Select Drug List - fm. · PDF fileThis list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration ... ANTIHISTAMINE AND

Select Drug List Drug list — Four Tier Drug Plan

Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA). Here are a few things to remember about the list:

o You and your doctor can use it as a guide to choose drugs that are best for you. Drugs that aren’t on this list may not be covered by your plan and may cost you more out of pocket.

o Your coverage has limitations and exclusions, which means there are certain rules about what’s covered by your plan and what isn’t. To find out more, read your Certificate or Evidence of Coverage or your Summary Plan Description. To download those documents, log in to anthem.com and select Plan Information from the menu.

o To help you see how the drug list works with your drug benefit, we've included some frequently asked questions (FAQ) about how the list is set up and what to do if a drug you take isn't on it.

o The most up-to-date drug list for your plan - including drugs that have been added, generic drugs and more - is available at anthem.com/pharmacyinformation. Select the Select Drug List.

If you have questions about your pharmacy benefits, we're here to help. Just call us at the Member Services number on your ID card.

05267KYMENABS IND

What is a drug list? The drug list, also called a formulary, is a list of prescription medicines your plan covers. It includes hundreds of brand-name and generic drugs approved by the U.S. Food & Drug Administration (FDA). Is this a complete listing of all covered drugs? Yes, this is a complete listing of all the drugs on the drug list. But, it’s possible a drug(s) on this list may not be covered, depending on your plan’s design. Your coverage has limitations and exclusions, which means there are certain conditions that determine what’s covered by your plan and what isn’t. To find out more, read your Certificate/Evidence of Coverage or your Summary Plan Description, which you got when you signed up for your plan. How can I find a drug on the list? The drugs are listed in alphabetical order based on the name of their drug class, also called therapeutic class. You can search the PDF drug list by:

o Drug name, using Ctrl + F on your keyboard, then type in the name of the drug you’re looking for. o Drug class, using the categories listed in alphabetical order.

The Notes column will tell you if you need preapproval before you can take the drug (called prior authorization or PA), or if you need to try other drugs first for your treatment (called step therapy or ST). When I search the list, I see that each drug is on a tier. What are the tiers for? The drug list is set up in tiers or levels. We place drugs on different tiers based on how well they work to improve health, whether there are over-the-counter (OTC) options and their costs compared to other drugs used for the same type of treatment. Your share of the drug cost will depend on what tier a drug is on. The lower the tier, the lower your share of the cost. Here’s a breakdown of the tiers in your plan:

o Tier 1 drugs have the lowest cost share for you. These are usually generic drugs that offer the best value compared to other drugs that treat the same conditions.

o Tier 2 drugs have a higher cost share than Tier 1. They may be preferred brand drugs, based on how well they work and their cost compared to other drugs used for the same type of treatment. Some are generic drugs that may cost more because they’re newer to the market.

o Tier 3 drugs have a higher cost share. They often include non-preferred brand and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA.

o Tier 4 drugs have the highest cost share and usually include specialty brand and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 4 may also include drugs recently approved by the FDA or specialty drugs used to treat serious, long-term health conditions and that may need special handling.

How will I know how much my drug will cost? You can go online to estimate your share of a drug’s cost and compare prices at different pharmacies. Here’s how:

o At the top right of the anthem.com home page, select Manage Prescriptions from the Popular Tasks icon, then log in using your user name and password. If you haven’t signed up on the site, you’ll need to do that first.

o On your personal Pharmacy Overview page, select Price a Medication, then select one or more pharmacies and enter the name of the drug you’d like to price.

Please note: This tool will provide you with an estimate of your cost, but may not reflect the actual amount you pay at the pharmacy. Actual prices are based on your plan design and also include sales tax where applicable.

Select Drug List

If my medicine isn’t on the drug list, what are my options? Here are a few things to think about:

o If you want to take a drug that’s not on the drug list, you may have to pay the full cost for it.

o You can also talk to your doctor or pharmacist to see if there’s another drug covered by your plan that will work just as well, or if generic or OTC drugs are an option. Only you and your doctor can decide what drugs are right for you.

o You can search for generic drugs at anthem.com. OTC drugs aren’t shown on the list.

o If a drug you’re taking isn’t covered, your doctor can ask us to review the coverage. This process is called preapproval

or prior authorization. Your doctor can get the process started by calling the Member Services number on the back of your member ID card or by downloading a prior authorization form from our website and submitting it. If your request is approved, the amount you pay for the drug will depend on your plan’s benefit.

Who decides what drugs are on the list? The drugs on the list are reviewed through our Pharmacy and Therapeutics (P&T) process. In this process, a group of independent doctors, pharmacists and other health care professionals decides which drugs we include on our lists. This group meets regularly to look at new and existing drugs and recommends drugs based on how safe they are, how well they work and the value they offer our members. What’s the difference between brand-name and generic drugs? A brand-name drug is FDA-approved and usually available from only one manufacturer. It may be protected by a patent, which means it can only be made or sold by the company that has the patent. A generic drug is also FDA-approved and has the same active ingredients as the brand-name drug. But a generic drug is usually available only after the patent on the brand-name drug ends. It may look different, but a generic drug works the same as the brand-name drug.

Does the drug list change, and how will I know if it does? Drugs on our list are reviewed on a regular basis. Sometimes, drugs are added, removed or moved to a different tier. We’ll let you know if a drug you take is taken off the list and, in some cases, if a drug you take is moved to a higher tier. You can always check the drug list to make sure medicines you take are still on it. You’ll find the most up-to-date drug list when you log in at anthem.com. Does my plan cover preventive drugs? We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA). A note about opioid analgesics. The member cost share for certain abuse-deterrent opioid analgesics may be lower in some states because of laws in those states. Opioid analgesics are a type of painkiller. In response to the global opioid epidemic, the U.S. Food and Drug Administration (FDA) has encouraged drug manufacturers to develop opioids with properties that help deter their misuse and abuse.

Drug(s) may be excluded from the list based on your plan's benefit design.

Search for a drug online

The most up-to-date drug list — including drugs that have been added, generic drugs and more — is always

available online when you log in at anthem.com. At the top right of the home page, choose Manage Prescriptions

from the Popular Tasks icon, then log in. On your personal Pharmacy Overview page, choose Search Your Drug

List and you can easily look up drugs by name, class or brand versus generic.

KEY Here are some terms and notes you’ll find on the drug list.

Brand name drugs are in UPPER CASE, bold type.

Generic drugs are in lower case, plain type.

$0 = preventive drugs. For some members, this product may be covered at 100% with $0 cost share with a

prescription from your provider if specified criteria are met.

DO = dose optimization. Usually, this means you may have to switch from taking a drug twice a day to taking it once

a day at a higher strength.

LD = limited distribution. These drugs are available only through certain pharmacies or wholesalers, depending on

what the manufacturer decides.

PA = prior authorization. You may need to get benefits approved before certain prescriptions can be filled.

QL = quantity limits. There are limits on the amount of medicine covered within a certain amount of time.

SP = specialty drugs. Specialty drugs are used to treat difficult, long-term conditions. You may need to get this drug

through a specialty pharmacy.

ST = step therapy. You may need to use another recommended drug first before a prescribed drug is covered.

2018 Kentucky Select Drug List

Table of Contents

ANALGESICS ...........................................................................................................................................................................7ANESTHETICS .........................................................................................................................................................................9ANTIARTHRITICS .................................................................................................................................................................... 9ANTIASTHMATICS .................................................................................................................................................................. 9ANTIBIOTICS ......................................................................................................................................................................... 11ANTICOAGULANTS .............................................................................................................................................................. 15ANTIDOTES ........................................................................................................................................................................... 16ANTIFUNGALS ...................................................................................................................................................................... 16ANTIHISTAMINE AND DECONGESTANT COMBINATION ................................................................................................. 17ANTIHISTAMINES ..................................................................................................................................................................17ANTIHYPERGLYCEMICS ...................................................................................................................................................... 17ANTIINFECTIVES/MISCELLANEOUS ...................................................................................................................................19ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS ....................................................................................20ANTINEOPLASTICS .............................................................................................................................................................. 20ANTIPARKINSON DRUGS .................................................................................................................................................... 22ANTIPLATELET DRUGS ....................................................................................................................................................... 22ANTIVIRALS ...........................................................................................................................................................................22AUTONOMIC DRUGS ............................................................................................................................................................ 24BIOLOGICALS ....................................................................................................................................................................... 25BLOOD ................................................................................................................................................................................... 28CARDIAC DRUGS ..................................................................................................................................................................28CARDIOVASCULAR .............................................................................................................................................................. 29CNS DRUGS ...........................................................................................................................................................................32COLONY STIMULATING FACTORS .....................................................................................................................................33CONTRACEPTIVES ............................................................................................................................................................... 34COUGH/COLD PREPARATIONS .......................................................................................................................................... 37DIAGNOSTIC ..........................................................................................................................................................................37DIURETICS .............................................................................................................................................................................37EENT PREPS ......................................................................................................................................................................... 38ELECT/CALORIC/H2O ...........................................................................................................................................................39GASTROINTESTINAL ............................................................................................................................................................40HORMONES ........................................................................................................................................................................... 42IMMUNOSUPPRESSANTS ....................................................................................................................................................44MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ..................................................................................... 45MUSCLE RELAXANTS .......................................................................................................................................................... 45PRE-NATAL VITAMINS ......................................................................................................................................................... 46PSYCHOTHERAPEUTIC DRUGS ..........................................................................................................................................47SEDATIVE/HYPNOTICS ........................................................................................................................................................ 49SKIN PREPS .......................................................................................................................................................................... 49SMOKING DETERRENTS ......................................................................................................................................................53THYROID PREPS ...................................................................................................................................................................53UNCLASSIFIED DRUG PRODUCTS .....................................................................................................................................53VITAMINS ............................................................................................................................................................................... 55

5

6

2018 Kentucky Select Drug List

CURRENT AS OF 4/1/2018

Drug Name Tier Notes

ANALGESICS

acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml

Tier 1 QL

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg

Tier 1 QL

almotriptan malate oral tablet

Tier 1 QL

asa-butalb-caff-cod #3 capsule

Tier 1 QL

ascomp with codeine oral capsule

Tier 1 QL

butalbital compound w/codeine oral capsule

Tier 1 QL

butalbital compound-codeine oral capsule

Tier 1 QL

butalbital-acetaminop-caf-cod oral capsule

Tier 1 QL

butalbital-acetaminophen oral tablet

Tier 1

butalbital-acetaminophen-caff oral capsule

Tier 1

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

Tier 1

butalbital-aspirin-caffeine oral capsule

Tier 1

butalbital-aspirin-caffeine oral tablet

Tier 1

butorphanol tartrate nasal spray,non-aerosol

Tier 1 PA; QL

capacet oral capsule Tier 1

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg

Tier 2 QL

diclofenac potassium oral tablet

Tier 1

diflunisal oral tablet Tier 1

dihydroergotamine nasal spray,non-aerosol

Tier 2 QL

diskets oral tablet,soluble Tier 1 PA; QL


eletriptan hbr oral tablet Tier 2 QL

ELMIRON ORAL CAPSULE

Tier 3

EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL

Tier 3 PA; QL

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

Tier 2 QL

ergotamine-caffeine oral tablet

Tier 1

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

Tier 2 PA; QL

frovatriptan oral tablet Tier 2 QL

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

Tier 1 QL

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

Tier 1 QL

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

Tier 1 QL

hydromorphone oral liquid Tier 1 QL

hydromorphone oral tablet 2 mg, 4 mg, 8 mg

Tier 1 QL

hydromorphone rectal suppository

Tier 2 QL

ibuprofen-oxycodone oral tablet

Tier 1 QL

isometh-dichloral-acetaminophn oral capsule

Tier 1

ketorolac oral tablet Tier 1 QL

levorphanol tartrate oral tablet

Tier 2 PA; QL

marten-tab oral tablet Tier 1

mefenamic acid oral capsule

Tier 1 QL

meperidine oral solution Tier 1 QL

meperidine oral tablet 100 mg, 50 mg

Tier 1 QL

Effective 4/1/2018

7


methadone intensol oral concentrate

Tier 1 PA; QL

methadone oral concentrate

Tier 1 PA; QL

methadone oral solution 10 mg/5 ml, 5 mg/5 ml

Tier 1 PA; QL

methadone oral tablet 10 mg, 5 mg

Tier 1 PA; QL

methadone oral tablet,soluble

Tier 1 PA; QL

methadose oral concentrate

Tier 1 PA; QL

methadose oral tablet,soluble

Tier 1 PA; QL

migergot rectal suppository

Tier 1

morphine concentrate oral solution

Tier 1 QL

morphine oral capsule,extend.release pellets

Tier 2 PA; QL

morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml)

Tier 1 QL

morphine oral tablet 15 mg, 30 mg

Tier 1 QL

morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg

Tier 2 PA; QL

morphine rectal suppository

Tier 1 QL

naratriptan oral tablet Tier 1 QL

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3 PA; QL

NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG

Tier 3 QL

oxycodone oral capsule Tier 2 QL

oxycodone oral concentrate

Tier 2 QL

oxycodone oral solution Tier 2 QL

oxycodone oral syringe Tier 2 QL

oxycodone oral tablet Tier 2 QL


oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Tier 1 QL

oxycodone-aspirin oral tablet

Tier 1 QL

oxymorphone oral tablet 10 mg, 5 mg

Tier 2 QL

oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg

Tier 2 PA; QL

pentazocine-naloxone oral tablet

Tier 1 QL

rizatriptan oral tablet Tier 1 QL

rizatriptan oral tablet,disintegrating

Tier 1 QL

sumatriptan nasal spray,non-aerosol

Tier 1 QL

sumatriptan succinate oral tablet

Tier 1 QL

sumatriptan succinate subcutaneous cartridge

Tier 2 QL

sumatriptan succinate subcutaneous pen injector

Tier 2 QL

sumatriptan succinate subcutaneous solution

Tier 2 QL

tencon oral tablet 50-325 mg

Tier 1

tramadol oral tablet Tier 1 QL

tramadol oral tablet extended release 24 hr

Tier 2 PA; QL

tramadol oral tablet, er multiphase 24 hr

Tier 2 PA; QL

vicodin es oral tablet Tier 2 QL

vicodin hp oral tablet Tier 2 QL

vicodin oral tablet Tier 2 QL

zebutal oral capsule 50-325-40 mg

Tier 2

ZIPSOR ORAL CAPSULE Tier 3 QL

ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG

Tier 3 PA; QL

zolmitriptan oral tablet Tier 1 QL

Effective 4/1/2018

8


zolmitriptan oral tablet,disintegrating

Tier 1 QL

ANESTHETICS

lidocaine viscous mucous membrane solution

Tier 1 QL

lidocaine-prilocaine topical cream

Tier 1 QL

lidocaine-prilocaine topical kit

Tier 1

phenazopyridine oral tablet 100 mg, 200 mg

Tier 1

SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING

Tier 3

ANTIARTHRITICS

allopurinol oral tablet Tier 1

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

Tier 2 ST; QL

COLCRYS ORAL TABLET

Tier 3 PA; QL

CUPRIMINE ORAL CAPSULE

Tier 3

diclofenac sodium oral tablet extended release 24 hr

Tier 1

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

Tier 1

etodolac oral capsule Tier 1

etodolac oral tablet Tier 1

etodolac oral tablet extended release 24 hr

Tier 1

fenoprofen oral tablet Tier 1 QL

flurbiprofen oral tablet Tier 1

ibuprofen oral suspension Tier 1 QL

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

Tier 1

indomethacin oral capsule 25 mg, 50 mg

Tier 1 QL

indomethacin oral capsule, extended release

Tier 1 QL

ketoprofen oral capsule Tier 1

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

Tier 1 QL


meclofenamate oral capsule

Tier 1

meloxicam oral suspension

Tier 1 QL

meloxicam oral tablet Tier 1 QL

nabumetone oral tablet Tier 1

naproxen oral suspension Tier 1

naproxen oral tablet Tier 1

naproxen oral tablet,delayed release (dr/ec)

