2016

BCN AdvantageSM

2016 Formulary (List of covered drugs) PLEASE READ: DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This formulary was updated on 12/01/2016. For more recent information or other questions, please contact BCN Advantage Customer Service at 1-800-450-3680 or, for TTY users, 711, 8 a.m. to 8 p.m. Monday through Friday, with weekend hours Oct. 1 through Feb. 14, or visit www.bcbsm.com/medicare. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

Last updated: 12/01/2016 Formulary 16202, Version 23 BCN Advantage is an HMO‑POS plan and an HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

Confidence comes w ith every card.®

bcbsm.com/medicare

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Blue Care Network. When it refers to “plan” or “our plan,” it means BCN Advantage. This document includes a list of the drugs (formulary) for our plan which is current as of 12/01/2016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network and/or copayments/ coinsurance may change on January 1, 2017.

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

Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive up to a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 12/01/2016. To get updated information about the drugs covered by BCN Advantage, please contact us. Our contact information appears on the front and back cover pages.

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

Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents.” If you know what your drug is used for, look for the category name in the list that begins page 1. Then look under the category name on your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page Index 1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

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

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: • Prior Authorization: BCN Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from BCN Advantage before you fill your prescriptions. If you don’t get approval, BCN Advantage may not cover the drug. • Quantity Limits: For certain drugs, BCN Advantage limits the amount of the drug that BCN Advantage will cover. For example, BCN Advantage provides thirty four tablets per prescription for Onglyza®. This may be in addition to a standard one-month or three-month supply.

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• Step Therapy: In some cases, BCN Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, BCN Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, BCN Advantage will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask BCN Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the BCN Advantage’s formulary?” on page ii for information about how to request an exception.

What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that BCN Advantage does not cover your drug, you have two options: • You can ask Customer Service for a list of similar drugs that are covered by BCN Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by BCN Advantage. • You can ask BCN Advantage to make an exception and cover your drug. See below for information about how to request an exception.

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How do I request an exception to the BCN Advantage Formulary? You can ask BCN Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. • You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. • You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, BCN Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, BCN Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 34-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 34-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 34-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Other times when we will cover a temporary 34-day transition supply (or less, if you have a prescription for fewer days) includes: • When you enter a long-term care facility from hospitals or other settings. • When you leave a long-term care facility and return to a home. • When you are discharged from a hospital to a home • When you leave a skilled nursing facility covered under Medicare Part A (where all pharmacy charges are covered) and must revert to coverage under the BCN Advantage Drug list • When you cancel hospice care to revert to standard Medicare Parts A and B benefits • When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized BCN Advantage will send you a letter within three business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options. Note: Our transition policy applies only to those drugs that are “Part D drugs” and that are bought at a network pharmacy. The transition policy can’t be used to buy a non-Part D drug or a drug out-of-network, unless you qualify for out-of-network access. In addition to any exclusions or limitations described in the BCN Advantage 2016 Formulary, or in the Evidence of Coverage, the following items and services aren’t covered under Original Medicare or by our plan: • Replacement prescriptions resulting from loss, theft or mishandling • Reimbursement for prescriptions that are not approved by the FDA • Reimbursement for prescriptions that are not purchased in the United States or its territories • Covered prescription drugs beyond 90-day supply limit, including early refill requests • Prescriptions written by prescribers who are subject to the plan’s Prescriber Block Policy. Out-of-state prescription refills are available to you when you spend time outside of Michigan; for example, if you travel to Florida in the winter months. Please call our Customer Service number located on the front and back covers of this booklet if you need help locating an out-of-state participating pharmacy. iii

For more information For more detailed information about your BCN Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about BCN Advantage, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users call 1-877-486-2048. Or, visit http://www.medicare.gov.

BCN Advantage Formulary The formulary below provides coverage information about the drugs covered by BCN Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page Index 1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., Crestor®) and generic drugs are listed in lower-case italics (e.g., sumatriptan). The information in the Requirements/Limits column tells you if BCN Advantage has any special requirements for coverage of your drug.

Your costs (see cost‑share tables below) The amount you pay for a covered drug will depend on: • Your coverage stage. BCN Advantage has different stages of coverage. In each stage, the amount you pay for a drug may change. • The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier may have a different copay or coinsurance amount. The “Drug Tiers” chart below explains what types of drugs are included in each tier and shows how costs may change with each tier. • The pharmacy you use. You may go to any of our network pharmacies. However, you will usually pay less for your threemonth supply of covered drugs if you use a preferred network pharmacy or network mail order pharmacy rather than a standard retail pharmacy. The Pharmacy Directory will tell you which of the pharmacies in our network are preferred network pharmacies and network mail order pharmacies. All drugs on our Formulary are available for mail order: Our plan’s mail-order service requires you to order at least a 34-day supply of the drug and no more than a 90-day supply. Tier 5 specialty drugs are limited to 34-day supply via mail order.

Description of our Formulary Drug Tiers

Drug Tiers Tier 1: Preferred Generic Drugs Tier 2: Generic Drugs

Includes This tier includes many commonly prescribed low-cost drugs. This tier includes additional low-cost drugs.

Tier 3: Preferred Brand Drugs Tier 4: NonPreferred Brand Drugs

This tier includes preferred brand-name drugs This tier includes nonpreferred brand-name drugs.

Tier 5: Specialty Tier Drugs

This tier includes very high-cost drugs.

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Helpful Tips This tier includes commonly prescribed generic drugs and may include other low-cost drugs. Use Tier 1 drugs for the lowest co-payments. This tier includes generic drugs and may include other low-cost drugs. Use Tier 2 drugs to keep your co-payments low. Drugs in this tier will generally have lower co-payments than nonpreferred drugs. Many non-preferred drugs have lower-cost alternatives in Tiers 1, 2 and 3. Ask your doctor if switching to a lower-cost generic or preferred brand drug may be right for you. Many Specialty drug prescriptions need prior authorization. Contact Customer Service at the numbers listed on the front and back cover of this booklet if you have questions regarding this tier.

BCN Advantage Prescription Drug Tier Costs* for Initial Coverage Stage *If you are eligible to receive a low-income subsidy for extra help, the copay and coinsurance amounts listed in this chart are not applicable. Refer to your Evidence of Coverage for cost-sharing details. The BCN Advantage Classic, Prestige, MyChoice and ConnectedCare plans have no deductible. You pay the amounts listed below until you reach your Initial Coverage Stage limit of $3,310. This amount includes the total drug costs paid by you (copayments and coinsurance) and the plan. The BCN Advantage Basic plan has a deductible. After you (or others on your behalf) have met your deductible, the plan pays its share of the costs of your drugs and you pay your share. Up to a 34‑day supply Tier

Tier 1

At preferred At the Drug network At long‑term At out‑of­ plan’s Description pharmacies or the mail network care plan’s mail order pharmacies** pharmacies order service service

At standard retail network pharmacies

Basic: 25% Coinsurance Classic: $7.50 Prestige:$7.50 MyChoice: $12.50 ConnectedCare: $12.50 Basic: 25% Coinsurance Classic: $25 Prestige: $25 MyChoice: $37.50 ConnectedCare: $37.50 Basic: 25% Coinsurance Classic: $100 Prestige: $87.50 MyChoice: $117.50 ConnectedCare: $117.50 Basic: 25% Coinsurance Classic: $200 Prestige: $187.50 MyChoice: $250 ConnectedCare: $250

Basic: 25% Coinsurance Classic: $9 Prestige: $9 MyChoice: $15 ConnectedCare: $15 Basic: 25% Coinsurance Classic: $30 Prestige: $30 MyChoice: $45 ConnectedCare: $45 Basic: 25% Coinsurance Classic: $120 Prestige: $105 MyChoice: $141 ConnectedCare: $141 Basic: 25% Coinsurance Classic: $240 Prestige: $225 MyChoice: $300 ConnectedCare: $300

Preferred Generic

Tier 2 Generic

Basic: 25% Coinsurance Classic: $3 Prestige: $3 MyChoice: $5 ConnectedCare: $5

Basic: 25% Coinsurance Classic: $10 Prestige: $10 MyChoice: $15 ConnectedCare: $15

Preferred Brand

Basic: 25% Coinsurance Classic: $40 Prestige: $35 MyChoice: $47 ConnectedCare: $47

Non Tier 4 Preferred Brand

Basic: 25% Coinsurance Classic: $80 Prestige: $75 MyChoice: $100 ConnectedCare: $100

Tier 3

Up to a 90‑day supply

Basic: 25% Coinsurance Tier 5 Specialty

Classic/Prestige/MyChoice/ ConnectedCare: 33% Coinsurance

A long-term supply is not available for drugs in Tier 5

**Brand-name solid oral dosage drugs are limited to a 14-day supply. v

BCN Advantage Drug Tier Costs* for Coverage Gap Stage *If you are eligible to receive a low-income subsidy for extra help, the copay and coinsurance amounts listed in this chart are not applicable. Refer to your Evidence of Coverage for cost-sharing details. After you leave the Initial Coverage Stage, we will continue to provide some prescription drug coverage until your yearly out-of-pocket costs reach a maximum of $4,850 for 2016. The BCN Advantage Prestige plan offers additional gap coverage. We provide additional drug coverage for Tier 1 (Preferred Generic) drugs only; you will be required to pay the applicable copayment or coinsurance. Up to a 34‑day supply Tier

At preferred At the Drug network At long‑term At out‑of­ plan’s Description pharmacies or the mail network care plan’s mail order pharmacies** pharmacies order service service Basic: 58% of the approved total cost Classic: 58% of the approved total cost

Tier 1

Up to a 90‑day supply

Preferred Generic

Prestige: the lesser of a $5 copay or 58% of the approved total cost MyChoice: 58% of the approved total cost. ConnectedCare: 58% of the approved total cost

At standard retail network pharmacies

Basic: 58% of the approved total cost

Basic: 58% of the approved total cost

Classic: 58% of the approved total cost

Classic: 58% of the approved total cost

Prestige: the lesser Prestige: the lesser of a $15 copay or of a $12.50 copay or 58% of the approved 58% of the approved total cost total cost MyChoice: MyChoice: 58% of the approved 58% of the approved total cost total cost ConnectedCare: ConnectedCare: 58% of the approved 58% of the approved total cost total cost

Tier 2 Generic

Basic, Classic, Prestige, MyChoice and ConnectedCare: 58% of the approved total cost

Basic, Classic, Basic, Classic, Prestige, MyChoice Prestige, MyChoice and ConnectedCare: and ConnectedCare: 58% of the approved 58% of the approved total cost total cost

Preferred Tier and Non 3 & 4 Preferred Brands

Basic, Classic, Prestige, MyChoice and ConnectedCare: 45% of the approved drug cost (plus a portion of the dispensing fee)

Basic, Classic, Basic, Classic, Prestige, MyChoice Prestige, MyChoice and ConnectedCare: and ConnectedCare: 45% of the approved 45% of the approved drug cost (plus drug cost (plus a portion of the a portion of the dispensing fee) dispensing fee)

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Up to a 34‑day supply Tier

Up to a 90‑day supply

At preferred At the Drug network Description At long‑term At out‑of­ plan’s pharmacies or the mail network care plan’s mail order pharmacies** pharmacies order service service

Tier 5 Specialty

Basic, Classic, Prestige, MyChoice and ConnectedCare:

Basic, Classic, Prestige, MyChoice and ConnectedCare:

Brands: 45% of the approved drug cost (plus a portion of the dispensing fee)

Brands: 45% of the approved drug cost (plus a portion of the dispensing fee)

Generics: 58% of the approved total cost

Generics: 58% of the approved total cost

At standard retail network pharmacies Basic, Classic, Prestige, My Choice and ConnectedCare: Brands: 45% of the approved drug cost (plus a portion of the dispensing fee) Generics: 58% of the total approved drug cost

It is important that you continue to use your BCN Advantage card when you are in the Coverage Gap Stage. Using your card assures you will pay the price your plan negotiated with the network pharmacy (usually less than retail prices) and, by tracking your spending, assures you will receive catastrophic coverage as soon as you are eligible.

**Brand-name solid oral dosage drugs are limited to a 14-day supply.

BCN Advantage Drug Tier Costs* for Catastrophic Coverage Stage *If you are eligible to receive a low-income subsidy for extra help, the copay and coinsurance amounts listed in this chart are not applicable. Refer to your Evidence of Coverage for cost-sharing details. When your out-of-pocket costs have reached the $4,850 Coverage Gap Stage limit, you move on to the Catastrophic Coverage Stage. The plan will pay for most of your drug costs for the rest of the calendar year. You will pay the following at network pharmacies: Tier Tier 1

Drug Description Preferred Generic

Up to a 34‑day supply at ALL retail pharmacies or the plan’s mail order service

Up to a 90‑day supply at preferred and standard network retail pharmacies

The greater of $2.95 or 5% of the plan’s approved amount

Tier 2 Generic Tier 3

Preferred Brand

Non Tier 4 Preferred Brand Tier 5 Specialty

The greater of $7.40 or 5% of the plan’s approved amount

The greater of $2.95 (generics) $7.40 (brands) or 5% of the plan’s approved amount

A long-term supply is not available for drugs in Tier 5

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List of Abbreviations

QL: Quantity Limit. For certain drugs, BCN Advantage limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, BCN Advantage requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. PA: Prior Authorization. BCN Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, we may not cover the drug. B/D: This drug may be covered under Medicare Part B or D depending on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. HI: Home Infusion. This prescription drug is covered under our medical benefit. For more information, call Customer Service. GC: Gap Coverage. For members in the Prestige plan, we provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, call Customer Service at the numbers listed on the cover of this document. BRAND-NAME DRUGS ARE CAPITALIZED. Generic drugs are lower-case italics.

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Drug Name

Drug Tier

ANTI - INFECTIVES ANTIFUNGAL AGENTS

Requirements /Limits

Drug Name

Drug Tier

fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml

2

fluconazole oral suspension for reconstitution

2

fluconazole oral tablet

2

ABELCET INTRAVENOUS SUSPENSION

4

AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTIO N

4

amphotericin b injection recon soln

2

flucytosine oral capsule

2

CANCIDAS INTRAVENOUS RECON SOLN

4

griseofulvin microsize oral suspension

2

clotrimazole mucous membrane troche

2

griseofulvin microsize oral tablet

2

ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN

4

griseofulvin ultramicrosize oral tablet

2

2

itraconazole oral capsule

2

fluconazole in dextrose(iso-o) intravenous piggyback

ketoconazole oral tablet

2

FLUCONAZOLE IN NACL (ISOOSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML

2

NOXAFIL INTRAVENOUS SOLUTION

5

NOXAFIL ORAL SUSPENSION

5

NOXAFIL ORAL TABLET,DELAYE D RELEASE (DR/EC)

5

nystatin oral suspension

2

Requirements /Limits

QL (105 per 34 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 1

Drug Name

Drug Tier

nystatin oral tablet

2

SPORANOX ORAL SOLUTION

3

terbinafine hcl oral tablet

2

voriconazole intravenous solution

2

voriconazole oral suspension for reconstitution

2

voriconazole oral tablet

2

ANTIVIRALS

Requirements /Limits

Drug Name

Drug Tier

APTIVUS ORAL CAPSULE

5

APTIVUS ORAL SOLUTION

5

ATRIPLA ORAL TABLET

5

BARACLUDE ORAL SOLUTION

3

cidofovir intravenous solution

2

COMPLERA ORAL TABLET

5

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

3

DAKLINZA ORAL TABLET

5

DESCOVY ORAL TABLET

5

didanosine oral capsule,delayed release(dr/ec)

2

EDURANT ORAL TABLET

5

abacavir oral tablet

2

abacavirlamivudinezidovudine oral tablet

5

acyclovir oral capsule

2

acyclovir oral suspension 200 mg/5 ml

2

acyclovir oral tablet

2

acyclovir sodium intravenous solution

2

EMTRIVA ORAL CAPSULE

3

adefovir oral tablet

5

EMTRIVA ORAL SOLUTION

3

amantadine hcl oral capsule

2

entecavir oral tablet

5

amantadine hcl oral solution

2

EPIVIR HBV ORAL SOLUTION

3

amantadine hcl oral tablet

2

EPIVIR ORAL SOLUTION

3

Requirements /Limits

PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 2

Drug Name

Drug Tier

EPZICOM ORAL TABLET

5

EVOTAZ ORAL TABLET

5

famciclovir oral tablet

2

foscarnet intravenous solution

2

FUZEON SUBCUTANEOUS RECON SOLN

5

ganciclovir sodium intravenous recon soln

2

GENVOYA ORAL TABLET

5

HARVONI ORAL TABLET

5

INTELENCE ORAL TABLET 100 MG, 200 MG

5

INTELENCE ORAL TABLET 25 MG

3

INVIRASE ORAL CAPSULE

4

INVIRASE ORAL TABLET

5

ISENTRESS ORAL POWDER IN PACKET

3

ISENTRESS ORAL TABLET

5

ISENTRESS ORAL TABLET,CHEWAB LE 100 MG

5

Requirements /Limits

PA

Drug Name

Drug Tier

ISENTRESS ORAL TABLET,CHEWAB LE 25 MG

3

KALETRA ORAL SOLUTION

5

KALETRA ORAL TABLET 100-25 MG

3

KALETRA ORAL TABLET 200-50 MG

5

lamivudine oral solution

2

lamivudine oral tablet

2

lamivudinezidovudine oral tablet

2

LEXIVA ORAL SUSPENSION

4

LEXIVA ORAL TABLET

5

moderiba dose pack oral tablets,dose pack

2

moderiba oral tablet

2

nevirapine oral suspension

2

nevirapine oral tablet

2

nevirapine oral tablet extended release 24 hr

2

NORVIR ORAL CAPSULE

3

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 3

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

5

REYATAZ ORAL POWDER IN PACKET

5

ribasphere oral capsule

2

ribasphere oral tablet 200 mg, 400 mg

2

ribasphere oral tablet 600 mg

5

ribasphere ribapak oral tablets,dose pack

5

ribavirin oral capsule

2

ribavirin oral tablet 200 mg

2

rimantadine oral tablet

2

SELZENTRY ORAL TABLET

5

SOVALDI ORAL TABLET

5

3

2

RESCRIPTOR ORAL TABLET, DISPERSIBLE

3

stavudine oral capsule stavudine oral recon soln

2

RETROVIR INTRAVENOUS SOLUTION

4

STRIBILD ORAL TABLET

5

SUSTIVA ORAL CAPSULE

3

NORVIR ORAL SOLUTION

3

NORVIR ORAL TABLET

3

ODEFSEY ORAL TABLET

5

OLYSIO ORAL CAPSULE

5

PREZCOBIX ORAL TABLET

5

PREZISTA ORAL SUSPENSION

5

PREZISTA ORAL TABLET 150 MG, 75 MG

3

PREZISTA ORAL TABLET 600 MG, 800 MG

5

REBETOL ORAL SOLUTION

4

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

3

RESCRIPTOR ORAL TABLET

PA

QL (180 per 90 days)

Requirements /Limits

PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 4

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

SUSTIVA ORAL TABLET

3

valganciclovir oral tablet

5

SYNAGIS INTRAMUSCULA R SOLUTION 50 MG/0.5 ML

5

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN

3

3

TAMIFLU ORAL CAPSULE 30 MG

3

QL (56 per 180 days)

VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN

TAMIFLU ORAL CAPSULE 45 MG, 75 MG

3

QL (28 per 180 days)

5

PA

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTIO N

3

QL (360 per 180 days)

VIEKIRA PAK ORAL TABLETS,DOSE PACK

5

PA

TECHNIVIE ORAL TABLET

5

VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR

5

TIVICAY ORAL TABLET 10 MG

4

VIRACEPT ORAL TABLET

3

TIVICAY ORAL TABLET 25 MG, 50 MG

5

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG

TRIUMEQ ORAL TABLET

5

5

TRUVADA ORAL TABLET

5

VIRAZOLE INHALATION RECON SOLN

3

VIREAD ORAL POWDER

5

TYBOST ORAL TABLET

5

VIREAD ORAL TABLET

3

TYZEKA ORAL TABLET

2

VITEKTA ORAL TABLET

5

valacyclovir oral tablet

5

ZEPATIER ORAL TABLET

5

valganciclovir oral recon soln

ZIAGEN ORAL SOLUTION

3

PA

B/D PA

PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 5

Drug Name

Drug Tier

zidovudine oral capsule

2

zidovudine oral syrup

2

zidovudine oral tablet

2

Requirements /Limits

CEPHALOSPORINS

CEDAX ORAL CAPSULE

4

cefaclor oral capsule

2

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

2

cefaclor oral tablet extended release 12 hr

2

cefadroxil oral capsule

2

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

2

cefadroxil oral tablet

2

cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml

2

cefazolin injection recon soln 1 gram, 100 gram, 20 gram, 300 g

2

HI

Drug Name

Drug Tier

cefazolin injection recon soln 10 gram, 500 mg

2

cefazolin intravenous recon soln

2

cefdinir oral capsule

2

cefdinir oral suspension for reconstitution

2

CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK

4

cefepime in dextrose,iso-osm intravenous piggyback

2

cefepime injection recon soln

2

cefixime oral suspension for reconstitution

2

cefotaxime injection recon soln 1 gram, 2 gram, 500 mg

2

cefotaxime injection recon soln 10 gram

2

CEFOTETAN IN DEXTROSE, ISOOSM INTRAVENOUS PIGGYBACK

4

cefotetan intravenous recon soln

2

Requirements /Limits HI

HI

HI

HI

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 6

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

cefoxitin in dextrose, iso-osm intravenous piggyback

2

HI

ceftriaxone intravenous recon soln

2

cefoxitin intravenous recon soln

2

HI

cefuroxime axetil oral tablet

2

cefpodoxime oral suspension for reconstitution

2

cefuroxime sodium injection recon soln 1.5 gram, 750 mg

2

HI

cefpodoxime oral tablet

2

2

HI

cefprozil oral suspension for reconstitution

2

cefuroxime sodium intravenous recon soln cephalexin oral capsule

1

GC

cefprozil oral tablet

2

1

GC

CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK

4

cephalexin oral suspension for reconstitution cephalexin oral tablet

1

GC

ceftazidime injection recon soln

2

4

HI

ceftibuten oral capsule

2

CLAFORAN INTRAVENOUS RECON SOLN 2 GRAM

ceftibuten oral suspension for reconstitution

2

FORTAZ IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK

4

ceftriaxone in dextrose,iso-os intravenous piggyback

2

FORTAZ INJECTION RECON SOLN 1 GRAM

4

ceftriaxone injection recon soln 1 gram, 2 gram

2

FORTAZ INTRAVENOUS RECON SOLN

4

ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg

2

HI

HI

HI

HI

HI

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 7

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

MAXIPIME INTRAVENOUS RECON SOLN 1 GRAM

4

azithromycin intravenous recon soln 500 mg (2 mg/ml)

2

MEFOXIN IN DEXTROSE (ISOOSM) INTRAVENOUS PIGGYBACK

4

azithromycin oral packet

2

azithromycin oral suspension for reconstitution

2

SUPRAX ORAL CAPSULE

4

azithromycin oral tablet

2

SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N

4

clarithromycin oral suspension for reconstitution

2

SUPRAX ORAL TABLET,CHEWAB LE

4

clarithromycin oral tablet

2 2

TAZICEF INJECTION RECON SOLN

4

clarithromycin oral tablet extended release 24 hr

5

TAZICEF INTRAVENOUS RECON SOLN

4

DIFICID ORAL TABLET e.e.s. 400 oral tablet

2 2

TEFLARO INTRAVENOUS RECON SOLN

4

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

ZERBAXA INTRAVENOUS RECON SOLN

4

ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG

3

erythrocin (as stearate) oral tablet 250 mg

1

ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous recon soln 500 mg

2

HI

Requirements /Limits

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 8

Drug Name

Drug Tier

Requirements /Limits

ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG

4

erythromycin ethylsuccinate oral suspension for reconstitution

1

erythromycin ethylsuccinate oral tablet

1

erythromycin oral capsule,delayed release(dr/ec)

1

GC

erythromycin oral tablet

1

GC

PCE ORAL TABLET, PARTICLES/CRYS TALS

4

ZMAX ORAL SUSPENSION,EXT ENDED REL RECON

4

MISCELLANEOUS ANTIINFECTIVES ALBENZA ORAL TABLET

4

ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N

3

ALINIA ORAL TABLET

3

GC

GC

Drug Name

Drug Tier

amikacin injection solution 1,000 mg/4 ml

2

amikacin injection solution 500 mg/2 ml

2

atovaquone oral suspension

2

atovaquoneproguanil oral tablet

2

AZACTAM IN DEXTROSE (ISOOSM) INTRAVENOUS PIGGYBACK

4

aztreonam injection recon soln 1 gram

2

aztreonam injection recon soln 2 gram

2

baciim intramuscular recon soln

2

bacitracin intramuscular recon soln

2

BETHKIS INHALATION SOLUTION FOR NEBULIZATION

5

BILTRICIDE ORAL TABLET

3

CAPASTAT INJECTION RECON SOLN

4

Requirements /Limits

HI

HI

B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 9

Drug Name

Drug Tier

Requirements /Limits

Drug Name

PA; QL (84 per 28 days)

CYCLOSERINE ORAL CAPSULE

3

DALVANCE INTRAVENOUS SOLUTION

5

dapsone oral tablet

2

daptomycin intravenous recon soln

4

DARAPRIM ORAL TABLET

3

ethambutol oral tablet

2

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 70 mg/50 ml, 90 mg/100 ml

2

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML

4

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 120 MG/100 ML

2

gentamicin in nacl (iso-osm) intravenous piggyback 60 mg/50 ml, 80 mg/100 ml

2

gentamicin injection solution

2

CAYSTON INHALATION SOLUTION FOR NEBULIZATION

5

chloramphenicol sod succinate intravenous recon soln

2

chloroquine phosphate oral tablet

2

clindamycin hcl oral capsule

2

clindamycin in 5 % dextrose intravenous piggyback

2

clindamycin palmitate hcl oral recon soln

2

clindamycin pediatric oral recon soln

2

clindamycin phosphate injection solution

2

clindamycin phosphate intravenous solution

2

COARTEM ORAL TABLET

3

colistin (colistimethate na) injection recon soln

2

HI

CUBICIN INTRAVENOUS RECON SOLN

4

B/D PA; HI

Drug Tier

Requirements /Limits

B/D PA; HI

HI

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 10

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

gentamicin sulfate (ped) (pf) injection solution

2

linezolid oral suspension for reconstitution

5

gentamicin sulfate (pf) intravenous solution 100 mg/10 ml, 80 mg/8 ml

2

linezolid oral tablet

5 5

GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML

2

linezolid-0.9% sodium chloride intravenous parenteral solution mefloquine oral tablet

2 2

hydroxychloroquine oral tablet

2

meropenem intravenous recon soln

imipenem-cilastatin intravenous recon soln

2

2

INVANZ INJECTION RECON SOLN

4

MEROPENEM0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK

2

INVANZ INTRAVENOUS RECON SOLN

4

metro i.v. intravenous piggyback

2

isoniazid injection solution

2

metronidazole in nacl (iso-os) intravenous piggyback

isoniazid oral solution

2

metronidazole oral capsule

2

isoniazid oral tablet

2

2

ivermectin oral tablet

2

metronidazole oral tablet

4

KETEK ORAL TABLET

4

NEBUPENT INHALATION RECON SOLN

linezolid intravenous parenteral solution

5

neomycin oral tablet

2

paromomycin oral capsule

2

Requirements /Limits

HI

B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 11

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

SYNERCID INTRAVENOUS RECON SOLN

5

tinidazole oral tablet

2

TOBI PODHALER INHALATION CAPSULE

5

TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE

5

tobramycin in 0.225 % nacl inhalation solution for nebulization

5

tobramycin sulfate injection recon soln

2

tobramycin sulfate injection solution

2

TRECATOR ORAL TABLET

4 4

HI

4

TYGACIL INTRAVENOUS RECON SOLN

4

XIFAXAN ORAL TABLET 200 MG

4

RIMSO-50 INTRAVESICAL SOLUTION

QL (9 per 3 days)

XIFAXAN ORAL TABLET 550 MG

4

QL (180 per 90 days)

