health net's 3 tier recommended drug list net's 3 tier recommended drug list tier 1 tier 2...

Health Net's 3 Tier Recommended Drug List

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Acetaminophen / Codeine Tablets AVINZA CAPSULES (QL) ACTIQ LOZENGES (PA)Acetaminophen 2.5 / Hydrocodone 1.67 Elixir DARVON CPD. CAPSULES Butorphanol Nasal Spray (PA) (QL)Acetaminophen 325 / Hydrocodone 5 Tablets EASPIRIN TABLETS COMBUNOX TABLETSAcetaminophen 500 / Hydrocodone 5 Tablets KADIAN CAPSULES (QL) Fentanyl Lozenges (PA)Acetaminophen 7.5 / Hydrocodone 650 Tablets OPANA ER TABLETS (QL) FENTORA BUCCAL TABLETS (PA)Butalbital 50 / Acetaminophen 325 / Caffeine 40 Tablets OPANA TABLETSButalbital 50 / Aspirin 325 / Caffeine 40 Tablets / Capsules Oxycodone SR Tablets (QL)Butalbital 50 / Aspirin 650 Tablets OXYCONTIN (QL)Codeine / Aspirin Tablets Pentazocine / Acetaminophen TabletsCODEINE TABLETS PERCOCET (All Strengths Except 5/325)Codeine Tablets STADOL NASAL SPRAY (PA) (QL)DARVOCET-N 100 Tablets TALWIN NX TABLETSDARVON CAPSULES Tramadol / Acetaminophen TabletsDEMEROL TABLETS ULTRACET TABLETSDILAUDID TABLETS ULTRAM ER TALETSDOLOPHINE TABLETS (QL) VICOPROFEN TABLETSDURAGESIC PATCHES (QL)EMPIRIN TABLETS #2, #3, #4ESGIC TABLETSFentanyl Patches (QL)FIORICET TABLETSFIORINAL TABLETS / CAPSULESFIORPAP TABLETSHydromorphone TabletsLORCET PLUS 7.5/650 TABLETSLORTAB 5/500 TABLETSLORTAB ELIXIRMeperidine Tablets Methadone Tablets (QL)Morphine SolutionMorphine SR Tablets (QL)Morphine SuppositoriesMS CONTIN TABLETS (QL)MSIR TABLETSNORCO TABLETSORAMORPH TABLETSOxycodone 4.5 / Aspirin 325 TabletsOxycodone 5 / Acetaminophen 325 TabletsOxycodone 5 / Acetaminophen 500 CapsulesPERCOCET 5/325 TABLETSPERCODAN FULL STRENGTH TABLETSPropoxyphene HCl 65 CapsulesPropoxyphene Napsylate / APAP TabletsRMS SUPPOSITORIESROXICET 5 / 325 TABLETSROXICODONETramadol Tablets (QL)TYLENOL CODEINE TABLETS #2, #3, #4TYLOX 5 / 500 CAPSULESULTRAM TABLETSVICODIN 5 / 500 TABLETSVICODIN ES 7.5 / 750 TABLETSVICODIN HP TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Clotrimazole Troches Griseofulvin Ultramicrosize NOXAFIL SUSPENSION (PA)DIFLUCAN Tablets (QL) GRIS-PEG TABLETSFluconazole Tablets (QL) VFEND TABLETS (PA)Ketoconazole TabletsLAMISIL TABLETS (PA)MYCELEX TROCHESMYCOSTATIN TabletsNILSTAT TabletsNIZORAL TABLETSNystatin Oral SuspensionNystatin TabletsSPORANOX CAPSULES (PA)Terbinafine Tablets (PA)

Analgesics

Antifungals

The 3-Tier Recommended Drug List has been designed to provide Health Net members with information about medications, their copayment tier, and alternative medications within a therapeutic class. Medications on tier one or two are available at a lower level copayment. Brand name medications are listed in CAPITAL LETTERS. If the medication name is ITALICIZED only the generic will be covered. The brand name is listed for reference only and ease of identification. Generic drugs are listed in lower case letters. The Recommended Drug List (RDL) has two main sections. The first section is an alphabetized list of brand and generic drugs and their corresponding copayment tier. The second section is arranged by therapeutic class. The available medications are listed by copayment tier. Selecting a generic medication within a therapeutic class or at a lower tier will save you money. The (PA) indicator means prior authorization (pre-approval) is required before the medication is covered. Review the RDL to see if a medication requires a prior authorization. A (QL) means that there are quantity or duration limits. Doses or duration beyond the standard will require prior authorization. Review the Recommended Drug List (RDL) to see if there are any restrictions or limitations regarding dose or duration for a particular medication. An (EST) means that there is an electronic step therapy or a pre-requisite drug required. If the pre-requisite drug has been used the claim will process automatically.

PA = Prior Authorization RequiredQL = Quantity Limit

1 of 22

rev: 2/1/08Brand Names Italicized Listed For Reference Only

Generics Used When Available


Tier 1 Tier 2 Tier 3 (Not on The Drug List)BROMFED CAPSULES ASTELIN NASAL SPRAY ALLEGRA BROMFED TABLETS PHENERGAN SYRUP ALLEGRA-DBrompheniramine 12 mg / Pseudoephedrine 120 mg PROMETHAZINE SYRUP CLARINEX Clemastine Tablets Fexofenadine / Pseudoephedrine Tablets Cyproheptadine 4 mg Tablets & Syrup Fexofenadine Tablets Dexchlorpheniramine Tablets XYZAL TABLETSPERIACTIN 2mg/5ml SYRUPPERIACTIN 4 mg TABLETSPOLARAMINE TABLETSPOLY-HISTINE ElixirTAVIST TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)BROMFED PD CAPSULES EXTENDRYL SR CAPSULESChlorpheniramine 2/ Phenylephrine 10/ Methscopolamine 1.25-Syrup Chlorpheniramine 4 / Pseudoephedrine 60 CapsulesChlorpheniramine 4.5 / Phenylephrine 5 SuspensionChlorpheniramine 8 / Phenylephrine 20/ Methscopolamine 2.5 CapsulesDECONAMINE SR CAPSULESEXTENDRYL SYRUPKRONOFED-A, JR. CAPSULESPromethazine & Phenylephrine SyrupRYNATAN PEDIATRIC SUSPENSIONRYNATAN-S PEDIATRIC SUSPENSION

Tier 1 Tier 2 Tier 3 (Not on The Drug List)HUMATIN CAPSULES YODOXIN TABLETS TINDAMAX TABLETS Paromomycin Capusles

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Mebendazole Tablets (QL) BILTRICIDE TABLETS ALBENZA TABLETSVERMOX Tablets (QL) MINTEZOL TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Hydroxychloroquine Tablets FANSIDAR TABLETS MALARONE TABLETSARALEN TABLETS PRIMAQUINE TABLETS QUININE CAPSULES (QL)Chloroquine 500mg TabletsLARIAM TABLETS (QL)Mefloquine Tablets (QL)PLAQUENIL 500 MG

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Ethambutol Tablets MYCOBUTIN CAPSULES DARAPRIM TABLETSIsoniazid Tablets PYRAZINAMIDE TABLETSMYAMBUTOL TABLETS TRECATOR TABLETSRIFADIN CAPSULESRifampin Capsules

Antihistamines And Antihistamine Combinations

Antihistamine / Decongestant Combinations

ANTI-INFECTIVESAmebicides

Anthelmintics

Antimalarials

Antituberculosis Medications


2 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)Acyclovir Oral Tablets / Capsules AGENERASE CAPSULES EPIVIR HBVAmantadine Capsules APTIVUS CAPSULES FAMVIR TABLETSCOPEGUS TABLETS (PA) ATRIPLA TABLETS (QL) RELENZA (PA)CYTOVENE CAPSULES BARACLUDE TABLETS (PA) TAMIFLU (PA) Ganciclovir Capsules COMBIVIR TABLETS TYZEKA TABLETS (PA)REBETOL CAPSULES (PA) CRIXIVAN CAPSULESRETROVIR CAPSULES/ TABLETS EMTRIVA CAPSULES 200MG (QL)Ribavirin Tablets / Capsules (PA) EPIVIR TABLETSSYMMETREL CAPSULES EPZICOM TABLETSVIDEX EC CAPSULES / TABLETS HEPSERA TABLETS (PA)ZOVIRAX ORAL TABLETS / CAPSULES HIVID TABLETS