Tier 1

naproxen sodium oral tablet 275 mg, 550 mg

Tier 1

ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN

Tier 4 PA; SP; QL

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR

Tier 4 PA; SP; QL

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML

Tier 4 PA; SP; QL

ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML, 87.5 MG/0.7 ML

Tier 4 PA; QL

oxaprozin oral tablet Tier 1

piroxicam oral capsule Tier 1

probenecid oral tablet Tier 1

probenecid-colchicine oral tablet

Tier 1

RIDAURA ORAL CAPSULE

Tier 3

sulindac oral tablet Tier 1

tolmetin oral capsule Tier 2

tolmetin oral tablet Tier 2

ULORIC ORAL TABLET Tier 3 ST

XELJANZ ORAL TABLET Tier 4 PA; SP; QL

ANTIASTHMATICS

acetylcysteine solution Tier 2

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE

Tier 2 QL

Effective 4/1/2018

9


ADVAIR HFA INHALATION HFA AEROSOL INHALER

Tier 2 QL

albuterol sulfate inhalation solution for nebulization

Tier 1

albuterol sulfate oral syrup Tier 1

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 3 QL

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 3 QL

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

Tier 2 QL

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

Tier 2

BREO ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 3 QL

BROVANA INHALATION SOLUTION FOR NEBULIZATION

Tier 3 QL

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml

Tier 1 QL

cromolyn inhalation solution for nebulization

Tier 2

DALIRESP ORAL TABLET

Tier 3 QL

DULERA INHALATION HFA AEROSOL INHALER

Tier 2 QL

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION

Tier 2 QL


FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION

Tier 2 QL

ipratropium bromide inhalation solution

Tier 1 QL

ipratropium-albuterol inhalation solution for nebulization

Tier 2

levalbuterol hcl inhalation solution for nebulization

Tier 2

metaproterenol oral syrup Tier 1

metaproterenol oral tablet Tier 1

montelukast oral granules in packet

Tier 1 QL

montelukast oral tablet Tier 1 QL

montelukast oral tablet,chewable

Tier 1 QL

PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION

Tier 3 QL

PROAIR HFA INHALATION HFA AEROSOL INHALER

Tier 2 QL

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2 QL

PROVENTIL HFA INHALATION HFA AEROSOL INHALER

Tier 3 QL

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2 QL

QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION

Tier 2 QL

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

Tier 2 QL

SPIRIVA RESPIMAT INHALATION MIST

Tier 3 QL

Effective 4/1/2018

10


SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 3 QL

STRIVERDI RESPIMAT INHALATION MIST

Tier 3 QL

SYMBICORT INHALATION HFA AEROSOL INHALER

Tier 2 QL

terbutaline oral tablet Tier 2

theochron oral tablet extended release 12 hr

Tier 1

theophylline oral elixir Tier 1

theophylline oral solution Tier 1

theophylline oral tablet extended release 12 hr

Tier 1

theophylline oral tablet extended release 24 hr

Tier 1

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 3 QL

VENTOLIN HFA INHALATION HFA AEROSOL INHALER

Tier 3 QL

XOPENEX HFA INHALATION HFA AEROSOL INHALER

Tier 3 QL

zafirlukast oral tablet Tier 1

zileuton oral tablet, er multiphase 12 hr

Tier 2 PA

ANTIBIOTICS

amoxicillin oral capsule Tier 1

amoxicillin oral suspension for reconstitution

Tier 1

amoxicillin oral tablet Tier 1

amoxicillin oral tablet,chewable 125 mg, 250 mg

Tier 1

amoxicillin-pot clavulanate oral suspension for reconstitution

Tier 1

amoxicillin-pot clavulanate oral tablet

Tier 1

amoxicillin-pot clavulanate oral tablet extended release 12 hr

Tier 1


amoxicillin-pot clavulanate oral tablet,chewable

Tier 1

ampicillin oral capsule Tier 1

avidoxy oral tablet Tier 1

AZASITE OPHTHALMIC (EYE) DROPS

Tier 3

azithromycin oral packet Tier 1 QL

azithromycin oral suspension for reconstitution

Tier 1 QL

azithromycin oral tablet 250 mg, 500 mg, 600 mg

Tier 1 QL

bacitracin ophthalmic (eye) ointment

Tier 1

bacitracin-polymyxin b ophthalmic (eye) ointment

Tier 1

BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

bp 10-1 topical cleanser Tier 1

CAYSTON INHALATION SOLUTION FOR NEBULIZATION

Tier 4 SP; LD

cefaclor oral capsule Tier 1

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

Tier 1

cefaclor oral tablet extended release 12 hr

Tier 2

cefadroxil oral capsule Tier 1

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

Tier 1

cefadroxil oral tablet Tier 1

cefazolin in dextrose 5 % intravenous solution

Tier 1

cefdinir oral capsule Tier 1

cefdinir oral suspension for reconstitution

Tier 1

cefditoren pivoxil oral tablet

Tier 2

cefpodoxime oral suspension for reconstitution

Tier 2

cefpodoxime oral tablet Tier 2

Effective 4/1/2018

11


cefprozil oral suspension for reconstitution

Tier 1

cefprozil oral tablet Tier 1

cefuroxime axetil oral tablet

Tier 1

cephalexin oral capsule Tier 1

cephalexin oral suspension for reconstitution

Tier 1

cephalexin oral tablet Tier 1

CIPRO HC OTIC (EAR) DROPS,SUSPENSION

Tier 3

CIPRODEX OTIC (EAR) DROPS,SUSPENSION

Tier 3 PA

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg

Tier 1 QL

ciprofloxacin hcl ophthalmic (eye) drops

Tier 1

ciprofloxacin hcl oral tablet Tier 1 QL

ciprofloxacin hcl otic (ear) dropperette

Tier 1

clarithromycin oral suspension for reconstitution

Tier 1

clarithromycin oral tablet Tier 1

clarithromycin oral tablet extended release 24 hr

Tier 1

cleansing wash topical cleanser

Tier 1

clindamycin hcl oral capsule

Tier 1

clindamycin palmitate hcl oral recon soln

Tier 1

clindamycin pediatric oral recon soln

Tier 1

clindamycin phosphate topical foam

Tier 1

clindamycin phosphate topical gel

Tier 1

clindamycin phosphate topical lotion

Tier 1

clindamycin phosphate topical solution

Tier 1

clindamycin phosphate topical swab

Tier 1


clindamycin phosphate vaginal cream

Tier 1

COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION

Tier 3

CORTISPORIN TOPICAL CREAM

Tier 3

CORTISPORIN TOPICAL OINTMENT

Tier 3

CYCLOSERINE ORAL CAPSULE

Tier 3

DAPSONE ORAL TABLET

Tier 2

demeclocycline oral tablet Tier 2

dicloxacillin oral capsule Tier 1

DIFICID ORAL TABLET Tier 3 PA

doxycycline hyclate oral capsule

Tier 1

doxycycline hyclate oral tablet 100 mg

Tier 1

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

Tier 1 PA

doxycycline monohydrate oral capsule

Tier 1

doxycycline monohydrate oral suspension for reconstitution

Tier 1

doxycycline monohydrate oral tablet

Tier 1

e.e.s. 400 oral tablet Tier 2

ery pads topical swab Tier 1

erygel topical gel Tier 1

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

Tier 1

erythrocin (as stearate) oral tablet 250 mg

Tier 1

erythromycin ethylsuccinate oral tablet

Tier 2

erythromycin ophthalmic (eye) ointment

Tier 1

erythromycin oral capsule,delayed release(dr/ec)

Tier 2

erythromycin oral tablet Tier 2

Effective 4/1/2018

12


erythromycin with ethanol topical gel

Tier 1

erythromycin with ethanol topical solution

Tier 1

erythromycin with ethanol topical swab

Tier 1

erythromycin-benzoyl peroxide topical gel

Tier 1

ethambutol oral tablet Tier 2

FACTIVE ORAL TABLET Tier 3 QL

gatifloxacin ophthalmic (eye) drops

Tier 1

gentak ophthalmic (eye) ointment

Tier 1

gentamicin ophthalmic (eye) drops

Tier 1

gentamicin ophthalmic (eye) ointment

Tier 1

gentamicin topical cream Tier 1

gentamicin topical ointment

Tier 1

INVANZ INJECTION RECON SOLN

Tier 3

INVANZ INTRAVENOUS RECON SOLN

Tier 3

isoniazid oral solution Tier 1

isoniazid oral tablet Tier 1

levofloxacin ophthalmic (eye) drops

Tier 1

levofloxacin oral tablet Tier 2 QL

linezolid oral suspension for reconstitution

Tier 2 PA; QL

linezolid oral tablet Tier 2 PA; QL

mafenide acetate topical packet

Tier 2

methenamine hippurate oral tablet

Tier 2

methenamine mandelate oral tablet

Tier 2

metronidazole oral capsule

Tier 1

metronidazole oral tablet Tier 1

metronidazole vaginal gel Tier 1

minocycline oral capsule Tier 1

minocycline oral tablet Tier 1


minocycline oral tablet extended release 24 hr 135 mg, 45 mg, 90 mg

Tier 1 PA

MONUROL ORAL PACKET

Tier 3

morgidox oral capsule 100 mg

Tier 1

MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR

Tier 3

moxifloxacin ophthalmic (eye) drops

Tier 1

mupirocin topical ointment Tier 1

neomycin oral tablet Tier 1

neomycin-bacitracin-poly-hc ophthalmic (eye) ointment

Tier 1

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment

Tier 1

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension

Tier 1

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment

Tier 1

neomycin-polymyxin-gramicidin ophthalmic (eye) drops

Tier 1

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension

Tier 1

neomycin-polymyxin-hc otic (ear) drops,suspension

Tier 1

neomycin-polymyxin-hc otic (ear) solution

Tier 1

neo-polycin hc ophthalmic (eye) ointment

Tier 1

neo-polycin ophthalmic (eye) ointment

Tier 1

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

Tier 1

nitrofurantoin monohyd/m-cryst oral capsule

Tier 1

nitrofurantoin oral suspension

Tier 1

Effective 4/1/2018

13


ofloxacin ophthalmic (eye) drops

Tier 1

ofloxacin oral tablet 300 mg, 400 mg

Tier 1 QL

ofloxacin otic (ear) drops Tier 1

ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE

Tier 3

penicillin v potassium oral recon soln

Tier 1

penicillin v potassium oral tablet

Tier 1

polycin ophthalmic (eye) ointment

Tier 1

polymyxin b sulf-trimethoprim ophthalmic (eye) drops

Tier 1

PRIFTIN ORAL TABLET Tier 3

PRIMSOL ORAL SOLUTION

Tier 3

pyrazinamide oral tablet Tier 2

rifabutin oral capsule Tier 2

rifampin oral capsule Tier 2

RIFATER ORAL TABLET Tier 3

silver sulfadiazine topical cream

Tier 1

SIRTURO ORAL TABLET Tier 3

SIVEXTRO ORAL TABLET

Tier 3 PA; QL

ssd topical cream Tier 1

sss 10-5 topical cream Tier 1

sss 10-5 topical foam Tier 1

sulfacetamide sodium ophthalmic (eye) drops

Tier 1

sulfacetamide sodium ophthalmic (eye) ointment

Tier 1

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

Tier 1

sulfacetamide sodium-sulfur topical cream 10-2 %, 10-5 % (w/w)

Tier 1

sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w)

Tier 1


sulfacetamide sodium-sulfur topical pads, medicated 10-4 %

Tier 1

sulfacetamide sodium-sulfur topical suspension

Tier 1

sulfacetamide sod-sulfur-urea topical cleanser

Tier 1

sulfacetamide-prednisolone ophthalmic (eye) drops

Tier 1

sulfacetamide-sulfur-cleansr23 topical kit

Tier 1

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

Tier 1

sulfadiazine oral tablet Tier 2

sulfamethoxazole-trimethoprim oral suspension

Tier 1

sulfamethoxazole-trimethoprim oral tablet

Tier 1

SULFAMYLON TOPICAL CREAM

Tier 3

sulfatrim oral suspension Tier 1

SUPRAX ORAL CAPSULE

Tier 3

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML

Tier 3

tetracycline oral capsule Tier 1

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

Tier 4 PA; SP; QL

TOBRADEX OPHTHALMIC (EYE) OINTMENT

Tier 3

tobramycin in 0.225 % nacl inhalation solution for nebulization

Tier 4 SP

tobramycin ophthalmic (eye) drops

Tier 1

tobramycin-dexamethasone ophthalmic (eye) drops,suspension

Tier 1

TRECATOR ORAL TABLET

Tier 3

Effective 4/1/2018

14


trimethoprim oral tablet Tier 1

vancomycin oral capsule Tier 2 PA

vandazole vaginal gel Tier 1

XIFAXAN ORAL TABLET200 MG, 550 MG

Tier 3 PA; QL

ANTICOAGULANTS

ELIQUIS ORAL TABLET2.5 MG, 5 MG

Tier 3 QL

ELIQUIS ORAL TABLETS,DOSE PACK

Tier 3 QL

enoxaparin subcutaneous solution

Tier 4 QL

enoxaparin subcutaneous syringe

Tier 4 QL

fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

Tier 4 PA; QL

FRAGMIN SUBCUTANEOUS SOLUTION

Tier 4 QL

FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML, 7,500 ANTI-XA UNIT/0.3 ML

Tier 4 QL

hep flush-10 (pf) intravenous solution

Tier 1

heparin (porcine) in 0.9% nacl intravenous parenteral solution 10,000 unit/1,000 ml, 100 unit/100 ml (1 unit/ml), 2,500 unit/500 ml (5 unit/ml), 250 unit/250 ml (1 unit/ml), 3,000 unit/500 ml (6 unit/ml), 30,000 unit/1,000 ml, 5,000 unit/1,000 ml

Tier 1

heparin (porcine) in 0.9% nacl intravenous syringe 30 unit/3 ml (10 unit/ml)

Tier 1


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

Tier 1

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

Tier 1

heparin (porcine) injection cartridge

Tier 1

heparin (porcine) injection solution

Tier 1

heparin flush(porcine)-0.9nacl intravenous kit

Tier 1

heparin lock flush (porcine) intravenous solution

Tier 1

heparin lock flush (porcine) intravenous syringe

Tier 1

heparin lock flush intravenous solution

Tier 1

heparin lock flush intravenous syringe

Tier 1

heparin lock intravenous solution

Tier 1

heparin lockflush(porcine)(pf) intravenous syringe

Tier 1

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml, 5,000 unit/1,000 ml

Tier 1

heparin, porcine (pf) injection solution

Tier 1

heparin, porcine (pf) injection syringe

Tier 1

heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml)

