memorial hermann advantage hmo formulario para 2019...

H7115_PH_S_CompFrmly_C 10/10/2018 1

Memorial Hermann Advantage HMO

Formulario para 2019

(Lista de medicamentos cubiertos)

LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

HPMS Approved Formulary File Submission ID 19563, Version Number 4 Este formulario resumido se actualizó el 08/24/2018. Para obtener información más reciente o si tiene otras preguntas, comuníquese con Memorial Hermann Advantage HMO al 855-645-8448, 1 de octubre a 31 de marzo: 8:00 a.m. a 8:00 p.m., 7 días a la semana horario de la zona central y 1 de abril a 30 de septiembre: 8:00 a.m. a 8:00 p.m., lunes a viernes horario de la zona central (los usuarios de TTY deben llamar al 711), o visite healthplan.memorialhermann.org/medicare.

Nota para los miembros actuales: este Formulario ha cambiado con respecto al año pasado. Revise este documento para asegurarse de que aún contiene los medicamentos que toma. Cuando esta Lista de medicamentos (Formulario) menciona “nosotros”, “nos” o “nuestro”, hace referencia a Memorial Hermann Advantage HMO. Cuando dice “plan” o “nuestro plan”, hace referencia a Memorial Hermann Advantage HMO.

Este documento incluye una lista de los medicamentos (Formulario) de nuestro plan, la cual está en vigencia desde el 08/24/2018. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior. Generalmente, debe concurrir a las farmacias de la red para usar el beneficio de medicamentos con receta. Los beneficios, el formulario, la red de farmacias o los copagos/el coseguro pueden cambiar el 1 de enero de 2019 y periódicamente durante el año.

¿Qué es el Formulario de Memorial Hermann Advantage HMO? Un Formulario es una lista de medicamentos cubiertos seleccionados por Memorial Hermann Advantage HMO con la colaboración de un equipo de proveedores de atención médica, que representa los tratamientos con receta que se considera que son parte necesaria de un programa de tratamiento de calidad. Normalmente, Memorial Hermann Advantage HMO cubrirá los medicamentos incluidos en el formulario, siempre que el medicamento sea médicamente necesario, el medicamento con receta se obtenga en una farmacia de la red de Memorial Hermann Advantage HMO y se cumpla con otras normas del plan. Para


obtener más información sobre cómo obtener sus medicamentos con receta, consulte la Evidencia de cobertura.

¿Puede cambiar el Formulario (lista de medicamentos)? En general, si usted toma un medicamento de nuestro Formulario para 2019 que estaba cubierto al comienzo del año, nosotros no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2019, excepto cuando esté disponible un nuevo medicamento genérico de menor costo, cuando se dé a conocer nueva información acerca de la seguridad o eficacia del medicamento, o el medicamento sea retirado del mercado. (Consulte los puntos a continuación para obtener más información sobre cambios que afectan a los miembros que actualmente toman el medicamento). Otros tipos de cambios en el Formulario, por ejemplo, la eliminación de un medicamento, no afectarán a los miembros que estén actualmente tomando el medicamento. Por el resto del año de cobertura, continuará disponible al mismo costo compartido para aquellos miembros que estén tomándolo. A continuación se incluyen cambios en la Lista de medicamentos que también afectarán a los miembros que actualmente toman un medicamento:

• Nuevos medicamentos genéricos. Podemos eliminar inmediatamente un medicamento de marca de nuestra Lista de medicamentos si lo reemplazamos con un nuevo medicamento genérico que aparecerá en el mismo nivel de costo compartido o en un nivel de costo compartido más bajo y con las mismas restricciones o menos. Además, cuando agreguemos el nuevo medicamento genérico, podemos decidir mantener el medicamento de marca en nuestra Lista de medicamentos pero inmediatamente moverlo a un nivel de costo compartido diferente o agregar nuevas restricciones. Si actualmente está tomando ese medicamento de marca, quizás no le informemos con antelación antes de que realicemos el cambio, pero más adelante le proporcionaremos información sobre los cambios específicos que hemos realizado.

o Si realizamos un cambio, usted o la persona autorizada a dar recetas pueden solicitarnos que hagamos una excepción y sigamos cubriendo el medicamento de marca para usted. El aviso que le proporcionaremos también incluirá información sobre los pasos que puede tomar para solicitar una excepción, y usted también puede encontrar información en la sección a continuación titulada “¿Cómo puedo solicitar que se haga una excepción al Formulario de Memorial Hermann Advantage HMO ?”.

• Medicamentos retirados del mercado. Si la Administración de Drogas y Alimentos considera que un medicamento de nuestro Formulario es inseguro o el fabricante del medicamento lo retira del mercado, eliminaremos de inmediato dicho medicamento de nuestro Formulario y les notificaremos a los miembros que toman el medicamento en cuestión.

• Otros cambios. Podemos hacer otros cambios que afectan a los miembros que actualmente toman un medicamento. Por ejemplo, podemos agregar un medicamento genérico que no es nuevo en el mercado para reemplazar un medicamento de marca que actualmente se encuentre en el Formulario o agregar nuevas restricciones al medicamento de marca o moverlo a un nivel de costo compartido diferente. O bien, podemos hacer cambios en función de las nuevas pautas clínicas. Si retiramos medicamentos de nuestro Formulario, agregamos autorizaciones previas, restricciones de límite de cantidad o de tratamiento escalonado en un medicamento o si pasamos un medicamento a un nivel superior de costo compartido, debemos notificarles a los miembros afectados por el cambio al menos 30 días antes de que entre en vigencia dicho cambio, o cuando el miembro solicite un resurtido del medicamento, momento en el cual el miembro recibirá un suministro del medicamento para 30 días.


El Formulario adjunto está vigente a partir del 08/24/2018. Para recibir información actualizada sobre los medicamentos cubiertos por Memorial Hermann Advantage HMO, comuníquese con nosotros. Nuestra información de contacto aparece en las páginas de la portada y la portada posterior. Si a mitad de año se realiza un cambio en el formulario, que no sea de mantenimiento, proporcionaremos los detalles en la Explicación de Beneficios de Medicare Parte D o directa a través de envios de miembros. Para revisar o imprimir los cambios realizados en el formulario durante el año, visite nuestro sitio web (healthplan.memorialhermann.org/medicare) y consulte el Anexo del formulario en la página “Buscar un medicamento”. Si desea recibir una copia del Anexo del formulario en su domicilio, llame al Servicio de Atención al Cliente de Memorial Hermann HMO al 855-645-8448, 1 de octubre a 31 de marzo: 8:00 a.m. a 8:00 p.m., 7 días a la semana horario de la zona central y 1 de abril a 30 de septiembre: 8:00 a.m. a 8:00 p.m., lunes a viernes horario de la zona central. Los usuarios de TTY deben llamar al 711.

¿Cómo utilizo el Formulario? Hay dos formas para encontrar su medicamento dentro del Formulario:

Afección médica El Formulario comienza en la página 8. Los medicamentos de este Formulario están agrupados en categorías según el tipo de afección médica para cuyo tratamiento se los emplea. Por ejemplo, los medicamentos utilizados para tratar una afección cardíaca se enumeran dentro de la categoría “agentes cardiovasculares”. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que empieza en la página 8. Luego, busque su medicamento debajo del nombre de la categoría.

Listado alfabético Si no está seguro de qué categoría consultar, debe buscar su medicamento en el Índice que comienza en la página 131. El Índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento. En el Índice, están tanto los medicamentos de marca como los genéricos. Busque en el Índice y encuentre su medicamento. Junto a su medicamento, verá el número de página donde puede encontrar información acerca de la cobertura. Vaya a la página que figura en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos? Memorial Hermann Advantage HMO cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado por la Administración de Drogas y Alimentos (FDA) dado que se considera que tiene el mismo ingrediente activo que el medicamento de marca. Normalmente, los medicamentos genéricos cuestan menos que los de marca.


¿Hay alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales de cobertura. Estos requisitos y límites pueden incluir:

• Autorización previa: Memorial Hermann Advantage HMO exige que usted [o su médico] obtenga una autorización previa para determinados medicamentos. Esto significa que necesitará contar con la aprobación de Memorial Hermann Advantage HMO antes de obtener sus medicamentos con receta. Si no consigue la autorización, es posible que Memorial Hermann Advantage HMO no cubra el medicamento.

• Límites de cantidad: para ciertos medicamentos, Memorial Hermann Advantage HMO limita la

cantidad del medicamento que cubrirá. Por ejemplo, Memorial Hermann Advantage HMO proporciona 30 comprimidos por receta para digoxina. Esto puede ser complementario a un suministro estándar para un mes o tres meses.

• Tratamiento escalonado: en algunos casos, Memorial Hermann Advantage HMO requiere que usted

primero pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa enfermedad. Por ejemplo, si el medicamento A y el medicamento B tratan su afección médica, es posible que Memorial Hermann Advantage HMO no cubra el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no funciona para usted, entonces Memorial Hermann Advantage HMO cubrirá el medicamento B.

Para averiguar si su medicamento tiene requisitos o límites adicionales, consulte el Formulario que empieza en la página 8. También puede obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicos en nuestro sitio web. Hemos publicado un documento en línea que explica(n) nuestra(s) restricciones de autorización previa y tratamiento escalonado. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior. Puede pedirle a Memorial Hermann Advantage HMO que haga una excepción a estas restricciones o límites, o puede solicitarle una lista de otros medicamentos similares que puedan tratar su afección médica. Consulte la sección “¿Cómo solicito una excepción al Formulario de Memorial Hermann Advantage HMO?” en la página 5 para obtener información acerca de cómo solicitar una excepción.

¿Qué pasa si mi medicamento no está en el Formulario? Si el medicamento que toma no está incluido en este Formulario (lista de medicamentos cubiertos), primero debe comunicarse con Servicios para los miembros y preguntar si su medicamento está cubierto.

Si resulta que Memorial Hermann Advantage HMO no cubre el medicamento que toma, tiene dos alternativas:


• Puede pedir a Servicios para los miembros una lista de medicamentos similares que estén cubiertos por Memorial Hermann Advantage HMO. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por Memorial Hermann Advantage HMO.

• Puede solicitar que Memorial Hermann Advantage HMO haga una excepción y cubra su

medicamento. Consulte a continuación para obtener información sobre cómo solicitar una excepción.

¿Cómo puedo solicitar que se haga una excepción al Formulario de Memorial Hermann Advantage HMO? Puede solicitarle a Memorial Hermann Advantage HMO que haga una excepción a nuestras normas de cobertura. Hay varios tipos de excepciones que puede solicitarnos.

• Puede pedirnos que cubramos un medicamento, incluso si no está en nuestro Formulario. Si se aprueba, este medicamento estará cubierto a un nivel de costo compartido predeterminado, y usted no podrá pedirnos que le brindemos el medicamento a un nivel de costo compartido menor.

• Puede pedirnos que cubramos un medicamento del Formulario a un nivel de costo compartido menor si este medicamento no está incluido en el nivel de medicamentos especializados. Si se aprueba, esto reduciría el monto que usted debe pagar por su medicamento.

• Puede pedirnos que no apliquemos restricciones o límites de cobertura para su medicamento. Por

ejemplo, para ciertos medicamentos, Memorial Hermann Advantage HMO limita la cantidad del medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, puede pedirnos que hagamos una excepción al límite y cubramos una cantidad mayor.

Por lo general, Memorial Hermann Advantage HMO solo aprobará su pedido de excepción si los medicamentos alternativos incluidos en el Formulario del plan, [el medicamento de menor costo compartido] o las restricciones de uso adicionales no fueran tan efectivos para tratar su afección o pudieran causarle efectos médicos adversos.

Debe comunicarse con nosotros para solicitarnos una decisión inicial de cobertura para una excepción al Formulario, nivel o a la restricción de uso. Cuando solicita una excepción al Formulario, nivel o a la restricción de uso, debe presentar una declaración de su médico o de la persona autorizada a dar recetas que respalde su solicitud. Por lo general, debemos tomar una decisión dentro de las 72 horas a partir de la fecha de haber recibido la declaración que respalda su solicitud por parte de la persona autorizada a dar recetas. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que esperar 72 horas para la toma de la decisión podría perjudicar gravemente su salud. Si se le concede el trámite rápido de la excepción, debemos comunicarle nuestra decisión a más tardar dentro de las 24 horas después de haber recibido la declaración de respaldo de su médico o de otra persona autorizada a dar recetas.

¿Qué debo hacer antes de hablar con mi médico sobre el cambio de los medicamentos que tomo o la solicitud de una excepción?


Como miembro nuevo o permanente de nuestro plan, es posible que esté tomando medicamentos que no están incluidos en el Formulario. También es posible que esté tomando un medicamento incluido en el Formulario pero su capacidad de conseguirlo sea limitada. Por ejemplo, puede necesitar nuestra autorización previa antes de poder obtener su medicamento con receta. Debe consultar con su médico para decidir si debe cambiar su medicamento por uno apropiado que nosotros cubramos o solicitar una excepción al formulario para que le cubramos el medicamento que toma. Mientras evalúa con su médico el procedimiento adecuado para seguir en su caso, podemos cubrir su medicamento, en ciertos casos, durante los primeros 90 días en que usted sea miembro de nuestro plan. Para cada uno de los medicamentos que no están incluidos en el Formulario o si su capacidad para conseguir los medicamentos es limitada, cubriremos un suministro temporal para 30 días. Si su receta está indicada para menos días, permitiremos que realice resurtidos por un máximo de hasta 30 días del medicamento. Después del primer suministro para 30 días, no seguiremos pagando estos medicamentos, incluso si ha sido miembro del plan durante menos de 90 días. Si es residente de un centro de atención a largo plazo y necesita un medicamento que no está en el Formulario o si su capacidad para conseguir los medicamentos es limitada, pero ya pasaron los primeros 93 días de membresía en nuestro plan, cubriremos un suministro de emergencia del medicamento para 31días mientras solicita la excepción al formulario.

Como miembro actual de nuestro plan, en caso de internación cubierta en un hospital o centro de enfermería especializada, los medicamentos que obtenga durante su estadía se cubrirán conforme a su beneficio médico y no a su beneficio para medicamentos recetados de Medicare Parte D.

Cuando se le dé el alta para regresar a su casa o lo trasladen a un centro de atención a largo plazo, es posible que reciba cobertura para muchos de los medicamentos recetados para pacientes ambulatorios que obtenga en una farmacia conforme a la cobertura de Medicare Parte D. El traslado de un entorno de tratamiento a otro se denomina cambio de nivel de atención. Debido a que su cobertura de medicamentos difiere en función del entorno en el que obtenga el medicamento, es posible que un medicamento que estaba tomando y que tenía cobertura conforme a su beneficio médico no tenga cobertura por medio de Medicare Parte D (por ejemplo, vitaminas o medicamentos para la tos). Si esto sucede, tendrá que pagar el costo total de ese medicamento, a menos que tenga otra cobertura (por ejemplo, cobertura de grupo patrocinada por el empleador).

Para obtener más información Para obtener información más detallada sobre la cobertura para medicamentos con receta de Memorial Hermann Advantage HMO, consulte la Evidencia de cobertura y otra documentación del plan.

Si tiene alguna pregunta sobre Memorial Hermann Advantage HMO, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior.

Si tiene preguntas generales sobre su cobertura para medicamentos con receta de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O visite http://www.medicare.gov.


Formulario de Memorial Hermann Advantage HMO El formulario que comienza en la siguiente página proporciona información acerca de la cobertura de los medicamentos cubiertos por Memorial Hermann Advantage HMO. Si tiene alguna dificultad para encontrar el medicamento que toma en la lista, consulte el Índice que comienza en la página 131.

La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de marca están en letra mayúscula (por ejemplo, SYNTHROID), y los medicamentos genéricos están en letra minúscula y cursiva (por ejemplo, levothyroxine).

La información incluida en la columna de Requisitos/límites indica si Memorial Hermann Advantage HMO tiene algún requisito especial para la cobertura del medicamento.

BvD= Este medicamento puede cubrirse bajo Medicare Parte B o D dependiendo de las circunstancias; PA: Se requiere autorización previa; ST: Se requiere excepción de terapia escalonada; QL: Límites de cantidad, límite de suministro de 30 días, a menos que se especifique lo contrario; LA: Acceso limitado. Esta receta puede estar disponible solo en ciertas farmacias; MO: Pedido por correo. Para obtener información, llame a 844-860-6750. Los usuarios de TTY deben llamar al 711, 24 horas al día, los 7 días de la semana. Fecha de la última actualización: 08/24/2018. 8

Nombre del medicamento Nivel del medicamento Requisitos/límites

ANALGESICS

OPIOID ANALGESICS, LONG-ACTING

buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr

Tier 3 MO

fentanyl transdermal patch 72 hour 100 mcg/hr, 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr

Tier 4 PA; MO; QL (10 EA per 30 days)

fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr


hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12 mg, 8 mg

Tier 4 MO

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 16 mg, 32 mg

Tier 5 MO

morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg

Tier 2 MO

morphine sulfate er oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg

Tier 2 MO

morphine sulfate er oral tablet extended release 100 mg, 60 mg

Tier 3 MO

morphine sulfate er oral tablet extended release 15 mg, 30 mg

Tier 2 MO

oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg

Tier 3 MO

oxymorphone hcl er oral tablet extended release 12 hour 15 mg, 20 mg, 30 mg, 40 mg, 7.5 mg

Tier 3 MO

OPIOID ANALGESICS, SHORT-ACTING

acetaminophen-codeine #3 oral tablet 300-30 mg Tier 1 MO



acetaminophen-codeine oral solution 120-12 mg/5ml

Tier 1 MO

acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg

Tier 1 MO

buprenorphine hcl sublingual tablet sublingual 2 mg


buprenorphine hcl sublingual tablet sublingual 8 mg


butalbital-apap-caff-cod oral capsule 50-325-40-30 mg

Tier 2 MO; QL (180 EA per 30 days)

butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg


codeine sulfate oral tablet 15 mg, 30 mg, 60 mg Tier 1 MO

duramorph injection solution 0.5 mg/ml, 1 mg/ml Tier 4 MO

ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG

Tier 3 MO

FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG


hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml

Tier 2 MO

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 7.5-300 mg

Tier 2 MO

hydrocodone-acetaminophen oral tablet 5-325 mg, 7.5-325 mg

Tier 1 MO

hydrocodone-ibuprofen oral tablet 5-200 mg, 7.5-200 mg

Tier 2 MO

hydromorphone hcl injection solution 2 mg/ml Tier 2 MO

hydromorphone hcl oral liquid 1 mg/ml Tier 4 MO

hydromorphone hcl oral tablet 2 mg, 4 mg Tier 1 MO

hydromorphone hcl oral tablet 8 mg Tier 2 MO



hydromorphone hcl pf injection solution 10 mg/ml, 50 mg/5ml

Tier 4 MO

hydromorphone hcl pf injection solution 2 mg/ml Tier 2 MO

meperidine hcl injection solution 100 mg/ml, 25 mg/ml, 50 mg/ml

Tier 2 BvD; MO

methadone hcl oral solution 10 mg/5ml, 5 mg/5ml Tier 1 MO

methadone hcl oral tablet 10 mg, 5 mg Tier 1 MO

morphine sulfate (concentrate) oral solution 100 mg/5ml

Tier 2 MO

morphine sulfate injection solution 2 mg/ml Tier 4 BvD; MO

morphine sulfate injection solution 5 mg/ml Tier 2 MO

morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml

Tier 1 MO

morphine sulfate oral tablet 15 mg, 30 mg Tier 1 MO

oxycodone hcl oral capsule 5 mg Tier 2 MO

oxycodone hcl oral solution 5 mg/5ml Tier 2 MO

oxycodone hcl oral tablet 10 mg, 15 mg, 5 mg Tier 1 MO

oxycodone hcl oral tablet 20 mg, 30 mg Tier 2 MO

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Tier 2 MO

oxycodone-aspirin oral tablet 4.8355-325 mg Tier 2 MO

oxycodone-ibuprofen oral tablet 5-400 mg Tier 2 MO

oxymorphone hcl oral tablet 10 mg, 5 mg Tier 2 MO

pentazocine-naloxone hcl oral tablet 50-0.5 mg Tier 2 MO

tramadol hcl oral tablet 50 mg Tier 1 MO; QL (240 EA per 30 days)

tramadol-acetaminophen oral tablet 37.5-325 mg Tier 2 MO; QL (240 EA per 30 days)



ANESTHETICS

LOCAL ANESTHETICS

lidocaine hcl external gel 2 % Tier 1 PA; MO; QL (30 ML per 30 days)

lidocaine-prilocaine external cream 2.5-2.5 % Tier 4 PA; MO; QL (30 GM per 30 days)

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium oral tablet delayed release 333 mg

Tier 2 MO

disulfiram oral tablet 250 mg, 500 mg Tier 2 MO

OPIOID ANTAGONISTS

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg


buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg


butorphanol tartrate nasal solution 10 mg/ml Tier 2 MO; QL (10 ML per 30 days)

naloxone hcl injection solution 0.4 mg/ml Tier 1 MO

naloxone hcl injection solution cartridge 0.4 mg/ml

Tier 1 MO

naloxone hcl injection solution prefilled syringe 2 mg/2ml

Tier 2 MO

naltrexone hcl oral tablet 50 mg Tier 2 MO

NARCAN NASAL LIQUID 4 MG/0.1ML Tier 3 MO; QL (2 EA per 30 days)

SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG




SUBOXONE SUBLINGUAL FILM 8-2 MG Tier 4 MO; QL (120 EA per 30 days)

VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG

Tier 5 MO

SMOKING CESSATION AGENTS

bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg

Tier 2 MO

CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG

Tier 3 MO

CHANTIX ORAL TABLET 0.5 MG, 1 MG Tier 3 MO

CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42

Tier 3 MO

NICOTROL INHALATION INHALER 10 MG Tier 4 MO

NICOTROL NS NASAL SOLUTION 10 MG/ML Tier 4 MO

ANTIBACTERIALS

AMINOGLYCOSIDES

amikacin sulfate injection solution 500 mg/2ml Tier 2 BvD; MO

BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML

Tier 5 PA; MO; QL (224 ML per 56 days)

gentamicin in saline intravenous solution 0.8-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%

Tier 2 MO

gentamicin sulfate injection solution 40 mg/ml Tier 2 MO

neomycin sulfate oral tablet 500 mg Tier 2 MO

paromomycin sulfate oral capsule 250 mg Tier 4 MO

streptomycin sulfate intramuscular solution reconstituted 1 gm

Tier 2 MO



TOBI PODHALER INHALATION CAPSULE 28 MG


tobramycin inhalation nebulization solution 300 mg/5ml


tobramycin sulfate injection solution 10 mg/ml Tier 4 MO

tobramycin sulfate injection solution 80 mg/2ml Tier 2 MO

ANTIBACTERIALS, OTHER

clindamycin hcl oral capsule 150 mg, 300 mg Tier 2 MO

clindamycin hcl oral capsule 75 mg Tier 1 MO

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml

Tier 4 MO

clindamycin phosphate in d5w intravenous solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml

Tier 4 MO

clindamycin phosphate injection solution 300 mg/2ml, 900 mg/6ml

Tier 2 BvD; MO

clindamycin phosphate injection solution 600 mg/4ml

Tier 2 MO

colistimethate sodium (cba) injection solution reconstituted 150 mg

Tier 4 MO

dapsone oral tablet 100 mg, 25 mg Tier 2 MO

daptomycin intravenous solution reconstituted 500 mg

Tier 5 PA; MO

linezolid intravenous solution 600 mg/300ml Tier 5 PA; MO

linezolid oral suspension reconstituted 100 mg/5ml Tier 5 PA; MO

linezolid oral tablet 600 mg Tier 5 PA; MO; QL (60 EA per 30 days)

methenamine hippurate oral tablet 1 gm Tier 1 MO

metronidazole in nacl intravenous solution 500-0.79 mg/100ml-%

Tier 2 BvD; MO



metronidazole oral capsule 375 mg Tier 2 MO

metronidazole oral tablet 250 mg, 500 mg Tier 1 MO

MONUROL ORAL PACKET 3 GM Tier 4 MO; QL (2 EA per 30 days)

NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG

Tier 3 BvD; MO

nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg

Tier 2 MO

nitrofurantoin monohyd macro oral capsule 100 mg

Tier 2 MO

nitrofurantoin oral suspension 25 mg/5ml Tier 2 MO

PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG

Tier 4 BvD; MO

tigecycline intravenous solution reconstituted 50 mg

Tier 5 BvD; MO

tinidazole oral tablet 250 mg, 500 mg Tier 2 MO

trimethoprim oral tablet 100 mg Tier 1 MO

vancomycin hcl in dextrose intravenous solution 750-5 mg/150ml-%

Tier 2 BvD; MO

vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-%, 500-0.9 mg/100ml-%, 750-0.9 mg/250ml-%

Tier 2 BvD; MO

vancomycin hcl intravenous solution reconstituted 1000 mg, 500 mg, 5000 mg, 750 mg