INVIRASE CAPSULESISENTRESS TABLETSKALETRA CAPSULESLEXIVA TABLETSNEBUPENT SOLUTIONNORVIR CAPSULESPREZISTA TABLETS (QL)RESCRIPTOR TABLETSREYATAZ CAPSULES (QL)SELZENTRY TABLETS (QL)SUSTIVA CAPSULES / TABLETSTRIZIVIR TABLETSTRUVADA TABLETSVALCYTE TABLETS (QL)VALTREX TABLETS (QL)VIDEX TABLETSVIRACEPT TABLETSVIRAMUNE TABLETSVIREAD TABLETS (QL)ZERIT CAPSULESZIAGEN TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)CECLOR CAPSULES / SUSPENSION CEFTIN SUSPENSION LORABID CAPSULES / SUSPENSIONCedinir Capsules / Suspension SPECTRACEF TABLETSCefaclor Capsules / SuspensionCefadroxil CapsulesCefprozil Capsules / SuspensionCEFTIN CAPSULESCefuroxime CapsulesCEFZIL CAPSULES / SUSPENSIONCephalexin Capsules / SuspensionDURICEFKEFLEX CAPSULES / SUSPENSIONOMNICEF CAPSULES / SUSPENSIONVANTIN SUSPENSIONVANTIN TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Azithromycin Tablets (QL) ERYPED TABLETSBIAXIN SUSPENSION ERY-TABBIAXIN TABLETS ZMAX ORAL SUSPENSION (QL)BIAXIN XL TABLETS (QL)Clarithromycin Suspension Clarithromycin TabletsClarithromycin Extended Release TabletsEES SUSPENSIONE-MYCIN TABLETSERYTHROCIN TABLETSErythromycin / Sulfisoxazole SuspensionErythromycin Base TabletsErythromycin Ethylsuccinate SuspensionErythromycin Stearate TABLETSPEDIAZOLE SUSPENSIONZITHROMAX TABLETS (QL)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)CIPRO TABLETS AVELOX TABLETS (QL) FACTIVE TABLETS (QL)CIPRO XR TABLETS (QL) LEVAQUIN (QL)Ciprofloxacin Extended Release Tablets NOROXIN TABLETSCiprofloxacin Tablets Ofloxacin Tablets

Antivirals & HIV

Cephalosporins

Erythromycins / Macrolides

Fluoroquinolones


3 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)Amoxicillin Capsules, Suspension, Chewable Tablets AUGMENTIN XR CAPSULES / SUSPENSION GEOCILLIN TABLETSAmoxicillin Clavulanate Potassium Tablets / SuspensionAMOXIL Ampicillin Capsules / SuspensionAUGMENTIN CAPSULES / SUSPENSIONBEEPEN-VK TABLETS / SUSPENSIONDicloxacillin Capsules / SuspensionDYNAPEN CAPSULES / SUSPENSIONPenicillin VK Tablets / SuspensionPRINCIPEN CAPSULES / SUSPENSIONTOTACILLIN CAPSULES / SUSPENSIONTRIMOX VEETIDS TABLETS / SUSPENSIONWYMOX

Tier 1 Tier 2 Tier 3 (Not on The Drug List)BACTRIM TABLETSBACTRIM DS TABLETSErythromycin / Sulfisoxazole SuspensionPEDIAZOLE SUSPENSIONSEPTRA TABLETSSEPTRA DS TABLETSSulfamethoxazole / Trimethoprim (SMZ / TMP) TabletsSulfamethoxazole / Trimethoprim DS (SMZ / TMP DS) Tablets

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ACHROMYCIN V CAPSULES DYNACIN -NOT COVERED USE MINOCYCLINE)DECLOMYCIN TABLETS DORYX CAPSULESDemeclocycline Tablets Doxycycline Hyclate 20mg, 40mg Capsules / TabletsDoxycycline Hyclate 50mg, 100mg Capsules / Tablets ORACEA CAPSULESMINOCIN 50 MG, 100 MG Immediate Release only-pellets not coveredMinocycline 50 mg,100 mg Immediate Release only-pellets not coveredSUMYCIN CAPSULESTetracycline CapsulesVIBRAMYCIN CAPSULESVIBRA-TABS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)CLEOCIN CAPSULES DAPSONE TABLETS ALINIA SUSPENSION / TABLETS Clindamycin Capsules MEPRON SUSPENSION HIPREX TABLETSFLAGYL TABLETS 250 mg or 500 mg MYCIFRADIN ORAL SOLUTION KETEK CAPSULES (PA)MACRODANTIN CAPSULES ZYVOX TABLETS (PA) Thalidomide Capsules (PA)MANDELAMINE Tablets THALOMID CAPSULES (PA)Methenamine Mandelate Tablets TOBI NEBULIZER SOLUTIONMetronidazole Tablets 250 mg and 500 mg Only VANCOCIN (PA) (QL)Neomycin VANCOMYCIN (PA) (QL)Nitrofurantoin Macrocrystals XIFAXAN TABLETS (QL)Trimethoprim Tablets

Tier 1 Tier 2 Tier 3 (Not on The Drug List)A/T/S SOLUTION (SWABS, PADS & PLEDGETS EXCLUDED) LOPROX CREAM / GEL / SUSPENSIONCLEOCIN T SOLN (SWABS, PADS & PLEDGETS EXCLUDED)Clindamycin Solution 1% (Swabs, Pads & Pledgets Excluded)ERYCETTE SOLN (SWABS, PADS & PLEDGETS EXCLUDED)ERYDERM SOLN (SWABS, PADS & PLEDGETS EXCLUDED)Erythromycin 2.0 % Soln (Swabs, Pads & Pledgets Excluded)GARAMYCIN CREAM / OINTMENTGentamicin Sulfate Cream / OintmentMYCOLOG II CREAM / OINTMENTMYCOTRIACET CREAM / OINTMENTTriamcinolone / Nystatin Cream / Ointment

Penicillins

Sulfonamides

Tetracyclines

Other Anti-infectives

Topical Antibacterials


4 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)EULEXIN CAPSULES ALKERAN TABLETSFluoxymesterone Tablets ARIMIDEX TABLETSFlutamide Capsules AROMASIN TABLETSHYDREA TABLETS CASODEX TABLETSHydroxyurea Tablets CEENU CAPSULESLeucovorin Tablets CYTOXAN TABLETSMercaptopurine Tablets DIETHYLSTILBESTROL TABLETSMethotrexate Tablets EFUDEX CREAM / SOLUTIONNOLVADEX TABLETS EMCYT CAPSULESPURINETHOL TABLETS FARESTON TABLETSRHEUMATREX TABLETS FEMARA TABLETSTamoxifen Citrate Tablets GLEEVEC TABLETS (PA)WELLCOVORIN TABLETS HALOTESTIN TABLETSVEPESID CAPSULES HEXALEN CAPSULES

IRESSA TABLETS (PA)LEUKERAN TABLETSLYSODREN TABLETSMATULANE CAPSULESMYLERAN TABLETSNEXAVAR TABLETS (PA)NILANDRON TABLETSSPRYCEL TABLETS (PA)SUTENT CAPSULES (PA)TARCEVA TABLETS (PA)TARGRETIN CAPSULESTASIGNA CAPSULESTEMODAR CAPSULES (QL)TESLAC TABLETSTHIOGUANINE TABLETSTYKERB TABLETS (PA)VESANOID CAPSULESXELODA TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Codeine 10 / Guaifenesin 100 / Pseudoephedrine 30 SolutionCodeine 10 / Brompheniramine 2 / Phenylephrine 12.5 SyrupCodeine 10 / Chlorpheniramine 2 / Pseudoephedrine 30 LiqCodeine 10/ Bromodiphenhydramine 12.5 SyrupDIMETANE-DC EXPECTORANTGuaifenesin 10 / Codeine Phosphate 100 Liq NR ExpectorantGuaifenesin 100 / Codeine 10 / Pseudoephedrine 30Guaifenesin 100 / Codeine 10 ExpectorantHISTUSSIN HC SYRUPHYCODAN SYRUPHYCOTUSS ExpectorantHydrocodone 2.5 / Phenylephrine 5 / Chlorpheniramine 2 SyrupHydrocodone 2.5 / Guaifenesin 100 /Pseudoephedrine 30 SolnHydrocodone 5 / Guaifenesin 100 ExpectorantHydrocodone 5 / Homatropine 1.5 Syrup NOVAHISTINE DH EXPECTORANTNOVAHISTINE EXPECTORANTPHENERGAN VC CODEINEPHENERGAN/ CODEINEPromethazine/ Codeine SyrupPromethazine/ Phenylephrine /Codeine SyrupROBITUSSIN AC EXPECTORANTROBITUSSIN DAC EXPECTORANTTUSSEND SYRUPTUSSI-ORGANIDIN NR SYRUP

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Benzonatate CapsulesCarbinoxamine 4 / Pseudoephedrine 60 / DM 15 SyrupGuaifenesin 600 / Pseudoephedrine 120 TabletsIodinated Glycerol / Dextromethorphan SyrupIOPHEN-DM SYRUPPHENERGAN / DM SYRUPPromethazine DM SyrupRONDEC-DM SYRUPTESSALON PERLES

ANTINEOPLASTICS

Antitussives - Narcotic

Antitussives Non-Narcotic


5 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)ENTEX PSE 120/400 MG TABLETS