SIRTURO ORAL TABLET

5

5

SIVEXTRO ORAL TABLET

5

ZYVOX INTRAVENOUS PARENTERAL SOLUTION

STREPTOMYCIN INTRAMUSCULA R RECON SOLN

4

PASER ORAL GRANULES DR FOR SUSP IN PACKET

4

PENTAM INJECTION RECON SOLN

4

polymyxin b sulfate injection recon soln

2

PRIFTIN ORAL TABLET

4

PRIMAQUINE ORAL TABLET

3

pyrazinamide oral tablet

2

quinine sulfate oral capsule

2

rifabutin oral capsule

2

rifampin intravenous recon soln

2

rifampin oral capsule

2

RIFATER ORAL TABLET

PA

B/D PA

HI

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 12

Drug Name

Drug Tier

ZYVOX ORAL SUSPENSION FOR RECONSTITUTIO N

5

ZYVOX ORAL

TABLET

5

Requirements /Limits

PENICILLINS amoxicillin oral capsule

1

GC

amoxicillin oral suspension for reconstitution

1

GC

amoxicillin oral tablet

1

GC

amoxicillin oral tablet,chewable 125 mg, 250 mg

1

GC

amoxicillin-pot clavulanate oral suspension for reconstitution

2

amoxicillin-pot clavulanate oral tablet

2

amoxicillin-pot clavulanate oral tablet extended release 12 hr

2

amoxicillin-pot clavulanate oral tablet,chewable

2

ampicillin oral capsule

1

GC

ampicillin oral suspension for reconstitution

1

GC

Drug Name

Drug Tier

ampicillin sodium injection recon soln 1 gram, 125 mg

2

ampicillin sodium injection recon soln 2 gram, 250 mg, 500 mg

2

ampicillin sodium intravenous recon soln

2

ampicillin-sulbactam injection recon soln 1.5 gram

2

ampicillin-sulbactam injection recon soln 15 gram, 3 gram

2

BICILLIN C-R INTRAMUSCULA R SYRINGE

4

BICILLIN L-A INTRAMUSCULA R SYRINGE

4

dicloxacillin oral capsule

2

nafcillin in dextrose iso-osm intravenous piggyback

2

nafcillin injection recon soln

2

nafcillin intravenous recon soln

2

oxacillin in dextrose(iso-osm) intravenous piggyback

2

Requirements /Limits HI

HI

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 13

Drug Name

Drug Tier

oxacillin injection recon soln 1 gram, 2 gram

4

OXACILLIN INJECTION RECON SOLN 10 GRAM

4

oxacillin intravenous recon soln 1 gram

2

OXACILLIN INTRAVENOUS RECON SOLN 2 GRAM

4

PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK

4

penicillin g potassium injection recon soln 20 million unit

2

penicillin g potassium injection recon soln 5 million unit

2

penicillin g procaine intramuscular syringe 1.2 million unit/2 ml

2

penicillin g procaine intramuscular syringe 600,000 unit/ml

4

penicillin g sodium injection recon soln

2

Requirements /Limits

HI

HI

HI

Drug Name

Drug Tier

Requirements /Limits

penicillin v potassium oral recon soln

1

GC

penicillin v potassium oral tablet

1

GC

pfizerpen-g injection recon soln 20 million unit

2

piperacillintazobactam intravenous recon soln 2.25 gram, 40.5 gram

2

piperacillintazobactam intravenous recon soln 3.375 gram, 4.5 gram

2

HI

ZOSYN IN DEXTROSE (ISOOSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML, 3.375 GRAM/50 ML

4

HI

ZOSYN IN DEXTROSE (ISOOSM) INTRAVENOUS PIGGYBACK 4.5 GRAM/100 ML

4

QUINOLONES HI

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr

2

QL (14 per 14 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 14

Drug Name

Drug Tier

ciprofloxacin hcl oral tablet

2

ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml

2

ciprofloxacin lactate intravenous solution

2

ciprofloxacin oral suspension,microcap sule recon

2

levofloxacin in d5w intravenous piggyback 500 mg/100 ml

2

levofloxacin intravenous solution

2

levofloxacin oral solution

2

levofloxacin oral tablet

2

moxifloxacin oral tablet

2

ofloxacin oral tablet 400 mg

2

Requirements /Limits

Drug Name

Drug Tier

sulfamethoxazoletrimethoprim oral tablet

1

sulfatrim oral suspension

2

Requirements /Limits GC

TETRACYCLINES

HI

SULFA'S / RELATED AGENTS

sulfadiazine oral tablet

2

sulfamethoxazoletrimethoprim intravenous solution

2

sulfamethoxazoletrimethoprim oral suspension

1

GC

demeclocycline oral tablet

2

doxy-100 intravenous recon soln

2

doxycycline hyclate intravenous recon soln

2

doxycycline hyclate oral capsule

2

doxycycline hyclate oral tablet

2

doxycycline hyclate oral tablet,delayed release (dr/ec)

2

doxycycline monohydrate oral capsule

2

doxycycline monohydrate oral suspension for reconstitution

2

doxycycline monohydrate oral tablet

2

minocycline oral capsule

2

minocycline oral tablet

2

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 15

Drug Name

Drug Tier

minocycline oral tablet extended release 24 hr

2

mondoxyne nl oral capsule

2

morgidox oral capsule

2

tetracycline oral capsule

2

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg

2

vancomycin intravenous recon soln 5 gram

2

2

URINARY TRACT AGENTS

VANCOMYCIN INTRAVENOUS RECON SOLN 750 MG

methenamine hippurate oral tablet

2

vancomycin oral capsule

2

methenamine mandelate oral tablet

2

nitrofurantoin macrocrystal oral capsule

2

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

nitrofurantoin monohyd/m-cryst oral capsule

2

nitrofurantoin oral suspension

2

trimethoprim oral tablet

2

VANCOMYCIN VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK

2

VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK

2

B/D PA

ADJUNCTIVE AGENTS amifostine crystalline intravenous recon soln

5

dexrazoxane hcl intravenous recon soln

2

ELITEK INTRAVENOUS RECON SOLN

5

FUSILEV INTRAVENOUS RECON SOLN

5

KEPIVANCE INTRAVENOUS RECON SOLN

4

leucovorin calcium injection recon soln

2

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 16

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

leucovorin calcium oral tablet

2

anastrozole oral tablet

2

levoleucovorin calcium intravenous recon soln

2

ARRANON INTRAVENOUS SOLUTION

4

LEVOLEUCOVORI N CALCIUM INTRAVENOUS SOLUTION

4

ARZERRA INTRAVENOUS SOLUTION 1,000 MG/50 ML

4

mesna intravenous solution

2

3

MESNEX ORAL TABLET

4

ARZERRA INTRAVENOUS SOLUTION 100 MG/5 ML

XGEVA SUBCUTANEOUS SOLUTION

5

ASTAGRAF XL ORAL CAPSULE,EXTEN DED RELEASE 24HR

4

AVASTIN INTRAVENOUS SOLUTION

5

azacitidine injection recon soln

5

AZASAN ORAL TABLET

4

B/D PA

azathioprine oral tablet

2

B/D PA

azathioprine sodium injection recon soln

2

B/D PA

BELEODAQ INTRAVENOUS RECON SOLN

5

PA

BENDEKA INTRAVENOUS SOLUTION

5

PA

PA

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTIO N

4

adrucil intravenous solution

2

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION

5

AFINITOR ORAL TABLET

5

PA

ALECENSA ORAL CAPSULE

5

PA

PA

B/D PA

ALIMTA 4 INTRAVENOUS RECON SOLN Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 17

Drug Name

Drug Tier

bexarotene oral capsule

5

bicalutamide oral tablet

2

BICNU INTRAVENOUS RECON SOLN

4

bleo 15k injection recon soln

2

bleomycin injection recon soln

2

BLINCYTO INTRAVENOUS KIT

5

BOSULIF ORAL TABLET

5

BUSULFEX INTRAVENOUS SOLUTION

4

CABOMETYX ORAL TABLET

5

CAMPATH INTRAVENOUS SOLUTION

3

CAPRELSA ORAL TABLET

5

carboplatin intravenous solution

2

CELLCEPT INTRAVENOUS RECON SOLN

4

cisplatin intravenous solution

2

cladribine intravenous solution

2

Requirements /Limits

Drug Name

PA

CLOLAR INTRAVENOUS SOLUTION

4

COMETRIQ ORAL CAPSULE

5

PA

COTELLIC ORAL TABLET

5

PA; LA

cyclophosphamide intravenous recon soln

2

CYCLOPHOSPHA MIDE ORAL CAPSULE

4

B/D PA

cyclosporine intravenous solution

2

B/D PA

cyclosporine modified oral capsule

2

B/D PA

cyclosporine modified oral solution

2

B/D PA

cyclosporine oral capsule

2

B/D PA

CYRAMZA INTRAVENOUS SOLUTION

5

PA

cytarabine (pf) injection solution

2

cytarabine injection solution

2

dacarbazine intravenous recon soln

2

PA

PA

PA

B/D PA

Drug Tier

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 18

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

PA; LA

ELLENCE INTRAVENOUS SOLUTION

4

Requirements /Limits

DARZALEX INTRAVENOUS SOLUTION

5

daunorubicin intravenous solution

2

EMCYT ORAL CAPSULE

3

decitabine intravenous recon soln

5

EMPLICITI INTRAVENOUS RECON SOLN

5

PA

DEPOCYT (PF) INTRATHECAL SUSPENSION

4

4

B/D PA

DOCEFREZ INTRAVENOUS RECON SOLN 20 MG

5

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR epirubicin intravenous solution

2 4

docetaxel intravenous solution 10 mg/ml, 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)

5

ERBITUX INTRAVENOUS SOLUTION ERIVEDGE ORAL CAPSULE

5

ERWINAZE INJECTION RECON SOLN

5

4

doxorubicin intravenous recon soln

2

ETOPOPHOS INTRAVENOUS RECON SOLN etoposide intravenous solution

2

doxorubicin intravenous solution

2

exemestane oral tablet

2

doxorubicin, pegliposomal intravenous suspension

2

FARESTON ORAL TABLET

3 5

DROXIA ORAL CAPSULE

4

FARYDAK ORAL CAPSULE

PA

PA; QL (6 per 21 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 19

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

FASLODEX INTRAMUSCULA R SYRINGE

5

HERCEPTIN INTRAVENOUS RECON SOLN

5

floxuridine injection recon soln

2

HEXALEN ORAL CAPSULE

5

fludarabine intravenous recon soln

2

hydroxyurea oral capsule

2 PA

2

IBRANCE ORAL CAPSULE

5

fludarabine intravenous solution

5

PA

fluorouracil intravenous solution

2

ICLUSIG ORAL TABLET 15 MG

2

ICLUSIG ORAL TABLET 45 MG

5

flutamide oral capsule

PA; QL (6 per 21 days)

2

GAZYVA INTRAVENOUS SOLUTION

5

idarubicin intravenous solution

2

gemcitabine intravenous recon soln

5

ifosfamide intravenous recon soln ifosfamide intravenous solution

2

gemcitabine intravenous solution

5

2

gengraf oral capsule

2

B/D PA

ifosfamide-mesna intravenous kit 1-1 gram

gengraf oral solution

2

B/D PA

imatinib oral tablet

5 PA

5

PA

IMBRUVICA ORAL CAPSULE

5

GILOTRIF ORAL TABLET

5

PA

GLEEVEC ORAL TABLET

5

INLYTA ORAL TABLET

3

IRESSA ORAL TABLET

5

GLEOSTINE ORAL CAPSULE 5 MG

2

HALAVEN INTRAVENOUS SOLUTION

5

irinotecan intravenous solution

PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 20

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

LONSURF ORAL TABLET

5

LUPRON DEPOT (3 MONTH) INTRAMUSCULA R SYRINGE KIT

5

LUPRON DEPOT (4 MONTH) INTRAMUSCULA R SYRINGE KIT

5

LUPRON DEPOT (6 MONTH) INTRAMUSCULA R SYRINGE KIT

5

LUPRON DEPOT INTRAMUSCULA R SYRINGE KIT

5

LUPRON DEPOTPED (3 MONTH) INTRAMUSCULA R SYRINGE KIT

5

LUPRON DEPOTPED INTRAMUSCULA R KIT

5

5

3

LYNPARZA ORAL CAPSULE

2

LYSODREN ORAL TABLET

3

leuprolide subcutaneous kit

2

MATULANE ORAL CAPSULE

5

lipodox 50 intravenous suspension

4

lipodox intravenous suspension

2

MEGACE ES ORAL SUSPENSION

IXEMPRA INTRAVENOUS RECON SOLN

5

JAKAFI ORAL TABLET

5

JEVTANA INTRAVENOUS SOLUTION

5

KADCYLA INTRAVENOUS RECON SOLN 100 MG

5

KADCYLA INTRAVENOUS RECON SOLN 160 MG

5

KEYTRUDA INTRAVENOUS RECON SOLN

5

KEYTRUDA INTRAVENOUS SOLUTION

5

LENVIMA ORAL CAPSULE

5

letrozole oral tablet

2

LEUKERAN ORAL TABLET

PA

B/D PA

PA

PA

Requirements /Limits PA

PA

PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 21

Drug Name

Drug Tier

Requirements /Limits

Drug Name

PA

mycophenolate mofetil oral suspension for reconstitution

2

B/D PA

mycophenolate mofetil oral tablet

2

B/D PA

mycophenolate sodium oral tablet,delayed release (dr/ec)

2

B/D PA

NEXAVAR ORAL TABLET

5

PA

NILANDRON ORAL TABLET

3

nilutamide oral tablet

2

NINLARO ORAL CAPSULE

5

NIPENT INTRAVENOUS RECON SOLN

4

NULOJIX INTRAVENOUS RECON SOLN

5

octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml

5

octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml

2

octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml)

2

megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml), 625 mg/5 ml

2

megestrol oral tablet

2

PA

MEKINIST ORAL TABLET

5

PA

melphalan hcl intravenous recon soln

2

mercaptopurine oral tablet

2

methotrexate sodium (pf) injection recon soln

2

methotrexate sodium (pf) injection solution

2

methotrexate sodium injection solution

2

methotrexate sodium oral tablet

2

mitomycin intravenous recon soln

2

mitoxantrone intravenous concentrate

2

MUSTARGEN INJECTION RECON SOLN

4

mycophenolate mofetil oral capsule

2

B/D PA

B/D PA

Drug Tier

Requirements /Limits

PA

B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 22

Drug Name

Drug Tier

octreotide acetate injection syringe 500 mcg/ml (1 ml)

5

ODOMZO ORAL

CAPSULE

5

ONCASPAR

INJECTION

SOLUTION

5

OPDIVO

INTRAVENOUS

SOLUTION

5

oxaliplatin

intravenous recon

soln

5

oxaliplatin intravenous solution

5

paclitaxel intravenous concentrate

2

PERJETA

INTRAVENOUS

SOLUTION

5

POMALYST ORAL CAPSULE

5

PORTRAZZA INTRAVENOUS SOLUTION

5

PROGRAF

INTRAVENOUS SOLUTION

4

PURIXAN ORAL

SUSPENSION

5

RAPAMUNE

ORAL SOLUTION

4

Requirements /Limits

PA; LA

PA; QL (34 per 34 days)

B/D PA

B/D PA

Drug Name

Drug Tier

Requirements /Limits

REVLIMID ORAL CAPSULE

5

PA; LA

RHEUMATREX ORAL

TABLETS,DOSE PACK

3

B/D PA

RITUXAN INTRAVENOUS CONCENTRATE

5

SANDIMMUNE INTRAVENOUS SOLUTION

4

SANDOSTATIN LAR DEPOT INTRAMUSCULA R KIT

5

SANDOSTATIN LAR DEPOT INTRAMUSCULA R

SUSPENSION,EXT

ENDED REL

RECON

5

SIGNIFOR LAR INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N

5

SIGNIFOR SUBCUTANEOUS SOLUTION

5

SIMULECT INTRAVENOUS

RECON SOLN

5

sirolimus oral tablet

2

B/D PA

B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 23

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

SOLTAMOX ORAL SOLUTION

3

TARGRETIN ORAL CAPSULE

5

PA

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE

5

TARGRETIN TOPICAL GEL

5

PA

TASIGNA ORAL CAPSULE

5

PA

SPRYCEL ORAL TABLET

5

5

PA

STIVARGA ORAL TABLET

5

TECENTRIQ INTRAVENOUS SOLUTION

5

SUPPRELIN LA IMPLANT KIT

4

TEMODAR INTRAVENOUS RECON SOLN

SUTENT ORAL CAPSULE

5

PA

THALOMID ORAL CAPSULE

5

SYLVANT INTRAVENOUS RECON SOLN 100 MG

5

PA

thiotepa injection recon soln

2

toposar intravenous solution

2

SYNRIBO SUBCUTANEOUS RECON SOLN

5

topotecan intravenous recon soln

2

TABLOID ORAL TABLET

3

PA

topotecan intravenous solution

2

tacrolimus oral capsule 0.5 mg, 1 mg

2

B/D PA

5

tacrolimus oral capsule 5 mg

5

B/D PA

TORISEL INTRAVENOUS RECON SOLN

5

TAFINLAR ORAL CAPSULE

5

PA

TREANDA INTRAVENOUS RECON SOLN

TAGRISSO ORAL TABLET

5

PA; LA

5

tamoxifen oral tablet

2

TARCEVA ORAL TABLET

5

TRELSTAR DEPOT INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N

PA

PA

PA

PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 24

Drug Name

Drug Tier

TRELSTAR INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N

5

TRELSTAR INTRAMUSCULA R SYRINGE

5

TRELSTAR LA INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N

5

tretinoin (chemotherapy) oral capsule

5

TREXALL ORAL TABLET

3

TRISENOX INTRAVENOUS SOLUTION

4

TYKERB ORAL TABLET

5

VALSTAR INTRAVESICAL SOLUTION

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

VENCLEXTA ORAL TABLET 100 MG

5

PA

VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK

5

PA

vinblastine intravenous solution

2

vincasar pfs intravenous solution

2

vincristine intravenous solution

2

vinorelbine intravenous solution

2

VOTRIENT ORAL TABLET

5

PA

XALKORI ORAL CAPSULE

5

PA; QL (68 per 34 days)

XTANDI ORAL CAPSULE

5

PA

5

PA

5

YERVOY INTRAVENOUS SOLUTION

5

PA

VECTIBIX INTRAVENOUS SOLUTION

5

YONDELIS INTRAVENOUS RECON SOLN

5

VELCADE INJECTION RECON SOLN

4

ZALTRAP INTRAVENOUS SOLUTION

4

VENCLEXTA ORAL TABLET 10 MG, 50 MG

4

ZANOSAR INTRAVENOUS RECON SOLN

B/D PA

PA

PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 25

Drug Name

Drug Tier

Requirements /Limits

Drug Name

PA; QL (272 per 34 days)

Drug Tier

Requirements /Limits

BRIVIACT ORAL SOLUTION

4

PA; QL (1800 per 90 days)

BRIVIACT ORAL TABLET

4

PA; QL (180 per 90 days)

carbamazepine oral capsule, er multiphase 12 hr

2

carbamazepine oral suspension 100 mg/5 ml

2

ZELBORAF ORAL TABLET

5

ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG

5

ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG

4

ZOLINZA ORAL CAPSULE

5

PA

ZORTRESS ORAL TABLET 0.25 MG

4

B/D PA

carbamazepine oral tablet

2

ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG

5

B/D PA

carbamazepine oral tablet extended release 12 hr

2

ZYDELIG ORAL TABLET

5

PA

carbamazepine oral tablet,chewable

2

ZYKADIA ORAL CAPSULE

5

PA

CELONTIN ORAL CAPSULE 300 MG

3

ZYTIGA ORAL TABLET

5

PA

CEREBYX INJECTION SOLUTION

4

clonazepam oral tablet

2

clonazepam oral tablet,disintegrating

2

diazepam rectal kit

2

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET

4

BANZEL ORAL SUSPENSION

3

DILANTIN 30 MG ORAL CAPSULE

3

BANZEL ORAL TABLET

3

divalproex oral capsule, sprinkle

2

BRIVIACT INTRAVENOUS SOLUTION

4

divalproex oral tablet extended release 24 hr

2

PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 26

Drug Name

Drug Tier

divalproex oral tablet,delayed release (dr/ec)

2

epitol oral tablet

2

ethosuximide oral capsule

2

ethosuximide oral solution

2

felbamate oral suspension

2

felbamate oral tablet

2

fosphenytoin injection solution

2

FYCOMPA ORAL SUSPENSION

4

FYCOMPA ORAL TABLET

4

gabapentin oral capsule

2

gabapentin oral solution

2

gabapentin oral tablet 600 mg, 800 mg

2

GABITRIL ORAL TABLET 12 MG, 16 MG

3

LAMICTAL ODT ORAL TABLET,DISINTE GRATING

4

Requirements /Limits

Drug Name

Drug Tier

LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING , DOSE PK

4

LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING , DOSE PK

4

LAMICTAL ODT STARTER

(ORANGE) ORAL TABLET DISINTEGRATING , DOSE PK

4

LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK

3

LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK

3

LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK

3

lamotrigine oral tablet

2

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 27

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits QL (180 per 90 days)

lamotrigine oral tablet disintegrating, dose pk

2

ONFI ORAL TABLET 10 MG, 20 MG

4

lamotrigine oral tablet extended release 24hr

2

oxcarbazepine oral suspension

2 2

lamotrigine oral tablet, chewable dispersible

2

oxcarbazepine oral tablet PEGANONE ORAL TABLET

3

lamotrigine oral tablet,disintegrating

2

phenobarbital oral elixir

2

lamotrigine oral tablets,dose pack 25 mg (35)

2

phenobarbital oral tablet

2

LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK

4

phenytoin oral suspension

2

phenytoin oral tablet,chewable

2

levetiracetam intravenous solution

2

2

levetiracetam oral solution

2

phenytoin sodium extended oral capsule

2

levetiracetam oral tablet

2

phenytoin sodium intravenous solution

2

levetiracetam oral tablet extended release 24 hr

2

phenytoin sodium intravenous syringe POTIGA ORAL TABLET

4

LYRICA ORAL CAPSULE

4

primidone oral tablet

2

LYRICA ORAL SOLUTION

4

roweepra oral tablet

2

4

SABRIL ORAL POWDER IN PACKET

5

ONFI ORAL SUSPENSION

SABRIL ORAL TABLET

5

QL (1440 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 28

Drug Name

Drug Tier

SPRITAM ORAL TABLET FOR SUSPENSION

4

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG

3

tiagabine oral tablet

2

topiramate oral capsule, sprinkle

2

topiramate oral tablet

2

valproate sodium intravenous solution

2

valproic acid (as sodium salt) oral solution

2

valproic acid oral capsule

2

VIMPAT INTRAVENOUS SOLUTION

4

VIMPAT ORAL SOLUTION

3

VIMPAT ORAL TABLET

3

zonisamide oral capsule

2

Requirements /Limits

5

AZILECT ORAL TABLET

3

Drug Tier

benztropine injection solution

2

benztropine oral tablet

2

bromocriptine oral capsule

2

bromocriptine oral tablet

2

PA

carbidopa oral tablet

2

PA

carbidopa-levodopa oral tablet

2

carbidopa-levodopa oral tablet extended release

2

carbidopa-levodopa oral tablet,disintegrating

2

carbidopa-levodopaentacapone oral tablet

2

DUOPA J-TUBE INTESTINAL PUMP SUSPENSION

4

entacapone oral tablet

2

NEUPRO TRANSDERMAL PATCH 24 HOUR

4

pramipexole oral tablet

2

pramipexole oral tablet extended release 24 hr

2

PA

ANTIPARKINSONISM AGENTS

APOKYN SUBCUTANEOUS CARTRIDGE

Drug Name

Requirements /Limits

PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 29

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

3

QL (24 per 90 days)

ropinirole oral tablet

2

ropinirole oral tablet extended release 24 hr

2

MIGRANAL NASAL SPRAY,NONAEROSOL

selegiline hcl oral capsule

2

naratriptan oral tablet

2

QL (27 per 90 days)

selegiline hcl oral tablet

2

RELPAX ORAL TABLET

4

ST; QL (18 per 90 days)

tolcapone oral tablet

2

rizatriptan oral tablet

2

QL (36 per 90 days)

trihexyphenidyl oral elixir

2

rizatriptan oral tablet,disintegrating

2

QL (36 per 90 days)

trihexyphenidyl oral tablet

2

sumatriptan nasal spray,non-aerosol

2

ZELAPAR ORAL TABLET,DISINTE GRATING

4

sumatriptan succinate oral tablet

2

sumatriptan succinate subcutaneous cartridge

2

sumatriptan succinate subcutaneous pen injector

2

sumatriptan succinate subcutaneous solution

2

2

MIGRAINE / CLUSTER HEADACHE THERAPY almotriptan malate oral tablet

2

ST; QL (36 per 90 days)

AXERT ORAL TABLET

4

ST; QL (36 per 90 days)

dihydroergotamine nasal spray,nonaerosol

2

QL (16 per 30 days)

ERGOMAR SUBLINGUAL TABLET

3

FROVA ORAL TABLET

4

ST; QL (36 per 90 days)

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml

frovatriptan oral tablet

2

ST; QL (36 per 90 days)

TREXIMET ORAL TABLET

4

QL (30 per 90 days)

migergot rectal suppository

2

zolmitriptan oral tablet

2

QL (18 per 90 days)

QL (60 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 30

Drug Name

Drug Tier

Requirements /Limits

Drug Name

zolmitriptan oral tablet,disintegrating

2

QL (18 per 90 days)

5

PA

ZOMIG NASAL SPRAY,NONAEROSOL

4

ST; QL (18 per 90 days)

LEMTRADA INTRAVENOUS SOLUTION memantine oral solution

2

PA; QL (1080 per 90 days)

MISCELLANEOUS NEUROLOGICAL THERAPY

memantine oral tablet

2

PA; QL (180 per 90 days)

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR

5

PA

MEMANTINE ORAL TABLETS,DOSE PACK

3

PA

AUBAGIO ORAL TABLET

5

PA

NAMENDA ORAL SOLUTION

3

PA; QL (1080 per 90 days)

COPAXONE SUBCUTANEOUS SYRINGE

5

PA

NAMENDA ORAL TABLET

3

PA; QL (180 per 90 days)

3

donepezil oral tablet

2

QL (90 per 90 days)

PA; QL (147 per 84 days)

donepezil oral tablet,disintegrating

2

QL (90 per 90 days)

NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK

EXELON TRANSDERMAL PATCH 24 HOUR

3

QL (90 per 90 days)

4

PA; QL (84 per 84 days)

galantamine oral capsule,ext rel. pellets 24 hr

2

NAMENDA XR ORAL CAP,SPRINKLE,E R 24HR DOSE PACK

4

PA; QL (90 per 90 days)

galantamine oral solution

2

NAMENDA XR ORAL CAPSULE,SPRINK LE,ER 24HR

galantamine oral tablet

2

NUEDEXTA ORAL CAPSULE

3

QL (180 per 90 days)

GILENYA ORAL CAPSULE

5

rivastigmine tartrate oral capsule

2

glatopa subcutaneous syringe

5

rivastigmine transdermal patch 24 hour

2

PA

Drug Tier

Requirements /Limits

QL (90 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 31

Drug Name

Drug Tier

Requirements /Limits

Drug Name MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE

3

metaxall oral tablet

2

methocarbamol injection solution

2

neostigmine methylsulfate intravenous solution

2

MUSCLE RELAXANTS / ANTISPASMODIC THERAPY

pyridostigmine bromide oral tablet

2

baclofen oral tablet

2

2

cyclobenzaprine oral tablet

2

pyridostigmine bromide oral tablet extended release

DANTRIUM INTRAVENOUS RECON SOLN

4

regonol injection solution

2 2

dantrolene oral capsule

2

revonto intravenous recon soln

2

enlon injection solution

2

tizanidine oral capsule tizanidine oral tablet

2

ENLON-PLUS INTRAVENOUS SOLUTION

4

NARCOTIC ANALGESICS

5

PA; QL (136 per 34 days)

LIORESAL INTRATHECAL SOLUTION

4

ABSTRAL SUBLINGUAL TABLET

2

QL (5000 per 30 days)

MESTINON ORAL SYRUP

3

acetaminophencodeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml acetaminophencodeine oral tablet

2

QL (1080 per 90 days)

TECFIDERA ORAL CAPSULE,DELAY ED RELEASE(DR/EC)

5

PA

tetrabenazine oral tablet

5

PA

TYSABRI INTRAVENOUS SOLUTION

5

XENAZINE ORAL TABLET

5

LA

PA

PA

B/D PA

Drug Tier

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 32

Drug Name

Drug Tier

BUPRENEX INJECTION SOLUTION

4

buprenorphine hcl injection solution

2

buprenorphine hcl injection syringe

2

buprenorphine hcl sublingual tablet

2

codeine sulfate oral tablet

2

diskets oral tablet,soluble

2

duramorph (pf) injection solution

2

endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5325 mg

2

fentanyl citrate (pf) injection solution

2

fentanyl citrate (pf) intravenous syringe 100 mcg/2 ml (50 mcg/ml)

2

fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 400 mcg, 600 mcg, 800 mcg

5

fentanyl citrate buccal lozenge on a handle 200 mcg

2

Requirements /Limits

Drug Name

HI

HI

QL (1080 per 90 days)

PA; QL (136 per 34 days)

PA; QL (136 per 34 days)

Drug Tier

Requirements /Limits

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

2

QL (45 per 90 days)

FENTORA BUCCAL TABLET, EFFERVESCENT

5

PA; QL (136 per 34 days)

hydrocodoneacetaminophen oral solution 10-325 mg/15 ml(15 ml), 7.5-325 mg/15 ml

2

QL (5550 per 30 days)

hydrocodoneacetaminophen oral solution 2.5-167 mg/5 ml

2

hydrocodoneacetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

2

QL (1080 per 90 days)

hydrocodoneibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

2

QL (1080 per 90 days)

hydromorphone (pf) injection solution

2

hydromorphone injection solution

2

HYDROMORPHO NE INJECTION SYRINGE 0.5 MG/0.5 ML

2

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 33

Drug Name

Drug Tier

Requirements /Limits

hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 mg/ml

2

hydromorphone oral tablet 2 mg

2

QL (1350 per 90 days)

hydromorphone oral tablet 4 mg

2

QL (720 per 90 days)

hydromorphone oral tablet 8 mg

2

QL (360 per 90 days)

ibuprofen-oxycodone oral tablet

2

QL (720 per 90 days)

