listahan ng m ga sakla w na gamot (formulary) p ara s a 2022

Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)

Listahan ng Mga Saklaw na Gamot (Formulary) para sa 2022

Mga County Los Angeles at San Diego

Ang formulary na ito ay na-update noong 08192021 Para sa mas bagong impormasyon o iba pang tanong mangyaring makipag-ugnayan sa Pangangalaga sa Customer ng Blue Shield Promise Cal MediConnect Plan sa 1-855-905-3825 (TTY 711) mula 800 am ndash 800 pm pitong araw sa isang linggo libre ang tawag o bisitahin ang wwwblueshieldcacompromisecalmediconnect

Formulary ID 22440 Bersyon 6

H0148_22_156_C_Approved08052021

10052021

10

Kung mayroon kayong mga tanong mangyaring tawagan ang Blue Shield Promise Cal MediConnect Plan sa 1-855-905-3825 (TTY 711) 800 am hanggang 800 pm pitong araw sa isang linggo Libre ang tawag Para sa higit pang impormasyon bisitahin ang wwwblueshieldcacompromisecalmediconnect

ii

Blue Shield Promise Cal MediConnect Plan | Listahan ng Mga Saklaw na Gamot (Formulary) para sa 2022

Panimula

Ang dokumentong ito ay tinatawag na Listahan ng Mga Saklaw na Gamot (tinatawag ding Listahan ng Gamot) Ipinapaalam nito sa inyo kung aling mga inireresetang gamot at mga over-the-counter na gamot at item ang sinasaklaw ng Blue Shield Promise Cal MediConnect Plan Ipinapaalam din sa inyo ng Listahan ng Gamot kung mayroong anumang espesyal na panuntunan o paghihigpit sa alinmang gamot na sinasaklaw ng Blue Shield Promise Cal MediConnect Plan Makikita ang mahahalagang termino at ang mga kahulugan ng mga ito sa huling kabanata ng Handbook ng Miyembro Maaari kayong humiling ng kopya sa pamamagitan ng pagtawag sa Pangangalaga sa Customer ng Blue Shield Promise Cal MediConnect Plan sa 1-855-905-3825 (TTY 711) mula 800 am ndash 800 pm pitong araw sa isang linggo libre ang tawag

Talaan ng Nilalaman

A Mga Disclaimer iv

B Mga Madalas Itanong (Frequently Asked Questions FAQ) vii

B1 Anong mga inireresetang gamot ang kasama sa Listahan ng Mga Saklaw na Gamot (Ang Listahan ng Mga Saklaw na Gamot ay tinatawag naming ldquoListahan ng Gamotrdquo para maikli) vii

B2 Nagbabago ba ang Listahan ng Gamot na ito viii

B3 Ano ang mangyayari kapag may nagbago sa Listahan ng Gamot ix

B4 Mayroon bang anumang mga paghihigpit o limitasyon sa pagsaklaw sa gamot o anumang kinakailangang pagkilos na dapat gawin para makakuha ng ilang partikular na gamot xi

B5 Paano ko malalaman kung may mga limitasyon ang isang gamot na gusto ko o kung may mga kinakailangang pagkilos na dapat gawin upang makuha ang gamot xii

B6 Ano ang mangyayari kung papalitan ng Blue Shield Promise Health Plan ang mga panuntunan nila kaugnay ng ilang gamot (halimbawa paunang pahintulot (pag-apruba) mga limitasyon sa dami ato mga paghihigpit sa step therapy) xii

B7 Paano ko mahahanap ang isang gamot sa Listahan ng Gamot xii


iii

B8 Paano kung wala sa Listahan ng Gamot ang gamot na gusto kong inumin xiii

B9 Paano kung isa akong bagong miyembro ng Blue Shield Promise Cal MediConnect Plan at hindi ko mahanap ang aking gamot sa Listahan ng Gamot o nagkakaproblema ako sa pagkuha ng aking gamot xiii

B10 Maaari ba akong humiling ng pagbubukod para saklawin ang aking gamot xiv

B11 Paano ako makakahiling ng pagbubukod xv

B12 Gaano katagal ang inaabot para makakuha ng pagbubukod xv

B13 Ano ang mga generic na gamot xv

B14 Ano ang mga OTC na gamot xvi

B15 Sinasaklaw ba ng Blue Shield Promise Cal MediConnect Plan ang mga OTC na produkto na hindi gamot xvi

B16 Ano ang aking copay xvi

B17 Ano ang mga tier ng gamot xvii

C Pangkalahatang-ideya ng Listahan ng Mga Saklaw na Gamot xvii

C1 Mga Gamot na Nakagrupo ayon sa Medikal na Kundisyon xx

D Index ng Mga Saklaw na Gamot 080 133


iv

A Mga Disclaimer

Isa itong listahan ng mga gamot na maaaring makuha ng mga miyembro sa Blue Shield Promise Cal MediConnect

Ang Blue Shield Promise Cal MediConnect ay isang planong pangkalusugan na nakikipagkontrata sa Medicare at Medi-Cal upang maibigay ang mga benepisyo ng parehong programa sa mga nagpapatala

Ang Listahan ng Mga Saklaw na Gamot ato mga network ng parmasya at provider ay maaaring magbago sa pag-usad ng taon Padadalhan namin kayo ng abiso bago kami gumawa ng pagbabagong makakaapekto sa inyo

Maaaring magbago ang mga benepisyo ato copay tuwing Enero 1 ng bawat taon

Maaari ninyong tingnan ang napapanahong Listahan ng Mga Saklaw na Gamot ng Blue Shield Promise Cal MediConnect anumang oras online sa wwwblueshieldcacompromisecalmediconnect o sa pamamagitan ng pagtawag sa 1-855-905-3825 (TTY 711) 800 am hanggang 800 pm pitong araw sa isang linggo Libre ang tawag

Maaaring may malapat na mga limitasyon copay at paghihigpit Para sa higit pang impormasyon tawagan ang Pangangalaga sa Customer ng Blue Shield Promise Cal MediConnect o basahin ang Handbook ng Miyembro ng Blue Shield Promise Cal MediConnect

Maaaring mag-iba-iba ang mga copay para sa mga inireresetang gamot batay sa antas ng Karagdagang Tulong na nakukuha ninyo Mangyaring makipag-ugnayan sa plano para sa iba pang mga detalye

PAUNAWA Kung nagsasalita kayo ng Tagalog may mga magagamit kayong libreng serbisyo ng tulong sa wika Tumawag sa 1-855-905-3825 (TTY 711) 800 am hanggang 800 pm pitong araw sa isang linggo Libre ang tawag

English ATTENTION If you speak English language assistance services free of charge are available to you Call 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is free


v

中文 (Chinese) 请留意如果您说中文可以免费获得语言协助服务请拨打 1-855-905-3825（听障

和语障专线711）每周七天办公早上 800 至晚上 800此电话为免付费专线

한국어(Korean)

주 귀하가 한국어를 사용하시는 경우 무료로 언어 지원 서비스를 이용하실 수 있습니다 1-855-905-3825(TTY 711)번으로 주 7일 오전 8시부터 오후 8시까지 전화하실 수 있습니다 이 전화는 무료입니다

Русский (Russian)

ОБРАТИТЕ ВНИМАНИЕ Если Вы говорите по-русски мы можем предложить Вам бесплатные услуги языковой поддержки Звоните по телефону 1-855-905-3825 (TTY 711) с 800 до 2000 без выходных Звонок бесплатный

) فارسیFarsi (

1- 855 باشد با شماره توجھ اگر بھ زبان فارسی صحبت می کنید خدمات امداد زبانی بدون اخذ ھزینھ در اختیار شما می 905-3825 (TTY 711) شب در ھفت روز ھفتھ تماس بگیرید این تماس رایگان است 800صبح تا 800 از ساعت

भाषा (Hindi)

धयान यद आप भाषा बोलत ह तो आपक लए भाषा सहायता सवाए नःशलक उपलबध ह फ़ोन करना 1-855-905-3825 (TTY 711) सबह 800 बज स शाम 800 बज तक सपताह क सात दन फ़ोन करना फर ह

Lus Hmoob (Hmong)

LUS CEEV Yog koj hais Lus Hmoob muaj kev pab txhais lus pub dawb rau kojHu rau 1-855-905-3825 (TTY 711) 800 teev sawv ntxov txog 800 teev tsaus ntuj xya hnub hauv ib lub as thivQhov hu xov tooj no yog hu dawb xwb

Espantildeol (Spanish)

ATENCIOacuteN Si usted habla espantildeol hay a su disposicioacuten servicios de asistencia de idiomas sin costo Llame al 1-855-905-3825 (TTY 711) de 800 am a 800 pm los siete diacuteas de la semana La llamada es gratuita

Tiếng Việt (Vietnamese) LƯU Yacute Nếu quyacute vị noacutei tiếng Việt chuacuteng tocirci sẽ cung cấp miễn phiacute dịch vụ hỗ trợ ngocircn ngữ cho quyacute vị Goi socirc 1-855-905-3825 (TTY 711) 8 giơ sang đến 8 giơ tocirci ba y ngay trong tuacircn Cuocircc goi na y miecircn phi


vi

Tagalog (Tagalog) PAUNAWA Kung nagsasalita kayo ng Tagalog may mga available na libreng serbisyo ng tulong sa wika para sa inyo Tumawag sa 1-855-905-3825 (TTY 711) 800 am hanggang 800 pm pitong araw sa isang linggo Libre ang tawag

) العربیةArabic(

3825-905-855-1اتصل على الرقم إذا كنت تتحدث اللغة العربیة یتوفر لك خدمات المساعدة اللغویة المجانیة تنبیھ (TTY711) علما بأن ھذه المكالمة مجانیة مساء طوال أیام الأسبوع 800صباحا إلى 800من الساعة

ພາສາລາວ (Laotian)

ສງສາຄນ ຖາທານເວາພາສາລາວແມນມບລການຊວຍເຫອທາງດານພາສາບເສຍຄາໃຫທານ ໂທຫາເບ 1-855-905-3825 (TTY 711) 800 ໂມງເຊາ ຫາ 800 ໂມງແລງ ເຈດວນຕອາທດ ການໂທແມນບເສຍຄາ

日本語 (Japanese)

注意事項日本語を話される場合無料の言語支援をご利用いただけます1-855-905-3825 (TTY 711）までお電話にてご連絡ください毎日午前 8 時から午後 8時まで受け付けています通話は無料です

ภาษาไทย (Thai)

เรยน หากคณพดภาษา ภาษาไทย เรามบรการความชวยเหลอดานภาษาใหแกคณโดยไมมคาใชจาย โทร 1-855-905-3825 (TTY 711) 800 น ถง 2000 น ไดตลอดเจดวนตอสปดาห โทรฟร ไมมคาใชจาย

ਪਜਾਬੀ (Punjabi)

ਸਾਵਧਾਨ ਜ ਤਸ [ਪਜਾਬੀ] ਬਲਦ ਹ ਤ ਤਹਾਡ ਲਈ ਮਫਤ ਭਾਸਾ ਸਹਾਇਤਾ ਸਵਾਵ ਉਪਲਬਧ ਹਨ | ਕਾਲ ਕਰ 1-855-905-3825 (TTY 711) ਸਵਰ 800 ਵਜ ਤ ਸਾਮ 800 ਵਜ ਤਕ ਹਫ਼ਤ ਦ ਸਤ ਿਦਨ |711) ਸਵਰ ਦ 8 ਵਜ ਤ ਲ ਕ ਰਾਤ ਦ 8 ਵਜ ਤਕ ਹਫ਼ਤ ਦ ਸਤ ਿਦਨ ਕਾਲ ਫੀ ਹ |

ែខរ (Khmer)

បរមណ េបើសនអកនយែខរ េសជនយ គនសបអក

េយឥតគតៃថ េ 1-855-905-3825 (TTY 711) េង 800 រពក ដល 800 យប

រពរៃថមយទតយ េគឥតគតៃថេទ

Հայերեն (Armenian) ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն Ձեզ տրամադրելի են անվճար լեզվական օգնության ծառայություններ Զանգահարեք 1-855-905-3825 (TTY 711) համարով 800-ից 2000 շաբաթը յոթ օր Հեռախոսազանգն անվճար է


vii

Українська (Ukrainian) ЗВЕРНІТЬ УВАГУ Якщо Ви розмовляєте українською ми можемо запропонувати Вам безкоштовні послуги мовної підтримки Телефонуйте 1-855-905-3825 (TTY 711) з 800 до 2000 без вихідних Дзвінок безкоштовний

Mienh (Mien)

TOV JANGX LONGX OC Beiv taix meih gorngv Mienh waac nor ninh mbuo gorn zangc duqv mbenc nzoih wang-henh nzie weih faan waac bun meih muangx maiv zuqc feix liuc cuotv zinh nyaanh Douc waac lorx taux 1-855-905-3825 (TTY 711) 800 diemv ziangh hoc lungh ndorm mingh taux 800 ziangh hoc lungh muonz yietc norm liv baaiz se koi nzoih siec hnoi Naaiv norm douc waac gorn se wang-henh longc maiv zuqc feix liuc cuotv zinh nyaanh

Maaari ninyong makuha ang dokumentong ito nang libre sa iba pang

format gaya ng malaking titik braille o audio Tawagan ang Pangangalaga sa Customer sa 1-855-905-3825 (TTY 711) 800 am ndash 800 pm pitong araw sa isang linggo Libre ang tawag

Ang Blue Shield of California Promise Health Plan ay isang independiyenteng lisensyado ng Blue Shield Association

Hindi ito kumpletong listahan Ang impormasyon ng benepisyo ay isang buod at hindi isang kumpletong paglalarawan ng mga benepisyo Para sa higit pang impormasyon tawagan ang plano o basahin ang Handbook ng Miyembro ng Blue Shield Promise Cal MediConnect Plan

Maaari kayong gumawa ng pangmatagalang kahilingan para makuha ang mga materyal sa isang wikang bukod sa Ingles o sa isang alternatibong format ngayon at sa hinaharap Para makagawa ng kahilingan mangyaring makipag-ugnayan sa Pangangalaga sa Customer ng Blue Shield Promise Cal MediConnect Plan

B Mga Madalas Itanong (Frequently Asked Questions FAQ)

Makahanap ng mga sagot dito sa mga tanong na mayroon kayo tungkol sa Listahan ng Mga Saklaw na Gamot na ito Maaari ninyong basahin ang lahat ng FAQ upang matuto pa o humanap ng tanong at sagot

B1 Anong mga inireresetang gamot ang kasama sa Listahan ng Mga Saklaw na Gamot (Ang Listahan ng Mga Saklaw na Gamot ay tinatawag naming ldquoListahan ng Gamotrdquo para maikli)


viii

Ang mga gamot sa Listahan ng Gamot ay ang mga gamot na sinasaklaw ng Blue Shield Promise Cal MediConnect Plan Ang mga gamot ay available sa mga parmasya sa aming network Ang isang parmasya ay nasa aming network kung mayroon kaming kasunduan sa kanila na makipagtulungan sa amin at bigyan kayo ng mga serbisyo Tinutukoy namin ang mga parmasyang ito bilang ldquomga parmasyang nasa networkrdquo

bull Sasaklawin ng Blue Shield Promise Cal MediConnect Plan ang lahat ng medikal na kinakailangang gamot sa Listahan ng Gamot kung

o sasabihin ng inyong doktor o ng iba pang tagareseta na kailangan ninyo ang mga ito para gumaling o manatiling malusog at

o kung pupunan ninyo ang reseta sa isang parmasyang nasa network ng Blue Shield Promise Cal MediConnect Plan

bull Sa ilang sitwasyon may kailangan pa kayong gawin bago kayo makakuha ng isang gamot (sumangguni sa tanong B4 sa ibaba)

Makakakita rin kayo ng napapanahong listahan ng mga gamot na sinasaklaw namin sa aming website sa wwwblueshieldcacompromisecalmediconnect o tumawag sa Pangangalaga sa Customer sa 1-855-905-3825 (TTY711) 800 am hanggang 800 pm pitong araw sa isang linggo

B2 Nagbabago ba ang Listahan ng Gamot na ito Oo at dapat sumunod ang Blue Shield Promise Cal MediConnect Plan sa mga panuntunan ng Medicare at Medicaid kapag nagsasagawa ito ng mga pagbabago Maaari kaming magdagdag o mag-alis ng mga gamot sa Listahan ng Gamot sa pag-usad ng taon

Maaari rin naming baguhin ang aming mga panuntunan tungkol sa mga gamot Halimbawa maaari naming

bull Pagpasyahang mag-atas o hindi mag-atas ng paunang pag-apruba para sa isang gamot (Ang paunang pag-apruba ay tumutukoy sa pahintulot mula sa Blue Shield Promise Cal MediConnect Plan bago ninyo makuha ang isang gamot)

bull Dagdagan o baguhin ang dami ng gamot na maaari ninyong makuha (tinatawag na mga limitasyon sa dami)

bull Dagdagan o baguhin ang mga paghihigpit sa step therapy ng isang gamot (Ibig sabihin ng step therapy dapat muna ninyong subukan ang isang gamot bago namin saklawin ang isa pang gamot)


ix

Para sa higit pang impormasyon tungkol sa mga panuntunan sa gamot na ito sumangguni sa tanong B4

Kung umiinom kayo ng gamot na sinasaklaw na sa simula ng taon karaniwang hindi na namin aalisin o babaguhin ang pagsaklaw sa gamot na iyon sa natitirang bahagi ng taon maliban na lang kung

bull may bago at mas murang gamot na lalabas sa merkado na kasingbisa ng gamot na kasalukuyang nasa Listahan ng Gamot o

bull kung mapag-aalaman naming hindi ligtas ang isang gamot o

bull kung aalisin ang isang gamot sa merkado

Makakakita kayo ng higit pang impormasyon sa tanong B3 at B6 sa ibaba tungkol sa kung ano ang mangyayari kapag nagbago ang Listahan ng Gamot

bull Maaari ninyong tingnan anumang oras ang napapanahong Listahan ng Gamot ng Blue Shield Promise Cal MediConnect Plan online sa wwwblueshieldcacompromisecalmediconnect

bull Maaari rin ninyong tawagan ang Pangangalaga sa Customer para matingnan ang kasalukuyang Listahan ng Gamot sa 1-855-905-3825 (TTY 711) 800 am hanggang 800 pm pitong araw sa isang linggo

B3 Ano ang mangyayari kapag may nagbago sa Listahan ng Gamot May ilang pagbabago sa Listahan ng Gamot na mangyayari kaagad Halimbawa

bull May naging available na bagong generic na gamot Kung minsan may bagong generic na gamot na lumalabas sa merkado na kasingbisa ng branded na gamot na kasalukuyang nasa Listahan ng Gamot Kapag nangyari iyon maaaring alisin namin ang branded na gamot at idagdag ang bagong generic na gamot ngunit hindi magbabago o di kayarsquoy bababa ang inyong gastusin para sa bagong gamot Kapag idinagdag namin ang bagong generic na gamot maaari rin naming pagpasyahang panatilihin ang branded na gamot sa listahan ngunit papalitan namin ang mga panuntunan o limitasyon nito sa pagsaklaw o Posibleng hindi namin kayo maabisuhan bago namin gawin ang

pagbabagong ito ngunit padadalhan namin kayo ng impormasyon tungkol sa partikular na pagbabagong ginawa namin kapag nagawa na ito


x

o Maaari kayong humiling o ang inyong provider ng pagbubukod sa mga pagbabagong ito Padadalhan namin kayo ng abisong naglalaman ng mga hakbang na maaari ninyong isagawa para makahiling ng pagbubukod Mangyaring tingnan ang tanong B10 para sa higit pang impormasyon tungkol sa mga pagbubukod

bull May inalis na gamot sa merkado Kung sasabihin ng Food and Drug Administration (FDA) na hindi ligtas ang isang gamot na iniinom ninyo o kung aalisin ng manufacturer nito ang gamot sa merkado aalisin namin ito sa Listahan ng Gamot Kung iniinom ninyo ang gamot ipapaalam namin sa inyo na inalis na ito sa Listahan ng Gamot at bibigyan namin kayo ng tagubilin tungkol sa susunod ninyong gagawin

Maaari kaming gumawa ng iba pang pagbabago na makakaapekto sa mga gamot na iniinom ninyo Ipapaalam namin sa inyo nang maaga ang tungkol sa iba pang mga pagbabagong ito sa Listahan ng Gamot Maaaring mangyari ang mga pagbabagong ito kung

bull Magbibigay ang FDA ng bagong gabay o kung may mga bagong klinikal na alituntunin tungkol sa isang gamot

bull Magdaragdag kami ng generic na gamot na hindi bago sa merkado at

o Papalitan namin ang isang branded na gamot na kasalukuyang nasa Listahan ng Gamot o

o Papalitan namin ang mga panuntunan o limitasyon sa pagsaklaw ng branded na gamot

Kapag nangyari ang mga pagbabagong ito gagawin namin ang mga sumusunod

bull Aabisuhan namin kayo tungkol dito sa loob ng hindi bababa sa 30 araw bago namin gawin ang pagbabago sa Listahan ng Gamot o

bull Ipapaalam namin ito sa inyo at bibigyan namin kayo ng pang-30 araw na supply ng gamot pagkatapos ninyong humiling ng pag-refill

Bibigyan kayo nito ng panahon para kausapin ang inyong doktor o ang iba pang tagareseta Matutulungan nila kayong magpasya

bull Kung may katulad na gamot sa Listahan ng Gamot na maaari ninyong ipalit o


xi

bull Kung hihiling kayo ng pagbubukod sa mga pagbabagong ito Para matutopa tungkol sa mga pagbubukod sumangguni sa tanong B10

B4 Mayroon bang anumang mga paghihigpit o limitasyon sa pagsaklaw sa gamot o anumang kinakailangang pagkilos na dapat gawin para makakuha ng ilang partikular na gamot

Oo ang ilang gamot ay may mga panuntunan sa pagsaklaw o mga limitasyon sa dami na maaari ninyong makuha Sa ilang sitwasyon kayo o ang inyong doktor o ang iba pang tagareseta ay may kailangan pang gawin bago ninyo makuha ang gamot Halimbawa

bull Paunang pag-apruba (o paunang pahintulot) Para sa ilang gamotkailangan muna ninyo o ng inyong doktor o ng iba pang tagareseta nakumuha ng pag-apruba mula sa Blue Shield Promise Cal MediConnect Planbago ninyo mapunan ang inyong reseta Maaaring hindi saklawin ngBlue Shield Promise Cal MediConnect Plan ang gamot kung hindi kayomakakakuha ng pag-apruba

bull Mga limitasyon sa dami Kung minsan nililimitahan ng Blue Shield PromiseCal MediConnect Plan ang dami ng gamot na maaari ninyong makuha

bull Step therapy Kung minsan inaatasan kayo ng Blue Shield Promise CalMediConnect Plan na magsagawa ng step therapy Ibig sabihin nitokakailanganin ninyong sumubok ng mga gamot sa isang partikular napagkakasunod-sunod para sa inyong medikal na kundisyon Maaaringkailanganin ninyong subukan muna ang isang gamot bago namin saklawinang isa pang gamot Kung sa palagay ng inyong doktor ay hindi mabisapara sa inyo ang unang gamot saka namin sasaklawin ang pangalawa

Maaari ninyong alamin kung may anumang karagdagang kinakailangan o limitasyon ang inyong gamot sa pamamagitan ng pagtingin sa mga talahanayan sa mga pahina lt1 ndash 120 gt Makakakuha rin kayo ng higit pang impormasyon sa pamamagitan ng pagbisita sa aming website sa wwwblueshieldcacompromisecalmediconnect Nag-post kami ng mga online na dokumento na nagpapaliwanag sa aming paunang pahintulot at mga paghihigpit sa step therapy Maaari rin ninyong hilingin sa amin na padalhan kayo ng kopya nito

Maaari kayong humiling ng pagbubukod sa mga limitasyong ito Bibigyan kayo nito ng panahon para kausapin ang inyong doktor o ang iba pang tagareseta Matutulungan nila kayong magpasya kung may katulad na gamot sa Listahan ng Gamot na maaari ninyong ipalit o kung hihiling kayo ng isang pagbubukod

1 - 132


xii

Mangyaring sumangguni sa mga tanong B10-B12 para sa higit pang impormasyon tungkol sa mga pagbubukod

B5 Paano ko malalaman kung may mga limitasyon ang isang gamot na gusto ko o kung may mga kinakailangang pagkilos na dapat gawin upang makuha ang gamot

Ang talahanayan ng mga gamot sa pahina lt1 ndash 120 gt ay may column na may label na ldquoMga kinakailangang pagkilos paghihigpit o limitasyon sa paggamitrdquo

B6 Ano ang mangyayari kung papalitan ng Blue Shield Promise Health Plan ang mga panuntunan nila kaugnay ng ilang gamot (halimbawa paunang pahintulot (pag-apruba) mga limitasyon sa dami ato mga paghihigpit sa step therapy)

Sa ilang sitwasyon ipapaalam namin sa inyo nang maaga kung daragdagan o babaguhin namin ang paunang pag-apruba mga limitasyon sa dami ato mga paghihigpit sa step therapy ng isang gamot Sumangguni sa tanong B3 para sa higit pang impormasyon tungkol sa paunang abiso na ito at sa mga sitwasyon kung kailan namin kayo hindi maaabisuhan nang maaga kapag nagbago ang aming mga panuntunan tungkol sa mga gamot sa Listahan ng Gamot

B7 Paano ko mahahanap ang isang gamot sa Listahan ng Gamot Mayroong dalawang paraan ng paghahanap ng gamot

bull Maaari kayong maghanap ayon sa pagkakasunod-sunod ng alpabeto(ayon sa gamot) pangalan ng gamot o

bull Maaari kayong maghanap ayon sa medikal na kundisyon

Para maghanap ayon sa pagkakasunod-sunod ng alpabeto sumangguni sa seksyong Index ng Mga Saklaw na Gamot Makikita ninyo ito sa index na nagsisimula sa pahina lt130gt Makikita sa Index ang isang listahan ng mga gamot na kasama sa dokumentong ito ayon sa pagkakasunod-sunod ng alpabeto Parehong nakalista sa Index ang mga branded na gamot at generic na gamot Tumingin sa Index at hanapin ang inyong gamot Sa tabi ng inyong gamot makikita ninyo ang numero ng pahina kung saan ninyo makikita ang impormasyon sa pagsaklaw nito Pumunta sa pahinang nakalista sa Index at hanapin ang pangalan ng inyong gamot sa unang column ng listahan

Para maghanap ayon sa medikal na kundisyon hanapin ang seksyong may label na ldquoMga Gamot na Nakagrupo ayon sa Medikal na Kundisyonrdquo sa pahina xx Ang mga gamot sa seksyong ito ay nakagrupo sa mga kategorya batay sa uri ng mga medikal na kundisyong ginagamot ng mga ito Halimbawa kung

133

1 - 132


xiii

mayroon kayong kundisyon sa puso dapat kayong tumingin sa kategoryang Mga cardiovascular agent Doon ninyo makikita ang mga gamot para sa mga kundisyon sa puso

B8 Paano kung wala sa Listahan ng Gamot ang gamot na gusto kong inumin

Kung hindi ninyo makikita ang inyong gamot sa Listahan ng Gamot tawagan ang Pangangalaga sa Customer sa 1-855-905-3825 (TTY 711) mula 800 am ndash 800 pm pitong araw sa isang linggo at magtanong tungkol dito libre ang tawag Kung mapag-aalaman ninyong hindi sasaklawin ng Blue Shield Promise Cal MediConnect Plan ang gamot maaari ninyong gawin ang isa sa mga bagay na ito

bull Humingi ng isang listahan ng mga gamot na katulad ng gamot na gusto ninyong inumin mula sa Pangangalaga sa Customer Pagkatapos ay ipakita ang listahan sa inyong doktor o iba pang tagareseta Maaari silang magreseta ng gamot na nasa Listahan ng Gamot na katulad ng gamot na gusto ninyong inumin O

bull Maaari ninyong hilingin sa planong pangkalusugan na gumawa ng pagbubukod upang saklawin ang inyong gamot Mangyaring sumangguni sa mga tanong B10-B12 para sa higit pang impormasyon tungkol sa mga pagbubukod

B9 Paano kung isa akong bagong miyembro ng Blue Shield Promise Cal MediConnect Plan at hindi ko mahanap ang aking gamot sa Listahan ng Gamot o nagkakaproblema ako sa pagkuha ng aking gamot

Makakatulong kami Maaari naming saklawin ang isang pansamantalang pang-30 araw na supply ng inyong gamot sa unang 90 araw na kayo ay miyembro ng Blue Shield Promise Cal MediConnect Plan Bibigyan kayo nito ng panahon para kausapin ang inyong doktor o ang iba pang tagareseta Matutulungan nila kayong magpasya kung may katulad na gamot sa Listahan ng Gamot na maaari ninyong ipalit o kung hihiling kayo ng isang pagbubukod

Kung ang inyong reseta ay para lamang sa ilang araw papayagan namin ang ilang beses na pag-refill upang makapagbigay ng hanggang pang-30 araw na gamot

Sasaklawin namin ang isang pang-30 araw na supply ng inyong gamot kung

bull umiinom kayo ng gamot na wala sa aming Listahan ng Gamot o

bull hindi kayo pinapahintulutan ng mga panuntunan ng planong pangkalusugan na makuha ang bilang na iniatas ng inyong tagareseta o


xiv

bull nangangailangan ang gamot ng paunang pag-apruba ng Blue Shield Promise Cal MediConnect Plan o

bull umiinom kayo ng gamot na bahagi ng paghihigpit sa step therapy

Kung kayo ay nasa isang nursing home o iba pang pasilidad ng pangmatagalang pangangalaga at kailangan ninyo ng gamot na wala sa Listahan ng Gamot o kung nahihirapan kayong makuha ang kailangan ninyong gamot makakatulong kami Kung mahigit 90 araw na kayong nasa plano nakatira kayo sa isang pasilidad ng pangmatagalang pangangalaga at nangangailangan kayo ng agarang supply

bull Sasaklawin namin ang isang pang-31 araw na supply ng gamot na kailangan ninyo (maliban na lang kung para lamang sa ilang araw ang inyong reseta) bagong miyembro man kayo ng Blue Shield Promise Cal MediConnect Plan o hindi

bull Bukod pa ito sa pansamantalang supply sa panahon ng unang 90 araw ng pagiging miyembro ninyo sa Blue Shield Promise Cal MediConnect Plan

Patakaran sa Paglipat Sa mga sitwasyon kung saan lilipat ang isang benepisyaryo mula sa isang lugar ng paggamot papunta sa isa pa titiyakin ng Blue Shield Promise Cal MediConnect Plan ang pagkakaroon ng isang mabilis na proseso para sa pag-apruba ng mga Part D na gamot na wala sa formulary Dapat ding malapat ang prosesong ito sa mga Part D na gamot na nasa formulary na nangangailangan ng paunang pahintulot o step-therapy Kabilang sa mga halimbawa ng mga pagbabago sa antas ng pangangalaga ang paglabas ng isang benepisyaryo sa ospital at paglipat niya sa bahay pagtatapos ng pananatili ng isang benepisyaryo sa isang pasilidad ng sanay na pag-aalaga alinsunod sa Medicare Part A at pagbalik sa Part D na formulary ng plano pagtatapos ng pananatili ng isang benepisyaryo sa isang pasilidad ng sanay na pag-aalaga at pagbalik niya sa komunidad at paglabas ng benepisyaryo sa isang psychiatric na ospital nang may mga rehimen sa gamot na ayon sa indibidwal na pangangailangan

B10 Maaari ba akong humiling ng pagbubukod para saklawin ang aking

gamot Oo Maaari ninyong hilingin sa Blue Shield Promise Cal MediConnect Plan na gumawa ng pagbubukod upang saklawin ang isang gamot na wala sa Listahan ng Gamot


xv

Maaari rin ninyong hilingin sa amin na baguhin ang mga panuntunan sa inyong gamot

bull Halimbawa maaaring limitahan ng Blue Shield Promise Cal MediConnect Plan ang dami ng gamot na sasaklawin namin Kung may limitasyon ang inyong gamot maaari ninyong hilingin sa amin na baguhin ang limitasyon at sumaklaw ng mas marami

bull Iba pang mga halimbawa Maaari ninyong hilingin sa amin na alisin ang mga paghihigpit sa step therapy o ang mga kinakailangan para sa paunang pag-apruba

B11 Paano ako makakahiling ng pagbubukod Para makahiling ng pagbubukod tawagan ang Pangangalaga sa Customer sa 1-855-905-3825 (TTY711) 800 am hanggang 800 pm pitong araw sa isang linggo Makikipagtulungan ang Pangangalaga sa Customer sa inyo at sa inyong provider para makahiling kayo ng pagbubukod Maaari rin ninyong basahin ang Kabanata 9 ng Handbook ng Miyembro para matuto pa tungkol sa mga pagbubukod

B12 Gaano katagal ang inaabot para makakuha ng pagbubukod Pagkatapos naming makatanggap ng pahayag mula sa inyong tagareseta na sumusuporta sa inyong kahilingan para sa isang pagbubukod bibigyan namin kayo ng pasya sa loob ng 72 oras Maaaring ipadala ng inyong tagareseta ang pahayag na ito sa elektronikong paraan (online o fax) o sa pamamagitan ng koreo Maaari rin niyang tawagan ang Departamento ng Parmasya ng Blue Shield Promise at berbal na ipaalam sa amin ang pahayag at padalhan kami ng nakasulat na pahayag kung kinakailangan

Kung naniniwala kayo o ang inyong tagareseta na maaaring malagay sa panganib ang inyong kalusugan kung kakailanganin pa ninyong maghintay ng 72 oras para sa isang pagpapasya maaari kayong humiling ng pinabilis na pagbubukod Isa itong mas mabilis na pagpapasya Kung susuportahan ng inyong tagareseta ang inyong kahilingan bibigyan namin kayo ng pasya sa loob ng 24 na oras pagkakuha namin ng pansuportang pahayag ng inyong tagareseta

B13 Ano ang mga generic na gamot Ang mga generic na gamot ay gawa sa mga parehong sangkap na gaya sa mga branded na gamot Kadalasang mas mura ang mga ito kaysa sa branded na gamot at hindi masyadong kilala ang pangalan ng mga ito Ang mga generic na gamot ay aprubado ng Food and Drug Administration (FDA)


xvi

Parehong sinasaklaw ng Blue Shield Promise Cal MediConnect Plan ang mga branded at generic na gamot

B14 Ano ang mga OTC na gamot Ang OTC ay tumutukoy sa ldquoover-the-counterrdquo Sinasaklaw ng Blue Shield Promise Cal MediConnect Plan ang ilang OTC na gamot kapag inireseta ng inyong provider ang mga ito

Maaari ninyong basahin ang Listahan ng Gamot ng Blue Shield Promise Cal MediConnect Plan upang malaman kung aling mga OTC na gamot ang sinasaklaw

B15 Sinasaklaw ba ng Blue Shield Promise Cal MediConnect Plan ang mga OTC na produkto na hindi gamot

Sinasaklaw ng Blue Shield Promise Cal MediConnect Plan ang ilang OTC na produkto na hindi gamot kapag inireseta ng inyong provider ang mga ito

Kasama sa mga halimbawa ng mga OTC na produkto na hindi gamot ang Vortex Adult Mask o ang Microchamber

Maaari ninyong basahin ang Listahan ng Gamot ng Blue Shield Promise Cal MediConnect Plan upang malaman kung aling mga OTC na produkto na hindi gamot ang sinasaklaw

B16 Ano ang aking copay Maaari ninyong basahin ang Listahan ng Gamot ng Blue Shield Promise Cal MediConnect Plan para malaman ang copay para sa bawat gamot Ang mga miyembro ng Blue Shield Promise Cal MediConnect Plan na nakatira sa mga nursing home o iba pang pasilidad ng pangmatagalang pangangalaga ay hindi magkakaroon ng mga copay Ang ilang mga miyembrong nakakatanggap ng pangmatagalang pangangalaga sa komunidad ay hindi rin magkakaroon ng mga copay

Nakalista ang mga copay ayon sa mga tier Ang mga tier ay mga grupo ng mga gamot na may magkaparehong copay Mag-iiba-iba ang halaga ang co-pay depende sa antas ng inyong pagiging karapat-dapat sa Medi-Cal

Tier Paglalarawan Co-payment Pang-30 araw

na supply Pang-90 araw


na supply Tier 1 Mga Piniling

Generic na Gamot $0 $0 $0


xvii

Tier 2 Mga Generic na Gamot

$0 hanggang $395 na copay


Hindi available

Tier 3 Mga Branded na Gamot



Hindi available

Tier 4 Mga Gamot na Hindi Inirereseta ng Medicare Mga over-the-counter (OTC) na gamot

$0 na copay $0 na copay Hindi available

Ang mga tier ay mga grupo ng mga gamot na nasa aming Listahan ng Gamot bull Ang mga Tier 1 na gamot ay Mga Piniling Generic na Gamot (may

pinakamababang co-payment)bull Ang mga Tier 2 na gamot ay Mga Generic na Gamot (may katamtamang

co-payment)bull Ang mga Tier 3 na gamot ay Mga Branded na Gamot (may pinakamataas

na co-payment)bull Ang mga Tier 4 na gamot ay Mga Gamot na Hindi Inirereseta ng Medicare

at Mga Over-the-Counter (OTC) na gamot (walang copayment)

B17 Ano ang mga tier ng gamot Ang mga tier ay mga grupo ng mga gamot na nasa aming Listahan ng Gamot

bull Ang mga Tier 1 na gamot ay Mga Piniling Generic na Gamotbull Ang mga Tier 2 na gamot ay Mga Generic na Gamotbull Ang mga Tier 3 na gamot ay Mga Branded na Gamotbull Ang mga Tier 4 na gamot ay Mga Gamot na Hindi Inirereseta ng Medicare

at Mga Over-the-Counter (OTC) na gamot

C Pangkalahatang-ideya ng Listahan ng Mga Saklaw na Gamot

Binibigyan kayo ng sumusunod na listahan ng mga saklaw na gamot ng impormasyon tungkol sa mga gamot na sinasaklaw ng Blue Shield Promise Cal MediConnect Plan Kung nagkakaproblema kayo sa paghahanap ng inyong gamot sa listahan pumunta sa Index ng Mga Saklaw na Gamot na nagsisimula sa pahina lt120gt Nakalista sa Index ang lahat ng mga gamot na sinasaklaw ng Blue Shield Promise Cal MediConnect Plan ayon sa pagkakasunod-sunod ng alpabeto

Nakalista sa unang column ng chart ang pangalan ng gamot Nakasulat sa malalaking titik ang mga branded na gamot (hal ELIQUIS) at nakasulat sa naka-italicize na maliliit na titik ang mga generic na gamot (hal simvastatin)

133


xviii

Ipinapaalam sa inyo ng impormasyon sa column na ldquoMga kinakailangang pagkilos paghihigpit o limitasyon sa paggamitrdquo kung mayroong anumang panuntunan ang Blue Shield Promise Cal MediConnect Plan para sa pagsaklaw ng inyong gamot

LEGEND

TIER PANGALAN

1 Mga Piniling Generic na Gamot

2 Mga Generic na Gamot

3 Mga Branded na Gamot

4 Mga Gamot na Hindi Inirereseta ng MedicareMga OTC na Gamot

SIMBOLO PANGALAN PAGLALARAWAN

LA

Limited Access (Limitadong Access)

Ang resetang ito ay maaaring available lang sa ilang partikular na parmasya Para sa higit pang impormasyon tawagan ang Pangangalaga sa Customer ng Blue Shield Promise Cal MediConnect Plan

PA

Prior Authorization (Paunang Pahintulot)

Kailangan ninyo (o ng inyong doktor) na kumuha ng paunang pahintulot mula sa Blue Shield Promise Cal MediConnect Plan bago ninyo mapunan ang inyong reseta para sa gamot na ito Kung wala ang paunang pag-apruba maaaring hindi saklawin ng Blue Shield Promise Cal MediConnect Plan ang gamot na ito

QL Quantity Limit (Limitasyon sa Dami)

Nililimitahan ng Blue Shield Promise Cal MediConnect Plan ang dami ng sasaklawin sa loob ng isang partikular na panahon para sa gamot na ito

ST Step Therapy

Bago magbigay ng pagsaklaw ang Blue Shield Promise Cal MediConnect Plan para sa gamot na ito dapat muna kayong sumubok ng ibang (mga) gamot sa formulary upang gamutin ang inyong medikal na kundisyon Maaari lang saklawin ang gamot na ito kung hindi magiging mabisa para sa inyo ang iba pang (mga) gamot

(xiii)


xix


BvD Part B kumpara sa Part D

Ang gamot na ito ay maaaring maging kwalipikado para sa pagbabayad sa ilalim ng Medicare Part B o Part D Kailangan ninyo (o ng inyong doktor) na kumuha ng paunang pahintulot mula sa Blue Shield Promise Cal MediConnect Plan para matukoy kung sinasaklaw ang gamot na ito sa ilalim ng Medicare Part D bago ninyo punan ang inyong reseta para sa gamot na ito Kung wala ang paunang pag-apruba maaaring hindi saklawin ng Blue Shield Promise Cal MediConnect Plan ang gamot na ito

NPD

Non-Part D Drug (Hindi Part D na Gamot)

Ang gamot na ito ay sinasaklaw ng Medi-Cal at hindi isang ldquoPart D na gamotrdquo Kung mayroon kayong mga tanong tawagan ang Pangangalaga sa Customer ng Blue Shield Promise Cal MediConnect Plan

NDS

Non-Extended Day Supply (Hindi Mapapalawig na Supply)

HINDI available ang gamot para sa pangmatagalang supply

Tandaan Ang NPD sa tabi ng isang gamot ay nangangahulugan na hindi ldquoPart D na gamotrdquo ang gamot Hindi ninyo kakailanganing magbayad ng copay para sa mga gamot na ito Mayroon ding ibat ibang panuntunan para sa pag-apela ang mga gamot na ito

bull Ang pag-apela ay isang pormal na paraan ng paghiling sa amin na suriin ang isang pasyang ginawa namin tungkol sa inyong pagsaklaw at baguhin ito kung naniniwala kayong nagkamali kami Halimbawa maaari naming mapagpasyahan na hindi saklawin ang isang gamot na gusto ninyo o hindi na ito saklawin ng Medicare o Medi-Cal

bull Kung hindi kayo sang-ayon ng inyong doktor sa aming pasya maaari kayong umapela Kung mayroon kayong tanong tawagan ang Pangangalaga sa Customer sa 1-855-905-3825 (TTY 711) 800 am hanggang 800 pm pitong araw sa isang linggo Maaari rin ninyong basahin ang Kabanata 9 ng Handbook ng Miyembro para matuto tungkol sa kung paano mag-apela


xx

C1 Mga Gamot na Nakagrupo ayon sa Medikal na Kundisyon Ang mga gamot sa seksyong ito ay nakagrupo sa mga kategorya depende sa uri ng mga medikal na kundisyong ginagamot ng mga ito Halimbawa kung mayroon kayong kundisyon sa puso dapat kayong tumingin sa kategoryang Mga Cardiovascular Agent Doon ninyo makikita ang mga gamot para sa mga kundisyon sa puso

Drugs Grouped by Medical ConditionANALGESICS 1

ANESTHETICS 4

ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS 5

ANTIBACTERIALS 6

ANTICONVULSANTS 13

ANTIDEMENTIA AGENTS 17

ANTIDEPRESSANTS 18

ANTIEMETICS 21

ANTIFUNGALS 22

ANTIGOUT AGENTS 24

ANTIMIGRAINE AGENTS 24

ANTIMYASTHENIC AGENTS 26

ANTIMYCOBACTERIALS 26

ANTINEOPLASTICS 27

ANTIPARASITICS 37

ANTIPARKINSON AGENTS 38

ANTIPSYCHOTICS 40

ANTISPASTICITY AGENTS 44

ANTIVIRALS 44

ANXIOLYTICS 50

BIPOLAR AGENTS 51

BLOOD GLUCOSE REGULATORS 52

BLOOD PRODUCTS AND MODIFIERS 56

CARDIOVASCULAR AGENTS 59

CENTRAL NERVOUS SYSTEM AGENTS 70

DENTAL AND ORAL AGENTS 74

DERMATOLOGICAL AGENTS 74

ELECTROLYTESMINERALSMETALSVITAMINS 77

GASTROINTESTINAL AGENTS 81

GENETIC OR ENZYME OR PROTEIN DISORDER REPLACEMENT MODIFIERS TREATMENT 83

GENITOURINARY AGENTS 85

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL) 86

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY) 88

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEX HORMONESMODIFIERS)

89

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID) 92

HORMONAL AGENTS SUPPRESSANT (PITUITARY) 93

HORMONAL AGENTS SUPPRESSANT (THYROID) 94

IMMUNOLOGICAL AGENTS 95

INFLAMMATORY BOWEL DISEASE AGENTS 101

METABOLIC BONE DISEASE AGENTS 102

MISCELLANEOUS THERAPEUTIC AGENTS 103

Non-Part D Drugs 118

OPHTHALMIC AGENTS 107

OTIC AGENTS 110

RESPIRATORY TRACTPULMONARY AGENTS 111

SKELETAL MUSCLE RELAXANTS 116

SLEEP DISORDER AGENTS 117

ANALGESICS

Name of drugWhat the drug willcost you(tier level)

Necessary actionsrestrictions or limits onuse

NONSTEROIDAL ANTI-INFLAMMATORY DRUGScelecoxib (cap 100 mg cap 200mg cap 50 mg)

Tier 2 QL (2 PER 1 DAYS)

celecoxib cap 400 mg Tier 2 QL (1 PER 1 DAYS)

diclofenac potassium tab 50 mg Tier 2

diclofenac sodium (tab delayedrelease 25 mg tab delayedrelease 50 mg tab delayedrelease 75 mg tab er 24hr 100mg)

Tier 2

diclofenac sodium gel 1 Tier 2

diflunisal tab 500 mg Tier 2

etodolac (tab 400 mg tab 500mg tab er 24hr 400 mg tab er24hr 500 mg tab er 24hr 600 mg)

Tier 2

flurbiprofen tab 100 mg Tier 2

ibuprofen (tab 400 mg tab 600mg tab 800 mg)

Tier 2

indomethacin (cap 25 mg cap50 mg)

Tier 2 PA

meloxicam (tab 15 mg tab 75mg)

Tier 2

nabumetone (tab 500 mg tab750 mg)