Guaifenesin 400 / Pseudoephedrine 120 Tab

PIMA SOLUTION

Potassium Iodide SolutionSSKI SOLUTION

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Acebutolol Capsules COREG CR CAPSULESCarvedilol TabletsCOREG TABLETS (QL)Labetalol TabletsNORMODYNE TABLETSSECTRAL CAPSULESTRANDATE TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Benazepril Capsules ACEON TABLETSACCUPRIL TABLETS ALTACE TABLETS (Not Covered-Use Capsules)ALTACE CAPSULES MAVIK TABLETSCAPOTEN TABLETS TARKA TABLETSCaptopril CapsulesEnalapril TabletsFosinopril CapsulesLisinopril TabletsLOTENSIN TABLETS MONOPRIL TABLETS Quinapril TabletsRamipril CapsulesUNIVASC TABLETS VASOTEC TABLETSZESTRIL TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)BENICAR HCT TABLETS (QL) ATACAND TABLETS (QL)BENICAR TABLETS (QL) ATACAND HCT TABLETS (QL)DIOVAN HCT TABLETS (QL) AVALIDE TABLETS (QL)DIOVAN TABLETS (QL) AVAPRO TABLETS (QL)

COZAAR TABLETS HYZAAR TABLETS MICARDIS TABLETS MICARDIS HCT TABLETS TEVETEN HCT CAPSULES (QL)TEVETEN TABLETS (QL)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Amiodarone Tablets PROCANBID TABLETSCORDARONE TABLETS RYTHMOL SR CAPSULESDisopyramide Capsules TIKOSYN CAPSULESDisopyramide Controlled Release CapsulesFlecainide TabletsMexiletine CapsulesMEXITIL CAPSULESNORPACE CAPSULESNORPACE CR CAPSULESProcainamide Tablets / CapsulesPRONESTYL TABLETS / CAPSULESPropafenone TabletsQUINAGLUTE TABLETSQUINIDEX TABLETSQuinidine Gluconate TabletsQuinidine Sulfate Sustained Release TabletsQuinidine Sulfate TabletsQUINIDINE TABLETSRYTHMOL TABLETSTAMBOCOR TABLETS

Expectorants

CARDIOVASCULAR MEDICATIONSAlpha-Beta Adrenergics

Angiotensin Converting Enzyme Inhibitors

Angiotensin II Receptor Blockers

Antiarrhythmics


6 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)Cholestyramine - Bulk Powder Only ADVICOR TABLETS (QL) ALTOPREV TABLETSCholestyramine Lite- Bulk Powder Only NIASPAN TABLETS CADUET TABLETS (PA)COLESTID TABLETS TRICOR TABLETS 48 mg, 145 mg COLESTID GRANULESColestipol Tablets VYTORIN TABLETS (QL) CRESTOR (QL) Fenofibrate Micronized Capsules 67mg, 134 mg, 160 mg, 200 mg LESCOL CAPSULES (QL)Fenofibrate Tablets 160 mg LESCOL XL TABLETS (QL)Gemfibrozil Tablets LIPITOR TABLETS (QL) LOPID TABLETS LOVAZA CAPSULES (QL)Lovastatin Tablets (QL) OMACOR CAPSULES (QL)MEVACOR TABLETS (ql) WELCHOL TABLETSPRAVACHOL TABLETS (QL) ZETIA TABLETSPravastatin TabletsQUESTRAN BULK - POWDER ONLYQUESTRAN LIGHT - POWDER ONLYSimvastatin TabletsZOCOR TABLETS (QL)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Atenolol Tablets INNOPRAN XL CAPSULESBETAPACE AF TABLETS KERLONE TABLETSBETAPACE TABLETSBisoprolol TabletsBLOCADREN TABLETSCORGARD TABLETSINDERAL TABLETSINDERAL LA CAPSULESLOPRESSOR TABLETSMetoprolol TabletsMetoprolol ER TabletsNadolol TabletsPindolol TabletsPropranolol TabletsSotalol TabletsTENORMIN TABLETSTimolol TabletsTOPROL XL TABLETSZEBETA TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ADALAT CC TABLETS NIMOTOP CAPSULES CARDENE CAPSULESADALAT TABLETS SULAR TABLETS CARDENE SR CAPSULESAmlodipine Tablets (QL) COVERA -HS TABLETSCALAN SR TABLETS DYNACIRC CR TABLETSCALAN TABLETS Nicardipine CapsulesCARDIZEM CD CAPSULES VERELAN PM CAPSULESCARDIZEM SR CAPSULESCARDIZEM TABLETSDILACOR XR CAPSULESDiltiazem Extended Release CapsulesDiltiazem Immediate Release TabletsDiltiazem SR CapsulesISOPTIN SR TABLETSISOPTIN TABLETSNifedipine Immediate Release TabletsNifedipine, Sustained Release TabletsNORVASC TABLETS (QL)PLENDIL TABLETSPROCARDIA TABLETSPROCARDIA XL TABLETSTIAZAC CAPSULESVerapamil SA TabletsVERELAN CAPSULESVerapamil Tablets

Tier 1 Tier 2 Tier 3 (Not on The Drug List)DIGITEK TABLETS LANOXICAPS CAPSULES

Digoxin TabletsLANOXIN TABLETS

Antihyperlipidemics

Beta Adrenergic Antagonists

Calcium Channel Blockers

Cardiac Glycosides


7 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)ACCURETIC TABLETS EXFORGE TABLETS (EST)ALDORIL TABLETSAtenolol / Chlorthalidone TabletsBenazepril / Amlodipine TabletsBenazepril / HCTZ TabletsBisoprolol / Hydrochlorothiazide TabletsCAPOZIDE TABLETSCaptopril / HCTZ TabletsEnalapril / Hydrochlorothiazide TabletsINDERIDE TABLETSLisinopril / HCTZ TabletsLOTENSIN HCT TABLETSLOTREL TABLETS (QL)Methyldopa / Hydrochlorothiazide TabletsMONOPRIL / HCT TABLETSPropranolol / Hydrochlorothiazide TabletsTENORETIC TABLETSUNIRETIC TABLETSVASERETIC TABLETSZESTORETIC TABLETSZIAC TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Clonidine (Tablets only) RESERPINE TABLETS CATAPRES-TTS PATCHESALDOMET TABLETSCATAPRES -TABLETS ONLYGuanabenz TabletsGuanfacine TabletsMethyldopa TabletsTENEX TABLETSWYTENSIN TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)TEKTURNA TABLETS (EST)TEKTURNA HCT TABLETS (EST)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)APRESOLINE TABLETS LETAIRIS TABLETS BIDIL TABLETSCARDURA TABLETS NITROLINGUAL SPRAY RANEXA TABLETS Doxazosin Mesylate Tablets TRACLEER TABLETS REVATIO TABLETS (PA)Hydralazine TabletsHYTRIN TABLETS / CAPSULESIMDUR TABLETSISORDIL TABLETSIsosorbide Dinitrate TabletsIsosorbide Mononitrate TabletsLONITEN TABLETSMINIPRES CAPSULESMinoxidil TabletsNITRO-BID CAPSULESNITRO-DUR PATCHES (QL)Nitroglycerin OintmentNitroglycerin Oral CapsulesNitroglycerin Patches (QL)Nitroglycerin Sublingual TabletsNITROSTAT SL TABLETSPrazosin CapsulesTerazosin Tablets / Capsules

Tier 1 Tier 2 Tier 3 (Not on The Drug List)COUMADIN TABLETS EXJADE TABLETS AGGRENOX CAPSULESCilostazol tablets MEPHYTON TABLETS AGRYLIN CAPSULESDipyridamole Tablets PLAVIX TABLETS REVLIMID (PA)Pentoxifylline TabletsPERSANTINE TABLETSPLETAL TABLETSTICLID TABLETSTiclopidine TabletsTRENTAL TABLETSWarfarin Sodium Tablets

Tier 1 Tier 2 Tier 3 (Not on The Drug List)DIBENZYLINE

Combination Antihypertensives

Anti-Adrenergic Agents

Vasodilating Medications

Hematological Agents

Direct Renin Inhibitors

Pheochromocytoma Agents


8 of 22




Tier 1 Tier 2 Tier 3Amitriptyline Tablets AMOXAPINE TABLETS Amitriptyline / Perphenazine TabletsANAFRANIL CAPSULES CYMBALTA CAPSULES (QL) Fluoxetine Tablets (10mg&20 mg Caps Covered Tier 1)AVENTYL CAPSULES EFFEXOR CAPSULES XR (QL) Fluvoxamine TabletsBupropion Sustained Release Tablets LEXAPRO TABLETS (QL) Nefazodone Tablets Bupropion Tablets PAXIL CR TABLETS (QL) PROZAC TABLETS (10mg & 20 mg Caps Covered Tier 1)CELEXA TABLETS (QL) PROZAC WEEKLY CAPSULESCitalopram Tablets (QL) SURMONTIL CAPSULESClomipramine Tablets TOFRANIL PM TABLETSDesipramine Tablets VIVACTIL TABLETSDESYREL TABLETSDoxepin CapsulesEFFEXOR TABLETSELAVIL TABLETSFluoxetine Capsules Only - 10mg, 20mg OnlyImipramine HCL TabletsMaprotiline TabletsMirtazapine Soluble TabsMirtazapine TabletsNORPRAMIN TABLETSNortriptyline TabletsPAMELOR CAPSULESParoxetine HCl TabletsPAXIL TABLETSPROZAC CAPSULES ONLY - 10 MG & 20 MG ONLYREMERON SOLTABSREMERON TABLETSSertraline TabletsSINEQUAN CAPSULESTOFRANIL TABLETSTrazodone TabletsVenlafaxine TabletsWELLBUTRIN SR TABLETSWELLBUTRIN TABLETSWELLBUTRIN XL TABLETS (QL)ZOLOFT TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ATIVAN TABLETS Meprobamate Tablets

