plus drug formulary (dmhc) · the blue shield plus drug formulary is a list of medications that are...

Plus Drug Formulary January 2020

Blue Shield of California

This formulary corresponds with the following plans:

Shield Spectrum PPO℠, Full PPO, Full PPO Savings, Access+ HMO®, Added Advantage POS℠, Local Access+

HMO®, Tandem PPO, Trio HMO

This formulary was last updated on 10/01/2019. This formulary is subject to change and all previous versions of

the formulary no longer apply. For the most current information about the Plus Drug Formulary, visit

www.blueshieldca.com/pharmacy.

You can find information about specific prescription drug benefits and drug benefit exclusions in the Blue Shield

Summary of Benefits and Evidence of Coverage. For plan and coverage documents, visit

https://www.blueshieldca.com/bsca/bsc/wcm/connect/employer/employer_contents_en/policies. For

additional information about your plan, call the customer service number on your Blue Shield member ID card.

blueshieldca.com

http://www.blueshieldca.com/pharmacyhttps://www.blueshieldca.com/bsca/bsc/wcm/connect/employer/employer_contents_en/policies

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Introduction to the formulary drug list

The Blue Shield Plus Drug Formulary is a list of medications that are approved by the Food and Drug

Administration (FDA) and are selected based on safety, effectiveness, and cost. This list of generic and

brand drugs is covered by your health insurance policy under the prescription drug benefit of the policy.

Definitions The following words and definitions will be used throughout the formulary drug list.

Term

“Brand name drug” is a drug that is marketed under a proprietary, trademark protected name. The

brand name drug shall be listed in all CAPITAL letters.

“Coinsurance” is a percentage of the cost of a covered health care benefit that an enrollee pays after

the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the

prescription drug benefit.

“Copayment” is a fixed dollar amount that an enrollee pays for a covered health care benefit after the

enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the

prescription drug benefit.

“Deductible” is the amount an enrollee pays for covered health care benefits before the enrollee's

health plan begins payment for all or part of the cost of the health care benefit under the terms of the

policy.

“Drug Tier” is a group of prescription drugs that corresponds to a specified cost sharing tier in the health

plan's prescription drug coverage. The tier in which a prescription drug is placed determines the

enrollee's portion of the cost for the drug.

“Enrollee” is a person enrolled in a health plan who is entitled to receive services from the plan. All

references to enrollees in this this formulary template shall also include subscriber as defined in this

section below.

“Exception request” is a request for coverage of a prescription drug. If an enrollee, his or her designee,

or prescribing health care provider submits an exception request for coverage of a prescription drug,

the health plan must cover the prescription drug when the drug is determined to be medically

necessary to treat the enrollee's condition.

“Exigent circumstances” are when an enrollee is suffering from a health condition that may seriously

jeopardize the enrollee's life, health, or ability to regain maximum function, or when an enrollee is

undergoing a current course of treatment using a non-formulary drug.

“Formulary” is the complete list of drugs preferred for use and eligible for coverage under a health plan

product, and includes all drugs covered under the outpatient prescription drug benefit of the health

plan product. Formulary is also known as a prescription drug list.

“Generic drug” is the same drug as its brand name equivalent in dosage, safety, strength, how it is

taken, quality, performance, and intended use. A generic drug is listed in bold and italicized lowercase

letters.

“Non-formulary drug” is a prescription drug that is not listed on the health plan's formulary.

“Out-of-pocket costs” are copayments, coinsurance, and the applicable deductible, plus all costs for

health care services that are not covered by the health plan.

“Prescribing provider” is a health care provider authorized to write a prescription to treat a medical

condition for a health plan enrollee.

“Prescription” is an oral, written, or electronic order by a prescribing provider for a specific enrollee that

contains the name of the prescription drug, the quantity of the prescribed drug, the date of issue, the

name and contact information of the prescribing provider, the signature of the prescribing provider if

the prescription is in writing, and if requested by the enrollee, the medical condition or purpose for

which the drug is being prescribed.

“Prescription drug” is a drug that is prescribed by the enrollee's prescribing provider and requires a

prescription under applicable law.

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Term

“Prior authorization” is a health plan's requirement that the enrollee or the enrollee's prescribing

provider obtain the health plan's authorization for a prescription drug before the health plan will cover

the drug. The health plan shall grant a prior authorization when it is medically necessary for the enrollee

to obtain the drug.

“Step therapy” is a process specifying the sequence in which different prescription drugs for a given

medical condition and medically appropriate for a particular patient are prescribed. The health plan

may require the enrollee to try one or more drugs to treat the enrollee's medical condition before the

health plan will cover a particular drug for the condition pursuant to a step therapy request. If the

enrollee's prescribing provider submits a request for step therapy exception, the health plans shall make

exceptions to step therapy when the criteria is met.

“Subscriber” means the person who is responsible for payment to a plan or whose employment or other

status, except for family dependency, is the basis for eligibility for membership in the plan.

How do I find a drug on this list? The drugs are listed alphabetically under the column titled “Prescription Drug Name” by its brand or

generic name under the therapeutic category and class to which it belongs. You can search this list using

the brand or generic name of the drug by:

• Searching for the category or class to which the drug belongs and search for the name of the

drug in alphabetical order or

• Searching the Alphabetical Index of Drugs by the name of the drug.

Listing a drug on the formulary does not guarantee that it will be prescribed by your doctor or prescriber.

How do I know if the drug listed is a brand or generic drug? • A generic name for a brand name drug is listed after the brand name of the drug in all lowercase

bold italics

o If a generic equivalent for a brand name drug is both available and covered, the

generic drug will be listed separately from the brand name drug in all lowercase bold

italics

o When a generic drug is marketed with a brand name, the brand name will be listed after

the generic name in parentheses in all CAPITALS.

• A brand name drug is listed in all CAPITALS followed by the generic name in parentheses in

lowercase bold italics.

Example

Drug Type How the drug name will appear in the

formulary drug list

generic drug atorvastatin calcium

generic drug marketed with a brand name oxycodone/acetaminophen (ENDOCET)

brand drug LIPITOR (atorvastatin calcium)

What are drug tiers? Drugs are placed into drug tiers based on defined categories. The amount you pay for drugs in different tiers

will vary. You can find information about what you pay by drug tier in the Summary of Benefits of your Blue

Shield Evidence of Coverage (EOC).

The column titled “Drug Tier” is the cost level you pay for a drug.

Drug

Tier† Description

1 Most generic drugs or low-cost, preferred brand drugs

2 Non-preferred generic drugs, preferred brand drugs, or drugs recommended by the P&T

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Committee based on drug safety, efficacy, and cost

3 Non-preferred brand drugs; drugs recommended by the P&T Committee based on safety,

efficacy, and cost; or drugs that generally have a preferred and often less costly therapeutic

alternative at a lower tier

4 Drugs that are biologics; drugs that the FDA or drug manufacturer requires to be distributed by

specialty pharmacies; drugs that require training or clinical monitoring for self-administration; or

drugs with a plan cost (net of rebates) greater than $600 for a one-month supply

† Affordable Care Act (ACA) drugs are preventive health drugs, including

contraceptive drugs and devices. These drugs are covered at $0 when specific criteria

are met.

Note about multi-source brand drugs: If you or your doctor choose a brand drug when a generic drug

equivalent is available, you will pay the difference in cost, plus the Tier 1 copayment or coinsurance. You or

your doctor can ask for an exception to the difference in cost through the Blue Shield prior authorization

process. (See “What is the prior authorization/exception request process?” below for more information.)

You can find information about specific prescription drug benefits and drug benefit exclusions in the Blue

Shield Evidence of Coverage. For additional information about specific plans, call the customer service

number on your Blue Shield member ID card.

Note: Blue Shield drug formularies apply to outpatient prescription drug benefits available through plans

underwritten by Blue Shield of California (individually and collectively referred to as Blue Shield throughout this

document).

How to read the formulary The column titled “Coverage Requirements and Limits” identifies coverage restrictions or limits for drugs when

applicable.

Coverage Requirements and Limits Description

AL1 Age Limit Prior authorization may be required if your age does not fall within

the FDA, manufacturer, or treatment guideline recommendations.

GL Gender Limit Prior authorization may be required if the FDA, manufacturer, or

treatment guidelines do not recommend the drug for a gender.

OAC Oral Anti-Cancer There is a maximum limit on the copayment/coinsurance amount for

orally administered anti-cancer drugs. Please see your Summary of

Benefits for more detailed information.

PA Prior Authorization Prior authorization is required to determine coverage.

PH Preventive Drugs Affordable Care Act (ACA) preventive health drugs, including

contraceptive drugs and devices, are covered at $0 when specific

criteria are met.*

QLC Quantity Limit The prescription quantity covered is limited. Prior authorization is

required for amounts greater than the limit.

RO Retail Only This prescription can be dispensed at retail pharmacies only. It is not

covered through mail service.

C Short Cycle Blue Shield’s Short Cycle Specialty Drug Program allows initial

prescriptions for select specialty drugs to be filled for a 15-day

supply. When this occurs, the copayment or coinsurance will be

prorated.

SP Specialty Pharmacy These drugs are available exclusively through select

specialty pharmacies.

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* Does not apply to grandfathered plans, plans purchased on or before March 23, 2010.

How often will the formulary change? This formulary is subject to change monthly. Formulary changes that may not have prior notice include the

following:

• A brand name drug may be moved to a higher tier or removed from the formulary if a new

generic drug is added to the formulary,

• A drug may be removed from the formulary when is it removed from the market because the

Food and Drug Administration (FDA) deems a drug to be unsafe or the drug’s manufacturer

removes the drug from the market, or

• A drug is added to the formulary, moved to a lower tier, or has a utilization management

requirement removed.

Formulary changes that will have at least 30-day prior notice to an affected insured before the change is

effective include the following:

• Moving a drug or dosage form to a higher tier,

• Removal of a drug or dosage form from the formulary,

• Adding or changing utilization management requirements or limits for a drug.

o When a step therapy utilization management requirement changes, the new requirement

will not require you to repeat the step therapy if you are already taking the drug for your

condition as long as the drugs is still appropriate, your provider continues to prescribe the

drug, and the drug is still considered safe and effective for your condition.

When a drug or dosage form is removed from the formulary and a drug was previously approved for

coverage for your medical condition, coverage for the drug will continue if your provider continues to

prescribe the drug for your condition and the drug is prescribed appropriately and is safe and effective for

your condition.

