prescription drug program formularyplease note: because prescription drug benefits vary by group,...

Prescription Drug Program Formulary Effective October 1, 2020

myibxtpa.com

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Dear Valued Member:

This Select Drug Program® Formulary Guide is intended to help you understand prescription drug coverage under the Independence Administrators Select Formulary. We are committed to providing you with comprehensive prescription drug coverage. To achieve this, we include a formulary feature in your prescription drug benefit. A formulary is a list of selected drugs. The drugs are approved by the U.S. Food and Drug Administration (FDA). They are also reviewed by our Pharmacy and Therapeutics Committee, a group of doctors and pharmacists from the area. These prescription drugs have been added to the Select Formulary for their reported medical effectiveness, safety, and value.

FutureScripts®, an independent company, is our pharmacy benefits manager. They monitor all drugs to ensure they are safe and effective drugs. They also make sure drugs are prescribed properly. They do so by using procedures such as safety edits. Safety edits are guidelines. They include, for example, age limits, quantity limits, and morphine milligram equivalent limits.

These guidelines are designed to help you get the most out of your prescription drug benefits. They are based on FDA guidelines and are approved by our Pharmacy and Therapeutics Committee.

Please note:Because prescription drug benefits vary by group, your plan may not cover every drug listed in the formulary. Drug coverage is based on medical necessity. This formulary guide was current at the time of printing and is subject to change. Please call Customer Service at the number listed on the back of your ID card if you have any questions about your prescription drug benefits. Please discuss any questions or concerns about your drug therapy with your provider or pharmacist.

Sincerely,

Independence Administrators

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INFORMATION FOR MEMBERS AND PROVIDERS

Select Formulary Tier Structure Each drug on the formulary is in a tier. The non-preferred tier will usually cost more than the preferred brand tier or generic tier. Below is a summary of tiers in the general order from lowest to highest level of cost-share. Benefits vary by group, the inclusion of a drug in this formulary does not guarantee coverage All cost-share tiers may not be available on all plans. - Low-Cost Generic (availability varies by benefit) - Generic - Preferred Brand - Non-Preferred Drug - Specialty (availability varies by benefit)

• Generally, when a brand drug has a generic equivalent, the brand version is covered at the non-preferred level of cost-sharing. The generic equivalent is covered at the generic level of cost-sharing. For example: Cipro® is a brand drug. It is covered at the non-preferred level of cost-sharing. Its generic equivalent, ciprofloxacin, is available at the generic level of cost-sharing.

• Sometimes brand-name drugs without generic equivalents, authorized generic drugs, and generic drugs are also covered at the non-preferred level of cost-sharing. This is because there are other more cost-effective options covered on the formulary to treat the same condition.

Covered generic drugs not listed in the formulary guide are available at the generic level of cost-sharing; covered brand drugs not listed in the formulary guide are available at the non-preferred level of cost-sharing.

The Low-Cost Generic [LCG] Tier offers copays lower than the cost-share for the generic tier, when possible. This applies to certain generic drugs that are typically used to treat chronic conditions such as high blood pressure, high cholesterol, diabetes, heart failure, and depression. Benefits may vary. Not all plans provide this incentive. The drug list is subject to change. When this incentive is not available on a plan, these drugs will be covered at the generic cost-share level.

Specialty Drugs [SP] meet certain criteria, including, but not limited to drugs used to treat rare, complex, or chronic diseases, drugs that have complex storage and/or shipping requirements, and drugs that require comprehensive patient monitoring and/or education. Specialty drugs covered under the pharmacy benefit may be managed by the FutureScripts® Specialty Pharmacy Program. Benefits may vary, and many plans cover specialty drugs on a specialty tier with higher cost-sharing. For cost-sharing purposes, drugs on the specialty tier are not eligible for tier lowering.

Authorized Generics [AG] are brand-name drugs that are marketed without the brand name on its label. An authorized generic may be marketed by the brand-name drug company, or another company with the brand company’s permission. These drugs are approved by the FDA. But they are not approved through the abbreviated new drug application (ANDA) process like a standard generic drug. For cost sharing purposes, authorized generics are treated as brand-name drugs and are not eligible for coverage on the generic tier(s). For example, oxycodone ER tablet, an authorized generic of brand OxyContin®, is listed as non-preferred and is available at the non-preferred level of cost-sharing.

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Affordable Care Act Preventive Medications [ACA]Certain preventive medications, as described in the Patient Protection and Affordable Care Act (PPACA) and detailed by the U.S. Preventive Services Task Force, are covered without cost-sharing with a prescription when provided by a participating retail or mail-order pharmacy.

This formulary was current at the time of printing and is subject to change. Please understand that this formulary is not intended as a substitute for a provider’s independent, professional judgment. Rather, it is offered as a tool to help Plan members and providers recognize formulary drugs to facilitate the appropriate drug therapy.

The following categories of drugs may be available at no member cost-share with a prescription. Please note that individual benefits may vary. Always refer to your benefits to determine your coverage. This list is subject to change. Refer to the searchable drug lookup tool on your health insurance plan’s website to check the status of a specific drug.

Category Product(s) Available at $0 at the Pharmacy

Aspirin products (OTC)For adults age 50-59 to prevent cardiovascular disease and colorectal cancer; low dose (81mg) for women after 12 weeks’ gestation who are at high risk for preeclampsia

aspirin 81mg (tab/chewable)

Bowel PreparationsBowel preparation for colonoscopy needed forpreventive colon cancer screening, for ages 50-75

generic bowel preparation products such as Gavilyte-C™, Gavilyte-G™, Gavilyte-N™,

Gavilyte-H™ with bisacodyl, polyethylene glycol (PEG) 3350 oral powder,

Trilyte® w/packetsBreast cancer chemo preventionFor asymptomatic females age 35 years and older without a prior diagnosis of breast cancer, ductal carcinoma in situ, or lobular carcinoma in situ, who are at high risk for breast cancer and at low risk for adverse effects from breast cancer chemoprevention

tamoxifen 20mg

ContraceptivesIncludes, but not limited to, oral, injectable, transdermal, diaphragms, cervical caps, intravaginal devices, female condoms, and contraceptive film and jelly (in accordance with the women’s preventive services provisions of the ACA).Note: IUDs and implantable products are covered under the medical benefit.

- Oral: all generics such as Amethia, Cryselle-28, Emoquette, Fayosim, Necon, Ocella, Sprintec, Trivora, Natazia

- Injectable: all generics such as medroxyprogesterone injection

- Transdermal: Xulane® patches- Diaphragms- Cervical Caps- Female condoms- Contraceptive film- Contraceptive gel/jelly/foam: such as VCF® foam

12.5%, 28%, Options Conceptrol® 4%, Options Gynol® 3%

- Emergency: all generics such as levonorgestrel 1.5mg tab, My Way® 1.5mg tab

- Intravaginal devices: etonogestrel-ethinyl estradiol vaginal ring

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Category Product(s) Available at $0 at the Pharmacy

Fluoride For children ages 6 months to 16 years. Includes generics strengths up to 0.5mg

sodium fluoride 1.1 (0.5f) mg/ml solutionsodium fluoride 0.55 (0.25f) mg chewable tab

Fluoritab 0.275 (0.125f) mg/drop solutionFluoritab 1.1 (0.5f) mg chewable tab

Folic acidFor women planning for or capable of pregnancy. Limited to 0.4 to 0.8mg of folic acid.For women younger than 51 years of age

folic acid 400mcg tabfolic acid 800mcg tab

folic acid 0.8mg capsule(including generic prenatal vitamins with

the above listed folic acid dose)Tobacco Cessation MedicationFor adults ages 18 years, who use tobacco products and want to quit

Chantix®

bupropion SR (generic Zyban®) tabletnicotine polacrilex lozenge

nicotine patch 24 hour transdermal Nicotrol® Inhaler

Nicotrol® NS SolutionStatins Low-to-moderate dose statin for prevention of cardiovascular disease, recommended for ages 40-75 years without a history of CVD when 1 or more CVD risk factors are present (e.g., dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year risk of a cardiovascular event of 10% or greater

lovastatin 10mglovastatin 20mglovastatin 40mg

HIV PrEPPreexposure prophylaxis (PrEP) with effective anti-retroviral therapy for persons who are at high risk of HIV acquisition

Truvada 200mg-300mgTenofovir 300mg

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Independence Administrators complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Independence Administrators does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Independence Administrators:• Provides free aids and services to people with disabilities to communicate effectively

with us and written information in other formats, such as large print• Provides free language services to people whose primary language is not English

and information written in other languages

If you need these services, contact our Civil Rights Coordinator.

If you believe that Independence Administrators has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator.

There are four ways to file a grievance directly with Independence Administrators: by mail: • Independence Administrators,

ATTN: Civil Rights Coordinator, 1900 Market Street, Philadelphia, PA 19103; • by phone: 888-356-7899 (TTY 711), • by fax: 215-761-0920, or • by email: [email protected].

If you need help filing a grievance, our Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Independence Administrators or Blue Student Health Languages IA 1 English 11 German 2 Spanish 12 Gujarati 3 Chinese 13 Polish 4 Vietnamese 14 French Creole 5 Russian 15 Mon-Khmer, Cambodia 6 Pennsylvania Dutch 16 Portuguese 7 Korean 17 Navajo 8 Italian 18 Tagalog 9 Arabic 19 Japanese 10 French 20 Persian (Farsi) ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call the number on your ID card (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que aparece en su tarjeta de identificación (TTY: 711). 注意：如果您使用简体中文，您可以免费获得语言协助服务。请致电您ID卡上的电话号码。 LƯU Ý: Nếu quý vị nói tiếng Việt, có dịch vụ trợ giúp ngôn ngữ miễn phí dành cho quý vị. Xin gọi số điện thoại trên thẻ ID của quý vị. ВНИМАНИЕ: Если вы говорите по-русски, вам предлагаются бесплатные услуги переводчика. Позвоните по телефону на вашем удостоверении. ATTENTION: If you speak Pennsylvania Dutch, language assistance services, free of charge, are available to you. Call the number on your ID card. 알림: 한국어 통역서비스가 필요한 분은 귀하의 ID 카드에 나와있는 번호로

전화하십시오. 통역서비스를 무료로 받으실 수 있습니다. ATTENZIONE: se parla italiano, sono disponibili per lei servizi di assistenza linguistica gratuiti. Contatti il numero che vede sulla sua carta d'identità.

اتصل على الرقم الموجود على بطاقة التعريف . إذا كنت تتحدث العربية فإن خدمات المساعدة اللغوية متوفرة لك مجانا : انتباه . الخاصة بك

ATTENTION: Si vous parlez français, des services d'assistance linguistique gratuits sont à votre disposition. Appelez le numéro indiqué sur votre carte d'identité.

