district of columbia, maryland, and virginia marketplace...

District of Columbia, Maryland, and Virginia

Marketplace Formulary Last Update: 9/1/2020

The formulary is a list of drugs covered by your plan. The preferred drugs in the formulary are chosen by a group of Kaiser Permanente physicians and pharmacists known as the Pharmacy and Therapeutics Committee. The Committee meets regularly to evaluate and select drugs that are safe and effective for our members.

This formulary applies only to outpatient drugs and self-administered drugs. It does not apply to medical service drugs or medications used in inpatient settings or administered in one of the Kaiser Permanente medical centers.

You may have specific exclusions, copays, or coinsurance amounts that are not reflected in the formulary drug list. Please consult your Evidence of Coverage or Membership Agreement for additional information regarding your pharmacy benefits, including any specific limitations or exclusions.

Generic, Brand Name and Specialty Drugs

Kaiser Permanente covers generic, brand name and specialty drugs at the applicable tier copay or cost share.

A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug.

Brand name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug. When the patent on a brand name drug expires, other pharmaceutical companies may then manufacture and sell the FDA- approved generic version of the drug at lower prices.

Specialty drugs are high cost, prescription medications used to treat serious or chronic medical conditions and require special handling, administration or monitoring.

In most cases, your doctor will prescribe a generic drug if one is available. Generic drugs generally cost less than brand name or specialty drugs.

Using the Kaiser Permanente Formulary List

When you look through the formulary drug listing beginning on page 4, you will see that products available in a generic form are listed by their generic names. Medications that are only available as a brand name product are listed in BOLD AND ALL CAPITAL letters, except where multiple branded products exist.

You can search the formulary drug list by using the “FIND” function in Adobe Reader, or by 1

referencing the therapeutic drug category.

The first column of the chart lists the drug name. Please note that some drugs have multiple dosage forms. Examples of dosage forms are tablets, capsules, creams, injections, etc. Please note that not all dosage forms and strengths for a particular drug listed may be on the same drug tier. The second column, “Drug Tier” will indicate what tier number the drug is in. Drugs on the Formulary are categorized in one of four tiers.

Tier 1: Generic Tier Tier 2: Preferred Brand Tier Tier 3: Non-Preferred Brand Tier Tier 4: Specialty Tier

Please remember that this list is subject to change and will be updated from time to time during the year. Any product not found on the list will be considered non-formulary.

Restrictions on medication coverage (Dispensing Limitations) Some covered drugs may have additional requirements or limits on coverage. Please consult your Evidence of Coverage or Membership Agreement for additional information regarding your pharmacy benefits, including any specific limitations or exclusions.

• Limited distribution: Some drugs may be subject to limited distribution or restricted access. A drug that is a limited distribution drug may only be available at one or a limited number of pharmacies.

• Medical Service Drugs: Drugs that may be covered under your medical benefit (physician visit or hospital visit). Medical service drugs require administration by a clinician or in a facility. They are not dispensed through the outpatient pharmacy

• Oral chemotherapy drugs: Drugs that fall under the District of Columbia and State of Maryland Oral Chemotherapy Parity Act.

• Prior Authorization: A review and approval procedure that applies to some outpatient prescription drugs and is used to encourage safe and cost-effective medication use. Prior authorization is generally applied to outpatient prescription drugs that have multiple medical uses, are higher in cost or have a significant safety concern. The purpose of prior authorization is to ensure that you receive the right medication for your medical condition. This means that when your physician or authorized provider prescribes a drug that has been identified as subject to prior authorization, the drug must be reviewed by the utilization management program to determine medical necessity before the prescription is filled. If a drug requires prior authorization, your prescribing physician or authorized provider must work with us to authorize the drug for your use. Drugs requiring prior authorization have specific clinical criteria, including but not limited to diagnosis of specified condition, laboratory requirements or prescriber specialty, that you must meet in order for the prescription to be eligible for coverage. Refer to the formulary for a complete list of medications requiring prior authorization. Once a prior authorization has been approved for a drug used to treat a chronic condition, no reauthorization for a repeat prescription will be needed for 1 year or for the duration of the standard course of treatment for the chronic condition being treated, whichever is less.

• Quantity limit: For certain drugs, Kaiser Permanente Pharmacy and Therapeutics Committee limits the amount of medication dispensed to a certain quantity per copay.

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• Step Therapy Process: A process that defines how and when a particular outpatient prescription drug can be covered by requiring the use of one or more prerequisite drugs (first line agents), as identified through your drug history, prior to the use of another drug (second line agent). The step therapy process encourages safe and cost-effective medication use. Under this process, a “step” approach is required to receive coverage for certain high cost medications. This means that to receive coverage, you may first be required to try a proven, cost effective medication before using a more costly medication. Your prescribing physician or authorized provider should prescribe a first-line medication appropriate for your condition. If your prescribing physician or authorized provider determines that a first-line drug is not appropriate or effective for you, a second-line medication may be covered after meeting certain conditions. Refer to the formulary for a complete list of medications requiring step therapy

• Zero Cost Share Preventive Drugs: Drugs that may be covered at $0 when written on a prescription.

• Key: (Refer to “Restrictions on medication coverage” section, above, for definitions of these terms)

LD = Limited Distribution Drugs

OC = Oral Chemotherapy Drugs

QL = A drug with a quantity limit

PA = Prior Authorization

PRV = Zero Cost Share Preventive Drugs

ST = Step Therapy

MSD = Medical Service Drugs

For more information about the Marketplace Formulary Drug List, you may contact Member Services at 301-468-6000 or 800-777-7902 (TTY 711). Representatives are available Monday through Friday, 7:30 a.m. until 9 p.m

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Name of drug Drug Tier Restrictions ANTI-INFECTIVE AGENTS ANTHELMINTICS albendazole 1, 3 EGATEN 3 EMVERM 3 ivermectin 1, 3 praziquantel 1, 3 ANTIBACTERIALS AEMCOLO 3 amikacin sulfate MSD amoxicillin 1, 3 amoxicillin & pot clavulanate 1, 3 ampicillin 1 ampicillin & sulbactam sodium MSD ampicillin sodium MSD ARIKAYCE 4 LD AVELOX MSD AVYCAZ MSD AZACTAM IN DEXTROSE MSD azithromycin 1, 2, 3, MSD aztreonam MSD bacitracin MSD BAXDELA 3, MSD BICILLIN C-R MSD BICILLIN L-A MSD CAYSTON 3 PA, LD cefaclor 1 CEFACLOR ER 1 cefadroxil 1 cefazolin sodium MSD CEFAZOLIN SODIUM-DEXTROSE MSD cefdinir 1 CEFDITOREN PIVOXIL 3 cefepime hcl MSD CEFEPIME-DEXTROSE MSD cefixime 1, 3 cefotaxime sodium MSD cefotetan disodium MSD CEFOTETAN DISODIUM-DEXTROSE MSD cefoxitin sodium MSD CEFOXITIN SODIUM-DEXTROSE MSD cefpodoxime proxetil 1 cefprozil 1 ceftazidime MSD CEFTAZIDIME AND DEXTROSE MSD ceftriaxone sodium MSD cefuroxime axetil 1, 2, 3 cefuroxime sodium MSD cephalexin 1, 3 CHLORAMPHENICOL SOD SUCCINATE MSD ciprofloxacin 1, 3, MSD ciprofloxacin hcl 1, 3 ciprofloxacin in d5w MSD CIPROFLOXACIN-CIPROFLOX HCL ER 1 clarithromycin 1

LEGEND LD = Limited Distribution MSD = Medical Service Drugs OC =Oral Chemotherapy Drugs

PA = Prior Authorization PRV = Zero Cost Share Preventive Drugs

QL = Quantity Limits ST = Step Therapy

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Name of drug Drug Tier Restrictions clindamycin hcl 1, 3 clindamycin palmitate hydrochloride 1, 3 clindamycin phosphate MSD clindamycin phosphate in d5w MSD colistimethate sodium MSD DALVANCE MSD daptomycin MSD demeclocycline hcl 1 dicloxacillin sodium 1 DIFICID 4 DORIBAX MSD doxycycline (monohydrate) 1, 3 doxycycline hyclate 1, 3, MSD ertapenem sodium MSD ERYTHROCIN LACTOBIONATE MSD ERYTHROCIN STEARATE 1 erythromycin base 1 erythromycin ethylsuccinate 1, 3 erythromycin-sulfisoxazole 1 FACTIVE 3 FETROJA MSD FORTAZ IN D5W MSD gentamicin in saline MSD gentamicin sulfate MSD imipenem-cilastatin MSD levofloxacin 1, 3, MSD levofloxacin in d5w MSD LINCOCIN MSD linezolid 1, 4, MSD LINEZOLID IN SODIUM CHLORIDE MSD meropenem MSD MEROPENEM-SODIUM CHLORIDE MSD minocycline hcl 1, 3, MSD moxifloxacin hcl 1, 3, MSD nafcillin sodium MSD NAFCILLIN SODIUM IN DEXTROSE MSD neomycin sulfate 1 NUZYRA 3, MSD ofloxacin 1 ORBACTIV MSD oxacillin sodium MSD OXACILLIN SODIUM IN DEXTROSE MSD PCE 3 PENICILLIN G POT IN DEXTROSE MSD penicillin g potassium MSD PENICILLIN G PROCAINE MSD PENICILLIN G SODIUM MSD penicillin v potassium 1 piperacillin sodium-tazobactam sodium MSD polymyxin b sulfate MSD RECARBRIO MSD SEYSARA 4 SIVEXTRO 4, MSD STREPTOMYCIN SULFATE MSD SULFADIAZINE 1

LEGEND LD = Limited Distribution MSD = Medical Service Drugs PA = Prior Authorization QL = Quantity Limits OC =Oral Chemotherapy Drugs PRV = Zero Cost Share Preventive Drugs ST = Step Therapy

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Name of drug Drug Tier Restrictions sulfamethoxazole-trimethoprim 1, 3, MSD sulfasalazine 1, 3 SYNERCID MSD TEFLARO MSD tetracycline hcl 1 TIGECYCLINE MSD TIMENTIN MSD tobramycin 1, 4 tobramycin sulfate MSD VABOMERE MSD vancomycin hcl 1, 3, 4, MSD VANCOMYCIN HCL IN DEXTROSE MSD VIBATIV MSD VIBRAMYCIN 3 XENLETA 3, MSD XERAVA MSD XIFAXAN 4 QL ZEMDRI MSD ZERBAXA MSD ZINACEF IN STERILE WATER MSD ZOSYN MSD ANTIFUNGALS ABELCET MSD AMBISOME MSD AMPHOTERICIN B MSD caspofungin acetate MSD ciclopirox 1, 3 PA CRESEMBA 4, MSD ERAXIS MSD fluconazole 1, 3 fluconazole in dextrose MSD fluconazole in nacl MSD flucytosine 1, 4 griseofulvin microsize 1 griseofulvin ultramicrosize 1, 3 itraconazole 1, 3, 4 PA JUBLIA 3 PA KERYDIN 3 PA ketoconazole 1 micafungin sodium MSD nystatin 1 nystatin (mouth-throat) 1 ORAVIG 3 posaconazole 4, MSD terbinafine hcl 1, 3 PA voriconazole 1, 3, MSD ANTIMYCOBACTERIALS CAPASTAT SULFATE MSD cycloserine 1 dapsone 1 ethambutol hcl 1, 3 isoniazid 1, MSD PASER 3 PRETOMANID 2 PRIFTIN 3


