flexible choice and out-of-area ppo (ooa-ppo) formulary · the following is a list of the drugs on...

Flexible Choice and Out-of-Area PPO (OOA-PPO) Formulary Last Update: 5/5/2020

The following is a list of the drugs on the Kaiser Permanente Mid-Atlantic States Flexible Choice and OOA-PPO formulary. 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 formulary applies only to outpatient drugs and self-administered drugs. It does not apply to medical service drugs or medications used in a hospital or surgery center or medications administered in a doctor’s office or infusion center. The formulary does not provide information about your plan’s specific coverage, limitations, or exclusions. For additional information regarding your pharmacy benefits, please consult your Evidence of Coverage (EOC) and/or Certificate of Insurance (COI).

There are many brand and generic medications on the Kaiser Permanente Flexible Choice and OOA- PPO formulary. In most cases, all your providers will prescribe a generic equivalent. As a Kaiser Permanente Flexible Choice or OOA-PPO member, the amount you pay for your prescription is determined by the tier (e.g., generic, preferred brand name, non-preferred brand name, specialty (if applicable) or non-formulary) along with where you decide to fil l your prescription . You may wan t to consult your physician for a generic alternative that may cost you less or asa FlexibleChoic emember have your prescription filled at one of our convenient Kaiser Permanente medical center pharmacies.

Some plans have a separate specialty drug tier with a specialty tier copay or coinsurance, depending on your plan. Specialty drugs include self-administered injectables, medications that are typically high cost and medications that require special dispensing and/or monitoring. The details of your outpatient prescription drug benefit, including any specific limitations or exclusions can be found in your EOC and/or COI. A listing of specialty tier drugs can be found on page 46.

Under Option 1 of your Flexible Choice plan, you may fill your prescription at a Kaiser Permanente medical center pharmacy. Your Permanente physician can send most prescriptions electronically from his or her office directly to the pharmacy, where you can pick up your medication. If your prescription is for a non-preferred brand name drug, your physician will need to request an exception to the formulary and document that the non-formulary drug is medically necessary for your treatment and that no formulary drug is suitable for you.

Under Option 2 of your Flexible Choice plan or under the Participating pharmacy network option (Par) of your OOA-PPO plan, MedImpact is the company Kaiser Permanente has chosen to manage the p harmacy benefits covered under your plan. MedImpact has a network that consists of local and national pharmacies. “Participating p harmacies” include:

• Costco• Harris Teeter• Rite Aid• Shoppers Food Warehouse• Walgreens• Wegmans

• CVS• Giant• Kmart• Safeway• Wal-Mart

Not all locations within a pharmacy chain company are contracted with MedImpact; some are independently contracted. To verify if a pharmacy participates, please log on to medimpact.com. To

140302_FlexibleChoiceFormulary 1

http://medimpact.com

obtain a complete list of participating pharmacies, call MedImpact customer service at 800-788-2949, 24 hours per day/seven days a week.

Under Option 3 of your Flexible Choice plan or under the Non-Participating out of network pharmacy (Non-Par) option of your OOA-PPO plan, you may fill your prescription at any pharmacy that is not part of Option 1, Option 2, or the Par network. If you fill your prescription at an Option 3 or Non- Par out-of- network pharmacy, you should expect to pay for your prescription drugs and then submit a claim for reimbursement.

How to use the formulary document

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. Drugs 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 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 specific 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 the following three tiers:

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

Please note that some plans have a separate specialty drug tier (Tier 4) with a specialty tier copay or coinsurance. The details of your outpatient prescription drug benefit, including any specific limitations or exclusions can be found in your EOC and/or COI . A listing of specialty tier d rugs c an be found on p age 4 6.

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

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Restrictions on medication coverage

Some covered drugs may have additional requirements or limits on coverage. Please consult your EOC and/or COI 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.

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

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

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

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

LD = Limited Distribution Drugs

OC = Oral Chemotherapy Drugs

QL =A dr ug wit h a quantit y limit

PRV = Zero Cost Share Preventive Drugs

MSD =M edical Servic e Drugs

For more information about the formulary or Option 1 of your Flexible Choice plan, please contact Member Services at 888-225-7202 (TTY 711) Monday through Friday, 7:30 a.m. until 5:30 p.m. For information on Options 2 or 3 of your Flexible Choice plan or the OOA-PPO plan, please contact Kaiser Permanente Insurance Company Member Services at 800-392-8649 Monday through Friday, 9 a.m. until 9 p.m.

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Name of drug Drug Tier RestrictionsANTI-INFECTIVE AGENTSANTHELMINTICSalbendazole 1, 3EMVERM 3ivermectin 1, 3praziquantel 1, 3ANTIBACTERIALSamikacin sulfate MSDamoxicillin 1, 3amoxicillin & pot clavulanate 1, 3ampicillin 1ampicillin & sulbactam sodium MSDampicillin sodium MSDARIKAYCE 3 LDAVYCAZ MSDAZACTAM IN DEXTROSE MSDazithromycin 1, 2, 3, MSDaztreonam MSDbacitracin MSDBAXDELA 3, MSDBICILLIN C-R MSDBICILLIN L-A MSDCAYSTON 3 LDcefaclor 1CEFACLOR ER 1cefadroxil 1cefazolin sodium MSDCEFAZOLIN SODIUM-DEXTROSE MSDcefdinir 1CEFDITOREN PIVOXIL 3cefepime hcl MSDCEFEPIME-DEXTROSE MSDcefixime 1, 3cefotaxime sodium MSDcefotetan disodium MSDCEFOTETAN DISODIUM-DEXTROSE MSDcefoxitin sodium MSDCEFOXITIN SODIUM-DEXTROSE MSDcefpodoxime proxetil 1cefprozil 1ceftazidime MSDCEFTAZIDIME AND DEXTROSE MSDceftriaxone sodium MSDcefuroxime axetil 1, 2, 3cefuroxime sodium MSDcephalexin 1, 3CHLORAMPHENICOL SOD SUCCINATE MSDciprofloxacin 1, 3, MSDciprofloxacin hcl 1, 3ciprofloxacin in d5w MSDCIPROFLOXACIN-CIPROFLOX HCL ER 1clarithromycin 1clindamycin hcl 1, 3clindamycin palmitate hydrochloride 1, 3clindamycin phosphate MSD

LEGENDLD = Limited Distribution OC = Oral Chemo Drugs MSD = Medical Service DrugsQL = Quantity Limit PRV = $0 Preventive Drugs PA = Prior Authorization

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Name of drug Drug Tier Restrictionsclindamycin phosphate in d5w MSDcolistimethate sodium MSDDALVANCE MSDdaptomycin MSDdemeclocycline hcl 1dicloxacillin sodium 1DIFICID 3DORIBAX MSDdoxycycline (monohydrate) 1, 3doxycycline hyclate 1, 3, MSDertapenem sodium MSDERYTHROCIN LACTOBIONATE MSDERYTHROCIN STEARATE 1erythromycin base 1erythromycin ethylsuccinate 1, 3erythromycin-sulfisoxazole 1FACTIVE 3FETROJA MSDFORTAZ IN D5W MSDgentamicin in saline MSDgentamicin sulfate MSDimipenem-cilastatin MSDlevofloxacin 1, 3, MSDlevofloxacin in d5w MSDLINCOCIN MSDlinezolid 1, MSDLINEZOLID IN SODIUM CHLORIDE MSDmeropenem MSDMEROPENEM-SODIUM CHLORIDE MSDminocycline hcl 1, 3, MSDmoxifloxacin hcl 1, 3, MSDmoxifloxacin hcl in sodium chloride MSDnafcillin sodium MSDNAFCILLIN SODIUM IN DEXTROSE MSDneomycin sulfate 1NUZYRA 3, MSDofloxacin 1ORBACTIV MSDoxacillin sodium MSDOXACILLIN SODIUM IN DEXTROSE MSDPCE 3PENICILLIN G POT IN DEXTROSE MSDpenicillin g potassium MSDPENICILLIN G PROCAINE MSDPENICILLIN G SODIUM MSDpenicillin v potassium 1piperacillin sodium-tazobactam sodium MSDpolymyxin b sulfate MSDRECARBRIO MSDSEYSARA 3SIVEXTRO 3, MSDSTREPTOMYCIN SULFATE MSDSULFADIAZINE 1sulfamethoxazole-trimethoprim 1, 3, MSDsulfasalazine 1, 3

LEGENDLD = Limited Distribution OC = Oral Chemo Drugs MSD = Medical Service DrugsQL = Quantity Limit PRV = $0 Preventive Drugs PA = Prior Authorization

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Name of drug Drug Tier RestrictionsSYNERCID MSDTEFLARO MSDtetracycline hcl 1TIGECYCLINE MSDTIMENTIN MSDtobramycin 1tobramycin sulfate MSDVABOMERE MSDvancomycin hcl 1, 3, MSDVANCOMYCIN HCL IN DEXTROSE MSDVIBATIV MSDVIBRAMYCIN 3XENLETA 3, MSDXERAVA MSDXIFAXAN 3ZEMDRI MSDZERBAXA MSDZINACEF IN STERILE WATER MSDZOSYN MSDANTIFUNGALSABELCET MSDAMBISOME MSDAMPHOTERICIN B MSDcaspofungin acetate MSDciclopirox 1, 3 PACRESEMBA 3, MSDERAXIS MSDfluconazole 1, 3fluconazole in dextrose MSDfluconazole in nacl MSDflucytosine 1griseofulvin microsize 1griseofulvin ultramicrosize 1, 3itraconazole 1, 3 PAJUBLIA 3 PAKERYDIN 3 PAketoconazole 1MYCAMINE MSDnystatin 1nystatin (mouth-throat) 1ORAVIG 3posaconazole 3, MSDterbinafine hcl 1, 3 PAvoriconazole 1, 3, MSDANTIMYCOBACTERIALSCAPASTAT SULFATE MSDcycloserine 1dapsone 1ethambutol hcl 1, 3isoniazid 1, MSDPASER 3PRIFTIN 3pyrazinamide 1rifabutin 1, 3RIFAMATE 3

LEGENDLD = Limited Distribution QL = Quantity Limit

OC = Oral Chemo Drugs PRV = $0 Preventive Drugs

MSD = Medical Service DrugsPA = Prior Authorization

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Name of drug Drug Tier Restrictionsrifampin 1, 3, MSDRIFATER 3SIRTURO 3 LDTRECATOR 3ANTIPROTOZOALSALINIA 3ARAKODA 2, 3atovaquone 1atovaquone-proguanil hcl 1, 3BENZNIDAZOLE 3 LDchloroquine phosphate 1 PA, QLCOARTEM 2DARAPRIM 3 LDhydroxychloroquine sulfate 1, 3 PA, QLIMPAVIDO 3mefloquine hcl 1metronidazole 1, 3metronidazole in nacl MSDparomomycin sulfate 1pentamidine isethionate 1, 2, MSDprimaquine phosphate 2quinine sulfate 1, 3SOLOSEC 3tinidazole 1ANTIVIRALSabacavir sulfate 1, 3abacavir sulfate-lamivudine 1, 3abacavir sulfate-lamivudine-zidovudine 1, 3acyclovir 1, 3acyclovir sodium MSDadefovir dipivoxil 1APTIVUS 2atazanavir sulfate 1, 2, 3ATRIPLA 2BIKTARVY 2cidofovir MSDCIMDUO 2COMPLERA 2CRIXIVAN 2DAKLINZA 3 QLDELSTRIGO 2DESCOVY 2DIDANOSINE 1, 2, 3DOVATO 2EDURANT 2efavirenz 1, 3EMTRIVA 2entecavir 1, 3EPCLUSA 2 QLEVOTAZ 2famciclovir 1FLUMADINE 1, 2fosamprenavir calcium 1, 2, 3FOSCAVIR MSDFUZEON 2 QL




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Name of drug Drug Tier RestrictionsGANCICLOVIR MSDganciclovir sodium MSDGENVOYA 2HARVONI 2 QLINTELENCE 2INVIRASE 2, 3ISENTRESS 2JULUCA 2lamivudine 1, 3lamivudine (hbv) 1, 3lamivudine-zidovudine 1, 3lopinavir-ritonavir 1, 2, 3 PA, QLMAVYRET 3 QLnevirapine 1, 3ODEFSEY 2OLYSIO 3 QLoseltamivir phosphate 1, 3 QLPEGASYS 2 QLPEGINTRON 3 QLPIFELTRO 2PLEGRIDY 3 QLPREVYMIS 2, MSDPREZCOBIX 2PREZISTA 2RAPIVAB MSDRELENZA DISKHALER 2 QLRESCRIPTOR 3ribavirin (hepatitis c) 1, 3ritonavir 1, 2, 3 PA, QLSELZENTRY 2, 3SOVALDI 3 QLstavudine 1, 3STRIBILD 2SYMFI 2SYMTUZA 2SYNAGIS MSDTECHNIVIE 3 QLtenofovir disoproxil fumarate 1, 3TIVICAY 2TRIUMEQ 2TROGARZO MSDTRUVADA 2, 3valacyclovir hcl 1, 3valganciclovir hcl 1VEMLIDY 3VIEKIRA PAK 3 QLVIRACEPT 2VIRAZOLE MSDVOSEVI 3 QLXOFLUZA (40 MG DOSE) 3ZEPATIER 2 QLzidovudine 1, 3, MSDURINARY ANTI-INFECTIVESmethenamine hippurate 1, 3methenamine-hyosc-methylene blue-sod phos-phenyl sal 1




