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Flexible Choice and Out-of-Area PPO (OOA-PPO) FormularyLastUpdate:6/5/2018

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 PharmacyandTherapeutics 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 fill your prescription. You may want to consult your physician for a generic alternative that may cost you less or as a Flexible Choice member 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 44.

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 pharmacy benefits covered under your plan. MedImpact has a network that consists of local and national pharmacies. “Participating pharmacies” include:

• Costco • CVS• HarrisTeeter • Giant• RiteAid • Kmart• Shoppers Food Warehouse • Safeway• Walgreens • Wal-Mart• Wegmans

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/sevendaysaweek.

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 formularydocument

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 drugs can be found on page 44.

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

OC=OralChemotherapyDrugs

QL=A drug with a quantity limit

PRV = Zero Cost Share Preventative Drugs

MSD =Medical Service 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 Restrictions ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA 2 BILTRICIDE 3 EMVERM 3 ivermectin 1, 3 YODOXIN 2 ANTIBACTERIALS amikacin sulfate MSD amoxicillin 1, 2, 3 amoxicillin & pot clavulanate 1, 2, 3 ampicillin 1, 2 ampicillin & sulbactam sodium MSD ampicillin sodium MSD AVELOX MSD AVYCAZ MSD AZACTAM IN DEXTROSE MSD azithromycin 1, 2, 3, MSD aztreonam MSD bacitracin MSD BACTOCILL IN DEXTROSE MSD BAXDELA 3, MSD BICILLIN C-R MSD BICILLIN L-A MSD CAYSTON 3 LD CEDAX 3 cefaclor 1, 2 CEFACLOR ER 3 cefadroxil 1 cefazolin sodium MSD CEFAZOLIN SODIUM-DEXTROSE MSD cefdinir 1 CEFDITOREN PIVOXIL 3 cefepime hcl MSD CEFEPIME-DEXTROSE MSD cefixime 1, 2, 3 CEFOTAXIME SODIUM MSD cefotetan disodium MSD CEFOTETAN DISODIUM-DEXTROSE MSD cefoxitin sodium MSD CEFOXITIN SODIUM-DEXTROSE MSD cefpodoxime proxetil 1 cefprozil 1 ceftazidime MSD CEFTAZIDIME AND DEXTROSE MSD ceftriaxone sodium MSD cefuroxime axetil 1, 2, 3 cefuroxime sodium MSD cephalexin 1, 3 CHLORAMPHENICOL SOD SUCCINATE MSD ciprofloxacin 1, 3, MSD ciprofloxacin hcl 1, 2, 3 ciprofloxacin in d5w MSD ciprofloxacin-ciprofloxacin hcl 1, 3 clarithromycin 1, 2, 3

LEGEND LD = Limited Distribution OC = Oral Chemo Drugs MSD = Medical Service Drugs QL = Quantity Limit PRV = $0 Preventative Drugs PA = Prior Authorization Required

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Name of drug Drug Tier Restrictions clindamycin hcl 1, 3 clindamycin palmitate hydrochloride 1, 3 clindamycin phosphate MSD clindamycin phosphate in d5w MSD colistimethate sodium MSD DALVANCE MSD daptomycin MSD demeclocycline hcl 1 dicloxacillin sodium 1 DIFICID 3 DORIBAX MSD doxycycline (monohydrate) 1, 3 doxycycline hyclate 1, 3, MSD ERYTHROCIN LACTOBIONATE MSD ERYTHROCIN STEARATE 3 erythromycin base 1, 3 erythromycin ethylsuccinate 1, 3 erythromycin-sulfisoxazole 1 FACTIVE 3 FORTAZ IN D5W MSD gentamicin in saline MSD gentamicin sulfate MSD imipenem-cilastatin MSD INVANZ MSD KETEK 3 levofloxacin 1, 2, 3, MSD levofloxacin in d5w MSD LINCOCIN MSD linezolid 1, MSD LINEZOLID IN SODIUM CHLORIDE MSD meropenem MSD MEROPENEM-SODIUM CHLORIDE MSD minocycline hcl 1, 3 moxifloxacin hcl 1, 3, MSD nafcillin sodium MSD NAFCILLIN SODIUM IN DEXTROSE MSD neomycin sulfate 1, 2 ofloxacin 1, 3 ORBACTIV MSD oxacillin sodium MSD PCE 3 PENICILLIN G POT IN DEXTROSE MSD penicillin g potassium MSD PENICILLIN G PROCAINE MSD PENICILLIN G SODIUM MSD penicillin v potassium 1, 2 piperacillin sodium-tazobactam sodium MSD polymyxin b sulfate MSD SIVEXTRO 3, MSD STREPTOMYCIN SULFATE MSD SULFADIAZINE 2 sulfamethoxazole-trimethoprim 1, 3, MSD sulfasalazine 1, 3 SYNERCID MSD TEFLARO MSD


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Name of drug Drug Tier Restrictions tetracycline hcl 1, 3 TIGECYCLINE MSD TIMENTIN MSD tobramycin 1 tobramycin sulfate MSD VABOMERE MSD vancomycin hcl 1, MSD VANCOMYCIN HCL IN DEXTROSE MSD VIBATIV MSD VIBRAMYCIN 3 XIFAXAN 3 ZERBAXA MSD ZINACEF IN STERILE WATER MSD ZOSYN MSD ANTIFUNGALS ABELCET MSD AMBISOME MSD AMPHOTERICIN B MSD caspofungin acetate MSD ciclopirox 1, 3 PA CRESEMBA 3, MSD ERAXIS MSD fluconazole 1, 3 fluconazole in dextrose MSD fluconazole in nacl MSD flucytosine 1 griseofulvin microsize 1, 3 griseofulvin ultramicrosize 1, 3 itraconazole 1, 2, 3 PA JUBLIA 3 PA KERYDIN 3 PA ketoconazole 1 MYCAMINE MSD NOXAFIL 3, MSD nystatin 1 nystatin (mouth-throat) 1 ORAVIG 3 terbinafine hcl 1, 3 PA voriconazole 1, 3, MSD ANTIMYCOBACTERIALS CAPASTAT SULFATE MSD CYCLOSERINE 3 dapsone 1 ethambutol hcl 1, 3 isoniazid 1, 2, MSD PASER 3 PRIFTIN 3 pyrazinamide 1 rifabutin 1, 3 RIFAMATE 3 rifampin 1, 3, MSD RIFATER 3 SIRTURO 3 LD TRECATOR 3 ANTIPROTOZOALS


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Name of drug Drug Tier Restrictions ALINIA 3 atovaquone 1, 3 atovaquone-proguanil hcl 1, 3 BENZNIDAZOLE 3 chloroquine phosphate 1 COARTEM 2 DARAPRIM 2 LD hydroxychloroquine sulfate 1, 3 IMPAVIDO 3 mefloquine hcl 1 metronidazole 1, 3 metronidazole in nacl MSD NEBUPENT 2, MSD paromomycin sulfate 1 PRIMAQUINE PHOSPHATE 2 quinine sulfate 1, 3 tinidazole 1 ANTIVIRALS abacavir sulfate 1, 2, 3 abacavir sulfate-lamivudine 1, 3 abacavir sulfate-lamivudine-zidovudine 1, 3 acyclovir 1, 3 acyclovir sodium MSD adefovir dipivoxil 1, 3 APTIVUS 2 atazanavir sulfate 1, 2, 3 ATRIPLA 2 BIKTARVY 3 cidofovir MSD COMPLERA 2 CRIXIVAN 2 DAKLINZA 3 QL DESCOVY 2 didanosine 1, 2, 3 EDURANT 2 efavirenz 1, 3 EMTRIVA 2 entecavir 1, 3 EPCLUSA 2 QL EVOTAZ 3 famciclovir 1, 3 fosamprenavir calcium 1, 3 FOSCARNET SODIUM MSD FUZEON 3 QL GANCICLOVIR MSD ganciclovir sodium MSD GENVOYA 2 HARVONI 2 QL INTELENCE 2 INVIRASE 2 ISENTRESS 2 JULUCA 3 lamivudine 1, 3 lamivudine (hbv) 1, 3 lamivudine-zidovudine 1, 3


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Name of drug Drug Tier Restrictions lopinavir-ritonavir 1, 2, 3 MAVYRET 3 QL nevirapine 1, 2, 3 ODEFSEY 2 OLYSIO 3 QL oseltamivir phosphate 1, 3 QL PEG-INTRON 2, 3 QL PEGASYS 2 QL PLEGRIDY 3 QL PREVYMIS 3, MSD PREZCOBIX 2 PREZISTA 2 RAPIVAB MSD RELENZA DISKHALER 2 QL RESCRIPTOR 2 ribavirin (hepatitis c) 1, 3 rimantadine hydrochloride 1, 3 ritonavir 1, 2 SELZENTRY 2, 3 SOVALDI 3 QL stavudine 1, 3 STRIBILD 2 SYMFI LO 3 SYNAGIS MSD TECHNIVIE 3 QL tenofovir disoproxil fumarate 1, 3 TIVICAY 2 TRIUMEQ 2 TRUVADA 2, 3 TYZEKA 3 valacyclovir hcl 1, 3 valganciclovir hcl 1 VEMLIDY 3 VIEKIRA PAK 3 QL VIRACEPT 2 VIRAZOLE MSD VITEKTA 3 VOSEVI 3 QL ZEPATIER 3 QL zidovudine 1, 3, MSD URINARY ANTI-INFECTIVES methenamine hippurate 1, 3 methenamine-hyosc-methylene blue-sod phos-phenyl sal 1 MONUROL 3 nitrofurantoin 1, 3 nitrofurantoin macrocrystal 1, 3 nitrofurantoin monohyd macro 1, 3 PRIMSOL 3 trimethoprim 1 UTA 1 ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate 1, 3 cetirizine hcl 1 CLARINEX-D 12 HOUR 3


