sparrow caregiver prescription drug list, october 20 · 10/1/2020 · this prescription drug list...

Sparrow Caregiver Prescription Drug List, March 2021

Introduction

This Prescription Drug List (PDL) is the list of covered medications for the Sparrow Health System employer group. The PDL applies only to prescription medications that a PHP member picks up at a pharmacy or other outpatient location; it does not include inpatient medications or medications obtained or administered in a Physician’s office. Some over-the-counter medications are covered due to federal regulations and the member’s specific pharmacy benefit plan.

The PDL does not define benefit coverage. Benefit coverage is determined by the member’s specific pharmacy benefit plan. This means that there may be medications listed on the PDL that are not covered because they are not a covered benefit under the member’s pharmacy benefit plan.

You may also access PDL information by visiting our website at PHPMichigan.com. For general questions regarding the PDL, call toll-free PHP’s Customer Service Department at 1.800.832.9186

Prescription Drug List Medication Overview

Medications on the PDL fall under different benefit tiers based on a review of clinical, economic, and other factors. The PHP Pharmacy & Therapeutics (P&T) Committee, composed of Physicians and Pharmacists, reviews new and existing medications and provides clinical guidance for formulary development and tier placement. Guidance is based on similarities and differences compared with other medications that treat the same disease or condition. This helps ensure members have access to a wide range of medications while controlling healthcare costs.

The tier placement of a medication on the PDL may be subject to change. When a medication changes tiers, the member may be required to pay more or less. These changes may occur without prior notice. Members may visit the PHP website at PHPMichigan.com. Call PHP’s Customer Service Department at 1.800.832.9186 or 517.364.8500 for the most up-to-date tier status and copayment information.

• The Prescription Drug Guide applies to Sparrow Health System Caregivers. Coverage is based upon the member’s benefit Summary Plan Description (SPD).

• Specific Over-The-Counter (OTC) medications are covered based upon Health Care Reform (HCR) and the member’s benefit. Members must refer to their SPD for coverage and benefit information.

Tier Designations

Prescription medications are categorized within four tiers on the PDL. Each tier is assigned a copayment, which is determined by the member’s pharmacy benefit plan. Providers may refer to the PDL as a guide to select the most appropriate medication with the lowest member copayment for your Patients.

ACA

A select list of prescription and over-the-counter medications are classified as preventive medications based upon the Health Care Reform (HCR) Affordable Care Act (ACA) guidelines. These medications are available to members at zero ($0) copayment. More information on preventive medications is included in the member’s specific benefit plan.

Tier 1

Medications on Tier 1 will have the lowest member cost share. Most medications on this tier are generic medications.

Tier 2

Tier 2 medications are preferred, branded, traditional, and specialty medications. A provider may consider a Tier 2 medication if no Tier 1 medication is appropriate to treat the member’s condition. Members will have a higher cost share for Tier 2 medications.

Tier 3

Tier 3 medications are non-preferred traditional medications. Members will have the highest cost share for Tier 3 medications, unless the medication is a specialty medication and is designated as Tier 4 based upon a member’s pharmacy benefit.

Tier 4

Tier 4 medications are non-preferred specialty medications. Tier 4 medications will have the highest member cost share based upon a member’s pharmacy benefit.

Specific information about the member’s cost share, including copays, deductible and coinsurance amounts, can be found in the member’s Certificate of Coverage. For more information, please call PHP’s Customer Service Department at 800.832.916 or 517.364.8500.

Medications listed in lowercase italics indicate the generic name of the medication. Medications listed in all UPPERCASE indicate a branded, single-source, or authorized generic medication.

Over-the-Counter Medications

For many conditions, an over-the-counter (OTC) medication may be the most appropriate treatment. OTC medications are defined as medications that do not require a prescription by federal or state law to be dispensed. Specific OTC medications are covered based on the member’s specific benefit plan and federal regulations. Therapeutic equivalent and OTC medications may not be covered under the member’s pharmacy benefit, and they may cost less than the member’s out-of-pocket expense for prescription medications. However, if the Patient or Physician requests a therapeutic equivalent product or an OTC product, the Patient may be required to pay the entire cost of the product. This is determined by the member’s pharmacy benefit plan.

Generic Medication Policy

Most generic medications are included on the PDL as Tier 1 medications. Members will have the lowest cost share with a Tier 1 medication, so consider prescribing a generic, Tier 1 medication when appropriate. Note that when a brand-name medication becomes available as a generic, that brand-name product may move to a higher tier. Unless the Physician specifies that the medication must be Dispensed As Written (DAW), the pharmacist may substitute the name brand for a lower cost generic equivalent. When generic substitution conflicts with state regulations or restrictions, the dispensing Pharmacist must obtain approval from the prescribing Physician or other healthcare professional to substitute the generic equivalent.

Self-Administered Injectables

Some members may have coverage for self-administered injectable medications through their pharmacy benefit plan. You will find these medications included in the body of this document within the appropriate therapeutic categories.

Medications Requiring Notification and Other Pharmacy Programs

Select medications may require Prior Authorization (PA) in order to be covered. These medications are noted with a PA in this document. The list of the medications requiring PA is provided below. The list is approved by the PHP Pharmacy and Therapeutics Committee. To initiate a PA review for a certain medication, the provider or provider’s designee must complete a Prior Authorization Request Form and fax the completed form to the PHP Pharmacy Department at 517.364.8413. The Prior Authorization Request Form for medications as well as PA criteria can be found on the website at www.phpmichigan.com/ providers/general-forms-and-information.

Quantity limitations are based on FDA-approved dosing recommendations and package size as well as plan benefit limitations. Such medications have a notation “QL,” for

http://www.phpmichigan.com/%20providers/general-forms-and-information

quantity limit. These quantity limitations define either the maximum supply of medication per copayment or a defined maximum amount that can be covered in a specific time period, as specified by the pharmacy benefit plan. Exceptions to the QL for certain medications are reviewed through the PA process, outlined above.

Some medications are excluded for certain uses or are only covered for specific diagnoses. In general, PHP benefit plans do not cover medications that are prescribed for conditions outside of those approved by the Federal Drug Administration (FDA).

If you have questions about the PDL or specific coverage requirements, call PHP’s Customer Service Department at 800.832.916 or 517.364.8500.

Keys To Symbols

Symbols used throughout the PDL have these definitions:

AL = Age Limitation. Prior notification may be required to be eligible for coverage depending on Patient age.

ACA = Affordable Care Act Preventative Medications. These are covered at zero copayment ($0) to the member.

LA = Limited Access. This medication may be covered only at certain pharmacies or as a medical benefit. Coverage is based upon the member’s benefit. For more information, please call Customer Service.

PA = Prior Authorization required. Approval of this medication is required prior to coverage by PHP.

QL = Quantity limit.

SP = Specialty Medication. This medication allows a maximum of a one month supply per fill.

ST = Step therapy. This medication requires trial of a preferred agent prior to coverage.

SEMS = Sparrow Extended Medication Supply Program List. 90-day supplies of medications on this list are available at Sparrow Pharmacies for one tier 1 copay.

Language Access Information ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1‐800‐649‐3777 (TTY: 711).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

Llame al 1‐800‐649‐3777 (TTY: 711).

Arabic:

كم: بملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم وال

1-800-649-377 (TTY: 711)

Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1‐800‐649‐3777

(TTY: 711)

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche

Hilfsdienstleistungen zur Verfügung. Rufnummer: 1‐800‐649‐3777 (TTY: 711).

Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza

linguistica gratuiti. Chiamare il numero 1‐800‐649‐3777 (TTY: 711).

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。

1‐800‐649‐3777 (TTY: 711) まで、お電話にてご連絡ください

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-

1‐800‐649‐3777 (TTY: 711) 번으로 전화해 주십시오.

Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.

Zadzwoń pod numer 1‐800‐649‐3777 (TTY: 711).

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги

перевода. Звоните 1‐800‐649‐3777 (TTY: 711).

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng

tulong sa wika nang walang bayad. Tumawag sa 1‐800‐649‐3777 (TTY: 711).

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.

Gọi số 1‐800‐649‐3777 (TTY: 711).

Bengali: লক্ষ্য করুনঃ যদি আপদন বাাংলা, কথা বলতে পাতেন, োহতল দনঃখেচায় ভাষা সহায়ো পদেতষবা

উপলব্ধ আতে। ফ ান করুন ১-1‐800‐649‐3777 (TTY: 711)।

Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa

pagesë. Telefononi në 1‐800‐649‐3777 (TTY: 711).

Serbo-Croatian: OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1‐800‐649‐3777 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711).

Syriac:

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty MB - Medical Benefit GH - Growth Hormone ACA- Affordable Care Act AL- Age Restriction F- Fertility Rider LA- Limited Access MNPA- Medical Necessity PA Gender- Gender Limits SEMS- Sparrow Extended Medication Supply Program

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Sparrow 4T eff 03/01/2021 Drug Name Drug Tier Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS AMPHETAMINES

