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Select Drug List Drug list — Four Tier Drug Plan Your plan includes coverage for medications you’ll find on this drug list. The drug list includes brand-name and generic prescription medications approved by the FDA. Drugs that are not on this list may cost you more out of pocket. You and your doctor can use this list as a guide to choose the medications that are best for you. Your coverage has limitations and exclusions. It’s best to refer to your Certificate/Evidence of Coverage or Summary Plan Description (SPD) for details about what’s covered and what’s not. Inside you will find more information about how this drug list works with your prescription drug coverage.
This booklet is updated on a quarterly basis. For the most up to date information, including newly added
medications, generics and more, you can visit anthem.com/pharmacyinformation. For additional
information, please call the Member Services number on your ID card.
05267MEMENABS
What is a drug list? The drug list (also called a formulary) is a list of prescription medications approved by the U.S. Food and Drug Administration (FDA). The list is made up of hundreds of brand-name and generic medications that have been reviewed and recommended for their quality and effectiveness through our Pharmacy and Therapeutics (P&T) process. Our P&T process involves an independent group of practicing doctors, pharmacists, and other health care professionals responsible for the research and decisions surrounding our drug lists. This group meets regularly to review new and existing drugs and chooses the top medications for our drug lists, based on their safety, effectiveness and value. The drug list is organized in tiers; medications on Tier 1 have the lowest member cost share while members pay more for drugs on higher tiers. How will I know about changes to the drug list? Drugs on our list are reviewed regularly. Sometimes this results in drugs being added or removed. We will always try to notify you of changes to the drug list that impact you. Now and then, it’s a good idea to check the status of any medications you are taking. On our website, you can view and search the drug list to see which drugs are covered and at what tier level, as well as information on dosage/strength options and prior authorization or step therapy requirements. You can also see if a brand-name drug has a generic equivalent. What’s the difference between brand-name and generic medications? A brand-name drug is usually available from only one manufacturer and may have patent protection. A generic drug is also FDA-approved and has the same active ingredients as its brand-name counterpart, but a generic is typically available only after the brand-name drug’s patent protection expires. Although it may look different, a generic drug works the same as its brand-name counterpart.
Is this a complete listing of all covered drugs? Yes, this is a complete listing of all drugs on the drug list; however, a drug(s) may be excluded based on your plan's benefit design. If a medication isn’t on this list, this means your plan doesn’t cover the medication(s), so you may have to pay out of pocket or switch to a covered prescription medication or an over the counter (OTC) option. If my medication is not included on the drug list, what are my options? The drug list includes many brand-name and generic drugs. You may have to pay the full cost of a medication that isn’t included on the drug list. When you visit our website, you can get more information about generic equivalent options, if available; however, OTC options will not be displayed. If an alternative isn’t listed, please talk to your doctor or pharmacist about whether another medication that is included on the drug list or an OTC may be right for you. Only you and your doctor can decide what drugs are right for you. If a medication you’re taking is not covered, your doctor can ask us to keep covering the drug(s) you take now by submitting a request for an exception. This process, called prior authorization, requires your doctor to call the member services number on your member ID card or go to our website to download and submit the prior authorization form. How will I know how much my drug will cost? Medications on the drug list are grouped into tiers. Your cost will depend on what tier the medication your doctor prescribes for you falls in and could be a set cost or a percentage of the total drug cost. In general, drugs on the lowest tier have the lowest member cost share, which is what you pay. Drugs on a higher tier may cost you more. Several factors determine what tier a drug is placed in, including:
• Clinical considerations. • Cost of the drug in comparison to other
drugs used for the same type of treatment.
• Availability of over-the-counter options.
Select Drug List
What types of drugs can I expect to find in the different tiers? Tier 1 drugs have the lowest member cost share. These are typically generic drugs that offer the greatest value compared to others that treat the same conditions. Tier 2 drugs have a medium cost share. They may be preferred brand drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs. Tier 3 drugs have a higher cost share. They generally include non-preferred brand and generic drugs. They may cost more than drugs placed on lower tiers that are used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA. Tier 4 specialty drugs have the highest cost share and typically consist of specialty (brand and generic) drugs. They may cost more than drugs placed on lower tiers that are used to treat the same condition. Tier 4 may also include drugs that were recently approved by the FDA or specialty drugs used to treat complex, chronic conditions and may need special handling.
Member cost share amount for certain abuse-deterrent opioid analgesics may be lower due to state law requirements.
We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA).
In selecting medications for the prescription drug formulary, the therapeutic efficacy and cost
effectiveness are addressed for each category. All therapeutic categories are represented on the
formulary by at least one medication. When a closed formulary is in effect, only medications that are
included on the formulary are a covered service. In certain clinical situations, a member may require use
of a non-formulary product. Anthem has criteria that permits a member to obtain a non-formulary
medication in a closed formulary plan. If specific criteria are met, a member can receive a non-formulary
drug for a formulary copay. The criteria preserves the clinical integrity of the drug formulary and provides
a process by which deviations from the formulary may be allowed. An appeals process is in place for any
medications that do not meet the criteria.
2017 Maine Select Drug List
Table of Contents
ANALGESICS ...........................................................................................................................................................................6ANESTHETICS .........................................................................................................................................................................8ANTIARTHRITICS .................................................................................................................................................................... 8ANTIASTHMATICS .................................................................................................................................................................. 9ANTIBIOTICS ......................................................................................................................................................................... 11ANTICOAGULANTS .............................................................................................................................................................. 15ANTIDOTES ........................................................................................................................................................................... 16ANTIFUNGALS ...................................................................................................................................................................... 16ANTIHISTAMINE AND DECONGESTANT COMBINATION ................................................................................................. 18ANTIHISTAMINES ..................................................................................................................................................................18ANTIHYPERGLYCEMICS ...................................................................................................................................................... 18ANTIINFECTIVES/MISCELLANEOUS ...................................................................................................................................20ANTINEOPLASTICS .............................................................................................................................................................. 20ANTI-OBESITY DRUGS .........................................................................................................................................................22ANTIPARKINSON DRUGS .................................................................................................................................................... 22ANTIPLATELET DRUGS ....................................................................................................................................................... 23ANTIVIRALS ...........................................................................................................................................................................23AUTONOMIC DRUGS ............................................................................................................................................................ 25BIOLOGICALS ....................................................................................................................................................................... 25BLOOD ................................................................................................................................................................................... 28CARDIAC DRUGS ..................................................................................................................................................................28CARDIOVASCULAR .............................................................................................................................................................. 29CNS DRUGS ...........................................................................................................................................................................32COLONY STIMULATING FACTORS .....................................................................................................................................34CONTRACEPTIVES ............................................................................................................................................................... 34COUGH/COLD PREPARATIONS .......................................................................................................................................... 37DIAGNOSTIC ..........................................................................................................................................................................37DIURETICS .............................................................................................................................................................................37EENT PREPS ......................................................................................................................................................................... 38ELECT/CALORIC/H2O ...........................................................................................................................................................39GASTROINTESTINAL ............................................................................................................................................................41HORMONES ........................................................................................................................................................................... 43IMMUNOSUPPRESSANTS ....................................................................................................................................................45MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ..................................................................................... 45MUSCLE RELAXANTS .......................................................................................................................................................... 46PRE-NATAL VITAMINS ......................................................................................................................................................... 46PSYCHOTHERAPEUTIC DRUGS ..........................................................................................................................................47SEDATIVE/HYPNOTICS ........................................................................................................................................................ 50SKIN PREPS .......................................................................................................................................................................... 50SMOKING DETERRENTS ......................................................................................................................................................53THYROID PREPS ...................................................................................................................................................................53UNCLASSIFIED DRUG PRODUCTS .....................................................................................................................................54VITAMINS ............................................................................................................................................................................... 55
4
2017 Maine Select Drug List
CURRENT AS OF 10/1/2017
Drug Name Tier Notes
ANALGESICS
acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml
Tier 1 QL
acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg
Tier 1 QL
almotriptan malate oral tablet
Tier 1 QL
asa-butalb-caff-cod #3 capsule
Tier 1 QL
ascomp with codeine oral capsule
Tier 1 QL
buprenorphine hcl injection solution
Tier 2 QL
buprenorphine hcl injection syringe
Tier 2 QL
butalbital compound w/codeine oral capsule
Tier 1 QL
butalbital compound-codeine oral capsule
Tier 1 QL
butalbital-acetaminop-caf-cod oral capsule
Tier 1 QL
butalbital-acetaminophen oral tablet
Tier 1
butalbital-acetaminophen-caff oral capsule
Tier 1
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
Tier 1