Alprazolam Tablets MILTOWN TABLETS

BUSPAR TABLETS XANAX XR TABLETS

Buspirone Tablets

Chlordiazepoxide CAPSULES

Clorazepate Capsules

Diazepam TabletsLIBRIUM CAPSULESLorazepam TabletsOxazepam CapsulesSERAX CAPSULESTRANXENE CAPSULESVALIUM TABLETSXANAX TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ESKALITH CAPSULES LITHOBID CAPSULESLithium Carbonate Tablets / Capsules

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Clozapine Tablets ABILIFY TABLETS / SOLUTION EMSAM PATCHESCLOZARIL TABLETS CHLORPROMAZINE TABLETS INVEGA ER TABLETSFluphenazine Tablets GEODON CAPSULES MOBAN TABLETSHaloperidol Tablets RISPERDAL TABLETS SYMBYAX CAPSULES Loxapine Capsules SEROQUEL TABLETS ZYPREXA ZYDIS LOXITANE CAPSULES SEROQUEL XR TABLETS (QL)NAVANE CAPSULES THORAZINE TABLETSPerphenazine tablets ZYPREXA TABLETS (ZYDIS TABS TIER 3)PROLIXIN TABLETSThioridazine TabletsTrifluoperazine Tablets

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Phenobarbital Tablets MEBARAL TABLETS

CENTRAL NERVOUS SYSTEM MEDICATIONSAntidepressants

Antianxiety Medications

Anti-mania

Antipsychotic Medications

Barbiturates


9 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)AMBIEN TABLETS (QL) AMBIEN CR (QL)ATARAX TABLETS DORAL TABLETSChloral Hydrate Capsules Estazolam TabletsDALMANE CAPSULES (QL) LUNESTA TABLETS (EST) (QL)

Flurazepam Capsules (QL) PROSOM TABLETS

HALCION TABLETS (QL) ROZEREM TABLETS (EST) (QL)Hydroxyzine Pamoate Capsules SONATA CAPSULES (QL)Hydroxyzine HCl TabletsRESTORIL CAPSULES (QL)Temazepam Capsules (QL)Triazolam Tablets (QL)VISTARIL CAPSULESZolpidem Tablets (QL)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)PARNATE TABLETS NARDIL TABLETSTranylcypromine Tablets

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ADDERALL TABLETS CONCERTA SA TABLETS (QL) ADDERALL XR CAPSULES (QL)DEXEDRINE TABLETS VYVANSE CAPSULES (QL) Amphetamine Salt Combo TabletsDEXEDRINE SPANSULES DAYTRANA PATCH

Dextroamphetamine Tablets DESOXYN TABLETS

Dextroamphetamine Sustained Release Capsules FOCALIN TABLETSMethylphenidate Tablets FOCALIN XR CAPSULES Methylphenidate SR TABLETS METADATE CD CAPSULES RITALIN TABLETS PROVIGIL TABLETS (QL) (PA)RITALIN SR TABLETS RITALIN LA CAPSULES

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Disulfiram Tablets ANATBUSE TABLETS CAMPRAL TABLETS Naltrexone Tablets GUANIDINE TABLETS RILUTEK TABLETSREVIA TABLETS STRATTERA (QL)

SUBOXONE TABLETS (PA)SUBUTEX (PA)XYREM SOLUTION (PA)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Citric Acid / Potassium Citrate / Sodium Citrate SyrupPOLY-CITRA SYRUPPotassium Citrate TabletsUROCIT-K TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)KAYEXALATE K-PHOS TABLETS FOSRENOL TABLETSSodium Polysterene Sulfonate Powder PHOSLO TABLETS / CAPSULES RENAGEL TABLETSSodium Polysterene Sulfonate Solution RENVELA TABLETSSPS SUSPENSION

Tier 1 Tier 2 Tier 3 (Not on The Drug List)CEPHULAC SOLUTION KRISTALOSE CRYSTALSLactulose Solution

Tier 1 Tier 2 Tier 3 (Not on The Drug List)KAON-CL UROCIT-K TABLETSK-DUR TABLETSKLOR-CONKLOR-CON PACKETS.K-LYTE (DS) PACKETSK-TABSMICRO-KPotassium Chloride 8 mEq, 10 mEq, 20 mEqPotassium Chloride Effervescent TabletsPotassium Chloride LiquidPotassium Chloride Packets.SLOW K

Sedative / Hypnotics

Monoamine Oxidase Inhibitors

CNS Stimulants

Miscellaneous CNS Agents

ELECTROLYTIC, CALORIC, AND WATER BALANCEAlkalinizing Agents

Electrolyte Depleters

Ammonia Detoxicants

Potassium Medications


10 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)Bumetanide Tablets DEMADEX TABLETS

BUMEX TABLETS EDECRIN TABLETSFurosemide Tablets Torsemide TabletsLASIX TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ALDACTAZIDE TABLETS INSPRA TABLETS ALDACTONE TABLETSAmiloride / Hydrochlorothiazide TabletsAmiloride TabletsDYAZIDE CAPSULESMAXZIDE TABLETSMODURETIC TABLETSSpironolactone / HCTZ TabletsSpironolactone TabletsTriamterene / HCTZ CapsulesTriamterene / HCTZ Tablets

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Chlorthalidone TabletsHydrochlorothiazide (HCTZ) 25mg,50mg TabletsHydrochlorothiazide (HCTZ) 12.5mg CapsulesHYDRODIURIL TABLETSHYGROTON TABLETSIndapamide TabletsLOZOL TABLETSMetolazone TabletsMICROZIDE CAPSULESZAROXOLYN TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Danazol Capsules METHITEST TABLETS ANDROGELDANOCRINE CAPSULES ANDRODERM PATCHES Fluoxymesterone Tablets STRIANT BUCCAL TABLETS Methyltestosterone Tablets TESTIM GEL OXANDRIN TABLETS (PA)Oxandrolone Tablets (PA)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)AMARYL TABLETS ACTOPLUS MET TABLETS FORTAMET TABLETSDIABETA TABLETS ACTOS TABLETS GLYSET TABLETSGlimepiride Tablets AVANDAMET TABLETS STARLIX TABLETSGlipizide Long Acting AVANDARYL TABLETS Glipizide Tablets AVANDIA TABLETS GLUCOPHAGE TABLETS DUETACT TABLETS (QL)GLUCOPHAGE XR TABLETS JANUMET TABLETSGLUCOTROL TABLETS JANUVIA TABLETSGLUCOTROL XL TABLETS PRANDIN TABLETSGLUCOVANCE TABLETS PRECOSE TABLETSGlyburide TabletsGlyburide Micronized TabletsGLYNASE TABLETSMETAGLIP TABLETSMetformin / Glipizide TabletsMetformin / Glyburide TabletsMetformin TabletsMetformin XR TabletsMICRONASE TABLETSTolazamide TabletsTolbutamide TabletsTOLINASE TABLETS

Loop Diuretics

Other AntihypertensivesPotassium Sparing Diuretics

Thiazide and Related Diuretics

ENDOCRINE AGENTSAndrogens

Antidiabetic Agents


11 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)HUMALOG INSULIN (QL) APIDRA HUMALOG INSULIN PENS (QL) EXUBERA INHALATIONHUMALOG MIX 50/50 INSULIN (QL) NOVOLIN (VIALS OR CARTRIDGES ONLY)HUMALOG MIX 50/50 INSULIN PENS (QL) NOVOLOG (VIALS OR CARTRIDGES ONLY)HUMALOG MIX 75/25 INSULIN (QL) NOVOLOG MIX (VIALS OR CARTS. ONLY)HUMALOG MIX 75/25 INSULIN PENS(QL)HUMULIN INSULIN 50/50 INSULIN (QL)HUMULIN INSULIN 70/30 INSULIN (QL)HUMULIN N INSULIN (QL)HUMULIN R INSULIN (QL)LANTUS VIALS (QL)LANTUS CARTRIDGES (PA) (QL)LEVEMIR INSULIN (QL)REGULAR ILETIN

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ACCU-CHEK ACTIVE TEST STRIPS (QL) ONE TOUCH TEST STRIPS (QL)ACCU-CHEK ADVANTAGE TEST STRIPS (QL)ACCU-CHEK AVIVA TEST STRIPS (QL)ACCU-CHEK COMFORT CURVE TEST STRIPS (QL)ACCU-CHEK COMPACT PLUS TEST STRIPS / DRUM (QL)FREESTYLE TEST LITE STRIPS (QL)FREESTYLE TEST STRIPS (QL)KETOSTIX STRIPSPRECISION Q.I.D. TEST STRIPS (QL)PRECISION XTRA TEST STRIPS (QL)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)B-D BRAND DISPOSABLE INSULIN NEEDLES & SYRINGESB-D PEN NEEDLES ORIGINAL 08290-3282-03B-D PEN NEEDLES SHORT 08290-3201-09B-D PEN NEEDLES MINI 08290-3201-19