ADDERALL Tier 3 QL

ADDERALL XR Tier 1 QL

amphetamine sulfate Tier 1 QL

amphetamine-dextroamphetamine Tier 1 QL

dextroamphetamine sulfate Tier 1

MYDAYIS Tier 3 QL

VYVANSE Tier 2 QL

ANALEPTICS caffeine citrate Tier 1

ANOREXIANTS NON-AMPHETAMINE ADIPEX-P Tier 3 QL

benzphetamine hcl Tier 1

diethylpropion hcl Tier 1

phendimetrazine tartrate Tier 1

phentermine hcl Tier 1

ANTI-OBESITY AGENTS CONTRAVE Tier 3 ST

SAXENDA Tier 3 PA

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS atomoxetine hcl Tier 1 QL

clonidine hcl (adhd) Tier 1

guanfacine hcl (adhd) Tier 1

INTUNIV Tier 3

KAPVAY Tier 3

DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS

(DNRIS) SUNOSI Tier 3 PA

STIMULANTS - MISC. APTENSIO XR Tier 3 ST, QL

armodafinil Tier 1 ST, QL

CONCERTA Tier 1 QL

COTEMPLA XR-ODT Tier 3 ST, QL

DAYTRANA Tier 2 ST, QL

dexmethylphenidate hcl CP24 Tier 1

dexmethylphenidate hcl TABS Tier 1 QL

FOCALIN Tier 3 QL

FOCALIN XR Tier 3

METHYLIN Tier 3 QL


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Drug Name Drug Tier Requirements/Limits

methylphenidate hcl CHEW Tier 1 QL

methylphenidate hcl CP24 10mg Tier 1 QL

methylphenidate hcl CP24 10mg, 15mg, 20mg, 30mg, 40mg, 50mg, 60mg

Tier 1 ST, QL

methylphenidate hcl CP24 20mg, 30mg, 40mg, 60mg

Tier 1

methylphenidate hcl CPCR Tier 1 QL

methylphenidate hcl SOLN Tier 1 QL

methylphenidate hcl TABS 5mg Tier 1 QL

methylphenidate hcl TABS 10mg, 20mg Tier 1

methylphenidate hcl TB24 Tier 1 QL

methylphenidate hcl TBCR Tier 1

modafinil Tier 1 QL

QUILLICHEW ER Tier 3

QUILLIVANT XR Tier 2 ST, QL

RITALIN 5mg Tier 3 QL

RITALIN 10mg, 20mg Tier 3

RITALIN LA 10mg Tier 3 QL

RITALIN LA 20mg, 30mg, 40mg Tier 3

AMEBICIDES AMEBICIDES

SOLOSEC Tier 3 QL

AMINOGLYCOSIDES AMINOGLYCOSIDES

amikacin sulfate LA

ARIKAYCE Tier 4 SP, PA

BETHKIS Tier 4 SP, PA

gentamicin in saline LA

gentamicin sulfate LA

KITABIS PAK Tier 4 SP, PA

neomycin sulfate Tier 1

paromomycin sulfate Tier 1

streptomycin sulfate LA

TOBI Tier 4 SP, PA

TOBI PODHALER Tier 2 SP

tobramycin Tier 1 SP, PA

tobramycin sulfate SOLN 1.2gm/30ml, 10mg/ml

LA

tobramycin sulfate SOLN 40mg/ml, 80mg/2ml

Tier 1

tobramycin sulfate SOLR LA

ZEMDRI LA PA


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ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES

HUMIRA Tier 2 SP, PA

HUMIRA PEDIATRIC CROHNS D Tier 2 SP, PA

HUMIRA PEN Tier 2 SP, PA

HUMIRA PEN-CD/UC/HS START Tier 2 SP, PA

HUMIRA PEN-PS/UV STARTER Tier 2 SP, PA

SIMPONI ARIA LA SP, PA; MB

ANTIRHEUMATIC - ENZYME INHIBITORS RINVOQ Tier 2 SP, PA

XELJANZ Tier 2 SP, PA, QL

XELJANZ XR Tier 2 SP, PA, QL

ANTIRHEUMATIC ANTIMETABOLITES OTREXUP Tier 4 SP, PA

RASUVO Tier 4 SP, PA

GOLD COMPOUNDS RIDAURA Tier 3 PA

INTERLEUKIN-1 BLOCKERS ARCALYST LA SP, PA

INTERLEUKIN-1BETA BLOCKERS ILARIS Tier 4 SP, PA

INTERLEUKIN-6 RECEPTOR INHIBITORS ACTEMRA LA SP, PA; MB

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) ARTHROTEC 50 Tier 3

ARTHROTEC 75 Tier 3

CALDOLOR LA

celecoxib Tier 1 QL

DAYPRO Tier 3

diclofenac potassium Tier 1

diclofenac sodium Tier 1

diclofenac w/ misoprostol Tier 1

EC-NAPROSYN Tier 3

etodolac Tier 1

FELDENE Tier 3

FENOPROFEN CALCIUM CAPS Tier 3 PA

fenoprofen calcium TABS Tier 1

FENORTHO Tier 3 PA

flurbiprofen Tier 1

ibuprofen Tier 1 SEMS

INDOCIN Tier 3


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indomethacin Tier 1

indomethacin sodium LA

ketoprofen Tier 1

KETOROLAC TROMETHAMINE SOLN 15.75mg/spray

Tier 2

ketorolac tromethamine SOLN 15mg/ml, 30mg/ml

LA

ketorolac tromethamine SOLN 30mg/ml Tier 1

ketorolac tromethamine TABS Tier 1 QL

meclofenamate sodium Tier 1

mefenamic acid Tier 1

meloxicam Tier 1

MOBIC Tier 3

nabumetone Tier 1

NALFON Tier 3

NAPROSYN Tier 3

naproxen SUSP Tier 1

naproxen TABS Tier 1

naproxen TBEC 375mg, 500mg Tier 1

NAPROXEN TBEC 375mg, 500mg Tier 1

naproxen sodium Tier 1

oxaprozin Tier 1

piroxicam Tier 1

SPRIX Tier 2

sulindac Tier 1

tolmetin sodium Tier 1

ZIPSOR Tier 3

PHOSPHODIESTERASE 4 (PDE4) INHIBITORS OTEZLA Tier 2 SP, PA, QL

PYRIMIDINE SYNTHESIS INHIBITORS ARAVA Tier 3

leflunomide Tier 1

SELECTIVE COSTIMULATION MODULATORS ORENCIA LA SP, PA; MB

SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL SOLN Tier 2 SP, ST

ENBREL SOLR; SOSY Tier 2 SP, PA

ENBREL MINI Tier 2 SP, PA

ENBREL SURECLICK Tier 2 SP, PA

ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS

ALLZITAL Tier 3 PA


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butalbital-acetaminophen Tier 1

butalbital-acetaminophen Tier 1 PA

butalbital-acetaminophen-caffeine Tier 1

butalbital-aspirin-caffeine Tier 1

BUTALBITAL/ASPIRIN/CAFFEI Tier 1

ESGIC Tier 3

FIORICET Tier 3

SALICYLATES diflunisal Tier 1

salsalate Tier 1

ANALGESICS - OPIOID OPIOID AGONISTS

ACTIQ Tier 3 PA, QL

ALFENTANIL HYDROCHLORIDE Tier 3

CODEINE SULFATE 15mg, 30mg Tier 1 PA

codeine sulfate 60mg Tier 1 PA

DEMEROL LA

DILAUDID LIQD; TABS Tier 3 PA

DILAUDID SOLN LA

fentanyl 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hr

Tier 1 QL

fentanyl 37.5mcg/hr, 62.5mcg/hr, 87.5mcg/hr

Tier 3 QL

fentanyl citrate LPOP Tier 1 PA, QL

fentanyl citrate SOCT; SOLN LA

fentanyl citrate TABS Tier 1 PA

FENTORA Tier 3 PA

hydrocodone bitartrate Tier 1 PA

hydromorphone hcl LIQD; TABS; TB24 Tier 1 PA

hydromorphone hcl SOLN LA

HYDROMORPHONE HYDROCHLORI LA

HYSINGLA ER Tier 3 PA

INFUMORPH 200 LA

INFUMORPH 500 LA

LAZANDA 100mcg/act Tier 3 PA

LAZANDA 400mcg/act Tier 3 PA, QL

levorphanol tartrate Tier 1 PA

meperidine hcl SOLN 25mg/ml, 50mg/ml, 100mg/ml

LA

meperidine hcl SOLN 50mg/5ml Tier 1 PA

meperidine hcl TABS Tier 1 PA

methadone hcl CONC Tier 1

methadone hcl SOLN 5mg/5ml, 10mg/5ml Tier 1


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methadone hcl SOLN 10mg/ml LA

METHADONE HCL SOLN 10mg/ml LA

methadone hcl TABS Tier 1

methadone hcl TBSO Tier 1

morphine sulfate CP24 10mg, 20mg, 30mg, 50mg, 60mg, 80mg, 100mg

Tier 1 QL

morphine sulfate CP24 40mg Tier 1

MORPHINE SULFATE SOLN 1mg/ml, 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml

LA

morphine sulfate SOLN 10mg/5ml, 20mg/5ml, 20mg/ml, 100mg/5ml

Tier 1 PA

morphine sulfate SOLN .5mg/ml, 1mg/ml, 4mg/ml, 8mg/ml, 10mg/ml, 50mg/ml

LA

morphine sulfate SUPP 5mg, 10mg, 20mg Tier 1 PA

MORPHINE SULFATE SUPP 30mg Tier 1 PA

morphine sulfate TABS Tier 1 PA

morphine sulfate TBCR Tier 1 QL

morphine sulfate beads Tier 1 QL

morphine sulfate for continuous microinfusion

LA

MS CONTIN Tier 3 QL

NUCYNTA Tier 3 PA

NUCYNTA ER Tier 3 PA

OXAYDO Tier 3 PA

oxycodone hcl CAPS Tier 1 PA

oxycodone hcl CONC Tier 1 PA

oxycodone hcl SOLN Tier 1 PA

oxycodone hcl T12A 10mg, 15mg, 20mg, 30mg

Tier 1 QL

oxycodone hcl T12A 40mg, 60mg, 80mg Tier 1

oxycodone hcl TABS Tier 1 PA

OXYCONTIN 10mg, 15mg, 20mg, 30mg Tier 3 QL

OXYCONTIN 40mg Tier 3

OXYCONTIN 60mg, 80mg Tier 1

oxymorphone hcl TABS Tier 1 PA

oxymorphone hcl TB12 5mg, 10mg, 20mg, 30mg, 40mg

Tier 1 PA

oxymorphone hcl TB12 7.5mg, 15mg Tier 1 PA, QL

ROXICODONE Tier 3 PA

sufentanil citrate LA PA

tramadol hcl TABS 50mg Tier 1 PA

tramadol hcl TABS 100mg Tier 1


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tramadol hcl TB24 Tier 1 QL

ULTIVA LA PA

XTAMPZA ER Tier 3 PA

ZOHYDRO ER Tier 3 PA

OPIOID COMBINATIONS acetaminophen w/ codeine SOLN Tier 1 PA

acetaminophen w/ codeine TABS Tier 1 PA, QL

acetaminophen-caff-dihydrocod Tier 1 PA, QL

butalbital-acetaminophen-caffeine w/ codeine

Tier 1 QL

butalbital-aspirin-caffeine w/cod Tier 1 QL

hydrocodone-acetaminophen SOLN Tier 1 PA

hydrocodone-acetaminophen SOLN Tier 1 PA, QL

hydrocodone-acetaminophen TABS Tier 1 PA, QL

hydrocodone-ibuprofen Tier 1 PA, QL

LORTAB Tier 3 PA

oxycodone w/ acetaminophen Tier 1 PA, QL

oxycodone-aspirin Tier 1 PA, QL

OXYCODONE/ACETAMINOPHEN Tier 3 PA

PERCOCET Tier 3 PA, QL

PROLATE Tier 3 PA

tramadol-acetaminophen Tier 1 PA, QL

ULTRACET Tier 3 PA, QL

OPIOID PARTIAL AGONISTS BELBUCA Tier 3 PA

buprenorphine Tier 1 QL

buprenorphine hcl SOLN LA PA

buprenorphine hcl SUBL Tier 1

buprenorphine hcl-naloxone hcl dihydrate Tier 1

butorphanol tartrate 1mg/ml, 2mg/ml LA

butorphanol tartrate 10mg/ml Tier 1 QL

nalbuphine hcl LA

pentazocine w/ naloxone Tier 1 PA

SUBLOCADE LA PA

SUBOXONE Tier 3

ZUBSOLV Tier 3

ANDROGENS-ANABOLIC ANABOLIC STEROIDS

ANADROL-50 Tier 3 PA

oxandrolone Tier 1

ANDROGENS ANDRODERM Tier 2 GENDER


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ANDROGEL 20.25mg/1.25gm, 40.5mg/2.5gm