For the most current information about the Blue Shield Plus Drug Formulary, visit

blueshieldca.com/pharmacy.

What is a medical benefit drug versus a drug covered under the Outpatient

Prescription Drug Benefit? A medical benefit drug is a drug that is not generally self-administered and administered by a health care

professional. The outpatient prescription drug benefit includes FDA-approved drugs that are self-

administered, commonly oral or self-injectable drugs, not otherwise excluded from coverage.

For additional information, check your Blue Shield Evidence of Coverage or call the customer service

number on your Blue Shield member ID card.

What are preventive health drugs? Preventive health drugs are select drugs required by health reform legislation to be covered at no charge

to the insured.* Preventive health drugs are determined based on evidence-based recommendations by

the United States Preventive Services Task Force. For more details about preventive health drugs, visit


What is a contraceptive drug or device? Contraceptives are drugs or devices, such as diaphragms or cervical caps, that help prevent pregnancy.

Most generic drug contraceptives and contraceptive devices are covered at no charge to the insured.* Most

ST Step Therapy A specific sequence in which prescription drugs for a

particular medical condition must be tried. If a drug is

subject to step therapy in this formulary, you may have

to try one or more other drugs before your health

insurance policy will cover that drug for your medical

condition.

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brand drug contraceptives require a copayment, which may be waived based on medical necessity. Physicians

or members may provide medical necessity information using the prior authorization process by calling or faxing

a form to Blue Shield Pharmacy Services. (See “What is the prior authorization/exception request process?”

below.)

What diabetes care drugs and products are covered under the Outpatient

Prescription Drug Benefit? FDA-approved drugs for the treatment of diabetes are included in the formulary drug list. Diabetic testing

supplies such as blood glucose test strips, urine test strips, lancets, insulin syringes/pens covered under the

Outpatient Prescription Drug Benefit are also included in the formulary drug list.

What is step therapy? Step therapy means a specific sequence in which prescription drugs for a particular medical condition must be

tried. If a drug is subject to step therapy in this formulary, you may have to try one or more other drugs before

your health insurance policy will cover that drug for your medical condition.

Step therapy requirements are based on how the FDA recommends that a drug should be used, nationally

recognized treatment guidelines, medical studies, information from the drug manufacturer, and the relative cost

of treatment for a condition. Your provider may submit a request for an exception to the step therapy

requirement.

To request an exception, please call the customer service number on your Blue Shield member ID card. You,

your representative, or your doctor may submit an exception request to Blue Shield.

What is the prior authorization/exception request process? Drug prior authorization involves getting advance approval of coverage for a prescription medication based on

medical necessity. Some drugs require review of the patient’s prescription and medical history to determine

coverage.

The exception process involves requesting coverage of a non-formulary drug. A formulary exception, which

allows coverage of a non-formulary drug is based on medical necessity.

To request prior authorization or a non-formulary coverage exception, please call the customer service

number on your Blue Shield member ID card. You, your representative, or your doctor may submit an

exception request to Blue Shield.

Once we receive all the needed supporting information, we will approve or deny the exception request

based on medical necessity within 72 hours for non-urgent requests, or within 24 hours in urgent or exigent

circumstances. If Blue Shield denies a request for prior authorization or an exception request, the member, an

authorized representative, or the provider can file an appeal/grievance with Blue Shield, as described in the

“Grievance Process” section of the EOC.

Participating retail pharmacies You can fill prescriptions at any participating (network) pharmacy, unless it is a prescription for a specialty

drug. Blue Shield contracts with a wide network of retail pharmacies. To find a network pharmacy, visit


What are specialty drugs? Specialty drugs are drugs that may require coordination of care, close monitoring, or extensive patient training

for self- administration. These requirements generally cannot be met by a retail pharmacy. Specialty drugs

may also require special handling or manufacturing processes (such as biotechnology), restriction to certain

physicians or pharmacies, or reporting of certain clinical events to the FDA. Specialty drugs are usually high-

cost.

Specialty drugs may require prior authorization for medical necessity by Blue Shield. Most specialty drugs are

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available exclusively from a Network Specialty Pharmacy. If coverage is approved, a Network Specialty

Pharmacy can provide specialty drugs by mail or, upon your request, can transfer the specialty drug to an

associated retail store for pickup. Call the customer service number on your Blue Shield member ID card or

visit blueshieldca.com/pharmacy if you have questions about specialty drugs.

Mail service pharmacy Blue Shield offers an easy-to-use mail service prescription drug program through our contracted mail service

pharmacy. You can save time and money using the mail service drug program. It can be a convenient way to

fill maintenance medications for up to a 90-day supply. Maintenance medications are drugs that doctors

prescribe on an ongoing, regular basis to maintain health. For more information on using the mail service

prescription benefit, visit blueshieldca.com/pharmacy.

Table of ContentsANALGESICS (Drugs for Pain) 1

ANESTHETICS (Drugs for Numbing) 14

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS (Drugs for Addiction/Substance Abuse) 14

ANTIBACTERIALS (Drugs for Bacterial Infections) 16

ANTICONVULSANTS (Drugs for Seizures) 25

ANTIDEMENTIA AGENTS (Drugs for Alzheimer's Disease and Dementia) 30

ANTIDEPRESSANTS (Drugs for Depression) 31

ANTIEMETICS (Drugs for Nausea and Vomiting) 35

ANTIFUNGALS (Drugs for Fungal Infections) 37

ANTIGOUT AGENTS (Drugs for Gout) 39

ANTIMIGRAINE AGENTS (Drugs for Migraine) 40

ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis) 42

ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections) 42

ANTINEOPLASTICS (Drugs for Cancer) 43

ANTIPARASITICS (Drugs for Parasitic Infections) 51

ANTIPARKINSON AGENTS (Drugs for Parkinson's Disease) 52

ANTIPSYCHOTICS (Drugs for Mental Health) 55

ANTISPASTICITY AGENTS (Drugs for Muscle Spasm) 57

ANTIVIRALS (Drugs for Viral Infections) 57

ANXIOLYTICS (Drugs for Anxiety) 66

BIPOLAR AGENTS (Drugs for Bipolar Disorder) 67

BLOOD GLUCOSE REGULATORS (Drugs for Diabetes) 68

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS (Drugs for Blood Disorders) 74

CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation) 77

CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions) 94

DENTAL AND ORAL AGENTS (Drugs for the Mouth) 103

DERMATOLOGICAL AGENTS (Drugs for the Skin) 104

ELECTROLYTES/MINERALS/METALS/VITAMINS 112

GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach) 122

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT (Drugs for Genetic or

Enzyme Disorders) 128

GENITOURINARY AGENTS (Drugs for the Genital, Bladder, and Kidney) 130

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) (Drugs for

Replacing/Stimulating Adrenal Gland Hormones) 134

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) (Drugs for

Replacing/Stimulating Pituitary Gland Hormones) 140

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) (Drugs

for Replacing/Stimulating Sex Hormones) 141

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) (Drugs for the Thyroid) 155

HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (Drugs for Suppressing Hormones from the Pituitary

Gland) 156

HORMONAL AGENTS, SUPPRESSANT (THYROID) (Drugs for the Thyroid) 157

LAST UPDATED 10/01/2019

IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing the Immune System) 157

INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for Inflammatory Bowel Disease) 160

METABOLIC BONE DISEASE AGENTS (Drugs for the Bone) 161

MISCELLANEOUS THERAPEUTIC AGENTS 163

OPHTHALMIC AGENTS (Drugs for the Eyes) 165

OTIC AGENTS (Drugs for the Ears) 171

RESPIRATORY TRACT/PULMONARY AGENTS (Drugs for the Lungs) 171

SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles) 182

SLEEP DISORDER AGENTS (Drugs for Insomnia) 183


PRESCRIPTION DRUG NAME DRUGTIER

COVERAGEREQUIREMENTS AND

LIMITS

ANALGESICS (Drugs for Pain)

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (Pain and ArthritisDrugs)

ANAPROX (naproxen sodium) TIER 3

ANAPROX DS (naproxen sodium) TIER 3

ARTHROTEC 50 (diclofenacsodium/misoprostol)

TIER 3

ARTHROTEC 75 (diclofenacsodium/misoprostol)

TIER 3

butalbital/aspirin/caffeine 50-325-40capsule

TIER 1 QLC (6 caps/day)

butalbital/aspirin/caffeine 50-325-40tablet

TIER 1 QLC (6 tabs/day)

CAMBIA (diclofenac potassium) TIER 3 PA, QLC (9 packs/month)

CELEBREX (celecoxib) 400 MG CAPSULE TIER 3 QLC (1 cap/day)

CELEBREX (celecoxib) 50 MG CAPSULE,100 MG CAPSULE, 200 MG CAPSULE


celecoxib 400 mg capsule TIER 1 QLC (1 cap/day)

celecoxib 50 mg capsule, 100 mgcapsule, 200 mg capsule


DAYPRO (oxaprozin) TIER 3

diclofenac epolamine TIER 1 PA, QLC (2 patches/day)

diclofenac potassium TIER 1

diclofenac sodium (KLOFENSAID II) TIER 1 PA, QLC (1 bottle/month)

diclofenac sodium 1.5 % drops TIER 1 PA, QLC (1 bottle/month)

diclofenac sodium 25 mg tablet dr, 50 mgtablet dr, 75 mg tablet dr, 100 mg tab er24h

TIER 1

diclofenac sodium/misoprostol TIER 1

diflunisal TIER 1

DISALCID (salsalate) TIER 3

DUEXIS (ibuprofen/famotidine) TIER 4 PA, QLC (3 tabs/day)

EC-NAPROSYN (naproxen) TIER 3


AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization;PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle;

SP – Specialty Pharmacy; ST – Step Therapy

1



LIMITSetodolac TIER 1

FELDENE (piroxicam) TIER 3

fenoprofen calcium (FENORTHO) TIER 3 PA, QLC (4 caps/day)

fenoprofen calcium (PROFENO) TIER 3 PA, QLC (4 tabs/day)

fenoprofen calcium 200 mg capsule TIER 3 PA, QLC (4 caps/day)

fenoprofen calcium 400 mg capsule TIER 3 PA, QLC (8 caps/day)

fenoprofen calcium 600 mg tablet TIER 3 PA, QLC (4 tabs/day)

FENORTHO (fenoprofen calcium) 200 MGCAPSULE

TIER 3 PA, QLC (4 caps/day)

FENORTHO (fenoprofen calcium) 400 MGCAPSULE


FIORINAL (butalbital/aspirin/caffeine) TIER 3 QLC (6 caps/day)

