your 2015 prescription drug list - oxhp · refill and save program – save money on your copayment...

1

Your 2015Prescription Drug ListEffective January 1, 2015Oxford Connecticut Advantage Three-Tier

1OptumRx is the administrator of your Oxford pharmacy benefit plan.Note: Diabetic supplies and prescription medications may be subject to different cost share arrangements. Please see your Summary of Benefits and Coverage (SBC) for specifics.

Please read: This document contains information about commonly prescribed medications.

For additional information:

Call us toll-free at the phone number on your health plan ID card. TTY users can dial 711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, 1-800-303-6719, 1-888-201-4746, or the phone number on your ID card for help in English and other languages.

Visit oxfordhealth.com, click the Pharmacies & Prescriptions tab and then “Online Pharmacy” to log in to the OptumRx1 website and:

•LocateaparticipatingretailpharmacybyZIPcode. •Lookuppossiblelower-costmedicationalternatives. •Comparemedicationpricingandoptions.

2

Your Prescription Drug List This Prescription Drug List (PDL) outlines the most commonly prescribed medications for certain conditions and organizes them into cost levels, also known as tiers. An important part of the PDL is giving you choices so you and your doctor can choose the best course of treatment for you.

Go to oxfordhealth.com for drug information. Since the PDL may change, we encourage you to visit our website, oxfordhealth.com. This website is the best source for accessing up-to-date information about the medications your pharmacy benefit covers, possible lower-cost options, and cost comparisons.

3

We want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the Prescription Drug List (PDL).

What is a Prescription Drug List (PDL)? This document is a list of commonly prescribed medications. Drugs are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA).

Please note: Where differences are noted between this PDL and your benefit plan documents, the benefit plan documents will rule. Not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or health plan to see what medications are covered under your plan. You may also log on to oxfordhealth.com or call us at the toll-free phone number on your health plan ID card for more information.

How do I use my PDL? When choosing a medication, you and your doctor should consult the PDL. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is a generic or brand-name drug, and if special programs apply. Bring this guide with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically.

If your medication is not listed in this guide, please visit oxfordhealth.com or call us at the toll-free phone number on your health plan ID card. TTY users can dial 711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, 1-800-303-6719, 1-888-201-4746, or the phone number on your ID card for help in English and other languages.

4

What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.

Check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

Tier 1Lowest Cost

Lower-cost drugs. Some brands and generics are also included.

Use Tier 1 drugs for the lowestout-of-pocket costs.

Tier 2Mid-range Cost

Mix of brands and generics.

Use Tier 2 drugs, instead ofTier 3, to help reduce yourout-of-pocket costs.

Tier 3Highest Cost

Mostly higher-cost brand-name drugs.

Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollment and plan materials on oxfordhealth.com, or call us toll-free at the phone number on your health plan ID card for more information about your benefit plan.

When does the PDL change?• Medications may move to a lower tier at any time.

• Medications may move to a higher tier when a generic becomes available.

• Medications may move to a higher tier or be excluded from coverage most often on January 1 or July 1.

When a medication changes tiers, you may have to pay a different amount for that medication.

For the most up-to-date list, call us toll-free at the phone number on your health plan ID card.

5

Programs and LimitsSome medications are noted with letters next to them. The letters refer to our pharmacy benefit programs. Your benefit plan determines how these medications are covered and may differ than what is noted in the PDL. Call us toll-free at the phone number on your ID card if you have any questions about your prescription drug coverage.

EMay be excluded from coverage or subject to prior authorization and/or trial/failure of another medication(s). Lower-cost options are available and covered.

MCMultiple Copayment – More than one month’s worth of medication included in package so additional copayment applies.

NNotification or Precertification (sometimes referred to as preauthorization) required1 – Your doctor is required to provide additional information to us to determine coverage.

RSRefill and Save Program – Save money on your copayment when you refill your prescription on time as prescribed. Program eligibility may vary.

SDPSelect Designated Pharmacy – Must use a lower cost medication at retail or transfer the impacted medication to the mail service pharmacy for in-network coverage.

SLSupply Limit – Amount of medication covered per copayment or in a specific time period.

STStep Therapy – Trial of a lower-cost medication is required before a higher-cost medication is covered.

1Depending on your benefit you may have notification or precertification requirements for select medications.

To learn more about a pharmacy program or to find out if it applies to you, please visit oxfordhealth.com or call us toll-free at the phone number on your health plan ID card. TTY users can dial 711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, 1-800-303-6719, 1-888-201-4746, or the phone number on your ID card for help in English and other languages.

6

Why are some medications excluded from coverage? A medication may be excluded from coverage under your pharmacy benefit when it works the same or similar as another prescription medication or an over-the-counter (OTC) medication.2 There may be other medication options available.

Should I talk to my doctor about over-the-counter (OTC) medications? An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options.

What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand-name medication also makes the generic version.

Is it a generic or brand-name drug?The drug list shows brand-name drugs in bold type (for example, Crestor) and generic drugs in plain type (for example, simvastatin).

What if my doctor writes a prescription for a brand-name medication? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Visit oxfordhealth.com to make sure.

Are you taking a specialty medication? Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit UHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn more.

Please note, not all specialty medications are listed here. If you’re taking a specialty medication that is on Tier 3, call us toll-free at the phone number on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program.

2 This is not applicable for Connecticut Public Sector plans. For Connecticut commercial business, a prescription drug product that is therapeutically equivalent to an over-the counter drug may be covered if it is determined to be medically necessary.

7

What is Mail Service Member Select? Your plan may include a home delivery program called Mail Service Member Select, which encourages you to use the OptumRx® Mail Service Pharmacy for medication you take regularly. Choosing home delivery can help you better manage the medication you take on a regular basis, and may save you time and money.

You can either confirm enrollment in the OptumRx Mail Service Pharmacy or you can disenroll from mail service and continue to fill your maintenance medications at a retail pharmacy. You can get up to two fills at a retail pharmacy before you have to decide. However, please be aware that you must make a decision about whether or not to enroll in Mail Service Member Select.

If you do nothing and continue to fill your medications at a retail pharmacy, you may pay up to 100 percent of your drug cost until you make a decision and take action. You must confirm your decision every year. To learn more, you may log on to oxfordhealth.com or call us toll-free at the phone number on your health plan ID card for more information.

How do I get updated information about my pharmacy benefit?Since the PDL may change during your plan year, we encourage you to visit oxfordhealth.com or call us toll-free at the phone number on your health plan ID card for more current information.

All branded medications are trademarks or registered trademarks of their respective owners.

Oxford HMO products are underwritten by Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc.

©2014 Oxford Health Plans LLC. All rights reserved.

Created November, 2014. January 1, 2015 Prescription Drug List – Oxford Connecticut Advantage Three-Tier CT-14-874

For more information

Call us toll-free at the phone number on your health plan ID card. TTY users can dial 711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, 1-800-303-6719, 1-888-201-4746, or the phone number on your ID card for help in English and other languages.

Or, visit oxfordhealth.com

In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in terms does not affect your benefit coverage.

Medications are categorized by common therapeutic conditions in this PDL for ease of reference only. These categories do not determine coverage for the medication for your condition. Your health plan determines coverage for these medications.

8

Product Name Benefit Tier Notification Supply

LimitStep

TherapySpecialty

Medication

2-DEOXY-D POW -GLUCOSE Tier 38-MOP CAP 10MG Tier 2ABACAV/LAMIV TAB /ZIDOVUD Tier 1 XABACAVIR TAB 300MG Tier 1 XABILIFY DISC TAB 10MG Tier 3 XABILIFY DISC TAB 15MG Tier 3 XABILIFY SOL 1MG/ML Tier 3ABILIFY TAB 10MG Tier 3 XABILIFY TAB 15MG Tier 3 XABILIFY TAB 20MG Tier 3 XABILIFY TAB 2MG Tier 3 XABILIFY TAB 30MG Tier 3 XABILIFY TAB 5MG Tier 3 XACAMPRO CAL TAB 333MG Tier 1ACARBOSE TAB 100MG Tier 1ACARBOSE TAB 25MG Tier 1ACARBOSE TAB 50MG Tier 1ACCOLATE TAB 10MG Tier 3 XACCOLATE TAB 20MG Tier 3 XACCU-CHEK MIS BATTERY Tier 3ACCUPRIL TAB 10MG Tier 3ACCUPRIL TAB 20MG Tier 3ACCUPRIL TAB 40MG Tier 3ACCUPRIL TAB 5MG Tier 3ACCURETIC TAB 10-12.5 Tier 3ACCURETIC TAB 20-12.5 Tier 3ACCURETIC TAB 20-25MG Tier 3ACD/FLUORIDE DRO 0.25MG Tier 1ACE ACD/ALUM SOL 2% OTIC Tier 1ACEBUTOLOL CAP 200MG Tier 1ACEBUTOLOL CAP 400MG Tier 1ACEON TAB 4MG Tier 3ACEON TAB 8MG Tier 3ACETASOL HC SOL OTIC Tier 2ACETAZOLAMID CAP 500MG ER Tier 1ACETAZOLAMID TAB 125MG Tier 1ACETAZOLAMID TAB 250MG Tier 1ACETIC ACID SOL 2% OTIC Tier 1ACETYLCYST SOL 10% Tier 1ACETYLCYST SOL 20% Tier 1ACITRETIN CAP 10MG Tier 1ACITRETIN CAP 17.5MG Tier 1ACITRETIN CAP 25MG Tier 1ACLARO EMU Tier 3ACLARO PD EMU 4% Tier 3

9


LimitStep

TherapySpecialty

Medication

ACLOVATE CRE 0.05% Tier 3ACTEMRA INJ 162/0.9 Tier 3 X X X XACTHAR HP INJ 80UNIT Tier 3 X X XACTICIN CRE 5% Tier 1ACTIGALL CAP 300MG Tier 3ACTIMMUNE INJ 2MU/0.5 Tier 2 X X XACTIVE MEDIC KIT SPECIMEN Tier 1ACTIVE OB CAP Tier 3ACTIVELLA TAB 0.5-0.1 Tier 3ACTIVELLA TAB 1-0.5MG Tier 3ACTONEL TAB 150MG Tier 3 XACTONEL TAB 30MG Tier 3ACTONEL TAB 35MG Tier 3 XACTONEL TAB 5MG Tier 3ACTOPLUS MET TAB 15-500MG Tier 3 XACTOPLUS MET TAB 15-850MG Tier 3 XACTOPLUS MET TAB XR Tier 3 XACULAR LS SOL 0.4% Tier 3ACULAR SOL 0.5% OP Tier 3ACUNOL TAB 600MG Tier 3ACYCLOVIR CAP 200MG Tier 1ACYCLOVIR OIN 5% Tier 3 X X XACYCLOVIR SUS 200/5ML Tier 1ACYCLOVIR TAB 400MG Tier 1ACYCLOVIR TAB 800MG Tier 1ACZONE GEL 5% Tier 3 XADALAT CC TAB 30MG ER Tier 3ADALAT CC TAB 60MG ER Tier 3ADALAT CC TAB 90MG ER Tier 3ADAPALENE CRE 0.1% Tier 3ADAPALENE GEL 0.1% Tier 3ADAPALENE GEL 0.3% Tier 3 XADASUVE INH 10MG Tier 3ADCIRCA TAB 20MG Tier 3 X X XADDERALL XR CAP 10MG Tier 2 XADDERALL XR CAP 15MG Tier 2 XADDERALL XR CAP 20MG Tier 2 XADDERALL XR CAP 25MG Tier 2 XADDERALL XR CAP 30MG Tier 2 XADDERALL XR CAP 5MG Tier 2 XADEFOV DIPIV TAB 10MG Tier 1 XADEMPAS TAB 0.5MG Tier 3 X XADEMPAS TAB 1.5MG Tier 3 X XADEMPAS TAB 1MG Tier 3 X XADEMPAS TAB 2.5MG Tier 3 X X

10


LimitStep

TherapySpecialty

Medication

ADEMPAS TAB 2MG Tier 3 X XADRENALIN INJ 1MG/ML Tier 3ADRENALIN SOL 1:1000 Tier 2ADVAIR DISKU AER 100/50 Tier 3 XADVAIR DISKU AER 250/50 Tier 3 XADVAIR DISKU AER 500/50 Tier 3 XADVAIR HFA AER 115/21 Tier 3 XADVAIR HFA AER 230/21 Tier 3 XADVAIR HFA AER 45/21 Tier 3 XADVANCED DNA KIT COLLECTI Tier 1ADVATE INJ 1000UNIT Tier 2 XADVATE INJ 1500UNIT Tier 2 XADVATE INJ 2000UNIT Tier 2 XADVATE INJ 250UNIT Tier 2 XADVATE INJ 3000UNIT Tier 2 XADVATE INJ 4000UNIT Tier 2 XADVATE INJ 500UNIT Tier 2 XADVICOR TAB 1000-20 Tier 3 XADVICOR TAB 1000-40 Tier 3 XADVICOR TAB 500-20MG Tier 3 XADVICOR TAB 750-20MG Tier 3 XAERCHMBR PLS MIS FLOW-VU Tier 3AERCHMBR PLS MIS LRG MASK Tier 3AERCHMBR PLS MIS SM MASK Tier 3AERO OTIC HC SOL Tier 1AEROCHAMBER MIS PLUS Tier 3AEROSPAN AER 80MCG Tier 3 XAFEDITAB TAB 30MG CR Tier 1AFEDITAB TAB 60MG CR Tier 1AFINITOR DIS TAB 2MG Tier 2 X X XAFINITOR DIS TAB 3MG Tier 2 X X XAFINITOR DIS TAB 5MG Tier 2 X X XAFINITOR TAB 10MG Tier 2 X X XAFINITOR TAB 2.5MG Tier 2 X X XAFINITOR TAB 5MG Tier 2 X X XAFINITOR TAB 7.5MG Tier 2 X X XAGGRENOX CAP 25-200MG Tier 3AGRYLIN CAP 0.5MG Tier 3AKNE-MYCIN OIN 2% Tier 2AK-POLY-BAC OIN OP Tier 1AKTEN GEL 3.5% Tier 3ALA QUIN CRE 3-0.5% Tier 3ALA SCALP LOT 2% Tier 3ALAGESIC LQ SOL Tier 2 XALBATUSSIN CAP Tier 3

11


LimitStep

TherapySpecialty

Medication

ALBATUSSIN LIQ NN Tier 2ALBENZA TAB 200MG Tier 2ALBUTEROL NEB 0.083% Tier 1ALBUTEROL NEB 0.5% Tier 1ALBUTEROL NEB 0.63MG/3 Tier 1ALBUTEROL NEB 1.25MG/3 Tier 1ALBUTEROL SYP 2MG/5ML Tier 1ALBUTEROL TAB 2MG Tier 1ALBUTEROL TAB 4MG Tier 1ALBUTEROL TAB 4MG ER Tier 1ALBUTEROL TAB 8MG ER Tier 1ALCAINE SOL 0.5% OP Tier 3ALCLOMETASON CRE 0.05% Tier 1ALCLOMETASON OIN 0.05% Tier 1ALCOH-GLOVE PAD CONTOURE Tier 3ALCOH-WIPE PAD 12"X12" Tier 3ALCORTIN A GEL Tier 3ALDACTAZIDE TAB 25/25 Tier 3ALDACTAZIDE TAB 50/50 Tier 2ALDACTONE TAB 100MG Tier 3ALDACTONE TAB 25MG Tier 3ALDACTONE TAB 50MG Tier 3ALDARA CRE 5% Tier 3 XALENDRONATE SOL 70/75ML Tier 1ALENDRONATE TAB 10MG Tier 1 XALENDRONATE TAB 35MG Tier 1 XALENDRONATE TAB 40MG Tier 1 XALENDRONATE TAB 5MG Tier 1 XALENDRONATE TAB 70MG Tier 1 XALEVEER DIS 0.0375-5 Tier 1ALFERON N INJ 5MU/ML Tier 2 XALFUZOSIN TAB 10MG Tier 1ALINIA SUS 100/5ML Tier 2 XALINIA TAB 500MG Tier 2 XALKERAN TAB 2MG Tier 2 XALLOPURINOL TAB 100MG Tier 1ALLOPURINOL TAB 300MG Tier 1ALOCRIL SOL 2% Tier 3ALODOX KIT 20MG Tier 3ALOMIDE SOL 0.1% OP Tier 3ALOQUIN GEL 1.25-1% Tier 3ALORA DIS 0.025MG Tier 3 XALORA DIS 0.05MG Tier 3 XALORA DIS 0.075MG Tier 3 XALORA DIS 0.1MG Tier 3 X

12


LimitStep

TherapySpecialty

Medication

ALPHAGAN P SOL 0.1% Tier 2 XALPHAGAN P SOL 0.15% Tier 3 XALPHANATE INJ VWF/HUM Tier 2 XALPHANINE SD INJ 1000UNIT Tier 2 XALPHANINE SD INJ 1500UNIT Tier 2 XALPHANINE SD INJ 500UNIT Tier 2 XALPHATREX GEL 0.05% Tier 1ALPRAZOLAM CON 1 MG/ML Tier 1ALPRAZOLAM TAB 0.25 ODT Tier 1ALPRAZOLAM TAB 0.25MG Tier 1ALPRAZOLAM TAB 0.5MG Tier 1ALPRAZOLAM TAB 0.5MG ER Tier 1ALPRAZOLAM TAB 0.5MG OD Tier 1ALPRAZOLAM TAB 0.5MG XR Tier 1ALPRAZOLAM TAB 1MG Tier 1ALPRAZOLAM TAB 1MG ER Tier 1ALPRAZOLAM TAB 1MG ODT Tier 1ALPRAZOLAM TAB 1MG XR Tier 1ALPRAZOLAM TAB 2MG Tier 1ALPRAZOLAM TAB 2MG ER Tier 1ALPRAZOLAM TAB 2MG ODT Tier 1ALPRAZOLAM TAB 2MG XR Tier 1ALPRAZOLAM TAB 3MG ER Tier 1ALPRAZOLAM TAB 3MG XR Tier 1ALPROLIX INJ 1000UNIT Tier 3 XALPROLIX INJ 2000UNIT Tier 3 XALPROLIX INJ 3000UNIT Tier 3 XALPROLIX INJ 500UNIT Tier 3 XALREX SUS 0.2% Tier 3 XALTABAX OIN 1% Tier 3 XALTACAINE SOL 0.5% OP Tier 1ALTACE CAP 1.25MG Tier 3ALTACE CAP 10MG Tier 3ALTACE CAP 2.5MG Tier 3ALTACE CAP 5MG Tier 3ALTAFLUOR SOL 0.25-0.4 Tier 1ALTAFRIN SOL 10% OP Tier 1ALTAFRIN SOL 2.5% OP Tier 1ALTAVERA TAB Tier 1ALUMINUM SOL ACETATE Tier 3ALUVEA CRE 39% Tier 3ALVESCO AER 160MCG Tier 1 XALVESCO AER 80MCG Tier 1 XALYACEN TAB 1/35 Tier 1ALYACEN TAB 7/7/7 Tier 3

13


LimitStep

TherapySpecialty

Medication

AMANTADINE CAP 100MG Tier 1AMANTADINE SYP 50MG/5ML Tier 1AMANTADINE TAB 100MG Tier 1AMARYL TAB 1MG Tier 3AMARYL TAB 2MG Tier 3AMARYL TAB 4MG Tier 3AMCINONIDE CRE 0.1% Tier 3AMCINONIDE LOT 0.1% Tier 3AMCINONIDE OIN 0.1% Tier 1AMERGE TAB 1MG Tier 3 XAMERGE TAB 2.5MG Tier 3 XAMETHIA LO TAB Tier 3 XAMETHIA TAB Tier 3 XAMETHYST TAB 90-20MCG Tier 3AMICAR SYP 25% Tier 3AMICAR TAB 1000MG Tier 3AMICAR TAB 500MG Tier 3AMILOR/HCTZ TAB 5-50 Tier 1AMILORIDE TAB 5MG Tier 1AMINOBEZ POT POW Tier 1AMINOCAPR AC SYP 25% Tier 1AMINOCAPR AC TAB 1000MG Tier 1AMINOCAPR AC TAB 500MG Tier 1AMIODARONE TAB 100MG Tier 1AMIODARONE TAB 200MG Tier 1AMIODARONE TAB 400MG Tier 1AMITIZA CAP 24MCG Tier 3 X X XAMITIZA CAP 8MCG Tier 3 X X XAMITRIPTYLIN TAB 100MG Tier 1AMITRIPTYLIN TAB 10MG Tier 1AMITRIPTYLIN TAB 150MG Tier 1AMITRIPTYLIN TAB 25MG Tier 1AMITRIPTYLIN TAB 50MG Tier 1AMITRIPTYLIN TAB 75MG Tier 1AMLOD/BENAZP CAP 10-20MG Tier 3 XAMLOD/BENAZP CAP 10-40MG Tier 3 XAMLOD/BENAZP CAP 2.5-10MG Tier 3 XAMLOD/BENAZP CAP 5-10MG Tier 3 XAMLOD/BENAZP CAP 5-20MG Tier 3 XAMLOD/BENAZP CAP 5-40MG Tier 3 XAMLODIPINE TAB 10MG Tier 1AMLODIPINE TAB 2.5MG Tier 1AMLODIPINE TAB 5MG Tier 1AMMONIA AROM INH Tier 3AMNESTEEM CAP 10MG Tier 3 X

14


LimitStep

TherapySpecialty

Medication

AMNESTEEM CAP 20MG Tier 3 XAMNESTEEM CAP 40MG Tier 3 XAMOX/K CLAV CHW 200MG Tier 1AMOX/K CLAV CHW 400MG Tier 1AMOX/K CLAV SUS 200/5ML Tier 1AMOX/K CLAV SUS 250/5ML Tier 1AMOX/K CLAV SUS 400/5ML Tier 1AMOX/K CLAV SUS 600/5ML Tier 1AMOX/K CLAV TAB 250MG Tier 1AMOX/K CLAV TAB 500MG Tier 1AMOX/K CLAV TAB 875MG Tier 1AMOXAPINE TAB 100MG Tier 1AMOXAPINE TAB 150MG Tier 1AMOXAPINE TAB 25MG Tier 1AMOXAPINE TAB 50MG Tier 1AMOXICILLIN CAP 250MG Tier 1AMOXICILLIN CAP 500MG Tier 1AMOXICILLIN CHW 125MG Tier 1AMOXICILLIN CHW 250MG Tier 1AMOXICILLIN SUS 125/5ML Tier 1AMOXICILLIN SUS 200/5ML Tier 1AMOXICILLIN SUS 250/5ML Tier 1AMOXICILLIN SUS 400/5ML Tier 1AMOXICILLIN TAB 500MG Tier 1AMOXICILLIN TAB 875MG Tier 1AMPHETAMINE TAB 10MG Tier 1 XAMPHETAMINE TAB 12.5MG Tier 1 XAMPHETAMINE TAB 15MG Tier 1 XAMPHETAMINE TAB 20MG Tier 1 XAMPHETAMINE TAB 30MG Tier 1 XAMPHETAMINE TAB 5MG Tier 1 XAMPHETAMINE TAB 7.5MG Tier 1 XAMPICILLIN CAP 250MG Tier 1AMPICILLIN CAP 500MG Tier 1AMPICILLIN SUS 125/5ML Tier 1AMPICILLIN SUS 250/5ML Tier 1AMPYRA TAB 10MG Tier 2 X X XANACAINE OIN Tier 2ANADROL-50 TAB 50MG Tier 3ANAFRANIL CAP 25MG Tier 3ANAFRANIL CAP 50MG Tier 3ANAFRANIL CAP 75MG Tier 3ANAGRELIDE CAP 0.5MG Tier 1ANAGRELIDE CAP 1MG Tier 1ANA-LEX KIT Tier 1

15


LimitStep

TherapySpecialty

Medication

ANALPRAM E KIT Tier 3 XANALPRAM-HC CRE 1-1% Tier 3ANALPRAM-HC CRE 1-2.5% Tier 3ANALPRAM-HC CRE SINGLES Tier 3ANALPRAM-HC LOT 2.5% Tier 3ANAPROX DS TAB 550MG Tier 3ANAPROX TAB 275MG Tier 3ANASPAZ TAB 0.125MG Tier 2ANASTROZOLE POW Tier 3ANASTROZOLE TAB 1MG Tier 1ANCOBON CAP 250MG Tier 3ANCOBON CAP 500MG Tier 3ANDEHIST SYP 4-60MG/5 Tier 3ANDRODERM DIS 2MG/24HR Tier 2 X XANDRODERM DIS 4MG/24HR Tier 2 X XANDROID CAP 10MG Tier 2ANDROXY TAB 10MG Tier 1ANGELIQ TAB 0.25-0.5 Tier 3ANGELIQ TAB 0.5-1MG Tier 3ANORO ELLIPT AER 62.5-25 Tier 3 XANTABUSE TAB 250MG Tier 3ANTABUSE TAB 500MG Tier 3ANTICOAG CIT SOL DEX SOL Tier 1ANTIPY/BENZO SOL OTIC Tier 1ANUCORT-HC SUP 25MG Tier 1ANUSOL-HC CRE 2.5% Tier 3ANUSOL-HC SUP 25MG Tier 3ANZEMET TAB 100MG Tier 3 XANZEMET TAB 50MG Tier 3 XAPAP/CODEINE SOL 120-12/5 Tier 1 XAPAP/CODEINE TAB 300-15MG Tier 1 XAPAP/CODEINE TAB 300-30MG Tier 1 XAPAP/CODEINE TAB 300-60MG Tier 1 XAPEXICON E CRE 0.05% Tier 2 XAPEXICON OIN 0.05% Tier 3 XAPIDRA INJ SOLOSTAR Tier 3APIDRA INJ U-100 Tier 3APOKYN INJ 10MG/ML Tier 2 XAPPBUTAMONE PAK Tier 3APPFORMIN PAK Tier 3APPFORMIN-D PAK Tier 3APRACLONIDIN SOL 0.5% OP Tier 1APRI TAB Tier 1APRISO CAP 0.375GM Tier 2 XAPTIOM TAB 200MG Tier 3 X

16


LimitStep

TherapySpecialty

Medication

APTIOM TAB 400MG Tier 3 XAPTIOM TAB 600MG Tier 3 XAPTIOM TAB 800MG Tier 3 XAPTIVUS CAP 250MG Tier 2 XAPTIVUS SOL Tier 3 XAQUORAL AER Tier 3ARALEN TAB 500MG Tier 3ARANELLE TAB Tier 1ARANESP INJ 100MCG Tier 2 X XARANESP INJ 150MCG Tier 2 X XARANESP INJ 200MCG Tier 2 X XARANESP INJ 25MCG Tier 2 X XARANESP INJ 300MCG Tier 2 X XARANESP INJ 40MCG Tier 2 X XARANESP INJ 500MCG Tier 2 X XARANESP INJ 60MCG Tier 2 X XARAVA TAB 10MG Tier 3ARAVA TAB 20MG Tier 3ARBINOXA SOL 4MG/5ML Tier 2ARBINOXA TAB 4MG Tier 1ARCALYST INJ 220MG Tier 2 X X XARCAPTA CAP 75MCG Tier 3 XARESTIN MIS 1MG Tier 3ARICEPT ODT TAB 10MG Tier 3ARICEPT TAB 10MG Tier 3ARICEPT TAB 5MG Tier 3ARIDOL KIT Tier 3ARIXTRA SOL 10/0.8 Tier 3 XARIXTRA SOL 2.5/0.5 Tier 3 XARIXTRA SOL 5.0/0.4 Tier 3 XARIXTRA SOL 7.5/0.6 Tier 3 XARMOUR THYRO TAB 120MG Tier 3ARMOUR THYRO TAB 15MG Tier 3ARMOUR THYRO TAB 180MG Tier 3ARMOUR THYRO TAB 240MG Tier 3ARMOUR THYRO TAB 300MG Tier 3ARMOUR THYRO TAB 30MG Tier 3ARMOUR THYRO TAB 60MG Tier 3ARMOUR THYRO TAB 90MG Tier 3AROMASIN TAB 25MG Tier 3ARTHROTEC 50 TAB Tier 3ARTHROTEC 75 TAB Tier 3ARTISS SOL 10ML Tier 3ARTISS SOL 2ML Tier 3ARTISS SOL 4ML Tier 3

17


LimitStep

TherapySpecialty

Medication

ARZOL SILVER MIS NITR APP Tier 3ASCOMP/COD CAP 30MG Tier 1ASMANEX 120 AER 220MCG Tier 1 XASMANEX 14 AER 220MCG Tier 1 XASMANEX 30 AER 110MCG Tier 1 XASMANEX 30 AER 220MCG Tier 1 XASMANEX 60 AER 220MCG Tier 1 XASMANEX 7 AER 110MCG Tier 1 XASTRINGYN SOL 259MG/GM Tier 3ATABEX EC TAB Tier 3ATABEX TAB PRENATAL Tier 2ATACAND HCT TAB 16-12.5 Tier 3 XATACAND HCT TAB 32-12.5 Tier 3 XATACAND HCT TAB 32-25MG Tier 3 XATACAND TAB 16MG Tier 3 XATACAND TAB 32MG Tier 3 XATACAND TAB 4MG Tier 3 XATACAND TAB 8MG Tier 3 XATENOL/CHLOR TAB 100-25MG Tier 1ATENOL/CHLOR TAB 50-25MG Tier 1ATENOLOL TAB 100MG Tier 1ATENOLOL TAB 25MG Tier 1ATENOLOL TAB 50MG Tier 1ATOPICLAIR CRE Tier 3ATORVASTATIN TAB 10MG Tier 1 XATORVASTATIN TAB 20MG Tier 1 XATORVASTATIN TAB 40MG Tier 1 XATORVASTATIN TAB 80MG Tier 1 XATOVAQ/PROGU TAB 250-100 Tier 3ATOVAQ/PROGU TAB 62.5-25 Tier 3ATOVAQUONE SUS 750/5ML Tier 3ATRAPRO CP KIT Tier 3ATRAPRO DERM SPR Tier 3ATRAPRO GEL HYDROGEL Tier 3ATRIPLA TAB Tier 2 XATROHIST LA TAB CR Tier 3ATROHIST SR CAP SPRINKLE Tier 3ATROPIN-CARE SOL 1% OP Tier 1ATROPINE POW SULFATE Tier 3ATROPINE SUL OIN 1% OP Tier 1ATROPINE SUL SOL 1% OP Tier 1ATROVENT HFA AER 17MCG Tier 3 XATROVENT NAS SOL 0.03% Tier 3ATROVENT NAS SOL 0.06% Tier 3AUBAGIO TAB 14MG Tier 3 X X X X

18


LimitStep

TherapySpecialty

Medication

AUBAGIO TAB 7MG Tier 3 X X X XAUBRA TAB 0.1-0.02 Tier 1AUG BETAMET CRE 0.05% Tier 1AUG BETAMET GEL 0.05% Tier 1AUG BETAMET LOT 0.05% Tier 3AUG BETAMET OIN 0.05% Tier 3AUGMENTIN SUS 125/5ML Tier 2AUGMENTIN SUS 250/5ML Tier 3AUGMENTIN SUS ES-600 Tier 3AUGMENTIN TAB 500MG Tier 2AUGMENTIN TAB 875MG Tier 2AURODEX SOL OTIC Tier 1AURSTAT ANTI GEL -ITCH Tier 3AURSTAT KIT HYDROGEL Tier 3AURUM LIQ 12X Tier 1AVAGE CRE 0.1% Tier 2AVAILNEX CHW 750MG Tier 3AVALIDE TAB 150-12.5 Tier 3 XAVALIDE TAB 300-12.5 Tier 3 XAVANDAMET TAB 2-1000MG Tier 3 XAVANDAMET TAB 2-500MG Tier 3 XAVANDAMET TAB 4-500MG Tier 3 XAVANDARYL TAB 4-1MG Tier 3 XAVANDARYL TAB 4-2MG Tier 3 XAVANDARYL TAB 4-4MG Tier 3 XAVANDARYL TAB 8-4MG Tier 3 XAVANDIA TAB 2MG Tier 3AVANDIA TAB 4MG Tier 3 XAVANDIA TAB 8MG Tier 3 XAVAPRO TAB 150MG Tier 3 XAVAPRO TAB 300MG Tier 3 XAVAPRO TAB 75MG Tier 3 XAVAR CLEANSE EMU 10-5% Tier 1AVAR GEL GREEN Tier 3AVAR LS LIQ 10-2% Tier 3AVAR-E EMOLL CRE 10-5% Tier 3AVAR-E GREEN CRE 10-5% Tier 3AVAR-E LS CRE 10-2% Tier 3AVC CRE 15% Tier 2AVIANE TAB Tier 1AVIDOXY DK KIT Tier 3AVIDOXY TAB 100MG Tier 1AVITA CRE 0.025% Tier 1AVITA GEL 0.025% Tier 1 XAVODART CAP 0.5MG Tier 3 X

19


LimitStep

TherapySpecialty

Medication

AVONEX KIT 30MCG Tier 2 X X XAVONEX PEN KIT 30MCG Tier 2 X X XAVONEX PREFL KIT 30MCG Tier 2 X X XAXERT TAB 12.5MG Tier 3 XAXERT TAB 6.25MG Tier 3 XAXID SOL 15MG/ML Tier 3AXONA POW Tier 3AYGESTIN TAB 5MG Tier 3AZASAN TAB 100MG Tier 3AZASAN TAB 75 MG Tier 3AZASITE SOL 1% Tier 3 XAZATHIOPRINE TAB 50MG Tier 1AZELASTINE DRO 0.05% Tier 3 XAZELASTINE SPR 0.1% Tier 3 XAZELEX CRE 20% Tier 3 XAZILECT TAB 0.5MG Tier 3AZILECT TAB 1MG Tier 3AZITHROMYCIN SUS 100/5ML Tier 1AZITHROMYCIN SUS 200/5ML Tier 1AZITHROMYCIN TAB 250MG Tier 1AZITHROMYCIN TAB 500MG Tier 1AZITHROMYCIN TAB 600MG Tier 1AZOPT SUS 1% OP Tier 2 XAZULFIDINE TAB 500MG Tier 3AZULFIDINE TAB 500MG EN Tier 3AZURETTE TAB 28 DAY Tier 3BACIT/POLYMY OIN OP Tier 1BACITRACIN OIN OP Tier 3BACLOFEN TAB 10MG Tier 1BACLOFEN TAB 20MG Tier 1BACTRIM DS TAB 800-160 Tier 3BACTRIM TAB 400-80MG Tier 3BACTROBAN CRE 2% Tier 3 XBACTROBAN OIN 2% Tier 3BACTROBAN OIN NASAL 2% Tier 2BAL-CARE MIS DHA Tier 2BALSALAZIDE CAP 750MG Tier 1BALZIVA TAB Tier 3BANZEL SUS 40MG/ML Tier 3BANZEL TAB 200MG Tier 3 XBANZEL TAB 400MG Tier 3 XBARACLUDE SOL .05MG/ML Tier 2 XBARACLUDE TAB 0.5MG Tier 2 XBARACLUDE TAB 1MG Tier 2 XBAR-TEST TAB 650MG Tier 2

20


LimitStep

TherapySpecialty

Medication

BASE CRE LIPOSOME Tier 3BAYCADRON ELX 0.5/5ML Tier 1BEBULIN INJ 200-1200 Tier 2 XBEBULIN VH INJ 200-1200 Tier 2 XBELLA/OPIUM SUP 16.2-30 Tier 1BELLA/OPIUM SUP 16.2-60 Tier 2BENAZEP/HCTZ TAB 10-12.5 Tier 1BENAZEP/HCTZ TAB 20-12.5 Tier 1BENAZEP/HCTZ TAB 20-25MG Tier 1BENAZEP/HCTZ TAB 5-6.25 Tier 1BENAZEPRIL TAB 10MG Tier 1BENAZEPRIL TAB 20MG Tier 1BENAZEPRIL TAB 40MG Tier 1BENAZEPRIL TAB 5MG Tier 1BENEFIX INJ 1000UNIT Tier 2 XBENEFIX INJ 2000UNIT Tier 2 XBENEFIX INJ 250UNIT Tier 2 XBENEFIX INJ 3000UNIT Tier 2 XBENEFIX INJ 500UNIT Tier 2 XBENICAR HCT TAB 20-12.5 Tier 2 XBENICAR HCT TAB 40-12.5 Tier 2 XBENICAR HCT TAB 40-25MG Tier 2 XBENICAR TAB 20MG Tier 2 XBENICAR TAB 40MG Tier 2 XBENICAR TAB 5MG Tier 2 XBENSAL HP OIN Tier 2BENTYL CAP 10MG Tier 3BENTYL TAB 20MG Tier 3BENZALKONIUM SOL 50% Tier 1BENZALKONIUM SOL NF Tier 2BENZAMYCIN GEL Tier 2 XBENZAMYCIN GEL 5-3% Tier 2 XBENZAMYCIN GEL PAK Tier 3BENZIQ GEL 5.25% Tier 3BENZIQ LS GEL 2.75% Tier 3BENZIQ WASH LIQ 5.25% Tier 3BENZOIN CMPD TIN Tier 3BENZOIN TIN NF Tier 3BENZONATATE CAP 100MG Tier 1BENZONATATE CAP 200MG Tier 1BENZTROPINE TAB 0.5MG Tier 1BENZTROPINE TAB 1MG Tier 1BENZTROPINE TAB 2MG Tier 1BERINERT INJ 500UNIT Tier 2 X X XBESIVANCE SUS 0.6% Tier 3

21


LimitStep

TherapySpecialty

Medication

BETADINE SOL 5% OP Tier 3BETAGAN SOL 0.5% OP Tier 3BETAMETH DIP CRE 0.05% Tier 3BETAMETH DIP LOT 0.05% Tier 1BETAMETH DIP OIN 0.05% Tier 3BETAMETH VAL CRE 0.1% Tier 1BETAMETH VAL LOT 0.1% Tier 1BETAMETH VAL OIN 0.1% Tier 1BETAPACE AF TAB 120MG Tier 3BETAPACE AF TAB 160MG Tier 3BETAPACE AF TAB 80MG Tier 3BETAPACE TAB 120MG Tier 3BETAPACE TAB 160MG Tier 3BETAPACE TAB 80MG Tier 3BETASERON INJ 0.3MG Tier 2 X X XBETAXOLOL SOL 0.5% OP Tier 1BETAXOLOL TAB 10MG Tier 1BETAXOLOL TAB 20MG Tier 1BETHANECHOL TAB 10MG Tier 1BETHANECHOL TAB 25MG Tier 1BETHANECHOL TAB 50MG Tier 1BETHANECHOL TAB 5MG Tier 1BETHKIS NEB 300/4ML Tier 2 X X XBETIMOL SOL 0.25% Tier 2 XBETIMOL SOL 0.5% Tier 2 XBETOPTIC-S SUS 0.25% OP Tier 3BIAXIN SUS 250/5ML Tier 3BIAXIN TAB 250MG Tier 3BIAXIN TAB 500MG Tier 3BIAXIN XL TAB 500MG Tier 3BIAXIN XL TAB PAC 500 Tier 3BICALUTAMIDE TAB 50MG Tier 1 XBIDIL TAB Tier 2BILTRICIDE TAB 600MG Tier 2BIO GLO TES 1MG OP Tier 1BIO-STATIN CAP 1000000 Tier 3BIO-STATIN CAP 500000 Tier 3BIO-STATIN POW Tier 1BIOTUSS LIQ Tier 1BIOTUSS LIQ PEDIATRC Tier 1BISOPRL/HCTZ TAB 10/6.25 Tier 1BISOPRL/HCTZ TAB 2.5/6.25 Tier 1BISOPRL/HCTZ TAB 5-6.25MG Tier 1BISOPROL FUM TAB 10MG Tier 1BISOPROL FUM TAB 5MG Tier 1

22


LimitStep

TherapySpecialty

Medication

BL DECONGEST TAB CR Tier 1BL DIXAPHEDR TAB 60MG Tier 1BL FOLIC ACD TAB 400MCG Tier 1BL TRIP ANTI OIN W/LID 4% Tier 1BLEPH-10 SOL 10% OP Tier 3BLEPHAMIDE OIN S.O.P. Tier 2BLEPHAMIDE SUS OP Tier 3BONIVA TAB 150MG Tier 3 XBORIC ACID GRA Tier 3BOSULIF TAB 100MG Tier 2 X X X XBOSULIF TAB 500MG Tier 2 X X X XBP 10-1 EMU Tier 1BP CLEANSING EMU 10-4% Tier 1BP FOLINATAL TAB PLUS B Tier 1BP MULTINATL CHW PLUS Tier 1BP MULTINATL TAB PLUS Tier 1BREO ELLIPTA INH 100-25 Tier 3 XBREVICON TAB 0.5/35 Tier 3BRIELLYN TAB Tier 3BRILINTA TAB 90MG Tier 3 X XBRIMONIDINE SOL 0.15% Tier 3 XBRIMONIDINE SOL 0.2% OP Tier 1BRINTELLIX TAB 10MG Tier 3 XBRINTELLIX TAB 20MG Tier 3 XBRINTELLIX TAB 5MG Tier 3 XBROMFED DM SYP Tier 1BROMOCRIPTIN CAP 5MG Tier 1BROMOCRIPTIN TAB 2.5MG Tier 1BROMPHENIRAM CHW 12MG Tier 1BROVANA NEB 15MCG Tier 3 XBUCALSEP SOL Tier 3BUCALSEP SPR Tier 3BUDESONIDE CAP 3MG/24HR Tier 3BUDESONIDE SUS 0.25MG/2 Tier 1 XBUDESONIDE SUS 0.5MG/2 Tier 1 XBUMETANIDE TAB 0.5MG Tier 1BUMETANIDE TAB 1MG Tier 1BUMETANIDE TAB 2MG Tier 1BUPAP TAB 50-300MG Tier 3BUPHENYL POW Tier 3 XBUPHENYL TAB 500MG Tier 3 XBUPIVACAINE POW HCL Tier 3BUPRENORPHIN SUB 2MG Tier 1 X XBUPRENORPHIN SUB 8MG Tier 1 X XBUPROPION TAB 100MG Tier 1

