sparrow caregiver prescription drug list, october 20 · 10/1/2020 · this prescription drug list...
TRANSCRIPT
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Sparrow Caregiver Prescription Drug List, March 2021
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Introduction
This Prescription Drug List (PDL) is the list of covered medications for the Sparrow Health System employer group. The PDL applies only to prescription medications that a PHP member picks up at a pharmacy or other outpatient location; it does not include inpatient medications or medications obtained or administered in a Physician’s office. Some over-the-counter medications are covered due to federal regulations and the member’s specific pharmacy benefit plan.
The PDL does not define benefit coverage. Benefit coverage is determined by the member’s specific pharmacy benefit plan. This means that there may be medications listed on the PDL that are not covered because they are not a covered benefit under the member’s pharmacy benefit plan.
You may also access PDL information by visiting our website at PHPMichigan.com. For general questions regarding the PDL, call toll-free PHP’s Customer Service Department at 1.800.832.9186
Prescription Drug List Medication Overview
Medications on the PDL fall under different benefit tiers based on a review of clinical, economic, and other factors. The PHP Pharmacy & Therapeutics (P&T) Committee, composed of Physicians and Pharmacists, reviews new and existing medications and provides clinical guidance for formulary development and tier placement. Guidance is based on similarities and differences compared with other medications that treat the same disease or condition. This helps ensure members have access to a wide range of medications while controlling healthcare costs.
The tier placement of a medication on the PDL may be subject to change. When a medication changes tiers, the member may be required to pay more or less. These changes may occur without prior notice. Members may visit the PHP website at PHPMichigan.com. Call PHP’s Customer Service Department at 1.800.832.9186 or 517.364.8500 for the most up-to-date tier status and copayment information.
• The Prescription Drug Guide applies to Sparrow Health System Caregivers. Coverage is based upon the member’s benefit Summary Plan Description (SPD).
• Specific Over-The-Counter (OTC) medications are covered based upon Health Care Reform (HCR) and the member’s benefit. Members must refer to their SPD for coverage and benefit information.
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Tier Designations
Prescription medications are categorized within four tiers on the PDL. Each tier is assigned a copayment, which is determined by the member’s pharmacy benefit plan. Providers may refer to the PDL as a guide to select the most appropriate medication with the lowest member copayment for your Patients.
ACA
A select list of prescription and over-the-counter medications are classified as preventive medications based upon the Health Care Reform (HCR) Affordable Care Act (ACA) guidelines. These medications are available to members at zero ($0) copayment. More information on preventive medications is included in the member’s specific benefit plan.
Tier 1
Medications on Tier 1 will have the lowest member cost share. Most medications on this tier are generic medications.
Tier 2
Tier 2 medications are preferred, branded, traditional, and specialty medications. A provider may consider a Tier 2 medication if no Tier 1 medication is appropriate to treat the member’s condition. Members will have a higher cost share for Tier 2 medications.
Tier 3
Tier 3 medications are non-preferred traditional medications. Members will have the highest cost share for Tier 3 medications, unless the medication is a specialty medication and is designated as Tier 4 based upon a member’s pharmacy benefit.
Tier 4
Tier 4 medications are non-preferred specialty medications. Tier 4 medications will have the highest member cost share based upon a member’s pharmacy benefit.
Specific information about the member’s cost share, including copays, deductible and coinsurance amounts, can be found in the member’s Certificate of Coverage. For more information, please call PHP’s Customer Service Department at 800.832.916 or 517.364.8500.
Medications listed in lowercase italics indicate the generic name of the medication. Medications listed in all UPPERCASE indicate a branded, single-source, or authorized generic medication.
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Over-the-Counter Medications
For many conditions, an over-the-counter (OTC) medication may be the most appropriate treatment. OTC medications are defined as medications that do not require a prescription by federal or state law to be dispensed. Specific OTC medications are covered based on the member’s specific benefit plan and federal regulations. Therapeutic equivalent and OTC medications may not be covered under the member’s pharmacy benefit, and they may cost less than the member’s out-of-pocket expense for prescription medications. However, if the Patient or Physician requests a therapeutic equivalent product or an OTC product, the Patient may be required to pay the entire cost of the product. This is determined by the member’s pharmacy benefit plan.
Generic Medication Policy
Most generic medications are included on the PDL as Tier 1 medications. Members will have the lowest cost share with a Tier 1 medication, so consider prescribing a generic, Tier 1 medication when appropriate. Note that when a brand-name medication becomes available as a generic, that brand-name product may move to a higher tier. Unless the Physician specifies that the medication must be Dispensed As Written (DAW), the pharmacist may substitute the name brand for a lower cost generic equivalent. When generic substitution conflicts with state regulations or restrictions, the dispensing Pharmacist must obtain approval from the prescribing Physician or other healthcare professional to substitute the generic equivalent.
Self-Administered Injectables
Some members may have coverage for self-administered injectable medications through their pharmacy benefit plan. You will find these medications included in the body of this document within the appropriate therapeutic categories.
Medications Requiring Notification and Other Pharmacy Programs
Select medications may require Prior Authorization (PA) in order to be covered. These medications are noted with a PA in this document. The list of the medications requiring PA is provided below. The list is approved by the PHP Pharmacy and Therapeutics Committee. To initiate a PA review for a certain medication, the provider or provider’s designee must complete a Prior Authorization Request Form and fax the completed form to the PHP Pharmacy Department at 517.364.8413. The Prior Authorization Request Form for medications as well as PA criteria can be found on the website at www.phpmichigan.com/ providers/general-forms-and-information.
Quantity limitations are based on FDA-approved dosing recommendations and package size as well as plan benefit limitations. Such medications have a notation “QL,” for
http://www.phpmichigan.com/%20providers/general-forms-and-information
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quantity limit. These quantity limitations define either the maximum supply of medication per copayment or a defined maximum amount that can be covered in a specific time period, as specified by the pharmacy benefit plan. Exceptions to the QL for certain medications are reviewed through the PA process, outlined above.
Some medications are excluded for certain uses or are only covered for specific diagnoses. In general, PHP benefit plans do not cover medications that are prescribed for conditions outside of those approved by the Federal Drug Administration (FDA).
If you have questions about the PDL or specific coverage requirements, call PHP’s Customer Service Department at 800.832.916 or 517.364.8500.
Keys To Symbols
Symbols used throughout the PDL have these definitions:
AL = Age Limitation. Prior notification may be required to be eligible for coverage depending on Patient age.
ACA = Affordable Care Act Preventative Medications. These are covered at zero copayment ($0) to the member.
LA = Limited Access. This medication may be covered only at certain pharmacies or as a medical benefit. Coverage is based upon the member’s benefit. For more information, please call Customer Service.
PA = Prior Authorization required. Approval of this medication is required prior to coverage by PHP.
QL = Quantity limit.
SP = Specialty Medication. This medication allows a maximum of a one month supply per fill.
ST = Step therapy. This medication requires trial of a preferred agent prior to coverage.
SEMS = Sparrow Extended Medication Supply Program List. 90-day supplies of medications on this list are available at Sparrow Pharmacies for one tier 1 copay.
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Language Access Information ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1‐800‐649‐3777 (TTY: 711).
Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1‐800‐649‐3777 (TTY: 711).
Arabic:
كم: بملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم وال
1-800-649-377 (TTY: 711)
Chinese: 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1‐800‐649‐3777
(TTY: 711)
German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche
Hilfsdienstleistungen zur Verfügung. Rufnummer: 1‐800‐649‐3777 (TTY: 711).
Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza
linguistica gratuiti. Chiamare il numero 1‐800‐649‐3777 (TTY: 711).
Japanese: 注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。
1‐800‐649‐3777 (TTY: 711) まで、お電話にてご連絡ください
Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-
1‐800‐649‐3777 (TTY: 711) 번으로 전화해 주십시오.
Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.
Zadzwoń pod numer 1‐800‐649‐3777 (TTY: 711).
Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги
перевода. Звоните 1‐800‐649‐3777 (TTY: 711).
Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng
tulong sa wika nang walang bayad. Tumawag sa 1‐800‐649‐3777 (TTY: 711).
Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.
Gọi số 1‐800‐649‐3777 (TTY: 711).
Bengali: লক্ষ্য করুনঃ যদি আপদন বাাংলা, কথা বলতে পাতেন, োহতল দনঃখেচায় ভাষা সহায়ো পদেতষবা
উপলব্ধ আতে। ফ ান করুন ১-1‐800‐649‐3777 (TTY: 711)।
Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa
pagesë. Telefononi në 1‐800‐649‐3777 (TTY: 711).
Serbo-Croatian: OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1‐800‐649‐3777 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711).
