National Drug List. Drug list Four (4) Tier Drug Plan

National Drug List Drug list — Four (4) Tier Drug Plan Anthem Blue Cross and Blue Shield (Anthem) prescription drug beneﬁts include medications on th...

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National Drug List Drug list — Four (4) Tier Drug Plan

Anthem Blue Cross and Blue Shield (Anthem) prescription drug beneﬁts include medications on the Anthem National Drug List. Your coverage has limitations and exclusions. For example, drugs used for cosmetic purposes usually are not covered. Always refer to your Certiﬁcate or Evidence of Coverage for details about what’s covered and what’s not. Then if you have additional questions, call Customer Service at the number on your member ID card.

39525MUMENABS

Anthem Blue Cross and Blue Shield Drug List Your prescription drug beneﬁt includes coverage for medications that you’ll ﬁnd on the Anthem National Drug List. You can often ﬁnd more savings when your doctor prescribes medicine on our National Drug List. Here are some commonly asked questions and answers about how the National Drug List works with your prescription drug plan.

Clinical considerations.

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Cost of the drug in comparison to other drugs used for the same type of treatment.

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Availability of over-the-counter options.

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Q. What are “clinically equivalent” medications? How does this affect my drug coverage? A. When drugs are compared in studies, some drugs are found to be just as effective as others. When one drug works just as well as another for the same purpose, they are said to be “clinically equivalent.” Part of the P&T process is to review the most current studies to see if multiple drugs used to treat a disease or a condition have the same effect on a patient. When this is the case, the review team may suggest that we cover only the lower-cost drug. (This helps keep the overall cost of health care as low as possible). This is also why your speciﬁc prescription drug plan may not cover some drugs (indicated by a CE symbol next to the drug name) that have “clinically equivalent” options.

Q. What is a Drug List? A. The Anthem National Drug List, also called a formulary, has drugs on it that are approved by the U.S. Food and Drug Administration (FDA). This includes brand-name and generic drugs, reviewed and recommended for their quality and for how well they work. The review is done by the National Pharmacy and Therapeutics (P&T) Process. The P&T process involves an independent group of practicing doctors and pharmacists in charge of the research and decisions surrounding our drug list. This group meets regularly to review new and existing drugs. They choose the top drugs for our list — based on their safety, how they work and their value. Drugs on our list are reviewed from time to time. Sometimes this results Q. Is this list a complete listing of all covered drugs under in drugs being added or removed. So now and then, it’s a the Anthem National Drug List? good idea to check the status of any drugs you may be A. Yes, this is a complete listing of all covered drugs under taking. You can see the list by going to anthem.com. the Anthem National Drug List. Also, we will always try to notify you of any changes to the formulary that impact you. Preventive care drugs: We cover preventive care drugs with zero cost share in compliance with the Affordable Care Q. How do we determine the tier of a drug? Act (ACA). A. Medications on the Anthem National Drug List are grouped into tiers. Drugs on the lowest tier have the lowest cost share, which is what you pay. Drugs on the highest tier cost you more. Several factors determine what tier a drug is placed in, including:

For more information about your drug plan, you can do the following: Go to anthem.com

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Call Customer Service at the number on your ID card

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Speech and hearing impaired (TDD/TTY users) should call 1-800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m. ET

}

Tier deﬁnitions Tier 1 drugs have the lowest cost share. These drugs offer the greatest value compared to others that treat the same conditions. Tier 2 drugs have a medium cost share. These may be preferred drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs. Tier 2 drugs have a higher cost share than Tier 1. Tier 3 drugs have a higher cost share. They may cost more than others used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA. Tier 3 drugs have a higher cost share than Tier 2. Tier 4 drugs have the highest cost share. They may cost more than others used to treat the same condition. Tier 4 may also include drugs that were recently approved by the FDA or drugs that are used to treat complex, chronic conditions and may need special handling. Member cost share amounts for certain abuse-deterrent opioid analgesics may be lower in the state of Maine due to state laws. For additional information, please call the Customer Service number on your ID card.

Anthem National Formulary Four-Tier

Table of Contents

ANALGESICS ........................................................................................................................................................................................................................................................................................................................... 6 ANESTHETICS .................................................................................................................................................................................................................................................................................................................... 11 ANTIALLERGY .................................................................................................................................................................................................................................................................................................................. 14 ANTIARTHRITICS ......................................................................................................................................................................................................................................................................................................... 14 ANTIASTHMATICS ...................................................................................................................................................................................................................................................................................................... 17 ANTIBIOTICS ....................................................................................................................................................................................................................................................................................................................... 19 ANTICOAGULANTS .................................................................................................................................................................................................................................................................................................... 30 ANTIDOTES ............................................................................................................................................................................................................................................................................................................................ 32 ANTIFUNGALS ................................................................................................................................................................................................................................................................................................................... 32 ANTIHISTAMINE AND DECONGESTANT COMBINATION ............................................................................................................................................................................... 34 ANTIHISTAMINES ........................................................................................................................................................................................................................................................................................................ 34 ANTIHYPERGLYCEMICS .................................................................................................................................................................................................................................................................................. 35 ANTIINFECTIVES .......................................................................................................................................................................................................................................................................................................... 39 ANTIINFECTIVES/MISCELLANEOUS .............................................................................................................................................................................................................................................. 38 ANTINEOPLASTICS .................................................................................................................................................................................................................................................................................................... 39 ANTI-OBESITY DRUGS .......................................................................................................................................................................................................................................................................................... 45 ANTIPARKINSON DRUGS .................................................................................................................................................................................................................................................................................. 45 ANTIPLATELET DRUGS ...................................................................................................................................................................................................................................................................................... 46 ANTIVIRALS .......................................................................................................................................................................................................................................................................................................................... 47 AUTONOMIC DRUGS ................................................................................................................................................................................................................................................................................................ 50 BIOLOGICALS .................................................................................................................................................................................................................................................................................................................... 52 BLOOD ........................................................................................................................................................................................................................................................................................................................................... 60 CARDIAC DRUGS ........................................................................................................................................................................................................................................................................................................... 63 CARDIOVASCULAR ................................................................................................................................................................................................................................................................................................... 67 CNS DRUGS ............................................................................................................................................................................................................................................................................................................................. 74 COLONY STIMULATING FACTORS ................................................................................................................................................................................................................................................... 78 CONTRACEPTIVES ..................................................................................................................................................................................................................................................................................................... 79 COUGH/COLD PREPARATIONS ............................................................................................................................................................................................................................................................... 83 DIAGNOSTIC ......................................................................................................................................................................................................................................................................................................................... 84 DIURETICS .............................................................................................................................................................................................................................................................................................................................. 87 EENT PREPS ........................................................................................................................................................................................................................................................................................................................... 88 ELECT/CALORIC/H2O ............................................................................................................................................................................................................................................................................................ 92 GASTROINTESTINAL ........................................................................................................................................................................................................................................................................................... 102 HORMONES ......................................................................................................................................................................................................................................................................................................................... 108 IMMUNOSUPPRESANT ...................................................................................................................................................................................................................................................................................... 114 MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ......................................................................................................................................................... 115 MUSCLE RELAXANTS ......................................................................................................................................................................................................................................................................................... 118 PRE-NATAL VITAMINS ...................................................................................................................................................................................................................................................................................... 119 PSYCHOTHERAPEUTIC DRUGS .......................................................................................................................................................................................................................................................... 123 SEDATIVE/HYPNOTICS ..................................................................................................................................................................................................................................................................................... 129 SKIN PREPS ......................................................................................................................................................................................................................................................................................................................... 130 SMOKING DETERRENTS ................................................................................................................................................................................................................................................................................ 140 THYROID PREPS .......................................................................................................................................................................................................................................................................................................... 141 UNCLASSIFIED DRUG PRODUCTS ................................................................................................................................................................................................................................................... 141 VITAMINS .............................................................................................................................................................................................................................................................................................................................. 148

4

5

Drug Name Anthem National Formulary Four-Tier

Drug Name

Tier

Notes

ANALGESICS

Tier

BUPRENEX INJECTION SOLUTION

3

buprenorphine hcl injection solution

1

buprenorphine hcl injection syringe

1

butalbital compound w/codeine oral capsule

1

butalbital-acetaminop-caf-co d oral capsule

1

butalbital-acetaminophen oral tablet

1 1

Notes

QL

ABSTRAL SUBLINGUAL TABLET

3

acetaminophen-codeine oral solution

1

butalbital-acetaminophen-caf f oral capsule

acetaminophen-codeine oral tablet 300-15 mg

1

butalbital-acetaminophen-caf f oral tablet

1

acetaminophen-codeine oral tablet 300-30 mg, 300-60 mg

1

butalbital-aspirin-caffeine oral capsule

1

butorphanol tartrate injection solution

1

butorphanol tartrate nasal spray,non-aerosol

1

QL

BUTRANS TRANSDERMAL PATCH WEEKLY

3

QL

PA; QL

QL

ACTIQ BUCCAL LOZENGE ON A HANDLE

3

ALFENTANIL INJECTION SOLUTION

3

ALLZITAL ORAL TABLET

3

almotriptan malate oral tablet

1

QL

CAFERGOT ORAL TABLET

3

ALSUMA SUBCUTANEOUS PEN INJECTOR

3

ST; QL

CAMBIA ORAL POWDER IN PACKET

3

AMERGE ORAL TABLET

capacet oral capsule

1

3

ascomp with codeine oral capsule

3

1

CAPITAL WITH CODEINE ORAL SUSPENSION

ASTRAMORPH-PF INJECTION SOLUTION

3

carisoprodol-asa-codeine oral tablet

1

AXERT ORAL TABLET

3

ST; QL

choline,magnesium salicylate oral liquid

1

BELBUCA BUCCAL FILM

3

PA; QL

clonidine (pf) epidural solution

1

belladonna alkaloids-opium rectal suppository

1

codeine sulfate oral tablet

1

belladonna-opium rectal suppository

1

codeine-butalbital-asa-caff oral capsule

1

BUPAP ORAL TABLET

3

CONZIP ORAL CAPSULE,ER BIPHASE 24 HR 17-83

3

PA; QL

ST; QL

QL

QL

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 6

Drug Name

Tier

CONZIP ORAL CAPSULE,ER BIPHASE 24 HR 25-75

3

D.H.E.45 INJECTION SOLUTION

3

Notes

Drug Name

QL

ELMIRON ORAL CAPSULE

3

EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL

3

PA; QL

endocet oral tablet

1

QL

endodan oral tablet

1

ERGOMAR SUBLINGUAL TABLET

3

ESGIC ORAL CAPSULE

3

ESGIC ORAL TABLET

3

EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR

3

fentanyl citrate (pf) injection solution

1

fentanyl citrate (pf) intravenous syringe

1

fentanyl citrate buccal lozenge on a handle

1

PA; QL

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

1

QL

FENTANYL TRANSDERMAL PATCH 72 HOUR 37.5 MCG/HOUR, 62.5 MCG/HOUR, 87.5 MCG/HOUR

3

QL

3

PA; QL

PA

Tier

Notes

DEMEROL (PF) INJECTION SOLUTION 100 MG/2 ML, 25 MG/0.5 ML, 50 MG/ML, 75 MG/1.5 ML

3

demerol (pf) injection solution 100 mg/ml

1

DEMEROL (PF) INJECTION SYRINGE

3

DEMEROL INJECTION SOLUTION

3

DEMEROL ORAL TABLET

3

diclofenac potassium oral tablet

1

diflunisal oral tablet

1

dihydrocode-acetaminophencaff oral capsule

1

dihydrocodeine-aspirin-caff oral capsule

1

dihydroergotamine injection solution

1

PA

dihydroergotamine nasal spray,non-aerosol

1

QL

DILAUDID ORAL LIQUID

3

DILAUDID ORAL TABLET

3

FENTORA BUCCAL TABLET, EFFERVESCENT

DILAUDID-HP (PF) INJECTION SOLUTION

3

FIORICET ORAL CAPSULE

3

diskets oral tablet,soluble

1

QL

3

DOLOPHINE ORAL TABLET

3

QL

FIORICET WITH CODEINE ORAL CAPSULE

DURACLON (PF) EPIDURAL SOLUTION

3

FIORINAL ORAL CAPSULE

3

DURAGESIC TRANSDERMAL PATCH 72 HOUR

FIORINAL-CODEINE #3 ORAL CAPSULE

3

3

FROVA ORAL TABLET

3

ST; QL

duramorph (pf) injection solution

frovatriptan oral tablet

1

QL

1

QL

ST; QL

ST; QL

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 7

Drug Name HYCET ORAL SOLUTION hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml), 2.5-167 mg/5 ml, 5-163 mg/7.5ml(7.5ml)

Tier 3

1

Notes

Drug Name

QL

QL

Tier

Notes

IMITREX NASAL SPRAY,NON-AEROSOL

3

ST; QL

IMITREX ORAL TABLET

3

ST; QL

IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE

3

ST; QL

IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR

3

ST; QL

IMITREX SUBCUTANEOUS SOLUTION

3

ST; QL

HYDROCODONE-ACET AMINOPHEN ORAL SOLUTION 7.5-325 MG/15 ML

3

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

1

hydrocodone-acetaminophen oral tablet 2.5-325 mg

1

INFUMORPH P/F INJECTION SOLUTION

3

hydrocodone-ibuprofen oral tablet 10-200 mg, 7.5-200 mg

1

IONSYS TRANSDERMAL SYSTEM,TRANSDERMA L PCA

3

hydrocodone-ibuprofen oral tablet 5-200 mg

1

isometh-dichloral-acetamino phn oral capsule

1

hydromorphone (pf) injection solution

1

isomethepten-caf-acetaminop hen oral tablet

1

hydromorphone injection solution

1

3

ST; QL

HYDROMORPHONE INJECTION SYRINGE 0.5 MG/0.5 ML

KADIAN ORAL CAPSULE,EXTEND.REL EASE PELLETS

3

ketorolac injection cartridge

1

QL

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

ketorolac injection solution

1

QL

1

ketorolac injection syringe

1

QL

hydromorphone oral liquid

1

ketorolac intramuscular solution

1

QL

hydromorphone oral tablet

1

1

QL

hydromorphone oral tablet extended release 24 hr

ketorolac intramuscular syringe

1

ketorolac oral tablet

1

QL

hydromorphone rectal suppository

1

LAZANDA NASAL SPRAY,NON-AEROSOL

3

PA; QL

HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR

3

levorphanol tartrate oral tablet

1

IBUDONE ORAL TABLET 10-200 MG

1

QL

3

lorcet (hydrocodone) oral tablet lorcet hd oral tablet

1

QL

IBUDONE ORAL TABLET 5-200 MG

3

lorcet plus oral tablet

1

QL

lortab 10-325 oral tablet

1

QL

ibuprofen-oxycodone oral tablet

1

lortab 5-325 oral tablet

1

QL

QL

QL

QL

QL

PA; QL

QL QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 8

Drug Name

Tier

Notes

Drug Name MORPHINE INTRAMUSCULAR PEN INJECTOR

3

morphine intravenous cartridge 10 mg/ml, 15 mg/ml, 2 mg/ml, 4 mg/ml

1

MORPHINE INTRAVENOUS CARTRIDGE 8 MG/ML

3

morphine intravenous pt controlled analgesia syring

1

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

1

QL

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

3

QL

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

3

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

1

morphine oral capsule, er multiphase 24 hr

1

QL

morphine oral capsule,extend.release pellets

1

QL

morphine oral solution 10 mg/5 ml

1

morphine oral solution 20 mg/5 ml (4 mg/ml)

1

QL

morphine oral tablet

1

QL

morphine oral tablet extended release

1

QL

morphine rectal suppository 10 mg, 30 mg, 5 mg

1

morphine rectal suppository 20 mg

1

QL

MS CONTIN ORAL TABLET EXTENDED RELEASE

3

QL

nalbuphine injection solution

1

naratriptan oral tablet

1

lortab 7.5-325 oral tablet

1

QL

LORTAB ELIXIR ORAL SOLUTION

3

QL

margesic oral capsule

1

marten-tab oral tablet

1

MAXALT ORAL TABLET

3

QL

MAXALT-MLT ORAL TABLET,DISINTEGRATI NG

3

mefenamic acid oral capsule

1

meperidine (pf) injection solution

1

meperidine injection cartridge

1

meperidine oral solution

1

meperidine oral tablet

1

methadone injection solution

1

QL

methadone intensol oral concentrate

1

QL

methadone oral concentrate

1

QL

methadone oral solution

1

QL

methadone oral tablet

1

QL

methadone oral tablet,soluble

1

QL

methadose oral concentrate

1

QL

methadose oral tablet,soluble

1

QL

migergot rectal suppository

1

MIGRANAL NASAL SPRAY,NON-AEROSOL

3

MIGRANOW KIT,GEL AND TABLET

3

morphine (pf) injection solution

1

morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml

1

morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml

1

morphine concentrate oral solution

1

morphine injection solution

1

morphine injection syringe

1

QL

QL

QL QL

Tier

Notes

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 9

Drug Name

Tier

nodolor oral capsule

1

NORCO ORAL TABLET

3

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR

3

NUCYNTA ORAL TABLET

3

OFIRMEV INTRAVENOUS SOLUTION

3

Notes

Drug Name

4

PA

QL

PRIALT INTRATHECAL SOLUTION

3

QL

ST; QL

PRIMLEV ORAL TABLET PRODRIN ORAL TABLET

3

RELPAX ORAL TABLET

2

reprexain oral tablet 10-200 mg, 2.5-200 mg

1

reprexain oral tablet 5-200 mg

1

RIMSO-50 INTRAVESICAL SOLUTION

3

rizatriptan oral tablet

1

QL

rizatriptan oral tablet,disintegrating

1

QL

ROXICODONE ORAL TABLET

3

QL

Tier

Notes

QL

QL

ONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED

3

OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

3

OPANA INJECTION SOLUTION

3

OPANA ORAL TABLET

3

OXAYDO ORAL TABLET, ORAL ONLY

3

SPRIX NASAL SPRAY,NON-AEROSOL

3

oxycodone oral capsule

1

oxycodone oral concentrate

1

SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL

3

oxycodone oral solution

1

sufenta intravenous solution

1

oxycodone oral tablet

1

SUFENTANIL CITRATE INTRAVENOUS SOLUTION

3

sumatriptan nasal spray,non-aerosol

1

QL

1

QL

QL

ST; QL

QL

PA; QL

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

3

oxycodone-acetaminophen oral tablet

1

QL

oxycodone-aspirin oral tablet

1

QL

sumatriptan succinate oral tablet

1

QL

QL

sumatriptan succinate subcutaneous cartridge

1

QL

QL

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

2

oxymorphone oral tablet

1

QL

sumatriptan succinate subcutaneous pen injector

oxymorphone oral tablet extended release 12 hr

1

QL

sumatriptan succinate subcutaneous solution

1

QL

pentazocine-naloxone oral tablet

1

sumatriptan succinate subcutaneous syringe

1

QL

PERCOCET ORAL TABLET

3

3

ST; QL

PONSTEL ORAL CAPSULE

3

SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR SYNALGOS-DC ORAL CAPSULE

3

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 10

Drug Name

Tier

Notes

TALWIN INJECTION SOLUTION

3

tencon oral tablet

1

TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 17-83

3

TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 25-75

3

QL

tramadol oral tablet

1

QL

tramadol oral tablet extended release 24 hr

1

QL

tramadol oral tablet, er multiphase 24 hr

1

QL

tramadol-acetaminophen oral tablet

1

QL

TREXIMET ORAL TABLET

3

ST; QL

TREZIX ORAL CAPSULE

3

TYLENOL-CODEINE #3 ORAL TABLET

Drug Name

Tier

Notes

XODOL 5/300 ORAL TABLET

3

QL

XODOL 7.5/300 ORAL TABLET

3

QL

XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 12HR TMPRR

3

xylon 10 oral tablet

1

zamicet oral solution

1

zebutal oral capsule

1

ZEMBRACE SYMTOUCH SUBCUTANEOUS PEN INJECTOR

3

ST; QL

ZIPSOR ORAL CAPSULE

3

ST; CE

ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR

3

PA; QL

QL

zolmitriptan oral tablet

1

QL

3

QL

zolmitriptan oral tablet,disintegrating

1

QL

TYLENOL-CODEINE #4 ORAL TABLET

3

QL

ZOMIG NASAL SPRAY,NON-AEROSOL

3

ST; QL

ULTIVA INTRAVENOUS RECON SOLN

3

ZOMIG ORAL TABLET

3

ST; QL

ULTRACET ORAL TABLET

3

QL

ZOMIG ZMT ORAL TABLET,DISINTEGRATI NG

3

ST; QL

ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR

3

QL

ULTRAM ORAL TABLET

3

QL

VANATOL LQ ORAL SOLUTION

3

verdrocet oral tablet

1

vicodin es oral tablet

1

QL

vicodin hp oral tablet

1

QL

vicodin oral tablet

1

QL

VICOPROFEN ORAL TABLET

3

QL

QL

QL

ANESTHETICS

XARTEMIS XR ORAL TAB,ORAL ONLY,IR ER, BIPHASE

3

XODOL 10/300 ORAL TABLET

3

ST; QL QL

AMIDATE INTRAVENOUS SOLUTION

3

AMIDATE INTRAVENOUS SYRINGE

3

ARTICADENT DENTAL INJECTION CARTRIDGE

3

BREVITAL INJECTION RECON SOLN

3

BUCALSEP MUCOUS MEMBRANE AEROSOL,SPRAY

3

BUCALSEP MUCOUS MEMBRANE SOLUTION

3

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 11

Drug Name

Tier

bupivacaine (pf) injection solution

1

bupivacaine injection solution

1

bupivacaine-dextrose-water( pf) injection solution

1

bupivacaine-epinephrine (pf) injection solution

1

BUPIVACAINE-EPINEPH RINE BITART INJECTION CARTRIDGE

Notes

Drug Name

Tier

KETALAR INJECTION SOLUTION

3

KETAMINE IN 0.9 % SOD CHLORIDE INTRAVENOUS SYRINGE

3

ketamine injection solution

1

LDO PLUS TOPICAL GEL

3

3

lidocaine (pf) in d7.5w intrathecal solution

1

bupivacaine-epinephrine injection solution

1

1

CARBOCAINE (PF) INJECTION SOLUTION 10 MG/ML (1 %), 20 MG/ML (2 %)

lidocaine (pf) injection solution 10 mg/ml (1 %), 15 mg/ml (1.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %)

3

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

3

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

1

lidocaine hcl injection solution

1

CARBOCAINE INJECTION SOLUTION

3

lidocaine hcl laryngotracheal solution

1

CITANEST FORTE DENTAL INJECTION CARTRIDGE

3

lidocaine hcl mucous membrane gel

1

lidocaine hcl mucous membrane jelly in applicator

1

lidocaine hcl mucous membrane solution

1

lidocaine topical adhesive patch,medicated

1

lidocaine topical ointment

1

lidocaine viscous mucous membrane solution

1

CITANEST PLAIN DENTAL INJECTION CARTRIDGE

3

cocaine topical solution

1

compound 347 inhalation gas

1

DIPRIVAN INTRAVENOUS EMULSION

3

ethyl chloride topical aerosol,spray

1

lidocaine-epinephrine (pf) injection solution

1

etomidate intravenous solution

1

3

EXPAREL (PF) LOCAL INFILTRATION SUSPENSION

LIDOCAINE-EPINEPHRI NE BIT INJECTION CARTRIDGE

3

lidocaine-epinephrine injection solution

1

forane inhalation liquid

1

glydo mucous membrane jelly in applicator

1

1

lidocaine-prilocaine topical cream

isoflurane inhalation liquid

1

lidocaine-prilocaine topical kit

1

IV INFUSION CPI KIT

3

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 12

Drug Name

Tier

LIDOCAINE-TETRACAI NE TOPICAL CREAM

3

LIDODERM TOPICAL ADHESIVE PATCH,MEDICATED

3

LIVIXIL PAK TOPICAL KIT

Notes

Drug Name

Tier

NESACAINE-MPF INJECTION SOLUTION

3

PAIN EASE TOPICAL AEROSOL,SPRAY

3

phenazopyridine oral tablet

1

3

PLIAGLIS TOPICAL CREAM

3

LP LITE PAK TOPICAL KIT

3

polocaine injection solution 1 % (10 mg/ml)

1

lta pre-attached laryngotracheal solution

1

POLOCAINE INJECTION SOLUTION 2 %

3

polocaine-mpf injection solution

1

PONTOCAINE TOPICAL SOLUTION

3

MARCAINE (PF) INJECTION SOLUTION 0.25 % (2.5 MG/ML), 0.5 % (5 MG/ML)

3

marcaine (pf) injection solution 0.75 % (7.5 mg/ml)

1

1

MARCAINE INJECTION SOLUTION

propofol intravenous emulsion

3

3

MARCAINE SPINAL (PF) INJECTION SOLUTION

PYRIDIUM ORAL TABLET

3

relador pak plus topical kit

1

MARCAINE-EPINEPHRI NE (PF) INJECTION SOLUTION

relador pak topical kit

1

3

ropivacaine (pf) injection solution

1

MARCAINE-EPINEPHRI NE INJECTION SOLUTION

3

SENSORCAINE INJECTION SOLUTION 0.25 % (2.5 MG/ML)

3

MEPIVACAINE (PF) INJECTION CARTRIDGE

3

sensorcaine injection solution 0.5 % (5 mg/ml)

1

midazolam (pf) injection cartridge

1

1

sensorcaine/epinephrine injection solution

midazolam (pf) injection solution

3

1

SENSORCAINE-MPF INJECTION SOLUTION

midazolam (pf) injection syringe 2 mg/2 ml (1 mg/ml)

1

SENSORCAINE-MPF SPINAL INJECTION SOLUTION

3

MIDAZOLAM (PF) INJECTION SYRINGE 5 MG/ML

3

SENSORCAINE-MPF/EPI NEPHRINE INJECTION SOLUTION

3

midazolam injection solution

1

sevoflurane inhalation liquid

1

NAROPIN (PF) INJECTION SOLUTION

3

sojourn inhalation liquid

1

NESACAINE INJECTION SOLUTION

3

SOLUPAK TOPICAL KIT,OINTMENT AND SPRAY

3

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 13

Drug Name

Tier

Notes

Drug Name

Tier

Notes

SPRAY AND STRETCH TOPICAL AEROSOL,SPRAY

3

CALDOLOR INTRAVENOUS RECON SOLN

3

SUPRANE INHALATION LIQUID

3

CAPXIB COMBO PACK, CAPSULE, PATCH

3

SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING

3

CELEBREX ORAL CAPSULE

3

ST; QL

celecoxib oral capsule

1

ST; QL

terrell inhalation liquid

1

tetracaine hcl (pf) injection solution

3

PA; QL

1

COLCHICINE ORAL CAPSULE

ULTANE INHALATION LIQUID

3

PA; QL

3

COLCHICINE ORAL TABLET

xylocaine dental-epinephrine injection cartridge

1

1

colchicine-probenecid oral tablet

XYLOCAINE INJECTION SOLUTION

3

3

COLCRYS ORAL TABLET COMFORT PAC-IBUPROFEN KIT

3

COMFORT PAC-MELOXICAM KIT

3

XYLOCAINE-EPINEPHR INE INJECTION SOLUTION

3

XYLOCAINE-MPF INJECTION SOLUTION

3

COMFORT PAC-NAPROXEN KIT

3

XYLOCAINE-MPF/EPIN EPHRINE INJECTION SOLUTION

3

CUPRIMINE ORAL CAPSULE

2

ZINGO INTRADERMAL PEN INJECTOR

DAYPRO ORAL TABLET

3

3

DEPEN TITRATABS ORAL TABLET

3

ANTIALLERGY cromolyn oral concentrate

1

diclofenac sodium oral tablet extended release 24 hr

1

GASTROCROM ORAL CONCENTRATE

3

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

1

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic

1

DISALCID ORAL TABLET

3

DUEXIS ORAL TABLET

3

DYLOJECT INTRAVENOUS SOLUTION

3

EC-NAPROSYN ORAL TABLET,DELAYED RELEASE (DR/EC)

3

ELITEK INTRAVENOUS RECON SOLN

3

ANTIARTHRITICS allopurinol oral tablet

1

aloprim intravenous recon soln

1

ANAPROX DS ORAL TABLET

3

ARAVA ORAL TABLET

3

ARTHROTEC 50 ORAL TABLET,IR,DELAYED REL,BIPHASIC

3

ARTHROTEC 75 ORAL TABLET,IR,DELAYED REL,BIPHASIC

3

ST

ST

PA; QL

QL

ST

ST; CE; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 14

Drug Name

Tier

Notes

Drug Name

Tier

Notes

ENBREL SUBCUTANEOUS RECON SOLN

4

PA; QL

HUMIRA SUBCUTANEOUS SYRINGE KIT

4

PA; QL

ENBREL SUBCUTANEOUS SYRINGE

4

PA; QL

HYALGAN INTRA-ARTICULAR SOLUTION

4

PA

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

4

PA; QL

HYALGAN INTRA-ARTICULAR SYRINGE

4

PA

etodolac oral capsule

1 1

HYMOVIS INTRA-ARTICULAR SYRINGE

etodolac oral tablet

4

etodolac oral tablet extended release 24 hr

1

ibuprofen oral suspension

1

ibuprofen oral tablet

1

INDOCIN ORAL SUSPENSION

3

ST

INDOCIN RECTAL SUPPOSITORY

3

ST

indomethacin oral capsule

1

indomethacin oral capsule, extended release

1

ketoprofen oral capsule

1

ketoprofen oral capsule,ext rel. pellets 24 hr

1

EUFLEXXA INTRA-ARTICULAR SYRINGE

4

FELDENE ORAL CAPSULE

3

FENOPROFEN ORAL CAPSULE 200 MG

3

FENOPROFEN ORAL CAPSULE 400 MG

3

fenoprofen oral tablet

1

flurbiprofen oral tablet

1

GEL-ONE INTRA-ARTICULAR SYRINGE

4

PA

KINERET SUBCUTANEOUS SYRINGE

4

PA

GENVISC 850 INTRA-ARTICULAR SYRINGE

4

PA

KRYSTEXXA INTRAVENOUS SOLUTION

4

PA

leflunomide oral tablet

1

meclofenamate oral capsule

1

meloxicam oral suspension

1

QL

meloxicam oral tablet

1

QL

MITIGARE ORAL CAPSULE

3

PA; QL

MOBIC ORAL SUSPENSION

3

QL

PA; QL

MOBIC ORAL TABLET

3

QL

4

PA

PA; QL

MONOVISC INTRA-ARTICULAR SYRINGE nabumetone oral tablet

1

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT HUMIRA PEN PSORIASIS STARTER SUBCUTANEOUS PEN INJECTOR KIT HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT

4

4

4

4

PA

ST

PA; QL

PA; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 15

Drug Name

Tier

Notes

NALFON ORAL CAPSULE

3

ST; CE

NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR

3

NAPROSYN ORAL SUSPENSION

3

NAPROSYN ORAL TABLET

3

naproxen oral suspension

1

naproxen oral tablet

1

naproxen oral tablet,delayed release (dr/ec)

1

naproxen sodium oral tablet

1

naproxen sodium oral tablet, er multiphase 24 hr

1

ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN

4

ORENCIA SUBCUTANEOUS SYRINGE

4

ORTHOVISC INTRA-ARTICULAR SYRINGE OTEZLA ORAL TABLET OTEZLA STARTER ORAL TABLETS,DOSE PACK OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.4 ML, 15 MG/0.4 ML, 20 MG/0.4 ML, 25 MG/0.4 ML, 7.5 MG/0.4 ML

Tier

Notes

RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR

4

PA; QL

RHEUMATREX ORAL TABLETS,DOSE PACK

2

RIDAURA ORAL CAPSULE

2

salsalate oral tablet

1

SIMPONI ARIA INTRAVENOUS SOLUTION

4

PA

SIMPONI SUBCUTANEOUS PEN INJECTOR

4

PA; QL

SIMPONI SUBCUTANEOUS SYRINGE

4

PA; QL

sulindac oral tablet

1

SUPARTZ FX INTRA-ARTICULAR SYRINGE

4

PA

PA; QL

SYNVISC INTRA-ARTICULAR SYRINGE

4

PA

4

PA

4

PA

4

PA; QL

SYNVISC-ONE INTRA-ARTICULAR SYRINGE TIVORBEX ORAL CAPSULE

3

ST; CE; QL

tolmetin oral capsule

1

tolmetin oral tablet

1

ULORIC ORAL TABLET

3

ST

VIMOVO ORAL TABLET,IR,DELAYED REL,BIPHASIC

3

ST; CE; QL

VIVLODEX ORAL CAPSULE

3

QL

VOLTAREN-XR ORAL TABLET EXTENDED RELEASE 24 HR

3

XELJANZ ORAL TABLET

4

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR

4

4

4

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

4

oxaprozin oral tablet

1

piroxicam oral capsule

1

probenecid oral tablet

1

Drug Name

PA

PA; QL

PA; QL

PA

PA; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 16

Drug Name

Tier

ZORVOLEX ORAL CAPSULE

3

ZYLOPRIM ORAL TABLET

3

Notes

Drug Name

ST; CE; QL

ANTIASTHMATICS ACCOLATE ORAL TABLET

3

acetylcysteine solution

1

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE

2

ADVAIR HFA INHALATION HFA AEROSOL INHALER

2

QL

AEROSPAN INHALATION HFA AEROSOL INHALER

3

QL

albuterol sulfate inhalation solution for nebulization

1

albuterol sulfate oral syrup

1

albuterol sulfate oral tablet

1

albuterol sulfate oral tablet extended release 12 hr

1

ALVESCO INHALATION HFA AEROSOL INHALER

3

aminophylline intravenous solution 250 mg/10 ml

1

AMINOPHYLLINE INTRAVENOUS SOLUTION 500 MG/20 ML ANORO ELLIPTA INHALATION BLISTER WITH DEVICE

QL

QL

3

2

QL

Tier

Notes

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)

2

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES)

2

ATROVENT HFA INHALATION HFA AEROSOL INHALER

2

QL

BREO ELLIPTA INHALATION BLISTER WITH DEVICE

2

QL

BROVANA INHALATION SOLUTION FOR NEBULIZATION

3

QL

budesonide inhalation suspension for nebulization

1

QL

CINQAIR INTRAVENOUS SOLUTION

4

COMBIVENT RESPIMAT INHALATION MIST

2

cromolyn inhalation solution for nebulization

1

DALIRESP ORAL TABLET

3

QL

DULERA INHALATION HFA AEROSOL INHALER

2

QL

ELIXOPHYLLIN ORAL ELIXIR

2

QL

QL

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

3

ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE

2

QL

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE

2

QL

ASMANEX HFA INHALATION HFA AEROSOL INHALER

2

QL

FLOVENT HFA INHALATION HFA AEROSOL INHALER

2

QL

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 17

Drug Name FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 2

Notes QL

INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE

3

ipratropium bromide inhalation solution

1

ipratropium-albuterol inhalation solution for nebulization

1

levalbuterol hcl inhalation solution for nebulization

1

metaproterenol oral syrup

1

metaproterenol oral tablet

1

montelukast oral granules in packet

1

QL

montelukast oral tablet

1

QL

montelukast oral tablet,chewable

1

QL

NUCALA SUBCUTANEOUS RECON SOLN

4

PA

QL QL

PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION

2

PROAIR HFA INHALATION HFA AEROSOL INHALER

2

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED

2

QL

PROVENTIL HFA INHALATION HFA AEROSOL INHALER

3

QL

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

2

PULMICORT INHALATION 3 SUSPENSION FOR NEBULIZATION Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program