FLECTOR (diclofenac epolamine) TIER 3 PA, QLC (2 patches/day)

flurbiprofen TIER 1

ibuprofen (IBU) TIER 1

ibuprofen 400 mg tablet, 600 mg tablet,800 mg tablet

TIER 1

INDOCIN (indomethacin) TIER 3

indomethacin TIER 1

ketoprofen TIER 1

ketorolac tromethamine 10 mg tablet TIER 1 QLC (4 tabs/day, not to exceed20 tabs/30 days)

LODINE (etodolac) TIER 3

meclofenamate sodium TIER 1

mefenamic acid TIER 1

meloxicam TIER 1

MOBIC (meloxicam) TIER 3

nabumetone TIER 1

NALFON (fenoprofen calcium) 400 MGCAPSULE


NALFON (fenoprofen calcium) 600 MGTABLET

TIER 3 PA, QLC (4 tabs/day)

NAPRELAN (naproxen sodium) CR 375 MGTABLET

TIER 4 ST, QLC (1 tab/day)




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LIMITSNAPRELAN (naproxen sodium) CR 500 MGTABLET, CR 750 MG TABLET

TIER 4 ST, QLC (2 tabs/day)

NAPROSYN (naproxen) TIER 3

naproxen TIER 1

naproxen sodium 275 mg tablet, 550 mgtablet

TIER 1

naproxen sodium 375 mg tbmp 24hr TIER 4 ST, QLC (1 tab/day)

naproxen sodium 500 mg tbmp 24hr TIER 4 ST, QLC (2 tabs/day)

oxaprozin TIER 1

PENNSAID (diclofenac sodium) TIER 4 PA, QLC (1 bottle/month)

piroxicam TIER 1

PONSTEL (mefenamic acid) TIER 3

QMIIZ ODT (meloxicam) TIER 3 PA, QLC (1 tab/day)

salsalate TIER 1

SPRIX (ketorolac tromethamine) TIER 4 PA, QLC (5 bottles/month)

sulindac TIER 1

TIVORBEX (indomethacin, submicronized) TIER 3 ST, QLC (3 caps/day)

tolmetin sodium TIER 1

VIMOVO (naproxen/esomeprazolemagnesium)


VIVLODEX (meloxicam, submicronized) TIER 3 PA, QLC (1 cap/day)

VOLTAREN-XR (diclofenac sodium) TIER 3

ZIPSOR (diclofenac potassium) TIER 4 ST, QLC (4 caps/day)

ZORVOLEX (diclofenac submicronized) TIER 3 ST, QLC (3 caps/day)

OPIOID ANALGESICS, LONG-ACTING (Long-acting Narcotic PainRelievers)

ARYMO ER (morphine sulfate) TIER 3 PA, QLC (3 tabs/day)

BELBUCA (buprenorphine hcl) TIER 3 PA, QLC (2 films/day)

buprenorphine TIER 1 PA, QLC (4 patches/28 days)

BUTRANS (buprenorphine) TIER 3 PA, QLC (4 patches/28 days)

CONZIP (tramadol hcl) TIER 3 ST, QLC (1 cap/day)

DISKETS (methadone hcl) TIER 3 PA, QLC (5 tabs/day)




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LIMITSDOLOPHINE HCL (methadone hcl) 10 MGTABLET


DOLOPHINE HCL (methadone hcl) 5 MGTABLET


DURAGESIC (fentanyl) TIER 3 PA, QLC (20 patches/month)

EMBEDA (morphine sulfate/naltrexonehcl) ER 20-0.8 MG CAPSULE


EMBEDA (morphine sulfate/naltrexonehcl) ER 30-1.2 MG CAPSULE, ER 50-2 MGCAPSULE, ER 60-2.4 MG CAPSULE


EMBEDA (morphine sulfate/naltrexonehcl) ER 80-3.2 MG CAPSULE, ER 100-4 MGCAPSULE

TIER 3 PA, QLC (1 cap/day)

EXALGO (hydromorphone hcl) ER 12 MGTABLET







TIER 3 PA, QLC (1 tab/day)

fentanyl 12 mcg/hr patch, 25 mcg/hrpatch, 50mcg/hr patch, 75mcg/hr patch,100 mcg/hr patch

TIER 1 PA, QLC (20 patches/month)

fentanyl 37.5mcg/hr patch, 62.5mcg/hrpatch, 87.5mcg/hr patch

TIER 4 PA, QLC (10 patches/month)

hydromorphone hcl 12 mg tab er 24h TIER 1 PA, QLC (5 tabs/day)



hydromorphone hcl 8 mg tab er 24h TIER 1 PA, QLC (1 tab/day)

HYSINGLA ER (hydrocodone bitartrate) ER20 MG TABLET, ER 30 MG TABLET, ER 40 MGTABLET, ER 60 MG TABLET


HYSINGLA ER (hydrocodone bitartrate) ER80 MG TABLET, ER 100 MG TABLET, ER 120MG TABLET


KADIAN (morphine sulfate) ER 10 MGCAPSULE, ER 30 MG CAPSULE, ER 40 MGCAPSULE, ER 50 MG CAPSULE, ER 100 MGCAPSULE





4



LIMITSKADIAN (morphine sulfate) ER 20 MGCAPSULE


KADIAN (morphine sulfate) ER 60 MGCAPSULE, ER 80 MG CAPSULE, ER 200 MGCAPSULE


levorphanol tartrate 2 mg tablet TIER 4 PA, QLC (9 tabs/day)

levorphanol tartrate 3 mg tablet TIER 4 PA, QLC (4 tabs/day)

methadone hcl (METHADONE INTENSOL) TIER 2 PA, QLC (18 ml/day)

methadone hcl (METHADOSE) TIER 2 PA, QLC (5 tabs/day)

methadone hcl 10 mg tablet TIER 2 PA, QLC (18 tabs/day)

methadone hcl 10 mg/5 ml solution TIER 2 PA, QLC (90 ml/day)

methadone hcl 10 mg/ml oral conc TIER 2 PA, QLC (18 ml/day)

methadone hcl 40 mg tablet sol TIER 2 PA, QLC (5 tabs/day)

methadone hcl 5 mg tablet TIER 2 PA, QLC (36 tabs/day)

methadone hcl 5 mg/5 ml solution TIER 2 PA, QLC (180 ml/day)

METHADOSE (methadone hcl) TIER 3 PA, QLC (18 ml/day)

MORPHABOND ER (morphine sulfate) TIER 3 PA, QLC (2 tabs/day)

morphine sulfate 10 mg cap er, 30 mgcap er, 50 mg cap er, 100 mg cap er


morphine sulfate 100 mg tablet er, 200mg tablet er


morphine sulfate 120 mg cpmp 24hr TIER 1 PA, QLC (13 caps/day)

morphine sulfate 15 mg tablet er, 30 mgtablet er


morphine sulfate 20 mg cap er pel TIER 1 PA, QLC (4 caps/day)

morphine sulfate 30 mg, 45 mg, 60 mg, 75mg


morphine sulfate 40 mg cap er pel TIER 1 PA, QLC (2 caps/day)

morphine sulfate 60 mg cap er pel, 80 mgcap er pel, 90 mg cpmp 24hr


morphine sulfate 60 mg tablet er TIER 1 QLC (5 tabs/day)

MS CONTIN (morphine sulfate) ER 100 MGTABLET, ER 200 MG TABLET


MS CONTIN (morphine sulfate) ER 15 MGTABLET, ER 30 MG TABLET





5



LIMITSMS CONTIN (morphine sulfate) ER 60 MGTABLET


NUCYNTA ER (tapentadol hcl) TIER 3 PA, QLC (2 tabs/day)

OPANA ER (oxymorphone hcl) 40 MGTABLET


OPANA ER (oxymorphone hcl) ER 5 MGTABLET, ER 7.5 MG TABLET, ER 10 MGTABLET, ER 15 MG TABLET, ER 20 MGTABLET, ER 30 MG TABLET


oxycodone hcl 10 mg tab er 12h TIER 1 PA, QLC (9 tabs/day)

oxycodone hcl 15 mg tab er, 20 mg taber, 30 mg tab er


oxycodone hcl 40 mg tab er, 80 mg taber


oxycodone hcl 60 mg tab er 12h TIER 1 PA, QLC (2 tabs/day)

OXYCONTIN (oxycodone hcl) ER 10 MGTABLET


OXYCONTIN (oxycodone hcl) ER 15 MGTABLET, ER 20 MG TABLET, ER 30 MG TABLET


OXYCONTIN (oxycodone hcl) ER 40 MGTABLET, ER 80 MG TABLET


OXYCONTIN (oxycodone hcl) ER 60 MGTABLET


oxymorphone hcl 40 mg tab er 12h TIER 1 PA, QLC (4 tabs/day)

oxymorphone hcl 5 mg tab er, 7.5 mg taber, 10 mg tab er, 15 mg tab er, 20 mg taber, 30 mg tab er


tramadol hcl 100 mg 25-75, 200 mg 25-75,300 mg 17-83

TIER 1 ST, QLC (1 cap/day)

tramadol hcl 100 mg tab er 24h TIER 1 ST, QLC (3 tabs/day)

tramadol hcl 100 mg tbmp 24hr, 200 mgtbmp 24hr, 200 mg tab er 24h, 300 mg taber 24h, 300 mg tbmp 24hr


tramadol hcl 150 mg cpbp 25-75 TIER 1 ST, QLC (2 caps/day)

ULTRAM ER (tramadol hcl) 100 MG TABLET TIER 3 ST, QLC (3 tabs/day)

ULTRAM ER (tramadol hcl) ER 200 MGTABLET, ER 300 MG TABLET


XTAMPZA ER (oxycodone myristate) TIER 3 PA, QLC (2 caps/day)




6



LIMITSZOHYDRO ER (hydrocodone bitartrate) TIER 3 PA, QLC (2 caps/day)

OPIOID ANALGESICS, SHORT-ACTING (Short-acting Narcotic PainRelievers)

ABSTRAL (fentanyl citrate) 100 MCG TABSUBLINGUAL

TIER 3 PA, QLC (56 tabs/month)