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Name of drug Drug Tier Restrictions pyrazinamide 1 rifabutin 1, 3 RIFAMATE 3 rifampin 1, 3, MSD RIFATER 3 SIRTURO 4 LD TRECATOR 3 ANTIPROTOZOALS ALINIA 3 ARAKODA 2, 3 atovaquone 4 atovaquone-proguanil hcl 1, 3 BENZNIDAZOLE 3 LD chloroquine phosphate 1 COARTEM 2 hydroxychloroquine sulfate 1, 3 IMPAVIDO 3 mefloquine hcl 1 metronidazole 1, 3 metronidazole in nacl MSD paromomycin sulfate 1 pentamidine isethionate 1, 2, MSD primaquine phosphate 2 pyrimethamine 1, 3 LD quinine sulfate 1, 3 SOLOSEC 3 tinidazole 1 ANTIVIRALS abacavir sulfate 1, 3 abacavir sulfate-lamivudine 1, 3 abacavir sulfate-lamivudine-zidovudine 1, 3 acyclovir 1, 3 acyclovir sodium MSD adefovir dipivoxil 4 APTIVUS 2 atazanavir sulfate 1, 2, 3 ATRIPLA 2 BIKTARVY 2 cidofovir MSD CIMDUO 2 COMPLERA 2 CRIXIVAN 2 DAKLINZA 4 PA, QL DELSTRIGO 2 DESCOVY 2 DIDANOSINE 1, 2, 3 DOVATO 2 EDURANT 2 efavirenz 1, 3 EMTRIVA 2 entecavir 1, 3, 4 EPCLUSA 4 PA, QL EVOTAZ 2 famciclovir 1 FLUMADINE 1, 2


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Name of drug Drug Tier Restrictions fosamprenavir calcium 1, 2, 3 FOSCAVIR MSD FUZEON 2 QL GANCICLOVIR MSD ganciclovir sodium MSD GENVOYA 2 HARVONI 2, 4 PA, QL INTELENCE 2 INVIRASE 2, 3 ISENTRESS 2 JULUCA 2 lamivudine 1, 3 lamivudine (hbv) 1, 3 lamivudine-zidovudine 1, 3 lopinavir-ritonavir 1, 2, 3 MAVYRET 4 PA, QL nevirapine 1, 3 ODEFSEY 2 OLYSIO 4 QL oseltamivir phosphate 1, 3 QL PEGASYS 4 QL PEGINTRON 3 QL PIFELTRO 2 PLEGRIDY 4 PA, QL PREVYMIS 2, MSD PREZCOBIX 2 PREZISTA 2 RAPIVAB MSD RELENZA DISKHALER 2 QL RESCRIPTOR 3 ribavirin (hepatitis c) 1, 3, 4 ritonavir 1, 2, 3 RUKOBIA 3 SELZENTRY 2, 3 SOVALDI 3, 4 PA, QL stavudine 1, 3 STRIBILD 2 SYMFI 2 SYMTUZA 2 SYNAGIS MSD TECHNIVIE 4 QL tenofovir disoproxil fumarate 1, 3 TIVICAY 2 TRIUMEQ 2 TROGARZO MSD TRUVADA 2, 3 valacyclovir hcl 1, 3 valganciclovir hcl 1, 4 VEMLIDY 3 VIEKIRA PAK 4 PA, QL VIRACEPT 2 VIRAZOLE MSD VOSEVI 4 PA, QL XOFLUZA (40 MG DOSE) 3 ZEPATIER 4 PA, QL


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Name of drug Drug Tier Restrictions zidovudine 1, 3, MSD URINARY ANTI-INFECTIVES methenamine hippurate 1, 3 methenamine-hyosc-methylene blue-sod phos-phenyl sal 1 MONUROL 3 nitrofurantoin 1, 3 nitrofurantoin macrocrystal 1, 3 nitrofurantoin monohyd macro 1, 3 PRIMSOL 3 trimethoprim 1 UTA 3 ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate 1, 3 cetirizine hcl 1, MSD CLARINEX-D 12 HOUR 3 CLEMASTINE FUMARATE 1 cyproheptadine hcl 1 desloratadine 1, 3 DEXCHLORPHENIRAMINE MALEATE 1, 3 diphenhydramine hcl MSD promethazine & phenylephrine 1 promethazine hcl 1, MSD SEMPREX-D 3 ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate 1, 4 PA, OC ABRAXANE MSD ALECENSA 4 PA, OC ALFERON N MSD ALIMTA MSD ALIQOPA MSD ALUNBRIG 4 OC anastrozole 1, 3 OC ARRANON MSD arsenic trioxide MSD ARZERRA MSD ASPARLAS MSD AVASTIN MSD azacitidine MSD AZEDRA DOSIMETRIC MSD BALVERSA 3 OC BAVENCIO MSD BELEODAQ MSD BENDAMUSTINE HCL MSD BESPONSA MSD bexarotene 1, 4 OC bicalutamide 1, 3 OC BICNU MSD bleomycin sulfate MSD BLINCYTO MSD BORTEZOMIB MSD BOSULIF 3 OC BRAFTOVI 4 LD, OC BRUKINSA 3 OC


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Name of drug Drug Tier Restrictions busulfan 2, MSD OC CABOMETYX 4 LD, OC CALQUENCE 4 OC CAMPATH MSD LD capecitabine 1, 3, 4 OC CAPRELSA 2, 4 LD, OC carboplatin MSD cisplatin MSD cladribine MSD clofarabine MSD COPIKTRA 4 OC COTELLIC 4 OC cyclophosphamide 1, 2, MSD PA CYRAMZA MSD cytarabine MSD dacarbazine MSD dactinomycin MSD DARZALEX MSD DARZALEX FASPRO MSD daunorubicin hcl MSD DAURISMO 4 OC decitabine MSD DOCETAXEL MSD doxorubicin hcl MSD doxorubicin hcl liposomal MSD ELIGARD 2, 3 QL ELIGARD 2, 3 QL ELIGARD 2, 3 QL ELZONRIS MSD EMCYT 4 OC EMPLICITI MSD ENHERTU MSD epirubicin hcl MSD ERBITUX MSD ERIVEDGE 4 OC ERLEADA 4 OC erlotinib hcl 4 OC ETOPOPHOS MSD etoposide 1, MSD OC everolimus 1, 4 OC exemestane 1, 3 OC FARYDAK 4 OC FIRMAGON MSD floxuridine MSD fludarabine phosphate MSD fluorouracil MSD flutamide 1 OC FOLOTYN MSD fulvestrant MSD GAZYVA MSD gemcitabine hcl MSD GILOTRIF 4 OC GLEOSTINE 2, 4 OC HALAVEN MSD HERCEPTIN MSD


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Name of drug Drug Tier Restrictions HERCEPTIN HYLECTA MSD HERZUMA MSD HEXALEN 4 OC hydroxyurea 1, 3 OC IBRANCE 4 PA, OC ICLUSIG 4 OC idarubicin hcl MSD IDHIFA 4 OC ifosfamide MSD imatinib mesylate 1, 4 OC IMBRUVICA 4 PA, OC IMFINZI MSD IMLYGIC MSD INFUGEM MSD INLYTA 4 OC INREBIC 4 OC INTRON A 4 QL IRESSA 2 OC irinotecan hcl MSD ISTODAX (OVERFILL) MSD IXEMPRA KIT MSD JAKAFI 2 OC JEVTANA MSD KADCYLA MSD KANJINTI MSD KEYTRUDA MSD KISQALI (200 MG DOSE) 4 OC KISQALI FEMARA (400 MG DOSE) 4 OC KYPROLIS MSD LARTRUVO MSD LENVIMA 4 LD, OC letrozole 1, 3 OC LEUKERAN 2 OC leuprolide acetate 1, 2, 3 PA, QL LIBTAYO MSD LONSURF 4 OC LORBRENA 4 OC LUMOXITI MSD LUPANETA PACK MSD LUPRON DEPOT-PED (1-MONTH) 4 QL LUPRON DEPOT-PED (3-MONTH) 4 QL LUTATHERA MSD LYNPARZA 4 OC LYSODREN 2 LD, OC MARQIBO MSD MATULANE 4 OC megestrol acetate 1 MEKINIST 4 OC MEKTOVI 4 LD, OC melphalan 1, 3 OC melphalan hcl MSD mercaptopurine 1, 4 OC methotrexate sodium 1, 3, MSD mitomycin MSD mitoxantrone hcl MSD


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Name of drug Drug Tier Restrictions MUSTARGEN MSD MVASI MSD MYLOTARG MSD NERLYNX 4 OC NEXAVAR 4 PA, OC nilutamide 1, 3 OC NINLARO 4 PA, OC NIPENT MSD NUBEQA 4 OC ODOMZO 2 OC OGIVRI MSD ONIVYDE MSD ONTRUZANT MSD OPDIVO MSD oxaliplatin MSD paclitaxel MSD PADCEV MSD PERJETA MSD PHESGO MSD PIQRAY (200 MG DAILY DOSE) 4 OC POLIVY MSD POMALYST 4 PA, LD, OC PORTRAZZA MSD POTELIGEO MSD PROLEUKIN MSD QINLOCK 4 OC RETEVMO 4 OC REVLIMID 4 PA, LD RITUXAN MSD RITUXAN HYCELA MSD ROZLYTREK 3 OC RUBRACA 4 OC RUXIENCE MSD RYDAPT 4 OC SARCLISA MSD SPRYCEL 4 PA, OC STIVARGA 4 OC SUTENT 4 OC SYLATRON 4 QL SYLVANT MSD SYNRIBO MSD TABLOID 2 OC TABRECTA 4 OC TAFINLAR 4 OC TAGRISSO 4 PA, OC TALZENNA 3 OC tamoxifen citrate 1, 3 PA TASIGNA 4 OC TAZVERIK 3 OC TECENTRIQ MSD temozolomide 1, 4, MSD OC temsirolimus MSD thiotepa MSD TIBSOVO 4 OC topotecan hcl 4, MSD OC


