopurinol 1 COLCRYS 3 probenecid 2 probenecid/colchicine

2

ULORIC 3 ST

ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS

cafergot 2 dihydroergotamine mesylate inj

2

migergot 2

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

naratriptan hcl 2 QL(9/30) rizatriptan benzoate 2 QL(12/30) rizatriptan benzoate odt

2 QL(12/30)

SUMATRIPTAN 3 QL(12/30) sumatriptan succinate inj 4mg/0.5ml

2 QL(4/30)

sumatriptan succinate inj 4mg/0.5ml, 6mg/0.5ml

2 QL(8/30)


2 QL(4/30)


2 QL(8/30)

sumatriptan succinate tabs

2 QL(9/30)

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

GUANIDINE HCL 3 MESTINON TIMESPAN

3

pyridostigmine bromide

2

regonol 4

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone 2 rifabutin 2

ANTITUBERCULARS

CAPASTAT SULFATE

4

cycloserine 2 ethambutol hcl 2 isoniazid inj 4



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isoniazid syrp 2 isoniazid tabs 100mg

2

isoniazid tabs 300mg

1

PASER 3 PRIFTIN 3 pyrazinamide 2 rifampin caps 2 rifampin inj 4 RIFATER 3 SIRTURO 4 PA TRECATOR 3

ANTINEOPLASTICS

ALKYLATING AGENTS

BICNU 4 B/D PA BUSULFEX 5 B/D PA CYCLOPHOSPHAMIDE CAPS

3 B/D PA

cyclophosphamide inj

4 B/D PA

cyclophosphamide tabs

2 B/D PA

dacarbazine 4 B/D PA HEXALEN 5 ifosfamide inj 1gm, 3gm

4 B/D PA

ifosfamide/mesna 5 B/D PA LEUKERAN 3 LOMUSTINE 3 MATULANE 5 melphalan hydrochloride

5 B/D PA

MUSTARGEN 4 B/D PA TEMODAR INJ 5 B/D PA TREANDA 5 B/D PA VALCHLOR 5 PA ZANOSAR 4 B/D PA

ANTIANDROGENS

bicalutamide 2 flutamide 2 NILANDRON 5 XTANDI 5 PA

QL(120/30) ZYTIGA 5 PA

QL(120/30)

ANTIANGIOGENIC AGENTS

CAPRELSA 5 PA REVLIMID 5 PA

QL(28/28) THALOMID CAPS 150MG, 200MG, 50MG

5 PA QL(60/30)

THALOMID CAPS 100MG

5 PA QL(90/30)

ANTIESTROGENS/MODIFIERS

EMCYT 3 FARESTON 5 FASLODEX 5 B/D PA SOLTAMOX 3 tamoxifen citrate 2

ANTIMETABOLITES

adrucil inj 2.5gm/50ml

4 B/D PA

cladribine 4 B/D PA CLOLAR 4 B/D PA cytarabine 4 B/D PA cytarabine aqueous 4 B/D PA DROXIA 3 ELITEK 5 B/D PA fluorouracil inj 2.5gm/50ml

4 B/D PA

FOLOTYN 5 B/D PA gemcitabine 4 B/D PA gemcitabine hcl 5 B/D PA hydroxyurea 2 mercaptopurine 2 TABLOID 3

ANTINEOPLASTICS

KYPROLIS 5 PA QL(6/28) ZALTRAP 5 PA

ANTINEOPLASTICS, OTHER

ABRAXANE 5 B/D PA adriamycin 2 B/D PA ALIMTA INJ 500MG 5 B/D PA amifostine 5 B/D PA ARRANON 4 AZACITIDINE 5 B/D PA bleomycin sulfate 4 B/D PA calcium folinate 4 carboplatin 4 B/D PA

cisplatin inj 100mg/100ml

4 B/D PA

COMETRIQ 5 PA COSMEGEN 5 B/D PA daunorubicin hcl 4 B/D PA DAUNOXOME 5 B/D PA decitabine 5 dexrazoxane inj 250mg

4 B/D PA

DOCEFREZ 5 B/D PA docetaxel inj 140mg/7ml, 20mg/ml, 80mg/4ml, 80mg/8ml

5 B/D PA

doxorubicin hcl inj 2mg/ml

2 B/D PA

DOXORUBICIN HCL LIPOSOME

5 B/D PA

ELLENCE INJ 200MG/100ML

4 B/D PA

epirubicin hcl inj 50mg/25ml

4 B/D PA

epirubicin hcl inj 200mg/100ml

5 B/D PA

ERIVEDGE 5 PA QL(30/30)

ERWINAZE 5 B/D PA fludarabine phosphate

4 B/D PA

FUSILEV 5 HALAVEN 5 PA ICLUSIG 5 PA idarubicin hcl inj 10mg/10ml

5 B/D PA

irinotecan inj 100mg/5ml

4 B/D PA

ISTODAX 5 PA IXEMPRA KIT 5 B/D PA JAKAFI 5 PA

QL(60/30) JEVTANA 5 B/D PA leucovorin calcium inj 100mg, 350mg, 500mg, 50mg

4

leucovorin calcium tabs

2

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits





40

LIPODOX 5 B/D PA LIPODOX 50 5 B/D PA MEKINIST 5 PA MENEST 3 PA mesna 2 B/D PA MESNEX TABS 5 mitomycin 4 B/D PA MITOXANTRONE HCL

3 B/D PA

ONCASPAR 5 B/D PA oxaliplatin inj 100mg/20ml

5 B/D PA

paclitaxel inj 300mg/50ml

4 B/D PA

PICATO 4 ST POMALYST 5 PA

QL(21/28) PROLEUKIN 5 B/D PA SYLATRON 5 PA SYNRIBO 5 PA TAXOTERE 5 B/D PA TRISENOX 4 B/D PA VELCADE 5 B/D PA vinblastine sulfate inj 1mg/ml

4 B/D PA

vincasar pfs 4 B/D PA vincristine sulfate 4 B/D PA vinorelbine tartrate 4 B/D PA ZINECARD INJ 250MG

4 B/D PA

ZOLINZA 5 QL(120/30)

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole 2 QL(30/30) exemestane 2 letrozole 2 QL(30/30)

ENZYME INHIBITORS

ETOPOPHOS 4 B/D PA ETOPOSIDE INJ 3 B/D PA TOPOSAR 3 B/D PA topotecan hcl inj 4mg

5

MOLECULAR TARGET INHIBITORS

AFINITOR 5 PA QL(30/30)

AFINITOR DISPERZ

5 PA QL(60/30)

BOSULIF 5 PA GILOTRIF 5 PA

QL(30/30) GLEEVEC 5 PA

QL(60/30) IMBRUVICA 5 PA

QL(120/30) INLYTA TABS 5MG 5 PA

QL(120/30) INLYTA TABS 1MG 5 PA

QL(240/30) NEXAVAR 5 PA SPRYCEL 5 PA STIVARGA 5 PA

QL(84/21) SUTENT CAPS 12.5MG, 25MG, 50MG

5 PA

TAFINLAR 5 PA TARCEVA 5 PA TASIGNA 5 PA TYKERB 5 PA VOTRIENT 5 PA

QL(120/30) XALKORI 5 PA

QL(60/30) ZELBORAF 5 PA

QL(240/30) ZYKADIA 5 PA

MONOCLONAL ANTIBODIES

ARZERRA 5 B/D PA AVASTIN INJ 100MG/4ML

5 B/D PA

ERBITUX 5 B/D PA GAZYVA 5 PA HERCEPTIN 5 B/D PA KADCYLA 5 PA PERJETA 5 PA RITUXAN 5 PA VECTIBIX INJ 100MG/5ML

3 B/D PA

YERVOY 5 B/D PA

RETINOIDS

PANRETIN 5 TARGRETIN 5 TRETINOIN CAPS 5

ANTIPARASITICS

ANTHELMINTICS

ALBENZA 3 STROMECTOL 3

ANTIPROTOZOALS

ALINIA 3 ATOVAQUONE 5 atovaquone/proguanil hcl

2

chloroquine phosphate

2

COARTEM 3 DARAPRIM 3 hydroxychloroquine sulfate

2

mefloquine hcl 2 NEBUPENT 3 B/D PA NEUTREXIN 5 PENTAM 300 3 PRIMAQUINE PHOSPHATE

3

quinine sulfate 1

PEDICULICIDES/SCABICIDES

acticin 2 lindane 2 malathion 2 permethrin crea 2

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mesylate inj

4 PA

benztropine mesylate tabs 2mg

1 PA

benztropine mesylate tabs 0.5mg, 1mg

2 PA

trihexyphenidyl hcl elix

2 PA

trihexyphenidyl hcl tabs 5mg

2 PA

trihexyphenidyl hcl tabs 2mg

1 PA

ANTIPARKINSON AGENTS, OTHER

entacapone 2 TASMAR 5

DOPAMINE AGONISTS

APOKYN 5 PA QL(60/30)