Tier 2

naproxen (tab 250 mg tab 375mg tab 500 mg tab ec 375 mgtab ec 500 mg)

Tier 2

piroxicam (cap 10 mg cap 20mg)

Tier 2

sulindac (tab 150 mg tab 200mg)

Tier 2

OPIOID ANALGESICS LONG-ACTINGfentanyl (patch 72hr 100 mcghrpatch 72hr 12 mcghr patch72hr 25 mcghr patch 72hr 50mcghr patch 72hr 75 mcghr)

Tier 2 PA QL (10 PER 30 OVERTIME) NDS

You can find information on what the symbols and abbreviations in this table meanby going to pages xvi - xvii and reading the explanation provided in the legends

1

ANALGESICS



methadone hcl (10 mg5mlsolution soln 10 mg5ml)

Tier 2 PA QL (450 PER 30OVER TIME) NDS

methadone hcl (10 mgmlsolution inj 10 mgml)

Tier 2 PA NDS



methadone hcl tab 10 mg Tier 2 PA QL (90 PER 30 OVERTIME) NDS

methadone hcl tab 5 mg Tier 2 PA QL (180 PER 30OVER TIME) NDS

morphine sulfate (tab er 100 mgtab er 200 mg tab er 60 mg)

Tier 2 QL (60 PER 30 OVERTIME) NDS

morphine sulfate tab er 15 mg Tier 2 QL (180 PER 30 OVERTIME) NDS


OPIOID ANALGESICS SHORT-ACTINGacetaminophen w codeine (tab300-15 mg tab 300-30 mg)

Tier 2 QL (12 PER 1 DAYS) NDS

acetaminophen w codeine soln120-12 mg5ml


acetaminophen w codeine tab300-60 mg


butalbital-acetaminophen-caffw cod cap 50-325-40-30 mg


codeine sulfate (30 mg tab tab30 mg)




CODEINE SULFATE 15 MG TAB Tier 2 QL (336 PER 30 OVERTIME) NDS


2

ANALGESICS



fentanyl citrate (100 mcg tab200 mcg tab 400 mcg tab 600mcg tab 800 mcg tab lozengeon a handle 1200 mcg lozengeon a handle 1600 mcg lozengeon a handle 200 mcg lozengeon a handle 400 mcg lozengeon a handle 600 mcg lozengeon a handle 800 mcg)


hydrocodone-acetaminophen(tab 10-325 mg tab 75-325 mg)


hydrocodone-acetaminophensoln 75-325 mg15ml


hydrocodone-acetaminophentab 5-325 mg


hydromorphone hcl liqd 1 mgml Tier 2 QL (675 PER 30 OVERTIME) NDS

hydromorphone hcl tab 2 mg Tier 2 QL (154 PER 30 OVERTIME) NDS



morphine sulfate (15 mg tab 30mg tab tab 15 mg tab 30 mg)


morphine sulfate oral soln 10mg5ml


morphine sulfate oral soln 100mg5ml (20 mgml)




oxycodone hcl (tab 15 mg tab30 mg)


oxycodone hcl soln 5 mg5ml Tier 2 QL (840 PER 30 OVERTIME) NDS

oxycodone hcl tab 10 mg Tier 2 QL (84 PER 30 OVERTIME) NDS



3

ANALGESICS




oxycodone w acetaminophen(tab 25-325 mg tab 5-325 mg)


oxycodone w acetaminophentab 10-325 mg




tramadol hcl tab 50 mg Tier 2 QL (8 PER 1 DAYS) NDS

tramadol-acetaminophen tab375-325 mg


ANESTHETICS



LOCAL ANESTHETICSlidocaine hcl (4 solution soln4)

Tier 2

lidocaine hcl viscous soln 2 Tier 2

lidocaine oint 5 Tier 2 QL (50 PER 30 OVERTIME)

lidocaine patch 5 Tier 2 PA QL (3 PER 1 DAYS)

lidocaine-prilocaine cream 25-25

Tier 2 QL (30 PER 30 OVERTIME)

NAYZILAM 5 MG01ML SOLUTION Tier 3 QL (10 PER 30 OVERTIME)


4

ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS



ALCOHOL DETERRENTSANTI-CRAVINGacamprosate calcium tabdelayed release 333 mg

Tier 2

disulfiram (tab 250 mg tab 500mg)

Tier 2

OPIOID DEPENDENCEbuprenorphine hcl sl tab 2 mg(base equiv)


buprenorphine hcl sl tab 8 mg(base equiv)


buprenorphine hcl-naloxone hcldihydrate (-naloxone sl film 2-05mg (base equiv) -naloxone sl film4-1 mg (base equiv))


buprenorphine hcl-naloxone hcldihydrate (-naloxone sl film 8-2mg (base equiv) -naloxone sltab 8-2 mg (base equiv))


buprenorphine hcl-naloxone hclsl film 12-3 mg (base equiv)


buprenorphine hcl-naloxone hclsl tab 2-05 mg (base equiv)


ZUBSOLV (07-018 MG SL TAB 14-036 MG SL TAB 57-14 MG SLTAB)


ZUBSOLV (114-29 MG SL TAB 29-071 MG SL TAB)


ZUBSOLV 86-21 MG SL TAB Tier 3 QL (2 PER 1 DAYS)

OPIOID REVERSAL AGENTSnaloxone hcl (inj 04 mgml inj 4mg10ml soln prefilled syringe 2mg2ml)

Tier 2

NALOXONE HCL 04 MGML SOLNCART

Tier 2 QL (2 PER 30 OVER TIME)

naltrexone hcl tab 50 mg Tier 2


5




NARCAN 4 MG01ML LIQUID Tier 3 QL (2 PER 30 OVER TIME)

SMOKING CESSATION AGENTSbupropion hcl (smokingdeterrent) tab er 12hr 150 mg


CHANTIX (05 MG TAB 1 MG TAB) Tier 3 QL (2 PER 1 DAYS)

CHANTIX CONTINUING MONTHPAK 1 MG TAB


CHANTIX STARTING MONTH PAK05 MG X 11 amp 1 MG X 42 TAB


NICOTROL 10 MG INHALER Tier 3

NICOTROL NS 10 MGMLSOLUTION

Tier 3

VARENICLINE TARTRATE (05 MGTAB 1 MG TAB)


ANTIBACTERIALS



AMINOGLYCOSIDESamikacin sulfate inj 500 mg2ml(250 mgml)

Tier 2

gentamicin sulfate (topical)(cream 01 oint 01)

Tier 2

gentamicin sulfate inj 40 mgml Tier 2

neomycin sulfate tab 500 mg Tier 2

paromomycin sulfate cap 250mg

Tier 2

STREPTOMYCIN SULFATE 1 GMRECON SOLN

Tier 2

tobramycin sulfate (10 mgmlsolution 2 gm50ml solution forinj 12 gm inj 12 gm30ml (40mgml) (base equiv) inj 80mg2ml (40 mgml) (base equiv))

Tier 2


6

ANTIBACTERIALS



ANTIBACTERIALS OTHERacetic acid otic soln 2 Tier 2

aztreonam (inj 1 gm inj 2 gm) Tier 2

clindamycin hcl (cap 150 mgcap 300 mg cap 75 mg)

Tier 2

clindamycin palmitate hcl forsoln 75 mg5ml (base equiv)

Tier 2

clindamycin phosphate (inj 300mg2ml inj 600 mg4ml inj 9gm60ml inj 900 mg6ml iv soln300 mg2ml iv soln 600 mg4mliv soln 900 mg6ml)

Tier 2

clindamycin phosphate in d5w(soln 300 mg50ml soln 600mg50ml soln 900 mg50ml)

Tier 2

CLINDAMYCIN PHOSPHATE INNACL (300-09 MG50ML-SOLUTION 600-09 MG50ML-SOLUTION 900-09 MG50ML-SOLUTION)

Tier 2

clindamycin phosphate swab 1 Tier 2

clindamycin phosphate vaginalcream 2

Tier 2

colistimethate sod for inj 150 mg(colistin base activity)

Tier 2

daptomycin (350 mg recon solnfor iv soln 350 mg for iv soln 500mg)

Tier 2

fosfomycin tromethamine powdpack 3 gm (base equivalent)


linezolid (for susp 100 mg5mltab 600 mg)

Tier 2 PA

LINEZOLID IN SODIUM CHLORIDE600-09 MG300ML- SOLUTION

Tier 2

linezolid iv soln 600 mg300ml (2mgml)

Tier 2

methenamine hippurate tab 1gm

Tier 2


7

ANTIBACTERIALS



metronidazole (5 mgml solutiontab 250 mg tab 500 mg)

Tier 2

metronidazole (topical) (cream075 gel 075 gel 1 lotion075)

Tier 2

metronidazole in nacl (074 ivsoln 500 mg100ml 079 iv soln500 mg100ml)

Tier 2

metronidazole vaginal gel 075 Tier 3

nitrofurantoin macrocrystal (linecap 100 mg line cap 25 mg linecap 50 mg)

Tier 2

nitrofurantoin monohydratemacrocrystalline cap 100 mg

Tier 2

ORBACTIV 400 MG RECON SOLN Tier 3 PA QL (9 PER 30 OVERTIME)

SYNERCID 150-350 MG RECONSOLN

Tier 3

tigecycline (50 mg recon soln foriv soln 50 mg)

Tier 2

trimethoprim (100 mg tab tab100 mg)

Tier 2

vancomycin hcl (125 gm reconsoln 15 gm recon soln 100 gmrecon soln 250 mg recon soln750 mg recon soln cap 125 mg(base equivalent) cap 250 mg(base equivalent) for iv soln 1gm (base equivalent) for iv soln10 gm (base equivalent) for ivsoln 500 mg (base equivalent)for iv soln 750 mg (baseequivalent))

Tier 2

XIFAXAN 200 MG TAB Tier 3 PA QL (9 PER 30 OVERTIME)

XIFAXAN 550 MG TAB Tier 3 PA QL (3 PER 1 DAYS)


8

ANTIBACTERIALS



BETA-LACTAM CEPHALOSPORINScefaclor (125 mg5ml recon susp250 mg cap 250 mg5ml reconsusp 375 mg5ml recon susp 500mg cap cap 250 mg cap 500mg)

Tier 2

cefadroxil (1 gm tab cap 500mg for susp 250 mg5ml for susp500 mg5ml tab 1 gm)

Tier 2

cefazolin sodium (1 gm reconsoln 100 gm recon soln 20 gmrecon soln 300 gm recon soln forinj 1 gm for inj 10 gm for inj 500mg)

Tier 2

cefdinir (cap 300 mg for susp 125mg5ml for susp 250 mg5ml)

Tier 2

cefepime hcl (inj 1 gm inj 2 gm) Tier 2

cefixime (cap 400 mg for susp100 mg5ml for susp 200 mg5ml)

Tier 2

cefotaxime sodium (1 gm reconsoln for inj 1 gm)

Tier 2

cefotetan disodium (inj 1 gm inj2 gm)

Tier 2

cefoxitin sodium (soln 1 gm soln10 gm soln 2 gm)

Tier 2

cefpodoxime proxetil (for susp100 mg5ml for susp 50 mg5mltab 100 mg tab 200 mg)

Tier 2

cefprozil (for susp 125 mg5ml forsusp 250 mg5ml tab 250 mgtab 500 mg)

Tier 2

ceftazidime (inj 1 gm inj 6 gm ivsoln 2 gm)

Tier 2

ceftriaxone sodium (inj 1 gm inj10 gm inj 2 gm inj 250 mg inj 500mg iv soln 1 gm iv soln 2 gm)

Tier 2

cefuroxime axetil (tab 250 mgtab 500 mg)

Tier 2


9

ANTIBACTERIALS



cefuroxime sodium (inj 75 gm inj750 mg iv soln 15 gm)

Tier 2

cephalexin (cap 250 mg cap500 mg for susp 125 mg5ml forsusp 250 mg5ml)

Tier 2

TAZICEF (1 GM RECON SOLN 6GM RECON SOLN)

Tier 2

TEFLARO (400 MG RECON SOLN600 MG RECON SOLN)

Tier 3

BETA-LACTAM PENICILLINSamoxicillin amp pot clavulanate (kclavulanate for susp 200-285mg5ml k clavulanate for susp250-625 mg5ml k clavulanatefor susp 400-57 mg5ml kclavulanate for susp 600-429mg5ml k clavulanate tab 250-125 mg k clavulanate tab 500-125 mg k clavulanate tab 875-125 mg)

Tier 2

AMOXICILLIN ((TRIHYDRATE) CAP250 MG (TRIHYDRATE) CAP 500MG (TRIHYDRATE) FOR SUSP 125MG5ML (TRIHYDRATE) FOR SUSP200 MG5ML (TRIHYDRATE) FORSUSP 250 MG5ML (TRIHYDRATE)FOR SUSP 400 MG5ML(TRIHYDRATE) TAB 500 MG(TRIHYDRATE) TAB 875 MG 125MG CHEW TAB 250 MG CHEWTAB)

Tier 2

AMOXICILLIN-POT CLAVULANATE(200-285 MG CHEW TAB 400-57MG CHEW TAB)

Tier 2

ampicillin amp sulbactam sodium(for inj 15 (1-05) gm for inj 3 (2-1)gm for iv soln 15 (10-5) gm)

Tier 2

AMPICILLIN 500 MG CAP Tier 2


10

ANTIBACTERIALS



ampicillin sodium (1 gm reconsoln 125 mg recon soln 2 gmrecon soln for inj 1 gm for inj 2gm for inj 250 mg for inj 500 mgfor iv soln 10 gm for iv soln 2 gm)

Tier 2

AMPICILLIN-SULBACTAM SODIUM(15 (1-05) GM RECON SOLN 3(2-1) GM RECON SOLN)

Tier 2

BICILLIN L-A (1200000 UNIT2MLSUSPENSION 2400000 UNIT4MLSUSPENSION 600000 UNITMLSUSPENSION)

Tier 3

dicloxacillin sodium (cap 250 mgcap 500 mg)

Tier 2

nafcillin sodium (1 gm recon soln2 gm recon soln for inj 1 gm forinj 2 gm for iv soln 10 gm)

Tier 2

penicillin g potassium (for inj20000000 unit for inj 5000000 unit)

Tier 2

PENICILLIN G SODIUM 5000000UNIT RECON SOLN

Tier 2

penicillin v potassium (125mg5ml recon soln 250 mg5mlrecon soln tab 250 mg tab 500mg)

Tier 2

PFIZERPEN (20000000 UNIT RECONSOLN 5000000 UNIT RECONSOLN)

Tier 2

piperacillin sodium-tazobactamsodium (na for inj 3375 gm (3-0375 gm) sod for inj 135 gm (12-15 gm) sod for inj 225 gm (2-025 gm) sod for inj 45 gm (4-05gm) sod for inj 405 gm (36-45gm))

Tier 2

CARBAPENEMSertapenem sodium for inj 1 gm(base equivalent)

Tier 2

imipenem-cilastatin (250 mgrecon soln intravenous for soln250 mg intravenous for soln 500mg)

Tier 2


11

ANTIBACTERIALS



meropenem (soln 1 gm soln 500mg)

Tier 2

MACROLIDESazithromycin (1 gm packet forsusp 100 mg5ml for susp 200mg5ml iv for soln 500 mg tab250 mg tab 500 mg tab 600 mg)

Tier 2

clarithromycin (125 mg5mlrecon susp 250 mg5ml reconsusp tab 250 mg tab 500 mgtab er 24hr 500 mg)

Tier 2

EES 400 400 MG TAB Tier 2

ERYTHROCIN LACTOBIONATE 500MG RECON SOLN

Tier 3

erythromycin base (250 mg cp drpart tab 250 mg tab 500 mg wdelayed release particles cap250 mg)

Tier 2

ERYTHROMYCIN ETHYLSUCCINATE400 MG TAB

Tier 2

QUINOLONESBESIVANCE 06 SUSPENSION Tier 3

CILOXAN 03 OINTMENT Tier 3

ciprofloxacin (susp 250 mg5ml(5) (5 gm100ml) susp 500mg5ml (10) (10 gm100ml))

Tier 2

ciprofloxacin 200 mg100ml ind5w

Tier 2

ciprofloxacin hcl (100 mg tabtab 250 mg (base equiv) tab 500mg (base equiv) tab 750 mg(base equiv))

Tier 2

ciprofloxacin hcl ophth soln 03(base equivalent)

Tier 2

levofloxacin (iv soln 25 mgmloral soln 25 mgml tab 250 mgtab 500 mg tab 750 mg)

Tier 2


12

ANTIBACTERIALS



levofloxacin in d5w (soln 500mg100ml soln 750 mg150ml)

Tier 2

moxifloxacin hcl tab 400 mg(base equiv)

Tier 2

ofloxacin (300 mg tab tab 400mg)

Tier 2

SULFONAMIDESsulfacetamide sodium lotion 10(acne)

Tier 2

SULFADIAZINE 500 MG TAB Tier 2

sulfamethoxazole-trimethoprim(iv soln 400-80 mg5ml susp 200-40 mg5ml tab 400-80 mg tab800-160 mg)

Tier 2

TETRACYCLINESdoxycycline (monohydrate) (cap100 mg cap 50 mg tab 100 mgtab 50 mg tab 75 mg)

Tier 2

doxycycline hyclate (cap 100mg cap 50 mg for inj 100 mgtab 100 mg tab 20 mg)

Tier 2

minocycline hcl (cap 100 mgcap 50 mg cap 75 mg tab 100mg tab 50 mg tab 75 mg)

Tier 2

tetracycline hcl (cap 250 mgcap 500 mg)

Tier 2

ANTICONVULSANTS



ANTICONVULSANTS OTHERBRIVIACT (10 MG TAB 100 MGTAB 25 MG TAB 50 MG TAB 75MG TAB)

Tier 3 ST QL (2 PER 1 DAYS)


13

ANTICONVULSANTS



BRIVIACT 10 MGML SOLUTION Tier 3 ST QL (20 PER 1 DAYS)

DIACOMIT (250 MG CAP 250 MGPACKET)

Tier 3 PA LA QL (3 PER 1DAYS)



divalproex sodium (cap delayedrelease sprinkle 125 mg tabdelayed release 125 mg tabdelayed release 250 mg tabdelayed release 500 mg tab er24 hr 250 mg tab er 24 hr 500mg)

Tier 2

EPIDIOLEX 100 MGML SOLUTION Tier 3 PA LA

felbamate (susp 600 mg5ml tab400 mg tab 600 mg)

Tier 2

FINTEPLA 22 MGML SOLUTION Tier 3 PA LA QL (12 PER 1DAYS)

FYCOMPA (10 MG TAB 12 MGTAB 4 MG TAB 6 MG TAB 8 MGTAB)


FYCOMPA 05 MGMLSUSPENSION


FYCOMPA 2 MG TAB Tier 3 QL (3 PER 1 DAYS)

lamotrigine (tab 100 mg tab 150mg tab 200 mg tab 25 mg tabchewable dispersible 25 mg tabchewable dispersible 5 mg)

Tier 2

levetiracetam (oral soln 100mgml tab 1000 mg tab 250 mgtab 500 mg tab 750 mg)

Tier 2

levetiracetam tab er 24hr 500 mg Tier 2 QL (6 PER 1 DAYS)


SPRITAM (250 MG TAB 500 MGTAB)

Tier 3 PA QL (2 PER 1 DAYS)

SPRITAM 1000 MG TAB Tier 3 PA QL (3 PER 1 DAYS)



14

ANTICONVULSANTS



topiramate (sprinkle cap 15 mgsprinkle cap 25 mg tab 100 mgtab 200 mg tab 25 mg tab 50mg)

Tier 2

valproate sodium (inj 100 mgmloral soln 250 mg5ml (baseequiv))

Tier 2

valproic acid cap 250 mg Tier 2

XCOPRI (100 MG TAB 50 MG TAB) Tier 3 PA QL (1 PER 1 DAYS)

XCOPRI (14 X 125 MG amp 14 X 25MG TAB THPK 14 X 150 MG amp 14X200 MG TAB THPK 14 X 50 MG amp14 X100 MG TAB THPK)

Tier 3 PA QL (28 PER 28 OVERTIME)

XCOPRI (150 MG TAB 200 MGTAB)


XCOPRI (250 MG DAILY DOSE)(100 amp 150 MG TAB THPK 50 amp200 MG TAB THPK)


XCOPRI (350 MG DAILY DOSE)150 amp 200 MG TAB THPK


CALCIUM CHANNEL MODIFYING AGENTSCELONTIN 300 MG CAP Tier 3

ethosuximide (cap 250 mg soln250 mg5ml)

Tier 2

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSclobazam suspension 25 mgml Tier 2 PA QL (16 PER 1 DAYS)

clobazam tab 10 mg Tier 2 PA QL (4 PER 1 DAYS)


DIAZEPAM 10 MG GEL Tier 2 QL (20 PER 30 OVERTIME)

DIAZEPAM 25 MG GEL Tier 2 QL (5 PER 30 OVER TIME)


gabapentin (tab 600 mg tab 800mg)



15

ANTICONVULSANTS



gabapentin cap 100 mg Tier 2 QL (12 PER 1 DAYS)



gabapentin oral soln 250 mg5ml Tier 2 QL (72 PER 1 DAYS)

phenobarbital (elixir 20 mg5mltab 100 mg tab 15 mg tab 162mg tab 30 mg tab 324 mg tab60 mg tab 648 mg tab 972 mg)

Tier 2 PA

primidone (tab 250 mg tab 50mg)

Tier 2

SYMPAZAN (10 MG FILM 20 MGFILM 5 MG FILM)


tiagabine hcl (tab 12 mg tab 16mg tab 2 mg tab 4 mg)

Tier 2 PA

VALTOCO 10 MG DOSE 10MG01ML LIQUID


VALTOCO 15 MG DOSE 75MG01ML LIQD THPK






vigabatrin (powd pack 500 mgtab 500 mg)


SODIUM CHANNEL AGENTSAPTIOM (200 MG TAB 400 MGTAB)


APTIOM (600 MG TAB 800 MGTAB)


carbamazepine (cap er 12hr 100mg cap er 12hr 200 mg cap er12hr 300 mg chew tab 100 mgsusp 100 mg5ml tab 200 mgtab er 12hr 100 mg tab er 12hr200 mg tab er 12hr 400 mg)

Tier 2

DILANTIN (100 MG CAP 30 MGCAP)

Tier 3


16

ANTICONVULSANTS



DILANTIN INFATABS 50 MG CHEWTAB

Tier 3

oxcarbazepine (susp 300 mg5ml(60 mgml) tab 150 mg tab 300mg tab 600 mg)

Tier 2

PEGANONE 250 MG TAB Tier 3

PHENYTEK (200 MG CAP 300 MGCAP)

Tier 3

phenytoin (chew tab 50 mg susp125 mg5ml)

Tier 2

phenytoin sodium extended(cap 100 mg cap 200 mg cap300 mg)

Tier 2

rufinamide susp 40 mgml Tier 2 ST QL (80 PER 1 DAYS)

rufinamide tab 200 mg Tier 2 ST QL (16 PER 1 DAYS)


VIMPAT (100 MG TAB 150 MGTAB 200 MG TAB 50 MG TAB)


VIMPAT 10 MGML SOLUTION Tier 3 QL (40 PER 1 DAYS)

VIMPAT 200 MG20ML SOLUTION Tier 3 PA

zonisamide (cap 100 mg cap 25mg cap 50 mg)

Tier 2

ANTIDEMENTIA AGENTS



ANTIDEMENTIA AGENTS OTHERERGOLOID MESYLATES 1 MG TAB Tier 2 PA

CHOLINESTERASE INHIBITORSdonepezil hydrochloride (orallydisintegrating tab 10 mg orallydisintegrating tab 5 mg tab 10mg tab 5 mg)

Tier 2


17

ANTIDEMENTIA AGENTS



rivastigmine (patch 24hr 133mg24hr patch 24hr 46 mg24hrpatch 24hr 95 mg24hr)


rivastigmine tartrate (cap 15 mg(base equivalent) cap 3 mg(base equivalent) cap 45 mg(base equivalent) cap 6 mg(base equivalent))

Tier 2

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl (cap er 24hr 14mg cap er 24hr 21 mg cap er24hr 28 mg cap er 24hr 7 mgoral solution 2 mgml tab 10 mgtab 28 x 5 mg amp 21 x 10 mgtitration pack tab 5 mg)

Tier 2

ANTIDEPRESSANTS



ANTIDEPRESSANTS OTHERbupropion hcl (tab 100 mg taber 12hr 100 mg)


bupropion hcl (tab er 12hr 150mg tab er 24hr 150 mg)


bupropion hcl tab 75 mg Tier 2 QL (6 PER 1 DAYS)

bupropion hcl tab er 12hr 200 mg Tier 2 QL (2 PER 1 DAYS)


LYBALVI (10-10 MG TAB 15-10 MGTAB 20-10 MG TAB 5-10 MG TAB)


MAPROTILINE HCL (25 MG TAB 50MG TAB 75 MG TAB)

Tier 2

mirtazapine (orally disintegratingtab 15 mg orally disintegratingtab 30 mg orally disintegratingtab 45 mg tab 15 mg tab 30mg tab 45 mg tab 75 mg)

Tier 2


18

ANTIDEPRESSANTS



MONOAMINE OXIDASE INHIBITORSEMSAM (12 MG24HR PATCH24HR 6 MG24HR PATCH 24HR 9MG24HR PATCH 24HR)

Tier 3 PA

MARPLAN 10 MG TAB Tier 3

phenelzine sulfate tab 15 mg Tier 2

tranylcypromine sulfate tab 10mg

Tier 2

SSRISSNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORSEROTONIN ANDNOREPINEPHRINE REUPTAKE INHIBITOR)citalopram hydrobromide (oralsoln 10 mg5ml tab 10 mg (baseequiv) tab 20 mg (base equiv)tab 40 mg (base equiv))

Tier 2

desvenlafaxine succinate (tab er24hr 25 mg (base equiv) tab er24hr 50 mg (base equiv))


desvenlafaxine succinate tab er24hr 100 mg (base equiv)


escitalopram oxalate (soln 5mg5ml (base equiv) tab 10 mg(base equiv) tab 20 mg (baseequiv) tab 5 mg (base equiv))

Tier 2

FETZIMA (120 MG CAP ER 24H 20MG CAP ER 24H 40 MG CAP ER24H 80 MG CAP ER 24H)


FETZIMA TITRATION 20 amp 40 MGCP24 THPK


fluoxetine hcl (cap 10 mg cap20 mg cap 40 mg solution 20mg5ml)

Tier 2

FLUOXETINE HCL (PMDD) (10 MGCAP 20 MG CAP)

Tier 2

FLUOXETINE HCL 90 MG CAP DR Tier 2 QL (4 PER 28 OVER TIME)

fluvoxamine maleate (tab 100mg tab 25 mg tab 50 mg)

Tier 2


19

ANTIDEPRESSANTS



nefazodone hcl (100 mg tab 150mg tab 200 mg tab 250 mg tab50 mg tab tab 250 mg tab 50mg)

Tier 2

paroxetine hcl (tab 10 mg tab 20mg tab 30 mg tab 40 mg)

Tier 2

paroxetine hcl oral susp 10mg5ml (base equiv)


PAXIL 10 MG5ML SUSPENSION Tier 3 QL (30 PER 1 DAYS)

sertraline hcl (oral concentratefor solution 20 mgml tab 100mg tab 25 mg tab 50 mg)

Tier 2

trazodone hcl (tab 100 mg tab150 mg tab 300 mg tab 50 mg)

Tier 2

TRINTELLIX (10 MG TAB 20 MGTAB 5 MG TAB)


venlafaxine hcl (cap er 24hr 150mg (base equivalent) cap er24hr 375 mg (base equivalent))


venlafaxine hcl (tab 100 mg(base equivalent) tab 25 mg(base equivalent) tab 375 mg(base equivalent) tab 50 mg(base equivalent) tab 75 mg(base equivalent))

Tier 2

venlafaxine hcl cap er 24hr 75mg (base equivalent)


VIIBRYD (10 MG TAB 20 MG TAB40 MG TAB)


VIIBRYD STARTER PACK 10 amp 20MG KIT

Tier 3 ST QL (30 PER 30 OVERTIME)

TRICYCLICSamitriptyline hcl (tab 10 mg tab100 mg tab 150 mg tab 25 mgtab 50 mg tab 75 mg)

Tier 2 PA

AMOXAPINE (100 MG TAB 150MG TAB 25 MG TAB 50 MG TAB)

Tier 2


20

ANTIDEPRESSANTS



clomipramine hcl (cap 25 mgcap 50 mg cap 75 mg)

Tier 2 PA

desipramine hcl (tab 10 mg tab100 mg tab 150 mg tab 25 mgtab 50 mg tab 75 mg)

Tier 2

doxepin hcl (150 mg cap cap 10mg cap 100 mg cap 25 mgcap 50 mg cap 75 mg conc 10mgml)

Tier 2 PA

imipramine hcl (tab 10 mg tab25 mg tab 50 mg)

Tier 2 PA

nortriptyline hcl (10 mg5mlsolution cap 10 mg cap 25 mgcap 50 mg cap 75 mg soln 10mg5ml)

Tier 2

nortriptyline oral solution (unitdose)

Tier 2

protriptyline hcl (tab 10 mg tab 5mg)

Tier 2

trimipramine maleate (cap 100mg cap 25 mg cap 50 mg)

Tier 2 PA

ANTIEMETICS



ANTIEMETICS OTHERmeclizine hcl (tab 125 mg tab25 mg)

Tier 2

metoclopramide hcl (inj 5 mgml(base equivalent) soln 5 mg5ml(10 mg10ml) (base equiv) tab10 mg (base equivalent) tab 5mg (base equivalent))

Tier 2

perphenazine (tab 16 mg tab 2mg tab 4 mg tab 8 mg)

Tier 2

prochlorperazine maleate (tab10 mg (base equivalent) tab 5mg (base equivalent))

Tier 2


21

ANTIEMETICS



prochlorperazine suppos 25 mg Tier 2

promethazine hcl (tab 125 mgtab 25 mg tab 50 mg)

Tier 2 PA

scopolamine td patch 72hr 1mg3days

Tier 2 PA

EMETOGENIC THERAPY ADJUNCTSaprepitant (capsule 125 mgcapsule 80 mg capsule therapypack 80 amp 125 mg)

Tier 2 BvD

aprepitant capsule 40 mg Tier 2 PA QL (1 PER 30 OVERTIME)

dronabinol (cap 10 mg cap 25mg cap 5 mg)


granisetron hcl (01 mgmlsolution inj 1 mgml inj 4 mg4ml(1 mgml))

Tier 2 BvD

granisetron hcl tab 1 mg Tier 2 QL (2 PER 1 DAYS) BvD

ondansetron (tab 4 mg tab 8mg)

Tier 2 QL (3 PER 1 DAYS) BvD

ondansetron hcl (24 mg tab tab24 mg)

Tier 2 QL (15 PER 30 OVERTIME) BvD

ondansetron hcl (tab 4 mg tab 8mg)


ondansetron hcl oral soln 4mg5ml


ANTIFUNGALS



ANTIFUNGALSABELCET 5 MGML SUSPENSION Tier 3 BvD

AMBISOME 50 MG RECON SUSP Tier 3 BvD

AMPHOTERICIN B 50 MG RECONSOLN

Tier 2 BvD


22

ANTIFUNGALS



caspofungin acetate (50 mgrecon soln 70 mg recon soln foriv soln 50 mg for iv soln 70 mg)

Tier 2 PA

ciclopirox olamine (cream 077(base equiv) susp 077 (baseequiv))

Tier 2

clotrimazole (topical) (cream 1soln 1)

Tier 2

clotrimazole troche 10 mg Tier 2

CRESEMBA (186 MG CAP 372MG RECON SOLN)

Tier 3 PA

econazole nitrate cream 1 Tier 2

fluconazole (for susp 10 mgmlfor susp 40 mgml tab 100 mgtab 150 mg tab 200 mg tab 50mg)

Tier 2

fluconazole in dextrose (inj 200mg100ml inj 400 mg200ml)

Tier 2

fluconazole in nacl (inj 200mg100ml inj 400 mg200ml)

Tier 2

flucytosine (cap 250 mg cap 500mg)

Tier 2

griseofulvin microsize (susp 125mg5ml tab 500 mg)

Tier 2

griseofulvin ultramicrosize (tab125 mg tab 250 mg)

Tier 2

itraconazole cap 100 mg Tier 2 PA

ketoconazole (topical) (cream2 shampoo 2)

Tier 2

ketoconazole tab 200 mg Tier 2

micafungin sodium (soln 100 mgsoln 50 mg)

Tier 2

MICONAZOLE 3 200 MG SUPPOS Tier 2

NOXAFIL 40 MGML SUSPENSION Tier 3 PA

nystatin (topical) (cream 100000unitgm oint 100000 unitgmtopical powder 100000 unitgm)

Tier 2


23

ANTIFUNGALS



nystatin susp 100000 unitml Tier 2

nystatin tab 500000 unit Tier 2

posaconazole tab delayedrelease 100 mg


terbinafine hcl tab 250 mg Tier 2 QL (1 PER 1 DAYS)

terconazole vaginal (cream04 cream 08 suppos 80 mg)

Tier 2

voriconazole (for susp 40 mgmltab 200 mg tab 50 mg)

Tier 2 PA

voriconazole for inj 200 mg Tier 2 BvD

ANTIGOUT AGENTS



ANTIGOUT AGENTSallopurinol (tab 100 mg tab 300mg)

Tier 2

colchicine (06 mg cap tab 06mg)


colchicine w probenecid tab05-500 mg

Tier 2

COLCRYS 06 MG TAB Tier 3 QL (4 PER 1 DAYS)

KRYSTEXXA 8 MGML SOLUTION Tier 3 PA LA

probenecid tab 500 mg Tier 2

ANTIMIGRAINE AGENTS



ANTIMIGRAINE AGENTS OTHERUBRELVY (100 MG TAB 50 MGTAB)



24

ANTIMIGRAINE AGENTS



ERGOT ALKALOIDSdihydroergotamine mesylate inj 1mgml

Tier 2 PA

dihydroergotamine mesylatenasal spray 4 mgml


MIGERGOT 2-100 MG SUPPOS Tier 3 QL (20 PER 30 OVERTIME)

PROPHYLACTICAIMOVIG (140 MG DOSE) 70MGML SOLN A-INJ


AIMOVIG (140 MGML SOLN A-INJ 70 MGML SOLN A-INJ)


timolol maleate (10 mg tab tab10 mg tab 20 mg tab 5 mg)

Tier 2

SEROTONIN (5-HT) RECEPTOR AGONISTnaratriptan hcl (tab 1 mg (baseequiv) tab 25 mg (base equiv))


rizatriptan benzoate (oraldisintegrating tab 10 mg (baseeq) oral disintegrating tab 5 mg(base eq) tab 10 mg (baseequivalent) tab 5 mg (baseequivalent))


sumatriptan (20 mgact 5mgact)


sumatriptan succinate (6mg05ml soln prsyr inj 6mg05ml solution auto-injector 4mg05ml solution auto-injector 6mg05ml solution cartridge 4mg05ml solution cartridge 6mg05ml)


sumatriptan succinate (tab 100mg tab 25 mg tab 50 mg)


zolmitriptan (orally disintegratingtab 25 mg orally disintegratingtab 5 mg tab 25 mg tab 5 mg)



25

ANTIMYASTHENIC AGENTS



PARASYMPATHOMIMETICSGUANIDINE HCL 125 MG TAB Tier 2

pyridostigmine bromide tab 60mg


ANTIMYCOBACTERIALS



ANTIMYCOBACTERIALS OTHERdapsone (tab 100 mg tab 25mg)

Tier 2

rifabutin cap 150 mg Tier 2

ANTITUBERCULARSCAPASTAT SULFATE 1 GM RECONSOLN

Tier 3

ethambutol hcl (tab 100 mg tab400 mg)

Tier 2

isoniazid (100 mg tab 100 mgmlsolution 50 mg5ml syrup tab100 mg tab 300 mg)

Tier 2

PASER 4 GM PACKET Tier 3

PRIFTIN 150 MG TAB Tier 3

pyrazinamide tab 500 mg Tier 2

rifampin (cap 150 mg cap 300mg for inj 600 mg)

Tier 2

RIFATER 50-120-300 MG TAB Tier 3

SIRTURO 100 MG TAB Tier 3 PA QL (24 PER 28 OVERTIME)

SIRTURO 20 MG TAB Tier 3 PA QL (120 PER 28OVER TIME)

TRECATOR 250 MG TAB Tier 3


26

ANTINEOPLASTICS



ALKYLATING AGENTScyclophosphamide (25 mg cap25 mg tab 50 mg cap 50 mgtab cap 25 mg cap 50 mg)

Tier 3 BvD

GLEOSTINE (10 MG CAP 100 MGCAP 40 MG CAP 5 MG CAP)

Tier 3

LEUKERAN 2 MG TAB Tier 3

MATULANE 50 MG CAP Tier 3 LA

thiotepa (inj 100 mg inj 15 mg) Tier 2 BvD

VALCHLOR 0016 GEL Tier 3 PA LA QL (60 PER 30OVER TIME)

ANTIANDROGENSabiraterone acetate tab 250 mg Tier 2 PA QL (4 PER 1 DAYS)

abiraterone acetate tab 500 mg Tier 2 PA QL (2 PER 1 DAYS)

bicalutamide tab 50 mg Tier 2

ERLEADA 60 MG TAB Tier 3 PA LA QL (4 PER 1DAYS)

flutamide (125 mg cap cap 125mg)

Tier 2

nilutamide tab 150 mg Tier 2 QL (1 PER 1 DAYS)

NUBEQA 300 MG TAB Tier 3 PA QL (4 PER 1 DAYS)

XTANDI (40 MG CAP 40 MG TAB) Tier 3 PA LA QL (4 PER 1DAYS)

XTANDI 80 MG TAB Tier 3 PA LA QL (2 PER 1DAYS)

ANTIANGIOGENIC AGENTSPOMALYST (1 MG CAP 2 MGCAP 3 MG CAP 4 MG CAP)


REVLIMID (10 MG CAP 15 MGCAP 25 MG CAP 20 MG CAP25 MG CAP 5 MG CAP)


THALOMID (100 MG CAP 50 MGCAP)



27

ANTINEOPLASTICS





ANTIESTROGENSMODIFIERSEMCYT 140 MG CAP Tier 3

fulvestrant (250 mg5ml solutioninj 250 mg5ml)

Tier 2

SOLTAMOX 10 MG5ML SOLUTION Tier 3 PA

tamoxifen citrate (tab 10 mg(base equivalent) tab 20 mg(base equivalent))

Tier 2

toremifene citrate tab 60 mg(base equivalent)

Tier 2

ANTIMETABOLITESDROXIA (200 MG CAP 300 MGCAP 400 MG CAP)

Tier 3

hydroxyurea cap 500 mg Tier 2

INQOVI 35-100 MG TAB Tier 3 PA LA QL (5 PER 28OVER TIME)

mercaptopurine tab 50 mg Tier 2

PURIXAN 2000 MG100MLSUSPENSION

Tier 3 PA LA

TABLOID 40 MG TAB Tier 3

ANTINEOPLASTICS OTHERAYVAKIT (100 MG TAB 200 MGTAB 25 MG TAB 300 MG TAB 50MG TAB)


BRUKINSA 80 MG CAP Tier 3 PA LA QL (4 PER 1DAYS)

FOTIVDA (089 MG CAP 134 MGCAP)

Tier 3 PA LA QL (21 PER 28OVER TIME)

IDHIFA (100 MG TAB 50 MG TAB) Tier 3 PA LA QL (1 PER 1DAYS)

INREBIC 100 MG CAP Tier 3 PA QL (4 PER 1 DAYS)


28

ANTINEOPLASTICS



KISQALI FEMARA (400 MG DOSE)200 amp 25 MG TAB THPK




KISQALI FEMARA(200 MG DOSE)200 amp 25 MG TAB THPK


KOSELUGO 10 MG CAP Tier 3 PA LA QL (8 PER 1DAYS)


leucovorin calcium (for inj 100mg for inj 350 mg tab 10 mgtab 15 mg tab 25 mg tab 5 mg)

Tier 2

LONSURF 15-614 MG TAB Tier 3 PA LA QL (100 PER 28OVER TIME)


LUMAKRAS 120 MG TAB Tier 3 PA QL (8 PER 1 DAYS)

LYSODREN 500 MG TAB Tier 3

NINLARO (23 MG CAP 3 MGCAP 4 MG CAP)


ONUREG (200 MG TAB 300 MGTAB)


QINLOCK 50 MG TAB Tier 3 PA LA QL (3 PER 1DAYS)

RETEVMO 40 MG CAP Tier 3 PA QL (6 PER 1 DAYS)


ROZLYTREK 100 MG CAP Tier 3 PA QL (5 PER 1 DAYS)


SYNRIBO 35 MG RECON SOLN Tier 3 BvD

TABRECTA (150 MG TAB 200 MGTAB)


TAZVERIK 200 MG TAB Tier 3 PA LA QL (8 PER 1DAYS)


29

ANTINEOPLASTICS



XPOVIO (100 MG ONCE WEEKLY)20 MG TAB THPK








XPOVIO (40 MG TWICE WEEKLY)20 MG TAB THPK
















ZOLINZA 100 MG CAP Tier 3 PA QL (4 PER 1 DAYS)

AROMATASE INHIBITORS 3RD GENERATIONanastrozole tab 1 mg Tier 2

exemestane tab 25 mg Tier 2

letrozole tab 25 mg Tier 2

MOLECULAR TARGET INHIBITORSAFINITOR 10 MG TAB Tier 3 PA QL (2 PER 1 DAYS)

AFINITOR DISPERZ 2 MG TAB SOL Tier 3 PA QL (2 PER 1 DAYS)



30

ANTINEOPLASTICS




ALECENSA 150 MG CAP Tier 3 PA LA QL (8 PER 1DAYS)

ALUNBRIG (180 MG TAB 90 MGTAB)


ALUNBRIG 30 MG TAB Tier 3 PA LA QL (2 PER 1DAYS)

ALUNBRIG 90 amp 180 MG TAB THPK Tier 3 PA LA QL (30 PER 30OVER TIME)

BALVERSA 3 MG TAB Tier 3 PA LA QL (3 PER 1DAYS)



BOSULIF (400 MG TAB 500 MGTAB)


BOSULIF 100 MG TAB Tier 3 PA QL (4 PER 1 DAYS)

BRAFTOVI 50 MG CAP Tier 3 PA LA QL (4 PER 1DAYS)


CABOMETYX (20 MG TAB 40 MGTAB 60 MG TAB)


CALQUENCE 100 MG CAP Tier 3 PA LA QL (2 PER 1DAYS)

CAPRELSA 100 MG TAB Tier 3 PA LA QL (2 PER 1DAYS)


COMETRIQ (100 MG DAILY DOSE)80 amp 20 MG KIT


COMETRIQ (140 MG DAILY DOSE)3 X 20 MG amp 80 MG KIT


COMETRIQ (60 MG DAILY DOSE)20 MG KIT



31

ANTINEOPLASTICS



COPIKTRA (15 MG CAP 25 MGCAP)


COTELLIC 20 MG TAB Tier 3 PA LA QL (63 PER 28OVER TIME)

DAURISMO 100 MG TAB Tier 3 PA LA QL (1 PER 1DAYS)


ERIVEDGE 150 MG CAP Tier 3 PA LA QL (1 PER 1DAYS)

erlotinib hcl (tab 100 mg (baseequivalent) tab 150 mg (baseequivalent))


erlotinib hcl tab 25 mg (baseequivalent)


everolimus (tab 10 mg tab 75mg tab for oral susp 2 mg)




everolimus tab for oral susp 3 mg Tier 2 PA QL (4 PER 1 DAYS)

FARYDAK (10 MG CAP 15 MGCAP 20 MG CAP)


GAVRETO 100 MG CAP Tier 3 PA LA QL (4 PER 1DAYS)

GILOTRIF (20 MG TAB 30 MG TAB40 MG TAB)


IBRANCE (100 MG CAP 100 MGTAB 125 MG CAP 125 MG TAB75 MG CAP 75 MG TAB)


ICLUSIG (10 MG TAB 15 MG TAB30 MG TAB 45 MG TAB)


imatinib mesylate tab 100 mg(base equivalent)




IMBRUVICA (280 MG TAB 420 MGTAB 560 MG TAB 70 MG CAP)



32

ANTINEOPLASTICS



IMBRUVICA 140 MG CAP Tier 3 PA LA QL (4 PER 1DAYS)

INLYTA 1 MG TAB Tier 3 PA LA QL (6 PER 1DAYS)


IRESSA 250 MG TAB Tier 3 PA LA QL (2 PER 1DAYS)

JAKAFI (10 MG TAB 15 MG TAB20 MG TAB 25 MG TAB 5 MGTAB)


KISQALI (200 MG DOSE) 200 MGTAB THPK






lapatinib ditosylate tab 250 mg(base equiv)


LENVIMA (10 MG DAILY DOSE) 10MG CAP THPK


LENVIMA (12 MG DAILY DOSE) 3 X4 MG CAP THPK


LENVIMA (14 MG DAILY DOSE) 10amp 4 MG CAP THPK


LENVIMA (18 MG DAILY DOSE) 10MG amp 2 X 4 MG CAP THPK




LENVIMA (24 MG DAILY DOSE) 2 X10 MG amp 4 MG CAP THPK






LORBRENA 100 MG TAB Tier 3 PA LA QL (1 PER 1DAYS)


33

ANTINEOPLASTICS




LYNPARZA (100 MG TAB 150 MGTAB)


MEKINIST 05 MG TAB Tier 3 PA LA QL (3 PER 1DAYS)


MEKTOVI 15 MG TAB Tier 3 PA LA QL (6 PER 1DAYS)

NERLYNX 40 MG TAB Tier 3 PA LA QL (6 PER 1DAYS)

NEXAVAR 200 MG TAB Tier 3 PA LA QL (4 PER 1DAYS)

ODOMZO 200 MG CAP Tier 3 PA LA QL (1 PER 1DAYS)

PEMAZYRE (135 MG TAB 45 MGTAB 9 MG TAB)


PIQRAY (200 MG DAILY DOSE)200 MG TAB THPK


PIQRAY (250 MG DAILY DOSE)200 amp 50 MG TAB THPK


PIQRAY (300 MG DAILY DOSE) 2 X150 MG TAB THPK


RUBRACA (200 MG TAB 250 MGTAB 300 MG TAB)