INFUMORPH P/F INJECTION SOLUTION

4

KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 200 MG

4

LAZANDA NASAL SPRAY,NONAEROSOL

5

levorphanol tartrate oral tablet

2

lorcet (hydrocodone) oral tablet

2

QL (1080 per 90 days)

lorcet hd oral tablet

2

QL (1080 per 90 days)

lorcet plus oral tablet 7.5-325 mg

2

QL (1080 per 90 days)

lortab 10-325 oral tablet

2

QL (1080 per 90 days)

lortab 5-325 oral tablet

2

QL (1080 per 90 days)

QL (180 per 90 days)

PA; QL (34 per 34 days)

Drug Name

Drug Tier

Requirements /Limits

lortab 7.5-325 oral tablet

2

QL (1080 per 90 days)

marten-tab oral tablet

2

methadone injection solution

2

methadone intensol oral concentrate

2

methadone oral concentrate

2

methadone oral solution

2

methadone oral tablet

2

methadone oral tablet,soluble

2

methadose oral tablet,soluble

2

morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml

2

morphine (pf) intravenous patient control.analgesia soln

2

morphine concentrate oral solution

2

morphine intravenous cartridge 10 mg/ml

4

morphine intravenous cartridge 2 mg/ml, 4 mg/ml

2

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 34

Drug Name

Drug Tier

MORPHINE INTRAVENOUS CARTRIDGE 8 MG/ML

4

morphine intravenous solution 10 mg/ml, 100 mg/4 ml, 25 mg/ml, 250 mg/10 ml, 50 mg/ml

2

MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML

4

MORPHINE INTRAVENOUS SYRINGE 10 MG/ML, 8 MG/ML

4

morphine intravenous syringe 2 mg/ml, 4 mg/ml

2

morphine oral capsule, er multiphase 24 hr

2

morphine oral capsule,extend.relea se pellets

2

morphine oral solution

2

morphine oral tablet

2

morphine oral tablet extended release

2

morphine rectal suppository

2

Requirements /Limits

QL (90 per 90 days) QL (90 per 90 days)

QL (270 per 90 days)

Drug Name

Drug Tier

Requirements /Limits

OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 20 MG, 30 MG, 40 MG, 5 MG

4

QL (180 per 90 days)

OPANA INJECTION SOLUTION

4

oxycodone oral capsule

2

QL (1080 per 90 days)

oxycodone oral concentrate

2

QL (1800 per 90 days)

oxycodone oral solution

2

oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg

2

QL (540 per 90 days)

oxycodone oral tablet 5 mg

2

QL (1080 per 90 days)

oxycodoneacetaminophen oral solution

2

QL (2108 per 34 days)

oxycodoneacetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

2

QL (1080 per 90 days)

oxycodone-aspirin oral tablet

2

QL (1080 per 90 days)

oxymorphone oral tablet

2

QL (540 per 90 days)

oxymorphone oral tablet extended release 12 hr

2

QL (180 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 35

Drug Name

Drug Tier

Requirements /Limits

Drug Name

reprexain oral tablet

2

QL (1080 per 90 days)

diclofenac sodium topical gel 1 %

2

SUBSYS SUBLINGUAL SPRAY,NONAEROSOL

5

PA; QL (136 per 34 days)

diclofenacmisoprostol oral tablet,ir,delayed rel,biphasic

2

tencon oral tablet 50-325 mg

2

diflunisal oral tablet

2

2

etodolac oral capsule

2

xylon 10 oral tablet

etodolac oral tablet

2

etodolac oral tablet extended release 24 hr

2

EVZIO INJECTION AUTO-INJECTOR

4 2

zamicet oral solution

2

QL (1080 per 90 days) QL (5550 per 30 days)

NON-NARCOTIC ANALGESICS

Drug Tier

Requirements /Limits

buprenorphinenaloxone sublingual tablet

2

butorphanol tartrate injection solution

2

fenoprofen oral tablet

2

flurbiprofen oral tablet

2

butorphanol tartrate nasal spray,nonaerosol

ibuprofen oral suspension

1

GC

celecoxib oral capsule

2

1

GC

clonidine (pf) epidural solution 5,000 mcg/10 ml

2

ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule

2

diclofenac potassium oral tablet

1

GC

2

diclofenac sodium oral tablet extended release 24 hr

1

GC

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg klofensaid ii topical drops

2

diclofenac sodium oral tablet,delayed release (dr/ec)

1

meclofenamate oral capsule

2

QL (180 per 90 days)

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 36

Drug Name

Drug Tier

Requirements /Limits

mefenamic acid oral capsule

2

meloxicam oral tablet

1

nabumetone oral tablet

2

nalbuphine injection solution

2

naloxone injection solution

2

naloxone injection syringe

2

naltrexone oral tablet

2

naproxen oral suspension

1

GC

naproxen oral tablet

1

GC

naproxen oral tablet,delayed release (dr/ec)

1

GC

naproxen sodium oral tablet 275 mg, 550 mg

1

GC

NARCAN NASAL SPRAY,NONAEROSOL

4

NUCYNTA ORAL TABLET

4

oxaprozin oral tablet

2

piroxicam oral capsule

1

PRIALT INTRATHECAL SOLUTION

4

GC

HI

Drug Name

Drug Tier

Requirements /Limits

salsalate oral tablet

2

SUBOXONE SUBLINGUAL FILM

3

sulindac oral tablet

2

tolmetin oral capsule

2

tolmetin oral tablet

2

tramadol oral tablet

2

QL (720 per 90 days)

tramadol oral tablet extended release 24 hr

2

QL (90 per 90 days)

tramadol oral tablet, er multiphase 24 hr

2

QL (90 per 90 days)

tramadolacetaminophen oral tablet

2

QL (1080 per 90 days)

VIVITROL INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON

5

VOLTAREN GEL TOPICAL GEL 1 %

4

PSYCHOTHERAPEUTIC DRUGS

GC

ABILIFY MAINTENA INTRAMUSCULA R

SUSPENSION,EXT ENDED REL RECON

5

ST

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 37

Drug Name

Drug Tier

Requirements /Limits

Drug Name

ST

bupropion hcl oral tablet extended release

1

GC

bupropion hcl oral tablet extended release 24 hr

1

GC

buspirone oral tablet

2

chlorpromazine injection solution

2

chlorpromazine oral tablet

2

Drug Tier

Requirements /Limits

ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL SYRING

5

ADASUVE INHALATION AEROSOL POWDR BREATH ACTIVATED

4

alprazolam intensol oral concentrate

2

citalopram oral solution

1

GC

alprazolam oral tablet

2

citalopram oral tablet

1

GC

amitriptyline oral tablet

2

clomipramine oral capsule

2

PA

amoxapine oral tablet

2

2

aripiprazole oral solution

2

clonidine hcl oral tablet extended release 12 hr

2

clorazepate dipotassium oral tablet

2

aripiprazole oral tablet aripiprazole oral tablet,disintegrating

2

clozapine oral tablet

2

5

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

2

ARISTADA INTRAMUSCULA R SUSPENSION,EXT ENDED REL SYRING

5

armodafinil oral tablet

2

PA; QL (90 per 90 days)

CLOZAPINE ORAL TABLET,DISINTE GRATING 150 MG, 200 MG

bupropion hcl oral tablet

1

GC

desipramine oral tablet

2

ST

PA

ST

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 38

Drug Tier

Requirements /Limits

Drug Name

dexedrine oral tablet 10 mg

2

QL (540 per 90 days)

dexedrine oral tablet 5 mg

2

QL (450 per 90 days)

dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15 mg, 20 mg, 30 mg, 40 mg

2

QL (90 per 90 days)

dexmethylphenidate oral tablet

2

dextroamphetamine oral capsule, extended release 10 mg, 5 mg

2

dextroamphetamine oral capsule, extended release 15 mg

2

dextroamphetamine oral solution

2

dextroamphetamine oral tablet 10 mg

2

QL (540 per 90 days)

dextroamphetamine oral tablet 5 mg

2

dextroamphetamineamphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 5 mg

2

dextroamphetamineamphetamine oral capsule,extended release 24hr 30 mg

2

Drug Name

Drug Tier

Requirements /Limits

dextroamphetamineamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg

2

QL (270 per 90 days)

dextroamphetamineamphetamine oral tablet 30 mg

2

QL (180 per 90 days)

diazepam intensol oral concentrate

2

diazepam oral concentrate

2

diazepam oral solution 5 mg/5 ml (1 mg/ml)

2

diazepam oral tablet

2

doxepin oral capsule

2

PA

doxepin oral concentrate

2

PA

duloxetine oral capsule,delayed release(dr/ec)

2

QL (450 per 90 days)

EMSAM TRANSDERMAL PATCH 24 HOUR

4

QL (270 per 90 days)

ergoloid oral tablet

2

escitalopram oxalate oral solution

2

escitalopram oxalate oral tablet

2

FANAPT ORAL TABLET

4

ST

FANAPT ORAL TABLETS,DOSE PACK

4

ST

QL (180 per 90 days) QL (102 per 34 days)

QL (136 per 34 days)

QL (180 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 39

Drug Name

Drug Tier

FAZACLO ORAL TABLET,DISINTE GRATING 150 MG, 200 MG

4

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK

4

FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR

4

fluoxetine oral capsule

2

fluoxetine oral capsule,delayed release(dr/ec)

2

fluoxetine oral solution

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

fluvoxamine oral tablet

2

GEODON INTRAMUSCULA R RECON SOLN

4

guanidine oral tablet

2

haloperidol decanoate intramuscular solution

2

haloperidol lactate injection solution

2

haloperidol lactate oral concentrate

2

haloperidol oral tablet

2

2

HETLIOZ ORAL CAPSULE

5

PA; QL (34 per 34 days)

fluoxetine oral tablet 10 mg, 20 mg

2

imipramine hcl oral tablet

2

PA

fluphenazine decanoate injection solution

2

imipramine pamoate oral capsule

2

PA

4

ST

fluphenazine hcl injection solution

2

fluphenazine hcl oral concentrate

2

INVEGA ORAL TABLET EXTENDED RELEASE 24HR

5

ST

fluphenazine hcl oral elixir

2

fluphenazine hcl oral tablet

2

fluvoxamine oral capsule,extended release 24hr

2

INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML

ST

ST

ST

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 40

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

ST

MARPLAN ORAL

TABLET

4

metadate er oral tablet extended release

2

methamphetamine oral tablet

2

methylphenidate oral capsule, er biphasic 30-70 10 mg, 20 mg, 40 mg, 60 mg

2

QL (90 per 90 days)

methylphenidate oral capsule, er biphasic 30-70 30 mg, 50 mg

2

QL (180 per 90 days)

methylphenidate oral capsule,er biphasic 50-50 20 mg, 40 mg

2

QL (90 per 90 days)

methylphenidate oral capsule,er biphasic 50-50 30 mg

2

QL (180 per 90 days)

INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 MG/0.25 ML, 78 MG/0.5 ML

4

INVEGA TRINZA INTRAMUSCULA R SYRINGE

5

KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR

4

ST

LATUDA ORAL TABLET

4

ST

lithium carbonate oral capsule

1

GC

lithium carbonate oral tablet

1

GC

lithium carbonate oral tablet extended release

1

GC

lithium citrate oral solution 8 meq/5 ml

1

lorazepam intensol oral concentrate

2

methylphenidate oral solution

2

lorazepam oral concentrate

2

methylphenidate oral tablet

2

QL (270 per 90 days)

lorazepam oral tablet

2

methylphenidate oral tablet extended release 10 mg

2

QL (270 per 90 days)

loxapine succinate oral capsule

2

2

QL (450 per 90 days)

maprotiline oral tablet

2

methylphenidate oral tablet extended release 20 mg

ST

GC

QL (450 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 41

Drug Name

Drug Tier

Requirements /Limits

Drug Name

methylphenidate oral tablet extended release 24hr

2

QL (180 per 90 days)

olanzapinefluoxetine oral capsule

2

methylphenidate oral tablet,chewable 10 mg

2

QL (540 per 90 days)

ORAP ORAL TABLET

3 2

methylphenidate oral tablet,chewable 2.5 mg, 5 mg

2

QL (270 per 90 days)

paliperidone oral tablet extended release 24hr

1

GC

mirtazapine oral tablet

2

paroxetine hcl oral tablet

GC

2

paroxetine hcl oral tablet extended release 24 hr

1

mirtazapine oral tablet,disintegrating modafinil oral tablet

2

PAXIL ORAL SUSPENSION

4

ST

molindone oral tablet

2

perphenazine oral tablet

2

nefazodone oral tablet

2

phenelzine oral tablet

2

nortriptyline oral capsule

1

GC

pimozide oral tablet

2

1

GC

NUPLAZID ORAL TABLET

5

PA

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR

4

nortriptyline oral solution

2

NUVIGIL ORAL TABLET

4

protriptyline oral tablet

2

olanzapine intramuscular recon soln

2

quetiapine oral tablet REXULTI ORAL TABLET

5

olanzapine oral tablet

2

olanzapine oral tablet,disintegrating

2

PA; QL (180 per 90 days)

PA; QL (90 per 90 days)

Drug Tier

Requirements /Limits

ST

ST

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 42

Drug Name

Drug Tier

Requirements /Limits

Drug Name

ST

Drug Tier

Requirements /Limits

STRATTERA ORAL CAPSULE 100 MG, 80 MG

4

QL (90 per 90 days)

SURMONTIL ORAL CAPSULE

4

PA

temazepam oral capsule

2

thioridazine oral tablet

2

thiothixene oral capsule

2

RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 12.5 MG/2 ML, 25 MG/2 ML

4

RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 MG/2 ML, 50 MG/2 ML

5

risperidone oral solution

2

tranylcypromine oral tablet

2

risperidone oral tablet

2

trazodone oral tablet

1

risperidone oral tablet,disintegrating

2

triazolam oral tablet

2 2

ROZEREM ORAL TABLET

4

trifluoperazine oral tablet

2

PA

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET

4

trimipramine oral capsule TRINTELLIX ORAL TABLET

4

ST

2

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR

4

venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet

2

sertraline oral concentrate

2

4

sertraline oral tablet

2

VERSACLOZ ORAL SUSPENSION

STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG, 60 MG

4

VIIBRYD ORAL TABLET

4

ST

QL (90 per 90 days) ST

ST

QL (180 per 90 days)

PA

GC

ST

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 43

Drug Name

Drug Tier

Requirements /Limits

Drug Name disopyramide phosphate oral capsule

2

dofetilide oral capsule

2

flecainide oral tablet

2

ibutilide fumarate intravenous solution

2

lidocaine (pf) in d7.5w intrathecal solution

2

lidocaine (pf) intravenous solution

2

lidocaine (pf) intravenous syringe

2

mexiletine oral capsule

2

MULTAQ ORAL TABLET

3

NORPACE CR ORAL CAPSULE, EXTENDED RELEASE

3

2

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)20 MG (23)

4

ST

VRAYLAR ORAL CAPSULE

5

ST

VRAYLAR ORAL CAPSULE,DOSE PACK

4

ST

XYREM ORAL SOLUTION

5

PA; LA

zaleplon oral capsule

2

PA; QL (90 per 90 days)

ziprasidone hcl oral capsule

2

ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N

5

ST

CARDIOVASCULAR, HYPERTENSION / LIPIDS

Drug Tier

adenosine intravenous solution

2

pacerone oral tablet 100 mg, 200 mg, 400 mg

2

adenosine intravenous syringe

2

procainamide injection solution

2

amiodarone intravenous solution

2

propafenone oral capsule,extended release 12 hr

amiodarone intravenous syringe

2

propafenone oral tablet

2

amiodarone oral tablet

2

quinidine gluconate injection solution

2

ANTIARRHYTHMIC AGENTS

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 44

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

quinidine gluconate oral tablet extended release

2

atenolol oral tablet

1

GC

1

GC

quinidine sulfate

oral tablet

2

atenololchlorthalidone oral

tablet

1

GC

AZOR ORAL TABLET

4

sorine oral tablet

QL (90 per 90 days)

sotalol af oral tablet

1

GC

1

GC

sotalol oral tablet

1

GC

benazepril oral tablet

TIKOSYN ORAL CAPSULE

3

benazeprilhydrochlorothiazide oral tablet

1

GC

XYLOCAINE (CARDIAC) (PF) INTRAVENOUS SOLUTION

4

BENICAR HCT ORAL TABLET

3

BENICAR ORAL TABLET

3

betaxolol oral tablet

1

BIDIL ORAL TABLET

3

bisoprolol fumarate oral tablet

1

GC

bisoprololhydrochlorothiazide oral tablet

1

GC

BREVIBLOC INTRAVENOUS SOLUTION 100 MG/10 ML (10 MG/ML)

4

bumetanide injection solution

2

bumetanide oral tablet

1

GC

candesartan oral tablet

1

GC

ANTIHYPERTENSIVE THERAPY

acebutolol oral capsule

2

afeditab cr oral tablet extended release

1

amiloride oral tablet

1

GC

amiloridehydrochlorothiazide oral tablet

1

GC

amlodipine oral tablet

1

GC

amlodipinebenazepril oral capsule

1

GC

amlodipinevalsartan oral tablet

1

GC

amlodipinevalsartan-hcthiazid oral tablet

1

GC

GC; QL (90 per 90 days)

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 45

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

candesartanhydrochlorothiazid oral tablet

1

GC

clonidine transdermal patch weekly

1

GC

captopril oral tablet

1

GC

4

captoprilhydrochlorothiazide oral tablet

1

GC

COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR

QL (90 per 90 days)

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG

4

CORLOPAM INTRAVENOUS SOLUTION

4

DEMSER ORAL CAPSULE

4

CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR

4

diltiazem hcl intravenous recon soln

2

1

GC

diltiazem hcl intravenous solution

2

cartia xt oral capsule,extended release 24hr

1

GC

carvedilol oral tablet

1

GC

diltiazem hcl oral capsule, extended release

chlorothiazide oral tablet

1

GC

1

GC

chlorothiazide sodium intravenous recon soln

2

diltiazem hcl oral capsule,ext release degradable

1

GC

chlorthalidone oral tablet 25 mg, 50 mg

1

diltiazem hcl oral capsule,extended release 12 hr

1

GC

CLEVIPREX INTRAVENOUS EMULSION

4

diltiazem hcl oral capsule,extended release 24hr

1

GC

clonidine (pf) epidural solution 1,000 mcg/10 ml (100 mcg/ml)

2

diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr

1

GC

clonidine hcl oral tablet

1

GC

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 46

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

dilt-xr oral capsule,ext release degradable

1

GC

fosinoprilhydrochlorothiazide oral tablet

1

doxazosin oral tablet

1

GC

2

EDARBYCLOR ORAL TABLET

4

furosemide injection solution

2

EDECRIN ORAL TABLET

3

furosemide injection syringe

1

GC

enalapril maleate oral tablet

1

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

enalaprilat intravenous solution

2

furosemide oral tablet

1

GC

enalaprilhydrochlorothiazide oral tablet

1

GC

hydralazine injection solution

2

eplerenone oral tablet

1

GC

hydralazine oral tablet

1

GC

epoprostenol (glycine) intravenous recon soln

2

hydrochlorothiazide oral capsule

1

GC

hydrochlorothiazide oral tablet

1

GC

eprosartan oral tablet

1

indapamide oral tablet

1

GC

esmolol intravenous solution

2

4

ethacrynic acid oral tablet

2

INNOPRAN XL ORAL CAPSULE,EXTEN DED RELEASE 24HR

felodipine oral tablet extended release 24 hr

1

irbesartan oral tablet

1

GC

FLOLAN INTRAVENOUS RECON SOLN

4

irbesartanhydrochlorothiazide oral tablet

1

GC

fosinopril oral tablet

1

isradipine oral capsule

1

GC

GC

GC

GC; QL (90 per 90 days)

GC

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 47

Drug Name

Drug Tier

labetalol intravenous solution

2

labetalol oral tablet

1

lisinopril oral tablet

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

metoprolol tartrate oral tablet

1

GC

minoxidil oral tablet

2

1

GC

moexipril oral tablet

1

GC

lisinoprilhydrochlorothiazide oral tablet

1

GC

moexiprilhydrochlorothiazide oral tablet

1

GC

losartan oral tablet

1

GC

nadolol oral tablet

1

GC

losartanhydrochlorothiazide oral tablet

1

GC

nadololbendroflumethiazide oral tablet

1

GC

matzim la oral tablet extended release 24 hr

1

GC

NICARDIPINE INTRAVENOUS SOLUTION

4

methyclothiazide oral tablet

2

nicardipine oral capsule

1

GC

methyldopahydrochlorothiazide oral tablet

2

nifedical xl oral tablet extended release 24hr

1

GC; QL (90 per 90 days)

methyldopate intravenous solution

2

nifedipine oral tablet extended release

1

GC; QL (90 per 90 days)

metolazone oral tablet

1

GC

1

GC; QL (90 per 90 days)

metoprolol succinate oral tablet extended release 24 hr

1

GC; QL (180 per 90 days)

nifedipine oral tablet extended release 24hr nimodipine oral capsule

2

metoprolol tahydrochlorothiaz oral tablet

1

nisoldipine oral tablet extended release 24 hr

2

metoprolol tartrate intravenous solution

2

NYMALIZE ORAL SOLUTION

4

metoprolol tartrate intravenous syringe

2

GC

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 48

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

PA

REMODULIN INJECTION SOLUTION

5

PA

spironolactone oral tablet

1

GC

spironolactonhydrochlorothiaz oral tablet

1

GC

taztia xt oral capsule, extended release

1

GC

TEKTURNA HCT ORAL TABLET

4

TEKTURNA ORAL TABLET

4

telmisartan oral tablet

1

GC

telmisartanamlodipine oral tablet

1

GC

1

GC

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG

4

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG

5

perindopril erbumine oral tablet

1

GC

pindolol oral tablet

1

GC

prazosin oral capsule

1

GC

propranolol intravenous solution

2

propranolol oral capsule,extended release 24 hr

1

GC

propranolol oral solution

1

GC

propranolol oral tablet

1

GC

telmisartanhydrochlorothiazid oral tablet

GC

1

GC

terazosin oral capsule

1

propranololhydrochlorothiazid oral tablet

timolol maleate oral tablet

1

GC

quinapril oral tablet

1

GC

torsemide oral tablet

1

GC

quinaprilhydrochlorothiazide oral tablet

1

GC

trandolapril oral tablet

1

GC

ramipril oral capsule

1

GC

trandolaprilverapamil oral tablet, ir - er, biphasic 24hr

1

GC

PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 49

Drug Name

Drug Tier

Requirements /Limits

Drug Name

GC

digitek oral tablet 250 mcg

2

digox oral tablet 125 mcg

2

digox oral tablet 250 mcg

2

digoxin injection solution

2

digoxin oral solution 50 mcg/ml

2

digoxin oral tablet 125 mcg

2

digoxin oral tablet 250 mcg

2

LANOXIN PEDIATRIC INJECTION SOLUTION

4

triamterenehydrochlorothiazid oral capsule

1

triamterenehydrochlorothiazid oral tablet

1

UPTRAVI ORAL TABLET

5

PA

UPTRAVI ORAL TABLETS,DOSE PACK

5

PA

valsartan oral tablet

1

GC

valsartanhydrochlorothiazide oral tablet

1

GC

veletri intravenous recon soln

2

verapamil intravenous solution

2

verapamil intravenous syringe

2

verapamil oral capsule, 24 hr er pellet ct

1

verapamil oral capsule,ext rel. pellets 24 hr

1

verapamil oral tablet verapamil oral tablet extended release

GC

Requirements /Limits

QL (90 per 90 days)

QL (90 per 90 days)

COAGULATION THERAPY

3

GC

AGGRENOX ORAL CAPSULE, ER MULTIPHASE 12 HR aminocaproic acid intravenous solution

2

GC

4

1

GC

ANGIOMAX INTRAVENOUS RECON SOLN

1

GC

ARGATROBAN IN 0.9 % SOD CHLOR INTRAVENOUS PARENTERAL SOLUTION

4

CARDIAC GLYCOSIDES digitek oral tablet 125 mcg

Drug Tier

2

QL (90 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 50

Drug Name

Drug Tier

ARGATROBAN INTRAVENOUS SOLUTION

4

aspirin-dipyridamole oral capsule, er multiphase 12 hr

2

BRILINTA ORAL TABLET

3

CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN

4

CEPROTIN (GREEN BAR) INTRAVENOUS RECON SOLN

4

cilostazol oral tablet

2

clopidogrel oral tablet

2

EFFIENT ORAL TABLET

3

ELIQUIS ORAL

TABLET

3

enoxaparin subcutaneous solution

2

enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml

5

Requirements /Limits

Drug Name

Drug Tier

enoxaparin subcutaneous syringe 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml

2

fondaparinux

subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

5

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml

2

FRAGMIN SUBCUTANEOUS SOLUTION

4

FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500

ANTI-XA UNIT/0.5 ML, 15,000 ANTIXA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 7,500 ANTI-XA UNIT/0.3 ML

5

FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTIXA UNIT/0.2 ML

4

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 51

Drug Name

Drug Tier

heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

2

heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml

2

heparin (porcine) injection cartridge

2

heparin (porcine) injection solution

2

HEPARIN(PORCIN E) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML

4

heparin, porcine (pf) injection solution

2

heparin, porcine (pf) injection syringe

2

jantoven oral tablet

1

NPLATE SUBCUTANEOUS RECON SOLN

5

pentoxifylline oral tablet extended release PRADAXA ORAL CAPSULE

Requirements /Limits

HI

Drug Name

Drug Tier

Requirements /Limits

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG

5

PA; LA

PROMACTA ORAL TABLET 75 MG

5

PA

THROMBATE III INTRAVENOUS RECON SOLN

4

ticlopidine oral tablet

2

tranexamic acid intravenous solution

2

warfarin oral tablet

1

XARELTO ORAL TABLET

3

XARELTO ORAL TABLETS,DOSE PACK

3

GC

LIPID/CHOLESTEROL LOWERING AGENTS amlodipineatorvastatin oral tablet

1

GC

atorvastatin oral tablet

1

GC

cholestyramine (with sugar) oral powder

2

2

cholestyramine (with sugar) oral powder in packet

2

3

cholestyramine light oral powder

2

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 52

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

JUXTAPID ORAL CAPSULE

5

PA

KYNAMRO SUBCUTANEOUS SYRINGE

5

PA

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HR

4

QL (90 per 90 days)

LIPOFEN ORAL CAPSULE

4

LIVALO ORAL

TABLET

4

ST

lovastatin oral tablet

1

GC

niacin oral tablet extended release 24 hr

2

omega-3 acid ethyl esters oral capsule

2

pravastatin oral tablet 10 mg, 20 mg, 80 mg

1

GC; QL (90 per 90 days)

pravastatin oral tablet 40 mg

1

GC; QL (135 per 90 days)

prevalite oral powder

2

GC

2

1

GC

prevalite oral powder in packet

1

GC; QL (90 per 90 days)

rosuvastatin oral tablet

2

fluvastatin oral tablet extended release 24 hr

QL (90 per 90 days)

simvastatin oral tablet

1

GC; QL (90 per 90 days)

gemfibrozil oral tablet

2

TRIGLIDE ORAL TABLET 160 MG

4

cholestyramine light oral powder in packet

2

colestipol oral granules

2

colestipol oral packet

2

colestipol oral tablet

2

CRESTOR ORAL TABLET 10 MG, 20 MG, 5 MG

4

ST; QL (90 per 90 days)

CRESTOR ORAL TABLET 40 MG

4

QL (90 per 90 days)

fenofibrate micronized oral capsule

1

GC

fenofibrate nanocrystallized oral tablet

1

fenofibrate oral tablet

1

GC

fenofibric acid (choline) oral capsule,delayed release(dr/ec)

1

GC

fenofibric acid oral tablet

1

fluvastatin oral capsule

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 53

Drug Name

Drug Tier

Requirements /Limits

VASCEPA ORAL CAPSULE

4

VYTORIN 10-10 ORAL TABLET

4

ST; QL (90 per 90 days)

VYTORIN 10-20 ORAL TABLET

4

ST; QL (90 per 90 days)

VYTORIN 10-40 ORAL TABLET

4

ST; QL (90 per 90 days)

VYTORIN 10-80 ORAL TABLET

4

WELCHOL ORAL POWDER IN PACKET

Drug Name

Drug Tier

Requirements /Limits

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR

4

VECAMYL ORAL TABLET

5

PA

isosorbide dinitrate oral tablet

1

GC

1

GC

3

isosorbide dinitrate oral tablet extended release

1

GC

WELCHOL ORAL TABLET

3

isosorbide mononitrate oral tablet

ZETIA ORAL TABLET

3

isosorbide mononitrate oral tablet extended release 24 hr

1

GC

nitro-bid transdermal ointment

2

ST; QL (90 per 90 days)

QL (90 per 90 days)

MISCELLANEOUS CARDIOVASCULAR AGENTS QL (180 per 90 days)

NITRATES

CORLANOR ORAL TABLET

4

dobutamine intravenous solution

2

nitroglycerin intravenous solution

2

dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/10 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/10 ml (80 mg/ml)

2

nitroglycerin sublingual tablet

2

nitroglycerin transdermal patch 24 hour

2

2

ISUPREL INJECTION SOLUTION

4

nitroglycerin translingual aerosol,spray nitroglycerin translingual spray,non-aerosol