Syriac:
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PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
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Sparrow 4T eff 03/01/2021 Drug Name Drug Tier Requirements/Limits
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS AMPHETAMINES
ADDERALL Tier 3 QL
ADDERALL XR Tier 1 QL
amphetamine sulfate Tier 1 QL
amphetamine-dextroamphetamine Tier 1 QL
dextroamphetamine sulfate Tier 1
MYDAYIS Tier 3 QL
VYVANSE Tier 2 QL
ANALEPTICS caffeine citrate Tier 1
ANOREXIANTS NON-AMPHETAMINE ADIPEX-P Tier 3 QL
benzphetamine hcl Tier 1
diethylpropion hcl Tier 1
phendimetrazine tartrate Tier 1
phentermine hcl Tier 1
ANTI-OBESITY AGENTS CONTRAVE Tier 3 ST
SAXENDA Tier 3 PA
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS atomoxetine hcl Tier 1 QL
clonidine hcl (adhd) Tier 1
guanfacine hcl (adhd) Tier 1
INTUNIV Tier 3
KAPVAY Tier 3
DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS
(DNRIS) SUNOSI Tier 3 PA
STIMULANTS - MISC. APTENSIO XR Tier 3 ST, QL
armodafinil Tier 1 ST, QL
CONCERTA Tier 1 QL
COTEMPLA XR-ODT Tier 3 ST, QL
DAYTRANA Tier 2 ST, QL
dexmethylphenidate hcl CP24 Tier 1
dexmethylphenidate hcl TABS Tier 1 QL
FOCALIN Tier 3 QL
FOCALIN XR Tier 3
METHYLIN Tier 3 QL
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PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
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Drug Name Drug Tier Requirements/Limits
methylphenidate hcl CHEW Tier 1 QL
methylphenidate hcl CP24 10mg Tier 1 QL
methylphenidate hcl CP24 10mg, 15mg, 20mg, 30mg, 40mg, 50mg, 60mg
Tier 1 ST, QL
methylphenidate hcl CP24 20mg, 30mg, 40mg, 60mg
Tier 1
methylphenidate hcl CPCR Tier 1 QL
methylphenidate hcl SOLN Tier 1 QL
methylphenidate hcl TABS 5mg Tier 1 QL
methylphenidate hcl TABS 10mg, 20mg Tier 1
methylphenidate hcl TB24 Tier 1 QL
methylphenidate hcl TBCR Tier 1
modafinil Tier 1 QL
QUILLICHEW ER Tier 3
QUILLIVANT XR Tier 2 ST, QL
RITALIN 5mg Tier 3 QL
RITALIN 10mg, 20mg Tier 3
RITALIN LA 10mg Tier 3 QL
RITALIN LA 20mg, 30mg, 40mg Tier 3
AMEBICIDES AMEBICIDES
SOLOSEC Tier 3 QL
AMINOGLYCOSIDES AMINOGLYCOSIDES
amikacin sulfate LA
ARIKAYCE Tier 4 SP, PA
BETHKIS Tier 4 SP, PA
gentamicin in saline LA
gentamicin sulfate LA
KITABIS PAK Tier 4 SP, PA
neomycin sulfate Tier 1
paromomycin sulfate Tier 1
streptomycin sulfate LA
TOBI Tier 4 SP, PA
TOBI PODHALER Tier 2 SP
tobramycin Tier 1 SP, PA
tobramycin sulfate SOLN 1.2gm/30ml, 10mg/ml
LA
tobramycin sulfate SOLN 40mg/ml, 80mg/2ml
Tier 1
tobramycin sulfate SOLR LA
ZEMDRI LA PA
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PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
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Drug Name Drug Tier Requirements/Limits
ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES
HUMIRA Tier 2 SP, PA
HUMIRA PEDIATRIC CROHNS D Tier 2 SP, PA
HUMIRA PEN Tier 2 SP, PA
HUMIRA PEN-CD/UC/HS START Tier 2 SP, PA
HUMIRA PEN-PS/UV STARTER Tier 2 SP, PA
SIMPONI ARIA LA SP, PA; MB
ANTIRHEUMATIC - ENZYME INHIBITORS RINVOQ Tier 2 SP, PA
XELJANZ Tier 2 SP, PA, QL
XELJANZ XR Tier 2 SP, PA, QL
ANTIRHEUMATIC ANTIMETABOLITES OTREXUP Tier 4 SP, PA
RASUVO Tier 4 SP, PA
GOLD COMPOUNDS RIDAURA Tier 3 PA
INTERLEUKIN-1 BLOCKERS ARCALYST LA SP, PA
INTERLEUKIN-1BETA BLOCKERS ILARIS Tier 4 SP, PA
INTERLEUKIN-6 RECEPTOR INHIBITORS ACTEMRA LA SP, PA; MB
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) ARTHROTEC 50 Tier 3
ARTHROTEC 75 Tier 3
CALDOLOR LA
celecoxib Tier 1 QL
DAYPRO Tier 3
diclofenac potassium Tier 1
diclofenac sodium Tier 1
diclofenac w/ misoprostol Tier 1
EC-NAPROSYN Tier 3
etodolac Tier 1
FELDENE Tier 3
FENOPROFEN CALCIUM CAPS Tier 3 PA
fenoprofen calcium TABS Tier 1
FENORTHO Tier 3 PA
flurbiprofen Tier 1
ibuprofen Tier 1 SEMS
INDOCIN Tier 3
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PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
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Drug Name Drug Tier Requirements/Limits
indomethacin Tier 1
indomethacin sodium LA
ketoprofen Tier 1
KETOROLAC TROMETHAMINE SOLN 15.75mg/spray
Tier 2
ketorolac tromethamine SOLN 15mg/ml, 30mg/ml
LA
ketorolac tromethamine SOLN 30mg/ml Tier 1
ketorolac tromethamine TABS Tier 1 QL
meclofenamate sodium Tier 1
mefenamic acid Tier 1
meloxicam Tier 1
MOBIC Tier 3
nabumetone Tier 1
NALFON Tier 3
NAPROSYN Tier 3
naproxen SUSP Tier 1
naproxen TABS Tier 1
naproxen TBEC 375mg, 500mg Tier 1
NAPROXEN TBEC 375mg, 500mg Tier 1
naproxen sodium Tier 1
oxaprozin Tier 1
piroxicam Tier 1
SPRIX Tier 2
sulindac Tier 1
tolmetin sodium Tier 1
ZIPSOR Tier 3
PHOSPHODIESTERASE 4 (PDE4) INHIBITORS OTEZLA Tier 2 SP, PA, QL
PYRIMIDINE SYNTHESIS INHIBITORS ARAVA Tier 3
leflunomide Tier 1
SELECTIVE COSTIMULATION MODULATORS ORENCIA LA SP, PA; MB
SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL SOLN Tier 2 SP, ST
ENBREL SOLR; SOSY Tier 2 SP, PA
ENBREL MINI Tier 2 SP, PA
ENBREL SURECLICK Tier 2 SP, PA
ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS
ALLZITAL Tier 3 PA
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PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
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Drug Name Drug Tier Requirements/Limits
butalbital-acetaminophen Tier 1
butalbital-acetaminophen Tier 1 PA
butalbital-acetaminophen-caffeine Tier 1
butalbital-aspirin-caffeine Tier 1
BUTALBITAL/ASPIRIN/CAFFEI Tier 1
ESGIC Tier 3
FIORICET Tier 3
SALICYLATES diflunisal Tier 1
salsalate Tier 1
ANALGESICS - OPIOID OPIOID AGONISTS
ACTIQ Tier 3 PA, QL
ALFENTANIL HYDROCHLORIDE Tier 3
CODEINE SULFATE 15mg, 30mg Tier 1 PA
codeine sulfate 60mg Tier 1 PA
DEMEROL LA
DILAUDID LIQD; TABS Tier 3 PA
DILAUDID SOLN LA
fentanyl 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hr
Tier 1 QL
fentanyl 37.5mcg/hr, 62.5mcg/hr, 87.5mcg/hr
Tier 3 QL
fentanyl citrate LPOP Tier 1 PA, QL
fentanyl citrate SOCT; SOLN LA
fentanyl citrate TABS Tier 1 PA
FENTORA Tier 3 PA
hydrocodone bitartrate Tier 1 PA
hydromorphone hcl LIQD; TABS; TB24 Tier 1 PA
hydromorphone hcl SOLN LA
HYDROMORPHONE HYDROCHLORI LA
HYSINGLA ER Tier 3 PA
INFUMORPH 200 LA
INFUMORPH 500 LA
LAZANDA 100mcg/act Tier 3 PA
LAZANDA 400mcg/act Tier 3 PA, QL
levorphanol tartrate Tier 1 PA
meperidine hcl SOLN 25mg/ml, 50mg/ml, 100mg/ml
LA
meperidine hcl SOLN 50mg/5ml Tier 1 PA
meperidine hcl TABS Tier 1 PA
methadone hcl CONC Tier 1
methadone hcl SOLN 5mg/5ml, 10mg/5ml Tier 1
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PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
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Drug Name Drug Tier Requirements/Limits
methadone hcl SOLN 10mg/ml LA
METHADONE HCL SOLN 10mg/ml LA
methadone hcl TABS Tier 1
methadone hcl TBSO Tier 1
morphine sulfate CP24 10mg, 20mg, 30mg, 50mg, 60mg, 80mg, 100mg
Tier 1 QL
morphine sulfate CP24 40mg Tier 1
MORPHINE SULFATE SOLN 1mg/ml, 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml
LA
morphine sulfate SOLN 10mg/5ml, 20mg/5ml, 20mg/ml, 100mg/5ml
Tier 1 PA
morphine sulfate SOLN .5mg/ml, 1mg/ml, 4mg/ml, 8mg/ml, 10mg/ml, 50mg/ml
LA
morphine sulfate SUPP 5mg, 10mg, 20mg Tier 1 PA
MORPHINE SULFATE SUPP 30mg Tier 1 PA
morphine sulfate TABS Tier 1 PA
morphine sulfate TBCR Tier 1 QL
morphine sulfate beads Tier 1 QL
morphine sulfate for continuous microinfusion
LA
MS CONTIN Tier 3 QL
NUCYNTA Tier 3 PA
NUCYNTA ER Tier 3 PA
OXAYDO Tier 3 PA
oxycodone hcl CAPS Tier 1 PA
oxycodone hcl CONC Tier 1 PA
oxycodone hcl SOLN Tier 1 PA
oxycodone hcl T12A 10mg, 15mg, 20mg, 30mg
Tier 1 QL
oxycodone hcl T12A 40mg, 60mg, 80mg Tier 1
oxycodone hcl TABS Tier 1 PA
OXYCONTIN 10mg, 15mg, 20mg, 30mg Tier 3 QL
OXYCONTIN 40mg Tier 3
OXYCONTIN 60mg, 80mg Tier 1
oxymorphone hcl TABS Tier 1 PA
oxymorphone hcl TB12 5mg, 10mg, 20mg, 30mg, 40mg
Tier 1 PA
oxymorphone hcl TB12 7.5mg, 15mg Tier 1 PA, QL
ROXICODONE Tier 3 PA
sufentanil citrate LA PA
tramadol hcl TABS 50mg Tier 1 PA
tramadol hcl TABS 100mg Tier 1
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PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
7
Drug Name Drug Tier Requirements/Limits
tramadol hcl TB24 Tier 1 QL
ULTIVA LA PA
XTAMPZA ER Tier 3 PA
ZOHYDRO ER Tier 3 PA
OPIOID COMBINATIONS acetaminophen w/ codeine SOLN Tier 1 PA
acetaminophen w/ codeine TABS Tier 1 PA, QL
acetaminophen-caff-dihydrocod Tier 1 PA, QL
butalbital-acetaminophen-caffeine w/ codeine
Tier 1 QL
butalbital-aspirin-caffeine w/cod Tier 1 QL
hydrocodone-acetaminophen SOLN Tier 1 PA
hydrocodone-acetaminophen SOLN Tier 1 PA, QL
hydrocodone-acetaminophen TABS Tier 1 PA, QL
hydrocodone-ibuprofen Tier 1 PA, QL
LORTAB Tier 3 PA
oxycodone w/ acetaminophen Tier 1 PA, QL
oxycodone-aspirin Tier 1 PA, QL
OXYCODONE/ACETAMINOPHEN Tier 3 PA
PERCOCET Tier 3 PA, QL
PROLATE Tier 3 PA
tramadol-acetaminophen Tier 1 PA, QL
ULTRACET Tier 3 PA, QL
OPIOID PARTIAL AGONISTS BELBUCA Tier 3 PA
buprenorphine Tier 1 QL
buprenorphine hcl SOLN LA PA
buprenorphine hcl SUBL Tier 1
buprenorphine hcl-naloxone hcl dihydrate Tier 1
butorphanol tartrate 1mg/ml, 2mg/ml LA
butorphanol tartrate 10mg/ml Tier 1 QL
nalbuphine hcl LA
pentazocine w/ naloxone Tier 1 PA
SUBLOCADE LA PA
SUBOXONE Tier 3
ZUBSOLV Tier 3
ANDROGENS-ANABOLIC ANABOLIC STEROIDS
ANADROL-50 Tier 3 PA
oxandrolone Tier 1
ANDROGENS ANDRODERM Tier 2 GENDER
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PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
8
Drug Name Drug Tier Requirements/Limits
ANDROGEL 20.25mg/1.25gm, 40.5mg/2.5gm
Tier 3 GENDER
ANDROGEL 25mg/2.5gm, 50mg/5gm Tier 3 QL; GENDER
ANDROGEL PUMP Tier 3 QL; GENDER
AVEED Tier 2 SP; GENDER
danazol Tier 1
DEPO-TESTOSTERONE Tier 3 GENDER
FORTESTA Tier 3 PA; GENDER
JATENZO Tier 3 PA; GENDER
NATESTO Tier 3 GENDER
TESTIM Tier 3 QL; GENDER
TESTOPEL Tier 2 GENDER
testosterone GEL 1%, 1.62%, 25mg/2.5gm, 50mg/5gm
Tier 1 QL; GENDER
testosterone GEL 10mg/act Tier 1 PA; GENDER
testosterone GEL 20.25mg/1.25gm, 40.5mg/2.5gm
Tier 1 GENDER
testosterone SOLN Tier 1 GENDER
testosterone cypionate Tier 1 GENDER
testosterone enanthate Tier 1
VOGELXO Tier 3 QL; GENDER
VOGELXO PUMP Tier 3 QL; GENDER
XYOSTED Tier 3 QL
ANORECTAL AND RELATED PRODUCTS INTRARECTAL STEROIDS
CORTENEMA Tier 3
CORTIFOAM Tier 2
hydrocortisone (intrarectal) Tier 1
UCERIS FOAM Tier 3 PA
RECTAL COMBINATIONS ANALPRAM-HC Tier 3
PROCORT Tier 3
PROCTOFOAM HC Tier 2
RECTAL STEROIDS ANUSOL-HC Tier 3
hydrocortisone (rectal) Tier 1
hydrocortisone acetate (rectal) Tier 1
PROCTOCORT Tier 3
VASODILATING AGENTS RECTIV Tier 2
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PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
9
Drug Name Drug Tier Requirements/Limits
ANTHELMINTICS ANTHELMINTICS
albendazole Tier 1 QL
ALBENZA Tier 3 QL
BILTRICIDE Tier 3 PA
EMVERM Tier 3 PA
ivermectin Tier 1
praziquantel Tier 1 PA
ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC.