Tier 2 BvD; MO

vancomycin hcl oral capsule 125 mg Tier 4 MO

vancomycin hcl oral capsule 250 mg Tier 5 MO

XIFAXAN ORAL TABLET 200 MG, 550 MG Tier 5 PA; MO

BETA-LACTAM, CEPHALOSPORINS

cefaclor oral capsule 250 mg, 500 mg Tier 2 MO



cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml

Tier 4 MO

cefadroxil oral capsule 500 mg Tier 2 MO

cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

Tier 2 MO

cefadroxil oral tablet 1 gm Tier 2 MO

cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg

Tier 2 MO

cefdinir oral capsule 300 mg Tier 2 MO

cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

Tier 2 MO

cefepime hcl injection solution reconstituted 1 gm, 2 gm

Tier 4 MO

cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

Tier 4 MO

cefotaxime sodium injection solution reconstituted 1 gm, 2 gm, 500 mg

Tier 2 MO

cefoxitin sodium injection solution reconstituted 10 gm

Tier 2 MO

cefoxitin sodium intravenous solution reconstituted 1 gm, 2 gm

Tier 4 BvD; MO

cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml

Tier 4 MO

cefpodoxime proxetil oral suspension reconstituted 50 mg/5ml

Tier 2 MO

cefpodoxime proxetil oral tablet 100 mg Tier 2 MO

cefpodoxime proxetil oral tablet 200 mg Tier 4 MO

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

Tier 2 MO

cefprozil oral tablet 250 mg, 500 mg Tier 2 MO



ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm

Tier 4 MO

ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg

Tier 2 BvD; MO

ceftriaxone sodium injection solution reconstituted 500 mg

Tier 4 BvD; MO

cefuroxime axetil oral tablet 250 mg, 500 mg Tier 2 MO

cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg

Tier 2 MO

cefuroxime sodium intravenous solution reconstituted 1.5 gm

Tier 4 MO

cephalexin oral capsule 250 mg, 500 mg Tier 1 MO

cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

Tier 2 MO

cephalexin oral tablet 250 mg Tier 2 MO

SUPRAX ORAL CAPSULE 400 MG Tier 3 MO

TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG

Tier 5 PA; MO

ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED 1.5 (1-0.5) GM

Tier 4 BvD; MO

BETA-LACTAM, OTHER

AZACTAM INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM

Tier 4 BvD; MO

aztreonam injection solution reconstituted 1 gm Tier 2 MO

CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG

Tier 5 PA; LA

doripenem intravenous solution reconstituted 500 mg

Tier 3 BvD; MO



imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg

Tier 4 BvD; MO

INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM

Tier 4 MO

meropenem intravenous solution reconstituted 1 gm, 500 mg

Tier 4 BvD; MO

BETA-LACTAM, PENICILLINS

amoxicillin oral capsule 250 mg, 500 mg Tier 1 MO

amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml

Tier 1 MO

amoxicillin oral tablet 500 mg, 875 mg Tier 1 MO

amoxicillin oral tablet chewable 125 mg, 250 mg Tier 1 MO

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml

Tier 2 MO

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

Tier 2 MO

amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg

Tier 2 MO

ampicillin oral capsule 500 mg Tier 1 MO

ampicillin sodium injection solution reconstituted 1 gm

Tier 4 MO

ampicillin sodium injection solution reconstituted 125 mg

Tier 2 MO

ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 3 (2-1) gm

Tier 4 MO

ampicillin-sulbactam sodium injection solution reconstituted 15 (10-5) gm

Tier 4 BvD; MO

BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/50ML

Tier 4 BvD; MO



BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION 900000-300000 UNIT/2ML

Tier 4 MO

BICILLIN C-R INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML

Tier 4 MO

BICILLIN L-A INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML

Tier 4 MO

dicloxacillin sodium oral capsule 250 mg, 500 mg Tier 2 MO

nafcillin sodium injection solution reconstituted 1 gm

Tier 2 MO

nafcillin sodium intravenous solution reconstituted 10 gm

Tier 2 MO

oxacillin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm

Tier 2 MO

penicillin g pot in dextrose intravenous solution 40000 unit/ml, 60000 unit/ml

Tier 2 MO

penicillin g potassium injection solution reconstituted 20000000 unit

Tier 4 MO

penicillin g sodium injection solution reconstituted 5000000 unit

Tier 4 BvD; MO

penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml

Tier 1 MO

penicillin v potassium oral tablet 250 mg, 500 mg Tier 1 MO

piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm

Tier 4 BvD; MO

ZOSYN INTRAVENOUS SOLUTION 2-0.25 GM/50ML, 3-0.375 GM/50ML

Tier 3 BvD; MO



MACROLIDES

azithromycin intravenous solution reconstituted 500 mg

Tier 2 BvD; MO

azithromycin oral packet 1 gm Tier 3 MO

azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

Tier 2 MO

azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg

Tier 2 MO

clarithromycin er oral tablet extended release 24 hour 500 mg

Tier 2 MO

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

Tier 2 MO

clarithromycin oral tablet 250 mg, 500 mg Tier 2 MO

DIFICID ORAL TABLET 200 MG Tier 5 ST; MO

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML

Tier 3 MO

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG

Tier 3 MO

ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

Tier 4 BvD; MO

ERYTHROCIN STEARATE ORAL TABLET 250 MG

Tier 4 MO

erythromycin base oral capsule delayed release particles 250 mg

Tier 4 MO

erythromycin base oral tablet 250 mg, 500 mg Tier 2 MO

erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml

Tier 3 MO



QUINOLONES

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg

Tier 2 MO

ciprofloxacin in d5w intravenous solution 200 mg/100ml

Tier 2 BvD; MO

ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%)

Tier 4 MO

ciprofloxacin oral suspension reconstituted 500 mg/5ml (10%)

Tier 2 MO

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000 mg, 500 mg

Tier 2 MO

levofloxacin in d5w intravenous solution 500 mg/100ml, 750 mg/150ml

Tier 2 BvD; MO

levofloxacin intravenous solution 25 mg/ml Tier 4 BvD; MO

levofloxacin oral solution 25 mg/ml Tier 4 MO

levofloxacin oral tablet 250 mg, 500 mg, 750 mg Tier 2 MO

moxifloxacin hcl in nacl intravenous solution 400 mg/250ml

Tier 2 BvD; MO

moxifloxacin hcl intravenous solution 400 mg/250ml

Tier 2 BvD; MO

moxifloxacin hcl oral tablet 400 mg Tier 2 MO

ofloxacin oral tablet 300 mg, 400 mg Tier 2 MO

SULFONAMIDES

sulfadiazine oral tablet 500 mg Tier 4 MO

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml

Tier 2 MO

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

Tier 1 MO



SULFATRIM PEDIATRIC ORAL SUSPENSION 200-40 MG/5ML

Tier 2 MO

TETRACYCLINES

DOXY 100 INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

Tier 3 BvD; MO

doxycycline hyclate oral capsule 100 mg Tier 2 MO

doxycycline hyclate oral capsule 50 mg Tier 1 MO

doxycycline hyclate oral tablet 100 mg Tier 2 MO

doxycycline hyclate oral tablet 20 mg Tier 1 MO

doxycycline monohydrate oral capsule 100 mg Tier 2 MO

doxycycline monohydrate oral capsule 50 mg Tier 1 MO

doxycycline monohydrate oral suspension reconstituted 25 mg/5ml

Tier 2 MO

doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg

Tier 2 MO

minocycline hcl oral capsule 100 mg Tier 2 MO

minocycline hcl oral capsule 50 mg, 75 mg Tier 1 MO

minocycline hcl oral tablet 100 mg, 50 mg, 75 mg Tier 2 MO

tetracycline hcl oral capsule 250 mg, 500 mg Tier 4 MO

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

BRIVIACT ORAL SOLUTION 10 MG/ML Tier 5 PA; MO

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG

Tier 5 PA; MO

levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg

Tier 4 MO



levetiracetam oral solution 100 mg/ml Tier 2 MO

levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg

Tier 2 MO

ROWEEPRA ORAL TABLET 1000 MG, 500 MG, 750 MG

Tier 2 MO

ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG

Tier 4 MO

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG


SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 250 MG, 500 MG, 750 MG


BARBITURATES

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

Tier 1 MO

primidone oral tablet 250 mg, 50 mg Tier 1 MO

BENZODIAZEPINES

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 MO

clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

Tier 1 MO

DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG

Tier 4 MO

DIASTAT PEDIATRIC RECTAL GEL 2.5 MG Tier 4 MO

ONFI ORAL SUSPENSION 2.5 MG/ML Tier 5 PA; MO

ONFI ORAL TABLET 10 MG Tier 4 PA; MO; QL (60 EA per 30 days)

ONFI ORAL TABLET 20 MG Tier 5 PA; MO; QL (60 EA per 30 days)

CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN ORAL CAPSULE 300 MG Tier 4 MO



ethosuximide oral capsule 250 mg Tier 2 MO

ethosuximide oral solution 250 mg/5ml Tier 2 MO

LYRICA ORAL CAPSULE 200 MG, 225 MG, 25 MG, 50 MG, 75 MG


LYRICA ORAL CAPSULE 300 MG Tier 3 MO; QL (60 EA per 30 days)

LYRICA ORAL SOLUTION 20 MG/ML Tier 3 MO; QL (900 ML per 30 days)

zonisamide oral capsule 100 mg, 25 mg, 50 mg Tier 2 MO

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg

Tier 2 MO

divalproex sodium oral capsule delayed release sprinkle 125 mg

Tier 2 MO

divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg

Tier 2 MO

FYCOMPA ORAL SUSPENSION 0.5 MG/ML Tier 4 PA; MO

FYCOMPA ORAL TABLET 10 MG, 2 MG, 4 MG, 6 MG, 8 MG

Tier 4 PA; MO

FYCOMPA ORAL TABLET 12 MG Tier 5 PA; MO

gabapentin oral capsule 100 mg Tier 1 MO

gabapentin oral capsule 300 mg, 400 mg Tier 2 MO

gabapentin oral solution 250 mg/5ml Tier 2 MO

gabapentin oral tablet 600 mg, 800 mg Tier 2 MO

SABRIL ORAL TABLET 500 MG Tier 5 PA; LA

tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg Tier 4 MO

valproate sodium oral solution 250 mg/5ml Tier 2 MO

valproic acid oral capsule 250 mg Tier 1 MO

vigabatrin oral packet 500 mg Tier 5 PA; LA



VIGADRONE ORAL PACKET 500 MG Tier 5 PA; LA

GLUTAMATE REDUCING AGENTS

felbamate oral suspension 600 mg/5ml Tier 5 MO

felbamate oral tablet 400 mg, 600 mg Tier 4 MO

LAMICTAL XR ORAL KIT 25 & 50 & 100 MG, 25 (21)-50 (7) MG, 50 & 100 & 200 MG

Tier 4 MO

lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 250 mg, 300 mg, 50 mg

Tier 4 MO

lamotrigine er oral tablet extended release 24 hour 25 mg

Tier 2 MO

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

Tier 2 MO

lamotrigine oral tablet chewable 25 mg, 5 mg Tier 2 MO

lamotrigine oral tablet dispersible 100 mg, 200 mg Tier 4 MO

lamotrigine oral tablet dispersible 25 mg, 50 mg Tier 2 MO

lamotrigine starter kit-blue oral kit 25 (35) mg Tier 4 MO

lamotrigine starter kit-green oral kit 25 (84)-100(14) mg

Tier 4 MO

lamotrigine starter kit-orange oral kit 25 (42)-100 (7) mg

Tier 4 MO

SUBVENITE ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG

Tier 2 MO

SUBVENITE STARTER KIT-BLUE ORAL KIT 25 (35) MG

Tier 4 MO

SUBVENITE STARTER KIT-GREEN ORAL KIT 25 (84)-100(14) MG

Tier 4 MO

SUBVENITE STARTER KIT-ORANGE ORAL KIT 25 (42)-100 (7) MG

Tier 4 MO



topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, 200 mg, 25 mg, 50 mg

Tier 3 MO

topiramate oral capsule sprinkle 15 mg, 25 mg Tier 2 MO

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg

Tier 2 MO

SODIUM CHANNEL AGENTS

APTIOM ORAL TABLET 200 MG, 400 MG Tier 5 PA; MO; QL (30 EA per 30 days)

APTIOM ORAL TABLET 600 MG Tier 5 PA; MO; QL (60 EA per 30 days)

APTIOM ORAL TABLET 800 MG Tier 5 PA; MO; QL (45 EA per 30 days)

BANZEL ORAL SUSPENSION 40 MG/ML Tier 5 PA; MO; QL (2400 ML per 30 days)

BANZEL ORAL TABLET 200 MG, 400 MG Tier 5 PA; MO; QL (240 EA per 30 days)

carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg

Tier 2 MO

carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg

Tier 2 MO

carbamazepine oral suspension 100 mg/5ml Tier 2 MO

carbamazepine oral tablet 200 mg Tier 2 MO

carbamazepine oral tablet chewable 100 mg Tier 1 MO

DILANTIN ORAL CAPSULE 30 MG Tier 3 MO

EPITOL ORAL TABLET 200 MG Tier 3 MO

oxcarbazepine oral suspension 300 mg/5ml Tier 4 MO

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg Tier 2 MO

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG, 600 MG

Tier 4 MO

PEGANONE ORAL TABLET 250 MG Tier 4 MO

phenytoin oral suspension 125 mg/5ml Tier 1 MO

phenytoin oral tablet chewable 50 mg Tier 1 MO



phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

Tier 1 MO

VIMPAT ORAL SOLUTION 10 MG/ML Tier 5 MO; QL (1200 ML per 30 days)

VIMPAT ORAL TABLET 100 MG, 50 MG Tier 4 MO; QL (60 EA per 30 days)

VIMPAT ORAL TABLET 150 MG, 200 MG Tier 5 MO; QL (60 EA per 30 days)

ANTIDEMENTIA AGENTS

CHOLINESTERASE INHIBITORS

donepezil hcl oral tablet 10 mg, 23 mg, 5 mg Tier 2 MO

donepezil hcl oral tablet dispersible 10 mg, 5 mg Tier 2 MO

galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg

Tier 2 MO

galantamine hydrobromide oral solution 4 mg/ml Tier 2 MO

galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg

Tier 2 MO

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

Tier 2 MO

rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr


N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

memantine hcl er oral capsule extended release 24 hour 14 mg, 21 mg, 28 mg, 7 mg

Tier 3 MO

memantine hcl oral solution 2 mg/ml Tier 3 MO

memantine hcl oral tablet 10 mg, 5 (28)-10 (21) mg, 5 mg

Tier 2 MO

NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 MG

Tier 3 MO



NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 & 14 & 21 &28 -10 MG

Tier 3 PA; MO

NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG

Tier 3 PA; MO

ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg

Tier 1 MO

bupropion hcl er (sr) oral tablet extended release 12 hour 200 mg

Tier 2 MO

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

Tier 2 MO

bupropion hcl oral tablet 100 mg, 75 mg Tier 1 MO

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

Tier 4 ST; MO; QL (30 EA per 30 days)

maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg Tier 2 MO

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg

Tier 1 MO

mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg

Tier 1 MO

nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

Tier 2 MO

trazodone hcl oral tablet 100 mg, 150 mg, 50 mg Tier 1 MO

trazodone hcl oral tablet 300 mg Tier 2 MO

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG




VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG


VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG

Tier 3 MO

MONOAMINE OXIDASE INHIBITORS

EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR


MARPLAN ORAL TABLET 10 MG Tier 4 MO

phenelzine sulfate oral tablet 15 mg Tier 1 MO

tranylcypromine sulfate oral tablet 10 mg Tier 4 MO

SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS

citalopram hydrobromide oral solution 10 mg/5ml Tier 1 MO

citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg

Tier 1 MO

desvenlafaxine er oral tablet extended release 24 hour 100 mg, 50 mg

Tier 2 MO

desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 25 mg, 50 mg

Tier 2 MO

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 40 mg, 60 mg

Tier 2 MO

escitalopram oxalate oral solution 5 mg/5ml Tier 2 MO

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg

Tier 2 MO

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG


FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG




fluoxetine hcl oral capsule 10 mg Tier 1 MO

fluoxetine hcl oral capsule 20 mg, 40 mg Tier 2 MO

fluoxetine hcl oral capsule delayed release 90 mg Tier 2 MO

fluoxetine hcl oral solution 20 mg/5ml Tier 2 MO

fluoxetine hcl oral tablet 10 mg, 20 mg Tier 2 MO

fluoxetine hcl oral tablet 60 mg Tier 3 MO

fluvoxamine maleate er oral capsule extended release 24 hour 100 mg, 150 mg

Tier 2 MO

fluvoxamine maleate oral tablet 100 mg, 25 mg Tier 2 MO

fluvoxamine maleate oral tablet 50 mg Tier 1 MO

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg

Tier 2 MO

paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, 25 mg, 37.5 mg

Tier 2 MO

paroxetine hcl oral tablet 10 mg, 20 mg, 40 mg Tier 1 MO

paroxetine hcl oral tablet 30 mg Tier 2 MO

PAXIL ORAL SUSPENSION 10 MG/5ML Tier 4 MO

PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG

Tier 4 ST; MO

sertraline hcl oral concentrate 20 mg/ml Tier 1 MO

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg Tier 1 MO

venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg

Tier 2 MO

venlafaxine hcl er oral tablet extended release 24 hour 150 mg, 37.5 mg, 75 mg

Tier 2 MO

venlafaxine hcl er oral tablet extended release 24 hour 225 mg

Tier 3 MO

venlafaxine hcl oral tablet 100 mg, 37.5 mg, 75 mg Tier 2 MO



venlafaxine hcl oral tablet 25 mg, 50 mg Tier 1 MO

TRICYCLICS

amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

Tier 1 MO

amoxapine oral tablet 100 mg, 25 mg, 50 mg Tier 1 MO

amoxapine oral tablet 150 mg Tier 2 MO

chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg

Tier 2 MO

clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg

Tier 4 MO

desipramine hcl oral tablet 10 mg, 25 mg Tier 1 MO

desipramine hcl oral tablet 100 mg, 150 mg, 50 mg, 75 mg

Tier 2 MO

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

Tier 1 MO

doxepin hcl oral concentrate 10 mg/ml Tier 1 MO

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg Tier 1 MO

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg

Tier 4 MO

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg

Tier 1 MO

nortriptyline hcl oral solution 10 mg/5ml Tier 2 MO

protriptyline hcl oral tablet 10 mg, 5 mg Tier 2 MO

trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg

Tier 2 MO



ANTIEMETICS

ANTIEMETICS, OTHER

meclizine hcl oral tablet 12.5 mg, 25 mg Tier 1 MO

scopolamine transdermal patch 72 hour 1 mg/3days

Tier 2 MO

trimethobenzamide hcl oral capsule 300 mg Tier 2 MO

EMETOGENIC THERAPY ADJUNCTS

aprepitant oral capsule 125 mg, 40 mg, 80 mg Tier 4 BvD; MO; QL (8 EA per 30 days)

aprepitant oral capsule 80 & 125 mg Tier 4 BvD; MO; QL (12 EA per 30 days)

dronabinol oral capsule 10 mg Tier 5 PA; MO; QL (60 EA per 30 days)

dronabinol oral capsule 2.5 mg Tier 2 PA; MO; QL (60 EA per 30 days)

dronabinol oral capsule 5 mg Tier 4 PA; MO; QL (60 EA per 30 days)

granisetron hcl oral tablet 1 mg Tier 4 BvD; MO; QL (60 EA per 30 days)

ondansetron hcl oral solution 4 mg/5ml Tier 4 BvD; MO; QL (450 ML per 30 days)

ondansetron hcl oral tablet 24 mg Tier 2 BvD; MO; QL (30 EA per 30 days)



ondansetron oral tablet dispersible 4 mg Tier 2 BvD; MO; QL (120 EA per 30 days)

ondansetron oral tablet dispersible 8 mg Tier 2 BvD; MO; QL (60 EA per 30 days)

VARUBI ORAL TABLET 90 MG Tier 4 PA; MO; QL (8 EA per 30 days)



ANTIFUNGALS

ANTIFUNGALS

ABELCET INTRAVENOUS SUSPENSION 5 MG/ML

Tier 5 BvD; MO

AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG

Tier 5 BvD; MO

amphotericin b injection solution reconstituted 50 mg

Tier 4 BvD; MO

caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg

Tier 5 PA; MO

clotrimazole mouth/throat lozenge 10 mg Tier 2 MO

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

Tier 4 PA; MO

fluconazole in sodium chloride intravenous solution 200-0.9 mg/100ml-%, 400-0.9 mg/200ml-%

Tier 1 BvD; MO

fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml

Tier 2 MO

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg

Tier 2 MO

flucytosine oral capsule 250 mg, 500 mg Tier 5 MO

griseofulvin microsize oral suspension 125 mg/5ml Tier 2 MO

griseofulvin microsize oral tablet 500 mg Tier 2 MO

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

Tier 2 MO

itraconazole oral capsule 100 mg Tier 4 PA; MO

ketoconazole oral tablet 200 mg Tier 2 MO



MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

Tier 5 PA; MO

NOXAFIL ORAL SUSPENSION 40 MG/ML Tier 5 PA; MO

NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG

Tier 5 PA; MO

nystatin mouth/throat suspension 100000 unit/ml Tier 2 MO

nystatin oral tablet 500000 unit Tier 1 MO

ORAVIG BUCCAL TABLET 50 MG Tier 3 MO

terbinafine hcl oral tablet 250 mg Tier 1 MO; QL (84 EA per 168 days)

voriconazole intravenous solution reconstituted 200 mg

Tier 5 BvD; MO

voriconazole oral suspension reconstituted 40 mg/ml

Tier 5 MO; QL (300 ML per 30 days)

voriconazole oral tablet 200 mg, 50 mg Tier 5 MO; QL (120 EA per 30 days)

ANTIGOUT AGENTS

ANTIGOUT AGENTS

allopurinol oral tablet 100 mg Tier 1 MO

colchicine oral capsule 0.6 mg Tier 2 MO

colchicine oral tablet 0.6 mg Tier 2 MO

colchicine-probenecid oral tablet 0.5-500 mg Tier 1 MO

COLCRYS ORAL TABLET 0.6 MG Tier 3 MO

MITIGARE ORAL CAPSULE 0.6 MG Tier 4 MO

probenecid oral tablet 500 mg Tier 1 MO

ULORIC ORAL TABLET 40 MG, 80 MG Tier 3 ST; MO



ANTI-INFLAMMATORY AGENTS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

BUPAP ORAL TABLET 50-300 MG Tier 3 MO; QL (180 EA per 30 days)

butalbital-acetaminophen oral tablet 50-325 mg Tier 2 MO; QL (180 EA per 30 days)

butalbital-apap-caffeine oral tablet 50-325-40 mg Tier 2 MO; QL (180 EA per 30 days)

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg


diclofenac potassium oral tablet 50 mg Tier 2 MO

diclofenac sodium er oral tablet extended release 24 hour 100 mg

Tier 1 MO

diclofenac sodium oral tablet delayed release 25 mg

Tier 2 MO

diclofenac sodium oral tablet delayed release 50 mg, 75 mg

Tier 1 MO

diclofenac sodium transdermal gel 1 % Tier 2 PA; MO; QL (1000 GM per 30 days)

diclofenac sodium transdermal solution 1.5 % Tier 4 PA; MO; QL (450 ML per 30 days)

diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75-0.2 mg

Tier 2 MO

diflunisal oral tablet 500 mg Tier 2 MO

etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg

Tier 2 MO

etodolac oral capsule 200 mg, 300 mg Tier 1 MO

etodolac oral tablet 400 mg, 500 mg Tier 1 MO

flurbiprofen oral tablet 100 mg, 50 mg Tier 1 MO

IBU ORAL TABLET 600 MG, 800 MG Tier 1 MO

ibuprofen oral suspension 100 mg/5ml Tier 1 MO



ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1 MO

indomethacin er oral capsule extended release 75 mg

Tier 2 MO

indomethacin oral capsule 25 mg, 50 mg Tier 1 MO

ketoprofen er oral capsule extended release 24 hour 200 mg

Tier 4 MO

ketoprofen oral capsule 75 mg Tier 2 MO

ketorolac tromethamine oral tablet 10 mg Tier 2 MO

meclofenamate sodium oral capsule 100 mg, 50 mg

Tier 2 MO

meloxicam oral tablet 15 mg, 7.5 mg Tier 1 MO

nabumetone oral tablet 500 mg, 750 mg Tier 1 MO

naproxen dr oral tablet delayed release 375 mg, 500 mg

Tier 2 MO

naproxen oral suspension 125 mg/5ml Tier 1 MO

naproxen oral tablet 250 mg, 375 mg, 500 mg Tier 1 MO

naproxen sodium oral tablet 275 mg, 550 mg Tier 2 MO

oxaprozin oral tablet 600 mg Tier 2 MO

piroxicam oral capsule 10 mg, 20 mg Tier 2 MO

sulindac oral tablet 150 mg, 200 mg Tier 1 MO

tolmetin sodium oral capsule 400 mg Tier 2 MO

tolmetin sodium oral tablet 600 mg Tier 2 MO

ANTIMIGRAINE AGENTS

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

dihydroergotamine mesylate nasal solution 4 mg/ml

Tier 5 ST; MO; QL (24 ML per 28 days)



eletriptan hydrobromide oral tablet 20 mg, 40 mg Tier 2 MO; QL (12 EA per 30 days)

ergotamine-caffeine oral tablet 1-100 mg Tier 3 MO; QL (40 EA per 28 days)

naratriptan hcl oral tablet 1 mg, 2.5 mg Tier 2 MO; QL (12 EA per 30 days)

rizatriptan benzoate oral tablet 10 mg, 5 mg Tier 2 MO; QL (12 EA per 30 days)

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg


sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg


sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml

Tier 2 MO

sumatriptan succinate subcutaneous solution 6 mg/0.5ml

Tier 2 MO

sumatriptan succinate subcutaneous solution auto-injector 6 mg/0.5ml

Tier 2 MO

zolmitriptan oral tablet 2.5 mg, 5 mg Tier 2 MO; QL (12 EA per 30 days)

zolmitriptan oral tablet dispersible 2.5 mg, 5 mg Tier 2 MO; QL (12 EA per 30 days)

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

guanidine hcl oral tablet 125 mg Tier 2 MO

pyridostigmine bromide oral tablet 60 mg Tier 1 MO

ANTIMYCOBACTERIALS

ANTITUBERCULARS

ethambutol hcl oral tablet 100 mg, 400 mg Tier 1 MO

isoniazid oral syrup 50 mg/5ml Tier 2 MO



isoniazid oral tablet 100 mg, 300 mg Tier 1 MO

PASER ORAL PACKET 4 GM Tier 4 MO

PRIFTIN ORAL TABLET 150 MG Tier 4 MO

pyrazinamide oral tablet 500 mg Tier 2 MO

rifabutin oral capsule 150 mg Tier 4 MO

rifampin intravenous solution reconstituted 600 mg

Tier 2 BvD; MO

rifampin oral capsule 150 mg, 300 mg Tier 2 MO

RIFATER ORAL TABLET 50-120-300 MG Tier 3 MO

TRECATOR ORAL TABLET 250 MG Tier 4 MO

ANTINEOPLASTICS

ALKYLATING AGENTS

cyclophosphamide oral capsule 25 mg Tier 2 BvD; MO

cyclophosphamide oral capsule 50 mg Tier 4 BvD; MO

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

Tier 4 PA; MO

HEXALEN ORAL CAPSULE 50 MG Tier 5 PA; MO

LEUKERAN ORAL TABLET 2 MG Tier 4 MO

ANTIANGIOGENIC AGENTS

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG

Tier 5 PA; MO

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

Tier 5 PA; MO



ANTIMETABOLITES

mercaptopurine oral tablet 50 mg Tier 2 MO

methotrexate sodium (pf) injection solution 50 mg/2ml

Tier 1 BvD; MO

methotrexate sodium injection solution 250 mg/10ml

Tier 1 BvD; MO

PURIXAN ORAL SUSPENSION 2000 MG/100ML

Tier 5 PA; LA

TABLOID ORAL TABLET 40 MG Tier 4 MO

ANTINEOPLASTICS

ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 UNIT/0.5ML

Tier 5 PA; LA

AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG


AFINITOR DISPERZ ORAL TABLET SOLUBLE 5 MG


AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG


ALECENSA ORAL CAPSULE 150 MG Tier 5 PA; MO

ALUNBRIG ORAL TABLET 180 MG Tier 5 PA; LA; QL (30 EA per 30 days)



ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG

Tier 5 PA; LA; QL (30 EA per 30 days)

bexarotene oral capsule 75 mg Tier 5 PA; MO

bicalutamide oral tablet 50 mg Tier 2 MO; QL (30 EA per 30 days)