HINWEIS: Wenn Sie Deutsch sprechen, steht Ihnen über Language Assistance Services ein Dolmetscher kostenlos zur Verfügung. Wenden Sie sich an die Nummer auf Ihrer ID-Karte. : , , , . ID . UWAGA: jeśli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer podany na Twojej karcie identyfikacyjnej. ATANSYON: Si ou pale kreyòl ayisyen, gen asistans ak lang disponib pou ou gratis. Rele nimewo ki sou do kat idantifikasyon ou a. - ATENÇÃO: se você fala português, serviços de assistência a idioma estão disponíveis gratuitamente para você. Ligue para o número no seu cartão de identificação. BAA !KON&N&ZIN: Din4 bizaad bee y1n7[ti'go, ata' hane' bee 1k1 i'iilyeed t'11 j77k'e bee n1 ah00t'i'. Naaltsoos bee n44h0zingo nanitin7g77 bik'ehgo hane'7 bik11'7g77 bich'8' h0lne'. PAUNAWA: Kung nagsasalita ka ng Tagalog, makakakuha ka ng mga serbisyo ng tulong para sa wika nang walang bayad. Tawagan ang numero sa ID card ninyo. 注意：日本語をお話しになる場合は、言語支援サービスを無料でご利用いただけます。

IDカードの番号にお電話ください。

با شماره . اگر به زبان فارسی صحبت می کنید، خدمات کمک در زمینه زبان، به رایگان در اختیار شما می باشد: توجه .نوشته شده روی کارت عضویت خود تماس بگیرید

HINWEIS: Wenn Sie Deutsch sprechen, steht Ihnen über Language Assistance Services ein Dolmetscher kostenlos zur Verfügung. Wenden Sie sich an die Nummer auf Ihrer ID-Karte.

: , , , . ID .

UWAGA: jeśli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer podany na Twojej karcie identyfikacyjnej.

ATANSYON: Si ou pale kreyòl ayisyen, gen asistans ak lang disponib pou ou gratis. Rele nimewo ki sou do kat idantifikasyon ou a.

-

ATENÇÃO: se você fala português, serviços de assistência a idioma estão disponíveis gratuitamente para você. Ligue para o número no seu cartão de identificação.

BAA !KON&N&ZIN: Din4 bizaad bee y1n7[ti'go, ata' hane' bee 1k1 i'iilyeed t'11 j77k'e bee n1 ah00t'i'. Naaltsoos bee n44h0zingo nanitin7g77 bik'ehgo hane'7 bik11'7g77 bich'8' h0lne'.

PAUNAWA: Kung nagsasalita ka ng Tagalog, makakakuha ka ng mga serbisyo ng tulong para sa wika nang walang bayad. Tawagan ang numero sa ID card ninyo.

注意：日本語をお話しになる場合は、言語支援サービスを無料でご利用いただけます。


با شماره . اگر به زبان فارسی صحبت می کنید، خدمات کمک در زمینه زبان، به رایگان در اختیار شما می باشد: توجه.نوشته شده روی کارت عضویت خود تماس بگیرید

알림: 한국어 통역서비스가 필요한 분은 귀하의 ID 카드에 나와있는 번호로

전화하십시오. 통역서비스를 무료로 받으실 수 있습니다.

ATTENZIONE: se parla italiano, sono disponibili per lei servizi di assistenza linguistica gratuiti. Contatti il numero che vede sulla sua carta d'identità.



Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf die Nummer uff dei ID-Card uff.


Independence Administrators: • Provides free aids and services to people with disabilities to communicate effectively






ATTN: Civil Rights Coordinator, 1900 Market Street, Philadelphia, PA 19103; • by phone: 888-356-7899 (TTY 711),• by fax: 215-761-0920, or• by email: [email protected].


You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800- 537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call the number on your ID card (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que aparece en su tarjeta de identificación (TTY: 711).

注意：如果您使用简体中文，您可以免费获得语言协助服务。请致电您ID卡上的电话号码。

LƯU Ý: Nếu quý vị nói tiếng Việt, có dịch vụ trợ giúp ngôn ngữ miễn phí dành cho quý vị. Xin gọi số điện thoại trên thẻ ID của quý vị.

ВНИМАНИЕ: Если вы говорите по-русски, вам предлагаются бесплатные услуги переводчика. Позвоните по телефону на вашем удостоверении.

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Independence Administrators:• Provides free aids and services to people with disabilities to communicate effectively






ATTN: Civil Rights Coordinator, 1900 Market Street, Philadelphia, PA 19103; • by phone: 888-356-7899 (TTY 711), • by fax: 215-761-0920, or • by email: [email protected].


You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.









: , , , . ID .



-














Independence Administrators: • Provides free aids and services to people with disabilities to communicate effectively






ATTN: Civil Rights Coordinator, 1900 Market Street, Philadelphia, PA 19103; • by phone: 888-356-7899 (TTY 711),• by fax: 215-761-0920, or• by email: [email protected].


You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800- 537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call the number on your ID card (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que aparece en su tarjeta de identificación (TTY: 711).

注意：如果您使用简体中文，您可以免费获得语言协助服务。请致电您ID卡上的电话号码。

LƯU Ý: Nếu quý vị nói tiếng Việt, có dịch vụ trợ giúp ngôn ngữ miễn phí dành cho quý vị. Xin gọi số điện thoại trên thẻ ID của quý vị.

ВНИМАНИЕ: Если вы говорите по-русски, вам предлагаются бесплатные услуги переводчика. Позвоните по телефону на вашем удостоверении.









: , , , . ID .



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: , , , . ID .



-













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Bold type = Brand Name Drug Lower case italic = Generic drug QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost GenericLDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider NF = Non FormularyG = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative DrugMME = Morphine Milligram Equivalent

DRUG NAME DRUG TIER

REQUIREMENTS/ LIMITS

azithromycin LCG QLBactrim,

Bactrim DS NPD

Baraclude NPD, SPBaxdela NPD QL

Benznidazole NPDBiaxin NPD

Biktarvy NPDBiltricide NPDcefaclor G

cefaclor ER Gcefadroxil Gcefdinir G

cefixime susp/cap Gceftibuten G

Ceftin NPDcefuroxime axetil G

cephalexin LCGchlorhexidine gluconate soln LCG

chloroquine phosphate G QL

Cimduo PBCipro NPD

Cipro XR NPDciprofloxacin G

ciprofloxacin ER tabs G

clarithromycin Gclarithromycin

ER G

Cleocin NPDclotrimazole

troches G

Combivir NPDComplera PBCresemba NPD QLCrixivan PB

DRUG NAME DRUG TIER


ANTIBIOTICS & OTHER DRUGS USED FOR INFECTIONabacavir sulfate

tab, soln G

abacavir sulfate/lamivudine G

abacavir/lamivudine/zidovudine

G

Acticlate NPDacyclovir G

acyclovir 5% cream G QL

adefovir dipivoxil G, SPAemcolo DR NPD QLalbendazole G

Altabax NPDamoxicillin LCGAmoxicillin

775mg PB

amoxicillin/clavulanate G

amoxicillin/clavulanate

extended-releaseG

ampicillin GAmzeeq NPDAncobon NPDArakoda NPDArikayce NPD, SPatazanavir Gatovaquone Gatovaquone/