RYDAPT 25 MG CAP Tier 3 PA QL (8 PER 1 DAYS)

SPRYCEL (100 MG TAB 140 MGTAB)


SPRYCEL (70 MG TAB 80 MG TAB) Tier 3 PA QL (2 PER 1 DAYS)

SPRYCEL 20 MG TAB Tier 3 PA QL (6 PER 1 DAYS)


STIVARGA 40 MG TAB Tier 3 PA LA QL (4 PER 1DAYS)

sunitinib malate (cap 375 mg(base equivalent) cap 50 mg(base equivalent))



34

ANTINEOPLASTICS



sunitinib malate cap 125 mg(base equivalent)


sunitinib malate cap 25 mg (baseequivalent)


TAFINLAR (50 MG CAP 75 MGCAP)


TAGRISSO (40 MG TAB 80 MGTAB)


TALZENNA 025 MG CAP Tier 3 PA LA QL (3 PER 1DAYS)


TASIGNA (150 MG CAP 200 MGCAP 50 MG CAP)


TEPMETKO 225 MG TAB Tier 3 PA LA QL (2 PER 1DAYS)

TIBSOVO 250 MG TAB Tier 3 PA LA QL (2 PER 1DAYS)

TRUSELTIQ (100MG DAILY DOSE)100 MG CAP THPK


TRUSELTIQ (125MG DAILY DOSE)100 amp 25 MG CAP THPK


TRUSELTIQ (50MG DAILY DOSE) 25MG CAP THPK




TUKYSA (150 MG TAB 50 MG TAB) Tier 3 PA LA QL (4 PER 1DAYS)

TURALIO 200 MG CAP Tier 3 PA LA QL (4 PER 1DAYS)

UKONIQ 200 MG TAB Tier 3 PA LA QL (4 PER 1DAYS)

VENCLEXTA 10 MG TAB Tier 3 PA LA QL (2 PER 1DAYS)



35

ANTINEOPLASTICS




VENCLEXTA STARTING PACK 10 amp50 amp 100 MG TAB THPK


VERZENIO (100 MG TAB 150 MGTAB 200 MG TAB 50 MG TAB)


VITRAKVI 100 MG CAP Tier 3 PA LA QL (2 PER 1DAYS)

VITRAKVI 20 MGML SOLUTION Tier 3 PA LA QL (10 PER 1DAYS)


VIZIMPRO (15 MG TAB 30 MGTAB 45 MG TAB)


VOTRIENT 200 MG TAB Tier 3 PA LA QL (4 PER 1DAYS)

XALKORI (200 MG CAP 250 MGCAP)


XOSPATA 40 MG TAB Tier 3 PA LA QL (3 PER 1DAYS)

ZEJULA 100 MG CAP Tier 3 PA LA QL (3 PER 1DAYS)

ZELBORAF 240 MG TAB Tier 3 PA LA QL (8 PER 1DAYS)

ZYDELIG (100 MG TAB 150 MGTAB)


ZYKADIA (150 MG CAP 150 MGTAB)


RETINOIDSbexarotene cap 75 mg Tier 2 PA QL (10 PER 1 DAYS)

PANRETIN 01 GEL Tier 3 PA

TARGRETIN 1 GEL Tier 3 PA QL (60 PER 30 OVERTIME)

tretinoin cap 10 mg Tier 2


36

ANTINEOPLASTICS



TREATMENT ADJUNCTSmesna inj 100 mgml Tier 2

MESNEX 400 MG TAB Tier 3

ANTIPARASITICS



ANTHELMINTHICSalbendazole tab 200 mg Tier 2

ivermectin tab 3 mg Tier 2

praziquantel tab 600 mg Tier 2

ANTIPROTOZOALSALINIA 100 MG5ML RECON SUSP Tier 3 PA QL (180 PER 3 OVER

TIME)

atovaquone susp 750 mg5ml Tier 2 PA

atovaquone-proguanil hcl (tab250-100 mg tab 625-25 mg)

Tier 2

BENZNIDAZOLE 100 MG TAB Tier 3 QL (240 PER 365 OVERTIME)


chloroquine phosphate (500 mgtab tab 500 mg)


chloroquine phosphate tab 250mg


COARTEM 20-120 MG TAB Tier 3 QL (24 PER 2 OVER TIME)

hydroxychloroquine sulfate tab200 mg


mefloquine hcl tab 250 mg Tier 2

nitazoxanide tab 500 mg Tier 2 PA QL (6 PER 3 OVERTIME)


37

ANTIPARASITICS



pentamidine isethionate fornebulization soln 300 mg

Tier 2 BvD

pentamidine isethionate for soln300 mg

Tier 2

primaquine phosphate (263 (15base) mg tab tab 263 mg (15mg base))

Tier 3

pyrimethamine tab 25 mg Tier 2 PA

quinine sulfate cap 324 mg Tier 2 PA QL (6 PER 1 DAYS)

ANTIPARKINSON AGENTS



ANTICHOLINERGICSbenztropine mesylate (inj 1mgml tab 05 mg tab 1 mg tab2 mg)

Tier 2

trihexyphenidyl hcl (oral soln 04mgml tab 2 mg tab 5 mg)

Tier 2

ANTIPARKINSON AGENTS OTHERamantadine hcl (cap 100 mgsoln 50 mg5ml syrup 50 mg5mltab 100 mg)

Tier 2

CARBIDOPA-LEVODOPA-ENTACAPONE (125-50-200 MGTAB 1875-75-200 MG TAB 25-100-200 MG TAB 3125-125-200MG TAB 375-150-200 MG TAB50-200-200 MG TAB)

Tier 2

entacapone tab 200 mg Tier 2 QL (8 PER 1 DAYS)

DOPAMINE AGONISTSAPOKYN 30 MG3ML SOLN CART Tier 3 PA LA

bromocriptine mesylate (cap 5mg (base equivalent) tab 25mg (base equivalent))

Tier 2


38




pramipexole dihydrochloride(tab 0125 mg tab 025 mg tab05 mg tab 075 mg tab 1 mgtab 15 mg)

Tier 2

ropinirole hydrochloride (tab 025mg tab 05 mg tab 1 mg tab 2mg tab 3 mg tab 4 mg tab 5mg)

Tier 2

DOPAMINE PRECURSORS ANDOR L-AMINO ACID DECARBOXYLASEINHIBITORScarbidopa tab 25 mg Tier 2

CARBIDOPA-LEVODOPA(CARBIDOPA amp LEVODOPAORALLY DISINTEGRATING TAB 10-100 MG CARBIDOPA ampLEVODOPA ORALLYDISINTEGRATING TAB 25-100 MGCARBIDOPA amp LEVODOPAORALLY DISINTEGRATING TAB 25-250 MG CARBIDOPA ampLEVODOPA TAB 10-100 MGCARBIDOPA amp LEVODOPA TAB25-100 MG CARBIDOPA ampLEVODOPA TAB 25-250 MGCARBIDOPA amp LEVODOPA TAB ER25-100 MG CARBIDOPA ampLEVODOPA TAB ER 50-200 MGCARBIDOPA-LEVODOPA 10-100MG TAB DISP CARBIDOPA-LEVODOPA 25-100 MG TAB DISPCARBIDOPA-LEVODOPA 25-250MG TAB DISP)

Tier 2

MONOAMINE OXIDASE B (MAO-B) INHIBITORSrasagiline mesylate (tab 05 mg(base equiv) tab 1 mg (baseequiv))


selegiline hcl (5 mg tab cap 5mg tab 5 mg)

Tier 2


39

ANTIPSYCHOTICS



1ST GENERATIONTYPICALchlorpromazine hcl (100 mgmlconc 30 mgml conc 50 mg2mlsolution inj 25 mgml tab 10 mgtab 100 mg tab 200 mg tab 25mg tab 50 mg)

Tier 2

fluphenazine decanoate inj 25mgml

Tier 2

fluphenazine hcl (25 mg5mlelixir 25 mgml solution 5 mgmlconc tab 1 mg tab 10 mg tab25 mg tab 5 mg)

Tier 2

haloperidol (tab 05 mg tab 1mg tab 10 mg tab 2 mg tab 20mg tab 5 mg)

Tier 2

haloperidol decanoate (soln 100mgml soln 50 mgml)

Tier 2

haloperidol lactate (inj 5 mgmloral conc 2 mgml)

Tier 2

loxapine succinate (cap 10 mgcap 25 mg cap 5 mg cap 50mg)

Tier 2

MOLINDONE HCL 10 MG TAB Tier 2 QL (8 PER 1 DAYS)



PIMOZIDE (1 MG TAB 2 MG TAB) Tier 2

thioridazine hcl (tab 10 mg tab100 mg tab 25 mg tab 50 mg)

Tier 2 PA

thiothixene (cap 1 mg cap 10mg cap 2 mg cap 5 mg)

Tier 2

trifluoperazine hcl (tab 1 mg(base equivalent) tab 10 mg(base equivalent) tab 2 mg(base equivalent) tab 5 mg(base equivalent))

Tier 2


40

ANTIPSYCHOTICS



2ND GENERATIONATYPICALABILIFY MAINTENA (300 MGPRSYR 300 MG SRER 400 MGPRSYR 400 MG SRER)

Tier 3 PA

aripiprazole (orally disintegratingtab 10 mg orally disintegratingtab 15 mg tab 5 mg)


aripiprazole (tab 10 mg tab 15mg tab 20 mg tab 30 mg)


aripiprazole oral solution 1 mgml Tier 2 QL (25 PER 1 DAYS)

aripiprazole tab 2 mg Tier 2 QL (4 PER 1 DAYS)

ARISTADA (1064 MG39MLPRSYR 441 MG16ML PRSYR 662MG24ML PRSYR 882 MG32MLPRSYR)

Tier 3 PA

ARISTADA INITIO 675 MG24MLPRSYR


asenapine maleate (sl tab 10 mg(base equiv) sl tab 25 mg (baseequiv) sl tab 5 mg (base equiv))


CAPLYTA 42 MG CAP Tier 3 PA QL (1 PER 1 DAYS)

FANAPT (1 MG TAB 10 MG TAB12 MG TAB 2 MG TAB 4 MG TAB6 MG TAB 8 MG TAB)


FANAPT TITRATION PACK 1 amp 2 amp4 amp 6 MG TAB


INVEGA SUSTENNA 117MG075ML SUSP PRSYR

Tier 3 PA QL (075 PER 28OVER TIME)

INVEGA SUSTENNA 156 MGMLSUSP PRSYR


INVEGA SUSTENNA 234 MG15MLSUSP PRSYR







41

ANTIPSYCHOTICS



INVEGA TRINZA 273 MG0875MLSUSP PRSYR








LATUDA (120 MG TAB 80 MGTAB)


LATUDA (20 MG TAB 40 MG TAB60 MG TAB)


NUPLAZID (10 MG TAB 34 MGCAP)


NUPLAZID 17 MG TAB Tier 3 PA LA QL (2 PER 1DAYS)

olanzapine (for im inj 10 mgorally disintegrating tab 10 mgorally disintegrating tab 15 mgorally disintegrating tab 20 mgorally disintegrating tab 5 mgtab 10 mg tab 15 mg tab 25mg tab 20 mg tab 5 mg tab 75mg)

Tier 2

paliperidone (tab er 24hr 15 mgtab er 24hr 3 mg tab er 24hr 9mg)


paliperidone tab er 24hr 6 mg Tier 2 PA QL (2 PER 1 DAYS)

PERSERIS (120 MG PRSYR 90 MGPRSYR)


quetiapine fumarate (tab 100mg tab 200 mg tab 25 mg tab300 mg tab 400 mg tab 50 mgtab er 24hr 150 mg tab er 24hr200 mg tab er 24hr 300 mg taber 24hr 400 mg tab er 24hr 50mg)

Tier 2

REXULTI (025 MG TAB 05 MGTAB 1 MG TAB 2 MG TAB 3 MGTAB 4 MG TAB)



42

ANTIPSYCHOTICS



RISPERDAL CONSTA (125 MGSRER 25 MG SRER 375 MG SRER50 MG SRER)

Tier 3

risperidone (025 mg tab disporally disintegrating tab 025 mgorally disintegrating tab 05 mgorally disintegrating tab 1 mgorally disintegrating tab 2 mgorally disintegrating tab 3 mgorally disintegrating tab 4 mgsoln 1 mgml tab 025 mg tab05 mg tab 1 mg tab 2 mg tab3 mg tab 4 mg)

Tier 2

SECUADO (38 MG24HR PATCH24HR 57 MG24HR PATCH 24HR76 MG24HR PATCH 24HR)


VRAYLAR (15 MG CAP 3 MGCAP 45 MG CAP 6 MG CAP)


VRAYLAR 15 amp 3 MG CAP THPK Tier 3 PA QL (7 PER 30 OVERTIME)

ziprasidone hcl (cap 20 mg cap40 mg cap 60 mg cap 80 mg)

Tier 2

ziprasidone mesylate for inj 20 mg(base equivalent)

Tier 2

ZYPREXA RELPREVV (210 MGRECON SUSP 300 MG RECONSUSP 405 MG RECON SUSP)

Tier 3 PA

TREATMENT-RESISTANTclozapine (125 mg tab disp 150mg tab disp 200 mg tab disporally disintegrating tab 100 mgorally disintegrating tab 25 mgtab 100 mg tab 200 mg tab 25mg tab 50 mg)

Tier 2

VERSACLOZ 50 MGMLSUSPENSION



43

ANTISPASTICITY AGENTS



ANTISPASTICITY AGENTSbaclofen tab 10 mg Tier 2 QL (8 PER 1 DAYS)

baclofen tab 20 mg Tier 2 QL (4 PER 1 DAYS)


dantrolene sodium (cap 100 mgcap 25 mg cap 50 mg)

Tier 2

tizanidine hcl (tab 2 mg (baseequivalent) tab 4 mg (baseequivalent))

Tier 2

ANTIVIRALS



ANTI-CYTOMEGALOVIRUS (CMV) AGENTSPREVYMIS 240 MG TAB Tier 3 QL (200 PER 365 OVER

TIME)

PREVYMIS 480 MG TAB Tier 3 QL (100 PER 365 OVERTIME)

valganciclovir hcl for soln 50mgml (base equiv)


valganciclovir hcl tab 450 mg(base equivalent)


ZIRGAN 015 GEL Tier 3 QL (5 PER 30 OVER TIME)

ANTI-HEPATITIS B (HBV) AGENTSadefovir dipivoxil tab 10 mg Tier 2 QL (1 PER 1 DAYS)

BARACLUDE 005 MGMLSOLUTION


entecavir (tab 05 mg tab 1 mg) Tier 2 QL (1 PER 1 DAYS)

EPIVIR HBV 5 MGML SOLUTION Tier 3

lamivudine tab 100 mg (hbv) Tier 2

VEMLIDY 25 MG TAB Tier 3 QL (1 PER 1 DAYS)


44

ANTIVIRALS



ANTI-HEPATITIS C (HCV) AGENTSEPCLUSA (200-50 MG TAB 400-100 MG TAB)


HARVONI (3375-150 MG PACKET45-200 MG TAB 90-400 MG TAB)


HARVONI 45-200 MG PACKET Tier 3 PA QL (2 PER 1 DAYS)

LEDIPASVIR-SOFOSBUVIR 90-400MG TAB


MAVYRET 100-40 MG TAB Tier 3 PA QL (3 PER 1 DAYS)

ribavirin (hepatitis c) (cap 200mg tab 200 mg)

Tier 2

SOFOSBUVIR-VELPATASVIR 400-100 MG TAB


VOSEVI 400-100-100 MG TAB Tier 3 PA QL (1 PER 1 DAYS)

ANTI-HIV AGENTS INTEGRASE INHIBITORS (INSTI)BIKTARVY 50-200-25 MG TAB Tier 3 QL (1 PER 1 DAYS)

DOVATO 50-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

GENVOYA 150-150-200-10 MGTAB


ISENTRESS (100 MG CHEW TAB 25MG CHEW TAB)


ISENTRESS 100 MG PACKET Tier 3 QL (2 PER 1 DAYS)

ISENTRESS 400 MG TAB Tier 3 QL (4 PER 1 DAYS)

ISENTRESS HD 600 MG TAB Tier 3 QL (2 PER 1 DAYS)

JULUCA 50-25 MG TAB Tier 3 QL (1 PER 1 DAYS)

STRIBILD 150-150-200-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

TIVICAY (10 MG TAB 25 MG TAB50 MG TAB)


TIVICAY PD 5 MG TAB SOL Tier 3 QL (6 PER 1 DAYS)

ANTI-HIV AGENTS NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS(NNRTI)COMPLERA 200-25-300 MG TAB Tier 3 QL (1 PER 1 DAYS)


45

ANTIVIRALS



DELSTRIGO 100-300-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

EDURANT 25 MG TAB Tier 3 QL (2 PER 1 DAYS)

efavirenz cap 200 mg Tier 2 QL (3 PER 1 DAYS)


efavirenz tab 600 mg Tier 2 QL (1 PER 1 DAYS)

efavirenz-emtricitabine-tenofovirdf tab 600-200-300 mg


efavirenz-lamivudine-tenofovirdisoproxil fumarate (tab 400-300-300 mg tab 600-300-300 mg)


etravirine tab 100 mg Tier 2 QL (4 PER 1 DAYS)


INTELENCE 25 MG TAB Tier 3 QL (12 PER 1 DAYS)

NEVIRAPINE 50 MG5MLSUSPENSION


NEVIRAPINE ER 100 MG TAB ER24H


nevirapine tab 200 mg Tier 2 QL (2 PER 1 DAYS)

nevirapine tab er 24hr 100 mg Tier 2 QL (3 PER 1 DAYS)


ODEFSEY 200-25-25 MG TAB Tier 3 QL (1 PER 1 DAYS)

PIFELTRO 100 MG TAB Tier 3 QL (2 PER 1 DAYS)

RESCRIPTOR 100 MG TAB Tier 3 QL (12 PER 1 DAYS)


ANTI-HIV AGENTS NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASEINHIBITORS (NRTI)abacavir sulfate soln 20 mgml(base equiv)


abacavir sulfate tab 300 mg(base equiv)


abacavir sulfate-lamivudine tab600-300 mg



46

ANTIVIRALS



abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg


CIMDUO 300-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

DESCOVY 200-25 MG TAB Tier 3 QL (1 PER 1 DAYS)

didanosine (200 mg cap dr 250mg cap dr 400 mg cap drdelayed release capsule 200 mgdelayed release capsule 250 mgdelayed release capsule 400 mg)


emtricitabine caps 200 mg Tier 2 QL (1 PER 1 DAYS)

emtricitabine-tenofovir disoproxilfumarate (tab 100-150 mg tab133-200 mg tab 167-250 mg tab200-300 mg)


EMTRIVA 10 MGML SOLUTION Tier 3 QL (24 PER 1 DAYS)

lamivudine oral soln 10 mgml Tier 2 QL (30 PER 1 DAYS)

lamivudine tab 150 mg Tier 2 QL (2 PER 1 DAYS)


lamivudine-zidovudine tab 150-300 mg


stavudine (15 mg cap 20 mgcap 30 mg cap 40 mg capcap 15 mg cap 20 mg cap 30mg cap 40 mg)


TEMIXYS 300-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

tenofovir disoproxil fumarate tab300 mg


TRIUMEQ 600-50-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

VIDEX 2 GM RECON SOLN Tier 3

VIDEX EC 125 MG CAP DR Tier 3 QL (1 PER 1 DAYS)

VIREAD (200 MG TAB 250 MGTAB)


VIREAD 150 MG TAB Tier 3 QL (2 PER 1 DAYS)

VIREAD 40 MGGM POWDER Tier 3 QL (240 PER 30 OVERTIME)


47

ANTIVIRALS



ZERIT 1 MGML RECON SOLN Tier 3 QL (80 PER 1 DAYS)

zidovudine cap 100 mg Tier 2 QL (6 PER 1 DAYS)

zidovudine syrup 10 mgml Tier 2 QL (60 PER 1 DAYS)

zidovudine tab 300 mg Tier 2 QL (2 PER 1 DAYS)

ANTI-HIV AGENTS OTHERCABENUVA 400 amp 600 MG2MLSUSP


CABENUVA 600 amp 900 MG3MLSUSP


FUZEON 90 MG RECON SOLN Tier 3 QL (60 PER 30 OVERTIME)

RUKOBIA 600 MG TAB ER 12H Tier 3 QL (2 PER 1 DAYS)

SELZENTRY (150 MG TAB 75 MGTAB)


SELZENTRY 20 MGML SOLUTION Tier 3 QL (60 PER 1 DAYS)

SELZENTRY 25 MG TAB Tier 3 QL (8 PER 1 DAYS)


TYBOST 150 MG TAB Tier 3 QL (1 PER 1 DAYS)

ANTI-HIV AGENTS PROTEASE INHIBITORS (PI)APTIVUS 100 MGML SOLUTION Tier 3 QL (10 PER 1 DAYS)

APTIVUS 250 MG CAP Tier 3 QL (4 PER 1 DAYS)

atazanavir sulfate (cap 150 mg(base equiv) cap 200 mg (baseequiv))


atazanavir sulfate cap 300 mg(base equiv)


CRIXIVAN 200 MG CAP Tier 3 QL (9 PER 1 DAYS)


EVOTAZ 300-150 MG TAB Tier 3 QL (1 PER 1 DAYS)

fosamprenavir calcium tab 700mg (base equiv)


INVIRASE 200 MG CAP Tier 3 QL (10 PER 1 DAYS)


48

ANTIVIRALS



INVIRASE 500 MG TAB Tier 3 QL (4 PER 1 DAYS)

LEXIVA 50 MGML SUSPENSION Tier 3 QL (56 PER 1 DAYS)

lopinavir-ritonavir soln 400-100mg5ml (80-20 mgml)


lopinavir-ritonavir tab 100-25 mg Tier 2 QL (10 PER 1 DAYS)


NORVIR (100 MG CAP 100 MGPACKET)


NORVIR 80 MGML SOLUTION Tier 3 QL (15 PER 1 DAYS)

PREZCOBIX 800-150 MG TAB Tier 3 QL (1 PER 1 DAYS)

PREZISTA 100 MGML SUSPENSION Tier 3 QL (12 PER 1 DAYS)

PREZISTA 150 MG TAB Tier 3 QL (8 PER 1 DAYS)




REYATAZ 50 MG PACKET Tier 3 QL (8 PER 1 DAYS)

ritonavir tab 100 mg Tier 2 QL (12 PER 1 DAYS)

SYMTUZA 800-150-200-10 MG TAB Tier 3 QL (1 PER 1 DAYS)

VIRACEPT 250 MG TAB Tier 3 QL (9 PER 1 DAYS)


ANTI-INFLUENZA AGENTSoseltamivir phosphate cap 30 mg(base equiv)


oseltamivir phosphate cap 45 mg(base equiv)




oseltamivir phosphate for susp 6mgml (base equiv)


RELENZA DISKHALER 5 MGBLISTERAER POW BA



49

ANTIVIRALS



RIMANTADINE HCL 100 MG TAB Tier 2

XOFLUZA (40 MG DOSE) (1 X 40MG TAB THPK 2 X 20 MG TABTHPK)


XOFLUZA (80 MG DOSE) 1 X 80MG TAB THPK




ANTIHERPETIC AGENTSacyclovir (cap 200 mg susp 200mg5ml tab 400 mg tab 800mg)

Tier 2

acyclovir sodium iv soln 50 mgml Tier 2 BvD

famciclovir (tab 125 mg tab 250mg tab 500 mg)

Tier 2

trifluridine (1 solution ophthsoln 1)

Tier 2

valacyclovir hcl (tab 1 gm tab500 mg)

Tier 2

ANXIOLYTICS



ANXIOLYTICS OTHERbuspirone hcl (tab 10 mg tab 15mg tab 30 mg tab 5 mg tab 75mg)

Tier 2

meprobamate (tab 200 mg tab400 mg)

Tier 2 PA

BENZODIAZEPINESalprazolam (tab 025 mg tab 05mg tab 1 mg)


alprazolam tab 2 mg Tier 2 QL (5 PER 1 DAYS)


50

ANXIOLYTICS



chlordiazepoxide hcl cap 10 mg Tier 2 PA QL (30 PER 1 DAYS)



clonazepam (orally disintegratingtab 0125 mg orallydisintegrating tab 025 mg orallydisintegrating tab 05 mg tab 05mg)


clonazepam (orally disintegratingtab 1 mg tab 1 mg)




clorazepate dipotassium tab 15mg






diazepam (conc 5 mgml tab 5mg)


diazepam oral soln 1 mgml Tier 2 QL (60 PER 1 DAYS)

diazepam tab 10 mg Tier 2 QL (6 PER 1 DAYS)


lorazepam (conc 2 mgml tab 2mg)


lorazepam tab 05 mg Tier 2 QL (20 PER 1 DAYS)


BIPOLAR AGENTS



MOOD STABILIZERSLITHIUM 8 MEQ5ML SOLUTION Tier 2


51

BIPOLAR AGENTS



lithium carbonate (150 mg cap300 mg cap 600 mg cap cap150 mg cap 300 mg cap 600mg tab 300 mg tab er 300 mgtab er 450 mg)

Tier 2

BLOOD GLUCOSE REGULATORS



ANTIDIABETIC AGENTSacarbose (tab 100 mg tab 25mg tab 50 mg)

Tier 2

FARXIGA (10 MG TAB 5 MG TAB) Tier 3 QL (1 PER 1 DAYS)

glimepiride (tab 1 mg tab 2 mgtab 4 mg)

Tier 1

glipizide (tab 10 mg tab 5 mgtab er 24hr 10 mg tab er 24hr 25mg tab er 24hr 5 mg)

Tier 1

glipizide-metformin hcl (tab 25-250 mg tab 25-500 mg tab 5-500 mg)

Tier 1

glyburide (tab 125 mg tab 25mg tab 5 mg)

Tier 1 PA

glyburide micronized (tab 15mg tab 3 mg tab 6 mg)

Tier 1 PA

glyburide-metformin (tab 125-250 mg tab 25-500 mg tab 5-500 mg)

Tier 1 PA

GLYXAMBI (10-5 MG TAB 25-5MG TAB)


JANUMET (50-1000 MG TAB 50-500 MG TAB)


JANUMET XR (100-1000 MG TABER 24H 50-500 MG TAB ER 24H)


JANUMET XR 50-1000 MG TAB ER24H



52




JANUVIA (100 MG TAB 25 MGTAB 50 MG TAB)


JARDIANCE (10 MG TAB 25 MGTAB)


JENTADUETO (25-1000 MG TAB25-500 MG TAB 25-850 MG TAB)


JENTADUETO XR 25-1000 MG TABER 24H




metformin hcl (tab 1000 mg tab500 mg tab 850 mg tab er 24hr500 mg tab er 24hr 750 mg)

Tier 1

miglitol (tab 100 mg tab 25 mgtab 50 mg)


nateglinide (tab 120 mg tab 60mg)

Tier 2

OZEMPIC (025 OR 05 MGDOSE)2 MG15ML SOLN PEN


OZEMPIC (1 MGDOSE) (2MG15ML SOLN PEN 4 MG3MLSOLN PEN)


pioglitazone hcl (tab 15 mg(base equiv) tab 30 mg (baseequiv) tab 45 mg (base equiv))

Tier 2

repaglinide (tab 05 mg tab 1mg tab 2 mg)

Tier 2

RYBELSUS (14 MG TAB 3 MG TAB7 MG TAB)


SYNJARDY (125-1000 MG TAB125-500 MG TAB 5-1000 MG TAB5-500 MG TAB)


SYNJARDY XR (10-1000 MG TABER 24H 125-1000 MG TAB ER 24H5-1000 MG TAB ER 24H)


SYNJARDY XR 25-1000 MG TAB ER24H



53




TRADJENTA 5 MG TAB Tier 3 QL (1 PER 1 DAYS)

TRULICITY (075 MG05ML SOLNPEN 15 MG05ML SOLN PEN 3MG05ML SOLN PEN 45MG05ML SOLN PEN)


VICTOZA 18 MG3ML SOLN PEN Tier 3 QL (9 PER 30 OVER TIME)

XIGDUO XR (10-1000 MG TAB ER24H 25-1000 MG TAB ER 24H 5-1000 MG TAB ER 24H)


XIGDUO XR (10-500 MG TAB ER24H 5-500 MG TAB ER 24H)


GLYCEMIC AGENTSBAQSIMI ONE PACK 3 MGDOSEPOWDER


BAQSIMI TWO PACK 3 MGDOSEPOWDER


diazoxide susp 50 mgml Tier 2

GLUCAGEN HYPOKIT 1 MGRECON SOLN


glucagon (rdna) for inj kit 1 mg Tier 3 QL (2 PER 2 OVER TIME)

GLUCAGON EMERGENCY (1 MGKIT 1 MGML RECON SOLN)


INSULINSHUMALOG (100 UNITML SOLNCART 100 UNITML SOLUTION)

Tier 3

HUMALOG JUNIOR KWIKPEN 100UNITML SOLN PEN

Tier 3

HUMALOG KWIKPEN (100 UNITMLSOLN PEN 200 UNITML SOLNPEN)

Tier 3

HUMALOG MIX 5050 (50-50) 100UNITML SUSPENSION

Tier 3

HUMALOG MIX 5050 KWIKPEN(50-50) 100 UNITML SUSP PEN

Tier 3


Tier 3


54





Tier 3

HUMULIN 7030 (70-30) 100UNITML SUSPENSION

Tier 3

HUMULIN 7030 KWIKPEN (70-30)100 UNITML SUSP PEN

Tier 3

HUMULIN N 100 UNITMLSUSPENSION

Tier 3

HUMULIN N KWIKPEN 100 UNITMLSUSP PEN

Tier 3

HUMULIN R 100 UNITMLSOLUTION

Tier 3

HUMULIN R U-500(CONCENTRATED) 500 UNITMLSOLUTION

Tier 3

HUMULIN R U-500 KWIKPEN 500UNITML SOLN PEN

Tier 3

INSULIN LISPRO (1 UNIT DIAL) 100UNITML SOLN PEN

Tier 3

INSULIN LISPRO 100 UNITMLSOLUTION

Tier 3

INSULIN LISPRO JUNIOR KWIKPEN100 UNITML SOLN PEN

Tier 3

INSULIN LISPRO PROT amp LISPRO(75-25) 100 UNITML SUSP PEN

Tier 3

LANTUS 100 UNITML SOLUTION Tier 3 QL (40 PER 30 OVERTIME)

LANTUS SOLOSTAR 100 UNITMLSOLN PEN


LYUMJEV 100 UNITML SOLUTION Tier 3

LYUMJEV KWIKPEN (100 UNITMLSOLN PEN 200 UNITML SOLNPEN)

Tier 3

NOVOLIN 7030 (70-30) 100UNITML SUSPENSION

Tier 3

NOVOLIN 7030 RELION (70-30)100 UNITML SUSPENSION

Tier 3


55




NOVOLIN N 100 UNITMLSUSPENSION

Tier 3

NOVOLIN N RELION 100 UNITMLSUSPENSION

Tier 3

NOVOLIN R 100 UNITMLSOLUTION

Tier 3

NOVOLIN R RELION 100 UNITMLSOLUTION

Tier 3

TOUJEO MAX SOLOSTAR 300UNITML SOLN PEN


TOUJEO SOLOSTAR 300 UNITMLSOLN PEN


BLOOD PRODUCTS AND MODIFIERS



ANTICOAGULANTSELIQUIS (25 MG TAB 5 MG TAB) Tier 3 QL (2 PER 1 DAYS)

ELIQUIS DVTPE STARTER PACK 5MG TAB THPK


enoxaparin sodium (inj 100mgml inj 150 mgml inj 300mg3ml)


enoxaparin sodium (inj 120mg08ml inj 80 mg08ml)


enoxaparin sodium inj 30mg03ml






fondaparinux sodiumsubcutaneous inj 10 mg08ml





56








heparin sodium (porcine) (inj1000 unitml inj 10000 unitml inj20000 unitml inj 5000 unitml)

Tier 2 BvD

PRADAXA (110 MG CAP 150 MGCAP 75 MG CAP)


warfarin sodium (tab 1 mg tab10 mg tab 2 mg tab 25 mg tab3 mg tab 4 mg tab 5 mg tab 6mg tab 75 mg)

Tier 2

XARELTO (10 MG TAB 15 MG TAB20 MG TAB)


XARELTO 25 MG TAB Tier 3 QL (2 PER 1 DAYS)

XARELTO STARTER PACK 15 amp 20MG TAB THPK


ZONTIVITY 208 MG TAB Tier 3 QL (1 PER 1 DAYS)

BLOOD PRODUCTS AND MODIFIERS OTHERanagrelide hcl (cap 05 mg cap1 mg)

Tier 2

ARANESP (ALBUMIN FREE) (10MCG04ML SOLN PRSYR 100MCG05ML SOLN PRSYR 100MCGML SOLUTION 150MCG03ML SOLN PRSYR 200MCG04ML SOLN PRSYR 200MCGML SOLUTION 25MCG042ML SOLN PRSYR 25MCGML SOLUTION 300MCG06ML SOLN PRSYR 300MCGML SOLUTION 40MCG04ML SOLN PRSYR 40MCGML SOLUTION 500MCGML SOLN PRSYR 60MCG03ML SOLN PRSYR 60MCGML SOLUTION)

Tier 3 PA

MOZOBIL 24 MG12ML SOLUTION Tier 3 PA LA


57




PROMACTA (125 MG PACKET125 MG TAB)


PROMACTA (25 MG TAB 50 MGTAB)


PROMACTA 25 MG PACKET Tier 3 PA LA QL (6 PER 1DAYS)

PROMACTA 75 MG TAB Tier 3 PA LA QL (2 PER 1DAYS)

RETACRIT (10000 UNITMLSOLUTION 2000 UNITMLSOLUTION 20000 UNITMLSOLUTION 3000 UNITMLSOLUTION 4000 UNITMLSOLUTION 40000 UNITMLSOLUTION)

Tier 3 PA

ZARXIO (300 MCG05ML SOLNPRSYR 480 MCG08ML SOLNPRSYR)

Tier 3 PA

HEMOSTASIS AGENTStranexamic acid iv soln 1000mg10ml (100 mgml)

Tier 2

tranexamic acid tab 650 mg Tier 2 QL (1 PER 1 DAYS)

PLATELET MODIFYING AGENTSaspirin-dipyridamole cap er 12hr25-200 mg

Tier 2

BRILINTA (60 MG TAB 90 MG TAB) Tier 3 QL (2 PER 1 DAYS)

CABLIVI 11 MG KIT Tier 3 PA LA QL (1 PER 1DAYS)

cilostazol (tab 100 mg tab 50mg)

Tier 2

clopidogrel bisulfate tab 75 mg(base equiv)


dipyridamole (tab 25 mg tab 50mg tab 75 mg)

Tier 2 PA

OXBRYTA 500 MG TAB Tier 3 PA LA QL (5 PER 1DAYS)


58




prasugrel hcl (tab 10 mg (baseequiv) tab 5 mg (base equiv))


TAVALISSE (100 MG TAB 150 MGTAB)


CARDIOVASCULAR AGENTS



ALPHA-ADRENERGIC AGONISTSclonidine (patch weekly 01mg24hr patch weekly 02mg24hr patch weekly 03mg24hr)

Tier 2

clonidine hcl (tab 01 mg tab 02mg tab 03 mg)

Tier 2

droxidopa cap 100 mg Tier 2 PA QL (252 PER 90OVER TIME)


droxidopa cap 300 mg Tier 2 PA QL (84 PER 90 OVERTIME)

guanfacine hcl (tab 1 mg tab 2mg)

Tier 2

methyldopa (250 mg tab 500mg tab tab 250 mg tab 500 mg)

Tier 2

midodrine hcl (tab 10 mg tab 25mg tab 5 mg)

Tier 2

ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate (tab 1 mgtab 2 mg tab 4 mg tab 8 mg)

Tier 2

prazosin hcl (cap 1 mg cap 2mg cap 5 mg)

Tier 2


59




terazosin hcl (cap 1 mg (baseequivalent) cap 10 mg (baseequivalent) cap 2 mg (baseequivalent) cap 5 mg (baseequivalent))

Tier 2

ANGIOTENSIN II RECEPTOR ANTAGONISTScandesartan cilexetil (tab 16 mgtab 32 mg tab 4 mg tab 8 mg)

Tier 2

EPROSARTAN MESYLATE 600 MGTAB


irbesartan (tab 150 mg tab 300mg tab 75 mg)

Tier 1

losartan potassium (tab 100 mgtab 25 mg tab 50 mg)

Tier 1

olmesartan medoxomil (tab 20mg tab 40 mg tab 5 mg)

Tier 2

telmisartan (tab 20 mg tab 40mg tab 80 mg)

Tier 1

valsartan (tab 160 mg tab 320mg tab 40 mg tab 80 mg)

Tier 1

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl (tab 10 mg tab 20mg tab 40 mg tab 5 mg)

Tier 1

captopril (tab 100 mg tab 125mg tab 25 mg tab 50 mg)

Tier 1

enalapril maleate (tab 10 mgtab 25 mg tab 20 mg tab 5 mg)

Tier 1

fosinopril sodium (tab 10 mg tab20 mg tab 40 mg)

Tier 1

lisinopril (tab 10 mg tab 25 mgtab 20 mg tab 30 mg tab 40mg tab 5 mg)

Tier 1

moexipril hcl (tab 15 mg tab 75mg)

Tier 1

perindopril erbumine (tab 2 mgtab 4 mg tab 8 mg)

Tier 1


60




quinapril hcl (tab 10 mg tab 20mg tab 40 mg tab 5 mg)

Tier 1

ramipril (cap 125 mg cap 10mg cap 25 mg cap 5 mg)

Tier 1

trandolapril (tab 1 mg tab 2 mgtab 4 mg)

Tier 1

ANTIARRHYTHMICSamiodarone hcl (tab 100 mg tab200 mg tab 400 mg)

Tier 2

disopyramide phosphate (cap100 mg cap 150 mg)

Tier 2

dofetilide (cap 125 mcg (0125mg) cap 250 mcg (025 mg)cap 500 mcg (05 mg))

Tier 2

flecainide acetate (tab 100 mgtab 150 mg tab 50 mg)

Tier 2

mexiletine hcl (cap 150 mg cap200 mg cap 250 mg)

Tier 2

MULTAQ 400 MG TAB Tier 3 QL (2 PER 1 DAYS)

propafenone hcl (tab 150 mgtab 225 mg tab 300 mg)

Tier 2

QUINIDINE SULFATE (200 MG TAB300 MG TAB)

Tier 2

sotalol hcl (afibafl) (tab 120 mgtab 160 mg tab 80 mg)

Tier 2

sotalol hcl (tab 120 mg tab 160mg tab 240 mg tab 80 mg)

Tier 2

BETA-ADRENERGIC BLOCKING AGENTSacebutolol hcl (cap 200 mg cap400 mg)

Tier 2

atenolol (tab 100 mg tab 25 mgtab 50 mg)

Tier 1

betaxolol hcl (tab 10 mg tab 20mg)

Tier 2

bisoprolol fumarate (tab 10 mgtab 5 mg)

Tier 2


61




carvedilol (tab 125 mg tab 25mg tab 3125 mg tab 625 mg)

Tier 1

labetalol hcl (tab 100 mg tab200 mg tab 300 mg)

Tier 2

metoprolol succinate (tab er 24hr100 mg (tartrate equiv) tab er24hr 200 mg (tartrate equiv) taber 24hr 25 mg (tartrate equiv)tab er 24hr 50 mg (tartrateequiv))

Tier 2

metoprolol tartrate (tab 100 mgtab 25 mg tab 50 mg)

Tier 1

nadolol (tab 20 mg tab 40 mgtab 80 mg)

Tier 2

nebivolol hcl (tab 10 mg (baseequivalent) tab 25 mg (baseequivalent) tab 20 mg (baseequivalent) tab 5 mg (baseequivalent))

Tier 2

pindolol (tab 10 mg tab 5 mg) Tier 2

propranolol hcl (20 mg5mlsolution 40 mg5ml solution caper 24hr 120 mg cap er 24hr 160mg cap er 24hr 60 mg cap er24hr 80 mg tab 10 mg tab 20mg tab 40 mg tab 60 mg tab80 mg)

Tier 2

CALCIUM CHANNEL BLOCKING AGENTS DIHYDROPYRIDINESamlodipine besylate (tab 10 mg(base equivalent) tab 25 mg(base equivalent) tab 5 mg(base equivalent))

Tier 1

felodipine (tab er 24hr 10 mg taber 24hr 25 mg tab er 24hr 5 mg)

Tier 2

nicardipine hcl (cap 20 mg cap30 mg)

Tier 2


62




nifedipine (cap 10 mg cap 20mg tab er 24hr 30 mg tab er24hr 60 mg tab er 24hr 90 mgtab er 24hr osmotic release 30mg tab er 24hr osmotic release60 mg tab er 24hr osmoticrelease 90 mg)

Tier 2

nimodipine cap 30 mg Tier 2

NYMALIZE 6 MGML SOLUTION Tier 3 QL (1260 PER 21 OVERTIME)

CALCIUM CHANNEL BLOCKING AGENTS NONDIHYDROPYRIDINESdiltiazem hcl (cap er 12hr 120mg cap er 12hr 60 mg cap er12hr 90 mg cap er 24hr 120 mgcap er 24hr 180 mg cap er 24hr240 mg tab 120 mg tab 30 mgtab 60 mg tab 90 mg)

Tier 2

diltiazem hcl coated beads (caper 24hr 120 mg cap er 24hr 180mg cap er 24hr 240 mg cap er24hr 300 mg cap er 24hr 360 mgtab er 24hr 180 mg tab er 24hr240 mg tab er 24hr 300 mg taber 24hr 360 mg tab er 24hr 420mg)

Tier 2

diltiazem hcl extended releasebeads (cap er 24hr 120 mg caper 24hr 180 mg cap er 24hr 240mg cap er 24hr 300 mg cap er24hr 360 mg cap er 24hr 420 mg)

Tier 2

verapamil hcl (cap er 24hr 100mg cap er 24hr 120 mg cap er24hr 180 mg cap er 24hr 200 mgcap er 24hr 240 mg cap er 24hr300 mg tab 120 mg tab 40 mgtab 80 mg tab er 120 mg tab er180 mg tab er 240 mg)

Tier 2

VERAPAMIL HCL ER (100 MG CAPER 24H 200 MG CAP ER 24H 300MG CAP ER 24H 360 MG CAP ER24H)

Tier 2


63




CARDIOVASCULAR AGENTS OTHERacetazolamide (tab 125 mg tab250 mg)

Tier 2

aliskiren fumarate (tab 150 mg(base equivalent) tab 300 mg(base equivalent))

Tier 2 PA

amiloride amp hydrochlorothiazidetab 5-50 mg

Tier 2

amlodipine besylate-benazeprilhcl (cap 10-20 mg cap 10-40mg cap 25-10 mg cap 5-10 mgcap 5-20 mg cap 5-40 mg)

Tier 1

amlodipine besylate-olmesartanmedoxomil (tab 10-20 mg tab10-40 mg tab 5-20 mg tab 5-40mg)

Tier 2

amlodipine besylate-valsartan(tab 10-160 mg tab 10-320 mgtab 5-160 mg tab 5-320 mg)

Tier 1

amlodipine-valsartan-hydrochlorothiazide (tab 10-160-125 mg tab 10-160-25 mg tab10-320-25 mg tab 5-160-125 mgtab 5-160-25 mg)

Tier 2

atenolol amp chlorthalidone (tab100-25 mg tab 50-25 mg)

Tier 1

benazepril amp hydrochlorothiazide(tab 10-125 mg tab 20-125 mgtab 20-25 mg tab 5-625 mg)

Tier 1

BENAZEPRIL-HYDROCHLOROTHIAZIDE 5-625MG TAB

Tier 1

bisoprolol amp hydrochlorothiazide(tab 10-625 mg tab 25-625 mgtab 5-625 mg)

Tier 2

candesartan cilexetil-hydrochlorothiazide (tab 16-125mg tab 32-125 mg tab 32-25mg)

Tier 2


64




CAPTOPRIL-HYDROCHLOROTHIAZIDE (25-15MG TAB 25-25 MG TAB 50-15 MGTAB 50-25 MG TAB)

Tier 1

CORLANOR (5 MG TAB 75 MGTAB)


CORLANOR 5 MG5ML SOLUTION Tier 3 PA QL (20 PER 1 DAYS)

digoxin (005 mgml solution oralsoln 005 mgml)

Tier 3

digoxin tab 125 mcg (0125 mg) Tier 2 QL (1 PER 1 DAYS)

digoxin tab 250 mcg (025 mg) Tier 2 PA QL (1 PER 1 DAYS)

enalapril maleate amphydrochlorothiazide (tab 10-25mg tab 5-125 mg)

Tier 1

ENTRESTO (24-26 MG TAB 49-51MG TAB 97-103 MG TAB)


fosinopril sodium amphydrochlorothiazide (tab 10-125mg tab 20-125 mg)

Tier 1

irbesartan-hydrochlorothiazide(tab 150-125 mg tab 300-125mg)

Tier 1

lisinopril amp hydrochlorothiazide(tab 10-125 mg tab 20-125 mgtab 20-25 mg)

Tier 1

losartan potassium amphydrochlorothiazide (tab 100-125mg tab 100-25 mg tab 50-125mg)

Tier 1

metoprolol amp hydrochlorothiazide(tab 100-25 mg tab 50-25 mg)

Tier 2

METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TAB

Tier 2

metyrosine cap 250 mg Tier 2


65




olmesartan medoxomil-amlodipine-hydrochlorothiazide(tab 20-5-125 mg tab 40-10-125mg tab 40-10-25 mg tab 40-5-125 mg tab 40-5-25 mg)

Tier 2

olmesartan medoxomil-hydrochlorothiazide (tab 20-125mg tab 40-125 mg tab 40-25mg)

Tier 2

pentoxifylline tab er 400 mg Tier 2

PROPRANOLOL-HCTZ (40-25 MGTAB 80-25 MG TAB)

Tier 2

quinapril-hydrochlorothiazide(tab 10-125 mg tab 20-125 mgtab 20-25 mg)

Tier 1

ranolazine (tab er 12hr 1000 mgtab er 12hr 500 mg)


spironolactone amphydrochlorothiazide tab 25-25mg

Tier 2

TEKTURNA HCT (150-125 MG TAB150-25 MG TAB 300-125 MG TAB300-25 MG TAB)