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bromocriptine mesylate

2

NEUPRO 4 PA QL(30/30)

pramipexole dihydrochloride

2 QL(90/30)

ropinirole hcl 2

DOPAMINE PRECURSORS/L- AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa 2 carbidopa/levodopa 2 carbidopa/levodopa er

2

carbidopa/levodopa odt

2

CARBIDOPA/LEVODOPA/ENTACAPONE

3

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

AZILECT 3 selegiline hcl 2

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

chlorpromazine hcl inj

4

chlorpromazine hcl tabs

2

compazine supp 2 compro 2 fluphenazine decanoate

4

fluphenazine hcl conc

2

fluphenazine hcl elix

2

fluphenazine hcl inj 4 fluphenazine hcl tabs 1mg

1

fluphenazine hcl tabs 10mg, 2.5mg, 5mg

2

haloperidol conc 2 haloperidol decanoate

4

haloperidol lactate 4

haloperidol tabs 0.5mg, 1mg, 2mg, 5mg

1

haloperidol tabs 10mg, 20mg

2

loxapine 2 loxapine succinate 2 ORAP 3 perphenazine 2 prochlorperazine 2 prochlorperazine edisylate

4


1


2

thioridazine hcl 2 PA thiothixene caps 10mg, 1mg, 5mg

2

thiothixene caps 2mg

1

trifluoperazine hcl 2

2ND GENERATION/ATYPICAL

ABILIFY DISCMELT

5 QL(60/30) ST

ABILIFY INJ 4 ST ABILIFY MAINTENA INJ 300MG

5 QL(1.5/30)


5 QL(2/30)

ABILIFY ORAL SOLN

4 QL(900/30) ST

ABILIFY TABS 5 QL(30/30) ST

FANAPT TABS 10MG, 12MG, 6MG, 8MG

5 QL(60/30) ST

FANAPT TABS 1MG, 2MG, 4MG

4 QL(60/30) ST

FANAPT TITRATION PACK

4 QL(16/30) ST

GEODON INJ 4 QL(60/30) INVEGA SUSTENNA INJ 39MG/0.25ML

4 QL(0.25/28)


4 QL(0.5/28)


5 QL(0.75/28)

INVEGA SUSTENNA INJ 156MG/ML

5 QL(1/28)


5 QL(1.5/28)

INVEGA TB24 9MG 5 QL(30/30) ST

INVEGA TB24 1.5MG, 3MG

4 QL(30/30) ST

INVEGA TB24 6MG 4 QL(60/30) ST

LATUDA TABS 120MG, 20MG, 40MG, 60MG

4 QL(30/30) ST

LATUDA TABS 80MG

4 QL(60/30) ST

olanzapine inj 4 olanzapine odt 2 QL(30/30) olanzapine tabs 2 QL(30/30) quetiapine fumarate 2 QL(90/30) RISPERDAL CONSTA INJ 12.5MG, 25MG

4


5

risperidone m-tab tbdp 0.5mg, 1mg, 2mg, 3mg

2 QL(90/30)

risperidone m-tab tbdp 4mg

2 QL(120/30)

risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg

2 QL(90/30)

risperidone odt tbdp 4mg

2 QL(120/30)

risperidone oral soln

2 QL(360/30)

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits





42

risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg

2 QL(90/30)

risperidone tabs 4mg

2 QL(120/30)

SAPHRIS 3 QL(60/30) ST

ziprasidone hcl 2 QL(60/30) ZYPREXA RELPREVV

5

TREATMENT-RESISTANT

clozapine 2 CLOZAPINE ODT 3 FAZACLO 4 ST VERSACLOZ 5

ANTISPASTICITY AGENTS

ANTISPASTICITY AGENTS

baclofen tabs 10mg 1 baclofen tabs 20mg 2 dantrolene sodium 2 tizanidine hcl tabs 2

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

cidofovir 5 foscarnet sodium 4 ganciclovir 4 B/D PA VALCYTE 5 ZIRGAN 3 ST

ANTI-HEPATITIS B (HBV) AGENTS

ADEFOVIR DIPIVOXIL

5 QL(30/30)

BARACLUDE ORAL SOLN

3

BARACLUDE TABS

5

INTRON-A 5 INTRON-A W/DILUENT INJ 10MU, 18MU

5

TYZEKA 5 PA

ANTI-HEPATITIS C (HCV) AGENTS

INCIVEK 5 PA QL(180/30)


5 PA


5 PA

MODERIBA MISC 5 PA moderiba tabs 2 PA OLYSIO 5 PA

QL(30/30) PEG-INTRON 5 PA PEG-INTRON REDIPEN

5 PA

PEG-INTRON REDIPEN PAK 4

5 PA

REBETOL ORAL SOLN

4 PA

ribasphere caps 2 PA RIBASPHERE RIBAPAK

5 PA

RIBASPHERE TABS 600MG

5 PA

ribasphere tabs 200mg

2 PA

RIBASPHERE TABS 400MG

4 PA

RIBATAB 5 PA ribavirin 2 PA SOVALDI 5 PA

QL(30/30) VICTRELIS 5 PA

QL(360/30) VIRAZOLE 5 B/D PA

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

ISENTRESS CHEW 25MG

3 QL(360/30)

ISENTRESS CHEW 100MG

5 QL(180/30)

ISENTRESS PACK 3 ISENTRESS TABS 5 QL(60/30) TIVICAY 5 QL(60/30)

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE

TRANSCRIPTASE INHIBITORS (NNRTI)

COMPLERA 5 EDURANT 3 INTELENCE TABS 200MG

5 QL(60/30)

INTELENCE TABS 100MG

5 QL(120/30)

INTELENCE TABS 25MG

4 QL(180/30)

nevirapine er 2 NEVIRAPINE SUSP

3

nevirapine tabs 2 RESCRIPTOR 3 STRIBILD 5 SUSTIVA 3 VIRAMUNE XR TB24 100MG

3

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE

TRANSCRIPTASE INHIBITORS (NRTI)

abacavir 2 abacavir sulfate/lamivudine/zidovudine

5

didanosine 2 EMTRIVA 3 EPIVIR HBV ORAL SOLN

3

EPIVIR ORAL SOLN

3

EPZICOM 5 lamivudine 2 lamivudine/zidovudine

5

RETROVIR IV INFUSION

4

stavudine 2 TRUVADA 5 VIDEX PEDIATRIC 3 VIREAD 5 ZIAGEN ORAL SOLN

3

zidovudine 2

ANTI-HIV AGENTS, OTHER

ATRIPLA 5 FUZEON 5 QL(60/30) SELZENTRY TABS 150MG

5 QL(60/30)

SELZENTRY TABS 300MG

5 QL(120/30)

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS 5



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CRIXIVAN 3 INVIRASE 5 KALETRA ORAL SOLN

5

KALETRA TABS 200MG; 50MG

5

KALETRA TABS 100MG; 25MG

4

LEXIVA SUSP 4 LEXIVA TABS 5 NORVIR 3 PREZISTA SUSP 5 QL(400/30) PREZISTA TABS 800MG

5 QL(30/30)

PREZISTA TABS 600MG

5 QL(60/30)

PREZISTA TABS 150MG

4 QL(180/30)

PREZISTA TABS 75MG

4 QL(360/30)

REYATAZ 5 VIRACEPT 5

ANTI-INFLUENZA AGENTS

amantadine hcl 2 rimantadine hcl 2 TAMIFLU CAPS 75MG

3 QL(56/365)

TAMIFLU CAPS 45MG

3 QL(60/365)

TAMIFLU CAPS 30MG

3 QL(120/365)

TAMIFLU SUSR 3 QL(700/365)