proguanil G

Atripla NPDAugmentin NPD

Augmentin XR NPDAvelox NPDavidoxy G

9


DRUG NAME DRUG TIER

REQUIREMENTS/ LIMITSDRUG NAME DRUG

TIERREQUIREMENTS/ LIMITS

Daklinza NPD, SP QL, Q/Tdapsone tab G

Daxbia NPDDelstrigo NPD

demeclocycline Gdicloxacillin Gdidanosine GDiflucan NPD

Doryx 50mg and 200mg DR

tabletNPD

Dovato NPDdoxycycline DR

40mg G

doxycycline hyclate G

doxycycline hyclate ER 80mg NPD

doxycycline monohydrate G

Edurant PBE.E.S. G

efavirenz GEgaten 250mg

tablet NPD

Emtriva PBEmverm NPD QLentecavir G, SPEpclusa NPD, SP QL, Q/TEpivir NPD

Epzicom NPDEryPed NPDEry-Tab NPD

Erythrocin NPDerythromycin

delayed release G

erythromycin ethylsuccinate G

erythromycin stearate G

ethambutol Gfamciclovir G

Firvanq Soln NPD ALFlagyl NPD

fluconazole LCGflucytosine GFlumadine NPD

fosamprenavir calcium tab G

Fuzeon NPDgriseofulvin microsize G

griseofulvin ultramicrosize G

Gris-PEG NPDHarvoni PB, SP QL, Q/THepsera NPD, SPHiprex NPD

hydroxychlor- oquine G QL

Impavido NPD QLInvirase PBIsentress PBisoniazid LCG

itraconazole Givermectin G

Juluca NPDKaletra Soln NPDKaletra Tabs PB

Kalydeco Tabs/Pack NPD, SP LDD

Keflex NPDketoconazole tab LCG

Krintafel NPDLamisil Tabs NPD

lamivudine G

10


DRUG NAME DRUG TIER



lamivudine/zidovudine G

ledipasvir-sofosbuvir tablet

90-400mgNPD, SP QL

Levaquin NPDlevofloxacin G

Lexiva NPDlinezolid G QLlopinavir/ritonavir G

Luliconazole cream NPD

Macrodantin NPDMalarone NPDMavyret PB, SP QL, Q/T

mefloquine GMepron NPD

methenamine hippurate G

metronidazole GMinocin NPD

minocycline caps Gminocycline ER

cap NPD

minocycline ER tablet G Q/T

minocycline tablet G

Minolira NPD Q/Tmoderiba G, SPMoxatag NPD

moxifloxacin hcl GMyambutol NPDMycobutin NPD

Mytesi NPDNebupent INH NPD

nevirapine G

nevirapine ER Gnitrofurantoin macrocrystals LCG

nitrofurantoin susp G AL

Norvir powder PBNorvir tablet NPD

Noxafil NPD QLNuzyra NPD QLOnmel NPDOracea NPD

Orkambi tablet/packet NPD, SP LDD

oseltamivir caps/soln G QL

Pegasys NPD, SPPegIntron NPD, SPpenicillin v potassium LCG

pentamidine INH GPifeltro NPD

Plaquenil NPD QLposaconazole G QLpraziquantel GPretomanid NPD

Prevymis NPD, SPPrezista PB

pyrimethamin G, SPQualaquin NPD

quinine sulfate GRelenza NPD QL, ALRetrovir NPDReyataz NPD

Ribasphere Ribapak

200mg & 400mg/400mg & 600mg

G, SP

rifabutin GRifadin NPD


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rifampin Grimantadine G

ritonavir GSelzentry PBSeysara NPD Q/TSivextro NPD QL

sofosbuvir-velpatasvir tablet

400-100mgNPD, SP QL

Solodyn NPD QL, Q/TSolosec GRA NPD

Sovaldi NPD, SP QL, Q/TSporanox NPD

SSKI Solution NPDstavudine GStribild PB

Stromectol NPDsulfamethox-

azole/tmp G

Suprax Susp 100mg/5ml, 200mg/5ml

NPD

Sustiva NPDSymfi PB

Symfi-Lo PBSymtuza NPDTalicia NPDTamiflu NPD QL

Targadox NPDTechnivie NPD, SP QL, Q/TTemixys NPDtenofovir G

terbinafine tabs GTindamax NPDtinidazole G

Tobi NPD, SPTobramycin nebulization

soln.PB, SP

Tolsura NPDTrikafta NPD, SPTriumeq PBTrizivir NPDTruvada PB

valacyclovir tab GValcyte NPD

valganciclovir GValtrex NPD

vancomycin GVemlidy NPD, SPVfend NPD

Vibramycin NPDVidex EC NPD

Viekira Pak NPD, SP QL, Q/TViekira XR NPD, SP QL, Q/TViramune NPD

Viramune XR NPDViread NPD

voriconazole GVosevi PB, SP QL, Q/T

Xenleta NPD QLXepi Cream 1% NPDXifaxan 200mg NPD QLXifaxan 550mg NPD QL, Q/T

Ximino ER NPDXofluza therapy

pack NPD Q/T

Zepatier NPD QL, Q/TZerit NPD

Ziagen NPDzidovudine GZithromax NPD QL

Zmax NPD QLZovirax NPDZyvox NPD QL

DRUG NAME DRUG TIER

REQUIREMENTS/ LIMITS DRUG NAME DRUG


CANCER & ORGAN TRANSPLANT DRUGS

abiraterone G, SPAfinitor NPD, SPAlecensa NPD, SPAlkeran NPD, SPAlunbrig tab/pak NPD, SP

anastrazole GArimidex NPDAromasin NPDAyvakit NPD, SP QL

azathioprine GBalversa NPD, SPBenlysta NPD, SP

bexarotene G, SPbicalutamide G

Bosulif NPD, SPBraftovi NPD, SPBrukinsa NPD, SP

Cabometyx NPD, SPCalquence NPD, SP

capecitabine G, SPCaprelsa NPD, SPCasodex NPDCellcept NPD

Cometriq NPD, SPCopiktra NPD, SPCotellic NPD, SP LDD

cyclophos-phamide G, SP

cyclosporine GCytoxan NPD, SPdanazol G

Danocrine NPDDaurismo NPD, SPDeltasone NPD

Emcyt NPD

Erivedge NPD, SPErleada NPD, SPerlotinib G, SPetoposide G, SPEulexin NPD

everolimus (generic for

Afinitor)G, SP

everolimus (generic for

Zortress)G

exemestane GFareston tab NPD

Farydak NPD, SP LDDFemara NPDflutamide GGilotrif NPD, SPGleevec NPD, SP

Gleostine NPD, SPHexalen NPD

Hycamtin NPD, SPHydrea NPD

hydroxyurea GIbrance NPD, SP LDDIclusig NPD, SPIdhifa NPD, SP

imatinib mesylate G, SPImbruvica NPD, SP

Imuran NPDInlyta NPD, SP

Inrebic NPD, SPKisqali NPD, SP LDD

Koselugo NPD, SPLenvima NPD, SP LDDletrozole G

leucovorin calcium G

Leukeran PB

12

DRUG NAME DRUG TIER




leuprolide G, SPLonsurf NPD, SP

Lorbrena NPD, SPLynparza PB, SPLysodren NPDMatulane PB, SP

Mavenclad pak NPD, SPMegace NPD

megestrol Gmegestrol acetate G

Mekinist NPD, SPMektovi NPD, SP

melphalan G, SPmercaptopurine G

Mesnex NPD, SPmethotrexate sodium inj G

methotrexate tab Gmycophenolate Gmycophenolic

acid G

Myfortic NPDMyleran NPDNeoral NPD

Nerlynx NPD, SPNexavar NPD, SP

Nilandron NPD, SPnilutamide G, SP

Ninlaro NPD, SPNubeqa NPD, SPOdomzo NPD, SP

Pemazyre NPD, SPPiqray NPD, SP

Pomalyst NPD, SPprednisone LCG

Prograf cap/packets NPD

Protopic NPD

Purixan NPD, SPRapamune 1mg/ml Sol NPD

Rapamune tab NPDRevlimid NPD, SPRozlytrek NPD, SPRubraca PB, SPRydapt NPD, SP

Sandimmune, Neoral NPD

Siklos NPDsirolimus tab/

soln G

Sprycel NPD, SPStivarga NPD, SPSutent NPD, SPTabloid NPD

tacrolimus GTafinlar NPD, SPTagrisso NPD, SPTalzenna NPD, SP

tamoxifen 10mg GTarceva NPD, SP

Targretin cap NPD, SPTasigna NPD, SP

Tazverik 200mg NPD, SPTemodar NPD, SP

temozolomide G, SPThalomid NPD, SP

thioguanine GTibsovo NPD, SP

toremifene tab Gtretinoin caps G, SPTrexall tab NPD

Tukysa NPD, SPTuralio NPD, SPTykerb NPD, SP

Valchlor NPD, SP

13

DRUG NAME DRUG TIER




14

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



Venclexta NPD, SPVerzenio NPD, SPVitrakvi NPD, SPVizimpro NPD, SPVotrient NPD, SPXalkori NPD, SPXatmep NPD ALXeloda NPD, SPXospata NPD, SP

Xpovio Pak NPD, SPXtandi NPD, SP LDDYonsa NPD, SPZejula PB, SP LDD

Zelboraf NPD, SP LDDZolinza NPD, SP LDDZortress NPDZydelig NPD, SP LDDZykadia NPD, SP LDDZytiga NPD, SP LDD

PAIN, NERVOUS SYSTEM, & PSYCH

Abilify NPDAbilify Mycite NPD

Abstral NPD QL, MMEacamprosate DR

tab 333mg G

acetaminophen/codeine LCG AL, QL, 5DS,

MMEActiq NPD QL, MME

Adderall NPD QLAdderall XR NPD QLAdhansia XR

Capsule NPD QL

Adipex-P NPD RAdzenys ER

Susp NPD QL

Adzenys XR ODT NPD QL

Aimovig PBAjovy PB

Allzital 25- 325mg NPD QL, 5DS

almotriptan maleate G QL, AL

alprazolam G ALalprazolam ER G AL

amantadine GAmbien NPD QL

Ambien CR NPD QLAmerge NPD QL, AL

amitriptyline hcl LCGamoxapine G

amphetamine aspartate/

amphetamine sulfate/dextro-amphetamine

G QL

amphetamine aspartate/

amphetamine sulfate/dextro-

amphetamine ER

G QL

amphetamine tablet G QL

amphetamine tablet (generic

Evekeo)G QL

amphetamine ER suspension NPD QL

Anafranil NPDAntabuse NPDApadaz NPD QL, 5DS, MME

Aplenzin NPDAptensio XR NPD QL

Aptiom NPDAricept NPD AL

aripiprazole Garmodafinil G

15

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



Arymo ER NPD QL, MMEAtivan NPD AL

atomoxetine G QLAubagio NPD, SPAustedo NPD, SPAvonex PB, SP QLAxert NPD QL, ALAzilect NPDBanzel NPD