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Name of drug Drug Tier RestrictionsMONUROL 3nitrofurantoin 1, 3nitrofurantoin macrocrystal 1, 3nitrofurantoin monohyd macro 1, 3PRIMSOL 3trimethoprim 1UTA 3ANTIHISTAMINE DRUGSANTIHISTAMINE DRUGScarbinoxamine maleate 1, 3cetirizine hcl 1CLARINEX-D 12 HOUR 3CLEMASTINE FUMARATE 1cyproheptadine hcl 1desloratadine 1, 3DEXCHLORPHENIRAMINE MALEATE 1, 3diphenhydramine hcl MSDpromethazine & phenylephrine 1promethazine hcl 1, MSDSEMPREX-D 3ANTINEOPLASTIC AGENTSANTINEOPLASTIC AGENTSabiraterone acetate 1 OCABRAXANE MSDALECENSA 2 OCALFERON N MSDALIMTA MSDALIQOPA MSDALUNBRIG 2 OCanastrozole 1, 3 OCARRANON MSDarsenic trioxide MSDARZERRA MSDASPARLAS MSDAVASTIN MSDazacitidine MSDAZEDRA DOSIMETRIC MSDBALVERSA 3 OCBAVENCIO MSDBELEODAQ MSDBENDAMUSTINE HCL MSDBESPONSA MSDbexarotene 1 OCbicalutamide 1, 3 OCBICNU MSDbleomycin sulfate MSDBLINCYTO MSDBORTEZOMIB MSDBOSULIF 3 OCBRAFTOVI 3 LD, OCbusulfan 2, MSD OCCABOMETYX 2 LD, OCCALQUENCE 3 OCCAMPATH MSD LDcapecitabine 1, 3 OC




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Name of drug Drug Tier RestrictionsCAPRELSA 2 LD, OCcarboplatin MSDcisplatin MSDcladribine MSDclofarabine MSDCOPIKTRA 3 OCCOTELLIC 3 OCcyclophosphamide 1, 2, MSD PACYRAMZA MSDcytarabine MSDdacarbazine MSDdactinomycin MSDDARZALEX MSDdaunorubicin hcl MSDDAURISMO 3 OCdecitabine MSDDOCETAXEL MSDdoxorubicin hcl MSDdoxorubicin hcl liposomal MSDELIGARD 2, 3 QLELIGARD 2, 3 QLELIGARD 2, 3 QLELZONRIS MSDEMCYT 2 OCEMPLICITI MSDENHERTU MSDepirubicin hcl MSDERBITUX MSDERIVEDGE 3 OCERLEADA 3 OCerlotinib hcl 3 OCETOPOPHOS MSDetoposide 1, MSD OCeverolimus 1 OCexemestane 1, 3 OCFARYDAK 3 OCFIRMAGON MSDfloxuridine MSDfludarabine phosphate MSDfluorouracil MSDflutamide 1 OCFOLOTYN MSDfulvestrant MSDGAZYVA MSDgemcitabine hcl MSDGILOTRIF 3 OCGLEOSTINE 2 OCHALAVEN MSDHERCEPTIN MSDHERCEPTIN HYLECTA MSDHEXALEN 3 OChydroxyurea 1, 3 OCIBRANCE 2 OCICLUSIG 3 OCidarubicin hcl MSD




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Name of drug Drug Tier RestrictionsIDHIFA 3 OCifosfamide MSDimatinib mesylate 1 OCIMBRUVICA 3 OCIMFINZI MSDIMLYGIC MSDINFUGEM MSDINLYTA 2 OCINREBIC 3 OCINTRON A 2 QLIRESSA 2 OCirinotecan hcl MSDISTODAX (OVERFILL) MSDIXEMPRA KIT MSDJAKAFI 2 OCJEVTANA MSDKADCYLA MSDKANJINTI MSDKEYTRUDA MSDKISQALI (200 MG DOSE) 3 OCKISQALI FEMARA (300 MG DOSE) 3 OCKYPROLIS MSDLARTRUVO MSDLENVIMA (10 MG DAILY DOSE) 3 LD, OCletrozole 1, 3 OCLEUKERAN 2 OCleuprolide acetate 1, 2, 3 PA, QLLIBTAYO MSDLONSURF 3 OCLORBRENA 3 OCLUMOXITI MSDLUPANETA PACK MSDLUPRON DEPOT-PED (1-MONTH) 2 QLLUPRON DEPOT-PED (3-MONTH) 2 QLLUTATHERA MSDLYNPARZA 3 OCLYSODREN 2 LD, OCMARQIBO MSDMATULANE 2 OCmegestrol acetate 1MEKINIST 3 OCMEKTOVI 3 LD, OCmelphalan 1, 3 OCmelphalan hcl MSDmercaptopurine 1 OCmethotrexate sodium 1, 3, MSDmitomycin MSDmitoxantrone hcl MSDMUSTARGEN MSDMVASI MSDMYLOTARG MSDNERLYNX 2 OCNEXAVAR 3 OCnilutamide 1, 3 OCNINLARO 3 OC




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Name of drug Drug Tier RestrictionsNIPENT MSDNUBEQA 3 OCODOMZO 2 OCOGIVRI MSDONIVYDE MSDOPDIVO MSDoxaliplatin MSDpaclitaxel MSDPADCEV MSDPERJETA MSDPIQRAY (200 MG DAILY DOSE) 3 OCPOLIVY MSDPOMALYST 2 LD, OCPORTRAZZA MSDPOTELIGEO MSDPROLEUKIN MSDREVLIMID 2 PA, LDRITUXAN MSDRITUXAN HYCELA MSDROZLYTREK 3 OCRUBRACA 2 OCRUXIENCE MSDRYDAPT 2 OCSPRYCEL 2 OCSTIVARGA 2 OCSUTENT 2 OCSYLATRON 2 QLSYLVANT MSDSYNRIBO MSDTABLOID 2 OCTAFINLAR 2 OCTAGRISSO 2 OCTALZENNA 3 OCtamoxifen citrate 1, 3 PATASIGNA 2 OCTAZVERIK 3 OCTECENTRIQ MSDtemozolomide 1, MSD OCtemsirolimus MSDthiotepa MSDTIBSOVO 2 OCtopotecan hcl 1, MSD OCtoremifene citrate 1 OCTRAZIMERA MSDTRELSTAR MIXJECT MSDtretinoin (chemotherapy) 1 OCTRUXIMA MSDTURALIO 3 OCTYKERB 2 OCUNITUXIN MSDVECTIBIX MSDVENCLEXTA 2 OCVERZENIO 3 OCVINBLASTINE SULFATE MSDvincristine sulfate MSD




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Name of drug Drug Tier Restrictionsvinorelbine tartrate MSDVITRAKVI 3 LD, OCVIZIMPRO 3 OCVOTRIENT 3 OCVYXEOS MSDXALKORI 3 OCXATMEP 3XOSPATA 3 OCXPOVIO (100 MG ONCE WEEKLY) 3 OCXTANDI 2 OCYERVOY MSDYONDELIS MSDZALTRAP MSDZANOSAR MSDZEJULA 2 OCZELBORAF 2 OCZIRABEV MSDZOLADEX MSDZOLINZA 2 OCZYDELIG 3 OCZYKADIA 2 OCAUTONOMIC DRUGSANTICHOLINERGIC AGENTSANORO ELLIPTA 3atropine sulfate MSDATROVENT HFA 3BEVESPI AEROSPHERE 3chlordiazepoxide hcl-clidinium bromide 1, 3COCAINE HCL MSDdicyclomine hcl 1, 3, MSDglycopyrrolate 1, 3, MSDhyoscyamine 1hyoscyamine sulfate 1, 3INCRUSE ELLIPTA 3ipratropium bromide 1ipratropium bromide (nasal) 1LONHALA MAGNAIR REFILL KIT 3METHSCOPOLAMINE BROMIDE 1PROPANTHELINE BROMIDE 1SPIRIVA HANDIHALER 2, 3STIOLTO RESPIMAT 2TUDORZA PRESSAIR 3YUPELRI 3AUTONOMIC DRUGS, MISCELLANEOUSbupropion hcl (smoking deterrent) PRVCHANTIX PRV QLnicotine PRVnicotine polacrilex PRVPARASYMPATHOMIMETIC (CHOLINERGIC) AGENTSbethanechol chloride 1, 3cevimeline hcl 1, 3donepezil hydrochloride 1, 3FIRDAPSE 3galantamine hydrobromide 1, 3GUANIDINE HCL 3




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Name of drug Drug Tier RestrictionsNEOSTIGMINE METHYLSULFATE MSDPHYSOSTIGMINE SALICYLATE MSDpilocarpine hcl (oral) 1, 3pyridostigmine bromide 1, 3, MSDrivastigmine 1, 3rivastigmine tartrate 1RUZURGI 3SKELETAL MUSCLE RELAXANTSbaclofen 1, MSDcarisoprodol 1, 3carisoprodol w/ aspirin 1carisoprodol w/ aspirin & codeine 1 QLchlorzoxazone 1, 3cyclobenzaprine hcl 1, 3dantrolene sodium 1, 3, MSDmetaxalone 1, 3methocarbamol 1, 3, MSDorphenadrine citrate 1, MSDtizanidine hcl 1, 3SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTSalfuzosin hcl 1, 3dihydroergotamine mesylate 1, 3 QLERGOLOID MESYLATES 1ERGOMAR 3phenoxybenzamine hcl 1, 3silodosin 1, 3tamsulosin hcl 1, 3SYMPATHOMIMETIC (ADRENERGIC) AGENTSAKOVAZ MSDalbuterol sulfate 1, 2, 3 QLARCAPTA NEOHALER 3BIORPHEN MSDBROVANA 3dobutamine hcl MSDdobutamine in d5w MSDepinephrine MSDepinephrine (anaphylaxis) 1, 2, 3, MSD PA, QLfluticasone-salmeterol 1, 2, 3 QLipratropium-albuterol 1, 3levalbuterol hcl 1, 3LEVALBUTEROL TARTRATE 1, 3metaproterenol sulfate 1midodrine hcl 1NORTHERA 3PERFOROMIST 3SEREVENT DISKUS 2STRIVERDI RESPIMAT 2terbutaline sulfate 1, MSDUTIBRON NEOHALER 3BLOOD FORMATION, COAGULATION, AND THROMBOSISCOAGULANTS AND ANTICOAGULANTSAFSTYLA MSDAGGRASTAT MSDALPHANATE/VWF COMPLEX/HUMAN MSDALPROLIX MSD




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Name of drug Drug Tier Restrictionsaminocaproic acid MSDanagrelide hcl 1, 3ANDEXXA MSDargatroban MSDARGATROBAN IN SODIUM CHLORIDE MSDaspirin-dipyridamole 1, 3BEVYXXA 3bivalirudin trifluoroacetate MSDBIVALIRUDIN-SODIUM CHLORIDE MSDBRILINTA 2cilostazol 1clopidogrel bisulfate 1, 3COAGADEX MSDDURLAZA 3ELIQUIS 3ELOCTATE MSDenoxaparin sodium 1, 2, 3 QLFIBRYGA MSDfondaparinux sodium 1, 3 QLFRAGMIN 3 QLHEMLIBRA 2 QLheparin (porcine) in sodium chloride MSDHEPARIN SOD (PORCINE) IN D5W MSDheparin sodium (porcine) 1 QLheparin sodium (porcine) lock flush MSDIDELVION MSDINTEGRILIN MSDIPRIVASK 3 QLIXINITY MSDJIVI MSDKCENTRA MSDKENGREAL MSDKOVALTRY MSDNOVOEIGHT MSDNUWIQ MSDOBIZUR MSDpentoxifylline 1PRADAXA 2prasugrel hcl 1, 3PRAXBIND MSDREBINYN MSDSAVAYSA 3TAVALISSE 3 LDtranexamic acid 1, 3, MSDTRETTEN MSDVONVENDI MSDwarfarin sodium 1, 3XARELTO 3YOSPRALA 3ZONTIVITY 3HEMATOPOIETIC AGENTSARANESP (ALBUMIN FREE) 3 QLARANESP ALBUMIN FREE 3 QLDOPTELET 3EPOGEN 2 QL