ANTIHERPETIC AGENTS

acyclovir 2 acyclovir sodium inj 1000mg, 50mg/ml

4

DENAVIR 3 famciclovir 2 QL(21/7) trifluridine 2 valacyclovir hcl tabs 1000mg

2 QL(30/30)

valacyclovir hcl tabs 500mg

2 QL(60/30)

ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl tabs 10mg, 5mg

1

buspirone hcl tabs 15mg, 30mg, 7.5mg

2

BENZODIAZEPINES

alprazolam odt tbdp 0.25mg, 0.5mg

2 QL(90/30)

alprazolam odt tbdp 1mg

2 QL(120/30)

alprazolam odt tbdp 2mg

2 QL(150/30)

alprazolam tabs 0.25mg, 0.5mg

2 QL(90/30)

alprazolam tabs 1mg

2 QL(120/30)

alprazolam tabs 2mg

2 QL(150/30)

clorazepate dipotassium tabs 3.75mg, 7.5mg

2 QL(90/30)

clorazepate dipotassium tabs 15mg

2 QL(120/30)

diazepam oral soln 2 QL(1200/30) diazepam tabs 2 QL(120/30) lorazepam conc 2 QL(120/30) lorazepam inj 2mg/ml, 4mg/ml

4

lorazepam tabs 2 QL(120/30) oxazepam 2 QL(120/30) temazepam 2 QL(90/365)

BIPOLAR AGENTS

MOOD STABILIZERS

lithium carbonate caps 300mg

1

lithium carbonate caps 150mg, 600mg

2

lithium carbonate er 2 lithium carbonate tabs

2

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose 2 QL(90/30) BYDUREON 3 QL(2.6/28) BYETTA 3 QL(2.4/30)

glimepiride tabs 1mg, 2mg

1 QL(30/30)

glimepiride tabs 4mg

1 QL(60/30)

glipizide 1 glipizide er 1 glipizide/metformin hcl

1

glyburide/metformin hcl

2 PA

GLYSET 3 JANUMET 3 QL(60/30) JANUMET XR TB24 1000MG; 100MG

3 QL(30/30)

JANUMET XR TB24 1000MG; 50MG, 500MG; 50MG

3 QL(60/30)

JANUVIA 3 QL(30/30) JENTADUETO 3 QL(60/30) metformin hcl 1 metformin hcl er tb24 500mg, 750mg

1

nateglinide 2 QL(90/30) pioglitazone hcl 2 QL(30/30) pioglitazone hcl-glimepiride

2 QL(30/30)

pioglitazone hcl/metformin hcl

2 QL(90/30)

repaglinide 2 RIOMET 3 TRADJENTA 3 QL(30/30)

GLYCEMIC AGENTS

clinimix 4.25%/dextrose 20%

4 B/D PA


4 B/D PA


4 B/D PA

CLINIMIX E 4.25%/DEXTROSE 25%

3 B/D PA

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits





44

dextrose 10%/nacl 0.45%

4 B/D PA

dextrose 10% flex container

4 B/D PA


4 B/D PA

dextrose 2.5%/nacl 0.45%

4 B/D PA

dextrose 2.5%/sodium chloride 0.45%

4 B/D PA

dextrose 5% 4 B/D PA dextrose 5%/nacl 0.2%

4 B/D PA


4 B/D PA


4 B/D PA


4 B/D PA


4 B/D PA


4 B/D PA


4 B/D PA

GLUCAGEN HYPOKIT

4

kcl 0.075%/d5w/nacl 0.45%

4 B/D PA

kcl 0.15%/d5w/ nacl 0.3%

4 B/D PA

kcl 0.15%/d5w/lr 4 B/D PA kcl 0.15%/d5w/nacl 0.2%

4 B/D PA

kcl 0.15%/d5w/nacl 0.45%

4 B/D PA

kcl 0.15%/d5w/nacl 0.9%

4 B/D PA

kcl 0.3%/d5w/nacl 0.45%

4 B/D PA

normosol-r in d5w 4 B/D PA potassium chloride 0.15% d5w/nacl 0.33%

4 B/D PA


4 B/D PA


4 B/D PA

potassium chloride 0.224%/d5w/nacl 0.45%

4 B/D PA

PROGLYCEM 3

INSULINS

HUMALOG 3 HUMALOG KWIKPEN

3

HUMALOG MIX 50/50

3


3

HUMALOG MIX 75/25

3


3

HUMULIN 70/30 3 HUMULIN 70/30 KWIKPEN

3

HUMULIN 70/30 PEN

3

HUMULIN N 3 HUMULIN N KWIKPEN

3

HUMULIN N U-100 PEN

3

HUMULIN R 3 HUMULIN R U-500 (CONCENTRATED)

3

LANTUS 3 LANTUS SOLOSTAR

3

LEVEMIR 3 LEVEMIR FLEXPEN

3

BLOOD PRODUCTS/MODIFIERS/VOLUME

EXPANDERS

ANTICOAGULANTS

COUMADIN 4

ELIQUIS 3 PA QL(60/30)


5 QL(24/30)

enoxaparin sodium inj 100mg/ml, 150mg/ml

5 QL(30/30)


4 QL(9/30)


4 QL(12/30)


4 QL(18/30)


4 QL(24/30)

enoxaparin sodium inj 300mg/3ml

4 QL(90/30)


4 QL(15/30)


5 QL(12/30)


5 QL(18/30)


5 QL(24/30)

heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 2000unit/ml, 2500unit/ml, 5000unit/ml

4

heparin sodium/d5w 4 heparin sodium/nacl 0.9%

4

jantoven 1 PRADAXA 3 PA

QL(60/30) warfarin sodium 1 XARELTO TABS 10MG, 20MG

3 PA QL(30/30)

XARELTO TABS 15MG

3 PA QL(60/30)

BLOOD FORMATION MODIFIERS



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anagrelide hydrochloride

2

ARANESP ALBUMIN FREE INJ 25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/0.3ML, 60MCG/ML

4 PA

ARANESP ALBUMIN FREE INJ 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML

5 PA

LEUKINE 5 PA NEULASTA 5 PA NEUMEGA 5 PA NEUPOGEN INJ 300MCG/0.5ML, 480MCG/0.8ML, 480MCG/1.6ML

5 PA

PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML

5 PA

PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

4 PA

PROMACTA 5 PA QL(30/30)

COAGULANTS

tranexamic acid inj 2 PA tranexamic acid tabs

2

PLATELET MODIFYING AGENTS

AGGRENOX 4 QL(60/30) BRILINTA 4 QL(60/30)

cilostazol 2 clopidogrel tabs 300mg

2 QL(1/30)

clopidogrel tabs 75mg

2 QL(30/30)

dipyridamole tabs 2 PA

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

clonidine hcl er 2 clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr

2 QL(4/28)

clonidine hcl ptwk 0.3mg/24hr

2 QL(8/28)

clonidine hcl tabs 0.3mg

2

clonidine hcl tabs 0.1mg, 0.2mg

1

methyldopate hcl 2 PA midodrine hcl 2

ALPHA-ADRENERGIC BLOCKING AGENTS

DIBENZYLINE 3 prazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS

AVALIDE 4 BENICAR 3 QL(30/30)

ST BENICAR HCT 3 QL(30/30)

ST candesartan cilexetil

2

COZAAR TABS 100MG

4 QL(30/30)

COZAAR TABS 25MG, 50MG

4 QL(60/30)

HYZAAR TABS 12.5MG; 100MG, 25MG; 100MG

4 QL(30/30)

HYZAAR TABS 12.5MG; 50MG

4 QL(60/30)

irbesartan 1 irbesartan/hydrochlorothiazide

1


1 QL(30/30)


1 QL(60/30)


1 QL(90/30)

losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg

1 QL(30/30)

losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg

1 QL(60/30)

telmisartan 2 QL(30/30) telmisartan/amlodipine

2 QL(30/30)

telmisartan/hydrochloroth

2 QL(30/30)

telmisartan/hydrochlorothiazide

2 QL(30/30)

valsartan/hydrochlorothiazide

2

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

ACCUPRIL 4 ACCURETIC 4 ACEON 4 ALTACE 4 benazepril hcl 1 benazepril hcl/hydrochlorothiazide