23


LimitStep

TherapySpecialty

Medication

BUPROPION TAB 100MG ER Tier 1BUPROPION TAB 100MG SR Tier 1BUPROPION TAB 150MG ER Tier 1BUPROPION TAB 150MG SR Tier 1BUPROPION TAB 200MG ER Tier 1BUPROPION TAB 200MG SR Tier 1BUPROPION TAB 75MG Tier 1BUPROPN HCL TAB 150MG XL Tier 1BUPROPN HCL TAB 300MG XL Tier 1BUSPIRONE TAB 10MG Tier 1BUSPIRONE TAB 15MG Tier 1BUSPIRONE TAB 30MG Tier 1BUSPIRONE TAB 5MG Tier 1BUSPIRONE TAB 7.5MG Tier 1BUT/APAP/CAF CAP Tier 1BUT/APAP/CAF TAB Tier 1 XBUT/ASA/CAF/ CAP COD 30MG Tier 1BUT/ASA/CAFF CAP Tier 1BUTAL/APAP TAB 50-325MG Tier 1BUTISOL SOD ELX 30MG/5ML Tier 3BUTISOL SOD TAB 30MG Tier 3BUTISOL SOD TAB 50MG Tier 3BUTORPHANOL SOL 10MG/ML Tier 3 XBUTRANS DIS 10MCG/HR Tier 3 X XBUTRANS DIS 15MCG/HR Tier 3 X XBUTRANS DIS 20MCG/HR Tier 3 X XBUTRANS DIS 5MCG/HR Tier 3 X XBXN MOUTHWSH SUS Tier 3BYETTA INJ 10MCG Tier 2 XBYETTA INJ 5MCG Tier 2 XBYSTOLIC TAB 10MG Tier 2BYSTOLIC TAB 2.5MG Tier 2BYSTOLIC TAB 20MG Tier 2BYSTOLIC TAB 5MG Tier 2CABERGOLINE TAB 0.5MG Tier 3CAFCIT SOL 60MG/3ML Tier 3CAFERGOT TAB 1-100MG Tier 3CAFFEINE CIT SOL 20MG/ML Tier 1CAFFEINE CIT SOL 60MG/3ML Tier 1CALAN SR TAB 120MG Tier 3CALAN SR TAB 180MG Tier 3CALAN SR TAB 240MG Tier 3CALAN TAB 120MG Tier 3CALAN TAB 80MG Tier 3CALC ACETATE CAP 667MG Tier 1

24


LimitStep

TherapySpecialty

Medication

CALC ACETATE TAB 667MG Tier 1CALCIFOL WAF Tier 3CALCIPOTRIEN CRE 0.005% Tier 3 XCALCIPOTRIEN OIN 0.005% Tier 3CALCIPOTRIEN OIN BETAMETH Tier 3 XCALCIPOTRIEN SOL 0.005% Tier 1 XCALCITONIN SPR 200/ACT Tier 3CALCITRENE OIN 0.005% Tier 3CALCITRIOL CAP 0.25MCG Tier 1CALCITRIOL CAP 0.5MCG Tier 1CALCITRIOL OIN 3MCG/GM Tier 1 XCALCITRIOL SOL 1MCG/ML Tier 1CALCIUM PNV CAP Tier 3CALCIUM POW FOLINATE Tier 3CALCIUM-FA WAF PLUS D Tier 1CAMILA TAB 0.35MG Tier 3CAMPRAL TAB 333MG Tier 3CAMRESE LO TAB Tier 3 XCAMRESE TAB Tier 3 XCANASA SUP 1000MG Tier 2CANDESA/HCTZ TAB 16-12.5 Tier 3 XCANDESA/HCTZ TAB 32-12.5 Tier 3 XCANDESA/HCTZ TAB 32-25MG Tier 3 XCANDESARTAN TAB 16MG Tier 3 XCANDESARTAN TAB 32MG Tier 3 XCANDESARTAN TAB 4MG Tier 3 XCANDESARTAN TAB 8MG Tier 3 XCANTIL TAB 25MG Tier 3CAPACET CAP Tier 1 XCAPECITABINE TAB 150MG Tier 1 X XCAPECITABINE TAB 500MG Tier 1 X XCAPEX SHA 0.01% Tier 2CAPITAL/COD SUS 120-12/5 Tier 2 XCAPRELSA TAB 100MG Tier 2 X X XCAPRELSA TAB 300MG Tier 2 X X XCAPTOPR/HCTZ TAB 25-15MG Tier 1CAPTOPR/HCTZ TAB 25-25MG Tier 1CAPTOPR/HCTZ TAB 50-15MG Tier 1CAPTOPR/HCTZ TAB 50-25MG Tier 1CAPTOPRIL TAB 100MG Tier 1CAPTOPRIL TAB 12.5MG Tier 1CAPTOPRIL TAB 25MG Tier 1CAPTOPRIL TAB 50MG Tier 1CARAC CRE 0.5% Tier 2CARAFATE SUS 1GM/10ML Tier 3

25


LimitStep

TherapySpecialty

Medication

CARAFATE TAB 1GM Tier 3CARB/LEVO 50 TAB /ENTACAP Tier 1CARB/LEVO 75 TAB /ENTACAP Tier 1CARB/LEVO ER TAB 25-100MG Tier 1CARB/LEVO ER TAB 50-200MG Tier 1CARB/LEVO TAB 10-100MG Tier 1CARB/LEVO TAB 25-100MG Tier 1CARB/LEVO TAB 25-250MG Tier 1CARB/LEVO100 TAB /ENTACAP Tier 1CARB/LEVO125 TAB /ENTACAP Tier 1CARB/LEVO150 TAB /ENTACAP Tier 1CARB/LEVO200 TAB /ENTACAP Tier 1CARBAGLU TAB 200MG Tier 2 XCARBAMAZEPIN CAP 100MG ER Tier 3CARBAMAZEPIN CAP 200MG ER Tier 3CARBAMAZEPIN CAP 300MG ER Tier 3CARBAMAZEPIN CHW 100MG Tier 1CARBAMAZEPIN SUS 100/5ML Tier 1CARBAMAZEPIN TAB 200MG Tier 1CARBAMAZEPIN TAB 200MG ER Tier 3CARBAMAZEPIN TAB 400MG ER Tier 3CARBAPHEN 12 LIQ Tier 3CARBAPHEN 12 SUS PED Tier 3CARBATROL CAP 100MG Tier 3CARBATROL CAP 200MG Tier 3CARBATROL CAP 300MG Tier 3CARBIDOPA TAB 25MG Tier 1CARBIN/PSE/ SYP DM Tier 1CARBINOXAMIN SOL 4MG/5ML Tier 1CARBINOXAMIN TAB 4MG Tier 1CARBOGEL GEL 940 Tier 3CARBOMER GEL AQUEOUS Tier 3CARBOMER GEL HYDROALC Tier 3CARDIOVID CAP PLUS Tier 3CARDIZEM CD CAP 120MG/24 Tier 3CARDIZEM CD CAP 180MG/24 Tier 3CARDIZEM CD CAP 240MG/24 Tier 3CARDIZEM CD CAP 300MG/24 Tier 3CARDIZEM CD CAP 360MG/24 Tier 3CARDIZEM LA TAB 120MG Tier 2CARDIZEM LA TAB 180MG Tier 3CARDIZEM LA TAB 240MG Tier 3CARDIZEM LA TAB 300MG/24 Tier 3CARDIZEM LA TAB 360MG Tier 3CARDIZEM LA TAB 420MG/24 Tier 3

26


LimitStep

TherapySpecialty

Medication

CARDIZEM TAB 120MG Tier 3CARDIZEM TAB 30MG Tier 3CARDIZEM TAB 60MG Tier 3CARDURA TAB 1MG Tier 3CARDURA TAB 2MG Tier 3CARDURA TAB 4MG Tier 3CARDURA TAB 8MG Tier 3CARDURA XL TAB 4MG Tier 3CARDURA XL TAB 8MG Tier 3CARISOPR/ASA TAB 200-325 Tier 1CARISOPRODOL TAB 350MG Tier 1CARISOPRODOL TAB ASA/COD Tier 1CARNITOR SF SOL 1GM/10ML Tier 3CARNITOR SOL 1GM/10ML Tier 3CARNITOR TAB 330MG Tier 3CARTEOLOL SOL 1% OP Tier 1CARTIA XT CAP 120/24HR Tier 3CARTIA XT CAP 180/24HR Tier 3CARTIA XT CAP 240/24HR Tier 3CARTIA XT CAP 300/24HR Tier 3CARTRIDGE MIS 3.15ML Tier 3CARTRIDGE MIS IR 1000 Tier 3CARTRIDGE MIS IR 1200 Tier 3CARTRIDGE MIS PUMP Tier 3CARVEDILOL TAB 12.5MG Tier 1CARVEDILOL TAB 25MG Tier 1CARVEDILOL TAB 3.125MG Tier 1CARVEDILOL TAB 6.25MG Tier 1CASCARA EXT SAGRADA Tier 1CASODEX TAB 50MG Tier 3CATAFLAM TAB 50MG Tier 3CATAPRES TAB 0.1MG Tier 3CATAPRES TAB 0.2MG Tier 3CATAPRES TAB 0.3MG Tier 3CATAPRES-TTS DIS 0.1/24HR Tier 3 XCATAPRES-TTS DIS 0.2/24HR Tier 3 XCATAPRES-TTS DIS 0.3/24HR Tier 3 XCAVAREST GEL 1.1% Tier 1CAVERJECT INJ 20MCG Tier 3 XCAVERJECT INJ 40MCG Tier 3 XCAVERJECT KIT 10MCG Tier 3 XCAVERJECT KIT 20MCG Tier 3 XCAVIRINSE SOL 0.2% Tier 1CAYSTON INH 75MG Tier 2 X X XCAZIANT PAK Tier 1

27


LimitStep

TherapySpecialty

Medication

CDP/AMITRIP TAB 10-25MG Tier 1CDP/AMITRIP TAB 5-12.5MG Tier 1CEDAX CAP 400MG Tier 3CEDAX SUS 180/5ML Tier 3CEDAX SUS 90MG/5ML Tier 3CEFACLOR CAP 250MG Tier 1CEFACLOR CAP 500MG Tier 1CEFACLOR ER TAB 500MG Tier 1CEFACLOR SUS 125/5ML Tier 3CEFACLOR SUS 250/5ML Tier 1CEFACLOR SUS 375/5ML Tier 3CEFADROXIL CAP 500MG Tier 1CEFADROXIL SUS 250/5ML Tier 1CEFADROXIL SUS 500/5ML Tier 1CEFADROXIL TAB 1GM Tier 1CEFDINIR CAP 300MG Tier 3CEFDINIR SUS 125/5ML Tier 3CEFDINIR SUS 250/5ML Tier 3CEFDITOREN TAB 200MG Tier 1CEFDITOREN TAB 400MG Tier 1CEFPODO PROX SUS 100/5ML Tier 1CEFPODO PROX SUS 50MG/5ML Tier 1CEFPODOXIME TAB 100MG Tier 1CEFPODOXIME TAB 200MG Tier 1CEFPROZIL SUS 125/5ML Tier 1CEFPROZIL SUS 250/5ML Tier 1CEFPROZIL TAB 250MG Tier 1CEFPROZIL TAB 500MG Tier 1CEFTIBUTEN CAP 400MG Tier 1CEFTIBUTEN SUS 180/5ML Tier 1CEFTIN SUS 125/5ML Tier 3CEFTIN SUS 250/5ML Tier 3CEFTIN TAB 250MG Tier 3CEFTIN TAB 500MG Tier 3CEFUROXIME SUS 125/5ML Tier 1CEFUROXIME TAB 250MG Tier 1CEFUROXIME TAB 500MG Tier 1CELEBREX CAP 100MG Tier 3 XCELEBREX CAP 200MG Tier 3 XCELEBREX CAP 400MG Tier 3 XCELEBREX CAP 50MG Tier 3 XCELLCEPT CAP 250MG Tier 3 XCELLCEPT SUS 200MG/ML Tier 2 XCELLCEPT TAB 500MG Tier 3 XCELONTIN CAP 300MG Tier 2

28


LimitStep

TherapySpecialty

Medication

CEM-UREA SOL 45% Tier 3CENTANY OIN 2% Tier 3CEPHALEXIN CAP 250MG Tier 1CEPHALEXIN CAP 500MG Tier 1CEPHALEXIN CAP 750MG Tier 1CEPHALEXIN SUS 125/5ML Tier 1CEPHALEXIN SUS 250/5ML Tier 1CEPHALEXIN TAB 250MG Tier 1CEPHALEXIN TAB 500MG Tier 1CERISA WASH EMU 10-1% Tier 1CEROVEL GEL 40% Tier 1CEROVEL LOT 40% Tier 1CERVIDIL VAG MIS 10MG INS Tier 3CESAMET CAP 1MG Tier 3CESIA PAK Tier 1CETRAXAL SOL 0.2% Tier 3CEVIMELINE CAP 30MG Tier 1CHATEAL TAB 0.15/30 Tier 1CHELIDONIUM LIQ COMPOUND Tier 3CHEMET CAP 100MG Tier 2CHENODAL TAB 250MG Tier 3 XCHERRY SYP Tier 3CHLORD/CLIDI CAP 5-2.5MG Tier 1CHLORDIAZEP CAP 10MG Tier 1CHLORDIAZEP CAP 25MG Tier 1CHLORDIAZEP CAP 5MG Tier 1CHLORHEX GLU SOL 0.12% Tier 1CHLOROQUINE TAB 250MG Tier 1CHLOROQUINE TAB 500MG Tier 1CHLOROTHIAZ TAB 250MG Tier 1CHLOROTHIAZ TAB 500MG Tier 1CHLORPROMAZ POW HCL Tier 3CHLORPROMAZ TAB 100MG Tier 1CHLORPROMAZ TAB 10MG Tier 1CHLORPROMAZ TAB 200MG Tier 1CHLORPROMAZ TAB 25MG Tier 1CHLORPROMAZ TAB 50MG Tier 1CHLORPROPAM TAB 100MG Tier 1CHLORPROPAM TAB 250MG Tier 1CHLORTHALID TAB 100MG Tier 1CHLORTHALID TAB 25MG Tier 1CHLORTHALID TAB 50MG Tier 1CHLORZOXAZON TAB 250MG Tier 1CHLORZOXAZON TAB 500MG Tier 1CHO MAG TRIS LIQ 500/5ML Tier 1

29


LimitStep

TherapySpecialty

Medication

CHO MAG TRIS TAB 1000MG Tier 1CHOLAC SYP 10GM/15 Tier 1CHOLESTYRAM POW 4GM Tier 1CHOLESTYRAM POW 4GM LITE Tier 1CHORIONIC POW GONADOTR Tier 3 XCIALIS TAB 10MG Tier 3 X XCIALIS TAB 2.5MG Tier 3 X X XCIALIS TAB 20MG Tier 3 X XCIALIS TAB 5MG Tier 3 X X XCICLODAN CRE 0.77% Tier 1CICLODAN SOL 8% Tier 1CICLOPIROX CRE 0.77% Tier 1CICLOPIROX GEL 0.77% Tier 1CICLOPIROX SHA 1% Tier 3CICLOPIROX SOL 8% Tier 1CICLOPIROX SUS 0.77% Tier 1CILOSTAZOL TAB 100MG Tier 1CILOSTAZOL TAB 50MG Tier 1CILOXAN OIN 0.3% OP Tier 3CILOXAN SOL 0.3% OP Tier 3CIMETIDINE SOL 300/5ML Tier 1CIMETIDINE TAB 200MG Tier 1CIMETIDINE TAB 300MG Tier 1CIMETIDINE TAB 400MG Tier 1CIMETIDINE TAB 800MG Tier 1CIMZIA KIT Tier 2 X X XCIMZIA KIT STARTER Tier 2 X X XCIMZIA PREFL KIT 200MG/ML Tier 2 X X XCIPRO HC SUS OTIC Tier 3CIPRO TAB 250MG Tier 3CIPRO TAB 500MG Tier 3CIPRO XR TAB 1000MG Tier 3CIPRO XR TAB 500MG Tier 3CIPRODEX SUS 0.3-0.1% Tier 2CIPROFLOXACN SOL 0.2% Tier 1CIPROFLOXACN SOL 0.3% OP Tier 1CIPROFLOXACN SUS 250MG/5 Tier 3CIPROFLOXACN SUS 500MG/5 Tier 3CIPROFLOXACN TAB 1000MG Tier 3CIPROFLOXACN TAB 100MG Tier 1CIPROFLOXACN TAB 250MG Tier 1CIPROFLOXACN TAB 500MG Tier 1CIPROFLOXACN TAB 500MG ER Tier 3CIPROFLOXACN TAB 750MG Tier 1CITALOPRAM SOL 10MG/5ML Tier 1

30


LimitStep

TherapySpecialty

Medication

CITALOPRAM TAB 10MG Tier 1CITALOPRAM TAB 20MG Tier 1CITALOPRAM TAB 40MG Tier 1CITRANATAL CAP HARMONY Tier 3CITRANATAL MIS 90 DHA Tier 3CITRANATAL MIS B-CALM Tier 3CITRANATAL PAK ASSURE Tier 3CITRANATAL PAK DHA Tier 3CITRANATAL TAB RX Tier 3CITRIC ACID/ SOL SOD CITR Tier 1CITROLITH TAB Tier 3CLARAVIS CAP 10MG Tier 3 XCLARAVIS CAP 20MG Tier 3 XCLARAVIS CAP 30MG Tier 3 XCLARAVIS CAP 40MG Tier 3 XCLARIFOAM EF AER 10-5% Tier 3CLARIS WASH EMU 10-4% Tier 1CLARITHROMYC SUS 125/5ML Tier 2CLARITHROMYC SUS 250/5ML Tier 3CLARITHROMYC TAB 250MG Tier 1CLARITHROMYC TAB 500MG Tier 1CLARITHROMYC TAB 500MG ER Tier 3CLEMASTINE SYP 0.5/5ML Tier 1CLEOCIN CAP 150MG Tier 3CLEOCIN CAP 300MG Tier 3CLEOCIN CAP 75MG Tier 2CLEOCIN CRE 2% VAG Tier 3CLEOCIN PED SOL 75MG/5ML Tier 3CLEOCIN SUP 100MG Tier 2CLEOCIN-T GEL 1% Tier 3 XCLEOCIN-T LOT 1% Tier 3CLEOCIN-T PAD 1% Tier 3CLEOCIN-T SOL 1% Tier 3CLIMARA DIS 0.025MG Tier 2 XCLIMARA DIS 0.0375MG Tier 2CLIMARA DIS 0.05MG Tier 2 XCLIMARA DIS 0.06MG Tier 2 XCLIMARA DIS 0.075MG Tier 2 XCLIMARA DIS 0.1MG Tier 2 XCLIMARA PRO DIS WEEKLY Tier 3 XCLINDACIN MIS ETZ 1% Tier 1CLINDACIN-P PAD 1% Tier 3CLINDAMAX GEL 1% Tier 3 XCLINDAMAX LOT 10MG/ML Tier 1CLINDAMY/BEN GEL 1.2-5% Tier 3

31


LimitStep

TherapySpecialty

Medication

CLINDAMYCIN AER 1% Tier 3 XCLINDAMYCIN CAP 150MG Tier 1CLINDAMYCIN CAP 300MG Tier 1CLINDAMYCIN CAP 75MG Tier 1CLINDAMYCIN CRE 2% VAG Tier 1CLINDAMYCIN GEL 1% Tier 3 XCLINDAMYCIN LOT 1% Tier 1CLINDAMYCIN LOT 10MG/ML Tier 1CLINDAMYCIN PAD 1% Tier 1CLINDAMYCIN SOL 1% Tier 1CLINDAMYCIN SOL 75MG/5ML Tier 3CLINDESSE CRE 2% Tier 2CLINPRO 5000 PST 1.1% Tier 1CLOBETASOL CRE 0.05% Tier 1CLOBETASOL E CRE 0.05% Tier 1CLOBETASOL GEL 0.05% Tier 1CLOBETASOL OIN 0.05% Tier 1CLOBETASOL SOL 0.05% Tier 1CLOBEX SPR 0.05% Tier 3 XCLOCORTOLONE CRE PIV 0.1% Tier 3 X XCLOMIPRAMINE CAP 25MG Tier 1CLOMIPRAMINE CAP 50MG Tier 1CLOMIPRAMINE CAP 75MG Tier 1CLONAZEP ODT TAB 0.125MG Tier 1CLONAZEP ODT TAB 0.25MG Tier 1CLONAZEP ODT TAB 0.5MG Tier 1CLONAZEP ODT TAB 1MG Tier 1CLONAZEP ODT TAB 2MG Tier 1CLONAZEPAM TAB 0.5MG Tier 1CLONAZEPAM TAB 1MG Tier 1CLONAZEPAM TAB 2MG Tier 1CLONIDINE DIS 0.1/24HR Tier 3 XCLONIDINE DIS 0.2/24HR Tier 3 XCLONIDINE DIS 0.3/24HR Tier 3 XCLONIDINE TAB 0.1MG Tier 1CLONIDINE TAB 0.2MG Tier 1CLONIDINE TAB 0.3MG Tier 1CLOPIDOGREL TAB 300MG Tier 1CLOPIDOGREL TAB 75MG Tier 1CLORAZ DIPOT TAB 15MG Tier 1CLORAZ DIPOT TAB 3.75MG Tier 1CLORAZ DIPOT TAB 7.5MG Tier 1CLORPRES TAB 0.1-15MG Tier 2CLORPRES TAB 0.2-15MG Tier 2CLORPRES TAB 0.3-15MG Tier 2

32


LimitStep

TherapySpecialty

Medication

CLOTRIM/BETA CRE 1-0.05% Tier 1 XCLOTRIM/BETA CRE DIPROP Tier 1 XCLOTRIM/BETA LOT DIPROP Tier 1CLOTRIMAZOLE LOZ 10MG Tier 1CLOTRIMAZOLE TRO 10MG Tier 1CLOZAPINE TAB 100/ODT Tier 1CLOZAPINE TAB 100MG Tier 1CLOZAPINE TAB 12.5/ODT Tier 1CLOZAPINE TAB 200MG Tier 1CLOZAPINE TAB 25MG Tier 1CLOZAPINE TAB 25MG ODT Tier 1CLOZAPINE TAB 50MG Tier 1CLOZARIL TAB 100MG Tier 3CLOZARIL TAB 25MG Tier 3C-NATE DHA CAP 28-1-200 Tier 3CNL8 NAIL KIT Tier 3COAL TAR SOL 20% Tier 3COARTEM TAB 20-120MG Tier 2COCAINE HCL SOL 10% Tier 1COCAINE HCL SOL 4% Tier 1CODEINE SULF SOL 30MG/5ML Tier 1CODEINE SULF TAB 30MG Tier 1CODEINE SULF TAB 60MG Tier 1COLAZAL CAP 750MG Tier 3COLCRYS TAB 0.6MG Tier 2COLESTID FLA GRA 5/7.5GM Tier 3COLESTID FLA GRA 5GM Tier 3COLESTID GRA 5GM Tier 3COLESTID POW 5GM Tier 3COLESTID TAB 1GM Tier 3COLESTIPOL GRA 5GM Tier 1COLESTIPOL TAB 1GM Tier 1COLISTIMETH INJ 150MG Tier 1COLLODION LIQ FLEXIBLE Tier 3COLOCORT ENE 100MG Tier 1COLY-MYCIN M INJ 150MG Tier 3COLY-MYCIN S SUS OTIC Tier 3COLYTE SOL Tier 3COLYTE/FLAVR SOL PACKS Tier 2COLYTE-FLAV SOL Tier 3COMBIGAN SOL 0.2/0.5% Tier 2 XCOMBIPATCH DIS .05/.14 Tier 3 XCOMBIPATCH DIS .05/.25 Tier 3 XCOMBIVENT AER RESPIMAT Tier 3 XCOMBIVIR TAB 150-300 Tier 3 X

33


LimitStep

TherapySpecialty

Medication

COMETRIQ KIT 100MG Tier 2 X XCOMETRIQ KIT 140MG Tier 2 X XCOMETRIQ KIT 60MG Tier 2 X X XCOMFORT SET MIS 23"/17MM Tier 3COMFORT SET MIS 31"/17MM Tier 2COMFORT SET MIS 32"/17MM Tier 3COMFORT SET MIS 43"/17MM Tier 3COMFORT SHRT MIS 23"/13MM Tier 3COMFORT SHRT MIS 31"/13MM Tier 2COMFORT SHRT MIS 32"/13MM Tier 3COMFORT SHRT MIS 43"/13MM Tier 3COMPAZINE PAK 5MG Tier 3COMPAZINE SUP 25MG Tier 1COMPAZINE TAB 10MG Tier 3COMPLERA TAB Tier 2 XCOMPLETE NAT PAK DHA Tier 1COMPLETENATE CHW Tier 1COMPRO SUP 25MG Tier 1COMTAN TAB 200MG Tier 3CO-NATAL FA TAB 29-1MG Tier 2CONCEPT DHA CAP Tier 3CONCEPT OB CAP Tier 3CONCERTA TAB 18MG Tier 2 X XCONCERTA TAB 27MG Tier 2 X XCONCERTA TAB 36MG Tier 2 X XCONCERTA TAB 54MG Tier 2 X XCONDYLOX GEL 0.5% Tier 3CONDYLOX SOL 0.5% Tier 3CONGESTANT TAB Tier 1CONSTULOSE SOL 10GM/15 Tier 1CONTROLRX CRE 1.1% Tier 1CONTROLRX PST 1.1% Tier 1COPAXONE KIT 20MG/ML Tier 2 X X XCOPEGUS TAB 200MG Tier 3 XCORDARONE TAB 200MG Tier 3CORDRAN 24X3 TAP 4MCG/CM Tier 3CORDRAN 24X3 TAP SML 24IN Tier 3CORDRAN 80X3 TAP 4MCG/CM Tier 3CORDRAN LOT 0.05% Tier 3 X XCORDRAN OIN 0.05% Tier 3CORDRAN SP CRE 0.05% Tier 3 X X COREG TAB 12.5MG Tier 3COREG TAB 25MG Tier 3COREG TAB 3.125MG Tier 3COREG TAB 6.25MG Tier 3

34


LimitStep

TherapySpecialty

Medication

CORGARD TAB 20MG Tier 3CORGARD TAB 40MG Tier 3CORGARD TAB 80MG Tier 3CORIFACT KIT Tier 2 XCORMAX SCALP SOL 0.05% Tier 1CORTALO GEL 2% Tier 1CORTANE-B DRO AQ OTIC Tier 2CORTANE-B DRO OTIC Tier 2CORTANE-B LOT Tier 3CORTEF TAB 10MG Tier 3CORTEF TAB 20MG Tier 3CORTEF TAB 5MG Tier 3CORTENEMA ENE 100MG Tier 3CORTIC-ND DRO Tier 1CORTIFOAM AER 90MG Tier 2CORTISONE AC TAB 25MG Tier 1CORTISPORIN CRE 0.5% Tier 2CORTISPORIN OIN 1% Tier 3CORTISPORIN SOL 1% OTIC Tier 3CORTISPORIN SUS -TC OTIC Tier 3CORTROSYN INJ 0.25MG Tier 3CORZIDE TAB 40-5MG Tier 3CORZIDE TAB 80-5MG Tier 3COSOPT SOL 2-0.5%OP Tier 3COSYNTROPIN INJ 0.25MG Tier 1COUMADIN TAB 10MG Tier 2COUMADIN TAB 1MG Tier 2COUMADIN TAB 2.5MG Tier 2COUMADIN TAB 2MG Tier 2COUMADIN TAB 3MG Tier 2COUMADIN TAB 4MG Tier 2COUMADIN TAB 5MG Tier 2COUMADIN TAB 6MG Tier 2COUMADIN TAB 7.5MG Tier 2COVARYX HS TAB Tier 1COVARYX TAB Tier 1COZAAR TAB 100MG Tier 3COZAAR TAB 25MG Tier 3COZAAR TAB 50MG Tier 3CPB WC LIQ Tier 3CREON CAP 12000UNT Tier 2CREON CAP 24000UNT Tier 2CREON CAP 3000UNIT Tier 2CREON CAP 36000UNT Tier 2CREON CAP 6000UNIT Tier 2

35


LimitStep

TherapySpecialty

Medication

CRESTOR TAB 10MG Tier 2 XCRESTOR TAB 20MG Tier 2 XCRESTOR TAB 40MG Tier 2 XCRESTOR TAB 5MG Tier 2 XCRESYLATE SOL 25% OTIC Tier 2CRINONE GEL 4% VAG Tier 2CRINONE GEL 8% VAG Tier 2 XCRIXIVAN CAP 200MG Tier 2 XCRIXIVAN CAP 400MG Tier 2 XCRNATAL PAK Tier 3CROMOLYN SOD CON 100/5ML Tier 1CROMOLYN SOD NEB 20MG/2ML Tier 1CROMOLYN SOD SOL 4% OP Tier 1CRYOSERV SOL Tier 3CRYSELLE-28 TAB 28 TABS Tier 1CUPRIMINE CAP 250MG Tier 2 XCUTIVATE CRE 0.05% Tier 3 XCUTIVATE LOT 0.05% Tier 3 XCUTIVATE OIN 0.005% Tier 3CUVPOSA SOL 1MG/5ML Tier 3CYANOCOBAL POW Tier 3CYCLACILLIN TAB 500MG Tier 1CYCLAFEM TAB 1/35 Tier 1CYCLAFEM TAB 7/7/7 Tier 3CYCLESSA PAK Tier 3CYCLOBENZAPR KIT COMFORT Tier 3CYCLOBENZAPR TAB 10MG Tier 1CYCLOBENZAPR TAB 5MG Tier 1CYCLOBENZAPR TAB 7.5MG Tier 1CYCLOGYL SOL 0.5% OP Tier 3CYCLOGYL SOL 1% OP Tier 3CYCLOGYL SOL 2% OP Tier 3CYCLOMYDRIL SOL OP Tier 3CYCLOPENTOL SOL 1% OP Tier 1CYCLOPENTOL SOL 2% OP Tier 1CYCLOPHOSPH TAB 25MG Tier 1 XCYCLOPHOSPH TAB 50MG Tier 1 XCYCLOPHOSPHA POW Tier 3 XCYCLOSERINE CAP 250MG Tier 1CYCLOSET TAB 0.8MG Tier 3CYCLOSPORINE CAP 100MG Tier 1 XCYCLOSPORINE CAP 100MG MD Tier 1 XCYCLOSPORINE CAP 25MG Tier 1 XCYCLOSPORINE CAP 25MG MOD Tier 1 XCYCLOSPORINE CAP 50MG MOD Tier 1 X

36


LimitStep

TherapySpecialty

Medication

CYCLOSPORINE SOL MODIFIED Tier 1 XCYOTIC DRO Tier 1CYPROHEPTAD SYP 2MG/5ML Tier 1CYPROHEPTAD TAB 4MG Tier 1CYSTADANE POW Tier 2 XCYSTAGON CAP 150MG Tier 2CYSTAGON CAP 50MG Tier 2CYSTARAN SOL 0.44% Tier 2 X X XCYTOMEL TAB 25MCG Tier 3CYTOMEL TAB 50MCG Tier 3CYTOMEL TAB 5MCG Tier 3CYTOTEC TAB 100MCG Tier 3CYTOTEC TAB 200MCG Tier 3CYTRA K GRA CRYSTALS Tier 1CYTRA-2 SOL Tier 1CYTRA-3 SYP Tier 1CYTRA-K SOL Tier 1D.H.E. 45 INJ 1MG/ML Tier 3DALIRESP TAB 500MCG Tier 3 X XDANAZOL CAP 100MG Tier 1DANAZOL CAP 200MG Tier 1DANAZOL CAP 50MG Tier 1DANTRIUM CAP 25MG Tier 3DANTRIUM CAP 50MG Tier 3DANTROLENE CAP 100MG Tier 1DANTROLENE CAP 25MG Tier 1DANTROLENE CAP 50MG Tier 1DAPSONE TAB 100MG Tier 2DAPSONE TAB 25MG Tier 2DARAPRIM TAB 25MG Tier 2DASETTA TAB 1/35 Tier 1DASETTA TAB 7/7/7 Tier 3DAYPRO TAB 600MG Tier 3DAYSEE TAB Tier 3 XDDAVP INJ 4MCG/ML Tier 3DDAVP SOL 0.01% Tier 3DDAVP SPR 0.01% Tier 3DDAVP TAB 0.1MG Tier 3DDAVP TAB 0.2MG Tier 3DEBACTEROL SOL 30-50% Tier 2DECON-A ELX 2-5MG/5M Tier 3DECON-G DRO 2-1-40MG Tier 2DECONSAL SR CAP SPRINKLE Tier 1DECONSAL TAB L.A. Tier 1DECONSAL-II TAB Tier 3

37


LimitStep

TherapySpecialty

Medication

DELTASONE TAB 20MG Tier 1DELYLA TAB 0.1-0.02 Tier 1DEMADEX TAB 100MG Tier 3DEMADEX TAB 10MG Tier 3DEMADEX TAB 20MG Tier 3DEMADEX TAB 5MG Tier 3DEMECLOCYCL TAB 150MG Tier 1DEMECLOCYCL TAB 300MG Tier 1DEMEROL TAB 100MG Tier 3DEMEROL TAB 50MG Tier 3DEMSER CAP 250MG Tier 3DENATURED SOL ALCOHOL Tier 3DENTA 5000 CRE PLUS Tier 1DENTA 5000 CRE PLUS 2PK Tier 1DENTAGEL GEL 1.1% Tier 1DEPAKENE CAP 250MG Tier 3DEPAKENE SYP 250/5ML Tier 3DEPAKOTE ER TAB 250MG Tier 3 X XDEPAKOTE ER TAB 500MG Tier 3 X XDEPAKOTE SPR CAP 125MG Tier 3 X XDEPAKOTE TAB 125MG DR Tier 3 XDEPAKOTE TAB 250MG DR Tier 3 XDEPAKOTE TAB 500MG DR Tier 3 XDEPEN TITRA TAB 250MG Tier 2DEPO-PROVERA INJ 150MG/ML Tier 3 XDEPO-SQ PROV INJ 104 Tier 2 XDEPO-TESTOST INJ 100MG/ML Tier 3DEPO-TESTOST INJ 200MG/ML Tier 3DERMANIC TAB Tier 3DERMA-SMOOTH OIL /FS BODY Tier 3 XDERMA-SMOOTH OIL /FS SCLP Tier 3 XDERMATODORON LIQ Tier 3DERMATOP CRE 0.1% Tier 3DERMATOP OIN 0.1% Tier 3DERMAZENE CRE 1% Tier 1DERMOTIC OIL 0.01% Tier 3DESIPRAMINE TAB 100MG Tier 1DESIPRAMINE TAB 10MG Tier 1DESIPRAMINE TAB 150MG Tier 1DESIPRAMINE TAB 25MG Tier 1DESIPRAMINE TAB 50MG Tier 1DESIPRAMINE TAB 75MG Tier 1DESMOPRESSIN INJ 4MCG/ML Tier 1DESMOPRESSIN SOL 0.01% Tier 1DESMOPRESSIN SPR 0.01% Tier 1

38


LimitStep

TherapySpecialty

Medication

DESMOPRESSIN TAB 0.1MG Tier 1DESMOPRESSIN TAB 0.2MG Tier 1DESO/ETHINYL TAB ESTRADIO Tier 3DESOGEN-28 TAB Tier 3DESONATE GEL 0.05% Tier 3 X XDESONIDE CRE 0.05% Tier 3 XDESONIDE LOT 0.05% Tier 3 XDESONIDE OIN 0.05% Tier 3 XDESOWEN CRE 0.05% Tier 3 XDESOWEN LOT 0.05% Tier 3 XDESOWEN OIN 0.05% Tier 3 XDESOXIMETAS CRE 0.05% Tier 1 XDESOXIMETAS CRE 0.25% Tier 1 XDESOXIMETAS GEL 0.05% Tier 3 XDESOXIMETAS OIN 0.05% Tier 3 XDESOXIMETAS OIN 0.25% Tier 3 XDESOXYN TAB 5MG Tier 3 XDEXAMETH PHO SOL 0.1% OP Tier 1DEXAMETH SOD POW PHOSPHAT Tier 3DEXAMETHASON CON 1MG/ML Tier 1DEXAMETHASON ELX 0.5/5ML Tier 1DEXAMETHASON SOL 0.5/5ML Tier 1DEXAMETHASON TAB 0.5MG Tier 1DEXAMETHASON TAB 0.75MG Tier 1DEXAMETHASON TAB 1.5MG Tier 1DEXAMETHASON TAB 1MG Tier 1DEXAMETHASON TAB 2MG Tier 1DEXAMETHASON TAB 4MG Tier 1DEXAMETHASON TAB 6MG Tier 1DEXCHLORPHEN SYP 2MG/5ML Tier 1DEXEDRINE CAP 10MG CR Tier 3 XDEXEDRINE CAP 15MG CR Tier 3 XDEXEDRINE CAP 5MG CR Tier 3 XDEXILANT CAP 30MG DR Tier 3 XDEXILANT CAP 60MG DR Tier 3 XDEXMETHYLPH TAB 10MG Tier 1 XDEXMETHYLPH TAB 2.5MG Tier 1 XDEXMETHYLPH TAB 5MG Tier 1 XDEXPAK PAK 10 DAY Tier 3DEXPAK PAK 13 DAY Tier 3DEXPAK PAK 6 DAY Tier 3DEXTROAMPHET CAP 10MG ER Tier 3 XDEXTROAMPHET CAP 15MG ER Tier 3 XDEXTROAMPHET CAP 5MG ER Tier 3 XDEXTROAMPHET SOL 5MG/5ML Tier 1 X

39


LimitStep

TherapySpecialty

Medication

DEXTROAMPHET TAB 10MG Tier 3 XDEXTROAMPHET TAB 5MG Tier 3 XDIAB F.D.G. GEL Tier 3DIAB GEL Tier 3DIABETA TAB 1.25MG Tier 3DIABETA TAB 2.5MG Tier 3DIABETA TAB 5MG Tier 3DIAMOX SEQUE CAP 500MG CR Tier 3DIASTAT ACDL GEL 12.5-20 Tier 3 XDIASTAT ACDL GEL 5-10MG Tier 3 XDIASTAT PED GEL 2.5M GEL Tier 2 XDIAZEPAM CON 5MG/ML Tier 2DIAZEPAM GEL 10MG Tier 1 XDIAZEPAM GEL 2.5MG Tier 1 XDIAZEPAM GEL 20MG Tier 1 XDIAZEPAM SOL 1MG/ML Tier 1DIAZEPAM TAB 10MG Tier 1DIAZEPAM TAB 2MG Tier 1DIAZEPAM TAB 5MG Tier 1DIBENZYLINE CAP 10MG Tier 2DICLEGIS TAB 10-10MG Tier 3DICLO/MISOPR TAB 50-0.2MG Tier 3DICLO/MISOPR TAB 75-0.2MG Tier 3DICLOFEN POT TAB 50MG Tier 1DICLOFENAC GEL 3% Tier 3DICLOFENAC SOL 0.1% OP Tier 1DICLOFENAC TAB 100MG ER Tier 1DICLOFENAC TAB 25MG DR Tier 1DICLOFENAC TAB 50MG DR Tier 1DICLOFENAC TAB 75MG DR Tier 1DICLOXACILL CAP 250MG Tier 1DICLOXACILL CAP 500MG Tier 1DICYCLOMINE CAP 10MG Tier 1DICYCLOMINE SOL 10MG/5ML Tier 1DICYCLOMINE TAB 20MG Tier 1DIDANOSINE CAP 125MG Tier 1 XDIDANOSINE CAP 200MG Tier 1 XDIDANOSINE CAP 250MG Tier 1 XDIDANOSINE CAP 400MG Tier 1 XDIFFERIN CRE 0.1% Tier 2 XDIFFERIN GEL 0.1% Tier 2 XDIFFERIN GEL 0.3% Tier 3 XDIFFERIN LOT 0.1% Tier 3 XDIFICID TAB 200MG Tier 3 XDIFIL-G FORT LIQ 100-100 Tier 1