Tier 1

heparin, porcine (pf) intravenous syringe

Tier 1

jantoven oral tablet Tier 1

PRADAXA ORAL CAPSULE

Tier 3 QL

Effective 4/1/2018

15


warfarin oral tablet Tier 1

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG

Tier 3 PA; QL

XARELTO ORAL TABLETS,DOSE PACK

Tier 3 PA; QL

ANTIDOTES

naloxone injection solution Tier 2 QL

naloxone injection syringe Tier 2 QL

naltrexone oral tablet Tier 1

ANTIFUNGALS

ciclopirox topical cream Tier 1

ciclopirox topical gel Tier 1

ciclopirox topical shampoo Tier 1

ciclopirox topical solution Tier 1

ciclopirox topical suspension

Tier 1

clotrimazole mucous membrane troche

Tier 2 QL

clotrimazole topical cream Tier 1

clotrimazole topical solution

Tier 1

clotrimazole-betamethasone topical cream

Tier 1

clotrimazole-betamethasone topical lotion

Tier 1

econazole topical cream Tier 1

ERTACZO TOPICAL CREAM

Tier 3

EXELDERM TOPICAL CREAM

Tier 3

EXELDERM TOPICAL SOLUTION

Tier 3

fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml

Tier 1 QL

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg

Tier 1 QL

flucytosine oral capsule Tier 2

griseofulvin microsize oral suspension

Tier 1


griseofulvin microsize oral tablet

Tier 1

griseofulvin ultramicrosize oral tablet

Tier 1

GYNAZOLE-1 VAGINAL CREAM

Tier 3

itraconazole oral capsule Tier 2 PA; QL

JUBLIA TOPICAL SOLUTION WITH APPLICATOR

Tier 3

KERYDIN TOPICAL SOLUTION WITH APPLICATOR

Tier 3

ketoconazole oral tablet Tier 1 QL

ketoconazole topical cream

Tier 1

ketoconazole topical foam Tier 1

ketoconazole topical shampoo

Tier 1

LUZU TOPICAL CREAM Tier 3

MENTAX TOPICAL CREAM

Tier 3

miconazole-3 vaginal suppository

Tier 1

NAFTIFINE TOPICAL CREAM 1 %

Tier 2

naftifine topical cream 2 % Tier 2

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

NOXAFIL ORAL SUSPENSION

Tier 3 QL

nyamyc topical powder Tier 1

nystatin oral powder 150 million unit, 500 million unit

Tier 1

nystatin oral suspension Tier 1

nystatin oral tablet Tier 1

nystatin topical cream Tier 1

nystatin topical ointment Tier 1

nystatin topical powder Tier 1

nystatin-triamcinolone topical cream

Tier 1

nystatin-triamcinolone topical ointment

Tier 1

nystop topical powder Tier 1

Effective 4/1/2018

16


ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET

Tier 3

oxiconazole topical cream Tier 2

OXISTAT TOPICAL LOTION

Tier 3

terbinafine hcl oral tablet Tier 1 PA; QL

terconazole vaginal cream Tier 1

terconazole vaginal suppository

Tier 1

voriconazole oral suspension for reconstitution

Tier 2 PA; QL

voriconazole oral tablet 200 mg, 50 mg

Tier 2 PA; QL

ANTIHISTAMINE AND DECONGESTANT COMBINATION

promethazine vc oral syrup

Tier 1

promethazine-phenylephrine syr

Tier 1

ANTIHISTAMINES

azelastine ophthalmic (eye) drops

Tier 1 QL

BEPREVE OPHTHALMIC (EYE) DROPS

Tier 3 PA; QL

carbinoxamine maleate oral liquid

Tier 1

carbinoxamine maleate oral tablet

Tier 1

cetirizine oral solution 1 mg/ml

Tier 1

clemastine oral tablet 2.68 mg

Tier 1

cyproheptadine oral syrup Tier 1

cyproheptadine oral tablet Tier 1

desloratadine oral tablet Tier 1

desloratadine oral tablet,disintegrating

Tier 1

diphenhydramine hcl injection solution 50 mg/ml

Tier 2

diphenhydramine hcl injection syringe

Tier 2

diphenhydramine hcl oral capsule 50 mg

Tier 1


EMADINE OPHTHALMIC (EYE) DROPS

Tier 3 ST; QL

epinastine ophthalmic (eye) drops

Tier 1 QL

fexofenadine oral tablet 180 mg

Tier 1

hydroxyzine hcl oral solution 10 mg/5 ml

Tier 1

hydroxyzine hcl oral tablet Tier 1

hydroxyzine pamoate oral capsule

Tier 1

LASTACAFT OPHTHALMIC (EYE) DROPS

Tier 3 PA; QL

levocetirizine oral solution Tier 1

levocetirizine oral tablet Tier 1

olopatadine ophthalmic (eye) drops 0.1 %, 0.2 %

Tier 2 PA; QL

promethazine oral syrup Tier 1

promethazine oral tablet Tier 1

ANTIHYPERGLYCEMICS

acarbose oral tablet Tier 1

APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 3 ST

AVANDIA ORAL TABLET2 MG, 4 MG

Tier 3 ST; QL

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR

Tier 3 ST; QL

BYDUREON SUBCUTANEOUS PEN INJECTOR

Tier 3 ST; QL

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON

Tier 3 ST; QL

chlorpropamide oral tablet Tier 1

CYCLOSET ORAL TABLET

Tier 3

FARXIGA ORAL TABLET Tier 3 ST; QL

glimepiride oral tablet Tier 1

Effective 4/1/2018

17


glipizide oral tablet Tier 1

glipizide oral tablet extended release 24hr

Tier 1

glipizide-metformin oral tablet

Tier 1

glyburide micronized oral tablet

Tier 1

glyburide oral tablet Tier 1

glyburide-metformin oral tablet

Tier 1

HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT

Tier 2

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION

Tier 2

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION

Tier 2

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE

Tier 2

HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 2

HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 2


HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 2

HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION

Tier 2

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION

Tier 2

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

Tier 2

INVOKAMET ORAL TABLET

Tier 3 ST; QL

INVOKANA ORAL TABLET

Tier 3 ST; QL

JANUMET ORAL TABLET

Tier 2 ST; QL

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 MG

Tier 2 ST; QL

JANUVIA ORAL TABLET Tier 2 ST; QL

JARDIANCE ORAL TABLET

Tier 2 ST; QL

JENTADUETO ORAL TABLET

Tier 2 ST; QL

LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 2

LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN

Tier 2

Effective 4/1/2018

18


LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 2

metformin oral tablet Tier 1

metformin oral tablet extended release 24 hr

Tier 1

metformin oral tablet extended release 24hr

Tier 1

miglitol oral tablet Tier 2

nateglinide oral tablet Tier 2 PA

NESINA ORAL TABLET Tier 3 ST; QL

NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION

Tier 2

NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION

Tier 2

NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE

Tier 2

NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION

Tier 2

ONGLYZA ORAL TABLET 2.5 MG

Tier 3 ST; DO

ONGLYZA ORAL TABLET 5 MG

Tier 3 ST; QL

pioglitazone oral tablet Tier 1 QL


SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR

Tier 3 PA

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR

Tier 3 PA

SYNJARDY ORAL TABLET

Tier 2 ST; QL

tolazamide oral tablet Tier 1

tolbutamide oral tablet Tier 2

TRADJENTA ORAL TABLET

Tier 2 ST; DO

TRULICITY SUBCUTANEOUS PEN INJECTOR

Tier 3 ST; QL

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR

Tier 2 ST; QL

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR

Tier 2 ST; QL

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 2.5-1,000 MG, 5-1,000 MG, 5-500 MG

Tier 3 ST; QL

ANTIINFECTIVES/MISCELLANEOUS

ALINIA ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ALINIA ORAL TABLET Tier 3

atovaquone oral suspension

Tier 2

atovaquone-proguanil oral tablet

Tier 1

BILTRICIDE ORAL TABLET

Tier 3

chloroquine phosphate oral tablet

Tier 1

COARTEM ORAL TABLET

Tier 3

DARAPRIM ORAL TABLET

Tier 3 PA; LD; QL

hydroxychloroquine oral tablet

Tier 1

ivermectin oral tablet Tier 1

Effective 4/1/2018

19


mefloquine oral tablet Tier 1

NEBUPENT INHALATION RECON SOLN

Tier 4

paromomycin oral capsule Tier 1

PRIMAQUINE ORAL TABLET

Tier 3

quinine sulfate oral capsule

Tier 2 PA; QL

ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT

Tier 4 PA; SP; LD; QL

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT


CIMZIA SUBCUTANEOUS SYRINGE KIT


ENBREL SUBCUTANEOUS RECON SOLN

Tier 4 PA; SP; QL

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML)

Tier 4 PA; SP; QL

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP; QL

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT

Tier 4 PA; SP; QL

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

Tier 4 PA; SP; QL

HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT

Tier 4 PA; SP; QL

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT

Tier 4 PA; SP; QL


HUMIRA SUBCUTANEOUS SYRINGE KIT

Tier 4 PA; SP; QL

SIMPONI ARIA INTRAVENOUS SOLUTION

Tier 4 PA; SP

SIMPONI SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP; QL

SIMPONI SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

ANTINEOPLASTICS

ACTIMMUNE SUBCUTANEOUS SOLUTION

Tier 4 PA; SP; LD

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION

Tier 4 PA; SP

AFINITOR ORAL TABLET

Tier 4 PA; SP

anastrozole oral tablet Tier 2 QL

bexarotene oral capsule Tier 4 PA; SP

bicalutamide oral tablet Tier 2

BOSULIF ORAL TABLET100 MG, 500 MG

Tier 4 PA; SP; QL

BOSULIF ORAL TABLET400 MG

Tier 4 PA; QL

capecitabine oral tablet Tier 4 PA; SP

CAPRELSA ORAL TABLET 100 MG, 300 MG

Tier 4 PA; QL

CARAC TOPICAL CREAM

Tier 2 QL

COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)

Tier 4 PA; LD; QL

CYCLOPHOSPHAMIDE ORAL CAPSULE

Tier 4 SP

diclofenac sodium topical gel 3 %

Tier 2 QL

EMCYT ORAL CAPSULE Tier 4 PA

ERIVEDGE ORAL CAPSULE

Tier 4 PA; SP; QL

Effective 4/1/2018

20


etoposide oral capsule Tier 4 SP

exemestane oral tablet Tier 2 PA; QL

FARESTON ORAL TABLET

Tier 4 QL

FARYDAK ORAL CAPSULE

Tier 4 PA; SP; QL

FIRMAGON SUBCUTANEOUS RECON SOLN 120 MG

Tier 4 PA; SP; QL

fluorouracil topical cream 5 %

Tier 1 QL

fluorouracil topical solution Tier 1 QL

flutamide oral capsule Tier 2

GILOTRIF ORAL TABLET


GLEOSTINE ORAL CAPSULE

Tier 4 PA

HEXALEN ORAL CAPSULE

Tier 4

HYCAMTIN ORAL CAPSULE

Tier 4 SP

hydroxyurea oral capsule Tier 2

IBRANCE ORAL CAPSULE

Tier 4 PA; SP; QL

ICLUSIG ORAL TABLET15 MG, 45 MG

Tier 4 PA; QL

imatinib oral tablet 100 mg, 400 mg

Tier 4 PA; SP; QL

IMBRUVICA ORAL CAPSULE 140 MG

Tier 4 PA; LD; QL

IMBRUVICA ORAL CAPSULE 70 MG

Tier 4 PA; QL

INLYTA ORAL TABLET 1 MG, 5 MG

Tier 4 PA; SP; QL

INTRON A INJECTION RECON SOLN

Tier 4 PA; SP

INTRON A INJECTION SOLUTION

Tier 4 PA; SP

JAKAFI ORAL TABLET10 MG, 15 MG, 20 MG, 25 MG, 5 MG



LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2)


letrozole oral tablet Tier 2 QL

LEUKERAN ORAL TABLET

Tier 4

leuprolide subcutaneous kit

Tier 4 PA; SP

LYNPARZA ORAL CAPSULE


LYNPARZA ORAL TABLET

Tier 4 PA; LD; QL

LYSODREN ORAL TABLET

Tier 4 QL

MATULANE ORAL CAPSULE

Tier 4 LD

MEKINIST ORAL TABLET 0.5 MG, 2 MG

Tier 4 PA; SP; QL

melphalan oral tablet Tier 4

mercaptopurine oral tablet Tier 2

methotrexate sodium oral tablet

Tier 2

MYLERAN ORAL TABLET

Tier 4

NEXAVAR ORAL TABLET

Tier 4 PA; SP; QL

nilutamide oral tablet Tier 4 QL

ODOMZO ORAL CAPSULE

Tier 4 PA; SP; QL

PICATO TOPICAL GEL0.015 %, 0.05 %

Tier 3 PA; QL

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG

Tier 4 PA; SP; QL

REVLIMID ORAL CAPSULE

Tier 4 PA; SP; QL

SPRYCEL ORAL TABLET

Tier 4 PA; SP; QL

STIVARGA ORAL TABLET

Tier 4 PA; SP; QL

Effective 4/1/2018

21


SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

Tier 4 PA; SP; QL

TABLOID ORAL TABLET Tier 4

TAFINLAR ORAL CAPSULE

Tier 4 PA; SP; QL

tamoxifen oral tablet Tier 2 $0

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG

Tier 4 PA; SP; QL

TARGRETIN TOPICAL GEL

Tier 4 PA; SP

TASIGNA ORAL CAPSULE

Tier 4 PA; SP; QL

temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg

Tier 4 PA; SP; QL

tretinoin (chemotherapy) oral capsule

Tier 2

TYKERB ORAL TABLET Tier 4 PA; SP; QL

VOTRIENT ORAL TABLET

Tier 4 PA; SP; QL

XALKORI ORAL CAPSULE

Tier 4 PA; SP; QL

XTANDI ORAL CAPSULE Tier 4 PA; SP; QL

ZELBORAF ORAL TABLET

Tier 4 PA; SP; QL

ZOLINZA ORAL CAPSULE

Tier 4 PA; SP; QL

ZYDELIG ORAL TABLET Tier 4 PA; LD; QL

ZYKADIA ORAL CAPSULE

Tier 4 PA; SP; QL

ZYTIGA ORAL TABLET250 MG

Tier 4 PA; SP; QL

ZYTIGA ORAL TABLET500 MG

Tier 4 PA; QL

ANTIPARKINSON DRUGS

amantadine hcl oral capsule

Tier 2 QL

amantadine hcl oral solution

Tier 2

amantadine hcl oral tablet Tier 2 QL

APOKYN SUBCUTANEOUS CARTRIDGE

Tier 4 SP; LD; QL


benztropine oral tablet Tier 1

bromocriptine oral capsule Tier 1

bromocriptine oral tablet Tier 1

carbidopa oral tablet Tier 2

carbidopa-levodopa oral tablet

Tier 1

carbidopa-levodopa oral tablet extended release

Tier 2

carbidopa-levodopa oral tablet,disintegrating

Tier 2

entacapone oral tablet Tier 2 QL

pramipexole oral tablet Tier 2 QL

rasagiline oral tablet Tier 2

ropinirole oral tablet Tier 1

ropinirole oral tablet extended release 24 hr

Tier 2

selegiline hcl oral capsule Tier 2

selegiline hcl oral tablet Tier 2

tolcapone oral tablet Tier 2 QL

trihexyphenidyl oral elixir Tier 1

trihexyphenidyl oral tablet Tier 1

ANTIPLATELET DRUGS

anagrelide oral capsule Tier 2

aspirin-dipyridamole oral capsule, er multiphase 12 hr

Tier 2 QL

BRILINTA ORAL TABLET

Tier 3 QL

cilostazol oral tablet Tier 2

clopidogrel oral tablet 300 mg

Tier 2

clopidogrel oral tablet 75 mg

Tier 2 QL

dipyridamole oral tablet Tier 2

prasugrel oral tablet 10 mg Tier 2 QL

prasugrel oral tablet 5 mg Tier 2 DO

ticlopidine oral tablet Tier 1

ZONTIVITY ORAL TABLET

Tier 3 QL

ANTIVIRALS

abacavir oral solution Tier 4

abacavir oral tablet Tier 4

Effective 4/1/2018

22


abacavir-lamivudine oral tablet

Tier 4

abacavir-lamivudine-zidovudine oral tablet

Tier 4

acyclovir oral capsule Tier 1

acyclovir oral suspension 200 mg/5 ml

Tier 1

acyclovir oral tablet Tier 1

acyclovir topical ointment Tier 3 QL

adefovir oral tablet Tier 4 SP

APTIVUS ORAL CAPSULE

Tier 4

APTIVUS ORAL SOLUTION

Tier 4

atazanavir oral capsule Tier 4

BARACLUDE ORAL SOLUTION

Tier 4 SP

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

Tier 4

DENAVIR TOPICAL CREAM

Tier 3 QL

didanosine oral capsule,delayed release(dr/ec)

Tier 4

EDURANT ORAL TABLET

Tier 4

efavirenz oral capsule Tier 4

efavirenz oral tablet Tier 4

EMTRIVA ORAL CAPSULE

Tier 4

EMTRIVA ORAL SOLUTION

Tier 4

entecavir oral tablet Tier 4 SP

EPCLUSA ORAL TABLET

Tier 4 PA; SP; QL

EPIVIR HBV ORAL SOLUTION

Tier 4 SP

EVOTAZ ORAL TABLET Tier 4

famciclovir oral tablet Tier 1

FUZEON SUBCUTANEOUS RECON SOLN

Tier 4

GENVOYA ORAL TABLET

Tier 4


HARVONI ORAL TABLET

Tier 4 PA; SP; QL

INTELENCE ORAL TABLET

Tier 4

INVIRASE ORAL CAPSULE

Tier 4

INVIRASE ORAL TABLET

Tier 4

ISENTRESS ORAL TABLET

Tier 4

ISENTRESS ORAL TABLET,CHEWABLE

Tier 4

KALETRA ORAL TABLET

Tier 4

lamivudine oral tablet 150 mg, 300 mg

Tier 4

lamivudine-zidovudine oral tablet

Tier 4

lopinavir-ritonavir oral solution

Tier 4

MAVYRET ORAL TABLET

Tier 4 PA; QL

MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 200 MG (28)- 400 MG (28), 400-400 MG (28)-MG (28), 600-400 MG (28)-MG (28), 600-600 MG (28)-MG (28)