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Name of drug Drug Tier RestrictionsFULPHILA 3 QLGRANIX 3 QLLEUKINE 2 QLMIRCERA 3 QLMOZOBIL MSDMULPLETA 3NEULASTA 3, MSD QLNEUMEGA 3 QLNEUPOGEN 3 QLNIVESTYM 3 QLNPLATE MSDPROMACTA 2, 3 LDREBLOZYL MSDRETACRIT 3 QLUDENYCA 3 QLZARXIO 2 QLCARDIOVASCULAR DRUGSA-ADRENERGIC BLOCKING AGENTSCARDURA XL 3doxazosin mesylate 1, 3prazosin hcl 1, 3terazosin hcl 1ANTILIPEMIC AGENTSatorvastatin calcium 1, 3cholestyramine 1, 3cholestyramine light 1, 3choline fenofibrate 1, 3colesevelam hcl 1, 3colestipol hcl 1, 3ezetimibe 1, 3ezetimibe-simvastatin 1, 3fenofibrate 1, 3fenofibrate micronized 1, 3FENOFIBRIC ACID 3fluvastatin sodium 1, 3gemfibrozil 1, 3JUXTAPID 3 LDKYNAMRO 3 QL, LDLIVALO 3lovastatin 1, 3niacin (antihyperlipidemic) 1, 3omega-3-acid ethyl esters 1, 3PRALUENT 3 PA, QLpravastatin sodium 1, 3REPATHA 3 PA, QLrosuvastatin calcium 1, 3simvastatin 1, 3VASCEPA 3ZYPITAMAG 3BETA-ADRENERGIC BLOCKING AGENTSesmolol hcl MSDlabetalol hcl MSDmetoprolol succinate 1metoprolol tartrate 1, MSDSOTYLIZE 3




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Name of drug Drug Tier RestrictionsCALCIUM-CHANNEL BLOCKING AGENTSamlodipine besylate 1, 3amlodipine besylate-atorvastatin calcium 1, 3amlodipine besylate-benazepril hcl 1, 3amlodipine besylate-olmesartan medoxomil 1, 3amlodipine besylate-valsartan 1, 3amlodipine-valsartan-hydrochlorothiazide 1, 3CARDENE IV MSDCLEVIPREX MSDCONSENSI 3diltiazem hcl 1, 3, MSDdiltiazem hcl coated beads 1, 3diltiazem hcl extended release beads 1, 3felodipine 1isradipine 1nicardipine hcl 1, MSDnifedipine 1, 3nimodipine 1, 3nisoldipine 1, 3olmesartan medoxomil-amlodipine-hydrochlorothiazide 1, 3PRESTALIA 3telmisartan-amlodipine 1, 3trandolapril-verapamil hcl 1, 3verapamil hcl 1, 3, MSDCARDIAC DRUGSadenosine MSDamiodarone hcl 1, MSDCORLANOR 3digoxin 1, 2, 3, MSDdisopyramide phosphate 1, 3dofetilide 1flecainide acetate 1lidocaine hcl (cardiac) MSDlidocaine in d5w MSDMEXILETINE HCL 1MULTAQ 3NEXTERONE MSDprocainamide hcl MSDpropafenone hcl 1, 3quinidine gluconate 1, MSDQUINIDINE SULFATE 1ranolazine 1, 3VYNDAMAX 3VYNDAQEL 3HYPOTENSIVE AGENTSclonidine 1, 3clonidine hcl 1, 3CORLOPAM MSDguanfacine hcl 1hydralazine hcl 1, MSDmethyldopa 1METHYLDOPA-HYDROCHLOROTHIAZIDE 1METHYLDOPATE HCL MSDminoxidil 1NIPRIDE RTU MSD




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Name of drug Drug Tier RestrictionsVECAMYL 3MISCELLANEOUS THERAPEUTIC AGENTSGIAPREZA MSDRENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORSaliskiren fumarate 1, 3benazepril & hydrochlorothiazide 1, 3benazepril hcl 1, 3candesartan cilexetil 1, 3candesartan cilexetil-hydrochlorothiazide 1, 3captopril 1CAPTOPRIL-HYDROCHLOROTHIAZIDE 1EDARBI 3EDARBYCLOR 3enalapril maleate 1, 3enalapril maleate & hydrochlorothiazide 1, 3ENTRESTO 2eplerenone 1, 3EPROSARTAN MESYLATE 1fosinopril sodium 1fosinopril sodium & hydrochlorothiazide 1irbesartan 1, 3irbesartan-hydrochlorothiazide 1, 3lisinopril 1, 3lisinopril & hydrochlorothiazide 1, 3losartan potassium 1, 3losartan potassium & hydrochlorothiazide 1, 3moexipril hcl 1moexipril-hydrochlorothiazide 1olmesartan medoxomil 1, 3olmesartan medoxomil-hydrochlorothiazide 1, 3perindopril erbumine 1quinapril hcl 1, 3quinapril-hydrochlorothiazide 1, 3ramipril 1, 3spironolactone 1, 3spironolactone & hydrochlorothiazide 1, 3TEKTURNA HCT 3telmisartan 1, 3telmisartan-hydrochlorothiazide 1, 3trandolapril 1valsartan 1, 3valsartan-hydrochlorothiazide 1, 3VASODILATING AGENTSBIDIL 3dipyridamole 1isosorbide dinitrate 1, 3isosorbide mononitrate 1nitroglycerin 1, 2, 3, MSDnitroglycerin in d5w MSDpapaverine hcl 1, MSDsildenafil citrate (pulmonary hypertension) 1, 3, MSD PAtadalafil (pulmonary hypertension) 1 PA, LD¿-ADRENERGIC BLOCKING AGENTSBYVALSON 3NADOLOL-BENDROFLUMETHIAZIDE 1




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Name of drug Drug Tier Restrictionspropranolol hcl 1, MSDPROPRANOLOL-HCTZ 1sotalol hcl 1, 3timolol maleate 1Ã¿-ADRENERGIC BLOCKING AGENTSBETAPACE AF 3BYSTOLIC 3carvedilol phosphate 1CORGARD 3LOPRESSOR 3propranolol hcl 1sotalol hcl 1TENORETIC 50 3TENORMIN 3TOPROL XL 3ß-ADRENERGIC BLOCKING AGENTSacebutolol hcl 1atenolol 1, 3atenolol & chlorthalidone 1, 3betaxolol hcl 1bisoprolol & hydrochlorothiazide 1, 3bisoprolol fumarate 1, 3BYSTOLIC 3carvedilol 1, 3carvedilol phosphate 1, 3INDERAL XL 3labetalol hcl 1, MSDmetoprolol & hydrochlorothiazide 1, 3metoprolol succinate 1, 3metoprolol tartrate 1, 3, MSDnadolol 1, 3nadolol & bendroflumethiazide 1, 3pindolol 1propranolol hcl 1, 3sotalol hcl 1, 3, MSDCENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICSacetaminophen w/ codeine 1, 3 QLacetaminophen-caff-dihydrocod 1, 3 QLalfentanil hcl MSDAPADAZ 1, 3 QLaspirin PRVaspirin buffered (cal carb-mag carb-mag oxide) PRVBUPRENORPHINE 1, 3 QLbuprenorphine hcl 1, 3 QLbutalbital-acetaminophen 1butalbital-acetaminophen-caffeine 1butalbital-acetaminophen-caffeine w/ codeine 1, 3 QLbutalbital-aspirin-caffeine 1, 3butalbital-aspirin-caffeine w/cod 1, 3 QLbutorphanol tartrate 1, MSD QLCAMBIA 3celecoxib 1, 3choline & mag salicylate 1clonidine hcl (analgesia) MSD




19

Name of drug Drug Tier Restrictionscodeine sulfate 1 QLdiclofenac potassium 1, 3diclofenac sodium 1diclofenac w/ misoprostol 1, 3diflunisal 1DUEXIS 3EMBEDA 2 QLetodolac 1, 3fenoprofen calcium 1, 3fentanyl 1, 3 QLfentanyl citrate 1, 3, MSD QLflurbiprofen 1GRALISE 3hydrocodone bitartrate 1, 3 QLhydrocodone-acetaminophen 1, 3 QLhydrocodone-ibuprofen 1 QLhydromorphone hcl 1, 3, MSD QLibuprofen 1ILARIS MSDindomethacin 1, 2, 3INFUMORPH 500 MSDIONSYS MSDketoprofen 1ketorolac tromethamine 1, 3, MSDlevorphanol tartrate 1 QLLYRICA CR 3MECLOFENAMATE SODIUM 1mefenamic acid 1, 3meloxicam 1, 3meperidine hcl 1, MSD QLmethadone hcl 1, 3, MSD QLmorphine sulfate 1, 2, 3, MSD QLMORPHINE SULFATE ER BEADS 1 QLnabumetone 1nalbuphine hcl MSDnaproxen 1, 3naproxen sodium 1, 3NUCYNTA 3 QLOFIRMEV MSDoxaprozin 1, 3oxycodone hcl 1, 2, 3 QLoxycodone w/ acetaminophen 1, 3 QLOXYCODONE-ASPIRIN 1 QLOXYCODONE-IBUPROFEN 1 QLoxymorphone hcl 1, 3 QLpentazocine w/ naloxone 1 QLpiroxicam 1, 3salsalate 1sulindac 1TALWIN MSDTOLMETIN SODIUM 1tramadol hcl 1, 3 QLtramadol-acetaminophen 1, 3 QLVIMOVO 3XTAMPZA ER 3 QL




20

Name of drug Drug Tier RestrictionsZORVOLEX 3ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTSADZENYS ER 1, 3amphetamine sulfate 1, 3amphetamine-dextroamphetamine 1, 2, 3armodafinil 1, 3caffeine citrate MSDCOTEMPLA XR-ODT 3dexmethylphenidate hcl 1, 3dextroamphetamine sulfate 1, 3methamphetamine hcl 1, 3methylphenidate hcl 1, 2, 3modafinil 1, 3SUNOSI 3VYVANSE 3ANTICONVULSANTSAPTIOM 3BANZEL 2BRIVIACT 3, MSDcarbamazepine 1, 3CELONTIN 2clobazam 1, 3clonazepam 1, 3 QLDIACOMIT 3 LDdivalproex sodium 1, 3EPIDIOLEX 3 LDEQUETRO 3ethosuximide 1, 3felbamate 1, 3fosphenytoin sodium MSDFYCOMPA 3gabapentin 1, 3HORIZANT 3lamotrigine 1, 3levetiracetam 1, 3, MSDLEVETIRACETAM IN NACL MSDmagnesium sulfate MSDNAYZILAM 3 QLoxcarbazepine 1, 3PEGANONE 3phenytoin 1, 3phenytoin sodium MSDphenytoin sodium extended 1, 2, 3POTIGA 3pregabalin 1, 3primidone 1, 3tiagabine hcl 1, 3topiramate 1, 3valproate sodium 1, 3, MSDvalproic acid 1, 3vigabatrin 1 LDVIMPAT 3, MSDzonisamide 1, 3ANTIMIGRAINE AGENTSAIMOVIG 3 QL




21

Name of drug Drug Tier RestrictionsAJOVY 3almotriptan malate 1, 3 QLeletriptan hydrobromide 1, 3 QLEMGALITY 3 QLergotamine w/ caffeine 1, 3frovatriptan succinate 1, 3 QLnaratriptan hcl 1, 3 QLrizatriptan benzoate 1, 3 QLsumatriptan 1, 3sumatriptan succinate 1, 3 QLsumatriptan-naproxen sodium 1, 3 QLzolmitriptan 1, 3 QLANTIPARKINSONIAN AGENTSamantadine hcl 1, 3 LDAPOKYN 3 QLbenztropine mesylate 1, MSDbromocriptine mesylate 1, 3cabergoline 1carbidopa 1, 3carbidopa-levodopa 1, 3CARBIDOPA-LEVODOPA-ENTACAPONE 1, 3entacapone 1, 3INBRIJA 3NEUPRO 3pramipexole dihydrochloride 1, 3rasagiline mesylate 1, 3ropinirole hydrochloride 1, 3selegiline hcl 1, 3tolcapone 1, 3trihexyphenidyl hcl 1XADAGO 3ANXIOLYTICS, SEDATIVES, AND HYPNOTICSalprazolam 1, 3 QLBELSOMRA 3 QLbuspirone hcl 1BUTISOL SODIUM 3chlordiazepoxide hcl 1 QLclorazepate dipotassium 1, 3 QLdexmedetomidine hcl MSDdexmedetomidine hcl in sodium chloride MSDDIASTAT ACUDIAL 1, 2 QLdiazepam 1, 3, MSD QLDORAL 3 QLdoxepin hcl (sleep) 1, 3 QLdroperidol MSDestazolam 1 QLeszopiclone 1, 3 QLetomidate MSDFLURAZEPAM HCL 1 QLHETLIOZ 3 LDhydroxyzine hcl 1, MSDhydroxyzine pamoate 1, 3ketamine hcl MSDlorazepam 1, 3, MSD QLmeprobamate 1




22

Name of drug Drug Tier Restrictionsmidazolam hcl 1, MSD QLoxazepam 1 QLphenobarbital 1PHENOBARBITAL SODIUM MSDpropofol MSDramelteon 1, 3 QLtemazepam 1, 3 QLtriazolam 1, 3 QLzaleplon 1 QLzolpidem tartrate 1, 3 QLCENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUSacamprosate calcium 1atomoxetine hcl 1, 3atracurium besylate MSDAUSTEDO 3BELVIQ 3cisatracurium besylate MSDclonidine hcl (adhd) 1, 3CONTRAVE 3flumazenil MSDguanfacine hcl (adhd) 1, 3INGREZZA 3ketamine hcl MSDmemantine hcl 1, 3MIVACRON MSDNAMZARIC 3NUEDEXTA 3phendimetrazine tartrate 1phentermine hcl 1QUELICIN MSDriluzole 1rocuronium bromide MSDSAVELLA 3sevoflurane MSDSUPRANE MSDtetrabenazine 1vecuronium bromide MSDXYREM 3 LDOPIATE ANTAGONISTSbuprenorphine hcl 1, MSD QLbuprenorphine hcl-naloxone hcl dihydrate 1, 3 QLnaloxone hcl 1, 2, 3 QLnaltrexone hcl 1SUBLOCADE MSD LDVIVITROL MSDPSYCHOTHERAPEUTIC AGENTSADASUVE MSDamitriptyline hcl 1AMOXAPINE 1APLENZIN 3aripiprazole 1, 3, MSDARISTADA MSDBRISDELLE 3bupropion hcl 1, 3 PACHLORDIAZEPOXIDE-AMITRIPTYLINE 1