40


LimitStep

TherapySpecialty

Medication

DIFLORASONE CRE 0.05% Tier 3DIFLORASONE OIN 0.05% Tier 3DIFLUCAN SUS 10MG/ML Tier 3DIFLUCAN SUS 40MG/ML Tier 3DIFLUCAN TAB 100MG Tier 3DIFLUCAN TAB 150MG Tier 3DIFLUCAN TAB 200MG Tier 3DIFLUCAN TAB 50MG Tier 3DIFLUNISAL TAB 500MG Tier 1DIGESTODORON LIQ Tier 3DIGIBAR 190 SUS Tier 3DIGOX TAB 0.125MG Tier 1DIGOX TAB 0.25MG Tier 1DIGOXIN SOL 50MCG/ML Tier 1DIGOXIN TAB 0.125MG Tier 1DIGOXIN TAB 0.25MG Tier 1DIHYDROCOD/ CAP ASA/CAFF Tier 1DIHYDROERGOT INJ 1MG/ML Tier 1DIHYDROERGOT POW MESYLATE Tier 3DIHYDROERGOT SPR 4MG/ML Tier 1DILANTIN CAP 100MG Tier 2DILANTIN CAP 30MG Tier 2DILANTIN CHW 50MG Tier 2DILANTIN-125 SUS 125/5ML Tier 2DILATRATE SR CAP 40MG Tier 3DILAUDID LIQ 1MG/ML Tier 3DILAUDID TAB 2MG Tier 3DILAUDID TAB 4MG Tier 3DILAUDID TAB 8MG Tier 3DILTIAZEM CAP 120MG CD Tier 3DILTIAZEM CAP 120MG ER Tier 1 DILTIAZEM CAP 120MG/24 Tier 3DILTIAZEM CAP 180MG CD Tier 3DILTIAZEM CAP 180MG ER Tier 1 DILTIAZEM CAP 180MG/24 Tier 3DILTIAZEM CAP 240MG CD Tier 3DILTIAZEM CAP 240MG ER Tier 1 DILTIAZEM CAP 240MG/24 Tier 3DILTIAZEM CAP 300MG CD Tier 3DILTIAZEM CAP 300MG ER Tier 3DILTIAZEM CAP 300MG/24 Tier 3DILTIAZEM CAP 360MG CD Tier 3DILTIAZEM CAP 360MG ER Tier 3DILTIAZEM CAP 360MG/24 Tier 3DILTIAZEM CAP 420MG/24 Tier 3

41


LimitStep

TherapySpecialty

Medication

DILTIAZEM CAP 60MG ER Tier 1DILTIAZEM CAP 90MG ER Tier 1DILTIAZEM ER TAB 180MG Tier 3DILTIAZEM ER TAB 240MG Tier 3DILTIAZEM ER TAB 300MG Tier 3DILTIAZEM ER TAB 360MG Tier 3DILTIAZEM ER TAB 420MG Tier 3DILTIAZEM TAB 120MG Tier 1DILTIAZEM TAB 30MG Tier 1DILTIAZEM TAB 60MG Tier 1DILTIAZEM TAB 90MG Tier 1DILT-XR CAP 120MG Tier 1DILT-XR CAP 180MG Tier 1DILT-XR CAP 240MG Tier 1DIOVAN TAB 160MG Tier 3 XDIOVAN TAB 320MG Tier 3 XDIOVAN TAB 40MG Tier 3 XDIOVAN TAB 80MG Tier 3 XDIPENTUM CAP 250MG Tier 3DIPHEN/ATROP LIQ 2.5/5 Tier 1DIPHEN/ATROP TAB 2.5MG Tier 1DIPROLENE AF CRE 0.05% Tier 3DIPROLENE LOT 0.05% Tier 3DIPROLENE OIN 0.05% Tier 3DIPYRIDAMOLE TAB 25MG Tier 1DIPYRIDAMOLE TAB 50MG Tier 1DIPYRIDAMOLE TAB 75MG Tier 1DISCUS LIQ COMPOSIT Tier 3DISOPYRAMIDE CAP 100MG Tier 1DISOPYRAMIDE CAP 150MG Tier 1DISULFIRAM TAB 250MG Tier 1DISULFIRAM TAB 500MG Tier 1DITROPAN XL TAB 10MG Tier 3DITROPAN XL TAB 15MG Tier 3DITROPAN XL TAB 5MG Tier 3DIURIL SUS 250/5ML Tier 2DIVALPROEX CAP 125MG Tier 3DIVALPROEX TAB 125MG DR Tier 1DIVALPROEX TAB 250MG DR Tier 1DIVALPROEX TAB 250MG ER Tier 1DIVALPROEX TAB 500MG DR Tier 1DIVALPROEX TAB 500MG ER Tier 1DIVIGEL GEL 0.25MG Tier 2DIVIGEL GEL 0.5MG Tier 2DIVIGEL GEL 1MG/GM Tier 2

42


LimitStep

TherapySpecialty

Medication

DM/CPM/PE DRO Tier 1DOBELLS SOL Tier 1DOLOPHINE TAB 10MG Tier 3DOLOPHINE TAB 5MG Tier 3DONEPEZIL TAB 10MG Tier 1DONEPEZIL TAB 10MG ODT Tier 3DONEPEZIL TAB 5MG Tier 1DONEPEZIL TAB 5MG ODT Tier 3DONNATAL ELX Tier 3DONNATAL TAB Tier 3DONNATAL TAB 16.2MG Tier 3DONNATAL TAB EXTENTAB Tier 3DORAL TAB 15MG Tier 3DORZOL/TIMOL SOL 2-0.5%OP Tier 3DORZOLAMIDE SOL 2% OP Tier 1DOVONEX CRE 0.005% Tier 3 XDOXAZOSIN TAB 1MG Tier 1DOXAZOSIN TAB 2MG Tier 1DOXAZOSIN TAB 4MG Tier 1DOXAZOSIN TAB 8MG Tier 1DOXEPIN HCL CAP 100MG Tier 1DOXEPIN HCL CAP 10MG Tier 1DOXEPIN HCL CAP 150MG Tier 1DOXEPIN HCL CAP 25MG Tier 1DOXEPIN HCL CAP 50MG Tier 1DOXEPIN HCL CAP 75MG Tier 1DOXEPIN HCL CON 10MG/ML Tier 1DOXERCALCIF CAP 0.5MCG Tier 1DOXERCALCIF CAP 1MCG Tier 1DOXERCALCIF CAP 2.5MCG Tier 1DOXYCYC MONO CAP 100MG Tier 1DOXYCYC MONO CAP 50MG Tier 1DOXYCYC MONO TAB 100MG Tier 1DOXYCYC MONO TAB 50MG Tier 1DOXYCYC MONO TAB 75MG Tier 1DOXYCYCL HYC CAP 100MG Tier 3DOXYCYCL HYC CAP 50MG Tier 3DOXYCYCL HYC TAB 100MG Tier 3DOXYCYCLINE POW HYCLATE Tier 3DOXYCYCLINE SUS 25MG/5ML Tier 3DOXYCYCLINE TAB 20MG Tier 1DOXYTEX LIQ Tier 2DPI VERSIFIX LIQ Tier 1DRISDOL CAP 50000UNT Tier 3DRITHO-CREME CRE HP 1% Tier 2

43


LimitStep

TherapySpecialty

Medication

DRONABINOL CAP 10MG Tier 1DRONABINOL CAP 2.5MG Tier 1DRONABINOL CAP 5MG Tier 1DROSPIR/ETHI TAB 3-0.03MG Tier 3DROXIA CAP 200MG Tier 2 XDROXIA CAP 300MG Tier 2 XDROXIA CAP 400MG Tier 2 XDRYSOL SOL 20% Tier 3DUAVEE TAB 0.45-20 Tier 3DUET DHA 400 MIS 25-1-400 Tier 3DUET DHA 430 MIS 25-1-430 Tier 3DUET DHA MIS BALANCED Tier 3DUETACT TAB 30-2MG Tier 3 XDUETACT TAB 30-4MG Tier 3 XDULERA AER 100-5MCG Tier 3 XDULERA AER 200-5MCG Tier 3 XDULOXETINE CAP 20MG Tier 3 XDULOXETINE CAP 30MG Tier 3 XDULOXETINE CAP 60MG Tier 3 XDURAXIN CAP Tier 1DUREZOL EMU 0.05% Tier 3DUTOPROL TAB 100-12.5 Tier 2 XDUTOPROL TAB 25-12.5 Tier 2 XDUTOPROL TAB 50-12.5 Tier 2 XDYAZIDE CAP 37.5-25 Tier 3DYRENIUM CAP 100MG Tier 3DYRENIUM CAP 50MG Tier 3E.E.S. 400 TAB 400MG Tier 3E.E.S. GRAN SUS 200/5ML Tier 3EASIVENT MIS Tier 3EASIVENT MIS MASK LG Tier 3EASIVENT MIS MASK MED Tier 3EASIVENT MIS MASK SM Tier 3EASYGEL GEL 0.4% Tier 1EASYGEL GEL 0.4%CHRY Tier 1EASYGEL GEL 0.4%CITR Tier 1EASYGEL GEL 0.4%MINT Tier 1EC-NAPROSYN TAB 375MG Tier 3EC-NAPROSYN TAB 500MG Tier 3ECONAZOLE CRE 1% Tier 1ECZEMOL TAB Tier 3ED CYTE F TAB Tier 3EDARBI TAB 40MG Tier 3 XEDARBI TAB 80MG Tier 3 XEDARBYCLOR TAB 40-12.5 Tier 3 X

44


LimitStep

TherapySpecialty

Medication

EDARBYCLOR TAB 40-25MG Tier 3 XED-CHLOR-TAN TAB 8MG Tier 2EDECRIN TAB 25MG Tier 3EDEX KIT 10MCG Tier 3 XEDEX KIT 20MCG Tier 3 XEDEX KIT 40MCG Tier 3 XED-FLEX CAP Tier 1ED-SPAZ TAB 0.125MG Tier 1EDURANT TAB 25MG Tier 2 XEFFER-K TAB 10MEQ Tier 2EFFER-K TAB 20MEQ Tier 2EFFER-K TAB 25MEQ EF Tier 1EFFIENT TAB 10MG Tier 3 XEFFIENT TAB 5MG Tier 3 XEFUDEX CRE 5% Tier 3EGRIFTA SOL 2MG Tier 3 XELDEPRYL CAP 5MG Tier 3ELENZAPATCH DIS 4-1% Tier 3ELESTRIN GEL 0.06% Tier 3ELETONE CRE Tier 3ELETONE CRE TWINPACK Tier 3ELIDEL CRE 1% Tier 3 X XELIGARD INJ 22.5MG Tier 3 X XELIGARD INJ 30MG Tier 3 X XELIGARD INJ 45MG Tier 3 X XELIGARD INJ 7.5MG Tier 3 X XELIMITE CRE 5% Tier 3ELINEST TAB Tier 1ELIPHOS TAB 667MG Tier 1ELIQUIS TAB 2.5MG Tier 3 XELIQUIS TAB 5MG Tier 3 XELITE-OB TAB Tier 3ELIXOPHYLLIN ELX 80/15ML Tier 3ELLA TAB 30MG Tier 1 XELMIRON CAP 100MG Tier 2ELOCON CRE 0.1% Tier 3ELOCON LOT 0.1% Tier 3ELOCON OIN 0.1% Tier 3EMCYT CAP 140MG Tier 2 XEMEND CAP 125MG Tier 2 XEMEND CAP 40MG Tier 2 XEMEND CAP 80MG Tier 2 XEMEND PAK 80 & 125 Tier 2 XEMLA CRE 2.5-2.5% Tier 3EMOQUETTE TAB Tier 1

45


LimitStep

TherapySpecialty

Medication

EMSAM DIS 12MG/24H Tier 3EMSAM DIS 6MG/24HR Tier 3EMSAM DIS 9MG/24HR Tier 3EMTRIVA CAP 200MG Tier 2 XEMTRIVA SOL 10MG/ML Tier 2 XEMULSION SB EMU Tier 3ENALAPR/HCTZ TAB 10-25MG Tier 1ENALAPR/HCTZ TAB 5-12.5MG Tier 1ENALAPRIL TAB 10MG Tier 1ENALAPRIL TAB 2.5MG Tier 1ENALAPRIL TAB 20MG Tier 1ENALAPRIL TAB 5MG Tier 1ENBREL INJ 25/0.5ML Tier 3 X X X XENBREL INJ 25MG Tier 3 X X X XENBREL INJ 50MG/ML Tier 3 X X X XENBREL SRCLK INJ 50MG/ML Tier 3 X X X XENDOCET TAB 10-325MG Tier 1 XENDOCET TAB 2.5-325 Tier 1 XENDOCET TAB 5-325MG Tier 1 XENDOCET TAB 7.5-325 Tier 1 XENDODAN TAB Tier 1ENDOMETRIN SUP 100MG Tier 3 XENJUVIA TAB 0.3MG Tier 3ENJUVIA TAB 0.45MG Tier 3ENJUVIA TAB 0.625MG Tier 3ENJUVIA TAB 0.9MG Tier 3ENJUVIA TAB 1.25MG Tier 3ENLITE MIS SERTER Tier 3ENLYTE CAP Tier 3ENOXAPARIN INJ 100MG/ML Tier 3 XENOXAPARIN INJ 120/0.8 Tier 3 XENOXAPARIN INJ 150MG/ML Tier 3 XENOXAPARIN INJ 30/0.3ML Tier 3 XENOXAPARIN INJ 300/3ML Tier 3 XENOXAPARIN INJ 40/0.4ML Tier 3 XENOXAPARIN INJ 60/0.6ML Tier 3 XENOXAPARIN INJ 80/0.8ML Tier 3 XENPRESSE-28 TAB Tier 1ENSKYCE TAB Tier 1ENTACAPONE TAB 200MG Tier 1ENTERAGAM POW 5GM Tier 3ENTEREG CAP 12MG Tier 3ENTERO VU POW 13% Tier 3ENTERO VU SUS 13% Tier 3ENTERO VU SUS 24% Tier 3

46


LimitStep

TherapySpecialty

Medication

ENULOSE SOL 10GM/15 Tier 1EPANED SOL 1MG/ML Tier 3 XEPICERAM EMU Tier 3EPIDUO GEL 0.1-2.5% Tier 3 XEPIFOAM AER 1% Tier 2EPINEPHR HCL SOL 2% OP Tier 1EPIPEN 2-PAK INJ 0.3MG Tier 2 XEPIPEN-JR INJ 2-PAK Tier 2 XEPIQUIN MICR CRE 4% Tier 3EPISONE CRE Tier 1EPITOL TAB 200MG Tier 1EPIVIR HBV SOL 5MG/ML Tier 2 XEPIVIR HBV TAB 100MG Tier 3 XEPIVIR SOL 10MG/ML Tier 2 XEPIVIR TAB 150MG Tier 3 XEPIVIR TAB 300MG Tier 3 XEPLERENONE TAB 25MG Tier 3EPLERENONE TAB 50MG Tier 3EPOGEN INJ 10000/ML Tier 2 X XEPOGEN INJ 2000/ML Tier 2 X XEPOGEN INJ 20000/ML Tier 2 X XEPOGEN INJ 3000/ML Tier 2 X XEPOGEN INJ 4000/ML Tier 2 X XEPROSART MES TAB 600MG Tier 1 XEPZICOM TAB 600-300 Tier 2 XEQUAGESIC TAB 200-325 Tier 3EQUETRO CAP 100MG Tier 3EQUETRO CAP 200MG Tier 3EQUETRO CAP 300MG Tier 3ERGOCALCIFER CAP 50000UNT Tier 1ERGOLOID MES TAB 1MG ORAL Tier 1ERGOMAR SUB 2MG Tier 2ERIVEDGE CAP 150MG Tier 2 X X XERRIN TAB 0.35MG Tier 3ERY PAD 2% Tier 1ERYGEL GEL 2% Tier 3ERYPED SUS 200/5ML Tier 3ERYPED SUS 400/5ML Tier 3ERYSIDORON LIQ #1 Tier 3ERY-TAB TAB 250MG EC Tier 2ERY-TAB TAB 333MG EC Tier 2ERY-TAB TAB 500MG EC Tier 2ERYTHROCIN TAB 250MG Tier 2ERYTHROM ETH TAB 400MG Tier 1ERYTHROMYCIN CAP 250MG EC Tier 1

47


LimitStep

TherapySpecialty

Medication

ERYTHROMYCIN GEL /BENZOYL Tier 1 XERYTHROMYCIN GEL 2% Tier 1ERYTHROMYCIN OIN 5MG/GM Tier 1ERYTHROMYCIN OIN OP Tier 1ERYTHROMYCIN PAD 2% Tier 1ERYTHROMYCIN SOL 2% Tier 1ERYTHROMYCIN TAB 250MG BS Tier 1ERYTHROMYCIN TAB 500MG BS Tier 1ESCAVITE CHW Tier 3ESCAVITE LQ DRO Tier 1ESCITALOPRAM SOL 5MG/5ML Tier 3ESCITALOPRAM TAB 10MG Tier 1ESCITALOPRAM TAB 20MG Tier 1ESCITALOPRAM TAB 5MG Tier 1ESGIC CAP Tier 3 XESGIC TAB Tier 3 XEST ESTROGEN TAB MTEST Tier 1EST ESTROGEN TAB MTEST DS Tier 1EST ESTROGEN TAB MTEST HS Tier 1ESTARYLLA TAB 0.25-35 Tier 3ESTAZOLAM TAB 1MG Tier 1ESTAZOLAM TAB 2MG Tier 1ESTRA/NORETH TAB 0.5-0.1 Tier 3ESTRA/NORETH TAB 1-0.5MG Tier 3ESTRACE TAB 0.5MG Tier 3ESTRACE TAB 1MG Tier 3ESTRACE TAB 2MG Tier 3ESTRACE VAG CRE 0.1MG/GM Tier 3ESTRADIOL DIS 0.025MG Tier 1 XESTRADIOL DIS 0.0375MG Tier 1ESTRADIOL DIS 0.05MG Tier 1 XESTRADIOL DIS 0.06MG Tier 1 XESTRADIOL DIS 0.075MG Tier 1 XESTRADIOL DIS 0.1MG Tier 1 XESTRADIOL TAB 0.5MG Tier 1ESTRADIOL TAB 1MG Tier 1ESTRADIOL TAB 2MG Tier 1ESTRING MIS 2MG Tier 2 XESTROGEL GEL Tier 3 XESTROPIPATE TAB 0.75MG Tier 1ESTROPIPATE TAB 1.5MG Tier 1ESTROPIPATE TAB 3MG Tier 1ESTROSTEP FE TAB Tier 3ESZOPICLONE TAB 1MG Tier 3 X XESZOPICLONE TAB 2MG Tier 3 X X

48


LimitStep

TherapySpecialty

Medication

ESZOPICLONE TAB 3MG Tier 3 X XETHAMBUTOL TAB 100MG Tier 1ETHAMBUTOL TAB 400MG Tier 1ETHOSUXIMIDE CAP 250MG Tier 1ETHOSUXIMIDE SOL 250/5ML Tier 1ETHYL CHLOR AER FINE PIN Tier 1ETHYL CHLOR AER FN STRM Tier 1ETHYL CHLOR AER MED JET Tier 1ETHYL CHLOR AER MED STRM Tier 1ETHYL CHLOR AER MIST Tier 1ETIDRON DISD TAB 200MG Tier 1ETIDRON DISD TAB 400MG Tier 1ETODOLAC CAP 200MG Tier 1ETODOLAC CAP 300MG Tier 1ETODOLAC ER TAB 400MG Tier 1ETODOLAC ER TAB 500MG Tier 1ETODOLAC ER TAB 600MG Tier 1ETODOLAC TAB 400MG Tier 1ETODOLAC TAB 500MG Tier 1ETOPOSIDE CAP 50MG Tier 1 XETOPOSIDE POW Tier 3 XEUCALYPTUS OIL Tier 1EURAX CRE 10% Tier 2EURAX LOT 10% Tier 3EVAMIST SPR 1.53MG Tier 2EVICEL KIT 2ML Tier 3EVICEL KIT 5ML Tier 3EVITHROM SOL 800-1200 Tier 3EVOCLIN AER 1% Tier 3 XEVOXAC CAP 30MG Tier 3EXACTUSS LIQ Tier 3EXALGO TAB 12MG Tier 3 X XEXALGO TAB 16MG Tier 3 X XEXALGO TAB 32MG Tier 3 X XEXALGO TAB 8MG Tier 3 X XEXELDERM CRE 1% Tier 3EXELDERM SOL 1% Tier 3EXELON CAP 1.5MG Tier 3EXELON CAP 3MG Tier 3EXELON CAP 4.5MG Tier 3EXELON CAP 6MG Tier 3EXELON DIS 13.3/24 Tier 3EXELON DIS 4.6MG/24 Tier 3EXELON DIS 9.5MG/24 Tier 3EXEMESTANE TAB 25MG Tier 3

49


LimitStep

TherapySpecialty

Medication

EXJADE TAB 125MG Tier 2 X XEXJADE TAB 250MG Tier 2 X XEXJADE TAB 500MG Tier 2 X XEXODERM LOT 25-1% Tier 1EXOTIC-HC DRO OTIC Tier 1EXTINA AER 2% Tier 3 XEXTRA-VIRT CAP PLUS DHA Tier 3E-Z SPACER MIS Tier 3E-Z SPACER MIS BODY GRD Tier 3E-Z-CAT DRY PAK Tier 3E-Z-DISK TAB 700MG Tier 3E-Z-DOSE ENE Tier 2E-Z-HD SUS 98% Tier 3EZIDE TAB 50MG Tier 1E-Z-PAQUE SUS 60% Tier 2E-Z-PAQUE SUS 96% Tier 2E-Z-PASTE CRE 60% Tier 2FACTIVE TAB 320MG Tier 3FALMINA TAB Tier 1FAMCICLOVIR TAB 125MG Tier 3 XFAMCICLOVIR TAB 250MG Tier 3 XFAMCICLOVIR TAB 500MG Tier 3 XFAMOTIDINE SUS 40MG/5ML Tier 1FAMVIR TAB 125MG Tier 3 XFAMVIR TAB 250MG Tier 3 XFAMVIR TAB 500MG Tier 3 XFANAPT PAK Tier 3 XFANAPT TAB 10MG Tier 3 XFANAPT TAB 12MG Tier 3 XFANAPT TAB 1MG Tier 3 XFANAPT TAB 2MG Tier 3 XFANAPT TAB 4MG Tier 3 XFANAPT TAB 6MG Tier 3 XFANAPT TAB 8MG Tier 3 XFARESTON TAB 60MG Tier 2FARXIGA TAB 10MG Tier 3 X X FARXIGA TAB 5MG Tier 3 X X FAZACLO TAB 100/ODT Tier 3FAZACLO TAB 12.5/ODT Tier 3FAZACLO TAB 150MG Tier 2FAZACLO TAB 200MG Tier 2FAZACLO TAB 25MG ODT Tier 3FEIBA NF INJ Tier 2 XFELBAMATE SUS 600/5ML Tier 1FELBAMATE TAB 400MG Tier 1

50


LimitStep

TherapySpecialty

Medication

FELBAMATE TAB 600MG Tier 1FELBATOL SUS 600/5ML Tier 3FELBATOL TAB 400MG Tier 3FELBATOL TAB 600MG Tier 3FELDENE CAP 10MG Tier 3FELDENE CAP 20MG Tier 3FELODIPINE TAB 10MG ER Tier 1FELODIPINE TAB 2.5MG ER Tier 1FELODIPINE TAB 5MG ER Tier 1FEM PH GEL Tier 3FEMCON FE CHW Tier 3FEMHRT TAB 0.5-2.5 Tier 3FEMRING MIS 0.05/24H Tier 3 XFEMRING MIS 0.1MG/24 Tier 3 XFENOFIBRATE TAB 160MG Tier 3FENOFIBRATE TAB 54MG Tier 3FENOPROFEN TAB 600MG Tier 1FENTANYL CIT INJ 0.05MG/1 Tier 1 XFENTANYL CIT INJ 1000MCG Tier 1 XFENTANYL CIT INJ 100MCG Tier 1 XFENTANYL CIT INJ 2500MCG Tier 1 XFENTANYL CIT INJ 250MCG Tier 1 XFENTANYL DIS 100MCG/H Tier 3 XFENTANYL DIS 12MCG/HR Tier 3 XFENTANYL DIS 25MCG/HR Tier 3 XFENTANYL DIS 50MCG/HR Tier 3FENTANYL DIS 75MCG/HR Tier 3 XFENTANYL OT LOZ 1200MCG Tier 3 X XFENTANYL OT LOZ 1600MCG Tier 3 X XFENTANYL OT LOZ 200MCG Tier 3 X XFENTANYL OT LOZ 400MCG Tier 3 X XFENTANYL OT LOZ 600MCG Tier 3 X XFENTANYL OT LOZ 800MCG Tier 3 X XFERRIPROX TAB 500MG Tier 3 X XFETZIMA CAP 120MG Tier 3 XFETZIMA CAP 20MG Tier 3 XFETZIMA CAP 40MG Tier 3 XFETZIMA CAP 80MG Tier 3 XFETZIMA CAP TITRATIO Tier 3 XFEXMID TAB 7.5MG Tier 3FINACEA GEL 15% Tier 3FINASTERIDE TAB 5MG Tier 1FIORICET CAP Tier 3FIORINAL CAP Tier 3FIRAZYR INJ 30MG/3ML Tier 3 X X X

51


LimitStep

TherapySpecialty

Medication

FIRMAGON INJ 120MG Tier 3 XFIRMAGON INJ 80MG Tier 3 XFIRST DUKES SUS MOUTHWSH Tier 3FIRST-MARYS SUS MOUTHWSH Tier 3FIRST-MOUTHW SUS BLM Tier 3FIRST-OMEPRA SUS 2MG/ML Tier 3FIRST-TESTOS CRE MC 2% Tier 3FIRST-TESTOS OIN 2% Tier 3FLAGYL CAP 375MG Tier 3FLAGYL ER TAB 750MG Tier 3FLAGYL TAB 250MG Tier 3FLAGYL TAB 500MG Tier 3FLAREX SUS 0.1% OP Tier 2FLAVOR BLEND SUS Tier 3FLAVOR PLUS LIQ Tier 3FLAVOR SWEET LIQ S/F Tier 3FLAVOR SWEET SYP Tier 3FLAVOXATE TAB 100MG Tier 1FLECAINIDE TAB 100MG Tier 1FLECAINIDE TAB 150MG Tier 1FLECAINIDE TAB 50MG Tier 1FLEXLINK MIS PLS/10MM Tier 2FLEXLINK MIS PLUS/6MM Tier 2FLEXLINK MIS PLUS/8MM Tier 2FLONASE SPR 0.05% Tier 3 XFLOVENT DISK AER 100MCG Tier 3 XFLOVENT DISK AER 250MCG Tier 3 XFLOVENT DISK AER 50MCG Tier 3 XFLOVENT HFA AER 110MCG Tier 3 XFLOVENT HFA AER 220MCG Tier 3 XFLOVENT HFA AER 44MCG Tier 3 XFLUCAINE SOL 0.25-0.5 Tier 1FLUCONAZOLE SUS 10MG/ML Tier 1FLUCONAZOLE SUS 40MG/ML Tier 1FLUCONAZOLE TAB 100MG Tier 1FLUCONAZOLE TAB 150MG Tier 1FLUCONAZOLE TAB 200MG Tier 1FLUCONAZOLE TAB 50MG Tier 1FLUCYTOSINE CAP 250MG Tier 1FLUCYTOSINE CAP 500MG Tier 1FLUDROCORT TAB 0.1MG Tier 1FLUMADINE TAB 100MG Tier 3FLUNISOLIDE SPR 0.025% Tier 3FLUOCIN ACET CRE 0.01% Tier 3 XFLUOCIN ACET CRE 0.025% Tier 3 X

52


LimitStep

TherapySpecialty

Medication

FLUOCIN ACET OIL 0.01% Tier 1FLUOCIN ACET OIL 0.01% SC Tier 3 XFLUOCIN ACET OIL BODY Tier 3 XFLUOCIN ACET OIL EAR0.01% Tier 1FLUOCIN ACET OIL SCALP Tier 3 XFLUOCIN ACET OIN 0.025% Tier 3 XFLUOCIN ACET SOL 0.01% Tier 3 XFLUOCINONIDE CRE 0.05% Tier 1FLUOCINONIDE CRE -E 0.05% Tier 1FLUOCINONIDE GEL 0.05% Tier 1FLUOCINONIDE OIN 0.05% Tier 1FLUOCINONIDE SOL 0.05% Tier 1FLUORABON DRO Tier 2FLUORACAINE SOL OP Tier 3FLUOR-A-DAY CHW 0.25MG F Tier 3FLUOR-A-DAY CHW 0.5MG F Tier 3FLUOR-A-DAY CHW 1MG F Tier 3FLUOR-A-DAY DRO 0.125MG Tier 1FLUORE-BENOX SOL 0.25-0.4 Tier 1FLUORESCEIN/ SOL PROPARAC Tier 1FLUORIDE CHW 0.25MG F Tier 1FLUORIDE CHW 0.5MG F Tier 1FLUORIDE CHW 1MG F Tier 1FLUORIDEX DD PST SENSITIV Tier 1FLUORIDEX GEL 1.1% Tier 1FLUORIDEX GEL SENSITIV Tier 3FLUORIDEX GEL WHITENIN Tier 1FLUOR-I-STRI TES 1MG OP Tier 1FLUORITAB CHW 0.25MG F Tier 1FLUORITAB CHW 0.5MG F Tier 1FLUORITAB CHW 1MG F Tier 1FLUORITAB CHW 2.2MG Tier 1FLUORITAB DRO 0.125MG Tier 1FLUOROMETHOL SUS 0.1% OP Tier 1FLUOROPLEX CRE 1% Tier 2FLUOROURACIL CRE 5% Tier 1FLUOROURACIL DRO 2% Tier 1 XFLUOROURACIL DRO 5% Tier 1 XFLUOROURACIL POW Tier 3 XFLUOROURACIL POW USP/NF Tier 3 XFLUOROURACIL SOL 2% Tier 1 XFLUOROURACIL SOL 5% Tier 1 XFLUOXETINE CAP 10MG Tier 1FLUOXETINE CAP 20MG Tier 1FLUOXETINE CAP 40MG Tier 1

53


LimitStep

TherapySpecialty

Medication

FLUOXETINE CAP 90MG DR Tier 1 XFLUOXETINE SOL 20MG/5ML Tier 1FLUOXETINE TAB 10MG Tier 1FLUOXETINE TAB 20MG Tier 1FLUOXETINE TAB 60MG Tier 3FLUPHENAZINE CON 5MG/ML Tier 1FLUPHENAZINE ELX 2.5/5ML Tier 1FLUPHENAZINE TAB 10MG Tier 1FLUPHENAZINE TAB 1MG Tier 1FLUPHENAZINE TAB 2.5MG Tier 1FLUPHENAZINE TAB 5MG Tier 1FLURA-DROPS DRO 0.125MG Tier 1FLURA-DROPS DRO 0.25MG F Tier 1FLURA-SAFE SOL Tier 3FLURAZEPAM CAP 15MG Tier 1FLURAZEPAM CAP 30MG Tier 1FLURBIPROFEN SOL 0.03% OP Tier 1FLURBIPROFEN TAB 100MG Tier 1FLURBIPROFEN TAB 50MG Tier 1FLUROX SOL OP Tier 1FLUTAMIDE CAP 125MG Tier 1 XFLUTICASONE CRE 0.05% Tier 1 XFLUTICASONE LOT 0.05% Tier 3 XFLUTICASONE OIN 0.005% Tier 1FLUTICASONE SPR 50MCG Tier 3 XFLUVASTATIN CAP 20MG Tier 1 XFLUVASTATIN CAP 40MG Tier 1 XFLUVOXAMINE CAP 100MG ER Tier 3 XFLUVOXAMINE CAP 150MG ER Tier 3 XFLUVOXAMINE TAB 100MG Tier 1FLUVOXAMINE TAB 25MG Tier 1FLUVOXAMINE TAB 50MG Tier 1FML FORTE SUS 0.25% OP Tier 2FML LIQUIFLM SUS 0.1% OP Tier 3FML OIN 0.1% OP Tier 2FOCALGIN-B TAB Tier 3FOCALIN TAB 10MG Tier 3 XFOCALIN TAB 2.5MG Tier 3 XFOCALIN TAB 5MG Tier 3 XFOLCAL DHA CAP Tier 3FOLCAPS CAP OMEGA 3 Tier 2FOLET ONE CAP 38-1-225 Tier 3FOLIC ACID INJ 5MG/ML Tier 1FOLIC ACID POW Tier 3FOLIC ACID TAB 1MG Tier 1

54


LimitStep

TherapySpecialty

Medication

FOLIVANE-F CAP Tier 3FOLIVANE-OB CAP Tier 3FOLIVANE-PRX CAP DHA NF Tier 3FONDAPARINUX SOL 10/0.8 Tier 3 XFONDAPARINUX SOL 2.5/0.5 Tier 3 XFONDAPARINUX SOL 5.0/0.4 Tier 3 XFONDAPARINUX SOL 7.5/0.6 Tier 3 XFOOD COLOR LIQ BLUE Tier 3FORADIL CAP AEROLIZE Tier 2 XFORANE SOL Tier 2FORMADON SOL Tier 3FORMALDEHYDE SOL 10% Tier 1FORMALDEHYDE SOL 37% Tier 3FORMA-RAY SOL 20% Tier 2FORTAMET TAB 1000MG Tier 3 XFORTAMET TAB 500MG Tier 3 XFORTEO SOL 600/2.4 Tier 2 X XFORTICAL SPR 200/ACT Tier 3FORTIGAN CAP Tier 1FOSAMAX + D TAB 70-2800 Tier 3 XFOSAMAX + D TAB 70-5600 Tier 3 XFOSAMAX TAB 70MG Tier 3 XFOSINOP/HCTZ TAB 10/12.5 Tier 1FOSINOP/HCTZ TAB 20/12.5 Tier 1FOSINOPRIL TAB 10MG Tier 1FOSINOPRIL TAB 20MG Tier 1FOSINOPRIL TAB 40MG Tier 1FOSRENOL CHW 1000MG Tier 2FOSRENOL CHW 500MG Tier 2FOSRENOL CHW 750MG Tier 2FOSTEUM CAP Tier 3FOSTEUM PLUS CAP Tier 3FOVEX CAP Tier 3FRAGMIN INJ 10000/ML Tier 3 XFRAGMIN INJ 12500UNT Tier 3 XFRAGMIN INJ 15000UNT Tier 3 XFRAGMIN INJ 18000UNT Tier 3 XFRAGMIN INJ 2500/0.2 Tier 3 XFRAGMIN INJ 25000/ML Tier 3 XFRAGMIN INJ 5000/0.2 Tier 3 XFRAGMIN INJ 7500/0.3 Tier 3 XFROVA TAB 2.5MG Tier 3 XFRST-HYDRCRT GEL 10% Tier 2FUL-GLO TES 0.6MG OP Tier 2FUL-GLO TES 1MG OP Tier 1

55


LimitStep

TherapySpecialty

Medication

FULYZAQ TAB 125MG Tier 3 X XFURADANTIN SUS 25MG/5ML Tier 3FUROSEMIDE SOL 10MG/ML Tier 1FUROSEMIDE SOL 8MG/ML Tier 1FUROSEMIDE TAB 20MG Tier 1FUROSEMIDE TAB 40MG Tier 1FUROSEMIDE TAB 80MG Tier 1FUZEON INJ 90MG Tier 2 XFYCOMPA TAB 10MG Tier 3 XFYCOMPA TAB 12MG Tier 3 XFYCOMPA TAB 2MG Tier 3 XFYCOMPA TAB 4MG Tier 3 XFYCOMPA TAB 6MG Tier 3 XFYCOMPA TAB 8MG Tier 3 XGABADONE CAP Tier 3GABAPENTIN CAP 100MG Tier 1GABAPENTIN CAP 300MG Tier 1GABAPENTIN CAP 400MG Tier 1GABAPENTIN SOL 250/5ML Tier 1GABAPENTIN TAB 600MG Tier 1GABAPENTIN TAB 800MG Tier 1GABAVALE-5 PAK Tier 3GABAZOLAMINE PAK Tier 3GABAZOLAMINE PAK 0.5MG Tier 3GABAZOLPIDEM PAK 5MG Tier 3GABITIDINE PAK 150MG Tier 3GABITRIL TAB 12MG Tier 2GABITRIL TAB 16MG Tier 2 GABITRIL TAB 2MG Tier 3GABITRIL TAB 4MG Tier 3GABOXETINE PAK Tier 3GALANTAMINE CAP 16MG ER Tier 1GALANTAMINE CAP 24MG ER Tier 1GALANTAMINE CAP 8MG ER Tier 1GALANTAMINE SOL 4MG/ML Tier 1GALANTAMINE TAB 12MG Tier 1GALANTAMINE TAB 4MG Tier 1GALANTAMINE TAB 8MG Tier 1GALZIN CAP 25MG Tier 3GALZIN CAP 50MG Tier 3GARAMYCIN OIN 0.3% OP Tier 1GARAMYCIN SOL 0.3% OP Tier 3GASTRINEX NF CAP Tier 3GASTROCROM CON 100/5ML Tier 3GASTROGRAFIN SOL 66-10% Tier 3

56


LimitStep

TherapySpecialty

Medication

GASTROMARK SUS 175MCG Tier 3GATIFLOXACIN SOL 0.5% Tier 3 XGATTEX KIT 5MG Tier 2 X XGAVILYTE-C SOL Tier 1GAVILYTE-G SOL Tier 1GAVILYTE-N SOL FLAV PK Tier 1GEBAUERS SPR AER /STRETCH Tier 3GELFILM MIS OP Tier 2GEL-KAM CON 0.63% Tier 3GEMFIBROZIL TAB 600MG Tier 1GENADUR LIQ Tier 3GENERLAC SOL 10GM/15 Tier 1GENE-XENE TAB 15MG Tier 1GENE-XENE TAB 3.75MG Tier 1GENE-XENE TAB 7.5MG Tier 1GENGRAF CAP 100MG Tier 1 XGENGRAF CAP 25MG Tier 1 XGENGRAF SOL 100MG/ML Tier 1 XGENTAK OIN 0.3% OP Tier 1GENTAMICIN CRE 0.1% Tier 1GENTAMICIN OIN 0.1% Tier 1GENTAMICIN OIN 0.3% OP Tier 1GENTAMICIN SOL 0.3% OP Tier 1GESTICARE PAK DHA Tier 3GIANVI TAB 3-0.02MG Tier 3GILDAGIA TAB 0.4-35 Tier 3GILDESS FE TAB 1.5/30 Tier 1GILDESS FE TAB 1/20 Tier 1GILDESS TAB 1.5/30 Tier 3GILDESS TAB 1/20 Tier 3GILENYA CAP 0.5MG Tier 3 X X X XGILOTRIF TAB 20MG Tier 3 X X XGILOTRIF TAB 30MG Tier 3 X X XGILOTRIF TAB 40MG Tier 3 X X XGILPHEX TR TAB 10-388MG Tier 3GILTUSS LIQ Tier 3GILTUSS LIQ PED-C Tier 3GILTUSS PED LIQ Tier 3GILTUSS TR CAP 7-14-288 Tier 2GILTUSS TR TAB Tier 3GLEEVEC TAB 100MG Tier 2 X X XGLEEVEC TAB 400MG Tier 2 X X XGLIMEPIRIDE TAB 1MG Tier 1GLIMEPIRIDE TAB 2MG Tier 1GLIMEPIRIDE TAB 4MG Tier 1

57


LimitStep

TherapySpecialty

Medication

GLIP/METFORM TAB 2.5-250M Tier 3GLIP/METFORM TAB 2.5-500M Tier 3GLIP/METFORM TAB 5-500MG Tier 3GLIPIZIDE ER TAB 10MG Tier 1GLIPIZIDE ER TAB 2.5MG Tier 1GLIPIZIDE ER TAB 5MG Tier 1GLIPIZIDE POW Tier 3GLIPIZIDE TAB 10MG Tier 1 XGLIPIZIDE TAB 5MG Tier 1 XGLIPIZIDE XL TAB 10MG Tier 1GLIPIZIDE XL TAB 2.5MG Tier 1GLIPIZIDE XL TAB 5MG Tier 1GLONOIN DRO HOMACCOR Tier 3GLUCAGEN INJ 1MG Tier 2 XGLUCAGEN INJ HYPOKIT Tier 2 XGLUCAGON KIT 1MG Tier 2 XGLUCOPHAGE TAB 1000MG Tier 3GLUCOPHAGE TAB 500MG Tier 3GLUCOPHAGE TAB 500MG XR Tier 3 XGLUCOPHAGE TAB 750MG XR Tier 3 XGLUCOPHAGE TAB 850MG Tier 3GLUCOTROL TAB 10MG Tier 3GLUCOTROL TAB 5MG Tier 3GLUCOTROL XL TAB 10MG Tier 3GLUCOTROL XL TAB 2.5MG Tier 3GLUCOTROL XL TAB 5MG Tier 3GLUCOVANCE TAB 1.25-250 Tier 3GLUCOVANCE TAB 2.5-500 Tier 3GLUCOVANCE TAB 5-500MG Tier 3GLUMETZA TAB 1000MG Tier 3 XGLUMETZA TAB 500MG Tier 3 XGLUTARALDEHY SOL 25% Tier 3GLYB/METFORM TAB 1.25-250 Tier 1GLYB/METFORM TAB 2.5-500 Tier 1GLYB/METFORM TAB 5-500MG Tier 1GLYBURID MCR TAB 1.5MG Tier 1GLYBURID MCR TAB 3MG Tier 1GLYBURID MCR TAB 6MG Tier 1GLYBURIDE TAB 1.25MG Tier 1GLYBURIDE TAB 2.5MG Tier 1GLYBURIDE TAB 5MG Tier 1GLYCERINE LIQ Tier 3GLYCEROL LIQ FORMAL Tier 3 XGLYCOPYRROL TAB 1MG Tier 1 XGLYCOPYRROL TAB 2MG Tier 1 X