2

captopril 1 captopril/hydrochlorothiazide

2

enalapril maleate 1 enalapril maleate/hydrochlorothiazide

1

fosinopril sodium 2 fosinopril sodium/hydrochlorothiazide

2

lisinopril 1

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits





46

lisinopril/hydrochlorothiazide

1

LOTENSIN 4 LOTENSIN HCT 4 MAVIK 4 moexipril hcl 2 moexipril/hydrochlorothiazide

2

perindopril erbumine

1

PRINIVIL 4 quinapril hcl 1 quinapril/hydrochlorothiazide

2

ramipril 1 trandolapril 2 UNIRETIC 4 UNIVASC 4 VASERETIC 4 VASOTEC TABS 10MG, 2.5MG, 20MG

4

ZESTORETIC 4 ZESTRIL 4

ANTIARRHYTHMICS

amiodarone hcl inj 50mg/ml

4

amiodarone hcl tabs

2

flecainide acetate 2 lidocaine hcl inj 10mg/ml

4

mexiletine hcl 2 MULTAQ 3 QL(60/30) pacerone 2 propafenone hcl 2 propafenone hcl er 2 quinidine sulfate 2 sorine 2 sotalol hcl 2 sotalol hcl (af) 2 TIKOSYN 3

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl 2 atenolol 1 atenolol/chlorthalidone

1

betaxolol hcl 2 bisoprolol fumarate 2 bisoprolol fumarate/hydrochlorothiazide

1

carvedilol 1 COREG CR 4 labetalol hcl inj 4 labetalol hcl tabs 2 metoprolol succinate er

2

metoprolol tartrate inj

4

metoprolol tartrate tabs

1

metoprolol/hydrochlorothiazide

2

nadolol tabs 80mg 2 nadolol tabs 20mg, 40mg

1

nadolol/bendroflumethiazide

2

pindolol 1 propranolol hcl er 2 propranolol hcl inj 4 propranolol hcl oral soln

2

propranolol hcl tabs 60mg

2

propranolol hcl tabs 10mg, 20mg, 40mg, 80mg

1

propranolol/hydrochlorothiazide

2

timolol maleate tabs 2

CALCIUM CHANNEL BLOCKING AGENTS

afeditab cr 2 amlodipine besylate 1 amlodipine besylate/benazepril hcl

2

amlodipine besylate/benazepril hydrochloride

2

cartia xt 2 dilt-xr 2 diltiazem cd 2

diltiazem hcl er cp12

2

diltiazem hcl er cp24

2

diltiazem hcl inj 100mg, 25mg/5ml, 50mg/10ml

4

diltiazem hcl tabs 1 EXFORGE 3 EXFORGE HCT 3 felodipine er 2 isradipine 2 matzim la 2 nicardipine hcl caps 2 nicardipine hcl inj 4 nifediac cc tb24 30mg, 60mg

2

nifedical xl 2 nifedipine er 2 nimodipine 2 nisoldipine 2 nisoldipine er 2 taztia xt 2 verapamil hcl er 2 verapamil hcl inj 4 verapamil hcl tabs 120mg, 80mg

1

verapamil hcl tabs 40mg

2

CARDIOVASCULAR AGENTS, OTHER

AMTURNIDE 3 ST DEMSER 5 digox tabs 125mcg 1 QL(30/30) digox tabs 250mcg 1 PA digoxin inj 4 PA digoxin tabs 125mcg

1 QL(30/30)

digoxin tabs 250mcg

1 PA

LANOXIN PEDIATRIC

4 PA

LANOXIN TABS 125MCG

4 QL(30/30)

LANOXIN TABS 250MCG

4 PA

pentoxifylline er 2 RANEXA TB12 1000MG

3 QL(60/30) ST



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RANEXA TB12 500MG

3 QL(120/30) ST

TEKAMLO 3 ST TEKTURNA 3 ST TEKTURNA HCT 3 ST

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide 2 acetazolamide sodium

4

DIURETICS, LOOP

bumetanide inj 4 bumetanide tabs 0.5mg, 1mg

1

bumetanide tabs 2mg

2

EDECRIN 3 furosemide inj 4 furosemide oral soln

2

furosemide tabs 1 SODIUM EDECRIN 4 torsemide tabs 2

DIURETICS, POTASSIUM-SPARING

amiloride hcl 2 amiloride/hydrochlorothiazide

1

spironolactone tabs 25mg

1

spironolactone tabs 100mg, 50mg

2

spironolactone/hydrochlorothiazide

2

triamterene/hydrochlorothiazide caps 25mg; 50mg

2

triamterene/hydrochlorothiazide caps 25mg; 37.5mg

1

triamterene/hydrochlorothiazide tabs

1

DIURETICS, THIAZIDE

candesartan cilexetil/hydrochlorothiazide

2

chlorothiazide 2

chlorothiazide sodium

4

chlorthalidone tabs 25mg, 50mg

1

hydrochlorothiazide caps

1

hydrochlorothiazide tabs 25mg, 50mg

1

hydrochlorothiazide tabs 12.5mg

2

indapamide 1 metolazone 2

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

fenofibrate caps 130mg, 43mg

2

fenofibrate micronized

2

fenofibrate tabs 2 fenofibric acid dr 2 gemfibrozil 2 LIPOFEN 3

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

atorvastatin calcium 2 QL(30/30) CRESTOR 3 QL(30/30) fluvastatin caps 20mg

2 QL(30/30)

fluvastatin caps 40mg

2 QL(60/30)

lovastatin tabs 40mg

2 QL(60/30)

lovastatin tabs 10mg, 20mg

1 QL(90/30)

pravastatin sodium tabs 80mg

1 QL(30/30)

pravastatin sodium tabs 40mg

1 QL(60/30)

pravastatin sodium tabs 10mg, 20mg

1 QL(90/30)

simvastatin tabs 20mg, 40mg, 80mg

1 QL(30/30)

simvastatin tabs 10mg, 5mg

1 QL(90/30)

DYSLIPIDEMICS, OTHER

cholestyramine 2

cholestyramine light 2 colestipol hcl 2 niacin er tbcr 500mg

2 QL(30/30)

niacin er tbcr 1000mg, 750mg

2 QL(60/30)

niacor 2 omega-3-acid ethyl esters

2 QL(120/30)

prevalite 2 WELCHOL 4 ZETIA 3 QL(30/30)

VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine hcl inj 4 hydralazine hcl tabs 2 minoxidil tabs 2

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

isoditrate er 2 isosorbide dinitrate 2 isosorbide dinitrate er

2

isosorbide mononitrate

2

isosorbide mononitrate er

2

minitran 2 nitroglycerin inj 4 nitroglycerin lingual translingual soln

2

nitroglycerin pt24 2 nitroglycerin transdermal

2

NITROSTAT 3

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS,

AMPHETAMINES

amphetamine/dextroamphetamine cp24

2 QL(60/30)

amphetamine/dextroamphetamine tabs

2 QL(90/30)

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits





48

dextroamphetamine sulfate er cp24 10mg, 5mg

2 QL(90/30)

dextroamphetamine sulfate er cp24 15mg

2 QL(120/30)

dextroamphetamine sulfate oral soln

2 QL(1800/30)


2 QL(90/30)


2 QL(180/30)

procentra 2 QL(1800/30)

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-

AMPHETAMINES

dexmethylphenidate hcl

2 QL(60/30)

metadate er 2 QL(90/30) methylphenidate hcl 2 QL(90/30) methylphenidate hcl er tbcr 20mg

2 QL(90/30)


2 QL(180/30)

methylphenidate hcl sr

2 QL(90/30)

STRATTERA 3

CENTRAL NERVOUS SYSTEM, OTHER

butalbital/acetaminophen/caffeine/codeine caps 325mg; 50mg; 40mg; 30mg

2 PA QL(180/30)

NUEDEXTA 3 PA riluzole 4 XENAZINE TABS 12.5MG

5 PA QL(90/30)

XENAZINE TABS 25MG

5 PA QL(120/30)

MULTIPLE SCLEROSIS AGENTS

AMPYRA 5 PA QL(60/30)

AVONEX 5 PA QL(4/28) AVONEX PEN 5 PA QL(4/28) COPAXONE INJ 20MG/ML

5 QL(30/30)

REBIF 5 PA QL(6/28)