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Name of drug Drug Tier Restrictions clemastine fumarate 1, 3 cyproheptadine hcl 1 desloratadine 1, 3 diphenhydramine hcl MSD promethazine & phenylephrine 1 promethazine hcl 1, MSD SEMPREX-D 3 ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS ABRAXANE MSD AFINITOR 2 OC ALECENSA 3 ALFERON N MSD ALIMTA MSD ALIQOPA MSD ALUNBRIG 3 OC anastrozole 1, 3 OC ARRANON MSD ARZERRA MSD AVASTIN MSD azacitidine 3, MSD QL BAVENCIO MSD BELEODAQ MSD BENDEKA MSD BESPONSA MSD bexarotene 1 OC bicalutamide 1, 3 OC BICNU MSD bleomycin sulfate MSD BLINCYTO MSD BORTEZOMIB MSD BOSULIF 3 OC busulfan 2, MSD CABOMETYX 3 LD, OC CALQUENCE 3 OC CAMPATH MSD LD capecitabine 1, 3 OC CAPRELSA 2 LD, OC carboplatin MSD CEENU 2 OC cisplatin MSD cladribine MSD clofarabine MSD COTELLIC 3 OC cyclophosphamide 1, 2, MSD PA CYRAMZA MSD cytarabine MSD dacarbazine MSD dactinomycin MSD DARZALEX MSD daunorubicin hcl MSD decitabine MSD DOCETAXEL MSD doxorubicin hcl MSD doxorubicin hcl liposomal MSD


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Name of drug Drug Tier Restrictions DROXIA 3 OC ELIGARD 2, 3 QL ELIGARD 2, 3 QL ELIGARD 2, 3 QL EMCYT 2 OC EMPLICITI MSD epirubicin hcl MSD ERBITUX MSD ERIVEDGE 3 OC ERLEADA 3 OC ETOPOPHOS MSD etoposide 2, MSD OC exemestane 1, 3 OC FARESTON 3 OC FARYDAK 3 OC FASLODEX MSD OC FIRMAGON MSD OC FLOXURIDINE MSD fludarabine phosphate MSD fluorouracil MSD flutamide 1 OC FOLOTYN MSD GAZYVA MSD gemcitabine hcl MSD GILOTRIF 3 OC HALAVEN MSD HERCEPTIN MSD HEXALEN 3 OC hydroxyurea 1, 3 OC IBRANCE 3 OC ICLUSIG 3 LD, OC idarubicin hcl MSD IDHIFA 3 OC ifosfamide MSD imatinib mesylate 1 IMBRUVICA 2 OC IMFINZI MSD IMLYGIC MSD INLYTA 2 OC INTRON A 2 QL IRESSA 2 OC irinotecan hcl MSD ISTODAX MSD IXEMPRA KIT MSD OC JAKAFI 2 OC JEVTANA MSD KADCYLA MSD KEYTRUDA MSD KISQALI 200 DOSE 3 OC KISQALI FEMARA 200 DOSE 3 OC KYPROLIS MSD LARTRUVO MSD LENVIMA 10 MG DAILY DOSE 3 LD, OC letrozole 1, 3 OC LEUKERAN 2 OC


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Name of drug Drug Tier Restrictions leuprolide acetate 1, 2, 3 PA, QL LONSURF 3 OC LUPANETA PACK MSD LUPRON DEPOT-PED 2 QL LUPRON DEPOT-PED (3-MONTH) 2 QL LUTATHERA MSD LYNPARZA 3 OC LYSODREN 2 OC MARQIBO MSD MATULANE 2 OC megestrol acetate 1, 3 OC MEKINIST 3 OC melphalan 1, 3 OC melphalan hcl MSD OC mercaptopurine 1 OC methotrexate sodium 1, 3, MSD mitomycin MSD mitoxantrone hcl MSD MUSTARGEN MSD OC MYLOTARG MSD NERLYNX 3 OC NEXAVAR 2 OC nilutamide 1, 3 OC NINLARO 3 OC NIPENT MSD ODOMZO 3 OC ONIVYDE MSD OPDIVO MSD oxaliplatin MSD paclitaxel MSD PERJETA MSD POMALYST 3 LD, OC PORTRAZZA MSD PROLEUKIN MSD REVLIMID 2 PA, LD RHEUMATREX 3 RITUXAN MSD RITUXAN HYCELA MSD RUBRACA 3 OC RYDAPT 3 SPRYCEL 2 OC STIVARGA 3 OC SUTENT 3 OC SYLATRON 3 QL SYLVANT MSD SYNRIBO 3 QL, OC TABLOID 2 OC TAFINLAR 3 OC TAGRISSO 3 OC tamoxifen citrate 1, 3 PA TARCEVA 3 OC TASIGNA 2 OC TECENTRIQ MSD temozolomide 1, MSD thiotepa MSD


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Name of drug Drug Tier Restrictions topotecan hcl 3, MSD TORISEL MSD TRELSTAR MIXJECT MSD OC tretinoin (chemotherapy) 1 OC TRISENOX MSD OC TYKERB 2 OC UNITUXIN MSD VECTIBIX MSD VENCLEXTA 2 OC VERZENIO 3 OC VINBLASTINE SULFATE MSD vincristine sulfate MSD vinorelbine tartrate MSD VOTRIENT 2 OC VYXEOS MSD XALKORI 2 OC XATMEP 3 XTANDI 2 OC YERVOY MSD YONDELIS MSD ZALTRAP MSD ZANOSAR MSD ZEJULA 3 ZELBORAF 2 OC ZOLADEX MSD ZOLINZA 3 OC ZYDELIG 3 OC ZYKADIA 2 OC ZYTIGA 2 OC AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANORO ELLIPTA 3 atropine sulfate 2, MSD ATROVENT HFA 2 BEVESPI AEROSPHERE 3 CANTIL 3 chlordiazepoxide hcl-clidinium bromide 1, 3 dicyclomine hcl 1, 3, MSD glycopyrrolate 1, 3, MSD hyoscyamine 1 hyoscyamine sulfate 1, 3 INCRUSE ELLIPTA 3 ipratropium bromide 1 ipratropium bromide (nasal) 1, 3 LONHALA MAGNAIR REFILL KIT 3 methscopolamine bromide 1 PROPANTHELINE BROMIDE 3 SPIRIVA HANDIHALER 2, 3 STIOLTO RESPIMAT 2 TUDORZA PRESSAIR 3 AUTONOMIC DRUGS, MISCELLANEOUS bupropion hcl (smoking deterrent) PRV CHANTIX PRV QL nicotine PRV nicotine polacrilex PRV


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Name of drug Drug Tier Restrictions PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride 1, 3 cevimeline hcl 1, 3 donepezil hydrochloride 1, 3 galantamine hydrobromide 1, 2, 3 GUANIDINE HCL 3 NEOSTIGMINE METHYLSULFATE MSD PHYSOSTIGMINE SALICYLATE MSD pilocarpine hcl (oral) 1, 3 pyridostigmine bromide 1, 2, 3, MSD rivastigmine 1, 3 rivastigmine tartrate 1, 3 SKELETAL MUSCLE RELAXANTS baclofen 1, MSD carisoprodol 1, 3 carisoprodol w/ aspirin 1 carisoprodol w/ aspirin & codeine 1 QL CHLORZOXAZONE 3 cyclobenzaprine hcl 1, 3 dantrolene sodium 1, 3, MSD metaxalone 1, 3 methocarbamol 1, 3, MSD orphenadrine citrate 1, MSD tizanidine hcl 1, 3 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl 1, 3 dihydroergotamine mesylate 1, 3 QL ERGOLOID MESYLATES 2 ERGOMAR 3 phenoxybenzamine hcl 1, 3 RAPAFLO 3 tamsulosin hcl 1, 3 SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADRENALIN 2, 3, MSD QL ADVAIR DISKUS 2, 3 AKOVAZ MSD albuterol sulfate 1, 2, 3 ARCAPTA NEOHALER 3 BROVANA 3 dobutamine hcl MSD dobutamine in d5w MSD epinephrine MSD FORADIL AEROLIZER 3 ipratropium-albuterol 1, 2 levalbuterol hcl 1, 3 LEVALBUTEROL TARTRATE 3 metaproterenol sulfate 1, 2, 3 midodrine hcl 1 NORTHERA 3 PHENYLEPHRINE HCL MSD SEREVENT DISKUS 2 STRIVERDI RESPIMAT 2 terbutaline sulfate 1, MSD UTIBRON NEOHALER 3 BLOOD FORMATION, COAGULATION, AND THROMBOSIS


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Name of drug Drug Tier Restrictions COAGULANTS AND ANTICOAGULANTS AFSTYLA MSD AGGRASTAT MSD ALPHANATE/VWF COMPLEX/HUMAN MSD ALPROLIX MSD aminocaproic acid MSD anagrelide hcl 1, 3 argatroban MSD ARGATROBAN MSD aspirin-dipyridamole 1, 2 BEVYXXA 3 bivalirudin trifluoroacetate MSD BRILINTA 2 cilostazol 1, 3 clopidogrel bisulfate 1, 3 COAGADEX MSD DURLAZA 3 ELIQUIS 3 ELOCTATE MSD enoxaparin sodium 1, 3 QL fondaparinux sodium 1, 3 QL FRAGMIN 3 QL HEMLIBRA 3 QL HEPARIN (PORCINE) IN D5W MSD heparin (porcine) in sodium chloride MSD heparin sodium (porcine) 1 QL heparin sodium (porcine) lock flush MSD IDELVION MSD INTEGRILIN MSD IPRIVASK 3 QL IXINITY MSD KCENTRA MSD KENGREAL MSD KOVALTRY MSD NUWIQ MSD OBIZUR MSD pentoxifylline 1 PRADAXA 2 prasugrel hcl 1, 3 PRAXBIND MSD SAVAYSA 3 TICLOPIDINE HCL 3 tranexamic acid 1, 3, MSD TRETTEN MSD VONVENDI MSD warfarin sodium 1, 3 XARELTO 3 YOSPRALA 3 ZONTIVITY 3 HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) 3 QL ARANESP ALBUMIN FREE SURECLICK 3 QL EPOGEN 2 QL GRANIX 3 QL LEUKINE 2 QL