Banzel Susp NPD ALBelbuca PB QL, MME

Belsomra NPD QLBelviq [XR] NPD R

benzphetamine G Rbenzhydro-

codone-aceta-minophen

NPD QL, 5DS, MME

benztropine LCGBetaseron PB, SP QLBrisdelle NPDBriviact NPD

Briviact soln NPD ALbromocriptine

mesylate G

Bunavail NPD QLbuprenorphine

hcl/naloxone hcl G QL

buprenorphine patch G QL, MME

buprenorphine SL G QLbupropion G

bupropion ER 150mg G QL

bupropion ER 450mg NPD

bupropion SR Gbupropion XL G

Buspar NPD

buspirone Gbutalbital-

acetaminophen 50-325mg

G QL, 5DS

butalbital-acetaminophen

50-300mgNPD QL, 5DS

butalbital/apap/caffeine G QL, 5DS

butalbital/apap/caffeine/codeine G QL, 5DS, AL,

MMEbutalbital/

aspirin/caffeine/codeine

G QL, 5DS, AL, MME

butorphanol tartrate nasal G QL, 5DS, AL,

MMEButrans NPD QL, MMECafergot NPDCaplyta NPD

carbamazepine Gcarbamazepine

susp G AL

carbamazepine XR G

Carbatrol NPDcarbidopa Gcarbidopa/levodopa G

carbidopa/levodopa ER G

carbidopa/levodopa ODT G

carbidopa/levodopa/

entacaponeG

carisoprodol-aspirin-codeine G QL, 5DS, AL,

MMECelexa NPD

Celontin PBChantix ACA QL

chlordiazepoxide LCG AL

16

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



chlorpromazine HCl G

citalopram Gclobazam G

clobazam susp G ALclomipramine

HCl G

clonazepam LCGclorazepate dipotassium G AL

clozapine Gclozapine ODT G

Clozaril NPDcodeine tabs LCG QL, 5DS, AL, MME

Comtan NPDConcerta NPD QL

Contrave ER NPD RConzip NPD AL, QL, MME

Copaxone PB, SP QLCotempla XR

ODT NPD QL

Cymbalta NPDDantrium NPDdantrolene NPD

Daypro NPDDaytrana NPD QLDayvigo NPD QLDemerol NPD QL, 5DS, MME

Depakene NPDDepakote NPD

Depakote ER NPDDepakote

Sprinkle Caps NPD

desipramine GDesoxyn NPD QL

Desvenlafaxine ER 24 HR PB

Dexedrine NPD QL

dexmethyl-phenidate ER G QL

dexmethyl-phenidate hcl G QL

dextroam-phetamine G QL

dextroam-phetamine ER G QL

D.H.E.45 NPDDiacomit NPD, SPDiastat NPD

diazepam LCGdiazepam rectal gel G

diclofenac potassium G

diclofenac sodium G

diclofenac sodium gel 1% G

diethylpropion G Rdiflunisal G

dihydrocodein/APAP/caff G QL, 5DS, AL,

MMEdihydrocodeine/aspirin/caffeine G QL, 5DS, AL,

MMEdihydroergo-

tamine inj G

dihydroergo-tamine

nasal sprayG

Dilantin chewable tablets PB

Dilaudid NPD QL, 5DS, MMEdisulfiram Gdivalproex

sodium G

divalproex sodium ER G

17

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



divalproex sprinkle cap G

Dolophine NPD QL, MMEdonepezil

hydrochloride G AL

Doral NPD ALdoxepin capsule Gdoxepin tablet G

Drizalma Sprinkle NPD

duloxetine GDuragesic patch NPD QL, MME

Dyanavel XR NPD QLEffexor XR NPD

Eldepryl NPDeletriptan G QL, ALEmbeda NPD QL, MMEEmgality PB QL

endocet G 5DS, QL, MMEentacapone G

Epidiolex Soln NPD, SPergotamine

tartrate/caffeine G

escitalopram GEsgic capsule G QL, 5DSEsgic tablet NPD QL, 5DSestazolam G QL, AL

eszopiclone G QL (3mg only)ethosuximide G

etodolac GEvekeo [ODT] NPD QL

Evzio NPD QLExalgo NPD QL, MMEExelon NPD ALExtavia NPD, SPFanapt NPDFazaclo NPD

felbamate G

Felbatol NPDFeldene NPD

fenoprofen calcium NPD

fentanyl citrate OTFC G QL, MME

Fentanyl citrate tablet NPD QL, MME

fentanyl transdermal G QL, MME

Fentora NPD QL, MMEFetzima NPDFioricet NPD QL, 5DSFioricet

with codeine NPD QL, AL, 5DS, MME

Fiorinal with codeine NPD QL, AL, 5DS,

MMEfluoxetine G QL (Weekly Only)

fluphenazine Gflurazepam G QL, ALflurbiprofen Gfluvoxamine G

fluvoxamine ER GFocalin NPD QL

Focalin XR NPD QLForFivo XL NPD

Frova NPD QL, ALfrovatriptan

succinate NPD QL, AL

Fycompa NPDgabapentin G

gabapentin soln G ALGabitril NPD

galantamine G ALgalantamine ER G AL

Geodon NPDGilenya NPD, SP

glatiramer acetate G, SP QL

18

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



glatopa G, SP QLGocovri NPD

guaifenesin-codeine soln

10mg/5mlLCG QL, AL, 5DS,

MME

guanfacine ER G QLHalcion NPD QL, AL

haloperidol LCGHetlioz NPD, SP QL

Horizant NPDhydrocodone ER G QL, MME

hydrocodone/acetaminophen G QL, 5DS, AL,

MMEhydrocodone-

homatropine tab LCG QL, 5DS, AL, MME

hydromorphone ER G QL, MME

hydromorphone IR G QL, 5DS, MME

Hysingla ER NPD QL, MME

Ibudone NPD QL, AL, 5DS, MME

ibuprofen/hydrocodone G QL, 5DS, MME,

ALimipramine G

Imitrex NPD ALInbrija NPD, SP

Indocin susp NPD ALIngrezza NPD, SP

Intermezzo NPD QLIntuniv NPD QL

Invega ER tablet NPD

isometheptene/dichloralphen-

azone/apapG

Jakafi NPD, SP LDDJornay PM

Capsule NPD QL

Kadian ER NPD QL, MMEKapvay NPD QLKeppra NPD

Keppra XR NPDketoprofen Gketorolac LCGKhedezla NPDKlonopin NPDLamictal NPD

Lamictal ODT NPDLamictal XR NPDlamotrigine G

lamotrigine ER Glamotrigine ODT G

Latuda NPDLazanda NPD QL, MME

levetiracetam Glevetiracetam ER G

levorphanol G QL, 5DS, MMELexapro NPDLibrax NPDlithium

carbonate LCG

lithium carbonate ER LCG

Lithobid NPDLodine NPD

Lodosyn NPDLomaira NPD R

lorazepam LCG ALLortab NPD QL, 5DS, ALloxapine G

Lucemyra NPD QL, Q/TLunesta NPD QLLyrica NPD

Lyrica CR NPDmaprotiline G

19

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



Maxalt, Maxalt-MLT NPD AL, QL

Mayzent tablet, starter pak NPD, SP

meclofenamate Gmemantine G AL

memantine ER G ALmeperidine HCl G QL, 5DS, MMEmeprobamate G

Mestinon syrup NPD ALMestinon tablet NPD

methadone G QL, MMEmethamphet-

amine NPD QL

methocarbamol GMethylin NPD QL

methylphenidate G QLmethylphenidate

ER G QL

methylphenidate ER (CD) G QL

methylphenidate ER (LA) G QL

Midrin NPDMigranal NPDMirapex NPD

Mirapex ER NPDmirtazapine Gmodafinil G

molindone hcl GMorphaBond

ER NPD QL, MME

morphine IR G QL, 5DS, MMEmorphine sulfate

ER G QL, MME

morphine suppositories G QL, 5DS, MME

MS Contin NPD QL, MME

Mydayis NPD QLMysoline NPD

nabumetone GNalfon NPDNalocet NPD QL, 5DS, MME

Naloxone Injection 2mg NPD QL

naltrexone 50mg GNamenda [XR] NPD AL

Namzaric NPD ALnaratriptan G QL, AL

Narcan 4mg/actuation spray PB QL

Nardil NPDNayzilam NPD QLnefazodone GNeurontin NPD

Neurontin soln NPD ALNorpramin NPDnortriptyline G

nortriptyline soln G ALNourianz NPDNucynta NPD QL, 5DS, MME

Nucynta ER NPD QL, MMENuplazid NPD

Nurtec chw 75mg ODT NPD QL

Nuvigil NPDolanzapine G

olanzapine ODT Golanzapine/

fluoxetine hcl G

Onfi NPDOnfi Susp NPD AL

Onzetra Xsail NPD QL, ALOpana NPD QL, 5DS, MME

Opana ER NPD QL, MMEOrap NPD

20

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



pimozide Gpiroxicam GPlegridy PB, SP QL

pramipexole Gpramipexole ER G

pregabalin Gprimidone LCGPrimlev NPD QL, 5DS, MMEPristiq NPD

Procentra 1mg/ml NPD QL

Prolate tab NPD QL, 5DS, MMEpromethegan

supp LCG

Provigil NPDProzac NPD

pyridostigmine Gpyridostigmine

soln G AL

Qmiiz ODT NPDQsymia ER NPD Rquazepam G QL, AL

Qudexy XR NPDquetiapine ER G

quetiapine fumarate G

Quillichew ER NPD QLQuillivant XR NPD QL

ramelteon G QLrasagiline GRazadyne NPD AL

Razadyne ER NPD ALRebif Rebidose NPD, SP

Regimex NPD RRelafen DS NPD

Relpax NPD QL, ALRemeron NPDRemeron SolTab NPD

Osmolex ER NPDoxaprozin GOxaydo NPD QL, 5DS, MME

oxazepam G ALoxcarbazepine GOxtellar XR NPD

oxycodone ER tablet NPD QL, MME

oxycodone IR G QL, 5DS, MMEoxycodone/

acetaminophen G QL, 5DS, MME

oxycodone/aspirin G QL, 5DS, MME

oxycodone/ibuprofen G QL, 5DS, MME

OxyContin NPD QL, MMEoxymorphone ER G QL, MMEoxymorphone IR G QL, 5DS, MMEpaliperidone er

tablet G

Pamelor NPDParlodel NPDParnate NPD

paroxetine Gparoxetine ER G

Paxil NPDPaxil CR NPD

pentazocine-naloxone G QL, 5DS, MME

Percocet NPD QL, 5DS, MMEperphenazine G

phendimetrazine tartrate G R

phenelzine Gphenobarbital G

phentermine hcl G RPhenytek NPDphenytoin LCG

21

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER


Requip NPDRequip XL NPD

Restoril NPD ALRexulti NPDReyvow NPD QL, ALRilutek NPDriluzole G

Risperdal, Risperdal

M-TabNPD

risperidone GRitalin LA NPD QLrivastigmine G ALrizatriptan benzoate G QL, AL

Robaxin NPDropinirole G

ropinirole ER GRoxicodone NPD QL, 5DS, MMERoxybond NPD QL, 5DS, MMERozerem NPD QLRytary NPDSabril NPD, SP

Saphris NPDSaxenda NPD R

Secuado Patch NPDselegiline HCl G

Seroquel NPDSeroquel XR NPD

sertraline GSilenor NPDSinemet NPD

Sinemet CR NPDSonata NPD QLSprix

Nasal Spray NPD QL

Stalevo NPDStrattera NPD QL

Suboxone Sublingual Film PB QL

Subsys NPD QL, MMEsulindac G

sumatriptan G QL, ALsumatriptan/

naproxen G QL

Sunosi PBSylatron NPD, SPSymbyax NPD

Sympazan Film NPDTasmar NPD

Tecfidera PB, SP LDDTegretol susp NPD ALTegretol [XR] NPD

temazepam LCG QL, ALtetrabenazine G, SPthioridazine LCGthiothixene G

tiagabine hcl GTiglutik Susp NPD, SP

Tivorbex NPDTofranil NPDtolcapone G

tolmetin sodium GTopamax NPDTopamax Sprinkle Capsules

NPD

topiramate Gtopiramate

sprinkle cap G

Tosymra Nasal Solution NPD QL, AL

tramadol G QL, AL, MMEtramadol ER cap NPD QL, AL, MME

tramadol ER (biphasic) tablet G QL, AL, MME

DRUG NAME DRUG TIER


22

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



tramadol ER tablet G QL, AL, MME

tramadol/acetaminophen LCG QL, AL, MME

Tranxene T NPD ALtranycypromine

sulfate G

trazodone LCGTreximet NPD QL, AL

Trezix NPDtriazolam G QL, AL

trifluoperazine Gtrihexyphenidyl LCG

Trileptal NPDtrimipramine G

Trintellix NPDTrokendi XR NPDtrymine CG

liquid LCG AL, QL, 5DS, MME

Tylenol w/Codeine NPD AL, QL, 5DS,

MMEUbrelvy NPD QL, ALUltracet NPD QL, AL, MMEUltram NPD QL, AL, MMEValium NPD

valproic acid GValtoco NPD QL

Vanatol S/LQ NPD QL, 5DSvenlafaxine G

venlafaxine ER Gvigabatrin G, SPvigadrone G, SP

Vimpat tab, soln NPDVivlodex NPDVraylar NPDVyvanse PB QLWakix NPD, SP QL

Wellbutrin SR NPD

Wellbutrin XL NPDXadago NPDXanax NPD AL

Xanax XR NPD ALXcopri pak/tab NPD

Xenazine NPD

Xodol, Norco NPD QL, 5DS, AL, MME

Xtampza ER PB QL, MMEXyrem NPD, SP QLzaleplon G QL

Zarontin NPDZembrace Symtouch NPD QL

Zenzedi NPD QLziprasidone G

Zohydro ER NPD QL, MMEzolmitriptan G QL, AL

Zoloft NPDzolpidem tartrate G QL (10mg only)zolpidem tartrate

ER G QL (12.5mg only)

zolpidem tartrate SL G QL (3.5mg only)