FLAGYL Tier 3
IMPAVIDO Tier 3 PA
metronidazole CAPS; TABS Tier 1
METRONIDAZOLE SOLN LA
metronidazole in nacl LA
NEBUPENT Tier 3
pentamidine isethionate Tier 1
PRIMSOL Tier 3
tinidazole Tier 1
trimethoprim Tier 1
XIFAXAN Tier 2 PA
ANTI-INFECTIVE MISC. - COMBINATIONS BACTRIM Tier 3
BACTRIM DS Tier 3
methenamine-hyosc-methylene blue-benzoic acid-phenyl sal
Tier 1
methenamine-hyosc-methylene blue-sod phos-phenyl sal
Tier 1
methenamine-hyoscamine-methylene blue-sodium phosphate
Tier 1
sulfamethoxazole-trimethoprim SOLN LA
sulfamethoxazole-trimethoprim SUSP; TABS
Tier 1
ANTIPROTOZOAL AGENTS ALINIA Tier 3 PA
atovaquone Tier 1
LAMPIT Tier 3 PA
nitazoxanide Tier 1 PA
CARBAPENEMS ertapenem sodium LA
imipenem-cilastatin LA
meropenem LA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
10
Drug Name Drug Tier Requirements/Limits
MERREM Tier 3
RECARBRIO LA PA
VABOMERE LA PA
CHLORAMPHENICOLS chloramphenicol sodium succinate LA
CYCLIC LIPOPEPTIDES daptomycin LA PA
GLYCOPEPTIDES FIRVANQ Tier 2
VANCOCIN Tier 3
VANCOCIN HCL Tier 3
VANCOMYCIN LA
vancomycin hcl CAPS Tier 1
VANCOMYCIN HCL SOLN LA
vancomycin hcl SOLR LA
VANCOMYCIN HYDROCHLORIDE/ LA
VIBATIV LA PA
LEPROSTATICS dapsone Tier 1
LINCOSAMIDES CLEOCIN CAPS Tier 3
CLEOCIN PEDIATRIC GRANULE Tier 3
CLEOCIN PHOSPHATE LA PA
clindamycin hcl Tier 1
clindamycin palmitate hydrochloride Tier 1
clindamycin phosphate LA
clindamycin phosphate in d5w LA
lincomycin hcl Tier 1
MONOBACTAMS AZACTAM LA PA
aztreonam LA
CAYSTON Tier 4 SP, PA
OXAZOLIDINONES linezolid SOLN LA PA
linezolid SUSR; TABS Tier 1 QL
linezolid in sodium chloride LA PA
SIVEXTRO SOLR LA PA
SIVEXTRO TABS Tier 3
ZYVOX LA PA
PLEUROMUTILINS XENLETA Tier 3 PA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
11
Drug Name Drug Tier Requirements/Limits
POLYMYXINS colistimethate sodium LA
COLY-MYCIN M LA PA
polymyxin b sulfate LA
URINARY ANTI-INFECTIVES fosfomycin tromethamine Tier 1
HIPREX Tier 3
MACROBID Tier 3
MACRODANTIN Tier 3
methenamine hippurate Tier 1
methenamine mandelate Tier 1
MONUROL Tier 3
nitrofurantoin Tier 1
nitrofurantoin macrocrystal Tier 1
nitrofurantoin monohyd macro Tier 1
ANTIANGINAL AGENTS ANTIANGINALS-OTHER
ranolazine Tier 1 QL
NITRATES DILATRATE SR Tier 3
GONITRO Tier 3
ISORDIL TITRADOSE Tier 3
isosorbide dinitrate Tier 1
isosorbide mononitrate Tier 1
NITRO-BID Tier 2
NITRO-DUR Tier 3
nitroglycerin Tier 1
NITROLINGUAL PUMPSPRAY Tier 3
NITROMIST Tier 3
ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC.
buspirone hcl Tier 1
droperidol LA
hydroxyzine hcl SOLN LA PA
hydroxyzine hcl SYRP; TABS Tier 1
hydroxyzine pamoate Tier 1
meprobamate Tier 1
VISTARIL Tier 3
BENZODIAZEPINES alprazolam Tier 1
ALPRAZOLAM INTENSOL Tier 2
ATIVAN SOLN LA PA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
12
Drug Name Drug Tier Requirements/Limits
ATIVAN TABS Tier 3
chlordiazepoxide hcl Tier 1
clorazepate dipotassium Tier 1
diazepam CONC Tier 1
diazepam SOLN 5mg/5ml Tier 1
diazepam SOLN 5mg/ml, 50mg/10ml LA
diazepam TABS Tier 1
lorazepam CONC; TABS Tier 1
lorazepam SOLN LA
oxazepam Tier 1
TRANXENE T Tier 3
VALIUM Tier 3
ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A
disopyramide phosphate Tier 1
NORPACE Tier 3
NORPACE CR Tier 3
quinidine gluconate Tier 1
quinidine sulfate Tier 1
ANTIARRHYTHMICS TYPE I-B mexiletine hcl Tier 1
ANTIARRHYTHMICS TYPE I-C flecainide acetate Tier 1
propafenone hcl Tier 1
RYTHMOL SR Tier 3
ANTIARRHYTHMICS TYPE III amiodarone hcl Tier 1
dofetilide Tier 1 SP
MULTAQ Tier 2
TIKOSYN Tier 4 SP
ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTI-INFLAMMATORY AGENTS
cromolyn sodium Tier 1
ANTIASTHMATIC - MONOCLONAL ANTIBODIES CINQAIR LA SP, PA
FASENRA LA SP, PA
FASENRA PEN Tier 4 SP, PA
NUCALA SOAJ; SOSY Tier 4 SP, PA
NUCALA SOLR LA SP, PA
XOLAIR LA SP, PA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
13
Drug Name Drug Tier Requirements/Limits
BRONCHODILATORS - ANTICHOLINERGICS ATROVENT HFA Tier 2
INCRUSE ELLIPTA Tier 2
ipratropium bromide Tier 1
LONHALA MAGNAIR STARTER K Tier 3 PA
SEEBRI NEOHALER Tier 3
SPIRIVA HANDIHALER Tier 2
SPIRIVA RESPIMAT Tier 2
TUDORZA PRESSAIR Tier 3
LEUKOTRIENE MODULATORS ACCOLATE Tier 3
montelukast sodium Tier 1
SINGULAIR Tier 3
zafirlukast Tier 1
ZYFLO Tier 3 PA
SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP 250mcg Tier 2 QL
DALIRESP 500mcg Tier 2
STEROID INHALANTS ARNUITY ELLIPTA Tier 2
ASMANEX HFA Tier 2
ASMANEX TWISTHALER 7 METE Tier 2
ASMANEX TWISTHALER 14 MET Tier 2 QL
ASMANEX TWISTHALER 30 MET 110mcg/inh
Tier 2
ASMANEX TWISTHALER 30 MET 220mcg/inh
Tier 2 QL
ASMANEX TWISTHALER 60 MET Tier 2 QL
ASMANEX TWISTHALER 120 ME Tier 2 QL
budesonide (inhalation) Tier 1 QL
FLOVENT DISKUS Tier 1
FLOVENT HFA Tier 1
PULMICORT Tier 3 QL
PULMICORT FLEXHALER Tier 2 QL
QVAR REDIHALER Tier 2
SYMPATHOMIMETICS ADVAIR DISKUS Tier 1
ADVAIR HFA Tier 2 QL
AIRDUO RESPICLICK 55/14 Tier 3
AIRDUO RESPICLICK 113/14 Tier 3
AIRDUO RESPICLICK 232/14 Tier 3
albuterol sulfate AERS Tier 1
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
14
Drug Name Drug Tier Requirements/Limits
albuterol sulfate NEBU 1.25mg/3ml Tier 1
albuterol sulfate NEBU .083%, .63mg/3ml, 2.5mg/0.5ml
Tier 1 QL
albuterol sulfate SYRP Tier 1
albuterol sulfate TABS Tier 1
albuterol sulfate TB12 Tier 1
ANORO ELLIPTA Tier 2
BEVESPI AEROSPHERE Tier 2
BREO ELLIPTA Tier 2
BREZTRI AEROSPHERE Tier 2
BROVANA Tier 2 PA
COMBIVENT RESPIMAT Tier 2
fluticasone-salmeterol Tier 1
ipratropium-albuterol Tier 1 QL
levalbuterol hcl Tier 1 QL
levalbuterol tartrate Tier 1 QL
PERFOROMIST Tier 2 QL
PROAIR HFA Tier 2
PROAIR RESPICLICK Tier 2
PROVENTIL HFA Tier 3
SEREVENT DISKUS Tier 2 QL
STIOLTO RESPIMAT Tier 2
STRIVERDI RESPIMAT Tier 2
SYMBICORT Tier 1
terbutaline sulfate TABS Tier 1
TRELEGY ELLIPTA Tier 2
VENTOLIN HFA Tier 3
XOPENEX Tier 3 QL
XOPENEX CONCENTRATE Tier 3 QL
XANTHINES ELIXOPHYLLIN Tier 2
THEO-24 Tier 3
theophylline Tier 1
ANTICOAGULANTS COUMARIN ANTICOAGULANTS
warfarin sodium Tier 1
DIRECT FACTOR XA INHIBITORS ELIQUIS Tier 2
ELIQUIS STARTER PACK Tier 2
XARELTO 2.5mg Tier 2 QL
XARELTO 10mg, 15mg, 20mg Tier 2
XARELTO STARTER PACK Tier 2
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
15
Drug Name Drug Tier Requirements/Limits
HEPARINS AND HEPARINOID-LIKE AGENTS ARIXTRA Tier 3
enoxaparin sodium Tier 1 QL
fondaparinux sodium Tier 1
FRAGMIN Tier 2
heparin (porcine) in sodium chloride LA
heparin sod (porcine) in d5w LA
HEPARIN SODIUM Tier 2 QL
heparin sodium (porcine) Tier 1
heparin sodium (porcine) lock flush 1unit/ml
LA
heparin sodium (porcine) lock flush 10unit/ml, 100unit/ml
Tier 1
HEPARIN SODIUM/DEXTROSE LA
HEPARIN SODIUM/NACL 0.45% LA
LOVENOX Tier 3 QL