ABSTRAL (fentanyl citrate) 200 MCG TABSUBLINGUAL


ABSTRAL (fentanyl citrate) 300 MCG TAB,400 MCG TAB


ABSTRAL (fentanyl citrate) 600 MCG TAB,800 MCG TAB


acetaminophen with codeine phosphate-15mg tablet, -30mg tablet

TIER 1 QLC (168 tabs/month)

acetaminophen with codeine phosphate120-12mg/5, 300mg/12.5

TIER 1 QLC (840 ml/month)

acetaminophen with codeine phosphate300mg-60mg tablet


acetaminophen/caffeine/dihydrocodeine bitartrate (DVORAH)


acetaminophen/caffeine/dihydrocodeine bitartrate (PANLOR)


acetaminophen/caffeine/dihydrocodeine bitartrateacetaminophen/caff/dihydrocod 320.5-30mg capsule

TIER 1 PA, QLC (140 caps/month)

acetaminophen/caffeine/dihydrocodeine bitartrateacetaminophen/caff/dihydrocod 325-30-16 tablet


ACTIQ (fentanyl citrate) TIER 3 PA, QLC (56 lozenges/month)

APADAZ (benzhydrocodonehcl/acetaminophen) 4.08-325 MG TABLET

TIER 3 PA, QLC (12 tabs/day; not toexceed 168 tabs/30 days)





aspirin/caffeine/dihydrocodeinebitartrate

TIER 1 QLC (168 caps/month)

benzhydrocodone hcl/acetaminophenbenzhydrocodone/acetaminophen 4.08-325mg tablet





7



LIMITSbenzhydrocodone hcl/acetaminophenbenzhydrocodone/acetaminophen 6.12-325mg tablet


benzhydrocodone hcl/acetaminophenbenzhydrocodone/acetaminophen 8.16-325mg tablet


butalbital/acetaminophen/caffeine/codeine phosphate


butorphanol tartrate 10 mg/ml spray TIER 1 QLC (4 canisters/month at 2canisters/fill)

CAPITAL W-CODEINE (acetaminophenwith codeine phosphate)


carisoprodol/aspirin/codeine phosphate TIER 1 AL1 (Up to 65 yrs old), QLC (8tabs/day)

codeinephosphate/butalbital/aspirin/caffeine


codeinephosphate/butalbital/aspirin/caffeine(ASCOMP WITH CODEINE)


codeine sulfate 15 mg tablet TIER 1 QLC (336 tabs/month)



DEMEROL (meperidine hcl) 100 MGTABLET

TIER 3 AL1 (Up to 65 yrs old), QLC (126tabs/month)

DEMEROL (meperidine hcl) 50 MG TABLET TIER 3 AL1 (Up to 65 yrs old), QLC (252tabs/month)

DILAUDID (hydromorphone hcl) 2 MGTABLET




DILAUDID (hydromorphone hcl) 5 MG/5ML ORAL LIQUID




fentanyl citrate 100 mcg tablet eff TIER 1 PA, QLC (56 tabs/month)


fentanyl citrate 200 mcg, 400 mcg, 600mcg, 800 mcg, 1200 mcg, 1600 mcg

TIER 1 PA, QLC (56 lozenges/month)





8



LIMITSfentanyl citrate 600 mcg tablet, 800 mcgtablet


FENTORA (fentanyl citrate) 100 MCGBUCCAL TABLET






FENTORA (fentanyl citrate) 600 MCGTABLET, 800 MCG TABLET


FIORICET WITH CODEINE(butalbital/acetaminophen/caffeine/codeine phosphate)


FIORINAL WITH CODEINE #3 (codeinephosphate/butalbital/aspirin/caffeine)


HYCET (hydrocodonebitartrate/acetaminophen)

TIER 3 QLC (90 ml/day; max 1260 ml/30days)

hydrocodone bitartrate/acetaminophen(LORCET HD)


hydrocodone bitartrate/acetaminophen(LORCET PLUS)


hydrocodone bitartrate/acetaminophen(LORCET)


hydrocodone bitartrate/acetaminophen(LORTAB) hydrocodone/acetaminophen10-300/15 solution


hydrocodone bitartrate/acetaminophen(LORTAB) hydrocodone/acetaminophen10mg-325mg tablet


hydrocodone bitartrate/acetaminophen(LORTAB) hydrocodone/acetaminophen5 mg-325mg tablet,hydrocodone/acetaminophen 7.5-325mg tablet


hydrocodone bitartrate/acetaminophen(VERDROCET)


hydrocodone bitartrate/acetaminophen(VICODIN ES)


hydrocodone bitartrate/acetaminophen(VICODIN HP)


hydrocodone bitartrate/acetaminophen(VICODIN)





9



LIMITShydrocodone bitartrate/acetaminophenhydrocodone/acetaminophen -300mgtablet, hydrocodone/acetaminophen -325mg tablet


hydrocodone bitartrate/acetaminophenhydrocodone/acetaminophen 10-325/15solution

TIER 1 PA, QLC (868 ml/month)

hydrocodone bitartrate/acetaminophenhydrocodone/acetaminophen 2.5-108/5,hydrocodone/acetaminophen 5-217mg/10

TIER 1 PA, QLC (90 ml/day; max 1260ml/30 days)

hydrocodone bitartrate/acetaminophenhydrocodone/acetaminophen 2.5-325mg tablet,hydrocodone/acetaminophen 5 mg-325mg tablet,hydrocodone/acetaminophen 5 mg-300mg tablet,hydrocodone/acetaminophen 7.5-325mg tablet,hydrocodone/acetaminophen 7.5-300mg tablet


hydrocodone bitartrate/acetaminophenhydrocodone/acetaminophen 7.5-325/15solution

TIER 1 QLC (90 ml/day; max 1260 ml/30days)

hydrocodone/ibuprofen (IBUDONE) TIER 1 QLC (112 tabs/month)

hydrocodone/ibuprofen (XYLON 10) TIER 1 QLC (70 tabs/month)

hydrocodone/ibuprofen 5mg-200mgtablet


hydrocodone/ibuprofen 7.5-200 mgtablet, 10mg-200mg tablet


hydromorphone hcl 1 mg/ml liquid TIER 1 QLC (56 ml/month)

hydromorphone hcl 2 mg tablet TIER 1 QLC (154 tabs/month)

hydromorphone hcl 3 mg supp.rect TIER 1 QLC (112 suppositories/month)



IBUDONE (hydrocodone/ibuprofen) TIER 3 QLC (70 tabs/month)

ibuprofen/oxycodone hcl TIER 1 QLC (56 tabs/month)

LAZANDA (fentanyl citrate) TIER 3 PA, QLC (14 bottles/month)

meperidine hcl 100 mg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (126tabs/month)




10



LIMITSmeperidine hcl 50 mg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (252

tabs/month)

meperidine hcl 50 mg/5 ml solution TIER 1 AL1 (Up to 65 yrs old), QLC (1260ml/month)

morphine sulfate 10 mg supp.rect TIER 1 QLC (126 suppositories/month)

morphine sulfate 10 mg/5 ml solution TIER 1 QLC (630 ml/month)

morphine sulfate 100 mg/5ml solution TIER 1 QLC (70 ml/month)

morphine sulfate 15 mg tablet TIER 1 QLC (84 tabs/month)


morphine sulfate 20 mg/5 ml solution TIER 1 QLC (84 ml/month)


morphine sulfate 30 mg tablet TIER 1 QLC (42 tabs/month)


NORCO (hydrocodonebitartrate/acetaminophen) 10-325 TABLET


NORCO (hydrocodonebitartrate/acetaminophen) 5-325 TABLET,7.5-325 TABLET


NUCYNTA (tapentadol hcl) 50 MG TABLET TIER 3 PA, QLC (70 tabs/month)

NUCYNTA (tapentadol hcl) 75 MG TABLET,100 MG TABLET


OPANA (oxymorphone hcl) 10 MG TABLET TIER 3 PA, QLC (56 tabs/month)

OPANA (oxymorphone hcl) 5 MG TABLET TIER 3 PA, QLC (84 tabs/month)

OXAYDO (oxycodone hcl) 5 MG TABLET TIER 3 PA, QLC (168 tabs/month)

OXAYDO (oxycodone hcl) 7.5 MG TABLET TIER 3 PA, QLC (112 tabs/month)

oxycodone hcl 10 mg tablet TIER 1 QLC (84 tabs/month)

oxycodone hcl 10mg/0.5ml syringe TIER 1 PA, QLC (3 ml/day)



oxycodone hcl 20 mg/ml oral conc TIER 1 QLC (42 ml/month)


oxycodone hcl 5 mg capsule TIER 1 QLC (168 caps/month)





11



LIMITSoxycodone hcl 5 mg/5 ml solution TIER 1 QLC (840 ml/month)

oxycodone hcl/acetaminophen(ENDOCET) 10mg-325mg tablet


oxycodone hcl/acetaminophen(ENDOCET) 2.5-325 mg tablet, 5 mg-325mg tablet


oxycodone hcl/acetaminophen(ENDOCET) 7.5-325 mg tablet


oxycodone hcl/acetaminophen(NALOCET)

TIER 3 PA, QLC (12 tabs/day; not toexceed 168 tabs/month)

oxycodone hcl/acetaminophen(PRIMLEV) 10mg-300mg tablet


oxycodone hcl/acetaminophen(PRIMLEV) 5 mg-300mg tablet


oxycodone hcl/acetaminophen(PRIMLEV) 7.5-300 mg tablet


oxycodone hcl/acetaminophen 10mg-325mg tablet


oxycodone hcl/acetaminophen 2.5-325mg tablet, 5 mg-325mg tablet


oxycodone hcl/acetaminophen 5-325/5ml solution


oxycodone hcl/acetaminophen 7.5-325mg tablet


oxycodone hcl/aspirin TIER 1 QLC (168 tabs/month)

oxymorphone hcl 10 mg tablet TIER 1 PA, QLC (56 tabs/month)

oxymorphone hcl 5 mg tablet TIER 1 PA, QLC (84 tabs/month)

pentazocine hcl/naloxone hcl TIER 1 AL1 (Up to 65 yrs old), QLC (18tabs/day)

PERCOCET (oxycodonehcl/acetaminophen) 10-325 MG TABLET


PERCOCET (oxycodonehcl/acetaminophen) 2.5-325 MG TABLET,5-325 MG TABLET


PERCOCET (oxycodonehcl/acetaminophen) 7.5-325 MG TABLET


ROXICODONE (oxycodone hcl) 15 MGTABLET


ROXICODONE (oxycodone hcl) 30 MGTABLET





12



LIMITSROXICODONE (oxycodone hcl) 5 MGTABLET


ROXYBOND (oxycodone hcl) 15 MGTABLET

TIER 3 PA, QLC (56 tabs/month, not toexceed 4 tabs/day)