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Name of drug Drug Tier Restrictions toremifene citrate 1, 4 OC TRAZIMERA MSD TRELSTAR MIXJECT MSD tretinoin (chemotherapy) 1 OC TRODELVY MSD TRUXIMA MSD TURALIO 4 OC TYKERB 4 OC UNITUXIN MSD VECTIBIX MSD VENCLEXTA 2 OC VERZENIO 4 OC VINBLASTINE SULFATE MSD vincristine sulfate MSD vinorelbine tartrate MSD VITRAKVI 4 LD, OC VIZIMPRO 4 OC VOTRIENT 4 PA, OC VYXEOS MSD XALKORI 4 OC XATMEP 3 XOSPATA 4 OC XPOVIO (100 MG ONCE WEEKLY) 3 OC XTANDI 4 PA, OC YERVOY MSD YONDELIS MSD ZALTRAP MSD ZANOSAR MSD ZEJULA 4 OC ZELBORAF 4 OC ZEPZELCA 6 ZIRABEV MSD ZOLADEX MSD ZOLINZA 4 OC ZYDELIG 3 OC ZYKADIA 4 OC AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANORO ELLIPTA 3 atropine sulfate MSD ATROVENT HFA 3 BEVESPI AEROSPHERE 3 chlordiazepoxide hcl-clidinium bromide 1, 3 COCAINE HCL MSD dicyclomine hcl 1, 3, MSD DUAKLIR PRESSAIR 3 glycopyrrolate 1, 3, MSD hyoscyamine 1 hyoscyamine sulfate 1, 3 INCRUSE ELLIPTA 3 ipratropium bromide 1 ipratropium bromide (nasal) 1 LONHALA MAGNAIR REFILL KIT 3 METHSCOPOLAMINE BROMIDE 1 phenobarbital-hyoscyamine-atropine-scopolamine 1


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Name of drug Drug Tier Restrictions PROPANTHELINE BROMIDE 1 SPIRIVA HANDIHALER 2, 3 STIOLTO RESPIMAT 2 TUDORZA PRESSAIR 3 YUPELRI 4 AUTONOMIC DRUGS, MISCELLANEOUS bupropion hcl (smoking deterrent) PRV CHANTIX PRV QL nicotine PRV nicotine polacrilex PRV PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride 1, 3 cevimeline hcl 1, 3 donepezil hydrochloride 1, 3 FIRDAPSE 4 PA galantamine hydrobromide 1, 3 GUANIDINE HCL 3 NEOSTIGMINE METHYLSULFATE MSD PHYSOSTIGMINE SALICYLATE MSD pilocarpine hcl (oral) 1, 3 pyridostigmine bromide 1, 3, MSD rivastigmine 1, 3 rivastigmine tartrate 1 RUZURGI 4 PA SKELETAL MUSCLE RELAXANTS baclofen 1, 3, MSD carisoprodol 1, 3 carisoprodol w/ aspirin 1 carisoprodol w/ aspirin & codeine 1 QL chlorzoxazone 1, 3 cyclobenzaprine hcl 1, 3 dantrolene sodium 1, 3, MSD metaxalone 1, 3 methocarbamol 1, 3, MSD orphenadrine citrate 1, MSD tizanidine hcl 1, 3 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl 1, 3 dihydroergotamine mesylate 1, 3 QL ERGOLOID MESYLATES 1 ERGOMAR 3 phenoxybenzamine hcl 1, 3 silodosin 1, 3 tamsulosin hcl 1, 3 SYMPATHOMIMETIC (ADRENERGIC) AGENTS AKOVAZ MSD albuterol sulfate 1, 2, 3 ARCAPTA NEOHALER 3 BIORPHEN MSD BROVANA 4 dobutamine hcl MSD dobutamine in d5w MSD epinephrine MSD epinephrine (anaphylaxis) 1, 2, 3, MSD PA, QL fluticasone-salmeterol 1, 2, 3 QL


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Name of drug Drug Tier Restrictions ipratropium-albuterol 1, 3 levalbuterol hcl 1, 3 LEVALBUTEROL TARTRATE 1, 3 metaproterenol sulfate 1 midodrine hcl 1 NORTHERA 4 PERFOROMIST 3 SEREVENT DISKUS 2 STRIVERDI RESPIMAT 2 terbutaline sulfate 1, MSD UTIBRON NEOHALER 3 BLOOD FORMATION, COAGULATION, AND THROMBOSIS COAGULANTS AND ANTICOAGULANTS AFSTYLA MSD AGGRASTAT MSD ALPHANATE/VWF COMPLEX/HUMAN MSD ALPROLIX MSD aminocaproic acid MSD anagrelide hcl 1, 3 ANDEXXA MSD argatroban MSD ARGATROBAN IN SODIUM CHLORIDE MSD aspirin-dipyridamole 1, 3 BEVYXXA 3 bivalirudin trifluoroacetate MSD BIVALIRUDIN-SODIUM CHLORIDE MSD BRILINTA 2 cilostazol 1 clopidogrel bisulfate 1, 3 COAGADEX MSD DURLAZA 3 ELIQUIS 3 ELOCTATE MSD enoxaparin sodium 1, 2, 3 QL FIBRYGA MSD fondaparinux sodium 1, 3 QL FRAGMIN 3 QL HEMLIBRA 2 QL heparin (porcine) in sodium chloride MSD HEPARIN SOD (PORCINE) IN D5W MSD heparin sodium (porcine) 1 QL heparin sodium (porcine) lock flush MSD IDELVION MSD INTEGRILIN MSD IPRIVASK 3 QL IXINITY MSD JIVI MSD KCENTRA MSD KENGREAL MSD KOVALTRY MSD NOVOEIGHT MSD NUWIQ MSD OBIZUR MSD pentoxifylline 1 PRADAXA 2


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Name of drug Drug Tier Restrictions prasugrel hcl 1, 3 PRAXBIND MSD REBINYN MSD SAVAYSA 3 TAVALISSE 3 LD tranexamic acid 1, 3, MSD TRETTEN MSD VONVENDI MSD warfarin sodium 1, 3 XARELTO 3 YOSPRALA 3 ZONTIVITY 3 HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) 4 PA, QL DOPTELET 4 EPOGEN 2, 3 QL FULPHILA 4 QL GRANIX 4 QL LEUKINE 4 QL MIRCERA 3 PA, QL MOZOBIL MSD MULPLETA 4 NEULASTA 4, MSD QL NEUMEGA 4 QL NEUPOGEN 4 QL NIVESTYM 4 QL NPLATE MSD PROMACTA 2, 3 LD REBLOZYL MSD RETACRIT 3 PA, QL UDENYCA 4 QL ZARXIO 2 QL CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA XL 3 doxazosin mesylate 1, 3 prazosin hcl 1, 3 terazosin hcl 1 ANTILIPEMIC AGENTS atorvastatin calcium 1, 3 cholestyramine 1, 3 cholestyramine light 1, 3 choline fenofibrate 1, 3 colesevelam hcl 1, 3 colestipol hcl 1, 3 ezetimibe 1, 3 ezetimibe-simvastatin 1, 3 fenofibrate 1, 3 fenofibrate micronized 1, 3 FENOFIBRIC ACID 3 fluvastatin sodium 1, 3 gemfibrozil 1, 3 JUXTAPID 4 LD KYNAMRO 4 QL, LD LIVALO 3


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Name of drug Drug Tier Restrictions lovastatin 1, 3 niacin (antihyperlipidemic) 1, 3 omega-3-acid ethyl esters 1, 3 PRALUENT 3 PA, QL pravastatin sodium 1, 3 REPATHA 3 PA, QL rosuvastatin calcium 1, 3 simvastatin 1, 3 VASCEPA 3 ZYPITAMAG 3 BETA-ADRENERGIC BLOCKING AGENTS esmolol hcl MSD labetalol hcl MSD metoprolol succinate 1 metoprolol tartrate 1, MSD SOTYLIZE 3 CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besylate 1, 3 amlodipine besylate-atorvastatin calcium 1, 3 amlodipine besylate-benazepril hcl 1, 3 amlodipine besylate-olmesartan medoxomil 1, 3 amlodipine besylate-valsartan 1, 3 amlodipine-valsartan-hydrochlorothiazide 1, 3 CARDENE IV MSD CLEVIPREX MSD CONSENSI 3 diltiazem hcl 1, 3, MSD diltiazem hcl coated beads 1, 3 diltiazem hcl extended release beads 1, 3 felodipine 1 isradipine 1 nicardipine hcl 1, MSD nifedipine 1, 3 nimodipine 1, 3 nisoldipine 1, 3 olmesartan medoxomil-amlodipine-hydrochlorothiazide 1, 3 PRESTALIA 3 telmisartan-amlodipine 1, 3 trandolapril-verapamil hcl 1, 3 verapamil hcl 1, 3, MSD CARDIAC DRUGS adenosine MSD amiodarone hcl 1, MSD CORLANOR 3 digoxin 1, 2, 3, MSD disopyramide phosphate 1, 3 dofetilide 1, 4 flecainide acetate 1 lidocaine hcl (cardiac) MSD lidocaine in d5w MSD MEXILETINE HCL 1 MULTAQ 3 NEXTERONE MSD procainamide hcl MSD propafenone hcl 1, 3


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Name of drug Drug Tier Restrictions quinidine gluconate 1, MSD QUINIDINE SULFATE 1 ranolazine 1, 3 VYNDAMAX 3 VYNDAQEL 3 HYPOTENSIVE AGENTS clonidine 1, 3 clonidine hcl 1, 3 CORLOPAM MSD guanfacine hcl 1 hydralazine hcl 1, MSD methyldopa 1 METHYLDOPA-HYDROCHLOROTHIAZIDE 1 METHYLDOPATE HCL MSD minoxidil 1 NIPRIDE RTU MSD VECAMYL 4 MISCELLANEOUS THERAPEUTIC AGENTS GIAPREZA MSD RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS aliskiren fumarate 1, 3 benazepril & hydrochlorothiazide 1, 3 benazepril hcl 1, 3 candesartan cilexetil 1, 3 candesartan cilexetil-hydrochlorothiazide 1, 3 captopril 1 CAPTOPRIL-HYDROCHLOROTHIAZIDE 1 EDARBI 3 EDARBYCLOR 3 enalapril maleate 1, 3 enalapril maleate & hydrochlorothiazide 1, 3 ENTRESTO 2 eplerenone 1, 3 EPROSARTAN MESYLATE 1 fosinopril sodium 1 fosinopril sodium & hydrochlorothiazide 1 irbesartan 1, 3 irbesartan-hydrochlorothiazide 1, 3 lisinopril 1, 3 lisinopril & hydrochlorothiazide 1, 3 losartan potassium 1, 3 losartan potassium & hydrochlorothiazide 1, 3 moexipril hcl 1 moexipril-hydrochlorothiazide 1 olmesartan medoxomil 1, 3 olmesartan medoxomil-hydrochlorothiazide 1, 3 perindopril erbumine 1 quinapril hcl 1, 3 quinapril-hydrochlorothiazide 1, 3 ramipril 1, 3 spironolactone 1, 3 spironolactone & hydrochlorothiazide 1, 3 TEKTURNA HCT 3 telmisartan 1, 3 telmisartan-hydrochlorothiazide 1, 3