Zomig NPD QL, ALZonegran NPD

zonsinamide GZorvolex NPDZubsolv PB QLZyban NPD QL

Zyprexa NPDZyprexa Zydis NPD

HEART, BLOOD PRESSURE, & CHOLESTEROL

Accupril NPDAccuretic NPDacebutolol G

acetazolamide G

23

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



acetazolamide ER G

Actimmune NPD, SPAdalat CC NPD

Adcirca NPD, SPAdempas PB, SPAdvate PB, SP

Adynovate NPD, SPAfstyla NPD, SP

Aggrenox NPDAgrylin NPD

Aldactazide NPDAldactone NPDaliskiren G

Alphanate NPD, SPAlphanine NPD, SPAlprolix NPD, SP LDDAltace NPD

Altoprev NPDambrisentan G, SP

Amicar NPDamiloride LCG

amiloride/HCTZ LCGaminocaproic

acid G

amiodarone Gamlodipine Gamlodipine besylate/

olmesartanG

amlodipine/benazepril G

amlodipine/valsartan G

amlodipine/valsartan/HCTZ G

anagrelide GAntara NPDArixtra NPD

aspirin-dipyridamole er G

Atacand NPDAtacand HCT NPD

atenolol LCGatenolol/

chlorthalidone G

atorvastatin Gatorvastatin/amlodipine G

Avalide NPDAvapro NPD

Azor NPDBebulin NPD, SP

benazepril LCGbenazepril/HCTZ G

BeneFIX PB, SPBenicar NPD

Benicar HCT NPDBetapace AF NPD

betaxolol GBevyxxa NPD QLbisoprolol LCG

bisoprolol/HCTZ Gbumetanide G

Bystolic PBByvalson NPDCaduet NPDCalan NPD

Calan SR NPDcandesartan Gcandesartan/hydrochloro-

thiazideG

captopril Gcaptopril/HCTZ G

Cardizem NPDCardizem CD NPD

24

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



Cardizem LA NPDCardura NPDCarospir NPD

Cartia XT LCGcarvedilol [ER] G

Catapres tablets NPDCatapres-TTS NPDchlorothiazide Gchlorthalidone LCGcholestyramine Gcholestyramine

light G

cilostazol Gclonidine ER

12 HR tab G QL

clonidine IR tablet LCG

clonidine patches Gclopidogrel GCoagadex NPD, SP

colesevelam GColestid NPD

colestipol HCl GCoreg NPD

Coreg CR NPDCorgard NPDCorifact NPDCorlanor NPDCorzide NPD

Coumadin PBCozaar NPDCrestor NPD

Demadex NPDDibenzyline NPD

digoxin LCGDilt-CD G

diltiazem HCl Gdiltiazem HCl CD LCG

diltiazem HCl ER LCGdiltiazem HCl LA LCGdiltiazem HCl SR LCG

Diltzac ER GDiovan NPD

Diovan HCT NPDdipyridamole Gdisopyramide G

dofetilide Gdoxazosin mesylate LCG

Durlaza NPDDutoprol NPDDyazide NPD

Dyrenium NPDEdarbi NPD

Edarbyclor NPDEdecrin NPDEffient NPDEliquis PBEloctate NPD, SPenalapril G

enalapril/HCTZ LCGenoxaparin GEntresto PB QL

Epaned Sol 1mg/ml NPD AL

eplerenone Geprosartan GEsperoct NPD, SP

ethacrynic acid GExforge NPD

Exforge HCT NPDEzzalor

Sprinkle Cap NPD

ezetimibe Gezetimibe/

simvastatin G

25

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



Feiba NPD, SPfelodipine ER G

fenofibrate Gfenofibrate

nanocrystallized G

fenofibric acid GFenoglide NPDFibricor NPDflecainide G

Flolipid susp NPD ALfluvastatin

sodium G

fondaparinux Gfosinopril LCG

fosinopril/HCTZ LCGFragmin NPD

furosemide LCGgemfibrozil Gguanfacine G

Helixate FS PB, SPHemlibra Soln NPD, SP

Hemofil M NPD, SPHumate-P PB, SPhydralazine LCGhydrochloro-

thiazide LCG

Hyzaar NPDindapamide LCGInderal LA NPD

InnoPran XL NPDInspra NPD

irbesartan Girbesartan

hydrochloro-thiazide

G

Isordil Titradose Tabs NPD

isosorbide dinitrate G

isosorbide dinitrate ER G

isosorbide mononitrate LCG

isosorbide mononitrate ER LCG

isradipine GIxinity NPD, SP

Jantoven LCGJivi NPD, SP

Juxtapid NPD, SPKapspargo NPD

Katerzia Susp NPD ALKoate-DVI NPD, SP

Kogenate FS PB, SPKynamro NPD, SP

labetalol HCl GLanoxin NPD

Lasix NPDLescol NPD

Letairis NPD, SPLipitor NPDLipofen NPDlisinopril LCG

lisinopril/HCTZ LCGLivalo NPDLopid NPD

Lopressor HCT NPDlosartan G

losartan-HCTZ GLotensin NPD

Lotrel NPDlovastatin GLovaza NPD

Lovenox NPDMaxzide NPD

methyldopa LCGmetolazone G

26

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



metoprolol succinate LCG

metoprolol tartrate LCG

metoprolol tartrate/HCT LCG

Mevacor NPDmexiletine HCl G

Micardis NPDMicardis HCT NPD

Microzide NPDMinipress NPDminitran LCGminoxidil LCGmoexipril LCG

moexipril/HCTZ GMonoclate-P NPD, SP

Mononine PB, SPMulpleta NPD, SPMultaq PBnadolol Gnadolol-

bendroflume thiazide

G

Nexletol NPDNexlizet NPD

niacin ER GNiaspan NPD

nicardipine GNifedical XL G

nifedipine Gnifedipine ER Gnimodipine G

nisoldipine ER GNitro-Bid PBNitro-Dur NPD

nitroglycerin ER LCGnitroglycerin

patches LCG

nitroglycerin SL LCGnitroglycerin

spray LCG

Nitrolingual Spray NPD

Nitromist NPDNitrostat SL NPDNocdurna SL NPD

Norpace NPDNorthera NPD, SPNorvasc NPD

Novoeight NPD, SPNovoSeven RT NPD, SP

Nuwiq NPD, SPObizur NPD

olmesartan medoxomil G

olmesartan/amlodipine/hctz G

olmesartan/hctz Gomega-3 acid ethyl esters G

Opsumit NPD, SPOrenitram NPD, SPPacerone G

pentoxifylline ER Gperindopril GPersantine NPD

phenoxybenz-amine hcl G

pindolol ER GPlavix NPD

Pradaxa PBPraluent PBprasugrel GPravachol NPDpravastatin G

prazosin G

27

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



Prevalite GPrinivil NPD

Procardia NPDProcardia XL NPD

Profilnine NPD, SPPromacta NPD, SP

propafenone Gpropafenone ER G

propranolol LCGpropranolol ER LCG

propranolol/HCTZ G

Qbrelis NPD ALQuestran NPD

Questran Light NPDquinapril LCG

quinapril/HCTZ LCGramipril GRanexa NPD

ranolazine tab ER G

Rebinyn Soln NPD, SPRecombinate PB, SP

Repatha PBRevatio NPD, SPRiastap NPDRixubis NPD, SP

rosuvastatin GRythmol NPD

Rythmol SR NPDSamsca NPD, SP LDD

sildenafil citrate 20mg tab,

10mg/ml suspG, SP

sildenafil citrate 25mg, 50mg,

100mgG QL

simvastatin Gsimvastatin susp NPD AL

sotalol HCl GSotylize soln NPD

spironolactone LCGspironolactone/

HCTZ LCG

Stimate NPDSular NPD

tadalafil (generic Adcirca) G, SP

tadalafil (generic Cialis) G QL

Tarka NPDTaztia XT LCGTekturna/

Tekturna HCT NPD

telmisartan Gtelmisartan-amlodipine G

telmisartan/hydrochloro-

thiazideG

Tenoretic NPDTenormin NPDtiadylt ER LCG

Tiazac NPDticlopidine HCl G

Tikosyn NPDtimolol LCG

Toprol XL NPDtorsemide LCGTracleer PB, SP LDD

trandolapril Gtrandolapril/verapamil ER G

Tretten NPD, SPtriamterene/

HCTZ LCG

triamterene cap GTribenzor NPD

28

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



Tricor NPDTrilipix NPDTwynsta NPDTyvaso NPD, SPUptravi NPD, SPvalsartan Gvalsartan/

hydrochloro-thiazide

G

Vascepa NPDVaseretic NPDVasotec NPDVecamyl GVentavis NPD, SP

verapamil HCl Gverapamil HCl

ER G

Verelan ER, PM LCGVonvendi NPD, SPVyndaqel, Vyndamax NPD, SP

Vytorin NPDwarfarin LCGWelchol NPDWilate NPD, SPXarelto PBXyntha PB, SP

Zestoretic NPDZestril NPDZetia NPDZiac NPD

Zocor NPDZypitamag NPD

SKIN MEDICATIONS

Absorica NPDAbsorica LD NPD

Acanya NPD

acitretin Gacyclovir GAczone NPD AL

Adapalene 0.1% lotion NPD AL

adapalene 0.1% soln G AL

adapalene 0.3% gel G AL

adapalene cream G ALadapalene-

benzoyl-peroxide gel 0.1-2.5%

G AL

adapalene pad 0.1% NPD AL

Aklief Cream 0.005% NPD AL

Aktipak NPDala-cort cream LCGalclometasone

cream, ointment G

Aldara NPDAltreno

0.05% lotion NPD AL

amcinonide Ganthralin G

ApexiCon E NPDArazlo lotion

0.045% NPD

Atralin NPD ALAvita G AL

azelaic acid gel 15% G

Azelex NPDBenzaclin NPD

Benzamycin gel NPDBenzamycinpak NPD

benzoyl peroxide/erythromycin G

29

DRUG NAME DRUG TIER



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betamethasone dipropionate G

betamethasone valerate G

betamethasone/clotrimazole G

Bryhali lotion 0.01% NPD

calcipotriene cream G

calcipotriene foam NPD

calcipotriene-betamethasone dp

ointG

calcipotriene-betamethasone dp

suspNPD

calcitriol ointment G

Capex NPDCarac NPD

ciclopirox 0.77% cream G

ciclopirox 8% solution G

ciclopirox cream, gel, shampoo,

suspensionG

Cleocin T NPDClindagel NPD

clindamycin, clindamycin-

benzoyl peroxide gel [w/pump]