ROXYBOND (oxycodone hcl) 30 MGTABLET

TIER 3 PA, QLC (28 tabs/month, not toexceed 2 tabs/day)

ROXYBOND (oxycodone hcl) 5 MG TABLET TIER 3 PA, QLC (168 tabs/month; not toexceed 12 tabs/day)

SKYRIZI (2 SYRINGES) KIT (risankizumab-rzaa)

TIER 4 PA, SP, QLC (1 kit/84 days)

SUBSYS (fentanyl) 100 MCG SPRAY, 1,200MCG SPRAY, 1,600 MCG SPRAY

TIER 3 PA, QLC (56 doses/month)

SUBSYS (fentanyl) 200 MCG SPRAY TIER 3 PA, QLC (42 doses/month)

SUBSYS (fentanyl) 400 MCG SPRAY, 600MCG SPRAY, 800 MCG SPRAY

TIER 3 PA, QLC (14 doses/month)

SYNALGOS-DC(aspirin/caffeine/dihydrocodeinebitartrate)


tramadol hcl 50 mg tablet TIER 1 QLC (112 tabs/month)

tramadol hcl/acetaminophen TIER 1 QLC (112 tabs/month)

TREZIX(acetaminophen/caffeine/dihydrocodeine bitartrate)

TIER 3 PA, QLC (140 caps/month)

TYLENOL-CODEINE NO.3 (acetaminophenwith codeine phosphate)


TYLENOL-CODEINE NO.4 (acetaminophenwith codeine phosphate)


ULTRACET (tramadol hcl/acetaminophen) TIER 3 QLC (112 tabs/month)

ULTRAM (tramadol hcl) TIER 3

XARTEMIS XR (oxycodonehcl/acetaminophen)


XODOL 10-300 (hydrocodonebitartrate/acetaminophen)


XODOL 5-300 (hydrocodonebitartrate/acetaminophen)


XODOL 7.5-300 (hydrocodonebitartrate/acetaminophen)


ZAMICET (hydrocodonebitartrate/acetaminophen)





13



LIMITS

ANESTHETICS (Drugs for Numbing)

LOCAL ANESTHETICS (Skin Numbing Drugs)lidocaine 5 % adh. patch TIER 1 QLC (90 patches/month)

lidocaine 5 % oint. (g) TIER 1 QLC (50 gm/month)

lidocaine hcl (GLYDO) TIER 1

lidocaine hcl 2 % jelly(ml), 2 % jel/pf app,2 % solution, 40 mg/ml solution

TIER 1

lidocaine/prilocaine 2.5 %-2.5% cream (g) TIER 1 QLC (30 gm/month)

LIDODERM (lidocaine) TIER 3 QLC (90 patches/month)

NAYZILAM (midazolam) TIER 3 QLC (2 sprayers/fill; max 5 fills/30days)

SYNERA (lidocaine/tetracaine) TIER 3 PA, QLC (1 patch/month)

XYLOCAINE (lidocaine hcl) 4% SOLUTION TIER 3

ZTLIDO (lidocaine) TIER 3 PA, QLC (3 patches/day)

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS (Drugs forAddiction/Substance Abuse)

ALCOHOL DETERRENTS/ANTI-CRAVING (Drugs for AlcoholDependence)

acamprosate calcium TIER 1

ANTABUSE (disulfiram) TIER 3

disulfiram TIER 1

naltrexone hcl TIER 1

OPIOID DEPENDENCE TREATMENTS (Drugs for Opioid Dependence)BUNAVAIL (buprenorphine hcl/naloxonehcl) 2.1-0.3 MG FILM

TIER 3 QLC (1 film/day)

BUNAVAIL (buprenorphine hcl/naloxonehcl) 4.2-0.7 MG FILM, 6.3-1 MG FILM

TIER 3 QLC (2 films/day)

buprenorphine hcl 2 mg tab subl TIER 1 QLC (12 tabs/day; not to exceed7 days therapy/90 days)

buprenorphine hcl 8 mg tab subl TIER 1 QLC (3 tabs/day; not to exceed 7days supply over 90 days)




14



LIMITSbuprenorphine hcl/naloxone hcl/naloxone 12 mg-3 mg film


buprenorphine hcl/naloxone hcl/naloxone 2 mg-0.5mg tab subl


buprenorphine hcl/naloxone hcl/naloxone 2 mg-0.5mg, /naloxone 4mg-1mg


buprenorphine hcl/naloxone hcl/naloxone 8 mg-2 mg film


buprenorphine hcl/naloxone hcl/naloxone 8 mg-2 mg tab subl


LUCEMYRA (lofexidine hcl) TIER 3 PA, QLC (16 tabs/day, not toexceed 224 tabs/6 months)

SUBOXONE (buprenorphine hcl/naloxonehcl) 12 MG-3 MG SL FILM


SUBOXONE (buprenorphine hcl/naloxonehcl) 2 MG-0.5 MG FILM, 4 MG-1 MG FILM


SUBOXONE (buprenorphine hcl/naloxonehcl) 8 MG-2 MG SL FILM


ZUBSOLV (buprenorphine hcl/naloxonehcl) 0.7-0.18 MG TABLET, 1.4-0.36 MGTABLET, 5.7-1.4 MG TABLET


ZUBSOLV (buprenorphine hcl/naloxonehcl) 2.9-0.71 MG TABLET, 11.4-2.9 MGTABLET

TIER 3 QLC (1 tab/day)

ZUBSOLV (buprenorphine hcl/naloxonehcl) 8.6-2.1 MG TABLET SL


OPIOID REVERSAL AGENTS (Drugs for Opioid Overdose)EVZIO (naloxone hcl) TIER 3 PA, QLC (2 injections [1 pack]/6

months)

naloxone hcl 0.4 mg/ml vial TIER 1 QLC (two 1 ml vials/month)

naloxone hcl 1 mg/ml syringe TIER 1 QLC (2 syringes/month)

NARCAN (naloxone hcl) TIER 2 QLC (2 doses/month)

SMOKING CESSATION AGENTS (Drugs to Help Quit Smoking)bupropion hcl 150 mg tab er 12h TIER 1 ACA (Preventive Health), QLC (2

tabs/day)

CHANTIX (varenicline tartrate) 0.5 MGTABLET, 1 MG TABLET, 1 MG CONT MONTHBOX

TIER 2 ACA (Preventive Health), QLC (2tabs/day)




15



LIMITSCHANTIX (varenicline tartrate) STARTINGMONTH BOX

TIER 2 ACA (Preventive Health), QLC (1starting month box/28 days)

NICOTROL (nicotine) TIER 2 ACA (Preventive Health), QLC (16cartridges/day)

NICOTROL NS (nicotine) TIER 2 ACA (Preventive Health), QLC (2ml/day)

ZYBAN (bupropion hcl) TIER 3 ACA (Preventive Health), QLC (2tabs/day)

ANTIBACTERIALS (Drugs for Bacterial Infections)

AMINOGLYCOSIDESARIKAYCE (amikacin sulfate liposomalwith nebulizer accessories)

TIER 4 PA, SP, QLC (1 vial/day)

gentamicin sulfate (GENTAK) TIER 1

gentamicin sulfate 0.1 % oint. (g), 0.1 %cream (g), 0.3 % oint. (g), 0.3 % drops

TIER 1

neomycin sulfate TIER 1

paromomycin sulfate TIER 1

tobramycin TIER 1

TOBREX (tobramycin) 0.3% EYE DROP TIER 3

TOBREX (tobramycin) 0.3% EYE OINTMENT TIER 2

ANTIBACTERIALS, OTHERAEMCOLO (rifamycin sodium) TIER 3 PA, QLC (12 tabs/30 days)

AKTIPAK (erythromycin base/benzoylperoxide)

TIER 3

ALTABAX (retapamulin) TIER 3 ST

bacitracin 500 unit/g oint. (g) TIER 1

BACTROBAN (mupirocin calcium) TIER 3

BACTROBAN (mupirocin) TIER 3

BACTROBAN NASAL (mupirocin calcium) TIER 3

BENZAMYCIN (erythromycin base/benzoylperoxide)

TIER 3

CENTANY (mupirocin) TIER 3

CLEOCIN (clindamycin phosphate) 100MG VAGINAL OVULE

TIER 2 QLC (3 suppositories/fill)




16



LIMITSCLEOCIN (clindamycin phosphate) 2%VAGINAL CREAM

TIER 3

CLEOCIN HCL (clindamycin hcl) TIER 3

CLEOCIN PALMITATE (clindamycinpalmitate hcl)

TIER 3

CLEOCIN T (clindamycin phosphate) TIER 3

CLINDAGEL (clindamycin phosphate) TIER 3 PA, QLC (1 bottle/month)

clindamycin hcl TIER 1

clindamycin palmitate hcl TIER 1

clindamycin phosphate (CLINDACIN ETZ) TIER 1

clindamycin phosphate (CLINDACIN P) TIER 1

clindamycin phosphate 1 % foam TIER 1 QLC (1 can/month)

clindamycin phosphate 1 % gel (gram), 1% lotion, 1 % med. swab, 1 % solution, 2 %cream/appl

TIER 1

clindamycin phosphate 1 % gel daily TIER 3 PA, QLC (1 bottle/month)

CLINDESSE (clindamycin phosphate) TIER 2

erythromycin base/benzoyl peroxide TIER 1

EVOCLIN (clindamycin phosphate) TIER 3 QLC (1 can/month)

FIRVANQ (vancomycin hcl) 25 MG/MLSOLUTION

TIER 3 PA, QLC (300 ml/month)

FIRVANQ (vancomycin hcl) 50 MG/MLSOLUTION

TIER 3 PA, QLC (450 ml/30 days)

FLAGYL (metronidazole) TIER 3

FURADANTIN (nitrofurantoin) TIER 3

HIPREX (methenamine hippurate) TIER 3

linezolid TIER 1 PA

MACROBID (nitrofurantoinmonohydrate/macrocrystals)

TIER 3

MACRODANTIN (nitrofurantoinmacrocrystal)

TIER 3

mafenide acetate TIER 1

methenamine hippurate TIER 1

METROGEL-VAGINAL (metronidazole) TIER 3




17



LIMITSmetronidazole 0.75 % gel w/appl, 250 mgtablet, 375 mg capsule, 500 mg tablet