23

Name of drug Drug Tier Restrictionschlorpromazine hcl 1, MSDcitalopram hydrobromide 1, 3clomipramine hcl 1, 3clozapine 1, 3 QLdesipramine hcl 1, 3DESVENLAFAXINE ER 3desvenlafaxine succinate 1, 3doxepin hcl 1duloxetine hcl 1, 3EMSAM 2escitalopram oxalate 1, 3FANAPT 3FETZIMA 3fluoxetine hcl 1, 3fluoxetine hcl (pmdd) 1, 3fluphenazine decanoate MSDfluphenazine hcl 1, MSDfluvoxamine maleate 1GEODON MSDhaloperidol 1haloperidol decanoate MSDhaloperidol lactate 1, MSDimipramine hcl 1, 3imipramine pamoate 1INVEGA SUSTENNA MSDLATUDA 3LITHIUM 2lithium carbonate 1, 3loxapine succinate 1MAPROTILINE HCL 1MARPLAN 3mirtazapine 1, 3MOLINDONE HCL 1NEFAZODONE HCL 1nortriptyline hcl 1, 3NUPLAZID 3olanzapine 1, 3, MSDolanzapine-fluoxetine hcl 1, 3ORAP 1, 3paliperidone 1, 3paroxetine hcl 1, 3perphenazine 1PERPHENAZINE-AMITRIPTYLINE 1PEXEVA 3phenelzine sulfate 1, 3prochlorperazine 1prochlorperazine maleate 1protriptyline hcl 1quetiapine fumarate 1, 3REXULTI 2RISPERDAL CONSTA MSDrisperidone 1, 3, MSDSAPHRIS 3sertraline hcl 1, 3SPRAVATO (5MSD MG DOSE) MSD




24

Name of drug Drug Tier Restrictionsthioridazine hcl 1thiothixene 1tranylcypromine sulfate 1, 3trazodone hcl 1trifluoperazine hcl 1trimipramine maleate 1, 3TRINTELLIX 3venlafaxine hcl 1, 3VIIBRYD 3VRAYLAR 3ziprasidone hcl 1, 3DIABETIC SUPPLIESDIABETIC SUPPLIESADVOCATE CONTROL SOLUTION 2BD INSULIN SYRINGE U-500 2BD LANCET ULTRAFINE 30G 2FREESTYLE TEST 2 QLNOVOFINE 2ONETOUCH VERIO FLEX SYSTEM 2PRECISION XTRA KETONE 2ELECTROLYTIC, CALORIC, AND WATER BALANCEACIDIFYING AND ALKALINIZING AGENTSK-PHOS NO 2 2pot & sod citrates w/citric ac 1potassium citrate (alkalinizer) 1, 3potassium citrate-citric acid 1SODIUM ACETATE MSDsodium bicarbonate MSDsodium citrate & citric acid 1SODIUM LACTATE MSDAMMONIA DETOXICANTSCARBAGLU 3lactulose 1, 3lactulose (encephalopathy) 1LITHOSTAT 3 LDRAVICTI 3 LDsodium phenylbutyrate 1CALORIC AGENTSamino acid electrolyte infusion MSDamino acid infusion MSDCLINIMIX E/DEXTROSE (2.75/10) MSDCLINIMIX E/DEXTROSE (2.75/5) MSDCLINIMIX E/DEXTROSE (4.25/25) MSDCLINIMIX E/DEXTROSE (5/15) MSDCLINIMIX E/DEXTROSE (5/20) MSDCLINIMIX/DEXTROSE (2.75/5) MSDCLINIMIX/DEXTROSE (4.25/10) MSDCLINIMIX/DEXTROSE (4.25/20) MSDCLINIMIX/DEXTROSE (4.25/25) MSDCLINIMIX/DEXTROSE (5/15) MSDdextrose MSDINTRALIPID MSDOMEGAVEN MSDDIURETICSamiloride & hydrochlorothiazide 1




25

Name of drug Drug Tier Restrictionsamiloride hcl 1bumetanide 1, MSDchlorothiazide 1, 3chlorothiazide sodium MSDchlorthalidone 1ethacrynate sodium MSDethacrynic acid 1, 3furosemide 1, 3, MSDhydrochlorothiazide 1, 3indapamide 1JYNARQUE 3 LDmannitol MSDMETHYCLOTHIAZIDE 1metolazone 1torsemide 1, 3triamterene 1, 3triamterene & hydrochlorothiazide 1, 3ION-REMOVING AGENTSAURYXIA 3lanthanum carbonate 1, 3LOKELMA 3sevelamer carbonate 1, 3sevelamer hcl 1, 3sodium polystyrene sulfonate 1, 2VELPHORO 3VELTASSA 3IRRIGATING SOLUTIONSacetic acid 1DIANEAL LOW CALCIUM/1.5% DEX 2EXTRANEAL 2irrigation solutions, physiological MSDlactated ringer's (irrigation) MSDRENACIDIN MSDringer's irrigation 1, MSDsodium chloride (gu irrigant) MSDwater for irrigation, sterile 1REPLACEMENT PREPARATIONSbacteriostatic sodium chloride MSDcalcium acetate (phosphate binder) 1, 2calcium chloride (dihydrate) MSDcalcium gluconate MSDdextrose in lactated ringers MSDdextrose w/ sodium chloride MSDHESPAN MSDIONOSOL-B IN D5W MSDIONOSOL-MB IN D5W MSDISOLYTE-P IN D5W MSDISOLYTE-S MSDK-PHOS 2KCL-LACTATED RINGERS-D5W MSDLACTATED RINGERS MSDMAGNESIUM SULFATE IN D5W MSDMANGANESE CHLORIDE MSDMANGANESE SULFATE MSDNORMOSOL-M IN D5W MSD




26

Name of drug Drug Tier RestrictionsNORMOSOL-R IN D5W MSDNORMOSOL-R PH 7.4 MSDparenteral electrolytes MSDPLASMA-LYTE 148 MSDPLASMA-LYTE A MSDpot phosphate monobasic w/ sod phosphate dibasic & monobasic 1, 2potassium acetate MSDpotassium bicarbonate 1, 2potassium chloride 1, 2, 3, MSDpotassium chloride in dextrose MSDpotassium chloride in dextrose & sodium chloride MSDpotassium chloride in nacl MSDpotassium chloride microencapsulated crystals cr 1, 2potassium phosphates MSDringer's MSDsodium chloride MSDsodium chloride flush MSDsodium phosphates (sodium phosphate dibasic & monobasic) MSDtrace minerals (cr-cu-mn-se-zn) MSDURICOSURIC AGENTScolchicine w/ probenecid 1DUZALLO 3probenecid 1ZURAMPIC 3ENZYMESENZYMESADAGEN MSD LDALDURAZYME MSDBRINEURA MSDCEREZYME MSDELAPRASE MSDELELYSO MSDELITEK MSDFABRAZYME MSDKANUMA MSDLUMIZYME MSDNAGLAZYME MSDPALYNZIQ 3 QL, LDPULMOZYME 2REVCOVI MSD LDSTRENSIQ 3 QL, LDSUCRAID 3 LDVIMIZIM MSDVITRASE MSDVPRIV MSDEYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONSANTI-INFECTIVESAZASITE 3BACITRACIN 1bacitracin-polymyxin b (ophth) 1BESIVANCE 3BETADINE OPHTHALMIC PREP MSDCETRAXAL 1, 3chlorhexidine gluconate (mouth-throat) 1, 3ciprofloxacin hcl (ophth) 1, 2, 3




27

Name of drug Drug Tier RestrictionsCIPROFLOXACIN-FLUOCINOLONE PF 3erythromycin (ophth) 1gatifloxacin (ophth) 1, 3gentamicin sulfate (ophth) 1levofloxacin (ophth) 1moxifloxacin hcl (ophth) 1, 3NATACYN 2neomycin-bacitracin zn-polymyxin 1NEOMYCIN-POLYMYXIN-GRAMICIDIN 1ofloxacin (ophth) 1, 3ofloxacin (otic) 1, 3OTIPRIO 3polymyxin b-trimethoprim 1, 3silver nitrate-potassium nitrate 1sulfacetamide sodium (ophth) 1tobramycin (ophth) 1, 2, 3TRIFLURIDINE 1, 2ZIRGAN 3ANTI-INFLAMMATORY AGENTSbacitracin-poly-neomycin-hc 1BECONASE AQ 3BLEPHAMIDE 1, 2, 3bromfenac sodium (ophth) 1, 3CEQUA 3CIPRO HC 3CIPRODEX 2COLY-MYCIN S 2DEXAMETHASONE SODIUM PHOSPHATE 1diclofenac sodium (ophth) 1DUREZOL 3FLAREX 3FLUNISOLIDE 1fluocinolone acetonide (otic) 1, 3fluorometholone (ophth) 1, 2, 3FLURBIPROFEN SODIUM 1hydrocortisone w/acetic acid 1ILEVRO 3ILUVIEN MSDketorolac tromethamine (ophth) 1, 3loteprednol etabonate 1, 3MAXIDEX 3mometasone furoate (nasal) 1, 3neomycin-polymy-dexameth 1, 3NEOMYCIN-POLYMYXIN-HC 1neomycin-polymyxin-hc (otic) 1OMNARIS 3OMNIPRED 1, 2, 3PRED-G 2, 3PREDNISOLONE SODIUM PHOSPHATE 1QNASL 3tobramycin-dexamethasone 1, 2, 3XIIDRA 3ZYLET 3ANTIALLERGIC AGENTSALOCRIL 3




28

Name of drug Drug Tier RestrictionsALOMIDE 3azelastine hcl 1, 3azelastine hcl (ophth) 1BEPREVE 3cromolyn sodium (ophth) 1DYMISTA 3epinastine hcl (ophth) 1, 3LASTACAFT 3olopatadine hcl 1, 3olopatadine hcl (nasal) 1, 3ANTIGLAUCOMA AGENTSacetazolamide 1, 3acetazolamide sodium MSDAZOPT 3betaxolol hcl (ophth) 1, 3BETIMOL 3bimatoprost 1, 3brimonidine tartrate 1, 3CARTEOLOL HCL 1COMBIGAN 3dorzolamide hcl 1, 3dorzolamide hcl-timolol maleate 1, 3KEVEYIS 3 LDlatanoprost 1, 3levobunolol hcl 1, 3methazolamide 1, 3METIPRANOLOL 1PHOSPHOLINE IODIDE 3pilocarpine hcl 1, 3SIMBRINZA 3timolol maleate (ophth) 1, 3travoprost 1, 3VYZULTA 3ZIOPTAN 3EENT DRUGS, MISCELLANEOUSacetic acid (otic) 1ACETIC ACID-ALUMINUM ACETATE 1apraclonidine hcl 1, 3BEOVU MSDBSS MSDCYSTARAN 3 LDDEBACTEROL 3EYLEA MSDJETREA MSDLACRISERT 3LUCENTIS MSD LDOXERVATE 3 LDPHOTREXA VISCOUS MSDRHOPRESSA 3ROCKLATAN 3TEPEZZA MSDLOCAL ANESTHETICSfluorescein w/ benoxinate MSDlidocaine hcl (mouth-throat) 1proparacaine hcl MSD




29

Name of drug Drug Tier Restrictionstetracaine hcl (ophth)MYDRIATICS

MSD

atropine sulfate (ophthalmic) 1, 3CYCLOMYDRIL MSDcyclopentolate hcl 1, 3HOMATROPAIRE 1OMIDRIA MSDtropicamide MSDVASOCONSTRICTORSphenylephrine hcl (mydriatic) 1GASTROINTESTINAL DRUGSANTI-INFLAMMATORY AGENTSalosetron hcl 1, 3balsalazide disodium 1, 3DIPENTUM 3mesalamine 1, 2, 3mesalamine w/ cleanser 1, 3ANTIDIARRHEA AGENTSdiphenoxylate w/ atropine 1, 3loperamide hcl 1MOTOFEN 3MYTESI 3XERMELO 3 LDANTIEMETICSAKYNZEO 2ALOXI MSDANZEMET 3aprepitant 1, 3, MSDBONJESTA 3CESAMET 3dronabinol 1, 3EMEND MSDgranisetron hcl 1, MSDmeclizine hcl 1ondansetron 1, 3ondansetron hcl 1, 3, MSDPROCHLORPERAZINE EDISYLATE MSDSANCUSO 3, MSDscopolamine 1, 2trimethobenzamide hcl 1, 3, MSDVARUBI (180 MG DOSE) 3ANTIULCER AGENTS AND ACID SUPPRESSANTSamoxicillin-clarithromycin w/ lansoprazole 1, 3cimetidine 1CIMETIDINE HCL 1DEXILANT 3esomeprazole magnesium 1, 3esomeprazole sodium MSDESOMEPRAZOLE STRONTIUM 3famotidine 1, 3, MSDFAMOTIDINE PREMIXED MSDlansoprazole 1, 3misoprostol 1, 3nizatidine 1OMECLAMOX-PAK 3