butalbital-aspirin-caffeine oral capsule
Tier 1
butalbital-aspirin-caffeine oral tablet
Tier 1
butorphanol tartrate nasal spray,non-aerosol
Tier 1 PA; QL
BUTRANS TRANSDERMAL PATCH WEEKLY
Tier 3 QL
CAMBIA ORAL POWDER IN PACKET
Tier 3 QL
capacet oral capsule Tier 1
codeine sulfate oral tablet Tier 1 QL
Drug Name Tier Notes
diclofenac potassium oral tablet
Tier 1
diflunisal oral tablet Tier 1
dihydroergotamine nasal spray,non-aerosol
Tier 2 QL
diskets oral tablet,soluble Tier 1 QL
eletriptan hbr oral tablet Tier 2
ELMIRON ORAL CAPSULE
Tier 3
EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL
Tier 1 PA; QL
endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 2 QL
ERGOMAR SUBLINGUAL TABLET
Tier 3
ergotamine-caffeine oral tablet
Tier 1
fentanyl citrate buccal lozenge on a handle
Tier 1 PA; QL
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
Tier 2 ST; QL
frovatriptan oral tablet Tier 2 QL
hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml
Tier 1 QL
hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg
Tier 1 QL
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg
Tier 1 QL
hydromorphone oral liquid Tier 1 QL
hydromorphone oral tablet Tier 1 QL
hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 32 mg, 8 mg
Tier 2 ST; QL
hydromorphone rectal suppository
Tier 2 QL
Effective 1/1/20176
Drug Name Tier Notes
HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG
Tier 1 PA; QL
ibuprofen-oxycodone oral tablet
Tier 1 QL
isometh-dichloral-acetaminophn oral capsule
Tier 1
ketorolac injection cartridge 15 mg/ml, 30 mg/ml
Tier 1 QL
ketorolac injection solution 15 mg/ml, 30 mg/ml, 30 mg/ml (1 ml)
Tier 1 QL
ketorolac injection syringe 15 mg/ml, 30 mg/ml
Tier 1 QL
ketorolac intramuscular solution
Tier 1 QL
ketorolac intramuscular syringe
Tier 1 QL
ketorolac oral tablet Tier 1 QL
levorphanol tartrate oral tablet
Tier 2
marten-tab oral tablet Tier 1
mefenamic acid oral capsule
Tier 1 QL
meperidine oral solution Tier 1 QL
meperidine oral tablet Tier 1 QL
methadone intensol oral concentrate
Tier 1 QL
methadone oral concentrate
Tier 1 QL
methadone oral solution 10 mg/5 ml, 5 mg/5 ml
Tier 1 QL
methadone oral tablet 10 mg, 5 mg
Tier 1 QL
methadone oral tablet,soluble
Tier 1 QL
methadose oral concentrate
Tier 1 QL
methadose oral tablet,soluble
Tier 1 QL
migergot rectal suppository
Tier 1
morphine concentrate oral solution
Tier 1 QL
Drug Name Tier Notes
morphine oral capsule,extend.release pellets
Tier 2 QL
morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml)
Tier 1 QL
morphine oral tablet 15 mg, 30 mg
Tier 1 QL
morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg
Tier 2 QL
morphine rectal suppository
Tier 1
nalbuphine injection solution
Tier 1
naratriptan oral tablet Tier 1 QL
nodolor oral capsule Tier 1
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR
Tier 3 ST; QL
NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG
Tier 3 QL
oxycodone oral capsule Tier 1 QL
oxycodone oral concentrate
Tier 1 QL
oxycodone oral solution Tier 1 QL
oxycodone oral tablet Tier 1 QL
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 1 QL
oxycodone-aspirin oral tablet
Tier 1 QL
oxymorphone oral tablet 10 mg, 5 mg
Tier 1 QL
oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg
Tier 1 QL
pentazocine-naloxone oral tablet
Tier 1 QL
rizatriptan oral tablet Tier 1 QL
rizatriptan oral tablet,disintegrating
Tier 1 QL
sumatriptan nasal spray,non-aerosol
Tier 1 QL
Effective 1/1/20177
Drug Name Tier Notes
sumatriptan succinate oral tablet
Tier 1 QL
sumatriptan succinate subcutaneous cartridge
Tier 1 QL
sumatriptan succinate subcutaneous pen injector
Tier 1 QL
sumatriptan succinate subcutaneous solution
Tier 1 QL
sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml
Tier 1 QL
TALWIN INJECTION SOLUTION
Tier 3
tencon oral tablet 50-325 mg
Tier 1
tramadol oral tablet Tier 1 QL
tramadol oral tablet extended release 24 hr
Tier 1 QL
tramadol oral tablet, er multiphase 24 hr
Tier 1 QL
vicodin es oral tablet Tier 2 QL
vicodin hp oral tablet Tier 2 QL
vicodin oral tablet Tier 2 QL
zamicet oral solution Tier 1 QL
zebutal oral capsule 50-325-40 mg
Tier 1
ZIPSOR ORAL CAPSULE Tier 3 QL
zolmitriptan oral tablet Tier 1 QL
zolmitriptan oral tablet,disintegrating
Tier 1 QL
ANESTHETICS
lidocaine viscous mucous membrane solution
Tier 1 QL
lidocaine-prilocaine topical cream
Tier 1 QL
lidocaine-prilocaine topical kit
Tier 1
phenazopyridine oral tablet 100 mg, 200 mg
Tier 1
SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING
Tier 3
ANTIARTHRITICS
allopurinol oral tablet Tier 1
CALDOLOR INTRAVENOUS RECON SOLN
Tier 3
Drug Name Tier Notes
celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg
Tier 2 ST; QL
COLCRYS ORAL TABLET
Tier 3 PA; QL
CUPRIMINE ORAL CAPSULE
Tier 3
diclofenac sodium oral tablet extended release 24 hr
Tier 1
diclofenac sodium oral tablet,delayed release (dr/ec)
Tier 1
ENBREL SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP; QL
ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML)
Tier 4 PA; SP; QL
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
etodolac oral capsule Tier 1
etodolac oral tablet Tier 1
etodolac oral tablet extended release 24 hr
Tier 1
fenoprofen oral tablet Tier 1 QL
flurbiprofen oral tablet Tier 1
HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; QL
HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; SP; QL
HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; SP; QL
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; SP; QL
HUMIRA SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; QL
ibuprofen oral suspension Tier 1 QL
Effective 1/1/20178
Drug Name Tier Notes
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
Tier 1
indomethacin oral capsule 25 mg, 50 mg
Tier 1 QL
indomethacin oral capsule, extended release
Tier 1 QL
ketoprofen oral capsule Tier 1
ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg
Tier 1 QL
KINERET SUBCUTANEOUS SYRINGE
Tier 4 PA; LD; QL
meclofenamate oral capsule
Tier 1
meloxicam oral suspension
Tier 1 QL
meloxicam oral tablet Tier 1 QL
nabumetone oral tablet Tier 1
naproxen oral suspension Tier 1
naproxen oral tablet Tier 1
naproxen oral tablet,delayed release (dr/ec)
Tier 1
naproxen sodium oral tablet 275 mg, 550 mg
Tier 1
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN
Tier 4 PA; SP
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR
Tier 4 PA; SP; QL
ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML
Tier 4 PA; SP; QL
ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML, 87.5 MG/0.7 ML
Tier 4 PA
OTEZLA ORAL TABLET Tier 4 PA; SP; QL
OTEZLA STARTER ORAL TABLETS,DOSE PACK
Tier 4 PA; SP; QL
oxaprozin oral tablet Tier 1
piroxicam oral capsule Tier 1
probenecid oral tablet Tier 1
probenecid-colchicine oral tablet
Tier 1
Drug Name Tier Notes
RIDAURA ORAL CAPSULE
Tier 3
SIMPONI ARIA INTRAVENOUS SOLUTION
Tier 4 PA; SP
SIMPONI SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
SIMPONI SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
sulindac oral tablet Tier 1
tolmetin oral capsule Tier 1
tolmetin oral tablet Tier 1
ULORIC ORAL TABLET Tier 3 ST
XELJANZ ORAL TABLET Tier 4 PA; SP; QL
ANTIASTHMATICS
acetylcysteine solution Tier 2
ADVAIR DISKUS INHALATION BLISTER WITH DEVICE
Tier 2 QL
ADVAIR HFA INHALATION HFA AEROSOL INHALER
Tier 2 QL
albuterol sulfate inhalation solution for nebulization
Tier 1
albuterol sulfate oral syrup Tier 1
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE
Tier 3 QL
ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE
Tier 3 QL
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)
Tier 2 QL
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES)
Tier 2
BREO ELLIPTA INHALATION BLISTER WITH DEVICE
Tier 3 QL
Effective 1/1/20179
Drug Name Tier Notes
BROVANA INHALATION SOLUTION FOR NEBULIZATION
Tier 3 QL
budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml
Tier 1 QL
cromolyn inhalation solution for nebulization
Tier 2
DALIRESP ORAL TABLET
Tier 3 QL
DULERA INHALATION HFA AEROSOL INHALER
Tier 2 QL
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION
Tier 2 QL
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION
Tier 2 QL
ipratropium bromide inhalation solution
Tier 1 QL
ipratropium-albuterol inhalation solution for nebulization
Tier 2
levalbuterol hcl inhalation solution for nebulization
Tier 1
metaproterenol oral syrup Tier 1
metaproterenol oral tablet Tier 1
montelukast oral granules in packet
Tier 1 QL
montelukast oral tablet Tier 1 QL
montelukast oral tablet,chewable
Tier 1 QL
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION
Tier 3 QL
PROAIR HFA INHALATION HFA AEROSOL INHALER
Tier 2 QL
PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL
Drug Name Tier Notes
PROVENTIL HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL
QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION
Tier 2 QL
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE
Tier 2 QL
SPIRIVA RESPIMAT INHALATION MIST
Tier 3 QL
SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE
Tier 3 QL
STRIVERDI RESPIMAT INHALATION MIST
Tier 3 QL
SYMBICORT INHALATION HFA AEROSOL INHALER
Tier 2 QL
terbutaline oral tablet Tier 2
theochron oral tablet extended release 12 hr
Tier 1
theophylline oral elixir Tier 1
theophylline oral solution Tier 1
theophylline oral tablet extended release 12 hr
Tier 1
theophylline oral tablet extended release 24 hr
Tier 1
TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 3 QL
VENTOLIN HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
XOPENEX HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
zafirlukast oral tablet Tier 1
zileuton oral tablet, er multiphase 12 hr
Tier 2 PA
ZYFLO ORAL TABLET Tier 3 PA
Effective 1/1/201710
Drug Name Tier Notes
ANTIBIOTICS
amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml
Tier 2
amoxicillin oral capsule Tier 1
amoxicillin oral suspension for reconstitution
Tier 1
amoxicillin oral tablet Tier 1
amoxicillin oral tablet,chewable 125 mg, 250 mg
Tier 1
amoxicillin-pot clavulanate oral suspension for reconstitution
Tier 1
amoxicillin-pot clavulanate oral tablet
Tier 1
amoxicillin-pot clavulanate oral tablet extended release 12 hr
Tier 1
amoxicillin-pot clavulanate oral tablet,chewable
Tier 1
ampicillin oral capsule Tier 1
ampicillin sodium injection recon soln
Tier 1
ampicillin sodium intravenous recon soln
Tier 1
ampicillin-sulbactam injection recon soln
Tier 2
ampicillin-sulbactam intravenous recon soln
Tier 2
avidoxy oral tablet Tier 1
AZASITE OPHTHALMIC (EYE) DROPS
Tier 3
azithromycin oral packet Tier 1 QL
azithromycin oral suspension for reconstitution
Tier 1 QL
azithromycin oral tablet 250 mg, 500 mg, 600 mg
Tier 1 QL
aztreonam injection recon soln
Tier 2
bacitracin ophthalmic (eye) ointment
Tier 1
bacitracin-polymyxin b ophthalmic (eye) ointment
Tier 1
BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
Drug Name Tier Notes
bp 10-1 topical cleanser Tier 1
CAPASTAT INJECTION RECON SOLN
Tier 3
CAYSTON INHALATION SOLUTION FOR NEBULIZATION
Tier 4 SP; LD
cefaclor oral capsule Tier 1
cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
Tier 1
cefaclor oral tablet extended release 12 hr
Tier 2
cefadroxil oral capsule Tier 1
cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml
Tier 1
cefadroxil oral tablet Tier 1
cefazolin in 0.9% sod chloride intravenous piggyback
Tier 1
cefazolin in 0.9% sod chloride intravenous solution
Tier 1
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml
Tier 1
cefazolin in dextrose 5 % intravenous solution
Tier 1
cefazolin injection recon soln
Tier 1
cefazolin intravenous recon soln
Tier 1
cefdinir oral capsule Tier 1
cefdinir oral suspension for reconstitution
Tier 1
cefditoren pivoxil oral tablet
Tier 2
CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK
Tier 2
cefepime in dextrose,iso-osm intravenous piggyback
Tier 2
cefepime injection recon soln
Tier 2
cefixime oral suspension for reconstitution
Tier 2
Effective 1/1/201711
Drug Name Tier Notes
cefotaxime injection recon soln
Tier 2
CEFOTETAN IN DEXTROSE, ISO-OSM INTRAVENOUS PIGGYBACK
Tier 2
cefotetan injection recon soln
Tier 2
cefotetan intravenous recon soln
Tier 2
cefoxitin in dextrose, iso-osm intravenous piggyback
Tier 1
cefoxitin intravenous recon soln
Tier 1
cefpodoxime oral suspension for reconstitution
Tier 2
cefpodoxime oral tablet Tier 2
cefprozil oral suspension for reconstitution
Tier 1
cefprozil oral tablet Tier 1
ceftazidime injection recon soln
Tier 2
ceftibuten oral capsule Tier 1
ceftibuten oral suspension for reconstitution
Tier 1
ceftriaxone in dextrose,iso-os intravenous piggyback
Tier 2
ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg
Tier 2
ceftriaxone intravenous recon soln
Tier 2
cefuroxime axetil oral tablet
Tier 1
cephalexin oral capsule Tier 1
cephalexin oral suspension for reconstitution
Tier 1
cephalexin oral tablet Tier 1
chloramphenicol sod succinate intravenous recon soln
Tier 2
CIPRO HC OTIC (EAR) DROPS,SUSPENSION
Tier 3
CIPRODEX OTIC (EAR) DROPS,SUSPENSION
Tier 3 PA
Drug Name Tier Notes
ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg
Tier 1 QL
ciprofloxacin hcl ophthalmic (eye) drops
Tier 1
ciprofloxacin hcl oral tablet Tier 1 QL
ciprofloxacin hcl otic (ear) dropperette
Tier 1
ciprofloxacin in 5 % dextrose intravenous piggyback
Tier 1
ciprofloxacin lactate intravenous solution
Tier 2
clarithromycin oral suspension for reconstitution
Tier 1
clarithromycin oral tablet Tier 1
clarithromycin oral tablet extended release 24 hr
Tier 1
cleansing wash topical cleanser
Tier 1
clindamycin hcl oral capsule
Tier 1
clindamycin palmitate hcl oral recon soln
Tier 1
clindamycin pediatric oral recon soln
Tier 1
clindamycin phosphate topical foam
Tier 1
clindamycin phosphate topical gel
Tier 1
clindamycin phosphate topical lotion
Tier 1
clindamycin phosphate topical solution
Tier 1
clindamycin phosphate topical swab
Tier 1
clindamycin phosphate vaginal cream
Tier 1
COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION
Tier 3
CORTISPORIN TOPICAL CREAM
Tier 3
CORTISPORIN TOPICAL OINTMENT
Tier 3
CYCLOSERINE ORAL CAPSULE
Tier 3
Effective 1/1/201712
Drug Name Tier Notes
DAPSONE ORAL TABLET
Tier 2
daptomycin intravenous recon soln
Tier 2
demeclocycline oral tablet Tier 2
dicloxacillin oral capsule Tier 1
DIFICID ORAL TABLET Tier 3 PA
DORIBAX INTRAVENOUS RECON SOLN
Tier 3
doxycycline hyclate oral capsule
Tier 1
doxycycline hyclate oral tablet 100 mg
Tier 1
doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg
Tier 1 PA
doxycycline monohydrate oral capsule
Tier 1
doxycycline monohydrate oral suspension for reconstitution
Tier 1
doxycycline monohydrate oral tablet
Tier 1
e.e.s. 400 oral tablet Tier 2
ery pads topical swab Tier 1
erygel topical gel Tier 1
ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg
Tier 1
erythrocin (as stearate) oral tablet 250 mg
Tier 1
erythromycin ethylsuccinate oral tablet
Tier 2
erythromycin ophthalmic (eye) ointment
Tier 1
erythromycin oral capsule,delayed release(dr/ec)
Tier 2
erythromycin oral tablet Tier 2
erythromycin with ethanol topical gel
Tier 1
erythromycin with ethanol topical solution
Tier 1
erythromycin with ethanol topical swab
Tier 1
Drug Name Tier Notes
erythromycin-benzoyl peroxide topical gel
Tier 1
ethambutol oral tablet Tier 1
FACTIVE ORAL TABLET Tier 3 QL