G

clindamycin/ benzoyl peroxide

1-5%NPD

clindamycin/tretinoin gel G AL

clobetasol cream, ointment,

solutionG

Clobex NPDclocortolone

pivalate NPD

clodan GCloderm NPDCondylox NPDCordran NPDCosentyx NPD, SP

Crotan lotion GCutivate NPD

dapsone gel 5% G ALdapsone gel

7.5% NPD AL

Denavir NPD QLDerma-Smoothe

FS NPD

Dermatop NPDDesonate NPDDesowen NPD

desoximetasone cream, gel, ointment

G

diclofenac 3% gel G

Differin 0.1% cream NPD AL

Differin 0.1% lotion NPD AL

Differin 0.3% gel NPD AL

diflorasone diacetate NPD

Diprolene, Diprolene AF NPD

Dovonex cream NPDdoxepin cream

5% G QL

30

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



Duac NPDDuobrii Lotion NPD

Dupixent PB, SPeconazole G

Ecoza NPDEfudex cream NPD, SP

Elidel NPDElimite NPDElocon NPDEnstilar NPDEpiduo NPD AL

Epiduo Forte gel PB AL

Ertaczo NPDErygel NPD

erythromycin gel, soln, swabs G

Eucrisa PBEurax Lotion NPD

Evoclin NPDExelderm NPD

Extina NPDFabior NPD AL

Fasenra PB, SPFinacea NPD

fluocinolone acetonide cream,

sol, oilG

fluocinonide gel, ointment G

Fluorouracil cream 0.5% PB

fluorouracil solution 2% G, SP

flurandrenolide cream, lotn, oint NPD

fluticasone propionate G

gentamicin topical cream,

ointmentG

halcinonide cream 0.1% G

halobetasol propionate G

halobetasol propionate foam

0.05%NPD

Halog NPDhydrocortisone

2.5% LCG

hydrocortisone butyrate 0.1% G

hydrocortisone lot 0.1% LCG

hydrocortisone butyrate/emoll G

hydrocortisone supp G

hydrocortisone valerate 0.2% G

hydrocortisone/lidocaine HCl G

imiquimod cream GImiquimod

Cream 3.75% Pump

NPD

Impoyz Cream 0.025% NPD

isotretinoin GJublia NPD

Kenalog Spray NPDKerydin NPD

ketoconazole cream G

ketoconazole shampoo G

Klaron NPD

31

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



Lexette Foam 0.05% NPD

lidocaine patch 5% G

lidocaine solution, gel,

ointmentG

Lidoderm NPDLocoid NPDLocoid

Lipocream NPD

Loprox NPDLotrisone NPD

Luxiq NPDLuzu NPD

malathion lotion Gmethoxsalen G

MetroCream NPDMetroGel NPD

MetroLotion NPDmetronidazole

cream, lotion, gel G

miconazole-zinc ointment NPD

Mirvaso PBmometasone

cream, ointment, solution

LCG

mupirocin cream, ointment G

naftifine cream, gel G

Naftin NPDNatroba NPDNizoral

shampoo NPD

Noritate NPDnystatin/

triamcinolone cream, ointment

G

Olux [E] NPDOnexton NPD

Ovide NPDoxiconazole

nitrate NPD

Oxistat NPDOxsoralen Ultra NPD

Pandel NPDPenlac NPD

permethrin Gpimecrolimus cre

1% G

podofilox soln Gprednicarbate

ointment G

prilocaine/lidocaine G

Proctofoam HC PBPrudoxin cream

5% NPD QL

Qbrexza Pad 2.4% NPD QL

Retin-A NPD ALRetin-A Micro NPD AL

Rhofade 1% cream NPD

Sernivo NPDSiliq NPD, SP

Silvadene NPDsilver

sulfadiazine LCG

Skyrizi Inj PB, SPsodium

sulfacetamide suspension

G

Solaraze NPDSoolantra PBSoriatane NPDspinosad G

32

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



sulconazole cream/solution NPD

Sulfamylon NPDSynalar NPDTaclonex NPD

Taltz Autoinjector NPD, SP

Targretin gel PBtazarotene cream

0.1% G AL

Tazorac cream 0.1% NPD AL

Temovate NPDTopicort NPDTremfya PB, SP

tretinoin gel, cream G AL

tretinoin microspheres gel NPD AL

triamcinolone acetonide LCG

triamcinolone oint 0.05% NPD

Trianex NPDtriderm cream LCG

Ultravate NPDVectical NPDVeltin NPD AL

Verdeso NPDVusion NPDXolegel NPDZiana NPD AL

Zonalon cream 5% NPD QL

Zovirax cream NPD QLZovirax oint NPDZtlido Patch NPD QL

EAR, NOSE, THROAT MEDICATIONS

acetasol HC, acetic acid HC

oticLCG

azelastine GBactroban nasal

oint PB

Cetraxal NPDcevimeline hcl G

Ciprodex PBciprofloxacin LCGciprofloxacin-

fluocinolone PF otic soln

NPD

cortane B otic drops G

Dermotic NPDEvoxac NPD

fluocinolone acetonide oil G

mometasone furoate nasal spray G

Nasonex NPDneomycin/polymyxin/

hydrocortisoneLCG

ofloxacin otic LCGolopatadine GOmnaris NPDPatanase NPD

pilocarpine HCl GQnasl NPD

ribavirin G, SPSalagen NPDVirazole NPD, SPXhance NPDZetonna NPD

33

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DRUG NAME DRUG TIER



DIABETES, THYROID, STEROIDS, & OTHER MISCELLANEOUS HORMONES

acarbose GActos NPD

Adlyxin NPDAdmelog NPD QLAfrezza NPD

Alogliptin benz/metformin hcl PB

Alogliptin benz/pioglitazone PB

Alogliptin benzoate PB

Amaryl NPDAndroderm

patch NPD

Androgel 1.62% Packet, Pump NPD

Androgel 1% NPDApidra NPD QL

Aveed Soln NPDAxiron NPD

Baqsimi PBBasaglar NPD QLBreeze2

Glucometer PB QL

Breeze2 Test Strips NPD QL

Bydureon PBByetta PB

calcitriol capsules G

Carnitor NPDCetrotide Kit NPD, SP R

cinacalcet GContour

Glucometer PB QL

Contour Next Test Strips NPD QL

Contour Test Strips NPD QL

Cortef NPDCytomel NPDdanazol GDDAVP NPD

Delatestryl NPDDepo-

Testosterone NPD

desmopressin acetate G

Dexabliss tab 1.5mg NPD

dexamethasone Gdexamethasone

tablet 6-day, 10-day, 13-day

G

Dexcom Continuous

Glucose Monitor Receiver

NPD

Dexcom Continuous

Glucose Monitor

Transmitter

NPD

Dexcom Continuous

Glucose Monitor G6,

G5, G4 Sensors

NPD

Dexpak pak 10-day, 13-day NPD

diazoxide suspension 50mg/ml

G

doxercalciferol GDuetact NPD

Dxevo 11-day Pak 1.5mg NPD

Emflaza NPDeuthyrox LCG

34

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER


Farxiga PBFiasp NPD QL

fludrocortisone acetate LCG

Fortamet NPDForteo NPD, SP Q/T

Fortesta NPDFreestyle

Glucometer PB QL

Freestyle InsuLinx

Test StripsNPD QL

Freestyle Lite Test Strips NPD QL

Freestyle Test Strips NPD QL

Genotropin NPD, SPglimepiride LCG

glipizide LCGglipizide ER LCGglipizide XL LCG

Glucagen Inj Hypokit NPD

Glucagon Emergency Kit PB

Glucophage NPDGlucophage XR NPD

Glucotrol NPDGlucotrol XL NPDGlucovance NPD

glyburide LCGglyburide

micronized LCG

Glynase NPDGlyset NPD

Glyxambi PBGvoke hypo inj PBGvoke PFS inj PB

Hectorol NPDHumalog NPD QL

Humatrope NPD, SPHumulin NPD QL

hydrocortisone LCGIncrelex NPD, SP LDD

insulin aspart inj NPD QLinsulin aspart protamin inj

flexpen NPD QL

insulin lispro 100 units/ml NPD QL

insulin lispro inj junior NPD QL

insulin lispro inj protamin NPD QL

Invokamet [XR] NPDInvokana NPDJanumet PB

Janumet XR PBJanuvia PB

Jardiance PBJatenzo NPD

Jentadueto tablet NPD

Jentadueto XR NPDKazano tablet NPD

Kombiglyze XR PBKorlym tablet NPD, SP

Lantus PB QLLevemir NPD QL, AL

levocarnitine Glevothyroxine LCG