30

Name of drug Drug Tier Restrictionsomeprazole 1omeprazole-sodium bicarbonate 1, 3pantoprazole sodium 1, 3, MSDPYLERA 3rabeprazole sodium 1, 3ranitidine hcl 1, 3, MSDsucralfate 1, 3CATHARTICS AND LAXATIVESbisacodyl PRVbisacodyl-peg 3350-pot chloride-sod bicarb-sod chloride PRVCLENPIQ PRVdocusate sodium PRVmagnesium citrate PRVMOVIPREP PRVOSMOPREP PRVpeg 3350-kcl-sod bicarb-sod chloride-sod sulfate PRVpeg 3350-potassium chloride-sod bicarbonate-sod chloride PRVpolyethylene glycol 3350 PRVSALINE LAXATIVE PRVSUPREP BOWEL PREP KIT PRVDIGESTANTSZENPEP 2, 3GI DRUGS, MISCELLANEOUSAMITIZA 3CHENODAL 3CHOLBAM 3CREON 2, 3ENTEREG 3ENTYVIO MSDGATTEX 3 QL, LDLINZESS 3metoclopramide hcl 1, 3, MSDMOTEGRITY 3MOVANTIK 3OCALIVA 3 LDRELISTOR 3 QLSYMPROIC 3TRULANCE 3ursodiol 1, 3VIBERZI 3 QLZELNORM 3GOLD COMPOUNDSGOLD COMPOUNDSMYOCHRYSINE MSDRIDAURA 3HEAVY METAL ANTAGONISTSHEAVY METAL ANTAGONISTSCHEMET 3deferasirox 1, 3deferoxamine mesylate MSDFERRIPROX 3penicillamine 1, 3RADIOGARDASE 3trientine hcl 1, 3HORMONES AND SYNTHETIC SUBSTITUTES




31

Name of drug Drug Tier RestrictionsADRENALSbudesonide 1, 3CELESTONE SOLUSPAN MSDCORTISONE ACETATE 1dexamethasone 1, 2dexamethasone sodium phosphate MSDEMFLAZA 3 LDfludrocortisone acetate 1hydrocortisone 1, 3INTRAROSA 3methylprednisolone 1, 2, 3methylprednisolone acetate MSDmethylprednisolone sod succ MSDMILLIPRED 1, 2, 3prednisolone sodium phosphate 1, 3prednisone 1, 2, 3SOLU-CORTEF MSDTRELEGY ELLIPTA 3triamcinolone acetonide MSDANDROGENSANADROL-50 3ANDROID 1, 3ANDROXY 1AVEED MSDdanazol 1oxandrolone 1testosterone 1, 3testosterone cypionate 1, 2 QLTESTOSTERONE ENANTHATE 1, 3 QLCONTRACEPTIVESBALCOLTRA PRVdesogestrel & ethinyl estradiol PRVdesogestrel-ethinyl estradiol (biphasic) PRVdesogestrel-ethinyl estradiol (triphasic) PRVdrospirenone-ethinyl estradiol PRVdrospirenone-ethinyl estradiol-levomefolate calcium PRVELLA PRVethynodiol diacet & eth estrad PRVetonogestrel-ethinyl estradiol PRVlevonorgestrel & eth estradiol PRVlevonorgestrel (emergency oc) PRVlevonorgestrel-eth estradiol (triphasic) PRVlevonorgestrel-ethinyl estradiol (91-day) PRVlevonorgestrel-ethinyl estradiol (continuous) PRVLO LOESTRIN FE PRVNATAZIA PRVNECON 10/11 (28) PRVnorethin acet & estrad-fe PRVnorethindrone & eth estradiol PRVnorethindrone & ethinyl estradiol-fe PRVnorethindrone (contraceptive) PRVnorethindrone acet & eth estra PRVnorethindrone acetate-ethinyl estradiol-fe PRVnorethindrone-eth estradiol (triphasic) PRVnorgestimate-ethinyl estradiol PRV




32

Name of drug Drug Tier Restrictionsnorgestimate-ethinyl estradiol (triphasic) PRVnorgestrel & ethinyl estradiol PRVSLYND PRVXULANE PRVDIABETIC AGENTSacarbose 1, 3ADLYXIN 3ADMELOG 2, 3AFREZZA 2, 3ALOGLIPTIN BENZOATE 1, 3ALOGLIPTIN-METFORMIN HCL 1, 3ALOGLIPTIN-PIOGLITAZONE 1, 3APIDRA 3AVANDIA 3BAQSIMI TWO PACK 2BASAGLAR KWIKPEN 2, 3BYDUREON 3CHLORPROPAMIDE 1CYCLOSET 3FARXIGA 3FIASP 3glimepiride 1, 3glipizide 1, 3glipizide-metformin hcl 1GLUCAGEN HYPOKIT 3GLUCAGON EMERGENCY 2glyburide 1glyburide micronized 1, 3glyburide-metformin 1, 3GLYXAMBI 3HUMALOG MIX 50/50 3HUMULIN 70/30 2, 3HUMULIN N 2, 3INVOKAMET 3INVOKANA 3JANUMET 3JANUVIA 3JARDIANCE 2JENTADUETO 3KOMBIGLYZE XR 3KORLYM 3 LDLEVEMIR 3metformin hcl 1, 3miglitol 1, 3nateglinide 1, 3NOVOLOG 3NOVOLOG MIX 70/30 3ONGLYZA 3OZEMPIC (0.25 OR 0.5 MG/DOSE) 3pioglitazone hcl 1, 3pioglitazone hcl-glimepiride 1, 3pioglitazone hcl-metformin hcl 1, 3PROGLYCEM 3QTERN 3repaglinide 1, 3




33

Name of drug Drug Tier RestrictionsREPAGLINIDE-METFORMIN HCL 1SEGLUROMET 3SOLIQUA 3STEGLATRO 3STEGLUJAN 3SYMLINPEN 120 3SYNJARDY 3TANZEUM 3TOLAZAMIDE 1TOLBUTAMIDE 1TRADJENTA 3TRESIBA 3TRULICITY 3VICTOZA 3XIGDUO XR 3XULTOPHY 3ESTROGENS AND ANTIESTROGENSANGELIQ 3BIJUVA 3CLIMARA PRO 3CLOMIPHENE CITRATE 1DEPO-ESTRADIOL 3 QLDUAVEE 3esterified estrogens & methyltestosterone 1estradiol 1, 2, 3estradiol & norethindrone acetate 1, 3estradiol vaginal 1, 2, 3estradiol valerate 1, 3 QLESTROPIPATE 1FEMRING 3MENEST 3norethindrone acetate-ethinyl estradiol 1, 3PREFEST 3PREMARIN 3, MSDPREMARIN 3PREMPHASE 3raloxifene hcl 1, 3GONADOTROPINSBRAVELLE 2 QLCETROTIDE 2 QLCHORIONIC GONADOTROPIN 2 QLFOLLISTIM AQ 2 QLGANIRELIX ACETATE 2 QLGONAL-F 2 QLMENOPUR 2 QLORILISSA 3SYNAREL 3TRIPTODUR MSDIUDKYLEENA MSDNEXPLANON MSDPARATHYROIDcalcitonin (salmon) 1, 3 QLFORTEO 3 QLNATPARA 3 QL, LD




34

Name of drug Drug Tier RestrictionsTYMLOS 3 QLPITUITARYACTHAR 3 QL, LDdesmopressin acetate 1, 2, 3 QLdesmopressin acetate refrigerated 1, 3desmopressin acetate spray 1, 3desmopressin acetate spray refrigerated 1VASOSTRICT MSDPROGESTINSCRINONE 3 PADEPO-PROVERA MSDHYDROXYPROGESTERONE CAPROATE MSDhydroxyprogesterone caproate 3, MSD QLmedroxyprogesterone acetate 1, 3medroxyprogesterone acetate (contraceptive) MSDmegestrol acetate (appetite) 1, 3norethindrone acetate 1, 3progesterone 1 PA, QLprogesterone micronized 1, 3 PASOMATOTROPIN AGONISTS AND ANTAGONISTSEGRIFTA 3 QL, LDGENOTROPIN 2, 3 QLINCRELEX 3 QLoctreotide acetate 1, 3, MSD QLSAIZEN 3 QL, LDSIGNIFOR 3 QLSIGNIFOR LAR MSDSOMATULINE DEPOT MSDSOMAVERT 3 QL, LDTHYROID AND ANTITHYROID AGENTSlevothyroxine sodium 1, 3, MSDliothyronine sodium 1, 3, MSDmethimazole 1, 3propylthiouracil 1thyroid 1, 3THYROLAR-1 3MEDICAL DEVICEDIAPHRAGMCAYA PRVFEMCAP PRVWIDE-SEAL DIAPHRAGM 60 PRVIUDPARAGARD INTRAUTERINE COPPER MSDMEDICAL DEVICEAEROCHAMBER Z-STAT PLUS 2AEROGEAR ACTION ASTHMA KIT 2CATHFLO ACTIVASE MSDDEVILBISS COMPACT COMPRESSOR 2DEVILBISS DISPOSABLE NEBULIZER 2PIKO 1 2MISCELLANEOUS THERAPEUTIC AGENTSMISCELLANEOUS THERAPEUTIC AGENTSacetylcysteine 1ACTEMRA 3, MSD QLACTIMMUNE 2 QL, LD




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Name of drug Drug Tier RestrictionsADAKVEO MSDADDYI 3 QLadenosine (diagnostic) MSDalbumin, human MSDalendronate sodium 1, 3ALLERGIST TRAY 2allopurinol 1, 3allopurinol sodium MSDamifostine MSDARCALYST 3 QLATGAM MSDAUBAGIO 3 LDAVONEX 3 QLazathioprine 1, 3AZATHIOPRINE SODIUM MSDBACTERIOSTATIC WATER(BENZ ALC) MSDBD BLUNT FILL NEEDLE 2BENLYSTA 3, MSD QLBERINERT 3, MSD QL, LDBOTOX MSDBRIDION MSDbupivacaine hcl MSDbupivacaine in dextrose MSDbupivacaine w/ epinephrine MSDCABLIVI MSDCAMPHOR 2CAMPHOR BLOCKS 2CAMPHOR SPIRIT 1CERDELGA 3 LDCERVIDIL MSDCHLORAMPHENICOL 2chloroprocaine hcl MSDCIMZIA 3, MSD QLcinacalcet hcl 1, 3COAL TAR 2colchicine 1, 3CORTROSYN MSDCRYSVITA MSDcyclosporine 1, 2, MSDcyclosporine modified (for microemulsion) 1, 3CYSTADANE 3 LDCYSTAGON 3 LDdalfampridine 1 LDDEFITELIO MSDDEMSER 3dexrazoxane hcl MSDDIETHYLSTILBESTROL 2DILTIAZEM HCL 2disulfiram 1, 3dopamine in d5w MSDDROXIA 3dutasteride 1, 3dutasteride-tamsulosin hcl 1, 3DYSPORT MSDELMIRON 3




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Name of drug Drug Tier RestrictionsENBREL 2, 3 QLENDARI 3EOVIST MSDETIDRONATE DISODIUM 1EVENITY MSDEXONDYS 51 MSDEXPAREL MSDEXTAVIA 2 QLFC2 FEMALE CONDOM PRVfebuxostat 1, 3finasteride 1, 3FLORIVA 3fomepizole MSDFOSAMAX PLUS D 3GADAVIST MSDGALAFOLD 3GAMIFANT MSDGILENYA 3GIVLAARI MSDglatiramer acetate 1, 3 QLGRASTEK 3HUMIRA 2, 3 QLHYDROCORTISONE 2HYDROCORTISONE MICRONIZED 2HYDROXYUREA 2ibandronate sodium 1, 3, MSDicatibant acetate 1 QLINFLECTRA MSDKALBITOR MSD LDKETAMINE HCL 2KETOPROFEN 2KEVZARA 3 QLKHAPZORY MSDKINERET 3 QLKUVAN 3leflunomide 1, 3LEMTRADA MSDLETS MSDleucovorin calcium 1, MSDLEUCOVORIN CALCIUM 2levocarnitine (metabolic modifiers) 3, MSDlevoleucovorin calcium MSDLEXISCAN MSDLIDOCAINE 2LIDOCAINE HCL 2lidocaine hcl (local anesth.) MSDLIDOCAINE IN DEXTROSE MSDlidocaine w/ epinephrine MSDLUCEMYRA 3MAGNEVIST MSDMAVENCLAD (10 TABS) 3 LDMAYZENT 3MENTHOL 2mepivacaine hcl MSDmesna 2, MSD