BOSULIF ORAL TABLET 100 MG Tier 5 PA; MO; QL (120 EA per 30 days)



BOSULIF ORAL TABLET 400 MG, 500 MG Tier 5 PA; MO; QL (30 EA per 30 days)

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG

Tier 5 PA; LA

CALQUENCE ORAL CAPSULE 100 MG Tier 5 PA; LA; QL (60 EA per 30 days)

CAPRELSA ORAL TABLET 100 MG Tier 5 PA; LA; QL (60 EA per 30 days)

CAPRELSA ORAL TABLET 300 MG Tier 5 PA; LA; QL (30 EA per 30 days)

COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG


COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG


COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG


COTELLIC ORAL TABLET 20 MG Tier 5 PA; LA

DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

Tier 3 MO

ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG

Tier 4 PA; MO

EMCYT ORAL CAPSULE 140 MG Tier 4 MO

ERIVEDGE ORAL CAPSULE 150 MG Tier 5 PA; MO

ERLEADA ORAL TABLET 60 MG Tier 5 PA; LA

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG

Tier 5 PA; MO

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG

Tier 5 PA; MO

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG

Tier 4 PA; MO

fluorouracil external cream 5 % Tier 4 MO

fluorouracil external solution 2 %, 5 % Tier 2 MO

flutamide oral capsule 125 mg Tier 2 MO



GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG

Tier 5 PA; LA

hydroxyurea oral capsule 500 mg Tier 1 MO

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG

Tier 5 PA; MO

ICLUSIG ORAL TABLET 15 MG Tier 5 PA; LA; QL (60 EA per 30 days)

ICLUSIG ORAL TABLET 45 MG Tier 5 PA; LA; QL (30 EA per 30 days)

IDHIFA ORAL TABLET 100 MG Tier 5 PA; LA; QL (30 EA per 30 days)

IDHIFA ORAL TABLET 50 MG Tier 5 PA; LA; QL (60 EA per 30 days)

imatinib mesylate oral tablet 100 mg Tier 5 PA; MO; QL (180 EA per 30 days)

imatinib mesylate oral tablet 400 mg Tier 5 PA; MO; QL (60 EA per 30 days)

IMBRUVICA ORAL CAPSULE 140 MG, 70 MG Tier 5 PA; LA

IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG

Tier 5 PA; LA

INLYTA ORAL TABLET 1 MG Tier 5 PA; MO; QL (180 EA per 30 days)

INLYTA ORAL TABLET 5 MG Tier 5 PA; MO; QL (60 EA per 30 days)

INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML

Tier 5 PA; MO

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

Tier 5 PA; MO

IRESSA ORAL TABLET 250 MG Tier 5 PA; LA

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG


KISQALI 200 DOSE ORAL TABLET 200 MG Tier 5 PA; MO



KISQALI FEMARA 200 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG

Tier 5 PA; MO




Tier 5 PA; MO


Tier 5 PA; MO

LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 MG

Tier 5 PA; MO

LENVIMA 14 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & 4 MG

Tier 5 PA; MO

LENVIMA 18 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & 4 (2) MG

Tier 5 PA; MO

LENVIMA 20 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 (2) MG

Tier 5 PA; MO

LENVIMA 24 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 (2) & 4 MG

Tier 5 PA; MO

LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 4 (2) MG

Tier 5 PA; MO

leucovorin calcium oral tablet 10 mg, 15 mg, 5 mg Tier 1 MO

leucovorin calcium oral tablet 25 mg Tier 2 MO

leuprolide acetate injection kit 1 mg/0.2ml Tier 2 PA; MO

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG

Tier 5 PA; LA

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG

Tier 5 PA; MO

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG, 22.5 MG

Tier 5 PA; MO

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30 MG

Tier 5 PA; MO

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45 MG

Tier 5 PA; MO

LYNPARZA ORAL CAPSULE 50 MG Tier 5 PA; LA



LYNPARZA ORAL TABLET 100 MG, 150 MG Tier 5 PA; LA

LYSODREN ORAL TABLET 500 MG Tier 5 MO

MATULANE ORAL CAPSULE 50 MG Tier 5 PA; LA

megestrol acetate oral suspension 40 mg/ml Tier 2 MO

megestrol acetate oral tablet 20 mg, 40 mg Tier 1 MO

MEKINIST ORAL TABLET 0.5 MG, 2 MG Tier 5 PA; LA

NERLYNX ORAL TABLET 40 MG Tier 5 PA; LA; QL (180 EA per 30 days)

NEXAVAR ORAL TABLET 200 MG Tier 5 PA; LA; QL (120 EA per 30 days)

nilutamide oral tablet 150 mg Tier 5 MO; QL (60 EA per 30 days)

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG

Tier 5 PA; MO

ODOMZO ORAL CAPSULE 200 MG Tier 5 PA; LA

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG

Tier 5 PA; LA

RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG

Tier 5 PA; LA

RYDAPT ORAL CAPSULE 25 MG Tier 5 PA; MO; QL (240 EA per 30 days)

SOLTAMOX ORAL SOLUTION 10 MG/5ML Tier 4 PA; MO

SPRYCEL ORAL TABLET 100 MG, 50 MG, 70 MG, 80 MG


SPRYCEL ORAL TABLET 140 MG Tier 5 PA; MO; QL (30 EA per 30 days)

SPRYCEL ORAL TABLET 20 MG Tier 5 PA; MO; QL (90 EA per 30 days)

STIVARGA ORAL TABLET 40 MG Tier 5 PA; LA

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

Tier 5 PA; MO

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG

Tier 5 PA; MO



SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG

Tier 5 PA; MO

TAFINLAR ORAL CAPSULE 50 MG, 75 MG Tier 5 PA; LA

TAGRISSO ORAL TABLET 40 MG, 80 MG Tier 5 PA; LA

tamoxifen citrate oral tablet 10 mg Tier 1 MO

tamoxifen citrate oral tablet 20 mg Tier 2 MO

TARCEVA ORAL TABLET 100 MG, 150 MG Tier 5 PA; MO; QL (30 EA per 30 days)

TARCEVA ORAL TABLET 25 MG Tier 5 PA; MO; QL (90 EA per 30 days)

TASIGNA ORAL CAPSULE 150 MG, 200 MG Tier 5 PA; MO; QL (120 EA per 30 days)

TASIGNA ORAL CAPSULE 50 MG Tier 5 PA; MO

TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG

Tier 5 PA; MO

tretinoin oral capsule 10 mg Tier 5 MO

TYKERB ORAL TABLET 250 MG Tier 5 PA; MO; QL (150 EA per 30 days)

VALCHLOR EXTERNAL GEL 0.016 % Tier 5 PA; MO; QL (60 GM per 30 days)

VENCLEXTA ORAL TABLET 10 MG, 50 MG Tier 4 PA; LA

VENCLEXTA ORAL TABLET 100 MG Tier 5 PA; LA

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG

Tier 5 PA; LA

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

Tier 5 PA; LA

VOTRIENT ORAL TABLET 200 MG Tier 5 PA; MO; QL (120 EA per 30 days)

XALKORI ORAL CAPSULE 200 MG, 250 MG Tier 5 PA; MO; QL (60 EA per 30 days)

XTANDI ORAL CAPSULE 40 MG Tier 5 PA; ST; LA; QL (120 EA per 30 days)

YONSA ORAL TABLET 125 MG Tier 5 PA; MO; QL (120 EA per 30 days)

ZEJULA ORAL CAPSULE 100 MG Tier 5 PA; LA; QL (90 EA per 30 days)



ZELBORAF ORAL TABLET 240 MG Tier 5 PA; MO; QL (240 EA per 30 days)

ZOLINZA ORAL CAPSULE 100 MG Tier 5 PA; MO; QL (120 EA per 30 days)

ZYDELIG ORAL TABLET 100 MG Tier 5 PA; LA; QL (90 EA per 30 days)

ZYDELIG ORAL TABLET 150 MG Tier 5 PA; LA; QL (60 EA per 30 days)

ZYKADIA ORAL CAPSULE 150 MG Tier 5 PA; MO

ZYTIGA ORAL TABLET 250 MG, 500 MG Tier 5 PA; MO; QL (120 EA per 30 days)

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole oral tablet 1 mg Tier 2 MO

exemestane oral tablet 25 mg Tier 4 MO; QL (60 EA per 30 days)

letrozole oral tablet 2.5 mg Tier 2 MO

TREATMENT ADJUNCTS

allopurinol oral tablet 300 mg Tier 1 MO

MESNEX ORAL TABLET 400 MG Tier 5 MO

ANTIPARASITICS

ANTHELMINTICS

ALBENZA ORAL TABLET 200 MG Tier 5 MO

benznidazole oral tablet 100 mg, 12.5 mg Tier 1 MO

EMVERM ORAL TABLET CHEWABLE 100 MG

Tier 4 MO

ivermectin oral tablet 3 mg Tier 2 MO

ANTIPROTOZOALS

ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML




ALINIA ORAL TABLET 500 MG Tier 4 PA; MO; QL (6 EA per 30 days)

atovaquone oral suspension 750 mg/5ml Tier 5 MO

atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg

Tier 2 MO

chloroquine phosphate oral tablet 250 mg, 500 mg Tier 1 MO

COARTEM ORAL TABLET 20-120 MG Tier 4 MO

hydroxychloroquine sulfate oral tablet 200 mg Tier 2 MO

mefloquine hcl oral tablet 250 mg Tier 2 MO

primaquine phosphate oral tablet 26.3 mg Tier 3 MO

quinine sulfate oral capsule 324 mg Tier 2 PA; MO

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg

Tier 1 MO

trihexyphenidyl hcl oral elixir 0.4 mg/ml Tier 1 MO

trihexyphenidyl hcl oral tablet 2 mg, 5 mg Tier 1 MO

ANTIPARKINSON AGENTS, OTHER

amantadine hcl oral capsule 100 mg Tier 2 MO

amantadine hcl oral syrup 50 mg/5ml Tier 2 MO

amantadine hcl oral tablet 100 mg Tier 2 MO

entacapone oral tablet 200 mg Tier 2 MO

GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 137 MG


GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 68.5 MG




DOPAMINE AGONISTS

APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML

Tier 5 PA; LA; QL (60 ML per 30 days)

bromocriptine mesylate oral capsule 5 mg Tier 2 MO

bromocriptine mesylate oral tablet 2.5 mg Tier 2 MO

NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR

Tier 4 ST; MO

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

Tier 2 MO

ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 mg, 4 mg, 6 mg, 8 mg

Tier 2 MO

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

Tier 2 MO

DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa-levodopa er oral tablet extended release 25-100 mg

Tier 1 MO

carbidopa-levodopa er oral tablet extended release 50-200 mg

Tier 2 MO

carbidopa-levodopa oral tablet 10-100 mg Tier 1 MO

carbidopa-levodopa oral tablet 25-100 mg, 25-250 mg

Tier 2 MO

carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg

Tier 1 MO

carbidopa-levodopa oral tablet dispersible 25-250 mg

Tier 2 MO

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 31.25-125-200 mg

Tier 2 MO



carbidopa-levodopa-entacapone oral tablet 25-100-200 mg, 37.5-150-200 mg, 50-200-200 mg

Tier 4 MO

RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG

Tier 4 ST; MO

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

rasagiline mesylate oral tablet 0.5 mg, 1 mg Tier 4 MO; QL (30 EA per 30 days)

selegiline hcl oral capsule 5 mg Tier 2 MO

selegiline hcl oral tablet 5 mg Tier 2 MO

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

chlorpromazine hcl oral tablet 10 mg, 100 mg, 25 mg

Tier 2 MO

chlorpromazine hcl oral tablet 200 mg, 50 mg Tier 4 MO

COMPRO RECTAL SUPPOSITORY 25 MG Tier 4 MO

fluphenazine decanoate injection solution 25 mg/ml

Tier 2 MO

fluphenazine hcl injection solution 2.5 mg/ml Tier 4 MO

fluphenazine hcl oral concentrate 5 mg/ml Tier 2 MO

fluphenazine hcl oral elixir 2.5 mg/5ml Tier 2 MO

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg Tier 1 MO

fluphenazine hcl oral tablet 5 mg Tier 2 MO

haloperidol decanoate intramuscular solution 100 mg/ml, 100 mg/ml 1 ml, 50 mg/ml

Tier 1 MO

haloperidol lactate injection solution 5 mg/ml, 5 mg/ml(1 ml prefilled syringe)

Tier 2 MO



haloperidol lactate oral concentrate 2 mg/ml Tier 2 MO

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

Tier 1 MO

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

Tier 1 MO

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg Tier 2 MO

perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg

Tier 2 MO

pimozide oral tablet 1 mg, 2 mg Tier 2 MO

prochlorperazine maleate oral tablet 10 mg, 5 mg Tier 1 MO

prochlorperazine rectal suppository 25 mg Tier 4 MO

thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

Tier 1 MO

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg Tier 1 MO

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg

Tier 1 MO

2ND GENERATION/ATYPICAL

ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG

Tier 5 ST; MO

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG

Tier 5 ST; MO

aripiprazole oral solution 1 mg/ml Tier 4 MO; QL (750 ML per 30 days)

aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg


aripiprazole oral tablet 2 mg, 5 mg Tier 4 MO; QL (60 EA per 30 days)

aripiprazole oral tablet dispersible 10 mg, 15 mg Tier 5 MO; QL (60 EA per 30 days)

FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG Tier 4 ST; MO; QL (60 EA per 30 days)



FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG, 8 MG


FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG


INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 78 MG/0.5ML

Tier 5 ST; MO

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 39 MG/0.25ML

Tier 4 ST; MO

INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML

Tier 5 ST; MO

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG


LATUDA ORAL TABLET 60 MG, 80 MG Tier 5 ST; MO; QL (60 EA per 30 days)

NUPLAZID ORAL CAPSULE 34 MG Tier 5 ST; LA

NUPLAZID ORAL TABLET 10 MG, 17 MG Tier 5 ST; LA

olanzapine oral tablet 10 mg, 15 mg, 20 mg, 5 mg Tier 3 MO; QL (30 EA per 30 days)

olanzapine oral tablet 2.5 mg, 7.5 mg Tier 2 MO; QL (30 EA per 30 days)

olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg


paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 6 mg


paliperidone er oral tablet extended release 24 hour 9 mg


quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg, 300 mg, 400 mg, 50 mg

Tier 3 MO

quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

Tier 2 MO



REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG


RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG

Tier 4 ST; MO

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 25 MG, 37.5 MG, 50 MG

Tier 5 ST; MO

risperidone oral solution 1 mg/ml Tier 2 MO

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

Tier 2 MO

risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg

Tier 2 MO

risperidone oral tablet dispersible 3 mg, 4 mg Tier 4 MO

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG


VRAYLAR ORAL CAPSULE 1.5 MG Tier 5 ST; MO; QL (120 EA per 30 days)

VRAYLAR ORAL CAPSULE 3 MG Tier 5 ST; MO; QL (60 EA per 30 days)

VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG Tier 5 ST; MO; QL (30 EA per 30 days)

VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG

Tier 4 ST; MO

ziprasidone hcl oral capsule 20 mg, 40 mg Tier 2 MO; QL (60 EA per 30 days)

ziprasidone hcl oral capsule 60 mg, 80 mg Tier 3 MO; QL (60 EA per 30 days)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG

Tier 4 ST; MO

TREATMENT-RESISTANT

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

Tier 2 MO

clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 25 mg

Tier 4 MO



clozapine oral tablet dispersible 200 mg Tier 5 MO

olanzapine intramuscular solution reconstituted 10 mg

Tier 4 MO

VERSACLOZ ORAL SUSPENSION 50 MG/ML Tier 5 ST; MO

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

PREVYMIS ORAL TABLET 240 MG, 480 MG Tier 5 PA; MO; QL (100 EA per 100 days)

valganciclovir hcl oral solution reconstituted 50 mg/ml

Tier 5 MO

valganciclovir hcl oral tablet 450 mg Tier 5 MO

ANTIHEPATITIS AGENTS

adefovir dipivoxil oral tablet 10 mg Tier 5 PA; MO; QL (30 EA per 30 days)

BARACLUDE ORAL SOLUTION 0.05 MG/ML Tier 5 PA; MO; QL (600 ML per 30 days)

entecavir oral tablet 0.5 mg, 1 mg Tier 5 PA; MO; QL (30 EA per 30 days)

EPIVIR HBV ORAL SOLUTION 5 MG/ML Tier 3 MO

lamivudine oral tablet 100 mg Tier 2 MO

REBETOL ORAL SOLUTION 40 MG/ML Tier 5 MO

RIBASPHERE ORAL CAPSULE 200 MG Tier 3 MO

RIBASPHERE ORAL TABLET 200 MG Tier 4 MO

RIBASPHERE ORAL TABLET 400 MG, 600 MG

Tier 5 MO

RIBASPHERE RIBAPAK ORAL TABLET 400 MG, 600 MG

Tier 5 MO

RIBASPHERE RIBAPAK ORAL TABLET THERAPY PACK 200 & 400 MG, 400 & 600 MG

Tier 5 MO



ribavirin oral capsule 200 mg Tier 2 MO; QL (180 EA per 30 days)

ribavirin oral tablet 200 mg Tier 3 MO; QL (180 EA per 30 days)

VEMLIDY ORAL TABLET 25 MG Tier 5 PA; MO

ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING

MAVYRET ORAL TABLET 100-40 MG Tier 5 PA; MO

VOSEVI ORAL TABLET 400-100-100 MG Tier 5 PA; MO

ANTI-HEPATITIS C (HCV) AGENTS, OTHER

MODERIBA 1200 DOSE PACK ORAL TABLET 600 MG

Tier 5 MO

MODERIBA 800 DOSE PACK ORAL TABLET 400 MG

Tier 5 MO

MODERIBA ORAL TABLET 200 MG Tier 4 MO

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML

Tier 5 PA; MO

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML

Tier 5 PA; MO

ANTIHERPETIC AGENTS

acyclovir oral capsule 200 mg Tier 1 MO

acyclovir oral suspension 200 mg/5ml Tier 2 MO

acyclovir oral tablet 400 mg, 800 mg Tier 1 MO

acyclovir sodium intravenous solution 50 mg/ml Tier 4 BvD; MO

famciclovir oral tablet 125 mg Tier 2 MO

famciclovir oral tablet 250 mg, 500 mg Tier 3 MO

valacyclovir hcl oral tablet 1 gm, 500 mg Tier 2 MO



ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS

ATRIPLA ORAL TABLET 600-200-300 MG Tier 5 MO

COMPLERA ORAL TABLET 200-25-300 MG Tier 5 MO

EDURANT ORAL TABLET 25 MG Tier 5 MO

efavirenz oral capsule 200 mg, 50 mg Tier 4 MO

efavirenz oral tablet 600 mg Tier 5 MO

GENVOYA ORAL TABLET 150-150-200-10 MG

Tier 5 MO

INTELENCE ORAL TABLET 100 MG, 200 MG Tier 5 MO

INTELENCE ORAL TABLET 25 MG Tier 4 MO

nevirapine er oral tablet extended release 24 hour 100 mg

Tier 2 MO

nevirapine er oral tablet extended release 24 hour 400 mg

Tier 3 MO

nevirapine oral tablet 200 mg Tier 2 MO

ODEFSEY ORAL TABLET 200-25-25 MG Tier 5 MO

RESCRIPTOR ORAL TABLET 100 MG, 200 MG

Tier 3 MO

SYMFI LO ORAL TABLET 400-300-300 MG Tier 5 MO

SYMFI ORAL TABLET 600-300-300 MG Tier 5 MO

VIRAMUNE ORAL SUSPENSION 50 MG/5ML Tier 3 MO

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS

abacavir sulfate oral solution 20 mg/ml Tier 4 MO

abacavir sulfate oral tablet 300 mg Tier 4 MO

abacavir sulfate-lamivudine oral tablet 600-300 mg

Tier 5 MO



abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

Tier 5 MO

BIKTARVY ORAL TABLET 50-200-25 MG Tier 5 MO

DESCOVY ORAL TABLET 200-25 MG Tier 5 MO

didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg

Tier 2 MO

EMTRIVA ORAL CAPSULE 200 MG Tier 4 MO

EMTRIVA ORAL SOLUTION 10 MG/ML Tier 4 MO

EVOTAZ ORAL TABLET 300-150 MG Tier 5 MO

JULUCA ORAL TABLET 50-25 MG Tier 5 MO

lamivudine oral solution 10 mg/ml Tier 2 MO

lamivudine oral tablet 150 mg, 300 mg Tier 2 MO

lamivudine-zidovudine oral tablet 150-300 mg Tier 4 MO

PREZCOBIX ORAL TABLET 800-150 MG Tier 5 MO

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg

Tier 2 MO

STRIBILD ORAL TABLET 150-150-200-300 MG

Tier 5 MO

tenofovir disoproxil fumarate oral tablet 300 mg Tier 5 MO

TRIUMEQ ORAL TABLET 600-50-300 MG Tier 5 MO

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG

Tier 5 MO

VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 MG

Tier 4 MO

VIDEX ORAL SOLUTION RECONSTITUTED 4 GM

Tier 4 MO

VIREAD ORAL POWDER 40 MG/GM Tier 5 MO

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

Tier 5 MO



ZERIT ORAL SOLUTION RECONSTITUTED 1 MG/ML

Tier 3 MO

zidovudine oral capsule 100 mg Tier 2 MO

zidovudine oral syrup 50 mg/5ml Tier 2 MO

zidovudine oral tablet 300 mg Tier 2 MO

ANTI-HIV AGENTS, OTHER

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG

Tier 5 MO

ISENTRESS HD ORAL TABLET 600 MG Tier 5 MO

ISENTRESS ORAL PACKET 100 MG Tier 3 MO

ISENTRESS ORAL TABLET 400 MG Tier 5 MO

ISENTRESS ORAL TABLET CHEWABLE 100 MG

Tier 5 MO

ISENTRESS ORAL TABLET CHEWABLE 25 MG

Tier 3 MO

SELZENTRY ORAL SOLUTION 20 MG/ML Tier 4 MO

SELZENTRY ORAL TABLET 150 MG, 300 MG Tier 5 MO

SELZENTRY ORAL TABLET 25 MG, 75 MG Tier 4 MO

TIVICAY ORAL TABLET 10 MG Tier 4 MO

TIVICAY ORAL TABLET 25 MG, 50 MG Tier 5 MO

TYBOST ORAL TABLET 150 MG Tier 3 MO

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS ORAL CAPSULE 250 MG Tier 5 MO

APTIVUS ORAL SOLUTION 100 MG/ML Tier 5 MO

atazanavir sulfate oral capsule 150 mg, 200 mg Tier 4 MO

atazanavir sulfate oral capsule 300 mg Tier 5 MO



CRIXIVAN ORAL CAPSULE 200 MG Tier 3 MO

CRIXIVAN ORAL CAPSULE 400 MG Tier 4 MO

fosamprenavir calcium oral tablet 700 mg Tier 5 MO

INVIRASE ORAL CAPSULE 200 MG Tier 5 MO

INVIRASE ORAL TABLET 500 MG Tier 5 MO

KALETRA ORAL TABLET 100-25 MG Tier 3 MO

KALETRA ORAL TABLET 200-50 MG Tier 5 MO

LEXIVA ORAL SUSPENSION 50 MG/ML Tier 4 MO

lopinavir-ritonavir oral solution 400-100 mg/5ml Tier 4 MO

NORVIR ORAL CAPSULE 100 MG Tier 4 MO

NORVIR ORAL PACKET 100 MG Tier 4 MO

NORVIR ORAL SOLUTION 80 MG/ML Tier 4 MO

PREZISTA ORAL SUSPENSION 100 MG/ML Tier 5 MO

PREZISTA ORAL TABLET 150 MG, 75 MG Tier 4 MO

PREZISTA ORAL TABLET 600 MG, 800 MG Tier 5 MO

REYATAZ ORAL PACKET 50 MG Tier 5 MO

ritonavir oral tablet 100 mg Tier 4 MO

VIRACEPT ORAL TABLET 250 MG, 625 MG Tier 5 MO

ANTI-INFLUENZA AGENTS

oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg

Tier 2 MO

oseltamivir phosphate oral suspension reconstituted 6 mg/ml

Tier 2 MO

RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER

Tier 3 MO

rimantadine hcl oral tablet 100 mg Tier 2 MO



ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl oral tablet 10 mg, 5 mg, 7.5 mg Tier 1 MO

buspirone hcl oral tablet 15 mg, 30 mg Tier 2 MO

hydroxyzine hcl oral syrup 10 mg/5ml Tier 1 MO

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg Tier 1 MO

hydroxyzine pamoate oral capsule 100 mg Tier 2 MO

hydroxyzine pamoate oral capsule 25 mg, 50 mg Tier 1 MO

meprobamate oral tablet 200 mg, 400 mg Tier 2 MO

BENZODIAZEPINES

alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg

Tier 2 MO

ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML

Tier 2 MO

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg

Tier 1 MO

alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg

Tier 2 MO

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg

Tier 1 MO

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg

Tier 2 MO

DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML

Tier 2 MO

diazepam oral solution 1 mg/ml Tier 1 MO

diazepam oral tablet 10 mg, 2 mg, 5 mg Tier 1 MO



lorazepam oral concentrate 2 mg/ml Tier 1 MO

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 MO

oxazepam oral capsule 10 mg, 15 mg, 30 mg Tier 2 MO

BIPOLAR AGENTS

MOOD STABILIZERS

GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG


lithium carbonate er oral tablet extended release 300 mg, 450 mg

Tier 1 MO

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

Tier 1 MO

lithium carbonate oral tablet 300 mg Tier 1 MO

lithium oral solution 8 meq/5ml Tier 1 MO

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose oral tablet 100 mg, 25 mg, 50 mg Tier 2 MO

AVANDIA ORAL TABLET 2 MG, 4 MG Tier 4 MO

CYCLOSET ORAL TABLET 0.8 MG Tier 4 MO

glimepiride oral tablet 1 mg, 2 mg, 4 mg Tier 1 MO

glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

Tier 1 MO

glipizide oral tablet 10 mg, 5 mg Tier 1 MO

glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

Tier 1 MO



glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

Tier 2 MO

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg Tier 2 MO

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

Tier 2 MO

INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG

Tier 3 ST; MO

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG

Tier 3 ST; MO

INVOKANA ORAL TABLET 100 MG, 300 MG Tier 3 ST; MO

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG


JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG


JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50-1000 MG, 50-500 MG


JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG


JARDIANCE ORAL TABLET 10 MG, 25 MG Tier 3 ST; MO

metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg

Tier 1 MO

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg

Tier 1 MO

miglitol oral tablet 100 mg, 25 mg, 50 mg Tier 2 MO

nateglinide oral tablet 120 mg, 60 mg Tier 2 MO

OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.25 OR 0.5 MG/DOSE, 1 MG/DOSE


pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg Tier 1 MO



pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg

Tier 2 MO

pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg

Tier 2 MO

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg Tier 2 MO

repaglinide-metformin hcl oral tablet 1-500 mg, 2-500 mg

Tier 2 MO

RIOMET ORAL SOLUTION 500 MG/5ML Tier 4 MO

SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-33 UNT-MCG/ML


SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML

Tier 4 PA; MO; QL (10.8 ML per 28 days)