IN VITRO/LOCK ANTICOAGULANTS ANTICOAGULANT SODIUM CITR Tier 3
ANTICONVULSANTS AMPA GLUTAMATE RECEPTOR ANTAGONISTS
FYCOMPA Tier 3 PA
ANTICONVULSANTS - BENZODIAZEPINES clobazam Tier 1 PA
clonazepam Tier 1
DIASTAT ACUDIAL Tier 3
DIASTAT PEDIATRIC Tier 3
diazepam (anticonvulsant) Tier 1
KLONOPIN Tier 3
NAYZILAM Tier 3 ST, QL
ONFI Tier 3 PA
SYMPAZAN Tier 3 PA
VALTOCO Tier 3 QL
ANTICONVULSANTS - MISC. APTIOM Tier 3
BANZEL Tier 3
BRIVIACT SOLN 10mg/ml Tier 3 PA
BRIVIACT SOLN 50mg/5ml LA PA
BRIVIACT TABS Tier 3 PA
carbamazepine Tier 1
CARBATROL Tier 3
DIACOMIT Tier 4 SP, PA
EPIDIOLEX Tier 3 SP, PA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
16
Drug Name Drug Tier Requirements/Limits
FINTEPLA Tier 2 SP, PA
gabapentin Tier 1
KEPPRA SOLN 100mg/ml Tier 3
KEPPRA SOLN 500mg/5ml LA PA
KEPPRA TABS Tier 3
KEPPRA XR Tier 3
LAMICTAL Tier 3
LAMICTAL CHEWABLE DISPERS Tier 3
LAMICTAL ODT Tier 3
LAMICTAL STARTER/NOT TAKI Tier 3
LAMICTAL STARTER/TAKING C Tier 3
LAMICTAL XR Tier 3
lamotrigine Tier 1
LEVETIRACETAM SOLN LA
levetiracetam SOLN 100mg/ml, 500mg/5ml
Tier 1
levetiracetam SOLN 500mg/5ml LA
levetiracetam TABS Tier 1
levetiracetam TB24 Tier 1
levetiracetam in sodium chloride LA
LYRICA CAPS 25mg, 50mg, 100mg, 150mg, 200mg, 225mg, 300mg
Tier 3 QL
LYRICA CAPS 75mg Tier 3
LYRICA SOLN Tier 3
MYSOLINE Tier 3
NEURONTIN Tier 3
oxcarbazepine Tier 1
OXTELLAR XR Tier 2
pregabalin CAPS 25mg, 50mg, 100mg, 150mg, 200mg, 225mg, 300mg
Tier 1 QL
pregabalin CAPS 75mg Tier 1
pregabalin SOLN Tier 1
primidone Tier 1
QUDEXY XR Tier 3
SPRITAM Tier 3 PA
TEGRETOL Tier 3
TEGRETOL-XR Tier 3
topiramate CPSP; TABS Tier 1
topiramate CS24 Tier 3
TROKENDI XR Tier 3
VIMPAT SOLN 10mg/ml Tier 3 PA
VIMPAT SOLN 200mg/20ml LA PA
VIMPAT TABS Tier 3 PA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
17
Drug Name Drug Tier Requirements/Limits
ZONEGRAN Tier 3
zonisamide Tier 1
CARBAMATES felbamate Tier 1
FELBATOL Tier 3
XCOPRI Tier 3 PA
GABA MODULATORS GABITRIL Tier 3
SABRIL Tier 4 SP, PA
tiagabine hcl Tier 1
HYDANTOINS CEREBYX 100mgpe/2ml LA PA
CEREBYX 500mgpe/10ml Tier 3
DILANTIN Tier 3
DILANTIN INFATABS Tier 3
DILANTIN-125 Tier 3
fosphenytoin sodium LA
PHENYTEK Tier 3
phenytoin Tier 1
phenytoin sodium LA
phenytoin sodium extended Tier 1
SUCCINIMIDES CELONTIN Tier 3
ethosuximide Tier 1
ZARONTIN Tier 3
VALPROIC ACID DEPAKOTE Tier 3
DEPAKOTE ER Tier 3
DEPAKOTE SPRINKLES Tier 3
divalproex sodium Tier 1
valproate sodium 100mg/ml, 500mg/5ml LA
valproate sodium 250mg/5ml Tier 1
valproic acid Tier 1
ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)
mirtazapine Tier 1
REMERON Tier 3
REMERON SOLTAB Tier 3
ANTIDEPRESSANTS - MISC. APLENZIN Tier 3 QL
bupropion hcl Tier 1
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
18
Drug Name Drug Tier Requirements/Limits
FORFIVO XL Tier 3 QL
maprotiline hcl Tier 1
MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM Tier 3 PA
MARPLAN Tier 3
NARDIL Tier 3
PARNATE Tier 3
phenelzine sulfate Tier 1
tranylcypromine sulfate Tier 1
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) CELEXA 10mg Tier 3 QL
CELEXA 20mg, 40mg Tier 3
citalopram hydrobromide SOLN Tier 1
citalopram hydrobromide TABS Tier 1 SEMS
escitalopram oxalate Tier 1
fluoxetine hcl Tier 1
FLUOXETINE HYDROCHLORIDE Tier 3
fluvoxamine maleate CP24 Tier 1 QL
fluvoxamine maleate TABS Tier 1
paroxetine hcl TABS Tier 1
paroxetine hcl TB24 Tier 1 QL
PAXIL SUSP Tier 2
PAXIL TABS Tier 3
PAXIL CR Tier 3 QL
PEXEVA Tier 3
sertraline hcl Tier 1
ZOLOFT Tier 3
SEROTONIN MODULATORS nefazodone hcl Tier 1
trazodone hcl Tier 1
TRINTELLIX Tier 2 ST
VIIBRYD Tier 2 ST
VIIBRYD STARTER PACK Tier 2 ST
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) DESVENLAFAXINE ER Tier 3
desvenlafaxine succinate Tier 1
duloxetine hcl Tier 1
FETZIMA Tier 3
FETZIMA TITRATION PACK Tier 3
PRISTIQ Tier 3
venlafaxine hcl CP24 37.5mg Tier 1 QL
venlafaxine hcl CP24 75mg, 150mg Tier 1
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
19
Drug Name Drug Tier Requirements/Limits
venlafaxine hcl TABS Tier 1
venlafaxine hcl TB24 Tier 1
TRICYCLIC AGENTS amitriptyline hcl Tier 1
amoxapine Tier 1
ANAFRANIL Tier 3
clomipramine hcl Tier 1
desipramine hcl Tier 1
doxepin hcl Tier 1
imipramine hcl Tier 1
imipramine pamoate Tier 1
NORPRAMIN Tier 3
nortriptyline hcl Tier 1
PAMELOR Tier 3
protriptyline hcl Tier 1
trimipramine maleate Tier 1
ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS
acarbose Tier 1
miglitol Tier 1
PRECOSE Tier 3
ANTIDIABETIC - AMYLIN ANALOGS SYMLINPEN 60 Tier 2
SYMLINPEN 120 Tier 2
ANTIDIABETIC COMBINATIONS ACTOPLUS MET Tier 3
DUETACT Tier 3
glipizide-metformin hcl Tier 1
glyburide-metformin Tier 1
GLYXAMBI Tier 3 ST
JANUMET Tier 2 ST, QL
JANUMET XR Tier 2 ST, QL
KOMBIGLYZE XR Tier 3 PA; MNPA
pioglitazone hcl-glimepiride Tier 1
pioglitazone hcl-metformin hcl Tier 1
QTERN Tier 3 PA
SOLIQUA 100/33 Tier 3 ST
XIGDUO XR Tier 2 ST
XULTOPHY 100/3.6 Tier 3 ST
BIGUANIDES metformin hcl SOLN Tier 1 PA
metformin hcl TABS; TB24 Tier 1 SEMS
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
20
Drug Name Drug Tier Requirements/Limits
RIOMET Tier 3 PA
DIABETIC OTHER BAQSIMI ONE PACK Tier 2 QL
BAQSIMI TWO PACK Tier 2 QL
glucagon (rdna) Tier 1 QL
GLUCAGON EMERGENCY KIT Tier 2 QL
GLUCAGON EMERGENCY KIT FO Tier 2 QL
GVOKE HYPOPEN 1-PACK Tier 2 QL
GVOKE HYPOPEN 2-PACK Tier 2 QL
GVOKE PFS Tier 2 QL
PROGLYCEM Tier 3 PA
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS alogliptin benzoate Tier 3 PA; MNPA
JANUVIA Tier 2 ST, QL
DOPAMINE RECEPTOR AGONISTS - ANTIDIABETIC CYCLOSET Tier 3
INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) ADLYXIN Tier 3 PA; MNPA
ADLYXIN STARTER PACK Tier 3 PA; MNPA
OZEMPIC Tier 2 ST
RYBELSUS Tier 2 ST
TRULICITY Tier 2 ST
VICTOZA Tier 2 ST, QL
INSULIN BASAGLAR KWIKPEN Tier 2
FIASP Tier 2
FIASP FLEXTOUCH Tier 2
FIASP PENFILL Tier 2
HUMULIN R U-500 (CONCENTR Tier 2
HUMULIN R U-500 KWIKPEN Tier 3
INSULIN ASPART PROTAMINE/ Tier 2
LEVEMIR Tier 2
LEVEMIR FLEXTOUCH Tier 2
NOVOLIN 70/30 Tier 1
NOVOLIN 70/30 FLEXPEN Tier 2 QL
NOVOLIN N Tier 1
NOVOLIN N FLEXPEN Tier 2 QL
NOVOLIN R Tier 1
NOVOLIN R FLEXPEN Tier 2 QL
NOVOLOG Tier 1
NOVOLOG FLEXPEN Tier 2
NOVOLOG MIX 70/30 Tier 1
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
21
Drug Name Drug Tier Requirements/Limits
NOVOLOG MIX 70/30 PREFILL Tier 2
NOVOLOG PENFILL Tier 2
TRESIBA Tier 2
TRESIBA FLEXTOUCH Tier 2
INSULIN SENSITIZING AGENTS ACTOS Tier 3
AVANDIA Tier 2
pioglitazone hcl Tier 1
MEGLITINIDE ANALOGUES nateglinide Tier 1
repaglinide Tier 1
STARLIX Tier 3
SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA Tier 2 ST
JARDIANCE Tier 2 ST
SULFONYLUREAS AMARYL Tier 3
glimepiride Tier 1