Drug Name

QL

QL

QL

QL

Tier

Notes

QVAR INHALATION AEROSOL

2

QL

SEEBRI NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

3

QL

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

2

QL

SINGULAIR ORAL GRANULES IN PACKET

3

QL

SINGULAIR ORAL TABLET

3

QL

SINGULAIR ORAL TABLET,CHEWABLE

3

QL

SPIRIVA RESPIMAT INHALATION MIST

2

QL

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE

2

QL

STIOLTO RESPIMAT INHALATION MIST

2

QL

STRIVERDI RESPIMAT INHALATION MIST

3

QL

SYMBICORT INHALATION HFA AEROSOL INHALER

2

QL

terbutaline oral tablet

1

terbutaline subcutaneous solution

1

THEO-24 ORAL CAPSULE,EXTENDED RELEASE 24HR

2

theochron oral tablet extended release 12 hr

1

theophylline in dextrose 5 % intravenous parenteral solution

1

theophylline oral elixir

1

theophylline oral solution

1

theophylline oral tablet extended release

1

Effective 7/1/16 18

Drug Name

Tier

theophylline oral tablet extended release 12 hr

1

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED

3

UTIBRON NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

3

VENTOLIN HFA INHALATION HFA AEROSOL INHALER

2

VOSPIRE ER ORAL TABLET EXTENDED RELEASE 12 HR

3

XOLAIR SUBCUTANEOUS RECON SOLN

4

XOPENEX CONCENTRATE INHALATION SOLUTION FOR NEBULIZATION

3

XOPENEX HFA INHALATION HFA AEROSOL INHALER

3

XOPENEX INHALATION SOLUTION FOR NEBULIZATION

3

zafirlukast oral tablet

1

ZYFLO CR ORAL TABLET, ER MULTIPHASE 12 HR

3

ZYFLO ORAL TABLET

3

Notes

Drug Name

QL

QL

QL

PA

QL

QL

QL

Tier

AMOXICILLIN ORAL TABLET, ER MULTIPHASE 24 HR

3

amoxicillin oral tablet,chewable

1

amoxicillin-pot clavulanate oral suspension for reconstitution

1

amoxicillin-pot clavulanate oral tablet

1

amoxicillin-pot clavulanate oral tablet extended release 12 hr

1

amoxicillin-pot clavulanate oral tablet,chewable

1

ampicillin oral capsule

1

ampicillin oral suspension for reconstitution

1

ampicillin sodium injection recon soln

1

ampicillin sodium intravenous recon soln

1

ampicillin-sulbactam injection recon soln

1

ampicillin-sulbactam intravenous recon soln

1

AUGMENTIN ES-600 ORAL SUSPENSION FOR RECONSTITUTION

3

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML

2

3

ACTICLATE ORAL TABLET

3

ST; CE

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 250-62.5 MG/5 ML

ADOXA ORAL CAPSULE

3

ST; CE

AUGMENTIN ORAL TABLET

3

amikacin injection solution

1

amoxicillin oral capsule

1

3

amoxicillin oral suspension for reconstitution

AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 12 HR

1

3

amoxicillin oral tablet

1

AVAR LS TOPICAL CLEANSER AVAR LS TOPICAL FOAM

3

ANTIBIOTICS

Notes

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 19

Drug Name

Tier

Notes

AVAR LS TOPICAL PADS, MEDICATED

3

avar topical cleanser

1

PA

AVAR TOPICAL FOAM

3

PA

AVAR TOPICAL PADS, MEDICATED

Drug Name

Tier

bacitracin ophthalmic ointment

1

bacitracin-polymyxin b ophthalmic ointment

1

3

BACTRIM DS ORAL TABLET

3

AVAR-E GREEN TOPICAL CREAM

3

BACTRIM ORAL TABLET

3

AVAR-E LS TOPICAL CREAM

3

BACTROBAN NASAL NASAL OINTMENT

2

AVAR-E TOPICAL CREAM

3

BACTROBAN TOPICAL CREAM

3

AVELOX ABC PACK ORAL TABLET

3

BENZAMYCIN TOPICAL GEL

3

BENZAMYCINPAK TOPICAL GEL

3

BENZODOX 30 KIT, CLEANSER ER AND TABLET

3

BENZODOX 60 KIT, CLEANSER ER AND TABLET

3

BESIVANCE OPHTHALMIC DROPS,SUSPENSION

3

BETHKIS INHALATION SOLUTION FOR NEBULIZATION

4

BIAXIN ORAL SUSPENSION FOR RECONSTITUTION

3

BIAXIN ORAL TABLET

3

BICILLIN C-R INTRAMUSCULAR SYRINGE

3

BICILLIN L-A INTRAMUSCULAR SYRINGE

3

BLEPH-10 OPHTHALMIC DROPS

3

BLEPHAMIDE OPHTHALMIC DROPS,SUSPENSION

3

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT

3

PA

QL

AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK

3

AVELOX ORAL TABLET

3

AVIDOXY DK KIT

3

AVYCAZ INTRAVENOUS RECON SOLN

3

AZACTAM IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK

3

AZACTAM INJECTION RECON SOLN

3

AZASITE OPHTHALMIC DROPS

2

azithromycin intravenous recon soln

1

azithromycin oral packet

1

QL

azithromycin oral suspension for reconstitution

1

QL

azithromycin oral tablet

1

QL

aztreonam injection recon soln

1

azuphen mb oral capsule

1

baciim intramuscular recon soln

1

bacitracin intramuscular recon soln

1

QL

Notes

ST

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 20

Drug Name

Tier

bp 10-1 topical cleanser

1

CAPASTAT INJECTION RECON SOLN

3

CAYSTON INHALATION SOLUTION FOR NEBULIZATION

4

CEDAX ORAL CAPSULE

3

CEDAX ORAL SUSPENSION FOR RECONSTITUTION

Notes

Drug Name

Tier

CEFOTAN INJECTION RECON SOLN

3

cefotaxime injection recon soln

1

CEFOTETAN IN DEXTROSE, ISO-OSM INTRAVENOUS PIGGYBACK

3

3

cefotetan injection recon soln

1 1

cefaclor oral capsule

1

cefotetan intravenous recon soln

cefaclor oral suspension for reconstitution

1

cefoxitin in dextrose, iso-osm intravenous piggyback

1

cefaclor oral tablet extended release 12 hr

1

cefoxitin intravenous recon soln

1

cefadroxil oral capsule

1

cefpodoxime oral suspension for reconstitution

1

cefadroxil oral suspension for reconstitution

1

cefpodoxime oral tablet

1

cefadroxil oral tablet

1

1

cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml

cefprozil oral suspension for reconstitution

1

cefprozil oral tablet

1

CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK

3

ceftazidime injection recon soln

1

ceftibuten oral capsule

1

ceftibuten oral suspension for reconstitution

1

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION

3

CEFTIN ORAL TABLET

3

ceftriaxone in dextrose,iso-os intravenous piggyback

1

ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg

1

3

CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML

3

cefazolin injection recon soln

1

cefazolin intravenous recon soln

1

cefdinir oral capsule

1

cefdinir oral suspension for reconstitution

1

cefditoren pivoxil oral tablet

1

CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK

3

cefepime in dextrose,iso-osm intravenous piggyback

1

cefepime injection recon soln

1

CEFTRIAXONE INJECTION RECON SOLN 100 GRAM

cefixime oral suspension for reconstitution

1

ceftriaxone intravenous recon soln

1

cefuroxime axetil oral tablet

1

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 21

Drug Name

Tier

cefuroxime sodium injection recon soln

1

cefuroxime sodium intravenous recon soln

1

cephalexin oral capsule

1

cephalexin oral suspension for reconstitution

Notes

Drug Name

Tier

ciprofloxacin oral suspension,microcapsule recon

1

3

1

CLAFORAN IN DEXTROSE(ISO-OSM) INTRAVENOUS PIGGYBACK

cephalexin oral tablet

1

CLAFORAN INJECTION RECON SOLN

3

CETRAXAL OTIC DROPPERETTE

3

3

chloramphenicol sod succinate intravenous recon soln

CLAFORAN INTRAVENOUS RECON SOLN

1

clarithromycin oral suspension for reconstitution

1

CILOXAN OPHTHALMIC DROPS

3

clarithromycin oral tablet

1

clarithromycin oral tablet extended release 24 hr

1

cleansing wash topical cleanser

1

CLEOCIN IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK

3

CLEOCIN INJECTION SOLUTION

3 3

CILOXAN OPHTHALMIC OINTMENT

3

CIPRO HC OTIC DROPS,SUSPENSION

3

CIPRO IN D5W INTRAVENOUS PIGGYBACK

3

CIPRO ORAL SUSPENSION,MICROCA PSULE RECON

3

QL

CIPRO ORAL TABLET

3

QL

CLEOCIN INTRAVENOUS SOLUTION

CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR

3

QL

CLEOCIN ORAL CAPSULE

3

CIPRODEX OTIC DROPS,SUSPENSION

CLEOCIN ORAL RECON SOLN

3

2

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr

CLEOCIN T TOPICAL GEL

3

1

ciprofloxacin hcl ophthalmic drops

3

1

CLEOCIN T TOPICAL LOTION

ciprofloxacin hcl oral tablet

1

CLEOCIN T TOPICAL SOLUTION

3

ciprofloxacin hcl otic dropperette

1

CLEOCIN T TOPICAL SWAB

3

ciprofloxacin in 5 % dextrose intravenous piggyback

1

CLEOCIN VAGINAL CREAM

3

ciprofloxacin lactate intravenous solution

1

CLEOCIN VAGINAL SUPPOSITORY

2

QL

QL

Notes QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 22

Drug Name

Tier

CLIN SINGLE USE INJECTION KIT

3

CLINDACIN ETZ TOPICAL KIT

3

clindacin etz topical swab

1

clindacin p topical swab

1

CLINDACIN PAC TOPICAL KIT

3

CLINDAGEL TOPICAL GEL

3

clindamycin hcl oral capsule

1

clindamycin in 5 % dextrose intravenous piggyback

Notes

Drug Name

Tier

CORTISPORIN TOPICAL CREAM

3

CORTISPORIN TOPICAL OINTMENT

3

CUBICIN INTRAVENOUS RECON SOLN

3

ST; CE

CYCLOSERINE ORAL CAPSULE

3

ST; CE

DALVANCE INTRAVENOUS SOLUTION

3

1

DAPSONE ORAL TABLET

3

clindamycin palmitate hcl oral recon soln

1

demeclocycline oral tablet

1

dicloxacillin oral capsule

1

clindamycin pediatric oral recon soln

1

DIFICID ORAL TABLET

3

clindamycin phosphate injection solution

1

3

clindamycin phosphate intravenous solution

DORIBAX INTRAVENOUS RECON SOLN

1

clindamycin phosphate topical foam

3

1

DORYX ORAL TABLET,DELAYED RELEASE (DR/EC)

clindamycin phosphate topical gel

1

doxy-100 intravenous recon soln

1

clindamycin phosphate topical lotion

1

doxycycline hyclate intravenous recon soln

1

clindamycin phosphate topical solution

1

doxycycline hyclate oral capsule

1

clindamycin phosphate topical swab

1

doxycycline hyclate oral tablet

1

clindamycin phosphate vaginal cream

1

1

CLINDESSE VAGINAL CREAM,EXTENDED RELEASE

doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 200 mg, 75 mg

3

1

colistin (colistimethate na) injection recon soln

1

doxycycline hyclate oral tablet,delayed release (dr/ec) 50 mg

COLY-MYCIN M PARENTERAL INJECTION RECON SOLN

doxycycline monohydrate oral capsule

1

3

3

COLY-MYCIN S OTIC DROPS,SUSPENSION

3

DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR - DELAY REL,BIPHASE

ST; CE

Notes

ST; CE

ST

ST; CE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 23

Drug Name

Tier

doxycycline monohydrate oral suspension for reconstitution

1

doxycycline monohydrate oral tablet

Notes

Drug Name

Tier

ethambutol oral tablet

1

EVOCLIN TOPICAL FOAM

3

1

FACTIVE ORAL TABLET

3

e.e.s. 400 oral tablet

1

E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION

3

3

FLAGYL ER ORAL TABLET EXTENDED RELEASE

ery pads topical swab

1

FLAGYL ORAL CAPSULE

3

erygel topical gel

1

FLAGYL ORAL TABLET

3

ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION

3

FORTAZ IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK

3

ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION

3

FORTAZ INJECTION RECON SOLN

3

FORTAZ INTRAVENOUS RECON SOLN

3

FURADANTIN ORAL SUSPENSION

3

gatifloxacin ophthalmic drops

1

gentak ophthalmic ointment

1

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml

1

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML

3

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

1

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

3

erythrocin (as stearate) oral tablet

1

ERYTHROCIN INTRAVENOUS RECON SOLN

3

erythromycin ethylsuccinate oral tablet

1

erythromycin ophthalmic ointment

1

erythromycin oral capsule,delayed release(dr/ec)

gentamicin injection solution

1

1

gentamicin ophthalmic drops

1

erythromycin oral tablet

1

gentamicin ophthalmic ointment

1

erythromycin with ethanol topical gel

1

gentamicin sulfate (ped) (pf) injection solution

1

erythromycin with ethanol topical solution

1

1

erythromycin with ethanol topical swab

1

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

erythromycin-benzoyl peroxide topical gel

1

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

3

Notes

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 24

Drug Name

Tier

Notes

Drug Name

Tier

Notes

1

PA; QL PA; QL

gentamicin topical cream

1

gentamicin topical ointment

1

linezolid oral suspension for reconstitution

HIPREX ORAL TABLET

3

linezolid oral tablet

1

hyolev mb oral tablet

1 1

1

hyophen oral tablet

linezolid-0.9% sodium chloride intravenous parenteral solution

ILOTYCIN OPHTHALMIC OINTMENT

3

MACROBID ORAL CAPSULE

3

imipenem-cilastatin intravenous recon soln

3

1

MACRODANTIN ORAL CAPSULE

INDIOMIN MB ORAL CAPSULE

3

3

MAXIPIME INJECTION RECON SOLN

INVANZ INJECTION RECON SOLN

3

MAXIPIME INTRAVENOUS RECON SOLN

3

INVANZ INTRAVENOUS RECON SOLN

3

3

isoniazid injection solution

1

MAXITROL OPHTHALMIC DROPS,SUSPENSION

isoniazid oral solution

1

isoniazid oral tablet

1

MAXITROL OPHTHALMIC OINTMENT

3

KEFLEX ORAL CAPSULE

3

KETEK ORAL TABLET

3

3

KITABIS PAK INHALATION SOLUTION FOR NEBULIZATION

MEFOXIN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK

4

meropenem intravenous recon soln

1

LEVAQUIN ORAL TABLET

3

3

levofloxacin in d5w intravenous piggyback

MEROPENEM-0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK

1

levofloxacin intravenous solution

3

1

MERREM INTRAVENOUS RECON SOLN

levofloxacin ophthalmic drops

1

methenamine hippurate oral tablet

1

LEVOFLOXACIN ORAL SOLUTION

3

QL

methenamine mandelate oral tablet

1

levofloxacin oral tablet

1

QL

1

LINCOCIN INJECTION SOLUTION

methen-sod phos-meth blue-hyos oral tablet

3

1

lincomycin injection solution

1

metro i.v. intravenous piggyback

linezolid intravenous parenteral solution

1

METROGEL VAGINAL VAGINAL GEL

3

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 25

Drug Name

Tier

Notes

metronidazole in nacl (iso-os) intravenous piggyback

1

metronidazole oral capsule

1

metronidazole oral tablet

1

metronidazole vaginal gel

1

MINOCIN INTRAVENOUS RECON SOLN

3

MINOCIN ORAL CAPSULE

3

ST; CE

minocycline oral capsule

1

ST

minocycline oral tablet

1

ST

minocycline oral tablet extended release 24 hr

1

ST

mondoxyne nl oral capsule

1

MONODOX ORAL CAPSULE

3

MONUROL ORAL PACKET

Drug Name

Tier

nafcillin intravenous recon soln

1

neomycin oral tablet

1

neomycin-bacitracin-poly-hc ophthalmic ointment

1

neomycin-bacitracin-polymy xin ophthalmic ointment

1

neomycin-polymyxin b-dexameth ophthalmic drops,suspension

1

neomycin-polymyxin b-dexameth ophthalmic ointment

1

neomycin-polymyxin-gramic idin ophthalmic drops

1

neomycin-polymyxin-hc ophthalmic drops,suspension

1

neomycin-polymyxin-hc otic drops,suspension

1

3

neomycin-polymyxin-hc otic solution

1

MORGIDOX 1X100 KIT

3

MORGIDOX 2X100 KIT

3

neo-polycin hc ophthalmic ointment

1

morgidox oral capsule

1

1

MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR

neo-polycin ophthalmic ointment

3

3

MOXEZA OPHTHALMIC DROPS, VISCOUS

2

NEOSPORIN (NEO-POLYM-GRAMICI D) OPHTHALMIC DROPS

moxifloxacin oral tablet

1

NEO-SYNALAR KIT TOPICAL CREAM

3

MOXIFLOXACIN-SOD.A CE,SUL-WATER INTRAVENOUS PIGGYBACK

3

NEO-SYNALAR TOPICAL CREAM

3 1

mupirocin calcium topical cream

nitrofurantoin macrocrystal oral capsule 1

mupirocin topical ointment

1

nitrofurantoin monohyd/m-cryst oral capsule

1

MYAMBUTOL ORAL TABLET

3

nitrofurantoin oral suspension

1

MYCOBUTIN ORAL CAPSULE

3

NUVESSA VAGINAL GEL

3

nafcillin in dextrose iso-osm intravenous piggyback

1

OCUFLOX OPHTHALMIC DROPS

3

nafcillin injection recon soln

1

ofloxacin ophthalmic drops

1

ST

ST; CE

QL

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 26

Drug Name

Tier

Notes

Drug Name

Tier

QL

3

ofloxacin oral tablet

1

ofloxacin otic drops

1

PLEXION TOPICAL CLEANSER

ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE

3

3

PLEXION TOPICAL CREAM

3

ORBACTIV INTRAVENOUS RECON SOLN

PLEXION TOPICAL LOTION 3

polycin ophthalmic ointment

1

polymyxin b sulfate injection recon soln

1

polymyxin b sulf-trimethoprim ophthalmic drops

1

POLYTRIM OPHTHALMIC DROPS

3

PRED-G OPHTHALMIC DROPS,SUSPENSION

3

PRED-G S.O.P. OPHTHALMIC OINTMENT

3

PRIFTIN ORAL TABLET

2

PRIMAXIN IV INTRAVENOUS RECON SOLN

3

PRIMSOL ORAL SOLUTION

3

pyrazinamide oral tablet

1

OTIPRIO INTRATYMPANIC SUSPENSION

3

oxacillin in dextrose(iso-osm) intravenous piggyback

1

oxacillin injection recon soln

1

oxacillin intravenous recon soln

1

PASER ORAL GRANULES DR FOR SUSP IN PACKET

3

PCE ORAL TABLET, PARTICLES/CRYSTALS

3

PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK

3

penicillin g potassium injection recon soln

1

rifabutin oral capsule

1

penicillin g procaine intramuscular syringe

1

3

penicillin g sodium injection recon soln

RIFADIN INTRAVENOUS RECON SOLN

1

3

penicillin v potassium oral recon soln

RIFADIN ORAL CAPSULE

1

3

penicillin v potassium oral tablet

RIFAMATE ORAL CAPSULE

1

1

pfizerpen-g injection recon soln

rifampin intravenous recon soln

1

rifampin oral capsule

1

phosphasal oral tablet

1

2

piperacillin-tazobactam intravenous recon soln

RIFATER ORAL TABLET

1

3

PLEXION CLEANSING CLOTHS TOPICAL PADS, MEDICATED

ROSANIL TOPICAL CLEANSER

3

rosula cleansing cloths topical pads, medicated

1

Notes

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 27

Drug Name

Tier

Notes

Drug Name

Tier

Notes

ROSULA TOPICAL CLEANSER

3

sulfacetamide sodium-sulfur topical pads, medicated

1

SILVADENE TOPICAL CREAM

3

sulfacetamide sodium-sulfur topical suspension 10-5 %

1

silver sulfadiazine topical cream

1

sulfacetamide sodium-sulfur topical suspension 8-4 %

1

SIRTURO ORAL TABLET

3

1

SIVEXTRO INTRAVENOUS RECON SOLN

sulfacetamide sod-sulfur-urea topical cleanser

3

sulfacetamide-prednisolone ophthalmic drops

1

SIVEXTRO ORAL TABLET

3

PA; QL

sulfacetamide-sulfur-cleansr2 3 topical kit

1

PA

SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR

3

ST; CE

sulfacleanse 8-4 topical suspension

1

PA

SPECTRACEF ORAL TABLET

3

1

ss 10-2 topical cleanser

1

sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream

ssd topical cream

1

sulfadiazine oral tablet

1

sss 10-5 topical cream

1

sulfamethoxazole-trimethopri m intravenous solution

1

sss 10-5 topical foam

1

sulfamethoxazole-trimethopri m oral suspension

1

sulfamethoxazole-trimethopri m oral tablet

1

PA

PA

STREPTOMYCIN INTRAMUSCULAR RECON SOLN

3

sulfacetamide sodium ophthalmic drops

1

SULFAMYLON TOPICAL CREAM

3

sulfacetamide sodium ophthalmic ointment

1

SULFAMYLON TOPICAL PACKET

3

sulfacetamide sodium-sulfur topical cleanser 10-2 %, 9.8-4.8 %

1

sulfatrim oral suspension

1 3

PA

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w), 9-4 %, 9-4.5 %

SUMADAN TOPICAL CLEANSER 1

PA

SUMADAN TOPICAL KIT

3

PA

sulfacetamide sodium-sulfur topical cream 10-2 %

1

PA

3

sulfacetamide sodium-sulfur topical cream 10-5 % (w/w), 9.8-4.8 %

1

SUMADAN XLT TOPICAL COMBO PACK,CLEANSER AND CREAM

3

PA

sulfacetamide sodium-sulfur topical foam

SUMAXIN CP TOPICAL KIT 1

3

PA

sulfacetamide sodium-sulfur topical lotion

SUMAXIN TOPICAL CLEANSER

1

SUMAXIN TOPICAL PADS, MEDICATED

3

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 28

Drug Name

Tier

SUMAXIN TS TOPICAL SUSPENSION

3

SUPRAX ORAL CAPSULE

3

Notes

Drug Name

Tier

PA

tobramycin in 0.9 % nacl intravenous piggyback

1

tobramycin ophthalmic drops

1

tobramycin sulfate injection recon soln

1

tobramycin sulfate injection solution

1

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION

3

SUPRAX ORAL TABLET,CHEWABLE

3

tobramycin-dexamethasone ophthalmic drops,suspension

1

SYNERCID INTRAVENOUS RECON SOLN

3

TOBREX OPHTHALMIC DROPS

3

TAZICEF INJECTION RECON SOLN

3

TOBREX OPHTHALMIC OINTMENT

3

TAZICEF INTRAVENOUS RECON SOLN

3

3

TRECATOR ORAL TABLET trimethoprim oral tablet

1 3

TEFLARO INTRAVENOUS RECON SOLN

3

TYGACIL INTRAVENOUS RECON SOLN

tetracycline oral capsule

1

3

THALOMID ORAL CAPSULE

UNASYN INJECTION RECON SOLN

2

ur n-c oral tablet

1

thermazene topical cream

1

uramit mb oral capsule

1

TOBI INHALATION SOLUTION FOR NEBULIZATION

URELLE ORAL TABLET

3

4

uretron d-s oral tablet

1

URIBEL ORAL CAPSULE

3

TOBI PODHALER INHALATION CAPSULE

4

urimar-t oral tablet

1

urin ds oral tablet

1

urogesic-blue oral tablet

1

uro-l oral tablet

1

urolet mb oral tablet

1

uro-mp oral capsule

1

urophen mb oral tablet

1

uryl oral tablet

1

ustell oral capsule

1

UTA ORAL CAPSULE

3

utira-c oral tablet

1

VANCOCIN ORAL CAPSULE

3

TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE

4

TOBRADEX OPHTHALMIC DROPS,SUSPENSION

3

TOBRADEX OPHTHALMIC OINTMENT

2

TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION tobramycin in 0.225 % nacl inhalation solution for nebulization

PA; QL

3

Notes

PA

4

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 29

Drug Name VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK

Tier

Notes

Drug Name

3

3

PA

Tier

Notes

ZITHROMAX INTRAVENOUS RECON SOLN

3

ZITHROMAX ORAL PACKET

3

QL

ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION

3

QL

ZITHROMAX ORAL TABLET

3

QL

ZITHROMAX TRI-PAK ORAL TABLET

3

QL

VANCOMYCIN IN DEXTROSE ISO-OSM INTRAVENOUS PIGGYBACK

3

vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg

1

PA

ZITHROMAX Z-PAK ORAL TABLET

3

QL

VANCOMYCIN INTRAVENOUS RECON SOLN 750 MG

3

PA

ZMAX ORAL SUSPENSION,EXTENDE D REL RECON

3

QL

vancomycin oral capsule

1

PA

vandazole vaginal gel

1

3

VIBATIV INTRAVENOUS RECON SOLN

ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK

3

ZOSYN INTRAVENOUS RECON SOLN

3

VIBRAMYCIN ORAL CAPSULE

3

ZYLET OPHTHALMIC DROPS,SUSPENSION

2

VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION

3

ZYMAXID OPHTHALMIC DROPS

3

VIBRAMYCIN ORAL SYRUP

3

ZYVOX INTRAVENOUS PARENTERAL SOLUTION

3

VIGAMOX OPHTHALMIC DROPS

2

3

PA; QL

XIFAXAN ORAL TABLET

3

PA; QL

ZYVOX ORAL SUSPENSION FOR RECONSTITUTION ZYVOX ORAL TABLET

3

PA; QL

zencia topical cleanser

1

PA

ZERBAXA INTRAVENOUS RECON SOLN

3

PA

ST; CE

ANTICOAGULANTS ACD SOLUTION

3

ACD-A SOLUTION

3 3

3

ZINACEF IN STERILE WATER INTRAVENOUS PIGGYBACK

3

ANGIOMAX INTRAVENOUS RECON SOLN

ZINACEF INJECTION RECON SOLN

3

ZINACEF INTRAVENOUS RECON SOLN

ANTICOAG CITRATE PHOS DEXTROSE SOLUTION

3

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 30

Drug Name

Tier

ARGATROBAN IN 0.9 % SOD CHLOR INTRAVENOUS PARENTERAL SOLUTION

3

ARGATROBAN IN 0.9 % SOD CHLOR INTRAVENOUS SOLUTION

3

Notes

Drug Name

Tier

heparin (porcine) injection solution

1

heparin flush intravenous kit

1

heparin flush(porcine)-0.9nacl intravenous kit

1

heparin lock flush (porcine) intravenous solution

1

heparin lock flush (porcine) intravenous syringe

1

heparin lock flush intravenous solution

1

heparin lock flush intravenous syringe

1

ARGATROBAN IN NACL (ISO-OS) INTRAVENOUS SOLUTION

3

ARGATROBAN INTRAVENOUS SOLUTION

3

ARIXTRA SUBCUTANEOUS SYRINGE

4

heparin lock intravenous solution

1

BIVALIRUDIN INTRAVENOUS RECON SOLN

1

3

heparin lockflush(porcine)(pf) intravenous syringe

COUMADIN ORAL TABLET

2

ELIQUIS ORAL TABLET

2

3

enoxaparin subcutaneous solution

4

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

enoxaparin subcutaneous syringe

4

1

fondaparinux subcutaneous syringe

4

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml heparin, porcine (pf) injection solution

1

heparin, porcine (pf) injection syringe

1

QL

FRAGMIN SUBCUTANEOUS SOLUTION

4

FRAGMIN SUBCUTANEOUS SYRINGE

4

heparin, porcine (pf) intravenous solution

1

hep flush-10 (pf) intravenous solution

1

heparin, porcine (pf) intravenous syringe

1

heparin (porcine) in 5 % dex intravenous parenteral solution

1

IPRIVASK SUBCUTANEOUS RECON SOLN

4

heparin (porcine) in nacl (pf) intravenous parenteral solution

jantoven oral tablet

1

1

4

heparin (porcine) injection cartridge

LOVENOX SUBCUTANEOUS SOLUTION

1

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 31

Drug Name

Tier

Notes

LOVENOX SUBCUTANEOUS SYRINGE

4

monoject prefill (pf) intravenous syringe

1

monoject prefill advanced (pf) intravenous syringe

1

PRADAXA ORAL CAPSULE

2

QL

SAVAYSA ORAL TABLET

3

QL

SODIUM CITRATE SOLUTION

3

TRICITRASOL INJECTION CONCENTRATE

3

warfarin oral tablet

1

XARELTO ORAL TABLET

2

XARELTO ORAL TABLETS,DOSE PACK

2

Drug Name

QL

ANTIDOTES EVZIO INJECTION AUTO-INJECTOR

3

MOVANTIK ORAL TABLET

3

naloxone injection solution

1

naloxone injection syringe

1

naltrexone oral tablet

1

NARCAN NASAL SPRAY,NON-AEROSOL

2

RELISTOR SUBCUTANEOUS SOLUTION

3

RELISTOR SUBCUTANEOUS SYRINGE

3

REVIA ORAL TABLET

3

PA; QL

PA

ANTIFUNGALS ABELCET INTRAVENOUS SUSPENSION

3

Tier

Notes

AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION

3

amphotericin b injection recon soln

1

ANCOBON ORAL CAPSULE

3

CANCIDAS INTRAVENOUS RECON SOLN

3

ciclopirox topical cream

1

ciclopirox topical gel

1

ciclopirox topical shampoo

1

ciclopirox topical solution

1

ciclopirox topical suspension

1

clotrimazole mucous membrane troche

1

clotrimazole topical cream

1

clotrimazole topical solution

1

clotrimazole-betamethasone topical cream

1

clotrimazole-betamethasone topical lotion

1

CRESEMBA INTRAVENOUS RECON SOLN

3

PA; QL

CRESEMBA ORAL CAPSULE

3

PA; QL

DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION

3

DIFLUCAN ORAL TABLET

3

econazole topical cream

1

ECOZA TOPICAL FOAM

3

ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN

3

ERTACZO TOPICAL CREAM

3

EXELDERM TOPICAL CREAM

3

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 32

Drug Name

Tier

EXELDERM TOPICAL SOLUTION

3

EXODERM TOPICAL LOTION

3

EXTINA TOPICAL FOAM

3

fluconazole in dextrose(iso-o) intravenous piggyback FLUCONAZOLE IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML

Notes

Drug Name

1

3

Tier

LAMISIL ORAL GRANULES IN PACKET

3

LAMISIL ORAL TABLET

3

LOPROX TOPICAL SHAMPOO

3

LOTRISONE TOPICAL CREAM

3

LUZU TOPICAL CREAM

3

MENTAX TOPICAL CREAM

3

miconazole-3 vaginal suppository

1

MYCAMINE INTRAVENOUS RECON SOLN

3

NAFTIFINE TOPICAL CREAM 1 %

3

naftifine topical cream 2 %

1

NAFTIN TOPICAL CREAM

3

NAFTIN TOPICAL GEL

3 3

Notes

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

1

fluconazole oral suspension for reconstitution

1

fluconazole oral tablet

1

flucytosine oral capsule

1

griseofulvin microsize oral suspension

1

griseofulvin microsize oral tablet

1

NATACYN OPHTHALMIC DROPS,SUSPENSION

griseofulvin ultramicrosize oral tablet

1

NIZORAL TOPICAL SHAMPOO

3

GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET

3

NOXAFIL INTRAVENOUS SOLUTION

3

GYNAZOLE-1 VAGINAL CREAM

3

NOXAFIL ORAL SUSPENSION

3

PA; QL

itraconazole oral capsule

1

JUBLIA TOPICAL SOLUTION WITH APPLICATOR

3

PA; QL

3

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) nyamyc topical powder

1

KERYDIN TOPICAL SOLUTION WITH APPLICATOR

3

NYATA TOPICAL COMBO PACK,GEL AND POWDER

3

ketoconazole oral tablet

1

nystatin oral powder

1

ketoconazole topical cream

1

nystatin oral suspension

1

ketoconazole topical foam

1

nystatin oral tablet

1

ketoconazole topical shampoo

1

nystatin topical cream

1

nystatin topical ointment

1

PA

ST

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 33

Drug Name

Tier

nystatin topical powder

1

nystatin-triamcinolone topical cream

1

nystatin-triamcinolone topical ointment

1

nystop topical powder

1

ONMEL ORAL TABLET

3

ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET

3

oxiconazole topical cream

1

OXISTAT TOPICAL CREAM

3

OXISTAT TOPICAL LOTION

3

PEDIADERM AF TOPICAL CREAM

Notes

Drug Name

PA

Tier

voriconazole intravenous solution

1

voriconazole oral suspension for reconstitution

1

voriconazole oral tablet

1

VUSION TOPICAL OINTMENT

3

XOLEGEL TOPICAL GEL

3

Notes

ANTIHISTAMINE AND DECONGESTANT COMBINATION ALLEGRA-D 24 HOUR ORAL TABLET EXTENDED RELEASE 24 HR

3

3

centergy oral drops

1

PENLAC TOPICAL SOLUTION

3

ST

CLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE 12 HR

3

SPORANOX ORAL CAPSULE

3

PA; QL

promethazine vc oral syrup

1

SPORANOX ORAL SOLUTION

PA; QL

promethazine-phenylephrine oral syrup

1

3

SPORANOX PULSEPAK ORAL CAPSULE

3

PA; QL

SEMPREX-D ORAL CAPSULE

3

TERAZOL 3 VAGINAL CREAM

3

TERAZOL 7 VAGINAL CREAM

3

terbinafine hcl oral tablet

1

terconazole vaginal cream

ST; CE; QL

ST; CE; QL

ST; CE

ANTIHISTAMINES arbinoxa oral liquid

1

arbinoxa oral tablet

1

azelastine ophthalmic drops

1

QL

3

ST; CE; QL

1

BEPREVE OPHTHALMIC DROPS

terconazole vaginal suppository

1

carbinoxamine maleate oral liquid

1

TRIACETIN LIQUID

3

carbinoxamine maleate oral tablet

1

TRIPLE DYE TOPICAL SWAB

3

cetirizine oral solution

1

QL

VFEND IV INTRAVENOUS SOLUTION

3

ST; CE; QL

3

CLARINEX ORAL SYRUP

3

ST; CE; QL

VFEND ORAL SUSPENSION FOR RECONSTITUTION

CLARINEX ORAL TABLET 3

PA; QL

clemastine oral tablet

1

VFEND ORAL TABLET

3

PA; QL

CYPROHEPTADINE ORAL SYRUP

3

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 34

Drug Name

Tier

Notes

cyproheptadine oral tablet

1

desloratadine oral tablet

1

QL

desloratadine oral tablet,disintegrating

1

QL

diphenhydramine hcl injection solution

1

diphenhydramine hcl injection syringe

1

diphenhydramine hcl oral capsule

1

diphenhydramine hcl oral elixir

1

ELESTAT OPHTHALMIC DROPS

3

ST; CE; QL

EMADINE OPHTHALMIC DROPS

3

ST; CE; QL

epinastine ophthalmic drops

1

QL

hydroxyzine hcl intramuscular solution

Drug Name

Tier

Notes

promethazine oral tablet

1

VISTARIL ORAL CAPSULE

3

XYZAL ORAL SOLUTION

3

ST; CE; QL

XYZAL ORAL TABLET

3

ST; CE; QL

ANTIHYPERGLYCEMIC S acarbose oral tablet

1

ACTOPLUS MET ORAL TABLET

3

QL

ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR

2

QL

ACTOS ORAL TABLET

3

QL

3

PA; QL

1

AFREZZA INHALATION CARTRIDGE, W/INHALATION DEVICE

HYDROXYZINE HCL ORAL SOLUTION

3

ALOGLIPTIN ORAL TABLET

3

ST; QL

hydroxyzine hcl oral tablet

1

ALOGLIPTIN-METFOR MIN ORAL TABLET

3

ST; QL

hydroxyzine pamoate oral capsule

1

ALOGLIPTIN-PIOGLITA ZONE ORAL TABLET

3

ST; QL

KARBINAL ER ORAL SUSPENSION,EXTENDE D REL 12 HR

3

AMARYL ORAL TABLET

3

LASTACAFT OPHTHALMIC DROPS

3

ST; CE; QL

APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN

3

ST

levocetirizine oral solution

1

QL

levocetirizine oral tablet

1

QL

3

ST

olopatadine ophthalmic drops

1

ST; QL

APIDRA SUBCUTANEOUS SOLUTION

PATADAY OPHTHALMIC DROPS

3

ST; CE; QL

AVANDAMET ORAL TABLET

3

ST; QL

PATANOL OPHTHALMIC DROPS

3

ST; CE; QL

AVANDIA ORAL TABLET

3

ST; QL

PAZEO OPHTHALMIC DROPS

3

ST; CE; QL

2

ST

PHENERGAN INJECTION SOLUTION

BYDUREON SUBCUTANEOUS PEN INJECTOR

3

promethazine injection solution

1

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDE D REL RECON

2

ST; QL

promethazine oral syrup

1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 35

Drug Name

Tier

Notes

Drug Name

Tier

Notes

BYETTA SUBCUTANEOUS PEN INJECTOR

2

ST; QL

GLYXAMBI ORAL TABLET

3

ST; QL

chlorpropamide oral tablet

1

PA

HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN

2

CYCLOSET ORAL TABLET

3 3

QL

2

FARXIGA ORAL TABLET

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

DUETACT ORAL TABLET

3

ST; QL

2

FORTAMET ORAL TABLET EXTENDED RELEASE 24HR

3

HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION

glimepiride oral tablet

1

2

glipizide oral tablet

1

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

glipizide oral tablet extended release 24hr

1

2

glipizide-metformin oral tablet

HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION

1

GLUCOPHAGE ORAL TABLET

2

3

HUMALOG SUBCUTANEOUS CARTRIDGE

GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR

2

3

HUMALOG SUBCUTANEOUS SOLUTION

GLUCOTROL ORAL TABLET

3

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN

2

GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR

3

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION

2

GLUCOVANCE ORAL TABLET

3

2

GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR

HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN

3

HUMULIN N SUBCUTANEOUS SUSPENSION

2

glyburide micronized oral tablet

1

HUMULIN R INJECTION SOLUTION

2

glyburide oral tablet

1

glyburide-metformin oral tablet

1

2

GLYNASE ORAL TABLET

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

3

GLYSET ORAL TABLET

2

ST; CE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 36

Drug Name HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION

Tier

Notes

Drug Name

Tier

nateglinide oral tablet

1

2

NESINA ORAL TABLET

3

INVOKAMET ORAL TABLET

2

3

ST; QL

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION

INVOKANA ORAL TABLET

3

ST; QL

NOVOLIN N SUBCUTANEOUS SUSPENSION

2

JANUMET ORAL TABLET

2

ST; QL

NOVOLIN R INJECTION SOLUTION

2

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR

2

ST; QL

NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN

2

JANUVIA ORAL TABLET

2

ST; QL

JARDIANCE ORAL TABLET

2

2

ST; QL

NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN

JENTADUETO ORAL TABLET

2

ST; QL

2

KAZANO ORAL TABLET

3

ST; QL

NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION

2

Notes ST; QL

KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR

3

ST; QL

NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE

KORLYM ORAL TABLET

4

PA

NOVOLOG SUBCUTANEOUS SOLUTION

2

LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN

2

ONGLYZA ORAL TABLET 2.5 MG

3

ST; DO

ONGLYZA ORAL TABLET 5 MG

3

ST; QL

OSENI ORAL TABLET

3

ST; QL

pioglitazone oral tablet

1

QL

pioglitazone-glimepiride oral tablet

1

QL QL

LANTUS SUBCUTANEOUS SOLUTION

2

LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN

2

LEVEMIR SUBCUTANEOUS SOLUTION

2

pioglitazone-metformin oral tablet

1

metformin oral tablet

1

PRANDIN ORAL TABLET

3

metformin oral tablet extended release 24 hr

1

PRECOSE ORAL TABLET

3

metformin oral tablet extended release 24hr

1

repaglinide oral tablet

1

metformin oral tablet,er gast.retention 24 hr

3

repaglinide-metformin oral tablet

1

miglitol oral tablet

1

RIOMET ORAL SOLUTION

3

ST; CE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 37

Drug Name STARLIX ORAL TABLET

Tier

Notes

Drug Name

3

Tier

ALINIA ORAL SUSPENSION FOR RECONSTITUTION

3

ALINIA ORAL TABLET

3

atovaquone oral suspension

1

atovaquone-proguanil oral tablet

1

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR

2

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR

2

SYNJARDY ORAL TABLET

2

ST; QL

BILTRICIDE ORAL TABLET

3

TANZEUM SUBCUTANEOUS PEN INJECTOR 30 MG/0.5 ML

3

ST; QL

chloroquine phosphate oral tablet

1

TANZEUM SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML

3

3

COARTEM ORAL TABLET

3

tolazamide oral tablet

1

DARAPRIM ORAL TABLET

tolbutamide oral tablet

1

EMVERM ORAL TABLET,CHEWABLE

3

TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN

3

fem ph vaginal gel

1

formadon topical solution

1

TRADJENTA ORAL TABLET

2

ST; DO

formadon topical solution with applicator

1

TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN

3

ST

formaldehyde topical solution with applicator

1

TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN

GLUTARALDEHYDE SOLUTION

2

3

glycine irrigation solution

1

glycine urologic irrigation solution

1

hydroxychloroquine oral tablet

1

IMPAVIDO ORAL CAPSULE

3

ivermectin oral tablet

1

MALARONE ORAL TABLET

3

MALARONE PEDIATRIC ORAL TABLET

3

mefloquine oral tablet

1

MEPRON ORAL SUSPENSION

3

NEBUPENT INHALATION RECON SOLN

2

TRULICITY SUBCUTANEOUS PEN INJECTOR

3

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR

2

ST

ST

ST; QL

ST; QL

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR

2

ST; QL

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

3

ST; QL

ANTIINFECTIVES/MISC ELLANEOUS ALBENZA ORAL TABLET

3

Notes

PA; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 38

Drug Name

Tier

paromomycin oral capsule

1

PENTAM INJECTION RECON SOLN

2

PLAQUENIL ORAL TABLET

Notes

Drug Name

Tier

Notes

ALIMTA INTRAVENOUS RECON SOLN

3 3

3

ALKERAN INTRAVENOUS RECON SOLN

PRIMAQUINE ORAL TABLET

2

ALKERAN ORAL TABLET

2

QUALAQUIN ORAL CAPSULE

anastrozole oral tablet

1

QL

3

PA; QL

3

QL

quinine sulfate oral capsule

1

PA; QL

ARIMIDEX ORAL TABLET

RELAGARD VAGINAL GEL

3

AROMASIN ORAL TABLET

3

QL

STROMECTOL ORAL TABLET

3

3

TINDAMAX ORAL TABLET

ARRANON INTRAVENOUS SOLUTION

3

3

PA

tinidazole oral tablet

1

ARZERRA INTRAVENOUS SOLUTION

ARESTIN DENTAL CARTRIDGE

3

AVASTIN INTRAVENOUS SOLUTION

3

PA

AVC VAGINAL VAGINAL CREAM

3

azacitidine injection recon soln

1

QL

BELEODAQ INTRAVENOUS RECON SOLN

3

PA

BENDEKA INTRAVENOUS SOLUTION

3

bexarotene oral capsule

1

bicalutamide oral tablet

1

BICNU INTRAVENOUS RECON SOLN

3

bleomycin injection recon soln

1

BLINCYTO INTRAVENOUS KIT

3

PA

BOSULIF ORAL TABLET

2

PA; QL

BUSULFEX INTRAVENOUS SOLUTION

3

CABOMETYX ORAL TABLET

3

ANTIINFECTIVES

ANTINEOPLASTICS ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION

3

ACTIMMUNE SUBCUTANEOUS SOLUTION

4

ADCETRIS INTRAVENOUS RECON SOLN

3

adrucil intravenous solution

1

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION

3

AFINITOR ORAL TABLET

2

ALECENSA ORAL CAPSULE

3

ALFERON N INJECTION SOLUTION

4

PA; QL

PA

PA PA PA; QL

PA

PA; QL

PA; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 39

Drug Name

Tier

Notes

CAMPATH INTRAVENOUS SOLUTION

3

CAMPTOSAR INTRAVENOUS SOLUTION

3

capecitabine oral tablet

1

PA; QL

CAPRELSA ORAL TABLET

2

PA; QL

CARAC TOPICAL CREAM

2

carboplatin intravenous recon soln

1

carboplatin intravenous solution

1

CASODEX ORAL TABLET

3

cisplatin intravenous solution cladribine intravenous solution

Drug Name

Tier

DARZALEX INTRAVENOUS SOLUTION

3

daunorubicin intravenous recon soln

1

daunorubicin intravenous solution

1

decitabine intravenous recon soln

1

DEPOCYT (PF) INTRATHECAL SUSPENSION

3

diclofenac sodium topical gel

1

DOCEFREZ INTRAVENOUS RECON SOLN

3 1

1

docetaxel intravenous solution

1

DOXIL INTRAVENOUS SUSPENSION

3

CLOLAR INTRAVENOUS SOLUTION

1

3

doxorubicin intravenous recon soln

1

COMETRIQ ORAL CAPSULE

doxorubicin intravenous solution 3

1

COSMEGEN INTRAVENOUS RECON SOLN

doxorubicin, peg-liposomal intravenous suspension

3

EFUDEX TOPICAL CREAM

3

COTELLIC ORAL TABLET

3

3

cyclophosphamide intravenous recon soln

ELIGARD SUBCUTANEOUS SYRINGE

1

CYCLOPHOSPHAMIDE ORAL CAPSULE

3

3

ELLENCE INTRAVENOUS SOLUTION EMCYT ORAL CAPSULE

2

EMPLICITI INTRAVENOUS RECON SOLN

3 1

PA; QL

PA; QL

CYRAMZA INTRAVENOUS SOLUTION

3

cytarabine (pf) injection solution

1

cytarabine injection solution

1

epirubicin intravenous recon soln

dacarbazine intravenous recon soln

1

epirubicin intravenous solution

1

3

ERBITUX INTRAVENOUS SOLUTION

3

DACOGEN INTRAVENOUS RECON SOLN

PA

Notes

PA; QL

PA

PA; QL

PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 40

Drug Name

Tier

Notes

ERIVEDGE ORAL CAPSULE

2

PA; QL

ERWINAZE INJECTION RECON SOLN

3

PA

ETOPOPHOS INTRAVENOUS RECON SOLN

3

etoposide intravenous solution

1

etoposide oral capsule

Drug Name

Tier

Notes

GAZYVA INTRAVENOUS SOLUTION

3

gemcitabine intravenous recon soln

1

gemcitabine intravenous solution

1 3

1

GEMZAR INTRAVENOUS RECON SOLN

EVOMELA INTRAVENOUS RECON SOLN

3

PA; QL

3

GILOTRIF ORAL TABLET

3

PA; QL

exemestane oral tablet

1

QL

GLEEVEC ORAL TABLET

FARESTON ORAL TABLET

2

QL

GLEOSTINE ORAL CAPSULE

3

PA

FARYDAK ORAL CAPSULE

3

PA; QL

GLIADEL WAFER IMPLANT WAFER

3

HALAVEN INTRAVENOUS SOLUTION

3

PA

PA

PA

FASLODEX INTRAMUSCULAR SYRINGE

3

FEMARA ORAL TABLET

3

QL

3

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN

HERCEPTIN INTRAVENOUS RECON SOLN

3

PA

HEXALEN ORAL CAPSULE

2

floxuridine injection recon soln

1

3

PA

fludarabine intravenous recon soln

HYCAMTIN INTRAVENOUS RECON SOLN

1

2

PA

fludarabine intravenous solution

HYCAMTIN ORAL CAPSULE

1

3

FLUOROPLEX TOPICAL CREAM

HYDREA ORAL CAPSULE

3

hydroxyurea oral capsule

1

fluorouracil intravenous solution

1

IBRANCE ORAL CAPSULE

3

PA; QL

FLUOROURACIL TOPICAL CREAM 0.5 %

ICLUSIG ORAL TABLET

2

PA; QL

3

fluorouracil topical cream 5 %

3

1

IDAMYCIN PFS INTRAVENOUS SOLUTION

fluorouracil topical solution

1

idarubicin intravenous solution

1

flutamide oral capsule

1

IFEX INTRAVENOUS RECON SOLN

3

PA

FOLOTYN INTRAVENOUS 3 SOLUTION Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program