Tier 3 GENDER

ANDROGEL 25mg/2.5gm, 50mg/5gm Tier 3 QL; GENDER

ANDROGEL PUMP Tier 3 QL; GENDER

AVEED Tier 2 SP; GENDER

danazol Tier 1

DEPO-TESTOSTERONE Tier 3 GENDER

FORTESTA Tier 3 PA; GENDER

JATENZO Tier 3 PA; GENDER

NATESTO Tier 3 GENDER

TESTIM Tier 3 QL; GENDER

TESTOPEL Tier 2 GENDER

testosterone GEL 1%, 1.62%, 25mg/2.5gm, 50mg/5gm

Tier 1 QL; GENDER

testosterone GEL 10mg/act Tier 1 PA; GENDER

testosterone GEL 20.25mg/1.25gm, 40.5mg/2.5gm

Tier 1 GENDER

testosterone SOLN Tier 1 GENDER

testosterone cypionate Tier 1 GENDER

testosterone enanthate Tier 1

VOGELXO Tier 3 QL; GENDER

VOGELXO PUMP Tier 3 QL; GENDER

XYOSTED Tier 3 QL

ANORECTAL AND RELATED PRODUCTS INTRARECTAL STEROIDS

CORTENEMA Tier 3

CORTIFOAM Tier 2

hydrocortisone (intrarectal) Tier 1

UCERIS FOAM Tier 3 PA

RECTAL COMBINATIONS ANALPRAM-HC Tier 3

PROCORT Tier 3

PROCTOFOAM HC Tier 2

RECTAL STEROIDS ANUSOL-HC Tier 3

hydrocortisone (rectal) Tier 1

hydrocortisone acetate (rectal) Tier 1

PROCTOCORT Tier 3

VASODILATING AGENTS RECTIV Tier 2


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ANTHELMINTICS ANTHELMINTICS

albendazole Tier 1 QL

ALBENZA Tier 3 QL

BILTRICIDE Tier 3 PA

EMVERM Tier 3 PA

ivermectin Tier 1

praziquantel Tier 1 PA

ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC.

FLAGYL Tier 3

IMPAVIDO Tier 3 PA

metronidazole CAPS; TABS Tier 1

METRONIDAZOLE SOLN LA

metronidazole in nacl LA

NEBUPENT Tier 3

pentamidine isethionate Tier 1

PRIMSOL Tier 3

tinidazole Tier 1

trimethoprim Tier 1

XIFAXAN Tier 2 PA

ANTI-INFECTIVE MISC. - COMBINATIONS BACTRIM Tier 3

BACTRIM DS Tier 3

methenamine-hyosc-methylene blue-benzoic acid-phenyl sal

Tier 1

methenamine-hyosc-methylene blue-sod phos-phenyl sal

Tier 1

methenamine-hyoscamine-methylene blue-sodium phosphate

Tier 1

sulfamethoxazole-trimethoprim SOLN LA

sulfamethoxazole-trimethoprim SUSP; TABS

Tier 1

ANTIPROTOZOAL AGENTS ALINIA Tier 3 PA

atovaquone Tier 1

LAMPIT Tier 3 PA

nitazoxanide Tier 1 PA

CARBAPENEMS ertapenem sodium LA

imipenem-cilastatin LA

meropenem LA


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MERREM Tier 3

RECARBRIO LA PA

VABOMERE LA PA

CHLORAMPHENICOLS chloramphenicol sodium succinate LA

CYCLIC LIPOPEPTIDES daptomycin LA PA

GLYCOPEPTIDES FIRVANQ Tier 2

VANCOCIN Tier 3

VANCOCIN HCL Tier 3

VANCOMYCIN LA

vancomycin hcl CAPS Tier 1

VANCOMYCIN HCL SOLN LA

vancomycin hcl SOLR LA

VANCOMYCIN HYDROCHLORIDE/ LA

VIBATIV LA PA

LEPROSTATICS dapsone Tier 1

LINCOSAMIDES CLEOCIN CAPS Tier 3

CLEOCIN PEDIATRIC GRANULE Tier 3

CLEOCIN PHOSPHATE LA PA

clindamycin hcl Tier 1

clindamycin palmitate hydrochloride Tier 1

clindamycin phosphate LA

clindamycin phosphate in d5w LA

lincomycin hcl Tier 1

MONOBACTAMS AZACTAM LA PA

aztreonam LA

CAYSTON Tier 4 SP, PA

OXAZOLIDINONES linezolid SOLN LA PA

linezolid SUSR; TABS Tier 1 QL

linezolid in sodium chloride LA PA

SIVEXTRO SOLR LA PA

SIVEXTRO TABS Tier 3

ZYVOX LA PA

PLEUROMUTILINS XENLETA Tier 3 PA


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POLYMYXINS colistimethate sodium LA

COLY-MYCIN M LA PA

polymyxin b sulfate LA

URINARY ANTI-INFECTIVES fosfomycin tromethamine Tier 1

HIPREX Tier 3

MACROBID Tier 3

MACRODANTIN Tier 3

methenamine hippurate Tier 1

methenamine mandelate Tier 1

MONUROL Tier 3

nitrofurantoin Tier 1

nitrofurantoin macrocrystal Tier 1

nitrofurantoin monohyd macro Tier 1

ANTIANGINAL AGENTS ANTIANGINALS-OTHER

ranolazine Tier 1 QL

NITRATES DILATRATE SR Tier 3

GONITRO Tier 3

ISORDIL TITRADOSE Tier 3

isosorbide dinitrate Tier 1

isosorbide mononitrate Tier 1

NITRO-BID Tier 2

NITRO-DUR Tier 3

nitroglycerin Tier 1

NITROLINGUAL PUMPSPRAY Tier 3

NITROMIST Tier 3

ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC.