TIER 1

MONUROL (fosfomycin tromethamine) TIER 3 QLC (1 packet/month)

mupirocin TIER 1

mupirocin calcium TIER 1

neomycin sulfate/polymyxin b sulfate TIER 1 PA, QLC (1 ml/day)

NEOSPORIN G.U. IRRIGANT (neomycinsulfate/polymyxin b sulfate)

TIER 3 PA, QLC (1 ml/day)

nitrofurantoin TIER 1

nitrofurantoin macrocrystal TIER 1

nitrofurantoinmonohydrate/macrocrystals

TIER 1

NUVESSA (metronidazole) TIER 3 QLC (2 tubes/month)

PRIMSOL (trimethoprim) TIER 3

SIVEXTRO (tedizolid phosphate) 200 MGTABLET


SOLOSEC (secnidazole) TIER 3 PA, QLC (1 pack/month)

SULFAMYLON (mafenide acetate) TIER 3

TINDAMAX (tinidazole) TIER 3 QLC (20 tabs/fill)

tinidazole 250 mg tablet TIER 1 QLC (40 tabs/fill)

tinidazole 500 mg tablet TIER 1 QLC (20 tabs/fill)

trimethoprim TIER 1

TRIMPEX (trimethoprim) TIER 3

VANCOCIN HCL (vancomycin hcl) TIER 3

vancomycin hcl 125 mg capsule, 250 mgcapsule

TIER 1

vancomycin hcl 50 mg/ml soln recon TIER 1 PA, QLC (450 ml/30 days)

VANDAZOLE (metronidazole) TIER 3

XIFAXAN (rifaximin) 200 MG TABLET TIER 3 PA, QLC (8 tabs/day)

XIFAXAN (rifaximin) 550 MG TABLET TIER 3 PA, QLC (3 tabs/day)

ZYVOX (linezolid) TIER 3 PA




18



LIMITS

BETA-LACTAM, CEPHALOSPORINSCEDAX (ceftibuten) TIER 3

cefaclor 125 mg/5ml susp recon, 250mg/5ml susp recon, 250 mg capsule, 375mg/5ml susp recon, 500 mg capsule

TIER 1

cefaclor 500 mg tab er 12h TIER 1 QLC (14 tabs/fill)

cefadroxil TIER 1

cefdinir TIER 1

cefditoren pivoxil TIER 1

cefixime TIER 1

cefpodoxime proxetil TIER 1

cefprozil TIER 1

ceftibuten TIER 1

CEFTIN (cefuroxime axetil) TIER 3

cefuroxime axetil TIER 1

cephalexin TIER 1

DAXBIA (cephalexin) TIER 3 PA, QLC (12 caps/day)

KEFLEX (cephalexin) TIER 3

SPECTRACEF (cefditoren pivoxil) TIER 3

SUPRAX (cefixime) TIER 3

BETA-LACTAM, PENICILLINSamoxicillin 125 mg/5ml susp recon, 125mg tab chew, 200 mg/5ml susp recon,250 mg tab chew, 250 mg/5ml susprecon, 250 mg capsule, 400 mg/5ml susprecon, 500 mg tablet, 500 mg capsule,875 mg tablet

TIER 1

amoxicillin 775 mg tbmp 24hr TIER 1 QLC (10 tabs/fill)

amoxicillin/potassium clavulanate 200-28.5/5 susp recon, 200-28.5mg tab chew,250-62.5/5 susp recon, 250-125 mg tablet,400-57mg/5 susp recon, 400-57mg tabchew, 500-125 mg tablet, 600-42.9/5 susprecon, 1000-62.5 tab er 12h

TIER 1

amoxicillin/potassium clavulanate 875-125 mg tablet





19



LIMITSampicillin trihydrate TIER 1

AUGMENTIN (amoxicillin/potassiumclavulanate) 125-31.25 MG/5 ML

TIER 2

AUGMENTIN (amoxicillin/potassiumclavulanate) 250-62.5 MG/5 ML, 500-125TABLET

TIER 3

AUGMENTIN (amoxicillin/potassiumclavulanate) 875-125 TABLET


AUGMENTIN ES-600 (amoxicillin/potassiumclavulanate)

TIER 3

AUGMENTIN XR (amoxicillin/potassiumclavulanate)

TIER 3

dicloxacillin sodium TIER 1

MOXATAG (amoxicillin) TIER 3 QLC (10 tabs/fill)

penicillin v potassium TIER 1

MACROLIDESAZASITE (azithromycin) TIER 3

azithromycin 1 g packet, 100 mg/5ml susprecon, 200 mg/5ml susp recon, 250 mgtablet, 500 mg tablet, 600 mg tablet

TIER 1

BIAXIN (clarithromycin) 250 MG TABLET,500 MG TABLET

TIER 3 QLC (42 tabs/fill)

BIAXIN (clarithromycin) 250 MG/5 MLSUSPENSION

TIER 3

clarithromycin 125 mg/5ml, 250 mg/5ml TIER 1

clarithromycin 250 mg tablet, 500 mgtablet, 500 mg tab er 24h


DIFICID (fidaxomicin) TIER 3 PA, QLC (20 tabs/month)

E.E.S. 200 (erythromycin ethylsuccinate) TIER 3

E.E.S. 400 (erythromycin ethylsuccinate) TIER 3

ERY-TAB (erythromycin base) TIER 2

ERYGEL (erythromycin base in ethanol) TIER 1

ERYPED 200 (erythromycin ethylsuccinate) TIER 3

ERYPED 400 (erythromycin ethylsuccinate) TIER 3

ERYTHROCIN STEARATE (erythromycinstearate)

TIER 2




20



LIMITSerythromycin base TIER 1

erythromycin base in ethanol TIER 1

erythromycin base in ethanol (ERY) TIER 1

erythromycin ethylsuccinate TIER 1

KETEK (telithromycin) TIER 3 QLC (20 tabs/fill)

PCE (erythromycin base) TIER 3

ZITHROMAX (azithromycin) 1 GM POWDERPACKET, 100 MG/5 ML SUSP, 200 MG/5 MLSUSP, 250 MG TABLET, 250 MG Z-PAKTABLET, 500 MG TABLET, 600 MG TABLET

TIER 3

ZITHROMAX TRI-PAK (azithromycin) TIER 3

ZMAX (azithromycin) TIER 3 QLC (1 bottle/fill)

QUINOLONESAVELOX (moxifloxacin hcl) TIER 3 QLC (10 tabs/fill)

AVELOX ABC PACK (moxifloxacin hcl) TIER 3 QLC (10 tabs/fill)

BAXDELA (delafloxacin meglumine) 450MG TABLET


BESIVANCE (besifloxacin hcl) TIER 3 QLC (5 ml/month)

CETRAXAL (ciprofloxacin hcl) TIER 3

CILOXAN (ciprofloxacin hcl) 0.3% EYEDROPS

TIER 3

CILOXAN (ciprofloxacin hcl) 0.3%OINTMENT

TIER 2

CIPRO (ciprofloxacin hcl) TIER 3 QLC (2 tabs/day)

CIPRO (ciprofloxacin) 10% SUSPENSION TIER 3 QLC (3 bottles/fill)

CIPRO (ciprofloxacin) 5% SUSPENSION TIER 3 QLC (2 bottles/fill)

CIPRO XR (ciprofloxacin/ciprofloxacin hcl)1,000 MG TABLET


CIPRO XR (ciprofloxacin/ciprofloxacin hcl)500 MG TABLET


ciprofloxacin 250 mg/5ml sus mc rec TIER 1 QLC (2 bottles/fill)

ciprofloxacin 500 mg/5ml sus mc rec TIER 1 QLC (3 bottles/fill)

ciprofloxacin hcl 0.2 % droperette, 0.3 %drops

TIER 1




21



LIMITSciprofloxacin hcl 100 mg tablet, 250 mgtablet, 500 mg tablet, 750 mg tablet


ciprofloxacin/ciprofloxacin hcl 1000 mgtbmp 24hr


ciprofloxacin/ciprofloxacin hcl 500 mgtbmp 24hr


FACTIVE (gemifloxacin mesylate) TIER 3 QLC (1 box/fill)

gatifloxacin TIER 1 QLC (one 2.5 ml bottle/month)

LEVAQUIN (levofloxacin) TIER 3 QLC (10 tabs/fill)

levofloxacin 0.5 % drops TIER 1

levofloxacin 250 mg tablet, 500 mg tablet,750 mg tablet


levofloxacin 250mg/10ml, 500mg/20ml TIER 1 QLC (300 ml/fill)

MOXEZA (moxifloxacin hcl) TIER 2

moxifloxacin hcl 0.5 % drops TIER 1

moxifloxacin hcl 400 mg tablet TIER 1 QLC (10 tabs/fill)

OCUFLOX (ofloxacin) TIER 3

ofloxacin TIER 1

VIGAMOX (moxifloxacin hcl) TIER 3

ZYMAXID (gatifloxacin) TIER 3 QLC (one 2.5 ml bottle/month)

SULFONAMIDESAVC (sulfanilamide) TIER 2

BACTRIM (sulfamethoxazole/trimethoprim) TIER 3

BACTRIM DS(sulfamethoxazole/trimethoprim)

TIER 3

BLEPH-10 (sulfacetamide sodium) TIER 3

KLARON (sulfacetamide sodium) TIER 3

SILVADENE (silver sulfadiazine) TIER 3

silver sulfadiazine TIER 1

SSD (silver sulfadiazine) TIER 3

sulfacetamide sodium 10 % suspension, 10% oint. (g), 10 % drops

TIER 1

sulfadiazine TIER 1




22



LIMITSsulfamethoxazole/trimethoprim 200-40mg/5 oral susp, 400mg-80mg tablet,800-160 mg tablet

TIER 1

sulfamethoxazole/trimethoprim 800-160/20 oral susp

TIER 1 PA

SULFATRIM(sulfamethoxazole/trimethoprim)

TIER 3

THERMAZENE (silver sulfadiazine) TIER 3

TETRACYCLINESACTICLATE (doxycycline hyclate) TIER 3 PA, QLC (1 tab/day)