18

Name of drug Drug Tier Restrictions trandolapril 1 valsartan 1, 3 valsartan-hydrochlorothiazide 1, 3 VASODILATING AGENTS BIDIL 3 dipyridamole 1 isosorbide dinitrate 1, 3 isosorbide mononitrate 1 nitroglycerin 1, 2, 3, MSD nitroglycerin in d5w MSD papaverine hcl 1, MSD sildenafil citrate (pulmonary hypertension) 1, 3, 4, MSD PA tadalafil (pulmonary hypertension) 1, 4 PA, LD ¿-ADRENERGIC BLOCKING AGENTS BYVALSON 3 NADOLOL-BENDROFLUMETHIAZIDE 1 propranolol hcl 1, MSD PROPRANOLOL-HCTZ 1 sotalol hcl 1, 3 timolol maleate 1 Ã¿-ADRENERGIC BLOCKING AGENTS BETAPACE AF 3 BYSTOLIC 3 carvedilol phosphate 1 CORGARD 3 LOPRESSOR 3 propranolol hcl 1 sotalol hcl 1 TENORETIC 50 3 TENORMIN 3 TOPROL XL 3 ß-ADRENERGIC BLOCKING AGENTS acebutolol hcl 1 atenolol 1, 3 atenolol & chlorthalidone 1, 3 betaxolol hcl 1 bisoprolol & hydrochlorothiazide 1, 3 bisoprolol fumarate 1, 3 BYSTOLIC 3 carvedilol 1, 3 carvedilol phosphate 1, 3 INDERAL XL 3 labetalol hcl 1, MSD metoprolol & hydrochlorothiazide 1, 3 metoprolol succinate 1, 3 metoprolol tartrate 1, 3, MSD nadolol 1, 3 nadolol & bendroflumethiazide 1, 3 pindolol 1 propranolol hcl 1, 3 sotalol hcl 1, 3, MSD sotalol hcl (afib/afl) 1 CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS acetaminophen w/ codeine 1, 3 QL


19

Name of drug Drug Tier Restrictions acetaminophen-caff-dihydrocod 1, 3 QL alfentanil hcl MSD APADAZ 1, 3 QL aspirin PRV aspirin buffered (cal carb-mag carb-mag oxide) PRV buprenorphine 1, 3 QL buprenorphine hcl 1, 3 QL butalbital-acetaminophen 1 butalbital-acetaminophen-caffeine 1 butalbital-acetaminophen-caffeine w/ codeine 1, 3 QL butalbital-aspirin-caffeine 1, 3 butalbital-aspirin-caffeine w/cod 1, 3 QL butorphanol tartrate 1, MSD QL CAMBIA 3 celecoxib 1, 3 choline & mag salicylate 1 clonidine hcl (analgesia) MSD codeine sulfate 1 QL diclofenac potassium 1, 3 diclofenac sodium 1 diclofenac w/ misoprostol 1, 3 diflunisal 1 DSUVIA MSD DUEXIS 4 EMBEDA 2 QL etodolac 1, 3 fenoprofen calcium 1, 3 fentanyl 1, 3 QL fentanyl citrate 1, 3, MSD QL flurbiprofen 1 GRALISE 3 hydrocodone bitartrate 1, 3 QL hydrocodone-acetaminophen 1, 3 QL hydrocodone-ibuprofen 1 QL hydromorphone hcl 1, 3, MSD QL ibuprofen 1 ILARIS MSD PA indomethacin 1, 2, 3 INFUMORPH 500 MSD IONSYS MSD ketoprofen 1 ketorolac tromethamine 1, 3, MSD levorphanol tartrate 1 QL LYRICA CR 3 MECLOFENAMATE SODIUM 1 mefenamic acid 1, 3 meloxicam 1, 3 meperidine hcl 1, MSD QL methadone hcl 1, 3, MSD QL morphine sulfate 1, 2, 3, MSD QL MORPHINE SULFATE ER BEADS 1 QL nabumetone 1 nalbuphine hcl MSD naproxen 1, 3 naproxen sodium 1, 3


20

Name of drug Drug Tier Restrictions naproxen-esomeprazole magnesium 1, 3 NUCYNTA 3, 4 QL OFIRMEV MSD oxaprozin 1, 3 oxycodone hcl 1, 2, 3 QL oxycodone w/ acetaminophen 1, 3 QL OXYCODONE-ASPIRIN 1 QL OXYCODONE-IBUPROFEN 1 QL oxymorphone hcl 1, 3 QL pentazocine w/ naloxone 1 QL piroxicam 1, 3 salsalate 1 sulindac 1 TALWIN MSD TOLMETIN SODIUM 1 tramadol hcl 1, 3 QL tramadol-acetaminophen 1, 3 QL XTAMPZA ER 3 QL ZORVOLEX 3 ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS ADZENYS ER 1, 3 amphetamine sulfate 1, 3 amphetamine-dextroamphetamine 1, 2, 3 armodafinil 1, 3 caffeine citrate MSD COTEMPLA XR-ODT 3 dexmethylphenidate hcl 1, 3 dextroamphetamine sulfate 1, 3 methamphetamine hcl 1, 3 methylphenidate hcl 1, 2, 3 modafinil 1, 3 SUNOSI 3 VYVANSE 3 WAKIX 3 ANTICONVULSANTS APTIOM 3 PA BANZEL 4 PA BRIVIACT 3, MSD PA carbamazepine 1, 3 CELONTIN 2 clobazam 1, 3, 4 PA clonazepam 1, 3 QL DIACOMIT 4 PA, LD divalproex sodium 1, 3 EPIDIOLEX 4 PA, LD EQUETRO 3 ethosuximide 1, 3 felbamate 1, 3 PA fosphenytoin sodium MSD FYCOMPA 3 PA gabapentin 1, 3 HORIZANT 3 lamotrigine 1, 3 levetiracetam 1, 3, MSD LEVETIRACETAM IN NACL MSD


21

Name of drug Drug Tier Restrictions magnesium sulfate MSD NAYZILAM 4 QL oxcarbazepine 1, 3 PEGANONE 3 phenytoin 1, 3 phenytoin sodium MSD phenytoin sodium extended 1, 2, 3 POTIGA 3 pregabalin 1, 3 primidone 1, 3 tiagabine hcl 1, 3 PA topiramate 1, 3 valproate sodium 1, 3, MSD valproic acid 1, 3 vigabatrin 1, 4 PA, LD VIMPAT 3, MSD PA XCOPRI 3 zonisamide 1, 3 ANTIMIGRAINE AGENTS AIMOVIG 3 PA, QL AJOVY 3 PA, QL almotriptan malate 1, 3 QL eletriptan hydrobromide 1, 3 QL EMGALITY 3, 4 PA, QL ergotamine w/ caffeine 1, 3 frovatriptan succinate 1, 3 QL naratriptan hcl 1, 3 QL rizatriptan benzoate 1, 3 QL sumatriptan 1, 3, 4 sumatriptan succinate 1, 3 QL sumatriptan-naproxen sodium 1, 3 QL UBRELVY 3 PA, QL zolmitriptan 1, 3 QL ANTIPARKINSONIAN AGENTS amantadine hcl 1, 3, 4 LD APOKYN 4 QL benztropine mesylate 1, MSD bromocriptine mesylate 1, 3 cabergoline 1 carbidopa 1, 3 carbidopa-levodopa 1, 3, 4 CARBIDOPA-LEVODOPA-ENTACAPONE 1, 3 entacapone 1, 3 INBRIJA 4 NEUPRO 3 NOURIANZ 3 LD pramipexole dihydrochloride 1, 3 rasagiline mesylate 1, 3 ropinirole hydrochloride 1, 3 selegiline hcl 1, 3 tolcapone 1, 3 trihexyphenidyl hcl 1 XADAGO 3 ANXIOLYTICS, SEDATIVES, AND HYPNOTICS alprazolam 1, 3 QL


22

Name of drug Drug Tier Restrictions BELSOMRA 3 QL buspirone hcl 1 BUTISOL SODIUM 3 chlordiazepoxide hcl 1 QL clorazepate dipotassium 1, 3 QL dexmedetomidine hcl MSD dexmedetomidine hcl in sodium chloride MSD DIASTAT ACUDIAL 1, 2 QL diazepam 1, 3, MSD QL DORAL 3 QL doxepin hcl (sleep) 1, 3 QL droperidol MSD estazolam 1 QL eszopiclone 1, 3 QL etomidate MSD FLURAZEPAM HCL 1 QL HETLIOZ 4 LD hydroxyzine hcl 1, MSD hydroxyzine pamoate 1, 3 ketamine hcl MSD lorazepam 1, 3, MSD QL meprobamate 1 midazolam hcl 1, MSD QL oxazepam 1 QL phenobarbital 1 phenobarbital sodium MSD propofol MSD ramelteon 1, 3 QL temazepam 1, 3 QL triazolam 1, 3 QL zaleplon 1 QL zolpidem tartrate 1, 3 QL CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS acamprosate calcium 1 atomoxetine hcl 1, 3 atracurium besylate MSD AUSTEDO 4 BELVIQ 3 cisatracurium besylate MSD clonidine hcl (adhd) 1, 3 CONTRAVE 3 flumazenil MSD guanfacine hcl (adhd) 1, 3 INGREZZA 4 ketamine hcl MSD memantine hcl 1, 3 MIVACRON MSD NAMZARIC 3 NUEDEXTA 3 phendimetrazine tartrate 1 phentermine hcl 1 QUELICIN MSD RADICAVA MSD riluzole 1, 4 rocuronium bromide MSD