Tier 4

moderiba dose pack oral tablets,dose pack 200 mg (7)- 400 mg (7), 400 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7)

Tier 4 SP

moderiba oral tablet Tier 4 SP

nevirapine oral suspension Tier 4

nevirapine oral tablet Tier 4

NORVIR ORAL CAPSULE

Tier 4

NORVIR ORAL SOLUTION

Tier 4

NORVIR ORAL TABLET Tier 4

oseltamivir oral capsule 30 mg, 45 mg, 75 mg

Tier 2 QL

oseltamivir oral suspension for reconstitution

Tier 2 QL

Effective 4/1/2018

23


PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP; QL

PEGASYS SUBCUTANEOUS SOLUTION

Tier 4 PA; SP; QL

PEGASYS SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML

Tier 4 PA; SP

PREZISTA ORAL SUSPENSION

Tier 4

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

Tier 4

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

Tier 2 QL

RESCRIPTOR ORAL TABLET

Tier 4

RESCRIPTOR ORAL TABLET, DISPERSIBLE

Tier 4

ribasphere oral capsule Tier 4 SP

ribasphere oral tablet Tier 4 SP

ribasphere ribapak oral tablets,dose pack

Tier 4 SP

ribavirin oral capsule Tier 4 SP

ribavirin oral tablet 200 mg Tier 4 SP

rimantadine oral tablet Tier 1

SELZENTRY ORAL TABLET

Tier 4

stavudine oral capsule Tier 4

stavudine oral recon soln Tier 4

STRIBILD ORAL TABLET

Tier 4

SUSTIVA ORAL TABLET Tier 4

TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG

Tier 2 QL

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION

Tier 2 QL

tenofovir disoproxil fumarate oral tablet

Tier 4

TIVICAY ORAL TABLET Tier 4


trifluridine ophthalmic (eye) drops

Tier 1

TRIUMEQ ORAL TABLET

Tier 4

TRUVADA ORAL TABLET

Tier 4

valacyclovir oral tablet Tier 1

valganciclovir oral recon soln

Tier 2 SP

valganciclovir oral tablet Tier 2 SP

VEREGEN TOPICAL OINTMENT

Tier 3

VIRACEPT ORAL TABLET

Tier 4

VIREAD ORAL TABLET150 MG, 200 MG, 250 MG

Tier 4

ZEPATIER ORAL TABLET

Tier 4 PA; SP; QL

zidovudine oral capsule Tier 4

zidovudine oral syrup Tier 4

zidovudine oral tablet Tier 4

ZIRGAN OPHTHALMIC (EYE) GEL

Tier 3

AUTONOMIC DRUGS

bethanechol chloride oral tablet

Tier 2

cevimeline oral capsule Tier 2

dextroamphetamine oral capsule, extended release

Tier 1 PA

dextroamphetamine oral solution

Tier 1 PA

dextroamphetamine oral tablet

Tier 1 PA

dextroamphetamine-amphetamine oral capsule,extended release 24hr

Tier 1 PA

dextroamphetamine-amphetamine oral tablet

Tier 1 PA

donepezil oral tablet Tier 2

donepezil oral tablet,disintegrating

Tier 2

epinephrine 0.3 mg auto-inject

Tier 1 QL

epinephrine 0.3 mg auto-inject inner

Tier 1 QL

Effective 4/1/2018

24


epinephrine 0.3 mg auto-inject latex-free, sdv

Tier 1 QL

epinephrine 0.3 mg auto-inject latex-free, suv

Tier 1 QL

epinephrine 0.3 mg auto-inject no latex, auto-injct

Tier 1 QL

epinephrine 0.3 mg auto-inject no latex, two-pack

Tier 1 QL

epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 mg/0.3 ml

Tier 1 QL

EPIPEN 2-PAK INJECTION AUTO-INJECTOR

Tier 2 QL

EPIPEN INJECTION AUTO-INJECTOR

Tier 2 QL

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR

Tier 2 QL

EPIPEN JR INJECTION AUTO-INJECTOR

Tier 2 QL

galantamine oral capsule,ext rel. pellets 24 hr

Tier 2

galantamine oral solution Tier 2

galantamine oral tablet Tier 2

guanidine oral tablet Tier 1

methamphetamine oral tablet

Tier 2 PA

midodrine oral tablet Tier 2

NORTHERA ORAL CAPSULE

Tier 3 SP; LD

phenoxybenzamine oral capsule

Tier 2

pilocarpine hcl oral tablet Tier 2

procentra oral solution Tier 1 PA

pyridostigmine bromide oral tablet

Tier 2

rivastigmine tartrate oral capsule

Tier 2

zenzedi oral tablet 10 mg, 5 mg

Tier 1 PA

BIOLOGICALS

ACTHIB (PF) INTRAMUSCULAR RECON SOLN

Tier 3 $0


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

Tier 3 $0

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

Tier 3 $0

AFLURIA 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

AFLURIA 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

AFLURIA QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

AFLURIA QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

BEXSERO INTRAMUSCULAR SYRINGE

Tier 2 $0

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION

Tier 3 $0

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

Tier 3 $0

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

FLUAD 2017-2018 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

Effective 4/1/2018

25


FLUARIX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLUBLOK 2017-2018 (PF) INTRAMUSCULAR SOLUTION

Tier 1 $0; QL

FLUBLOK QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLUCELVAX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLUCELVAX QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

FLULAVAL QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLULAVAL QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLUVIRIN 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