58


LimitStep

TherapySpecialty

Medication

GLYNASE TAB 1.5MG Tier 3GLYNASE TAB 3MG Tier 3GLYNASE TAB 6MG Tier 3GLYSET TAB 100MG Tier 2GLYSET TAB 25MG Tier 2GLYSET TAB 50MG Tier 2GNP ALLERGY ELX CHILDREN Tier 1GNP DECONGES TAB ADV.FORM Tier 1GNP DIPHEDRY TAB 60MG Tier 1GNP DIXAPHED TAB 12 HR Tier 1GNP HYDROCOR OIN 1% W/ALO Tier 1GNP SUPHEDRI TAB PLUS Tier 1GOLYTELY SOL Tier 2GOLYTELY SOL PINEAPPL Tier 3GORDOFILM SOL Tier 2GORDONS UREA OIN 40% Tier 3GRAFCO SILVR MIS NIT APPL Tier 1GRANISETRON TAB 1MG Tier 3 XGRANISOL SOL 2MG/10ML Tier 3 XGRANULEX AER Tier 3GRASTEK SUB 2800BAU Tier 3 X XGREEN GLO MIS 1.5MG Tier 1GRIFULVIN V TAB 500MG Tier 3GRISEOFULVIN SUS 125/5ML Tier 1GRISEOFULVIN TAB MICR 500 Tier 1GRISEOFULVIN TAB ULTR 125 Tier 1GRISEOFULVIN TAB ULTR 250 Tier 1GRIS-PEG TAB 125MG Tier 3GRIS-PEG TAB 250MG Tier 3GRX HICORT SUP 25MG Tier 1GUANFACINE TAB 1MG Tier 1GUANFACINE TAB 2MG Tier 1GUANIDINE TAB 125MG Tier 3GYNAZOLE-1 CRE 2% Tier 3HALAC KIT Tier 1HALCION TAB 0.25MG Tier 3HALOBETASOL CRE 0.05% Tier 3HALOBETASOL OIN 0.05% Tier 3 XHALOG CRE 0.1% Tier 3 X XHALOG OIN 0.1% Tier 3 X XHALONATE KIT Tier 2HALONATE PAC KIT Tier 1HALOPERIDOL CON 2MG/ML Tier 1HALOPERIDOL TAB 0.5MG Tier 1HALOPERIDOL TAB 10MG Tier 1

59


LimitStep

TherapySpecialty

Medication

HALOPERIDOL TAB 1MG Tier 1HALOPERIDOL TAB 20MG Tier 1HALOPERIDOL TAB 2MG Tier 1HALOPERIDOL TAB 5MG Tier 1HALOTIN CRE 1% Tier 3HC AC/ALOE GEL 2% Tier 1HC BUTYRATE OIN 0.1% Tier 1HC BUTYRATE SOL 0.1% Tier 1HC PRAMOXINE CRE 1-1% Tier 1HC PRAMOXINE CRE 1-2.5% Tier 1HC PRAMOXINE CRE 2.5-1% Tier 1HC VALERATE CRE 0.2% Tier 3 XHC VALERATE OIN 0.2% Tier 3 XHC/ACET ACID SOL OTIC Tier 1HC/LIDOCAINE KIT 2-2% Tier 1HEATHER TAB 0.35MG Tier 3HECORIA CAP 0.5MG Tier 1 XHECORIA CAP 1MG Tier 1 XHECORIA CAP 5MG Tier 1 XHECTOROL CAP 0.5MCG Tier 3HECTOROL CAP 1MCG Tier 3HECTOROL CAP 2.5MCG Tier 3HELIXATE FS INJ 1000UNIT Tier 2 XHELIXATE FS INJ 2000UNIT Tier 2 XHELIXATE FS INJ 250UNIT Tier 2 XHELIXATE FS INJ 3000UNIT Tier 2 XHELIXATE FS INJ 500UNIT Tier 2 XHELIXATE FS SOL 1000UNIT Tier 2 XHELIXATE FS SOL 500UNIT Tier 2 XHEMATINIC/FA TAB Tier 1HEMENATAL OB MIS + DHA Tier 2HEMENATAL OB TAB 28-6-1MG Tier 2HEMOCYTE-F TAB Tier 1HEMOFIL M INJ 1000UNIT Tier 2 XHEMOFIL M INJ 1700UNIT Tier 2 XHEMOFIL M INJ 220-400 Tier 2 XHEMOFIL M INJ 250UNIT Tier 2 XHEMOFIL M INJ 401-800 Tier 2 XHEMOFIL M INJ 500UNIT Tier 2 XHEMOFIL M SOL 501-2000 Tier 2 XHEMOFIL M SOL 801-1500 Tier 2 XHEMORRHOIDAL SUP -HC 25MG Tier 1HEP FLUSH-10 INJ 10UNT/ML Tier 1HEPARIN LOCK INJ 100/ML Tier 1HEPARIN LOCK INJ 10UNT/ML Tier 1

60


LimitStep

TherapySpecialty

Medication

HEPARIN SOD INJ 1000/ML Tier 1HEPARIN SOD INJ 10000/ML Tier 1HEPARIN SOD INJ 2000/ML Tier 1HEPARIN SOD INJ 20000/ML Tier 1HEPARIN SOD INJ 2500/ML Tier 1HEPARIN SOD INJ 5000/0.5 Tier 1HEPARIN SOD INJ 5000/ML Tier 1HEPARIN SOD INJ 5000U Tier 1HEPSERA TAB 10MG Tier 3 XHETLIOZ CAP 20MG Tier 3 X X XHEXALEN CAP 50MG Tier 2 XHIPREX TAB 1GM Tier 3HOMATROPAIRE SOL 5% OP Tier 1HOMATROPINE SOL 5% OP Tier 1HPR AER Tier 1HPR PLUS AER Tier 1HPR PLUS CRE Tier 3HPR PLUS MB KIT HYDROGEL Tier 3HUMALOG INJ 100/ML Tier 2HUMALOG KWIK INJ 100/ML Tier 2HUMALOG MIX INJ 50/50 Tier 1HUMALOG MIX INJ 50/50KWP Tier 2HUMALOG MIX INJ 75/25KWP Tier 2HUMALOG MIX SUS 75/25 Tier 1HUMAPEN MIS LUXURA Tier 3HUMATE-P INJ 600UNIT Tier 2 XHUMATE-P SOL 1200UNIT Tier 2 XHUMATE-P SOL 2400UNIT Tier 2 XHUMIBID L.A. TAB 600MG Tier 3HUMIBID SPRI CAP 300MG Tier 3HUMIBID-DM TAB Tier 3HUMIRA KIT 20MG/0.4 Tier 2 X X XHUMIRA KIT 40MG/0.8 Tier 2 X X XHUMIRA PEN KIT 40MG/0.8 Tier 2 X X XHUMIRA PEN KIT CROHNS Tier 2 X X XHUMIRA PEN KIT PSORIASI Tier 2 X X XHUMULIN 70/30 INJ Tier 1HUMULIN 70/30 KWIK INJ Tier 2HUMULIN N INJ U-100 Tier 1HUMULIN N KWIK INJ 100 Tier 2HUMULIN R INJ U-100 Tier 1HUMULIN R INJ U-500 Tier 1HYALURONATE GEL 0.2% Tier 1HYCAMTIN CAP 0.25MG Tier 2 X X XHYCAMTIN CAP 1MG Tier 2 X X X

61


LimitStep

TherapySpecialty

Medication

HYCET SOL 7.5-325 Tier 3 XHYD POL/CPM LIQ 10-8/5ML Tier 3 XHYDRALAZINE TAB 100MG Tier 1HYDRALAZINE TAB 10MG Tier 1HYDRALAZINE TAB 25MG Tier 1HYDRALAZINE TAB 50MG Tier 1HYDREA CAP 500MG Tier 3 XHYDRO 35 AER Tier 3HYDRO 40 AER FOAM Tier 3HYDRO/CHLOR/ LIQ PSE HCL Tier 3 XHYDROCHLOROT CAP 12.5MG Tier 1HYDROCHLOROT TAB 12.5MG Tier 1HYDROCHLOROT TAB 25MG Tier 1HYDROCHLOROT TAB 50MG Tier 1HYDROCO/APAP SOL 7.5-325 Tier 3 XHYDROCO/APAP TAB 10-325MG Tier 1 XHYDROCO/APAP TAB 2.5-325 Tier 1HYDROCO/APAP TAB 5-325MG Tier 1 XHYDROCO/APAP TAB 7.5-325 Tier 1 XHYDROCOD/HOM SYP 5-1.5/5 Tier 1HYDROCOD/IBU TAB 10-200MG Tier 1HYDROCOD/IBU TAB 2.5-200 Tier 1HYDROCOD/IBU TAB 5-200MG Tier 1HYDROCOD/IBU TAB 7.5-200 Tier 1HYDROCODONE/ TAB HOMATROP Tier 1HYDROCORT AC SUP 25MG Tier 1HYDROCORT AC SUP 30MG Tier 1HYDROCORT CRE 2.5% Tier 1HYDROCORT ENE 100MG Tier 1HYDROCORT LOT 2.5% Tier 1HYDROCORT OIN 1% Tier 1HYDROCORT OIN 2.5% Tier 1HYDROCORT TAB 10MG Tier 1HYDROCORT TAB 20MG Tier 1HYDROCORT TAB 5MG Tier 1HYDROCORT/ CRE IODOQUIN Tier 1HYDROCORT/ KIT PRAMOXIN Tier 1 XHYDROCORT/AB OIN 1% Tier 1HYDROGEL GEL Tier 1HYDROMET SYP 5-1.5/5 Tier 1HYDROMORPHON LIQ 1MG/ML Tier 1HYDROMORPHON SUP 3MG Tier 1HYDROMORPHON TAB 12MG ER Tier 3 X XHYDROMORPHON TAB 16MG ER Tier 3 X XHYDROMORPHON TAB 2MG Tier 1

62


LimitStep

TherapySpecialty

Medication

HYDROMORPHON TAB 32MG ER Tier 3 X XHYDROMORPHON TAB 4MG Tier 1HYDROMORPHON TAB 8MG Tier 1HYDROMORPHON TAB 8MG ER Tier 3 X XHYDROPHEN SYP Tier 1HYDROQUINONE CRE 4% TR Tier 1HYDROXYCHLOR TAB 200MG Tier 1HYDROXYUREA CAP 500MG Tier 1 XHYDROXYUREA POW Tier 3 XHYDROXYZ HCL SOL 10MG/5ML Tier 1HYDROXYZ HCL SYP 10MG/5ML Tier 1HYDROXYZ HCL TAB 10MG Tier 1HYDROXYZ HCL TAB 25MG Tier 1HYDROXYZ HCL TAB 50MG Tier 1HYDROXYZ PAM CAP 100MG Tier 1HYDROXYZ PAM CAP 25MG Tier 1HYDROXYZ PAM CAP 50MG Tier 1HYGEL GEL 0.2% Tier 1HYLASE WOUND GEL Tier 3HYLATOPIC AER Tier 3HYLATOPIC AER PLUS Tier 3HYLATOPIC CRE PLUS Tier 3HYLIRA GEL 0.2% Tier 2HYLIRA LOT 0.1% Tier 3HYOMAX-SL SUB 0.125MG Tier 1HYOPHEN TAB Tier 1HYOSCYAMINE DRO 0.125/ML Tier 1HYOSCYAMINE ELX 0.125/5 Tier 1HYOSCYAMINE SUB 0.125MG Tier 1HYOSCYAMINE TAB 0.125MG Tier 1HYOSCYAMINE TAB 0.375 ER Tier 1HYOSCYAMINE TAB 0.375 SR Tier 1HYOSYNE DRO 0.125/ML Tier 1HYOSYNE ELX 0.125/5 Tier 1HYPERCARE SOL 20% Tier 1HYPERSAL NEB 3.5% Tier 2HYPERSAL NEB 7% Tier 2HYPER-SAL NEB 7% Tier 2HYPERTENEVID PAK 12.5MG Tier 3HYPERTENIPIN PAK 2.5MG Tier 3HYPERTENSA CAP Tier 3HYPERTENSOLO PAK Tier 3HYPO NEEDLE MIS 18GX1" Tier 3HYZAAR TAB 100-12.5 Tier 3HYZAAR TAB 100-25 Tier 3

63


LimitStep

TherapySpecialty

Medication

HYZAAR TAB 50-12.5 Tier 3IBANDRONATE TAB 150MG Tier 3 XIBUDONE TAB 10-200MG Tier 3IBUDONE TAB 5-200MG Tier 3IBUPROFEN KIT COMFORT Tier 3IBUPROFEN TAB 400MG Tier 1IBUPROFEN TAB 600MG Tier 1IBUPROFEN TAB 800MG Tier 1IC 400 KIT 400MG Tier 3IC 800 KIT 800MG Tier 3ICLUSIG TAB 15MG Tier 3 X XICLUSIG TAB 45MG Tier 3 X XILOTYCIN OIN OP Tier 1IMBRUVICA CAP 140MG Tier 3 X X XIMDUR TAB 120MG ER Tier 3IMDUR TAB 30MG ER Tier 3IMDUR TAB 60MG ER Tier 3IMIPRAM HCL TAB 10MG Tier 1IMIPRAM HCL TAB 25MG Tier 1IMIPRAM HCL TAB 50MG Tier 1IMIPRAM PAM CAP 100MG Tier 1IMIPRAM PAM CAP 125MG Tier 1IMIPRAM PAM CAP 150MG Tier 1IMIPRAM PAM CAP 75MG Tier 1IMIQUIMOD CRE 5% Tier 3 XIMITREX SPR 20MG/ACT Tier 3 XIMITREX SPR 5MG/ACT Tier 3 XIMURAN TAB 50MG Tier 3INATAL ADV TAB Tier 1INATAL GT TAB Tier 2INATAL ULTRA TAB Tier 1INCIVEK TAB 375MG Tier 2 X X XINCRELEX INJ 40MG/4ML Tier 2 X X XINDAPAMIDE TAB 1.25MG Tier 1INDAPAMIDE TAB 2.5MG Tier 1INDERAL LA CAP 120MG Tier 3INDERAL LA CAP 160MG Tier 3INDERAL LA CAP 60MG Tier 3INDERAL LA CAP 80MG Tier 3INDERAL XL CAP 120MG Tier 3INDERAL XL CAP 80MG Tier 3INDOCIN SUP 50MG Tier 3INDOCIN SUS 25MG/5ML Tier 3INDOMETHACIN CAP 25MG Tier 1INDOMETHACIN CAP 50MG Tier 1

64


LimitStep

TherapySpecialty

Medication

INDOMETHACIN CAP 75MG ER Tier 1INFANATE CAP BALANCE Tier 3INFUSION SET MIS 23" Tier 3INFUSION SET MIS 23" 13MM Tier 3INFUSION SET MIS 23" 17MM Tier 3INFUSION SET MIS 23" 6MM Tier 3INFUSION SET MIS 23" 8MM Tier 3INFUSION SET MIS 23" 9MM Tier 3INFUSION SET MIS 24" Tier 3INFUSION SET MIS 24" 6MM Tier 3INFUSION SET MIS 24" 9MM Tier 3INFUSION SET MIS 31" Tier 3INFUSION SET MIS 31" 6MM Tier 3INFUSION SET MIS 31" 9MM Tier 3INFUSION SET MIS 32" 8MM Tier 3INFUSION SET MIS 42" 6MM Tier 3INFUSION SET MIS 42" 9MM Tier 3INFUSION SET MIS 43" Tier 3INFUSION SET MIS 43" 13MM Tier 3INFUSION SET MIS 43" 17MM Tier 3INFUSION SET MIS 43" 6MM Tier 3INFUSION SET MIS 43" 8MM Tier 2INFUSION SET MIS 43" 9MM Tier 3INLYTA TAB 1MG Tier 3 X X XINLYTA TAB 5MG Tier 3 X X XINNOPRAN XL CAP 120MG Tier 3INNOPRAN XL CAP 80MG Tier 3INOVA 4/1 KIT ACNE CON Tier 3INOVA 8/2 KIT ACNE CON Tier 3INOVA KIT 4% Tier 3INOVA KIT 8% Tier 3INSPIREASE MIS BAGS Tier 2INSPIREASE MIS DD SYST Tier 3INSPIREASE MIS MOUTHPCE Tier 2INSPIREASE MIS RES BAG Tier 2INSPRA TAB 25MG Tier 3INSPRA TAB 50MG Tier 3INTEGRA F CAP Tier 3INTELENCE TAB 100MG Tier 2 XINTELENCE TAB 200MG Tier 2 XINTELENCE TAB 25MG Tier 2 XINTERARTICUL KIT JOINT Tier 3INTROL SOL 75% Tier 2INTRON-A INJ 10MU Tier 3 X XINTRON-A INJ 18MU Tier 3 X X

65


LimitStep

TherapySpecialty

Medication

INTRON-A INJ 25MU Tier 3 X XINTRON-A INJ 50MU Tier 3 X XINTROVALE TAB Tier 3 XINVEGA TAB 1.5MG Tier 3 XINVEGA TAB 3MG Tier 3 XINVEGA TAB 6MG Tier 3 XINVEGA TAB 9MG Tier 3 XINVIRASE CAP 200MG Tier 2 XINVIRASE TAB 500MG Tier 2 XINVOKANA TAB 100MG Tier 2 X X INVOKANA TAB 300MG Tier 2 X X IODINE SOL STRONG Tier 2IODINE TIN 2% Tier 1IODINE TIN 2% MILD Tier 1IODINE TIN STRONG Tier 3IOPIDINE SOL 0.5% OP Tier 3IOPIDINE SOL 1% OP Tier 3IPRATROPIUM SOL 0.02%INH Tier 1IPRATROPIUM SPR 0.03% Tier 1IPRATROPIUM SPR 0.06% Tier 1IPRATROPIUM/ SOL ALBUTER Tier 3IRBESAR/HCTZ TAB 150-12.5 Tier 3 XIRBESAR/HCTZ TAB 300-12.5 Tier 3 XIRBESARTAN TAB 150MG Tier 3 XIRBESARTAN TAB 300MG Tier 3 XIRBESARTAN TAB 75MG Tier 3 XISENTRESS CHW 100MG Tier 2 XISENTRESS CHW 25MG Tier 2 XISENTRESS POW 100MG Tier 2 XISENTRESS TAB 400MG Tier 2 XISO ATROPINE SOL 1% OP Tier 3ISO CARBACHO SOL 1.5% OP Tier 2ISO CARBACHO SOL 3% OP Tier 2ISO HOMATROP SOL 2% OP Tier 2ISO HOMATROP SOL 5% OP Tier 3ISO HYOSCINE SOL 0.25% OP Tier 2ISODITRATE TAB 40MG ER Tier 1ISOFLURANE SOL Tier 1ISOMETH/APAP CAP DICHLOR Tier 1ISOMETH/CAFF TAB /APAP Tier 1ISONIAZID SYP 50MG/5ML Tier 1ISONIAZID TAB 100MG Tier 1ISONIAZID TAB 300MG Tier 1ISOPROTEREN AER 131MCG Tier 1ISOPTIN SR TAB 120MG Tier 3

66


LimitStep

TherapySpecialty

Medication

ISOPTIN SR TAB 180MG Tier 3ISOPTIN SR TAB 240MG Tier 3ISOPTO CARP SOL 1% OP Tier 3ISOPTO CARP SOL 2% OP Tier 3ISOPTO CARP SOL 4% OP Tier 3ISORDIL TAB 40MG Tier 2ISORDIL TAB 5MG Tier 3ISOSORB DIN TAB 10MG Tier 1ISOSORB DIN TAB 20MG Tier 1ISOSORB DIN TAB 30MG Tier 1ISOSORB DIN TAB 40MG ER Tier 1ISOSORB DIN TAB 5MG Tier 1ISOSORB MONO TAB 10MG Tier 1ISOSORB MONO TAB 120MG ER Tier 1ISOSORB MONO TAB 20MG Tier 1ISOSORB MONO TAB 30MG ER Tier 1ISOSORB MONO TAB 60MG ER Tier 1ISOXSUPRINE TAB 10MG Tier 1ISOXSUPRINE TAB HCL 20MG Tier 1ISRADIPINE CAP 2.5MG Tier 1ISRADIPINE CAP 5MG Tier 1ISTALOL SOL 0.5% OP Tier 3ITRACONAZOLE CAP 100MG Tier 1 XJAKAFI TAB 10MG Tier 2 X X XJAKAFI TAB 15MG Tier 2 X X XJAKAFI TAB 20MG Tier 2 X X XJAKAFI TAB 25MG Tier 2 X X XJAKAFI TAB 5MG Tier 2 X X XJANTOVEN TAB 10MG Tier 1JANTOVEN TAB 1MG Tier 1JANTOVEN TAB 2.5MG Tier 1JANTOVEN TAB 2MG Tier 1JANTOVEN TAB 3MG Tier 1JANTOVEN TAB 4MG Tier 1JANTOVEN TAB 5MG Tier 1JANTOVEN TAB 6MG Tier 1JANTOVEN TAB 7.5MG Tier 1JANUMET TAB 50-1000 Tier 3 X X JANUMET TAB 50-500MG Tier 3 X X JANUMET XR TAB 100-1000 Tier 3 X X JANUMET XR TAB 50-1000 Tier 3 X X JANUMET XR TAB 50-500MG Tier 3 X X JANUVIA TAB 100MG Tier 3 X X JANUVIA TAB 25MG Tier 3 X X JANUVIA TAB 50MG Tier 3 X X

67


LimitStep

TherapySpecialty

Medication

JENCYCLA TAB 0.35MG Tier 3JENTADUETO TAB 2.5-1000 Tier 2 XJENTADUETO TAB 2.5-500 Tier 2 XJENTADUETO TAB 2.5-850 Tier 2 XJINTELI TAB 1MG-5MCG Tier 3JNT/TUNNEL/ KIT TRIGGER Tier 1JOLESSA TAB Tier 3 XJOLIVETTE TAB 0.35MG Tier 3JUBLIA SOL 10% Tier 3 X XJUNEL 1.5/30 TAB Tier 3JUNEL 1/20 TAB Tier 3JUNEL FE TAB 1.5/30 Tier 1JUNEL FE TAB 1/20 Tier 1JUXTAPID CAP 10MG Tier 3 X XJUXTAPID CAP 20MG Tier 3 X XJUXTAPID CAP 5MG Tier 3 X XKALETRA SOL Tier 2 XKALETRA TAB 100-25MG Tier 2 XKALETRA TAB 200-50MG Tier 2 XKALYDECO TAB 150MG Tier 2 X X XKARBINAL ER SUS 4MG/5ML Tier 3KARIDIUM DRO 0.125MG Tier 1KARIGEL GEL 0.5% Tier 1KARIGEL-N GEL 1.1% Tier 1KARIVA TAB 28 DAY Tier 3KAYEXALATE POW Tier 3KAZANO 12.5- TAB 1000MG Tier 2 XKAZANO 12.5- TAB 500MG Tier 2 XK-EFFERVESCE TAB 25MEQ EF Tier 1KEFLEX CAP 250MG Tier 3KEFLEX CAP 500MG Tier 3KEFLEX CAP 750MG Tier 3KELNOR TAB 1/35 Tier 1KENALOG AER SPRAY Tier 2KEPPRA SOL 100MG/ML Tier 3 X XKEPPRA TAB 1000MG Tier 3 X XKEPPRA TAB 250MG Tier 3 X XKEPPRA TAB 500MG Tier 3 X XKEPPRA TAB 750MG Tier 3 X XKEPPRA XR TAB 500MG Tier 3 X XKEPPRA XR TAB 750MG Tier 3 X XKERAFOAM 42 AER 42% Tier 3KERAFOAM AER 30% Tier 3KERALYT GEL 6% Tier 3KERLONE TAB 10MG Tier 3

68


LimitStep

TherapySpecialty

Medication

KERLONE TAB 20MG Tier 3KERR TRIPLE MIS DYE SWAB Tier 2KETEK TAB 300MG Tier 3KETEK TAB 400MG Tier 3KETOCONAZOLE CRE 2% Tier 1KETOCONAZOLE SHA 2% Tier 1KETOCONAZOLE TAB 200MG Tier 1KETODAN AER 2% Tier 3 XKETOPROFEN CAP 200MG ER Tier 1KETOPROFEN CAP 50MG Tier 1KETOPROFEN CAP 75MG Tier 1KETOPROFEN CRE 5% KIT Tier 3KETOROLAC SOL 0.4% Tier 1KETOROLAC SOL 0.5% Tier 1KETOROLAC TAB 10MG Tier 1KINERET INJ Tier 3 X X XKIONEX POW Tier 1KIONEX SUS 15GM/60 Tier 1KLARON LOT 10% Tier 3KLONOPIN TAB 0.5MG Tier 3KLONOPIN TAB 1MG Tier 3KLONOPIN TAB 2MG Tier 3KLOR-CON 10 TAB 10MEQ ER Tier 1KLOR-CON 8 TAB 8MEQ ER Tier 1KLOR-CON M10 TAB 10MEQ ER Tier 1KLOR-CON M15 TAB Tier 3KLOR-CON M20 TAB 20MEQ ER Tier 1KLOR-CON POW 20MEQ Tier 1KLOR-CON/EF TAB 25MEQ FR Tier 1KLOR-CON-25 POW 25MEQ Tier 1KOATE-DVI INJ 1000UNIT Tier 2 XKOATE-DVI INJ 250UNIT Tier 2 XKOATE-DVI INJ 500UNIT Tier 2KOGENATE FS INJ 1000/BS Tier 2 XKOGENATE FS INJ 1000UNIT Tier 2 XKOGENATE FS INJ 2000/BS Tier 2 XKOGENATE FS INJ 2000UNIT Tier 2 XKOGENATE FS INJ 250/BS Tier 2 XKOGENATE FS INJ 250UNIT Tier 2 XKOGENATE FS INJ 3000/BS Tier 2 XKOGENATE FS INJ 3000UNIT Tier 2 XKOGENATE FS INJ 500/BS Tier 2 XKOGENATE FS INJ 500UNIT Tier 2 XKOMBIGLYZE TAB 2.5-1000 Tier 2 XKOMBIGLYZE TAB 5-1000MG Tier 2 X

69


LimitStep

TherapySpecialty

Medication

KOMBIGLYZE TAB 5-500MG Tier 2 XKORLYM TAB 300MG Tier 3 X XK-PHOS TAB Tier 2K-PHOS TAB NEUTRAL Tier 3K-PHOS TAB NO 2 Tier 2K-PRIME TAB 25MEQ EF Tier 1KRISGEL 100 GEL Tier 3KRISTALOSE PAK 10GM Tier 3KRISTALOSE PAK 20GM Tier 3K-TAB TAB 10MEQ CR Tier 3K-TAB TAB 20MEQ Tier 3KURVELO TAB 0.15/30 Tier 1KUVAN POW 100MG Tier 2 X XKUVAN TAB 100MG Tier 2 X X XK-VESCENT POW 20MEQ Tier 1K-VESCENT TAB 25MEQ EF Tier 1KYNAMRO INJ 200MG/ML Tier 3 X X XLABETALOL TAB 100MG Tier 1LABETALOL TAB 200MG Tier 1LABETALOL TAB 300MG Tier 1LACRISERT MIS 5MG OP Tier 2LACTIC ACID CRE /VIT E Tier 1LACTIC ACID CRE E Tier 1LACTIC ACID LOT 10% Tier 1LACTULOSE SOL 10GM/15 Tier 1LACTULOSE SOL 20GM/30 Tier 1LACTULOSE SYP 10GM/15 Tier 1LAMICTAL CHW 25MG Tier 3 X XLAMICTAL CHW 2MG Tier 3 XLAMICTAL CHW 5MG Tier 3 X XLAMICTAL KIT START 35 Tier 3 X XLAMICTAL KIT START 49 Tier 3 X XLAMICTAL KIT START 98 Tier 3 X XLAMICTAL ODT KIT Tier 3 X XLAMICTAL ODT TAB 100MG Tier 3 X XLAMICTAL ODT TAB 200MG Tier 3 X XLAMICTAL ODT TAB 25MG Tier 3 X XLAMICTAL ODT TAB 50MG Tier 3 X XLAMICTAL TAB 100MG Tier 3 X XLAMICTAL TAB 150MG Tier 3 X XLAMICTAL TAB 200MG Tier 3 X XLAMICTAL TAB 25MG Tier 3 X XLAMICTAL XR KIT Tier 3 X XLAMICTAL XR TAB 100MG Tier 3 X XLAMICTAL XR TAB 200MG Tier 3 X X

70


LimitStep

TherapySpecialty

Medication

LAMICTAL XR TAB 250MG Tier 3 X XLAMICTAL XR TAB 25MG Tier 3 X XLAMICTAL XR TAB 300MG Tier 3 X XLAMICTAL XR TAB 50MG Tier 3 X XLAMISIL GRA 125MG Tier 3 XLAMISIL GRA 187.5MG Tier 3 XLAMISIL SPR 1% Tier 2LAMISIL TAB 250MG Tier 3 XLAMIVUD/ZIDO TAB 150-300 Tier 1 XLAMIVUDINE TAB 100MG Tier 1 XLAMIVUDINE TAB 150MG Tier 1 XLAMIVUDINE TAB 300MG Tier 1 XLAMOTRIGINE CHW 25MG Tier 1LAMOTRIGINE CHW 5MG Tier 1LAMOTRIGINE TAB 100MG Tier 1LAMOTRIGINE TAB 100MG ER Tier 3 XLAMOTRIGINE TAB 150MG Tier 1LAMOTRIGINE TAB 200MG Tier 1LAMOTRIGINE TAB 200MG ER Tier 3 XLAMOTRIGINE TAB 250MG ER Tier 3 XLAMOTRIGINE TAB 25MG Tier 1LAMOTRIGINE TAB 25MG ER Tier 3 XLAMOTRIGINE TAB 300MG ER Tier 3 XLAMOTRIGINE TAB 50MG ER Tier 3 XLANOLIN ANHY OIN Tier 3LANOLIN OIN Tier 1LANOXIN TAB 0.0625MG Tier 3LANOXIN TAB 0.125MG Tier 2LANOXIN TAB 0.1875MG Tier 3LANOXIN TAB 0.25MG Tier 2LANSOPRAZOLE SUS 3MG/ML Tier 3LANTUS INJ 100/ML Tier 3LANTUS INJ SOLOSTAR Tier 3LARIN FE TAB 1.5/30 Tier 1LARIN FE TAB 1/20 Tier 1LARIN TAB 1.5/30 Tier 3LARIN TAB 1/20 Tier 3LASIX TAB 20MG Tier 3LASIX TAB 40MG Tier 3LASIX TAB 80MG Tier 3LASTACAFT SOL 0.25% Tier 3 XLATANOPROST SOL 0.005% Tier 1LATRIX SUS 50% Tier 2LATRIX XM EMU 45% Tier 2LATUDA TAB 120MG Tier 3 X

71


LimitStep

TherapySpecialty

Medication

LATUDA TAB 20MG Tier 3 XLATUDA TAB 40MG Tier 3 XLATUDA TAB 60MG Tier 3 XLATUDA TAB 80MG Tier 3 XLAVARE WOUND GEL WASH Tier 1LAZANDA SPR 100MCG Tier 3 X XLAZANDA SPR 400MCG Tier 3 X XL-CYSTINE POW Tier 3LECITHIN GRA Tier 1LEENA TAB Tier 1LEFLUNOMIDE TAB 10MG Tier 1LEFLUNOMIDE TAB 20MG Tier 1LESCOL CAP 20MG Tier 3 XLESCOL CAP 40MG Tier 3 XLESCOL XL TAB 80MG Tier 3 XLESSINA TAB Tier 1LETAIRIS TAB 10MG Tier 2 X X XLETAIRIS TAB 5MG Tier 2 X X XLETROZOLE TAB 2.5MG Tier 1LEUCOVOR CA TAB 10MG Tier 1LEUCOVOR CA TAB 15MG Tier 1LEUCOVOR CA TAB 25MG Tier 1LEUCOVOR CA TAB 5MG Tier 1LEUCOVORIN POW CALCIUM Tier 3LEUKERAN TAB 2MG Tier 2LEUKINE INJ 250MCG Tier 2 XLEUPROLIDE INJ 1MG/0.2 Tier 1 X XLEVACET TAB Tier 3LEVAQUIN SOL 25MG/ML Tier 3LEVAQUIN TAB 250MG Tier 3LEVAQUIN TAB 500MG Tier 3LEVAQUIN TAB 750MG Tier 3LEVATOL TAB 20MG Tier 3LEVBID TAB 0.375 ER Tier 3LEVEMIR INJ Tier 1LEVEMIR INJ FLEXPEN Tier 1LEVEMIR INJ FLEXTOUC Tier 1LEVETIRACETA SOL 100MG/ML Tier 1LEVETIRACETA SOL 500/5ML Tier 1LEVETIRACETA TAB 1000MG Tier 1LEVETIRACETA TAB 250MG Tier 1LEVETIRACETA TAB 500MG Tier 1LEVETIRACETA TAB 500MG ER Tier 3LEVETIRACETA TAB 750MG Tier 1LEVETIRACETA TAB 750MG ER Tier 3

72


LimitStep

TherapySpecialty

Medication

LEVITRA TAB 10MG Tier 3 XLEVITRA TAB 2.5MG Tier 3 XLEVITRA TAB 20MG Tier 3 XLEVITRA TAB 5MG Tier 3 XLEVOBUNOLOL SOL 0.25% OP Tier 1LEVOBUNOLOL SOL 0.5% OP Tier 1LEVOCARNITIN SOL 1GM/10ML Tier 1LEVOCARNITIN TAB 330MG Tier 1LEVOCETIRIZI SOL 2.5/5ML Tier 3LEVOCETIRIZI TAB 5MG Tier 1 XLEVOFLOXACIN SOL 0.5% Tier 1LEVOFLOXACIN SOL 25MG/ML Tier 1LEVOFLOXACIN TAB 250MG Tier 1LEVOFLOXACIN TAB 500MG Tier 1LEVOFLOXACIN TAB 750MG Tier 1LEVOMEFOLATE CAP DHA Tier 2LEVONEST TAB Tier 1LEVONOR/ETHI TAB 0.1-0.02 Tier 1LEVONOR/ETHI TAB ESTRADIO Tier 2LEVONORGESTR TAB 0.75MG Tier 1LEVONORGESTR TAB 1.5MG Tier 1LEVORA-28 TAB 0.15/30 Tier 1LEVORPHANOL TAB 2MG Tier 1LEVOTHYROXIN TAB 100MCG Tier 1LEVOTHYROXIN TAB 112MCG Tier 1LEVOTHYROXIN TAB 125MCG Tier 1LEVOTHYROXIN TAB 137MCG Tier 1LEVOTHYROXIN TAB 150MCG Tier 1LEVOTHYROXIN TAB 175MCG Tier 1LEVOTHYROXIN TAB 200MCG Tier 1LEVOTHYROXIN TAB 25MCG Tier 1LEVOTHYROXIN TAB 300MCG Tier 1LEVOTHYROXIN TAB 50MCG Tier 1LEVOTHYROXIN TAB 75MCG Tier 1LEVOTHYROXIN TAB 88MCG Tier 1LEVOXYL TAB 100MCG Tier 3LEVOXYL TAB 112MCG Tier 3LEVOXYL TAB 125MCG Tier 3LEVOXYL TAB 137MCG Tier 3LEVOXYL TAB 150MCG Tier 3LEVOXYL TAB 175MCG Tier 3LEVOXYL TAB 200MCG Tier 3LEVOXYL TAB 25MCG Tier 3LEVOXYL TAB 50MCG Tier 3LEVOXYL TAB 75MCG Tier 3

73


LimitStep

TherapySpecialty

Medication

LEVOXYL TAB 88MCG Tier 3LEVSIN TAB 0.125MG Tier 3LEVSIN/SL SUB 0.125MG Tier 3LEVULAN KERA SOL 20% Tier 3LEXIVA SUS 50MG/ML Tier 2 XLEXIVA TAB 700MG Tier 2 XLIALDA TAB 1.2GM Tier 2 XLIBRAX CAP 5-2.5MG Tier 3LIDAZONE CRE Tier 1LIDO/PRILOCN CRE 2.5-2.5% Tier 1LIDO/PRILOCN KIT 2.5-2.5% Tier 1LIDOCAINE CRE 3% Tier 1LIDOCAINE GEL 2% JELLY Tier 1LIDOCAINE LOT 3% Tier 1LIDOCAINE OIN 5% Tier 1 XLIDOCAINE PAD 5% Tier 3 XLIDOCAINE SOL 2% VISC Tier 1LIDOCAINE SOL 4% Tier 1LIDOCAINE/HC CRE 3%-0.5% Tier 1LIDOCAINE/HC KIT 2-2% Tier 1LIDOCAINE/HC KIT 3%-0.5% Tier 1LIDOCAINE/HC KIT 3%-1% Tier 1LIDOCAINE/HC KIT 3-2.5% Tier 1LIDO-HYDRO GEL 2.8-0.55 Tier 2LIDOVIR OIN 4-4% Tier 3LIMBREL CAP 250MG Tier 3LIMBREL CAP 500MG Tier 3LIMBREL250 CAP 250-50MG Tier 3LIMBREL500 CAP 500-50MG Tier 3LINDANE LOT 1% Tier 1 XLINDANE SHA 1% Tier 1 XLINK ASSIST MIS ACCU-CHK Tier 3LINZESS CAP 145MCG Tier 2 X XLINZESS CAP 290MCG Tier 2 X XLIOTHYRONINE TAB 25MCG Tier 3LIOTHYRONINE TAB 50MCG Tier 3LIOTHYRONINE TAB 5MCG Tier 3LIPICHOL 540 CAP Tier 3LISINOP/HCTZ TAB 10-12.5 Tier 1LISINOP/HCTZ TAB 20-12.5 Tier 1LISINOP/HCTZ TAB 20-25MG Tier 1LISINOPRIL TAB 10MG Tier 1LISINOPRIL TAB 2.5MG Tier 1LISINOPRIL TAB 20MG Tier 1LISINOPRIL TAB 30MG Tier 1

74


LimitStep

TherapySpecialty

Medication

LISINOPRIL TAB 40MG Tier 1LISINOPRIL TAB 5MG Tier 1LISSAMINE GR TES 1.5MG Tier 1LISTER-V CAP Tier 3LITHIUM CARB CAP 150MG Tier 1LITHIUM CARB CAP 300MG Tier 1LITHIUM CARB CAP 600MG Tier 1LITHIUM CARB TAB 300MG Tier 1LITHIUM CARB TAB 300MG ER Tier 1LITHIUM CARB TAB 450MG ER Tier 1LITHIUM CITR SOL 8MEQ/5ML Tier 1LITHOBID TAB 300MG CR Tier 3LITHOSTAT TAB 250MG Tier 3LIVALO TAB 1MG Tier 3 XLIVALO TAB 2MG Tier 3 XLIVALO TAB 4MG Tier 3L-METHYL-MC TAB NAC Tier 1LO LOESTRIN TAB Tier 3LOCOID CRE 0.1% Tier 3LOCOID OIN 0.1% Tier 3LOCOID SOL 0.1% Tier 3LODOSYN TAB 25MG Tier 3LOESTRIN 21 TAB 1.5/30 Tier 3LOESTRIN FE TAB 1.5/30 Tier 3LOESTRIN FE TAB 1/20 Tier 3LOESTRIN TAB 1/20-21 Tier 3LOFENE TAB 2.5MG Tier 1LOFIBRA CAP 134MG Tier 3LOFIBRA CAP 200MG Tier 3LOFIBRA CAP 67MG Tier 3LOKARA LOT 0.05% Tier 3 XLOMEDIA 24 TAB FE Tier 3LOMOTIL TAB 2.5MG Tier 3LOMUSTINE CAP 100MG Tier 1 XLOMUSTINE CAP 10MG Tier 1 XLOMUSTINE CAP 40MG Tier 1 XLONOX TAB 2.5MG Tier 1LOPID TAB 600MG Tier 3LOPRESS HCT TAB 100-25MG Tier 3LOPRESS HCT TAB 50-25MG Tier 3LOPRESSOR TAB 100MG Tier 3LOPRESSOR TAB 50MG Tier 3LOPROX SHA 1% Tier 3LORAZEPAM CON 2MG/ML Tier 1LORAZEPAM TAB 0.5MG Tier 1