23

Name of drug Drug Tier Restrictions SAVELLA 3 sevoflurane MSD SUPRANE MSD tetrabenazine 1, 4 vecuronium bromide MSD XYREM 4 PA, QL, LD OPIATE ANTAGONISTS buprenorphine hcl 1, MSD QL buprenorphine hcl-naloxone hcl dihydrate 1, 3 QL naloxone hcl 1, 2, 3 QL naltrexone hcl 1 SUBLOCADE MSD LD VIVITROL MSD PSYCHOTHERAPEUTIC AGENTS ADASUVE MSD amitriptyline hcl 1 AMOXAPINE 1 APLENZIN 3 aripiprazole 1, 3, 4, MSD ARISTADA MSD BRISDELLE 3 bupropion hcl 1, 3 PA CHLORDIAZEPOXIDE-AMITRIPTYLINE 1 chlorpromazine hcl 1, MSD citalopram hydrobromide 1, 3 clomipramine hcl 1, 3 clozapine 1, 3 QL desipramine hcl 1, 3 DESVENLAFAXINE ER 3 desvenlafaxine succinate 1, 3 doxepin hcl 1 duloxetine hcl 1, 3 EMSAM 4 escitalopram oxalate 1, 3 FANAPT 3, 4 FETZIMA 3 fluoxetine hcl 1, 3 fluoxetine hcl (pmdd) 1, 3 fluphenazine decanoate MSD fluphenazine hcl 1, MSD fluvoxamine maleate 1 haloperidol 1 haloperidol decanoate MSD haloperidol lactate 1, MSD imipramine hcl 1, 3 imipramine pamoate 1 INVEGA SUSTENNA MSD LATUDA 3 LITHIUM 2 lithium carbonate 1, 3 loxapine succinate 1 MAPROTILINE HCL 1 MARPLAN 3 mirtazapine 1, 3 MOLINDONE HCL 1


24

Name of drug Drug Tier Restrictions NEFAZODONE HCL 1 nortriptyline hcl 1, 3 NUPLAZID 4 olanzapine 1, 3, MSD olanzapine-fluoxetine hcl 1, 3 ORAP 1, 3 paliperidone 1, 3 paroxetine hcl 1, 3 perphenazine 1 PERPHENAZINE-AMITRIPTYLINE 1 PEXEVA 3 phenelzine sulfate 1, 3 prochlorperazine 1 prochlorperazine maleate 1 protriptyline hcl 1 quetiapine fumarate 1, 3 REXULTI 4 RISPERDAL CONSTA MSD risperidone 1, 3, MSD SAPHRIS 3 sertraline hcl 1, 3 SPRAVATO (56 MG DOSE) MSD thioridazine hcl 1 thiothixene 1 tranylcypromine sulfate 1, 3 trazodone hcl 1 trifluoperazine hcl 1 trimipramine maleate 1, 3 TRINTELLIX 3 venlafaxine hcl 1, 3 VIIBRYD 3 VRAYLAR 3 ziprasidone hcl 1, 3 ziprasidone mesylate 6 ZULRESSO MSD DIABETIC SUPPLIES DIABETIC SUPPLIES ADVOCATE CONTROL SOLUTION 2 BD INSULIN SYRINGE U-500 2 BD LANCET ULTRAFINE 30G 2 FREESTYLE TEST 2 QL NOVOFINE 2 ONETOUCH VERIO FLEX SYSTEM 2 PRECISION XTRA KETONE 2 ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS K-PHOS NO 2 2 pot & sod citrates w/citric ac 1 potassium citrate (alkalinizer) 1, 3 potassium citrate-citric acid 1 SODIUM ACETATE MSD sodium bicarbonate MSD sodium citrate & citric acid 1 SODIUM LACTATE MSD AMMONIA DETOXICANTS


25

Name of drug Drug Tier Restrictions CARBAGLU 3 lactulose 1, 3 lactulose (encephalopathy) 1 LITHOSTAT 3 LD RAVICTI 4 LD sodium phenylbutyrate 1, 4 CALORIC AGENTS amino acid electrolyte infusion MSD amino acid infusion MSD CLINIMIX E/DEXTROSE (2.75/10) MSD CLINIMIX E/DEXTROSE (2.75/5) MSD CLINIMIX E/DEXTROSE (4.25/25) MSD CLINIMIX E/DEXTROSE (5/15) MSD CLINIMIX E/DEXTROSE (5/20) MSD CLINIMIX/DEXTROSE (2.75/5) MSD CLINIMIX/DEXTROSE (4.25/10) MSD CLINIMIX/DEXTROSE (4.25/20) MSD CLINIMIX/DEXTROSE (4.25/25) MSD CLINIMIX/DEXTROSE (5/15) MSD dextrose MSD ELCYS MSD INTRALIPID MSD OMEGAVEN MSD DIURETICS amiloride & hydrochlorothiazide 1 amiloride hcl 1 bumetanide 1, MSD chlorothiazide 1, 3 chlorothiazide sodium MSD chlorthalidone 1 ethacrynate sodium MSD ethacrynic acid 1, 3 furosemide 1, 3, MSD hydrochlorothiazide 1, 3 indapamide 1 JYNARQUE 3 PA, QL, LD mannitol MSD METHYCLOTHIAZIDE 1 metolazone 1 torsemide 1, 3 triamterene 1, 3 triamterene & hydrochlorothiazide 1, 3 ION-REMOVING AGENTS AURYXIA 4 lanthanum carbonate 1, 3, 4 LOKELMA 3 sevelamer carbonate 1, 3 sevelamer hcl 1, 3 sodium polystyrene sulfonate 1, 2 VELPHORO 3 VELTASSA 3 IRRIGATING SOLUTIONS acetic acid 1 DIANEAL LOW CALCIUM/1.5% DEX 2 EXTRANEAL 2


26

Name of drug Drug Tier Restrictions irrigation solutions, physiological MSD lactated ringer's (irrigation) MSD RENACIDIN MSD ringer's irrigation 1, MSD sodium chloride (gu irrigant) MSD water for irrigation, sterile 1 REPLACEMENT PREPARATIONS bacteriostatic sodium chloride MSD calcium acetate (phosphate binder) 1, 2 calcium chloride (dihydrate) MSD calcium gluconate MSD CALCIUM GLUCONATE-NACL MSD dextrose in lactated ringers MSD dextrose w/ sodium chloride MSD HESPAN MSD IONOSOL-B IN D5W MSD IONOSOL-MB IN D5W MSD ISOLYTE-P IN D5W MSD ISOLYTE-S MSD K-PHOS 2 KCL-LACTATED RINGERS-D5W MSD LACTATED RINGERS MSD MAGNESIUM SULFATE IN D5W MSD MANGANESE CHLORIDE MSD MANGANESE SULFATE MSD NORMOSOL-M IN D5W MSD NORMOSOL-R IN D5W MSD NORMOSOL-R PH 7.4 MSD parenteral electrolytes MSD PLASMA-LYTE 148 MSD PLASMA-LYTE A MSD pot phosphate monobasic w/ sod phosphate dibasic & monobasic 1, 2 potassium acetate MSD potassium bicarbonate 1, 2 potassium chloride 1, 2, 3, MSD potassium chloride in dextrose MSD potassium chloride in dextrose & sodium chloride MSD potassium chloride in nacl MSD potassium chloride microencapsulated crystals cr 1, 2 potassium phosphates MSD ringer's MSD SELENIOUS ACID MSD sodium chloride MSD sodium chloride flush MSD sodium phosphates (sodium phosphate dibasic & monobasic) MSD trace minerals (cr-cu-mn-se-zn) MSD URICOSURIC AGENTS colchicine w/ probenecid 1 DUZALLO 3 probenecid 1 ZURAMPIC 3 ENZYMES ENZYMES ADAGEN MSD LD ALDURAZYME MSD


27

Name of drug Drug Tier Restrictions BRINEURA MSD CEREZYME MSD ELAPRASE MSD ELELYSO MSD ELITEK MSD FABRAZYME MSD KANUMA MSD LUMIZYME MSD NAGLAZYME MSD PALYNZIQ 3 QL, LD PULMOZYME 2 REVCOVI MSD LD STRENSIQ 3 QL, LD SUCRAID 3 LD VIMIZIM MSD VITRASE MSD VPRIV MSD EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES AZASITE 3 BACITRACIN 1 bacitracin-polymyxin b (ophth) 1 BESIVANCE 3 BETADINE OPHTHALMIC PREP MSD CETRAXAL 1, 3 chlorhexidine gluconate (mouth-throat) 1, 3 ciprofloxacin hcl (ophth) 1, 2, 3 CIPROFLOXACIN-FLUOCINOLONE PF 3 erythromycin (ophth) 1 gatifloxacin (ophth) 1, 3 gentamicin sulfate (ophth) 1 levofloxacin (ophth) 1 moxifloxacin hcl (ophth) 1, 3 NATACYN 2 neomycin-bacitracin zn-polymyxin 1 NEOMYCIN-POLYMYXIN-GRAMICIDIN 1 ofloxacin (ophth) 1, 3 ofloxacin (otic) 1, 3 OTIPRIO 3 polymyxin b-trimethoprim 1, 3 silver nitrate-potassium nitrate 1 sulfacetamide sodium (ophth) 1 tobramycin (ophth) 1, 2, 3 TRIFLURIDINE 1, 2 ZIRGAN 3 ANTI-INFLAMMATORY AGENTS bacitracin-poly-neomycin-hc 1 BECONASE AQ 3 BLEPHAMIDE 1, 2, 3 bromfenac sodium (ophth) 1, 3 CEQUA 3 QL CIPRO HC 3 CIPRODEX 2 COLY-MYCIN S 2 DEXAMETHASONE SODIUM PHOSPHATE 1


28

Name of drug Drug Tier Restrictions diclofenac sodium (ophth) 1 DUREZOL 3 FLAREX 3 FLUNISOLIDE 1 fluocinolone acetonide (otic) 1, 3 fluorometholone (ophth) 1, 2, 3 FLURBIPROFEN SODIUM 1 hydrocortisone w/acetic acid 1 ILEVRO 3 ILUVIEN MSD ketorolac tromethamine (ophth) 1, 3 loteprednol etabonate 1, 3 MAXIDEX 3 mometasone furoate (nasal) 1, 3, MSD neomycin-polymy-dexameth 1, 3 NEOMYCIN-POLYMYXIN-HC 1 neomycin-polymyxin-hc (otic) 1 OMNARIS 3 OMNIPRED 1, 2, 3 PRED-G 2, 3 PREDNISOLONE SODIUM PHOSPHATE 1 QNASL 3 tobramycin-dexamethasone 1, 2, 3 XIIDRA 3 QL ZYLET 3 ANTIALLERGIC AGENTS ALOCRIL 3 ALOMIDE 3 azelastine hcl 1, 3 azelastine hcl (ophth) 1 azelastine hcl-fluticasone propionate 1, 3 BEPREVE 3 cromolyn sodium (ophth) 1 epinastine hcl (ophth) 1, 3 LASTACAFT 3 olopatadine hcl 1, 3 olopatadine hcl (nasal) 1, 3 ZERVIATE 3 ANTIGLAUCOMA AGENTS acetazolamide 1, 3 acetazolamide sodium MSD AZOPT 3 betaxolol hcl (ophth) 1, 3 BETIMOL 3 bimatoprost 1, 3 brimonidine tartrate 1, 3 CARTEOLOL HCL 1 COMBIGAN 3 dorzolamide hcl 1, 3 dorzolamide hcl-timolol maleate 1, 3 KEVEYIS 4 LD latanoprost 1, 3 levobunolol hcl 1, 3 methazolamide 1, 3 METIPRANOLOL 1