REBIF REBIDOSE 5 PA QL(6/28) REBIF REBIDOSE TITRATION PACK

5 PA QL(4.2/28)

REBIF TITRATION PACK

5 PA QL(4.2/28)

TYSABRI 5 PA

DENTAL AND ORAL AGENTS

DENTAL AND ORAL AGENTS

chlorhexidine gluconate oral rinse

1

oralone 2 periogard 1 pilocarpine hcl tabs 2 pilocarpine hydrochloride

2

triamcinolone acetonide pste

2

triamcinolone in orabase

2

DERMATOLOGICAL AGENTS

DERMATOLOGICAL AGENTS

acitretin 5 PA ammonium lactate 2 amnesteem 2 calcipotriene crea 2 calcipotriene external soln

2

calcipotriene oint 2 QL(120/30) calcitrene 2 QL(120/30) CALCITRIOL OINT 3 CARAC 3 claravis 2 clindacin etz pledgets

2

clindacin-p 2 clindamycin phosphate external soln

2

clindamycin phosphate gel

2

clindamycin phosphate lotn

2

clindamycin phosphate swab

2

curity gauze pads 2"x2"

2

ELIDEL 3

erythromycin/benzoyl peroxide

2

FLUOROPLEX 3 fluorouracil crea 2 fluorouracil external soln

2

imiquimod 2 laclotion 2 methoxsalen 5 myorisan 2 podofilox 2 PROTOPIC 3 PRUDOXIN 3 REGRANEX 5 PA SANTYL 3 selenium sulfide lotn

1

sulfacetamide sodium susp

2

TAZORAC CREA 3 QL(120/30) TAZORAC GEL 3 QL(100/30) tretinoin crea 2 PA

QL(45/30) tretinoin gel 2 PA

QL(45/30) tretinoin microsphere

2 PA QL(50/30)

tretinoin microsphere pump gel 0.04%

2 PA QL(50/30)

UVADEX 4 B/D PA VECTICAL 3 VOLTAREN 3 QL(1000/30)

ST zenatane 2 ZONALON 3 ZYCLARA 5

ENZYME REPLACEMENT/MODIFIERS

ENZYME REPLACEMENT/MODIFIERS

ADAGEN 5 PA ALDURAZYME 5 PA BUPHENYL TABS 5 CEREZYME INJ 400UNIT

5 B/D PA

CREON 3 CYSTADANE 5 CYSTAGON 3 ELAPRASE 5 PA



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FABRAZYME 5 B/D PA KUVAN 5 PA LUMIZYME 5 PA NAGLAZYME 5 PA ORFADIN 5 PANCRELIPASE 3 SODIUM PHENYLBUTYRATE

5

VPRIV 5 PA ZAVESCA 5 ZENPEP 3

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

atropine sulfate inj 0.05mg/ml, 0.1mg/ml

4

dicyclomine hcl caps

1

dicyclomine hcl oral soln

2

dicyclomine hcl tabs 1 glycopyrrolate inj 4mg/20ml

4

glycopyrrolate tabs 2 methscopolamine bromide

2

propantheline bromide

2

GASTROINTESTINAL AGENTS, OTHER

cromolyn sodium conc

2

diphenoxylate/atropine

2

lofene 2 lonox 2 loperamide hcl caps 2 metoclopramide hcl inj

4

metoclopramide hcl oral soln

1

metoclopramide hcl tabs 10mg

1

metoclopramide hcl tabs 5mg

2

OSMOPREP 4 RELISTOR INJ 8MG/0.4ML

4 PA QL(12/30)

RELISTOR INJ VIAL12MG/0.6ML

4 PA QL(18/30)

RELISTOR INJ KIT12MG/0.6ML

4 PA QL(28/28)

ursodiol 2

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine 2 cimetidine hcl 2 famotidine inj 20mg/2ml

4

famotidine premixed

4

famotidine tabs 20mg

1

famotidine tabs 40mg

2

nizatidine caps 2 ranitidine hcl caps 2 ranitidine hcl inj 150mg/6ml

4

ranitidine hcl syrp 2 ranitidine hcl tabs 1

IRRITABLE BOWEL SYNDROME AGENTS

AMITIZA 3 QL(60/30) LOTRONEX 5 PA

QL(60/30)

LAXATIVES

constulose 1 enulose 1 gavilyte-c 2 gavilyte-n/flavor pack

2

generlac 1 lactulose 1 MOVIPREP 4 peg 3350/electrolytes

2

peg-3350/nacl/na bicarbonate/kcl

2

polyethylene glycol 3350 powd

2

trilyte 2

PROTECTANTS

CARAFATE SUSP 3 misoprostol 2 sucralfate 2

PROTON PUMP INHIBITORS

ESOMEPRAZOLE SODIUM

4

lansoprazole 2 QL(60/30) omeprazole cpdr 2 QL(60/30) pantoprazole sodium tbec

2 QL(60/30)

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

flavoxate hcl 2 oxybutynin chloride 1 oxybutynin chloride er tb24 5mg

2 QL(30/30)

oxybutynin chloride er tb24 10mg, 15mg

2 QL(60/30)

tolterodine tartrate 1 VESICARE 3 QL(30/30)

BENIGN PROSTATIC HYPERTROPHY AGENTS

AVODART 3 doxazosin mesylate tabs 1mg, 2mg, 4mg

1 QL(30/30)

doxazosin mesylate tabs 8mg

1 QL(60/30)

finasteride tabs 5mg

2 QL(30/30)

JALYN 3 RAPAFLO 4 QL(30/30) tamsulosin hcl 2 terazosin hcl caps 1mg, 5mg

1 QL(30/30)

terazosin hcl caps 10mg, 2mg

1 QL(60/30)

GENITOURINARY AGENTS, OTHER

bethanechol chloride

2

ELMIRON 3

PHOSPHATE BINDERS

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits





50

FOSRENOL 5 ST RENVELA PACK 2.4GM

5 QL(180/30)

RENVELA PACK 0.8GM

3 QL(180/30)

RENVELA TABS 3 QL(540/30)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYI

NG (ADRENAL)


NG (ADRENAL)

a-hydrocort 4 a-methapred 4 ala cort 1 ALA SCALP 3 alclometasone dipropionate

2

alphatrex 2 amcinonide 2 apexicon 2 augmented betamethasone dipropionate

2

betamethasone dipropionate

2

betamethasone valerate

2

budesonide cp24 2 clobetasol propionate crea

2

clobetasol propionate e

2

clobetasol propionate emollient crea

2

clobetasol propionate external soln

2

clobetasol propionate foam

2

clobetasol propionate gel

2

clobetasol propionate oint

2

clotrimazole/betamethasone dipropionate

2

colocort 2 cormax scalp application

2

cortisone acetate 2 DEPO-MEDROL INJ 20MG/ML

4

desonide lotn 2 desonide oint 2 desoximetasone crea

2

desoximetasone gel 2 desoximetasone oint 0.25%

2

dexamethasone elix 2 DEXAMETHASONE INTENSOL

3

dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml

4

dexamethasone tabs 0.5mg, 0.75mg, 4mg

1

dexamethasone tabs 1.5mg, 1mg, 2mg, 6mg

2

diflorasone diacetate

2

fludrocortisone acetate

2

fluocinolone acetonide crea

2

fluocinolone acetonide external soln

1

fluocinolone acetonide oint

2

fluocinonide 2 fluocinonide-e 2 fluticasone propionate crea

2

fluticasone propionate oint

2

halobetasol propionate

2

hydrocortisone butyrate

2

hydrocortisone butyrate (lipophilic)

2

hydrocortisone crea 1%, 2.5%

1

hydrocortisone in absorbase

2

hydrocortisone lotn 2.5%

2

hydrocortisone oint 1%, 2.5%

2

hydrocortisone tabs 2 hydrocortisone valerate

2

MEDROL TABS 2MG

3

methylprednisolone 2 methylprednisolone acetate

4

methylprednisolone dose pack

2

methylprednisolone sodiumsuccinate inj 125mg, 40mg

4

mometasone furoate

2

prednicarbate oint 2 prednisolone sodium phosphate oral soln

2

PREDNISONE INTENSOL

3

prednisone oral soln

2

prednisone tabs 50mg

2

prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg

1

procto-pak 2 proctosol hc 2 proctozone-hc 2 SOLU-CORTEF INJ 1000MG, 250MG, 500MG

4

TEXACORT 3 triamcinolone acetonide crea 0.1%

1



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triamcinolone acetonide crea 0.025%, 0.5%

2

triamcinolone acetonide lotn

2

triamcinolone acetonide oint

2

triderm 1 u-cort 2


NG (PITUITARY)