Tier 3 PA

telmisartan-hydrochlorothiazide(tab 40-125 mg tab 80-125 mgtab 80-25 mg)

Tier 1

triamterene amphydrochlorothiazide (cap 375-25mg tab 375-25 mg tab 75-50mg)

Tier 2

valsartan-hydrochlorothiazide(tab 160-125 mg tab 160-25 mgtab 320-125 mg tab 320-25 mgtab 80-125 mg)

Tier 1

VYNDAMAX 61 MG CAP Tier 3 PA LA QL (1 PER 1DAYS)

DIURETICS LOOPbumetanide (inj 025 mgml tab05 mg tab 1 mg tab 2 mg)

Tier 2


66




furosemide (8 mgml solution inj10 mgml oral soln 10 mgml)

Tier 2

furosemide (tab 20 mg tab 40mg tab 80 mg)

Tier 1

torsemide (tab 10 mg tab 100mg tab 20 mg tab 5 mg)

Tier 2

DIURETICS POTASSIUM-SPARINGamiloride hcl tab 5 mg Tier 2

eplerenone (tab 25 mg tab 50mg)

Tier 2

spironolactone (tab 100 mg tab25 mg tab 50 mg)

Tier 2

DIURETICS THIAZIDEchlorothiazide (500 mg tab tab500 mg)

Tier 2

chlorthalidone (tab 25 mg tab50 mg)

Tier 2

hydrochlorothiazide (cap 125mg tab 125 mg tab 25 mg tab50 mg)

Tier 1

indapamide (tab 125 mg tab25 mg)

Tier 2

metolazone (tab 10 mg tab 25mg tab 5 mg)

Tier 2

DYSLIPIDEMICS FIBRIC ACID DERIVATIVEScholine fenofibrate (cap dr 135mg (fenofibric acid equiv) capdr 45 mg (fenofibric acid equiv))

Tier 2

fenofibrate (tab 145 mg tab 160mg tab 48 mg tab 54 mg)

Tier 2

fenofibrate micronized (cap 130mg cap 134 mg cap 200 mgcap 43 mg cap 67 mg)

Tier 2

gemfibrozil tab 600 mg Tier 2


67




DYSLIPIDEMICS HMG COA REDUCTASE INHIBITORSatorvastatin calcium (tab 10 mg(base equivalent) tab 20 mg(base equivalent) tab 40 mg(base equivalent) tab 80 mg(base equivalent))

Tier 1

fluvastatin sodium (cap 20 mg(base equivalent) cap 40 mg(base equivalent))

Tier 1

fluvastatin sodium tab er 24 hr 80mg (base equivalent)

Tier 2

lovastatin (tab 10 mg tab 20 mgtab 40 mg)

Tier 1

pravastatin sodium (tab 10 mgtab 20 mg tab 40 mg tab 80mg)

Tier 1

rosuvastatin calcium (tab 10 mgtab 20 mg tab 40 mg tab 5 mg)

Tier 1

simvastatin (tab 10 mg tab 20mg tab 40 mg tab 5 mg tab 80mg)

Tier 1

DYSLIPIDEMICS OTHERcholestyramine (powder 4gmdose powder packets 4 gm)

Tier 2

cholestyramine light (powder 4gmdose powder packets 4 gm)

Tier 2

colesevelam hcl (packet for susp375 gm tab 625 mg)

Tier 2

colestipol hcl (granule packets 5gm granules 5 gm tab 1 gm)

Tier 2

ezetimibe tab 10 mg Tier 2

ezetimibe-simvastatin (tab 10-10mg tab 10-20 mg tab 10-40 mgtab 10-80 mg)

Tier 2

icosapent ethyl cap 1 gm Tier 2 QL (4 PER 1 DAYS)

JUXTAPID (40 MG CAP 60 MGCAP)



68




JUXTAPID 10 MG CAP Tier 3 PA LA QL (6 PER 1DAYS)




niacin (antihyperlipidemic) (taber 1000 mg (antihyperlipidemic)tab er 750 mg(antihyperlipidemic))


NIACIN (ANTIHYPERLIPIDEMIC)500 MG TAB

Tier 2

niacin tab er 500 mg(antihyperlipidemic)


NIACOR 500 MG TAB Tier 2

omega-3-acid ethyl esters cap 1gm


REPATHA 140 MGML SOLN PRSYR Tier 3 PA QL (2 PER 28 OVERTIME)

REPATHA PUSHTRONEX SYSTEM420 MG35ML SOLN CART


REPATHA SURECLICK 140 MGMLSOLN A-INJ


VASCEPA 05 GM CAP Tier 3 QL (8 PER 1 DAYS)

VASODILATORS DIRECT-ACTING ARTERIALhydralazine hcl (tab 10 mg tab100 mg tab 25 mg tab 50 mg)

Tier 2

minoxidil (tab 10 mg tab 25 mg) Tier 2

VASODILATORS DIRECT-ACTING ARTERIALVENOUSisosorbide dinitrate (tab 10 mgtab 20 mg tab 30 mg tab 5 mg)

Tier 2

ISOSORBIDE DINITRATE ER 40 MGTAB ER

Tier 2


69




isosorbide mononitrate (tab 10mg tab 20 mg tab er 24hr 120mg tab er 24hr 30 mg tab er24hr 60 mg)

Tier 2

NITRO-BID 2 OINTMENT Tier 3

nitroglycerin (sl tab 03 mg sl tab04 mg sl tab 06 mg td patch24hr 01 mghr td patch 24hr 02mghr td patch 24hr 04 mghrtd patch 24hr 06 mghr)

Tier 2

NITROSTAT (03 MG SL TAB 04MG SL TAB 06 MG SL TAB)

Tier 3

RECTIV 04 OINTMENT Tier 3 PA QL (30 PER 30 OVERTIME)

CENTRAL NERVOUS SYSTEM AGENTS



ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS AMPHETAMINESamphetamine-dextroamphetamine (cap er24hr 10 mg cap er 24hr 15 mgcap er 24hr 20 mg cap er 24hr25 mg cap er 24hr 30 mg cap er24hr 5 mg tab 30 mg)


amphetamine-dextroamphetamine (tab 10 mgtab 15 mg tab 5 mg tab 75 mg)


amphetamine-dextroamphetamine tab 125 mg




dextroamphetamine sulfate (caper 24hr 10 mg tab 10 mg tab 5mg)


dextroamphetamine sulfate (caper 24hr 15 mg tab 15 mg)



70




dextroamphetamine sulfate caper 24hr 5 mg


dextroamphetamine sulfate tab20 mg




ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS NON-AMPHETAMINESatomoxetine hcl (cap 10 mg(base equiv) cap 18 mg (baseequiv) cap 25 mg (base equiv))


atomoxetine hcl (cap 100 mg(base equiv) cap 60 mg (baseequiv) cap 80 mg (base equiv))


atomoxetine hcl cap 40 mg(base equiv)


clonidine hcl tab er 12hr 01 mg Tier 2

dexmethylphenidate hcl (tab 10mg tab 25 mg tab 5 mg)


guanfacine hcl (adhd) (tab er24hr 1 mg (base equiv) tab er24hr 2 mg (base equiv) tab er24hr 3 mg (base equiv) tab er24hr 4 mg (base equiv))


methylphenidate hcl (tab 10 mgtab er 10 mg)




methylphenidate hcl tab 5 mg Tier 2 QL (12 PER 1 DAYS)

CENTRAL NERVOUS SYSTEM OTHERAUSTEDO (12 MG TAB 9 MG TAB) Tier 3 PA QL (4 PER 1 DAYS)

AUSTEDO 6 MG TAB Tier 3 PA QL (8 PER 1 DAYS)

butalbital-acetaminophen-caffeine tab 50-325-40 mg


FIRDAPSE 10 MG TAB Tier 3 PA LA QL (8 PER 1DAYS)


71




INGREZZA (60 MG CAP 80 MGCAP)


INGREZZA 40 amp 80 MG CAP THPK Tier 3 PA LA QL (28 PER 28OVER TIME)

INGREZZA 40 MG CAP Tier 3 PA LA QL (2 PER 1DAYS)

riluzole tab 50 mg Tier 2

tetrabenazine tab 125 mg Tier 2 PA LA QL (8 PER 1DAYS)


FIBROMYALGIA AGENTSDRIZALMA SPRINKLE (20 MG CAPDR 30 MG CAP DR)


DRIZALMA SPRINKLE (40 MG CAPDR 60 MG CAP DR)


duloxetine hcl (cap 20 mg (baseeq) cap 60 mg (base eq))


duloxetine hcl enteric coatedpellets cap 30 mg (base eq)


pregabalin (cap 100 mg cap150 mg cap 25 mg cap 50 mgcap 75 mg)


pregabalin (cap 200 mg cap225 mg cap 300 mg)


pregabalin soln 20 mgml Tier 2 QL (30 PER 1 DAYS)

SAVELLA (100 MG TAB 125 MGTAB 25 MG TAB 50 MG TAB)


SAVELLA TITRATION PACK 125 amp25 amp 50 MG MISC


MULTIPLE SCLEROSIS AGENTSAUBAGIO (14 MG TAB 7 MG TAB) Tier 3 PA LA QL (1 PER 1

DAYS)

AVONEX 30 MCG KIT Tier 3 PA QL (4 PER 28 OVERTIME)


72




AVONEX PEN 30 MCG05ML AUT-IJ KIT


AVONEX PREFILLED 30MCG05ML PREF SY KT


BETASERON 03 MG KIT Tier 3 PA QL (15 PER 30 OVERTIME)

dalfampridine tab er 12hr 10 mg Tier 2 PA QL (2 PER 1 DAYS)

dimethyl fumarate (capsuledelayed release 120 mg capsuledelayed release 240 mg capsuledr starter pack 120 mg amp 240 mg)


EXTAVIA 03 MG KIT Tier 3 PA QL (15 PER 30 OVERTIME)

GILENYA 05 MG CAP Tier 3 PA QL (1 PER 1 DAYS)

glatiramer acetate soln prefilledsyringe 20 mgml


PLEGRIDY (125 MCG05ML SOLNPEN 125 MCG05ML SOLNPRSYR)

Tier 3 PA LA

PLEGRIDY STARTER PACK 63 amp 94MCG05ML SOLN PEN

Tier 3 PA LA

PLEGRIDY STARTER PACK 63 amp 94MCG05ML SOLN PRSYR


REBIF (22 MCG05ML SOLNPRSYR 44 MCG05ML SOLNPRSYR)


REBIF REBIDOSE (22 MCG05MLSOLN A-INJ 44 MCG05ML SOLNA-INJ)


REBIF REBIDOSE TITRATION PACK6X88 amp 6X22 MCG SOLN A-INJ


REBIF TITRATION PACK 6X88 amp6X22 MCG SOLN PRSYR


TYSABRI 300 MG15ML CONC Tier 3 PA LA


73

DENTAL AND ORAL AGENTS



DENTAL AND ORAL AGENTSchlorhexidine gluconate soln012

Tier 2

KEPIVANCE 625 MG RECONSOLN

Tier 3 BvD

pilocarpine hcl (oral) (tab 5 mgtab 75 mg)

Tier 2

triamcinolone acetonide dentalpaste 01

Tier 2

DERMATOLOGICAL AGENTS



ACNE AND ROSACEA AGENTSacitretin (cap 10 mg cap 175mg cap 25 mg)

Tier 2

adapalene gel 01 Tier 2 PA

isotretinoin (cap 10 mg cap 20mg cap 30 mg cap 40 mg)

Tier 2

tazarotene cream 01 Tier 2

TAZORAC 005 CREAM Tier 3

tretinoin (cream 0025 cream005 cream 01 gel 001 gel0025)

Tier 2 PA

DERMATITIS AND PRURITUS AGENTSalclometasone dipropionate oint005

Tier 2

betamethasone dipropionate(topical) (cream 005 lotion005)

Tier 2

BETAMETHASONE DIPROPIONATEAUG 005 GEL

Tier 2


74




betamethasone dipropionateaugmented oint 005

Tier 2

betamethasone valerate (cream01 (base equivalent) lotion01 (base equivalent) oint 01(base equivalent))

Tier 2

clobetasol propionate (cream005 gel 005 oint 005 soln005)

Tier 2

clobetasol propionate emollientbase cream 005

Tier 2

desonide (cream 005 oint005)

Tier 2

desoximetasone (cream 025oint 025)

Tier 2

fluocinolone acetonide (cream001 cream 0025 oil 001(body oil) oil 001 (scalp oil)oint 0025 soln 001)

Tier 2

fluocinonide (cream 005 gel005 oint 005 soln 005)

Tier 2

fluocinonide emulsified basecream 005

Tier 2

fluticasone propionate (cream005 oint 0005)

Tier 2

halobetasol propionate (cream005 oint 005)


hydrocortisone (rectal) (cream1 cream 25)

Tier 2

hydrocortisone (topical) (cream25 lotion 25 oint 1 oint25)

Tier 2

hydrocortisone butyrate (01 solution soln 01)

Tier 2 ST

hydrocortisone valerate cream02

Tier 2 ST

lactic acid (ammonium lactate)(cream 12 lotion 12)

Tier 2


75




mometasone furoate solution01 (lotion)

Tier 2

selenium sulfide lotion 25 Tier 2

tacrolimus (topical) (oint 003oint 01)


triamcinolone acetonide(topical) (cream 0025 cream01 cream 05 lotion 0025lotion 01 oint 0025 oint 01oint 05)

Tier 2

DERMATOLOGICAL AGENTS OTHERcalcipotriene (cream 0005 oint0005 soln 0005 (50 mcgml))

Tier 2

clotrimazole w betamethasone(cream 1-005 lotion 1-005)

Tier 2

diclofenac sodium (actinickeratoses) gel 3


FLUOROURACIL (2 SOLUTION 5 SOLUTION)

Tier 2

fluorouracil cream 5 Tier 2

imiquimod cream 5 Tier 2 QL (24 PER 30 OVERTIME)

nystatin-triamcinolone (cream100000-01 unitgm- oint100000-01 unitgm-)

Tier 2

OTEZLA 30 MG TAB Tier 3 PA QL (2 PER 1 DAYS)

podofilox soln 05 Tier 2

REGRANEX 001 GEL Tier 3 PA QL (15 PER 2 OVERTIME)

SANTYL 250 UNITGM OINTMENT Tier 3 QL (180 PER 30 OVERTIME)

silver sulfadiazine cream 1 Tier 2

TOLAK 4 CREAM Tier 3


76




PEDICULICIDESSCABICIDESLINDANE 1 SHAMPOO Tier 2

malathion lotion 05 Tier 3

permethrin cream 5 Tier 2

TOPICAL ANTI-INFECTIVESacyclovir oint 5 Tier 2 PA QL (30 PER 30 OVER

TIME)

ciclopirox solution 8 Tier 2

clindamycin phosphate (topical)(gel 1 lotion 1 soln 1)

Tier 2

ERY 2 PAD Tier 2

erythromycin (acne aid) (gel 2soln 2)

Tier 2

mupirocin oint 2 Tier 2

SULFAMYLON 85 MGGM CREAM Tier 3

ELECTROLYTESMINERALSMETALSVITAMINS



ELECTROLYTEMINERAL REPLACEMENTamino acid electrolyte infusion85

Tier 2 BvD

amino acid infusion 15 Tier 2 BvD

AMINO ACID 10 SOLUTION Tier 2 BvD

AMINOSYN (10 SOLUTION 85 SOLUTION)

Tier 2 BvD

AMINOSYN II (10 SOLUTION 85 SOLUTION)

Tier 2 BvD

AMINOSYN II 15 SOLUTION Tier 3 BvD

AMINOSYN-HBC 7 SOLUTION Tier 3 BvD


77




AMINOSYN-PF 10 SOLUTION Tier 2 BvD


AMINOSYN-RF 52 SOLUTION Tier 2 BvD

AMINOSYNELECTROLYTES(AMINOSYNELECTROLYTES 7 SOLUTIONAMINOSYNELECTROLYTES 85 SOLUTION)

Tier 2 BvD

CARBAGLU 200 MG TAB Tier 3 PA LA

CRYSVITA 10 MGML SOLUTION Tier 3 PA LA QL (2 PER 28OVER TIME)



FREAMINE III 10 SOLUTION Tier 2 BvD

HEPATAMINE 8 SOLUTION Tier 3 BvD

INTRALIPID (20 EMULSION 30 EMULSION)

Tier 3 BvD

KCL IN DEXTROSE-NACL (20-5-0225 MEQL-- SOLUTION 20-5-033 MEQL-- SOLUTION 40-5-09 MEQL-- SOLUTION)

Tier 2

NORMOSOL-M IN D5WSOLUTION

Tier 2

NUTRILIPID 20 EMULSION Tier 3 BvD

potassium chloride (10meq100ml solution 20meq100ml solution 40meq100ml solution cap er 10meq cap er 8 meq inj 10meq100ml inj 2 meqml inj 20meq100ml inj 40 meq100mloral soln 10 (20 meq15ml) oralsoln 20 (40 meq15ml) tab er 10meq tab er 20 meq (1500 mg)tab er 8 meq (600 mg))

Tier 2

POTASSIUM CHLORIDE ER (20MEQ TAB ER 8 MEQ TAB ER)

Tier 2


78




potassium chloride in dextrose ampsodium chloride (20 meql(015) in dextrose 5nacl 02inj 20 meql (015) in dextrose5nacl 033 inj 20 meql(015) in dextrose 5nacl 045inj 20 meql (015) in dextrose5nacl 09 inj)

Tier 2

POTASSIUM CHLORIDE IN NACL(40-09 MEQL- SOLUTION KCL20 MEQL (015)09 INJ KCL 40MEQL (03)09 INJ)

Tier 2

potassium chloridemicroencapsulated crystals er(crys er tab 10 meq crys er tab15 meq crys er tab 20 meq)

Tier 2

potassium citrate (alkalinizer)(tab er 10 meq (1080 mg) tab er15 meq (1620 mg) tab er 5 meq(540 mg))

Tier 2

PREMASOL 10 SOLUTION Tier 2 BvD

sodium chloride (09 solutioninj 25 meqml (146) iv soln045 iv soln 09 iv soln 3 ivsoln 5 preservative free (pf) inj09)

Tier 2

SYNTHAMIN 17 10 SOLUTION Tier 2 BvD

TRAVASOL 10 SOLUTION Tier 2 BvD

TROPHAMINE 10 SOLUTION Tier 2 BvD

ELECTROLYTEMINERALMETAL MODIFIERSdeferasirox (tab 180 mg tab 360mg tab 90 mg tab for oral susp125 mg tab for oral susp 250 mgtab for oral susp 500 mg)

Tier 2

deferiprone tab 500 mg Tier 2 PA LA

FERRIPROX (100 MGMLSOLUTION 1000 MG TAB)

Tier 3 PA LA

FERRIPROX TWICE-A-DAY 1000MG TAB

Tier 3 PA LA


79




trientine hcl cap 250 mg Tier 2 PA QL (8 PER 1 DAYS)

PHOSPHATE BINDERSAURYXIA 1 GM 210 MG(FE) TAB Tier 3 PA QL (12 PER 1 DAYS)

calcium acetate (phosphatebinder) (cap 667 mg (169 mgca) tab 667 mg)

Tier 2

sevelamer carbonate tab 800mg

Tier 2

POTASSIUM BINDERSsodium polystyrene sulfonate(powder oral susp 15gm60ml)

Tier 2

SPS 15 GM60ML SUSPENSION Tier 2

VELTASSA (168 GM PACKET 252GM PACKET 84 GM PACKET)

Tier 3

VITAMINSdextrose (inj 10 inj 5) Tier 2

dextrose 5 in lactated ringers Tier 2

dextrose w sodium chloride(25 w sodium chloride 0455 w sodium chloride 02 5w sodium chloride 0225 5 wsodium chloride 03 5 wsodium chloride 033 5 wsodium chloride 045 5 wsodium chloride 09)

Tier 2

DEXTROSE-NACL (10-02 SOLUTION 10-0225 SOLUTION10-045 SOLUTION 25-045 SOLUTION 5-0225 SOLUTION 5-03 SOLUTION)

Tier 2

DEXTROSE-SODIUM CHLORIDE (5-0225 SOLUTION 5-03 SOLUTION)

Tier 2

KCL-LACTATED RINGERS-D5W 20MEQL SOLUTION

Tier 2


80




lactated ringers for irrigation Tier 2

lactated ringers solution Tier 2

LACTATED RINGERS SOLUTION Tier 2

levocarnitine tab 330 mg Tier 2

POTASSIUM CHLORIDE INDEXTROSE (20 MEQL (015)5INJ 40-5 MEQL- SOLUTION)

Tier 2

prenatal vitamins Tier 3

ringers solution Tier 2

ringers solution for irrigation Tier 2

SMOFLIPID 20 EMULSION Tier 3 BvD

sodium fluoride (chew tab 025mg f (from 055 mg naf) chewtab 05 mg f (from 11 mg naf)chew tab 1 mg f (from 22 mgnaf) soln 05 mgml f (from 11mgml naf))

Tier 2

TPN ELECTROLYTES CONC Tier 3 BvD

GASTROINTESTINAL AGENTS



ANTI-CONSTIPATION AGENTSAMITIZA (24 MCG CAP 8 MCGCAP)


lactulose (encephalopathy)solution 10 gm15ml

Tier 2

lactulose solution 10 gm15ml Tier 2

LINZESS (145 MCG CAP 290 MCGCAP 72 MCG CAP)


LUBIPROSTONE (24 MCG CAP 8MCG CAP)



81




MOVANTIK (125 MG TAB 25 MGTAB)


peg 3350-kcl-sod bicarb-nacl forsoln 420 gm

Tier 2

RELISTOR (12 MG06MLSOLUTION 8 MG04MLSOLUTION)

Tier 3 PA

SUPREP BOWEL PREP KIT 175-313-16 GM177ML SOLUTION

Tier 3

ANTI-DIARRHEAL AGENTSalosetron hcl (tab 05 mg (baseequiv) tab 1 mg (base equiv))

Tier 2 PA

diphenoxylate w atropine tab25-0025 mg

Tier 2

DIPHENOXYLATE-ATROPINE 25-0025 MG5ML LIQUID

Tier 2

loperamide hcl cap 2 mg Tier 2

XERMELO 250 MG TAB Tier 3 PA LA QL (3 PER 1DAYS)

ANTISPASMODICS GASTROINTESTINALdicyclomine hcl (cap 10 mg tab20 mg)

Tier 2 PA

glycopyrrolate (tab 1 mg tab 2mg)

Tier 2

GASTROINTESTINAL AGENTS OTHERGATTEX 5 MG KIT Tier 3 PA LA

GAVILYTE-C 240 GM RECONSOLN

Tier 2

MYALEPT 113 MG RECON SOLN Tier 3 PA LA QL (60 PER 30OVER TIME)

peg 3350-kcl-sod bicarb-sodchloride-sod sulfate (soln 236 gmsoln 240 gm)

Tier 2

ursodiol (cap 300 mg tab 250mg tab 500 mg)

Tier 2


82




HISTAMINE2 (H2) RECEPTOR ANTAGONISTScimetidine (tab 200 mg tab 300mg tab 400 mg tab 800 mg)

Tier 2

cimetidine hcl (300 mg5mlsolution soln 300 mg5ml)

Tier 2

famotidine (tab 20 mg tab 40mg)

Tier 2

nizatidine (150 mg cap 300 mgcap cap 150 mg cap 300 mg)

Tier 2

PROTECTANTSmisoprostol (tab 100 mcg tab200 mcg)

Tier 2

sucralfate tab 1 gm Tier 2

PROTON PUMP INHIBITORSlansoprazole cap delayedrelease 15 mg

Tier 2

lansoprazole cap delayedrelease 30 mg


omeprazole (cap delayedrelease 10 mg cap delayedrelease 20 mg)

Tier 2

omeprazole cap delayedrelease 40 mg


pantoprazole sodium ec tab 20mg (base equiv)

Tier 2



rabeprazole sodium ec tab 20mg

Tier 2

GENETIC OR ENZYME OR PROTEIN DISORDER REPLACEMENTMODIFIERS TREATMENT




83

GENETIC OR ENZYME OR PROTEIN DISORDER REPLACEMENT MODIFIERSTREATMENTALDURAZYME 29 MG5MLSOLUTION

Tier 3 LA BvD




ARALAST NP (1000 MG RECONSOLN 500 MG RECON SOLN)

Tier 3 LA BvD

CERDELGA 84 MG CAP Tier 3 PA LA QL (2 PER 1DAYS)

CEREZYME 400 UNIT RECON SOLN Tier 3 PA LA

CHOLBAM 250 MG CAP Tier 3 PA QL (5 PER 1 DAYS)


CREON (12000 UNIT CP DR PART24000-76000 UNIT CP DR PART3000-9500 UNIT CP DR PART36000 UNIT CP DR PART 6000 UNITCP DR PART)

Tier 3

cromolyn sodium oral conc 100mg5ml

Tier 2

CYSTADANE POWDER Tier 3 LA

CYSTAGON (150 MG CAP 50 MGCAP)

Tier 3 PA LA

CYSTARAN 044 SOLUTION Tier 3 PA LA QL (60 PER 28OVER TIME)

FABRAZYME 35 MG RECON SOLN Tier 3 LA BvD

miglustat cap 100 mg Tier 2 PA LA QL (3 PER 1DAYS)

NAGLAZYME 1 MGML SOLUTION Tier 3 LA BvD

nitisinone (cap 10 mg cap 2 mgcap 5 mg)

Tier 2 PA

NITYR (10 MG TAB 2 MG TAB 5MG TAB)

Tier 3 PA LA

PROCYSBI (25 MG CAP DR 300MG PACKET 75 MG CAP DR 75MG PACKET)

Tier 3 PA LA


84




PROLASTIN-C (1000 MG RECONSOLN 1000 MG20ML SOLUTION)

Tier 3 LA BvD

RAVICTI 11 GMML LIQUID Tier 3 PA LA QL (525 PER 30OVER TIME)

sapropterin dihydrochloride(powder packet 100 mg powderpacket 500 mg tab 100 mg)

Tier 2 PA

sodium phenylbutyrate (oralpowder 3 gmteaspoonful tab500 mg)

Tier 2 PA

STRENSIQ (18 MG045MLSOLUTION 28 MG07MLSOLUTION 40 MGML SOLUTION)

Tier 3 PA LA

STRENSIQ 80 MG08ML SOLUTION Tier 3 PA LA QL (384 PER 28OVER TIME)

VYNDAQEL 20 MG CAP Tier 3 PA LA QL (4 PER 1DAYS)

ZENPEP (10000-32000 UNIT CP DRPART 15000-47000 UNIT CP DRPART 20000-63000 UNIT CP DRPART 25000-79000 UNIT CP DRPART 3000-14000 UNIT CP DRPART 40000-126000 UNIT CP DRPART 5000-24000 UNIT CP DRPART)

Tier 3

GENITOURINARY AGENTS



ANTISPASMODICS URINARYMYRBETRIQ (25 MG TAB ER 24H50 MG TAB ER 24H)

Tier 3

oxybutynin chloride (syrup 5mg5ml tab 5 mg tab er 24hr 10mg tab er 24hr 15 mg tab er24hr 5 mg)

Tier 2


85




solifenacin succinate (tab 10 mgtab 5 mg)


tolterodine tartrate (cap er 24hr 2mg cap er 24hr 4 mg tab 1 mgtab 2 mg)

Tier 2 ST

trospium chloride tab 20 mg Tier 2

BENIGN PROSTATIC HYPERTROPHY AGENTSalfuzosin hcl tab er 24hr 10 mg Tier 2

dutasteride cap 05 mg Tier 2 QL (1 PER 1 DAYS)

finasteride tab 5 mg Tier 2

tamsulosin hcl cap 04 mg Tier 2

GENITOURINARY AGENTS OTHERbethanechol chloride (tab 10mg tab 25 mg tab 5 mg tab 50mg)

Tier 2

penicillamine tab 250 mg Tier 2 PA

THIOLA EC (100 MG TAB DR 300MG TAB DR)

Tier 3 PA LA

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL)



HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL)ACTHAR 80 UNITML GEL Tier 3 PA LA

alclometasone dipropionatecream 005

Tier 2

betamethasone dipropionateaugmented (cream 005 lotion005)

Tier 2

betamethasone dipropionateoint 005

Tier 2


86





Tier 2

CORTISONE ACETATE 25 MG TAB Tier 2

dexamethasone (05 mg5mlsolution 1 mg tab 2 mg tab elixir05 mg5ml tab 05 mg tab 075mg tab 15 mg tab 4 mg tab 6mg)

Tier 2

dexamethasone sodiumphosphate (inj 10 mgml inj 100mg10ml sod phosphatepreservative free inj 10 mgml)

Tier 2 BvD

dexamethasone sodiumphosphate (inj 120 mg30ml inj20 mg5ml inj 4 mgml)

Tier 2

fludrocortisone acetate tab 01mg

Tier 2

HEMADY 20 MG TAB Tier 3 PA QL (2 PER 1 DAYS)

hydrocortisone butyrate oint 01 Tier 2 ST

hydrocortisone valerate oint 02 Tier 2

KORLYM 300 MG TAB Tier 3 PA LA QL (4 PER 1DAYS)

methylprednisolone (tab 16 mgtab 32 mg tab 4 mg tab 8 mgtab therapy pack 4 mg (21))

Tier 2

methylprednisolone acetate (injsusp 40 mgml inj susp 80 mgml)

Tier 2

methylprednisolone sod succ (inj125 mg (base equiv) inj 40 mg(base equiv))

Tier 2

mometasone furoate (cream01 oint 01)

Tier 2

prednisolone (15 mg5mlsolution syrup 15 mg5ml (uspsolution equivalent))

Tier 2

PREDNISOLONE SODIUMPHOSPHATE (25 MG5MLSOLUTION SOD PHOSPH ORALSOLN 67 MG5ML (5 MG5MLBASE))

Tier 2


87




prednisone (5 mg5ml solutiontab 1 mg tab 10 mg tab 25 mgtab 20 mg tab 5 mg tab 50 mg)

Tier 2

PREDNISONE INTENSOL 5 MGMLCONC

Tier 2

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY)



HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY)desmopressin acetate (inj 4mcgml preservative free (pf) inj4 mcgml tab 01 mg tab 02mg)

Tier 2

desmopressin acetate nasalspray soln 001

Tier 2

desmopressin acetate nasalspray soln 001 (refrigerated)

Tier 2

EGRIFTA 1 MG RECON SOLN Tier 3 PA LA QL (60 PER 30OVER TIME)

EGRIFTA SV 2 MG RECON SOLN Tier 3 PA LA QL (30 PER 30OVER TIME)

INCRELEX 40 MG4ML SOLUTION Tier 3 PA LA

NORDITROPIN FLEXPRO (10MG15ML SOLN PEN 15MG15ML SOLN PEN 30 MG3MLSOLN PEN 5 MG15ML SOLNPEN)

Tier 3 PA

SEROSTIM (4 MG RECON SOLN 5MG RECON SOLN 6 MG RECONSOLN)

Tier 3 PA LA


88

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEXHORMONESMODIFIERS)



ANABOLIC STEROIDSANADROL-50 50 MG TAB Tier 3

oxandrolone (tab 10 mg tab 25mg)

Tier 2 PA

ANDROGENSANDRODERM (2 MG24HR PATCH24HR 4 MG24HR PATCH 24HR)


danazol (cap 100 mg cap 200mg cap 50 mg)

Tier 2

testosterone (125 mgact (1)gel 25 mg25gm (1) gel 50mg5gm (1) gel td gel 125mgact (1) td gel 25 mg25gm(1) td gel 50 mg5gm (1))


testosterone cypionate (100mgml solution 200 mgmlsolution im inj in oil 100 mgml iminj in oil 200 mgml)

Tier 2

testosterone enanthate (200mgml solution im inj in oil 200mgml)


ESTROGENSDEPO-ESTRADIOL 5 MGML OIL Tier 3

desogest-eth estrad amp eth estradtab 015-002001 mg(215)

Tier 2

desogest-ethin est tab 01-00250125-0025015-0025mg-mg

Tier 2

desogestrel amp ethinyl estradioltab 015 mg-30 mcg

Tier 2

drospirenone-ethinyl estradiol(tab 3-002 mg tab 3-003 mg)

Tier 2


89




estradiol (patch twice weekly0025 mg24hr patch twiceweekly 00375 mg24hr patchtwice weekly 005 mg24hrpatch twice weekly 0075mg24hr patch twice weekly 01mg24hr)


estradiol (patch weekly 0025mg24hr patch weekly 00375mg24hr (375 mcg24hr) patchweekly 005 mg24hr patchweekly 006 mg24hr patchweekly 0075 mg24hr patchweekly 01 mg24hr)


estradiol (tab 05 mg tab 1 mgtab 2 mg)

Tier 2 PA

estradiol vaginal (cream 01mggm tab 10 mcg)

Tier 2

ESTRING 2 MG RING Tier 3 QL (1 PER 84 OVER TIME)

ethynodiol diacet amp eth estrad(ethinyl estradiol tab 1 mg-35mcg ethinyl estradiol tab 1 mg-50 mcg)

Tier 2

etonogestrel-ethinyl estradiol varing 0120-0015 mg24hr


levonorgestrel amp eth estradiol(ethinyl estradiol tab 01 mg-20mcg ethinyl estradiol tab 015mg-30 mcg)

Tier 2

levonorgestrel amp ethinyl estradiol(91-day) tab 015-003 mg

Tier 2

levonorgestrel-eth estra tab 005-300075-400125-30mg-mcg

Tier 2

LOESTRIN FE 1530 15-30 MG-MCG TAB

Tier 2

LOESTRIN FE 120 1-20 MG-MCGTAB

Tier 2

MENEST (03 MG TAB 0625 MGTAB 125 MG TAB 25 MG TAB)

Tier 3 PA


90




norethin acet amp estrad-fe (ethinylestradiol-fe tab 1 mg-20 mcgethinyl estradiol-fe tab 15 mg-30mcg)

Tier 2

norethindrone amp eth estradiol(ethinyl estradiol tab 04 mg-35mcg ethinyl estradiol tab 05 mg-35 mcg ethinyl estradiol tab 1mg-35 mcg)

Tier 2

norethindrone amp ethinyl estradiol-fe chew tab 04 mg-35 mcg

Tier 2

norethindrone acet amp eth estra(ethinyl estradiol tab 1 mg-20mcg ethinyl estradiol tab 15 mg-30 mcg)

Tier 2

norethindrone acetate-ethinylestradiol (tab 05 mg-25 mcgtab 1 mg-5 mcg)

Tier 2 PA

norethindrone-eth estradiol(triphasic) (tab 05-35075-351-35 mg-mcg tab 05-351-3505-35 mg-mcg)

Tier 2

norgestimate amp ethinyl estradioltab 025 mg-35 mcg

Tier 2

norgestimate-eth estrad tab 018-350215-35025-35 mg-mcg

Tier 2

norgestrel amp ethinyl estradiol tab03 mg-30 mcg

Tier 2

PREMARIN (03 MG TAB 045 MGTAB 0625 MG TAB 09 MG TAB125 MG TAB)

Tier 3 PA

PREMARIN 0625 MGGM CREAM Tier 3

PREMPHASE 0625-5 MG TAB Tier 3 PA

PREMPRO (03-15 MG TAB 045-15 MG TAB 0625-25 MG TAB0625-5 MG TAB)



91




PROGESTINSDEPO-PROVERA 400 MGMLSUSPENSION

Tier 3

HYDROXYPROGESTERONECAPROATE 125 GM5MLSOLUTION

Tier 2

medroxyprogesterone acetate(contraceptive) (susp 150 mgmlsusp prefilled syr 150 mgml)

Tier 2

medroxyprogesterone acetate(tab 10 mg tab 25 mg tab 5mg)

Tier 2

megestrol acetate (susp 40mgml tab 20 mg tab 40 mg)

Tier 2 PA

megestrol acetate susp 625mg5ml

Tier 2 PA

norethindrone acetate tab 5 mg Tier 2

norethindrone tab 035 mg Tier 2

progesterone (cap 100 mg cap200 mg)

Tier 2

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTSOSPHENA 60 MG TAB Tier 3 PA QL (1 PER 1 DAYS)

raloxifene hcl tab 60 mg Tier 2 QL (1 PER 1 DAYS)

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID)



HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID)levothyroxine sodium (tab 100mcg tab 112 mcg tab 125 mcgtab 137 mcg tab 150 mcg tab175 mcg tab 200 mcg tab 25mcg tab 300 mcg tab 50 mcgtab 75 mcg tab 88 mcg)

Tier 2


92




liothyronine sodium (tab 25 mcgtab 5 mcg tab 50 mcg)

Tier 2

SYNTHROID (100 MCG TAB 112MCG TAB 125 MCG TAB 137MCG TAB 150 MCG TAB 175MCG TAB 200 MCG TAB 25MCG TAB 300 MCG TAB 50MCG TAB 75 MCG TAB 88 MCGTAB)

Tier 3

HORMONAL AGENTS SUPPRESSANT (PITUITARY)



HORMONAL AGENTS SUPPRESSANT (PITUITARY)cabergoline tab 05 mg Tier 2 QL (16 PER 30 OVER

TIME)

FIRMAGON (240 MG DOSE) 120MGVIAL RECON SOLN

Tier 3

FIRMAGON 80 MG RECON SOLN Tier 3

leuprolide acetate inj kit 5 mgml Tier 2

LUPRON DEPOT (1-MONTH) (375MG KIT 75 MG KIT)

Tier 3


Tier 3

LUPRON DEPOT (4-MONTH) 30MG KIT

Tier 3


Tier 3

LUPRON DEPOT-PED (1-MONTH)(1125 MG KIT 15 MG KIT 75 MGKIT)

Tier 3

LUPRON DEPOT-PED (3-MONTH)(1125 MG (PED) KIT 30 MG (PED)KIT)

Tier 3


93




octreotide acetate (100 mcgmlsoln prsyr 1000 mcgml solution200 mcgml solution 50 mcgmlsoln prsyr 500 mcgml soln prsyrinj 100 mcgml (01 mgml) inj1000 mcgml (1 mgml) inj 200mcgml (02 mgml) inj 50mcgml (005 mgml) inj 500mcgml (05 mgml))

Tier 2 PA

ORGOVYX 120 MG TAB Tier 3 PA LA QL (1 PER 1DAYS)

SANDOSTATIN LAR DEPOT (10 MGKIT 20 MG KIT 30 MG KIT)

Tier 3 PA

SIGNIFOR (03 MGML SOLUTION06 MGML SOLUTION 09 MGMLSOLUTION)


SOMATULINE DEPOT (120MG05ML SOLUTION 60MG02ML SOLUTION 90MG03ML SOLUTION)

Tier 3 PA

SOMAVERT (10 MG RECON SOLN15 MG RECON SOLN 20 MGRECON SOLN 25 MG RECONSOLN 30 MG RECON SOLN)


SYNAREL 2 MGML SOLUTION Tier 3

TRELSTAR MIXJECT (1125 MGRECON SUSP 225 MG RECONSUSP 375 MG RECON SUSP)

Tier 3 BvD

HORMONAL AGENTS SUPPRESSANT (THYROID)



ANTITHYROID AGENTSmethimazole (tab 10 mg tab 5mg)

Tier 2

propylthiouracil tab 50 mg Tier 2


94

IMMUNOLOGICAL AGENTS



ANGIOEDEMA AGENTSBERINERT 500 UNIT KIT Tier 3 PA LA

CINRYZE 500 UNIT RECON SOLN Tier 3 PA LA

HAEGARDA (2000 UNIT RECONSOLN 3000 UNIT RECON SOLN)

Tier 3 PA LA

icatibant acetate inj 30 mg3ml(base equivalent)


RUCONEST 2100 UNIT RECONSOLN

Tier 3 PA LA

IMMUNOGLOBULINSBIVIGAM 10 GM100ML SOLUTION Tier 3 LA

BIVIGAM 5 GM50ML SOLUTION Tier 3 PA LA

FLEBOGAMMA DIF (05 GM10MLSOLUTION 10 GM100MLSOLUTION 10 GM200MLSOLUTION 25 GM50MLSOLUTION 20 GM200MLSOLUTION 20 GM400MLSOLUTION 5 GM100MLSOLUTION 5 GM50ML SOLUTION)

Tier 3 PA

GAMMAGARD (1 GM10MLSOLUTION 10 GM100MLSOLUTION 25 GM25MLSOLUTION 20 GM200MLSOLUTION 30 GM300MLSOLUTION 5 GM50ML SOLUTION)

Tier 3 PA

GAMMAGARD SD LESS IGA (10GM RECON SOLN 5 GM RECONSOLN)

Tier 3 PA

GAMMAKED (1 GM10MLSOLUTION 10 GM100MLSOLUTION 20 GM200MLSOLUTION 5 GM50ML SOLUTION)

Tier 3 PA

GAMMAPLEX (10 GM100MLSOLUTION 20 GM200MLSOLUTION 20 GM400MLSOLUTION 5 GM100MLSOLUTION 5 GM50ML SOLUTION)

Tier 3 PA LA


95




GAMMAPLEX 10 GM200MLSOLUTION

Tier 3 PA

GAMUNEX-C (1 GM10MLSOLUTION 10 GM100MLSOLUTION 25 GM25MLSOLUTION 20 GM200MLSOLUTION 40 GM400MLSOLUTION 5 GM50ML SOLUTION)

Tier 3 PA

HIZENTRA (1 GM5ML SOLNPRSYR 1 GM5ML SOLUTION 10GM50ML SOLUTION 2 GM10MLSOLN PRSYR 2 GM10MLSOLUTION 4 GM20ML SOLNPRSYR 4 GM20ML SOLUTION)

Tier 3 PA LA

PRIVIGEN (10 GM100MLSOLUTION 20 GM200MLSOLUTION 40 GM400MLSOLUTION 5 GM50ML SOLUTION)

Tier 3 PA

VARIZIG 125 UNIT12MLSOLUTION

Tier 3

IMMUNOLOGICAL AGENTS OTHERARCALYST 220 MG RECON SOLN Tier 3 PA LA

BENLYSTA (200 MGML SOLN A-INJ 200 MGML SOLN PRSYR)


ILARIS (150 MG RECON SOLN 150MGML SOLUTION)

Tier 3 PA LA

OTEZLA 10 amp 20 amp 30 MG TABTHPK


SKYRIZI (150 MG DOSE) 75MG083ML PREF SY KT

Tier 3 PA

SKYRIZI (150 MGML SOLN A-INJ150 MGML SOLN PRSYR)

Tier 3 PA

STELARA (45 MG05ML SOLNPRSYR 45 MG05ML SOLUTION90 MGML SOLN PRSYR)

Tier 3 PA

TALTZ (80 MGML SOLN A-INJ 80MGML SOLN PRSYR)


XELJANZ (10 MG TAB 5 MG TAB) Tier 3 PA QL (2 PER 1 DAYS)


96




XELJANZ 1 MGML SOLUTION Tier 3 PA QL (10 PER 1 DAYS)

XOLAIR (150 MG RECON SOLN150 MGML SOLN PRSYR 75MG05ML SOLN PRSYR)

Tier 3 PA LA

IMMUNOSTIMULANTSACTIMMUNE 2000000 UNIT05MLSOLUTION

Tier 3 PA LA

INTRON A (10000000 UNIT RECONSOLN 10000000 UNITMLSOLUTION 18000000 UNIT RECONSOLN 50000000 UNIT RECONSOLN 6000000 UNITMLSOLUTION)

Tier 3 LA

PEGASYS 180 MCG05ML SOLNPRSYR


PEGASYS 180 MCGML SOLUTION Tier 3 PA QL (4 PER 30 OVERTIME)

PEGASYS PROCLICK 180MCG05ML SOLN A-INJ


SYLATRON (200 MCG KIT 300MCG KIT 600 MCG KIT)

Tier 3 LA

IMMUNOSUPPRESSANTSAZATHIOPRINE SODIUM 100 MGRECON SOLN

Tier 2 BvD

azathioprine tab 50 mg Tier 2 BvD

cyclosporine (cap 100 mg cap25 mg iv soln 50 mgml)

Tier 2 BvD

cyclosporine modified (formicroemulsion) (cap 100 mgcap 25 mg cap 50 mg oral soln100 mgml)

Tier 2 BvD

ENBREL (25 MG RECON SOLN 25MG05ML SOLN PRSYR 25MG05ML SOLUTION 50 MGMLSOLN PRSYR)

Tier 3 PA

ENBREL SURECLICK 50 MGMLSOLN A-INJ

Tier 3 PA


97




ENVARSUS XR (075 MG TAB ER24H 1 MG TAB ER 24H 4 MG TABER 24H)

Tier 3 PA

everolimus (immunosuppressant)(tab 025 mg tab 05 mg tab075 mg)

Tier 2 PA

HUMIRA (10 MG01ML PREF SYKT 10 MG02ML PREF SY KT 20MG02ML PREF SY KT 20MG04ML PREF SY KT 40MG04ML PREF SY KT 40MG08ML PREF SY KT 80MG08ML PEN KIT)

Tier 3 PA

HUMIRA PEDIATRIC CROHNSSTART (40 MG08ML PREF SY KT80 MG08ML amp 40MG04MLPREF SY KT 80 MG08ML PREF SYKT)

Tier 3 PA

HUMIRA PEN (40 MG04ML PENKIT 40 MG08ML PEN KIT)

Tier 3 PA

HUMIRA PEN-CDUCHS STARTER(40 MG08ML PEN KIT 80MG08ML PEN KIT)

Tier 3 PA

HUMIRA PEN-PEDIATRIC UC START80 MG08ML PEN KIT

Tier 3 PA

HUMIRA PEN-PSUVADOL HSSTART 40 MG08ML PEN KIT

Tier 3 PA

HUMIRA PEN-PSORUVEIT STARTER80 MG08ML amp 40MG04ML PENKIT

Tier 3 PA

leflunomide (tab 10 mg tab 20mg)

Tier 2

methotrexate sodium (250mg10ml solution for inj 1 gm inj50 mg2ml (25 mgml) inj pf 1000mg40ml (25 mgml) inj pf 250mg10ml (25 mgml) inj pf 50mg2ml (25 mgml))

Tier 2 BvD

methotrexate sodium tab 25 mg(base equiv)

Tier 2


98




mycophenolate mofetil (cap 250mg for oral susp 200 mgml tab500 mg)

Tier 2 BvD

mycophenolate mofetil hcl for ivsoln 500 mg (base equiv)