gatifloxacin ophthalmic (eye) drops
Tier 1
gentak ophthalmic (eye) ointment
Tier 1
gentamicin ophthalmic (eye) drops
Tier 1
gentamicin ophthalmic (eye) ointment
Tier 1
gentamicin topical cream Tier 1
gentamicin topical ointment
Tier 1
imipenem-cilastatin intravenous recon soln
Tier 2
INVANZ INJECTION RECON SOLN
Tier 3
INVANZ INTRAVENOUS RECON SOLN
Tier 3
isoniazid oral solution Tier 1
isoniazid oral tablet Tier 1
levofloxacin ophthalmic (eye) drops
Tier 1
levofloxacin oral tablet Tier 2 QL
LINCOCIN INJECTION SOLUTION
Tier 3
lincomycin injection solution
Tier 2
linezolid oral suspension for reconstitution
Tier 2 PA; QL
linezolid oral tablet Tier 2 PA; QL
meropenem intravenous recon soln
Tier 2
methenamine hippurate oral tablet
Tier 1
methenamine mandelate oral tablet
Tier 1
metronidazole oral capsule
Tier 1
metronidazole oral tablet Tier 1
metronidazole vaginal gel Tier 1
minocycline oral capsule Tier 1
minocycline oral tablet Tier 1
minocycline oral tablet extended release 24 hr
Tier 1 PA
Effective 1/1/201713
Drug Name Tier Notes
MONUROL ORAL PACKET
Tier 3
morgidox oral capsule 100 mg
Tier 1
MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR
Tier 3
moxifloxacin ophthalmic (eye) drops
Tier 1
mupirocin topical ointment Tier 1
nafcillin in dextrose iso-osm intravenous piggyback
Tier 2
nafcillin injection recon soln
Tier 2
nafcillin intravenous recon soln
Tier 2
neomycin oral tablet Tier 1
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment
Tier 1
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment
Tier 1
neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension
Tier 1
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment
Tier 1
neomycin-polymyxin-gramicidin ophthalmic (eye) drops
Tier 1
neomycin-polymyxin-hc ophthalmic (eye) drops,suspension
Tier 1
neomycin-polymyxin-hc otic (ear) drops,suspension
Tier 1
neomycin-polymyxin-hc otic (ear) solution
Tier 1
neo-polycin hc ophthalmic (eye) ointment
Tier 1
neo-polycin ophthalmic (eye) ointment
Tier 1
NEO-SYNALAR KIT TOPICAL CREAM
Tier 3
NEO-SYNALAR TOPICAL CREAM
Tier 3
Drug Name Tier Notes
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg
Tier 1
nitrofurantoin monohyd/m-cryst oral capsule
Tier 1
nitrofurantoin oral suspension
Tier 1
ofloxacin ophthalmic (eye) drops
Tier 1
ofloxacin oral tablet 300 mg, 400 mg
Tier 1 QL
ofloxacin otic (ear) drops Tier 1
ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE
Tier 3
oxacillin injection recon soln
Tier 2
oxacillin intravenous recon soln
Tier 2
PASER ORAL GRANULES DR FOR SUSP IN PACKET
Tier 3
penicillin g potassium injection recon soln
Tier 1
penicillin v potassium oral recon soln
Tier 1
penicillin v potassium oral tablet
Tier 1
pfizerpen-g injection recon soln
Tier 1
piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram
Tier 1
polycin ophthalmic (eye) ointment
Tier 1
polymyxin b sulfate injection recon soln
Tier 1
polymyxin b sulf-trimethoprim ophthalmic (eye) drops
Tier 1
PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT
Tier 3
PRIFTIN ORAL TABLET Tier 3
PRIMSOL ORAL SOLUTION
Tier 3
Effective 1/1/201714
Drug Name Tier Notes
pyrazinamide oral tablet Tier 1
rifabutin oral capsule Tier 2
rifampin oral capsule Tier 1
RIFATER ORAL TABLET Tier 3
silver sulfadiazine topical cream
Tier 1
SIRTURO ORAL TABLET Tier 3
SIVEXTRO ORAL TABLET
Tier 3 PA; QL
ssd topical cream Tier 1
sss 10-5 topical cream Tier 1
sss 10-5 topical foam Tier 1
STREPTOMYCIN INTRAMUSCULAR RECON SOLN
Tier 3
sulfacetamide sodium ophthalmic (eye) drops
Tier 1
sulfacetamide sodium ophthalmic (eye) ointment
Tier 1
sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w), 9-4 %, 9-4.5 %
Tier 1
sulfacetamide sodium-sulfur topical cream 10-2 %, 10-5 % (w/w)
Tier 1
sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w)
Tier 1
sulfacetamide sodium-sulfur topical pads, medicated 10-4 %
Tier 1
sulfacetamide sodium-sulfur topical suspension
Tier 1
sulfacetamide sod-sulfur-urea topical cleanser
Tier 1
sulfacetamide-prednisolone ophthalmic (eye) drops
Tier 1
sulfacetamide-sulfur-cleansr23 topical kit
Tier 1
sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream
Tier 1
sulfadiazine oral tablet Tier 2
sulfamethoxazole-trimethoprim oral suspension
Tier 1
Drug Name Tier Notes
sulfamethoxazole-trimethoprim oral tablet
Tier 1
SULFAMYLON TOPICAL CREAM
Tier 3
sulfatrim oral suspension Tier 1
SUPRAX ORAL CAPSULE
Tier 3
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML
Tier 3
TEFLARO INTRAVENOUS RECON SOLN
Tier 3
tetracycline oral capsule Tier 1
THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG
Tier 4 PA; SP; QL
thermazene topical cream Tier 1
TOBRADEX OPHTHALMIC (EYE) OINTMENT
Tier 3
tobramycin in 0.225 % nacl inhalation solution for nebulization
Tier 4 SP
tobramycin ophthalmic (eye) drops
Tier 1
tobramycin-dexamethasone ophthalmic (eye) drops,suspension
Tier 1
TRECATOR ORAL TABLET
Tier 3
trimethoprim oral tablet Tier 1
TYGACIL INTRAVENOUS RECON SOLN
Tier 3
vancomycin oral capsule Tier 2 PA
vandazole vaginal gel Tier 1
VIBATIV INTRAVENOUS RECON SOLN 750 MG
Tier 3
XIFAXAN ORAL TABLET200 MG, 550 MG
Tier 3 PA; QL
ANTICOAGULANTS
ELIQUIS ORAL TABLET2.5 MG, 5 MG
Tier 3 QL
enoxaparin subcutaneous solution
Tier 4 QL
Effective 1/1/201715
Drug Name Tier Notes
enoxaparin subcutaneous syringe
Tier 4 QL
fondaparinux subcutaneous syringe
Tier 4 PA; QL
FRAGMIN SUBCUTANEOUS SOLUTION
Tier 4 QL
FRAGMIN SUBCUTANEOUS SYRINGE
Tier 4 QL
hep flush-10 (pf) intravenous solution
Tier 1
heparin (porcine) in 0.9% nacl intravenous parenteral solution 10,000 unit/1,000 ml, 100 unit/100 ml (1 unit/ml), 2,500 unit/500 ml (5 unit/ml), 25,000 unit/250 ml, 250 unit/250 ml (1 unit/ml), 3,000 unit/500 ml (6 unit/ml), 30,000 unit/1,000 ml, 4000 unit/1000 ml (4 unit/ml), 5,000 unit/1,000 ml, 5,000 unit/500 ml (10 unit/ml), 6,000 unit/1000 ml (6 unit/ml)
Tier 1
heparin (porcine) in 0.9% nacl intravenous syringe
Tier 1
heparin (porcine) in 5 % dex intravenous parenteral solution
Tier 1
heparin (porcine) in nacl (pf) intravenous parenteral solution
Tier 1
heparin (porcine) injection cartridge
Tier 1
heparin (porcine) injection solution
Tier 1
heparin flush(porcine)-0.9nacl intravenous kit
Tier 1
heparin lock flush (porcine) intravenous solution
Tier 1
heparin lock flush (porcine) intravenous syringe
Tier 1
heparin lock flush intravenous solution
Tier 1
heparin lock flush intravenous syringe
Tier 1
Drug Name Tier Notes
heparin lock intravenous solution
Tier 1
heparin lockflush(porcine)(pf) intravenous syringe
Tier 1
heparin(porcine) in 0.45% nacl intravenous parenteral solution 100 unit/100 ml (1 unit/ml), 25,000 unit/250 ml, 25,000 unit/500 ml, 5,000 unit/1,000 ml
Tier 1
heparin, porcine (pf) injection solution
Tier 1
heparin, porcine (pf) injection syringe
Tier 1
heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml)
Tier 1
heparin, porcine (pf) intravenous syringe
Tier 1
jantoven oral tablet Tier 1
PRADAXA ORAL CAPSULE
Tier 3 QL
warfarin oral tablet Tier 1
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG
Tier 3 PA; QL
XARELTO ORAL TABLETS,DOSE PACK
Tier 3 PA
ANTIDOTES
naloxone injection solution Tier 1 QL
naloxone injection syringe Tier 1 QL
naltrexone oral tablet Tier 1
RELISTOR SUBCUTANEOUS SOLUTION
Tier 3 PA
RELISTOR SUBCUTANEOUS SYRINGE
Tier 3 PA
ANTIFUNGALS
amphotericin b injection recon soln
Tier 2
ciclopirox topical cream Tier 1
ciclopirox topical gel Tier 1
ciclopirox topical shampoo Tier 1
ciclopirox topical solution Tier 1
Effective 1/1/201716
Drug Name Tier Notes
ciclopirox topical suspension
Tier 1
clotrimazole mucous membrane troche
Tier 2 QL
clotrimazole topical cream Tier 1
clotrimazole topical solution
Tier 1
clotrimazole-betamethasone topical cream
Tier 1
clotrimazole-betamethasone topical lotion
Tier 1
econazole topical cream Tier 1
ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN
Tier 3
ERTACZO TOPICAL CREAM
Tier 3
EXELDERM TOPICAL CREAM
Tier 3
EXELDERM TOPICAL SOLUTION
Tier 3
fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml
Tier 1 QL
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg
Tier 1 QL
flucytosine oral capsule Tier 1
griseofulvin microsize oral suspension
Tier 1
griseofulvin microsize oral tablet
Tier 1
griseofulvin ultramicrosize oral tablet
Tier 1
GYNAZOLE-1 VAGINAL CREAM
Tier 3
itraconazole oral capsule Tier 2 PA; QL
JUBLIA TOPICAL SOLUTION WITH APPLICATOR
Tier 3
KERYDIN TOPICAL SOLUTION WITH APPLICATOR
Tier 3
ketoconazole oral tablet Tier 1 QL
Drug Name Tier Notes
ketoconazole topical cream
Tier 1
ketoconazole topical foam Tier 1
ketoconazole topical shampoo
Tier 1
LUZU TOPICAL CREAM Tier 3
MENTAX TOPICAL CREAM
Tier 3
miconazole-3 vaginal suppository
Tier 1
MYCAMINE INTRAVENOUS RECON SOLN
Tier 3
NAFTIFINE TOPICAL CREAM 1 %
Tier 2
naftifine topical cream 2 % Tier 2
NAFTIN TOPICAL GEL Tier 3
NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
NOXAFIL ORAL SUSPENSION
Tier 3 QL
nyamyc topical powder Tier 1
nystatin oral powder 150 million unit, 500 million unit
Tier 1
nystatin oral suspension Tier 1
nystatin oral tablet Tier 1
nystatin topical cream Tier 1
nystatin topical ointment Tier 1
nystatin topical powder Tier 1
nystatin-triamcinolone topical cream
Tier 1
nystatin-triamcinolone topical ointment
Tier 1
nystop topical powder Tier 1
ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET
Tier 3
oxiconazole topical cream Tier 2
OXISTAT TOPICAL LOTION
Tier 3
terbinafine hcl oral tablet Tier 1 PA; QL
terconazole vaginal cream Tier 1
terconazole vaginal suppository
Tier 1
Effective 1/1/201717
Drug Name Tier Notes
voriconazole oral suspension for reconstitution
Tier 2 QL
voriconazole oral tablet 200 mg, 50 mg
Tier 2 QL
ANTIHISTAMINE AND DECONGESTANT COMBINATION
promethazine vc oral syrup
Tier 1
promethazine-phenylephrine syr
Tier 1
ANTIHISTAMINES
azelastine ophthalmic (eye) drops
Tier 1 QL
BEPREVE OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
carbinoxamine maleate oral liquid
Tier 1
carbinoxamine maleate oral tablet
Tier 1
cetirizine oral solution 1 mg/ml
Tier 1
clemastine oral tablet 2.68 mg
Tier 1
cyproheptadine oral syrup Tier 1
cyproheptadine oral tablet Tier 1
desloratadine oral tablet Tier 1
desloratadine oral tablet,disintegrating
Tier 1
diphenhydramine hcl injection solution 50 mg/ml
Tier 1
diphenhydramine hcl injection syringe
Tier 1
diphenhydramine hcl oral capsule 50 mg
Tier 1
EMADINE OPHTHALMIC (EYE) DROPS
Tier 3 ST; QL
epinastine ophthalmic (eye) drops
Tier 1 QL
fexofenadine oral tablet 180 mg
Tier 1
hydroxyzine hcl oral solution 10 mg/5 ml
Tier 1
hydroxyzine hcl oral tablet Tier 1
hydroxyzine pamoate oral capsule
Tier 1
Drug Name Tier Notes
LASTACAFT OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
levocetirizine oral solution Tier 1
levocetirizine oral tablet Tier 1
olopatadine ophthalmic (eye) drops
Tier 2 PA; QL
promethazine oral syrup Tier 1
promethazine oral tablet Tier 1
ANTIHYPERGLYCEMICS
acarbose oral tablet Tier 1
APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN
Tier 3 ST
APIDRA SUBCUTANEOUS SOLUTION
Tier 3 ST
AVANDIA ORAL TABLET2 MG, 4 MG
Tier 3 ST; QL
BYDUREON SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON
Tier 3 ST; QL
chlorpropamide oral tablet Tier 1
CYCLOSET ORAL TABLET
Tier 3
FARXIGA ORAL TABLET Tier 3 ST; QL
glimepiride oral tablet Tier 1
glipizide oral tablet Tier 1
glipizide oral tablet extended release 24hr
Tier 1
glipizide-metformin oral tablet
Tier 1
glyburide micronized oral tablet
Tier 1
glyburide oral tablet Tier 1
glyburide-metformin oral tablet
Tier 1
HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
Effective 1/1/201718
Drug Name Tier Notes
HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION
Tier 2
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION
Tier 2
HUMALOG SUBCUTANEOUS CARTRIDGE
Tier 2
HUMALOG SUBCUTANEOUS SOLUTION
Tier 2
HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMULIN 70/30 SUBCUTANEOUS SUSPENSION
Tier 2
HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMULIN N SUBCUTANEOUS SUSPENSION
Tier 2
HUMULIN R U-100 INJECTION SOLUTION
Tier 2
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION
Tier 2
INVOKAMET ORAL TABLET
Tier 3 ST; QL
INVOKANA ORAL TABLET
Tier 3 ST; QL
JANUMET ORAL TABLET
Tier 2 ST; QL
JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 MG
Tier 2 ST; QL
JANUVIA ORAL TABLET Tier 2 ST; QL
Drug Name Tier Notes
JARDIANCE ORAL TABLET
Tier 2 ST; QL
JENTADUETO ORAL TABLET
Tier 2 ST; QL
LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN
Tier 2
LANTUS SUBCUTANEOUS SOLUTION
Tier 2
LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN
Tier 2
LEVEMIR SUBCUTANEOUS SOLUTION
Tier 2
metformin oral tablet Tier 1
metformin oral tablet extended release 24 hr
Tier 1
metformin oral tablet extended release 24hr
Tier 1
miglitol oral tablet Tier 2
nateglinide oral tablet Tier 2 PA
NESINA ORAL TABLET Tier 3 ST; QL
NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION
Tier 2
NOVOLIN N SUBCUTANEOUS SUSPENSION
Tier 2
NOVOLIN R INJECTION SOLUTION
Tier 2
NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN
Tier 2
NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN
Tier 2
NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION
Tier 2
NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE
Tier 2
NOVOLOG SUBCUTANEOUS SOLUTION
Tier 2
ONGLYZA ORAL TABLET 2.5 MG
Tier 3 ST; DO
Effective 1/1/201719
Drug Name Tier Notes
ONGLYZA ORAL TABLET 5 MG
Tier 3 ST; QL
pioglitazone oral tablet Tier 1 QL
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR
Tier 3 PA
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR
Tier 3 PA
SYNJARDY ORAL TABLET
Tier 2 ST; QL
TANZEUM SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
tolazamide oral tablet Tier 1
tolbutamide oral tablet Tier 1
TRADJENTA ORAL TABLET
Tier 2 ST; DO
TRULICITY SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR
Tier 2 ST; QL
VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR
Tier 2 ST; QL
XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5-1,000 MG, 5-500 MG
Tier 3 ST; QL
ANTIINFECTIVES/MISCELLANEOUS
ALBENZA ORAL TABLET
Tier 3
ALINIA ORAL SUSPENSION FOR RECONSTITUTION
Tier 3
ALINIA ORAL TABLET Tier 3
atovaquone oral suspension
Tier 2
atovaquone-proguanil oral tablet
Tier 1
BILTRICIDE ORAL TABLET
Tier 3
chloroquine phosphate oral tablet
Tier 1
COARTEM ORAL TABLET
Tier 3
Drug Name Tier Notes
DARAPRIM ORAL TABLET
Tier 3 PA; LD; QL
hydroxychloroquine oral tablet
Tier 1
ivermectin oral tablet Tier 1
mefloquine oral tablet Tier 1
NEBUPENT INHALATION RECON SOLN
Tier 4
paromomycin oral capsule Tier 1
PRIMAQUINE ORAL TABLET
Tier 3
quinine sulfate oral capsule
Tier 2 PA; QL
ANTINEOPLASTICS
ACTIMMUNE SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; LD
AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION
Tier 4 PA; SP
AFINITOR ORAL TABLET
Tier 4 PA; SP
anastrozole oral tablet Tier 1 QL
bexarotene oral capsule Tier 4 PA; SP
bicalutamide oral tablet Tier 4
BOSULIF ORAL TABLET100 MG, 500 MG
Tier 4 PA; SP; QL
capecitabine oral tablet Tier 4 PA; SP
CAPRELSA ORAL TABLET 100 MG, 300 MG
Tier 4 PA; QL
CARAC TOPICAL CREAM
Tier 2 QL
COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)
Tier 4 PA; LD; QL
CYCLOPHOSPHAMIDE ORAL CAPSULE
Tier 4 SP
diclofenac sodium topical gel 3 %
Tier 1 QL
EMCYT ORAL CAPSULE Tier 4 PA