ADOXA (doxycycline monohydrate) TIER 3

demeclocycline hcl TIER 1

DORYX (doxycycline hyclate) DR 200 MGTABLET


DORYX (doxycycline hyclate) DR 50 MGTABLET


DORYX MPC (doxycycline hyclate) TIER 3 PA, QLC (2 tabs/day)

doxycycline hyclate (MORGIDOX) TIER 1

doxycycline hyclate (SOLOXIDE) TIER 1 PA, QLC (1 tab/day)

doxycycline hyclate 20 mg tablet TIER 1 QLC (2 tabs/day)

doxycycline hyclate 50 mg capsule, 100mg capsule, 100 mg tablet

TIER 1

doxycycline hyclate 50 mg tablet, 50 mgtablet dr


doxycycline hyclate 75 mg tablet dr, 100mg tablet dr

TIER 1 PA

doxycycline hyclate 75 mg tablet, 150 mgtablet dr, 150 mg tablet, 200 mg tablet dr


doxycycline hyclate 80 mg tablet dr TIER 3 PA, QLC (2 tabs/day)

doxycycline monohydrate (AVIDOXY) TIER 1

doxycycline monohydrate (MONDOXYNENL)

TIER 1

doxycycline monohydrate (OKEBO) TIER 1




23



LIMITSdoxycycline monohydrate 25 mg/5 mlsusp recon, 50 mg capsule, 50 mg tablet,75 mg tablet, 75 mg capsule, 100 mgcapsule, 100 mg tablet, 150 mg capsule,150 mg tablet

TIER 1

doxycycline monohydrate 40 mg cap ir TIER 1 PA, QLC (1 cap/day; max 120caps/5 months)

MINOCIN (minocycline hcl) 50 MG CAP,75 MG CAP, 100 MG CAP

TIER 3

minocycline hcl (COREMINO) TIER 3 PA, QLC (1 tab/day)

minocycline hcl 45 mg tab er, 65 mg taber, 90 mg tab er, 115mg tab er, 135 mgtab er


minocycline hcl 50 mg tablet, 50 mgcapsule, 75 mg capsule, 75 mg tablet,100 mg tablet, 100 mg capsule

TIER 1

minocycline hcl 55 mg tab er 24h TIER 3 PA, QLC (1 tab/day)

minocycline hcl 80 mg tab er, 105 mg taber


MINOLIRA ER (minocycline hcl) TIER 3 PA, QLC (1 tab/day)

MONODOX (doxycycline monohydrate) TIER 3

NUZYRA (omadacycline tosylate) 150 MGTABLET

TIER 4 PA, QLC (6 tabs/28 days)

NUZYRA (omadacycline tosylate) 150 MGTABLET-7 DAY


NUZYRA (omadacycline tosylate) 150 MG-7 DAY WITH LOAD


ORACEA (doxycycline monohydrate) TIER 3 PA, QLC (1 cap/day; max 120caps/5 months)

SEYSARA (sarecycline hcl) TIER 4 PA, QLC (1 tab/day)

SOLODYN (minocycline hcl) TIER 3 PA, QLC (1 tab/day)

TARGADOX (doxycycline hyclate) TIER 3 PA, QLC (2 tabs/day)

tetracycline hcl TIER 1

VIBRAMYCIN (doxycycline calcium) TIER 2

VIBRAMYCIN (doxycycline hyclate) TIER 3

VIBRAMYCIN (doxycycline monohydrate) TIER 3

XIMINO (minocycline hcl) TIER 4 PA, QLC (1 cap/day)




24



LIMITS

ANTICONVULSANTS (Drugs for Seizures)

ANTICONVULSANTS, OTHER (Other Seizure Control Drugs)BRIVIACT (brivaracetam) 10 MG TABLET,25 MG TABLET, 50 MG TABLET, 75 MGTABLET, 100 MG TABLET


BRIVIACT (brivaracetam) 10 MG/ML ORALSOLN

TIER 3 ST, QLC (20 ml/day)

DIACOMIT (stiripentol) 250 MG CAPSULE TIER 4 PA, SP, QLC (3 caps/day)

DIACOMIT (stiripentol) 250 MG POWDERPACKET

TIER 4 PA, SP, QLC (3 packets/day)

DIACOMIT (stiripentol) 500 MG CAPSULE TIER 4 PA, SP, QLC (6 caps/day)

DIACOMIT (stiripentol) 500 MG POWDERPACKET

TIER 4 PA, SP, QLC (6 packets/day)

EPIDIOLEX (cannabidiol (cbd) extract) TIER 4 PA, SP, QLC (4 bottles/28 days)

KEPPRA (levetiracetam) 100 MG/ML ORALSOLN, 250 MG TABLET, 500 MG TABLET, 750MG TABLET, 1,000 MG TABLET

TIER 3

KEPPRA XR (levetiracetam) 500 MGTABLET


KEPPRA XR (levetiracetam) 750 MGTABLET


levetiracetam (ROWEEPRA XR) 500 mgtab er 24h


levetiracetam (ROWEEPRA XR) 750 mgtab er 24h


levetiracetam (ROWEEPRA) TIER 1

levetiracetam 100 mg/ml solution, 250 mgtablet, 500 mg tablet, 500 mg/5mlsolution, 750 mg tablet, 1000 mg tablet

TIER 1

levetiracetam 500 mg tab er 24h TIER 1 QLC (6 tabs/day)

levetiracetam 750 mg tab er 24h TIER 1 QLC (4 tabs/day)

POTIGA (ezogabine) 200 MG TABLET, 300MG TABLET, 400 MG TABLET


POTIGA (ezogabine) 50 MG TABLET TIER 3 QLC (9 tabs/day)

SPRITAM (levetiracetam) 1,000 MG TABLET TIER 3 PA, QLC (3 tabs/day)




25



LIMITSSPRITAM (levetiracetam) 250 MG TABLET,500 MG TABLET


SPRITAM (levetiracetam) 750 MG TABLET TIER 3 PA, QLC (4 tabs/day)

CALCIUM CHANNEL MODIFYING AGENTSCELONTIN (methsuximide) TIER 3

ethosuximide TIER 1

ZARONTIN (ethosuximide) TIER 3

ZONEGRAN (zonisamide) TIER 3

zonisamide TIER 1

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSclobazam 10 mg tablet, 20 mg tablet TIER 1 ST, QLC (2 tabs/day)

clobazam 2.5 mg/ml oral susp TIER 1 ST, QLC (16 ml/day)

DEPAKENE (valproic acid (as sodium salt)(valproate sodium))

TIER 3

DEPAKENE (valproic acid) TIER 3

DEPAKOTE (divalproex sodium) TIER 3

DEPAKOTE ER (divalproex sodium) TIER 3

DEPAKOTE SPRINKLE (divalproex sodium) TIER 3

DIASTAT (diazepam) TIER 3 QLC (1 kit [2 doses]/fill)

DIASTAT ACUDIAL (diazepam) TIER 3 QLC (1 kit [2 doses]/fill)

diazepam 2.5 mg, 5-7.5-10mg, 12.5-15-20 TIER 1 QLC (1 kit [2 doses]/fill)

divalproex sodium TIER 1

gabapentin 100 mg capsule, 300 mgcapsule, 400 mg capsule, 600 mg tablet,800 mg tablet

TIER 1

gabapentin 250 mg/5ml, 300 mg/6ml TIER 1 PA

GABITRIL (tiagabine hcl) TIER 3

GRALISE (gabapentin) 30-DAY STARTERPACK

TIER 3 PA, QLC (1 pack/month)

GRALISE (gabapentin) ER 300 MG TABLET TIER 3 PA, QLC (1 tab/day)

GRALISE (gabapentin) ER 600 MG TABLET TIER 3 PA, QLC (3 tabs/day)

MYSOLINE (primidone) TIER 3




26



LIMITSNEURONTIN (gabapentin) TIER 3

ONFI (clobazam) 10 MG TABLET, 20 MGTABLET


ONFI (clobazam) 2.5 MG/ML SUSPENSION TIER 3 ST, QLC (16 ml/day)

phenobarbital TIER 1

primidone TIER 1

SABRIL (vigabatrin) 500 MG POWDERPACKET

TIER 4 PA, SP, QLC (6 packs/day)

SABRIL (vigabatrin) 500 MG TABLET TIER 4 PA, SP, QLC (6 tabs/day)

SYMPAZAN (clobazam) TIER 3 PA, QLC (2 films/day)

tiagabine hcl TIER 1

valproic acid TIER 1

valproic acid (as sodium salt) (valproatesodium) 250 mg/5ml, 500mg/10ml

TIER 1

vigabatrin (VIGADRONE) TIER 4 PA, SP, QLC (6 packs/day)

vigabatrin 500 mg powd pack TIER 4 PA, SP, QLC (6 packs/day)

vigabatrin 500 mg tablet TIER 4 PA, SP, QLC (6 tabs/day)

GLUTAMATE REDUCING AGENTSfelbamate TIER 1

FELBATOL (felbamate) TIER 3

FYCOMPA (perampanel) 0.5 MG/MLORAL SUSP


FYCOMPA (perampanel) 2 MG TABLET TIER 3 ST, QLC (3 tabs/day)

FYCOMPA (perampanel) 4 MG TABLET, 6MG TABLET, 8 MG TABLET, 10 MG TABLET,12 MG TABLET


LAMICTAL (BLUE) (lamotrigine) TIER 3

LAMICTAL (GREEN) (lamotrigine) TIER 3

LAMICTAL (lamotrigine) TIER 3

LAMICTAL (ORANGE) (lamotrigine) TIER 3

LAMICTAL ODT (BLUE) (lamotrigine) TIER 3 PA, QLC (1 starter kit/month)

LAMICTAL ODT (GREEN) (lamotrigine) TIER 3 PA, QLC (1 starter kit/month)

LAMICTAL ODT (lamotrigine) TIER 3 PA




27



LIMITSLAMICTAL ODT (ORANGE) (lamotrigine) TIER 3 PA, QLC (1 starter kit/month)

LAMICTAL XR (BLUE) (lamotrigine) TIER 3 ST, QLC (1 kit/month)

LAMICTAL XR (GREEN) (lamotrigine) TIER 3 ST, QLC (1 kit/month)

LAMICTAL XR (lamotrigine) 200 MG TABLET TIER 3 ST, QLC (3 tabs/day)

LAMICTAL XR (lamotrigine) 25 MG TABLET,50 MG TABLET, 100 MG TABLET


LAMICTAL XR (lamotrigine) 250 MGTABLET, 300 MG TABLET


LAMICTAL XR (ORANGE) (lamotrigine) TIER 3 ST, QLC (1 kit/month)

lamotrigine (SUBVENITE (BLUE)) TIER 1

lamotrigine (SUBVENITE (GREEN)) TIER 1

lamotrigine (SUBVENITE (ORANGE)) TIER 1

lamotrigine (SUBVENITE) TIER 1

lamotrigine 200 mg tab er 24 TIER 1 ST, QLC (3 tabs/day)

lamotrigine 25 mg tab er 24, 50 mg tab er24, 100 mg tab er 24


lamotrigine 25 mg tab rapdis, 50 mg tabrapdis, 100 mg tab rapdis, 200 mg tabrapdis