Tier 1 Tier 2 Tier 3 (Not on The Drug List)CLIMARA PATCHES ESTRACE VAGINAL CREAM ALORA PATCHESESTRACE TABLETS ESTRADERM PATCHES CENESTIN TABLETSESTRADERM PATCHES ESTRATAB TABLETS ESTRASORB TOPICAL EMULSIONEstradiol Patches - BI-WEEKLY MENEST TABLETS ESTRING ( 3 Month's Supply)Estradiol Patches - WEEKLY PREMARIN TABLETS ESTROGEL (QL)Estradiol Tablets PREMARIN VAGINAL CREAM FEMRING (3 months Supply)Estropipate Tablets VIVELLE PATCHES MENOSTAR PATCH OGEN TABLETS VIVELLE-DOT PATCHES VAGIFEM VAGINAL TABLETSORTHO-EST TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ESTRATEST HS TABLETS CLIMARA PRO PATCH ACTIVELLA TABLETSESTRATEST TABLETS PREMPHASE TABLETS ANGELIQ TABLETS

PREMPRO TABLETS COMBIPATCH TABLETSFEMHRT TABLETSPREFEST TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Alendronate Tablets (QL) ACTONEL TABLETS (QL) BONIVA TABLETS (QL)Calcitonin (Salmon) Nasal Soln ACTONEL WITH CALCIUM TABLETS (QL) DIDRONEL TABLETSFORTICAL NASAL SPRAY EVISTA TABLETS (QL)FOSAMAX TABLETS (QL) FOSAMAX-D TABLETS (QL)MIACALCIN NASAL SPRAY

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ARMOUR THYROID TABLETS CYTOMEL TABLETS THYROLAR TABLETSLEVOTHROID TABLETSLevothyroxine TabletsLEVOXYL TABLETSSYNTHROID TABLETSThyroid, Dessicated tablets

Insulin

Blood Glucose Test Strips

Insulin Needles & Syringes

Estrogens

Estrogen Progestin Combinations

Osteoporosis Agents

Thyroid Hormones


12 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)Propylthiouracil (PTU) TabletsMethimazole TabletsTAPAZOLE TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)DDAVP TABLETS/ SPRAY SYNAREL NASAL SOLUTION Cabergoline Tablets (QL)Desmopressin Tablets / Spray DOSTINEX TABLETS (QL)MEGACE TABLETS and SUSPENSION SARAFEM CAPSULES (PA)Megestrol Tablets SENSIPAR TABLETS

ZAVESCA CAPSULES (PA)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Acetazolamide Tabs ALPHAGAN P OPHTHALMIC SOLN. COSOPT OPHTHALMIC SOLN.ALPHAGAN OPHTHALMIC SOLN. AZOPT OPHTHALMIC SOLN. COMBIGAN OPHTHALMIC SOLN.BETAGAN OPHTHALMIC SOLN. BETIMOL OPHTHALMIC SOLN. MetiPranolol Ophth. Soln.Betaxolol Ophthalmic Solution BETOPTIC-S OPHTHALMIC SOLN. RESCULA OPHTHALMIC SOLN.Brimonidine Ophthalmic Solution DIAMOX SEQUELS TRUSOPT OPHTHALMIC SOLN.CARBOPTIC OPHTHALMIC SOLN. ISOPTO CARBACHOL OPHTHALMIC SOLN. XALATAN OPHTHALMIC SOLN. (QL)DIAMOX TABLETS LUMIGAN OPHTHALMIC SOLN. (QL)Dipivefrin Ophthalmic Solution PHOSPHOLINE IODIDE OPHTHALMIC SOLN.Epinephrine HCl Ophthalmic Solution PILOPINE HS GELISOPTO CARPINE OPHTHALMIC SOLN. TIMOPTIC XE GELLevobunolol Ophthalmic Solution TRAVATAN OPHTHALMIC SOLN. (QL)Methazolamide Tablets TRAVATAN Z OPHTHALMIC SOLN. (QL)NEPTAZANE TABLETSPILOCAR OPHTHALMIC SOLN.Pilocarpine HCL Ophthalmic SolutionPROPINE OPHTHALMIC SOLN.Timolol Maleate Ophthalmic GelTimolol Maleate Ophthalmic SolutionTIMOPTIC OPHTHALMIC SOLUTIONTIMOPTIC XE OPHTHALMIC SOLUTION

Tier 1 Tier 2 Tier 3 (Not on The Drug List)AK-TOB OPHTHALMIC SOLUTION NATACYN OPHTHALMIC SUSPENSION QUIXIN OPHTHALMIC SOLN.BLEPH 10 OPHTHALMIC OINT./ SOLUTION VIGAMOX OPHTHALMIC SOLUTION (QL) ZYMAR OPHTHALMIC SOLN.CILOXAN OPHTHALMIC SOLUTIONCiprofloxacin Ophthalmic SolutionErythromycin Ophthalmic Solution & OintmentGARAMYCIN OPHTHALMIC OINT./ SOLUTIONGENOPTIC OPHTHALMIC OINT./ SOLUTIONGENTACIDIN OPHTHALMIC SOLUTIONGentamicin Ophthalmic Solution & OintmentNeomycin / Bacitracin / Polymyxin Ophthalmic Solution & Oint.NEOSPORIN OPHTHALMIC OINTMENTNEOSPORIN OPHTHALMIC SOLN.OCUFLOX OPHTHALMIC SOLUTIONOfloxacin Ophthalmic SolutionPolymixin B Sulfate / Trimethoprim Ophthalmic SolutionPOLYTRIM OPHTHALMIC SOLUTIONSulfacetamide Ophthalmic SolutionTobramycin Ophth. Ophthalmic Solution & OintmentTOBREX OPHTHALMIC OINT./ SOLUTION

Anti-thyroid Medications

Miscellaneous Endocrine Agents

EYE, EAR, NOSE & THROATAnti-Glaucoma Medications

Ophthalmic Antibiotics


13 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)DECADRON OPHTHALMIC SOLUTION & OINTMENT ACULAR LS OPHTHALMIC SOLUTION VEXOL OPHTHALMIC SUSPENSIONDexamethasone Ophthalmic Solution & Ointment ACULAR OPHTHALMIC SOLUTION XIBROM OPHTHALMIC SUSPENSIONDiclofenac Ophtnalmic Solution FLAREX OPHTHALMIC SOLUTIONECONOPRED OPHTHALMIC SOLUTION FML FORTE OPHTHALMIC SOLUTIONECONOPRED PLUS OPHTHALMIC SOLUTION LOTEMAX OPHTHALMIC SUSPENSION (QL)Fluorometholone Ophthalmic SuspensionFluorometholone Ophthalmic Suspension & OintmentFLUOR-OP OPHTHALMIC SOLUTIONFlurbiprofen Ophthalmic SolutionFML OPHTHALMIC SOLUTION & OINTMENTINFLAMASE FORTE OPHTHALMIC SOLUTION & OINTMENTOCUFEN OPHTHALMIC SOLUTIONPRED FORTE OPHTHALMIC SUSPENSIONPRED MILD OPHTHALMIC SUSPENSIONPrednisolone Acetate Ophthalmic SuspensionPrednisolone Phosphate Ophthalmic SolutionVOLTAREN OPHTHALMIC SOLUTION

Tier 1 Tier 2 Tier 3 (Not on The Drug List)CORTISPORIN OPHTHALMIC SOLUTION & OINTMENT BLEPHAMIDE OPHTHALMIC OINTMENTDexamethasone / Neomycin / Polymyxin Ophth. Soln & Oint ISOPTO CETAPRED OPHTHALMIC SOLUTIONHydrocortisone / Neomycin / Polymyxin Ophth. Susp & Oint TOBRADEX OPHTHALMIC SUSPENSION (QL)MAXITROL OPHTHALMIC SOLUTION & OINTMENT ZYLET OPHTHALMIC SUSPENSION (QL)Neomycin / Polymyxin / Prednisone Ophth. Soln.Sulfacetamide / Prednisolone Acetate Susp. & Oint.Sulfacetamide / Prednisolone Ophthalmic Ointment

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Trifluridine Ophthalmic SolutionVIROPTIC OPHTHALMIC SOLUTION

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Atropine Sulfate Ophthalmic Solution & Ointment ALOMIDE OPHTHALMIC SOLUTION ALOCRIL OPHTHALMIC SOLUTIONCROLOM OPHTHALMIC SOLUTION ISOPTO-HYOSCINE OPHTHALMIC SOLUTION ELESTAT OPHTHALMIC SOLUTIONCromolyn Sodium Ophthalmic Solution PATADAY OPHTHALMIC SOLUTION (QL) LIVOSTIN OPHTHALMIC SOLUTIONCYCLOGYL OPHTHALMIC SOLUTION PATANOL OPHTHALMIC SOLUTION OPTIVAR OPHTHALMIC SOLUTIONCyclopentolate Ophthalmic Solution RESTASIS OPHTHALMIC EMULSIONHomatropine Ophthalmic SolutionISOPTO ATROPINE OPHTHALMIC SOLUTIONISOPTO-HOMATROPINE OPHTHALMIC SOLUTIONMYDFRIN OPHTHALMIC SOLUTIONPhenylephrine 2.5% Ophthalmic SolutionScopolamine HBr Ophthalmic Solution