NG (PITUITARY)

chorionic gonadotropin

4 PA

desmopressin acetate inj

4

desmopressin acetate nasal soln 0.01%

2

DESMOPRESSIN ACETATE NASAL SOLN 0.01%

3

desmopressin acetate tabs

2

INCRELEX 4 PA novarel 4 PA pregnyl w/diluent benzyl alcohol/nacl

4 PA

SAIZEN 5 PA SAIZEN CLICK.EASY

5 PA

STIMATE 3


NG (SEX HORMONES/MODIFIERS)

ANABOLIC STEROIDS

ANADROL-50 5 PA oxandrolone tabs 10mg

2 PA QL(60/30)

oxandrolone tabs 2.5mg

2 PA QL(120/30)

ANDROGENS

ANDROXY 3 PA

danazol 2 TESTIM 3 PA testosterone cypionate

4 PA

testosterone enanthate

4 PA

ESTROGENS

ALORA 3 PA QL(8/28) altavera 2 alyacen 1/35 2 alyacen 7/7/7 2 apri 2 aranelle 2 aubra 2 aviane 2 azurette 2 balziva 2 briellyn 2 caziant 2 chateal 2 cryselle-28 2 cyclafem 1/35 2 cyclafem 7/7/7 2 dasetta 1/35 2 dasetta 7/7/7 2 DEPO-ESTRADIOL 4 desogestrel/ethinyl estradiol tabs 0.15mg; 30mcg

2

elinest 2 emoquette 2 enpresse-28 2 enskyce 2 estarylla 2 estradiol ptwk 2 PA QL(4/28) estradiol tabs 2 PA estradiol valerate 4 estradiol/norethindrone acetate

2 PA

ESTRING 3 QL(1/90) falmina 2 FEMRING 3 gildagia 2 gildess 1.5/30 2 gildess 1/20 2 gildess fe 1.5/30 2 gildess fe 1/20 2

introvale 2 junel 1.5/30 2 junel 1/20 2 junel fe 1.5/30 2 junel fe 1/20 2 kariva 2 kelnor 1/35 2 kurvelo 2 larin 1/20 2 larin fe 1.5/30 2 larin fe 1/20 2 lessina 2 levonest 2 levonorgestrel/ethinyl estradiol

2

levora 0.15/30-28 2 low-ogestrel 2 lutera 2 marlissa 2 MENOSTAR 3 PA QL(4/28) microgestin 1.5/30 2 microgestin 1/20 2 microgestin fe 2 microgestin fe 1.5/30

2

mimvey 2 PA mimvey lo 2 PA MINIVELLE PTTW 0.1MG/24HR

3 PA QL(8/28)

mono-linyah 2 myzilra 2 necon 0.5/35-28 2 necon 1/35 2 necon 10/11-28 2 necon 7/7/7 2 norgestimate/ethinyl estradiol

2

nortrel 0.5/35 (28) 2 nortrel 1/35 2 nortrel 7/7/7 2 ogestrel 2 orsythia 2 philith 2 pimtrea 2 pirmella 1/35 2 pirmella 7/7/7 2 portia-28 2

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits





52

PREMARIN CREA 3 PREMARIN INJ 4 PREMARIN TABS 4 PA

QL(30/30) previfem 2 quasense 2 reclipsen 2 sprintec 28 2 sronyx 2 tilia fe 2 tri-estarylla 2 tri-legest fe 2 tri-linyah 2 tri-previfem 2 tri-sprintec 2 trivora-28 2 velivet 2 viorele 2 VIVELLE-DOT 3 PA QL(8/28) vyfemla 2 wera 2 zenchent 2 zovia 1/35e 2 zovia 1/50e 2

PROGESTERONE AGONISTS/ANTAGONISTS

ELLA 3

PROGESTINS

camila 2 DEPO-PROVERA 4 errin 2 heather 2 jencycla 2 lyza 2 MAKENA 5 medroxyprogesterone acetate inj

4 QL(1/90)

medroxyprogesterone acetate tabs

1

megestrol acetate 2 PA norethindrone 2 norethindrone acetate

2

progesterone caps 2

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

raloxifene hydrochloride

2 QL(30/30)


NG (THYROID)


NG (THYROID)

levothyroxine sodium tabs

1

LEVOXYL 4 liothyronine sodium inj

4

liothyronine sodium tabs

2

SYNTHROID 4 THYROLAR-1 3 THYROLAR-1/2 3 THYROLAR-1/4 3 THYROLAR-2 3 THYROLAR-3 3 UNITHROID 4 UNITHROID DIRECT

4

HORMONAL AGENTS, SUPPRESSANT (ADRENAL)

HORMONAL AGENTS, SUPPRESSANT (ADRENAL)

LYSODREN 3

HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)

HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)

SENSIPAR TABS 30MG

3 QL(60/30)

SENSIPAR TABS 60MG

5 QL(60/30)

SENSIPAR TABS 90MG

5 QL(120/30)

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline 2 ELIGARD INJ 30MG

4 PA QL(1/120)

ELIGARD INJ 45MG

4 PA QL(1/180)

ELIGARD INJ 7.5MG

4 PA QL(1/30)

ELIGARD INJ 22.5MG

4 PA QL(1/90)

firmagon inj 80mg 4 B/D PA QL(4/28)

FIRMAGON INJ 120MG

5 B/D PA QL(6/365)

leuprolide acetate 4 PA QL(30/30)

LUPRON DEPOT 5 PA QL(1/30) LUPRON DEPOT-PED

5 PA QL(1/30)

octreotide acetate inj 1000mcg/ml, 500mcg/ml

5 PA

octreotide acetate inj 100mcg/ml, 200mcg/ml, 50mcg/ml

4 PA

SANDOSTATIN LAR DEPOT

5 PA

SOMATULINE DEPOT

5 PA

SOMAVERT INJ 15MG, 20MG

5 PA QL(60/30)

SOMAVERT INJ 10MG

5 PA QL(90/30)

SYNAREL 5 PA TRELSTAR DEPOT 5 PA QL(1/28) TRELSTAR DEPOT MIXJECT

5 PA QL(2/28)

TRELSTAR LA 5 PA QL(1/84) TRELSTAR LA MIXJECT

5 PA QL(2/84)

TRELSTAR MIXJECT

5 PA QL(2/168)

HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole 2 propylthiouracil 2

IMMUNOLOGICAL AGENTS

ANGIOEDEMA (HAE) AGENTS

CINRYZE 5 PA



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FIRAZYR 5 PA

IMMUNE SUPPRESSANTS

ASTAGRAF XL 4 B/D PA AZASAN 3 B/D PA azathioprine 2 B/D PA CELLCEPT INTRAVENOUS

4 B/D PA

CELLCEPT SUSR 3 B/D PA cyclosporine caps 2 B/D PA cyclosporine inj 4 B/D PA cyclosporine modified

2 B/D PA

ENBREL 5 PA QL(8/28) ENBREL SURECLICK

5 PA QL(8/28)

gengraf 2 B/D PA hecoria 2 B/D PA HUMIRA INJ 20MG/0.4ML

5 PA QL(2/28)

HUMIRA INJ 40MG/0.8ML

5 PA QL(6/28)

HUMIRA PEN 5 PA QL(6/28) HUMIRA PEN-CROHNS DISEASESTARTER

5 PA QL(6/28)

methotrexate 2 methotrexate sodium

4

mycophenolate mofetil

2 B/D PA

mycophenolic acid dr

2 B/D PA

NULOJIX 5 PA PROGRAF INJ 4 B/D PA RAPAMUNE ORAL SOLN

3 B/D PA

RAPAMUNE TABS 1MG, 2MG

3 B/D PA

REMICADE 5 PA sirolimus 2 B/D PA tacrolimus 2 B/D PA TORISEL 3 B/D PA ZORTRESS TABS 0.25MG

4 B/D PA

ZORTRESS TABS 0.5MG, 0.75MG

5 B/D PA

IMMUNIZING AGENTS, PASSIVE

ATGAM 4 B/D PA BIVIGAM 4 B/D PA FLEBOGAMMA DIF 4 B/D PA gamastan s/d 4 B/D PA GAMMAGARD LIQUID

4 B/D PA

GAMMAKED 4 B/D PA GAMMAPLEX INJ 10GM/200ML, 2.5GM/50ML, 5GM/100ML

4 B/D PA

GAMUNEX-C 4 B/D PA OCTAGAM INJ 10GM/200ML, 2.5GM/50ML, 5GM/100ML

4 B/D PA

PRIVIGEN INJ 10GM/100ML, 20GM/200ML, 5GM/50ML

4 B/D PA

THYMOGLOBULIN 3 B/D PA

IMMUNOMODULATORS

ACTIMMUNE 5 PA ARCALYST 5 PA ILARIS 5 PA leflunomide 2 QL(30/30) PROVENGE 5 B/D PA RIDAURA 5 SIMULECT 5 B/D PA SYNAGIS INJ 50MG/0.5ML

5 PA

VACCINES

ACTHIB 4 ADACEL 4 BOOSTRIX 4 CERVARIX 4 COMVAX 4 DAPTACEL 4 DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

4

ENGERIX-B 4 B/D PA GARDASIL 4 HAVRIX 4

IMOVAX RABIES (H.D.C.V.)