2

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 54

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

NITROMIST TRANSLINGUAL AEROSOL,SPRAY

3

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR

5

PA

NITROSTAT SUBLINGUAL TABLET

4

COSENTYX SUBCUTANEOUS SYRINGE

5

PA

DERMATOLOGICALS/TOPICA L THERAPY

EPIFOAM TOPICAL FOAM

4

ANTIPSORIATIC / ANTISEBORRHEIC

PRAMOSONE TOPICAL CREAM 1-1 %

4

acitretin oral capsule 10 mg

2

PRAMOSONE TOPICAL LOTION

4

acitretin oral capsule 17.5 mg, 25 mg

5

selenium sulfide topical lotion

2

calcipotriene scalp solution

2

STELARA SUBCUTANEOUS SYRINGE

5

calcipotriene topical cream

2

4

calcipotriene topical ointment

2

TACLONEX TOPICAL SUSPENSION

calcitrene topical ointment

2

silver sulfadiazine topical cream

2

calcitriol topical ointment

2

ssd topical cream

2

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE

5

thermazene topical cream

2

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR

5

PA

BURN THERAPY

PA

MISCELLANEOUS DERMATOLOGICALS PA

8-MOP ORAL CAPSULE

4

ammonium lactate topical cream

2

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 55

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

ammonium lactate topical lotion

2

prudoxin topical cream

2

CARAC TOPICAL CREAM

3

REGRANEX TOPICAL GEL

4

CONDYLOX TOPICAL GEL

3

tacrolimus topical ointment

2

diclofenac sodium topical gel 3 %

2

4

doxepin topical cream

2

UVADEX INJECTION SOLUTION

5

ELIDEL TOPICAL CREAM

3

VALCHLOR TOPICAL GEL

FLUOROURACIL TOPICAL CREAM 0.5 %

3

fluorouracil topical cream 5 %

Requirements /Limits

PA

THERAPY FOR ACNE

adapalene topical cream

2

adapalene topical gel

2

2

2

fluorouracil topical solution

2

adapalene topical gel with pump

2

AZELEX TOPICAL CREAM

4

imiquimod topical cream in packet

4

METHOXSALEN RAPID ORAL CAPSULE

5

BENZACLIN PUMP TOPICAL GEL WITH PUMP claravis oral capsule

2

OXSORALEN TOPICAL LOTION

3

clindacin etz topical swab

2

PANRETIN TOPICAL GEL

3

clindacin p topical swab

2

PICATO TOPICAL GEL 0.015 %

5

QL (3 per 34 days)

2

PICATO TOPICAL GEL 0.05 %

5

QL (2 per 34 days)

clindamycin phosphate topical foam

2

podofilox topical solution

2

clindamycin phosphate topical gel

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 56

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

clindamycin phosphate topical lotion

2

metronidazole topical gel with pump

2

clindamycin phosphate topical solution

2

metronidazole topical lotion

2

neuac topical gel

2

clindamycin phosphate topical swab

2

rosadan topical cream

2

clindamycin-benzoyl peroxide topical gel

2

rosadan topical gel

2 3

clindamycin-benzoyl peroxide topical gel with pump

2

TAZORAC TOPICAL CREAM TAZORAC TOPICAL GEL

3

DIFFERIN TOPICAL LOTION

3

2

ery pads topical swab

2

tretinoin microspheres topical gel

2

erygel topical gel

2

tretinoin microspheres topical gel with pump

erythromycin with ethanol topical gel

2

tretinoin topical cream

2

erythromycin with ethanol topical solution

2

tretinoin topical gel

2 4

erythromycin with ethanol topical swab

2

TRETIN-X TOPICAL CREAM 0.075 %

erythromycinbenzoyl peroxide topical gel

2

FINACEA TOPICAL GEL

4

metronidazole topical cream

2

metronidazole topical gel

2

Requirements /Limits

TOPICAL ANESTHETICS

carbocaine (pf) injection solution 15 mg/ml (1.5 %)

2

CARBOCAINE INJECTION SOLUTION 2 %

4

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 57

Drug Name

Drug Tier

glydo mucous membrane jelly in applicator

2

lidocaine (pf) injection solution 10 mg/ml (1 %), 5 mg/ml (0.5 %)

2

LIDOCAINE (PF) INJECTION SOLUTION 20 MG/ML (2 %)

2

lidocaine hcl injection solution

2

lidocaine hcl laryngotracheal solution

Requirements /Limits

Drug Name

Drug Tier

LIDOCAINEEPINEPHRINE BIT INJECTION CARTRIDGE 2 %1:50,000

4

lidocaineepinephrine injection solution

2

lidocaine-prilocaine topical cream

2

MEPIVACAINE (PF) INJECTION CARTRIDGE

4

2

NAROPIN (PF) INJECTION SOLUTION

4

lidocaine hcl mucous membrane gel

2

4

lidocaine hcl mucous membrane jelly in applicator

2

NESACAINE INJECTION SOLUTION 10 MG/ML (1 %)

2

lidocaine hcl mucous membrane solution

2

relador pak plus topical kit

2

lidocaine hcl urethral gel

2

relador pak topical kit

5

lidocaine topical adhesive patch,medicated

2

ropivacaine (pf) injection solution 5 mg/ml (0.5 %)

2

lidocaine topical ointment

2

xylocaine dentalepinephrine injection cartridge

lidocaine viscous mucous membrane solution

2

4

lidocaineepinephrine (pf) injection solution

2

XYLOCAINEMPF/EPINEPHRIN E INJECTION SOLUTION 1 %1:200,000

PA; QL (270 per 90 days)

Requirements /Limits

TOPICAL ANTIBACTERIALS

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 58

Drug Name

Drug Tier

CENTANY TOPICAL OINTMENT

4

gentamicin topical cream

2

gentamicin topical ointment

2

mupirocin calcium topical cream

2

mupirocin topical ointment

2

sulfacetamide sodium (acne) topical suspension

2

SULFAMYLON TOPICAL CREAM

4

TOPICAL ANTIFUNGALS

Requirements /Limits

Drug Name

Drug Tier

clotrimazole topical solution

2

clotrimazolebetamethasone topical cream

2

clotrimazolebetamethasone topical lotion

2

econazole topical cream

2

ERTACZO TOPICAL CREAM

4

EXELDERM TOPICAL CREAM

4

EXELDERM TOPICAL SOLUTION

4

ciclodan topical cream

2

ketoconazole topical cream

2

ciclodan topical solution

2

ketoconazole topical foam

2

ciclopirox topical cream

2

ketoconazole topical shampoo

2

ciclopirox topical gel

2

MENTAX TOPICAL CREAM

4

ciclopirox topical shampoo

2

naftifine topical cream 2 %

2

ciclopirox topical solution

2

NAFTIN TOPICAL CREAM 2 %

4

ciclopirox topical suspension

2

NAFTIN TOPICAL GEL

4

clotrimazole topical cream

2

nyamyc topical powder

2

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 59

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

nystatin topical cream

2

amcinonide topical lotion

2

nystatin topical ointment

2

amcinonide topical ointment

2

nystatin topical powder

2

apexicon e topical cream

2

nystatintriamcinolone topical cream

2

betamethasone dipropionate topical cream

2

nystatintriamcinolone topical ointment

2

betamethasone dipropionate topical lotion

2

nystop topical powder

2

2

oxiconazole topical cream

2

betamethasone dipropionate topical ointment

2

OXISTAT TOPICAL CREAM

4

betamethasone valerate topical cream

OXISTAT TOPICAL LOTION

4

betamethasone valerate topical foam

2

betamethasone valerate topical lotion

2

betamethasone valerate topical ointment

2

betamethasone, augmented topical cream

2

betamethasone, augmented topical gel

2

betamethasone, augmented topical lotion

2

TOPICAL ANTIVIRALS

acyclovir topical ointment

2

DENAVIR TOPICAL CREAM

4

ZOVIRAX TOPICAL CREAM

3

TOPICAL CORTICOSTEROIDS

alclometasone topical cream

2

alclometasone topical ointment

2

amcinonide topical cream

2

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 60

Drug Name

Drug Tier

betamethasone, augmented topical ointment

2

CAPEX TOPICAL SHAMPOO

3

clobetasol scalp solution

2

clobetasol topical cream

2

clobetasol topical foam

2

clobetasol topical gel

2

clobetasol topical lotion

2

clobetasol topical ointment

2

clobetasol topical shampoo

2

clobetasol topical spray,non-aerosol

2

clobetasol-emollient topical cream

2

clobetasol-emollient topical foam

2

clodan topical shampoo

2

cormax scalp solution

2

CUTIVATE TOPICAL LOTION

3

Requirements /Limits

Drug Name

Drug Tier

DERMASMOOTHE/FS SCALP OIL SCALP OIL

4

desonide topical cream

2

desonide topical lotion

2

desonide topical ointment

2

desoximetasone topical cream

2

desoximetasone topical gel

2

desoximetasone topical ointment

2

diflorasone topical cream

2

diflorasone topical ointment

2

fluocinolone and shower cap scalp oil

2

fluocinolone topical cream

2

fluocinolone topical oil

2

fluocinolone topical ointment

2

fluocinolone topical solution

2

fluocinonide topical cream

2

fluocinonide topical gel

2

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 61

Drug Name

Drug Tier

fluocinonide topical ointment

2

fluocinonide topical solution

2

fluocinonide-e topical cream

2

flurandrenolide topical cream

2

flurandrenolide topical lotion

2

fluticasone topical cream

2

fluticasone topical lotion

2

fluticasone topical ointment

2

halobetasol propionate topical cream

Requirements /Limits

Drug Name

Drug Tier

hydrocortisone butyr-emollient topical cream

2

hydrocortisone topical cream 1 %, 2.5 %

2

hydrocortisone topical lotion 2.5 %

2

hydrocortisone topical ointment 1 %, 2.5 %

2

hydrocortisone valerate topical cream

2

hydrocortisone valerate topical ointment

2

2

hydrocortisone-min oil-wht pet topical ointment

2

halobetasol propionate topical ointment

2

mometasone topical cream

2

4

mometasone topical ointment

2

HALOG TOPICAL CREAM

2

HALOG TOPICAL OINTMENT

4

mometasone topical solution

2

PANDEL TOPICAL CREAM

4

hydrocortisone butyrate topical cream

prednicarbate topical ointment

2

hydrocortisone butyrate topical ointment

2

triamcinolone acetonide topical cream

2

hydrocortisone butyrate topical solution

2

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 62

Drug Name

Drug Tier

triamcinolone acetonide topical lotion

2

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

2

trianex topical ointment

2

triderm topical cream

2

Requirements /Limits

PROTOPAM CHLORIDE INJECTION RECON SOLN

Drug Tier

3

TOPICAL SCABICIDES / PEDICULICIDES EURAX TOPICAL CREAM

3

EURAX TOPICAL LOTION

3

4

lindane topical shampoo

2

malathion topical lotion

2

permethrin topical cream

2

SKLICE TOPICAL LOTION

4

lactated ringers irrigation solution

2

neomycin-polymyxin b gu irrigation solution

2

ringers irrigation solution

2

SORBITOL IRRIGATION SOLUTION

4

tis-u-sol pentalyte irrigation solution

2

MISCELLANEOUS AGENTS

acamprosate oral tablet,delayed release (dr/ec)

2

acetic acid irrigation solution

3

ADAGEN INTRAMUSCULA R SOLUTION

5

alendronate oral tablet 40 mg

2

DIAGNOSTICS / MISCELLANEOUS AGENTS

AMMONUL INTRAVENOUS SOLUTION

4

ANTIDOTES

anagrelide oral capsule

2

acetylcysteine intravenous solution

Requirements /Limits

IRRIGATING SOLUTIONS

TOPICAL ENZYMES

SANTYL TOPICAL OINTMENT

Drug Name

2

QL (90 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 63

Drug Name

Drug Tier

ARALAST NP INTRAVENOUS RECON SOLN

5

AURYXIA ORAL TABLET

5

BUPHENYL ORAL TABLET

4

caffeine citrated intravenous solution

2

caffeine citrated oral solution

2

CARBAGLU ORAL TABLET, DISPERSIBLE

5

cevimeline oral capsule

2

CHEMET ORAL CAPSULE

3

d10 %-0.45 % sodium chloride intravenous parenteral solution

Requirements /Limits

Drug Name

Drug Tier

dextrose 10 % in water (d10w) intravenous parenteral solution

2

dextrose 20 % in water (d20w) intravenous parenteral solution

2

dextrose 25 % in water (d25w) intravenous syringe

2

dextrose 30 % in water (d30w) intravenous parenteral solution

2

dextrose 40 % in water (d40w) intravenous parenteral solution

2

2

dextrose 5 % in water (d5w) intravenous parenteral solution

2

d2.5 %-0.45 % sodium chloride intravenous parenteral solution

2

dextrose 5 % in water (d5w) intravenous piggyback

2

d5 % and 0.9 % sodium chloride intravenous parenteral solution

2

dextrose 5 %lactated ringers intravenous parenteral solution

2

d5 %-0.45 % sodium chloride intravenous parenteral solution

2

dextrose 5%-0.2 % sod chloride intravenous parenteral solution

2

deferoxamine injection recon soln

2

LA

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 64

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

INCRELEX SUBCUTANEOUS SOLUTION

5

JADENU ORAL TABLET

5

kionex (with sorbitol) oral suspension

2

kionex oral powder

2

levocarnitine (with sugar) oral solution

2

B/D PA

levocarnitine intravenous solution

2

B/D PA

levocarnitine oral tablet

2

B/D PA

midodrine oral tablet

2

2

NORTHERA ORAL CAPSULE

5

etidronate disodium oral tablet

2

ORFADIN ORAL CAPSULE

5

EXJADE ORAL TABLET, DISPERSIBLE

5

ORFADIN ORAL SUSPENSION

5

FERRIPROX ORAL SOLUTION

5

pilocarpine hcl oral tablet

2

FERRIPROX ORAL TABLET

5

PROLASTIN-C INTRAVENOUS RECON SOLN

5

FOSRENOL ORAL POWDER IN PACKET

4

RAVICTI ORAL LIQUID

5

FOSRENOL ORAL TABLET,CHEWAB LE

4

RENAGEL ORAL TABLET

3

dextrose 5%-0.3 % sod.chloride intravenous parenteral solution

2

dextrose 50 % in water (d50w) intravenous parenteral solution

2

dextrose 50 % in water (d50w) intravenous syringe

2

dextrose 70 % in water (d70w) intravenous parenteral solution

2

dextrose with sodium chloride intravenous parenteral solution

2

disulfiram oral tablet

PA

PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 65

Drug Name

Drug Tier

RENVELA ORAL POWDER IN PACKET

3

RENVELA ORAL TABLET

3

riluzole oral tablet

2

risedronate oral tablet 30 mg

Requirements /Limits

Drug Name

Drug Tier

SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML

2

5

2

SOLIRIS INTRAVENOUS SOLUTION

2

sps (with sorbitol) oral suspension

2

sodium benzoate-sod phenylacet intravenous solution

sps (with sorbitol) rectal enema

2

sodium chloride 0.9 % intravenous parenteral solution

2

SYPRINE ORAL CAPSULE

4

sodium chloride 0.9 % intravenous piggyback

2

VELTASSA ORAL POWDER IN PACKET

5

sodium chloride irrigation solution

2

water for irrigation, sterile irrigation solution

2

sodium phenylbutyrate oral powder

2

ZEMAIRA INTRAVENOUS RECON SOLN

4

sodium polystyrene (sorb free) oral suspension

2

2

sodium polystyrene sulfonate oral powder

2

ZOLEDRONIC ACID-MANNITOLWATER INTRAVENOUS PIGGYBACK 5 MG/100 ML

sodium polystyrene sulfonate oral suspension

2

zoledronic acidmannitol-water intravenous solution

2

sodium polystyrene sulfonate rectal enema 30 gram/120 ml

2

SMOKING DETERRENTS

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 66

Drug Name

Drug Tier

Requirements /Limits

Drug Name

GC

chlorhexidine gluconate mucous membrane mouthwash

2

CLINPRO 5000 DENTAL PASTE

4

denta 5000 plus dental cream

2

dentagel dental gel

2

ipratropium bromide nasal spray,nonaerosol

1

olopatadine nasal spray,non-aerosol

2

oralone dental paste

2

Drug Tier

bupropion hcl (smoking deter) oral tablet extended release

1

CHANTIX CONTINUING MONTH BOX ORAL TABLET

3

CHANTIX ORAL TABLET

3

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

3

NICOTROL INHALATION CARTRIDGE

4

paroex oral rinse mucous membrane mouthwash

2

NICOTROL NS NASAL SPRAY,NONAEROSOL

4

periogard mucous membrane mouthwash

2

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE

4

PREVIDENT 5000 DRY MOUTH DENTAL GEL

4

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE

4

PREVIDENT 5000 SENSITIVE DENTAL PASTE

4

EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal aerosol,spray

2

azelastine nasal spray,non-aerosol

2

BACTROBAN NASAL OINTMENT

3

Requirements /Limits

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 67

Drug Name

Drug Tier

sf 5000 plus dental cream

2

sf dental gel

2

triamcinolone acetonide dental paste

2

TYZINE NASAL DROPS 0.05 %

3

Requirements /Limits

MISCELLANEOUS OTIC PREPARATIONS

Drug Name

Drug Tier

COLY-MYCIN S OTIC DROPS,SUSPENSI ON

4

neomycinpolymyxin-hc otic drops,suspension

2

neomycinpolymyxin-hc otic solution

2

ENDOCRINE/DIABETES

acetasol hc otic drops

2

acetic acid otic solution

2

ACTHAR H.P. INJECTION GEL

5

acetic acidaluminum acetate otic drops

2

a-hydrocort injection recon soln

2 4

ciprofloxacin hcl otic dropperette

2

floxin otic drops

2

ARISTOSPAN INTRAARTICULAR INJECTION SUSPENSION

fluocinolone acetonide oil otic drops

2

betamethasone acet,sod phos injection suspension

2

hydrocortisoneacetic acid otic drops

2

cortisone oral tablet

2 2

ofloxacin otic drops

2

deltasone oral tablet 20 mg DEPO-MEDROL INJECTION SUSPENSION

4

dexamethasone intensol oral drops

2

dexamethasone oral elixir

1

OTIC STEROID / ANTIBIOTIC

CIPRO HC OTIC DROPS,SUSPENSI ON

3

CIPRODEX OTIC DROPS,SUSPENSI ON

3

Requirements /Limits

ADRENAL HORMONES PA

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 68

Drug Name

Drug Tier

Requirements /Limits

Drug Name methylprednisolone oral tablets,dose pack

1

methylprednisolone sodium succ injection recon soln 125 mg, 40 mg

2

methylprednisolone sodium succ intravenous recon soln

2

prednisolone oral solution 15 mg/5 ml

2

prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

2

prednisolone sodium phosphate oral tablet,disintegrating

2

prednisone intensol oral concentrate

1

GC

prednisone oral solution

1

GC

prednisone oral tablet

1

GC

prednisone oral tablets,dose pack

1

GC

SOLU-CORTEF (PF) INJECTION RECON SOLN

4

dexamethasone oral solution

1

GC

dexamethasone oral tablet

1

GC

dexamethasone sodium phos (pf) injection solution

2

dexamethasone sodium phosphate injection solution 4 mg/ml

2

dexamethasone sodium phosphate injection syringe

2

DEXPAK 10 DAY ORAL TABLETS,DOSE PACK

4

DEXPAK 13 DAY ORAL TABLETS,DOSE PACK

4

DEXPAK 6 DAY ORAL TABLETS,DOSE PACK

4

fludrocortisone oral tablet

1

hydrocortisone oral tablet

1

methylprednisolone acetate injection suspension

2

methylprednisolone oral tablet

1

GC GC

GC

Drug Tier

Requirements /Limits GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 69

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

SOLU-CORTEF INJECTION RECON SOLN

4

BD INSULIN PEN NEEDLE UF MINI NEEDLE

2

QL (600 per 90 days)

SOLU-MEDROL (PF) INJECTION RECON SOLN

4

BD INSULIN PEN NEEDLE UF ORIG NEEDLE

2

QL (600 per 90 days)

SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN

4

BD INSULIN PEN NEEDLE UF SHORT NEEDLE

2

QL (600 per 90 days)

4

BD ULTRA-FINE NANO PEN NEEDLES NEEDLE

2

SOLU-MEDROL INTRAVENOUS RECON SOLN

QL (600 per 90 days)

triamcinolone acetonide injection suspension

2

BYDUREON SUBCUTANEOUS PEN INJECTOR

3

PA; QL (12 per 90 days)

BYDUREON SUBCUTANEOUS SUSPENSION,EXT ENDED REL RECON

3

PA; QL (12 per 90 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML

3

PA; QL (7.2 per 90 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML

3

PA; QL (3.6 per 90 days)

CYCLOSET ORAL TABLET

3

QL (540 per 90 days)

FARXIGA ORAL TABLET

3

ST

gauze pads 2 x 2

2

ANTITHYROID AGENTS

methimazole oral tablet 10 mg, 5 mg

2

propylthiouracil oral tablet

2

DIABETES THERAPY

acarbose oral tablet

2

alcohol pads topical pads, medicated

2

APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN

3

ST

APIDRA SUBCUTANEOUS SOLUTION

3

ST

AVANDIA ORAL TABLET 2 MG, 4 MG

4

QL (180 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 70

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

3

ST

HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION

3

ST

HUMALOG SUBCUTANEOUS CARTRIDGE

3

ST

3

ST

glimepiride oral tablet

1

GC

glipizide oral tablet

1

GC

glipizide oral tablet extended release 24hr

1

GC

glipizide-metformin oral tablet

1

GC

GLUCAGEN HYPOKIT INJECTION RECON SOLN

3

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT

3

HUMALOG SUBCUTANEOUS SOLUTION

3

ST

GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR

4

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN HUMULIN 70/30 SUBCUTANEOUS SUSPENSION

3

ST

GLYSET ORAL TABLET

4

3

ST

HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN

3

HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN

3

ST

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

3

HUMULIN N SUBCUTANEOUS SUSPENSION HUMULIN R INJECTION SOLUTION

3

ST

HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION

3

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN

3

ST

ST

ST

ST

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 71

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

ST

LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN

2

LANTUS SUBCUTANEOUS SOLUTION

2

Requirements /Limits

HUMULIN R U-500 (CONCENTRATED ) SUBCUTANEOUS SOLUTION

3

insulin pen needle

2

QL (600 per 90 days)

INSULIN PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16"

2

QL (600 per 90 days)

LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN

2

insulin syringe (disp) u-100 0.3 ml, 1 ml, 1/2 ml

2

QL (600 per 90 days)

LEVEMIR SUBCUTANEOUS SOLUTION

2

INVOKAMET ORAL TABLET

3

ST

metformin oral tablet

1

GC

INVOKANA ORAL TABLET

3

ST

1

GC

JANUMET ORAL TABLET

3

QL (180 per 90 days)

metformin oral tablet extended release 24 hr

1

GC

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR

3

metformin oral tablet extended release 24hr miglitol oral tablet

2 2

JANUVIA ORAL TABLET

3

QL (90 per 90 days)

KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG

3

QL (180 per 90 days)

MONOJECT INSULIN SAFETY SYRING SYRINGE 29 GAUGE X 1/2" nateglinide oral tablet

2

needles, insulin disp.,safety

2

QL (600 per 90 days)

KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG

3

NOVOFINE 30 NEEDLE

2

QL (600 per 90 days)

NOVOFINE 32 NEEDLE

2

QL (600 per 90 days)

QL (90 per 90 days)

QL (90 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 72

Drug Tier

Requirements /Limits

Drug Name

NOVOFINE PLUS NEEDLE

2

QL (600 per 90 days)

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION

2

NOVOLIN N SUBCUTANEOUS SUSPENSION

2

NOVOLIN R INJECTION SOLUTION

2

NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN

2

NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN

2

NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION

2

NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE

2

NOVOLOG SUBCUTANEOUS SOLUTION

2

NOVOTWIST NEEDLE

2

ONGLYZA ORAL TABLET

3

Drug Name

QL (600 per 90 days) QL (90 per 90 days)

Drug Tier

Requirements /Limits

PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16"

2

QL (600 per 90 days)

pioglitazone oral tablet

2

QL (90 per 90 days)

pioglitazoneglimepiride oral tablet

2

QL (90 per 90 days)

pioglitazonemetformin oral tablet

2

QL (270 per 90 days)

PROGLYCEM ORAL SUSPENSION

4

repaglinide oral tablet

1

repaglinidemetformin oral tablet

2

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR

4

PA

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR

4

PA

TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN

3

VGO 20 DEVICE

3

VGO 30 DEVICE

3

VGO 40 DEVICE

3

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 73

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR

3

PA; QL (27 per 90 days)

calcitriol intravenous solution 1 mcg/ml

2

B/D PA

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR

3

PA; QL (27 per 90 days)

calcitriol oral capsule

2

B/D PA

2

B/D PA

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR

3

ST

calcitriol oral solution CERDELGA ORAL CAPSULE

5

CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5

chorionic gonadotropin, human intramuscular recon soln

2

danazol oral capsule

2

desmopressin injection solution

2

desmopressin nasal aerosol,spray

2

desmopressin nasal solution

2 2

MISCELLANEOUS HORMONES

ALDURAZYME INTRAVENOUS SOLUTION

5

ANDRODERM TRANSDERMAL PATCH 24 HOUR

3

PA; QL (90 per 90 days)

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

3

PA

ANDROGEL TRANSDERMAL GEL IN PACKET

3

ANDROID ORAL CAPSULE

4

desmopressin nasal spray,non-aerosol

2

androxy oral tablet

2

desmopressin oral tablet

cabergoline oral tablet

2

doxercalciferol intravenous solution

2

B/D PA

calcitonin (salmon) nasal spray,nonaerosol

2

doxercalciferol oral capsule

2

B/D PA

PA

PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 74

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

ELAPRASE INTRAVENOUS SOLUTION

5

MYOZYME INTRAVENOUS RECON SOLN

5

ELELYSO INTRAVENOUS RECON SOLN

5

NAGLAZYME INTRAVENOUS SOLUTION

5

FABRAZYME INTRAVENOUS RECON SOLN

5

NATPARA SUBCUTANEOUS CARTRIDGE

5

fortical nasal spray,non-aerosol

2

2

HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML (1 ML)

4

novarel intramuscular recon soln oxandrolone oral tablet

2 2

KANUMA INTRAVENOUS SOLUTION

5

pamidronate intravenous recon soln

2

KORLYM ORAL TABLET

5

PA

pamidronate intravenous solution

5

PA

PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION

4

KUVAN ORAL POWDER IN PACKET KUVAN ORAL TABLET,SOLUBL E

5

PA

paricalcitol intravenous solution

2 B/D PA

4

paricalcitol oral capsule

2

METHITEST ORAL TABLET

5

PA

methyltestosterone oral capsule

2

SAMSCA ORAL TABLET

3

B/D PA

SENSIPAR ORAL TABLET 30 MG

3

MIACALCIN INJECTION SOLUTION

5

MYALEPT SUBCUTANEOUS RECON SOLN

5

PA

SENSIPAR ORAL TABLET 60 MG, 90 MG

PA

PA

PA

B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 75

Drug Name

Drug Tier

Requirements /Limits

Drug Name

PA

TESTOSTERONE TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM)

4

TESTRED ORAL CAPSULE

4

vasopressin injection solution

2

VPRIV INTRAVENOUS RECON SOLN

5

ZAVESCA ORAL CAPSULE

5

ZEMPLAR INTRAVENOUS SOLUTION

4

Drug Tier

SOMAVERT SUBCUTANEOUS RECON SOLN

5

STIMATE NASAL SPRAY,NONAEROSOL

3

STRENSIQ SUBCUTANEOUS SOLUTION

5

SYNAREL NASAL SPRAY,NONAEROSOL

3

TESTIM TRANSDERMAL GEL

4

TESTOPEL IMPLANT PELLET

4

testosterone cypionate intramuscular oil

2

zoledronic acid intravenous recon soln

2

testosterone enanthate intramuscular oil

2

zoledronic acid intravenous solution

2

TESTOSTERONE TRANSDERMAL GEL

4

PA

TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP

4

PA

testosterone transdermal gel in packet 1 % (25 mg/2.5gram)

2

PA

PA

Requirements /Limits PA

B/D PA

THYROID HORMONES

PA

levothyroxine intravenous recon soln 200 mcg, 500 mcg

1

GC

levothyroxine oral tablet

1

GC

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

1

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 76

Drug Name

Drug Tier

liothyronine intravenous solution

2

liothyronine oral tablet

1

np thyroid oral tablet

2

unithroid oral tablet

1

Requirements /Limits

Drug Name

Drug Tier

LIBRAX (WITH CLIDINIUM) ORAL CAPSULE

4

loperamide oral capsule

2

methscopolamine oral tablet

2

GASTROENTEROLOGY

opium tincture oral tincture

2

ANTIDIARRHEALS / ANTISPASMODICS

paregoric oral liquid

2

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml

2

chlordiazepoxideclidinium oral capsule

2

dicyclomine intramuscular solution

GC

GC

Requirements /Limits

MISCELLANEOUS GASTROINTESTINAL AGENTS AKYNZEO ORAL CAPSULE

4

B/D PA

alosetron oral tablet

2

QL (180 per 90 days)