75


LimitStep

TherapySpecialty

Medication

LORAZEPAM TAB 1MG Tier 1LORAZEPAM TAB 2MG Tier 1LORCET HD TAB 10-325MG Tier 1 XLORCET PLUS TAB 7.5-325 Tier 1 XLORCET TAB 5-325MG Tier 1 XLORTAB TAB 10-325MG Tier 1 XLORTAB TAB 5-325MG Tier 1 XLORTAB TAB 7.5-325 Tier 1 XLORYNA TAB 3-0.02MG Tier 3LOSARTAN POT TAB 100MG Tier 1LOSARTAN POT TAB 25MG Tier 1LOSARTAN POT TAB 50MG Tier 1LOSARTAN/HCT TAB 100-12.5 Tier 1LOSARTAN/HCT TAB 100-25 Tier 1LOSARTAN/HCT TAB 50-12.5 Tier 1LOSEASONIQUE TAB Tier 3 XLOTEMAX OIN 0.5% Tier 3LOTEMAX SUS 0.5% Tier 3 XLOTENSIN HCT TAB 10-12.5 Tier 3LOTENSIN HCT TAB 20-12.5 Tier 3LOTENSIN HCT TAB 20-25MG Tier 3LOTENSIN TAB 10MG Tier 3LOTENSIN TAB 20MG Tier 3LOTENSIN TAB 40MG Tier 3LOTREL CAP 10-20MG Tier 3 XLOTREL CAP 10-40MG Tier 3 XLOTREL CAP 2.5-10MG Tier 3 XLOTREL CAP 5-10MG Tier 3 XLOTREL CAP 5-20MG Tier 3 XLOTREL CAP 5-40MG Tier 3 XLOTRISONE CRE Tier 3 XLOTRONEX TAB 0.5MG Tier 2 X XLOTRONEX TAB 1MG Tier 2 X XLOUTREX CRE Tier 3LOVASTATIN TAB 10MG Tier 1LOVASTATIN TAB 20MG Tier 1LOVASTATIN TAB 40MG Tier 1LOVENOX INJ 100MG/ML Tier 3 XLOVENOX INJ 120/0.8 Tier 3 XLOVENOX INJ 150MG/ML Tier 3 XLOVENOX INJ 30/0.3ML Tier 3 XLOVENOX INJ 300/3ML Tier 3 XLOVENOX INJ 40/0.4ML Tier 3 XLOVENOX INJ 60/0.6ML Tier 3 XLOVENOX INJ 80/0.8ML Tier 3 X

76


LimitStep

TherapySpecialty

Medication

LOW-OGESTREL TAB Tier 1LOXAPINE CAP 10MG Tier 1LOXAPINE CAP 25MG Tier 1LOXAPINE CAP 50MG Tier 1LOXAPINE CAP 5MG Tier 1LOZI-FLUR LOZ 1MG F Tier 2LTA 360 KIT SOL 4% Tier 3LUDENT CHW 0.25MG F Tier 1LUDENT CHW 0.5MG F Tier 1LUDENT CHW 1MG F Tier 1LUFYLLIN TAB 200MG Tier 3LUFYLLIN TAB 400MG Tier 3LUGOLS SOL STRONG Tier 1LUKAID GLA EMU 1GM/ML Tier 2LUMIGAN SOL 0.01% Tier 2LUPANETA KIT 11.25-5 Tier 3LUPANETA KIT 3.75-5 Tier 3LURIDE CHW 0.25MG F Tier 3LURIDE CHW 0.5MG F Tier 3LURIDE CHW 1MG F Tier 3LURIDE DRO 0.5MG/ML Tier 3LUTERA TAB Tier 1LUVOX CR CAP 100MG Tier 3 XLUVOX CR CAP 150MG Tier 3 XLYCELLE GEL Tier 3LYRICA CAP 100MG Tier 3 XLYRICA CAP 150MG Tier 3 XLYRICA CAP 200MG Tier 3 XLYRICA CAP 225MG Tier 3 XLYRICA CAP 25MG Tier 3 XLYRICA CAP 300MG Tier 3 XLYRICA CAP 50MG Tier 3 XLYRICA CAP 75MG Tier 3 XLYRICA SOL 20MG/ML Tier 3 XLYSODREN TAB 500MG Tier 2 XLYSTEDA TAB 650MG Tier 3 XLYTENSOPRIL MIS -90 KIT Tier 3LYTENSOPRIL PAK KIT Tier 3LYZA TAB 0.35MG Tier 3MACNATAL CN CAP DHA Tier 2MACROBID CAP 100MG Tier 3MACRODANTIN CAP 100MG Tier 3MACRODANTIN CAP 25MG Tier 2MACRODANTIN CAP 50MG Tier 3MACUTEK TAB Tier 3

77


LimitStep

TherapySpecialty

Medication

MAFENIDE ACE PAK 5% Tier 1MAGNEBIND TAB 400 Tier 2MALARONE TAB 250-100 Tier 3MALARONE TAB 62.5-25 Tier 3MALATHION LOT 0.5% Tier 1MAPROTILINE TAB 25MG Tier 1MAPROTILINE TAB 50MG Tier 1MAPROTILINE TAB 75MG Tier 1MARGESIC CAP Tier 1 XMARINOL CAP 10MG Tier 3MARINOL CAP 2.5MG Tier 3MARINOL CAP 5MG Tier 3MARLISSA TAB 0.15/30 Tier 1MARNATAL-F CAP Tier 3MARPLAN TAB 10MG Tier 3MARTEN-TAB TAB 50-325MG Tier 1MATULANE CAP 50MG Tier 2 XMATZIM LA TAB 180MG/24 Tier 3MATZIM LA TAB 240MG/24 Tier 3MATZIM LA TAB 300MG/24 Tier 3MATZIM LA TAB 360MG/24 Tier 3MATZIM LA TAB 420MG/24 Tier 3MAVIK TAB 1MG Tier 3MAVIK TAB 2MG Tier 3MAVIK TAB 4MG Tier 3MAXIBAR SUS 210% Tier 3MAXIDEX SUS 0.1% OP Tier 2MAXITROL OIN 0.1% OP Tier 3MAXITROL SUS 0.1% OP Tier 3MAXZIDE TAB 75-50 Tier 3MAXZIDE-25 TAB Tier 3MB HYDROGEL KIT Tier 3MD-GASTROVIE SOL 66-10% Tier 1MDL ANTIHIST ELX 12.5/5ML Tier 1MECLOFEN SOD CAP 100MG Tier 1MECLOFEN SOD CAP 50MG Tier 1MED 12HR REL TAB 6-120 CR Tier 1MED CIT MAGN SOL Tier 1MEDROL PAK 4MG Tier 3MEDROL TAB 16MG Tier 3MEDROL TAB 2MG Tier 2MEDROL TAB 32MG Tier 3MEDROL TAB 4MG Tier 3MEDROL TAB 8MG Tier 3MEDROX-RX OIN Tier 3

78


LimitStep

TherapySpecialty

Medication

MEDROXYPR AC INJ 150MG/ML Tier 1 XMEDROXYPR AC TAB 10MG Tier 1MEDROXYPR AC TAB 2.5MG Tier 1MEDROXYPR AC TAB 5MG Tier 1MEFENAM ACID CAP 250MG Tier 3MEFLOQUINE TAB 250MG Tier 1MEGACE ES SUS 625/5ML Tier 3MEGACE ORAL SUS 40MG/ML Tier 3MEGESTROL AC SUS 40MG/ML Tier 1MEGESTROL AC TAB 20MG Tier 1MEGESTROL AC TAB 40MG Tier 1MEKINIST TAB 0.5MG Tier 2 X X XMEKINIST TAB 2MG Tier 2 X X XMELOXICAM KIT COMFORT Tier 3MELOXICAM SUS 7.5/5ML Tier 1MELOXICAM TAB 15MG Tier 1MELOXICAM TAB 7.5MG Tier 1MELQUIN 3 SOL 3% Tier 2MENEST TAB 0.3MG Tier 3MENEST TAB 0.625MG Tier 3MENEST TAB 1.25MG Tier 3MENEST TAB 2.5MG Tier 3MENOSTAR DIS 14MCG Tier 3 XMENTAX CRE 1% Tier 3ME-PB-HYOS ELX Tier 1ME-PB-HYOS TAB 16.2MG Tier 1MEPERIDINE SOL 50MG/5ML Tier 1MEPERIDINE TAB 100MG Tier 1MEPERIDINE TAB 50MG Tier 1MEPERIDINE/ CAP PROMETH Tier 3MEPERITAB TAB 100MG Tier 1MEPERITAB TAB 50MG Tier 1MEPHYTON TAB 5MG Tier 2MEPROBAMATE TAB 2MG Tier 1 XMEPROBAMATE TAB 4MG Tier 1MERCAPTOPUR TAB 50MG Tier 1 XMERCAPTOPURI POW Tier 3 XMERCAPTOPURI POW MONOHYDR Tier 3 XMESALAMINE ENE 4GM Tier 1MESALAMINE KIT 4GM Tier 1MESNEX TAB 400MG Tier 3 XMESTINON SYP 60MG/5ML Tier 2MESTINON TAB 60MG Tier 3MESTINON TAB TIMESPAN Tier 2METADATE CD CAP 10MG Tier 2 X X

79


LimitStep

TherapySpecialty

Medication

METADATE CD CAP 20MG Tier 2 X XMETADATE CD CAP 30MG Tier 2 X XMETADATE CD CAP 40MG Tier 2 X XMETADATE CD CAP 50MG Tier 2 X XMETADATE CD CAP 60MG Tier 2 X XMETADATE TAB 20MG ER Tier 1 XMETAFOLBIC TAB PLUS Tier 1METAPROTEREN SYP 10MG/5ML Tier 1METAPROTEREN TAB 10MG Tier 1METAPROTEREN TAB 20MG Tier 1METAXALONE TAB 800MG Tier 3METFORMIN ER TAB 1000MG Tier 3 XMETFORMIN TAB 1000MG Tier 1METFORMIN TAB 500MG Tier 1METFORMIN TAB 500MG ER Tier 3 XMETFORMIN TAB 750MG ER Tier 1 XMETFORMIN TAB 850MG Tier 1METHADONE CON 10MG/ML Tier 1METHADONE SOL 10MG/5ML Tier 1METHADONE SOL 5MG/5ML Tier 1METHADONE TAB 10MG Tier 1METHADONE TAB 40MG Tier 1METHADONE TAB 5MG Tier 1METHADOSE CON 10MG/ML Tier 1METHADOSE SF CON 10MG/ML Tier 1METHADOSE TAB 10MG Tier 1METHADOSE TAB 40MG Tier 1METHAMPHETAM TAB 5MG Tier 1 XMETHAZOLAMID TAB 25MG Tier 1METHAZOLAMID TAB 50MG Tier 1METHENAM HIP TAB 1GM Tier 1METHENAM MAN TAB 1000MG Tier 1METHENAM MAN TAB 1GM Tier 1METHENAM MAN TAB 500MG Tier 1METHIMAZOLE TAB 10MG Tier 1METHIMAZOLE TAB 5MG Tier 1METHITEST TAB 10MG Tier 2METHOCARBAM TAB 500MG Tier 1METHOCARBAM TAB 750MG Tier 1METHOTREXATE POW Tier 3METHOTREXATE TAB 2.5MG Tier 1METHOXSALEN CAP 10MG Tier 1METHSCOPOLAM TAB 2.5MG Tier 1METHSCOPOLAM TAB 5MG Tier 1METHYCLOTHIA TAB 5MG Tier 1

80


LimitStep

TherapySpecialty

Medication

METHYL SALIC LIQ Tier 1METHYLD/HCTZ TAB 250/15 Tier 1METHYLD/HCTZ TAB 250/25 Tier 1METHYLDOPA TAB 250MG Tier 1METHYLDOPA TAB 500MG Tier 1METHYLERGON TAB 0.2MG Tier 1METHYLIN CHW 10MG Tier 3 XMETHYLIN CHW 2.5MG Tier 3 XMETHYLIN CHW 5MG Tier 3 XMETHYLIN SOL 10MG/5ML Tier 3 XMETHYLIN SOL 5MG/5ML Tier 3 XMETHYLPHENID SOL 10MG/5ML Tier 1 XMETHYLPHENID SOL 5MG/5ML Tier 1 XMETHYLPHENID TAB 10MG Tier 1 XMETHYLPHENID TAB 10MG ER Tier 1 XMETHYLPHENID TAB 20MG Tier 1 XMETHYLPHENID TAB 20MG ER Tier 1 XMETHYLPHENID TAB 20MG SR Tier 1 XMETHYLPHENID TAB 5MG Tier 1 XMETHYLPRED PAK 4MG Tier 1METHYLPRED POW ACETATE Tier 3METHYLPRED TAB 16MG Tier 1METHYLPRED TAB 32MG Tier 1METHYLPRED TAB 4MG Tier 1METHYLPRED TAB 8MG Tier 1METIPRANOLOL SOL 0.3% OPH Tier 1METOCLOPRAM SOL 5MG/5ML Tier 1METOCLOPRAM TAB 10MG Tier 1METOCLOPRAM TAB 5MG Tier 1METOLAZONE TAB 10MG Tier 1METOLAZONE TAB 2.5MG Tier 1METOLAZONE TAB 5MG Tier 1METOPIRONE CAP 250MG Tier 2METOPRL/HCTZ TAB 100-25MG Tier 1METOPRL/HCTZ TAB 100-50MG Tier 1METOPRL/HCTZ TAB 50-25MG Tier 1METOPROL TAR TAB 100MG Tier 1METOPROL TAR TAB 25MG Tier 1METOPROL TAR TAB 50MG Tier 1METOPROLOL TAB 100MG ER Tier 3METOPROLOL TAB 200MG ER Tier 3METOPROLOL TAB 25MG ER Tier 1METOPROLOL TAB 50MG ER Tier 3METROCREAM CRE 0.75% Tier 3METROGEL-VAG GEL 0.75% Tier 3

81


LimitStep

TherapySpecialty

Medication

METROLOTION LOT 0.75% Tier 3METRONIDAZOL CAP 375MG Tier 1METRONIDAZOL CRE 0.75% Tier 1METRONIDAZOL GEL 0.75% Tier 1METRONIDAZOL GEL 0.75%VAG Tier 1METRONIDAZOL LOT 0.75% Tier 1METRONIDAZOL TAB 250MG Tier 1METRONIDAZOL TAB 500MG Tier 1METVIXIA CRE 16.8% Tier 3MEVACOR TAB 20MG Tier 3MEVACOR TAB 40MG Tier 3MEXILETINE CAP 150MG Tier 1MEXILETINE CAP 200MG Tier 1MEXILETINE CAP 250MG Tier 1MIACALCIN INJ 200/ML Tier 3MIACALCIN SPR 200/ACT Tier 3MICONAZOLE 3 SUP 200MG Tier 1MICONAZOLE POW NITRATE Tier 3MICROGESTIN TAB 1.5/30 Tier 3MICROGESTIN TAB 1/20 Tier 3MICROGESTIN TAB FE 1/20 Tier 1MICROGESTIN TAB FE1.5/30 Tier 1MICRO-K CAP 10MEQ CR Tier 3MICRO-K CAP 8MEQ CR Tier 3MICROZIDE CAP 12.5MG Tier 3MIDAZOLAM SYP 2MG/ML Tier 1MIDODRINE TAB 10MG Tier 1MIDODRINE TAB 2.5MG Tier 1MIDODRINE TAB 5MG Tier 1MIGERGOT SUP 2/100 Tier 3MIGRAGESIC CAP IDA Tier 1MIGRAL TAB 130MG Tier 2MIGRALAM CAP Tier 3MIGRANAL SPR 4MG/ML Tier 3MILLIPRED DP PAK 5MG Tier 2MILLIPRED SOL 10MG/5ML Tier 3MILLIPRED TAB 5MG Tier 2MIMVEY LO TAB 0.5-0.1 Tier 3MIMVEY TAB 1-0.5MG Tier 3MINERAL OIL HEAVY Tier 3MINILINK RT KIT REPLACE Tier 3MINILINK RT KIT STARTER Tier 3MINILINK RT MIS TRANSMIT Tier 3MINIMED PUMP MIS RES 3ML Tier 3MINIPRESS CAP 1MG Tier 3

82


LimitStep

TherapySpecialty

Medication

MINIPRESS CAP 2MG Tier 3MINIPRESS CAP 5MG Tier 3MINITRAN DIS 0.1MG/HR Tier 1MINITRAN DIS 0.2MG/HR Tier 1MINITRAN DIS 0.4MG/HR Tier 1MINITRAN DIS 0.6MG/HR Tier 1MINIVELLE DIS 0.0375MG Tier 3 XMINIVELLE DIS 0.05MG Tier 3 XMINIVELLE DIS 0.075MG Tier 3 XMINIVELLE DIS 0.1MG Tier 3 XMINOCIN CAP 100MG Tier 3MINOCIN CAP 50MG Tier 3MINOCIN KIT 100MG Tier 3MINOCIN KIT 50MG Tier 3MINOCYCLINE CAP 100MG Tier 1MINOCYCLINE CAP 50MG Tier 1MINOCYCLINE CAP 75MG Tier 1MINOCYCLINE TAB 100MG Tier 3MINOCYCLINE TAB 135MG ER Tier 3MINOCYCLINE TAB 45MG ER Tier 3MINOCYCLINE TAB 50MG Tier 3MINOCYCLINE TAB 75MG Tier 3MINOCYCLINE TAB 90MG ER Tier 3MINOXIDIL TAB 10MG Tier 1MINOXIDIL TAB 2.5MG Tier 1MIO INF SET MIS 18"/6MM Tier 2MIO INF SET MIS 23"/6MM Tier 2MIO INF SET MIS 32"/6MM Tier 2MIO INF SET MIS 32"/9MM Tier 2MIRAPEX TAB 0.125MG Tier 3MIRAPEX TAB 0.25MG Tier 3MIRAPEX TAB 0.5MG Tier 3MIRAPEX TAB 0.75MG Tier 3MIRAPEX TAB 1.5MG Tier 3MIRAPEX TAB 1MG Tier 3MIRCETTE TAB 28 DAY Tier 3MIRTAZAPINE TAB 15MG Tier 1MIRTAZAPINE TAB 15MG ODT Tier 1MIRTAZAPINE TAB 30MG Tier 1MIRTAZAPINE TAB 30MG ODT Tier 1MIRTAZAPINE TAB 45MG Tier 1MIRTAZAPINE TAB 45MG ODT Tier 1MIRTAZAPINE TAB 7.5MG Tier 1MIRVASO GEL 0.33% Tier 3 XMISOPROSTOL TAB 100MCG Tier 1

83


LimitStep

TherapySpecialty

Medication

MISOPROSTOL TAB 200MCG Tier 1MITOMYCIN C POW Tier 3 XMITOMYCIN POW Tier 3 XMITOSOL KIT 0.2MG Tier 3MOBIC SUS 7.5/5ML Tier 3MOBIC TAB 15MG Tier 3MOBIC TAB 7.5MG Tier 3MODICON TAB 0.5/35 Tier 3MOEXIPR/HCTZ TAB 15-12.5 Tier 1MOEXIPR/HCTZ TAB 15-25MG Tier 1MOEXIPR/HCTZ TAB 7.5-12.5 Tier 1MOEXIPRIL TAB 15MG Tier 1MOEXIPRIL TAB 7.5MG Tier 1MOMETASONE CRE 0.1% Tier 1MOMETASONE OIN 0.1% Tier 1MOMETASONE SOL 0.1% Tier 1MONOCLATE-P INJ 1000UNIT Tier 2 XMONOCLATE-P INJ 1500UNIT Tier 2 XMONOCLATE-P INJ 250UNIT Tier 2 XMONOCLATE-P INJ 500UNIT Tier 2 XMONO-LINYAH TAB 0.25-35 Tier 3MONONESSA TAB Tier 3MONONINE INJ 1000UNIT Tier 2 XMONONINE INJ 250UNIT Tier 3 XMONONINE INJ 500UNIT Tier 2 XMONSELS FERR SOL SUBSULF Tier 1MONTELUKAST CHW 4MG Tier 1 XMONTELUKAST CHW 5MG Tier 1 XMONTELUKAST GRA 4MG Tier 3 XMONTELUKAST TAB 10MG Tier 1 XMONUROL PAK GRANULES Tier 3MORCIN CRE Tier 3MORCOMINE SYP Tier 1MORGIDOX CAP 1X100MG Tier 1MORGIDOX CAP 2X100MG Tier 1MORPHINE SUL CAP 120MG ER Tier 3 X XMORPHINE SUL CAP 45MG ER Tier 3 X XMORPHINE SUL CAP 75MG ER Tier 3 X XMORPHINE SUL CAP 90MG ER Tier 3 X XMORPHINE SUL SOL 100/5ML Tier 1MORPHINE SUL SOL 10MG/5ML Tier 1MORPHINE SUL SOL 20MG/5ML Tier 1MORPHINE SUL SOL 20MG/ML Tier 1MORPHINE SUL SUP 10MG Tier 3MORPHINE SUL SUP 20MG Tier 1

84


LimitStep

TherapySpecialty

Medication

MORPHINE SUL SUP 30MG Tier 1MORPHINE SUL SUP 5MG Tier 1MORPHINE SUL TAB 100MG ER Tier 1 XMORPHINE SUL TAB 15MG Tier 1MORPHINE SUL TAB 15MG ER Tier 1 XMORPHINE SUL TAB 200MG ER Tier 1 XMORPHINE SUL TAB 30MG Tier 1MORPHINE SUL TAB 30MG ER Tier 1 XMORPHINE SUL TAB 60MG ER Tier 1 XMOTOFEN TAB Tier 3MOVIPREP SOL Tier 3MOXATAG TAB 775MG Tier 3MOXEZA SOL 0.5% Tier 3MOXIFLOXACIN TAB 400MG Tier 3MOZOBIL INJ Tier 2 XMS CONTIN TAB 100MG CR Tier 3 XMS CONTIN TAB 15MG CR Tier 3 XMS CONTIN TAB 200MG CR Tier 3 XMS CONTIN TAB 30MG CR Tier 3 XMS CONTIN TAB 60MG CR Tier 3 XMST 600 TAB Tier 2MTEST HS/EST TAB ESTROGEN Tier 1MTEST/EST TAB ESTROGEN Tier 1MULTAQ TAB 400MG Tier 2MULTI-VIT/FE DRO /FL 0.25 Tier 1MULTIVIT/FL CHW 0.25MG Tier 1MULTIVIT/FL CHW 0.5MG Tier 1MULTIVIT/FL CHW 1MG Tier 1MULTI-VIT/FL DRO /FE 0.25 Tier 1MULTI-VIT/FL DRO 0.25MG Tier 1MULTI-VIT/FL DRO 0.5MG/ML Tier 1MULT-VIT/FL CHW 0.5MG Tier 1MUPIROCIN CA CRE 2% Tier 3 XMUPIROCIN CRE 2% Tier 3 XMUPIROCIN OIN 2% Tier 1MUSE SUP 1000MCG Tier 3 XMUSE SUP 125MCG Tier 3 XMUSE SUP 250MCG Tier 3 XMUSE SUP 500MCG Tier 3 XMVC-FLUORIDE CHW 0.25MG Tier 1MVC-FLUORIDE CHW 0.5MG Tier 1MVC-FLUORIDE CHW 1MG Tier 1M-VIT TAB 27-1MG Tier 1MYAMBUTOL TAB 100MG Tier 3MYAMBUTOL TAB 400MG Tier 3

85


LimitStep

TherapySpecialty

Medication

MYCOBUTIN CAP 150MG Tier 3MYCOPHENOLAT CAP 250MG Tier 1 XMYCOPHENOLAT TAB 500MG Tier 1 XMYCOPHENOLIC TAB 180MG DR Tier 1 XMYCOPHENOLIC TAB 360MG DR Tier 1 XMYDRAL SOL 0.5% OP Tier 1MYDRAL SOL 1% OP Tier 1MYDRIACYL SOL 1% OP Tier 3MYFORTIC TAB 180MG Tier 3 XMYFORTIC TAB 360MG Tier 3 XMYKIDZ IRON SUS FL Tier 3MYLERAN TAB 2MG Tier 2 XMYNATAL CAP Tier 2MYNATAL PLUS TAB Tier 1MYNATAL TAB Tier 2MYNATAL TAB ADVANCE Tier 2MYNATAL-Z TAB Tier 2MYNATE 90 TAB PLUS Tier 1MYORISAN CAP 10MG Tier 3 XMYORISAN CAP 20MG Tier 3 XMYORISAN CAP 40MG Tier 3 XMYOXIN SUS OTIC Tier 1MYSOLINE TAB 250MG Tier 2MYSOLINE TAB 50MG Tier 2MYZILRA TAB Tier 1NA HYDROXIDE SOL 10% Tier 1NABUMETONE TAB 500MG Tier 1NABUMETONE TAB 750MG Tier 1N-ACETYL-L- CAP CYSTEINE Tier 1NADOLOL TAB 20MG Tier 1NADOLOL TAB 40MG Tier 1NADOLOL TAB 80MG Tier 1NADOLOL/BEND TAB 40-5MG Tier 1NADOLOL/BEND TAB 80-5MG Tier 1NAFRINSE CHW 1MG F Tier 1NAFRINSE DLY SOL /NEUTRAL Tier 2NAFRINSE DRO 0.125MG Tier 1NAFRINSE SOL DAILY Tier 2NAFRINSE WK SOL 0.2% Tier 3NALFON CAP 400MG Tier 3 XNALTREXONE TAB 50MG Tier 1NAMENDA SOL 10MG/5ML Tier 3NAMENDA TAB 10MG Tier 3NAMENDA TAB 5-10MG Tier 3NAMENDA TAB 5MG Tier 3

86


LimitStep

TherapySpecialty

Medication

NAMENDA XR CAP 14MG Tier 3NAMENDA XR CAP 21MG Tier 3NAMENDA XR CAP 28MG Tier 3NAMENDA XR CAP 7MG Tier 3NAMENDA XR CAP TITRATIO Tier 3NAPHAZOLINE SOL 0.1% OP Tier 1NAPROSYN SUS 125/5ML Tier 3NAPROSYN TAB 250MG Tier 3NAPROSYN TAB 375MG Tier 3NAPROSYN TAB 500MG Tier 3NAPROXEN DR TAB 375MG Tier 1NAPROXEN DR TAB 500MG Tier 1NAPROXEN SOD TAB 275MG Tier 1NAPROXEN SOD TAB 550MG Tier 1NAPROXEN SUS 125/5ML Tier 1NAPROXEN TAB 250MG Tier 1NAPROXEN TAB 375MG Tier 1NAPROXEN TAB 500MG Tier 1NARATRIPTAN TAB 1MG Tier 1 XNARATRIPTAN TAB 2.5MG Tier 1 XNARDIL TAB 15MG Tier 3NASCOBAL SPR 500MCG Tier 3NATACHEW CHW Tier 3NATACYN SUS 5% OP Tier 3NATALVIRT CA PAK Tier 3NATALVIRT MIS 90 DHA Tier 3NATALVIT TAB 75-1MG Tier 2NATAZIA TAB Tier 1NATEGLINIDE TAB 120MG Tier 3 XNATEGLINIDE TAB 60MG Tier 3 XNATELLE ONE CAP Tier 3NATURE THROI TAB 162.5MG Tier 3NATURE-THROI TAB 113.75MG Tier 3NATURE-THROI TAB 130MG Tier 3NATURE-THROI TAB 146.25MG Tier 3NATURE-THROI TAB 16.25MG Tier 3NATURE-THROI TAB 195MG Tier 3NATURE-THROI TAB 260MG Tier 3NATURE-THROI TAB 32.5MG Tier 3NATURE-THROI TAB 325MG Tier 3NATURE-THROI TAB 48.75MG Tier 3NATURE-THROI TAB 65MG Tier 3NATURE-THROI TAB 81.25MG Tier 3NATURE-THROI TAB 97.5MG Tier 3NEBUPENT INH 300MG Tier 2

87


LimitStep

TherapySpecialty

Medication

NEBUSAL NEB 3% Tier 1NEBUSAL NEB 6% Tier 3NECON TAB 0.5/35 Tier 1NECON TAB 1/35 Tier 1NECON TAB 1/50-28 Tier 1NECON TAB 10/11-28 Tier 1NECON TAB 7/7/7 Tier 3NEEDLES 22G X 1 1/2" Tier 3NEEVO DHA CAP 27-1.13 Tier 3NEFAZODONE TAB 100MG Tier 1NEFAZODONE TAB 150MG Tier 1NEFAZODONE TAB 200MG Tier 1NEFAZODONE TAB 250MG Tier 1NEFAZODONE TAB 50MG Tier 1NEO/BAC/POLY OIN OP Tier 1NEO/POLY/BAC OIN /HC 1%OP Tier 1NEO/POLY/DEX OIN 0.1% OP Tier 1NEO/POLY/DEX SUS 0.1% OP Tier 1NEO/POLY/GRA SOL OP Tier 1NEO/POLY/HC SOL 1% OTIC Tier 1NEO/POLY/HC SUS 1% OTIC Tier 1NEO/POLY/HC SUS OP Tier 1NEO-FRADIN SOL 125/5ML Tier 2NEOFRIN SOL 10% OP Tier 1NEOFRIN SOL 2.5% OP Tier 1NEOMYCIN TAB 500MG Tier 1NEO-POLYCIN OIN HC 1%OP Tier 1NEO-POLYCIN OIN OP Tier 1NEORAL CAP 100MG Tier 3 XNEORAL CAP 25MG Tier 3 XNEORAL SOL 100MG/ML Tier 3 XNEOSALUS AER Tier 3NEOSALUS CP CRE Tier 3NEOSALUS CRE Tier 3NEOSALUS LOT Tier 3NEOSPORIN SOL OP Tier 3NEOTUSS PLUS LIQ Tier 3NEOTUSS-D LIQ Tier 3NEPTAZANE TAB 25MG Tier 3NEPTAZANE TAB 50MG Tier 3NESINA TAB 12.5MG Tier 2 XNESINA TAB 25MG Tier 2 XNESINA TAB 6.25MG Tier 2 XNESTABS ABC MIS Tier 3NESTABS DHA PAK Tier 3

88


LimitStep

TherapySpecialty

Medication

NESTABS TAB Tier 3NEUAC GEL 1.2-5% Tier 3NEULASTA INJ 6MG/0.6M Tier 3 XNEUMEGA INJ 5MG Tier 2 XNEUPOGEN INJ 300/0.5 Tier 2 XNEUPOGEN INJ 300MCG Tier 2 XNEUPOGEN INJ 480/0.8 Tier 2 XNEUPOGEN INJ 480MCG Tier 2 XNEUPRO DIS 1MG/24HR Tier 3NEUPRO DIS 2MG/24HR Tier 3NEUPRO DIS 3MG/24HR Tier 3NEUPRO DIS 4MG/24HR Tier 3NEUPRO DIS 6MG/24HR Tier 3NEUPRO DIS 8MG/24HR Tier 3NEUREPA CAP Tier 3NEURONTIN CAP 100MG Tier 3 X XNEURONTIN CAP 300MG Tier 3 X XNEURONTIN CAP 400MG Tier 3 X XNEURONTIN SOL 250/5ML Tier 3 X XNEURONTIN TAB 600MG Tier 3 X XNEURONTIN TAB 800MG Tier 3 X XNEUTRAGARD GEL 1.1% Tier 1NEUTRASAL POW Tier 3NEVANAC SUS 0.1% Tier 3 XNEVIRAPINE SUS 50MG/5ML Tier 1 XNEVIRAPINE TAB 200MG Tier 1 XNEVIRAPINE TAB 400MG ER Tier 3 XNEWGEN TAB 32-1MG Tier 3NEXA PLUS CAP Tier 3NEXAVAR TAB 200MG Tier 2 X X XNEXIUM GRA 10MG DR Tier 3 X X XNEXIUM GRA 2.5MG DR Tier 3 X XNEXIUM GRA 20MG DR Tier 3 X X XNEXIUM GRA 40MG DR Tier 3 X X XNEXIUM GRA 5MG DR Tier 3 X XNEXT CHOICE TAB 1.5MG Tier 1NIACIN ER TAB 1000MG Tier 3NIACIN ER TAB 500MG Tier 3NIACIN ER TAB 750MG Tier 3NIACOR TAB 500MG Tier 2NIASPAN TAB 1000 ER Tier 2NIASPAN TAB 500MG ER Tier 2NIASPAN TAB 750MG ER Tier 2NICARDIPINE CAP 20MG Tier 1NICARDIPINE CAP 30MG Tier 1

89


LimitStep

TherapySpecialty

Medication

NIFEDICAL XL TAB 30MG Tier 1NIFEDICAL XL TAB 60MG Tier 1NIFEDIPINE CAP 10MG Tier 1NIFEDIPINE CAP 20MG Tier 1NIFEDIPINE TAB 30MG ER Tier 1NIFEDIPINE TAB 60MG ER Tier 1NIFEDIPINE TAB 90MG ER Tier 1NILANDRON TAB 150MG Tier 2NIMODIPINE CAP 30MG Tier 1NIRAVAM TAB 0.25MG Tier 3NISOLDIPINE TAB 17MG ER Tier 3NISOLDIPINE TAB 20MG Tier 3NISOLDIPINE TAB 25.5MG Tier 3NISOLDIPINE TAB 30MG Tier 3NISOLDIPINE TAB 34MG ER Tier 3NISOLDIPINE TAB 40MG Tier 3NISOLDIPINE TAB 8.5MG ER Tier 3NITRO-BID OIN 2% Tier 1NITRO-DUR DIS 0.1MG/HR Tier 3NITRO-DUR DIS 0.2MG/HR Tier 3NITRO-DUR DIS 0.3MG/HR Tier 3NITRO-DUR DIS 0.4MG/HR Tier 3NITRO-DUR DIS 0.6MG/HR Tier 3NITRO-DUR DIS 0.8MG/HR Tier 3NITROFUR MAC CAP 100MG Tier 1NITROFUR MAC CAP 50MG Tier 1NITROFURANTN CAP 100MG Tier 1NITROFURANTN SUS 25MG/5ML Tier 1NITROFURANZO OIN 0.2% Tier 1NITROGLYCER AER 400MCG Tier 3 XNITROGLYCER CAP 2.5MG ER Tier 1NITROGLYCER CAP 6.5MG ER Tier 1NITROGLYCER CAP 9MG ER Tier 1NITROGLYCER DIS 0.1MG/HR Tier 1NITROGLYCER DIS 0.2MG/HR Tier 1NITROGLYCER DIS 0.4MG/HR Tier 1NITROGLYCER DIS 0.6MG/HR Tier 1NITROGLYCERI DIS 0.6MG/HR Tier 1NITROMIST AER 400MCG Tier 3 XNITROSTAT SUB 0.3MG Tier 2NITROSTAT SUB 0.4MG Tier 2NITROSTAT SUB 0.6MG Tier 2NITRO-TIME CAP 2.5MG CR Tier 1NITRO-TIME CAP 6.5MG CR Tier 1NITRO-TIME CAP 9MG CR Tier 1

90


LimitStep

TherapySpecialty

Medication

NIVATOPIC CRE PLUS Tier 3NIZATIDINE SOL 15MG/ML Tier 3NIZORAL SHA 2% Tier 3NOCLOT-50 SOL ACD-A Tier 3NODOLOR CAP Tier 1NORA-BE TAB 0.35MG Tier 3NORCO TAB 10-325MG Tier 3 XNORCO TAB 5-325MG Tier 3 XNORCO TAB 7.5-325 Tier 3 XNORETH/ETHIN TAB 1/20 Tier 3NORETH/ETHIN TAB FE 1/20 Tier 1NORETHIN ACE TAB 5MG Tier 1NORETHINDRON TAB 0.35MG Tier 3NORGEST/ETHI TAB 0.25/35 Tier 3NORGEST/ETHI TAB ESTRADIO Tier 3NORINYL TAB 1/35 Tier 3NORINYL TAB 1+50-28 Tier 3NORLYROC TAB 0.35MG Tier 3NOROXIN TAB 400MG Tier 3NORPACE CAP 100MG Tier 3NORPACE CAP 100MG CR Tier 2NORPACE CAP 150MG Tier 3NORPACE CAP 150MG CR Tier 2NORPRAMIN TAB 100MG Tier 3NORPRAMIN TAB 10MG Tier 3NORPRAMIN TAB 150MG Tier 3NORPRAMIN TAB 25MG Tier 3NORPRAMIN TAB 50MG Tier 3NORPRAMIN TAB 75MG Tier 3NOR-QD TAB 0.35MG Tier 3NORTREL TAB 0.5/35 Tier 1NORTREL TAB 1/35 Tier 1NORTREL TAB 7/7/7 Tier 3NORTRIPTYLIN CAP 10MG Tier 1NORTRIPTYLIN CAP 25MG Tier 1NORTRIPTYLIN CAP 50MG Tier 1NORTRIPTYLIN CAP 75MG Tier 1NORTRIPTYLIN SOL 10MG/5ML Tier 1NORTUSS-DE DRO Tier 1NORTUSS-EX LIQ 200-20/5 Tier 1NORVASC TAB 10MG Tier 3NORVASC TAB 2.5MG Tier 3NORVASC TAB 5MG Tier 3NORVIR CAP 100MG Tier 2 XNORVIR SOL 80MG/ML Tier 2 X

91


LimitStep

TherapySpecialty

Medication

NORVIR TAB 100MG Tier 2 XNOVACORT GEL Tier 3NOVOLOG INJ 100/ML Tier 3 XNOVOLOG INJ FLEXPEN Tier 3 XNOVOLOG INJ PENFILL Tier 3 XNOVOLOG MIX INJ 70/30 Tier 3 XNOVOLOG MIX INJ FLEXPEN Tier 3 XNOVOPEN ECHO MIS Tier 3 XNOVOSEVEN RT INJ 1MG Tier 2NOVOSEVEN RT INJ 2MG Tier 2NOVOSEVEN RT INJ 5MG Tier 2 XNOVOSEVEN RT INJ 8MG Tier 2NOXAFIL SUS 40MG/ML Tier 2NP THYROID TAB 30MG Tier 1NP THYROID TAB 60MG Tier 1NP THYROID TAB 90MG Tier 1NUCORT LOT 2% Tier 3NUCYNTA ER TAB 100MG Tier 3 X XNUCYNTA ER TAB 150MG Tier 3 X XNUCYNTA ER TAB 200MG Tier 3 X XNUCYNTA ER TAB 250MG Tier 3 X XNUCYNTA ER TAB 50MG Tier 3 X XNUCYNTA TAB 100MG Tier 3 XNUCYNTA TAB 50MG Tier 3 XNUCYNTA TAB 75MG Tier 3 XNUEDEXTA CAP 20-10MG Tier 2NULEV TAB 0.125MG Tier 3NULYTELY SOL FLAV PKS Tier 3NUOX GEL 6-3% Tier 3NUQUIN HP GEL 4% Tier 1NUTRIDOX KIT Tier 3NUTROPIN AQ INJ 10MG/2ML Tier 2 X X XNUTROPIN AQ INJ 20MG/2ML Tier 2 X X XNUTROPIN AQ INJ NUSPIN 5 Tier 2 X XNUVAIL SOL 16% Tier 3NUVARING MIS Tier 2NUVIGIL TAB 150MG Tier 3 X XNUVIGIL TAB 200MG Tier 3 X XNUVIGIL TAB 250MG Tier 3 X XNUVIGIL TAB 50MG Tier 3 X XNUZON GEL 2% Tier 3NYAMYC POW 100000 Tier 1NYMALIZE SOL 60/20ML Tier 2NYSTATIN CRE 100000 Tier 1NYSTATIN OIN 100000 Tier 1