4

INFANRIX 4 IPOL INACTIVATED IPV

4

IXIARO 4 M-M-R II W/DILUENT 10 DOSE

4

MENACTRA 4 MENOMUNE-A/C/Y/W-135

4

MENVEO 4 PEDVAX HIB 4 PROQUAD 4 RABAVERT 4 RECOMBIVAX HB INJ 10MCG/ML, 40MCG/ML

4 B/D PA

ROTARIX 3 ROTATEQ 3 tenivac 4 tetanus toxoid adsorbed

4

tetanus/diphtheria toxoids-adsorbed adult

4

TWINRIX 4 TYPHIM VI 4 VAQTA 4 VARIVAX 4 yf-vax 4 ZOSTAVAX 4

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

APRISO 3 balsalazide disodium

2

DELZICOL 3 mesalamine 2

SULFONAMIDES

sulfasalazine tabs 2 sulfazine 2 sulfazine ec 2

METABOLIC BONE DISEASE AGENTS

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

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54

METABOLIC BONE DISEASE AGENTS

ACTONEL TABS 35MG

3 QL(4/28)

ACTONEL TABS 30MG, 5MG

3 QL(30/30)

alendronate sodium tabs 35mg, 70mg

1 QL(4/28)

alendronate sodium tabs 10mg, 40mg, 5mg

2 QL(30/30)

calcitonin-salmon 2 QL(3.7/30) calcitriol caps 2 calcitriol inj 4 B/D PA calcitriol oral soln 2 doxercalciferol caps 2 doxercalciferol inj 4 B/D PA etidronate disodium 2 FORTEO 5 PA

QL(2.4/28) ibandronate sodium tabs

2 QL(1/28)

MIACALCIN INJ 4 pamidronate disodium inj 30mg/10ml, 6mg/ml, 90mg/10ml

4 B/D PA

paricalcitol 2 PROLIA 4 QL(1/180)

ST risedronate sodium 2 QL(1/28) XGEVA 5 PA zoledronic acid inj 4mg/5ml

5 B/D PA

zoledronic acid inj 5mg/100ml

4 B/D PA

ZOMETA INJ 4MG/100ML

5 B/D PA

MISCELLANEOUS THERAPEUTIC AGENTS


fomepizole 5 lactated ringers irrigation

4

levocarnitine inj 4 B/D PA levocarnitine oral soln

2

levocarnitine tabs 2

novofine 30gx8mm 2 QL(200/30) novofine 31 2 QL(200/30) novofine 32gx6mm 2 QL(200/30) novofine autocover 30gx8mm

2 QL(200/30)

novotwist 30gx8mm 2 QL(200/30) novotwist 32gx5mm 2 QL(200/30) physiolyte 4 B/D PA physiosol irrigation 4 ringers irrigation 4 sodium chloride 0.9%

4

sterile water irrigation

4

tis-u-sol 4 VORAXAZE 5

OPHTHALMIC AGENTS

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

COMBIGAN 3 latanoprost 2 QL(5/30) TRAVATAN Z 3 QL(5/30) ST

OPHTHALMIC AGENTS, OTHER

LACRISERT 3 mydral 2 naphazoline hcl 2 neo-polycin 2 neomycin/polymyxin/bacitracin zinc

2

parcaine 2 polycin 2 proparacaine hcl 2 RESTASIS 3 QL(64/30) trimethoprim sulfate/polymyxin b sulfate

2

tropicamide 2

OPHTHALMIC ANTI-ALLERGY AGENTS

ALOCRIL 3 azelastine hcl ophthalmic soln

2

cromolyn sodium ophthalmic soln

2

epinastine hcl 2 PATADAY 3 PATANOL 3

OPHTHALMIC ANTI-INFLAMMATORIES

bromfenac 2 dexamethasone sodium phosphate ophthalmic soln

2

diclofenac sodium ophthalmic soln

2

DUREZOL 3 FLUOROMETHOLONE

3

flurbiprofen sodium 2 ketorolac tromethamine ophthalmic soln

2

neomycin/polymyxin/dexamethasone

2

poly-dex 2 PRED MILD 3 PRED-G 3 PRED-G S.O.P. 3 PREDNISOLONE ACETATE

3

prednisolone sodium phosphate ophthalmic soln

1

TOBRADEX OINT 3 tobramycin/dexamethasone

2

OPHTHALMIC ANTIGLAUCOMA AGENTS

acetazolamide er 2 apraclonidine 2 AZOPT 3 ST betaxolol hcl 2 brimonidine tartrate ophthalmic soln 0.2%

2

BRIMONIDINE TARTRATE OPHTHALMIC SOLN 0.15%

3

carteolol hcl 2 dorzolamide hcl 2 dorzolamide hcl/timolol maleate

2



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LEVOBUNOLOL HCL OPHTHALMIC SOLN 0.25%

3

levobunolol hcl ophthalmic soln 0.5%

1

methazolamide 2 metipranolol 2 PHOSPHOLINE IODIDE

4

PILOCARPINE HCL OPHTHALMIC SOLN

3

timolol maleate ophthalmic soln

1

OTIC AGENTS

OTIC AGENTS

acetasol hc 2 acetic acid 2 COLY-MYCIN S 3 CORTISPORIN-TC 3 fluocinolone acetonide oil

2

hydrocortisone/acetic acid

2

neomycin/polymyxin/hc

2


2

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

budesonide susp 32mcg/act

2 QL(17.2/30)

budesonide susp 0.25mg/2ml, 0.5mg/2ml

2 B/D PA QL

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits





56

CYSTIC FIBROSIS AGENTS

PULMOZYME 5 B/D PA TOBI PODHALER 5 QL(1568/36

5) tobramycin 4 B/D PA

MAST CELL STABILIZERS

cromolyn sodium nebu

2 B/D PA

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

aminophylline 4 DALIRESP 3 PA

QL(30/30) THEO-24 4 theochron 2 theophylline cr 2 theophylline er tb12 200mg, 300mg, 450mg

2

theophylline er tb24 2

PULMONARY ANTIHYPERTENSIVES

LETAIRIS 5 PA QL(30/30)

REMODULIN 5 B/D PA sildenafil 2 PA

QL(90/30) TRACLEER 5 PA

QL(60/30)

RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine inhalation soln

2 B/D PA

ARALAST NP INJ 1000MG

5 B/D PA

PROLASTIN-C 5 B/D PA TYZINE 3 TYZINE PEDIATRIC NASAL DROPS

3

XOLAIR 5 PA ZEMAIRA 5 B/D PA

SKELETAL MUSCLE RELAXANTS

SKELETAL MUSCLE RELAXANTS

chlorzoxazone 2 PA cyclobenzaprine hcl tabs 10mg, 5mg

2 PA

orphenadrine citrate er

2 PA

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

zaleplon 2 QL(90/365) zolpidem tartrate 2 PA

QL(90/365)

SLEEP DISORDERS, OTHER

MODAFINIL TABS 100MG

4 PA QL(30/30)

modafinil tabs 200mg

5 PA QL(60/30)

ROZEREM 3 QL(30/30) SILENOR 3 QL(30/30) XYREM 5 PA

QL(540/30)