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Name of drug Drug Tier Restrictions MIRCERA 3 QL MOZOBIL 3 QL NEULASTA 3 QL NEUMEGA 3 QL NEUPOGEN 2 QL PROMACTA 2 LD ZARXIO 2 QL CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA XL 3 doxazosin mesylate 1, 3 prazosin hcl 1, 3 terazosin hcl 1 ANTILIPEMIC AGENTS atorvastatin calcium PRV cholestyramine 1, 3 cholestyramine light 1, 3 choline fenofibrate 1, 3 colestipol hcl 1, 3 ezetimibe 1, 3 ezetimibe-simvastatin 1, 3 fenofibrate 1, 3 fenofibrate micronized 1, 3 FENOFIBRIC ACID 3 fluvastatin sodium PRV gemfibrozil 1, 3 JUXTAPID 3 LD KYNAMRO 3 QL, LD LIVALO 3 lovastatin PRV niacin (antihyperlipidemic) 1, 3 omega-3-acid ethyl esters 1, 3 PRALUENT 3 PA, QL pravastatin sodium PRV REPATHA 3 PA, QL rosuvastatin calcium PRV simvastatin PRV VASCEPA 3 WELCHOL 3 BETA-ADRENERGIC BLOCKING AGENTS esmolol hcl MSD labetalol hcl MSD metoprolol tartrate 1, MSD SOTYLIZE 3 CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besylate 1, 3 amlodipine besylate-atorvastatin calcium 1, 3 amlodipine besylate-benazepril hcl 1, 3 amlodipine besylate-olmesartan medoxomil 1, 3 amlodipine besylate-valsartan 1, 3 amlodipine-valsartan-hydrochlorothiazide 1, 3 CARDENE IV MSD CLEVIPREX MSD diltiazem hcl 1, 3, MSD diltiazem hcl coated beads 1, 3


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Name of drug Drug Tier Restrictions diltiazem hcl extended release beads 1, 3 felodipine 1 isradipine 1 nicardipine hcl 1, MSD nifedipine 1, 3 nimodipine 1, 3 nisoldipine 1, 3 olmesartan medoxomil-amlodipine-hydrochlorothiazide 1, 3 PRESTALIA 3 telmisartan-amlodipine 1, 3 trandolapril-verapamil hcl 1, 3 verapamil hcl 1, 3, MSD CARDIAC DRUGS adenosine MSD amiodarone hcl 1, 3, MSD CORLANOR 3 digoxin 1, 2, 3, MSD disopyramide phosphate 1, 3 dofetilide 1 flecainide acetate 1 lidocaine hcl (cardiac) MSD lidocaine in d5w MSD mexiletine hcl 1 MULTAQ 3 NEXTERONE MSD procainamide hcl MSD propafenone hcl 1, 3 quinidine gluconate 1, MSD quinidine sulfate 1, 2 RANEXA 3 HYPOTENSIVE AGENTS clonidine hcl 1, 3 clonidine hcl (adhd) 1, 3 CLORPRES 3 guanfacine hcl 1, 3 hydralazine hcl 1, MSD methyldopa 1 METHYLDOPA-HYDROCHLOROTHIAZIDE 3 METHYLDOPATE HCL MSD minoxidil 1 NIPRIDE RTU MSD RESERPINE 3 VECAMYL 3 RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS benazepril & hydrochlorothiazide 1, 3 benazepril hcl 1, 3 candesartan cilexetil 1, 3 candesartan cilexetil-hydrochlorothiazide 1, 3 captopril 1 CAPTOPRIL-HYDROCHLOROTHIAZIDE 3 EDARBI 3 EDARBYCLOR 3 enalapril maleate 1, 2, 3 enalapril maleate & hydrochlorothiazide 1, 3 ENTRESTO 2


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Name of drug Drug Tier Restrictions eplerenone 1, 3 EPROSARTAN MESYLATE 3 fosinopril sodium 1 fosinopril sodium & hydrochlorothiazide 1 irbesartan 1, 3 irbesartan-hydrochlorothiazide 1, 3 lisinopril 1, 3 lisinopril & hydrochlorothiazide 1, 3 losartan potassium 1, 3 losartan potassium & hydrochlorothiazide 1, 3 moexipril hcl 1 moexipril-hydrochlorothiazide 1 olmesartan medoxomil 1, 3 olmesartan medoxomil-hydrochlorothiazide 1, 3 perindopril erbumine 1, 3 quinapril hcl 1, 3 quinapril-hydrochlorothiazide 1, 3 ramipril 1, 3 spironolactone 1, 3 spironolactone & hydrochlorothiazide 1, 3 TEKAMLO 3 TEKTURNA 3 TEKTURNA HCT 3 telmisartan 1, 3 telmisartan-hydrochlorothiazide 1, 3 trandolapril 1, 3 valsartan 1, 3 valsartan-hydrochlorothiazide 1, 3 VASODILATING AGENTS ADCIRCA 3 PA, LD AMYL NITRITE 2 BIDIL 3 dipyridamole 1, 3 isosorbide dinitrate 1, 2, 3 isosorbide mononitrate 1 nitroglycerin 1, 2, 3, MSD nitroglycerin in d5w MSD papaverine hcl 1, MSD sildenafil citrate (pulmonary hypertension) 1, 3, MSD PA ¿-ADRENERGIC BLOCKING AGENTS BYVALSON 3 DUTOPROL 3 metoprolol tartrate MSD propranolol hcl MSD sotalol hcl 1, 3 TIMOLOL MALEATE 3 Ã¿-ADRENERGIC BLOCKING AGENTS BETAPACE AF 3 BYSTOLIC 3 carvedilol phosphate 1 CORGARD 3 LOPRESSOR 3 propranolol hcl 1 TENORETIC 50 3 TENORMIN 3


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Name of drug Drug Tier Restrictions TOPROL XL 3 ß-ADRENERGIC BLOCKING AGENTS acebutolol hcl 1, 3 atenolol 1, 3 atenolol & chlorthalidone 1, 3 betaxolol hcl 1 bisoprolol & hydrochlorothiazide 1, 3 bisoprolol fumarate 1, 3 BYSTOLIC 3 carvedilol 1, 3 carvedilol phosphate 1, 3 INDERAL XL 3 labetalol hcl 1, MSD LEVATOL 3 metoprolol & hydrochlorothiazide 1, 3 metoprolol succinate 1, 3 metoprolol tartrate 1, 3, MSD nadolol 1, 3 nadolol & bendroflumethiazide 1, 3 pindolol 1 propranolol hcl 1, 2, 3 PROPRANOLOL-HCTZ 3 sotalol hcl 1, 3, MSD sotalol hcl (afib/afl) 1 CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS acetaminophen w/ codeine 1, 3 QL acetaminophen-caff-dihydrocod 1, 3 QL ASCRIPTIN PRV aspirin PRV aspirin buffered (cal carb-mag carb-mag oxide) PRV AVINZA 3 QL BUPRENORPHINE 3 QL buprenorphine hcl 1, 3 QL butalbital-acetaminophen 1, 3 butalbital-acetaminophen-caffeine 1, 3 butalbital-acetaminophen-caffeine w/ codeine 1, 3 QL butalbital-aspirin-caffeine 1, 3 butalbital-aspirin-caffeine w/cod 1, 3 QL butorphanol tartrate 1, MSD QL CAMBIA 3 celecoxib 1, 3 choline & mag salicylate 1 clonidine hcl (analgesia) MSD CODEINE PHOSPHATE 2 QL CODEINE SULFATE 2 QL diclofenac potassium 1, 3 diclofenac sodium 1, 3 diclofenac w/ misoprostol 1, 3 diflunisal 1 DUEXIS 3 EMBEDA 2 QL etodolac 1, 3 fenoprofen calcium 1, 3 fentanyl 1, 3 QL


18

Name of drug Drug Tier Restrictions fentanyl citrate 1, 3, MSD QL flurbiprofen 1 GRALISE 3 hydrocodone-acetaminophen 1, 3 QL hydrocodone-ibuprofen 1, 3 QL hydromorphone hcl 1, 2, 3, MSD QL HYSINGLA ER 3 QL ibuprofen 1 ILARIS MSD indomethacin 1, 2, 3 INFUMORPH 500 MSD IONSYS MSD ketoprofen 1, 2 ketorolac tromethamine 1, 3, MSD LEVORPHANOL TARTRATE 3 QL LYRICA CR 3 MECLOFENAMATE SODIUM 3 mefenamic acid 1, 3 meloxicam 1, 3 meperidine hcl 1, 3, MSD QL methadone hcl 1, 3, MSD QL morphine sulfate 1, 2, 3, MSD QL nabumetone 1 nalbuphine hcl MSD naproxen 1, 3 naproxen sodium 1, 3 NUCYNTA 3 QL OFIRMEV MSD oxaprozin 1, 3 oxycodone hcl 1, 2, 3 QL oxycodone w/ acetaminophen 1, 2, 3 QL oxycodone-aspirin 1 QL OXYCODONE-IBUPROFEN 3 QL oxymorphone hcl 1, 3 QL pentazocine w/ naloxone 1 QL piroxicam 1, 3 salsalate 1 sulindac 1 SYNALGOS-DC 3 QL TALWIN MSD tolmetin sodium 1, 3 tramadol hcl 1, 3 QL tramadol-acetaminophen 1, 3 QL VIMOVO 3 XTAMPZA ER 3 QL ZORVOLEX 3 ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS ADZENYS ER 3 amphetamine-dextroamphetamine 1, 2, 3 armodafinil 1, 3 caffeine citrate MSD COTEMPLA XR-ODT 3 dexmethylphenidate hcl 1, 3 dextroamphetamine sulfate 1, 3 EVEKEO 3