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Acetic Acid 2% / Hydrocortisone 1% Otic Solution CIPRODEX OTIC SOLUTION CIPRO HC OTIC SOLUTIONAcetic Acid 2% Otic Solution FLOXIN OTIC SOLUTIONAcetic Acid Otic Aluminum Acetate SolutionAURALGAN Otic SolutionAUROTO Otic SolutionBenzocaine / Antipyrine Otic SolutionCORTISPORIN OTIC SOLUTION / SUSPENSIONDOMEBORO OTIC SOLUTIONHydrocortisone / Neomycin / Polymyxin Otic Solution / SuspensionVOSOL HC OTIC SOLUTIONVOSOL OTIC SOLUTION

Tier 1 Tier 2 Tier 3 (Not on The Drug List)FLONASE (QL) ASTELIN NASAL SPRAY BECONASE AQ (QL)Fluticasone Nasal Spray (QL) NASACORT AQ (QL) NASAREL NASAL SOLUTION

NASONEX (QL) RHINOCORT AQUA (QL)VERAMYST NASAL SUSPENSION

Ophthalmic Anti-Inflammatory / Anti-Infective Combinations

Ophthalmic Anti-Inflammatory Medications

Ophthalmic Antivirals

Other Ophthalmics

Otic Preparations

Nasal Preparations


14 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)Chlorhexidine Gluconate (Covered Only If Dental Rider) ORABASE HCAKENALOG IN ORABASELidocaine, ViscousPERIDEX (Covered Only With Dental Rider)Pilocarpine TabletsSALAGEN TABLETSTriamcinolone 0.1% in OrabaseVISCOUS XYLOCAINE

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Diphenoxylate / Atropine Tablets

LOMOTIL TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)COMPAZINE TABLETS / SUPPOSITORIES ANZEMET (QL)Ondansetron Orally Disintegrating Tablets (QL) CESAMET CAPSULES (PA) (QL)Ondansetron Tablets (QL) EMEND CAPSULES (QL)PHENERGAN TABLETS KYTRIL TABLETS (QL)Prochlorperazine Tablets / SupositoriesPromethazine TabletsTIGAN CAPSULESTrimethobenzamide Capsules ZOFRAN ODT (QL)ZOFRAN TABLETS (QL)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Belladonna / Phenobarbital Tablets/ Elixir LOTRONEX TABLETS (PA)ANASPAZ TABLETS ROBINUL TABLETSBENTYL CAPSULESClidinium / Chlordiazepoxide CapsulesDicyclomine CapsulesDONNATAL TABLETS / ELIXIRErgotamine/ Belladonna/ PhenobarbitalHyoscyamine Sulfate CR TabletsHyoscyamine Sulfate TabletsLEVSIN TABLETSLEVSINEX TABLETSLIBRAX CAPSULESMetoclopramide TabletsREGLAN TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)CARAFATE TABLETS ACIPHEX TABLETS (QL) AXID TABLETSCimetidine 400 MG,800 MG Tablets NEXIUM CAPSULES (PA) (QL)CYTOTEC TABLETS PREVACID CAPSULES (NOT COVERED-USE SOLUTABS)Famotidine Tablets PREVACID NAPRAPAC (PA) (QL)Misoprostol Tablets PREVACID SOLUTABS (PA) (QL)Omeprazole 10 MG, 20MG Only (QL) PREVPAC (PA) (QL)PEPCID TABLETS PRILOSEC 40MG CAPSULES Not Covered -USE 2 x 20MGPRILOSEC 10MG, 20MG ONLY (QL) PROTONIX TABLETS (QL)Ranitidine 300 mg Tablets OnlyRanitidine 75mg/5ml SyrupSucralfate TabletsTAGAMET 300 MG TABLETSZANTAC TABLETS ONLY

Throat and Mouth Preparations

GASTROINTESTINAL DRUGSAnti-diarrheal Medications

Anti-emetics / Anti-vertigo

Antispasmodics and GI Motility

Anti-ulcer / Anti-peptic Medications


15 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)ACTIGALL CAPSULES ASACOL TABLETS (QL) AMITIZA CAPSULESANUSOL-HC SUPPOSITORIES CANASA SUPPOSITORIES DIPENTUM CAPSULESAZULFIDINE TABS (ENTERIC COATED NOT COVERED) CORTIFOAM ENTOCORT EC CAPSULES Balsalazide Capsules (QL) PROCTOFOAM HC PENTASA TABLETS COLAZAL TABLETS (QL) URSO TABLETS 250 mgCOLYTE SOLUTIONCORTENEMAHydrocortisone Retention EnemaHydrocortisone SuppositoriesMesalamine EnemaMIRALAX POWDER (QL)NULYTELY SOLUTIONOral Colon Lavage SolutionPolyethylene Glycol 3350 /Sodium Carb /Potassium for Solution 240 gmPolyethylene Glycol 3350/ Sodium Carb /Potassium for Solution 420 gmROWASA ENEMASulfasalazine Tablets (Enteric Coated Tablets Not Covered)TRILYTE SOLUTIONUrecholine TabletsUrsodiol 300 mg Capsules

Tier 1 Tier 2 Tier 3 (Not on The Drug List)COTAZYM (S)CREON CAPSULESPANCREASE (MT)ULTRASE (MT) CAPSULESVIOKASE POWDER

Tier 1 Tier 2 Tier 3 (Not on The Drug List)CARDURA TABLETS FLOMAX CAPSULES AVODART CAPSULES Doxazosin Mesylate Tablets UROXATRAL TABLETS (QL)HYTRIN CAPSULES / TABLETSFinasteride (QL)PROSCAR TABLETS (QL)Terazosin Capsules / Tablets

Tier 1 Tier 2 Tier 3 (Not on The Drug List)DITROPAN TABLETS DETROL TABLETS DITROPAN XL TABLETS Oxybutynin Immediate Release Tablets DETROL LA CAPSULES ENABLEX TABLETS

OXYTROL PATCHESSANCTURA TAB 20MGVESICARE TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)CIALIS (PA) (QL)VIAGRA (PA) (QL)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Bethanecol Tablets URISED TABLETS ELMIRON CAPSULESFlavoxate TabletsMACROBID CAPSULESMACRODANTIN CAPSULESMethenamine / Methylene Blue / Atropine TabletsNitrofurantoin MacrocrystalsPhenazopyridine TabletsPYRIDIUM TABLETSTrimethoprim TabletsTRIMPEX TABLETSURISPAS TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Azathioprine Tablets CELLCEPT MYFORTIC CAPSULES (PA)Cyclosporine Capsules PROGRAF RAPAMUNE (PA)Cyclosporine Microemulsion Capsules

DELTASONE TABLETSIMURAN TABLETSNEORAL CAPSULES Prednisone TabletsSANDIMMUNE CAPSULES

Other GI Medications

Digestive Enzymes

GENITOURINARY AGENTSBenign Prostatic Hyperplasia Agents

Overactive Bladder

MiscellaneoDrugs To Treat Impotence (NOT COVERED BY ALL PLANS - CHECK BENEFITS AND SPECIFIC COPAY)

Miscellaneous Genitourinary Drugs

IMMUNOSUPPRESSANTS (Drugs for Transplants)


16 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)Fludrocortisone TabletsCORTEF TABLETSCortisone TabletsCORTONE TABLETSDECADRON TABLETSDELTA CORTEF TABLETSDELTASONE TABLETSDexamethasone TabletsDEXONE TABLETSFLORINEF TABLETSHydrocortisone TabletsHYDROCORTONE TABLETSLIQUID PRED SOLUTIONMEDROL TABLETSMethylprednisolone TabletsORASONE TABLETSPrednisolone TabletsPrednisone TabletsPRELONE SYRUP

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Hydroxychloroquine 200MG Tablets CUPRIMINE CAPSULES ARAVA TABLETSMethotrexate Tablets DEPEN TABLETS Leflunomide TabletsPLAQUENIL 200MG TABLETS RIDAURA CAPSULESRHEUMATREX TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Allopurinol Tablets