ERIVEDGE ORAL CAPSULE
Tier 4 PA; SP; QL
Effective 1/1/201720
Drug Name Tier Notes
ETOPOPHOS INTRAVENOUS RECON SOLN
Tier 4 SP
etoposide oral capsule Tier 4 SP
exemestane oral tablet Tier 4 PA; QL
FARESTON ORAL TABLET
Tier 4 QL
FARYDAK ORAL CAPSULE
Tier 4 PA; SP; QL
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG, 80 MG
Tier 4 PA; SP; QL
FIRMAGON SUBCUTANEOUS RECON SOLN 120 MG
Tier 4 PA; SP; QL
fludarabine intravenous recon soln
Tier 4 SP
fludarabine intravenous solution
Tier 4 SP
fluorouracil topical cream 5 %
Tier 1 QL
fluorouracil topical solution Tier 1 QL
flutamide oral capsule Tier 1
GILOTRIF ORAL TABLET
Tier 4 PA; SP; LD; QL
GLEOSTINE ORAL CAPSULE
Tier 4 PA
HEXALEN ORAL CAPSULE
Tier 4
HYCAMTIN ORAL CAPSULE
Tier 4 SP
hydroxyurea oral capsule Tier 1
IBRANCE ORAL CAPSULE
Tier 4 PA; SP; QL
ICLUSIG ORAL TABLET15 MG, 45 MG
Tier 4 PA; QL
imatinib oral tablet 100 mg, 400 mg
Tier 4 PA; SP; QL
IMBRUVICA ORAL CAPSULE
Tier 4 PA; LD; QL
INLYTA ORAL TABLET 1 MG, 5 MG
Tier 4 PA; SP; QL
INTRON A INJECTION RECON SOLN
Tier 4 PA; SP
INTRON A INJECTION SOLUTION
Tier 4 PA; SP
Drug Name Tier Notes
JAKAFI ORAL TABLET10 MG, 15 MG, 20 MG, 25 MG, 5 MG
Tier 4 PA; SP; LD; QL
LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2)
Tier 4 PA; SP; LD; QL
letrozole oral tablet Tier 4 QL
LEUKERAN ORAL TABLET
Tier 4
leuprolide subcutaneous kit
Tier 4 PA; SP
LYNPARZA ORAL CAPSULE
Tier 4 PA; SP; LD; QL
LYSODREN ORAL TABLET
Tier 4 QL
MATULANE ORAL CAPSULE
Tier 4 LD
MEKINIST ORAL TABLET 0.5 MG, 2 MG
Tier 4 PA; SP; QL
melphalan hcl intravenous recon soln
Tier 4 SP
melphalan oral tablet Tier 4
mercaptopurine oral tablet Tier 4
methotrexate sodium oral tablet
Tier 1
MYLERAN ORAL TABLET
Tier 4
NEXAVAR ORAL TABLET
Tier 4 PA; SP; QL
nilutamide oral tablet Tier 4 QL
ODOMZO ORAL CAPSULE
Tier 4 PA; SP; QL
PANRETIN TOPICAL GEL
Tier 3 SP
PICATO TOPICAL GEL0.015 %, 0.05 %
Tier 3 PA; QL
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG
Tier 4 PA; SP; QL
REVLIMID ORAL CAPSULE
Tier 4 PA; SP; QL
Effective 1/1/201721
Drug Name Tier Notes
RITUXAN INTRAVENOUS CONCENTRATE
Tier 4 PA; SP
SPRYCEL ORAL TABLET
Tier 4 PA; SP; QL
STIVARGA ORAL TABLET
Tier 4 PA; SP; QL
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG
Tier 4 PA; SP; QL
SYNRIBO SUBCUTANEOUS RECON SOLN
Tier 4 LD
TABLOID ORAL TABLET Tier 4
TAFINLAR ORAL CAPSULE
Tier 4 SP; QL
tamoxifen oral tablet Tier 1 $0
TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG
Tier 4 PA; SP; QL
TARGRETIN TOPICAL GEL
Tier 4 PA; SP
TASIGNA ORAL CAPSULE
Tier 4 PA; SP; QL
temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg
Tier 4 PA; SP; QL
topotecan intravenous recon soln
Tier 4 SP
topotecan intravenous solution
Tier 4 SP
TORISEL INTRAVENOUS RECON SOLN
Tier 4 SP
TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG, 22.5 MG, 3.75 MG
Tier 4 PA; SP; QL
TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML, 22.5 MG/2 ML, 3.75 MG/2 ML
Tier 4 PA; SP; QL
tretinoin (chemotherapy) oral capsule
Tier 4
TYKERB ORAL TABLET Tier 4 PA; SP; QL
VOTRIENT ORAL TABLET
Tier 4 PA; SP; QL
XALKORI ORAL CAPSULE
Tier 4 PA; SP; LD; QL
Drug Name Tier Notes
XTANDI ORAL CAPSULE Tier 4 PA; SP; QL
YERVOY INTRAVENOUS SOLUTION
Tier 4 PA; SP
ZANOSAR INTRAVENOUS RECON SOLN
Tier 4 SP
ZELBORAF ORAL TABLET
Tier 4 PA; SP; QL
ZOLINZA ORAL CAPSULE
Tier 4 PA; SP; QL
ZYDELIG ORAL TABLET Tier 4 PA; LD; QL
ZYKADIA ORAL CAPSULE
Tier 4 PA; SP; QL
ZYTIGA ORAL TABLET250 MG
Tier 4 PA; SP; QL
ZYTIGA ORAL TABLET500 MG
Tier 4 PA; QL
ANTI-OBESITY DRUGS
BELVIQ ORAL TABLET Tier 3 PA
CONTRAVE ORAL TABLET EXTENDED RELEASE
Tier 3 PA
phendimetrazine tartrate oral capsule, extended release
Tier 1 PA
phendimetrazine tartrate oral tablet
Tier 1 PA
phentermine oral capsule Tier 1 PA
phentermine oral tablet Tier 1 PA
QSYMIA ORAL CAPSULE, ER MULTIPHASE 24 HR
Tier 3 PA
ANTIPARKINSON DRUGS
amantadine hcl oral capsule
Tier 2 QL
amantadine hcl oral solution
Tier 2
amantadine hcl oral tablet Tier 2 QL
APOKYN SUBCUTANEOUS CARTRIDGE
Tier 4 SP; LD; QL
benztropine oral tablet Tier 1
bromocriptine oral capsule Tier 1
bromocriptine oral tablet Tier 1
carbidopa oral tablet Tier 2
carbidopa-levodopa oral tablet
Tier 1
Effective 1/1/201722
Drug Name Tier Notes
carbidopa-levodopa oral tablet extended release
Tier 1
carbidopa-levodopa oral tablet,disintegrating
Tier 1
entacapone oral tablet Tier 2 QL
pramipexole oral tablet Tier 2 QL
rasagiline oral tablet Tier 2
ropinirole oral tablet Tier 1
ropinirole oral tablet extended release 24 hr
Tier 2
selegiline hcl oral capsule Tier 1
selegiline hcl oral tablet Tier 1
tolcapone oral tablet Tier 2 QL
trihexyphenidyl oral elixir Tier 1
trihexyphenidyl oral tablet Tier 1
ANTIPLATELET DRUGS
anagrelide oral capsule Tier 2
aspirin-dipyridamole oral capsule, er multiphase 12 hr
Tier 2 QL
BRILINTA ORAL TABLET
Tier 3 QL
cilostazol oral tablet Tier 1
clopidogrel oral tablet 300 mg
Tier 2
clopidogrel oral tablet 75 mg
Tier 2 QL
dipyridamole oral tablet Tier 1
EFFIENT ORAL TABLET10 MG
Tier 3 QL
EFFIENT ORAL TABLET5 MG
Tier 3 DO
prasugrel oral tablet Tier 2
ticlopidine oral tablet Tier 1
ZONTIVITY ORAL TABLET
Tier 3 QL
ANTIVIRALS
abacavir oral tablet Tier 4
abacavir-lamivudine oral tablet
Tier 4
abacavir-lamivudine-zidovudine oral tablet
Tier 4
acyclovir oral capsule Tier 1
acyclovir oral suspension 200 mg/5 ml
Tier 1
acyclovir oral tablet Tier 1
Drug Name Tier Notes
acyclovir topical ointment Tier 3 QL
adefovir oral tablet Tier 4 SP
APTIVUS ORAL CAPSULE
Tier 4
APTIVUS ORAL SOLUTION
Tier 4
BARACLUDE ORAL SOLUTION
Tier 4 SP
cidofovir intravenous solution
Tier 2 SP
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
Tier 4
DENAVIR TOPICAL CREAM
Tier 3 QL
didanosine oral capsule,delayed release(dr/ec)
Tier 4
EDURANT ORAL TABLET
Tier 4
EMTRIVA ORAL CAPSULE
Tier 4
EMTRIVA ORAL SOLUTION
Tier 4
entecavir oral tablet Tier 4 SP
EPCLUSA ORAL TABLET
Tier 4 PA; SP; QL
EPIVIR HBV ORAL SOLUTION
Tier 4 SP
EVOTAZ ORAL TABLET Tier 4
famciclovir oral tablet Tier 1
foscarnet intravenous solution
Tier 2
FUZEON SUBCUTANEOUS RECON SOLN
Tier 4
ganciclovir sodium intravenous recon soln
Tier 4 SP
GENVOYA ORAL TABLET
Tier 4
HARVONI ORAL TABLET
Tier 4 PA; SP; QL
INTELENCE ORAL TABLET
Tier 4
INVIRASE ORAL CAPSULE
Tier 4
INVIRASE ORAL TABLET
Tier 4
Effective 1/1/201723
Drug Name Tier Notes
ISENTRESS ORAL TABLET
Tier 4
ISENTRESS ORAL TABLET,CHEWABLE
Tier 4
KALETRA ORAL TABLET
Tier 4
lamivudine oral tablet 150 mg, 300 mg
Tier 4
lamivudine-zidovudine oral tablet
Tier 4
lopinavir-ritonavir oral solution
Tier 4
moderiba dose pack oral tablets,dose pack
Tier 4 SP
moderiba oral tablet Tier 4 SP
nevirapine oral suspension Tier 4
nevirapine oral tablet Tier 4
NORVIR ORAL CAPSULE
Tier 4
NORVIR ORAL SOLUTION
Tier 4
NORVIR ORAL TABLET Tier 4
OLYSIO ORAL CAPSULE
Tier 4 PA; SP; QL
oseltamivir oral capsule 30 mg, 45 mg, 75 mg
Tier 2 QL
PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
PEGASYS SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; QL
PEGASYS SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML
Tier 4 PA; SP
PREZISTA ORAL SUSPENSION
Tier 4
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG
Tier 4
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE
Tier 2 QL
RESCRIPTOR ORAL TABLET
Tier 4
Drug Name Tier Notes
RESCRIPTOR ORAL TABLET, DISPERSIBLE
Tier 4
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG
Tier 4
ribasphere oral capsule Tier 4 SP
ribasphere oral tablet Tier 4 SP
ribasphere ribapak oral tablets,dose pack
Tier 4 SP
ribavirin oral capsule Tier 4 SP
ribavirin oral tablet 200 mg Tier 4 SP
rimantadine oral tablet Tier 1
SELZENTRY ORAL TABLET
Tier 4
SOVALDI ORAL TABLET Tier 4 PA; SP; QL
stavudine oral capsule Tier 4
stavudine oral recon soln Tier 4
STRIBILD ORAL TABLET
Tier 4
SUSTIVA ORAL CAPSULE
Tier 4
SUSTIVA ORAL TABLET Tier 4
TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION
Tier 2 QL
TECHNIVIE ORAL TABLET
Tier 4 PA; SP; QL
TIVICAY ORAL TABLET Tier 4
trifluridine ophthalmic (eye) drops
Tier 1
TRIUMEQ ORAL TABLET
Tier 4
TRUVADA ORAL TABLET
Tier 4
valacyclovir oral tablet Tier 1
valganciclovir oral recon soln
Tier 2 SP
valganciclovir oral tablet Tier 2 SP
VEREGEN TOPICAL OINTMENT
Tier 3
VIEKIRA PAK ORAL TABLETS,DOSE PACK
Tier 4 PA; SP; QL
VIRACEPT ORAL TABLET
Tier 4
VIREAD ORAL TABLET Tier 4
zidovudine oral capsule Tier 4
zidovudine oral syrup Tier 4
Effective 1/1/201724
Drug Name Tier Notes
zidovudine oral tablet Tier 4
ZIRGAN OPHTHALMIC (EYE) GEL
Tier 3
AUTONOMIC DRUGS
bethanechol chloride oral tablet
Tier 2
BOTOX INJECTION RECON SOLN
Tier 4 PA; SP
cevimeline oral capsule Tier 2
dextroamphetamine oral capsule, extended release
Tier 1 PA
dextroamphetamine oral solution
Tier 1 PA
dextroamphetamine oral tablet
Tier 1 PA
dextroamphetamine-amphetamine oral capsule,extended release 24hr
Tier 1 PA
dextroamphetamine-amphetamine oral tablet
Tier 1 PA
donepezil oral tablet Tier 2
donepezil oral tablet,disintegrating
Tier 2
epinephrine 0.3 mg auto-inject
Tier 1 QL
epinephrine 0.3 mg auto-inject inner
Tier 1 QL
epinephrine 0.3 mg auto-inject latex-free, sdv
Tier 1 QL
epinephrine 0.3 mg auto-inject latex-free, suv
Tier 1 QL
epinephrine 0.3 mg auto-inject no latex, auto-injct
Tier 1 QL
epinephrine 0.3 mg auto-inject no latex, two-pack
Tier 1 QL
epinephrine injection auto-injector 0.15 mg/0.15 ml
Tier 1 QL
EPIPEN 2-PAK INJECTION AUTO-INJECTOR
Tier 2 QL
EPIPEN INJECTION AUTO-INJECTOR
Tier 2 QL
EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR
Tier 2 QL
EPIPEN JR INJECTION AUTO-INJECTOR
Tier 2 QL
Drug Name Tier Notes
galantamine oral capsule,ext rel. pellets 24 hr
Tier 2
galantamine oral solution Tier 2
galantamine oral tablet Tier 2
guanidine oral tablet Tier 1
methamphetamine oral tablet
Tier 2 PA
midodrine oral tablet Tier 1
NORTHERA ORAL CAPSULE
Tier 3 SP; LD
phenoxybenzamine oral capsule
Tier 2
pilocarpine hcl oral tablet Tier 2
procentra oral solution Tier 1 PA
pyridostigmine bromide oral tablet
Tier 1
rivastigmine tartrate oral capsule
Tier 2
zenzedi oral tablet 10 mg, 5 mg
Tier 1 PA
BIOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN
Tier 3 $0
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
AFLURIA 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0
AFLURIA 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1 $0
AFLURIA QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0
AFLURIA QUAD 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1 $0
ATGAM INTRAVENOUS SOLUTION
Tier 4 SP
Effective 1/1/201725
Drug Name Tier Notes
BEXSERO INTRAMUSCULAR SYRINGE
Tier 2 $0
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION
Tier 3 $0
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE
Tier 3 $0
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
FLUAD 2017-2018 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE
Tier 1
FLUARIX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0
FLUBLOK 2017-2018 (PF) INTRAMUSCULAR SOLUTION
Tier 1 $0
FLUBLOK QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0
FLUCELVAX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0
FLUCELVAX QUAD 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1 $0
FLULAVAL QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0
Drug Name Tier Notes
FLULAVAL QUAD 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1 $0
FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0
FLUVIRIN 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1 $0
FLUZONE HIGH-DOSE 2017-18 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0
FLUZONE INTRADERM QUAD 2017-18 INTRADERMAL SYRINGE
Tier 1 $0
FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SUSPENSION
Tier 1 $0
FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1
FLUZONE QUAD 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1 $0
FLUZONE QUAD PEDI 2017-18 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0
GAMASTAN S/D INTRAMUSCULAR SOLUTION
Tier 4 PA; SP
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION
Tier 2 $0
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE
Tier 2 $0
HAVRIX (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
HAVRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
HYQVIA SUBCUTANEOUS SOLUTION
Tier 4 PA; SP
Effective 1/1/201726
Drug Name Tier Notes
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN
Tier 3
INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
IPOL INJECTION SUSPENSION
Tier 3 $0
IXIARO (PF) INTRAMUSCULAR SYRINGE
Tier 3
KINRIX (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
KINRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
MENACTRA (PF) INTRAMUSCULAR SOLUTION
Tier 3 $0
MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN
Tier 3 $0
MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN
Tier 3 $0
MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN
Tier 3 $0
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT
Tier 3 $0
M-M-R II (PF) SUBCUTANEOUS RECON SOLN
Tier 3 $0
OCTAGAM INTRAVENOUS SOLUTION
Tier 4 PA; SP
PEDIARIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION
Tier 3 $0
PENTACEL (PF) INTRAMUSCULAR KIT
Tier 3 $0
Drug Name Tier Notes
PNEUMOVAX 23 INJECTION SOLUTION
Tier 2 $0
PNEUMOVAX 23 INJECTION SYRINGE
Tier 2 $0
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE
Tier 2 $0
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3 $0
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 3
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
ROTARIX ORAL SUSPENSION FOR RECONSTITUTION
Tier 3 $0
ROTATEQ VACCINE ORAL SOLUTION
Tier 3 $0
TENIVAC (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
TENIVAC (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION
Tier 3 $0
THYMOGLOBULIN INTRAVENOUS RECON SOLN
Tier 4 SP
TRUMENBA INTRAMUSCULAR SYRINGE
Tier 2 $0
TWINRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
Effective 1/1/201727
Drug Name Tier Notes
TYPHIM VI INTRAMUSCULAR SOLUTION
Tier 3
TYPHIM VI INTRAMUSCULAR SYRINGE
Tier 3
VAQTA (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
VAQTA (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3 $0
VIVOTIF BERNA VACCINE ORAL CAPSULE,DELAYED RELEASE(DR/EC)
Tier 2
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 2 $0
BLOOD
DROXIA ORAL CAPSULE
Tier 4
pentoxifylline oral tablet extended release
Tier 1
tranexamic acid intravenous solution
Tier 2
tranexamic acid oral tablet Tier 1
CARDIAC DRUGS
afeditab cr oral tablet extended release 30 mg
Tier 1 DO
afeditab cr oral tablet extended release 60 mg
Tier 1 QL
amiodarone oral tablet Tier 1
amlodipine oral tablet 10 mg
Tier 1 QL
amlodipine oral tablet 2.5 mg, 5 mg
Tier 1 DO
cartia xt oral capsule,extended release 24hr 120 mg, 180 mg
Tier 1 DO
Drug Name Tier Notes
cartia xt oral capsule,extended release 24hr 240 mg, 300 mg
Tier 1 QL
digox oral tablet Tier 1
digoxin oral solution 50 mcg/ml
Tier 1
digoxin oral tablet Tier 1
diltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg
Tier 1 DO
diltiazem hcl oral capsule,ext.rel 24h degradable 240 mg
Tier 1 QL
diltiazem hcl oral capsule,extended release 12 hr
Tier 2 QL
diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg
Tier 1 DO
diltiazem hcl oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1 QL
diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg
Tier 1 DO
diltiazem hcl oral capsule,extended release 24hr 240 mg, 300 mg, 360 mg