92


LimitStep

TherapySpecialty

Medication

NYSTATIN POW Tier 1NYSTATIN POW 100000 Tier 1NYSTATIN SUS 100000 Tier 1NYSTATIN TAB 500000 Tier 1NYSTOP POW 100000 Tier 1OB COMPLETE CAP 400 Tier 3OB COMPLETE CAP ONE Tier 3OB COMPLETE CAP PETITE Tier 3OB COMPLETE CHW Tier 3OB COMPLETE TAB Tier 3OB COMPLETE TAB PREMIER Tier 3OB COMPLETE/ CAP DHA Tier 3OBSTETRIX EC TAB Tier 3OBSTETRIX PAK DHA Tier 2O-CAL FA TAB Tier 2O-CAL TAB PRENATAL Tier 2OCELLA TAB 3-0.03MG Tier 3OCTREOTIDE INJ 1000MCG Tier 1 X XOCTREOTIDE INJ 100MCG Tier 1 X XOCTREOTIDE INJ 200MCG Tier 1 X XOCTREOTIDE INJ 500MCG Tier 1 X XOCTREOTIDE INJ 50MCG/ML Tier 1 X XOCUDOX KIT Tier 2OCUFEN SOL 0.03% OP Tier 3OCUFLOX DRO 0.3% OP Tier 3OFLOXACIN DRO 0.3% OP Tier 1OFLOXACIN DRO 0.3%OTIC Tier 1OFLOXACIN TAB 300MG Tier 1OFLOXACIN TAB 400MG Tier 1OGESTREL TAB Tier 3OLANZA/FLUOX CAP 12-25MG Tier 3 XOLANZA/FLUOX CAP 12-50MG Tier 3 XOLANZA/FLUOX CAP 3-25MG Tier 3 XOLANZA/FLUOX CAP 6-25MG Tier 3 XOLANZA/FLUOX CAP 6-50MG Tier 3 XOLANZAPINE TAB 10MG Tier 1 XOLANZAPINE TAB 10MG ODT Tier 3 XOLANZAPINE TAB 15MG Tier 1 XOLANZAPINE TAB 15MG ODT Tier 3 XOLANZAPINE TAB 2.5MG Tier 1 XOLANZAPINE TAB 20MG Tier 1 XOLANZAPINE TAB 20MG ODT Tier 3 XOLANZAPINE TAB 5MG Tier 1 XOLANZAPINE TAB 5MG ODT Tier 3 XOLANZAPINE TAB 7.5MG Tier 1 X

93


LimitStep

TherapySpecialty

Medication

OLUX-E AER 0.05% Tier 3 XOLYSIO CAP 150MG Tier 2 X X XOMECLAMOX- MIS PAK Tier 3 XOMEGA-3-ACID CAP 1GM Tier 3 XOMEPRAZOLE + SUS SYRSPEND Tier 3OMEPRAZOLE CAP 10MG Tier 1OMEPRAZOLE CAP 20MG Tier 1OMEPRAZOLE CAP 40MG Tier 1OMNIFLEX DPR Tier 3OMNIPRED SUS 1% OP Tier 3ONDANSETRON SOL 4MG/5ML Tier 1ONDANSETRON TAB 24MG Tier 1ONDANSETRON TAB 4MG Tier 1ONDANSETRON TAB 4MG ODT Tier 1ONDANSETRON TAB 8MG Tier 1ONDANSETRON TAB 8MG ODT Tier 1ONFI SUS 2.5MG/ML Tier 3 XONFI TAB 10MG Tier 3 XONFI TAB 20MG Tier 3 XONGLYZA TAB 2.5MG Tier 2 XONGLYZA TAB 5MG Tier 2 XOPANA ER TAB 10MG Tier 2 X XOPANA ER TAB 15MG Tier 2 X XOPANA ER TAB 20MG Tier 2 X XOPANA ER TAB 30MG Tier 2 X XOPANA ER TAB 40MG Tier 2 X XOPANA ER TAB 5MG Tier 2 X XOPANA ER TAB 7.5MG Tier 2 X XOPANA TAB 10MG Tier 3 XOPANA TAB 5MG Tier 3 XOPIUM TIN 1% Tier 1OPIUM TINCT TIN 2MG/5ML Tier 1OPSUMIT TAB 10MG Tier 3 X X XOPTIHALER MIS Tier 3ORA-BLEND SF SUS Tier 3ORA-BLEND SUS Tier 3ORACEA CAP 40MG Tier 3ORACIT SOL Tier 2ORAL MIX LIQ SUSPENDI Tier 3ORAL MIX SF LIQ Tier 3ORAL SUSPEND LIQ Tier 3ORAL SYRUP LIQ FLAVORED Tier 3ORAL SYRUP LIQ SF Tier 3ORALAIR SUB 300 IR Tier 3 X XORALONE PST 0.1% Tier 1

94


LimitStep

TherapySpecialty

Medication

ORAP TAB 1MG Tier 2ORAP TAB 2MG Tier 2ORA-PLUS LIQ Tier 3ORAPRED ODT TAB 10MG Tier 3ORA-SWEET SF SYP Tier 3ORA-SWEET SYP Tier 2ORAVIG TAB 50MG Tier 3ORENCIA INJ 125MG/ML Tier 3 X X X XORENITRAM TAB 0.125MG Tier 3 X XORENITRAM TAB 0.25MG Tier 3 X XORENITRAM TAB 1MG Tier 3 X XORENITRAM TAB 2.5MG Tier 3 X XORFADIN CAP 10MG Tier 3ORFADIN CAP 2MG Tier 3ORFADIN CAP 5MG Tier 3ORPH/ASA/CAF TAB Tier 2ORPHENADRINE TAB 100MG ER Tier 3ORSYTHIA TAB Tier 1ORTHO COIL DPR KIT 100 Tier 2ORTHO COIL DPR KIT 105 Tier 2ORTHO COIL DPR KIT 50 Tier 2ORTHO FLAT DPR KIT 55 Tier 2ORTHO FLAT DPR KIT 60 Tier 2ORTHO FLAT DPR KIT 65 Tier 2ORTHO FLAT DPR KIT 70 Tier 2ORTHO FLAT DPR KIT 75 Tier 2ORTHO FLAT DPR KIT 80 Tier 2ORTHO FLAT DPR KIT 85 Tier 2ORTHO FLAT DPR KIT 90 Tier 2ORTHO FLAT DPR KIT 95 Tier 2ORTHO MICRON TAB 0.35MG Tier 1ORTHO TRI- TAB CYCLEN Tier 1ORTHO TRI- TAB CYCLN LO Tier 3ORTHO-CEPT TAB 28 Tier 3ORTHO-CYCLEN TAB 0.25/35 Tier 1ORTHO-EST TAB 0.625 Tier 1ORTHO-EST TAB 1.25 Tier 1ORTHO-NOVUM TAB 1/35 Tier 3ORTHO-NOVUM TAB 7/7/7 Tier 1OSCIMIN SR TAB 0.375MG Tier 1OSCIMIN SUB 0.125MG Tier 1OSCIMIN TAB 0.125MG Tier 1OSCION CLNSR LOT 6% Tier 3OSENI TAB 12.5-15 Tier 2 XOSENI TAB 12.5-30 Tier 2 X

95


LimitStep

TherapySpecialty

Medication

OSENI TAB 12.5-45 Tier 2 XOSENI TAB 25-15MG Tier 2 XOSENI TAB 25-30MG Tier 2 XOSENI TAB 25-45MG Tier 2 XOSMOPREP TAB 1.5GM Tier 3OSPHENA TAB 60MG Tier 3OTEZLA TAB 10/20/30 Tier 3 X X X XOTEZLA TAB 30MG Tier 3 X X X XOTIC CARE DRO Tier 1OTICIN DRO 1-0.1% Tier 1OTICIN HC DRO Tier 2OTO-END 10 SOL Tier 1OTOMAX-HC DRO Tier 1OTOZIN DRO Tier 1OVACE PLUS CRE 10% Tier 3OVACE PLUS GEL 10% WASH Tier 3OVACE PLUS LIQ 10% WASH Tier 3OVACE PLUS SHA 10% Tier 3OVACE WASH LIQ 10% Tier 3OVCON-35 TAB Tier 3OVIDE LOT 0.5% Tier 3 XOXANDRIN TAB 10MG Tier 3OXANDRIN TAB 2.5MG Tier 3OXANDROLONE TAB 10MG Tier 3OXANDROLONE TAB 2.5MG Tier 3OXAPROZIN TAB 600MG Tier 1OXAZEPAM CAP 10MG Tier 1OXAZEPAM CAP 15MG Tier 1OXAZEPAM CAP 30MG Tier 1OXCARBAZEPIN SUS 300MG/5M Tier 1OXCARBAZEPIN TAB 150MG Tier 1OXCARBAZEPIN TAB 300MG Tier 1OXCARBAZEPIN TAB 600MG Tier 1OXISTAT CRE 1% Tier 3OXSORALEN LOT 1% Tier 3OXSORALEN-UL CAP 10MG Tier 2OXYBUTYNIN SYP 5MG/5ML Tier 1OXYBUTYNIN TAB 10MG ER Tier 3OXYBUTYNIN TAB 15MG ER Tier 3OXYBUTYNIN TAB 5MG Tier 1OXYBUTYNIN TAB 5MG ER Tier 3OXYCOD/APAP TAB 10-325MG Tier 1 XOXYCOD/APAP TAB 2.5-325 Tier 1 XOXYCOD/APAP TAB 5-325MG Tier 1 XOXYCOD/APAP TAB 7.5-325 Tier 1 X

96


LimitStep

TherapySpecialty

Medication

OXYCOD/ASA TAB Tier 1OXYCOD/IBU TAB 5-400MG Tier 1OXYCODONE CAP 5MG Tier 1OXYCODONE CON 100/5ML Tier 1OXYCODONE CON 20MG/ML Tier 1OXYCODONE SOL 5MG/5ML Tier 1OXYCODONE TAB 10MG Tier 1OXYCODONE TAB 15MG Tier 1OXYCODONE TAB 20MG Tier 1OXYCODONE TAB 30MG Tier 1OXYCODONE TAB 5MG Tier 1OXYCONTIN TAB 10MG CR Tier 2 X XOXYCONTIN TAB 15MG CR Tier 2 X XOXYCONTIN TAB 20MG CR Tier 2 X XOXYCONTIN TAB 30MG CR Tier 2 X XOXYCONTIN TAB 40MG CR Tier 2 X XOXYCONTIN TAB 60MG CR Tier 2 X XOXYCONTIN TAB 80MG CR Tier 2 X XOXYMORPHONE TAB 10MG ER Tier 3 X XOXYMORPHONE TAB 15MG ER Tier 3 X XOXYMORPHONE TAB 20MG ER Tier 3 X XOXYMORPHONE TAB 30MG ER Tier 3 X XOXYMORPHONE TAB 40MG ER Tier 3 X XOXYMORPHONE TAB 5MG ER Tier 3 X XOXYMORPHONE TAB 7.5MG ER Tier 3 X XOXYMORPHONE TAB HCL 10MG Tier 3 XOXYMORPHONE TAB HCL 5MG Tier 3 XPACERONE TAB 100MG Tier 3PACERONE TAB 200MG Tier 1PACERONE TAB 400MG Tier 3PAIN EASE AER MD STRM Tier 3PAIN EASE AER MIST Tier 3PAIRE OB MIS Tier 3PAMELOR CAP 10MG Tier 3PAMELOR CAP 25MG Tier 3PAMELOR CAP 50MG Tier 3PAMELOR CAP 75MG Tier 3PAMINE FQ KIT Tier 3PAMINE TAB 2.5MG Tier 3PANCREAZE CAP 10500UNT Tier 3PANCREAZE CAP 16800UNT Tier 3PANCREAZE CAP 21000UNT Tier 3PANCREAZE CAP 4200UNIT Tier 3PANCRELIPASE CAP 5000UNIT Tier 1PANDEL CRE 0.1% Tier 3

97


LimitStep

TherapySpecialty

Medication

PANRETIN GEL 0.1% Tier 3PANTOPRAZOLE TAB 20MG Tier 1PANTOPRAZOLE TAB 40MG Tier 1PAPAVERINE POW HCL Tier 3PARADIGM MIS UPGRADE Tier 3PARADIGM QR MIS POLY 24" Tier 3PARADIGM QR MIS POLY 42" Tier 3PARADIGM REA MIS TRANSMIT Tier 3PARADIGM RES MIS 1.76ML Tier 3PARADIGM RES MIS 3ML Tier 3PARADIGM SOF MIS -SET 24" Tier 2PARADIGM SOF MIS -SET 42" Tier 2PARAFON FORT TAB 500MG Tier 3PARCAINE SOL 0.5% OP Tier 1PAREMYD SOL 1-0.25% Tier 3PARICALCITOL CAP 1 MCG Tier 1PARICALCITOL CAP 2 MCG Tier 1PARICALCITOL CAP 4 MCG Tier 1PARLODEL CAP 5MG Tier 3PARNATE TAB 10MG Tier 3PAROEX SOL 0.12% Tier 1PAROMOMYCIN CAP 250MG Tier 1PAROXETIN ER TAB 12.5MG Tier 3 XPAROXETIN ER TAB 37.5MG Tier 3 XPAROXETINE TAB 10MG Tier 1PAROXETINE TAB 20MG Tier 1PAROXETINE TAB 25MG ER Tier 3 XPAROXETINE TAB 30MG Tier 1PAROXETINE TAB 40MG Tier 1PASER GRA 4GM Tier 3PATANASE SPR 0.6% Tier 3 XPAXIL CR TAB 12.5MG Tier 3 XPAXIL CR TAB 25MG Tier 3 XPAXIL CR TAB 37.5MG Tier 3 XPAXIL SUS 10MG/5ML Tier 3PAXIL TAB 10MG Tier 3PAXIL TAB 20MG Tier 3PAXIL TAB 30MG Tier 3PAXIL TAB 40MG Tier 3PCA INJECTOR MIS Tier 3 XPCCA ACACIA SYP BASE Tier 3PCCA COBASE OIN #1 Tier 3PCCA CUSTOM CRE LIPO-MAX Tier 3PCCA LIPOSOM CRE DRY Tier 3PCCA LIPOSOM CRE NORMAL Tier 3

98


LimitStep

TherapySpecialty

Medication

PCCA LIPOSOM CRE OILY Tier 3PCCA LIPOSOM CRE SENSITIV Tier 3PCCA SWEET SYP -SF Tier 3PCCA SYRUP SYP VEHICLE Tier 3PCCA-PLUS SUS Tier 3PCE TAB 333MG EC Tier 3PCE TAB 500MG EC Tier 3PE/GUAIFENES DRO 1.5-20MG Tier 1PEDIADERM HC KIT Tier 3PEDIAPRED SOL 6.7/5ML Tier 2PEDIATEX TD LIQ Tier 3PEDIATEX TDM SUS Tier 3PEDI-DRI POW 100000 Tier 1PEG 3350 POW Tier 2PEG 3350 SOL ELECTROL Tier 1PEG-3350 SOL ELECTROL Tier 1PEG-3350/KCL SOL /SODIUM Tier 1PEGANONE TAB 250MG Tier 2PEGASYS INJ Tier 2 X X XPEGASYS INJ 180MCG/M Tier 2 X X XPEGASYS INJ PROCLICK Tier 2 X X XPEGASYS KIT Tier 2 X X XPEG-INTRON KIT 120 RP Tier 3 X X X XPEG-INTRON KIT 120MCG Tier 3 X X X XPEG-INTRON KIT 150 RP Tier 3 X X X XPEG-INTRON KIT 150MCG Tier 3 X X X XPEG-INTRON KIT 50MCG Tier 3 X X X XPEG-INTRON KIT 50MCG RP Tier 3 X X X XPEG-INTRON KIT 80MCG Tier 3 X X X XPEG-INTRON KIT 80MCG RP Tier 3 X X X XPEGYLAX POW Tier 1PENICILLN VK SOL 125/5ML Tier 1PENICILLN VK SOL 250/5ML Tier 1PENICILLN VK TAB 250MG Tier 1PENICILLN VK TAB 500MG Tier 1PENLAC SOL 8% Tier 3PENTAZ/NALOX TAB 50-0.5MG Tier 1PENTOXIFYLLI TAB 400MG ER Tier 1PEPCID SUS 40MG/5ML Tier 3PERCODAN TAB Tier 3PERCURA CAP Tier 3PERFOROMIST NEB 20MCG Tier 3 XPERIDEX SOL 0.12% Tier 3PERINDOPRIL TAB 2MG Tier 3PERINDOPRIL TAB 4MG Tier 3

99


LimitStep

TherapySpecialty

Medication

PERINDOPRIL TAB 8MG Tier 3PERIO MED CON 0.63% Tier 1PERIOGARD SOL 0.12% Tier 1PERIOSTAT TAB Tier 3PERMETHRIN CRE 5% Tier 1PERPHEN/AMIT TAB 2-10MG Tier 1PERPHEN/AMIT TAB 2-25MG Tier 1PERPHEN/AMIT TAB 4-10MG Tier 1PERPHEN/AMIT TAB 4-25MG Tier 1PERPHEN/AMIT TAB 4-50MG Tier 1PERPHENAZINE TAB 16MG Tier 1PERPHENAZINE TAB 2MG Tier 1PERPHENAZINE TAB 4MG Tier 1PERPHENAZINE TAB 8MG Tier 1PERSANTINE TAB 25MG Tier 3PERSANTINE TAB 50MG Tier 3PERSANTINE TAB 75MG Tier 3PETN TAB 80MG Tier 1PETROLATUM OIN WHITE Tier 3PETROLATUM OIN YELLOW Tier 3PHENADOZ SUP 12.5MG Tier 1PHENADOZ SUP 25MG Tier 1PHENA-S LIQ Tier 3PHENAZO TAB 200MG Tier 1PHENAZOPYRID TAB 100MG Tier 1PHENAZOPYRID TAB 200MG Tier 1PHENELZINE TAB 15MG Tier 1PHENOBARB ELX 20/5ML Tier 1PHENOBARB ELX 20MG/5ML Tier 1PHENOBARB SOL 20MG/5ML Tier 1PHENOBARB TAB 100MG Tier 1PHENOBARB TAB 15MG Tier 1PHENOBARB TAB 16.2MG Tier 1PHENOBARB TAB 30MG Tier 1PHENOBARB TAB 32.4MG Tier 1PHENOBARB TAB 60MG Tier 1PHENOBARB TAB 64.8MG Tier 1PHENOBARB TAB 97.2MG Tier 1PHENYLBUTYRA POW SODIUM Tier 1 XPHENYLEPHRIN SOL 10% OP Tier 1PHENYLEPHRIN SOL 2.5% OP Tier 1PHENYTEK CAP 200MG Tier 3PHENYTEK CAP 300MG Tier 3PHENYTOIN CHW 50MG Tier 3PHENYTOIN EX CAP 100MG Tier 1

100


LimitStep

TherapySpecialty

Medication

PHENYTOIN EX CAP 200MG Tier 1PHENYTOIN EX CAP 300MG Tier 1PHENYTOIN SUS 125/5ML Tier 1PHILITH TAB 0.4-35 Tier 3PHOS-FLUR GEL 1.1% Tier 1PHOSLO CAP 667MG Tier 3PHOSLYRA SOL Tier 3PHOSPHA 250 TAB NEUTRAL Tier 1PHOSPHASAL TAB Tier 1PHOSPHOLINE SOL 0.125%OP Tier 2PICATO GEL 0.015% Tier 3 XPICATO GEL 0.05% Tier 3 XPILOCARPINE SOL 1% OP Tier 1PILOCARPINE SOL 2% OP Tier 1PILOCARPINE SOL 4% OP Tier 1 XPILOCARPINE TAB 5MG Tier 1PILOCARPINE TAB 7.5MG Tier 1PIMTREA TAB Tier 3PINDOLOL TAB 10MG Tier 1PINDOLOL TAB 5MG Tier 1PINNACAINE DRO 20% OTIC Tier 3PIOGLIT/GLIM TAB 30-2MG Tier 1 XPIOGLIT/GLIM TAB 30-4MG Tier 1 XPIOGLITA/MET TAB 15-500MG Tier 3 XPIOGLITA/MET TAB 15-850MG Tier 3 XPIOGLITAZONE TAB 15MG Tier 3 XPIOGLITAZONE TAB 30MG Tier 3 XPIOGLITAZONE TAB 45MG Tier 3 XPIRMELLA TAB 1/35 Tier 1PIRMELLA TAB 7/7/7 Tier 3PIROXICAM CAP 10MG Tier 1PIROXICAM CAP 20MG Tier 1PLACEBO #00 CAP Tier 2PLAN B TAB 0.75MG Tier 1PLAN B TAB 1.5MG Tier 1PLAQUENIL TAB 200MG Tier 3PLETAL TAB 100MG Tier 3PLETAL TAB 50MG Tier 3PLIAGLIS CRE 7-7% Tier 3PLO GEL MEDIFLO Tier 3PLO MEDIFLO KIT KIT Tier 3PLO TRANSDER CRE Tier 3PLO20 BASE GEL Tier 3PNEUMODORON LIQ Tier 3PNV FE FUM TAB DOC/FA Tier 3

101


LimitStep

TherapySpecialty

Medication

PNV FOLIC AC TAB + IRON Tier 3PNV OB+DHA PAK Tier 3PNV PRENATAL TAB PLUS Tier 3PNV TABS TAB 29-1MG Tier 3PNV-DHA CAP Tier 3PNV-DHA CAP DOCUSATE Tier 3PNV-OMEGA CAP Tier 3PNV-SELECT TAB Tier 3PNV-TOTAL CAP Tier 2PODOCON SOL 25% Tier 1PODOFILOX SOL 0.5% Tier 1POLIBAR ACB KIT 96% Tier 3POLIBAR PLUS SUS 105% Tier 2POLIBAR SUS 100% Tier 3POLYCIN B OIN OP Tier 1POLYCIN OIN OP Tier 1POLY-DEX OIN 0.1% OP Tier 1POLYETH GLYC OIN 8000 Tier 3POLYETH GLYC POW 3350 NF Tier 1POLYFIN 24" MIS INFUSION Tier 3POLYFIN 42" MIS INFUSION Tier 3POLYFIN 42" MIS QR INFUS Tier 3POLYFIN 60" MIS TUBING Tier 3POLYMYXIN B/ SOL TRIMETHP Tier 1POLYPEG OIN BASE Tier 3POLYSORBATE LIQ 80 Tier 3POLYTRIM SOL OP Tier 3POLY-VI-FLOR CHW 0.25MG Tier 3POLY-VI-FLOR CHW 0.5MG Tier 3POLY-VI-FLOR CHW 1MG Tier 3POLY-VI-FLOR CHW W/IRON Tier 3POLY-VI-FLOR SUS /IRON Tier 3POLY-VI-FLOR SUS 0.25/ML Tier 3POMALYST CAP 1MG Tier 3 X X XPOMALYST CAP 2MG Tier 3 X X XPOMALYST CAP 3MG Tier 3 X X XPOMALYST CAP 4MG Tier 3 X X XPONSTEL CAP 250MG Tier 3PONTOCAINE SOL 2% Tier 3PORTIA-28 TAB Tier 1POT CHLORIDE CAP 10MEQ CR Tier 1POT CHLORIDE CAP 10MEQ ER Tier 1POT CHLORIDE CAP 8MEQ ER Tier 1POT CHLORIDE LIQ 10% Tier 1POT CHLORIDE LIQ 10% SF Tier 1

102


LimitStep

TherapySpecialty

Medication

POT CHLORIDE LIQ 20% Tier 1POT CHLORIDE POW 20MEQ Tier 1POT CHLORIDE SOL 10% SF Tier 1POT CHLORIDE TAB 10MEQ CR Tier 1POT CHLORIDE TAB 10MEQ ER Tier 1POT CHLORIDE TAB 20MEQ ER Tier 1POT CHLORIDE TAB 25MEQ EF Tier 1POT CHLORIDE TAB 8MEQ ER Tier 1POT CHLORIDE TAB 8MEQ SR Tier 1POT CITRATE- PAK CIT ACID Tier 1POT CITRATE TAB 1080MG Tier 1POT CITRATE TAB 1620MG Tier 1POT CITRATE TAB 540MG Tier 1POT CL MICRO TAB 10MEQ CR Tier 1POT CL MICRO TAB 10MEQ ER Tier 1POT CL MICRO TAB 20MEQ ER Tier 1POT HYDROXID SOL 5% Tier 2POT PHOSPHAT GRA DIBASIC Tier 3POT/CHLORIDE TAB 25MEQ EF Tier 1POTABA CAP 500MG Tier 3POTABA TAB 500MG Tier 3POTASSIUM TAB 25MEQ EF Tier 1POTIGA TAB 200MG Tier 3 XPOTIGA TAB 300MG Tier 3 XPOTIGA TAB 400MG Tier 3 XPOTIGA TAB 50MG Tier 3 XPR CREAM KIT Tier 2PR NATAL 400 PAK Tier 3PR NATAL 400 PAK EC Tier 3PR NATAL 430 PAK Tier 3PR NATAL 430 PAK EC Tier 3PRADAXA CAP 150MG Tier 2 XPRADAXA CAP 75MG Tier 2 XPRAMCORT CRE 1-1% Tier 1PRAMIPEXOLE TAB 0.125MG Tier 1PRAMIPEXOLE TAB 0.25MG Tier 1PRAMIPEXOLE TAB 0.5MG Tier 1PRAMIPEXOLE TAB 0.75MG Tier 1PRAMIPEXOLE TAB 1.5MG Tier 1PRAMIPEXOLE TAB 1MG Tier 1PRAMOSONE CRE 1% Tier 2PRAMOSONE CRE 1-2.5% Tier 3PRAMOSONE LOT 1% Tier 2PRAMOSONE LOT 2.5% Tier 2PRAMOSONE OIN 1% Tier 2

103


LimitStep

TherapySpecialty

Medication

PRAMOSONE OIN 2.5% Tier 3PRAMOTIC DRO 1-0.1% Tier 3PRAMOX GEL 1% Tier 1PRAMOXINE-HC DRO AQ OTIC Tier 1PRANDIMET TAB 1-500MG Tier 3PRANDIMET TAB 2-500MG Tier 3PRANDIN TAB 0.5MG Tier 3 XPRANDIN TAB 1MG Tier 3 XPRANDIN TAB 2MG Tier 3 XPRASCION EMU Tier 1PRASCION FC PAD 10-5% Tier 1PRASCION RA CRE 10-5% Tier 1PRAVACHOL TAB 20MG Tier 3PRAVACHOL TAB 40MG Tier 3PRAVACHOL TAB 80MG Tier 3PRAVASTATIN TAB 10MG Tier 1PRAVASTATIN TAB 20MG Tier 1PRAVASTATIN TAB 40MG Tier 1PRAVASTATIN TAB 80MG Tier 1PRAZOLAMINE PAK Tier 3PRAZOSIN HCL CAP 1MG Tier 1PRAZOSIN HCL CAP 2MG Tier 1PRAZOSIN HCL CAP 5MG Tier 1PRECOSE TAB 100MG Tier 3PRECOSE TAB 25MG Tier 3PRECOSE TAB 50MG Tier 3PRED FORTE SUS 1% OP Tier 3PRED MILD SUS 0.12% OP Tier 2PRED SOD PHO SOL 1% OP Tier 1PRED SOD PHO SOL 5MG/5ML Tier 1PRED-G S.O.P OIN OP Tier 3PRED-G SUS OP Tier 3PREDNICARBAT CRE 0.1% Tier 1PREDNICARBAT OIN 0.1% Tier 1PREDNISOLONE SOL 15MG/5ML Tier 1PREDNISOLONE SOL 25MG/5ML Tier 1PREDNISOLONE SUS 1% OP Tier 1PREDNISOLONE SYP 15MG/5ML Tier 1PREDNISONE CON 5MG/ML Tier 1PREDNISONE PAK 10MG Tier 1PREDNISONE PAK 5MG Tier 1PREDNISONE SOL 5MG/5ML Tier 1PREDNISONE TAB 10MG Tier 1PREDNISONE TAB 1MG Tier 1PREDNISONE TAB 2.5MG Tier 1

104


LimitStep

TherapySpecialty

Medication

PREDNISONE TAB 20MG Tier 1PREDNISONE TAB 50MG Tier 1PREDNISONE TAB 5MG Tier 1PREFERA OB MIS + DHA Tier 3PREFERA OB TAB Tier 3PREFERAOB CAP ONE Tier 3PREFEST TAB Tier 2PREFOL-DHA CAP Tier 3PRELONE SYP 15MG/5ML Tier 3PREMARIN TAB 0.3MG Tier 3PREMARIN TAB 0.45MG Tier 3PREMARIN TAB 0.625MG Tier 3PREMARIN TAB 0.9MG Tier 3PREMARIN TAB 1.25MG Tier 3PREMARIN VAG CRE 0.625MG Tier 3PREMPHASE TAB Tier 3PREMPRO TAB .625-2.5 Tier 3PREMPRO TAB 0.3-1.5 Tier 3PREMPRO TAB 0.45-1.5 Tier 3PREMPRO TAB 0.625-5 Tier 3PRENA1 CAP QUATREFO Tier 3PRENA1 CHW Tier 3PRENA1 PEARL CAP Tier 3PRENA1 PLUS MIS QUATREFO Tier 3PRENAISSANCE CAP Tier 2PRENAISSANCE CAP BALANCE Tier 2PRENAISSANCE CAP PLUS Tier 2PRENAISSANCE MIS HARMONY Tier 3PRENAISSANCE PAK 90 DHA Tier 3PRENAISSANCE PAK DHA Tier 3PRENAISSANCE PAK PROMISE Tier 3PRENAISSANCE TAB NEXT Tier 2PRENAISSANCE TAB NEXT-B Tier 3PRENAPLUS TAB Tier 1PRENAT PLUS TAB 27-1MG Tier 3PRENATA CHW 29-1MG Tier 3PRENATABS FA TAB Tier 1PRENATABS RX TAB Tier 1PRENATAL 19 CHW 29-1MG Tier 3PRENATAL 19 CHW TAB Tier 1PRENATAL 19 TAB Tier 1PRENATAL 19 TAB 29-1MG Tier 3PRENATAL AD TAB Tier 1PRENATAL MIS COMPLEAT Tier 3PRENATAL TAB 27-1MG Tier 3

105


LimitStep

TherapySpecialty

Medication

PRENATAL TAB PLUS Tier 1PRENATAL+FE TAB 29-1MG Tier 3PRENATAL-U CAP Tier 1PRENATE AM TAB 1MG Tier 3PRENATE CAP ENHANCE Tier 3PRENATE CAP ESSENT Tier 3PRENATE CAP ESSENTIA Tier 3PRENATE CAP RESTORE Tier 3PRENATE CHW 0.6-0.4 Tier 3PRENATE DHA CAP Tier 3PRENATE MINI CAP Tier 3PRENATE STAR TAB 20-1MG Tier 3PRENATE TAB ELITE Tier 3PRENTIF MIS 22MM Tier 3PRENTIF MIS 25MM Tier 3PRENTIF MIS 28MM Tier 3PRENTIF MIS 31MM Tier 3PRENTIF MIS FITTING Tier 3PREPIDIL GEL 0.5MG/3G Tier 3PREPLUS TAB 27-1MG Tier 3PREPOPIK PAK Tier 3PREQUE 10 TAB Tier 3PRESERA AER Tier 3PRETAB TAB 29-1MG Tier 3PREVACID TAB 15MG STB Tier 3 X XPREVACID TAB 30MG STB Tier 3 X XPREVALITE POW 4GM Tier 1PREVALITE POW 4GM PK Tier 1PREVDNT 5000 PST 1.1% Tier 3PREVIDENT CRE 5000 PLS Tier 3PREVIDENT GEL 1.1% Tier 3PREVIDENT GEL 1.1% BER Tier 3PREVIDENT GEL 1.1% CHR Tier 3PREVIDENT GEL 1.1% MIN Tier 3PREVIDENT PST 5000 BST Tier 3PREVIDENT PST 5000 SEN Tier 3PREVIDENT SOL RINSE Tier 3PREVIFEM TAB Tier 3PREZISTA SUS 100MG/ML Tier 2 XPREZISTA TAB 150MG Tier 2 XPREZISTA TAB 600MG Tier 2 XPREZISTA TAB 75MG Tier 2 XPREZISTA TAB 800MG Tier 2 XPRIFTIN TAB 150MG Tier 2PRIMAQUINE TAB 26.3MG Tier 1

106


LimitStep

TherapySpecialty

Medication

PRIMIDONE TAB 250MG Tier 1PRIMIDONE TAB 50MG Tier 1PRIMLEV TAB 10-300MG Tier 3 XPRIMLEV TAB 5-300MG Tier 3 XPRIMLEV TAB 7.5-300 Tier 3 XPRIMSOL SOL 50MG/5ML Tier 3PRINIVIL TAB 10MG Tier 3PRINIVIL TAB 20MG Tier 3PRINIVIL TAB 5MG Tier 3PRISTIQ TAB 100MG Tier 3 XPRISTIQ TAB 50MG Tier 3 XPROAIR HFA AER Tier 3 XPROBEN/COLCH TAB 500-0.5 Tier 1PROBENECID TAB 500MG Tier 1PROCARDIA CAP 10MG Tier 3PROCARDIA XL TAB 30MG CR Tier 3PROCARDIA XL TAB 60MG CR Tier 3PROCARDIA XL TAB 90MG CR Tier 3PROCENTRA SOL 5MG/5ML Tier 3 XPROCHLORPER SUP 25MG Tier 1PROCHLORPER TAB 10MG Tier 1PROCHLORPER TAB 5MG Tier 1PROCRIT INJ 10000/ML Tier 2 X XPROCRIT INJ 2000/ML Tier 2 X XPROCRIT INJ 20000/ML Tier 2 X XPROCRIT INJ 3000/ML Tier 2 X XPROCRIT INJ 4000/ML Tier 2 X XPROCRIT INJ 40000/ML Tier 2 X XPROCTOCORT CRE 1% Tier 3PROCTOCORT SUP 30MG Tier 3PROCTOFOAM AER HC 1% Tier 2PROCTO-PAK CRE 1% Tier 1PROCTOSOL HC CRE 2.5% Tier 1PROCTOZONE CRE -HC 2.5% Tier 1PROCYSBI CAP 25MG Tier 3 X XPROCYSBI CAP 75MG Tier 3 X XPRODRIN TAB Tier 3PROFERRIN- TAB FORTE Tier 3PROFILNINE INJ 1000UNIT Tier 2 XPROFILNINE INJ 1500UNIT Tier 2 XPROFILNINE INJ 500UNIT Tier 2 XPROGESTERONE CAP 100MG Tier 3PROGESTERONE CAP 200MG Tier 3PROGESTERONE INJ 50MG/ML Tier 1PROGESTERONE POW MICRONIZ Tier 3

107


LimitStep

TherapySpecialty

Medication

PROGESTERONE SUP VGS 100 Tier 3 XPROGESTERONE SUP VGS 200 Tier 3 XPROGESTERONE SUP VGS 25 Tier 3 XPROGESTERONE SUP VGS 400 Tier 3 XPROGESTERONE SUP VGS 50 Tier 3 XPROGLYCEM SUS 50MG/ML Tier 3PROGRAF CAP 0.5MG Tier 3 XPROGRAF CAP 1MG Tier 3 XPROGRAF CAP 5MG Tier 3 XPROMACTA TAB 12.5MG Tier 3 X XPROMACTA TAB 25MG Tier 3 X XPROMACTA TAB 50MG Tier 3 X XPROMACTA TAB 75MG Tier 3 X XPROMETH VC SYP PLAIN Tier 1PROMETH VC/ SYP CODEINE Tier 1PROMETH/COD SYP 6.25-10 Tier 1PROMETHAZINE SOL 6.25/5ML Tier 1PROMETHAZINE SUP 12.5MG Tier 1PROMETHAZINE SUP 25MG Tier 1PROMETHAZINE SYP 6.25/5ML Tier 1PROMETHAZINE SYP DM Tier 1PROMETHAZINE TAB 12.5MG Tier 1PROMETHAZINE TAB 25MG Tier 1PROMETHAZINE TAB 50MG Tier 1PROMETHEGAN SUP 12.5MG Tier 1PROMETHEGAN SUP 25MG Tier 1PROMETHEGAN SUP 50MG Tier 1PROMETRIUM CAP 100MG Tier 3PROMETRIUM CAP 200MG Tier 3PROMISEB CRE Tier 3PROPAFENONE CAP 225MG ER Tier 3PROPAFENONE CAP 325MG ER Tier 3PROPAFENONE CAP 425MG SR Tier 3PROPAFENONE TAB 150MG Tier 1PROPAFENONE TAB 225MG Tier 1PROPAFENONE TAB 300MG Tier 1PROPANTHELIN TAB 15MG Tier 1PROPARACAINE SOL 0.5% OP Tier 1PROPRAN/HCTZ TAB 40/25 Tier 1PROPRAN/HCTZ TAB 80/25 Tier 1PROPRANOLOL CAP 120MG ER Tier 3PROPRANOLOL CAP 160MG ER Tier 3PROPRANOLOL CAP 60MG ER Tier 3PROPRANOLOL CAP 80MG ER Tier 3PROPRANOLOL SOL 20MG/5ML Tier 1

108


LimitStep

TherapySpecialty

Medication

PROPRANOLOL SOL 40MG/5ML Tier 1PROPRANOLOL TAB 10MG Tier 1PROPRANOLOL TAB 20MG Tier 1PROPRANOLOL TAB 40MG Tier 1PROPRANOLOL TAB 60MG Tier 1PROPRANOLOL TAB 80MG Tier 1PROPYLENE GL SOL Tier 3PROPYLTHIOUR TAB 50MG Tier 1 XPROSCAR TAB 5MG Tier 3PROSED/DS TAB Tier 3PROSTIN E2 SUP 20MG Tier 3PROTOPIC OIN 0.03% Tier 2 X XPROTOPIC OIN 0.1% Tier 2 X XPROTRIPTYLIN TAB 10MG Tier 1PROTRIPTYLIN TAB 5MG Tier 1PROVENTIL AER HFA Tier 3 XPROVERA TAB 10MG Tier 3PROVERA TAB 2.5MG Tier 3PROVERA TAB 5MG Tier 3PROVIDA OB CAP Tier 3PROZAC WEEKL CAP 90MG Tier 3 XPRUCLAIR CRE Tier 3PRUDOXIN CRE 5% Tier 1PRUMYX CRE Tier 3PRVDNT 5000 PST ENAML PR Tier 3PSORIZIDE TAB FORTE Tier 2PSORIZIDE TAB ULTRA Tier 3PULMICORT INH 180MCG Tier 3 XPULMICORT INH 90MCG Tier 3 XPULMICORT SUS 0.25MG/2 Tier 3 XPULMICORT SUS 0.5MG/2 Tier 3 XPULMICORT SUS 1MG/2ML Tier 2 XPULMONA CAP Tier 2PULMOPHYLLIN PAK Tier 3PULMOSAL NEB 7% Tier 1PULMOZYME SOL 1MG/ML Tier 2 X X XPURALOR CHW Tier 3PUREFE OB CAP PLUS Tier 3PURIFIED LIQ WATER Tier 3PURINETHOL TAB 50MG Tier 3 XPYLERA CAP Tier 3 XPYRAZINAMIDE TAB 500MG Tier 1PYRIDIUM TAB 100MG Tier 3PYRIDIUM TAB 200MG Tier 3PYRIDOSTIGM TAB 60MG Tier 1

109


LimitStep

TherapySpecialty

Medication

PYROGALL ACD OIN Tier 2Q2 ORAL CLEA KIT SYSTEM Tier 3Q4 ORAL CLEA KIT SYSTEM Tier 3Q-BID-LA TAB 600MG Tier 1QNAPRIL/HCTZ TAB 10-12.5 Tier 3QNAPRIL/HCTZ TAB 20-12.5 Tier 3QNAPRIL/HCTZ TAB 20-25MG Tier 3QUALAQUIN CAP 324MG Tier 3 XQUASENSE TAB Tier 3 XQUAZEPAM TAB 15MG Tier 1QUESTRAN POW 4GM Tier 3QUESTRAN POW 4GM LITE Tier 3 XQUETIAPINE TAB 100MG Tier 3 XQUETIAPINE TAB 200MG Tier 3 XQUETIAPINE TAB 25MG Tier 3 XQUETIAPINE TAB 300MG Tier 3 XQUETIAPINE TAB 400MG Tier 3 XQUETIAPINE TAB 50MG Tier 3 XQUFLORA PED CHW 0.25MG Tier 3QUFLORA PED CHW 0.5MG Tier 3QUFLORA PED CHW 1MG Tier 3QUFLORA PED DRO 0.25MG Tier 3QUFLORA PED DRO 0.5MG/ML Tier 3QUICK-SET MIS 18"/6MM Tier 2QUICK-SET MIS 23"/6MM Tier 2QUICK-SET MIS 23"/9MM Tier 2QUICK-SET MIS 32"/6MM Tier 2QUICK-SET MIS 32"/9MM Tier 2QUICK-SET MIS 43"/6MM Tier 2QUICK-SET MIS 43"/9MM Tier 2QUINAPRIL TAB 10MG Tier 1QUINAPRIL TAB 20MG Tier 1QUINAPRIL TAB 40MG Tier 1QUINAPRIL TAB 5MG Tier 1QUINIDINE GL TAB 324MG CR Tier 1QUINIDINE GL TAB 324MG ER Tier 1QUINIDINE SU TAB 200MG Tier 1QUINIDINE SU TAB 300MG Tier 1QUINIDINE SU TAB 300MG ER Tier 1QUININE SULF CAP 324MG Tier 1 XQUTENZA KIT 8% 1-PCH Tier 3 XQUTENZA KIT 8% 2-PCH Tier 3 XQVAR AER 40MCG Tier 1 XQVAR AER 80MCG Tier 1 XRABEPRAZOLE TAB 20MG Tier 3 X