Levoxyl LCGliothyronine GMedtronic Continuous

Glucose Monitor Receiver

NPD

DRUG NAME DRUG TIER


35

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



Medtronic Continuous

Glucose Monitor

Guardian Transmitter

NPD

Medtronic Continuous

Glucose Monitor Enlite,

MiniMed Guardian Sensors

NPD

Medrol NPDmetformin G

metformin ER (generic for

Glucophage XR)G

metformin HCL 500mg/5ml soln NPD

metformin/glyburide G

methimazole LCGmethylpred-

nisolone LCG

methyltest-osterone G

miglitol GMillipred NPDMyalept NPD, SP

nateglinide GNatesto NPDNatpara NPD, SP

Nesina tablet NPDNoctiva

Emulsion NPD

Non Preferred Diabetic Meters PB QL

Norditropin PB, SPNovolin PB QL

Novolin R PB QL

Novolog PB QLNutropin AQ PB, SPOmnitrope NPD, SPOne Touch Glucometer PB QL

One Touch Test Strips PB QL

Onglyza PBOrapred ODT NPD

Orilissa NPD QLOseni NPD

Oxandrin NPDoxandrolone G

Ozempic PBparicalcitol Gpioglitazone Gpioglitazone/glimepiride G

Prandin NPDPrecision

Glucometer PB QL

Precision XTRA Test Strips NPD QL

Precose NPDprednisolone G

Prelone NPDProcysbi NPD, SP

propylthiouracil LCGQtern NPDRayos NPD

Regranex gel NPDrepaglinide GRocaltrol capsules NPD

Rybelsus PB QLSaizen NPD, SP

Segluromet NPDSensipar NPD

36

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



Serostim NPD, SP LDDSignifor NPD, SPSoliqua PB

Somavert NPD, SPStarlix NPD

Steglatro NPDSteglujan NPD

Striant buccal system NPD

Symlin PBSynjardy PB

Synjardy XR PBSynthroid NPDTanzeum NPDTapazole NPD

Teriparatide inj NPD, SP 5DSTestim Gel NPDtestosterone cypionate solution

G

testosterone gel 10mg/act

(2%)G

testosterone gel 1%, 1.62% G

testosterone solution 30mg/act

G

Tirosint NPDtolbutamide G

Toujeo Solostar PB QLTradjenta tablet NPD

Tresiba NPD QL, ALTrijardy XR PB

Trulicity PBTymlos NPD, SP Q/TUceris NPD

Unithroid LCGVeripred soln

20mg/5ml NPD

Victoza PBVogelxo NPD

Xigduo XR PBXultophy NPD

Xyosted Soln NPDZemplar NPD

Zomacton NPD, SP

STOMACH, ULCER, & BOWEL MEDS

Aciphex NPD QLAciphex Sprinkle NPD QL, AL

Actigall NPDAmitiza NPD

amoxicill-clarithro-

lansoprazoleG

Ampyra NPD, SP QLAnusol-HC

cream NPD

aprepitant G QLAsacol HD NPDAzulfidine NPDbalsalazide G

Bentyl NPDBonjesta NPD

budesonide ER tab G

Canasa supp NPDCarafate susp PBCarafate tabs NPD

Chenodal NPD, SPchlordiaze-

poxide/clidinium

G

Cholbam NPD, SPcimetidine G

Clenpiq Soln NPD

37

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



Colazal NPDColocort NPD

Creon PBcromolyn sodium

solution G

Cytotec NPDDelzicol NPDDexilant NPD QLDiclegis NPD

dicyclomine LCGdiphenoxylate HCl/atropine G

doxylamine-pyridoxine G

dronabinol GEmend NPD QL

Emverm NPD QLEndari powder NPD

Entocort EC NPDesomeprazole G QLesomeprazole

strontium NPD QL

famotidine 40mg tab, suspension G

Gastrocrom NPDGattex NPD, SP

granisetron Ghydrocortisone

cream LCG

hydrocortisone retention enema G

Kristalose Pak NPDlactulose pak NPDlactulose soln G

lansoprazole cap G QLlansoprazole

solutab G QL

Lialda NPDLinzess PB

Lomotil NPDloperamide LCG

Marinol NPDmeclizine LCG

mesalamine Gmesalamine DR G

mesalamine rectal susp G

metoclopramide LCGmisoprostol LCG

Motegrity tab NPDMovantik NPD

Nexium capsule NPD QLNexium packets NPD QL, AL

nizatidine solution G

Nulytely NPD QLomeprazole G QL

ondansetron HCl Gorlistat G R

Pancreaze NPDpancrelipase EC/

SA G

pantoprazole G QLPEG 3350 & electrolytes G

Pentasa PBPepcid tabs, suspension NPD

Pertzye NPDPlenvu Soln NPD

Prevacid caps NPD QLPrevacid SoluTab NPD QL

Prilosec packets NPD QLprochlorperazine

suppository G

prochlorperazine tabs LCG

38

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



Protonix NPD QLProtonix packets NPD QL

rabeprazole DR tab 20mg G QL

Rabeprazole Sprinkle Cap

10mgNPD QL

ranitidine 300mg GReglan NPDRelistor NPD

scopolamine patch G

SFRowasa enema NPD

sucralfate tabs Gsulfasalazine LCG

Symproic PBSyndros NPDTigan NPD

Transderm-Scop patch NPD

trimetho-benzamide G

Trulance NPDursodiol GVarubi NPDViberzi NPDViokace NPDXenical NPD RXermelo NPDZantac NPD

Zegerid packets NPD QLZelnorm NPDZenpep PBZofran NPD

Zorbtive NPD, SPZuplenz NPD

BONE, JOINT, & MUSCLE

Actemra SC NPD, SPActonel NPD QL

alendronate G QLallopurinol LCG

alosetron hcl GAmrix NPD

Anaprox DS NPDArava NPD

Arcalyst NPD, SPArthrotec NPD

Atelvia NPD QLbaclofen GBinosto NPD QLBoniva NPD QL

calcitonin-salmon

(rDNA origin) nasal spray

G

carisoprodol LCGCelebrex NPDcelecoxib G

chlorzoxazone 375mg, 500mg,

750mgG

Cimzia PB, SPColchicine NPDcolchicine/probenecid LCG

Colcrys PBCuprimine NPD, SPCuvposa NPD

cyclobenzaprine Gcyclobenzaprine

ER NPD

Dantrium NPDdantrolene G

39

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER



diclofenac epolamine

transdermal 1.3%

NPD QL

diclofenac potassium G

diclofenac sodium DR G

diclofenac sodium ER G

diclofenac sodium soln 1.5% G

diclofenac/misoprostol G

EC-Naprosyn NPDEnbrel NPD, SP

etidronate disodium G

etodolac GEvista NPD

febuxostat GFeldene NPD

fenoprofen calcium NPD

Fenortho NPDFexmid NPD

Flector Patch NPD QLflurbiprofen GFosamax NPD QL

Fosamax Plus D NPD QLGloperba Soln NPD

Humira PB, SPibandronate G QLibuprofen LCG

indomethacin LCGindomethacin 20mg capsule NPD

indomethacin SR LCGketoprofen G

ketoprofen ER G

ketorolac Gketorolac sol tromethamine NPD QL

Kevzara NPD, SPKineret NPD, SP

leflunomide GLorzone NPDLotronex NPD

meclofenamate Gmeloxicam Gmetaxalone NPD

methocarbamol LCGMiacalcin NPDMitigare PBMobic NPD

nabumetone GNalfon NPD

Naprelan NPDNaprosyn NPD

Naprosyn susp NPD ALnaproxen sodium Gnaproxen sodium

DR G

naproxen sodium ER G

naproxen sodium susp G AL

Olumiant NPD, SPOrencia NPD, SP

orphenadrine ER GOtezla PB, SP

Otrexup NPDoxaprozin G

Ozobax Soln NPDPennsaid NPDpiroxicam Gprobenecid G

raloxifene hcl G

40


Rasuvo NPDrisedronate G QL

risedronate DR G QLRobaxin NPDsilodosin GSimponi PB, SPSkelaxin NPD

Soma NPDStelara PBsulindac G

tizanidine Gtolmetin GToviaz NPDUloric NPD

Viibryd NPDVoltaren Gel NPDXeljanz [XR] PB, SP

Zanaflex NPDZipsor NPD QL

Zurampic 200mg NPD

Zyloprim NPDFEMALE, HORMONE REPLACEMENT, & BIRTH CONTROL

The Injectable Fertility Agents in this section are covered only under certain benefits programs.