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML


SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 MG

Tier 3 ST; MO

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 MG

Tier 3 ST; MO

tolazamide oral tablet 250 mg, 500 mg Tier 2 MO

tolbutamide oral tablet 500 mg Tier 1 MO

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML


VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML


XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-3.6 UNIT-MG/ML


GLYCEMIC AGENTS

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG

Tier 3 MO



GLUCAGON EMERGENCY INJECTION KIT 1 MG

Tier 3 MO

PROGLYCEM ORAL SUSPENSION 50 MG/ML Tier 5 MO

INSULINS

FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

Tier 3 MO

FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML

Tier 3 MO

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

Tier 3 MO

LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML

Tier 3 MO

LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

Tier 3 MO

LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML

Tier 3 MO

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

Tier 3 MO

NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML

Tier 3 MO

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML

Tier 3 MO

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

Tier 3 MO

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

Tier 3 MO

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

Tier 3 MO



NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML

Tier 3 MO

NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML

Tier 3 MO

TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

Tier 3 MO

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

Tier 3 MO

TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

Tier 3 MO

BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS

ANTICOAGULANTS

ELIQUIS ORAL TABLET 2.5 MG, 5 MG Tier 3 MO

ELIQUIS STARTER PACK ORAL TABLET 5 MG

Tier 3 MO

enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

Tier 4 MO

fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 5 mg/0.4ml, 7.5 mg/0.6ml

Tier 5 MO

fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml

Tier 4 MO

FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML

Tier 5 MO

FRAGMIN SUBCUTANEOUS SOLUTION 2500 UNIT/0.2ML, 5000 UNIT/0.2ML

Tier 4 MO



heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

Tier 2 MO

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

Tier 1 MO

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG

Tier 4 ST; MO

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

Tier 1 MO

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG

Tier 3 MO

XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG

Tier 3 MO

BLOOD FORMATION MODIFIERS

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

Tier 3 PA; ST; MO

LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG

Tier 5 PA; MO

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML

Tier 5 PA; MO

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

Tier 5 PA; MO

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

Tier 4 PA; MO

PROCRIT INJECTION SOLUTION 20000 UNIT/ML, 40000 UNIT/ML

Tier 5 PA; MO

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG




TAVALISSE ORAL TABLET 100 MG, 150 MG Tier 5 PA; MO; QL (60 EA per 30 days)

tranexamic acid oral tablet 650 mg Tier 2 MO

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

Tier 5 PA; MO

PLATELET MODIFYING AGENTS

anagrelide hcl oral capsule 0.5 mg, 1 mg Tier 2 MO

aspirin-dipyridamole er oral capsule extended release 12 hour 25-200 mg

Tier 2 MO

BRILINTA ORAL TABLET 60 MG, 90 MG Tier 3 MO

cilostazol oral tablet 100 mg, 50 mg Tier 2 MO

clopidogrel bisulfate oral tablet 75 mg Tier 2 MO

dipyridamole oral tablet 25 mg, 50 mg, 75 mg Tier 2 MO

prasugrel hcl oral tablet 10 mg, 5 mg Tier 4 MO

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg Tier 1 MO

clonidine hcl transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr

Tier 2 MO

guanfacine hcl oral tablet 1 mg, 2 mg Tier 1 MO

methyldopa oral tablet 250 mg, 500 mg Tier 1 MO

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg Tier 2 MO

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg

Tier 1 MO



ergoloid mesylates oral tablet 1 mg Tier 2 MO

prazosin hcl oral capsule 1 mg, 2 mg Tier 1 MO

prazosin hcl oral capsule 5 mg Tier 2 MO

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg Tier 1 MO

ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg

Tier 2 MO

eprosartan mesylate oral tablet 600 mg Tier 2 MO

irbesartan oral tablet 150 mg, 300 mg, 75 mg Tier 1 MO

losartan potassium oral tablet 100 mg, 25 mg, 50 mg

Tier 1 MO

olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg

Tier 2 MO

TEKTURNA ORAL TABLET 150 MG, 300 MG Tier 3 MO

telmisartan oral tablet 20 mg, 40 mg, 80 mg Tier 2 MO

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

Tier 1 MO

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

Tier 1 MO

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg

Tier 2 MO

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

Tier 1 MO

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg Tier 1 MO

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

Tier 1 MO



moexipril hcl oral tablet 15 mg, 7.5 mg Tier 1 MO

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg Tier 1 MO

quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

Tier 1 MO

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

Tier 1 MO

trandolapril oral tablet 1 mg, 2 mg, 4 mg Tier 1 MO

ANTIARRHYTHMICS

amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg

Tier 2 MO

disopyramide phosphate oral capsule 100 mg, 150 mg

Tier 2 MO

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg Tier 4 MO

flecainide acetate oral tablet 100 mg, 150 mg, 50 mg

Tier 2 MO

mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

Tier 2 MO

MULTAQ ORAL TABLET 400 MG Tier 3 MO

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

Tier 2 MO

quinidine sulfate oral tablet 200 mg, 300 mg Tier 1 MO

ANTIHYPERTENSIVE COMBINATIONS

amiloride-hydrochlorothiazide oral tablet 5-50 mg Tier 1 MO

amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 5-40 mg

Tier 2 MO

amlodipine besy-benazepril hcl oral capsule 2.5-10 mg, 5-10 mg, 5-20 mg

Tier 1 MO



amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg

Tier 2 MO

amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg

Tier 2 MO

amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

Tier 2 MO

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

Tier 1 MO

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

Tier 1 MO

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

Tier 1 MO

candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg

Tier 2 MO

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

Tier 2 MO

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

Tier 1 MO

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG


fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg

Tier 1 MO

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg

Tier 2 MO

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

Tier 1 MO

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

Tier 1 MO

methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg

Tier 1 MO



metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg

Tier 1 MO

moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg

Tier 1 MO

nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg

Tier 2 MO

olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg

Tier 2 MO

olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

Tier 2 MO

propranolol-hctz oral tablet 40-25 mg, 80-25 mg Tier 1 MO

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

Tier 1 MO

spironolactone-hctz oral tablet 25-25 mg Tier 1 MO

TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG

Tier 3 MO

telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg

Tier 2 MO

telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg

Tier 2 MO

trandolapril-verapamil hcl er oral tablet extended release 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg

Tier 2 MO

triamterene-hctz oral capsule 37.5-25 mg Tier 1 MO

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg Tier 1 MO

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

Tier 1 MO

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl oral capsule 200 mg, 400 mg Tier 1 MO



atenolol oral tablet 100 mg, 25 mg, 50 mg Tier 1 MO

betaxolol hcl oral tablet 10 mg, 20 mg Tier 1 MO

bisoprolol fumarate oral tablet 10 mg, 5 mg Tier 1 MO

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG

Tier 3 MO

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

Tier 1 MO

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg Tier 1 MO

metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg

Tier 1 MO

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

Tier 1 MO

nadolol oral tablet 20 mg, 40 mg, 80 mg Tier 2 MO

pindolol oral tablet 10 mg, 5 mg Tier 2 MO

propranolol hcl er oral capsule extended release 24 hour 120 mg, 60 mg, 80 mg

Tier 1 MO

propranolol hcl er oral capsule extended release 24 hour 160 mg

Tier 2 MO

propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml

Tier 2 MO

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

Tier 1 MO

SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG

Tier 2 MO

sotalol hcl (af) oral tablet 120 mg Tier 2 MO

sotalol hcl oral tablet 160 mg, 240 mg, 80 mg Tier 2 MO

timolol maleate oral tablet 10 mg, 5 mg Tier 1 MO

timolol maleate oral tablet 20 mg Tier 2 MO



CALCIUM CHANNEL BLOCKING AGENTS

AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG

Tier 1 MO

amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg

Tier 1 MO

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG

Tier 3 MO

diltiazem hcl er beads oral capsule extended release 24 hour 360 mg, 420 mg

Tier 1 MO

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

Tier 1 MO

diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg

Tier 2 MO

diltiazem hcl oral tablet 120 mg, 90 mg Tier 2 MO

diltiazem hcl oral tablet 30 mg, 60 mg Tier 1 MO

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

Tier 3 MO

felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

Tier 1 MO

isradipine oral capsule 2.5 mg Tier 1 MO

isradipine oral capsule 5 mg Tier 2 MO

nicardipine hcl oral capsule 20 mg, 30 mg Tier 2 MO

nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

Tier 1 MO

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

Tier 1 MO

nifedipine oral capsule 10 mg, 20 mg Tier 2 MO



TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

Tier 3 MO

verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg

Tier 1 MO

verapamil hcl er oral capsule extended release 24 hour 300 mg, 360 mg

Tier 2 MO

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

Tier 1 MO

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg Tier 1 MO

CARDIOVASCULAR AGENTS, OTHER

amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg

Tier 2 MO

BIDIL ORAL TABLET 20-37.5 MG Tier 4 MO

CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT

Tier 5 PA; LA

CORLANOR ORAL TABLET 5 MG, 7.5 MG Tier 4 PA; MO

DEMSER ORAL CAPSULE 250 MG Tier 5 PA; MO

DIGITEK ORAL TABLET 125 MCG Tier 3 MO; QL (30 EA per 30 days)

DIGITEK ORAL TABLET 250 MCG Tier 3 MO

DIGOX ORAL TABLET 125 MCG Tier 1 MO; QL (30 EA per 30 days)

DIGOX ORAL TABLET 250 MCG Tier 1 MO

digoxin oral solution 0.05 mg/ml Tier 2 MO

digoxin oral tablet 125 mcg Tier 1 MO; QL (30 EA per 30 days)

digoxin oral tablet 250 mcg Tier 1 MO

epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3ml




FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML

Tier 5 PA; MO

NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG

Tier 5 PA; LA

pentoxifylline er oral tablet extended release 400 mg

Tier 1 MO

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG

Tier 3 PA; MO

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide er oral capsule extended release 12 hour 500 mg

Tier 2 MO

acetazolamide oral tablet 125 mg, 250 mg Tier 2 MO

methazolamide oral tablet 25 mg, 50 mg Tier 4 MO

DIURETICS, LOOP

bumetanide injection solution 0.25 mg/ml Tier 2 MO

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 MO

furosemide injection solution 10 mg/ml, 10 mg/ml (4ml syringe)

Tier 2 MO

furosemide oral solution 10 mg/ml, 8 mg/ml Tier 1 MO

furosemide oral tablet 20 mg, 40 mg, 80 mg Tier 1 MO

torsemide oral tablet 10 mg, 20 mg, 5 mg Tier 1 MO

torsemide oral tablet 100 mg Tier 2 MO

DIURETICS, POTASSIUM-SPARING

amiloride hcl oral tablet 5 mg Tier 1 MO

CAROSPIR ORAL SUSPENSION 25 MG/5ML Tier 4 MO

eplerenone oral tablet 25 mg, 50 mg Tier 2 MO



spironolactone oral tablet 100 mg, 25 mg, 50 mg Tier 1 MO

DIURETICS, THIAZIDE

chlorothiazide oral tablet 250 mg, 500 mg Tier 1 MO

chlorthalidone oral tablet 25 mg, 50 mg Tier 1 MO

DIURIL ORAL SUSPENSION 250 MG/5ML Tier 3 MO

hydrochlorothiazide oral capsule 12.5 mg Tier 1 MO

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

Tier 1 MO

indapamide oral tablet 1.25 mg, 2.5 mg Tier 1 MO

methyclothiazide oral tablet 5 mg Tier 1 MO

metolazone oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 MO

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

fenofibrate micronized oral capsule 134 mg, 200 mg, 43 mg, 67 mg

Tier 1 MO

fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg

Tier 1 MO

fenofibric acid oral tablet 105 mg, 35 mg Tier 1 MO

gemfibrozil oral tablet 600 mg Tier 2 MO

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

Tier 1 MO

fluvastatin sodium er oral tablet extended release 24 hour 80 mg

Tier 2 MO

fluvastatin sodium oral capsule 20 mg, 40 mg Tier 2 MO

LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG Tier 3 MO

lovastatin oral tablet 10 mg, 20 mg, 40 mg Tier 1 MO



pravastatin sodium oral tablet 10 mg, 20 mg Tier 1 MO

pravastatin sodium oral tablet 40 mg, 80 mg Tier 2 MO

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg

Tier 1 MO

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg

Tier 1 MO

DYSLIPIDEMICS, OTHER

cholestyramine light oral powder 4 gm/dose Tier 2 MO

cholestyramine oral packet 4 gm Tier 2 MO

colestipol hcl oral packet 5 gm Tier 2 MO

colestipol hcl oral tablet 1 gm Tier 2 MO

ezetimibe oral tablet 10 mg Tier 2 MO

ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg

Tier 3 MO

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG

Tier 5 PA; MO

KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML

Tier 5 PA; LA

niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg

Tier 2 MO

NIACOR ORAL TABLET 500 MG Tier 3 MO

omega-3-acid ethyl esters oral capsule 1 gm Tier 2 MO

PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 150 MG/ML, 75 MG/ML

Tier 5 PA; MO

PREVALITE ORAL PACKET 4 GM Tier 3 MO

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 420 MG/3.5ML

Tier 5 PA; MO



REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML

Tier 5 PA; MO

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML

Tier 5 PA; MO

VASCEPA ORAL CAPSULE 0.5 GM, 1 GM Tier 4 MO

WELCHOL ORAL PACKET 3.75 GM Tier 3 MO

WELCHOL ORAL TABLET 625 MG Tier 3 MO

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

isosorbide dinitrate er oral tablet extended release 40 mg

Tier 2 MO

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

Tier 1 MO

isosorbide mononitrate er oral tablet extended release 24 hour 120 mg

Tier 2 MO

isosorbide mononitrate er oral tablet extended release 24 hour 30 mg, 60 mg

Tier 1 MO

isosorbide mononitrate oral tablet 10 mg, 20 mg Tier 1 MO

NITRO-BID TRANSDERMAL OINTMENT 2 % Tier 3 MO

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

Tier 3 MO

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg

Tier 1 MO

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr

Tier 1 MO

nitroglycerin transdermal patch 24 hour 0.6 mg/hr Tier 2 MO

nitroglycerin translingual solution 0.4 mg/spray Tier 2 MO



VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

Tier 1 MO

minoxidil oral tablet 10 mg, 2.5 mg Tier 1 MO

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

Tier 2 MO

dextroamphetamine sulfate oral tablet 10 mg, 5 mg Tier 2 MO

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg


atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg


clonidine hcl er oral tablet extended release 12 hour 0.1 mg

Tier 2 MO

dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg

Tier 1 MO

methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg

Tier 2 MO

methylphenidate hcl er oral tablet extended release 72 mg

Tier 2 MO

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg

Tier 1 MO

methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 mg

Tier 2 MO



CENTRAL NERVOUS SYSTEM, OTHER

AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG


NUEDEXTA ORAL CAPSULE 20-10 MG Tier 3 PA; MO

riluzole oral tablet 50 mg Tier 4 PA; MO

tetrabenazine oral tablet 12.5 mg Tier 5 PA; MO; QL (90 EA per 30 days)

tetrabenazine oral tablet 25 mg Tier 5 PA; MO; QL (120 EA per 30 days)

FIBROMYALGIA AGENTS

LYRICA ORAL CAPSULE 100 MG, 150 MG Tier 3 MO; QL (120 EA per 30 days)

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG


SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG


MULTIPLE SCLEROSIS AGENTS

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR 10 MG


AUBAGIO ORAL TABLET 14 MG, 7 MG Tier 5 PA; LA; QL (30 EA per 30 days)

AVONEX INTRAMUSCULAR KIT 30 MCG Tier 5 PA; MO

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 MCG/0.5ML

Tier 5 PA; MO

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML

Tier 5 PA; MO

BETASERON SUBCUTANEOUS KIT 0.3 MG Tier 5 PA; MO

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML, 40 MG/ML

Tier 5 PA; MO

GILENYA ORAL CAPSULE 0.5 MG Tier 5 PA; MO; QL (28 EA per 28 days)



glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml, 40 mg/ml

Tier 5 PA; MO

PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML

Tier 5 PA; MO

PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML

Tier 5 PA; MO

PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 125 MCG/0.5ML

Tier 5 PA; MO

PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MCG/0.5ML

Tier 5 PA; MO

TECFIDERA ORAL 120 & 240 MG Tier 5 PA; MO; QL (60 EA per 30 days)

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG


DENTAL AND ORAL AGENTS

DENTAL AND ORAL AGENTS

cevimeline hcl oral capsule 30 mg Tier 2 MO

chlorhexidine gluconate mouth/throat solution 0.12 %

Tier 1 MO

lidocaine viscous mouth/throat solution 2 % Tier 1 MO

PERIOGARD MOUTH/THROAT SOLUTION 0.12 %

Tier 2 MO

pilocarpine hcl oral tablet 5 mg, 7.5 mg Tier 2 MO

triamcinolone acetonide mouth/throat paste 0.1 % Tier 2 MO



DERMATOLOGICAL AGENTS

DERMATOLOGICAL AGENTS

acitretin oral capsule 10 mg, 17.5 mg, 25 mg Tier 5 PA; MO

acyclovir external ointment 5 % Tier 4 MO

adapalene external cream 0.1 % Tier 4 PA; MO

adapalene external gel 0.1 %, 0.3 % Tier 4 PA; MO

alclometasone dipropionate external cream 0.05 %

Tier 2 MO

alclometasone dipropionate external ointment 0.05 %

Tier 2 MO

amcinonide external cream 0.1 % Tier 4 MO

amcinonide external lotion 0.1 % Tier 2 MO

amcinonide external ointment 0.1 % Tier 4 MO

ammonium lactate external cream 12 % Tier 1 MO

ammonium lactate external lotion 12 % Tier 1 MO

AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG

Tier 3 MO

benzoyl peroxide-erythromycin external gel 5-3 % Tier 2 MO

betamethasone dipropionate aug external cream 0.05 %

Tier 2 MO

betamethasone dipropionate aug external gel 0.05 %

Tier 2 MO

betamethasone dipropionate aug external lotion 0.05 %

Tier 2 MO

betamethasone dipropionate aug external ointment 0.05 %

Tier 2 MO



betamethasone dipropionate external cream 0.05 %

Tier 2 MO

betamethasone dipropionate external lotion 0.05 %

Tier 1 MO

betamethasone dipropionate external ointment 0.05 %

Tier 2 MO

betamethasone valerate external cream 0.1 % Tier 1 MO

betamethasone valerate external lotion 0.1 % Tier 1 MO

betamethasone valerate external ointment 0.1 % Tier 1 MO

calcipotriene external ointment 0.005 % Tier 4 MO

calcipotriene external solution 0.005 % Tier 4 MO

calcitriol external ointment 3 mcg/gm Tier 4 MO

ciclopirox external gel 0.77 % Tier 2 MO

ciclopirox external shampoo 1 % Tier 2 MO

ciclopirox external solution 8 % Tier 1 MO

ciclopirox olamine external cream 0.77 % Tier 2 MO

ciclopirox olamine external suspension 0.77 % Tier 2 MO

CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

Tier 4 MO

clindamycin phosphate external gel 1 % Tier 2 MO

clindamycin phosphate external lotion 1 % Tier 2 MO

clindamycin phosphate external solution 1 % Tier 2 MO

clindamycin phosphate external swab 1 % Tier 2 MO

clobetasol propionate e external cream 0.05 % Tier 2 MO

clobetasol propionate external cream 0.05 % Tier 2 MO

clobetasol propionate external lotion 0.05 % Tier 2 MO

clobetasol propionate external ointment 0.05 % Tier 4 MO



clobetasol propionate external shampoo 0.05 % Tier 3 MO

clobetasol propionate external solution 0.05 % Tier 2 MO

clotrimazole external cream 1 % Tier 1 MO

clotrimazole external solution 1 % Tier 1 MO

clotrimazole-betamethasone external cream 1-0.05 %

Tier 2 MO

clotrimazole-betamethasone external lotion 1-0.05 %

Tier 2 MO

COLOCORT RECTAL ENEMA 100 MG/60ML Tier 2 MO

CONDYLOX EXTERNAL GEL 0.5 % Tier 4 ST; MO

desonide external cream 0.05 % Tier 2 MO

desonide external lotion 0.05 % Tier 2 MO

desonide external ointment 0.05 % Tier 2 MO

desoximetasone external cream 0.05 % Tier 4 MO

desoximetasone external cream 0.25 % Tier 2 MO

desoximetasone external gel 0.05 % Tier 4 MO

desoximetasone external ointment 0.05 % Tier 4 MO

desoximetasone external ointment 0.25 % Tier 2 MO

diclofenac sodium transdermal gel 3 % Tier 5 PA; MO; QL (300 GM per 365 days)

diflorasone diacetate external cream 0.05 % Tier 4 MO

diflorasone diacetate external ointment 0.05 % Tier 4 MO

econazole nitrate external cream 1 % Tier 2 MO

ELIDEL EXTERNAL CREAM 1 % Tier 4 ST; MO

ery external pad 2 % Tier 3 MO

erythromycin external gel 2 % Tier 1 MO

erythromycin external solution 2 % Tier 1 MO

EUCRISA EXTERNAL OINTMENT 2 % Tier 4 ST; MO



FINACEA EXTERNAL FOAM 15 % Tier 4 MO

FINACEA EXTERNAL GEL 15 % Tier 4 MO

fluocinolone acetonide external cream 0.01 %, 0.025 %

Tier 2 MO

fluocinolone acetonide external ointment 0.025 % Tier 2 MO

fluocinolone acetonide external solution 0.01 % Tier 2 MO

fluocinolone acetonide scalp external oil 0.01 % Tier 2 MO

fluocinonide emulsified base external cream 0.05 %

Tier 2 MO

fluocinonide external cream 0.05 % Tier 2 MO

fluocinonide external gel 0.05 % Tier 2 MO

fluocinonide external ointment 0.05 % Tier 2 MO

fluocinonide external solution 0.05 % Tier 2 MO

fluticasone propionate external cream 0.05 % Tier 2 MO

fluticasone propionate external ointment 0.005 % Tier 2 MO

gentamicin sulfate external cream 0.1 % Tier 2 MO

gentamicin sulfate external ointment 0.1 % Tier 2 MO

halobetasol propionate external cream 0.05 % Tier 1 MO

halobetasol propionate external ointment 0.05 % Tier 2 MO

hydrocortisone ace-pramoxine rectal cream 1-1 % Tier 2 MO

hydrocortisone butyrate external cream 0.1 % Tier 2 MO

hydrocortisone butyrate external ointment 0.1 % Tier 2 MO

hydrocortisone butyrate external solution 0.1 % Tier 2 MO

hydrocortisone external cream 1 %, 2.5 % Tier 1 MO

hydrocortisone external lotion 2.5 % Tier 1 MO

hydrocortisone external ointment 1 %, 2.5 % Tier 1 MO

hydrocortisone rectal enema 100 mg/60ml Tier 2 MO



imiquimod external cream 5 % Tier 2 MO

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg

Tier 3 MO

ketoconazole external cream 2 % Tier 2 MO

ketoconazole external shampoo 2 % Tier 1 MO

lidocaine external ointment 5 % Tier 4 PA; MO; QL (50 GM per 30 days)

lidocaine external patch 5 % Tier 4 PA; MO; QL (90 EA per 30 days)

lidocaine hcl external solution 4 % Tier 2 PA; MO

lindane external shampoo 1 % Tier 2 MO

methoxsalen rapid oral capsule 10 mg Tier 5 PA; MO

metronidazole external cream 0.75 % Tier 2 MO

metronidazole external gel 0.75 %, 1 % Tier 2 MO

metronidazole external lotion 0.75 % Tier 2 MO

mometasone furoate external cream 0.1 % Tier 1 MO

mometasone furoate external ointment 0.1 % Tier 1 MO

mometasone furoate external solution 0.1 % Tier 1 MO

mupirocin calcium external cream 2 % Tier 2 MO

mupirocin external ointment 2 % Tier 2 MO

NYAMYC EXTERNAL POWDER 100000 UNIT/GM

Tier 3 MO

nystatin external cream 100000 unit/gm Tier 1 MO

nystatin external ointment 100000 unit/gm Tier 1 MO

nystatin external powder 100000 unit/gm Tier 2 MO

nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

Tier 2 MO

nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%

Tier 2 MO



NYSTOP EXTERNAL POWDER 100000 UNIT/GM

Tier 3 MO

PANRETIN EXTERNAL GEL 0.1 % Tier 5 PA; MO

permethrin external cream 5 % Tier 4 MO

podofilox external solution 0.5 % Tier 2 MO

prednicarbate external cream 0.1 % Tier 2 MO

prednicarbate external ointment 0.1 % Tier 2 MO

PROCTOFOAM HC RECTAL FOAM 1-1 % Tier 3 MO

PROCTO-MED HC RECTAL CREAM 2.5 % Tier 4 MO

PROCTO-PAK RECTAL CREAM 1 % Tier 3 MO

PROCTOSOL HC RECTAL CREAM 2.5 % Tier 4 MO

PROCTOZONE-HC RECTAL CREAM 2.5 % Tier 4 MO

REGRANEX EXTERNAL GEL 0.01 % Tier 5 PA; MO

SANTYL EXTERNAL OINTMENT 250 UNIT/GM

Tier 4 MO

selenium sulfide external lotion 2.5 % Tier 2 MO

silver sulfadiazine external cream 1 % Tier 2 MO

SSD EXTERNAL CREAM 1 % Tier 3 MO

sulfacetamide sodium (acne) external lotion 10 % Tier 2 MO

SULFAMYLON EXTERNAL CREAM 85 MG/GM

Tier 4 MO

tacrolimus external ointment 0.03 %, 0.1 % Tier 4 ST; MO

TARGRETIN EXTERNAL GEL 1 % Tier 5 PA; MO

tazarotene external cream 0.1 % Tier 4 PA; MO

TAZORAC EXTERNAL CREAM 0.05 % Tier 4 PA; MO

TAZORAC EXTERNAL GEL 0.05 %, 0.1 % Tier 4 PA; MO

tretinoin external cream 0.025 %, 0.05 %, 0.1 % Tier 2 PA; MO



tretinoin external gel 0.01 %, 0.025 % Tier 2 PA; MO

triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 %

Tier 1 MO

triamcinolone acetonide external lotion 0.025 % Tier 1 MO

triamcinolone acetonide external lotion 0.1 % Tier 2 MO

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

Tier 1 MO

UCERIS RECTAL FOAM 2 MG/ACT Tier 4 ST; MO

ELECTROLYTES/MINERALS/METALS/VITAMINS

ELECTROLYTE/MINERAL REPLACEMENT

CARBAGLU ORAL TABLET 200 MG Tier 5 PA; LA

dextrose-nacl intravenous solution 10-0.2 %, 10-0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.33 %, 5-0.45 %, 5-0.9 %