Effective 7/1/16 41

Drug Name

Tier

Notes

Drug Name

Tier

Notes

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1)

3

PA; QL

LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2), 8 MG/DAY (4 MG X 2)

3

PA

letrozole oral tablet

1

QL

ifosfamide intravenous recon soln

1

ifosfamide intravenous solution

1

ifosfamide-mesna intravenous kit

1

imatinib oral tablet

1

PA; QL

IMBRUVICA ORAL CAPSULE

3

PA; QL

IMLYGIC INJECTION SUSPENSION

3

INLYTA ORAL TABLET

2

PA; QL

2

INTRON A INJECTION RECON SOLN

LEUKERAN ORAL TABLET

4

PA

leuprolide subcutaneous kit

1

INTRON A INJECTION SOLUTION

4

PA

LEVULAN TOPICAL SOLUTION

3

IRESSA ORAL TABLET

2

PA; QL

1

irinotecan intravenous solution

lipodox 50 intravenous suspension

1

1

ISTODAX INTRAVENOUS RECON SOLN

lipodox intravenous suspension

3

LONSURF ORAL TABLET

3

PA

IXEMPRA INTRAVENOUS RECON SOLN

3

3

PA

JAKAFI ORAL TABLET

2

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT

3

PA

LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT

3

PA; QL

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT

3

PA

LYNPARZA ORAL CAPSULE

3

PA; QL

LYSODREN ORAL TABLET

2

QL

MARQIBO INTRAVENOUS KIT

3

MATULANE ORAL CAPSULE

2

JEVTANA INTRAVENOUS SOLUTION

3

KADCYLA INTRAVENOUS RECON SOLN

3

KEYTRUDA INTRAVENOUS RECON SOLN

3

KEYTRUDA INTRAVENOUS SOLUTION

3

KYPROLIS INTRAVENOUS RECON SOLN

3

PA; QL

PA

PA

PA

PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 42

Drug Name

Tier

megestrol oral tablet

1

MEKINIST ORAL TABLET

3

melphalan hcl intravenous recon soln

1

mercaptopurine oral tablet

1

methotrexate sodium (pf) injection recon soln

1

methotrexate sodium (pf) injection solution

1

methotrexate sodium injection solution

Notes

Drug Name

Tier

Notes

paclitaxel intravenous concentrate

1

PANRETIN TOPICAL GEL

3

PERJETA INTRAVENOUS SOLUTION

3

PHOTOFRIN INTRAVENOUS RECON SOLN

3

PICATO TOPICAL GEL

3

PA; QL

1

3

PA; QL

methotrexate sodium oral tablet

POMALYST ORAL CAPSULE

1

3

mitomycin intravenous recon soln

1

PORTRAZZA INTRAVENOUS SOLUTION

mitoxantrone intravenous concentrate

1

PROLEUKIN INTRAVENOUS RECON SOLN

3

MUSTARGEN INJECTION RECON SOLN

3

PROVENGE INTRAVENOUS SUSPENSION

4

PA

MYLERAN ORAL TABLET

2

PURIXAN ORAL SUSPENSION

3

PA

NAVELBINE INTRAVENOUS SOLUTION

3

REVLIMID ORAL CAPSULE

2

PA; QL

NEXAVAR ORAL TABLET

2

PA; QL

RITUXAN INTRAVENOUS CONCENTRATE

3

PA

NILANDRON ORAL TABLET

2

QL

SOLARAZE TOPICAL GEL

3

PA; QL

NINLARO ORAL CAPSULE

3

PA; QL

SOLTAMOX ORAL SOLUTION

2

NIPENT INTRAVENOUS RECON SOLN

3

SPRYCEL ORAL TABLET

2

PA; QL

ODOMZO ORAL CAPSULE

3

STIVARGA ORAL TABLET

2

PA; QL

ONIVYDE INTRAVENOUS DISPERSION

3

SUTENT ORAL CAPSULE

2

PA; QL

OPDIVO INTRAVENOUS SOLUTION

3

3

SYLATRON SUBCUTANEOUS KIT

oxaliplatin intravenous recon soln

1

SYLVANT INTRAVENOUS RECON SOLN

4

PA; QL

PA; QL

PA

PA

PA

oxaliplatin intravenous 1 solution Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 43

Drug Name

Tier

Notes

SYNRIBO SUBCUTANEOUS RECON SOLN

3

TABLOID ORAL TABLET

2

TAFINLAR ORAL CAPSULE

3

PA; QL

TAGRISSO ORAL TABLET

3

PA; QL

tamoxifen oral tablet

1

TARCEVA ORAL TABLET

2

PA; QL

TARGRETIN ORAL CAPSULE

3

TARGRETIN TOPICAL GEL

Drug Name

Tier

Notes

topotecan intravenous recon soln

1

topotecan intravenous solution

1

TORISEL INTRAVENOUS RECON SOLN

2

TREANDA INTRAVENOUS RECON SOLN

3

PA

TRELSTAR INTRAMUSCULAR SYRINGE

3

PA; QL

PA

tretinoin (chemotherapy) oral capsule

1

2

PA

2

TASIGNA ORAL CAPSULE

TREXALL ORAL TABLET

2

PA; QL

3

TAXOTERE INTRAVENOUS SOLUTION

TRISENOX INTRAVENOUS SOLUTION

3

TYKERB ORAL TABLET

2

UNITUXIN INTRAVENOUS SOLUTION

3

UVADEX INJECTION SOLUTION

3

VALCHLOR TOPICAL GEL

3

VALSTAR INTRAVESICAL SOLUTION

2

VANTAS IMPLANT KIT

3

PA

VECTIBIX INTRAVENOUS SOLUTION

3

PA

VELCADE INJECTION RECON SOLN

3

PA

VENCLEXTA ORAL TABLET

3

VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK

3

VIDAZA INJECTION RECON SOLN

3

TECENTRIQ INTRAVENOUS SOLUTION

PA

3

TEMODAR INTRAVENOUS RECON SOLN

2

TEMODAR ORAL CAPSULE

3

PA; QL

temozolomide oral capsule

1

PA; QL

TENIPOSIDE INTRAVENOUS SOLUTION

3

THERACYS INTRAVESICAL SUSPENSION FOR RECONSTITUTION

3

thiotepa injection recon soln

1

TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION

4

TOLAK TOPICAL CREAM

3

toposar intravenous solution

1

PA

PA; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 44

Drug Name

Tier

Notes

vinblastine intravenous solution

1

vincasar pfs intravenous solution

1

vincristine intravenous solution

1

vinorelbine intravenous solution

1

VOTRIENT ORAL TABLET

2

PA; QL

XALKORI ORAL CAPSULE

2

PA; QL

XELODA ORAL TABLET

3

PA

XTANDI ORAL CAPSULE

2

PA; QL

YERVOY INTRAVENOUS SOLUTION

3

PA

YONDELIS INTRAVENOUS RECON SOLN

3

ZALTRAP INTRAVENOUS SOLUTION

3

ZANOSAR INTRAVENOUS RECON SOLN

3

ZELBORAF ORAL TABLET

2

ZEVALIN (Y-90) INTRAVENOUS KIT

3

Drug Name

PA

PA; QL

ZOLADEX SUBCUTANEOUS IMPLANT

3

PA; QL

ZOLINZA ORAL CAPSULE

2

PA; QL

ZYDELIG ORAL TABLET

3

PA; QL

ZYKADIA ORAL CAPSULE

3

PA; QL

ZYTIGA ORAL TABLET

2

PA; QL

3

Notes

ADIPEX-P ORAL TABLET

3

PA

BELVIQ ORAL TABLET

3

PA

benzphetamine oral tablet 25 mg

1

benzphetamine oral tablet 50 mg

1

PA

CONTRAVE ORAL TABLET EXTENDED RELEASE

3

PA

diethylpropion oral tablet

1

PA

diethylpropion oral tablet extended release

1

PA

phendimetrazine tartrate oral capsule, extended release

1

PA

phendimetrazine tartrate oral tablet

1

PA

phentermine oral capsule

1

PA

phentermine oral tablet

1

PA

QSYMIA ORAL CAPSULE, ER MULTIPHASE 24 HR

3

PA

REGIMEX ORAL TABLET

3

PA

SAXENDA SUBCUTANEOUS PEN INJECTOR

3

PA

SUPRENZA ORAL TABLET,DISINTEGRATI NG

3

PA

XENICAL ORAL CAPSULE

3

ANTIPARKINSON DRUGS

ANTI-OBESITY DRUGS ADIPEX-P ORAL CAPSULE

Tier

PA

amantadine hcl oral capsule

1

amantadine hcl oral solution

1

amantadine hcl oral tablet

1

APOKYN SUBCUTANEOUS CARTRIDGE

4

AZILECT ORAL TABLET

2

benztropine injection solution

1

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 45

Drug Name

Tier

benztropine oral tablet

1

bromocriptine oral capsule

1

bromocriptine oral tablet

1

carbidopa oral tablet

Notes

Drug Name

Tier

ropinirole oral tablet extended release 24 hr

1 3

1

RYTARY ORAL CAPSULE, EXTENDED RELEASE

carbidopa-levodopa oral tablet

1

selegiline hcl oral capsule

1

selegiline hcl oral tablet

1

carbidopa-levodopa oral tablet extended release

1

3

carbidopa-levodopa oral tablet,disintegrating

1

SINEMET CR ORAL TABLET EXTENDED RELEASE

carbidopa-levodopa-entacapo ne oral tablet

3

1

SINEMET ORAL TABLET

COGENTIN INJECTION SOLUTION

3

3

STALEVO 100 ORAL TABLET

COMTAN ORAL TABLET

3

3

STALEVO 125 ORAL TABLET STALEVO 150 ORAL TABLET

3

STALEVO 200 ORAL TABLET

3

STALEVO 50 ORAL TABLET

3

STALEVO 75 ORAL TABLET

3

TASMAR ORAL TABLET

3

tolcapone oral tablet

1

trihexyphenidyl oral elixir

1

trihexyphenidyl oral tablet

1

ZELAPAR ORAL TABLET,DISINTEGRATI NG

3

DUOPA J-TUBE INTESTINAL PUMP SUSPENSION

3

ELDEPRYL ORAL CAPSULE

3

entacapone oral tablet

1

LODOSYN ORAL TABLET

3

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR

3

MIRAPEX ORAL TABLET

3

NEUPRO TRANSDERMAL PATCH 24 HOUR

3

PARLODEL ORAL CAPSULE

3

PARLODEL ORAL TABLET

3

pramipexole oral tablet

1

pramipexole oral tablet extended release 24 hr

1

REQUIP ORAL TABLET

PA

QL

Notes

PA; QL

ANTIPLATELET DRUGS AGGRASTAT IN SODIUM CHLORIDE INTRAVENOUS SOLUTION

3

AGGRENOX ORAL CAPSULE, ER MULTIPHASE 12 HR

3

3

3

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HR

AGRYLIN ORAL CAPSULE

3

anagrelide oral capsule

1 1

ropinirole oral tablet

1

aspirin-dipyridamole oral capsule, er multiphase 12 hr

QL

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 46

Drug Name

Tier

Notes

Drug Name

Tier

QL

acyclovir sodium intravenous solution

1

acyclovir topical ointment

1

adefovir oral tablet

4

APTIVUS ORAL CAPSULE

2

APTIVUS ORAL SOLUTION

2

ATRIPLA ORAL TABLET

2

BRILINTA ORAL TABLET

2

cilostazol oral tablet

1

clopidogrel oral tablet 300 mg

1

clopidogrel oral tablet 75 mg

1

dipyridamole oral tablet

1

DURLAZA ORAL CAPSULE,EXTENDED RELEASE 24HR

3

QL

EFFIENT ORAL TABLET 10 MG

2

QL

BARACLUDE ORAL SOLUTION

4

EFFIENT ORAL TABLET 5 MG

2

DO

BARACLUDE ORAL TABLET

4

eptifibatide intravenous solution

1

cidofovir intravenous solution

1

INTEGRILIN INTRAVENOUS SOLUTION

3

COMBIVIR ORAL TABLET

3

COMPLERA ORAL TABLET

2

COPEGUS ORAL TABLET

4

QL

Notes

KENGREAL INTRAVENOUS RECON SOLN

3

PERSANTINE ORAL TABLET

3

CRIXIVAN ORAL CAPSULE

2

PLAVIX ORAL TABLET 300 MG

3

4

PLAVIX ORAL TABLET 75 MG

3

CYTOVENE INTRAVENOUS RECON SOLN DAKLINZA ORAL TABLET

4

PA; QL

DENAVIR TOPICAL CREAM

3

PA; CE

DESCOVY ORAL TABLET

3 1

REOPRO INTRAVENOUS SOLUTION

3

ticlopidine oral tablet

1

ZONTIVITY ORAL TABLET

3

QL

QL

abacavir oral tablet

1

didanosine oral capsule,delayed release(dr/ec)

abacavir-lamivudine-zidovud ine oral tablet

1

EDURANT ORAL TABLET

2

acyclovir oral capsule

1

EMTRIVA ORAL CAPSULE

2

acyclovir oral suspension

1

acyclovir oral tablet

1

EMTRIVA ORAL SOLUTION

2

acyclovir sodium intravenous recon soln

1

entecavir oral tablet

4

ANTIVIRALS

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 47

Drug Name

Tier

EPIVIR HBV ORAL SOLUTION

4

EPIVIR HBV ORAL TABLET

4

EPIVIR ORAL SOLUTION

3

EPIVIR ORAL TABLET

3

EPZICOM ORAL TABLET

2

EVOTAZ ORAL TABLET

3

famciclovir oral tablet

Notes

Drug Name

Tier

Notes

KALETRA ORAL TABLET

2

lamivudine oral solution

1

lamivudine oral tablet 100 mg

4

lamivudine oral tablet 150 mg, 300 mg

1

lamivudine-zidovudine oral tablet

1 2

1

LEXIVA ORAL SUSPENSION

FAMVIR ORAL TABLET

3

LEXIVA ORAL TABLET

2

FLUMADINE ORAL TABLET

3

moderiba dose pack oral tablets,dose pack

4

foscarnet intravenous solution

moderiba oral tablet

4

1

nevirapine oral suspension

1

FOSCAVIR INTRAVENOUS SOLUTION

nevirapine oral tablet

1

3

nevirapine oral tablet extended release 24 hr

1

FUZEON SUBCUTANEOUS RECON SOLN

2

NORVIR ORAL CAPSULE

2

ganciclovir sodium intravenous recon soln

4

NORVIR ORAL SOLUTION

2

GENVOYA ORAL TABLET

NORVIR ORAL TABLET

2

2

3

HARVONI ORAL TABLET

ODEFSEY ORAL TABLET

4

4

PA; QL

HEPSERA ORAL TABLET

OLYSIO ORAL CAPSULE

4

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR

4

PA; QL

PEGASYS SUBCUTANEOUS SOLUTION

4

PA; QL

PEGASYS SUBCUTANEOUS SYRINGE

4

PA; QL

PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT

4

PA PA

INTELENCE ORAL TABLET

PA; QL

2

INVIRASE ORAL CAPSULE

2

INVIRASE ORAL TABLET

2

ISENTRESS ORAL POWDER IN PACKET

3

ISENTRESS ORAL TABLET

2

ISENTRESS ORAL TABLET,CHEWABLE

2

PEGINTRON SUBCUTANEOUS KIT

4

KALETRA ORAL SOLUTION

2

PREZCOBIX ORAL TABLET

3

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 48

Drug Name

Tier

Notes

Drug Name

Tier

Notes

PREZISTA ORAL SUSPENSION

2

STRIBILD ORAL TABLET

2

PREZISTA ORAL TABLET

2

SUSTIVA ORAL CAPSULE

2

RAPIVAB INTRAVENOUS SOLUTION

SUSTIVA ORAL TABLET

2

3

4

PA

REBETOL ORAL SOLUTION

4

SYNAGIS INTRAMUSCULAR SOLUTION TAMIFLU ORAL CAPSULE

2

QL

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION

2

QL

TECHNIVIE ORAL TABLET

4

PA; QL

TIVICAY ORAL TABLET

3

trifluridine ophthalmic drops

1

TRIUMEQ ORAL TABLET

2

TRIZIVIR ORAL TABLET

3 3

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

2

RESCRIPTOR ORAL TABLET

2

RESCRIPTOR ORAL TABLET, DISPERSIBLE

2

RETROVIR INTRAVENOUS SOLUTION

2

RETROVIR ORAL CAPSULE

3

RETROVIR ORAL SYRUP

3

REYATAZ ORAL CAPSULE

2

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG

REYATAZ ORAL POWDER IN PACKET

2

TRUVADA ORAL TABLET 200-300 MG

2

ribasphere oral capsule

4

TYZEKA ORAL TABLET

4

ribasphere oral tablet

4

valacyclovir oral tablet

1

ribasphere ribapak oral tablets,dose pack

4

VALCYTE ORAL RECON SOLN

3

ribavirin oral capsule

4

VALCYTE ORAL TABLET

3

ribavirin oral tablet

4

valganciclovir oral tablet

1

rimantadine oral tablet

1

SELZENTRY ORAL TABLET

3

2

VALTREX ORAL TABLET VEREGEN TOPICAL OINTMENT

3

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN

2

VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN

2

SITAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET

3

SOVALDI ORAL TABLET

4

stavudine oral capsule

1

stavudine oral recon soln

1

QL

PA; CE PA; QL

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 49

Drug Name

Tier

Notes

Drug Name

Tier

VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

VIEKIRA PAK ORAL TABLETS,DOSE PACK

4

VIRACEPT ORAL TABLET

2

VIRAMUNE ORAL SUSPENSION

3

ADDERALL ORAL TABLET

3

VIRAMUNE ORAL TABLET

3

1

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR

ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR

3

3

VIRAZOLE INHALATION RECON SOLN

ADRENACLICK INJECTION AUTO-INJECTOR

3

adrenalin injection solution

1

VIREAD ORAL POWDER

2

VIREAD ORAL TABLET

2

3

VIROPTIC OPHTHALMIC DROPS

ADZENYS XR-ODT ORAL TABLET,DISINTIG ER BIPHASE 24H

3

anectine injection solution

1

VISTIDE INTRAVENOUS SOLUTION

3

ARICEPT ORAL TABLET

3

VITEKTA ORAL TABLET

3

atracurium intravenous solution

1

XERESE TOPICAL CREAM

3

PA; CE

bethanechol chloride oral tablet

1

ZEPATIER ORAL TABLET

4

PA; QL

3

ZERIT ORAL CAPSULE

3

BLOXIVERZ INTRAVENOUS SOLUTION

ZERIT ORAL RECON SOLN

3

4

PA

ZIAGEN ORAL SOLUTION

BOTOX COSMETIC INJECTION RECON SOLN

2

ZIAGEN ORAL TABLET

3

BOTOX COSMETIC INTRAMUSCULAR RECON SOLN

4

PA

zidovudine oral capsule

1

zidovudine oral syrup

1

BOTOX INJECTION RECON SOLN

4

PA

zidovudine oral tablet

1

cevimeline oral capsule

1

ZIRGAN OPHTHALMIC GEL

3

cisatracurium intravenous solution

1

ZOVIRAX ORAL CAPSULE

3

DESOXYN ORAL TABLET

3

ZOVIRAX ORAL SUSPENSION

3

dexedrine oral tablet

1

PA; QL

ZOVIRAX ORAL TABLET

3

ZOVIRAX TOPICAL CREAM

3

ZOVIRAX TOPICAL OINTMENT

3

Notes

PA; CE; QL

AUTONOMIC DRUGS

PA

PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 50

Drug Name

Tier

Notes

Drug Name

Tier

DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE

3

ST

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR

2

dextroamphetamine oral capsule, extended release

1

PA

EPISNAP INJECTION KIT

3

dextroamphetamine oral solution

1

PA

EVEKEO ORAL TABLET

3

dextroamphetamine oral tablet

3

1

EVOXAC ORAL CAPSULE EXELON ORAL CAPSULE

3

EXELON TRANSDERMAL PATCH 24 HOUR

3

galantamine oral capsule,ext rel. pellets 24 hr

1

PA

dextroamphetamine-ampheta mine oral capsule,extended release 24hr

1

dextroamphetamine-ampheta mine oral tablet

1

DIBENZYLINE ORAL CAPSULE

3

galantamine oral solution

1

donepezil oral tablet

1

galantamine oral tablet

1

donepezil oral tablet,disintegrating

1

guanidine oral tablet

1

dopamine in 5 % dextrose intravenous solution

1

ISUPREL INJECTION SOLUTION

3

dopamine intravenous solution

1

3

DYANAVEL XR ORAL SUSPEN, IR - ER, BIPHASIC 24HR

LEVOPHED (BITARTRATE) INTRAVENOUS SOLUTION

3

MESTINON ORAL SYRUP

2

DYSPORT INTRAMUSCULAR RECON SOLN

4

MESTINON ORAL TABLET

3

enlon injection solution

1

3

ENLON-PLUS INTRAVENOUS SOLUTION

MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE

3

methamphetamine oral tablet

1

EPINEPHRINE HCL (PF) INTRAVENOUS SOLUTION

midodrine oral tablet

1

3

4

epinephrine injection auto-injector

MYOBLOC INTRAMUSCULAR SOLUTION

1

epinephrine injection solution

1

1

neostigmine methylsulfate intravenous solution 0.5 mg/ml

epinephrine injection syringe

1

NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION 1 MG/ML

3

NIMBEX INTRAVENOUS SOLUTION

3

EPIPEN 2-PAK INJECTION AUTO-INJECTOR

PA; CE PA

ST

PA

2

Notes

ST

ST

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 51

Drug Name

Tier

norepinephrine bitartrate intravenous solution

1

NORTHERA ORAL CAPSULE

3

pancuronium intravenous solution

1

phenoxybenzamine oral capsule

1

phentolamine injection recon soln

1

physostigmine salicylate injection solution

1

pilocarpine hcl oral tablet

1

procentra oral solution

1

pyridostigmine bromide oral tablet

1

pyridostigmine bromide oral tablet extended release

1

QUELICIN INJECTION SOLUTION

Notes

Drug Name ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

Tier 3

Notes ST

BIOLOGICALS ACTHIB (PF) INTRAMUSCULAR RECON SOLN

3

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION

3

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE

3

AFLURIA 2015-2016 (PF) INTRAMUSCULAR SYRINGE

2

QL

2

QL

3

AFLURIA 2015-2016 INTRAMUSCULAR SUSPENSION

RAZADYNE ER ORAL CAPSULE,EXT REL. PELLETS 24 HR

3

ALL EXT-CAL PEPPER TREE POLLEN INJECTION SOLUTION

3

RAZADYNE ORAL TABLET

3

ALL EXT-WEED POL-SHEEP SORREL INJECTION SOLUTION

3

regonol injection solution

1

rivastigmine tartrate oral capsule

1

ALL XT-WEED POL-RUSSIAN THISTL INJECTION SOLUTION

3

rivastigmine transdermal patch 24 hour

1

3

rocuronium intravenous solution

ALL.XT,KBLUE-JUNE GRASS POLLEN INJECTION SOLUTION

1

SALAGEN ORAL TABLET

3

3

URECHOLINE ORAL TABLET

ALLER EXT-ALTERNARIA ALTERNATA INJECTION SOLUTION

3

vecuronium bromide intravenous recon soln

3

1

ALLER EXT-AMERICAN COCKROACH INJECTION SOLUTION

XEOMIN INTRAMUSCULAR RECON SOLN

4

ALLER EXT-TREE POLL,RED CEDAR INJECTION SOLUTION

3

zenzedi oral tablet 10 mg, 5 mg

1

ALLER EXT-TREE POLLEN,AM ELM INJECTION SOLUTION

3

PA ST

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 52

Drug Name

Tier

Notes

Drug Name

Tier

ALLER EXT-TREE POLLEN,BAYBERRY INJECTION SOLUTION

3

ALLERG EX,GRASS POLLEN-ORCHARD INJECTION SOLUTION

3

ALLER EXT-TREE POLLEN,MESQUITE INJECTION SOLUTION

3

ALLERG EX-GRASS POLLEN-JOHNSON INJECTION SOLUTION

3

ALLER EXT-WEED POLLEN-KOCHIA INJECTION SOLUTION

3

ALLERG EXT,GRASS POLLEN-REDTOP INJECTION SOLUTION

3

ALLER XT-SHAGBARK HICKORY POLL INJECTION SOLUTION

3

3

ALLER XT-TREE POL,E.COTTONWOOD INJECTION SOLUTION

ALLERG EXT-ACREMONIUM STRICTUM INJECTION SOLUTION

3

3

ALLER XT-TREE POLLEN,BOX ELDER INJECTION SOLUTION

ALLERG EXT-BLACK WALNUT POLLEN INJECTION SOLUTION

3

3

ALLER XT-TREE POLLEN,HACKBERRY INJECTION SOLUTION

3

ALLERG EXT-GRASS,PERENNIAL RYE INJECTION SOLUTION

ALLER XT-TREE POLLEN,RED BIRCH INJECTION SOLUTION

3

3

ALLERG EXT-PENICILLIUM NOTATUM INJECTION SOLUTION

3

ALLERG EXT-TREE POLLEN-ACACIA INJECTION SOLUTION

3

3

ALLERG EXT-TREE POLLEN-ALDER INJECTION SOLUTION

3

3

ALLERG EXT-TREE POLL-JUN, WEST INJECTION SOLUTION

3

3

ALLERG EXT-TREE POLL-RED MAPLE INJECTION SOLUTION

3

3

ALLERG EXT-WEED POLLEN-MUGWORT INJECTION SOLUTION

3

3

ALLERG EX-WEED POL-RGH PIGWEED INJECTION SOLUTION

3

3

ALLERG XT,GRASS POLLEN-TIMOTHY INJECTION SOLUTION

3

ALLER XT-TREE POLLEN,WHITE ASH INJECTION SOLUTION ALLER XT-TREE POLLEN-MELALEUCA INJECTION SOLUTION ALLER XT-TREE POLLEN-WHITE OAK INJECTION SOLUTION ALLER XT-WEED POLLEN-COCKLEBUR INJECTION SOLUTION ALLER XT-WEED POLLEN-SAGEBRUSH INJECTION SOLUTION ALLER XT-WEED POLL-YELLOW DOCK INJECTION SOLUTION ALLERG EX,GRASS POLLEN-BERMUDA INJECTION SOLUTION

Notes

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 53

Drug Name

Tier

ALLERG XT,GRASS-MEADOW FESCUE INJECTION SOLUTION

3

ALLERG XT-SHEEP SOR,YELLW DOCK INJECTION SOLUTION

3

ALLERG XT-WEED POLL-DOG FENNEL INJECTION SOLUTION

3

ALLERG XT-WHITE BIRCH POLLEN INJECTION SOLUTION ALLERG XT-WHITE PINE POLLEN INJECTION SOLUTION ALLERGEN EX-FUSARIUM OXYSPORUM INJECTION SOLUTION ALLERGEN EXT-ASPERGILLUS FUMIG INJECTION SOLUTION

Tier 3

ALLERGEN EXT-ENGLISH PLANTAIN INJECTION SOLUTION

3

3

3

ALLERGEN EXT-GERMAN COCKROACH INJECTION SOLUTION

3

3

ALLERGEN EXT-OLIVE TREE POLLEN INJECTION SOLUTION

3

3

ALLERGEN EXT-RABBIT EPITHELIUM INJECTION SOLUTION

3

3

ALLERGEN EXTRACT-D.SOROKINI ANA INJECTION SOLUTION ALLERGEN EXTRACT-S. CEREVISIAE INJECTION SOLUTION

3

ALLERGEN EXT-T. MENTAGROPHYTES INJECTION SOLUTION

3

ALLERGEN EXT-TREE POLLEN,PECAN INJECTION SOLUTION

3

ALLERGEN XT TREE POL-AUST PINE INJECTION SOLUTION

3

ALLERGEN XT-AM.SYCAMORE POLLEN INJECTION SOLUTION

3

ALLERGEN XT-GRASS POLLEN-BAHIA INJECTION SOLUTION

3

ALLERGEN XT-MITE,D.PTERONYSS IN INJECTION SOLUTION

3

3

ALLERGEN EXT-AUREOBA.PULLUL ANS INJECTION SOLUTION

3

ALLERGEN EXT-BOTRYTIS CINEREA INJECTION SOLUTION

3

ALLERGEN EXT-C.CLADOSPORIOI DES INJECTION SOLUTION

3

ALLERGEN EXT-CANDIDA ALBICANS INJECTION SOLUTION

Drug Name ALLERGEN EXT-CATTLE EPITHELIUM INJECTION SOLUTION

ALLERGEN EXT-ASPERGILLUS,MIX ED INJECTION SOLUTION

ALLERGEN EXT-C.SPHAEROSPERM UM INJECTION SOLUTION

Notes

3

3

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 54

Drug Name

Tier

ALLERGEN XT-QUEEN PALM POLLEN INJECTION SOLUTION

3

ALLERGEN XT-VIRGINIA LIVE OAK INJECTION SOLUTION

3

ALLERGENIC EX-HORSE EPITHELIUM INJECTION SOLUTION

3

ALLERGENIC EXT, MIXED FEATHERS INJECTION SOLUTION

3

ALLERGENIC EXT-DOG EPITHELIUM INJECTION SOLUTION

3

ALLERGENIC EXT-MITE, D FARINAE INJECTION SOLUTION

3

ALLERGENIC EXT-MIXED RAGWEED INJECTION SOLUTION

3

Notes

Drug Name

Tier

ALLERGENIC XT-MOUSE EPITHELIUM INJECTION SOLUTION

3

ALLERGEN-WEED-LAM BSQUARTERS INJECTION SOLUTION

3

ALLERGN EXT-MOUNT.CEDAR POLLEN INJECTION SOLUTION

3

ALLERGN XT-RED MULBERRY POLLEN INJECTION SOLUTION

3

ANASCORP INTRAVENOUS RECON SOLN

3

ANTIVENIN LATRODECTUS MACTANS INJECTION RECON SOLN

3

ANTIVENIN MICRURUS FULVIUS INJECTION COMBO PACK

3

APLISOL INTRADERMAL SOLUTION

3

ATGAM INTRAVENOUS SOLUTION

4

BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

3

ALLERGENIC EXT-MUCOR PLUMBEUS INJECTION SOLUTION

3

ALLERGENIC EXT-PHOMA HERBARUM INJECTION SOLUTION

3

ALLERGENIC EXTRACT-CURVULARI A INJECTION SOLUTION

3

ALLERGENIC EXTRACT-FIRE ANT INJECTION SOLUTION

3

BEXSERO (PF) INTRAMUSCULAR SYRINGE

ALLERGENIC EXTRACT-MOSQUITO INJECTION SOLUTION

3

3

BIOTHRAX INTRAMUSCULAR SUSPENSION BIVIGAM INTRAVENOUS SOLUTION

4

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION

3

ALLERGENIC EXT-RHIZOPUS ORYZAE INJECTION SOLUTION

3

ALLERGENIC XT-EPICOCCUM NIGRUM INJECTION SOLUTION

3

QL

Notes

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 55

Drug Name

Tier

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

3

candin intradermal allergen

1

Notes

Drug Name

Tier

Notes

FLEBOGAMMA DIF INTRAVENOUS SOLUTION

4

PA

FLUARIX QUAD 2015-2016 (PF) INTRAMUSCULAR SYRINGE

2

QL

2

QL

3

FLUBLOK 2015-2016 (PF) INTRAMUSCULAR SOLUTION

CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE

2

QL

2

FLUCELVAX 2015-2016 (PF) INTRAMUSCULAR SYRINGE

CROFAB INJECTION RECON SOLN

3

2

QL

CYTOGAM INTRAVENOUS SOLUTION

FLULAVAL QUAD 2015-2016 INTRAMUSCULAR SUSPENSION

4

FLUMIST QUAD 2015-2016 NASAL NASAL SPRAY SYRINGE

2

QL

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION

3

FLUVIRIN 2015-2016 (PF) INTRAMUSCULAR SYRINGE

2

QL

3

FLUVIRIN 2015-2016 INTRAMUSCULAR SUSPENSION

2

QL

3

FLUZONE 2015-2016 INTRAMUSCULAR SUSPENSION

2

QL

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION

3

FLUZONE HIGH-DOSE 2015-16 (PF) INTRAMUSCULAR SYRINGE

2

QL

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

3

2

QL

EPIFIX AMNIOTIC MEMBRANE TOPICAL SHEET

FLUZONE INTRADERM QUAD 2015-16 INTRADERMAL SYRINGE

3

2

QL

QL

FLUZONE QUAD 2015-2016 (PF) INTRAMUSCULAR SUSPENSION

2

QL

QL

FLUZONE QUAD 2015-2016 (PF) INTRAMUSCULAR SYRINGE

CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN CAT HAIR STD ALLERGENIC EXT INJECTION SOLUTION

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

EZ FLU 2015-16 (FLUVIRIN) (PF) INTRAMUSCULAR SYRINGE KIT EZ FLU 2015-16(FLUCELVAX)(PF ) INTRAMUSCULAR SYRINGE KIT

4

2

2

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 56

Drug Name FLUZONE QUAD 2015-2016 INTRAMUSCULAR SUSPENSION

Tier 2

Notes

Drug Name

QL

Tier

HAVRIX (PF) INTRAMUSCULAR SYRINGE

3

HEPAGAM B INJECTION SOLUTION

4

HIZENTRA SUBCUTANEOUS SOLUTION

4

HYPERHEP B S/D INTRAMUSCULAR SOLUTION

4

HYPERHEP B S/D INTRAMUSCULAR SYRINGE

4

HYPERHEP B S-D NEONATAL INTRAMUSCULAR SYRINGE

4

HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION

4

HYPERRHO S/D INTRAMUSCULAR SYRINGE

4

FLUZONE QUAD PEDI 2015-16 (PF) INTRAMUSCULAR SYRINGE

2

GAMASTAN S/D INTRAMUSCULAR SOLUTION

4

PA

GAMMAGARD LIQUID INJECTION SOLUTION

4

PA

GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN

4

GAMMAKED INJECTION SOLUTION

4

GAMMAPLEX INTRAVENOUS SOLUTION

4

GAMUNEX-C INJECTION SOLUTION

4

GARDASIL (PF) INTRAMUSCULAR SUSPENSION

2

HYPERTET S/D (PF) INTRAMUSCULAR SYRINGE

3

GARDASIL (PF) INTRAMUSCULAR SYRINGE

2

HYQVIA SUBCUTANEOUS SOLUTION

4

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION

2

IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION

4

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

2

3

GRAFIX CORE TOPICAL SHEET

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN

3

GRAFIX PRIME TOPICAL SHEET

3

3

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

GRASTEK SUBLINGUAL TABLET

3

3

HAVRIX (PF) INTRAMUSCULAR SUSPENSION

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

3

IPOL INJECTION SUSPENSION

3

QL

PA

PA PA PA

PA; QL

Notes

PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 57

Drug Name IXIARO (PF) INTRAMUSCULAR SYRINGE

Tier

Notes

Drug Name

3

Tier

PENTACEL (PF) INTRAMUSCULAR KIT

3

PNEUMOVAX 23 INJECTION SOLUTION

2

PNEUMOVAX 23 INJECTION SYRINGE

2

KINRIX (PF) INTRAMUSCULAR SUSPENSION

3

KINRIX (PF) INTRAMUSCULAR SYRINGE

3

PRE-PEN INTRADERMAL SOLUTION

3

MENACTRA (PF) INTRAMUSCULAR SOLUTION

3

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE

2

MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN

3

PRIVIGEN INTRAVENOUS SOLUTION

4

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

3

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

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

3

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION

3

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT

3

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

3

MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SYRINGE

4

RAGWITEK SUBLINGUAL TABLET

3

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

3

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

3

4

M-M-R II (PF) SUBCUTANEOUS RECON SOLN

3

NABI-HB INTRAMUSCULAR SOLUTION

4

OCTAGAM INTRAVENOUS SOLUTION

4

PA

RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SYRINGE

ORALAIR SUBLINGUAL TABLET

3

PA; QL

RHOPHYLAC INJECTION SYRINGE

4

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

3

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION

3

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION

3

3

ROTATEQ VACCINE ORAL SUSPENSION

Notes

PA

PA; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 58

Drug Name SPHERUSOL INTRADERMAL SOLUTION

Tier

Notes

Drug Name

3

Tier

TWINRIX (PF) INTRAMUSCULAR SUSPENSION

3

TWINRIX (PF) INTRAMUSCULAR SYRINGE

3

3

STD GRASS POLLEN-SWEET VERNAL INJECTION SOLUTION

3

TENIVAC (PF) INTRAMUSCULAR SUSPENSION

3

TYPHIM VI INTRAMUSCULAR SOLUTION

TENIVAC (PF) INTRAMUSCULAR SYRINGE

3

3

TYPHIM VI INTRAMUSCULAR SYRINGE VAQTA (PF) INTRAMUSCULAR SUSPENSION

3

VAQTA (PF) INTRAMUSCULAR SYRINGE

3

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

VARIZIG INTRAMUSCULAR RECON SOLN

3

VARIZIG INTRAMUSCULAR SOLUTION

3

VIVOTIF BERNA VACCINE ORAL CAPSULE,DELAYED RELEASE(DR/EC)

2

VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC)