19

Name of drug Drug Tier Restrictions methamphetamine hcl 1, 3 methylphenidate hcl 1, 2, 3 modafinil 1, 3 VYVANSE 3 ANTICONVULSANTS APTIOM 3 BANZEL 2 BRIVIACT 3, MSD carbamazepine 1, 3 CELONTIN 2 clonazepam 1, 3 QL divalproex sodium 1, 3 EQUETRO 3 ethosuximide 1, 3 felbamate 1, 3 fosphenytoin sodium MSD FYCOMPA 3 gabapentin 1, 3 HORIZANT 3 lamotrigine 1, 3 levetiracetam 1, 3, MSD LEVETIRACETAM IN NACL MSD LYRICA 3 magnesium sulfate MSD ONFI 3 QL oxcarbazepine 1, 3 PEGANONE 3 phenytoin 1, 2, 3 phenytoin sodium MSD phenytoin sodium extended 1, 2, 3 POTIGA 3 primidone 1, 3 tiagabine hcl 1, 3 topiramate 1, 3 valproate sodium 1, 3, MSD valproic acid 1, 3 vigabatrin 1 LD VIMPAT 3, MSD zonisamide 1, 3 ANTIMIGRAINE AGENTS almotriptan malate 1, 3 QL eletriptan hydrobromide 1, 3 QL ergotamine w/ caffeine 1, 2 frovatriptan succinate 1, 3 QL naratriptan hcl 1, 3 QL rizatriptan benzoate 1, 3 QL sumatriptan 1, 3 QL sumatriptan succinate 1, 3 QL sumatriptan-naproxen sodium 1, 3 QL zolmitriptan 1, 3 QL ANTIPARKINSONIAN AGENTS amantadine hcl 1 LD APOKYN 3 QL benztropine mesylate 1, MSD bromocriptine mesylate 1, 3


20

Name of drug Drug Tier Restrictions cabergoline 1 carbidopa 1, 3 carbidopa-levodopa 1, 3 CARBIDOPA-LEVODOPA-ENTACAPONE 3 EMSAM 3 entacapone 1, 3 NEUPRO 3 pramipexole dihydrochloride 1, 3 rasagiline mesylate 1, 3 ropinirole hydrochloride 1, 3 selegiline hcl 1, 3 tolcapone 1, 3 trihexyphenidyl hcl 1 XADAGO 3 ANXIOLYTICS, SEDATIVES, AND HYPNOTICS alprazolam 1, 3 QL BELSOMRA 3 QL buspirone hcl 1 BUTISOL SODIUM 3 chlordiazepoxide hcl 1 QL clorazepate dipotassium 1, 3 QL dexmedetomidine hcl MSD DIASTAT ACUDIAL 2 QL diazepam 1, 2, 3, MSD QL DORAL 3 QL droperidol MSD estazolam 1 QL eszopiclone 1, 3 QL etomidate MSD FLURAZEPAM HCL 3 QL HETLIOZ 3 LD hydroxyzine hcl 1, MSD hydroxyzine pamoate 1, 2, 3 ketamine hcl MSD lorazepam 1, 3, MSD QL meprobamate 1 midazolam hcl 1, MSD QL oxazepam 1 QL phenobarbital 1, 2 PHENOBARBITAL SODIUM MSD PRECEDEX MSD propofol MSD ROZEREM 3 QL SILENOR 3 QL temazepam 1, 3 QL triazolam 1, 3 QL zaleplon 1, 3 QL zolpidem tartrate 1, 3 QL CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS acamprosate calcium 1 atomoxetine hcl 1, 3 atracurium besylate MSD AUSTEDO 3 LD BELVIQ 3 cisatracurium besylate MSD


21

Name of drug Drug Tier Restrictions CONTRAVE 3 flumazenil MSD guanfacine hcl (adhd) 1, 3 INGREZZA 3 ketamine hcl MSD memantine hcl 1, 3 MIVACRON MSD NAMZARIC 3 NUEDEXTA 3 phendimetrazine tartrate 1 phentermine hcl 1 QUELICIN MSD riluzole 1 rocuronium bromide MSD SAVELLA 3 sevoflurane MSD SUPRANE MSD tetrabenazine 1 vecuronium bromide MSD XYREM 3 LD OPIATE ANTAGONISTS buprenorphine hcl 1 QL buprenorphine hcl-naloxone hcl dihydrate 1, 3 QL naloxone hcl 1, 2, 3 QL naltrexone hcl 1 SUBLOCADE MSD VIVITROL MSD PSYCHOTHERAPEUTIC AGENTS ADASUVE MSD amitriptyline hcl 1 AMOXAPINE 3 APLENZIN 3 aripiprazole 1, 3, MSD ARISTADA MSD BRINTELLIX 3 BRISDELLE 3 bupropion hcl 1, 3 PA CHLORDIAZEPOXIDE-AMITRIPTYLINE 3 chlorpromazine hcl 1, MSD citalopram hydrobromide 1, 3 clomipramine hcl 1, 3 clozapine 1, 3 QL desipramine hcl 1, 3 DESVENLAFAXINE ER 3 desvenlafaxine succinate 1, 3 doxepin hcl 1 duloxetine hcl 1, 3 escitalopram oxalate 1, 3 FANAPT 3 FETZIMA 3 fluoxetine hcl 1, 3 fluphenazine decanoate MSD fluphenazine hcl 1, 2, 3, MSD fluvoxamine maleate 1 GEODON MSD


22

Name of drug Drug Tier Restrictions haloperidol 1 haloperidol decanoate MSD haloperidol lactate 1, MSD imipramine hcl 1, 3 imipramine pamoate 1, 3 INVEGA SUSTENNA MSD LATUDA 3 LITHIUM 2 lithium carbonate 1, 3 loxapine succinate 1 MAPROTILINE HCL 3 MARPLAN 3 mirtazapine 1, 3 MOLINDONE HCL 3 nefazodone hcl 1, 2 nortriptyline hcl 1, 3 NUPLAZID 3 olanzapine 1, 3, MSD olanzapine-fluoxetine hcl 1, 3 paliperidone 1, 3 paroxetine hcl 1, 3 perphenazine 1 PERPHENAZINE-AMITRIPTYLINE 3 PEXEVA 3 phenelzine sulfate 1, 3 pimozide 1, 3 prochlorperazine 1 prochlorperazine edisylate MSD prochlorperazine maleate 1 protriptyline hcl 1 quetiapine fumarate 1, 3 REXULTI 3 RISPERDAL CONSTA MSD risperidone 1, 3 SAPHRIS 3 SARAFEM 3 sertraline hcl 1, 3 thioridazine hcl 1 thiothixene 1 tranylcypromine sulfate 1, 3 trazodone hcl 1, 3 trifluoperazine hcl 1 trimipramine maleate 1, 3 venlafaxine hcl 1, 3 VIIBRYD 3 VRAYLAR 3 ziprasidone hcl 1, 3 DIABETIC SUPPLIES DIABETIC SUPPLIES ADVOCATE CONTROL SOLUTION 2 BD INSULIN SYRINGE U-500 2 BD LANCET ULTRAFINE 30G 2 FREESTYLE TEST 2 QL NOVOFINE 2 ONETOUCH VERIO FLEX SYSTEM 2


23

Name of drug Drug Tier Restrictions PRECISION XTRA KETONE 2 ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS K-PHOS NO 2 2 potassium citrate (alkalinizer) 1, 3 potassium citrate-citric acid 1 sodium acetate MSD sodium bicarbonate MSD sodium citrate & citric acid 1 SODIUM LACTATE MSD TRICITRATES 2 AMMONIA DETOXICANTS CARBAGLU 3 lactulose 1, 3 lactulose (encephalopathy) 1 LITHOSTAT 3 RAVICTI 3 LD sodium phenylbutyrate 1 CALORIC AGENTS amino acid electrolyte infusion MSD amino acid infusion MSD CLINIMIX E/DEXTROSE (2.75/10) MSD CLINIMIX E/DEXTROSE (2.75/5) MSD CLINIMIX E/DEXTROSE (4.25/25) MSD CLINIMIX E/DEXTROSE (5/15) MSD CLINIMIX E/DEXTROSE (5/20) MSD CLINIMIX/DEXTROSE (2.75/5) MSD CLINIMIX/DEXTROSE (4.25/10) MSD CLINIMIX/DEXTROSE (4.25/20) MSD CLINIMIX/DEXTROSE (4.25/25) MSD CLINIMIX/DEXTROSE (5/15) MSD dextrose MSD fat emulsion MSD L-CYSTEINE HCL MSD DIURETICS amiloride & hydrochlorothiazide 1 amiloride hcl 1 bumetanide 1, MSD chlorothiazide 1, 2, 3 chlorothiazide sodium MSD chlorthalidone 1 DYRENIUM 3 ethacrynate sodium MSD ethacrynic acid 1, 3 furosemide 1, 2, 3, MSD hydrochlorothiazide 1, 3 indapamide 1 mannitol MSD METHYCLOTHIAZIDE 3 metolazone 1 SAMSCA 3 torsemide 1, 3, MSD triamterene & hydrochlorothiazide 1, 3 ION-REMOVING AGENTS AURYXIA 3