Tier 2 BvD

mycophenolate sodium (tab dr180 mg (mycophenolic acidequiv) tab dr 360 mg(mycophenolic acid equiv))

Tier 2 BvD

PROGRAF (02 MG PACKET 1 MGPACKET)

Tier 3 PA

REZUROCK 200 MG TAB Tier 3 PA LA QL (1 PER 1DAYS)

RINVOQ 15 MG TAB ER 24H Tier 3 PA QL (1 PER 1 DAYS)

SANDIMMUNE 100 MGMLSOLUTION

Tier 3 BvD

sirolimus (oral soln 1 mgml tab05 mg tab 1 mg tab 2 mg)

Tier 2 BvD

tacrolimus (cap 05 mg cap 1mg cap 5 mg)

Tier 2 BvD

XATMEP 25 MGML SOLUTION Tier 3 PA

XELJANZ XR (11 MG TAB ER 24H22 MG TAB ER 24H)


ZORTRESS 1 MG TAB Tier 3 PA

VACCINESACTHIB RECON SOLN Tier 3

ADACEL 5-2-155 LF-MCG05SUSPENSION

Tier 3

BCG VACCINE INJECTABLE Tier 3

BEXSERO SUSP PRSYR Tier 3

BOOSTRIX (5-25-185 LF-MCG05SUSP PRSYR 5-25-185 LF-MCG05 SUSPENSION)

Tier 3

DAPTACEL 23-15-5 SUSPENSION Tier 3

DIPHTHERIA-TETANUS TOXOIDS DT25-5 LFU05ML SUSPENSION

Tier 3


99




ENGERIX-B (10 MCG05MLINJECTABLE 10 MCG05MLSUSPENSION 20 MCGMLINJECTABLE 20 MCGMLSUSPENSION)

Tier 3 BvD

GARDASIL 9 (SUSP PRSYRSUSPENSION)

Tier 3

HAVRIX (1440 EL UMLSUSPENSION 720 EL U05MLSUSPENSION)

Tier 3

HIBERIX 10 MCG RECON SOLN Tier 3

IMOVAX RABIES 25 UNITMLINJECTABLE

Tier 3

INFANRIX 25-58-10 SUSPENSION Tier 3

IPOL INJECTABLE Tier 3

IXIARO SUSPENSION Tier 3

KINRIX (05 ML SUSP PRSYRSUSPENSION)

Tier 3

M-M-R II RECON SOLN Tier 3

MENACTRA SOLUTION Tier 3

MENQUADFI SOLUTION Tier 3

MENVEO RECON SOLN Tier 3

PEDIARIX SUSPENSION Tier 3

PEDVAX HIB 75 MCG05MLSUSPENSION

Tier 3

PROQUAD RECON SUSP Tier 3

QUADRACEL SUSPENSION Tier 3

RABAVERT RECON SUSP Tier 3

RECOMBIVAX HB (10 MCGMLSUSPENSION 40 MCGMLSUSPENSION 5 MCG05MLSUSPENSION)

Tier 3 BvD

ROTARIX RECON SUSP Tier 3

ROTATEQ SOLUTION Tier 3


100




SHINGRIX 50 MCG05ML RECONSUSP


TDVAX 2-2 LF05ML SUSPENSION Tier 3

TENIVAC 5-2 LFU INJECTABLE Tier 3

TRUMENBA SUSP PRSYR Tier 3

TWINRIX 720-20 ELU-MCGMLSUSP PRSYR

Tier 3 BvD

TYPHIM VI 25 MCG05MLSOLUTION

Tier 3

VAQTA (25 UNIT05MLSUSPENSION 50 UNITMLSUSPENSION)

Tier 3

VARIVAX 1350 PFU05MLINJECTABLE

Tier 3

YF-VAX INJECTABLE Tier 3

ZOSTAVAX 19400 UNT065MLRECON SUSP


INFLAMMATORY BOWEL DISEASE AGENTS



AMINOSALICYLATESbalsalazide disodium cap 750 mg Tier 2

mesalamine (cap er 24hr 0375gm tab delayed release 12 gm)


mesalamine (enema 4 gmsuppos 1000 mg)

Tier 2

sulfasalazine (tab 500 mg tabdelayed release 500 mg)

Tier 2

GLUCOCORTICOIDSbudesonide delayed releaseparticles cap 3 mg



101




budesonide tab er 24hr 9 mg Tier 2 PA QL (1 PER 1 DAYS)

hydrocortisone (tab 10 mg tab20 mg tab 5 mg)

Tier 2

hydrocortisone enema 100mg60ml

Tier 2

METABOLIC BONE DISEASE AGENTS



METABOLIC BONE DISEASE AGENTSalendronate sodium (40 mg tab5 mg tab tab 10 mg tab 35 mgtab 5 mg tab 70 mg)

Tier 1

calcitonin (salmon) nasal soln 200unitact


calcitriol (1 mcgml solution cap025 mcg cap 05 mcg inj 1mcgml oral soln 1 mcgml)

Tier 2 BvD

cinacalcet hcl (tab 30 mg (baseequiv) tab 60 mg (base equiv)tab 90 mg (base equiv))

Tier 2 BvD

doxercalciferol (cap 05 mcgcap 1 mcg cap 25 mcg inj 4mcg2ml (2 mcgml))

Tier 2 BvD

ETIDRONATE DISODIUM 200 MGTAB

Tier 2

FORTEO 620 MCG248ML SOLNPEN

Tier 3 PA

ibandronate sodium iv soln 3mg3ml (base equivalent)

Tier 2 PA

ibandronate sodium tab 150 mg(base equivalent)

Tier 2

NATPARA (100 MCG CARTRIDGE25 MCG CARTRIDGE 50 MCGCARTRIDGE 75 MCGCARTRIDGE)



102




paricalcitol (cap 1 mcg cap 2mcg cap 4 mcg iv soln 2mcgml iv soln 5 mcgml)

Tier 2 BvD

PROLIA 60 MGML SOLN PRSYR Tier 3 PA

risedronate sodium (tab 150 mgtab 35 mg tab 5 mg)

Tier 2

TYMLOS 3120 MCG156ML SOLNPEN


XGEVA 120 MG17ML SOLUTION Tier 3 PA QL (17 PER 28 OVERTIME)

zoledronic acid (4 mg recon soln4 mg100ml solution inj conc foriv infusion 4 mg5ml iv soln 5mg100ml)

Tier 2 BvD

MISCELLANEOUS THERAPEUTIC AGENTS



MISCELLANEOUS THERAPEUTIC AGENTSADVOCATE ALCOHOL PREP PADS70 PAD

Tier 2

ALCOHOL 70 PADS Tier 2

ALCOHOL PREP (70 PAD PAD) Tier 2

ALCOHOL WIPES 70 MISC Tier 2

BD ECLIPSE SYRINGE 30G X 12 1ML MISC

Tier 2

BD INSULIN SYRINGE 275G X 582 ML MISC

Tier 2

BD Pen Needle Mini UF 31G X 5MM MISC

Tier 2

BD Pen Needle Nano UF 32G X 4MM MISC

Tier 2

BD Pen Needle Original UF 29GX 127MM MISC

Tier 2


103




BD Pen Needle Short UF 31G X 8MM MISC

Tier 2

BIOGUARD GAUZE SPONGES2X2 PAD

Tier 2

CAREONE UNIFINE PENTIPS PLUS33G X 4 MM MISC

Tier 2

CARETOUCH INSULIN SYRINGE (X516 05 ML MISC X 516 1 MLMISC)

Tier 2

COMFORT TOUCH ALCOHOLPREP 70 PAD

Tier 2

COMFORT TOUCH INSULIN PENNEED (31G X 4 MM MISC 31G X5 MM MISC 31G X 6 MM MISC31G X 8 MM MISC 32G X 4 MMMISC 32G X 5 MM MISC 32G X 6MM MISC 32G X 8 MM MISC)

Tier 2

CVS ISOPROPYL ALCOHOL WIPES70 MISC

Tier 2

EASY TOUCH INSULIN SYRINGE(27G X 12 05 ML MISC 28G X12 05 ML MISC 28G X 12 1 MLMISC 29G X 12 05 ML MISC29G X 12 1 ML MISC)

Tier 2

EASY TOUCH PEN NEEDLES 30G X6 MM MISC

Tier 2

gauze pads 2x2 Tier 2

GNP ISOPROPYL ALCOHOL WIPES70 MISC

Tier 2

GNP STERILE GAUZE 2X2 PAD Tier 2

H-E-B INCONTROL PEN NEEDLES31G X 5 MM MISC

Tier 2

H-E-B INCONTROL UNIFINE PENTIP(31G X 5 MM MISC 31G X 6 MMMISC 31G X 8 MM MISC 32G X 4MM MISC 33G X 4 MM MISC)

Tier 2

HM ULTICARE MINI PEN NEEDLES31G X 5 MM MISC

Tier 2


104




INSULIN PEN NEEDLES Tier 2

INSULIN SYRINGE 03 ML Tier 2



INSULIN SYRINGE-NEEDLE U-10030G X 516 1 ML MISC

Tier 2

ISOPROPYL ALCOHOL 70 MISC Tier 2

ISOPROPYL ALCOHOL WIPES 70 MISC

Tier 2

MEDPURA ALCOHOL PADS 70 MISC

Tier 2

methylergonovine maleate tab02 mg

Tier 2

novofine 32g x 6 mm misc Tier 2

novotwist 32g x 5 mm misc Tier 2

RA ISOPROPYL ALCOHOL WIPES70 MISC

Tier 2

RELION PEN NEEDLES (31G X 6MM MISC 31G X 8 MM MISC32G X 4 MM MISC)

Tier 2

RUZURGI 10 MG TAB Tier 3 PA LA QL (10 PER 1DAYS)

TRUE COMFORT PEN NEEDLES(31G X 8 MM MISC 32G X 5 MMMISC 32G X 6 MM MISC 33G X 4MM MISC 33G X 5 MM MISC33G X 6 MM MISC)

Tier 2

TRUE COMFORT PRO ALCOHOLPREP 70 PAD

Tier 2

TRUE COMFORT PRO INSULIN SYR(30G X 12 05 ML MISC 30G X12 1 ML MISC 30G X 516 05ML MISC 30G X 516 1 ML MISC31G X 516 05 ML MISC 31G X516 1 ML MISC 32G X 516 05ML MISC 32G X 516 1 ML MISC)

Tier 2


105




TRUE COMFORT PRO PENNEEDLES (31G X 5 MM MISC 31GX 6 MM MISC 32G X 4 MMMISC)

Tier 2

ULTICARE MINI PEN NEEDLES 30GX 5 MM MISC

Tier 2

ULTICARE SHORT PEN NEEDLES30G X 8 MM MISC

Tier 2

ULTIGUARD SAFEPACK PENNEEDLE (29G X 127MM MISC31G X 5 MM MISC 31G X 8 MMMISC 32G X 4 MM MISC 32G X 6MM MISC)

Tier 2

ULTIGUARD SAFEPACKSYRNEEDLE (30G X 12 03 MLMISC 30G X 12 05 ML MISC30G X 12 1 ML MISC 31G X516 03 ML MISC 31G X 516 05ML MISC 31G X 516 1 ML MISC)

Tier 2

ULTRA FLO INSULIN PEN NEEDLES(31G X 5 MM MISC 31G X 8 MMMISC 32G X 4 MM MISC 33G X 4MM MISC)

Tier 2

ULTRA FLO INSULIN SYR 12 UNIT(30G X 12 03 ML MISC 30G X516 03 ML MISC 31G X 516 03ML MISC)

Tier 2

ULTRA FLO INSULIN SYRINGE (29GX 12 05 ML MISC 29G X 12 1ML MISC 30G X 12 03 ML MISC30G X 12 05 ML MISC 30G X12 1 ML MISC 30G X 516 03ML MISC 30G X 516 05 MLMISC 30G X 516 1 ML MISC31G X 516 03 ML MISC 31G X516 05 ML MISC 31G X 516 1ML MISC)

Tier 2

UNIFINE PEN NEEDLES 32G X 4 MMMISC

Tier 2

UNIFINE PENTIPS (31G X 5 MMMISC 31G X 6 MM MISC 31G X 8MM MISC 32G X 4 MM MISC)

Tier 2


106




water for irrigation sterileirrigation soln

Tier 2

ZEVRX INSULIN SYRINGE (X 12 05ML MISC X 12 1 ML MISC X516 05 ML MISC X 516 1 MLMISC)

Tier 2

ZEVRX PEN NEEDLES (31G X 5 MMMISC 31G X 6 MM MISC 31G X 8MM MISC 32G X 4 MM MISC)

Tier 2

ZEVRX STERILE ALCOHOL PREPPAD 70 PAD

Tier 2

OPHTHALMIC AGENTS



OPHTHALMIC AGENTS OTHERATROPINE SULFATE 1 SOLUTION Tier 2

bacitracin-polymyxin b ophthoint

Tier 2

bacitracin-polymyxin-neomycin-hc ophth oint 1

Tier 2

COMBIGAN 02-05 SOLUTION Tier 3

DORZOLAMIDE HCL-TIMOLOLMAL 223-68 MGML SOLUTION

Tier 2

dorzolamide hcl-timolol maleateophth soln 223-68 mgml

Tier 2

neomycin-bacitrac zn-polymyx5(35)mg-400unt-10000unt op oin

Tier 2

neomycin-polymy-dexameth(oint 01 susp 01)

Tier 2

NEOMYCIN-POLYMYXIN-GRAMICIDIN 175-10000-025SOLUTION

Tier 2

RESTASIS 005 EMULSION Tier 3 QL (60 PER 30 OVERTIME)


107

OPHTHALMIC AGENTS



RESTASIS MULTIDOSE 005 EMULSION


ROCKLATAN 002-0005 SOLUTION


sulfacetamide sodium-prednisolone ophth soln 10-023(025)

Tier 2

SULFACETAMIDE-PREDNISOLONE10-023 SOLUTION

Tier 2

tobramycin-dexamethasoneophth susp 03-01

Tier 2

OPHTHALMIC ANTI-ALLERGY AGENTSazelastine hcl ophth soln 005 Tier 2

cromolyn sodium ophth soln 4 Tier 2

olopatadine hcl (soln 01 (baseequivalent) soln 02 (baseequivalent))

Tier 2

OPHTHALMIC ANTI-INFECTIVESBACITRACIN 500 UNITGMOINTMENT

Tier 2

erythromycin ophth oint 5mggm

Tier 2

GENTAK 03 OINTMENT Tier 2

gentamicin sulfate ophth soln03

Tier 2

levofloxacin ophth soln 05 Tier 2

moxifloxacin hcl (ophth) (soln05 (base eq) (2 times daily)soln 05 (base equiv))

Tier 2

NATACYN 5 SUSPENSION Tier 3

ofloxacin ophth soln 03 Tier 2

polymyxin b-trimethoprim ophthsoln 10000 unitml-01

Tier 2

SULFACETAMIDE SODIUM 10 OINTMENT

Tier 2


108

OPHTHALMIC AGENTS



sulfacetamide sodium ophth soln10

Tier 2

tobramycin ophth soln 03 Tier 2

OPHTHALMIC ANTI-INFLAMMATORIESALREX 02 SUSPENSION Tier 3

DEXAMETHASONE SODIUMPHOSPHATE 01 SOLUTION

Tier 2

diclofenac sodium ophth soln01

Tier 2

fluorometholone ophth susp 01 Tier 2

flurbiprofen sodium (003 solution ophth soln 003)

Tier 2

ILEVRO 03 SUSPENSION Tier 3 QL (17 PER 30 OVERTIME)

ketorolac tromethamine (ophth)(soln 04 soln 05)

Tier 2

loteprednol etabonate ophthsusp 05

Tier 2

PREDNISOLONE ACETATE 1 SUSPENSION

Tier 2

PREDNISOLONE SODIUMPHOSPHATE 1 SOLUTION

Tier 2

PROLENSA 007 SOLUTION Tier 3

OPHTHALMIC BETA-ADRENERGIC BLOCKING AGENTSbetaxolol hcl ophth soln 05 Tier 2

CARTEOLOL HCL 1 SOLUTION Tier 2

carteolol hcl ophth soln 1 Tier 2

levobunolol hcl (05 solutionophth soln 05)

Tier 2

METIPRANOLOL 03 SOLUTION Tier 2

TIMOLOL MALEATE (025 GEL FSOLN 05 GEL F SOLN)

Tier 2

timolol maleate (ophth) (gelforming soln 025 gel formingsoln 05 soln 025 soln 05)

Tier 2


109

OPHTHALMIC AGENTS



OPHTHALMIC INTRAOCULAR PRESSURE LOWERING AGENTS OTHERacetazolamide cap er 12hr 500mg

Tier 2

ALPHAGAN P 01 SOLUTION Tier 3

apraclonidine hcl ophth soln05 (base equivalent)

Tier 2

AZOPT 1 SUSPENSION Tier 3

brimonidine tartrate (soln 015soln 02)

Tier 2

dorzolamide hcl ophth soln 2 Tier 2

methazolamide (tab 25 mg tab50 mg)

Tier 2

PHOSPHOLINE IODIDE 0125 RECON SOLN

Tier 3

pilocarpine hcl (soln 1 soln 2soln 4)

Tier 2

RHOPRESSA 002 SOLUTION Tier 3 QL (25 PER 25 OVERTIME)

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGSbimatoprost ophth soln 003 Tier 2 ST QL (5 PER 30 OVER

TIME)

latanoprost (0005 solutionophth soln 0005)

Tier 2

LUMIGAN 001 SOLUTION Tier 3 QL (5 PER 30 OVER TIME)

travoprost ophth soln 0004(benzalkonium free) (bak free)


OTIC AGENTS



OTIC AGENTSCIPROFLOXACIN HCL 02 SOLUTION

Tier 2


110

OTIC AGENTS



ciprofloxacin-dexamethasoneotic susp 03-01

Tier 2

COLY-MYCIN S 33-3-10-05MGML SUSPENSION

Tier 3

CORTISPORIN-TC 33-3-10-05MGML SUSPENSION

Tier 3

DERMOTIC 001 OIL Tier 3

hydrocortisone w acetic acidotic soln 1-2

Tier 2

neomycin-polymyxin-hc (otic)(soln 1 susp 35 mgml-10000unitml-1)

Tier 2

ofloxacin otic soln 03 Tier 2

RESPIRATORY TRACTPULMONARY AGENTS



ANTI-INFLAMMATORIES INHALED CORTICOSTEROIDSbudesonide (inhalation) (susp025 mg2ml susp 05 mg2mlsusp 1 mg2ml)

Tier 2 BvD

FLOVENT DISKUS (100 MCGBLISTAER POW BA 50 MCGBLIST AERPOW BA)


FLOVENT DISKUS 250 MCGBLISTAER POW BA


FLOVENT HFA (110 MCGACTAEROSOL 220 MCGACTAEROSOL)


FLOVENT HFA 44 MCGACTAEROSOL


FLUNISOLIDE 25 MCGACT(0025) SOLUTION


fluticasone propionate nasal susp50 mcgact



111




PULMICORT FLEXHALER (180MCGACT AER POW BA 90MCGACT AER POW BA)


QVAR REDIHALER (40 MCGACTAERO BA 80 MCGACT AEROBA)


ANTIHISTAMINESazelastine hcl (01 (137 mcg)015 (2055 mcg))


cyproheptadine hcl tab 4 mg Tier 2 PA

hydroxyzine hcl (tab 10 mg tab25 mg tab 50 mg)

Tier 2 PA

levocetirizine dihydrochloride tab5 mg

Tier 2

promethazine hcl (inj 25 mgmlinj 50 mgml syrup 625 mg5ml)

Tier 2 PA

ANTILEUKOTRIENESmontelukast sodium (chew tab 4mg (base equiv) chew tab 5 mg(base equiv) oral granulespacket 4 mg (base equiv) tab10 mg (base equiv))


zafirlukast (tab 10 mg tab 20 mg) Tier 2 QL (2 PER 1 DAYS)

BRONCHODILATORS ANTICHOLINERGICATROVENT HFA 17 MCGACTAERO SOLN


INCRUSE ELLIPTA 625 MCGINHAER POW BA


ipratropium bromide inhal soln002

Tier 2 BvD

ipratropium bromide nasal soln003 (21 mcgspray)




SPIRIVA HANDIHALER 18 MCGCAP



112




SPIRIVA RESPIMAT (125MCGACT AERO SOLN 25MCGACT AERO SOLN)


BRONCHODILATORS SYMPATHOMIMETICalbuterol 90mcg hfa inhaler(generic proair)


albuterol 90mg hfa inhaler(generic proair)


albuterol 90mg hfa inhaler(generic proventil)


albuterol 90mg hfa inhaler(generic ventolin)


albuterol sulfate (soln nebu0083 (25 mg3ml) soln nebu05 (5 mgml) soln nebu 063mg3ml (base equiv) soln nebu125 mg3ml (base equiv))

Tier 2 BvD

albuterol sulfate (tab 2 mg tab 4mg)

Tier 2

epinephrine (anaphylaxis)(solution auto-injector 015mg03ml (12000) solution auto-injector 03 mg03ml (11000))


EPINEPHRINE 03 MG03ML SOLNA-INJ


EPINEPHRINE AUTOINJECTOR(GENERIC ADRENACLICK)


levalbuterol hcl (soln nebu 031mg3ml (base equiv) soln nebu063 mg3ml (base equiv) solnnebu 125 mg3ml (base equiv)soln nebu conc 125 mg05ml(base equiv))

Tier 2 PA

LEVALBUTEROL TARTRATE 45MCGACT AEROSOL


SEREVENT DISKUS 50 MCGDOSEAER POW BA


STRIVERDI RESPIMAT 25MCGACT AERO SOLN



113




CYSTIC FIBROSIS AGENTSCAYSTON 75 MG RECON SOLN Tier 3 PA LA QL (84 PER 28

OVER TIME)

KALYDECO (150 MG TAB 25 MGPACKET 50 MG PACKET 75 MGPACKET)


PULMOZYME 25 MG25MLSOLUTION


SYMDEKO (100-150 amp 150 MG TABTHPK 50-75 amp 75 MG TAB THPK)


TOBI PODHALER 28 MG CAP Tier 3 PA LA QL (224 PER 28OVER TIME)

tobramycin nebu soln 300mg4ml




TRIKAFTA (100-50-75 amp 150 MGTAB THPK 50-25-375 amp 75 MG TABTHPK)


MAST CELL STABILIZERScromolyn sodium soln nebu 20mg2ml

Tier 2 BvD

PHOSPHODIESTERASE INHIBITORS AIRWAYS DISEASEDALIRESP 250 MCG TAB Tier 3 PA QL (28 PER 180

OVER TIME)

DALIRESP 500 MCG TAB Tier 3 PA QL (1 PER 1 DAYS)

theophylline (soln 80 mg15mltab er 12hr 100 mg tab er 12hr200 mg tab er 12hr 300 mg taber 12hr 450 mg tab er 24hr 400mg tab er 24hr 600 mg)

Tier 2

THEOPHYLLINE ER (300 MG TAB ER12H 450 MG TAB ER 12H)

Tier 2


114




PULMONARY ANTIHYPERTENSIVESADEMPAS (05 MG TAB 1 MGTAB 15 MG TAB 2 MG TAB 25MG TAB)


ambrisentan (tab 10 mg tab 5mg)


bosentan tab 125 mg Tier 2 PA LA QL (2 PER 1DAYS)


OPSUMIT 10 MG TAB Tier 3 PA LA QL (1 PER 1DAYS)

sildenafil citrate for suspension 10mgml


sildenafil citrate tab 20 mg Tier 3 PA QL (3 PER 1 DAYS)

tadalafil tab 20 mg (pah) Tier 2 PA QL (2 PER 1 DAYS)

TRACLEER 32 MG TAB SOL Tier 3 PA LA QL (4 PER 1DAYS)

VENTAVIS 10 MCGML SOLUTION Tier 3 LA QL (270 PER 30 OVERTIME) BvD


PULMONARY FIBROSIS AGENTSESBRIET (267 MG CAP 267 MGTAB)


ESBRIET 801 MG TAB Tier 3 PA LA QL (3 PER 1DAYS)

OFEV (100 MG CAP 150 MGCAP)


RESPIRATORY TRACT AGENTS OTHERacetylcysteine (soln 10 soln20)

Tier 2 BvD

ANORO ELLIPTA 625-25 MCGINHAER POW BA



115




BEVESPI AEROSPHERE 9-48MCGACT AEROSOL


COMBIVENT RESPIMAT 20-100MCGACT AERO SOLN


FLUTICASONE-SALMETEROL (113-14 MCGACT AER POW BA 232-14 MCGACT AER POW BA 55-14MCGACT AER POW BA)


fluticasone-salmeterol (aerpowder ba 100-50 mcgdoseaer powder ba 250-50mcgdose aer powder ba 500-50 mcgdose)


ipratropium-albuterol nebu soln05-25(3) mg3ml

Tier 2 BvD

NUCALA (100 MG RECON SOLN100 MGML SOLN A-INJ 100MGML SOLN PRSYR)


ribavirin for inhal soln 6 gm Tier 2 BvD

TRELEGY ELLIPTA (100-625-25MCGINH AER POW BA 200-625-25 MCGINH AER POW BA)


SKELETAL MUSCLE RELAXANTS



SKELETAL MUSCLE RELAXANTScarisoprodol tab 350 mg Tier 2 PA QL (4 PER 1 DAYS)

cyclobenzaprine hcl (tab 10 mgtab 5 mg)

Tier 2 PA

methocarbamol (tab 500 mgtab 750 mg)

Tier 2 PA


116

SLEEP DISORDER AGENTS



SLEEP PROMOTING AGENTSestazolam (tab 1 mg tab 2 mg) Tier 2 QL (1 PER 1 DAYS)

eszopiclone (tab 1 mg tab 2 mgtab 3 mg)


HETLIOZ 20 MG CAP Tier 3 PA LA QL (1 PER 1DAYS)

ramelteon tab 8 mg Tier 2 QL (1 PER 1 DAYS)

temazepam cap 15 mg Tier 2 QL (2 PER 1 DAYS)


triazolam tab 0125 mg Tier 2 QL (4 PER 1 DAYS)


zaleplon cap 10 mg Tier 2 QL (2 PER 1 DAYS)


zolpidem tartrate tab 10 mg Tier 2 QL (1 PER 1 DAYS)


WAKEFULNESS PROMOTING AGENTSmodafinil tab 100 mg Tier 2 PA QL (3 PER 1 DAYS)

modafinil tab 200 mg Tier 2 PA QL (2 PER 1 DAYS)

XYREM 500 MGML SOLUTION Tier 3 PA LA QL (540 PER 30OVER TIME)


117

Non-Part D Drugs



NONSTEROIDAL ANTI-INFLAMMATORY DRUGSaspirin ((300 mg suppos 600 mgsuppos chew tab 81 mg tab 325mg tab delayed release 325 mgtab delayed release 81 mg) 300mg suppos 600 mg supposchew tab 81 mg tab 325 mgtab delayed release 325 mg)

Tier 4 NPD

aspirin buffered (ca carb-mgcarb-mg ox) tab 325 mg

Tier 4 NPD

BAYER PLUS 500 MG TAB Tier 4 NPD

ibuprofen ((cap 200 mg chewtab 100 mg susp 40 mgml tab100 mg tab 200 mg) cap 200mg chew tab 100 mg susp 40mgml tab 100 mg)

Tier 4 NPD

SMOKING CESSATION AGENTSnicotine ((patch 24hr 14 mg24hrpatch 24hr 21 mg24hr patch24hr 7 mg24hr) td patch 24hr 14mg24hr td patch 24hr 21mg24hr)

Tier 4 NPD

nicotine polacrilex ((gum 2 mggum 4 mg lozenge 2 mglozenge 4 mg) gum 2 mg gum 4mg lozenge 2 mg)

Tier 4 NPD

ANTIBACTERIALS OTHERbacitracin oint 500 unitgm Tier 4 NPD

bacitracin zinc oint 500 unitgm Tier 4 NPD

bacitracin-polymyxin b oint Tier 4 NPD

neomycin-bacitracin-polymyxinoint

Tier 4 NPD

neomycin-polymyxin wpramoxine cream 1

Tier 4 NPD

ANTIEMETICS OTHERmeclizine hcl chew tab 25 mg Tier 4 NPD


118

Non-Part D Drugs



ANTIFUNGALSclotrimazole vaginal cream 1 Tier 4 NPD

miconazole nitrate vaginal((cream 2 suppos 100 mg)cream 2)

Tier 4 NPD

tioconazole vaginal oint 65 Tier 4 NPD

tolnaftate cream 1 Tier 4 NPD

ANTHELMINTHICSpyrantel pamoate susp 144mgml (50 mgml base equiv)

Tier 4 NPD

ANTIHERPETIC AGENTSdocosanol cream 10 Tier 4 NPD

GLYCEMIC AGENTSGLUCOSE CHEW TAB 4 GM Tier 4 NPD

GLUCOSE-VITAMIN C CHEW TAB4-6 GM-MG

Tier 4 NPD

HEMOSTASIS AGENTSphytonadione tab 100 mcg Tier 4 NPD

phytonadione tab 5 mg Tier 4 QL (5 PER 7 OVER TIME)NPD

DYSLIPIDEMICS OTHERniacin ((cap er 250 mg cap er500 mg tab 100 mg tab 250 mgtab 50 mg tab 500 mg tab er250 mg tab er 500 mg tab er750 mg) cap er 250 mg cap er500 mg tab 100 mg tab 250 mgtab 50 mg tab 500 mg tab er250 mg tab er 500 mg)

Tier 4 NPD

NIACIN ER 1000 MG TAB ER Tier 4 NPD

niacinamide tab 500 mg Tier 4 NPD


119

Non-Part D Drugs



CENTRAL NERVOUS SYSTEM OTHERacetaminophen ((tab 325 mgtab 500 mg) tab 325 mg)

Tier 4 NPD

phentermine hcl ((cap 15 mgcap 30 mg) cap 15 mg)

Tier 4 PA NPD

QSYMIA ((1125-69 MG CAP ER24H 15-92 MG CAP ER 24H 375-23 MG CAP ER 24H 75-46 MGCAP ER 24H) 1125-69 MG CAPER 24H 15-92 MG CAP ER 24H375-23 MG CAP ER 24H)

Tier 4 PA NPD

DERMATITIS AND PRURITUS AGENTSCALAMINE LOTION Tier 4 NPD

hydrocortisone (topical) ((cream05 cream 1 oint 05)cream 05 cream 1)

Tier 4 NPD

hydrocortisone-aloe vera((cream 05 cream 1) cream05)

Tier 4 NPD

selenium sulfide lotion 1 Tier 4 NPD

DERMATOLOGICAL AGENTS OTHERbenzoyl peroxide ((cream 10gel 10 liq 10) cream 10 gel10)

Tier 4 NPD

CALAMINE LOTION Tier 4 NPD

CALAMINE-ZINC OXIDE 8-8 SUSPENSION

Tier 4 NPD

EQ CALAMINE 8-8 SUSPENSION Tier 4 NPD

GOODSENSE CALAMINE 8-8 SUSPENSION

Tier 4 NPD

RA CALAMINE 8-8 SUSPENSION Tier 4 NPD

RA DAYLOGIC ACNE FOAMINGWASH 10 FOAM

Tier 4 NPD


120

Non-Part D Drugs



PEDICULICIDESSCABICIDESCVS LICE SOLUTION 3-STEP KIT Tier 4 NPD

NIX COMPLETE LICE TREATMENT 1amp 025 KIT

Tier 4 NPD

permethrin ((creme rinse 1lotion 1) creme rinse 1)

Tier 4 NPD

pyreth-piperonyl butox sham-permeth aero-nit remover gel kit

Tier 4 NPD

pyrethrins-piperonyl butoxide ((liq033-4 shampoo 033-4) liq033-4)

Tier 4 NPD

RID 033-4 LIQUID Tier 4 NPD

RID COMPLETE LICE ELIMINATIONKIT

Tier 4 NPD

RID ESSENTIAL LICE ELIMINATION033-4 KIT

Tier 4 NPD

ELECTROLYTEMINERAL REPLACEMENTferrous sulfate ((tab 27 mg(elemental fe) tab 325 mg (65mg elemental fe)) tab 27 mg(elemental fe))

Tier 4 NPD

oral electrolyte solution Tier 4 NPD

VITAMINSascorbic acid ((tab 1000 mg tab250 mg) tab 1000 mg)

Tier 4 NPD

B-12 5000 MCG TAB DISP Tier 4 NPD

B-12 DOTS 500 MCG TAB DISP Tier 4 NPD

CALCI-CHEW 1250 (500 CA) MGCHEW TAB

Tier 4 NPD

calcium ascorbate tab 500 mg Tier 4 NPD


121

Non-Part D Drugs



calcium carbonate ((1250 (500ca) mg chew tab tab 1250 mg(500 mg elemental ca) tab 1500mg (600 mg elemental ca) tab600 mg) 1250 (500 ca) mg chewtab tab 1250 mg (500 mgelemental ca) tab 1500 mg (600mg elemental ca))

Tier 4 NPD

calcium carbonate-cholecalciferol ((tab 250 mg-125unit tab 500 mg-125 unit tab 500mg-200 unit tab 500 mg-400 unittab 500 mg-600 unit) tab 250mg-125 unit tab 500 mg-125 unittab 500 mg-200 unit tab 500 mg-400 unit)

Tier 4 NPD

calcium carbonate-ergocalciferol tab 500mg-200unit

Tier 4 NPD

calcium carbonate-vitamin d((tab 250 mg-125 unit tab 500mg-125 unit tab 500 mg-200unit) tab 250 mg-125 unit tab500 mg-125 unit)

Tier 4 NPD

CALCIUM GLUCONATE ((50 MGTAB 500 MG TAB) 50 MG TAB)

Tier 4 NPD

calcium tab 600 mg Tier 4 NPD

CALCIUMCD 500-10-250 MG-MG-UNIT CHEW TAB

Tier 4 NPD

CHEWABLE CALCIUMD3 500-15MG-MCG WAFER

Tier 4 NPD

ferrous sulfate ((220 (44 fe)mg5ml liquid elixir 220 mg5ml(44 mg5ml fe) soln 75 mgml (15mgml fe) syrup 300 mg5ml (60mg5ml fe) tab ec 325 mg (65mg fe equivalent)) 220 (44 fe)mg5ml liquid elixir 220 mg5ml(44 mg5ml fe) soln 75 mgml (15mgml fe) syrup 300 mg5ml (60mg5ml fe))

Tier 4 NPD

ferrous sulfate dried tab 200 mg(65 mg elemental fe)

Tier 4 NPD


122

Non-Part D Drugs



folic acid ((cap 08 mg tab 1mg tab 400 mcg tab 800 mcg)cap 08 mg tab 1 mg tab 400mcg)

Tier 4 NPD

MAG-G 500 (27 MG) MG TAB Tier 4 NPD

magnesium gluconate tab 500mg (27 mg elemental mg)

Tier 4 NPD

omega-3 fatty acids cap 1000mg

Tier 4 NPD

OYSTER SHELL CALCIUM 500 + D500-125 MG-UNIT TAB

Tier 4 NPD

oyster shell calcium tab 500 mg Tier 4 NPD

OYSTER SHELL CALCIUMD 500-200 MG-UNIT TAB

Tier 4 NPD

PRE-NATAL FORMULA TAB Tier 4 NPD

PRENATAL (WIRON amp FA) 27-08MG TAB

Tier 4 NPD

PRENATAL FORTE TAB Tier 4 NPD

PRENATAL VITAMIN WITH IRONTAB 27-08 MG

Tier 4 NPD


Tier 4 NPD

PRENATALIRON TAB Tier 4 NPD

pyridoxine hcl ((tab 100 mg tab50 mg) tab 100 mg)

Tier 4 NPD

RA OYSTER SHELL CALCIUMD2500-200 MG-UNIT TAB

Tier 4 NPD

riboflavin ((tab 100 mg tab 50mg) tab 100 mg)

Tier 4 NPD

thiamine hcl tab 100 mg Tier 4 NPD

thiamine mononitrate tab 100mg

Tier 4 NPD

vitamin a cap 3 mg (10000 unit) Tier 4 NPD


123

Non-Part D Drugs



vitamin e ((cap 180 mg (400unit) cap 268 mg (400 unit) cap400 unit) cap 180 mg (400 unit)cap 268 mg (400 unit))

Tier 4 NPD

VITAMIN K 100 MCG TAB Tier 4 NPD

ANTI-CONSTIPATION AGENTSbisacodyl ((suppos 10 mg tabdelayed release 5 mg) suppos10 mg)

Tier 4 NPD

docusate sodium ((cap 100 mgcap 250 mg liquid 150 mg15ml)cap 100 mg cap 250 mg)

Tier 4 NPD

glycerin (laxative) ((suppos 1 gmsuppos 12 gm suppos 2 gmsuppos 21 gm suppos 807)suppos 1 gm suppos 12 gmsuppos 2 gm suppos 21 gm)

Tier 4 NPD

magnesium citrate soln Tier 4 NPD

polyethylene glycol 3350 ((oralpacket 17 gm oral powder 17gmscoop) oral packet 17 gm)

Tier 4 NPD

sennosides tab 86 mg Tier 4 NPD

ANTI-DIARRHEAL AGENTSANTI-DIARRHEAL 1 MG5MLLIQUID

Tier 4 NPD

loperamide hcl ((liq 1 mg5ml(02 mgml) liq 1 mg75ml tab 2mg) liq 1 mg5ml (02 mgml) liq1 mg75ml)

Tier 4 NPD

GASTROINTESTINAL AGENTS OTHERALLI 60 MG CAP Tier 4 PA NPD

alum amp mag hydrox-simethicone((mag hydroxide-simethiconesusp 200-200-20 mg5ml maghydroxide-simethicone susp 400-400-40 mg5ml) mag hydroxide-simethicone susp 200-200-20mg5ml)

Tier 4 NPD


124

Non-Part D Drugs



ALUMINUM HYDROXIDE GEL 320MG5ML SUSPENSION

Tier 4 NPD

aluminum hydroxide-magnesiumcarbonate chew tab 160-105 mg

Tier 4 NPD

aluminum hydroxide-magnesiumtrisilicate chew tab 80-20 mg

Tier 4 NPD

bismuth subsalicylate ((chew tab262 mg susp 525 mg15ml tab262 mg) chew tab 262 mg susp525 mg15ml)

Tier 4 NPD

calcium carbonate (antacid)((chew tab 500 mg chew tab750 mg) chew tab 500 mg)

Tier 4 NPD

CALCIUM CARBONATE ANTACID648 MG TAB

Tier 4 NPD

simethicone ((cap 125 mg chewtab 80 mg susp 40 mg06ml)cap 125 mg chew tab 80 mg)

Tier 4 NPD

SM FOAMING ANTACID 80-20 MGCHEW TAB

Tier 4 NPD

sodium bicarbonate tab 325 mg Tier 4 NPD

HISTAMINE2 (H2) RECEPTOR ANTAGONISTSfamotidine tab 10 mg Tier 4 NPD

PROTON PUMP INHIBITORSomeprazole delayed release tab20 mg

Tier 4 NPD

GENITOURINARY AGENTS OTHEROPTIONS GYNOL IICONTRACEPTIVE 3 GEL

Tier 4 NPD

VCF VAGINAL CONTRACEPTIVE((125 FOAM 4 GEL) 125 FOAM)

Tier 4 NPD

PROGESTINSlevonorgestrel tab 15 mg Tier 4 NPD


125

Non-Part D Drugs



METABOLIC BONE DISEASE AGENTSergocalciferol ((cap 125 mg(50000 unit) soln 200 mcgml(8000 unitml)) cap 125 mg(50000 unit))

Tier 4 NPD

VITAMIN D2 10 MCG (400 UNIT)TAB

Tier 4 NPD

MISCELLANEOUS THERAPEUTIC AGENTSAEROCHAMBER MINI CHAMBERDEVICE

Tier 4 QL (2 PER 365 OVERTIME) NPD

AEROCHAMBER MV MISC Tier 4 QL (2 PER 365 OVERTIME) NPD

AEROCHAMBER PLUS FLO-VUMISC


AEROCHAMBER PLUS FLO-VULARGE MISC


AEROCHAMBER PLUS FLO-VUMEDIUM MISC


AEROCHAMBER PLUS FLO-VUSMALL MISC


AEROCHAMBER PLUS FLO-VUWMASK MISC


AEROCHAMBER PLUS FLOW VUMISC


AEROCHAMBER WFLOWSIGNALMISC


AEROCHAMBER Z-STAT PLUSMISC


AEROCHAMBER Z-STAT PLUSCHAMBR MISC


AEROCHAMBER Z-STATPLUSLARGE MISC


AEROCHAMBER Z-STATPLUSMEDIUM MISC


AEROCHAMBER Z-STATPLUSSMALL MISC



126

Non-Part D Drugs



AEROVENT PLUS DEVICE Tier 4 QL (2 PER 365 OVERTIME) NPD

ARIAL CHAMBER DEVICE Tier 4 QL (2 PER 365 OVERTIME) NPD

BREATHE EASE LARGE DEVICE Tier 4 QL (2 PER 365 OVERTIME) NPD

BREATHE EASE MEDIUM DEVICE Tier 4 QL (2 PER 365 OVERTIME) NPD

BREATHE EASE SMALL DEVICE Tier 4 QL (2 PER 365 OVERTIME) NPD

BREATHERITE MISC Tier 4 QL (2 PER 365 OVERTIME) NPD

BREATHERITE COLL SPACER ADULTMISC


BREATHERITE COLL SPACER CHILDMISC


BREATHERITE COLL SPACERINFANT MISC


BREATHERITE RIGID SPACERMASKMISC


BREATHERITE SPACER NEONATEMISC


BREATHERITE SPACER SMALLCHILD MISC


BREATHERITELARGE MASK MISC Tier 4 QL (2 PER 365 OVERTIME) NPD

BREATHERITEMEDIUM MASKMISC


BREATHERITESMALL MASK MISC Tier 4 QL (2 PER 365 OVERTIME) NPD

CLEVER CHOICE HOLDINGCHAMBER DEVICE


COMPACT SPACE CHAMBERDEVICE


COMPACT SPACE CHAMBERLGMASK DEVICE



127

Non-Part D Drugs



COMPACT SPACECHAMBERMED MASK DEVICE


COMPACT SPACE CHAMBERSMMASK DEVICE


CONDOMS LATEX LUBRICATED Tier 4 NPD

cromolyn sodium nasal aerosolsoln 52 mgact (4)

Tier 4 NPD

EASIVENT MISC Tier 4 QL (2 PER 365 OVERTIME) NPD

EASIVENT MASK LARGE MISC Tier 4 QL (2 PER 365 OVERTIME) NPD

EASIVENT MASK MEDIUM MISC Tier 4 QL (2 PER 365 OVERTIME) NPD

EASIVENT MASK SMALL MISC Tier 4 QL (2 PER 365 OVERTIME) NPD

EQ SPACE CHAMBER ANTI-STATICDEVICE


EQ SPACE CHAMBER ANTI-STATICL DEVICE


EQ SPACE CHAMBER ANTI-STATICM DEVICE


EQ SPACE CHAMBER ANTI-STATICS DEVICE


FLEXICHAMBER DEVICE Tier 4 QL (2 PER 365 OVERTIME) NPD

INSPIRACHAMBERLARGEDEVICE


INSPIRACHAMBERMEDIUMDEVICE


INSPIRACHAMBERMOUTHPIECEDEVICE


INSPIRACHAMBERSMALLDEVICE


INSPIREASE MISC Tier 4 QL (2 PER 365 OVERTIME) NPD

LITEAIRE DEVICE Tier 4 QL (2 PER 365 OVERTIME) NPD


128

Non-Part D Drugs



MICROCHAMBER ((DEVICEMISC) DEVICE)


MICROSPACER MISC Tier 4 QL (2 PER 365 OVERTIME) NPD

OPTICHAMBER ADVANTAGE-LGMASK MISC


OPTICHAMBER ADVANTAGE-MEDMASK MISC


OPTICHAMBER ADVANTAGE-SMMASK MISC


OPTICHAMBER DIAMOND MISC Tier 4 QL (2 PER 365 OVERTIME) NPD

OPTICHAMBER DIAMOND-LGMASK DEVICE


OPTICHAMBER DIAMOND-MDMASK MISC


OPTICHAMBER DIAMOND-SMMASK MISC


OPTICHAMBER FACE MASK-LARGE MISC


OPTICHAMBER FACE MASK-MEDIUM MISC


OPTICHAMBER FACE MASK-SMALL MISC


OPTIHALER ((DEVICE MISC)DEVICE)


POCKET CHAMBER DEVICE Tier 4 QL (2 PER 365 OVERTIME) NPD

POCKET SPACER DEVICE Tier 4 QL (2 PER 365 OVERTIME) NPD

PRO COMFORT SPACER ADULTMISC


PRO COMFORT SPACER CHILDMISC


PRO COMFORT SPACER INFANTDEVICE



129

Non-Part D Drugs



PROCARE SPACERADULT MASKDEVICE


PROCARE SPACERCHILD MASKDEVICE


RITEFLO DEVICE Tier 4 QL (2 PER 365 OVERTIME) NPD

saline nasal spray 065 Tier 4 NPD

SAXENDA 18 MG3ML SOLN PEN Tier 4 PA NPD

VALVED HOLDING CHAMBERDEVICE


VORTEX VALVED HOLDINGCHAMBER DEVICE


WATCHHALER DEVICE Tier 4 QL (2 PER 365 OVERTIME) NPD

OPHTHALMIC AGENTS OTHEReye wash Tier 4 NPD

MURO 128 2 SOLUTION Tier 4 NPD

naphazoline w pheniramineophth soln 0027-0315

Tier 4 NPD

polyvinyl alcohol ophth soln 14 Tier 4 NPD

sodium chloride hypertonicophth soln 5

Tier 4 NPD

OPHTHALMIC ANTI-ALLERGY AGENTSketotifen fumarate ophth soln0025 (base equiv)

Tier 4 NPD

OTIC AGENTScarbamide peroxide 65 oticsoln

Tier 4 NPD

ANTI-INFLAMMATORIES INHALED CORTICOSTEROIDSNASACORT ALLERGY 24HR 55MCGACT AEROSOL

Tier 4 NPD

NASACORT ALLERGY 24HRCHILDREN 55 MCGACTAEROSOL

Tier 4 NPD


130

Non-Part D Drugs



triamcinolone acetonide nasalaerosol suspension 55 mcgact

Tier 4 NPD

ANTIHISTAMINEScetirizine hcl ((tab 10 mg tab 5mg) tab 10 mg)