Tier 2 BvD; MO

IONOSOL-MB IN D5W INTRAVENOUS SOLUTION

Tier 3 BvD; MO

ISOLYTE-P IN D5W INTRAVENOUS SOLUTION

Tier 4 BvD; MO

ISOLYTE-S INTRAVENOUS SOLUTION Tier 4 BvD; MO

kcl in dextrose-nacl intravenous solution 10-5-0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.33 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%, 40-5-0.9 meq/l-%-%

Tier 2 BvD; MO

kcl-lactated ringers-d5w intravenous solution 20 meq/l

Tier 2 BvD; MO

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ

Tier 3 MO



KLOR-CON M10 ORAL TABLET EXTENDED RELEASE 10 MEQ

Tier 1 MO


Tier 3 MO


Tier 1 MO

KLOR-CON ORAL PACKET 20 MEQ Tier 2 MO

KLOR-CON ORAL TABLET EXTENDED RELEASE 8 MEQ

Tier 3 MO

KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE 10 MEQ, 8 MEQ

Tier 3 MO

K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ, 8 MEQ

Tier 3 MO

magnesium sulfate injection solution 50 %, 50 % (10ml syringe)

Tier 1 MO

NORMOSOL-M IN D5W INTRAVENOUS SOLUTION

Tier 3 BvD; MO

NORMOSOL-R IN D5W INTRAVENOUS SOLUTION

Tier 3 BvD; MO

NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION

Tier 4 BvD; MO

PLASMA-LYTE 148 INTRAVENOUS SOLUTION

Tier 3 BvD; MO

PLASMA-LYTE A INTRAVENOUS SOLUTION

Tier 3 BvD; MO

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

Tier 1 MO

potassium chloride er oral capsule extended release 10 meq, 8 meq

Tier 1 MO

potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq

Tier 1 MO



potassium chloride in dextrose intravenous solution 20-5 meq/l-%, 40-5 meq/l-%

Tier 2 BvD; MO

potassium chloride in nacl intravenous solution 20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-%

Tier 2 BvD; MO

potassium chloride intravenous solution 10 meq/100ml, 2 meq/ml (20 ml), 20 meq/100ml, 40 meq/100ml

Tier 2 BvD; MO

potassium chloride intravenous solution 2 meq/ml Tier 4 BvD; MO

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

Tier 2 MO

potassium citrate er oral tablet extended release 10 meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg)

Tier 2 MO

prenatal oral tablet 27-1 mg Tier 2 MO

sodium chloride injection solution 2.5 meq/ml Tier 2 MO

sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 %

Tier 2 BvD; MO

sodium fluoride oral tablet 2.2 (1 f) mg Tier 2 MO

sodium lactate intravenous solution 5 meq/ml Tier 2 BvD; MO

TPN ELECTROLYTES INTRAVENOUS SOLUTION

Tier 2 BvD; MO

ELECTROLYTE/MINERAL/METAL MODIFIERS

DEPEN TITRATABS ORAL TABLET 250 MG Tier 5 PA; MO

EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG

Tier 5 PA; LA

FERRIPROX ORAL SOLUTION 100 MG/ML Tier 5 PA; LA

FERRIPROX ORAL TABLET 500 MG Tier 5 PA; LA

JADENU ORAL TABLET 180 MG, 360 MG, 90 MG

Tier 5 PA; MO



JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, 90 MG

Tier 5 PA; MO

JYNARQUE ORAL TABLET THERAPY PACK 45 & 15 MG, 60 & 30 MG, 90 & 30 MG

Tier 5 PA; MO

KIONEX ORAL SUSPENSION 15 GM/60ML Tier 3 MO

SAMSCA ORAL TABLET 15 MG, 30 MG Tier 5 PA; MO

sodium polystyrene sulfonate oral powder Tier 2 MO

SPS ORAL SUSPENSION 15 GM/60ML Tier 3 MO

trientine hcl oral capsule 250 mg Tier 5 PA; MO

NUTRIENTS

AMINOSYN II INTRAVENOUS SOLUTION 10 %, 8.5 %

Tier 4 BvD; MO

AMINOSYN II/ELECTROLYTES INTRAVENOUS SOLUTION 8.5 %

Tier 3 BvD; MO

AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 7 %

Tier 4 BvD; MO

AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 8.5 %

Tier 3 BvD; MO

AMINOSYN-HBC INTRAVENOUS SOLUTION 7 %

Tier 4 BvD; MO

AMINOSYN-PF INTRAVENOUS SOLUTION 10 %, 7 %

Tier 4 BvD; MO

AMINOSYN-RF INTRAVENOUS SOLUTION 5.2 %

Tier 4 BvD; MO

CLINIMIX E/DEXTROSE (2.75/10) INTRAVENOUS SOLUTION 2.75 %

Tier 4 BvD; MO


Tier 4 BvD; MO




Tier 4 BvD; MO


Tier 4 BvD; MO


Tier 4 BvD; MO

CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 %

Tier 4 BvD; MO


Tier 4 BvD; MO


Tier 4 BvD; MO

CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 %

Tier 4 BvD; MO


Tier 4 BvD; MO


Tier 4 BvD; MO


Tier 4 BvD; MO


Tier 4 BvD; MO

CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 %

Tier 4 BvD; MO


Tier 4 BvD; MO


Tier 4 BvD; MO

CLINISOL SF INTRAVENOUS SOLUTION 15 %

Tier 4 BvD; MO

dextrose intravenous solution 10 %, 5 % Tier 2 BvD; MO



FREAMINE HBC INTRAVENOUS SOLUTION 6.9 %

Tier 4 BvD; MO

HEPATAMINE INTRAVENOUS SOLUTION 8 %

Tier 3 BvD; MO

INTRALIPID INTRAVENOUS EMULSION 20 %, 30 %

Tier 4 BvD; MO

NEPHRAMINE INTRAVENOUS SOLUTION 5.4 %

Tier 4 BvD; MO

nutrilipid intravenous emulsion 20 % Tier 4 BvD; MO

PLENAMINE INTRAVENOUS SOLUTION 15 %

Tier 4 BvD; MO

PREMASOL INTRAVENOUS SOLUTION 10 % Tier 4 BvD; MO

PREMASOL INTRAVENOUS SOLUTION 6 % Tier 3 BvD; MO

PROCALAMINE INTRAVENOUS SOLUTION 3 %

Tier 4 BvD; MO

PROSOL INTRAVENOUS SOLUTION 20 % Tier 3 BvD; MO

TRAVASOL INTRAVENOUS SOLUTION 10 % Tier 4 BvD; MO

TROPHAMINE INTRAVENOUS SOLUTION 10 %

Tier 4 BvD; MO

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

dicyclomine hcl oral capsule 10 mg Tier 1 MO

dicyclomine hcl oral solution 10 mg/5ml Tier 2 MO

dicyclomine hcl oral tablet 20 mg Tier 1 MO

glycopyrrolate oral tablet 1 mg Tier 1 MO

glycopyrrolate oral tablet 2 mg Tier 2 MO



GASTROINTESTINAL AGENTS, OTHER

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml

Tier 2 MO

diphenoxylate-atropine oral tablet 2.5-0.025 mg Tier 1 MO

loperamide hcl oral capsule 2 mg Tier 1 MO

metoclopramide hcl oral solution 5 mg/5ml Tier 1 MO

metoclopramide hcl oral tablet 10 mg, 5 mg Tier 1 MO

MOVANTIK ORAL TABLET 12.5 MG, 25 MG Tier 3 MO

MYTESI ORAL TABLET DELAYED RELEASE 125 MG

Tier 4 PA; MO

ursodiol oral capsule 300 mg Tier 2 MO

ursodiol oral tablet 250 mg, 500 mg Tier 2 MO

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine hcl oral solution 300 mg/5ml Tier 2 MO

cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg

Tier 2 MO

famotidine oral suspension reconstituted 40 mg/5ml

Tier 2 MO

famotidine oral tablet 20 mg, 40 mg Tier 1 MO

nizatidine oral capsule 150 mg, 300 mg Tier 1 MO

nizatidine oral solution 15 mg/ml Tier 3 MO

ranitidine hcl oral capsule 150 mg, 300 mg Tier 1 MO

ranitidine hcl oral syrup 75 mg/5ml Tier 2 MO

ranitidine hcl oral tablet 150 mg, 300 mg Tier 1 MO



IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl oral tablet 0.5 mg, 1 mg Tier 5 PA; MO

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG Tier 3 MO

GATTEX SUBCUTANEOUS KIT 5 MG Tier 5 PA; LA

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG

Tier 3 MO

LAXATIVES

CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM -GM/160ML

Tier 4 MO

constulose oral solution 10 gm/15ml Tier 1 MO

enulose oral solution 10 gm/15ml Tier 2 MO

GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM

Tier 2 MO

GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM

Tier 2 MO

GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM

Tier 2 MO

generlac oral solution 10 gm/15ml Tier 2 MO

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

Tier 3 MO

lactulose oral solution 10 gm/15ml Tier 1 MO

peg 3350/electrolytes oral solution reconstituted 240 gm

Tier 1 MO

peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm

Tier 2 MO

peg-3350/electrolytes oral solution reconstituted 236 gm

Tier 2 MO

polyethylene glycol 3350 oral powder Tier 1 MO



PREPOPIK ORAL PACKET 10-3.5-12 MG-GM-GM

Tier 3 MO

SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13-1.6 GM/180ML

Tier 2 MO

TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM

Tier 2 MO

PROTECTANTS

amoxicill-clarithro-lansopraz oral Tier 3 MO

CARAFATE ORAL SUSPENSION 1 GM/10ML Tier 4 MO

misoprostol oral tablet 100 mcg, 200 mcg Tier 1 MO

sucralfate oral tablet 1 gm Tier 1 MO

PROTON PUMP INHIBITORS

DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 MG


lansoprazole oral capsule delayed release 15 mg, 30 mg

Tier 2 MO

lansoprazole oral tablet dispersible 15 mg, 30 mg Tier 3 MO

omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg

Tier 2 MO

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg

Tier 2 MO



GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

ENZYME REPLACEMENT/ MODIFIERS

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

Tier 3 MO

CYSTADANE ORAL POWDER Tier 5 MO

ENDARI ORAL PACKET 5 GM Tier 5 PA; LA; QL (180 EA per 30 days)

KUVAN ORAL PACKET 100 MG, 500 MG Tier 5 PA; LA

KUVAN ORAL TABLET SOLUBLE 100 MG Tier 5 PA; LA

levocarnitine oral solution 1 gm/10ml Tier 2 MO

levocarnitine oral tablet 330 mg Tier 2 MO

miglustat oral capsule 100 mg Tier 5 PA; MO

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG

Tier 5 PA; LA

ORFADIN ORAL SUSPENSION 4 MG/ML Tier 5 PA; LA

RAVICTI ORAL LIQUID 1.1 GM/ML Tier 5 PA; LA

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 15000-51000 UNIT, 20000-63000 UNIT, 25000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 5000 UNIT, 5000-24000 UNIT

Tier 3 MO



GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

Tier 2 MO

darifenacin hydrobromide er oral tablet extended release 24 hour 15 mg, 7.5 mg

Tier 2 MO

flavoxate hcl oral tablet 100 mg Tier 2 MO

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 25 MG, 50 MG

Tier 3 MO

oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg

Tier 2 MO

oxybutynin chloride oral syrup 5 mg/5ml Tier 1 MO

oxybutynin chloride oral tablet 5 mg Tier 1 MO

tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg

Tier 2 MO

tolterodine tartrate oral tablet 1 mg, 2 mg Tier 2 MO

trospium chloride er oral capsule extended release 24 hour 60 mg

Tier 2 MO

trospium chloride oral tablet 20 mg Tier 2 MO

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl er oral tablet extended release 24 hour 10 mg

Tier 2 MO

dutasteride oral capsule 0.5 mg Tier 2 MO

dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg Tier 2 MO

finasteride oral tablet 5 mg Tier 1 MO

RAPAFLO ORAL CAPSULE 4 MG, 8 MG Tier 4 MO



tamsulosin hcl oral capsule 0.4 mg Tier 2 MO

GENITOURINARY AGENTS, OTHER

CYSTAGON ORAL CAPSULE 150 MG, 50 MG Tier 4 LA

ELMIRON ORAL CAPSULE 100 MG Tier 4 MO

LITHOSTAT ORAL TABLET 250 MG Tier 4 MO

sodium chloride irrigation solution 0.9 % Tier 1 MO

PHOSPHATE BINDERS

AURYXIA ORAL TABLET 1 GM 210 MG(FE) Tier 4 MO

calcium acetate (phos binder) oral capsule 667 mg Tier 2 MO

calcium acetate (phos binder) oral tablet 667 mg Tier 1 MO

sevelamer carbonate oral packet 0.8 gm, 2.4 gm Tier 5 MO

sevelamer carbonate oral tablet 800 mg Tier 4 MO

VAGINAL PRODUCTS

AVC VAGINAL VAGINAL CREAM 15 % Tier 2 MO

clindamycin phosphate vaginal cream 2 % Tier 2 MO

estradiol vaginal cream 0.1 mg/gm Tier 3 MO

estradiol vaginal tablet 10 mcg Tier 2 MO

INTRAROSA VAGINAL INSERT 6.5 MG Tier 3 PA; MO

metronidazole vaginal gel 0.75 % Tier 2 MO

miconazole 3 vaginal suppository 200 mg Tier 2 MO

PREMARIN VAGINAL CREAM 0.625 MG/GM Tier 3 MO

terconazole vaginal cream 0.4 %, 0.8 % Tier 2 MO

terconazole vaginal suppository 80 mg Tier 4 MO

VANDAZOLE VAGINAL GEL 0.75 % Tier 3 MO



YUVAFEM VAGINAL TABLET 10 MCG Tier 3 MO

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)

GLUCOCORTICOIDS/MINERALOCORTICOIDS

budesonide er oral tablet extended release 24 hour 9 mg

Tier 4 ST; MO

budesonide oral capsule delayed release particles 3 mg

Tier 5 MO

DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML

Tier 2 MO

dexamethasone oral elixir 0.5 mg/5ml Tier 2 MO

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg

Tier 1 MO

dexamethasone oral tablet 6 mg Tier 2 MO

fludrocortisone acetate oral tablet 0.1 mg Tier 1 MO

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg Tier 1 MO

MEDROL ORAL TABLET 2 MG Tier 3 MO

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

Tier 2 MO

methylprednisolone oral tablet therapy pack 4 mg Tier 2 MO

prednisolone oral solution 15 mg/5ml Tier 2 MO

prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml

Tier 4 MO

prednisolone sodium phosphate oral solution 25 mg/5ml, 6.7 (5 base) mg/5ml

Tier 2 MO

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML

Tier 2 MO

prednisone oral solution 5 mg/5ml Tier 2 MO



prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

Tier 1 MO

prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48)

Tier 1 MO

triamcinolone acetonide injection suspension 40 mg/ml

Tier 2 MO

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS)

ANABOLIC STEROIDS

ANADROL-50 ORAL TABLET 50 MG Tier 5 MO

oxandrolone oral tablet 10 mg Tier 5 PA; MO

oxandrolone oral tablet 2.5 mg Tier 3 PA; MO

ANDROGENS

ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%)

Tier 3 PA; MO

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)

Tier 3 PA; MO

danazol oral capsule 100 mg, 50 mg Tier 2 MO

danazol oral capsule 200 mg Tier 4 MO

methyltestosterone oral capsule 10 mg Tier 5 PA; MO

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

Tier 2 PA; MO

testosterone enanthate intramuscular solution 200 mg/ml

Tier 2 PA; MO

testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 50 mg/5gm (1%)

Tier 2 PA; MO



testosterone transdermal gel 25 mg/2.5gm (1%) Tier 3 PA; MO

testosterone transdermal solution 30 mg/act Tier 3 PA; MO

CONTRACEPTIVES

ALTAVERA ORAL TABLET 0.15-30 MG-MCG Tier 1 MO

alyacen 1/35 oral tablet 1-35 mg-mcg Tier 1 MO

AMETHIA LO ORAL TABLET 0.1-0.02 & 0.01 MG

Tier 2 MO

AMETHIA ORAL TABLET 0.15-0.03 &0.01 MG Tier 2 MO

APRI ORAL TABLET 0.15-30 MG-MCG Tier 1 MO

ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG

Tier 1 MO

AUBRA ORAL TABLET 0.1-20 MG-MCG Tier 1 MO

AVIANE ORAL TABLET 0.1-20 MG-MCG Tier 1 MO

BALZIVA ORAL TABLET 0.4-35 MG-MCG Tier 1 MO

BEKYREE ORAL TABLET 0.15-0.02/0.01 MG (21/5)

Tier 2 MO

BLISOVI 24 FE ORAL TABLET 1-20 MG-MCG(24)

Tier 2 MO

BLISOVI FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

Tier 1 MO

BLISOVI FE 1/20 ORAL TABLET 1-20 MG-MCG

Tier 1 MO

briellyn oral tablet 0.4-35 mg-mcg Tier 1 MO

CAMILA ORAL TABLET 0.35 MG Tier 1 MO

CAMRESE LO ORAL TABLET 0.1-0.02 & 0.01 MG

Tier 2 MO

CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG

Tier 1 MO



CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG

Tier 1 MO

CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG

Tier 1 MO

CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

Tier 1 MO

DEBLITANE ORAL TABLET 0.35 MG Tier 1 MO

DELYLA ORAL TABLET 0.1-20 MG-MCG Tier 1 MO

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)

Tier 2 MO

desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg

Tier 1 MO

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

Tier 2 MO

EMOQUETTE ORAL TABLET 0.15-30 MG-MCG

Tier 1 MO

ENPRESSE-28 ORAL TABLET Tier 1 MO

ENSKYCE ORAL TABLET 0.15-30 MG-MCG Tier 1 MO

ERRIN ORAL TABLET 0.35 MG Tier 1 MO

ESTARYLLA ORAL TABLET 0.25-35 MG-MCG

Tier 1 MO

ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg

Tier 1 MO

FALMINA ORAL TABLET 0.1-20 MG-MCG Tier 1 MO

FEMYNOR ORAL TABLET 0.25-35 MG-MCG Tier 1 MO

GIANVI ORAL TABLET 3-0.02 MG Tier 2 MO

INTROVALE ORAL TABLET 0.15-0.03 MG Tier 1 MO

ISIBLOOM ORAL TABLET 0.15-30 MG-MCG Tier 1 MO

JOLIVETTE ORAL TABLET 0.35 MG Tier 1 MO



JULEBER ORAL TABLET 0.15-30 MG-MCG Tier 1 MO

JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG Tier 1 MO

JUNEL 1/20 ORAL TABLET 1-20 MG-MCG Tier 1 MO

JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

Tier 1 MO

JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG Tier 1 MO

JUNEL FE 24 ORAL TABLET 1-20 MG-MCG(24)

Tier 2 MO

KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5)

Tier 2 MO

KELNOR 1/35 ORAL TABLET 1-35 MG-MCG Tier 1 MO

KELNOR 1/50 ORAL TABLET 1-50 MG-MCG Tier 1 MO

KIMIDESS ORAL TABLET 0.15-0.02/0.01 MG (21/5)

Tier 2 MO

KURVELO ORAL TABLET 0.15-30 MG-MCG Tier 1 MO

LARIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG Tier 1 MO

LARIN 1/20 ORAL TABLET 1-20 MG-MCG Tier 1 MO

LARIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

Tier 1 MO

LARIN FE 1/20 ORAL TABLET 1-20 MG-MCG Tier 1 MO

LARISSIA ORAL TABLET 0.1-20 MG-MCG Tier 1 MO

LEENA ORAL TABLET 0.5/1/0.5-35 MG-MCG Tier 1 MO

LESSINA ORAL TABLET 0.1-20 MG-MCG Tier 1 MO

LEVONEST ORAL TABLET Tier 1 MO

levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 &0.01 mg

Tier 2 MO

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg

Tier 1 MO



levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

Tier 1 MO

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

Tier 2 MO

levonorg-eth estrad triphasic oral tablet Tier 1 MO

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG

Tier 1 MO

LORYNA ORAL TABLET 3-0.02 MG Tier 2 MO

LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG

Tier 1 MO

LUTERA ORAL TABLET 0.1-20 MG-MCG Tier 1 MO

LYZA ORAL TABLET 0.35 MG Tier 1 MO

marlissa oral tablet 0.15-30 mg-mcg Tier 1 MO

medroxyprogesterone acetate intramuscular suspension 150 mg/ml

Tier 2 MO

medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 mg/ml

Tier 2 MO

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG

Tier 1 MO

MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG

Tier 1 MO

MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

Tier 1 MO

MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG

Tier 1 MO

MILI ORAL TABLET 0.25-35 MG-MCG Tier 1 MO

MONONESSA ORAL TABLET 0.25-35 MG-MCG

Tier 1 MO

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

Tier 1 MO



NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

Tier 1 MO

NIKKI ORAL TABLET 3-0.02 MG Tier 2 MO

NORA-BE ORAL TABLET 0.35 MG Tier 1 MO

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg(24)

Tier 2 MO

norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg

Tier 1 MO

norethindrone oral tablet 0.35 mg Tier 1 MO

norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg

Tier 2 MO

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

Tier 1 MO

norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg

Tier 1 MO

NORLYROC ORAL TABLET 0.35 MG Tier 2 MO

NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

Tier 1 MO

NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG

Tier 1 MO

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG

Tier 1 MO

NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

Tier 1 MO

OCELLA ORAL TABLET 3-0.03 MG Tier 2 MO

OGESTREL ORAL TABLET 0.5-50 MG-MCG Tier 1 MO

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG Tier 1 MO

PIMTREA ORAL TABLET 0.15-0.02/0.01 MG (21/5)

Tier 2 MO



PIRMELLA 1/35 ORAL TABLET 1-35 MG-MCG

Tier 1 MO

PORTIA-28 ORAL TABLET 0.15-30 MG-MCG Tier 1 MO

PREVIFEM ORAL TABLET 0.25-35 MG-MCG Tier 1 MO

QUASENSE ORAL TABLET 0.15-0.03 MG Tier 1 MO

RECLIPSEN ORAL TABLET 0.15-30 MG-MCG Tier 1 MO

SETLAKIN ORAL TABLET 0.15-0.03 MG Tier 1 MO

SHAROBEL ORAL TABLET 0.35 MG Tier 1 MO

SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG

Tier 1 MO

SRONYX ORAL TABLET 0.1-20 MG-MCG Tier 1 MO

SYEDA ORAL TABLET 3-0.03 MG Tier 2 MO

TARINA FE 1/20 ORAL TABLET 1-20 MG-MCG

Tier 1 MO

TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 MG-MCG

Tier 2 MO

TRI-LO-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-25 MCG

Tier 2 MO

TRI-MILI ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

Tier 1 MO

TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

Tier 1 MO

TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

Tier 1 MO

TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

Tier 1 MO

TRIVORA (28) ORAL TABLET Tier 1 MO

TRI-VYLIBRA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

Tier 1 MO



VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG

Tier 1 MO

VESTURA ORAL TABLET 3-0.02 MG Tier 2 MO

VIENVA ORAL TABLET 0.1-20 MG-MCG Tier 1 MO

VYFEMLA ORAL TABLET 0.4-35 MG-MCG Tier 1 MO

VYLIBRA ORAL TABLET 0.25-35 MG-MCG Tier 1 MO

WYMZYA FE ORAL TABLET CHEWABLE 0.4-35 MG-MCG

Tier 2 MO

ZARAH ORAL TABLET 3-0.03 MG Tier 2 MO

ZENCHENT ORAL TABLET 0.4-35 MG-MCG Tier 1 MO

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG

Tier 1 MO

ESTROGENS

AMABELZ ORAL TABLET 0.5-0.1 MG, 1-0.5 MG

Tier 4 MO

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY

Tier 4 MO

DIVIGEL TRANSDERMAL GEL 1 MG/GM Tier 3 MO

ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%)

Tier 3 MO

estradiol oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 MO

estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

Tier 1 MO

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

Tier 1 MO



estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

Tier 2 MO

estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg

Tier 2 MO

estropipate oral tablet 0.75 mg, 1.5 mg Tier 1 MO

EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY

Tier 3 MO

FYAVOLV ORAL TABLET 0.5-2.5 MG-MCG, 1-5 MG-MCG

Tier 1 MO

JINTELI ORAL TABLET 1-5 MG-MCG Tier 4 MO

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

Tier 3 MO

MIMVEY LO ORAL TABLET 0.5-0.1 MG Tier 4 MO

MIMVEY ORAL TABLET 1-0.5 MG Tier 4 MO

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

Tier 2 MO

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

Tier 3 MO

PREMPHASE ORAL TABLET 0.625-5 MG Tier 3 MO

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

Tier 3 MO

PROGESTINS

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

Tier 4 BvD; MO

medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg

Tier 1 MO

megestrol acetate oral suspension 625 mg/5ml Tier 4 MO

norethindrone acetate oral tablet 5 mg Tier 2 MO



progesterone micronized oral capsule 100 mg, 200 mg

Tier 1 MO

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

FARESTON ORAL TABLET 60 MG Tier 5 PA; MO; QL (30 EA per 30 days)

OSPHENA ORAL TABLET 60 MG Tier 3 PA; MO

raloxifene hcl oral tablet 60 mg Tier 2 MO

HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY)

cabergoline oral tablet 0.5 mg Tier 2 MO

desmopressin ace spray refrig nasal solution 0.01 %

Tier 2 MO

desmopressin acetate oral tablet 0.1 mg, 0.2 mg Tier 2 MO

INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML

Tier 5 PA; LA

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

Tier 5 PA; MO

HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID)

LEVO-T ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 1 MO



levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

Tier 1 MO

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 3 MO

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg

Tier 1 MO

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 2 MO

THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG), 60 MG

Tier 2 MO

THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG), 30 MG

Tier 2 MO

THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG (MCG), 15 MG

Tier 2 MO

THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG), 120 MG

Tier 2 MO

THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG), 180 MG

Tier 2 MO

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 3 MO

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

KORLYM ORAL TABLET 300 MG Tier 5 PA; LA; QL (120 EA per 30 days)



octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml

Tier 2 PA; MO

octreotide acetate injection solution 1000 mcg/ml, 500 mcg/ml

Tier 5 PA; MO

octreotide acetate injection solution 200 mcg/ml Tier 4 PA; MO

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML

Tier 5 PA; LA; QL (60 ML per 30 days)

SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML

Tier 5 PA; MO

SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG

Tier 5 PA; LA

SYNAREL NASAL SOLUTION 2 MG/ML Tier 5 PA; MO

HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole oral tablet 10 mg, 5 mg Tier 1 MO

propylthiouracil oral tablet 50 mg Tier 1 MO

IMMUNOLOGICAL AGENTS

IMMUNE SUPPRESSANTS

ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG

Tier 4 BvD; MO

ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 5 MG

Tier 5 BvD; MO

AZASAN ORAL TABLET 100 MG, 75 MG Tier 4 BvD; MO

azathioprine oral tablet 50 mg Tier 2 BvD; MO



BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML

Tier 5 PA; MO

BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML

Tier 5 PA; MO

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

Tier 2 BvD; MO

cyclosporine modified oral solution 100 mg/ml Tier 2 BvD; MO

cyclosporine oral capsule 100 mg Tier 4 BvD; MO

cyclosporine oral capsule 25 mg Tier 2 BvD; MO

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.75 MG, 1 MG, 4 MG

Tier 4 BvD; MO

GENGRAF ORAL CAPSULE 100 MG, 25 MG Tier 3 BvD; MO

GENGRAF ORAL SOLUTION 100 MG/ML Tier 3 BvD; MO

methotrexate oral tablet 2.5 mg Tier 1 BvD; MO

mycophenolate mofetil oral capsule 250 mg Tier 3 BvD; MO

mycophenolate mofetil oral suspension reconstituted 200 mg/ml

Tier 5 BvD; MO

mycophenolate mofetil oral tablet 500 mg Tier 3 BvD; MO

mycophenolate sodium oral tablet delayed release 180 mg

Tier 2 BvD; MO

mycophenolate sodium oral tablet delayed release 360 mg

Tier 4 BvD; MO

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 20 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML

Tier 4 PA; MO

RAPAMUNE ORAL SOLUTION 1 MG/ML Tier 5 BvD; MO



RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML

Tier 4 PA; MO

SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG

Tier 4 BvD; MO

SANDIMMUNE ORAL SOLUTION 100 MG/ML Tier 4 BvD; MO

sirolimus oral tablet 0.5 mg Tier 2 BvD; MO

sirolimus oral tablet 1 mg Tier 4 BvD; MO

sirolimus oral tablet 2 mg Tier 5 BvD; MO

tacrolimus oral capsule 0.5 mg Tier 2 BvD; MO

tacrolimus oral capsule 1 mg, 5 mg Tier 4 BvD; MO

TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG

Tier 4 BvD; MO

XATMEP ORAL SOLUTION 2.5 MG/ML Tier 5 BvD; MO

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG

Tier 5 PA; MO

IMMUNIZING AGENTS, PASSIVE

CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 6 GM

Tier 5 PA; MO

FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML

Tier 5 PA; MO

GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

Tier 5 PA; MO



GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM

Tier 5 PA; MO

GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML

Tier 5 PA; MO

GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML

Tier 5 PA; MO

GAMUNEX-C INJECTION SOLUTION 1 GM/10ML

Tier 5 PA; MO

VARIZIG INTRAMUSCULAR SOLUTION 125 UNIT/1.2ML

Tier 3 PA; MO

IMMUNOMODULATORS

ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML

Tier 5 PA; MO

ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG

Tier 5 PA; LA

COSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML

Tier 5 PA; MO

COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

Tier 5 PA; MO

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML

Tier 5 PA; MO

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG

Tier 5 PA; MO

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML

Tier 5 PA; MO



HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 40 MG/0.8ML (6 PACK), 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

Tier 5 PA; MO

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML

Tier 5 PA; MO

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

Tier 5 PA; MO

HUMIRA PEN-PS/UV STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

Tier 5 PA; MO

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML

Tier 5 PA; MO

leflunomide oral tablet 10 mg, 20 mg Tier 2 MO

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML, 50 MG/0.5ML

Tier 5 PA; MO

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML

Tier 5 PA; MO

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML

Tier 5 PA; MO

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML, 90 MG/ML

Tier 5 PA; MO

XELJANZ ORAL TABLET 10 MG, 5 MG Tier 5 PA; MO

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG

Tier 5 PA; MO



VACCINES

ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED

Tier 3 MO

ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 (PREFILLED SYRINGE), 5-2-15.5 LF-MCG/0.5

Tier 3 MO

bcg vaccine injection injectable Tier 3 BvD; MO

BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

Tier 3 MO

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 , 5-2.5-18.5 (0.5ML SYRINGE)

Tier 3 MO

DAPTACEL INTRAMUSCULAR SUSPENSION 15-23-5 LF-MCG/0.5

Tier 3 MO

diphtheria-tetanus toxoids dt intramuscular suspension 25-5 lfu/0.5ml

Tier 2 BvD; MO

ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML

Tier 3 BvD; MO

GARDASIL 9 INTRAMUSCULAR SUSPENSION

Tier 3 MO

GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

Tier 3 MO

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 1440 EL U/ML 1 ML, 720 EL U/0.5ML, 720 EL U/0.5ML 0.5 ML

Tier 3 MO

HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG

Tier 3 MO

IMOVAX RABIES INTRAMUSCULAR INJECTABLE 2.5 UNIT/ML

Tier 3 BvD; MO

INFANRIX INTRAMUSCULAR SUSPENSION 25-58-10

Tier 3 MO



IPOL INJECTION INJECTABLE Tier 3 MO

IXIARO INTRAMUSCULAR SUSPENSION Tier 3 MO

KINRIX INTRAMUSCULAR SUSPENSION , INJECTION 0.5 ML

Tier 3 MO

MENACTRA INTRAMUSCULAR INJECTABLE

Tier 3 MO

MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED

Tier 3 MO

M-M-R II SUBCUTANEOUS INJECTABLE Tier 3 MO

PEDIARIX INTRAMUSCULAR SUSPENSION Tier 3 MO

PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML

Tier 3 MO

PROQUAD SUBCUTANEOUS INJECTABLE Tier 3 MO

QUADRACEL INTRAMUSCULAR SUSPENSION

Tier 3 MO

RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED

Tier 3 BvD; MO

RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 10 MCG/ML (1ML SYRINGE), 40 MCG/ML, 5 MCG/0.5ML

Tier 3 BvD; MO

ROTARIX ORAL SUSPENSION RECONSTITUTED

Tier 3 MO

ROTATEQ ORAL SOLUTION Tier 3 MO

SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG

Tier 3 BvD; MO

TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU

Tier 3 BvD; MO

tetanus-diphtheria toxoids td intramuscular suspension 2-2 lf/0.5ml

Tier 2 BvD; MO



TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

Tier 3 MO

TWINRIX INTRAMUSCULAR SUSPENSION 720-20

Tier 3 BvD; MO

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML, 25 MCG/0.5ML (0.5ML SYRINGE)

Tier 3 MO

VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 25 UNIT/0.5ML 0.5 ML, 50 UNIT/ML, 50 UNIT/ML 1 ML

Tier 3 MO

VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML

Tier 3 MO

YF-VAX SUBCUTANEOUS INJECTABLE Tier 3 MO

ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED 19400 UNT/0.65ML

Tier 3 MO

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM

Tier 3 MO

balsalazide disodium oral capsule 750 mg Tier 2 MO

LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM

Tier 3 MO

mesalamine oral tablet delayed release 800 mg Tier 3 MO

mesalamine rectal enema 4 gm Tier 2 MO

sulfasalazine oral tablet 500 mg Tier 1 MO

sulfasalazine oral tablet delayed release 500 mg Tier 1 MO



METABOLIC BONE DISEASE AGENTS

METABOLIC BONE DISEASE AGENTS

alendronate sodium oral solution 70 mg/75ml Tier 1 MO

alendronate sodium oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg

Tier 1 MO

calcitonin (salmon) nasal solution 200 unit/act Tier 2 BvD; MO

calcitriol oral capsule 0.25 mcg, 0.5 mcg Tier 1 BvD; MO

calcitriol oral solution 1 mcg/ml Tier 2 BvD; MO

FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML


FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70-5600 MG-UNIT

Tier 3 MO

ibandronate sodium oral tablet 150 mg Tier 2 MO

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 MCG, 50 MCG, 75 MCG

Tier 5 PA; LA

paricalcitol oral capsule 1 mcg, 4 mcg Tier 3 BvD; MO

paricalcitol oral capsule 2 mcg Tier 4 BvD; MO

PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML

Tier 4 ST; MO

risedronate sodium oral tablet 150 mg, 35 mg, 35 mg (12 pack), 35 mg (4 pack), 5 mg

Tier 2 MO

risedronate sodium oral tablet 30 mg Tier 4 MO

risedronate sodium oral tablet delayed release 35 mg

Tier 2 MO

SENSIPAR ORAL TABLET 30 MG Tier 3 BvD; MO; QL (120 EA per 30 days)





TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 MCG/1.56ML

Tier 5 PA; MO

XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML


MISCELLANEOUS

MISCELLANEOUS

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML

Tier 4 MO

COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 1 ML

Tier 4 MO

cvs gauze sterile pad 2"x2" Tier 4 MO

EXEL COMFORT POINT PEN NEEDLE 29G X 12MM

Tier 4 MO

global alcohol prep ease pad 70 % Tier 2 MO

preferred plus insulin syringe 28g x 1/2" 0.5 ml Tier 4 MO

RELI-ON INSULIN SYRINGE 29G 0.3 ML Tier 4 MO

OPHTHALMIC AGENTS

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

bimatoprost ophthalmic solution 0.03 % Tier 2 MO; QL (5 ML per 25 days)

latanoprost ophthalmic solution 0.005 % Tier 1 MO; QL (2.5 ML per 20 days)

LUMIGAN OPHTHALMIC SOLUTION 0.01 % Tier 3 MO; QL (2.5 ML per 20 days)

TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %

Tier 3 MO; QL (2.5 ML per 20 days)



OPHTHALMIC AGENTS, OTHER

atropine sulfate ophthalmic solution 1 % Tier 1 MO

CYSTARAN OPHTHALMIC SOLUTION 0.44 %


ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 %

Tier 1 MO

proparacaine hcl ophthalmic solution 0.5 % Tier 1 MO

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 %

Tier 3 MO; QL (5.5 ML per 20 days)

RESTASIS OPHTHALMIC EMULSION 0.05 % Tier 3 MO; QL (60 EA per 30 days)

OPHTHALMIC ANTI INFECTIVES

bacitracin ophthalmic ointment 500 unit/gm Tier 2 MO

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

Tier 1 MO

BESIVANCE OPHTHALMIC SUSPENSION 0.6 %

Tier 4 MO

ciprofloxacin hcl ophthalmic solution 0.3 % Tier 1 MO

erythromycin ophthalmic ointment 5 mg/gm Tier 1 MO

gatifloxacin ophthalmic solution 0.5 % Tier 2 MO

GENTAK OPHTHALMIC OINTMENT 0.3 % Tier 2 MO

gentamicin sulfate ophthalmic solution 0.3 % Tier 1 MO

levofloxacin ophthalmic solution 0.5 % Tier 1 MO

MOXEZA OPHTHALMIC SOLUTION 0.5 % Tier 3 MO

moxifloxacin hcl ophthalmic solution 0.5 % Tier 2 MO

NATACYN OPHTHALMIC SUSPENSION 5 % Tier 4 MO

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

Tier 2 MO



neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

Tier 2 MO

ofloxacin ophthalmic solution 0.3 % Tier 1 MO

polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-%

Tier 1 MO

sulfacetamide sodium ophthalmic solution 10 % Tier 1 MO

tobramycin ophthalmic solution 0.3 % Tier 1 MO

trifluridine ophthalmic solution 1 % Tier 2 MO

OPHTHALMIC ANTI-ALLERGY AGENTS

azelastine hcl ophthalmic solution 0.05 % Tier 2 MO

BEPREVE OPHTHALMIC SOLUTION 1.5 % Tier 4 MO

cromolyn sodium ophthalmic solution 4 % Tier 1 MO

epinastine hcl ophthalmic solution 0.05 % Tier 2 MO

olopatadine hcl ophthalmic solution 0.1 %, 0.2 % Tier 2 MO

PAZEO OPHTHALMIC SOLUTION 0.7 % Tier 4 MO

OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

Tier 3 MO

apraclonidine hcl ophthalmic solution 0.5 % Tier 1 MO

AZOPT OPHTHALMIC SUSPENSION 1 % Tier 3 MO

betaxolol hcl ophthalmic solution 0.5 % Tier 1 MO

brimonidine tartrate ophthalmic solution 0.15 %, 0.2 %

Tier 2 MO

carteolol hcl ophthalmic solution 1 % Tier 1 MO

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 %




dorzolamide hcl ophthalmic solution 2 % Tier 1 MO

dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml

Tier 1 MO

levobunolol hcl ophthalmic solution 0.5 % Tier 1 MO

metipranolol ophthalmic solution 0.3 % Tier 2 MO

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %

Tier 3 MO

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % Tier 1 MO

SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 %

Tier 4 MO

timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 %

Tier 1 MO

timolol maleate ophthalmic solution 0.25 %, 0.5 % Tier 1 MO

timolol maleate ophthalmic solution 0.5 % (daily) Tier 2 MO

OPHTHALMIC ANTI-INFLAMMATORIES

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

Tier 2 MO

BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 %

Tier 3 MO

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 %

Tier 4 MO

dexamethasone sodium phosphate ophthalmic solution 0.1 %

Tier 2 MO

diclofenac sodium ophthalmic solution 0.1 % Tier 1 MO

DUREZOL OPHTHALMIC EMULSION 0.05 % Tier 3 MO

fluorometholone ophthalmic suspension 0.1 % Tier 1 MO

flurbiprofen sodium ophthalmic solution 0.03 % Tier 1 MO

ILEVRO OPHTHALMIC SUSPENSION 0.3 % Tier 3 MO



ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 %

Tier 2 MO

LOTEMAX OPHTHALMIC GEL 0.5 % Tier 4 MO

LOTEMAX OPHTHALMIC OINTMENT 0.5 % Tier 4 MO

LOTEMAX OPHTHALMIC SUSPENSION 0.5 %

Tier 4 MO

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1

Tier 1 MO

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

Tier 1 MO

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

Tier 2 MO

PRED-G OPHTHALMIC SUSPENSION 0.3-1 % Tier 4 MO

PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 %

Tier 4 MO

prednisolone acetate ophthalmic suspension 1 % Tier 2 MO

prednisolone sodium phosphate ophthalmic solution 1 %

Tier 1 MO

PROLENSA OPHTHALMIC SOLUTION 0.07 % Tier 4 MO

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

Tier 2 MO

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %

Tier 2 MO

ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % Tier 4 MO

OTIC AGENTS

OTIC AGENTS

acetic acid otic solution 2 % Tier 1 MO



CIPRODEX OTIC SUSPENSION 0.3-0.1 % Tier 3 MO

ciprofloxacin hcl otic solution 0.2 % Tier 2 MO

fluocinolone acetonide otic oil 0.01 % Tier 2 MO

hydrocortisone-acetic acid otic solution 1-2 % Tier 2 MO

neomycin-polymyxin-hc otic solution 1 % Tier 2 MO

neomycin-polymyxin-hc otic suspension 3.5-10000-1

Tier 2 MO

ofloxacin otic solution 0.3 % Tier 4 MO

RESPIRATORY TRACT AGENTS

ANTIHISTAMINES

carbinoxamine maleate oral solution 4 mg/5ml Tier 1 MO

carbinoxamine maleate oral tablet 4 mg Tier 1 MO

cetirizine hcl oral solution 1 mg/ml Tier 1 MO

clemastine fumarate oral tablet 2.68 mg Tier 1 MO

cyproheptadine hcl oral syrup 2 mg/5ml Tier 1 MO

cyproheptadine hcl oral tablet 4 mg Tier 1 MO

desloratadine oral tablet 5 mg Tier 2 MO

levocetirizine dihydrochloride oral solution 2.5 mg/5ml

Tier 1 MO

levocetirizine dihydrochloride oral tablet 5 mg Tier 1 MO

PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG

Tier 2 MO

promethazine hcl oral syrup 6.25 mg/5ml Tier 1 MO

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

Tier 1 MO



promethazine hcl rectal suppository 12.5 mg, 25 mg

Tier 2 MO

promethazine hcl rectal suppository 50 mg Tier 4 MO

promethazine vc plain oral solution 6.25-5 mg/5ml Tier 2 MO

PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG

Tier 2 MO

PROMETHEGAN RECTAL SUPPOSITORY 50 MG

Tier 4 MO

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT

Tier 3 MO

ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH

Tier 3 MO

ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH

Tier 3 MO

ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH

Tier 3 MO

ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT

Tier 3 MO

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml

Tier 4 BvD; MO

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST

Tier 3 MO

FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT

Tier 3 MO



ANTILEUKOTRIENES

montelukast sodium oral packet 4 mg Tier 2 MO

montelukast sodium oral tablet 10 mg Tier 2 MO

montelukast sodium oral tablet chewable 4 mg, 5 mg

Tier 2 MO

zafirlukast oral tablet 10 mg, 20 mg Tier 2 MO

BRONCHODILATORS, ANTICHOLINERGIC

acetylcysteine inhalation solution 20 % Tier 2 BvD; MO

ipratropium bromide inhalation solution 0.02 % Tier 2 BvD; MO

SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG

Tier 3 MO

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT

Tier 3 MO

BRONCHODILATORS, PHOSPHODIESTERASE INHIBITORS (XANTHINES)

theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg

Tier 1 MO

theophylline er oral tablet extended release 24 hour 400 mg, 600 mg

Tier 2 MO

theophylline oral solution 80 mg/15ml Tier 2 MO

BRONCHODILATORS, SYMPATHOMIMETIC

ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

Tier 3 MO



ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT

Tier 3 MO

albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 mg

Tier 2 MO

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml

Tier 2 BvD; MO

albuterol sulfate oral syrup 2 mg/5ml Tier 1 MO

albuterol sulfate oral tablet 2 mg, 4 mg Tier 2 MO

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH

Tier 3 MO

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT

Tier 4 MO

fluticasone-salmeterol inhalation aerosol powder breath activated 113-14 mcg/act, 232-14 mcg/act, 55-14 mcg/act

Tier 2 MO

ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml

Tier 2 BvD; MO

levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml

Tier 2 BvD; MO

levalbuterol tartrate inhalation aerosol 45 mcg/act Tier 1 MO; QL (30 GM per 30 days)

metaproterenol sulfate oral syrup 10 mg/5ml Tier 1 MO

metaproterenol sulfate oral tablet 10 mg, 20 mg Tier 4 MO

PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

Tier 3 MO; QL (17 GM per 30 days)

PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT




SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE

Tier 3 MO

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT

Tier 3 MO

terbutaline sulfate oral tablet 2.5 mg, 5 mg Tier 2 MO

MAST CELL STABILIZERS

cromolyn sodium inhalation nebulization solution 20 mg/2ml

Tier 2 BvD; MO

cromolyn sodium oral concentrate 100 mg/5ml Tier 2 MO

NASAL AGENTS

azelastine hcl nasal solution 0.1 %, 0.15 % Tier 2 MO

flunisolide nasal solution 25 mcg/act (0.025%) Tier 1 MO

fluticasone propionate nasal suspension 50 mcg/act

Tier 1 MO

ipratropium bromide nasal solution 0.03 %, 0.06 %

Tier 1 MO

triamcinolone acetonide nasal aerosol 55 mcg/act Tier 2 MO

PULMONARY ANTIHYPERTENSIVES

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG


LETAIRIS ORAL TABLET 10 MG, 5 MG Tier 5 PA; LA; QL (30 EA per 30 days)

OPSUMIT ORAL TABLET 10 MG Tier 5 PA; LA; QL (30 EA per 30 days)

sildenafil citrate oral tablet 20 mg Tier 2 PA; MO; QL (90 EA per 30 days)

TRACLEER ORAL TABLET 125 MG, 62.5 MG Tier 5 PA; LA; QL (60 EA per 30 days)

TRACLEER ORAL TABLET SOLUBLE 32 MG Tier 5 PA; LA; QL (120 EA per 30 days)



UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

Tier 5 PA; LA

UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG

Tier 5 PA; LA

PULMONARY FIBROSIS AGENTS

ESBRIET ORAL CAPSULE 267 MG Tier 5 PA; MO

ESBRIET ORAL TABLET 267 MG, 801 MG Tier 5 PA; MO

OFEV ORAL CAPSULE 100 MG, 150 MG Tier 5 PA; LA

SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 MG

Tier 5 PA; LA

RESPIRATORY TRACT AGENTS, OTHER

DALIRESP ORAL TABLET 250 MCG, 500 MCG


KALYDECO ORAL PACKET 50 MG, 75 MG Tier 5 PA; LA

KALYDECO ORAL TABLET 150 MG Tier 5 PA; LA

NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 100 MG

Tier 5 PA; MO

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG

Tier 5 PA; LA

PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

Tier 5 PA; LA

PULMOZYME INHALATION SOLUTION 1 MG/ML

Tier 5 PA; MO

XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG




SKELETAL MUSCLE RELAXANTS

SKELETAL MUSCLE RELAXANTS

baclofen oral tablet 10 mg, 20 mg, 5 mg Tier 2 MO

carisoprodol oral tablet 350 mg Tier 1 MO

chlorzoxazone oral tablet 500 mg Tier 1 MO

cyclobenzaprine hcl oral tablet 10 mg, 5 mg Tier 2 MO

metaxalone oral tablet 400 mg, 800 mg Tier 4 MO

methocarbamol oral tablet 500 mg, 750 mg Tier 2 MO

orphenadrine citrate er oral tablet extended release 12 hour 100 mg

Tier 2 MO

tizanidine hcl oral tablet 2 mg, 4 mg Tier 2 MO

SLEEP DISORDER AGENTS

BARBITURATES

BUTISOL SODIUM ORAL TABLET 30 MG Tier 4 MO

phenobarbital oral elixir 20 mg/5ml Tier 1 MO

BENZODIAZEPINES

estazolam oral tablet 1 mg, 2 mg Tier 1 MO

flurazepam hcl oral capsule 15 mg Tier 1 MO; QL (60 EA per 30 days)

flurazepam hcl oral capsule 30 mg Tier 1 MO; QL (30 EA per 30 days)

temazepam oral capsule 15 mg, 30 mg Tier 1 MO; QL (30 EA per 30 days)

temazepam oral capsule 22.5 mg Tier 2 MO; QL (30 EA per 30 days)

temazepam oral capsule 7.5 mg Tier 2 MO; QL (120 EA per 30 days)



triazolam oral tablet 0.125 mg, 0.25 mg Tier 2 MO

GABA RECEPTOR MODULATORS

zaleplon oral capsule 10 mg Tier 1 MO

zaleplon oral capsule 5 mg Tier 1 MO; QL (30 EA per 30 days)

zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 mg


zolpidem tartrate oral tablet 10 mg, 5 mg Tier 2 MO; QL (30 EA per 30 days)

zolpidem tartrate sublingual tablet sublingual 1.75 mg, 3.5 mg

Tier 2 MO

SLEEP DISORDERS, OTHER

armodafinil oral tablet 150 mg, 200 mg, 250 mg Tier 4 PA; MO; QL (30 EA per 30 days)

armodafinil oral tablet 50 mg Tier 2 PA; MO; QL (30 EA per 30 days)

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG


modafinil oral tablet 100 mg, 200 mg Tier 3 PA; MO; QL (30 EA per 30 days)

SILENOR ORAL TABLET 3 MG, 6 MG Tier 4 MO

XYREM ORAL SOLUTION 500 MG/ML Tier 5 PA; LA; QL (540 ML per 30 days)

131

Índice de medicamentos

A abacavir sulfate .................... 53 abacavir sulfate-lamivudine . 53 abacavir-lamivudine-

zidovudine ....................... 54 ABELCET ........................... 32 ABILIFY MAINTENA ....... 48 acamprosate calcium ........... 11 acarbose ............................... 58 acebutolol hcl ....................... 68 acetaminophen-codeine ......... 9 acetaminophen-codeine #3 .... 8 acetazolamide ...................... 72 acetazolamide er .................. 72 acetic acid .......................... 122 acetylcysteine .................... 125 acitretin ................................ 79 ACTEMRA ........................ 112 ACTHIB ............................ 114 ACTIMMUNE .................... 38 acyclovir ........................ 52, 79 acyclovir sodium ................. 52 ADACEL ........................... 114 adapalene ............................. 79 adefovir dipivoxil ................ 51 ADEMPAS ........................ 127 ADVAIR DISKUS ............ 125 ADVAIR HFA ................... 126 AFEDITAB CR ................... 70 AFINITOR .......................... 38 AFINITOR DISPERZ ......... 38 ALBENZA .......................... 44 albuterol sulfate ................. 126 albuterol sulfate er ............. 126 alclometasone dipropionate . 79 ALECENSA ........................ 38 alendronate sodium ............ 117 alfuzosin hcl er .................... 95 ALINIA ......................... 44, 45 allopurinol ...................... 33, 44 alosetron hcl ......................... 92 ALPHAGAN P .................. 120 alprazolam ........................... 57 alprazolam er ....................... 57

ALPRAZOLAM INTENSOL .......................................... 57

ALTAVERA ........................ 99 ALUNBRIG ......................... 38 alyacen 1/35 ......................... 99 AMABELZ ........................ 105 amantadine hcl ..................... 45 AMBISOME ........................ 32 amcinonide ........................... 79 AMETHIA ........................... 99 AMETHIA LO ..................... 99 amikacin sulfate ................... 12 amiloride hcl......................... 72 amiloride-hydrochlorothiazide

.......................................... 66 AMINOSYN II .................... 88 AMINOSYN

II/ELECTROLYTES........ 88 AMINOSYN/ELECTROLYT

ES ..................................... 88 AMINOSYN-HBC ............... 88 AMINOSYN-PF .................. 88 AMINOSYN-RF .................. 88 amiodarone hcl ..................... 66 AMITIZA ............................. 92 amitriptyline hcl ................... 30 amlodipine besy-benazepril hcl

.......................................... 66 amlodipine besylate .............. 70 amlodipine besylate-valsartan

.......................................... 67 amlodipine-atorvastatin ........ 71 amlodipine-olmesartan ......... 67 amlodipine-valsartan-hctz .... 67 ammonium lactate ................ 79 AMNESTEEM ..................... 79 amoxapine ............................ 30 amoxicill-clarithro-lansopraz

.......................................... 93 amoxicillin ........................... 17 amoxicillin-pot clavulanate .. 17 amphetamine-

dextroamphetamine .......... 76 amphotericin b ...................... 32 ampicillin ............................. 17

ampicillin sodium ................ 17 ampicillin-sulbactam sodium

......................................... 17 AMPYRA ............................ 77 ANADROL-50 .................... 98 anagrelide hcl ....................... 64 anastrozole ........................... 44 ANDROGEL ....................... 98 ANDROGEL PUMP ........... 98 APOKYN ............................. 46 apraclonidine hcl ................ 120 aprepitant ............................. 31 APRI .................................... 99 APRISO ............................. 116 APTIOM .............................. 25 APTIVUS ............................ 55 ARANELLE ........................ 99 ARCALYST ...................... 112 aripiprazole .......................... 48 armodafinil ......................... 130 ARNUITY ELLIPTA ........ 124 ASMANEX 120 METERED