29

Name of drug Drug Tier Restrictions PHOSPHOLINE IODIDE 3 pilocarpine hcl 1, 3 SIMBRINZA 3 timolol maleate (ophth) 1, 3 travoprost 1, 3 VYZULTA 3 ZIOPTAN 3 EENT DRUGS, MISCELLANEOUS acetic acid (otic) 1 ACETIC ACID-ALUMINUM ACETATE 1 apraclonidine hcl 1, 3 BEOVU MSD BSS MSD CYSTARAN 3 LD DEBACTEROL 3 EYLEA MSD JETREA MSD LACRISERT 3 LUCENTIS MSD LD OXERVATE 3 LD PHOTREXA VISCOUS MSD RHOPRESSA 3 ROCKLATAN 3 TEPEZZA MSD LOCAL ANESTHETICS fluorescein w/ benoxinate MSD lidocaine hcl (mouth-throat) 1 proparacaine hcl MSD tetracaine hcl (ophth) MSD MYDRIATICS atropine sulfate (ophthalmic) 1, 3 CYCLOMYDRIL MSD cyclopentolate hcl 1, 3 HOMATROPAIRE 1 OMIDRIA MSD tropicamide MSD VASOCONSTRICTORS phenylephrine hcl (mydriatic) 1 GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS alosetron hcl 1, 3, 4 balsalazide disodium 1, 3 DIPENTUM 3 mesalamine 1, 2, 3 mesalamine w/ cleanser 1, 3 ANTIDIARRHEA AGENTS diphenoxylate w/ atropine 1, 3 loperamide hcl 1 MOTOFEN 3 MYTESI 3 XERMELO 4 LD ANTIEMETICS AKYNZEO 2 ALOXI MSD ANZEMET 3


30

Name of drug Drug Tier Restrictions aprepitant 1, 3, MSD BONJESTA 3 CESAMET 3 dronabinol 1, 3 EMEND MSD granisetron hcl 1, MSD meclizine hcl 1 ondansetron 1, 3 ondansetron hcl 1, 3, MSD PROCHLORPERAZINE EDISYLATE MSD SANCUSO 3, MSD scopolamine 1, 2 trimethobenzamide hcl 1, 3, MSD VARUBI (180 MG DOSE) 3 ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicillin-clarithromycin w/ lansoprazole 1, 3 cimetidine 1 CIMETIDINE HCL 1 DEXILANT 3 esomeprazole magnesium 1, 3 esomeprazole sodium MSD ESOMEPRAZOLE STRONTIUM 3 famotidine 1, 3, MSD FAMOTIDINE PREMIXED MSD HELIDAC THERAPY 3 lansoprazole 1, 3 misoprostol 1, 3 nizatidine 1 OMECLAMOX-PAK 3 omeprazole 1 omeprazole-sodium bicarbonate 1, 3 pantoprazole sodium 1, 3, MSD PYLERA 3 rabeprazole sodium 1, 3 sucralfate 1, 3 ZANTAC MSD CATHARTICS AND LAXATIVES bisacodyl PRV bisacodyl-peg 3350-pot chloride-sod bicarb-sod chloride PRV CLENPIQ PRV docusate sodium PRV magnesium citrate PRV MOVIPREP PRV OSMOPREP PRV peg 3350-kcl-sod bicarb-sod chloride-sod sulfate PRV peg 3350-potassium chloride-sod bicarbonate-sod chloride PRV polyethylene glycol 3350 PRV SALINE LAXATIVE PRV SUPREP BOWEL PREP KIT PRV DIGESTANTS ZENPEP 2, 3 GI DRUGS, MISCELLANEOUS AMITIZA 3 PA CHENODAL 3 CHOLBAM 4


31

Name of drug Drug Tier Restrictions CREON 2, 3 ENTEREG 3 ENTYVIO MSD GATTEX 4 QL, LD LINZESS 3 PA metoclopramide hcl 1, 3, MSD MOTEGRITY 3 PA MOVANTIK 3 PA OCALIVA 4 PA, LD RELISTOR 3 PA, QL SYMPROIC 3 PA TRULANCE 3 PA ursodiol 1, 3 VIBERZI 3 PA, QL ZELNORM 3 GOLD COMPOUNDS GOLD COMPOUNDS MYOCHRYSINE MSD RIDAURA 3 HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET 4 deferasirox 1, 3, 4 deferoxamine mesylate MSD FERRIPROX 3, 4 penicillamine 1, 3, 4 RADIOGARDASE 3 trientine hcl 1, 3 HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS budesonide 1, 3, 4 CELESTONE SOLUSPAN MSD CORTISONE ACETATE 1 dexamethasone 1, 2 dexamethasone sodium phosphate MSD EMFLAZA 4 PA, LD fludrocortisone acetate 1 hydrocortisone 1, 3 INTRAROSA 3 methylprednisolone 1, 2, 3 methylprednisolone acetate MSD methylprednisolone sod succ MSD MILLIPRED 1, 2, 3 prednisolone sodium phosphate 1, 3 prednisone 1, 2, 3 SOLU-CORTEF MSD TRELEGY ELLIPTA 3 triamcinolone acetonide MSD ANDROGENS ANADROL-50 3 ANDROID 1, 3 ANDROXY 1 AVEED MSD danazol 1 oxandrolone 1, 4


32

Name of drug Drug Tier Restrictions testosterone 1, 3 testosterone cypionate 1, 2 QL TESTOSTERONE ENANTHATE 1, 3 QL CONTRACEPTIVES ANNOVERA PRV BALCOLTRA PRV desogestrel & ethinyl estradiol PRV desogestrel-ethinyl estradiol (biphasic) PRV desogestrel-ethinyl estradiol (triphasic) PRV drospirenone-ethinyl estradiol PRV drospirenone-ethinyl estradiol-levomefolate calcium PRV ELLA PRV ethynodiol diacet & eth estrad PRV etonogestrel-ethinyl estradiol PRV levonorgestrel & eth estradiol PRV levonorgestrel (emergency oc) PRV levonorgestrel-eth estradiol (triphasic) PRV levonorgestrel-ethinyl estradiol (91-day) PRV levonorgestrel-ethinyl estradiol (continuous) PRV LO LOESTRIN FE PRV NATAZIA PRV NECON 10/11 (28) PRV norethin acet & estrad-fe PRV norethindrone & eth estradiol PRV norethindrone & ethinyl estradiol-fe PRV norethindrone (contraceptive) PRV norethindrone acet & eth estra PRV norethindrone acetate-ethinyl estradiol-fe PRV norethindrone-eth estradiol (triphasic) PRV norgestimate-ethinyl estradiol PRV norgestimate-ethinyl estradiol (triphasic) PRV norgestrel & ethinyl estradiol PRV SLYND PRV TWIRLA PRV XULANE PRV DIABETIC AGENTS acarbose 1, 3 ADLYXIN 3 ADMELOG 1, 2, 3 AFREZZA 2, 3 ALOGLIPTIN BENZOATE 1, 3 ALOGLIPTIN-METFORMIN HCL 1, 3 ALOGLIPTIN-PIOGLITAZONE 1, 3 APIDRA 3 AVANDIA 3 BAQSIMI TWO PACK 2 BYDUREON 3 CHLORPROPAMIDE 1 CYCLOSET 3 diazoxide 1, 3 FARXIGA 3 FIASP 3 glimepiride 1, 3 glipizide 1, 3 glipizide-metformin hcl 1


33

Name of drug Drug Tier Restrictions GLUCAGEN HYPOKIT 3 GLUCAGON EMERGENCY 2 glyburide 1 glyburide micronized 1, 3 glyburide-metformin 1, 3 GLYXAMBI 3 HUMALOG MIX 50/50 3 HUMULIN 70/30 2, 3 HUMULIN N 2, 3 INVOKAMET 3 INVOKANA 3 JANUMET 3 JANUVIA 3 JARDIANCE 2 JENTADUETO 3 KOMBIGLYZE XR 3 KORLYM 3 LD LANTUS 2, 3 LEVEMIR 3 metformin hcl 1, 3 miglitol 1, 3 nateglinide 1, 3 NOVOLOG 3 NOVOLOG MIX 70/30 3 ONGLYZA 3 OZEMPIC (0.25 OR 0.5 MG/DOSE) 3 pioglitazone hcl 1, 3 pioglitazone hcl-glimepiride 1, 3 pioglitazone hcl-metformin hcl 1, 3 QTERN 3 repaglinide 1, 3 REPAGLINIDE-METFORMIN HCL 1 SEGLUROMET 3 STEGLATRO 3 STEGLUJAN 3 SYMLINPEN 120 3 SYNJARDY 3 TANZEUM 3 TOLAZAMIDE 1 TOLBUTAMIDE 1 TRADJENTA 3 TRESIBA 3 TRULICITY 3 VICTOZA 3 XIGDUO XR 3 XULTOPHY 3 ESTROGENS AND ANTIESTROGENS ANGELIQ 3 BIJUVA 3 CLIMARA PRO 3 CLOMIPHENE CITRATE 1 DEPO-ESTRADIOL 3 QL DUAVEE 3 esterified estrogens & methyltestosterone 1 estradiol 1, 2, 3


34

Name of drug Drug Tier Restrictions estradiol & norethindrone acetate 1, 3 estradiol vaginal 1, 2, 3 estradiol valerate 1, 3 QL ESTROPIPATE 1 FEMRING 3 MENEST 3 norethindrone acetate-ethinyl estradiol 1, 3 PREFEST 3 PREMARIN 3, MSD PREMARIN 3 PREMPHASE 3 raloxifene hcl 1, 3 GONADOTROPINS BRAVELLE 2 QL CETROTIDE 2 QL CHORIONIC GONADOTROPIN 2 QL FENSOLVI (6 MONTH) MSD FOLLISTIM AQ 2 QL GANIRELIX ACETATE 2 QL GONAL-F 2 QL MENOPUR 2 QL ORILISSA 3 SYNAREL 3 TRIPTODUR MSD IUD KYLEENA MSD NEXPLANON MSD PARATHYROID calcitonin (salmon) 1, 3 QL FORTEO 4 QL NATPARA 4 QL, LD TYMLOS 4 QL PITUITARY ACTHAR 4 PA, QL, LD desmopressin acetate 1, 2, 3 QL desmopressin acetate refrigerated 1, 3 desmopressin acetate spray 1, 3 desmopressin acetate spray refrigerated 1 VASOSTRICT MSD PROGESTINS CRINONE 3 PA DEPO-PROVERA MSD HYDROXYPROGESTERONE CAPROATE MSD hydroxyprogesterone caproate 3, MSD QL medroxyprogesterone acetate 1, 3 medroxyprogesterone acetate (contraceptive) MSD megestrol acetate (appetite) 1, 3 norethindrone acetate 1, 3 progesterone 1 PA, QL progesterone micronized 1, 3 PA SOMATOTROPIN AGONISTS AND ANTAGONISTS EGRIFTA 3 QL, LD GENOTROPIN 2, 3, 4 QL INCRELEX 4 QL octreotide acetate 1, 3, 4, MSD QL