buspirone hcl Tier 1

droperidol LA

hydroxyzine hcl SOLN LA PA

hydroxyzine hcl SYRP; TABS Tier 1

hydroxyzine pamoate Tier 1

meprobamate Tier 1

VISTARIL Tier 3

BENZODIAZEPINES alprazolam Tier 1

ALPRAZOLAM INTENSOL Tier 2

ATIVAN SOLN LA PA


12


ATIVAN TABS Tier 3

chlordiazepoxide hcl Tier 1

clorazepate dipotassium Tier 1

diazepam CONC Tier 1

diazepam SOLN 5mg/5ml Tier 1

diazepam SOLN 5mg/ml, 50mg/10ml LA

diazepam TABS Tier 1

lorazepam CONC; TABS Tier 1

lorazepam SOLN LA

oxazepam Tier 1

TRANXENE T Tier 3

VALIUM Tier 3

ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A

disopyramide phosphate Tier 1

NORPACE Tier 3

NORPACE CR Tier 3

quinidine gluconate Tier 1

quinidine sulfate Tier 1

ANTIARRHYTHMICS TYPE I-B mexiletine hcl Tier 1

ANTIARRHYTHMICS TYPE I-C flecainide acetate Tier 1

propafenone hcl Tier 1

RYTHMOL SR Tier 3

ANTIARRHYTHMICS TYPE III amiodarone hcl Tier 1

dofetilide Tier 1 SP

MULTAQ Tier 2

TIKOSYN Tier 4 SP

ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTI-INFLAMMATORY AGENTS

cromolyn sodium Tier 1

ANTIASTHMATIC - MONOCLONAL ANTIBODIES CINQAIR LA SP, PA

FASENRA LA SP, PA

FASENRA PEN Tier 4 SP, PA

NUCALA SOAJ; SOSY Tier 4 SP, PA

NUCALA SOLR LA SP, PA

XOLAIR LA SP, PA


13


BRONCHODILATORS - ANTICHOLINERGICS ATROVENT HFA Tier 2

INCRUSE ELLIPTA Tier 2

ipratropium bromide Tier 1

LONHALA MAGNAIR STARTER K Tier 3 PA

SEEBRI NEOHALER Tier 3

SPIRIVA HANDIHALER Tier 2

SPIRIVA RESPIMAT Tier 2

TUDORZA PRESSAIR Tier 3

LEUKOTRIENE MODULATORS ACCOLATE Tier 3

montelukast sodium Tier 1

SINGULAIR Tier 3

zafirlukast Tier 1

ZYFLO Tier 3 PA

SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP 250mcg Tier 2 QL

DALIRESP 500mcg Tier 2

STEROID INHALANTS ARNUITY ELLIPTA Tier 2

ASMANEX HFA Tier 2

ASMANEX TWISTHALER 7 METE Tier 2

ASMANEX TWISTHALER 14 MET Tier 2 QL

ASMANEX TWISTHALER 30 MET 110mcg/inh

Tier 2

ASMANEX TWISTHALER 30 MET 220mcg/inh

Tier 2 QL

ASMANEX TWISTHALER 60 MET Tier 2 QL

ASMANEX TWISTHALER 120 ME Tier 2 QL

budesonide (inhalation) Tier 1 QL

FLOVENT DISKUS Tier 1

FLOVENT HFA Tier 1

PULMICORT Tier 3 QL

PULMICORT FLEXHALER Tier 2 QL

QVAR REDIHALER Tier 2

SYMPATHOMIMETICS ADVAIR DISKUS Tier 1

ADVAIR HFA Tier 2 QL

AIRDUO RESPICLICK 55/14 Tier 3



albuterol sulfate AERS Tier 1


14


albuterol sulfate NEBU 1.25mg/3ml Tier 1

albuterol sulfate NEBU .083%, .63mg/3ml, 2.5mg/0.5ml

Tier 1 QL

albuterol sulfate SYRP Tier 1

albuterol sulfate TABS Tier 1

albuterol sulfate TB12 Tier 1

ANORO ELLIPTA Tier 2

BEVESPI AEROSPHERE Tier 2

BREO ELLIPTA Tier 2

BREZTRI AEROSPHERE Tier 2

BROVANA Tier 2 PA

COMBIVENT RESPIMAT Tier 2

fluticasone-salmeterol Tier 1

ipratropium-albuterol Tier 1 QL

levalbuterol hcl Tier 1 QL

levalbuterol tartrate Tier 1 QL

PERFOROMIST Tier 2 QL

PROAIR HFA Tier 2

PROAIR RESPICLICK Tier 2

PROVENTIL HFA Tier 3

SEREVENT DISKUS Tier 2 QL

STIOLTO RESPIMAT Tier 2

STRIVERDI RESPIMAT Tier 2

SYMBICORT Tier 1

terbutaline sulfate TABS Tier 1

TRELEGY ELLIPTA Tier 2

VENTOLIN HFA Tier 3

XOPENEX Tier 3 QL

XOPENEX CONCENTRATE Tier 3 QL

XANTHINES ELIXOPHYLLIN Tier 2

THEO-24 Tier 3

theophylline Tier 1

ANTICOAGULANTS COUMARIN ANTICOAGULANTS

warfarin sodium Tier 1

DIRECT FACTOR XA INHIBITORS ELIQUIS Tier 2

ELIQUIS STARTER PACK Tier 2

XARELTO 2.5mg Tier 2 QL

XARELTO 10mg, 15mg, 20mg Tier 2

XARELTO STARTER PACK Tier 2


15


HEPARINS AND HEPARINOID-LIKE AGENTS ARIXTRA Tier 3

enoxaparin sodium Tier 1 QL

fondaparinux sodium Tier 1

FRAGMIN Tier 2

heparin (porcine) in sodium chloride LA

heparin sod (porcine) in d5w LA

HEPARIN SODIUM Tier 2 QL

heparin sodium (porcine) Tier 1

heparin sodium (porcine) lock flush 1unit/ml

LA

heparin sodium (porcine) lock flush 10unit/ml, 100unit/ml

Tier 1

HEPARIN SODIUM/DEXTROSE LA

HEPARIN SODIUM/NACL 0.45% LA

LOVENOX Tier 3 QL

IN VITRO/LOCK ANTICOAGULANTS ANTICOAGULANT SODIUM CITR Tier 3

ANTICONVULSANTS AMPA GLUTAMATE RECEPTOR ANTAGONISTS

FYCOMPA Tier 3 PA

ANTICONVULSANTS - BENZODIAZEPINES clobazam Tier 1 PA

clonazepam Tier 1

DIASTAT ACUDIAL Tier 3

DIASTAT PEDIATRIC Tier 3

diazepam (anticonvulsant) Tier 1

KLONOPIN Tier 3

NAYZILAM Tier 3 ST, QL

ONFI Tier 3 PA

SYMPAZAN Tier 3 PA

VALTOCO Tier 3 QL

ANTICONVULSANTS - MISC. APTIOM Tier 3

BANZEL Tier 3

BRIVIACT SOLN 10mg/ml Tier 3 PA

BRIVIACT SOLN 50mg/5ml LA PA

BRIVIACT TABS Tier 3 PA

carbamazepine Tier 1

CARBATROL Tier 3

DIACOMIT Tier 4 SP, PA

EPIDIOLEX Tier 3 SP, PA


16


FINTEPLA Tier 2 SP, PA

gabapentin Tier 1

KEPPRA SOLN 100mg/ml Tier 3

KEPPRA SOLN 500mg/5ml LA PA

KEPPRA TABS Tier 3

KEPPRA XR Tier 3

LAMICTAL Tier 3

LAMICTAL CHEWABLE DISPERS Tier 3

LAMICTAL ODT Tier 3

LAMICTAL STARTER/NOT TAKI Tier 3

LAMICTAL STARTER/TAKING C Tier 3

LAMICTAL XR Tier 3

lamotrigine Tier 1

LEVETIRACETAM SOLN LA

levetiracetam SOLN 100mg/ml, 500mg/5ml

Tier 1

levetiracetam SOLN 500mg/5ml LA

levetiracetam TABS Tier 1

levetiracetam TB24 Tier 1

levetiracetam in sodium chloride LA

LYRICA CAPS 25mg, 50mg, 100mg, 150mg, 200mg, 225mg, 300mg

Tier 3 QL

LYRICA CAPS 75mg Tier 3

LYRICA SOLN Tier 3

MYSOLINE Tier 3

NEURONTIN Tier 3

oxcarbazepine Tier 1

OXTELLAR XR Tier 2

pregabalin CAPS 25mg, 50mg, 100mg, 150mg, 200mg, 225mg, 300mg

Tier 1 QL

pregabalin CAPS 75mg Tier 1

pregabalin SOLN Tier 1

primidone Tier 1

QUDEXY XR Tier 3

SPRITAM Tier 3 PA

TEGRETOL Tier 3

TEGRETOL-XR Tier 3

topiramate CPSP; TABS Tier 1

topiramate CS24 Tier 3

TROKENDI XR Tier 3

VIMPAT SOLN 10mg/ml Tier 3 PA

VIMPAT SOLN 200mg/20ml LA PA

VIMPAT TABS Tier 3 PA


17


ZONEGRAN Tier 3

zonisamide Tier 1

CARBAMATES felbamate Tier 1

FELBATOL Tier 3

XCOPRI Tier 3 PA

GABA MODULATORS GABITRIL Tier 3

SABRIL Tier 4 SP, PA

tiagabine hcl Tier 1

HYDANTOINS CEREBYX 100mgpe/2ml LA PA

CEREBYX 500mgpe/10ml Tier 3

DILANTIN Tier 3

DILANTIN INFATABS Tier 3

DILANTIN-125 Tier 3

fosphenytoin sodium LA

PHENYTEK Tier 3

phenytoin Tier 1

phenytoin sodium LA

phenytoin sodium extended Tier 1

SUCCINIMIDES CELONTIN Tier 3

ethosuximide Tier 1

ZARONTIN Tier 3

VALPROIC ACID DEPAKOTE Tier 3

DEPAKOTE ER Tier 3

DEPAKOTE SPRINKLES Tier 3

divalproex sodium Tier 1

valproate sodium 100mg/ml, 500mg/5ml LA

valproate sodium 250mg/5ml Tier 1

valproic acid Tier 1

ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)

mirtazapine Tier 1

REMERON Tier 3

REMERON SOLTAB Tier 3

ANTIDEPRESSANTS - MISC. APLENZIN Tier 3 QL

bupropion hcl Tier 1


18


FORFIVO XL Tier 3 QL

maprotiline hcl Tier 1

MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM Tier 3 PA

MARPLAN Tier 3

NARDIL Tier 3

PARNATE Tier 3

phenelzine sulfate Tier 1

tranylcypromine sulfate Tier 1

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) CELEXA 10mg Tier 3 QL

CELEXA 20mg, 40mg Tier 3

citalopram hydrobromide SOLN Tier 1

citalopram hydrobromide TABS Tier 1 SEMS

escitalopram oxalate Tier 1

fluoxetine hcl Tier 1

FLUOXETINE HYDROCHLORIDE Tier 3

fluvoxamine maleate CP24 Tier 1 QL

fluvoxamine maleate TABS Tier 1

paroxetine hcl TABS Tier 1

paroxetine hcl TB24 Tier 1 QL

PAXIL SUSP Tier 2

PAXIL TABS Tier 3

PAXIL CR Tier 3 QL

PEXEVA Tier 3

sertraline hcl Tier 1

ZOLOFT Tier 3

SEROTONIN MODULATORS nefazodone hcl Tier 1

trazodone hcl Tier 1

TRINTELLIX Tier 2 ST

VIIBRYD Tier 2 ST

VIIBRYD STARTER PACK Tier 2 ST

SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) DESVENLAFAXINE ER Tier 3

desvenlafaxine succinate Tier 1

duloxetine hcl Tier 1

FETZIMA Tier 3

FETZIMA TITRATION PACK Tier 3

PRISTIQ Tier 3

venlafaxine hcl CP24 37.5mg Tier 1 QL

venlafaxine hcl CP24 75mg, 150mg Tier 1


19


venlafaxine hcl TABS Tier 1

venlafaxine hcl TB24 Tier 1

TRICYCLIC AGENTS amitriptyline hcl Tier 1

amoxapine Tier 1

ANAFRANIL Tier 3

clomipramine hcl Tier 1

desipramine hcl Tier 1

doxepin hcl Tier 1

imipramine hcl Tier 1

imipramine pamoate Tier 1

NORPRAMIN Tier 3

nortriptyline hcl Tier 1

PAMELOR Tier 3

protriptyline hcl Tier 1

trimipramine maleate Tier 1

ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS

acarbose Tier 1

miglitol Tier 1

PRECOSE Tier 3

ANTIDIABETIC - AMYLIN ANALOGS SYMLINPEN 60 Tier 2

SYMLINPEN 120 Tier 2

ANTIDIABETIC COMBINATIONS ACTOPLUS MET Tier 3

DUETACT Tier 3

glipizide-metformin hcl Tier 1

glyburide-metformin Tier 1

GLYXAMBI Tier 3 ST

JANUMET Tier 2 ST, QL

JANUMET XR Tier 2 ST, QL

KOMBIGLYZE XR Tier 3 PA; MNPA

pioglitazone hcl-glimepiride Tier 1

pioglitazone hcl-metformin hcl Tier 1

QTERN Tier 3 PA

SOLIQUA 100/33 Tier 3 ST

XIGDUO XR Tier 2 ST

XULTOPHY 100/3.6 Tier 3 ST

BIGUANIDES metformin hcl SOLN Tier 1 PA

metformin hcl TABS; TB24 Tier 1 SEMS


20


RIOMET Tier 3 PA

DIABETIC OTHER BAQSIMI ONE PACK Tier 2 QL

BAQSIMI TWO PACK Tier 2 QL

glucagon (rdna) Tier 1 QL

GLUCAGON EMERGENCY KIT Tier 2 QL

GLUCAGON EMERGENCY KIT FO Tier 2 QL

GVOKE HYPOPEN 1-PACK Tier 2 QL

GVOKE HYPOPEN 2-PACK Tier 2 QL

GVOKE PFS Tier 2 QL

PROGLYCEM Tier 3 PA

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS alogliptin benzoate Tier 3 PA; MNPA