DOSES ........................... 124 ASMANEX 30 METERED

DOSES ........................... 124 ASMANEX 60 METERED

DOSES ........................... 124 ASMANEX HFA............... 124 aspirin-dipyridamole er ........ 64 ASSURE ID INSULIN

SAFETY SYR ............... 118 ASTAGRAF XL ................ 109 atazanavir sulfate ................. 55 atenolol ................................ 69 atenolol-chlorthalidone ........ 67 atomoxetine hcl .................... 76 atorvastatin calcium ............. 73 atovaquone ........................... 45 atovaquone-proguanil hcl .... 45 ATRIPLA ............................ 53 atropine sulfate ................... 119 AUBAGIO ........................... 77 AUBRA ............................... 99 AURYXIA ........................... 96 AUSTEDO ........................... 77

. 132

AVANDIA .......................... 58 AVC VAGINAL ................. 96 AVIANE .............................. 99 AVONEX ............................ 77 AVONEX PEN .................... 77 AVONEX PREFILLED ...... 77 AZACTAM ......................... 16 AZASAN ........................... 109 azathioprine ....................... 109 azelastine hcl ............. 120, 127 azithromycin ........................ 19 AZOPT .............................. 120 aztreonam ............................ 16 B bacitracin ........................... 119 bacitracin-polymyxin b ...... 119 bacitra-neomycin-polymyxin-

hc ................................... 121 baclofen ............................. 129 BACTOCILL IN DEXTROSE

......................................... 17 balsalazide disodium ......... 116 BALZIVA ............................ 99 BANZEL ............................. 25 BARACLUDE ..................... 51 bcg vaccine ........................ 114 BEKYREE ........................... 99 BELSOMRA ..................... 130 benazepril hcl ....................... 65 benazepril-hydrochlorothiazide

......................................... 67 BENLYSTA ...................... 110 benznidazole ........................ 44 benzoyl peroxide-

erythromycin .................... 79 benztropine mesylate ........... 45 BEPREVE ......................... 120 BESIVANCE ..................... 119 betamethasone dipropionate 80 betamethasone dipropionate

aug ................................... 79 betamethasone valerate ........ 80 BETASERON ...................... 77 betaxolol hcl ................ 69, 120 bethanechol chloride ............ 95

BETHKIS ............................. 12 bexarotene ............................ 38 BEXSERO ......................... 114 bicalutamide ......................... 38 BICILLIN C-R ..................... 18 BICILLIN C-R 900/300 ....... 18 BICILLIN L-A ..................... 18 BIDIL ................................... 71 BIKTARVY ......................... 54 bimatoprost ......................... 118 bisoprolol fumarate .............. 69 bisoprolol-hydrochlorothiazide

.......................................... 67 BLEPHAMIDE .................. 121 BLEPHAMIDE S.O.P. ....... 121 BLISOVI 24 FE ................... 99 BLISOVI FE 1.5/30 ............. 99 BLISOVI FE 1/20 ................ 99 BOOSTRIX ........................ 114 BOSULIF ....................... 38, 39 BREO ELLIPTA ................ 126 briellyn ................................. 99 BRILINTA ........................... 64 brimonidine tartrate ............ 120 BRIVIACT ........................... 21 bromocriptine mesylate ........ 46 budesonide ................... 97, 124 budesonide er ....................... 97 bumetanide ........................... 72 BUPAP ................................. 34 buprenorphine ........................ 8 buprenorphine hcl................... 9 buprenorphine hcl-naloxone

hcl ..................................... 11 bupropion hcl ....................... 27 bupropion hcl er (smoking det)

.......................................... 12 bupropion hcl er (sr) ............. 27 bupropion hcl er (xl)............. 27 buspirone hcl ........................ 57 butalbital-acetaminophen ..... 34 butalbital-apap-caff-cod ......... 9 butalbital-apap-caffeine........ 34 butalbital-asa-caff-codeine ..... 9 BUTISOL SODIUM .......... 129

butorphanol tartrate .............. 11 BYSTOLIC .......................... 69 C cabergoline ......................... 107 CABOMETYX .................... 39 calcipotriene ......................... 80 calcitonin (salmon) ............ 117 calcitriol ....................... 80, 117 calcium acetate (phos binder)

......................................... 96 CALQUENCE ..................... 39 CAMILA .............................. 99 CAMRESE LO .................... 99 candesartan cilexetil ............. 65 candesartan cilexetil-hctz ..... 67 CAPRELSA ......................... 39 captopril ............................... 65 captopril-hydrochlorothiazide

......................................... 67 CARAFATE ........................ 93 CARBAGLU ....................... 85 carbamazepine ..................... 25 carbamazepine er ................. 25 carbidopa-levodopa .............. 46 carbidopa-levodopa er ......... 46 carbidopa-levodopa-

entacapone ................. 46, 47 carbinoxamine maleate ...... 123 CARIMUNE NF ................ 111 carisoprodol ....................... 129 CAROSPIR .......................... 72 carteolol hcl ....................... 120 CARTIA XT ........................ 70 carvedilol ............................. 69 caspofungin acetate .............. 32 CAYSTON .......................... 16 CAZIANT ............................ 99 cefaclor .......................... 14, 15 cefadroxil ............................. 15 cefazolin sodium .................. 15 cefdinir ................................. 15 cefepime hcl ......................... 15 cefixime ............................... 15 cefotaxime sodium ............... 15 cefoxitin sodium .................. 15

. 133

cefpodoxime proxetil ........... 15 cefprozil ............................... 15 ceftazidime .......................... 16 ceftriaxone sodium .............. 16 cefuroxime axetil ................. 16 cefuroxime sodium .............. 16 celecoxib .............................. 34 CELONTIN ......................... 22 cephalexin ............................ 16 cetirizine hcl ...................... 123 cevimeline hcl ...................... 78 CHANTIX ........................... 12 CHANTIX CONTINUING

MONTH PAK ................. 12 CHANTIX STARTING

MONTH PAK ................. 12 chlordiazepoxide hcl ............ 57 chlordiazepoxide-amitriptyline

......................................... 30 chlorhexidine gluconate ....... 78 chloroquine phosphate ......... 45 chlorothiazide ...................... 73 chlorpromazine hcl .............. 47 chlorthalidone ...................... 73 chlorzoxazone .................... 129 cholestyramine ..................... 74 cholestyramine light ............ 74 ciclopirox ............................. 80 ciclopirox olamine ............... 80 cilostazol .............................. 64 cimetidine ............................ 91 cimetidine hcl ...................... 91 CINRYZE ............................ 71 CIPRODEX ....................... 123 ciprofloxacin ........................ 20 ciprofloxacin hcl .. 20, 119, 123 ciprofloxacin in d5w ............ 20 ciprofloxacin-ciproflox hcl er

......................................... 20 citalopram hydrobromide .... 28 CLARAVIS ......................... 80 clarithromycin ...................... 19 clarithromycin er ................. 19 clemastine fumarate ........... 123 CLENPIQ ............................ 92

clindamycin hcl .................... 13 clindamycin palmitate hcl .... 13 clindamycin phosphate .. 13, 80,

96 clindamycin phosphate in d5w

.......................................... 13 CLINIMIX E/DEXTROSE

(2.75/10) ........................... 88 CLINIMIX E/DEXTROSE

(2.75/5) ............................. 88 CLINIMIX E/DEXTROSE



(4.25/5) ............................. 89 CLINIMIX E/DEXTROSE

(5/15) ................................ 89 CLINIMIX E/DEXTROSE

(5/20) ................................ 89 CLINIMIX E/DEXTROSE

(5/25) ................................ 89 CLINIMIX/DEXTROSE

(2.75/5) ............................. 89 CLINIMIX/DEXTROSE

(4.25/10) ........................... 89 CLINIMIX/DEXTROSE



(4.25/5) ............................. 89 CLINIMIX/DEXTROSE



(5/25) ................................ 89 CLINISOL SF ...................... 89 clobetasol propionate ..... 80, 81 clobetasol propionate e ......... 80 clomipramine hcl .................. 30 clonazepam ........................... 22 clonidine hcl ......................... 64 clonidine hcl er ..................... 76

clopidogrel bisulfate ............ 64 clorazepate dipotassium ....... 57 clotrimazole ................... 32, 81 clotrimazole-betamethasone 81 clozapine ........................ 50, 51 COARTEM .......................... 45 codeine sulfate ....................... 9 colchicine ............................. 33 colchicine-probenecid .......... 33 COLCRYS ........................... 33 colestipol hcl ........................ 74 colistimethate sodium (cba) . 13 COLOCORT ........................ 81 COMBIGAN...................... 120 COMBIPATCH ................. 105 COMBIVENT RESPIMAT

....................................... 126 COMETRIQ (100 MG DAILY

DOSE) .............................. 39 COMETRIQ (140 MG DAILY

DOSE) .............................. 39 COMETRIQ (60 MG DAILY

DOSE) .............................. 39 COMFORT ASSIST

INSULIN SYRINGE ..... 118 COMPLERA........................ 53 COMPRO ............................ 47 CONDYLOX ....................... 81 constulose ............................ 92 COPAXONE........................ 77 CORLANOR ....................... 71 COSENTYX 300 DOSE.... 112 COSENTYX SENSOREADY

300 DOSE ...................... 112 COTELLIC .......................... 39 CREON ................................ 94 CRIXIVAN .......................... 56 cromolyn sodium ....... 120, 127 CRYSELLE-28 .................. 100 cvs gauze sterile ................. 118 CYCLAFEM 1/35 ............. 100 CYCLAFEM 7/7/7 ............ 100 cyclobenzaprine hcl ........... 129 cyclophosphamide ............... 37 CYCLOSET ......................... 58

. 134

cyclosporine ....................... 110 cyclosporine modified ....... 110 cyproheptadine hcl ............. 123 CYSTADANE ..................... 94 CYSTAGON ....................... 96 CYSTARAN ...................... 119 D DALIRESP ........................ 128 danazol ................................. 98 dapsone ................................ 13 DAPTACEL ...................... 114 daptomycin .......................... 13 darifenacin hydrobromide er 95 DEBLITANE ..................... 100 DELYLA ........................... 100 DEMSER ............................. 71 DEPEN TITRATABS ......... 87 DEPO-PROVERA ............. 106 DESCOVY .......................... 54 desipramine hcl .................... 30 desloratadine ...................... 123 desmopressin ace spray refrig

....................................... 107 desmopressin acetate ......... 107 desogestrel-ethinyl estradiol

....................................... 100 desonide ............................... 81 desoximetasone .................... 81 desvenlafaxine er ................. 28 desvenlafaxine succinate er . 28 dexamethasone .................... 97 DEXAMETHASONE

INTENSOL ...................... 97 dexamethasone sodium

phosphate ....................... 121 DEXILANT ......................... 93 dexmethylphenidate hcl ....... 76 dextroamphetamine sulfate .. 76 dextrose ................................ 89 dextrose-nacl ........................ 85 DIASTAT ACUDIAL ......... 22 DIASTAT PEDIATRIC ...... 22 diazepam .............................. 57 DIAZEPAM INTENSOL .... 57 diclofenac potassium ........... 34

diclofenac sodium .. 34, 81, 121 diclofenac sodium er ............ 34 diclofenac-misoprostol ......... 34 dicloxacillin sodium ............. 18 dicyclomine hcl .................... 90 didanosine ............................ 54 DIFICID ............................... 19 diflorasone diacetate............. 81 diflunisal ............................... 34 DIGITEK.............................. 71 DIGOX ................................. 71 digoxin ................................. 71 dihydroergotamine mesylate 35 DILANTIN ........................... 25 diltiazem hcl ......................... 70 diltiazem hcl er ..................... 70 diltiazem hcl er beads ........... 70 diltiazem hcl er coated beads

.......................................... 70 dilt-xr .................................... 70 diphenoxylate-atropine ......... 91 diphtheria-tetanus toxoids dt

........................................ 114 dipyridamole ........................ 64 disopyramide phosphate ....... 66 disulfiram ............................. 11 DIURIL ................................ 73 divalproex sodium ................ 23 divalproex sodium er ............ 23 DIVIGEL............................ 105 dofetilide .............................. 66 donepezil hcl ........................ 26 doripenem ............................. 16 dorzolamide hcl .................. 121 dorzolamide hcl-timolol mal

........................................ 121 doxazosin mesylate .............. 64 doxepin hcl ........................... 30 DOXY 100 ........................... 21 doxycycline hyclate .............. 21 doxycycline monohydrate .... 21 dronabinol ............................ 31 drospirenone-ethinyl estradiol

........................................ 100 DROXIA .............................. 39

duloxetine hcl ....................... 28 duramorph .............................. 9 DUREZOL ......................... 121 dutasteride ............................ 95 dutasteride-tamsulosin hcl ... 95 E econazole nitrate .................. 81 EDURANT .......................... 53 efavirenz .............................. 53 ELESTRIN ........................ 105 eletriptan hydrobromide ....... 36 ELIDEL ............................... 81 ELIGARD ............................ 39 ELIQUIS .............................. 62 ELIQUIS STARTER PACK 62 ELMIRON ........................... 96 EMCYT ............................... 39 EMOQUETTE ................... 100 EMSAM ............................... 28 EMTRIVA ........................... 54 EMVERM ............................ 44 enalapril maleate .................. 65 enalapril-hydrochlorothiazide

......................................... 67 ENBREL ............................ 112 ENBREL SURECLICK..... 112 ENDARI .............................. 94 ENDOCET ............................. 9 ENGERIX-B ...................... 114 enoxaparin sodium ............... 62 ENPRESSE-28 .................. 100 ENSKYCE ......................... 100 entacapone ........................... 45 entecavir ............................... 51 ENTRESTO ......................... 67 enulose ................................. 92 ENVARSUS XR ................ 110 epinastine hcl ..................... 120 epinephrine .......................... 71 EPITOL ................................ 25 EPIVIR HBV ....................... 51 eplerenone ............................ 72 EPOGEN .............................. 63 eprosartan mesylate ............. 65 ERAXIS ............................... 32

. 135

ergoloid mesylates ............... 65 ergotamine-caffeine ............. 36 ERIVEDGE ......................... 39 ERLEADA .......................... 39 ERRIN ............................... 100 ery ........................................ 81 ERYPED 400 ....................... 19 ERY-TAB ............................ 19 ERYTHROCIN

LACTOBIONATE .......... 19 ERYTHROCIN STEARATE

......................................... 19 erythromycin ................ 81, 119 erythromycin base ............... 19 erythromycin ethylsuccinate 19 ESBRIET ........................... 128 escitalopram oxalate ............ 28 ESTARYLLA .................... 100 estazolam ........................... 129 estradiol ....................... 96, 105 estradiol valerate ................ 106 estradiol-norethindrone acet

....................................... 106 estropipate .......................... 106 ethambutol hcl ..................... 36 ethosuximide ........................ 23 ethynodiol diac-eth estradiol

....................................... 100 etodolac ................................ 34 etodolac er ........................... 34 EUCRISA ............................ 81 EVAMIST ......................... 106 EVOTAZ ............................. 54 EXEL COMFORT POINT

PEN NEEDLE ............... 118 exemestane .......................... 44 EXJADE .............................. 87 ezetimibe .............................. 74 ezetimibe-simvastatin .......... 74 F FALMINA ......................... 100 famciclovir ........................... 52 famotidine ............................ 91 FANAPT ........................ 48, 49

FANAPT TITRATION PACK .......................................... 49

FARESTON ....................... 107 FARYDAK .......................... 39 felbamate .............................. 24 felodipine er ......................... 70 FEMYNOR ........................ 100 fenofibrate ............................ 73 fenofibrate micronized ......... 73 fenofibric acid ...................... 73 fentanyl ................................... 8 FENTORA ............................. 9 FERRIPROX ........................ 87 FETZIMA ............................ 28 FETZIMA TITRATION ...... 28 FIASP ................................... 61 FIASP FLEXTOUCH .......... 61 FINACEA ............................ 82 finasteride ............................. 95 FIRAZYR ............................. 72 FIRMAGON ........................ 39 flavoxate hcl ......................... 95 FLEBOGAMMA DIF ........ 111 flecainide acetate .................. 66 FLOVENT DISKUS .......... 124 FLOVENT HFA ................ 124 fluconazole ........................... 32 fluconazole in sodium chloride

.......................................... 32 flucytosine ............................ 32 fludrocortisone acetate ......... 97 flunisolide ........................... 127 fluocinolone acetonide . 82, 123 fluocinolone acetonide scalp 82 fluocinonide.......................... 82 fluocinonide emulsified base82 fluorometholone ................. 121 fluorouracil ........................... 39 fluoxetine hcl ........................ 29 fluphenazine decanoate ........ 47 fluphenazine hcl ................... 47 flurazepam hcl .................... 129 flurbiprofen .......................... 34 flurbiprofen sodium ............ 121 flutamide .............................. 39

fluticasone propionate .. 82, 127 fluticasone-salmeterol ........ 126 fluvastatin sodium ................ 73 fluvastatin sodium er ............ 73 fluvoxamine maleate ............ 29 fluvoxamine maleate er ........ 29 fondaparinux sodium ........... 62 FORFIVO XL ...................... 27 FORTEO ............................ 117 FOSAMAX PLUS D ......... 117 fosamprenavir calcium ......... 56 fosinopril sodium ................. 65 fosinopril sodium-hctz ......... 67 FRAGMIN ........................... 62 FREAMINE HBC ................ 90 furosemide ........................... 72 FUZEON .............................. 55 FYAVOLV ........................ 106 FYCOMPA .......................... 23 G gabapentin ............................ 23 galantamine hydrobromide .. 26 galantamine hydrobromide er

......................................... 26 GAMMAGARD ................ 111 GAMMAGARD S/D LESS

IGA ................................ 112 GAMMAKED ................... 112 GAMMAPLEX.................. 112 GAMUNEX-C ................... 112 GARDASIL 9 .................... 114 gatifloxacin ........................ 119 GATTEX ............................. 92 GAVILYTE-C ..................... 92 GAVILYTE-G ..................... 92 GAVILYTE-N WITH

FLAVOR PACK .............. 92 gemfibrozil ........................... 73 generlac ................................ 92 GENGRAF ........................ 110 GENTAK ........................... 119 gentamicin in saline ............. 12 gentamicin sulfate .. 12, 82, 119 GENVOYA .......................... 53 GEODON ............................ 58

. 136

GIANVI ............................. 100 GILENYA ........................... 77 GILOTRIF ........................... 40 glatiramer acetate ................. 78 GLEOSTINE ....................... 37 glimepiride ........................... 58 glipizide ............................... 58 glipizide er ........................... 58 glipizide-metformin hcl ....... 58 global alcohol prep ease .... 118 GLUCAGEN HYPOKIT ..... 60 GLUCAGON EMERGENCY

......................................... 61 glyburide .............................. 59 glyburide micronized ........... 59 glyburide-metformin ............ 59 glycopyrrolate ...................... 90 GOCOVRI ........................... 45 GOLYTELY ........................ 92 granisetron hcl ..................... 31 griseofulvin microsize ......... 32 griseofulvin ultramicrosize .. 32 guanfacine hcl ...................... 64 guanidine hcl ....................... 36 H halobetasol propionate ......... 82 haloperidol ........................... 48 haloperidol decanoate .......... 47 haloperidol lactate ......... 47, 48 HAVRIX ............................ 114 heparin sodium (porcine) ..... 63 HEPATAMINE ................... 90 HEXALEN .......................... 37 HIBERIX ........................... 114 HUMIRA ........................... 113 HUMIRA PEDIATRIC

CROHNS START ......... 113 HUMIRA PEN .................. 113 HUMIRA PEN-CD/UC/HS

STARTER ..................... 113 HUMIRA PEN-PS/UV

STARTER ..................... 113 hydralazine hcl ..................... 76 hydrochlorothiazide ............. 73 hydrocodone-acetaminophen . 9

hydrocodone-ibuprofen .......... 9 hydrocortisone ................ 82, 97 hydrocortisone ace-pramoxine

.......................................... 82 hydrocortisone butyrate ........ 82 hydrocortisone-acetic acid . 123 hydromorphone hcl ................ 9 hydromorphone hcl er ............ 8 hydromorphone hcl pf .......... 10 hydroxychloroquine sulfate .. 45 hydroxyurea.......................... 40 hydroxyzine hcl .................... 57 hydroxyzine pamoate ........... 57 I ibandronate sodium ............ 117 IBRANCE ............................ 40 IBU ....................................... 34 ibuprofen ........................ 34, 35 ICLUSIG .............................. 40 IDHIFA ................................ 40 ILEVRO ............................. 121 imatinib mesylate ................. 40 IMBRUVICA ....................... 40 imipenem-cilastatin .............. 17 imipramine hcl ..................... 30 imipramine pamoate ............. 30 imiquimod ............................ 83 IMOVAX RABIES ............ 114 INCRELEX ........................ 107 indapamide ........................... 73 indomethacin ........................ 35 indomethacin er .................... 35 INFANRIX ......................... 114 INLYTA ............................... 40 INTELENCE ........................ 53 INTRALIPID ....................... 90 INTRAROSA ....................... 96 INTRON A ........................... 40 INTROVALE ..................... 100 INVANZ .............................. 17 INVEGA SUSTENNA ........ 49 INVEGA TRINZA ............... 49 INVIRASE ........................... 56 INVOKAMET ..................... 59 INVOKAMET XR ............... 59

INVOKANA ........................ 59 IONOSOL-MB IN D5W ..... 85 IPOL .................................. 115 ipratropium bromide .. 125, 127 ipratropium-albuterol ......... 126 irbesartan .............................. 65 irbesartan-hydrochlorothiazide

......................................... 67 IRESSA................................ 40 ISENTRESS ........................ 55 ISENTRESS HD .................. 55 ISIBLOOM ........................ 100 ISOLYTE-P IN D5W .......... 85 ISOLYTE-S ......................... 85 isoniazid ......................... 36, 37 ISOPTO ATROPINE......... 119 isosorbide dinitrate ............... 75 isosorbide dinitrate er .......... 75 isosorbide mononitrate ......... 75 isosorbide mononitrate er .... 75 isotretinoin ........................... 83 isradipine .............................. 70 itraconazole .......................... 32 ivermectin ............................ 44 IXIARO ............................. 115 J JADENU .............................. 87 JADENU SPRINKLE .......... 88 JAKAFI................................ 40 JANTOVEN ........................ 63 JANUMET ........................... 59 JANUMET XR .................... 59 JANUVIA ............................ 59 JARDIANCE ....................... 59 JINTELI ............................. 106 JOLIVETTE ...................... 100 JULEBER .......................... 101 JULUCA .............................. 54 JUNEL 1.5/30 .................... 101 JUNEL 1/20 ....................... 101 JUNEL FE 1.5/30 .............. 101 JUNEL FE 1/20 ................. 101 JUNEL FE 24 .................... 101 JUXTAPID .......................... 74 JYNARQUE ........................ 88

. 137

K KALETRA .......................... 56 KALYDECO ..................... 128 KARIVA ............................ 101 kcl in dextrose-nacl .............. 85 kcl-lactated ringers-d5w ...... 85 KELNOR 1/35 ................... 101 KELNOR 1/50 ................... 101 ketoconazole .................. 32, 83 ketoprofen ............................ 35 ketoprofen er ........................ 35 ketorolac tromethamine 35, 122 KIMIDESS ........................ 101 KINRIX ............................. 115 KIONEX .............................. 88 KISQALI 200 DOSE ........... 40 KISQALI 400 DOSE ........... 40 KISQALI 600 DOSE ........... 40 KISQALI FEMARA 200

DOSE ............................... 40 KISQALI FEMARA 400

DOSE ............................... 41 KISQALI FEMARA 600

DOSE ............................... 41 KLOR-CON ........................ 86 KLOR-CON 10 ................... 85 KLOR-CON M10 ................ 86 KLOR-CON M15 ................ 86 KLOR-CON M20 ................ 86 KLOR-CON SPRINKLE .... 86 KORLYM .......................... 108 K-TAB ................................. 86 KURVELO ........................ 101 KUVAN ............................... 94 KYNAMRO ........................ 74 L labetalol hcl ......................... 69 lactulose ............................... 92 LAMICTAL XR .................. 24 lamivudine ..................... 51, 54 lamivudine-zidovudine ........ 54 lamotrigine ........................... 24 lamotrigine er ....................... 24 lamotrigine starter kit-blue .. 24 lamotrigine starter kit-green 24

lamotrigine starter kit-orange .......................................... 24

lansoprazole.......................... 93 LANTUS .............................. 61 LANTUS SOLOSTAR ........ 61 LARIN 1.5/30 .................... 101 LARIN 1/20 ....................... 101 LARIN FE 1.5/30 ............... 101 LARIN FE 1/20 .................. 101 LARISSIA .......................... 101 latanoprost .......................... 118 LATUDA ............................. 49 LEENA ............................... 101 leflunomide ........................ 113 LENVIMA 10 MG DAILY

DOSE ............................... 41 LENVIMA 14 MG DAILY





DOSE ............................... 41 LESSINA ........................... 101 LETAIRIS .......................... 127 letrozole ................................ 44 leucovorin calcium ............... 41 LEUKERAN ........................ 37 LEUKINE ............................ 63 leuprolide acetate ................. 41 levalbuterol hcl ................... 126 levalbuterol tartrate ............ 126 LEVEMIR ............................ 61 LEVEMIR FLEXTOUCH ... 61 levetiracetam ........................ 22 levetiracetam er .................... 21 levobunolol hcl ................... 121 levocarnitine ......................... 94 levocetirizine dihydrochloride

........................................ 123 levofloxacin .................. 20, 119 levofloxacin in d5w .............. 20

LEVONEST ....................... 101 levonorgest-eth estrad 91-day

....................................... 101 levonorgestrel-ethinyl estrad

....................................... 102 levonorg-eth estrad triphasic

....................................... 102 LEVORA 0.15/30 (28) ...... 102 LEVO-T ............................. 107 levothyroxine sodium ........ 108 LEVOXYL ........................ 108 LEXIVA .............................. 56 LIALDA ............................ 116 lidocaine ............................... 83 lidocaine hcl ................... 11, 83 lidocaine viscous .................. 78 lidocaine-prilocaine ............. 11 lindane .................................. 83 linezolid ............................... 13 LINZESS ............................. 92 liothyronine sodium ........... 108 lisinopril ............................... 65 lisinopril-hydrochlorothiazide