2

ALOXI INTRAVENOUS SOLUTION

4

dicyclomine oral capsule

2

AMITIZA ORAL CAPSULE

4

dicyclomine oral solution

2

4

dicyclomine oral tablet

2

ANALPRAM-HC RECTAL CREAM 1-1 %

4

diphenoxylateatropine oral liquid

2

ANZEMET INTRAVENOUS SOLUTION 100 MG/5 ML

diphenoxylateatropine oral tablet

2

ANZEMET ORAL TABLET

4

glycopyrrolate injection solution

2

4

glycopyrrolate oral tablet

2

APRISO ORAL CAPSULE,EXTEN DED RELEASE 24HR

PA; QL (180 per 90 days)

B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 77

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

CREON ORAL CAPSULE,DELAY ED RELEASE(DR/EC)

3

2

2

cromolyn oral concentrate

2

CYSTADANE ORAL POWDER

4

budesonide oral capsule,delayed,exte nd.release

3

CANASA RECTAL SUPPOSITORY

3

DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS)

CHOLBAM ORAL CAPSULE

5

PA

dimenhydrinate injection solution

2

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT

5

PA

DIPENTUM ORAL CAPSULE

4

dronabinol oral capsule

2

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT

5

droperidol injection solution

2 3

CIMZIA SUBCUTANEOUS SYRINGE KIT

5

EMEND INTRAVENOUS RECON SOLN

3

B/D PA

colocort rectal enema

2

EMEND ORAL CAPSULE

3

B/D PA

compro rectal suppository

1

EMEND ORAL CAPSULE,DOSE PACK

constulose oral solution

2

3

B/D PA

CORTIFOAM RECTAL FOAM

3

EMEND ORAL SUSPENSION FOR RECONSTITUTIO N enulose oral solution

2

ASACOL HD ORAL TABLET,DELAYE D RELEASE (DR/EC)

3

balsalazide oral capsule

PA

PA

GC

B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 78

Drug Name

Drug Tier

Requirements /Limits

Drug Name

PA

hydrocortisone rectal cream

2

hydrocortisone rectal enema

2

lactulose oral solution

2

LIALDA ORAL TABLET,DELAYE D RELEASE (DR/EC)

4

LINZESS ORAL CAPSULE

4 2

Drug Tier

GATTEX 30-VIAL SUBCUTANEOUS KIT

5

GATTEX ONEVIAL SUBCUTANEOUS KIT

5

gavilyte-c oral recon soln

2

gavilyte-g oral recon soln

2

gavilyte-h and bisacodyl oral kit

2

gavilyte-n oral recon soln

2

meclizine oral tablet 12.5 mg, 25 mg

2

mesalamine rectal enema

2

generlac oral solution

2

GOLYTELY ORAL POWDER IN PACKET

4

mesalamine with cleansing wipe rectal enema kit

2

granisetron (pf) intravenous solution 1 mg/ml (1 ml)

2

metoclopramide hcl injection solution metoclopramide hcl injection syringe

2

granisetron (pf) intravenous solution 100 mcg/ml

2

metoclopramide hcl oral solution

2

granisetron hcl intravenous solution 1 mg/ml

2

metoclopramide hcl oral tablet

2 4

granisetron hcl intravenous solution 1 mg/ml (1 ml)

2

MOVANTIK ORAL TABLET

4

granisetron hcl oral tablet

2

MOVIPREP ORAL POWDER IN PACKET ondansetron hcl (pf) injection solution

2

PA

QL (3 per 90 days)

HI

HI

B/D PA

Requirements /Limits

PA

PA

HI

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 79

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml)

2

B/D PA

prochlorperazine maleate oral tablet

1

GC

2

B/D PA

prochlorperazine rectal suppository

1

GC

ondansetron oral tablet,disintegrating

2

B/D PA

PROCTOFOAM HC RECTAL FOAM

4

OSMOPREP ORAL TABLET

4

procto-med hc rectal cream

2

PANCREAZE ORAL CAPSULE,DELAY ED RELEASE(DR/EC)

3

proctosol hc rectal cream

2

proctozone-hc rectal cream

2 3

peg 3350electrolytes oral recon soln

2

RELISTOR SUBCUTANEOUS SOLUTION

PA; QL (16.8 per 28 days)

3

peg-electrolyte soln oral recon soln

2

PA; QL (16.8 per 28 days)

peg-prep oral kit

2

RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 8 MG/0.4 ML

3

PA

REMICADE INTRAVENOUS RECON SOLN

5

PA

SANCUSO TRANSDERMAL PATCH WEEKLY

5

QL (4 per 28 days)

sulfasalazine oral tablet

1

GC

ondansetron hcl (pf) injection syringe

2

ondansetron hcl intravenous solution

2

ondansetron hcl oral solution

2

ondansetron hcl oral tablet

PENTASA ORAL CAPSULE, EXTENDED RELEASE

3

polyethylene glycol 3350 oral powder

2

polyethylene glycol 3350 oral powder in packet

2

QL (3 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 80

Drug Name

Drug Tier

sulfasalazine oral tablet,delayed release (dr/ec)

1

SUPREP BOWEL PREP KIT ORAL RECON SOLN

4

TRANSDERMSCOP TRANSDERMAL PATCH 3 DAY

3

trilyte with flavor packets oral recon soln

2

ursodiol oral capsule

2

ursodiol oral tablet

2

ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC)

3

ULCER THERAPY

Requirements /Limits

Drug Name

Drug Tier

GC

famotidine oral tablet 20 mg, 40 mg

2

lansoprazole oral capsule,delayed release(dr/ec)

2

misoprostol oral tablet

2

nizatidine oral capsule

2

nizatidine oral solution

2

omeprazole oral capsule,delayed release(dr/ec)

2

pantoprazole intravenous recon soln

2

pantoprazole oral tablet,delayed release (dr/ec)

1

4

Requirements /Limits

GC

carafate oral suspension

2

PYLERA ORAL CAPSULE

1

GC

esomeprazole sodium intravenous recon soln

2

ranitidine hcl oral capsule ranitidine hcl oral syrup

1

GC

famotidine (pf) intravenous solution

2

1

GC

famotidine (pf)-nacl (iso-os) intravenous piggyback

2

ranitidine hcl oral tablet 150 mg, 300 mg sucralfate oral tablet

2

famotidine intravenous solution

2

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

famotidine oral suspension

2

BIOTECHNOLOGY DRUGS

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 81

Drug Name

Drug Tier

ACTIMMUNE SUBCUTANEOUS SOLUTION

5

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML

5

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML, 60 MCG/ML

4

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML, 60 MCG/0.3 ML

4

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML

5

ARCALYST SUBCUTANEOUS RECON SOLN

5

Requirements /Limits

PA

PA

PA

PA

PA

Drug Name

Drug Tier

Requirements /Limits

AVONEX (WITH ALBUMIN) INTRAMUSCULA R KIT

5

PA

AVONEX INTRAMUSCULA R PEN INJECTOR KIT

5

PA

AVONEX INTRAMUSCULA R SYRINGE

5

PA

AVONEX INTRAMUSCULA R SYRINGE KIT

5

PA

BETASERON SUBCUTANEOUS KIT

5

PA

EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG

5

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

4

PA

EXTAVIA SUBCUTANEOUS KIT

5

PA

EXTAVIA SUBCUTANEOUS RECON SOLN

5

PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 82

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

PA

INTRON A INJECTION SOLUTION

5

LEUKINE INJECTION

RECON SOLN

5

MOZOBIL SUBCUTANEOUS SOLUTION

5

PA

NEULASTA SUBCUTANEOUS SYRINGE

5

QL (2 per 34 days)

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR

5

QL (2 per 34 days)

NEUPOGEN INJECTION SOLUTION

5

NEUPOGEN INJECTION SYRINGE

5

NORDITROPIN FLEXPRO SUBCUTANEOUS

PEN INJECTOR

5

PA

NUTROPIN AQ NUSPIN

SUBCUTANEOUS PEN INJECTOR

5

PA

NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 10 MG/2 ML (5 MG/ML)

5

PA

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML

4

GENOTROPIN

MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML

5

GENOTROPIN

SUBCUTANEOUS CARTRIDGE

5

GRANIX

SUBCUTANEOUS SYRINGE

5

HUMATROPE

INJECTION CARTRIDGE

5

PA

HUMATROPE

INJECTION RECON SOLN

5

PA

ILARIS (PF)

SUBCUTANEOUS RECON SOLN

5

INTRON A

INJECTION RECON SOLN

5

PA

PA

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 83

Drug Name

Drug Tier

Requirements /Limits

Drug Name PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML

3

PA

5

PA

Drug Tier

Requirements /Limits

OMNITROPE SUBCUTANEOUS CARTRIDGE

4

PA

OMNITROPE SUBCUTANEOUS RECON SOLN

5

PA

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR

5

PA; QL (4 per 28 days)

PEGASYS SUBCUTANEOUS SOLUTION

5

PA; QL (4 per 28 days)

PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML

5

PA; QL (4 per 28 days)

PROLEUKIN INTRAVENOUS RECON SOLN

5

PEGASYS SUBCUTANEOUS SYRINGE

PA

5

PA; QL (4 per 28 days)

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

5

PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT

5

PA

PEGINTRON SUBCUTANEOUS KIT

5

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR

5

PA

PLEGRIDY SUBCUTANEOUS PEN INJECTOR

5

PA

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

PA

5

PA

SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE

5

PLEGRIDY SUBCUTANEOUS SYRINGE

SAIZEN SUBCUTANEOUS RECON SOLN

5

PA

SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG

5

PA

PA; QL (4 per 28 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 84

Drug Name

Drug Tier

SYLATRON SUBCUTANEOUS KIT

5

ZARXIO INJECTION SYRINGE

5

ZORBTIVE SUBCUTANEOUS RECON SOLN

5

Requirements /Limits

Drug Name

PA

BOOSTRIX TDAP INTRAMUSCULA R SUSPENSION

3

BOOSTRIX TDAP INTRAMUSCULA R SYRINGE

3

CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM

5

CERVARIX VACCINE (PF) INTRAMUSCULA R SYRINGE

3

CYTOGAM INTRAVENOUS SOLUTION 50 MG/ML

4

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULA R SUSPENSION

3

DYSPORT INTRAMUSCULA R RECON SOLN

4

PA

ENGERIX-B (PF) INTRAMUSCULA R SUSPENSION

3

B/D PA

3

B/D PA

3

B/D PA

PA

VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) INTRAMUSCULA R RECON SOLN

3

ADACEL(TDAP ADOLESN/ADULT )(PF) INTRAMUSCULA R SUSPENSION

3

ADACEL(TDAP ADOLESN/ADULT )(PF) INTRAMUSCULA R SYRINGE

3

BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTIO N

4

BEXSERO (PF) INTRAMUSCULA R SYRINGE

3

ENGERIX-B (PF) INTRAMUSCULA R SYRINGE

BIVIGAM INTRAVENOUS SOLUTION

5

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SUSPENSION

B/D PA

Drug Tier

Requirements /Limits

B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 85

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

GARDASIL (PF) INTRAMUSCULA R SUSPENSION

3

GARDASIL (PF) INTRAMUSCULA R SYRINGE

3

GARDASIL 9 (PF) INTRAMUSCULA R SUSPENSION

3

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SYRINGE

3

B/D PA

FLEBOGAMMA DIF INTRAVENOUS SOLUTION

5

B/D PA

fomepizole intravenous solution

2 3

B/D PA

GARDASIL 9 (PF) INTRAMUSCULA R SYRINGE

3

GAMASTAN S/D INTRAMUSCULA R SOLUTION

5

B/D PA

GRASTEK SUBLINGUAL TABLET

4

GAMMAGARD LIQUID INJECTION SOLUTION

3

GAMMAGARD SD (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN

5

HAVRIX (PF) INTRAMUSCULA R SUSPENSION HAVRIX (PF) INTRAMUSCULA R SYRINGE

3

GAMMAKED INJECTION SOLUTION 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %)

5

HEPAGAM B INJECTION SOLUTION

3

HIBERIX (PF) INTRAMUSCULA R RECON SOLN

3

HIZENTRA SUBCUTANEOUS SOLUTION

5

GAMMAPLEX INTRAVENOUS SOLUTION

5

B/D PA

HYPERHEP B S/D INTRAMUSCULA R SOLUTION

3

GAMUNEX-C INJECTION SOLUTION

5

B/D PA

HYPERHEP B S/D INTRAMUSCULA R SYRINGE

3

B/D PA

B/D PA

Requirements /Limits

B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 86

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

KINRIX (PF) INTRAMUSCULA R SUSPENSION

3

KINRIX (PF) INTRAMUSCULA R SYRINGE

3

MENACTRA (PF) INTRAMUSCULA R SOLUTION

3

MENHIBRIX (PF) INTRAMUSCULA R RECON SOLN

3

3

3

MENOMUNE A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN

3

IMOVAX RABIES VACCINE (PF) INTRAMUSCULA R RECON SOLN

3

MENOMUNE A/C/Y/W-135 SUBCUTANEOUS RECON SOLN

3

INFANRIX (DTAP) (PF) INTRAMUSCULA R SUSPENSION

3

MENVEO A-C-YW-135-DIP (PF) INTRAMUSCULA R KIT M-M-R II (PF) SUBCUTANEOUS RECON SOLN

3

INFANRIX (DTAP) (PF) INTRAMUSCULA R SYRINGE

3

NABI-HB INTRAMUSCULA R SOLUTION

3

IPOL INJECTION SUSPENSION

3

OCTAGAM INTRAVENOUS SOLUTION

5

IXIARO (PF) INTRAMUSCULA R SYRINGE

3

PEDIARIX (PF) INTRAMUSCULA R SYRINGE

3

HYPERHEP B S-D NEONATAL INTRAMUSCULA R SYRINGE

3

HYPERRAB S/D (PF) INTRAMUSCULA R SOLUTION

3

HYPERTET S/D (PF) INTRAMUSCULA R SYRINGE

3

HYQVIA SUBCUTANEOUS SOLUTION

5

IMOGAM RABIESHT (PF) INTRAMUSCULA R SOLUTION

B/D PA

B/D PA

Requirements /Limits

B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 87

Drug Name

Drug Tier

PEDVAX HIB (PF) INTRAMUSCULA R SOLUTION

3

PENTACEL (PF) INTRAMUSCULA R KIT

3

PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULA R RECON SOLN

3

PRIVIGEN INTRAVENOUS SOLUTION

5

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTIO N

3

QUADRACEL (PF)

INTRAMUSCULA R SUSPENSION

3

RABAVERT (PF)

INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N

3

RAGWITEK

SUBLINGUAL TABLET

4

RECOMBIVAX HB

(PF) INTRAMUSCULA R SUSPENSION

3

Requirements /Limits

B/D PA

B/D PA

Drug Name

Drug Tier

RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE

3

RHOPHYLAC INJECTION SYRINGE

4

ROTARIX ORAL SUSPENSION FOR RECONSTITUTIO N

3

ROTATEQ VACCINE ORAL SUSPENSION

3

TENIVAC (PF) INTRAMUSCULA R SUSPENSION

3

TENIVAC (PF) INTRAMUSCULA

R SYRINGE

3

TETANUS,DIPHTH ERIA TOX

PED(PF) INTRAMUSCULA R SUSPENSION

3

TETANUSDIPHTHERIA TOXOIDS-TD

INTRAMUSCULA R SUSPENSION

3

THERACYS INTRAVESICAL SUSPENSION FOR RECONSTITUTIO N

4

Requirements /Limits B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 88

Drug Name

Drug Tier

Drug Tier

Requirements /Limits

Drug Name

B/D PA

VARIZIG INTRAMUSCULA R SOLUTION

3

THYMOGLOBULI N INTRAVENOUS RECON SOLN

5

TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTIO N

4

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTIO N

3

TRUMENBA INTRAMUSCULA R SYRINGE

3

3

TWINRIX (PF) INTRAMUSCULA R SUSPENSION

3

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTIO N

TWINRIX (PF) INTRAMUSCULA R SYRINGE

3

TYPHIM VI INTRAMUSCULA R SOLUTION

3

TYPHIM VI INTRAMUSCULA R SYRINGE

3

VAQTA (PF) INTRAMUSCULA R SUSPENSION

Requirements /Limits

MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol oral tablet

1

GC

COLCHICINE ORAL CAPSULE

3

QL (360 per 90 days)

COLCHICINE ORAL TABLET

3

QL (360 per 90 days)

3

colchicineprobenecid oral tablet

2

VAQTA (PF) INTRAMUSCULA R SYRINGE

3

COLCRYS ORAL TABLET

3 5

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTIO N

3

KRYSTEXXA INTRAVENOUS SOLUTION probenecid oral tablet

2

VARIZIG INTRAMUSCULA R RECON SOLN

3

ULORIC ORAL TABLET

3

QL (360 per 90 days)

ST

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 89

Drug Name ZURAMPIC ORAL TABLET

Drug Tier 4

Requirements /Limits

Drug Name

PA

risedronate oral tablet 5 mg

Drug Tier

Requirements /Limits

2

OSTEOPOROSIS THERAPY

OTHER RHEUMATOLOGICALS

alendronate oral solution

2

5

PA

alendronate oral tablet 10 mg, 5 mg

2

QL (90 per 90 days)

alendronate oral tablet 35 mg, 70 mg

2

QL (12 per 90 days)

ACTEMRA INTRAVENOUS SOLUTION 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML)

PA

4

B/D PA

ACTEMRA SUBCUTANEOUS SYRINGE

5

BONIVA INTRAVENOUS SYRINGE

5

PA

BENLYSTA INTRAVENOUS RECON SOLN

5

FORTEO SUBCUTANEOUS PEN INJECTOR

4

QL (12 per 90 days)

DEPEN TITRATABS ORAL TABLET

4

FOSAMAX PLUS D ORAL TABLET ibandronate intravenous solution

2

5

ibandronate intravenous syringe

2

ENBREL SUBCUTANEOUS RECON SOLN

5

ibandronate oral tablet

2

QL (1 per 28 days)

ENBREL SUBCUTANEOUS SYRINGE

PROLIA SUBCUTANEOUS SYRINGE

4

PA

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

5

raloxifene oral tablet

1

GC; QL (90 per 90 days)

5

risedronate oral tablet 150 mg

2

QL (3 per 90 days)

risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack)

2

QL (12 per 90 days)

HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 90

Drug Name

Drug Tier

Requirements /Limits

HUMIRA PEN PSORIASISUVEITIS SUBCUTANEOUS PEN INJECTOR KIT

5

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT

5

HUMIRA SUBCUTANEOUS SYRINGE KIT

5

KINERET SUBCUTANEOUS SYRINGE

5

leflunomide oral tablet

2

QL (90 per 90 days)

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR

5

PA

ORENCIA SUBCUTANEOUS SYRINGE

5

OTEZLA ORAL TABLET OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)20 MG (4)-30 MG (47)

Drug Name

Drug Tier

Requirements /Limits

OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 12.5 MG/0.4 ML, 17.5 MG/0.4 ML, 22.5 MG/0.4 ML, 7.5 MG/0.4 ML

4

RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR

4

RIDAURA ORAL CAPSULE

3

SAVELLA ORAL TABLET

3

SAVELLA ORAL TABLETS,DOSE PACK

3

SIMPONI ARIA INTRAVENOUS SOLUTION

5

PA

5

PA

PA

SIMPONI SUBCUTANEOUS PEN INJECTOR

5

PA

5

PA

SIMPONI SUBCUTANEOUS SYRINGE

PA

PA

XELJANZ ORAL TABLET

5

5

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR

5

PA

PA; QL (23 per 34 days)

OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS amabelz oral tablet

2

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 91

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

MAKENA INTRAMUSCULA R OIL

5

2

4

medroxyprogesteron e intramuscular suspension

2

DEPO-PROVERA INTRAMUSCULA R SOLUTION

3

medroxyprogesteron e intramuscular syringe medroxyprogesteron e oral tablet

2

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE

4

MENEST ORAL TABLET 1.25 MG, 2.5 MG

4

errin oral tablet

2

2

ESTRACE VAGINAL CREAM

3

norethindrone (contraceptive) oral tablet

2

estradiol oral tablet

2

norethindrone acetate oral tablet

estradiol valerate intramuscular oil 20 mg/ml

2

2

ESTRING VAGINAL RING

3

norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg norlyroc oral tablet

2

FEMRING VAGINAL RING

3

PREMARIN VAGINAL CREAM

3

heather oral tablet

2

2

HYDROXYPROGE STERONE CAPROATE INTRAMUSCULA R OIL

4

progesterone micronized oral capsule sharobel oral tablet

2 3

jencycla oral tablet

2

VAGIFEM VAGINAL TABLET

jinteli oral tablet

2

lyza oral tablet

2

camila oral tablet

2

CRINONE VAGINAL GEL

3

deblitane oral tablet

2

DEPO-ESTRADIOL INTRAMUSCULA R OIL

PA

QL (1 per 90 days) QL (1 per 90 days)

PA

Requirements /Limits

PA

MISCELLANEOUS OB/GYN

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 92

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

AVC VAGINAL VAGINAL CREAM

4

alyacen 7/7/7 (28) oral tablet

2

CLEOCIN VAGINAL SUPPOSITORY

4

amethia lo oral tablets,dose pack,3 month

2

QL (91 per 91 days)

clindamycin phosphate vaginal cream

2

amethia oral tablets,dose pack,3 month

2

QL (91 per 91 days)

CLINDESSE VAGINAL

CREAM,EXTENDE

D RELEASE

4

amethyst oral tablet

2

apri oral tablet

2 2

GYNAZOLE-1 VAGINAL CREAM

4

aranelle (28) oral tablet

2

metronidazole vaginal gel

2

ashlyna oral tablets,dose pack,3 month

miconazole-3 vaginal suppository

1

aubra oral tablet

2

aviane oral tablet

2

NUVARING VAGINAL RING

4

azurette (28) oral tablet

2

terconazole vaginal cream

2

balziva (28) oral tablet

2

terconazole vaginal suppository

2

bekyree (28) oral tablet

2

tranexamic acid oral tablet

2

blisovi 24 fe oral tablet

2

vandazole vaginal gel

2

blisovi fe 1.5/30 (28) oral tablet

2

ORAL CONTRACEPTIVES / RELATED AGENTS

blisovi fe 1/20 (28) oral tablet

2

altavera (28) oral tablet

2

briellyn oral tablet

2 2

alyacen 1/35 (28) oral tablet

2

camrese lo oral tablets,dose pack,3 month

GC QL (3 per 90 days)

QL (30 per 21 days)

QL (91 per 91 days)

QL (91 per 91 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 93

Drug Tier

Requirements /Limits

Drug Name

camrese oral tablets,dose pack,3 month

2

QL (91 per 91 days)

enpresse oral tablet

2

enskyce oral tablet

2

caziant (28) oral tablet

2

estarylla oral tablet

2 2

chateal oral tablet

2

falmina (28) oral tablet

cryselle (28) oral tablet

2

gildagia oral tablet

2 2

cyclafem 1/35 (28) oral tablet

2

gildess 1.5/30 (21) oral tablet

2

cyclafem 7/7/7 (28) oral tablet

2

gildess 24 fe oral tablet

2

cyred oral tablet

2

introvale oral tablets,dose pack,3 month

QL (91 per 91 days)

dasetta 1/35 (28) oral tablet

2

2

QL (91 per 91 days)

dasetta 7/7/7 (28) oral tablet

2

jolessa oral tablets,dose pack,3 month juleber oral tablet

2

daysee oral tablets,dose pack,3 month

2

junel 1.5/30 (21) oral tablet

2

delyla (28) oral tablet

2

junel 1/20 (21) oral tablet

2

desoge.estradiol/e.estradio l oral tablet

2

junel fe 1.5/30 (28) oral tablet

2 2

desogestrel-ethinyl estradiol oral tablet

2

junel fe 1/20 (28) oral tablet

2

drospirenone-ethinyl estradiol oral tablet

2

junel fe 24 oral tablet

2

elinest oral tablet

2

kaitlib fe oral tablet,chewable

ELLA ORAL TABLET

3

kariva (28) oral tablet

2

emoquette oral tablet

2

kelnor 1/35 (28) oral tablet

2

Drug Name

QL (91 per 91 days)

QL (2 per 30 days)

Drug Tier

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 94

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

kimidess (28) oral tablet

2

loryna (28) oral tablet

2

kurvelo oral tablet

2

2

l norgest/e.estradiole.estrad oral tablets,dose pack,3 month

2

low-ogestrel (28) oral tablet lutera (28) oral tablet

2

marlissa oral tablet

2

larin 1.5/30 (21) oral tablet

2

microgestin 1.5/30 (21) oral tablet

2

larin 1/20 (21) oral tablet

2

microgestin 1/20 (21) oral tablet

2

larin 24 fe oral tablet

2

microgestin fe 1.5/30 (28) oral tablet

2

larin fe 1.5/30 (28) oral tablet

2

microgestin fe 1/20 (28) oral tablet

2

larin fe 1/20 (28) oral tablet

2

mono-linyah oral tablet

2

larissia oral tablet

2

myzilra oral tablet

2

layolis fe oral tablet,chewable

2

necon 0.5/35 (28) oral tablet

2

lessina oral tablet

2 2

necon 1/35 (28) oral tablet

2

levonest (28) oral tablet

2

levonorgestrelethinyl estrad oral tablet

2

necon 10/11 (28) oral tablet nikki (28) oral tablet

2

levonorgestrelethinyl estrad oral tablets,dose pack,3 month

2

noreth-ethinyl estradiol-iron oral tablet,chewable

2

2

levonorg-eth estrad triphasic oral tablet

2

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg

levora-28 oral tablet

2

norethindronee.estradiol-iron oral tablet

2

QL (91 per 91 days)

QL (91 per 91 days)

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 95

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

norgestimate-ethinyl estradiol oral tablet

2

tri-estarylla oral tablet

2

nortrel 0.5/35 (28) oral tablet

2

tri-legest fe oral tablet

2

nortrel 1/35 (21) oral tablet

2

tri-linyah oral tablet

2

2

tri-lo-estarylla oral tablet

2

nortrel 1/35 (28) oral tablet

2

tri-lo-marzia oral tablet

2

nortrel 7/7/7 (28) oral tablet

2

tri-lo-sprintec oral tablet

2

ogestrel (28) oral tablet

2

trinessa lo oral tablet

2

orsythia oral tablet philith oral tablet

2

2

pimtrea (28) oral tablet

2

tri-previfem (28) oral tablet

2

pirmella oral tablet

2

tri-sprintec (28) oral tablet

portia oral tablet

2

trivora (28) oral tablet

2

previfem oral tablet

2 2

velivet triphasic regimen (28) oral tablet

2

quasense oral tablets,dose pack,3 month

2

vestura (28) oral tablet

2

reclipsen (28) oral tablet

vienva oral tablet

2

setlakin oral tablets,dose pack,3 month

2

viorele (28) oral tablet

2

sprintec (28) oral tablet

2

wera (28) oral tablet

2 2

sronyx oral tablet

2

wymzya fe oral tablet,chewable

syeda oral tablet

2

zarah oral tablet

2

tarina fe 1/20 (28) oral tablet

2

zenchent (28) oral tablet

2

QL (91 per 91 days)

QL (91 per 91 days)