24

Name of drug Drug Tier Restrictions lanthanum carbonate 1, 3 RENAGEL 3 sevelamer carbonate 1, 3 sodium polystyrene sulfonate 1, 3 VELPHORO 3 VELTASSA 3 IRRIGATING SOLUTIONS acetic acid 1 irrigation solutions, physiological MSD lactated ringer's (irrigation) MSD RENACIDIN MSD ringer's irrigation 1, MSD sodium chloride (gu irrigant) MSD water for irrigation, sterile 1 REPLACEMENT PREPARATIONS calcium acetate (phosphate binder) 1, 2, 3 calcium chloride (dihydrate) MSD calcium gluconate MSD dextrose in lactated ringers MSD dextrose w/ sodium chloride MSD HESPAN MSD IONOSOL-B IN D5W MSD IONOSOL-MB IN D5W MSD ISOLYTE-P IN D5W MSD ISOLYTE-S MSD K-PHOS 2 KCL-LACTATED RINGERS-D5W MSD lactated ringer's MSD MAGNESIUM SULFATE IN D5W MSD MANGANESE CHLORIDE MSD MANGANESE SULFATE MSD NORMOSOL-M IN D5W MSD NORMOSOL-R IN D5W MSD NORMOSOL-R PH 7.4 MSD parenteral electrolytes MSD PLASMA-LYTE 148 MSD PLASMA-LYTE A MSD PLASMA-LYTE-5MSD IN D5W MSD pot phosphate monobasic w/ sod phosphate dibasic & monobasi 1, 2 potassium acetate MSD potassium bicarbonate 1 potassium chloride 1, 2, 3, MSD potassium chloride in dextrose MSD potassium chloride in dextrose & sodium chloride MSD potassium chloride in nacl MSD potassium chloride microencapsulated crystals cr 1, 2, 3 potassium phosphates MSD ringer's MSD saline, bacteriostatic MSD sodium chloride MSD sodium chloride flush MSD sodium phosphates (sodium phosphate dibasic & monobasic) MSD trace minerals (cr-cu-mn-se-zn) MSD URICOSURIC AGENTS colchicine w/ probenecid 1


25

Name of drug Drug Tier Restrictions DUZALLO 3 probenecid 1 ZURAMPIC 3 ENZYMES ENZYMES ADAGEN MSD LD ALDURAZYME MSD BRINEURA MSD CEREZYME MSD ELAPRASE MSD ELELYSO MSD ELITEK MSD FABRAZYME MSD KANUMA MSD LUMIZYME MSD NAGLAZYME MSD PULMOZYME 2 STRENSIQ 3 QL, LD SUCRAID 3 LD VIMIZIM MSD VPRIV MSD EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES ARZOL SILVER NIT APPLICATORS 2 AZASITE 3 BACITRACIN 2 bacitracin-polymyxin b (ophth) 1 BESIVANCE 3 BETADINE OPHTHALMIC PREP MSD chlorhexidine gluconate (mouth-throat) 1, 3 ciprofloxacin hcl (ophth) 1, 2, 3 erythromycin (ophth) 1 gatifloxacin (ophth) 1, 3 gentamicin sulfate (ophth) 1, 2, 3 levofloxacin (ophth) 1 moxifloxacin hcl (ophth) 1, 3 NATACYN 2 neomycin-bacitracin zn-polymyxin 1 neomycin-polymyxin-gramicidin 1, 3 ofloxacin (ophth) 1, 3 ofloxacin (otic) 1, 3 OTIPRIO 3 OTOVEL 3 polymyxin b-trimethoprim 1, 3 sulfacetamide sodium (ophth) 1, 2, 3 tobramycin (ophth) 1, 2, 3 trifluridine 1, 3 ZIRGAN 3 ANTI-INFLAMMATORY AGENTS ALREX 3 bacitracin-poly-neomycin-hc 1 BECONASE AQ 3 bromfenac sodium (ophth) 1, 3 CIPRO HC 3 CIPRODEX 2


26

Name of drug Drug Tier Restrictions COLY-MYCIN S 2 dexamethasone sodium phosphate (ophth) 1 diclofenac sodium (ophth) 1 DUREZOL 3 FLAREX 3 FLUNISOLIDE 2 fluocinolone acetonide (otic) 1, 3 fluorometholone (ophth) 1, 2, 3 FLURBIPROFEN SODIUM 2, 3 hydrocortisone w/acetic acid 1 ILEVRO 3 ILUVIEN MSD ketorolac tromethamine (ophth) 1, 3 MAXIDEX 3 mometasone furoate (nasal) 1, 3 neomycin-polymy-dexameth 1, 3 NEOMYCIN-POLYMYXIN-HC 2 neomycin-polymyxin-hc (otic) 1 OMNARIS 3 PRED-G 2, 3 prednisolone acetate (ophth) 1, 2, 3 PREDNISOLONE SODIUM PHOSPHATE 2 QNASL 3 RESTASIS 3 sulfacetamide sod-prednisolone 1, 2, 3 tobramycin-dexamethasone 1, 2, 3 VERAMYST 3 VEXOL 2 XIIDRA 3 ZYLET 3 ANTIALLERGIC AGENTS ALOCRIL 3 ALOMIDE 3 azelastine hcl 1, 3 azelastine hcl (ophth) 1 BEPREVE 3 cromolyn sodium (ophth) 1 DYMISTA 3 EMADINE 3 epinastine hcl (ophth) 1, 3 LASTACAFT 3 olopatadine hcl 1, 3 olopatadine hcl (nasal) 1, 3 ANTIGLAUCOMA AGENTS acetazolamide 1, 3 acetazolamide sodium MSD AZOPT 3 betaxolol hcl (ophth) 1, 3 BETIMOL 3 BIMATOPROST 3 brimonidine tartrate 1, 3 CARTEOLOL HCL 3 COMBIGAN 3 dorzolamide hcl 1, 3 dorzolamide hcl-timolol maleate 1, 3


27

Name of drug Drug Tier Restrictions KEVEYIS 3 LD latanoprost 1, 3 levobunolol hcl 1, 3 methazolamide 1, 3 METIPRANOLOL 2 PHOSPHOLINE IODIDE 3 pilocarpine hcl 1, 3 SIMBRINZA 3 timolol maleate (ophth) 1, 3 TRAVATAN Z 3 VYZULTA 3 ZIOPTAN 3 EENT DRUGS, MISCELLANEOUS acetic acid (otic) 1 ACETIC ACID-ALUMINUM ACETATE 2 apraclonidine hcl 1, 3 CYSTARAN 3 LD DEBACTEROL 3 JETREA MSD LACRISERT 3 LUCENTIS MSD LD ophthalmic irrigation solution - intraocular MSD PHOTREXA VISCOUS MSD RESCULA 3 RHOPRESSA 3 LOCAL ANESTHETICS fluorescein w/ benoxinate MSD lidocaine hcl (mouth-throat) 1 proparacaine hcl MSD tetracaine hcl (ophth) MSD MYDRIATICS atropine sulfate (ophthalmic) 1, 3 CYCLOMYDRIL MSD cyclopentolate hcl 1, 2 homatropine hbr 1 OMIDRIA MSD tropicamide MSD VASOCONSTRICTORS NAPHAZOLINE HCL 3 phenylephrine hcl (ophth) 1 TYZINE 3 GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS alosetron hcl 1, 3 balsalazide disodium 1, 3 DIPENTUM 3 mesalamine 1, 2, 3 mesalamine w/ cleanser 1, 3 ANTIDIARRHEA AGENTS diphenoxylate w/ atropine 1, 2, 3 FULYZAQ 3 loperamide hcl 1 MOTOFEN 3 XERMELO 3 LD ANTIEMETICS


28

Name of drug Drug Tier Restrictions AKYNZEO 2 ALOXI MSD ANZEMET 3, MSD aprepitant 1, 3, MSD BONJESTA 3 CESAMET 3 dronabinol 1, 3 granisetron hcl 1, MSD meclizine hcl 1 ondansetron 1, 3 ondansetron hcl 1, 3, MSD SANCUSO 3, MSD scopolamine 1, 3 trimethobenzamide hcl 1, 3, MSD VARUBI 3 ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicillin-clarithromycin w/ lansoprazole 1, 3 cimetidine 1 CIMETIDINE HCL 3 DEXILANT 3 esomeprazole magnesium 1, 3 esomeprazole sodium MSD ESOMEPRAZOLE STRONTIUM 3 famotidine 1, 3, MSD FAMOTIDINE PREMIXED MSD lansoprazole 1, 3 misoprostol 1, 3 nizatidine 1, 3 OMECLAMOX-PAK 3 omeprazole 1, 3 omeprazole-sodium bicarbonate 1, 3 pantoprazole sodium 1, 2, 3, MSD PYLERA 3 rabeprazole sodium 1, 3 ranitidine hcl 1, 3, MSD sucralfate 1, 3 CATHARTICS AND LAXATIVES bisacodyl PRV bisacodyl-peg 3350-pot chloride-sod bicarb-sod chloride PRV CLENPIQ PRV docusate sodium PRV magnesium citrate PRV MOVIPREP PRV OSMOPREP PRV peg 3350-kcl-sod bicarb-sod chloride-sod sulfate PRV peg 3350-potassium chloride-sod bicarbonate-sod chloride PRV polyethylene glycol 3350 PRV sodium phosphates PRV SUCLEAR PRV SUPREP BOWEL PREP KIT PRV DIGESTANTS CREON 2, 3 PANCRELIPASE 16000 2 GI DRUGS, MISCELLANEOUS AMITIZA 3