TIER 1 PA

lamotrigine 25-50-100, 25(21)-50, 50(42)-100

TIER 1 PA, QLC (1 starter pack/month)

lamotrigine 250 mg tab er 24, 300 mg taber 24


lamotrigine 5 mg tb chw dsp, 25(84)-100tab ds pk, 25 mg tb chw dsp, 25 mgtablet, 25(42)-100 tab ds pk, 25mg (35)tab ds pk, 100 mg tablet, 150 mg tablet,200 mg tablet

TIER 1

QUDEXY XR (topiramate) 150 MGCAPSULE, 200 MG CAPSULE


QUDEXY XR (topiramate) 25 MG CAPSULE,50 MG CAPSULE, 100 MG CAPSULE


TOPAMAX (topiramate) TIER 3

topiramate 15 mg cap sprink, 25 mgtablet, 25 mg cap sprink, 50 mg tablet,100 mg tablet, 200 mg tablet

TIER 1

topiramate 150 mg cap 24, 200 mg cap24





28



LIMITStopiramate 25 mg cap 24, 50 mg cap 24,100 mg cap 24


TROKENDI XR (topiramate) 200 MGCAPSULE


TROKENDI XR (topiramate) 25 MGCAPSULE, 100 MG CAPSULE


TROKENDI XR (topiramate) 50 MGCAPSULE


SODIUM CHANNEL AGENTSAPTIOM (eslicarbazepine acetate) 200MG TABLET, 400 MG TABLET


APTIOM (eslicarbazepine acetate) 600MG TABLET, 800 MG TABLET


BANZEL (rufinamide) 200 MG TABLET TIER 3 ST, QLC (2 tabs/day)

BANZEL (rufinamide) 40 MG/MLSUSPENSION


BANZEL (rufinamide) 400 MG TABLET TIER 3 ST, QLC (8 tabs/day)

carbamazepine TIER 1

carbamazepine (EPITOL) TIER 1

CARBATROL (carbamazepine) TIER 3

DILANTIN (phenytoin sodium extended) TIER 2

DILANTIN (phenytoin) TIER 2

DILANTIN-125 (phenytoin) TIER 2

oxcarbazepine 150 mg tablet, 300 mgtablet


oxcarbazepine 300 mg/5ml oral susp TIER 1 QLC (40 ml/day)

oxcarbazepine 600 mg tablet TIER 1 QLC (4 tabs/day)

OXTELLAR XR (oxcarbazepine) 150 MGTABLET, 300 MG TABLET


OXTELLAR XR (oxcarbazepine) 600 MGTABLET


PEGANONE (ethotoin) TIER 3

PHENYTEK (phenytoin sodium extended) TIER 3

phenytoin TIER 1

phenytoin sodium extended TIER 1




29



LIMITSTEGRETOL (carbamazepine) TIER 3

TEGRETOL XR (carbamazepine) TIER 3

TRILEPTAL (oxcarbazepine) 150 MGTABLET, 300 MG TABLET


TRILEPTAL (oxcarbazepine) 300 MG/5 MLSUSP

TIER 3 QLC (40 ml/day)

TRILEPTAL (oxcarbazepine) 600 MG TABLET TIER 3 QLC (4 tabs/day)

VIMPAT (lacosamide) 10 MG/MLSOLUTION


VIMPAT (lacosamide) 50 MG TABLET, 100MG TABLET, 150 MG TABLET, 200 MGTABLET


ANTIDEMENTIA AGENTS (Drugs for Alzheimer's Disease andDementia)

ANTIDEMENTIA AGENTS, OTHERergoloid mesylates TIER 1

CHOLINESTERASE INHIBITORSARICEPT (donepezil hcl) 23 MG TABLET TIER 3 ST, QLC (1 tab/day)

ARICEPT (donepezil hcl) 5 MG TABLET, 10MG TABLET

TIER 3

donepezil hcl 23 mg tablet TIER 1 ST, QLC (1 tab/day)

donepezil hcl 5 mg tab rapdis, 5 mgtablet, 10 mg tab rapdis, 10 mg tablet

TIER 1

EXELON (rivastigmine tartrate) TIER 3

EXELON (rivastigmine) TIER 3 QLC (1 patch/day)

galantamine hbr TIER 1

NAMZARIC (memantine hcl/donepezilhcl) 7 MG-10 MG CAPSULE, 14 MG-10 MGCAPSULE, 21 MG-10 MG CAPSULE, 28 MG-10 MG CAPSULE

TIER 2 QLC (1 cap/day)

NAMZARIC (memantine hcl/donepezilhcl) TITRATION PACK

TIER 2 QLC (1 dose-pack/6 months)

RAZADYNE (galantamine hbr) TIER 3

RAZADYNE ER (galantamine hbr) TIER 3




30



LIMITSrivastigmine TIER 1 QLC (1 patch/day)

rivastigmine tartrate TIER 1

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl 2 mg/ml solution, 5 mg-10mg tab ds pk

TIER 1

memantine hcl 5 mg tablet, 10 mg tablet TIER 1 QLC (2 tabs/day)

memantine hcl 7 mg cap 24, 14 mg cap24, 21 mg cap 24, 28 mg cap 24


NAMENDA (memantine hcl) 2 MG/MLSOLUTION, 5-10 MG TITRATION PK

TIER 3

NAMENDA (memantine hcl) 5 MG TABLET,10 MG TABLET


NAMENDA XR (memantine hcl) 7 MGCAPSULE, 14 MG CAPSULE, 21 MGCAPSULE, 28 MG CAPSULE


NAMENDA XR (memantine hcl) TITRATIONPACK


ANTIDEPRESSANTS (Drugs for Depression)

ANTIDEPRESSANTS, OTHERamitriptyline hcl/chlordiazepoxide TIER 1

APLENZIN (bupropion hbr) TIER 3 ST, QLC (1 tab/day)

bupropion hcl 100 mg tab sr 12h, 100 mgtablet


bupropion hcl 150 mg tab sr 12h, 150 mgtab er 24h


bupropion hcl 200 mg tab sr 12h TIER 1 QLC (2 tabs/day)

bupropion hcl 300 mg tab er 24h TIER 1 QLC (1 tab/day)

bupropion hcl 450 mg tab er 24h TIER 1 ST, QLC (1 tab/day)

bupropion hcl 75 mg tablet TIER 1 QLC (6 tabs/day)

FORFIVO XL (bupropion hcl) TIER 3 ST, QLC (1 tab/day)

mirtazapine TIER 1

olanzapine/fluoxetine hcl TIER 1

perphenazine/amitriptyline hcl TIER 1




31



LIMITSREMERON (mirtazapine) TIER 3

SYMBYAX (olanzapine/fluoxetine hcl) TIER 3

WELLBUTRIN (bupropion hcl) 100 MGTABLET


WELLBUTRIN (bupropion hcl) 75 MG TABLET TIER 3 QLC (6 tabs/day)

WELLBUTRIN SR (bupropion hcl) 100 MGTABLET






WELLBUTRIN XL (bupropion hcl) 150 MGTABLET


WELLBUTRIN XL (bupropion hcl) 300 MGTABLET


MONOAMINE OXIDASE INHIBITORSEMSAM (selegiline) TIER 3

MARPLAN (isocarboxazid) TIER 3

NARDIL (phenelzine sulfate) TIER 3

PARNATE (tranylcypromine sulfate) TIER 3

phenelzine sulfate TIER 1

tranylcypromine sulfate TIER 1

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKEINHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)

BRISDELLE (paroxetine mesylate) TIER 3 QLC (1 cap/day)

CELEXA (citalopram hydrobromide) 10MG TABLET






CITALOPRAM HBR (citalopramhydrobromide)

TIER 1 QLC (40 mg/day)

citalopram hydrobromide 10 mg tablet TIER 1 QLC (4 tabs/day)

citalopram hydrobromide 10 mg/5 mlsolution

TIER 1 QLC (40 mg/day)




32



LIMITScitalopram hydrobromide 20 mg tablet TIER 1 QLC (2 tabs/day)

citalopram hydrobromide 40 mg tablet TIER 1 QLC (1 tab/day)

desvenlafaxine TIER 3 ST, QLC (1 tab/day)

desvenlafaxine fumarate TIER 3 ST, QLC (1 tab/day)

desvenlafaxine succinate TIER 1 QLC (1 tab/day)

EFFEXOR XR (venlafaxine hcl) 37.5 MGCAPSULE, 150 MG CAPSULE


EFFEXOR XR (venlafaxine hcl) 75 MGCAPSULE


escitalopram oxalate 10 mg tablet TIER 1 QLC (4 tabs/day)



escitalopram oxalate 5 mg/5 ml solution TIER 1 QLC (24 ml/day)

FETZIMA (levomilnacipran hcl) TIER 3 PA, QLC (1 cap/day)

fluoxetine hcl 10 mg capsule, 10 mgtablet, 20 mg capsule, 20 mg tablet, 20mg/5 ml solution, 40 mg capsule

TIER 1

fluoxetine hcl 60 mg tablet TIER 3

fluoxetine hcl 90 mg capsule dr TIER 1 QLC (4 caps/month)

fluvoxamine maleate 100 mg cap er 24h TIER 1 ST, QLC (3 caps/day)

fluvoxamine maleate 150 mg cap er 24h TIER 1 ST, QLC (2 caps/day)

fluvoxamine maleate 25 mg tablet, 50 mgtablet, 100 mg tablet

TIER 1

KHEDEZLA (desvenlafaxine) TIER 3 ST, QLC (1 tab/day)

LEXAPRO (escitalopram oxalate) 10 MGTABLET






LEXAPRO (escitalopram oxalate) 5 MG/5ML SOLUTION

TIER 3 QLC (24 ml/day)

maprotiline hcl TIER 1

nefazodone hcl TIER 1

paroxetine hcl TIER 1




33



LIMITSparoxetine mesylate TIER 1 QLC (1 cap/day)

PAXIL (paroxetine hcl) 10 MG TABLET, 20MG TABLET, 30 MG TABLET, 40 MG TABLET

TIER 3

PAXIL (parox

plus drug formulary (dmhc) · the blue shield plus drug formulary is a list of medications that are...

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