Requirements /Limits

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 96

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

zenchent fe oral tablet,chewable

2

ciprofloxacin hcl ophthalmic drops

1

zovia 1/35e (28) oral tablet

2

erythromycin ophthalmic ointment

2

zovia 1/50e (28) oral tablet

2

gatifloxacin ophthalmic drops

2

gentak ophthalmic ointment

2

gentamicin ophthalmic drops

2

OXYTOCICS HEMABATE INTRAMUSCULA R SOLUTION

4

methergine oral tablet

2

gentamicin ophthalmic ointment

2

METHYLERGONO VINE INJECTION SOLUTION

4

levofloxacin ophthalmic drops

2

2

MOXEZA OPHTHALMIC DROPS, VISCOUS

4

methylergonovine oral tablet

NATACYN OPHTHALMIC DROPS,SUSPENSI ON

3

neomycinbacitracinpolymyxin ophthalmic ointment

2

neomycinpolymyxingramicidin ophthalmic drops

2

neo-polycin ophthalmic ointment

2

ofloxacin ophthalmic drops

2

polycin ophthalmic ointment

1

OPHTHALMOLOGY ANTIBIOTICS AZASITE OPHTHALMIC DROPS

4

bacitracin ophthalmic ointment

1

GC

bacitracinpolymyxin b ophthalmic ointment

1

GC

BESIVANCE OPHTHALMIC DROPS,SUSPENSI ON

4

CILOXAN OPHTHALMIC OINTMENT

3

Requirements /Limits GC

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 97

Drug Name

Drug Tier

polymyxin b sulftrimethoprim ophthalmic drops

2

tobramycin ophthalmic drops

1

VIGAMOX OPHTHALMIC DROPS

3

Requirements /Limits

GC

ANTIVIRALS

trifluridine ophthalmic drops

2

ZIRGAN OPHTHALMIC GEL

3

Drug Name

Drug Tier

timolol maleate ophthalmic gel forming solution

1

TIMOPTIC OCUDOSE (PF) OPHTHALMIC DROPPERETTE

4

TIMOPTIC OPHTHALMIC DROPS

4

Requirements /Limits GC

CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE OPHTHALMIC DROPS

BETA-BLOCKERS

3

betaxolol ophthalmic drops

2

CYCLOPLEGIC MYDRIATICS

BETIMOL OPHTHALMIC DROPS 0.25 %

4

atropine ophthalmic drops

BETOPTIC S OPHTHALMIC DROPS,SUSPENSI ON

3

carteolol ophthalmic drops

2

levobunolol ophthalmic drops 0.5 %

1

metipranolol ophthalmic drops

2

timolol maleate ophthalmic drops

1

2

DIRECT ACTING MIOTICS pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 %

2

MISCELLANEOUS OPHTHALMOLOGICS GC

GC

ALOCRIL OPHTHALMIC DROPS

3

ALOMIDE OPHTHALMIC DROPS

3

azelastine ophthalmic drops

2

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 98

Drug Name

Drug Tier

BEPREVE OPHTHALMIC DROPS

4

cromolyn ophthalmic drops

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

bromfenac ophthalmic drops

2

1

2

diclofenac sodium ophthalmic drops

5

flurbiprofen sodium ophthalmic drops

2

CYSTARAN OPHTHALMIC DROPS

4

EMADINE OPHTHALMIC DROPS

4

ILEVRO OPHTHALMIC DROPS,SUSPENSI ON

2

ketorolac ophthalmic drops

2

epinastine ophthalmic drops

4

LACRISERT OPHTHALMIC INSERT

3

NEVANAC OPHTHALMIC DROPS,SUSPENSI ON

olopatadine ophthalmic drops

2

ORAL DRUGS FOR GLAUCOMA

3

acetazolamide oral capsule, extended release

2

PATADAY OPHTHALMIC DROPS

3

acetazolamide oral tablet

2

PAZEO OPHTHALMIC DROPS

2

proparacaine ophthalmic drops

2

acetazolamide sodium injection recon soln

3

methazolamide oral tablet

2

RESTASIS OPHTHALMIC DROPPERETTE

OTHER GLAUCOMA DRUGS

NON-STEROIDAL ANTIINFLAMMATORY AGENTS ACUVAIL (PF) OPHTHALMIC DROPPERETTE

GC

4

AZOPT OPHTHALMIC DROPS,SUSPENSI ON

3

bimatoprost ophthalmic drops

2

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 99

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

COMBIGAN OPHTHALMIC DROPS

4

neomycin-polymyxin b-dexameth ophthalmic ointment

2

dorzolamide ophthalmic drops

2

2

dorzolamide-timolol ophthalmic drops

2

neomycinpolymyxin-hc ophthalmic drops,suspension

latanoprost ophthalmic drops

2

neo-polycin hc ophthalmic ointment

1

LUMIGAN OPHTHALMIC DROPS 0.01 %

3

PRED-G OPHTHALMIC DROPS,SUSPENSI ON

4

SIMBRINZA OPHTHALMIC DROPS,SUSPENSI ON

3

PRED-G S.O.P. OPHTHALMIC OINTMENT

4

TRAVATAN Z OPHTHALMIC DROPS

3

TOBRADEX OPHTHALMIC OINTMENT

3

travoprost (benzalkonium) ophthalmic drops

2

TOBRADEX ST OPHTHALMIC DROPS,SUSPENSI ON

3

ZIOPTAN (PF) OPHTHALMIC DROPPERETTE

4

tobramycindexamethasone ophthalmic drops,suspension

2

4

STEROID-ANTIBIOTIC COMBINATIONS neomycinbacitracin-poly-hc ophthalmic ointment

2

ZYLET OPHTHALMIC DROPS,SUSPENSI ON

neomycin-polymyxin b-dexameth ophthalmic drops,suspension

2

STEROIDS

ALREX OPHTHALMIC DROPS,SUSPENSI ON

Requirements /Limits

GC

4

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 100

Drug Name

Drug Tier

dexamethasone sodium phosphate ophthalmic drops

2

DUREZOL OPHTHALMIC DROPS

3

FLAREX OPHTHALMIC DROPS,SUSPENSI ON

4

fluorometholone ophthalmic drops,suspension

Requirements /Limits

Drug Name

Drug Tier

PRED MILD OPHTHALMIC DROPS,SUSPENSI ON

3

prednisolone acetate ophthalmic drops,suspension

2

prednisolone sodium phosphate ophthalmic drops

2

2

RETISERT INTRAVITREAL IMPLANT

5

FML FORTE OPHTHALMIC DROPS,SUSPENSI ON

4

VEXOL OPHTHALMIC DROPS,SUSPENSI ON

3

FML S.O.P. OPHTHALMIC OINTMENT

4

STEROID-SULFONAMIDE COMBINATIONS

LOTEMAX OPHTHALMIC DROPS,GEL

4

LOTEMAX OPHTHALMIC DROPS,SUSPENSI ON

BLEPHAMIDE OPHTHALMIC DROPS,SUSPENSI ON

3

4

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT

3

LOTEMAX OPHTHALMIC OINTMENT

4

sulfacetamideprednisolone ophthalmic drops

2

MAXIDEX OPHTHALMIC DROPS,SUSPENSI ON

4

SULFONAMIDES

OZURDEX INTRAVITREAL IMPLANT

4

BLEPH-10 OPHTHALMIC DROPS

Requirements /Limits

3

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 101

Drug Name

Drug Tier

Requirements /Limits

Drug Tier

Requirements /Limits

desloratadine oral tablet,disintegrating

2

QL (90 per 90 days)

diphenhydramine hcl injection solution 50 mg/ml

2

PA

2

SYMPATHOMIMETICS

diphenhydramine hcl injection syringe

ALPHAGAN P OPHTHALMIC DROPS 0.1 %

3

epinephrine injection autoinjector

2

apraclonidine ophthalmic drops

1

GC

2

brimonidine ophthalmic drops

1

GC

epinephrine injection syringe 0.1 mg/ml

3

IOPIDINE OPHTHALMIC DROPPERETTE

4

EPIPEN 2-PAK INJECTION AUTOINJECTOR EPIPEN JR 2-PAK INJECTION AUTOINJECTOR

3

levocetirizine oral solution

2 2

QL (90 per 90 days)

sulfacetamide sodium ophthalmic drops

2

sulfacetamide sodium ophthalmic ointment

2

RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS

Drug Name

adrenaclick injection auto-injector

2

levocetirizine oral tablet

2

PA

adrenalin injection solution

2

phenadoz rectal suppository

2

PA

cetirizine oral solution 1 mg/ml

2

phenergan rectal suppository

2

PA

cyproheptadine oral syrup

2

PA

promethazine injection solution

2

PA

cyproheptadine oral tablet

2

PA

promethazine oral syrup

2

PA

desloratadine oral tablet

2

promethazine oral tablet promethazine rectal suppository

2

PA

QL (90 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 102

Drug Name promethegan rectal suppository

Drug Tier 2

Requirements /Limits

Drug Name

PA

PULMONARY AGENTS acetylcysteine solution

2

B/D PA

ADCIRCA ORAL TABLET

5

PA

ADEMPAS ORAL TABLET

5

PA

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE

3

QL (180 per 90 days)

ADVAIR HFA INHALATION HFA AEROSOL INHALER

3

QL (36 per 90 days)

albuterol sulfate inhalation solution for nebulization

1

albuterol sulfate oral syrup

1

GC

albuterol sulfate oral tablet

1

GC

albuterol sulfate oral tablet extended release 12 hr

1

GC

ALVESCO INHALATION HFA AEROSOL INHALER

3

aminophylline intravenous solution

2

B/D PA; GC

QL (37 per 90 days)

Drug Tier

Requirements /Limits

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

4

QL (90 per 90 days)

ASMANEX HFA INHALATION HFA AEROSOL INHALER

3

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

3

ATROVENT HFA INHALATION HFA AEROSOL INHALER

3

BECONASE AQ NASAL SPRAY,NONAEROSOL

3

BERINERT INTRAVENOUS KIT

5

BROVANA INHALATION SOLUTION FOR NEBULIZATION

4

B/D PA

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml

2

B/D PA

QL (3 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 103

Drug Name

Drug Tier

Requirements /Limits

budesonide inhalation suspension for nebulization 1 mg/2 ml

2

budesonide nasal spray,non-aerosol

2

CINRYZE INTRAVENOUS RECON SOLN

5

COMBIVENT RESPIMAT INHALATION MIST

4

cromolyn inhalation solution for nebulization

1

B/D PA; GC

DALIRESP ORAL TABLET

4

PA

DULERA INHALATION HFA AEROSOL INHALER

3

QL (39 per 90 days)

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML

3

ESBRIET ORAL CAPSULE

5

FIRAZYR SUBCUTANEOUS SYRINGE

5

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE

3

PA

PA

QL (360 per 90 days)

Drug Name

Drug Tier

Requirements /Limits

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION , 220 MCG/ACTUATION

3

QL (72 per 90 days)

FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION

3

QL (32 per 90 days)

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)

2

fluticasone nasal spray,suspension

2

FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE

3

QL (180 per 90 days)

ipratropium bromide inhalation solution

1

B/D PA; GC

ipratropiumalbuterol inhalation solution for nebulization

1

B/D PA; GC

KALYDECO ORAL GRANULES IN PACKET

5

PA

KALYDECO ORAL TABLET

5

PA

LETAIRIS ORAL TABLET

5

PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 104

Drug Name

Drug Tier

Requirements /Limits

Drug Name

B/D PA

levalbuterol hcl inhalation solution for nebulization

2

metaproterenol oral syrup

2

metaproterenol oral tablet

2

mometasone nasal spray,non-aerosol

2

montelukast oral granules in packet

2

QL (90 per 90 days)

montelukast oral tablet

2

QL (90 per 90 days)

montelukast oral tablet,chewable

2

QL (90 per 90 days)

NASONEX NASAL SPRAY,NONAEROSOL

4

OFEV ORAL CAPSULE

5

PA

OMNARIS NASAL SPRAY,NONAEROSOL

4

ST

OPSUMIT ORAL TABLET

5

PA

ORKAMBI ORAL TABLET

5

PA

PROAIR HFA INHALATION HFA AEROSOL INHALER

3

QL (102 per 90 days)

Drug Tier

Requirements /Limits

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED

3

QL (12 per 90 days)

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

3

PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML

3

B/D PA

PULMOZYME INHALATION SOLUTION

5

B/D PA

QVAR INHALATION AEROSOL

3

REVATIO ORAL SUSPENSION FOR RECONSTITUTIO N

5

PA

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

3

QL (180 per 90 days)

sildenafil oral tablet

2

PA; QL (270 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 105

Drug Name

Drug Tier

Requirements /Limits

SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION

3

SPIRIVA

RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION

3

QL (90 per 90 days)

SPIRIVA WITH

HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE

3

QL (90 per 90 days)

STIOLTO

RESPIMAT INHALATION MIST

3

STRIVERDI RESPIMAT INHALATION MIST

3

SYMBICORT INHALATION HFA AEROSOL INHALER

3

terbutaline oral tablet

2

terbutaline subcutaneous solution

2

theophylline oral tablet extended release 12 hr

2

QL (30.6 per 90 days)

Drug Name

Drug Tier

Requirements /Limits

theophylline oral tablet extended release 24 hr

2

TRACLEER ORAL TABLET

5

PA; LA

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH

ACTIVATED 400 MCG/ACTUATION

4

QL (3 per 90 days)

TUDORZA PRESSAIR INHALATION AEROSOL POWDR

BREATH ACTIVATED 400 MCG/ACTUATION (30 ACTUAT)

4

QL (1 per 30 days)

TYVASO INHALATION SOLUTION FOR NEBULIZATION

5

B/D PA

TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION

5

B/D PA

TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION

5

B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 106

Drug Name

Drug Tier

Requirements /Limits

Drug Name

B/D PA

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

3

oxybutynin chloride oral syrup

2

oxybutynin chloride oral tablet

2

oxybutynin chloride oral tablet extended release 24hr

2

tolterodine oral capsule,extended release 24hr

2

tolterodine oral tablet

2

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR

3

trospium oral capsule,extended release 24hr

2

trospium oral tablet

2

VESICARE ORAL TABLET

3

TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION

5

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION

5

VENTOLIN HFA INHALATION HFA AEROSOL INHALER

3

VERAMYST NASAL SPRAY,SUSPENSI ON

4

XOLAIR SUBCUTANEOUS RECON SOLN

5

PA

XOPENEX HFA INHALATION HFA AEROSOL INHALER

4

QL (90 per 90 days)

zafirlukast oral tablet

2

ZYFLO CR ORAL TABLET, ER MULTIPHASE 12 HR

4

ZYFLO ORAL TABLET

4

B/D PA

QL (216 per 90 days)

ST

QL (180 per 90 days) QL (360 per 90 days)

UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS flavoxate oral tablet

1

GC

Drug Tier

Requirements /Limits

QL (180 per 90 days)

QL (90 per 90 days)

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin oral tablet extended release 24 hr

1

GC

AVODART ORAL CAPSULE

3

QL (90 per 90 days)

dutasteride oral capsule

2

QL (90 per 90 days)

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 107

Drug Name

Drug Tier

finasteride oral tablet 5 mg

2

tamsulosin oral capsule,extended release 24hr

1

Requirements /Limits

GC

CHOLINERGIC STIMULANTS bethanechol chloride oral tablet

2

MISCELLANEOUS UROLOGICALS CYSTAGON ORAL CAPSULE

4

cytra k crystals oral packet

2

ELMIRON ORAL CAPSULE

3

K-PHOS NO 2 ORAL TABLET

4

K-PHOS ORIGINAL ORAL TABLET,SOLUBL E

4

potassium citrate oral tablet extended release

2

potassium citratecitric acid oral packet

Drug Name

Drug Tier

RENACIDIN IRRIGATION SOLUTION 6.6023.268 GRAM/100 ML

4

sodium citrate-citric acid oral solution

2

Requirements /Limits

VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate oral capsule

1

GC

calcium acetate oral tablet 667 mg

1

GC

calcium chloride intravenous solution

2

calcium chloride intravenous syringe

2

calcium gluconate intravenous solution

2

dextrose-kcl-nacl intravenous solution

2

effer-k oral tablet, effervescent 25 meq

2

2

eliphos oral tablet

1 4

potassium citratecitric acid oral solution

2

HYPERLYTE CR INTRAVENOUS SOLUTION

2

PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE

5

k-effervescent oral tablet, effervescent klor-con 10 oral tablet extended release

1

PA

GC

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 108

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

klor-con 8 oral tablet extended release

1

GC

NEUT INTRAVENOUS SOLUTION

4

klor-con m10 oral tablet,er particles/crystals

1

GC

4

klor-con m15 oral tablet,er particles/crystals

1

GC

NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION PHOSLYRA ORAL SOLUTION

4

klor-con m20 oral tablet,er particles/crystals

1

phospha 250 neutral oral tablet

2 2

klor-con oral packet

2

klor-con sprinkle oral capsule, extended release

1

potassium acetate intravenous solution 2 meq/ml

2

klor-con/ef oral tablet, effervescent

2

potassium bicarb and chloride oral tablet, effervescent

2

k-phos-neutral oral tablet

2

potassium bicarbcitric acid oral tablet, effervescent

k-tab oral tablet extended release 8 meq

1

potassium chloridd5-0.45%nacl intravenous parenteral solution

2

lactated ringers intravenous parenteral solution

2

2

magnesium sulfate in water intravenous parenteral solution

4

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

4

magnesium sulfate injection syringe

2

potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l

2

magnesium sulfate in water intravenous piggyback

potassium chloride in lr-d5 intravenous parenteral solution

2

GC

GC

GC

Requirements /Limits

B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 109

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

HI

potassium chlorided5-0.2%nacl intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l

2

potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 40 meq/100 ml

2

potassium chloride intravenous piggyback 10 meq/50 ml, 20 meq/50 ml

2

potassium chlorided5-0.3%nacl intravenous parenteral solution 20 meq/l

2

potassium chloride intravenous piggyback 30 meq/100 ml

4

potassium chlorided5-0.9%nacl intravenous parenteral solution

2

potassium chloride oral capsule, extended release

1

GC

potassium phosphate m-/d-basic intravenous solution

2

potassium chloride oral liquid

1

GC

ringers intravenous parenteral solution

2

potassium chloride oral packet

2

sodium acetate intravenous solution

2

potassium chloride oral tablet extended release

1

GC

sodium bicarbonate intravenous solution

2

1

GC

sodium bicarbonate intravenous syringe

2

potassium chloride oral tablet,er particles/crystals

2

potassium chloride0.45 % nacl intravenous parenteral solution

2

sodium chloride 0.45 % intravenous parenteral solution sodium chloride 0.45 % intravenous piggyback

2

sodium chloride 3 % intravenous parenteral solution

2

Requirements /Limits

HI

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 110

Drug Name

Drug Tier

sodium chloride 5 % intravenous parenteral solution

2

sodium chloride intravenous parenteral solution

2

sodium lactate intravenous solution

2

sodium phosphate intravenous solution

2

virt-phos 250 neutral oral tablet

2

Requirements /Limits

Drug Name

Drug Tier

Requirements /Limits

AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

AMINOSYN-PF 7 % (SULFITEFREE) INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

BAL IN OIL INTRAMUSCULA R SOLUTION

4

4

B/D PA

CALCIUM DISODIUM VERSENATE INJECTION SOLUTION

4

MISCELLANEOUS NUTRITION PRODUCTS amino acids 15 % intravenous

parenteral solution

2

B/D PA

AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS

PARENTERAL

SOLUTION

4

AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION

AMINOSYN II 7 % INTRAVENOUS

PARENTERAL

SOLUTION

4

B/D PA

cysteine (l-cysteine) intravenous solution

2 4

B/D PA

AMINOSYN-HBC 7% INTRAVENOUS

PARENTERAL

SOLUTION

4

FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION freamine iii 10 % intravenous parenteral solution

2

B/D PA

B/D PA

B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 111

Drug Name

Drug Tier

Requirements /Limits

Drug Name

Drug Tier

PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

plasmanate intravenous parenteral solution

2

premasol 10 % intravenous parenteral solution

2

B/D PA

PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

SMOFLIPID INTRAVENOUS EMULSION

4

B/D PA

intralipid intravenous emulsion 20 %

2

B/D PA

INTRALIPID INTRAVENOUS EMULSION 30 %

4

B/D PA

ISOLYTE S PH 7.4 INTRAVENOUS PARENTERAL SOLUTION

4

ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

4

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION

4

KABIVEN INTRAVENOUS EMULSION

4

NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION

4

NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION

4

NUTRILIPID INTRAVENOUS EMULSION

4

B/D PA

THAM INTRAVENOUS SOLUTION

4

PERIKABIVEN INTRAVENOUS EMULSION

4

B/D PA

travasol 10 % intravenous parenteral solution

2

B/D PA

B/D PA

B/D PA

B/D PA

B/D PA

B/D PA

Requirements /Limits

B/D PA

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 112

Drug Name TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION

Drug Tier 4

Requirements /Limits

Drug Name

B/D PA

sodium fluoride oral tablet

2

sodium fluoride oral tablet,chewable

2

tri-vit with fluoride and iron oral drops

2

tri-vitamin with fluoride oral drops

2

vitamins a,c,d and fluoride oral drops

2

VITAMINS / HEMATINICS fluor-a-day (with xylitol) oral tablet,chewable 0.25 mg f (0.55 mg)236.79mg, 1 mg f (2.2 mg)-236.79 mg

2

fluoritab oral tablet,chewable

2

ludent fluoride oral tablet,chewable

2

multi-vit with fluoride-iron oral drops

2

multi-vitamin with fluoride oral drops

2

multivitamin with fluoride oral tablet,chewable

2

multi-vitamin with fluoride oral tablet,chewable 0.5 mg

2

multivitamins with fluoride oral tablet,chewable

2

mvc-fluoride oral tablet,chewable

2

prenatal vitamin oral tablet

2

sodium fluoride oral drops

1

Drug Tier

Requirements /Limits

GC

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Brand 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only GC – (Prestige Only) Gap Coverage HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 113

Index 8 8-MOP..................................55

A abacavir ..................................2

abacavir-lamivudinezidovudine ..........................2

ABELCET..............................1

ABILIFY MAINTENA.. 37, 38

ABRAXANE........................17

ABSTRAL............................32

acamprosate..........................63

acarbose................................70

acebutolol ............................. 45

acetaminophen-codeine........32

acetasol hc ............................68

acetazolamide .......................99

acetazolamide sodium ..........99

acetic acid....................... 63, 68

acetic acid-aluminum acetate68

acetylcysteine ............... 63, 103

acitretin.................................55

ACTEMRA ..........................90

ACTHAR H.P. .....................68

ACTHIB (PF).......................85

ACTIMMUNE .....................82

ACUVAIL (PF)....................99

acyclovir ........................... 2, 60

acyclovir sodium ....................2

ADACEL(TDAP

ADOLESN/ADULT)(PF) 85

ADAGEN ............................. 63

adapalene.............................. 56

ADASUVE........................... 38

ADCIRCA.......................... 103

adefovir................................... 2

ADEMPAS......................... 103

adenosine.............................. 44

adrenaclick ......................... 102

adrenalin .............................102

adrucil................................... 17

ADVAIR DISKUS.............103

ADVAIR HFA ................... 103

afeditab cr.............................45

AFINITOR ........................... 17

AFINITOR DISPERZ ..........17

AGGRENOX ....................... 50

a-hydrocort ...........................68

AKYNZEO...........................77

ALBENZA .............................9

albuterol sulfate ..................103

alclometasone .......................60

alcohol pads..........................70

ALDURAZYME ..................74

ALECENSA .........................17

alendronate .....................63, 90

alfuzosin .............................107

ALIMTA ..............................17

ALINIA ..................................9

allopurinol ............................89

almotriptan malate................30

ALOCRIL.............................98

ALOMIDE............................98

alosetron ...............................77

ALOXI..................................77

ALPHAGAN P...................102

alprazolam ............................38

alprazolam intensol...............38

ALREX...............................100

altavera (28)..........................93

ALVESCO.......................... 103

alyacen 1/35 (28) ..................93

alyacen 7/7/7 (28).................93

amabelz.................................91

amantadine hcl........................2

AMBISOME ..........................1

amcinonide ...........................60

amethia .................................93

amethia lo .............................93

amethyst................................93

amifostine crystalline ...........16

amikacin .................................9

amiloride...............................45

amiloride-hydrochlorothiazide

..........................................45

amino acids 15 % ...............111

aminocaproic acid.................50

aminophylline.....................103

AMINOSYN 7 % WITH

ELECTROLYTES..........111

AMINOSYN II 15 % .........111

AMINOSYN II 7 % ...........111

AMINOSYN-HBC 7%.......111

AMINOSYN-PF 10 % .......111

AMINOSYN-PF 7 %

(SULFITE-FREE) ..........111

AMINOSYN-RF 5.2 %......111

amiodarone ...........................44

AMITIZA .............................77

amitriptyline .........................38

amlodipine ............................45

amlodipine-atorvastatin ........52

amlodipine-benazepril ..........45

amlodipine-valsartan ............45

amlodipine-valsartan-hcthiazid

..........................................45

ammonium lactate ..........55, 56

AMMONUL .........................63

amoxapine.............................38

amoxicillin............................13

amoxicillin-pot clavulanate ..13

amphotericin b ........................1

ampicillin..............................13

ampicillin sodium .................13

ampicillin-sulbactam ............13

AMPYRA .............................31

anagrelide ............................. 63

ANALPRAM-HC.................77

anastrozole ............................17

ANDRODERM ....................74

ANDROGEL ........................74

ANDROID............................74

androxy .................................74

ANGIOMAX ........................50

ANZEMET ...........................77

apexicon e.............................60

APIDRA ...............................70

APIDRA SOLOSTAR..........70

APOKYN .............................29

apraclonidine ......................102

apri ........................................93

APRISO................................77

APTIOM...............................26

APTIVUS ...............................2

ARALAST NP......................64

aranelle (28)..........................93

ARANESP (IN

POLYSORBATE) ............82

ARCALYST .........................82

ARCAPTA NEOHALER...103

ARGATROBAN ..................51

ARGATROBAN IN 0.9 %

SOD CHLOR....................50

aripiprazole ...........................38

ARISTADA ..........................38

Index 1

ARISTOSPAN INTRAARTICULAR ...................68

armodafinil ........................... 38

ARRANON ..........................17

ARZERRA ...........................17

ASACOL HD .......................78

ashlyna..................................93

ASMANEX HFA ...............103

ASMANEX TWISTHALER

........................................103

aspirin-dipyridamole ............51

ASTAGRAF XL ..................17

atenolol .................................45

atenolol-chlorthalidone.........45

atorvastatin ...........................52

atovaquone .............................9

atovaquone-proguanil.............9

ATRIPLA ...............................2

atropine........................... 77, 98

ATROVENT HFA ............. 103

AUBAGIO ...........................31

aubra .....................................93

AURYXIA ...........................64

AVANDIA ........................... 70

AVASTIN ............................ 17

AVC VAGINAL .................. 93

aviane ...................................93

AVODART ........................ 107

AVONEX ............................. 82

AVONEX (WITH ALBUMIN)

.......................................... 82

AXERT................................. 30

azacitidine............................. 17

AZACTAM IN DEXTROSE

(ISO-OSM)......................... 9

AZASAN.............................. 17

AZASITE .............................97

azathioprine ..........................17

azathioprine sodium .............17

azelastine ........................ 67, 98

AZELEX ..............................56

AZILECT ............................. 29

azithromycin...........................8

AZOPT .................................99

AZOR ...................................45

aztreonam ...............................9

azurette (28)..........................93

B

baciim ..................................... 9

Index 2

bacitracin ..........................9, 97

bacitracin-polymyxin b.........97

baclofen ................................32

BACTROBAN NASAL .......67

BAL IN OIL .......................111

balsalazide ............................78

balziva (28)...........................93

BANZEL ..............................26

BARACLUDE........................2

BCG VACCINE, LIVE (PF) 85

BD INSULIN PEN NEEDLE

UF MINI...........................70

BD INSULIN PEN NEEDLE

UF ORIG ..........................70

BD INSULIN PEN NEEDLE

UF SHORT.......................70

BD ULTRA-FINE NANO

PEN NEEDLES................70

BECONASE AQ ................103

bekyree (28)..........................93

BELEODAQ ........................17

benazepril .............................45

benazepril-hydrochlorothiazide

..........................................45

BENDEKA...........................17

BENICAR ............................45

BENICAR HCT ...................45

BENLYSTA .........................90

BENZACLIN PUMP ...........56

benztropine ...........................29

BEPREVE ............................99

BERINERT ........................103

BESIVANCE........................97

betamethasone acet,sod phos 68

betamethasone dipropionate .60

betamethasone valerate.........60

betamethasone, augmented..60,

61

BETASERON ......................82

betaxolol .........................45, 98

bethanechol chloride...........108

BETHKIS ...............................9

BETIMOL ............................98

BETOPTIC S........................98

bexarotene ............................18

BEXSERO (PF)....................85

bicalutamide .........................18

BICILLIN C-R .....................13

BICILLIN L-A .....................13

BICNU..................................18

BIDIL ...................................45

BILTRICIDE ..........................9

bimatoprost ...........................99

bisoprolol fumarate...............45

bisoprolol-hydrochlorothiazide

..........................................45

BIVIGAM.............................85

bleo 15k ................................18

bleomycin .............................18

BLEPH-10 ..........................101

BLEPHAMIDE ..................101

BLEPHAMIDE S.O.P. .......101

BLINCYTO ..........................18

blisovi 24 fe ..........................93

blisovi fe 1.5/30 (28) ............93

blisovi fe 1/20 (28) ...............93

BONIVA...............................90

BOOSTRIX TDAP...............85

BOSULIF .............................18

BREVIBLOC .......................45

briellyn..................................93

BRILINTA ...........................51

brimonidine.........................102

BRIVIACT ...........................26

bromfenac .............................99

bromocriptine .......................29

BROVANA ........................103

budesonide............78, 103, 104

bumetanide ...........................45

BUPHENYL.........................64

BUPRENEX .........................33

buprenorphine hcl .................33

buprenorphine-naloxone.......36

bupropion hcl........................38

bupropion hcl (smoking deter)

..........................................67

buspirone ..............................38

BUSULFEX .........................18

butorphanol tartrate ..............36

BYDUREON ........................70

BYETTA ..............................70

C cabergoline ........................... 74

CABOMETYX.....................18

caffeine citrated ....................64

calcipotriene .........................55

calcitonin (salmon) ...............74

calcitrene...............................55

calcitriol.......................... 55, 74

calcium acetate ................... 108

calcium chloride ................. 108

CALCIUM DISODIUM

VERSENATE................. 111

calcium gluconate............... 108

camila ...................................92

CAMPATH .......................... 18

camrese................................. 94

camrese lo............................. 93

CANASA ............................. 78

CANCIDAS ........................... 1

candesartan ........................... 45

candesartan-hydrochlorothiazid

..........................................46

CAPASTAT ........................... 9

CAPEX................................. 61

CAPRELSA ......................... 18

captopril................................ 46

captopril-hydrochlorothiazide

..........................................46

CARAC ................................56

carafate .................................81

CARBAGLU........................ 64

carbamazepine...................... 26

carbidopa .............................. 29

carbidopa-levodopa .............. 29

carbidopa-levodopaentacapone........................ 29

CARBOCAINE.................... 57

carbocaine (pf)...................... 57

carboplatin............................ 18

CARDIZEM LA................... 46

CARDURA XL .................... 46

CARIMUNE NF

NANOFILTERED ........... 85

carteolol................................ 98

cartia xt................................. 46

carvedilol.............................. 46

CAYSTON ........................... 10

caziant (28)........................... 94

CEDAX .................................. 6

cefaclor ................................... 6

cefadroxil................................ 6

cefazolin ................................. 6

cefazolin in dextrose (iso-os) .6

cefdinir ................................... 6

cefepime ................................. 6

CEFEPIME IN DEXTROSE 5

%......................................... 6

cefepime in dextrose,iso-osm .6

cefixime ..................................6

cefotaxime ..............................6

cefotetan .................................6

CEFOTETAN IN

DEXTROSE, ISO-OSM.....6

cefoxitin..................................7

cefoxitin in dextrose, iso-osm 7

cefpodoxime ...........................7

cefprozil..................................7

ceftazidime .............................7

CEFTAZIDIME IN D5W ......7

ceftibuten ................................7

ceftriaxone ..............................7

ceftriaxone in dextrose,iso-os.7

cefuroxime axetil....................7

cefuroxime sodium .................7

celecoxib...............................36

CELLCEPT INTRAVENOUS

..........................................18

CELONTIN ..........................26

CENTANY...........................59

cephalexin...............................7

CEPROTIN (BLUE BAR) ...51

CEPROTIN (GREEN BAR) 51

CERDELGA.........................74

CEREBYX ...........................26

CEREZYME ........................74

CERVARIX VACCINE (PF)