glipizide Tier 1 SEMS
GLUCOTROL Tier 3
GLUCOTROL XL Tier 3
glyburide Tier 1 SEMS
glyburide micronized Tier 1
GLYNASE Tier 3
tolbutamide Tier 1
ANTIDIARRHEAL/PROBIOTIC AGENTS ANTIDIARRHEAL - CHLORIDE CHANNEL ANTAGONISTS
MYTESI Tier 3 PA
ANTIPERISTALTIC AGENTS diphenoxylate w/ atropine Tier 1
LOMOTIL Tier 3
MOTOFEN Tier 2
ANTIDOTES AND SPECIFIC ANTAGONISTS ANTIDOTES - CHELATING AGENTS
CHEMET Tier 2
deferasirox Tier 1 SP, PA
FERRIPROX SOLN Tier 4 SP, PA
FERRIPROX TABS Tier 4 SP, PA
FERRIPROX TWICE-A-DAY Tier 4 SP, PA
JADENU Tier 4 SP, PA
JADENU SPRINKLE Tier 4 SP, PA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
22
Drug Name Drug Tier Requirements/Limits
ANTIDOTES AND SPECIFIC ANTAGONISTS ACETADOTE LA
acetylcysteine (antidote) LA
deferoxamine mesylate LA SP, PA
DESFERAL LA SP, PA
VISTOGARD Tier 4 SP, PA
BENZODIAZEPINE ANTAGONISTS flumazenil LA PA
OPIOID ANTAGONISTS naloxone hcl Tier 1
naltrexone hcl Tier 1
NARCAN Tier 1
VIVITROL LA
ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS
ALOXI LA PA
ANZEMET Tier 2
granisetron hcl SOLN LA
granisetron hcl TABS Tier 1
ondansetron Tier 1
ondansetron hcl SOLN 4mg/2ml LA
ondansetron hcl SOLN 4mg/5ml, 40mg/20ml
Tier 1
ondansetron hcl TABS Tier 1
palonosetron hcl LA
SANCUSO Tier 3 PA
SUSTOL Tier 2
ZOFRAN Tier 3
ZUPLENZ Tier 3 PA
ANTIEMETICS - ANTICHOLINERGIC DIMENHYDRINATE Tier 1
meclizine hcl CHEW Tier 1
meclizine hcl TABS 12.5mg, 25mg Tier 1
meclizine hcl TABS 25mg Tier 1
MECLIZINE HYDROCHLORIDE Tier 3
scopolamine Tier 1
TIGAN CAPS Tier 3
TIGAN SOLN LA
TRANSDERM SCOP Tier 3
TRANSDERM-SCOP Tier 3
trimethobenzamide hcl Tier 1
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
23
Drug Name Drug Tier Requirements/Limits
ANTIEMETICS - MISCELLANEOUS AKYNZEO CAPS Tier 3 PA
AKYNZEO SOLN; SOLR LA PA
BONJESTA Tier 3 PA
dronabinol Tier 1
MARINOL Tier 3
SYNDROS Tier 3
SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS aprepitant Tier 1 QL
CINVANTI LA
EMEND CAPS Tier 3 QL
EMEND SUSR Tier 2
fosaprepitant dimeglumine LA
VARUBI Tier 3 PA
ANTIFUNGALS ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS
(ECHINOCANDINS) caspofungin acetate LA
ERAXIS LA
ANTIFUNGALS ABELCET LA
AMBISOME LA
amphotericin b LA
ANCOBON Tier 3
flucytosine Tier 1
griseofulvin microsize Tier 1
griseofulvin ultramicrosize Tier 1
nystatin Tier 1
terbinafine hcl Tier 1
IMIDAZOLE-RELATED ANTIFUNGALS CRESEMBA CAPS Tier 3
CRESEMBA SOLR LA PA
DIFLUCAN Tier 3
fluconazole Tier 1
fluconazole in nacl LA
itraconazole Tier 1
ketoconazole Tier 1
NOXAFIL SOLN LA PA
NOXAFIL SUSP Tier 2
POSACONAZOLE Tier 1
SPORANOX Tier 3
SPORANOX PULSEPAK Tier 3
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
24
Drug Name Drug Tier Requirements/Limits
TOLSURA Tier 3 PA
VFEND Tier 3
VFEND IV LA PA
voriconazole SOLR LA PA
voriconazole SUSR; TABS Tier 1
ANTIHISTAMINES ANTIHISTAMINES - ETHANOLAMINES
carbinoxamine maleate SOLN Tier 1
carbinoxamine maleate TABS 4mg Tier 1
carbinoxamine maleate TABS 6mg Tier 3
clemastine fumarate 1.34mg Tier 1
clemastine fumarate 2.68mg Tier 1
diphenhydramine hcl CAPS Tier 1
diphenhydramine hcl ELIX 12.5mg/5ml Tier 1
diphenhydramine hcl ELIX 12.5mg/5ml Tier 1
diphenhydramine hcl SOLN LA
KARBINAL ER Tier 3
RYVENT Tier 3
ANTIHISTAMINES - NON-SEDATING desloratadine Tier 1
loratadine Tier 1
ANTIHISTAMINES - PHENOTHIAZINES PHENERGAN Tier 3
promethazine hcl SOLN LA
promethazine hcl SUPP; SYRP; TABS Tier 1
ANTIHISTAMINES - PIPERIDINES cyproheptadine hcl Tier 1
ANTIHYPERLIPIDEMICS ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORS
NEXLETOL Tier 2 PA
ANTIHYPERLIPIDEMICS - COMBINATIONS ezetimibe-simvastatin Tier 1
NEXLIZET Tier 2 PA
VYTORIN Tier 3
ANTIHYPERLIPIDEMICS - MISC. LOVAZA Tier 3 QL
omega-3-acid ethyl esters Tier 1 QL
VASCEPA Tier 2
BILE ACID SEQUESTRANTS cholestyramine Tier 1
cholestyramine light Tier 1
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
25
Drug Name Drug Tier Requirements/Limits
colesevelam hcl Tier 1
COLESTID Tier 3
COLESTID FLAVORED Tier 3
colestipol hcl Tier 1
QUESTRAN Tier 3
QUESTRAN LIGHT Tier 3
WELCHOL Tier 3
FIBRIC ACID DERIVATIVES ANTARA Tier 3
choline fenofibrate Tier 1
fenofibrate Tier 1
fenofibrate micronized Tier 1
fenofibric acid 35mg, 105mg Tier 1
fenofibric acid 105mg Tier 3
FENOGLIDE Tier 3
FIBRICOR Tier 3
gemfibrozil Tier 1
LIPOFEN Tier 3
LOPID Tier 3
TRICOR Tier 3
TRILIPIX Tier 3
HMG COA REDUCTASE INHIBITORS ALTOPREV Tier 2
atorvastatin calcium 10mg, 20mg ACA AL; SEMS
atorvastatin calcium 40mg, 80mg Tier 1 SEMS
FLOLIPID Tier 3 PA, QL
fluvastatin sodium ACA AL
LESCOL XL Tier 3
LIPITOR Tier 3
lovastatin ACA AL; SEMS
PRAVACHOL Tier 3 QL
pravastatin sodium ACA QL; AL
rosuvastatin calcium 5mg, 10mg ACA QL; AL
rosuvastatin calcium 20mg, 40mg Tier 1 QL
simvastatin 5mg, 10mg, 20mg, 40mg ACA AL; SEMS
simvastatin 80mg Tier 1 SEMS
ZOCOR Tier 3 QL
INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ezetimibe Tier 1
ZETIA Tier 3
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
26
Drug Name Drug Tier Requirements/Limits
MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP)
INHIBITORS JUXTAPID Tier 4 SP, PA
NICOTINIC ACID DERIVATIVES niacin (antihyperlipidemic) Tier 1
NIASPAN Tier 3
PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS PRALUENT Tier 3 PA
REPATHA Tier 3 PA
REPATHA PUSHTRONEX SYSTEM Tier 3 PA
REPATHA SURECLICK Tier 3 PA
ANTIHYPERTENSIVES ACE INHIBITORS
ACCUPRIL Tier 3
benazepril hcl Tier 1
captopril Tier 1
enalapril maleate Tier 1
fosinopril sodium Tier 1
lisinopril Tier 1 SEMS
LOTENSIN Tier 3
moexipril hcl Tier 1
perindopril erbumine Tier 1
PRINIVIL Tier 3
QBRELIS Tier 3
quinapril hcl Tier 1
ramipril Tier 1
trandolapril Tier 1
VASOTEC Tier 3
ZESTRIL Tier 3
AGENTS FOR PHEOCHROMOCYTOMA DIBENZYLINE Tier 3 PA
phenoxybenzamine hcl Tier 1 PA
PHENTOLAMINE MESYLATE Tier 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND Tier 3
AVAPRO Tier 3
candesartan cilexetil Tier 1
COZAAR Tier 3
DIOVAN Tier 3
EDARBI Tier 3
irbesartan Tier 1
losartan potassium Tier 1
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
27
Drug Name Drug Tier Requirements/Limits
MICARDIS Tier 3
olmesartan medoxomil Tier 1
telmisartan Tier 1
valsartan Tier 1
ANTIADRENERGIC ANTIHYPERTENSIVES CARDURA Tier 3
CATAPRES-TTS-1 Tier 3
CATAPRES-TTS-2 Tier 3
CATAPRES-TTS-3 Tier 3
clonidine Tier 1
clonidine hcl Tier 1
doxazosin mesylate Tier 1
guanfacine hcl Tier 1
methyldopa Tier 1
MINIPRESS Tier 3
prazosin hcl Tier 1
terazosin hcl Tier 1
ANTIHYPERTENSIVE COMBINATIONS ACCURETIC Tier 3
amlodipine besylate-benazepril hcl Tier 1
amlodipine besylate-olmesartan medoxomil Tier 1
amlodipine besylate-valsartan Tier 1
amlodipine-valsartan-hydrochlorothiazide Tier 1