JANUVIA Tier 2 ST, QL

DOPAMINE RECEPTOR AGONISTS - ANTIDIABETIC CYCLOSET Tier 3

INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) ADLYXIN Tier 3 PA; MNPA

ADLYXIN STARTER PACK Tier 3 PA; MNPA

OZEMPIC Tier 2 ST

RYBELSUS Tier 2 ST

TRULICITY Tier 2 ST

VICTOZA Tier 2 ST, QL

INSULIN BASAGLAR KWIKPEN Tier 2

FIASP Tier 2

FIASP FLEXTOUCH Tier 2

FIASP PENFILL Tier 2

HUMULIN R U-500 (CONCENTR Tier 2

HUMULIN R U-500 KWIKPEN Tier 3

INSULIN ASPART PROTAMINE/ Tier 2

LEVEMIR Tier 2

LEVEMIR FLEXTOUCH Tier 2

NOVOLIN 70/30 Tier 1

NOVOLIN 70/30 FLEXPEN Tier 2 QL

NOVOLIN N Tier 1

NOVOLIN N FLEXPEN Tier 2 QL

NOVOLIN R Tier 1

NOVOLIN R FLEXPEN Tier 2 QL

NOVOLOG Tier 1

NOVOLOG FLEXPEN Tier 2

NOVOLOG MIX 70/30 Tier 1


21


NOVOLOG MIX 70/30 PREFILL Tier 2

NOVOLOG PENFILL Tier 2

TRESIBA Tier 2

TRESIBA FLEXTOUCH Tier 2

INSULIN SENSITIZING AGENTS ACTOS Tier 3

AVANDIA Tier 2

pioglitazone hcl Tier 1

MEGLITINIDE ANALOGUES nateglinide Tier 1

repaglinide Tier 1

STARLIX Tier 3

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA Tier 2 ST

JARDIANCE Tier 2 ST

SULFONYLUREAS AMARYL Tier 3

glimepiride Tier 1

glipizide Tier 1 SEMS

GLUCOTROL Tier 3

GLUCOTROL XL Tier 3

glyburide Tier 1 SEMS

glyburide micronized Tier 1

GLYNASE Tier 3

tolbutamide Tier 1

ANTIDIARRHEAL/PROBIOTIC AGENTS ANTIDIARRHEAL - CHLORIDE CHANNEL ANTAGONISTS

MYTESI Tier 3 PA

ANTIPERISTALTIC AGENTS diphenoxylate w/ atropine Tier 1

LOMOTIL Tier 3

MOTOFEN Tier 2

ANTIDOTES AND SPECIFIC ANTAGONISTS ANTIDOTES - CHELATING AGENTS

CHEMET Tier 2

deferasirox Tier 1 SP, PA

FERRIPROX SOLN Tier 4 SP, PA

FERRIPROX TABS Tier 4 SP, PA

FERRIPROX TWICE-A-DAY Tier 4 SP, PA

JADENU Tier 4 SP, PA

JADENU SPRINKLE Tier 4 SP, PA


22


ANTIDOTES AND SPECIFIC ANTAGONISTS ACETADOTE LA

acetylcysteine (antidote) LA

deferoxamine mesylate LA SP, PA

DESFERAL LA SP, PA

VISTOGARD Tier 4 SP, PA

BENZODIAZEPINE ANTAGONISTS flumazenil LA PA

OPIOID ANTAGONISTS naloxone hcl Tier 1

naltrexone hcl Tier 1

NARCAN Tier 1

VIVITROL LA

ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS

ALOXI LA PA

ANZEMET Tier 2

granisetron hcl SOLN LA

granisetron hcl TABS Tier 1

ondansetron Tier 1

ondansetron hcl SOLN 4mg/2ml LA

ondansetron hcl SOLN 4mg/5ml, 40mg/20ml

Tier 1

ondansetron hcl TABS Tier 1

palonosetron hcl LA

SANCUSO Tier 3 PA

SUSTOL Tier 2

ZOFRAN Tier 3

ZUPLENZ Tier 3 PA

ANTIEMETICS - ANTICHOLINERGIC DIMENHYDRINATE Tier 1

meclizine hcl CHEW Tier 1

meclizine hcl TABS 12.5mg, 25mg Tier 1

meclizine hcl TABS 25mg Tier 1

MECLIZINE HYDROCHLORIDE Tier 3

scopolamine Tier 1

TIGAN CAPS Tier 3

TIGAN SOLN LA

TRANSDERM SCOP Tier 3

TRANSDERM-SCOP Tier 3

trimethobenzamide hcl Tier 1


23


ANTIEMETICS - MISCELLANEOUS AKYNZEO CAPS Tier 3 PA

AKYNZEO SOLN; SOLR LA PA

BONJESTA Tier 3 PA

dronabinol Tier 1

MARINOL Tier 3

SYNDROS Tier 3

SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS aprepitant Tier 1 QL

CINVANTI LA

EMEND CAPS Tier 3 QL

EMEND SUSR Tier 2

fosaprepitant dimeglumine LA

VARUBI Tier 3 PA

ANTIFUNGALS ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS

(ECHINOCANDINS) caspofungin acetate LA

ERAXIS LA

ANTIFUNGALS ABELCET LA

AMBISOME LA

amphotericin b LA

ANCOBON Tier 3

flucytosine Tier 1

griseofulvin microsize Tier 1

griseofulvin ultramicrosize Tier 1

nystatin Tier 1

terbinafine hcl Tier 1

IMIDAZOLE-RELATED ANTIFUNGALS CRESEMBA CAPS Tier 3

CRESEMBA SOLR LA PA

DIFLUCAN Tier 3

fluconazole Tier 1

fluconazole in nacl LA

itraconazole Tier 1

ketoconazole Tier 1

NOXAFIL SOLN LA PA

NOXAFIL SUSP Tier 2

POSACONAZOLE Tier 1

SPORANOX Tier 3

SPORANOX PULSEPAK Tier 3


24


TOLSURA Tier 3 PA

VFEND Tier 3

VFEND IV LA PA

voriconazole SOLR LA PA

voriconazole SUSR; TABS Tier 1

ANTIHISTAMINES ANTIHISTAMINES - ETHANOLAMINES

carbinoxamine maleate SOLN Tier 1

carbinoxamine maleate TABS 4mg Tier 1

carbinoxamine maleate TABS 6mg Tier 3

clemastine fumarate 1.34mg Tier 1

clemastine fumarate 2.68mg Tier 1

diphenhydramine hcl CAPS Tier 1

diphenhydramine hcl ELIX 12.5mg/5ml Tier 1

diphenhydramine hcl ELIX 12.5mg/5ml Tier 1

diphenhydramine hcl SOLN LA

KARBINAL ER Tier 3

RYVENT Tier 3

ANTIHISTAMINES - NON-SEDATING desloratadine Tier 1

loratadine Tier 1

ANTIHISTAMINES - PHENOTHIAZINES PHENERGAN Tier 3

promethazine hcl SOLN LA

promethazine hcl SUPP; SYRP; TABS Tier 1

ANTIHISTAMINES - PIPERIDINES cyproheptadine hcl Tier 1

ANTIHYPERLIPIDEMICS ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORS

NEXLETOL Tier 2 PA

ANTIHYPERLIPIDEMICS - COMBINATIONS ezetimibe-simvastatin Tier 1

NEXLIZET Tier 2 PA

VYTORIN Tier 3

ANTIHYPERLIPIDEMICS - MISC. LOVAZA Tier 3 QL

omega-3-acid ethyl esters Tier 1 QL

VASCEPA Tier 2

BILE ACID SEQUESTRANTS cholestyramine Tier 1

cholestyramine light Tier 1


25


colesevelam hcl Tier 1

COLESTID Tier 3

COLESTID FLAVORED Tier 3

colestipol hcl Tier 1

QUESTRAN Tier 3

QUESTRAN LIGHT Tier 3

WELCHOL Tier 3

FIBRIC ACID DERIVATIVES ANTARA Tier 3

choline fenofibrate Tier 1

fenofibrate Tier 1

fenofibrate micronized Tier 1

fenofibric acid 35mg, 105mg Tier 1

fenofibric acid 105mg Tier 3

FENOGLIDE Tier 3

FIBRICOR Tier 3

gemfibrozil Tier 1

LIPOFEN Tier 3

LOPID Tier 3

TRICOR Tier 3

TRILIPIX Tier 3

HMG COA REDUCTASE INHIBITORS ALTOPREV Tier 2

atorvastatin calcium 10mg, 20mg ACA AL; SEMS

atorvastatin calcium 40mg, 80mg Tier 1 SEMS

FLOLIPID Tier 3 PA, QL

fluvastatin sodium ACA AL

LESCOL XL Tier 3

LIPITOR Tier 3

lovastatin ACA AL; SEMS

PRAVACHOL Tier 3 QL

pravastatin sodium ACA QL; AL

rosuvastatin calcium 5mg, 10mg ACA QL; AL

rosuvastatin calcium 20mg, 40mg Tier 1 QL

simvastatin 5mg, 10mg, 20mg, 40mg ACA AL; SEMS

simvastatin 80mg Tier 1 SEMS

ZOCOR Tier 3 QL

INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ezetimibe Tier 1

ZETIA Tier 3


26


MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP)

INHIBITORS JUXTAPID Tier 4 SP, PA

NICOTINIC ACID DERIVATIVES niacin (antihyperlipidemic) Tier 1

NIASPAN Tier 3

PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS PRALUENT Tier 3 PA

REPATHA Tier 3 PA

REPATHA PUSHTRONEX SYSTEM Tier 3 PA

REPATHA SURECLICK Tier 3 PA

ANTIHYPERTENSIVES ACE INHIBITORS

ACCUPRIL Tier 3

benazepril hcl Tier 1

captopril Tier 1

enalapril maleate Tier 1

fosinopril sodium Tier 1

lisinopril Tier 1 SEMS

LOTENSIN Tier 3

moexipril hcl Tier 1

perindopril erbumine Tier 1

PRINIVIL Tier 3

QBRELIS Tier 3

quinapril hcl Tier 1

ramipril Tier 1

trandolapril Tier 1

VASOTEC Tier 3

ZESTRIL Tier 3

AGENTS FOR PHEOCHROMOCYTOMA DIBENZYLINE Tier 3 PA

phenoxybenzamine hcl Tier 1 PA

PHENTOLAMINE MESYLATE Tier 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND Tier 3