FLUZONE HIGH-DOSE 2017-18 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

FLUZONE INTRADERM QUAD 2017-18 INTRADERMAL SYRINGE

Tier 1 $0; QL

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL


FLUZONE QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 1 $0; QL

FLUZONE QUAD PEDI 2017-18 (PF) INTRAMUSCULAR SYRINGE

Tier 1 $0; QL

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION

Tier 2 $0

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

Tier 2 $0

GRASTEK SUBLINGUAL TABLET

Tier 3 PA; QL

HAVRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

HAVRIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

HYQVIA SUBCUTANEOUS SOLUTION

Tier 4 PA; SP

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN

Tier 3

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

IPOL INJECTION SUSPENSION

Tier 3 $0

IXIARO (PF) INTRAMUSCULAR SYRINGE

Tier 3

KINRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

KINRIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

MENACTRA (PF) INTRAMUSCULAR SOLUTION

Tier 3 $0

Effective 4/1/2018

26


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

Tier 3 $0

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

Tier 3 $0

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION

Tier 3 $0

PENTACEL (PF) INTRAMUSCULAR KIT

Tier 3 $0

PNEUMOVAX 23 INJECTION SOLUTION

Tier 2 $0

PNEUMOVAX 23 INJECTION SYRINGE

Tier 2 $0

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE

Tier 2 $0

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 $0

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 3

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION

Tier 3 $0

ROTATEQ VACCINE ORAL SOLUTION

Tier 3 $0

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 2 $0

SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 2 $0


TENIVAC (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

TENIVAC (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION

Tier 3 $0

TRUMENBA INTRAMUSCULAR SYRINGE

Tier 2 $0

TWINRIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

TYPHIM VI INTRAMUSCULAR SOLUTION

Tier 3

TYPHIM VI INTRAMUSCULAR SYRINGE

Tier 3

VAQTA (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

VAQTA (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 $0

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

Tier 2

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 2 $0

Effective 4/1/2018

27


BLOOD

DROXIA ORAL CAPSULE

Tier 4

pentoxifylline oral tablet extended release

Tier 1

tranexamic acid oral tablet Tier 1

CARDIAC DRUGS

afeditab cr oral tablet extended release 30 mg

Tier 2 DO

afeditab cr oral tablet extended release 60 mg

Tier 2 QL

amiodarone oral tablet Tier 1

amlodipine oral tablet 10 mg

Tier 1 QL

amlodipine oral tablet 2.5 mg, 5 mg

Tier 1 DO

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

Tier 1 DO

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

Tier 1 QL

digox oral tablet Tier 1

digoxin oral solution 50 mcg/ml

Tier 1

digoxin oral tablet Tier 1

diltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg

Tier 1 DO

diltiazem hcl oral capsule,ext.rel 24h degradable 240 mg

Tier 1 QL

diltiazem hcl oral capsule,extended release 12 hr

Tier 2 QL

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

Tier 1 DO

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

Tier 1 QL

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

Tier 1 DO


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

Tier 1 QL

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

Tier 1 QL

diltiazem hcl oral tablet extended release 24 hr 180 mg

Tier 1 DO

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

Tier 1 QL

dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg

Tier 1 DO

dilt-xr oral capsule,ext.rel 24h degradable 240 mg

Tier 1 QL

disopyramide phosphate oral capsule

Tier 2

dofetilide oral capsule Tier 2

felodipine oral tablet extended release 24 hr 10 mg

Tier 1 QL

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

Tier 1 DO

flecainide oral tablet Tier 2

isosorbide dinitrate oral tablet

Tier 1

isosorbide dinitrate oral tablet extended release

Tier 1

isosorbide mononitrate oral tablet

Tier 1

isosorbide mononitrate oral tablet extended release 24 hr

Tier 1

isradipine oral capsule 2.5 mg, 5 mg

Tier 1 QL

LANOXIN ORAL TABLET Tier 3

matzim la oral tablet extended release 24 hr 180 mg

Tier 1 DO

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

Tier 1 QL

Effective 4/1/2018

28


mexiletine oral capsule Tier 2

MULTAQ ORAL TABLET Tier 3

nicardipine oral capsule 20 mg, 30 mg

Tier 2 QL

nifedipine oral capsule Tier 2 QL

nifedipine oral tablet extended release 24hr 30 mg

Tier 2 DO

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

Tier 2 QL

nifedipine oral tablet extended release 30 mg

Tier 2 DO

nifedipine oral tablet extended release 60 mg, 90 mg

Tier 2 QL

nimodipine oral capsule Tier 2 QL

nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 8.5 mg

Tier 1 DO

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

Tier 1 QL

nitro-bid transdermal ointment

Tier 1

nitroglycerin oral capsule, extended release

Tier 2

nitroglycerin sublingual tablet

Tier 1

nitroglycerin translingual spray,non-aerosol

Tier 2

nitro-time oral capsule, extended release

Tier 1

pacerone oral tablet 100 mg, 200 mg, 400 mg

Tier 2

propafenone oral capsule,extended release 12 hr

Tier 2

propafenone oral tablet Tier 2

quinidine sulfate oral tablet Tier 1

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

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

Tier 1 DO


taztia xt oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg

Tier 1 QL

verapamil oral capsule, 24 hr er pellet ct 100 mg

Tier 1 DO

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

Tier 1 QL

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

Tier 1 DO

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

Tier 1 QL

verapamil oral tablet 120 mg, 40 mg, 80 mg

Tier 1 QL

verapamil oral tablet extended release

Tier 1 QL

CARDIOVASCULAR

acebutolol oral capsule Tier 1

ADCIRCA ORAL TABLET

Tier 4 PA; SP; QL

ADEMPAS ORAL TABLET


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

Tier 1 QL

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

Tier 1 DO

amlodipine-benazepril oral capsule

Tier 1

atenolol oral tablet Tier 1

atenolol-chlorthalidone oral tablet

Tier 1

atorvastatin oral tablet 10 mg, 20 mg

Tier 1 DO; $0

atorvastatin oral tablet 40 mg

Tier 1 DO

atorvastatin oral tablet 80 mg

Tier 1 QL

benazepril oral tablet Tier 1

benazepril-hydrochlorothiazide oral tablet

Tier 1

Effective 4/1/2018

29


betaxolol oral tablet Tier 1

bisoprolol fumarate oral tablet

Tier 1

bisoprolol-hydrochlorothiazide oral tablet

Tier 1

BYSTOLIC ORAL TABLET

Tier 3

candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg

Tier 1 QL

candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg

Tier 1 QL

candesartan-hydrochlorothiazid oral tablet 32-25 mg

Tier 1

captopril oral tablet Tier 2

captopril-hydrochlorothiazide oral tablet

Tier 2

carvedilol oral tablet Tier 1

cholestyramine (with sugar) oral powder

Tier 2 QL

cholestyramine (with sugar) oral powder in packet

Tier 2 QL

cholestyramine light oral powder

Tier 2 QL

cholestyramine light oral powder in packet

Tier 2

clonidine hcl oral tablet Tier 1

colestipol oral granules Tier 1

colestipol oral packet Tier 1

colestipol oral tablet Tier 1

doxazosin oral tablet Tier 1

EDARBI ORAL TABLET40 MG

Tier 3 DO

EDARBI ORAL TABLET80 MG

Tier 3 QL

enalapril maleate oral tablet

Tier 1

enalapril-hydrochlorothiazide oral tablet

Tier 1

eprosartan oral tablet Tier 1 QL


ergoloid oral tablet Tier 2

ezetimibe oral tablet Tier 2 PA; QL

fenofibrate micronized oral capsule 130 mg, 43 mg

Tier 1

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

Tier 1 QL

fenofibrate nanocrystallized oral tablet

Tier 1 QL

fenofibrate oral tablet 160 mg, 54 mg

Tier 1 QL

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

Tier 1 QL

fenofibric acid oral tablet Tier 1 QL

fluvastatin oral capsule Tier 1 DO; $0

fluvastatin oral tablet extended release 24 hr

Tier 1 $0

fosinopril oral tablet Tier 1

fosinopril-hydrochlorothiazide oral tablet

Tier 1

gemfibrozil oral tablet Tier 1

guanfacine oral tablet Tier 1

hydralazine oral tablet Tier 1

irbesartan oral tablet 150 mg, 75 mg

Tier 1 DO

irbesartan oral tablet 300 mg

Tier 1 QL

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg

Tier 1 QL

irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg

Tier 1

labetalol oral tablet Tier 1

LETAIRIS ORAL TABLET Tier 4 PA; SP; LD; QL

LEVATOL ORAL TABLET

Tier 3

lisinopril oral tablet Tier 1

lisinopril-hydrochlorothiazide oral tablet

Tier 1

LIVALO ORAL TABLET 1 MG, 2 MG

Tier 3 ST; DO

Effective 4/1/2018

30


LIVALO ORAL TABLET 4 MG

Tier 3 ST; QL

losartan oral tablet 100 mg, 25 mg, 50 mg

Tier 1 QL

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

Tier 1 QL

losartan-hydrochlorothiazide oral tablet 50-12.5 mg

Tier 1 DO

lovastatin oral tablet 10 mg, 20 mg

Tier 1 DO; $0

lovastatin oral tablet 40 mg

Tier 1 $0; QL

methyldopa oral tablet Tier 1

methyldopa-hydrochlorothiazide oral tablet

Tier 1

metoprolol succinate oral tablet extended release 24 hr

Tier 1

metoprolol ta-hydrochlorothiaz oral tablet

Tier 1

metoprolol tartrate oral tablet

Tier 1

minoxidil oral tablet Tier 1

moexipril oral tablet Tier 1

moexipril-hydrochlorothiazide oral tablet

Tier 1

nadolol oral tablet Tier 2

nadolol-bendroflumethiazide oral tablet

Tier 1

niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg

Tier 1 QL

olmesartan oral tablet 20 mg

Tier 2 DO

olmesartan oral tablet 40 mg, 5 mg

Tier 2 QL

OPSUMIT ORAL TABLET Tier 4 PA; SP; LD; QL

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG

Tier 4 PA; SP; LD


ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG

Tier 4 PA; LD

perindopril erbumine oral tablet

Tier 1

pindolol oral tablet Tier 2

pravastatin oral tablet 10 mg, 20 mg

Tier 1 DO; $0

pravastatin oral tablet 40 mg

Tier 1 $0

pravastatin oral tablet 80 mg

Tier 1 $0; QL

prazosin oral capsule Tier 1

prevalite oral powder Tier 2 QL

prevalite oral powder in packet

Tier 2

propranolol oral capsule,extended release 24 hr

Tier 1

propranolol oral solution Tier 1

propranolol oral tablet Tier 1

propranolol-hydrochlorothiazid oral tablet

Tier 1

quinapril oral tablet Tier 1

quinapril-hydrochlorothiazide oral tablet

Tier 1

ramipril oral capsule Tier 1

REMODULIN INJECTION SOLUTION

Tier 4 PA; SP; LD

rosuvastatin oral tablet 10 mg, 5 mg

Tier 2 DO; $0

rosuvastatin oral tablet 20 mg

Tier 2 DO

rosuvastatin oral tablet 40 mg

Tier 2 QL

sildenafil (antihypertensive) oral tablet

Tier 4 PA; SP; QL

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

Tier 1 DO; $0

simvastatin oral tablet 80 mg

Tier 1 PA; QL

sorine oral tablet Tier 2

sotalol af oral tablet Tier 2

Effective 4/1/2018

31


sotalol oral tablet Tier 2

TEKTURNA ORAL TABLET 150 MG

Tier 3 DO

TEKTURNA ORAL TABLET 300 MG

Tier 3 QL

telmisartan oral tablet 20 mg, 40 mg

Tier 1 DO

telmisartan oral tablet 80 mg

Tier 1 QL

terazosin oral capsule Tier 1

timolol maleate oral tablet Tier 1

TRACLEER ORAL TABLET

Tier 4 PA; SP; QL

trandolapril oral tablet Tier 1

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

Tier 1 DO

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

Tier 1 QL

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

Tier 1 QL

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg

Tier 1 DO

valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg

Tier 1 QL

VECAMYL ORAL TABLET

Tier 3

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION


WELCHOL ORAL POWDER IN PACKET

Tier 3

WELCHOL ORAL TABLET

Tier 3

CNS DRUGS

APTIOM ORAL TABLET Tier 3

AUBAGIO ORAL TABLET

Tier 4 PA; SP; QL

BANZEL ORAL SUSPENSION

Tier 3


BANZEL ORAL TABLET Tier 3

carbamazepine oral capsule, er multiphase 12 hr

Tier 1

carbamazepine oral suspension 100 mg/5 ml

Tier 1

carbamazepine oral tablet Tier 1

carbamazepine oral tablet extended release 12 hr

Tier 1

carbamazepine oral tablet,chewable

Tier 1

CELONTIN ORAL CAPSULE 300 MG

Tier 3

clonazepam oral tablet Tier 1

clonazepam oral tablet,disintegrating

Tier 1

DIASTAT ACUDIAL RECTAL KIT

Tier 2 QL

DIASTAT RECTAL KIT Tier 2 QL

diazepam rectal kit Tier 2 QL

divalproex oral capsule, delayed rel sprinkle

Tier 2

divalproex oral tablet extended release 24 hr

Tier 2

divalproex oral tablet,delayed release (dr/ec)

Tier 2

epitol oral tablet Tier 1

ethosuximide oral capsule Tier 1

ethosuximide oral solution Tier 1

EXTAVIA SUBCUTANEOUS KIT

Tier 4 PA; SP

EXTAVIA SUBCUTANEOUS RECON SOLN

Tier 4 PA; SP

felbamate oral suspension Tier 2

felbamate oral tablet Tier 2

FYCOMPA ORAL TABLET

Tier 3

gabapentin oral capsule Tier 2

gabapentin oral solution Tier 2

gabapentin oral tablet 600 mg, 800 mg

Tier 2

GILENYA ORAL CAPSULE

Tier 4 PA; SP; QL

Effective 4/1/2018

32


glatiramer subcutaneous syringe 20 mg/ml

Tier 4 PA

glatopa subcutaneous syringe 20 mg/ml

Tier 4 PA; SP

HORIZANT ORAL TABLET EXTENDED RELEASE

Tier 3 PA; QL

lamotrigine oral tablet Tier 1

lamotrigine oral tablet, chewable dispersible

Tier 1

levetiracetam oral solution Tier 2

levetiracetam oral tablet Tier 2

levetiracetam oral tablet extended release 24 hr

Tier 2 PA

LYRICA ORAL CAPSULE100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

Tier 3 PA; QL

LYRICA ORAL SOLUTION

Tier 3 PA; QL

memantine oral solution Tier 2

memantine oral tablet Tier 2

memantine oral tablets,dose pack

Tier 3

NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK

Tier 3

ONFI ORAL SUSPENSION

Tier 3

ONFI ORAL TABLET 10 MG, 20 MG

Tier 3

oxcarbazepine oral suspension

Tier 2

oxcarbazepine oral tablet Tier 2

PEGANONE ORAL TABLET

Tier 3

phenytoin sodium extended oral capsule

Tier 1

PLEGRIDY SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP

PLEGRIDY SUBCUTANEOUS SYRINGE

Tier 4 PA; SP

primidone oral tablet Tier 1


REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

Tier 4 PA; SP

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

Tier 4 PA; SP

riluzole oral tablet Tier 4 SP

SABRIL ORAL TABLET Tier 3 SP; LD

tetrabenazine oral tablet Tier 2 PA; SP; LD

tiagabine oral tablet Tier 2

topiramate oral capsule, sprinkle

Tier 1

topiramate oral tablet Tier 1

valproic acid (as sodium salt) oral solution

Tier 1

valproic acid oral capsule Tier 1

vigabatrin oral powder in packet

Tier 2 LD

VIMPAT ORAL SOLUTION

Tier 3

VIMPAT ORAL TABLET Tier 3

zonisamide oral capsule Tier 2

COLONY STIMULATING FACTORS

ARANESP (IN POLYSORBATE) INJECTION SOLUTION

Tier 4 PA; SP

ARANESP (IN POLYSORBATE) INJECTION SYRINGE

Tier 4 PA; SP

NEULASTA SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR

Tier 4 PA; SP; QL

NEUPOGEN INJECTION SOLUTION

Tier 4 PA; SP

NEUPOGEN INJECTION SYRINGE

Tier 4 PA; SP

PROCRIT INJECTION SOLUTION

Tier 4 PA; SP

Effective 4/1/2018

33


PROMACTA ORAL TABLET

Tier 4 PA; SP

CONTRACEPTIVES

AFTERA ORAL TABLET Tier 1 $0; QL

altavera (28) oral tablet Tier 1 $0

alyacen 1/35 (28) oral tablet

Tier 1 $0

alyacen 7/7/7 (28) oral tablet

Tier 1 $0

amethia lo oral tablets,dose pack,3 month

Tier 1 $0

amethia oral tablets,dose pack,3 month

Tier 1 $0

amethyst oral tablet Tier 1 $0

apri oral tablet Tier 1 $0

aranelle (28) oral tablet Tier 1 $0

ashlyna oral tablets,dose pack,3 month

Tier 1 $0

aubra oral tablet Tier 1 $0

aviane oral tablet Tier 1 $0

azurette (28) oral tablet Tier 1 $0

balziva (28) oral tablet Tier 1 $0

BEKYREE (28) ORAL TABLET

Tier 1 $0

BLISOVI 24 FE ORAL TABLET

Tier 1 $0

BLISOVI FE 1.5/30 (28) ORAL TABLET

Tier 1 $0

BLISOVI FE 1/20 (28) ORAL TABLET

Tier 1 $0

briellyn oral tablet Tier 1 $0

camila oral tablet Tier 1 $0

camrese lo oral tablets,dose pack,3 month

Tier 1 $0

camrese oral tablets,dose pack,3 month

Tier 1 $0

caziant (28) oral tablet Tier 1 $0

chateal oral tablet Tier 1 $0

cryselle (28) oral tablet Tier 1 $0

cyclafem 1/35 (28) oral tablet

Tier 1 $0

cyclafem 7/7/7 (28) oral tablet

Tier 1 $0

cyred oral tablet Tier 1 $0


dasetta 1/35 (28) oral tablet

Tier 1 $0

dasetta 7/7/7 (28) oral tablet

Tier 1 $0

daysee oral tablets,dose pack,3 month

Tier 1 $0

deblitane oral tablet Tier 1 $0

delyla (28) oral tablet Tier 1 $0

desog-e.estradiol/e.estradiol oral tablet

Tier 1 $0

desogestrel-ethinyl estradiol oral tablet

Tier 1 $0

drospirenone-e.estradiol-lm.fa oral tablet

Tier 1 $0

drospirenone-ethinyl estradiol oral tablet

Tier 1 $0

econtra ez oral tablet Tier 1 $0; QL

elinest oral tablet Tier 1 $0

ELLA ORAL TABLET Tier 3 $0

emoquette oral tablet Tier 1 $0

enpresse oral tablet Tier 1 $0

enskyce oral tablet Tier 1 $0

errin oral tablet Tier 1 $0

estarylla oral tablet Tier 1 $0

ethynodiol diac-eth estradiol oral tablet

Tier 1 $0

falmina (28) oral tablet Tier 1 $0

FAYOSIM ORAL TABLETS,DOSE PACK,3 MONTH

Tier 1 $0

femynor oral tablet Tier 1 $0

gianvi (28) oral tablet Tier 1 $0

heather oral tablet Tier 1 $0

introvale oral tablets,dose pack,3 month

Tier 1 $0

isibloom oral tablet Tier 1 $0

jencycla oral tablet Tier 1 $0

jolessa oral tablets,dose pack,3 month

Tier 1 $0

jolivette oral tablet Tier 1 $0

JULEBER ORAL TABLET

Tier 1 $0

junel 1.5/30 (21) oral tablet Tier 1 $0

Effective 4/1/2018

34


junel 1/20 (21) oral tablet Tier 1 $0

junel fe 1.5/30 (28) oral tablet

Tier 1 $0

junel fe 1/20 (28) oral tablet

Tier 1 $0

junel fe 24 oral tablet Tier 1 $0

KAITLIB FE ORAL TABLET,CHEWABLE

Tier 1 $0

kariva (28) oral tablet Tier 1 $0

kelnor 1/35 (28) oral tablet Tier 1 $0

kimidess (28) oral tablet Tier 1 $0

kurvelo oral tablet Tier 1 $0

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

Tier 1 $0

larin 1.5/30 (21) oral tablet Tier 1 $0

larin 1/20 (21) oral tablet Tier 1 $0

larin 24 fe oral tablet Tier 1 $0

larin fe 1.5/30 (28) oral tablet

Tier 1 $0

larin fe 1/20 (28) oral tablet

Tier 1 $0

LARISSIA ORAL TABLET

Tier 1 $0

layolis fe oral tablet,chewable

Tier 1 $0

leena 28 oral tablet Tier 1 $0

lessina oral tablet Tier 1 $0

levonest (28) oral tablet Tier 1 $0

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg

Tier 1 $0

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

Tier 1 $0

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

Tier 1 $0

levonorg-eth estrad triphasic oral tablet

Tier 1 $0

levora-28 oral tablet Tier 1 $0

lillow oral tablet Tier 1 $0

LO LOESTRIN FE ORAL TABLET

Tier 3 $0

loryna (28) oral tablet Tier 1 $0


low-ogestrel (28) oral tablet

Tier 1 $0

lutera (28) oral tablet Tier 1 $0

lyza oral tablet Tier 1 $0

marlissa oral tablet Tier 1 $0

medroxyprogesterone intramuscular suspension

Tier 1 $0

medroxyprogesterone intramuscular syringe

Tier 1 $0

MELODETTA 24 FE ORAL TABLET,CHEWABLE

Tier 1 $0

MIBELAS 24 FE ORAL TABLET,CHEWABLE

Tier 1 $0

microgestin 1.5/30 (21) oral tablet

Tier 1 $0

microgestin 1/20 (21) oral tablet

Tier 1 $0

microgestin fe 1.5/30 (28) oral tablet

Tier 1 $0

microgestin fe 1/20 (28) oral tablet

Tier 1 $0

mono-linyah oral tablet Tier 1 $0

mononessa (28) oral tablet Tier 1 $0

my way oral tablet Tier 1 $0; QL

myzilra oral tablet Tier 1 $0

NATAZIA ORAL TABLET Tier 3 $0

necon 0.5/35 (28) oral tablet

Tier 1 $0

necon 7/7/7 (28) oral tablet

Tier 1 $0

next choice one dose oral tablet

Tier 1 $0; QL

nikki (28) oral tablet Tier 1 $0

nora-be oral tablet Tier 1 $0

noreth-ethinyl estradiol-iron oral tablet,chewable

Tier 1 $0

norethindrone (contraceptive) oral tablet

Tier 1 $0

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

Tier 1 $0

norethindrone-e.estradiol-iron oral tablet

Tier 1 $0

norethindrone-e.estradiol-iron oral tablet,chewable

Tier 1 $0

Effective 4/1/2018

35


norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28)

Tier 1 $0

norgestimate-ethinyl estradiol oral tablet 0.25-35 mg-mcg

Tier 1 $0

NORLYDA ORAL TABLET

Tier 1 $0

norlyroc oral tablet Tier 1 $0

nortrel 0.5/35 (28) oral tablet

Tier 1 $0

nortrel 1/35 (21) oral tablet Tier 1 $0

nortrel 1/35 (28) oral tablet Tier 1 $0

nortrel 7/7/7 (28) oral tablet

Tier 1 $0

NUVARING VAGINAL RING

Tier 3 $0

ocella oral tablet Tier 1 $0

ogestrel (28) oral tablet Tier 1 $0

opcicon one-step oral tablet

Tier 1 $0; QL

orsythia oral tablet Tier 1 $0

philith oral tablet Tier 1 $0

pimtrea (28) oral tablet Tier 1 $0

pirmella oral tablet Tier 1 $0

PLAN B ONE-STEP ORAL TABLET

Tier 1 $0; QL

portia oral tablet Tier 1 $0

previfem oral tablet Tier 1 $0

quasense oral tablets,dose pack,3 month

Tier 1 $0

RAJANI ORAL TABLET Tier 1 $0

reclipsen (28) oral tablet Tier 1 $0

RIVELSA ORAL TABLETS,DOSE PACK,3 MONTH

Tier 1 $0

SAFYRAL ORAL TABLET

Tier 3

setlakin oral tablets,dose pack,3 month

Tier 1 $0

sharobel oral tablet Tier 1 $0

sprintec (28) oral tablet Tier 1 $0

sronyx oral tablet Tier 1 $0


syeda oral tablet Tier 1 $0

TAKE ACTION ORAL TABLET

Tier 1 $0; QL

tarina fe 1/20 (28) oral tablet

Tier 1 $0

TAYTULLA ORAL CAPSULE

Tier 3 $0

tilia fe oral tablet Tier 1 $0

TRI FEMYNOR ORAL TABLET

Tier 1 $0

tri-estarylla oral tablet Tier 1 $0

tri-legest fe oral tablet Tier 1 $0

tri-linyah oral tablet Tier 1 $0

TRI-LO-ESTARYLLA ORAL TABLET

Tier 1 $0

tri-lo-marzia oral tablet Tier 1 $0

TRI-LO-SPRINTEC ORAL TABLET

Tier 1 $0

trinessa (28) oral tablet Tier 1 $0

TRINESSA LO ORAL TABLET

Tier 1 $0

tri-previfem (28) oral tablet Tier 1 $0

tri-sprintec (28) oral tablet Tier 1 $0

trivora (28) oral tablet Tier 1 $0

tri-vylibra oral tablet Tier 1 $0

velivet triphasic regimen (28) oral tablet

Tier 1 $0

vestura (28) oral tablet Tier 1 $0

VIENVA ORAL TABLET Tier 1 $0

viorele (28) oral tablet Tier 1 $0

vyfemla (28) oral tablet Tier 1 $0

vylibra oral tablet Tier 1 $0

wera (28) oral tablet Tier 1 $0

wymzya fe oral tablet,chewable

Tier 1 $0

xulane transdermal patch weekly

Tier 1 $0

zarah oral tablet Tier 1 $0

zenchent (28) oral tablet Tier 1 $0

zovia 1/35e (28) oral tablet Tier 1 $0

zovia 1/50e (28) oral tablet Tier 1 $0

Effective 4/1/2018

36


COUGH/COLD PREPARATIONS

benzonatate oral capsule 100 mg, 200 mg

Tier 1

cheratussin ac oral liquid Tier 1

codeine-guaifen 10-100 mg/5 ml (otc)