BENEMID TABLETS

COL-BENEMID TABLETS

COLCHICINE TABLETSColchicine TabletsProbenecid / Colchicine TabletsProbenecid TabletsZYLOPRIM TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ANAPROX DS TABLETS ARTHROTEC TABLETSANAPROX TABLETS CATAFLAM TabletsCLINORIL TABLETS CELEBREX (QL)DAYPRO TABLETS Diclofenac Extended Release TabletsDiclofenac Sodium Tablets (Immediate Release only) PONSTEL CAPSULESEtodolac ER Tablets VOLTAREN XR TABLETSEtodolac Tablets / CapsulesFenoprofen CapsulesFELDENE CAPSULESIbuprofen TabletsINDOCIN CAPSULESINDOCIN SR CAPSULESIndomethacin CapsulesIndomethacin, Sustained Release CapsulesKetoprofen CapsulesKetorolac Oral Tablets (QL)LODINE TABLETS / CAPSULESLODINE XL TABLETSMeclofenamate CapsulesMeloxicam Tablets (QL)MOBIC TABLETS (QL)MOTRIN TABLETSNabumetone Tablets (QL)NAPROSYN TABLETSNaproxen Sodium TabletsNaproxen Sodium, DS TabletsNaproxen Tablets (Enteric Coated Not Covered)ORUDIS CAPSULESOxaprozin TabletsPiroxicam CapsulesRELAFEN TABLETS (QL)Sulindac TabletsTOLECTIN DS CAPSULESTOLECTIN TABLETSTolmetin CapsulesTolmetin DS CapsulesTORADOL TABLETS (QL) VOLTAREN IMMEDIATE RELEASE TABLETS

JOINT / CONNECTIVE TISSUE / MUSCULOSKELETAL AGENTSAdrenal Corticosteroids (Steroids)

Antirheumatics

Gout Medications

Non-Steroidal Anti-Inflammatory Medications


17 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)Aspirin, Sustained Release Tablets Diflunisal TabletsCholine Magnesium Salicylate Tablets DOLOBID TABLETSSalsalate TabletsTRILISATE TABLETSZORPRIN TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Baclofen Tablets Cyclobenzaprine 5 mg TabletsCarisoprodol Tablets Chlorzaxosone Tablets

Cyclobenzaprine 10 mg Tablets FLEXERIL 5 MG TABLETS

DANTRIUM CAPSULES SKELAXIN TABLETS

Diazepam Tablets Tizanidine Tablets

FLEXERIL 10 MG TABLETS ZANAFLEX TABLETS

LIORESAL TABLETS

Methocarbamol Tablets

NORFLEX TABLETS

NORGESIC FORTE TABLETSNORGESIC TABLETSOrphenadrine / Aspirin / Caffeine TabletsOrphenadrine Citrate TabletsROBAXIN TABLETSSOMA TABLETSVALIUM TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)MESTINON TABLETS MESTINON TIMESPAN TABLETS / SYRUPPyridostigmine Tablets PROSTIGMIN TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ARICEPT TABLETS COGNEX CAPSULES EXELON TABLETS NAMENDA TABLETS

RAZADYNE ER CAPSULES RAZADYNE TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Carbamazepine Tablets CELONTIN CAPSULES GABITRIL TABLETSClonazepam Tablets DEPAKOTE ER TABLETS LYRICA TABLETS (QL)DEPAKENE CAPSULES DEPAKOTE TABLETSDILANTIN CAPSULES / TABLETS FELBATOL TABLETSEthosuximide Capsules KEPPRA TABLETSGabapentin Capsules / Tablets TEGRETOL XR TABLETSGABARONE TABLETS TOPAMAX TABLETSKLONOPIN TABLETSLAMICTAL CHEWABLE TABLETS 5MG, 25MGLamotrigine Chewable Tablets 5mg, 25mgMYSOLINE TABLETSNEURONTIN CAPSULES / TABLETSPHENYTEK CAPSULESPhenytoin CapsulesPrimidone TabletsTEGRETOL TABLETSTRILEPTAL TABLETSValproic Acid CapsulesZARONTIN CAPSULESZONEGRAN CAPSULESZonisamide Capsules

Tier 1 Tier 2 Tier 3 (Not on The Drug List)APAP / Dichloralphenazone / Isometheptene Capsules AMERGE TABLETS (QL) AXERT TABLETS (QL)CAFERGOT TABLETS / SUPPOSITORIES ERGOMAR TABLETS FROVA TABLETS (QL)DURADRIN CAPSULES IMITREX NASAL SPRAY (QL) MAXALT TABLETS (QL)Ergotamine / Caffeine Tablets / Suppositories IMITREX TABLETS (QL) MAXALT-MLT TABLETS (QL)Ergotamine Tartrate Tablets MIGRANAL NASAL SPRAY (QL)MIDRIN CAPSULES RELPAX TABLETS (QL)MIGRATINE CAPSULES ZOMIG TABLETS / NASAL SPRAY (QL)

ZOMIG ZMT TABLETS (QL)

Salicylates

Skeletal Muscle Relaxants

Micellaneous Muscle Relaxants

NEUROLOGICAL AGENTSAlzheimers Agents

Anticonvulsants

Migraine Medications


18 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)Amantadine Capsules AZILECT TABLETS COMTAN TABLETSARTANE TABLETS MIRAPEX TABLETS NEUPRO PATCHES(QL)Benztropine Mesylate Tablets REQUIP TABLETS TASMAR TABLETSBromcriptine Capsules/ Tablets STALEVO TABLETSCarbidopa / Levodopa CR TabletsCarbidopa / Levodopa TabletsCOGENTIN TABLETSDOPAR CAPSULESELDEPRYL CAPSULESLARODOPA TABLETSLevodopa Capsules / TabletsPARLODEL CAPSULES / TABLETSSelegiline TabletsSINEMET CR TABLETSSINEMET TABLETSSYMMETREL CAPSULESTrihexyphenidyl Tablets

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ALESSE (Aviane, Lutera) YASMIN OVCON (Balzia)DEMULEN (Zovia, Kelnor) YAZ Jolessa (3 MO SUPPLY)LEVLEN (Levora, NORDETTE, Portia) SEASONALE (3 MO SUPPLY) (Quasense, Jolessa)LEVLITE (Lessina, Sronyx)LO/OVRAL ( Low-Ogestrel, Cryselle)LOESTRIN (Microgestin, Junel )LOESTRIN FE (Microgestin Fe, Junel Fe)MODICON (BREVICON , Necon 0.5/35, Nortrel 0.5/35)ORTHO NOVUM 1/35 (NORINYL 1+35 , Necon 1/35, Nortrel 1/35)ORTHO NOVUM 1/50 (NORINYL 1+50 , Necon 1/50)ORTHO-CEPT (Apri, Reclipsen, Solia, DESOGEN)ORTHO-CYCLEN (Sprintec, Previfem, Mononessa)OVRAL (OGESTREL)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)MIRCETTE (Kariva) SEASONIQUE (3 MONTH SUPPLY)ORTHO-NOVUM 10/11 (Necon10/11)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)CYCLESSA (Velivet, Cesia) ORTHO TRI-CYCLEN LO ESTROSTEP FeORTHO TRI-CYCLEN (Trinessa, Tri-Previfem,Tri-Sprintec)ORTHO-NOVUM 7/7/7 (Necon 7/7/7, Nortrel 7/7/7)TRI-LEVLEN (Enpresse, TRIPHASIL, Trivora)TRI-NORINYL ( Aranelle, Leena)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)LYBREL TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ORTHO MICRONOR (Errin, Camila, Jolivette , Nora-BE, NOR-QD) CERVICAL CAP

NUVARINGORTHO DIAPHRAGMORTHO EVRA PATCH

Tier 1 Tier 2 Tier 3 (Not on The Drug List)PLAN B TABLETS (AGE RESTRICTION-OTC FOR 18 AND OLDER)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)AYGESTIN TABLETS PROMETRIUM CAPSULES

Medroxyprogesterone TabletsNorethindrone TabletsPROVERA TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)CLEOCIN VAGINAL CREAM TERAZOL VAGINAL CREAM / TABLETSClindamycin Vaginal CreamDIFLUCAN 150 MG TAB ONLYFluconazole TabletsMETROGEL VAGINAL GELMetronidazole Vageinal Gel 0.75%VANDAZOLE VAGINAL GEL

Anti-parkinson Medications

OBSTETRICAL AND GYNECOLOGICAL MEDICATIONSContraceptives

Monophasic (Equivalent Products In Parens)

Biphasic (Equivalent Products In Parens)

Triphasic (Equivalent Products In Parens)

Other Contraceptives

Emergency Contraceptives

Progestins

Vaginal Anti-Infectives

Non-Cyclic Contraceptives


19 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)CLOMID TABLETS (PA) (QL) CRINONE 8% VAGINAL CREAM PRENATE ELITE TABLETSADVANCED NATALCARE TABLET ERGOTRATE TABLETS PROCHIEVE VAGINAL CREAM (PA)ADVANCED-RF NATALCARE TAB METHERGINE TABLETS (QL)CITRACAL PRENATAL RX TABLETClomiphene Tablets (PA) (QL)Ergonovine Maleate TabletsINATAL ULTRA TABLETNATAFORT TABLETNATALCARE PLUS TABLETNATALCARE RX TABLETNATALCARE THREE TABLETNATATAB CFE TABLETNATATAB FA TABLETPRECARE CONCEIVE TABLETPRECARE PRENATAL CAPLETPRENATAL MR 90 FE TABLET SAPrenatal Vitamins With Folic Acid 1 mgPRENATE GT TABLETSPRENATE ULTRA TABLETSSEROPHENE TABLETS (PA) (QL)ULTRA NATALCARE TABLETVINATE GT TABLET