Please check your handbook to determine coverage.Activella NPD

Addyi NPDAlora NPD

Annovera Mis NPD QLAygestin NPDBalcoltra NPD

Beyaz NPDBijuva cap NPD

Bravelle NPD, SP QL, RBrevicon NPDCenestin PB

Cleocin vaginal NPDClimara patch NPD

clomiphene citrate G

Cyclessa NPDDepo SubqQ

Provera NPD QL

Depo-Provera NPD QLDesogen NPD

desogestrel-ethinyl estradiol ACA

Diflucan NPDDivigel NPD

drospirenone-ethinyl estradiol ACA

eluryng mis ACA QLEstrace NPDestradiol G

estradiol cream 0.1% G

estradiol transdermal G

Estring PBestropipate G

Estrostep FE NPDEvista NPD

Femcon FE NPDFemHRT NPD

fluconazole 150mg G

Follistim AQ NPD, SP QL, RGeneress FE NPD

Gonal PB, SP QL, Rhailey 1.5/30 ACA

Imvexxy NPDIntrarosa NPD

levonorgestrel-ethinyl estradiol ACA

DRUG NAME DRUG TIER



41

DRUG NAME DRUG TIER



DRUG NAME DRUG TIER


levonorgestrel/my way/next dose ACA

Loestrin NPDLo Loestrin FE NPDLoseasonique NPD

Lysteda NPDmedroxypro-

gesterone acetate

suspension IMACA QL

medroxypro-gesterone

acetate tabLCG

Menopur NPD, SP QL, RMetrogel vaginal NPD

metronidazole Gmetronidazole

vaginal gel G

Minastrin 24 FE NPDMinivelle NPDMircette NPDNatazia ACA

norethindrone Gnorethindrone

acetate G

norethindrone-ethinyl estradiol ACA

norethindrone-mestranol ACA

norgestimate-ethinyl estradiol ACA

norgestrel-ethinyl estradiol ACA

Nuvaring NPD QLOB Complete NPD

Ortho Micronor NPDOrtho Novum NPD

Ortho Tri-Cyclen NPD

Ortho Tri-Cyclen Lo NPD

Ortho Cyclen NPDOvidrel NPD, SP R

Plan B One-Step NPD QL

Premarin PBPremarin

vaginal cream PB

Premphase PBPrempro PB

progesterone, micronized G

Prometrium NPDProvera NPD

Quartette NPDraloxifene GSafyral NPD

Seasonique NPDSlynd NPD

Synarel NPDTaytulla NPD

terconazole cream G

Tri-norinyl NPDVagifem NPD

Vandazole NPDVivelle Dot NPD

Vyleesi NPD QLxulane ACA QL

Yasmin NPDYAZ NPD

yuvafem G

EYE MEDICATIONS

Acular/Acular LS NPDAlcaine NPD

Alphagan P 0.15% soln NPD

42


DRUG NAME DRUG TIER



Alphagan P 0.01% soln PB

Alrex NPDapraclonidine G

atropine sulfate Gazelastine HCL

drops G

Azopt PBbacitracin ophth G

bacitracin/polymyxin B ophth oint

LCG

Besivance PBBetagan NPDbetaxolol GBetimol NPD

Betoptic S NPDbimatoprost G

Bleph 10 NPDBlephamide

S.O.P. ointment PB

brimonidine tartrate G

Bromsite sol 0.075% NPD

carteolol GCequa Sol

0.09% NPD QL

Ciloxan Sol NPDciprofloxacin G

Combigan soln 0.2-0.5% PB

Cosopt NPDCosopt PF NPD

cromolyn ophth LCGCyclogyl NPD

cyclopentolate HCl LCG

dexamethasone ophth G

Diamox Sequels NPDdiclofenac soln

0.1% opth LCG

dorzolamide HCl 2% G

dorzolamide-timolol G

Elestat NPDepinastine HCl Gerythromycin

etyhylsuccinate susp

G

erythromycin ophth oint G

fluorometholone Gflurbiprofen G

FML Liquifilm suspension NPD

Gentak NPDgentamicin ophth LCG

homatropine opthalmic LCG

Ilevro Susp 0.3% NPDInveltys Susp 1% NPD

Iopidine NPDIsopto Carpine NPDIstalol Drops NPDketorolac opth

soln G

latanoprost Glevobunolol LCG

Lotemax [SM] NPDloteprednol susp

0.5% G

Lumigan PBMaxitrol NPD

methazolamide G

43

DRUG NAME DRUG TIER




Moxeza PBmoxifloxacin

ophthalmic soln G

Mydriacyl NPDneomycin/

polymyxin B/dexamethasone

LCG

Neosporin soln NPDNevanac Susp

0.1% NPD

Ocufen NPDOcuflox NPDofloxacin G

olopatadine hcl GOmnipred NPD

Oxervate soln 200mcg/ml NPD, SP QL

Patanol NPDPhospholine

Iodide PB

pilocarpine Gpolymyxin B/neo/

bacitracin G

polymyxin B/neo/gramicidin G

Polytrim NPDPred-Forte NPDprednisolone

acetate G

prednisolone sodium

phosphateLCG

prednisolone/sodium

sulfacetamideG

Prolensa sol 0.07% PB

proparacaine GRescula NPDRestasis PB QL

Rhopressa Soln 0.02% PB

Rocklatan Soln 0.02-0.005% NPD

Simbrinza Susp 1-0.2% PB

sulfacetamide Gtimolol ophth G

Timoptic NPDTimoptic XE NPD

Tobradex NPDtobramycin-

dexamethasone G

tobramycin ophthalmic LCG

Tobrex NPDTravatan Z NPDtravoprost Gtrifluridine G

trimethoprim sulfate/

polymyxin BG

trimethoprim tab LCGtropicamide LCG

Trusopt NPDVigamox NPDViroptic NPD

Vyzulta Soln 0.024% OP NPD

Xalatan NPDXelpros

Emulsion 0.005%

NPD

Xiidra PBZioptan NPDZymaxid NPD

ALLERGY, COUGH & COLD, LUNG MEDS

Accolate NPD AL

44


DRUG NAME DRUG TIER


acetylcysteine GAdvair Diskus PBAdvair HFA PB

Aerospan NPDAirDuo

RespiClick NPD

Albuterol AER HFA

(authorized generic for

Ventolin HFA)

NPD QL

albuterol AER HFA (generic of ProAir HFA and Proventil HFA)

G QL

albuterol sulfate er G

albuterol sulfate nebulizer soln,

syrup, tabG

Alvesco NPDAnoro Ellipta PB

ArmonAir RespiClick NPD

Arnuity Ellipta PB

Asmanex NPDAsmanex HFA NPDAtrovent HFA PBAuvi-Q 0.1mg NPD QL, ALAuvi-Q 0.15mg

and 0.3mg NPD QL

azelastine nasal spray G

azelastine/fluticasone spray

137-50G

Beconase AQ NPDbenzonatate G

Bevespi Aerosphere NPD

DRUG NAME DRUG TIER


bosentan G, SPBreo Ellipta PBBromfed DM G

budesonide susp. Gbudesonide-formoterol NPD

carbinoxamine GCayston NPD, SP

Cheratussin AC G 5DS, QL, AL, MME

Cheratussin DAC G 5DS, QL, AL,

MMEClarinex NPD

clemastine GCombivent Respimat PB

cromolyn inhalation soln G

cyproheptadine LCGdalfampridin ER G, SP QL

Daliresp NPDdexchlor-

pheniramine soln

NPD

Duaklir NPDDulera NPD

Dymista NPDElixophyllin

Elixir NPD

Epinephrine pen 0.15mg PB QL

epinephrine pen 0.3mg G QL

EpiPen NPD QLEpiPen Jr. NPD QL

Esbriet NPD, SP LDDFlovent Diskus PBFlovent HFA PB

flunisolide G

45

DRUG NAME DRUG TIER




fluticasone proprionate LCG

fluticasone-salmeterol AER

powderG

Grastek NPDHycofenix NPD QL, 5DS

hydrocodon-cpm-phenylephrine G QL, 5DS, AL,

MMEhydrocod-cpm-

pseudoephedrine G QL, 5DS, AL, MME

hydrocodone bit/homatrop syrup LCG QL, 5DS, AL,

MMEhydrocodone-chlorphenira-

mine suspLCG QL, 5DS, AL,

MME

hydromet LCG QL, 5DS, AL, MME

hydroxyzine HCl LCGhydroxyzine

pamoate LCG

Hypersal GIncruse Ellipta PB

ipratropium-albuterol G

ipratropium inhalation soln G

ipratropium nasal spray G

Isturisa NPD, SPKitabis Pak NPD, SP LDD

levalbuterol neb GLevalbuterol tartrate HFA NPD QL

Lonhala Magnair Soln NPD

metaproterenol Gmontelukast

sodium G

Nucala Soln PB, SPObredon NPD QL, 5DS, AL, MME

Odactra SL NPDOfev NPD, SP

Oralair NPDPalforzia cap/

powder NPD, SP

ProAir Digihaler NPD QL

ProAir HFA PB QLProAir

RespiClick PB QL

promethazine LCGpromethazine/

codeine LCG QL, 5DS, AL, MME

promethazine/dextrometh-

orphanLCG

promethazine/phenylephrine G

Proventil HFA NPD QLPulmicort Flexhaler PB

Pulmicort Respules NPD

Pulmozyme PB, SPQvar NPD

Ragwitek NPDRebetol NPD, SPRezira NPD QL, 5DS, AL, MME

Ryclora NPDRyvent NPDSeebri NPD

Semprex-D NPD QLSerevent Diskus PB

Singulair NPD sodium chloride

inhalation G

Spiriva PBStiolto Respimat PB

Symbicort PB

46


DRUG NAME DRUG TIER


Symdeko NPD, SPSymjepi Inj NPD QLterbutaline sulfate tabs G

Tessalon Perles NPDTheo-24 PB

Theochron Gtheophylline soln G

theophylline extended release G

Thiola [EC] NPD, SPTracleer NPD, SP

Trelegy Ellipta PBTudorza Pressair NPD

Tussicap NPD QL, 5DS, AL, MMETuxarin ER

tabs NPD QL, 5DS, AL, MME

Tuzistra XR NPD QL, 5DS, AL, MMEUtibron Neohaler NPD

Ventolin HFA NPD QLVistaril NPDVituz NPD QL, 5DS, AL, MME

VoSpire ER NPDwixela inhub aer G

Xhance NPDXopenex NPD

Xopenex HFA NPD QLYupelri Soln NPDZ-Tuss AC NPD QL, 5DS, AL, MMEzafirlukast G AL

zileuton ER 600mg G ALZutripro NPD QL, 5DS, AL, MME

Zyflo 600mg tab NPD ALZyflo CR 600mg NPD AL

URINARY & PROSTATE MEDS

alfuzosin GAvodart NPD AL

bethanechol GCardura NPDCaverject PB QL

Cialis NPD QLdarifenacin ER G

Detrol NPDDetrol LA NPD

Ditropan XL NPDdoxazosin mesylate G

dutasteride G ALdutasteride/

tamsulosin hcl G

Edex NPD QLElmiron NPDEnablex NPD

finasteride G ALflavoxate GFlomax NPD

IFE-PG 20 NPD QLJalyn NPD

Levitra NPD QLMuse PB QL

Myrbetriq PBoxybutynin LCG

oxybutynin ER Gpotassium citrate

ER G

Proscar NPD ALRapaflo NPD

solifenacin GStaxyn NPD QLStendra NPD QL

tamsulosin G

DRUG NAME DRUG TIER


47


DRUG NAME DRUG TIER


terazosin Gtolterodine

tartrate G

tolterodine tartrate LA G

trospium chloride G

Urecholine NPDUrocit-K NPDUroxatral NPDvardenafil G QL

vardenafil ODT G QLVesicare NPDViagra NPD QL

VITAMINS & ELECTROLYTES

Brand Prenatal Vitamins NPD

Buphenyl NPD, SPCalciferol NPDCitranatal NPD

Dailyvite w/Zinc & NephlexRx NPD

Duzallo NPDergocalciferol G

Fosrenol NPDJynarque NPDK-Phos NPDK-Tab NPD

Klor-Con Glanthanum

chewable tab G

Lokelma PAK NPDMephyton NPD

multivitamin with fluoride drops,

tabsG

Nascobal NPDNestabs One NPD

phytonadione tab Gpotassium

bicarbonate/potassium citrate

effervescentG

potassium chloride G

Quflora NPDRayaldee NPD

sodium phenylbutyrate

tabG, SP

Tri-Vi-Flor, Poly-Vi-Flor

with and without iron

NPD

DIAGNOSTICS & MISCELLANEOUS AGENTS

Berinert NPD, SPCablivi Kit NPD, SP QL

calcium acetate GCarbaglu NPD, SPCerdelga NPD, SPChemet PB

Chorionic gonadotropin NPD, SP

Cinryze NPD, SPclovique G, SP

Cystadane NPD, SPCystagon NPD, SP

deferasirox GD-Penamine 125mg tablet NPD, SP

Doptelet NPD, SPExjade NPD

Ferriprox NPDFirazyr NPD, SP QL

Firdapse NPD, SPGalafold NPD, SP QL

DRUG NAME DRUG TIER


48


ganirelix acetate soln G, SP R

Haegarda NPD, SPicatibant inj G, SP

Idelvion NPD, SPJadenu NPDKeveyis NPD, SP

Metopirone NPDmidodrine HCl G

miglustat G, SP nitisinone G, SP

Nityr NPD, SPNovarel

5000 units NPD, SP

Novarel 10000 units PB, SP

Ocaliva NPD, SPOrfadin NPD, SPOxbryta NPD, SPPalynziq NPD, SP

penicillamine capsule G, SP

penicillamine tablet G, SP

PhosLo NPDphospha LCGPotaba NPDPregnyl PB, SPRenagel NPDRenvela NPDRidaura NPD, SPRinvoq PB, SP

Ruconest NPD, SPRuzurgi NPD, SP

sevelamer carbonate G

Strensiq NPD, SPSyprine NPD, SP

Takhzyro Inj NPD, SPTavalisse NPD, SPTegsedi NPD, SPtrientine G, SPV-GO PB

Vumerity NPD, SPXuriden NPD, SPZavesca NPD, SP

DRUG NAME DRUG TIER



10/20IAnoPA

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Blue Cross and Blue Shield Association.

10/20IAwPA

prescription drug program formularyplease note: because prescription drug benefits vary by group,...

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