29

Name of drug Drug Tier Restrictions CHENODAL 3 CHOLBAM 3 ENTEREG 3 ENTYVIO MSD GATTEX 3 QL, LD LINZESS 3 metoclopramide hcl 1, 3, MSD MOVANTIK 3 OCALIVA 3 LD RELISTOR 3 QL SYMPROIC 3 TRULANCE 3 ursodiol 1, 3 VIBERZI 3 QL GOLD COMPOUNDS GOLD COMPOUNDS MYOCHRYSINE MSD RIDAURA 3 HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET 3 CUPRIMINE 2, 3 deferoxamine mesylate MSD EXJADE 3 FERRIPROX 3 RADIOGARDASE 3 trientine hcl 1, 3 HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS A-HYDROCORT MSD budesonide 1, 3 CELESTONE SOLUSPAN MSD CORTISONE ACETATE 2 dexamethasone 1, 2, 3 dexamethasone sodium phosphate MSD EMFLAZA 3 LD FLO-PRED 3 fludrocortisone acetate 1 hydrocortisone 1, 3 methylprednisolone 1, 2, 3 methylprednisolone acetate MSD methylprednisolone sod succ MSD prednisolone 1, 2, 3 prednisolone sodium phosphate 1, 3 prednisone 1, 2, 3 TRELEGY ELLIPTA 3 triamcinolone acetonide MSD ANDROGENS ANADROL-50 3 ANDROID 1, 3 ANDROXY 3 AVEED MSD danazol 1 oxandrolone 1 testosterone 1, 3


30

Name of drug Drug Tier Restrictions testosterone cypionate 1, 2, 3 QL testosterone enanthate 1 QL CONTRACEPTIVES BALCOLTRA PRV desogestrel & ethinyl estradiol PRV desogestrel-ethinyl estradiol (biphasic) PRV desogestrel-ethinyl estradiol (triphasic) PRV drospirenone-ethinyl estradiol PRV drospirenone-ethinyl estradiol-levomefolate calcium PRV ELLA PRV ethynodiol diacet & eth estrad PRV FALESSA PRV levonorgestrel & eth estradiol PRV levonorgestrel (emergency oc) PRV levonorgestrel-eth estradiol (triphasic) PRV levonorgestrel-ethinyl estradiol (91-day) PRV levonorgestrel-ethinyl estradiol (continuous) PRV LO LOESTRIN FE PRV NATAZIA PRV NECON 1/50 (28) PRV NECON 10/11 (28) PRV norethin acet & estrad-fe PRV norethindrone & eth estradiol PRV norethindrone & ethinyl estradiol-fe PRV norethindrone (contraceptive) PRV norethindrone acet & eth estra PRV norethindrone acetate-ethinyl estradiol-fe PRV norethindrone-eth estradiol (triphasic) PRV norgestimate-ethinyl estradiol PRV norgestimate-ethinyl estradiol (triphasic) PRV norgestrel & ethinyl estradiol PRV NUVARING PRV ORTHO EVRA PRV DIABETIC AGENTS acarbose 1, 3 ADLYXIN 3 ADMELOG 2, 3 AFREZZA 2, 3 ALOGLIPTIN BENZOATE 3 ALOGLIPTIN-METFORMIN HCL 3 ALOGLIPTIN-PIOGLITAZONE 3 APIDRA 3 AVANDAMET 3 AVANDARYL 3 AVANDIA 3 BASAGLAR KWIKPEN 2, 3 BYDUREON 3 CHLORPROPAMIDE 3 CYCLOSET 3 FARXIGA 3 FIASP 3 glimepiride 1, 3 glipizide 1, 3 glipizide-metformin hcl 1 GLUCAGEN HYPOKIT 3


31

Name of drug Drug Tier Restrictions GLUCAGON EMERGENCY 2 glyburide 1, 3 glyburide micronized 1, 3 glyburide-metformin 1, 3 GLYXAMBI 3 HUMALOG MIX 50/50 3 HUMULIN 70/30 2, 3 HUMULIN N 2, 3 INVOKAMET 3 INVOKANA 3 JANUMET 3 JANUVIA 3 JARDIANCE 2 JENTADUETO 3 KOMBIGLYZE XR 3 KORLYM 3 LD LEVEMIR 3 metformin hcl 1, 3 miglitol 1, 3 nateglinide 1, 3 NOVOLOG MIX 70/30 3 ONGLYZA 3 OZEMPIC 3 pioglitazone hcl 1, 3 pioglitazone hcl-glimepiride 1, 3 pioglitazone hcl-metformin hcl 1, 3 PRANDIMET 3 PROGLYCEM 3 QTERN 3 repaglinide 1, 3 SEGLUROMET 3 SOLIQUA 3 STEGLATRO 3 STEGLUJAN 3 SYMLINPEN 120 3 SYNJARDY 3 TANZEUM 3 TOLAZAMIDE 3 TOLBUTAMIDE 3 TRADJENTA 3 TRESIBA FLEXTOUCH 3 TRULICITY 3 VICTOZA 3 XIGDUO XR 3 XULTOPHY 3 ESTROGENS AND ANTIESTROGENS ANGELIQ 3 CLIMARA PRO 3 CLOMIPHENE CITRATE 2 DEPO-ESTRADIOL MSD DUAVEE 3 ENJUVIA 3 esterified estrogens & methyltestosterone 1 estradiol 1, 2, 3 estradiol & norethindrone acetate 1, 3


32

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


33

Name of drug Drug Tier Restrictions SOMATULINE DEPOT MSD SOMAVERT 3 QL, LD THYROID AND ANTITHYROID AGENTS levothyroxine sodium 1, 3, MSD liothyronine sodium 1, 3, MSD methimazole 1, 3 propylthiouracil 1 thyroid 1, 3 THYROLAR-1 3 MEDICAL DEVICE DIAPHRAGM CAYA PRV FEMCAP PRV WIDE-SEAL DIAPHRAGM 60 PRV IUD PARAGARD INTRAUTERINE COPPER MSD MEDICAL DEVICE AEROCHAMBER Z-STAT PLUS 2 AEROGEAR ACTION ASTHMA KIT 2 CATHFLO ACTIVASE MSD DEVILBISS COMPACT COMPRESSOR 2 DEVILBISS DISPOSABLE NEBULIZER 2 PIKO 1 2 MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS acetylcysteine 1 ACTEMRA 3, MSD QL ACTIMMUNE 2 QL, LD ADDYI 3 QL adenosine (diagnostic) MSD albumin, human MSD alendronate sodium 1, 3 ALLERGIST TRAY 2 allopurinol 1, 3 allopurinol sodium MSD amifostine MSD AMPYRA 3 LD ARCALYST 3 QL ATGAM MSD AUBAGIO 3 LD AVONEX 2 QL azathioprine 1, 3 AZATHIOPRINE SODIUM MSD BENLYSTA 3, MSD QL BERINERT 3, MSD QL, LD BETASERON 2 QL BOTOX MSD BRIDION MSD bupivacaine hcl MSD bupivacaine in dextrose MSD bupivacaine w/ epinephrine MSD CERDELGA 2 LD chloroprocaine hcl MSD CIMZIA 3, MSD QL COAL TAR EXTRACT 2


34

Name of drug Drug Tier Restrictions COLCHICINE 2, 3 CORTROSYN MSD CRYSVITA MSD cyclosporine 1, 2, MSD cyclosporine modified (for microemulsion) 1, 3 CYSTADANE 3 LD CYSTAGON 3 LD DEFITELIO MSD DEMSER 3 dexrazoxane MSD disulfiram 1, 3 dopamine in d5w MSD dutasteride 1, 3 dutasteride-tamsulosin hcl 1, 3 DYSPORT MSD ELMIRON 2 ENBREL 2, 3 QL ENDARI 3 EOVIST MSD ETIDRONATE DISODIUM 2, 3 EXONDYS 51 MSD EXPAREL MSD FC2 FEMALE CONDOM PRV finasteride 1, 3 FIRAZYR 2 QL FLORIVA 3 fomepizole MSD FOSAMAX PLUS D 3 GADAVIST MSD GILENYA 3 glatiramer acetate 1, 3 QL GRASTEK 2 HUMIRA 2, 3 QL ibandronate sodium 1, 3, MSD INFLECTRA MSD KEVZARA 3 QL KINERET 3 QL, LD KUVAN 3 leflunomide 1, 3 LEMTRADA MSD LETS MSD leucovorin calcium 1, 2, MSD levocarnitine (metabolic modifiers) 1, 3, MSD levoleucovorin calcium MSD LEXISCAN MSD lidocaine hcl (local anesth.) MSD LIDOCAINE IN DEXTROSE MSD lidocaine w/ epinephrine MSD MAGNEVIST MSD mepivacaine hcl MSD mesna 2, MSD methylergonovine maleate 1 miglustat 1, 3 LD MONOJECT PISTON SYRINGE 2 MONOJECT SYRINGE 2


35

Name of drug Drug Tier Restrictions MYALEPT 3 QL, LD mycophenolate mofetil 1, 3 mycophenolate mofetil hcl MSD mycophenolate sodium 1, 3 NITYR 3 nonoxynol-9 PRV NULOJIX MSD OCREVUS MSD ODACTRA 2 ORALAIR 3 ORENCIA 2, MSD QL OSPHENA 3 OTEZLA 2 QL OTREXUP 2, 3 QL oxytocin MSD pamidronate disodium MSD PANHEMATIN MSD PARSABIV MSD PLASMANATE MSD PROLIA 3, MSD QL PROVAYBLUE MSD PROVOCHOLINE MSD PYRIDIUM 3 QUADRAMET MSD RAGWITEK 2 RAPLIXA MSD READI-CAT 2 2 REMICADE MSD RENFLEXIS MSD risedronate sodium 1, 3 ropivacaine hcl MSD RUCONEST MSD LD SAXENDA 3 QL SCULPTRA MSD SENSIPAR 2 SIMPONI 3, MSD QL SIMULECT MSD sirolimus 1, 3 sodium fluoride PRV SSKI 2 SUPPRELIN LA MSD tacrolimus 1, 3, MSD TECFIDERA 3 LD THALOMID 2 PA, LD THYMOGLOBULIN MSD THYMOL 2 TUBERSOL MSD TYBOST 3 TYSABRI MSD ULORIC 3 VISICOL PRV VISTOGARD 3 VORAXAZE MSD water for injection, sterile MSD XELJANZ 3