Tier 1 QL
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg
Tier 1 QL
diltiazem hcl oral tablet extended release 24 hr 180 mg
Tier 1 DO
diltiazem hcl oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1 QL
dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg
Tier 1 DO
dilt-xr oral capsule,ext.rel 24h degradable 240 mg
Tier 1 QL
disopyramide phosphate oral capsule
Tier 1
dofetilide oral capsule Tier 2
Effective 1/1/201728
Drug Name Tier Notes
felodipine oral tablet extended release 24 hr 10 mg
Tier 1 QL
felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg
Tier 1 DO
flecainide oral tablet Tier 2
isosorbide dinitrate oral tablet
Tier 1
isosorbide dinitrate oral tablet extended release
Tier 1
isosorbide mononitrate oral tablet
Tier 1
isosorbide mononitrate oral tablet extended release 24 hr
Tier 1
isradipine oral capsule 2.5 mg, 5 mg
Tier 1 QL
LANOXIN ORAL TABLET Tier 3
matzim la oral tablet extended release 24 hr 180 mg
Tier 1 DO
matzim la oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1 QL
mexiletine oral capsule Tier 2
MULTAQ ORAL TABLET Tier 3
nicardipine oral capsule 20 mg, 30 mg
Tier 2 QL
nifedipine oral capsule Tier 1 QL
nifedipine oral tablet extended release 24hr 30 mg
Tier 1 DO
nifedipine oral tablet extended release 24hr 60 mg, 90 mg
Tier 1 QL
nifedipine oral tablet extended release 30 mg
Tier 1 DO
nifedipine oral tablet extended release 60 mg, 90 mg
Tier 1 QL
nimodipine oral capsule Tier 2 QL
nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 8.5 mg
Tier 1 DO
nisoldipine oral tablet extended release 24 hr 25.5 mg, 30 mg, 34 mg, 40 mg
Tier 1 QL
Drug Name Tier Notes
nitro-bid transdermal ointment
Tier 1
nitroglycerin oral capsule, extended release
Tier 2
nitroglycerin sublingual tablet
Tier 1
nitroglycerin translingual aerosol,spray
Tier 2
nitroglycerin translingual spray,non-aerosol
Tier 2
nitro-time oral capsule, extended release
Tier 1
pacerone oral tablet 100 mg, 200 mg, 400 mg
Tier 2
procainamide injection solution
Tier 2
propafenone oral capsule,extended release 12 hr
Tier 2
propafenone oral tablet Tier 2
quinidine sulfate oral tablet Tier 1
RANEXA ORAL TABLET EXTENDED RELEASE 12 HR
Tier 3
taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg
Tier 1 DO
taztia xt oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg
Tier 1 QL
verapamil oral capsule, 24 hr er pellet ct 100 mg
Tier 1 DO
verapamil oral capsule, 24 hr er pellet ct 200 mg, 300 mg
Tier 1 QL
verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg
Tier 1 DO
verapamil oral capsule,ext rel. pellets 24 hr 240 mg, 360 mg
Tier 1 QL
verapamil oral tablet 120 mg, 40 mg, 80 mg
Tier 1 QL
verapamil oral tablet extended release
Tier 1 QL
CARDIOVASCULAR
acebutolol oral capsule Tier 1
Effective 1/1/201729
Drug Name Tier Notes
ADCIRCA ORAL TABLET
Tier 4 PA; SP; QL
ADEMPAS ORAL TABLET
Tier 4 PA; SP; LD; QL
amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-80 mg
Tier 1 QL
amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg
Tier 1 DO
amlodipine-benazepril oral capsule
Tier 1
atenolol oral tablet Tier 1
atenolol-chlorthalidone oral tablet
Tier 1
atorvastatin oral tablet 10 mg, 20 mg, 40 mg
Tier 1 DO
atorvastatin oral tablet 80 mg
Tier 1 QL
benazepril oral tablet Tier 1
benazepril-hydrochlorothiazide oral tablet
Tier 1
betaxolol oral tablet Tier 1
bisoprolol fumarate oral tablet
Tier 1
bisoprolol-hydrochlorothiazide oral tablet
Tier 1
BYSTOLIC ORAL TABLET
Tier 3
candesartan oral tablet 16 mg, 32 mg
Tier 1 QL
candesartan oral tablet 4 mg, 8 mg
Tier 1 DO; QL
candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg
Tier 1 QL
candesartan-hydrochlorothiazid oral tablet 32-25 mg
Tier 1
captopril oral tablet Tier 2
captopril-hydrochlorothiazide oral tablet
Tier 2
carvedilol oral tablet Tier 1
Drug Name Tier Notes
cholestyramine (with sugar) oral powder
Tier 1 QL
cholestyramine (with sugar) oral powder in packet
Tier 1 QL
cholestyramine light oral powder
Tier 1 QL
cholestyramine light oral powder in packet
Tier 1
clonidine hcl oral tablet Tier 1
colestipol oral granules Tier 1
colestipol oral packet Tier 1
colestipol oral tablet Tier 1
doxazosin oral tablet Tier 1
EDARBI ORAL TABLET40 MG
Tier 3 DO
EDARBI ORAL TABLET80 MG
Tier 3
enalapril maleate oral tablet
Tier 1
enalapril-hydrochlorothiazide oral tablet
Tier 1
eprosartan oral tablet Tier 1 QL
ergoloid oral tablet Tier 2
ezetimibe oral tablet Tier 2 PA; QL
fenofibrate micronized oral capsule 130 mg, 43 mg
Tier 1
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg
Tier 1 QL
fenofibrate nanocrystallized oral tablet
Tier 1 QL
fenofibrate oral tablet 160 mg, 54 mg
Tier 1 QL
fenofibric acid (choline) oral capsule,delayed release(dr/ec)
Tier 1 QL
fenofibric acid oral tablet Tier 1 QL
fluvastatin oral capsule Tier 1 DO
fosinopril oral tablet Tier 1
fosinopril-hydrochlorothiazide oral tablet
Tier 1
gemfibrozil oral tablet Tier 1
guanfacine oral tablet Tier 1
Effective 1/1/201730
Drug Name Tier Notes
HEMANGEOL ORAL SOLUTION
Tier 4
hydralazine oral tablet Tier 1
indomethacin sodium intravenous recon soln
Tier 2
irbesartan oral tablet 150 mg, 75 mg
Tier 1 DO
irbesartan oral tablet 300 mg
Tier 1 QL
irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg
Tier 1 QL
irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg
Tier 1
labetalol oral tablet Tier 1
LETAIRIS ORAL TABLET Tier 4 PA; SP; LD; QL
LEVATOL ORAL TABLET
Tier 3
lisinopril oral tablet Tier 1
lisinopril-hydrochlorothiazide oral tablet
Tier 1
LIVALO ORAL TABLET 1 MG, 2 MG
Tier 3 ST; DO
LIVALO ORAL TABLET 4 MG
Tier 3 ST; QL
losartan oral tablet 100 mg, 25 mg, 50 mg
Tier 1 QL
losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg
Tier 1 QL
losartan-hydrochlorothiazide oral tablet 50-12.5 mg
Tier 1 DO
lovastatin oral tablet 10 mg, 20 mg
Tier 1 DO
lovastatin oral tablet 40 mg
Tier 1 QL
methyldopa oral tablet Tier 1
methyldopa-hydrochlorothiazide oral tablet
Tier 1
methyldopate intravenous solution
Tier 2
metoprolol succinate oral tablet extended release 24 hr
Tier 1
Drug Name Tier Notes
metoprolol ta-hydrochlorothiaz oral tablet
Tier 1
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
Tier 1
minoxidil oral tablet Tier 1
moexipril oral tablet Tier 1
moexipril-hydrochlorothiazide oral tablet
Tier 1
nadolol oral tablet Tier 1
nadolol-bendroflumethiazide oral tablet
Tier 1
niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg
Tier 1 QL
olmesartan oral tablet 20 mg
Tier 2 DO
olmesartan oral tablet 40 mg, 5 mg
Tier 2 QL
OPSUMIT ORAL TABLET Tier 4 PA; SP; LD; QL
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG
Tier 4 PA; SP; LD
ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG
Tier 4 PA; LD
perindopril erbumine oral tablet
Tier 1
pindolol oral tablet Tier 1
pravastatin oral tablet 10 mg, 20 mg
Tier 1 DO
pravastatin oral tablet 40 mg
Tier 1
pravastatin oral tablet 80 mg
Tier 1 QL
prazosin oral capsule Tier 1
prevalite oral powder Tier 1
prevalite oral powder in packet
Tier 1
propranolol oral capsule,extended release 24 hr
Tier 1
propranolol oral solution Tier 1
propranolol oral tablet Tier 1
Effective 1/1/201731
Drug Name Tier Notes
propranolol-hydrochlorothiazid oral tablet
Tier 1
quinapril oral tablet Tier 1
quinapril-hydrochlorothiazide oral tablet
Tier 1
ramipril oral capsule Tier 1
REMODULIN INJECTION SOLUTION
Tier 4 PA; SP; LD
rosuvastatin oral tablet 10 mg, 20 mg, 5 mg
Tier 2 DO
rosuvastatin oral tablet 40 mg
Tier 2 QL
sildenafil oral tablet Tier 4 PA; SP; QL
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
Tier 1 DO
simvastatin oral tablet 80 mg
Tier 1 PA; QL
sorine oral tablet Tier 1
sotalol af oral tablet Tier 2
sotalol oral tablet Tier 2
TEKTURNA ORAL TABLET 150 MG
Tier 3 DO
TEKTURNA ORAL TABLET 300 MG
Tier 3 QL
telmisartan oral tablet 20 mg, 40 mg
Tier 1 DO
telmisartan oral tablet 80 mg
Tier 1 QL
terazosin oral capsule Tier 1
timolol maleate oral tablet Tier 1
TRACLEER ORAL TABLET
Tier 4 PA; SP; QL
trandolapril oral tablet Tier 1
trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 mg
Tier 1 DO
trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 2-180 mg, 2-240 mg, 4-240 mg
Tier 1 QL
valsartan oral tablet 160 mg, 320 mg
Tier 1 QL
valsartan oral tablet 40 mg, 80 mg
Tier 1 DO; QL
Drug Name Tier Notes
valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg
Tier 1 DO
valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg
Tier 1 QL
VECAMYL ORAL TABLET
Tier 3
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION
Tier 4 PA; SP; LD; QL
WELCHOL ORAL POWDER IN PACKET
Tier 3
WELCHOL ORAL TABLET
Tier 3
CNS DRUGS
AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR
Tier 4 PA; SP; QL
APTIOM ORAL TABLET Tier 3
AUBAGIO ORAL TABLET
Tier 4 PA; SP; QL
BANZEL ORAL SUSPENSION
Tier 3
BANZEL ORAL TABLET Tier 3
carbamazepine oral capsule, er multiphase 12 hr
Tier 1
carbamazepine oral suspension 100 mg/5 ml
Tier 1
carbamazepine oral tablet Tier 1
carbamazepine oral tablet extended release 12 hr
Tier 1
carbamazepine oral tablet,chewable
Tier 1
CELONTIN ORAL CAPSULE 300 MG
Tier 3
clonazepam oral tablet Tier 1
clonazepam oral tablet,disintegrating
Tier 1
COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML
Tier 4 PA; SP
COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML
Tier 4 PA; SP
diazepam rectal kit Tier 2
Effective 1/1/201732
Drug Name Tier Notes
divalproex oral capsule, delayed rel sprinkle
Tier 2
divalproex oral tablet extended release 24 hr
Tier 2
divalproex oral tablet,delayed release (dr/ec)
Tier 2
epitol oral tablet Tier 1
ethosuximide oral capsule Tier 1
ethosuximide oral solution Tier 1
EXTAVIA SUBCUTANEOUS KIT
Tier 4 PA; SP
EXTAVIA SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP
felbamate oral suspension Tier 1
felbamate oral tablet Tier 1
fosphenytoin injection solution
Tier 2
FYCOMPA ORAL TABLET
Tier 3
gabapentin oral capsule Tier 2
gabapentin oral solution Tier 2
gabapentin oral tablet 600 mg, 800 mg
Tier 2
GILENYA ORAL CAPSULE
Tier 4 PA; SP; QL
HORIZANT ORAL TABLET EXTENDED RELEASE
Tier 3 PA; QL
lamotrigine oral tablet Tier 1
lamotrigine oral tablet, chewable dispersible
Tier 1
levetiracetam oral solution Tier 2
levetiracetam oral tablet Tier 2
levetiracetam oral tablet extended release 24 hr
Tier 2 PA
LYRICA ORAL CAPSULE100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG
Tier 3 PA; QL
LYRICA ORAL SOLUTION
Tier 3 PA; QL
memantine oral solution Tier 2
memantine oral tablet Tier 2
memantine oral tablets,dose pack
Tier 3
Drug Name Tier Notes
NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK
Tier 3
NUEDEXTA ORAL CAPSULE
Tier 3
ONFI ORAL SUSPENSION
Tier 3
ONFI ORAL TABLET 10 MG, 20 MG
Tier 3
oxcarbazepine oral suspension
Tier 2
oxcarbazepine oral tablet Tier 2
PEGANONE ORAL TABLET
Tier 3
phenytoin sodium extended oral capsule
Tier 1
PLEGRIDY SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP
PLEGRIDY SUBCUTANEOUS SYRINGE
Tier 4 PA; SP
primidone oral tablet Tier 1
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE
Tier 4 PA; SP
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE
Tier 4 PA; SP
riluzole oral tablet Tier 4 SP
SABRIL ORAL POWDER IN PACKET
Tier 3 SP; LD
SABRIL ORAL TABLET Tier 3 SP; LD
TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG
Tier 4 PA; SP; QL
tetrabenazine oral tablet Tier 2 PA; SP; LD
tiagabine oral tablet Tier 2
topiramate oral capsule, sprinkle
Tier 1
topiramate oral tablet Tier 1
valproic acid (as sodium salt) oral solution
Tier 1
valproic acid oral capsule Tier 1
Effective 1/1/201733
Drug Name Tier Notes
vigabatrin oral powder in packet
Tier 2
VIMPAT ORAL SOLUTION
Tier 3
VIMPAT ORAL TABLET Tier 3
zonisamide oral capsule Tier 2
COLONY STIMULATING FACTORS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION
Tier 4 PA; SP
ARANESP (IN POLYSORBATE) INJECTION SYRINGE
Tier 4 PA; SP
LEUKINE INJECTION RECON SOLN
Tier 4 PA; SP
MOZOBIL SUBCUTANEOUS SOLUTION
Tier 4 PA; SP
NEULASTA SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR
Tier 4 SP; QL
NEUPOGEN INJECTION SOLUTION
Tier 4 PA; SP
NEUPOGEN INJECTION SYRINGE
Tier 4 PA; SP
PROCRIT INJECTION SOLUTION
Tier 4 PA; SP
PROMACTA ORAL TABLET
Tier 4 PA; SP
CONTRACEPTIVES
AFTERA ORAL TABLET Tier 1 $0; QL
altavera (28) oral tablet Tier 1 $0
alyacen 1/35 (28) oral tablet
Tier 1 $0
alyacen 7/7/7 (28) oral tablet
Tier 1 $0
amethia lo oral tablets,dose pack,3 month
Tier 1 $0
amethia oral tablets,dose pack,3 month
Tier 1 $0
amethyst oral tablet Tier 1 $0
apri oral tablet Tier 1 $0
aranelle (28) oral tablet Tier 1 $0
Drug Name Tier Notes
ashlyna oral tablets,dose pack,3 month
Tier 1 $0
aubra oral tablet Tier 1 $0
aviane oral tablet Tier 1 $0
azurette (28) oral tablet Tier 1 $0
balziva (28) oral tablet Tier 1 $0
BEKYREE (28) ORAL TABLET
Tier 1 $0
BLISOVI 24 FE ORAL TABLET
Tier 1 $0
BLISOVI FE 1.5/30 (28) ORAL TABLET
Tier 1 $0
BLISOVI FE 1/20 (28) ORAL TABLET
Tier 1 $0
briellyn oral tablet Tier 1 $0
camila oral tablet Tier 1 $0
camrese lo oral tablets,dose pack,3 month
Tier 1 $0
camrese oral tablets,dose pack,3 month
Tier 1 $0
caziant (28) oral tablet Tier 1 $0
chateal oral tablet Tier 1 $0
cryselle (28) oral tablet Tier 1 $0
cyclafem 1/35 (28) oral tablet
Tier 1 $0
cyclafem 7/7/7 (28) oral tablet
Tier 1 $0
cyred oral tablet Tier 1 $0
dasetta 1/35 (28) oral tablet
Tier 1 $0
dasetta 7/7/7 (28) oral tablet
Tier 1 $0
daysee oral tablets,dose pack,3 month
Tier 1 $0
deblitane oral tablet Tier 1 $0
delyla (28) oral tablet Tier 1 $0
desog-e.estradiol/e.estradiol oral tablet
Tier 1 $0
desogestrel-ethinyl estradiol oral tablet
Tier 1 $0
drospirenone-e.estradiol-lm.fa oral tablet
Tier 1
drospirenone-ethinyl estradiol oral tablet
Tier 1 $0
econtra ez oral tablet Tier 1 $0; QL
elinest oral tablet Tier 1 $0
Effective 1/1/201734
Drug Name Tier Notes
ELLA ORAL TABLET Tier 3 $0
emoquette oral tablet Tier 1 $0
enpresse oral tablet Tier 1 $0
enskyce oral tablet Tier 1 $0
errin oral tablet Tier 1 $0
estarylla oral tablet Tier 1 $0
ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg
Tier 1 $0
fallback solo oral tablet Tier 1 $0; QL
falmina (28) oral tablet Tier 1 $0
FAYOSIM ORAL TABLETS,DOSE PACK,3 MONTH
Tier 1 $0
femynor oral tablet Tier 1 $0
gianvi (28) oral tablet Tier 1 $0
gildagia oral tablet Tier 1 $0
heather oral tablet Tier 1 $0
introvale oral tablets,dose pack,3 month
Tier 1 $0
isibloom oral tablet Tier 1
jencycla oral tablet Tier 1 $0
jolessa oral tablets,dose pack,3 month
Tier 1 $0
jolivette oral tablet Tier 1 $0
JULEBER ORAL TABLET
Tier 1 $0
junel 1.5/30 (21) oral tablet Tier 1 $0
junel 1/20 (21) oral tablet Tier 1 $0
junel fe 1.5/30 (28) oral tablet
Tier 1 $0
junel fe 1/20 (28) oral tablet
Tier 1 $0
junel fe 24 oral tablet Tier 1 $0
KAITLIB FE ORAL TABLET,CHEWABLE
Tier 1 $0
kariva (28) oral tablet Tier 1 $0
kelnor 1/35 (28) oral tablet Tier 1 $0
kimidess (28) oral tablet Tier 1 $0
kurvelo oral tablet Tier 1 $0
l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month
Tier 1 $0
larin 1.5/30 (21) oral tablet Tier 1 $0
larin 1/20 (21) oral tablet Tier 1 $0
Drug Name Tier Notes
larin 24 fe oral tablet Tier 1 $0
larin fe 1.5/30 (28) oral tablet
Tier 1 $0
larin fe 1/20 (28) oral tablet
Tier 1 $0
larissia oral tablet Tier 1 $0
layolis fe oral tablet,chewable
Tier 1 $0
leena 28 oral tablet Tier 1 $0
lessina oral tablet Tier 1 $0
levonest (28) oral tablet Tier 1 $0