110


LimitStep

TherapySpecialty

Medication

RADIAGEL GEL Tier 2RADIAPLEXRX GEL Tier 3RADIOGARDASE CAP 0.5GM Tier 3RAGWITEK SUB Tier 3 X XRALOXIFENE TAB 60MG Tier 3RAMIPRIL CAP 1.25MG Tier 1RAMIPRIL CAP 10MG Tier 1RAMIPRIL CAP 2.5MG Tier 1RAMIPRIL CAP 5MG Tier 1RANEXA TAB 1000MG Tier 2RANEXA TAB 500MG Tier 2RANITIDINE SYP 150/10ML Tier 1RANITIDINE SYP 15MG/ML Tier 1RANITIDINE SYP 75MG/5ML Tier 1RAPAFLO CAP 4MG Tier 3RAPAFLO CAP 8MG Tier 3RAPAMUNE SOL 1MG/ML Tier 2 XRAPAMUNE TAB 0.5MG Tier 3 XRAPAMUNE TAB 1MG Tier 2 XRAPAMUNE TAB 2MG Tier 2 XRAPID-D INF MIS 24"/10MM Tier 3RAPID-D INF MIS 24"/6MM Tier 3RAPID-D INF MIS 24"/8MM Tier 3RAPID-D INF MIS 31"/10MM Tier 3RAPID-D INF MIS 31"/6MM Tier 3RAPID-D INF MIS 31"/8MM Tier 3RAPID-D INF MIS 43"/10MM Tier 3RAPID-D INF MIS 43"/6MM Tier 3RAPID-D INF MIS 43"/8MM Tier 3RASPBERRY SYP Tier 1RAVICTI LIQ 1.1GM/ML Tier 3 X X XRAZADYNE ER CAP 16MG Tier 3RAZADYNE ER CAP 24MG Tier 3RAZADYNE ER CAP 8MG Tier 3RAZADYNE SOL 4MG/ML Tier 3RAZADYNE TAB 12MG Tier 3RAZADYNE TAB 4MG Tier 3RAZADYNE TAB 8MG Tier 3READI-CAT 2 SUS 2.1% Tier 2READI-CAT 2 SUS APPLE Tier 2READI-CAT 2 SUS BANANA Tier 2READI-CAT 2 SUS MOCHACCI Tier 2READI-CAT 2 SUS VANILLA Tier 2READI-CAT SUS 1.3% Tier 2REBETOL CAP 200MG Tier 3 X

111


LimitStep

TherapySpecialty

Medication

REBETOL SOL 40MG/ML Tier 2 XREBIF INJ 22/0.5 Tier 3 X X X XREBIF INJ 44/0.5 Tier 3 X X X XREBIF REBIDO INJ 22/0.5 Tier 3 X X X XREBIF REBIDO INJ 44/0.5 Tier 3 X X X XREBIF REBIDO SOL TITRATN Tier 3 X X X XREBIF TITRTN SOL PACK Tier 3 X X X XRECLIPSEN TAB Tier 1RECOMBINATE INJ Tier 2 XRECOMBINATE INJ 220-400 Tier 2 XRECOMBINATE INJ 401-800 Tier 2 XRECOMBINATE INJ 801-1240 Tier 2 XRECOTHROM SOL 20000UNT Tier 3RECOTHROM SOL 5000UNIT Tier 3RECTACORT-HC SUP 25MG Tier 1RECTIV OIN 0.4% Tier 3 X XREDICHEW RX CHW Tier 3REGENECARE GEL Tier 3REGLAN TAB 10MG Tier 3REGLAN TAB 5MG Tier 3REGRANEX GEL 0.01% Tier 2 XRELAGARD GEL Tier 3RELENZA MIS DISKHALE Tier 3 XRELHIST CHW Tier 2RELISTOR INJ 12/0.6ML Tier 2RELISTOR INJ 8/0.4ML Tier 2RELISTOR KIT 12/0.6ML Tier 2RELNATE DHA CAP Tier 2RELPAX TAB 20MG Tier 2 XRELPAX TAB 40MG Tier 2 XREMERON SLTB TAB 15MG Tier 3REMERON SLTB TAB 30MG Tier 3REMERON SLTB TAB 45MG Tier 3REMERON TAB 15MG Tier 3REMERON TAB 30MG Tier 3REMERON TAB 45MG Tier 3REMEVEN CRE 50% Tier 2RENAGEL TAB 400MG Tier 2RENAGEL TAB 800MG Tier 2RENVELA PAK 0.8GM Tier 2RENVELA PAK 2.4GM Tier 2REPAGLINIDE TAB 0.5MG Tier 3 XREPAGLINIDE TAB 1MG Tier 3 XREPAGLINIDE TAB 2MG Tier 3 XREPREXAIN TAB 10-200MG Tier 3 X

112


LimitStep

TherapySpecialty

Medication

REPREXAIN TAB 2.5-200 Tier 3REPREXAIN TAB 5-200MG Tier 3REQUIP TAB 0.25MG Tier 3REQUIP TAB 0.5MG Tier 3REQUIP TAB 1MG Tier 3REQUIP TAB 2MG Tier 3REQUIP TAB 3MG Tier 3REQUIP TAB 4MG Tier 3REQUIP TAB 5MG Tier 3RESCON-JR TAB Tier 3RESCON-MX TAB Tier 3RESCRIPTOR TAB 100 MG Tier 2 XRESCRIPTOR TAB 200MG Tier 2 XRESCULA SOL 0.15% Tier 3 X XRESERPINE TAB 0.1MG Tier 1RESERPINE TAB 0.25MG Tier 1RESPA-BR TAB 11MG Tier 3RESTASIS EMU 0.05% Tier 3 X XRESTORA RX CAP 60-1.25 Tier 3RESTORIL CAP 15MG Tier 3RESTORIL CAP 22.5MG Tier 3RESTORIL CAP 30MG Tier 3RESTORIL CAP 7.5MG Tier 3RETIN-A CRE 0.025% Tier 3 XRETIN-A CRE 0.05% Tier 3 XRETIN-A CRE 0.1% Tier 3 XRETIN-A GEL 0.01% Tier 3 XRETIN-A GEL 0.025% Tier 3 XRETROVIR CAP 100MG Tier 3 XRETROVIR SYP 50MG/5ML Tier 3 XREVIA TAB 50MG Tier 3REVINA OIN Tier 1REVLIMID CAP 10MG Tier 2 X X XREVLIMID CAP 15MG Tier 2 X X XREVLIMID CAP 2.5MG Tier 2 X X XREVLIMID CAP 20MG Tier 2 X XREVLIMID CAP 25MG Tier 2 X X XREVLIMID CAP 5MG Tier 2 X X XREYATAZ CAP 150MG Tier 2 XREYATAZ CAP 200MG Tier 2 XREYATAZ CAP 300MG Tier 2 XREZIRA SOL 60-5/5ML Tier 3REZYST IM CHW Tier 3REZYST SB CHW 250MG Tier 3RHEUMADORON LIQ 102A Tier 3

113


LimitStep

TherapySpecialty

Medication

RHEUMATE CAP Tier 3RHEUMATREX TAB 2.5MG Tier 2RIASTAP SOL 1GM Tier 3 XRIBASPHERE CAP 200MG Tier 1 XRIBASPHERE TAB 200MG Tier 1 XRIBASPHERE TAB 400MG Tier 1 XRIBASPHERE TAB 600MG Tier 1 XRIBATAB PAK 1000/DAY Tier 1 XRIBATAB TAB 1200/DAY Tier 1 XRIBATAB TAB 800/DAY Tier 1 XRIBAVIRIN CAP 200MG Tier 1RIBAVIRIN POW Tier 3RIBAVIRIN TAB 200MG Tier 1 XRIDAURA CAP 3MG Tier 3RIFABUTIN CAP 150MG Tier 1RIFADIN CAP 150MG Tier 3RIFADIN CAP 300MG Tier 3RIFAMATE CAP Tier 3RIFAMPIN CAP 150MG Tier 1RIFAMPIN CAP 300MG Tier 1RIFATER TAB Tier 2RILUTEK TAB 50MG Tier 3RILUZOLE TAB 50MG Tier 1RIMANTADINE TAB 100MG Tier 1RIMANTALIST PAK Tier 3RIOMET SOL Tier 3RISEDRONATE TAB 150MG Tier 3 XRISPERIDONE SOL 1MG/ML Tier 1RISPERIDONE TAB 0.25 ODT Tier 1RISPERIDONE TAB 0.25MG Tier 1RISPERIDONE TAB 0.5MG Tier 1RISPERIDONE TAB 0.5MG OD Tier 1RISPERIDONE TAB 1MG Tier 1RISPERIDONE TAB 1MG ODT Tier 1RISPERIDONE TAB 2MG Tier 1RISPERIDONE TAB 2MG ODT Tier 1RISPERIDONE TAB 3MG Tier 1RISPERIDONE TAB 3MG ODT Tier 1 XRISPERIDONE TAB 4MG Tier 1RISPERIDONE TAB 4MG ODT Tier 1RITALIN TAB 10MG Tier 3 XRITALIN TAB 20MG Tier 3 XRITALIN TAB 20MG SR Tier 3 XRITALIN TAB 5MG Tier 3 XRIVASTIGMINE CAP 1.5MG Tier 1

114


LimitStep

TherapySpecialty

Medication

RIVASTIGMINE CAP 3MG Tier 1RIVASTIGMINE CAP 4.5MG Tier 1RIVASTIGMINE CAP 6MG Tier 1RIXUBIS INJ 1000UNIT Tier 2 XRIXUBIS INJ 2000UNIT Tier 2 XRIXUBIS INJ 250 UNIT Tier 2 XRIXUBIS INJ 3000UNIT Tier 2 XRIXUBIS INJ 500UNIT Tier 2 XRIZATRIPTAN TAB 10MG Tier 3 XRIZATRIPTAN TAB 10MG ODT Tier 3 XRIZATRIPTAN TAB 5MG Tier 3 XRIZATRIPTAN TAB 5MG ODT Tier 3 XR-NATAL OB CAP 20-1-320 Tier 3ROBAXIN TAB 500MG Tier 3ROBAXIN-750 TAB 750MG Tier 3ROBINUL FORT TAB 2MG Tier 3ROBINUL TAB 1MG Tier 3ROCALTROL CAP 0.25MCG Tier 3ROCALTROL CAP 0.5MCG Tier 3ROCALTROL SOL 1MCG/ML Tier 3ROMYCIN OIN OP Tier 1ROPINIROLE TAB 0.25MG Tier 1ROPINIROLE TAB 0.5MG Tier 1ROPINIROLE TAB 1MG Tier 1ROPINIROLE TAB 2MG Tier 1ROPINIROLE TAB 3MG Tier 1ROPINIROLE TAB 4MG Tier 1ROPINIROLE TAB 5MG Tier 1ROSADAN CRE 0.75% Tier 1ROSADAN GEL 0.75% Tier 1ROSANIL EMU CLEANSER Tier 1ROSANIL KIT Tier 3ROSE GLO TES 1.5MG Tier 3ROWASA KIT 4GM Tier 3ROXICET SOL 5-325/5 Tier 2 XROXICET TAB 5-325MG Tier 1 XROXICODONE TAB 15MG Tier 3ROXICODONE TAB 30MG Tier 3ROXICODONE TAB 5MG Tier 3ROZEREM TAB 8MG Tier 3 X XRYTHMOL SR CAP 225MG Tier 3RYTHMOL SR CAP 325MG Tier 3RYTHMOL SR CAP 425MG Tier 3RYTHMOL TAB 150MG Tier 3RYTHMOL TAB 225MG Tier 3

115


LimitStep

TherapySpecialty

Medication

SABRIL POW 500MG Tier 2 XSABRIL TAB 500MG Tier 2 XSAFTY NEEDLE MIS 18GX1" Tier 2SAFTY NEEDLE MIS 18GX1.5" Tier 2SAFTY NEEDLE MIS 19GX1" Tier 2SAFTY NEEDLE MIS 19GX1.5" Tier 2SAFTY NEEDLE MIS 20GX1" Tier 2SAFTY NEEDLE MIS 20GX1.5" Tier 2SAFTY NEEDLE MIS 21GX1" Tier 2SAFTY NEEDLE MIS 21GX1.5" Tier 2SAFTY NEEDLE MIS 22GX1" Tier 2SAFTY NEEDLE MIS 22GX1.5" Tier 2SAFTY NEEDLE MIS 23GX1" Tier 2SAFTY NEEDLE MIS 25GX1" Tier 2SAFTY NEEDLE MIS 25GX5/8" Tier 2SAIZEN INJ 5MG Tier 2 X X XSAIZEN INJ 8.8MG Tier 2 X X XSALACYN CRE 6% Tier 1SALACYN LOT 6% Tier 1SALAGEN TAB 5MG Tier 3SALAGEN TAB 7.5MG Tier 3SALEX CREAM KIT 6% Tier 3SALEX LOTION KIT 6% Tier 3SALEX SHA 6% Tier 3SALICYLIC AC AER 6% Tier 1SALICYLIC AC CRE 6% Tier 1SALICYLIC AC GEL 6% Tier 1SALICYLIC AC KIT 6% Tier 1SALICYLIC AC KIT 6% CREAM Tier 1SALICYLIC AC KIT 6% LOTN Tier 1SALICYLIC AC LIQ 26% Tier 1SALICYLIC AC LIQ 27.5% Tier 1SALICYLIC AC LOT 6% Tier 1SALICYLIC AC SHA 6% Tier 1SALICYLIC AER 6% Tier 1SALKERA AER 6% Tier 3SALSALATE TAB 500MG Tier 1SALSALATE TAB 750MG Tier 1SALVAX AER 6% Tier 3SALVAX DUO KIT PLUS Tier 3SAMSCA TAB 15MG Tier 2 X XSAMSCA TAB 30MG Tier 2 X XSANARE SCAR CRE THERAPY Tier 3SANDIMMUNE CAP 100MG Tier 3 XSANDIMMUNE CAP 25MG Tier 3 X

116


LimitStep

TherapySpecialty

Medication

SANDIMMUNE SOL 100MG/ML Tier 3 XSANDOSTATIN INJ 1000MCG Tier 3 X XSANDOSTATIN INJ 100MCG Tier 3 X XSANDOSTATIN INJ 200MCG Tier 3 X XSANDOSTATIN INJ 500MCG Tier 3 X XSANDOSTATIN INJ 50MCG/ML Tier 3 X XSANTYL OIN 250/GM Tier 3SAPHRIS SUB 10MG Tier 3 XSAPHRIS SUB 5MG Tier 3 XSARAFEM TAB 10MG Tier 3SARAFEM TAB 20MG Tier 3SAVELLA MIS TITR PAK Tier 3 XSAVELLA TAB 100MG Tier 3 XSAVELLA TAB 12.5MG Tier 3 XSAVELLA TAB 25MG Tier 3 XSAVELLA TAB 50MG Tier 3 XSCALACORT DK KIT Tier 3SCALACORT LOT 2% Tier 1SEASONIQUE TAB Tier 3 XSEB-PREV LIQ WASH Tier 1SECONAL CAP 100MG Tier 3SECTRAL CAP 200MG Tier 3SECTRAL CAP 400MG Tier 3SELECT-OB CHW Tier 3SELECT-OB+ PAK DHA Tier 3SELEGILINE CAP 5MG Tier 1SELEGILINE TAB 5MG Tier 1SELENIUM SUL LOT 2.5% Tier 1SELENIUM SUL SHA 2.25% Tier 1SELENIUM SUL SHA 2.5% Tier 1SELZENTRY TAB 150MG Tier 2 X XSELZENTRY TAB 300MG Tier 2 X XSEMPREX-D CAP 8-60MG Tier 3SE-NATAL 19 CHW Tier 1SE-NATAL 19 TAB Tier 1SENNA LEAVES MIS Tier 3SENSIPAR TAB 30MG Tier 3SENSIPAR TAB 60MG Tier 3SENSIPAR TAB 90MG Tier 3SENTRA AM CAP Tier 3SENTRA PM CAP Tier 3SENTRADINE PAK Tier 3SENTRAFLOX PAK AM-10 Tier 3SENTRALOPRAM PAK AM-10 Tier 3SENTRAVIL PM PAK -25 Tier 3

117


LimitStep

TherapySpecialty

Medication

SENTRAZOLAM PAK AM 0.25 Tier 3SENTRAZOLPID PAK PM-5 Tier 3SENTROXATINE PAK Tier 3SEREVENT DIS AER 50MCG Tier 3 XSEROQUEL XR TAB 150MG Tier 3 XSEROQUEL XR TAB 200MG Tier 3 XSEROQUEL XR TAB 300MG Tier 3 XSEROQUEL XR TAB 400MG Tier 3 XSEROQUEL XR TAB 50MG Tier 3 XSEROSTIM INJ 4MG Tier 3 X X XSEROSTIM INJ 5MG Tier 3 X X XSEROSTIM INJ 6MG Tier 3 X X XSERTRALINE CON 20MG/ML Tier 1SERTRALINE TAB 100MG Tier 1SERTRALINE TAB 25MG Tier 1SERTRALINE TAB 50MG Tier 1SE-TAN DHA CAP Tier 1SEVELAMER TAB 800MG Tier 3SEVOFLURANE SOL Tier 1SF 5000 PLUS CRE 1.1% Tier 1SF GEL 1.1% Tier 1SFROWASA ENE 4GM Tier 3SHOHLS SOL MODIFIED Tier 2SIGNIFOR INJ 0.3MG/ML Tier 2 X XSIGNIFOR INJ 0.6MG/ML Tier 2 X XSIGNIFOR INJ 0.9MG/ML Tier 2 X XSILDENAFIL TAB 20MG Tier 1 X X XSILHOUETTE MIS 13MM Tier 3SILHOUETTE MIS 17MM Tier 3SILHOUETTE MIS 18"/13MM Tier 3SILHOUETTE MIS 23" SET Tier 3SILHOUETTE MIS 32"/17MM Tier 3SILHOUETTE MIS 43" SET Tier 3SILHOUETTE MIS COMBO Tier 3SILHOUETTE MIS FULL SET Tier 3SILVADENE CRE 1% Tier 3SILVER NITRA OIN 10% Tier 1SILVER NITRA SOL 0.5% Tier 1SILVER NITRA SOL 10% Tier 1SILVER NITRA SOL 25% Tier 1SILVER NITRA SOL 50% Tier 1SILVER SULFA CRE 1% Tier 1SIMCOR TAB 1000-20 Tier 3 XSIMCOR TAB 1000-40 Tier 3 XSIMCOR TAB 500-20MG Tier 3 X

118


LimitStep

TherapySpecialty

Medication

SIMCOR TAB 500-40MG Tier 3 XSIMCOR TAB 750-20MG Tier 3 XSIMPLE SYP Tier 1SIMPONI INJ 100MG/ML Tier 2 X X XSIMPONI INJ 50/0.5ML Tier 2 X X XSIMVASTATIN TAB 10MG Tier 1SIMVASTATIN TAB 20MG Tier 1SIMVASTATIN TAB 40MG Tier 1SIMVASTATIN TAB 5MG Tier 1SIMVASTATIN TAB 80MG Tier 1SINEMET CR TAB 25-100MG Tier 3SINEMET CR TAB 50-200MG Tier 3SINEMET TAB 10-100MG Tier 3SINEMET TAB 25-100MG Tier 3SINEMET TAB 25-250MG Tier 3SINGULAIR GRA 4MG Tier 3 XSIROLIMUS TAB 0.5MG Tier 1 XSIRTURO TAB 100MG Tier 2 XSIVEXTRO TAB 200MG Tier 3SKLICE LOT 0.5% Tier 3 XSMZ/TMP DS TAB 800-160 Tier 1SMZ-TMP SUS 200-40/5 Tier 1SMZ-TMP TAB 400-80MG Tier 1SNAP PUMP MIS CONTROLL Tier 3SOD CHLORIDE NEB 0.9% Tier 1SOD FLUORIDE CHW 0.25MG F Tier 1SOD FLUORIDE CHW 0.5MG F Tier 1SOD FLUORIDE CHW 1.1MG Tier 1SOD FLUORIDE CHW 1MG F Tier 1SOD FLUORIDE CHW 2.2MG Tier 1SOD FLUORIDE DRO 0.5MG/ML Tier 1SOD FLUORIDE SOL 0.2% Tier 1SOD FLUORIDE SOL 0.2%MINT Tier 1SOD FLUORIDE TAB 0.5MG F Tier 1SOD FLUORIDE TAB 1MG F Tier 1SOD POLY SUL POW Tier 1SOD POLY SUL SUS 15GM/60 Tier 1SOD POLY SUL SUS 30/120ML Tier 1SOD POLY SUL SUS 50/200ML Tier 1SOD SUL/SULF AER 10-5% Tier 1SOD SUL/SULF CRE 10-2% Tier 1SOD SUL/SULF CRE 10-5% Tier 1SOD SUL/SULF EMU 10-5% Tier 1SOD SUL/SULF GEL 10-5% Tier 1SOD SUL/SULF LIQ 10-2% Tier 1

119


LimitStep

TherapySpecialty

Medication

SOD SUL/SULF LIQ 9-4.5% Tier 1SOD SUL/SULF LIQ WASH Tier 1SOD SUL/SULF LOT 10-5% Tier 1SOD SUL/SULF PAD 10-4% Tier 1SOD SUL/SULF PAD 10-5% Tier 1SOD SUL/SULF SUS 10-5% Tier 1SOD SUL/SULF SUS 8-4% Tier 1SOD SULFACET GEL 10% Tier 1SOD SULFACET SHA 10% Tier 1SOD SULFACET SOL 10% OP Tier 1SODIUM CHLOR NEB 10% Tier 1SODIUM CHLOR NEB 3% Tier 1SODIUM CHLOR NEB 7% Tier 1SODIUM POW BICARBON Tier 3SODIUM POW CHLORIDE Tier 3SODIUM SULFA LIQ 10% WASH Tier 1SOF-SET 24" KIT INFUSION Tier 2SOF-SET 24" KIT MICRO QR Tier 2SOF-SET 24" KIT ULTIM QR Tier 2SOF-SET 42" KIT INFUSION Tier 2SOF-SET 42" KIT MICRO QR Tier 2SOF-SET 42" KIT ULTIM QR Tier 2SOJOURN SOL Tier 1SOLARAZE GEL 3% W/W Tier 3SOLIA TAB Tier 1SOLODYN TAB 105MG Tier 3SOLODYN TAB 115MG Tier 3SOLODYN TAB 55MG Tier 3SOLODYN TAB 65MG Tier 3SOLODYN TAB 80MG Tier 3SOMA TAB 350MG Tier 3SOMATULINE INJ 120/.5ML Tier 3 X XSOMATULINE INJ 60/0.2ML Tier 3 X XSOMATULINE INJ 90/0.3ML Tier 3 X XSOMAVERT INJ 10MG Tier 3 XSOMAVERT INJ 15MG Tier 3SOMAVERT INJ 20MG Tier 3SONATA CAP 10MG Tier 3 X XSONATA CAP 5MG Tier 3 X XSORIATANE CAP 10MG Tier 3SORIATANE CAP 17.5MG Tier 3SORIATANE CAP 25MG Tier 3SOTALOL AF TAB 120MG Tier 1SOTALOL AF TAB 160MG Tier 1SOTALOL AF TAB 80MG Tier 1

120


LimitStep

TherapySpecialty

Medication

SOTALOL HCL TAB 120MG Tier 1SOTALOL HCL TAB 160MG Tier 1SOTALOL HCL TAB 240MG Tier 1SOTALOL HCL TAB 80MG Tier 1SOVALDI TAB 400MG Tier 3 X X XSPECTRACEF TAB 200MG Tier 3SPECTRACEF TAB 400MG Tier 3SPEED GEL GEL TRAUMA Tier 3SPEEDGEL RX GEL Tier 3SPINOSAD SUS 0.9% Tier 3SPIRIVA CAP HANDIHLR Tier 2 XSPIRONO/HCTZ TAB 25/25 Tier 1SPIRONOLACT TAB 100MG Tier 1SPIRONOLACT TAB 25MG Tier 1SPIRONOLACT TAB 50MG Tier 1SPORANOX CAP 100MG Tier 3 XSPORANOX CAP PULSEPAK Tier 3 XSPORANOX SOL 10MG/ML Tier 2 XSPRINTEC 28 TAB 28 DAY Tier 3SPRIX SPR 15.75MG Tier 3SPRYCEL TAB 100MG Tier 3 X X X XSPRYCEL TAB 140MG Tier 3 X X X XSPRYCEL TAB 20MG Tier 3 X X X XSPRYCEL TAB 50MG Tier 3 X X X XSPRYCEL TAB 70MG Tier 3 X X X XSPRYCEL TAB 80MG Tier 3 X X X XSPS SUS 15GM/60 Tier 1SRONYX TAB Tier 1SSD CRE 1% Tier 1SSKI SOL 1GM/ML Tier 3SSS 10-5 AER 10-5% Tier 1SSS CRE 10%-5% Tier 1STALEVO 100 TAB Tier 3STALEVO 125 TAB Tier 3STALEVO 150 TAB Tier 3STALEVO 200 TAB Tier 3STALEVO 50 TAB Tier 3STALEVO 75 TAB Tier 3STAN FLUORID CON 0.63% Tier 1STARLIX TAB 120MG Tier 3 XSTARLIX TAB 60MG Tier 3 XSTAVUDINE CAP 15MG Tier 1 XSTAVUDINE CAP 20MG Tier 1 XSTAVUDINE CAP 30MG Tier 1 XSTAVUDINE CAP 40MG Tier 1 X

121


LimitStep

TherapySpecialty

Medication

STAVUDINE SOL 1MG/ML Tier 1 XSTAVZOR CAP 125MG Tier 3 X XSTAVZOR CAP 250MG Tier 3 X XSTAVZOR CAP 500MG Tier 3 X XSTELARA INJ 45MG/0.5 Tier 2 X X XSTELARA INJ 90MG/ML Tier 2 X X XSTENDRA TAB 100MG Tier 3 XSTENDRA TAB 200MG Tier 3 XSTENDRA TAB 50MG Tier 3 XSTERYMINE GEL Tier 3STIMATE SOL 1.5MG/ML Tier 3STIVARGA TAB 40MG Tier 2 X X XSTRATTERA CAP 100MG Tier 3 XSTRATTERA CAP 10MG Tier 3 XSTRATTERA CAP 18MG Tier 3 XSTRATTERA CAP 25MG Tier 3 XSTRATTERA CAP 40MG Tier 3 XSTRATTERA CAP 60MG Tier 3 XSTRATTERA CAP 80MG Tier 3 XSTRAZEPAM PAK Tier 3STRIANT MIS 30MG Tier 3 X XSTRIBILD TAB Tier 3 X XSTROMECTOL TAB 3MG Tier 2SUBLIMAZE INJ 0.05MG/1 Tier 3 XSUBSYS SPR 100MCG Tier 3 X XSUBSYS SPR 1200MCG Tier 3 X XSUBSYS SPR 1600MCG Tier 3 X XSUBSYS SPR 200MCG Tier 3 X XSUBSYS SPR 400MCG Tier 3 X XSUBSYS SPR 600MCG Tier 3 X XSUBSYS SPR 800MCG Tier 3 X XSUCLEAR KIT Tier 3SUCRAID SOL 8500/ML Tier 2 XSUCRALFATE TAB 1GM Tier 1SULAR TAB 17MG Tier 3SULAR TAB 34MG Tier 3SULAR TAB 8.5MG Tier 3SULF LIME SOL Tier 3SULF/PRED NA SOL OP Tier 1SULFACET SOD OIN 10% OP Tier 1SULFACET SOD SOL 10% OP Tier 1SULFACETAMID LOT 10% Tier 1SULFACETAMID SUS 10% Tier 1SULFACLEANSE SUS 8-4% Tier 1SULFADIAZINE TAB 500MG Tier 1

122


LimitStep

TherapySpecialty

Medication

SULFAMYLON CRE 85MG/GM Tier 3SULFAMYLON PAK 5% Tier 3SULFASALAZIN TAB 500MG Tier 1SULFASALAZIN TAB 500MG DR Tier 1SULFATRIM PD SUS 200-40/5 Tier 1SULFAZINE EC TAB 500MG Tier 1SULFAZINE TAB 500MG Tier 1SULFOAM SHA 2% Tier 3SULINDAC TAB 150MG Tier 1SULINDAC TAB 200MG Tier 1SUMATRIPTAN INJ 4MG/0.5 Tier 1 XSUMATRIPTAN INJ 6MG/0.5 Tier 1 XSUMATRIPTAN SPR 20MG/ACT Tier 3 XSUMATRIPTAN SPR 5MG/ACT Tier 3 XSUMATRIPTAN TAB 100MG Tier 1 XSUMATRIPTAN TAB 25MG Tier 1 XSUMATRIPTAN TAB 50MG Tier 1 XSUMAVEL DOSE INJ 6MG/0.5 Tier 3 XSUMAXIN PAD 10-4% Tier 3SUMAXIN WASH LIQ 9-4% Tier 3SUPRANE INH Tier 2SUPRANE SOL Tier 2SUPRAX CAP 400MG Tier 3SUPRAX SUS 100/5ML Tier 3SUPRAX SUS 200/5ML Tier 3SUPRAX SUS 500/5ML Tier 3SUPREP BOWEL SOL PREP Tier 3SURE-T MIS 23"/6MM Tier 3SURE-T MIS 23"/8MM Tier 2SURMONTIL CAP 100MG Tier 3SURMONTIL CAP 25MG Tier 3SURMONTIL CAP 50MG Tier 3SURVANTA INH Tier 3SUSTIVA CAP 200MG Tier 2 XSUSTIVA CAP 50MG Tier 2 XSUSTIVA TAB 600MG Tier 2 XSUTENT CAP 12.5MG Tier 2 X X XSUTENT CAP 25MG Tier 2 X X XSUTENT CAP 37.5MG Tier 2 X XSUTENT CAP 50MG Tier 2 X X XSUTTAR-2 SYP Tier 3SUTTAR-SF SYP Tier 3SYEDA TAB 3-0.03MG Tier 3SYLATRON KIT 296MCG Tier 2 X X XSYLATRON KIT 444MCG Tier 2 X X X

123


LimitStep

TherapySpecialty

Medication

SYLATRON KIT 888MCG Tier 2 X XSYMAX DUOTAB TAB Tier 3SYMAX FASTAB TAB 0.125MG Tier 1SYMAX-SL SUB 0.125MG Tier 1SYMAX-SR TAB 0.375MG Tier 1SYMBYAX CAP 12-25MG Tier 3 XSYMBYAX CAP 12-50MG Tier 3 XSYMBYAX CAP 3-25MG Tier 3 XSYMBYAX CAP 6-25MG Tier 3 XSYMBYAX CAP 6-50MG Tier 3 XSYMLINPEN 60 INJ 1000MCG Tier 3 XSYMLNPEN 120 INJ 1000MCG Tier 3 XSYNALAR CRE 0.025% Tier 3 XSYNALAR OIN 0.025% Tier 3 XSYNALAR SOL 0.01% Tier 3 XSYNALGOS-DC CAP Tier 3SYNAREL SOL 2MG/ML Tier 2SYNERA DIS 70-70MG Tier 3SYNTHROID TAB 100MCG Tier 2SYNTHROID TAB 112MCG Tier 2SYNTHROID TAB 125MCG Tier 2SYNTHROID TAB 137MCG Tier 2SYNTHROID TAB 150MCG Tier 2SYNTHROID TAB 175MCG Tier 2SYNTHROID TAB 200MCG Tier 2SYNTHROID TAB 25MCG Tier 2SYNTHROID TAB 300MCG Tier 2SYNTHROID TAB 50MCG Tier 2SYNTHROID TAB 75MCG Tier 2SYNTHROID TAB 88MCG Tier 2SYPRINE CAP 250MG Tier 3 X X XSYRPALTA SYP Tier 1SYRPALTA SYP CLEAR Tier 1T.R.U.E. TES Tier 3T:SLIM 3ML MIS CARTRDGE Tier 3TABLOID TAB 40MG Tier 2TACLONEX SUS Tier 3 XTACROLIMUS CAP 0.5MG Tier 1 XTACROLIMUS CAP 1MG Tier 1 XTACROLIMUS CAP 5MG Tier 1 XTACROLIMUS POW Tier 3TACROLIMUS POW MONOHYD Tier 3 XTAFINLAR CAP 50MG Tier 2 X X XTAFINLAR CAP 75MG Tier 2 X X XTAGITOL V SUS 40% Tier 2

124


LimitStep

TherapySpecialty

Medication

TAKE ACTION TAB 1.5MG Tier 1TAMIFLU CAP 30MG Tier 3 XTAMIFLU CAP 45MG Tier 3 XTAMIFLU CAP 75MG Tier 3 XTAMIFLU SUS 6MG/ML Tier 3 XTAMOXIFEN TAB 10MG Tier 1TAMOXIFEN TAB 20MG Tier 1TAMSULOSIN CAP 0.4MG Tier 1TANDEM F CAP Tier 3TANZEUM INJ 30MG Tier 2TANZEUM INJ 50MG Tier 2TAPAZOLE TAB 10MG Tier 3TAPAZOLE TAB 5MG Tier 3TARCEVA TAB 100MG Tier 2 X X XTARCEVA TAB 150MG Tier 2 X X XTARCEVA TAB 25MG Tier 2 X X XTARGRETIN CAP 75MG Tier 2 XTARGRETIN GEL 1% Tier 2TARKA TAB 1-240 CR Tier 3TARKA TAB 2-180 CR Tier 3TARKA TAB 2-240 CR Tier 3TARKA TAB 4-240 CR Tier 3TARON GRA CRYSTALS Tier 1TARON-BC MIS Tier 2TARON-C DHA CAP Tier 3TARON-PREX CAP Tier 3TASIGNA CAP 150MG Tier 2 X X XTASIGNA CAP 200MG Tier 2 X X XTASMAR TAB 100MG Tier 2TAZORAC CRE 0.05% Tier 3 XTAZORAC CRE 0.1% Tier 3 XTAZORAC GEL 0.05% Tier 3 XTAZORAC GEL 0.1% Tier 3 XTAZTIA XT CAP 120MG/24 Tier 3TAZTIA XT CAP 180MG/24 Tier 3TAZTIA XT CAP 240MG/24 Tier 3TAZTIA XT CAP 300MG/24 Tier 3TAZTIA XT CAP 360MG/24 Tier 3TBC AER Tier 1TEARS AGAIN CAP HYDRATE Tier 3TECFIDERA CAP 120MG Tier 2 X X XTECFIDERA CAP 240MG Tier 2 X X XTECFIDERA MIS STARTER Tier 2 X X XTEGADERM AG PAD 2"X2" Tier 3TEGADERM AG PAD 4"X5" Tier 3

125


LimitStep

TherapySpecialty

Medication

TEGADERM AG PAD 4"X8" Tier 3TEGADERM AG PAD 8"X8" Tier 3TEGRETOL SUS 100/5ML Tier 2TEGRETOL TAB 200MG Tier 2TEGRETOL-XR TAB 100MG Tier 2TEGRETOL-XR TAB 200MG Tier 3TEGRETOL-XR TAB 400MG Tier 3TEKTURNA HCT TAB 150-12.5 Tier 3 XTEKTURNA HCT TAB 150-25MG Tier 3 XTEKTURNA HCT TAB 300-12.5 Tier 3 XTEKTURNA HCT TAB 300-25MG Tier 3 XTEKTURNA TAB 150MG Tier 3 XTEKTURNA TAB 300MG Tier 3 XTELMISA/HCTZ TAB 40-12.5 Tier 3 XTELMISA/HCTZ TAB 80-12.5 Tier 3 XTELMISA/HCTZ TAB 80-25MG Tier 3 XTELMISARTAN TAB 20MG Tier 3 XTELMISARTAN TAB 40MG Tier 3 XTELMISARTAN TAB 80MG Tier 3 XTEMAZEPAM CAP 15MG Tier 1TEMAZEPAM CAP 22.5MG Tier 1TEMAZEPAM CAP 30MG Tier 1TEMAZEPAM CAP 7.5MG Tier 1TEMODAR CAP 100MG Tier 2 X XTEMODAR CAP 140MG Tier 2 X XTEMODAR CAP 180MG Tier 2 X XTEMODAR CAP 20MG Tier 2 X XTEMODAR CAP 250MG Tier 2 X XTEMODAR CAP 5MG Tier 2 X XTEMOVATE CRE 0.05% Tier 3TEMOVATE E CRE 0.05%EML Tier 3TEMOVATE GEL 0.05% Tier 3TEMOVATE OIN 0.05% Tier 3TEMOVATE SOL 0.05% Tier 3TEMOZOLOMIDE CAP 100MG Tier 1 X XTEMOZOLOMIDE CAP 140MG Tier 1 X XTEMOZOLOMIDE CAP 180MG Tier 1 X XTEMOZOLOMIDE CAP 20MG Tier 1 X XTEMOZOLOMIDE CAP 250MG Tier 1 X XTEMOZOLOMIDE CAP 5MG Tier 1 X XTENCON TAB 50-325MG Tier 1TENEX TAB 1MG Tier 3TENEX TAB 2MG Tier 3TENORETIC TAB 100 Tier 3TENORETIC TAB 50 Tier 3

126


LimitStep

TherapySpecialty

Medication

TENORMIN TAB 100MG Tier 3TENORMIN TAB 25MG Tier 3TENORMIN TAB 50MG Tier 3TERAZOL 3 CRE 0.8% Tier 3TERAZOL 7 CRE 0.4% Tier 3TERAZOSIN CAP 10MG Tier 1TERAZOSIN CAP 2MG Tier 1TERAZOSIN CAP 5MG Tier 1TERBINAFINE TAB 250MG Tier 1 XTERBUTALINE POW SULFATE Tier 3TERBUTALINE TAB 2.5MG Tier 1TERBUTALINE TAB 5MG Tier 1TERCONAZOLE CRE 0.4% Tier 1TERCONAZOLE CRE 0.8% Tier 1TERCONAZOLE SUP 80MG Tier 1TERRELL SOL Tier 1TERSI FOAM AER 2.25% Tier 3TESSALON PER CAP 100MG Tier 3TESTIM GEL 1%(50MG) Tier 2 X XTESTOST CYP INJ 100MG/ML Tier 1TESTOST CYP INJ 200MG/ML Tier 1TESTOST ENAN INJ 200MG/ML Tier 1TESTOSTERONE POW CYPIONAT Tier 3TESTOSTERONE POW ENANTHAT Tier 3TESTRED CAP 10MG Tier 2TETCAINE SOL 0.5% OP Tier 1TETRACAINE SOL 0.5% OP Tier 1TETRACYCLINE CAP 250MG Tier 3TETRACYCLINE CAP 500MG Tier 3TETRAVISC SOL 0.5% OP Tier 1TETRAVISC SOL FORTE Tier 1TEVETEN HCT TAB 600-12.5 Tier 3 XTEVETEN HCT TAB 600-25MG Tier 3 XTEVETEN TAB 600MG Tier 3 XTEV-TROPIN INJ 5MG Tier 2 X X XTEXACORT SOL 2.5% Tier 2TGQ 15DM/5PE SYP H/2CPM Tier 1TGQ 30/ SYP 150/15 Tier 1TGQ 30/PSE/3 SYP BRM/15DM Tier 1TGQ 50PSE/3 SYP BRM/30DM Tier 1TGQ 7.5PEH/4 LIQ BRM/15DM Tier 1THALAMUS SUB COMPOSIT Tier 3THALOMID CAP 100MG Tier 2 X X XTHALOMID CAP 150MG Tier 2 X X XTHALOMID CAP 200MG Tier 2 X X X

127


LimitStep

TherapySpecialty

Medication

THALOMID CAP 50MG Tier 2 X X XTHEO-24 CAP 100MG CR Tier 3THEO-24 CAP 200MG CR Tier 3THEO-24 CAP 300MG CR Tier 3THEO-24 CAP 400MG ER Tier 3THEOCHRON TAB 100MG CR Tier 1THEOCHRON TAB 200MG CR Tier 1THEOCHRON TAB 300MG CR Tier 1THEOPHYLLINE SOL 80/15ML Tier 1THEOPHYLLINE TAB 100MG CR Tier 1THEOPHYLLINE TAB 200MG CR Tier 1THEOPHYLLINE TAB 300MG ER Tier 1THEOPHYLLINE TAB 400MG ER Tier 1THEOPHYLLINE TAB 450MG ER Tier 1THEOPHYLLINE TAB 600MG ER Tier 1THERABENZAPR PAK -60 Tier 3THERABENZAPR PAK -90 Tier 3THERABENZAPR PAK -90-5 Tier 3THERACODEINE PAK -300 Tier 3THERACODOPHN PAK -325 Tier 3THERAFELDAMI PAK Tier 3THERA-FLUR-N DRO 1.1% Tier 3THERAMINE CAP Tier 3THERAMINE POW PLUS Tier 3THERAPENTIN PAK -60 Tier 3THERAPENTIN PAK -90 Tier 3THERAPROFEN PAK -60 Tier 3THERAPROFEN PAK 800MG Tier 3THERAPROFEN PAK -90 Tier 3THERAPROXEN PAK 500MG Tier 3THERAPROXEN PAK -60 Tier 3THERAPROXEN PAK -90 Tier 3THERATRAMADO PAK -60 Tier 3THERATRAMADO PAK -90 Tier 3THERMAZENE CRE 1% Tier 1THIOGUANINE POW Tier 3 XTHIOLA TAB 100MG Tier 3THIORIDAZINE TAB 100MG Tier 1THIORIDAZINE TAB 10MG Tier 1THIORIDAZINE TAB 25MG Tier 1THIORIDAZINE TAB 50MG Tier 1THIOTHIXENE CAP 10MG Tier 1THIOTHIXENE CAP 1MG Tier 1THIOTHIXENE CAP 2MG Tier 1THIOTHIXENE CAP 5MG Tier 1