35

Name of drug Drug Tier Restrictions SAIZEN 3, 4 QL, LD SIGNIFOR 4 QL SIGNIFOR LAR MSD SOMATULINE DEPOT MSD SOMAVERT 4 QL, LD THYROID AND ANTITHYROID AGENTS levothyroxine sodium 1, 3, MSD liothyronine sodium 1, 3, MSD methimazole 1, 3 propylthiouracil 1 thyroid 1, 3 THYROLAR-1 3 MEDICAL DEVICE DIAPHRAGM CAYA PRV FEMCAP PRV WIDE-SEAL DIAPHRAGM 60 PRV IUD PARAGARD INTRAUTERINE COPPER MSD MEDICAL DEVICE AEROCHAMBER Z-STAT PLUS 2 AEROGEAR ACTION ASTHMA KIT 2 CATHFLO ACTIVASE MSD DEVILBISS COMPACT COMPRESSOR 2 DEVILBISS DISPOSABLE NEBULIZER 2 PIKO 1 2 MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS acetylcysteine 1 ACTEMRA 3, MSD PA, QL ACTIMMUNE 4 QL, LD ADAKVEO MSD ADDYI 3 QL adenosine (diagnostic) MSD albumin, human MSD alendronate sodium 1, 3 ALLERGIST TRAY 2 allopurinol 1, 3 allopurinol sodium MSD amifostine MSD ARCALYST 4 QL ATGAM MSD AUBAGIO 4 PA, LD AVONEX 3 PA, QL AVSOLA MSD azathioprine 1, 3 AZATHIOPRINE SODIUM MSD BACTERIOSTATIC WATER(BENZ ALC) MSD BASAGLAR KWIKPEN 3 BD BLUNT FILL NEEDLE 2 BENLYSTA 4, MSD QL BERINERT 4, MSD QL, LD BOTOX MSD BRIDION MSD bupivacaine hcl MSD


36

Name of drug Drug Tier Restrictions bupivacaine in dextrose MSD bupivacaine w/ epinephrine MSD CABLIVI MSD CAMPHOR 2 CAMPHOR BLOCKS 2 CAMPHOR SPIRIT 1 CERDELGA 4 LD CERVIDIL MSD CHLORAMPHENICOL 2 chloroprocaine hcl MSD CIMZIA 3, 4, MSD PA, QL cinacalcet hcl 1, 3 COAL TAR 2 colchicine 1, 3 CORTROSYN MSD CRYSVITA MSD cyclosporine 1, 2, MSD cyclosporine modified (for microemulsion) 1, 3 CYSTADANE 4 LD CYSTAGON 4 LD dalfampridine 1, 4 PA, LD DEFITELIO MSD DEMSER 3 dexrazoxane hcl MSD DIETHYLSTILBESTROL 2 DILTIAZEM HCL 2 disulfiram 1, 3 dopamine in d5w MSD DROXIA 3, 4 dutasteride 1, 3 dutasteride-tamsulosin hcl 1, 3 DYSPORT MSD ELMIRON 3 ENBREL 2, 3 PA, QL ENDARI 3 EOVIST MSD ETIDRONATE DISODIUM 1 EVENITY MSD everolimus (immunosuppressant) 1, 3, 4 EXONDYS 51 MSD EXPAREL MSD EXTAVIA 2 QL FC2 FEMALE CONDOM PRV febuxostat 1, 3 finasteride 1, 3 FLORIVA 3 fomepizole MSD FOSAMAX PLUS D 3 GADAVIST MSD GALAFOLD 3 GAMIFANT MSD GILENYA 4 PA GIVLAARI MSD glatiramer acetate 1, 3, 4 QL GLUCAGEN DIAGNOSTIC MSD


37

Name of drug Drug Tier Restrictions GRASTEK 3 HUMIRA 2, 3 PA, QL HYDROCORTISONE 2 HYDROCORTISONE MICRONIZED 2 HYDROXYUREA 2 ibandronate sodium 1, 3, MSD icatibant acetate 1, 4 QL INFLECTRA MSD KALBITOR MSD LD KETAMINE HCL 2 KETOPROFEN 2 KEVZARA 4 PA, QL KHAPZORY MSD KINERET 3 PA, QL KUVAN 4 leflunomide 1, 3 LEMTRADA MSD LETS MSD leucovorin calcium 1, MSD LEUCOVORIN CALCIUM 2 levocarnitine (metabolic modifiers) 3, MSD levoleucovorin calcium MSD LEXISCAN MSD LIDOCAINE 2 LIDOCAINE HCL 2 lidocaine hcl (local anesth.) MSD LIDOCAINE IN DEXTROSE MSD lidocaine w/ epinephrine MSD LUCEMYRA 3 MAGNEVIST MSD MAVENCLAD (10 TABS) 3 PA, LD MAYZENT 3 PA MENTHOL 2 mepivacaine hcl MSD mesna 2, MSD methylergonovine maleate 1, MSD MIFEPREX 2 miglustat 1, 4 LD MONOJECT PISTON SYRINGE 2 MONOJECT SYRINGE 2 MYALEPT 3 QL, LD mycophenolate mofetil 1, 3 mycophenolate mofetil hcl MSD mycophenolate sodium 1, 3 NITYR 3, 4 LD nonoxynol-9 PRV NULOJIX MSD NYSTATIN 2 OCREVUS MSD ODACTRA 2 OLUMIANT 3, 4 PA ONPATTRO MSD ORALAIR 3 ORENCIA 4, MSD PA, QL OSPHENA 3


38

Name of drug Drug Tier Restrictions OTEZLA 4 PA, QL OTREXUP 3 PA, QL OXBRYTA 3 oxytocin MSD pamidronate disodium MSD PANHEMATIN MSD PARSABIV MSD PCCA LIPODERM BASE 2 PHENOL 2 PHEXXI MSD PLASMANATE MSD PROLIA 4, MSD QL PROVAYBLUE MSD PROVOCHOLINE MSD PYRIDIUM 3 QUADRAMET MSD RAGWITEK 3 READI-CAT 2 2 REMICADE MSD RENFLEXIS MSD RINVOQ 4 PA risedronate sodium 1, 3 ropivacaine hcl MSD RUCONEST MSD LD SALICYLIC ACID 2 SAXENDA 3 QL SCULPTRA MSD SIMPONI 4, MSD PA, QL SIMULECT MSD sirolimus 1, 3, 4 sodium fluoride PRV SOLIQUA 3 SPINRAZA MSD SSKI 2 SULFAMETHOXAZOLE 2 SULFUR 2 SUPPRELIN LA MSD tacrolimus 1, 3, MSD TAKHZYRO 3 QL TECFIDERA 4 PA, LD TEGSEDI 3 PA, QL THALOMID 4 PA, LD THIOLA 4 LD THYMOGLOBULIN MSD THYMOL 2 THYROGEN MSD TUBERSOL MSD TYBOST 3 TYSABRI MSD ULTOMIRIS MSD LD VISTOGARD 3 VORAXAZE MSD VUMERITY 3 PA VYONDYS 53 MSD water for injection, sterile MSD


39

Name of drug Drug Tier Restrictions XELJANZ 2, 3 PA XEOMIN MSD XURIDEN 3 yohimbine hcl 1 ZINBRYTA 4 QL zoledronic acid MSD ZOLGENSMA 10.1-10.5 KG MSD MUSCULOSKELETAL THEARPY BETASERON 4 QL DUROLANE MSD VITAMINS phytonadione MSD potassium aminobenzoate 1, 2, 3 RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR MSD cromolyn sodium 1 cromolyn sodium (mastocytosis) 1, 4 FASENRA 4, MSD PA, QL montelukast sodium 1, 3 NUCALA 3, MSD PA, QL zafirlukast 1, 3 zileuton 1, 3, 4 ANTITUSSIVES benzonatate 1 DURATUSS HD 2 FLOWTUSS 3 QL guaifenesin-codeine 1 QL HYCOFENIX 3 QL hydrocodone w/ homatropine 1 QL phenyleph-cpm w/ hydrocod 1 phenylephrine-ephedrine-chlorpheniramine w/ carbetapentane 1 TUZISTRA XR 3 QL VITUZ 3 QL RESPIRATORY AGENTS, MISCELLANEOUS ADEMPAS 4 LD ALVESCO 2 ambrisentan 1, 4 LD ARALAST NP MSD LD ARNUITY ELLIPTA 3 ASMANEX (120 METERED DOSES) 3 bosentan 4 LD BREO ELLIPTA 3 brompheniramine & phenyleph 1 budesonide (inhalation) 1, 3 BUDESONIDE-FORMOTEROL FUMARATE 1, 3 DALIRESP 3 DULERA 3 ESBRIET 3, 4 LD FLOVENT DISKUS 3 FLOVENT HFA 2, 3 KALYDECO 3 LD OFEV 4 PA, LD OPSUMIT 4 LD ORENITRAM 4 LD


40

Name of drug Drug Tier Restrictions ORKAMBI 2, 3 LD QVAR 3 QVAR REDIHALER 3 sodium chloride (inhalant) 1 SYMDEKO 4 LD treprostinil 3, MSD LD TRIKAFTA 4 LD UPTRAVI 4 LD VENTAVIS 4 LD XOLAIR MSD LD SERUMS, TOXOIDS, AND VACCINES SERUMS ASCENIV MSD BIVIGAM MSD CUTAQUIG 4 QL GAMASTAN MSD GAMMAGARD 2 QL HIZENTRA 4 QL HYQVIA 3, 4 QL, LD IMOGAM RABIES-HT MSD NABI-HB MSD PANZYGA MSD VARIZIG MSD XEMBIFY 4 QL ZINPLAVA MSD TOXOIDS ADACEL MSD DIPHTHERIA-TETANUS TOXOIDS DT MSD KINRIX MSD TDVAX MSD TE ANATOXAL BERNA MSD VACCINES ACTHIB MSD ADACEL MSD BEXSERO MSD DAPTACEL MSD ENGERIX-B MSD FLULAVAL QUADRIVALENT MSD FLUZONE HIGH-DOSE QUADRIVALENT MSD GARDASIL 9 MSD HAVRIX MSD HEPLISAV-B MSD IMOVAX RABIES MSD IPOL MSD IXIARO MSD JE-VAX MSD M-M-R II MSD MENACTRA MSD MENOMUNE MSD MENVEO MSD MERUVAX II W/DILUENT 10 DOSE MSD MUMPSVAX W/DILUENT 10 DOSE MSD PEDIARIX MSD PNEUMOVAX 23 MSD PREVNAR 13 MSD