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Name of drug Drug Tier Restrictions XEOMIN MSD XURIDEN 3 ZINBRYTA 3 QL zoledronic acid MSD ZORTRESS 3 MUSCULOSKELETAL THEARPY HYALGAN MSD THIOLA 3 LD VITAMINS potassium aminobenzoate 1, 2, 3 VITAMIN K1 MSD RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR MSD cromolyn sodium 1 cromolyn sodium (mastocytosis) 1 FASENRA MSD montelukast sodium 1, 3 NUCALA MSD zafirlukast 1, 3 zileuton 1, 3 ANTITUSSIVES benzonatate 1 DURATUSS HD 2 FLOWTUSS 3 QL guaifenesin-codeine 1 QL HYCOFENIX 3 QL hydrocodone w/ homatropine 1 QL phenyleph-cpm w/ hydrocod 1 phenylephrine-ephedrine-chlorpheniramine w/ carbetapentane 1 TUZISTRA XR 3 QL VITUZ 3 QL RESPIRATORY AGENTS, MISCELLANEOUS ADEMPAS 2 LD AEROSPAN 3 ALVESCO 3 ARALAST NP MSD LD ARMONAIR RESPICLICK 113 3 ARNUITY ELLIPTA 3 ASMANEX 120 METERED DOSES 2, 3 BREO ELLIPTA 3 brompheniramine & phenyleph 1 budesonide (inhalation) 1, 3 DALIRESP 3 DULERA 3 ESBRIET 3 LD FLOVENT HFA 2, 3 KALYDECO 3 LD LETAIRIS 3 LD OFEV 3 LD OPSUMIT 2 LD ORENITRAM 3 LD ORKAMBI 2, 3 LD QVAR 2 QVAR REDIHALER 3


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Name of drug Drug Tier Restrictions REMODULIN MSD LD sodium chloride (inhalant) 1 SURFAXIN MSD SYMBICORT 3 SYMDEKO 3 LD TRACLEER 3 LD TYVASO 3 LD UPTRAVI 3 LD VENTAVIS 3 LD XOLAIR MSD SERUMS, TOXOIDS, AND VACCINES SERUMS BIVIGAM MSD GAMASTAN S/D MSD GAMMAGARD 2 QL HIZENTRA 3 QL HYQVIA 3 QL, LD NABI-HB MSD VARIZIG MSD ZINPLAVA MSD TOXOIDS ADACEL MSD DIPHTHERIA-TETANUS TOXOIDS DT MSD KINRIX MSD TE ANATOXAL BERNA MSD TENIVAC MSD VACCINES ACTHIB MSD ADACEL MSD BEXSERO MSD DAPTACEL MSD ENGERIX-B MSD FLUCELVAX QUADRIVALENT MSD FLULAVAL QUADRIVALENT MSD FLUZONE HIGH-DOSE MSD GARDASIL 9 MSD HAVRIX MSD HEPLISAV-B MSD IMOVAX RABIES MSD IPOL MSD IXIARO MSD JE-VAX MSD M-M-R II MSD MENACTRA MSD MENOMUNE MSD MENVEO MSD MERUVAX II W/DILUENT 10 DOSE MSD MUMPSVAX W/DILUENT 10 DOSE MSD PEDIARIX MSD PNEUMOVAX 23 MSD PREVNAR 13 MSD PROQUAD MSD RABAVERT MSD ROTARIX MSD ROTATEQ MSD


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Name of drug Drug Tier Restrictions SHINGRIX MSD STAMARIL MSD TRUMENBA MSD TWINRIX MSD TYPHIM VI MSD VARIVAX MSD VAXCHORA MSD VIVOTIF 2 ZOSTAVAX MSD SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir topical 1, 3 ALTABAX 3 BACTROBAN NASAL 3 benzoyl peroxide-erythromycin 1, 3 ciclopirox 1, 3 ciclopirox olamine 1, 3 CLINDACIN PAC 3 clindamycin phosphate (topical) 1, 3 clindamycin phosphate vaginal 1, 3 clindamycin phosphate-benzoyl peroxide 1, 3 clindamycin phosphate-benzoyl peroxide (refrigerate) 1, 3 CLINDESSE 3 clotrimazole 1 clotrimazole (topical) 1 clotrimazole w/ betamethasone 1, 3 DENAVIR 3 econazole nitrate 1, 3 ERTACZO 3 erythromycin (acne aid) 1, 2 EURAX 3 EXELDERM 3 gentamicin sulfate (topical) 1 GYNAZOLE-1 3 iodoquinol-hc 1 iodoquinol-hydrocortisone in aloe vehicle 1, 3 ketoconazole (topical) 1, 3 KETODAN 3 lindane 1, 3 LUZU 3 mafenide acetate 1, 3 malathion 1, 3 MENTAX 3 metronidazole (topical) 1, 3 metronidazole vaginal 1, 3 MICONAZOLE 3 3 mupirocin 1, 3 mupirocin calcium (topical) 1, 3 naftifine hcl 1, 3 NATROBA 3 neomycin/polymyxin b gu 1 NEUAC 3 nystatin (topical) 1 NYSTATIN VAGINAL 2 OVACE PLUS 3


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Name of drug Drug Tier Restrictions oxiconazole nitrate 1, 3 permethrin 1, 3 ROSADAN 3 selenium sulfide 1 silver sulfadiazine 1, 3 SKLICE 3 SOOLANTRA 3 sulfacetamide sodium (acne) 1, 3 sulfacetamide sodium w/ sulfur 1, 3 terconazole vaginal 1, 3 ULESFIA 3 XERESE 3 ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) alclometasone dipropionate 1 AMCINONIDE 3 APEXICON E 3 betamethasone dipropionate (topical) 1 betamethasone dipropionate augmented 1, 2, 3 betamethasone valerate 1, 3 calcipotriene-betamethasone dipropionate 1, 3 CLIOQUINOL/HYDROCORTISONE 2 clobetasol propionate 1, 2, 3 clobetasol propionate emollient base 1 CLOCORTOLONE PIVALATE 3 CLODAN 3 CORTIFOAM 3 CORTISPORIN 3 CORTISPORIN 3 desonide 1, 3 desoximetasone 1, 3 DIFLORASONE DIACETATE 2, 3 EUCRISA 3 fluocinolone acetonide 1, 3 fluocinonide 1, 3 fluocinonide emulsified base 1 flurandrenolide 1, 3 fluticasone propionate 1, 3 halobetasol propionate 1, 3 HALOG 3 hydrocortisone (intrarectal) 1, 3 hydrocortisone (rectal) 1, 2, 3 hydrocortisone (topical) 1, 3 hydrocortisone acetate (rectal) 1 hydrocortisone butyrate 1, 3 hydrocortisone butyrate hydrophilic lipo base 1, 3 hydrocortisone valerate 1 MICORT-HC 3 mometasone furoate 1, 3 NEO-SYNALAR 3 NEO-SYNALAR 3 nystatin-triamcinolone 1 OLUX-E 3 PANDEL 3 prednicarbate 1, 3 triamcinolone acetonide (mouth) 1


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Name of drug Drug Tier Restrictions triamcinolone acetonide (topical) 1, 2, 3 UCERIS 3 urea-hc acetate 1 WHYTEDERM TDPAK 3 ANTIPRURITICS AND LOCAL ANESTHETICS ADAZIN 3 DOXEPIN HCL 3 hydrocortisone acetate w/ pramoxine 1, 2 lidocaine 1, 3 lidocaine hcl 1, 3 lidocaine-hydrocortisone acetate (rectal) 1 lidocaine-prilocaine 1 PAIN RELIEF 3 PLIAGLIS 3, MSD VEXA 3 CELL STIMULANTS AND PROLIFERANTS KEPIVANCE MSD TRETIN-X 3 tretinoin 1, 2, 3 tretinoin microsphere 1, 3 SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS 8-MOP 3 acitretin 1, 3 adapalene 1, 2, 3 adapalene-benzoyl peroxide 1, 2 aluminum chloride 1, 3 AMELUZ MSD AZELEX 2 calcipotriene 1, 3 CALCITRIOL 2, 3 clindamycin phosphate-tretinoin 1, 3 COSENTYX 3 QL dapsone (topical) 1, 3 DERMACINRX LEXITRAL PHARMAPAK 3 diclofenac sodium (actinic keratoses) 1, 3 diclofenac sodium (topical) 1, 3 DOXYCYCLINE 3 DUPIXENT 3 QL ELIDEL 3 FABIOR 3 FINACEA 2, 3 FLECTOR 3 fluorouracil (topical) 1, 2, 3 imiquimod 1, 3 isotretinoin 1, 3 lactic acid (ammonium lactate) 1 methoxsalen rapid 1, 3 MIRVASO 3 OXSORALEN 2 PANRETIN 3 PICATO 3 podofilox 1, 2, 3 RECTIV 3 REGRANEX 3 RHOFADE 3