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Name of drug Drug Tier Restrictionsmethylergonovine maleate 1, MSDmiglustat 1 LDMONOJECT PISTON SYRINGE 2MONOJECT SYRINGE 2MYALEPT 3 QL, LDmycophenolate mofetil 1, 3mycophenolate mofetil hcl MSDmycophenolate sodium 1, 3NITYR 3 LDnonoxynol-9 PRVNULOJIX MSDNYSTATIN 2OCREVUS MSDODACTRA 2OLUMIANT 3ONPATTRO MSDORALAIR 3ORENCIA 2, MSD QLOSPHENA 3OTEZLA 2 QLOTREXUP 3 QLOXBRYTA 3oxytocin MSDpamidronate disodium MSDPANHEMATIN MSDPARSABIV MSDPCCA LIPODERM BASE 2PHENOL 2PLASMANATE MSDPROLIA 3, MSD QLPROVAYBLUE MSDPROVOCHOLINE MSDPYRIDIUM 3QUADRAMET MSDRAGWITEK 3READI-CAT 2 2REMICADE MSDRENFLEXIS MSDRINVOQ 3risedronate sodium 1, 3ropivacaine hcl MSDRUCONEST MSD LDSALICYLIC ACID 2SAXENDA 3 QLSCULPTRA MSDSIMPONI 3, MSD QLSIMULECT MSDsirolimus 1, 3sodium fluoride PRVSSKI 2SULFAMETHOXAZOLE 2SULFUR 2SUPPRELIN LA MSDtacrolimus 1, 3, MSDTAKHZYRO 3 QL




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Name of drug Drug Tier RestrictionsTECFIDERA 3 PA, LDTEGSEDI 3 QLTHALOMID 3 PA, LDTHIOLA 3 LDTHYMOGLOBULIN MSDTHYMOL 2TUBERSOL MSDTYBOST 3TYSABRI MSDULTOMIRIS MSD LDVISTOGARD 3VORAXAZE MSDVYONDYS 53 MSDwater for injection, sterile MSDXELJANZ 2XEOMIN MSDXURIDEN 3yohimbine hcl 1ZINBRYTA 3 QLzoledronic acid MSDZORTRESS 3MUSCULOSKELETAL THEARPYBETASERON 3 QLHYALGAN MSDVITAMINSphytonadione MSDpotassium aminobenzoate 1, 2, 3RESPIRATORY TRACT AGENTSANTI-INFLAMMATORY AGENTSCINQAIR MSDcromolyn sodium 1cromolyn sodium (mastocytosis) 1FASENRA 3, MSD QLmontelukast sodium 1, 3NUCALA 3, MSD QLzafirlukast 1, 3zileuton 1, 3ANTITUSSIVESbenzonatate 1DURATUSS HD 2FLOWTUSS 3 QLguaifenesin-codeine 1 QLHYCOFENIX 3 QLhydrocodone w/ homatropine 1 QLphenyleph-cpm w/ hydrocod 1phenylephrine-ephedrine-chlorpheniramine w/ carbetapentane 1TUZISTRA XR 3 QLVITUZ 3 QLRESPIRATORY AGENTS, MISCELLANEOUSADEMPAS 3 LDALVESCO 2ambrisentan 1 LDARALAST NP MSD LDARNUITY ELLIPTA 3ASMANEX (120 METERED DOSES) 3




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Name of drug Drug Tier Restrictionsbosentan 3 LDBREO ELLIPTA 3brompheniramine & phenyleph 1budesonide (inhalation) 1, 3BUDESONIDE-FORMOTEROL FUMARATE 1, 3DALIRESP 3DULERA 3 QLESBRIET 3 LDFLOVENT DISKUS 3 QLFLOVENT HFA 2, 3 QLKALYDECO 3 LDOFEV 3 LDOPSUMIT 3 LDORENITRAM 3 LDORKAMBI 2, 3 LDQVAR 3QVAR REDIHALER 3sodium chloride (inhalant) 1SYMDEKO 3 LDtreprostinil 3, MSD LDTRIKAFTA 3 LDUPTRAVI 3 LDVENTAVIS 3 LDXOLAIR MSD LDSERUMS, TOXOIDS, AND VACCINESSERUMSASCENIV MSDBIVIGAM MSDCUTAQUIG 3 QLGAMASTAN S/D MSDGAMMAGARD 2 QLHIZENTRA 3 QLHYQVIA 3 QL, LDIMOGAM RABIES-HT MSDNABI-HB MSDPANZYGA MSDVARIZIG MSDXEMBIFY 3 QLZINPLAVA MSDTOXOIDSADACEL MSDDIPHTHERIA-TETANUS TOXOIDS DT MSDKINRIX MSDTDVAX MSDTE ANATOXAL BERNA MSDVACCINESACTHIB MSDADACEL MSDBEXSERO MSDDAPTACEL MSDENGERIX-B MSDFLULAVAL QUADRIVALENT MSDFLUZONE HIGH-DOSE MSDGARDASIL 9 MSDHAVRIX MSD




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Name of drug Drug Tier RestrictionsHEPLISAV-B MSDIMOVAX RABIES MSDIPOL MSDIXIARO MSDJE-VAX MSDM-M-R II MSDMENACTRA MSDMENOMUNE MSDMENVEO MSDMERUVAX II W/DILUENT 10 DOSE MSDMUMPSVAX W/DILUENT 10 DOSE MSDPEDIARIX MSDPNEUMOVAX 23 MSDPREVNAR 13 MSDPROQUAD MSDRABAVERT MSDROTARIX MSDROTATEQ MSDSHINGRIX MSDSTAMARIL MSDTRUMENBA MSDTWINRIX MSDTYPHIM VI MSDVARIVAX MSDVAXCHORA MSDVIVOTIF 2ZOSTAVAX MSDSKIN AND MUCOUS MEMBRANE AGENTSANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)acyclovir topical 1, 3ALTABAX 3BACTROBAN 1, 3BACTROBAN NASAL 3benzoyl peroxide-erythromycin 1, 3ciclopirox 1, 3ciclopirox olamine 1, 3CLINDACIN PAC 3clindamycin phosphate (topical) 1, 3clindamycin phosphate vaginal 1, 3clindamycin phosphate-benzoyl peroxide 1, 3clindamycin phosphate-benzoyl peroxide (refrigerate) 1, 3CLINDESSE 3clotrimazole 1clotrimazole (topical) 1clotrimazole w/ betamethasone 1, 3DENAVIR 3econazole nitrate 1, 3ERTACZO 3erythromycin (acne aid) 1, 3EURAX 3EXELDERM 3gentamicin sulfate (topical) 1GYNAZOLE-1 3iodoquinol-hc 1iodoquinol-hydrocortisone in aloe vehicle 1, 3




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Name of drug Drug Tier Restrictionsivermectin (rosacea) 1, 3ketoconazole (topical) 1, 3LINDANE 1LULICONAZOLE 3mafenide acetate 1, 3malathion 1, 3MENTAX 3metronidazole (topical) 1, 3metronidazole vaginal 1, 2, 3MICONAZOLE 3 1mupirocin 1, 3naftifine hcl 1, 3NATROBA 1, 3NEOMYCIN-POLYMYXIN B GU 1NEUAC 3nystatin (topical) 1OVACE PLUS 3oxiconazole nitrate 1, 3permethrin 1, 3ROSADAN 3selenium sulfide 1silver sulfadiazine 1, 3SKLICE 3sulfacetamide sodium (acne) 1, 3sulfacetamide sodium w/ sulfur 1, 3terconazole vaginal 1ULESFIA 3XEPI 3XERESE 3ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE)alclometasone dipropionate 1AMCINONIDE 1APEXICON E 3betamethasone dipropionate (topical) 1betamethasone dipropionate augmented 1, 3betamethasone valerate 1, 3calcipotriene-betamethasone dipropionate 1, 3clobetasol propionate 1, 2, 3clobetasol propionate emollient base 1clobetasol propionate emulsion 1, 3CLOCORTOLONE PIVALATE 1, 3CLODAN 3CORTIFOAM 3CORTISPORIN 3CORTISPORIN 3DERMATOP 1, 3desonide 1, 3desoximetasone 1, 3diflorasone diacetate 1DUOBRII 3EUCRISA 3fluocinolone acetonide 1, 3fluocinonide 1, 3fluocinonide emulsified base 1flurandrenolide 1, 3




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Name of drug Drug Tier Restrictionsfluticasone propionate 1, 3halcinonide 1, 3halobetasol propionate 1, 3hydrocortisone (intrarectal) 1, 3hydrocortisone (rectal) 1, 3hydrocortisone (topical) 1, 3hydrocortisone acetate (rectal) 1hydrocortisone butyrate 1, 3hydrocortisone butyrate hydrophilic lipo base 1, 3hydrocortisone valerate 1MICORT-HC 3mometasone furoate 1, 3NEO-SYNALAR 3NEO-SYNALAR 3nystatin-triamcinolone 1PANDEL 3triamcinolone acetonide (mouth) 1triamcinolone acetonide (topical) 1, 2, 3UCERIS 3urea-hc acetate 1ANTIPRURITICS AND LOCAL ANESTHETICSADAZIN 3DOXEPIN HCL 1, 3hydrocortisone acetate w/ pramoxine 1, 3lidocaine 1, 3lidocaine hcl 1, 3lidocaine-prilocaine 1PLIAGLIS 3, MSDCELL STIMULANTS AND PROLIFERANTSKEPIVANCE MSDtretinoin 1, 2, 3tretinoin microsphere 1, 3SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUSacitretin 1, 3adapalene 1, 2, 3adapalene-benzoyl peroxide 1, 3aluminum chloride 1, 3AMELUZ MSDazelaic acid 1, 3AZELEX 3calcipotriene 1, 3CALCITRIOL 2, 3clindamycin phosphate-tretinoin 1, 3COSENTYX 3 QLdapsone (topical) 1, 3DICLOFENAC EPOLAMINE 1, 3diclofenac sodium (actinic keratoses) 1, 3diclofenac sodium (topical) 1, 3DOXYCYCLINE 1, 3DUPIXENT 3 QLFABIOR 3fluorouracil (topical) 1, 3ILUMYA MSDimiquimod 1, 3isotretinoin 1, 3




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Name of drug Drug Tier Restrictionslactic acid (ammonium lactate) 1methoxsalen rapid 1, 3MIRVASO 3PANRETIN 3PICATO 3pimecrolimus 1, 3podofilox 1, 3QBREXZA 3RECTIV 3REGRANEX 3RHOFADE 3salicylic acid 1, 2SANTYL 2SILIQ 3 QL, LDSKYRIZI (150 MG DOSE) 3 QLSTELARA MSDSTELARA 3 QLtacrolimus (topical) 1, 3TALTZ 3 QLTARGRETIN 3tazarotene 1, 3TREMFYA 3 QLurea 1, 3UVADEX MSDVALCHLOR 3 LDVEREGEN 3XIMINO 3SMOOTH MUSCLE RELAXANTSSMOOTH MUSCLE RELAXANTSaminophylline MSDdarifenacin hydrobromide 1, 3flavoxate hcl 1MYRBETRIQ 3oxybutynin chloride 1, 3solifenacin succinate 1, 3theophylline 1, 3tolterodine tartrate 1, 3TOVIAZ 3trospium chloride 1VASODILATING AGENTSMISCELLANEOUS THERAPEUTIC AGENTSCAVERJECT 2 QLLEVITRA 3 QLsildenafil citrate 1, 3 QLtadalafil 1, 3 PA, QLVITAMINSVITAMINSAQUASOL A MSDascorbic acid MSDcalcitriol 1, 3, MSDcyanocobalamin 1, 3 QLdoxercalciferol 1, MSDDURACHOL 3ENBRACE HR 3ergocalciferol 1




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Name of drug Drug Tier RestrictionsFERIVA 21/7 3FERIVAFA 3ferrous sulfate PRVFLORIVA 3folic acid 1, PRV QLINFED MSDINFUVITE ADULT MSDINFUVITE PEDIATRIC MSDiron polysaccharide complex-vit b12-folic acid 1multiple vitamins w/ minerals 1NIACOR 1paricalcitol 1, 3, MSDped multivitamins w/fl & iron 1, 2pediatric multivitamins w/fl 1, 3pediatric vitamins acd fluoride & iron 1pediatric vitamins acd w/ fluoride 1phytonadione 1, 2, MSDprenatal vit w/ ferrous fumarate-folic acid 1prenatal vit w/ iron carbonyl-folic acid 1, 2PYRIDOXINE HCL MSDRAYALDEE 3thiamine hcl MSDTRIFERIC MSDVENOFER MSDVINATE M 2




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Specialty Drugs

The following is a list of medications that are considered specialty drugs. Some plans have a separate specialty drug tier with a specialty tier copay.

Specialty drugs include self-administered injectables, medications that are high cost, and/or medications that require special handling, dispensing procedures, and/or monitoring.