Tier 1 Tier 2 Tier 3 (Not on The Drug List)QVAR (QL) AEROBID INHALERPULMICORT FLEXHALER (QL) AEROBID-M INHALERPULMICORT RESPULES (QL)FLOVENT HFA (QL)AZMACORT (QL)ASMANEX TWISTHALER (QL)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)AEROCHAMBERINSPIREASEPEAK FLOW METER

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Acetylcysteine ADVAIR (QL) BROVANA SOLUTION FOR INHALATIONAlbuterol Inhaler (QL) ADVAIR HFA (QL) COMBIVENT INHALERCromolyn Sodium Inhaler ALUPENT INHALER DUONEB INAHALTION SOLN.Ipratropium Inhaler ATROVENT HFA INHALER PROAIR HFA (Not Covered-Use Proventil HFA)MUCOMYST BRETHAIRE INHALER SYMBICORT INHALATIONPROVENTIL INHALER (QL) FORADIL AEROLIZER (QL) XOPENEX NEBULIZER SOLUTION

INTAL MDI ZYFLO TABLETSMAXAIR AUTOHALER MAXAIR INHALERPROVENTIL HFA INHALER (QL)PULMOZYME (QL)SEREVENT DISKUS (QL)SINGULAIR TABLETS SPIRIVA HANDIHALER (QL)TILADE AEROSOLXOPENEX HFA AEROSOL (QL)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Albuterol ER Tablets ACCOLATE TABLETS THEO-24 CAPSULES.Albuterol TabletsALUPENT TABLETSAminophylline TabletsAMINOPHYLLINE TabletsBRETHINE TabletsMetaproterenol Oral TabletsPROVENTIL TABSSLO-BID CAPSULESTerbutaline Sulfate TabletsTHEODUR TABLETSTheophylline LiquidTheophylline, 80mg/15cc (Alcohol Free)Theophylline, Immediate Release TabletsTheophylline, Sustained Release CapsulesUNIPHYL TABLETSVOSPIRE ER TABLETS

Other Obstetrical and Gynecologicals

RESPIRATORY AGENTSInhaled Steroids

Devices For The Treatment of Asthma

Inhaled Respiratory Medications

Oral Medication For Asthma or Lung Problems


20 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)A/T/S SOLUTION (SWABS, PADS & PLEDGETS EXCLUDED) DIFFERIN GEL / CR / SOL / PADS (QL) AZELEX CREAMACCUTANE CAPSULES (QL) DUAC GEL (QL) BENZACLIN GELAMNESTEEM CAPSULES (QL) FINACEA GEL CLENIA CREAMBENZAMYCIN METROGEL TOPICAL GEL KLARON LOTIONCLEOCIN T SOLN (SWABS, PADS & PLEDGETS EXCLUDED) RETIN-A MICRO PLEXION CREAMClindamycin Solution 1% (Swabs, Pads & Pledgets Excluded) TAZORAC CREAM / GEL (QL) ROSAC CREAMEMGEL ROSULA GELERYCETTE SOLN (SWABS, PADS & PLEDGETS EXCLUDED) ZONALON CREAMERYDERM SOLN (SWABS, PADS & PLEDGETS EXCLUDED)ERYGELErythromycin / Benzoyl Peroxide CreamErythromycin 1.5 % Soln (Swabs, Pads & Pledgets Excluded)Erythromycin 2 % GelErythromycin 2.0 % Soln (Swabs, Pads & Pledgets Excluded)Isotretinoin Caps (QL)METROCREAM TOPICAL CREAMMetronidazole Topical CreamRETIN-A CREAM / GELSOTRET CAPSULES (QL)SULFACET-R LOTION (QL)Tretinoin Cream / Gel

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Clotrimazole / Betamethasone Cream / Lotion (QL) DENAVIR CREAM (QL)Econazole Cream ERTACZO CREAMKetoconazole Cream (QL) EXELDERM CREAM / SOLUTIONLOTRISONE CREAM / LOTION (QL) Ketoconazole 2% ShampooMYCOSTATIN Cream / Ointment LOPROX CREAM / GEL / SUSPENSIONNIZORAL CREAM (QL) NAFTIN CREAMNystatin Cream / Ointment OXISTAT CREAMSPECTAZOLE CREAM PENLAC NAIL LACQUER (PA)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)BACTROBAN OINTMENT ZOVIRAX OINTMENT (QL) ALTABAX OINTMENTCENTANY Ointment PANRETIN GEL Mupirocin OintmentSILVADENE CREAMSilver Sulfadiazine creamSSD CREAM

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Aclometasone Dipropionate Cream / OintmentACLOVATE CREAM / OINTMENTDesonide Cream / Ointment / LotionDESOWEN CREAM / OINTMENT/ LOTIONFluocinolone Acetonide 0.01% Cream / Ointment / SolutionHydrocortisone 2.5% Cream / Ointment / LotionHYTONE CREAM / OINTMENTSYNALAR 0.01% CREAM / OINTMENT / SOLUTION

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ARISTOCORT CREAM / OINTMENT CORDRAN CREAM / OINTMENT / TAPEELOCON CREAM / OINTMENT CUTIVATE CREAM /OINTMENTFluocinolone Acetonide 0.025% Cream / Ointment Hydrocortisone Valerate Cream / OintmentKENALOG CREAM / OINTMENT LOCOID CREAM / OINTMENTMometasone Furoate Cream / Ointment / Lotion WESTCORT CREAM / OINTMENTSYNALAR 0.025% CREAM / OINTMENTTriamcinolone Acetonide Cream / Ointment / Lotion

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Betamethasone Dipropionate Cream / Ointment HALOG CREAM / OINTMENTDesoximetasone 0.05% CREAM Diflorasone Diacetate, Emollient CreamDIPROSONE CREAM / OINTMENTFluocinolone Acetonide 0.2% HP CreamFluocinonide Cream/ OintmentLIDEX CREAM / OINTMENTLIDEX E CREAM MAXIVATE CREAM / OINTMENTSYNALAR HP CREAM TOPICORT LP CREAM

SKIN AND MUCOUS MEMBRANE AGENTS Acne Medications

Topical Antifungals

Topical Anti-Infectives

Topical Anti-inflammatory / SteroidsLOW POTENCY

MEDIUM POTENCY

HIGH POTENCY


21 of 22




Tier 1 Tier 2 Tier 3 (Not on The Drug List)Augmented Betamethasone Dipropionate Cream CLOBEX LOTIONClobetasol Propionate Cream / Ointment/ Gel / Solution/ EmollientDiflorasone Diacetate Cream / OinmentDIPROLENE AF CREAM FLORONE CREAM MAXIFLOR CREAM / OINTMENTPSORCON CREAM / OINTMENTTEMOVATE CREAM / OINTMENT/ GEL/ SOLUTION/ EMOLLIENTULTRAVATE CREAM / OINTMENT

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Selenium Sulfide 2.5% Lotion DOVONEX CREAM / OINTMENT (QL) SORIATANE CAPSULESSELSUN LOTION TAZORAC CREAM / GEL (QL)SEBIZON Lotion

Tier 1 Tier 2 Tier 3 (Not on The Drug List)ACTICIN CREAM (QL) EURAX CREAM / LOTION OVIDE LOTIONELIMITE CREAM (QL)Permethrin Cream / Lotion (QL)

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Aluminum Chloride Hexahydrate CONDYLOX – GEL ALDARACARAC CREAM FLUOROPLEX CREAM / SOLUTION ELIDEL CREAMDRYSOL OXSORALEN ULTRA TABLETS ONLY EMLA CREAMEFUDEX CREAM / SOLUTION PROTOPIC OINTMENT (PA) FLECTOR PADS (QL)Fluorouracil Cream / Solution KERALAC CREAM / LOTION

LIDODERM PATCHES REGRANEX GEL SOLARAZE GELSYNERA PATCHESVEREGEN OINT (QL)VOLTAREN GEL

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Hydrocortisone (Rectal Cream) CORTIFOAMPROCTO-CREAM PROCTOFOAM NS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Prenatal Multivitamins / Folic Acid (Rx Strength)NATALCARE TABLETSPRECARE PRENATAL TABLETSPRENATE ADVANCE TABLETSPRENATE GT TABLETSSTRONGSTART TABLETS

Tier 1 Tier 2 Tier 3 (Not on The Drug List)Calcitriol Capsules HECTOROL CAPSULESDRISDOL CAPSULES ZEMPLAR CAPSULESErgocalciferol CapulesFluoride / Polyvitamins (Without Iron; Drops & Tabs) Fluoride / Vitamins A,D,C (Without Iron; Drops & Tabs)Folic Acid 1 mg TabletsLURIDE TABLETSPOLY-VI-FLOR TABLETS / DROPSROCALTROL CAPSULESSodium Fluoride Tablets and DropsTRI-VI-FLOR TABLETS / DROPSVI-DAYLIN /F TABLETS / DROPS

Antipsoriasis

Prenatal Vitamins

Vitamin and Fluoride Medications / Miscellaneous Supplements

Scabicides

Miscellaneous Skin and Mucous Membrane

Anorectal Medications

VITAMINS

VERY HIGH POTENCY


22 of 22



health net's 3 tier recommended drug list net's 3 tier recommended drug list tier 1 tier 2...

Documents