Tier 4 NPD

chlorpheniramine maleate syrup2 mg5ml

Tier 4 NPD

diphenhydramine hcl ((cap 25mg elixir 125 mg5ml liquid 125mg5ml tab 25 mg) cap 25 mgelixir 125 mg5ml liquid 125mg5ml)

Tier 4 NPD

fexofenadine hcl ((tab 180 mgtab 60 mg) tab 180 mg)

Tier 4 NPD

loratadine ((rapidly-disintegratingtab 10 mg tab 10 mg) rapidly-disintegrating tab 10 mg)

Tier 4 NPD

BRONCHODILATORS SYMPATHOMIMETICNASAL DECONGESTANT ((30MG5ML LIQUID 30 MG5MLSYRUP) 30 MG5ML LIQUID)

Tier 4 NPD

pseudoephedrine hcl ((tab 30mg tab 60 mg) tab 30 mg)

Tier 4 NPD

RESPIRATORY TRACT AGENTS OTHERbenzonatate ((cap 100 mg cap200 mg) cap 100 mg)

Tier 4 NPD

guaifenesin liquid 100 mg5ml Tier 4 NPD

guaifenesin-codeine soln 100-10mg5ml

Tier 4 QL (420 PER 30 OVERTIME) NDS NPD

HYCODAN 5-15 MG5ML SYRUP Tier 4 QL (210 PER 30 OVERTIME) NDS NPD

hydrocodone w homatropinesyrup 5-15 mg5ml


promethazine w codeine syrup625-10 mg5ml

Tier 4 PA QL (240 PER 30OVER TIME) NDS NPD


131

Non-Part D Drugs



promethazine-dm ((625-15mg5ml solution syrup 625-15mg5ml) 625-15 mg5mlsolution)

Tier 4 PA NPD

promethazine-phenylephrine-codeine syrup 625-5-10 mg5ml


triprolidine amp pseudoephedrinetab 25-60 mg

Tier 4 NPD


132

Index

Aabacavir sulfate 46abacavir sulfate-lamivudine 46abacavir sulfate-lamivudine-zidovudine 47ABELCET 22ABILIFY MAINTENA 41abiraterone acetate 27acamprosate calcium 5acarbose 52acebutolol hcl 61acetaminophen 120acetaminophen w codeine 2acetazolamide 64110acetic acid (otic) 7acetylcysteine 115acitretin 74ACTHAR 86ACTHIB 99ACTIMMUNE 97acyclovir 50acyclovir sodium 50acyclovir topical 77ADACEL 99adapalene 74adefovir dipivoxil 44ADEMPAS 115ADVOCATE ALCOHOL PREP PADS 103AEROCHAMBER MINI CHAMBER 126AEROCHAMBER MV 126AEROCHAMBER PLUS FLO-VU 126AEROCHAMBER PLUS FLO-VU LARGE 126AEROCHAMBER PLUS FLO-VU MEDIUM 126AEROCHAMBER PLUS FLO-VU SMALL 126AEROCHAMBER PLUS FLO-VU WMASK 126AEROCHAMBER PLUS FLOW VU 126AEROCHAMBER WFLOWSIGNAL 126AEROCHAMBER Z-STAT PLUS 126AEROCHAMBER Z-STAT PLUS CHAMBR 126AEROCHAMBER Z-STAT PLUSLARGE 126AEROCHAMBER Z-STAT PLUSMEDIUM 126AEROCHAMBER Z-STAT PLUSSMALL 126AEROVENT PLUS 127

AFINITOR 30AFINITOR DISPERZ 3031AIMOVIG 25AIMOVIG (140 MG DOSE) 25albendazole 37albuterol 90mcg hfa inhaler (genericproair) 113albuterol 90mg hfa inhaler (genericproair) 113albuterol 90mg hfa inhaler (genericproventil) 113Albuterol 90mg HFA inhaler (GenericVentolin) 113albuterol sulfate 113alclometasone dipropionate 7486ALCOHOL 70 PADS 103ALCOHOL PREP 103ALCOHOL WIPES 103ALDURAZYME 84ALECENSA 31alendronate sodium 102alfuzosin hcl 86ALINIA 37aliskiren fumarate 64ALLI 124allopurinol 24alosetron hcl 82ALPHAGAN P 110alprazolam 50ALREX 109alum amp mag hydrox-simethicone 124ALUMINUM HYDROXIDE GEL 125aluminum hydroxide-mag carb 125aluminum hydroxide-mag trisil 125ALUNBRIG 31amantadine hcl 38AMBISOME 22ambrisentan 115amikacin sulfate 6amiloride amp hydrochlorothiazide 64amiloride hcl 67AMINO ACID 77amino acid electrolyte infusion 77

133

amino acid infusion 77AMINOSYN 77AMINOSYN II 77AMINOSYN-HBC 77AMINOSYN-PF 78AMINOSYN-RF 78AMINOSYNELECTROLYTES 78amiodarone hcl 61AMITIZA 81amitriptyline hcl 20amlodipine besylate 62amlodipine besylate-benazepril hcl 64amlodipine besylate-olmesartanmedoxomil 64amlodipine besylate-valsartan 64amlodipine-valsartan-hydrochlorothiazide 64AMOXAPINE 20AMOXICILLIN 10amoxicillin amp pot clavulanate 10AMOXICILLIN-POT CLAVULANATE 10amphetamine-dextroamphetamine 70AMPHOTERICIN B 22AMPICILLIN 10ampicillin amp sulbactam sodium 10ampicillin sodium 11AMPICILLIN-SULBACTAM SODIUM 11ANADROL-50 89anagrelide hcl 57anastrozole 30ANDRODERM 89ANORO ELLIPTA 115ANTI-DIARRHEAL 124APOKYN 38apraclonidine hcl 110aprepitant 22APTIOM 16APTIVUS 48ARALAST NP 84ARANESP (ALBUMIN FREE) 57ARCALYST 96ARIAL CHAMBER 127aripiprazole 41ARISTADA 41ARISTADA INITIO 41

ascorbic acid 121asenapine maleate 41aspirin 118aspirin buffered (cal carb-mag carb-magoxide) 118aspirin-dipyridamole 58atazanavir sulfate 48atenolol 61atenolol amp chlorthalidone 64atomoxetine hcl 71atorvastatin calcium 68atovaquone 37atovaquone-proguanil hcl 37ATROPINE SULFATE 107ATROVENT HFA 112AUBAGIO 72AURYXIA 80AUSTEDO 71AVONEX 72AVONEX PEN 73AVONEX PREFILLED 73AYVAKIT 28azathioprine 97AZATHIOPRINE SODIUM 97azelastine hcl 112azelastine hcl (ophth) 108azithromycin 12AZOPT 110aztreonam 7

BB-12 121B-12 DOTS 121BACITRACIN 108bacitracin (topical) 118bacitracin zinc 118bacitracin-poly-neomycin-hc 107bacitracin-polymyxin b (ophth) 107bacitracin-polymyxin b oint 118baclofen 44balsalazide disodium 101BALVERSA 31BAQSIMI ONE PACK 54BAQSIMI TWO PACK 54BARACLUDE 44

134

BAYER PLUS 118BCG VACCINE 99BD ECLIPSE SYRINGE 103BD INSULIN SYRINGE 103BD Pen Needle Mini UF 31G X 5 MMMISC 103BD Pen Needle Nano UF 32G X 4 MMMISC 103BD Pen Needle Original UF 29G X 127MMMISC 103BD Pen Needle Short UF 31G X 8 MMMISC 104benazepril amp hydrochlorothiazide 64benazepril hcl 60BENAZEPRIL-HYDROCHLOROTHIAZIDE 64BENLYSTA 96BENZNIDAZOLE 37benzonatate 131benzoyl peroxide 120benztropine mesylate 38BERINERT 95BESIVANCE 12betamethasone dipropionate(topical) 7486BETAMETHASONE DIPROPIONATE AUG 74betamethasone dipropionateaugmented 7586betamethasone valerate 75BETASERON 73betaxolol hcl 61betaxolol hcl (ophth) 109bethanechol chloride 86BEVESPI AEROSPHERE 116bexarotene 36BEXSERO 99bicalutamide 27BICILLIN L-A 11BIKTARVY 45bimatoprost 110BIOGUARD GAUZE SPONGES 104bisacodyl 124bismuth subsalicylate 125bisoprolol amp hydrochlorothiazide 64bisoprolol fumarate 61BIVIGAM 95

BOOSTRIX 99bosentan 115BOSULIF 31BRAFTOVI 31BREATHE EASE LARGE 127BREATHE EASE MEDIUM 127BREATHE EASE SMALL 127BREATHERITE 127BREATHERITE COLL SPACER ADULT 127BREATHERITE COLL SPACER CHILD 127BREATHERITE COLL SPACER INFANT 127BREATHERITE RIGID SPACERMASK 127BREATHERITE SPACER NEONATE 127BREATHERITE SPACER SMALL CHILD 127BREATHERITELARGE MASK 127BREATHERITEMEDIUM MASK 127BREATHERITESMALL MASK 127BRILINTA 58brimonidine tartrate 110BRIVIACT 1314bromocriptine mesylate 38BRUKINSA 28budesonide 101102budesonide (inhalation) 111bumetanide 66buprenorphine hcl 5buprenorphine hcl-naloxone hcldihydrate 5bupropion hcl 18bupropion hcl (smoking deterrent) 6buspirone hcl 50butalbital-acetaminophen-caffeine 71butalbital-acetaminophen-caffeine wcodeine 2

CCABENUVA 48cabergoline 93CABLIVI 58CABOMETYX 31CALAMINE LOTION 120CALAMINE-ZINC OXIDE 120CALCI-CHEW 121calcipotriene 76calcitonin (salmon) 102

135

calcitriol 102calcium 122calcium acetate (phosphate binder) 80calcium ascorbate 121calcium carbonate 122calcium carbonate (antacid) 125CALCIUM CARBONATE ANTACID 125calcium carbonate-cholecalciferol 122calcium carbonate-ergocalciferol 122calcium carbonate-vitamin d 122CALCIUM GLUCONATE 122CALCIUMCD 122CALQUENCE 31candesartan cilexetil 60candesartan cilexetil-hydrochlorothiazide 64CAPASTAT SULFATE 26CAPLYTA 41CAPRELSA 31captopril 60CAPTOPRIL-HYDROCHLOROTHIAZIDE 65CARBAGLU 78carbamazepine 16carbamide peroxide (otic) 130carbidopa 39CARBIDOPA-LEVODOPA 39CARBIDOPA-LEVODOPA-ENTACAPONE 38CAREONE UNIFINE PENTIPS PLUS 104CARETOUCH INSULIN SYRINGE 104carisoprodol 116CARTEOLOL HCL 109carteolol hcl (ophth) 109carvedilol 62caspofungin acetate 23CAYSTON 114cefaclor 9cefadroxil 9cefazolin sodium 9cefdinir 9cefepime hcl 9cefixime 9cefotaxime sodium 9cefotetan disodium 9cefoxitin sodium 9cefpodoxime proxetil 9

cefprozil 9ceftazidime 9ceftriaxone sodium 9cefuroxime axetil 9cefuroxime sodium 10celecoxib 1CELONTIN 15cephalexin 10CERDELGA 84CEREZYME 84cetirizine hcl 131CHANTIX 6CHANTIX CONTINUING MONTH PAK 6CHANTIX STARTING MONTH PAK 6CHEWABLE CALCIUMD3 122chlordiazepoxide hcl 51chlorhexidine gluconate (mouth-throat)74chloroquine phosphate 37chlorothiazide 67chlorpheniramine maleate 131chlorpromazine hcl 40chlorthalidone 67CHOLBAM 84cholestyramine 68cholestyramine light 68choline fenofibrate 67ciclopirox 77ciclopirox olamine 23cilostazol 58CILOXAN 12CIMDUO 47cimetidine 83cimetidine hcl 83cinacalcet hcl 102CINRYZE 95ciprofloxacin 12ciprofloxacin hcl 12CIPROFLOXACIN HCL 110ciprofloxacin hcl (ophth) 12ciprofloxacin in d5w 12ciprofloxacin-dexamethasone 111citalopram hydrobromide 19clarithromycin 12CLEVER CHOICE HOLDING CHAMBER 127clindamycin hcl 7

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clindamycin palmitate hydrochloride 7clindamycin phosphate 7clindamycin phosphate (topical) 777clindamycin phosphate in d5w 7CLINDAMYCIN PHOSPHATE IN NACL 7clindamycin phosphate vaginal 7clobazam 15clobetasol propionate 75clobetasol propionate emollientbase 7587clomipramine hcl 21clonazepam 51clonidine 59clonidine hcl 59clonidine hcl (adhd) 71clopidogrel bisulfate 58clorazepate dipotassium 51clotrimazole 23clotrimazole (topical) 23clotrimazole vaginal 119clotrimazole w betamethasone 76clozapine 43COARTEM 37codeine sulfate 2CODEINE SULFATE 2colchicine 24colchicine w probenecid 24COLCRYS 24colesevelam hcl 68colestipol hcl 68colistimethate sodium 7COLY-MYCIN S 111COMBIGAN 107COMBIVENT RESPIMAT 116COMETRIQ (100 MG DAILY DOSE) 31COMETRIQ (140 MG DAILY DOSE) 31COMETRIQ (60 MG DAILY DOSE) 31COMFORT TOUCH ALCOHOL PREP 104COMFORT TOUCH INSULIN PEN NEED 104COMPACT SPACE CHAMBER 127COMPACT SPACE CHAMBERLG MASK 127COMPACT SPACE CHAMBERMEDMASK 128COMPACT SPACE CHAMBERSM MASK128COMPLERA 45

CONDOMS LATEX LUBRICATED 128COPIKTRA 32CORLANOR 65CORTISONE ACETATE 87CORTISPORIN-TC 111COTELLIC 32CREON 84CRESEMBA 23CRIXIVAN 48cromolyn sodium 114cromolyn sodium (mastocytosis) 84cromolyn sodium (nasal) 128cromolyn sodium (ophth) 108CRYSVITA 78CVS ISOPROPYL ALCOHOL WIPES 104CVS LICE SOLUTION 3-STEP 121cyclobenzaprine hcl 116cyclophosphamide 27cyclosporine 97cyclosporine modified (formicroemulsion) 97cyproheptadine hcl 112CYSTADANE 84CYSTAGON 84CYSTARAN 84

Ddalfampridine 73DALIRESP 114danazol 89dantrolene sodium 44dapsone 26DAPTACEL 99daptomycin 7DAURISMO 32deferasirox 79deferiprone 79DELSTRIGO 46DEPO-ESTRADIOL 89DEPO-PROVERA 92DERMOTIC 111DESCOVY 47desipramine hcl 21desmopressin acetate 88desmopressin acetate spray 88

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desmopressin acetate sprayrefrigerated 88desogestrel amp ethinyl estradiol 89desogestrel-ethinyl estradiol (biphasic) 89desogestrel-ethinyl estradiol (triphasic) 89desonide 75desoximetasone 75desvenlafaxine succinate 19dexamethasone 87dexamethasone sodium phosphate 87DEXAMETHASONE SODIUM PHOSPHATE109dexmethylphenidate hcl 71dextroamphetamine sulfate 7071dextrose 80dextrose in lactated ringers 80dextrose w sodium chloride 80DEXTROSE-NACL 80DEXTROSE-SODIUM CHLORIDE 80DIACOMIT 14DIAZEPAM 15diazepam 51diazoxide 54diclofenac potassium 1diclofenac sodium 1diclofenac sodium (actinic keratoses) 76diclofenac sodium (ophth) 109diclofenac sodium (topical) 1dicloxacillin sodium 11dicyclomine hcl 82didanosine 47diflunisal 1digoxin 65dihydroergotamine mesylate 25DILANTIN 16DILANTIN INFATABS 17diltiazem hcl 63diltiazem hcl coated beads 63diltiazem hcl extended release beads 63dimethyl fumarate 73diphenhydramine hcl 131diphenoxylate w atropine 82DIPHENOXYLATE-ATROPINE 82DIPHTHERIA-TETANUS TOXOIDS DT 99dipyridamole 58disopyramide phosphate 61

disulfiram 5divalproex sodium 14docosanol 119docusate sodium 124dofetilide 61donepezil hydrochloride 17dorzolamide hcl 110DORZOLAMIDE HCL-TIMOLOL MAL 107dorzolamide hcl-timolol maleate 107DOVATO 45doxazosin mesylate 59doxepin hcl 21doxercalciferol 102doxycycline (monohydrate) 13doxycycline hyclate 13DRIZALMA SPRINKLE 72dronabinol 22drospirenone-ethinyl estradiol 89DROXIA 28droxidopa 59duloxetine hcl 72dutasteride 86

EEES 400 12EASIVENT 128EASIVENT MASK LARGE 128EASIVENT MASK MEDIUM 128EASIVENT MASK SMALL 128EASY TOUCH INSULIN SYRINGE 104EASY TOUCH PEN NEEDLES 104econazole nitrate 23EDURANT 46efavirenz 46efavirenz-emtricitabine-tenofovirdisoproxil fumarate 46efavirenz-lamivudine-tenofovir disoproxilfumarate 46EGRIFTA 88EGRIFTA SV 88ELIQUIS 56ELIQUIS DVTPE STARTER PACK 56EMCYT 28EMSAM 19emtricitabine 47

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emtricitabine-tenofovir disoproxilfumarate 47EMTRIVA 47enalapril maleate 60enalapril maleate amphydrochlorothiazide 65ENBREL 97ENBREL SURECLICK 97ENGERIX-B 100enoxaparin sodium 56entacapone 38entecavir 44ENTRESTO 65ENVARSUS XR 98EPCLUSA 45EPIDIOLEX 14EPINEPHRINE 113epinephrine (anaphylaxis) 113EPINEPHRINE AUTOINJECTOR (GENERICADRENACLICK) 113EPIVIR HBV 44eplerenone 67EPROSARTAN MESYLATE 60EQ CALAMINE 120EQ SPACE CHAMBER ANTI-STATIC 128EQ SPACE CHAMBER ANTI-STATIC L 128EQ SPACE CHAMBER ANTI-STATIC M 128EQ SPACE CHAMBER ANTI-STATIC S 128ergocalciferol 126ERGOLOID MESYLATES 17ERIVEDGE 32ERLEADA 27erlotinib hcl 32ertapenem sodium 11ERY 77ERYTHROCIN LACTOBIONATE 12erythromycin (acne aid) 77erythromycin (ophth) 108erythromycin base 12ERYTHROMYCIN ETHYLSUCCINATE 12ESBRIET 115escitalopram oxalate 19estazolam 117estradiol 90estradiol vaginal 90

ESTRING 90eszopiclone 117ethambutol hcl 26ethosuximide 15ethynodiol diacet amp eth estrad 90ETIDRONATE DISODIUM 102etodolac 1etonogestrel-ethinyl estradiol 90etravirine 46everolimus 32everolimus (immunosuppressant) 98EVOTAZ 48exemestane 30EXTAVIA 73eye wash 130ezetimibe 68ezetimibe-simvastatin 68

FFABRAZYME 84famciclovir 50famotidine 83125FANAPT 41FANAPT TITRATION PACK 41FARXIGA 52FARYDAK 32felbamate 14felodipine 62fenofibrate 67fenofibrate micronized 67fentanyl 1fentanyl citrate 3FERRIPROX 79FERRIPROX TWICE-A-DAY 79ferrous sulfate 121122ferrous sulfate dried 122FETZIMA 19FETZIMA TITRATION 19fexofenadine hcl 131finasteride 86FINTEPLA 14FIRDAPSE 71FIRMAGON 93FIRMAGON (240 MG DOSE) 93FLEBOGAMMA DIF 95

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flecainide acetate 61FLEXICHAMBER 128FLOVENT DISKUS 111FLOVENT HFA 111fluconazole 23fluconazole in dextrose 23fluconazole in nacl 23flucytosine 23fludrocortisone acetate 87FLUNISOLIDE 111fluocinolone acetonide 75fluocinonide 75fluocinonide emulsified base 75fluorometholone (ophth) 109FLUOROURACIL 76fluorouracil (topical) 76fluoxetine hcl 19FLUOXETINE HCL 19FLUOXETINE HCL (PMDD) 19fluphenazine decanoate 40fluphenazine hcl 40flurbiprofen 1flurbiprofen sodium 109flutamide 27fluticasone propionate 75fluticasone propionate (nasal) 111FLUTICASONE-SALMETEROL 116fluticasone-salmeterol 116fluvastatin sodium 68fluvoxamine maleate 19folic acid 123fondaparinux sodium 5657FORTEO 102fosamprenavir calcium 48fosfomycin tromethamine 7fosinopril sodium 60fosinopril sodium amp hydrochlorothiazide 65FOTIVDA 28FREAMINE III 78fulvestrant 28furosemide 67FUZEON 48FYCOMPA 14

Ggabapentin 1516GAMMAGARD 95GAMMAGARD SD LESS IGA 95GAMMAKED 95GAMMAPLEX 9596GAMUNEX-C 96GARDASIL 9 100GATTEX 82gauze pads 2x2 104GAVILYTE-C 82GAVRETO 32gemfibrozil 67GENTAK 108gentamicin sulfate 6gentamicin sulfate (ophth) 108gentamicin sulfate (topical) 6GENVOYA 45GILENYA 73GILOTRIF 32glatiramer acetate 73GLEOSTINE 27glimepiride 52glipizide 52glipizide-metformin hcl 52GLUCAGEN HYPOKIT 54glucagon (rdna) 54GLUCAGON EMERGENCY 54GLUCOSE CHEW TAB 4 GM 119GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 119glyburide 52glyburide micronized 52glyburide-metformin 52glycerin (laxative) 124glycopyrrolate 82GLYXAMBI 52GNP ISOPROPYL ALCOHOL WIPES 104GNP STERILE GAUZE 104GOODSENSE CALAMINE 120granisetron hcl 22griseofulvin microsize 23griseofulvin ultramicrosize 23guaifenesin 131

140

guaifenesin-codeine 131guanfacine hcl 59guanfacine hcl (adhd) 71GUANIDINE HCL 26

HH-E-B INCONTROL PEN NEEDLES 104H-E-B INCONTROL UNIFINE PENTIP 104HAEGARDA 95halobetasol propionate 75haloperidol 40haloperidol decanoate 40haloperidol lactate 40HARVONI 45HAVRIX 100HEMADY 87heparin sodium (porcine) 57HEPATAMINE 78HETLIOZ 117HIBERIX 100HIZENTRA 96HM ULTICARE MINI PEN NEEDLES 104HUMALOG 54HUMALOG JUNIOR KWIKPEN 54HUMALOG KWIKPEN 54HUMALOG MIX 5050 54HUMALOG MIX 5050 KWIKPEN 54HUMALOG MIX 7525 54HUMALOG MIX 7525 KWIKPEN 55HUMIRA 98HUMIRA PEDIATRIC CROHNS START 98HUMIRA PEN 98HUMIRA PEN-CDUCHS STARTER 98HUMIRA PEN-PEDIATRIC UC START 98HUMIRA PEN-PSUVADOL HS START 98HUMIRA PEN-PSORUVEIT STARTER 98HUMULIN 7030 55HUMULIN 7030 KWIKPEN 55HUMULIN N 55HUMULIN N KWIKPEN 55HUMULIN R 55HUMULIN R U-500 (CONCENTRATED) 55HUMULIN R U-500 KWIKPEN 55HYCODAN 131hydralazine hcl 69

hydrochlorothiazide 67hydrocodone w homatropine 131hydrocodone-acetaminophen 3hydrocortisone 102hydrocortisone (intrarectal) 102hydrocortisone (rectal) 75hydrocortisone (topical) 75120hydrocortisone butyrate 7587hydrocortisone valerate 7587hydrocortisone wacetic acid 111hydrocortisone-aloe vera 120hydromorphone hcl 3hydroxychloroquine sulfate 37HYDROXYPROGESTERONE CAPROATE 92hydroxyurea 28hydroxyzine hcl 112

Iibandronate sodium 102IBRANCE 32ibuprofen 1118icatibant acetate 95ICLUSIG 32icosapent ethyl 68IDHIFA 28ILARIS 96ILEVRO 109imatinib mesylate 32IMBRUVICA 3233imipenem-cilastatin 11imipramine hcl 21imiquimod 76IMOVAX RABIES 100INCRELEX 88INCRUSE ELLIPTA 112indapamide 67indomethacin 1INFANRIX 100INGREZZA 72INLYTA 33INQOVI 28INREBIC 28INSPIRACHAMBERLARGE 128INSPIRACHAMBERMEDIUM 128INSPIRACHAMBERMOUTHPIECE 128

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INSPIRACHAMBERSMALL 128INSPIREASE 128INSULIN LISPRO 55INSULIN LISPRO (1 UNIT DIAL) 55INSULIN LISPRO JUNIOR KWIKPEN 55INSULIN LISPRO PROT amp LISPRO 55INSULIN PEN NEEDLES 105INSULIN SYRINGE 03 ML 105INSULIN SYRINGE 05 ML 105INSULIN SYRINGE 1 ML 105INSULIN SYRINGE-NEEDLE U-100 105INTELENCE 46INTRALIPID 78INTRON A 97INVEGA SUSTENNA 41INVEGA TRINZA 42INVIRASE 4849IPOL 100ipratropium bromide 112ipratropium bromide (nasal) 112ipratropium-albuterol 116irbesartan 60irbesartan-hydrochlorothiazide 65IRESSA 33ISENTRESS 45ISENTRESS HD 45isoniazid 26ISOPROPYL ALCOHOL 105ISOPROPYL ALCOHOL WIPES 105isosorbide dinitrate 69ISOSORBIDE DINITRATE ER 69isosorbide mononitrate 70isotretinoin 74itraconazole 23ivermectin 37IXIARO 100

JJAKAFI 33JANUMET 52JANUMET XR 52JANUVIA 53JARDIANCE 53JENTADUETO 53JENTADUETO XR 53

JULUCA 45JUXTAPID 6869

KKALYDECO 114KCL IN DEXTROSE-NACL 78KCL-LACTATED RINGERS-D5W 80KEPIVANCE 74ketoconazole 23ketoconazole (topical) 23ketorolac tromethamine (ophth) 109ketotifen fumarate (ophth) 130KINRIX 100KISQALI (200 MG DOSE) 33KISQALI (400 MG DOSE) 33KISQALI (600 MG DOSE) 33KISQALI FEMARA (400 MG DOSE) 29KISQALI FEMARA (600 MG DOSE) 29KISQALI FEMARA(200 MG DOSE) 29KORLYM 87KOSELUGO 29KRYSTEXXA 24

Llabetalol hcl 62lactated ringers 81lactated ringers (irrigation) 81LACTATED RINGERS 81lactic acid (ammonium lactate) 75lactulose 81lactulose (encephalopathy) 81lamivudine 47lamivudine (hbv) 44lamivudine-zidovudine 47lamotrigine 14lansoprazole 83LANTUS 55LANTUS SOLOSTAR 55lapatinib ditosylate 33latanoprost 110LATUDA 42LEDIPASVIR-SOFOSBUVIR 45leflunomide 98LENVIMA (10 MG DAILY DOSE) 33LENVIMA (12 MG DAILY DOSE) 33

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LENVIMA (14 MG DAILY DOSE) 33LENVIMA (18 MG DAILY DOSE) 33LENVIMA (20 MG DAILY DOSE) 33LENVIMA (24 MG DAILY DOSE) 33LENVIMA (4 MG DAILY DOSE) 33LENVIMA (8 MG DAILY DOSE) 33letrozole 30leucovorin calcium 29LEUKERAN 27leuprolide acetate 93levalbuterol hcl 113LEVALBUTEROL TARTRATE 113levetiracetam 14levobunolol hcl 109levocarnitine (metabolic modifiers) 81levocetirizine dihydrochloride 112levofloxacin 12levofloxacin (ophth) 108levofloxacin in d5w 13levonorgestrel amp eth estradiol 90levonorgestrel (emergency oc) 125levonorgestrel-eth estradiol (triphasic) 90levonorgestrel-ethinyl estradiol (91-day) 90levothyroxine sodium 92LEXIVA 49lidocaine 4lidocaine hcl 4lidocaine hcl (mouth-throat) 4lidocaine-prilocaine 4LINDANE 77linezolid 7LINEZOLID IN SODIUM CHLORIDE 7LINZESS 81liothyronine sodium 93lisinopril 60lisinopril amp hydrochlorothiazide 65LITEAIRE 128LITHIUM 51lithium carbonate 52LOESTRIN FE 1530 90LOESTRIN FE 120 90LONSURF 29loperamide hcl 82124lopinavir-ritonavir 49loratadine 131

lorazepam 51LORBRENA 3334losartan potassium 60losartan potassium amphydrochlorothiazide 65loteprednol etabonate 109lovastatin 68loxapine succinate 40LUBIPROSTONE 81LUMAKRAS 29LUMIGAN 110LUPRON DEPOT (1-MONTH) 93LUPRON DEPOT (3-MONTH) 93LUPRON DEPOT (4-MONTH) 93LUPRON DEPOT (6-MONTH) 93LUPRON DEPOT-PED (1-MONTH) 93LUPRON DEPOT-PED (3-MONTH) 93LYBALVI 18LYNPARZA 34LYSODREN 29LYUMJEV 55LYUMJEV KWIKPEN 55

MM-M-R II 100MAG-G 123magnesium citrate 124magnesium gluconate 123malathion 77MAPROTILINE HCL 18MARPLAN 19MATULANE 27MAVYRET 45meclizine hcl 21118MEDPURA ALCOHOL PADS 105medroxyprogesterone acetate 92medroxyprogesterone acetate(contraceptive) 92mefloquine hcl 37megestrol acetate 92megestrol acetate (appetite) 92MEKINIST 34MEKTOVI 34meloxicam 1memantine hcl 18

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MENACTRA 100MENEST 90MENQUADFI 100MENVEO 100meprobamate 50mercaptopurine 28meropenem 12mesalamine 101mesna 37MESNEX 37metformin hcl 53methadone hcl 2methazolamide 110methenamine hippurate 7methimazole 94methocarbamol 116methotrexate sodium 98methyldopa 59methylergonovine maleate 105methylphenidate hcl 71methylprednisolone 87methylprednisolone acetate 87methylprednisolone sod succ 87METIPRANOLOL 109metoclopramide hcl 21metolazone 67metoprolol amp hydrochlorothiazide 65metoprolol succinate 62metoprolol tartrate 62METOPROLOL-HYDROCHLOROTHIAZIDE 65metronidazole 8metronidazole (topical) 8metronidazole in nacl 8metronidazole vaginal 8metyrosine 65mexiletine hcl 61micafungin sodium 23MICONAZOLE 3 23miconazole nitrate vaginal 119MICROCHAMBER 129MICROSPACER 129midodrine hcl 59MIGERGOT 25miglitol 53miglustat 84

minocycline hcl 13minoxidil 69mirtazapine 18misoprostol 83modafinil 117moexipril hcl 60MOLINDONE HCL 40mometasone furoate 7687montelukast sodium 112morphine sulfate 23MOVANTIK 82moxifloxacin hcl 13moxifloxacin hcl (ophth) 108MOZOBIL 57MULTAQ 61mupirocin 77MURO 128 130MYALEPT 82mycophenolate mofetil 99mycophenolate mofetil hcl 99mycophenolate sodium 99MYRBETRIQ 85

Nnabumetone 1nadolol 62nafcillin sodium 11NAGLAZYME 84naloxone hcl 5NALOXONE HCL 5naltrexone hcl 5naphazoline w pheniramine 130naproxen 1naratriptan hcl 25NARCAN 6NASACORT ALLERGY 24HR 130NASACORT ALLERGY 24HR CHILDREN 130NASAL DECONGESTANT 131NATACYN 108nateglinide 53NATPARA 102NAYZILAM 4nebivolol hcl 62nefazodone hcl 20neomycin sulfate 6

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neomycin-bacitracin zn-polymyxin 107neomycin-bacitracin-polymyxin oint 118neomycin-polymy-dexameth 107neomycin-polymyxin w pramoxine 118NEOMYCIN-POLYMYXIN-GRAMICIDIN 107neomycin-polymyxin-hc (otic) 111NERLYNX 34NEVIRAPINE 46nevirapine 46NEVIRAPINE ER 46NEXAVAR 34niacin 119niacin (antihyperlipidemic) 69NIACIN (ANTIHYPERLIPIDEMIC) 69NIACIN ER 119niacinamide 119NIACOR 69nicardipine hcl 62nicotine 118nicotine polacrilex 118NICOTROL 6NICOTROL NS 6nifedipine 63nilutamide 27nimodipine 63NINLARO 29nitazoxanide 37nitisinone 84NITRO-BID 70nitrofurantoin macrocrystal 8nitrofurantoin monohyd macro 8nitroglycerin 70NITROSTAT 70NITYR 84NIX COMPLETE LICE TREATMENT 121nizatidine 83NORDITROPIN FLEXPRO 88norethin acet amp estrad-fe 91norethindrone amp eth estradiol 91norethindrone amp ethinyl estradiol-fe 91norethindrone (contraceptive) 92norethindrone acet amp eth estra 91norethindrone acetate 92norethindrone acetate-ethinyl estradiol 91norethindrone-eth estradiol (triphasic) 91

norgestimate-ethinyl estradiol 91norgestimate-ethinyl estradiol(triphasic) 91norgestrel amp ethinyl estradiol 91NORMOSOL-M IN D5W 78nortriptyline hcl 21nortriptyline oral solution (unit dose) 21NORVIR 49NovoFine 32G X 6 MM MISC 105NOVOLIN 7030 55NOVOLIN 7030 RELION 55NOVOLIN N 56NOVOLIN N RELION 56NOVOLIN R 56NOVOLIN R RELION 56NovoTwist 32G X 5 MM MISC 105NOXAFIL 23NUBEQA 27NUCALA 116NUPLAZID 42NUTRILIPID 78NYMALIZE 63nystatin 24nystatin (mouth-throat) 24nystatin (topical) 23nystatin-triamcinolone 76

Ooctreotide acetate 94ODEFSEY 46ODOMZO 34OFEV 115ofloxacin 13ofloxacin (ophth) 108ofloxacin (otic) 111olanzapine 42olmesartan medoxomil 60olmesartan medoxomil-amlodipine-hydrochlorothiazide 66olmesartan medoxomil-hydrochlorothiazide 66olopatadine hcl 108omega-3 fatty acids cap 1000 mg 123omega-3-acid ethyl esters 69omeprazole 83125

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ondansetron 22ondansetron hcl 22ONUREG 29OPSUMIT 115OPTICHAMBER ADVANTAGE-LG MASK 129OPTICHAMBER ADVANTAGE-MEDMASK 129OPTICHAMBER ADVANTAGE-SM MASK 129OPTICHAMBER DIAMOND 129OPTICHAMBER DIAMOND-LG MASK 129OPTICHAMBER DIAMOND-MD MASK 129OPTICHAMBER DIAMOND-SM MASK 129OPTICHAMBER FACE MASK-LARGE 129OPTICHAMBER FACE MASK-MEDIUM 129OPTICHAMBER FACE MASK-SMALL 129OPTIHALER 129OPTIONS GYNOL II CONTRACEPTIVE 125oral electrolyte solution 121ORBACTIV 8ORGOVYX 94oseltamivir phosphate 49OSPHENA 92OTEZLA 7696oxandrolone 89OXBRYTA 58oxcarbazepine 17oxybutynin chloride 85oxycodone hcl 34oxycodone w acetaminophen 4oyster shell 123OYSTER SHELL CALCIUM 500 + D 123OYSTER SHELL CALCIUMD 123OZEMPIC (025 OR 05 MGDOSE) 53OZEMPIC (1 MGDOSE) 53

Ppaliperidone 42PANRETIN 36pantoprazole sodium 83paricalcitol 103paromomycin sulfate 6paroxetine hcl 20PASER 26PAXIL 20PEDIARIX 100

PEDVAX HIB 100peg 3350-kcl-sod bicarb-sod chloride-sodsulfate 82peg 3350-potassium chloride-sodbicarbonate-sod chloride 82PEGANONE 17PEGASYS 97PEGASYS PROCLICK 97PEMAZYRE 34penicillamine 86penicillin g potassium 11PENICILLIN G SODIUM 11penicillin v potassium 11pentamidine isethionate 38pentoxifylline 66perindopril erbumine 60permethrin 77121perphenazine 21PERSERIS 42PFIZERPEN 11phenelzine sulfate 19phenobarbital 16phentermine hcl 120PHENYTEK 17phenytoin 17phenytoin sodium extended 17PHOSPHOLINE IODIDE 110phytonadione 119PIFELTRO 46pilocarpine hcl 110pilocarpine hcl (oral) 74PIMOZIDE 40pindolol 62pioglitazone hcl 53piperacillin sodium-tazobactam sodium 11PIQRAY (200 MG DAILY DOSE) 34PIQRAY (250 MG DAILY DOSE) 34PIQRAY (300 MG DAILY DOSE) 34piroxicam 1PLEGRIDY 73PLEGRIDY STARTER PACK 73POCKET CHAMBER 129POCKET SPACER 129podofilox 76polyethylene glycol 3350 124

146

polymyxin b-trimethoprim 108polyvinyl alcohol 130POMALYST 27posaconazole 24potassium chloride 78POTASSIUM CHLORIDE ER 78POTASSIUM CHLORIDE IN DEXTROSE 81potassium chloride in dextrose amp sodiumchloride 79POTASSIUM CHLORIDE IN NACL 79potassium chloride microencapsulatedcrystals er 79potassium citrate (alkalinizer) 79PRADAXA 57pramipexole dihydrochloride 39prasugrel hcl 59pravastatin sodium 68praziquantel 37prazosin hcl 59PRE-NATAL FORMULA 123prednisolone 87PREDNISOLONE ACETATE 109PREDNISOLONE SODIUMPHOSPHATE 87109prednisone 88PREDNISONE INTENSOL 88pregabalin 72PREMARIN 91PREMASOL 79PREMPHASE 91PREMPRO 91PRENATAL (WIRON amp FA) 123PRENATAL FORTE 123PRENATAL VITAMIN WITH IRON TAB 27-08MG 123PRENATAL VITAMIN WITH IRON TAB 28-08MG 123prenatal vitamins 81PRENATALIRON 123PREVYMIS 44PREZCOBIX 49PREZISTA 49PRIFTIN 26primaquine phosphate 38primidone 16

PRIVIGEN 96PRO COMFORT SPACER ADULT 129PRO COMFORT SPACER CHILD 129PRO COMFORT SPACER INFANT 129probenecid 24PROCARE SPACERADULT MASK 130PROCARE SPACERCHILD MASK 130prochlorperazine 22prochlorperazine maleate 21PROCYSBI 84progesterone 92PROGRAF 99PROLASTIN-C 85PROLENSA 109PROLIA 103PROMACTA 58promethazine hcl 22112promethazine wcodeine 131promethazine-dm 132promethazine-phenylephrine-codeine 132propafenone hcl 61propranolol hcl 62PROPRANOLOL-HCTZ 66propylthiouracil 94PROQUAD 100protriptyline hcl 21pseudoephedrine hcl 131PULMICORT FLEXHALER 112PULMOZYME 114PURIXAN 28pyrantel pamoate 119pyrazinamide 26pyrethrins-piperonyl butoxide 121pyrethrins-piperonyl butoxide-permethrin-nit remover 121pyridostigmine bromide 26pyridoxine hcl 123pyrimethamine 38

QQINLOCK 29QSYMIA 120QUADRACEL 100quetiapine fumarate 42quinapril hcl 61

147

quinapril-hydrochlorothiazide 66QUINIDINE SULFATE 61quinine sulfate 38QVAR REDIHALER 112

RRA CALAMINE 120RA DAYLOGIC ACNE FOAMING WASH 120RA ISOPROPYL ALCOHOL WIPES 105RA OYSTER SHELL CALCIUMD2 123RABAVERT 100rabeprazole sodium 83raloxifene hcl 92ramelteon 117ramipril 61ranolazine 66rasagiline mesylate 39RAVICTI 85REBIF 73REBIF REBIDOSE 73REBIF REBIDOSE TITRATION PACK 73REBIF TITRATION PACK 73RECOMBIVAX HB 100RECTIV 70REGRANEX 76RELENZA DISKHALER 49RELION PEN NEEDLES 105RELISTOR 82repaglinide 53REPATHA 69REPATHA PUSHTRONEX SYSTEM 69REPATHA SURECLICK 69RESCRIPTOR 46RESTASIS 107RESTASIS MULTIDOSE 108RETACRIT 58RETEVMO 29REVLIMID 27REXULTI 42REYATAZ 49REZUROCK 99RHOPRESSA 110ribavirin 116ribavirin (hepatitis c) 45riboflavin 123

RID 121RID COMPLETE LICE ELIMINATION 121RID ESSENTIAL LICE ELIMINATION 121rifabutin 26rifampin 26RIFATER 26riluzole 72RIMANTADINE HCL 50ringers 81ringers irrigation 81RINVOQ 99risedronate sodium 103RISPERDAL CONSTA 43risperidone 43RITEFLO 130ritonavir 49rivastigmine 18rivastigmine tartrate 18rizatriptan benzoate 25ROCKLATAN 108ropinirole hydrochloride 39rosuvastatin calcium 68ROTARIX 100ROTATEQ 100ROZLYTREK 29RUBRACA 34RUCONEST 95rufinamide 17RUKOBIA 48RUZURGI 105RYBELSUS 53RYDAPT 34

Ssaline 130SANDIMMUNE 99SANDOSTATIN LAR DEPOT 94SANTYL 76sapropterin dihydrochloride 85SAVELLA 72SAVELLA TITRATION PACK 72SAXENDA 130scopolamine 22SECUADO 43selegiline hcl 39

148

selenium sulfide 76120SELZENTRY 48sennosides 124SEREVENT DISKUS 113SEROSTIM 88sertraline hcl 20sevelamer carbonate 80SHINGRIX 101SIGNIFOR 94sildenafil citrate (pulmonaryhypertension) 115silver sulfadiazine 76simethicone 125simvastatin 68sirolimus 99SIRTURO 26SKYRIZI 96SKYRIZI (150 MG DOSE) 96SM FOAMING ANTACID 125SMOFLIPID 81sodium bicarbonate (antacid) 125sodium chloride 79sodium chloride hypertonic 130sodium fluoride 81sodium phenylbutyrate 85sodium polystyrene sulfonate 80SOFOSBUVIR-VELPATASVIR 45solifenacin succinate 86SOLTAMOX 28SOMATULINE DEPOT 94SOMAVERT 94sotalol hcl 61sotalol hcl (afibafl) 61SPIRIVA HANDIHALER 112SPIRIVA RESPIMAT 113spironolactone 67spironolactone amp hydrochlorothiazide 66SPRITAM 14SPRYCEL 34SPS 80stavudine 47STELARA 96STIVARGA 34STRENSIQ 85STREPTOMYCIN SULFATE 6

STRIBILD 45STRIVERDI RESPIMAT 113sucralfate 83sulfacetamide sod-prednisolone 108SULFACETAMIDE SODIUM 108sulfacetamide sodium (acne) 13sulfacetamide sodium (ophth) 109SULFACETAMIDE-PREDNISOLONE 108SULFADIAZINE 13sulfamethoxazole-trimethoprim 13SULFAMYLON 77sulfasalazine 101sulindac 1sumatriptan 25sumatriptan succinate 25sunitinib malate 3435SUPREP BOWEL PREP KIT 82SYLATRON 97SYMDEKO 114SYMPAZAN 16SYMTUZA 49SYNAREL 94SYNERCID 8SYNJARDY 53SYNJARDY XR 53SYNRIBO 29SYNTHAMIN 17 79SYNTHROID 93

TTABLOID 28TABRECTA 29tacrolimus 99tacrolimus (topical) 76tadalafil (pulmonary hypertension) 115TAFINLAR 35TAGRISSO 35TALTZ 96TALZENNA 35tamoxifen citrate 28tamsulosin hcl 86TARGRETIN 36TASIGNA 35TAVALISSE 59tazarotene 74

149

TAZICEF 10TAZORAC 74TAZVERIK 29TDVAX 101TEFLARO 10TEKTURNA HCT 66telmisartan 60telmisartan-hydrochlorothiazide 66temazepam 117TEMIXYS 47TENIVAC 101tenofovir disoproxil fumarate 47TEPMETKO 35terazosin hcl 60terbinafine hcl 24terconazole vaginal 24testosterone 89testosterone cypionate 89testosterone enanthate 89tetrabenazine 72tetracycline hcl 13THALOMID 2728theophylline 114THEOPHYLLINE ER 114thiamine hcl 123thiamine mononitrate 123THIOLA EC 86thioridazine hcl 40thiotepa 27thiothixene 40tiagabine hcl 16TIBSOVO 35tigecycline 8timolol maleate 25TIMOLOL MALEATE 109timolol maleate (ophth) 109tioconazole vaginal 119TIVICAY 45TIVICAY PD 45tizanidine hcl 44TOBI PODHALER 114tobramycin 114tobramycin (ophth) 109tobramycin sulfate 6tobramycin-dexamethasone 108

TOLAK 76tolnaftate 119tolterodine tartrate 86topiramate 15toremifene citrate 28torsemide 67TOUJEO MAX SOLOSTAR 56TOUJEO SOLOSTAR 56TPN ELECTROLYTES 81TRACLEER 115TRADJENTA 54tramadol hcl 4tramadol-acetaminophen 4trandolapril 61tranexamic acid 58tranylcypromine sulfate 19TRAVASOL 79travoprost 110trazodone hcl 20TRECATOR 26TRELEGY ELLIPTA 116TRELSTAR MIXJECT 94tretinoin 74tretinoin (chemotherapy) 36triamcinolone acetonide (mouth) 74triamcinolone acetonide (nasal) 131triamcinolone acetonide (topical) 76triamterene amp hydrochlorothiazide 66triazolam 117trientine hcl 80trifluoperazine hcl 40trifluridine 50trihexyphenidyl hcl 38TRIKAFTA 114trimethoprim 8trimipramine maleate 21TRINTELLIX 20triprolidine amp pseudoephedrine 132TRIUMEQ 47TROPHAMINE 79trospium chloride 86TRUE COMFORT PEN NEEDLES 105TRUE COMFORT PRO ALCOHOL PREP 105TRUE COMFORT PRO INSULIN SYR 105TRUE COMFORT PRO PEN NEEDLES 106