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg
Tier 1 $0
levonorgestrel-ethinyl estrad oral tablet 90-20 mcg
Tier 1 $0
levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month
Tier 1 $0
levonorg-eth estrad triphasic oral tablet
Tier 1 $0
levora-28 oral tablet Tier 1 $0
lillow oral tablet Tier 1 $0
LO LOESTRIN FE ORAL TABLET
Tier 3 $0
lomedia 24 fe oral tablet Tier 1 $0
loryna (28) oral tablet Tier 1 $0
low-ogestrel (28) oral tablet
Tier 1 $0
lutera (28) oral tablet Tier 1 $0
lyza oral tablet Tier 1 $0
marlissa oral tablet Tier 1 $0
medroxyprogesterone intramuscular suspension
Tier 1 $0
medroxyprogesterone intramuscular syringe
Tier 1 $0
MIBELAS 24 FE ORAL TABLET,CHEWABLE
Tier 1 $0
microgestin 1.5/30 (21) oral tablet
Tier 1 $0
microgestin 1/20 (21) oral tablet
Tier 1 $0
microgestin fe 1.5/30 (28) oral tablet
Tier 1 $0
microgestin fe 1/20 (28) oral tablet
Tier 1 $0
Effective 1/1/201735
Drug Name Tier Notes
mono-linyah oral tablet Tier 1 $0
mononessa (28) oral tablet Tier 1 $0
my way oral tablet Tier 1 $0; QL
myzilra oral tablet Tier 1 $0
NATAZIA ORAL TABLET Tier 3 $0
necon 0.5/35 (28) oral tablet
Tier 1 $0
necon 1/50 (28) oral tablet Tier 1 $0
necon 7/7/7 (28) oral tablet
Tier 1 $0
next choice one dose oral tablet
Tier 1 $0; QL
nikki (28) oral tablet Tier 1 $0
nora-be oral tablet Tier 1 $0
noreth-ethinyl estradiol-iron oral tablet,chewable
Tier 1 $0
norethindrone (contraceptive) oral tablet
Tier 1 $0
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg
Tier 1 $0
norethindrone-e.estradiol-iron oral tablet
Tier 1 $0
norethindrone-e.estradiol-iron oral tablet,chewable
Tier 1 $0
norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28)
Tier 1 $0
norgestimate-ethinyl estradiol oral tablet 0.25-35 mg-mcg
Tier 1 $0
NORLYDA ORAL TABLET
Tier 1 $0
norlyroc oral tablet Tier 1 $0
nortrel 0.5/35 (28) oral tablet
Tier 1 $0
nortrel 1/35 (21) oral tablet Tier 1 $0
nortrel 1/35 (28) oral tablet Tier 1 $0
nortrel 7/7/7 (28) oral tablet
Tier 1 $0
NUVARING VAGINAL RING
Tier 3 $0
ocella oral tablet Tier 1 $0
ogestrel (28) oral tablet Tier 1 $0
Drug Name Tier Notes
opcicon one-step oral tablet
Tier 1 $0; QL
orsythia oral tablet Tier 1 $0
philith oral tablet Tier 1 $0
pimtrea (28) oral tablet Tier 1 $0
pirmella oral tablet Tier 1 $0
PLAN B ONE-STEP ORAL TABLET
Tier 1 $0; QL
portia oral tablet Tier 1 $0
previfem oral tablet Tier 1 $0
quasense oral tablets,dose pack,3 month
Tier 1 $0
RAJANI ORAL TABLET Tier 1 $0
reclipsen (28) oral tablet Tier 1 $0
RIVELSA ORAL TABLETS,DOSE PACK,3 MONTH
Tier 1 $0
SAFYRAL ORAL TABLET
Tier 3 $0
setlakin oral tablets,dose pack,3 month
Tier 1 $0
sharobel oral tablet Tier 1 $0
sprintec (28) oral tablet Tier 1 $0
sronyx oral tablet Tier 1 $0
syeda oral tablet Tier 1 $0
TAKE ACTION ORAL TABLET
Tier 1 $0; QL
tarina fe 1/20 (28) oral tablet
Tier 1 $0
TAYTULLA ORAL CAPSULE
Tier 3 $0
tilia fe oral tablet Tier 1 $0
TRI FEMYNOR ORAL TABLET
Tier 1 $0
tri-estarylla oral tablet Tier 1 $0
tri-legest fe oral tablet Tier 1 $0
tri-linyah oral tablet Tier 1 $0
TRI-LO-ESTARYLLA ORAL TABLET
Tier 1 $0
tri-lo-marzia oral tablet Tier 1 $0
TRI-LO-SPRINTEC ORAL TABLET
Tier 1 $0
trinessa (28) oral tablet Tier 1 $0
TRINESSA LO ORAL TABLET
Tier 1 $0
tri-previfem (28) oral tablet Tier 1 $0
Effective 1/1/201736
Drug Name Tier Notes
tri-sprintec (28) oral tablet Tier 1 $0
trivora (28) oral tablet Tier 1 $0
velivet triphasic regimen (28) oral tablet
Tier 1 $0
vestura (28) oral tablet Tier 1 $0
VIENVA ORAL TABLET Tier 1 $0
viorele (28) oral tablet Tier 1 $0
vyfemla (28) oral tablet Tier 1 $0
wera (28) oral tablet Tier 1 $0
wymzya fe oral tablet,chewable
Tier 1 $0
xulane transdermal patch weekly
Tier 1 $0
zarah oral tablet Tier 1 $0
zenchent (28) oral tablet Tier 1 $0
zenchent fe oral tablet,chewable
Tier 1 $0
zovia 1/35e (28) oral tablet Tier 1 $0
zovia 1/50e (28) oral tablet Tier 1 $0
COUGH/COLD PREPARATIONS
benzonatate oral capsule 100 mg, 200 mg
Tier 1
cheratussin ac oral liquid Tier 1
codeine-guaifen 10-100 mg/5 ml a/f,d/f,s/f (otc)
Tier 1
FLOWTUSS ORAL SOLUTION
Tier 3
guaiatussin ac liquid Tier 1
guaiatussin ac liquid outer Tier 1
guaifen-codeine 100-10 mg/5 ml (otc)
Tier 1
guaifenesin ac oral liquid Tier 1
guaifenesin-codeine syrup (otc)
Tier 1
HYCOFENIX ORAL SOLUTION
Tier 3
hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr
Tier 1
hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml
Tier 1
OBREDON ORAL SOLUTION
Tier 3
promethazine vc-codeine oral syrup
Tier 1
Drug Name Tier Notes
promethazine-codeine oral syrup
Tier 1
promethazine-dm oral syrup
Tier 1
promethazine-phenyleph-codeine oral syrup
Tier 1
TUZISTRA XR ORAL SUSPENSION,EXTENDED REL 12 HR
Tier 3
VITUZ ORAL SOLUTION Tier 3
DIAGNOSTIC
ACCU-CHEK AVIVA PLUS TEST STRP STRIP
Tier 2 QL
ACCU-CHEK COMPACT PLUS TEST STRIP
Tier 2 QL
ACCU-CHEK GUIDE STRIP
Tier 2 QL
ACCU-CHEK SMARTVIEW TEST STRIP STRIP
Tier 2 QL
ACCUTREND GLUCOSE STRIP
Tier 2 QL
dipyridamole intravenous solution
Tier 2
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN
Tier 2
GLUCAGON HCL INJECTION RECON SOLN
Tier 2
ONETOUCH ULTRA TEST STRIP
Tier 2 QL
ONETOUCH VERIO STRIP
Tier 2 QL
DIURETICS
acetazolamide oral capsule, extended release
Tier 1
acetazolamide oral tablet Tier 1
amiloride oral tablet Tier 1
AMMONIUM CHLORIDE INTRAVENOUS SOLUTION
Tier 3
bumetanide oral tablet Tier 1
chlorothiazide oral tablet Tier 1
chlorthalidone oral tablet 25 mg, 50 mg
Tier 1
Effective 1/1/201737
Drug Name Tier Notes
DYRENIUM ORAL CAPSULE
Tier 3
eplerenone oral tablet Tier 2
ethacrynic acid oral tablet Tier 2
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)
Tier 1
furosemide oral tablet Tier 1
hydrochlorothiazide oral capsule
Tier 1
hydrochlorothiazide oral tablet
Tier 1
indapamide oral tablet Tier 1
methazolamide oral tablet Tier 1
methyclothiazide oral tablet
Tier 1
metolazone oral tablet Tier 1
SAMSCA ORAL TABLET Tier 3 SP; LD
spironolactone oral tablet Tier 1
torsemide oral tablet Tier 1
triamterene-hydrochlorothiazid oral capsule
Tier 1
triamterene-hydrochlorothiazid oral tablet
Tier 1
EENT PREPS
acetic acid otic (ear) solution
Tier 1
ALOCRIL OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
ALOMIDE OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
apraclonidine ophthalmic (eye) drops
Tier 1
azelastine nasal aerosol,spray
Tier 1 QL
AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
betaxolol ophthalmic (eye) drops
Tier 1
bimatoprost ophthalmic (eye) drops
Tier 2
brimonidine ophthalmic (eye) drops
Tier 1
bromfenac ophthalmic (eye) drops
Tier 2
Drug Name Tier Notes
carteolol ophthalmic (eye) drops
Tier 1
COMBIGAN OPHTHALMIC (EYE) DROPS
Tier 3
cromolyn ophthalmic (eye) drops
Tier 1 QL
CYSTARAN OPHTHALMIC (EYE) DROPS
Tier 3 LD
dexamethasone sodium phosphate ophthalmic (eye) drops
Tier 1
diclofenac sodium ophthalmic (eye) drops
Tier 1
dorzolamide ophthalmic (eye) drops
Tier 1
dorzolamide-timolol ophthalmic (eye) drops
Tier 1
DUREZOL OPHTHALMIC (EYE) DROPS
Tier 3 QL
DYMISTA NASAL SPRAY,NON-AEROSOL
Tier 3 QL
flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)
Tier 1 ST; QL
fluocinolone acetonide oil otic (ear) drops
Tier 1
fluorometholone ophthalmic (eye) drops,suspension
Tier 1
flurbiprofen sodium ophthalmic (eye) drops
Tier 1
fluticasone nasal spray,suspension
Tier 1 QL
FML S.O.P. OPHTHALMIC (EYE) OINTMENT
Tier 3
hydrocortisone-acetic acid otic (ear) drops
Tier 1
ketorolac ophthalmic (eye) drops
Tier 1
LACRISERT OPHTHALMIC (EYE) INSERT
Tier 3
latanoprost ophthalmic (eye) drops
Tier 1
levobunolol ophthalmic (eye) drops 0.5 %
Tier 1
Effective 1/1/201738
Drug Name Tier Notes
LOTEMAX OPHTHALMIC (EYE) DROPS,GEL
Tier 3
LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
LOTEMAX OPHTHALMIC (EYE) OINTMENT
Tier 3
LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %
Tier 3
metipranolol ophthalmic (eye) drops
Tier 1
NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
olopatadine nasal spray,non-aerosol
Tier 1 QL
OMNARIS NASAL SPRAY,NON-AEROSOL
Tier 3 ST; QL
PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS
Tier 3
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %
Tier 1
prednisolone acetate ophthalmic (eye) drops,suspension
Tier 1
prednisolone sodium phosphate ophthalmic (eye) drops
Tier 1
RESTASIS OPHTHALMIC (EYE) DROPPERETTE
Tier 3
SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
timolol maleate ophthalmic (eye) drops
Tier 1
timolol maleate ophthalmic (eye) gel forming solution
Tier 1
TRAVATAN Z OPHTHALMIC (EYE) DROPS
Tier 3
tropicamide ophthalmic (eye) drops
Tier 1
TYZINE NASAL DROPS Tier 3
TYZINE NASAL SPRAY,NON-AEROSOL
Tier 3
ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE
Tier 3
Drug Name Tier Notes
ELECT/CALORIC/H2O
calcium acetate oral tablet 667 mg
Tier 2
cytra k crystals oral packet Tier 1
cytra-k oral solution Tier 1
denta 5000 plus dental cream
Tier 1
dentagel dental gel Tier 1
EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ
Tier 3
effer-k oral tablet, effervescent 25 meq
Tier 1
eliphos oral tablet Tier 1 PA
fe c plus oral tablet Tier 1
fluoride (sodium) dental solution
Tier 1
fluoride (sodium) oral drops
Tier 1 $0
fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
Tier 1 $0
fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1
fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)
Tier 1 $0
fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1
FOSRENOL ORAL POWDER IN PACKET
Tier 3 PA
FOSRENOL ORAL TABLET,CHEWABLE
Tier 3 PA
GLUCAGEN HYPOKIT INJECTION RECON SOLN
Tier 2
GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT
Tier 2
ISOLYTE S PH 7.4 INTRAVENOUS PARENTERAL SOLUTION
Tier 3
Effective 1/1/201739
Drug Name Tier Notes
ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION
Tier 3
k-effervescent oral tablet, effervescent
Tier 1
kionex (with sorbitol) oral suspension
Tier 1
kionex oral powder Tier 1
klor-con 10 oral tablet extended release
Tier 1
klor-con 8 oral tablet extended release
Tier 1
klor-con m10 oral tablet,er particles/crystals
Tier 1
klor-con m15 oral tablet,er particles/crystals
Tier 1
klor-con m20 oral tablet,er particles/crystals
Tier 1
klor-con/ef oral tablet, effervescent
Tier 1
ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
Tier 1 $0
ludent fluoride oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1
magnesium sulfate in water intravenous parenteral solution
Tier 1
magnesium sulfate in water intravenous piggyback
Tier 1
magnesium sulfate injection syringe
Tier 1
NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION
Tier 3
NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION
Tier 3
NUTRAMINE ORAL POWDER
Tier 3
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION
Tier 3
Drug Name Tier Notes
PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION
Tier 3
potassium bicarb and chloride oral tablet, effervescent
Tier 1
potassium bicarb-citric acid oral tablet, effervescent
Tier 1
potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l
Tier 2
potassium chloride intravenous piggyback
Tier 1
potassium chloride intravenous solution
Tier 1
potassium chloride oral capsule, extended release
Tier 1
potassium chloride oral tablet extended release
Tier 1
potassium chloride oral tablet,er particles/crystals
Tier 1
potassium chloride-0.45 % nacl intravenous parenteral solution
Tier 2
potassium citrate oral tablet extended release
Tier 2
potassium citrate-citric acid oral solution
Tier 1
PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE
Tier 3
PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE
Tier 3
PREVIDENT DENTAL GEL
Tier 3
PROGLYCEM ORAL SUSPENSION
Tier 3
RENVELA ORAL TABLET
Tier 2
sevelamer carbonate oral powder in packet
Tier 1
sf dental gel Tier 1
SHOHL'S MODIFIED ORAL SOLUTION
Tier 3
Effective 1/1/201740
Drug Name Tier Notes
sodium chloride 0.45 % intravenous parenteral solution
Tier 1
sodium chloride 0.45 % intravenous piggyback
Tier 1
sodium chloride 0.9 % injection solution
Tier 1
sodium chloride 0.9 % intravenous parenteral solution
Tier 1
sodium chloride 0.9 % intravenous piggyback
Tier 1
sodium chloride 3 % intravenous parenteral solution
Tier 1
sodium chloride 5 % intravenous parenteral solution
Tier 1
sodium chloride intravenous parenteral solution 2.5 meq/ml
Tier 1
sodium polystyrene (sorb free) oral suspension
Tier 1
sodium polystyrene sulfonate oral powder
Tier 1
sodium polystyrene sulfonate oral suspension
Tier 1
sodium polystyrene sulfonate rectal enema 30 gram/120 ml
Tier 1
sps (with sorbitol) oral suspension
Tier 1
sps (with sorbitol) rectal enema
Tier 1
SSKI ORAL SOLUTION Tier 3
VELPHORO ORAL TABLET,CHEWABLE
Tier 3 PA
GASTROINTESTINAL
AKYNZEO ORAL CAPSULE
Tier 3 QL
alosetron oral tablet Tier 2 QL
ALOXI INTRAVENOUS SOLUTION
Tier 3
AMITIZA ORAL CAPSULE
Tier 3
anaspaz oral tablet,disintegrating
Tier 2
anucort-hc rectal suppository
Tier 1
Drug Name Tier Notes
ANZEMET ORAL TABLET
Tier 3 QL
aprepitant oral capsule 125 mg, 40 mg, 80 mg
Tier 2 QL
aprepitant oral capsule,dose pack
Tier 2 QL
APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR
Tier 3 QL
atropine injection syringe 0.05 mg/ml, 0.1 mg/ml
Tier 1
balsalazide oral capsule Tier 1 QL
BUPHENYL ORAL TABLET
Tier 3 PA
carafate oral suspension Tier 1
CESAMET ORAL CAPSULE
Tier 3 ST
CHOLBAM ORAL CAPSULE
Tier 3 PA; LD; QL
cimetidine hcl oral solution Tier 1
cimetidine oral tablet Tier 1
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT
Tier 4 PA; SP; LD; QL
CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; LD; QL
CIMZIA SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; LD; QL
COMPAZINE ORAL TABLET
Tier 1
constulose oral solution Tier 1
DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS
Tier 3 PA; QL
dicyclomine oral capsule Tier 1
dicyclomine oral solution Tier 1
dicyclomine oral tablet Tier 1
DIPENTUM ORAL CAPSULE
Tier 3 QL
diphenoxylate-atropine oral liquid
Tier 1
diphenoxylate-atropine oral tablet
Tier 1
dronabinol oral capsule Tier 2
enulose oral solution Tier 1
Effective 1/1/201741
Drug Name Tier Notes
esomeprazole magnesium oral capsule,delayed release(dr/ec)
Tier 2 PA; QL
famotidine oral suspension Tier 1
famotidine oral tablet 20 mg, 40 mg
Tier 1
gavilyte-c oral recon soln Tier 1 $0
gavilyte-g oral recon soln Tier 1 $0
gavilyte-n oral recon soln Tier 1 $0
generlac oral solution Tier 1
glycopyrrolate oral tablet 1 mg, 2 mg
Tier 1
granisetron hcl oral tablet Tier 2 QL
hydrocortisone acetate rectal suppository
Tier 1
hydrocortisone-pramoxine rectal cream
Tier 1
hyoscyamine sulfate oral tablet
Tier 1
hyoscyamine sulfate oral tablet extended release 12 hr
Tier 1
hyoscyamine sulfate oral tablet,disintegrating
Tier 1
hyoscyamine sulfate sublingual tablet
Tier 1
KEPIVANCE INTRAVENOUS RECON SOLN
Tier 4 LD
lactulose oral solution Tier 1
lansoprazole oral capsule,delayed release(dr/ec)
Tier 1 QL
laxaclear powder Tier 1 $0
LINZESS ORAL CAPSULE
Tier 2
meclizine oral tablet 12.5 mg, 25 mg
Tier 1
methscopolamine oral tablet
Tier 1
metoclopramide hcl oral solution
Tier 1
metoclopramide hcl oral tablet
Tier 1
misoprostol oral tablet Tier 1
MOTOFEN ORAL TABLET
Tier 3
Drug Name Tier Notes
MOVIPREP ORAL POWDER IN PACKET
Tier 3
NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET
Tier 3 PA; QL
nizatidine oral capsule Tier 1
nizatidine oral solution Tier 1
omega-3 acid ethyl esters oral capsule
Tier 1 QL