ATACAND HCT Tier 3
atenolol & chlorthalidone Tier 1
AVALIDE Tier 3
AZOR Tier 3
benazepril & hydrochlorothiazide Tier 1
bisoprolol & hydrochlorothiazide Tier 1
candesartan cilexetil-hydrochlorothiazide Tier 1
captopril & hydrochlorothiazide Tier 1
DIOVAN HCT Tier 3
DUTOPROL Tier 3
EDARBYCLOR Tier 3
enalapril maleate & hydrochlorothiazide Tier 1
EXFORGE Tier 3
EXFORGE HCT Tier 3
fosinopril sodium & hydrochlorothiazide Tier 1
HYZAAR Tier 3
irbesartan-hydrochlorothiazide Tier 1
lisinopril & hydrochlorothiazide Tier 1
losartan potassium & hydrochlorothiazide Tier 1
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
28
Drug Name Drug Tier Requirements/Limits
LOTENSIN HCT Tier 3
LOTREL Tier 3
methyldopa & hydrochlorothiazide Tier 1
metoprolol & hydrochlorothiazide Tier 1
MICARDIS HCT Tier 3
olmesartan medoxomil-amlodipine-hydrochlorothiazide
Tier 1
olmesartan medoxomil-hydrochlorothiazide Tier 1
PRESTALIA Tier 3
propranolol & hydrochlorothiazide Tier 1
quinapril-hydrochlorothiazide Tier 1
TEKTURNA HCT Tier 2
telmisartan-amlodipine Tier 1
telmisartan-hydrochlorothiazide Tier 1
TENORETIC 50 Tier 3
TENORETIC 100 Tier 3
trandolapril-verapamil hcl Tier 1
TRIBENZOR Tier 3
TWYNSTA Tier 3
valsartan-hydrochlorothiazide Tier 1
VASERETIC Tier 3
ZESTORETIC Tier 3
ZIAC Tier 3
ANTIHYPERTENSIVES - MISC. VECAMYL Tier 3
DIRECT RENIN INHIBITORS aliskiren fumarate Tier 1
TEKTURNA Tier 3
SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) eplerenone Tier 1
INSPRA Tier 3
VASODILATORS hydralazine hcl TABS Tier 1
minoxidil Tier 1
ANTIMALARIALS ANTIMALARIAL COMBINATIONS
atovaquone-proguanil hcl Tier 1 PA
COARTEM Tier 2
MALARONE Tier 3 PA
ANTIMALARIALS chloroquine phosphate Tier 1
DARAPRIM Tier 2 PA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
29
Drug Name Drug Tier Requirements/Limits
hydroxychloroquine sulfate Tier 1
mefloquine hcl Tier 1
QUALAQUIN Tier 3
quinine sulfate Tier 1
ANTIMYASTHENIC/CHOLINERGIC AGENTS ANTIMYASTHENIC/CHOLINERGIC AGENTS
GUANIDINE HCL Tier 1
MESTINON Tier 3
MESTINON TIMESPAN Tier 3
pyridostigmine bromide Tier 1
ANTIMYCOBACTERIAL AGENTS ANTIMYCOBACTERIAL AGENTS
CAPASTAT SULFATE LA PA
cycloserine Tier 2
ethambutol hcl Tier 1
isoniazid SOLN LA
isoniazid SYRP; TABS Tier 1
MYAMBUTOL Tier 3
MYCOBUTIN Tier 3
PASER Tier 3
PRETOMANID Tier 3 PA
PRIFTIN Tier 3
pyrazinamide Tier 1
rifabutin Tier 1
RIFADIN LA PA
rifampin CAPS Tier 1
rifampin SOLR LA
SIRTURO Tier 3 PA
TRECATOR Tier 3
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKYLATING AGENTS
ALKERAN SOLR LA PA
ALKERAN TABS Tier 3 PA
BELRAPZO LA SP, PA
BENDEKA LA SP, PA
BICNU LA PA
BUSULFEX LA PA
carboplatin LA
carmustine LA PA
cisplatin LA
CYCLOPHOSPHAMIDE CAPS Tier 1
CYCLOPHOSPHAMIDE SOLN LA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
30
Drug Name Drug Tier Requirements/Limits
cyclophosphamide SOLR 1gm, 500mg LA
cyclophosphamide SOLR 2gm Tier 1
GLEOSTINE Tier 3
GLIADEL WAFER LA
IFEX LA PA
ifosfamide SOLN LA PA
ifosfamide SOLR 1gm LA PA
IFOSFAMIDE SOLR 3gm LA PA
LEUKERAN Tier 2 PA
melphalan Tier 1 PA
melphalan hcl LA
MYLERAN Tier 2 PA
oxaliplatin LA
TEMODAR CAPS Tier 4 SP
TEMODAR SOLR LA SP, PA
temozolomide Tier 1 SP
TEPADINA LA PA
thiotepa 15mg Tier 1
thiotepa 100mg LA PA
TREANDA LA SP, PA
YONDELIS LA SP, PA
ZEPZELCA LA SP, PA
ANTIMETABOLITES ALIMTA LA
ARRANON LA
azacitidine Tier 1 SP
capecitabine Tier 1 SP
cladribine LA
clofarabine LA PA
cytarabine LA
DACOGEN Tier 4 SP
decitabine LA SP
floxuridine LA
fludarabine phosphate LA
fluorouracil LA
FOLOTYN LA SP, PA
gemcitabine hcl LA
GEMCITABINE HYDROCHLORIDE LA
mercaptopurine Tier 1
methotrexate sodium Tier 1
ONUREG Tier 4 SP, PA, QL
PURIXAN Tier 4 SP, PA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
31
Drug Name Drug Tier Requirements/Limits
TABLOID Tier 2 PA
TREXALL Tier 3 PA
VIDAZA LA SP, PA
XATMEP Tier 3
XELODA Tier 4 SP
ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS CYRAMZA LA SP, PA
MVASI LA SP
ZALTRAP LA SP, PA
ZIRABEV LA SP
ANTINEOPLASTIC - ANTIBODIES ADCETRIS LA SP, PA
ARZERRA LA SP, PA
BAVENCIO LA SP, PA
BESPONSA LA SP, PA
BLINCYTO LA SP, PA
CAMPATH Tier 3
DARZALEX LA SP, PA
EMPLICITI LA SP, PA
ENHERTU LA SP, PA
ERBITUX LA SP, PA
GAZYVA LA SP, PA
HERZUMA LA SP, PA
IMFINZI LA SP, PA
KADCYLA LA SP, PA
KANJINTI LA SP, PA
KEYTRUDA LA SP, PA
LUMOXITI LA SP, PA
MONJUVI LA SP, PA
MYLOTARG LA SP, PA
ONTRUZANT LA SP, PA
OPDIVO LA SP, PA
PADCEV LA SP, PA
PERJETA LA SP, PA
POLIVY LA SP, PA
PORTRAZZA LA SP, PA
POTELIGEO LA SP, PA
RITUXAN LA SP, PA
RUXIENCE LA SP, PA
SARCLISA LA SP, PA
TECENTRIQ LA SP, PA
TRAZIMERA LA SP, PA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
32
Drug Name Drug Tier Requirements/Limits
TRODELVY LA SP, PA
TRUXIMA LA SP, PA
UNITUXIN LA SP, PA
VECTIBIX LA SP, PA
YERVOY LA SP, PA
ANTINEOPLASTIC - BCL-2 INHIBITORS VENCLEXTA Tier 4 SP, PA
VENCLEXTA STARTING PACK Tier 4 SP, PA
ANTINEOPLASTIC - CELLULAR IMMUNOTHERAPY TECARTUS LA SP, PA
ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS DAURISMO Tier 4 SP, PA
ERIVEDGE Tier 4 SP, PA
ODOMZO Tier 4 SP, PA
ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS abiraterone acetate Tier 1 SP, PA; GENDER
anastrozole Tier 1
ARIMIDEX Tier 3 PA
AROMASIN Tier 3
bicalutamide Tier 1 PA
CASODEX Tier 3 PA
ELIGARD Tier 2 SP
EMCYT Tier 2 PA
ERLEADA Tier 2 SP, PA
exemestane Tier 1
FARESTON Tier 3 PA
FASLODEX LA
FEMARA Tier 3 PA
FIRMAGON Tier 4 SP
flutamide Tier 1 PA
fulvestrant LA
hydroxyprogesterone caproate (antineoplastic)
LA PA
letrozole Tier 1
leuprolide acetate Tier 1 SP
LUPRON DEPOT (1-MONTH) Tier 2 SP
LUPRON DEPOT (3-MONTH) Tier 2 SP
LUPRON DEPOT (4-MONTH) Tier 2 SP
LUPRON DEPOT (6-MONTH) Tier 2 SP
LYSODREN Tier 2 PA
megestrol acetate Tier 1
NILANDRON Tier 3 PA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
33
Drug Name Drug Tier Requirements/Limits
NUBEQA Tier 2 SP, PA
SOLTAMOX Tier 3 PA
tamoxifen citrate Tier 1
TRELSTAR MIXJECT LA SP, PA
VANTAS LA SP, PA
XTANDI Tier 2 SP, PA
YONSA Tier 2 SP, PA; GENDER
ZOLADEX LA SP, PA
ZYTIGA Tier 4 SP, PA; GENDER
ANTINEOPLASTIC - IMMUNOMODULATORS POMALYST Tier 4 SP, PA
ANTINEOPLASTIC - XPO1 INHIBITORS XPOVIO 40 MG ONCE WEEKLY Tier 4 SP, PA
XPOVIO 40 MG TWICE WEEKLY Tier 4 SP, PA
XPOVIO 60 MG ONCE WEEKLY Tier 4 SP, PA
XPOVIO 60 MG TWICE WEEKLY Tier 4 SP, PA
XPOVIO 80 MG ONCE WEEKLY Tier 4 SP, PA
XPOVIO 80 MG TWICE WEEKLY Tier 4 SP, PA
XPOVIO 100 MG ONCE WEEKLY Tier 4 SP, PA
ANTINEOPLASTIC ANTIBIOTICS bleomycin sulfate LA
COSMEGEN LA PA
dactinomycin LA PA
daunorubicin hcl LA
DOXIL LA PA
doxorubicin hcl LA
doxorubicin hcl liposomal LA PA
ELLENCE LA
epirubicin hcl LA
IDAMYCIN PFS LA PA
idarubicin hcl LA PA
JELMYTO LA SP, PA
mitomycin LA
mitoxantrone hcl LA SP