150

TRULICITY 54TRUMENBA 101TRUSELTIQ (100MG DAILY DOSE) 35TRUSELTIQ (125MG DAILY DOSE) 35TRUSELTIQ (50MG DAILY DOSE) 35TRUSELTIQ (75MG DAILY DOSE) 35TUKYSA 35TURALIO 35TWINRIX 101TYBOST 48TYMLOS 103TYPHIM VI 101TYSABRI 73

UUBRELVY 24UKONIQ 35ULTICARE MINI PEN NEEDLES 106ULTICARE SHORT PEN NEEDLES 106ULTIGUARD SAFEPACK PEN NEEDLE 106ULTIGUARD SAFEPACK SYRNEEDLE 106ULTRA FLO INSULIN PEN NEEDLES 106ULTRA FLO INSULIN SYR 12 UNIT 106ULTRA FLO INSULIN SYRINGE 106UNIFINE PEN NEEDLES 106UNIFINE PENTIPS 106ursodiol 82

Vvalacyclovir hcl 50VALCHLOR 27valganciclovir hcl 44valproate sodium 15valproic acid 15valsartan 60valsartan-hydrochlorothiazide 66VALTOCO 10 MG DOSE 16VALTOCO 15 MG DOSE 16VALTOCO 20 MG DOSE 16VALTOCO 5 MG DOSE 16VALVED HOLDING CHAMBER 130vancomycin hcl 8VAQTA 101VARENICLINE TARTRATE 6VARIVAX 101

VARIZIG 96VASCEPA 69VCF VAGINAL CONTRACEPTIVE 125VELTASSA 80VEMLIDY 44VENCLEXTA 3536VENCLEXTA STARTING PACK 36venlafaxine hcl 20VENTAVIS 115verapamil hcl 63VERAPAMIL HCL ER 63VERSACLOZ 43VERZENIO 36VICTOZA 54VIDEX 47VIDEX EC 47vigabatrin 16VIIBRYD 20VIIBRYD STARTER PACK 20VIMPAT 17VIRACEPT 49VIREAD 47vitamin a 123VITAMIN D2 126vitamin e 124VITAMIN K 124VITRAKVI 36VIZIMPRO 36voriconazole 24VORTEX VALVED HOLDING CHAMBER 130VOSEVI 45VOTRIENT 36VRAYLAR 43VYNDAMAX 66VYNDAQEL 85

Wwarfarin sodium 57WATCHHALER 130water for irrigation sterile 107

XXALKORI 36XARELTO 57XARELTO STARTER PACK 57

151

XATMEP 99XCOPRI 15XCOPRI (250 MG DAILY DOSE) 15XCOPRI (350 MG DAILY DOSE) 15XELJANZ 9697XELJANZ XR 99XERMELO 82XGEVA 103XIFAXAN 8XIGDUO XR 54XOFLUZA (40 MG DOSE) 50XOFLUZA (80 MG DOSE) 50XOLAIR 97XOSPATA 36XPOVIO (100 MG ONCE WEEKLY) 30XPOVIO (40 MG ONCE WEEKLY) 30XPOVIO (40 MG TWICE WEEKLY) 30XPOVIO (60 MG ONCE WEEKLY) 30XPOVIO (60 MG TWICE WEEKLY) 30XPOVIO (80 MG ONCE WEEKLY) 30XPOVIO (80 MG TWICE WEEKLY) 30XTANDI 27XYREM 117

YYF-VAX 101

Zzafirlukast 112zaleplon 117ZARXIO 58ZEJULA 36ZELBORAF 36ZENPEP 85ZERIT 48ZEVRX INSULIN SYRINGE 107ZEVRX PEN NEEDLES 107ZEVRX STERILE ALCOHOL PREP PAD 107zidovudine 48ziprasidone hcl 43ziprasidone mesylate 43ZIRGAN 44zoledronic acid 103ZOLINZA 30zolmitriptan 25

zolpidem tartrate 117zonisamide 17ZONTIVITY 57ZORTRESS 99ZOSTAVAX 101ZUBSOLV 5ZYDELIG 36ZYKADIA 36ZYPREXA RELPREVV 43

152

Blue Shield of California Promise Health Plan

601 Potrero Grande Drive Monterey Park CA 91755

H0148_20_503

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Ang Diskriminasyon ay Labag sa Batas

Sumusunod ang Blue Shield of California Promise Health Plan sa mga naaangkop na batas ng estado at pederal na batas sa karapatang sibil at hindi ito nandidiskrimina nagbubukod ng mga tao o pinapakitunguhan sila nang naiiba batay sa lahi kulay pinanggal ingang bansa pagkakakilanlang etnikong pangkat medikal na kundisyon genetic na impormasyon lipi relihiyon kasarian katayuan sa pag-aasawa kasarian pagkakakilanlang kasarian sekswal na oryentasyon edad kapansanan sa pag-iisip o pisikal na kapansanan

Nagbibigay ang Blue Shield of California Promise Health Plan ng

bull Mga libreng tulong at serbisyo sa mga taong may kapansanan upang magawa nilang

makipag-ugnayan nang maayos sa amin gaya ng

o Mga kwalipikadong interpreter ng sign language o Nakasulat na impormasyon sa ibang format (may malaking font audio naa-access na

electronic na format iba pang format) bull Mga libreng serbisyo sa wika para sa mga taong hindi Ingles ang pangunahing wika gaya ng

o Mga kwalipikadong interpreter o Impormasyong nakasulat sa ibang wika

Kung kailangan ninyo ang mga serbisyong ito makipag-ugnayan sa Tagaayos para sa Mga Karapatang Sibil ng Blue Shield of California Promise Health Plan

Kung naniniwala kayong hindi naibigay ng Blue Shield of California Promise Health Plan ang

mga serbisyong ito o nandiskrimina ito sa ibang paraan batay sa lahi kulay pinanggalingang

bansa pagkakakilanlang etnikong pangkat medikal na kundisyon genetic na impormasyon

lipi relihiyon kasarian katayuan sa pag-aasawa kasarian pagkakakilanlang kasarian sekswal

na oryentasyon edad kapansanan sa pag-iisip o pisikal na kapansanan maaari kayong

maghain ng karaingan sa


Civil Rights Coordinator

601 Potrero Grande Dr

Monterey Park CA 91755

Telepono (844) 883-2233 (TTY 711)

Fax (323) 889-2228

Email BSCPHPCivilRightsblueshieldcacom

Maaari kayong maghain ng karaingan nang personal o sa pamamagitan ng koreo fax o email

Kung kailangan ninyo ng tulong sa paghahain ng karaingan matutulungan kayo ng Tagaayos

para sa Mga Karapatang Sibil

Maaari din kayong maghain ng reklamo tungkol sa mga karapatang sibil sa Department of Health and Human Services ng US Office for Civil Rights sa electronic na paraan sa pamamagitan ng Portal para sa Reklamo ng Office for Civil Rights na available sa httpsocrportalhhsgovocrportallobbyjsf o sa pamamagitan ng mail o telepono sa US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 (TTY 800-537-7697 )

Portal para sa Reklamo httpsocrportalhhsgovocrcpwizard_cpjsf

Available ang mga form para sa reklamo sa httpwwwhhsgovocrofficefileindexhtml


601 Potrero Grande Drive | Monterey Park CA 91755

Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association A52631 -CMC (421)

Language Assistance Notice

English

ATTENTION If you speak English language assistance services free of charge are

available to you Call 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a

week The call is free

中文 (Chinese)

请留意如果您说中文可以免费获得语言协助服务请拨打 1-855-905-3825（听障和语障

专线711）每周七天办公早上 800 至晚上 800此电话为免付费专线

한국어(Korean)

주 귀하가 한국어를 사용하시는 경우 무료로 언어 지원 서비스를 이용하실 수 있습니다

1-855-905-3825(TTY 711)번으로 주 7일 오전 8시부터 오후 8시까지 전화하실 수 있습니다

이 전화는 무료입니다

Русский (Russian) ОБРАТИТЕ ВНИМАНИЕ Если Вы говорите по-русски мы можем предложить Вам бесплатные услуги языковой поддержки Звоните по телефону 1-855-905-3825 (TTY 711) с 800 до 2000 без выходных Звонок бесплатный

( Farsiفارسی ) 3825-905-855-1توجه اگر به زبان فارسی صحبت می کنید خدمات امداد زبانی بدون اخذ هزینه در اختیار شما می باشد با شماره

(TTY 711) شب در هفت روز هفته تماس بگیرید این تماس رایگان است 800صبح تا 800 از ساعت


धयान यदि आप भाषा बोलत ह तो आपक ललए भाषा सहायता सवाए ननिःशलक उपलबध ह फोन करना 1-855-905-3825 (TTY 711) सबह 800 बज स शाम 800 बज तक सपताह क सातो दिन फोन करना फरी ह

Lus Hmoob (Hmong)

LUS CEEV Yog koj hais Lus Hmoob muaj kev pab txhais lus pub dawb rau kojHu rau

1-855-905-3825 (TTY 711) 800 teev sawv ntxov txog 800 teev tsaus ntuj xya hnub hauv

ib lub as thivQhov hu xov tooj no yog hu dawb xwb


ATENCIOacuteN Si usted habla espantildeol hay a su disposicioacuten servicios de asistencia de

idiomas sin costo Llame al 1-855-905-3825 (TTY 711) de 800 am a 800 pm los siete

diacuteas de la semana La llamada es gratuita

Tiếng Việt (Vietnamese) LƯU Yacute Nếu quyacute vị noacutei tiếng Việt chuacuteng tocirci sẽ cung cấp miễn phiacute dịch vụ hỗ trợ ngocircn ngữ cho quyacute vị Goi socirc 1-855-905-3825 (TTY 711) 8 giơ sang đến 8 giơ tocirci bay ngay trong tuacircn Cuocircc goi nay miễn phiacute

Tagalog (Tagalog)

PAUNAWA Kung nagsasalita kayo ng Tagalog may mga available na libreng serbisyo

ng tulong sa wika para sa inyo Tumawag sa 1-855-905-3825 (TTY 711) 800 am

hanggang 800 pm pitong araw sa isang linggo Libre ang tawag

(Arabicالعربية )

3825-905-855-1اتصل على الرقم یتوفر لك خدمات المساعدة اللغویة المجانیةإذا كنت تتحدث اللغة العربیة تنبیه (TTY 711) علما بأن هذه المكالمة مجانیة مساء طوال أیام الأسبوع 800صباحا إلى 800 من الساعة


ສ ງສ ຳຄນ ຖຳທ ຳນເວ ຳພຳສຳລຳວແມ ນມບ ລ ກຳນຊວຍເຫ ອທຳງດຳນພຳສຳບ ເສຍຄຳໃຫທ ຳນ ໂທຫຳເບ 1-855-905-3825 (TTY 711) 800 ໂມງເຊ ຳ ຫຳ 800 ໂມງແລງ ເຈດວນຕ ອຳທ ດ ກຳນໂທແມ ນບ ເສຍຄຳ


注意事項日本語を話される場合無料の言語支援をご利用いただけます1-855-905-3825

(TTY 711）までお電話にてご連絡ください毎日午前 8時から午後 8時まで受け付けてい

ます通話は無料です

ภาษาไทย (Thai) เรยน หากคณพดภาษา ภาษาไทย เรามบรการความชวยเหลอดานภาษาใหแกคณโดยไมมคาใชจาย โทร 1-855-905-3825 (TTY 711) 800 น ถง 2000 น ไดตลอดเจดวนตอสปดาห โทรฟร ไมมคาใชจาย


ਸਾਵਧਾਨ ਜ ਤਸੀ [ਪਜਾਬੀ] ਬਲਦ ਹ ਤਾ ਤਹਾਡ ਲਈ ਮਫਤ ਭਾਸਾ ਸਹਾਇਤਾ ਸਵਾਵਾ ਉਪਲਬਧ ਹਨ | ਕਾਲ ਕਰ 1-855-905-3825 (TTY 711) ਸਵਰ 800 ਵਜ ਤ ਸਾਮ 800 ਵਜ ਤਕ ਹਫਤ ਦ ਸਤ ਦਦਨ |711) ਸਵਰ ਦ 8 ਵਜ ਤ ਲ ਕ ਰਾਤ ਦ 8 ਵਜ ਤਕ ਹਫਤ ਦ ਸਤ ਦਦਨ ਕਾਲ ਫਰੀ ਹ |

ខមែរ (Khmer)

ចាបអារមមណ បបើសនអនកនយាយភាសាខមមរ បសវាជនយភាសា គមានសរាបអនក បោយឥតគតថលៃ បៅ

1-855-905-3825 (TTY 711) បមាោ ង 800 ពរក ដល 800 យប ពរររថលៃមយអាទតយ

បៅគឥតគតថលៃបទ

Հայերեն (Armenian)

ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն Ձեզ տրամադրելի են անվճար լեզվական

օգնության ծառայություններ Զանգահարեք 1-855-905-3825 (TTY 711) համարով 800-ից

2000 շաբաթը յոթ օր Հեռախոսազանգն անվճար է

Українська (Ukrainian) ЗВЕРНІТЬ УВАГУ Якщо Ви розмовляєте українською ми можемо запропонувати Вам безкоштовні послуги мовної підтримки Телефонуйте 1-855-905-3825 (TTY 711) з 800 до 2000 без вихідних Дзвінок безкоштовний Mienh (Mien)

TOV JANGX LONGX OC Beiv taix meih gorngv Mienh waac nor ninh mbuo gorn

zangc duqv mbenc nzoih wang-henh nzie weih faan waac bun meih muangx maiv

zuqc feix liuc cuotv zinh nyaanh Douc waac lorx taux 1-855-905-3825 (TTY 711)

800 diemv ziangh hoc lungh ndorm mingh taux 800 ziangh hoc lungh muonz yietc

norm liv baaiz se koi nzoih siec hnoi Naaiv norm douc waac gorn se wang-henh longc

maiv zuqc feix liuc cuotv zinh nyaanh

H0148_21_166

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08172021

Ang formulary na ito ay na-update noong 08192021 Para sa mas bagong impormasyon o iba pang tanong mangyaring makipag-ugnayan sa Pangangalaga sa Customer ng Blue Shield Promise Cal MediConnect Plan sa 1-855-905-3825 (TTY 711) mula 800 am ndash 800 pm pitong araw sa isang linggoo bisitahin ang wwwblueshieldcacompromisecalmediconnect

10052021

Blue Shield Promise Cal MediConnect Plan

(Medicare-Medicaid Plan)



Ang formulary na ito ay na-update noong 08192021 Para sa mas bagong impormasyon o iba pang tanong mangyaring makipag-ugnayan sa Pangangalaga sa Customer ng Blue Shield Promise Cal MediConnect Plan sa 1-855-905-3825 (TTY 711) mula 800 am


A Mga Disclaimer iv





















D Index ng Mga Saklaw na Gamot 080

A Mga Disclaimer



Sasaklawin ng Blue Shield Promise Cal MediConnect Plan ang lahat ng medikal na kinakailangang gamot sa Listahan ng Gamot kung



Sa ilang sitwasyon may kailangan pa kayong gawin bago kayo makakuha ng isang gamot (sumangguni sa tanong B4 sa ibaba)

B2 Nagbabago ba ang Listahan ng Gamot na ito

may bago at mas murang gamot na lalabas sa merkado na kasingbisa ng gamot na kasalukuyang nasa Listahan ng Gamot o

kung mapag-aalaman naming hindi ligtas ang isang gamot o

kung aalisin ang isang gamot sa merkado

Maaari ninyong tingnan anumang oras ang napapanahong Listahan ng Gamot ng Blue Shield Promise Cal MediConnect Plan online sa wwwblueshieldcacompromisecalmediconnect

Maaari rin ninyong tawagan ang Pangangalaga sa Customer para matingnan ang kasalukuyang Listahan ng Gamot sa 1-855-905-3825 (TTY 711) 800 am hanggang 800 pm pitong araw sa isang linggo

B3 Ano ang mangyayari kapag may nagbago sa Listahan ng Gamot

May naging available na bagong generic na gamot Kung minsan may bagong generic na gamot na lumalabas sa merkado na kasingbisa ng branded na gamot na kasalukuyang nasa Listahan ng Gamot Kapag nangyari iyon maaaring alisin namin ang branded na gam

o Posibleng hindi namin kayo maabisuhan bago namin gawin ang pagbabagong ito ngunit padadalhan namin kayo ng impormasyon tungkol sa partikular na pagbabagong ginawa namin kapag nagawa na ito

o Maaari kayong humiling o ang inyong provider ng pagbubukod sa mga pagbabagong ito Padadalhan namin kayo ng abisong naglalaman ng mga hakbang na maaari ninyong isagawa para makahiling ng pagbubukod Mangyaring tingnan ang tanong B10 para sa higit

May inalis na gamot sa merkado Kung sasabihin ng Food and Drug Administration (FDA) na hindi ligtas ang isang gamot na iniinom ninyo o kung aalisin ng manufacturer nito ang gamot sa merkado aalisin namin ito sa Listahan ng Gamot Kung iniinom niny

Magbibigay ang FDA ng bagong gabay o kung may mga bagong klinikal na alituntunin tungkol sa isang gamot

Magdaragdag kami ng generic na gamot na hindi bago sa merkado at



Aabisuhan namin kayo tungkol dito sa loob ng hindi bababa sa 30 araw bago namin gawin ang pagbabago sa Listahan ng Gamot o

Ipapaalam namin ito sa inyo at bibigyan namin kayo ng pang-30 araw na supply ng gamot pagkatapos ninyong humiling ng pag-refill

Kung may katulad na gamot sa Listahan ng Gamot na maaari ninyong ipalit o

Kung hihiling kayo ng pagbubukod sa mga pagbabagong ito Para matuto pa tungkol sa mga pagbubukod sumangguni sa tanong B10


Paunang pag-apruba (o paunang pahintulot) Para sa ilang gamot kailangan muna ninyo o ng inyong doktor o ng iba pang tagareseta na kumuha ng pag-apruba mula sa Blue Shield Promise Cal MediConnect Plan bago ninyo mapunan ang inyong reseta Maaaring

Mga limitasyon sa dami Kung minsan nililimitahan ng Blue Shield Promise Cal MediConnect Plan ang dami ng gamot na maaari ninyong makuha

Step therapy Kung minsan inaatasan kayo ng Blue Shield Promise Cal MediConnect Plan na magsagawa ng step therapy Ibig sabihin nito kakailanganin ninyong sumubok ng mga gamot sa isang partikular na pagkakasunod-sunod para sa inyong medikal na kun



B7 Paano ko mahahanap ang isang gamot sa Listahan ng Gamot

Para maghanap ayon sa pagkakasunod-sunod ng alpabeto sumangguni sa seksyong Index ng Mga Saklaw na Gamot Makikita ninyo ito sa index na nagsisimula sa pahina lt130gt Makikita sa Index ang isang listahan ng mga gamot na kasama sa dokumentong ito ayo



Sasaklawin namin ang isang pang-31 araw na supply ng gamot na kailangan ninyo (maliban na lang kung para lamang sa ilang araw ang inyong reseta) bagong miyembro man kayo ng Blue Shield Promise Cal MediConnect Plan o hindi

Bukod pa ito sa pansamantalang supply sa panahon ng unang 90 araw ng pagiging miyembro ninyo sa Blue Shield Promise Cal MediConnect Plan

Patakaran sa Paglipat Sa mga sitwasyon kung saan lilipat ang isang benepisyaryo mula sa isang lugar ng paggamot papunta sa isa pa titiyakin ng Blue Shield Promise Cal MediConnect Plan ang pagkakaroon ng isang mabilis na proseso para sa pag-apruba ng

B10 Maaari ba akong humiling ng pagbubukod para saklawin ang aking gamot

B11 Paano ako makakahiling ng pagbubukod

B12 Gaano katagal ang inaabot para makakuha ng pagbubukod

B13 Ano ang mga generic na gamot

B14 Ano ang mga OTC na gamot


B16 Ano ang aking copay


Ang mga Tier 1 na gamot ay Mga Piniling Generic na Gamot (may pinakamababang co-payment)

Ang mga Tier 2 na gamot ay Mga Generic na Gamot (may katamtamang co-payment)

Ang mga Tier 3 na gamot ay Mga Branded na Gamot (may pinakamataas na co-payment)

Ang mga Tier 4 na gamot ay Mga Gamot na Hindi Inirereseta ng Medicare at Mga Over-the-Counter (OTC) na gamot (walang copayment)

B17 Ano ang mga tier ng gamot

Ang mga Tier 1 na gamot ay Mga Piniling Generic na Gamot

Ang mga Tier 2 na gamot ay Mga Generic na Gamot

Ang mga Tier 3 na gamot ay Mga Branded na Gamot

Ang mga Tier 4 na gamot ay Mga Gamot na Hindi Inirereseta ng Medicare at Mga Over-the-Counter (OTC) na gamot


Ang pag-apela ay isang pormal na paraan ng paghiling sa amin na suriin ang isang pasyang ginawa namin tungkol sa inyong pagsaklaw at baguhin ito kung naniniwala kayong nagkamali kami Halimbawa maaari naming mapagpasyahan na hindi saklawin ang isan

Kung hindi kayo sang-ayon ng inyong doktor sa aming pasya maaari kayong umapela Kung mayroon kayong tanong tawagan ang Pangangalaga sa Customer sa 1-855-905-3825 (TTY 711) 800 am hanggang 800 pm pitong araw sa isang linggo Maaari rin nin

C1 Mga Gamot na Nakagrupo ayon sa Medikal na Kundisyon

Ang mga gamot sa seksyong ito ay nakagrupo sa mga kategorya depende sa uri ng mga medikal na kundisyong ginagamot ng mga ito Halimbawa kung mayroon kayong kundisyon sa puso dapat kayong tumingin sa kategoryang Mga Cardiovascular Agent Doon ninyo m

List of Covered Drugs


Alphabetical Listing

Category Listing



ii

Blue Shield Promise Cal MediConnect Plan | Listahan ng Mga Saklaw na Gamot (Formulary) para sa 2022

Panimula

Ang dokumentong ito ay tinatawag na Listahan ng Mga Saklaw na Gamot (tinatawag ding Listahan ng Gamot) Ipinapaalam nito sa inyo kung aling mga inireresetang gamot at mga over-the-counter na gamot at item ang sinasaklaw ng Blue Shield Promise Cal MediConnect Plan Ipinapaalam din sa inyo ng Listahan ng Gamot kung mayroong anumang espesyal na panuntunan o paghihigpit sa alinmang gamot na sinasaklaw ng Blue Shield Promise Cal MediConnect Plan Makikita ang mahahalagang termino at ang mga kahulugan ng mga ito sa huling kabanata ng Handbook ng Miyembro Maaari kayong humiling ng kopya sa pamamagitan ng pagtawag sa Pangangalaga sa Customer ng Blue Shield Promise Cal MediConnect Plan sa 1-855-905-3825 (TTY 711) mula 800 am ndash 800 pm pitong araw sa isang linggo libre ang tawag

Talaan ng Nilalaman

A Mga Disclaimer iv










iii















iv

A Mga Disclaimer











v



한국어(Korean)




) فارسیFarsi (




Lus Hmoob (Hmong)






vi












ែខរ (Khmer)






vii


Mienh (Mien)











viii













ix













x














xi









1 - 132


xii











133

1 - 132


xiii













xiv










xv









xvi
















xvii




Hindi available




Hindi available














133


xviii


LEGEND

TIER PANGALAN






LA



PA





ST Step Therapy


(xiii)


xix




NPD



NDS







xx



ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 13


ANTIDEPRESSANTS 18

ANTIEMETICS 21

ANTIFUNGALS 22

ANTIGOUT AGENTS 24




ANTINEOPLASTICS 27

ANTIPARASITICS 37


ANTIPSYCHOTICS 40


ANTIVIRALS 44

ANXIOLYTICS 50

BIPOLAR AGENTS 51














89










OTIC AGENTS 110




ANALGESICS








Tier 2




Tier 2



Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




1

ANALGESICS






Tier 2 PA NDS























2

ANALGESICS





























3

ANALGESICS













ANESTHETICS




Tier 2








4





Tier 2


Tier 2



















Tier 2





5














Tier 3



ANTIBACTERIALS




Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


6

ANTIBACTERIALS






Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


7

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2



Tier 3


Tier 2


Tier 2


Tier 2




8

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


9

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2



10

ANTIBACTERIALS




Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


11

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 3


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


12

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2

ANTICONVULSANTS






13

ANTICONVULSANTS









Tier 2



Tier 2








Tier 2


Tier 2








14

ANTICONVULSANTS




Tier 2


Tier 2













Tier 2










15

ANTICONVULSANTS








Tier 2 PA


Tier 2




Tier 2 PA
















Tier 2


Tier 3


16

ANTICONVULSANTS




Tier 3


Tier 2



Tier 3


Tier 2


Tier 2









Tier 2

ANTIDEMENTIA AGENTS





Tier 2


17

ANTIDEMENTIA AGENTS






Tier 2


Tier 2

ANTIDEPRESSANTS













Tier 2


Tier 2


18

ANTIDEPRESSANTS




Tier 3 PA




Tier 2


Tier 2






Tier 2






Tier 2


Tier 2



Tier 2


19

ANTIDEPRESSANTS




Tier 2


Tier 2





Tier 2


Tier 2






Tier 2








Tier 2 PA


Tier 2


20

ANTIDEPRESSANTS




Tier 2 PA


Tier 2


Tier 2 PA


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2 PA

ANTIEMETICS




Tier 2


Tier 2


Tier 2


Tier 2


21

ANTIEMETICS





Tier 2 PA


Tier 2 PA


Tier 2 BvD





Tier 2 BvD










ANTIFUNGALS






Tier 2 BvD


22

ANTIFUNGALS




Tier 2 PA


Tier 2


Tier 2



Tier 3 PA



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2




Tier 2


23

ANTIFUNGALS









Tier 2


Tier 2 PA


ANTIGOUT AGENTS




Tier 2




Tier 2




ANTIMIGRAINE AGENTS






24

ANTIMIGRAINE AGENTS




Tier 2 PA









Tier 2














25







ANTIMYCOBACTERIALS




Tier 2



Tier 3


Tier 2


Tier 2





Tier 2






26

ANTINEOPLASTICS




Tier 3 BvD


Tier 3










Tier 2












27

ANTINEOPLASTICS







Tier 2



Tier 2


Tier 2


Tier 3





Tier 3 PA LA










28

ANTINEOPLASTICS












Tier 2



















29

ANTINEOPLASTICS



































30

ANTINEOPLASTICS





























31

ANTINEOPLASTICS


































32

ANTINEOPLASTICS



































33

ANTINEOPLASTICS
































34

ANTINEOPLASTICS































35

ANTINEOPLASTICS




























36

ANTINEOPLASTICS





ANTIPARASITICS







TIME)



Tier 2













37

ANTIPARASITICS




Tier 2 BvD


Tier 2


Tier 3







Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


38





Tier 2


Tier 2



Tier 2




Tier 2


39

ANTIPSYCHOTICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2






Tier 2 PA


Tier 2


Tier 2


40

ANTIPSYCHOTICS




Tier 3 PA








Tier 3 PA





















41

ANTIPSYCHOTICS



















Tier 2







Tier 2




42

ANTIPSYCHOTICS




Tier 3


Tier 2







Tier 2


Tier 2


Tier 3 PA


Tier 2




43








Tier 2


Tier 2

ANTIVIRALS




TIME)















44

ANTIVIRALS












Tier 2




















45

ANTIVIRALS

































46

ANTIVIRALS































47

ANTIVIRALS
































48

ANTIVIRALS


































49

ANTIVIRALS











Tier 2



Tier 2


Tier 2


Tier 2

ANXIOLYTICS




Tier 2


Tier 2 PA





50

ANXIOLYTICS



























BIPOLAR AGENTS





51

BIPOLAR AGENTS




Tier 2





Tier 2



Tier 1


Tier 1


Tier 1


Tier 1 PA


Tier 1 PA


Tier 1 PA










52















Tier 1




Tier 2






Tier 2


Tier 2










53























Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


54





Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3






Tier 3


Tier 3


Tier 3


55





Tier 3


Tier 3


Tier 3


Tier 3


























56









Tier 2 BvD




Tier 2








Tier 2


Tier 3 PA



57











Tier 3 PA


Tier 3 PA


Tier 2



Tier 2




Tier 2




Tier 2 PA



58












Tier 2


Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


59





Tier 2


Tier 2




Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


60





Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


61





Tier 1


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2



Tier 2


Tier 1


Tier 2


Tier 2


62





Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


63





Tier 2


Tier 2 PA


Tier 2


Tier 1


Tier 2


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


64





Tier 1





Tier 3




Tier 1




Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2



65





Tier 2


Tier 2



Tier 2


Tier 1




Tier 2


Tier 3 PA


Tier 1


Tier 2


Tier 1



Tier 2


66





Tier 2


Tier 1


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



67





Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2





68











Tier 2













Tier 2



Tier 2


Tier 2


69





Tier 2



Tier 2


Tier 3


















70
































71





























DAYS)



72

















Tier 3 PA LA


Tier 3 PA LA













73





Tier 2


Tier 3 BvD


Tier 2


Tier 2





Tier 2



Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


74





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2 ST


Tier 2 ST


Tier 2


75





Tier 2





Tier 2


Tier 2


Tier 2




Tier 2




Tier 2








76








TIME)



Tier 2

ERY 2 PAD Tier 2


Tier 2







Tier 2 BvD




Tier 2 BvD


Tier 2 BvD




77








Tier 2 BvD








Tier 3 BvD


Tier 2


Tier 2



Tier 2


Tier 2


78





Tier 2


Tier 2


Tier 2


Tier 2



Tier 2





Tier 2



Tier 3 PA LA


Tier 3 PA LA


79







Tier 2


Tier 2


Tier 2



Tier 3




Tier 2


Tier 2


Tier 2


Tier 2


80









Tier 2






Tier 2








Tier 2







81







Tier 2


Tier 3 PA


Tier 3


Tier 2 PA


Tier 2


Tier 2




Tier 2 PA


Tier 2



Tier 2



Tier 2


Tier 2


82





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2




Tier 2




Tier 2




Tier 2





83


Tier 3 LA BvD





Tier 3 LA BvD






Tier 3


Tier 2



Tier 3 PA LA






Tier 2 PA


Tier 3 PA LA


Tier 3 PA LA


84





Tier 3 LA BvD



Tier 2 PA


Tier 2 PA


Tier 3 PA LA




Tier 3





Tier 3


Tier 2


85







Tier 2 ST







Tier 2



Tier 3 PA LA






Tier 2


Tier 2


Tier 2


86





Tier 2



Tier 2


Tier 2 BvD


Tier 2


Tier 2






Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


87





Tier 2


Tier 2





Tier 2


Tier 2


Tier 2





Tier 3 PA


Tier 3 PA LA


88






Tier 2 PA




Tier 2




Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


89









Tier 2 PA


Tier 2



Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3 PA


90





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3 PA






91





Tier 3


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2 PA




Tier 2







Tier 2


92





Tier 2


Tier 3





TIME)


Tier 3




Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


93





Tier 2 PA



Tier 3 PA




Tier 3 PA





Tier 3 BvD





Tier 2



94







Tier 3 PA LA




Tier 3 PA LA




Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA LA


95





Tier 3 PA


Tier 3 PA


Tier 3 PA LA


Tier 3 PA


Tier 3





Tier 3 PA LA




Tier 3 PA


Tier 3 PA


Tier 3 PA





96






Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA







Tier 3 LA


Tier 2 BvD



Tier 2 BvD


Tier 2 BvD


Tier 3 PA


Tier 3 PA


97





Tier 3 PA


Tier 2 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 2


Tier 2 BvD


Tier 2


98





Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 3 PA




Tier 3 BvD


Tier 2 BvD


Tier 2 BvD







Tier 3




Tier 3



Tier 3


99





Tier 3 BvD


Tier 3


Tier 3



Tier 3





Tier 3







Tier 3





Tier 3 BvD




100










Tier 3 BvD


Tier 3


Tier 3


Tier 3











Tier 2


Tier 2




101






Tier 2


Tier 2





Tier 1




Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 2


Tier 3 PA


Tier 2 PA


Tier 2




102





Tier 2 BvD



Tier 2





Tier 2 BvD





Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


103





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


104









Tier 2



Tier 2


Tier 2


Tier 2




Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


105





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


106





Tier 2


Tier 2


Tier 2


Tier 2

OPHTHALMIC AGENTS





Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



107

OPHTHALMIC AGENTS








Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2



Tier 2



Tier 2




Tier 2


Tier 2


108

OPHTHALMIC AGENTS




Tier 2




Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


109

OPHTHALMIC AGENTS




Tier 2



Tier 2



Tier 2



Tier 2


Tier 3


Tier 2



TIME)


Tier 2




OTIC AGENTS




Tier 2


110

OTIC AGENTS




Tier 2


Tier 3


Tier 3



Tier 2


Tier 2






Tier 2 BvD














111












Tier 2 PA


Tier 2


Tier 2 PA









Tier 2 BvD








112















Tier 2 BvD


Tier 2








Tier 2 PA








113





OVER TIME)















Tier 2 BvD


OVER TIME)



Tier 2


Tier 2


114
























Tier 2 BvD




115













Tier 2 BvD











Tier 2 PA


Tier 2 PA


116





















117

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD





Tier 4 NPD


Tier 4 NPD



118

Non-Part D Drugs





Tier 4 NPD




Tier 4 NPD




Tier 4 NPD




Tier 4 NPD




119

Non-Part D Drugs




Tier 4 NPD


Tier 4 PA NPD


Tier 4 PA NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


120

Non-Part D Drugs





Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD




Tier 4 NPD



121

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


122

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



123

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


124

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



125

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD





























126

Non-Part D Drugs
































127

Non-Part D Drugs









Tier 4 NPD

























128

Non-Part D Drugs




































129

Non-Part D Drugs


















Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


130

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD










131

Non-Part D Drugs




Tier 4 PA NPD




Tier 4 NPD


132

Index



133




134




135



136




137




138




139



140





141






142




143




144




145




146




147





148




149



150







151


YYF-VAX 101



152



H0148_20_503

An

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lue

Sh

ield

of C

alif

orn

ia P

rom

ise

He

alth P

lan

ay isa

ng

ind

ep

en

diy

en

ten

g li

sensy

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o n

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sso

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tio

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51247

-CM

S (9

18)




















Telepono (844) 883-2233 (TTY 711)

Fax (323) 889-2228












English




中文 (Chinese)



한국어(Korean)









Lus Hmoob (Hmong)









Tagalog (Tagalog)






























H0148_21_166

_C

_A

cc

ep

ted

08172021


10052021







A Mga Disclaimer iv






















A Mga Disclaimer
































































Category Listing



iii















iv

A Mga Disclaimer











v



한국어(Korean)




) فارسیFarsi (




Lus Hmoob (Hmong)






vi












ែខរ (Khmer)






vii


Mienh (Mien)











viii













ix













x














xi









1 - 132


xii











133

1 - 132


xiii













xiv










xv









xvi
















xvii




Hindi available




Hindi available














133


xviii


LEGEND

TIER PANGALAN






LA



PA





ST Step Therapy


(xiii)


xix




NPD



NDS







xx



ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 13


ANTIDEPRESSANTS 18

ANTIEMETICS 21

ANTIFUNGALS 22

ANTIGOUT AGENTS 24




ANTINEOPLASTICS 27

ANTIPARASITICS 37


ANTIPSYCHOTICS 40


ANTIVIRALS 44

ANXIOLYTICS 50

BIPOLAR AGENTS 51














89










OTIC AGENTS 110




ANALGESICS








Tier 2




Tier 2



Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




1

ANALGESICS






Tier 2 PA NDS























2

ANALGESICS





























3

ANALGESICS













ANESTHETICS




Tier 2








4





Tier 2


Tier 2



















Tier 2





5














Tier 3



ANTIBACTERIALS




Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


6

ANTIBACTERIALS






Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


7

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2



Tier 3


Tier 2


Tier 2


Tier 2




8

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


9

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2



10

ANTIBACTERIALS




Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


11

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 3


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


12

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2

ANTICONVULSANTS






13

ANTICONVULSANTS









Tier 2



Tier 2








Tier 2


Tier 2








14

ANTICONVULSANTS




Tier 2


Tier 2













Tier 2










15

ANTICONVULSANTS








Tier 2 PA


Tier 2




Tier 2 PA
















Tier 2


Tier 3


16

ANTICONVULSANTS




Tier 3


Tier 2



Tier 3


Tier 2


Tier 2









Tier 2

ANTIDEMENTIA AGENTS





Tier 2


17

ANTIDEMENTIA AGENTS






Tier 2


Tier 2

ANTIDEPRESSANTS













Tier 2


Tier 2


18

ANTIDEPRESSANTS




Tier 3 PA




Tier 2


Tier 2






Tier 2






Tier 2


Tier 2



Tier 2


19

ANTIDEPRESSANTS




Tier 2


Tier 2





Tier 2


Tier 2






Tier 2








Tier 2 PA


Tier 2


20

ANTIDEPRESSANTS




Tier 2 PA


Tier 2


Tier 2 PA


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2 PA

ANTIEMETICS




Tier 2


Tier 2


Tier 2


Tier 2


21

ANTIEMETICS





Tier 2 PA


Tier 2 PA


Tier 2 BvD





Tier 2 BvD










ANTIFUNGALS






Tier 2 BvD


22

ANTIFUNGALS




Tier 2 PA


Tier 2


Tier 2



Tier 3 PA



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2




Tier 2


23

ANTIFUNGALS









Tier 2


Tier 2 PA


ANTIGOUT AGENTS




Tier 2




Tier 2




ANTIMIGRAINE AGENTS






24

ANTIMIGRAINE AGENTS




Tier 2 PA









Tier 2














25







ANTIMYCOBACTERIALS




Tier 2



Tier 3


Tier 2


Tier 2





Tier 2






26

ANTINEOPLASTICS




Tier 3 BvD


Tier 3










Tier 2












27

ANTINEOPLASTICS







Tier 2



Tier 2


Tier 2


Tier 3





Tier 3 PA LA










28

ANTINEOPLASTICS












Tier 2



















29

ANTINEOPLASTICS



































30

ANTINEOPLASTICS





























31

ANTINEOPLASTICS


































32

ANTINEOPLASTICS



































33

ANTINEOPLASTICS
































34

ANTINEOPLASTICS































35

ANTINEOPLASTICS




























36

ANTINEOPLASTICS





ANTIPARASITICS







TIME)



Tier 2













37

ANTIPARASITICS




Tier 2 BvD


Tier 2


Tier 3







Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


38





Tier 2


Tier 2



Tier 2




Tier 2


39

ANTIPSYCHOTICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2






Tier 2 PA


Tier 2


Tier 2


40

ANTIPSYCHOTICS




Tier 3 PA








Tier 3 PA





















41

ANTIPSYCHOTICS



















Tier 2







Tier 2




42

ANTIPSYCHOTICS




Tier 3


Tier 2







Tier 2


Tier 2


Tier 3 PA


Tier 2




43








Tier 2


Tier 2

ANTIVIRALS




TIME)















44

ANTIVIRALS












Tier 2




















45

ANTIVIRALS

































46

ANTIVIRALS































47

ANTIVIRALS
































48

ANTIVIRALS


































49

ANTIVIRALS











Tier 2



Tier 2


Tier 2


Tier 2

ANXIOLYTICS




Tier 2


Tier 2 PA





50

ANXIOLYTICS



























BIPOLAR AGENTS





51

BIPOLAR AGENTS




Tier 2





Tier 2



Tier 1


Tier 1


Tier 1


Tier 1 PA


Tier 1 PA


Tier 1 PA










52















Tier 1




Tier 2






Tier 2


Tier 2










53























Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


54





Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3






Tier 3


Tier 3


Tier 3


55





Tier 3


Tier 3


Tier 3


Tier 3


























56









Tier 2 BvD




Tier 2








Tier 2


Tier 3 PA



57











Tier 3 PA


Tier 3 PA


Tier 2



Tier 2




Tier 2




Tier 2 PA



58












Tier 2


Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


59





Tier 2


Tier 2




Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


60





Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


61





Tier 1


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2



Tier 2


Tier 1


Tier 2


Tier 2


62





Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


63





Tier 2


Tier 2 PA


Tier 2


Tier 1


Tier 2


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


64





Tier 1





Tier 3




Tier 1




Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2



65





Tier 2


Tier 2



Tier 2


Tier 1




Tier 2


Tier 3 PA


Tier 1


Tier 2


Tier 1



Tier 2


66





Tier 2


Tier 1


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



67





Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2





68











Tier 2













Tier 2



Tier 2


Tier 2


69





Tier 2



Tier 2


Tier 3


















70
































71





























DAYS)



72

















Tier 3 PA LA


Tier 3 PA LA













73





Tier 2


Tier 3 BvD


Tier 2


Tier 2





Tier 2



Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


74





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2 ST


Tier 2 ST


Tier 2


75





Tier 2





Tier 2


Tier 2


Tier 2




Tier 2




Tier 2








76








TIME)



Tier 2

ERY 2 PAD Tier 2


Tier 2







Tier 2 BvD




Tier 2 BvD


Tier 2 BvD




77








Tier 2 BvD








Tier 3 BvD


Tier 2


Tier 2



Tier 2


Tier 2


78





Tier 2


Tier 2


Tier 2


Tier 2



Tier 2





Tier 2



Tier 3 PA LA


Tier 3 PA LA


79







Tier 2


Tier 2


Tier 2



Tier 3




Tier 2


Tier 2


Tier 2


Tier 2


80









Tier 2






Tier 2








Tier 2







81







Tier 2


Tier 3 PA


Tier 3


Tier 2 PA


Tier 2


Tier 2




Tier 2 PA


Tier 2



Tier 2



Tier 2


Tier 2


82





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2




Tier 2




Tier 2




Tier 2





83


Tier 3 LA BvD





Tier 3 LA BvD






Tier 3


Tier 2



Tier 3 PA LA






Tier 2 PA


Tier 3 PA LA


Tier 3 PA LA


84





Tier 3 LA BvD



Tier 2 PA


Tier 2 PA


Tier 3 PA LA




Tier 3





Tier 3


Tier 2


85







Tier 2 ST







Tier 2



Tier 3 PA LA






Tier 2


Tier 2


Tier 2


86





Tier 2



Tier 2


Tier 2 BvD


Tier 2


Tier 2






Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


87





Tier 2


Tier 2





Tier 2


Tier 2


Tier 2





Tier 3 PA


Tier 3 PA LA


88






Tier 2 PA




Tier 2




Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


89









Tier 2 PA


Tier 2



Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3 PA


90





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3 PA






91





Tier 3


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2 PA




Tier 2







Tier 2


92





Tier 2


Tier 3





TIME)


Tier 3




Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


93





Tier 2 PA



Tier 3 PA




Tier 3 PA





Tier 3 BvD





Tier 2



94







Tier 3 PA LA




Tier 3 PA LA




Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA LA


95





Tier 3 PA


Tier 3 PA


Tier 3 PA LA


Tier 3 PA


Tier 3





Tier 3 PA LA




Tier 3 PA


Tier 3 PA


Tier 3 PA





96






Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA







Tier 3 LA


Tier 2 BvD



Tier 2 BvD


Tier 2 BvD


Tier 3 PA


Tier 3 PA


97





Tier 3 PA


Tier 2 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 2


Tier 2 BvD


Tier 2


98





Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 3 PA




Tier 3 BvD


Tier 2 BvD


Tier 2 BvD







Tier 3




Tier 3



Tier 3


99





Tier 3 BvD


Tier 3


Tier 3



Tier 3





Tier 3







Tier 3





Tier 3 BvD




100










Tier 3 BvD


Tier 3


Tier 3


Tier 3











Tier 2


Tier 2




101






Tier 2


Tier 2





Tier 1




Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 2


Tier 3 PA


Tier 2 PA


Tier 2




102





Tier 2 BvD



Tier 2





Tier 2 BvD





Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


103





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


104









Tier 2



Tier 2


Tier 2


Tier 2




Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


105





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


106





Tier 2


Tier 2


Tier 2


Tier 2

OPHTHALMIC AGENTS





Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



107

OPHTHALMIC AGENTS








Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2



Tier 2



Tier 2




Tier 2


Tier 2


108

OPHTHALMIC AGENTS




Tier 2




Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


109

OPHTHALMIC AGENTS




Tier 2



Tier 2



Tier 2



Tier 2


Tier 3


Tier 2



TIME)


Tier 2




OTIC AGENTS




Tier 2


110

OTIC AGENTS




Tier 2


Tier 3


Tier 3



Tier 2


Tier 2






Tier 2 BvD














111












Tier 2 PA


Tier 2


Tier 2 PA









Tier 2 BvD








112















Tier 2 BvD


Tier 2








Tier 2 PA








113





OVER TIME)















Tier 2 BvD


OVER TIME)



Tier 2


Tier 2


114
























Tier 2 BvD




115













Tier 2 BvD











Tier 2 PA


Tier 2 PA


116





















117

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD





Tier 4 NPD


Tier 4 NPD



118

Non-Part D Drugs





Tier 4 NPD




Tier 4 NPD




Tier 4 NPD




Tier 4 NPD




119

Non-Part D Drugs




Tier 4 NPD


Tier 4 PA NPD


Tier 4 PA NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


120

Non-Part D Drugs





Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD




Tier 4 NPD



121

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


122

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



123

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


124

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



125

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD





























126

Non-Part D Drugs
































127

Non-Part D Drugs









Tier 4 NPD

























128

Non-Part D Drugs




































129

Non-Part D Drugs


















Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


130

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD










131

Non-Part D Drugs




Tier 4 PA NPD




Tier 4 NPD


132

Index



133




134




135



136




137




138




139



140





141






142




143




144




145




146




147





148




149



150







151


YYF-VAX 101



152



H0148_20_503

An

g B

lue

Sh

ield

of C

alif

orn

ia P

rom

ise

He

alth P

lan

ay isa

ng

ind

ep

en

diy

en

ten

g li

sensy

ad

o n

g B

lue

Shie

ld A

sso

cia

tio

n A

51247

-CM

S (9

18)




















Telepono (844) 883-2233 (TTY 711)

Fax (323) 889-2228












English




中文 (Chinese)



한국어(Korean)









Lus Hmoob (Hmong)









Tagalog (Tagalog)






























H0148_21_166

_C

_A

cc

ep

ted

08172021


10052021







A Mga Disclaimer iv






















A Mga Disclaimer
































































Category Listing



iv

A Mga Disclaimer











v



한국어(Korean)