..........................................85

cetirizine .............................102

cevimeline ............................64

CHANTIX ............................67

CHANTIX CONTINUING

MONTH BOX..................67

CHANTIX STARTING

MONTH BOX..................67

chateal...................................94

CHEMET.............................. 64

chloramphenicol sod succinate

..........................................10

chlordiazepoxide-clidinium..77

chlorhexidine gluconate .......67

chloroquine phosphate..........10

chlorothiazide .......................46

chlorothiazide sodium ..........46

chlorpromazine.....................38

chlorthalidone.......................46

CHOLBAM ..........................78

cholestyramine (with sugar) .52

cholestyramine light .......52, 53

chorionic gonadotropin, human

..........................................74

ciclodan.................................59

ciclopirox ..............................59

cidofovir .................................2

cilostazol...............................51

CILOXAN ............................97

CIMZIA ................................78

CIMZIA POWDER FOR

RECONST........................78

CIMZIA STARTER KIT .....78

CINRYZE...........................104

CIPRO HC............................68

CIPRODEX ..........................68

ciprofloxacin.........................15

ciprofloxacin (mixture).........14

ciprofloxacin hcl .......15, 68, 97

ciprofloxacin in 5 % dextrose

..........................................15

ciprofloxacin lactate .............15

cisplatin.................................18

citalopram .............................38

cladribine ..............................18

CLAFORAN...........................7

claravis..................................56

clarithromycin.........................8

CLEOCIN.............................93

CLEVIPREX ........................46

clindacin etz..........................56

clindacin p ............................56

clindamycin hcl ....................10

clindamycin in 5 % dextrose 10

clindamycin palmitate hcl.....10

clindamycin pediatric ...........10

clindamycin phosphate ..10, 56,

57, 93

clindamycin-benzoyl peroxide

..........................................57

CLINDESSE.........................93

CLINIMIX E 4.25%/D10W

SUL FREE......................111

CLINPRO 5000 ....................67

clobetasol ..............................61

clobetasol-emollient .............61

clodan ...................................61

CLOLAR ..............................18

clomipramine ........................38

clonazepam ...........................26

clonidine ...............................46

Index 3

clonidine (pf) ..................36, 46

clonidine hcl ................... 38, 46

clopidogrel............................51

clorazepate dipotassium .......38

clotrimazole......................1, 59

clotrimazole-betamethasone.59

clozapine...............................38

CLOZAPINE........................38

COARTEM .......................... 10

codeine sulfate...................... 33

COLCHICINE...................... 89

colchicine-probenecid ..........89

COLCRYS ........................... 89

colestipol .............................. 53

colistin (colistimethate na) ... 10

colocort................................. 78

COLY-MYCIN S ................. 68

COMBIGAN ...................... 100

COMBIVENT RESPIMAT104

COMETRIQ ......................... 18

COMPLERA ..........................2

compro..................................78

CONDYLOX .......................56

constulose .............................78

COPAXONE ........................31

COREG CR ..........................46

CORLANOR........................54

CORLOPAM........................46

cormax..................................61

CORTIFOAM ......................78

cortisone ...............................68

COSENTYX.........................55

COSENTYX (2 SYRINGES)

..........................................55

COSENTYX PEN ................55

COSENTYX PEN (2 PENS) 55

COTELLIC...........................18

CREON ................................78

CRESTOR............................53

CRINONE ............................92

CRIXIVAN ............................2

cromolyn................. 78, 99, 104

cryselle (28)..........................94

CUBICIN .............................10

CUTIVATE..........................61

cyclafem 1/35 (28) ...............94

cyclafem 7/7/7 (28) ..............94

cyclobenzaprine....................32

cyclophosphamide................18

Index 4

CYCLOPHOSPHAMIDE ....18

CYCLOSERINE ..................10

CYCLOSET .........................70

cyclosporine..........................18

cyclosporine modified ..........18

cyproheptadine ...................102

CYRAMZA ..........................18

cyred .....................................94

CYSTADANE......................78

CYSTAGON ......................108

CYSTARAN ........................99

cysteine (l-cysteine)............111

cytarabine .............................18

cytarabine (pf) ......................18

CYTOGAM..........................85

cytra k crystals....................108

D d10 %-0.45 % sodium chloride ..........................................64

d2.5 %-0.45 % sodium

chloride.............................64

d5 % and 0.9 % sodium

chloride.............................64

d5 %-0.45 % sodium chloride

..........................................64

dacarbazine...........................18

DAKLINZA ...........................2

DALIRESP.........................104

DALVANCE ........................10

danazol..................................74

DANTRIUM ........................32

dantrolene .............................32

dapsone.................................10

DAPTACEL (DTAP

PEDIATRIC) (PF)............85

daptomycin ...........................10

DARAPRIM.........................10

DARZALEX ........................19

dasetta 1/35 (28) ...................94

dasetta 7/7/7 (28) ..................94

daunorubicin.........................19

daysee ...................................94

deblitane ...............................92

decitabine..............................19

deferoxamine ........................64

deltasone...............................68

delyla (28).............................94

DELZICOL ..........................78

demeclocycline.....................15

DEMSER..............................46

DENAVIR ............................60

denta 5000 plus.....................67

dentagel.................................67

DEPEN TITRATABS ..........90

DEPOCYT (PF)....................19

DEPO-ESTRADIOL ............92

DEPO-MEDROL .................68

DEPO-PROVERA................92

DEPO-SUBQ PROVERA 104

..........................................92

DERMA-SMOOTHE/FS

SCALP OIL ......................61

DESCOVY .............................2

desipramine...........................38

desloratadine.......................102

desmopressin ........................74

desog-e.estradiol/e.estradiol .94

desogestrel-ethinyl estradiol.94

desonide................................61

desoximetasone.....................61

dexamethasone ...............68, 69

dexamethasone intensol........68

dexamethasone sodium phos

(pf) ....................................69

dexamethasone sodium

phosphate ..................69, 101

dexedrine ..............................39

dexmethylphenidate..............39

DEXPAK 10 DAY ...............69

DEXPAK 13 DAY ...............69

DEXPAK 6 DAY .................69

dexrazoxane hcl ....................16

dextroamphetamine ..............39

dextroamphetamineamphetamine.....................39

dextrose 10 % in water (d10w)

..........................................64

dextrose 20 % in water (d20w)

..........................................64

dextrose 25 % in water (d25w)

..........................................64

dextrose 30 % in water (d30w)

..........................................64

dextrose 40 % in water (d40w)

..........................................64

dextrose 5 % in water (d5w).64

dextrose 5 %-lactated ringers64

dextrose 5%-0.2 % sod chloride.............................64

dextrose 5%-0.3 %

sod.chloride ...................... 65

dextrose 50 % in water (d50w)

.......................................... 65

dextrose 70 % in water (d70w)

.......................................... 65

dextrose with sodium chloride

.......................................... 65

dextrose-kcl-nacl ................ 108

diazepam......................... 26, 39

diazepam intensol.................39

diclofenac potassium ............36

diclofenac sodium ....36, 56, 99

diclofenac-misoprostol .........36

dicloxacillin..........................13

dicyclomine ..........................77

didanosine...............................2

DIFFERIN............................57

DIFICID .................................8

diflorasone............................61

diflunisal...............................36

digitek...................................50

digox.....................................50

digoxin..................................50

dihydroergotamine ...............30

DILANTIN 30 MG ..............26

diltiazem hcl .........................46

dilt-xr....................................47

dimenhydrinate.....................78

DIPENTUM ......................... 78

diphenhydramine hcl ..........102

diphenoxylate-atropine.........77

diskets...................................33

disopyramide phosphate.......44

disulfiram ............................. 65

divalproex....................... 26, 27

dobutamine ...........................54

DOCEFREZ .........................19

docetaxel...............................19

dofetilide............................... 44

donepezil .............................. 31

dopamine .............................. 54

dorzolamide........................ 100

dorzolamide-timolol ...........100

doxazosin.............................. 47

doxepin ........................... 39, 56

doxercalciferol......................74

doxorubicin........................... 19

doxorubicin, peg-liposomal..19

doxy-100...............................15

doxycycline hyclate..............15

doxycycline monohydrate ....15

dronabinol.............................78

droperidol .............................78

drospirenone-ethinyl estradiol

..........................................94

DROXIA ..............................19

DULERA............................104

duloxetine .............................39

DUOPA ................................29

duramorph (pf) .....................33

DUREZOL .........................101

dutasteride ..........................107

DYSPORT............................85

E

e.e.s. 400.................................8

econazole ..............................59

EDARBYCLOR...................47

EDECRIN.............................47

EDURANT.............................2

effer-k .................................108

EFFIENT ..............................51

EGRIFTA .............................82

ELAPRASE..........................75

ELELYSO ............................75

ELIDEL ................................56

elinest....................................94

eliphos ................................108

ELIQUIS ..............................51

ELITEK ................................16

ELIXOPHYLLIN ...............104

ELLA....................................94

ELLENCE ............................19

ELMIRON..........................108

EMADINE............................99

EMCYT ................................19

EMEND................................78

emoquette .............................94

EMPLICITI ..........................19

EMSAM ...............................39

EMTRIVA..............................2

enalapril maleate...................47

enalaprilat .............................47

enalapril-hydrochlorothiazide

..........................................47

ENBREL ..............................90

ENBREL SURECLICK .......90

endocet..................................33

ENGERIX-B (PF) ................85

ENGERIX-B PEDIATRIC

(PF) .............................85, 86

enlon .....................................32

ENLON-PLUS .....................32

enoxaparin ............................51

enpresse ................................94

enskyce .................................94

entacapone ............................29

entecavir .................................2

enulose..................................78

ENVARSUS XR ..................19

EPIFOAM.............................55

epinastine..............................99

epinephrine .........................102

EPIPEN 2-PAK ..................102

EPIPEN JR 2-PAK .............102

epirubicin ..............................19

epitol .....................................27

EPIVIR ...................................2

EPIVIR HBV..........................2

eplerenone.............................47

EPOGEN ..............................82

epoprostenol (glycine) ..........47

eprosartan .............................47

EPZICOM...............................3

ERAXIS(WATER DILUENT)

............................................1

ERBITUX.............................19

ergoloid.................................39

ERGOMAR ..........................30

ERIVEDGE ..........................19

errin.......................................92

ERTACZO............................59

ERWINAZE .........................19

ery pads.................................57

erygel ....................................57

ery-tab.....................................8

ERY-TAB...............................8

ERYTHROCIN ......................9

erythrocin (as stearate) ...........8

erythromycin.....................9, 97

erythromycin ethylsuccinate...9

erythromycin with ethanol....57

erythromycin-benzoyl peroxide

..........................................57

ESBRIET ............................104

escitalopram oxalate .............39

esmolol .................................47

esomeprazole sodium ...........81

Index 5

estarylla ................................94

ESTRACE ............................92

estradiol ................................ 92

estradiol valerate ..................92

ESTRING .............................92

ethacrynic acid......................47

ethambutol............................10

ethosuximide ........................27

etidronate disodium .............. 65

etodolac ................................36

ETOPOPHOS.......................19

etoposide...............................19

EURAX ................................63

EVOTAZ................................ 3

EVZIO.................................. 36

EXELDERM ........................59

EXELON..............................31

exemestane ...........................19

EXJADE...............................65

EXTAVIA ............................82

F FABRAZYME .....................75

falmina (28) ..........................94

famciclovir .............................3

famotidine............................. 81

famotidine (pf)...................... 81

famotidine (pf)-nacl (iso-os)81

FANAPT .............................. 39

FARESTON ......................... 19

FARXIGA ............................70

FARYDAK...........................19

FASLODEX .........................20

FAZACLO ...........................40

felbamate .............................. 27

felodipine..............................47

FEMRING............................92

fenofibrate ............................53

fenofibrate micronized ......... 53

fenofibrate nanocrystallized .53

fenofibric acid ...................... 53

fenofibric acid (choline) .......53

fenoprofen ............................36

fentanyl................................. 33

fentanyl citrate......................33

fentanyl citrate (pf)...............33

FENTORA ...........................33

FERRIPROX........................ 65

FETZIMA.............................40

FINACEA............................. 57

Index 6

finasteride ...........................108

FIRAZYR...........................104

FLAREX ............................101

flavoxate .............................107

FLEBOGAMMA DIF ..........86

flecainide ..............................44

FLOLAN ..............................47

FLOVENT DISKUS ..........104

FLOVENT HFA.................104

floxin ....................................68

floxuridine ............................20

fluconazole .............................1

fluconazole in dextrose(iso-o) 1

fluconazole in nacl (iso-osm) .1

FLUCONAZOLE IN NACL

(ISO-OSM).........................1

flucytosine ..............................1

fludarabine............................20

fludrocortisone......................69

flunisolide...........................104

fluocinolone..........................61

fluocinolone acetonide oil ....68

fluocinolone and shower cap 61

fluocinonide....................61, 62

fluocinonide-e.......................62

fluor-a-day (with xylitol)....113

fluoritab ..............................113

fluorometholone .................101

fluorouracil .....................20, 56

FLUOROURACIL ...............56

fluoxetine..............................40

fluphenazine decanoate ........40

fluphenazine hcl ...................40

flurandrenolide .....................62

flurbiprofen...........................36

flurbiprofen sodium..............99

flutamide...............................20

fluticasone ....................62, 104

fluvastatin .............................53

fluvoxamine..........................40

FML FORTE ......................101

FML S.O.P. ........................101

fomepizole ............................86

fondaparinux.........................51

FORADIL AEROLIZER ...104

FORTAZ ................................7

FORTAZ IN DEXTROSE 5 %

............................................7

FORTEO ..............................90

fortical...................................75

FOSAMAX PLUS D ............90

foscarnet .................................3

fosinopril...............................47

fosinopril-hydrochlorothiazide

..........................................47

fosphenytoin .........................27

FOSRENOL .........................65

FRAGMIN............................51

FREAMINE HBC 6.9 % ....111

freamine iii 10 % ................111

FROVA.................................30

frovatriptan ...........................30

furosemide ............................47

FUSILEV..............................16

FUZEON ................................3

FYCOMPA...........................27

G

gabapentin.............................27

GABITRIL ...........................27

galantamine...........................31

GAMASTAN S/D ................86

GAMMAGARD LIQUID ....86

GAMMAGARD S-D (IGA < 1

MCG/ML).........................86

GAMMAKED ......................86

GAMMAPLEX ....................86

GAMUNEX-C......................86

ganciclovir sodium .................3

GARDASIL (PF)..................86

GARDASIL 9 (PF)...............86

gatifloxacin ...........................97

GATTEX 30-VIAL ..............79

GATTEX ONE-VIAL ..........79

gauze pad ..............................70

gavilyte-c ..............................79

gavilyte-g ..............................79

gavilyte-h and bisacodyl.......79

gavilyte-n ..............................79

GAZYVA .............................20

gemcitabine...........................20

gemfibrozil ...........................53

generlac.................................79

gengraf ..................................20

GENOTROPIN.....................83

GENOTROPIN MINIQUICK

..........................................83

gentak ...................................97

gentamicin ................10, 59, 97

gentamicin in nacl (iso-osm) 10

GENTAMICIN IN NACL

(ISO-OSM)....................... 10

gentamicin sulfate (ped) (pf) 11

gentamicin sulfate (pf) .........11

GENTAMICIN SULFATE

(PF)................................... 11

GENVOYA ............................ 3

GEODON ............................. 40

gildagia ................................. 94

gildess 1.5/30 (21) ................ 94

gildess 24 fe.......................... 94

GILENYA ............................ 31

GILOTRIF............................ 20

glatopa .................................. 31

GLEEVEC............................ 20

GLEOSTINE........................ 20

glimepiride ...........................71

glipizide................................ 71

glipizide-metformin.............. 71

GLUCAGEN HYPOKIT ..... 71

GLUCAGON EMERGENCY

KIT (HUMAN) ................ 71

GLUMETZA........................ 71

glycopyrrolate....................... 77

glydo..................................... 58

GLYSET............................... 71

GOLYTELY......................... 79

granisetron (pf)..................... 79

granisetron hcl ...................... 79

GRANIX ..............................83

GRASTEK ...........................86

griseofulvin microsize ............ 1

griseofulvin ultramicrosize..... 1

guanidine ..............................40

GYNAZOLE-1.....................93

H

HALAVEN...........................20

halobetasol propionate..........62

HALOG................................62

haloperidol............................40

haloperidol decanoate...........40

haloperidol lactate ................40

HARVONI ............................. 3

HAVRIX (PF) ......................86

heather ..................................92

HECTOROL.........................75

HEMABATE........................97

HEPAGAM B ...................... 86

heparin (porcine) .................. 52

heparin (porcine) in 5 % dex 52

heparin (porcine) in nacl (pf)52

HEPARIN(PORCINE) IN

0.45% NACL....................52

heparin, porcine (pf) .............52

HERCEPTIN ........................20

HETLIOZ .............................40

HEXALEN ...........................20

HIBERIX (PF)......................86

HIZENTRA ..........................86

HUMALOG..........................71

HUMALOG KWIKPEN ......71

HUMALOG MIX 50-50 ......71

HUMALOG MIX 50-50

KWIKPEN........................71

HUMALOG MIX 75-25 ......71

HUMALOG MIX 75-25

KWIKPEN........................71

HUMATROPE .....................83

HUMIRA..............................91

HUMIRA PEN .....................91

HUMIRA PEN CROHN'SUC-HS START ................90

HUMIRA PEN PSORIASISUVEITIS ..........................91

HUMULIN 70/30 .................71

HUMULIN 70/30 KWIKPEN

..........................................71

HUMULIN N .......................71

HUMULIN N KWIKPEN....71

HUMULIN R .......................71

HUMULIN R U-500 (CONC)

KWIKPEN........................71

HUMULIN R U-500

(CONCENTRATED) .......72

hydralazine ...........................47

hydrochlorothiazide..............47

hydrocodone-acetaminophen33

hydrocodone-ibuprofen ........33

hydrocortisone ..........62, 69, 79

hydrocortisone butyrate........62

hydrocortisone butyr-emollient

..........................................62

hydrocortisone valerate ........62

hydrocortisone-acetic acid....68

hydrocortisone-min oil-wht pet

..........................................62

hydromorphone ..............33, 34

HYDROMORPHONE .........33

hydromorphone (pf) .............33

hydroxychloroquine..............11

HYDROXYPROGESTERON

E CAPROATE..................92

hydroxyurea ..........................20

HYPERHEP B S/D...............86

HYPERHEP B S-D

NEONATAL ....................87

HYPERLYTE CR ..............108

HYPERRAB S/D (PF) .........87

HYPERTET S/D (PF) ..........87

HYQVIA ..............................87

I

ibandronate ...........................90

IBRANCE.............................20

ibuprofen...............................36

ibuprofen-oxycodone............34

ibutilide fumarate..................44

ICLUSIG ..............................20

idarubicin ..............................20

ifosfamide .............................20

ifosfamide-mesna .................20

ILARIS (PF) .........................83

ILEVRO ...............................99

imatinib.................................20

IMBRUVICA .......................20

imipenem-cilastatin ..............11

imipramine hcl......................40

imipramine pamoate .............40

imiquimod.............................56

IMOGAM RABIES-HT (PF)

..........................................87

IMOVAX RABIES VACCINE

(PF) ...................................87

INCRELEX ..........................65

indapamide ...........................47

INFANRIX (DTAP) (PF).....87

INFUMORPH P/F ................34

INLYTA ...............................20

INNOPRAN XL ...................47

insulin pen needle .................72

INSULIN PEN NEEDLE .....72

insulin syringe (disp) u-100..72

INTELENCE ..........................3

intralipid .............................112

INTRALIPID......................112

INTRON A ...........................83

introvale................................94

INVANZ...............................11

INVEGA...............................40

INVEGA SUSTENNA ...40, 41

Index 7

INVEGA TRINZA...............41

INVIRASE ............................. 3

INVOKAMET......................72

INVOKANA ........................72

IOPIDINE...........................102

IPOL .....................................87

ipratropium bromide .....67, 104

ipratropium-albuterol .........104

irbesartan ..............................47

irbesartan-hydrochlorothiazide

..........................................47

IRESSA ................................20

irinotecan..............................20

ISENTRESS ...........................3

ISOLYTE S PH 7.4............112

ISOLYTE-P IN 5 %

DEXTROSE ...................112

ISOLYTE-S........................112

isoniazid ...............................11

isosorbide dinitrate ...............54

isosorbide mononitrate .........54

isradipine ..............................47

ISUPREL..............................54

itraconazole ............................1

ivermectin.............................11

IXEMPRA............................ 21

IXIARO (PF)........................ 87

J

JADENU .............................. 65

JAKAFI ................................ 21

jantoven ................................52

JANUMET ........................... 72

JANUMET XR.....................72

JANUVIA.............................72

jencycla................................. 92

JEVTANA............................21

jinteli..................................... 92

jolessa ................................... 94

juleber................................... 94

junel 1.5/30 (21) ...................94

junel 1/20 (21) ......................94

junel fe 1.5/30 (28) ...............94

junel fe 1/20 (28) ..................94

junel fe 24.............................94

JUXTAPID...........................53

K

KABIVEN..........................112

KADCYLA ..........................21

KADIAN ..............................34

Index 8

kaitlib fe................................94

KALETRA .............................3

KALYDECO ......................104

KANUMA ............................75

kariva (28) ............................94

k-effervescent .....................108

kelnor 1/35 (28) ....................94

KEPIVANCE .......................16

KETEK.................................11

ketoconazole.....................1, 59

ketoprofen.............................36

ketorolac ...............................99

KEYTRUDA ........................21

KHEDEZLA.........................41

kimidess (28) ........................95

KINERET.............................91

KINRIX (PF)........................87

kionex ...................................65

kionex (with sorbitol) ...........65

klofensaid ii ..........................36

klor-con ..............................109

klor-con 10 .........................108

klor-con 8 ...........................109

klor-con m10 ......................109

klor-con m15 ......................109

klor-con m20 ......................109

klor-con sprinkle.................109

klor-con/ef ..........................109

KOMBIGLYZE XR .............72

KORLYM.............................75

K-PHOS NO 2....................108

K-PHOS ORIGINAL .........108

k-phos-neutral.....................109

KRYSTEXXA......................89

k-tab....................................109

kurvelo..................................95

KUVAN................................75

KYNAMRO .........................53

L l norgest/e.estradiol-e.estrad.95

labetalol ................................48

LACRISERT ........................99

lactated ringers .............63, 109

lactulose................................79

LAMICTAL ODT ................27

LAMICTAL ODT STARTER

(BLUE).............................27

LAMICTAL ODT STARTER

(GREEN) ..........................27

LAMICTAL ODT STARTER (ORANGE).......................27

LAMICTAL STARTER

(BLUE) KIT .....................27

LAMICTAL STARTER

(GREEN) KIT ..................27

LAMICTAL STARTER

(ORANGE) KIT ...............27

lamivudine ..............................3

lamivudine-zidovudine ...........3

lamotrigine......................27, 28

LANOXIN PEDIATRIC ......50

lansoprazole ..........................81

lantus ....................................72

lantus solostar ......................72

larin 1.5/30 (21) ....................95

larin 1/20 (21) .......................95

larin 24 fe..............................95

larin fe 1.5/30 (28) ................95

larin fe 1/20 (28) ...................95

larissia...................................95

latanoprost ..........................100

LATUDA..............................41

layolis fe ...............................95

LAZANDA...........................34

leflunomide...........................91

LEMTRADA ........................31

LENVIMA............................21

LESCOL XL.........................53

lessina ...................................95

LETAIRIS ..........................104

letrozole ................................21

leucovorin calcium .........16, 17

LEUKERAN.........................21

LEUKINE.............................83

leuprolide..............................21

levalbuterol hcl ...................105

levemir ..................................72

levemir flextouch ..................72

levetiracetam.........................28

LEVETIRACETAM IN NACL

(ISO-OS)...........................28

levobunolol ...........................98

levocarnitine .........................65

levocarnitine (with sugar).....65

levocetirizine ......................102

levofloxacin ....................15, 97

levofloxacin in d5w ..............15

levoleucovorin calcium ........17

LEVOLEUCOVORIN CALCIUM .......................17

levonest (28).........................95

levonorgestrel-ethinyl estrad 95

levonorg-eth estrad triphasic 95

levora-28...............................95

levorphanol tartrate ..............34

levothyroxine........................76

levoxyl..................................76

LEXIVA .................................3

LIALDA ...............................79

LIBRAX (WITH

CLIDINIUM) ...................77

lidocaine ...............................58

lidocaine (pf) in d7.5w ........44

lidocaine (pf) ..................44, 58

LIDOCAINE (PF) ................58

lidocaine hcl .........................58

lidocaine viscous ..................58

lidocaine-epinephrine ...........58

lidocaine-epinephrine (pf) ....58

LIDOCAINE-EPINEPHRINE

BIT ................................... 58

lidocaine-prilocaine.............. 58

lindane .................................. 63

linezolid................................ 11

linezolid-0.9% sodium chloride

..........................................11

LINZESS.............................. 79

LIORESAL........................... 32

liothyronine .......................... 77

lipodox.................................. 21

lipodox 50............................. 21

LIPOFEN ............................. 53

lisinopril ............................... 48

lisinopril-hydrochlorothiazide

..........................................48

lithium carbonate.................. 41

lithium citrate .......................41

LIVALO ............................... 53

LONSURF............................ 21

loperamide............................ 77

lorazepam ............................. 41

lorazepam intensol................ 41

lorcet (hydrocodone) ............ 34

lorcet hd................................ 34

lorcet plus .............................34

lortab 10-325 ........................ 34

lortab 5-325 ..........................34

lortab 7.5-325 .......................34

loryna (28) ............................95

losartan .................................48

losartan-hydrochlorothiazide 48

LOTEMAX ........................101

lovastatin ..............................53

low-ogestrel (28) ..................95

loxapine succinate ................41

ludent fluoride ....................113

LUMIGAN .........................100

LUPRON DEPOT ................21

LUPRON DEPOT (3

MONTH) ..........................21

LUPRON DEPOT (4

MONTH) ..........................21

LUPRON DEPOT (6

MONTH) ..........................21

LUPRON DEPOT-PED .......21

LUPRON DEPOT-PED (3

MONTH) ..........................21

lutera (28) .............................95

LYNPARZA.........................21

LYRICA ...............................28

LYSODREN.........................21

lyza .......................................92

M

magnesium sulfate..............109

magnesium sulfate in water 109

MAKENA ............................92

malathion ..............................63

maprotiline............................41

marlissa.................................95

MARPLAN ..........................41

marten-tab.............................34

MATULANE........................21

matzim la ..............................48

MAXIDEX .........................101

MAXIPIME............................8

meclizine ..............................79

meclofenamate......................36

medroxyprogesterone ...........92

mefenamic acid.....................37

mefloquine............................11

MEFOXIN IN DEXTROSE

(ISO-OSM).........................8

MEGACE ES .......................21

megestrol ..............................22

MEKINIST...........................22

meloxicam ............................37

melphalan hcl .......................22

memantine ............................31

MEMANTINE......................31

MENACTRA (PF)................87

MENEST ..............................92

MENHIBRIX (PF) ...............87

MENOMUNE - A/C/Y/W-135

..........................................87

MENOMUNE - A/C/Y/W-135

(PF) ...................................87

MENTAX .............................59

MENVEO A-C-Y-W-135-DIP

(PF) ...................................87

MEPIVACAINE (PF) ..........58

mercaptopurine .....................22

meropenem ...........................11

MEROPENEM-0.9%

SODIUM CHLORIDE .....11

mesalamine ...........................79

mesalamine with cleansing

wipe ..................................79

mesna....................................17

MESNEX..............................17

MESTINON .........................32

MESTINON TIMESPAN ....32

metadate er............................41

metaproterenol ....................105

metaxall ................................32

metformin .............................72

methadone.............................34

methadone intensol ...............34

methadose .............................34

methamphetamine.................41

methazolamide......................99

methenamine hippurate ........16

methenamine mandelate .......16

methergine ............................97

methimazole .........................70

METHITEST ........................75

methocarbamol .....................32

methotrexate sodium ............22

methotrexate sodium (pf) .....22

METHOXSALEN RAPID ...56

methscopolamine ..................77

methyclothiazide...................48

methyldopahydrochlorothiazide ..........48

methyldopate ........................48

methylergonovine .................97

METHYLERGONOVINE ...97

methylphenidate .............41, 42

methylprednisolone ..............69

Index 9

methylprednisolone acetate ..69

methylprednisolone sodium

succ................................... 69

methyltestosterone................75

metipranolol ......................... 98

metoclopramide hcl ..............79

metolazone ........................... 48

metoprolol succinate ............48

metoprolol ta-hydrochlorothiaz

..........................................48

metoprolol tartrate ................48

metro i.v. .............................. 11

metronidazole ...........11, 57, 93

metronidazole in nacl (iso-os)