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Name of drug Drug Tier Restrictions salicylic acid 1, 2 SALICYLIC ACID 2 SANTYL 2 SILIQ 3 QL, LD STELARA MSD STELARA 3 QL tacrolimus (topical) 1, 3 TALTZ 3 QL TARGRETIN 3 tazarotene 1, 3 TREMFYA 3 QL urea 1, 3 UVADEX MSD VALCHLOR 3 LD VEREGEN 3 XIMINO 3 SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS aminophylline 2, MSD darifenacin hydrobromide 1, 3 flavoxate hcl 1 GELNIQUE 3 MYRBETRIQ 3 oxybutynin chloride 1, 3 theophylline 1, 3 tolterodine tartrate 1, 3 TOVIAZ 3 trospium chloride 1 VESICARE 3 VASODILATING AGENTS MISCELLANEOUS THERAPEUTIC AGENTS yohimbine hcl 1 PHOSPHODIESTERASE INHIBITORS CAVERJECT 2 QL CIALIS 3 PA, QL LEVITRA 3 QL sildenafil 1 QL VIAGRA 3 QL VITAMINS VITAMINS AQUASOL A MSD ascorbic acid MSD calcitriol 1, 3, MSD cholecalciferol PRV cyanocobalamin 1, 3 QL doxercalciferol 1, 3, MSD DURACHOL 3 ENBRACE HR 3 ergocalciferol 1, 5 FERIVA 21/7 3 FERIVAFA 3 ferrous sulfate PRV FLORIVA 3 folic acid 1, 5, MSD INFED MSD


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Name of drug Drug Tier Restrictions INFUVITE MSD INFUVITE PEDIATRIC MSD iron polysaccharide complex-vit b12-folic acid 1 MAXFE 3 multiple vitamins w/ minerals 1 NIACOR 2 OCUVEL 3 paricalcitol 1, 3, MSD ped multivitamins w/fl & iron 1, 2 pediatric multivitamins w/fl 1, 3 pediatric vitamins acd fluoride & iron 1 pediatric vitamins acd w/ fluoride 1 phytonadione 2, MSD prenatal vit w/ ferrous fumarate-folic acid 1, 2 prenatal vit w/ iron carbonyl-folic acid 1, 2 prenatal vit w/ selenium-fe fumarate-folic acid 1 pyridoxine hcl MSD RAYALDEE 3 thiamine hcl MSD TRIFERIC MSD VENOFER MSD


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Specialty Drugs This 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 injectable, medications that are typically high cost and medications that require special dispensing and/or monitoring.

ACTEMRA INJ 162/0.9 ACTIMMUNE INJ 2MU/0.5 ADCIRCA TAB 20MG 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 10MCG ARANESP ALBUMIN FREE INJ 150MCG ARANESP ALBUMIN FREE INJ 200MCG ARANESP ALBUMIN FREE INJ 25MCG ARANESP ALBUMIN FREE INJ 300MCG ARANESP ALBUMIN FREE INJ 40MCG ARANESP ALBUMIN FREE INJ 500MCG ARANESP ALBUMIN FREE INJ 60MCG ARANESP ALBUMIN FREE SURECLICK INJ 100MCG ARANESP ALBUMIN FREE SURECLICK INJ 300MCG ARCALYST INJ 220MG AUBAGIO TAB 14MG AUBAGIO TAB 7MG AUSTEDO TABS 12 MG AUSTEDO TABS 6 MG AUSTEDO TABS 9 MG BARACLUDE SOL .05MG/ML BENLYSTA SOAJ 200 MG/ML

BENLYSTA SOSY 200 MG/ML BETASERON INJ 0.3MG BETHKIS NEB 300/4ML BUPHENYL POW BUPHENYL TAB 500MG CABOMETYX TABS 20 MG CABOMETYX TABS 40 MG CABOMETYX TABS 60 MG CALQUENCE CAPS 100 MG CAPRELSA TAB 100MG 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 COSENTYX INJ 150MG/ML COTELLIC TABS 20MG CRESEMBA CAP 186 MG CYSTADANE POW CYSTAGON CAP 150MG CYSTAGON CAP 50MG DAKLINZA TAB 90MG DAKLINZA TAB 30MG DAKLINZA TAB 60MG DIFICID TAB 200MG 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 ENTOCORT EC CAP 3MG/24HR EPCLUSA TABS 400-100 MG ERIVEDGE CAP 150MG ESBRIET CAP 267MG EXJADE TAB 125MG

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EXJADE TAB 250MG EXJADE TAB 500MG FARYDAK CAP 10MG FARYDAK CAP 15MG FARYDAK CAP 20MG FERRIPROX TAB 500MG FIRAZYR INJ 30MG/3ML FORTEO SOL 600/2.4 FOSRENOL CHW 500MG 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 0.5MG GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG GLEEVEC TAB 100MG GLEEVEC TAB 400MG GOCOVRI CP24 137 MG GOCOVRI CP24 68.5 MG GRANIX INJ 300/0.5 GRANIX INJ 480/0.8 H.P. ACTHAR INJ 80UNIT HAEGARDA SOLR 2000 UNIT HAEGARDA SOLR 3000 UNIT 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 IDHIFA TABS 50 MG IMBRUVICA CAP 140MG INCRELEX INJ 40MG/4ML INGREZZA CAPS 40 MG INGREZZA CAPS 80 MG INLYTA TAB 1MG INLYTA TAB 5MG 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 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 LETAIRIS TAB 10MG LETAIRIS TAB 5MG

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LEUKINE 500 MCG/ML VIAL LEUKINE INJ 250MCG LEUKINE INJ 500 MCG LONSURF TABS 15-6.14 MG LONSURF TABS 20-8.19 MG LOTRONEX TAB 1MG 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 MODERIBA 1200 DOSE PACK PAK 1200/DAY MODERIBA PAK 600/DAY MOZOBIL 20 MG/ML VIAL NATPARA INJ 100MCG NATPARA INJ 25MCG NATPARA INJ 50MCG NATPARA INJ 75MCG 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 NITYR TABS 10 MG NITYR TABS 2 MG NITYR TABS 5 MG NORDITROPIN FLEXPRO INJ 10/1.5ML NORTHERA CAP 100MG NORTHERA CAP 200MG NORTHERA CAP 300MG NOXAFIL SUS 40MG/ML NOXAFIL TAB 100MG NUPLAZID TABS 17MG NUTROPIN AQ PEN INJ 20MG/2ML OCALIVA TAB 10 MG OCALIVA TAB 5MG ODOMZO 200MG CAPSULES OFEV CAP 100MG OFEV CAP 150MG 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 PEGASYS INJ PEGASYS INJ 180MCG/M PEGASYS KIT PEGASYS PROCLICK INJ PROCLICK PLEGRIDY INJ PLEGRIDY INJ PEN PLEGRIDY STARTER PACK INJ STARTER POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG PROCYSBI CAP 25MG PROCYSBI CAP 75MG PROGLYCEM SUS 50MG/ML PROMACTA TAB 12.5MG PROMACTA TAB 25MG PROMACTA TAB 50MG PROMACTA TAB 75MG PURIXAN 20MG/ML SUSP 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 RIBASPHERE RIBAPAK PAK 1200/DAY RIBASPHERE RIBAPAK PAK 600/DAY RIBATAB TAB 1200/DAY RILUTEK TAB 50MG RUBRACA TABS 200 MG RUBRACA TABS 250 MG RUBRACA TABS 300 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

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SIGNIFOR INJ 0.3MG/ML SIGNIFOR INJ 0.6MG/ML SIGNIFOR INJ 0.9MG/ML SILIQ SOSY 210 MG/1.5ML SIMPONI INJ 100MG/ML SIMPONI INJ 50/0.5ML SIRTURO TAB 100MG SIVEXTRO TAB 200MG SOMAVERT INJ 10MG SOMAVERT INJ 15MG SOMAVERT INJ 20MG SOMAVERT INJ 25MG SOMAVERT INJ 30MG SOVALDI TAB 400MG 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 SYLATRON KIT 444MCG SYLATRON KIT 888MCG SYNRIBO INJ 3.5MG 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 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 TAB 100MG TIKOSYN CAP 125MCG TIKOSYN CAP 250MCG TIKOSYN CAP 500MCG TOBI NEB 300/5ML TOBI PODHALER CAP 28MG TRACLEER TAB 125MG TRACLEER TAB 62.5MG TRACLEER TABS FOR ORAL SUSPENSION 32 MG TREMFYA SOSY 100 MG/ML TYKERB TAB 250MG TYMLOS SOPN 3120 MCG/1.56ML 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 VALCHLOR GEL 0.016% VALCYTE SOL 50MG/ML VALCYTE TAB 450MG VANCOCIN HCL CAP 125MG VANCOCIN HCL CAP 250MG VECAMYL TAB 2.5MG VENTAVIS SOL 10MCG/ML VENTAVIS SOL 20MCG/ML VERZENIO TABS 100 MG VERZENIO TABS 150 MG VERZENIO TABS 200 MG VERZENIO TABS 50 MG VICTRELIS CAP 200MG VIDAZA INJ 100MG VIEKIRA PAK TAB VIEKIRA XR TB24 200-8.33-50- 33.33 MG VOSEVI TABS 400-100-100 MG VOTRIENT TAB 200MG XALKORI CAP 200MG XALKORI CAP 250MG XELJANZ TAB 5MG XELJANZ XR TB24 11 MG XELODA TAB 500MG XENAZINE TAB 12.5MG XENAZINE TAB 25MG XERMELO TABS 250 MG XGEVA INJ XTANDI CAP 40MG XYREM SOL 500MG/ML

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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 ZORBTIVE INJ 8.8MG ZORTRESS TAB 0.5MG ZORTRESS TAB 0.75MG ZYDELIG TAB 100MG ZYDELIG TAB 150MG ZYFLO CR TAB 600MG ZYKADIA CAP 150MG ZYTIGA TAB 250MG ZYTIGA TABS 500 MG ZYVOX SUS 100MG/5M ZYVOX TAB 600MG

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

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 o

Qualified sign language interpreters 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 o

Qualified interpreters 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.

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

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

LEGEND • Brand-name drugs are in bold type and all capital letters •For drugs not indicated in bold, generic drugs will be dispensed as the formulary agent

• Limited Distribution-LD • Quantity Limits-QL •Oral Chemo Drugs-OC

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