Tier 1

codeine-guaifen 10-100 mg/5 ml a/f,d/f,s/f (otc)

Tier 1

g tussin ac oral liquid Tier 1

guaiatussin ac oral liquid Tier 1

guaifen-codeine 100-10 mg/5 ml (otc)

Tier 1

guaifen-codeine 100-10 mg/5 ml inner (otc)

Tier 1

guaifen-codeine 100-10 mg/5 ml outer (otc)

Tier 1

guaifen-codeine 200-20 mg/10 ml inner (otc)

Tier 1

guaifen-codeine 200-20 mg/10 ml outer (otc)

Tier 1

guaifenesin ac oral liquid Tier 1

guaifenesin-codeine syrup (otc)

Tier 1

guaifenesin-codeine syrup (otc)

Tier 1

hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr

Tier 1

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

Tier 1

promethazine vc-codeine oral syrup

Tier 1

promethazine-codeine oral syrup

Tier 1

promethazine-dm oral syrup

Tier 1

promethazine-phenyleph-codeine oral syrup

Tier 1

TUZISTRA XR ORAL SUSPENSION,EXTENDED REL 12 HR

Tier 3

virtussin ac oral liquid Tier 1

VITUZ ORAL SOLUTION Tier 3


DIAGNOSTIC

ACCU-CHEK AVIVA PLUS TEST STRP STRIP

Tier 2 QL

ACCU-CHEK COMPACT PLUS TEST STRIP

Tier 2 QL

ACCU-CHEK GUIDE STRIP

Tier 2 QL

ACCU-CHEK SMARTVIEW TEST STRIP STRIP

Tier 2 QL

ACCUTREND GLUCOSE STRIP

Tier 2 QL

GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN

Tier 2

GLUCAGON HCL INJECTION RECON SOLN

Tier 2

ONETOUCH ULTRA TEST STRIP

Tier 2 QL

ONETOUCH VERIO STRIP

Tier 2 QL

DIURETICS

acetazolamide oral capsule, extended release

Tier 1

acetazolamide oral tablet Tier 1

amiloride oral tablet Tier 2

AMMONIUM CHLORIDE INTRAVENOUS SOLUTION

Tier 3

bumetanide oral tablet Tier 1

chlorothiazide oral tablet Tier 1

chlorthalidone oral tablet 25 mg, 50 mg

Tier 1

DYRENIUM ORAL CAPSULE

Tier 3

eplerenone oral tablet Tier 2

ethacrynic acid oral tablet Tier 2

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

Tier 1

furosemide oral tablet Tier 1

hydrochlorothiazide oral capsule

Tier 1

Effective 4/1/2018

37


hydrochlorothiazide oral tablet

Tier 1

indapamide oral tablet Tier 1

methazolamide oral tablet Tier 2

methyclothiazide oral tablet

Tier 1

metolazone oral tablet Tier 1

SAMSCA ORAL TABLET Tier 3 SP; LD

spironolactone oral tablet Tier 1

torsemide oral tablet Tier 1

triamterene-hydrochlorothiazid oral capsule

Tier 1

triamterene-hydrochlorothiazid oral tablet

Tier 1

EENT PREPS

acetic acid otic (ear) solution

Tier 1

ALOCRIL OPHTHALMIC (EYE) DROPS

Tier 3 PA; QL

ALOMIDE OPHTHALMIC (EYE) DROPS

Tier 3 PA; QL

apraclonidine ophthalmic (eye) drops

Tier 1

azelastine nasal aerosol,spray

Tier 1 QL

AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

betaxolol ophthalmic (eye) drops

Tier 1

bimatoprost ophthalmic (eye) drops

Tier 2

brimonidine ophthalmic (eye) drops

Tier 1

bromfenac ophthalmic (eye) drops

Tier 2

carteolol ophthalmic (eye) drops

Tier 1

COMBIGAN OPHTHALMIC (EYE) DROPS

Tier 3

cromolyn ophthalmic (eye) drops

Tier 1 QL


dexamethasone sodium phosphate ophthalmic (eye) drops

Tier 1

diclofenac sodium ophthalmic (eye) drops

Tier 1

dorzolamide ophthalmic (eye) drops

Tier 1

dorzolamide-timolol ophthalmic (eye) drops

Tier 1

DUREZOL OPHTHALMIC (EYE) DROPS

Tier 3 QL

DYMISTA NASAL SPRAY,NON-AEROSOL

Tier 3 QL

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

Tier 1 ST; QL

fluocinolone acetonide oil otic (ear) drops

Tier 1

fluorometholone ophthalmic (eye) drops,suspension

Tier 1

flurbiprofen sodium ophthalmic (eye) drops

Tier 1

fluticasone nasal spray,suspension

Tier 1 QL

FML S.O.P. OPHTHALMIC (EYE) OINTMENT

Tier 3

hydrocortisone-acetic acid otic (ear) drops

Tier 1

ketorolac ophthalmic (eye) drops

Tier 1

LACRISERT OPHTHALMIC (EYE) INSERT

Tier 3

latanoprost ophthalmic (eye) drops

Tier 1

levobunolol ophthalmic (eye) drops 0.5 %

Tier 1

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL

Tier 3

LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

LOTEMAX OPHTHALMIC (EYE) OINTMENT

Tier 3

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %

Tier 3

Effective 4/1/2018

38


metipranolol ophthalmic (eye) drops

Tier 1

NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

olopatadine nasal spray,non-aerosol

Tier 1 QL

OMNARIS NASAL SPRAY,NON-AEROSOL

Tier 3 ST; QL

PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS

Tier 3

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %

Tier 1

prednisolone acetate ophthalmic (eye) drops,suspension

Tier 1

prednisolone sodium phosphate ophthalmic (eye) drops

Tier 1

RESTASIS OPHTHALMIC (EYE) DROPPERETTE

Tier 3

SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

timolol maleate ophthalmic (eye) drops

Tier 1

timolol maleate ophthalmic (eye) gel forming solution

Tier 1

TRAVATAN Z OPHTHALMIC (EYE) DROPS

Tier 3

tropicamide ophthalmic (eye) drops

Tier 1

TYZINE NASAL DROPS0.05 %

Tier 3

ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE

Tier 3

ELECT/CALORIC/H2O

calcium acetate oral tablet 667 mg

Tier 2

cytra k crystals oral packet Tier 1

cytra-k oral solution Tier 1

dentagel dental gel Tier 1


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

Tier 3

effer-k oral tablet, effervescent 25 meq

Tier 1

eliphos oral tablet Tier 2 PA

fe c plus tablet (rx) Tier 1

fluoride (sodium) oral drops

Tier 1 $0

fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

Tier 1 $0

fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

Tier 1

fluoridex daily defense dental paste

Tier 1

fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)

Tier 1 $0

fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

Tier 1

FOSRENOL ORAL POWDER IN PACKET

Tier 3 PA

GLUCAGEN HYPOKIT INJECTION RECON SOLN

Tier 2

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT

Tier 2

k-effervescent oral tablet, effervescent

Tier 1

kionex (with sorbitol) oral suspension

Tier 2

kionex oral powder Tier 2

klor-con 10 oral tablet extended release

Tier 1

klor-con 8 oral tablet extended release

Tier 1

klor-con m10 oral tablet,er particles/crystals

Tier 1


Tier 1

Effective 4/1/2018

39



Tier 1

klor-con/ef oral tablet, effervescent

Tier 1

lanthanum oral tablet,chewable

Tier 2 PA

ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

Tier 1 $0

ludent fluoride oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

Tier 1

magnesium sulfate in 0.9 %nacl intravenous solution 40 gram/1,000ml (40 mg/ml)

Tier 2

NUTRAMINE ORAL POWDER

Tier 3

NUTRESTORE ORAL POWDER IN PACKET

Tier 3

potassium bicarb and chloride oral tablet, effervescent

Tier 1

potassium bicarb-citric acid oral tablet, effervescent

Tier 1

potassium chloride oral capsule, extended release

Tier 1

potassium chloride oral tablet extended release

Tier 1

potassium chloride oral tablet,er particles/crystals

Tier 1

potassium citrate oral tablet extended release

Tier 2

potassium citrate-citric acid oral solution

Tier 1

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE

Tier 3

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE

Tier 3

PREVIDENT DENTAL GEL

Tier 3

PURE BLISS ORAL POWDER

Tier 3


sevelamer carbonate oral powder in packet

Tier 1

sevelamer carbonate oral tablet

Tier 1

sf dental gel Tier 1

SHOHL'S MODIFIED ORAL SOLUTION

Tier 3

sodium chloride 0.45 % intravenous parenteral solution

Tier 1

sodium chloride 0.45 % intravenous piggyback

Tier 1

sodium chloride 0.9 % injection solution

Tier 1

sodium chloride 0.9 % intravenous parenteral solution

Tier 1

sodium chloride 0.9 % intravenous piggyback

Tier 1

sodium chloride 3 % intravenous parenteral solution

Tier 1

sodium chloride 5 % intravenous parenteral solution

Tier 1

sodium chloride intravenous parenteral solution 2.5 meq/ml

Tier 1

sodium polystyrene (sorb free) oral suspension

Tier 2

sodium polystyrene sulfonate oral powder

Tier 2

sodium polystyrene sulfonate oral suspension

Tier 2

sodium polystyrene sulfonate rectal enema 30 gram/120 ml

Tier 1

sps (with sorbitol) oral suspension

Tier 2

sps (with sorbitol) rectal enema

Tier 1

SSKI ORAL SOLUTION Tier 3

VELPHORO ORAL TABLET,CHEWABLE

Tier 3 PA

GASTROINTESTINAL

AKYNZEO ORAL CAPSULE

Tier 3 QL

Effective 4/1/2018

40


alosetron oral tablet Tier 2 QL

AMITIZA ORAL CAPSULE

Tier 3

anaspaz oral tablet,disintegrating

Tier 2

anucort-hc rectal suppository

Tier 1

ANZEMET ORAL TABLET

Tier 3 QL

aprepitant oral capsule 125 mg, 40 mg, 80 mg

Tier 2 QL

aprepitant oral capsule,dose pack

Tier 2 QL

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3 QL

balsalazide oral capsule Tier 1 QL

carafate oral suspension Tier 1

CESAMET ORAL CAPSULE

Tier 3

CHOLBAM ORAL CAPSULE

Tier 3 PA; LD; QL

cimetidine hcl oral solution Tier 1

cimetidine oral tablet Tier 1

COMPAZINE ORAL TABLET

Tier 1

constulose oral solution Tier 1

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS

Tier 3 PA; QL

dicyclomine oral capsule Tier 1

dicyclomine oral solution Tier 1

dicyclomine oral tablet Tier 1

DIPENTUM ORAL CAPSULE

Tier 3 QL

diphenoxylate-atropine oral liquid

Tier 1

diphenoxylate-atropine oral tablet

Tier 1

dronabinol oral capsule Tier 2

enulose oral solution Tier 1

famotidine oral suspension Tier 1

famotidine oral tablet 20 mg, 40 mg

Tier 1

gavilyte-c oral recon soln Tier 1 $0


gavilyte-g oral recon soln Tier 1 $0

gavilyte-n oral recon soln Tier 1 $0

generlac oral solution Tier 1

glycopyrrolate oral tablet 1 mg, 2 mg

Tier 1

granisetron hcl oral tablet Tier 2 QL

hydrocortisone acetate rectal suppository

Tier 1

hydrocortisone-pramoxine rectal cream

Tier 1

hyoscyamine sulfate oral tablet

Tier 1

hyoscyamine sulfate oral tablet extended release 12 hr

Tier 1

hyoscyamine sulfate oral tablet,disintegrating

Tier 1

hyoscyamine sulfate sublingual tablet

Tier 1

lactulose oral solution Tier 1

lansoprazole oral capsule,delayed release(dr/ec)

Tier 1 QL

laxaclear powder Tier 1 $0

LINZESS ORAL CAPSULE

Tier 2

meclizine oral tablet 12.5 mg, 25 mg

Tier 1

methscopolamine oral tablet

Tier 1

metoclopramide hcl injection syringe

Tier 1

metoclopramide hcl oral solution

Tier 1

metoclopramide hcl oral tablet

Tier 1

metoclopramide hcl oral tablet,disintegrating

Tier 1

misoprostol oral tablet Tier 1

MOTOFEN ORAL TABLET

Tier 3

MOVIPREP ORAL POWDER IN PACKET

Tier 3

nizatidine oral capsule Tier 1

nizatidine oral solution Tier 1

Effective 4/1/2018

41


omega-3 acid ethyl esters oral capsule

Tier 1 QL

omeprazole oral capsule,delayed release(dr/ec)

Tier 1 QL

ondansetron hcl oral solution

Tier 2 QL

ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg

Tier 2 QL

ondansetron oral tablet,disintegrating 4 mg, 8 mg

Tier 2 QL

OSMOPREP ORAL TABLET

Tier 3

pantoprazole oral tablet,delayed release (dr/ec)

Tier 2 QL

peg 3350-electrolytes oral recon soln

Tier 1 $0

peg-3350 with flavor packs oral recon soln

Tier 1 $0

phenadoz rectal suppository

Tier 2

polyethylene glycol 3350 oral powder in packet

Tier 1 $0

pramcort rectal cream Tier 1

PREPOPIK ORAL POWDER IN PACKET

Tier 3

prochlorperazine maleate oral tablet

Tier 1

promethazine rectal suppository

Tier 2

promethegan rectal suppository

Tier 2

rabeprazole oral tablet,delayed release (dr/ec)

Tier 2 QL

ranitidine hcl oral capsule Tier 1

ranitidine hcl oral syrup Tier 1

ranitidine hcl oral tablet 150 mg, 300 mg

Tier 1

RECTIV RECTAL OINTMENT

Tier 3

SANCUSO TRANSDERMAL PATCH WEEKLY

Tier 3 QL


scopolamine base transdermal patch 3 day

Tier 2

sodium phenylbutyrate oral tablet

Tier 2 PA; QL

sucralfate oral tablet Tier 1

sulfasalazine oral tablet Tier 1 QL

sulfasalazine oral tablet,delayed release (dr/ec)

Tier 1 QL

SUPREP BOWEL PREP KIT ORAL RECON SOLN

Tier 3

trilyte with flavor packets oral recon soln

Tier 1 $0

trimethobenzamide oral capsule

Tier 1

ursodiol oral capsule Tier 2

ursodiol oral tablet Tier 2

VARUBI ORAL TABLET Tier 3 QL

VASCEPA ORAL CAPSULE 0.5 GRAM, 1 GRAM

Tier 3 QL

VIBERZI ORAL TABLET Tier 3 PA; QL

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)10,000-34,000 -55,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000- 16,000 UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000 -27,000 UNIT, 5,000-17,000- 24,000 UNIT

Tier 2

HORMONES

AMABELZ ORAL TABLET

Tier 1

ANADROL-50 ORAL TABLET

Tier 3

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP20.25 MG/1.25 GRAM (1.62 %)