omeprazole oral capsule,delayed release(dr/ec)
Tier 1 QL
ondansetron hcl oral solution
Tier 2 QL
ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg
Tier 2 QL
ondansetron oral tablet,disintegrating 4 mg, 8 mg
Tier 2 QL
OSMOPREP ORAL TABLET
Tier 3
pantoprazole oral tablet,delayed release (dr/ec)
Tier 2 QL
peg 3350-electrolytes oral recon soln
Tier 1 $0
peg-3350 with flavor packs oral recon soln
Tier 1 $0
phenadoz rectal suppository
Tier 1
polyethylene glycol 3350 oral powder in packet
Tier 1 $0
pramcort rectal cream Tier 1
PREPOPIK ORAL POWDER IN PACKET
Tier 3
prochlorperazine maleate oral tablet
Tier 1
promethazine rectal suppository
Tier 1
promethegan rectal suppository
Tier 1
rabeprazole oral tablet,delayed release (dr/ec)
Tier 2 QL
ranitidine hcl oral capsule Tier 1
ranitidine hcl oral syrup Tier 1
ranitidine hcl oral tablet 150 mg, 300 mg
Tier 1
Effective 1/1/201742
Drug Name Tier Notes
RECTIV RECTAL OINTMENT
Tier 3
REMICADE INTRAVENOUS RECON SOLN
Tier 4 PA; SP
SANCUSO TRANSDERMAL PATCH WEEKLY
Tier 3 QL
scopolamine base transdermal patch 3 day
Tier 2
SCOPOLAMINE HBR INJECTION SOLUTION
Tier 3
sucralfate oral tablet Tier 1
sulfasalazine oral tablet Tier 1 QL
sulfasalazine oral tablet,delayed release (dr/ec)
Tier 1 QL
SUPREP BOWEL PREP KIT ORAL RECON SOLN
Tier 3
trilyte with flavor packets oral recon soln
Tier 1 $0
trimethobenzamide oral capsule
Tier 1
ursodiol oral capsule Tier 2
ursodiol oral tablet Tier 2
VARUBI ORAL TABLET Tier 3 QL
VASCEPA ORAL CAPSULE 0.5 GRAM, 1 GRAM
Tier 3 QL
VIBERZI ORAL TABLET Tier 3 PA; QL
ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)
Tier 2
HORMONES
AMABELZ ORAL TABLET
Tier 1
ANADROL-50 ORAL TABLET
Tier 3
ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP20.25 MG/1.25 GRAM (1.62 %)
Tier 3 PA; QL
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)
Tier 3 PA; QL
Drug Name Tier Notes
budesonide oral capsule,delayed,extend.release
Tier 2 QL
cabergoline oral tablet Tier 1
calcitonin (salmon) nasal spray,non-aerosol
Tier 1 QL
chorionic gonadotropin, human intramuscular recon soln
Tier 4 PA; SP
cortisone oral tablet Tier 1
covaryx h.s. oral tablet Tier 1
covaryx oral tablet Tier 1
danazol oral capsule Tier 2
desmopressin nasal aerosol,spray
Tier 2
desmopressin nasal solution
Tier 2
desmopressin nasal spray,non-aerosol
Tier 2
desmopressin oral tablet Tier 1
dexamethasone intensol oral drops
Tier 1
dexamethasone oral elixir Tier 1
dexamethasone oral solution
Tier 1
dexamethasone oral tablet Tier 1
DUAVEE ORAL TABLET Tier 3 QL
eemt hs oral tablet Tier 1
eemt oral tablet Tier 1
ESTRACE VAGINAL CREAM
Tier 3
estradiol oral tablet Tier 1
estradiol transdermal patch semiweekly
Tier 1 QL
estradiol transdermal patch weekly
Tier 1
estradiol vaginal tablet Tier 2
estradiol-norethindrone acet oral tablet
Tier 1
ESTRING VAGINAL RING
Tier 3 QL
estrogens-methyltestosterone oral tablet
Tier 1
estropipate oral tablet Tier 1
fludrocortisone oral tablet Tier 1
Effective 1/1/201743
Drug Name Tier Notes
GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR
Tier 3 PA; SP
GONAL-F RFF SUBCUTANEOUS RECON SOLN
Tier 3 PA; SP
GONAL-F SUBCUTANEOUS RECON SOLN
Tier 3 PA; SP
hydrocortisone oral tablet Tier 1
hydrocortisone rectal enema
Tier 2
INCRELEX SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; LD
jinteli oral tablet Tier 1
LOPREEZA ORAL TABLET
Tier 1
LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET
Tier 4 PA; SP; QL
LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET
Tier 4 PA; SP; QL
medroxyprogesterone oral tablet
Tier 1 QL
MENEST ORAL TABLET0.3 MG, 0.625 MG, 1.25 MG
Tier 3
METHITEST ORAL TABLET
Tier 3
methylprednisolone oral tablet
Tier 1
methylprednisolone oral tablets,dose pack
Tier 1
millipred dp oral tablets,dose pack
Tier 1
millipred oral tablet Tier 1
mimvey lo oral tablet Tier 1
mimvey oral tablet Tier 1
MYALEPT SUBCUTANEOUS RECON SOLN
Tier 4 SP; LD
norethindrone acetate oral tablet
Tier 1
NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP
oxandrolone oral tablet Tier 2 PA
Drug Name Tier Notes
prednisolone oral solution 15 mg/5 ml
Tier 1
prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
Tier 1
prednisone intensol oral concentrate
Tier 1
prednisone oral solution Tier 1
prednisone oral tablet Tier 1
prednisone oral tablets,dose pack
Tier 1
PREMARIN ORAL TABLET
Tier 3 QL
PREMARIN VAGINAL CREAM
Tier 3 QL
PREMPHASE ORAL TABLET
Tier 3
PREMPRO ORAL TABLET
Tier 3
progesterone micronized oral capsule 100 mg, 200 mg
Tier 1 QL
SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG
Tier 4 PA; SP; QL
SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 4 PA; SP; LD; QL
SIGNIFOR SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; LD; QL
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE
Tier 4 SP; QL
SYNAREL NASAL SPRAY,NON-AEROSOL
Tier 4 PA; SP; QL
testosterone cypionate intramuscular oil
Tier 1
testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)
Tier 1 PA; QL
Effective 1/1/201744
Drug Name Tier Notes
testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)
Tier 1 PA; QL
veripred 20 oral solution Tier 1
YUVAFEM VAGINAL TABLET
Tier 2 QL
IMMUNOSUPPRESSANTS
ACTEMRA INTRAVENOUS SOLUTION
Tier 4 PA; SP; QL
ACTEMRA SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
azathioprine oral tablet Tier 2
cyclosporine modified oral capsule
Tier 4 SP
cyclosporine modified oral solution
Tier 4 SP
cyclosporine oral capsule Tier 4 SP
ELIDEL TOPICAL CREAM
Tier 3 PA
gengraf oral capsule 100 mg, 25 mg
Tier 4 SP
GENGRAF ORAL CAPSULE 50 MG
Tier 4 SP
gengraf oral solution Tier 4 SP
mycophenolate mofetil hcl intravenous recon soln
Tier 4 SP
mycophenolate mofetil oral capsule
Tier 4 SP
mycophenolate mofetil oral tablet
Tier 4 SP
mycophenolate sodium oral tablet,delayed release (dr/ec)
Tier 4 SP
RAPAMUNE ORAL SOLUTION
Tier 4 SP
SIMULECT INTRAVENOUS RECON SOLN
Tier 4 SP
sirolimus oral tablet Tier 4 SP
STELARA INTRAVENOUS SOLUTION
Tier 4 PA; SP; QL
STELARA SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; QL
Drug Name Tier Notes
STELARA SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
tacrolimus oral capsule Tier 4 SP
tacrolimus topical ointment Tier 1 PA
ZORTRESS ORAL TABLET
Tier 4 PA; SP
MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG
ACCU-CHEK AVIVA CONNECT METER
Tier 2
ACCU-CHEK AVIVA CONTROL SOLN SOLUTION
Tier 2
ACCU-CHEK AVIVA PLUS METER
Tier 2
ACCU-CHEK COMP BLUE CONT, M-H SOLUTION
Tier 2
ACCU-CHEK COMPACT PLUS CARE KIT
Tier 2
ACCU-CHEK COMPACT PLUS CONTROL SOLUTION
Tier 2
ACCU-CHEK FASTCLIX Tier 2
ACCU-CHEK FASTCLIX KIT
Tier 2
ACCU-CHEK GUIDE GLUCOSE METER
Tier 2
ACCU-CHEK GUIDE L1-L2 CTRL SOL SOLUTION
Tier 2
ACCU-CHEK MULTICLIX LANCET
Tier 2
ACCU-CHEK MULTICLIX LANCET KIT
Tier 2
ACCU-CHEK NANO Tier 2
ACCU-CHEK SAFE-T-PRO PLUS
Tier 2
ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION
Tier 2
ACCU-CHEK SOFT DEV LANCETS KIT
Tier 2
ACCU-CHEK SOFTCLIX LANCET DEV
Tier 2
ACCU-CHEK SOFTCLIX LANCETS
Tier 2
Effective 1/1/201745
Drug Name Tier Notes
ACCU-CHEK VOICEMATE KIT
Tier 2
ACCUTREND GLUCOSE CONTROL SOLUTION
Tier 2
acti-lance lancets 17 gauge, 28 gauge
Tier 1
CHEMSTRIP BG LOG BOOK
Tier 2
e-z ject lancets Tier 1
E-Z JECT THIN LANCETS
Tier 1
insulin syringe-needle u-100 syringe 1 ml 30 gauge x 3/8"
Tier 1
ONETOUCH DELICA LANC DEVICE KIT
Tier 2
ONETOUCH DELICA LANCETS
Tier 2
ONETOUCH SURESOFT LANCING DEV
Tier 2
ONETOUCH ULTRA CONTROL SOLUTION
Tier 2
ONETOUCH ULTRA2 KIT Tier 2
ONETOUCH ULTRAMINI KIT
Tier 2
ONETOUCH ULTRASOFT LANCETS
Tier 2
ONETOUCH VERIO FLEX
Tier 2
ONETOUCH VERIO HIGH CONTROL SOLUTION
Tier 2
ONETOUCH VERIO IQ METER
Tier 2
ONETOUCH VERIO MID CONTROL SOLUTION
Tier 2
ONETOUCH VERIO SYNC KIT
Tier 2
ONETOUCH VERIO SYSTEM
Tier 2
thinpro insulin syringe syringe 0.3 ml 29 gauge x 1/2", 0.5 ml 29 gauge x 1/2", 1 ml 29 gauge x 1/2"
Tier 1
MUSCLE RELAXANTS
baclofen oral tablet Tier 2
carisoprodol oral tablet Tier 1
chlorzoxazone oral tablet 500 mg
Tier 1
Drug Name Tier Notes
cyclobenzaprine oral tablet Tier 1
dantrolene oral capsule Tier 2
metaxalone oral tablet Tier 1
methocarbamol oral tablet Tier 1
orphenadrine citrate oral tablet extended release
Tier 1
tizanidine oral capsule Tier 1
tizanidine oral tablet Tier 1
PRE-NATAL VITAMINS
c-nate dha oral capsule Tier 1
completenate oral tablet,chewable
Tier 1
elite ob with dha oral capsule
Tier 1
elite-ob 400 oral capsule Tier 1
ELITE-OB ORAL TABLET
Tier 1
folivane-ob oral capsule Tier 1
hemenatal ob oral tablet Tier 1
levomefolate dha oral capsule
Tier 1
mynatal advance oral tablet
Tier 1
mynatal oral capsule Tier 1
mynatal oral tablet Tier 1
mynatal plus oral tablet Tier 1
mynatal-z oral tablet Tier 1
mynate 90 plus oral tablet extended release
Tier 1
pnv-dha + docusate oral capsule
Tier 1
pnv-dha oral capsule Tier 1
pnv-ferrous fumarate-docu-fa oral tablet
Tier 1
pnv-omega oral capsule Tier 1
pnv-select oral tablet Tier 1
pr natal 400 ec oral combo pack,tablet and cap,dr
Tier 1
pr natal 400 oral combo pack
Tier 1
pr natal 430 ec oral combo pack,tablet and cap,dr
Tier 1
pr natal 430 oral combo pack
Tier 1
prenaissance oral capsule Tier 1
Effective 1/1/201746
Drug Name Tier Notes
prenaissance plus oral capsule
Tier 1
prenatabs fa oral tablet Tier 1
prenatabs rx oral tablet Tier 1
prenatal 19 (with docusate) oral tablet
Tier 1
prenatal low iron oral tablet
Tier 1
prenatal multivitamins oral tablet
Tier 1 $0
PRENATAL ONE DAILY ORAL TABLET
Tier 1 $0
prenatal plus (calcium carb) oral tablet
Tier 1
prenatal plus oral tablet Tier 1
prenatal vitamin plus low iron
Tier 1
prenatal-u oral capsule Tier 1
preplus oral tablet Tier 1
relnate dha oral capsule Tier 1
se-natal 19 (with docusate) oral tablet
Tier 1
se-natal 19 oral tablet,chewable
Tier 1
taron-c dha oral capsule Tier 1
taron-prex prenatal-dha oral capsule
Tier 1
tl-select oral capsule Tier 1
triadvance oral tablet Tier 1
trinatal gt oral tablet Tier 1
trinatal rx 1 oral tablet Tier 1
trinate oral tablet Tier 1
triveen-one oral capsule Tier 1
triveen-prx rnf oral capsule Tier 1
ultimatecare one nf oral capsule
Tier 1
ultimatecare one oral capsule
Tier 1
vemavite-prx-2 oral capsule
Tier 1
vinacal oral tablet Tier 1
vinate care oral tablet,chewable
Tier 1
vinate gt oral tablet Tier 1
vinate ii oral tablet Tier 1
vinate m oral tablet Tier 1
Drug Name Tier Notes
vinate one oral tablet Tier 1
vinate pn care oral tablet Tier 1
vinate ultra oral tablet Tier 1
VIRT-NATE DHA ORAL CAPSULE
Tier 1
virt-pn dha oral capsule Tier 1
virt-pn oral tablet Tier 1
virt-pn plus oral capsule Tier 1
virt-select oral capsule Tier 1
vitafol-ob oral tablet Tier 1
vol-nate oral tablet Tier 1
vol-plus oral tablet Tier 1
vol-tab rx oral tablet Tier 1
vp-ch plus oral capsule Tier 1
vp-ch-pnv oral capsule Tier 1
vp-ggr-b6 oral tablet Tier 1
vp-heme ob oral tablet Tier 1
vp-heme one oral capsule Tier 1
zatean-ch oral capsule Tier 1
zatean-pn dha oral capsule
Tier 1
zatean-pn plus oral capsule
Tier 1
zingiber oral tablet Tier 1
PSYCHOTHERAPEUTIC DRUGS
ADDYI ORAL TABLET Tier 3 PA; QL
alprazolam oral tablet Tier 1
amitriptyline oral tablet Tier 1
amoxapine oral tablet Tier 1
aripiprazole oral solution Tier 2
aripiprazole oral tablet Tier 2
armodafinil oral tablet 150 mg, 250 mg, 50 mg
Tier 2 PA; QL
armodafinil oral tablet 200 mg
Tier 2 PA
atomoxetine oral capsule Tier 2 PA
bupropion hcl oral tablet 100 mg
Tier 1 QL
bupropion hcl oral tablet 75 mg
Tier 1 DO
bupropion hcl oral tablet extended release 12 hr 100 mg
Tier 1 DO
Effective 1/1/201747
Drug Name Tier Notes
bupropion hcl oral tablet extended release 12 hr 150 mg
Tier 1 $0
bupropion hcl oral tablet extended release 12 hr 200 mg
Tier 1
bupropion hcl oral tablet extended release 24 hr 150 mg
Tier 1 DO
bupropion hcl oral tablet extended release 24 hr 300 mg
Tier 1 QL
buspirone oral tablet Tier 1
chlorpromazine oral tablet Tier 2
citalopram oral solution Tier 1 QL
citalopram oral tablet 10 mg, 20 mg
Tier 1 DO
citalopram oral tablet 40 mg
Tier 1 QL
clomipramine oral capsule Tier 2
clonidine hcl oral tablet extended release 12 hr
Tier 1 PA
clozapine oral tablet Tier 2
clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg
Tier 2
desipramine oral tablet Tier 1
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg
Tier 1 QL
desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg
Tier 1 DO
dexmethylphenidate oral capsule,er biphasic 50-50
Tier 1 PA
dexmethylphenidate oral tablet
Tier 1 PA
diazepam intensol oral concentrate
Tier 1
diazepam oral concentrate Tier 1
diazepam oral solution Tier 1
diazepam oral tablet Tier 1
doxepin oral capsule Tier 1
doxepin oral concentrate Tier 1
Drug Name Tier Notes
duloxetine oral capsule,delayed release(dr/ec) 20 mg, 40 mg, 60 mg
Tier 2 PA; QL
duloxetine oral capsule,delayed release(dr/ec) 30 mg
Tier 2 PA; DO
EMSAM TRANSDERMAL PATCH 24 HOUR
Tier 3
escitalopram oxalate oral solution
Tier 1 QL
escitalopram oxalate oral tablet 10 mg, 5 mg
Tier 1 DO
escitalopram oxalate oral tablet 20 mg
Tier 1 QL
FANAPT ORAL TABLET Tier 3
FANAPT ORAL TABLETS,DOSE PACK
Tier 3
FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK
Tier 3 ST; QL
FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR
Tier 3 ST; QL
fluoxetine oral capsule 10 mg, 20 mg
Tier 1 DO
fluoxetine oral capsule 40 mg
Tier 1 QL
fluoxetine oral capsule,delayed release(dr/ec)
Tier 1 QL
fluoxetine oral solution Tier 1 QL
fluoxetine oral tablet 10 mg
Tier 1 DO
fluoxetine oral tablet 20 mg
Tier 1
fluphenazine hcl oral concentrate
Tier 1
fluphenazine hcl oral elixir Tier 1
fluphenazine hcl oral tablet Tier 1
fluvoxamine oral tablet 100 mg
Tier 1 QL
fluvoxamine oral tablet 25 mg, 50 mg
Tier 1 DO
guanfacine oral tablet extended release 24 hr
Tier 1 PA
haloperidol oral tablet Tier 1
imipramine hcl oral tablet Tier 1
Effective 1/1/201748
Drug Name Tier Notes
LATUDA ORAL TABLET Tier 3
lithium carbonate oral capsule
Tier 1
lithium carbonate oral tablet
Tier 1
lithium carbonate oral tablet extended release
Tier 1
lithium citrate oral solution Tier 1
loxapine succinate oral capsule
Tier 1
maprotiline oral tablet Tier 1
MARPLAN ORAL TABLET
Tier 3
meprobamate oral tablet Tier 1
metadate er oral tablet extended release
Tier 1 PA
methylphenidate hcl oral capsule, er biphasic 30-70
Tier 1 PA
methylphenidate hcl oral capsule,er biphasic 50-50 20 mg, 30 mg, 40 mg
Tier 1 PA
methylphenidate hcl oral capsule,er biphasic 50-50 60 mg
Tier 1
methylphenidate hcl oral solution
Tier 1 PA
methylphenidate hcl oral tablet
Tier 1 PA
methylphenidate hcl oral tablet extended release
Tier 1 PA
methylphenidate hcl oral tablet extended release 24hr
Tier 1 PA
mirtazapine oral tablet Tier 1
mirtazapine oral tablet,disintegrating
Tier 1
modafinil oral tablet 100 mg
Tier 1 PA; DO
modafinil oral tablet 200 mg
Tier 1 PA; QL
nefazodone oral tablet Tier 1
nortriptyline oral capsule Tier 1
nortriptyline oral solution Tier 1
olanzapine oral tablet Tier 2
olanzapine oral tablet,disintegrating
Tier 2
paliperidone oral tablet extended release 24hr
Tier 2
Drug Name Tier Notes
paroxetine hcl oral tablet 10 mg, 20 mg
Tier 1 DO
paroxetine hcl oral tablet 30 mg, 40 mg
Tier 1 QL
paroxetine hcl oral tablet extended release 24 hr 12.5 mg
Tier 1 DO
paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg
Tier 1 QL
perphenazine oral tablet Tier 1
phenelzine oral tablet Tier 1
pimozide oral tablet Tier 2