2

3

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION

3

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION

3

THYMOGLOBULIN INTRAVENOUS RECON SOLN

4

TREE POLLEN-ARIZONA CYPRESS INJECTION SOLUTION

3

TREE POLLEN-BALD CYPRESS INJECTION SOLUTION

3

TREE POLLEN-BLACK WILLOW INJECTION SOLUTION

3

TREE POLLEN-PRIVET INJECTION SOLUTION

3

TREE POLLEN-SWEET GUM INJECTION SOLUTION

3

WEED POLLEN-SHORT RAGWEED INJECTION SOLUTION

TRUMENBA INTRAMUSCULAR SYRINGE

3

3

WEED POLLEN-TRUE MARSH ELDER INJECTION SOLUTION

TRUSKIN TOPICAL SHEET

4

3

WINRHO SDF INJECTION SOLUTION

TUBERSOL INTRADERMAL SOLUTION

3

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

Notes

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 59

Drug Name ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier

Notes

Drug Name

2

BLOOD ACTIVASE INTRAVENOUS RECON SOLN

3

ADVATE INTRAVENOUS RECON SOLN

4

PA

Tier

Notes

ALPHANINE SD INTRAVENOUS RECON SOLN

4

PA

ALPROLIX INTRAVENOUS RECON SOLN

4

PA

AMICAR ORAL SOLUTION

3

AMICAR ORAL TABLET

3

aminocaproic acid intravenous solution

1

ASTRINGYN TOPICAL SOLUTION

3

AVITENE FLOUR TOPICAL POWDER

3

AVITENE TOPICAL POWDER IN PACKET

3

ADYNOVATE INTRAVENOUS SOLUTION

4

ALBUKED-25 INTRAVENOUS PARENTERAL SOLUTION

3

ALBUKED-5 INTRAVENOUS PARENTERAL SOLUTION

3

AVITENE TOPICAL SHEET

3

albumin, human 25 % intravenous parenteral solution

4

PA

1

BEBULIN INTRAVENOUS RECON SOLN

ALBUMIN, HUMAN 5 % INTRAVENOUS PARENTERAL SOLUTION

BENEFIX INTRAVENOUS KIT

4

PA

2

buminate 25 % intravenous parenteral solution

1

albuminar 25 % intravenous parenteral solution

1

1

buminate 5 % intravenous parenteral solution

albuminar 5 % intravenous parenteral solution

1

CATHFLO ACTIVASE INTRA-CATHETER RECON SOLN

3

alburx (human) 25 % intravenous parenteral solution

1

CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN

4

alburx (human) 5 % intravenous parenteral solution

1

CEPROTIN (GREEN BAR) INTRAVENOUS RECON SOLN

4

albutein 25 % intravenous parenteral solution

1

4

PA

albutein 5 % intravenous parenteral solution

1

COAGADEX INTRAVENOUS RECON SOLN

ALPHANATE INTRAVENOUS RECON SOLN

CORIFACT INTRAVENOUS KIT

4

PA

4

CYKLOKAPRON INTRAVENOUS SOLUTION

3

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 60

Drug Name

Tier

DEFITELIO INTRAVENOUS SOLUTION

4

DROXIA ORAL CAPSULE

2

ELOCTATE INTRAVENOUS RECON SOLN

4

ENDO AVITENE TOPICAL SHEET

3

EVICEL TOPICAL SOLUTION

3

FEIBA NF INTRAVENOUS RECON SOLN

4

FLEXBUMIN 25 % INTRAVENOUS PARENTERAL SOLUTION

3

FLEXBUMIN 5 % INTRAVENOUS PARENTERAL SOLUTION

3

GELFOAM COMPRESSED SIZE 100 TOPICAL SPONGE

3

GELFOAM MUCOUS MEMBRANE POWDER

3

GELFOAM SPONGE SIZE 100 TOPICAL SPONGE

Notes

Drug Name

PA

PA

3

Tier

Notes

HEMOFIL M HIGH INTRAVENOUS RECON SOLN

4

PA

HEMOFIL M LOW INTRAVENOUS RECON SOLN

4

PA

HEMOFIL M MID INTRAVENOUS RECON SOLN

4

PA

HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN

4

PA

HESPAN 6 % IN NS INTRAVENOUS SOLUTION

3

hetastarch 6 % in 0.9 % nacl intravenous solution

1

HEXTEND INTRAVENOUS SOLUTION

3

HUMATE-P INTRAVENOUS KIT

4

IDELVION INTRAVENOUS RECON SOLN

4

IXINITY INTRAVENOUS RECON SOLN

4

KCENTRA INTRAVENOUS KIT

3

3

PA

PA

GELFOAM SPONGE SIZE 12-7MM TOPICAL SPONGE

3

KEDBUMIN INTRAVENOUS PARENTERAL SOLUTION

GELFOAM SPONGE SIZE 200 TOPICAL SPONGE

4

PA

3

KOATE-DVI INTRAVENOUS RECON SOLN

GELFOAM SPONGE SIZE 50 TOPICAL SPONGE

4

PA

3

KOGENATE FS INTRAVENOUS RECON SOLN

GELFOAM TOPICAL SPONGE

3

KOVALTRY INTRAVENOUS RECON SOLN

4

HELIXATE FS INTRAVENOUS RECON SOLN

4

lmd 10 % in 0.9 % sodium chlor intravenous parenteral solution

1

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 61

Drug Name

Tier

Notes

lmd 10 % in 5 % dextrose intravenous parenteral solution

1

LYSTEDA ORAL TABLET

3

MONOCLATE-P INTRAVENOUS KIT

4

PA

MONONINE INTRAVENOUS KIT

4

PA

MONSEL'S TOPICAL SOLUTION

3

MONSEL'S TOPICAL SOLUTION WITH APPLICATOR

3

NOVOEIGHT INTRAVENOUS RECON SOLN

4

NOVOSEVEN RT INTRAVENOUS RECON SOLN

4

PA

NUWIQ INTRAVENOUS RECON SOLN

4

PA

OBIZUR INTRAVENOUS RECON SOLN

4

PA

OCTAPLAS (BLOOD GROUP A) INTRAVENOUS SOLUTION

3

Drug Name

PA

Tier

Notes

plasbumin 5 % intravenous parenteral solution

1

plasmanate intravenous parenteral solution

1

PRAXBIND INTRAVENOUS SOLUTION

3

PROFILNINE INTRAVENOUS RECON SOLN

4

protamine intravenous solution

1

RECOMBINATE INTRAVENOUS RECON SOLN

4

RECOTHROM SPRAY KIT TOPICAL RECON SOLN

3

RECOTHROM TOPICAL RECON SOLN

3

RETAVASE INTRAVENOUS KIT

3

RIASTAP INTRAVENOUS RECON SOLN

3

PA

RIXUBIS INTRAVENOUS RECON SOLN

4

PA

SOLIRIS INTRAVENOUS SOLUTION

4

PA

SYRINGE AVITENE TOPICAL POWDER

3

TACHOSIL TOPICAL ADHESIVE PATCH,MEDICATED

3

THROMBATE III INTRAVENOUS RECON SOLN

3

THROMBI-GEL TOPICAL PADS, MEDICATED

3

OCTAPLAS (BLOOD GROUP AB) INTRAVENOUS SOLUTION

3

OCTAPLAS (BLOOD GROUP B) INTRAVENOUS SOLUTION

3

OCTAPLAS (BLOOD GROUP O) INTRAVENOUS SOLUTION

3

OXYCEL COTTON-TYPE PLEDGET PAD

3

3

pentoxifylline oral tablet extended release

THROMBIN-JMI NASAL NASAL SPRAY SYRINGE

1

3

plasbumin 25 % intravenous parenteral solution

THROMBIN-JMI TOPICAL RECON SOLN

1

PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 62

Drug Name THROMBIN-JMI TOPICAL SPRAY SYRINGE

Tier

Notes

Drug Name

3

Tier

Notes

adenosine intravenous solution

1

adenosine intravenous syringe

1

afeditab cr oral tablet extended release 30 mg

1

DO QL

THROMBIN-JMI TOPICAL SPRAY,NON-AEROSOL

3

THROMBI-PAD TOPICAL PADS, MEDICATED

3

afeditab cr oral tablet extended release 60 mg

1

TISSEEL VHSD TOPICAL KIT

3

amiodarone intravenous solution

1

TISSEEL VHSD TOPICAL SYRINGE

3

amiodarone intravenous syringe

1

TNKASE INTRAVENOUS KIT

amiodarone oral tablet

1

3

amlodipine oral tablet 10 mg

1

QL

tranexamic acid intravenous solution

1

QL

amlodipine oral tablet 2.5 mg, 5 mg

1

DO

tranexamic acid oral tablet

1

QL

CALAN ORAL TABLET

3

QL

PA

CALAN SR ORAL TABLET EXTENDED RELEASE

3

QL

CARDENE IV IN DEXTROSE INTRAVENOUS PIGGYBACK

3

CARDENE IV IN SODIUM CHLORIDE INTRAVENOUS PIGGYBACK

3

CARDENE IV INTRAVENOUS SOLUTION

3

cardioplegic soln perfusion solution

1

CARDIZEM CD ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG

3

DO

CARDIZEM CD ORAL CAPSULE,EXTENDED RELEASE 24HR 240 MG, 300 MG, 360 MG

3

QL

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG, 180 MG

3

DO

TRETTEN INTRAVENOUS RECON SOLN

4

ULTRAFOAM TOPICAL SPONGE

3

VOLUVEN 6 % INTRAVENOUS SOLUTION

3

WILATE INTRAVENOUS KIT

4

PA

WILATE INTRAVENOUS RECON SOLN

4

PA

XYNTHA INTRAVENOUS SOLUTION

4

XYNTHA SOLOFUSE INTRAVENOUS SYRINGE

4

PA

PA

CARDIAC DRUGS ADALAT CC ORAL TABLET EXTENDED RELEASE 30 MG

3

DO

ADALAT CC ORAL TABLET EXTENDED RELEASE 60 MG, 90 MG

3

QL

ADENOCARD INTRAVENOUS SYRINGE

3

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 63

Drug Name

Tier

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 240 MG, 300 MG, 360 MG, 420 MG

3

CARDIZEM ORAL TABLET

3

cartia xt oral capsule,extended release 24hr 120 mg, 180 mg

1

cartia xt oral capsule,extended release 24hr 240 mg, 300 mg

1

CLEVIPREX INTRAVENOUS EMULSION

3

CORDARONE ORAL TABLET

2

CORLANOR ORAL TABLET

2

CORVERT INTRAVENOUS SOLUTION

3

digitek oral tablet

1

digox oral tablet

1

digoxin injection solution

1

digoxin injection syringe

1

digoxin oral solution

1

digoxin oral tablet

Notes

Drug Name

Tier

Notes

diltiazem hcl oral capsule,ext release degradable 240 mg

1

QL

diltiazem hcl oral capsule,extended release 12 hr

1

QL

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg

1

DO

diltiazem hcl oral capsule,extended release 24hr 240 mg, 300 mg, 360 mg

1

QL

diltiazem hcl oral tablet

1

QL

diltiazem hcl oral tablet extended release 24 hr 180 mg

1

DO

diltiazem hcl oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg

1

QL

dilt-xr oral capsule,ext release degradable 120 mg, 180 mg

1

DO

dilt-xr oral capsule,ext release degradable 240 mg

1

QL

disopyramide phosphate oral capsule

1 1

1

dobutamine in d5w intravenous parenteral solution

DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE

2

dobutamine intravenous solution

1

diltiazem hcl intravenous recon soln

1

QL

1

felodipine oral tablet extended release 24 hr 10 mg

diltiazem hcl intravenous solution

1

felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg

1

DO

flecainide oral tablet

1

ibutilide fumarate intravenous solution

1

ISOCHRON ORAL TABLET EXTENDED RELEASE

3

ISORDIL ORAL TABLET

2

ISORDIL TITRADOSE ORAL TABLET

3

QL

QL DO

QL

PA; QL

diltiazem hcl oral capsule, extended release 120 mg, 180 mg

1

DO

diltiazem hcl oral capsule, extended release 240 mg, 300 mg, 360 mg, 420 mg

1

QL

diltiazem hcl oral capsule,ext release degradable 120 mg, 180 mg

1

DO

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 64

Drug Name

Tier

Notes

Drug Name

Tier

Notes

isosorbide dinitrate oral tablet

1

nifedical xl oral tablet extended release 24hr 30 mg

1

DO

isosorbide dinitrate oral tablet extended release

1

nifedical xl oral tablet extended release 24hr 60 mg

1

QL

isosorbide mononitrate oral tablet

1

nifedipine oral capsule

1

QL

isosorbide mononitrate oral tablet extended release 24 hr

1

DO

1

nifedipine oral tablet extended release 24hr 30 mg

isradipine oral capsule

1

1

QL

LANOXIN INJECTION SOLUTION

nifedipine oral tablet extended release 24hr 60 mg, 90 mg

3

1

DO

LANOXIN ORAL TABLET

nifedipine oral tablet extended release 30 mg

2

LANOXIN PEDIATRIC INJECTION SOLUTION

1

QL

2

nifedipine oral tablet extended release 60 mg, 90 mg

lidocaine (pf) intravenous solution

nimodipine oral capsule

1

QL

1

lidocaine (pf) intravenous syringe

1

DO

1

nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 8.5 mg nisoldipine oral tablet extended release 24 hr 25.5 mg, 30 mg, 34 mg, 40 mg

1

QL

nitro-bid transdermal ointment

1

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

3

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

2

nitroglycerin in 5 % dextrose intravenous solution

1

lidocaine in 5 % dextrose (pf) intravenous parenteral solution

QL

1

matzim la oral tablet extended release 24 hr 180 mg

1

matzim la oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg

1

mexiletine oral capsule

1

milrinone in 5 % dextrose intravenous piggyback

1

milrinone intravenous solution

1

MINITRAN TRANSDERMAL PATCH 24 HOUR

3

nitroglycerin intravenous solution

1

MULTAQ ORAL TABLET

3

nitroglycerin oral capsule, extended release

1

NEXTERONE INTRAVENOUS SOLUTION

3

nitroglycerin transdermal patch 24 hour

1

nicardipine intravenous solution

1

1

nitroglycerin translingual aerosol,spray

nicardipine oral capsule

1

nitroglycerin translingual spray,non-aerosol

1

DO

QL

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 65

Drug Name

Tier

Notes

NITROLINGUAL TRANSLINGUAL SPRAY,NON-AEROSOL

3

NITROMIST TRANSLINGUAL AEROSOL,SPRAY

3

NITROSTAT SUBLINGUAL TABLET

2

nitro-time oral capsule, extended release

1

NORPACE CR ORAL CAPSULE, EXTENDED RELEASE

2

NORPACE ORAL CAPSULE

3

NORVASC ORAL TABLET 10 MG

3

QL

NORVASC ORAL TABLET 2.5 MG, 5 MG

3

DO

NYMALIZE ORAL SOLUTION

3

pacerone oral tablet

1

PLEGISOL PERFUSION SOLUTION

3

procainamide injection solution

1

PROCARDIA ORAL CAPSULE

3

PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG

3

Drug Name

QL DO

Tier

Notes

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR

2

RYTHMOL ORAL TABLET

3

RYTHMOL SR ORAL CAPSULE,EXTENDED RELEASE 12 HR

3

SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG, 8.5 MG

3

DO

SULAR ORAL TABLET EXTENDED RELEASE 24 HR 34 MG

3

QL

taztia xt oral capsule, extended release 120 mg, 180 mg

1

DO

taztia xt oral capsule, extended release 240 mg, 300 mg, 360 mg

1

QL

TIAZAC ORAL CAPSULE, EXTENDED RELEASE 120 MG, 180 MG

3

DO

TIAZAC ORAL CAPSULE, EXTENDED RELEASE 240 MG, 300 MG, 360 MG, 420 MG

3

QL

TIKOSYN ORAL CAPSULE

3

verapamil intravenous solution

1

verapamil intravenous syringe

1

verapamil oral capsule, 24 hr er pellet ct 100 mg

1

DO

PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR 60 MG, 90 MG

3

propafenone oral capsule,extended release 12 hr

1

verapamil oral capsule, 24 hr er pellet ct 200 mg, 300 mg

1

QL

propafenone oral tablet

1

1

DO

quinidine gluconate injection solution

1

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg

quinidine gluconate oral tablet extended release

1

verapamil oral capsule,ext rel. pellets 24 hr 240 mg, 360 mg

1

QL

quinidine sulfate oral tablet

1

verapamil oral tablet

1

QL

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 66

Drug Name

Tier

verapamil oral tablet extended release

1

VERELAN ORAL CAPSULE,EXT REL. PELLETS 24 HR 120 MG, 180 MG

3

VERELAN ORAL CAPSULE,EXT REL. PELLETS 24 HR 240 MG, 360 MG VERELAN PM ORAL CAPSULE, 24 HR ER PELLET CT 100 MG

3

3

VERELAN PM ORAL CAPSULE, 24 HR ER PELLET CT 200 MG, 300 MG

3

XYLOCAINE (CARDIAC) (PF) INTRAVENOUS SOLUTION

3

Notes

Drug Name

QL

DO

QL

DO

QL

CARDIOVASCULAR

Tier

Notes

amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg

1

amlodipine-benazepril oral capsule

1

amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-320 mg

1

QL

amlodipine-valsartan oral tablet 5-160 mg

1

DO

amlodipine-valsartan-hcthiaz id oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-25 mg

1

QL

amlodipine-valsartan-hcthiaz id oral tablet 5-160-12.5 mg

1

DO

ANTARA ORAL CAPSULE

3

ASCLERA INTRAVENOUS SOLUTION

3

ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG

3

ATACAND HCT ORAL TABLET 32-25 MG

3

ATACAND ORAL TABLET

3

atenolol oral tablet

1 1

DO

ACCUPRIL ORAL TABLET

3

ACCURETIC ORAL TABLET

3

acebutolol oral capsule

1

ACEON ORAL TABLET

3

ADCIRCA ORAL TABLET

4

PA; QL

ADEMPAS ORAL TABLET

4

PA; QL

alprostadil injection solution

1

atenolol-chlorthalidone oral tablet

ALTACE ORAL CAPSULE

3

atorvastatin oral tablet 10 mg, 20 mg, 40 mg

1

DO

atorvastatin oral tablet 80 mg

1

QL

ATROPEN INTRAMUSCULAR PEN INJECTOR

3

AVALIDE ORAL TABLET 150-12.5 MG

3

AVALIDE ORAL TABLET 300-12.5 MG

3

AVAPRO ORAL TABLET 150 MG, 75 MG

3

ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR 20 MG, 40 MG

3

ST; DO

ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR 60 MG

3

ST; QL

amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-80 mg

1

QL

QL

QL

QL

DO

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 67

Drug Name

Tier

AVAPRO ORAL TABLET 300 MG

3

AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-40 MG

2

AZOR ORAL TABLET 5-20 MG

2

benazepril oral tablet

Notes

Drug Name

Tier

Notes

CADUET ORAL TABLET 2.5-10 MG, 2.5-20 MG, 2.5-40 MG, 5-10 MG, 5-20 MG, 5-40 MG

3

DO

candesartan oral tablet

1

QL

1

QL

1

candesartan-hydrochlorothiaz id oral tablet 16-12.5 mg, 32-12.5 mg

benazepril-hydrochlorothiazi de oral tablet

1

candesartan-hydrochlorothiaz id oral tablet 32-25 mg

1

BENICAR HCT ORAL TABLET 20-12.5 MG

captopril oral tablet

1

2

1

BENICAR HCT ORAL TABLET 40-12.5 MG, 40-25 MG

captopril-hydrochlorothiazid e oral tablet

2

QL

CARDURA ORAL TABLET

3

BENICAR ORAL TABLET 20 MG

2

DO

3

BENICAR ORAL TABLET 40 MG, 5 MG

CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR

2

QL

carvedilol oral tablet

1

BETAPACE AF ORAL TABLET

3

CATAPRES ORAL TABLET

3

BETAPACE ORAL TABLET

3

3

betaxolol oral tablet

1

CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY

BIDIL ORAL TABLET

2

3

bisoprolol fumarate oral tablet

1

CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY

bisoprolol-hydrochlorothiazi de oral tablet

1

CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY

3

cholestyramine (with sugar) oral powder

1

cholestyramine (with sugar) oral powder in packet

1

cholestyramine light oral powder

1

cholestyramine light oral powder in packet

1

clonidine hcl oral tablet

1

clonidine transdermal patch weekly

1

clorpres oral tablet 0.1-15 mg, 0.2-15 mg

1

CLORPRES ORAL TABLET 0.3-15 MG

3

BREVIBLOC IN NACL (ISO-OSM) INTRAVENOUS PARENTERAL SOLUTION

QL DO

DO

3

BREVIBLOC INTRAVENOUS SOLUTION

3

BYSTOLIC ORAL TABLET

3

CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-80 MG

QL

3

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 68

Drug Name

Tier

COLESTID FLAVORED ORAL GRANULES

3

COLESTID FLAVORED ORAL PACKET

3

COLESTID ORAL GRANULES

3

COLESTID ORAL PACKET

3

COLESTID ORAL TABLET

3

colestipol oral granules

1

colestipol oral packet

1

colestipol oral tablet

1

COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR

2

COREG ORAL TABLET

3

CORGARD ORAL TABLET

3

CORLOPAM INTRAVENOUS SOLUTION

3

CORZIDE ORAL TABLET

3

COZAAR ORAL TABLET

3

Notes

Drug Name

QL

Tier

EDARBYCLOR ORAL TABLET

3

enalapril maleate oral tablet

1

enalaprilat intravenous solution

1

enalapril-hydrochlorothiazide oral tablet

1

ENTRESTO ORAL TABLET

2

EPANED ORAL RECON SOLN

3

epoprostenol (glycine) intravenous recon soln

4

PA

eprosartan oral tablet

1

QL

ergoloid oral tablet

1

esmolol intravenous solution

1

ETHAMOLIN INTRAVENOUS SOLUTION

3

EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-25 MG

3

QL

EXFORGE HCT ORAL TABLET 5-160-12.5 MG

3

DO

3

QL DO

CRESTOR ORAL TABLET 10 MG, 20 MG, 5 MG

2

DO

EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-320 MG

CRESTOR ORAL TABLET 40 MG

2

QL

EXFORGE ORAL TABLET 5-160 MG

3

DEMSER ORAL CAPSULE

3

fenofibrate micronized oral capsule

1

DIOVAN HCT ORAL TABLET 160-12.5 MG, 80-12.5 MG

1

3

fenofibrate nanocrystallized oral tablet

3

DIOVAN HCT ORAL TABLET 160-25 MG, 320-12.5 MG, 320-25 MG

FENOFIBRATE ORAL CAPSULE 3

QL

FENOFIBRATE ORAL TABLET 120 MG, 40 MG

3

DIOVAN ORAL TABLET

3

QL

1

doxazosin oral tablet

1

fenofibrate oral tablet 160 mg, 54 mg

1 1

DO

Notes

DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR

3

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

EDARBI ORAL TABLET

3

fenofibric acid oral tablet

QL

PA; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 69

Drug Name

Tier

Notes

FENOGLIDE ORAL TABLET

3

FIBRICOR ORAL TABLET

3

FLOLAN INTRAVENOUS RECON SOLN

4

PA

fluvastatin oral capsule

1

DO

fluvastatin oral tablet extended release 24 hr

Drug Name

Tier

Notes

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 5 MG

3

PA

JUXTAPID ORAL CAPSULE 40 MG, 60 MG

3

PA; QL

KYNAMRO SUBCUTANEOUS SYRINGE

3

PA; QL

1

labetalol intravenous solution

1

fosinopril oral tablet

1

labetalol intravenous syringe

1

fosinopril-hydrochlorothiazid e oral tablet

labetalol oral tablet

1

1

3

ST; DO

gemfibrozil oral tablet

1

LESCOL ORAL CAPSULE

guanfacine oral tablet

1

3

ST

HEMANGEOL ORAL SOLUTION

3

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HR

hydralazine injection solution

1

LETAIRIS ORAL TABLET

4

PA; QL

hydralazine oral tablet

1

HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG

3

3

LEVATOL ORAL TABLET

HYZAAR ORAL TABLET 50-12.5 MG

3

ST; DO; CE

3

LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG

ibuprofen lysine (pf) intravenous solution

3

ST; CE; QL

1

LIPITOR ORAL TABLET 80 MG

INDERAL LA ORAL CAPSULE,EXTENDED RELEASE 24 HR

LIPOCHOL PLUS ORAL TABLET

3

3

LIPOFEN ORAL CAPSULE

3

INDERAL XL ORAL CAPSULE,EXTENDED RELEASE 24HR

lisinopril oral tablet

1

3

lisinopril-hydrochlorothiazid e oral tablet

1

indomethacin sodium intravenous recon soln

1

LIVALO ORAL TABLET 1 MG, 2 MG

3

ST; DO

INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE 24HR

3

LIVALO ORAL TABLET 4 MG

3

ST; QL

irbesartan oral tablet 150 mg, 75 mg

1

DO

LOFIBRA ORAL CAPSULE

3

irbesartan oral tablet 300 mg

1

QL

LOFIBRA ORAL TABLET

3

irbesartan-hydrochlorothiazid e oral tablet 150-12.5 mg

1

QL

LOPID ORAL TABLET

3

irbesartan-hydrochlorothiazid e oral tablet 300-12.5 mg

1

LOPRESSOR HCT ORAL TABLET

3

isoxsuprine oral tablet

1

QL DO

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 70

Drug Name

Tier

Notes

LOPRESSOR INTRAVENOUS SOLUTION

3

LOPRESSOR ORAL TABLET

3

losartan oral tablet

1

QL

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg

1

QL

losartan-hydrochlorothiazide oral tablet 50-12.5 mg

1

DO

LOTENSIN HCT ORAL TABLET

3

LOTENSIN ORAL TABLET

3

LOTREL ORAL CAPSULE

3

lovastatin oral tablet 10 mg, 20 mg

1

DO

lovastatin oral tablet 40 mg

1

QL

MAVIK ORAL TABLET

Drug Name

Tier

Notes

MICARDIS ORAL TABLET 80 MG

3

MINIPRESS ORAL CAPSULE

3

minoxidil oral tablet

1

moexipril oral tablet

1

moexipril-hydrochlorothiazid e oral tablet

1

nadolol oral tablet

1

nadolol-bendroflumethiazide oral tablet

1

NATRECOR INTRAVENOUS RECON SOLN

4

NEOPROFEN (IBUPROFEN LYSN)(PF) INTRAVENOUS SOLUTION

3

niacin oral tablet extended release 24 hr

1

3

NIACOR ORAL TABLET

3

methyldopa oral tablet

1

methyldopa-hydrochlorothiaz ide oral tablet

1

3

methyldopate intravenous solution

1

NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR

metoprolol succinate oral tablet extended release 24 hr

1

NITROPRESS INTRAVENOUS SOLUTION

3

metoprolol ta-hydrochlorothiaz oral tablet

1

OPSUMIT ORAL TABLET

4

PA; QL

metoprolol tartrate intravenous solution

1

ORENITRAM ORAL TABLET EXTENDED RELEASE

4

PA

metoprolol tartrate intravenous syringe

1

papaverine injection solution

1

QL

metoprolol tartrate oral tablet

1

perindopril erbumine oral tablet

1

MICARDIS HCT ORAL TABLET 40-12.5 MG

3

DO

phenylephrine hcl injection solution

1

MICARDIS HCT ORAL TABLET 80-12.5 MG, 80-25 MG

3

QL

3

MICARDIS ORAL TABLET 20 MG, 40 MG

3

DO

PHENYLEPHRINE IN 0.9% NACL(PF) INTRAVENOUS SYRINGE pindolol oral tablet

1

QL

QL

ST; CE; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 71

Drug Name PRALUENT PEN SUBCUTANEOUS PEN INJECTOR

Tier

Notes

Drug Name

Tier

4

PA; QL

QUESTRAN ORAL POWDER

3

QUESTRAN ORAL POWDER IN PACKET

3

Notes

PRALUENT SYRINGE SUBCUTANEOUS SYRINGE

4

PA; QL

quinapril oral tablet

1

PRAVACHOL ORAL TABLET 20 MG

3

DO

quinapril-hydrochlorothiazid e oral tablet

1

PRAVACHOL ORAL TABLET 40 MG

ramipril oral capsule

1

3

4

PA

PRAVACHOL ORAL TABLET 80 MG

REMODULIN INJECTION SOLUTION

3

pravastatin oral tablet 10 mg, 20 mg

4

PA; QL

1

DO

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR

pravastatin oral tablet 40 mg

1

4

PA; QL

pravastatin oral tablet 80 mg

1

QL

REPATHA SYRINGE SUBCUTANEOUS SYRINGE

prazosin oral capsule

1

reserpine oral tablet

1

PRESTALIA ORAL TABLET 14-10 MG

3

QL

4

PA; QL

PRESTALIA ORAL TABLET 3.5-2.5 MG, 7-5 MG

REVATIO INTRAVENOUS SOLUTION

3

DO

4

PA; QL

prevalite oral powder

1

REVATIO ORAL SUSPENSION FOR RECONSTITUTION

prevalite oral powder in packet

1

REVATIO ORAL TABLET

4

PA; QL

PRINIVIL ORAL TABLET 10 MG, 5 MG

3

rosuvastatin oral tablet 10 mg, 20 mg, 5 mg

2

DO

PRINIVIL ORAL TABLET 20 MG

rosuvastatin oral tablet 40 mg

2

QL

3

3

propranolol intravenous solution

SECTRAL ORAL CAPSULE

1

4

PA; QL

propranolol oral capsule,extended release 24 hr

sildenafil intravenous solution

1

sildenafil oral tablet

4

PA; QL

propranolol oral solution

1

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1

DO

propranolol oral tablet

1

simvastatin oral tablet 80 mg

1

PA; QL

propranolol-hydrochlorothiaz id oral tablet

1

sorine oral tablet

1

sotalol af oral tablet

1

PROSTIN VR PEDIATRIC INJECTION SOLUTION

3

SOTALOL INTRAVENOUS SOLUTION

3

QUESTRAN LIGHT ORAL POWDER

3

sotalol oral tablet

1

QL

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 72

Drug Name

Tier

SOTRADECOL INTRAVENOUS SOLUTION

3

SOTYLIZE ORAL SOLUTION TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR 1-240 MG TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR 2-180 MG, 2-240 MG, 4-240 MG

Notes

Drug Name

Tier

Notes

TENORMIN ORAL TABLET

3

terazosin oral capsule

1

3

timolol maleate oral tablet

1

3

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR

3

TRACLEER ORAL TABLET

4

PA; QL

QL

trandolapril oral tablet

1

QL

1

DO; QL

QL

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 mg trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 2-180 mg, 2-240 mg, 4-240 mg

1

QL

3

DO

TEKAMLO ORAL TABLET 150-10 MG, 300-10 MG, 300-5 MG

3

TEKAMLO ORAL TABLET 150-5 MG

3

DO

TEKTURNA HCT ORAL TABLET 150-12.5 MG

3

DO

2

TEKTURNA HCT ORAL TABLET 150-25 MG, 300-12.5 MG, 300-25 MG

TRIBENZOR ORAL TABLET

3

QL

TRICOR ORAL TABLET

3

TEKTURNA ORAL TABLET 150 MG

3

3

DO

TRIGLIDE ORAL TABLET

TEKTURNA ORAL TABLET 300 MG

3

QL

TRILIPIX ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

telmisartan oral tablet 20 mg, 40 mg

1

DO

3

QL

telmisartan oral tablet 80 mg

1

QL

TWYNSTA ORAL TABLET 40-10 MG, 80-10 MG, 80-5 MG TWYNSTA ORAL TABLET 40-5 MG

3

DO

TYVASO INHALATION SOLUTION FOR NEBULIZATION

4

PA; QL

TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION

4

PA; QL

TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION

4

PA; QL

TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION

4

PA; QL

telmisartan-amlodipine oral tablet 40-10 mg, 80-10 mg, 80-5 mg

1

telmisartan-amlodipine oral tablet 40-5 mg

1

DO

telmisartan-hydrochlorothiazi d oral tablet 40-12.5 mg

1

DO

telmisartan-hydrochlorothiazi d oral tablet 80-12.5 mg, 80-25 mg

1

TENEX ORAL TABLET

3

TENORETIC 100 ORAL TABLET

3

TENORETIC 50 ORAL TABLET

3

QL

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 73

Drug Name

Tier

UPTRAVI ORAL TABLET

4

UPTRAVI ORAL TABLETS,DOSE PACK

4

valsartan oral tablet

1

Notes

Drug Name

QL

Tier

Notes

ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG

3

DO

ZOCOR ORAL TABLET 80 MG

3

PA; QL

CNS DRUGS

valsartan-hydrochlorothiazid e oral tablet 160-12.5 mg, 80-12.5 mg

1

DO

valsartan-hydrochlorothiazid e oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg

1

QL

VARITHENA INTRAVENOUS FOAM

3

VASERETIC ORAL TABLET

3

VASOTEC ORAL TABLET

3

VAZCULEP INJECTION SOLUTION

3

VECAMYL ORAL TABLET

3

veletri intravenous recon soln

4

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION

ACTIVE-PAC KIT,GEL AND CAPSULE

3

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR

4

APTIOM ORAL TABLET

3

AUBAGIO ORAL TABLET

4

PA; QL

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT

4

PA

AVONEX INTRAMUSCULAR PEN INJECTOR KIT

4

PA

PA

AVONEX INTRAMUSCULAR SYRINGE

4

PA

4

PA

AVONEX INTRAMUSCULAR SYRINGE KIT

4

PA

VYTORIN 10-10 ORAL TABLET

3

ST; QL

BANZEL ORAL SUSPENSION

3

VYTORIN 10-20 ORAL TABLET

BANZEL ORAL TABLET

3

3

ST; QL

4

VYTORIN 10-40 ORAL TABLET

BETASERON SUBCUTANEOUS KIT

3

ST; QL

VYTORIN 10-80 ORAL TABLET

3

3

ST; QL

BRIVIACT INTRAVENOUS SOLUTION

WELCHOL ORAL POWDER IN PACKET

2

BRIVIACT ORAL SOLUTION

3

WELCHOL ORAL TABLET

2

BRIVIACT ORAL TABLET

3

ZEBETA ORAL TABLET

3

CAFCIT INTRAVENOUS SOLUTION

3

ZESTORETIC ORAL TABLET

3

caffeine citrated intravenous solution

1

ZESTRIL ORAL TABLET

3

ZETIA ORAL TABLET

3

caffeine citrated oral solution

1

ZIAC ORAL TABLET

3

caffeine-sodium benzoate injection solution

1

ST; QL

PA; QL

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 74

Drug Name

Tier

carbamazepine oral capsule, er multiphase 12 hr

1

carbamazepine oral suspension

1

carbamazepine oral tablet

Notes

Drug Name

Tier

Notes

DILANTIN EXTENDED ORAL CAPSULE

2 2

1

DILANTIN INFATABS ORAL TABLET,CHEWABLE

carbamazepine oral tablet extended release 12 hr

1

DILANTIN ORAL CAPSULE

2

carbamazepine oral tablet,chewable

1

DILANTIN-125 ORAL SUSPENSION

2

CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR

1

2

divalproex oral capsule, sprinkle

1

CELONTIN ORAL CAPSULE

divalproex oral tablet extended release 24 hr 3

1

CEREBYX INJECTION SOLUTION

divalproex oral tablet,delayed release (dr/ec)

3

clonazepam oral tablet

1

DOPRAM INTRAVENOUS SOLUTION

3

clonazepam oral tablet,disintegrating

1

doxapram intravenous solution

1

COPAXONE SUBCUTANEOUS SYRINGE

4

epitol oral tablet

1 1

DEHYDRATED ALCOHOL INJECTION SOLUTION

ethanol (ethyl alcohol) injection solution 3

ethosuximide oral capsule

1

ethosuximide oral solution

1

DEPACON INTRAVENOUS SOLUTION

2

EXTAVIA SUBCUTANEOUS KIT

4

PA

DEPAKENE ORAL CAPSULE

2

EXTAVIA SUBCUTANEOUS RECON SOLN

4

PA

DEPAKENE ORAL SOLUTION

2

felbamate oral suspension

1

felbamate oral tablet

1

FELBATOL ORAL SUSPENSION

2

FELBATOL ORAL TABLET

2

fosphenytoin injection solution

1

FYCOMPA ORAL TABLET

3

gabapentin oral capsule

1

gabapentin oral solution

1

gabapentin oral tablet

1

PA

DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR

2

DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC)