Tier 3 PA; QL

Effective 4/1/2018

42


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

Tier 3 PA; QL

budesonide oral capsule,delayed,extend.release

Tier 2 QL

cabergoline oral tablet Tier 1

calcitonin (salmon) nasal spray,non-aerosol

Tier 2 QL

chorionic gonadotropin, human intramuscular recon soln

Tier 4 PA; SP

cortisone oral tablet Tier 1

covaryx h.s. oral tablet Tier 1

covaryx oral tablet Tier 1

danazol oral capsule Tier 2

DELTASONE ORAL TABLET 20 MG

Tier 1

desmopressin nasal aerosol,spray

Tier 2

desmopressin nasal solution

Tier 2

desmopressin nasal spray,non-aerosol

Tier 2

desmopressin oral tablet Tier 1

dexamethasone intensol oral drops

Tier 1

dexamethasone oral elixir Tier 1

dexamethasone oral solution

Tier 1

dexamethasone oral tablet Tier 1

DUAVEE ORAL TABLET Tier 3 QL

eemt hs oral tablet Tier 1

eemt oral tablet Tier 1

estradiol oral tablet Tier 1

estradiol transdermal patch semiweekly

Tier 1 QL

estradiol transdermal patch weekly

Tier 1

estradiol vaginal cream Tier 2

estradiol vaginal tablet Tier 2 QL

estradiol-norethindrone acet oral tablet

Tier 1


ESTRING VAGINAL RING

Tier 3 QL

estrogens-methyltestosterone oral tablet

Tier 1

estropipate oral tablet Tier 1

fludrocortisone oral tablet Tier 1

GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP

GONAL-F RFF SUBCUTANEOUS RECON SOLN

Tier 4 PA; SP

GONAL-F SUBCUTANEOUS RECON SOLN

Tier 4 PA; SP

hydrocortisone oral tablet Tier 1

hydrocortisone rectal enema

Tier 2

jinteli oral tablet Tier 1

LOPREEZA ORAL TABLET

Tier 1

LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET

Tier 4 PA; SP; QL

LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET

Tier 4 PA; SP; QL

medroxyprogesterone oral tablet

Tier 1 QL

MENEST ORAL TABLET0.3 MG, 0.625 MG, 1.25 MG

Tier 3

METHITEST ORAL TABLET

Tier 3

methylprednisolone oral tablet

Tier 1

methylprednisolone oral tablets,dose pack

Tier 1

millipred dp oral tablets,dose pack

Tier 1

millipred oral tablet Tier 1

mimvey lo oral tablet Tier 1

mimvey oral tablet Tier 1

MYALEPT SUBCUTANEOUS RECON SOLN

Tier 4 SP; LD

Effective 4/1/2018

43


norethindrone acetate oral tablet

Tier 1

NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP

oxandrolone oral tablet Tier 2 PA

prednisolone oral solution 15 mg/5 ml

Tier 1

prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

Tier 1

prednisone intensol oral concentrate

Tier 1

prednisone oral solution Tier 1

prednisone oral tablet Tier 1

prednisone oral tablets,dose pack

Tier 1

PREMARIN ORAL TABLET

Tier 3 QL

PREMARIN VAGINAL CREAM

Tier 3 QL

PREMPHASE ORAL TABLET

Tier 3

PREMPRO ORAL TABLET

Tier 3

progesterone micronized oral capsule 100 mg, 200 mg

Tier 1 QL

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG

Tier 4 PA; SP; QL

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION


SIGNIFOR SUBCUTANEOUS SOLUTION


SOMATULINE DEPOT SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL


SYNAREL NASAL SPRAY,NON-AEROSOL

Tier 4 PA; SP; QL

testosterone cypionate intramuscular oil

Tier 1

testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)

Tier 2 PA; QL

testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)

Tier 2 PA; QL

veripred 20 oral solution Tier 1

YUVAFEM VAGINAL TABLET

Tier 2 QL

IMMUNOSUPPRESSANTS

ACTEMRA INTRAVENOUS SOLUTION

Tier 4 PA; SP; QL

ACTEMRA SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

azathioprine oral tablet Tier 2

cyclosporine modified oral capsule

Tier 4 SP

cyclosporine modified oral solution

Tier 4 SP

cyclosporine oral capsule Tier 4 SP

ELIDEL TOPICAL CREAM

Tier 3 PA

gengraf oral capsule 100 mg, 25 mg

Tier 4 SP

GENGRAF ORAL CAPSULE 50 MG

Tier 4 SP

gengraf oral solution Tier 4 SP

mycophenolate mofetil oral capsule

Tier 4 SP

mycophenolate mofetil oral tablet

Tier 4 SP

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

Tier 4 SP

RAPAMUNE ORAL SOLUTION

Tier 4 SP

STELARA INTRAVENOUS SOLUTION

Tier 4 PA; SP; QL

Effective 4/1/2018

44


STELARA SUBCUTANEOUS SOLUTION

Tier 4 PA; SP; QL

STELARA SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

tacrolimus oral capsule Tier 4 SP

tacrolimus topical ointment Tier 1 PA

MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG

ACCU-CHEK AVIVA CONNECT METER

Tier 2

ACCU-CHEK AVIVA CONTROL SOLN SOLUTION

Tier 2

ACCU-CHEK AVIVA PLUS METER

Tier 2

ACCU-CHEK COMP BLUE CONT, M-H SOLUTION

Tier 2

ACCU-CHEK COMPACT PLUS CARE KIT

Tier 2

ACCU-CHEK COMPACT PLUS CONTROL SOLUTION

Tier 2

ACCU-CHEK FASTCLIX Tier 2

ACCU-CHEK FASTCLIX KIT

Tier 2

ACCU-CHEK GUIDE GLUCOSE METER

Tier 2

ACCU-CHEK GUIDE L1-L2 CTRL SOL SOLUTION

Tier 2

ACCU-CHEK MULTICLIX LANCET

Tier 2

ACCU-CHEK MULTICLIX LANCET KIT

Tier 2

ACCU-CHEK NANO Tier 2

ACCU-CHEK SAFE-T-PRO PLUS

Tier 2

ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION

Tier 2

ACCU-CHEK SOFT DEV LANCETS KIT

Tier 2

ACCU-CHEK SOFTCLIX LANCET DEV

Tier 2


ACCU-CHEK SOFTCLIX LANCETS

Tier 2

ACCU-CHEK VOICEMATE KIT

Tier 2

ACCUTREND GLUCOSE CONTROL SOLUTION

Tier 2

acti-lance lancets 17 gauge, 28 gauge

Tier 1

CHEMSTRIP BG LOG BOOK

Tier 2

e-z ject lancets Tier 1

E-Z JECT THIN LANCETS

Tier 1

insulin syringe-needle u-100 syringe 1 ml 30 gauge x 3/8"

Tier 1

ONETOUCH DELICA LANC DEVICE KIT

Tier 2

ONETOUCH DELICA LANCETS

Tier 2

ONETOUCH SURESOFT LANCING DEV

Tier 2

ONETOUCH ULTRA CONTROL SOLUTION

Tier 2

ONETOUCH ULTRA2 KIT Tier 2

ONETOUCH ULTRAMINI KIT

Tier 2

ONETOUCH ULTRASOFT LANCETS

Tier 2

ONETOUCH VERIO FLEX

Tier 2

ONETOUCH VERIO HIGH CONTROL SOLUTION

Tier 2

ONETOUCH VERIO IQ METER

Tier 2

ONETOUCH VERIO MID CONTROL SOLUTION

Tier 2

ONETOUCH VERIO SYSTEM

Tier 2

thinpro insulin syringe syringe 0.3 ml 29 gauge x 1/2", 0.5 ml 29 gauge x 1/2", 1 ml 29 gauge x 1/2"

Tier 1

MUSCLE RELAXANTS

baclofen oral tablet Tier 2

carisoprodol oral tablet Tier 1

Effective 4/1/2018

45


chlorzoxazone oral tablet Tier 1

cyclobenzaprine oral tablet Tier 1

dantrolene oral capsule Tier 2

metaxalone oral tablet Tier 1

methocarbamol oral tablet Tier 1

orphenadrine citrate oral tablet extended release

Tier 1

tizanidine oral capsule Tier 1

tizanidine oral tablet Tier 1

PRE-NATAL VITAMINS

c-nate dha oral capsule Tier 1

completenate oral tablet,chewable

Tier 1

elite ob with dha oral capsule

Tier 1

elite-ob 400 oral capsule Tier 1

ELITE-OB ORAL TABLET

Tier 1

folivane-ob oral capsule Tier 1

hemenatal ob oral tablet Tier 1

mynatal advance oral tablet

Tier 1

mynatal oral capsule Tier 1

mynatal oral tablet Tier 1

mynatal plus oral tablet Tier 1

mynatal-z oral tablet Tier 1

mynate 90 plus oral tablet extended release

Tier 1

pnv-dha + docusate oral capsule

Tier 1

pnv-dha oral capsule Tier 1

pnv-ferrous fumarate-docu-fa oral tablet

Tier 1

pnv-omega oral capsule Tier 1

pnv-select oral tablet Tier 1

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

Tier 1

pr natal 400 oral combo pack

Tier 1

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

Tier 1

pr natal 430 oral combo pack

Tier 1

prenaissance oral capsule Tier 1


prenaissance plus oral capsule

Tier 1

prenatabs fa oral tablet Tier 1

prenatabs rx oral tablet Tier 1

prenatal 19 (with docusate) oral tablet

Tier 1

prenatal low iron oral tablet

Tier 1

prenatal multivitamin tablet Tier 1 $0

PRENATAL ONE DAILY ORAL TABLET

Tier 1 $0

prenatal plus (calcium carb) oral tablet

Tier 1

prenatal plus oral tablet Tier 1

PRENATAL VITAMIN PLUS LOW IRON

Tier 1

prenatal-u oral capsule Tier 1

preplus oral tablet Tier 1

relnate dha oral capsule Tier 1

se-natal 19 (with docusate) oral tablet

Tier 1

se-natal 19 oral tablet,chewable

Tier 1

taron-c dha oral capsule Tier 1

taron-prex prenatal-dha oral capsule

Tier 1

tl-select oral capsule Tier 1

triadvance oral tablet Tier 1

trinatal gt oral tablet Tier 1

trinatal rx 1 oral tablet Tier 1

trinate oral tablet Tier 1

triveen-one oral capsule Tier 1

triveen-prx rnf oral capsule Tier 1

ultimatecare one nf oral capsule

Tier 1

ultimatecare one oral capsule

Tier 1

vemavite-prx-2 oral capsule

Tier 1

vinacal oral tablet Tier 1

vinate care oral tablet,chewable

Tier 1

vinate gt oral tablet Tier 1

vinate ii oral tablet Tier 1

Effective 4/1/2018

46


vinate m oral tablet Tier 1

vinate one oral tablet Tier 1

vinate pn care oral tablet Tier 1

vinate ultra oral tablet Tier 1

VIRT-NATE DHA ORAL CAPSULE

Tier 1

virt-pn dha oral capsule Tier 1

virt-pn oral tablet Tier 1

virt-pn plus oral capsule Tier 1

virt-select oral capsule Tier 1

vitafol-ob oral tablet Tier 1

vol-nate oral tablet Tier 1

vol-plus oral tablet Tier 1

vol-tab rx oral tablet Tier 1

vp-ch plus oral capsule Tier 1

vp-ch-pnv oral capsule Tier 1

vp-ggr-b6 oral tablet Tier 1

vp-heme ob oral tablet Tier 1

vp-heme one oral capsule Tier 1

zatean-ch oral capsule Tier 1

zatean-pn dha oral capsule

Tier 1

zatean-pn plus oral capsule

Tier 1

zingiber oral tablet Tier 1

PSYCHOTHERAPEUTIC DRUGS

ADDYI ORAL TABLET Tier 3 PA; QL

alprazolam oral tablet Tier 1

amitriptyline oral tablet Tier 1

amoxapine oral tablet Tier 1

aripiprazole oral solution Tier 2

aripiprazole oral tablet Tier 2

armodafinil oral tablet 150 mg, 250 mg, 50 mg

Tier 2 PA; QL

armodafinil oral tablet 200 mg

Tier 2 PA

atomoxetine oral capsule Tier 2 PA

bupropion hcl oral tablet 100 mg

Tier 1 QL

bupropion hcl oral tablet 75 mg

Tier 1 DO


bupropion hcl oral tablet extended release 12 hr 100 mg

Tier 1 DO


Tier 1 $0


Tier 1


Tier 1 DO


Tier 1 QL

buspirone oral tablet Tier 1

chlorpromazine oral tablet Tier 2

citalopram oral solution Tier 1 QL

citalopram oral tablet 10 mg, 20 mg

Tier 1 DO

citalopram oral tablet 40 mg

Tier 1 QL

clomipramine oral capsule Tier 2

clonidine hcl oral tablet extended release 12 hr

Tier 1 PA

clozapine oral tablet Tier 2

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

Tier 2

desipramine oral tablet Tier 2

desvenlafaxine succinate oral tablet extended release 24 hr 100 mg

Tier 1 QL

desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg

Tier 1 DO

dexmethylphenidate oral capsule,er biphasic 50-50

Tier 1 PA

dexmethylphenidate oral tablet

Tier 1 PA

diazepam intensol oral concentrate

Tier 1

diazepam oral concentrate Tier 1

diazepam oral solution Tier 1

diazepam oral tablet Tier 1

doxepin oral capsule Tier 1

Effective 4/1/2018

47


doxepin oral concentrate Tier 1

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

Tier 2 PA; QL

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

Tier 2 PA; DO

EMSAM TRANSDERMAL PATCH 24 HOUR

Tier 3

escitalopram oxalate oral solution

Tier 1 QL

escitalopram oxalate oral tablet 10 mg, 5 mg

Tier 1 DO

escitalopram oxalate oral tablet 20 mg

Tier 1 QL

FANAPT ORAL TABLET Tier 3

FANAPT ORAL TABLETS,DOSE PACK

Tier 3

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK

Tier 3 ST; QL

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR

Tier 3 ST; QL

fluoxetine oral capsule 10 mg, 20 mg

Tier 1 DO

fluoxetine oral capsule 40 mg

Tier 1 QL

fluoxetine oral capsule,delayed release(dr/ec)

Tier 1 QL

fluoxetine oral solution Tier 1 QL

fluoxetine oral tablet 10 mg

Tier 1 DO

fluoxetine oral tablet 20 mg

Tier 1

fluphenazine hcl oral concentrate

Tier 1

fluphenazine hcl oral elixir Tier 1

fluphenazine hcl oral tablet Tier 1

fluvoxamine oral tablet 100 mg

Tier 1 QL

fluvoxamine oral tablet 25 mg, 50 mg

Tier 1 DO

guanfacine oral tablet extended release 24 hr

Tier 1 PA


haloperidol oral tablet Tier 1

imipramine hcl oral tablet Tier 1

LATUDA ORAL TABLET Tier 3

lithium carbonate oral capsule

Tier 1

lithium carbonate oral tablet

Tier 1

lithium carbonate oral tablet extended release

Tier 1

lithium citrate oral solution Tier 1

loxapine succinate oral capsule

Tier 1

maprotiline oral tablet Tier 1

MARPLAN ORAL TABLET

Tier 3

meprobamate oral tablet Tier 1

metadate er oral tablet extended release

Tier 1 PA

methylphenidate hcl oral capsule, er biphasic 30-70

Tier 1 PA

methylphenidate hcl oral capsule,er biphasic 50-50

Tier 1 PA

methylphenidate hcl oral solution

Tier 1 PA

methylphenidate hcl oral tablet

Tier 1 PA

methylphenidate hcl oral tablet extended release

Tier 1 PA

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

Tier 1 PA

mirtazapine oral tablet Tier 1

mirtazapine oral tablet,disintegrating

Tier 1

modafinil oral tablet 100 mg

Tier 2 PA; DO

modafinil oral tablet 200 mg

Tier 2 PA; QL

nefazodone oral tablet Tier 1

nortriptyline oral capsule Tier 1

nortriptyline oral solution Tier 1

olanzapine oral tablet Tier 2

olanzapine oral tablet,disintegrating

Tier 2

Effective 4/1/2018

48


paliperidone oral tablet extended release 24hr

Tier 2

paroxetine hcl oral tablet 10 mg, 20 mg

Tier 1 DO

paroxetine hcl oral tablet 30 mg, 40 mg

Tier 1 QL

paroxetine hcl oral tablet extended release 24 hr 12.5 mg

Tier 1 DO

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

Tier 1 QL

perphenazine oral tablet Tier 1

phenelzine oral tablet Tier 1

pimozide oral tablet Tier 2

protriptyline oral tablet Tier 2

quetiapine oral tablet Tier 2

quetiapine oral tablet extended release 24 hr

Tier 2

risperidone oral solution Tier 1

risperidone oral tablet Tier 1

risperidone oral tablet,disintegrating

Tier 2

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET

Tier 3

sertraline oral concentrate Tier 1 QL

sertraline oral tablet 100 mg

Tier 1 QL

sertraline oral tablet 25 mg, 50 mg

Tier 1 DO

thioridazine oral tablet Tier 1

thiothixene oral capsule Tier 1

tranylcypromine oral tablet Tier 1

trazodone oral tablet Tier 1

trifluoperazine oral tablet Tier 1

trimipramine oral capsule Tier 1

TRINTELLIX ORAL TABLET 10 MG, 5 MG

Tier 3 ST; DO

TRINTELLIX ORAL TABLET 20 MG

Tier 3 ST; QL

venlafaxine oral capsule,extended release 24hr 150 mg

Tier 1 QL


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

Tier 1 DO

venlafaxine oral tablet Tier 1 QL

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

Tier 1 QL

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

Tier 1 DO

VIIBRYD ORAL TABLET10 MG, 20 MG

Tier 3 ST; DO

VIIBRYD ORAL TABLET40 MG

Tier 3 ST; QL

VIIBRYD ORAL TABLETS,DOSE PACK10 MG (7)- 20 MG (23)