AVAPRO Tier 3

candesartan cilexetil Tier 1

COZAAR Tier 3

DIOVAN Tier 3

EDARBI Tier 3

irbesartan Tier 1

losartan potassium Tier 1


27


MICARDIS Tier 3

olmesartan medoxomil Tier 1

telmisartan Tier 1

valsartan Tier 1

ANTIADRENERGIC ANTIHYPERTENSIVES CARDURA Tier 3

CATAPRES-TTS-1 Tier 3



clonidine Tier 1

clonidine hcl Tier 1

doxazosin mesylate Tier 1

guanfacine hcl Tier 1

methyldopa Tier 1

MINIPRESS Tier 3

prazosin hcl Tier 1

terazosin hcl Tier 1

ANTIHYPERTENSIVE COMBINATIONS ACCURETIC Tier 3

amlodipine besylate-benazepril hcl Tier 1

amlodipine besylate-olmesartan medoxomil Tier 1

amlodipine besylate-valsartan Tier 1

amlodipine-valsartan-hydrochlorothiazide Tier 1

ATACAND HCT Tier 3

atenolol & chlorthalidone Tier 1

AVALIDE Tier 3

AZOR Tier 3

benazepril & hydrochlorothiazide Tier 1

bisoprolol & hydrochlorothiazide Tier 1

candesartan cilexetil-hydrochlorothiazide Tier 1

captopril & hydrochlorothiazide Tier 1

DIOVAN HCT Tier 3

DUTOPROL Tier 3

EDARBYCLOR Tier 3

enalapril maleate & hydrochlorothiazide Tier 1

EXFORGE Tier 3

EXFORGE HCT Tier 3

fosinopril sodium & hydrochlorothiazide Tier 1

HYZAAR Tier 3

irbesartan-hydrochlorothiazide Tier 1

lisinopril & hydrochlorothiazide Tier 1

losartan potassium & hydrochlorothiazide Tier 1


28


LOTENSIN HCT Tier 3

LOTREL Tier 3

methyldopa & hydrochlorothiazide Tier 1

metoprolol & hydrochlorothiazide Tier 1

MICARDIS HCT Tier 3

olmesartan medoxomil-amlodipine-hydrochlorothiazide

Tier 1

olmesartan medoxomil-hydrochlorothiazide Tier 1

PRESTALIA Tier 3

propranolol & hydrochlorothiazide Tier 1

quinapril-hydrochlorothiazide Tier 1

TEKTURNA HCT Tier 2

telmisartan-amlodipine Tier 1

telmisartan-hydrochlorothiazide Tier 1

TENORETIC 50 Tier 3

TENORETIC 100 Tier 3

trandolapril-verapamil hcl Tier 1

TRIBENZOR Tier 3

TWYNSTA Tier 3

valsartan-hydrochlorothiazide Tier 1

VASERETIC Tier 3

ZESTORETIC Tier 3

ZIAC Tier 3

ANTIHYPERTENSIVES - MISC. VECAMYL Tier 3

DIRECT RENIN INHIBITORS aliskiren fumarate Tier 1

TEKTURNA Tier 3

SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) eplerenone Tier 1

INSPRA Tier 3

VASODILATORS hydralazine hcl TABS Tier 1

minoxidil Tier 1

ANTIMALARIALS ANTIMALARIAL COMBINATIONS

atovaquone-proguanil hcl Tier 1 PA

COARTEM Tier 2

MALARONE Tier 3 PA

ANTIMALARIALS chloroquine phosphate Tier 1

DARAPRIM Tier 2 PA


29


hydroxychloroquine sulfate Tier 1

mefloquine hcl Tier 1

QUALAQUIN Tier 3

quinine sulfate Tier 1

ANTIMYASTHENIC/CHOLINERGIC AGENTS ANTIMYASTHENIC/CHOLINERGIC AGENTS

GUANIDINE HCL Tier 1

MESTINON Tier 3

MESTINON TIMESPAN Tier 3

pyridostigmine bromide Tier 1

ANTIMYCOBACTERIAL AGENTS ANTIMYCOBACTERIAL AGENTS

CAPASTAT SULFATE LA PA

cycloserine Tier 2

ethambutol hcl Tier 1

isoniazid SOLN LA

isoniazid SYRP; TABS Tier 1

MYAMBUTOL Tier 3

MYCOBUTIN Tier 3

PASER Tier 3

PRETOMANID Tier 3 PA

PRIFTIN Tier 3

pyrazinamide Tier 1

rifabutin Tier 1

RIFADIN LA PA

rifampin CAPS Tier 1

rifampin SOLR LA

SIRTURO Tier 3 PA

TRECATOR Tier 3

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKYLATING AGENTS

ALKERAN SOLR LA PA

ALKERAN TABS Tier 3 PA

BELRAPZO LA SP, PA

BENDEKA LA SP, PA

BICNU LA PA

BUSULFEX LA PA

carboplatin LA

carmustine LA PA

cisplatin LA

CYCLOPHOSPHAMIDE CAPS Tier 1

CYCLOPHOSPHAMIDE SOLN LA


30


cyclophosphamide SOLR 1gm, 500mg LA

cyclophosphamide SOLR 2gm Tier 1

GLEOSTINE Tier 3

GLIADEL WAFER LA

IFEX LA PA

ifosfamide SOLN LA PA

ifosfamide SOLR 1gm LA PA

IFOSFAMIDE SOLR 3gm LA PA

LEUKERAN Tier 2 PA

melphalan Tier 1 PA

melphalan hcl LA

MYLERAN Tier 2 PA

oxaliplatin LA

TEMODAR CAPS Tier 4 SP

TEMODAR SOLR LA SP, PA

temozolomide Tier 1 SP

TEPADINA LA PA

thiotepa 15mg Tier 1

thiotepa 100mg LA PA

TREANDA LA SP, PA

YONDELIS LA SP, PA

ZEPZELCA LA SP, PA

ANTIMETABOLITES ALIMTA LA

ARRANON LA

azacitidine Tier 1 SP

capecitabine Tier 1 SP

cladribine LA

clofarabine LA PA

cytarabine LA

DACOGEN Tier 4 SP

decitabine LA SP

floxuridine LA

fludarabine phosphate LA

fluorouracil LA

FOLOTYN LA SP, PA

gemcitabine hcl LA

GEMCITABINE HYDROCHLORIDE LA

mercaptopurine Tier 1

methotrexate sodium Tier 1

ONUREG Tier 4 SP, PA, QL

PURIXAN Tier 4 SP, PA


31


TABLOID Tier 2 PA

TREXALL Tier 3 PA

VIDAZA LA SP, PA

XATMEP Tier 3

XELODA Tier 4 SP

ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS CYRAMZA LA SP, PA

MVASI LA SP

ZALTRAP LA SP, PA

ZIRABEV LA SP

ANTINEOPLASTIC - ANTIBODIES ADCETRIS LA SP, PA

ARZERRA LA SP, PA

BAVENCIO LA SP, PA

BESPONSA LA SP, PA

BLINCYTO LA SP, PA

CAMPATH Tier 3

DARZALEX LA SP, PA

EMPLICITI LA SP, PA

ENHERTU LA SP, PA

ERBITUX LA SP, PA

GAZYVA LA SP, PA

HERZUMA LA SP, PA

IMFINZI LA SP, PA

KADCYLA LA SP, PA

KANJINTI LA SP, PA

KEYTRUDA LA SP, PA

LUMOXITI LA SP, PA

MONJUVI LA SP, PA

MYLOTARG LA SP, PA

ONTRUZANT LA SP, PA

OPDIVO LA SP, PA

PADCEV LA SP, PA

PERJETA LA SP, PA

POLIVY LA SP, PA

PORTRAZZA LA SP, PA

POTELIGEO LA SP, PA

RITUXAN LA SP, PA

RUXIENCE LA SP, PA

SARCLISA LA SP, PA

TECENTRIQ LA SP, PA

TRAZIMERA LA SP, PA


32


TRODELVY LA SP, PA

TRUXIMA LA SP, PA

UNITUXIN LA SP, PA

VECTIBIX LA SP, PA

YERVOY LA SP, PA

ANTINEOPLASTIC - BCL-2 INHIBITORS VENCLEXTA Tier 4 SP, PA

VENCLEXTA STARTING PACK Tier 4 SP, PA

ANTINEOPLASTIC - CELLULAR IMMUNOTHERAPY TECARTUS LA SP, PA

ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS DAURISMO Tier 4 SP, PA

ERIVEDGE Tier 4 SP, PA

ODOMZO Tier 4 SP, PA

ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS abiraterone acetate Tier 1 SP, PA; GENDER

anastrozole Tier 1

ARIMIDEX Tier 3 PA

AROMASIN Tier 3

bicalutamide Tier 1 PA

CASODEX Tier 3 PA

ELIGARD Tier 2 SP

EMCYT Tier 2 PA

ERLEADA Tier 2 SP, PA

exemestane Tier 1

FARESTON Tier 3 PA

FASLODEX LA

FEMARA Tier 3 PA

FIRMAGON Tier 4 SP

flutamide Tier 1 PA

fulvestrant LA

hydroxyprogesterone caproate (antineoplastic)