128


LimitStep

TherapySpecialty

Medication

THROMBIN KIT 5000UNIT Tier 3THROMBIN-JMI KIT 20000UNT Tier 3THROMBIN-JMI KIT 5000UNIT Tier 3THROMBOGEN KIT 10000UNT Tier 3THROMBOGEN SOL 10000UNT Tier 3THROMBOGEN SOL 1000UNIT Tier 3THYROLAR-1 TAB 60MG Tier 3THYROLAR-1/2 TAB 30MG Tier 3THYROLAR-1/4 TAB 15MG Tier 3THYROLAR-2 TAB 120MG Tier 3THYROLAR-3 TAB 180MG Tier 3TIAGABINE TAB 2MG Tier 1TIAGABINE TAB 4MG Tier 1TIAZAC CAP 120MG/24 Tier 3TIAZAC CAP 180MG/24 Tier 3 XTIAZAC CAP 240MG/24 Tier 3TIAZAC CAP 300MG/24 Tier 3TIAZAC CAP 360MG/24 Tier 3TIAZAC CAP 420MG/24 Tier 3TICLOPIDINE TAB 250MG Tier 1TIGAN CAP 300MG Tier 3TIKOSYN CAP 125MCG Tier 2TIKOSYN CAP 250MCG Tier 2TIKOSYN CAP 500MCG Tier 2TILIA FE TAB Tier 3TIMOLOL GEL SOL 0.25% OP Tier 1TIMOLOL GEL SOL 0.5% OP Tier 1TIMOLOL MAL SOL 0.25% OP Tier 1TIMOLOL MAL SOL 0.5% OP Tier 1TIMOLOL MAL TAB 10MG Tier 1TIMOLOL MAL TAB 20MG Tier 1TIMOLOL MAL TAB 5MG Tier 1TIMOPTIC OCU SOL 0.25% OP Tier 2TIMOPTIC OCU SOL 0.5% OP Tier 2TIMOPTIC SOL 0.25% OP Tier 3TIMOPTIC SOL 0.5% OP Tier 3TIMOPTIC-XE SOL 0.25% OP Tier 3TIMOPTIC-XE SOL 0.5% OP Tier 3TINDAMAX TAB 250MG Tier 3TINDAMAX TAB 500MG Tier 3TINIDAZOLE TAB 250MG Tier 3TINIDAZOLE TAB 500MG Tier 3TIROSINT CAP 100MCG Tier 2TIROSINT CAP 112MCG Tier 2TIROSINT CAP 125MCG Tier 2

129


LimitStep

TherapySpecialty

Medication

TIROSINT CAP 137MCG Tier 2TIROSINT CAP 13MCG Tier 2TIROSINT CAP 150MCG Tier 2TIROSINT CAP 25MCG Tier 2TIROSINT CAP 50MCG Tier 2TIROSINT CAP 75MCG Tier 2TIROSINT CAP 88MCG Tier 2TISSEEL KIT Tier 3TISSEEL SOL Tier 3TIVICAY TAB 50MG Tier 3 XTIZANIDINE CAP 2MG Tier 3TIZANIDINE CAP 4MG Tier 3TIZANIDINE CAP 6MG Tier 3TIZANIDINE TAB 2MG Tier 1TIZANIDINE TAB 4MG Tier 1TL TRISEB CRE Tier 3TL-CARE DHA CAP 27-1-500 Tier 3TL-FLUORIVIT CHW Tier 3TL-ICARE CAP Tier 3TL-SELECT CAP Tier 2TL-SELECT CAP DHA Tier 3TOBI PODHALR CAP 28MG Tier 3 X X XTOBRA/DEXAME SUS 0.3-0.1% Tier 3TOBRADEX OIN 0.3-0.1% Tier 3TOBRADEX SUS 0.3-0.1% Tier 3TOBRAMYCIN SOL 0.3% OP Tier 1TOBREX OIN 0.3% OP Tier 3TOBREX SOL 0.3% OP Tier 3TOFRANIL TAB 10MG Tier 3TOFRANIL TAB 25MG Tier 3TOFRANIL TAB 50MG Tier 3TOFRANIL-PM CAP 100MG Tier 3TOFRANIL-PM CAP 125MG Tier 3TOFRANIL-PM CAP 150MG Tier 3TOFRANIL-PM CAP 75MG Tier 3TOLAZAMIDE TAB 250MG Tier 1TOLAZAMIDE TAB 500MG Tier 1TOLBUTAMIDE TAB 500MG Tier 1TOLMETIN SOD CAP 400MG Tier 3TOLMETIN SOD TAB 200MG Tier 3TOLMETIN SOD TAB 600MG Tier 3TOPAMAX SPR CAP 15MG Tier 3 X XTOPAMAX SPR CAP 25MG Tier 3 X XTOPAMAX TAB 100MG Tier 3 X XTOPAMAX TAB 200MG Tier 3 X X

130


LimitStep

TherapySpecialty

Medication

TOPAMAX TAB 25MG Tier 3 X XTOPAMAX TAB 50MG Tier 3 X XTOPEX TOPCAL SPR ANESTHET Tier 3TOPICORT CRE 0.05% Tier 3 XTOPICORT CRE 0.25% Tier 3 XTOPICORT GEL 0.05% Tier 3 XTOPICORT OIN 0.05% Tier 3 XTOPICORT OIN 0.25% Tier 3 XTOPIRAGEN TAB 100MG Tier 1TOPIRAGEN TAB 200MG Tier 1TOPIRAGEN TAB 25MG Tier 1TOPIRAGEN TAB 50MG Tier 1TOPIRAMATE CAP 15MG Tier 1TOPIRAMATE CAP 25MG Tier 1TOPIRAMATE TAB 100MG Tier 1TOPIRAMATE TAB 200MG Tier 1TOPIRAMATE TAB 25MG Tier 1TOPIRAMATE TAB 50MG Tier 1TOPROL XL TAB 100MG Tier 3TOPROL XL TAB 200MG Tier 3TOPROL XL TAB 25MG Tier 3TOPROL XL TAB 50MG Tier 3TORSEMIDE TAB 100MG Tier 1TORSEMIDE TAB 10MG Tier 1TORSEMIDE TAB 20MG Tier 1TORSEMIDE TAB 5MG Tier 1TOVIAZ TAB 4MG Tier 3TOVIAZ TAB 8MG Tier 3TOZAL CAP Tier 3TRACLEER TAB 125MG Tier 2 X X XTRACLEER TAB 62.5MG Tier 2 X X XTRADJENTA TAB 5MG Tier 2 XTRAMADL/APAP TAB 37.5-325 Tier 1 XTRAMADOL HCL CAP 150MG ER Tier 1TRAMADOL HCL TAB 100MG ER Tier 2 XTRAMADOL HCL TAB 200MG ER Tier 2 XTRAMADOL HCL TAB 300MG ER Tier 2 XTRAMADOL HCL TAB 50MG Tier 1TRANDATE TAB 100MG Tier 3TRANDATE TAB 200MG Tier 3TRANDATE TAB 300MG Tier 3TRANDOLAPRIL TAB 1MG Tier 1TRANDOLAPRIL TAB 2MG Tier 1TRANDOLAPRIL TAB 4MG Tier 1TRANEX ACID TAB 650MG Tier 3 X

131


LimitStep

TherapySpecialty

Medication

TRANSDERMAL CRE PAIN BAS Tier 3TRANSDERM-SC DIS 1.5MG Tier 3TRANS-PEN CRE Tier 3TRANXENE T TAB 15MG Tier 3TRANXENE T TAB 3.75MG Tier 3TRANXENE T TAB 7.5MG Tier 3TRANYLCYPROM TAB 10MG Tier 1TRANZGEL GEL Tier 3TRAUMANIL GEL Tier 3TRAVATAN Z DRO 0.004% Tier 2 XTRAVOPROST DRO 0.004% Tier 3 XTRAZAMINE PAK 50MG Tier 3TRAZODONE TAB 100MG Tier 1TRAZODONE TAB 150MG Tier 1TRAZODONE TAB 300MG Tier 1TRAZODONE TAB 50MG Tier 1TREAGAN OTIC DRO Tier 3TRECATOR TAB 250MG Tier 2TRENTAL TAB 400MG Tier 3TREPADONE CAP Tier 3TREPOXICAM PAK 7.5MG Tier 3TRETINOIN CAP 10MG Tier 3 X XTRETINOIN CRE 0.025% Tier 1TRETINOIN CRE 0.05% Tier 1TRETINOIN CRE 0.1% Tier 1TRETINOIN GEL 0.01% Tier 1TRETINOIN GEL 0.025% Tier 1TREXALL TAB 10MG Tier 2TREXALL TAB 15MG Tier 2TREXALL TAB 5MG Tier 2TREXALL TAB 7.5MG Tier 2TRIADVANCE TAB Tier 1TRIAMCIN/ORA PST 0.1% Tier 1TRIAMCINOLON CRE 0.025% Tier 1TRIAMCINOLON CRE 0.1% Tier 1TRIAMCINOLON CRE 0.5% Tier 1TRIAMCINOLON LOT 0.025% Tier 1TRIAMCINOLON LOT 0.1% Tier 1TRIAMCINOLON OIN 0.025% Tier 1TRIAMCINOLON OIN 0.1% Tier 1TRIAMCINOLON OIN 0.5% Tier 1TRIAMCINOLON PST 0.1% Tier 1TRIAMT/HCTZ CAP 37.5-25 Tier 1TRIAMT/HCTZ CAP 50/25 Tier 1TRIAMT/HCTZ CAP 50-25MG Tier 1

132


LimitStep

TherapySpecialty

Medication

TRIAMT/HCTZ TAB 37.5-25 Tier 1TRIAMT/HCTZ TAB 75-50MG Tier 1TRIAZOLAM TAB 0.125MG Tier 1TRIAZOLAM TAB 0.25MG Tier 1TRICARE PRE CAP 27-1-500 Tier 3TRICARE TAB PRENATAL Tier 3TRI-CHLOR LIQ 80% Tier 2TRICITRASOL CON Tier 3TRICITRATES SOL Tier 1TRIDERM CRE 0.1% Tier 1TRI-ESTARYLL TAB Tier 3TRIFLUOPERAZ TAB 10MG Tier 1TRIFLUOPERAZ TAB 1MG Tier 1TRIFLUOPERAZ TAB 2MG Tier 1TRIFLUOPERAZ TAB 5MG Tier 1TRIFLURIDINE SOL 1% OP Tier 1TRIHEXYPHEN ELX 0.4MG/ML Tier 1TRIHEXYPHEN TAB 2MG Tier 1TRIHEXYPHEN TAB 5MG Tier 1TRI-LEGEST TAB FE Tier 3TRILEPTAL SUS 300MG/5M Tier 3 X XTRILEPTAL TAB 150MG Tier 3 X XTRILEPTAL TAB 300MG Tier 3 X XTRILEPTAL TAB 600MG Tier 3 X XTRI-LINYAH TAB Tier 3TRI-LUMA CRE Tier 3TRILYTE SOL Tier 1TRIMETHOBENZ CAP 300MG Tier 1TRIMETHOPRIM SOL POLYMYXN Tier 1TRIMETHOPRIM TAB 100MG Tier 1TRINATAL GT TAB Tier 2TRINATAL RX TAB 1 Tier 1TRINATE TAB Tier 1TRINESSA TAB Tier 3TRI-NORINYL TAB 28 Tier 3TRI-PREVIFEM TAB Tier 3TRI-SPRINTEC TAB Tier 3TRI-TABS DHA MIS Tier 3TRIVEEN-DUO PAK DHA Tier 2TRIVEEN-PRX CAP RNF Tier 2TRI-VI-FLOR SUS 0.25/ML Tier 3TRI-VI-FLOR SUS 0.5MG/ML Tier 3TRI-VI-FLORO SUS 0.25/ML Tier 3TRI-VI-FLORO SUS 0.5MG/ML Tier 3TRI-VIT/FE DRO /FL 0.25 Tier 1

133


LimitStep

TherapySpecialty

Medication

TRI-VIT/FL DRO 0.25MG Tier 1TRI-VIT/FL DRO 0.5MG Tier 1TRI-VIT/FLUO DRO 0.25MG Tier 1TRI-VIT/FLUO DRO 0.5MG Tier 1TRI-VITA/FL DRO 0.25MG Tier 1TRIVORA-28 TAB Tier 1TRIZIVIR TAB Tier 3 XTROPAZONE CRE Tier 1TROPAZONE LOT Tier 3TROPICAMIDE SOL 0.5% OP Tier 1TROPICAMIDE SOL 1% OP Tier 1TRUSOPT SOL 2% OP Tier 3TRUVADA TAB 200-300 Tier 2 X XTRYPTOPHAN CAP 500MG Tier 3TUDORZA PRES AER 400/ACT Tier 2 XTURPENTINE SOL SPIRITS Tier 3TUSNEL CAP Tier 3TUSSICAPS CAP 10-8MG Tier 3TUSSICAPS CAP 5-4MG Tier 3TUSSIGON TAB 5MG Tier 3TUSSIONEX SUS EXT-REL Tier 3 XTYKERB TAB 250MG Tier 2 X X XTYLENOL/COD TAB #3 Tier 3 XTYLENOL/COD TAB #4 Tier 3 XTYVASO REFIL SOL 0.6MG/ML Tier 2 X XTYVASO SOL 0.6MG/ML Tier 2 X XTYVASO START SOL 0.6MG/ML Tier 2 X XTYZEKA TAB 600MG Tier 3 XTYZINE PED DRO 0.05% Tier 3TYZINE SOL 0.1% Tier 3UCERIS TAB 9MG Tier 3U-KERA E CRE 40% Tier 1ULESFIA LOT 5% Tier 3ULORIC TAB 40MG Tier 3 XULORIC TAB 80MG Tier 3 XULTANE SOL Tier 3ULTIMATECARE CAP ONE Tier 1ULTIMATECARE CAP ONE NF Tier 1ULTRA TABS TAB Tier 2ULTRACET TAB 37.5-325 Tier 3 XULTRAFLEX MIS 24"/10MM Tier 3ULTRAFLEX MIS 24"/8MM Tier 3ULTRAFLEX MIS 31"/10MM Tier 3ULTRAFLEX MIS 31"/8MM Tier 3ULTRAFLEX MIS 43"/10MM Tier 3

134


LimitStep

TherapySpecialty

Medication

ULTRAFLEX MIS 43"/8MM Tier 3ULTRAM ER TAB 100MG Tier 3 XULTRAM ER TAB 200MG Tier 3 XULTRAM ER TAB 300MG Tier 3 XULTRAM TAB 50MG Tier 3ULTRAVATE CRE 0.05% Tier 3 XULTRAVATE OIN 0.05% Tier 3 XUNIRETIC TAB 15-12.5 Tier 3UNITH DIRECT TAB 100MCG Tier 1UNITH DIRECT TAB 112MCG Tier 1UNITH DIRECT TAB 125MCG Tier 1UNITH DIRECT TAB 150MCG Tier 1UNITH DIRECT TAB 175MCG Tier 1UNITH DIRECT TAB 200MCG Tier 1UNITH DIRECT TAB 25MCG Tier 1UNITH DIRECT TAB 300MCG Tier 1UNITH DIRECT TAB 50MCG Tier 1UNITH DIRECT TAB 75MCG Tier 1UNITH DIRECT TAB 88MCG Tier 1UNITHROID TAB 100MCG Tier 1UNITHROID TAB 112MCG Tier 1UNITHROID TAB 125MCG Tier 1UNITHROID TAB 137MCG Tier 1UNITHROID TAB 150MCG Tier 1UNITHROID TAB 175MCG Tier 1UNITHROID TAB 200MCG Tier 1UNITHROID TAB 25MCG Tier 1UNITHROID TAB 300MCG Tier 1UNITHROID TAB 50MCG Tier 1UNITHROID TAB 75MCG Tier 1UNITHROID TAB 88MCG Tier 1UNIVASC TAB 15MG Tier 3UNIVASC TAB 7.5MG Tier 3UNIVERT TAB 32MG Tier 1UR N-C TAB Tier 1URAMAXIN AER 20% Tier 3URAMAXIN CRE 45% Tier 3URAMAXIN LOT 45% Tier 3UREA 40% SUS NAIL Tier 1UREA CRE 39% Tier 1UREA CRE 40% Tier 1UREA CRE 45% Tier 1UREA CRE 50% Tier 1UREA EMU 50% Tier 1UREA GEL 40% Tier 1

135


LimitStep

TherapySpecialty

Medication

UREA HYDRATI AER 35% Tier 1UREA LOT 40% Tier 1UREA LOT 45% Tier 1UREA NAIL GEL 45% Tier 1UREA NAIL KIT Tier 1UREA NAIL MIS 50% Tier 1UREA SUS 50% Tier 1UREA TOPICAL SUS 40% Tier 1UREA-C40 LOT 40% Tier 1URECHOLINE TAB 10MG Tier 3URECHOLINE TAB 25MG Tier 3URECHOLINE TAB 50MG Tier 3URECHOLINE TAB 5MG Tier 3URELLE TAB Tier 3URETRON D/S TAB Tier 1UREX TAB 1GM Tier 3URIBEL CAP 118MG Tier 3URI-CONTROL TAB RX Tier 3URIMAR-T TAB Tier 2URIN D/S TAB Tier 1UROCIT-K 10 TAB Tier 3UROCIT-K 15 TAB Tier 3UROCIT-K 5 TAB Tier 3UROGESIC- TAB BLUE Tier 2UROQID #2 TAB Tier 3UROXATRAL TAB 10MG Tier 3URSO 250 TAB 250MG Tier 3URSO FORTE TAB 500MG Tier 3URSODIOL CAP 300MG Tier 1URSODIOL TAB 250MG Tier 1URSODIOL TAB 500MG Tier 1URYL TAB Tier 2USTELL CAP Tier 1UTA CAP 120MG Tier 3UTICAP CAP Tier 1UTIRA-C TAB Tier 2UTRONA-C TAB Tier 1VAGIFEM TAB 10MCG Tier 2VALACYCLOVIR TAB 1GM Tier 3 XVALACYCLOVIR TAB 500MG Tier 3 XVALCHLOR GEL 0.016% Tier 3 X XVALCYTE SOL 50MG/ML Tier 3VALCYTE TAB 450MG Tier 2 XVALPROIC ACD CAP 250MG Tier 1VALPROIC ACD SOL 250/5ML Tier 1

136


LimitStep

TherapySpecialty

Medication

VALPROIC ACD SYP 250/5ML Tier 1VALSART/HCTZ TAB 160-12.5 Tier 3 XVALSART/HCTZ TAB 160-25MG Tier 3 XVALSART/HCTZ TAB 320-12.5 Tier 3 XVALSART/HCTZ TAB 320-25MG Tier 3 XVALSART/HCTZ TAB 80-12.5 Tier 3 XVANCOCIN HCL CAP 125MG Tier 3 XVANCOCIN HCL CAP 250MG Tier 3 XVANCOMYCIN CAP 125MG Tier 1 XVANCOMYCIN CAP 250MG Tier 1 XVANCOMYCN 25 SOL 25MG/ML Tier 3VANCOMYCN 50 SOL 50MG/ML Tier 3VANDAZOLE GEL 0.75% Tier 1VANOXIDE-HC LOT 5-0.5% Tier 3VARIBAR HONE SUS 40% Tier 3VARIBAR NECT SUS 40% Tier 3VARIBAR PST PUDDING Tier 3VARIBAR THIN SUS HONEY Tier 3VARIBAR THIN SUS LIQUID Tier 3VASCEPA CAP 1GM Tier 3 XVASCULERA TAB Tier 3VASERETIC TAB 10-25MG Tier 3VASOLEX OIN Tier 1VASOTEC TAB 10MG Tier 3VASOTEC TAB 2.5MG Tier 3VASOTEC TAB 20MG Tier 3VASOTEC TAB 5MG Tier 3VAYACOG CAP Tier 3VAYARIN CAP Tier 3VAYAROL CAP Tier 3VECAMYL TAB 2.5MG Tier 3 X XVECTICAL OIN 3MCG/GM Tier 3 XVELIVET PAK Tier 1VELPHORO CHW 500MG Tier 3VEMAVITE- CAP PRX 2 Tier 3VENA-BAL MIS DHA Tier 2VENATAL-FA TAB Tier 3VENELEX OIN Tier 3VENLAFAXINE CAP 150MG ER Tier 1VENLAFAXINE CAP 37.5 ER Tier 1VENLAFAXINE CAP 75MG ER Tier 1VENLAFAXINE TAB 100MG Tier 1VENLAFAXINE TAB 25MG Tier 1VENLAFAXINE TAB 37.5MG Tier 1VENLAFAXINE TAB 50MG Tier 1

137


LimitStep

TherapySpecialty

Medication

VENLAFAXINE TAB 75MG Tier 1VENTAVIS SOL 10MCG/ML Tier 2 X XVENTAVIS SOL 20MCG/ML Tier 2 X XVENTOLIN HFA AER Tier 1 XVERAPAMIL CAP 100MG ER Tier 3VERAPAMIL CAP 120MG ER Tier 1VERAPAMIL CAP 120MG SR Tier 1VERAPAMIL CAP 180MG ER Tier 1VERAPAMIL CAP 180MG SR Tier 1VERAPAMIL CAP 200MG ER Tier 3VERAPAMIL CAP 240MG ER Tier 1VERAPAMIL CAP 240MG SR Tier 1VERAPAMIL CAP 300MG ER Tier 3VERAPAMIL CAP 360MG SR Tier 1VERAPAMIL TAB 120MG Tier 1VERAPAMIL TAB 120MG ER Tier 1VERAPAMIL TAB 180MG ER Tier 1VERAPAMIL TAB 240MG ER Tier 1VERAPAMIL TAB 40MG Tier 1VERAPAMIL TAB 80MG Tier 1VERDROCET TAB 2.5-325 Tier 1VEREGEN OIN 15% Tier 3 XVERELAN CAP 120MG SR Tier 3VERELAN CAP 180MG SR Tier 3VERELAN CAP 240MG SR Tier 3VERELAN CAP 360MG SR Tier 3VERELAN PM CAP 100MG ER Tier 3VERELAN PM CAP 200MG ER Tier 3VERELAN PM CAP 300MG ER Tier 3VERIPRED 20 SOL 20MG/5ML Tier 3VERSACLOZ SUS 50MG/ML Tier 3VERSAFREE SYP Tier 3VERSAPLUS SYP Tier 3VERSICLEAR LOT Tier 1VERTIGOHEEL SUB Tier 3VESTURA TAB 3-0.02MG Tier 3VEXOL SUS 1% OP Tier 2VFEND SUS 40MG/ML Tier 3VFEND TAB 200MG Tier 3 XVFEND TAB 50MG Tier 3 XVIAGRA TAB 100MG Tier 3 XVIAGRA TAB 25MG Tier 3 XVIAGRA TAB 50MG Tier 3 XVIBRAMYCIN CAP 100MG Tier 3VIBRAMYCIN SUS 25MG/5ML Tier 3

138


LimitStep

TherapySpecialty

Medication

VIBRAMYCIN SYP 50MG/5ML Tier 3VICOPROFEN TAB 7.5-200 Tier 3VICTOZA INJ 18MG/3ML Tier 3 XVICTRELIS CAP 200MG Tier 3 X X XVIDEX EC CAP 125MG Tier 3 XVIDEX EC CAP 200MG Tier 3 XVIDEX EC CAP 250MG Tier 3 XVIDEX EC CAP 400MG Tier 3 XVIDEX SOL 2GM Tier 2 XVIDEX SOL 4GM Tier 2 XVIGAMOX DRO 0.5% Tier 3VIIBRYD KIT Tier 3 XVIIBRYD TAB 10MG Tier 3 XVIIBRYD TAB 20MG Tier 3 XVIIBRYD TAB 40MG Tier 3 XVIMPAT SOL 10MG/ML Tier 3 XVIMPAT TAB 100MG Tier 3 XVIMPAT TAB 150MG Tier 3 XVIMPAT TAB 200MG Tier 3 XVIMPAT TAB 50MG Tier 3 XVINACAL B MIS Tier 3VINATE AZ EX TAB Tier 1VINATE C TAB Tier 1VINATE CAL TAB Tier 3VINATE CARE CHW Tier 1VINATE DHA CAP 27-1.13 Tier 3VINATE IC CAP Tier 1VINATE II TAB Tier 1VINATE M TAB Tier 1VINATE ONE TAB Tier 1VIORELE TAB Tier 3VIRACEPT TAB 250MG Tier 2 XVIRACEPT TAB 625MG Tier 2 XVIRAMUNE SUS 50MG/5ML Tier 3 XVIRAMUNE TAB 200MG Tier 3 XVIRAMUNE XR TAB 100MG Tier 2 XVIRAZOLE INH 6GM Tier 2VIREAD POW 40MG/GM Tier 3 XVIREAD TAB 150MG Tier 2 XVIREAD TAB 200MG Tier 2 XVIREAD TAB 250MG Tier 2 XVIREAD TAB 300MG Tier 2 XVIRILEX CAP Tier 2VIROPTIC SOL 1% OP Tier 3VIRTI-SULF CRE 10-5% Tier 1

139


LimitStep

TherapySpecialty

Medication

VIRT-PHOS TAB 250 NEUT Tier 1VIRT-PN DHA CAP Tier 3VIRT-PN PLUS CAP Tier 3VIRT-PN TAB Tier 3VIRT-SELECT CAP Tier 3VISTARIL CAP 25MG Tier 3VISTARIL CAP 50MG Tier 3VITAFOL CAP ULTRA Tier 3VITAFOL-NANO TAB Tier 3VITAFOL-OB PAK +DHA Tier 3VITAFOL-OB TAB 65-1MG Tier 3VITAFOL-ONE CAP Tier 3VITAMEDMD CAP ONE RX Tier 3VITAMEDMD MIS PLUS RX Tier 3VITAMIN D CAP 50000UNT Tier 1VITAPEARL CAP Tier 3VITA-PREN TAB Tier 3VIVA DHA CAP Tier 3VIVACTIL TAB 10MG Tier 3VIVACTIL TAB 5MG Tier 3VIVELLE-DOT DIS 0.025MG Tier 2 XVIVELLE-DOT DIS 0.0375MG Tier 2 XVIVELLE-DOT DIS 0.05MG Tier 2 XVIVELLE-DOT DIS 0.075MG Tier 2 XVIVELLE-DOT DIS 0.1MG Tier 2 XVOL-NATE TAB Tier 3VOL-PLUS TAB Tier 3VOL-TAB RX TAB Tier 3VOLTAREN GEL 1% Tier 2VOLTAREN-XR TAB 100MG Tier 3VOLUMEN SUS 0.1% Tier 2VORICONAZOLE SUS 40MG/ML Tier 1VORICONAZOLE TAB 200MG Tier 1 XVORICONAZOLE TAB 50MG Tier 1 XVORTEX VALVE MIS CHAMBER Tier 2VOSOL HC SOL OTIC Tier 3VOSPIRE ER TAB 4MG Tier 3VOSPIRE ER TAB 8MG Tier 3VOTRIENT TAB 200MG Tier 2 X X XVP CH ULTRA CAP Tier 3VP-CH PLUS CAP Tier 3VP-CH-PNV CAP Tier 2VP-GGR-B6 TAB PRENATAL Tier 2VP-GSTN CAP Tier 1VP-HEME OB MIS + DHA Tier 3

140


LimitStep

TherapySpecialty

Medication

VP-HEME ONE CAP Tier 3VP-HEME-OB TAB 28-6-1MG Tier 3VP-PNV-DHA CAP Tier 3VP-PRECIP CAP Tier 1VYFEMLA TAB 0.4-35 Tier 3VYTONE CRE 1-1.9% Tier 3VYTORIN TAB 10-10MG Tier 3 XVYTORIN TAB 10-20MG Tier 3 XVYTORIN TAB 10-40MG Tier 3 XVYTORIN TAB 10-80MG Tier 3 XVYVANSE CAP 20MG Tier 2 X XVYVANSE CAP 30MG Tier 2 X XVYVANSE CAP 40MG Tier 2 X XVYVANSE CAP 50MG Tier 2 X XVYVANSE CAP 60MG Tier 2 X XVYVANSE CAP 70MG Tier 2 X XWARFARIN TAB 10MG Tier 1WARFARIN TAB 1MG Tier 1WARFARIN TAB 2.5MG Tier 1WARFARIN TAB 2MG Tier 1WARFARIN TAB 3MG Tier 1WARFARIN TAB 4MG Tier 1WARFARIN TAB 5MG Tier 1WARFARIN TAB 6MG Tier 1WARFARIN TAB 7.5MG Tier 1WATCHHALER MIS Tier 3WELCHOL PAK 3.75GM Tier 2WELCHOL TAB 625MG Tier 2WELLBUTRIN TAB 100MG Tier 3WELLBUTRIN TAB 75MG Tier 3WERA TAB 0.5/35 Tier 1WESTCORT OIN 0.2% Tier 3 XWESTHROID TAB 113.75MG Tier 3WESTHROID TAB 130MG Tier 3WESTHROID TAB 146.25MG Tier 3WESTHROID TAB 16.25MG Tier 3WESTHROID TAB 162.50MG Tier 3WESTHROID TAB 195MG Tier 3WESTHROID TAB 260MG Tier 3WESTHROID TAB 32.5MG Tier 3WESTHROID TAB 325MG Tier 3WESTHROID TAB 48.75MG Tier 3WESTHROID TAB 65MG Tier 3WESTHROID TAB 81.25MG Tier 3WESTHROID TAB 97.5MG Tier 3

141


LimitStep

TherapySpecialty

Medication

WHEAT GERM OIL Tier 3WIDE-SEAL DPR KIT 60 Tier 2WIDE-SEAL DPR KIT 65 Tier 2WIDE-SEAL DPR KIT 70 Tier 2WIDE-SEAL DPR KIT 75 Tier 2WIDE-SEAL DPR KIT 80 Tier 2WIDE-SEAL DPR KIT 85 Tier 2WIDE-SEAL DPR KIT 90 Tier 2WIDE-SEAL DPR KIT 95 Tier 2WILATE INJ Tier 2 XWP THYROID TAB 113.75MG Tier 3WP THYROID TAB 130MG Tier 3WP THYROID TAB 16.25MG Tier 3WP THYROID TAB 32.5MG Tier 3WP THYROID TAB 48.75MG Tier 3WP THYROID TAB 65MG Tier 3WP THYROID TAB 81.25MG Tier 3WP THYROID TAB 97.5MG Tier 3WYMZYA FE CHW 0.4MG-35 Tier 3XALATAN SOL 0.005% Tier 3XALKORI CAP 200MG Tier 2 X X XXALKORI CAP 250MG Tier 2 X X XXARELTO TAB 10MG Tier 2 XXARELTO TAB 15MG Tier 2 XXARELTO TAB 20MG Tier 2 XXELJANZ TAB 5MG Tier 3 X X X XXELODA TAB 150MG Tier 3 X XXELODA TAB 500MG Tier 3 X XXENADERM OIN Tier 3XENAZINE TAB 12.5MG Tier 3 XXENAZINE TAB 25MG Tier 3 XXERAC-AC SOL 6.25% Tier 2XIFAXAN TAB 200MG Tier 3 X XXIFAXAN TAB 550MG Tier 3 X XXOLEGEL DUO/ KIT HEAD&SHD Tier 3XOLEGEL DUO/ KIT XOLEX Tier 3XOLEGEL GEL 2% Tier 3XOLEGEL KIT COREPAK Tier 3XOPENEX HFA AER Tier 3 XXTANDI CAP 40MG Tier 3 X X X XXULANE DIS 150-35 Tier 3X-VIATE CRE 40% Tier 1X-VIATE GEL 40% Tier 3X-VIATE LOT 40% Tier 1XYLOCAINE SOL 4% Tier 3

142


LimitStep

TherapySpecialty

Medication

XYLON TAB 10-200MG Tier 1XYNTHA INJ 1000UNIT Tier 2 XXYNTHA INJ 2000UNIT Tier 2 XXYNTHA INJ 250UNIT Tier 2 XXYNTHA INJ 500UNIT Tier 2 XXYNTHA SOLOF INJ 1000UNIT Tier 2 XXYNTHA SOLOF INJ 2000UNIT Tier 2 XXYNTHA SOLOF INJ 3000UNIT Tier 2 XXYNTHA SOLOF INJ 500UNIT Tier 2 XXYNTHA SOLOF KIT 250UNIT Tier 2 XXYREM SOL 500MG/ML Tier 3 X X XXYZAL SOL Tier 3XYZAL SOL 2.5/5ML Tier 3XYZAL TAB 5MG Tier 3 XYASMIN 28 TAB 3-0.03MG Tier 1YAZ TAB 3-0.02MG Tier 2YODOXIN TAB 210MG Tier 2YODOXIN TAB 650MG Tier 2ZACARE KIT KIT 4% Tier 3ZACARE KIT KIT 8% Tier 3ZACLIR LOT 8% Tier 1ZAFIRLUKAST TAB 10MG Tier 1 XZAFIRLUKAST TAB 20MG Tier 1 XZALEPLON CAP 10MG Tier 1 XZALEPLON CAP 5MG Tier 1 XZAMICET SOL 10-325MG Tier 3 XZANAFLEX CAP 2MG Tier 3ZANAFLEX CAP 4MG Tier 3ZANAFLEX CAP 6MG Tier 3ZANAFLEX TAB 4MG Tier 3ZARAH TAB 3-0.03MG Tier 3ZARONTIN CAP 250MG Tier 3ZARONTIN SOL 250/5ML Tier 3ZAROXOLYN TAB 2.5MG Tier 3ZAROXOLYN TAB 5MG Tier 3ZATEAN-CH CAP Tier 2ZATEAN-PN CAP DHA Tier 3ZATEAN-PN CAP PLUS Tier 1ZATEAN-PN TAB Tier 3ZAVESCA CAP 100MG Tier 3 XZAZOLE CRE 0.4% Tier 1ZAZOLE CRE 0.8% Tier 1ZAZOLE SUP 80MG Tier 1ZEBETA TAB 10MG Tier 3ZEBETA TAB 5MG Tier 3

143


LimitStep

TherapySpecialty

Medication

ZEBUTAL CAP Tier 1 XZEGERID POW 20-1680 Tier 3 XZEGERID POW 40-1680 Tier 3 XZELAPAR TAB 1.25MG Tier 3ZELBORAF TAB 240MG Tier 2 X X XZEMPLAR CAP 1MCG Tier 3ZEMPLAR CAP 2MCG Tier 3ZEMPLAR CAP 4MCG Tier 3ZENATANE CAP 10MG Tier 3 XZENATANE CAP 20MG Tier 3 XZENATANE CAP 40MG Tier 3 XZENCHENT FE CHW 0.4MG-35 Tier 3ZENCHENT TAB Tier 3ZENCIA LIQ 9-4% Tier 1ZENPEP CAP 10000UNT Tier 2ZENPEP CAP 15000UNT Tier 2ZENPEP CAP 20000UNT Tier 2ZENPEP CAP 25000UNT Tier 2ZENPEP CAP 3000UNIT Tier 2ZENPEP CAP 5000UNIT Tier 2ZERIT CAP 15MG Tier 3 XZERIT CAP 20MG Tier 3 XZERIT CAP 30MG Tier 3 XZERIT CAP 40MG Tier 3 XZERIT SOL 1MG/ML Tier 3 XZESTORETIC TAB 10-12.5 Tier 3ZESTORETIC TAB 20-12.5 Tier 3ZESTORETIC TAB 20-25MG Tier 3ZESTRIL TAB 10MG Tier 3ZESTRIL TAB 2.5MG Tier 3ZESTRIL TAB 20MG Tier 3ZESTRIL TAB 30MG Tier 3ZESTRIL TAB 40MG Tier 3ZESTRIL TAB 5MG Tier 3ZETIA TAB 10MG Tier 3 XZETONNA AER 37MCG Tier 3 XZIAC TAB 10/6.25 Tier 3ZIAC TAB 2.5/6.25 Tier 3ZIAC TAB 5-6.25MG Tier 3ZIAGEN SOL 20MG/ML Tier 2 XZIAGEN TAB 300MG Tier 3 XZIDOVUDINE CAP 100MG Tier 1 XZIDOVUDINE SYP 50MG/5ML Tier 1 XZIDOVUDINE TAB 300MG Tier 1 XZIOPTAN DRO 0.0015% Tier 3 X X

144


LimitStep

TherapySpecialty

Medication

ZIPRASIDONE CAP 20MG Tier 3 XZIPRASIDONE CAP 40MG Tier 3 XZIPRASIDONE CAP 60MG Tier 3 XZIPRASIDONE CAP 80MG Tier 3 XZIRGAN GEL 0.15% Tier 3 XZITHRANOL SHA 1% Tier 3ZITHRANOL-RR CRE 1.2% Tier 3ZITHROMAX SUS 100/5ML Tier 3ZITHROMAX SUS 200/5ML Tier 3ZITHROMAX TAB 250MG Tier 3ZITHROMAX TAB 500MG Tier 3ZITHROMAX TAB 600MG Tier 3ZITHROMAX TAB TRI-PAK Tier 3ZITHROMAX TAB Z-PAK Tier 3ZMAX SUS 2GM Tier 3ZOCOR TAB 10MG Tier 3ZOCOR TAB 20MG Tier 3ZOCOR TAB 40MG Tier 3ZOCOR TAB 5MG Tier 3ZOCOR TAB 80MG Tier 3ZOFRAN SOL 4MG/5ML Tier 3ZOFRAN TAB 4MG Tier 3ZOFRAN TAB 4MG ODT Tier 3ZOFRAN TAB 8MG Tier 3ZOFRAN TAB 8MG ODT Tier 3ZOHYDRO ER CAP 10MG Tier 3 X XZOHYDRO ER CAP 15MG Tier 3 X XZOHYDRO ER CAP 20MG Tier 3 X XZOHYDRO ER CAP 30MG Tier 3 X XZOHYDRO ER CAP 40MG Tier 3 X XZOHYDRO ER CAP 50MG Tier 3 X XZOLINZA CAP 100MG Tier 2 X XZOLMITRIPTAN TAB 2.5 MG Tier 3 XZOLMITRIPTAN TAB 2.5MG Tier 3 XZOLMITRIPTAN TAB 5MG Tier 3 XZOLPIDEM TAB 10MG Tier 1 XZOLPIDEM TAB 5MG Tier 1 XZOLPIMIST SPR 5MG Tier 3 X XZOMIG NASAL SPR 5MG Tier 3 XZOMIG SPR 2.5MG Tier 3 XZOMIG TAB 2.5MG Tier 3 XZOMIG TAB 5MG Tier 3 XZOMIG ZMT TAB 2.5 MG Tier 3 XZOMIG ZMT TAB 5MG Tier 3 XZONALON CRE 5% Tier 3

145


LimitStep

TherapySpecialty

Medication

ZONEGRAN CAP 100MG Tier 3 X XZONEGRAN CAP 25MG Tier 3 X XZONISAMIDE CAP 100MG Tier 1ZONISAMIDE CAP 25MG Tier 1ZONISAMIDE CAP 50MG Tier 1ZONTIVITY TAB 2.08MG Tier 3 X XZORBTIVE INJ 8.8MG Tier 3 X X XZORTRESS TAB 0.25MG Tier 3 XZORTRESS TAB 0.5MG Tier 3 XZORTRESS TAB 0.75MG Tier 3 XZOVIA 1/35E TAB Tier 1ZOVIA 1/50E TAB Tier 1ZOVIRAX CAP 200MG Tier 3ZOVIRAX SUS 200/5ML Tier 3ZOVIRAX TAB 400MG Tier 3ZOVIRAX TAB 800MG Tier 3ZUBSOLV SUB 1.4-0.36 Tier 2 X XZUBSOLV SUB 5.7-1.4 Tier 2 X XZYDELIG TAB 100MG Tier 3ZYDELIG TAB 150MG Tier 3ZYFLO CR TAB 600MG Tier 3 XZYFLO TAB 600MG Tier 3ZYKADIA CAP 150MG Tier 3 X X XZYLET SUS 0.5-0.3% Tier 3ZYLOPRIM TAB 100MG Tier 3ZYLOPRIM TAB 300MG Tier 3ZYMAXID SOL 0.5% Tier 3 XZYTIGA TAB 250MG Tier 2 X X XZYVOX SUS 100MG/5M Tier 2 XZYVOX TAB 600MG Tier 2 X

your 2015 prescription drug list - oxhp · refill and save program – save money on your copayment...

Documents