......................................... 67 lithium .................................. 58 lithium carbonate ................. 58 lithium carbonate er ............. 58 LITHOSTAT ....................... 96 LIVALO .............................. 73 LONSURF ........................... 41 loperamide hcl ..................... 91 lopinavir-ritonavir ................ 56 lorazepam ............................. 58 LORYNA ........................... 102 losartan potassium ............... 65 losartan potassium-hctz ....... 67 LOTEMAX ........................ 122 lovastatin .............................. 73 LOW-OGESTREL ............ 102 loxapine succinate ................ 48 LUMIGAN ........................ 118 LUPRON DEPOT (1-

MONTH) ......................... 41 LUPRON DEPOT (3-

MONTH) ......................... 41

. 138

LUPRON DEPOT (4-MONTH) ......................... 41

LUPRON DEPOT (6-MONTH) ......................... 41

LUTERA ........................... 102 LYNPARZA .................. 41, 42 LYRICA ........................ 23, 77 LYSODREN ........................ 42 LYZA ................................ 102 M magnesium sulfate ............... 86 maprotiline hcl ..................... 27 marlissa .............................. 102 MARPLAN .......................... 28 MATULANE ....................... 42 MAVYRET ......................... 52 meclizine hcl ........................ 31 meclofenamate sodium ........ 35 MEDROL ............................ 97 medroxyprogesterone acetate

............................... 102, 106 mefloquine hcl ..................... 45 megestrol acetate ......... 42, 106 MEKINIST .......................... 42 meloxicam ........................... 35 memantine hcl ..................... 26 memantine hcl er ................. 26 MENACTRA ..................... 115 MENEST ........................... 106 MENVEO .......................... 115 meperidine hcl ..................... 10 meprobamate ....................... 57 mercaptopurine .................... 38 meropenem .......................... 17 mesalamine ........................ 116 MESNEX ............................. 44 metaproterenol sulfate ....... 126 metaxalone ......................... 129 metformin hcl ...................... 59 metformin hcl er .................. 59 methadone hcl ...................... 10 methazolamide ..................... 72 methenamine hippurate ....... 13 methimazole ...................... 109 methocarbamol .................. 129

methotrexate ....................... 110 methotrexate sodium ............ 38 methotrexate sodium (pf) ..... 38 methoxsalen rapid ................ 83 methyclothiazide .................. 73 methyldopa ........................... 64 methyldopa-

hydrochlorothiazide.......... 67 methylphenidate hcl ............. 76 methylphenidate hcl er ......... 76 methylprednisolone .............. 97 methyltestosterone................ 98 metipranolol ....................... 121 metoclopramide hcl .............. 91 metolazone ........................... 73 metoprolol succinate er ........ 69 metoprolol tartrate ................ 69 metoprolol-

hydrochlorothiazide.......... 68 metronidazole ........... 14, 83, 96 metronidazole in nacl ........... 13 mexiletine hcl ....................... 66 miconazole 3 ........................ 96 MICROGESTIN 1.5/30 ..... 102 MICROGESTIN 1/20 ........ 102 MICROGESTIN FE 1.5/30 102 MICROGESTIN FE 1/20 ... 102 midodrine hcl ....................... 64 miglitol ................................. 59 miglustat ............................... 94 MILI ................................... 102 MIMVEY ........................... 106 MIMVEY LO ..................... 106 minocycline hcl .................... 21 minoxidil .............................. 76 mirtazapine ........................... 27 misoprostol ........................... 93 MITIGARE .......................... 33 M-M-R II ............................ 115 modafinil ............................ 130 MODERIBA ........................ 52 MODERIBA 1200 DOSE

PACK ............................... 52 MODERIBA 800 DOSE

PACK ............................... 52

moexipril hcl ........................ 66 moexipril-hydrochlorothiazide

......................................... 68 mometasone furoate ............. 83 MONONESSA .................. 102 montelukast sodium ........... 125 MONUROL ......................... 14 morphine sulfate .................. 10 morphine sulfate (concentrate)

......................................... 10 morphine sulfate er ................ 8 morphine sulfate er beads ...... 8 MOVANTIK ........................ 91 MOXEZA .......................... 119 moxifloxacin hcl .......... 20, 119 moxifloxacin hcl in nacl ...... 20 MULTAQ ............................ 66 mupirocin ............................. 83 mupirocin calcium ............... 83 MYCAMINE ....................... 33 mycophenolate mofetil ...... 110 mycophenolate sodium ...... 110 MYRBETRIQ ...................... 95 MYTESI .............................. 91 N nabumetone .......................... 35 nadolol ................................. 69 nadolol-bendroflumethiazide

......................................... 68 nafcillin sodium ................... 18 naloxone hcl ......................... 11 naltrexone hcl ....................... 11 NAMENDA XR TITRATION

PACK ............................... 26 NAMZARIC ........................ 27 naproxen .............................. 35 naproxen dr .......................... 35 naproxen sodium .................. 35 naratriptan hcl ...................... 36 NARCAN ............................ 11 NATACYN ........................ 119 nateglinide ............................ 59 NATPARA ........................ 117 NEBUPENT ........................ 14 NECON 0.5/35 (28) ........... 102

. 139

NECON 7/7/7 .................... 103 nefazodone hcl ..................... 27 neomycin sulfate .................. 12 neomycin-bacitracin zn-

polymyx ......................... 119 neomycin-polymyxin-

dexameth ........................ 122 neomycin-polymyxin-

gramicidin ...................... 120 neomycin-polymyxin-hc ... 122,

123 NEPHRAMINE ................... 90 NERLYNX .......................... 42 NEUPOGEN ........................ 63 NEUPRO ............................. 46 nevirapine ............................ 53 nevirapine er ........................ 53 NEXAVAR .......................... 42 niacin er (antihyperlipidemic)

......................................... 74 NIACOR .............................. 74 nicardipine hcl ..................... 70 NICOTROL ......................... 12 NICOTROL NS ................... 12 nifedipine ............................. 70 nifedipine er ......................... 70 nifedipine er osmotic release 70 NIKKI ................................ 103 nilutamide ............................ 42 NINLARO ........................... 42 NITRO-BID ......................... 75 NITRO-DUR ....................... 75 nitrofurantoin ....................... 14 nitrofurantoin macrocrystal . 14 nitrofurantoin monohyd macro

......................................... 14 nitroglycerin ........................ 75 nizatidine ............................. 91 NORA-BE ......................... 103 NORDITROPIN FLEXPRO

....................................... 107 norethin ace-eth estrad-fe .. 103 norethindrone ..................... 103 norethindrone acetate ......... 106

norethindrone acet-ethinyl est ........................................ 103

norethindrone-eth estradiol 106 norethin-eth estradiol-fe ..... 103 norgestimate-eth estradiol .. 103 norgestim-eth estrad triphasic

........................................ 103 NORLYROC ...................... 103 NORMOSOL-M IN D5W.... 86 NORMOSOL-R IN D5W .... 86 NORMOSOL-R PH 7.4 ....... 86 NORTHERA ........................ 72 NORTREL 0.5/35 (28) ...... 103 NORTREL 1/35 (21) ......... 103 NORTREL 1/35 (28) ......... 103 NORTREL 7/7/7 ................ 103 nortriptyline hcl .................... 30 NORVIR .............................. 56 NOVOLIN 70/30 ................. 61 NOVOLIN N ........................ 61 NOVOLIN R ........................ 61 NOVOLOG .......................... 62 NOVOLOG FLEXPEN ....... 61 NOVOLOG MIX 70/30 ....... 61 NOVOLOG MIX 70/30

FLEXPEN ........................ 61 NOVOLOG PENFILL ......... 62 NOXAFIL ............................ 33 NUCALA ........................... 128 NUEDEXTA ........................ 77 NUPLAZID .......................... 49 nutrilipid ............................... 90 NYAMYC ............................ 83 nystatin ........................... 33, 83 nystatin-triamcinolone.......... 83 NYSTOP .............................. 84 O OCELLA ............................ 103 octreotide acetate ................ 109 ODEFSEY ............................ 53 ODOMZO ............................ 42 OFEV ................................. 128 ofloxacin ............... 20, 120, 123 OGESTREL ....................... 103 olanzapine ...................... 49, 51

olanzapine-fluoxetine hcl ..... 29 olmesartan medoxomil ......... 65 olmesartan medoxomil-hctz. 68 olmesartan-amlodipine-hctz 68 olopatadine hcl ................... 120 omega-3-acid ethyl esters .... 74 omeprazole ........................... 93 ondansetron .......................... 31 ondansetron hcl .................... 31 ONFI .................................... 22 OPSUMIT .......................... 127 ORAVIG .............................. 33 ORFADIN............................ 94 ORKAMBI ........................ 128 orphenadrine citrate er ....... 129 ORSYTHIA ....................... 103 oseltamivir phosphate .......... 56 OSPHENA ......................... 107 OTREXUP ......................... 110 oxacillin sodium ................... 18 oxandrolone ......................... 98 oxaprozin ............................. 35 oxazepam ............................. 58 oxcarbazepine ...................... 25 OXTELLAR XR .................. 25 oxybutynin chloride ............. 95 oxybutynin chloride er ......... 95 oxycodone hcl ...................... 10 oxycodone hcl er .................... 8 oxycodone-acetaminophen .. 10 oxycodone-aspirin ................ 10 oxycodone-ibuprofen ........... 10 oxymorphone hcl ................. 10 oxymorphone hcl er ............... 8 OZEMPIC ............................ 59 P paliperidone er ..................... 49 PANRETIN .......................... 84 pantoprazole sodium ............ 93 paricalcitol ......................... 117 paromomycin sulfate ........... 12 paroxetine hcl ....................... 29 paroxetine hcl er .................. 29 PASER ................................. 37 PAXIL .................................. 29

. 140

PAZEO .............................. 120 PEDIARIX ........................ 115 PEDVAX HIB ................... 115 peg 3350/electrolytes ........... 92 peg 3350-kcl-na bicarb-nacl 92 peg-3350/electrolytes .......... 92 PEGANONE ........................ 25 PEGASYS ........................... 52 PEGASYS PROCLICK ....... 52 penicillin g pot in dextrose .. 18 penicillin g potassium .......... 18 penicillin g sodium .............. 18 penicillin v potassium .......... 18 PENTAM ............................. 14 pentazocine-naloxone hcl .... 10 pentoxifylline er ................... 72 perindopril erbumine ........... 66 PERIOGARD ...................... 78 permethrin ............................ 84 perphenazine ........................ 48 perphenazine-amitriptyline .. 48 PEXEVA ............................. 29 PHENADOZ ...................... 123 phenelzine sulfate ................ 28 phenobarbital ............... 22, 129 phenytoin ............................. 25 phenytoin sodium extended . 26 PHOSPHOLINE IODIDE . 121 pilocarpine hcl ............. 78, 121 pimozide .............................. 48 PIMTREA .......................... 103 pindolol ................................ 69 pioglitazone hcl ................... 59 pioglitazone hcl-glimepiride 60 pioglitazone hcl-metformin hcl

......................................... 60 piperacillin sod-tazobactam so

......................................... 18 PIRMELLA 1/35 ............... 104 piroxicam ............................. 35 PLASMA-LYTE 148 .......... 86 PLASMA-LYTE A ............. 86 PLEGRIDY ......................... 78 PLEGRIDY STARTER PACK

......................................... 78

PLENAMINE ....................... 90 podofilox .............................. 84 polyethylene glycol 3350 ..... 92 polymyxin b-trimethoprim . 120 POMALYST ........................ 42 PORTIA-28 ........................ 104 potassium chloride ............... 87 potassium chloride crys er .... 86 potassium chloride er ........... 86 potassium chloride in dextrose

.......................................... 87 potassium chloride in nacl .... 87 potassium citrate er .............. 87 PRADAXA .......................... 63 PRALUENT ......................... 74 pramipexole dihydrochloride

.......................................... 46 prasugrel hcl ......................... 64 pravastatin sodium ............... 74 prazosin hcl .......................... 65 PRED-G ............................. 122 PRED-G S.O.P. .................. 122 prednicarbate ........................ 84 prednisolone ......................... 97 prednisolone acetate ........... 122 prednisolone sodium

phosphate ................. 97, 122 prednisone ...................... 97, 98 PREDNISONE INTENSOL 97 preferred plus insulin syringe

........................................ 118 PREMARIN ................. 96, 106 PREMASOL ........................ 90 PREMPHASE .................... 106 PREMPRO ......................... 106 prenatal ................................. 87 PREPOPIK ........................... 93 PREVALITE ........................ 74 PREVIFEM ........................ 104 PREVYMIS ......................... 51 PREZCOBIX ....................... 54 PREZISTA ........................... 56 PRIFTIN ............................... 37 primaquine phosphate .......... 45 primidone ............................. 22

PROAIR HFA .................... 126 PROAIR RESPICLICK ..... 126 probenecid ............................ 33 PROCALAMINE ................ 90 prochlorperazine .................. 48 prochlorperazine maleate ..... 48 PROCRIT ............................ 63 PROCTOFOAM HC ........... 84 PROCTO-MED HC ............. 84 PROCTO-PAK .................... 84 PROCTOSOL HC ............... 84 PROCTOZONE-HC ............ 84 progesterone micronized .... 107 PROGLYCEM ..................... 61 PROLASTIN-C ................. 128 PROLENSA ....................... 122 PROLIA ............................. 117 PROMACTA ....................... 63 promethazine hcl ........ 123, 124 promethazine vc plain ........ 124 PROMETHEGAN ............. 124 propafenone hcl ................... 66 proparacaine hcl ................. 119 propranolol hcl ..................... 69 propranolol hcl er ................. 69 propranolol-hctz ................... 68 propylthiouracil .................. 109 PROQUAD ........................ 115 PROSOL .............................. 90 protriptyline hcl ................... 30 PULMOZYME .................. 128 PURIXAN............................ 38 pyrazinamide ........................ 37 pyridostigmine bromide ....... 36 Q QUADRACEL ................... 115 QUASENSE ...................... 104 quetiapine fumarate ............. 49 quetiapine fumarate er ......... 49 quinapril hcl ......................... 66 quinapril-hydrochlorothiazide

......................................... 68 quinidine sulfate ................... 66 quinine sulfate ...................... 45

. 141

R RABAVERT ...................... 115 raloxifene hcl ..................... 107 ramipril ................................ 66 RANEXA ............................ 72 ranitidine hcl ........................ 91 RAPAFLO ........................... 95 RAPAMUNE ..................... 110 rasagiline mesylate .............. 47 RASUVO ........................... 111 RAVICTI ............................. 94 REBETOL ........................... 51 RECLIPSEN ...................... 104 RECOMBIVAX HB .......... 115 REGRANEX ....................... 84 RELENZA DISKHALER ... 56 RELI-ON INSULIN

SYRINGE ...................... 118 repaglinide ........................... 60 repaglinide-metformin hcl ... 60 REPATHA ........................... 75 REPATHA PUSHTRONEX

SYSTEM ......................... 74 REPATHA SURECLICK ... 75 RESCRIPTOR ..................... 53 RESTASIS ......................... 119 RESTASIS MULTIDOSE . 119 REVLIMID .......................... 37 REXULTI ............................ 50 REYATAZ .......................... 56 RIBASPHERE ..................... 51 RIBASPHERE RIBAPAK .. 51 ribavirin ............................... 52 rifabutin ............................... 37 rifampin ............................... 37 RIFATER ............................ 37 riluzole ................................. 77 rimantadine hcl .................... 56 RIOMET .............................. 60 risedronate sodium ............. 117 RISPERDAL CONSTA ...... 50 risperidone ........................... 50 ritonavir ............................... 56 rivastigmine ......................... 26 rivastigmine tartrate ............. 26

rizatriptan benzoate .............. 36 ropinirole hcl ........................ 46 ropinirole hcl er .................... 46 rosuvastatin calcium ............. 74 ROTARIX .......................... 115 ROTATEQ ......................... 115 ROWEEPRA ........................ 22 ROWEEPRA XR ................. 22 RUBRACA .......................... 42 RYDAPT .............................. 42 RYTARY ............................. 47 S SABRIL ............................... 23 SAMSCA ............................. 88 SANDIMMUNE ................ 111 SANTYL .............................. 84 SAPHRIS ............................. 50 SAVELLA ........................... 77 SAVELLA TITRATION

PACK ............................... 77 scopolamine.......................... 31 selegiline hcl......................... 47 selenium sulfide ................... 84 SELZENTRY ....................... 55 SENSIPAR ......................... 117 SEREVENT DISKUS ........ 127 sertraline hcl ......................... 29 SETLAKIN ........................ 104 sevelamer carbonate ............. 96 SHAROBEL ....................... 104 SHINGRIX ......................... 115 SIGNIFOR ......................... 109 sildenafil citrate .................. 127 SILENOR ........................... 130 silver sulfadiazine................. 84 SIMBRINZA ...................... 121 SIMPONI ........................... 113 simvastatin ........................... 74 sirolimus ............................. 111 sodium chloride .............. 87, 96 sodium fluoride .................... 87 sodium lactate....................... 87 sodium polystyrene sulfonate

.......................................... 88 SOLIQUA ............................ 60

SOLTAMOX ....................... 42 SOMATULINE DEPOT ... 109 SOMAVERT ..................... 109 SORINE ............................... 69 sotalol hcl ............................. 69 sotalol hcl (af) ...................... 69 SPIRIVA HANDIHALER. 125 SPIRIVA RESPIMAT ....... 125 spironolactone ...................... 73 spironolactone-hctz .............. 68 SPRINTEC 28 ................... 104 SPRITAM ............................ 22 SPRYCEL ............................ 42 SPS ....................................... 88 SRONYX ........................... 104 SSD ...................................... 84 stavudine .............................. 54 STELARA ......................... 113 STIOLTO RESPIMAT ...... 127 STIVARGA ......................... 42 streptomycin sulfate ............. 12 STRIBILD ........................... 54 SUBOXONE.................. 11, 12 SUBVENITE ....................... 24 SUBVENITE STARTER KIT-

BLUE ............................... 24 SUBVENITE STARTER KIT-

GREEN ............................ 24 SUBVENITE STARTER KIT-

ORANGE ......................... 24 sucralfate .............................. 93 sulfacetamide sodium ........ 120 sulfacetamide sodium (acne) 84 sulfacetamide-prednisolone 122 sulfadiazine .......................... 20 sulfamethoxazole-

trimethoprim .................... 20 SULFAMYLON .................. 84 sulfasalazine ....................... 116 SULFATRIM PEDIATRIC . 21 sulindac ................................ 35 sumatriptan succinate ........... 36 sumatriptan succinate refill .. 36 SUPRAX.............................. 16

. 142

SUPREP BOWEL PREP KIT ......................................... 93

SUTENT .............................. 42 SYEDA .............................. 104 SYLATRON ........................ 42 SYMDEKO ....................... 128 SYMFI ................................. 53 SYMFI LO ........................... 53 SYMLINPEN 120 ............... 60 SYMLINPEN 60 ................. 60 SYNAREL ......................... 109 SYNJARDY ........................ 60 SYNJARDY XR .................. 60 SYNRIBO ............................ 43 SYNTHROID .................... 108 T TABLOID ............................ 38 tacrolimus .................... 84, 111 TAFINLAR ......................... 43 TAGRISSO .......................... 43 tamoxifen citrate .................. 43 tamsulosin hcl ...................... 96 TARCEVA .......................... 43 TARGRETIN ...................... 84 TARINA FE 1/20 .............. 104 TASIGNA ............................ 43 TAVALISSE ....................... 64 tazarotene ............................. 84 TAZORAC .......................... 84 TAZTIA XT ........................ 71 TECFIDERA ....................... 78 TEFLARO ........................... 16 TEKTURNA ........................ 65 TEKTURNA HCT ............... 68 telmisartan ........................... 65 telmisartan-amlodipine ........ 68 telmisartan-hctz ................... 68 temazepam ......................... 129 TENIVAC .......................... 115 tenofovir disoproxil fumarate

......................................... 54 terazosin hcl ......................... 65 terbinafine hcl ...................... 33 terbutaline sulfate .............. 127 terconazole ........................... 96

testosterone ..................... 98, 99 testosterone cypionate .......... 98 testosterone enanthate .......... 98 tetanus-diphtheria toxoids td

........................................ 115 tetrabenazine ........................ 77 tetracycline hcl ..................... 21 THALOMID ........................ 37 theophylline ........................ 125 theophylline er .................... 125 thioridazine hcl ..................... 48 thiothixene ............................ 48 THYROLAR-1 ................... 108 THYROLAR-1/2 ............... 108 THYROLAR-1/4 ............... 108 THYROLAR-2 ................... 108 THYROLAR-3 ................... 108 tiagabine hcl ......................... 23 tigecycline ............................ 14 timolol maleate ............. 69, 121 tinidazole .............................. 14 TIVICAY ............................. 55 tizanidine hcl ...................... 129 TOBI PODHALER .............. 13 tobramycin.................... 13, 120 tobramycin sulfate ................ 13 tobramycin-dexamethasone 122 tolazamide ............................ 60 tolbutamide ........................... 60 tolmetin sodium .................... 35 tolterodine tartrate ................ 95 tolterodine tartrate er ............ 95 topiramate ............................. 25 topiramate er......................... 25 torsemide .............................. 72 TOUJEO MAX SOLOSTAR

.......................................... 62 TOUJEO SOLOSTAR ......... 62 TPN ELECTROLYTES ....... 87 TRACLEER ....................... 127 tramadol hcl .......................... 10 tramadol-acetaminophen ...... 10 trandolapril ........................... 66 trandolapril-verapamil hcl er 68 tranexamic acid .................... 64

tranylcypromine sulfate ....... 28 TRAVASOL ........................ 90 TRAVATAN Z .................. 118 trazodone hcl ........................ 27 TRECATOR ........................ 37 TRELSTAR MIXJECT ....... 43 TRESIBA FLEXTOUCH .... 62 tretinoin .................... 43, 84, 85 TREXALL ......................... 111 triamcinolone acetonide 78, 85,

98, 127 triamterene-hctz ................... 68 triazolam ............................ 130 trientine hcl .......................... 88 trifluoperazine hcl ................ 48 trifluridine .......................... 120 trihexyphenidyl hcl .............. 45 TRI-LEGEST FE ............... 104 TRI-LO-ESTARYLLA ...... 104 TRILYTE ............................. 93 trimethobenzamide hcl ......... 31 trimethoprim ........................ 14 TRI-MILI ........................... 104 trimipramine maleate ........... 30 TRINESSA (28) ................. 104 TRINTELLIX ...................... 27 TRI-PREVIFEM ................ 104 TRI-SPRINTEC ................. 104 TRIUMEQ ........................... 54 TRIVORA (28) .................. 104 TRI-VYLIBRA .................. 104 TROPHAMINE ................... 90 trospium chloride ................. 95 trospium chloride er ............. 95 TRULICITY ........................ 60 TRUMENBA ..................... 116 TRUVADA .......................... 54 TWINRIX .......................... 116 TYBOST .............................. 55 TYKERB ............................. 43 TYMLOS ........................... 118 TYPHIM VI ....................... 116 U UCERIS ............................... 85 ULORIC .............................. 33

. 143

UNITHROID ..................... 108 UPTRAVI .......................... 128 ursodiol ................................ 91 V valacyclovir hcl ................... 52 VALCHLOR ....................... 43 valganciclovir hcl ................ 51 valproate sodium ................. 23 valproic acid ........................ 23 valsartan ............................... 65 valsartan-hydrochlorothiazide

......................................... 68 vancomycin hcl .................... 14 vancomycin hcl in dextrose . 14 vancomycin hcl in nacl ........ 14 VANDAZOLE .................... 96 VAQTA ............................. 116 VARIVAX ......................... 116 VARIZIG ........................... 112 VARUBI .............................. 31 VASCEPA ........................... 75 VELIVET .......................... 105 VEMLIDY ........................... 52 VENCLEXTA ..................... 43 VENCLEXTA STARTING

PACK .............................. 43 venlafaxine hcl ............... 29, 30 venlafaxine hcl er ................ 29 verapamil hcl ....................... 71 verapamil hcl er ................... 71 VERSACLOZ ...................... 51 VERZENIO ......................... 43 VESTURA ......................... 105 VICTOZA ............................ 60

VIDEX ................................. 54 VIDEX EC ........................... 54 VIENVA ............................ 105 vigabatrin.............................. 23 VIGADRONE ...................... 24 VIIBRYD ............................. 28 VIIBRYD STARTER PACK

.......................................... 28 VIMPAT .............................. 26 VIRACEPT .......................... 56 VIRAMUNE ........................ 53 VIREAD ............................... 54 VIVITROL ........................... 12 voriconazole ......................... 33 VOSEVI ............................... 52 VOTRIENT .......................... 43 VRAYLAR .......................... 50 VYFEMLA ........................ 105 VYLIBRA .......................... 105 W warfarin sodium ................... 63 WELCHOL .......................... 75 WYMZYA FE .................... 105 X XALKORI ............................ 43 XARELTO ........................... 63 XARELTO STARTER PACK

.......................................... 63 XATMEP ........................... 111 XELJANZ .......................... 113 XELJANZ XR .................... 113 XGEVA .............................. 118 XIFAXAN ............................ 14 XOLAIR ............................. 128

XTANDI .............................. 43 XULTOPHY ........................ 60 XYREM ............................. 130 Y YF-VAX ............................ 116 YONSA................................ 43 YUVAFEM.......................... 97 Z zafirlukast .......................... 125 zaleplon .............................. 130 ZARAH .............................. 105 ZARXIO .............................. 64 ZEJULA ............................... 43 ZELBORAF ......................... 44 ZENCHENT ...................... 105 ZENPEP ............................... 94 ZERBAXA .......................... 16 ZERIT .................................. 55 zidovudine ............................ 55 ziprasidone hcl ..................... 50 ZOLINZA ............................ 44 zolmitriptan .......................... 36 zolpidem tartrate ................ 130 zolpidem tartrate er ............ 130 zonisamide ........................... 23 ZORTRESS ....................... 111 ZOSTAVAX ...................... 116 ZOSYN ................................ 18 ZOVIA 1/35E (28) ............. 105 ZYDELIG ............................ 44 ZYKADIA ........................... 44 ZYLET ............................... 122 ZYPREXA RELPREVV ..... 50 ZYTIGA .............................. 44

H7115_PH_S_CompFrmly_C 10/10/2018

Memorial Hermann Advantage HMO es proporcionado por Memorial Hermann Health Plan, Inc., una organizacion de Medicare Advantage con uno contrato de Medicare. La inscripción en este plan depende de la renovación del contrato. Memorial Hermann Advantage HMO cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

Este formulario resumido se actualizó el 08/24/2018. Para obtener información más reciente o si tiene otras preguntas, comuníquese con Memorial Hermann Advantage HMO al al 855-645-8448, 1 de octubre a 31 de marzo: 8:00 a.m. a 8:00 p.m., 7 días a la semana horario de la zona central y 1 de abril a 30 de septiembre: 8:00 a.m. a 8:00 p.m., lunes a viernes horario de la zona central (los usuarios de TTY deben llamar al 711), o visite healthplan.memorialhermann.org/medicare.

memorial hermann advantage hmo formulario para 2019...

Documents