2

DEPAKOTE SPRINKLES ORAL CAPSULE, SPRINKLE

2

DIASTAT ACUDIAL RECTAL KIT

2

QL

DIASTAT RECTAL KIT

2

QL

diazepam rectal kit

1

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 75

Drug Name

Tier

Notes

GABITRIL ORAL TABLET

2

GILENYA ORAL CAPSULE

4

PA; QL

glatopa subcutaneous syringe

4

PA

GRALISE 30-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 24 HR

Drug Name

Tier

LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE

2

LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK

2

2

LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK

2

2

LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK

2

HORIZANT ORAL TABLET EXTENDED RELEASE

3

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR

3

KEPPRA INTRAVENOUS SOLUTION

2

3

KEPPRA ORAL SOLUTION

2

LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK

KEPPRA ORAL TABLET

2

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR

3

2

LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK

KLONOPIN ORAL TABLET

3

LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK

3

lamotrigine oral tablet

1

lamotrigine oral tablet disintegrating, dose pk

1

lamotrigine oral tablet extended release 24hr

1

lamotrigine oral tablet, chewable dispersible

1

lamotrigine oral tablet,disintegrating

1

lamotrigine oral tablets,dose pack

1

LEMTRADA INTRAVENOUS SOLUTION

4

LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK

3

GRALISE ORAL TABLET EXTENDED RELEASE 24 HR

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

2

2

2

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

2

LAMICTAL ORAL TABLET

2

Notes

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 76

Drug Name

Tier

Notes

Drug Name

Tier

Notes

levetiracetam intravenous solution

1

oxcarbazepine oral suspension

1

levetiracetam oral solution

1

oxcarbazepine oral tablet

1

levetiracetam oral tablet

1

levetiracetam oral tablet extended release 24 hr

3

1

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR

LYRICA ORAL CAPSULE

3

PA; QL

PEGANONE ORAL TABLET

3

LYRICA ORAL SOLUTION

3

PA; QL

PHENYTEK ORAL CAPSULE

2

memantine oral solution

1

phenytoin oral suspension

1

memantine oral tablet

1

1

MEMANTINE ORAL TABLETS,DOSE PACK

phenytoin oral tablet,chewable

3

phenytoin sodium extended oral capsule

1

MYSOLINE ORAL TABLET

3

phenytoin sodium intravenous solution

1

NAMENDA ORAL SOLUTION

3

1

NAMENDA ORAL TABLET

phenytoin sodium intravenous syringe

3

4

PA

NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK

2

PLEGRIDY SUBCUTANEOUS PEN INJECTOR

NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK

4

PA

2

PLEGRIDY SUBCUTANEOUS SYRINGE POTIGA ORAL TABLET

3

primidone oral tablet

1

QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR

3

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

4

PA

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR

4

PA

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

4

PA

NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR

2

NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR

3

NEURONTIN ORAL CAPSULE

3

NEURONTIN ORAL SOLUTION

3

NEURONTIN ORAL TABLET

3

NUEDEXTA ORAL CAPSULE

3

RILUTEK ORAL TABLET

4

ONFI ORAL SUSPENSION

3

riluzole oral tablet

4

ONFI ORAL TABLET

3

roweepra oral tablet

1

SABRIL ORAL POWDER IN PACKET

3

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 77

Drug Name

Tier

Notes

Drug Name

Tier

Notes

SABRIL ORAL TABLET

3

3

SMARTRX GABAKIT KIT, CREAM AND CAPSULE

VIMPAT INTRAVENOUS SOLUTION

3

VIMPAT ORAL SOLUTION

3

SMARTRX GABA-V KIT KIT, CREAM AND CAPSULE

VIMPAT ORAL TABLET

3

3

XENAZINE ORAL TABLET

3

SPRITAM ORAL TABLET FOR SUSPENSION

3

ZARONTIN ORAL CAPSULE

2

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

2

4

ZARONTIN ORAL SOLUTION

3

TEGRETOL ORAL SUSPENSION

ZONEGRAN ORAL CAPSULE 2

zonisamide oral capsule

1

TEGRETOL ORAL TABLET

2

COLONY STIMULATING FACTORS

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR

2

ARANESP (IN POLYSORBATE) INJECTION SOLUTION

4

PA

tetrabenazine oral tablet

1

tiagabine oral tablet

1

ARANESP (IN POLYSORBATE) INJECTION SYRINGE

4

PA

TOPAMAX ORAL CAPSULE, SPRINKLE

2

EPOGEN INJECTION SOLUTION

4

PA

TOPAMAX ORAL TABLET

2

4

PA

topiramate oral capsule, sprinkle

1

GRANIX SUBCUTANEOUS SYRINGE LEUKINE INJECTION RECON SOLN

4

PA

MIRCERA INJECTION SYRINGE

4

PA

MOZOBIL SUBCUTANEOUS SOLUTION

4

PA

NEULASTA SUBCUTANEOUS SYRINGE

4

PA; QL

4

PA; QL

QL

PA; QL

PA

PA

TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR

3

topiramate oral tablet

1

TRILEPTAL ORAL SUSPENSION

2

TRILEPTAL ORAL TABLET

3

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR

2

valproate sodium intravenous solution

1

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR

valproic acid (as sodium salt) oral solution

1

NEUPOGEN INJECTION SOLUTION

4

PA

valproic acid oral capsule

1

NEUPOGEN INJECTION SYRINGE

4

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 78

Drug Name

Tier

Notes

Drug Name

Tier

Notes

PA

CAYA CONTOURED VAGINAL DIAPHRAGM

2

caziant (28) oral tablet

1

chateal oral tablet

1

PA PA

NPLATE SUBCUTANEOUS RECON SOLN

4

PROCRIT INJECTION SOLUTION

4

PA

PROMACTA ORAL TABLET

cryselle (28) oral tablet

1

4

PA

cyclafem 1/35 (28) oral tablet

1

ZARXIO INJECTION SYRINGE

4

PA

cyclafem 7/7/7 (28) oral tablet

1

CYCLESSA (28) ORAL TABLET

3

PA

cyred oral tablet

1

PA

dasetta 1/35 (28) oral tablet

1

PA

dasetta 7/7/7 (28) oral tablet

1

PA

daysee oral tablets,dose pack,3 month

1

PA

CONTRACEPTIVES altavera (28) oral tablet

1

PA

alyacen 1/35 (28) oral tablet

1

PA

alyacen 7/7/7 (28) oral tablet

1

PA

amethia lo oral tablets,dose pack,3 month

1

PA

amethia oral tablets,dose pack,3 month

1

PA

deblitane oral tablet

1

PA

amethyst oral tablet

1

PA

delyla (28) oral tablet

1

PA

apri oral tablet

1

PA

aranelle (28) oral tablet

1

PA

DEPO-PROVERA INTRAMUSCULAR SUSPENSION

3

PA

ashlyna oral tablets,dose pack,3 month

1

3

PA

aubra oral tablet

1

PA

DEPO-PROVERA INTRAMUSCULAR SYRINGE

aviane oral tablet

1

PA

azurette (28) oral tablet

1

PA

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE

3

PA

balziva (28) oral tablet

1

PA

bekyree (28) oral tablet

1

PA

desog-e.estradiol/e.estradiol oral tablet

1

PA

BEYAZ ORAL TABLET

3

PA

blisovi 24 fe oral tablet

1

PA

DESOGEN ORAL TABLET

3

PA

blisovi fe 1.5/30 (28) oral tablet

1

desogestrel-ethinyl estradiol oral tablet

1

PA

blisovi fe 1/20 (28) oral tablet

1

PA

drospirenone-ethinyl estradiol oral tablet

1

PA

BREVICON (28) ORAL TABLET

3

PA

elinest oral tablet

1

PA

ELLA ORAL TABLET

3

briellyn oral tablet

1

PA

emoquette oral tablet

1

camila oral tablet

1

PA

enpresse oral tablet

1

PA

camrese lo oral tablets,dose pack,3 month

1

PA

enskyce oral tablet

1

PA

errin oral tablet

1

PA

camrese oral tablets,dose pack,3 month

1

estarylla oral tablet

1

PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 79

Drug Name

Tier

Notes

ESTROSTEP FE-28 ORAL TABLET

3

PA

falmina (28) oral tablet

1

PA

FEMCAP VAGINAL DEVICE

2

FEMCON FE ORAL TABLET,CHEWABLE

3

PA

GENERESS FE ORAL TABLET,CHEWABLE

3

PA

gianvi (28) oral tablet

1

PA

gildagia oral tablet

1

gildess 1.5/30 (21) oral tablet

1

PA

gildess 1/20 (21) oral tablet

1

PA

gildess 24 fe oral tablet

1

gildess fe 1.5/30 (28) oral tablet

1

gildess fe 1/20 (28) oral tablet

1

heather oral tablet

1

PA

introvale oral tablets,dose pack,3 month

1

PA

jencycla oral tablet

1

jolessa oral tablets,dose pack,3 month

Drug Name

Tier

Notes

larin 1/20 (21) oral tablet

1

PA

larin 24 fe oral tablet

1

PA

larin fe 1.5/30 (28) oral tablet

1

PA

larin fe 1/20 (28) oral tablet

1

PA

layolis fe oral tablet,chewable

1

PA

leena 28 oral tablet

1

PA

lessina oral tablet

1

PA

levonest (28) oral tablet

1

PA

levonorgestrel-ethinyl estrad oral tablet

1

PA

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month

1

PA

levonorg-eth estrad triphasic oral tablet

1

levora-28 oral tablet

1

LILETTA INTRAUTERINE INTRAUTERINE DEVICE

3

PA

LO LOESTRIN FE ORAL TABLET

2

PA

1

PA

LOESTRIN 1.5/30 (21) ORAL TABLET

3

PA

jolivette oral tablet

1

PA

juleber oral tablet

1

LOESTRIN 1/20 (21) ORAL TABLET

3

PA

junel 1.5/30 (21) oral tablet

1

PA

junel 1/20 (21) oral tablet

1

PA

LOESTRIN FE 1.5/30 (28-DAY) ORAL TABLET

3

PA

junel fe 1.5/30 (28) oral tablet

1

PA

LOESTRIN FE 1/20 (28-DAY) ORAL TABLET

3

PA

junel fe 1/20 (28) oral tablet

1

PA

lomedia 24 fe oral tablet

1

junel fe 24 oral tablet

1

PA

loryna (28) oral tablet

1

PA

kaitlib fe oral tablet,chewable

1

kariva (28) oral tablet

1

PA

LOSEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH

3

PA

kelnor 1/35 (28) oral tablet

1

PA

low-ogestrel (28) oral tablet

1

PA

kimidess (28) oral tablet

1

lutera (28) oral tablet

1

PA

kurvelo oral tablet

1

PA

lyza oral tablet

1

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

1

PA

marlissa oral tablet

1

PA

1

PA

larin 1.5/30 (21) oral tablet

1

medroxyprogesterone intramuscular suspension

PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 80

Drug Name

Tier

Notes

Drug Name

Tier

Notes

medroxyprogesterone intramuscular syringe

1

PA

norethindrone ac-eth estradiol oral tablet

1

PA

microgestin 1.5/30 (21) oral tablet

1

PA

norethindrone-e.estradiol-iro n oral tablet

1

PA

microgestin 1/20 (21) oral tablet

1

PA

1

MICROGESTIN 24 FE ORAL TABLET

norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg

3

microgestin fe 1.5/30 (28) oral tablet

1

PA

1

PA

microgestin fe 1/20 (28) oral tablet

norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg

1

PA

3

PA

MINASTRIN 24 FE ORAL TABLET,CHEWABLE

NORINYL 1+35 (28) ORAL TABLET

2

PA

3

PA

MIRCETTE (28) ORAL TABLET

NORINYL 1+50 (28) ORAL TABLET

3

PA

norlyroc oral tablet

1

PA

NOR-QD ORAL TABLET

3

PA

nortrel 0.5/35 (28) oral tablet

1

PA

nortrel 1/35 (21) oral tablet

1

PA

nortrel 1/35 (28) oral tablet

1

PA

nortrel 7/7/7 (28) oral tablet

1

PA

NUVARING VAGINAL RING

2

PA

ocella oral tablet

1

PA

ogestrel (28) oral tablet

1

PA

orsythia oral tablet

1

ORTHO MICRONOR ORAL TABLET

3

ORTHO TRI-CYCLEN (28) ORAL TABLET

3

PA

ORTHO TRI-CYCLEN LO (28) ORAL TABLET

3

PA

ORTHO-CYCLEN (28) ORAL TABLET

3

PA

ORTHO-NOVUM 1/35 (28) ORAL TABLET

3

ORTHO-NOVUM 7/7/7 (28) ORAL TABLET

3

MIRENA INTRAUTERINE INTRAUTERINE DEVICE

3

MODICON (28) ORAL TABLET

3

mono-linyah oral tablet

1

PA

mononessa (28) oral tablet

1

PA

my way oral tablet

1

QL

myzilra oral tablet

1

NATAZIA ORAL TABLET

3

PA

necon 0.5/35 (28) oral tablet

1

PA

necon 1/35 (28) oral tablet

1

PA

necon 1/50 (28) oral tablet

1

PA

necon 10/11 (28) oral tablet

1

PA

necon 7/7/7 (28) oral tablet

1

PA

NEXPLANON SUBDERMAL IMPLANT

4

next choice one dose oral tablet

1

nikki (28) oral tablet

1

nora-be oral tablet

1

PA

OVCON-35 (28) ORAL TABLET

3

PA

noreth-ethinyl estradiol-iron oral tablet,chewable

1

PA

norethindrone (contraceptive) oral tablet

3

QL

1

PA

PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 81

Drug Name

Tier

Notes

Drug Name

Tier

Notes

philith oral tablet

1

PA

tri-previfem (28) oral tablet

1

pimtrea (28) oral tablet

1

PA

tri-sprintec (28) oral tablet

1

PA

pirmella oral tablet 0.5/0.75/1 mg- 35 mcg

1

trivora (28) oral tablet

1

PA

pirmella oral tablet 1-35 mg-mcg

1

PA

1

velivet triphasic regimen (28) oral tablet vestura (28) oral tablet

1

PA

PLAN B ONE-STEP ORAL TABLET

3

QL

vienva oral tablet

1

portia oral tablet

1

PA

viorele (28) oral tablet

1

previfem oral tablet

1

vyfemla (28) oral tablet

1

QUARTETTE ORAL TABLETS,DOSE PACK,3 MONTH

wera (28) oral tablet

1

3

2

quasense oral tablets,dose pack,3 month

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM

1

PA

reclipsen (28) oral tablet

1

PA

WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM

2

SAFYRAL ORAL TABLET

3

2

SEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH

WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM

3

2

setlakin oral tablets,dose pack,3 month

1

PA

WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM

sharobel oral tablet

1

PA

2

SKYLA INTRAUTERINE INTRAUTERINE DEVICE

WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM

3

2

sprintec (28) oral tablet

1

PA

WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM

sronyx oral tablet

1

PA

2

syeda oral tablet

1

PA

WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM

tarina fe 1/20 (28) oral tablet

1

PA

tilia fe oral tablet

1

PA

2

tri-estarylla oral tablet

1

PA

WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM

tri-legest fe oral tablet

1

PA

wymzya fe oral tablet,chewable

1

tri-linyah oral tablet

1

PA

tri-lo-estarylla oral tablet

1

xulane transdermal patch weekly

1

QL

tri-lo-marzia oral tablet

1

PA

1

YASMIN (28) ORAL TABLET

3

tri-lo-sprintec oral tablet trinessa (28) oral tablet

1

YAZ (28) ORAL TABLET

3

PA

trinessa lo oral tablet

1

zarah oral tablet

1

TRI-NORINYL (28) ORAL TABLET

zenchent (28) oral tablet

1

3

PA

PA

PA

PA

PA PA

PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 82

Drug Name

Tier

Notes

Drug Name

zenchent fe oral tablet,chewable

1

PA

hydrocodone-homatropine oral tablet

1

zovia 1/35e (28) oral tablet

1

PA

hydromet oral syrup

1

zovia 1/50e (28) oral tablet

1

PA

iophen c-nr oral liquid

1

lortuss ex oral syrup

1

MAR-COF BP ORAL LIQUID

3

MAR-COF CG ORAL LIQUID

3

COUGH/COLD PREPARATIONS

Tier

AKOVAZ INTRAVENOUS SOLUTION

3

benzonatate oral capsule

1

m-clear wc oral liquid

1

BROMFED DM ORAL SYRUP

3

M-END MAX D ORAL LIQUID

3

brompheniramine-pseudoeph -dm oral syrup

1

M-END PE ORAL LIQUID

3

CAPCOF ORAL LIQUID

3

centergy dm oral drops

1

NINJACOF-XG ORAL LIQUID

3

cheratussin ac oral liquid

1

3

cheratussin dac oral syrup

1

OBREDON ORAL SOLUTION

CODEINE-GUAIFENESI N ORAL LIQUID

phenylhistine dh oral liquid

1

3

2

ephedrine sulfate injection solution

POLY-TUSSIN AC ORAL LIQUID

1

1

EPHEDRINE SULFATE-0.9%NACL(PF ) INTRAVENOUS SYRINGE

promethazine vc-codeine oral syrup

3

promethazine-codeine oral syrup

1

promethazine-dm oral syrup

1

FLOWTUSS ORAL SOLUTION

3

promethazine-phenyleph-cod eine oral syrup

1

guaifenesin ac oral liquid

1

guaifenesin dac oral syrup

1

3

HISTEX-AC ORAL SYRUP

PRO-RED AC (W/ DEXCHLORPHENIR) ORAL LIQUID

3

relcof c oral liquid

1

HYCOFENIX ORAL SOLUTION

3

3

hydrocodone-chlorphenirami ne oral suspension,extended rel 12 hr

RESPA-AR ORAL TABLET EXTENDED RELEASE 12 HR

1

REZIRA ORAL SOLUTION

3

hydrocodone-cpm-pseudoeph ed oral solution

1

rydex oral liquid

1

hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

3

1

TESSALON PERLES ORAL CAPSULE tusnel c oral syrup

1

HYDROCODONE-HOMA TROPINE ORAL SYRUP 5-1.5 MG/5 ML (5 ML)

3

TUSNEL PEDIATRIC ORAL LIQUID

3

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 83

Drug Name

Tier

Notes

Drug Name

Tier

TUSSICAPS ORAL CAPSULE,EXTENDED RELEASE 12 HR

2

ZODRYL DEC 30 ORAL SUSPENSION

2

tussigon oral tablet

1

ZODRYL DEC 35 ORAL SUSPENSION

3

ZODRYL DEC 40 ORAL SUSPENSION

3

ZODRYL DEC 50 ORAL SUSPENSION

3

TUSSIONEX PENNKINETIC ER ORAL SUSPENSION,EXTENDE D REL 12 HR

3

TUZISTRA XR ORAL SUSPENSION,EXTENDE D REL 12 HR

3

ZODRYL DEC 60 ORAL SUSPENSION

3

virtussin ac oral liquid

1

ZODRYL DEC 80 ORAL SUSPENSION

3

virtussin dac oral syrup

1

VITUZ ORAL SOLUTION

3

ZONATUSS ORAL CAPSULE

3

ZODRYL AC 25 ORAL SUSPENSION

3

Z-TUSS AC ORAL LIQUID

2

ZODRYL AC 30 ORAL SUSPENSION

3

ZUTRIPRO ORAL SOLUTION

3

ZODRYL AC 35 ORAL SUSPENSION

3

ZODRYL AC 40 ORAL SUSPENSION

2

ZODRYL AC 50 ORAL SUSPENSION

3

ZODRYL AC 60 ORAL SUSPENSION

3

ZODRYL AC 80 ORAL SUSPENSION

3

ZODRYL DAC 25 ORAL SUSPENSION

3

ZODRYL DAC 30 ORAL SUSPENSION

Notes

DIAGNOSTIC ACCU-CHEK AVIVA PLUS TEST STRP STRIP

2

QL

ACCU-CHEK AVIVA STRIP

2

QL

ACCU-CHEK COMPACT PLUS TEST STRIP

2

QL

ACCU-CHEK COMPACT TEST STRIP

2

QL

ACCU-CHEK SMARTVIEW TEST STRIP STRIP

2

QL

3

ACCUTREND GLUCOSE STRIP

3

QL

ZODRYL DAC 35 ORAL SUSPENSION

3

ACURA TEST STRIPS STRIP

3

ST; QL

ZODRYL DAC 40 ORAL SUSPENSION

3

3

ST; QL

ZODRYL DAC 50 ORAL SUSPENSION

ADVANCED GLUC METER TEST STRIP STRIP

3

3

ST; QL

ZODRYL DAC 60 ORAL SUSPENSION

ADVOCATE REDI-CODE STRIP

3

3

ST; QL

ZODRYL DAC 80 ORAL SUSPENSION

ADVOCATE REDI-CODE+ STRIP

3

3

ST; QL

ZODRYL DEC 25 ORAL SUSPENSION

ADVOCATE TEST STRIPS STRIP

3

AGAMATRIX AMP TEST STRIPS STRIP

3

ST; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 84

Drug Name

Tier

Notes

Drug Name

Tier

Notes

ASSURE 4 STRIPS STRIP

3

ST; QL

EASYGLUCO PLUS STRIP

ASSURE PLATINUM STRIP

3

ST; QL

3

ST; QL

EASYGLUCO TEST STRIP

ASSURE PRISM MULTI STRIP STRIP

3

ST; QL

3

ST; QL

EASYMAX 15 STRIP

3

ST; QL

BG-STAR STRIP

3

ST; QL

EASYMAX STRIP

3

ST; QL

BIONIME RIGHTEST TEST STRIPS STRIP

3

ST; QL

ELEMENT COMPACT TEST STRIPS STRIP

3

ST; QL

BLOOD GLUCOSE TEST STRIP

3

ST; QL

ELEMENT TEST STRIPS STRIP

3

ST; QL

BREEZE 2 TEST STRIPS STRIP

3

ST; QL

3

ST; QL

CARESENS N TEST STRIPS STRIP

EMBRACE BLOOD GLUCOSE SYSTEM STRIP

3

ST; QL

3

ST; QL

CLEVER CHOICE MICRO TEST STRIP STRIP

EMBRACE EVO TEST STRIPS STRIP

3

ST; QL

EMBRACE PRO TEST STRIPS STRIP

3

ST; QL

CLEVER CHOICE PRO STRIP

3

ST; QL

EVENCARE G2 STRIP

3

ST; QL

CLEVER CHOICE TEST STRIPS STRIP

3

ST; QL

3

EVENCARE G3 TEST STRIP

CLEVER CHOICE VOICE+ TEST STRIP

3

ST; QL

EVENCARE MINI GLUCOSE TEST STR STRIP

3

ST; QL

CONTOUR NEXT STRIPS STRIP

3

ST; QL

EVENCARE TEST STRIP

3

ST; QL

CONTOUR TEST STRIPS STRIP

3

ST; QL

3

ST; QL

EVOLUTION TEST STRIPS STRIP

CONTROL G3 STRIP

3

ST; QL

EZ SMART PLUS TEST STRIP

3

ST; QL

CONTROL TEST STRIP

3

ST; QL

EZ SMART TEST STRIP

3

ST; QL

COOL GLUCOSE TEST STRIP STRIP

3

ST; QL

FIFTY50 TEST STRIP STRIP

3

ST; QL

DIATRUE PLUS TEST STRIP STRIP

3

ST; QL

FORA D10 STRIP

3

ST; QL

FORA D15G STRIP

3

ST; QL

EASY GLUCO G2 STRIP

3

ST; QL

FORA D20 STRIP

3

ST; QL

EASY PLUS II TEST STRIP

3

ST; QL

FORA D40-G31 TEST STRIPS STRIP

3

ST; QL

EASY STEP STRIP

3

ST; QL

FORA G20 STRIP

3

ST; QL

EASY TALK GLUCOSE TEST STRIP

3

ST; QL

FORA G30A STRIP

3

ST; QL

EASY TOUCH STRIP

3

ST; QL

FORA GD50 TEST STRIPS STRIP

3

ST; QL

EASY TRAK GLUCOSE TEST STRIP

3

ST; QL

FORA TEST STRIP STRIP

3

ST; QL

ST; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 85

Drug Name

Tier

Notes

Drug Name

Tier

Notes

FORA TN'G VOICE TEST STRIPS STRIP

3

ST; QL

GMATE TEST STRIPS STRIP

3

ST; QL

FORA V10 STRIP

3

ST; QL

HEALTHPRO TEST STRIPS STRIP

FORA V12 GLUCOSE STRIP

3

ST; QL

3

ST; QL

3

ST; QL

ST; QL

INFINITY TEST STRIPS STRIP

FORA V20 STRIP

3

FORA V30A STRIP

3

ST; QL

LIBERTY TEST STRIP

3

ST; QL

FORACARE GD20 STRIP

3

ST; QL

MAXIMA STRIP

3

ST; QL

FORACARE GD40 STRIP

3

ST; QL

3

ST; QL

FORTISCARE GLUCOSE TEST STRIPS STRIP

MICRO BLOOD GLUCOSE STRIP

3

ST; QL

3

ST; QL

FREESTYLE INSULINX STRIP

3

ST; QL

MICRODOT BLOOD GLUCOSE SYSTEM STRIP

FREESTYLE INSULINX TEST STRIPS STRIP

3

ST; QL

3

ST; QL

MYGLUCOHEALTH STRIP

FREESTYLE LITE STRIPS STRIP

3

ST; QL

3

ST; QL

NEUTEK 2TEK TEST STRIPS STRIP

FREESTYLE PRECISION NEO STRIPS STRIP

ST; QL

ST; QL

3

3

NOVA MAX GLUCOSE TEST STRIP

FREESTYLE TEST STRIP

ST; QL

ST; QL

3

3

ON CALL EXPRESS TEST STRIP STRIP

G-4 TEST STRIP

3

ST; QL

ON CALL PLUS TEST STRIP STRIP

3

ST; QL

GE100 BLOOD GLUCOSE TEST STRIP STRIP

3

ST; QL

ON CALL VIVID TEST STRIP STRIP

3

ST; QL

GENSTRIP TEST STRIP STRIP

2

QL

3

ST; QL

ONETOUCH ULTRA TEST STRIP

GLUCO NAVII TEST STRIP STRIP

2

QL

3

ST; QL

ONETOUCH VERIO STRIP OPTIUM EZ STRIP

3

ST; QL

GLUCOCARD 01 SENSOR PLUS STRIP

3

ST; QL

OPTIUM TEST STRIP

3

ST; QL

GLUCOCARD EXPRESSION STRIP

OPTUMRX STRIP

3

ST; QL

3

ST; QL

3

ST; QL

GLUCOCARD SHINE TEST STRIPS STRIP

PHARMACIST CHOICE STRIP

3

3

ST; QL

GLUCOCARD VITAL SENSOR STRIP

PRECISION PCX PLUS TEST STRIP

3

3

ST; QL

GLUCOCARD VITAL TEST STRIPS STRIP

PRECISION PCX TEST STRIP

3

3

ST; QL

GLUCOCOM GLUCOSE STRIP

PRECISION POINT OF CARE TEST STRIP

3

ST; QL

3

ST; QL

GM100 STRIP

3

ST; QL

PRECISION Q-I-D TEST STRIP PRECISION XTRA TEST STRIP

3

ST; QL

ST; QL ST; QL ST; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 86

Drug Name

Tier

Notes

Drug Name

PREMIUM V10 STRIP

3

ST; QL

DIURETICS

PRODIGY NO CODING STRIP

3

ST; QL

acetazolamide oral capsule, extended release

1

QUINTET AC STRIP

3

ST; QL

acetazolamide oral tablet

1

REFUAH PLUS STRIP

3

ST; QL

1

RELION CONFIRM-MICRO STRIP

acetazolamide sodium injection recon soln

3

ST; QL

ALDACTAZIDE ORAL TABLET

3

RELION PRIME TEST STRIPS STRIP

3

ST; QL

ALDACTONE ORAL TABLET

3

RELION ULTIMA STRIP

3

ST; QL

amiloride oral tablet

1

REVEAL TEST STRIP STRIP

3

ST; QL

amiloride-hydrochlorothiazid e oral tablet

1

RIGHTEST GS550 TEST STRIPS STRIP

3

ST; QL

3

SMART SENSE TEST STRIPS STRIP

AMMONIUM CHLORIDE INTRAVENOUS SOLUTION

3

ST; QL

bumetanide injection solution

1

SMARTEST TEST STRIP

3

ST; QL

bumetanide oral tablet

1

SOLUS V2 TEST STRIPS STRIP

3

ST; QL

chlorothiazide oral tablet

1

SURE-TEST EASYPLUS MINI STRIP

1

3

chlorothiazide sodium intravenous recon soln chlorthalidone oral tablet

1

TELCARE TEST STRIPS STRIP

3

ST; QL

DEMADEX ORAL TABLET

3

TEST N'GO TEST STRIP

3

ST; QL

TRUE METRIX GLUCOSE TEST STRIP STRIP

3

3

ST; QL

DIAMOX SEQUELS ORAL CAPSULE, EXTENDED RELEASE

TRUETEST TEST STRIPS STRIP

3

ST; QL

DIURIL IV INTRAVENOUS RECON SOLN

3

TRUETRACK TEST STRIP

3

ST; QL

DIURIL ORAL SUSPENSION

3

ULTIMA TEST STRIPS STRIP

3

ST; QL

DYAZIDE ORAL CAPSULE

3

ULTRATRAK STRIP

3

ST; QL

3

ULTRATRAK ULTIMATE STRIP

DYRENIUM ORAL CAPSULE

3

ST; QL

3

UNISTRIP1 TEST STRIP STRIP

EDECRIN ORAL TABLET

3

ST; QL

eplerenone oral tablet

1

WAVESENSE JAZZ STRIP

3

ST; QL

ethacrynate sodium intravenous recon soln

1

WAVESENSE PRESTO STRIP

3

ST; QL

furosemide injection solution

1

furosemide injection syringe

1

ST; QL

Tier

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 87

Drug Name

Tier

furosemide oral solution

1

furosemide oral tablet

Notes

Drug Name

Tier

1

3

hydrochlorothiazide oral capsule

SODIUM EDECRIN INTRAVENOUS RECON SOLN

1

spironolactone oral tablet

1

hydrochlorothiazide oral tablet

1

spironolacton-hydrochlorothi az oral tablet

1

indapamide oral tablet

1

torsemide oral tablet

1

INSPRA ORAL TABLET

3

1

LASIX ORAL TABLET

3

triamterene-hydrochlorothiaz id oral capsule

mannitol 10 % intravenous parenteral solution

1

1

triamterene-hydrochlorothiaz id oral tablet

mannitol 20 % intravenous parenteral solution

1

VAPRISOL INTRAVENOUS SOLUTION

3

mannitol 25 % intravenous solution

1

EENT PREPS

mannitol 5 % intravenous parenteral solution

Notes

acetasol hc otic drops

1

1

acetic acid otic solution

1

MAXZIDE ORAL TABLET

3

acetic acid-aluminum acetate otic drops

1

MAXZIDE-25MG ORAL TABLET

3

acuicyn topical spray,non-aerosol

1

methazolamide oral tablet

1

3

methyclothiazide oral tablet

1

ACULAR LS OPHTHALMIC DROPS

metolazone oral tablet

1

ACULAR OPHTHALMIC DROPS

3

MICROZIDE ORAL CAPSULE

3

3

NEPTAZANE ORAL TABLET

3

ACUVAIL (PF) OPHTHALMIC DROPPERETTE

OSMITROL 10 % INTRAVENOUS PARENTERAL SOLUTION

ADRENALIN NASAL SOLUTION

3

3

AKTEN (PF) OPHTHALMIC GEL

3

osmitrol 15 % intravenous parenteral solution

3

1

ALCAINE OPHTHALMIC DROPS

osmitrol 20 % intravenous parenteral solution

3

ST; CE; QL

1

ALOCRIL OPHTHALMIC DROPS ALOMIDE OPHTHALMIC DROPS

3

ST; CE; QL

ALPHAGAN P OPHTHALMIC DROPS 0.1 %

2

ALPHAGAN P OPHTHALMIC DROPS 0.15 %

3

OSMITROL 5 % INTRAVENOUS PARENTERAL SOLUTION

3

RESECTISOL URETHRAL SOLUTION

3

SAMSCA ORAL TABLET

3

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 88

Drug Name

Tier

Notes

ALREX OPHTHALMIC DROPS,SUSPENSION

3

altacaine ophthalmic drops

1

altafluor ophthalmic drops

1

AMVISC INTRAOCULAR SYRINGE

4

AMVISC PLUS INTRAOCULAR SYRINGE

4

apraclonidine ophthalmic drops

1

ASTEPRO NASAL SPRAY,NON-AEROSOL

2

atropine ophthalmic drops

1

atropine ophthalmic ointment

1

ATROVENT NASAL SPRAY,NON-AEROSOL

3

AVENOVA TOPICAL SPRAY,NON-AEROSOL

3

azelastine nasal aerosol,spray

1

QL

azelastine nasal spray,non-aerosol

1

QL

AZOPT OPHTHALMIC DROPS,SUSPENSION

Drug Name

Tier

bromfenac ophthalmic drops

1

bss intraocular solution

1

BSS PLUS INTRAOCULAR SOLUTION

3

budesonide nasal spray,non-aerosol

1

carteolol ophthalmic drops

1

CELLUGEL INTRAOCULAR SYRINGE

3

COMBIGAN OPHTHALMIC DROPS

2

CORTANE-B TOPICAL LOTION

3

COSOPT (PF) OPHTHALMIC DROPPERETTE

3

COSOPT OPHTHALMIC DROPS

3

cromolyn ophthalmic drops

1

CYCLOGYL OPHTHALMIC DROPS

3

2

3

balanced salt intraocular solution

CYCLOMYDRIL OPHTHALMIC DROPS

1

1

BECONASE AQ NASAL SPRAY,NON-AEROSOL

cyclopentolate ophthalmic drops

3

3

BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION

CYSTARAN OPHTHALMIC DROPS

3

DERMOTIC OIL OTIC DROPS

3 1

BETAGAN OPHTHALMIC DROPS

dexamethasone sodium phosphate ophthalmic drops 3

1

betaxolol ophthalmic drops

1

diclofenac sodium ophthalmic drops

BETIMOL OPHTHALMIC DROPS

3

DISCOVISC INTRAOCULAR SYRINGE

3

BETOPTIC S OPHTHALMIC DROPS,SUSPENSION

2

dorzolamide ophthalmic drops

1

bimatoprost ophthalmic drops

1

dorzolamide-timolol ophthalmic drops

1

brimonidine ophthalmic drops

1

QL

QL

ST; CE; QL

Notes

QL

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 89

Drug Name

Tier

Notes

DUOVISC VISCO ELASTIC INTRAOCULAR SYRINGE

3

DUREZOL OPHTHALMIC DROPS

2

QL

DYMISTA NASAL SPRAY,NON-AEROSOL

3

EYLEA INTRAVITREAL SOLUTION

4

FLAREX OPHTHALMIC DROPS,SUSPENSION

3

flucaine ophthalmic drops

1

flunisolide nasal spray,non-aerosol

1

fluocinolone acetonide oil otic drops

1

fluorescein-benoxinate ophthalmic drops

1

fluorescein-proparacaine ophthalmic drops

1

fluorometholone ophthalmic drops,suspension

1

flurbiprofen sodium ophthalmic drops

1

flurox ophthalmic drops

1

Drug Name

Tier

ILUVIEN INTRAVITREAL IMPLANT

4

IOPIDINE OPHTHALMIC DROPPERETTE

3

QL

IOPIDINE OPHTHALMIC DROPS

3

PA

ipratropium bromide nasal spray,non-aerosol

1

ISOPTO ATROPINE OPHTHALMIC DROPS

3

ISOPTO CARPINE OPHTHALMIC DROPS

3

ISTALOL OPHTHALMIC DROPS, ONCE DAILY

3

JETREA (PF) INTRAVITREAL SOLUTION

3

ketorolac ophthalmic drops

1

LACRISERT OPHTHALMIC INSERT

3

latanoprost ophthalmic drops

1

levobunolol ophthalmic drops

1 3

3

LOTEMAX OPHTHALMIC DROPS,GEL

2

3

LOTEMAX OPHTHALMIC DROPS,SUSPENSION

FML S.O.P. OPHTHALMIC OINTMENT

2

3

LOTEMAX OPHTHALMIC OINTMENT

GELFILM OPHTHALMIC FILM

4

3

LUCENTIS INTRAVITREAL SOLUTION

homatropaire ophthalmic drops

1

LUMIGAN OPHTHALMIC DROPS

2

homatropine hbr ophthalmic drops

1

MACUGEN INTRAVITREAL SYRINGE

4

hydrocortisone-acetic acid otic drops

1

3

ILEVRO OPHTHALMIC DROPS,SUSPENSION

2

MAXIDEX OPHTHALMIC DROPS,SUSPENSION

FML FORTE OPHTHALMIC DROPS,SUSPENSION FML LIQUIFILM OPHTHALMIC DROPS,SUSPENSION

ST; QL

Notes PA

QL

PA

PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 90

Drug Name

Tier

MEMBRANEBLUE INTRAOCULAR SYRINGE

3

metipranolol ophthalmic drops

1

MIOCHOL-E INTRAOCULAR KIT

3

miostat intraocular solution

Notes

Drug Name

Tier

pilocarpine hcl ophthalmic drops

1

PRED FORTE OPHTHALMIC DROPS,SUSPENSION

3

3

1

PRED MILD OPHTHALMIC DROPS,SUSPENSION

MITOSOL OPHTHALMIC KIT

3

prednisolone acetate ophthalmic drops,suspension

1

mometasone nasal spray,non-aerosol

1

prednisolone sodium phosphate ophthalmic drops

1

MYDRIACYL OPHTHALMIC DROPS

3

PROLENSA OPHTHALMIC DROPS

3

naphazoline ophthalmic drops

1

proparacaine ophthalmic drops

1

NASONEX NASAL SPRAY,NON-AEROSOL

3

PROVISC INTRAOCULAR SYRINGE

4

NEVANAC OPHTHALMIC DROPS,SUSPENSION

3

QNASL NASAL HFA AEROSOL INHALER

3

ocucoat intraocular syringe

1

RESCULA OPHTHALMIC DROPS

3

OCUFEN OPHTHALMIC DROPS

3

2

olopatadine nasal spray,non-aerosol

1

RESTASIS OPHTHALMIC DROPPERETTE

OMIDRIA INTRAOCULAR CONCENTRATE

3

RETISERT INTRAVITREAL IMPLANT

3

OMNARIS NASAL SPRAY,NON-AEROSOL

3

RHINOCORT AQUA NASAL SPRAY,NON-AEROSOL

3

OMNIPRED OPHTHALMIC DROPS,SUSPENSION

3

SIMBRINZA OPHTHALMIC DROPS,SUSPENSION

2

OZURDEX INTRAVITREAL IMPLANT

3

tetcaine ophthalmic drops

1 1

PAREMYD OPHTHALMIC DROPS

tetracaine hcl (pf) ophthalmic drops

3

QL

1

PATANASE NASAL SPRAY,NON-AEROSOL

tetracaine hcl ophthalmic drops

3

QL

phenylephrine hcl ophthalmic drops

3

1

TETRAVISC FORTE OPHTHALMIC DROPPERETTE,HYPER VISCOUS

PHOSPHOLINE IODIDE OPHTHALMIC DROPS

3

ST; CE; QL

ST; CE; QL

QL

ST; CE; QL

PA

Notes

ST; CE; QL

ST; CE; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 91

Drug Name TETRAVISC FORTE OPHTHALMIC DROPS,HYPERVISCOUS

Tier

Notes

Drug Name

3

Tier

VISIONBLUE INTRAOCULAR SYRINGE

3

XALATAN OPHTHALMIC DROPS

3

ZETONNA NASAL HFA AEROSOL INHALER

3 3

TETRAVISC OPHTHALMIC DROPPERETTE,VISCOU S

3

TETRAVISC OPHTHALMIC DROPS, VISCOUS

3

ZIOPTAN (PF) OPHTHALMIC DROPPERETTE

timolol maleate ophthalmic drops

1

ELECT/CALORIC/H2O

timolol maleate ophthalmic gel forming solution

1

ACTIVE FE ORAL TABLET

3

TIMOPTIC OCUDOSE (PF) OPHTHALMIC DROPPERETTE

3

ADDAMEL N INTRAVENOUS SOLUTION

3

TIMOPTIC OPHTHALMIC DROPS

3

amino acids 15 % intravenous parenteral solution

1

TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION

3

2

TRAVATAN Z OPHTHALMIC DROPS

2

AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION

travoprost (benzalkonium) ophthalmic drops

1

2

TRIESENCE (PF) INTRAOCULAR SUSPENSION

AMINOSYN 3.5 % INTRAVENOUS PARENTERAL SOLUTION

3

2

tropicamide ophthalmic drops

1

AMINOSYN 7 % INTRAVENOUS PARENTERAL SOLUTION

TRUSOPT OPHTHALMIC DROPS

3

TYZINE NASAL DROPS 0.05 %

3

3

AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION

TYZINE NASAL DROPS 0.1 %

3

TYZINE NASAL SPRAY,NON-AEROSOL

2

3

AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION

VERAMYST NASAL SPRAY,SUSPENSION

3

VEXOL OPHTHALMIC DROPS,SUSPENSION

2

3

AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION

VISCOAT INTRAOCULAR SYRINGE

3

QL

ST; CE; QL

Notes

ST; CE; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 92

Drug Name

Tier

AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION

3

AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION

3

AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION

Drug Name

3

3

AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION

3

AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION

3

AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION

3

AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION

3

AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION

Notes

3

AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION

3

AURYXIA ORAL TABLET

3

bd posiflush normal saline injection syringe

1

bd posiflush saline blunt cann injection syringe

1

ST

Tier

bd pre-filled normal saline injection syringe

1

bd pre-filled saline blunt can injection syringe

1

BIFERA RX ORAL TABLET

3

calcium acetate oral capsule

1

calcium acetate oral tablet

1

calcium chloride intravenous solution

1

calcium chloride intravenous syringe

1

calcium gluconate intravenous solution

1

calcium-folic acid-vitamin d oral wafer

1

centratex oral capsule

1

chromium chloride intravenous solution

1

CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION

3

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 93

Drug Name CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 5%-D20W(SULFITE-FRE E) INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION

Tier

Notes

Drug Name

Tier

3

CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION

3

3

CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION

3

CLINPRO 5000 DENTAL PASTE

3

copper chloride intravenous solution

1

corvita 150 oral tablet

1

CORVITE 150 ORAL TABLET

3

CORVITE FE ORAL TABLET

3

cysteine (l-cysteine) intravenous solution

1

cytra k crystals oral packet

1

cytra-2 oral solution

1

cytra-3 oral solution

1

cytra-k oral solution

1

d10 %-0.45 % sodium chloride intravenous parenteral solution

1

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

1

d5 % and 0.9 % sodium chloride intravenous parenteral solution

1

d5 %-0.45 % sodium chloride intravenous parenteral solution

1

delflex with 2.5 % dextrose intraperitoneal solution

1

delflex-lc/1.5% dextrose intraperitoneal solution

1

3

3

3

3

3

CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION

3

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 94

Drug Name

Tier

delflex-lc/2.5% dextrose intraperitoneal solution

1

delflex-lc/4.25% dextrose intraperitoneal solution

1

DELFLEX-SM WITH 1.5% DEXTROSE INTRAPERITONEAL SOLUTION

2

denta 5000 plus dental cream

1

dentagel dental gel

1

dextrose 10 % and 0.2 % nacl intravenous parenteral solution

1

dextrose 10 % in water (d10w) intravenous parenteral solution

1

dextrose 20 % in water (d20w) intravenous parenteral solution

1

dextrose 25 % in water (d25w) intravenous syringe

1

dextrose 30 % in water (d30w) intravenous parenteral solution

1

dextrose 40 % in water (d40w) intravenous parenteral solution

1

dextrose 5 % in ringers intravenous parenteral solution

1

dextrose 5 % in water (d5w) intravenous parenteral solution

1

dextrose 5 % in water (d5w) intravenous piggyback

1

dextrose 5 %-lactated ringers intravenous parenteral solution

1

dextrose 5%-0.2 % sod chloride intravenous parenteral solution

1

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

1

Notes

Drug Name

Tier

dextrose 50 % in water (d50w) intravenous parenteral solution

1

dextrose 50 % in water (d50w) intravenous syringe

1

dextrose 70 % in water (d70w) intravenous parenteral solution

1

DIANEAL LOW CALCIUM/1.5% DEX INTRAPERITONEAL SOLUTION

3

DIANEAL LOW CALCIUM/4.25% DEX INTRAPERITONEAL SOLUTION

3

DIANEAL PD-2 WITH 2.5 % DEX INTRAPERITONEAL SOLUTION

3

DIANEAL PD-2 WITH 4.25 % DEX INTRAPERITONEAL SOLUTION

3

DIANEAL PD-2/1.5% DEXTROSE INTRAPERITONEAL SOLUTION

3

DIANEAL WITH 1.5% DEXTROSE INTRAPERITONEAL SOLUTION

3

DIANEAL WITH 2.5 % DEXTROSE INTRAPERITONEAL SOLUTION

3

DIANEAL WITH 4.25 % DEXTROSE INTRAPERITONEAL SOLUTION

3

EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ

3

effer-k oral tablet, effervescent 25 meq

1

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 95

Drug Name

Tier

electrolyte-48 in d5w intravenous parenteral solution

1

eliphos oral tablet

1

EXTRANEAL 7.5 % INTRAPERITONEAL SOLUTION

3

fe c plus oral tablet

1

FERAHEME INTRAVENOUS SOLUTION FERIVA 21-7 TABLET ORAL TABLET

Notes

Drug Name

Tier

Notes

fluoritab oral tablet,chewable

1

FLURA-DROPS ORAL DROPS

3

focalgin dss oral tablet

1

FOLGARD OS ORAL TABLET

3

folivane-f oral capsule

1

folivane-plus oral capsule

1

3

FOSRENOL ORAL POWDER IN PACKET

3

ST

3

FOSRENOL ORAL TABLET,CHEWABLE

3

ST

FERIVA FA (SUMALATE) ORAL CAPSULE

3

3

FERIVA ORAL CAPSULE,EXT RELEASE MULTIPHASE

FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION

3

freamine iii 10 % intravenous parenteral solution

1

ferocon oral capsule

1

3

FERRALET 90 DUAL-IRON DELIVERY ORAL TABLET

FUSION PLUS ORAL CAPSULE

3

3

ferraplus 90 oral tablet

1

FUSION SPRINKLES ORAL POWDER IN PACKET

FERRLECIT INTRAVENOUS SOLUTION

3

GLUCAGEN HYPOKIT INJECTION RECON SOLN

2

ferrocite plus oral tablet

1

ferrogels forte oral capsule

1

2

FLORIVA (FLUORIDE-VITAMIN D3) ORAL DROPS

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT

3

3

FLUORABON ORAL DROPS

GLYCOPHOS INTRAVENOUS SOLUTION

3

1

fluor-a-day (with xylitol) oral tablet,chewable

hematinic plus vit/minerals oral tablet

1

1

FLUOR-A-DAY ORAL DROPS

hematinic/folic acid oral tablet

3

hematogen fa oral capsule

1

fluoridex daily defense dental gel

1

hematogen forte oral capsule

1

hematogen oral capsule

1

FLUORIDEX SENSITIVITY RELIEF DENTAL GEL

3

HEMATRON ORAL LIQUID

3

FLUORITAB ORAL DROPS

3

HEMATRON-AF ORAL TABLET EXTENDED RELEASE 24 HR

3

ST

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 96

Drug Name

Tier

HEMAX ORAL TABLET EXTENDED RELEASE 24 HR

3

hemetab oral tablet

1

HEMOCYTE-F ORAL TABLET

3

HEMOCYTE-PLUS ORAL CAPSULE

3

HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION

3

HYDROCHLORIC ACID (BULK) LIQUID

3

Notes

Drug Name

Tier

ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

3

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION

3

KABIVEN INTRAVENOUS EMULSION

3

KAYEXALATE ORAL POWDER

3

k-effervescent oral tablet, effervescent

1

kionex oral powder

1

kionex oral suspension

1 1

HYPERLYTE CR INTRAVENOUS SOLUTION

3

ICAR-C PLUS ORAL TABLET

3

infed injection solution

1

klor-con 10 oral tablet extended release

INJECTAFER INTRAVENOUS SOLUTION

1

3

klor-con 8 oral tablet extended release

1

INTEGRA F ORAL CAPSULE

klor-con m10 oral tablet,er particles/crystals 3

1

INTEGRA PLUS ORAL CAPSULE

klor-con m15 oral tablet,er particles/crystals

3

1

IODOPEN INTRAVENOUS SOLUTION

klor-con m20 oral tablet,er particles/crystals

3

klor-con oral packet

1

klor-con sprinkle oral capsule, extended release

1

KLOR-CON/25 ORAL PACKET

3

klor-con/ef oral tablet, effervescent

1

K-PHOS NO 2 ORAL TABLET

3

K-PHOS ORIGINAL ORAL TABLET,SOLUBLE

2

k-phos-neutral oral tablet

1

k-sol oral liquid

1

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ

3

IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION

3

IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION

3

IROSPAN 24/6 ORAL TABLET

3

ISOLYTE S PH 7.4 INTRAVENOUS PARENTERAL SOLUTION

3

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 97

Drug Name

Tier

k-tab oral tablet extended release 8 meq

1

lactated ringers intravenous parenteral solution

1

ludent fluoride oral tablet,chewable

1

lugols oral solution

1

LYSIPLEX PLUS ORAL TABLET

3

MAGNEBIND 400 ORAL TABLET

3

magnesium chloride injection solution

1

MAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK

3

Notes

Drug Name

Tier

MULTITRACE-4 CONCENTRATE INTRAVENOUS SOLUTION

3

MULTITRACE-4 INTRAVENOUS SOLUTION

3

MULTITRACE-4 NEONATAL INTRAVENOUS SOLUTION

3

multitrace-4 pediatric intravenous solution

1

MULTITRACE-5 CONCENTRATE INTRAVENOUS SOLUTION

3

MULTITRACE-5 INTRAVENOUS SOLUTION

3

3

magnesium sulfate in water intravenous parenteral solution

1

magnesium sulfate in water intravenous piggyback

1

magnesium sulfate injection solution

1

NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION

magnesium sulfate injection syringe

1

NEPHRON FA ORAL TABLET

3

manganese chloride intravenous solution

1

NEUT INTRAVENOUS SOLUTION

3

manganese sulfate intravenous solution

1

normal saline flush injection syringe

1

NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

3

NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

3

NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION

3

NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION

3

MAXARON FORTE ORAL TABLET

3

MAXFE (FOLATE-DOCUSATE) ORAL TABLET

3

monoject 0.9% sodium chloride injection syringe

1

monoject prefill advanced ns injection syringe

1

monoject prefill saline flush injection syringe

1

multigen folic oral tablet

1

multigen plus oral tablet

1

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 98

Drug Name

Tier

NUFERA ORAL TABLET

3

NUTRESTORE ORAL POWDER IN PACKET

3

nutrilyte intravenous solution

1

ORACIT ORAL SOLUTION

Notes

Drug Name

Tier

potassium chlorid-d5-0.45%nacl intravenous parenteral solution

1

3

potassium chloride in 0.9%nacl intravenous parenteral solution

1

PEDITRACE INTRAVENOUS SOLUTION

3

potassium chloride in 5 % dex intravenous parenteral solution

1

PERIKABIVEN INTRAVENOUS EMULSION

3

potassium chloride in lr-d5 intravenous parenteral solution

1

perio med dental solution

1

PHOSLO ORAL CAPSULE

1

3

potassium chloride intravenous piggyback

PHOSLYRA ORAL SOLUTION

1

3

potassium chloride intravenous solution

phospha 250 neutral oral tablet

1

1

potassium chloride oral capsule, extended release

PHOXILLUM BK HEMODIALYSIS SOLUTION

potassium chloride oral liquid

1

3

potassium chloride oral packet

1

potassium chloride oral tablet extended release

1

potassium chloride oral tablet,er particles/crystals

1

potassium chloride-0.45 % nacl intravenous parenteral solution

1

potassium chloride-d5-0.2%nacl intravenous parenteral solution

1

potassium chloride-d5-0.3%nacl intravenous parenteral solution

1

1

PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION

3

PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION

3

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

3

pot,sodium citrate-citric acid oral solution

1

potassium acetate intravenous solution

1

ST ST

potassium bicarb and chloride oral tablet, effervescent

1

potassium chloride-d5-0.9%nacl intravenous parenteral solution

potassium bicarb-citric acid oral tablet, effervescent

1

potassium citrate oral tablet extended release

1

potassium citrate-citric acid oral packet

1

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 99

Drug Name

Tier

potassium citrate-citric acid oral solution

1

potassium phosphate m-/d-basic intravenous solution

1

premasol 10 % intravenous parenteral solution

1

PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION

3

Notes

Drug Name

Tier

PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION

3

purevit dualfe plus oral capsule

1

RENACIDIN IRRIGATION SOLUTION

3

RENAGEL ORAL TABLET

3

RENVELA ORAL POWDER IN PACKET

2

RENVELA ORAL TABLET

2

ringers intravenous parenteral solution

1

SACCHARIN POWDER

3

selenium intravenous solution

1

se-tan plus oral capsule

1

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE

3

PREVIDENT 5000 DRY MOUTH DENTAL GEL

3

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE

3

PREVIDENT 5000 PLUS DENTAL CREAM

3

PREVIDENT 5000 SENSITIVE DENTAL PASTE

sf 5000 plus dental cream

1

3

sf dental gel

1

PREVIDENT DENTAL GEL

3

3

SHOHL'S MODIFIED ORAL SOLUTION

PREVIDENT DENTAL SOLUTION

sodium acetate intravenous solution

1

3

sodium bicarbonate intravenous solution

1

sodium bicarbonate intravenous syringe

1

sodium chloride 0.45 % intravenous parenteral solution

1

sodium chloride 0.45 % intravenous piggyback

1

sodium chloride 0.9 % injection solution

1

sodium chloride 0.9 % injection syringe

1

SODIUM CHLORIDE 0.9 % INJECTION SYRINGE, WITH SWAB CAP

3

sodium chloride 0.9 % intravenous parenteral solution

1

PRISMASOL B22GK HEMODIALYSIS SOLUTION

3

PRISMASOL BGK HEMODIALYSIS SOLUTION

3

PRISMASOL BK HEMODIALYSIS SOLUTION

3

PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION

3

PROFERRIN-FORTE ORAL TABLET

3

PROGLYCEM ORAL SUSPENSION

3

Notes

ST

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 100

Drug Name

Tier

sodium chloride 0.9 % intravenous piggyback

1

sodium chloride 3 % intravenous parenteral solution

1

sodium chloride 5 % intravenous parenteral solution

1

sodium chloride intravenous parenteral solution

1

sodium citrate-citric acid oral solution

Notes

Drug Name

Tier

syrex sodium chloride 0.9% injection syringe

1

TANDEM PLUS ORAL CAPSULE

3

taron forte oral capsule

1

THAM INTRAVENOUS SOLUTION

3

tl g-fol os oral tablet

1

tl icon oral capsule

1

1

tl-hem 150 oral tablet extended release 24 hr

1

sodium ferric gluconat-sucrose intravenous solution

1

TPN ELECTROLYTES II INTRAVENOUS SOLUTION

3

sodium fluoride dental solution

1

3

sodium fluoride oral drops

1

TPN ELECTROLYTES INTRAVENOUS SOLUTION

sodium fluoride oral tablet,chewable

1

3

sodium lactate intravenous solution

1

TRACE ELEMENTS 4/PEDIATRIC INTRAVENOUS SOLUTION

sodium phosphate intravenous solution

1

1

travasol 10 % intravenous parenteral solution tricitrates oral solution

1

sodium polystyrene (sorb free) oral suspension

1

tricon oral capsule

1

sodium polystyrene sulfonate oral powder

1

TRIFERIC HEMODIALYSIS SOLUTION

3

sodium polystyrene sulfonate oral suspension

1

trigels-f forte oral capsule

1

sodium polystyrene sulfonate rectal enema 30 gram/120 ml

1

3

SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML

TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION

3

3

SORBITOL POWDER

3

TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION

sps oral suspension

1

sps rectal enema

1

3

SSKI ORAL SOLUTION

3

ULTRABAG/DIANEAL PD-2/1.5% DEX INTRAPERITONEAL SOLUTION

strong iodine oral solution

1

SWABFLUSH INJECTION SYRINGE, WITH SWAB CAP

3

ULTRABAG/DIANEAL PD-2/2.5% DEX INTRAPERITONEAL SOLUTION

3

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 101

Drug Name ULTRABAG/DIANEAL PD-2/4.25%DEX INTRAPERITONEAL SOLUTION

Tier

Notes

Drug Name

3

Tier

ACIPHEX SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE

3

ACTIGALL ORAL CAPSULE

3

AKYNZEO ORAL CAPSULE

3

alosetron oral tablet

1

ALOXI INTRAVENOUS SOLUTION

3

ULTRABAG/DIANEAL/2. 5% DEXTROSE INTRAPERITONEAL SOLUTION

3

UROCIT-K 10 ORAL TABLET EXTENDED RELEASE

3

UROCIT-K 15 ORAL TABLET EXTENDED RELEASE

3

AMITIZA ORAL CAPSULE

2

UROCIT-K 5 ORAL TABLET EXTENDED RELEASE

3

AMMONUL INTRAVENOUS SOLUTION

3

UROQID-ACID NO.2 ORAL TABLET

3

amoxicil-clarithromy-lansopr az oral combo pack

1

VELPHORO ORAL TABLET,CHEWABLE

3

ANA-LEX KIT RECTAL KIT

3

VELTASSA ORAL POWDER IN PACKET

3

3

VENOFER INTRAVENOUS SOLUTION

ANALPRAM E RECTAL KIT,CREAM AND TOWELETTE

3

ANALPRAM-HC RECTAL CREAM

3

virt-phos 250 neutral oral tablet

1

3

virtrate-2 oral solution

1

ANALPRAM-HC SINGLES RECTAL CREAM

virtrate-3 oral solution

1

anaspaz oral tablet,disintegrating

1

virtrate-k oral solution

1

VITAFOL ORAL TABLET

3

3

ANTIVERT ORAL TABLET anucort-hc rectal suppository

1

XURIDEN ORAL GRANULES IN PACKET

3

ANUSOL-HC RECTAL CREAM

3

zinc chloride intravenous solution

1

ANUSOL-HC RECTAL SUPPOSITORY

3

zinc sulfate intravenous solution

1

zinc sulfate oral capsule

1

3

GASTROINTESTINAL

ANZEMET INTRAVENOUS SOLUTION 100 MG/5 ML, 12.5 MG/0.625 ML

ACIPHEX ORAL TABLET,DELAYED RELEASE (DR/EC)

ANZEMET INTRAVENOUS SOLUTION 20 MG/ML

3

3

ST

ST; CE; QL

Notes ST; CE; QL

QL

PA

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 102

Drug Name

Tier

Notes

Drug Name

Tier

Notes

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT

4

PA; QL

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT

4

PA; QL

CIMZIA SUBCUTANEOUS SYRINGE KIT

4

PA; QL

ANZEMET ORAL TABLET

3

QL

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR

3

ST

ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC)

2

atropine injection solution

1

atropine injection syringe

1

3

AZULFIDINE EN-TABS ORAL TABLET,DELAYED RELEASE (DR/EC)

COLAZAL ORAL CAPSULE

3

COLYTE WITH FLAVOR PACKS ORAL RECON SOLN

3

AZULFIDINE ORAL TABLET

3

COMPAZINE ORAL TABLET

3

balsalazide oral capsule

1

3

BENTYL INTRAMUSCULAR SOLUTION

COMPAZINE RECTAL SUPPOSITORY

3

compro rectal suppository

1

constulose oral solution

1

BENTYL ORAL CAPSULE

3

2

BENTYL ORAL TABLET

3

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC)

BUPHENYL ORAL POWDER

3

CUVPOSA ORAL SOLUTION

3

BUPHENYL ORAL TABLET

3

CYTOTEC ORAL TABLET

3

CANASA RECTAL SUPPOSITORY

2

2

carafate oral suspension

1

DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC)

CARAFATE ORAL TABLET

3

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS

3

ST; CE; QL

CESAMET ORAL CAPSULE

3

3

PA; QL

CHENODAL ORAL TABLET

3

DICLEGIS ORAL TABLET,DELAYED RELEASE (DR/EC)

chlordiazepoxide-clidinium oral capsule

1

1

dicyclomine intramuscular solution dicyclomine oral capsule

1

CHOLBAM ORAL CAPSULE

3

dicyclomine oral solution

1

dicyclomine oral tablet

1

cimetidine hcl oral solution

1

cimetidine oral tablet

1

dimenhydrinate injection solution

1

DIPENTUM ORAL CAPSULE

3

PA

PA; QL

ST

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 103

Drug Name

Tier

diphenoxylate-atropine oral liquid

1

diphenoxylate-atropine oral tablet

1

DONNATAL ORAL ELIXIR

Notes

Drug Name

Tier

gavilyte-h and bisacodyl oral kit

1

gavilyte-n oral recon soln

1

generlac oral solution

1

3

GIAZO ORAL TABLET

3

DONNATAL ORAL TABLET

3

glycopyrrolate injection solution

1

dronabinol oral capsule

1

glycopyrrolate oral tablet

1

ed-spaz oral tablet,disintegrating

1

GOLYTELY ORAL POWDER IN PACKET

3

EMEND INTRAVENOUS RECON SOLN

3

PA

GOLYTELY ORAL RECON SOLN

3

EMEND ORAL CAPSULE

3

QL

granisetron (pf) intravenous solution

1

EMEND ORAL CAPSULE,DOSE PACK

3

QL

granisetron hcl intravenous solution

1

ENTEREG ORAL CAPSULE

3

granisetron hcl oral tablet

1

ENTYVIO INTRAVENOUS RECON SOLN

1

4

hemmorex-hc rectal suppository

1

enulose oral solution

1

hydrocortisone acetate rectal suppository

esomeprazole magnesium oral capsule,delayed release(dr/ec)

hydrocortisone rectal cream

1

3

hydrocortisone-pramoxine rectal cream

1

esomeprazole sodium intravenous recon soln

1

hyoscyamine sulfate oral drops

1

famotidine (pf) intravenous solution

1

hyoscyamine sulfate oral elixir

1

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

1

hyoscyamine sulfate oral tablet

1

famotidine intravenous solution

1

hyoscyamine sulfate oral tablet extended release 12 hr

1

famotidine oral suspension

1

1

famotidine oral tablet

1

hyoscyamine sulfate oral tablet,disintegrating hyoscyamine sulfate sublingual tablet

1

hyosyne oral drops

1

hyosyne oral elixir

1

intralipid intravenous emulsion 20 %

1

INTRALIPID INTRAVENOUS EMULSION 30 %

3

PA; QL

ST; CE; QL

FULYZAQ ORAL TABLET,DELAYED RELEASE (DR/EC)

3

PA

GATTEX 30-VIAL SUBCUTANEOUS KIT

3

PA

GATTEX ONE-VIAL SUBCUTANEOUS KIT

3

PA

gavilyte-c oral recon soln

1

gavilyte-g oral recon soln

1

Notes

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 104

Drug Name

Tier

Notes

Drug Name

Tier

ipecac oral syrup

1

2

KEPIVANCE INTRAVENOUS RECON SOLN

LINZESS ORAL CAPSULE

4

3

KINEVAC INJECTION RECON SOLN

LIPOSYN II INTRAVENOUS EMULSION

3

1

KRISTALOSE ORAL PACKET

liposyn iii intravenous emulsion

3

3

lactulose oral solution

1

LITHOSTAT ORAL TABLET

lansoprazole oral capsule,delayed release(dr/ec)

3

3

LOMOTIL ORAL TABLET loperamide oral capsule

1

LEVBID ORAL TABLET EXTENDED RELEASE 12 HR

3

LOTRONEX ORAL TABLET

3

LEVSIN INJECTION SOLUTION

3

2

LOVAZA ORAL CAPSULE

LEVSIN ORAL TABLET

3

MARINOL ORAL CAPSULE

3

LEVSIN/SL SUBLINGUAL TABLET

3

meclizine oral tablet

1

mesalamine rectal enema

1

LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC)

2

mesalamine with cleansing wipe rectal enema kit

1

methscopolamine oral tablet

1

metoclopramide hcl injection solution

1

metoclopramide hcl injection syringe

1

metoclopramide hcl oral solution

1

LIBRAX (WITH CLIDINIUM) ORAL CAPSULE

QL

3

LIDOCAINE HCL-HYDROCORTISON AC RECTAL CREAM 3 %-1 % (7 GRAM)

3

lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %

1

metoclopramide hcl oral tablet

1

LIDOCAINE HCL-HYDROCORTISON AC RECTAL GEL

3

metoclopramide hcl oral tablet,disintegrating

1

lidocaine hcl-hydrocortison ac rectal kit

1

METOZOLV ODT ORAL TABLET,DISINTEGRATI NG

3

lidocaine-hydrocortisone-alo e rectal gel

1

misoprostol oral tablet

1

MOTOFEN ORAL TABLET

3

MOVIPREP ORAL POWDER IN PACKET

3

NEXIUM IV INTRAVENOUS RECON SOLN

3

LIDOCAINE-HYDROCO RTISONE-ALOE RECTAL KIT 2-2 %

3

lidocaine-hydrocortisone-alo e rectal kit 3-2.5 % (7 gram)

1

Notes

ST; CE; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 105

Drug Name

Tier

NEXIUM ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET

2

nizatidine oral capsule

1

nizatidine oral solution NULEV ORAL TABLET,DISINTEGRATI NG

Notes

Drug Name

Tier

Notes

oscimin sl sublingual tablet

1

oscimin sr oral tablet extended release 12 hr

1

OSMOPREP ORAL TABLET

3 3

1

PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

pantoprazole intravenous recon soln

1

QL

pantoprazole oral tablet,delayed release (dr/ec)

1

QL

paregoric oral liquid

1

QL

peg 3350-electrolytes oral recon soln

1

peg-3350 with flavor packs oral recon soln

1

peg-electrolyte soln oral recon soln

1

peg-prep oral kit

1

PENTASA ORAL CAPSULE, EXTENDED RELEASE

2

ST; CE; QL

QL

NULYTELY WITH FLAVOR PACKS ORAL RECON SOLN

3

NUTRILIPID INTRAVENOUS EMULSION

3

NUTRIPORT BALLOON KIT

2

OCALIVA ORAL TABLET

4

OMECLAMOX-PAK ORAL COMBO PACK

3

omega-3 acid ethyl esters oral capsule

1

ST; CE; QL

3

omeprazole oral capsule,delayed release(dr/ec)

PEPCID ORAL SUSPENSION

1

QL

PEPCID ORAL TABLET

3

omeprazole-sodium bicarbonate oral capsule

1

QL

PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

ondansetron hcl (pf) injection solution

1

phenadoz rectal suppository

1

phenergan rectal suppository

1

ondansetron hcl (pf) injection syringe

1

phenobarb-hyoscy-atropine-s cop oral tablet

1

ondansetron hcl intravenous solution

1

phenohytro oral tablet

1

ondansetron hcl oral solution

1

QL

polyethylene glycol 3350 oral powder

1

ondansetron hcl oral tablet

1

QL

ondansetron oral tablet,disintegrating

1

1

QL

polyethylene glycol 3350 oral powder in packet pramcort rectal cream

1

opium tincture oral tincture

1

oscimin oral tablet

1

PREPOPIK ORAL POWDER IN PACKET

3

oscimin oral tablet,disintegrating

1

PREVACID ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

PA

ST; CE; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 106

Drug Name

Tier

PREVACID SOLUTAB ORAL TABLET,DISINTEGRAT, DELAY REL

3

PREVPAC ORAL COMBO PACK

3

PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON

3

prochlorperazine edisylate injection solution

Notes

Drug Name

Tier

ranitidine hcl injection solution

1

ranitidine hcl oral capsule

1

ranitidine hcl oral syrup

1

ranitidine hcl oral tablet

1

RAVICTI ORAL LIQUID

3

RECTIV RECTAL OINTMENT

3

1

REGLAN ORAL TABLET

3

prochlorperazine maleate oral tablet

1

REMICADE INTRAVENOUS RECON SOLN

4

prochlorperazine rectal suppository

1

RESTORA RX ORAL CAPSULE

3

PROCORT RECTAL CREAM

3

3

PROCTOCORT RECTAL CREAM

3

RESTORA SPRINKLES ORAL POWDER IN PACKET

PROCTOCORT RECTAL SUPPOSITORY

3

3

ROBINUL FORTE ORAL TABLET

PROCTOFOAM HC RECTAL FOAM

3

3

ROBINUL INJECTION SOLUTION

procto-med hc rectal cream

1

ROBINUL ORAL TABLET

3

procto-pak rectal cream

1

3

proctosol hc rectal cream

1

ROWASA RECTAL ENEMA KIT

proctozone-hc rectal cream

1

3

promethazine rectal suppository

1

SANCUSO TRANSDERMAL PATCH WEEKLY

promethegan rectal suppository

3

1

SCOPOLAMINE HBR INJECTION SOLUTION

propantheline oral tablet

1

SENSURA CLICK OSTOMY POUCH

3

PROTONIX INTRAVENOUS RECON SOLN

3

SENSURA OSTOMY BASE PLATE

3

SFROWASA RECTAL ENEMA

3

sodium phenylbutyrate oral powder

1

SUCRAID ORAL SOLUTION

4

sucralfate oral tablet

1

sulfasalazine oral tablet

1

sulfasalazine oral tablet,delayed release (dr/ec)

1

PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET

3

PROTONIX ORAL TABLET,DELAYED RELEASE (DR/EC)

3

PYLERA ORAL CAPSULE

3

rabeprazole oral 1 tablet,delayed release (dr/ec) Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program

ST; CE; QL

QL

ST

ST; QL

ST; CE; QL

ST; CE; QL

Notes

PA; QL

PA

QL

Effective 7/1/16 107

Drug Name

Tier

SUPREP BOWEL PREP KIT ORAL RECON SOLN

3

SYMAX DUOTAB ORAL TABLET,EXT RELEASE MULTIPHASE

Notes

Drug Name

Tier

Notes

3

3

ZOFRAN (AS HYDROCHLORIDE) INTRAVENOUS SOLUTION

symax fastabs oral tablet,disintegrating

3

QL

1

ZOFRAN (AS HYDROCHLORIDE) ORAL SOLUTION

symax-sl sublingual tablet

1

3

QL

symax-sr oral tablet extended release 12 hr

1

ZOFRAN (AS HYDROCHLORIDE) ORAL TABLET

TIGAN INTRAMUSCULAR SOLUTION

3

QL

3

ZOFRAN ODT ORAL TABLET,DISINTEGRATI NG

3

QL

3

ZUPLENZ ORAL FILM

TIGAN ORAL CAPSULE TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY

3

2

ZYPRAM RECTAL KIT,CREAM AND TOWELETTE

trilyte with flavor packets oral recon soln

1

ACTHAR H.P. INJECTION GEL

4

trimethobenzamide oral capsule

1

3

URSO 250 ORAL TABLET

3

ACTHREL INTRAVENOUS RECON SOLN

URSO FORTE ORAL TABLET

3

ACTIVE INJECTION KIT D INJECTION KIT

3

ursodiol oral capsule

1

ACTIVELLA ORAL TABLET

3

ursodiol oral tablet

1

VARUBI ORAL TABLET

3

QL

a-hydrocort injection recon soln

1

VASCEPA ORAL CAPSULE

3

ST; CE; QL

ALORA TRANSDERMAL PATCH SEMIWEEKLY

3

VIBERZI ORAL TABLET

3

PA; QL

3

VIOKACE ORAL TABLET

ANADROL-50 ORAL TABLET

3

ANDRODERM TRANSDERMAL PATCH 24 HOUR

3

PA; QL

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %)

3

PA; QL

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

2

PA; QL

HORMONES

ZANTAC INJECTION SOLUTION

3

ZANTAC ORAL TABLET

3

ZEGERID ORAL CAPSULE

3

ST; CE; QL

ZEGERID ORAL PACKET

3

ST; QL

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)

2

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 108

Drug Name ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM)

Tier

3

ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

2

ANDROID ORAL CAPSULE

3

androxy oral tablet

1

ANGELIQ ORAL TABLET

3

ARISTOSPAN INTRA-ARTICULAR INJECTION SUSPENSION

3

ARISTOSPAN INTRALESIONAL INJECTION SUSPENSION

3

AVEED INTRAMUSCULAR SOLUTION

3

AXIRON TRANSDERMAL SOLUTION IN METERED PUMP W/APP

3

AYGESTIN ORAL TABLET

3

BETA-1 INJECTION KIT

3

betamethasone acet,sod phos injection suspension

1

BRAVELLE INJECTION RECON SOLN

4

budesonide oral capsule,delayed,extend.releas e

1

cabergoline oral tablet

1

calcitonin (salmon) nasal spray,non-aerosol

1

CELESTONE SOLUSPAN INJECTION SUSPENSION

3

Notes

Drug Name

3

PA; QL

CERVIDIL VAGINAL INSERT, EXTENDED RELEASE CETROTIDE SUBCUTANEOUS KIT

4

PA

chorionic gonadotropin, human intramuscular recon soln

4

PA

CLIMARA PRO TRANSDERMAL PATCH WEEKLY

2

CLIMARA TRANSDERMAL PATCH WEEKLY

3

clomiphene citrate oral tablet

1

colocort rectal enema

1

COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY

2

CORTEF ORAL TABLET

3

CORTENEMA RECTAL ENEMA

3

CORTIFOAM RECTAL FOAM

3

cortisone oral tablet

1

CORTROSYN INJECTION RECON SOLN

3

cosyntropin injection recon soln

1

COSYNTROPIN INTRAVENOUS SOLUTION

3

covaryx h.s. oral tablet

1

covaryx oral tablet

1

CRINONE VAGINAL GEL

4

danazol oral capsule

1

DDAVP INJECTION SOLUTION

3

DDAVP NASAL AEROSOL,SPRAY

3

DDAVP NASAL SOLUTION

3

PA; QL

PA; QL

ST

QL

Tier

Notes

PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 109

Drug Name

Tier

DDAVP ORAL TABLET

3

DELESTROGEN INTRAMUSCULAR OIL

3

deltasone oral tablet

1

DEPO-ESTRADIOL INTRAMUSCULAR OIL

3

DEPO-MEDROL INJECTION SUSPENSION

3

DEPO-PROVERA INTRAMUSCULAR SOLUTION

3

DEPO-TESTOSTERONE INTRAMUSCULAR OIL

3

desmopressin injection solution

1

desmopressin nasal aerosol,spray

1

desmopressin nasal solution

1

desmopressin nasal spray,non-aerosol

1

desmopressin oral tablet

1

dexamethasone intensol oral drops

1

dexamethasone oral elixir

1

dexamethasone oral solution

1

dexamethasone oral tablet

1

dexamethasone sodium phos (pf) injection solution

Notes

Drug Name

Tier

Notes

DUAVEE ORAL TABLET

3

eemt hs oral tablet

1

eemt oral tablet

1

EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG

4

PA; QL

EGRIFTA SUBCUTANEOUS RECON SOLN 2 MG

4

PA

ELESTRIN TRANSDERMAL GEL IN METERED-DOSE PUMP

3

ENDOMETRIN VAGINAL INSERT

3

ENJUVIA ORAL TABLET

3

ENTOCORT EC ORAL CAPSULE,DELAYED,EX TEND.RELEASE

3

ESTRACE ORAL TABLET

3

ESTRACE VAGINAL CREAM

3

estradiol oral tablet

1

estradiol transdermal patch semiweekly

1

estradiol transdermal patch weekly

1 1

1

estradiol valerate intramuscular oil

dexamethasone sodium phosphate injection solution

1

1

estradiol-norethindrone acet oral tablet

dexamethasone sodium phosphate injection syringe

2

1

ESTRING VAGINAL RING

DEXPAK 10 DAY ORAL TABLETS,DOSE PACK

3

ESTROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP

3

DEXPAK 13 DAY ORAL TABLETS,DOSE PACK

3

estrogens-methyltestosterone oral tablet

1

DEXPAK 6 DAY ORAL TABLETS,DOSE PACK

3

estropipate oral tablet

1

DIVIGEL TRANSDERMAL GEL IN PACKET

2

2

EVAMIST TRANSDERMAL SPRAY,NON-AEROSOL

DOUBLEDEX INJECTION KIT

3

3

FEMHRT LOW DOSE ORAL TABLET

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 110

Drug Name

Tier

Notes

FEMRING VAGINAL RING

3

fludrocortisone oral tablet

1

FOLLISTIM AQ INJECTION SOLUTION

4

PA

FOLLISTIM AQ SUBCUTANEOUS CARTRIDGE

4

PA

FORTESTA TRANSDERMAL GEL IN METERED-DOSE PUMP

3

PA; QL

fortical nasal spray,non-aerosol

1

QL

fyavolv oral tablet

1

GANIRELIX SUBCUTANEOUS SYRINGE

4

PA

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE

4

PA

GENOTROPIN SUBCUTANEOUS CARTRIDGE

4

PA

GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR

4

ST

GONAL-F RFF SUBCUTANEOUS RECON SOLN

4

GONAL-F SUBCUTANEOUS RECON SOLN

4

HEMABATE INTRAMUSCULAR SOLUTION

3

HUMATROPE INJECTION CARTRIDGE

4

HUMATROPE INJECTION RECON SOLN

4

hydrocortisone oral tablet

1

hydrocortisone rectal enema

1

Drug Name

Tier

Notes

INCRELEX SUBCUTANEOUS SOLUTION

4

jevantique lo oral tablet

1

jinteli oral tablet

1

KENALOG INJECTION SUSPENSION

3

lopreeza oral tablet

1

LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET

4

PA

LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET

4

PA

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT

4

PA

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT

4

PA; QL

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT

4

PA

LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25 MG, 15 MG

4

PA

ST

LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED)

4

PA; QL

ST

MAKENA INTRAMUSCULAR OIL 250 MG/ML

4

PA

MAKENA INTRAMUSCULAR OIL 250 MG/ML (1 ML)

4

PA

MEDROL (PAK) ORAL TABLETS,DOSE PACK

3 3

PA

MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG MEDROL ORAL TABLET 2 MG

2

medroxyprogesterone oral tablet

1

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 111

Drug Name MENEST ORAL TABLET MENOPUR SUBCUTANEOUS RECON SOLN

Tier

Notes

Drug Name

PA

2 4

Tier

Notes

NATESTO NASAL GEL IN METERED-DOSE PUMP

3

PA; QL

NATPARA SUBCUTANEOUS CARTRIDGE

3

PA; QL

4

PA

MENOSTAR TRANSDERMAL PATCH WEEKLY

3

methergine oral tablet

1

METHITEST ORAL TABLET

3

NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR

METHYLERGONOVINE INJECTION SOLUTION

1

3

norethindrone acetate oral tablet

methylergonovine oral tablet

1

norethindrone ac-eth estradiol oral tablet

1

methylprednisolone acetate injection suspension

1

novarel intramuscular recon soln

4

PA

methylprednisolone oral tablet

1

4

PA

methylprednisolone oral tablets,dose pack

1

NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR

methylprednisolone sodium succ injection recon soln

1

NUTROPIN AQ SUBCUTANEOUS CARTRIDGE

4

PA

methylprednisolone sodium succ intravenous recon soln

1

octreotide acetate injection solution

4

PA

methyltestosterone oral capsule

1

octreotide acetate injection syringe

4

PA

MIACALCIN INJECTION SOLUTION

4

4

PA

MIACALCIN NASAL SPRAY,NON-AEROSOL

OMNITROPE SUBCUTANEOUS CARTRIDGE

3

millipred dp oral tablets,dose pack

4

PA

1

OMNITROPE SUBCUTANEOUS RECON SOLN ORAPRED ODT ORAL TABLET,DISINTEGRATI NG

3

PA

4

PA

QL

MILLIPRED ORAL SOLUTION

3

millipred oral tablet

1

mimvey lo oral tablet

1

mimvey oral tablet

1

OVIDREL SUBCUTANEOUS SYRINGE

MINIVELLE TRANSDERMAL PATCH SEMIWEEKLY

3

PA

3

OXANDRIN ORAL TABLET oxandrolone oral tablet

1

PA

MYALEPT SUBCUTANEOUS RECON SOLN

oxytocin injection solution

1

4

PEDIAPRED ORAL SOLUTION

3

PITOCIN INJECTION SOLUTION

3

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 112

Drug Name

Tier

prednisolone oral solution

1

prednisolone sodium phosphate oral solution

1

Notes

Drug Name

Tier

PROVERA ORAL TABLET

3 3

Notes

prednisolone sodium phosphate oral tablet,disintegrating

1

RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC)

prednisone intensol oral concentrate

4

PA

1

SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE

prednisone oral solution

1

PA

1

4

prednisone oral tablet

SAIZEN SUBCUTANEOUS RECON SOLN

prednisone oral tablets,dose pack

1

SANDOSTATIN INJECTION SOLUTION

4

PA

PREFEST ORAL TABLET

3

4

PA

PREGNYL INTRAMUSCULAR RECON SOLN

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT

4

PREMARIN INJECTION RECON SOLN

2

4

PA

PREMARIN ORAL TABLET

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDE D REL RECON

2

serophene oral tablet

1

PA

PREMARIN VAGINAL CREAM

2

4

PA

PREMPHASE ORAL TABLET

SEROSTIM SUBCUTANEOUS RECON SOLN

2

PREMPRO ORAL TABLET

2

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

4

PREPIDIL VAGINAL GEL

3

4

PRO-C-DURE 5 INJECTION KIT

3

SIGNIFOR SUBCUTANEOUS SOLUTION

PRO-C-DURE 6 INJECTION KIT

3

SOLU-CORTEF (PF) INJECTION RECON SOLN

3

progesterone in oil intramuscular oil

1

3

progesterone intramuscular oil

SOLU-CORTEF INJECTION RECON SOLN

1

progesterone micronized oral capsule

3

1

SOLU-MEDROL (PF) INJECTION RECON SOLN

PROMETRIUM ORAL CAPSULE

3

3

PROSTIN E2 VAGINAL SUPPOSITORY

SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN

3

SOLU-MEDROL INTRAVENOUS RECON SOLN

3

PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 113

Drug Name

Tier

Notes

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE

4

STIMATE NASAL SPRAY,NON-AEROSOL

3

STRIANT BUCCAL MUCOADHESIVE SYSTEM ER 12 HR

3

SUPPRELIN LA IMPLANT KIT

4

SYNAREL NASAL SPRAY,NON-AEROSOL

4

PA

TESTIM TRANSDERMAL GEL

3

PA; QL

TESTONE CIK INTRAMUSCULAR KIT

3

TESTOPEL IMPLANT PELLET

3

testosterone cypionate intramuscular oil

Drug Name

Tier

Notes

VASOSTRICT INTRAVENOUS SOLUTION

3

veripred 20 oral solution

1

VIVELLE-DOT TRANSDERMAL PATCH SEMIWEEKLY

3

VOGELXO TRANSDERMAL GEL

3

PA; QL

VOGELXO TRANSDERMAL GEL IN METERED-DOSE PUMP

3

PA; QL

VOGELXO TRANSDERMAL GEL IN PACKET

3

PA; QL

ZOMACTON SUBCUTANEOUS RECON SOLN

4

PA

1

ZORBTIVE SUBCUTANEOUS RECON SOLN

4

PA

testosterone enanthate intramuscular oil

1

IMMUNOSUPPRESANT

TESTOSTERONE TRANSDERMAL GEL

3

PA; QL

4

PA

TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP

ACTEMRA INTRAVENOUS SOLUTION

3

PA; QL

4

PA

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

ACTEMRA SUBCUTANEOUS SYRINGE

1

PA; QL

3

PA

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

ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR AZASAN ORAL TABLET

2

PA

3

PA; QL

azathioprine oral tablet

1

PA

TESTRED ORAL CAPSULE

1

PA

3

azathioprine sodium injection recon soln

triamcinolone acetonide injection suspension

1

3

PA

UCERIS ORAL TABLET,DELAYED AND EXT.RELEASE

CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN

3

CELLCEPT ORAL CAPSULE

2

PA

UCERIS RECTAL FOAM

3

VAGIFEM VAGINAL TABLET

2

PA

2

CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION

vasopressin injection solution

1

CELLCEPT ORAL TABLET

2

PA

PA; QL PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 114

Drug Name

Tier

Notes

cyclosporine intravenous solution

1

PA

cyclosporine modified oral capsule

1

PA

cyclosporine modified oral solution

1

PA

cyclosporine oral capsule

1

PA

ELIDEL TOPICAL CREAM

2

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR

3

gengraf oral capsule

Drug Name

Tier

Notes

SANDIMMUNE INTRAVENOUS SOLUTION

3

PA

SANDIMMUNE ORAL CAPSULE

2

PA

SANDIMMUNE ORAL SOLUTION

2

PA

ST

SIMULECT INTRAVENOUS RECON SOLN

3

PA

PA

sirolimus oral tablet

1

PA

1

PA

4

PA; QL

gengraf oral solution

1

PA

STELARA SUBCUTANEOUS SYRINGE

PA

PA

1

3

tacrolimus oral capsule

IMURAN ORAL TABLET

tacrolimus topical ointment

1

ST

mycophenolate mofetil oral capsule

1

PA

ZORTRESS ORAL TABLET

2

PA

mycophenolate mofetil oral suspension for reconstitution

1

PA

mycophenolate mofetil oral tablet

1

PA

MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG

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

PA

1ST TIER UNILET COMFORTOUCH

2

1

ACCU-CHEK FASTCLIX

2

MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC)