ABILIFY MYCITE TAB 10 MG ABILIFY MYCITE TAB 15 MG ABILIFY MYCITE TAB 2 MG ABILIFY MYCITE TAB 20 MG ABILIFY MYCITE TAB 30 MG ABILIFY MYCITE TAB 5 MG ACTEMRA INJ 162/0.9 ACTIMMUNE INJ 2MU/0.5 ADCIRCA TAB 20MG ADEFOVIR DIPIVOXIL TAB 10MG ADEMPAS TAB 0.5MG ADEMPAS TAB 1.5MG ADEMPAS TAB 1MG ADEMPAS TAB 2.5MG ADEMPAS TAB 2MG AFINITOR DISPERZ TAB 2MG AFINITOR DISPERZ TAB 3MG AFINITOR DISPERZ TAB 5MG AFINITOR TAB 10MG AFINITOR TAB 2.5MG AFINITOR TAB 5MG AFINITOR TAB 7.5MG ALECENSA CAPS 150 MG ALUNBRIG TABS 180 MG ALUNBRIG TABS 30 MG ALUNBRIG TABS 90 MG ALUNBRIG TBPK 90 & 180 MG AMPYRA TAB 10MG ANCOBON CAP 250MG ANCOBON CAP 500MG APOKYN INJ 10MG/ML ARANESP ALBUMIN FREE INJ 100MCG ARANESP ALBUMIN FREE INJ 100MCG ARANESP ALBUMIN FREE INJ 10MCG ARANESP ALBUMIN FREE INJ 150MCG ARANESP ALBUMIN FREE INJ 150MCG ARANESP ALBUMIN FREE INJ 200MCG ARANESP ALBUMIN FREE INJ 25MCG ARANESP ALBUMIN FREE INJ 25MCG ARANESP ALBUMIN FREE INJ 300MCG ARANESP ALBUMIN FREE INJ 300MCG ARANESP ALBUMIN FREE INJ 40MCG ARANESP ALBUMIN FREE INJ 40MCG ARANESP ALBUMIN FREE INJ 500MCG ARANESP ALBUMIN FREE INJ 60MCG ARANESP ALBUMIN FREE INJ 60MCG ARANESP ALBUMIN FREE SURECLICK INJ 100MCG ARANESP ALBUMIN FREE SURECLICK INJ 300MCG ARCALYST INJ 220MG ARIKAYCE INHALATION SUSP 590 MG/8.4 ML ATOVAQUONE ORAL SUSP 750MG/5ML

AUBAGIO TAB 14MG AUBAGIO TAB 7MG AURYXIA TAB 210MG AUSTEDO TABS 12 MG AUSTEDO TABS 6 MG AUSTEDO TABS 9 MG BANZEL ORAL SUSP 40 MG/ML BANZEL TAB 200MG BANZEL TAB 400MG BARACLUDE SOL .05MG/ML BENLYSTA SOAJ 200 MG/ML BENLYSTA SOSY 200 MG/ML BETASERON INJ 0.3MG BETHKIS NEB 300/4ML BOSENTAN TAB 125 MG BOSENTAN TAB 62.5 MG BRAFTOVI CAPS 50 MG BRAFTOVI CAPS 75 MG BROVANA INHALATION SOLN 15MCG/2ML BUPHENYL POW BUPHENYL TAB 500MG CABOMETYX TABS 20 MG CABOMETYX TABS 40 MG CABOMETYX TABS 60 MG CALQUENCE CAPS 100 MG CAPRELSA TAB 100MG CARAC CREAM 0.5 % CERDELGA CAP 84MG CHEMET CAP 100MG CHOLBAM CAP 250MG CHOLBAM CAP 50MG CIMZIA KIT 200MG/ML COMETRIQ KIT 100MG COMETRIQ KIT 140MG COMETRIQ KIT 60MG COPAXONE INJ 40MG/ML COPEGUS TAB 200MG COPIKTRA CAP 15 MG COPIKTRA CAP 25 MG COSENTYX INJ 150MG/ML COSENTYX INJ 150MG/ML COTELLIC TABS 20MG CRESEMBA CAP 186 MG CUPRIMINE CAP 250MG CUTAQUIG INJ SOLN CYSTADANE POW CYSTAGON CAP 150MG CYSTAGON CAP 50MG DAKLINZA TAB 90MG DAKLINZA TAB 30MG DAKLINZA TAB 60MG DAURISMO TAB 100 MG DAURISMO TAB 25 MG DEFERASIROX TAB 250MG

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DEFERASIROX TAB 500MG DIACOMIT CAP 250 MG DIACOMIT CAP 500 MG DIACOMIT POWDER FOR ORAL SUSPENSION PACKET 250 MG DIACOMIT POWDER FOR ORAL SUSPENSION PACKET 500 MG DIFICID TAB 200MG DOPTELET TABS 20 MG DUEXIS TAB 800-26.6 MG DUOPA 4.63/20 MG/ML ENTERAL SUSP DUPIXENT SOSY 300 MG/2ML EMCYT CAP 140MG EMFLAZA SUSP 22.75 MG/ML EMFLAZA TABS 18 MG EMFLAZA TABS 30 MG EMFLAZA TABS 36 MG EMFLAZA TABS 6 MG EMGALITY INJ 100MG/ML EMSAM PT24 12 MG/24HR EMSAM PT24 6 MG/24HR EMSAM PT24 9 MG/24HR ENSTILAR FOAM 0.005-0.064 % ENTOCORT EC CAP 3MG/24HR EPCLUSA TABS 400-100 MG EPIDIOLEX ORAL SOL 100 MG/ML ERIVEDGE CAP 150MG ERLEADA TABS 60 MG ERLOTINIB TAB 100MG ERLOTINIB TAB 150MG ERLOTINIB TAB 25MG ESBRIET CAP 267MG EXJADE TAB 125MG EXJADE TAB 250MG EXJADE TAB 500MG FANAPT TAB 1 MG FANAPT TAB 12 MG FANAPT TAB 2 MG FANAPT TAB 4 MG FANAPT TAB 6 MG FANAPT TAB 8 MG FARESTON TAB 60 MG FARYDAK CAP 10MG FARYDAK CAP 15MG FARYDAK CAP 20MG FASENRA PEN INJ 30MG/ML FERRIPROX TAB 500MG FERRIPROX TABS 1000 MG FIRAZYR INJ 30MG/3ML FIRDAPSE TAB 10 MG FORTEO SOL 600/2.4 FOSRENOL CHW 500MG FULPHILA SOSY 6 MG/0.6ML GASTROCROM 100 MG/5 ML CONC

GATTEX KIT 5MG GENOTROPIN INJ 12MG GENOTROPIN INJ 5MG GENOTROPIN MINIQUICK INJ 0.4MG GENOTROPIN MINIQUICK INJ 0.6MG GENOTROPIN MINIQUICK INJ 0.8MG GENOTROPIN MINIQUICK INJ 1.2MG GENOTROPIN MINIQUICK INJ 1.4MG GENOTROPIN MINIQUICK INJ 1.6MG GENOTROPIN MINIQUICK INJ 1.8MG GENOTROPIN MINIQUICK INJ 1MG GENOTROPIN MINIQUICK INJ 2MG GILENYA CAP 0.25 MG GILENYA CAP 0.5MG GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG GLEEVEC TAB 100MG GLEEVEC TAB 400MG GLEOSTINE CAP 100 MG GLEOSTINE CAP 40 MG GOCOVRI CP24 137 MG GOCOVRI CP24 68.5 MG GRANIX INJ 300 MCG/ML GRANIX INJ 300/0.5 GRANIX INJ 480 MCG/1.6 ML GRANIX INJ 480/0.8 H.P. ACTHAR INJ 80UNIT HAEGARDA SOLR 2000 UNIT HAEGARDA SOLR 3000 UNIT HARVONI TAB 45-200MG HEPSERA TAB 10MG HETLIOZ CAP 20MG HEXALEN CAP 50MG HIZENTRA INJ 1GM/5ML HIZENTRA INJ 2GM/10ML HIZENTRA INJ 4GM/20ML HIZENTRA SOLN 10 GM/50ML HUMATROPE COMBO PACK INJ 5MG HUMATROPE INJ 12MG HUMATROPE INJ 24MG HUMATROPE INJ 6MG HYCAMTIN 0.25 MG CAP HYCAMTIN 1 MG CAP HYQVIA KIT 10 GM/100ML HYQVIA KIT 20 GM/200ML HYQVIA KIT 30 GM/300ML HYQVIA KIT 5 GM/50ML IBRANCE CAP 100MG IBRANCE CAP 125MG IBRANCE CAP 75MG ICLUSIG TAB 15MG ICLUSIG TAB 45MG IDHIFA TABS 100 MG

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IDHIFA TABS 50 MG IMBRUVICA CAP 140MG IMBRUVICA CAPS 70 MG IMBRUVICA TABS 140 MG IMBRUVICA TABS 280 MG IMBRUVICA TABS 420 MG IMBRUVICA TABS 560 MG INBRIJA INHALATION POWDER CAPS 42 MG INCRELEX INJ 40MG/4ML INGREZZA CAP PK 40 & 80 MG INGREZZA CAPS 40 MG INGREZZA CAPS 80 MG INLYTA TAB 1MG INLYTA TAB 5MG INREBIC CAP 100 MG INTRON-A INJ 18MU INTRON-A INJ 18MU INTRON-A INJ 25MU INTRON-A KIT 10MU/ML INTRON-A W/DILUENT INJ 10MU INTRON-A W/DILUENT INJ 50MU JADENU SPRINKLE PACK 180 MG JADENU SPRINKLE PACK 360 MG JADENU TAB 180MG JADENU TAB 360MG JADENU TAB 90MG JAKAFI TAB 10MG JAKAFI TAB 15MG JAKAFI TAB 20MG JAKAFI TAB 25MG JAKAFI TAB 5MG JUXTAPID CAP 10MG JUXTAPID CAP 20MG JUXTAPID CAP 5MG JUXTAPID CAPS 30 MG JUXTAPID CAPS 40 MG JUXTAPID CAPS 60 MG KEVEYIS 50MG TAB KEVZARA SOAJ 150 MG/1.14ML KEVZARA SOAJ 200 MG/1.14ML KEVZARA SOSY 150 MG/1.14ML KEVZARA SOSY 200 MG/1.14ML KISQALI 200 DOSE TABS 200 MG KISQALI 400 DOSE TABS 200 MG KISQALI 600 DOSE TABS 200 MG KISQALI FEMARA 200 DOSE TBPK 200 & 2.5 MG KISQALI FEMARA 400 DOSE TBPK 200 & 2.5 MG KISQALI FEMARA 600 DOSE TBPK 200 & 2.5 MG KITABIS PAK NEB 300/5ML KORLYM TAB 300MG KUVAN PACK 500 MG

KUVAN POW 100MG KUVAN TAB 100MG KYNAMRO INJ 200MG/ML LENVIMA CAP 18MG LENVIMA CAP 8MG LENVIMA 10MG DAILY DOSE CAP 10MG LENVIMA 14MG DAILY DOSE CAP 14MG LENVIMA 20MG DAILY DOSE CAP 20MG LENVIMA 24MG DAILY DOSE CAP 24MG LENVIMA CAP 12 MG LENVIMA CAP 4 MG LETAIRIS TAB 10MG LETAIRIS TAB 5MG LEUKINE 500 MCG/ML VIAL LEUKINE INJ 250MCG LEXETTE FOAM 0.05% LONSURF TABS 15-6.14 MG LONSURF TABS 20-8.19 MG LORBRENA TAB 100 MG LORBRENA TAB 25 MG LOTRONEX TAB 1MG LUPRON DEPOT-PED INJ 11.25MG LUPRON DEPOT-PED INJ 11.25MG LUPRON DEPOT-PED INJ 15MG LUPRON DEPOT-PED INJ 30MG LUPRON DEPOT-PED INJ 7.5MG LYNPARZA CAP 50MG LYNPARZA TABS 100 MG LYNPARZA TABS 150 MG MATULANE CAP 50MG MAVYRET TABS 100-40 MG MEKINIST TAB 0.5MG MEKINIST TAB 2MG MEKTOVI TABS 15 MG MEPRON ORAL SUSP750MG/5ML MODERIBA 1200 DOSE PACK PAK 1200/DAY MODERIBA PAK 600/DAY MULPLETA TAB 3MG NATPARA INJ 100MCG NATPARA INJ 25MCG NATPARA INJ 50MCG NATPARA INJ 75MCG NAYZILAM NASAL SPR 5MG NERLYNX TABS 40 MG NEULASTA INJ 6MG/0.6M NEUMEGA INJ 5MG NEUPOGEN INJ 300/0.5 NEUPOGEN INJ 300MCG NEUPOGEN INJ 480/0.8 NEUPOGEN INJ 480MCG NEXAVAR TAB 200MG NINLARO CAPS 2.3 MG NINLARO CAPS 3 MG NINLARO CAPS 4 MG