41

Name of drug Drug Tier Restrictions PROQUAD MSD RABAVERT MSD ROTARIX MSD ROTATEQ MSD SHINGRIX MSD STAMARIL MSD TRUMENBA MSD TWINRIX MSD TYPHIM VI MSD VARIVAX MSD VAXCHORA MSD VIVOTIF 2 ZOSTAVAX MSD SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir topical 1, 3 ALTABAX 3 BACTROBAN NASAL 3 benzoyl peroxide-erythromycin 1, 3 ciclopirox 1, 3 ciclopirox olamine 1, 3 CLINDACIN PAC 3 clindamycin phosphate (topical) 1, 3 clindamycin phosphate vaginal 1, 3 clindamycin phosphate-benzoyl peroxide 1, 3 clindamycin phosphate-benzoyl peroxide (refrigerate) 1, 3 CLINDESSE 3 clotrimazole 1 clotrimazole (topical) 1 clotrimazole w/ betamethasone 1, 3 DENAVIR 3 econazole nitrate 1, 3 ERTACZO 3 erythromycin (acne aid) 1, 3 ESKATA MSD EURAX 3 EXELDERM 3 gentamicin sulfate (topical) 1 GYNAZOLE-1 3 iodoquinol-hc 1 iodoquinol-hydrocortisone in aloe vehicle 1, 3 ivermectin (rosacea) 1, 3 ketoconazole (topical) 1, 3 LINDANE 1 LULICONAZOLE 3 mafenide acetate 1, 3 malathion 1, 3 MENTAX 3 metronidazole (topical) 1, 3 metronidazole vaginal 1, 2, 3 MICONAZOLE 3 1 mupirocin 1, 3 mupirocin calcium (topical) 1, 3 naftifine hcl 1, 3 NATROBA 1, 3


42

Name of drug Drug Tier Restrictions NEOMYCIN-POLYMYXIN B GU 1 NEUAC 3 nystatin (topical) 1 OVACE PLUS 3 oxiconazole nitrate 1, 3 permethrin 1, 3 ROSADAN 3 selenium sulfide 1 silver sulfadiazine 1, 3 SKLICE 3 sulfacetamide sodium (acne) 1, 3 sulfacetamide sodium w/ sulfur 1, 3 terconazole vaginal 1 ULESFIA 3 XEPI 3 XERESE 3 ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) alclometasone dipropionate 1 AMCINONIDE 1 APEXICON E 3 betamethasone dipropionate (topical) 1 betamethasone dipropionate augmented 1, 3 betamethasone valerate 1, 3 calcipotriene-betamethasone dipropionate 1, 3, 4 clobetasol propionate 1, 2, 3 clobetasol propionate emollient base 1 clobetasol propionate emulsion 1, 3 CLOCORTOLONE PIVALATE 1, 3 CLODAN 3 CORTIFOAM 3 CORTISPORIN 3 CORTISPORIN 3 DERMATOP 1, 3 desonide 1, 3 desoximetasone 1, 3 diflorasone diacetate 1 DUOBRII 3 EUCRISA 3 fluocinolone acetonide 1, 3 fluocinonide 1, 3 fluocinonide emulsified base 1 flurandrenolide 1, 3 fluticasone propionate 1, 3 halcinonide 1, 3 halobetasol propionate 1, 3, 4 hydrocortisone (intrarectal) 1, 3 hydrocortisone (rectal) 1, 3 hydrocortisone (topical) 1, 3 hydrocortisone acetate (rectal) 1 hydrocortisone butyrate 1, 3 hydrocortisone butyrate hydrophilic lipo base 1, 3 hydrocortisone valerate 1 MICORT-HC 3 mometasone furoate 1, 3 NEO-SYNALAR 3


43

Name of drug Drug Tier Restrictions NEO-SYNALAR 3 nystatin-triamcinolone 1 PANDEL 3 triamcinolone acetonide (mouth) 1 triamcinolone acetonide (topical) 1, 2, 3 UCERIS 3 urea-hc acetate 1 ANTIPRURITICS AND LOCAL ANESTHETICS ADAZIN 3 DOXEPIN HCL 1, 3 hydrocortisone acetate w/ pramoxine 1, 3 lidocaine 1, 3 lidocaine hcl 1, 3 lidocaine-prilocaine 1 PLIAGLIS 3, MSD CELL STIMULANTS AND PROLIFERANTS AKLIEF 3 KEPIVANCE MSD tretinoin 1, 2, 3 tretinoin microsphere 1, 3 SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS acitretin 1, 3 adapalene 1, 2, 3 adapalene-benzoyl peroxide 1, 3 aluminum chloride 1, 3 AMELUZ MSD azelaic acid 1, 3 AZELEX 3 calcipotriene 1, 3 CALCITRIOL 2, 3 clindamycin phosphate-tretinoin 1, 3 COSENTYX 4 PA, QL dapsone (topical) 1, 3 DICLOFENAC EPOLAMINE 1, 3 diclofenac sodium (actinic keratoses) 1, 3 diclofenac sodium (topical) 1, 3 DOXYCYCLINE 1, 3 DUPIXENT 3, 4 PA, QL FABIOR 3 fluorouracil (topical) 1, 3, 4 ILUMYA MSD PA imiquimod 1, 3 isotretinoin 1, 3 lactic acid (ammonium lactate) 1 methoxsalen rapid 1, 3 MIRVASO 3 PANRETIN 3 PICATO 3 pimecrolimus 1, 3 podofilox 1, 3 QBREXZA 3 RECTIV 3 REGRANEX 3 RHOFADE 3 salicylic acid 1, 2


44

Name of drug Drug Tier Restrictions SANTYL 2 SILIQ 4 PA, QL, LD SKYRIZI (150 MG DOSE) 4 PA, QL STELARA MSD STELARA 4 PA, QL tacrolimus (topical) 1, 3 TALTZ 4 PA, QL TARGRETIN 3 tazarotene 1, 3 TREMFYA 4 PA, QL urea 1, 3 UVADEX MSD VALCHLOR 4 LD VEREGEN 3 XIMINO 3 SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS aminophylline MSD darifenacin hydrobromide 1, 3 flavoxate hcl 1 MYRBETRIQ 3 oxybutynin chloride 1, 3 solifenacin succinate 1, 3 theophylline 1, 3 tolterodine tartrate 1, 3 TOVIAZ 3 trospium chloride 1 VASODILATING AGENTS MISCELLANEOUS THERAPEUTIC AGENTS CAVERJECT 2 QL LEVITRA 3 QL sildenafil citrate 1, 3 QL tadalafil 1, 3 PA, QL VITAMINS VITAMINS AQUASOL A MSD ascorbic acid MSD calcitriol 1, 3, MSD cyanocobalamin 1, 3 QL doxercalciferol 1, MSD DURACHOL 3 ENBRACE HR 3 ergocalciferol 1 FERIVA 21/7 3 FERIVAFA 3 ferrous sulfate PRV FLORIVA 3 folic acid 1, PRV QL INFED MSD INFUVITE ADULT MSD INFUVITE PEDIATRIC MSD iron polysaccharide complex-vit b12-folic acid 1 multiple vitamins w/ minerals 1 NIACOR 1 paricalcitol 1, 3, MSD


45

Name of drug Drug Tier Restrictions ped multivitamins w/fl & iron 1, 2 pediatric multivitamins w/fl 1, 3 pediatric vitamins acd fluoride & iron 1 pediatric vitamins acd w/ fluoride 1 phytonadione 1, 2, MSD prenatal vit w/ ferrous fumarate-folic acid 1 prenatal vit w/ iron carbonyl-folic acid 1, 2 PYRIDOXINE HCL MSD RAYALDEE 3 thiamine hcl MSD TRIFERIC MSD VENOFER MSD VINATE M 2


46

Nondiscrimination Statement

It is the policy of Kaiser Foundation Health Plan of the Mid-Atlantic, Inc. (Kaiser Health Plan) not to discriminate on the basis of race, color, national origin, sex, age or disability. Kaiser Health Plan has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. 18116) and its implementing regulations at 45 CFR part 92, issued by the U.S. Department of Health and Human Services. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age or disability in certain health programs and activities. Section 1557 and its implementing regulations may be examined in the office of Kaiser Civil Rights Coordinator, 2101 East Jefferson Street, Rockville, MD 20852, telephone number: 1-800- 777- 7902, who has been designated to coordinate the efforts of the Kaiser Health Plan to comply with Section 1557.

Any person who believes someone has been subjected to discrimination on the basis of race, color, national origin, sex, age or disability may file a grievance under this procedure. It is against the law for Kaiser Health Plan to retaliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance.

Procedure:

• Grievances must be submitted to the Section 1557 Coordinator within (60 days) of the date the person filing the grievance becomes aware of the alleged discriminatory action.

• A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought.

• The Section 1557 Coordinator (or her/his designee) shall conduct an investigation of the complaint. This investigation may be informal, but it will be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 1557 Coordinator will maintain the files and records of Kaiser Health Plan relating to such grievances. To the extent possible, and in accordance with applicable law, the Section 1557 Coordinator will take appropriate steps to preserve the confidentiality of files and records relating to grievances and will share them only with those who have a need to know.

• The Section 1557 Coordinator will issue a written decision on the grievance, based on a preponderance of the evidence, no later than 30 days after its filing, including a notice to the complainant of their right to pursue further administrative or legal remedies.

The availability and use of this grievance procedure does not prevent a person from pursuing other legal or administrative remedies, including filing a complaint of discrimination on the basis of race, color, national origin, sex, age or disability in court or with the U.S. Department of Health and Human Services, Office for Civil Rights. A person can file a complaint of

discrimination electronically through the Office for Civil Rights Complaint Portal, which is available at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201. Toll free#:800-368-1019 TDD: 800-537-7697

Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html. Such complaints must be filed within 180 days of the date of the alleged discrimination.

Kaiser Health Plan will make appropriate arrangements to ensure that individuals with disabilities and individuals with limited English proficiency are provided auxiliary aids and services or language assistance services, respectively, if needed to participate in this grievance process. Such arrangements may include, but are not limited to, providing qualified interpreters, providing taped cassettes of material for individuals with low vision, or assuring a barrier-free location for the proceedings. The Section 1557 Coordinator will be responsible for such arrangements.

http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Language Accessibility Statement

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