ANTINEOPLASTIC COMBINATIONS DARZALEX FASPRO LA SP, PA
HERCEPTIN HYLECTA LA SP, PA
INQOVI Tier 4 SP, PA
KISQALI FEMARA 200 DOSE Tier 4 SP, PA
KISQALI FEMARA 400 DOSE Tier 4 SP, PA
KISQALI FEMARA 600 DOSE Tier 4 SP, PA
LONSURF Tier 4 SP, PA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
34
Drug Name Drug Tier Requirements/Limits
PHESGO LA SP, PA
RITUXAN HYCELA Tier 4 SP, PA
VYXEOS LA SP, PA
ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR Tier 4 SP, PA
AFINITOR DISPERZ Tier 4 SP, PA
ALECENSA Tier 4 SP, PA
ALIQOPA LA SP, PA
ALUNBRIG Tier 4 SP, PA
AYVAKIT Tier 4 SP, PA
BALVERSA Tier 4 SP, PA
BELEODAQ LA SP, PA
BORTEZOMIB LA SP, PA
BOSULIF 100mg, 500mg LA SP, PA
BOSULIF 400mg Tier 4 SP, PA
BRAFTOVI Tier 4 SP, PA
BRUKINSA Tier 4 SP, PA
CABOMETYX Tier 4 SP, PA
CALQUENCE Tier 4 SP, PA
CAPRELSA Tier 4 SP, PA
COMETRIQ Tier 4 SP, PA
COPIKTRA Tier 4 SP, PA
COTELLIC Tier 4 SP, PA
erlotinib hcl Tier 1 SP, PA
everolimus Tier 1 SP, PA
FARYDAK Tier 4 SP
GAVRETO Tier 4 SP, PA
GILOTRIF Tier 4 SP, PA
IBRANCE Tier 2 SP, PA
ICLUSIG Tier 4 SP, PA
IDHIFA Tier 4 SP, PA
imatinib mesylate Tier 1 SP, PA
IMBRUVICA CAPS Tier 4 SP, PA, QL
IMBRUVICA TABS 140mg Tier 3 SP, PA, QL
IMBRUVICA TABS 280mg, 420mg, 560mg Tier 4 SP, PA, QL
INLYTA Tier 4 SP, PA
INREBIC Tier 4 SP, PA
IRESSA Tier 4 SP, PA
ISTODAX (OVERFILL) LA SP, PA
JAKAFI Tier 4 SP, PA
KOSELUGO Tier 4 SP, PA
KYPROLIS LA SP, PA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
35
Drug Name Drug Tier Requirements/Limits
lapatinib ditosylate Tier 1 SP, PA
LENVIMA 4 MG DAILY DOSE Tier 4 SP, PA
LENVIMA 8 MG DAILY DOSE Tier 4 SP, PA
LENVIMA 10 MG DAILY DOSE Tier 4 SP, PA
LENVIMA 12MG DAILY DOSE Tier 4 SP, PA
LENVIMA 14 MG DAILY DOSE Tier 4 SP, PA
LENVIMA 18 MG DAILY DOSE Tier 4 SP, PA
LENVIMA 20 MG DAILY DOSE Tier 4 SP, PA
LENVIMA 24 MG DAILY DOSE Tier 4 SP, PA
LORBRENA Tier 4 SP, PA
LYNPARZA Tier 2 SP, PA
MEKINIST Tier 4 SP, PA
MEKTOVI Tier 4 SP, PA
NERLYNX Tier 4 SP, PA
NEXAVAR Tier 2 SP, PA
NINLARO Tier 4 SP, PA
PEMAZYRE Tier 4 SP, PA
PIQRAY 200MG DAILY DOSE Tier 4 SP, PA
PIQRAY 250MG DAILY DOSE Tier 4 SP, PA
PIQRAY 300MG DAILY DOSE Tier 4 SP, PA
QINLOCK Tier 4 SP, PA
RETEVMO Tier 4 SP, PA
ROMIDEPSIN LA SP, PA
ROZLYTREK Tier 4 SP, PA
RUBRACA Tier 2 SP, PA
RYDAPT Tier 4 SP, PA
SPRYCEL Tier 4 SP, PA
STIVARGA Tier 4 SP, PA
SUTENT Tier 2 SP, PA
TABRECTA Tier 4 SP, PA
TAFINLAR Tier 4 SP, PA
TAGRISSO Tier 4 SP, PA
TALZENNA Tier 4 SP, PA, QL
TARCEVA Tier 4 SP, PA
TASIGNA 50mg Tier 4 SP, PA, QL
TASIGNA 150mg, 200mg Tier 4 SP, PA
TAZVERIK Tier 4 SP, PA
temsirolimus LA SP
TUKYSA Tier 4 SP, PA
TURALIO Tier 4 SP, PA
TYKERB Tier 4 SP, PA
VELCADE LA SP, PA
VERZENIO Tier 2 SP, PA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
36
Drug Name Drug Tier Requirements/Limits
VITRAKVI Tier 4 SP, PA
VIZIMPRO Tier 4 SP, PA, QL
VOTRIENT Tier 4 SP, PA
XALKORI Tier 4 SP, PA
XOSPATA Tier 4 SP, PA
ZEJULA Tier 2 SP, PA
ZELBORAF Tier 4 SP, PA
ZOLINZA Tier 4 SP, PA, QL
ZYDELIG Tier 4 SP, PA
ZYKADIA Tier 4 SP, PA
ANTINEOPLASTIC ENZYMES ASPARLAS LA SP, PA
ERWINAZE LA SP, PA
ONCASPAR LA SP, PA
ANTINEOPLASTIC RADIOPHARMACEUTICALS LUTATHERA LA SP, PA
ANTINEOPLASTICS MISC. ACTIMMUNE Tier 2 SP, PA
ALFERON N LA SP, PA
arsenic trioxide LA PA
bexarotene Tier 1 SP, PA
dacarbazine LA
ELZONRIS LA SP, PA
HYDREA Tier 3
hydroxyurea Tier 1
INTRON A Tier 2 SP, PA
MATULANE Tier 2 SP, PA
NIPENT LA PA
PHOTOFRIN LA
PROLEUKIN LA SP
SYNRIBO LA SP, PA
TARGRETIN CAPS Tier 4 SP, PA
tretinoin (chemotherapy) Tier 1
TRISENOX LA PA
CHEMOTHERAPY ADJUNCTS ELITEK LA PA
KEPIVANCE LA
CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS dexrazoxane hcl LA
KHAPZORY LA SP
leucovorin calcium SOLN; TABS Tier 1
leucovorin calcium SOLR LA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
37
Drug Name Drug Tier Requirements/Limits
levoleucovorin calcium 175mg/17.5ml LA SP, PA
levoleucovorin calcium 250mg/25ml Tier 1 SP, PA
mesna LA PA
MESNEX SOLN LA PA
MESNEX TABS Tier 2 PA
TOTECT LA
VORAXAZE LA SP, PA
MITOTIC INHIBITORS ABRAXANE LA PA
DOCETAXEL CONC 20mg/ml, 80mg/4ml LA
docetaxel CONC 20mg/ml, 80mg/4ml, 160mg/8ml
LA
docetaxel SOLN 20mg/2ml LA
DOCETAXEL SOLN 80mg/8ml, 160mg/16ml
LA
ETOPOPHOS LA
etoposide CAPS Tier 1
etoposide SOLN LA
HALAVEN LA SP, PA
IXEMPRA KIT LA SP, PA
JEVTANA LA SP, PA
NAVELBINE LA PA
paclitaxel LA
TENIPOSIDE LA
vinblastine sulfate LA
vincristine sulfate LA
vinorelbine tartrate LA
TOPOISOMERASE I INHIBITORS CAMPTOSAR 40mg/2ml, 100mg/5ml LA PA
CAMPTOSAR 300mg/15ml LA
HYCAMTIN Tier 4 SP, PA
irinotecan hcl 40mg/2ml, 100mg/5ml, 300mg/15ml
LA
irinotecan hcl 500mg/25ml LA PA
ONIVYDE LA SP, PA
topotecan hcl LA
ANTIPARKINSON AND RELATED THERAPY AGENTS ANTIPARKINSON ADJUNCTIVE THERAPY
carbidopa Tier 1
LODOSYN Tier 3
ANTIPARKINSON ANTICHOLINERGICS benztropine mesylate SOLN LA
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
38
Drug Name Drug Tier Requirements/Limits
benztropine mesylate TABS Tier 1
COGENTIN LA PA
trihexyphenidyl hcl Tier 1
ANTIPARKINSON COMT INHIBITORS COMTAN Tier 3
entacapone Tier 1
TASMAR Tier 3
tolcapone Tier 1
ANTIPARKINSON DOPAMINERGICS amantadine hcl Tier 1
APOKYN Tier 2 SP
bromocriptine mesylate Tier 1
carbidopa-levodopa Tier 1
carbidopa-levodopa-entacapone Tier 1
DUOPA Tier 4 SP, PA
KYNMOBI Tier 4 SP, PA
MIRAPEX Tier 3
MIRAPEX ER Tier 3
NEUPRO Tier 3
pramipexole dihydrochloride Tier 1
ropinirole hydrochloride Tier 1
RYTARY Tier 3 PA
SINEMET Tier 3
STALEVO 50 Tier 3
STALEVO 75 Tier 3
STALEVO 100 Tier 3
STALEVO 125 Tier 3
STALEVO 150 Tier 3
STALEVO 200 Tier 3
ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS AZILECT Tier 3
rasagiline mesylate Tier 1
selegiline hcl Tier 1 PA
XADAGO Tier 3 PA
ZELAPAR Tier 3 PA
ANTIPSYCHOTICS/ANTIMANIC AGENTS ANTIMANIC AGENTS
LITHIUM Tier 1
lithium carbonate Tier 1
LITHOBID Tier 3
ANTIPSYCHOTICS - MISC. CAPLYTA Tier 3 ST
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
39
Drug Name Drug Tier Requirements/Limits
EQUETRO Tier 3
GEODON CAPS Tier 3 ST
GEODON SOLR LA ST
LATUDA Tier 3 ST
NUPLAZID Tier 4 SP, PA
VRAYLAR Tier 3 ST
ziprasidone hcl Tier 1
BENZISOXAZOLES FANAPT Tier 3 ST
FANAPT TITRATION PACK Tier 3 ST
INVEGA SUSTENNA LA PA
INVEGA TRINZA LA PA
paliperidone Tier 1 ST
PERSERIS LA QL
RISPERDAL Tier 3
RISPERDAL CONSTA LA
risperidone Tier 1
BUTYROPHENONES HALDOL DECANOATE 50 LA
HALDOL DECANOATE 100 LA
haloperidol Tier 1
haloperidol decanoate LA
haloperidol lactate CONC Tier 1
haloperidol lactate SOLN LA
DIBENZAPINES ADASUVE Tier 3
asenapine maleate Tier 1 ST
clozapine Tier 1
CLOZARIL Tier 3
loxapine succinate Tier 1
olanzapine SOLR LA PA, QL
olanzapine TABS; TBDP Tier 1 QL
quetiapine fumarate Tier 1
SAPHRIS Tier 3 ST