3

PA

ACCU-CHEK FASTCLIX KIT

2

NEORAL ORAL CAPSULE

2

PA

ACCU-CHEK MULTICLIX LANCET

2

NEORAL ORAL SOLUTION

2

PA

ACCU-CHEK MULTICLIX LANCET KIT

2

NULOJIX INTRAVENOUS RECON SOLN

3

PA

ACCU-CHEK SAFE-T-PRO

2

ACCU-CHEK SAFE-T-PRO PLUS

2

ACCU-CHEK SOFT DEV LANCETS KIT

2

ACCU-CHEK SOFTCLIX LANCETS

2

acti-lance lancets 17 gauge, 28 gauge

1

ACTI-LANCE LANCETS 23 GAUGE

2

ADVANCED LANCING DEVICE KIT

2

PROGRAF INTRAVENOUS SOLUTION

2

PROGRAF ORAL CAPSULE

2

PROTOPIC TOPICAL OINTMENT

3

RAPAMUNE ORAL SOLUTION

2

RAPAMUNE ORAL TABLET

2

PA PA ST PA PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 115

Drug Name

Tier

ADVANCED TRAVEL LANCETS

2

ADVOCATE LANCET

2

ALTERNATE SITE LANCET

2

ASSURE HAEMOLANCE PLUS

2

ASSURE LANCE

2

ASSURE LANCE PLUS

2

AUTOLET IMPRESSION LANC DEV KIT

2

BD MICROTAINER LANCET

2

BD ULTRA FINE LANCETS

Notes

Drug Name

Tier

FIFTY50 SAFETY SEAL LANCETS

2

FINE 30 UNIVERSAL LANCETS

2

FINGERSTIX LANCETS

2

FIRST CHOICE LANCETS THIN

2

FORA V10-V12-D10-D20 COMBO PACK

3

FORACARE LANCETS

2

FREESTYLE LANCETS

2

FREESTYLE UNISTIK 2

2

GLUCOCOM LANCETS

2

2

GMATE LANCETS

2

BD ULTRA-FINE II LANCETS

2

HEALTHY ACCENTS UNILET LANCET

2

BULLSEYE MINI SAFETY LANCETS

2

HYPOLANCE AST LANCING KIT

2

CAREONE THIN LANCET

2

INCONTROL SUPER THIN LANCETS

2

CAREONE ULTRA THIN LANCET

2

INCONTROL ULTRA THIN LANCETS

2

CLEVER CHEK LANCETS

INJECT EASE LANCETS

2

2

INVACARE LANCETS

2

COAGUCHEK LANCETS

2

2

COLOR LANCETS

2

KINNEY BRAND LANCETS

COMFORT LANCETS

2

LANCETS

2

DROPLET LANCETS

2

LANCETS, SUPER THIN

2

EASY COMFORT LANCETS

LANCETS,THIN

2

2

LANCETS,ULTRA THIN

2

EASY TOUCH LANCETS

2

2

EASY TOUCH SAFETY LANCETS

LANCING DEVICE WITH LANCETS KIT

2

3

EASY TOUCH TWIST LANCETS

LANZO LANCING DEVICE KIT

2

LITE TOUCH LANCETS

2

EASY TWIST AND CAP LANCETS

2

MEDISENSE THIN LANCETS

2

EMBRACE LANCETS

2

2

e-z ject lancets

1

MEDLANCE PLUS LANCETS

E-Z JECT THIN LANCETS

MICRO THIN LANCETS

2

2

2

EZ SMART LANCETS

2

MICROLET 2 LANCING DEVICE KIT

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 116

Drug Name

Tier

Notes

Drug Name

Tier

MICROLET LANCET

2

SMARTEST LANCET

2

MONOLET LANCETS

2

SOFT TOUCH LANCETS

2

MONOLET THIN LANCETS

2

SOLUS V2 LANCETS

2

MULTI-LANCET DEVICE 2 KIT

2

2

SOLUS V2 LANCING DEVICE KIT STERILANCE TL

2

MYGLUCOHEALTH LANCETS

2

SUPER THIN LANCETS

2

NOVA SAFETY LANCETS

2

SURE COMFORT LANCETS

2

NOVA SUREFLEX LANCETS

2

SUREFLEX DEVICE WITH LANCETS KIT

2

ON CALL LANCET

2

SURE-LANCE

2

ON CALL PLUS LANCET

2

SURE-LANCE ULTRA THIN

2

ONETOUCH DELICA LANC DEVICE KIT

2

SURE-TOUCH LANCET

2

ONETOUCH DELICA LANCETS

TECHLITE LANCETS

2

2

TELCARE LANCETS

2

ONETOUCH SURESOFT LANCING DEV

2

THIN LANCETS

2

ONETOUCH ULTRASOFT LANCETS

2

2

TOPCARE UNIVERSAL1 LANCET TRUEPLUS LANCETS

2

ON-THE-GO LANCETS

2

ULTI-LANCE KIT

2

PRESSURE ACTIVATED LANCETS

2

ULTILET BASIC LANCETS

2

PRODIGY LANCETS

2

PRODIGY TWIST TOP LANCET

2

2

ULTILET CLASSIC LANCETS ULTILET LANCETS

2

RELIAMED LANCET

2

RELIAMED SAFETY SEAL LANCETS

2

2

ULTILET SAFETY LANCETS

RELION THIN LANCETS

2

ULTRA THIN II LANCETS

2

RELION ULTRA THIN PLUS LANCETS

2

ULTRA THIN LANCETS

2

RIGHTEST GL300 LANCETS

2

2

ULTRA THIN PLUS LANCETS ULTRA TLC LANCETS

2

SAFETY LANCETS

2

SAFETY SEAL LANCETS

2

ULTRALANCE LANCETS

2

SAFETY-LET LANCETS

2

2

SINGLE-LET

2

ULTRA-THIN II LANCETS

SMART SENSE LANCETS

2

UNILET COMFORTOUCH LANCET

2

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 117

Drug Name

Tier

UNILET EXCELITE II LANCET

2

UNILET EXCELITE LANCET

2

UNILET GP LANCET

2

UNILET LANCET

2

UNILET LANCETS

Notes

Drug Name

Tier

Notes

COMFORT PAC-TIZANIDINE KIT

3

cyclobenzaprine oral tablet

1

DANTRIUM INTRAVENOUS RECON SOLN

3

2

3

UNILET SUPER THIN LANCETS

DANTRIUM ORAL CAPSULE

2

dantrolene oral capsule

1

UNISTIK 2 DEVICE KIT

2

FEXMID ORAL TABLET

3

UNISTIK 2 NORMAL LANCET,DEVICE KIT

2

4

UNISTIK 3 COMFORT DEVICE KIT

GABLOFEN INTRATHECAL SOLUTION

2

4

UNISTIK 3 COMFORT LANCET

2

GABLOFEN INTRATHECAL SYRINGE

UNISTIK 3 EXTRA LANCET

2

LIORESAL INTRATHECAL SOLUTION

3

UNISTIK 3 GENTLE

2

UNISTIK 3 KIT

2

LORZONE ORAL TABLET

3

UNISTIK 3 LANCETS

2

metaxall oral tablet

1

UNISTIK 3 NEONATAL DEVICE KIT

2

metaxalone oral tablet

1

UNISTIK 3 NEONATAL KIT

1

2

methocarbamol injection solution methocarbamol oral tablet

1

UNISTIK 3 NORMAL LANCET

2

orphenadrine citrate injection solution

1

UNISTIK CZT LANCET

2

UNISTIK SAFETY

2

orphenadrine citrate oral tablet extended release

1

UNISTIK TOUCH LANCETS

2

PARAFON FORTE DSC ORAL TABLET

3

UNIVERSAL 1 LANCETS

2

revonto intravenous recon soln

1

ROBAXIN INJECTION SOLUTION

3

QL

ROBAXIN ORAL TABLET

3

QL

ROBAXIN-750 ORAL TABLET

3

RYANODEX INTRAVENOUS SUSPENSION FOR RECONSTITUTION

3

MUSCLE RELAXANTS AMRIX ORAL CAPSULE,EXTENDED RELEASE 24HR

3

baclofen oral tablet

1

carisoprodol oral tablet

1

carisoprodol-aspirin oral tablet

1

chlorzoxazone oral tablet

1

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 118

Drug Name

Tier

SKELAXIN ORAL TABLET

3

SOMA ORAL TABLET

3

tizanidine oral capsule

1

tizanidine oral tablet

Notes

Drug Name

Tier

completenate oral tablet,chewable

1

CONCEPT DHA ORAL CAPSULE

3

1

3

ZANAFLEX ORAL CAPSULE

CONCEPT OB ORAL CAPSULE

3

dothelle dha oral capsule

1

ZANAFLEX ORAL TABLET

3

DUET DHA BALANCED ORAL COMBO PACK

3 3

ACTIVE OB ORAL CAPSULE

3

DUET DHA WITH OMEGA-3 ORAL COMBO PACK elite-ob 400 oral capsule

1

ATABEX EC ORAL TABLET,DELAYED RELEASE (DR/EC)

2

elite-ob oral capsule

1

ENBRACE HR ORAL CAPSULE,IR - DELAY REL,BIPHASE

3

EXTRA-VIRT PLUS DHA ORAL CAPSULE

2

focalgin 90 dha oral combo pack

1

focalgin ca oral combo pack

1

PRE-NATAL VITAMINS

BAL-CARE DHA ESSENTIAL ORAL COMBO PACK,TABLET AND CAP,DR

3

bal-care dha oral combo pack,tablet and cap,dr

1

CADEAU DHA ORAL CAPSULE

3

calcium pnv oral capsule

1

folbecal oral tablet, er multiphase 24 hr

1

CITRANATAL (DUAL-IRON) ORAL TABLET

3

FOLET DHA ORAL COMBO PACK

3

FOLET ONE ORAL CAPSULE

3

CITRANATAL 90 DHA (ALGAL OIL) ORAL COMBO PACK

3

folivane-ob oral capsule

1

CITRANATAL ASSURE ORAL COMBO PACK

3

hemenatal ob + dha oral combo pack

1

CITRANATAL B-CALM (FE GLUC) ORAL TABLETS, SEQUENTIAL

hemenatal ob oral tablet

1

3

inatal advance oral tablet

1

inatal ultra oral tablet

1

CITRANATAL DHA (ALGAL OIL) ORAL COMBO PACK

3

levomefolate dha oral capsule

1

macnatal cn dha oral capsule

1

CITRANATAL HARMONY (IRON FUM) ORAL CAPSULE

3

MARNATAL-F ORAL CAPSULE

3

c-nate dha oral capsule

1

MAXINATE ORAL TABLET

3

complete natal dha oral combo pack

1

M-VIT ORAL TABLET

3

mynatal advance oral tablet

1

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 119

Drug Name

Tier

mynatal oral capsule

1

mynatal oral tablet

1

mynatal plus oral tablet

1

mynatal-z oral tablet

1

mynate 90 plus oral tablet extended release

1

NATACHEW (FE BIS-GLYCINATE) ORAL TABLET,CHEWABLE

Notes

Drug Name

Tier

OBSTETRIX EC ORAL TABLET,DELAYED RELEASE (DR/EC)

3

OBTREX DHA ORAL COMBO PACK,TABLET AND CAP,DR

3

O-CAL FA ORAL TABLET

3

3

O-CAL PRENATAL ORAL TABLET

3

NATALVIT ORAL TABLET

3

PAIRE OB PLUS DHA ORAL COMBO PACK

3

NATELLE ONE ORAL CAPSULE

3

pnv 29-1 oral tablet

1

pnv ob+dha oral combo pack

1

NEEVODHA (WITH ALGAL OIL) ORAL CAPSULE

3

pnv-dha + docusate oral capsule

1

NESTABS ABC ORAL COMBO PACK

pnv-dha oral capsule

1

3

1

NESTABS DHA ORAL COMBO PACK

pnv-ferrous fumarate-docu-fa oral tablet

3

pnv-omega oral capsule

1

NESTABS ORAL TABLET

3

pnv-select oral tablet

1

pnv-vp-u oral capsule

1

newgen oral tablet

1

NEXA PLUS ORAL CAPSULE

1

3

pr natal 400 ec oral combo pack,tablet and cap,dr pr natal 400 oral combo pack

1

NIVA-PLUS ORAL TABLET

3

pr natal 430 ec oral combo pack,tablet and cap,dr

1

OB COMPLETE GOLD ORAL CAPSULE

3

pr natal 430 oral combo pack

1

OB COMPLETE ONE ORAL CAPSULE

3

PREFERA-OB ONE ORAL CAPSULE

3

3

PREFERA-OB ORAL TABLET

3

3

PREFERA-OB PLUS DHA ORAL COMBO PACK

3

prena1 chew oral tablet,chew,ir - dr,biphase

1

prena1 pearl oral capsule,ir delay rel,biphase

1

prena1 true oral combo pack

1

prenaissance next oral tablet

1

prenaissance oral capsule

1

prenaissance plus oral capsule

1

OB COMPLETE ORAL TABLET OB COMPLETE PETITE ORAL CAPSULE OB COMPLETE PREMIER ORAL TABLET

3

OB COMPLETE WITH DHA ORAL CAPSULE

3

obstetrix dha oral combo pack,tablet and cap,dr

1

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 120

Drug Name

Tier

PRENATA ORAL TABLET,CHEWABLE

3

prenatabs fa oral tablet

1

prenatabs rx oral tablet

1

Notes

Drug Name

Tier

PRENATE RESTORE ORAL CAPSULE

3

PRENATE STAR ORAL TABLET

3

preplus oral tablet

1

PREQUE 10 ORAL TABLET

3

pretab oral tablet

1

PROVIDA DHA ORAL CAPSULE

3

PROVIDA OB ORAL CAPSULE

3

PUREFE OB PLUS ORAL CAPSULE

3

PUREFE PLUS ORAL CAPSULE

3

relnate dha oral capsule

1

R-NATAL OB ORAL CAPSULE

3

PRENATAL 19 (WITH DOCUSATE) ORAL TABLET

3

PRENATAL 19 ORAL TABLET,CHEWABLE

3

prenatal low iron oral tablet

1

prenatal plus (calcium carb) oral tablet

1

prenatal plus oral tablet

1

prenatal vitamin plus low iron oral tablet

1

prenatal-u oral capsule

1

PRENATE AM ORAL TABLET

3

PRENATE CHEWABLE ORAL TABLET,CHEWABLE

3

rulavite dha oral capsule

1

PRENATE DHA (FERR ASP GLYCIN) ORAL CAPSULE

3

3

SELECT-OB (FOLIC ACID) ORAL TABLET,CHEWABLE

PRENATE DHA ORAL CAPSULE

3

3

SELECT-OB + DHA ORAL COMBO PACK SELECT-OB ORAL TABLET,CHEWABLE

3

se-natal 19 (with docusate) oral tablet

1

PRENATE ELITE (IRON ASP GLYC) ORAL TABLET

3

PRENATE ELITE ORAL TABLET

3

se-natal 19 oral tablet,chewable

1

PRENATE ENHANCE ORAL CAPSULE

3

se-tan dha oral capsule

1

PRENATE ESSENTIAL ORAL CAPSULE

taron-c dha oral capsule

1

3

1

PRENATE ESSENTIAL(IRON-ASP-G L) ORAL CAPSULE

taron-prex prenatal-dha oral capsule

3

THRIVITE RX ORAL TABLET

3

PRENATE MINI (FERR ASP GLYCIN) ORAL CAPSULE

thrivite-19 oral tablet

1

3

tl-select oral capsule

1

triadvance oral tablet

1

PRENATE MINI ORAL CAPSULE

3

TRICARE ORAL TABLET

3

Notes

QL

QL

PRENATE PIXIE ORAL 3 CAPSULE Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 121

Drug Name

Tier

TRICARE PRENATAL DHA ONE ORAL CAPSULE

3

trinatal gt oral tablet

Notes

Drug Name

Tier

virt-pn plus oral capsule

1

VIRTPREX ORAL CAPSULE

3

1

virt-select oral capsule

1

trinatal rx 1 oral tablet

1

virt-vite gt oral tablet

1

trinate oral tablet

1

TRISTART DHA ORAL CAPSULE

3

VITAFOL FE+ (WITH DOCUSATE) ORAL CAPSULE

3

tri-tabs dha oral combo pack

1

triveen-duo dha oral combo pack

3

1

VITAFOL GUMMIES ORAL TABLET,CHEWABLE

triveen-one oral capsule

1

3

triveen-prx rnf oral capsule

1

VITAFOL NANO ORAL TABLET

trust natal dha oral combo pack

3

1

VITAFOL ULTRA ORAL CAPSULE vitafol-ob oral tablet

1

ultimatecare one nf oral capsule

1

3

ultimatecare one oral capsule

1

VITAFOL-OB+DHA ORAL COMBO PACK

vemavite-prx-2 oral capsule

1

VITAFOL-ONE ORAL CAPSULE

3

vena-bal dha oral combo pack,tablet and cap,dr

1

VITAMED MD ONE RX ORAL CAPSULE

3

vinacal oral tablet

1

vinate care oral tablet,chewable

3

1

VITAMED MD PLUS RX ORAL COMBO PACK

vinate dha oral capsule

1

3

VINATE DHA RF ORAL CAPSULE

3

VITAMEDMD REDICHEW RX ORAL TABLET,CHEW,IR DR,BIPHASE

vinate gt oral tablet

1

3

vinate ii oral tablet

1

VITAPEARL ORAL CAPSULE,IR - DELAY REL,BIPHASE

vinate m oral tablet

1

3

vinate one oral tablet

1

VITATRUE ORAL COMBO PACK

vinate pn care oral tablet

1

3

vinate ultra oral tablet

1

VIVA DHA ORAL CAPSULE

virt nate oral tablet

1

vol-nate oral tablet

1

virt-advance oral tablet

1

vol-plus oral tablet

1

virt-c dha oral capsule

1

vol-tab rx oral tablet

1

virt-care one oral capsule

1

vp-ch plus oral capsule

1

virt-nate dha oral capsule

1

vp-ch-pnv oral capsule

1

virt-nate oral tablet

1

vp-ggr-b6 oral tablet

1

virt-pn dha oral capsule

1

vp-heme ob + dha oral combo pack

1

virt-pn oral tablet

1

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 122

Drug Name

Tier

vp-heme ob oral tablet

1

vp-heme one oral capsule

1

VP-PNV-DHA ORAL CAPSULE

3

zatean-ch oral capsule

1

zatean-pn dha oral capsule

1

zatean-pn plus oral capsule

1

zingiber oral tablet

1

Notes

Drug Name

PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDE D REL RECON

3

Tier

Notes

APTENSIO XR ORAL CAP,ER SPRINKLE,BIPHASIC 40-60

3

ST

aripiprazole oral solution

1

PA

aripiprazole oral tablet

1

PA

aripiprazole oral tablet,disintegrating

1

PA

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDE D REL SYRING

3

armodafinil oral tablet

1

ATIVAN ORAL TABLET

3

BRISDELLE ORAL CAPSULE

3

PA; QL

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDE D REL SYRING

3

bupropion hcl oral tablet 100 mg

1

QL

ABILIFY ORAL TABLET

3

1

DO

ADASUVE INHALATION AEROSOL POWDR BREATH ACTIVATED

bupropion hcl oral tablet 75 mg

3

bupropion hcl oral tablet extended release 100 mg

1

DO

ADDYI ORAL TABLET

3

1

PA; QL

alprazolam intensol oral concentrate

bupropion hcl oral tablet extended release 150 mg

1

1

alprazolam oral tablet

1

bupropion hcl oral tablet extended release 200 mg

alprazolam oral tablet extended release 24 hr

1

bupropion hcl oral tablet extended release 24 hr 150 mg

1

DO

alprazolam oral tablet,disintegrating

1

1

QL

amitriptyline oral tablet

1

bupropion hcl oral tablet extended release 24 hr 300 mg

amitriptyline-chlordiazepoxi de oral tablet

1

buspirone oral tablet

1

amoxapine oral tablet

1

CELEXA ORAL TABLET 10 MG, 20 MG

3

ST; DO

ANAFRANIL ORAL CAPSULE

3

CELEXA ORAL TABLET 40 MG

3

ST; QL

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG

3

chlordiazepoxide hcl oral capsule

1

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 348 MG, 522 MG

chlorpromazine injection solution

1

3

chlorpromazine oral tablet

1

PA

citalopram oral solution

1

QL

PA; QL

ST; DO

ST; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 123

Drug Name

Tier

Notes

Drug Name

Tier

Notes

DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 100 MG

3

ST; QL

DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 MG

3

ST; DO; QL

1

PA PA

citalopram oral tablet 10 mg, 20 mg

1

DO

citalopram oral tablet 40 mg

1

QL

clomipramine oral capsule

1

clonidine hcl oral tablet extended release 12 hr

1

clorazepate dipotassium oral tablet

1

clozapine oral tablet

1

PA

dexmethylphenidate oral capsule,er biphasic 50-50

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

1

PA

dexmethylphenidate oral tablet

1

diazepam injection solution

1

CLOZAPINE ORAL TABLET,DISINTEGRATI NG 150 MG, 200 MG

diazepam injection syringe

1

3

1

CLOZARIL ORAL TABLET

diazepam intensol oral concentrate

2

diazepam oral concentrate

1

diazepam oral solution

1

diazepam oral tablet

1

doxepin oral capsule

1

doxepin oral concentrate

1

droperidol injection solution

1

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 40 mg, 60 mg

1

PA; QL

duloxetine oral capsule,delayed release(dr/ec) 30 mg

1

PA; DO

EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR 150 MG

3

ST; QL

EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR 37.5 MG, 75 MG

3

ST; DO

EMSAM TRANSDERMAL PATCH 24 HOUR

3

EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR

3

escitalopram oxalate oral solution

1

CONCERTA ORAL TABLET EXTENDED RELEASE 24HR

3

CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG, 60 MG

3

CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 30 MG

3

DAYTRANA TRANSDERMAL PATCH 24 HOUR

3

desipramine oral tablet

1

DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR

3

DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG

3

DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG

3

PA PA ST

PA; QL

PA; DO

ST; QL

ST; QL

ST; QL

ST; DO; QL

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 124

Drug Name

Tier

Notes

escitalopram oxalate oral tablet 10 mg, 5 mg

1

DO

escitalopram oxalate oral tablet 20 mg

1

QL

FANAPT ORAL TABLET

3

PA

FANAPT ORAL TABLETS,DOSE PACK

3

PA

FAZACLO ORAL TABLET,DISINTEGRATI NG

2

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK

3

Drug Name

Tier

Notes

FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50

3

ST

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR

3

ST; QL

GEODON INTRAMUSCULAR RECON SOLN

2

PA

GEODON ORAL CAPSULE

3

PA

ST; QL

guanfacine oral tablet extended release 24 hr

1 3

PA

PA

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR

3

ST; QL

HALDOL DECANOATE INTRAMUSCULAR SOLUTION

fluoxetine oral capsule 10 mg, 20 mg

1

DO

HALDOL INJECTION SOLUTION

3

PA

fluoxetine oral capsule 40 mg

1

QL

haloperidol decanoate intramuscular solution

1

PA

fluoxetine oral capsule,delayed release(dr/ec)

1

QL

haloperidol lactate injection solution

1

PA

fluoxetine oral solution

1

QL

1

PA

fluoxetine oral tablet 10 mg

1

DO

haloperidol lactate oral concentrate

1

PA

1

haloperidol oral tablet

fluoxetine oral tablet 20 mg

imipramine hcl oral tablet

1

FLUOXETINE ORAL TABLET 60 MG

3

QL

1

fluphenazine decanoate injection solution

imipramine pamoate oral capsule

1

PA

fluphenazine hcl injection solution

3

1

INTUNIV ER ORAL TABLET EXTENDED RELEASE 24 HR

fluphenazine hcl oral concentrate

1

PA

INVEGA ORAL TABLET EXTENDED RELEASE 24HR

3

PA

fluphenazine hcl oral elixir

1

PA

fluphenazine hcl oral tablet

1

PA

3

PA

fluvoxamine oral capsule,extended release 24hr

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

1

QL

3

PA

fluvoxamine oral tablet 100 mg

INVEGA TRINZA INTRAMUSCULAR SYRINGE

1

QL

fluvoxamine oral tablet 25 mg, 50 mg

3

PA; QL

1

DO

IRENKA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

FOCALIN ORAL TABLET

3

ST

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HR

3

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 125

Drug Name KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG

Tier

Notes

Drug Name

Tier

Notes

3

ST; QL

methylphenidate oral capsule,er biphasic 50-50

1

PA

methylphenidate oral solution

1

PA

KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG

3

ST; DO

methylphenidate oral tablet

1

PA

LATUDA ORAL TABLET

3

PA

methylphenidate oral tablet extended release

1

PA

LEXAPRO ORAL SOLUTION

3

ST; QL

methylphenidate oral tablet extended release 24hr

1

PA

LEXAPRO ORAL TABLET 10 MG, 5 MG

3

ST; DO

methylphenidate oral tablet,chewable

1

PA

LEXAPRO ORAL TABLET 20 MG

3

ST; QL

mirtazapine oral tablet

1

lithium carbonate oral capsule

1

mirtazapine oral tablet,disintegrating

1

lithium carbonate oral tablet

1

modafinil oral tablet 100 mg

1

PA; DO

lithium carbonate oral tablet extended release

modafinil oral tablet 200 mg

1

PA; QL

1

molindone oral tablet

1

PA

lithium citrate oral solution

1

NARDIL ORAL TABLET

3

nefazodone oral tablet

1

LITHOBID ORAL TABLET EXTENDED RELEASE

2

NORPRAMIN ORAL TABLET

3

lorazepam intensol oral concentrate

1

nortriptyline oral capsule

1

nortriptyline oral solution

1

lorazepam oral concentrate

1

lorazepam oral tablet

1

NUPLAZID ORAL TABLET

4

loxapine succinate oral capsule

1

NUVIGIL ORAL TABLET 150 MG, 250 MG, 50 MG

3

PA; QL

maprotiline oral tablet

1

MARPLAN ORAL TABLET

3

PA

3

NUVIGIL ORAL TABLET 200 MG

meprobamate oral tablet

1

olanzapine intramuscular recon soln

1

PA

METADATE CD ORAL CAPSULE, ER BIPHASIC 30-70

3

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 5 mg, 7.5 mg

1

olanzapine oral tablet 20 mg

1

metadate er oral tablet extended release

1

1

METHYLIN ORAL SOLUTION

3

ST

olanzapine oral tablet,disintegrating 10 mg, 20 mg

METHYLIN ORAL TABLET,CHEWABLE

3

ST

olanzapine oral tablet,disintegrating 15 mg, 5 mg

1

PA

methylphenidate oral capsule, er biphasic 30-70

1

PA

olanzapine-fluoxetine oral capsule

1

PA

PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 126

Drug Name

Tier

OLEPTRO ER ORAL TABLET EXTENDED RELEASE 24 HR

3

ORAP ORAL TABLET

3

oxazepam oral capsule

1

paliperidone oral tablet extended release 24hr

1

PAMELOR ORAL CAPSULE

Notes

Drug Name

Tier

Notes

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG

2

QL

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG

2

DO

protriptyline oral tablet

1

3

PROVIGIL ORAL TABLET 100 MG

3

PA; DO

PARNATE ORAL TABLET

3

PROVIGIL ORAL TABLET 200 MG

3

PA; QL

paroxetine hcl oral tablet 10 mg, 20 mg

1

DO

PROZAC ORAL CAPSULE 10 MG, 20 MG

3

ST; DO

paroxetine hcl oral tablet 30 mg, 40 mg

1

QL

PROZAC ORAL CAPSULE 40 MG

3

ST; QL

3

ST; QL

PA

PA

paroxetine hcl oral tablet extended release 24 hr 12.5 mg

1

DO

PROZAC WEEKLY ORAL CAPSULE,DELAYED RELEASE(DR/EC)

paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg

1

QL

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg

1

quetiapine oral tablet 400 mg, 50 mg

1

PA

QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BI PHASIC24HR

3

ST

QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON

3

ST

REMERON ORAL TABLET

3

REMERON SOLTAB ORAL TABLET,DISINTEGRATI NG

3

REXULTI ORAL TABLET

3

PA

RISPERDAL CONSTA INTRAMUSCULAR SYRINGE

2

PA

RISPERDAL M-TAB ORAL TABLET,DISINTEGRATI NG

3

PA

RISPERDAL ORAL SOLUTION

3

PA

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 12.5 MG

3

ST; DO

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 37.5 MG

3

PAXIL ORAL SUSPENSION

3

PAXIL ORAL TABLET 10 MG, 20 MG

3

ST; DO

PAXIL ORAL TABLET 30 MG, 40 MG

3

ST; QL

perphenazine oral tablet

1

perphenazine-amitriptyline oral tablet

1

PEXEVA ORAL TABLET 10 MG, 20 MG

3

ST; DO

PEXEVA ORAL TABLET 30 MG, 40 MG

3

ST; QL

phenelzine oral tablet

1

pimozide oral tablet

1

ST; QL

ST; QL

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 127

Drug Name

Tier

Notes

RISPERDAL ORAL TABLET

3

PA

risperidone oral solution

1

PA

risperidone oral tablet

1

PA

risperidone oral tablet,disintegrating

1

PA

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 60 MG

3

ST

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 20 MG, 30 MG, 40 MG

3

RITALIN ORAL TABLET

3

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET

3

SARAFEM ORAL TABLET 10 MG

3

SARAFEM ORAL TABLET 20 MG

3

SEROQUEL ORAL TABLET

3

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR

2

sertraline oral concentrate

Drug Name

Tier

Notes

trifluoperazine oral tablet

1

trimipramine oral capsule

1

TRINTELLIX ORAL TABLET 10 MG, 5 MG

3

ST; DO

TRINTELLIX ORAL TABLET 20 MG

3

ST; QL

VALIUM ORAL TABLET

3

venlafaxine oral capsule,extended release 24hr 150 mg

1

QL

venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg

1

DO

venlafaxine oral tablet

1

QL

VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 150 MG, 225 MG

3

QL

VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 37.5 MG, 75 MG

3

DO

VERSACLOZ ORAL SUSPENSION

3

PA

PA

VIIBRYD ORAL TABLET 10 MG, 20 MG

3

ST; DO

1

QL

3

ST; QL

sertraline oral tablet 100 mg

1

QL

VIIBRYD ORAL TABLET 40 MG

sertraline oral tablet 25 mg, 50 mg

1

DO

VIIBRYD ORAL TABLETS,DOSE PACK

3

ST; QL

STRATTERA ORAL CAPSULE

2

VRAYLAR ORAL CAPSULE

3

PA

SURMONTIL ORAL CAPSULE

3

VRAYLAR ORAL CAPSULE,DOSE PACK

3

PA

SYMBYAX ORAL CAPSULE

3

VYVANSE ORAL CAPSULE

2

PA

thioridazine oral tablet

1

3

DO

thiothixene oral capsule

1

WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 100 MG

TOFRANIL ORAL TABLET

3

TRANXENE T-TAB ORAL TABLET

3

3

WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 150 MG, 200 MG

tranylcypromine oral tablet

1

trazodone oral tablet

1

PA DO

PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 128

Drug Name

Tier

Notes

Drug Name

Tier

Notes

DO

dexmedetomidine intravenous solution

1

DORAL ORAL TABLET

3

EDLUAR SUBLINGUAL TABLET

3

estazolam oral tablet

1

eszopiclone oral tablet 1 mg, 2 mg

1

QL

eszopiclone oral tablet 3 mg

1

PA; QL

WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 150 MG

3

WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 300 MG

3

XANAX ORAL TABLET

3

XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR

3

ziprasidone hcl oral capsule

1

PA

flurazepam oral capsule

1

ZOLOFT ORAL CONCENTRATE

3

ST; QL

HALCION ORAL TABLET

3

ZOLOFT ORAL TABLET 100 MG

3

ST; QL

HETLIOZ ORAL CAPSULE

4

PA; QL

ZOLOFT ORAL TABLET 25 MG, 50 MG

3

ST; DO

INTERMEZZO SUBLINGUAL TABLET

3

ST; QL

lorazepam injection solution

1

lorazepam injection syringe

1

LUNESTA ORAL TABLET

3

midazolam oral syrup

1

NEMBUTAL SODIUM INJECTION SOLUTION

3

phenobarbital oral elixir

1

phenobarbital oral tablet

1

phenobarbital sodium injection solution

1

PRECEDEX IN 0.9 % SODIUM CHLOR INTRAVENOUS SOLUTION

3

ZYPREXA INTRAMUSCULAR RECON SOLN

3

ZYPREXA ORAL TABLET 10 MG, 2.5 MG, 20 MG, 7.5 MG

3

ZYPREXA ORAL TABLET 15 MG, 5 MG

3

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

3

ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATI NG

3

QL

PA

PA

PA

SEDATIVE/HYPNOTICS AMBIEN CR ORAL TABLET,EXT RELEASE MULTIPHASE

3

ST; QL

PRECEDEX INTRAVENOUS SOLUTION

3

AMBIEN ORAL TABLET

3

ST; QL

quazepam oral tablet

1

AMYTAL INJECTION RECON SOLN

3

RESTORIL ORAL CAPSULE

3

ATIVAN INJECTION SOLUTION

3

ROZEREM ORAL TABLET

3

BELSOMRA ORAL TABLET

3

seconal sodium oral capsule

1

BUTISOL ORAL TABLET

3

SILENOR ORAL TABLET

3

ST; QL

ST; QL

ST; QL

ST; QL

ST; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 129

Drug Name

Tier

Notes

Drug Name

SONATA ORAL CAPSULE

3

ST; QL

ALCORTIN A TOPICAL GEL

3

temazepam oral capsule

1

3

triazolam oral tablet

1

ALCORTIN A TOPICAL GEL IN PACKET

XYREM ORAL SOLUTION

3

PA; QL

ALDARA TOPICAL CREAM IN PACKET

3

zaleplon oral capsule

1

ST; QL

1

QL

3

zolpidem oral tablet

ALEVICYN ANTIPRURITIC SG TOPICAL SPRAY GEL

zolpidem oral tablet,ext release multiphase

1

ST; QL

3

zolpidem sublingual tablet

1

ST; QL

ALEVICYN ANTIPRURITIC TOPICAL GEL

ZOLPIMIST ORAL SPRAY,NON-AEROSOL

3

ST; QL

ALEVICYN DERMAL TOPICAL SPRAY,NON-AEROSOL

3

ALOQUIN TOPICAL GEL

3

alphaquin hp topical cream

1

ALTABAX TOPICAL OINTMENT

2

aluminum acetate topical solution

1

ALUVEA TOPICAL CREAM

3

amcinonide topical cream

3

ST; CE

amcinonide topical lotion

3

ST; CE

amcinonide topical ointment

3

ST; CE

ammonium lactate topical cream

1

ammonium lactate topical lotion

1

AMPHADASE INJECTION SOLUTION

3

ANALPRAM-HC TOPICAL LOTION

3

apexicon e topical cream

3

ST; CE

AQUA GLYCOLIC HC TOPICAL COMBO PACK

3

ST; CE

ARTISS TOPICAL SYRINGE

3

ATOPICLAIR TOPICAL CREAM

3

ATRALIN TOPICAL GEL

3

SKIN PREPS 8-MOP ORAL CAPSULE

2

ABSORICA ORAL CAPSULE

3

ACANYA TOPICAL GEL

2

acetic acid irrigation solution

1

acitretin oral capsule

1

ACLARO TOPICAL EMULSION

3

ACZONE TOPICAL GEL

3

PA

ACZONE TOPICAL GEL WITH PUMP

3

PA

adapalene topical cream

1

PA

adapalene topical gel

1

PA

adapalene topical gel with pump

1

ADAPALENE TOPICAL LOTION

3

PA; CE

ADVANCED ALLERGY COLLECT KIT TOPICAL KIT

3

ST; CE

ala-cort topical cream

1

ALA-QUIN TOPICAL CREAM

3

ALA-SCALP TOPICAL LOTION

3

alclometasone topical cream

1

alclometasone topical ointment

1

PA; QL

ST; CE

Tier

Notes

PA; QL

PA; CE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 130

Drug Name ATRAPRO CP TOPICAL COMBO PACK,CREAM AND GEL

Tier

Notes

Drug Name

3

Tier

Notes

betamethasone valerate topical lotion

3

ST; CE

betamethasone valerate topical ointment

3

ST; CE

betamethasone, augmented topical cream

1

betamethasone, augmented topical gel

1

ST ST

ATRAPRO DERMAL SPRAY TOPICAL SPRAY,NON-AEROSOL

3

ATRAPRO HYDROGEL TOPICAL GEL

3

AVAGE TOPICAL CREAM

3

PA

betamethasone, augmented topical lotion

1

avita topical cream

1

PA

AVITA TOPICAL GEL

3

PA; CE

betamethasone, augmented topical ointment

1

avo cream topical emulsion

1

3

AZELEX TOPICAL CREAM

BIAFINE EMULSION TOPICAL EMULSION

3

3

BEAU RX TOPICAL GEL

3

BIONECT TOPICAL CREAM

BENSAL HP TOPICAL OINTMENT

3

BIONECT TOPICAL FOAM

3

BENZACLIN PUMP TOPICAL GEL

BIONECT TOPICAL GEL

3

3

ST

blanche topical cream

1

BENZACLIN TOPICAL GEL

3

ST

bp-50% urea topical emulsion

1

BENZEFOAM TOPICAL FOAM

3

PA

bpo topical gel

1

PA

bpo topical towelette

1

PA

BENZEFOAM ULTRA TOPICAL FOAM

3

calcipotriene scalp solution

1

calcipotriene topical cream

1

PA

PA

BENZEPRO (MICROSPHERES) TOPICAL CLEANSER

3

PA

calcipotriene topical ointment

1

benzepro topical towelette

1

PA

1

benzoyl peroxide topical cleanser

calcipotriene-betamethasone topical ointment

1

PA

calcitrene topical ointment

1

benzoyl peroxide topical foam

1

PA

calcitriol topical ointment

1

betamethasone dipropionate topical cream

3

3

ST; CE

CAPEX TOPICAL SHAMPOO

betamethasone dipropionate topical lotion

1

3

ST; CE

celacyn topical gel with pump cem-urea topical gel

1

betamethasone dipropionate topical ointment

3

ST; CE

CERAMAX TOPICAL CREAM

3

betamethasone valerate topical cream

3

ST; CE

claravis oral capsule

2

betamethasone valerate topical foam

1

3

ST; CE

clindamycin-benzoyl peroxide topical gel clobetasol scalp solution

1

ST; CE

PA; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 131

Drug Name

Tier

Notes

Drug Name

Tier

Notes

clobetasol topical cream

1

cormax scalp solution

1

clobetasol topical foam

1

clobetasol topical gel

1

4

PA; QL

clobetasol topical lotion

1

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE

clobetasol topical ointment

1

clobetasol topical shampoo

1

4

PA; QL

clobetasol topical spray,non-aerosol

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR

1

clobetasol-emollient topical cream

4

PA; QL

1

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR

clobetasol-emollient topical foam

1

COSENTYX SUBCUTANEOUS SYRINGE

4

PA; QL

CLOBEX TOPICAL LOTION

3

ST; CE

CUTIVATE TOPICAL CREAM

3

ST; CE

CLOBEX TOPICAL SHAMPOO

3

ST; CE

CUTIVATE TOPICAL LOTION

3

ST; CE

CLOBEX TOPICAL SPRAY,NON-AEROSOL

3

ST; CE

DERMA-SMOOTHE/FS BODY OIL TOPICAL OIL

3

ST; CE

CLOCORTOLONE PIVALATE TOPICAL CREAM

3

ST; CE

DERMA-SMOOTHE/FS SCALP OIL SCALP OIL

3

ST; CE

DERMATOP TOPICAL CREAM

3

ST; CE

DERMATOP TOPICAL OINTMENT

3

ST; CE

DERMAWERX SDS TOPICAL KIT

3

ST; CE

dermazene topical cream

1

DERMAZONE TOPICAL KIT

3

CE

DESONATE TOPICAL GEL

3

ST; CE

desonide topical cream

3

ST; CE

desonide topical lotion

3

ST; CE

desonide topical ointment

3

ST; CE

CLODAN KIT TOPICAL KIT,SHAMPOO AND CLEANSER

3

clodan topical shampoo

1

CLODERM TOPICAL CREAM

3

COAL TAR TOPICAL SOLUTION

3

CONDYLOX TOPICAL GEL

3

CONDYLOX TOPICAL SOLUTION

3

CORDRAN TAPE LARGE ROLL TOPICAL TAPE

3

ST; CE

CORDRAN TAPE SMALL ROLL TOPICAL TAPE

3

ST; CE

DESOWEN TOPICAL CREAM

3

ST; CE

CORDRAN TOPICAL CREAM

3

ST; CE

DESOWEN TOPICAL LOTION

3

ST; CE

CORDRAN TOPICAL LOTION

3

ST; CE

desoximetasone topical cream

3

ST; CE

CORDRAN TOPICAL OINTMENT

3

ST; CE

desoximetasone topical gel

3

ST; CE

ST; CE

ST; CE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 132

Drug Name

Tier

Notes

desoximetasone topical ointment

3

ST; CE

diclofenac sodium topical drops

1

diclofenac sodium topical gel

1

DIFFERIN TOPICAL CREAM

Drug Name

Tier

Notes

EPICERAM TOPICAL EMULSION, EXTENDED RELEASE

3

ST

EPIDUO FORTE TOPICAL GEL WITH PUMP

3

PA

3

PA

EPIDUO TOPICAL GEL

3

PA

DIFFERIN TOPICAL GEL

3

PA

EPIDUO TOPICAL GEL WITH PUMP

3

PA

DIFFERIN TOPICAL GEL WITH PUMP

3

PA

EPIFOAM TOPICAL FOAM

3

DIFFERIN TOPICAL LOTION

3

PA; CE

EURAX TOPICAL CREAM

3

diflorasone topical cream

3

ST; CE

3

diflorasone topical ointment

3

ST; CE

EURAX TOPICAL LOTION

DIPROLENE AF TOPICAL CREAM

3

PA; CE

3

ST; CE

FABIOR TOPICAL FOAM

DIPROLENE TOPICAL LOTION

2

PA

3

ST; CE

FINACEA TOPICAL FOAM FINACEA TOPICAL GEL

2

PA

DIPROLENE TOPICAL OINTMENT

3

ST; CE

3

ST

DOVONEX TOPICAL CREAM

3

FLECTOR TRANSDERMAL PATCH 12 HOUR

doxepin topical cream

1

fluocinolone and shower cap scalp oil

3

ST; CE

drithocreme hp topical cream

1

fluocinolone topical cream

3

ST; CE

DRYSOL DAB-O-MATIC TOPICAL SOLUTION

3

fluocinolone topical oil

3

ST; CE

DRYSOL TOPICAL SOLUTION

fluocinolone topical ointment

3

ST; CE

3

fluocinolone topical solution

3

ST; CE

DUAC TOPICAL GEL

3

fluocinonide topical cream

1

eletone topical cream

1

fluocinonide topical gel

1

ELIMITE TOPICAL CREAM

fluocinonide topical ointment

1

3

fluocinonide topical solution

1

ELOCON TOPICAL CREAM

3

fluocinonide-e topical cream

1

flurandrenolide topical cream

3

ST; CE

ELOCON TOPICAL OINTMENT

3

fluticasone topical cream

3

ST; CE

fluticasone topical lotion

3

ST; CE

fluticasone topical ointment

3

ST; CE

ST; CE ST; CE

ELOCON TOPICAL SOLUTION

3

emulsion sb topical emulsion

1

forma-ray solution

1

ENSTILAR TOPICAL FOAM

3

GENADUR (WITH LEXINAL) KIT

3

ST; CE

ST

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 133

Drug Name

Tier

Notes

Drug Name

Tier

GENADUR TOPICAL LIQUID

3

hydrocortisone-min oil-wht pet topical ointment

1

GORDONS UREA TOPICAL OINTMENT

3

hydrocortisone-pramoxine topical cream

1

GUAIACOL LIQUID

3

halobetasol propionate topical cream

1

1

hydroquinone microspheres topical cream,extended release

halobetasol propionate topical ointment

hydroquinone topical cream

1

1

HYGEL TOPICAL GEL

3

HALOG TOPICAL CREAM

3

ST; CE

HYLATOPIC TOPICAL FOAM

3

HALOG TOPICAL OINTMENT

3

ST; CE

HYLATOPICPLUS TOPICAL CREAM

3

hpr plus hydrogel topical kit,cream and gel

1

HYLATOPICPLUS TOPICAL FOAM

3

hpr plus topical cream

1

1

hpr plus topical foam

1

imiquimod topical cream in packet INOVA 4-1 TOPICAL COMBO PACK

3

INOVA 8-2 TOPICAL COMBO PACK

3

INOVA TOPICAL COMBO PACK

3

IODOFLEX TOPICAL PADS, MEDICATED

3

iodoquinol-hc topical cream

1

HPR PLUS-MB HYDROGEL TOPICAL COMBO PACK,GEL AND FOAM

3

hpr topical foam

1

HYDRO 35 TOPICAL FOAM

3

HYDRO 40 TOPICAL FOAM

3

hydrocortisone butyrate topical cream

3

ST; CE

IODOSORB TOPICAL GEL

3

hydrocortisone butyrate topical ointment

3

ST; CE

KENALOG TOPICAL AEROSOL

3

hydrocortisone butyrate topical solution

3

ST; CE

KERAFOAM TOPICAL FOAM

3

hydrocortisone butyr-emollient topical cream

3

ST; CE

KERALAC TOPICAL CREAM

3

hydrocortisone topical cream

1

3

hydrocortisone topical lotion

1

KERALYT RX TOPICAL GEL

hydrocortisone topical ointment

1

3

hydrocortisone valerate topical cream

3

ST; CE

KERALYT SCALP COMPLETE TOPICAL KIT,SHAMPOO AND GEL

hydrocortisone valerate topical ointment

3

ST; CE

KLARON TOPICAL SUSPENSION

3

hydrocortisone-iodoquinol-al oe topical cream in packet

klofensaid ii topical drops

1

1

Notes

PA; QL

ST; CE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 134

Drug Name

Tier

lactated ringers irrigation solution

1

lactic acid e topical cream

1

lactic acid topical lotion

Notes

Drug Name

Tier

METROGEL TOPICAL GEL

3 3

1

METROGEL TOPICAL GEL WITH PUMP

LATISSE BASE OF THE EYELASHES DROPS WITH APPLICATOR

3

3

METROLOTION TOPICAL LOTION metronidazole topical cream

1

latrix topical suspension

1

metronidazole topical gel

1

lidocaine hcl-hydrocortison ac topical cream

1

metronidazole topical gel with pump

1

lindane topical shampoo

1

metronidazole topical lotion

1

LOCOID LIPOCREAM TOPICAL CREAM

3

ST; CE

MICROCYN HYDROGEL TOPICAL GEL

3

LOCOID TOPICAL CREAM

3

ST; CE

MICROCYN TOPICAL SPRAY,NON-AEROSOL

3

LOCOID TOPICAL LOTION

3

ST; CE

MIRVASO TOPICAL GEL

3

LOCOID TOPICAL OINTMENT

3

ST; CE

MIRVASO TOPICAL GEL WITH PUMP

3

LOCOID TOPICAL SOLUTION

3

ST; CE

mometasone topical cream

1

mometasone topical ointment

1

LOUTREX TOPICAL CREAM

3

mometasone topical solution

1

lugols topical solution

1

myorisan oral capsule

2

luxamend topical cream

1

NATROBA TOPICAL SUSPENSION

3

LUXIQ TOPICAL FOAM

3

LYCELLE TOPICAL GEL

1

3

neomycin-polymyxin b gu irrigation solution

malathion topical lotion

1

NEOSALUS TOPICAL CREAM

3

mb hydrogel (cyclomethicone) topical kit,cream and gel

1

NEOSALUS TOPICAL FOAM

3

mb hydrogel topical kit,cream and gel

3

1

NEOSALUS TOPICAL LOTION

melpaque hp topical cream

1

3

melquin 3 topical solution

1

NEOSPORIN GU IRRIGANT IRRIGATION SOLUTION

methoxsalen rapid oral capsule

1

NEUAC KIT TOPICAL COMBO PACK,CREAM AND GEL

3

methyl salicylate topical liquid

1

neuac topical gel

1

METROCREAM TOPICAL CREAM

nivatopic plus topical cream

1

3

NORITATE TOPICAL CREAM

3

ST; CE

Notes

PA; QL

ST

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 135

Drug Name

Tier

Notes

Drug Name

Tier

Notes

PEDIADERM HC TOPICAL KIT,LOTION AND CREAM,EMOLLIENT

3

ST; CE

PEDIADERM TA TOPICAL CREAM

3

ST; CE

PEDIAPALM TOPICAL SPRAY,NON-AEROSOL

3

PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP

3

permethrin topical cream

1

PHENOL LIQUID

3

PHYSIOLYTE IRRIGATION SOLUTION

3 3

NOVACORT (WITH ALOE) TOPICAL GEL

3

NOXIPAK TOPICAL KIT

3

NUOX TOPICAL GEL

3

NUVAIL TOPICAL NAIL FILM SOLUTION

3

OLUX TOPICAL FOAM

3

ST; CE

OLUX-E TOPICAL FOAM

3

ST; CE

ONEXTON TOPICAL GEL

2

OVACE PLUS SHAMPOO TOPICAL SHAMPOO

3

OVACE PLUS TOPICAL CLEANSER,EXTENDED RELEASE

3

OVACE PLUS TOPICAL CREAM

3

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION

OVACE PLUS TOPICAL FOAM

PODOCON TOPICAL LIQUID

3

3

podofilox topical solution

1

OVACE PLUS TOPICAL LOTION

3

3

OVACE PLUS WASH TOPICAL CLEANSER,GEL EXTENDED RELEASE

POTASSIUM HYDROXIDE TOPICAL SOLUTION

3

3

OVACE TOPICAL CLEANSER

PR BENZOYL PEROXIDE TOPICAL CLEANSER

3

pr cream topical cream

1

OVIDE TOPICAL LOTION

3

PRAMOSONE E TOPICAL CREAM

3

OXSORALEN TOPICAL LOTION

3

PRAMOSONE TOPICAL CREAM 1-1 %

2

OXSORALEN ULTRA ORAL CAPSULE

3

PRAMOSONE TOPICAL CREAM 2.5-1 %

3

PACNEX HP TOPICAL PADS, MEDICATED

3

PA

PRAMOSONE TOPICAL LOTION

2

PACNEX LP TOPICAL PADS, MEDICATED

3

PA

PRAMOSONE TOPICAL OINTMENT

2

PACNEX MX TOPICAL CLEANSER

prednicarbate topical cream

3

ST; CE

3

PA

3

ST; CE

PACNEX TOPICAL CLEANSER

prednicarbate topical ointment

3

3

PANDEL TOPICAL CREAM

PRESERA TOPICAL FOAM

3

CE

PA

ST

PA

ST; CE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 136

Drug Name

Tier

PROMISEB COMPLETE TOPICAL KIT,CLEANSER AND CREAM

3

PROMISEB TOPICAL CREAM

3

pruclair topical cream

Notes

Drug Name

Tier

ROSADAN TOPICAL KIT, CLEANSER AND GEL

3

ROSADAN TOPICAL KIT,CLEANSER AND CREAM

3

1

salacyn topical cream

1

prudoxin topical cream

1

salacyn topical lotion

1

prumyx topical cream

1

3

prutect topical emulsion

1

SALEX TOPICAL COMBO PACK

PSORCON TOPICAL CREAM

3

3

PYROGALLIC ACID TOPICAL OINTMENT

SALEX TOPICAL KIT,CLEANSER AND CREAM ER

3

3

QUTENZA TOPICAL KIT

2

SALEX TOPICAL SHAMPOO

RADIAPLEXRX TOPICAL GEL

1

3

salicylic acid er-ceramides topical combo pack

rea lo 39 topical cream

1

1

rea lo 40 topical cream

1

salicylic acid er-ceramides topical kit,cleanser and cream er

rea lo 40 topical lotion

1

salicylic acid topical cream

1

recedo topical gel

1

1

refissa topical cream

1

salicylic acid topical cream,extended release salicylic acid topical film forming liquid w/appl

1

salicylic acid topical foam

1

salicylic acid topical gel

1

salicylic acid topical liquid

1

salicylic acid topical lotion

1

salicylic acid topical lotion,extended release

1

REGRANEX TOPICAL GEL

3

remeven topical cream

1

RENOVA TOPICAL CREAM

3

ST; CE

PA

PA

RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.04 %, 0.1 %

3

PA

RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.08 %

3

PA; CE

salicylic acid topical shampoo

1

RETIN-A MICRO TOPICAL GEL

3

3

PA

SALKERA TOPICAL FOAM

RETIN-A TOPICAL CREAM

3

PA

SALVAX DUO PLUS TOPICAL FOAM

3

RETIN-A TOPICAL GEL

3

PA

salvax topical foam

1

ringers irrigation solution

1

SANADERMRX TOPICAL KIT

3

rosadan topical cream

1

rosadan topical gel

1

SANTYL TOPICAL OINTMENT

3

SCALACORT DK TOPICAL COMBO PACK

3

Notes

ST; CE

ST; CE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 137

Drug Name

Tier

scalacort topical lotion

1

seb-prev topical cleanser

1

selenium sulfide topical lotion

1

selenium sulfide topical shampoo

Notes

Drug Name

Tier

Notes

SURE RESULT DSS PREMIUM PACK TOPICAL COMBO PACK,SOLUTION AND CREAM

3

1

SURE RESULT TAC PAK TOPICAL KIT

3

ST; CE

SELRX TOPICAL SHAMPOO

3

SYNALAR CREAM KIT TOPICAL CREAM

3

ST; CE

SERNIVO TOPICAL SPRAY WITH PUMP

3

silver nitrate applicators topical stick

3

ST; CE

1

SYNALAR OINTMENT KIT TOPICAL COMBO PACK,OINTMENT AND CREAM

silver nitrate topical ointment

1

3

ST; CE

silver nitrate topical solution

1

SYNALAR TOPICAL CREAM

SILVRSTAT TOPICAL GEL

3

SYNALAR TOPICAL OINTMENT

3

ST; CE

SKLICE TOPICAL LOTION

3

SYNALAR TOPICAL SOLUTION

3

ST; CE

sodium chloride irrigation solution

1

SYNALAR TS TOPICAL KIT

3

ST; CE

sonafine topical emulsion

1

TACLONEX TOPICAL OINTMENT

3

SOOLANTRA TOPICAL CREAM

3

TACLONEX TOPICAL SUSPENSION

3

SORBITOL IRRIGATION SOLUTION

3

SORBITOL-MANNITOL URETHRAL SOLUTION

4

PA; QL

3

TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR

SORIATANE ORAL CAPSULE

3

4

PA; QL

SORILUX TOPICAL FOAM

3

TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR

spinosad topical suspension

1

sulfacetamide sodium (acne) topical suspension

4

PA; QL

1

TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR

sulfacetamide sodium topical cleanser

1

TALTZ SYRINGE (2 PACK) SUBCUTANEOUS SYRINGE

4

PA; QL

SULFACETAMIDE SODIUM TOPICAL CLEANSER, GEL

3

TALTZ SYRINGE (3 PACK) SUBCUTANEOUS SYRINGE

4

PA; QL

sulfacetamide sodium topical shampoo

1

TALTZ SYRINGE SUBCUTANEOUS SYRINGE

4

PA; QL

TAZORAC TOPICAL CREAM

2

CE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 138

Drug Name

Tier

TAZORAC TOPICAL GEL

2

TEMOVATE E TOPICAL CREAM

3

TEMOVATE TOPICAL CREAM

3

TEMOVATE TOPICAL OINTMENT

3

TERSI FOAM TOPICAL FOAM

Notes

Drug Name

Tier

Notes

triamcinolone acetonide topical ointment

1

trianex topical ointment

1

tri-chlor topical solution

1

TRICHLOROACETIC ACID TOPICAL RECON SOLN

3

triderm topical cream

1

3

TRI-LUMA TOPICAL CREAM

3

TETRIX TOPICAL CREAM

3

TROPAZONE LOTION TOPICAL LOTION

3

TEXACORT TOPICAL SOLUTION

3

ST; CE

ULESFIA TOPICAL LOTION

3

TOPICORT TOPICAL CREAM

3

ST; CE

TOPICORT TOPICAL GEL

3

3

ST; CE

ULTRASAL-ER TOPICAL FILM-FORMING SOLN ER W/ APPL

TOPICORT TOPICAL OINTMENT

3

ST; CE

ULTRAVATE TOPICAL CREAM

3

ST; CE

TOPICORT TOPICAL SPRAY,NON-AEROSOL

3

ST; CE

ULTRAVATE TOPICAL LOTION

3

ST; CE

tretinoin (emollient) topical cream

1

PA

ULTRAVATE TOPICAL OINTMENT

3

ST; CE

tretinoin microspheres topical gel

1

PA

ULTRAVATE X TOPICAL COMBO PACK

3

ST; CE

tretinoin microspheres topical gel with pump

1

PA

3

ST; CE

tretinoin topical cream

1

PA

ULTRAVATE X TOPICAL COMBO PACK,OINTMENT AND CREAM

tretinoin topical gel

1

PA

TRETIN-X CREAM KIT TOPICAL COMBO PACK

3

PA; CE

3

TRETIN-X TOPICAL CREAM

3

PA; CE

UMECTA NAIL FILM PEN TOPICAL NAIL FILM SUSP, PEN APPLICATOR

triamcinolone acetonide topical aerosol

3

1

ST; QL

UMECTA PD TOPICAL EMULSION, ADHESIVE

triamcinolone acetonide topical cream 0.025 %, 0.5 %

3

1

QL

UMECTA PD TOPICAL SUSPENSION,ADHESIVE

triamcinolone acetonide topical cream 0.1 %

3

1

ST

UMECTA TOPICAL EMULSION umecta topical foam

1

triamcinolone acetonide topical lotion 0.025 %

1

QL

UMECTA TOPICAL NAIL FILM SUSPENSION

3

triamcinolone acetonide topical lotion 0.1 %

1

URAMAXIN GT TOPICAL GEL

3

ST; CE ST; CE ST; CE

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 139

Drug Name

Tier

Notes

Drug Name

Tier

Notes

VERDESO TOPICAL FOAM

3

ST; CE

VIRASAL TOPICAL FILM FORMING LIQUID W/APPL

3

URAMAXIN GT TOPICAL KIT,CREAM AND GEL

3

URAMAXIN TOPICAL CREAM

3

URAMAXIN TOPICAL FOAM

3

VITRASE INJECTION SOLUTION

3

URAMAXIN TOPICAL GEL

3

VOLTAREN TOPICAL GEL

3

URAMAXIN TOPICAL LOTION

3

VYTONE TOPICAL CREAM IN PACKET

3

urea nail stick topical solution

1

water for irrigation, sterile irrigation solution

1

urea topical cream

1

3

ST; CE

urea topical foam

1

WHYTEDERM TDPAK TOPICAL KIT

urea topical gel

1

3

ST; CE

UREA TOPICAL LOTION 40 %

3

WHYTEDERM TRILASIL PAK TOPICAL KIT

urea topical lotion 45 %

1

XCLAIR TOPICAL CREAM

3

urea topical nail film suspension

1

urea-hyaluronate sodium topical kit

3

1

XELITRAL TOPICAL COMBO PACK,SOLUTION AND CREAM

ure-k topical cream

1

XRYLIX TOPICAL KIT

3

UREVAZ TOPICAL CREAM

3

ZANABIN TOPICAL GEL

3

zenatane oral capsule

2

PA; QL

UTOPIC TOPICAL CREAM

3

ZIANA TOPICAL GEL

3

ST

VANIQA TOPICAL CREAM

3

ZITHRANOL TOPICAL SHAMPOO

3

VANOS TOPICAL CREAM

3

ZITHRANOL-RR TOPICAL CREAM, RAPID RELEASE

3

VANOXIDE-HC TOPICAL SUSPENSION

3

ZONALON TOPICAL CREAM

3

VASELINE WHITE PETROLEUM TOPICAL OINTMENT IN PACKET

3

ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP

3

PA; QL

VASHE WOUND THERAPY IRRIGATION IRRIGATION SOLUTION

3

ZYCLARA TOPICAL CREAM IN PACKET

3

PA; QL

VECTICAL TOPICAL OINTMENT

3

SMOKING DETERRENTS

VELTIN TOPICAL GEL

3

ST; CE

bupropion hcl (smoking deter) oral tablet extended release

ST

1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 140

Drug Name

Tier

Notes

Drug Name

CHANTIX CONTINUING MONTH BOX ORAL TABLET

3

PA; QL

THYROLAR-1/2 ORAL TABLET

3

CHANTIX ORAL TABLET

3

3

THYROLAR-1/4 ORAL TABLET THYROLAR-2 ORAL TABLET

3

THYROLAR-3 ORAL TABLET

3

PA

TIROSINT ORAL CAPSULE

3 3

PA; QL

Tier

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

3

NICOTROL INHALATION CARTRIDGE

3

NICOTROL NS NASAL SPRAY,NON-AEROSOL

3

PA

TRIOSTAT INTRAVENOUS SOLUTION

ZYBAN ORAL TABLET EXTENDED RELEASE

3

PA; QL

unithroid oral tablet

1

westhroid oral tablet

1 3

PA; QL

THYROID PREPS ARMOUR THYROID ORAL TABLET

2

WP THYROID ORAL TABLET

CYTOMEL ORAL TABLET

3

UNCLASSIFIED DRUG PRODUCTS acamprosate oral tablet,delayed release (dr/ec)

1 3

1

ACETADOTE INTRAVENOUS SOLUTION

levothyroxine oral tablet

1

acetylcysteine intravenous solution

1

levoxyl oral tablet

1

liothyronine intravenous solution

3

1

ACTONEL ORAL TABLET

liothyronine oral tablet

1

4

methimazole oral tablet

1

ADAGEN INTRAMUSCULAR SOLUTION

nature-throid oral tablet

1

4

np thyroid oral tablet

1

ALDURAZYME INTRAVENOUS SOLUTION

propylthiouracil oral tablet

1

alendronate oral solution

1

SYNTHROID ORAL TABLET

2

alendronate oral tablet

1

TAPAZOLE ORAL TABLET

alfuzosin oral tablet extended release 24 hr

1

3

amifostine crystalline intravenous recon soln

1

ANTABUSE ORAL TABLET

3

APLIGRAF TOPICAL DISK

3

LEVOTHYROXINE INTRAVENOUS RECON SOLN 100 MCG

3

levothyroxine intravenous recon soln 200 mcg, 500 mcg

THYROGEN INTRAMUSCULAR RECON SOLN

3

THYROLAR-1 ORAL TABLET

3

Notes

QL

PA

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 141

Drug Name

Tier

AQUORAL MUCOUS MEMBRANE AEROSOL,SPRAY

3

ARALAST NP INTRAVENOUS RECON SOLN

4

Notes

Notes

3

CAPHOSOL MUCOUS MEMBRANE SOLUTION

3

CARBAGLU ORAL TABLET, DISPERSIBLE

4

CARDIOVID PLUS ORAL CAPSULE

3

CARNITOR (SUGAR-FREE) ORAL SOLUTION

3

CARNITOR INTRAVENOUS SOLUTION

3

CARNITOR ORAL SOLUTION

3

CARNITOR ORAL TABLET

3

CARTICEL IMPLANT SUSPENSION

3 3

PA

PA

CAVERJECT IMPULSE INTRACAVERNOSAL KIT CAVERJECT INTRACAVERNOSAL RECON SOLN

3

PA

CELACYN POST PROCEDURE TOPICAL COMBO PACK,GEL AND SPRAY

3

CELLULOSE (BULK) POWDER

3

CERDELGA ORAL CAPSULE

4

PA

CEREZYME INTRAVENOUS RECON SOLN

4

PA

CETYLEV ORAL TABLET, EFFERVESCENT

3

CHEMET ORAL CAPSULE

3

chlorhexidine gluconate mucous membrane mouthwash

1

PA

4

ATELVIA ORAL TABLET,DELAYED RELEASE (DR/EC)

3

QL

AVODART ORAL CAPSULE

3

PA

bacteriostatic water(parabens) injection solution

1

BAL IN OIL INTRAMUSCULAR SOLUTION

3

BENLYSTA INTRAVENOUS RECON SOLN

4 4

Tier

CALCIUM DISODIUM VERSENATE INJECTION SOLUTION

ARCALYST SUBCUTANEOUS RECON SOLN

BERINERT INTRAVENOUS KIT

Drug Name

PA; QL

PA

BINOSTO ORAL TABLET, EFFERVESCENT

3

QL

BONIVA INTRAVENOUS SYRINGE

4

ST

BONIVA ORAL TABLET

3

ST; QL

BRIDION INTRAVENOUS SOLUTION

3

BUNAVAIL BUCCAL FILM

3

buprenorphine hcl sublingual tablet

1

PA; QL

buprenorphine-naloxone sublingual tablet

1

PA; QL

BUTYLATED HYDROXYTOLUENE POWDER

3

CA-DTPA INTRAVENOUS SOLUTION

3

PA; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 142

Drug Name

Tier

CIALIS ORAL TABLET 10 MG, 20 MG

2

CIALIS ORAL TABLET 2.5 MG, 5 MG

3

CINRYZE INTRAVENOUS RECON SOLN

4

CO-BALAMIN ORAL CAPSULE

3

CONCEPTION KIT

3

CO-VERATROL ORAL CAPSULE

3

cryoserv solution

1

CUROSURF INTRATRACHEAL SUSPENSION

Notes

Drug Name

PA PA; QL PA; QL

3

Tier

Notes

DILUENT FOR EPOPROSTENOL/FLOL A INTRAVENOUS SOLUTION

3

disulfiram oral tablet

1

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR

3

doxercalciferol intravenous solution

1

doxercalciferol oral capsule

1

doxycycline hyclate oral tablet

1

DUODOTE INTRAMUSCULAR PEN INJECTOR

3

dutasteride oral capsule

1

PA

dutasteride-tamsulosin oral capsule, er multiphase 24 hr

1

PA

EDEX INTRACAVERNOSAL KIT

3

PA

ELAPRASE INTRAVENOUS SOLUTION

4

PA

ELELYSO INTRAVENOUS RECON SOLN

4

PA

ELLIOTTS B (PF) INTRATHECAL SOLUTION

3

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HR

3

ENDOFORM FENESTRATED TOPICAL SHEET

3

CYANOKIT INTRAVENOUS RECON SOLN

3

CYSTADANE ORAL POWDER

3

CYSTAGON ORAL CAPSULE

4

darifenacin oral tablet extended release 24 hr

1

DEBACTEROL MUCOUS MEMBRANE SOLUTION

3

DEBACTEROL MUCOUS MEMBRANE SWAB

3

deferoxamine injection recon soln

4

DERMAGRAFT TOPICAL SHEET

3

DESFERAL INJECTION RECON SOLN

4

DETROL LA ORAL CAPSULE,EXTENDED RELEASE 24HR

3

ST

ENDOFORM TOPICAL SHEET

3

DETROL ORAL TABLET

3

ST

dexrazoxane hcl intravenous recon soln

1

EPISIL MUCOUS MEMBRANE GEL FORMING SOLUTION

3

DIGIFAB INTRAVENOUS RECON SOLN

3

ESBRIET ORAL CAPSULE

4

ethyl acetate liquid

1

ST

ST

PA; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 143

Drug Name

Tier

etidronate disodium oral tablet

1

EUCALYPTUS FLAVOR OIL

3

EVISTA ORAL TABLET

3

EXJADE ORAL TABLET, DISPERSIBLE

Notes

Drug Name

Tier

Notes

GELCLAIR MUCOUS MEMBRANE GEL IN PACKET

3

GELFILM IMPLANT FILM

3

4

3

FABRAZYME INTRAVENOUS RECON SOLN

GELNIQUE TRANSDERMAL GEL IN PACKET

4

GELX MUCOUS MEMBRANE GEL

3

FERRIPROX ORAL SOLUTION

4

4

FERRIPROX ORAL TABLET

GLASSIA INTRAVENOUS SOLUTION

4 1

3

finasteride oral tablet 1 mg

HECTOROL INTRAVENOUS SOLUTION

finasteride oral tablet 5 mg

1

PA

FIRAZYR SUBCUTANEOUS SYRINGE

HECTOROL ORAL CAPSULE

3

4

PA

HYLENEX INJECTION SOLUTION

3

flavoxate oral tablet

1

FLOMAX ORAL CAPSULE,EXTENDED RELEASE 24HR

3

HYPER-SAL INHALATION SOLUTION FOR NEBULIZATION

3

flumazenil intravenous solution

1

ibandronate intravenous solution

1

ST

fomepizole intravenous solution

1

ibandronate intravenous syringe

4

ST

FORTEO SUBCUTANEOUS PEN INJECTOR

ibandronate oral tablet

1

ST; QL

4

4

PA

FOSAMAX ORAL TABLET

3

ILARIS (PF) SUBCUTANEOUS RECON SOLN INFASURF INTRATRACHEAL SUSPENSION

3

JADENU ORAL TABLET

4

PA; QL QL

ST

PA

FOSAMAX PLUS D ORAL TABLET 70-2,800 MG-UNIT

2

FOSAMAX PLUS D ORAL TABLET 70-5,600 MG-UNIT

2

JALYN ORAL CAPSULE, ER MULTIPHASE 24 HR

3

PA

FUSILEV INTRAVENOUS RECON SOLN

4

PA

3

KALBITOR SUBCUTANEOUS SOLUTION

GALZIN ORAL CAPSULE

4

PA; QL

3

KALYDECO ORAL GRANULES IN PACKET KALYDECO ORAL TABLET

4

PA; QL

QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 144

Drug Name

Tier

KANUMA INTRAVENOUS SOLUTION

3

KEVEYIS ORAL TABLET

4

KUVAN ORAL POWDER IN PACKET

4

KUVAN ORAL TABLET,SOLUBLE

4

leucovorin calcium injection recon soln

1

leucovorin calcium oral tablet

1

LEVITRA ORAL TABLET

3

levocarnitine (with sugar) oral solution

1

levocarnitine intravenous solution

1

levocarnitine oral tablet

1

levoleucovorin calcium intravenous solution

1

LUMIZYME INTRAVENOUS RECON SOLN

4

MEGACE ES ORAL SUSPENSION

Notes

Drug Name

Tier

Notes

MURI-LUBE OIL

2

MUSE URETHRAL SUPPOSITORY

3

PA

MYOZYME INTRAVENOUS RECON SOLN

4

PA

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

3

NAGLAZYME INTRAVENOUS SOLUTION

4

NEBUSAL INHALATION SOLUTION FOR NEBULIZATION

2

NEUTRASAL MUCOUS MEMBRANE POWDER IN PACKET

3

NEXAVIR INJECTION SOLUTION

3

niacin-aze ac-turmer-fa-b6-zn oral tablet

1

NICADAN ORAL TABLET

3

NICAZEL FORTE ORAL TABLET

3

3

NICAZEL ORAL TABLET

3

MEGACE ORAL SUSPENSION

3

3

megestrol oral suspension

1

NITHIODOTE INTRAVENOUS SOLUTION

mesna intravenous solution

1

MESNEX INTRAVENOUS SOLUTION

NUMOISYN MUCOUS MEMBRANE LIQUID

3

3

NUMOISYN MUCOUS MEMBRANE LOZENGE

3

MESNEX ORAL TABLET

2

OFEV ORAL CAPSULE

4

METASTRON INTRAVENOUS SOLUTION

3

ORAFATE MUCOUS MEMBRANE PASTE

3

oralone dental paste

1

methylene blue (antidote) intravenous solution

1

3

MIFEPREX ORAL TABLET

3

ORAMAGICRX MUCOUS MEMBRANE MOUTHWASH

MUGARD MUCOUS MEMBRANE SOLUTION

4

3

ORFADIN ORAL CAPSULE

PA; QL PA PA

PA

PA

QL

PA

PA; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 145

Drug Name

Tier

Notes

Drug Name

ORKAMBI ORAL TABLET

4

PA; QL

PROPECIA ORAL TABLET

3

OSPHENA ORAL TABLET

3

PA; QL

PROSCAR ORAL TABLET

3

oxybutynin chloride oral syrup

1

PROTHELIAL MUCOUS MEMBRANE PASTE

3

oxybutynin chloride oral tablet

1

3

oxybutynin chloride oral tablet extended release 24hr

PROTOPAM CHLORIDE INJECTION RECON SOLN

1

1

OXYTROL TRANSDERMAL PATCH SEMIWEEKLY

pulmosal inhalation solution for nebulization

3

4

pamidronate intravenous recon soln

PULMOZYME INHALATION SOLUTION

4

Q-CARE RX Q2 KIT

3

pamidronate intravenous solution

4

Q-CARE RX Q4 KIT

3

RADIAGEL TOPICAL GEL

3

RADIGEL ACEMANNAN HYDROGEL TOPICAL GEL

3

RADIOGARDASE ORAL CAPSULE

3

ST

Tier

Notes

PA

PANHEMATIN INTRAVENOUS RECON SOLN

3

PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION

3

paricalcitol oral capsule

1

raloxifene oral tablet

1

paroex oral rinse mucous membrane mouthwash

1

RAPAFLO ORAL CAPSULE

3

PERIDEX MUCOUS MEMBRANE MOUTHWASH

3

RECLAST INTRAVENOUS SOLUTION

4

periogard mucous membrane mouthwash

1

risedronate oral tablet

1

QL

PH 12 DILUENT FOR FLOLAN INTRAVENOUS SOLUTION

1

QL

3

risedronate oral tablet,delayed release (dr/ec)

PRALIDOXIME INTRAMUSCULAR PEN INJECTOR

4

PA; QL

3

RUCONEST INTRAVENOUS RECON SOLN

PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE

3

4

SALIVAMAX MUCOUS MEMBRANE POWDER IN PACKET

PROLASTIN-C INTRAVENOUS RECON SOLN

3

4

SALIVATERX MUCOUS MEMBRANE POWDER IN PACKET

2

QL

PROLIA SUBCUTANEOUS SYRINGE

SAVELLA ORAL TABLET 3

SAVELLA ORAL TABLETS,DOSE PACK

2

QL

ST

PA

PA; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 146

Drug Name

Tier

SCLEROSOL INTRAPLEURAL INTRAPLEURAL AEROSOL POWDER

3

SENSIPAR ORAL TABLET

4

sodium bisulfite granules

1

sodium chlor 0.9% bacteriostat injection solution

1

sodium chloride inhalation solution for nebulization

1

SODIUM NITRITE INTRAVENOUS SOLUTION

3

sodium succinate powder

1

sodium thiosulfate intravenous solution

1

SOMAVERT SUBCUTANEOUS RECON SOLN

4

sorbitol solution

1

STAXYN ORAL TABLET,DISINTEGRATI NG

3

STENDRA ORAL TABLET

3

Notes

Drug Name

Tier

tamsulosin oral capsule,extended release 24hr

1

THIOLA ORAL TABLET

3

tolterodine oral capsule,extended release 24hr

1

tolterodine oral tablet

1

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR

3

triamcinolone acetonide dental paste

1

trospium oral capsule,extended release 24hr

1

trospium oral tablet

1

TYBOST ORAL TABLET

3

TYSABRI INTRAVENOUS SOLUTION

4

PA

UROXATRAL ORAL TABLET EXTENDED RELEASE 24 HR

3

PA

VENELEX TOPICAL OINTMENT

3

VENELEX TOPICAL OINTMENT IN PACKET

3

VESICARE ORAL TABLET

3

STERILE TALC INTRAPLEURAL SUSPENSION FOR RECONSTITUTION

3

sterile water for injection injection solution

1

VIAGRA ORAL TABLET

2

STRENSIQ SUBCUTANEOUS SOLUTION

4

PA

VIASPAN (BELZER UW) COLD SS PERFUSION IRRIGATION SOLUTION

3

SUBOXONE SUBLINGUAL FILM

2

PA; QL

VIMIZIM INTRAVENOUS SOLUTION

4

SURFAXIN INTRATRACHEAL SUSPENSION

3

VISTOGARD ORAL GRANULES IN PACKET

3

SURVANTA INTRATRACHEAL SUSPENSION

3

VISUDYNE INTRAVENOUS RECON SOLN

4

SYPRINE ORAL CAPSULE

2

Notes

PA; QL

QL

PA

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 147

Drug Name VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDE D REL RECON

Tier 4

Notes

Drug Name

PA

Tier

zoledronic acid intravenous solution

1

ZOLEDRONIC ACID-MANNITOL-WATE R INTRAVENOUS PIGGYBACK

4

zoledronic acid-mannitol-water intravenous solution

4

ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML

3

Notes PA

VORAXAZE INTRAVENOUS RECON SOLN

3

VPRIV INTRAVENOUS RECON SOLN

4

vp-zel oral tablet

1

water for inject, bacteriostat injection solution

1

water for injection, sterile injection solution

1

3

PA

water for injection, sterile intravenous parenteral solution

ZOMETA INTRAVENOUS SOLUTION 4 MG/5 ML

1

ZUBSOLV SUBLINGUAL TABLET

3

PA; QL

PA

VITAMINS

WHYTEDERM SURGIPAK TOPICAL KIT

3

XGEVA SUBCUTANEOUS SOLUTION

3

XIAFLEX INJECTION RECON SOLN

4

PA

XOFIGO INTRAVENOUS SOLUTION

3

ZAVESCA ORAL CAPSULE

advanced am-pm oral combo pack

1

ANIMI-3 WITH VITAMIN D ORAL CAPSULE

3

AQUASOL A INTRAMUSCULAR SOLUTION

3

PA

ascorbic acid (vitamin c) injection solution

1

4

PA

b complex 100 injection solution

1

ZEMAIRA INTRAVENOUS RECON SOLN

4

PA

B-12 COMPLIANCE INJECTION KIT

3

b-12 kit injection kit

1

ZEMPLAR INTRAVENOUS SOLUTION

2

BACMIN ORAL TABLET

3 1

ZEMPLAR ORAL CAPSULE

calcitriol intravenous solution

3

calcitriol oral capsule

1

ZINECARD (AS HCL) INTRAVENOUS RECON SOLN

calcitriol oral solution

1

3

3

ZN-DTPA INTRAVENOUS SOLUTION

CARDIOTEK-RX (BIOPERINE) ORAL TABLET

3

1

zoledronic acid intravenous recon soln

1

chewable multivit-a,b,d,e,k,zn oral tablet,chewable ciferex oral capsule

1

PA; QL

PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 148

Drug Name

Tier

COMPLETE FORMULATION D3000 ORAL CAPSULE

3

COMPLETE FORMULATION PEDIATRIC ORAL DROPS

3

corvita oral tablet

1

CORVITE FREE ORAL TABLET

3

CORVITE ORAL TABLET

3

cyanocobalamin (vitamin b-12) injection solution

1

DIALYVITE 3000 ORAL TABLET

3

DIALYVITE 5000 ORAL TABLET

3

DIALYVITE 800 WITH IRON ORAL TABLET

3

dialyvite oral tablet

1

DIALYVITE SUPREME D ORAL TABLET

Notes

Drug Name

Tier

folbee plus oral tablet

1

FOLGARD RX ORAL TABLET

3

folic acid injection solution

1

folic acid oral tablet

1

folic acid-vit b6-vit b12 oral tablet

1

folplex 2.2 oral tablet

1

FOLTRATE ORAL TABLET

3

FORTAVIT ORAL CAPSULE

3

hydroxocobalamin intramuscular solution

1

INFUVITE ADULT INTRAVENOUS SOLUTION

3

INFUVITE PEDIATRIC INTRAVENOUS SOLUTION

3

3

levomefolate calcium oral tablet

1

DRISDOL ORAL CAPSULE

3

m.v.i. adult intravenous solution

1

DURACHOL ORAL CAPSULE

3

M.V.I. PEDIATRIC INTRAVENOUS RECON SOLN

3

ELDERCAPS ORAL CAPSULE

3

ergocalciferol (vitamin d2) oral capsule

3

1

M.V.I.-12 (WITHOUT VITAMIN K) INTRAVENOUS SOLUTION

ESCAVITE D ORAL TABLET,CHEW,IR DR,BIPHASE

3

MACUZIN ORAL CAPSULE

3

ESCAVITE LQ ORAL DROPS

2

3

MEPHYTON ORAL TABLET

ESCAVITE ORAL TABLET,CHEWABLE

1

3

multi-vit with fluoride-iron oral drops

fabb oral tablet

1

multi-vitamin with fluoride oral drops

1

FLORIVA ORAL TABLET,CHEWABLE

3

multivitamin with fluoride oral tablet,chewable

1

FLORIVA PLUS ORAL DROPS

3

multi-vitamin with fluoride oral tablet,chewable

1

folbee oral tablet

1

multivitamins with fluoride oral tablet,chewable

1

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 149

Drug Name

Tier

mvc-fluoride oral tablet,chewable

1

MYKIDZ IRON FLUORIDE ORAL SUSPENSION

2

mynephrocaps oral capsule

1

NASCOBAL NASAL SPRAY,NON-AEROSOL

3

nephplex rx oral tablet

1

NEPHROCAPS ORAL CAPSULE

Notes

Drug Name

Tier

POLY-VI-FLOR WITH IRON ORAL DROPS,SUSPENSION BIPHASIC

3

POLY-VI-FLOR WITH IRON ORAL TABLET,CHEWABLE

3

POTABA ORAL CAPSULE

3 3

3

PROTECT IRON ORAL TABLET

NEPHROCAPS QT ORAL TABLET,DISINTEGRATI NG

3

3

PURALOR CI ORAL TABLET,CHEW,IR DR,BIPHASE

nephro-vite rx oral tablet

1

pyridoxine (vitamin b6) injection solution

1

NEURIN-SL SUBLINGUAL TABLET

3

QUFLORA PEDIATRIC DROPS ORAL DROPS

3

NICOMIDE (SELENIUM-CHROMIU M) ORAL TABLET

3

QUFLORA PEDIATRIC ORAL TABLET,CHEWABLE

3

NICOMIDE ORAL TABLET

3

renal caps oral capsule

1

rena-vite rx oral tablet

1

NOXIFOL-D3 ORAL TABLET

3

reno caps oral capsule

1

NUTRICAP ORAL TABLET

REQ49+ ORAL TABLET

3

3

3

ortho d oral capsule

1

REVESTA ORAL CAPSULE

PED MULTIVITAMINS-A,B,D, E,K,ZN ORAL DROPS

3

3

ROCALTROL ORAL CAPSULE

3

PHYSICIANS EZ USE B-12 INJECTION KIT

ROCALTROL ORAL SOLUTION 3

SOFTGELS MULTIVIT-A,B,D,E,K,ZN ORAL CAPSULE

3

STROVITE FORTE ORAL TABLET

3

STROVITE ONE ORAL TABLET

3

SUPERVITE (EC) ORAL TABLET,DELAYED RELEASE (DR/EC)

3

SUPERVITE ORAL LIQUID

3

TEXAVITE LQ ORAL DROPS

3

PHYTONADIONE (VITAMIN K1) INJECTION SYRINGE

3

POLY-VI-FLOR FS ORAL FILM

3

POLY-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC

3

POLY-VI-FLOR ORAL TABLET,CHEWABLE

3

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 150

Drug Name

Tier

thiamine hcl (vitamin b1) injection solution

1

tl gard rx oral tablet

1

triphrocaps oral capsule

1

triple vitamin with fluoride oral drops

1

TRI-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC

3

tri-vit with fluoride and iron oral drops

1

tri-vitamin with fluoride oral drops

1

UDAMIN SP ORAL TABLET

3

v-c forte oral capsule

1

vic-forte oral capsule

1

VIRT-CAPS ORAL CAPSULE

3

virt-gard oral tablet

1

virt-vite oral tablet

1

VIRT-VITE PLUS ORAL TABLET

3

vit 3 oral capsule

1

VITAL-D RX ORAL TABLET

3

vitamin d2 oral capsule

1

vitamin k injection solution

1

vitamin k1 injection solution

1

vitamins a,c,d and fluoride oral drops

1

VITA-RESPA ORAL TABLET

3

vol-care rx oral tablet

1

vp-vite rx oral tablet

1

zavara oral capsule

1

Notes

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit CE = Clinically Equivalent Program Effective 7/1/16 151

KEY CE = CLINICALLY EQUIVALENT DRUG. This product has clinically equivalent alternatives included on the drug list. As a result, this product may not be covered under your pharmacy benefit. For coverage details, consult your online account through your health plan website at anthem.com. PA = PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of beneﬁts before certain prescriptions may be ﬁlled. QL = QUANTITY LIMITS. Certain prescription drugs have speciﬁc quantity limits per prescription or per month. ST = STEP THERAPY REQUIRED. You may need to use one medication before beneﬁts for the use of another medication can be authorized. DO = DOSE OPTIMIZATION REQUIRED. Normally involves the conversion from twice-daily dosing to a once-daily dosing schedule. Not all medications and not all plans are subject to prior authorization and quantity limits. For more information regarding prior authorization or quantity limits, contact Customer Service at the telephone number listed on your identification card.

For Kentucky Residents Only: In selecting medications for the prescription drug formulary, the therapeutic efficacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the formulary by at least one medication. When a closed formulary is in effect, only medications that are included on the formulary are a covered service. In certain clinical situations, a member may require use of a non-formulary product. Anthem has criteria that permits a member to obtain a nonformulary medication in a closed formulary plan. If specific criteria are met, a member can receive a non-formulary drug for a formulary copay. The criteria preserves the clinical integrity of the drug formulary and provides a process by which deviations from the formulary may be allowed. An appeals process is in place for any medications that do not meet the criteria.

For more information, please visit anthem.com If you have additional questions about your prescription beneﬁts please call the Customer Service number on your ID card

}

Speech and hearing impaired (TDD/TTY users) should call 1-800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m. ET

}

For the most current version of this prescription drug list, please visit anthem.com

}

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain afﬁliates administer non-HMO beneﬁts underwritten by HALIC and HMO beneﬁts underwritten by HMO Missouri, Inc. RIT and certain afﬁliates only provide administrative services for self-funded plans and do not underwrite beneﬁts. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (excluding the city of Fairfax, the town of Vienna and the area east of State Route 123): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin (“BCBSWi”), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (“Compcare”), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans. Rev. 02/16