..........................................11

mexiletine .............................44

MIACALCIN ....................... 75

miconazole-3 ........................93

microgestin 1.5/30 (21) ........95

microgestin 1/20 (21) ...........95

microgestin fe 1.5/30 (28) ....95

microgestin fe 1/20 (28) .......95

midodrine .............................65

migergot ...............................30

miglitol .................................72

MIGRANAL ........................30

minocycline ....................15, 16

minoxidil ..............................48

mirtazapine ...........................42

misoprostol ...........................81

mitomycin.............................22

mitoxantrone.........................22

M-M-R II (PF)......................87

modafinil ..............................42

moderiba.................................3

moderiba dose pack................3

moexipril ..............................48

moexipril-hydrochlorothiazide

..........................................48

molindone.............................42

mometasone.................. 62, 105

mondoxyne nl.......................16

MONOJECT INSULIN

SAFETY SYRING...........72

mono-linyah .........................95

montelukast ........................105

morgidox ..............................16

morphine......................... 34, 35

MORPHINE .........................35

Index 10

morphine (pf)........................34

morphine concentrate ...........34

MOVANTIK ........................79

MOVIPREP..........................79

MOXEZA.............................97

moxifloxacin.........................15

MOZOBIL............................83

MULTAQ.............................44

multi-vit with fluoride-iron 113

multivitamin with fluoride..113

multi-vitamin with fluoride 113

multi-vitamin with fluoride 113

multivitamins with fluoride 113

mupirocin..............................59

mupirocin calcium................59

MUSTARGEN .....................22

mvc-fluoride .......................113

MYALEPT ...........................75

mycophenolate mofetil .........22

mycophenolate sodium.........22

MYOZYME .........................75

MYRBETRIQ ....................107

myzilra..................................95

N NABI-HB .............................87

nabumetone ..........................37

nadolol ..................................48

nadolol-bendroflumethiazide48

nafcillin.................................13

nafcillin in dextrose iso-osm 13

naftifine ................................59

NAFTIN ...............................59

NAGLAZYME.....................75

nalbuphine ............................37

naloxone ...............................37

naltrexone .............................37

NAMENDA..........................31

NAMENDA TITRATION

PAK ..................................31

NAMENDA XR ...................31

naproxen ...............................37

naproxen sodium ..................37

naratriptan.............................30

NARCAN .............................37

NAROPIN (PF) ....................58

NASONEX.........................105

NATACYN ..........................97

nateglinide ............................72

NATPARA ...........................75

NEBUPENT .........................11

necon 0.5/35 (28)..................95

necon 1/35 (28).....................95

necon 10/11 (28)...................95

needles, insulin disp.,safety ..72

nefazodone............................42

neomycin ..............................11

neomycin-bacitracin-poly-hc

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

neomycin-bacitracinpolymyxin.........................97

neomycin-polymyxin b gu....63

neomycin-polymyxin bdexameth.........................100

neomycin-polymyxingramicidin.........................97

neomycin-polymyxin-hc......68,

100

neo-polycin ...........................97

neo-polycin hc ....................100

neostigmine methylsulfate....32

NEPHRAMINE 5.4 %........112

NESACAINE .......................58

neuac.....................................57

NEULASTA .........................83

NEUPOGEN.........................83

NEUPRO ..............................29

NEUT .................................109

NEVANAC...........................99

nevirapine ...............................3

NEXAVAR...........................22

niacin ....................................53

nicardipine ............................48

NICARDIPINE.....................48

NICOTROL..........................67

NICOTROL NS....................67

nifedical xl ............................48

nifedipine..............................48

nikki (28) ..............................95

NILANDRON ......................22

nilutamide .............................22

nimodipine ............................48

NINLARO ............................22

NIPENT ................................22

nisoldipine ............................48

nitro-bid ................................54

nitrofurantoin ........................16

nitrofurantoin macrocrystal ..16

nitrofurantoin monohyd/mcryst .................................. 16

nitroglycerin ......................... 54

NITROMIST ........................55

NITROSTAT........................ 55

nizatidine ..............................81

NORDITROPIN FLEXPRO 83

noreth-ethinyl estradiol-iron.95

norethindrone (contraceptive)

..........................................92

norethindrone acetate ...........92

norethindrone ac-eth estradiol

.................................... 92, 95

norethindrone-e.estradiol-iron

.......................................... 95

norgestimate-ethinyl estradiol

.......................................... 96

norlyroc ................................92

NORMOSOL-R .................109

NORMOSOL-R PH 7.4 ..... 112

NORPACE CR.....................44

NORTHERA ........................65

nortrel 0.5/35 (28) ................ 96

nortrel 1/35 (21) ................... 96

nortrel 1/35 (28) ................... 96

nortrel 7/7/7 (28) ..................96

nortriptyline..........................42

NORVIR............................. 3, 4

novarel..................................75

NOVOFINE 30 ....................72

NOVOFINE 32 ....................72

NOVOFINE PLUS...............73

novolin 70/30........................73

novolin n...............................73

novolin r ...............................73

novolog .................................73

novolog flexpen ....................73

novolog mix 70-30................73

novolog mix 70-30 flexpen ...73

novolog penfill......................73

NOVOTWIST ......................73

NOXAFIL ..............................1

np thyroid ............................. 77

NPLATE............................... 52

NUCYNTA ..........................37

NUEDEXTA ........................ 31

NULOJIX .............................22

NUPLAZID..........................42

NUTRILIPID .....................112

NUTROPIN AQ...................83

NUTROPIN AQ NUSPIN....83

NUVARING.........................93

NUVIGIL .............................42

nyamyc .................................59

NYMALIZE .........................48

nystatin .........................1, 2, 60

nystatin-triamcinolone..........60

nystop ...................................60

O OCTAGAM..........................87

octreotide acetate............22, 23

ODEFSEY ..............................4

ODOMZO ............................23

OFEV..................................105

ofloxacin...................15, 68, 97

ogestrel (28)..........................96

olanzapine.............................42

olanzapine-fluoxetine ...........42

olopatadine .....................67, 99

OLYSIO .................................4

omega-3 acid ethyl esters .....53

omeprazole ...........................81

OMNARIS..........................105

OMNITROPE.......................84

ONCASPAR.........................23

ondansetron ..........................80

ondansetron hcl.....................80

ondansetron hcl (pf)........79, 80

ONFI.....................................28

ONGLYZA...........................73

OPANA ................................35

OPANA ER ..........................35

OPDIVO...............................23

opium tincture.......................77

OPSUMIT ..........................105

oralone ..................................67

ORAP ...................................42

ORENCIA ............................91

ORENCIA CLICKJECT ......91

ORENITRAM ......................49

ORFADIN ............................65

ORKAMBI .........................105

orsythia .................................96

OSMOPREP.........................80

OTEZLA ..............................91

OTEZLA STARTER............91

OTREXUP (PF) ...................91

oxacillin ................................14

OXACILLIN ........................14

oxacillin in dextrose(iso-osm) ..........................................13

oxaliplatin .............................23

oxandrolone ..........................75

oxaprozin ..............................37

oxcarbazepine .......................28

oxiconazole...........................60

OXISTAT .............................60

OXSORALEN ......................56

oxybutynin chloride............107

oxycodone.............................35

oxycodone-acetaminophen ...35

oxycodone-aspirin ................35

oxymorphone ........................35

OZURDEX .........................101

P

pacerone................................44

paclitaxel...............................23

paliperidone ..........................42

pamidronate ..........................75

PANCREAZE.......................80

PANDEL ..............................62

PANRETIN ..........................56

pantoprazole .........................81

paregoric ...............................77

paricalcitol ............................75

PARICALCITOL .................75

paroex oral rinse ...................67

paromomycin ........................11

paroxetine hcl .......................42

PASER..................................12

PATADAY ...........................99

PAXIL ..................................42

PAZEO .................................99

PCE.........................................9

PEDIARIX (PF) ...................87

PEDVAX HIB (PF) ..............88

peg 3350-electrolytes............80

PEGANONE.........................28

PEGASYS ............................84

PEGASYS PROCLICK........84

peg-electrolyte soln ..............80

PEGINTRON .......................84

PEGINTRON REDIPEN......84

peg-prep ................................80

PEN NEEDLE ......................73

PENICILLIN G POT IN

DEXTROSE .....................14

penicillin g potassium...........14

penicillin g procaine .............14

Index 11

penicillin g sodium ...............14

penicillin v potassium...........14

PENTACEL (PF) .................88

PENTACEL ACTHIB

COMPONENT (PF).........88

PENTAM .............................12

PENTASA............................80

pentoxifylline .......................52

PERIKABIVEN .................112

perindopril erbumine ............49

periogard...............................67

PERJETA ............................. 23

permethrin ............................ 63

perphenazine.........................42

pfizerpen-g ...........................14

phenadoz.............................102

phenelzine.............................42

phenergan ........................... 102

phenobarbital........................ 28

phenytoin.............................. 28

phenytoin sodium ................. 28

phenytoin sodium extended.. 28

philith ................................... 96

PHOSLYRA....................... 109

phospha 250 neutral ...........109

PHOSPHOLINE IODIDE....98

PICATO ...............................56

pilocarpine hcl ................65, 98

pimozide ...............................42

pimtrea (28) ..........................96

pindolol.................................49

pioglitazone ..........................73

pioglitazone-glimepiride ......73

pioglitazone-metformin........73

piperacillin-tazobactam ........14

pirmella.................................96

piroxicam..............................37

PLASMA-LYTE 148 .........112

PLASMA-LYTE A ............112

PLASMA-LYTE-56 IN 5 %

DEXTROSE ...................112

plasmanate..........................112

PLEGRIDY ..........................84

podofilox ..............................56

polycin..................................97

polyethylene glycol 3350 .....80

polymyxin b sulfate..............12

polymyxin b sulf-trimethoprim

..........................................98

Index 12

POMALYST ........................23

portia.....................................96

PORTRAZZA ......................23

potassium acetate................109

potassium bicarb and chloride

........................................109

potassium bicarb-citric acid109

potassium chlorid-d50.45%nacl .......................109

potassium chloride..............110

potassium chloride in 0.9%nacl

........................................109

potassium chloride in 5 % dex

........................................109

potassium chloride in lr-d5.109

potassium chloride-0.45 % nacl

........................................110

potassium chloride-d50.2%nacl .........................110

potassium chloride-d50.3%nacl .........................110

potassium chloride-d50.9%nacl .........................110

potassium citrate.................108

potassium citrate-citric acid108

potassium phosphate m-/dbasic................................110

POTIGA ...............................28

PRADAXA...........................52

pramipexole ..........................29

PRAMOSONE .....................55

pravastatin ............................53

prazosin ................................49

PRED MILD.......................101

PRED-G..............................100

PRED-G S.O.P. ..................100

prednicarbate ........................62

prednisolone .........................69

prednisolone acetate ...........101

prednisolone sodium phosphate

..................................69, 101

prednisone ............................69

prednisone intensol...............69

PREMARIN .........................92

premasol 10 % ....................112

PREMASOL 6 % ...............112

prenatal vitamin oral tablet.113

prevalite ................................53

PREVIDENT 5000 BOOSTER PLUS ................................67

PREVIDENT 5000 DRY

MOUTH ...........................67

PREVIDENT 5000 ENAMEL

PROTECT ........................67

PREVIDENT 5000

SENSITIVE ......................67

previfem................................96

PREZCOBIX ..........................4

PREZISTA .............................4

PRIALT ................................37

PRIFTIN ...............................12

PRIMAQUINE .....................12

primidone..............................28

PRISTIQ ...............................42

PRIVIGEN ...........................88

PROAIR HFA ....................105

PROAIR RESPICLICK......105

probenecid ............................89

procainamide ........................44

prochlorperazine ...................80

prochlorperazine edisylate....80

prochlorperazine maleate......80

PROCRIT .............................84

PROCTOFOAM HC ............80

procto-med hc .......................80

proctosol hc ..........................80

proctozone-hc .......................80

PROCYSBI.........................108

progesterone micronized ......92

PROGLYCEM .....................73

PROGRAF............................23

PROLASTIN-C ....................65

PROLEUKIN .......................84

PROLIA................................90

PROMACTA........................52

promethazine ......................102

promethegan .......................103

propafenone ..........................44

proparacaine .........................99

propranolol ...........................49

propranolol-hydrochlorothiazid

..........................................49

propylthiouracil ....................70

PROQUAD (PF)...................88

PROSOL 20 % ...................112

PROTOPAM CHLORIDE ...63

protriptyline ..........................42

prudoxin ...............................56

PULMICORT.....................105

PULMICORT FLEXHALER

........................................ 105

PULMOZYME...................105

PURIXAN ............................ 23

PYLERA .............................. 81

pyrazinamide ........................ 12

pyridostigmine bromide .......32

Q

QUADRACEL (PF) .............88

quasense ...............................96

quetiapine .............................42

quinapril ...............................49

quinapril-hydrochlorothiazide

..........................................49

quinidine gluconate ........44, 45

quinidine sulfate ...................45

quinine sulfate ......................12

QVAR.................................105

R

RABAVERT (PF) ................88

RAGWITEK.........................88

raloxifene..............................90

ramipril .................................49

RANEXA ............................. 54

ranitidine hcl.........................81

RAPAMUNE .......................23

RASUVO (PF) .....................91

RAVICTI..............................65

REBETOL..............................4

REBIF (WITH ALBUMIN).84

REBIF REBIDOSE ..............84

REBIF TITRATION PACK 84

reclipsen (28)........................96

RECOMBIVAX HB (PF) ....88

regonol..................................32

REGRANEX ........................ 56

relador pak............................58

relador pak plus ....................58

RELENZA DISKHALER ......4

RELISTOR...........................80

RELPAX ..............................30

REMICADE ......................... 80

REMODULIN......................49

RENACIDIN...................... 108

RENAGEL ...........................65

RENVELA ...........................66

repaglinide............................73

repaglinide-metformin..........73

reprexain...............................36

RESCRIPTOR........................4

RESTASIS............................99

RETISERT .........................101

RETROVIR ............................4

REVATIO ..........................105

REVLIMID ..........................23

revonto..................................32

REXULTI.............................42

REYATAZ .............................4

RHEUMATREX ..................23

RHOPHYLAC......................88

ribasphere ...............................4

ribasphere ribapak ..................4

ribavirin ..................................4

RIDAURA............................91

rifabutin ................................12

rifampin ................................12

RIFATER .............................12

riluzole..................................66

rimantadine.............................4

RIMSO-50 ............................12

ringers...........................63, 110

risedronate ......................66, 90

RISPERDAL CONSTA .......43

risperidone ............................43

RITUXAN ............................23

rivastigmine ..........................31

rivastigmine tartrate..............31

rizatriptan..............................30

ropinirole ..............................30

ropivacaine (pf) ....................58

rosadan..................................57

rosuvastatin...........................53

ROTARIX ............................88

ROTATEQ VACCINE.........88

roweepra ...............................28

ROZEREM...........................43

S SABRIL................................28

SAIZEN................................84

SAIZEN CLICK.EASY .......84

salsalate ................................37

SAMSCA..............................75

SANCUSO ...........................80

SANDIMMUNE ..................23

SANDOSTATIN LAR

DEPOT .............................23

SANTYL ..............................63

SAPHRIS (BLACK CHERRY).........................43

SAVELLA ............................91

selegiline hcl .........................30

selenium sulfide ....................55

SELZENTRY .........................4

SENSIPAR ...........................75

SEREVENT DISKUS ........105

SEROQUEL XR...................43

SEROSTIM ..........................84

sertraline ...............................43

setlakin..................................96

sf 68

sf 5000 plus...........................68

sharobel.................................92

SIGNIFOR............................23

SIGNIFOR LAR...................23

sildenafil .............................105

silver sulfadiazine .................55

SIMBRINZA ......................100

SIMPONI..............................91

SIMPONI ARIA ...................91

SIMULECT ..........................23

simvastatin............................53

sirolimus ...............................23

SIRTURO .............................12

SIVEXTRO ..........................12

SKLICE ................................63

SMOFLIPID .......................112

sodium acetate ....................110

sodium benzoate-sod

phenylacet.........................66

sodium bicarbonate.............110

sodium chloride ............66, 111

sodium chloride 0.45 %......110

sodium chloride 0.9 %..........66

sodium chloride 3 %...........110

sodium chloride 5 %...........111

sodium citrate-citric acid ....108

sodium fluoride...................113

sodium lactate .....................111

sodium phenylbutyrate .........66

sodium phosphate ...............111

sodium polystyrene (sorb free)

..........................................66

sodium polystyrene sulfonate

..........................................66

SODIUM POLYSTYRENE

SULFONATE...................66

SOLIRIS ...............................66

Index 13

SOLTAMOX........................24

SOLU-CORTEF...................70

SOLU-CORTEF (PF)...........69

SOLU-MEDROL ................. 70

SOLU-MEDROL (PF) .........70

SOMATULINE DEPOT ......24

SOMAVERT........................76

SORBITOL ..........................63

sorine ....................................45

sotalol ...................................45

sotalol af ...............................45

SOVALDI .............................. 4

SPIRIVA RESPIMAT ....... 106

SPIRIVA WITH

HANDIHALER.............. 106

spironolactone ......................49

spironolacton-hydrochlorothiaz

..........................................49

SPORANOX ..........................2

sprintec (28)..........................96

SPRITAM.............................29

SPRYCEL ............................ 24

sps (with sorbitol).................66

sronyx ...................................96

ssd......................................... 55

stavudine................................. 4

STELARA............................55

STIMATE.............................76

STIOLTO RESPIMAT ...... 106

STIVARGA..........................24

STRATTERA.......................43

STRENSIQ...........................76

STREPTOMYCIN ...............12

STRIBILD..............................4

STRIVERDI RESPIMAT ..106

SUBOXONE ........................ 37

SUBSYS...............................36

sucralfate ..............................81

sulfacetamide sodium.........102

sulfacetamide sodium (acne) 59

sulfacetamide-prednisolone 101

sulfadiazine...........................15

sulfamethoxazole-trimethoprim

.......................................... 15

SULFAMYLON................... 59

sulfasalazine ...................80, 81

sulfatrim ...............................15

sulindac................................. 37

sumatriptan ...........................30

Index 14

sumatriptan succinate ...........30

SUPPRELIN LA ..................24

SUPRAX ................................8

SUPREP BOWEL PREP KIT

..........................................81

SURMONTIL.......................43

SUSTIVA ...........................4, 5

SUTENT...............................24

syeda.....................................96

SYLATRON.........................85

SYLVANT ...........................24

SYMBICORT.....................106

SYMLINPEN 120 ................73

SYMLINPEN 60 ..................73

SYNAGIS...............................5

SYNAREL............................76

SYNERCID ..........................12

SYNRIBO ............................24

SYPRINE .............................66

T

TABLOID ............................24

TACLONEX ........................55

tacrolimus .......................24, 56

TAFINLAR ..........................24

TAGRISSO ..........................24

TAMIFLU ..............................5

tamoxifen..............................24

tamsulosin...........................108

TARCEVA ...........................24

TARGRETIN .......................24

tarina fe 1/20 (28) .................96

TASIGNA ............................24

TAZICEF................................8

TAZORAC ...........................57

taztia xt .................................49

TECENTRIQ........................24

TECFIDERA ........................32

TECHNIVIE...........................5

TEFLARO ..............................8

TEGRETOL XR...................29

TEKTURNA ........................49

TEKTURNA HCT ...............49

telmisartan ............................49

telmisartan-amlodipine.........49

telmisartan-hydrochlorothiazid

..........................................49

temazepam............................43

TEMODAR ..........................24

tencon ...................................36

TENIVAC (PF) ....................88

terazosin................................49

terbinafine hcl .........................2

terbutaline ...........................106

terconazole............................93

TESTIM................................76

TESTOPEL...........................76

testosterone ...........................76

TESTOSTERONE................76

testosterone cypionate .......... 76

testosterone enanthate...........76

TESTRED.............................76

TETANUS,DIPHTHERIA

TOX PED(PF) ..................88

TETANUS-DIPHTHERIA

TOXOIDS-TD..................88

tetrabenazine.........................32

tetracycline ........................... 16

THALOMID.........................24

THAM ................................112

theophylline ........................106

THERACYS .........................88

thermazene............................55

thioridazine ...........................43

thiotepa .................................24

thiothixene ............................43

THROMBATE III ................52

THYMOGLOBULIN ...........89

tiagabine ...............................29

TICE BCG ............................89

ticlopidine .............................52

TIKOSYN.............................45

timolol maleate ...............49, 98

TIMOPTIC ...........................98

TIMOPTIC OCUDOSE (PF)

..........................................98

tinidazole ..............................12

tis-u-sol pentalyte .................63

TIVICAY................................5

tizanidine ..............................32

TOBI PODHALER ..............12

TOBRADEX ......................100

TOBRADEX ST.................100

tobramycin ............................98

tobramycin in 0.225 % nacl..12

tobramycin sulfate ................12

tobramycin-dexamethasone 100

tolcapone...............................30

tolmetin.................................37

tolterodine........................... 107

topiramate............................. 29

toposar ..................................24

topotecan .............................. 24

TORISEL ............................. 24

torsemide .............................. 49

TOUJEO SOLOSTAR ......... 73

TOVIAZ ............................. 107

TRACLEER .......................106

tramadol................................ 37

tramadol-acetaminophen ......37

trandolapril ........................... 49

trandolapril-verapamil.......... 49

tranexamic acid ..............52, 93

TRANSDERM-SCOP..........81

tranylcypromine ...................43

travasol 10 %......................112

TRAVATAN Z .................. 100

travoprost (benzalkonium) .100

trazodone ..............................43

TREANDA...........................24

TRECATOR.........................12

TRELSTAR..........................25

TRELSTAR DEPOT............24

TRELSTAR LA ...................25

tretinoin ................................57

tretinoin (chemotherapy) ......25

tretinoin microspheres ..........57

TRETIN-X ........................... 57

TREXALL............................25

TREXIMET..........................30

triamcinolone acetonide 62, 63,

68, 70

triamterene-hydrochlorothiazid

.......................................... 50

trianex...................................63

triazolam...............................43

triderm ..................................63

tri-estarylla ...........................96

trifluoperazine ......................43

trifluridine.............................98

TRIGLIDE ........................... 53

trihexyphenidyl..................... 30

tri-legest fe............................96

tri-linyah ............................... 96

tri-lo-estarylla ....................... 96

tri-lo-marzia..........................96

tri-lo-sprintec........................96

trilyte with flavor packets.....81

trimethoprim.........................16

trimipramine .........................43

trinessa lo..............................96

TRINTELLIX.......................43

tri-previfem (28) ...................96

TRISENOX ..........................25

tri-sprintec (28).....................96

TRIUMEQ..............................5

tri-vit with fluoride and iron

........................................113

tri-vitamin with fluoride .....113

trivora (28)............................96

TROPHAMINE 10 % ........113

trospium..............................107

TRUMENBA........................89

TRUVADA ............................5

TUDORZA PRESSAIR .....106

TWINRIX (PF).....................89

TYBOST ................................5

TYGACIL ............................12

TYKERB ..............................25

TYPHIM VI .........................89

TYSABRI.............................32

TYVASO............................106

TYVASO INSTITUTIONAL

START KIT....................106

TYVASO REFILL KIT......106

TYVASO STARTER KIT .107

TYZEKA ................................5

TYZINE................................68

U

ULORIC ...............................89

unithroid ...............................77

UPTRAVI.............................50

ursodiol.................................81

UVADEX .............................56

V

VAGIFEM............................92

valacyclovir ............................5

VALCHLOR ........................56

valganciclovir .........................5

valproate sodium ..................29

valproic acid .........................29

valproic acid (as sodium salt)

..........................................29

valsartan................................50

valsartan-hydrochlorothiazide

..........................................50

VALSTAR............................25

vancomycin ..........................16

VANCOMYCIN ..................16

VANCOMYCIN IN 0.9% SODIUM CL ....................16

VANCOMYCIN IN

DEXTROSE 5 %..............16

vandazole ..............................93

VAQTA (PF) ........................89

VARIVAX (PF)....................89

VARIZIG..............................89

VASCEPA............................54

vasopressin ...........................76

VECAMYL ..........................54

VECTIBIX ...........................25

VELCADE ...........................25

veletri....................................50

velivet triphasic regimen (28)

..........................................96

VELTASSA..........................66

VENCLEXTA ......................25

VENCLEXTA STARTING

PACK ...............................25

venlafaxine ...........................43

VENTAVIS ........................107

VENTOLIN HFA ...............107

VERAMYST ......................107

verapamil ..............................50

VERSACLOZ.......................43

VESICARE.........................107

vestura (28) ...........................96

VEXOL...............................101

VGO 20 ................................73

VGO 30 ................................73

VGO 40 ................................73

VICTOZA 2-PAK ................74

VICTOZA 3-PAK ................74

VIDEX 2 GRAM PEDIATRIC

............................................5

VIDEX 4 GRAM PEDIATRIC

............................................5

VIEKIRA PAK.......................5

VIEKIRA XR .........................5

vienva ...................................96

VIGAMOX...........................98

VIIBRYD .......................43, 44

VIMPAT...............................29

vinblastine.............................25

vincasar pfs ...........................25

vincristine .............................25

vinorelbine............................25

viorele (28) ...........................96

VIRACEPT.............................5

Index 15

VIRAMUNE XR....................5

VIRAZOLE............................5

VIREAD.................................5

virt-phos 250 neutral ..........111

vitamins a,c,d and fluoride .113

VITEKTA...............................5

VIVITROL ...........................37

VOLTAREN GEL................37

voriconazole ...........................2

VOTRIENT..........................25

VPRIV..................................76

VRAYLAR...........................44

VYTORIN 10-10..................54

VYTORIN 10-20..................54

VYTORIN 10-40..................54

VYTORIN 10-80..................54

W warfarin ................................52

water for irrigation, sterile....66

WELCHOL ..........................54

wera (28) ..............................96

wymzya fe ............................96

X

XALKORI............................25

XARELTO ...........................52

XELJANZ ............................91

XELJANZ XR......................91

XENAZINE..........................32

XGEVA................................17

XIFAXAN............................12

XIGDUO XR........................74

XOLAIR.............................107

XOPENEX HFA ................107

Index 16

XTANDI...............................25

XYLOCAINE (CARDIAC)

(PF)...................................45

xylocaine dental-epinephrine58

XYLOCAINEMPF/EPINEPHRINE .......58

xylon 10................................36

XYREM................................44

Y

YERVOY .............................25

YF-VAX (PF).......................89

YONDELIS ..........................25

Z

zafirlukast ...........................107

zaleplon ................................44

ZALTRAP ............................25

zamicet..................................36

ZANOSAR ...........................25

zarah .....................................96

ZARXIO...............................85

ZAVESCA............................ 76

ZELAPAR ............................30

ZELBORAF .........................26

ZEMAIRA............................66

ZEMPLAR ...........................76

zenchent (28) ........................96

zenchent fe............................97

ZENPEP ...............................81

ZEPATIER .............................5

ZERBAXA .............................8

ZETIA ..................................54

ZIAGEN .................................5

zidovudine ..............................6

ZIOPTAN (PF) ...................100

ziprasidone hcl......................44

ZIRGAN ...............................98

ZMAX ....................................9

ZOLADEX ...........................26

zoledronic acid......................76

zoledronic acid-mannitol-water

..........................................66

ZOLEDRONIC ACIDMANNITOL-WATER .....66

ZOLINZA.............................26

zolmitriptan.....................30, 31

ZOMIG .................................31

zonisamide............................29

ZORBTIVE ..........................85

ZORTRESS ..........................26

ZOSTAVAX (PF) ................89

ZOSYN IN DEXTROSE (ISOOSM) ................................14

zovia 1/35e (28) ....................97

zovia 1/50e (28) ....................97

ZOVIRAX ............................60

ZURAMPIC .........................90

ZYDELIG.............................26

ZYFLO ...............................107

ZYFLO CR .........................107

ZYKADIA ............................26

ZYLET ...............................100

ZYPREXA RELPREVV ......44

ZYTIGA ...............................26

ZYVOX ..........................12, 13

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Macomb

Washtenaw Wayne

This formulary was updated on St. Joseph Branch Hillsdale Lenawee Monroe 12/01/2016. For more recent information or other questions, please contact BCN Advantage Customer Service at 1-800-450-3680 or, for TTY users, 711, 8 a.m. to 8 p.m. Monday through Friday, with weekend hours Oct. 1 through Feb. 14, or visit www.bcbsm.com/medicare. The formulary, pharmacy network, and provider network may change at any time. You will receive notice when necessary. Medicare Customer Service: 1-800-MEDICARE (TTY/TDD 1-877-486-2048) 24 hours a day seven days a week Blue Care Network Corporate Offices P.O. Box 5043 Southfield, MI 48086-5043 R063417 DB 13991 DEC 16

H5883_C_2016Formulary CMS Accepted 090815