49

NITYR TABS 10 MG NITYR TABS 2 MG NITYR TABS 5 MG NIVESTYM INJ 300 MCG/0.5 ML NIVESTYM INJ 480 MCG/0.8 ML NIVESTYM INJ SOLN 300 MCG/ML NIVESTYM INJ SOLN 480 MCG/1.6 ML NORDITROPIN FLEXPRO INJ 10/1.5ML NORTHERA CAP 100MG NORTHERA CAP 200MG NORTHERA CAP 300MG NOXAFIL SUS 40MG/ML NOXAFIL TAB 100MG NUBEQA TAB 300MG NUCYNTA ER TAB 12 200 MG NUCYNTA ER TAB 12 250 MG NUCYNTA TAB 100 MG NUPLAZID CAPS 34 MG NUPLAZID TABS 10 MG NUPLAZID TABS 17MG NUTROPIN AQ NUSPIN 20 SOLN 20 MG/2ML NUTROPIN AQ PEN INJ 20MG/2ML OCALIVA TAB 10 MG OCALIVA TAB 5MG ODOMZO 200MG CAPSULES OFEV CAP 100MG OFEV CAP 150MG OLUMIANT TABS 2 MG OLYSIO CAP 150MG OMNITROPE INJ 10/1.5ML OPSUMIT TAB 10MG ORENCIA CLCK INJ 125MG/ML ORENCIA INJ 125MG/ML ORENCIA SOSY 50 MG/0.4ML ORENCIA SOSY 87.5 MG/0.7ML ORENITRAM TAB 0.125MG ORENITRAM TAB 0.25MG ORENITRAM TAB 1MG ORENITRAM TAB 2.5MG ORENITRAM TBCR 5 MG ORFADIN CAP 10MG ORFADIN CAP 2MG ORFADIN CAP 5MG OTEZLA TAB 30MG OTEZLA TBPK 10 & 20 & 30 MG -28-day starter pack OXANDROLONE TAB 10MG PEGASYS INJ PEGASYS INJ PEGASYS INJ 180MCG/M PEGASYS KIT PEGASYS PROCLICK INJ PROCLICK PENICILLAMINE CAP 250 MG PIQRAY 200 MG DAILY DOSE TAB PK 200 MG

PIQRAY 250 MG DAILY DOSE TAB PK 200 & 50 MG PIQRAY 300 MG DAILY DOSE TAB PK 2x150 MG PLEGRIDY INJ PLEGRIDY INJ PEN PLEGRIDY STARTER PACK INJ STARTER PLEGRIDY STARTER PACK INJ STARTER POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG POSACONAZOLE ORAL SUS 40MG/ML POSACONAZOLE TAB 100MG PROCYSBI CAP 25MG PROCYSBI CAP 75MG PROMACTA TAB 12.5MG PROMACTA TAB 25MG PROMACTA TAB 50MG PROMACTA TAB 75MG PURIXAN 20MG/ML SUSP RAPAMUNE ORAL SOLN 1 MG/ML RAVICTI LIQ 1.1GM/ML REVATIO TAB 20MG REVLIMID CAP 10MG REVLIMID CAP 15MG REVLIMID CAP 2.5MG REVLIMID CAP 20MG REVLIMID CAP 25MG REVLIMID CAP 5MG REXULTI TAB 0.25 MG REXULTI TAB 0.5 MG REXULTI TAB 1 MG REXULTI TAB 2 MG REXULTI TAB 3 MG REXULTI TABS 4 MG RIBASPHERE RIBAPAK PAK 1200/DAY RIBASPHERE RIBAPAK PAK 600/DAY RIBATAB TAB 1200/DAY RILUTEK TAB 50MG RINVOQ TAB 24 15 MG RUBRACA TABS 200 MG RUBRACA TABS 250 MG RUBRACA TABS 300 MG RUZURGI TAB 10 MG RYDAPT CAPS 25 MG SABRIL POW 500MG SABRIL TAB 500MG SAIZEN INJ 5MG SAIZENPREP SOLR 8.8 MG SANDOSTATIN INJ 100MCG SANDOSTATIN INJ 200MCG SEYSARA TAB 100 MG SEYSARA TAB 150 MG SEYSARA TAB 60 MG SIGNIFOR INJ 0.3MG/ML

50

SIGNIFOR INJ 0.6MG/ML SIGNIFOR INJ 0.9MG/ML SIKLOS TAB 1000 MG SILIQ SOSY 210 MG/1.5ML SIMPONI INJ 100MG/ML SIMPONI INJ 100MG/ML SIMPONI INJ 50/0.5ML SIMPONI INJ 50/0.5ML SIROLIMUS ORAL SOLN 1 MG/ML SIRTURO TAB 100MG SIVEXTRO TAB 200MG SKYRIZI INJ (150 MG DOSE) 75 MG/0.83 ML SOFOSBUVIR-VELPATASVIR TABS 400-100 MG SOMAVERT INJ 10MG SOMAVERT INJ 15MG SOMAVERT INJ 20MG SOMAVERT INJ 25MG SOMAVERT INJ 30MG SOVALDI TAB 400MG SOVALDI TAB 200MG SPRYCEL TAB 100MG SPRYCEL TAB 140MG SPRYCEL TAB 20MG SPRYCEL TAB 50MG SPRYCEL TAB 70MG SPRYCEL TAB 80MG STELARA INJ 45MG/0.5 STELARA INJ 90MG/ML STELARA SOLN 45 MG/0.5ML STIVARGA TAB 40MG SUTENT CAP 12.5MG SUTENT CAP 25MG SUTENT CAP 37.5MG SUTENT CAP 50MG SYLATRON KIT 296MCG (200mcg Sylatron) SYLATRON KIT 444MCG (300mcg Sylatron) SYLATRON KIT 888MCG (600mcg Sylatron) SYMDEKO TBPK 100-150 & 150 MG SYMDEKO TAB PK 50-75 & 75 MG SYMPAZAN ORAL FILM 10 MG SYMPAZAN ORAL FILM 20 MG TACLONEX TOPICAL SUSP 0.005-0.064 % TAFINLAR CAP 50MG TAFINLAR CAP 75MG TAGRISSO TABS 40 MG TAGRISSO TABS 80 MG TALTZ SOAJ 80MG/ML TALTZ SOSY 80MG/ML TARCEVA TAB 100MG TARCEVA TAB 150MG TARCEVA TAB 25MG TARGRETIN CAP 75MG TASIGNA CAP 150MG

TASIGNA CAP 200MG TASIGNA CAPS 50 MG TECFIDERA CAP 120MG TECFIDERA CAP 240MG TECFIDERA STARTER PACK MIS STARTER TECHNIVIE TABS 12.5-75-50 MG TEMODAR CAP 100MG TEMODAR CAP 140MG TEMODAR CAP 180MG TEMODAR CAP 20MG TEMODAR CAP 250MG TEMODAR CAP 5MG THALOMID CAP 100MG THALOMID CAP 150MG THALOMID CAP 200MG THALOMID CAP 50MG THIOLA EC TAB 100 MG THIOLA EC TAB 300 MG THIOLA TAB 100MG TIBSOVO TABS 250 MG TIGLUTIK ORAL SUSP 50 MG/10 ML TIKOSYN CAP 125MCG TIKOSYN CAP 250MCG TIKOSYN CAP 500MCG TOBI NEB 300/5ML TOBI PODHALER CAP 28MG TOBI PODHALER CAP 28MG TOLSURA CAP 65 MG TOSYMRA NASAL SOL 10MG TRACLEER TAB 125MG TRACLEER TAB 62.5MG TRACLEER TABS FOR ORAL SUSPENSION 32 MG TREMFYA INJ 100 MG/ML TREMFYA SOSY 100 MG/ML TRIKAFTA TAB 100-50-75 mg &150 mg TURALIO CAPS 200 MG TYKERB TAB 250MG TYMLOS SOPN 3120 MCG/1.56ML UDENYCA INJ 6 MG/0.6 ML UPTRAVI TABS 1000 MCG UPTRAVI TABS 1200 MCG UPTRAVI TABS 1400 MCG UPTRAVI TABS 1600 MCG UPTRAVI TABS 200 MCG UPTRAVI TABS 400 MCG UPTRAVI TABS 600 MCG UPTRAVI TABS 800 MCG UPTRAVI TBPK 200 & 800 MCG Titration pack VALCHLOR GEL 0.016% VALCYTE SOL 50MG/ML VALCYTE TAB 450MG VANCOCIN HCL CAP 125MG VANCOCIN HCL CAP 250MG VECAMYL TAB 2.5MG

51

VENTAVIS SOL 10MCG/ML VENTAVIS SOL 20MCG/ML VERZENIO TABS 100 MG VERZENIO TABS 150 MG VERZENIO TABS 200 MG VERZENIO TABS 50 MG VIEKIRA PAK TAB VIEKIRA XR TB24 200-8.33-50- 33.33 MG VITRAKVI CAP 100 MG VITRAKVI CAP 25 MG VITRAKVI ORAL SOLN 20 MG/ML VIZIMPRO TAB 15 MG VIZIMPRO TAB 30 MG VIZIMPRO TAB 45 MG VOSEVI TABS 400-100-100 MG VOTRIENT TAB 200MG XALKORI CAP 200MG XALKORI CAP 250MG XELJANZ TAB 5MG XELJANZ TABS 10 MG XELJANZ XR TB24 11 MG XELODA TAB 500MG XEMBIFY INJ 10G/50ML XEMBIFY INJ 1GM/5ML XEMBIFY INJ 4GM/20ML XEMBIFY INJ 2GM/10ML XENAZINE TAB 12.5MG XENAZINE TAB 25MG XERMELO TABS 250 MG XGEVA INJ XIFAXAN TAB 200 MG XIFAXAN TAB 550 MG XOSPATA TAB 40 MG XTANDI CAP 40MG XYREM SOL 500MG/ML YONSA TABS 125 MG YUPELRI INHALATION SOLN 175 MCG/3 ML ZARXIO 300MCG/.5ML ZARXIO 480MCG/.8ML ZAVESCA CAP 100MG ZEJULA CAPS 100 MG ZELBORAF TAB 240MG ZEPATIER TABS 50MG/100MG ZINBRYTA SOSY 150 MG/ML ZOLINZA CAP 100MG ZOMACTON SOLR 10 MG ZOMACTON SOLR 10 MG ZORBTIVE INJ 8.8MG ZORTRESS TAB 0.5MG ZORTRESS TAB 0.75MG ZORTRESS TAB 1 MG ZYDELIG TAB 100MG ZYDELIG TAB 150MG ZYFLO CR TAB 600MG

ZYKADIA CAP 150MG ZYKADIA TAB 150 MG ZYTIGA TAB 250MG ZYTIGA TABS 500 MG ZYVOX SUS 100MG/5ML ZYVOX TAB 600MG

52

Kaiser Permanente Insurance Company (KPIC) complies with applicable federal civil rights law and does not discriminate on the basis of race, color, national origin, age, disability, or sex. KPIC does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. We also:

• Provide no cost aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreters o Written information in other formats, such as large print, audio, and accessible

electronic formats • Provide no cost language services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If you need these services, call the number provided below. Maryland, Virginia, D.C. 1-888-251-7052 TTY 711

If you believe that KPIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the KPIC Civil Rights Coordinator, Permanente Advantage, LLC, Grievance 1577, 5855 Copley Drive, Suite 250, San Diego, CA 92111, telephone number 1-888-251-7052. You can file a grievance by mail or phone. If you need help filing a grievance, the KPIC Civil Rights Coordinator is able to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, 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, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

KPIC-ND 16-003-MD-VA-DC

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

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

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 f or 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

Interpreter Services Are Available for Free

ATTENTION: If you speak [language], language assistance services, free of charge, are available to you. Call 855-249-5019 (TTY: 711).

Español/Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 855-249-5019 (TTY: 711).

አማርኛ/Amharic ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 855-249-5019 (መስማት ለተሳናቸው: 711).

Arabic/ العربیةم (رق 5019-249-855-ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم

).711-ھاتف الصم والبكم:

Ɓàsɔ́ɔ̀-wùɖù-po-nyɔ̀ /Bassa Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m̀ [Ɓàsɔ́ ɔ̀ -wùɖù-po-nyɔ̀ ] jǔ ní, nìí, à wuɖu kà kò ɖò po-poɔ̀ ɓɛ́ ìn m̀ gbo kpáa. Ɖá 855-249-5019 (TTY: 711).

中文/Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電855-249-5019 (TTY: 711).

یفارس /Farsi -5019-249-855رت رایگان برای شما .بگیرید تماستوجھ: اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصو

(TTY: 711).با. باشد می فر (

Français/French ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 855-249-5019 (ATS: 711).

ગજુરાતી/Gujarati

855-249-5019 (TTY: 711).

kreyòl ayisyen/Haitian Creole

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele -855-249-5019 (TTY: 711). Igbo Ntị: Ọ bụrụ na asụ Ibo, asụsụ aka ọasụ n’efu, defu, aka. Call 855-249-5019 (TTY: 711). 한국어/Korean

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 855-

249-5019 (TTY: 711).)번으로 전화해 주십시오. Português/Portuguese ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 855-249-5019 (TTY: 711). Русский/Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 855-249-5019 (телетайп: 711).

Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 855-249-5019 (TTY: 711). Urdu/اردو

خدمات مفت میں دستیاب ہیں ۔ کالخبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی

855-249-5019 (TTY: 711).کریں.( Tiếng Việt/Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 855-249-5019 (TTY: 711). Yorùbá/Yoruba AKIYESI: Bi o ba nsọ èdè Yorùbú ọfé ni iranlọwọ lori èdè wa fun yin o. Ẹ pe ẹrọ-ibanisọrọ yi 1-855-249-5019 (TTY: 711).

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