protriptyline oral tablet Tier 1
quetiapine oral tablet Tier 1
quetiapine oral tablet extended release 24 hr
Tier 2
risperidone oral solution Tier 1
risperidone oral tablet Tier 1
risperidone oral tablet,disintegrating
Tier 1
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET
Tier 3
sertraline oral concentrate Tier 1 QL
sertraline oral tablet 100 mg
Tier 1 QL
sertraline oral tablet 25 mg, 50 mg
Tier 1 DO
thioridazine oral tablet Tier 1
thiothixene oral capsule Tier 1
tranylcypromine oral tablet Tier 1
trazodone oral tablet Tier 1
trifluoperazine oral tablet Tier 1
trimipramine oral capsule Tier 1
TRINTELLIX ORAL TABLET 10 MG, 5 MG
Tier 3 ST; DO
TRINTELLIX ORAL TABLET 20 MG
Tier 3 ST; QL
venlafaxine oral capsule,extended release 24hr 150 mg
Tier 1 QL
venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg
Tier 1 DO
venlafaxine oral tablet Tier 1 QL
Effective 1/1/201749
Drug Name Tier Notes
venlafaxine oral tablet extended release 24hr 150 mg, 225 mg
Tier 1 QL
venlafaxine oral tablet extended release 24hr 37.5 mg, 75 mg
Tier 1 DO
VIIBRYD ORAL TABLET10 MG, 20 MG
Tier 3 ST; DO
VIIBRYD ORAL TABLET40 MG
Tier 3 ST; QL
VIIBRYD ORAL TABLETS,DOSE PACK10 MG (7)- 20 MG (23)
Tier 3 ST; QL
VYVANSE ORAL CAPSULE
Tier 3 PA
ziprasidone hcl oral capsule
Tier 1
SEDATIVE/HYPNOTICS
estazolam oral tablet Tier 1
eszopiclone oral tablet 1 mg, 2 mg
Tier 1 QL
eszopiclone oral tablet 3 mg
Tier 1 PA; QL
HETLIOZ ORAL CAPSULE
Tier 4 PA; SP; LD; QL
hm nighttime sleep aid 50 mg softgel,max strength
Tier 1
phenobarbital oral elixir Tier 1
phenobarbital oral tablet Tier 1
ROZEREM ORAL TABLET
Tier 3 ST; QL
SILENOR ORAL TABLET Tier 3 QL
XYREM ORAL SOLUTION
Tier 3 PA; SP; LD; QL
zaleplon oral capsule Tier 1 QL
zolpidem oral tablet Tier 1 QL
SKIN PREPS
acitretin oral capsule Tier 2
ACZONE TOPICAL GEL Tier 3
adapalene topical cream Tier 1
adapalene topical gel Tier 1
adapalene topical gel with pump
Tier 1
ADAPALENE TOPICAL LOTION
Tier 2
Drug Name Tier Notes
adapalene-benzoyl peroxide topical gel with pump
Tier 2
alclometasone topical cream
Tier 1
alclometasone topical ointment
Tier 1
ALTABAX TOPICAL OINTMENT
Tier 3
amcinonide topical cream Tier 1
amcinonide topical lotion Tier 1
amcinonide topical ointment
Tier 1
ammonium lactate topical cream
Tier 1
ammonium lactate topical lotion
Tier 1
AMNESTEEM ORAL CAPSULE
Tier 1
avita topical cream Tier 1 PA
AZELEX TOPICAL CREAM
Tier 3 PA
benzoyl peroxide topical cleanser 3 %, 6 %, 9 %
Tier 1
benzoyl peroxide topical foam
Tier 1
betamethasone dipropionate topical cream
Tier 1
betamethasone dipropionate topical lotion
Tier 1
betamethasone dipropionate topical ointment
Tier 1
betamethasone valerate topical cream
Tier 1
betamethasone valerate topical foam
Tier 1
betamethasone valerate topical lotion
Tier 1
betamethasone valerate topical ointment
Tier 1
betamethasone, augmented topical cream
Tier 1
betamethasone, augmented topical gel
Tier 1
betamethasone, augmented topical lotion
Tier 1
Effective 1/1/201750
Drug Name Tier Notes
betamethasone, augmented topical ointment
Tier 1
bpo topical gel Tier 1
bpo topical towelette 6 % Tier 1
calcipotriene scalp solution
Tier 1
calcipotriene topical cream Tier 1
calcipotriene topical ointment
Tier 1
calcipotriene-betamethasone topical ointment
Tier 1
calcitrene topical ointment Tier 1
calcitriol topical ointment Tier 1
claravis oral capsule Tier 1 PA
clindamycin-benzoyl peroxide topical gel
Tier 1
clindamycin-tretinoin topical gel
Tier 2
clobetasol emollnt 0.05% foam
Tier 1
clobetasol scalp solution Tier 1
clobetasol topical cream Tier 1
clobetasol topical foam Tier 1
clobetasol topical gel Tier 1
clobetasol topical lotion Tier 1
clobetasol topical ointment Tier 1
clobetasol topical shampoo
Tier 1
clobetasol-emollient topical cream
Tier 1
CLODERM TOPICAL CREAM
Tier 3
CORDRAN TAPE LARGE ROLL TOPICAL TAPE
Tier 3
cormax scalp solution Tier 1
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
Drug Name Tier Notes
COSENTYX SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
desonide topical cream Tier 1
desonide topical lotion Tier 1
desonide topical ointment Tier 1
desoximetasone topical cream
Tier 1
desoximetasone topical gel
Tier 1
desoximetasone topical ointment
Tier 1
diclofenac sodium topical gel 1 %
Tier 2 QL
diflorasone topical cream Tier 1
diflorasone topical ointment
Tier 1
EURAX TOPICAL CREAM
Tier 3
EURAX TOPICAL LOTION
Tier 3
FINACEA TOPICAL GEL Tier 3
FLECTOR TRANSDERMAL PATCH 12 HOUR
Tier 3 QL
fluocinolone and shower cap scalp oil
Tier 1
fluocinolone topical cream Tier 1
fluocinolone topical oil Tier 1
fluocinolone topical ointment
Tier 1
fluocinolone topical solution
Tier 1
fluocinonide topical cream Tier 1
fluocinonide topical gel Tier 1
fluocinonide topical ointment
Tier 1
fluocinonide topical solution
Tier 1
fluocinonide-e topical cream
Tier 1
fluocinonide-emollient topical cream
Tier 1
flurandrenolide topical cream
Tier 2
flurandrenolide topical lotion
Tier 2
Effective 1/1/201751
Drug Name Tier Notes
fluticasone topical cream Tier 1
fluticasone topical lotion Tier 1
fluticasone topical ointment
Tier 1
halobetasol propionate topical cream
Tier 1
halobetasol propionate topical ointment
Tier 1
HALOG TOPICAL CREAM
Tier 3
HALOG TOPICAL OINTMENT
Tier 3
hydrocortisone butyrate topical cream
Tier 1
hydrocortisone butyrate topical ointment
Tier 1
hydrocortisone butyrate topical solution
Tier 1
hydrocortisone butyr-emollient topical cream
Tier 1
hydrocortisone topical cream 2.5 %
Tier 1
hydrocortisone topical cream with perineal applicator
Tier 1
hydrocortisone topical lotion 2.5 %
Tier 1
hydrocortisone topical ointment 2.5 %
Tier 1
hydrocortisone valerate topical cream
Tier 1
hydrocortisone valerate topical ointment
Tier 1
hydrocortisone-pramoxine topical cream
Tier 1
imiquimod topical cream in packet
Tier 1 PA; QL
IODOFLEX TOPICAL PADS, MEDICATED
Tier 3
iodoquinol-hc topical cream
Tier 1
lindane topical shampoo Tier 1
malathion topical lotion Tier 1
methoxsalen oral capsule,liqd-filled,rapid rel
Tier 2 PA; SP
metronidazole topical 0.75% gl
Tier 1
Drug Name Tier Notes
metronidazole topical cream
Tier 1
metronidazole topical gel 1 %
Tier 1
metronidazole topical gel with pump
Tier 1
metronidazole topical lotion
Tier 1
MIRVASO TOPICAL GEL Tier 3
MIRVASO TOPICAL GEL WITH PUMP
Tier 3
mometasone topical cream
Tier 1
mometasone topical ointment
Tier 1
mometasone topical solution
Tier 1
NUOX TOPICAL GEL Tier 3
OVACE TOPICAL CLEANSER
Tier 3
permethrin topical cream Tier 1
PHYSIOLYTE IRRIGATION SOLUTION
Tier 3
podofilox topical solution Tier 1
prednicarbate topical cream
Tier 1
prednicarbate topical ointment
Tier 1
PROCTOSOL-HC 2.5% CREAM
Tier 1
proctozone-hc topical cream with perineal applicator
Tier 1
prudoxin topical cream Tier 2
REGRANEX TOPICAL GEL
Tier 3
rosadan topical cream Tier 1
ROSADAN TOPICAL GEL
Tier 1
salicylic acid topical cream Tier 1
salicylic acid topical cream,extended release
Tier 1
salicylic acid topical foam Tier 1
salicylic acid topical gel Tier 1
salicylic acid topical lotion Tier 1
salicylic acid topical lotion,extended release
Tier 1
Effective 1/1/201752
Drug Name Tier Notes
salicylic acid topical shampoo
Tier 1
salvax topical foam Tier 1
SANTYL TOPICAL OINTMENT
Tier 3
seb-prev topical cleanser Tier 1
selenium sulfide 2.25% shampoo
Tier 1
selenium sulfide topical lotion
Tier 1
selenium sulfide topical shampoo 2.25 %
Tier 1
SKLICE TOPICAL LOTION
Tier 3
sodium chloride irrigation solution
Tier 1
spinosad topical suspension
Tier 1
sulfacetamide sodium (acne) topical suspension
Tier 1
sulfacetamide sodium topical cleanser
Tier 1
sulfacetamide sodium topical cleanser, gel
Tier 1
sulfacetamide sodium topical shampoo
Tier 1
TACLONEX TOPICAL SUSPENSION
Tier 3
tazarotene topical cream Tier 2
TAZORAC TOPICAL CREAM 0.05 %
Tier 3
TAZORAC TOPICAL GEL Tier 3
TIS-U-SOL PENTALYTE IRRIGATION SOLUTION
Tier 3
tretinoin (emollient) topical cream
Tier 1
tretinoin topical cream Tier 1 PA
tretinoin topical gel 0.01 %, 0.025 %
Tier 1 PA
triamcinolone acetonide topical cream
Tier 1
triamcinolone acetonide topical lotion
Tier 1
triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %
Tier 1
trianex topical ointment Tier 1
Drug Name Tier Notes
triderm topical cream 0.1 %
Tier 1
TRIDERM TOPICAL CREAM 0.5 %
Tier 1
ULESFIA TOPICAL LOTION
Tier 3
zenatane oral capsule Tier 1 PA
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended release 12 hr
Tier 1 $0; QL
CHANTIX CONTINUING MONTH BOX ORAL TABLET
Tier 3 $0; QL
CHANTIX ORAL TABLET Tier 3 $0; QL
CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK
Tier 3 $0; QL
NICOTROL INHALATION CARTRIDGE
Tier 3
NICOTROL NS NASAL SPRAY,NON-AEROSOL
Tier 3
THYROID PREPS
ARMOUR THYROID ORAL TABLET
Tier 1
levothyroxine oral tablet Tier 1
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 1
liothyronine oral tablet Tier 1
methimazole oral tablet 10 mg, 5 mg
Tier 1
nature-throid oral tablet Tier 1
NP THYROID ORAL TABLET 120 MG, 15 MG
Tier 1
np thyroid oral tablet 30 mg, 60 mg, 90 mg
Tier 1
propylthiouracil oral tablet Tier 1
SYNTHROID ORAL TABLET
Tier 1
THYROLAR-1 ORAL TABLET
Tier 3
THYROLAR-1/2 ORAL TABLET
Tier 3
THYROLAR-1/4 ORAL TABLET
Tier 3
Effective 1/1/201753
Drug Name Tier Notes
THYROLAR-2 ORAL TABLET
Tier 3
THYROLAR-3 ORAL TABLET
Tier 3
unithroid oral tablet Tier 1
westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg
Tier 1
WP THYROID ORAL TABLET
Tier 1
UNCLASSIFIED DRUG PRODUCTS
acamprosate oral tablet,delayed release (dr/ec)
Tier 2 QL
ADAGEN INTRAMUSCULAR SOLUTION
Tier 4 LD
ALDURAZYME INTRAVENOUS SOLUTION
Tier 4 PA; SP
alendronate oral solution Tier 1
alendronate oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg
Tier 1 QL
alfuzosin oral tablet extended release 24 hr
Tier 1
amifostine crystalline intravenous recon soln
Tier 4 PA; SP
ARCALYST SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP; LD; QL
BENLYSTA INTRAVENOUS RECON SOLN
Tier 4 PA; SP
BERINERT INTRAVENOUS KIT
Tier 4 PA; LD
BERINERT INTRAVENOUS RECON SOLN
Tier 4 PA; LD
buprenorphine hcl sublingual tablet 2 mg, 8 mg
Tier 2 QL
buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg
Tier 1 QL
CARBAGLU ORAL TABLET, DISPERSIBLE
Tier 4 LD
CERDELGA ORAL CAPSULE
Tier 4 PA; SP
Drug Name Tier Notes
CHEMET ORAL CAPSULE
Tier 3
chlorhexidine gluconate mucous membrane mouthwash
Tier 1
CIALIS ORAL TABLET2.5 MG, 5 MG
Tier 3 PA; QL
CYSTADANE ORAL POWDER
Tier 3 LD
darifenacin oral tablet extended release 24 hr
Tier 2 ST
DEBACTEROL MUCOUS MEMBRANE SOLUTION
Tier 3
DEBACTEROL MUCOUS MEMBRANE SWAB
Tier 3
disulfiram oral tablet Tier 1
doxercalciferol oral capsule
Tier 2
doxycycline hyclate oral tablet 20 mg
Tier 1
dutasteride oral capsule Tier 2 PA
ELAPRASE INTRAVENOUS SOLUTION
Tier 4 PA
ELELYSO INTRAVENOUS RECON SOLN
Tier 4 PA; SP; LD
etidronate disodium oral tablet
Tier 2
EXJADE ORAL TABLET, DISPERSIBLE
Tier 4 PA; SP
FABRAZYME INTRAVENOUS RECON SOLN
Tier 4 PA; SP
FERRIPROX ORAL TABLET
Tier 4 PA; LD
finasteride oral tablet 1 mg Tier 1
finasteride oral tablet 5 mg Tier 1 PA
flavoxate oral tablet Tier 1
FORTEO SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
FOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT
Tier 3 ST; QL
FOSAMAX PLUS D ORAL TABLET 70 MG- 5,600 UNIT
Tier 3 ST
ibandronate oral tablet Tier 1 QL
Effective 1/1/201754
Drug Name Tier Notes
KALYDECO ORAL GRANULES IN PACKET
Tier 4 PA; SP; LD; QL
KALYDECO ORAL TABLET
Tier 4 PA; SP; LD; QL
KEVEYIS ORAL TABLET Tier 3 PA; LD; QL
KUVAN ORAL TABLET,SOLUBLE
Tier 4 PA; SP; LD
leucovorin calcium oral tablet
Tier 4
levocarnitine (with sugar) oral solution
Tier 1
levocarnitine oral tablet Tier 1
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR
Tier 3
NAGLAZYME INTRAVENOUS SOLUTION
Tier 4 PA; SP; LD
oralone dental paste Tier 1
ORFADIN ORAL CAPSULE
Tier 4 LD
OSPHENA ORAL TABLET
Tier 3 QL
oxybutynin chloride oral syrup
Tier 1
oxybutynin chloride oral tablet
Tier 1
oxybutynin chloride oral tablet extended release 24hr
Tier 1
pamidronate intravenous recon soln
Tier 4 SP
pamidronate intravenous solution
Tier 4 SP
paricalcitol oral capsule Tier 2
paroex oral rinse mucous membrane mouthwash
Tier 1
periogard mucous membrane mouthwash
Tier 1
PROLIA SUBCUTANEOUS SYRINGE
Tier 3 PA; SP; QL
raloxifene oral tablet Tier 1 $0
RAPAFLO ORAL CAPSULE
Tier 3
risedronate oral tablet 150 mg, 30 mg, 35 mg, 5 mg
Tier 1 QL
Drug Name Tier Notes
SAVELLA ORAL TABLET
Tier 3 QL
SAVELLA ORAL TABLETS,DOSE PACK
Tier 3 QL
SENSIPAR ORAL TABLET
Tier 4
sodium chlor 0.9% bacteriostat injection solution
Tier 1
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG
Tier 4 PA; SP; LD; QL
SYPRINE ORAL CAPSULE
Tier 3 SP
tamsulosin oral capsule,extended release 24hr
Tier 1
tolterodine oral tablet Tier 1
TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR
Tier 3
triamcinolone acetonide dental paste
Tier 1
trospium oral capsule,extended release 24hr
Tier 2
VESICARE ORAL TABLET
Tier 3
VIAGRA ORAL TABLET Tier 2 PA
VPRIV INTRAVENOUS RECON SOLN
Tier 4 PA; SP
XIAFLEX INJECTION RECON SOLN
Tier 4 PA
ZAVESCA ORAL CAPSULE
Tier 4 PA; SP; LD
ZEMAIRA INTRAVENOUS RECON SOLN
Tier 4 SP; LD
zoledronic acid intravenous recon soln
Tier 4 PA; SP
zoledronic acid intravenous solution
Tier 4 PA; SP
zoledronic acid-mannitol-water intravenous piggyback
Tier 4 PA; SP
VITAMINS
calcitriol oral capsule Tier 1
Effective 1/1/201755
Drug Name Tier Notes
calcitriol oral solution Tier 1
cyanocobalamin (vitamin b-12) injection solution
Tier 1
ergocalciferol (vitamin d2) oral capsule
Tier 1
folic acid oral tablet 1 mg Tier 1
tl gard rx oral tablet Tier 1
vitamin d2 oral capsule Tier 1
Effective 1/1/201756
KEY Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type SP = SPECIALTY DRUGS. This specialty drug may be required to be dispensed through a specialty pharmacy. LD = LIMITED DISTRIBUTION. Limited distribution drugs are those drugs that are available only through select pharmacies or wholesalers as determined by the manufacturer. PA = PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled. QL = QUANTITY LIMITS. Certain prescription medications have specific quantity limits per prescription or per month. ST = STEP THERAPY REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized. DO = DOSE OPTIMIZATION REQUIRED. Normally this means switching from taking a drug twice a day to taking it once a day (at a higher strength). $0: PREVENTIVE DRUGS: For some members, this product may be covered at 100% with $0 cost share with a prescription from your provider if specified criteria are met.
Drug(s) may be excluded based on your plan's benefit design. If you have additional questions about your prescription benefits please call the Member Services number on your ID card. Most plans include our home delivery program at no extra cost to you. Find out more by going online to anthem.com or call 866-217-2328.
For more information, please visit anthem.com/pharmacyinformation If you have additional questions about your prescription benefits please call the Member Services number on your ID card. Speech and hearing impaired (TDD/TTY users) should call 1-800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m. ET For the most current version of this prescription drug list, please visit anthem.com/pharmacyinformation.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans. Rev. 2/17