) فارسیFarsi (




Lus Hmoob (Hmong)






vi












ែខរ (Khmer)






vii


Mienh (Mien)











viii













ix













x














xi









1 - 132


xii











133

1 - 132


xiii













xiv










xv









xvi
















xvii




Hindi available




Hindi available














133


xviii


LEGEND

TIER PANGALAN






LA



PA





ST Step Therapy


(xiii)


xix




NPD



NDS







xx



ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 13


ANTIDEPRESSANTS 18

ANTIEMETICS 21

ANTIFUNGALS 22

ANTIGOUT AGENTS 24




ANTINEOPLASTICS 27

ANTIPARASITICS 37


ANTIPSYCHOTICS 40


ANTIVIRALS 44

ANXIOLYTICS 50

BIPOLAR AGENTS 51














89










OTIC AGENTS 110




ANALGESICS








Tier 2




Tier 2



Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




1

ANALGESICS






Tier 2 PA NDS























2

ANALGESICS





























3

ANALGESICS













ANESTHETICS




Tier 2








4





Tier 2


Tier 2



















Tier 2





5














Tier 3



ANTIBACTERIALS




Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


6

ANTIBACTERIALS






Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


7

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2



Tier 3


Tier 2


Tier 2


Tier 2




8

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


9

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2



10

ANTIBACTERIALS




Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


11

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 3


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


12

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2

ANTICONVULSANTS






13

ANTICONVULSANTS









Tier 2



Tier 2








Tier 2


Tier 2








14

ANTICONVULSANTS




Tier 2


Tier 2













Tier 2










15

ANTICONVULSANTS








Tier 2 PA


Tier 2




Tier 2 PA
















Tier 2


Tier 3


16

ANTICONVULSANTS




Tier 3


Tier 2



Tier 3


Tier 2


Tier 2









Tier 2

ANTIDEMENTIA AGENTS





Tier 2


17

ANTIDEMENTIA AGENTS






Tier 2


Tier 2

ANTIDEPRESSANTS













Tier 2


Tier 2


18

ANTIDEPRESSANTS




Tier 3 PA




Tier 2


Tier 2






Tier 2






Tier 2


Tier 2



Tier 2


19

ANTIDEPRESSANTS




Tier 2


Tier 2





Tier 2


Tier 2






Tier 2








Tier 2 PA


Tier 2


20

ANTIDEPRESSANTS




Tier 2 PA


Tier 2


Tier 2 PA


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2 PA

ANTIEMETICS




Tier 2


Tier 2


Tier 2


Tier 2


21

ANTIEMETICS





Tier 2 PA


Tier 2 PA


Tier 2 BvD





Tier 2 BvD










ANTIFUNGALS






Tier 2 BvD


22

ANTIFUNGALS




Tier 2 PA


Tier 2


Tier 2



Tier 3 PA



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2




Tier 2


23

ANTIFUNGALS









Tier 2


Tier 2 PA


ANTIGOUT AGENTS




Tier 2




Tier 2




ANTIMIGRAINE AGENTS






24

ANTIMIGRAINE AGENTS




Tier 2 PA









Tier 2














25







ANTIMYCOBACTERIALS




Tier 2



Tier 3


Tier 2


Tier 2





Tier 2






26

ANTINEOPLASTICS




Tier 3 BvD


Tier 3










Tier 2












27

ANTINEOPLASTICS







Tier 2



Tier 2


Tier 2


Tier 3





Tier 3 PA LA










28

ANTINEOPLASTICS












Tier 2



















29

ANTINEOPLASTICS



































30

ANTINEOPLASTICS





























31

ANTINEOPLASTICS


































32

ANTINEOPLASTICS



































33

ANTINEOPLASTICS
































34

ANTINEOPLASTICS































35

ANTINEOPLASTICS




























36

ANTINEOPLASTICS





ANTIPARASITICS







TIME)



Tier 2













37

ANTIPARASITICS




Tier 2 BvD


Tier 2


Tier 3







Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


38





Tier 2


Tier 2



Tier 2




Tier 2


39

ANTIPSYCHOTICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2






Tier 2 PA


Tier 2


Tier 2


40

ANTIPSYCHOTICS




Tier 3 PA








Tier 3 PA





















41

ANTIPSYCHOTICS



















Tier 2







Tier 2




42

ANTIPSYCHOTICS




Tier 3


Tier 2







Tier 2


Tier 2


Tier 3 PA


Tier 2




43








Tier 2


Tier 2

ANTIVIRALS




TIME)















44

ANTIVIRALS












Tier 2




















45

ANTIVIRALS

































46

ANTIVIRALS































47

ANTIVIRALS
































48

ANTIVIRALS


































49

ANTIVIRALS











Tier 2



Tier 2


Tier 2


Tier 2

ANXIOLYTICS




Tier 2


Tier 2 PA





50

ANXIOLYTICS



























BIPOLAR AGENTS





51

BIPOLAR AGENTS




Tier 2





Tier 2



Tier 1


Tier 1


Tier 1


Tier 1 PA


Tier 1 PA


Tier 1 PA










52















Tier 1




Tier 2






Tier 2


Tier 2










53























Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


54





Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3






Tier 3


Tier 3


Tier 3


55





Tier 3


Tier 3


Tier 3


Tier 3


























56









Tier 2 BvD




Tier 2








Tier 2


Tier 3 PA



57











Tier 3 PA


Tier 3 PA


Tier 2



Tier 2




Tier 2




Tier 2 PA



58












Tier 2


Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


59





Tier 2


Tier 2




Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


60





Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


61





Tier 1


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2



Tier 2


Tier 1


Tier 2


Tier 2


62





Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


63





Tier 2


Tier 2 PA


Tier 2


Tier 1


Tier 2


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


64





Tier 1





Tier 3




Tier 1




Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2



65





Tier 2


Tier 2



Tier 2


Tier 1




Tier 2


Tier 3 PA


Tier 1


Tier 2


Tier 1



Tier 2


66





Tier 2


Tier 1


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



67





Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2





68











Tier 2













Tier 2



Tier 2


Tier 2


69





Tier 2



Tier 2


Tier 3


















70
































71





























DAYS)



72

















Tier 3 PA LA


Tier 3 PA LA













73





Tier 2


Tier 3 BvD


Tier 2


Tier 2





Tier 2



Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


74





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2 ST


Tier 2 ST


Tier 2


75





Tier 2





Tier 2


Tier 2


Tier 2




Tier 2




Tier 2








76








TIME)



Tier 2

ERY 2 PAD Tier 2


Tier 2







Tier 2 BvD




Tier 2 BvD


Tier 2 BvD




77








Tier 2 BvD








Tier 3 BvD


Tier 2


Tier 2



Tier 2


Tier 2


78





Tier 2


Tier 2


Tier 2


Tier 2



Tier 2





Tier 2



Tier 3 PA LA


Tier 3 PA LA


79







Tier 2


Tier 2


Tier 2



Tier 3




Tier 2


Tier 2


Tier 2


Tier 2


80









Tier 2






Tier 2








Tier 2







81







Tier 2


Tier 3 PA


Tier 3


Tier 2 PA


Tier 2


Tier 2




Tier 2 PA


Tier 2



Tier 2



Tier 2


Tier 2


82





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2




Tier 2




Tier 2




Tier 2





83


Tier 3 LA BvD





Tier 3 LA BvD






Tier 3


Tier 2



Tier 3 PA LA






Tier 2 PA


Tier 3 PA LA


Tier 3 PA LA


84





Tier 3 LA BvD



Tier 2 PA


Tier 2 PA


Tier 3 PA LA




Tier 3





Tier 3


Tier 2


85







Tier 2 ST







Tier 2



Tier 3 PA LA






Tier 2


Tier 2


Tier 2


86





Tier 2



Tier 2


Tier 2 BvD


Tier 2


Tier 2






Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


87





Tier 2


Tier 2





Tier 2


Tier 2


Tier 2





Tier 3 PA


Tier 3 PA LA


88






Tier 2 PA




Tier 2




Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


89









Tier 2 PA


Tier 2



Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3 PA


90





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3 PA






91





Tier 3


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2 PA




Tier 2







Tier 2


92





Tier 2


Tier 3





TIME)


Tier 3




Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


93





Tier 2 PA



Tier 3 PA




Tier 3 PA





Tier 3 BvD





Tier 2



94







Tier 3 PA LA




Tier 3 PA LA




Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA LA


95





Tier 3 PA


Tier 3 PA


Tier 3 PA LA


Tier 3 PA


Tier 3





Tier 3 PA LA




Tier 3 PA


Tier 3 PA


Tier 3 PA





96






Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA







Tier 3 LA


Tier 2 BvD



Tier 2 BvD


Tier 2 BvD


Tier 3 PA


Tier 3 PA


97





Tier 3 PA


Tier 2 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 2


Tier 2 BvD


Tier 2


98





Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 3 PA




Tier 3 BvD


Tier 2 BvD


Tier 2 BvD







Tier 3




Tier 3



Tier 3


99





Tier 3 BvD


Tier 3


Tier 3



Tier 3





Tier 3







Tier 3





Tier 3 BvD




100










Tier 3 BvD


Tier 3


Tier 3


Tier 3











Tier 2


Tier 2




101






Tier 2


Tier 2





Tier 1




Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 2


Tier 3 PA


Tier 2 PA


Tier 2




102





Tier 2 BvD



Tier 2





Tier 2 BvD





Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


103





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


104









Tier 2



Tier 2


Tier 2


Tier 2




Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


105





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


106





Tier 2


Tier 2


Tier 2


Tier 2

OPHTHALMIC AGENTS





Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



107

OPHTHALMIC AGENTS








Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2



Tier 2



Tier 2




Tier 2


Tier 2


108

OPHTHALMIC AGENTS




Tier 2




Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


109

OPHTHALMIC AGENTS




Tier 2



Tier 2



Tier 2



Tier 2


Tier 3


Tier 2



TIME)


Tier 2




OTIC AGENTS




Tier 2


110

OTIC AGENTS




Tier 2


Tier 3


Tier 3



Tier 2


Tier 2






Tier 2 BvD














111












Tier 2 PA


Tier 2


Tier 2 PA









Tier 2 BvD








112















Tier 2 BvD


Tier 2








Tier 2 PA








113





OVER TIME)















Tier 2 BvD


OVER TIME)



Tier 2


Tier 2


114
























Tier 2 BvD




115













Tier 2 BvD











Tier 2 PA


Tier 2 PA


116





















117

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD





Tier 4 NPD


Tier 4 NPD



118

Non-Part D Drugs





Tier 4 NPD




Tier 4 NPD




Tier 4 NPD




Tier 4 NPD




119

Non-Part D Drugs




Tier 4 NPD


Tier 4 PA NPD


Tier 4 PA NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


120

Non-Part D Drugs





Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD




Tier 4 NPD



121

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


122

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



123

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


124

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



125

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD





























126

Non-Part D Drugs
































127

Non-Part D Drugs









Tier 4 NPD

























128

Non-Part D Drugs




































129

Non-Part D Drugs


















Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


130

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD










131

Non-Part D Drugs




Tier 4 PA NPD




Tier 4 NPD


132

Index



133




134




135



136




137




138




139



140





141






142




143




144




145




146




147





148




149



150







151


YYF-VAX 101



152



H0148_20_503

An

g B

lue

Sh

ield

of C

alif

orn

ia P

rom

ise

He

alth P

lan

ay isa

ng

ind

ep

en

diy

en

ten

g li

sensy

ad

o n

g B

lue

Shie

ld A

sso

cia

tio

n A

51247

-CM

S (9

18)




















Telepono (844) 883-2233 (TTY 711)

Fax (323) 889-2228












English




中文 (Chinese)



한국어(Korean)









Lus Hmoob (Hmong)









Tagalog (Tagalog)






























H0148_21_166

_C

_A

cc

ep

ted

08172021


10052021







A Mga Disclaimer iv






















A Mga Disclaimer
































































Category Listing



v



한국어(Korean)




) فارسیFarsi (




Lus Hmoob (Hmong)






vi












ែខរ (Khmer)






vii


Mienh (Mien)











viii













ix













x














xi









1 - 132


xii











133

1 - 132


xiii













xiv










xv









xvi
















xvii




Hindi available




Hindi available














133


xviii


LEGEND

TIER PANGALAN






LA



PA





ST Step Therapy


(xiii)


xix




NPD



NDS







xx



ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 13


ANTIDEPRESSANTS 18

ANTIEMETICS 21

ANTIFUNGALS 22

ANTIGOUT AGENTS 24




ANTINEOPLASTICS 27

ANTIPARASITICS 37


ANTIPSYCHOTICS 40


ANTIVIRALS 44

ANXIOLYTICS 50

BIPOLAR AGENTS 51














89










OTIC AGENTS 110




ANALGESICS








Tier 2




Tier 2



Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




1

ANALGESICS






Tier 2 PA NDS























2

ANALGESICS





























3

ANALGESICS













ANESTHETICS




Tier 2








4





Tier 2


Tier 2



















Tier 2





5














Tier 3



ANTIBACTERIALS




Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


6

ANTIBACTERIALS






Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


7

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2



Tier 3


Tier 2


Tier 2


Tier 2




8

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


9

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2



10

ANTIBACTERIALS




Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


11

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 3


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


12

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2

ANTICONVULSANTS






13

ANTICONVULSANTS









Tier 2



Tier 2








Tier 2


Tier 2








14

ANTICONVULSANTS




Tier 2


Tier 2













Tier 2










15

ANTICONVULSANTS








Tier 2 PA


Tier 2




Tier 2 PA
















Tier 2


Tier 3


16

ANTICONVULSANTS




Tier 3


Tier 2



Tier 3


Tier 2


Tier 2









Tier 2

ANTIDEMENTIA AGENTS





Tier 2


17

ANTIDEMENTIA AGENTS






Tier 2


Tier 2

ANTIDEPRESSANTS













Tier 2


Tier 2


18

ANTIDEPRESSANTS




Tier 3 PA




Tier 2


Tier 2






Tier 2






Tier 2


Tier 2



Tier 2


19

ANTIDEPRESSANTS




Tier 2


Tier 2





Tier 2


Tier 2






Tier 2








Tier 2 PA


Tier 2


20

ANTIDEPRESSANTS




Tier 2 PA


Tier 2


Tier 2 PA


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2 PA

ANTIEMETICS




Tier 2


Tier 2


Tier 2


Tier 2


21

ANTIEMETICS





Tier 2 PA


Tier 2 PA


Tier 2 BvD





Tier 2 BvD










ANTIFUNGALS






Tier 2 BvD


22

ANTIFUNGALS




Tier 2 PA


Tier 2


Tier 2



Tier 3 PA



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2




Tier 2


23

ANTIFUNGALS









Tier 2


Tier 2 PA


ANTIGOUT AGENTS




Tier 2




Tier 2




ANTIMIGRAINE AGENTS






24

ANTIMIGRAINE AGENTS




Tier 2 PA









Tier 2














25







ANTIMYCOBACTERIALS




Tier 2



Tier 3


Tier 2


Tier 2





Tier 2






26

ANTINEOPLASTICS




Tier 3 BvD


Tier 3










Tier 2












27

ANTINEOPLASTICS







Tier 2



Tier 2


Tier 2


Tier 3





Tier 3 PA LA










28

ANTINEOPLASTICS












Tier 2



















29

ANTINEOPLASTICS



































30

ANTINEOPLASTICS





























31

ANTINEOPLASTICS


































32

ANTINEOPLASTICS



































33

ANTINEOPLASTICS
































34

ANTINEOPLASTICS































35

ANTINEOPLASTICS




























36

ANTINEOPLASTICS





ANTIPARASITICS







TIME)



Tier 2













37

ANTIPARASITICS




Tier 2 BvD


Tier 2


Tier 3







Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


38





Tier 2


Tier 2



Tier 2




Tier 2


39

ANTIPSYCHOTICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2






Tier 2 PA


Tier 2


Tier 2


40

ANTIPSYCHOTICS




Tier 3 PA








Tier 3 PA





















41

ANTIPSYCHOTICS



















Tier 2







Tier 2




42

ANTIPSYCHOTICS




Tier 3


Tier 2







Tier 2


Tier 2


Tier 3 PA


Tier 2




43








Tier 2


Tier 2

ANTIVIRALS




TIME)















44

ANTIVIRALS












Tier 2




















45

ANTIVIRALS

































46

ANTIVIRALS































47

ANTIVIRALS
































48

ANTIVIRALS


































49

ANTIVIRALS











Tier 2



Tier 2


Tier 2


Tier 2

ANXIOLYTICS




Tier 2


Tier 2 PA





50

ANXIOLYTICS



























BIPOLAR AGENTS





51

BIPOLAR AGENTS




Tier 2





Tier 2



Tier 1


Tier 1


Tier 1


Tier 1 PA


Tier 1 PA


Tier 1 PA










52















Tier 1




Tier 2






Tier 2


Tier 2










53























Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


54





Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3






Tier 3


Tier 3


Tier 3


55





Tier 3


Tier 3


Tier 3


Tier 3


























56









Tier 2 BvD




Tier 2








Tier 2


Tier 3 PA



57











Tier 3 PA


Tier 3 PA


Tier 2



Tier 2




Tier 2




Tier 2 PA



58












Tier 2


Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


59





Tier 2


Tier 2




Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


60





Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


61





Tier 1


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2



Tier 2


Tier 1


Tier 2


Tier 2


62





Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


63





Tier 2


Tier 2 PA


Tier 2


Tier 1


Tier 2


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


64





Tier 1





Tier 3




Tier 1




Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2



65





Tier 2


Tier 2



Tier 2


Tier 1




Tier 2


Tier 3 PA


Tier 1


Tier 2


Tier 1



Tier 2


66





Tier 2


Tier 1


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



67





Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2





68











Tier 2













Tier 2



Tier 2


Tier 2


69





Tier 2



Tier 2


Tier 3


















70
































71





























DAYS)



72

















Tier 3 PA LA


Tier 3 PA LA













73





Tier 2


Tier 3 BvD


Tier 2


Tier 2





Tier 2



Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


74





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2 ST


Tier 2 ST


Tier 2


75





Tier 2





Tier 2


Tier 2


Tier 2




Tier 2




Tier 2








76








TIME)



Tier 2

ERY 2 PAD Tier 2


Tier 2







Tier 2 BvD




Tier 2 BvD


Tier 2 BvD




77








Tier 2 BvD








Tier 3 BvD


Tier 2


Tier 2



Tier 2


Tier 2


78





Tier 2


Tier 2


Tier 2


Tier 2



Tier 2





Tier 2



Tier 3 PA LA


Tier 3 PA LA


79







Tier 2


Tier 2


Tier 2



Tier 3




Tier 2


Tier 2


Tier 2


Tier 2


80









Tier 2






Tier 2








Tier 2







81







Tier 2


Tier 3 PA


Tier 3


Tier 2 PA


Tier 2


Tier 2




Tier 2 PA


Tier 2



Tier 2



Tier 2


Tier 2


82





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2




Tier 2




Tier 2




Tier 2





83


Tier 3 LA BvD





Tier 3 LA BvD






Tier 3


Tier 2



Tier 3 PA LA






Tier 2 PA


Tier 3 PA LA


Tier 3 PA LA


84





Tier 3 LA BvD



Tier 2 PA


Tier 2 PA


Tier 3 PA LA




Tier 3





Tier 3


Tier 2


85







Tier 2 ST







Tier 2



Tier 3 PA LA






Tier 2


Tier 2


Tier 2


86





Tier 2



Tier 2


Tier 2 BvD


Tier 2


Tier 2






Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


87





Tier 2


Tier 2





Tier 2


Tier 2


Tier 2





Tier 3 PA


Tier 3 PA LA


88






Tier 2 PA




Tier 2




Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


89









Tier 2 PA


Tier 2



Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3 PA


90





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3 PA






91





Tier 3


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2 PA




Tier 2







Tier 2


92





Tier 2


Tier 3





TIME)


Tier 3




Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


93





Tier 2 PA



Tier 3 PA




Tier 3 PA





Tier 3 BvD





Tier 2



94







Tier 3 PA LA




Tier 3 PA LA




Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA LA


95





Tier 3 PA


Tier 3 PA


Tier 3 PA LA


Tier 3 PA


Tier 3





Tier 3 PA LA




Tier 3 PA


Tier 3 PA


Tier 3 PA





96






Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA







Tier 3 LA


Tier 2 BvD



Tier 2 BvD


Tier 2 BvD


Tier 3 PA


Tier 3 PA


97





Tier 3 PA


Tier 2 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 2


Tier 2 BvD


Tier 2


98





Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 3 PA




Tier 3 BvD


Tier 2 BvD


Tier 2 BvD







Tier 3




Tier 3



Tier 3


99





Tier 3 BvD


Tier 3


Tier 3



Tier 3





Tier 3







Tier 3





Tier 3 BvD




100










Tier 3 BvD


Tier 3


Tier 3


Tier 3











Tier 2


Tier 2




101






Tier 2


Tier 2





Tier 1




Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 2


Tier 3 PA


Tier 2 PA


Tier 2




102





Tier 2 BvD



Tier 2





Tier 2 BvD





Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


103





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


104









Tier 2



Tier 2


Tier 2


Tier 2




Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


105





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


106





Tier 2


Tier 2


Tier 2


Tier 2

OPHTHALMIC AGENTS





Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



107

OPHTHALMIC AGENTS








Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2



Tier 2



Tier 2




Tier 2


Tier 2


108

OPHTHALMIC AGENTS




Tier 2




Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


109

OPHTHALMIC AGENTS




Tier 2



Tier 2



Tier 2



Tier 2


Tier 3


Tier 2



TIME)


Tier 2




OTIC AGENTS




Tier 2


110

OTIC AGENTS




Tier 2


Tier 3


Tier 3



Tier 2


Tier 2






Tier 2 BvD














111












Tier 2 PA


Tier 2


Tier 2 PA









Tier 2 BvD








112















Tier 2 BvD


Tier 2








Tier 2 PA








113





OVER TIME)















Tier 2 BvD


OVER TIME)



Tier 2


Tier 2


114
























Tier 2 BvD




115













Tier 2 BvD











Tier 2 PA


Tier 2 PA


116





















117

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD





Tier 4 NPD


Tier 4 NPD



118

Non-Part D Drugs





Tier 4 NPD




Tier 4 NPD




Tier 4 NPD




Tier 4 NPD




119

Non-Part D Drugs




Tier 4 NPD


Tier 4 PA NPD


Tier 4 PA NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


120

Non-Part D Drugs





Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD




Tier 4 NPD



121

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


122

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



123

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


124

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



125

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD





























126

Non-Part D Drugs
































127

Non-Part D Drugs









Tier 4 NPD

























128

Non-Part D Drugs




































129

Non-Part D Drugs


















Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


130

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD










131

Non-Part D Drugs




Tier 4 PA NPD




Tier 4 NPD


132

Index



133




134




135



136




137




138




139



140





141






142




143




144




145




146




147





148




149



150







151


YYF-VAX 101



152



H0148_20_503

An

g B

lue

Sh

ield

of C

alif

orn

ia P

rom

ise

He

alth P

lan

ay isa

ng

ind

ep

en

diy

en

ten

g li

sensy

ad

o n

g B

lue

Shie

ld A

sso

cia

tio

n A

51247

-CM

S (9

18)




















Telepono (844) 883-2233 (TTY 711)

Fax (323) 889-2228












English




中文 (Chinese)



한국어(Korean)









Lus Hmoob (Hmong)









Tagalog (Tagalog)






























H0148_21_166

_C

_A

cc

ep

ted

08172021


10052021







A Mga Disclaimer iv






















A Mga Disclaimer
































































Category Listing



vi












ែខរ (Khmer)






vii


Mienh (Mien)











viii













ix













x














xi









1 - 132


xii











133

1 - 132


xiii













xiv










xv









xvi
















xvii




Hindi available




Hindi available














133


xviii


LEGEND

TIER PANGALAN






LA



PA





ST Step Therapy


(xiii)


xix




NPD



NDS







xx



ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 13


ANTIDEPRESSANTS 18

ANTIEMETICS 21

ANTIFUNGALS 22

ANTIGOUT AGENTS 24




ANTINEOPLASTICS 27

ANTIPARASITICS 37


ANTIPSYCHOTICS 40


ANTIVIRALS 44

ANXIOLYTICS 50

BIPOLAR AGENTS 51














89










OTIC AGENTS 110




ANALGESICS








Tier 2




Tier 2



Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




1

ANALGESICS






Tier 2 PA NDS























2

ANALGESICS





























3

ANALGESICS













ANESTHETICS




Tier 2








4





Tier 2


Tier 2



















Tier 2





5














Tier 3



ANTIBACTERIALS




Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


6

ANTIBACTERIALS






Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


7

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2



Tier 3


Tier 2


Tier 2


Tier 2




8

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


9

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2



10

ANTIBACTERIALS




Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


11

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 3


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


12

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2

ANTICONVULSANTS






13

ANTICONVULSANTS









Tier 2



Tier 2








Tier 2


Tier 2








14

ANTICONVULSANTS




Tier 2


Tier 2













Tier 2










15

ANTICONVULSANTS








Tier 2 PA


Tier 2




Tier 2 PA
















Tier 2


Tier 3


16

ANTICONVULSANTS




Tier 3


Tier 2



Tier 3


Tier 2


Tier 2









Tier 2

ANTIDEMENTIA AGENTS





Tier 2


17

ANTIDEMENTIA AGENTS






Tier 2


Tier 2

ANTIDEPRESSANTS













Tier 2


Tier 2


18

ANTIDEPRESSANTS




Tier 3 PA




Tier 2


Tier 2






Tier 2






Tier 2


Tier 2



Tier 2


19

ANTIDEPRESSANTS




Tier 2


Tier 2





Tier 2


Tier 2






Tier 2








Tier 2 PA


Tier 2


20

ANTIDEPRESSANTS




Tier 2 PA


Tier 2


Tier 2 PA


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2 PA

ANTIEMETICS




Tier 2


Tier 2


Tier 2


Tier 2


21

ANTIEMETICS





Tier 2 PA


Tier 2 PA


Tier 2 BvD





Tier 2 BvD










ANTIFUNGALS






Tier 2 BvD


22

ANTIFUNGALS




Tier 2 PA


Tier 2


Tier 2



Tier 3 PA



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2




Tier 2


23

ANTIFUNGALS









Tier 2


Tier 2 PA


ANTIGOUT AGENTS




Tier 2




Tier 2




ANTIMIGRAINE AGENTS






24

ANTIMIGRAINE AGENTS




Tier 2 PA









Tier 2














25







ANTIMYCOBACTERIALS




Tier 2



Tier 3


Tier 2


Tier 2





Tier 2






26

ANTINEOPLASTICS




Tier 3 BvD


Tier 3










Tier 2












27

ANTINEOPLASTICS







Tier 2



Tier 2


Tier 2


Tier 3





Tier 3 PA LA










28

ANTINEOPLASTICS












Tier 2



















29

ANTINEOPLASTICS



































30

ANTINEOPLASTICS





























31

ANTINEOPLASTICS


































32

ANTINEOPLASTICS



































33

ANTINEOPLASTICS
































34

ANTINEOPLASTICS































35

ANTINEOPLASTICS




























36

ANTINEOPLASTICS





ANTIPARASITICS







TIME)



Tier 2













37

ANTIPARASITICS




Tier 2 BvD


Tier 2


Tier 3







Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


38





Tier 2


Tier 2



Tier 2




Tier 2


39

ANTIPSYCHOTICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2






Tier 2 PA


Tier 2


Tier 2


40

ANTIPSYCHOTICS




Tier 3 PA








Tier 3 PA





















41

ANTIPSYCHOTICS



















Tier 2







Tier 2




42

ANTIPSYCHOTICS




Tier 3


Tier 2







Tier 2


Tier 2


Tier 3 PA


Tier 2




43








Tier 2


Tier 2

ANTIVIRALS




TIME)















44

ANTIVIRALS












Tier 2




















45

ANTIVIRALS

































46

ANTIVIRALS































47

ANTIVIRALS
































48

ANTIVIRALS


































49

ANTIVIRALS











Tier 2



Tier 2


Tier 2


Tier 2

ANXIOLYTICS




Tier 2


Tier 2 PA





50

ANXIOLYTICS



























BIPOLAR AGENTS





51

BIPOLAR AGENTS




Tier 2





Tier 2



Tier 1


Tier 1


Tier 1


Tier 1 PA


Tier 1 PA


Tier 1 PA










52















Tier 1




Tier 2






Tier 2


Tier 2










53























Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


54





Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3






Tier 3


Tier 3


Tier 3


55





Tier 3


Tier 3


Tier 3


Tier 3


























56









Tier 2 BvD




Tier 2








Tier 2


Tier 3 PA



57











Tier 3 PA


Tier 3 PA


Tier 2



Tier 2




Tier 2




Tier 2 PA



58












Tier 2


Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


59





Tier 2


Tier 2




Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


60





Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


61





Tier 1


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2



Tier 2


Tier 1


Tier 2


Tier 2


62





Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


63





Tier 2


Tier 2 PA


Tier 2


Tier 1


Tier 2


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


64





Tier 1





Tier 3




Tier 1




Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2



65





Tier 2


Tier 2



Tier 2


Tier 1




Tier 2


Tier 3 PA


Tier 1


Tier 2


Tier 1



Tier 2


66





Tier 2


Tier 1


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



67





Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2





68











Tier 2













Tier 2



Tier 2


Tier 2


69





Tier 2



Tier 2


Tier 3


















70
































71





























DAYS)



72

















Tier 3 PA LA


Tier 3 PA LA













73





Tier 2


Tier 3 BvD


Tier 2


Tier 2





Tier 2



Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


74





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2 ST


Tier 2 ST


Tier 2


75





Tier 2





Tier 2


Tier 2


Tier 2




Tier 2




Tier 2








76








TIME)



Tier 2

ERY 2 PAD Tier 2


Tier 2







Tier 2 BvD




Tier 2 BvD


Tier 2 BvD




77








Tier 2 BvD








Tier 3 BvD


Tier 2


Tier 2



Tier 2


Tier 2


78





Tier 2


Tier 2


Tier 2


Tier 2



Tier 2





Tier 2



Tier 3 PA LA


Tier 3 PA LA


79







Tier 2


Tier 2


Tier 2



Tier 3




Tier 2


Tier 2


Tier 2


Tier 2


80









Tier 2






Tier 2








Tier 2







81







Tier 2


Tier 3 PA


Tier 3


Tier 2 PA


Tier 2


Tier 2




Tier 2 PA


Tier 2



Tier 2



Tier 2


Tier 2


82





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2




Tier 2




Tier 2




Tier 2





83


Tier 3 LA BvD





Tier 3 LA BvD






Tier 3


Tier 2



Tier 3 PA LA






Tier 2 PA


Tier 3 PA LA


Tier 3 PA LA


84





Tier 3 LA BvD



Tier 2 PA


Tier 2 PA


Tier 3 PA LA




Tier 3





Tier 3


Tier 2


85







Tier 2 ST







Tier 2



Tier 3 PA LA






Tier 2


Tier 2


Tier 2


86





Tier 2



Tier 2


Tier 2 BvD


Tier 2


Tier 2






Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


87





Tier 2


Tier 2





Tier 2


Tier 2


Tier 2





Tier 3 PA


Tier 3 PA LA


88






Tier 2 PA




Tier 2




Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


89









Tier 2 PA


Tier 2



Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3 PA


90





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3 PA






91





Tier 3


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2 PA




Tier 2







Tier 2


92





Tier 2


Tier 3





TIME)


Tier 3




Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


93





Tier 2 PA



Tier 3 PA




Tier 3 PA





Tier 3 BvD





Tier 2



94







Tier 3 PA LA




Tier 3 PA LA




Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA LA


95





Tier 3 PA


Tier 3 PA


Tier 3 PA LA


Tier 3 PA


Tier 3





Tier 3 PA LA




Tier 3 PA


Tier 3 PA


Tier 3 PA





96






Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA







Tier 3 LA


Tier 2 BvD



Tier 2 BvD


Tier 2 BvD


Tier 3 PA


Tier 3 PA


97





Tier 3 PA


Tier 2 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 2


Tier 2 BvD


Tier 2


98





Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 3 PA




Tier 3 BvD


Tier 2 BvD


Tier 2 BvD







Tier 3




Tier 3



Tier 3


99





Tier 3 BvD


Tier 3


Tier 3



Tier 3





Tier 3







Tier 3





Tier 3 BvD




100










Tier 3 BvD


Tier 3


Tier 3


Tier 3











Tier 2


Tier 2




101






Tier 2


Tier 2





Tier 1




Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 2


Tier 3 PA


Tier 2 PA


Tier 2




102





Tier 2 BvD



Tier 2





Tier 2 BvD





Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


103





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


104









Tier 2



Tier 2


Tier 2


Tier 2




Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


105





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


106





Tier 2


Tier 2


Tier 2


Tier 2

OPHTHALMIC AGENTS





Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



107

OPHTHALMIC AGENTS








Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2



Tier 2



Tier 2




Tier 2


Tier 2


108

OPHTHALMIC AGENTS




Tier 2




Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


109

OPHTHALMIC AGENTS




Tier 2



Tier 2



Tier 2



Tier 2


Tier 3


Tier 2



TIME)


Tier 2




OTIC AGENTS




Tier 2


110

OTIC AGENTS




Tier 2


Tier 3


Tier 3



Tier 2


Tier 2






Tier 2 BvD














111












Tier 2 PA


Tier 2


Tier 2 PA









Tier 2 BvD








112















Tier 2 BvD


Tier 2








Tier 2 PA








113





OVER TIME)















Tier 2 BvD


OVER TIME)



Tier 2


Tier 2


114
























Tier 2 BvD




115













Tier 2 BvD











Tier 2 PA


Tier 2 PA


116





















117

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD





Tier 4 NPD


Tier 4 NPD



118

Non-Part D Drugs





Tier 4 NPD




Tier 4 NPD




Tier 4 NPD




Tier 4 NPD




119

Non-Part D Drugs




Tier 4 NPD


Tier 4 PA NPD


Tier 4 PA NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


120

Non-Part D Drugs





Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD




Tier 4 NPD



121

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


122

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



123

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


124

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



125

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD





























126

Non-Part D Drugs
































127

Non-Part D Drugs









Tier 4 NPD

























128

Non-Part D Drugs




































129

Non-Part D Drugs


















Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


130

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD










131

Non-Part D Drugs




Tier 4 PA NPD




Tier 4 NPD


132

Index



133




134




135



136




137




138




139



140





141






142




143




144




145




146




147





148




149



150







151


YYF-VAX 101



152



H0148_20_503

An

g B

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ield

of C

alif

orn

ia P

rom

ise

He

alth P

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ay isa

ng

ind

ep

en

diy

en

ten

g li

sensy

ad

o n

g B

lue

Shie

ld A

sso

cia

tio

n A

51247

-CM

S (9

18)




















Telepono (844) 883-2233 (TTY 711)

Fax (323) 889-2228












English




中文 (Chinese)



한국어(Korean)









Lus Hmoob (Hmong)









Tagalog (Tagalog)






























H0148_21_166

_C

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ep

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08172021


10052021







A Mga Disclaimer iv






















A Mga Disclaimer
































































Category Listing



vii


Mienh (Mien)











viii













ix













x














xi









1 - 132


xii











133

1 - 132


xiii













xiv










xv









xvi
















xvii




Hindi available




Hindi available














133


xviii


LEGEND

TIER PANGALAN






LA



PA





ST Step Therapy


(xiii)


xix




NPD



NDS







xx



ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 13


ANTIDEPRESSANTS 18

ANTIEMETICS 21

ANTIFUNGALS 22

ANTIGOUT AGENTS 24




ANTINEOPLASTICS 27

ANTIPARASITICS 37


ANTIPSYCHOTICS 40


ANTIVIRALS 44

ANXIOLYTICS 50

BIPOLAR AGENTS 51














89










OTIC AGENTS 110




ANALGESICS








Tier 2




Tier 2



Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




1

ANALGESICS






Tier 2 PA NDS























2

ANALGESICS





























3

ANALGESICS













ANESTHETICS




Tier 2








4





Tier 2


Tier 2



















Tier 2





5














Tier 3



ANTIBACTERIALS




Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


6

ANTIBACTERIALS






Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


7

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2



Tier 3


Tier 2


Tier 2


Tier 2




8

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


9

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2



10

ANTIBACTERIALS




Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


11

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 3


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


12

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2

ANTICONVULSANTS






13

ANTICONVULSANTS









Tier 2



Tier 2








Tier 2


Tier 2








14

ANTICONVULSANTS




Tier 2


Tier 2













Tier 2










15

ANTICONVULSANTS








Tier 2 PA


Tier 2




Tier 2 PA
















Tier 2


Tier 3


16

ANTICONVULSANTS




Tier 3


Tier 2



Tier 3


Tier 2


Tier 2









Tier 2

ANTIDEMENTIA AGENTS





Tier 2


17

ANTIDEMENTIA AGENTS






Tier 2


Tier 2

ANTIDEPRESSANTS













Tier 2


Tier 2


18

ANTIDEPRESSANTS




Tier 3 PA




Tier 2


Tier 2






Tier 2






Tier 2


Tier 2



Tier 2


19

ANTIDEPRESSANTS




Tier 2


Tier 2





Tier 2


Tier 2






Tier 2








Tier 2 PA


Tier 2


20

ANTIDEPRESSANTS




Tier 2 PA


Tier 2


Tier 2 PA


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2 PA

ANTIEMETICS




Tier 2


Tier 2


Tier 2


Tier 2


21

ANTIEMETICS





Tier 2 PA


Tier 2 PA


Tier 2 BvD





Tier 2 BvD










ANTIFUNGALS






Tier 2 BvD


22

ANTIFUNGALS




Tier 2 PA


Tier 2


Tier 2



Tier 3 PA



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2




Tier 2


23

ANTIFUNGALS









Tier 2


Tier 2 PA


ANTIGOUT AGENTS




Tier 2




Tier 2




ANTIMIGRAINE AGENTS






24

ANTIMIGRAINE AGENTS




Tier 2 PA









Tier 2














25







ANTIMYCOBACTERIALS




Tier 2



Tier 3


Tier 2


Tier 2





Tier 2






26

ANTINEOPLASTICS




Tier 3 BvD


Tier 3










Tier 2












27

ANTINEOPLASTICS







Tier 2



Tier 2


Tier 2


Tier 3





Tier 3 PA LA










28

ANTINEOPLASTICS












Tier 2



















29

ANTINEOPLASTICS



































30

ANTINEOPLASTICS





























31

ANTINEOPLASTICS


































32

ANTINEOPLASTICS



































33

ANTINEOPLASTICS
































34

ANTINEOPLASTICS































35

ANTINEOPLASTICS




























36

ANTINEOPLASTICS





ANTIPARASITICS







TIME)



Tier 2













37

ANTIPARASITICS




Tier 2 BvD


Tier 2


Tier 3







Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


38





Tier 2


Tier 2



Tier 2




Tier 2


39

ANTIPSYCHOTICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2






Tier 2 PA


Tier 2


Tier 2


40

ANTIPSYCHOTICS




Tier 3 PA








Tier 3 PA





















41

ANTIPSYCHOTICS



















Tier 2







Tier 2




42

ANTIPSYCHOTICS




Tier 3


Tier 2







Tier 2


Tier 2


Tier 3 PA


Tier 2




43








Tier 2


Tier 2

ANTIVIRALS




TIME)















44

ANTIVIRALS












Tier 2




















45

ANTIVIRALS

































46

ANTIVIRALS































47

ANTIVIRALS
































48

ANTIVIRALS


































49

ANTIVIRALS











Tier 2



Tier 2


Tier 2


Tier 2

ANXIOLYTICS




Tier 2


Tier 2 PA





50

ANXIOLYTICS



























BIPOLAR AGENTS





51

BIPOLAR AGENTS




Tier 2





Tier 2



Tier 1


Tier 1


Tier 1


Tier 1 PA


Tier 1 PA


Tier 1 PA










52















Tier 1




Tier 2






Tier 2


Tier 2










53























Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


54





Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3






Tier 3


Tier 3


Tier 3


55





Tier 3


Tier 3


Tier 3


Tier 3


























56









Tier 2 BvD




Tier 2








Tier 2


Tier 3 PA



57











Tier 3 PA


Tier 3 PA


Tier 2



Tier 2




Tier 2




Tier 2 PA



58












Tier 2


Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


59





Tier 2


Tier 2




Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


60





Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


61





Tier 1


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2



Tier 2


Tier 1


Tier 2


Tier 2


62





Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


63





Tier 2


Tier 2 PA


Tier 2


Tier 1


Tier 2


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


64





Tier 1





Tier 3




Tier 1




Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2



65





Tier 2


Tier 2



Tier 2


Tier 1




Tier 2


Tier 3 PA


Tier 1


Tier 2


Tier 1



Tier 2


66





Tier 2


Tier 1


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



67





Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2





68











Tier 2













Tier 2



Tier 2


Tier 2


69





Tier 2



Tier 2


Tier 3


















70
































71





























DAYS)



72

















Tier 3 PA LA


Tier 3 PA LA













73





Tier 2


Tier 3 BvD


Tier 2


Tier 2





Tier 2



Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


74





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2 ST


Tier 2 ST


Tier 2


75





Tier 2





Tier 2


Tier 2


Tier 2




Tier 2




Tier 2








76








TIME)



Tier 2

ERY 2 PAD Tier 2


Tier 2







Tier 2 BvD




Tier 2 BvD


Tier 2 BvD




77








Tier 2 BvD








Tier 3 BvD


Tier 2


Tier 2



Tier 2


Tier 2


78





Tier 2


Tier 2


Tier 2


Tier 2



Tier 2





Tier 2



Tier 3 PA LA


Tier 3 PA LA


79







Tier 2


Tier 2


Tier 2



Tier 3




Tier 2


Tier 2


Tier 2


Tier 2


80









Tier 2






Tier 2








Tier 2







81







Tier 2


Tier 3 PA


Tier 3


Tier 2 PA


Tier 2


Tier 2




Tier 2 PA


Tier 2



Tier 2



Tier 2


Tier 2


82





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2




Tier 2




Tier 2




Tier 2





83


Tier 3 LA BvD





Tier 3 LA BvD






Tier 3


Tier 2



Tier 3 PA LA






Tier 2 PA


Tier 3 PA LA


Tier 3 PA LA


84





Tier 3 LA BvD



Tier 2 PA


Tier 2 PA


Tier 3 PA LA




Tier 3





Tier 3


Tier 2


85







Tier 2 ST







Tier 2



Tier 3 PA LA






Tier 2


Tier 2


Tier 2


86





Tier 2



Tier 2


Tier 2 BvD


Tier 2


Tier 2






Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


87





Tier 2


Tier 2





Tier 2


Tier 2


Tier 2





Tier 3 PA


Tier 3 PA LA


88






Tier 2 PA




Tier 2




Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


89









Tier 2 PA


Tier 2



Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3 PA


90





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3 PA






91





Tier 3


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2 PA




Tier 2







Tier 2


92





Tier 2


Tier 3





TIME)


Tier 3




Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


93





Tier 2 PA



Tier 3 PA




Tier 3 PA





Tier 3 BvD





Tier 2



94







Tier 3 PA LA




Tier 3 PA LA




Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA LA


95





Tier 3 PA


Tier 3 PA


Tier 3 PA LA


Tier 3 PA


Tier 3





Tier 3 PA LA




Tier 3 PA


Tier 3 PA


Tier 3 PA





96






Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA







Tier 3 LA


Tier 2 BvD



Tier 2 BvD


Tier 2 BvD


Tier 3 PA


Tier 3 PA


97





Tier 3 PA


Tier 2 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 2


Tier 2 BvD


Tier 2


98





Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 3 PA




Tier 3 BvD


Tier 2 BvD


Tier 2 BvD







Tier 3




Tier 3



Tier 3


99





Tier 3 BvD


Tier 3


Tier 3



Tier 3





Tier 3







Tier 3





Tier 3 BvD




100










Tier 3 BvD


Tier 3


Tier 3


Tier 3











Tier 2


Tier 2




101






Tier 2


Tier 2





Tier 1




Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 2


Tier 3 PA


Tier 2 PA


Tier 2




102





Tier 2 BvD



Tier 2





Tier 2 BvD





Tier 2





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


103





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


104









Tier 2



Tier 2


Tier 2


Tier 2




Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


105





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


106





Tier 2


Tier 2


Tier 2


Tier 2

OPHTHALMIC AGENTS





Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



107

OPHTHALMIC AGENTS








Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2



Tier 2



Tier 2




Tier 2


Tier 2


108

OPHTHALMIC AGENTS




Tier 2




Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


109

OPHTHALMIC AGENTS




Tier 2



Tier 2



Tier 2



Tier 2


Tier 3


Tier 2



TIME)


Tier 2




OTIC AGENTS




Tier 2


110

OTIC AGENTS




Tier 2


Tier 3


Tier 3



Tier 2


Tier 2






Tier 2 BvD














111












Tier 2 PA


Tier 2


Tier 2 PA









Tier 2 BvD








112















Tier 2 BvD


Tier 2








Tier 2 PA








113





OVER TIME)















Tier 2 BvD


OVER TIME)



Tier 2


Tier 2


114
























Tier 2 BvD




115













Tier 2 BvD











Tier 2 PA


Tier 2 PA


116





















117

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD





Tier 4 NPD


Tier 4 NPD



118

Non-Part D Drugs





Tier 4 NPD




Tier 4 NPD




Tier 4 NPD




Tier 4 NPD




119

Non-Part D Drugs




Tier 4 NPD


Tier 4 PA NPD


Tier 4 PA NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


120

Non-Part D Drugs





Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD




Tier 4 NPD



121

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


122

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



123

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


124

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



125

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD





























126

Non-Part D Drugs
































127

Non-Part D Drugs









Tier 4 NPD

























128

Non-Part D Drugs




































129

Non-Part D Drugs


















Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


130

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD










131

Non-Part D Drugs




Tier 4 PA NPD




Tier 4 NPD


132

Index



133




134




135



136




137




138




139



140





141






142




143




144




145




146




147





148




149



150







151


YYF-VAX 101



152



H0148_20_503

An

g B

lue

Sh

ield

of C

alif

orn

ia P

rom

ise

He

alth P

lan

ay isa

ng

ind

ep

en

diy

en

ten

g li

sensy

ad

o n

g B

lue

Shie

ld A

sso

cia

tio

n A

51247

-CM

S (9

18)




















Telepono (844) 883-2233 (TTY 711)

Fax (323) 889-2228












English




中文 (Chinese)



한국어(Korean)









Lus Hmoob (Hmong)









Tagalog (Tagalog)






























H0148_21_166

_C

_A

cc

ep

ted

08172021


10052021







A Mga Disclaimer iv






















A Mga Disclaimer
































































Category Listing


listahan ng m ga sakla w na gamot (formulary) p ara s a 2022

Documents