LA PA

letrozole Tier 1

leuprolide acetate Tier 1 SP

LUPRON DEPOT (1-MONTH) Tier 2 SP




LYSODREN Tier 2 PA

megestrol acetate Tier 1

NILANDRON Tier 3 PA


33


NUBEQA Tier 2 SP, PA

SOLTAMOX Tier 3 PA

tamoxifen citrate Tier 1

TRELSTAR MIXJECT LA SP, PA

VANTAS LA SP, PA

XTANDI Tier 2 SP, PA

YONSA Tier 2 SP, PA; GENDER

ZOLADEX LA SP, PA

ZYTIGA Tier 4 SP, PA; GENDER

ANTINEOPLASTIC - IMMUNOMODULATORS POMALYST Tier 4 SP, PA

ANTINEOPLASTIC - XPO1 INHIBITORS XPOVIO 40 MG ONCE WEEKLY Tier 4 SP, PA

XPOVIO 40 MG TWICE WEEKLY Tier 4 SP, PA

XPOVIO 60 MG ONCE WEEKLY Tier 4 SP, PA





ANTINEOPLASTIC ANTIBIOTICS bleomycin sulfate LA

COSMEGEN LA PA

dactinomycin LA PA

daunorubicin hcl LA

DOXIL LA PA

doxorubicin hcl LA

doxorubicin hcl liposomal LA PA

ELLENCE LA

epirubicin hcl LA

IDAMYCIN PFS LA PA

idarubicin hcl LA PA

JELMYTO LA SP, PA

mitomycin LA

mitoxantrone hcl LA SP

ANTINEOPLASTIC COMBINATIONS DARZALEX FASPRO LA SP, PA

HERCEPTIN HYLECTA LA SP, PA

INQOVI Tier 4 SP, PA

KISQALI FEMARA 200 DOSE Tier 4 SP, PA



LONSURF Tier 4 SP, PA


34


PHESGO LA SP, PA

RITUXAN HYCELA Tier 4 SP, PA

VYXEOS LA SP, PA

ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR Tier 4 SP, PA

AFINITOR DISPERZ Tier 4 SP, PA

ALECENSA Tier 4 SP, PA

ALIQOPA LA SP, PA

ALUNBRIG Tier 4 SP, PA

AYVAKIT Tier 4 SP, PA

BALVERSA Tier 4 SP, PA

BELEODAQ LA SP, PA

BORTEZOMIB LA SP, PA

BOSULIF 100mg, 500mg LA SP, PA

BOSULIF 400mg Tier 4 SP, PA

BRAFTOVI Tier 4 SP, PA

BRUKINSA Tier 4 SP, PA

CABOMETYX Tier 4 SP, PA

CALQUENCE Tier 4 SP, PA

CAPRELSA Tier 4 SP, PA

COMETRIQ Tier 4 SP, PA

COPIKTRA Tier 4 SP, PA

COTELLIC Tier 4 SP, PA

erlotinib hcl Tier 1 SP, PA

everolimus Tier 1 SP, PA

FARYDAK Tier 4 SP

GAVRETO Tier 4 SP, PA

GILOTRIF Tier 4 SP, PA

IBRANCE Tier 2 SP, PA

ICLUSIG Tier 4 SP, PA

IDHIFA Tier 4 SP, PA

imatinib mesylate Tier 1 SP, PA

IMBRUVICA CAPS Tier 4 SP, PA, QL

IMBRUVICA TABS 140mg Tier 3 SP, PA, QL

IMBRUVICA TABS 280mg, 420mg, 560mg Tier 4 SP, PA, QL

INLYTA Tier 4 SP, PA

INREBIC Tier 4 SP, PA

IRESSA Tier 4 SP, PA

ISTODAX (OVERFILL) LA SP, PA

JAKAFI Tier 4 SP, PA

KOSELUGO Tier 4 SP, PA

KYPROLIS LA SP, PA


35


lapatinib ditosylate Tier 1 SP, PA

LENVIMA 4 MG DAILY DOSE Tier 4 SP, PA



LENVIMA 12MG DAILY DOSE Tier 4 SP, PA





LORBRENA Tier 4 SP, PA

LYNPARZA Tier 2 SP, PA

MEKINIST Tier 4 SP, PA

MEKTOVI Tier 4 SP, PA

NERLYNX Tier 4 SP, PA

NEXAVAR Tier 2 SP, PA

NINLARO Tier 4 SP, PA

PEMAZYRE Tier 4 SP, PA

PIQRAY 200MG DAILY DOSE Tier 4 SP, PA



QINLOCK Tier 4 SP, PA

RETEVMO Tier 4 SP, PA

ROMIDEPSIN LA SP, PA

ROZLYTREK Tier 4 SP, PA

RUBRACA Tier 2 SP, PA

RYDAPT Tier 4 SP, PA

SPRYCEL Tier 4 SP, PA

STIVARGA Tier 4 SP, PA

SUTENT Tier 2 SP, PA

TABRECTA Tier 4 SP, PA

TAFINLAR Tier 4 SP, PA

TAGRISSO Tier 4 SP, PA

TALZENNA Tier 4 SP, PA, QL

TARCEVA Tier 4 SP, PA

TASIGNA 50mg Tier 4 SP, PA, QL

TASIGNA 150mg, 200mg Tier 4 SP, PA

TAZVERIK Tier 4 SP, PA

temsirolimus LA SP

TUKYSA Tier 4 SP, PA

TURALIO Tier 4 SP, PA

TYKERB Tier 4 SP, PA

VELCADE LA SP, PA

VERZENIO Tier 2 SP, PA


36


VITRAKVI Tier 4 SP, PA

VIZIMPRO Tier 4 SP, PA, QL

VOTRIENT Tier 4 SP, PA

XALKORI Tier 4 SP, PA

XOSPATA Tier 4 SP, PA

ZEJULA Tier 2 SP, PA

ZELBORAF Tier 4 SP, PA

ZOLINZA Tier 4 SP, PA, QL

ZYDELIG Tier 4 SP, PA

ZYKADIA Tier 4 SP, PA

ANTINEOPLASTIC ENZYMES ASPARLAS LA SP, PA

ERWINAZE LA SP, PA

ONCASPAR LA SP, PA

ANTINEOPLASTIC RADIOPHARMACEUTICALS LUTATHERA LA SP, PA

ANTINEOPLASTICS MISC. ACTIMMUNE Tier 2 SP, PA

ALFERON N LA SP, PA

arsenic trioxide LA PA

bexarotene Tier 1 SP, PA

dacarbazine LA

ELZONRIS LA SP, PA

HYDREA Tier 3

hydroxyurea Tier 1

INTRON A Tier 2 SP, PA

MATULANE Tier 2 SP, PA

NIPENT LA PA

PHOTOFRIN LA

PROLEUKIN LA SP

SYNRIBO LA SP, PA

TARGRETIN CAPS Tier 4 SP, PA

tretinoin (chemotherapy) Tier 1

TRISENOX LA PA

CHEMOTHERAPY ADJUNCTS ELITEK LA PA

KEPIVANCE LA

CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS dexrazoxane hcl LA

KHAPZORY LA SP

leucovorin calcium SOLN; TABS Tier 1

leucovorin calcium SOLR LA


37


levoleucovorin calcium 175mg/17.5ml LA SP, PA

levoleucovorin calcium 250mg/25ml Tier 1 SP, PA

mesna LA PA

MESNEX SOLN LA PA

MESNEX TABS Tier 2 PA

TOTECT LA

VORAXAZE LA SP, PA

MITOTIC INHIBITORS ABRAXANE LA PA

DOCETAXEL CONC 20mg/ml, 80mg/4ml LA

docetaxel CONC 20mg/ml, 80mg/4ml, 160mg/8ml

LA

docetaxel SOLN 20mg/2ml LA

DOCETAXEL SOLN 80mg/8ml, 160mg/16ml

LA

ETOPOPHOS LA

etoposide CAPS Tier 1

etoposide SOLN LA

HALAVEN LA SP, PA

IXEMPRA KIT LA SP, PA

JEVTANA LA SP, PA

NAVELBINE LA PA

paclitaxel LA

TENIPOSIDE LA

vinblastine sulfate LA

vincristine sulfate LA

vinorelbine tartrate LA

TOPOISOMERASE I INHIBITORS CAMPTOSAR 40mg/2ml, 100mg/5ml LA PA

CAMPTOSAR 300mg/15ml LA

HYCAMTIN Tier 4 SP, PA

irinotecan hcl 40mg/2ml, 100mg/5ml, 300mg/15ml

LA

irinotecan hcl 500mg/25ml LA PA

ONIVYDE LA SP, PA

topotecan hcl LA

ANTIPARKINSON AND RELATED THERAPY AGENTS ANTIPARKINSON ADJUNCTIVE THERAPY

carbidopa Tier 1

LODOSYN Tier 3

ANTIPARKINSON ANTICHOLINERGICS benztropine mesylate SOLN LA


38


benztropine mesylate TABS Tier 1

COGENTIN LA PA

trihexyphenidyl hcl Tier 1

ANTIPARKINSON COMT INHIBITORS COMTAN Tier 3

entacapone Tier 1

TASMAR Tier 3

tolcapone Tier 1

ANTIPARKINSON DOPAMINERGICS amantadine hcl Tier 1

APOKYN Tier 2 SP

bromocriptine mesylate Tier 1

carbidopa-levodopa Tier 1

carbidopa-levodopa-entacapone Tier 1

DUOPA Tier 4 SP, PA

KYNMOBI Tier 4 SP, PA

MIRAPEX Tier 3

MIRAPEX ER Tier 3

NEUPRO Tier 3

pramipexole dihydrochloride Tier 1

ropinirole hydrochloride Tier 1

RYTARY Tier 3 PA

SINEMET Tier 3

STALEVO 50 Tier 3

STALEVO 75 Tier 3

STALEVO 100 Tier 3

STALEVO 125 Tier 3

STALEVO 150 Tier 3

STALEVO 200 Tier 3

ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS AZILECT Tier 3

rasagiline mesylate Tier 1

selegiline hcl Tier 1 PA

XADAGO Tier 3 PA

ZELAPAR Tier 3 PA

ANTIPSYCHOTICS/ANTIMANIC AGENTS ANTIMANIC AGENTS

LITHIUM Tier 1

lithium carbonate Tier 1

LITHOBID Tier 3

ANTIPSYCHOTICS - MISC. CAPLYTA Tier 3 ST


39


EQUETRO Tier 3

GEODON CAPS Tier 3 ST

GEODON SOLR LA ST

LATUDA Tier 3 ST

NUPLAZID Tier 4 SP, PA

VRAYLAR Tier 3 ST

ziprasidone hcl Tier 1

BENZISOXAZOLES FANAPT Tier 3 ST

FANAPT TITRATION PACK Tier 3 ST

INVEGA SUSTENNA LA PA

INVEGA TRINZA LA PA

paliperidone Tier 1 ST

PERSERIS LA QL

RISPERDAL Tier 3

RISPERDAL CONSTA LA

risperidone Tier 1

BUTYROPHENONES HALDOL DECANOATE 50 LA

HALDOL DECANOATE 100 LA

haloperidol Tier 1

haloperidol decanoate LA

haloperidol lactate CONC Tier 1

haloperidol lactate SOLN LA