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYT

ES

ELECTROLYTE/MINERAL MODIFIERS

CHEMET 3 CUPRIMINE 5 DEPEN TITRATABS

3

EXJADE 5 kionex 2 SAMSCA TABS 30MG

5 PA QL(60/30)

SAMSCA TABS 15MG

5 PA QL(90/30)

sodium bicarbonate inj 7.5%, 8.4%

4

sodium lactate 4 B/D PA sodium polystyrene sulfonate powd

2

sodium polystyrene sulfonate susp 15gm/60ml

2

sps 2 SYPRINE 5

ELECTROLYTE/MINERAL REPLACEMENT

AMINO ACIDS 4 B/D PA AMINOSYN 4 B/D PA AMINOSYN 7%/ELECTROLYTES

4 B/D PA

AMINOSYN 8.5%/ELECTROLYTES

4 B/D PA

AMINOSYN II 4 B/D PA AMINOSYN II 8.5%/ELECTROLYTES

4 B/D PA

AMINOSYN M 4 B/D PA AMINOSYN-HBC 4 B/D PA AMINOSYN-HF 4 B/D PA AMINOSYN-PF 4 B/D PA AMINOSYN-PF 7% 4 B/D PA calcium acetate caps

2

calcium acetate tabs 667mg

2

CARBAGLU 5 CLINIMIX 2.75%/DEXTROSE 5%

4 B/D PA


4 B/D PA


4 B/D PA


4 B/D PA


4 B/D PA

clinisol sf 15% 4 B/D PA dextrose 5% /electrolyte #48 viaflex

4 B/D PA

dextrose 5%/potassium chloride 0.15%

4 B/D PA

fluoride chew 0.25mg, 1.1mg, 2.2mg

1

fluoritab chew 1 FREAMINE III 4 B/D PA FREAMINE III 3% 4 B/D PA hepatamine 4 B/D PA HEPATASOL 4 B/D PA



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isolyte-m/dextrose 5%

4 B/D PA

k-vescent pack 2 klor-con 2 klor-con m10 1 klor-con m20 1 lactated ringers dextrose 5% viaflex

4

lactated ringers inj 3meq/l; 109meq/l; 28meq/l; 4meq/l; 130meq/l

4

lactated ringers viaflex

4

ludent 1 magnesium sulfate inj 50%

4 B/D PA

MOZOBIL 5 QL(9.6/30) nafrinse 1 normosol-m in d5w 4 B/D PA NORMOSOL-R 4 B/D PA PHOSLYRA 4 potassium chloride 0.15%/d5w

4

potassium chloride 0.15%/nacl 0.9%

4 B/D PA

POTASSIUM CHLORIDE 0.3%/ NACL 0.9%

4 B/D PA

potassium chloride 0.3%/d5w

4 B/D PA

potassium chloride 0.3%/nacl 0.9%/viaflex

4 B/D PA

potassium chloride cr

1

potassium chloride er cpcr

2

POTASSIUM CHLORIDE ER TBCR 10MEQ

3

potassium chloride er tbcr 10meq, 20meq

1

potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml

4 B/D PA

potassium chloride liqd

2

potassium chloride pack

2

POTASSIUM CHLORIDE SR

3

POTASSIUM CITRATE

3

PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML

4 B/D PA

premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml

4 B/D PA

PROCALAMINE 4 B/D PA PROSOL 4 B/D PA ringers injection 4 sodium chloride 0.45% viaflex

4 B/D PA

sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5%

4 B/D PA

sodium fluoride chew 0.25mg, 0.5mg, 1mg, 2.2mg

1

sodium fluoride tabs 1 tpn electrolytes 4 B/D PA TRAVASOL 4 B/D PA

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits

Drug Name Drug Tier

Reqs/Limits





58

TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML

4 B/D PA

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYT

ES

intralipid inj 2.25%; 20%

4 B/D PA

liposyn iii inj 2.5%; 30%

4 B/D PA

VITAMINS

OB COMPLETE 400

3

OB COMPLETE/DHA

3

PRENATABS OBN 3



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Needles And Syringes



bd insulin syringe safetyglide/1ml/29g x 1/2"

2 QL(200/30)

bd insulin syringe ultrafine/0.3ml/31g x 5/16"

2 QL(200/30)

bd insulin syringe ultrafine/0.5ml/30g x 1/2"

2 QL(200/30)

bd insulin syringe ultrafine/1ml/31g x 5/16"

2 QL(200/30)

bd insulin syringe ultrafine/u-100/0.3ml/31g x 15/64"

2 QL(200/30)

bd insulin syringe ultrafine/u-100/0.5ml/31g x 15/64"

2 QL(200/30)

bd insulin syringe ultrafine/u-100/1ml/31g x 15/64"

2 QL(200/30)

bd pen needle/mini/ultrafine/31g x 3/16"

2 QL(200/30)

bd pen needle/nano/ultra fine/32g x 4mm

2 QL(200/30)

bd pen needle/ultrafine/29g x 12.7mm

2 QL(200/30)

monoject insulin syringe/detach needle/1ml/27g x 1/2"

2 QL(200/30)

monoject insulin syringe/safety/perm needle/0.3ml/29g x 1/2"

2 QL(200/30)

monoject insulin syringe/u-100/0.5ml/30g x 5/16"

2 QL(200/30)

monoject insulin syringe/u-100/1ml/30g x 5/16"

2 QL(200/30)

monoject ultra comfort insulin syringe/0.3ml/30g x 5/16"

2 QL(200/30)


2 QL(200/30)


2 QL(200/30)

monoject ultra comfort insulin syringe/1ml/28g x 1/2"

2 QL(200/30)

ulticare insulin syringe/u-100/0.3ml/30g x 1/2"

2 QL(200/30)

ulticare insulin syringe/u-100/0.5ml/31g x 5/16"

2 QL(200/30)

ulticare insulin syringe/u-100/1ml/30g x 1/2"

2 QL(200/30)

www.cignahealthspring.com

This drug list was updated on August 2014. For more recent information or other questions, please contact Cigna-HealthSpring Rx Customer Service, at 1-800-222-6700 or, for TTY users, 711, 8 a.m. – 8 p.m., local time, 7 days a week. (From February 15 – September 30, Monday – Friday 8 a.m. – 8 p.m. local time, Saturday and Sunday 10 a.m. – 6 p.m., EST, customer service agents available. Messaging service used weekends after hours). Or visit www.cignahealthspring.com. Esta lista de medicamentos se actualizó en agosto de 2014. Para información más reciente u otras preguntas, favor de contactar al Departamento de servicio al cliente de Cigna-HealthSpring Rx, al 1-800-222-6700 o, para los usuarios de TTY, 711, de 8 a.m. a 8 p.m., hora local, 7 días de la semana. (Del 15 de febrero al 30 de septiembre, de lunes a viernes, de 8 a.m. a 8 p.m. hora local; y los sábados y domingos, de 10 a.m. a 6 p.m., Hora del este, nuestros representantes de servicio al cliente estás disponibles. Si llama los fines de semana, o fuera del horario de servicio, entrará el servicio de contestadora automática). O visite www.cignahealthspring.com. This information is available for free in other languages. Please call our Customer Service number at 1-800-222-6700 for additional information (TTY users should call 711), 8 a.m. – 8 p.m., local time, 7 days a week. (From February 15 – September 30, Monday – Friday 8 a.m. – 8 p.m. local time, Saturday and Sunday 10 a.m. – 6 p.m., EST, customer service agents available. Messaging service used weekends after hours). Customer Service also has free language interpreter services available for non-English speakers. Esta información está disponible de forma gratuita en otros idiomas. Favor de ponerse en contacto con nuestro Departamento de servicio al cliente al 1-800-222-6700 para información adicional. (Los usuarios de TTY deben llamar al 711). De 8 a.m. a 8 p.m., hora local, 7 días de la semana. (Del 15 de febrero al 30 de septiembre, de lunes a viernes, de 8 a.m. a 8 p.m. hora local; y los sábados y domingos, de 10 a.m. a 6 p.m., Hora del este, nuestros representantes de servicio al cliente estás disponibles. Si llama los fines de semana, o fuera del horario de servicio, entrará el servicio de contestadora automática). El Departamento de servicio al cliente también tiene servicios gratuitos de intérprete de idiomas para las personas que no hablan inglés. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Todos los productos y servicios de Cigna se brindan exclusivamente por o a través de subsidiarias operativas de Cigna Corporation, incluyendo Cigna Health and Life Insurance Company. El nombre de Cigna, los logotipos, y otras marcas de Cigna son propiedad de Cigna Intellectual Property, Inc. © 2014 Cigna

cigna-healthspring comprehensive drug list · cigna-healthspring rx covers both brand name drugs...

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