Tier 3 ST; QL

VYVANSE ORAL CAPSULE

Tier 3 PA

ziprasidone hcl oral capsule

Tier 2

SEDATIVE/HYPNOTICS

estazolam oral tablet Tier 1

eszopiclone oral tablet 1 mg, 2 mg

Tier 1 QL

eszopiclone oral tablet 3 mg

Tier 1 PA; QL

HETLIOZ ORAL CAPSULE


hm nighttime sleep aid 50 mg softgel,max strength

Tier 1

phenobarbital oral elixir Tier 1

phenobarbital oral tablet Tier 1

ROZEREM ORAL TABLET

Tier 3 ST; QL

SILENOR ORAL TABLET Tier 3 QL

XYREM ORAL SOLUTION


zaleplon oral capsule Tier 1 QL

zolpidem oral tablet Tier 1 QL

SKIN PREPS

acitretin oral capsule Tier 2

adapalene topical cream Tier 1

adapalene topical gel Tier 1

Effective 4/1/2018

49


adapalene topical gel with pump

Tier 1

adapalene-benzoyl peroxide topical gel with pump

Tier 2

alclometasone topical cream

Tier 1

alclometasone topical ointment

Tier 1

ALTABAX TOPICAL OINTMENT

Tier 3

amcinonide topical cream Tier 1

amcinonide topical lotion Tier 1

amcinonide topical ointment

Tier 1

ammonium lactate topical cream

Tier 1

ammonium lactate topical lotion

Tier 1

AMNESTEEM ORAL CAPSULE

Tier 2 PA

avita topical cream Tier 1 PA

AZELEX TOPICAL CREAM

Tier 3 PA

benzoyl peroxide 9.8% foam emollient foam (otc)

Tier 1

benzoyl peroxide topical cleanser 3 %, 6 %, 9 %

Tier 1

benzoyl peroxide topical foam 5.3 %

Tier 1

betamethasone dipropionate topical cream

Tier 1

betamethasone dipropionate topical lotion

Tier 1

betamethasone dipropionate topical ointment

Tier 1

betamethasone valerate topical cream

Tier 1

betamethasone valerate topical foam

Tier 1

betamethasone valerate topical lotion

Tier 1

betamethasone valerate topical ointment

Tier 1

betamethasone, augmented topical cream

Tier 1


betamethasone, augmented topical gel

Tier 1

betamethasone, augmented topical lotion

Tier 1

betamethasone, augmented topical ointment

Tier 1

bpo topical gel Tier 1

bpo topical towelette 6 % Tier 1

calcipotriene scalp solution

Tier 1

calcipotriene topical cream Tier 1

calcipotriene topical ointment

Tier 1

calcipotriene-betamethasone topical ointment

Tier 1

calcitrene topical ointment Tier 1

calcitriol topical ointment Tier 1

claravis oral capsule Tier 2 PA

clindamycin-benzoyl peroxide topical gel

Tier 1

clindamycin-benzoyl peroxide topical gel with pump

Tier 1

clindamycin-tretinoin topical gel

Tier 2

clobetasol scalp solution Tier 1

clobetasol topical cream Tier 1

clobetasol topical foam Tier 1

clobetasol topical gel Tier 1

clobetasol topical lotion Tier 1

clobetasol topical ointment Tier 1

clobetasol topical shampoo

Tier 1

clobetasol-emollient topical cream

Tier 1

clobetasol-emollient topical foam

Tier 1

CLODERM TOPICAL CREAM

Tier 3

CORDRAN TAPE LARGE ROLL TOPICAL TAPE

Tier 3

cormax scalp solution Tier 1

Effective 4/1/2018

50


COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP; QL

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP; QL

COSENTYX SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

dapsone topical gel Tier 2

desonide topical cream Tier 1

desonide topical lotion Tier 1

desonide topical ointment Tier 1

desoximetasone topical cream

Tier 1

desoximetasone topical gel

Tier 1

desoximetasone topical ointment

Tier 1

diclofenac sodium topical gel 1 %

Tier 2 QL

diflorasone topical cream Tier 1

diflorasone topical ointment

Tier 1

EURAX TOPICAL CREAM

Tier 3

EURAX TOPICAL LOTION

Tier 3

FINACEA TOPICAL GEL Tier 3

FLECTOR TRANSDERMAL PATCH 12 HOUR

Tier 3 QL

fluocinolone and shower cap scalp oil

Tier 1

fluocinolone topical cream Tier 1

fluocinolone topical oil Tier 1

fluocinolone topical ointment

Tier 1

fluocinolone topical solution

Tier 1

fluocinonide topical cream Tier 1

fluocinonide topical gel Tier 1


fluocinonide topical ointment

Tier 1

fluocinonide topical solution

Tier 1

fluocinonide-e topical cream

Tier 1

fluocinonide-emollient topical cream

Tier 1

flurandrenolide topical cream

Tier 2

flurandrenolide topical lotion

Tier 2

fluticasone topical cream Tier 1

fluticasone topical lotion Tier 1

fluticasone topical ointment

Tier 1

halobetasol propionate topical cream

Tier 1

halobetasol propionate topical ointment

Tier 1

HALOG TOPICAL CREAM

Tier 3

HALOG TOPICAL OINTMENT

Tier 3

hydrocortisone butyrate topical cream

Tier 1

hydrocortisone butyrate topical lotion

Tier 1

hydrocortisone butyrate topical ointment

Tier 1

hydrocortisone butyrate topical solution

Tier 1

hydrocortisone butyr-emollient topical cream

Tier 1

hydrocortisone topical cream 2.5 %

Tier 1

hydrocortisone topical cream with perineal applicator

Tier 1

hydrocortisone topical lotion 2.5 %

Tier 1

hydrocortisone topical ointment 2.5 %

Tier 1

hydrocortisone valerate topical cream

Tier 1

hydrocortisone valerate topical ointment

Tier 1

Effective 4/1/2018

51


hydrocortisone-pramoxine topical cream

Tier 1

imiquimod topical cream in packet

Tier 1 PA; QL

iodoquinol-hc topical cream

Tier 1

lindane topical shampoo Tier 1

malathion topical lotion Tier 1

methoxsalen oral capsule,liqd-filled,rapid rel

Tier 2 PA; SP

metronidazole topical cream

Tier 1

metronidazole topical gel Tier 1

metronidazole topical gel with pump

Tier 1

metronidazole topical lotion

Tier 1

MIRVASO TOPICAL GEL Tier 3

MIRVASO TOPICAL GEL WITH PUMP

Tier 3

mometasone topical cream

Tier 1

mometasone topical ointment

Tier 1

mometasone topical solution

Tier 1

OVACE TOPICAL CLEANSER

Tier 3

permethrin topical cream Tier 1

PHYSIOLYTE IRRIGATION SOLUTION

Tier 3

podofilox topical solution Tier 1

prednicarbate topical cream

Tier 1

prednicarbate topical ointment

Tier 1

PROCTOSOL-HC 2.5% CREAM

Tier 1

proctozone-hc topical cream with perineal applicator

Tier 1

prudoxin topical cream Tier 2

REGRANEX TOPICAL GEL

Tier 3

rosadan topical cream Tier 1


ROSADAN TOPICAL GEL

Tier 1

salicylic acid topical cream Tier 1

salicylic acid topical cream,extended release

Tier 1

salicylic acid topical foam Tier 1

salicylic acid topical gel Tier 1

salicylic acid topical lotion Tier 1

salicylic acid topical lotion,extended release

Tier 1

salicylic acid topical shampoo

Tier 1

salvax topical foam Tier 1

SANTYL TOPICAL OINTMENT

Tier 3

seb-prev topical cleanser Tier 1

selenium sulfide topical lotion

Tier 1

selenium sulfide topical shampoo 2.25 %

Tier 1

SKLICE TOPICAL LOTION

Tier 3

sodium chloride irrigation solution

Tier 1

spinosad topical suspension

Tier 1

sulfacetamide sodium (acne) topical suspension

Tier 1

sulfacetamide sodium topical cleanser

Tier 1

sulfacetamide sodium topical cleanser, gel

Tier 1

sulfacetamide sodium topical shampoo

Tier 1

tazarotene topical cream Tier 2

TAZORAC TOPICAL CREAM 0.05 %

Tier 3

TAZORAC TOPICAL GEL Tier 3

tretinoin (emollient) topical cream

Tier 1

tretinoin topical cream Tier 1 PA

tretinoin topical gel 0.01 %, 0.025 %

Tier 1 PA

triamcinolone acetonide topical cream

Tier 1

Effective 4/1/2018

52


triamcinolone acetonide topical lotion

Tier 1

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

Tier 1

trianex topical ointment Tier 1

triderm topical cream 0.1 %

Tier 1

TRIDERM TOPICAL CREAM 0.5 %

Tier 1

ULESFIA TOPICAL LOTION

Tier 3

zenatane oral capsule Tier 2 PA

SMOKING DETERRENTS

bupropion hcl (smoking deter) oral tablet extended release 12 hr

Tier 1 $0; QL

CHANTIX CONTINUING MONTH BOX ORAL TABLET

Tier 3 $0; QL

CHANTIX ORAL TABLET Tier 3 $0; QL

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

Tier 3 $0; QL

NICOTROL INHALATION CARTRIDGE

Tier 3 $0

NICOTROL NS NASAL SPRAY,NON-AEROSOL

Tier 3 $0

ZYBAN ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3 $0; QL

THYROID PREPS

ARMOUR THYROID ORAL TABLET

Tier 1

levothyroxine oral tablet Tier 1

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

Tier 1

liothyronine oral tablet Tier 1

methimazole oral tablet 10 mg, 5 mg

Tier 1

nature-throid oral tablet Tier 1

NP THYROID ORAL TABLET 120 MG, 15 MG

Tier 1


np thyroid oral tablet 30 mg, 60 mg, 90 mg

Tier 1

propylthiouracil oral tablet Tier 1

SYNTHROID ORAL TABLET

Tier 1

THYROLAR-1 ORAL TABLET

Tier 3

THYROLAR-1/2 ORAL TABLET

Tier 3

THYROLAR-1/4 ORAL TABLET

Tier 3


Tier 3


Tier 3

unithroid oral tablet Tier 1

westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg

Tier 1

WP THYROID ORAL TABLET

Tier 1

UNCLASSIFIED DRUG PRODUCTS

acamprosate oral tablet,delayed release (dr/ec)

Tier 2 QL

alendronate oral solution Tier 1

alendronate oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg

Tier 1 QL

alfuzosin oral tablet extended release 24 hr

Tier 1

ARCALYST SUBCUTANEOUS RECON SOLN


BERINERT INTRAVENOUS KIT

Tier 4 PA; LD

BERINERT INTRAVENOUS RECON SOLN

Tier 4 PA; LD

buprenorphine hcl sublingual tablet 2 mg, 8 mg

Tier 2 QL

buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg

Tier 1 QL

Effective 4/1/2018

53


CARBAGLU ORAL TABLET, DISPERSIBLE

Tier 4 LD

CARNITOR (SUGAR-FREE) ORAL SOLUTION

Tier 3

CARNITOR INTRAVENOUS SOLUTION

Tier 3

CARNITOR ORAL SOLUTION

Tier 3

CARNITOR ORAL TABLET

Tier 3

CERDELGA ORAL CAPSULE

Tier 4 PA; SP

CHEMET ORAL CAPSULE

Tier 3

chlorhexidine gluconate mucous membrane mouthwash

Tier 1

CIALIS ORAL TABLET2.5 MG, 5 MG

Tier 3 PA; QL

CYSTADANE ORAL POWDER

Tier 3 LD

darifenacin oral tablet extended release 24 hr

Tier 2 ST

DEBACTEROL MUCOUS MEMBRANE SOLUTION

Tier 3

DEBACTEROL MUCOUS MEMBRANE SWAB

Tier 3

disulfiram oral tablet Tier 1

doxercalciferol oral capsule

Tier 2

doxycycline hyclate oral tablet 20 mg

Tier 1

dutasteride oral capsule Tier 2 PA

etidronate disodium oral tablet

Tier 2

FERRIPROX ORAL TABLET

Tier 4 PA; LD

finasteride oral tablet 1 mg Tier 1

finasteride oral tablet 5 mg Tier 1 PA

flavoxate oral tablet Tier 1

FORTEO SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP; QL

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

Tier 3 ST; QL


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

Tier 3 ST

ibandronate oral tablet Tier 1 QL

KALYDECO ORAL GRANULES IN PACKET


KALYDECO ORAL TABLET


KEVEYIS ORAL TABLET Tier 4 PA; LD; QL

KUVAN ORAL TABLET,SOLUBLE

Tier 4 PA; SP; LD

leucovorin calcium oral tablet

Tier 2

levocarnitine (with sugar) oral solution

Tier 1

levocarnitine oral tablet Tier 2

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

oralone dental paste Tier 1

OSPHENA ORAL TABLET

Tier 3 QL

oxybutynin chloride oral syrup

Tier 1

oxybutynin chloride oral tablet

Tier 1

oxybutynin chloride oral tablet extended release 24hr

Tier 1

paricalcitol oral capsule Tier 2

paroex oral rinse mucous membrane mouthwash

Tier 1

periogard mucous membrane mouthwash

Tier 1

raloxifene oral tablet Tier 1 $0

RAPAFLO ORAL CAPSULE

Tier 3

risedronate oral tablet 150 mg, 30 mg, 35 mg, 5 mg

Tier 1 QL

SAVELLA ORAL TABLET

Tier 3 QL

SAVELLA ORAL TABLETS,DOSE PACK

Tier 3 QL

SENSIPAR ORAL TABLET 30 MG, 60 MG

Tier 4 QL

Effective 4/1/2018

54


SENSIPAR ORAL TABLET 90 MG

Tier 4

SHINGRIX ADJUVANT COMPONENT-PF INTRAMUSCULAR SUSPENSION

Tier 2 $0

sildenafil oral tablet Tier 1 PA; QL

SYPRINE ORAL CAPSULE

Tier 3 SP

tamsulosin oral capsule,extended release 24hr

Tier 1

tolterodine oral tablet Tier 1

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

triamcinolone acetonide dental paste

Tier 1

trientine oral capsule Tier 2

trospium oral capsule,extended release 24hr

Tier 2

VESICARE ORAL TABLET

Tier 3

ZAVESCA ORAL CAPSULE

Tier 4 PA; SP; LD

VITAMINS

ascorbic acid (vitamin c) injection solution

Tier 1

calcitriol oral capsule Tier 1

calcitriol oral solution Tier 2

cyanocobalamin (vitamin b-12) injection solution

Tier 1

ergocalciferol (vitamin d2) oral capsule

Tier 1

folic acid oral tablet 1 mg Tier 1

MEPHYTON ORAL TABLET

Tier 3

PHYTONADIONE (VITAMIN K1) INJECTION SYRINGE

Tier 3

thiamine hcl (vitamin b1) injection solution

Tier 1

tl gard rx oral tablet Tier 1

vitamin d2 oral capsule Tier 1

vitamin k injection solution Tier 1


vitamin k1 injection solution

Tier 1

Effective 4/1/2018

55

Effective 4/1/2018

56

Most plans include our home delivery program at no extra cost to you. Find out more by going online to anthem.com or call 866-216-4540.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.

Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans. Rev. 3/18

For information about your pharmacy benefit, log in at anthem.com. You’ll find the most up-to-date drug list and details about your benefits. If you still have questions, we’re here. Just call the Member Services number on your ID card.

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

Documents

Select Drug List - fm. · PDF fileThis list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration ... ANTIHISTAMINE AND