DIBENZAPINES ADASUVE Tier 3

asenapine maleate Tier 1 ST

clozapine Tier 1

CLOZARIL Tier 3

loxapine succinate Tier 1

olanzapine SOLR LA PA, QL

olanzapine TABS; TBDP Tier 1 QL

quetiapine fumarate Tier 1

SAPHRIS Tier 3 ST

SECUADO Tier 3 ST

SEROQUEL Tier 3 ST

SEROQUEL XR Tier 3

VERSACLOZ Tier 3

ZYPREXA SOLR LA PA, QL

ZYPREXA TABS Tier 3 QL

ZYPREXA RELPREVV LA PA

ZYPREXA ZYDIS Tier 3 QL


40


DIHYDROINDOLONES molindone hcl Tier 1

PHENOTHIAZINES chlorpromazine hcl SOLN 25mg/ml Tier 1

CHLORPROMAZINE HCL SOLN 50mg/2ml Tier 1

chlorpromazine hcl TABS Tier 1

fluphenazine decanoate LA

fluphenazine hcl CONC; ELIX; TABS Tier 1

fluphenazine hcl SOLN LA

perphenazine Tier 1

prochlorperazine Tier 1

prochlorperazine edisylate LA

prochlorperazine maleate Tier 1

thioridazine hcl Tier 1

trifluoperazine hcl Tier 1

QUINOLINONE DERIVATIVES ABILIFY Tier 3 ST

ABILIFY MAINTENA PRSY 300mg LA

ABILIFY MAINTENA PRSY 400mg Tier 3

ABILIFY MAINTENA SRER LA

aripiprazole SOLN; TABS Tier 1

aripiprazole TBDP Tier 1 PA

ARISTADA LA

ARISTADA INITIO LA

REXULTI Tier 3 ST

THIOXANTHENES thiothixene Tier 1

ANTISEPTICS & DISINFECTANTS ANTISEPTIC COMBINATIONS

IV PREP WIPES Tier 2

MICROCLENS WIPES Tier 2

UNI-SOLVE Tier 2

CHLORINE ANTISEPTICS CHLORHEXIDINE GLUCONATE Tier 3

ANTIVIRALS ANTIRETROVIRALS

abacavir sulfate Tier 1 SP

abacavir sulfate-lamivudine Tier 1 SP

abacavir sulfate-lamivudine-zidovudine Tier 1 SP

APTIVUS Tier 4 SP

atazanavir sulfate Tier 1 SP


41


BIKTARVY Tier 2 SP

CIMDUO Tier 2 SP

CRIXIVAN Tier 4 SP

DELSTRIGO Tier 4 SP

DESCOVY Tier 2 SP

DOVATO Tier 2 SP

EDURANT Tier 4 SP

efavirenz Tier 1 SP

efavirenz-lamivudine-tenofovir disoproxil fumarate

Tier 2 SP

emtricitabine Tier 2 SP

emtricitabine-tenofovir disoproxil fumarate Tier 1 SP

EMTRIVA Tier 2 SP

EPZICOM Tier 4 SP

EVOTAZ Tier 4 SP

fosamprenavir calcium Tier 1 SP

FUZEON Tier 4 SP

GENVOYA Tier 2 SP

INTELENCE Tier 2 SP

INVIRASE Tier 4 SP

ISENTRESS Tier 2 SP

ISENTRESS HD Tier 2 SP

JULUCA Tier 4 SP

KALETRA Tier 4 SP

lamivudine Tier 1 SP

lamivudine-zidovudine Tier 1 SP

LEXIVA Tier 4 SP

lopinavir-ritonavir Tier 1 SP

nevirapine Tier 1 SP

NORVIR Tier 4 SP

ODEFSEY Tier 2 SP

PIFELTRO Tier 4 SP

PREZCOBIX Tier 2 SP

PREZISTA Tier 2 SP

RETROVIR Tier 4 SP

RETROVIR IV INFUSION LA SP

REYATAZ Tier 4 SP

ritonavir Tier 1 SP

RUKOBIA Tier 4 SP, PA

SELZENTRY SOLN Tier 4 SP

SELZENTRY TABS 25mg, 75mg Tier 4 SP, QL

SELZENTRY TABS 150mg, 300mg Tier 4 SP

SUSTIVA Tier 4 SP


42


SYMFI Tier 2 SP

SYMFI LO Tier 2 SP

SYMTUZA Tier 4 SP

TEMIXYS Tier 2 SP

tenofovir disoproxil fumarate Tier 1 SP

TIVICAY Tier 4 SP

TIVICAY PD Tier 4 SP

TRIUMEQ Tier 2 SP

TRIZIVIR Tier 4 SP

TROGARZO LA SP, PA

TRUVADA Tier 4 SP

TYBOST Tier 4 SP

VIRACEPT Tier 4 SP

VIRAMUNE Tier 4 SP

VIRAMUNE XR Tier 4 SP

VIREAD Tier 4 SP

zidovudine Tier 1 SP

CMV AGENTS cidofovir LA

FOSCAVIR LA

ganciclovir sodium LA

PREVYMIS Tier 3 ST

VALCYTE Tier 3

valganciclovir hcl Tier 1

HEPATITIS AGENTS adefovir dipivoxil Tier 1 SP

BARACLUDE Tier 4 SP

entecavir Tier 1 SP

EPIVIR HBV Tier 4 SP

HEPSERA Tier 4 SP

lamivudine (hbv) Tier 1 SP

MAVYRET Tier 2 SP, PA

PEGASYS 180mcg/0.5ml Tier 4 SP

PEGASYS 180mcg/ml Tier 4 SP, PA, QL

PEGINTRON Tier 2 SP

ribavirin (hepatitis c) Tier 1 SP

sofosbuvir/velpatasvir Tier 2 SP, PA

VEMLIDY Tier 4 SP

HERPES AGENTS acyclovir Tier 1

acyclovir sodium LA

famciclovir Tier 1


43


SITAVIG Tier 3

valacyclovir hcl Tier 1

ZOVIRAX Tier 3

INFLUENZA AGENTS oseltamivir phosphate Tier 1

RELENZA DISKHALER Tier 2

rimantadine hydrochloride Tier 1

TAMIFLU Tier 3

XOFLUZA Tier 3 QL

RESPIRATORY SYNCYTIAL VIRUS (RSV) AGENTS VIRAZOLE Tier 3

BETA BLOCKERS ALPHA-BETA BLOCKERS

carvedilol Tier 1 SEMS

carvedilol phosphate Tier 1

COREG Tier 3

COREG CR Tier 3

labetalol hcl Tier 1

BETA BLOCKERS CARDIO-SELECTIVE acebutolol hcl Tier 1

atenolol Tier 1 SEMS

betaxolol hcl Tier 1

bisoprolol fumarate Tier 1

BYSTOLIC Tier 2

LOPRESSOR Tier 3

metoprolol succinate Tier 1

metoprolol tartrate Tier 1 SEMS

TENORMIN Tier 3

TOPROL XL Tier 3

BETA BLOCKERS NON-SELECTIVE BETAPACE Tier 3

BETAPACE AF Tier 3

CORGARD Tier 3

HEMANGEOL Tier 3

INDERAL LA Tier 3

INDERAL XL Tier 3 PA

INNOPRAN XL Tier 3 PA

nadolol Tier 1

pindolol Tier 1

propranolol hcl Tier 1

sotalol hcl Tier 1

sotalol hcl (afib/afl) Tier 1


44


SOTYLIZE Tier 3

timolol maleate Tier 1

CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS

amlodipine besylate Tier 1

CALAN SR Tier 3

CARDIZEM Tier 3

CARDIZEM CD Tier 3

CARDIZEM LA Tier 3

diltiazem hcl Tier 1 SEMS

diltiazem hcl coated beads Tier 1 SEMS

diltiazem hcl extended release beads Tier 1 SEMS

felodipine Tier 1

isradipine Tier 1

nicardipine hcl Tier 1

nifedipine Tier 1 SEMS

nimodipine Tier 1

nisoldipine Tier 1

NORVASC Tier 3

NYMALIZE Tier 3 PA

PROCARDIA Tier 3

PROCARDIA XL Tier 3

SULAR Tier 3

TIAZAC Tier 3

verapamil hcl CP24 Tier 1

verapamil hcl TABS; TBCR Tier 1 SEMS

VERELAN Tier 3

VERELAN PM Tier 3

CARDIOTONICS CARDIAC GLYCOSIDES

digoxin SOLN .05mg/ml Tier 1

digoxin TABS Tier 1 SEMS

LANOXIN SOLN LA PA

LANOXIN TABS Tier 3

PHOSPHODIESTERASE INHIBITORS milrinone lactate LA PA

milrinone lactate in dextrose LA PA

CARDIOVASCULAR AGENTS - MISC. CARDIOVASCULAR AGENTS MISC. - COMBINATIONS

amlodipine besylate-atorvastatin calcium Tier 1

BIDIL Tier 2

CADUET Tier 3


45


ENTRESTO Tier 2

IMPOTENCE AGENTS CAVERJECT IMPULSE Tier 2 QL; GENDER

EDEX Tier 2 QL; GENDER

sildenafil citrate Tier 1 QL; GENDER

tadalafil Tier 1 QL; GENDER

PROSTAGLANDIN VASODILATORS epoprostenol sodium LA SP, PA

ORENITRAM Tier 4 SP, PA

REMODULIN LA SP, PA

TYVASO Tier 2 SP, PA

TYVASO REFILL Tier 2 SP, PA

TYVASO STARTER Tier 2 SP, PA

VENTAVIS Tier 2 SP

PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR

ANTAGONISTS ambrisentan Tier 1 SP, PA

bosentan Tier 1 SP, PA, QL

OPSUMIT Tier 4 SP, PA

TRACLEER Tier 2 SP, PA

PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS ADCIRCA Tier 4 SP, PA

REVATIO SOLN LA SP, PA

REVATIO SUSR; TABS Tier 4 SP, PA

sildenafil citrate (pulmonary hypertension) SOLN

LA SP, PA

sildenafil citrate (pulmonary hypertension) SUSR; TABS

Tier 1 SP, PA

tadalafil (pulmonary hypertension) Tier 1 SP, PA

PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST UPTRAVI Tier 4 SP, PA

PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE

STIMULATOR ADEMPAS Tier 4 SP, PA

SINUS NODE INHIBITORS CORLANOR Tier 3

TRANSTHYRETIN STABILIZERS VYNDAMAX Tier 4 SP, PA

CEPH

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