SECUADO Tier 3 ST
SEROQUEL Tier 3 ST
SEROQUEL XR Tier 3
VERSACLOZ Tier 3
ZYPREXA SOLR LA PA, QL
ZYPREXA TABS Tier 3 QL
ZYPREXA RELPREVV LA PA
ZYPREXA ZYDIS Tier 3 QL
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
40
Drug Name Drug Tier Requirements/Limits
DIHYDROINDOLONES molindone hcl Tier 1
PHENOTHIAZINES chlorpromazine hcl SOLN 25mg/ml Tier 1
CHLORPROMAZINE HCL SOLN 50mg/2ml Tier 1
chlorpromazine hcl TABS Tier 1
fluphenazine decanoate LA
fluphenazine hcl CONC; ELIX; TABS Tier 1
fluphenazine hcl SOLN LA
perphenazine Tier 1
prochlorperazine Tier 1
prochlorperazine edisylate LA
prochlorperazine maleate Tier 1
thioridazine hcl Tier 1
trifluoperazine hcl Tier 1
QUINOLINONE DERIVATIVES ABILIFY Tier 3 ST
ABILIFY MAINTENA PRSY 300mg LA
ABILIFY MAINTENA PRSY 400mg Tier 3
ABILIFY MAINTENA SRER LA
aripiprazole SOLN; TABS Tier 1
aripiprazole TBDP Tier 1 PA
ARISTADA LA
ARISTADA INITIO LA
REXULTI Tier 3 ST
THIOXANTHENES thiothixene Tier 1
ANTISEPTICS & DISINFECTANTS ANTISEPTIC COMBINATIONS
IV PREP WIPES Tier 2
MICROCLENS WIPES Tier 2
UNI-SOLVE Tier 2
CHLORINE ANTISEPTICS CHLORHEXIDINE GLUCONATE Tier 3
ANTIVIRALS ANTIRETROVIRALS
abacavir sulfate Tier 1 SP
abacavir sulfate-lamivudine Tier 1 SP
abacavir sulfate-lamivudine-zidovudine Tier 1 SP
APTIVUS Tier 4 SP
atazanavir sulfate Tier 1 SP
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
41
Drug Name Drug Tier Requirements/Limits
BIKTARVY Tier 2 SP
CIMDUO Tier 2 SP
CRIXIVAN Tier 4 SP
DELSTRIGO Tier 4 SP
DESCOVY Tier 2 SP
DOVATO Tier 2 SP
EDURANT Tier 4 SP
efavirenz Tier 1 SP
efavirenz-lamivudine-tenofovir disoproxil fumarate
Tier 2 SP
emtricitabine Tier 2 SP
emtricitabine-tenofovir disoproxil fumarate Tier 1 SP
EMTRIVA Tier 2 SP
EPZICOM Tier 4 SP
EVOTAZ Tier 4 SP
fosamprenavir calcium Tier 1 SP
FUZEON Tier 4 SP
GENVOYA Tier 2 SP
INTELENCE Tier 2 SP
INVIRASE Tier 4 SP
ISENTRESS Tier 2 SP
ISENTRESS HD Tier 2 SP
JULUCA Tier 4 SP
KALETRA Tier 4 SP
lamivudine Tier 1 SP
lamivudine-zidovudine Tier 1 SP
LEXIVA Tier 4 SP
lopinavir-ritonavir Tier 1 SP
nevirapine Tier 1 SP
NORVIR Tier 4 SP
ODEFSEY Tier 2 SP
PIFELTRO Tier 4 SP
PREZCOBIX Tier 2 SP
PREZISTA Tier 2 SP
RETROVIR Tier 4 SP
RETROVIR IV INFUSION LA SP
REYATAZ Tier 4 SP
ritonavir Tier 1 SP
RUKOBIA Tier 4 SP, PA
SELZENTRY SOLN Tier 4 SP
SELZENTRY TABS 25mg, 75mg Tier 4 SP, QL
SELZENTRY TABS 150mg, 300mg Tier 4 SP
SUSTIVA Tier 4 SP
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
42
Drug Name Drug Tier Requirements/Limits
SYMFI Tier 2 SP
SYMFI LO Tier 2 SP
SYMTUZA Tier 4 SP
TEMIXYS Tier 2 SP
tenofovir disoproxil fumarate Tier 1 SP
TIVICAY Tier 4 SP
TIVICAY PD Tier 4 SP
TRIUMEQ Tier 2 SP
TRIZIVIR Tier 4 SP
TROGARZO LA SP, PA
TRUVADA Tier 4 SP
TYBOST Tier 4 SP
VIRACEPT Tier 4 SP
VIRAMUNE Tier 4 SP
VIRAMUNE XR Tier 4 SP
VIREAD Tier 4 SP
zidovudine Tier 1 SP
CMV AGENTS cidofovir LA
FOSCAVIR LA
ganciclovir sodium LA
PREVYMIS Tier 3 ST
VALCYTE Tier 3
valganciclovir hcl Tier 1
HEPATITIS AGENTS adefovir dipivoxil Tier 1 SP
BARACLUDE Tier 4 SP
entecavir Tier 1 SP
EPIVIR HBV Tier 4 SP
HEPSERA Tier 4 SP
lamivudine (hbv) Tier 1 SP
MAVYRET Tier 2 SP, PA
PEGASYS 180mcg/0.5ml Tier 4 SP
PEGASYS 180mcg/ml Tier 4 SP, PA, QL
PEGINTRON Tier 2 SP
ribavirin (hepatitis c) Tier 1 SP
sofosbuvir/velpatasvir Tier 2 SP, PA
VEMLIDY Tier 4 SP
HERPES AGENTS acyclovir Tier 1
acyclovir sodium LA
famciclovir Tier 1
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
43
Drug Name Drug Tier Requirements/Limits
SITAVIG Tier 3
valacyclovir hcl Tier 1
ZOVIRAX Tier 3
INFLUENZA AGENTS oseltamivir phosphate Tier 1
RELENZA DISKHALER Tier 2
rimantadine hydrochloride Tier 1
TAMIFLU Tier 3
XOFLUZA Tier 3 QL
RESPIRATORY SYNCYTIAL VIRUS (RSV) AGENTS VIRAZOLE Tier 3
BETA BLOCKERS ALPHA-BETA BLOCKERS
carvedilol Tier 1 SEMS
carvedilol phosphate Tier 1
COREG Tier 3
COREG CR Tier 3
labetalol hcl Tier 1
BETA BLOCKERS CARDIO-SELECTIVE acebutolol hcl Tier 1
atenolol Tier 1 SEMS
betaxolol hcl Tier 1
bisoprolol fumarate Tier 1
BYSTOLIC Tier 2
LOPRESSOR Tier 3
metoprolol succinate Tier 1
metoprolol tartrate Tier 1 SEMS
TENORMIN Tier 3
TOPROL XL Tier 3
BETA BLOCKERS NON-SELECTIVE BETAPACE Tier 3
BETAPACE AF Tier 3
CORGARD Tier 3
HEMANGEOL Tier 3
INDERAL LA Tier 3
INDERAL XL Tier 3 PA
INNOPRAN XL Tier 3 PA
nadolol Tier 1
pindolol Tier 1
propranolol hcl Tier 1
sotalol hcl Tier 1
sotalol hcl (afib/afl) Tier 1
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
44
Drug Name Drug Tier Requirements/Limits
SOTYLIZE Tier 3
timolol maleate Tier 1
CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS
amlodipine besylate Tier 1
CALAN SR Tier 3
CARDIZEM Tier 3
CARDIZEM CD Tier 3
CARDIZEM LA Tier 3
diltiazem hcl Tier 1 SEMS
diltiazem hcl coated beads Tier 1 SEMS
diltiazem hcl extended release beads Tier 1 SEMS
felodipine Tier 1
isradipine Tier 1
nicardipine hcl Tier 1
nifedipine Tier 1 SEMS
nimodipine Tier 1
nisoldipine Tier 1
NORVASC Tier 3
NYMALIZE Tier 3 PA
PROCARDIA Tier 3
PROCARDIA XL Tier 3
SULAR Tier 3
TIAZAC Tier 3
verapamil hcl CP24 Tier 1
verapamil hcl TABS; TBCR Tier 1 SEMS
VERELAN Tier 3
VERELAN PM Tier 3
CARDIOTONICS CARDIAC GLYCOSIDES
digoxin SOLN .05mg/ml Tier 1
digoxin TABS Tier 1 SEMS
LANOXIN SOLN LA PA
LANOXIN TABS Tier 3
PHOSPHODIESTERASE INHIBITORS milrinone lactate LA PA
milrinone lactate in dextrose LA PA
CARDIOVASCULAR AGENTS - MISC. CARDIOVASCULAR AGENTS MISC. - COMBINATIONS
amlodipine besylate-atorvastatin calcium Tier 1
BIDIL Tier 2
CADUET Tier 3
-
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program
45
Drug Name Drug Tier Requirements/Limits
ENTRESTO Tier 2
IMPOTENCE AGENTS CAVERJECT IMPULSE Tier 2 QL; GENDER
EDEX Tier 2 QL; GENDER
sildenafil citrate Tier 1 QL; GENDER
tadalafil Tier 1 QL; GENDER
PROSTAGLANDIN VASODILATORS epoprostenol sodium LA SP, PA
ORENITRAM Tier 4 SP, PA
REMODULIN LA SP, PA
TYVASO Tier 2 SP, PA
TYVASO REFILL Tier 2 SP, PA
TYVASO STARTER Tier 2 SP, PA
VENTAVIS Tier 2 SP
PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR
ANTAGONISTS ambrisentan Tier 1 SP, PA
bosentan Tier 1 SP, PA, QL
OPSUMIT Tier 4 SP, PA
TRACLEER Tier 2 SP, PA
PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS ADCIRCA Tier 4 SP, PA
REVATIO SOLN LA SP, PA
REVATIO SUSR; TABS Tier 4 SP, PA
sildenafil citrate (pulmonary hypertension) SOLN
LA SP, PA
sildenafil citrate (pulmonary hypertension) SUSR; TABS
Tier 1 SP, PA
tadalafil (pulmonary hypertension) Tier 1 SP, PA
PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST UPTRAVI Tier 4 SP, PA
PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE
STIMULATOR ADEMPAS Tier 4 SP, PA
SINUS NODE INHIBITORS CORLANOR Tier 3
TRANSTHYRETIN STABILIZERS VYNDAMAX Tier 4 SP, PA
CEPH